Preferred Drug List 2007 Formulary (3-Tier Open)

M0001_S5810_7B_61205 (01/2007) 18.05.303.1 (1/07) ©2007 Aetna Inc.

Drug Category List Adrenal Regulating Drugs Alcohol, Smoking Deterrents and Antidotes

1

page 9 pages 9 – 10

Eye and Ear Drugs Gout Drugs

pages 73 – 80 page 80

Allergy / Asthma / COPD Drugs

pages 10 – 25

Heart Blood Pressure and Cholesterol Drugs pages 80 – 93

Alzheimer’s / Antidementia Drugs

pages 25 – 26

Migraine Drugs

Anesthetic Drugs

page 26

Miscellaneous Drugs

pages 93 – 94 page 94

Anti-anxiety Drugs

pages 26 – 27

Muscle Relaxers

pages 94 – 95

Antibiotics

pages 27 – 34

Myesthenia Gravis Drugs

Anti-cancer Drugs

pages 34 – 38

Nausea/Vomiting Drugs

pages 95 – 96

Antidepressant Drugs

pages 38 – 40

Osteoporosis (Bone loss) Drugs

pages 96 – 97

Antifungal Drugs

pages 40 – 42

Pain Drugs (Analgesics)

Anti-inflammatory Drugs

pages 42 – 45

Parathyroid Suppressant Drugs

page 103

Antipsychotic / Bipolar Drugs

pages 46 – 47

Parkinson’s Drugs

page 103

page 95

pages 97 – 103

Attention Deficit Disorder / Narcolepsy Drugs pages 47 – 48

Pituitary Drugs

pages 103 – 105

Blood Products

pages 48 – 49

Seizure Control Drugs

pages 105 – 106

Bowel Disease Drugs

pages 50 – 52

Sleep Aids

Dental and Drugs for the Mouth

page 52

Therapeutic Supplements

page 106 pages 106 – 116

Diabetes Drugs

pages 52 – 55

Thyroid Drugs

Drugs for Skin Conditions

pages 55 – 65

Tuberculosis Drugs

pages 116 – 117

Ulcer and Stomach Drugs

pages 117 – 119

Drugs for the treatment of Parasites

page 66

page 116

Enzymes

pages 67 – 68

Urinary and Prostate Drugs

pages 120 – 122

(Prostaglandins)

pages 68 – 73

Vaccines and Immunology Drugs

pages 122 – 125

Viral Infection Drugs

pages 125 – 127

(Prostaglandins); Ulcer and Stomach Drugs

page 73

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Coverage for prescription drugs continues to be one of the most important benefits in a health care plan. Your Medicare prescription drug coverage can be through a stand-alone Aetna Medicare RxSM Plan (PDP) or an Aetna Medicare Advantage Plan with Medicare prescription drug coverage (MA-PD). You can use the Centers for Medicare and Medicaid Services (CMS) approved 2007 Aetna Medicare Preferred Drug List to help you determine what medications will be covered. We have selected these drugs based on their effectiveness, quality, safety and value. Translation of this material into another language may be available. For assistance, please call Member Services at the toll-free telephone number on your Aetna Medicare Member ID card (or 1-800-628-3323 TTY/TDD), Monday to Friday, 8 a.m. to 6 p.m. or visit our website at www.aetnamedicare.com.

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. This document includes the Aetna Medicare Plan’s comprehensive formulary as of January 1, 2007. You can always access current formulary drug status by visiting our website at www.aetnamedicare.com or by calling the toll-free number on the back of your Aetna Medicare member ID card, Monday to Friday, 8 a.m. to 6 p.m. TTY/TDD users should call 1-800-628-3323.

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What is the Aetna Medicare Preferred Drug List (formulary)? The Aetna Medicare Preferred Drug List (formulary) is a list of covered drugs selected by Aetna Medicare 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. Aetna Medicare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Aetna Medicare network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

name of your drug in the first column of the list.

What are generic drugs? Aetna Medicare covers both brand and generic drugs. A generic drug has the same active ingredient as the brand drug. Generic drugs usually cost less than brand drugs and are approved by the Food and Drug Administration (FDA).

Can the formulary change?

Are there any restrictions on my coverage?

Generally, if you are taking a drug on our 2007 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2007 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.

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

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 improve the safety of your drugs. 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 January 1, 2007. To get updated information about the drugs covered by Aetna Medicare, please visit our website at www.aetnamedicare.com or call Aetna Medicare Services at the toll-free telephone number on your Aetna Medicare Member ID card, Monday to Friday, 8 a.m. to 6 p.m. TTY/TDD users should call 1-800-628-3323.

How do I use the formulary? There are two ways to find your drug within the formulary: ■

Medical Condition The formulary begins on page 9. 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, Heart, Blood Pressure and Cholesterol Drugs, etc. If you know what your drug is used for, look for the category name in the list that appears inside the front cover. Then look under the category name for your drug.

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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 128. The Index provides an alphabetical list of all 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

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Precertification (or Prior Authorization) Once you have enrolled for coverage through an Aetna Medicare Plan, you may be required to get precertification for certain medications. Precertification encourages the appropriate cost-effective use of medications by allowing coverage only when certain conditions are met. There are several reasons why we require precertification of certain medications: ■

Some are more likely to be taken incorrectly.

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Some may be prescribed for inappropriate reasons or used in amounts that exceed recommendations for dosage or length of treatment.

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Some are more expensive than other medications that have been shown to be clinically or therapeutically similar.

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The precertification program is based on current medical findings, FDA-approved manufacturer labeling information and cost and manufacturer rebate arrangements.

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For medications requiring precertification, your doctor must request authorization of coverage for the medication. If the request is approved, you and your doctor will be notified and the medication will then be covered at the applicable copay or coinsurance under your plan. If the request is denied, you and your doctor will be notified.

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The medications that require precertification are noted in the Aetna Medicare Preferred Drug List.

The medications requiring precertification are subject to change. Please refer to our website at www.aetnamedicare.com or contact an Aetna Medicare representative at the toll-free telephone number on your Aetna Medicare Member ID card. TTY/TDD users should call 1-800-628-3323.

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Quantity Limits

Are there any other restrictions on coverage?

Quantity limits apply to certain medications as part of the precertification program and are designed to help promote appropriate and efficient medication use and enhance patient safety. Once you have enrolled in one of the Aetna Medicare Plans with prescription drug coverage, in order to receive coverage for amounts above the quantities on this drug list, your physician must obtain prior authorization.

In accordance with Medicare coverage guidelines, the following medications are not covered in an Aetna Medicare Plan with prescription drug coverage. ■

Agents when used for anorexia, weight loss, or weight gain.

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Agents when used to promote fertility.

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Agents when used for cosmetic purposes or hair growth.

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Agents when used for symptomatic relief of cough and colds.

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Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations.

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Non-prescription drugs

3. Quantity Limits Over Time: limits coverage of prescriptions to a specific number of units per a defined amount of time.

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Covered outpatient drugs which the manufacturer seeks to require as a condition of sale that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee.

The medications that have quantity limits are subject to change. Please refer to our website at www.aetnamedicare.com or contact an Aetna representative at the toll-free telephone number on your Aetna Medicare Member ID card. TTY/TDD users should call 1-800-628-3323.

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Barbiturates

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Benzodiazepines

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Agents when used for the treatment of sexual or erectile dysfunction, unless such agents are used to treat a condition, other than sexual or erectile dysfunction, for which the agents have been approved by the Food and Drug Administration.

Quantity limits are based on generally accepted pharmaceutical guidelines, efficient dosing regimens and dosing recommendations. Three types of quantity limits are in place. They are: 1. Dose Efficiency Edits: limits coverage of prescriptions to one pill per dose or per day for medications that are approved for once-daily dosing. 2. Maximum Daily Dose: an information message is sent to the pharmacy if a prescription lies outside recommended minimum and maximum doses.

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Step Therapy With step therapy, you must first try one or more “prerequisite” medications before a step therapy medication will be covered. Prerequisite medications and their corresponding step therapy medications are FDA-approved and are used to treat the same conditions. Step therapy does not apply to all medications, however. If it is medically necessary, you can obtain coverage for step therapy medication without trying a prerequisite medication first. In this case, your doctor must request coverage for a step therapy medication as a medical exception. If the request is approved, you and your doctor will be notified and the medication will then be covered at the applicable copay or coinsurance under your plan. If the request is denied, you and your doctor will be notified. Step therapy is based upon current medical findings, FDA-approved manufacturer labeling information, and cost and manufacturer rebate arrangements. The medications requiring step therapy are subject to change. Please refer to our website at www.aetnamedicare.com or contact an Aetna Medicare representative at 1-800-213-4599.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 9. You can ask Aetna Medicare to make an exception to these restrictions or limits. See the section, “How do I request an exception to the Aetna Medicare Formulary?” on page 6 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 Aetna Medicare Customer Service and ask if your drug is covered. You can contact Aetna Medicare at the toll-free telephone number on your Aetna Medicare Member ID card, Monday to Friday, 8 a.m. to 6 p.m. TTY/TDD users should call 1-800-628-3323. If you learn that Aetna Medicare does not cover your drug, you have two options: ■

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

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You can ask Aetna Medicare to make an exception and cover your drug. See below for information about how to request an exception.

NOTE: Due to a change in Medicare, most Medicare Drug Plans will no longer cover erectile dysfunction (ED) drugs like Viagra, Cialis, Levitra, and Caverject starting January 1, 2007. Call your Medicare drug plan for more information.

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How do I request an exception to the Aetna Medicare formulary?

Aetna Transition of Care Policy

You can ask Aetna Medicare to make an exception to our coverage rules. There are a few types of exceptions that you can ask us to make.

Aetna understands the importance of maintaining a consistent drug regimen, the challenges associated with changing coverage and the uncertainty changing coverage can have on drug coverage. All Medicare prescription drug plans include a Transition provision for medications that are not on our Aetna Medicare Preferred Drug List or are included in our Precertification or Step Therapy programs.

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You can ask us to cover your drug even if it is not on our formulary.

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You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Aetna Medicare limits 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.

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You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier subject to the tiering exceptions process tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the tier designated as the high-cost/unique drug tier.

Generally, Aetna Medicare will only approve your request for an exception if the alternative drugs included on the plan’s formulary, 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, tiering or utilization restriction exception. When you are requesting a formulary, tiering 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 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 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 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31-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 cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days 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.

To diminish the impact changing coverage can have upon you, Aetna has established a liberal transition benefit that provides you with up to one courtesy fill (maximum of a 31 day supply) for each prescription you may already be taking and that is not on our Preferred Drug List, or that requires Precertification or Step Therapy. The courtesy fill can be used anytime during your first 90 days in the plan. If you reside in a Long Term Care facility, we will extend the courtesy fill up to two additional fills as long as they occur during your first 90 days in the plan. You will share in the cost of the drug in the same manner as if the drug were on our Preferred Drug List. Following your courtesy fill, you will receive a letter from Aetna instructing you of the action(s) you must take prior to filling that prescription again, in order to not interrupt your drug regimen. Of course, you always have the option to switch prescriptions to a drug on our Preferred Drug List in advance of filling your prescription, which will serve to reduce your drug costs and limit any future interruptions. You may also be eligible to receive courtesy fill(s) at other times during the year, such as changes in setting of care, emergencies, etc. The important thing to keep in mind is Aetna’s commitment to working with you and your physician to assure you have the safest and most effective drug necessary to treat your health care needs.

For more information For more detailed information about your Aetna Medicare prescription drug coverage, please review your Aetna Medicare Evidence of Coverage (EOC) and other plan materials. If you have questions about Aetna Medicare, please call Aetna Medicare at the toll-free telephone number on your Aetna Medicare Member ID card, Monday to Friday, 8 a.m. to 6 p.m. TTY/TDD users should call 1-800-628-3323. Or visit www.aetnamedicare.com. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (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.

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KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits Drug Name

3-Tier Open

How do you read the Aetna formulary?

A D R E N A L R E G U L AT I N G D R U G S

The formulary that begins on page 9 provides coverage information about the drugs covered by Aetna Medicare. If you have trouble finding your drug in the list, turn to the Index that begins on page 128.

A-METHAPRED

1

ARISTOSPAN INTRA-ARTICULA

3

BUBBLI-PRED

1

CELESTONE

3

CORTEF

3

cortisone acetate

1

What is the difference between Aetna Medicare’s open and closed formularies?

CYTADREN

2

FLORINEF

3

Aetna Medicare’s closed formulary limits coverage of Medicare Part D medications to only those medications designated as covered on the Aetna Medicare Preferred Drug List. The copay tiers for covered prescription medications are listed below:

fludrocortisone acetate

1

KENALOG-10

2

KENALOG-40

2

LYSODREN

3

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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., simvastatin). The information in the Utilization Management column tells you if Aetna Medicare has any special requirements for coverage of your drug.

Copay Tier Tier 1 (Lowest Copay Amount) Tier 2 Tier 3

Type of Drug Generic medications Brand Name medications Specialty medications (both Brand Name & Generic)

Aetna Medicare’s open formulary covers all Medicare Part D medications. Non-preferred levels of copay apply to some medications on the Aetna Medicare Preferred Drug List. The copay tiers for covered prescription medication are listed below: Copay Tier Tier 1 (Lowest Copay Amount) Tier 2 Tier 3 Tier 4

Type of Drug Generic medications Preferred Brand Name medications Non-preferred Brand Name medications Specialty medications (both Brand Name & Generic)

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

(PR)

ALCOHOL, SMOKING DETERRENTS AND ANTIDOTES ACETADOTE

3

ANTABUSE

3

ANTIZOL

3

BUPROBAN

1

CAMPRAL

3

CHANTIX

3

CHEMET

3

DEPADE

1

DICHLOROACETIC ACID

1

EXJADE

2

KAYEXALATE

3

KIONEX

1

methylene blue

1

naltrexone hydrochloride

1

NARCAN

3

nicotine td patch

1

(PR)

NICOTROL INHALER

3

(PR)

NICOTROL NS

3

(PR)

(QL)

1/1 day(s)

(PR)

(QL) (PR) (ST)

2/1 day(s)

9

10

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

physostigmine salicylate

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

1

ALDEX-CT CHEW

3

REVEX

3

ALENAZE-D

3

REVIA

3

ALLANTAN PEDIATRIC

1

sodium polystyrene sulfonate

1

ALLANVAN-S

1

SPS

1

ALLEGRA 180MG

SYPRINE

3

VIVITROL

3

(QL) (PR) (ST)

ZYBAN

3

(PR)

ALLERGY / ASTHMA / COPD DRUGS

1/30 day(s)

Utilization Management

QL/ Day(s)

3

(QL) (PR)

1/1 day(s)

ALLEGRA 30, 60MG

3

(QL) (PR)

2/1 day(s)

ALLEGRA-D 12 HOUR

3

(QL) (PR)

2/1 day(s)

ALLEGRA-D 24 HOUR

3

(QL) (PR)

1/1 day(s)

ALLERSCRIPT

3

ABER-FED

1

ALLERX PE

3

ACCOLATE

3

ALLERX SUSPENSION

3

ACCUHIST

3

ALLERX TABLETS

3

ACCUNEB

3

(PR)

ALLFEN JR

3

acetylcysteine

1

(PR)

ALTEX-PSE

1

ADRENALIN

3

ALUPENT

3

ADVAIR DISKUS

2

AMBI

1

ADVAIR HFA

2

AMBIFED-G

3

AEROHIST

3

AMDRY-C

1

AEROHIST PLUS

1

AMERIFED

3

AEROKID

3

AMIDAL

1

AH-CHEW

1

aminophylline

1

AH-CHEW II

3

AMI-TEX LA

1

AHIST

3

AMITEX PSE

1

AIRET

1

ANDEHIST NR

1

ALACOL

3

AQUATAB D

3

albuterol hfa

1

ARALAST

3

albuterol inhaler

1

ASMANEX

2

albuterol neb solution

1

ASTELIN

3

albuterol syrup

1

ATROVENT HFA

3

albuterol tablets

1

ATROVENT NASAL SOLUTION

3

ALDEX

3

AZMACORT

2

ALDEX G

3

BECONASE AQ

3

(PR)

(PR)

NC = Not covered

(PR)

11

12

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

BENADRYL

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

3

CENTEX-PSE ER

1

BEN-TANN

1

CERON

1

BIDHIST

1

CHLOR-MES JR

1

BIDHIST-D

1

chlorpheniramine maleate

1

BIOHIST LA

3

BPM

1

chlorpheniramine maleate and methscopolamine nitrate and phenylephrine hydrochloride

1

BPM PSEUDO

1

BRETHINE

3

BROFED

3

chlorpheniramine maleate and methscopolamine nitrate and pseudoephedrine hydrochloride

1

BROMAXEFED RF

1

chlorpheniramine maleate and pseudoephedrine hydrochloride

1

BROMDEC

1

BROMFED

3

chlorpheniramine maleate and pseudoephedrine hydrochloride sr

1

BROMFED PD

3

BROMFENEX

1

chlorpheniramine tannate and phenylephrine tannate

1

BROMFENEX PD

1

CLARINEX 5MG

BROMHIST PEDIATRIC

1

BROMHIST-NR

1

brompheniramine

1

NC = Not covered

Utilization Management

QL/ Day(s)

3

(QL) (PR)

1/1 day(s)

CLARINEX REDITABS

3

(QL) (PR)

1/1 day(s)

CLARINEX SYRUP

3

(QL) (PR)

10/1 day(s)

CLARINEX-D 12 HOUR

3

(QL) (PR)

2/1 day(s)

CLARINEX-D 24 HOUR

3

(QL) (PR)

1/1 day(s)

brompheniramine tannate and phenylephrine tannate

1

clemastine fumarate

1

BRONCAP

3

CODIMAL L.A.

1

BRONCHOLATE

3

COLDAMINE

1

BRONCODUR

3

COLDMIST JR

1

BRONCOMAR-1

3

COLDMIST LA

1

BRONDIL

3

COLDMIST S

1

BROVEX

3

COLFED-A

1

BROVEX CT

3

COMBIVENT

3

BROVEX SR

3

CONEX

3

BROVEX-D

3

CONPEC

3

B-VEX

1

CONPEC LA NR

1

carbinoxamine maleate

1

COPD

1

CARDEC

1

COPHENE #2

1

13

14

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

C-PHED TANNATE

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

1

DILEX-G

1

C-PHEN

1

DILOR

3

CPM 8/PE 20/MSC 1.25

1

DILOR-G

1

CPM 8/PSE 90/MSC 2.5

1

diphenhydramine hydrochloride

1

CRANTEX

1

DIPHENTANN-D

1

CRANTEX ER

1

DONATUSSIN

1

CRANTEX LA

1

DREXOPHED SR

1

CRANTEX LAC

1

DRIHIST SR

1

cromolyn sodium neb solution

1

(PR)

DRIXOMED

1

cyproheptadine hydrochloride

1

(PR)

DRYSEC

1

DALLERGY

3

D-TANN

1

DALLERGY JR

3

DUOMAX

1

D-AMINE-SR

1

DUONATE-12

1

DECON-A

3

DUONEB

3

DECONAMINE SR

3

DUOTAN

1

DECON-E

3

DUOTAN PD

1

DECONEX

3

DURADRYL

1

DECONGEST II

1

DURAFED

1

DECONGESTINE TR

1

DURAHIST

3

DECONSAL CT CHEW

3

DURAHIST D

3

DECONSAL II

3

DURAHIST PE

3

DEHISTINE

1

DURAPHEN II

3

DENAZE

1

DURASAL II

1

DESAL-II

1

DURATUSS

3

DESPEC

1

DURATUSS GP

3

DESPEC SR

3

DYFLEX-G

1

DEXAPHEN SA

1

DY-G

1

dexchlorpheniramine maleate

1

DYLIX

3

D-FEDA II

1

DYNAHIST ER

1

DG 200

1

DYNEX

3

DIFIL G FORTE

1

DYPHYLLINE/GG

1

DIFIL-G

3

DYTAN

3

(PR)

NC = Not covered

Utilization Management

(PR)

(PR)

(PR)

QL/ Day(s)

15

16

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

DYTAN-D

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

3

GENERIC ENTEX LA

1

DYTUSS

1

GENTEX LA

3

ED A-HIST

3

GFN 1200/PHENYLEPHRINE 40

1

ED CHLORPED

3

GFN 1200/PSE 50

1

ED-BRON G

3

GFN 550/PSE 60

3

ED-CHLOR-TAN

3

GFN 595/PSE 48

1

ELIXOPHYLLIN

3

GFN 800/PE 25

1

ELIXOPHYLLIN-GG

3

GFN/PSE

1

ENTEX

3

GILPHEX TR

3

ENTEX ER

3

GP-1200

1

ENTEX LA

3

G-PHED

1

ENTEX PSE

3

G-PHED-PD

1

epinephrine hydrochloride

1

GRIPEX PE PEDIATRIC

1

EUDAL-SR

3

GUAIFED

3

EXEFEN-PD

1

GUAIFED-PD

3

EXETUSS

1

EXTENDRYL

3

guaifenesin and phenylephrine hydrochloride

1

EXTENDRYL JR

3

guaifenesin and pseudoephedrine hydrochloride

1

EXTENDRYL SR

3

guaifenesin nr

1

fexofenadine hydrochloride 180mg

1

(QL) (PR)

1/1 day(s)

guaifenesin tab

1

fexofenadine hydrochloride 30, 60mg

1

(QL) (PR)

1/1 day(s)

GUAIFENEX GP

1

FLONASE

3

GUAIFENEX PSE

1

FLOVENT

2

GUAIMAX-D

1

FLOVENT HFA

2

GUAIMIST S

1

FLOVENT ROTADISK

2

GUAIPHEN-D

1

flunisolide

1

GUAIPHEN-D 1200

1

fluticasone spray

1

GUAIPHEN-PD

1

FORADIL AEROLIZER

2

GUAPETEX

1

G P TEX

1

GUIADEX D

1

G/P

1

GUIADEX PD

1

G/P 1200/60

1

GUIADRINE GP

1

GANDIDIN NR

1

NC = Not covered

Utilization Management

QL/ Day(s)

17

18

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

H 9600 SR

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

3

LIQUIBID-D 1200

3

HCA ALLERGY RELIEF

1

LIQUIBID-PD

3

HEXAFED

3

LODRANE

3

HISTADE MX

1

LODRANE 12 HOUR

3

HISTADE SR

1

LODRANE 12D

3

HISTALET

3

LODRANE 24

3

HISTATAB PH

1

LODRANE D

3

HISTA-VENT DA

1

LODRANE LD

1

HISTA-VENT PSE

1

LODRANE XR

3

HISTEX

3

LOHIST-12

1

HISTEX SR

3

LOHIST-12D

1

INTAL

3

LOHIST-D

1

INTAL 112

2

LOHIST-LQ

1

INTAL 200

2

LOHIST-PD

1

INTAL INHALER

2

LUFYLLIN

3

IOFED

1

LUFYLLIN-GG

3

IOPHEN-NR

1

LUSONEX

3

IOSAL II

1

MAXAIR AUTOHALER

2

IOTEX PSE

1

MAXIFED

3

ipratropium bromide inhalant

1

MAXIFED-G

3

ipratropium bromide spray

1

MAXIPHEN

3

isoproterenol hcl

1

MAXIPHEN-G

3

ISUPREL

3

MEDENT LD

3

JAY-PHYL

1

metaproterenol sulfate neb solution

1

J-MAX

3

metaproterenol sulfate syrup

1

J-TAN

3

metaproterenol sulfate tablets

1

J-TAN D

3

MINDAL

1

KRONOFED-A

1

MINTAB D

1

K-TAN

1

MINTEX

1

LEV/PSE/GG

1

MIRAPHEN PE

1

LEVALL G

3

MIRAPHEN PSE

1

LIQUIBID

1

MONTEPHEN

1

(PR)

(PR)

(PR)

NC = Not covered

Utilization Management

(PR)

QL/ Day(s)

19

20

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered QL/ Day(s)

Drug Name

3-Tier Open

Utilization Management

MUCOMYST-10

3

(PR)

NALEX-CR

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

PHENAVENT D

1

1

PHENAVENT LA

1

NARIZ

3

PHENAVENT PED

1

NASACORT AQ

3

PHENCLOR TANNATE PEDIATRI

1

NASAREL

3

PHENYDEX PEDIATRIC

1

NASATAB LA

3

PHENYDRYL

1

NASEX

1

NASEX-G

1

phenylephrine cm (chlorpheniramine maleate and methscopolamine nitrate and phenylephrine hydrochloride)

1

NASONEX

3

POLY-HISTINE

3

ND-STAT

1

POLY-VENT

3

NESCON-PD

1

POLY-VENT JR.

3

NOHIST

1

PRE-HIST D

1

NOHIST-EXT

1

PROFEN FORTE

3

NOREL SD

1

PROFEN II

3

NUHIST PEDIATRIC

1

PROLASTIN

3

NUMOBID

3

PROLEX D

3

NUMONYL

1

PROLEX PD

3

NY-TANNIC

1

PROMETHAZINE VC

3

OMNIHIST II LA

3

PROSET D

1

OMNIHIST L.A.

1

PRO-TANNATE PEDIATRIC

1

ORGAN-I NR

1

PROVENTIL

3

ORGANIDIN NR

3

PROVENTIL HFA

2

PALGIC

1

PROVENTIL NEB

3

PANFIL-G

3

PSE 15/CPM 2

1

PCM

1

PSE 90/CPM 8/MSC 2.5

1

PCM ALLERGY

1

PSE BPM

1

PCM LA

1

PSE CPM

1

PENDEX

1

PSEUBROM

1

P-EPD TAN/CHLOR-TAN

1

PSEUBROM-PD

1

PHANASIN

3

PSEUDATEX

1

PHENABID

1

PSEUDO CM

1

PHENAVENT

1

PSEUDO GG TR

1

NC = Not covered

Utilization Management

(PR)

QL/ Day(s)

21

22

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

PSEUDO MAX

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

1

RONDEC

3

PSEUDOVENT

1

RONDEX

1

PSEUDOVENT 400

1

R-TANNA

1

PSEUDOVENT PED

1

R-TANNA PEDIATRIC

1

PULMICORT

3

R-TANNA S

1

PULMICORT TURBUHALER

3

RU-TUSS JR.

1

PYRILAFEN TANNATE-12

1

RYNA-12

3

QC ALLERGY RELIEF INTENSE

1

RYNA-12 S

3

QDALL

3

RYNATAN

3

QDALL AR

3

RYNATAN CHEWABLE

3

QUIBRON

3

RYNATAN SUSPENSION

3

QUIBRON-T

3

RYNEZE

1

QUINTEX

1

RY-T-12

1

QV-ALLERGY

1

SEMPREX-D

3

QVAR

3

SEREVENT DISKUS

3

RE TANN D CHEW

3

SILDEC

1

RE2+30

1

SIL-TEX

1

RELERA

1

SIMUC

1

RELURI

1

SINA-12X

3

RESCON-ED

1

SINGULAIR

2

RESCON-JR

3

SINUVENT PE

3

RESCON-MX

3

SITREX

3

RESPA-1ST

3

SLO-BID GYROCAPS

3

RESPAHIST

1

SPIRIVA HANDIHALER

2

RESPAIRE-60

3

STAMOIST E

1

RESPA-PE

3

SUCLOR

1

RHINABID

1

SUDAL 12

3

RHINABID PD

1

SUDATEX

1

RHINOCORT AQUA

3

TANA PSE

1

RICOBID

3

TANA R-12

1

RICOBID NR

3

TANACOF-XR

3

RICOBID-H

3

TANAFED DP

3

(PR)

NC = Not covered

Utilization Management

QL/ Day(s)

(QL) (PR)

4/1 day(s)

(PR)

23

24

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

TANATAN RF

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

1

VENTOLIN HFA

3

TANAVAN

1

VIRAVAN-S

3

TANNATE PEDIATRIC

1

VITA-NUMONYL

3

terbutaline sulfate

1

VITA-NUMONYL EX

3

THEO-24

3

VOSPIRE ER

1

THEOCAP

1

V-TANN B.I.D

1

THEOCHRON

1

WE ALLERGY

1

THEOMAR GG

3

WE MIST II LA

1

theophylline

1

WELLBID-D

1

theophylline cr

1

XEDEC

3

theophylline er

1

XIRAL SR

1

theophylline sr

1

XOLAIR

3

theophylline td

1

XOPENEX

3

TILADE

2

XOPENEX HFA

3

TIME-HIST

1

XPECT-PE

1

TOURO ALLERGY

3

ZEMAIRA

3

TOURO LA

3

ZEPHREX

1

TOURO LA-LD

3

ZEPHREX LA

3

TRACLEER

2

ZOTEX -GP

3

TRI-HISTINE

1

ZOTEX GPX

3

TUSNEL PEDIATRIC

3

ZYFLO

3

TUSSBID

1

ZYMINE

3

TYZINE

3

ZYMINE-D

3

TYZINE PEDIATRIC NASAL DR

3

ZYRTEC

ULTRABROM

1

ULTRABROM PD

(PR)

NC = Not covered

Utilization Management

QL/ Day(s)

(PR)

(QL)

4/1 day(s)

3

(QL) (PR)

1/1 day(s)

ZYRTEC SYRUP

3

(QL) (PR)

10/1 day(s)

1

ZYRTEC-D

3

(QL) (PR)

2/1 day(s)

UNI-HIST

1

ALHEIMER’S / ANTIDEMENTIA DRUGS

UNIPHYL

3

ARICEPT

2

UNI-TEX 120/10 ER

1

ARICEPT ODT

2

VAZOL

3

COGNEX

3

VAZOL-D

3

ERGOLOID MESYLATES

1

VENTOLIN

3

EXELON

2

(PR)

25

26

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

HYDERGINE

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

Drug Name

3-Tier Open

Utilization Management

QL/ Day(s)

3

EFFEXOR 50MG

3

(QL) (ST)

6/1 day(s)

NAMENDA

2

EFFEXOR 75MG

3

(QL) (ST)

5/1 day(s)

NAMENDA TITRATION PAK

2

EFFEXOR XR 150MG

2

(QL) (ST)

2/1 day(s)

RAZADYNE

3

EFFEXOR XR 37.5, 75MG

2

(QL) (ST)

1/1 day(s)

RAZADYNE ER

3

hydroxyzine hydrochloride

1

hydroxyzine pamoate

1

ANISTHETIC DRUGS

(PR)

AMERICAINE

3

HYZINE

1

ANACAINE

3

meprobamate

1

(PR)

ANESTACON

1

paroxetine 10, 20mg

1

(QL)

1/1 day(s)

BUCALCIDE

3

paroxetine 30, 40mg

1

(QL)

2/1 day(s)

EMLA

3

PAXIL 10,20MG

3

(QL) (ST)

1/1 day(s)

EMLA/TEGADERM

3

PAXIL 30, 40MG

3

(QL) (ST)

2/1 day(s)

EXACTACAIN

1

PAXIL CR

3

(QL) (ST)

2/1 day(s)

LIDAMANTLE

3

PAXIL SUSPENSION

3

(QL)

30/1 day(s)

lidocaine and prilocaine

1

lidocaine cream

1

perphenazine and amitriptyline hydrochloride

1

lidocaine hydrochloride jelly

1

PEXEVA 10, 20MG

3

(QL) (ST)

1/1 day(s)

LIDODERM

2

PEXEVA 30,40MG

3

(QL) (ST)

2/1 day(s)

LIDOMAR VISCOUS

1

VANSPAR

3

LIDOSITE

3

venlafaxine 150mg

1

(QL)

3/1 day(s)

ORASEP

3

venlafaxine 25mg

1

(QL)

3/1 day(s)

SENATEC

1

venlafaxine 37.5mg

1

(QL)

4/1 day(s)

SYNERA

3

venlafaxine 50mg

1

(QL)

6/1 day(s)

XYLOCAINE GEL

3

venlafaxine 75mg

1

(QL)

5/1 day(s)

XYLOCAINE INJECTION

3

VISTARIL

3

(PR)

ADOXA

3

(PR)

amikacin sulfate

1

AMIKIN

3

AMOCLAN

1

amoxicillin

1

amoxicillin and clavulanic acid

1

(QL) (PR) (ST)

(QL) (PR) (ST)

25/30 day(s)

1/1 day(s)

ANTIBIOTICS

ANTI-ANXIETY DRUGS ATARAX

3

BUSPAR

3

buspirone hydrochloride

1

DUO-VIL

1

EFFEXOR 25, 100MG

3

(QL) (ST)

3/1 day(s)

EFFEXOR 37.5MG

3

(QL) (ST)

4/1 day(s)

27

28

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

AMOXIL

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

1

cefoxitin

1

ampicillin

1

cefpodoxime proxetil

1

ampicillin sodium and sulbactam sodium

1

cefprozil

1

AUGMENTIN

3

ceftazidime

1

AUGMENTIN ES-600

3

CEFTIN

3

AUGMENTIN XR

3

ceftriaxone sodium

1

AVELOX

2

(PR)

AVELOX ABC PACK

2

(PR)

ceftriaxone sodium and dextrose (anhydrous)

1

AZACTAM

3

cefuroxime sodium

1

AZACTAM IN DEXTROSE

3

cefuroxime sodium and dextrose monohydrate

1

azithromycin

1

CEFZIL

3

BACIIM

1

cephalexin monohydrate

1

BACI-RX

3

cephradine

1

BACITRACIN INJECTION

3

chloramphenicol sodium succinate

1

BACTOCILL IN DEXTROSE

3

CHLOROMYCETIN

3

BACTRIM

3

CIPRO

3

(PR)

BACTRIM DS

3

CIPRO I.V.

3

(PR)

BACTROBAN NASAL

3

CIPRO XR

3

(PR)

BIAXIN

3

ciprofloxacin

1

(PR)

BIAXIN XL

3

CLAFORAN

3

BICILLIN C-R

3

CLAFORAN/D5W

3

BICILLIN L-A

3

clarithromycin

1

CEDAX

3

CLEOCIN

3

cefaclor

1

CLEOCIN SUPPOSITORY

3

cefaclor er

1

clindamycin hydrochloride

1

cefadroxil hemihydrate

1

CLINDESSE

3

cefadroxil monohydrate

1

COLISTIMETHATE SODIUM

1

cefazolin sodium

1

COLY-MYCIN-M

3

CEFAZOLIN SODIUM-DEXTROSE

3

CUBICIN

3

CEFIZOX

3

DECLOMYCIN

3

(PR)

CEFIZOX IN DEXTROSE 5%

3

demeclocycline hydrochloride

1

(PR)

cefotaxime sodium

1

dicloxacillin sodium

1

NC = Not covered

Utilization Management

QL/ Day(s)

29

30

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

DISPERMOX

3

DORYX

3

DOXY-CAPS

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

HUMATIN

3

(PR)

INVANZ

3

1

(PR)

kanamycin sulfate

1

doxycycline hyclate

1

(PR)

KEFLEX

3

doxycycline monohydrate

1

(PR)

KETEK

3

DURICEF

3

LEVAQUIN

3

(PR)

DYNABAC D5-PAK

3

LEVAQUIN PREMIX

3

(PR)

DYNACIN

1

LINCOCIN

3

E.E.S.

1

LORABID

3

E-MYCIN

3

MACROBID

3

ERYC

3

MACRODANTIN

3

ERYPED

3

MANDOL/D5W

3

ERY-TAB

3

MAXIPIME

2

ERYTHROCIN

3

MEFOXIN

3

erythromycin and sulfisoxazole

1

MEFOXIN IN DEXTROSE

3

erythromycin dr

1

MERREM

3

erythromycin ec

1

METRO IV

3

erythromycin ethylsuccinate

1

METROGEL VAGINAL

3

erythromycin lactobionate

1

metronidazole

1

erythromycin stearate

1

MINOCIN

3

(PR)

FACTIVE

3

minocycline hydrochloride

1

(PR)

FLAGYL

3

MONODOX

3

(PR)

FLAGYL ER

3

MONUROL

3

FLOXIN

3

MYRAC

1

FORTAZ

3

nafcillin sodium

1

FORTAZ GALAXY

3

NALLPEN ISO-OSMOTIC IN DE

3

FURADANTIN

3

NALLPEN/DEXTROSE

3

GANTRISIN PEDIATRIC

3

NEBCIN

3

GARAMYCIN

3

NEGGRAM

3

gentamicin sulfate

1

NEO-FRADIN

3

gentamicin sulfate and sodium chloride

1

neomycin sulfate

1

GEOCILLIN

2

nitrofurantoin macrocrystalline

1

(PR)

(PR)

(PR)

NC = Not covered

Utilization Management

(PR)

QL/ Day(s)

31

32

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered QL/ Day(s)

Drug Name

3-Tier Open

Utilization Management

NOROXIN

3

ofloxacin

1

OMNICEF

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

Drug Name

3-Tier Open

(PR)

SMZ-TMP DS

1

(PR)

SOLODYN

3

3

SPECTRACEF

3

OMNI-PAC

3

streptomycin sulfate

1

oxacillin sodium

1

sulfadiazine

1

PANIXINE DISPERDOSE

3

sulfamethoxazole and trimethoprim

1

paromomycin sulfate

1

sulfasalazine dr

1

(QL)

12/1 day(s)

PCE

3

sulfasalazine ec

1

(QL)

12/1 day(s)

PEDIAZOLE

3

SULFATRIM

1

penicillin g potassium

1

sulfisoxazole

1

penicillin g potassium and dextrose (anhydrous)

SUMYCIN

3

1

SUPRAX

3

PENICILLIN G PROCAINE

3

SYNERCID

3

penicillin g sodium

1

TAZICEF

1

penicillin v potassium

1

tetracycline hydrochloride

1

PENICILLIN VK

1

TIMENTIN

3

PERIOSTAT

3

TOBI

3

PFIZERPEN-G

1

tobramycin sulfate

1

PFIZERPEN-G

3

tobramycin sulfate and sodium chloride

1

piperacillin sodium

1

trimethoprim

1

PIPRACIL/D5W

3

TRIMOX

1

polymyxin b sulfate

1

TYGACIL

2

PRIMAXIN I.M.

3

UNASYN

3

PRIMAXIN IV

3

VANCOCIN CAPSULE

2

PRIMSOL

3

VANCOCIN HCL ISO-OSMOTIC

3

PROLOPRIM

3

VANCOCIN INJECTION

3

PROQUIN XR

3

vancomycin hydrochloride

1

RANICLOR

3

VANDAZOLE

1

ROCEPHIN

3

VANTIN

3

ROCEPHIN IN ISO-OSMOTIC D

3

VEETIDS

1

SEPTRA

3

VELOSEF

3

SEPTRA DS

3

VIBRAMYCIN

3

(PR)

(PR)

Utilization Management

QL/ Day(s)

(PR)

(PR)

(PR)

(PR)

(PR)

33

34

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered QL/ Day(s)

Drug Name

3-Tier Open

Utilization Management

VIBRATAB

3

(PR)

XIFAXAN

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

cisplatin

1

3

cladribine

1

ZINACEF

3

CLOLAR

3

ZINACEF/D5W

3

COSMEGEN

3

ZITHROMAX

3

cyclophosphamide

1

ZITHROMAX TRI-PAK

3

cytarabine

1

ZITHROMAX Z-PAK

3

CYTOXAN

3

ZMAX

3

dacarbazine

1

ZOSYN

2

DACOGEN

3

ZYVOX

2

daunorubicin hydrochloride

1

DAUNOXOME

3

(PR)

ANTI-CANCER DRUGS ABRAXANE

3

dexrazoxane

1

ADRIAMYCIN

1

DOXIL

3

ADRUCIL

1

doxorubicin hydrochloride

1

ALIMTA

3

DROXIA

3

ALKERAN INJECTION

2

(PR)

DTIC-DOME

3

ALKERAN TABLETS

2

(PR)

ELITEK

2

ARIMIDEX

3

ELLENCE

3

AROMASIN

3

ELOXATIN

3

ARRANON

3

ELSPAR

3

AVASTIN

3

EMCYT

2

BEXXAR

3

ERBITUX

3

BEXXAR 131 IODINE

3

ETHYOL

3

BICNU

3

ETOPOPHOS

3

BLENOXANE

3

etoposide

1

bleomycin sulfate

1

FARESTON

3

BUSULFEX

3

FASLODEX

3

CAMPATH

3

FEMARA

2

CAMPTOSAR

3

FLUDARA

3

carboplatin

1

FLUDARABINE PHOSPHATE

1

CEENU

3

fluorouracil injection

1

CERUBIDINE

3

GEMZAR

3

(PR)

NC = Not covered

Utilization Management

(PR)

(PR)

(PR)

QL/ Day(s)

35

36

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

GLEEVEC

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

2

MYLOTARG

3

HERCEPTIN

3

NAVELBINE

3

HEXALEN

3

NEXAVAR

3

HYCAMTIN

3

NIPENT

3

HYDREA

3

(PR)

NOVANTRONE

3

hydroxyurea

1

(PR)

ONCASPAR

3

IDAMYCIN PFS

3

ONTAK

3

IDARUBICIN

1

ONXOL

1

IFEX

3

PACLITAXEL

1

IFEX/MESNEX

3

PARAPLATIN

3

IFEX/MESNEX COMBO PACK

3

PHOTOFRIN

3

ifosfamide

1

PLATINOL AQ

3

IFOSFAMIDE/MESNA

1

PROLEUKIN

3

IRESSA

3

PURINETHOL

3

KEPIVANCE

3

QUADRAMET

3

leucovorin calcium injection

1

RITUXAN

3

leucovorin calcium tablets

1

SOLTAMOX

3

LEUKERAN

3

SPRYCEL

2

MATULANE

3

SUTENT

3

MEGACE ES

3

TABLOID

3

MEGACE ORAL

3

tamoxifen citrate

1

megestrol acetate

1

TARCEVA

2

mercaptopurine

1

TARGRETIN CAPSULES

2

mesna

1

TAXOTERE

3

MESNEX

3

TESLAC

3

(PR)

methotrexate sodium

1

THERACYS

2

(PR)

methotrexate sodium 2.5mg

1

thiotepa

1

mitomycin

1

TICE BCG

2

mitomycin c

1

TOPOSAR

1

mitoxantrone hydrochloride

1

TRELSTAR DEPOT

3

(PR)

MUSTARGEN

3

TRELSTAR LA

3

(PR)

MUTAMYCIN

3

TREXALL

3

(PR)

(PR)

(PR)

(PR)

NC = Not covered

Utilization Management

(PR)

(PR)

(PR)

(PR)

(PR)

QL/ Day(s)

37

38

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

TRISENOX

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

Drug Name

3-Tier Open

3

clomipramine hcl

1

trolamine (triethanolamine)

1

CYMBALTA

2

UVADEX

3

desipramine hydrochloride

1

VECTIBIX

3

DESYREL

3

(ST)

VELCADE

3

EMSAM

3

(QL) (PR) (ST)

1/1 day(s)

VESANOID

2

fluoxetine hcl 10mg

1

(QL)

1/1 day(s)

VIDAZA

3

fluoxetine hcl 20mg

1

(QL)

4/1 day(s)

vinblastine sulfate

1

fluoxetine hcl 40mg

1

(QL)

2/1 day(s)

VINCASAR PFS

1

fluoxetine hcl solution

1

(QL)

10/1 day(s)

vincristine sulfate

1

fluvoxamine maleate

1

(QL)

3/1 day(s)

vinorelbine tartrate

1

imipramine hydrochloride

1

VUMON

3

LEXAPRO

3

(QL) (ST)

1/1 day(s)

ZANOSAR

3

LEXAPRO SOLUTION

3

(QL) (ST)

20/1 day(s)

ZEVALIN IN-111

3

LIMBITROL

3

ZINECARD

3

LIMBITROL DS

3

ZOLINZA

3

maprotiline hydrochloride 25mg

1

(QL)

1/1 day(s)

maprotiline hydrochloride 50mg

1

(QL)

2/1 day(s)

(QL)

3/1 day(s)

(QL) (PR)

4/1 day(s)

ANTIDEPRESSANT DRUGS

Utilization Management

QL/ Day(s)

(QL) (ST)

2/1 day(s)

amitriptyline

1

maprotiline hydrochloride 75mg

1

amitriptyline and chlordiazepoxide

1

MARPLAN

3

amoxapine

1

mirtazapine

1

(QL)

1/1 day(s)

ANAFRANIL

3

mirtazapine orally disenegrating tablet

1

(QL)

1/1 day(s)

AVENTYL

3

NARDIL

2

BUDEPRION

1

(QL)

2/1 day(s)

nefazodone hydrochloride

1

bupropion hcl 75, 100mg

1

(QL)

6/1 day(s)

NORPRAMIN

3

bupropion hcl er 100, 150mg

1

(QL)

2/1 day(s)

nortriptyline hydrochloride

1

bupropion hcl sr 150, 200mg

1

(QL)

2/1 day(s)

PAMELOR

3

CELEXA 10, 20, 40MG

3

(QL) (ST)

1/1 day(s)

PARNATE

3

CELEXA SOLUTION

3

(ST)

protriptylin

1

PROZAC 10MG

3

(QL) (ST)

1/1 day(s)

PROZAC 20MG

3

(QL) (ST)

4/1 day(s)

PROZAC 40MG

3

(QL) (ST)

2/1 day(s)

PROZAC SOLUTION

3

(QL) (ST)

10/1 day(s)

chlordiazepoxide and amitriptyline hydrochloride

1

citalopram hydrobromide 10, 20, 40mg

1

citalopram hydrobromide solution

1

(QL)

1/1 day(s)

(ST)

39

40

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

Utilization Management

QL/ Day(s)

Drug Name

3-Tier Open

PROZAC WEEKLY

3

(QL) (ST)

4/28 day(s)

BIO-STATIN

3

RAPIFLUX

3

(QL) (ST)

4/1 day(s)

CANCIDAS

3

REMERON

3

(QL) (ST)

1/1 day(s)

clotrimazole

1

REMERON SOLTAB

3

(QL) (ST)

1/1 day(s)

clotrimazole lozenge

1

RISPERDAL M-TAB 0.5, 1, 2, 3MG

2

(QL)

2/1 day(s)

clotrimazole troche

1

SARAFEM 10MG

3

(QL)

1/1 day(s)

DIFLUCAN

3

(PR)

SARAFEM 20MG

3

(QL)

4/1 day(s)

DIFLUCAN 150MG

3

(QL)

sertraline hcl 100mg

1

(QL)

2/1 day(s)

DIFLUCAN IN ISO-OSMOTIC D

3

(PR)

sertraline hcl 25mg

1

(QL)

1/1 day(s)

DIFLUCAN IN NACL

3

(PR)

sertraline hcl 50mg

1

(QL)

1.5/1 day(s)

EQ MICONAZOLE 3 COMBO PAC

1

sertraline hcl oral conc

1

(QL)

10/1 day(s)

EQ TIOCONAZOLE 1

1

SURMONTIL

3

ERAXIS

3

(PR)

TOFRANIL

3

fluconazole

1

(PR)

TOFRANIL-PM

3

fluconazole 150mg

1

(QL)

tranylcypromine sulfate

1

fluconazole and sodium chloride

1

(PR)

trazodone hydrochloride

1

FUNGIZONE

3

trimipramine maleate

1

GRIFULVIN-V

3

VIVACTIL

3

GRISEOFULVIN MICROSIZE

1

WELLBUTRIN 75, 100MG

3

(QL) (ST)

6/1 day(s)

GRISEOFULVIN ULTRAMICROSI

1

WELLBUTRIN SR 100, 150, 200MG

3

(QL) (ST)

2/1 day(s)

GRIS-PEG

3

WELLBUTRIN XL 150, 300MG

2

(QL) (ST)

1/1 day(s)

GYNAZOLE-1

3

ZOLOFT 100MG

3

(QL) (ST)

2/1 day(s)

itraconazole

1

ZOLOFT 25MG

3

(QL) (ST)

1/1 day(s)

ketoconazole

1

ZOLOFT 50MG

3

(QL) (ST)

1.5/1 day(s)

LAMISIL

2

ZOLOFT SOLUTION

3

(QL) (ST)

10/1 day(s)

MICONAZOLE 3

1

MONISTAT 3

3

ANTIFUNGUL DRUGS ABELCET

3

MONISTAT 7 COMBINATION PA

3

AMBISOME

3

MYCAMINE

2

AMPHOCIN

1

MYCELEX

3

AMPHOTEC

3

MYCOSTATIN SUSPENSION

3

amphotericin b

1

NEBUPENT

3

ANCOBON

3

NIZORAL

3

NC = Not covered

Utilization Management

(PR)

(PR)

(PR)

(PR)

QL/ Day(s)

1/30 day(s)

1/30 day(s)

41

42

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered QL/ Day(s)

Drug Name

3-Tier Open

Utilization Management

NOXAFIL SUSPENSION

3

(PR)

nystatin

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

Drug Name

3-Tier Open

Utilization Management

QL/ Day(s)

CELEBREX 200MG

3

(QL) (PR)

1/1 day(s)

1

choline magnesium trisalicylate

1

nystatin oral powder

1

CLINORIL

3

nystatin suspension

1

CMT

1

PENLAC NAIL LACQUER

3

CUPRIMINE

3

PENTAM 300

3

DAYPRO

3

pentamidine isethionate

1

DECADRON

3

RA CLOTRIMAZOLE 3

1

DELTASONE

1

SB MICONAZOLE 3-DAY COMBO

1

DEPEN TITRATABS

3

SPORANOX

3

(PR)

DEPO-MEDROL

3

SPORANOX INJECTION

3

(PR)

dexamethasone injection

1

SPORANOX PULSEPAK

3

(PR)

dexamethasone solution

3

SPORANOX SOLUTION

3

(PR)

dexamethasone tablets

1

TERAZOL 3

3

DEXPAK

3

TERAZOL 7

3

diclofenac potassium

1

terconazole

1

diclofenac sodium dr

1

VAGISTAT-1

3

diclofenac sodium ec

1

VAGISTAT-3

1

diclofenac sodium er

1

VFEND

3

(PR)

diclofenac sodium sr

1

VFEND IV

3

(PR)

diclofenac sodium xr

1

ZAZOLE

1

diflunisal

1

DOLOBID

3

(PR)

A N T I - I N F L A M M AT O RY D R U G S AEROBID

3

EC-NAPROSYN

3

AEROBID-M

3

ENTOCORT EC

3

AMIGESIC

1

etodolac

1

ANAPROX

3

etodolac er

1

ANAPROX DS

3

FELDENE

3

ANSAID

3

fenoprofen calcium

1

ARTHROTEC

3

flurbiprofen

1

C.M.T

1

IBU

1

CATAFLAM

3

ibuprofen

1

CELEBREX 100, 400MG

3

INDOCIN

3

(QL) (PR)

2/1 day(s)

(PR)

(PR)

(PR)

43

44

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered QL/ Day(s)

Drug Name

3-Tier Open

Utilization Management

INDOCIN IV

3

INDOCIN SR

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

(PR)

ORAPRED ODT

3

3

(PR)

ORUDIS

3

indomethacin

1

(PR)

ORUVAIL

3

indomethacin cr

1

(PR)

oxaprozin

1

indomethacin er

1

(PR)

PEDIAPRED

3

indomethacin sa

1

(PR)

piroxicam

1

indomethacin sr

1

(PR)

PONSTEL

3

ketoprofen

1

prednisolone acetate

1

ketorolac tromethamine injection

1

(PR)

prednisolone anhydrous syrup

1

ketorolac tromethamine tablets

1

(QL) (PR)

prednisolone sodium phosphate

1

KEY-PRED

3

prednisone

1

MAGAN

3

PREDNISONE INTENSOL

3

meclofenamate sodium

1

PRELONE

3

MEDROL

3

PREVACID NAPRAPAC

3

MEDROL DOSEPAK

1

RELAFEN

3

meloxicam

1

RUFEN

1

methylprednisolone

1

SALFLEX

1

methylprednisolone acetate

1

salsalate

1

methylprednisolone sodium succinate

1

SOLU-CORTEF

3

MOBIC

3

SOLU-MEDROL

3

MOTRIN

3

SOLUREX LA

3

MST 600

1

STERAPRED

3

nabumetone

1

sulindac

1

NALFON

3

TOLECTIN DS

3

NAPRELAN

3

tolmetin sodium

1

NAPROSYN

3

TORADOL ORAL

3

naproxen

1

TRICOSAL

1

naproxen dr

1

TRILISATE

3

naproxen ec

1

VOLTAREN

3

naproxen er

1

VOLTAREN-XR

3

NOVASAL

3

ZORPRIN

3

ORAPRED

3

(PR)

(ST)

(ST)

20/30 day(s)

NC = Not covered

Utilization Management

45

QL/ Day(s)

(PR)

(PR)

(PR)

(QL)

20/30 day(s)

46

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

ANTIPSYCHOTIC / BIPOLAR DRUGS

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

ORAP

3

NC = Not covered

Utilization Management

QL/ Day(s)

ABILIFY

3

(QL) (ST)

1/1 day(s)

perphenazine

1

ABILIFY DISCMELT

3

(QL) (ST)

2/1 day(s)

RISPERDAL 0.25, 0.5, 1, 2, 3MG

2

(QL)

2/1 day(s)

ABILIFY SOLUTION

3

(QL) (ST)

30/1 day(s)

RISPERDAL 4MG

2

(QL)

4/1 day(s)

chlorpromazine hydrochloride

1

RISPERDAL INJECTION

3

clozapine 100mg

1

(QL)

9/1 day(s)

RISPERDAL M-TAB 4MG

2

(QL)

4/1 day(s)

clozapine 12.5mg

1

(QL)

2/1 day(s)

RISPERDAL SOLUTION

2

clozapine 200mg

1

(QL)

4/1 day(s)

SEROQUEL 200MG

2

(QL)

4/1 day(s)

clozapine 25, 50mg

1

(QL)

3/1 day(s)

SEROQUEL 25MG

2

(QL)

6/1 day(s)

CLOZARIL 100MG

3

(QL)

9/1 day(s)

SEROQUEL 300, 400MG

2

(QL)

2/1 day(s)

CLOZARIL 25MG

3

(QL)

3/1 day(s)

SEROQUEL 50, 100MG

2

(QL)

3/1 day(s)

EQUETRO

3

SYMBYAX

3

(QL)

1/1 day(s)

ESKALITH

3

thioridazine hydrochloride

1

(PR)

ESKALITH CR

3

thiothixene

1

FAZACLO

3

trifluoperazine hydrochloride

1

fluphenazine decanoate

1

VESPRIN

3

fluphenazine hydrochloride

1

ZYPREXA

2

GEODON

3

ZYPREXA 2.5MG

2

(QL)

2/1 day(s)

GEODON INJECTION

2

ZYPREXA 5, 7.5, 10, 15, 20MG

2

(QL)

1/1 day(s)

HALDOL

3

ZYPREXA ZYDIS

2

(QL)

1/1 day(s)

HALDOL DECANOATE-100

3

AT T E N T I O N D E F I C I T D I S O R D E R / N A R C O L E P S Y D R U G S

haloperidol

1

ADDERALL 20MG

3

(QL) (ST)

3/1 day(s)

haloperidol decanoate

1

ADDERALL 5, 7.5, 10, 12.5, 15, 30MG

3

(QL) (ST)

2/1 day(s)

haloperidol lactate

1

ADDERALL XR

3

(QL) (ST)

2/1 day(s)

lithium carbonate

1

lithium carbonate er

1

AMPHETAMINE SALT COMBO 5, 7.5, 10, 12.5, 15, 30MG

1

(QL) (PR)

2/1 day(s)

lithium citrate

1

AMPHETAMINE SALTS COMBO 20MG

1

(QL) (PR)

3/1 day(s)

LITHOBID

3

CONCERTA 18MG

3

(QL) (ST)

3/1 day(s)

loxapine succinate

1

CONCERTA 27, 36, 54MG

3

(QL) (ST)

2/1 day(s)

LOXITANE

3

DAYTRANA

3

(QL) (ST)

1/1 day(s)

MOBAN

3

DESOXYN

3

(QL) (PR) (ST)

4/1 day(s)

NAVANE

3

DEXEDRINE 10MG

3

(QL) (PR)

3/1 day(s)

(QL)

(QL) (ST)

9/1 day(s)

2/1 day(s)

47

48

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

Utilization Management

QL/ Day(s)

Drug Name

3-Tier Open

DEXEDRINE 5MG

3

(QL) (PR)

4/1 day(s)

cilostazol

1

DEXEDRINE CR 5, 15MG

3

(QL) (PR)

3/1 day(s)

COUMADIN

3

dextroamphetamine sulfate

1

(QL) (PR)

4/1 day(s)

CYKLOKAPRON

3

dextroamphetamine sulfate cr

1

(QL) (PR)

3/1 day(s)

DEXTROSTAT

1

(QL) (PR)

4/1 day(s)

dextrose (anhydrous) and heparin sodium (porcine)

1

FOCALIN

3

(QL) (ST)

2/1 day(s)

dipyridamole

1

FOCALIN XR

3

(QL) (ST)

1/1 day(s)

EPOGEN

3

METADATE CD 10, 20, 30MG

3

(QL) (ST)

1/1 day(s)

FRAGMIN

3

METADATE ER 10MG

3

(QL) (ST)

3/1 day(s)

HEPARIN SODIUM

1

METADATE ER 20MG

1

(QL)

3/1 day(s)

heparin sodium (porcine)

1

methamphetamine hydrochloride

1

(QL) (PR)

4/1 day(s)

heparin sodium (porcine) and sodium chloride

1

METHYLIN

1

(QL)

3/1 day(s)

INNOHEP

3

METHYLIN CHEWABLE

3

(QL) (ST)

6/1 day(s)

JANTOVEN

1

METHYLIN 10MG/5ML SOLUTION

3

(QL) (ST)

30/1 day(s)

LEUKINE

3

METHYLIN 5MG/5ML SOLUTION

3

(QL) (ST)

60/1 day(s)

LOVENOX

2

METHYLIN CHEWS

3

(QL) (ST)

6/1 day(s)

NEULASTA

3

METHYLIN ER

1

(QL)

3/1 day(s)

NEUMEGA

3

methylphenidate hydrochloride

1

(QL)

3/1 day(s)

NEUPOGEN

3

methylphenidate hydrochloride er

1

(QL)

3/1 day(s)

PENTOPAK

1

methylphenidate hydrochloride sr

1

(QL)

3/1 day(s)

pentoxifylline cr

1

PROVIGIL

3

(QL) (PR)

2/1 day(s)

pentoxifylline er

1

RITALIN

3

(QL) (ST)

3/1 day(s)

PENTOXIL

1

RITALIN LA

3

(QL) (ST)

2/1 day(s)

PERSANTINE

3

RITALIN SR

3

(QL) (ST)

3/1 day(s)

PLAVIX

3

STRATTERA

3

(QL) (ST)

2/1 day(s)

PLETAL

3

XYREM

3

(PR)

PROCRIT

2

(PR)

TICLID

3

(PR) (PR)

BLOOD PRODUCTS AGGRENOX

2

ticlopidine hydrochloride

1

AGRYLIN

3

TRENTAL

3

anagrelide

1

warfarin sodium

1

ARANESP

2, 3

XIGRIS

3

ARIXTRA

3

(PR)

NC = Not covered

Utilization Management

(PR)

(PR)

QL/ Day(s)

49

50

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

BOWEL DISEASE DRUGS (PR) (ST)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

Drug Name

3-Tier Open

Utilization Management

QL/ Day(s)

DIPENTUM

3

(QL)

12/1 day(s)

DIPHENATOL

1

AMITIZA

3

ANALPRAM-HC

3

GASTROCROM

2

ANAMANTLE HC

3

GLYCOLAX

1

ANASPAZ

3

GOLYTELY

3

ANUSOL-HC

3

HALFLYTELY BOWEL PREP KIT

3

ASACOL

3

(QL)

HEMORRHOIDAL-HC

1

A-SPAS

1

(PR)

hydrocortisone enema

1

ATREZA

1

(PR)

LIDAZONE HC

1

atropine sulfate and diphenoxylate hydrochloride

LOFENE

1

1

LOMOTIL

3

atropine sulfate injection

1

(PR)

LONOX

1

AZULFIDINE

3

(QL)

12/1 day(s)

loperamide hydrochloride

1

AZULFIDINE EN-TABS

3

(QL)

12/1 day(s)

mesalamine (5-asa)

1

B & O 15-A SUPPRETTE

3

(PR)

MIRALAX

3

B & O 16-A SUPPRETTE

3

(PR)

MOTOFEN

3

belladonna

1

(PR)

MOVIPREP

3

BELLADONNA ALKALOIDS & OP

1

(PR)

NULYTELY

3

belladonna extract and opium

1

(PR)

opium tincture

1

CANASA 1000MG

2

(QL)

2/1 day(s)

OSMOPREP

3

CANASA 500MG

2

(QL)

3/1 day(s)

paregoric

1

CANTIL

3

PEG 3350/ELECTROLYTES

1

cascara sagrada

1

PENTASA 250MG

3

(QL)

20/1 day(s)

COLAZAL

2

(QL)

PENTASA 500MG

3

(QL)

10/1 day(s)

COLIDROPS

1

(PR)

polyethylene glycol

1

COLOCORT

1

PROCTOCARE-HC

1

COLYTE

3

PROCTOCREAM-HC 1%

3

COLYTROL

3

PROCTOCREAM-HC 2.5%

1

COLYTROL PEDIATRIC

3

PROCTOFOAM HC

3

CORTIFOAM

3

PROCTO-KIT

1

CYSTOSPAZ-M

3

PROCTOSOL HC 2.5%

1

DI-ATRO

1

PROCTOZONE-HC 2.5%

1

(PR)

(PR)

(PR)

12/1 day(s)

9/1 day(s)

51

52

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

RECTAGEL HC

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

3

AVANDIA

2

ROWASA

3

insulin pen needle

3

simethicone

1

syringe w-ndl, disp., insulin

3

sulfasalazine

1

(QL)

12/1 day(s)

B-D INSLUIN PEN NEEDLE

2

sulfasalazine ec

1

(QL)

12/1 day(s)

B-D SYRINGE W-NEEDLE, INSULIN

2

TRILYTE

1

BYETTA

VISICOL

3

D E N TA L A N D D R U G S F O R T H E M O U T H

NC = Not covered

Utilization Management

QL/ Day(s)

2

(QL)

1/30 day(s)

chlorpropamide

1

(PR)

DIABETA

3

APHTHASOL

3

DIABINESE

3

ARESTIN

3

DUETACT

3

ATRIDOX

3

EXUBERA KIT

3

(QL) (PR)

CAPHOSOL

3

EXUBERA COMBINATION PACK

3

(PR)

CAVAREST

1

FORTAMET

3

(ST)

chlorhexidine gluconate

1

gauze pads & dressings - pads 2" x 2"

1

DEBACTEROL

3

glimepiride

1

EVOXAC

3

glipizide

1

KENALOG IN ORABASE

3

glipizide and metformin hydrochloride

1

PERIDEX

3

glipizide er

1

PERIOGARD

1

glipizide xl

1

PERISOL

1

GLUCAGON EMERGENCY KIT

2

pilocarpine hydrochloride

1

GLUCOPHAGE

3

(ST)

SALAGEN

3

GLUCOPHAGE XR

3

(ST)

triamcinolone acetonide dental paste

1

GLUCOTROL

3

GLUCOTROL XL

3

DIABETES DRUGS ACTOPLUS MET

2

GLUCOVANCE

3

ACTOS

2

GLUMETZA

3

ALCOHOL SWABS

1

glyburide

1

AMARYL

3

glyburide and metformin hydrochloride

1

APIDRA

2

glyburide micronized

1

APIDRA OPTICLIK

2

GLYCRON

1

AVANDAMET

2

GLYNASE

3

AVANDARYL

2

GLYSET

2

53

(PR)

1/365 day(s)

54

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

HUMALOG

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

2

NOVOLOG PENFILL

2

HUMALOG MIX 50/50 PEN

2

PRANDIN

2

HUMALOG MIX 75/25 PEN

2

PRECOSE

3

HUMALOG PEN

2

PROGLYCEM

2

HUMULIN 50/50

2

RELION 70/30

3

HUMULIN 70/30 PEN

2

RELION 70/30 INNOLET

3

HUMULIN N

2

RELION N

3

HUMULIN R

2

RELION N INNOLET

3

ILETIN II LENTE/PORK

3

RELION R

3

JANUVIA

3

RIOMET

3

LANTUS

3

STARLIX

2

LANTUS OPTICLIK

3

SYMLIN

2

LEVEMIR

2

tolazamide

1

LEVEMIR FLEXPEN

2

tolbutamide

1

METAGLIP

3

TOLINASE

3

metformin hydrochloride

1

DRUGS FOR SKIN CONDITIONS

metformin hydrochloride er

1

50% UREA NAIL STICK

1

MICRONASE

3

8-MOP

3

NOVOLIN 70/30

2

ACCUTANE

3

NOVOLIN 70/30 INNOLET

2

ACCUZYME

3

NOVOLIN 70/30 PENFILL

2

ACLOVATE

3

NOVOLIN N

2

ACNE MEDICATION-5

1

NOVOLIN N INNOLET

2

AKNE-MYCIN

3

NOVOLIN N U-100 PENFILL

2

ALA-CORT

1

NOVOLIN R

2

ALA-SCALP

3

NOVOLIN R INNOLET

2

alclometasone

1

NOVOLIN R U-100 PENFILL

2

ALDARA

2

NOVOLOG

2

ALLANFIL 405

1

NOVOLOG FLEXPEN

2

ALLANFIL SPRAY

1

NOVOLOG MIX 70/30

2

ALLANZYME OINTMENT

1

NOVOLOG MIX 70/30 PENFILL

2

ALLANZYME SPRAY

1

NOVOLOG MIX 70/30 PREFILL

2

ALPHATREX

1

(QL) (ST)

1/1 day(s)

NC = Not covered

55

Utilization Management

QL/ Day(s)

(QL)

20/30 day(s)

(PR)

56

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

amcinonide

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

1

benzoyl peroxide and urea (carbamide)

1

AMEVIVE

3

BENZOYL PEROXIDE WASH

1

AMMONIUM LACTATE

1

betamethasone dipropionate

1

AMNESTEEM

1

anthralin

1

betamethasone dipropionate and clotrimazole

1

APEXICON

1

betamethasone valerate

1

APEXICON E

1

BETA-VAL

1

ARISTOCORT

3

BINORA CREAMY WASH

3

ARISTOCORT A

3

BREVOXYL

3

augmented betamethasone dipropionate

1

BREVOXYL CREAMY WASH

3

AVAR

3

BUCALSEP

3

AVAR CLEANSER

1

CAPEX

3

AVAR GREEN

3

CAPITROL

3

AVAR-E EMOLLIENT

1

CARAC

3

AVAR-E GREEN

1

CARMOL 40

1

AVITA

1

CARMOL SCALP TREATMENT

3

AZELEX

3

CARMOL-HC

3

BACTROBAN

3

CENTANY

1

BENSAL HP

3

CEROVEL

1

BENZAC AC

3

CETACORT

1

BENZAC AC WASH

3

chlorophyllin copper and papain and urea (carbamide)

1

BENZAC W

3

ciclopirox olamine

1

BENZAC W WASH

3

CLARAVIS

1

BENZACLIN

3

CLEARPLEX X

1

BENZAGEL

3

CLENIA

1

BENZAGEL WASH

1

CLENIA FOAMING WASH

1

BENZAMYCIN

3

CLEOCIN-T

3

BENZASHAVE

1

CLINAC BPO

3

BENZIQ

3

CLINDAGEL

3

BENZIQ LS

3

CLINDAMAX

1

BENZIQ WASH

3

clindamycin phosphate

1

benzoyl peroxide

1

(PR)

(PR)

NC = Not covered

Utilization Management

(PR)

QL/ Day(s)

57

58

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

CLINDETS

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

1

econazole nitrate

1

clobetasol propionate

1

EFUDEX

3

CLOBEVATE

1

EFUDEX OCCLUSION PACK

3

CLOBEX

3

ELIDEL

3

CLODERM

3

ELOCON

3

clotrimazole solution

1

EMBELINE

1

CONDYLOX

3

EMBELINE E

1

CORDRAN

3

EMCIN CLEAR

1

CORDRAN SP

3

EPIFOAM

3

CORDRAN TAPE

3

ERTACZO

3

CORMAX

1

ERYDERM

1

CORTANE-B LOTION

3

ERYGEL

3

CORTISPORIN CREAM/OINTMENT

3

erythromycin

1

CUTIVATE

3

erythromycin and benzoyl peroxide

1

CYCLOCORT

3

ETHEXDERM BPW-10

1

DEL-AQUA

1

ETHEZYME

3

DEL-BETA

1

EVOCLIN

3

DERMA-SMOOTHE/FS SCALP OI

3

EXELDERM

3

DERMATOP

3

FINACEA

3

desonide

1

FIRST-HYDROCORTISONE

3

DESOWEN

3

fluocinolone acetonide

1

desoximetasone

1

fluocinonide

1

DESQUAM-E

3

FLUOCINONIDE-E

1

DESQUAM-X

3

FLUOROPLEX

3

DIFFERIN

3

fluorouracil solution

1

diflorasone diacetate

1

fluticasone cream/ointment

1

DIPROLENE

3

gentamicin sulfate cream/ointment

1

DIPROLENE AF

3

GERI-HYDROLAC

1

DOVONEX

3

GLADASE

1

doxepin hydrochloride

1

GLADASE-C

1

DRITHO-SCALP

3

GORDON'S UREA

3

DUAC

3

halobetasol propionate

1

NC = Not covered

Utilization Management

QL/ Day(s)

59

60

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

HALOG

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

3

LIDAMANTLE HC

3

HC PRAMOXINE

1

LIDEX

3

hydrocortisone

1

LIDEX-E

3

hydrocortisone butyrate

1

LOCOID

1

hydrocortisone butyrate solution

1

LOCOID LIPOCREAM

3

hydrocortisone cream

1

LOKARA

1

hydrocortisone valerate

1

LOPROX

3

HYPERCARE

1

LOPROX SHAMPOO

3

HYTONE

3

LOTRISONE

3

isotretinoin

1

LUXIQ

3

ISOVATE

1

MAXIFLOR

3

KENALOG

3

MENTAX

3

KERALAC

3

METROCREAM

3

KERALAC NAILSTIK

3

METROGEL

3

KERALYT

3

METROLOTION

3

KERATOL 40

1

metronidazole lotion

1

KERATOL HC

1

MEXAR WASH

1

KEROL REDI-CLOTHS

3

mometasone furoate

1

ketoconazole cream

1

MONISTAT-DERM

3

KLARON

3

mupirocin

1

KOVIA

1

MYCOSTATIN CREAM

3

KURIC

1

MYTREX

1

LACCREAM

1

NAFTIN

3

LAC-HYDRIN

3

NAFTIN-MP

3

LACLOTION

1

NEOBENZ MICRO

3

LACTIC ACID

1

NIZORAL SHAMPOO

3

LACTIC ACID E

1

NORITATE

3

LACTICARE-HC

1

NUOX

3

LACTINOL

3

NUTRACORT

1

LACTREX

1

NYAMYC

1

LAMISIL SPRAY

3

nystatin and triamcinolone acetonide

1

LEVULAN KERASTICK

3

nystatin cream

1

(PR)

(ST)

(PR)

NC = Not covered

Utilization Management

QL/ Day(s)

61

62

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

NYSTOP

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

1

PROTOPIC

3

OLUX

3

PRUDOXIN

1

ORACEA

3

PSORCON E

3

OSCION CLEANSER

1

PSORIATEC

3

OVACE

3

RAPTIVA

3

OVACE WASH

3

RE 10 WASH

1

OXISTAT

3

RE 40

1

OXSORALEN ULTRA

2

RE SA CREAM

1

PANAFIL

3

REGRANEX

3

PANDEL

3

RETIN-A

3

(PR)

PANOXYL

1

RETIN-A MICRO

3

(PR)

PANOXYL AQ

1

RINGER’S IRRIGATION

1

PANRETIN

3

ROSAC

3

PAP-UREA

1

ROSADERM

1

PEDI-DRI

1

ROSANIL CLEANSER

1

PHYSIOLYTE

1

ROSULA

3

ROSULA NS

3

ROZEX

3

(QL) (PR)

1/1 day(s)

physiosol irrigation (magnesium chloride and potassium chloride and sodium acetate and sodium chloride and sodium gluconate)

1

SALEX

3

PLEXION CLEANSER

3

SALEX SHAMPOO

3

PLEXION CLEANSING CLOTH

3

SANTYL

2

PLEXION SCT

3

SB CLOTRIMAZOLE FOOT

1

PLEXION TS

3

SCALP TREATMENT

1

PODOCON 25 IN BENZOIN TIN

1

SEBA-GEL

1

PODODERM

1

SEB-PREV

1

podofilox

1

selenium sulfide

1

PRASCION

1

SELENIUM SULFIDE

1

PRASCION AV CLEANSER

1

SELSEB

3

PRASCION PADS

1

SELSUN SHAMPOO

3

PRASCION RA WITH SUNSCREE

1

SENATEC HC

1

PROCTOCORT

3

SILVADENE

3

PROCTO-PAK

1

silver nitrate

1

NC = Not covered

Utilization Management

QL/ Day(s)

63

64

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

silver nitrate-potassium nitrate applicator

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

1

TRIAZ CLEANSER

3

silver sulfadiazine

1

TRIDERM

1

SOLARAZE

2

TRIDESILON

3

SORIATANE

3

TRIPLE ANTIBIOTIC

1

SOTRET 10, 20, 40MG

1

(PR)

U-CORT

1

SOTRET 30MG

3

(PR)

U-KERA E

1

SPECTAZOLE

3

ULTRALYTIC 2

3

SSD

1

ULTRAVATE

3

SSD AF

1

UMECTA

3

sulfacetamide sodium and sulfur

1

UMECTA NAIL FILM

3

sulfacetamide sodium and urea (carbamide)

1

urea carbamide

1

SULFACET-R

3

urea nail gel

1

SULFAMYLON

3

UREA-C40

1

SULFATOL

1

UREALAC

1

SULFATOL CLEANSER

1

UREALAC NAIL GEL

1

SULFOXYL REGULAR

3

VANAMIDE

1

SUPHERA

1

VANOS

3

SYNALAR

3

VANOXIDE-HC

3

TACLONEX

3

VERDESO

3

TARGRETIN GEL

2

VERSICLEAR

1

TAZORAC

2

WESTCORT

3

TEMOVATE

3

XERAC AC

3

TEMOVATE E

3

XOLEGEL

3

TEXACORT

1

X-VIATE

1

THERMAZENE

1

ZACLIR CLEANSING

3

TIS-U-SOL

1

Z-CLINZ 10

3

TOPICORT

3

ZETACET

1

TOPICORT LP

3

ZIOX

1

tretinoin

1

ZODERM

3

triamcinolone acetonide

1

ZODERM CLEANSER

3

triamcinolone acetonide and nystatin

1

ZONALON

3

TRIAZ

3

(ST)

(PR)

NC = Not covered

Utilization Management

QL/ Day(s)

65

66

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits Drug Name

ST = Step therapy PR = Precertification

3-Tier Open

D R U G S F O R T H E T R E AT M E N T O F PA R A S I T E S

ENZYMES

ACTICIN

1

ALDURAZYME

3

ALBENZA

3

CEREDASE

3

ALINIA

3

CEREZYME

3

ARALEN

3

CREON

3

BILTRICIDE

3

CYSTADANE

2

chloroquine phosphate

1

CYSTAGON

2

DARAPRIM

3

DYGASE

1

ELIMITE

3

ELAPRASE

3

EURAX

3

ENZYCAP

1

FANSIDAR

3

ENZYMAX

3

hydroxychloroquine sulfate

1

FABRAZYME

3

LARIAM

3

KUTRASE

3

lindane

1

KU-ZYME

3

MALARONE

3

KU-ZYME HP

3

malathion

1

LAPASE

1

mebendazole

1

LIPRAM 4500

1

mefloquine hcl

1

MYOZYME

3

MEPRON

3

NAGLAZYME

3

MINTEZOL

3

PALCAPS 10

3

NEUTREXIN

3

PALIPASE

1

OVIDE

3

PALIPASE MT 16

1

permethrin

1

PALPEON DR 10

1

PLAQUENIL

3

PALPEON MT 20

1

primaquine phosphate

1

PALTRASE V8

1

QUINERVA

1

PANCREASE

3

quinine sulfate

1

PANCREASE MT 10

3

STROMECTOL

3

PANCRECARB MS-16

3

TINDAMAX

3

PANCRELIPASE

1

VERMOX

3

PANCRON 10

1

YODOXIN

3

PANGESTYME CN 10

1

PANOCAPS

3

NC = Not covered

Utilization Management

(PR)

QL/ Day(s)

67

68

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

PANOKASE

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

1

CRINONE

3

PLARETASE 8000

1

CRYSELLE

1

PULMOZYME

3

CYCLESSA

3

SUCRAID

3

danazol

1

ULTRACAPS MT 20

3

DELESTROGEN

3

ULTRASE

1

DEMULEN

3

VIOKASE 16

2

DEPO-ESTRADIOL

3

ZAVESCA

3

DEPO-PROVERA

3

DEPO-PROVERA CONTRACEPTIVE

3

(PR)

(PR)

( P R O S TA G L A N D I N S )

NC = Not covered

Utilization Management

QL/ Day(s)

ACTIVELLA

3

DEPO-SUBQ PROVERA 104

3

ALESSE

3

DEPO-TESTOSTERONE

3

ALORA

3

DESOGEN

3

ANADROL-50

3

ENJUVIA

3

ANDRODERM

2

ENPRESSE-28

1

ANDROGEL

2

ERRIN

1

ANDROGEL PUMP

2

ESCLIM

3

(QL)

8/28 day(s)

ANDROID

3

ESTRACE

3

(QL)

1/1 day(s)

ANDROXY

3

ESTRACE VAGINAL CREAM

3

ANGELIQ

3

ESTRADERM

3

(QL)

8/28 day(s)

APRI

1

estradiol

1

(QL)

1/1 day(s)

ARANELLE

1

estradiol patch

1

(QL)

4/28 day(s)

AVIANE

1

ESTRASORB

3

AYGESTIN

3

ESTRING

3

BALZIVA

3

ESTRO-5

1

BREVICON

3

ESTROGEL

3

CAMILA

1

estropipate

1

CASODEX

3

ESTROSTEP FE

3

CENESTIN

3

FEMHRT 1/5

3

CESIA

1

FEMHRT LOW DOSE

3

CLIMARA

3

(QL)

4/28 day(s)

FEMRING

3

CLIMARA PRO

3

(QL)

4/28 day(s)

FEMTRACE

3

COMBIPATCH

3

(QL)

8/28 day(s)

FIRST-PROGESTERONE MC 10

3

(QL)

8/28 day(s)

(PR)

(QL)

1/1 day(s)

69

70

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

Drug Name

3-Tier Open

FIRST-PROGESTERONE VGS 10

3

FIRST-TESTOSTERONE

3

(ST)

GYNODIOL 0.5, 1, 2MG

1

(QL)

GYNODIOL 1.5MG

3

(QL)

IMPLANON

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

NECON 1/35-28

1

NECON 1/50-28

1

1/1 day(s)

NECON 10/11-28

1

1/1 day(s)

NECON 7/7/7

1

3

NORA-BE

1

JOLESSA

1

NORDETTE

3

JOLIVETTE

1

norethindrone acetate

1

JUNEL

1

NORINYL

3

KARIVA

1

NOR-QD

3

KELNOR 1/35

1

NORTREL

1

KESTRONE 5

1

NUVARING

3

LEENA

1

OGEN

3

LESSINA

1

OGESTREL

1

LEVLEN

3

ORTHO EVRA

3

LEVLEN CONTRACT PACK

3

ORTHO MICRONOR

3

LEVLITE

3

ORTHO TRI-CYCLEN

3

LEVORA

1

ORTHO TRI-CYCLEN LO

3

LO/OVRAL

3

ORTHO-CEPT

3

LOESTRIN

3

ORTHO-CEPT-28

3

LOW-OGESTREL

1

ORTHO-CYCLEN

3

LUTERA

1

ORTHO-EST

1

medroxyprogesterone acetate

1

ORTHO-NOVUM

3

MENEST

3

(QL)

1/1 day(s)

OVCON

3

MENOSTAR

3

(QL)

4/28 day(s)

OVCON FE CHEW

3

METHITEST

3

(PR)

OXANDRIN

3

MICROGESTIN 1.5/30

1

PLAN B

3

MIRCETTE

3

PORTIA

1

MIRENA

3

PREFEST

3

MODICON-28

3

PREMARIN

3

MONONESSA

1

PREMARIN INJECTION

3

nandrolone decanoate

1

PREMARIN VAG CREAM

3

NECON 0.5/35-28

1

PREMPHASE

3

(PR)

NC = Not covered

Utilization Management

QL/ Day(s)

(PR)

(QL)

1/1 day(s)

71

72

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

PREMPRO

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

3

VALERTEST #1

3

PREVIFEM

1

VELIVET

1

PROCHIEVE

3

VIVELLE

PROCHIEVE VAGINAL

3

progesterone

NC = Not covered

Utilization Management

QL/ Day(s)

3

(QL)

8/28 day(s)

VIVELLE-DOT

3

(QL)

8/28 day(s)

1

YASMIN

3

progesterone vaginal suppository

3

YAZ

3

PROMETRIUM

3

ZOVIA

1

propylthiouracil

1

( P R O S TA G L A N D I N S ) , U L C E R A N D S T O M A C H D R U G S

PROVERA

3

CYTOTEC

3

QUASENSE

1

misoprostol

1

RECLIPSEN

1

EYE AND EAR DRUGS

SEASONALE

3

A/B EAR DROPS

1

SEASONIQUE

3

A/B OTIC

1

SOLIA

1

ACETASOL HC

1

SPRINTEC

1

acetic acid and aluminum acetate

1

SRONYX

1

acetic acid and hydrocortisone

1

STRIANT

3

(ST)

acetic acid hc

1

TESTIM

3

(ST)

ACULAR

2

TESTOPEL

3

ACULAR LS

2

testosterone

1

ACULAR PF

2

testosterone cypionate

1

AERO OTIC HC

1

testosterone enanthate

1

AK-CON

1

testosterone propionate

1

AK-DILATE

1

TESTRED

3

AK-POLY-BAC

1

TRI-LEVLEN

3

AK-TAINE

1

TRINESSA

1

AK-TOB

1

TRI-NORINYL

3

ALAMAST

3

TRIPHASIL

3

ALBALON

3

TRI-PREVIFEM

1

ALCAINE

3

TRI-SPRINTEC

1

ALLERGEN

1

TRIVORA

1

ALLERSOL

1

VAGIFEM

3

(PR)

73

74

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

ALOCRIL

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

3

BETOPTIC-S

3

ALOMIDE

3

BLEPH-10

3

ALPHAGAN P

2

BLEPHAMIDE

3

ALREX

2

BLEPHAMIDE LIQUIFILM

3

ALTAFRIN

1

BLEPHAMIDE S.O.P.

3

AMERICAINE OTIC

3

BOROFAIR

1

ANTIBEN

1

BOTOX

3

ANTIBIOTIC EAR

1

brimonidine tartrate

1

antipyrine and benzocaine

1

CARBASTAT

1

atropine sulfate opthl ointment

1

CARBOPTIC

1

ATROPINE-CARE

1

carteolol hcl

1

AUROBIOTIC-HC

1

CILOXAN

3

AURODEX

1

CIPRO HC

3

AUROGUARD

1

CIPRODEX

3

AUROTO

1

ciprofloxacin optical solution

1

AZOPT

2

CLEERAVUE-M

3

bacitracin optical ointment

1

COLY-MYCIN S

3

CORTANE-B AQUEOUS

3

CORTANE-B-OTIC

3

CORTIC

1

bacitracin zinc and hydrocortisone acetate and neomycin sulfate and polymyxin b sulfate

1

bacitracin zinc and neomycin sulfate and polymyxin b sulfate

1

CORTIC-ND

1

bacitracin zinc and polymyxin b sulfate

1

CORTISPORIN OPTHL

3

bacitracin zinc, neomycin and polymyxin b

1

CORTISPORIN OTIC

3

bacitracin zinc,hydrocortisone, neomycin and polymyxin b

CORTOMYCIN

1

1

COSOPT

2

BALAGAN

1

CRESYLATE

3

BENZOTIC

1

CROLOM

3

BETAGAN

3

cromolyn sodium opthl

1

BETAGAN C CAP QD

3

CYOTIC

1

BETAGAN WITHOUT C CAP

3

DERMOTIC

3

betaxolol hydrochloride opthl solution

1

BETIMOL

3

dexamethasone and neomycin sulfate and polymyxin b sulfate

1

NC = Not covered

Utilization Management

QL/ Day(s)

(PR)

(QL) (PR) (ST)

1/30 day(s)

75

76

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

dexamethasone opthl solution

1

DEXASOL

1

DEXASPORIN

1

dipivefrin hydrochloride

1

DOLOTIC

1

EAR DROPS

1

EAR-GESIC

1

ECONOPRED PLUS

3

ELESTAT

3

EMADINE

3

erythromycin opthl ointment

1

EXOTIC-HC

1

FLAREX

3

FLOXIN OTIC

3

fluorometholone

1

FLUOR-OP

1

flurbiprofen sodium opthl

1

FML FORTE

3

FML LIQUIFILM

3

FML S.O.P.

3

FML-S LIQUIFILM

3

GENEXOTIC-HC

1

GENEZOTO-HC

1

GENOPTIC

1

GENTACIDIN

1

GENTAK

1

gentamicin sulfate opthl

1

GENTASOL

1

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

hydrocortisone and neomycin sulfate and polymyxin b sulfate

1

INFLAMASE FORTE

3

INFLAMASE MILD

3

IOPIDINE

3

ISOPTO ATROPINE

3

ISOPTO CARBACHOL

3

ISOPTO CARPINE

3

ISOPTO HOMATROPINE

3

ISTALOL

3

ketotifen fumarate ophth soln

1

LACRISERT

3

levobunolol hydrochloride

1

LOTEMAX

2

LUMIGAN

2

MAXIDEX

3

MAXITROL

3

MEDIOTIC-HC

1

metipranolol

1

MIOSTAT

3

MYDFRIN

3

MYDRAL

1

MYDRIACYL

3

NAPHAZOLE

1

naphazoline hydrochloride

1

NATACYN

2

NEOCIN

1

NEOCIN-PG

1

NEOFRIN

1

gramicidin and neomycin sulfate and polymyxin b sulfate

1

NEOSPORIN

3

HOMATROPAIRE

1

NEO-SYNEPHRINE SOLUTION

1

NEVANAC

2

NC = Not covered

Utilization Management

QL/ Day(s)

77

78

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

OCUFEN

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

3

POLYMYXIN/GRAMICIDIN/NEOM

1

OCUFLOX

3

POLY-PRED

3

OCUMYCIN

1

POLYSPORIN

3

OCUSULF-10

1

POLYTRIM

3

OCUTRICIN

1

PRED FORTE

3

ofloxacin opthl

1

PRED MILD

3

OMEDIA OTIC

1

PRED-G

3

OPTIPRANOLOL

3

PRED-G S.O.P.

3

OPTIVAR

2

PREDNISOL

1

OTICAINE OTIC

1

OTICIN HC

3

prednisolone acetate and sulfacetamide sodium anhydrous

1

OTIMAR

1

prednisolone acetate opthl

1

OTIRX

1

prednisolone sodium phosphate and sulfacetamide sodium

1

OTOCAIN

1

prednisolone sodium phosphate opthl

1

OTOGESIC

1

PRO-OTIC

1

OTOGESIC OTIC

1

proparacaine hydrochloride

1

OTOMAR-HC

1

PROPINE

3

OTOZONE

1

QUIXIN

3

OTRA NR

1

RESTASIS

2

PARCAINE

1

ROMYCIN

1

PATANOL

3

S.O.S.S.

1

PEDIOTIC

3

SULF-10

1

PHENOPTIC

1

SULFAC

1

phenylephrine hydrochloride opthl

1

sulfacetamide sodium ophtl ointment

1

PHOSPHOLINE IODIDE

3

sulfacetamide sodium ophtl solution

1

PILOCAR

1

timolol maleate ophthalmic

1

pilocarpine hydrochloride

1

TIMOPTIC

3

PILOPINE HS

3

TIMOPTIC OCUDOSE

3

PILOPTIC-1

1

TIMOPTIC-XE

3

POLYCIN B

1

TOBRADEX

3

POLY-DEX

1

tobramycin sulfate

1

polymyxin b sulfate and trimethoprim sulfate

1

TOBRASOL

1

NC = Not covered

Utilization Management

QL/ Day(s)

79

80

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

TOBREX

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

Drug Name

3-Tier Open

Utilization Management

QL/ Day(s)

3

ACCUPRIL 5, 10 20MG

3

(QL) (ST)

2/1 day(s)

TRAVATAN

2

ACCURETIC

3

(ST)

TRAVATAN Z

2

acebutolol

1

trifluridine

1

ACEON 2, 4MG

3

(QL) (ST)

TRI-OTIC

1

ACEON 8MG

3

(ST)

TRIPLE ANTIBIOTIC OPHTL

1

acetazolamide

1

TROPICACYL

1

ADALAT CC 30, 60MG

3

(QL) (ST)

tropicamide

1

ADALAT CC 90MG

3

(ST)

TRUSOPT

3

ADVICOR

3

(QL)

2/1 day(s)

TYMPAGESIC DROPS

3

AFEDITAB CR 30MG

1

(QL)

1/1 day(s)

UNI-OTIC

1

AFEDITAB CR 60MG

1

(QL)

2/1 day(s)

VEXOL

3

ALDACTAZIDE

3

VIGAMOX

3

ALDACTONE

3

VIROPTIC

3

ALDORIL

3

VOLTAREN OPTHL SOLUTION

2

ALTACE 1.25, 2.5, 5MG

2

(QL)

2/1 day(s)

XALATAN

2

ALTACE 10MG

2

XIBROM

3

ALTOPREV

3

(QL) (ST)

1/1 day(s)

ZADITOR

3

amiloride hydrochloride (anhydrous)

1

ZOLENE HC

1

ZOTANE HC

1

amiloride hydrochloride (anhydrous) and hydrochlorothiazide

1

ZOTO-HC

1

amiodarone

1

ZYLET

3

ANTARA

3

ZYMAR

3

ATACAND 32MG

3

(ST)

ATACAND 4, 8, 16MG

3

(QL) (ST)

2/1 day(s)

ATACAND HCT 5, 7.5, 10, 12.5, 15, 30MG

3

(QL) (ST)

2/1 day(s)

ATACAND HCT 32-12.5MG

3

(ST)

atenolol

1

atenolol and chlorthalidone

1

AVALIDE 150-12.5MG

3

(QL) (ST)

AVALIDE 300-12.5, 300-25MG

3

(ST)

AVAPRO 300MG

3

(ST)

AVAPRO 75, 150MG

3

(QL) (ST)

GOUT DRUGS allopurinol

1

ALOPRIM

3

colchicine

1

probenecid

1

probenecid and colchicine

1

ZYLOPRIM

3

H E A R T, B O O D P R E S S U R E A N D C H O L E S T E R O L D R U G S ACCUPRIL 40MG

3

(ST)

2/1 day(s)

1/1 day(s)

1/1 day(s)

1/1 day(s)

81

82

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

Drug Name

3-Tier Open

Utilization Management

QL/ Day(s)

Drug Name

3-Tier Open

Utilization Management

QL/ Day(s)

benazepril

1

(QL)

2/1 day(s)

CARDIZEM 30, 60, 90MG

3

(QL) (ST)

4/1 day(s)

benazepril 40mg

1

CARDIZEM CD 240, 300, 360MG

3

(ST)

benazepril and hydrochlorothiazide

1

CARDIZEM CD 120MG

3

(QL) (ST)

1/1 day(s)

benazepril, 10, 20mg

1

(QL)

CARDIZEM CD 180MG

3

(QL) (ST)

3/1 day(s)

BENICAR 40MG

3

(ST)

CARDIZEM INJECTION

3

(ST)

BENICAR 5, 20MG

3

(QL) (ST)

CARDIZEM LA 120MG

2

(QL)

1/1 day(s)

BENICAR HCT 40-12.5, 40-25MG

3

(ST)

CARDIZEM LA 180MG

2

(QL)

3/1 day(s)

BENICAR HCT 20-12.5MG

3

(QL) (ST)

CARDIZEM LA 240, 300, 306, 420MG

2

BETAPACE

3

CARDURA

3

BETAPACE AF

3

CARDURA XL

3

betaxolol hydrochloride

1

CARTIA XT 120MG

1

(QL)

1/1 day(s)

BIDIL

3

CARTIA XT 180MG

1

(QL)

3/1 day(s)

bisoprolol fumarate

1

CARTIA XT 240, 300MG

1

bisoprolol fumarate and hydrochlorothiazide

1

CARTROL

3

bumetanide

1

CATAPRES

3

BUMEX

3

CATAPRES-TTS

3

CADUET

3

(QL) (ST)

1/1 day(s)

chlorothiazide

1

CALAN

3

(QL) (ST)

4/1 day(s)

chlorthalidone

1

CALAN SR 120MG

3

(QL) (ST)

1/1 day(s)

cholestyramine

1

CALAN SR 180MG

3

(QL) (ST)

2/1 day(s)

cholestyramine light

1

CALAN SR 240MG

3

(ST)

clofibrate

1

CAPOTEN

3

(ST)

clonidine hydrochloride

1

CAPOZIDE

3

(ST)

CLORPRES

1

captopril

1

COLESTID

3

captopril and hydrochlorothiazide

1

COLESTID FLAVORED

3

CARDENE 20MG

3

(QL) (ST)

6/1 day(s)

colestipol hcl granule packets

1

CARDENE 30MG

3

(QL) (ST)

4/1 day(s)

CORDARONE

3

CARDENE I.V.

3

(ST)

CORDARONE I.V.

3

CARDENE SR

3

(QL)

1/1 day(s)

COREG

2

CARDENE SR 30MG

3

(QL)

1/1 day(s)

CORGARD

3

CARDENE SR 60MG

3

CORZIDE

3

CARDIZEM 120MG

3

COVERA-HS 180MG

3

(QL) (ST)

2/1 day(s)

(QL) (ST)

2/1 day(s)

1/1 day(s)

1/1 day(s)

3/1 day(s)

83

84

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered QL/ Day(s)

Drug Name

3-Tier Open

Utilization Management

COVERA-HS 240MG

3

(ST)

COZAAR 100MG

2

COZAAR 25, 50MG

2

(QL)

CRESTOR

2

(QL)

DEMADEX

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

Drug Name

3-Tier Open

Utilization Management

QL/ Day(s)

DIOVAN HCT 80-12.5, 160-12.5, 160-25MG

2

(QL)

1/1 day(s)

disopyramide phosphate

1

2/1 day(s)

DIURIL

3

1/1 day(s)

doxazosin mesylate

1

3

DYAZIDE

3

DEMSER

3

DYNACIRC

3

(QL)

4/1 day(s)

DIBENZYLINE

3

DYNACIRC CR 10MG

3

DIGITEK

1

DYNACIRC-CR 5MG

3

(QL)

4/1 day(s)

digoxin

1

DYRENIUM

3

DILACOR XR 120MG

3

(QL) (ST)

1/1 day(s)

EDECRIN

3

DILACOR XR 180MG

3

(QL) (ST)

3/1 day(s)

enalapril maleate 2.5, 5, 10mg

1

(QL)

2/1 day(s)

DILACOR XR 240MG

3

(ST)

enalapril maleate 20mg

1

DILATRATE SR

3

enalapril maleate and hydrochlorothiazide

1

DILTIA XT 120MG

1

(QL)

1/1 day(s)

ephedrine sulfate

1

DILTIA XT 180MG

1

(QL)

3/1 day(s)

EPIPEN

3

DILTIA XT 240MG

1

EPIPEN-JR

3

diltiazem hcl injection

3

ETHMOZINE

3

diltiazem hcl sr 420mg

1

felodipine er

1

diltiazem hydrochloride 30, 60, 90, 120mg

1

(QL)

4/1 day(s)

fenofibrate

1

diltiazem hydrochloride cd 120mg

1

(QL)

1/1 day(s)

flecainide acetate

1

diltiazem hydrochloride cd 180mg

1

(QL)

3/1 day(s)

fosinopril sodium

1

diltiazem hydrochloride cd 240, 300, 360mg

1

fosinopril sodium 10, 20mg

1

(QL)

2/1 day(s)

diltiazem hydrochloride er 120mg

1

fosinopril sodium 40mg

1

(QL)

2/1 day(s)

diltiazem hydrochloride er 60, 90, 240, 300, 360mg

fosinopril sodium and hydrochlorothiazide

1

1

furosemide

1

diltiazem hydrochloride sr 120mg

1

gemfibrozil

1

diltiazem hydrochloride sr 240, 300, 360mg

1

guanabenz acetate

1

diltiazem hydrochloride xr 240, 300, 360mg

1

guanfacine hcl

1

DILT-XR 180MG

1

hydralazine hydrochloride

1

DIOVAN 320MG

2

DIOVAN 40, 80, 160MG

2

hydralazine hydrochloride and hydrochlorothiazide

1

DIOVAN HCT 320-12.5, 320-25MG

2

hydrochlorothiazide

1

(QL)

(QL)

(QL)

(QL)

1/1 day(s)

1/1 day(s)

3/1 day(s)

2/1 day(s)

85

86

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

HYTRIN

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

Drug Name

3-Tier Open

Utilization Management

QL/ Day(s)

3

LIPITOR

2

(QL)

1/1 day(s)

HYZAAR 100-12.5, 100-25MG

2

lisinopril 2.5, 5, 10, 20, 30mg

1

(QL)

2/1 day(s)

HYZAAR 50-12.5MG

2

lisinopril 40 mg

1

IMDUR

3

lisinopril and hydrochlorothiazide

1

indapamide

1

LOFIBRA

3

INDERIDE 40/25

3

LOPID

3

INSPRA

3

LOPRESSOR

3

INVERSINE

3

LOPRESSOR HCT

3

ISMO

3

LOTENSIN 40MG

3

(ST)

ISMOTIC

3

LOTENSIN 5, 10, 20MG

3

(QL) (ST)

ISOCHRON

1

LOTENSIN HCT

3

(ST)

ISOPTIN SR 120MG

3

(QL)

1/1 day(s)

LOTREL

2

ISOPTIN SR 180MG

3

(QL)

2/1 day(s)

lovastatin

1

ISOPTIN SR 240MG

3

(ST)

LOZOL

3

ISORDIL TITRADOSE

3

MAVIK 1MG

isosorbide dinitrate

1

isosorbide dinitrate er

(QL)

1/1 day(s)

2/1 day(s)

(QL)

2/1 day(s)

3

(QL) (ST)

2/1 day(s)

MAVIK 2MG

3

(QL) (ST)

2/1 day(s)

1

MAVIK 4MG

3

(ST)

isosorbide dinitrate sa

1

MAXZIDE

3

isosorbide dinitrate tr

1

methazolamide

1

isosorbide mononitrate

1

methyclothiazide

1

isosorbide mononitrate er

1

methyldopa

1

isradipine

1

methyldopa and amitriptyline hydrochloride

1

KERLONE

3

methyldopa and hydrochlorothiazide

1

labetalol hydrochloride

1

methyldopate hydrochloride

1

LANOXICAPS

3

metolazone

1

LANOXIN

3

metoprolol tartrate

1

LASIX

3

metoprolol tartrate and hydrochlorothiazide

1

LESCOL

3

(QL) (ST)

2/1 day(s)

MEVACOR

3

LESCOL XL

3

(QL) (ST)

1/1 day(s)

mexiletine hydrochloride

1

LEVATOL

3

MEXITIL

3

LEXXEL

3

MICARDIS 20,40MG

lidocaine hydrochloride injection

1

MICARDIS 80MG

(QL)

4/1 day(s)

(QL) (ST)

2/1 day(s)

3

(QL) (ST)

1/1 day(s)

3

(ST)

87

88

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

Drug Name

3-Tier Open

Utilization Management

QL/ Day(s)

Drug Name

3-Tier Open

MICARDIS HCT 40-12.5MG

3

(QL) (ST)

1/1 day(s)

NITRO-BID

3

MICARDIS HCT 80-12.5, 80-25MG

3

(ST)

NITRO-DUR

3

MICROZIDE

3

NITROGARD

3

MIDAMOR

3

nitroglycerin cr

1

midodrine hcl

1

nitroglycerin er

1

MINIPRESS

3

nitroglycerin injection

1

MINITRAN

1

NITROGLYCERIN OINTMENT

3

MINIZIDE

3

nitroglycerin sr

1

minoxidil

1

nitroglycerin sublingual

1

MODURETIC 5-50

3

nitroglycerin td

1

MONOKET

3

nitroglycerin transdermal

1

MONOPRIL 10, 20MG

3

(QL) (ST)

NITROLINGUAL PUMPSPRAY

3

MONOPRIL 40MG

3

(ST)

NITROQUICK

1

MONOPRIL HCT

3

(ST)

NITROSTAT

3

nadolol

1

NITRO-TIME

1

NATURETIN

3

NORPACE

3

NEO-SYNEPHRINE

3

NORPACE CR

3

nicardipine hcl 20mg

1

(QL)

6/1 day(s)

NORVASC

2

nicardipine hcl 30mg

1

(QL)

4/1 day(s)

OMACOR

3

NIFEDIAC CC 30MG

1

(QL)

1/1 day(s)

PACERONE

3

NIFEDIAC CC 60MG

1

(QL)

2/1 day(s)

papaverine hydrochloride cr

1

NIFEDIAC CC 90MG

1

papaverine hydrochloride er

1

NIFEDICAL XL 30MG

1

(QL)

1/1 day(s)

papaverine hydrochloride injection

1

NIFEDICAL XL 60MG

1

(QL)

2/1 day(s)

PARA-TIME

1

nifedipine 10mg

1

(QL) (PR)

12/1 day(s)

phenylephrine hydrochloride

1

nifedipine 20mg

1

(PR)

pindolol

1

nifedipine cr 90mg

1

PLENDIL 10MG

3

nifedipine er 30mg

1

(QL)

1/1 day(s)

PLENDIL 2.5, 5MG

3

(QL)

1/1 day(s)

nifedipine er 60mg

1

(QL)

2/1 day(s)

PRAVACHOL

3

(QL) (ST)

1/1 day(s)

nifedipine er 90mg

1

pravastatin

1

(QL)

1/1 day(s)

NIMOTOP

3

prazosin hydrochloride

1

NITREK

1

PREVALITE

1

(QL)

2/1 day(s)

252/21 day(s)

Utilization Management

QL/ Day(s)

(QL) (PR) (ST)

4/1 day(s)

(PR)

89

90

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

Drug Name

3-Tier Open

Utilization Management

QL/ Day(s)

Drug Name

3-Tier Open

Utilization Management

PRINIVIL 2.5, 5, 10, 20MG

3

(QL) (ST)

2/1 day(s)

REVATIO

2

(PR)

PRINIVIL 40MG

3

(ST)

RYTHMOL

3

PRINZIDE

3

(ST)

RYTHMOL SR

3

PROAMATINE

3

SECTRAL

3

procainamide hydrochloride

1

simvastatin

1

procainamide hydrochloride cr

1

SODIUM EDECRIN

3

procainamide hydrochloride er

1

SORINE

1

PROCANBID

3

sotalol af

1

PROCARDIA 20MG

3

(QL) (ST)

12/1 day(s)

sotalol hydrochloride

1

PROCARDIA XL 30MG

3

(QL) (ST)

1/1 day(s)

spironolactone

1

PROCARDIA XL 60MG

3

(QL) (ST)

2/1 day(s)

spironolactone and hydrochlorothiazide

1

PROCARDIA XL 90MG

3

(ST)

SULAR 10, 20MG

PRONESTYL

3

propafenone hcl

1

propranolol hydrochloride and hydrochlorothiazide

1

QUESTRAN

3

QUESTRAN LIGHT

3

quinapril hcl 40mg

1

quinapril hcl 5, 10, 20mg

1

quinapril hcl and hydrochlorothiazide

1

QUINARETIC

1

quinidine gluconate

1

quinidine gluconate cr

1

quinidine gluconate er

1

quinidine gluconate sa

1

quinidine sulfate

1

quinidine sulfate er

1

RANEXA

2

RAUWOLFIA/BENDROFLUMETHIA

1

REMODULIN

3

reserpine

1

(QL)

(QL) (PR) (ST)

(PR)

2/1 day(s)

4/1 day(s)

QL/ Day(s)

(QL)

1/1 day(s)

3

(QL)

1/1 day(s)

SULAR 30MG

3

(QL)

2/1 day(s)

SULAR 40MG

3

TAMBOCOR

3

TARKA

3

TAZTIA XT

1

(QL)

1/1 day(s)

TENEX

3

TENORETIC 100

3

TENORMIN

3

terazosin hcl

1

TEVETEN 400MG

3

(QL) (ST)

2/1 day(s)

TEVETEN 600MG

3

(ST)

TEVETEN HCT

3

(ST)

THALITONE

3

TIAZAC 240, 300, 360, 420MG

3

(ST)

TIAZAC 120MG

3

(QL) (ST)

1/1 day(s)

TIAZAC 180MG

3

(QL) (ST)

3/1 day(s)

TIKOSYN

2

TIMOLIDE

3

TOPROL XL

2

torsemide

1

91

92

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

TRANDATE

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

93

Drug Name

3-Tier Open

3

ZEBETA

3

TRANDATE IV

3

ZESTORETIC

3

(ST)

triamterene and hydrochlorothiazide

1

ZESTRIL 2.5, 5, 10, 20, 30MG

3

(QL) (ST)

TRICOR

2

ZESTRIL 40MG

3

(ST)

TRIGLIDE

3

ZETIA

3

(QL) (PR)

1/1 day(s)

TWINJECT

3

(PR)

ZIAC

3

UNIRETIC

3

(ST)

ZOCOR

3

(QL) (ST)

1/1 day(s)

UNIVASC

3

(ST)

MIGRAINE DRUGS

VASERETIC

3

(ST)

AMERGE

2

(QL)

9/30 day(s)

VASOTEC 2.5, 5, 10MG

3

(QL) (ST)

AXERT 12.5MG

3

(QL)

6/30 day(s)

VASOTEC 20MG

3

(ST)

AXERT 6.25MG

3

(QL)

6/30 day(s)

VENTAVIS

3

(PR)

BLOCADREN

3

verapamil hydrochloride 40, 80, 120mg

1

(QL)

4/1 day(s)

CAFERGOT

3

verapamil hydrochloride cr 120mg

1

(QL)

1/1 day(s)

D.H.E. 45

3

verapamil hydrochloride cr 180mg

1

(QL)

2/1 day(s)

dihydroergotamine mesylate

1

verapamil hydrochloride cr 240, 360mg

1

ERGOMAR

3

verapamil hydrochloride er 120mg

1

(QL)

1/1 day(s)

ergotamine tartrate and caffeine

1

verapamil hydrochloride er 180mg

1

(QL)

2/1 day(s)

FROVA

3

(QL)

9/30 day(s)

verapamil hydrochloride er 240, 360mg

1

IMITREX NASAL SPRAY

2

(QL)

6/30 day(s)

verapamil hydrochloride injection

1

IMITREX STATDOSE PEN

2

(QL)

4/30 day(s)

verapamil hydrochloride sr 120mg

1

(QL)

1/1 day(s)

IMITREX TABLETS

2

(QL)

18/30 day(s)

verapamil hydrochloride sr 180mg

1

(QL)

2/1 day(s)

IMITREX VIALS

2

(QL)

5/30 day(s)

verapamil hydrochloride sr 240, 360mg

1

INDERAL

3

VERELAN 120MG

3

(QL) (ST)

1/1 day(s)

INDERAL LA

3

VERELAN 180MG

3

(QL) (ST)

2/1 day(s)

INNOPRAN XL

3

VERELAN 240, 360MG

3

(ST)

MAXALT

2

(QL)

12/30 day(s)

VERELAN PM 100MG

3

(QL)

1/1 day(s)

MAXALT-MLT

2

(QL)

12/30 day(s)

VERELAN PM 200MG

3

(QL)

2/1 day(s)

MIGERGOT

3

VERELAN PM 300MG

3

MIGRANAL

3

(QL)

16/30 day(s)

VYTORIN

2

PROPRANOLOL HCL INTENSOL

3

WELCHOL

3

propranolol hydrochloride

1

ZAROXOLYN

3

propranolol hydrochloride er

1

(QL)

2/1 day(s)

1/1 day(s)

Utilization Management

QL/ Day(s)

2/1 day(s)

94

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

Drug Name

3-Tier Open

Utilization Management

QL/ Day(s)

Drug Name

3-Tier Open

Utilization Management

RELPAX 20MG

2

(QL)

12/30 day(s)

NORFLEX

3

(PR)

RELPAX 40MG

2

(QL)

6/30 day(s)

NORGESIC FORTE

3

(PR)

timolol maleate

1

orphenadrine citrate

1

(PR)

ZOMIG 2.5MG

3

(QL)

18/30 day(s)

orphenadrine citrate and aspirin and caffeine

1

(PR)

ZOMIG 5MG

3

(QL)

9/30 day(s)

orphenadrine citrate cr

1

(PR)

ZOMIG SPRAY

3

(QL)

6/30 day(s)

ORPHENADRINE COMPOUND

1

(PR)

ZOMIG ZMT 2.5MG

3

(QL)

12/30 day(s)

ORPHENGESIC

1

(PR)

ZOMIG ZMT 5MG

3

(QL)

6/30 day(s)

ORPHENGESIC FORTE

1

(PR)

PARAFON FORTE DSC

3

(PR)

MISCELLANEOUS DRUGS ACIDIC VAGINAL JELLY

1

ROBAXIN

3

AMINO ACID CERVICAL

1

SKELAXIN

3

(PR)

AMINO-CERV

3

SOMA

3

(PR)

BUPHENYL

3

SOMA COMPOUND

3

(PR)

FEM PH

3

SOMA COMPOUND/CODEINE

3

(PR)

METHERGINE

3

tizanidine hydrochloride

1

ORFADIN

3

ZANAFLEX

3

oxytocin

1

M Y E S T H E N I A G R AV I S D R U G S

PITOCIN

3

ENLON-PLUS

3

RELAGARD

3

guanidine hydrochloride

1

RILUTEK

3

MESTINON

3

MESTINON TIMESPAN

3

MYTELASE

3

(PR)

(PR)

MUSCLE RELAXERS baclofen

1

carisoprodol

1

(PR)

neostigmine methylsulfate

1

carisoprodol and aspirin

1

(PR)

PROSTIGMIN

3

CARISOPRODOL COMPOUND

1

(PR)

PROSTIGMIN INJECTION

3

carisoprodol, codeine phosphate and aspirin

1

(PR)

pyridostigmine bromide

1

chlorzoxazone

1

(PR)

REGONOL

1

cyclobenzaprine hydrochloride

1

(PR)

NAUSEA / VOMITING DRUGS

DANTRIUM

3

ALOXI

3

dantrolene sodium

1

ANTIVERT

3

FLEXERIL

3

(PR)

ANZEMET 50, 100MG

3

(QL) (PR)

methocarbamol

1

(PR)

ANZEMET SOLUTION

3

(PR)

QL/ Day(s)

(PR)

5/30 day(s)

95

96

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

97

Drug Name

3-Tier Open

Utilization Management

QL/ Day(s)

Drug Name

3-Tier Open

Utilization Management

QL/ Day(s)

CESAMET

3

(QL) (PR)

20/30 day(s)

BONIVA 2.5MG

3

(QL)

1/1 day(s)

COMPAZINE

3

BONIVA INJECTION

3

COMPRO

1

DIDRONEL

3

KYTRIL

3

(PR)

etidronate disodium

1

KYTRIL SOLUTION

3

(QL) (PR)

50/30 day(s)

EVISTA

2

KYTRIL TABLET

3

(QL) (PR)

10/30 day(s)

FORTEO

2

MALDEMAR

1

FORTICAL

1

MARINOL

3

FOSAMAX 35, 70MG

2

(QL)

4/28 day(s)

meclizine hydrochloride

1

FOSAMAX 5, 10, 40MG

2

PHENADOZ

1

FOSAMAX PLUS D

2

(QL)

4/28 day(s)

PHENERGAN

3

FOSAMAX SOLUTION

2

(QL)

300/28 day(s)

prochlorperazine edisylate injection

1

MIACALCIN

3

prochlorperazine maleate

1

PAMIDRONATE DISODIUM

1

prochlorperazine sup

1

SKELID

3

promethazine hydrochloride

1

ZOMETA

2

PROMETHEGAN

1

PA I N D R U G S ( A N A L G E S I C S )

SCOPACE

3

acetaminophen and codeine

1

TIGAN

3

acetaminophen and hydrocodone

1

TRANSDERM-SCOP

3

acetaminophen and hydrocodone bitartrate

1

trimethobenzamide hydrochloride

1

acetaminophen and oxycodone

1

UNIVERT

1

acetaminophen and propoxyphene napsylate

1

(PR)

VERTIN-32

1

ACTIQ

3

(QL)

ZOFRAN INJECTION

2

(PR)

ACUFLEX

3

ZOFRAN ODT

2

(QL) (PR)

12/30 day(s)

ALCET

3

ZOFRAN SOLUTION

2

(QL) (PR)

50/30 day(s)

ALI-FLEX

1

ZOFRAN TABLETS

2

(QL) (PR)

5/30 day(s)

ALPAIN

3

ANABAR

1

ANEXSIA

1

ASCOMP/CODEINE

1

ASP 300/200/20

1

aspirin and butalbital and caffeine and codeine phosphate

1

(PR)

(PR)

OSTEOPOROSIS (BONE LOSS) DRUGS ACTONEL 35MG

2

ACTONEL 5, 30MG

2

ACTONEL WITH CALCIUM

2

AREDIA

3

BONIVA 150MG

3

(QL)

(QL)

(QL)

4/28 day(s)

4/28 day(s)

3/90 day(s)

(ST)

6/1 day(s)

98

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

aspirin and codeine

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

1

DOLOGESIC

3

aspirin, butalbital, caffeine and codeine

1

DOLOPHINE

3

aspirin, caffeine and propoxyphene

1

DOLOREX

1

aspirin, oxycodone and oxycodone

1

DOLOREX FORTE

1

ASTRAMORPH

1

DURABAC

3

AVINZA

3

DURABAC FORTE

3

BALACET 325

1

(PR)

DURACLON

3

BANCAP-HC

3

(ST)

DURAGESIC

3

BE-FLEX PLUS

1

DURAMORPH

1

BUPRENEX

3

DURAXIN

3

buprenorphine hydrochloride

1

ED-FLEX

1

ENDOCET

1

ENDODAN

1

ETH-OXYDOSE

1

fentanyl citrate

1

fentanyl citrate ot lozenge

(PR)

(PR)

butalbital, acetaminophen, caffeine and codeine phosphate

1

butorphanol tartrate injection

1

butorphanol tartrate nasal solution

1

BY-ACHE

1

CAFGESIC

1

CAPITAL/CODEINE

3

codeine phosphate

1

codeine sulfate

1

CO-GESIC

1

COMBUNOX

3

(QL) (ST)

DARVOCET

3

(PR) (ST)

DARVOCET-N

3

(PR) (ST)

DARVON

3

(PR) (ST)

DARVON COMPOUND

3

(PR) (ST)

DARVON-N

3

(PR) (ST)

DEMEROL

3

(PR)

DEPODUR

3

DILAUDID

3

DOLACET

1

DOLAGESIC

1

(QL)

5/30 day(s)

(ST)

4/1 day(s)

NC = Not covered

99

Utilization Management

QL/ Day(s)

(QL)

20/30 day(s)

1

(QL)

6/1 day(s)

fentanyl patch

1

(QL)

20/30 day(s)

FENTORA

3

(QL) (ST)

4/1 day(s)

FIORICET/CODEINE

3

(ST)

FIORINAL/CODEINE #3

3

(ST)

FLEXTRA

3

FLEXTRA DS

3

GENECAR

1

GENEDOLOREX

1

GENE-R-GESIC

1

HYCET

3

HYDROCET

1

hydrocodone bitartrate and ibuprofen

1

hydromorphone hydrochloride

1

HYDROMORPHONE/NS

3

HYFLEX-650

1

HYFLEX-DS

1

100

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

INFUMORPH 200

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

1

NOVAGESIC

1

KADIAN

3

NUBAIN

3

LAGESIC

3

NUMORPHAN

3

LEVACET

3

OPANA

LEVO-DROMORAN

3

levorphanol tartrate

1

LORCET 10/650

3

LORCET PLUS

3

LORCET-HD

1

LORTAB 10

3

LYNOX

3

MAG-PHEN

NC = Not covered

Utilization Management

QL/ Day(s)

3

(QL) (ST)

6/1 day(s)

OPANA ER

3

(QL) (ST)

4/1 day(s)

ORAMORPH SR

3

(ST)

oxycodone

1

(ST)

oxycodone cr

1

(QL)

4/1 day(s)

oxycodone er

1

(QL)

4/1 day(s)

(ST)

OXYCONTIN

3

(QL) (ST)

4/1 day(s)

(ST)

OXYFAST

1

1

OXYIR

3

MAGSAL

3

PANLOR DC

3

MARGESIC-H

1

PANLOR SS

3

MAXIDONE

3

PENTAZOCINE HCL/ACETAMINO

1

(PR)

MEPERIDINE HCL/NS

3

meperidine hydrochloride

1

pentazocine hydrochloride and acetaminophen

1

(PR)

MEPERIDINE/NS

3

pentazocine hydrochloride and naloxone hydrochloride

1

(PR)

MEPERITAB

1

PERCOCET

3

(ST)

methadone hydrochloride

1

PERCODAN

3

(ST)

METHADOSE

1

PERCOLONE

1

morphine sulfate

1

PERLOXX

3

morphine sulfate er

1

PHRENILIN W/CAFFEINE/CODE

1

MORPHINE SULFATE IN DEXTR

3

PRIALT

3

MS CONTIN

3

PROPOXACET

1

(PR)

MS/L

1

PROPOXACET-N

1

(PR)

MYOBLOC

3

PROPOXYPHENE COMPOUND

1

(PR)

MYOGESIC

1

propoxyphene hydrochloride

1

(PR)

MYOPHEN

1

nalbuphine hydrochloride

1

propoxyphene hydrochloride and acetaminophen

1

(PR)

NARVOX

1

propoxyphene napsylate and acetaminophen

1

(PR)

NORCO

3

RELAGESIC

3

(PR)

(PR)

(PR)

(ST)

101

102

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered QL/ Day(s)

Drug Name

3-Tier Open

Utilization Management

REPREXAIN

3

(ST)

RHINOFLEX

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

VICODIN HP

1

1

VICOPROFEN

3

(ST)

RHINOFLEX-650

1

VOPAC

3

(ST)

RID-A-PAIN

3

XODOL

3

(ST)

RMS

3

ZERLOR

1

ROXANOL

3

ZYDONE

3

ROXICET 5-325MG

1

PA R AT H Y R O I D S U P P R E S S A N T D R U G S

ROXICET 5-500MG

3

SENSIPAR

ROXICET SOLUTION

3

PA R K I N S O N ’ S D R U G S

ROXICODONE

3

AKINETON

3

STADOL

3

APOKYN

3

STAFLEX

3

ATAMET

1

STAGESIC

1

AZILECT

3

SUBOXONE

3

(PR)

benztropine mesylate

1

SUBUTEX

3

(PR)

carbidopa anhydrous and levodopa

1

SYNALGOS-DC

3

COGENTIN

3

TALACEN

3

COMTAN

2

TALWIN

3

ELDEPRYL

3

TALWIN NX

3

KEMADRIN

3

TETRA-MAG

1

LODOSYN

3

tramadol hcl

1

MIRAPEX

2

tramadol hcl and acetaminophen

1

PARCOPA

3

TRYCET

3

(PR) (ST)

REQUIP

2

TYLENOL/CODEINE #3

3

(ST)

selegiline hcl

1

TYLENOL/CODEINE #4

3

(ST)

SINEMET

3

TYLOX

3

(ST)

SINEMET CR

3

ULTRACET

3

STALEVO 100

2

ULTRAM

3

TASMAR

3

ULTRAM ER

3

trihexyphenidyl hydrochloride

1

VANACET

1

ZELAPAR

3

VICODIN

3

(ST)

VICODIN ES

3

(ST)

(PR) (ST)

(PR)

Utilization Management

QL/ Day(s)

(ST)

2

P I T U I TA RY D R U G S bromocriptine mesylate

NC = Not covered

1

(ST)

(QL)

2/1 day(s)

103

104

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

cabergoline

1

DDAVP

3

desmopressin acetate

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

Drug Name

3-Tier Open

TAPAZOLE

3

TEV-TROPIN

2

(PR)

1

VIADUR

3

(PR)

DOSTINEX

3

ZOLADEX

3

(PR)

ELIGARD

3

(PR)

ZORBTIVE

3

(PR)

GENOTROPIN

3

(PR)

SEIZURE CONTROL DRUGS

GENOTROPIN MINIQUICK

3

(PR)

carbamazepine

1

HUMATROPE

3

(PR)

CARBATROL

3

leuprolide acetate

1

(PR)

CELONTIN

3

LUPRON DEPOT

3

(PR)

CEREBYX

3

methimazole

1

DEPACON

3

MINIRIN

1

DEPAKENE

3

NORDITROPIN CARTRIDGE

2

(PR)

DEPAKOTE ER

2

NORDITROPIN CARTRIDGE

2

(PR)

DEPAKOTE SPRINKLES

2

NORDITROPIN NORDIFLEX

2

(PR)

DIAMOX

3

NORDITROPIN NORDIFLEX PEN

2

(PR)

DILANTIN

3

NUTROPIN

3

(PR)

DILANTIN INFATABS

3

NUTROPIN AQ

3

(PR)

DILANTIN SUSPENSION

3

NUTROPIN AQ PEN

3

(PR)

DILANTIN-125

3

octreotide acetate

1

EPITOL

1

PARLODEL

3

ethosuximide

1

pergolide mesylate

1

FELBATOL

3

PERMAX

3

gabapentin

1

(QL)

6/1 day(s)

PLENAXIS

3

(PR)

GABARONE

3

(QL)

6/1 day(s)

SAIZEN

2

(PR)

GABITRIL

3

(ST)

SAIZEN CLICK.EASY

2

(PR)

KEPPRA

2

SANDOSTATIN

3

LAMICTAL

2

SANDOSTATIN LAR DEPOT

3

lamotrigine chewable

1

SEROSTIM

3

LYRICA

3

SOMAVERT

3

MYSOLINE

3

STIMATE

3

NEURONTIN

3

SYNAREL

3

NEURONTIN SOLUTION

3

(ST)

(PR)

Utilization Management

QL/ Day(s)

(QL) (PR) (ST)

3/1 day(s)

(QL)

6/1 day(s)

105

106

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

PEGANONE

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

3

AMINOSYN

3

PHENYTEK

3

AMINOSYN II

3

phenytoin

1

AMINOSYN M

3

phenytoin sodium

1

AMINOSYN-HBC

3

primidone

1

AMINOSYN-HF

1

TEGRETOL

3

AMINOSYN-PF

3

TEGRETOL-XR

3

AMINOSYN-RF

3

TOPAMAX

3

ammonium chloride

1

TRILEPTAL

3

ANEMAGEN OB

1

valproate acid syrup

1

ATABEX PRENATAL

3

valproate sodium

1

BACTERIOSTATIC WATER FOR

1

valproic acid

1

BICITRA

3

ZARONTIN

3

BRIGHT BEGINNINGS PRENATA

3

ZONEGRAN

3

CALCIJEX

3

zonisamide

1

calcitriol

1

CAL-NATE

1

(ST)

(ST)

SLEEP AIDS AMBIEN 10MG

2

(QL)

1/1 day(s)

CARENATE 600

1

AMBIEN 5MG

2

(QL)

2/1 day(s)

CARNITOR

3

AMBIEN CR

3

(QL)

1/1 day(s)

CAVIRINSE

1

AQUACHLORAL

3

CENOGEN ULTRA

3

chloral hydrate

1

CITRACAL PRENATAL + DHA

3

LUNESTA

3

CITRACAL PRENATAL RX

3

ROZEREM

3

SOMNOTE

3

citric acid and lysine hydrochloride and potassium bicarbonate and potassium chloride

1

SONATA 10MG

3

(QL)

2/1 day(s)

citric acid and potassium citrate

1

SONATA 5MG

3

(QL)

4/1 day(s)

citric acid and sodium citrate

1

CITROLITH

3

CLINIMIX

3

CLINIMIX E

3

CLINISOL SF

1

CO-NATAL FA

1

CONTROLRX

1

THERAPEUTIC SUPPLEMENTS ADVANCED NATALCARE

1

ADVANCED-RF NATALCARE

1

alcohol, usp and dextrose (anhydrous)

1

AMINATE FE-90

1

AMINESS

3

(QL)

1/1 day(s)

NC = Not covered

Utilization Management

QL/ Day(s)

107

108

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

CYTRA K CRYSTALS

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

1

HYPERLYTE

1

CYTRA-2

1

ICAR PRENATAL COMBO PACK

3

CYTRA-3

1

INATAL ADVANCE

1

CYTRA-K

1

INATAL GT

1

DENTA 5000 PLUS

1

INATAL ULTRA

1

DENTAGEL

1

INTRALIPID

1

DENTALL 1100 PLUS

1

IONOSOL-B/DEXTROSE 5%

3

dextrose

1

IONOSOL-MB/DEXTROSE 5%

3

dextrose (anhydrous)

1

IONOSOL-T/DEXTROSE 5%

3

dextrose (anhydrous) and potassium chloride

1

JUST FOR KIDS GEL

1

dextrose (anhydrous) and sodium chloride

1

K+ POTASSIUM

1

dextrose lactated ringers

1

KAOCHLOR

1

DUET

3

KAON

3

DUET DHA

3

KAON-CL

3

EASYGEL

1

KAON-CL-10

1

ED K+10

1

KARIDIUM

1

EFFER-K

1

KARIGEL

1

EFFERVESCENT POT CHLORIDE

1

KARIGEL-N

1

EFFERVESCENT POTASSIUM

1

KAY CIEL

1

EFFERVESCENT POTASSIUM/CH

1

K-DUR

3

ETHEDENT

1

K-EFFERVESCENT

1

FLUORABON

1

K-LOR

3

FLUOR-A-DAY

1

KLOR-CON 10

1

FLUORIDE

1

KLOR-CON M15

3

FLUORITAB

1

KLOTRIX

1

FLURA-DROPS

1

K-LYTE

3

FREAMINE HBC

3

K-LYTE DS

3

FREAMINE III

3

K-LYTE/CL

3

GEL-KAM ORAL CARE RINSE

3

K-PHOS

2

HECTOROL

3

K-PHOS MF

2

HEPATAMINE

1

K-PHOS NO 2

2

HEPATASOL

3

K-TABS

3

NC = Not covered

Utilization Management

QL/ Day(s)

109

110

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

K-VESCENT

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

1

NATALCARE THREE

1

LACTATED RINGER'S

1

NATALVIT

3

LACTATED RINGER'S DEXTROS

1

NATAMAR RX

1

levocarnitine

1

NATATAB CFE

1

LIPOSYN II

3

NATATAB FA

1

LIPOSYN III

3

NATATAB RX

1

LOZI-FLUR

1

NATELLE

3

LURIDE

3

NATELLE C

3

magnesium chloride

1

NATELLE EZ

3

magnesium sulfate, heptahydrate

1

NATELLE PREFER

3

MARNATAL-F PLUS DUO PACK

3

NEEVO

3

MATERNITY

1

NEPHRAMINE

3

MATERNITY-90

1

NESTABS CBF

3

MICRO-K

3

NESTABS FA

3

M-VIT

1

NESTABS RX

3

MYNATAL

3

NEUT

3

MYNATAL ADVANCE

1

NEUTRAGARD ADVANCED

1

MYNATAL PLUS

1

NIACOR

1

MYNATAL ULTRACAPLET

1

NIASPAN

3

MYNATAL-Z

1

MYNATE 90 PLUS

1

niferex pn (calcium carbonate and cyanocobalamin and folic acid and niacinamide and polysaccharide iron complex)

1

NACL 0.9%/DEXTROSE 0.2%

3

NATACAPS

1

NATACHEW

3

niferex-pn forte (ascorbic acid and calcium carbonate and cupric oxide and cyanocobalamin and ergocalciferol)

1

NATAFOLIC-PN

1

NORMOSOL -R

1

NATAFORT

1

NORMOSOL-M IN D5W

1

NATALCARE CFE 60

1

NORMOSOL-R

3

NATALCARE GLOSSTABS

1

NORMOSOL-R IN D5W

1

NATALCARE PIC

1

NOVAMINE

1

NATALCARE PIC FORTE

1

NOVANATAL

3

NATALCARE PLUS

1

NOVASTART

3

NATALCARE RX

1

NU-NATAL ADVANCED

1

NC = Not covered

Utilization Management

QL/ Day(s)

111

112

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

NUTRACARE

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

3

potassium chloride cr

1

NUTRILYTE

1

potassium chloride er

1

NUTRILYTE II

1

potassium chloride injection

1

NUTRINATE

1

potassium chloride liquid

1

NUTRISPIRE

1

potassium chloride sr

1

OB COMPLETE

3

potassium citrate extended

1

OBSTETRIX EC

1

POTASSIUM EFFERVESCENT

1

OBSTETRIX-100

3

PRECARE

3

OBTREX

3

PRECARE CONCEIVE

3

O-CAL PRENATAL

3

PRECARE PREMIER

3

OMNII GEL

3

PRECARE PRENATAL

3

ORACIT

3

PREMASOL

3

ORIGINAL PRENATAL FORMULA

1

PREMESIS RX

3

PERF CHOICE GEL

1

PRENA-CAP

3

PERFECT CHOICE BRUSH-ON

1

PRENAFIRST

1

PERFECT CHOICE HOME GEL

1

PRENATABS CBF

1

PERFECT CHOICE PERIO RINS

1

PRENATABS FA

1

PERIO MED

1

PRENATABS OBN

1

PERRY PRENATAL

3

PRENATABS RX

1

PHARMAFLUR

1

PRENATAL

1

PHOS-FLUR

1

PRENATAL 1 + IRON

1

PLASMA-LYTE A

3

PRENATAL 1 PLUS 1

1

POLY IRON PN

1

PRENATAL 1+1

1

POLY IRON PN FORTE

1

PRENATAL 19

1

POLYCITRA

3

PRENATAL AD

1

POLYCITRA-K CRYSTALS

3

PRENATAL ADVANTAGE

1

POLYCITRA-K SOLUTION

3

PRENATAL FA

1

POLYCITRA-LC

3

PRENATAL FORMULA

1

potassium acetate

1

PRENATAL FORMULA 3

1

potassium bicarbonate

1

PRENATAL LOW IRON

1

POTASSIUM CHLORIDE 0.15%

3

PRENATAL MR 90 FE

1

potassium chloride and sodium chloride

1

PRENATAL MTR/SELENIUM

1

NC = Not covered

Utilization Management

QL/ Day(s)

113

114

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

PRENATAL MULTIVITAMIN

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

1

SF 5000 PLUS

1

PRENATAL MULTIVITAMIN-ULT

1

SHOHL’S SOLUTION MODIFIED

3

PRENATAL OPT

1

sodium acetate

1

PRENATAL PLUS

1

sodium bicarbonate

1

PRENATAL PLUS NF

1

sodium chloride

1

PRENATAL PLUS/27MG IRON

1

sodium fluoride chewable

1

PRENATAL PLUS/BETACAROTEN

1

sodium fluoride gel

1

PRENATAL PLUS/IRON

1

sodium lactate

1

PRENATAL RX

1

STANNOUS FLUORIDE ORAL RI

1

PRENATAL RX 1

1

STRONGSTART

3

PRENATAL RX/BETA-CAROTENE

1

STUARTNATAL PLUS 3

3

PRENATAL S

1

T-4 GEL

1

PRENATAL START

1

TERNAMAR

1

PRENATAL Z

1

THERA-FLUR-N

3

PRENATAL Z ADVANCED FORMU

1

T-NAF

1

PRENATAL/FOLIC ACID

1

T-PERIO

1

PRENATAL-H

1

TPN ELECTROLYTES FTV

1

PRENATAL-U

1

TRAVASOL

3

PRENATE ELITE

3

TRAVERT

1

PRENATE GT

3

TRICARE

1

PREVIDENT

3

TRICITRATES

1

PREVIDENT 5000 PLUS

3

TRINATE

1

PRIMACARE

3

TROPHAMINE

3

PRIMACARE ONE

3

ULTRA NATAL

1

PROCALAMINE

3

ULTRA NATALCARE

1

QUICK-K

3

ULTRA TABS

1

RENAMIN

3

ULTRA-NATAL

1

RINGER'S INJECTION

1

UROCIT-K 10

3

ROCALTROL

3

URO-KP-NEUTRAL

3

RUM-K

3

VINATAL 600

1

SELECT-OB

3

VINATAL FORTE

1

SF

1

VINATE 90

1

NC = Not covered

Utilization Management

QL/ Day(s)

115

116

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

VINATE ADVANCED

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

1

isoniazid

1

VINATE GOOD START

1

MYAMBUTOL

3

VINATE GT

1

MYCOBUTIN

3

VINATE II

1

NYDRAZID

3

VINATE M

1

PASER

3

VINATE ULTRA

1

PRIFTIN

3

VITAFOL-OB

1

pyrazinamide

1

VITAFOL-PN

3

RIFADIN

3

VITA-NATAL

1

RIFAMATE

3

VITA-PREN

3

rifampin

1

VYNATAL FA

1

RIFATER

3

ZEMPLAR

2

RIMACTANE

1

SEROMYCIN

3

THYROID DRUGS

NC = Not covered

Utilization Management

QL/ Day(s)

(QL) (PR) (ST)

1/1 day(s)

117

ARMOUR THYROID

3

(PR)

TRECATOR

3

BIO-THROID

1

(PR)

TRECATOR-SC

3

CYTOMEL

3

ULCER AND STOMACH DRUGS

LEVOTHROID

1

ACIPHEX

3

levothyroxine

1

ACTIGALL

3

LEVOXYL

1

AXID

3

NATURE-THROID

1

BENTYL

3

SYNTHROID

3

CARAFATE

3

thyroid

1

cimetidine

1

THYROLAR-1

3

CONSTULOSE

1

TRIOSTAT

3

CYSTOSPAZ

3

UNITHROID

1

dicyclomine hydrochloride

1

WESTHROID

1

(PR)

DISPAS

1

(PR)

WESTHROID-3

1

(PR)

EMEND 40, 80, 125MG

2

(QL) (PR)

5/30 day(s)

EMEND 80-125MG

2

(QL) (PR)

6/30 day(s)

TUBERCULOSIS DRUGS

(PR)

(PR)

CAPASTAT SULFATE

3

ENULOSE

1

dapsone

1

famotidine

1

ethambutol hydrochloride

1

GENERLAC

1

ISONARIF

1

glycopyrrolate

1

(ST)

118

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

119

Drug Name

3-Tier Open

Utilization Management

QL/ Day(s)

Drug Name

3-Tier Open

Utilization Management

HELIDAC

3

(QL)

56/14 day(s)

PREVACID I.V.

2

(PR)

hyoscyamine

1

(PR)

PREVACID SOLUTAB

2

(QL) (PR)

1/1 day(s)

hyoscyamine sulfate

1

(PR)

PREVPAC

3

(QL)

14/14 day(s)

hyoscyamine sulfate cr

1

(PR)

PRILOSEC

3

(QL) (PR) (ST)

1/1 day(s)

hyoscyamine sulfate er

1

(PR)

PRO-BANTHINE

3

hyoscyamine sulfate sr

1

(PR)

propantheline bromide

1

(PR)

hyoscyamine sulfate tr

1

(PR)

PROTONIX 20, 40MG

2

(QL) (PR)

HYOSPAZ

1

(PR)

PROTONIX INJECTION

2

(PR)

HYOSYNE

1

(PR)

ranitidine hydrochloride

1

IB-STAT

3

(PR)

REGLAN

3

KRISTALOSE

3

ROBINUL

3

lactulose

1

ROBINUL FORTE

3

LEVBID

3

(PR)

SAL-TROPINE

3

LEVSIN

3

(PR)

scopolamine hydrobromide

1

LEVSIN/SL

3

(PR)

SIMETYL

3

LEVSINEX

3

(PR)

SPACOL T/S

1

(PR)

LOTRONEX

2

(PR)

SPASDEL

1

(PR)

MAR-SPAS

3

(PR)

sucralfate

1

metoclopramide hydrochloride

1

SYMAX DUOTAB

3

(PR)

NEOSOL

1

(PR)

SYMAX FASTABS

1

(PR)

NEXIUM

2

(QL) (PR)

SYMAX-SL

1

(PR)

NEXIUM I.V.

3

(PR)

SYMAX-SR

1

(PR)

nizatidine

1

TAGAMET

3

(ST)

NULEV

3

(PR)

TALADINE

3

(ST)

omeprazole

1

(QL) (PR)

URSO 250

3

PAMINE

3

URSO FORTE

3

PAMINE FORTE

3

URSODIOL

1

PEPCID

3

ZANTAC

3

(ST)

PEPCID I.V.

3

ZANTAC SYRUP

3

(ST)

PEPCID PREMIXED

3

ZEGERID

3

(QL) (PR) (ST)

1/1 day(s)

PEPCID RPD

3

(ST)

ZEGERID CAPSULE

3

(QL) (PR) (ST)

1/1 day(s)

PREVACID

2

(QL) (PR)

ZELNORM

3

1/1 day(s)

1/1 day(s)

(ST)

1/1 day(s)

QL/ Day(s)

1/1 day(s)

(PR)

120

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

U R I N A RY A N D P R O S TAT E D R U G S

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

Utilization Management

PROSCAR

3

(PR)

acetic acid irrigation soln

1

PROSED EC

3

(PR)

AMINOAC ACID

1

PROSED/DS (ATROPINE FREE)

3

(PR)

AVODART

2

PYRIDIUM

3

bethanechol chloride

1

PYRIDIUM PLUS

3

RENAGEL

2

SANCTURA

3

sodium chloride

1

suby’s solution g for irrigation

1

THIOLA

3

TRAC

3

TRELLIUM PLUS

1

URECHOLINE

3

URELIEF PLUS

1

URELLE

3

(PR)

URETRON D/S

3

(PR)

UREX

3

URIMAR-T

1

(PR)

URIN D/S

1

(PR)

URINARY ANTISEPTIC #2

1

(PR)

URINARY ANTISEPTIC F.C.

1

(PR)

URISED

3

(PR)

URISEPTIC

1

(PR)

URISPAS

3

URISYM

3

(PR)

URITACT DS

3

(PR)

URITACT-EC

1

(PR)

URO BLUE

1

(PR)

UROGESIC-BLUE

1

(PR)

UROQID #2

3

UROXATRAL

2

(PR)

USEPT

1

(PR)

butabarbital and hyoscyamine hydrobromide and phenazopyridine hydrochloride

1

DETROL

2

DETROL LA

2

DITROPAN

3

DITROPAN XL

3

ELMIRON

3

ENABLEX

3

finasteride

1

flavoxate hydrochloride

1

FLOMAX

2

flutamide

1

FOSRENOL

2

HIPREX

3

LITHOSTAT

3

MANDELAMINE

3

methenamine hippurate

1

methenamine mandelate

1

MHP-A

1

neomycin sulfate and polymyxin b sulfate

1

NEOSPORIN GU SOL

3

NILANDRON

3

oxybutynin chloride

1

OXYTROL

2

phenazopyridine hydrochloride

1

PHOSLO

2

(PR)

(PR)

(PR)

(PR)

NC = Not covered

(PR)

QL/ Day(s)

121

122

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered QL/ Day(s)

Drug Name

3-Tier Open

Utilization Management

UTA

3

UTIRA

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

Drug Name

3-Tier Open

Utilization Management

(PR)

ENGERIX-B

2

(PR)

3

(PR)

FLEBOGAMMA

3

(PR)

UTRONA

1

(PR)

GAMASTAN S/D

1

(PR)

VANTAS

3

(PR)

GAMMAGARD LIQUID

3

(PR)

VESICARE

2

GAMMAGARD S/D

3

(PR)

GAMMAR-P I.V.

1

(PR)

GAMUNEX

3

(PR)

GARDASIL

2

(PR) (PR)

VA C C I N E S A N D I M M U N O L O G Y D R U G S ACTHIB

2

ACTIMMUNE

3

ADACEL

2

GENGRAF

1

ADAGEN

3

gold sodium thiomalate

1

ALFERON N

3

HAVRIX

2

ARAVA

3

HIBTITER

2

ATGAM

3

HUMIRA

2

ATTENUVAX

2

HUMIRA PEN

2

aurothioglucose

1

IMMUNE GLOBULIN

1

(PR)

AVONEX

2

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

2

(PR)

AZASAN

3

(PR)

IMURAN

3

(PR)

azathioprine

1

(PR)

INCRELEX

3

BAYGAM

1

(PR)

INFANRIX

2

BETASERON

2

INFERGEN

3

(PR)

BOOSTRIX

2

INTRON-A

3

(PR)

CARIMUNE

1

(PR)

INTRON-A W/DILUENT

3

(PR)

CARIMUNE NANOFILTERED

3

(PR)

IPLEX

3

(PR)

CELLCEPT

2

(PR)

IPOL INACTIVATED IPV

2

CELLCEPT INTRAVENOUS

2

IVEEGAM EN

1

COMVAX

2

JE-VAX

2

COPAXONE

2

KINERET

3

cyclosporine

1

leflunomide

1

DAPTACEL

2

MENACTRA

2

DECAVAC

2

MENOMUNE-A/C/Y/W-135

2

DIPTHERIA/TETANUS TOXOID

1

MERUVAX II W/DILUENT 10 D

2

ENBREL

2

M-M-R II

2

(PR)

(PR)

(PR)

(PR)

(PR)

(PR)

QL/ Day(s)

123

124

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

Drug Name

3-Tier Open

M-M-R II W/DILUENT 1 DOSE

ST = Step therapy PR = Precertification

NC = Not covered

Utilization Management

QL/ Day(s)

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

2

RIDAURA

3

M-R-VAX II

2

ROFERON-A

3

MUMPSVAX W/DILUENT 10 DOS

2

ROTATEQ

2

MYFORTIC

3

SANDIMMUNE

3

(PR)

MYOCHRYSINE

3

SIMULECT

3

(PR)

NEORAL

3

(PR)

SYNAGIS

3

(PR)

OCTAGAM

3

(PR)

TE ANATOXAL BERNA

2

(PR)

ORENCIA

3

tetanus toxoid

1

(PR)

ORTHOCLONE OKT3

3

(PR)

TETANUS TOXOID ADSORBED

2

(PR)

PANGLOBULIN

3

(PR)

TETANUS/DIPHTHERIA TOXOID

1

PANGLOBULIN NF

1

(PR)

THALOMID

3

PEDIARIX

2

THYMOGLOBULIN

3

PEDVAX HIB

2

TRIHIBIT

2

PEGASYS

2

(PR)

TRIPEDIA

2

PEG-INTRON

2

(PR)

TWINRIX

2

PEG-INTRON REDIPEN

2

(PR)

TYPHIM VI

2

POLYGAM S/D

3

(PR)

TYPHOID VI

2

PROGRAF

3

(PR)

TYSABRI

3

PROQUAD

2

VAQTA

2

RABAVERT

2

(PR)

VARIVAX

2

RAPAMUNE

3

(PR)

VENOGLOBULIN-S

3

(PR)

REBETOL

3

(PR)

VIVAGLOBIN

3

(PR)

REBETRON

3

(PR)

VIVOTIF BERNA

2

REBIF

2

YF-VAX

2

RECOMBIVAX HB

2

ZENAPAX

3

(PR)

REMICADE

3

ZOSTAVAX

3

(PR)

REVLIMID

3

VIRAL INFECTION DRUGS

RHEUMATREX

3

acyclovir

1

RIBAPAK

1

(PR)

AGENERASE

3

RIBASPHERE

1

(PR)

amantadine

1

RIBATAB

1

(PR)

APTIVUS

3

ribavirin

1

(PR)

ATRIPLA

3

(PR)

(PR)

NC = Not covered

Utilization Management

(PR)

(PR)

(PR)

QL/ Day(s)

125

126

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

NC = Not covered

KEY: UPPERCASE = Brand name medications 1, 2, 3 = Copay tier level Lower case italics = Generic medications QL = Quantity limits

ST = Step therapy PR = Precertification

Drug Name

3-Tier Open

Utilization Management

QL/ Day(s)

Drug Name

3-Tier Open

BARACLUDE

3

(QL)

1/1 day(s)

SUSTIVA

3

BARACLUDE SOLUTION

3

(QL)

20/1 day(s)

SYMMETREL

3

COMBIVIR

3

TAMIFLU CAPSULES

COPEGUS

3

CRIXIVAN

NC = Not covered

127

Utilization Management

QL/ Day(s)

3

(QL) (PR)

20/365 day(s)

TAMIFLU SUSPENSION

3

(PR)

3

TRIZIVIR

3

CYTOVENE

3

TRUVADA

3

DENAVIR

3

VALCYTE

3

didanosine

1

VALTREX

2

EMTRIVA

3

VIDEX

3

EPIVIR

3

VIDEX BUFFER

3

EPIVIR HBV

2

VIDEX EC

3

EPZICOM

3

VIRACEPT

2

FAMVIR

2

VIRAMUNE

3

FLUMADINE

3

VIRAZOLE

3

foscarnet sodium

1

VIREAD

3

FOSCAVIR

3

VISTIDE

3

FUZEON

2

ZERIT

3

ganciclovir

1

ZIAGEN

3

HEPSERA

3

zidovudine

1

HIVID

3

ZOVIRAX CPASULES

3

INVIRASE

3

ZOVIRAX CREAM

3

KALETRA

3

LEXIVA

2

NORVIR

3

PREZISTA

3

RELENZA DISKHALER

3

RESCRIPTOR

2

RETROVIR

3

RETROVIR IV INFUSION

2

RETROVIR SYRUP

3

REYATAZ

2

rimantadine hydrochloride

1

(PR)

(QL)

40/365 day(s)

128

Aetna Medicare Pre-Enrollment Preferred Drug List Alphabetical Listing 55

129 AEROHIST PLUS

10

ALDEX G

10

AEROKID

10

ALDEX-CT CHEW

11

50% UREA NAIL STICK

55

ACNE MEDICATION-5

8-MOP

55

ACTHIB

122

AFEDITAB CR 30MG

81

ALDORIL

81

A/B EAR DROPS

73

ACTICIN

66

AFEDITAB CR 60MG

81

ALDURAZYME

67

A/B OTIC

73

ACTIGALL

117

AGENERASE

125

ALENAZE-D

11

ABELCET

40

ACTIMMUNE

122

AGGRENOX

48

ALESSE

68

ABER-FED

10

ACTIQ

97

AGRYLIN

48

ALFERON N

ABILIFY

46

ACTIVELLA

68

AH-CHEW

10

ALI-FLEX

97

ABILIFY DISCMELT

46

ACTONEL 35MG

96

AH-CHEW II

10

ALIMTA

34

ABILIFY SOLUTION

46

ACTONEL 5, 30MG

96

AHIST

10

ALINIA

66

ABRAXANE

34

ACTONEL WITH CALCIUM

96

AIRET

10

ALKERAN INJECTION

34

ACCOLATE

10

ACTOPLUS MET

52

AK-CON

73

ALKERAN TABLETS

34

ACCUHIST

10

ACTOS

52

AK-DILATE

73

ALLANFIL 405

55

ACCUNEB

10

ACUFLEX

97

AKINETON

103

ALLANFIL SPRAY

55

ACCUPRIL 40MG

80

ACULAR

73

AKNE-MYCIN

55

ALLANTAN PEDIATRIC

11

ACCUPRIL 5, 10 20MG

81

ACULAR LS

73

AK-POLY-BAC

73

ALLANVAN-S

11

ACCURETIC

81

ACULAR PF

73

AK-TAINE

73

ALLANZYME OINTMENT

55

ACCUTANE

55

acyclovir

125

AK-TOB

73

ALLANZYME SPRAY

55

ACCUZYME

55

ADACEL

122

ALACOL

10

ALLEGRA 180MG

11

acebutolol

81

ADAGEN

122

ALA-CORT

55

ALLEGRA 30, 60MG

11

ACEON 2, 4MG

81

ADALAT CC 30, 60MG

81

ALAMAST

73

ALLEGRA-D 12 HOUR

11

ACEON 8MG

81

ADALAT CC 90MG

81

ALA-SCALP

55

ALLEGRA-D 24 HOUR

11

ACETADOTE

9

ADDERALL 20MG

47

ALBALON

73

ALLERGEN

73

122

acetaminophen and codeine

97

ADDERALL 5, 7.5, 10, 12.5, 15, 30MG

47

ALBENZA

66

ALLERSCRIPT

11

acetaminophen and hydrocodone

97

ADDERALL XR

47

albuterol hfa

10

ALLERSOL

73

acetaminophen and hydrocodone bitartrate

97

ADOXA

27

albuterol inhaler

10

ALLERX PE

11

acetaminophen and oxycodone

97

ADRENALIN

10

albuterol neb solution

10

ALLERX SUSPENSION

11

acetaminophen and propoxyphene napsylate

97

ADRIAMYCIN

34

albuterol syrup

10

ALLERX TABLETS

11

ACETASOL HC

73

ADRUCIL

34

albuterol tablets

10

ALLFEN JR

11

acetazolamide

81

ADVAIR DISKUS

10

ALCAINE

73

allopurinol

80

acetic acid and aluminum acetate

73

ADVAIR HFA

10

ALCET

97

ALOCRIL

74

acetic acid and hydrocortisone

73

ADVANCED NATALCARE

106

alclometasone

55

ALOMIDE

74

acetic acid hc

73

ADVANCED-RF NATALCARE

106

ALCOHOL SWABS

52

ALOPRIM

80

106

ALORA

68

acetic acid irrigation soln

120

ADVICOR

81

alcohol, usp and dextrose (anhydrous)

acetylcysteine

10

AERO OTIC HC

73

ALDACTAZIDE

81

ALOXI

95

ACIDIC VAGINAL JELLY

94

AEROBID

42

ALDACTONE

81

ALPAIN

97

AEROBID-M

42

ALDARA

55

ALPHAGAN P

74

AEROHIST

10

ALDEX

10

ALPHATREX

55

ACIPHEX ACLOVATE

117 55

130

131

ALREX

74

AMINOSYN M

107

ANDEHIST NR

11

ARESTIN

52

ALTACE 1.25, 2.5, 5MG

81

AMINOSYN-HBC

107

ANDRODERM

68

ARICEPT

25

ALTACE 10MG

81

AMINOSYN-HF

107

ANDROGEL

68

ARICEPT ODT

25

ALTAFRIN

74

AMINOSYN-PF

107

ANDROGEL PUMP

68

ARIMIDEX

34

ALTEX-PSE

11

AMINOSYN-RF

107

ANDROID

68

ARISTOCORT

56

ALTOPREV

81

amiodarone

81

ANDROXY

68

ARISTOCORT A

56

ALUPENT

11

AMI-TEX LA

11

ANEMAGEN OB

125

AMITEX PSE

11

ANESTACON

26

ARIXTRA

amantadine

107

ARISTOSPAN INTRA-ARTICULA

9 48

AMARYL

52

AMITIZA

50

ANEXSIA

97

ARMOUR THYROID

116

AMBI

11

amitriptyline

38

ANGELIQ

68

AROMASIN

34

38

ANSAID

42

ARRANON

34

ARTHROTEC

42

AMBIEN 10MG

106

amitriptyline and chlordiazepoxide

AMBIEN 5MG

106

ammonium chloride

AMBIEN CR

106

AMMONIUM LACTATE

56

ANTARA

81

ASACOL

50

AMBIFED-G

11

AMNESTEEM

56

anthralin

56

ASCOMP/CODEINE

97

AMBISOME

40

AMOCLAN

27

ANTIBEN

74

ASMANEX

11

amcinonide

56

amoxapine

38

ANTIBIOTIC EAR

74

ASP 300/200/20

97

AMDRY-C

11

amoxicillin

27

antipyrine and benzocaine

74

A-SPAS

50

AMERGE

93

amoxicillin and clavulanic acid

27

ANTIVERT

95

AMERICAINE

26

AMOXIL

28

ANTIZOL

9

aspirin and butalbital and caffeine and codeine phosphate

97

AMERICAINE OTIC

74

AMERIFED

11

AMPHETAMINE SALT COMBO 5, 7.5, 10, 12.5, 15, 30MG

A-METHAPRED

9

107

ANTABUSE

9

ANUSOL-HC

50

aspirin and codeine

98

47

ANZEMET 50, 100MG

95

aspirin, butalbital, caffeine and codeine

98

AMPHETAMINE SALTS COMBO 20MG

47

ANZEMET SOLUTION

95

aspirin, caffeine and propoxyphene

98

AMEVIVE

56

AMPHOCIN

40

APEXICON

56

aspirin, oxycodone and oxycodone

98

AMIDAL

11

AMPHOTEC

40

APEXICON E

56

ASTELIN

11

AMIGESIC

42

amphotericin b

40

APHTHASOL

52

ASTRAMORPH

98

amikacin sulfate

27

ampicillin

28

APIDRA

52

ATABEX PRENATAL

AMIKIN

27

ampicillin sodium and sulbactam sodium

28

APIDRA OPTICLIK

52

ATACAND 32MG

81

amiloride hydrochloride (anhydrous)

81

ANABAR

97

APOKYN

ATACAND 4, 8, 16MG

81

ANACAINE

26

APRI

ATACAND HCT 32-12.5MG

81

ANADROL-50

68

APTIVUS

125

ATACANDHCT 5, 7.5, 10, 12.5, 15,30MG

81

106

ATAMET

103

amiloride hydrochloride (anhydrous) and hydrochlorothiazide

81

103 68

107

AMINATE FE-90

106

ANAFRANIL

38

AQUACHLORAL

AMINESS

106

anagrelide

48

AQUATAB D

11

ATARAX

26

94

ANALPRAM-HC

50

ARALAST

11

atenolol

81

120

ANAMANTLE HC

50

ARALEN

66

atenolol and chlorthalidone

81

AMINO ACID CERVICAL AMINOAC ACID AMINO-CERV

94

ANAPROX

42

ARANELLE

68

ATGAM

122

aminophylline

11

ANAPROX DS

42

ARANESP

48

ATREZA

50

AMINOSYN

107

ANASPAZ

50

ARAVA

122

ATRIDOX

52

AMINOSYN II

107

ANCOBON

40

AREDIA

96

ATRIPLA

125

132

133

atropine sulfate and diphenoxylate hydrochloride

50

AXERT 6.25MG

atropine sulfate injection

50

AXID

atropine sulfate opthl ointment

74

AYGESTIN

ATROPINE-CARE

74

ATROVENT HFA ATROVENT NASAL SOLUTION ATTENUVAX

BARACLUDE

126

benztropine mesylate

BARACLUDE SOLUTION

126

BETAGAN

74

68

BAYGAM

122

BETAGAN C CAP QD

74

AZACTAM

28

B-D INSLUIN PEN NEEDLE

53

BETAGAN WITHOUT C CAP

74

11

AZACTAM IN DEXTROSE

28

B-D SYRINGE W-NEEDLE, INSULIN

53

betamethasone dipropionate

57

11

AZASAN

122

BECONASE AQ

11

betamethasone dipropionate and clotrimazole

57

azathioprine

122

BE-FLEX PLUS

98

betamethasone valerate

57

belladonna

50

BETAPACE

82

BELLADONNA ALKALOIDS & OP

50

BETAPACE AF

82 122

122

93 117

103

augmented betamethasone dipropionate

56

AZELEX

56

AUGMENTIN

28

AZILECT

103

AUGMENTIN ES-600

28

azithromycin

28

belladonna extract and opium

50

BETASERON

AUGMENTIN XR

28

AZMACORT

11

BENADRYL

12

BETA-VAL

57

AUROBIOTIC-HC

74

AZOPT

74

benazepril

82

betaxolol hydrochloride

82

AURODEX

74

AZULFIDINE

50

benazepril 40mg

82

betaxolol hydrochloride opthl solution

74

AUROGUARD

74

AZULFIDINE EN-TABS

50

benazepril and hydrochlorothiazide

82

bethanechol chloride

122

B & O 15-A SUPPRETTE

50

benazepril, 10, 20mg

82

BETIMOL

74

AUROTO

74

B & O 16-A SUPPRETTE

50

BENICAR 40MG

82

BETOPTIC-S

75

AVALIDE 150-12.5MG

81

BACIIM

28

BENICAR 5, 20MG

82

BEXXAR

34

AVALIDE 300-12.5, 300-25MG

81

BACI-RX

28

BENICAR HCT 20-12.5MG

82

BEXXAR 131 IODINE

34

AVANDAMET

52

BACITRACIN INJECTION

28

BENICAR HCT 40-12.5, 40-25MG

82

BIAXIN

28

AVANDARYL

52

bacitracin optical ointment

74

BENSAL HP

56

BIAXIN XL

28

AVANDIA

53

bacitracin zinc and hydrocortisone acetate and neomycin sulfate and polymyxin b sulfate

BEN-TANN

12

BICILLIN C-R

28

74

117

BICILLIN L-A

28

bacitracin zinc and neomycin sulfate and polymyxin b sulfate

74

bacitracin zinc and polymyxin b sulfate

74

bacitracin zinc, neomycin and polymyxin b

74

aurothioglucose

AVAPRO 300MG

81

AVAPRO 75, 150MG

81

AVAR

56

AVAR CLEANSER

56

AVAR GREEN

56

AVAR-E EMOLLIENT

56

bacitracin zinc,hydrocortisone, neomycin and polymyxin b

AVAR-E GREEN

56

baclofen

AVASTIN

34

BACTERIOSTATIC WATER FOR

AVELOX

28

BACTOCILL IN DEXTROSE

AVELOX ABC PACK

28

AVENTYL

BENTYL

120

BENZAC AC

56

BICITRA

BENZAC AC WASH

56

BICNU

34

BENZAC W

56

BIDHIST

12

BENZAC W WASH

56

BIDHIST-D

12

74

BENZACLIN

56

BIDIL

82

94

BENZAGEL

56

BILTRICIDE

66

BENZAGEL WASH

56

BINORA CREAMY WASH

57

28

BENZAMYCIN

56

BIOHIST LA

12

BACTRIM

28

BENZASHAVE

56

BIO-STATIN

41

38

BACTRIM DS

28

BENZIQ

56

BIO-THROID

116

AVIANE

68

BACTROBAN

56

BENZIQ LS

56

bisoprolol fumarate

82

AVINZA

98

BACTROBAN NASAL

28

BENZIQ WASH

56

bisoprolol fumarate and hydrochlorothiazide

82

AVITA

56

BALACET 325

98

BENZOTIC

74

BLENOXANE

34

107

107

AVODART

120

BALAGAN

74

benzoyl peroxide

56

bleomycin sulfate

34

AVONEX

122

BALZIVA

68

benzoyl peroxide and urea (carbamide)

57

BLEPH-10

75

BANCAP-HC

98

BENZOYL PEROXIDE WASH

57

BLEPHAMIDE

75

AXERT 12.5MG

93

134

135

BLEPHAMIDE LIQUIFILM

75

BUBBLI-PRED

9

CAMPRAL

BLEPHAMIDE S.O.P.

75

BUCALCIDE

26

CAMPTOSAR

BLOCADREN

93

BUCALSEP

57

BONIVA 150MG

96

BUDEPRION

BONIVA 2.5MG

97

BONIVA INJECTION

97

9

CARDIZEM LA 180MG

83

34

CARDIZEM LA 240, 300, 306, 420MG

83

CANASA 1000MG

50

CARDURA

83

38

CANASA 500MG

50

CARDURA XL

83

bumetanide

82

CANCIDAS

41

CARENATE 600

107

BUMEX

82

CANTIL

50

CARIMUNE

122

CARIMUNE NANOFILTERED

122

BOOSTRIX

122

BUPHENYL

94

CAPASTAT SULFATE

BOROFAIR

75

BUPRENEX

98

CAPEX

57

carisoprodol

94

BOTOX

75

buprenorphine hydrochloride

98

CAPHOSOL

52

carisoprodol and aspirin

94

BPM

12

BUPROBAN

CAPITAL/CODEINE

98

CARISOPRODOL COMPOUND

94

BPM PSEUDO

12

bupropion hcl 75, 100mg

38

CAPITROL

57

carisoprodol, codeine phosphate and aspirin

94

BRETHINE

12

bupropion hcl er 100, 150mg

38

CAPOTEN

82

CARMOL 40

57

BREVICON

68

bupropion hcl sr 150, 200mg

38

CAPOZIDE

82

CARMOL SCALP TREATMENT

57

BREVOXYL

57

BUSPAR

26

captopril

82

CARMOL-HC

57

BREVOXYL CREAMY WASH

57

buspirone hydrochloride

26

captopril and hydrochlorothiazide

82

CARNITOR

107

BUSULFEX

34

CARAC

57

carteolol hcl

75

BRIGHT BEGINNINGS PRENATA brimonidine tartrate BROFED

107 75 12

BROMAXEFED RF

12

BROMDEC

12

BROMFED

12

BROMFED PD

12

BROMFENEX

12

BROMFENEX PD

12

BROMHIST PEDIATRIC

12

BROMHIST-NR

12

bromocriptine mesylate brompheniramine

103 12

brompheniramine tannate and phenylephrine tannate 12 BRONCAP

12

BRONCHOLATE

12

BRONCODUR

12

BRONCOMAR-1

12

BRONDIL

12

BROVEX

12

BROVEX CT

12

BROVEX SR

12

BROVEX-D

12

butabarbital and hyoscyamine hydrobromide and phenazopyridine hydrochloride

9

120

butalbital, acetaminophen, caffeine and codeine phosphate

98

butorphanol tartrate injection

98

butorphanol tartrate nasal solution

98

B-VEX

12

BY-ACHE

98

BYETTA

53

C.M.T

42

cabergoline

104

CADUET

82

CAFERGOT

93

CAFGESIC

98

CALAN

82

CALAN SR 120MG

82

CALAN SR 180MG

82

CALAN SR 240MG

82

CALCIJEX

107

calcitriol

107

CAL-NATE

107

CAMILA

68

CAMPATH

34

116

CARAFATE

117

CARTIA XT 120MG

83

carbamazepine

105

CARTIA XT 180MG

83

CARTIA XT 240, 300MG

83

CARBASTAT

75

CARBATROL

105

CARTROL

83

carbidopa anhydrous and levodopa

103

cascara sagrada

50

carbinoxamine maleate

12

CASODEX

68

carboplatin

34

CATAFLAM

42

CARBOPTIC

75

CATAPRES

83

CARDEC

12

CATAPRES-TTS

83

CARDENE 20MG

82

CAVAREST

52

CARDENE 30MG

82

CAVIRINSE

107

CARDENE I.V.

82

CEDAX

28

CARDENE SR

82

CEENU

34

CARDENE SR 30MG

82

cefaclor

28

CARDENE SR 60MG

82

cefaclor er

28

CARDIZEM 120MG

82

cefadroxil hemihydrate

28

CARDIZEM 30, 60, 90MG

83

cefadroxil monohydrate

28

CARDIZEM CD 120MG

83

cefazolin sodium

28

CARDIZEM CD 180MG

83

CEFAZOLIN SODIUM-DEXTROSE

28

CARDIZEM CD 240, 300, 360MG

83

CEFIZOX

28

CARDIZEM INJECTION

83

CEFIZOX IN DEXTROSE 5%

28

CARDIZEM LA 120MG

83

cefotaxime sodium

28

136 cefoxitin cefpodoxime proxetil cefprozil ceftazidime CEFTIN ceftriaxone sodium ceftriaxone sodium and dextrose (anhydrous) cefuroxime sodium cefuroxime sodium and dextrose monohydrate CEFZIL CELEBREX 100, 400MG CELEBREX 200MG CELESTONE CELEXA 10, 20, 40MG CELEXA SOLUTION CELLCEPT CELLCEPT INTRAVENOUS CELONTIN CENESTIN CENOGEN ULTRA CENTANY CENTEX-PSE ER cephalexin monohydrate cephradine CEREBYX CEREDASE CEREZYME CERON CEROVEL CERUBIDINE CESAMET CESIA CETACORT CHANTIX CHEMET chloral hydrate chloramphenicol sodium succinate chlordiazepoxide and amitriptyline hydrochloride

137 29 29 29 29 29 29 29 29 29 29 42 43 9 38 38 122 122 105 68 107 57 13 29 29 105 67 67 13 57 34 96 68 57 9 9 106 29 38

chlorhexidine gluconate

CLOBEX

58

13

citric acid and lysine hydrochloride and potassium bicarbonate and potassium chloride

107

CLODERM

58

29

citric acid and potassium citrate

107

clofibrate

83

chlorophyllin copper and papain and urea (carbamide) 57

citric acid and sodium citrate

107

CLOLAR

35

chloroquine phosphate

66

CITROLITH

107

clomipramine hcl

39

83

cladribine

35

clonidine hydrochloride

83

13

CLAFORAN

29

CLORPRES

83

CLAFORAN/D5W

29

clotrimazole

41

CLARAVIS

57

clotrimazole lozenge

41

CLARINEX 5MG

13

clotrimazole solution

58

CLARINEX REDITABS

13

clotrimazole troche

41

CLARINEX SYRUP

13

clozapine 100mg

46

CLARINEX-D 12 HOUR

13

clozapine 12.5mg

46

CLARINEX-D 24 HOUR

13

clozapine 200mg

46

chlorpheniramine tannate and phenylephrine tannate 13

clarithromycin

29

clozapine 25, 50mg

46

chlorpromazine hydrochloride

46

CLEARPLEX X

57

CLOZARIL 100MG

46

53

CLEERAVUE-M

75

CLOZARIL 25MG

46

83

clemastine fumarate

13

CMT

43

94

CLENIA

57

codeine phosphate

98

83

CLENIA FOAMING WASH

57

codeine sulfate

98

83

CLEOCIN

29

CODIMAL L.A.

13

43

CLEOCIN SUPPOSITORY

29

COGENTIN

103

57

CLEOCIN-T

57

CO-GESIC

98

49

CLIMARA

68

COGNEX

25

75

CLIMARA PRO

68

COLAZAL

50

117

CLINAC BPO

57

colchicine

80

29

CLINDAGEL

57

COLDAMINE

13

75

CLINDAMAX

57

COLDMIST JR

13

29

clindamycin hydrochloride

29

COLDMIST LA

13

29

clindamycin phosphate

57

COLDMIST S

13

75

CLINDESSE

29

COLESTID

83

29

CLINDETS

58

COLESTID FLAVORED

83

75

CLINIMIX

107

colestipol hcl granule packets

83

35

CLINIMIX E

107

COLFED-A

13

38

CLINISOL SF

107

COLIDROPS

50

38

CLINORIL

43

COLISTIMETHATE SODIUM

29

107

clobetasol propionate

58

COLOCORT

50

107

CLOBEVATE

58

COLY-MYCIN S

75

CHLOR-MES JR CHLOROMYCETIN

chlorothiazide chlorpheniramine maleate chlorpheniramine maleate and methscopolamine nitrate and phenylephrine hydrochloride chlorpheniramine maleate and methscopolamine nitrate and pseudoephedrine hydrochloride chlorpheniramine maleate and pseudoephedrine hydrochloride chlorpheniramine maleate and pseudoephedrine hydrochloride sr

chlorpropamide chlorthalidone chlorzoxazone cholestyramine cholestyramine light choline magnesium trisalicylate ciclopirox olamine cilostazol CILOXAN cimetidine CIPRO CIPRO HC CIPRO I.V. CIPRO XR CIPRODEX ciprofloxacin ciprofloxacin optical solution cisplatin citalopram hydrobromide 10, 20, 40mg citalopram hydrobromide solution CITRACAL PRENATAL + DHA CITRACAL PRENATAL RX

52

13 13 13 13

138

139

COLY-MYCIN-M

29

CORTIC-ND

75

cyclophosphamide

COLYTE

50

CORTIFOAM

50

cyclosporine

COLYTROL

50

cortisone acetate

COLYTROL PEDIATRIC

50

CORTISPORIN CREAM/OINTMENT

COMBIPATCH

68

COMBIVENT

13

COMBIVIR

126

9

35 122

DAUNOXOME

35

DAYPRO

43 47

CYKLOKAPRON

49

DAYTRANA

58

CYMBALTA

39

DDAVP

CORTISPORIN OPTHL

75

CYOTIC

75

DEBACTEROL

52

CORTISPORIN OTIC

75

cyproheptadine hydrochloride

14

DECADRON

43

CORTOMYCIN

75

CYSTADANE

67

DECAVAC DECLOMYCIN

29

DECON-A

14

DECONAMINE SR

14

104

122

COMBUNOX

98

CORZIDE

83

CYSTAGON

67

COMPAZINE

96

COSMEGEN

35

CYSTOSPAZ

117

COMPRO

96

COSOPT

75

CYSTOSPAZ-M

COMTAN

103

COUMADIN

49

CYTADREN

9

DECON-E

14

COMVAX

122

COVERA-HS 180MG

83

cytarabine

35

DECONEX

14

CO-NATAL FA

107

COVERA-HS 240MG

84

CYTOMEL

116

DECONGEST II

14

73

DECONGESTINE TR

14

DECONSAL CT CHEW

14

DECONSAL II

14

50

CONCERTA 18MG

47

COZAAR 100MG

84

CYTOTEC

CONCERTA 27, 36, 54MG

47

COZAAR 25, 50MG

84

CYTOVENE

126

CONDYLOX

58

C-PHED TANNATE

14

CYTOXAN

35

CONEX

13

C-PHEN

14

CYTRA K CRYSTALS

108

DEHISTINE

14

CONPEC

13

CPM 8/PE 20/MSC 1.25

14

CYTRA-2

108

DEL-AQUA

58

CONPEC LA NR

13

CPM 8/PSE 90/MSC 2.5

14

CYTRA-3

108

DEL-BETA

58

CONSTULOSE

117

CRANTEX

14

CYTRA-K

108

DELESTROGEN

69

CONTROLRX

107

CRANTEX ER

14

D.H.E. 45

93

DELTASONE

43

COPAXONE

122

CRANTEX LA

14

dacarbazine

35

DEMADEX

84

13

CRANTEX LAC

14

DACOGEN

35

demeclocycline hydrochloride

29

CREON

67

DALLERGY

14

DEMEROL

98

COPD COPEGUS

126

COPHENE #2

13

CRESTOR

84

DALLERGY JR

14

DEMSER

84

CORDARONE

83

CRESYLATE

75

D-AMINE-SR

14

DEMULEN

69

CORDARONE I.V.

83

CRINONE

69

danazol

69

DENAVIR

126

CORDRAN

58

CRIXIVAN

126

DANTRIUM

94

DENAZE

14

CORDRAN SP

58

CROLOM

75

dantrolene sodium

94

DENTA 5000 PLUS

108

CORDRAN TAPE

58

cromolyn sodium neb solution

14

dapsone

116

DENTAGEL

108

COREG

83

cromolyn sodium opthl

75

DAPTACEL

122

DENTALL 1100 PLUS

108

CORGARD

83

CRYSELLE

69

DARAPRIM

66

DEPACON

105

CORMAX

58

CUBICIN

29

DARVOCET

98

DEPADE

CORTANE-B AQUEOUS

75

CUPRIMINE

43

DARVOCET-N

98

DEPAKENE

105

CORTANE-B LOTION

58

CUTIVATE

58

DARVON

98

DEPAKOTE ER

105

CORTANE-B-OTIC

75

CYCLESSA

69

DARVON COMPOUND

98

DEPAKOTE SPRINKLES

105

cyclobenzaprine hydrochloride

94

DARVON-N

98

DEPEN TITRATABS

43

CYCLOCORT

58

daunorubicin hydrochloride

35

DEPODUR

98

CORTEF

9

CORTIC

75

9

140

141

DEPO-ESTRADIOL

69

dexrazoxane

35

digoxin

84

DIPROLENE

58

DEPO-MEDROL

43

dextroamphetamine sulfate

48

dihydroergotamine mesylate

93

DIPROLENE AF

58

DEPO-PROVERA

69

dextroamphetamine sulfate cr

48

DILACOR XR 120MG

84

DIPTHERIA/TETANUS TOXOID

DEPO-PROVERA CONTRACEPTIVE

69

dextrose

108

DILACOR XR 180MG

84

dipyridamole

49

DEPO-SUBQ PROVERA 104

69

dextrose (anhydrous)

108

DILACOR XR 240MG

84

disopyramide phosphate

85

DEPO-TESTOSTERONE

69

dextrose (anhydrous) and heparin sodium (porcine)

DERMA-SMOOTHE/FS SCALP OI

58

dextrose (anhydrous) and potassium chloride

DERMATOP

58

DERMOTIC

DILANTIN

105

DISPAS

108

DILANTIN INFATABS

105

DISPERMOX

dextrose (anhydrous) and sodium chloride

108

DILANTIN SUSPENSION

105

DITROPAN

120

75

dextrose lactated ringers

108

DILANTIN-125

105

DITROPAN XL

120

DESAL-II

14

DEXTROSTAT

48

DILATRATE SR

84

DIURIL

85

desipramine hydrochloride

39

D-FEDA II

14

DILAUDID

98

DOLACET

98

104

DG 200

14

DILEX-G

15

DOLAGESIC

98

DESOGEN

69

DIABETA

53

DILOR

15

DOLOBID

43

desonide

58

DIABINESE

53

DILOR-G

15

DOLOGESIC

99

DESOWEN

58

DIAMOX

105

DILTIA XT 120MG

84

DOLOPHINE

99

desoximetasone

58

DI-ATRO

50

DILTIA XT 180MG

84

DOLOREX

99

DESOXYN

47

DIBENZYLINE

84

DILTIA XT 240MG

84

DOLOREX FORTE

99

DESPEC

14

DICHLOROACETIC ACID

9

diltiazem hcl injection

84

DOLOTIC

76

DESPEC SR

14

diclofenac potassium

43

diltiazem hcl sr 420mg

84

DONATUSSIN

15

DESQUAM-E

58

diclofenac sodium dr

43

diltiazem hydrochloride 30, 60, 90, 120mg

84

DORYX

30

DESQUAM-X

58

diclofenac sodium ec

43

diltiazem hydrochloride cd 120mg

84

DOSTINEX

104

DESYREL

39

diclofenac sodium er

43

diltiazem hydrochloride cd 180mg

84

DOVONEX

58

DETROL

120

diclofenac sodium sr

43

diltiazem hydrochloride cd 240, 300, 360mg

84

doxazosin mesylate

85

DETROL LA

120

diclofenac sodium xr

43

diltiazem hydrochloride er 120mg

84

doxepin hydrochloride

58

dicloxacillin sodium

29

diltiazem hydrochloride er 60, 90, 240, 300, 360mg 84

DOXIL

35

desmopressin acetate

49

122

117 30

dexamethasone and neomycin sulfate and polymyxin b sulfate

75

dicyclomine hydrochloride

117

diltiazem hydrochloride sr 120mg

84

doxorubicin hydrochloride

35

dexamethasone injection

43

didanosine

126

diltiazem hydrochloride sr 240, 300, 360mg

84

DOXY-CAPS

30

dexamethasone opthl solution

76

DIDRONEL

97

diltiazem hydrochloride xr 240, 300, 360mg

84

doxycycline hyclate

30

dexamethasone solution

43

DIFFERIN

58

DILT-XR 180MG

84

doxycycline monohydrate

30

dexamethasone tablets

43

DIFIL G FORTE

14

DIOVAN 320MG

84

DREXOPHED SR

15

DEXAPHEN SA

14

DIFIL-G

14

DIOVAN 40, 80, 160MG

84

DRIHIST SR

15

DEXASOL

76

diflorasone diacetate

58

DIOVAN HCT 320-12.5, 320-25MG

84

DRITHO-SCALP

58

DEXASPORIN

76

DIFLUCAN

41

DIOVANHCT80-12.5, 160-12.5,160-25MG

85

DRIXOMED

15

dexchlorpheniramine maleate

14

DIFLUCAN 150MG

41

DIPENTUM

51

DROXIA

35

DEXEDRINE 10MG

47

DIFLUCAN IN ISO-OSMOTIC D

41

DIPHENATOL

51

DRYSEC

15

DEXEDRINE 5MG

48

DIFLUCAN IN NACL

41

diphenhydramine hydrochloride

15

D-TANN

15

DEXEDRINE CR 5, 15MG

48

diflunisal

43

DIPHENTANN-D

15

DTIC-DOME

35

DEXPAK

43

DIGITEK

84

dipivefrin hydrochloride

76

DUAC

58

142

143

DUET

108

DYRENIUM

85

ELIXOPHYLLIN-GG

16

EPIFOAM

59

DUET DHA

108

DYTAN

15

ELLENCE

35

epinephrine hydrochloride

16

DUETACT

53

DYTAN-D

16

ELMIRON

120

EPIPEN

85

DUOMAX

15

DYTUSS

16

ELOCON

59

EPIPEN-JR

85

DUONATE-12

15

E.E.S.

30

ELOXATIN

35

EPITOL

105

DUONEB

15

EAR DROPS

76

ELSPAR

35

EPIVIR

126

DUOTAN

15

EAR-GESIC

76

EMADINE

76

EPIVIR HBV

126

DUOTAN PD

15

EASYGEL

108

EMBELINE

59

EPOGEN

49

DUO-VIL

26

EC-NAPROSYN

43

EMBELINE E

59

EPZICOM

126

DURABAC

99

econazole nitrate

59

EMCIN CLEAR

59

EQ MICONAZOLE 3 COMBO PAC

41

DURABAC FORTE

99

ECONOPRED PLUS

76

EMCYT

35

EQ TIOCONAZOLE 1

41

DURACLON

99

ED A-HIST

16

EMEND 40, 80, 125MG

117

EQUETRO

46

DURADRYL

15

ED CHLORPED

16

EMEND 80-125MG

117

ERAXIS

41

DURAFED

15

ED K+10

EMLA

26

ERBITUX

35

DURAGESIC

99

ED-BRON G

16

EMLA/TEGADERM

26

ERGOLOID MESYLATES

25

DURAHIST

15

ED-CHLOR-TAN

16

EMSAM

39

ERGOMAR

93

DURAHIST D

15

EDECRIN

85

EMTRIVA

126

ergotamine tartrate and caffeine

93

DURAHIST PE

15

ED-FLEX

99

E-MYCIN

30

ERRIN

69

DURAMORPH

99

EFFER-K

108

ENABLEX

120

ERTACZO

59

DURAPHEN II

15

EFFERVESCENT POT CHLORIDE

108

enalapril maleate 2.5, 5, 10mg

85

ERYC

30

DURASAL II

15

EFFERVESCENT POTASSIUM

108

enalapril maleate 20mg

85

ERYDERM

59

DURATUSS

15

EFFERVESCENT POTASSIUM/CH

108

enalapril maleate and hydrochlorothiazide

85

ERYGEL

59

DURATUSS GP

15

EFFEXOR 25, 100MG

26

ENBREL

122

ERYPED

30

DURAXIN

99

EFFEXOR 37.5MG

26

ENDOCET

99

ERY-TAB

30

DURICEF

30

EFFEXOR 50MG

27

ENDODAN

99

ERYTHROCIN

30

DYAZIDE

85

EFFEXOR 75MG

27

ENGERIX-B

123

erythromycin

59

DYFLEX-G

15

EFFEXOR XR 150MG

27

ENJUVIA

69

erythromycin and benzoyl peroxide

59

DY-G

15

EFFEXOR XR 37.5, 75MG

27

ENLON-PLUS

95

erythromycin and sulfisoxazole

30

DYGASE

67

EFUDEX

59

ENPRESSE-28

69

erythromycin dr

30

DYLIX

15

EFUDEX OCCLUSION PACK

59

ENTEX

16

erythromycin ec

30

DYNABAC D5-PAK

30

ELAPRASE

67

ENTEX ER

16

erythromycin ethylsuccinate

30

DYNACIN

30

ELDEPRYL

103

ENTEX LA

16

erythromycin lactobionate

30

DYNACIRC

85

ELESTAT

76

ENTEX PSE

16

erythromycin opthl ointment

76

DYNACIRC CR 10MG

85

ELIDEL

59

ENTOCORT EC

43

erythromycin stearate

30

DYNACIRC-CR 5MG

85

ELIGARD

104

ENULOSE

117

ESCLIM

69

DYNAHIST ER

15

ELIMITE

66

ENZYCAP

67

ESKALITH

46

DYNEX

15

ELITEK

35

ENZYMAX

67

ESKALITH CR

46

DYPHYLLINE/GG

15

ELIXOPHYLLIN

16

ephedrine sulfate

85

ESTRACE

69

108

144

145

ESTRACE VAGINAL CREAM

69

EXUBERA COMBINATION PACK

53

flavoxate hydrochloride

120

fluphenazine decanoate

46

ESTRADERM

69

EXUBERA KIT

53

FLEBOGAMMA

123

fluphenazine hydrochloride

46

estradiol

69

FABRAZYME

67

flecainide acetate

85

FLURA-DROPS

estradiol patch

69

FACTIVE

30

FLEXERIL

94

flurbiprofen

43

ESTRASORB

69

famotidine

117

FLEXTRA

99

flurbiprofen sodium opthl

76

ESTRING

69

FAMVIR

126

FLEXTRA DS

99

flutamide

ESTRO-5

69

FANSIDAR

66

FLOMAX

120

ESTROGEL

69

FARESTON

35

FLONASE

16

estropipate

69

FASLODEX

35

FLORINEF

9

ESTROSTEP FE

69

FAZACLO

46

FLOVENT

ethambutol hydrochloride

116

FELBATOL

105

ETHEDENT

108

FELDENE

108

120

fluticasone cream/ointment

59

fluticasone spray

16

fluvoxamine maleate

39

16

FML FORTE

76

FLOVENT HFA

16

FML LIQUIFILM

76

43

FLOVENT ROTADISK

16

FML S.O.P.

76

ETHEXDERM BPW-10

59

felodipine er

85

FLOXIN

30

FML-S LIQUIFILM

76

ETHEZYME

59

FEM PH

94

FLOXIN OTIC

76

FOCALIN

48

ETHMOZINE

85

FEMARA

35

fluconazole

41

FOCALIN XR

48

ethosuximide

105

FEMHRT 1/5

69

fluconazole 150mg

41

FORADIL AEROLIZER

16

ETH-OXYDOSE

99

FEMHRT LOW DOSE

69

fluconazole and sodium chloride

41

FORTAMET

53

ETHYOL

35

FEMRING

69

FLUDARA

35

FORTAZ

30

etidronate disodium

97

FEMTRACE

69

FLUDARABINE PHOSPHATE

35

FORTAZ GALAXY

30

etodolac

43

fenofibrate

85

fludrocortisone acetate

FORTEO

97

etodolac er

43

fenoprofen calcium

43

FLUMADINE

FORTICAL

97

ETOPOPHOS

35

fentanyl citrate

99

flunisolide

16

FOSAMAX 35, 70MG

97

etoposide

35

fentanyl citrate ot lozenge

99

fluocinolone acetonide

59

FOSAMAX 5, 10, 40MG

97

EUDAL-SR

16

fentanyl patch

99

fluocinonide

59

FOSAMAX PLUS D

97

EURAX

66

FENTORA

99

FLUOCINONIDE-E

59

FOSAMAX SOLUTION

97

EVISTA

97

fexofenadine hydrochloride 180mg

16

FLUORABON

108

foscarnet sodium

126

EVOCLIN

59

fexofenadine hydrochloride 30, 60mg

16

FLUOR-A-DAY

108

FOSCAVIR

126

EVOXAC

52

FINACEA

59

FLUORIDE

108

fosinopril sodium

85

EXACTACAIN

26

finasteride

120

FLUORITAB

108

fosinopril sodium 10, 20mg

85

EXEFEN-PD

16

FIORICET/CODEINE

99

fluorometholone

76

fosinopril sodium 40mg

85

EXELDERM

59

FIORINAL/CODEINE #3

99

FLUOR-OP

76

fosinopril sodium and hydrochlorothiazide

85

EXELON

25

FIRST-HYDROCORTISONE

59

FLUOROPLEX

59

FOSRENOL

120

EXETUSS

16

FIRST-PROGESTERONE MC 10

69

fluorouracil injection

35

FRAGMIN

49

EXJADE

9

FIRST-PROGESTERONE VGS 10

70

fluorouracil solution

59

FREAMINE HBC

108 108

9 126

EXOTIC-HC

76

FIRST-TESTOSTERONE

70

fluoxetine hcl 10mg

39

FREAMINE III

EXTENDRYL

16

FLAGYL

30

fluoxetine hcl 20mg

39

FROVA

93

EXTENDRYL JR

16

FLAGYL ER

30

fluoxetine hcl 40mg

39

FUNGIZONE

41

EXTENDRYL SR

16

FLAREX

76

fluoxetine hcl solution

39

FURADANTIN

30

146 furosemide

147 85

gentamicin sulfate cream/ointment

59

gold sodium thiomalate

gentamicin sulfate opthl

76

GOLYTELY

123

HALDOL DECANOATE-100

46

51

HALFLYTELY BOWEL PREP KIT

51

FUZEON

126

G P TEX

16

GENTASOL

76

GORDON’s UREA

59

halobetasol propionate

59

G/P

16

GENTEX LA

17

GP-1200

17

HALOG

60

G/P 1200/60

16

GEOCILLIN

30

G-PHED

17

haloperidol

46

gabapentin

105

GEODON

46

G-PHED-PD

17

haloperidol decanoate

46

GABARONE

105

GEODON INJECTION

46

haloperidol lactate

46

59

gramicidin and neomycin sulfate and polymyxin b sulfate

76

HAVRIX

17

GRIFULVIN-V

41

HC PRAMOXINE

60

17

GRIPEX PE PEDIATRIC

17

HCA ALLERGY RELIEF

18

17

GRISEOFULVIN MICROSIZE

41

HECTOROL

108

17

GRISEOFULVIN ULTRAMICROSI

41

HELIDAC

118

17

GRIS-PEG

41

HEMORRHOIDAL-HC

51

17

GUAIFED

17

HEPARIN SODIUM

49

17

GUAIFED-PD

17

heparin sodium (porcine)

49

59

guaifenesin and phenylephrine hydrochloride

17

heparin sodium (porcine) and sodium chloride

49

59

guaifenesin and pseudoephedrine hydrochloride

17

HEPATAMINE

108

36

guaifenesin nr

17

HEPATASOL

108

53

guaifenesin tab

17

HEPSERA

126

53

GUAIFENEX GP

17

HERCEPTIN

36

53

GUAIFENEX PSE

17

HEXAFED

18

53

GUAIMAX-D

17

HEXALEN

36

53

GUAIMIST S

17

HIBTITER

123

53

GUAIPHEN-D

17

HIPREX

120

53

GUAIPHEN-D 1200

17

HISTADE MX

18

53

GUAIPHEN-PD

17

HISTADE SR

18

53

guanabenz acetate

85

HISTALET

18

53

guanfacine hcl

85

HISTATAB PH

18

53

guanidine hydrochloride

95

HISTA-VENT DA

18

53

GUAPETEX

17

HISTA-VENT PSE

18

53

GUIADEX D

17

HISTEX

18

53

GUIADEX PD

17

HISTEX SR

18

53

GUIADRINE GP

17

HIVID

51

GYNAZOLE-1

41

HOMATROPAIRE

76

GYNODIOL 0.5, 1, 2MG

70

HUMALOG

54

53

GYNODIOL 1.5MG

70

HUMALOG MIX 50/50 PEN

54

53

H 9600 SR

18

HUMALOG MIX 75/25 PEN

54

53

HALDOL

46

HUMALOG PEN

54

GABITRIL GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S/D GAMMAR-P I.V. GAMUNEX ganciclovir GANDIDIN NR GANTRISIN PEDIATRIC GARAMYCIN GARDASIL GASTROCROM gauze pads & dressings - pads 2" x 2" GEL-KAM ORAL CARE RINSE gemfibrozil GEMZAR GENECAR GENEDOLOREX GENE-R-GESIC GENERIC ENTEX LA GENERLAC GENEXOTIC-HC GENEZOTO-HC GENGRAF GENOPTIC GENOTROPIN GENOTROPIN MINIQUICK GENTACIDIN GENTAK gentamicin sulfate gentamicin sulfate and sodium chloride

105 123 123 123 123 123 126 16 30 30 123 51 53 108 85 35 99 99 99 17 117 76 76 123 76 104 104 76 76 30 30

GERI-HYDROLAC GFN 1200/PHENYLEPHRINE 40 GFN 1200/PSE 50 GFN 550/PSE 60 GFN 595/PSE 48 GFN 800/PE 25 GFN/PSE GILPHEX TR GLADASE GLADASE-C GLEEVEC glimepiride glipizide glipizide and metformin hydrochloride glipizide er glipizide xl GLUCAGON EMERGENCY KIT GLUCOPHAGE GLUCOPHAGE XR GLUCOTROL GLUCOTROL XL GLUCOVANCE GLUMETZA glyburide glyburide and metformin hydrochloride glyburide micronized GLYCOLAX glycopyrrolate GLYCRON GLYNASE GLYSET

117

123

126

148 HUMATIN

149 31

hyoscyamine sulfate tr

118

INDERAL LA

93

IPOL INACTIVATED IPV

123

HUMATROPE

104

HYOSPAZ

118

INDERIDE 40/25

86

ipratropium bromide inhalant

18

HUMIRA

123

HYOSYNE

118

INDOCIN

43

ipratropium bromide spray

18

HUMIRA PEN

123

HYPERCARE

60

INDOCIN IV

44

IRESSA

36

HUMULIN 50/50

54

HYPERLYTE

109

INDOCIN SR

44

ISMO

86

HUMULIN 70/30 PEN

54

HYTONE

60

indomethacin

44

ISMOTIC

86

HUMULIN N

54

HYTRIN

86

indomethacin cr

44

ISOCHRON

86

HUMULIN R

54

HYZAAR 100-12.5, 100-25MG

86

indomethacin er

44

ISONARIF

116

HYCAMTIN

36

HYZAAR 50-12.5MG

86

indomethacin sa

44

isoniazid

117

HYCET

99

HYZINE

27

indomethacin sr

44

isoproterenol hcl

18

HYDERGINE

26

IB-STAT

118

INFANRIX

123

ISOPTIN SR 120MG

86

hydralazine hydrochloride

85

IBU

43

INFERGEN

123

ISOPTIN SR 180MG

86

hydralazine hydrochloride and hydrochlorothiazide

85

ibuprofen

43

INFLAMASE FORTE

77

ISOPTIN SR 240MG

86

HYDREA

36

ICAR PRENATAL COMBO PACK

109

INFLAMASE MILD

77

ISOPTO ATROPINE

77

HYDROCET

99

IDAMYCIN PFS

36

INFUMORPH 200

100

ISOPTO CARBACHOL

77

hydrochlorothiazide

85

IDARUBICIN

36

INNOHEP

49

ISOPTO CARPINE

77

hydrocodone bitartrate and ibuprofen

99

IFEX

36

INNOPRAN XL

93

ISOPTO HOMATROPINE

77

hydrocortisone

60

IFEX/MESNEX

36

INSPRA

86

ISORDIL TITRADOSE

86

hydrocortisone and neomycin sulfate and polymyxin b sulfate

IFEX/MESNEX COMBO PACK

36

insulin pen needle

53

isosorbide dinitrate

86

77

ifosfamide

36

INTAL

18

isosorbide dinitrate er

86

hydrocortisone butyrate

60

IFOSFAMIDE/MESNA

36

INTAL 112

18

isosorbide dinitrate sa

86

hydrocortisone butyrate solution

60

ILETIN II LENTE/PORK

54

INTAL 200

18

isosorbide dinitrate tr

86

hydrocortisone cream

60

IMDUR

86

INTAL INHALER

18

isosorbide mononitrate

86

hydrocortisone enema

51

imipramine hydrochloride

39

INTRALIPID

109

isosorbide mononitrate er

86

hydrocortisone valerate

60

IMITREX NASAL SPRAY

93

INTRON-A

123

isotretinoin

60

hydromorphone hydrochloride

99

IMITREX STATDOSE PEN

93

INTRON-A W/DILUENT

123

ISOVATE

60

HYDROMORPHONE/NS

99

IMITREX TABLETS

93

INVANZ

31

isradipine

86

hydroxychloroquine sulfate

66

IMITREX VIALS

93

INVERSINE

86

ISTALOL

77

hydroxyurea

36

IMMUNE GLOBULIN

123

INVIRASE

126

ISUPREL

18

hydroxyzine hydrochloride

27

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

123

IOFED

18

itraconazole

41

hydroxyzine pamoate

27

IMPLANON

IONOSOL-B/DEXTROSE 5%

109

IVEEGAM EN

123

HYFLEX-650

99

IMURAN

123

IONOSOL-MB/DEXTROSE 5%

109

JANTOVEN

49

HYFLEX-DS

99

INATAL ADVANCE

109

IONOSOL-T/DEXTROSE 5%

109

JANUVIA

54

hyoscyamine

118

INATAL GT

109

IOPHEN-NR

18

JAY-PHYL

18

hyoscyamine sulfate

118

INATAL ULTRA

109

IOPIDINE

77

JE-VAX

123

hyoscyamine sulfate cr

118

INCRELEX

123

IOSAL II

18

J-MAX

18

hyoscyamine sulfate er

118

indapamide

86

IOTEX PSE

18

JOLESSA

70

hyoscyamine sulfate sr

118

INDERAL

93

IPLEX

JOLIVETTE

70

70

123

150

151

J-TAN

18

ketoconazole

41

LACTATED RINGER’S

110

LEVEMIR FLEXPEN

54

J-TAN D

18

ketoconazole cream

60

LACTATED RINGER’S DEXTROS

110

LEVLEN

70

JUNEL

70

ketoprofen

44

LACTIC ACID

60

LEVLEN CONTRACT PACK

70

JUST FOR KIDS GEL

109

ketorolac tromethamine injection

44

LACTIC ACID E

60

LEVLITE

70

K+ POTASSIUM

109

ketorolac tromethamine tablets

44

LACTICARE-HC

60

levobunolol hydrochloride

77

KADIAN

100

ketotifen fumarate ophth soln

77

LACTINOL

60

levocarnitine

110

KALETRA

126

KEY-PRED

44

LACTREX

60

LEVO-DROMORAN

100

31

KINERET

123

lactulose

118

LEVORA

KAOCHLOR

109

KIONEX

9

LAGESIC

100

levorphanol tartrate

100

KAON

109

KLARON

60

LAMICTAL

105

LEVOTHROID

116

KAON-CL

109

K-LOR

109

LAMISIL

41

levothyroxine

116

KAON-CL-10

109

KLOR-CON 10

109

LAMISIL SPRAY

60

LEVOXYL

116

KARIDIUM

109

KLOR-CON M15

109

lamotrigine chewable

LEVSIN

118

KARIGEL

109

KLOTRIX

109

LANOXICAPS

86

LEVSIN/SL

118

KARIGEL-N

109

K-LYTE

109

LANOXIN

86

LEVSINEX

118

kanamycin sulfate

105

70

KARIVA

70

K-LYTE DS

109

LANTUS

54

LEVULAN KERASTICK

60

KAY CIEL

109

K-LYTE/CL

109

LANTUS OPTICLIK

54

LEXAPRO

39 39

KAYEXALATE

9

KOVIA

60

LAPASE

67

LEXAPRO SOLUTION

K-DUR

109

K-PHOS

109

LARIAM

66

LEXIVA

126

K-EFFERVESCENT

109

K-PHOS MF

109

LASIX

86

LEXXEL

86

70

LIDAMANTLE

26

LIDAMANTLE HC

61

KEFLEX

31

K-PHOS NO 2

109

LEENA

KELNOR 1/35

70

KRISTALOSE

118

leflunomide

KEMADRIN

103

KENALOG

60

K-TABS

109

KENALOG IN ORABASE

52

K-TAN

KENALOG-10

9

KENALOG-40 KEPIVANCE KEPPRA

LESCOL

86

LIDAZONE HC

51

LESCOL XL

86

LIDEX

61

18

LESSINA

70

LIDEX-E

61

KURIC

60

leucovorin calcium injection

36

lidocaine and prilocaine

26

9

KUTRASE

67

leucovorin calcium tablets

36

lidocaine cream

26

36

KU-ZYME

67

LEUKERAN

36

lidocaine hydrochloride injection

86

KU-ZYME HP

67

LEUKINE

49

lidocaine hydrochloride jelly

26

LIDODERM

26

LIDOMAR VISCOUS

26

LIDOSITE

26

105

KRONOFED-A

18

123

KERALAC

60

K-VESCENT

110

leuprolide acetate

104

KERALAC NAILSTIK

60

KYTRIL

96

LEV/PSE/GG

KERALYT

60

KYTRIL SOLUTION

96

LEVACET

100

KERATOL 40

60

KYTRIL TABLET

96

LEVALL G

18

LIMBITROL

39

KERATOL HC

60

labetalol hydrochloride

86

LEVAQUIN

31

LIMBITROL DS

39

KERLONE

86

LACCREAM

60

LEVAQUIN PREMIX

31

LINCOCIN

31

KEROL REDI-CLOTHS

60

LAC-HYDRIN

60

LEVATOL

86

lindane

66

KESTRONE 5

70

LACLOTION

60

LEVBID

118

LIPITOR

87

KETEK

31

LACRISERT

77

LEVEMIR

18

54

LIPOSYN II

110

152 LIPOSYN III

153 110

LOPRESSOR HCT

87

magnesium sulfate, heptahydrate

110

MEDENT LD

19

LIPRAM 4500

67

LOPROX

61

MAG-PHEN

100

MEDIOTIC-HC

77

LIQUIBID

18

LOPROX SHAMPOO

61

MAGSAL

100

MEDROL

44

LIQUIBID-D 1200

19

LORABID

31

MALARONE

66

MEDROL DOSEPAK

44

LIQUIBID-PD

19

LORCET 10/650

100

malathion

66

medroxyprogesterone acetate

70

lisinopril 2.5, 5, 10, 20, 30mg

87

LORCET PLUS

100

MALDEMAR

96

mefloquine hcl

66

lisinopril 40 mg

87

LORCET-HD

100

MANDELAMINE

120

MEFOXIN

31

lisinopril and hydrochlorothiazide

87

LORTAB 10

100

MANDOL/D5W

31

MEFOXIN IN DEXTROSE

31

lithium carbonate

46

LOTEMAX

77

maprotiline hydrochloride 25mg

39

MEGACE ES

36

lithium carbonate er

46

LOTENSIN 40MG

87

maprotiline hydrochloride 50mg

39

MEGACE ORAL

36

lithium citrate

46

LOTENSIN 5, 10, 20MG

87

maprotiline hydrochloride 75mg

39

megestrol acetate

36

LITHOBID

46

LOTENSIN HCT

87

MARGESIC-H

meloxicam

44

LITHOSTAT

120

LOTREL

87

MARINOL

LO/OVRAL

70

LOTRISONE

61

MARNATAL-F PLUS DUO PACK

LOCOID

61

LOTRONEX

118

MARPLAN

39

LOCOID LIPOCREAM

61

lovastatin

87

MAR-SPAS

118

MENOSTAR

70

LODOSYN

103

LOVENOX

49

MATERNITY

110

MENTAX

61

LODRANE

19

LOW-OGESTREL

70

MATERNITY-90

110

MEPERIDINE HCL/NS

100

LODRANE 12 HOUR

19

loxapine succinate

46

MATULANE

36

meperidine hydrochloride

100

LODRANE 12D

19

LOXITANE

46

MAVIK 1MG

87

MEPERIDINE/NS

100

LODRANE 24

19

LOZI-FLUR

110

MAVIK 2MG

87

MEPERITAB

100

LODRANE D

19

LOZOL

87

MAVIK 4MG

87

meprobamate

27

LODRANE LD

19

LUFYLLIN

19

MAXAIR AUTOHALER

19

MEPRON

66

LODRANE XR

19

LUFYLLIN-GG

19

MAXALT

93

mercaptopurine

36

LOESTRIN

70

LUMIGAN

77

MAXALT-MLT

93

MERREM

31

LOFENE

51

LUNESTA

106

MAXIDEX

77

MERUVAX II W/DILUENT 10 D

LOFIBRA

87

LUPRON DEPOT

104

MAXIDONE

LOHIST-12

19

LURIDE

110

MAXIFED

LOHIST-12D

19

LUSONEX

19

LOHIST-D

19

LUTERA

LOHIST-LQ

19

LOHIST-PD

100 96 110

100

MENACTRA MENEST MENOMUNE-A/C/Y/W-135

123 70 123

123

mesalamine (5-asa)

51

19

mesna

36

MAXIFED-G

19

MESNEX

36

70

MAXIFLOR

61

MESTINON

95

LUXIQ

61

MAXIPHEN

19

MESTINON TIMESPAN

95

19

LYNOX

100

MAXIPHEN-G

19

METADATE CD 10, 20, 30MG

48

LOKARA

61

LYRICA

105

MAXIPIME

31

METADATE ER 10MG

48

LOMOTIL

51

LYSODREN

9

MAXITROL

77

METADATE ER 20MG

48

LONOX

51

MACROBID

31

MAXZIDE

87

METAGLIP

54

loperamide hydrochloride

51

MACRODANTIN

31

mebendazole

66

metaproterenol sulfate neb solution

19

LOPID

87

MAGAN

44

meclizine hydrochloride

96

metaproterenol sulfate syrup

19

LOPRESSOR

87

magnesium chloride

110

meclofenamate sodium

44

metaproterenol sulfate tablets

19

154

155

metformin hydrochloride

54

METROCREAM

61

MIRAPEX

metformin hydrochloride er

54

METROGEL

61

MIRAPHEN PE

103

MST 600

44

19

MUCOMYST-10

20

methadone hydrochloride

100

METROGEL VAGINAL

31

MIRAPHEN PSE

19

MUMPSVAX W/DILUENT 10 DOS

124

METHADOSE

100

METROLOTION

61

MIRCETTE

70

mupirocin

61

methamphetamine hydrochloride

48

metronidazole

31

MIRENA

70

MUSTARGEN

36

methazolamide

87

metronidazole lotion

61

mirtazapine

39

MUTAMYCIN

36

methenamine hippurate

120

MEVACOR

87

mirtazapine orally disenegrating tablet

39

M-VIT

110

methenamine mandelate

120

MEXAR WASH

61

misoprostol

73

MYAMBUTOL

117

mexiletine hydrochloride

87

mitomycin

36

MYCAMINE

41

mitomycin c

36

MYCELEX

41

mitoxantrone hydrochloride

36

MYCOBUTIN

METHERGINE

94

methimazole

104

MEXITIL

87

METHITEST

70

MHP-A

120

methocarbamol

94

MIACALCIN

97

M-M-R II

123

MYCOSTATIN CREAM

61

methotrexate sodium

36

MICARDIS 20,40MG

87

M-M-R II W/DILUENT 1 DOSE

124

MYCOSTATIN SUSPENSION

41

methotrexate sodium 2.5mg

36

MICARDIS 80MG

87

MOBAN

46

MYDFRIN

77

methyclothiazide

87

MICARDIS HCT 40-12.5MG

88

MOBIC

44

MYDRAL

77

methyldopa

87

MICARDIS HCT 80-12.5, 80-25MG

88

MODICON-28

70

MYDRIACYL

77

methyldopa and amitriptyline hydrochloride

87

MICONAZOLE 3

41

MODURETIC 5-50

88

MYFORTIC

124

methyldopa and hydrochlorothiazide

87

MICROGESTIN 1.5/30

70

mometasone furoate

61

MYLOTARG

37

methyldopate hydrochloride

87

MICRO-K

MONISTAT 3

41

MYNATAL

110

methylene blue

110

117

9

MICRONASE

54

MONISTAT 7 COMBINATION PA

41

MYNATAL ADVANCE

110

METHYLIN

48

MICROZIDE

88

MONISTAT-DERM

61

MYNATAL PLUS

110

METHYLIN 10MG/5ML SOLUTION

48

MIDAMOR

88

MONODOX

31

MYNATAL ULTRACAPLET

110

METHYLIN 5MG/5ML SOLUTION

48

midodrine hcl

88

MONOKET

88

MYNATAL-Z

110

METHYLIN CHEWABLE

48

MIGERGOT

93

MONONESSA

70

MYNATE 90 PLUS

110

METHYLIN CHEWS

48

MIGRANAL

93

MONOPRIL 10, 20MG

88

MYOBLOC

100

METHYLIN ER

48

MINDAL

19

MONOPRIL 40MG

88

MYOCHRYSINE

124

methylphenidate hydrochloride

48

MINIPRESS

88

MONOPRIL HCT

88

MYOGESIC

100

methylphenidate hydrochloride er

48

MINIRIN

MONTEPHEN

19

MYOPHEN

100

methylphenidate hydrochloride sr

48

MINITRAN

88

MONUROL

31

MYOZYME

67

methylprednisolone

44

MINIZIDE

88

morphine sulfate

100

MYRAC

31

methylprednisolone acetate

44

MINOCIN

31

morphine sulfate er

100

MYSOLINE

105

methylprednisolone sodium succinate

44

minocycline hydrochloride

31

MORPHINE SULFATE IN DEXTR

100

MYTELASE

95

metipranolol

77

minoxidil

88

MOTOFEN

51

MYTREX

61

MINTAB D

19

MOTRIN

44

nabumetone

44

NACL 0.9%/DEXTROSE 0.2%

metoclopramide hydrochloride

118

104

metolazone

87

MINTEX

19

MOVIPREP

51

110

metoprolol tartrate

87

MINTEZOL

66

M-R-VAX II

124

nadolol

88

metoprolol tartrate and hydrochlorothiazide

87

MIOSTAT

77

MS CONTIN

100

nafcillin sodium

31

METRO IV

31

MIRALAX

51

MS/L

100

NAFTIN

61

156

157

NAFTIN-MP

61

NATALCARE PLUS

110

neostigmine methylsulfate

95

NAGLAZYME

67

NATALCARE RX

110

NEO-SYNEPHRINE

88

NATALCARE THREE

111

NEO-SYNEPHRINE SOLUTION

77

nalbuphine hydrochloride

100

111

niferex-pn forte (ascorbic acid and calcium carbonate and cupric oxide and cyanocobalamin and ergocalciferol) 111

NALEX-CR

20

NATALVIT

111

NEPHRAMINE

NALFON

44

NATAMAR RX

111

NESCON-PD

20

NALLPEN ISO-OSMOTIC IN DE

31

NATATAB CFE

111

NESTABS CBF

111

NIMOTOP

88

NALLPEN/DEXTROSE

31

NATATAB FA

111

NESTABS FA

111

NIPENT

37

9

NATATAB RX

111

NESTABS RX

111

NITREK

88

naltrexone hydrochloride

111

niferex pn (calcium carbonate and cyanocobalamin and folic acid and niacinamide and polysaccharide iron complex)

NILANDRON

120

NAMENDA

26

NATELLE

111

NEULASTA

49

NITRO-BID

89

NAMENDA TITRATION PAK

26

NATELLE C

111

NEUMEGA

49

NITRO-DUR

89

nandrolone decanoate

70

NATELLE EZ

111

NEUPOGEN

49

nitrofurantoin macrocrystalline

31

NAPHAZOLE

77

NATELLE PREFER

111

NEURONTIN

105

NITROGARD

89

naphazoline hydrochloride

77

NATURE-THROID

116

NEURONTIN SOLUTION

105

nitroglycerin cr

89

NAPRELAN

44

NATURETIN

88

NEUT

111

nitroglycerin er

89

NAPROSYN

44

NAVANE

46

NEUTRAGARD ADVANCED

111

nitroglycerin injection

89

naproxen

44

NAVELBINE

37

NEUTREXIN

66

NITROGLYCERIN OINTMENT

89

naproxen dr

44

ND-STAT

20

NEVANAC

77

nitroglycerin sr

89

naproxen ec

44

NEBCIN

31

NEXAVAR

37

nitroglycerin sublingual

89

naproxen er

44

NEBUPENT

41

NEXIUM

118

nitroglycerin td

89

NECON 0.5/35-28

70

NEXIUM I.V.

118

nitroglycerin transdermal

89

NARCAN

9

NARDIL

39

NECON 1/35-28

71

NIACOR

111

NITROLINGUAL PUMPSPRAY

89

NARIZ

20

NECON 1/50-28

71

NIASPAN

111

NITROQUICK

89

100

NECON 10/11-28

71

nicardipine hcl 20mg

88

NITROSTAT

89

71

nicardipine hcl 30mg

88

NITRO-TIME

89

NARVOX NASACORT AQ

20

NECON 7/7/7

NASAREL

20

NEEVO

NASATAB LA

20

nefazodone hydrochloride

NASEX

20

NASEX-G

nicotine td patch

9

nizatidine

118

39

NICOTROL INHALER

9

NIZORAL

41

NEGGRAM

31

NICOTROL NS

9

NIZORAL SHAMPOO

61

20

NEOBENZ MICRO

61

NIFEDIAC CC 30MG

88

NOHIST

20

NASONEX

20

NEOCIN

77

NIFEDIAC CC 60MG

88

NOHIST-EXT

20

NATACAPS

110

NEOCIN-PG

77

NIFEDIAC CC 90MG

88

NORA-BE

71

NATACHEW

110

NEO-FRADIN

31

NIFEDICAL XL 30MG

88

NORCO

NEOFRIN

77

NIFEDICAL XL 60MG

88

NORDETTE

31

nifedipine 10mg

88

NORDITROPIN CARTRIDGE

104

NATACYN

77

111

100 71

NATAFOLIC-PN

110

neomycin sulfate

NATAFORT

110

neomycin sulfate and polymyxin b sulfate

120

nifedipine 20mg

88

NORDITROPIN NORDIFLEX

104

NATALCARE CFE 60

110

NEORAL

124

nifedipine cr 90mg

88

NORDITROPIN NORDIFLEX PEN

104

NATALCARE GLOSSTABS

110

NEOSOL

118

nifedipine er 30mg

88

NOREL SD

20

NATALCARE PIC

110

NEOSPORIN

77

nifedipine er 60mg

88

norethindrone acetate

71

NATALCARE PIC FORTE

110

NEOSPORIN GU SOL

120

nifedipine er 90mg

88

NORFLEX

95

158

159

NORGESIC FORTE

95

NUBAIN

NORINYL

71

NUHIST PEDIATRIC

NORITATE

61

NULEV

101

OCUSULF-10

78

ORPHENADRINE COMPOUND

95

20

OCUTRICIN

78

ORPHENGESIC

95

ofloxacin

32

ORPHENGESIC FORTE

95

118

NORMOSOL -R

111

NULYTELY

51

ofloxacin opthl

78

ORTHO EVRA

71

NORMOSOL-M IN D5W

111

NUMOBID

20

OGEN

71

ORTHO MICRONOR

71

NORMOSOL-R

111

NUMONYL

20

OGESTREL

71

ORTHO TRI-CYCLEN

71

NORMOSOL-R IN D5W

111

NUMORPHAN

101

OLUX

62

ORTHO TRI-CYCLEN LO

71

111

OMACOR

89

ORTHO-CEPT

71

OMEDIA OTIC

78

ORTHO-CEPT-28

71

NOROXIN

32

NU-NATAL ADVANCED

NORPACE

89

NUOX

NORPACE CR

89

NUTRACARE

112

NORPRAMIN

39

NUTRACORT

61

NOR-QD

71

NUTRILYTE

NORTREL

71

nortriptyline hydrochloride NORVASC

61

omeprazole

118

ORTHOCLONE OKT3

124

OMNICEF

32

ORTHO-CYCLEN

71

112

OMNIHIST II LA

20

ORTHO-EST

71

NUTRILYTE II

112

OMNIHIST L.A.

20

ORTHO-NOVUM

71

39

NUTRINATE

112

OMNII GEL

112

ORUDIS

45

89

NUTRISPIRE

112

OMNI-PAC

32

ORUVAIL

45

NORVIR

126

NUTROPIN

104

ONCASPAR

37

OSCION CLEANSER

62

NOVAGESIC

101

NUTROPIN AQ

104

ONTAK

37

OSMOPREP

51

NOVAMINE

111

NUTROPIN AQ PEN

104

ONXOL

37

OTICAINE OTIC

78

NOVANATAL

111

NUVARING

71

OPANA

101

OTICIN HC

78

61

OPANA ER

101

OTIMAR

78

NOVANTRONE

37

NYAMYC

NOVASAL

44

NYDRAZID

NOVASTART

111

117

opium tincture

51

OTIRX

78

nystatin

42

OPTIPRANOLOL

78

OTOCAIN

78

NOVOLIN 70/30

54

nystatin and triamcinolone acetonide

61

OPTIVAR

78

OTOGESIC

78

NOVOLIN 70/30 INNOLET

54

nystatin cream

61

ORACEA

62

OTOGESIC OTIC

78

NOVOLIN 70/30 PENFILL

54

nystatin oral powder

42

ORACIT

112

OTOMAR-HC

78

NOVOLIN N

54

nystatin suspension

42

ORAMORPH SR

101

OTOZONE

78

NOVOLIN N INNOLET

54

NYSTOP

62

ORAP

47

OTRA NR

78

NOVOLIN N U-100 PENFILL

54

NY-TANNIC

20

ORAPRED

44

OVACE

62

NOVOLIN R

54

OB COMPLETE

112

ORAPRED ODT

45

OVACE WASH

62

NOVOLIN R INNOLET

54

OBSTETRIX EC

112

ORASEP

26

OVCON

71

NOVOLIN R U-100 PENFILL

54

OBSTETRIX-100

112

ORENCIA

124

OVCON FE CHEW

71

NOVOLOG

54

OBTREX

112

ORFADIN

94

OVIDE

66

NOVOLOG FLEXPEN

54

O-CAL PRENATAL

112

ORGAN-I NR

20

oxacillin sodium

32

NOVOLOG MIX 70/30

54

OCTAGAM

124

ORGANIDIN NR

20

OXANDRIN

71

NOVOLOG MIX 70/30 PENFILL

54

octreotide acetate

104

ORIGINAL PRENATAL FORMULA

112

oxaprozin

45

NOVOLOG MIX 70/30 PREFILL

54

OCUFEN

78

orphenadrine citrate

95

OXISTAT

62

NOVOLOG PENFILL

55

OCUFLOX

78

orphenadrine citrate and aspirin and caffeine

95

OXSORALEN ULTRA

62

NOXAFIL SUSPENSION

42

OCUMYCIN

78

orphenadrine citrate cr

95

oxybutynin chloride

120

160

161

oxycodone

101

PANOXYL AQ

62

PENDEX

20

PERLOXX

101

oxycodone cr

101

PANRETIN

62

penicillin g potassium

32

PERMAX

104

oxycodone er

101

papaverine hydrochloride cr

89

penicillin g potassium and dextrose (anhydrous)

32

permethrin

66

OXYCONTIN

101

papaverine hydrochloride er

89

PENICILLIN G PROCAINE

32

perphenazine

47

OXYFAST

101

papaverine hydrochloride injection

89

penicillin g sodium

32

perphenazine and amitriptyline hydrochloride

27

OXYIR

101

PAP-UREA

62

penicillin v potassium

32

PERRY PRENATAL

PARAFON FORTE DSC

95

PENICILLIN VK

32

PERSANTINE

49

oxytocin

94

112

OXYTROL

120

PARAPLATIN

37

PENLAC NAIL LACQUER

42

PEXEVA 10, 20MG

27

PACERONE

89

PARA-TIME

89

PENTAM 300

42

PEXEVA 30,40MG

27

PACLITAXEL

37

PARCAINE

78

pentamidine isethionate

42

PFIZERPEN-G

32

PALCAPS 10

67

PARCOPA

103

PENTASA 250MG

51

PHANASIN

20

PALGIC

20

paregoric

51

PENTASA 500MG

51

PHARMAFLUR

PALIPASE

67

PARLODEL

104

PALIPASE MT 16

67

PARNATE

PALPEON DR 10

67

paromomycin sulfate

PALPEON MT 20 PALTRASE V8 PAMELOR PAMIDRONATE DISODIUM PAMINE PAMINE FORTE PANAFIL PANCREASE PANCREASE MT 10 PANCRECARB MS-16

67 67 39 97 118 118 62 67 67 67

paroxetine 10, 20mg paroxetine 30, 40mg PASER PATANOL PAXIL 10,20MG PAXIL 30, 40MG PAXIL CR PAXIL SUSPENSION PCE PCM

112

PENTAZOCINE HCL/ACETAMINO

101

PHENABID

20

39

pentazocine hydrochloride and acetaminophen

101

PHENADOZ

96

32

PHENAVENT

20

27

pentazocine hydrochloride and naloxone hydrochloride

101

PHENAVENT D

21

27

PENTOPAK

49

PHENAVENT LA

21

117

pentoxifylline cr

49

PHENAVENT PED

21

78

pentoxifylline er

49

phenazopyridine hydrochloride

120

27

PENTOXIL

49

PHENCLOR TANNATE PEDIATRI

21

27

PEPCID

118

PHENERGAN

96

27

PEPCID I.V.

118

PHENOPTIC

78

27

PEPCID PREMIXED

118

PHENYDEX PEDIATRIC

21

32

PEPCID RPD

118

PHENYDRYL

21

20

P-EPD TAN/CHLOR-TAN

101

21

20

PANCRELIPASE

67

PCM ALLERGY

20

PERCOCET

PANCRON 10

67

PCM LA

20

PERCODAN

101

phenylephrine cm (chlorpheniramine maleate and methscopolamine nitrate and phenylephrine hydrochloride)

PANDEL

62

PEDIAPRED

45

PERCOLONE

101

phenylephrine hydrochloride

89

PANFIL-G

20

PEDIARIX

PERF CHOICE GEL

112

phenylephrine hydrochloride opthl

78

PANGESTYME CN 10

67

PEDIAZOLE

32

PERFECT CHOICE BRUSH-ON

112

PHENYTEK

106

124

PANGLOBULIN

124

PEDI-DRI

62

PERFECT CHOICE HOME GEL

112

phenytoin

106

PANGLOBULIN NF

124

PEDIOTIC

78

PERFECT CHOICE PERIO RINS

112

phenytoin sodium

106

pergolide mesylate

104

PHOS-FLUR

112

PHOSLO

120

PANIXINE DISPERDOSE

32

PEDVAX HIB

124 51

PERIDEX

52

PANLOR DC

101

PEG 3350/ELECTROLYTES

PANLOR SS

101

PEGANONE

106

PERIO MED

112

PANOCAPS

67

PEGASYS

124

PERIOGARD

PANOKASE

68

PEG-INTRON

124

PANOXYL

62

PEG-INTRON REDIPEN

124

PHOSPHOLINE IODIDE

78

52

PHOTOFRIN

37

PERIOSTAT

32

PHRENILIN W/CAFFEINE/CODE

PERISOL

52

PHYSIOLYTE

101 62

162

163

physiosol irrigation (magnesium chloride and potassium chloride and sodium acetate and sodium chloride and sodium gluconate)

62

physostigmine salicylate

10

PILOCAR

78

pilocarpine hydrochloride

52, 78

PILOPINE HS

78

PILOPTIC-1

78

pindolol

89

piperacillin sodium

32

PIPRACIL/D5W

32

piroxicam

45

PITOCIN

94

PLAN B

71

PLAQUENIL

66

PLARETASE 8000

68

PLASMA-LYTE A

112

PLATINOL AQ

37

PLAVIX

49

PLENAXIS

104

PLENDIL 10MG

89

PLENDIL 2.5, 5MG

89

PLETAL

49

PLEXION CLEANSER

62

PLEXION CLEANSING CLOTH

62

PLEXION SCT

62

PLEXION TS

62

PODOCON 25 IN BENZOIN TIN

62

PODODERM

62

podofilox

62

POLY IRON PN

112

POLY IRON PN FORTE

112

POLYCIN B

78

POLYCITRA

112

POLYCITRA-K CRYSTALS

112

POLYCITRA-K SOLUTION

112

POLYCITRA-LC

112

POLY-DEX

78

polyethylene glycol

51

POLYGAM S/D

124

PRED-G

79

PRENATAL FORMULA 3

113

POLY-HISTINE

21

PRED-G S.O.P.

79

PRENATAL LOW IRON

113

polymyxin b sulfate

32

PREDNISOL

79

PRENATAL MR 90 FE

113

polymyxin b sulfate and trimethoprim sulfate

78

prednisolone acetate

45

PRENATAL MTR/SELENIUM

113

POLYMYXIN/GRAMICIDIN/NEOM

79

PRENATAL MULTIVITAMIN

114

79

prednisolone acetate and sulfacetamide sodium anhydrous

79

PRENATAL MULTIVITAMIN-ULT

114

79

prednisolone acetate opthl

79

PRENATAL OPT

114

79

prednisolone anhydrous syrup

45

PRENATAL PLUS

114

21

prednisolone sodium phosphate

45

PRENATAL PLUS NF

114

POLY-VENT JR.

21

114

45

79

PRENATAL PLUS/27MG IRON

PONSTEL

prednisolone sodium phosphate and sulfacetamide sodium

114

71

79

PRENATAL PLUS/BETACAROTEN

PORTIA

prednisolone sodium phosphate opthl prednisone

45

PRENATAL PLUS/IRON

114

PREDNISONE INTENSOL

45

PRENATAL RX

114

PREFEST

71

PRENATAL RX 1

114

PRE-HIST D

21

PRENATAL RX/BETA-CAROTENE

114

PRELONE

45

PRENATAL S

114

PREMARIN

71

PRENATAL START

114

PREMARIN INJECTION

71

PRENATAL Z

114

PREMARIN VAG CREAM

71

PRENATAL Z ADVANCED FORMU

114

PRENATAL/FOLIC ACID

114

PRENATAL-H

114

PRENATAL-U

114

PRENATE ELITE

114

PRENATE GT

114

PREVACID

118

PREVACID I.V.

119

POLY-PRED POLYSPORIN POLYTRIM POLY-VENT

potassium acetate

112

potassium bicarbonate

112

POTASSIUM CHLORIDE 0.15%

112

potassium chloride and sodium chloride

112

potassium chloride cr

113

potassium chloride er

113

potassium chloride injection

113

potassium chloride liquid

113

potassium chloride sr

113

potassium citrate extended

113

POTASSIUM EFFERVESCENT

113

PRANDIN

55

PRASCION

62

PRASCION AV CLEANSER

62

PRASCION PADS

62

PRASCION RA WITH SUNSCREE

62

PRAVACHOL

89

pravastatin

89

prazosin hydrochloride

89

PRECARE

113

PRECARE CONCEIVE

113

PRECARE PREMIER

113

PRECARE PRENATAL

113

PRECOSE

55

PRED FORTE

79

PRED MILD

79

PREMASOL

113

PREMESIS RX

113

PREMPHASE

71

PREMPRO

72

PRENA-CAP

113

PRENAFIRST

113

PRENATABS CBF

113

PRENATABS FA

113

PRENATABS OBN

113

PRENATABS RX

113

PRENATAL

113

PRENATAL 1 + IRON

113

PRENATAL 1 PLUS 1

113

PRENATAL 1+1

113

PRENATAL 19

113

PRENATAL AD

113

PRENATAL ADVANTAGE

113

PRENATAL FA

113

PRENATAL FORMULA

113

PREVACID NAPRAPAC PREVACID SOLUTAB

45 119

PREVALITE

89

PREVIDENT

114

PREVIDENT 5000 PLUS

114

PREVIFEM

72

PREVPAC

119

PREZISTA

126

PRIALT

101

PRIFTIN

117

PRILOSEC

119

PRIMACARE

114

164 PRIMACARE ONE

165 114

PROFEN II

21

PROSTIGMIN INJECTION

95

PYRIDIUM PLUS

121

21

pyridostigmine bromide

95

primaquine phosphate

66

progesterone

72

PRO-TANNATE PEDIATRIC

PRIMAXIN I.M.

32

progesterone vaginal suppository

72

PROTONIX 20, 40MG

119

PYRILAFEN TANNATE-12

22

PRIMAXIN IV

32

PROGLYCEM

55

PROTONIX INJECTION

119

QC ALLERGY RELIEF INTENSE

22

primidone

106

PRIMSOL

32

PRINIVIL 2.5, 5, 10, 20MG

124

PROTOPIC

63

QDALL

22

PROLASTIN

21

protriptylin

39

QDALL AR

22

90

PROLEUKIN

37

PROVENTIL

21

QUADRAMET

37

PRINIVIL 40MG

90

PROLEX D

21

PROVENTIL HFA

21

QUASENSE

72

PRINZIDE

90

PROLEX PD

21

PROVENTIL NEB

21

QUESTRAN

90

PROAMATINE

90

PROLOPRIM

32

PROVERA

72

QUESTRAN LIGHT

90

promethazine hydrochloride

96

PROVIGIL

48

QUIBRON

22 22

PRO-BANTHINE

119

PROGRAF

probenecid

80

PROMETHAZINE VC

21

PROZAC 10MG

39

QUIBRON-T

probenecid and colchicine

80

PROMETHEGAN

96

PROZAC 20MG

39

QUICK-K

procainamide hydrochloride

90

PROMETRIUM

72

PROZAC 40MG

39

quinapril hcl 40mg

90

procainamide hydrochloride cr

90

PRONESTYL

90

PROZAC SOLUTION

39

quinapril hcl 5, 10, 20mg

90

procainamide hydrochloride er

90

PRO-OTIC

79

PROZAC WEEKLY

40

quinapril hcl and hydrochlorothiazide

90

propafenone hcl

90

PRUDOXIN

63

QUINARETIC

90

PSE 15/CPM 2

21

QUINERVA

66

PROCALAMINE

114

119

114

PROCANBID

90

propantheline bromide

PROCARDIA 20MG

90

proparacaine hydrochloride

79

PSE 90/CPM 8/MSC 2.5

21

quinidine gluconate

90

PROCARDIA XL 30MG

90

PROPINE

79

PSE BPM

21

quinidine gluconate cr

90

PROCARDIA XL 60MG

90

PROPOXACET

101

PSE CPM

21

quinidine gluconate er

90

PROCARDIA XL 90MG

90

PROPOXACET-N

101

PSEUBROM

21

quinidine gluconate sa

90

PROCHIEVE

72

PROPOXYPHENE COMPOUND

101

PSEUBROM-PD

21

quinidine sulfate

90

PROCHIEVE VAGINAL

72

propoxyphene hydrochloride

101

PSEUDATEX

21

quinidine sulfate er

90

prochlorperazine edisylate injection

96

propoxyphene hydrochloride and acetaminophen

101

PSEUDO CM

21

quinine sulfate

66

prochlorperazine maleate

96

propoxyphene napsylate and acetaminophen

101

PSEUDO GG TR

21

QUINTEX

22

prochlorperazine sup

96

PROPRANOLOL HCL INTENSOL

93

PSEUDO MAX

22

QUIXIN

79

PROCRIT

49

propranolol hydrochloride

93

PSEUDOVENT

22

QV-ALLERGY

22

PROCTOCARE-HC

51

propranolol hydrochloride and hydrochlorothiazide

90

PSEUDOVENT 400

22

QVAR

22

PROCTOCORT

62

propranolol hydrochloride er

93

PSEUDOVENT PED

22

RA CLOTRIMAZOLE 3

42

PROCTOCREAM-HC 1%

51

propylthiouracil

72

PSORCON E

63

RABAVERT

PROCTOCREAM-HC 2.5%

51

PROQUAD

124

PSORIATEC

63

RANEXA

90

PROCTOFOAM HC

51

PROQUIN XR

32

PULMICORT

22

RANICLOR

32

PROCTO-KIT

51

PROSCAR

121

PULMICORT TURBUHALER

22

ranitidine hydrochloride

119

PROCTO-PAK

62

PROSED EC

121

PULMOZYME

68

RAPAMUNE

124

PROCTOSOL HC 2.5%

51

PROSED/DS (ATROPINE FREE)

121

PURINETHOL

37

RAPIFLUX

40

PROCTOZONE-HC 2.5%

51

PROSET D

21

pyrazinamide

117

RAPTIVA

63

PROFEN FORTE

21

PROSTIGMIN

95

PYRIDIUM

121

RAUWOLFIA/BENDROFLUMETHIA

90

124

166

167

RAZADYNE

26

RESCON-JR

22

RILUTEK

RAZADYNE ER

26

RESCON-MX

22

RIMACTANE

RE 10 WASH

63

RESCRIPTOR

126

RE 40

63

reserpine

RE SA CREAM

63

RE TANN D CHEW RE2+30

94

ROXICODONE

102

117

ROZEREM

106

rimantadine hydrochloride

126

ROZEX

63

90

RINGER’S INJECTION

114

R-TANNA

23

RESPA-1ST

22

RINGER’S IRRIGATION

63

R-TANNA PEDIATRIC

23

22

RESPAHIST

22

RIOMET

55

R-TANNA S

23

22

RESPAIRE-60

22

RISPERDAL 0.25, 0.5, 1, 2, 3MG

47

RUFEN

45 114

REBETOL

124

RESPA-PE

22

RISPERDAL 4MG

47

RUM-K

REBETRON

124

RESTASIS

79

RISPERDAL INJECTION

47

RU-TUSS JR.

23

REBIF

124

RETIN-A

63

RISPERDAL M-TAB 0.5, 1, 2, 3MG

40

RYNA-12

23

RETIN-A MICRO

63

RISPERDAL M-TAB 4MG

47

RYNA-12 S

23

RECLIPSEN RECOMBIVAX HB RECTAGEL HC REGLAN

72 124 52 119

RETROVIR

126

RISPERDAL SOLUTION

47

RYNATAN

23

RETROVIR IV INFUSION

126

RITALIN

48

RYNATAN CHEWABLE

23

RETROVIR SYRUP

126

RITALIN LA

48

RYNATAN SUSPENSION

23

REGONOL

95

REVATIO

91

RITALIN SR

48

RYNEZE

23

REGRANEX

63

REVEX

10

RITUXAN

37

RY-T-12

23

RELAFEN

45

REVIA

10

RMS

RYTHMOL

91

RELAGARD

94

REVLIMID

124

ROBAXIN

95

RYTHMOL SR

91

RELAGESIC

101

REYATAZ

126

ROBINUL

119

S.O.S.S.

79

RELENZA DISKHALER

126

RHEUMATREX

124

ROBINUL FORTE

119

SAIZEN

104

114

SAIZEN CLICK.EASY

104

102

RELERA

22

RHINABID

22

ROCALTROL

RELION 70/30

55

RHINABID PD

22

ROCEPHIN

32

SALAGEN

52

RELION 70/30 INNOLET

55

RHINOCORT AQUA

22

ROCEPHIN IN ISO-OSMOTIC D

32

SALEX

63

RELION N

55

RHINOFLEX

102

ROFERON-A

SALEX SHAMPOO

63

RELION N INNOLET

55

RHINOFLEX-650

102

ROMYCIN

79

SALFLEX

45

RELION R

55

RIBAPAK

124

RONDEC

23

salsalate

45

RELPAX 20MG

94

RIBASPHERE

124

RONDEX

23

SAL-TROPINE

119

RELPAX 40MG

94

RIBATAB

124

ROSAC

63

SANCTURA

121

RELURI

22

ribavirin

124

ROSADERM

63

SANDIMMUNE

125

REMERON

40

RICOBID

22

ROSANIL CLEANSER

63

SANDOSTATIN

104

REMERON SOLTAB

40

RICOBID NR

22

ROSULA

63

SANDOSTATIN LAR DEPOT

104

124

RICOBID-H

22

ROSULA NS

63

SANTYL

63

90

RID-A-PAIN

102

ROTATEQ

125

SARAFEM 10MG

40

SARAFEM 20MG

40

REMICADE REMODULIN

125

RENAGEL

121

RIDAURA

125

ROWASA

52

RENAMIN

114

RIFADIN

117

ROXANOL

102

SB CLOTRIMAZOLE FOOT

63

REPREXAIN

102

RIFAMATE

117

ROXICET 5-325MG

102

SB MICONAZOLE 3-DAY COMBO

42

REQUIP

103

rifampin

117

ROXICET 5-500MG

102

SCALP TREATMENT

63

22

RIFATER

117

ROXICET SOLUTION

102

SCOPACE

96

RESCON-ED

168 scopolamine hydrobromide

169 119

simethicone

52

SORINE

91

SUBUTEX

102

119

sotalol af

91

suby’s solution g for irrigation

121

sotalol hydrochloride

91

SUCLOR

23

SOTRET 10, 20, 40MG

64

SUCRAID

68

64

sucralfate

119

SEASONALE

72

SIMETYL

SEASONIQUE

72

SIMUC

SEBA-GEL

63

SIMULECT

125

SEB-PREV

63

simvastatin

91

SOTRET 30MG

SECTRAL

91

SINA-12X

23

SPACOL T/S

119

SUDAL 12

23

SELECT-OB

114

SINEMET

103

SPASDEL

119

SUDATEX

23

selegiline hcl

103

SINEMET CR

103

SPECTAZOLE

64

SULAR 10, 20MG

91

selenium sulfide

63

SINGULAIR

23

SPECTRACEF

33

SULAR 30MG

91

SELENIUM SULFIDE

63

SINUVENT PE

23

SPIRIVA HANDIHALER

23

SULAR 40MG

91

SELSEB

63

SITREX

23

spironolactone

91

SULF-10

79

SELSUN SHAMPOO

63

SKELAXIN

95

spironolactone and hydrochlorothiazide

91

SULFAC

79

SEMPREX-D

23

SKELID

97

SPORANOX

42

sulfacetamide sodium and sulfur

64

SENATEC

26

SLO-BID GYROCAPS

23

SPORANOX INJECTION

42

sulfacetamide sodium and urea (carbamide)

64

SENATEC HC

63

SMZ-TMP DS

33

SPORANOX PULSEPAK

42

sulfacetamide sodium ophtl ointment

79

sodium acetate

115

SPORANOX SOLUTION

42

sulfacetamide sodium ophtl solution

79

115

SPRINTEC

72

SULFACET-R

64

SPRYCEL

37

sulfadiazine

33

SPS

10

sulfamethoxazole and trimethoprim

33

SENSIPAR

103

SEPTRA

32

sodium bicarbonate

SEPTRA DS

32

sodium chloride

SEREVENT DISKUS

23

SODIUM EDECRIN

SEROMYCIN

117

23

115, 121 91

sodium fluoride chewable

115

SRONYX

72

SULFAMYLON

64

SEROQUEL 200MG

47

sodium fluoride gel

115

SSD

64

sulfasalazine

52

SEROQUEL 25MG

47

sodium lactate

115

SSD AF

64

sulfasalazine dr

33

SEROQUEL 300, 400MG

47

sodium polystyrene sulfonate

10

STADOL

102

sulfasalazine ec

33, 52

SEROQUEL 50, 100MG

47

SOLARAZE

64

STAFLEX

102

SULFATOL

64

SOLIA

72

STAGESIC

102

SULFATOL CLEANSER

64

SEROSTIM

104

sertraline hcl 100mg

40

SOLODYN

33

STALEVO 100

103

SULFATRIM

33

sertraline hcl 25mg

40

SOLTAMOX

37

STAMOIST E

23

sulfisoxazole

33

sertraline hcl 50mg

40

SOLU-CORTEF

45

STANNOUS FLUORIDE ORAL RINSE

SULFOXYL REGULAR

64

sertraline hcl oral conc

40

SOLU-MEDROL

45

STARLIX

55

sulindac

45

45

SUMYCIN

33

104

SUPHERA

64

115

SF

114

SOLUREX LA

45

STERAPRED

SF 5000 PLUS

115

SOMA

95

STIMATE

SHOHL’S SOLUTION MODIFIED

115

SOMA COMPOUND

95

STRATTERA

48

SUPRAX

33

95

streptomycin sulfate

33

SURMONTIL

40

SILDEC

23

SOMA COMPOUND/CODEINE

SIL-TEX

23

SOMAVERT

104

STRIANT

72

SUSTIVA

127

SILVADENE

63

SOMNOTE

106

STROMECTOL

66

SUTENT

37

silver nitrate

63

SONATA 10MG

106

STRONGSTART

115

SYMAX DUOTAB

119

silver nitrate-potassium nitrate applicator

64

SONATA 5MG

106

STUARTNATAL PLUS 3

115

SYMAX FASTABS

119

silver sulfadiazine

64

SORIATANE

SUBOXONE

102

SYMAX-SL

119

64

170

171

SYMAX-SR

119

TAXOTERE

37

THEO-24

24

tizanidine hydrochloride

SYMBYAX SYMLIN

95

47

TAZICEF

33

THEOCAP

24

T-NAF

115

55

TAZORAC

64

THEOCHRON

24

TOBI

33

SYMMETREL

127

TAZTIA XT

91

THEOMAR GG

24

TOBRADEX

79

SYNAGIS

125

TE ANATOXAL BERNA

125

theophylline

24

tobramycin sulfate

SYNALAR

64

TEGRETOL

106

theophylline cr

24

tobramycin sulfate and sodium chloride

33

106

theophylline er

24

TOBRASOL

79

33, 79

SYNALGOS-DC

102

TEGRETOL-XR

SYNAREL

104

TEMOVATE

64

theophylline sr

24

TOBREX

80

SYNERA

26

TEMOVATE E

64

theophylline td

24

TOFRANIL

40

SYNERCID

33

TENEX

91

THERACYS

37

TOFRANIL-PM

40

TENORETIC 100

91

THERA-FLUR-N

115

tolazamide

55

64

tolbutamide

55

TOLECTIN DS

45

SYNTHROID

116

SYPRINE

10

TENORMIN

91

THERMAZENE

syringe w-ndl, disp., insulin

53

TERAZOL 3

42

THIOLA

115

TERAZOL 7

42

thioridazine hydrochloride

47

TOLINASE

55

TABLOID

37

terazosin hcl

91

thiotepa

37

tolmetin sodium

45

TACLONEX

64

terbutaline sulfate

24

thiothixene

47

TOPAMAX

106

TAGAMET

119

terconazole

42

THYMOGLOBULIN

125

TOPICORT

64

TALACEN

102

TERNAMAR

115

thyroid

116

TOPICORT LP

64

TALADINE

119

TESLAC

37

THYROLAR-1

116

TOPOSAR

37

TALWIN

102

TESTIM

72

TIAZAC 120MG

91

TOPROL XL

91

TALWIN NX

102

TESTOPEL

72

TIAZAC 180MG

91

TORADOL ORAL

45

TAMBOCOR

91

testosterone

72

TIAZAC 240, 300, 360, 420MG

91

torsemide

91

T-4 GEL

121

TAMIFLU CAPSULES

127

testosterone cypionate

72

TICE BCG

37

TOURO ALLERGY

24

TAMIFLU SUSPENSION

127

testosterone enanthate

72

TICLID

49

TOURO LA

24

tamoxifen citrate

37

testosterone propionate

72

ticlopidine hydrochloride

49

TOURO LA-LD

24

TANA PSE

23

TESTRED

72

TIGAN

96

T-PERIO

115

TANA R-12

23

tetanus toxoid

125

TIKOSYN

91

TPN ELECTROLYTES FTV

115

TANACOF-XR

23

TETANUS TOXOID ADSORBED

125

TILADE

24

TRAC

121

TANAFED DP

23

TETANUS/DIPHTHERIA TOXOID

125

TIME-HIST

24

TRACLEER

TANATAN RF

24

tetracycline hydrochloride

33

TIMENTIN

33

tramadol hcl

102

TANAVAN

24

TETRA-MAG

102

TIMOLIDE

91

tramadol hcl and acetaminophen

102

TANNATE PEDIATRIC

24

TEVETEN 400MG

91

timolol maleate

94

TRANDATE

92

TAPAZOLE

105

TEVETEN 600MG

91

timolol maleate ophthalmic

79

TRANDATE IV

92

TARCEVA

37

TEVETEN HCT

91

TIMOPTIC

79

TRANSDERM-SCOP

96

TARGRETIN CAPSULES

37

TEV-TROPIN

105

TIMOPTIC OCUDOSE

79

tranylcypromine sulfate

40

TARGRETIN GEL

64

TEXACORT

64

TIMOPTIC-XE

79

TRAVASOL

115

TARKA

91

THALITONE

91

TINDAMAX

66

TRAVATAN

80

103

THALOMID

125

TIS-U-SOL

64

TRAVATAN Z

80

TASMAR

24

172 TRAVERT trazodone hydrochloride

173 115

TRI-NORINYL

72

ULTRABROM

24

URISYM

121

ULTRABROM PD

24

URITACT DS

121

ULTRACAPS MT 20

68

URITACT-EC

121

102

URO BLUE

121

UROCIT-K 10

115

40

TRIOSTAT

116

TRECATOR

117

TRI-OTIC

80

TRECATOR-SC

117

TRIPEDIA

125

TRELLIUM PLUS

121

TRIPHASIL

72

ULTRALYTIC 2

ULTRACET

65

TRELSTAR DEPOT

37

TRIPLE ANTIBIOTIC

65

ULTRAM

102

UROGESIC-BLUE

121

TRELSTAR LA

37

TRIPLE ANTIBIOTIC OPHTL

80

ULTRAM ER

102

URO-KP-NEUTRAL

115

TRENTAL

49

TRI-PREVIFEM

72

ULTRA-NATAL

115

UROQID #2

121

tretinoin

64

TRISENOX

38

ULTRASE

68

UROXATRAL

121

TREXALL

37

TRI-SPRINTEC

72

ULTRAVATE

65

URSO 250

119

triamcinolone acetonide

64

TRIVORA

72

UMECTA

65

URSO FORTE

119

triamcinolone acetonide and nystatin

64

TRIZIVIR

127

UMECTA NAIL FILM

65

URSODIOL

119

triamcinolone acetonide dental paste

52

trolamine (triethanolamine)

38

UNASYN

33

USEPT

121

triamterene and hydrochlorothiazide

92

TROPHAMINE

115

UNI-HIST

24

UTA

122

TRIAZ

64

TROPICACYL

80

UNI-OTIC

80

UTIRA

122

TRIAZ CLEANSER

65

tropicamide

80

UNIPHYL

24

UTRONA

122

UNIRETIC

92

UVADEX

38

24

VAGIFEM

72

116

VAGISTAT-1

42 42

TRICARE

115

TRUSOPT

80

TRICITRATES

115

TRUVADA

127

UNI-TEX 120/10 ER

102

UNITHROID

TRICOR

92

TRYCET

TRICOSAL

45

TUSNEL PEDIATRIC

24

UNIVASC

92

VAGISTAT-3

TRIDERM

65

TUSSBID

24

UNIVERT

96

VALCYTE

TRIDESILON

65

TWINJECT

92

urea carbamide

65

VALERTEST #1

trifluoperazine hydrochloride

47

TWINRIX

125

urea nail gel

65

valproate acid syrup

106

trifluridine

80

TYGACIL

33

UREA-C40

65

valproate sodium

106

TRIGLIDE

92

TYLENOL/CODEINE #3

102

UREALAC

65

valproic acid

106

trihexyphenidyl hydrochloride

103

TYLENOL/CODEINE #4

102

UREALAC NAIL GEL

65

VALTREX

127

TRIHIBIT

125

TYLOX

102

URECHOLINE

121

VANACET

102

80

URELIEF PLUS

121

VANAMIDE

65

TYMPAGESIC DROPS

127 73

TRI-HISTINE

24

TRILEPTAL

106

TYPHIM VI

125

URELLE

121

VANCOCIN CAPSULE

33

TRI-LEVLEN

72

TYPHOID VI

125

URETRON D/S

121

VANCOCIN HCL ISO-OSMOTIC

33

TRILISATE

45

TYSABRI

125

UREX

121

VANCOCIN INJECTION

33

TRILYTE

52

TYZINE

24

URIMAR-T

121

vancomycin hydrochloride

33

trimethobenzamide hydrochloride

96

TYZINE PEDIATRIC NASAL DR

24

URIN D/S

121

VANDAZOLE

33

trimethoprim

33

U-CORT

65

URINARY ANTISEPTIC #2

121

VANOS

65

trimipramine maleate

40

U-KERA E

65

URINARY ANTISEPTIC F.C.

121

VANOXIDE-HC

65

TRIMOX

33

ULTRA NATAL

115

URISED

121

VANSPAR

27

TRINATE

115

ULTRA NATALCARE

115

URISEPTIC

121

VANTAS

122

TRINESSA

72

ULTRA TABS

115

URISPAS

121

VANTIN

33

174

175

VAQTA

125

VERELAN PM 300MG

92

VIRAVAN-S

25

WESTHROID-3

116

VARIVAX

125

VERMOX

66

VIRAZOLE

127

XALATAN

80

127

XEDEC

25

VASERETIC

92

VERSICLEAR

65

VIREAD

VASOTEC 2.5, 5, 10MG

92

VERTIN-32

96

VIROPTIC

80

XERAC AC

65

VASOTEC 20MG

92

VESANOID

38

VISICOL

52

XIBROM

80

VAZOL

24

VESICARE

122

VISTARIL

27

XIFAXAN

34

VAZOL-D

24

VESPRIN

47

VISTIDE

127

XIGRIS

49

VECTIBIX

38

VEXOL

80

VITAFOL-OB

116

XIRAL SR

25

VEETIDS

33

VFEND

42

VITAFOL-PN

116

XODOL

103

VELCADE

38

VFEND IV

42

VITA-NATAL

116

XOLAIR

25

VELIVET

73

VIADUR

105

VELOSEF

33

VIBRAMYCIN

venlafaxine 150mg

27

venlafaxine 25mg

VITA-NUMONYL

25

XOLEGEL

65

33

VITA-NUMONYL EX

25

XOPENEX

25

VIBRATAB

34

VITA-PREN

XOPENEX HFA

25

27

VICODIN

102

VIVACTIL

40

XPECT-PE

25

venlafaxine 37.5mg

27

VICODIN ES

102

VIVAGLOBIN

125

X-VIATE

65

venlafaxine 50mg

27

VICODIN HP

103

VIVELLE

73

XYLOCAINE GEL

26

venlafaxine 75mg

27

VICOPROFEN

103

VIVELLE-DOT

73

XYLOCAINE INJECTION

26

VENOGLOBULIN-S

125

VIVITROL

10

XYREM

48

125

YASMIN

73 73

VIDAZA

38

116

VENTAVIS

92

VIDEX

127

VIVOTIF BERNA

VENTOLIN

24

VIDEX BUFFER

127

VOLTAREN

45

YAZ

VENTOLIN HFA

25

VIDEX EC

127

VOLTAREN OPTHL SOLUTION

80

YF-VAX

verapamil hydrochloride 40, 80, 120mg

92

VIGAMOX

80

VOLTAREN-XR

45

YODOXIN

66

verapamil hydrochloride cr 120mg

92

VINATAL 600

115

VOPAC

ZACLIR CLEANSING

65

verapamil hydrochloride cr 180mg

92

VINATAL FORTE

115

VOSPIRE ER

25

ZADITOR

80

verapamil hydrochloride cr 240, 360mg

92

VINATE 90

115

V-TANN B.I.D

25

ZANAFLEX

95

verapamil hydrochloride er 120mg

92

VINATE ADVANCED

116

VUMON

38

ZANOSAR

38

verapamil hydrochloride er 180mg

92

VINATE GOOD START

116

VYNATAL FA

verapamil hydrochloride er 240, 360mg

92

VINATE GT

116

VYTORIN

verapamil hydrochloride injection

92

VINATE II

116

verapamil hydrochloride sr 120mg

92

VINATE M

verapamil hydrochloride sr 180mg

92

VINATE ULTRA

verapamil hydrochloride sr 240, 360mg

92

vinblastine sulfate

VERDESO

65

VERELAN 120MG

103

116

125

ZANTAC

119

92

ZANTAC SYRUP

119

warfarin sodium

49

ZARONTIN

106

116

WE ALLERGY

25

ZAROXOLYN

92

116

WE MIST II LA

25

ZAVESCA

68

38

WELCHOL

92

ZAZOLE

42

VINCASAR PFS

38

WELLBID-D

25

Z-CLINZ 10

65

92

vincristine sulfate

38

WELLBUTRIN 75, 100MG

40

ZEBETA

93

VERELAN 180MG

92

vinorelbine tartrate

38

WELLBUTRIN SR 100, 150, 200MG

40

ZEGERID

119

VERELAN 240, 360MG

92

VIOKASE 16

68

WELLBUTRIN XL 150, 300MG

40

ZEGERID CAPSULE

119

VERELAN PM 100MG

92

VIRACEPT

127

WESTCORT

65

ZELAPAR

103

VERELAN PM 200MG

92

VIRAMUNE

127

WESTHROID

116

ZELNORM

119

176 ZEMAIRA

25

ZOMETA

97

ZEMPLAR

116

ZOMIG 2.5MG

94

ZENAPAX

125

ZOMIG 5MG

94

ZEPHREX

25

ZOMIG SPRAY

94

ZEPHREX LA

25

ZOMIG ZMT 2.5MG

94

ZERIT

127

ZOMIG ZMT 5MG

94

ZERLOR

103

ZONALON

65

ZESTORETIC

93

ZONEGRAN

106

ZESTRIL 2.5, 5, 10, 20, 30MG

93

zonisamide

106

ZESTRIL 40MG

93

ZORBTIVE

105

ZETACET

65

ZORPRIN

45

ZETIA

93

ZOSTAVAX

ZEVALIN IN-111

38

ZOSYN

34

ZIAC

93

ZOTANE HC

80

ZIAGEN

127

ZOTEX -GP

25

zidovudine

127

ZOTEX GPX

25

125

ZINACEF

34

ZOTO-HC

80

ZINACEF/D5W

34

ZOVIA

73

ZINECARD

38

ZOVIRAX CAPSULES

127

ZIOX

65

ZOVIRAX CREAM

127

ZITHROMAX

34

ZYBAN

ZITHROMAX TRI-PAK

34

ZYDONE

ZITHROMAX Z-PAK

34

ZYFLO

25

ZMAX

34

ZYLET

80

ZOCOR

93

ZYLOPRIM

80

ZODERM

65

ZYMAR

80

ZODERM CLEANSER

65

ZYMINE

25

ZOFRAN INJECTION

96

ZYMINE-D

25

ZOFRAN ODT

96

ZYPREXA

47

ZOFRAN SOLUTION

96

ZYPREXA 2.5MG

47

ZOFRAN TABLETS

96

ZYPREXA 5, 7.5, 10, 15, 20MG

47

ZYPREXA ZYDIS

47

ZOLADEX

105

10 103

ZOLENE HC

80

ZYRTEC

25

ZOLINZA

38

ZYRTEC SYRUP

25

ZOLOFT 100MG

40

ZYRTEC-D

25

ZOLOFT 25MG

40

ZYVOX

34

ZOLOFT 50MG

40

ZOLOFT SOLUTION

40

Benefits coverage is provided by Aetna Life Insurance Company, a Medicare Prescription Drug Plan sponsor with a Medicare contract. Benefits, limitations, service areas, and premiums are subject to change on January 1 of each year. See plan documents for a complete description of benefits, exclusions, limitations, and conditions of coverage. Plan features are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna’s Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Pharmacy clinical programs such as pre-certification, step therapy, and quantity limits may apply to your prescription drug coverage. Enrollees must use network pharmacies to receive plan benefits except under emergency circumstances. Covered Part D drugs are available at out-of-network pharmacies in special circumstances, including illness while traveling within the United States but outside of the plan’s service area where there is no network pharmacy. An additional cost may be incurred for drugs received at an out-of-network pharmacy. While this material is believed to be accurate as of the print date, it is subject to change. This document may be available in alternate formats (e.g. Braille, foreign languages, audiotapes, large print). For assistance, please call Member Services at the toll-free telephone number on your Aetna Medicare Member ID card. Puede estar disponible la traducicion de este material en otro idoma. Por favor, para ayuda llame a Servicios al Miembro al 1-800-213-4599 o TTY/TDD 1-800-628-3323. ©2007 Aetna Inc.