EMBLEMHEALTH ENHANCED CARE PRIME NETWORK FOR NY STATE OF HEALTH 2016 Formulary If you have general questions about prescription drug coverage, please contact Customer Service at 1-877-842-3625, 8 am to 8 pm, seven days a week (excluding major holidays). If you have a hearing or speech impairment, please dial 711 for TTY/TDD.

EMBLEMHEALTH ENHANCED CARE PRIME NETWORK FOR NY STATE OF HEALTH FORMULARY 2016 Formulary (List of Most Commonly Prescribed Preferred Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN.

Please review this document to make sure it contains the drugs you need. When this drug list (formulary) refers to “we,” “us” or “our,” it is referring to the EmblemHealth Enhanced Care Prime Network for NY State of Health Plan. This document includes a list of covered pharmacy drugs (formulary) for this plan and is current as of January 1, 2016. Our contact information, along with the date we last updated the formulary, appear on the front and back cover. For an updated formulary, please go to emblemhealth.com. Generally, you must use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2017. Can the Formulary (drug list) change? When a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released, the formulary drug list may change. This formulary is current as of January 1, 2016. Our contact information appears on the front and back cover pages. To get updated information about the drugs covered by EmblemHealth Enhanced Care Prime Network for NY State of Health Plan, go to emblemhealth.com.

i

How do I use the Formulary? Medical Condition

The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular, Hypertension & Lipids.” If you know what your drug is used for, look for the category name in the list. Then look under the category name for your drug. What are generic drugs? EmblemHealth Enhanced Care Prime Network for NY State of Health Plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: • Prior Authorization: EmblemHealth Enhanced Care Prime Network for NY State of Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from this plan before you fill your prescriptions. If you don’t get approval, this plan may not cover the drug. • Quantity Limits: For certain drugs, EmblemHealth Enhanced Care Prime Network for NY State of Health Plan limits the amount of the drug that it will cover. • Step Therapy: In some cases, EmblemHealth Enhanced Care Prime Network for NY State of Health Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, this plan will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary. You can also get more information about the restrictions applied to specific covered drugs by visiting emblemhealth.com. Our contact information appears on the front and back covers. The date we last updated the formulary appears on the back cover. You can ask EmblemHealth Enhanced Care Prime Network for NY State of Health Plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. For more information If you have questions about the EmblemHealth Enhanced Care Prime Network for NY State of Health Formulary, please call us or go to emblemhealth.com. If you have general questions about prescription drug coverage, please contact Customer Service at 1-877-842-3625, 8 am to 8 pm, seven days a week (excluding major holidays). If you have a hearing or speech impairment, please dial 711 for TTY/TDD. You can find information on the symbols and abbreviations in the table on page iv. ii

EmblemHealth Enhanced Care Prime Network Formulary The formulary that begins on page 1 provides coverage information about the pharmacy drugs covered by EmblemHealth Enhanced Care Prime Network for NY State of Health Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 117. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., SYNTHROID) and generic drugs are listed in lower-case italics (e.g., atenolol). The information in the Requirements/Limits column tells you if the EmblemHealth Enhanced Care Prime Network for NY State of Health Plan Formulary has any special requirements for coverage of your drug. On the next page is a list of abbreviations that may appear in the Requirements/Limits column that tells you if there are any special requirements for coverage of your drug. Disclaimer

Please refer to your benefit materials for specific coverage information. Your benefit design determines what is covered for you and what your copayment will be. The presence of a medication on this formulary does not guarantee that you as a plan member will be covered for that drug. Additionally, these medications may be subject to Prior Authorization. Coverage for some drugs may be limited to specific dosage forms and/or strengths. The medications listed on this formulary are subject to change pursuant to the formulary management activities of EmblemHealth’s Pharmacy Benefit Services. As new generics become available, the corresponding brand name drug will no longer be considered a preferred agent. This is a list of the most commonly prescribed drugs for members with the Enhanced Care Prime Network Formulary. Make sure to ask your doctor to prescribe generic drugs whenever appropriate; this may lower your out-of-pocket expenses. NOTE: Not all drugs listed are covered by all pharmacy benefit programs, so coverage is not guaranteed. Check your benefit materials for the copay and any other responsibilities you may have under your pharmacy benefit. For additional questions about your prescription drug coverage, please call the phone number on the back of your ID card.

iii

List of Abbreviations Abbreviations List for 2016 Abbreviation

Abbreviation Definition

ACA

Affordable Care Act.*

LA

Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service.

PA

Prior Authorization. This Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

ST

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

QL

Quantity Limit. For certain drugs, this Plan limits the amount of the drug that we will cover.

*Certain restrictions may apply based on benefit. Tier Structure Please refer to the table below for information regarding the tier number and the corresponding name. Tier Number Tier Name 1

Generic

2

Preferred Brand

3

Nonpreferred Brand

4

Zero Cost Share Preventive Drugs*

*Certain restrictions may apply based on benefit.

iv

Table of Contents

ANTI - INFECTIVES .......................................................................................................................................... 2 ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS .......................................................................... 10 AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ........................................................................... 14 CARDIOVASCULAR, HYPERTENSION & LIPIDS ..................................................................................... 34 DERMATOLOGICALS/TOPICAL THERAPY ............................................................................................... 44 DIAGNOSTICS & MISCELLANEOUS AGENTS .......................................................................................... 57 EAR, NOSE & THROAT MEDICATIONS...................................................................................................... 59 ENDOCRINE/DIABETES ................................................................................................................................ 61 GASTROENTEROLOGY ................................................................................................................................. 67 IMMUNOLOGY, VACCINES & BIOTECHNOLOGY .................................................................................. 75 MUSCULOSKELETAL & RHEUMATOLOGY ............................................................................................. 77 OBSTETRICS & GYNECOLOGY ................................................................................................................... 79 OPHTHALMOLOGY ........................................................................................................................................ 87 RESPIRATORY, ALLERGY, COUGH & COLD ............................................................................................ 93 UROLOGICALS ................................................................................................................................................ 99 VITAMINS, HEMATINICS & ELECTROLYTES ........................................................................................ 102 Index ................................................................................................................................................................. 116

1

Drug Name

Drug Tier

Requirements / Limits

ANTI - INFECTIVES ANTIFUNGAL AGENTS ANCOBON

3

clotrimazole

1

CRESEMBA

3

DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION

3

DIFLUCAN ORAL TABLET 100 MG, 200 MG, 50 MG

3

DIFLUCAN ORAL TABLET 150 MG

3

fluconazole oral suspension for reconstitution

1

fluconazole oral tablet 100 mg, 200 mg, 50 mg

1

fluconazole oral tablet 150 mg

1

flucytosine

1

GRIFULVIN V

3

griseofulvin microsize

1

griseofulvin ultramicrosize

1

GRIS-PEG (ULTRAMICROSIZE)

3

itraconazole

1

ketoconazole

1

LAMISIL

3

NOXAFIL

3

nystatin

1

ONMEL

3

ORAVIG

3

SPORANOX

3

SPORANOX PULSEPAK

3

terbinafine hcl

1

VFEND

3

voriconazole

1

QL

QL

ANTIVIRALS abacavir

1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 2

Drug Name

Drug Tier

Requirements / Limits

abacavir-lamivudine-zidovudine

1

acyclovir

1

adefovir

1

amantadine hcl

1

APTIVUS

2

ATRIPLA

2

BARACLUDE ORAL SOLUTION

2

BARACLUDE ORAL TABLET

3

COMBIVIR

3

COMPLERA

2

CRIXIVAN

2

DAKLINZA

3

didanosine

1

EDURANT

2

EMTRIVA

2

entecavir

1

EPIVIR

3

EPIVIR HBV ORAL SOLUTION

2

EPIVIR HBV ORAL TABLET

3

EPZICOM

2

EVOTAZ

3

famciclovir

1

FAMVIR

3

FLUMADINE

3

FUZEON

2

PA; LA; QL

HARVONI

3

PA; QL

HEPSERA

3

PA

INTELENCE

2

INVIRASE

2

ISENTRESS ORAL POWDER IN PACKET

3

ISENTRESS ORAL TABLET

2

ISENTRESS ORAL TABLET,CHEWABLE

2

PA

PA; QL

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 3

Drug Name

Drug Tier

Requirements / Limits

KALETRA

2

lamivudine

1

lamivudine-zidovudine

1

LEXIVA

2

nevirapine

1

NORVIR

2

OLYSIO

3

PA; QL

PREZCOBIX

3

QL

PREZISTA

2

RELENZA DISKHALER

2

RESCRIPTOR

2

RETROVIR

3

REYATAZ

2

rimantadine

1

SELZENTRY

2

SITAVIG

3

SOVALDI

3

stavudine

1

STRIBILD

2

SUSTIVA

2

TAMIFLU

2

QL

TECHNIVIE

3

PA; QL

TIVICAY

3

TRIUMEQ

3

TRIZIVIR

3

TRUVADA

2

TYBOST

3

TYZEKA

2

valacyclovir

1

VALCYTE

3

valganciclovir

1

VALTREX

3

QL

PA; QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 4

Drug Name

Drug Tier

VIDEX 2 GRAM PEDIATRIC

2

VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 125 MG

2

VIDEX EC ORAL CAPSULE,DELAYED RELEASE(DR/EC) 200 MG, 250 MG, 400 MG

3

VIEKIRA PAK

2

VIRACEPT

2

VIRAMUNE

3

VIRAMUNE XR

3

VIREAD ORAL POWDER

3

VIREAD ORAL TABLET

2

VITEKTA

3

ZERIT

3

ZIAGEN ORAL SOLUTION

2

ZIAGEN ORAL TABLET

3

zidovudine

1

ZOVIRAX

3

Requirements / Limits

PA; QL

QL

CEPHALOSPORINS CEDAX

3

cefaclor

1

cefadroxil

1

cefdinir

1

cefditoren pivoxil

1

cefixime

1

cefpodoxime

1

cefprozil

1

ceftibuten

1

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION

2

CEFTIN ORAL TABLET

3

cefuroxime axetil

1

cephalexin

1

KEFLEX

3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 5

Drug Name

Drug Tier

SPECTRACEF

3

SUPRAX

3

Requirements / Limits

ERYTHROMYCINS & OTHER MACROLIDES azithromycin

1

BIAXIN

3

clarithromycin

1

DIFICID

3

e.e.s. 400

1

E.E.S. GRANULES

3

ERYPED 200

3

ERYPED 400

3

ery-tab oral tablet,delayed release (dr/ec) 250 mg, 333 mg

1

ERY-TAB ORAL TABLET,DELAYED RELEASE (DR/EC) 500 MG

2

erythrocin (as stearate)

1

erythromycin

1

erythromycin ethylsuccinate

1

PCE

3

ZITHROMAX

3

ZMAX

3

MISCELLANEOUS ANTIINFECTIVES ALBENZA

2

ALINIA

3

atovaquone

1

atovaquone-proguanil

1

BETHKIS

3

BILTRICIDE

3

CAYSTON

3

chloroquine phosphate

1

CLEOCIN ORAL CAPSULE

3

CLEOCIN ORAL RECON SOLN

3

QL

LA LA; QL

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 6

Drug Name

Drug Tier

Requirements / Limits

clindamycin hcl

1

clindamycin palmitate hcl

1

QL

clindamycin pediatric

1

QL

COARTEM

2

QL

CYCLOSERINE

3

DAPSONE

2

DARAPRIM

3

ethambutol

1

FLAGYL

3

FLAGYL ER

3

hydroxychloroquine

1

isoniazid

1

ivermectin

1

KETEK

3

KITABIS PAK

3

LA

linezolid

1

QL

MALARONE

3

MALARONE PEDIATRIC

3

mefloquine

1

MEPRON

3

metronidazole

1

MYAMBUTOL

3

MYCOBUTIN

3

NEBUPENT

3

neomycin

1

paromomycin

1

PASER

3

PLAQUENIL

3

PRIFTIN

3

PRIMAQUINE

3

pyrazinamide

1

QUALAQUIN

3

PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 7

Drug Name

Drug Tier

Requirements / Limits

quinine sulfate

1

rifabutin

1

RIFADIN

3

RIFAMATE

3

rifampin

1

RIFATER

3

SIRTURO

3

SIVEXTRO

3

STROMECTOL

3

TINDAMAX

3

QL

tinidazole

1

QL

TOBI

3

LA

TOBI PODHALER

3

LA

tobramycin in 0.225 % nacl

1

PA

TRECATOR

3

XIFAXAN ORAL TABLET 200 MG

3

XIFAXAN ORAL TABLET 550 MG

2

ZYVOX

3

LA

QL QL

PENICILLINS amoxicillin oral capsule

1

amoxicillin oral suspension for reconstitution

1

amoxicillin oral tablet

1

AMOXICILLIN ORAL TABLET, ER MULTIPHASE 24 HR

3

amoxicillin oral tablet,chewable

1

amoxicillin-pot clavulanate

1

ampicillin

1

AUGMENTIN

3

AUGMENTIN ES-600

3

AUGMENTIN XR

3

dicloxacillin

1

MOXATAG

3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 8

Drug Name penicillin v potassium

Drug Tier

Requirements / Limits

1

QUINOLONES AVELOX

3

AVELOX ABC PACK

3

CIPRO

3

CIPRO XR

3

ciprofloxacin

1

ciprofloxacin (mixture)

1

ciprofloxacin hcl

1

FACTIVE

3

LEVAQUIN

3

levofloxacin

1

moxifloxacin

1

ofloxacin

1

QL

SULFA'S & RELATED AGENTS BACTRIM

3

BACTRIM DS

3

sulfadiazine

1

sulfamethoxazole-trimethoprim

1

sulfatrim

1

TETRACYCLINES ACTICLATE

3

ST

ADOXA

3

ST

avidoxy

1

AVIDOXY DK

3

demeclocycline

1

DORYX

3

doxycycline hyclate

1

doxycycline monohydrate oral capsule

1

DOXYCYCLINE MONOHYDRATE ORAL CAPSULE,IR & DELAY REL,BIPHASE

3

ST ST

ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 9

Drug Name

Drug Tier

Requirements / Limits

doxycycline monohydrate oral suspension for reconstitution

1

doxycycline monohydrate oral tablet

1

MINOCIN

3

ST

MINOCIN KIT WITH WIPES

3

ST

minocycline

1

mondoxyne nl

1

MONODOX

3

morgidox

1

MORGIDOX 1X100

3

ST

ORACEA

3

ST

SOLODYN

3

ST

tetracycline

1

VIBRAMYCIN

3

ST

ST

URINARY TRACT AGENTS FURADANTIN

3

HIPREX

3

MACROBID

3

MACRODANTIN

3

methenamine hippurate

1

methenamine mandelate

1

MONUROL

3

nitrofurantoin

1

nitrofurantoin macrocrystal

1

nitrofurantoin monohyd/m-cryst

1

PRIMSOL

3

trimethoprim

1

VANCOMYCIN VANCOCIN

3

vancomycin

1

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 10

Drug Name

Drug Tier

leucovorin calcium

1

MESNEX

2

Requirements / Limits

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS AFINITOR

3

PA; QL

AFINITOR DISPERZ

3

PA; QL

ALKERAN

2

anastrozole

1

ARIMIDEX

3

AROMASIN

3

ASTAGRAF XL

3

AZASAN

3

azathioprine

1

bexarotene

1

bicalutamide

1

BOSULIF

3

PA; LA; QL

capecitabine

1

PA

CAPRELSA

3

PA; LA; QL

CASODEX

3

CELLCEPT ORAL CAPSULE

3

CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION

3

CELLCEPT ORAL TABLET

3

COMETRIQ

3

CYCLOPHOSPHAMIDE

3

cyclosporine

1

cyclosporine modified oral capsule

1

cyclosporine modified oral solution

1

DROXIA

2

EMCYT

2

ENVARSUS XR

3

ERIVEDGE

3

etoposide

1

PA

QL

QL

PA; LA

QL PA PA; LA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 11

Drug Name

Drug Tier

Requirements / Limits

exemestane

1

FARESTON

2

FARYDAK

3

FEMARA

3

flutamide

1

gengraf oral capsule

1

gengraf oral solution

1

QL

GILOTRIF

3

PA; LA

GLEEVEC ORAL TABLET 100 MG

2

PA; QL

GLEEVEC ORAL TABLET 400 MG

2

PA

GLEOSTINE

3

GLIADEL WAFER

3

HEXALEN

2

PA

HYCAMTIN

3

PA; LA; QL

HYDREA

3

hydroxyurea

1

IBRANCE

3

PA; LA

ICLUSIG

3

PA; LA

IMBRUVICA

3

PA; LA

IMURAN

3

INLYTA

3

PA; LA

IRESSA

3

PA; LA

JAKAFI

3

PA; LA

LENVIMA

3

PA; LA

letrozole

1

LEUKERAN

2

leuprolide

1

LOMUSTINE

3

LONSURF

3

PA

LYNPARZA

3

PA; LA

LYSODREN

2

MATULANE

2

PA; LA

PA; LA

PA; LA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 12

Drug Name

Drug Tier

Requirements / Limits

MEGACE

3

MEGACE ES

3

megestrol oral suspension

1

megestrol oral tablet

1

PA

MEKINIST

3

PA; LA

mercaptopurine

1

methotrexate sodium (pf)

1

PA; LA

methotrexate sodium injection

1

PA; LA

methotrexate sodium oral

1

mycophenolate mofetil oral capsule

1

mycophenolate mofetil oral suspension for reconstitution

1

mycophenolate mofetil oral tablet

1

mycophenolate sodium

1

MYFORTIC

3

MYLERAN

2

NEORAL ORAL CAPSULE

2

NEORAL ORAL SOLUTION

2

QL

NEXAVAR

3

PA; LA

ODOMZO

3

PA

PROGRAF

2

PURIXAN

3

LA

RAPAMUNE ORAL SOLUTION

2

QL

RAPAMUNE ORAL TABLET

3

RHEUMATREX

3

SANDIMMUNE ORAL CAPSULE

2

SANDIMMUNE ORAL SOLUTION

2

QL

SANDOSTATIN

3

PA; LA

SIGNIFOR

3

PA; LA

sirolimus

1

SOLTAMOX

3

LA

SPRYCEL

3

PA; QL

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 13

Drug Name

Drug Tier

Requirements / Limits

STIVARGA

3

PA; LA

SUTENT

3

PA; LA; QL

SYNRIBO

3

PA; LA

TABLOID

2

PA

tacrolimus

1

TAFINLAR

3

tamoxifen

1

TARCEVA

2

PA; LA; QL

TARGRETIN

3

QL

TASIGNA

3

PA

TEMODAR

3

PA

temozolomide

1

PA

THALOMID

2

PA; LA

tretinoin (chemotherapy)

1

PA

TREXALL

3

TYKERB

3

PA; LA; QL

VOTRIENT

3

PA; LA; QL

XALKORI

3

PA; LA

XELODA

3

XTANDI

3

PA; LA

ZELBORAF

3

PA; LA; QL

ZOLINZA

3

PA; LA; QL

ZORTRESS

3

ZYDELIG

3

PA; LA

ZYKADIA

3

PA; LA

ZYTIGA

3

LA; QL

PA; LA; QL

AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ANTICONVULSANTS APTIOM

3

BANZEL

3

carbamazepine

1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 14

Drug Name

Drug Tier

Requirements / Limits

CARBATROL

3

CELONTIN

2

clonazepam

1

DEPAKENE

3

DEPAKOTE

3

DEPAKOTE ER

3

DEPAKOTE SPRINKLES

3

DIASTAT

2

QL

DIASTAT ACUDIAL

3

QL

diazepam

1

QL

DILANTIN

2

DILANTIN EXTENDED

2

DILANTIN INFATABS

2

DILANTIN-125

2

divalproex

1

epitol

1

EQUETRO

3

ethosuximide

1

felbamate

1

FELBATOL

3

FYCOMPA

3

gabapentin

1

GABITRIL

3

GRALISE

3

GRALISE 30-DAY STARTER PACK

3

KEPPRA

3

KEPPRA XR

3

KLONOPIN

3

LAMICTAL

3

LAMICTAL ODT

3

LAMICTAL ODT STARTER (BLUE)

3

LAMICTAL ODT STARTER (GREEN)

3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 15

Drug Name

Drug Tier

LAMICTAL ODT STARTER (ORANGE)

3

LAMICTAL STARTER (BLUE) KIT

3

LAMICTAL STARTER (GREEN) KIT

3

LAMICTAL STARTER (ORANGE) KIT

3

LAMICTAL XR

3

LAMICTAL XR STARTER (BLUE)

3

LAMICTAL XR STARTER (GREEN)

3

LAMICTAL XR STARTER (ORANGE)

3

lamotrigine

1

levetiracetam

1

LYRICA

2

MYSOLINE

3

NEURONTIN

3

ONFI

3

oxcarbazepine

1

OXTELLAR XR

3

PEGANONE

3

phenobarbital

1

PHENYTEK

2

phenytoin

1

phenytoin sodium extended

1

POTIGA

3

primidone

1

QUDEXY XR

3

SABRIL

3

TEGRETOL

3

TEGRETOL XR

2

tiagabine

1

TOPAMAX

3

topiramate oral capsule, sprinkle

1

TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR

3

Requirements / Limits

LA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 16

Drug Name

Drug Tier

topiramate oral tablet

1

TRILEPTAL ORAL SUSPENSION

2

TRILEPTAL ORAL TABLET

3

TROKENDI XR

3

valproic acid

1

valproic acid (as sodium salt)

1

VIMPAT

3

ZARONTIN

3

ZONEGRAN

3

zonisamide

1

Requirements / Limits

ANTIPARKINSONISM AGENTS APOKYN

3

AZILECT

3

benztropine

1

bromocriptine

1

carbidopa

1

carbidopa-levodopa

1

carbidopa-levodopa-entacapone

1

COMTAN

3

DUOPA

3

ELDEPRYL

3

entacapone

1

LODOSYN

3

MIRAPEX

3

MIRAPEX ER

3

NEUPRO

3

PARLODEL

3

pramipexole

1

REQUIP

3

REQUIP XL

3

ropinirole

1

RYTARY

3

PA; LA; QL

LA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 17

Drug Name

Drug Tier

selegiline hcl

1

SINEMET

3

SINEMET CR

3

STALEVO 100

3

STALEVO 125

3

STALEVO 150

3

STALEVO 200

3

STALEVO 50

3

STALEVO 75

3

TASMAR

2

tolcapone

1

trihexyphenidyl

1

ZELAPAR

3

Requirements / Limits

MIGRAINE & CLUSTER HEADACHE THERAPY almotriptan malate

1

QL

ALSUMA

3

ST; QL

AMERGE

3

ST; QL

AXERT

3

ST; QL

CAFERGOT

3

dihydroergotamine

1

ERGOMAR

3

FROVA

3

ST; QL

IMITREX

3

ST; QL

IMITREX STATDOSE KIT REFILL

3

ST; QL

IMITREX STATDOSE PEN

3

ST; QL

isometh-dichloral-acetaminophn

1

isomethepten-caf-acetaminophen

1

MAXALT

3

ST; QL

MAXALT-MLT

3

ST; QL

migergot

1

MIGRANAL

3

QL

naratriptan

1

QL

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 18

Drug Name

Drug Tier

Requirements / Limits

nodolor

1

RELPAX

3

ST; QL

rizatriptan

1

QL

sumatriptan

1

ST; QL

sumatriptan succinate

1

QL

SUMAVEL DOSEPRO

3

ST; QL

TREXIMET

2

ST; QL

ZECUITY

3

ST; LA; QL

zolmitriptan

1

QL

ZOMIG NASAL

2

QL

ZOMIG ORAL

3

ST; QL

ZOMIG ZMT

3

ST; QL

AMPYRA

3

PA; LA

ARICEPT

3

donepezil

1

EXELON

3

galantamine

1

HORIZANT

3

memantine oral solution

1

memantine oral tablet

1

MEMANTINE ORAL TABLETS,DOSE PACK

3

NAMENDA

3

NAMENDA TITRATION PAK

3

NAMENDA XR

2

NAMZARIC

3

NUEDEXTA

3

RAZADYNE

3

RAZADYNE ER

3

rivastigmine

1

rivastigmine tartrate

1

tetrabenazine

1

MISCELLANEOUS NEUROLOGICAL THERAPY

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 19

Drug Name

Drug Tier

XENAZINE

3

Requirements / Limits

MUSCLE RELAXANTS & ANTISPASMODIC THERAPY AMRIX

3

baclofen

1

carisoprodol oral tablet 250 mg

1

carisoprodol oral tablet 350 mg

1

QL

carisoprodol-asa-codeine

1

PA; QL

carisoprodol-aspirin

1

QL

chlorzoxazone

1

cyclobenzaprine

1

DANTRIUM

3

dantrolene

1

FEXMID

3

LORZONE

3

meprobamate

1

MESTINON ORAL SYRUP

2

MESTINON ORAL TABLET

3

MESTINON TIMESPAN

3

metaxalone

1

methocarbamol

1

orphenadrine citrate

1

PARAFON FORTE DSC

3

pyridostigmine bromide

1

ROBAXIN

3

ROBAXIN-750

3

SKELAXIN

3

SOMA ORAL TABLET 250 MG

3

SOMA ORAL TABLET 350 MG

3

tizanidine

1

ZANAFLEX

3

QL

NARCOTIC ANALGESICS ABSTRAL

3

PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 20

Drug Name

Drug Tier

Requirements / Limits

acetaminophen-codeine

1

PA; QL

ACTIQ

3

PA; QL

ascomp with codeine

1

PA

BUPAP

3

buprenorphine hcl

1

QL

butalbital compound w/codeine

1

PA

butalbital-acetaminop-caf-cod

1

PA

butalbital-acetaminophen

1

QL

butalbital-acetaminophen-caff oral capsule 50300-40 mg

1

PA

butalbital-acetaminophen-caff oral capsule 50325-40 mg

1

butalbital-acetaminophen-caff oral tablet

1

butalbital-aspirin-caffeine

1

PA

BUTRANS

3

PA

capacet

1

CAPITAL WITH CODEINE

3

PA; QL

codeine sulfate

1

PA

DEMEROL

3

PA

dihydrocode-acetaminophen-caff

1

PA

dihydrocodeine-aspirin-caff

1

PA

DILAUDID ORAL LIQUID

3

PA; QL

DILAUDID ORAL TABLET

3

PA

diskets

1

PA

DOLOPHINE

3

PA

DURAGESIC

3

PA

EMBEDA

3

ST; QL

endocet

1

PA; QL

endodan

1

PA

ESGIC

3

EXALGO ER

3

ST; QL

fentanyl citrate

1

PA; QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 21

Drug Name

Drug Tier

Requirements / Limits

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

1

PA

FENTANYL TRANSDERMAL PATCH 72 HOUR 37.5 MCG/HOUR, 62.5 MCG/HOUR, 87.5 MCG/HOUR

3

PA

FENTORA

3

PA

FIORICET

3

PA

FIORICET WITH CODEINE

3

PA

FIORINAL

3

PA

FIORINAL-CODEINE #3

3

PA

HYCET

3

PA; QL

hydrocodone-acetaminophen oral solution

1

PA; QL

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

1

PA; QL

hydrocodone-acetaminophen oral tablet 2.5-325 mg

1

PA

hydrocodone-ibuprofen

1

PA

hydromorphone oral liquid

1

PA; QL

hydromorphone oral tablet

1

PA

hydromorphone oral tablet extended release 24 hr

1

PA; QL

hydromorphone rectal

1

PA

HYSINGLA ER

3

ST; QL

IBUDONE

3

PA

ibuprofen-oxycodone

1

PA; QL

IONSYS

3

KADIAN

3

ST; QL

LAZANDA

3

PA

levorphanol tartrate

1

PA

lorcet (hydrocodone)

1

PA; QL

lorcet hd

1

PA; QL

lorcet plus

1

PA; QL

lortab 10-325

1

PA; QL

lortab 5-325

1

PA; QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 22

Drug Name

Drug Tier

Requirements / Limits

lortab 7.5-325

1

PA; QL

LORTAB ELIXIR

3

PA; QL

margesic

1

marten-tab

1

QL

meperidine oral solution

1

PA; QL

meperidine oral tablet

1

PA

meperitab

1

PA

methadone oral concentrate

1

PA; QL

methadone oral solution

1

PA; QL

methadone oral tablet

1

PA

methadone oral tablet,soluble

1

PA

methadose oral concentrate

1

PA; QL

methadose oral tablet,soluble

1

PA

morphine concentrate

1

PA; QL

morphine oral capsule, er multiphase 24 hr

1

PA; QL

morphine oral capsule,extend.release pellets

1

PA; QL

morphine oral solution

1

PA; QL

morphine oral tablet

1

PA

morphine oral tablet extended release

1

PA; QL

morphine rectal

1

PA

MS CONTIN

3

ST; QL

NORCO

3

PA; QL

OPANA

3

PA; QL

OPANA ER

3

ST; QL

OXAYDO

3

PA

OXECTA

3

PA

oxycodone oral capsule

1

PA

oxycodone oral concentrate

1

PA; QL

oxycodone oral solution

1

PA; QL

oxycodone oral tablet 10 mg, 15 mg, 30 mg, 5 mg

1

PA

oxycodone oral tablet 20 mg

1

PA; QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 23

Drug Name

Drug Tier

Requirements / Limits

OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR

3

ST; QL

oxycodone-acetaminophen

1

PA; QL

oxycodone-aspirin

1

PA

OXYCONTIN

3

ST; QL

oxymorphone

1

PA; QL

PERCOCET

3

PA; QL

PRIMLEV

3

PA

reprexain

1

PA

ROXICODONE

3

PA

SUBSYS

3

PA

SYNALGOS-DC

3

PA

tencon

1

QL

TREZIX

3

PA

TYLENOL-CODEINE #3

3

PA; QL

TYLENOL-CODEINE #4

3

PA; QL

VANATOL LQ

3

verdrocet

1

PA

vicodin

1

PA; QL

vicodin es

1

PA; QL

vicodin hp

1

PA; QL

VICOPROFEN

3

PA

XARTEMIS XR

3

ST; QL

XODOL 10/300

3

PA; QL

XODOL 5/300

3

PA; QL

XODOL 7.5/300

3

PA; QL

xylon 10

1

PA

zamicet

1

PA; QL

zebutal

1

ZOHYDRO ER

3

ST; QL

3

ST

NON-NARCOTIC ANALGESICS ANAPROX

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 24

Drug Name

Drug Tier

Requirements / Limits

ANAPROX DS

3

ST

ARTHROTEC 50

3

ST

ARTHROTEC 75

3

ST

aspirin

4

ACA; OTC

aspir-low

4

ACA; OTC

BUNAVAIL

3

buprenorphine-naloxone

1

QL

butorphanol tartrate

1

PA; QL

CAMBIA

3

ST

CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG

3

ST; QL

CELEBREX ORAL CAPSULE 50 MG

3

ST

celecoxib oral capsule 100 mg, 200 mg, 400 mg

1

QL

celecoxib oral capsule 50 mg

1

choline,magnesium salicylate

1

CONZIP

3

ST; QL

DAYPRO

3

ST

diclofenac potassium

1

diclofenac sodium oral

1

diclofenac sodium topical

1

diclofenac-misoprostol

1

diflunisal

1

DISALCID

3

DUEXIS

3

ST

EC-NAPROSYN

3

ST

etodolac

1

FELDENE

3

ST

FENOPROFEN ORAL CAPSULE

3

ST

fenoprofen oral tablet

1

FLECTOR

3

flurbiprofen

1

ibuprofen

1

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 25

Drug Name

Drug Tier

Requirements / Limits

INDOCIN

3

ST

indomethacin

1

ketoprofen

1

ketorolac

1

meclofenamate

1

mefenamic acid

1

meloxicam

1

QL

MOBIC

3

ST; QL

nabumetone

1

NALFON

3

naltrexone

1

NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR 375 MG

3

NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR 500 MG, 750 MG

3

ST

NAPROSYN

3

ST

naproxen

1

naproxen sodium

1

NUCYNTA

2

NUCYNTA ER

2

oxaprozin

1

PENNSAID

3

ST

pentazocine-naloxone

1

PA

piroxicam

1

PONSTEL

3

REVIA

3

salsalate

1

SPRIX

3

SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG

2

SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 82 MG

2

sulindac

1

QL

ST

ST

ST; LA

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 26

Drug Name

Drug Tier

Requirements / Limits

TIVORBEX

3

tolmetin

1

TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 17-83

3

ST; QL

TRAMADOL ORAL CAPSULE,ER BIPHASE 24 HR 25-75

3

ST; QL

tramadol oral tablet

1

tramadol oral tablet extended release 24 hr

1

QL

tramadol oral tablet, er multiphase 24 hr

1

QL

tramadol-acetaminophen

1

QL

TREPADONE (WITH BROMELAIN)

3

ULTRACET

3

ST; QL

ULTRAM

3

ST

ULTRAM ER

3

ST; QL

VIMOVO

2

ST; QL

VOLTAREN

3

ST; QL

VOLTAREN-XR

3

ST

ZIPSOR

3

ST

ZORVOLEX

3

ST

ZUBSOLV

3

ST

PSYCHOTHERAPEUTIC DRUGS ABILIFY ORAL TABLET 10 MG, 15 MG, 20 MG, 30 MG, 5 MG

3

ST; QL

ABILIFY ORAL TABLET 2 MG

3

ST

ADASUVE

3

ADDERALL

3

ADDERALL XR

2

alprazolam

1

alprazolam intensol

1

QL

AMBIEN

3

ST; QL

AMBIEN CR

3

ST; QL

amitriptyline

1

amitriptyline-chlordiazepoxide

1

ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 27

Drug Name

Drug Tier

Requirements / Limits

amoxapine

1

amphetamine salt combo

1

ANAFRANIL

3

APLENZIN

3

APTENSIO XR

3

ST

aripiprazole oral solution

1

QL

aripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg

1

QL

aripiprazole oral tablet 2 mg

1

aripiprazole oral tablet,disintegrating

1

ATIVAN

3

BELSOMRA

3

BRINTELLIX

3

BRISDELLE

3

bupropion hcl oral tablet

1

bupropion hcl oral tablet extended release

1

bupropion hcl oral tablet extended release 24 hr 150 mg

1

bupropion hcl oral tablet extended release 24 hr 300 mg

1

buspirone

1

BUTISOL

3

CELEXA

3

chlordiazepoxide hcl

1

chlorpromazine

1

citalopram

1

clomipramine

1

clonidine hcl

1

clorazepate dipotassium

1

clozapine oral tablet

1

clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg

1

QL

QL

ST; QL

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 28

Drug Name

Drug Tier

Requirements / Limits

CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG, 200 MG

3

ST

CLOZARIL

3

ST

CONCERTA

3

ST; QL

CYMBALTA

3

QL

DAYTRANA

3

ST

desipramine

1

DESOXYN

3

DESVENLAFAXINE

3

DESVENLAFAXINE FUMARATE

3

dexedrine

1

DEXEDRINE SPANSULE

3

dexmethylphenidate

1

dextroamphetamine

1

dextroamphetamine-amphetamine

1

PA

diazepam intensol

1

QL

diazepam oral solution

1

QL

diazepam oral tablet

1

doxepin oral capsule

1

doxepin oral concentrate

1

QL

duloxetine

1

QL

EDLUAR

3

ST

EFFEXOR XR

3

EMSAM

3

ergoloid

1

escitalopram oxalate oral solution

1

escitalopram oxalate oral tablet

1

estazolam

1

eszopiclone

1

QL

EVEKEO

3

PA

FANAPT

3

ST

FAZACLO

3

ST

ST

ST

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 29

Drug Name

Drug Tier

Requirements / Limits

FETZIMA

3

fluoxetine oral capsule

1

fluoxetine oral capsule,delayed release(dr/ec)

1

QL

fluoxetine oral solution

1

QL

fluoxetine oral tablet 10 mg, 20 mg

1

FLUOXETINE ORAL TABLET 60 MG

3

fluphenazine hcl oral concentrate

1

QL

fluphenazine hcl oral elixir

1

QL

fluphenazine hcl oral tablet

1

flurazepam

1

fluvoxamine

1

FOCALIN

3

ST

FOCALIN XR

3

ST

FORFIVO XL

3

GEODON

3

guanfacine

1

guanidine

1

HALCION

3

haloperidol

1

haloperidol lactate

1

QL

HETLIOZ

3

PA; LA

imipramine hcl

1

imipramine pamoate

1

INTERMEZZO

3

ST

INTUNIV ER

3

ST

INVEGA

2

IRENKA

3

QL

KAPVAY

3

ST

KHEDEZLA

3

LATUDA

3

ST

LEXAPRO ORAL SOLUTION

3

ST; QL

LEXAPRO ORAL TABLET

3

ST

ST

ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 30

Drug Name

Drug Tier

Requirements / Limits

lithium carbonate

1

lithium citrate

1

LITHOBID

3

lorazepam intensol

1

QL

lorazepam oral concentrate

1

QL

lorazepam oral tablet

1

loxapine succinate

1

LUNESTA

3

maprotiline

1

MARPLAN

3

METADATE CD

3

metadate er

1

methamphetamine

1

METHYLIN ORAL SOLUTION

3

ST; QL

METHYLIN ORAL TABLET,CHEWABLE

3

ST

methylphenidate oral capsule, er biphasic 30-70

1

methylphenidate oral capsule,er biphasic 50-50

1

methylphenidate oral solution

1

methylphenidate oral tablet

1

methylphenidate oral tablet extended release

1

methylphenidate oral tablet extended release 24hr

1

methylphenidate oral tablet,chewable

1

midazolam

1

mirtazapine

1

modafinil

1

NARDIL

3

nefazodone

1

NORPRAMIN

3

nortriptyline oral capsule

1

nortriptyline oral solution

1

QL

NUVIGIL

3

ST

olanzapine

1

QL

ST; QL

ST

QL

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 31

Drug Name

Drug Tier

Requirements / Limits

olanzapine-fluoxetine

1

OLEPTRO ER

3

ORAP

3

oxazepam

1

paliperidone

1

PAMELOR

3

PARNATE

3

paroxetine hcl

1

PAXIL CR

3

ST

PAXIL ORAL SUSPENSION

3

ST; QL

PAXIL ORAL TABLET

3

ST

perphenazine

1

perphenazine-amitriptyline

1

PEXEVA

3

phenelzine

1

pimozide

1

PRISTIQ

2

procentra

1

protriptyline

1

PROVIGIL

3

ST

PROZAC

3

ST

PROZAC WEEKLY

3

ST; QL

quetiapine

1

QUILLIVANT XR

3

REMERON

3

REMERON SOLTAB

3

RESTORIL

3

ST

REXULTI

3

ST

RISPERDAL M-TAB

3

ST

RISPERDAL ORAL SOLUTION

3

ST; QL

RISPERDAL ORAL TABLET

3

ST

risperidone oral solution

1

QL

ST

ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 32

Drug Name

Drug Tier

Requirements / Limits

risperidone oral tablet

1

risperidone oral tablet,disintegrating

1

RITALIN

3

ST

RITALIN LA

3

ST

ROZEREM

3

PA

SAPHRIS (BLACK CHERRY)

3

ST

SARAFEM

3

ST

seconal sodium

1

PA

SEROQUEL

3

ST

SEROQUEL XR

2

sertraline oral concentrate

1

sertraline oral tablet

1

SILENOR

3

ST

SONATA

3

ST; QL

STRATTERA

2

SURMONTIL

3

SYMBYAX

3

temazepam

1

thioridazine

1

thiothixene

1

TOFRANIL

3

TOFRANIL-PM

3

TRANXENE T-TAB

3

tranylcypromine

1

trazodone

1

triazolam

1

trifluoperazine

1

trimipramine

1

VALIUM

3

venlafaxine

1

VERSACLOZ

3

VIIBRYD

2

QL

ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 33

Drug Name

Drug Tier

Requirements / Limits

VYVANSE

3

WELLBUTRIN

3

WELLBUTRIN SR

3

WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 150 MG

3

WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR 300 MG

3

XANAX

3

XANAX XR

3

XYREM

3

PA; LA; QL

zaleplon

1

QL

zenzedi oral tablet 10 mg, 5 mg

1

ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG

3

ziprasidone hcl

1

ZOLOFT ORAL CONCENTRATE

3

ST; QL

ZOLOFT ORAL TABLET

3

ST

zolpidem

1

QL

ZYPREXA

3

ST

ZYPREXA ZYDIS

3

ST

ST

QL

ST

CARDIOVASCULAR, HYPERTENSION & LIPIDS ANTIARRHYTHMIC AGENTS amiodarone

1

BETAPACE

3

ST

BETAPACE AF

3

ST

CORDARONE

3

disopyramide phosphate

1

flecainide

1

mexiletine

1

MULTAQ

3

NORPACE

3

NORPACE CR

2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 34

Drug Name

Drug Tier

pacerone

1

propafenone

1

quinidine gluconate

1

quinidine sulfate

1

RYTHMOL

3

RYTHMOL SR

3

sotalol

1

sotalol af

1

SOTYLIZE

3

TIKOSYN

3

Requirements / Limits

ANTIHYPERTENSIVE THERAPY ACCUPRIL

3

ST

ACCURETIC

3

acebutolol

1

ACEON

3

ST

ADALAT CC

3

QL

afeditab cr

1

QL

ALDACTAZIDE

3

ALDACTONE

3

ALTACE

3

amiloride

1

amiloride-hydrochlorothiazide

1

amlodipine

1

QL

amlodipine-benazepril

1

QL

amlodipine-valsartan

1

amlodipine-valsartan-hcthiazid

1

ATACAND

3

ST; QL

ATACAND HCT

3

ST; QL

atenolol

1

atenolol-chlorthalidone

1

AVALIDE

3

ST; QL

AVAPRO

3

ST; QL

ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 35

Drug Name

Drug Tier

Requirements / Limits

AZOR

2

ST

benazepril

1

benazepril-hydrochlorothiazide

1

BENICAR

3

ST; QL

BENICAR HCT

3

ST; QL

betaxolol

1

BIDIL

3

bisoprolol fumarate

1

bisoprolol-hydrochlorothiazide

1

bumetanide

1

BYSTOLIC

3

CALAN

3

CALAN SR

3

candesartan

1

QL

candesartan-hydrochlorothiazid

1

QL

captopril

1

captopril-hydrochlorothiazide

1

CARDENE SR

3

CARDIZEM

3

CARDIZEM CD

3

CARDIZEM LA

3

CARDURA

3

CARDURA XL

3

carvedilol

1

CATAPRES

3

CATAPRES-TTS-1

3

CATAPRES-TTS-2

3

CATAPRES-TTS-3

3

chlorothiazide

1

chlorthalidone

1

clonidine

1

clonidine hcl

1

ST

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 36

Drug Name

Drug Tier

Requirements / Limits

clorpres oral tablet 0.1-15 mg, 0.2-15 mg

1

CLORPRES ORAL TABLET 0.3-15 MG

3

COREG

3

COREG CR

2

CORGARD

3

ST

CORZIDE

3

ST

COZAAR

3

ST; QL

DEMADEX

3

DIBENZYLINE

3

DIOVAN

3

ST; QL

DIOVAN HCT

3

ST; QL

DIURIL

3

doxazosin

1

DUTOPROL

3

DYAZIDE

3

DYRENIUM

3

EDARBI

2

ST

EDARBYCLOR

2

ST

EDECRIN

3

enalapril maleate

1

enalapril-hydrochlorothiazide

1

EPANED

3

eplerenone

1

eprosartan

1

QL

EXFORGE

3

ST

EXFORGE HCT

3

ST

felodipine

1

QL

fosinopril

1

fosinopril-hydrochlorothiazide

1

furosemide

1

guanfacine

1

HEMANGEOL

3

ST

ST

LA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 37

Drug Name

Drug Tier

Requirements / Limits

hydralazine

1

hydrochlorothiazide

1

HYZAAR

3

indapamide

1

INDERAL LA

3

ST

INDERAL XL

3

ST

INNOPRAN XL

3

ST

INSPRA

3

irbesartan

1

QL

irbesartan-hydrochlorothiazide

1

QL

isradipine

1

labetalol

1

LASIX

3

LEVATOL

3

lisinopril

1

lisinopril-hydrochlorothiazide

1

LOPRESSOR

3

ST

LOPRESSOR HCT

3

ST

losartan

1

QL

losartan-hydrochlorothiazide

1

LOTENSIN

3

LOTENSIN HCT

3

LOTREL

3

matzim la

1

MAVIK

3

MAXZIDE

3

MAXZIDE-25MG

3

methyclothiazide

1

methyldopa

1

methyldopa-hydrochlorothiazide

1

metolazone

1

metoprolol succinate

1

ST

ST

ST QL ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 38

Drug Name

Drug Tier

Requirements / Limits

metoprolol ta-hydrochlorothiaz

1

metoprolol tartrate

1

MICARDIS

3

ST; QL

MICARDIS HCT

3

ST; QL

MICROZIDE

3

MINIPRESS

3

minoxidil

1

moexipril

1

moexipril-hydrochlorothiazide

1

nadolol

1

nadolol-bendroflumethiazide

1

nicardipine

1

nifedical xl

1

nifedipine oral capsule 10 mg

1

nifedipine oral capsule 20 mg

1

QL

nifedipine oral tablet extended release

1

QL

nifedipine oral tablet extended release 24hr

1

QL

nimodipine

1

nisoldipine

1

NORVASC

3

NYMALIZE

3

ORENITRAM

3

perindopril erbumine

1

phenoxybenzamine

1

pindolol

1

prazosin

1

PRESTALIA

3

PRINIVIL

3

PROCARDIA

3

PROCARDIA XL

3

propranolol

1

propranolol-hydrochlorothiazid

1

QL

QL LA

ST QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 39

Drug Name

Drug Tier

Requirements / Limits

quinapril

1

quinapril-hydrochlorothiazide

1

ramipril

1

reserpine

1

SECTRAL

3

spironolactone

1

spironolacton-hydrochlorothiaz

1

SULAR

3

TARKA

3

TEKAMLO

2

TEKTURNA

3

TEKTURNA HCT

3

telmisartan

1

telmisartan-amlodipine

1

telmisartan-hydrochlorothiazid

1

TENEX

3

TENORETIC 100

3

ST

TENORETIC 50

3

ST

TENORMIN

3

ST

terazosin

1

TIAZAC

3

timolol maleate

1

TOPROL XL

3

torsemide

1

TRANDATE

3

trandolapril

1

trandolapril-verapamil

1

triamterene-hydrochlorothiazid

1

TRIBENZOR

3

ST

TWYNSTA

3

ST

valsartan

1

QL

valsartan-hydrochlorothiazide

1

QL

ST

QL QL

QL ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 40

Drug Name

Drug Tier

Requirements / Limits

VASERETIC

3

VASOTEC

3

verapamil

1

VERELAN

3

VERELAN PM

3

ZEBETA

3

ZESTORETIC

3

ZESTRIL

3

ST

ZIAC

3

ST

ST

ST

CARDIAC GLYCOSIDES digitek

1

digox

1

digoxin

1

LANOXIN

2

COAGULATION THERAPY AGGRENOX

3

AMICAR

3

ARIXTRA

3

aspirin-dipyridamole

1

BRILINTA

2

cilostazol

1

clopidogrel oral tablet 300 mg

1

clopidogrel oral tablet 75 mg

1

COUMADIN

2

dipyridamole

1

DURLAZA

3

EFFIENT

2

ELIQUIS

2

enoxaparin

1

PA; QL

fondaparinux

1

PA

FRAGMIN

3

PA; QL

jantoven

1

PA QL

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 41

Drug Name

Drug Tier

Requirements / Limits

LOVENOX

3

MEPHYTON

2

pentoxifylline

1

PERSANTINE

3

PLAVIX ORAL TABLET 300 MG

3

PLAVIX ORAL TABLET 75 MG

3

PLETAL

3

PRADAXA

3

QL

PROMACTA

3

LA

SAVAYSA

3

ticlopidine

1

warfarin

1

XARELTO, XARELTO STARTER PACK

2

ZONTIVITY

3

PA; QL

QL

LIPID/CHOLESTEROL LOWERING AGENTS ADVICOR

3

ST; QL

ALTOPREV

3

ST; QL

amlodipine-atorvastatin

1

ANTARA

3

ST

atorvastatin

1

QL

CADUET

3

cholestyramine (with sugar)

1

cholestyramine light

1

COLESTID

3

COLESTID FLAVORED

3

colestipol

1

CRESTOR

2

fenofibrate micronized

1

fenofibrate nanocrystallized

1

FENOFIBRATE ORAL CAPSULE

3

ST

FENOFIBRATE ORAL TABLET 120 MG, 40 MG

3

ST

ST; QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 42

Drug Name

Drug Tier

Requirements / Limits

fenofibrate oral tablet 160 mg, 54 mg

1

fenofibric acid

1

fenofibric acid (choline)

1

FENOGLIDE

3

ST

FIBRICOR

3

ST

fluvastatin

1

QL

gemfibrozil

1

JUXTAPID

3

PA; LA

KYNAMRO

3

PA; LA

LESCOL

3

ST; QL

LESCOL XL

3

ST; QL

LIPITOR

3

ST; QL

LIPOFEN

3

ST

LIVALO

3

ST

LOFIBRA

3

ST

LOPID

3

ST

lovastatin

1

QL

LOVAZA

3

ST

niacin

1

QL

NIASPAN EXTENDED-RELEASE

3

QL

omega-3 acid ethyl esters

1

PRAVACHOL

3

ST; QL

pravastatin

1

QL

prevalite

1

QUESTRAN

3

QUESTRAN LIGHT

3

SIMCOR

2

ST; QL

simvastatin

1

QL

TRICOR

3

ST

TRIGLIDE

3

ST

TRILIPIX

3

ST

VASCEPA

3

ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 43

Drug Name

Drug Tier

Requirements / Limits

VYTORIN 10-10

3

ST; QL

VYTORIN 10-20

3

ST; QL

VYTORIN 10-40

3

ST; QL

VYTORIN 10-80

3

ST; QL

WELCHOL

3

ZETIA

3

ZOCOR

3

ST; QL

MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR

3

RANEXA

2

VECAMYL

3

LA

NITRATES DILATRATE-SR

3

ISOCHRON

3

ISORDIL

3

ISORDIL TITRADOSE

3

isosorbide dinitrate

1

isosorbide mononitrate

1

MINITRAN

3

nitro-bid

1

NITRO-DUR

3

nitroglycerin

1

NITROLINGUAL

3

NITROMIST

3

NITROSTAT

2

nitro-time

1

DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin

1

ANALPRAM-HC

3

calcipotriene

1

ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 44

Drug Name

Drug Tier

Requirements / Limits

calcipotriene-betamethasone

1

calcitrene

1

calcitriol

1

COAL TAR

3

COSENTYX

3

ST; LA

COSENTYX (2 SYRINGES)

3

ST; LA

COSENTYX PEN

3

ST; LA

COSENTYX PEN (2 PENS)

3

ST; LA

DOVONEX

3

drithocreme hp

1

EPIFOAM

3

hydrocortisone-pramoxine

1

OVACE

3

OVACE PLUS

3

OVACE PLUS SHAMPOO

3

OVACE PLUS WASH

3

PRAMOSONE

3

ST

PRAMOSONE E

3

ST

seb-prev

1

selenium sulfide

1

SELRX

3

SORIATANE

3

SORILUX

3

sulfacetamide sodium topical cleanser

1

SULFACETAMIDE SODIUM TOPICAL CLEANSER, GEL

3

sulfacetamide sodium topical cleanser,gel extended release

1

sulfacetamide sodium topical shampoo

1

TACLONEX TOPICAL OINTMENT

3

TACLONEX TOPICAL SUSPENSION

3

TERSI FOAM

3

QL

ST

PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 45

Drug Name

Drug Tier

VECTICAL

3

ZITHRANOL

3

ZITHRANOL-RR

3

Requirements / Limits QL

BURN THERAPY SILVADENE

3

silver sulfadiazine

1

ssd

1

thermazene

1

ST

KERATOLYTICS BENSAL HP

3

ST

INOVA 4-1

3

ST

INOVA 8-2

3

ST

KERALYT RX

3

ST

KERALYT SCALP COMPLETE

3

ST

PODOCON

3

ST

POTASSIUM HYDROXIDE

3

ST

salacyn

1

SALEX

3

salicylic acid

1

salicylic acid sr-ceramides

1

SALKERA

3

salvax

1

SALVAX DUO PLUS

3

ST

ULTRASAL-ER

3

ST

VIRASAL

3

ST

ST

ST

MISCELLANEOUS DERMATOLOGICALS 8-MOP

2

ALEVICYN ANTIPRURITIC

3

ALUVEA

3

ammonium lactate

1

bp-50% urea

1

ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 46

Drug Name

Drug Tier

Requirements / Limits

CARAC

3

cem-urea

1

CONDYLOX TOPICAL GEL

2

ST

CONDYLOX TOPICAL SOLUTION

3

ST

CORTANE-B

3

DERMASORB XM COMPLETE KIT

3

ST

diclofenac sodium

1

QL

EFUDEX

3

ELIDEL

3

FLUOROPLEX

2

FLUOROURACIL TOPICAL CREAM 0.5 %

3

fluorouracil topical cream 5 %

1

fluorouracil topical solution

1

GORDONS UREA

3

HPR PLUS-MB HYDROGEL

3

HYDRO 35

3

ST

HYDRO 40

3

ST

KERAFOAM

3

ST

KERALAC

3

ST

lactic acid

1

lactic acid e

1

latrix

1

LEVULAN

3

mb hydrogel

1

methoxsalen rapid

1

OXSORALEN

3

OXSORALEN ULTRA

3

PANRETIN

3

PICATO

3

podofilox

1

PROTOPIC

3

prudoxin

1

ST; QL

ST

QL

ST; QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 47

Drug Name

Drug Tier

Requirements / Limits

rea lo 39

1

rea lo 40

1

REGRANEX

3

RELYYT

3

remeven

1

silver nitrate

1

silver nitrate applicators

1

SOLARAZE

3

PA; QL

tacrolimus

1

ST; QL

TOLAK

3

U-CORT

3

ST

UMECTA NAIL FILM PEN

3

ST

UMECTA PD

3

ST

UMECTA TOPICAL EMULSION

3

ST

umecta topical foam

1

UMECTA TOPICAL NAIL FILM SUSPENSION

3

ST

URAMAXIN

3

ST

URAMAXIN GT

3

ST

urea

1

urea nail stick

1

urea-hyaluronate sodium

1

UTOPIC

3

ST

VALCHLOR

3

LA

VEREGEN

3

QL

PA

THERAPY FOR ACNE ABSORICA

3

ACANYA

3

ACZONE

3

adapalene topical cream

1

adapalene topical gel

1

adapalene topical gel with pump

1

ADAPALENE TOPICAL LOTION

3

ST; QL

ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 48

Drug Name

Drug Tier

Requirements / Limits

amnesteem

1

ATRALIN

3

ST

AVAR LS

3

ST

avar topical cleanser

1

AVAR TOPICAL FOAM

3

ST

AVAR TOPICAL PADS, MEDICATED

3

ST

AVAR-E GREEN

3

ST

AVAR-E LS

3

ST

avita topical cream

1

PA

AVITA TOPICAL GEL

3

ST

AZELEX

3

ST

BENZACLIN

3

ST

BENZACLIN PUMP

3

ST

BENZAMYCIN

3

ST

BENZAMYCINPAK

3

ST

BENZEFOAM

3

ST

BENZEFOAM ULTRA

3

ST

benzepro

1

BENZEPRO (MICROSPHERES)

3

benzoyl peroxide

1

bp 10-1

1

bpo

1

claravis

1

CLARIFOAM EF

3

cleansing wash

1

CLEOCIN T

3

ST

CLINDACIN ETZ

3

ST

clindacin p

1

CLINDACIN PAC

3

ST

CLINDAGEL

3

ST

clindamycin phosphate

1

clindamycin-benzoyl peroxide

1

ST

ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 49

Drug Name

Drug Tier

Requirements / Limits

DIFFERIN

3

ST

DUAC

3

ST

EPIDUO

3

ST

EPIDUO FORTE

3

ST

ery pads

1

erygel

1

erythromycin with ethanol

1

erythromycin-benzoyl peroxide

1

EVOCLIN

3

ST

FABIOR

3

ST

FINACEA

3

INOVA

3

METROCREAM

3

METROGEL

3

METROLOTION

3

metronidazole

1

MIRVASO

3

neuac

1

NEUAC KIT

3

NORITATE

3

ONEXTON

3

ST

PACNEX

3

ST

PLEXION

3

ST

PLEXION CLEANSING CLOTHS

3

ST

RETIN-A

3

ST

RETIN-A MICRO

3

ST

RETIN-A MICRO PUMP

3

ST

rosadan topical cream

1

rosadan topical gel

1

ROSADAN TOPICAL KIT, CLEANSER & GEL

3

ROSADAN TOPICAL KIT,CLEANSER AND CREAM

3

ST

ST ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 50

Drug Name

Drug Tier

Requirements / Limits

ROSANIL

3

ST

ROSULA

3

ST

rosula cleansing cloths

1

SOOLANTRA

3

ss 10-2

1

sss 10-5

1

sulfacetamide sodium-sulfur

1

sulfacetamide sod-sulfur-urea

1

sulfacetamide-sulfur-cleansr23

1

sulfacleanse 8-4

1

sulfact na-sul-avobnz-otn-ocsa

1

SUMADAN

3

ST

SUMADAN XLT

3

ST

SUMAXIN

3

ST

SUMAXIN CP

3

ST

SUMAXIN TS

3

ST

TAZORAC

2

tretinoin

1

PA

tretinoin microspheres

1

PA

TRETIN-X

3

ST

TRETIN-X CREAM KIT

3

ST

VELTIN

3

ST

zenatane

1

zencia

1

ZIANA

3

ST

ST

TOPICAL ANESTHETICS BUCALSEP

3

EMLA

3

glydo

1

lidocaine hcl

1

lidocaine hcl-hydrocortison ac

1

lidocaine viscous

1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 51

Drug Name

Drug Tier

Requirements / Limits

lidocaine-prilocaine

1

LIDOCAINE-TETRACAINE

3

PA

NOVACORT

3

ST

PLIAGLIS

3

PA

relador pak

1

relador pak plus

1

SYNERA

3

PA

TOPICAL ANTIBACTERIALS ALTABAX

3

BACTROBAN

3

ST

CENTANY

3

ST

CENTANY AT

3

ST

CORTISPORIN

2

gentamicin

1

KLARON

3

mupirocin

1

mupirocin calcium

1

NEO-SYNALAR

3

NEO-SYNALAR KIT

3

sulfacetamide sodium (acne)

1

SULFAMYLON

3

ST

ST

TOPICAL ANTIFUNGALS ciclodan

1

CICLODAN KIT

3

ciclopirox

1

ciclopirox-ure-camph-menth-euc

1

clotrimazole

1

clotrimazole-betamethasone

1

CNL 8 NAIL

3

econazole

1

ECOZA

3

ERTACZO

3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 52

Drug Name

Drug Tier

Requirements / Limits

EXELDERM

3

EXODERM

3

EXTINA

3

JUBLIA

3

ST

KERYDIN

3

PA

ketoconazole

1

LOPROX

3

LOTRISONE

3

LUZU

3

MENTAX

3

NAFTIFINE

3

NAFTIN

3

NIZORAL

3

nyamyc

1

nystatin

1

nystatin-triamcinolone

1

nystop

1

OXISTAT

3

PEDIADERM AF

3

PENLAC

3

TRIACETIN

3

TRIPLE DYE

3

VUSION

3

QL

XOLEGEL

3

QL

TOPICAL ANTIVIRALS acyclovir

1

DENAVIR

3

XERESE

3

QL

ZOVIRAX TOPICAL CREAM

3

PA

ZOVIRAX TOPICAL OINTMENT

3

TOPICAL CORTICOSTEROIDS ala-cort

1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 53

Drug Name

Drug Tier

Requirements / Limits

ALA-SCALP

3

alclometasone

1

amcinonide

1

apexicon e

1

AQUA GLYCOLIC HC

3

betamethasone dipropionate

1

betamethasone valerate topical cream

1

betamethasone valerate topical foam

1

betamethasone valerate topical lotion

1

betamethasone valerate topical ointment

1

betamethasone, augmented

1

CAPEX

3

clobetasol

1

clobetasol-emollient

1

CLOBEX

3

ST

CLOCORTOLONE PIVALATE

3

ST

clodan

1

CLODAN KIT

3

ST

CLODERM

3

ST

CORDRAN

3

ST

CORDRAN TAPE SMALL ROLL

3

ST

cormax

1

CUTIVATE

3

ST

DERMA-SMOOTHE/FS BODY OIL

3

ST

DERMA-SMOOTHE/FS SCALP OIL

3

ST

DERMASORB HC COMPLETE KIT

3

ST

DERMASORB TA COMPLETE KIT

3

ST

DERMATOP

3

ST

DESONATE

3

ST

desonide

1

DESOWEN

3

desoximetasone

1

ST

ST

QL

ST

ST

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 54

Drug Name

Drug Tier

Requirements / Limits

diflorasone

1

DIPROLENE

3

ST

DIPROLENE AF

3

ST

ELOCON

3

ST

fluocinolone

1

fluocinolone and shower cap

1

fluocinonide topical cream 0.05 %

1

fluocinonide topical cream 0.1 %

1

fluocinonide topical gel

1

fluocinonide topical ointment

1

fluocinonide topical solution

1

fluocinonide-e

1

fluticasone

1

halobetasol propionate

1

HALOG

3

hydrocortisone

1

hydrocortisone butyrate

1

hydrocortisone butyr-emollient

1

hydrocortisone valerate

1

hydrocortisone-min oil-wht pet

1

KENALOG

3

ST

LOCOID TOPICAL CREAM

3

ST; QL

LOCOID TOPICAL LOTION

3

ST

LOCOID TOPICAL OINTMENT

3

ST

LOCOID TOPICAL SOLUTION

3

ST

LUXIQ

3

ST; QL

mometasone

1

OLUX

3

ST

OLUX-E

3

ST

PANDEL

3

ST; QL

PEDIADERM HC

3

ST

PEDIADERM TA

3

ST

QL

ST

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 55

Drug Name

Drug Tier

Requirements / Limits

prednicarbate

1

PSORCON

3

scalacort

1

SCALACORT DK

3

ST

SYNALAR

3

ST

SYNALAR CREAM KIT

3

ST

SYNALAR OINTMENT KIT

3

ST

SYNALAR TS

3

ST

TEMOVATE

3

ST

TEMOVATE E

3

ST

TEXACORT

3

ST

TOPICORT

3

ST

triamcinolone acetonide

1

trianex

1

triderm

1

ULTRAVATE

3

ST

ULTRAVATE X

3

ST

VANOS

3

ST; QL

VERDESO

3

ST

GRANULEX

3

QL

SANTYL

3

QL

ST

TOPICAL ENZYMES

TOPICAL SCABICIDES / PEDICULICIDES ELIMITE

3

EURAX

3

lindane

1

LYCELLE

3

malathion

1

NATROBA

3

OVIDE

3

permethrin

1

SKLICE

3

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 56

Drug Name

Drug Tier

spinosad

1

ULESFIA

3

Requirements / Limits QL

DIAGNOSTICS & MISCELLANEOUS AGENTS ANOREXIANTS ADIPEX-P

3

PA

BELVIQ

3

PA

benzphetamine

1

PA

BONTRIL PDM

3

PA

CONTRAVE

3

PA

diethylpropion

1

PA

phendimetrazine tartrate

1

PA

phentermine

1

PA

QSYMIA

3

PA

REGIMEX

3

PA

SAXENDA

3

PA

SUPRENZA

3

PA

XENICAL

3

PA

IRRIGATING SOLUTIONS SORBITOL

3

SORBITOL-MANNITOL

3

MISCELLANEOUS AGENTS acamprosate

1

ACTONEL

3

AGRYLIN

3

alendronate

1

anagrelide

1

ANTABUSE

3

BUPHENYL ORAL POWDER

3

LA

BUPHENYL ORAL TABLET

3

PA; LA

caffeine citrated

1

CARBAGLU

3

ST; QL QL

LA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 57

Drug Name

Drug Tier

Requirements / Limits

CARNITOR (SUGAR-FREE)

3

CARNITOR ORAL SOLUTION

3

CARNITOR ORAL TABLET

3

cevimeline

1

CHEMET

2

disulfiram

1

etidronate disodium

1

EVOXAC

3

EXJADE

3

PA; LA

FERRIPROX

3

PA; LA

INCRELEX

3

PA; LA; QL

INFASURF

3

JADENU

3

PA; LA

levocarnitine

1

PA

levocarnitine (with sugar)

1

LIPOCHOL PLUS

3

LITHOSTAT

3

METOPIRONE

3

midodrine

1

NORTHERA

3

LA

ORFADIN

3

LA

pilocarpine hcl

1

RADIOGARDASE

3

PA

RAVICTI

3

LA

RILUTEK

3

riluzole

1

risedronate

1

SALAGEN

3

sodium phenylbutyrate

1

SURVANTA

3

SYPRINE

3

PA PA

LA

QL

PA

SMOKING DETERRENTS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 58

Drug Name

Drug Tier

Requirements / Limits

buproban

4

ACA; QL

bupropion hcl

4

ACA; QL

CHANTIX

4

ACA; QL

CHANTIX CONTINUING MONTH BOX

4

ACA; QL

CHANTIX STARTING MONTH BOX

4

ACA; QL

NICODERM CQ

4

ACA; OTC

nicorelief

4

ACA; OTC; QL

NICORETTE

4

ACA; OTC

nicotine

4

ACA; OTC; QL

NICOTROL

4

ACA

NICOTROL NS

4

ACA

QUIT 2

4

ACA; OTC; QL

QUIT 4

4

ACA; OTC; QL

ZYBAN

4

ACA

ASTEPRO

3

QL

ATROVENT

3

QL

azelastine

1

QL

BACTROBAN NASAL

2

chlorhexidine gluconate

1

CLINPRO 5000

3

DEBACTEROL

3

denta 5000 plus

1

dentagel

1

fluoridex daily defense

1

FLUORIDEX SENSITIVITY RELIEF

3

ipratropium bromide

1

MUCOTROL

3

olopatadine

1

oralone

1

EAR, NOSE & THROAT MEDICATIONS MISCELLANEOUS AGENTS

QL QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 59

Drug Name

Drug Tier

PATANASE

3

PERIDEX

3

periogard

1

pilocarpine hcl

1

PREVIDENT

3

PREVIDENT 5000 BOOSTER PLUS

3

PREVIDENT 5000 DRY MOUTH

3

PREVIDENT 5000 ENAMEL PROTECT

3

PREVIDENT 5000 PLUS

3

PREVIDENT 5000 SENSITIVE

3

Q-CARE RX Q4

3

SALAGEN

3

sf

1

sf 5000 plus

1

sodium fluoride

1

triamcinolone acetonide

1

TYZINE

3

Requirements / Limits QL

MISCELLANEOUS OTIC PREPARATIONS acetasol hc

1

acetic acid

1

acetic acid-aluminum acetate

1

CETRAXAL

3

ciprofloxacin hcl

1

DERMOTIC OIL

3

fluocinolone acetonide oil

1

hydrocortisone-acetic acid

1

ofloxacin

1

OTIC STEROID / ANTIBIOTIC CIPRO HC

3

CIPRODEX

2

COLY-MYCIN S

2

CORTISPORIN-TC

2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 60

Drug Name neomycin-polymyxin-hc

Drug Tier

Requirements / Limits

1

ENDOCRINE/DIABETES ADRENAL HORMONES CORTEF

3

cortisone

1

deltasone

1

dexamethasone

1

dexamethasone intensol

1

DEXPAK 10 DAY

3

DEXPAK 13 DAY

3

DEXPAK 6 DAY

3

fludrocortisone

1

hydrocortisone

1

MEDROL

3

MEDROL (PAK)

3

methylprednisolone

1

millipred dp

1

MILLIPRED ORAL SOLUTION

3

millipred oral tablet

1

ORAPRED ODT

3

PEDIAPRED

3

prednisolone

1

prednisolone sodium phosphate

1

prednisone

1

prednisone intensol

1

RAYOS

3

veripred 20

1

ANTITHYROID AGENTS methimazole

1

propylthiouracil

1

SSKI

3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 61

Drug Name

Drug Tier

TAPAZOLE

3

Requirements / Limits

GLUCOSE ELEVATING AGENTS GLUCAGON EMERGENCY KIT (HUMAN)

3

PROGLYCEM

3

QL

INSULIN THERAPY AFREZZA INHALATION CARTRIDGE, W/INHALATION DEVICE 4 UNIT, 4 UNIT (30)/ 8 UNIT (60), 4 UNIT (60)/ 8 UNIT (30)

3

AFREZZA INHALATION CARTRIDGE, W/INHALATION DEVICE 8 UNIT (60)/ 12 UNIT (30)

3

PA

APIDRA

3

ST

APIDRA SOLOSTAR

3

ST

HUMALOG

3

ST

HUMALOG KWIKPEN

3

ST

HUMALOG MIX 50-50

3

ST

HUMALOG MIX 50-50 KWIKPEN

3

ST

HUMALOG MIX 75-25

3

ST

HUMALOG MIX 75-25 KWIKPEN

3

ST

HUMULIN 70/30

3

ST

HUMULIN 70/30 KWIKPEN

3

ST

HUMULIN N

3

ST

HUMULIN N KWIKPEN

3

ST

HUMULIN R

3

ST

HUMULIN R U-500 (CONCENTRATED)

3

ST

LANTUS

3

ST

LANTUS SOLOSTAR

3

ST

LEVEMIR

2

LEVEMIR FLEXTOUCH

2

NOVOLIN 70/30

2

NOVOLIN N

2

NOVOLIN R

2

NOVOLOG

2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 62

Drug Name

Drug Tier

NOVOLOG FLEXPEN

2

NOVOLOG MIX 70-30

2

NOVOLOG MIX 70-30 FLEXPEN

2

NOVOLOG PENFILL

2

TOUJEO SOLOSTAR

3

Requirements / Limits

ST

MISCELLANEOUS HORMONES ANADROL-50

3

ANDRODERM

3

ST

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP

2

QL

ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM)

3

QL

ANDROGEL TRANSDERMAL GEL IN PACKET 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)

2

QL

ANDROID

3

androxy

1

AXIRON

2

QL

BRAVELLE

2

PA; LA

cabergoline

1

calcitonin (salmon)

1

calcitriol

1

CERDELGA

3

PA

CETROTIDE

3

PA; LA

chorionic gonadotropin, human

1

PA; LA

clomiphene citrate

1

PA

danazol

1

DDAVP

3

desmopressin

1

doxercalciferol

1

FOLLISTIM AQ

3

PA; LA

FORTESTA

3

ST; QL

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 63

Drug Name

Drug Tier

Requirements / Limits

fortical

1

QL

GANIRELIX

3

PA; LA

GONAL-F

2

PA; LA

GONAL-F RFF

2

PA; LA

GONAL-F RFF REDI-JECT

2

PA; LA

HECTOROL

3

KORLYM

2

PA; LA

KUVAN

3

PA; LA

MENOPUR

2

PA; LA

METHITEST

3

methyltestosterone

1

MIACALCIN

3

QL

NATESTO

3

ST

novarel

1

PA; LA

OVIDREL

3

PA; LA

OXANDRIN

3

oxandrolone

1

paricalcitol

1

PREGNYL

3

ROCALTROL

3

SAMSCA

3

SENSIPAR

2

SOMAVERT

3

STIMATE

3

STRIANT

3

SYNAREL

3

TESTIM

3

ST; QL

TESTOSTERONE

3

ST; QL

TESTRED

3

VOGELXO

3

ST; QL

ZAVESCA

3

LA

ZEMPLAR

3

PA; LA LA LA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 64

Drug Name

Drug Tier

Requirements / Limits

NON-INSULIN HYPOGLYCEMIC AGENTS acarbose

1

ACTOPLUS MET

3

ACTOPLUS MET XR

3

ACTOS

3

AMARYL

3

AVANDAMET

2

LA

AVANDIA

2

LA

BYDUREON

2

BYETTA

3

chlorpropamide

1

CYCLOSET

3

DIABETA

3

DUETACT

3

FARXIGA

2

FORTAMET

3

glimepiride

1

glipizide

1

glipizide-metformin

1

GLUCOPHAGE

3

GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 500 MG

3

GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR 750 MG

3

GLUCOTROL

3

GLUCOTROL XL

3

GLUCOVANCE

3

GLUMETZA

3

glyburide

1

glyburide micronized

1

glyburide-metformin

1

GLYNASE

3

QL QL

QL

QL

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 65

Drug Name

Drug Tier

Requirements / Limits

GLYSET

3

GLYXAMBI

3

INVOKAMET

2

INVOKANA

2

JANUMET

2

JANUMET XR

2

JANUVIA

2

JARDIANCE

3

JENTADUETO

3

KAZANO

3

KOMBIGLYZE XR

2

metformin oral tablet

1

metformin oral tablet extended release 24 hr 500 mg

1

metformin oral tablet extended release 24 hr 750 mg

1

QL

metformin oral tablet extended release 24hr 1,000 mg

1

QL

metformin oral tablet extended release 24hr 500 mg

1

nateglinide

1

NESINA

3

ONGLYZA

2

OSENI

3

pioglitazone

1

pioglitazone-glimepiride

1

pioglitazone-metformin

1

PRANDIMET

3

PRANDIN

3

PRECOSE

3

repaglinide

1

RIOMET

2

STARLIX

3

QL QL

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 66

Drug Name

Drug Tier

Requirements / Limits

SYMLINPEN 120

2

QL

SYMLINPEN 60

2

QL

tolazamide

1

tolbutamide

1

TRADJENTA

3

VICTOZA 2-PAK

2

XIGDUO XR

2

QL

THYROID HORMONES ARMOUR THYROID

2

CYTOMEL

2

levothyroxine

1

levoxyl

1

liothyronine

1

nature-throid

1

np thyroid

1

SYNTHROID

2

THYROLAR-1

2

THYROLAR-1/2

2

THYROLAR-1/4

2

THYROLAR-2

2

THYROLAR-3

2

TIROSINT

3

unithroid

1

westhroid

1

WP THYROID

3

GASTROENTEROLOGY ANTIDIARRHEALS & ANTISPASMODICS anaspaz

1

belladonna alkaloids-opium

1

PA

belladonna-opium

1

PA

BENTYL

3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 67

Drug Name

Drug Tier

CANTIL

3

chlordiazepoxide-clidinium

1

CUVPOSA

3

dicyclomine

1

diphenoxylate-atropine

1

DONNATAL

3

ed-spaz

1

FULYZAQ

3

glycopyrrolate

1

hyoscyamine sulfate

1

hyosyne

1

LEVBID

3

LEVSIN

3

LEVSIN/SL

3

LIBRAX (WITH CLIDINIUM)

3

LOMOTIL

3

loperamide

1

methscopolamine

1

MOTOFEN

3

NULEV

3

opium tincture

1

oscimin

1

oscimin sl

1

oscimin sr

1

paregoric

1

propantheline

1

ROBINUL

3

ROBINUL FORTE

3

SYMAX DUOTAB

3

symax fastabs

1

symax-sl

1

symax-sr

1

Requirements / Limits

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 68

Drug Name

Drug Tier

Requirements / Limits

MISCELLANEOUS GASTROINTESTINAL AGENTS ACTIGALL

3

AKYNZEO

3

alophen

4

alosetron

1

AMITIZA

3

ANA-LEX KIT

3

ANALPRAM E

3

ANALPRAM-HC

3

ANALPRAM-HC SINGLES

3

ANTIVERT

3

anucort-hc

1

ANUSOL-HC

3

ANZEMET

3

APRISO

3

ASACOL HD

2

AURYXIA

3

AZULFIDINE

3

AZULFIDINE EN-TABS

3

balsalazide

1

budesonide

1

calcium acetate

1

CANASA

3

CESAMET

3

CHENODAL

3

LA

CHOLBAM

3

LA

CIMZIA

3

ST; LA

citroma

4

ACA; OTC

COLAZAL

3

colocort

1

COLYTE WITH FLAVOR PACKS

3

COMPAZINE

3

ACA; OTC

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 69

Drug Name

Drug Tier

Requirements / Limits

compro

1

constulose

1

CORTENEMA

3

CORTIFOAM

3

CREON

2

cromolyn

1

CYSTADANE

3

DELZICOL

2

DICLEGIS

2

DIPENTUM

2

dronabinol oral capsule 10 mg

1

dronabinol oral capsule 2.5 mg, 5 mg

1

eliphos

1

EMEND

2

ENTOCORT EC

3

enulose

1

FOSRENOL ORAL POWDER IN PACKET

3

FOSRENOL ORAL TABLET,CHEWABLE

3

GASTROCROM

3

GATTEX 30-VIAL

3

PA; LA

gavilyte-c

4

ACA

gavilyte-g

4

ACA

gavilyte-n

4

ACA

generlac

1

gentlelax

4

GIAZO

3

GOLYTELY

3

granisetron hcl

1

QL

healthylax

4

ACA; OTC

hemmorex-hc

1

hydrocortisone

1

hydrocortisone acetate

1

LA

PA

ST

ACA; OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 70

Drug Name

Drug Tier

Requirements / Limits

hydrocortisone-pramox-e-pram#1

1

hydrocortisone-pramoxine

1

KAYEXALATE

3

kionex

1

KRISTALOSE

3

lactulose

1

laxative feminine

4

LIALDA

2

LIDOCAINE HCL-HYDROCORTISON AC RECTAL CREAM 3 %-1 % (7 GRAM)

3

lidocaine hcl-hydrocortison ac rectal cream 3-0.5 %

1

LIDOCAINE HCL-HYDROCORTISON AC RECTAL GEL

3

lidocaine hcl-hydrocortison ac rectal kit

1

lidocaine-hydrocortisone-aloe

1

LINZESS

2

LOTRONEX

3

MAGNEBIND 400

3

MARINOL

3

marlexate

1

meclizine

1

mesalamine

1

mesalamine with cleansing wipe

1

metoclopramide hcl

1

METOZOLV ODT

3

milk of magnesia concentrated

4

MOVANTIK

2

MOVIPREP

2

NULYTELY WITH FLAVOR PACKS

3

ondansetron

1

QL

ondansetron hcl

1

QL

OSMOPREP

3

ACA; OTC

ACA; OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 71

Drug Name

Drug Tier

Requirements / Limits

PANCREAZE

3

ST

peg 3350-electrolytes

4

ACA

peg-3350 with flavor packs

4

ACA

peg-electrolyte soln

4

ACA

peg-prep

4

ACA

PENTASA

3

PERTZYE

3

PHOSLO

3

PHOSLYRA

3

QL

polyethylene glycol 3350

4

ACA

pramcort

1

preparation cleansing

4

PREPOPIK

3

prochlorperazine

1

prochlorperazine maleate

1

PROCORT

3

PROCTOCORT

3

PROCTOFOAM HC

3

procto-pak

1

proctosol hc

1

proctozone-hc

1

RECTIV

3

REGLAN

3

RELISTOR SUBCUTANEOUS SOLUTION

2

QL

RELISTOR SUBCUTANEOUS SYRINGE 12 MG/0.6 ML

2

QL

RELISTOR SUBCUTANEOUS SYRINGE 8 MG/0.4 ML

2

RENAGEL

2

RENVELA

2

ROWASA

3

SANCUSO

3

ST

ACA; OTC

ST

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 72

Drug Name

Drug Tier

Requirements / Limits

SFROWASA

3

sodium polystyrene sulfonate oral

1

sodium polystyrene sulfonate rectal enema 30 gram/120 ml

1

SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML

3

sps

1

SUCRAID

3

sulfasalazine

1

sulfazine

1

sulfazine ec

1

SUPREP BOWEL PREP KIT

2

TIGAN

3

TRANSDERM-SCOP

3

trilyte with flavor packets

4

trimethobenzamide

1

UCERIS ORAL

3

UCERIS RECTAL

3

ULTRESA

3

URSO 250

3

URSO FORTE

3

ursodiol

1

VELPHORO

3

ST

VIOKACE

3

ST

ZENPEP

2

ZOFRAN (AS HYDROCHLORIDE)

3

QL

ZOFRAN ODT

3

QL

ZUPLENZ

3

QL

ACIPHEX

3

ST; QL

ACIPHEX SPRINKLE

3

ST; QL

amoxicil-clarithromy-lansopraz

1

LA

ACA PA ST

ULCER THERAPY

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 73

Drug Name

Drug Tier

Requirements / Limits

carafate oral suspension

1

CARAFATE ORAL TABLET

3

cimetidine

1

cimetidine hcl

1

CYTOTEC

3

DEXILANT

2

ST; QL

esomeprazole magnesium

1

QL

famotidine

1

lansoprazole

1

misoprostol

1

NEXIUM

3

ST; QL

NEXIUM PACKET

3

ST; QL

nizatidine

1

OMECLAMOX-PAK

3

omeprazole

1

omeprazole-sodium bicarbonate

1

pantoprazole

1

PEPCID

3

PREVACID

3

ST; QL

PREVACID SOLUTAB

3

ST; QL

PREVPAC

3

PRILOSEC ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

ST; QL

PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON

3

ST

PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET

3

ST

PROTONIX ORAL TABLET,DELAYED RELEASE (DR/EC)

3

ST; QL

PYLERA

3

rabeprazole

1

ranitidine hcl

1

sucralfate

1

QL

QL QL

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 74

Drug Name

Drug Tier

Requirements / Limits

ZANTAC

3

ZEGERID ORAL CAPSULE

3

ST

ZEGERID ORAL PACKET

3

ST; QL

IMMUNOLOGY, VACCINES & BIOTECHNOLOGY GROWTH HORMONES EGRIFTA

3

LA; QL

GENOTROPIN

3

PA; LA

GENOTROPIN MINIQUICK

3

PA; LA

HUMATROPE

3

PA; LA

NORDITROPIN FLEXPRO

2

PA; LA

NUTROPIN AQ

3

PA; LA

NUTROPIN AQ NUSPIN

3

PA; LA

OMNITROPE

3

PA; LA

SAIZEN

3

PA; LA

SAIZEN CLICK.EASY

3

PA; LA

SEROSTIM

3

PA; LA

ZOMACTON

3

PA; LA

ZORBTIVE

3

PA; LA

AUBAGIO

3

ST; LA

AVONEX

2

LA; QL

AVONEX (WITH ALBUMIN)

2

LA; QL

BETASERON

3

ST; LA

COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML

2

LA; QL

COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML

2

LA

COPEGUS

3

PA

EXTAVIA SUBCUTANEOUS KIT

3

ST; LA

EXTAVIA SUBCUTANEOUS RECON SOLN

3

ST

GILENYA

3

ST; QL

glatopa

1

ST; LA; QL

INTERFERONS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 75

Drug Name

Drug Tier

Requirements / Limits

moderiba

1

PA

moderiba dose pack

1

PA

PEGASYS PROCLICK

3

PA; LA

PEGASYS SUBCUTANEOUS SOLUTION

3

PA; LA; QL

PEGASYS SUBCUTANEOUS SYRINGE

3

PA; LA

PEGINTRON

2

PA; LA; QL

PEGINTRON REDIPEN

2

PA; LA; QL

PLEGRIDY

3

ST; LA

POMALYST

3

PA; LA

REBETOL ORAL CAPSULE

3

PA

REBETOL ORAL SOLUTION

3

PA; QL

REBIF (WITH ALBUMIN)

3

ST; LA; QL

REBIF REBIDOSE

3

ST; LA; QL

REBIF TITRATION PACK

3

ST; LA; QL

REVLIMID

2

PA; LA

ribasphere

1

PA

ribasphere ribapak

1

PA

ribavirin

1

PA

SYLATRON

3

PA; LA

TECFIDERA

2

LA

ACTIMMUNE

3

PA; LA; QL

ALDARA

3

QL

ARCALYST

3

PA; LA

imiquimod

1

QL

INTRON A

2

PA; LA; QL

KINERET

3

ST; LA; QL

ZYCLARA

3

INTERLEUKINS

VACCINES & MISCELLANEOUS IMMUNOLOGICALS AFLURIA 2015-2016

4

ACA

AFLURIA 2015-2016 (PF)

4

ACA

EZ FLU 2015-16 (FLUVIRIN) (PF)

4

ACA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 76

Drug Name

Drug Tier

Requirements / Limits

EZ FLU 2015-16(FLUCELVAX)(PF)

4

FLUARIX QUAD 2015-2016 (PF)

4

ACA

FLUBLOK 2015-2016 (PF)

4

ACA

FLUCELVAX 2015-2016 (PF)

4

ACA

FLULAVAL QUAD 2015-2016

4

ACA

FLUMIST QUAD 2015-2016

4

FLUVIRIN 2015-2016

4

ACA

FLUVIRIN 2015-2016 (PF)

4

ACA

FLUZONE 2015-2016

4

ACA

FLUZONE HIGH-DOSE 2015-16 (PF)

4

ACA

FLUZONE INTRADERM QUAD 2015-16

4

ACA

FLUZONE QUAD 2015-2016

4

ACA

FLUZONE QUAD 2015-2016 (PF)

4

ACA

FLUZONE QUAD PEDI 2015-16 (PF)

4

ACA

MENOMUNE - A/C/Y/W-135

4

PA; ACA

MENOMUNE - A/C/Y/W-135 (PF)

4

PA; ACA

PNEUMOVAX 23

4

ACA

PREVNAR 13 (PF)

4

PA; ACA; LA

QUADRACEL (PF)

4

ACA

ROTARIX

4

ACA

VIVOTIF BERNA VACCINE

4

ACA

YF-VAX (PF)

4

PA; ACA; LA

ZOSTAVAX (PF)

4

ACA

MUSCULOSKELETAL & RHEUMATOLOGY GOUT THERAPY allopurinol

1

COLCHICINE

3

colchicine-probenecid

1

COLCRYS

2

MITIGARE

3

probenecid

1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 77

Drug Name

Drug Tier

ULORIC

2

ZYLOPRIM

3

Requirements / Limits

OSTEOPOROSIS THERAPY ACTONEL

3

ST; QL

alendronate

1

QL

ATELVIA

3

ST

BINOSTO

3

ST

BONIVA

3

ST; QL

EVISTA

3

ST; QL

FORTEO

2

LA; QL

FOSAMAX

3

ST; QL

FOSAMAX PLUS D

3

QL

ibandronate

1

QL

raloxifene

1

QL

risedronate oral tablet

1

QL

risedronate oral tablet,delayed release (dr/ec)

1

OTHER RHEUMATOLOGICALS ARAVA

3

QL

CUPRIMINE

2

DEPEN TITRATABS

3

ENBREL

2

LA; QL

ENBREL SURECLICK

2

LA; QL

HUMIRA

2

LA; QL

HUMIRA PEDIATRIC CROHN'S START

2

LA; QL

HUMIRA PEN

2

LA; QL

leflunomide

1

QL

ORENCIA

3

ST; LA; QL

OTEZLA

3

ST; LA

OTEZLA STARTER

3

ST; LA

OTREXUP (PF)

3

PA; LA

RASUVO (PF)

3

PA; LA

RIDAURA

2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 78

Drug Name

Drug Tier

Requirements / Limits

SAVELLA

3

SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML

3

ST; LA

SIMPONI SUBCUTANEOUS PEN INJECTOR 50 MG/0.5 ML

3

ST; LA; QL

SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML

3

ST; LA

SIMPONI SUBCUTANEOUS SYRINGE 50 MG/0.5 ML

3

ST; LA; QL

XELJANZ

3

ST; QL

OBSTETRICS & GYNECOLOGY DIAPHRAGMS AND OTHER NON-ORAL CONTRACEPTIVES CAYA CONTOURED

4

ACA

FC2 FEMALE CONDOM

4

ACA; OTC

FEMCAP

4

ACA

WIDE-SEAL DIAPHRAGM 60

4

ACA

ESTROGENS & PROGESTINS ACTIVELLA

3

ALORA

3

ANGELIQ

3

AYGESTIN

3

camila

4

ACA

CLIMARA

3

QL

CLIMARA PRO

2

QL

COMBIPATCH

2

QL

covaryx

1

covaryx h.s.

1

CRINONE

3

PA

deblitane

4

ACA

DEPO-PROVERA

4

PA; ACA; LA; QL

DEPO-SUBQ PROVERA 104

4

PA; ACA; LA; QL

DIVIGEL

3

DUAVEE

3

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 79

Drug Name

Drug Tier

Requirements / Limits

eemt

1

eemt hs

1

ELESTRIN

3

ENDOMETRIN

3

ENJUVIA

3

errin

4

ESTRACE ORAL

3

ESTRACE VAGINAL

2

estradiol oral

1

estradiol transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.075 mg/24 hr

1

estradiol transdermal patch semiweekly 0.05 mg/24 hr, 0.1 mg/24 hr

1

estradiol transdermal patch weekly

1

estradiol-norethindrone acet

1

ESTRING

2

ESTROGEL

3

estrogens-methyltestosterone

1

estropipate

1

EVAMIST

3

FEMHRT LOW DOSE

3

FEMRING

3

heather

4

ACA

jencycla

4

ACA

jinteli

1

jolivette

4

lopreeza

1

lyza

4

ACA

medroxyprogesterone intramuscular

4

PA; ACA; LA; QL

medroxyprogesterone oral

1

MENEST

3

MENOSTAR

3

PA ACA

QL

QL

ACA

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 80

Drug Name

Drug Tier

Requirements / Limits

mimvey

1

mimvey lo

1

MINIVELLE

3

QL

nora-be

4

ACA

norethindrone (contraceptive)

4

ACA

norethindrone acetate

1

norethindrone ac-eth estradiol

1

norlyroc

4

ACA

NOR-QD

4

ACA

ORTHO MICRONOR

4

ACA

PREFEST

2

PREMARIN

2

PREMPHASE

2

PREMPRO

2

progesterone micronized

1

PROMETRIUM

3

PROVERA

3

sharobel

4

VAGIFEM

3

VIVELLE-DOT

3

ACA QL

MISCELLANEOUS OB/GYN AVC VAGINAL

3

CLEOCIN

3

clindamycin phosphate

1

CLINDESSE

3

CONCEPTROL

4

GYNAZOLE-1

3

gynol ii

4

isoxsuprine

1

LYSTEDA

3

METROGEL VAGINAL

3

metronidazole

1

ACA; OTC ACA; OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 81

Drug Name

Drug Tier

Requirements / Limits

miconazole-3

1

NUVARING

4

NUVESSA

3

OSPHENA

3

TERAZOL 3

3

TERAZOL 7

3

terconazole

1

TODAY CONTRACEPTIVE SPONGE

4

tranexamic acid

1

VAGINAL CONTRACEPTIVE FILM

4

ACA; OTC

vaginal contraceptive foam

4

ACA; OTC

vandazole

1

xulane

4

ACA; QL

AFTERA

4

ACA; OTC; QL

altavera (28)

4

ACA

alyacen 1/35 (28)

4

ACA

alyacen 7/7/7 (28)

4

ACA

amethia

4

ACA

amethia lo

4

ACA

amethyst

4

ACA

apri

4

ACA

aranelle (28)

4

ACA

ashlyna

4

ACA

aubra

4

ACA

aviane

4

ACA

azurette (28)

4

ACA

balziva (28)

4

ACA

BEYAZ

4

ACA

BREVICON (28)

4

ACA

briellyn

4

ACA

camrese

4

ACA

ACA; QL

ACA; OTC

ORAL CONTRACEPTIVES & RELATED AGENTS

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 82

Drug Name

Drug Tier

Requirements / Limits

camrese lo

4

ACA

caziant (28)

4

ACA

chateal

4

ACA

cryselle (28)

4

ACA

cyclafem 1/35 (28)

4

ACA

cyclafem 7/7/7 (28)

4

ACA

CYCLESSA (28)

4

ACA

cyred

4

ACA

dasetta 1/35 (28)

4

ACA

dasetta 7/7/7 (28)

4

ACA

daysee

4

ACA

delyla (28)

4

ACA

desog-e.estradiol/e.estradiol

4

ACA

DESOGEN

4

ACA

desogestrel-ethinyl estradiol

4

ACA

drospirenone-ethinyl estradiol

4

ACA

econtra ez

4

ACA; OTC; QL

elinest

4

ACA

ELLA

4

ACA; QL

emoquette

4

ACA

enpresse

4

ACA

enskyce

4

ACA

estarylla

4

ACA

ESTROSTEP FE-28

4

ACA

fallback solo

4

ACA; OTC; QL

falmina (28)

4

ACA

FEMCON FE

4

ACA

GENERESS FE

4

ACA

gianvi (28)

4

ACA

gildagia

4

ACA

gildess 1.5/30 (21)

4

ACA

gildess 1/20 (21)

4

ACA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 83

Drug Name

Drug Tier

Requirements / Limits

gildess 24 fe

4

ACA

gildess fe 1.5/30 (28)

4

ACA

gildess fe 1/20 (28)

4

ACA

introvale

4

ACA

jolessa

4

ACA

juleber

4

ACA

junel 1.5/30 (21)

4

ACA

junel 1/20 (21)

4

ACA

junel fe 1.5/30 (28)

4

ACA

junel fe 1/20 (28)

4

ACA

junel fe 24

4

ACA

kariva (28)

4

ACA

kelnor 1/35 (28)

4

ACA

kimidess (28)

4

ACA

kurvelo

4

ACA

l norgest/e.estradiol-e.estrad

4

ACA

larin 1.5/30 (21)

4

ACA

larin 1/20 (21)

4

ACA

larin 24 fe

4

ACA

larin fe 1.5/30 (28)

4

ACA

larin fe 1/20 (28)

4

ACA

layolis fe

4

ACA

leena 28

4

ACA

lessina

4

ACA

levonest (28)

4

ACA

levonorgestrel

4

ACA; QL

levonorgestrel-ethinyl estrad

4

ACA

levora-28

4

ACA

LO LOESTRIN FE

4

ACA

LOESTRIN 1.5/30 (21)

4

ACA

LOESTRIN 1/20 (21)

4

ACA

LOESTRIN FE 1.5/30 (28-DAY)

4

ACA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 84

Drug Name

Drug Tier

Requirements / Limits

LOESTRIN FE 1/20 (28-DAY)

4

ACA

lomedia 24 fe

4

ACA

loryna (28)

4

ACA

LOSEASONIQUE

4

ACA

low-ogestrel (28)

4

ACA

lutera (28)

4

ACA

marlissa

4

ACA

microgestin 1.5/30 (21)

4

ACA

microgestin 1/20 (21)

4

ACA

microgestin fe 1.5/30 (28)

4

ACA

microgestin fe 1/20 (28)

4

ACA

MINASTRIN 24 FE

4

ACA

MIRCETTE (28)

4

ACA

MODICON (28)

4

ACA

mono-linyah

4

ACA

mononessa (28)

4

ACA

my way

4

ACA; OTC; QL

myzilra

4

ACA

NATAZIA

4

ACA

necon 0.5/35 (28)

4

ACA

necon 1/35 (28)

4

ACA

necon 1/50 (28)

4

ACA

necon 10/11 (28)

4

ACA

necon 7/7/7 (28)

4

ACA

next choice one dose

4

ACA; OTC; QL

nikki (28)

4

ACA

noreth-ethinyl estradiol-iron

4

ACA

norethindrone ac-eth estradiol

4

ACA

norethindrone-e.estradiol-iron

4

ACA

norgestimate-ethinyl estradiol

4

ACA

NORINYL 1+35 (28)

4

ACA

NORINYL 1+50 (28)

4

ACA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 85

Drug Name

Drug Tier

Requirements / Limits

nortrel 0.5/35 (28)

4

ACA

nortrel 1/35 (21)

4

ACA

nortrel 7/7/7 (28)

4

ACA

ocella

4

ACA

ogestrel (28)

4

ACA

opcicon one-step

4

ACA; OTC; QL

orsythia

4

ACA

ORTHO TRI-CYCLEN (28)

4

ACA

ORTHO TRI-CYCLEN LO (28)

4

ACA

ORTHO-CYCLEN (28)

4

ACA

ORTHO-NOVUM 1/35 (28)

4

ACA

ORTHO-NOVUM 7/7/7 (28)

4

ACA

OVCON-35 (28)

4

ACA

philith

4

ACA

pimtrea (28)

4

ACA

pirmella

4

ACA

PLAN B ONE-STEP

4

ACA; QL

portia

4

ACA

previfem

4

ACA

QUARTETTE

4

ACA

quasense

4

ACA

reclipsen (28)

4

ACA

SAFYRAL

4

ACA

SEASONIQUE

4

ACA

setlakin

4

ACA

sprintec (28)

4

ACA

sronyx

4

ACA

syeda

4

ACA

TAKE ACTION

4

ACA; OTC; QL

tarina fe 1/20 (28)

4

ACA

tilia fe

4

ACA

tri-estarylla

4

ACA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 86

Drug Name

Drug Tier

Requirements / Limits

tri-legest fe

4

ACA

tri-linyah

4

ACA

trinessa (28)

4

ACA

TRI-NORINYL (28)

4

ACA

tri-previfem (28)

4

ACA

tri-sprintec (28)

4

ACA

trivora (28)

4

ACA

velivet triphasic regimen (28)

4

ACA

vestura (28)

4

ACA

viorele (28)

4

ACA

vyfemla (28)

4

ACA

wera (28)

4

ACA

wymzya fe

4

ACA

YASMIN (28)

4

ACA

YAZ (28)

4

ACA

zarah

4

ACA

zenchent (28)

4

ACA

zenchent fe

4

ACA

zeosa

4

ACA

zovia 1/35e (28)

4

ACA

zovia 1/50e (28)

4

ACA

OXYTOCICS methylergonovine

1

OPHTHALMOLOGY ANTIBIOTICS ak-poly-bac

1

AZASITE

3

bacitracin

1

bacitracin-polymyxin b

1

BESIVANCE

3

BETADINE OPHTHALMIC PREP

3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 87

Drug Name

Drug Tier

CILOXAN

3

ciprofloxacin hcl

1

erythromycin

1

garamycin

1

gatifloxacin

1

gentak

1

gentamicin

1

ILOTYCIN

3

levofloxacin

1

MOXEZA

3

NATACYN

2

neomycin-bacitracin-polymyxin

1

neomycin-polymyxin-gramicidin

1

neo-polycin

1

NEOSPORIN (NEO-POLYM-GRAMICID)

3

OCUFLOX

3

ofloxacin

1

polycin

1

polymyxin b sulf-trimethoprim

1

POLYTRIM

3

tobramycin

1

TOBREX OPHTHALMIC DROPS

3

TOBREX OPHTHALMIC OINTMENT

2

VIGAMOX

3

ZYMAXID

3

Requirements / Limits

ANTIVIRALS trifluridine

1

VIROPTIC

3

ZIRGAN

3

BETA-BLOCKERS BETAGAN

3

betaxolol

1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 88

Drug Name

Drug Tier

BETIMOL

3

BETOPTIC S

2

carteolol

1

ISTALOL

3

levobunolol

1

metipranolol

1

timolol maleate

1

TIMOPTIC

3

TIMOPTIC OCUDOSE (PF)

3

TIMOPTIC-XE

3

Requirements / Limits

CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE

3

CYCLOPLEGIC MYDRIATICS atropine

1

CYCLOGYL OPHTHALMIC DROPS 0.5 %

2

CYCLOGYL OPHTHALMIC DROPS 2 %

3

cyclopentolate

1

homatropaire

1

homatropine hbr

1

ISOPTO ATROPINE

3

MYDRIACYL

3

PAREMYD

3

tropicamide

1

DIRECT ACTING MIOTICS ISOPTO CARPINE

3

MIOCHOL-E

3

pilocarpine hcl

1

MISCELLANEOUS OPHTHALMOLOGICS acuicyn

1

AKTEN (PF)

3

ALCAINE

3

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 89

Drug Name

Drug Tier

Requirements / Limits

ALOCRIL

3

QL

ALOMIDE

2

QL

altacaine

1

altafluor

1

AVENOVA

3

azelastine

1

QL

BEPREVE

3

ST; QL

cromolyn

1

CYSTARAN

3

LA

ELESTAT

3

ST; QL

EMADINE

3

ST; QL

epinastine

1

QL

flucaine

1

fluorescein-benoxinate

1

fluorescein-proparacaine

1

flurox

1

LASTACAFT

2

QL

PATADAY

3

ST; QL

PATANOL

3

ST; QL

PAZEO

3

ST; QL

proparacaine

1

RESTASIS

3

tetcaine

1

tetracaine hcl

1

tetracaine hcl (pf)

1

TETRAVISC

3

TETRAVISC FORTE

3

QL

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACULAR

3

ACULAR LS

3

ACUVAIL (PF)

2

bromfenac

1

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 90

Drug Name

Drug Tier

diclofenac sodium

1

flurbiprofen sodium

1

ILEVRO

3

ketorolac

1

NEVANAC

3

OCUFEN

3

PROLENSA

3

Requirements / Limits

QL

ORAL DRUGS FOR GLAUCOMA acetazolamide

1

DIAMOX SEQUELS

3

methazolamide

1

NEPTAZANE

3

OTHER GLAUCOMA DRUGS AZOPT

3

QL

bimatoprost

1

QL

COMBIGAN

2

COSOPT

3

COSOPT (PF)

3

dorzolamide

1

dorzolamide-timolol

1

latanoprost

1

QL

LUMIGAN

2

ST; QL

MITOSOL

3

RESCULA

3

SIMBRINZA

3

TRAVATAN Z

3

ST; QL

travoprost (benzalkonium)

1

QL

TRUSOPT

3

QL

XALATAN

3

ST; QL

ZIOPTAN (PF)

3

ST

QL

STEROID-ANTIBIOTIC COMBINATIONS You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 91

Drug Name

Drug Tier

MAXITROL

3

neomycin-bacitracin-poly-hc

1

neomycin-polymyxin b-dexameth

1

neomycin-polymyxin-hc

1

neo-polycin hc

1

PRED-G

2

PRED-G S.O.P.

2

TOBRADEX OPHTHALMIC DROPS,SUSPENSION

3

TOBRADEX OPHTHALMIC OINTMENT

2

TOBRADEX ST

3

tobramycin-dexamethasone

1

ZYLET

3

Requirements / Limits

STEROIDS ALREX

3

dexamethasone sodium phosphate

1

DUREZOL

3

FLAREX

3

fluorometholone

1

FML FORTE

2

FML LIQUIFILM

3

FML S.O.P.

2

LOTEMAX

3

MAXIDEX

3

OMNIPRED

3

PRED FORTE

3

PRED MILD

2

prednisolone acetate

1

prednisolone sodium phosphate

1

VEXOL

3

STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE

2

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 92

Drug Name

Drug Tier

BLEPHAMIDE S.O.P.

2

sulfacetamide-prednisolone

1

Requirements / Limits

SULFONAMIDES BLEPH-10

3

sulfacetamide sodium

1

SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS 0.1 %

2

ALPHAGAN P OPHTHALMIC DROPS 0.15 %

3

apraclonidine

1

brimonidine

1

IOPIDINE

3

VASOCONSTRICTOR DECONGESTANTS CYCLOMYDRIL

3

naphazoline

1

phenylephrine hcl

1

RESPIRATORY, ALLERGY, COUGH & COLD ANTIHISTAMINE & ANTIALLERGENIC AGENTS ADRENACLICK

3

QL

arbinoxa

1

carbinoxamine maleate

1

cetirizine

1

CLARINEX

3

clemastine

1

cyproheptadine

1

desloratadine

1

diphenhydramine hcl

1

epinephrine

1

QL

EPIPEN 2-PAK

2

QL

EPIPEN JR 2-PAK

2

QL

hydroxyzine hcl

1

hydroxyzine pamoate

1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 93

Drug Name

Drug Tier

KARBINAL ER

3

levocetirizine

1

phenadoz

1

phenergan

1

promethazine

1

promethegan

1

VISTARIL

3

XYZAL

3

Requirements / Limits

COUGH & COLD THERAPY benzonatate

1

BROMFED DM

3

brompheniramine-pseudoeph-dm

1

CAPCOF

3

centergy

1

cheratussin ac

1

PA

cheratussin dac

1

PA

CLARINEX-D 12 HOUR

3

codeine-guaifenesin

1

PA

cpm-pseudoephed-hydrocodone

1

PA

FLOWTUSS

3

PA

guaiatussin ac

1

PA

guaifenesin ac

1

PA

guaifenesin dac

1

PA

HISTEX-AC

3

PA

HYCOFENIX

3

PA

hydrocodone-chlorpheniramine

1

PA

hydrocodone-homatropine

1

PA

hydromet

1

PA

iophen c-nr

1

PA

lortuss ex

1

PA

MAR-COF BP

3

PA

MAR-COF CG

3

PA

PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 94

Drug Name

Drug Tier

Requirements / Limits

m-clear wc

1

PA

M-END MAX D

3

PA

M-END PE

3

PA

NINJACOF-XG

3

PA

OBREDON

3

PA

phenylhistine dh

1

PA

POLY-TUSSIN AC

3

PA

PRO-CLEAR AC

3

PA

PRO-CLEAR CAPS

3

PA

promethazine vc

1

promethazine vc-codeine

1

PA

promethazine-codeine

1

PA

promethazine-dm

1

promethazine-phenyleph-codeine

1

PA

PRO-RED AC (W/ DEXCHLORPHENIR)

3

PA

relcof c

1

PA

RESPA-AR

3

REZIRA

3

PA

rydex

1

PA

SEMPREX-D

3

TESSALON PERLES

3

tusnel c

1

TUSNEL PEDIATRIC

3

TUSSICAPS

3

PA

tussigon

1

PA

TUSSIONEX PENNKINETIC ER

3

PA

TUZISTRA XR

3

PA

virtussin ac

1

PA

virtussin dac

1

PA

VITUZ

3

PA

ZODRYL AC 25

3

PA

ZODRYL AC 30

3

PA

PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 95

Drug Name

Drug Tier

Requirements / Limits

ZODRYL AC 35

3

PA

ZODRYL AC 40

3

PA

ZODRYL AC 50

3

PA

ZODRYL AC 60

3

PA

ZODRYL AC 80

3

PA

ZODRYL DAC 25

3

PA

ZODRYL DAC 30

3

PA

ZODRYL DAC 35

3

PA

ZODRYL DAC 40

3

PA

ZODRYL DAC 50

3

PA

ZODRYL DAC 60

3

PA

ZODRYL DAC 80

3

PA

ZODRYL DEC 25

3

PA

ZODRYL DEC 30

3

PA

ZODRYL DEC 35

3

PA

ZODRYL DEC 40

3

PA

ZODRYL DEC 50

3

PA

ZODRYL DEC 60

3

PA

ZODRYL DEC 80

3

PA

ZONATUSS

3

Z-TUSS AC

3

PA

ZUTRIPRO

3

PA

ACCOLATE

3

QL

acetylcysteine

1

ADCIRCA

3

ADEMPAS

3

ADRENALIN

3

ADVAIR DISKUS

2

QL

ADVAIR HFA

2

QL

AEROSPAN

3

ST

albuterol sulfate inhalation

1

QL

PULMONARY AGENTS

PA; LA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 96

Drug Name

Drug Tier

Requirements / Limits

albuterol sulfate oral syrup

1

QL

albuterol sulfate oral tablet

1

albuterol sulfate oral tablet extended release 12 hr

1

ALVESCO

3

ANORO ELLIPTA

3

ARCAPTA NEOHALER

3

ARNUITY ELLIPTA

2

ASMANEX HFA

3

ST; QL

ASMANEX TWISTHALER

3

ST; QL

ATROVENT HFA

2

QL

BECONASE AQ

3

ST; QL

BREO ELLIPTA

2

BROVANA

3

budesonide

1

COMBIVENT RESPIMAT

2

cromolyn

1

CUROSURF

3

DALIRESP

2

DULERA

3

ST; QL

DYMISTA

3

ST

ELIXOPHYLLIN

3

ESBRIET

3

PA; LA

FIRAZYR

3

LA

FLOVENT DISKUS

2

FLOVENT HFA

2

QL

flunisolide

1

QL

fluticasone

1

QL

FORADIL AEROLIZER

2

INCRUSE ELLIPTA

3

ipratropium bromide

1

QL

ipratropium-albuterol

1

QL

KALYDECO

3

PA; LA; QL

ST; QL QL

QL QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 97

Drug Name

Drug Tier

Requirements / Limits

LETAIRIS

2

LA

levalbuterol hcl

1

QL

metaproterenol oral syrup

1

QL

metaproterenol oral tablet

1

montelukast

1

QL

NASONEX

3

ST; QL

OFEV

3

PA; LA

OMNARIS

3

ST; QL

OPSUMIT

3

LA

ORKAMBI

3

PA; LA; QL

PERFOROMIST

3

QL

PROAIR HFA

3

QL

PROAIR RESPICLICK

3

PROVENTIL HFA

2

QL

PULMICORT

2

QL

PULMICORT FLEXHALER

2

QL

PULMOZYME

2

PA

QNASL

3

ST

QVAR

3

ST; QL

REVATIO ORAL SUSPENSION FOR RECONSTITUTION

3

REVATIO ORAL TABLET

3

QL

RHINOCORT AQUA

3

ST; QL

SEEBRI NEOHALER

3

SEREVENT DISKUS

2

QL

sildenafil

1

QL

SINGULAIR

3

QL

SPIRIVA RESPIMAT

2

SPIRIVA WITH HANDIHALER

2

STIOLTO RESPIMAT

3

STRIVERDI RESPIMAT

3

SYMBICORT

3

ST; QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 98

Drug Name

Drug Tier

Requirements / Limits

terbutaline oral

1

terbutaline subcutaneous

1

THEO-24

3

theophylline

1

TRACLEER

3

LA; QL

triamcinolone acetonide

1

QL

TUDORZA PRESSAIR

3

TYVASO

3

LA; QL

TYVASO REFILL KIT

3

LA; QL

TYVASO STARTER KIT

3

LA; QL

VENTAVIS

3

LA

VENTOLIN HFA

2

QL

VERAMYST

2

ST; QL

VOSPIRE ER

3

XOPENEX

3

QL

XOPENEX CONCENTRATE

3

QL

XOPENEX HFA

3

QL

zafirlukast

1

QL

ZETONNA

3

ST

ZYFLO

3

ZYFLO CR

3

PA; LA

UROLOGICALS ANTICHOLINERGICS & ANTISPASMODICS DETROL

3

DETROL LA

3

DITROPAN XL

3

ENABLEX

3

flavoxate

1

GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP

3

GELNIQUE TRANSDERMAL GEL IN PACKET

3

MYRBETRIQ

3

QL

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 99

Drug Name

Drug Tier

oxybutynin chloride

1

OXYTROL

3

tolterodine

1

TOVIAZ

3

trospium

1

VESICARE

3

Requirements / Limits

BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY alfuzosin

1

AVODART

3

CIALIS

2

dutasteride

1

finasteride

1

FLOMAX

3

JALYN

3

PROSCAR

3

RAPAFLO

3

tamsulosin

1

UROXATRAL

3

QL

CHOLINERGIC STIMULANTS bethanechol chloride

1

URECHOLINE

3

MISCELLANEOUS UROLOGICALS azuphen mb

1

CAVERJECT

2

QL

CAVERJECT IMPULSE

3

QL

CIALIS

2

QL

CYSTAGON

3

LA

cytra k crystals

1

cytra-2

1

cytra-3

1

cytra-k

1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 100

Drug Name

Drug Tier

Requirements / Limits

EDEX

3

QL

ELMIRON

3

hyolev mb

1

hyophen

1

INDIOMIN MB

3

K-PHOS NO 2

3

K-PHOS ORIGINAL

3

LEVITRA

3

MUSE

3

ORACIT

3

phosphasal

1

pot & sod citrate-citric acid

1

potassium citrate

1

potassium citrate-citric acid

1

PROCYSBI

3

SHOHL'S MODIFIED

3

sodium citrate-citric acid

1

STAXYN

3

ST; QL

STENDRA

3

ST; QL

tricitrates

1

ur n-c

1

uramit mb

1

URELLE

3

uretron d-s

1

URIBEL

3

urimar-t

1

urin ds

1

uro-blue

1

UROCIT-K 10

3

UROCIT-K 15

3

UROCIT-K 5

3

urogesic-blue

1

ST; QL

LA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 101

Drug Name

Drug Tier

uro-l

1

urolet mb

1

uro-mp

1

urophen mb

1

UROQID-ACID NO.2

3

uryl

1

ustell

1

UTA (WITH PHENYL SALICYLATE)

3

utira-c

1

VIAGRA

2

virtrate-2

1

virtrate-3

1

virtrate-k

1

Requirements / Limits

QL

URINARY ANESTHETICS phenazopyridine

1

PYRIDIUM

3

VITAMINS, HEMATINICS & ELECTROLYTES ELECTROLYTES calcium carb & citrate-vit d3

4

ACA; OTC

calcium carbonate-vitamin d3

4

ACA; OTC

calcium citrate-vitamin d2

4

ACA; OTC

citrus calcium

4

ACA; OTC

EFFER-K ORAL TABLET, EFFERVESCENT 10 MEQ, 20 MEQ

3

effer-k oral tablet, effervescent 25 meq

1

GALZIN

3

k-effervescent

1

klor-con

1

klor-con 10

1

klor-con 8

1

klor-con m10

1

klor-con m15

1

PA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 102

Drug Name

Drug Tier

klor-con m20

1

klor-con sprinkle

1

KLOR-CON/25

3

klor-con/ef

1

k-phos-neutral

1

k-sol

1

K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ, 20 MEQ

3

k-tab oral tablet extended release 8 meq

1

lugols

1

oysco 500/d

4

phospha 250 neutral

1

potassium bicarb and chloride

1

potassium bicarb-citric acid

1

potassium chloride oral capsule, extended release

1

potassium chloride oral liquid

1

potassium chloride oral packet

1

potassium chloride oral tablet extended release

1

potassium chloride oral tablet,er particles/crystals

1

strong iodine

1

virt-phos 250 neutral

1

Requirements / Limits

QL

ACA; OTC

QL

MISCELLANEOUS VITAMINS, HEMATINICS, & ELECTROLYTES FORTAVIT

3

VITAMINS & HEMATINICS ACTIVE FE

3

ACTIVE OB

3

advanced am-pm

1

ANIMI-3 WITH VITAMIN D

3

ATABEX EC

3

b complex-vitamin c-folic acid

4

BACMIN

3

balanced b-100 complex

4

ACA; OTC ACA; OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 103

Drug Name

Drug Tier

balanced b-50

4

bal-care dha

1

BAL-CARE DHA ESSENTIAL

3

BIFERA RX

3

bp vit 3 plus

1

calcium pnv

1

calcium-folic acid-vitamin d

1

calvite p&d

4

CARDIOTEK-RX (BIOPERINE)

3

centratex

1

CEREFOLIN

3

chewable multivit-a,b,d,e,k,zn

1

cholecalciferol (vitamin d3)

4

ciferex

1

CITRANATAL (DUAL-IRON)

3

CITRANATAL 90 DHA (ALGAL OIL)

3

CITRANATAL ASSURE

3

CITRANATAL B-CALM (FE GLUC)

3

CITRANATAL DHA (ALGAL OIL)

3

CITRANATAL HARMONY (IRON FUM)

3

classic prenatal

4

c-nate dha

1

complete natal dha

1

completenate

1

CONCEPT DHA

3

CONCEPT OB

3

corvita

1

corvita 150

1

CORVITE

3

CORVITE 150

3

CORVITE FE

3

CORVITE FREE

3

Requirements / Limits ACA; OTC

ACA; OTC

ACA; OTC

ACA; OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 104

Drug Name

Drug Tier

dialyvite

1

DIALYVITE 3000

3

DIALYVITE 5000

3

dialyvite 800

4

DIALYVITE 800 WITH IRON

3

DIALYVITE SUPREME D

3

dothelle dha

1

DRISDOL

3

DUET DHA BALANCED

3

DUET DHA WITH OMEGA-3

3

d-vi-sol

4

ELDERCAPS

3

elite-ob

1

ENBRACE HR

3

ergocalciferol (vitamin d2) oral capsule

1

ergocalciferol (vitamin d2) oral tablet

4

ESCAVITE

3

ESCAVITE LQ

3

EXTRA-VIRT PLUS DHA

2

fabb

1

fer-iron

4

ferocon

1

FERRALET 90 DUAL-IRON DELIVERY

3

ferraplus 90

1

ferrex 150 forte

1

ferrex 150 forte plus

1

ferrex 28

1

ferrocite plus

1

ferrogels forte

1

FLORIVA (FLUORIDE-VITAMIN D3)

3

FLUORABON

3

FLUOR-A-DAY

3

Requirements / Limits

ACA; OTC

ACA; OTC

ACA; OTC

ACA; OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 105

Drug Name

Drug Tier

Requirements / Limits

fluor-a-day (with xylitol) oral tablet,chewable 0.25 mg f (0.55 mg)-236.79mg, 0.5 mg f (1.1 mg)236.79 mg

4

ACA

fluor-a-day (with xylitol) oral tablet,chewable 1 mg f (2.2 mg)-236.79 mg

1

FLUORITAB ORAL DROPS

3

fluoritab oral tablet,chewable 0.5 mg fluoride (1.1 mg)

4

fluoritab oral tablet,chewable 1 mg fluoride (2.2 mg)

1

FLURA-DROPS

3

focalgin 90 dha

1

focalgin ca

1

focalgin dss

1

folbecal

1

folbee

1

folbee plus

1

folbic

1

folbic rf

1

FOLET DHA

3

FOLET ONE

3

FOLGARD OS

3

FOLGARD RX

3

folic acid oral tablet 1 mg

1

folic acid oral tablet 400 mcg, 800 mcg

4

folic acid-vit b6-vit b12

1

folivane-f

1

folivane-ob

1

folivane-plus

1

folplex 2.2

1

foltabs 800

4

ACA; OTC

full spectrum b-vitamin c

4

ACA; OTC

FUSION PLUS

3

ACA

ACA; OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 106

Drug Name

Drug Tier

hematinic plus vit/minerals

1

hematinic/folic acid

1

hematogen

1

hematogen fa

1

hematogen forte

1

HEMATRON

3

HEMATRON-AF

3

HEMAX

3

hemenatal ob

1

hemenatal ob + dha

1

hemetab

1

HEMOCYTE-F

3

HEMOCYTE-PLUS

3

ICAR-C PLUS

3

iferex 150 forte

1

inatal advance

1

inatal ultra

1

INTEGRA F

3

INTEGRA PLUS

3

IROSPAN 24/6

3

kpn

4

levomefolate dha

1

l-methyl-mc

1

lmthf-pyridoxine-cyanocobalamn

1

ludent fluoride oral tablet,chewable 0.25 mg fluorid (0.55 mg), 0.5 mg fluoride (1.1 mg)

4

ludent fluoride oral tablet,chewable 1 mg fluoride (2.2 mg)

1

macnatal cn dha

1

MARNATAL-F

3

MAXARON FORTE

3

MAXINATE

3

Requirements / Limits

ACA; OTC

ACA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 107

Drug Name

Drug Tier

Requirements / Limits

metafolbic

1

MULTICHEW

3

multigen

1

multigen folic

1

multigen plus

1

multi-vit with fluoride & iron

4

ACA

multivitamin with fluoride

4

ACA

multi-vitamin with fluoride

4

ACA

multivitamins with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

4

ACA

multivitamins with fluoride oral tablet,chewable 1 mg

1

mvc-fluoride oral tablet,chewable 0.25 mg, 0.5 mg

4

mvc-fluoride oral tablet,chewable 1 mg

1

M-VIT

3

myferon 150 forte

1

MYKIDZ IRON FLUORIDE

3

mynatal

1

mynatal advance

1

mynatal plus

1

mynatal-z

1

mynate 90 plus

1

mynephrocaps

1

NATACHEW (FE BIS-GLYCINATE)

3

NATALVIT

3

NATELLE ONE

3

natural b-100 complex

4

NEEVODHA (WITH ALGAL OIL)

3

nephplex rx

1

NEPHROCAPS

3

NEPHROCAPS QT

3

NEPHRON FA

3

ACA

ACA; OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 108

Drug Name

Drug Tier

Requirements / Limits

nephro-vite rx

1

NESTABS

3

NESTABS ABC

3

NESTABS DHA

3

newgen

1

NEXA PLUS

3

NICOMIDE

3

NICOMIDE (SELENIUM-CHROMIUM)

3

NIVA-FOL

3

NIVA-PLUS

3

NUTRICAP

3

OB COMPLETE

3

OB COMPLETE ONE

3

OB COMPLETE PETITE

3

OB COMPLETE PREMIER

3

OB COMPLETE WITH DHA

3

obstetrix dha

1

OBSTETRIX EC

3

OBTREX DHA

3

O-CAL FA

3

O-CAL PRENATAL

3

one daily prenatal

4

ACA; OTC

oyster shell calcium-vit d3

4

ACA; OTC

PAIRE OB PLUS DHA

3

perry prenatal

4

pnv 29-1

1

pnv ob+dha

1

pnv-dha

1

pnv-dha + docusate

1

pnv-ferrous fumarate-docu-fa

1

pnv-omega

1

pnv-select

1

ACA; OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 109

Drug Name

Drug Tier

Requirements / Limits

pnv-vp-u

1

poly-iron 150 forte

1

POLY-VI-FLOR

3

POLY-VI-FLOR FS

3

POLY-VI-FLOR WITH IRON

3

poly-vitamin with iron

4

pr natal 400

1

pr natal 400 ec

1

pr natal 430

1

pr natal 430 ec

1

PREFERA-OB

3

PREFERA-OB ONE

3

PREFERA-OB PLUS DHA

3

prena1 chew

1

prena1 pearl

1

prenaissance

1

prenaissance next

1

prenaissance plus

1

PRENATA

3

prenatabs fa

1

prenatabs rx

1

prenatal

4

ACA; OTC

prenatal complete

4

ACA; OTC

prenatal plus

1

prenatal plus (calcium carb)

1

prenatal vit#96-ferrous fum-fa

4

prenatal vitamins low iron

1

prenatal-u

1

PRENATE AM

3

PRENATE CHEWABLE

3

PRENATE DHA

3

PRENATE DHA (FERR ASP GLYCIN)

3

ACA; OTC

ACA; OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 110

Drug Name

Drug Tier

PRENATE ELITE (IRON ASP GLYC)

3

PRENATE ENHANCE

3

PRENATE ESSENTIAL(IRON-ASP-GL)

3

PRENATE MINI

3

PRENATE MINI (FERR ASP GLYCIN)

3

PRENATE PIXIE

3

PRENATE RESTORE

3

PRENATE STAR

3

preplus

1

PREQUE 10

3

pretab

1

PROFERRIN-FORTE

3

PROTECT IRON

3

PROVIDA DHA

3

PROVIDA OB

3

PUREFE OB PLUS

3

PUREFE PLUS

3

purevit dualfe plus

1

relnate dha

1

renal caps

1

rena-vite

4

rena-vite rx

1

reno caps

1

R-NATAL OB

3

rulavite dha

1

SELECT-OB + DHA

3

se-natal 19

1

se-natal 19 (with docusate)

1

se-tan dha

1

se-tan plus

1

sodium fluoride oral drops

4

Requirements / Limits

ACA; OTC

ACA

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 111

Drug Name

Drug Tier

sodium fluoride oral tablet,chewable 0.25 mg fluorid (0.55 mg), 0.5 mg fluoride (1.1 mg)

4

sodium fluoride oral tablet,chewable 1 mg fluoride (2.2 mg)

1

stress formula

4

STROVITE FORTE

3

STROVITE ONE

3

SUPERVITE

3

SUPERVITE (EC)

3

TANDEM PLUS

3

taron forte

1

taron-bc

1

taron-c dha

1

taron-prex prenatal-dha

1

TEXAVITE LQ

3

THRIVITE RX

3

thrivite-19

1

TL FOLATE

3

tl gard rx

1

tl g-fol os

1

tl icon

1

tl-hem 150

1

total b/c

4

triadvance

1

TRICARE

3

TRICARE PRENATAL DHA ONE

3

tricon

1

trigels-f forte

1

trinatal gt

1

trinatal rx 1

1

trinate

1

triphrocaps

1

Requirements / Limits ACA

ACA; OTC

ACA; OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 112

Drug Name

Drug Tier

Requirements / Limits

triple vitamin with fluoride

4

ACA

TRISTART DHA

3

tri-tabs dha

1

triveen-duo dha

1

triveen-prx rnf

1

TRI-VI-FLOR

3

tri-vit with fluoride & iron

4

ACA

tri-vitamin with fluoride

4

ACA

trust natal dha

1

UDAMIN SP

3

ultimatecare one

1

ultimatecare one nf

1

v-c forte

1

vemavite-prx-2

1

vena-bal dha

1

vic-forte

1

vinate care

1

vinate dha

1

VINATE DHA RF

3

vinate ii

1

vinate m

1

vinate one

1

vinate ultra

1

virt nate

1

virt-advance

1

virt-c dha

1

VIRT-CAPS

3

virt-care one

1

virt-gard

1

virt-pn

1

virt-pn dha

1

virt-pn plus

1

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 113

Drug Name

Drug Tier

Requirements / Limits

VIRTPREX

3

virt-select

1

virt-vite

1

virt-vite forte

1

virt-vite gt

1

VIRT-VITE PLUS

3

vit 3

1

vit b complex-folic acid

4

VITAFOL

3

VITAFOL FE+ (WITH DOCUSATE)

3

VITAFOL NANO

3

vitafol-ob

1

VITAFOL-OB+DHA

3

VITAFOL-ONE

3

VITAL-D RX

3

VITAMED MD ONE RX

3

VITAMED MD PLUS RX

3

vitamin d3

4

ACA; OTC

vitamins a,c,d & fluoride

4

ACA

VITAPEARL

3

VITA-RESPA

3

VIVA DHA

3

vol-care rx

1

vol-nate

1

vol-plus

1

vol-tab rx

1

vp-ch plus

1

vp-ch-pnv

1

vp-ggr-b6

1

vp-heme ob

1

vp-heme one

1

VP-PNV-DHA

3

ACA; OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 114

Drug Name

Drug Tier

vp-vite rx

1

wee care

4

zatean-ch

1

zatean-pn dha

1

zatean-pn plus

1

zingiber

1

Requirements / Limits ACA; OTC

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 115

Index 8 8-MOP .................................. 46 A abacavir .................................. 2 abacavir-lamivudinezidovudine .......................... 3 ABILIFY .............................. 27 ABSORICA .......................... 48 ABSTRAL............................ 20 acamprosate .......................... 57 ACANYA ............................. 48 acarbose ................................ 65 ACCOLATE......................... 96 ACCUPRIL .......................... 35 ACCURETIC ....................... 35 acebutolol ............................. 35 ACEON ................................ 35 acetaminophen-codeine ........ 21 acetasol hc ............................ 60 acetazolamide ....................... 91 acetic acid ............................. 60 acetic acid-aluminum acetate60 acetylcysteine ....................... 96 ACIPHEX............................. 73 ACIPHEX SPRINKLE ........ 73 acitretin ................................. 44 ACTICLATE .......................... 9 ACTIGALL .......................... 69 ACTIMMUNE ..................... 76 ACTIQ .................................. 21 ACTIVE FE........................ 103 ACTIVE OB....................... 103 ACTIVELLA ....................... 79 ACTONEL ..................... 57, 78 ACTOPLUS MET ................ 65 ACTOPLUS MET XR ......... 65 ACTOS ................................. 65 acuicyn ................................. 89 ACULAR ............................. 90 ACULAR LS ........................ 90 ACUVAIL (PF) .................... 90 acyclovir ........................... 3, 53 ACZONE .............................. 48 ADALAT CC ....................... 35 adapalene .............................. 48 ADAPALENE ...................... 48

ADASUVE ........................... 27 ADCIRCA ............................ 96 ADDERALL ........................ 27 ADDERALL XR .................. 27 adefovir ................................... 3 ADEMPAS ........................... 96 ADIPEX-P ............................ 57 ADOXA.................................. 9 ADRENACLICK ................. 93 ADRENALIN ....................... 96 ADVAIR DISKUS ............... 96 ADVAIR HFA ..................... 96 advanced am-pm................. 103 ADVICOR ............................ 42 AEROSPAN ......................... 96 afeditab cr ............................. 35 AFINITOR ........................... 11 AFINITOR DISPERZ .......... 11 AFLURIA 2015-2016 .......... 76 AFLURIA 2015-2016 (PF) .. 76 AFREZZA ............................ 62 AFTERA .............................. 82 AGGRENOX........................ 41 AGRYLIN ............................ 57 ak-poly-bac ........................... 87 AKTEN (PF) ........................ 89 AKYNZEO ........................... 69 ala-cort .................................. 53 ALA-SCALP ........................ 54 ALBENZA ............................. 6 albuterol sulfate .............. 96, 97 ALCAINE ............................ 89 alclometasone ....................... 54 ALDACTAZIDE .................. 35 ALDACTONE...................... 35 ALDARA ............................. 76 alendronate ..................... 57, 78 ALEVICYN ANTIPRURITIC .......................................... 46 alfuzosin ............................. 100 ALINIA .................................. 6 ALKERAN ........................... 11 allopurinol ............................ 77 almotriptan malate ................ 18 ALOCRIL ............................. 90 ALOMIDE............................ 90

alophen .................................69 ALORA ................................ 79 alosetron ...............................69 ALPHAGAN P .....................93 alprazolam ............................27 alprazolam intensol ...............27 ALREX .................................92 ALSUMA .............................18 ALTABAX ...........................52 altacaine ................................ 90 ALTACE ..............................35 altafluor.................................90 altavera (28) ..........................82 ALTOPREV .........................42 ALUVEA ..............................46 ALVESCO ............................97 alyacen 1/35 (28) ..................82 alyacen 7/7/7 (28) .................82 amantadine hcl ........................3 AMARYL .............................65 AMBIEN ..............................27 AMBIEN CR ........................27 amcinonide ...........................54 AMERGE .............................18 amethia .................................82 amethia lo .............................82 amethyst ................................ 82 AMICAR ..............................41 amiloride ...............................35 amiloride-hydrochlorothiazide ..........................................35 amiodarone ...........................34 AMITIZA .............................69 amitriptyline .........................27 amitriptyline-chlordiazepoxide ..........................................27 amlodipine ............................35 amlodipine-atorvastatin ........42 amlodipine-benazepril ..........35 amlodipine-valsartan ............35 amlodipine-valsartan-hcthiazid ..........................................35 ammonium lactate ................46 amnesteem ............................49 amoxapine.............................28

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 116

amoxicil-clarithromy-lansopraz .......................................... 73 amoxicillin.............................. 8 AMOXICILLIN ..................... 8 amoxicillin-pot clavulanate .... 8 amphetamine salt combo ...... 28 ampicillin................................ 8 AMPYRA ............................. 19 AMRIX................................. 20 ANADROL-50 ..................... 63 ANAFRANIL ....................... 28 anagrelide ............................. 57 ANA-LEX KIT .................... 69 ANALPRAM E .................... 69 ANALPRAM-HC........... 44, 69 ANALPRAM-HC SINGLES69 ANAPROX........................... 24 ANAPROX DS .................... 25 anaspaz ................................. 67 anastrozole ............................ 11 ANCOBON ............................ 2 ANDRODERM .................... 63 ANDROGEL ........................ 63 ANDROID ........................... 63 androxy ................................. 63 ANGELIQ ............................ 79 ANIMI-3 WITH VITAMIN D ........................................ 103 ANORO ELLIPTA .............. 97 ANTABUSE......................... 57 ANTARA ............................. 42 ANTIVERT .......................... 69 anucort-hc ............................. 69 ANUSOL-HC ....................... 69 ANZEMET ........................... 69 apexicon e............................. 54 APIDRA ............................... 62 APIDRA SOLOSTAR ......... 62 APLENZIN .......................... 28 APOKYN ............................. 17 apraclonidine ........................ 93 apri ........................................ 82 APRISO ................................ 69 APTENSIO XR .................... 28 APTIOM............................... 14 APTIVUS ............................... 3 AQUA GLYCOLIC HC....... 54 aranelle (28).......................... 82

ARAVA ................................ 78 arbinoxa ................................ 93 ARCALYST ......................... 76 ARCAPTA NEOHALER ..... 97 ARICEPT ............................. 19 ARIMIDEX .......................... 11 aripiprazole ........................... 28 ARIXTRA ............................ 41 ARMOUR THYROID ......... 67 ARNUITY ELLIPTA ........... 97 AROMASIN ......................... 11 ARTHROTEC 50 ................. 25 ARTHROTEC 75 ................. 25 ASACOL HD ....................... 69 ascomp with codeine ............ 21 ashlyna .................................. 82 ASMANEX HFA ................. 97 ASMANEX TWISTHALER 97 aspirin ................................... 25 aspirin-dipyridamole ............ 41 aspir-low ............................... 25 ASTAGRAF XL................... 11 ASTEPRO ............................ 59 ATABEX EC ...................... 103 ATACAND .......................... 35 ATACAND HCT ................. 35 ATELVIA ............................. 78 atenolol ................................. 35 atenolol-chlorthalidone ......... 35 ATIVAN ............................... 28 atorvastatin ........................... 42 atovaquone.............................. 6 atovaquone-proguanil ............. 6 ATRALIN ............................ 49 ATRIPLA ............................... 3 atropine ................................. 89 ATROVENT ........................ 59 ATROVENT HFA ............... 97 AUBAGIO............................ 75 aubra ..................................... 82 AUGMENTIN ........................ 8 AUGMENTIN ES-600 ........... 8 AUGMENTIN XR ................. 8 AURYXIA............................ 69 AVALIDE ............................ 35 AVANDAMET .................... 65 AVANDIA ........................... 65 AVAPRO.............................. 35

avar .......................................49 AVAR ...................................49 AVAR LS .............................49 AVAR-E GREEN .................49 AVAR-E LS .........................49 AVC VAGINAL ..................81 AVELOX ................................9 AVELOX ABC PACK ...........9 AVENOVA ..........................90 aviane ....................................82 avidoxy ...................................9 AVIDOXY DK .......................9 avita ......................................49 AVITA ..................................49 AVODART.........................100 AVONEX .............................75 AVONEX (WITH ALBUMIN) ..........................................75 AXERT .................................18 AXIRON...............................63 AYGESTIN ..........................79 AZASAN ..............................11 AZASITE .............................87 azathioprine ..........................11 azelastine ........................59, 90 AZELEX...............................49 AZILECT .............................17 azithromycin ...........................6 AZOPT .................................91 AZOR ...................................36 AZULFIDINE ......................69 AZULFIDINE EN-TABS ....69 azuphen mb .........................100 azurette (28) ..........................82 B b complex-vitamin c-folic acid ........................................103 bacitracin ..............................87 bacitracin-polymyxin b .........87 baclofen ................................ 20 BACMIN ............................103 BACTRIM ..............................9 BACTRIM DS ........................9 BACTROBAN .....................52 BACTROBAN NASAL .......59 balanced b-100 complex .....103 balanced b-50......................104 bal-care dha ........................104

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 117

BAL-CARE DHA ESSENTIAL................... 104 balsalazide ............................ 69 balziva (28)........................... 82 BANZEL .............................. 14 BARACLUDE ....................... 3 BECONASE AQ .................. 97 belladonna alkaloids-opium . 67 belladonna-opium ................. 67 BELSOMRA ........................ 28 BELVIQ ............................... 57 benazepril ............................. 36 benazepril-hydrochlorothiazide .......................................... 36 BENICAR ............................ 36 BENICAR HCT ................... 36 BENSAL HP ........................ 46 BENTYL .............................. 67 BENZACLIN ....................... 49 BENZACLIN PUMP ........... 49 BENZAMYCIN ................... 49 BENZAMYCINPAK ........... 49 BENZEFOAM ..................... 49 BENZEFOAM ULTRA ....... 49 benzepro ............................... 49 BENZEPRO (MICROSPHERES) ......... 49 benzonatate ........................... 94 benzoyl peroxide .................. 49 benzphetamine ...................... 57 benztropine ........................... 17 BEPREVE ............................ 90 BESIVANCE ....................... 87 BETADINE OPHTHALMIC PREP ................................ 87 BETAGAN ........................... 88 betamethasone dipropionate . 54 betamethasone valerate ........ 54 betamethasone, augmented... 54 BETAPACE ......................... 34 BETAPACE AF ................... 34 BETASERON ...................... 75 betaxolol ......................... 36, 88 bethanechol chloride .......... 100 BETHKIS ............................... 6 BETIMOL ............................ 89 BETOPTIC S........................ 89 bexarotene ............................ 11

BEYAZ ................................. 82 BIAXIN .................................. 6 bicalutamide ......................... 11 BIDIL ................................... 36 BIFERA RX ....................... 104 BILTRICIDE .......................... 6 bimatoprost ........................... 91 BINOSTO ............................. 78 bisoprolol fumarate............... 36 bisoprolol-hydrochlorothiazide .......................................... 36 BLEPH-10 ............................ 93 BLEPHAMIDE .................... 92 BLEPHAMIDE S.O.P. ......... 93 BONIVA .............................. 78 BONTRIL PDM ................... 57 BOSULIF ............................. 11 bp 10-1 .................................. 49 bp vit 3 plus ........................ 104 bp-50% urea ......................... 46 bpo ........................................ 49 BRAVELLE ......................... 63 BREO ELLIPTA .................. 97 BREVICON (28) .................. 82 briellyn.................................. 82 BRILINTA ........................... 41 brimonidine .......................... 93 BRINTELLIX ...................... 28 BRISDELLE ........................ 28 BROMFED DM ................... 94 bromfenac ............................. 90 bromocriptine ....................... 17 brompheniramine-pseudoephdm ..................................... 94 BROVANA .......................... 97 BUCALSEP.......................... 51 budesonide ...................... 69, 97 bumetanide ........................... 36 BUNAVAIL ......................... 25 BUPAP ................................. 21 BUPHENYL ......................... 57 buprenorphine hcl ................. 21 buprenorphine-naloxone....... 25 buproban ............................... 59 bupropion hcl .................. 28, 59 buspirone .............................. 28 butalbital compound w/codeine .......................................... 21

butalbital-acetaminop-caf-cod ..........................................21 butalbital-acetaminophen .....21 butalbital-acetaminophen-caff ..........................................21 butalbital-aspirin-caffeine.....21 BUTISOL .............................28 butorphanol tartrate ..............25 BUTRANS ...........................21 BYDUREON ........................65 BYETTA ..............................65 BYSTOLIC...........................36 C cabergoline ...........................63 CADUET ..............................42 CAFERGOT .........................18 caffeine citrated ....................57 CALAN ................................ 36 CALAN SR ..........................36 calcipotriene .........................44 calcipotriene-betamethasone 45 calcitonin (salmon) ...............63 calcitrene...............................45 calcitriol .......................... 45, 63 calcium acetate .....................69 calcium carb & citrate-vit d3 ........................................102 calcium carbonate-vitamin d3 ........................................102 calcium citrate-vitamin d2 ..102 calcium pnv ........................104 calcium-folic acid-vitamin d ........................................104 calvite p&d .........................104 CAMBIA ..............................25 camila ...................................79 camrese .................................82 camrese lo .............................83 CANASA ..............................69 candesartan ...........................36 candesartan-hydrochlorothiazid ..........................................36 CANTIL ...............................68 capacet ..................................21 CAPCOF...............................94 capecitabine ..........................11 CAPEX .................................54

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 118

CAPITAL WITH CODEINE .......................................... 21 CAPRELSA ......................... 11 captopril ................................ 36 captopril-hydrochlorothiazide .......................................... 36 CARAC ................................ 47 carafate ................................. 74 CARAFATE ......................... 74 CARBAGLU ........................ 57 carbamazepine ...................... 14 CARBATROL...................... 15 carbidopa .............................. 17 carbidopa-levodopa .............. 17 carbidopa-levodopaentacapone ........................ 17 carbinoxamine maleate ......... 93 CARDENE SR ..................... 36 CARDIOTEK-RX (BIOPERINE) ................ 104 CARDIZEM ......................... 36 CARDIZEM CD .................. 36 CARDIZEM LA ................... 36 CARDURA .......................... 36 CARDURA XL .................... 36 carisoprodol .......................... 20 carisoprodol-asa-codeine ...... 20 carisoprodol-aspirin .............. 20 CARNITOR ......................... 58 CARNITOR (SUGAR-FREE) .......................................... 58 carteolol ................................ 89 carvedilol .............................. 36 CASODEX ........................... 11 CATAPRES ......................... 36 CATAPRES-TTS-1.............. 36 CATAPRES-TTS-2.............. 36 CATAPRES-TTS-3.............. 36 CAVERJECT ..................... 100 CAVERJECT IMPULSE ... 100 CAYA CONTOURED ......... 79 CAYSTON ............................. 6 caziant (28) ........................... 83 CEDAX .................................. 5 cefaclor ................................... 5 cefadroxil................................ 5 cefdinir ................................... 5 cefditoren pivoxil ................... 5

cefixime .................................. 5 cefpodoxime ........................... 5 cefprozil .................................. 5 ceftibuten ................................ 5 CEFTIN .................................. 5 cefuroxime axetil .................... 5 CELEBREX ......................... 25 celecoxib ............................... 25 CELEXA .............................. 28 CELLCEPT .......................... 11 CELONTIN .......................... 15 cem-urea ............................... 47 CENTANY ........................... 52 CENTANY AT..................... 52 centergy ................................ 94 centratex ............................. 104 cephalexin ............................... 5 CERDELGA ......................... 63 CEREFOLIN ...................... 104 CESAMET ........................... 69 cetirizine ............................... 93 CETRAXAL......................... 60 CETROTIDE ........................ 63 cevimeline ............................ 58 CHANTIX ............................ 59 CHANTIX CONTINUING MONTH BOX .................. 59 CHANTIX STARTING MONTH BOX .................. 59 chateal ................................... 83 CHEMET.............................. 58 CHENODAL ........................ 69 cheratussin ac ....................... 94 cheratussin dac ..................... 94 chewable multivit-a,b,d,e,k,zn ........................................ 104 chlordiazepoxide hcl............. 28 chlordiazepoxide-clidinium .. 68 chlorhexidine gluconate ....... 59 chloroquine phosphate ............ 6 chlorothiazide ....................... 36 chlorpromazine ..................... 28 chlorpropamide ..................... 65 chlorthalidone ....................... 36 chlorzoxazone....................... 20 CHOLBAM .......................... 69 cholecalciferol (vitamin d3)104 cholestyramine (with sugar) . 42

cholestyramine light .............42 choline,magnesium salicylate ..........................................25 chorionic gonadotropin, human ..........................................63 CIALIS ............................... 100 ciclodan.................................52 CICLODAN KIT ..................52 ciclopirox ..............................52 ciclopirox-ure-camph-mentheuc.....................................52 ciferex .................................104 cilostazol ...............................41 CILOXAN ............................88 cimetidine .............................74 cimetidine hcl .......................74 CIMZIA ................................ 69 CIPRO ....................................9 CIPRO HC ............................60 CIPRO XR ..............................9 CIPRODEX ..........................60 ciprofloxacin ...........................9 ciprofloxacin (mixture) ...........9 ciprofloxacin hcl .........9, 60, 88 citalopram .............................28 CITRANATAL (DUALIRON) .............................104 CITRANATAL 90 DHA (ALGAL OIL) ................104 CITRANATAL ASSURE ..104 CITRANATAL B-CALM (FE GLUC) ............................104 CITRANATAL DHA (ALGAL OIL) ................104 CITRANATAL HARMONY (IRON FUM) ..................104 citroma ..................................69 citrus calcium......................102 claravis ..................................49 CLARIFOAM EF .................49 CLARINEX ..........................93 CLARINEX-D 12 HOUR ....94 clarithromycin.........................6 classic prenatal....................104 cleansing wash ......................49 clemastine .............................93 CLEOCIN .........................6, 81 CLEOCIN T .........................49

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 119

CLIMARA ........................... 79 CLIMARA PRO ................... 79 CLINDACIN ETZ................ 49 clindacin p ............................ 49 CLINDACIN PAC ............... 49 CLINDAGEL ....................... 49 clindamycin hcl ...................... 7 clindamycin palmitate hcl ...... 7 clindamycin pediatric ............. 7 clindamycin phosphate ... 49, 81 clindamycin-benzoyl peroxide .......................................... 49 CLINDESSE ........................ 81 CLINPRO 5000 .................... 59 clobetasol .............................. 54 clobetasol-emollient ............. 54 CLOBEX .............................. 54 CLOCORTOLONE PIVALATE ...................... 54 clodan ................................... 54 CLODAN KIT...................... 54 CLODERM .......................... 54 clomiphene citrate ................ 63 clomipramine........................ 28 clonazepam ........................... 15 clonidine ............................... 36 clonidine hcl ................... 28, 36 clopidogrel ............................ 41 clorazepate dipotassium ....... 28 clorpres ................................. 37 CLORPRES.......................... 37 clotrimazole ...................... 2, 52 clotrimazole-betamethasone . 52 clozapine............................... 28 CLOZAPINE ........................ 29 CLOZARIL .......................... 29 c-nate dha ........................... 104 CNL 8 NAIL ........................ 52 COAL TAR .......................... 45 COARTEM ............................ 7 codeine sulfate ...................... 21 codeine-guaifenesin .............. 94 COLAZAL ........................... 69 COLCHICINE ...................... 77 colchicine-probenecid .......... 77 COLCRYS ........................... 77 COLESTID........................... 42 COLESTID FLAVORED .... 42

colestipol .............................. 42 colocort ................................. 69 COLY-MYCIN S ................. 60 COLYTE WITH FLAVOR PACKS ............................. 69 COMBIGAN ........................ 91 COMBIPATCH .................... 79 COMBIVENT RESPIMAT . 97 COMBIVIR ............................ 3 COMETRIQ ......................... 11 COMPAZINE ....................... 69 COMPLERA .......................... 3 complete natal dha .............. 104 completenate ....................... 104 compro .................................. 70 COMTAN............................. 17 CONCEPT DHA ................ 104 CONCEPT OB ................... 104 CONCEPTROL .................... 81 CONCERTA ........................ 29 CONDYLOX........................ 47 constulose ............................. 70 CONTRAVE ........................ 57 CONZIP................................ 25 COPAXONE ........................ 75 COPEGUS ............................ 75 CORDARONE ..................... 34 CORDRAN .......................... 54 CORDRAN TAPE SMALL ROLL................................ 54 COREG ................................ 37 COREG CR .......................... 37 CORGARD .......................... 37 CORLANOR ........................ 44 cormax .................................. 54 CORTANE-B ....................... 47 CORTEF............................... 61 CORTENEMA ..................... 70 CORTIFOAM ...................... 70 cortisone ............................... 61 CORTISPORIN .................... 52 CORTISPORIN-TC ............. 60 corvita ................................. 104 corvita 150 .......................... 104 CORVITE ........................... 104 CORVITE 150 .................... 104 CORVITE FE ..................... 104 CORVITE FREE ................ 104

CORZIDE .............................37 COSENTYX .........................45 COSENTYX (2 SYRINGES) ..........................................45 COSENTYX PEN ................45 COSENTYX PEN (2 PENS) 45 COSOPT ...............................91 COSOPT (PF) .......................91 COUMADIN ........................41 covaryx .................................79 covaryx h.s. ...........................79 COZAAR ..............................37 cpm-pseudoephedhydrocodone .....................94 CREON.................................70 CRESEMBA...........................2 CRESTOR ............................42 CRINONE ............................79 CRIXIVAN.............................3 cromolyn ...................70, 90, 97 cryselle (28) ..........................83 CUPRIMINE ........................78 CUROSURF .........................97 CUTIVATE ..........................54 CUVPOSA ...........................68 cyclafem 1/35 (28) ................83 cyclafem 7/7/7 (28)...............83 CYCLESSA (28) ..................83 cyclobenzaprine ....................20 CYCLOGYL ........................89 CYCLOMYDRIL .................93 cyclopentolate .......................89 CYCLOPHOSPHAMIDE ....11 CYCLOSERINE.....................7 CYCLOSET .........................65 cyclosporine ..........................11 cyclosporine modified ..........11 CYMBALTA ........................29 cyproheptadine .....................93 cyred .....................................83 CYSTADANE ......................70 CYSTAGON ......................100 CYSTARAN.........................90 CYTOMEL ...........................67 CYTOTEC ............................74 cytra k crystals ....................100 cytra-2 .................................100 cytra-3 .................................100

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 120

cytra-k................................. 100 D DAKLINZA ........................... 3 DALIRESP ........................... 97 danazol ................................. 63 DANTRIUM ........................ 20 dantrolene ............................. 20 DAPSONE ............................. 7 DARAPRIM ........................... 7 dasetta 1/35 (28) ................... 83 dasetta 7/7/7 (28) .................. 83 DAYPRO ............................. 25 daysee ................................... 83 DAYTRANA ....................... 29 DDAVP ................................ 63 DEBACTEROL ................... 59 deblitane ............................... 79 deltasone ............................... 61 delyla (28) ............................ 83 DELZICOL .......................... 70 DEMADEX .......................... 37 demeclocycline ....................... 9 DEMEROL........................... 21 DENAVIR ............................ 53 denta 5000 plus..................... 59 dentagel ................................ 59 DEPAKENE ......................... 15 DEPAKOTE ......................... 15 DEPAKOTE ER ................... 15 DEPAKOTE SPRINKLES .. 15 DEPEN TITRATABS .......... 78 DEPO-PROVERA ............... 79 DEPO-SUBQ PROVERA 104 .......................................... 79 DERMA-SMOOTHE/FS BODY OIL ....................... 54 DERMA-SMOOTHE/FS SCALP OIL ...................... 54 DERMASORB HC COMPLETE KIT ............. 54 DERMASORB TA COMPLETE KIT ............. 54 DERMASORB XM COMPLETE KIT ............. 47 DERMATOP ........................ 54 DERMOTIC OIL ................. 60 desipramine .......................... 29 desloratadine......................... 93

desmopressin ........................ 63 desog-e.estradiol/e.estradiol . 83 DESOGEN ........................... 83 desogestrel-ethinyl estradiol . 83 DESONATE ......................... 54 desonide ................................ 54 DESOWEN .......................... 54 desoximetasone .................... 54 DESOXYN ........................... 29 DESVENLAFAXINE .......... 29 DESVENLAFAXINE FUMARATE .................... 29 DETROL .............................. 99 DETROL LA ........................ 99 dexamethasone ..................... 61 dexamethasone intensol ........ 61 dexamethasone sodium phosphate .......................... 92 dexedrine .............................. 29 DEXEDRINE SPANSULE .. 29 DEXILANT .......................... 74 dexmethylphenidate.............. 29 DEXPAK 10 DAY ............... 61 DEXPAK 13 DAY ............... 61 DEXPAK 6 DAY ................. 61 dextroamphetamine .............. 29 dextroamphetamineamphetamine .................... 29 DIABETA ............................ 65 dialyvite .............................. 105 DIALYVITE 3000 ............. 105 DIALYVITE 5000 ............. 105 dialyvite 800 ....................... 105 DIALYVITE 800 WITH IRON ........................................ 105 DIALYVITE SUPREME D ........................................ 105 DIAMOX SEQUELS ........... 91 DIASTAT ............................. 15 DIASTAT ACUDIAL .......... 15 diazepam ......................... 15, 29 diazepam intensol ................. 29 DIBENZYLINE ................... 37 DICLEGIS ............................ 70 diclofenac potassium ............ 25 diclofenac sodium..... 25, 47, 91 diclofenac-misoprostol ......... 25 dicloxacillin ............................ 8

dicyclomine ..........................68 didanosine ...............................3 diethylpropion.......................57 DIFFERIN ............................50 DIFICID .................................6 diflorasone ............................55 DIFLUCAN ............................2 diflunisal ...............................25 digitek ...................................41 digox .....................................41 digoxin ..................................41 dihydrocode-acetaminophencaff ....................................21 dihydrocodeine-aspirin-caff .21 dihydroergotamine ................18 DILANTIN ...........................15 DILANTIN EXTENDED .....15 DILANTIN INFATABS ......15 DILANTIN-125 ....................15 DILATRATE-SR .................44 DILAUDID...........................21 DIOVAN ..............................37 DIOVAN HCT .....................37 DIPENTUM .........................70 diphenhydramine hcl ............93 diphenoxylate-atropine .........68 DIPROLENE ........................55 DIPROLENE AF ..................55 dipyridamole .........................41 DISALCID ...........................25 diskets ...................................21 disopyramide phosphate .......34 disulfiram ..............................58 DITROPAN XL....................99 DIURIL.................................37 divalproex .............................15 DIVIGEL ..............................79 DOLOPHINE .......................21 donepezil...............................19 DONNATAL ........................68 DORYX ..................................9 dorzolamide ..........................91 dorzolamide-timolol .............91 dothelle dha ........................105 DOVONEX ..........................45 doxazosin ..............................37 doxepin .................................29 doxercalciferol ......................63

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 121

doxycycline hyclate ................ 9 doxycycline monohydrate 9, 10 DOXYCYCLINE MONOHYDRATE............. 9 DRISDOL........................... 105 drithocreme hp...................... 45 dronabinol............................. 70 drospirenone-ethinyl estradiol .......................................... 83 DROXIA .............................. 11 DUAC................................... 50 DUAVEE ............................. 79 DUET DHA BALANCED . 105 DUET DHA WITH OMEGA-3 ........................................ 105 DUETACT ........................... 65 DUEXIS ............................... 25 DULERA .............................. 97 duloxetine ............................. 29 DUOPA ................................ 17 DURAGESIC ....................... 21 DUREZOL ........................... 92 DURLAZA ........................... 41 dutasteride .......................... 100 DUTOPROL......................... 37 d-vi-sol ............................... 105 DYAZIDE ............................ 37 DYMISTA ............................ 97 DYRENIUM ........................ 37 E e.e.s. 400 ................................. 6 E.E.S. GRANULES ............... 6 EC-NAPROSYN .................. 25 econazole .............................. 52 econtra ez.............................. 83 ECOZA................................. 52 EDARBI ............................... 37 EDARBYCLOR ................... 37 EDECRIN............................. 37 EDEX ................................. 101 EDLUAR .............................. 29 ed-spaz .................................. 68 EDURANT ............................. 3 eemt ...................................... 80 eemt hs.................................. 80 effer-k ................................. 102 EFFER-K............................ 102 EFFEXOR XR...................... 29

EFFIENT .............................. 41 EFUDEX .............................. 47 EGRIFTA ............................. 75 ELDEPRYL.......................... 17 ELDERCAPS ..................... 105 ELESTAT ............................. 90 ELESTRIN ........................... 80 ELIDEL ................................ 47 ELIMITE .............................. 56 elinest.................................... 83 eliphos .................................. 70 ELIQUIS .............................. 41 elite-ob ................................ 105 ELIXOPHYLLIN ................. 97 ELLA .................................... 83 ELMIRON .......................... 101 ELOCON .............................. 55 EMADINE............................ 90 EMBEDA ............................. 21 EMCYT ................................ 11 EMEND ................................ 70 EMLA ................................... 51 emoquette ............................. 83 EMSAM ............................... 29 EMTRIVA .............................. 3 ENABLEX ........................... 99 enalapril maleate................... 37 enalapril-hydrochlorothiazide .......................................... 37 ENBRACE HR ................... 105 ENBREL .............................. 78 ENBREL SURECLICK ....... 78 endocet.................................. 21 endodan ................................ 21 ENDOMETRIN.................... 80 ENJUVIA ............................. 80 enoxaparin ............................ 41 enpresse ................................ 83 enskyce ................................. 83 entacapone ............................ 17 entecavir ................................. 3 ENTOCORT EC................... 70 enulose .................................. 70 ENVARSUS XR .................. 11 EPANED .............................. 37 EPIDUO ............................... 50 EPIDUO FORTE .................. 50 EPIFOAM ............................ 45

epinastine ..............................90 epinephrine ...........................93 EPIPEN 2-PAK ....................93 EPIPEN JR 2-PAK ...............93 epitol .....................................15 EPIVIR ...................................3 EPIVIR HBV ..........................3 eplerenone.............................37 eprosartan .............................37 EPZICOM...............................3 EQUETRO ...........................15 ergocalciferol (vitamin d2) .105 ergoloid .................................29 ERGOMAR ..........................18 ERIVEDGE ..........................11 errin.......................................80 ERTACZO ............................52 ery pads .................................50 erygel ....................................50 ERYPED 200..........................6 ERYPED 400..........................6 ery-tab .....................................6 ERY-TAB ...............................6 erythrocin (as stearate) ...........6 erythromycin.....................6, 88 erythromycin ethylsuccinate ...6 erythromycin with ethanol ....50 erythromycin-benzoyl peroxide ..........................................50 ESBRIET ..............................97 ESCAVITE .........................105 ESCAVITE LQ ..................105 escitalopram oxalate .............29 ESGIC...................................21 esomeprazole magnesium .....74 estarylla.................................83 estazolam ..............................29 ESTRACE ............................80 estradiol ................................ 80 estradiol-norethindrone acet .80 ESTRING .............................80 ESTROGEL ..........................80 estrogens-methyltestosterone80 estropipate.............................80 ESTROSTEP FE-28 .............83 eszopiclone ...........................29 ethambutol ..............................7 ethosuximide.........................15

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 122

etidronate disodium .............. 58 etodolac ................................ 25 etoposide............................... 11 EURAX ................................ 56 EVAMIST ............................ 80 EVEKEO .............................. 29 EVISTA ................................ 78 EVOCLIN ............................ 50 EVOTAZ ................................ 3 EVOXAC ............................. 58 EXALGO ER ....................... 21 EXELDERM ........................ 53 EXELON .............................. 19 exemestane ........................... 12 EXFORGE ........................... 37 EXFORGE HCT .................. 37 EXJADE ............................... 58 EXODERM .......................... 53 EXTAVIA ............................ 75 EXTINA ............................... 53 EXTRA-VIRT PLUS DHA 105 EZ FLU 2015-16 (FLUVIRIN) (PF) ................................... 76 EZ FLU 201516(FLUCELVAX)(PF) .... 77 F fabb ..................................... 105 FABIOR ............................... 50 FACTIVE ............................... 9 fallback solo ......................... 83 falmina (28) .......................... 83 famciclovir ............................. 3 famotidine............................. 74 FAMVIR ................................ 3 FANAPT .............................. 29 FARESTON ......................... 12 FARXIGA ............................ 65 FARYDAK........................... 12 FAZACLO ........................... 29 FC2 FEMALE CONDOM ... 79 felbamate .............................. 15 FELBATOL ......................... 15 FELDENE ............................ 25 felodipine .............................. 37 FEMARA ............................. 12 FEMCAP .............................. 79 FEMCON FE........................ 83 FEMHRT LOW DOSE ........ 80

FEMRING ............................ 80 fenofibrate ............................ 43 FENOFIBRATE ................... 42 fenofibrate micronized ......... 42 fenofibrate nanocrystallized . 42 fenofibric acid....................... 43 fenofibric acid (choline) ....... 43 FENOGLIDE........................ 43 fenoprofen ............................ 25 FENOPROFEN .................... 25 fentanyl ................................. 22 FENTANYL ......................... 22 fentanyl citrate ...................... 21 FENTORA............................ 22 fer-iron ................................ 105 ferocon ................................ 105 FERRALET 90 DUAL-IRON DELIVERY .................... 105 ferraplus 90 ......................... 105 ferrex 150 forte ................... 105 ferrex 150 forte plus ........... 105 ferrex 28 ............................. 105 FERRIPROX ........................ 58 ferrocite plus ....................... 105 ferrogels forte ..................... 105 FETZIMA ............................. 30 FEXMID ............................... 20 FIBRICOR............................ 43 FINACEA ............................. 50 finasteride ........................... 100 FIORICET ............................ 22 FIORICET WITH CODEINE .......................................... 22 FIORINAL ........................... 22 FIORINAL-CODEINE #3 ... 22 FIRAZYR ............................. 97 FLAGYL ................................ 7 FLAGYL ER .......................... 7 FLAREX .............................. 92 flavoxate ............................... 99 flecainide .............................. 34 FLECTOR ............................ 25 FLOMAX ........................... 100 FLORIVA (FLUORIDEVITAMIN D3) ............... 105 FLOVENT DISKUS ............ 97 FLOVENT HFA ................... 97 FLOWTUSS ......................... 94

FLUARIX QUAD 2015-2016 (PF) ...................................77 FLUBLOK 2015-2016 (PF) .77 flucaine .................................90 FLUCELVAX 2015-2016 (PF) ..........................................77 fluconazole .............................2 flucytosine ..............................2 fludrocortisone ......................61 FLULAVAL QUAD 20152016 ..................................77 FLUMADINE.........................3 FLUMIST QUAD 2015-2016 ..........................................77 flunisolide .............................97 fluocinolone ..........................55 fluocinolone acetonide oil ....60 fluocinolone and shower cap 55 fluocinonide ..........................55 fluocinonide-e .......................55 FLUORABON ....................105 FLUOR-A-DAY .................105 fluor-a-day (with xylitol) ....106 fluorescein-benoxinate .........90 fluorescein-proparacaine ......90 fluoridex daily defense .........59 FLUORIDEX SENSITIVITY RELIEF.............................59 fluoritab .............................. 106 FLUORITAB ......................106 fluorometholone ...................92 FLUOROPLEX ....................47 fluorouracil ...........................47 FLUOROURACIL ...............47 fluoxetine ..............................30 FLUOXETINE .....................30 fluphenazine hcl....................30 FLURA-DROPS .................106 flurazepam ............................30 flurbiprofen ...........................25 flurbiprofen sodium ..............91 flurox ....................................90 flutamide ...............................12 fluticasone.......................55, 97 fluvastatin .............................43 FLUVIRIN 2015-2016 .........77 FLUVIRIN 2015-2016 (PF) .77 fluvoxamine ..........................30

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 123

FLUZONE 2015-2016 ......... 77 FLUZONE HIGH-DOSE 2015-16 (PF) .................... 77 FLUZONE INTRADERM QUAD 2015-16 ................ 77 FLUZONE QUAD 2015-2016 .......................................... 77 FLUZONE QUAD 2015-2016 (PF) ................................... 77 FLUZONE QUAD PEDI 2015-16 (PF) .................... 77 FML FORTE ........................ 92 FML LIQUIFILM ................ 92 FML S.O.P. .......................... 92 focalgin 90 dha ................... 106 focalgin ca .......................... 106 focalgin dss ......................... 106 FOCALIN............................. 30 FOCALIN XR ...................... 30 folbecal ............................... 106 folbee .................................. 106 folbee plus .......................... 106 folbic................................... 106 folbic rf ............................... 106 FOLET DHA ...................... 106 FOLET ONE ...................... 106 FOLGARD OS ................... 106 FOLGARD RX .................. 106 folic acid ............................. 106 folic acid-vit b6-vit b12 ...... 106 folivane-f ............................ 106 folivane-ob ......................... 106 folivane-plus ....................... 106 FOLLISTIM AQ .................. 63 folplex 2.2........................... 106 foltabs 800 .......................... 106 fondaparinux......................... 41 FORADIL AEROLIZER ..... 97 FORFIVO XL ...................... 30 FORTAMET ........................ 65 FORTAVIT ........................ 103 FORTEO .............................. 78 FORTESTA.......................... 63 fortical .................................. 64 FOSAMAX .......................... 78 FOSAMAX PLUS D ............ 78 fosinopril .............................. 37

fosinopril-hydrochlorothiazide .......................................... 37 FOSRENOL ......................... 70 FRAGMIN............................ 41 FROVA ................................ 18 full spectrum b-vitamin c ... 106 FULYZAQ ........................... 68 FURADANTIN .................... 10 furosemide ............................ 37 FUSION PLUS ................... 106 FUZEON ................................ 3 FYCOMPA........................... 15 G gabapentin ............................ 15 GABITRIL ........................... 15 galantamine .......................... 19 GALZIN ............................. 102 GANIRELIX ........................ 64 garamycin ............................. 88 GASTROCROM .................. 70 gatifloxacin ........................... 88 GATTEX 30-VIAL .............. 70 gavilyte-c .............................. 70 gavilyte-g .............................. 70 gavilyte-n .............................. 70 GELNIQUE .......................... 99 gemfibrozil ........................... 43 GENERESS FE .................... 83 generlac ................................ 70 gengraf .................................. 12 GENOTROPIN .................... 75 GENOTROPIN MINIQUICK .......................................... 75 gentak ................................... 88 gentamicin ...................... 52, 88 gentlelax ............................... 70 GEODON ............................. 30 gianvi (28) ............................ 83 GIAZO.................................. 70 gildagia ................................. 83 gildess 1.5/30 (21) ................ 83 gildess 1/20 (21) ................... 83 gildess 24 fe .......................... 84 gildess fe 1.5/30 (28) ............ 84 gildess fe 1/20 (28) ............... 84 GILENYA ............................ 75 GILOTRIF ............................ 12 glatopa .................................. 75

GLEEVEC ............................12 GLEOSTINE ........................12 GLIADEL WAFER ..............12 glimepiride ............................65 glipizide ................................ 65 glipizide-metformin ..............65 GLUCAGON EMERGENCY KIT (HUMAN) .................62 GLUCOPHAGE ...................65 GLUCOPHAGE XR ............65 GLUCOTROL ......................65 GLUCOTROL XL................65 GLUCOVANCE...................65 GLUMETZA ........................65 glyburide ...............................65 glyburide micronized ............65 glyburide-metformin.............65 glycopyrrolate .......................68 glydo .....................................51 GLYNASE ...........................65 GLYSET ...............................66 GLYXAMBI.........................66 GOLYTELY .........................70 GONAL-F.............................64 GONAL-F RFF ....................64 GONAL-F RFF REDI-JECT 64 GORDONS UREA ...............47 GRALISE .............................15 GRALISE 30-DAY STARTER PACK ...............................15 granisetron hcl ......................70 GRANULEX ........................56 GRIFULVIN V .......................2 griseofulvin microsize ............2 griseofulvin ultramicrosize .....2 GRIS-PEG (ULTRAMICROSIZE).......2 guaiatussin ac........................94 guaifenesin ac .......................94 guaifenesin dac .....................94 guanfacine.......................30, 37 guanidine ..............................30 GYNAZOLE-1 .....................81 gynol ii ..................................81 H HALCION ............................30 halobetasol propionate ..........55 HALOG ................................ 55

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 124

haloperidol ............................ 30 haloperidol lactate ................ 30 HARVONI ............................. 3 healthylax ............................. 70 heather .................................. 80 HECTOROL......................... 64 HEMANGEOL..................... 37 hematinic plus vit/minerals 107 hematinic/folic acid ............ 107 hematogen .......................... 107 hematogen fa ...................... 107 hematogen forte .................. 107 HEMATRON ..................... 107 HEMATRON-AF ............... 107 HEMAX ............................. 107 hemenatal ob ...................... 107 hemenatal ob + dha ............ 107 hemetab .............................. 107 hemmorex-hc........................ 70 HEMOCYTE-F .................. 107 HEMOCYTE-PLUS........... 107 HEPSERA .............................. 3 HETLIOZ ............................. 30 HEXALEN ........................... 12 HIPREX ............................... 10 HISTEX-AC ......................... 94 homatropaire......................... 89 homatropine hbr ................... 89 HORIZANT ......................... 19 HPR PLUS-MB HYDROGEL .......................................... 47 HUMALOG ......................... 62 HUMALOG KWIKPEN ...... 62 HUMALOG MIX 50-50 ...... 62 HUMALOG MIX 50-50 KWIKPEN ....................... 62 HUMALOG MIX 75-25 ...... 62 HUMALOG MIX 75-25 KWIKPEN ....................... 62 HUMATROPE ..................... 75 HUMIRA .............................. 78 HUMIRA PEDIATRIC CROHN'S START ........... 78 HUMIRA PEN ..................... 78 HUMULIN 70/30 ................. 62 HUMULIN 70/30 KWIKPEN .......................................... 62 HUMULIN N ....................... 62

HUMULIN N KWIKPEN .... 62 HUMULIN R ....................... 62 HUMULIN R U-500 (CONCENTRATED) ....... 62 HYCAMTIN ........................ 12 HYCET................................. 22 HYCOFENIX ....................... 94 hydralazine ........................... 38 HYDREA ............................. 12 HYDRO 35 ........................... 47 HYDRO 40 ........................... 47 hydrochlorothiazide .............. 38 hydrocodone-acetaminophen 22 hydrocodone-chlorpheniramine .......................................... 94 hydrocodone-homatropine.... 94 hydrocodone-ibuprofen ........ 22 hydrocortisone .......... 55, 61, 70 hydrocortisone acetate .......... 70 hydrocortisone butyrate ........ 55 hydrocortisone butyr-emollient .......................................... 55 hydrocortisone valerate ........ 55 hydrocortisone-acetic acid .... 60 hydrocortisone-min oil-wht pet .......................................... 55 hydrocortisone-pramox-epram#1 .............................. 71 hydrocortisone-pramoxine... 45, 71 hydromet ............................... 94 hydromorphone .................... 22 hydroxychloroquine................ 7 hydroxyurea .......................... 12 hydroxyzine hcl .................... 93 hydroxyzine pamoate ........... 93 hyolev mb ........................... 101 hyophen .............................. 101 hyoscyamine sulfate ............. 68 hyosyne ................................. 68 HYSINGLA ER ................... 22 HYZAAR ............................. 38 I ibandronate ........................... 78 IBRANCE ............................ 12 IBUDONE ............................ 22 ibuprofen .............................. 25 ibuprofen-oxycodone............ 22

ICAR-C PLUS ....................107 ICLUSIG ..............................12 iferex 150 forte ...................107 ILEVRO ...............................91 ILOTYCIN ...........................88 IMBRUVICA .......................12 imipramine hcl ......................30 imipramine pamoate .............30 imiquimod.............................76 IMITREX .............................18 IMITREX STATDOSE KIT REFILL.............................18 IMITREX STATDOSE PEN18 IMURAN ..............................12 inatal advance .....................107 inatal ultra ...........................107 INCRELEX ..........................58 INCRUSE ELLIPTA ............97 indapamide ...........................38 INDERAL LA ......................38 INDERAL XL ......................38 INDIOMIN MB ..................101 INDOCIN .............................26 indomethacin ........................26 INFASURF ...........................58 INLYTA ...............................12 INNOPRAN XL ...................38 INOVA .................................50 INOVA 4-1 ...........................46 INOVA 8-2 ...........................46 INSPRA ................................ 38 INTEGRA F .......................107 INTEGRA PLUS ................107 INTELENCE ..........................3 INTERMEZZO.....................30 INTRON A ...........................76 introvale ................................ 84 INTUNIV ER .......................30 INVEGA ...............................30 INVIRASE .............................3 INVOKAMET ......................66 INVOKANA.........................66 IONSYS ................................ 22 iophen c-nr ............................94 IOPIDINE .............................93 ipratropium bromide .......59, 97 ipratropium-albuterol ............97 irbesartan ..............................38

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 125

irbesartan-hydrochlorothiazide .......................................... 38 IRENKA ............................... 30 IRESSA ................................ 12 IROSPAN 24/6 ................... 107 ISENTRESS ........................... 3 ISOCHRON ......................... 44 isometh-dichloralacetaminophn ................... 18 isomethepten-cafacetaminophen .................. 18 isoniazid ................................. 7 ISOPTO ATROPINE ........... 89 ISOPTO CARPINE .............. 89 ISORDIL .............................. 44 ISORDIL TITRADOSE ....... 44 isosorbide dinitrate ............... 44 isosorbide mononitrate ......... 44 isoxsuprine ........................... 81 isradipine .............................. 38 ISTALOL ............................. 89 itraconazole ............................ 2 ivermectin ............................... 7 J JADENU .............................. 58 JAKAFI ................................ 12 JALYN ............................... 100 jantoven ................................ 41 JANUMET ........................... 66 JANUMET XR..................... 66 JANUVIA............................. 66 JARDIANCE ........................ 66 jencycla................................. 80 JENTADUETO .................... 66 jinteli..................................... 80 jolessa ................................... 84 jolivette ................................. 80 JUBLIA ................................ 53 juleber ................................... 84 junel 1.5/30 (21) ................... 84 junel 1/20 (21) ...................... 84 junel fe 1.5/30 (28) ............... 84 junel fe 1/20 (28) .................. 84 junel fe 24 ............................. 84 JUXTAPID ........................... 43 K KADIAN .............................. 22 KALETRA ............................. 4

KALYDECO ........................ 97 KAPVAY ............................. 30 KARBINAL ER ................... 94 kariva (28) ............................ 84 KAYEXALATE ................... 71 KAZANO ............................. 66 k-effervescent ..................... 102 KEFLEX ................................. 5 kelnor 1/35 (28) .................... 84 KENALOG ........................... 55 KEPPRA............................... 15 KEPPRA XR ........................ 15 KERAFOAM........................ 47 KERALAC ........................... 47 KERALYT RX ..................... 46 KERALYT SCALP COMPLETE ..................... 46 KERYDIN ............................ 53 KETEK ................................... 7 ketoconazole ..................... 2, 53 ketoprofen ............................. 26 ketorolac ......................... 26, 91 KHEDEZLA ......................... 30 kimidess (28) ........................ 84 KINERET ............................. 76 kionex ................................... 71 KITABIS PAK ....................... 7 KLARON ............................. 52 KLONOPIN.......................... 15 klor-con .............................. 102 klor-con 10 ......................... 102 klor-con 8 ........................... 102 klor-con m10 ...................... 102 klor-con m15 ...................... 102 klor-con m20 ...................... 103 klor-con sprinkle................. 103 KLOR-CON/25 .................. 103 klor-con/ef .......................... 103 KOMBIGLYZE XR ............. 66 KORLYM ............................. 64 K-PHOS NO 2 .................... 101 K-PHOS ORIGINAL ......... 101 k-phos-neutral ..................... 103 kpn ...................................... 107 KRISTALOSE...................... 71 k-sol .................................... 103 k-tab .................................... 103 K-TAB ................................ 103

kurvelo ..................................84 KUVAN ................................ 64 KYNAMRO .........................43 L l norgest/e.estradiol-e.estrad .84 labetalol ................................ 38 lactic acid ..............................47 lactic acid e ...........................47 lactulose ................................ 71 LAMICTAL .........................15 LAMICTAL ODT ................15 LAMICTAL ODT STARTER (BLUE) .............................15 LAMICTAL ODT STARTER (GREEN) ..........................15 LAMICTAL ODT STARTER (ORANGE) .......................16 LAMICTAL STARTER (BLUE) KIT .....................16 LAMICTAL STARTER (GREEN) KIT ..................16 LAMICTAL STARTER (ORANGE) KIT ...............16 LAMICTAL XR ...................16 LAMICTAL XR STARTER (BLUE) .............................16 LAMICTAL XR STARTER (GREEN) ..........................16 LAMICTAL XR STARTER (ORANGE) .......................16 LAMISIL ................................2 lamivudine ..............................4 lamivudine-zidovudine ...........4 lamotrigine ............................16 LANOXIN ............................41 lansoprazole ..........................74 LANTUS ..............................62 LANTUS SOLOSTAR .........62 larin 1.5/30 (21) ....................84 larin 1/20 (21) .......................84 larin 24 fe ..............................84 larin fe 1.5/30 (28) ................84 larin fe 1/20 (28) ...................84 LASIX ..................................38 LASTACAFT .......................90 latanoprost ............................91 latrix ......................................47 LATUDA ..............................30

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 126

laxative feminine .................. 71 layolis fe ............................... 84 LAZANDA........................... 22 leena 28 ................................ 84 leflunomide........................... 78 LENVIMA ........................... 12 LESCOL ............................... 43 LESCOL XL ........................ 43 lessina ................................... 84 LETAIRIS ............................ 98 letrozole ................................ 12 leucovorin calcium ............... 11 LEUKERAN ........................ 12 leuprolide.............................. 12 levalbuterol hcl ..................... 98 LEVAQUIN ........................... 9 LEVATOL ........................... 38 LEVBID ............................... 68 LEVEMIR ............................ 62 LEVEMIR FLEXTOUCH ... 62 levetiracetam ........................ 16 LEVITRA ........................... 101 levobunolol ........................... 89 levocarnitine ......................... 58 levocarnitine (with sugar)..... 58 levocetirizine ........................ 94 levofloxacin ...................... 9, 88 levomefolate dha ................ 107 levonest (28) ......................... 84 levonorgestrel ....................... 84 levonorgestrel-ethinyl estrad 84 levora-28............................... 84 levorphanol tartrate .............. 22 levothyroxine ........................ 67 levoxyl .................................. 67 LEVSIN ................................ 68 LEVSIN/SL .......................... 68 LEVULAN ........................... 47 LEXAPRO ........................... 30 LEXIVA ................................. 4 LIALDA ............................... 71 LIBRAX (WITH CLIDINIUM) ................... 68 lidocaine hcl ......................... 51 lidocaine hcl-hydrocortison ac .................................... 51, 71 LIDOCAINE HCLHYDROCORTISON AC . 71

lidocaine viscous .................. 51 lidocaine-hydrocortisone-aloe .......................................... 71 lidocaine-prilocaine .............. 52 LIDOCAINE-TETRACAINE .......................................... 52 lindane .................................. 56 linezolid .................................. 7 LINZESS .............................. 71 liothyronine .......................... 67 LIPITOR ............................... 43 LIPOCHOL PLUS ............... 58 LIPOFEN.............................. 43 lisinopril................................ 38 lisinopril-hydrochlorothiazide .......................................... 38 lithium carbonate .................. 31 lithium citrate ....................... 31 LITHOBID ........................... 31 LITHOSTAT ........................ 58 LIVALO ............................... 43 l-methyl-mc ........................ 107 lmthf-pyridoxinecyanocobalamn ............... 107 LO LOESTRIN FE ............... 84 LOCOID ............................... 55 LODOSYN ........................... 17 LOESTRIN 1.5/30 (21) ........ 84 LOESTRIN 1/20 (21) ........... 84 LOESTRIN FE 1.5/30 (28DAY) ................................ 84 LOESTRIN FE 1/20 (28-DAY) .......................................... 85 LOFIBRA ............................. 43 lomedia 24 fe ........................ 85 LOMOTIL ............................ 68 LOMUSTINE ....................... 12 LONSURF ............................ 12 loperamide ............................ 68 LOPID .................................. 43 lopreeza ................................ 80 LOPRESSOR ....................... 38 LOPRESSOR HCT .............. 38 LOPROX .............................. 53 lorazepam ............................. 31 lorazepam intensol ................ 31 lorcet (hydrocodone) ............ 22 lorcet hd ................................ 22

lorcet plus .............................22 lortab 10-325 ........................22 lortab 5-325 ..........................22 lortab 7.5-325 .......................23 LORTAB ELIXIR ................23 lortuss ex ...............................94 loryna (28) ............................85 LORZONE ...........................20 losartan .................................38 losartan-hydrochlorothiazide 38 LOSEASONIQUE ................85 LOTEMAX...........................92 LOTENSIN...........................38 LOTENSIN HCT..................38 LOTREL ...............................38 LOTRISONE ........................53 LOTRONEX.........................71 lovastatin...............................43 LOVAZA ..............................43 LOVENOX ...........................42 low-ogestrel (28) ..................85 loxapine succinate ................31 ludent fluoride ....................107 lugols ..................................103 LUMIGAN ...........................91 LUNESTA ............................31 lutera (28) .............................85 LUXIQ ..................................55 LUZU ...................................53 LYCELLE ............................56 LYNPARZA .........................12 LYRICA ...............................16 LYSODREN .........................12 LYSTEDA ............................81 lyza .......................................80 M macnatal cn dha ..................107 MACROBID.........................10 MACRODANTIN ................10 MAGNEBIND 400 ...............71 MALARONE .........................7 MALARONE PEDIATRIC....7 malathion ..............................56 maprotiline ............................31 MAR-COF BP ......................94 MAR-COF CG .....................94 margesic ................................ 23 MARINOL ...........................71

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 127

marlexate .............................. 71 marlissa................................. 85 MARNATAL-F.................. 107 MARPLAN .......................... 31 marten-tab............................. 23 MATULANE ....................... 12 matzim la .............................. 38 MAVIK ................................ 38 MAXALT ............................. 18 MAXALT-MLT ................... 18 MAXARON FORTE.......... 107 MAXIDEX ........................... 92 MAXINATE....................... 107 MAXITROL ......................... 92 MAXZIDE ........................... 38 MAXZIDE-25MG................ 38 mb hydrogel.......................... 47 m-clear wc ............................ 95 meclizine .............................. 71 meclofenamate ..................... 26 MEDROL ............................. 61 MEDROL (PAK) ................. 61 medroxyprogesterone ........... 80 mefenamic acid .................... 26 mefloquine.............................. 7 MEGACE ............................. 13 MEGACE ES ....................... 13 megestrol .............................. 13 MEKINIST ........................... 13 meloxicam ............................ 26 memantine ............................ 19 MEMANTINE ..................... 19 M-END MAX D................... 95 M-END PE ........................... 95 MENEST .............................. 80 MENOMUNE - A/C/Y/W-135 .......................................... 77 MENOMUNE - A/C/Y/W-135 (PF) ................................... 77 MENOPUR .......................... 64 MENOSTAR ........................ 80 MENTAX ............................. 53 meperidine ............................ 23 meperitab .............................. 23 MEPHYTON........................ 42 meprobamate ........................ 20 MEPRON ............................... 7 mercaptopurine ..................... 13

mesalamine ........................... 71 mesalamine with cleansing wipe .................................. 71 MESNEX.............................. 11 MESTINON ......................... 20 MESTINON TIMESPAN .... 20 METADATE CD ................. 31 metadate er ........................... 31 metafolbic ........................... 108 metaproterenol ...................... 98 metaxalone............................ 20 metformin ............................. 66 methadone ............................ 23 methadose ............................. 23 methamphetamine ................ 31 methazolamide...................... 91 methenamine hippurate ........ 10 methenamine mandelate ....... 10 methimazole ......................... 61 METHITEST ........................ 64 methocarbamol ..................... 20 methotrexate sodium ............ 13 methotrexate sodium (pf) ..... 13 methoxsalen rapid................. 47 methscopolamine .................. 68 methyclothiazide .................. 38 methyldopa ........................... 38 methyldopahydrochlorothiazide .......... 38 methylergonovine ................. 87 METHYLIN ......................... 31 methylphenidate ................... 31 methylprednisolone .............. 61 methyltestosterone ................ 64 metipranolol.......................... 89 metoclopramide hcl .............. 71 metolazone............................ 38 METOPIRONE .................... 58 metoprolol succinate............. 38 metoprolol ta-hydrochlorothiaz .......................................... 39 metoprolol tartrate ................ 39 METOZOLV ODT ............... 71 METROCREAM .................. 50 METROGEL ........................ 50 METROGEL VAGINAL ..... 81 METROLOTION ................. 50 metronidazole ............. 7, 50, 81

mexiletine .............................34 MIACALCIN .......................64 MICARDIS...........................39 MICARDIS HCT..................39 miconazole-3 ........................82 microgestin 1.5/30 (21) ........85 microgestin 1/20 (21) ...........85 microgestin fe 1.5/30 (28) ....85 microgestin fe 1/20 (28) .......85 MICROZIDE ........................39 midazolam ............................31 midodrine ..............................58 migergot ................................ 18 MIGRANAL.........................18 milk of magnesia concentrated ..........................................71 millipred ...............................61 MILLIPRED .........................61 millipred dp ..........................61 mimvey .................................81 mimvey lo .............................81 MINASTRIN 24 FE .............85 MINIPRESS .........................39 MINITRAN ..........................44 MINIVELLE ........................81 MINOCIN.............................10 MINOCIN KIT WITH WIPES ..........................................10 minocycline ..........................10 minoxidil...............................39 MIOCHOL-E ........................89 MIRAPEX ............................17 MIRAPEX ER ......................17 MIRCETTE (28) ..................85 mirtazapine ...........................31 MIRVASO ............................50 misoprostol ...........................74 MITIGARE...........................77 MITOSOL ............................91 MOBIC .................................26 modafinil...............................31 moderiba ...............................76 moderiba dose pack ..............76 MODICON (28) ...................85 moexipril...............................39 moexipril-hydrochlorothiazide ..........................................39 mometasone ..........................55

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 128

mondoxyne nl ....................... 10 MONODOX ......................... 10 mono-linyah ......................... 85 mononessa (28) .................... 85 montelukast .......................... 98 MONUROL.......................... 10 morgidox .............................. 10 MORGIDOX 1X100 ............ 10 morphine............................... 23 morphine concentrate ........... 23 MOTOFEN........................... 68 MOVANTIK ........................ 71 MOVIPREP .......................... 71 MOXATAG ........................... 8 MOXEZA ............................. 88 moxifloxacin........................... 9 MS CONTIN ........................ 23 MUCOTROL ....................... 59 MULTAQ ............................. 34 MULTICHEW ................... 108 multigen .............................. 108 multigen folic ..................... 108 multigen plus ...................... 108 multi-vit with fluoride & iron ........................................ 108 multivitamin with fluoride . 108 multi-vitamin with fluoride 108 multivitamins with fluoride 108 mupirocin ............................. 52 mupirocin calcium ................ 52 MUSE ................................. 101 mvc-fluoride ....................... 108 M-VIT ................................ 108 my way ................................. 85 MYAMBUTOL...................... 7 MYCOBUTIN ........................ 7 mycophenolate mofetil ......... 13 mycophenolate sodium ......... 13 MYDRIACYL...................... 89 myferon 150 forte ............... 108 MYFORTIC ......................... 13 MYKIDZ IRON FLUORIDE ........................................ 108 MYLERAN .......................... 13 mynatal ............................... 108 mynatal advance ................. 108 mynatal plus ....................... 108 mynatal-z ............................ 108

mynate 90 plus.................... 108 mynephrocaps ..................... 108 MYRBETRIQ ...................... 99 MYSOLINE ......................... 16 myzilra .................................. 85 N nabumetone .......................... 26 nadolol .................................. 39 nadolol-bendroflumethiazide 39 NAFTIFINE ......................... 53 NAFTIN ............................... 53 NALFON .............................. 26 naltrexone ............................. 26 NAMENDA.......................... 19 NAMENDA TITRATION PAK .................................. 19 NAMENDA XR ................... 19 NAMZARIC ......................... 19 naphazoline........................... 93 NAPRELAN CR .................. 26 NAPROSYN ........................ 26 naproxen ............................... 26 naproxen sodium .................. 26 naratriptan ............................. 18 NARDIL ............................... 31 NASONEX ........................... 98 NATACHEW (FE BISGLYCINATE) ................ 108 NATACYN .......................... 88 NATALVIT ........................ 108 NATAZIA ............................ 85 nateglinide ............................ 66 NATELLE ONE ................. 108 NATESTO ............................ 64 NATROBA ........................... 56 natural b-100 complex ........ 108 nature-throid ......................... 67 NEBUPENT ........................... 7 necon 0.5/35 (28) .................. 85 necon 1/35 (28) ..................... 85 necon 1/50 (28) ..................... 85 necon 10/11 (28) ................... 85 necon 7/7/7 (28).................... 85 NEEVODHA (WITH ALGAL OIL) ................................ 108 nefazodone............................ 31 neomycin ................................ 7 neomycin-bacitracin-poly-hc 92

neomycin-bacitracinpolymyxin .........................88 neomycin-polymyxin bdexameth...........................92 neomycin-polymyxingramicidin .........................88 neomycin-polymyxin-hc.61, 92 neo-polycin ...........................88 neo-polycin hc ......................92 NEORAL ..............................13 NEOSPORIN (NEO-POLYMGRAMICID).....................88 NEO-SYNALAR ..................52 NEO-SYNALAR KIT ..........52 nephplex rx .........................108 NEPHROCAPS ..................108 NEPHROCAPS QT ............108 NEPHRON FA ...................108 nephro-vite rx .....................109 NEPTAZANE.......................91 NESINA ...............................66 NESTABS ..........................109 NESTABS ABC .................109 NESTABS DHA .................109 neuac .....................................50 NEUAC KIT .........................50 NEUPRO ..............................17 NEURONTIN .......................16 NEVANAC...........................91 nevirapine ...............................4 newgen ................................ 109 NEXA PLUS ......................109 NEXAVAR...........................13 NEXIUM ..............................74 NEXIUM PACKET..............74 next choice one dose .............85 niacin ....................................43 NIASPAN EXTENDEDRELEASE.........................43 nicardipine ............................39 NICODERM CQ ..................59 NICOMIDE ........................109 NICOMIDE (SELENIUMCHROMIUM) ................109 nicorelief ...............................59 NICORETTE ........................59 nicotine .................................59 NICOTROL ..........................59

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 129

NICOTROL NS.................... 59 nifedical xl ............................ 39 nifedipine.............................. 39 nikki (28) .............................. 85 nimodipine............................ 39 NINJACOF-XG ................... 95 nisoldipine ............................ 39 nitro-bid ................................ 44 NITRO-DUR ........................ 44 nitrofurantoin ........................ 10 nitrofurantoin macrocrystal .. 10 nitrofurantoin monohyd/mcryst .................................. 10 nitroglycerin ......................... 44 NITROLINGUAL ................ 44 NITROMIST ........................ 44 NITROSTAT........................ 44 nitro-time .............................. 44 NIVA-FOL ......................... 109 NIVA-PLUS ....................... 109 nizatidine .............................. 74 NIZORAL ............................ 53 nodolor ................................. 19 nora-be .................................. 81 NORCO ................................ 23 NORDITROPIN FLEXPRO 75 noreth-ethinyl estradiol-iron. 85 norethindrone (contraceptive) .......................................... 81 norethindrone acetate ........... 81 norethindrone ac-eth estradiol .................................... 81, 85 norethindrone-e.estradiol-iron .......................................... 85 norgestimate-ethinyl estradiol .......................................... 85 NORINYL 1+35 (28) ........... 85 NORINYL 1+50 (28) ........... 85 NORITATE .......................... 50 norlyroc ................................ 81 NORPACE ........................... 34 NORPACE CR ..................... 34 NORPRAMIN ...................... 31 NOR-QD .............................. 81 NORTHERA ........................ 58 nortrel 0.5/35 (28) ................ 86 nortrel 1/35 (21) ................... 86 nortrel 7/7/7 (28) .................. 86

nortriptyline .......................... 31 NORVASC ........................... 39 NORVIR ................................. 4 NOVACORT ........................ 52 novarel .................................. 64 NOVOLIN 70/30 .................. 62 NOVOLIN N ........................ 62 NOVOLIN R ........................ 62 NOVOLOG .......................... 62 NOVOLOG FLEXPEN ........ 63 NOVOLOG MIX 70-30 ....... 63 NOVOLOG MIX 70-30 FLEXPEN ........................ 63 NOVOLOG PENFILL ......... 63 NOXAFIL .............................. 2 np thyroid ............................. 67 NUCYNTA .......................... 26 NUCYNTA ER .................... 26 NUEDEXTA ........................ 19 NULEV ................................ 68 NULYTELY WITH FLAVOR PACKS ............................. 71 NUTRICAP ........................ 109 NUTROPIN AQ ................... 75 NUTROPIN AQ NUSPIN.... 75 NUVARING ......................... 82 NUVESSA............................ 82 NUVIGIL ............................. 31 nyamyc ................................. 53 NYMALIZE ......................... 39 nystatin ............................. 2, 53 nystatin-triamcinolone .......... 53 nystop ................................... 53 O OB COMPLETE ................ 109 OB COMPLETE ONE ....... 109 OB COMPLETE PETITE .. 109 OB COMPLETE PREMIER ........................................ 109 OB COMPLETE WITH DHA ........................................ 109 OBREDON ........................... 95 obstetrix dha ....................... 109 OBSTETRIX EC ................ 109 OBTREX DHA .................. 109 O-CAL FA .......................... 109 O-CAL PRENATAL .......... 109 ocella .................................... 86

OCUFEN ..............................91 OCUFLOX ...........................88 ODOMZO.............................13 OFEV ....................................98 ofloxacin .....................9, 60, 88 ogestrel (28) ..........................86 olanzapine .............................31 olanzapine-fluoxetine ...........32 OLEPTRO ER ......................32 olopatadine ...........................59 OLUX ...................................55 OLUX-E ...............................55 OLYSIO .................................4 OMECLAMOX-PAK...........74 omega-3 acid ethyl esters .....43 omeprazole ...........................74 omeprazole-sodium bicarbonate .......................74 OMNARIS ............................98 OMNIPRED .........................92 OMNITROPE .......................75 ondansetron...........................71 ondansetron hcl .....................71 one daily prenatal ...............109 ONEXTON ...........................50 ONFI .....................................16 ONGLYZA ...........................66 ONMEL ..................................2 OPANA ................................ 23 OPANA ER ..........................23 opcicon one-step ...................86 opium tincture .......................68 OPSUMIT.............................98 ORACEA ..............................10 ORACIT .............................101 oralone ..................................59 ORAP ...................................32 ORAPRED ODT ..................61 ORAVIG.................................2 ORENCIA ............................78 ORENITRAM ......................39 ORFADIN ............................58 ORKAMBI ...........................98 orphenadrine citrate ..............20 orsythia .................................86 ORTHO MICRONOR ..........81 ORTHO TRI-CYCLEN (28) 86

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 130

ORTHO TRI-CYCLEN LO (28) ................................... 86 ORTHO-CYCLEN (28) ....... 86 ORTHO-NOVUM 1/35 (28) 86 ORTHO-NOVUM 7/7/7 (28) .......................................... 86 oscimin ................................. 68 oscimin sl.............................. 68 oscimin sr ............................. 68 OSENI .................................. 66 OSMOPREP ......................... 71 OSPHENA ........................... 82 OTEZLA .............................. 78 OTEZLA STARTER............ 78 OTREXUP (PF) ................... 78 OVACE ................................ 45 OVACE PLUS ..................... 45 OVACE PLUS SHAMPOO . 45 OVACE PLUS WASH......... 45 OVCON-35 (28)................... 86 OVIDE ................................. 56 OVIDREL ............................ 64 OXANDRIN......................... 64 oxandrolone .......................... 64 oxaprozin .............................. 26 OXAYDO............................. 23 oxazepam.............................. 32 oxcarbazepine ....................... 16 OXECTA .............................. 23 OXISTAT ............................. 53 OXSORALEN ...................... 47 OXSORALEN ULTRA ....... 47 OXTELLAR XR .................. 16 oxybutynin chloride............ 100 oxycodone ............................ 23 OXYCODONE..................... 24 oxycodone-acetaminophen ... 24 oxycodone-aspirin ................ 24 OXYCONTIN ...................... 24 oxymorphone........................ 24 OXYTROL ......................... 100 oysco 500/d ........................ 103 oyster shell calcium-vit d3 . 109 P pacerone ............................... 35 PACNEX .............................. 50 PAIRE OB PLUS DHA ..... 109 paliperidone .......................... 32

PAMELOR ........................... 32 PANCREAZE ...................... 72 PANDEL .............................. 55 PANRETIN .......................... 47 pantoprazole ......................... 74 PARAFON FORTE DSC ..... 20 paregoric ............................... 68 PAREMYD .......................... 89 paricalcitol ............................ 64 PARLODEL ......................... 17 PARNATE............................ 32 paromomycin .......................... 7 paroxetine hcl ....................... 32 PASER.................................... 7 PATADAY ........................... 90 PATANASE ......................... 60 PATANOL ........................... 90 PAXIL .................................. 32 PAXIL CR ............................ 32 PAZEO ................................. 90 PCE......................................... 6 PEDIADERM AF................. 53 PEDIADERM HC ................ 55 PEDIADERM TA ................ 55 PEDIAPRED ........................ 61 peg 3350-electrolytes ........... 72 peg-3350 with flavor packs .. 72 PEGANONE ........................ 16 PEGASYS ............................ 76 PEGASYS PROCLICK ....... 76 peg-electrolyte soln .............. 72 PEGINTRON ....................... 76 PEGINTRON REDIPEN ..... 76 peg-prep ................................ 72 penicillin v potassium............. 9 PENLAC .............................. 53 PENNSAID .......................... 26 PENTASA ............................ 72 pentazocine-naloxone ........... 26 pentoxifylline........................ 42 PEPCID ................................ 74 PERCOCET.......................... 24 PERFOROMIST .................. 98 PERIDEX ............................. 60 perindopril erbumine ............ 39 periogard ............................... 60 permethrin ............................ 56 perphenazine ......................... 32

perphenazine-amitriptyline ...32 perry prenatal ......................109 PERSANTINE ......................42 PERTZYE.............................72 PEXEVA ..............................32 phenadoz ...............................94 phenazopyridine .................102 phendimetrazine tartrate .......57 phenelzine .............................32 phenergan .............................94 phenobarbital ........................16 phenoxybenzamine ...............39 phentermine ..........................57 phenylephrine hcl .................93 phenylhistine dh....................95 PHENYTEK .........................16 phenytoin ..............................16 phenytoin sodium extended ..16 philith ....................................86 PHOSLO...............................72 PHOSLYRA .........................72 phospha 250 neutral ............103 phosphasal ..........................101 PHOSPHOLINE IODIDE ....89 PICATO ................................ 47 pilocarpine hcl ..........58, 60, 89 pimozide ...............................32 pimtrea (28) ..........................86 pindolol .................................39 pioglitazone ..........................66 pioglitazone-glimepiride.......66 pioglitazone-metformin ........66 pirmella .................................86 piroxicam ..............................26 PLAN B ONE-STEP ............86 PLAQUENIL ..........................7 PLAVIX ...............................42 PLEGRIDY ..........................76 PLETAL ...............................42 PLEXION .............................50 PLEXION CLEANSING CLOTHS...........................50 PLIAGLIS ............................52 PNEUMOVAX 23................77 pnv 29-1 .............................. 109 pnv ob+dha .........................109 pnv-dha ............................... 109 pnv-dha + docusate .............109

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 131

pnv-ferrous fumarate-docu-fa ........................................ 109 pnv-omega .......................... 109 pnv-select ........................... 109 pnv-vp-u ............................. 110 PODOCON........................... 46 podofilox .............................. 47 polycin .................................. 88 polyethylene glycol 3350 ..... 72 poly-iron 150 forte ............. 110 polymyxin b sulf-trimethoprim .......................................... 88 POLYTRIM ......................... 88 POLY-TUSSIN AC.............. 95 POLY-VI-FLOR ................ 110 POLY-VI-FLOR FS ........... 110 POLY-VI-FLOR WITH IRON ........................................ 110 poly-vitamin with iron ........ 110 POMALYST ........................ 76 PONSTEL ............................ 26 portia..................................... 86 pot & sod citrate-citric acid 101 potassium bicarb and chloride ........................................ 103 potassium bicarb-citric acid 103 potassium chloride.............. 103 potassium citrate ................. 101 potassium citrate-citric acid 101 POTASSIUM HYDROXIDE .......................................... 46 POTIGA ............................... 16 pr natal 400 ......................... 110 pr natal 400 ec .................... 110 pr natal 430 ......................... 110 pr natal 430 ec .................... 110 PRADAXA........................... 42 pramcort ............................... 72 pramipexole .......................... 17 PRAMOSONE ..................... 45 PRAMOSONE E .................. 45 PRANDIMET....................... 66 PRANDIN ............................ 66 PRAVACHOL ..................... 43 pravastatin ............................ 43 prazosin ................................ 39 PRECOSE ............................ 66 PRED FORTE ...................... 92

PRED MILD......................... 92 PRED-G................................ 92 PRED-G S.O.P. .................... 92 prednicarbate ........................ 56 prednisolone ......................... 61 prednisolone acetate ............. 92 prednisolone sodium phosphate .................................... 61, 92 prednisone ............................ 61 prednisone intensol ............... 61 PREFERA-OB.................... 110 PREFERA-OB ONE .......... 110 PREFERA-OB PLUS DHA ........................................ 110 PREFEST ............................. 81 PREGNYL............................ 64 PREMARIN ......................... 81 PREMPHASE ...................... 81 PREMPRO ........................... 81 prena1 chew ........................ 110 prena1 pearl ........................ 110 prenaissance........................ 110 prenaissance next ................ 110 prenaissance plus ................ 110 PRENATA.......................... 110 prenatabs fa......................... 110 prenatabs rx ........................ 110 prenatal ............................... 110 prenatal complete ............... 110 prenatal plus ....................... 110 prenatal plus (calcium carb)110 prenatal vit#96-ferrous fum-fa ........................................ 110 prenatal vitamins low iron .. 110 prenatal-u ............................ 110 PRENATE AM................... 110 PRENATE CHEWABLE ... 110 PRENATE DHA ................ 110 PRENATE DHA (FERR ASP GLYCIN)........................ 110 PRENATE ELITE (IRON ASP GLYC) ............................ 111 PRENATE ENHANCE ...... 111 PRENATE ESSENTIAL(IRON-ASPGL) ................................. 111 PRENATE MINI ................ 111

PRENATE MINI (FERR ASP GLYCIN) ........................111 PRENATE PIXIE ...............111 PRENATE RESTORE .......111 PRENATE STAR ...............111 preparation cleansing ............72 preplus ................................ 111 PREPOPIK ...........................72 PREQUE 10........................111 PRESTALIA.........................39 pretab ..................................111 PREVACID ..........................74 PREVACID SOLUTAB .......74 prevalite ................................ 43 PREVIDENT ........................60 PREVIDENT 5000 BOOSTER PLUS ................................ 60 PREVIDENT 5000 DRY MOUTH ...........................60 PREVIDENT 5000 ENAMEL PROTECT ........................60 PREVIDENT 5000 PLUS ....60 PREVIDENT 5000 SENSITIVE ......................60 previfem ................................ 86 PREVNAR 13 (PF) ..............77 PREVPAC ............................74 PREZCOBIX ..........................4 PREZISTA .............................4 PRIFTIN .................................7 PRILOSEC ...........................74 PRIMAQUINE .......................7 primidone ..............................16 PRIMLEV.............................24 PRIMSOL .............................10 PRINIVIL .............................39 PRISTIQ ...............................32 PROAIR HFA ......................98 PROAIR RESPICLICK........98 probenecid ............................77 PROCARDIA .......................39 PROCARDIA XL .................39 procentra ...............................32 prochlorperazine ...................72 prochlorperazine maleate ......72 PRO-CLEAR AC .................95 PRO-CLEAR CAPS .............95 PROCORT ............................72

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 132

PROCTOCORT ................... 72 PROCTOFOAM HC ............ 72 procto-pak............................. 72 proctosol hc .......................... 72 proctozone-hc ....................... 72 PROCYSBI ........................ 101 PROFERRIN-FORTE ........ 111 progesterone micronized ...... 81 PROGLYCEM ..................... 62 PROGRAF ........................... 13 PROLENSA ......................... 91 PROMACTA........................ 42 promethazine ........................ 94 promethazine vc ................... 95 promethazine vc-codeine...... 95 promethazine-codeine .......... 95 promethazine-dm .................. 95 promethazine-phenylephcodeine ............................. 95 promethegan ......................... 94 PROMETRIUM ................... 81 propafenone .......................... 35 propantheline ........................ 68 proparacaine ......................... 90 propranolol ........................... 39 propranolol-hydrochlorothiazid .......................................... 39 propylthiouracil .................... 61 PRO-RED AC (W/ DEXCHLORPHENIR) .... 95 PROSCAR.......................... 100 PROTECT IRON ............... 111 PROTONIX .......................... 74 PROTOPIC........................... 47 protriptyline .......................... 32 PROVENTIL HFA ............... 98 PROVERA ........................... 81 PROVIDA DHA ................ 111 PROVIDA OB.................... 111 PROVIGIL ........................... 32 PROZAC .............................. 32 PROZAC WEEKLY ............ 32 prudoxin ............................... 47 PSORCON ........................... 56 PULMICORT ....................... 98 PULMICORT FLEXHALER .......................................... 98 PULMOZYME..................... 98

PUREFE OB PLUS ............ 111 PUREFE PLUS .................. 111 purevit dualfe plus .............. 111 PURIXAN ............................ 13 PYLERA .............................. 74 pyrazinamide .......................... 7 PYRIDIUM ........................ 102 pyridostigmine bromide ....... 20 Q Q-CARE RX Q4 ................... 60 QNASL................................. 98 QSYMIA .............................. 57 QUADRACEL (PF) ............. 77 QUALAQUIN ........................ 7 QUARTETTE ...................... 86 quasense................................ 86 QUDEXY XR....................... 16 QUESTRAN......................... 43 QUESTRAN LIGHT ............ 43 quetiapine ............................. 32 QUILLIVANT XR ............... 32 quinapril................................ 40 quinapril-hydrochlorothiazide .......................................... 40 quinidine gluconate .............. 35 quinidine sulfate ................... 35 quinine sulfate ........................ 8 QUIT 2 ................................. 59 QUIT 4 ................................. 59 QVAR ................................... 98 R rabeprazole ........................... 74 RADIOGARDASE .............. 58 raloxifene .............................. 78 ramipril ................................. 40 RANEXA ............................. 44 ranitidine hcl ......................... 74 RAPAFLO .......................... 100 RAPAMUNE........................ 13 RASUVO (PF) ..................... 78 RAVICTI .............................. 58 RAYOS ................................ 61 RAZADYNE ........................ 19 RAZADYNE ER .................. 19 rea lo 39 ................................ 48 rea lo 40 ................................ 48 REBETOL ............................ 76 REBIF (WITH ALBUMIN) . 76

REBIF REBIDOSE ..............76 REBIF TITRATION PACK .76 reclipsen (28) ........................86 RECTIV ................................ 72 REGIMEX ............................57 REGLAN ..............................72 REGRANEX ........................48 relador pak ............................52 relador pak plus ....................52 relcof c ..................................95 RELENZA DISKHALER ......4 RELISTOR ...........................72 relnate dha ..........................111 RELPAX...............................19 RELYYT ..............................48 REMERON...........................32 REMERON SOLTAB ..........32 remeven ................................ 48 RENAGEL ...........................72 renal caps ............................111 rena-vite .............................. 111 rena-vite rx..........................111 reno caps .............................111 RENVELA ...........................72 repaglinide ............................66 reprexain ...............................24 REQUIP ................................ 17 REQUIP XL .........................17 RESCRIPTOR ........................4 RESCULA ............................91 reserpine ...............................40 RESPA-AR ...........................95 RESTASIS ............................90 RESTORIL ...........................32 RETIN-A ..............................50 RETIN-A MICRO ................50 RETIN-A MICRO PUMP ....50 RETROVIR ............................4 REVATIO.............................98 REVIA ..................................26 REVLIMID...........................76 REXULTI .............................32 REYATAZ .............................4 REZIRA ................................ 95 RHEUMATREX ..................13 RHINOCORT AQUA ..........98 ribasphere .............................76 ribasphere ribapak ................76

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 133

ribavirin ................................ 76 RIDAURA ............................ 78 rifabutin .................................. 8 RIFADIN ................................ 8 RIFAMATE ........................... 8 rifampin .................................. 8 RIFATER ............................... 8 RILUTEK ............................. 58 riluzole.................................. 58 rimantadine ............................. 4 RIOMET............................... 66 risedronate ...................... 58, 78 RISPERDAL ........................ 32 RISPERDAL M-TAB .......... 32 risperidone ...................... 32, 33 RITALIN .............................. 33 RITALIN LA........................ 33 rivastigmine .......................... 19 rivastigmine tartrate.............. 19 rizatriptan ............................. 19 R-NATAL OB .................... 111 ROBAXIN ............................ 20 ROBAXIN-750 .................... 20 ROBINUL ............................ 68 ROBINUL FORTE .............. 68 ROCALTROL ...................... 64 ropinirole .............................. 17 rosadan ................................. 50 ROSADAN........................... 50 ROSANIL............................. 51 ROSULA .............................. 51 rosula cleansing cloths ......... 51 ROTARIX ............................ 77 ROWASA............................. 72 ROXICODONE ................... 24 ROZEREM ........................... 33 rulavite dha ......................... 111 rydex ..................................... 95 RYTARY ............................. 17 RYTHMOL .......................... 35 RYTHMOL SR .................... 35 S SABRIL................................ 16 SAFYRAL............................ 86 SAIZEN ................................ 75 SAIZEN CLICK.EASY ....... 75 salacyn .................................. 46 SALAGEN ..................... 58, 60

SALEX ................................. 46 salicylic acid ......................... 46 salicylic acid sr-ceramides.... 46 SALKERA............................ 46 salsalate ................................ 26 salvax .................................... 46 SALVAX DUO PLUS ......... 46 SAMSCA.............................. 64 SANCUSO ........................... 72 SANDIMMUNE .................. 13 SANDOSTATIN .................. 13 SANTYL .............................. 56 SAPHRIS (BLACK CHERRY) ........................ 33 SARAFEM ........................... 33 SAVAYSA ........................... 42 SAVELLA ............................ 79 SAXENDA ........................... 57 scalacort ................................ 56 SCALACORT DK ............... 56 SEASONIQUE ..................... 86 seb-prev ................................ 45 seconal sodium ..................... 33 SECTRAL ............................ 40 SEEBRI NEOHALER .......... 98 SELECT-OB + DHA ......... 111 selegiline hcl ......................... 18 selenium sulfide.................... 45 SELRX ................................. 45 SELZENTRY ......................... 4 SEMPREX-D ....................... 95 se-natal 19........................... 111 se-natal 19 (with docusate) . 111 SENSIPAR ........................... 64 SEREVENT DISKUS .......... 98 SEROQUEL ......................... 33 SEROQUEL XR................... 33 SEROSTIM .......................... 75 sertraline ............................... 33 se-tan dha ............................ 111 se-tan plus ........................... 111 setlakin.................................. 86 sf 60 sf 5000 plus .......................... 60 SFROWASA ........................ 73 sharobel ................................ 81 SHOHL'S MODIFIED ....... 101 SIGNIFOR............................ 13

sildenafil ...............................98 SILENOR .............................33 SILVADENE ........................46 silver nitrate ..........................48 silver nitrate applicators .......48 silver sulfadiazine .................46 SIMBRINZA ........................91 SIMCOR ...............................43 SIMPONI ..............................79 simvastatin ............................43 SINEMET .............................18 SINEMET CR ......................18 SINGULAIR.........................98 sirolimus ...............................13 SIRTURO ...............................8 SITAVIG ................................4 SIVEXTRO ............................8 SKELAXIN ..........................20 SKLICE ................................ 56 sodium citrate-citric acid ....101 sodium fluoride .....60, 111, 112 sodium phenylbutyrate .........58 sodium polystyrene sulfonate ..........................................73 SODIUM POLYSTYRENE SULFONATE ...................73 SOLARAZE .........................48 SOLODYN ...........................10 SOLTAMOX ........................13 SOMA...................................20 SOMAVERT ........................64 SONATA ..............................33 SOOLANTRA ......................51 SORBITOL...........................57 SORBITOL-MANNITOL ....57 SORIATANE .......................45 SORILUX .............................45 sotalol ...................................35 sotalol af ...............................35 SOTYLIZE ...........................35 SOVALDI...............................4 SPECTRACEF .......................6 spinosad ................................ 57 SPIRIVA RESPIMAT ..........98 SPIRIVA WITH HANDIHALER ................98 spironolactone.......................40

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 134

spironolacton-hydrochlorothiaz .......................................... 40 SPORANOX .......................... 2 SPORANOX PULSEPAK ..... 2 sprintec (28).......................... 86 SPRIX................................... 26 SPRYCEL ............................ 13 sps ......................................... 73 sronyx ................................... 86 ss 10-2 .................................. 51 ssd ......................................... 46 SSKI ..................................... 61 sss 10-5 ................................. 51 STALEVO 100 ..................... 18 STALEVO 125 ..................... 18 STALEVO 150 ..................... 18 STALEVO 200 ..................... 18 STALEVO 50 ....................... 18 STALEVO 75 ....................... 18 STARLIX ............................. 66 stavudine................................. 4 STAXYN............................ 101 STENDRA ......................... 101 STIMATE............................. 64 STIOLTO RESPIMAT ........ 98 STIVARGA .......................... 14 STRATTERA ....................... 33 stress formula ..................... 112 STRIANT ............................. 64 STRIBILD .............................. 4 STRIVERDI RESPIMAT .... 98 STROMECTOL ..................... 8 strong iodine ....................... 103 STROVITE FORTE ........... 112 STROVITE ONE ............... 112 SUBOXONE ........................ 26 SUBSYS ............................... 24 SUCRAID ............................ 73 sucralfate .............................. 74 SULAR ................................. 40 sulfacetamide sodium ..... 45, 93 SULFACETAMIDE SODIUM .......................................... 45 sulfacetamide sodium (acne) 52 sulfacetamide sodium-sulfur 51 sulfacetamide sod-sulfur-urea .......................................... 51 sulfacetamide-prednisolone.. 93

sulfacetamide-sulfur-cleansr23 .......................................... 51 sulfacleanse 8-4 .................... 51 sulfact na-sul-avobnz-otn-ocsa .......................................... 51 sulfadiazine............................. 9 sulfamethoxazole-trimethoprim ............................................ 9 SULFAMYLON ................... 52 sulfasalazine ......................... 73 sulfatrim.................................. 9 sulfazine................................ 73 sulfazine ec ........................... 73 sulindac................................. 26 SUMADAN .......................... 51 SUMADAN XLT ................. 51 sumatriptan ........................... 19 sumatriptan succinate ........... 19 SUMAVEL DOSEPRO ....... 19 SUMAXIN ........................... 51 SUMAXIN CP ..................... 51 SUMAXIN TS ...................... 51 SUPERVITE ...................... 112 SUPERVITE (EC) .............. 112 SUPRAX ................................ 6 SUPRENZA ......................... 57 SUPREP BOWEL PREP KIT .......................................... 73 SURMONTIL ....................... 33 SURVANTA ........................ 58 SUSTIVA ............................... 4 SUTENT............................... 14 syeda ..................................... 86 SYLATRON ......................... 76 SYMAX DUOTAB .............. 68 symax fastabs ....................... 68 symax-sl................................ 68 symax-sr ............................... 68 SYMBICORT ....................... 98 SYMBYAX .......................... 33 SYMLINPEN 120 ................ 67 SYMLINPEN 60 .................. 67 SYNALAR ........................... 56 SYNALAR CREAM KIT .... 56 SYNALAR OINTMENT KIT .......................................... 56 SYNALAR TS ..................... 56 SYNALGOS-DC .................. 24

SYNAREL ............................64 SYNERA ..............................52 SYNRIBO.............................14 SYNTHROID .......................67 SYPRINE .............................58 T TABLOID.............................14 TACLONEX.........................45 tacrolimus .......................14, 48 TAFINLAR ..........................14 TAKE ACTION ...................86 TAMIFLU ..............................4 tamoxifen ..............................14 tamsulosin ...........................100 TANDEM PLUS ................112 TAPAZOLE .........................62 TARCEVA ...........................14 TARGRETIN .......................14 tarina fe 1/20 (28) .................86 TARKA ................................ 40 taron forte ...........................112 taron-bc ............................... 112 taron-c dha ..........................112 taron-prex prenatal-dha ......112 TASIGNA.............................14 TASMAR .............................18 TAZORAC ...........................51 TECFIDERA ........................76 TECHNIVIE ...........................4 TEGRETOL .........................16 TEGRETOL XR ...................16 TEKAMLO...........................40 TEKTURNA.........................40 TEKTURNA HCT................40 telmisartan ............................40 telmisartan-amlodipine .........40 telmisartan-hydrochlorothiazid ..........................................40 temazepam ............................33 TEMODAR ..........................14 TEMOVATE ........................56 TEMOVATE E .....................56 temozolomide .......................14 tencon ...................................24 TENEX .................................40 TENORETIC 100 .................40 TENORETIC 50 ...................40 TENORMIN .........................40

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 135

TERAZOL 3 ......................... 82 TERAZOL 7 ......................... 82 terazosin ............................... 40 terbinafine hcl ......................... 2 terbutaline ............................. 99 terconazole ........................... 82 TERSI FOAM ...................... 45 TESSALON PERLES .......... 95 TESTIM ............................... 64 TESTOSTERONE ............... 64 TESTRED ............................ 64 tetcaine ................................. 90 tetrabenazine......................... 19 tetracaine hcl ........................ 90 tetracaine hcl (pf) ................. 90 tetracycline ........................... 10 TETRAVISC ........................ 90 TETRAVISC FORTE .......... 90 TEXACORT......................... 56 TEXAVITE LQ .................. 112 THALOMID......................... 14 THEO-24 .............................. 99 theophylline .......................... 99 thermazene ........................... 46 thioridazine ........................... 33 thiothixene ............................ 33 THRIVITE RX ................... 112 thrivite-19 ........................... 112 THYROLAR-1 ..................... 67 THYROLAR-1/2 .................. 67 THYROLAR-1/4 .................. 67 THYROLAR-2 ..................... 67 THYROLAR-3 ..................... 67 tiagabine ............................... 16 TIAZAC ............................... 40 ticlopidine ............................. 42 TIGAN ................................. 73 TIKOSYN ............................ 35 tilia fe.................................... 86 timolol maleate ............... 40, 89 TIMOPTIC ........................... 89 TIMOPTIC OCUDOSE (PF) .......................................... 89 TIMOPTIC-XE .................... 89 TINDAMAX .......................... 8 tinidazole ................................ 8 TIROSINT ............................ 67 TIVICAY ............................... 4

TIVORBEX .......................... 27 tizanidine .............................. 20 TL FOLATE ....................... 112 tl gard rx ............................. 112 tl g-fol os ............................ 112 tl icon .................................. 112 tl-hem 150........................... 112 TOBI....................................... 8 TOBI PODHALER ................ 8 TOBRADEX ........................ 92 TOBRADEX ST................... 92 tobramycin ............................ 88 tobramycin in 0.225 % nacl .... 8 tobramycin-dexamethasone .. 92 TOBREX .............................. 88 TODAY CONTRACEPTIVE SPONGE .......................... 82 TOFRANIL .......................... 33 TOFRANIL-PM ................... 33 TOLAK ................................ 48 tolazamide ............................ 67 tolbutamide ........................... 67 tolcapone .............................. 18 tolmetin................................. 27 tolterodine........................... 100 TOPAMAX .......................... 16 TOPICORT .......................... 56 topiramate ....................... 16, 17 TOPIRAMATE .................... 16 TOPROL XL ........................ 40 torsemide .............................. 40 total b/c ............................... 112 TOUJEO SOLOSTAR ......... 63 TOVIAZ ............................. 100 TRACLEER ......................... 99 TRADJENTA ....................... 67 tramadol ................................ 27 TRAMADOL ....................... 27 tramadol-acetaminophen ...... 27 TRANDATE ........................ 40 trandolapril ........................... 40 trandolapril-verapamil .......... 40 tranexamic acid..................... 82 TRANSDERM-SCOP .......... 73 TRANXENE T-TAB ............ 33 tranylcypromine.................... 33 TRAVATAN Z..................... 91 travoprost (benzalkonium) ... 91

trazodone ..............................33 TRECATOR ...........................8 TREPADONE (WITH BROMELAIN) .................27 tretinoin.................................51 tretinoin (chemotherapy) ......14 tretinoin microspheres ..........51 TRETIN-X ............................51 TRETIN-X CREAM KIT .....51 TREXALL ............................14 TREXIMET ..........................19 TREZIX ................................ 24 TRIACETIN .........................53 triadvance ...........................112 triamcinolone acetonide.56, 60, 99 triamterene-hydrochlorothiazid ..........................................40 trianex ...................................56 triazolam ...............................33 TRIBENZOR ........................40 TRICARE ...........................112 TRICARE PRENATAL DHA ONE ................................ 112 tricitrates .............................101 tricon ...................................112 TRICOR ...............................43 triderm ..................................56 tri-estarylla ............................86 trifluoperazine.......................33 trifluridine .............................88 trigels-f forte .......................112 TRIGLIDE ............................43 trihexyphenidyl .....................18 tri-legest fe ............................87 TRILEPTAL .........................17 tri-linyah ...............................87 TRILIPIX .............................43 trilyte with flavor packets .....73 trimethobenzamide ...............73 trimethoprim .........................10 trimipramine .........................33 trinatal gt .............................112 trinatal rx 1 .........................112 trinate ..................................112 trinessa (28) ..........................87 TRI-NORINYL (28) .............87 triphrocaps ..........................112

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 136

TRIPLE DYE ....................... 53 triple vitamin with fluoride 113 tri-previfem (28) ................... 87 tri-sprintec (28) ..................... 87 TRISTART DHA ............... 113 tri-tabs dha .......................... 113 TRIUMEQ .............................. 4 triveen-duo dha ................... 113 triveen-prx rnf .................... 113 TRI-VI-FLOR .................... 113 tri-vit with fluoride & iron . 113 tri-vitamin with fluoride ..... 113 trivora (28)............................ 87 TRIZIVIR ............................... 4 TROKENDI XR ................... 17 tropicamide ........................... 89 trospium.............................. 100 TRUSOPT ............................ 91 trust natal dha ..................... 113 TRUVADA ............................ 4 TUDORZA PRESSAIR ....... 99 tusnel c.................................. 95 TUSNEL PEDIATRIC ......... 95 TUSSICAPS ......................... 95 tussigon................................. 95 TUSSIONEX PENNKINETIC ER ..................................... 95 TUZISTRA XR .................... 95 TWYNSTA .......................... 40 TYBOST ................................ 4 TYKERB .............................. 14 TYLENOL-CODEINE #3.... 24 TYLENOL-CODEINE #4.... 24 TYVASO .............................. 99 TYVASO REFILL KIT ....... 99 TYVASO STARTER KIT ... 99 TYZEKA ................................ 4 TYZINE ............................... 60 U UCERIS ................................ 73 U-CORT ............................... 48 UDAMIN SP ...................... 113 ULESFIA ............................. 57 ULORIC ............................... 78 ultimatecare one ................. 113 ultimatecare one nf ............. 113 ULTRACET ......................... 27 ULTRAM ............................. 27

ULTRAM ER ....................... 27 ULTRASAL-ER ................... 46 ULTRAVATE ...................... 56 ULTRAVATE X .................. 56 ULTRESA ............................ 73 umecta .................................. 48 UMECTA ............................. 48 UMECTA NAIL FILM PEN 48 UMECTA PD ....................... 48 unithroid ............................... 67 ur n-c................................... 101 URAMAXIN ........................ 48 URAMAXIN GT .................. 48 uramit mb ........................... 101 urea ....................................... 48 urea nail stick........................ 48 urea-hyaluronate sodium ...... 48 URECHOLINE .................. 100 URELLE ............................. 101 uretron d-s........................... 101 URIBEL.............................. 101 urimar-t ............................... 101 urin ds ................................. 101 uro-blue .............................. 101 UROCIT-K 10 .................... 101 UROCIT-K 15 .................... 101 UROCIT-K 5 ...................... 101 urogesic-blue ...................... 101 uro-l .................................... 102 urolet mb............................. 102 uro-mp ................................ 102 urophen mb ......................... 102 UROQID-ACID NO.2........ 102 UROXATRAL ................... 100 URSO 250 ............................ 73 URSO FORTE ...................... 73 ursodiol ................................. 73 uryl...................................... 102 ustell ................................... 102 UTA (WITH PHENYL SALICYLATE) .............. 102 utira-c.................................. 102 UTOPIC................................ 48 V VAGIFEM ............................ 81 VAGINAL CONTRACEPTIVE FILM .......................................... 82

vaginal contraceptive foam...82 valacyclovir ............................4 VALCHLOR ........................48 VALCYTE .............................4 valganciclovir .........................4 VALIUM ..............................33 valproic acid .........................17 valproic acid (as sodium salt) ..........................................17 valsartan ................................ 40 valsartan-hydrochlorothiazide ..........................................40 VALTREX .............................4 VANATOL LQ ....................24 VANCOCIN .........................10 vancomycin...........................10 vandazole ..............................82 VANOS ................................ 56 VASCEPA ............................43 VASERETIC ........................41 VASOTEC ............................41 v-c forte .............................. 113 VECAMYL ..........................44 VECTICAL ..........................46 velivet triphasic regimen (28) ..........................................87 VELPHORO .........................73 VELTIN ................................ 51 vemavite-prx-2 ...................113 vena-bal dha........................113 venlafaxine ...........................33 VENTAVIS ..........................99 VENTOLIN HFA .................99 VERAMYST ........................99 verapamil ..............................41 VERDESO ............................56 verdrocet ...............................24 VEREGEN ...........................48 VERELAN ...........................41 VERELAN PM .....................41 veripred 20 ............................61 VERSACLOZ.......................33 VESICARE.........................100 vestura (28) ...........................87 VEXOL.................................92 VFEND ...................................2 VIAGRA.............................102 VIBRAMYCIN ....................10

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 137

vic-forte .............................. 113 vicodin .................................. 24 vicodin es.............................. 24 vicodin hp ............................. 24 VICOPROFEN ..................... 24 VICTOZA 2-PAK ................ 67 VIDEX 2 GRAM PEDIATRIC ............................................ 5 VIDEX EC ............................. 5 VIEKIRA PAK ...................... 5 VIGAMOX........................... 88 VIIBRYD ............................. 33 VIMOVO ............................. 27 VIMPAT............................... 17 vinate care .......................... 113 vinate dha ........................... 113 VINATE DHA RF ............. 113 vinate ii ............................... 113 vinate m .............................. 113 vinate one ........................... 113 vinate ultra .......................... 113 VIOKACE ............................ 73 viorele (28) ........................... 87 VIRACEPT ............................ 5 VIRAMUNE .......................... 5 VIRAMUNE XR .................... 5 VIRASAL............................. 46 VIREAD ................................. 5 VIROPTIC ........................... 88 virt nate............................... 113 virt-advance ........................ 113 virt-c dha ............................ 113 VIRT-CAPS ....................... 113 virt-care one........................ 113 virt-gard .............................. 113 virt-phos 250 neutral .......... 103 virt-pn ................................. 113 virt-pn dha .......................... 113 virt-pn plus ......................... 113 VIRTPREX ........................ 114 virtrate-2 ............................. 102 virtrate-3 ............................. 102 virtrate-k ............................. 102 virt-select ............................ 114 virtussin ac............................ 95 virtussin dac.......................... 95 virt-vite ............................... 114 virt-vite forte ...................... 114

virt-vite gt ........................... 114 VIRT-VITE PLUS ............. 114 VISTARIL ............................ 94 vit 3 ..................................... 114 vit b complex-folic acid ...... 114 VITAFOL ........................... 114 VITAFOL FE+ (WITH DOCUSATE) ................. 114 VITAFOL NANO .............. 114 vitafol-ob ............................ 114 VITAFOL-OB+DHA ......... 114 VITAFOL-ONE ................. 114 VITAL-D RX ..................... 114 VITAMED MD ONE RX .. 114 VITAMED MD PLUS RX . 114 vitamin d3 ........................... 114 vitamins a,c,d & fluoride .... 114 VITAPEARL ...................... 114 VITA-RESPA..................... 114 VITEKTA ............................... 5 VITUZ .................................. 95 VIVA DHA ........................ 114 VIVELLE-DOT.................... 81 VIVOTIF BERNA VACCINE .......................................... 77 VOGELXO ........................... 64 vol-care rx........................... 114 vol-nate ............................... 114 vol-plus ............................... 114 vol-tab rx ............................ 114 VOLTAREN ........................ 27 VOLTAREN-XR.................. 27 voriconazole ........................... 2 VOSPIRE ER ....................... 99 VOTRIENT .......................... 14 vp-ch plus ........................... 114 vp-ch-pnv............................ 114 vp-ggr-b6 ............................ 114 vp-heme ob ......................... 114 vp-heme one ....................... 114 VP-PNV-DHA.................... 114 vp-vite rx ............................ 115 VUSION ............................... 53 vyfemla (28) ......................... 87 VYTORIN 10-10 .................. 44 VYTORIN 10-20 .................. 44 VYTORIN 10-40 .................. 44 VYTORIN 10-80 .................. 44

VYVANSE ...........................34 W warfarin.................................42 wee care .............................. 115 WELCHOL...........................44 WELLBUTRIN ....................34 WELLBUTRIN SR ..............34 WELLBUTRIN XL ..............34 wera (28) ...............................87 westhroid ..............................67 WIDE-SEAL DIAPHRAGM 60 ......................................79 WP THYROID .....................67 wymzya fe ............................87 X XALATAN ...........................91 XALKORI ............................14 XANAX ................................ 34 XANAX XR .........................34 XARELTO ...........................42 XARTEMIS XR ...................24 XELJANZ.............................79 XELODA ..............................14 XENAZINE ..........................20 XENICAL.............................57 XERESE ...............................53 XIFAXAN ..............................8 XIGDUO XR ........................67 XODOL 10/300 ....................24 XODOL 5/300 ......................24 XODOL 7.5/300 ...................24 XOLEGEL ............................53 XOPENEX ...........................99 XOPENEX CONCENTRATE ..........................................99 XOPENEX HFA ..................99 XTANDI ...............................14 xulane ...................................82 xylon 10 ................................ 24 XYREM ................................ 34 XYZAL.................................94 Y YASMIN (28) .......................87 YAZ (28) ..............................87 YF-VAX (PF) .......................77 Z zafirlukast .............................99 zaleplon.................................34

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 138

zamicet ................................. 24 ZANAFLEX ......................... 20 ZANTAC .............................. 75 zarah ..................................... 87 ZARONTIN ......................... 17 zatean-ch............................. 115 zatean-pn dha...................... 115 zatean-pn plus ..................... 115 ZAVESCA ........................... 64 ZEBETA............................... 41 zebutal .................................. 24 ZECUITY ............................. 19 ZEGERID ............................. 75 ZELAPAR ............................ 18 ZELBORAF ......................... 14 ZEMPLAR ........................... 64 zenatane ................................ 51 zenchent (28) ........................ 87 zenchent fe............................ 87 zencia .................................... 51 ZENPEP ............................... 73 zenzedi.................................. 34 ZENZEDI ............................. 34 zeosa ..................................... 87 ZERIT..................................... 5 ZESTORETIC ...................... 41 ZESTRIL .............................. 41 ZETIA .................................. 44 ZETONNA ........................... 99 ZIAC..................................... 41 ZIAGEN ................................. 5 ZIANA ................................. 51 zidovudine .............................. 5 zingiber ............................... 115 ZIOPTAN (PF) ..................... 91

ziprasidone hcl ...................... 34 ZIPSOR ................................ 27 ZIRGAN ............................... 88 ZITHRANOL ....................... 46 ZITHRANOL-RR ................ 46 ZITHROMAX ........................ 6 ZMAX .................................... 6 ZOCOR ................................ 44 ZODRYL AC 25 .................. 95 ZODRYL AC 30 .................. 95 ZODRYL AC 35 .................. 96 ZODRYL AC 40 .................. 96 ZODRYL AC 50 .................. 96 ZODRYL AC 60 .................. 96 ZODRYL AC 80 .................. 96 ZODRYL DAC 25 ............... 96 ZODRYL DAC 30 ............... 96 ZODRYL DAC 35 ............... 96 ZODRYL DAC 40 ............... 96 ZODRYL DAC 50 ............... 96 ZODRYL DAC 60 ............... 96 ZODRYL DAC 80 ............... 96 ZODRYL DEC 25 ................ 96 ZODRYL DEC 30 ................ 96 ZODRYL DEC 35 ................ 96 ZODRYL DEC 40 ................ 96 ZODRYL DEC 50 ................ 96 ZODRYL DEC 60 ................ 96 ZODRYL DEC 80 ................ 96 ZOFRAN (AS HYDROCHLORIDE) ...... 73 ZOFRAN ODT ..................... 73 ZOHYDRO ER .................... 24 ZOLINZA ............................. 14 zolmitriptan .......................... 19

ZOLOFT ...............................34 zolpidem ...............................34 ZOMACTON .......................75 ZOMIG .................................19 ZOMIG ZMT........................19 ZONATUSS .........................96 ZONEGRAN ........................17 zonisamide ............................17 ZONTIVITY.........................42 ZORBTIVE ..........................75 ZORTRESS ..........................14 ZORVOLEX.........................27 ZOSTAVAX (PF) ................77 zovia 1/35e (28) ....................87 zovia 1/50e (28) ....................87 ZOVIRAX ........................5, 53 Z-TUSS AC ..........................96 ZUBSOLV ............................27 ZUPLENZ ............................73 ZUTRIPRO...........................96 ZYBAN ................................ 59 ZYCLARA ...........................76 ZYDELIG .............................14 ZYFLO .................................99 ZYFLO CR ...........................99 ZYKADIA ............................14 ZYLET .................................92 ZYLOPRIM ..........................78 ZYMAXID ...........................88 ZYPREXA ............................34 ZYPREXA ZYDIS ...............34 ZYTIGA ...............................14 ZYVOX ..................................8

You can find information on what the symbols and abbreviations on this table mean by going to the beginning of this table. 139

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