2014 Florida Medicaid Comprehensive Preferred Drug List (List of Covered Drugs) WellCare of Florida 00
Please read: This document contains information about the drugs we cover in this plan. Please note that the Florida Medicaid Preferred Drug List is updated quarterly. Providers, please visit our website at https://florida.wellcare.com/provider/pharmacy to view updates to the preferred drug list. Members, please visit our website at https://florida.wellcare.com/member/default to view updates to the preferred drug list. Last updated (01/01/2014)
Florida Medicaid Cough & Cold Drug List PLEASE NOTE: The preferred cough & cold drugs on this list are covered only for members 20 years old or younger.
Non-Preferred Drugs
Preferred Drugs ANTITUSSIVES,NON-NARCOTIC Benzonatate
TESSALON 200 MG CAPSULE
BENZONATATE 100 MG CAPSULE
BENZONATATE 200 MG CAPSULE
Dextromethorphan Polistirex DELSYM 30 MG/5 ML EXTENDED-RELEASE SUSPENSION
Dextromethorphan HBr ROBITUSSIN PEDIATRIC COUGH SYP
Dextromethorphan HBr/Menthol DELSYM COUGH RELIEF PLUS LOZENGE
NON-NARC ANTITUSS-1ST GEN. ANTIHISTAMINE-DECONGEST Brompheniramine/Dextromethorphan HBr/Pseudoephedrine HCl ALLANHIST PDX DROPS BROMFED DM SYRUP
BROMHIST PDX DROPS ENDACOF-PD DROPS
BROTAPP DM LIQUID
Q-TAPP DM ELIXIR
Brophenaramine/Dextromethorphan HBr/Phenylephrine HCl COLD/COUGH CHILDRENS ELIXIR RYNEX DM
DIMAPHEN DM ELIXIR
Chlorpheniramine/Dextromethorphan HBr/Phenylephrine HCl C-PHEN DM PD-COF SYRUP
RONDEX-DM SYRUP SILDEC PE-DM SYRUP
DE-CHLOR DM LIQUID CORFEN DM
NOHIST-DM TRI-DEX PE
Chlorpheniramine/Dextromethorphan HBr/Pseudoephedrine HCl PEDIATRIC COUGH-COLD LIQUID KIDKARE COUGH/COLD
MESEHIST DM
Dexchlorpheniramine/Pseudoephedrine HCl/Chlophedianol HCl VANACOF LIQUID
Chlorpheniramine/Dextromethorphan HBr DIMETAPP LONG-ACTING COUGH LIQ
ROBITUSSIN LONG ACTING LIQUID
Promethazine HCl/Dextromethorphan HBr PROMETHAZINE-DM SYRUP
NON-NARC ANTITUSS-1ST GEN. ANTIHIST-ANALGESIC COMBINATION Dextromethorphan HBr/Acetaminophen/Doxylamine DELSYM NIGHTTIME MULTI-SYMPTOM
EXPECTORANTS DECONGESTANT-EXPECTORANT COMBINATIONS Guaifenesin/Phenylephrine HCl DONATUSSIN DROPS
PE-GUAI DROPS
DESPEC LIQUID
RESCON-GG LIQUID
NON-NARCOTIC DECONGESTANT-EXPECTORANT-ANTITUSSIVE Guaifenesin/Dextromethorphan HBr/Phenylephreine ROBAFEN CF SYRUP
Last updated 01/01/14
Page 1 of 2
Florida Medicaid Cough & Cold Drug List PLEASE NOTE: The preferred cough & cold drugs on this list are covered only for members 20 years old or younger.
Non-Preferred Drugs Preferred Drugs NON-NARCOTIC ANTITUSSIVE AND EXPECTORANT COMB. Dextromethorphan HBr/Guaifenesin DURATUSS DM ELIXIR SIMUC-DM ELIXIR
SU-TUSS DM ELIXIR
MUCUS RELIEF COUGH LIQUID DIABETIC TUSSIN DM LIQUID GUAIFENESIN DM SYRUP Q-TUSSIN-DM SYRUP EXTRA ACTION COUGH SILTUSSIN DM COUGH SYRUP REFENESEN DM SILTUSSIN DM DAS COUGH SYRUP MUCOSA DM ROBITUSSIN COUGH CHEST CONGESTION DM LIQUID
NARCOTIC ANTITUSSIVE-1ST GENERATION ANTIHISTAMINE Chlorpheniramine/Hydrocodone Polistirex TUSSIONEX PENNKINETIC SUSP
TUSSICAPS (min. age 6 years old)
HYDROCODONE-CHLORPHENIRAMINE SUSPENSION (min. age 6 years old)
Codeine Phosphate/Promethazine HCl PROMETHAZINE-CODEINE SYRUP (min. age 6 years old)
NARCOTIC ANTITUSSIVE-1ST GEN. ANTIHISTAMINE-DECONGESTANT Dexbrompheniramine/Hydrocodone Bit/Phenylephrine HCl CYTUSS-HC NR SYRUP HC 2.5-PE 5-DBROM 1 MG SYRUP
HC/PE/DBROM SYRUP
Codeine/Phenylephrine HCl/Promethazine PROMETH VC W/COD SYRUP
PROMETHAZINE VC/COD SYRUP
Pseudoephedrine HCl/Codeine/Chlorpheniramine PHENYLHISTINE DH
NARCOTIC ANTITUSSIVE-ANTICHOLINERGIC COMBINATION Hydrocodone Bit/Homatropine HYDROCODONE-HOMATROPINE
HYDROMET SYRUP
NARCOTIC ANTITUSSIVE-EXPECTORANT COMBINATION Guaifenesin/Hydrocodone Bit HYDROCODONE-GUAIFENESIN SYRUP NARCOF SYRUP
Codeine Phosphate/Guaifenesin
TUSSICLEAR DH SYRUP
CHERATUSSIN AC SYRUP GUAIFENESIN-CODEINE SYRUP
IOPHEN C-NR
NARCOTIC ANTITUSSIVE-DECONGESTANT-EXPECTORANT COMBINATIONS Codeine Phosphate/Guaifenesin/Pseudoephedrine HCl CHERATUSSIN DAC SYRUP
Last updated 01/01/14
Page 2 of 2
Vaccines: Vaccines are covered under the Vaccines for Children program for members through 18 years of age. Coverage beyond the age of 18 is evaluated through the PA process.
UPPERCASE = Brand name drugs italics = Generic drugs
Drug Name
Preference Details P = Preferred Dagger (†) = N/A Asterisk (*) = N/A Asterisk (**) = N/A Asterisk (***) = N/A XX = N/A
Coverage Details PA = Prior Authorization ST = Step Therapy QL = Quantity Limit AL = Age Limit OTC = OTC- Covered w/Rx
Preference Details Coverage Details
*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexia nts* *Amphetamines** *Amphetamine Mixtures*** ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG
P
Amphetamine-Dextroamphetamine ORAL TABLET 10 MG, 12.5 MG, 15 MG, 5 MG, 7.5 MG
P
Amphetamine-Dextroamphetamine ORAL TABLET 20 MG
P
QL (93 EA per 31 day(s))
Amphetamine-Dextroamphetamine ORAL TABLET 30 MG
P
QL (62 EA per 31 day(s))
QL (62 EA per 31 day(s)); AL (Min 5 Years and Max 20 Years)
*Amphetamines*** Dextroamphetamine Sulfate ORAL TABLET 10 MG, 5 MG
P
Dextroamphetamine Sulfate ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 5 MG
P
ST; QL (31 EA per 31 Day(s)); AL (Min 5 Years and Max 20 Years)
VYVANSE ORAL CAPSULE 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG
P
QL (31 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years)
*Stimulants - Misc.**
1
Drug Name
Preference Details Coverage Details
*Stimulants - Misc.*** Dexmethylphenidate HCl ORAL TABLET 10 MG, 2.5 MG, 5 MG
P
QL (62 EA per 31 day(s)); AL (Min 6 Years)
METHYLIN ORAL TABLET CHEWABLE 10 MG, 2.5 MG, 5 MG
P
AL (Min 6 Years)
Methylphenidate HCl ORAL TABLET 10 MG, 5 MG
P
AL (Min 6 Years)
Methylphenidate HCl ORAL TABLET 20 MG
P
QL (93 EA per 31 Day(s)); AL (Min 6 Years)
Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 10 MG
P
AL (Min 6 Years)
Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 18 MG, 27 MG, 36 MG
P
QL (62 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years)
Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 20 MG
P
QL (93 EA per 31 day(s)); AL (Min 6 Years)
Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 54 MG
P
QL (31 EA per 31 day(s)); AL (Min 6 Years and Max 20 Years)
Melatonin ORAL TABLET 5 MG
P
OTC
Melatonin Maximum Strength ORAL TABLET 5 MG
P
OTC
P
PA
HUMIRA SUBCUTANEOUS* KIT 20 MG/0.4ML, 40 MG/0.8ML
P
PA
HUMIRA PEN SUBCUTANEOUS* KIT 40 MG/0.8ML
P
PA
HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* KIT 40 MG/0.8ML
P
PA
*Alternative Medicines* *Alternative Medicine - M's** *Alternative Medicine - Me's***
*Aminoglycosides* *Aminoglycosides** *Aminoglycosides*** TOBI INHALATION NEBULIZATION SOLUTION 300 MG/5ML *Analgesics - Anti-Inflammatory* *Anti-Tnf-Alpha - Monoclonal Antibodies** *Anti-Tnf-Alpha - Monoclonal Antibodies***
2
Drug Name SIMPONI SUBCUTANEOUS* SOLUTION 100 MG/ML, 50 MG/0.5ML
Preference Details Coverage Details P
PA
*Gold Compounds** *Gold Compounds*** RIDAURA ORAL CAPSULE 3 MG
P
*Nonsteroidal Anti-Inflammatory Agents (Nsaids)** *Cyclooxygenase 2 (Cox-2) Inhibitors*** CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, 50 MG
P
ST; QL (31 EA per 31 day(s))
Childrens Ibuprofen ORAL SUSPENSION 40 MG/ML
P
OTC
Diclofenac Potassium ORAL TABLET 50 MG
P
Diclofenac Sodium ORAL TABLET DELAYED RELEASE 25 MG, 50 MG, 75 MG
P
Diclofenac Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG
P
Etodolac ORAL CAPSULE 200 MG, 300 MG
P
Etodolac ORAL TABLET 400 MG, 500 MG
P
Fenoprofen Calcium ORAL TABLET 600 MG
P
Flurbiprofen ORAL TABLET 100 MG, 50 MG
P
Ibuprofen ORAL SUSPENSION 100 MG/5ML
P
OTC
Ibuprofen ORAL TABLET 200 MG
P
OTC
Ibuprofen ORAL TABLET 400 MG, 600 MG, 800 MG
P
Indomethacin ORAL CAPSULE 25 MG, 50 MG
P
Ketoprofen ORAL CAPSULE 50 MG, 75 MG
P
Ketorolac Tromethamine ORAL TABLET 10 MG
P
Meloxicam ORAL TABLET 15 MG, 7.5 MG
P
Nabumetone ORAL TABLET 500 MG, 750 MG
P
Naproxen ORAL SUSPENSION 125 MG/5ML
P
*Nonsteroidal Anti-Inflammatory Agents (Nsaids)***
QL (20 EA per 31 day(s))
QL (2000 ML per 31 day(s))
3
Drug Name
Preference Details Coverage Details
Naproxen ORAL TABLET 250 MG, 375 MG, 500 MG
P
Naproxen DR ORAL TABLET DELAYED RELEASE 500 MG
P
Naproxen Sodium ORAL TABLET 275 MG, 550 MG
P
Oxaprozin ORAL TABLET 600 MG
P
Piroxicam ORAL CAPSULE 10 MG, 20 MG
P
Sulindac ORAL TABLET 150 MG, 200 MG
P
Tolmetin Sodium ORAL CAPSULE 400 MG
P
*Pyrimidine Synthesis Inhibitors** *Pyrimidine Synthesis Inhibitors*** Leflunomide ORAL TABLET 10 MG, 20 MG
P
*Analgesics - Nonnarcotic* *Analgesic Combinations** *Analgesics-Sedatives*** Butalbital-Acetaminophen ORAL TABLET 50-325 MG
P
QL (186 EA per 31 day(s))
Butalbital-APAP-Caffeine ORAL CAPSULE 50-325-40 MG
P
QL (186 EA per 31 day(s))
Butalbital-APAP-Caffeine ORAL TABLET 50-325-40 MG, 50-500-40 MG
P
QL (186 EA per 31 day(s))
Butalbital-ASA-Caffeine ORAL CAPSULE 50-325-40 MG
P
TENCON ORAL TABLET 50-650 MG
P
QL (124 EA per 31 day(s))
ZEBUTAL ORAL CAPSULE 50-500-40 MG
P
QL (186 EA per 31 day(s))
Acetaminophen ORAL SOLUTION 160 MG/5ML
P
OTC
Acetaminophen ORAL TABLET 325 MG
P
OTC; QL (279 EA per 31 day(s))
Acetaminophen ORAL TABLET 500 MG
P
OTC; QL (186 EA per 31 day(s))
Mapap ORAL LIQUID† 160 MG/5ML
P
OTC
Mapap Infants ORAL SUSPENSION 160 MG/5ML
P
OTC
Pain & Fever Childrens ORAL SOLUTION 160 MG/5ML
P
OTC
*Analgesics Other** *Analgesics Other***
*Salicylates** 4
Drug Name
Preference Details Coverage Details
*Salicylate Combinations*** Choline & Mag Trisalicylate ORAL TABLET 1000 MG
P
Choline-Mag Trisalicylate ORAL LIQUID† 500 MG/5ML
P
*Salicylates*** Aspirin ORAL TABLET 325 MG, 81 MG
P
OTC
Aspirin ORAL TABLET CHEWABLE 81 MG
P
OTC
Aspirin RE SUPPOSITORY 300 MG, 600 MG
P
OTC
Aspirin Low Dose ORAL TABLET 81 MG
P
OTC
Diflunisal ORAL TABLET 500 MG
P
Salsalate ORAL TABLET 500 MG, 750 MG
P
*Analgesics - Opioid* *Opioid Agonists** *Opioid Agonists*** Codeine Phosphate INJECTION SOLUTION 15 MG/ML, 30 MG/ML
P
Codeine Sulfate ORAL TABLET 15 MG, 30 MG, 60 MG
P
QL (248 EA per 31 day(s))
FentaNYL TRANSDERMAL PATCH 72 HR 100 MCG/HR, 12 MCG/HR, 25 MCG/HR, 50 MCG/HR, 75 MCG/HR
P
PA; QL (10 EA per 30 day(s))
HYDROmorphone HCl ORAL LIQUID† 1 MG/ML
P
HYDROmorphone HCl ORAL TABLET 2 MG, 4 MG, 8 MG
P
HYDROmorphone HCl RE SUPPOSITORY 3 MG
P
Methadone HCl ORAL SOLUTION 10 MG/5ML, 5 MG/5ML
P
Methadone HCl ORAL TABLET 10 MG, 5 MG
P
QL (248 EA per 31 day(s))
METHADOSE ORAL TABLET 10 MG
P
QL (248 EA per 31 day(s))
Morphine Sulfate INJECTION SOLUTION 10 MG/ML, 15 MG/ML, 5 MG/ML, 8 MG/ML
P
Morphine Sulfate INTRAVENOUS* SOLUTION 1 MG/ML, 25 MG/ML, 50 MG/ML
P
QL (248 EA per 31 day(s))
5
Drug Name
Preference Details Coverage Details
Morphine Sulfate ORAL SOLUTION 10 MG/5ML, 20 MG/5ML
P
Morphine Sulfate ORAL TABLET 15 MG, 30 MG
P
Morphine Sulfate RE SUPPOSITORY 10 MG, 20 MG, 30 MG, 5 MG
P
Morphine Sulfate (Concentrate) ORAL SOLUTION 20 MG/ML
P
Morphine Sulfate (PF) INJECTION SOLUTION 0.5 MG/ML
P
Morphine Sulfate (PF) INTRAVENOUS* SOLUTION 8 MG/ML
P
Morphine Sulfate ER ORAL TABLET EXTENDEDRELEASE* 100 MG, 15 MG, 200 MG, 30 MG, 60 MG
P
QL (248 EA per 31 day(s))
OxyCODONE HCl ORAL CAPSULE 5 MG
P
QL (248 EA per 31 day(s))
OxyCODONE HCl ORAL SOLUTION 5 MG/5ML
P
OxyCODONE HCl ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG
P
OxyCODONE HCl ORAL TABLET 30 MG
P
TraMADol HCl ORAL TABLET 50 MG
P
QL (248 EA per 31 day(s))
QL (248 EA per 31 day(s))
QL (248 EA per 31 day(s))
*Opioid Combinations** *Codeine Combinations*** Acetaminophen-Codeine ORAL SOLUTION 120-12 MG/5ML
P
Acetaminophen-Codeine #2 ORAL TABLET 300-15 MG
P
QL (248 EA per 31 day(s))
Acetaminophen-Codeine #3 ORAL TABLET 300-30 MG
P
QL (248 EA per 31 day(s))
Acetaminophen-Codeine #4 ORAL TABLET 300-60 MG
P
QL (248 EA per 31 day(s))
ASCOMP-CODEINE ORAL CAPSULE 50-325-40-30 MG
P
Butalbital-APAP-Caff-Cod ORAL CAPSULE 50-325-40-30 MG
P
Butalbital-ASA-Caff-Codeine ORAL CAPSULE 50-325-40-30 MG
P
*Hydrocodone Combinations***
6
QL (186 EA per 31 day(s))
Drug Name
Preference Details Coverage Details
Hydrocodone-Acetaminophen ORAL SOLUTION 7.5-325 MG/15ML, 7.5-500 MG/15ML
P
QL (3720 ML per 31 day(s))
Hydrocodone-Acetaminophen ORAL TABLET 10-325 MG, 10-500 MG, 10-650 MG, 10-660 MG, 10-750 MG, 2.5-500 MG, 5-325 MG, 5-500 MG, 7.5-325 MG, 7.5-500 MG, 7.5-650 MG, 7.5-750 MG
P
QL (248 EA per 31 day(s))
Hydrocodone-Ibuprofen ORAL TABLET 7.5-200 MG
P
QL (155 EA per 31 day(s))
HYDROGESIC ORAL CAPSULE 5-500 MG
P
QL (248 EA per 31 day(s))
ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG, 7.5-500 MG
P
QL (248 EA per 31 day(s))
ENDOCET ORAL TABLET 10-650 MG
P
QL (186 EA per 31 day(s))
Oxycodone-Acetaminophen ORAL CAPSULE 5-500 MG
P
QL (248 EA per 31 day(s))
Oxycodone-Acetaminophen ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG, 7.5-500 MG
P
QL (248 EA per 31 day(s))
Oxycodone-Acetaminophen ORAL TABLET 10-650 MG
P
QL (186 EA per 31 day(s))
Oxycodone-Aspirin ORAL TABLET 4.8355-325 MG
P
QL (186 EA per 31 day(s))
ROXICET ORAL TABLET 5-325 MG
P
QL (248 EA per 31 day(s))
Buprenorphine HCl SUBLINGUAL TABLET SUBLINGUAL 2 MG, 8 MG
P
PA
Butorphanol Tartrate NASAL SOLUTION 10 MG/ML
P
QL (3 ML per 31 day(s))
Pentazocine-Naloxone HCl ORAL TABLET 50-0.5 MG
P
SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG, 8-2 MG
P
PA
P
PA
*Opioid Combinations***
*Opioid Partial Agonists** *Opioid Partial Agonists***
*Androgens-Anabolic* *Anabolic Steroids** *Anabolic Steroids*** Oxandrolone ORAL TABLET 10 MG, 2.5 MG *Androgens** 7
Drug Name
Preference Details Coverage Details
*Androgens*** Danazol ORAL CAPSULE 100 MG, 200 MG, 50 MG
P
Methitest ORAL TABLET 10 MG
P
TESTIM TRANSDERMAL GEL 50 MG/5GM
P
Testosterone Cypionate INTRAMUSCULAR* OIL 100 MG/ML, 200 MG/ML
P
Testosterone Enanthate INTRAMUSCULAR* OIL 200 MG/ML
P
PA
*Anorectal Agents* *Intrarectal Steroids** *Intrarectal Steroids*** Hydrocortisone RE ENEMA 100 MG/60ML
P
*Rectal Steroids** *Rectal Steroids*** PROCTOSOL HC RE CREAM 2.5 %
P
PROCTOZONE-HC RE CREAM 2.5 %
P
*Antacids* *Antacids - Aluminum Salts** *Antacids - Aluminum Salts*** Aluminum Hydroxide Gel ORAL SUSPENSION 320 MG/5ML
P
OTC
P
OTC
P
OTC
ALBENZA ORAL TABLET 200 MG
P
PA
BILTRICIDE ORAL TABLET 600 MG
P
PA
*Antacids - Calcium Salts** *Antacids - Calcium Salts*** Calcium Carbonate Antacid ORAL TABLET CHEWABLE 500 MG *Antacids - Magnesium Salts** *Antacids - Magnesium Salts*** Magnesium Oxide ORAL TABLET 250 MG, 400 MG, 420 MG *Anthelmintics* *Anthelmintics** *Anthelmintics***
8
Drug Name
Preference Details Coverage Details
Reeses Pinworm Medicine ORAL SUSPENSION 144 MG/ML
P
OTC
STROMECTOL ORAL TABLET 3 MG
P
QL (10 EA per 31 day(s))
*Antianginal Agents* *Nitrates** *Nitrates*** Isosorbide Dinitrate ORAL TABLET 10 MG, 20 MG, 30 MG, 5 MG
P
Isosorbide Dinitrate ER ORAL TABLET EXTENDEDRELEASE* 40 MG
P
Isosorbide Mononitrate ORAL TABLET 10 MG, 20 MG
P
Isosorbide Mononitrate ER ORAL TABLET EXTENDED RELEASE 24 HR* 120 MG, 30 MG, 60 MG
P
NITRO-BID TRANSDERMAL OINTMENT 2 %
P
Nitroglycerin TRANSDERMAL PATCH 24 HR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR
P
NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG
P
*Antianxiety Agents* *Antianxiety Agents - Misc.** *Antianxiety Agents - Misc.*** BusPIRone HCl ORAL TABLET 10 MG, 15 MG, 30 MG, 5 MG, 7.5 MG
P
HydrOXYzine HCl ORAL SOLUTION 10 MG/5ML
P
QL (450 ML per 31 day(s))
HydrOXYzine HCl ORAL SYRUP 10 MG/5ML
P
QL (450 ML per 31 day(s))
HydrOXYzine HCl ORAL TABLET 10 MG, 25 MG, 50 MG
P
HydrOXYzine Pamoate ORAL CAPSULE 100 MG, 25 MG, 50 MG
P
Meprobamate ORAL TABLET 200 MG, 400 MG
P
*Benzodiazepines** *Benzodiazepines***
9
Drug Name
Preference Details Coverage Details
ALPRAZolam ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG
P
ChlordiazePOXIDE HCl ORAL CAPSULE 10 MG, 25 MG, 5 MG
P
Clorazepate Dipotassium ORAL TABLET 15 MG, 3.75 MG, 7.5 MG
P
Diazepam INJECTION SOLUTION 5 MG/ML
P
Diazepam ORAL SOLUTION 1 MG/ML
P
Diazepam ORAL TABLET 10 MG, 2 MG, 5 MG
P
LORazepam INJECTION SOLUTION 2 MG/ML, 4 MG/ML
P
LORazepam ORAL TABLET 0.5 MG, 1 MG, 2 MG
P
Oxazepam ORAL CAPSULE 10 MG, 15 MG, 30 MG
P
*Antiarrhythmics* *Antiarrhythmics Type I-A** *Antiarrhythmics Type I-A*** Disopyramide Phosphate ORAL CAPSULE 100 MG, 150 MG
P
Procainamide HCl INJECTION SOLUTION 100 MG/ML, 500 MG/ML
P
QuiNIDine Gluconate INJECTION SOLUTION 80 MG/ML
P
QuiNIDine Gluconate ER ORAL TABLET EXTENDEDRELEASE* 324 MG
P
QuiNIDine Sulfate ORAL TABLET 300 MG
P
*Antiarrhythmics Type I-B** *Antiarrhythmics Type I-B*** Lidocaine HCl (Cardiac) INTRAVENOUS* SOLUTION 20 MG/ML
P
Mexiletine HCl ORAL CAPSULE 150 MG, 200 MG, 250 MG
P
*Antiarrhythmics Type I-C** *Antiarrhythmics Type I-C*** Flecainide Acetate ORAL TABLET 100 MG, 150 MG, 50 MG
10
P
AL (Min 9 Years)
QL (1240 ML per 31 day(s))
Drug Name Propafenone HCl ORAL TABLET 150 MG, 225 MG, 300 MG
Preference Details Coverage Details P
*Antiarrhythmics Type Iii** *Antiarrhythmics Type Iii*** Amiodarone HCl INTRAVENOUS* SOLUTION 150 MG/3ML
P
Amiodarone HCl ORAL TABLET 200 MG, 400 MG
P
PACERONE ORAL TABLET 200 MG, 400 MG
P
*Antiasthmatic And Bronchodilator Agents* *Antiasthmatic - Monoclonal Antibodies** *Anti-Ige Monoclonal Antibodies*** XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG
P
PA
*Anti-Inflammatory Agents** *Anti-Inflammatory Agents*** Cromolyn Sodium INHALATION NEBULIZATION SOLUTION 20 MG/2ML
P
*Bronchodilators - Anticholinergics** *Bronchodilators - Anticholinergics*** ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT
P
QL (25.8 GM per 31 day(s))
Ipratropium Bromide INHALATION SOLUTION 0.02 %
P
QL (480 ML per 31 day(s))
TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT
P
QL (1 EA per 30 day(s))
*Leukotriene Modulators** *Leukotriene Receptor Antagonists*** Montelukast Sodium ORAL PACKET 4 MG
P
Montelukast Sodium ORAL TABLET 10 MG
P
Montelukast Sodium ORAL TABLET CHEWABLE 4 MG, 5 MG
P
Zafirlukast ORAL TABLET 10 MG, 20 MG
P
*Steroid Inhalants** *Steroid Inhalants***
11
Drug Name
Preference Details Coverage Details
ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH
P
ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH
P
ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH
P
QL (1 EA per 30 day(s))
ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH
P
QL (1 EA per 30 day(s))
ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 110 MCG/INH
P
Budesonide INHALATION SUSPENSION 0.25 MG/2ML, 0.5 MG/2ML
P
QL (120 ML per 31 day(s)); AL (Max 8 Years)
FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST
P
QL (60 EA per 30 day(s))
FLOVENT HFA INHALATION AEROSOL† 110 MCG/ACT, 220 MCG/ACT
P
QL (12 GM per 30 day(s))
FLOVENT HFA INHALATION AEROSOL† 44 MCG/ACT
P
QL (10.6 GM per 30 day(s))
PULMICORT INHALATION SUSPENSION 1 MG/2ML
P
QL (120 ML per 31 day(s)); AL (Max 8 Years)
QVAR INHALATION AEROSOL, SOLUTION 40 MCG/ACT
P
QL (8.7 GM per 30 day(s))
QVAR INHALATION AEROSOL, SOLUTION 80 MCG/ACT
P
QL (17.4 GM per 30 day(s))
ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE
P
QL (60 EA per 30 day(s))
ADVAIR HFA INHALATION AEROSOL† 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT
P
QL (12 GM per 30 day(s))
QL (1 EA per 30 day(s))
*Sympathomimetics** *Adrenergic Combinations***
12
Drug Name
Preference Details Coverage Details
COMBIVENT INHALATION AEROSOL† 18-103 MCG/ACT
P
QL (29.4 GM per 31 day(s))
COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION 20-100 MCG/ACT
P
QL (4 GM per 20 day(s))
DULERA INHALATION AEROSOL† 100-5 MCG/ACT, 200-5 MCG/ACT
P
QL (13 GM per 30 day(s))
Ipratropium-Albuterol INHALATION SOLUTION 0.5-2.5 (3) MG/3ML
P
QL (720 ML per 31 day(s))
SYMBICORT INHALATION AEROSOL† 160-4.5 MCG/ACT, 80-4.5 MCG/ACT
P
QL (10.2 GM per 30 day(s))
Albuterol Sulfate INHALATION NEBULIZATION SOLUTION (2.5 MG/3ML) 0.083%
P
QL (720 ML per 31 day(s))
Albuterol Sulfate INHALATION NEBULIZATION SOLUTION (5 MG/ML) 0.5%
P
QL (60 ML per 30 day(s))
Albuterol Sulfate INHALATION NEBULIZATION SOLUTION 0.63 MG/3ML, 1.25 MG/3ML
P
QL (300 ML per 31 day(s))
Albuterol Sulfate ORAL SYRUP 2 MG/5ML
P
QL (2480 ML per 31 day(s))
Albuterol Sulfate ORAL TABLET 2 MG, 4 MG
P
FORADIL AEROLIZER INHALATION CAPSULE 12 MCG
P
Metaproterenol Sulfate ORAL SYRUP 10 MG/5ML
P
SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 50 MCG/DOSE
P
Terbutaline Sulfate INJECTION SOLUTION 1 MG/ML
P
Terbutaline Sulfate ORAL TABLET 2.5 MG, 5 MG
P
VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT
P
*Beta Adrenergics***
QL (60 EA per 30 day(s))
QL (60 EA per 30 day(s))
QL (36 GM per 31 day(s))
*Xanthines** *Xanthines*** Aminophylline INTRAVENOUS* SOLUTION 25 MG/ML
P 13
Drug Name
Preference Details Coverage Details
ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML
P
Theophylline ORAL SOLUTION 80 MG/15ML
P
Theophylline ER ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG, 200 MG, 300 MG, 450 MG
P
Theophylline ER ORAL TABLET EXTENDED RELEASE 24 HR* 400 MG, 600 MG
P
*Anticoagulants* *Coumarin Anticoagulants** *Coumarin Anticoagulants*** JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG
P
Warfarin Sodium ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG
P
*Direct Factor Xa Inhibitors** *Direct Factor Xa Inhibitors*** XARELTO ORAL TABLET 10 MG
P
QL (35 EA per 365 day(s))
Enoxaparin Sodium INJECTION SOLUTION 300 MG/3ML
P
QL (24 ML per 31 day(s))
Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 100 MG/ML, 150 MG/ML
P
QL (28 ML per 31 day(s))
Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 120 MG/0.8ML, 80 MG/0.8ML
P
QL (22.4 ML per 31 day(s))
Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 30 MG/0.3ML, 40 MG/0.4ML
P
QL (8.4 ML per 31 day(s))
Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 60 MG/0.6ML
P
QL (16.8 ML per 31 day(s))
Fondaparinux Sodium SUBCUTANEOUS* SOLUTION 10 MG/0.8ML
P
QL (11.2 ML per 31 day(s))
Fondaparinux Sodium SUBCUTANEOUS* SOLUTION 2.5 MG/0.5ML
P
QL (16 ML per 31 day(s))
*Heparins And Heparinoid-Like Agents** *Low Molecular Weight Heparins***
*Synthetic Heparinoid-Like Agents***
14
Drug Name
Preference Details Coverage Details
Fondaparinux Sodium SUBCUTANEOUS* SOLUTION 5 MG/0.4ML
P
QL (5.6 ML per 31 day(s))
Fondaparinux Sodium SUBCUTANEOUS* SOLUTION 7.5 MG/0.6ML
P
QL (8.4 ML per 31 day(s))
*Anticonvulsants* *Anticonvulsants - Benzodiazepines** *Anticonvulsants - Benzodiazepines*** ClonazePAM ORAL TABLET 0.5 MG, 1 MG, 2 MG
P
Diazepam RE GEL 10 MG, 2.5 MG, 20 MG
P
QL (3 EA per 31 day(s))
CarBAMazepine ORAL SUSPENSION 100 MG/5ML
P
QL (2480 ML per 31 day(s))
CarBAMazepine ORAL TABLET 200 MG
P
QL (248 EA per 31 day(s))
CarBAMazepine ORAL TABLET CHEWABLE 100 MG
P
QL (310 EA per 31 day(s))
EPITOL ORAL TABLET 200 MG
P
QL (248 EA per 31 day(s))
Gabapentin ORAL CAPSULE 100 MG
P
QL (310 EA per 31 day(s))
Gabapentin ORAL CAPSULE 300 MG
P
QL (372 EA per 31 day(s))
Gabapentin ORAL CAPSULE 400 MG
P
QL (279 EA per 31 day(s))
Gabapentin ORAL SOLUTION 250 MG/5ML
P
QL (2230 ML per 31 day(s))
Gabapentin ORAL TABLET 600 MG, 800 MG
P
LamoTRIgine ORAL TABLET 100 MG, 150 MG, 200 MG
P
LamoTRIgine ORAL TABLET 25 MG
P
QL (310 EA per 31 day(s))
LamoTRIgine ORAL TABLET CHEWABLE 25 MG, 5 MG
P
QL (310 EA per 31 day(s))
LevETIRAcetam INTRAVENOUS* SOLUTION 500 MG/5ML
P
LevETIRAcetam ORAL SOLUTION 100 MG/ML
P
LevETIRAcetam ORAL TABLET 1000 MG, 500 MG, 750 MG
P
LevETIRAcetam ORAL TABLET 250 MG
P
QL (372 EA per 31 day(s))
OXcarbazepine ORAL SUSPENSION 300 MG/5ML
P
QL (1240 ML per 31 day(s))
OXcarbazepine ORAL TABLET 150 MG
P
QL (310 EA per 31 day(s))
*Anticonvulsants - Misc.** *Anticonvulsants - Misc.***
QL (1000 ML per 31 day(s))
15
Drug Name
Preference Details Coverage Details
OXcarbazepine ORAL TABLET 300 MG
P
QL (248 EA per 31 day(s))
OXcarbazepine ORAL TABLET 600 MG
P
Primidone ORAL TABLET 250 MG
P
QL (248 EA per 31 day(s))
Primidone ORAL TABLET 50 MG
P
QL (310 EA per 31 day(s))
Topiramate ORAL CAPSULE SPRINKLE 15 MG, 25 MG
P
QL (310 EA per 31 day(s))
Topiramate ORAL TABLET 100 MG, 25 MG, 50 MG
P
QL (310 EA per 31 day(s))
Topiramate ORAL TABLET 200 MG
P
QL (248 EA per 31 day(s))
Zonisamide ORAL CAPSULE 100 MG
P
QL (186 EA per 31 day(s))
Zonisamide ORAL CAPSULE 25 MG
P
QL (310 EA per 31 day(s))
Zonisamide ORAL CAPSULE 50 MG
P
QL (372 EA per 31 day(s))
*Gaba Modulators** *Gaba Modulators*** GABITRIL ORAL TABLET 12 MG, 16 MG
P
TiaGABine HCl ORAL TABLET 2 MG, 4 MG
P
*Hydantoins** *Hydantoins*** DILANTIN ORAL CAPSULE 30 MG
P
QL (310 EA per 31 day(s))
Fosphenytoin Sodium INJECTION SOLUTION 100 MG PE/2ML
P
PEGANONE ORAL TABLET 250 MG
P
QL (372 EA per 31 day(s))
Phenytoin ORAL SUSPENSION 125 MG/5ML
P
QL (930 ML per 31 day(s))
Phenytoin ORAL TABLET CHEWABLE 50 MG
P
QL (372 EA per 31 day(s))
Phenytoin Sodium INJECTION SOLUTION 50 MG/ML
P
Phenytoin Sodium Extended ORAL CAPSULE 100 MG, 200 MG, 300 MG
P
*Succinimides** *Succinimides*** Ethosuximide ORAL CAPSULE 250 MG
P
Ethosuximide ORAL SOLUTION 250 MG/5ML
P
*Valproic Acid** *Valproic Acid***
16
QL (930 ML per 31 day(s))
Drug Name
Preference Details Coverage Details
Divalproex Sodium ORAL CAPSULE SPRINKLE 125 MG
P
QL (310 EA per 31 day(s))
Divalproex Sodium ORAL TABLET DELAYED RELEASE 125 MG, 250 MG
P
QL (310 EA per 31 day(s))
Divalproex Sodium ORAL TABLET DELAYED RELEASE 500 MG
P
QL (279 EA per 31 day(s))
Divalproex Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 250 MG
P
QL (310 EA per 31 day(s))
Divalproex Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 500 MG
P
QL (279 EA per 31 day(s))
Valproic Acid ORAL CAPSULE 250 MG
P
QL (310 EA per 31 day(s))
Valproic Acid ORAL SOLUTION 250 MG/5ML
P
QL (2790 ML per 31 day(s))
Valproic Acid ORAL SYRUP 250 MG/5ML
P
QL (2790 ML per 31 day(s))
*Antidepressants* *Alpha-2 Receptor Antagonists (Tetracyclics)** *Alpha-2 Receptor Antagonists (Tetracyclics)*** Mirtazapine ORAL TABLET 15 MG, 30 MG, 45 MG, 7.5 MG
P
Mirtazapine ORAL TABLET DISPERSIBLE 15 MG, 30 MG, 45 MG
P
*Antidepressants - Misc.** *Antidepressants - Misc.*** BUDEPRION SR ORAL TABLET EXTENDED RELEASE 12 HR* 150 MG
P
BuPROPion HCl ORAL TABLET 100 MG, 75 MG
P
BuPROPion HCl ER (SR) ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG, 150 MG, 200 MG
P
BuPROPion HCl ER (XL) ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 300 MG
P
Maprotiline HCl ORAL TABLET 25 MG, 50 MG, 75 MG
P
*Modified Cyclics** *Modified Cyclics*** Nefazodone HCl ORAL TABLET 100 MG, 150 MG, 200 MG, 250 MG, 50 MG
P 17
Drug Name TraZODone HCl ORAL TABLET 100 MG, 150 MG, 50 MG
Preference Details Coverage Details P
*Monoamine Oxidase Inhibitors (Maois)** *Monoamine Oxidase Inhibitors (Maois)*** Phenelzine Sulfate ORAL TABLET 15 MG
P
Tranylcypromine Sulfate ORAL TABLET 10 MG
P
*Selective Serotonin Reuptake Inhibitors (Ssris)** *Selective Serotonin Reuptake Inhibitors (Ssris)*** Citalopram Hydrobromide ORAL TABLET 10 MG, 20 MG, 40 MG
P
Escitalopram Oxalate ORAL TABLET 10 MG, 20 MG, 5 MG
P
FLUoxetine HCl ORAL CAPSULE 10 MG, 20 MG, 40 MG
P
FLUoxetine HCl ORAL SOLUTION 20 MG/5ML
P
FLUoxetine HCl ORAL TABLET 10 MG, 20 MG
P
FluvoxaMINE Maleate ORAL TABLET 100 MG, 25 MG, 50 MG
P
PARoxetine HCl ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG
P
Sertraline HCl ORAL TABLET 100 MG, 25 MG, 50 MG
P
*Serotonin-Norepinephrine Reuptake Inhibitors (Snris)** *Serotonin-Norepinephrine Reuptake Inhibitors (Snris)*** Venlafaxine HCl ORAL TABLET 100 MG, 25 MG, 37.5 MG, 50 MG, 75 MG
P
Venlafaxine HCl ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 150 MG, 37.5 MG, 75 MG
P
*Tricyclic Agents** *Tricyclic Agents*** Amitriptyline HCl ORAL TABLET 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 MG 18
P
QL (31 EA per 31 day(s))
Drug Name
Preference Details Coverage Details
Amoxapine ORAL TABLET 100 MG, 150 MG, 25 MG, 50 MG
P
ClomiPRAMINE HCl ORAL CAPSULE 25 MG, 50 MG, 75 MG
P
Desipramine HCl ORAL TABLET 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 MG
P
Doxepin HCl ORAL CAPSULE 10 MG, 100 MG, 25 MG, 50 MG, 75 MG
P
Doxepin HCl ORAL CONCENTRATE 10 MG/ML
P
Imipramine HCl ORAL TABLET 10 MG, 25 MG, 50 MG
P
Nortriptyline HCl ORAL CAPSULE 10 MG, 25 MG, 50 MG, 75 MG
P
Nortriptyline HCl ORAL SOLUTION 10 MG/5ML
P
Protriptyline HCl ORAL TABLET 10 MG, 5 MG
P
QL (2325 ML per 31 day(s))
*Antidiabetics* *Alpha-Glucosidase Inhibitors** *Alpha-Glucosidase Inhibitors*** Acarbose ORAL TABLET 100 MG, 25 MG, 50 MG
P
*Antidiabetic Combinations** *Dipeptidyl Peptidase-4 Inhibitor-Biguanide Combinations*** JANUMET ORAL TABLET 50-1000 MG, 50-500 MG
P
ST
JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 100-1000 MG, 50-1000 MG, 50-500 MG
P
ST
JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG
P
ST; QL (31 EA per 31 day(s))
*Sulfonylurea-Biguanide Combinations*** GlipiZIDE-MetFORMIN HCl ORAL TABLET 2.5-250 MG, 2.5-500 MG, 5-500 MG
P
GlyBURIDE-MetFORMIN ORAL TABLET 1.25-250 MG, 2.5-500 MG, 5-500 MG
P
*Sulfonylurea-Thiazolidinedione Combinations*** 19
Drug Name AVANDARYL ORAL TABLET 4-1 MG, 4-2 MG, 4-4 MG, 8-2 MG, 8-4 MG
Preference Details Coverage Details P
ST
AVANDAMET ORAL TABLET 2-1000 MG, 2-500 MG, 4-1000 MG, 4-500 MG
P
ST
Pioglitazone HCl-Metformin HCl ORAL TABLET 15-500 MG, 15-850 MG
P
ST
*Thiazolidinedione-Biguanide Combinations***
*Biguanides** *Biguanides*** MetFORMIN HCl ORAL TABLET 1000 MG, 500 MG, 850 MG
P
MetFORMIN HCl ER ORAL TABLET EXTENDED RELEASE 24 HR* 500 MG, 750 MG
P
MetFORMIN HCl ER (OSM) ORAL TABLET EXTENDED RELEASE 24 HR* 500 MG
P
RIOMET ORAL SOLUTION 500 MG/5ML
P
QL (900 ML per 31 day(s))
GLUCAGEN INJECTION SOLUTION RECONSTITUTED 1 MG
P
QL (2 EA per 31 day(s))
GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG
P
QL (2 EA per 31 day(s))
GLUCAGON EMERGENCY INJECTION KIT 1 MG
P
QL (2 EA per 31 day(s))
Glucose ORAL TABLET CHEWABLE 4 GM
P
OTC
JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG
P
ST
TRADJENTA ORAL TABLET 5 MG
P
ST; QL (31 EA per 31 Day(s))
P
ST; QL (4 EA per 28 day(s))
*Diabetic Other** *Diabetic Other***
*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors** *Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors***
*Incretin Mimetic Agents (Glp-1 Receptor Agonists)** *Incretin Mimetic Agents (Glp-1 Receptor Agonists)*** BYDUREON SUBCUTANEOUS* SUSPENSION RECONSTITUTED 2 MG *Insulin Sensitizing Agents**
20
Drug Name
Preference Details Coverage Details
*Thiazolidinediones*** AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG
P
ST
Pioglitazone HCl ORAL TABLET 15 MG, 30 MG, 45 MG
P
ST
APIDRA INJECTION SOLUTION 100 UNIT/ML
P
QL (60 ML per 31 day(s))
APIDRA SOLOSTAR SUBCUTANEOUS* SOLUTION 100 UNIT/ML
P
QL (60 ML per 31 day(s))
HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML
P
QL (60 ML per 31 day(s))
HUMALOG KWIKPEN SUBCUTANEOUS* SOLUTION 100 UNIT/ML
P
QL (60 ML per 31 day(s))
HUMALOG MIX 50/50 SUBCUTANEOUS* SUSPENSION (50-50) 100 UNIT/ML
P
QL (60 ML per 31 day(s))
HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS* SUSPENSION (50-50) 100 UNIT/ML
P
QL (60 ML per 31 day(s))
HUMALOG MIX 75/25 SUBCUTANEOUS* SUSPENSION (75-25) 100 UNIT/ML
P
QL (60 ML per 31 day(s))
HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS* SUSPENSION (75-25) 100 UNIT/ML
P
QL (60 ML per 31 day(s))
HUMULIN 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML
P
OTC; QL (60 ML per 31 day(s))
HUMULIN 70/30 PEN SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML
P
OTC; QL (60 ML per 31 day(s))
HUMULIN N SUBCUTANEOUS* SUSPENSION 100 UNIT/ML
P
OTC; QL (60 ML per 31 day(s))
HUMULIN N PEN SUBCUTANEOUS* SUSPENSION 100 UNIT/ML
P
OTC; QL (60 ML per 31 day(s))
HUMULIN R INJECTION SOLUTION 100 UNIT/ML
P
OTC; QL (60 ML per 31 day(s))
HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML
P
QL (60 ML per 31 day(s))
LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML
P
QL (60 ML per 31 day(s))
*Insulin** *Human Insulin***
21
Drug Name LANTUS SOLOSTAR SUBCUTANEOUS* SOLUTION 100 UNIT/ML
Preference Details Coverage Details P
QL (60 ML per 31 day(s))
*Sulfonylureas** *Sulfonylureas*** ChlorproPAMIDE ORAL TABLET 100 MG, 250 MG
P
Glimepiride ORAL TABLET 1 MG, 2 MG, 4 MG
P
GlipiZIDE ORAL TABLET 10 MG, 5 MG
P
GlipiZIDE ER ORAL TABLET EXTENDED RELEASE 24 HR* 10 MG, 2.5 MG, 5 MG
P
GLIPIZIDE XL ORAL TABLET EXTENDED RELEASE 24 HR* 10 MG, 2.5 MG, 5 MG
P
GlyBURIDE ORAL TABLET 1.25 MG, 2.5 MG, 5 MG
P
GlyBURIDE Micronized ORAL TABLET 1.5 MG, 3 MG, 6 MG
P
*Antidiarrheals* *Antiperistaltic Agents** *Antiperistaltic Agents*** Diphenoxylate-Atropine ORAL LIQUID† 2.5-0.025 MG/5ML
P
Diphenoxylate-Atropine ORAL TABLET 2.5-0.025 MG
P
LONOX ORAL TABLET 2.5-0.025 MG
P
Loperamide HCl ORAL CAPSULE 2 MG
P
*Antidotes* *Antidotes - Chelating Agents** *Antidotes - Chelating Agents*** EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG
P
*Antidotes** *Antidotes*** Deferoxamine Mesylate INJECTION SOLUTION RECONSTITUTED 2 GM, 500 MG *Opioid Antagonists** *Opioid Antagonists*** 22
P
PA
Drug Name Naltrexone HCl ORAL TABLET 50 MG
Preference Details Coverage Details P
*Antiemetics* *5-Ht3 Receptor Antagonists** *5-Ht3 Receptor Antagonists*** Ondansetron ORAL TABLET DISPERSIBLE 4 MG, 8 MG
P
Ondansetron HCl ORAL SOLUTION 4 MG/5ML
P
Ondansetron HCl ORAL TABLET 4 MG, 8 MG
P
*Antiemetics - Anticholinergic** *Antiemetics - Anticholinergic*** Meclizine HCl ORAL TABLET 12.5 MG, 25 MG
P
OTC
Meclizine HCl ORAL TABLET CHEWABLE 25 MG
P
OTC
Travel Sickness ORAL TABLET CHEWABLE 25 MG
P
OTC
Griseofulvin Microsize ORAL SUSPENSION 125 MG/5ML
P
QL (450 ML per 31 day(s))
Griseofulvin Microsize ORAL TABLET 500 MG
P
Griseofulvin Ultramicrosize ORAL TABLET 125 MG, 250 MG
P
Nystatin ORAL TABLET 500000 UNIT
P
Terbinafine HCl ORAL TABLET 250 MG
P
*Antifungals* *Antifungals** *Antifungals***
*Imidazole-Related Antifungals** *Imidazoles*** Ketoconazole ORAL TABLET 200 MG
P
*Triazoles*** Fluconazole ORAL SUSPENSION RECONSTITUTED 10 MG/ML, 40 MG/ML
P
Fluconazole ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG
P
*Antihistamines*
23
Drug Name
Preference Details Coverage Details
*Antihistamines - Alkylamines** *Antihistamines - Alkylamines*** P
OTC
Aler-Dryl ORAL TABLET 50 MG
P
OTC
BENADRYL ALLERGY CHILDRENS ORAL LIQUID† 12.5 MG/5ML
P
OTC
DiphenhydrAMINE HCl ORAL CAPSULE 25 MG, 50 MG
P
OTC
DiphenhydrAMINE HCl ORAL TABLET 25 MG
P
OTC
ALLEGRA ALLERGY CHILDRENS ORAL TABLET 30 MG
P
OTC
Allergy ORAL TABLET DISPERSIBLE 10 MG
P
OTC
Cetirizine HCl ORAL SYRUP 1 MG/ML, 5 MG/5ML
P
OTC; QL (300 ML per 31 day(s))
Cetirizine HCl ORAL TABLET 10 MG, 5 MG
P
OTC
Cetirizine HCl Childrens ORAL SOLUTION 1 MG/ML
P
OTC; QL (300 ML per 31 day(s))
Childrens Loratadine ORAL SYRUP 5 MG/5ML
P
OTC; QL (310 ML per 31 day(s))
Fexofenadine HCl ORAL TABLET 180 MG, 60 MG
P
OTC
Loratadine ORAL TABLET 10 MG
P
OTC
Allergy ORAL TABLET 4 MG *Antihistamines - Ethanolamines** *Antihistamines - Ethanolamines***
*Antihistamines - Non-Sedating** *Antihistamines - Non-Sedating***
*Antihistamines - Phenothiazines** *Antihistamines - Phenothiazines*** Promethazine HCl ORAL SYRUP 6.25 MG/5ML
P
Promethazine HCl ORAL TABLET 12.5 MG, 25 MG, 50 MG
P
Promethazine HCl RE SUPPOSITORY 25 MG
P
PROMETHEGAN RE SUPPOSITORY 12.5 MG, 25 MG, 50 MG
P
*Antihistamines - Piperidines** 24
Drug Name
Preference Details Coverage Details
*Antihistamines - Piperidines*** Cyproheptadine HCl ORAL SYRUP 2 MG/5ML
P
Cyproheptadine HCl ORAL TABLET 4 MG
P
QL (300 ML per 31 day(s))
*Antihyperlipidemics* *Antihyperlipidemics - Combinations** *Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib Comb*** VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG
P
PA
*Bile Acid Sequestrants** *Bile Acid Sequestrants*** Cholestyramine ORAL PACKET 4 GM
P
Cholestyramine ORAL POWDER 4 GM/DOSE
P
Cholestyramine Light ORAL PACKET 4 GM
P
Cholestyramine Light ORAL POWDER 4 GM/DOSE
P
*Fibric Acid Derivatives** *Fibric Acid Derivatives*** Fenofibrate ORAL TABLET 160 MG, 54 MG
P
Fenofibrate Micronized ORAL CAPSULE 134 MG, 200 MG, 67 MG
P
Gemfibrozil ORAL TABLET 600 MG
P
*Hmg Coa Reductase Inhibitors** *Hmg Coa Reductase Inhibitors*** Atorvastatin Calcium ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG
P
Lovastatin ORAL TABLET 10 MG, 20 MG, 40 MG
P
Pravastatin Sodium ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG
P
Simvastatin ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG, 80 MG
P
ST
*Intestinal Cholesterol Absorption Inhibitors** *Intestinal Cholesterol Absorption Inhibitors*** ZETIA ORAL TABLET 10 MG
P
PA
*Nicotinic Acid Derivatives** 25
Drug Name
Preference Details Coverage Details
*Nicotinic Acid Derivatives*** NIACOR ORAL TABLET 500 MG
P
*Antihypertensives* *Ace Inhibitors** *Ace Inhibitors*** Benazepril HCl ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG
P
Captopril ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG
P
Enalapril Maleate ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG
P
Fosinopril Sodium ORAL TABLET 10 MG, 20 MG, 40 MG
P
Lisinopril ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, 40 MG, 5 MG
P
Quinapril HCl ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG
P
Ramipril ORAL CAPSULE 1.25 MG, 10 MG, 2.5 MG, 5 MG
P
*Angiotensin Ii Receptor Antagonists** *Angiotensin Ii Receptor Antagonists*** Losartan Potassium ORAL TABLET 100 MG, 25 MG, 50 MG
P
*Antiadrenergic Antihypertensives** *Antiadrenergics - Centrally Acting*** CloNIDine HCl ORAL TABLET 0.1 MG, 0.2 MG, 0.3 MG
P
GuanFACINE HCl ORAL TABLET 1 MG, 2 MG
P
Methyldopa ORAL TABLET 250 MG, 500 MG
P
*Antiadrenergics - Peripherally Acting*** Doxazosin Mesylate ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG
P
Prazosin HCl ORAL CAPSULE 1 MG, 2 MG, 5 MG
P
Terazosin HCl ORAL CAPSULE 1 MG, 10 MG, 2 MG, 5 MG
P
*Antihypertensive Combinations** *Ace Inhibitors & Thiazide/Thiazide-Like*** 26
QL (31 EA per 31 day(s))
Drug Name
Preference Details Coverage Details
Benazepril-Hydrochlorothiazide ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG, 5-6.25 MG
P
Captopril-Hydrochlorothiazide ORAL TABLET 25-15 MG, 25-25 MG, 50-15 MG, 50-25 MG
P
Enalapril-Hydrochlorothiazide ORAL TABLET 10-25 MG, 5-12.5 MG
P
Lisinopril-Hydrochlorothiazide ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG
P
*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-Like*** Losartan Potassium-HCTZ ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 MG
P
QL (31 EA per 31 day(s))
*Beta Blocker & Diuretic Combinations*** Atenolol-Chlorthalidone ORAL TABLET 100-25 MG, 50-25 MG
P
Bisoprolol-Hydrochlorothiazide ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG
P
Propranolol-HCTZ ORAL TABLET 40-25 MG, 80-25 MG
P
*Vasodilators** *Vasodilators*** HydrALAZINE HCl INJECTION SOLUTION 20 MG/ML
P
HydrALAZINE HCl ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG
P
Minoxidil ORAL TABLET 10 MG, 2.5 MG
P
*Anti-Infective Agents - Misc.* *Anti-Infective Agents - Misc.** *Anti-Infective Agents - Misc.*** MetroNIDAZOLE ORAL TABLET 250 MG, 500 MG
P
Trimethoprim ORAL TABLET 100 MG
P
Vancomycin HCl INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG, 500 MG, 750 MG
P
Vancomycin HCl ORAL CAPSULE 125 MG, 250 MG
P
PA
27
Drug Name
Preference Details Coverage Details
*Anti-Infective Misc. - Combinations** *Anti-Infective Misc. - Combinations*** Erythromycin-Sulfisoxazole ORAL SUSPENSION RECONSTITUTED 200-600 MG/5ML
P
Sulfamethoxazole-TMP DS ORAL TABLET 800-160 MG
P
Sulfamethoxazole-Trimethoprim ORAL SUSPENSION 200-40 MG/5ML
P
Sulfamethoxazole-Trimethoprim ORAL TABLET 400-80 MG
P
QL (1200 ML per 31 day(s))
*Antiprotozoal Agents** *Antiprotozoal Agents*** MEPRON ORAL SUSPENSION 750 MG/5ML
P
*Leprostatics** *Leprostatics*** Dapsone ORAL TABLET 100 MG, 25 MG
P
*Lincosamides** *Lincosamides*** Clindamycin HCl ORAL CAPSULE 150 MG, 300 MG, 75 MG
P
Clindamycin Palmitate HCl ORAL SOLUTION RECONSTITUTED 75 MG/5ML
P
Clindamycin Phosphate INJECTION SOLUTION 300 MG/2ML, 600 MG/4ML, 9 GM/60ML, 900 MG/6ML
P
Clindamycin Phosphate INTRAVENOUS* SOLUTION 300 MG/2ML
P
*Antimalarials* *Antimalarial Combinations** *Antimalarial Combinations*** Atovaquone-Proguanil HCl ORAL TABLET 250-100 MG, 62.5-25 MG
P
*Antimalarials** *Antimalarials*** DARAPRIM ORAL TABLET 25 MG
P
Hydroxychloroquine Sulfate ORAL TABLET 200 MG
P
28
QL (2400 ML per 31 day(s))
Drug Name
Preference Details Coverage Details
Mefloquine HCl ORAL TABLET 250 MG
P
Primaquine Phosphate ORAL TABLET 26.3 MG
P
*Antimyasthenic/Cholinergic Agents* *Antimyasthenic/Cholinergic Agents** *Antimyasthenic/Cholinergic Agents*** MESTINON ORAL SYRUP 60 MG/5ML
P
MESTINON ORAL TABLET EXTENDEDRELEASE* 180 MG
P
PROSTIGMIN ORAL TABLET 15 MG
P
Pyridostigmine Bromide ORAL TABLET 60 MG
P
*Antimycobacterial Agents* *Antimycobacterial Agents** *Antimycobacterial Agents*** Ethambutol HCl ORAL TABLET 100 MG, 400 MG
P
Isoniazid INJECTION SOLUTION 100 MG/ML
P
Isoniazid ORAL TABLET 100 MG, 300 MG
P
MYCOBUTIN ORAL CAPSULE 150 MG
P
Pyrazinamide ORAL TABLET 500 MG
P
Rifampin INTRAVENOUS* SOLUTION RECONSTITUTED 600 MG
P
Rifampin ORAL CAPSULE 150 MG, 300 MG
P
*Antineoplastics And Adjunctive Therapies* *Alkylating Agents** *Alkylating Agents*** HEXALEN ORAL CAPSULE 50 MG
P
PA
MYLERAN ORAL TABLET 2 MG
P
PA
P
PA
ALKERAN ORAL TABLET 2 MG
P
PA
Cyclophosphamide ORAL TABLET 25 MG, 50 MG
P
PA
*Imidazotetrazines*** Temozolomide ORAL CAPSULE 100 MG, 140 MG, 180 MG, 20 MG, 250 MG, 5 MG *Nitrogen Mustards***
29
Drug Name LEUKERAN ORAL TABLET 2 MG
Preference Details Coverage Details P
PA
P
PA
ADRUCIL INTRAVENOUS* SOLUTION 500 MG/10ML
P
PA
Fluorouracil INTRAVENOUS* SOLUTION 500 MG/10ML
P
PA
Gemcitabine HCl INTRAVENOUS* SOLUTION 1 GM/26.3ML, 2 GM/52.6ML, 200 MG/5.26ML
P
PA
Gemcitabine HCl INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM, 2 GM, 200 MG
P
PA
Mercaptopurine ORAL TABLET 50 MG
P
Methotrexate ORAL TABLET 2.5 MG
P
Methotrexate Sodium INJECTION SOLUTION 25 MG/ML
P
Methotrexate Sodium INJECTION SOLUTION RECONSTITUTED 1 GM
P
Methotrexate Sodium (PF) INJECTION SOLUTION 25 MG/ML
P
TABLOID ORAL TABLET 40 MG
P
PA
XELODA ORAL TABLET 150 MG, 500 MG
P
PA
P
PA
P
PA
*Nitrosoureas*** Lomustine ORAL CAPSULE 10 MG, 100 MG, 40 MG *Antimetabolites** *Antimetabolites***
*Antineoplastic - Angiogenesis Inhibitors** *Vascular Endothelial Growth Factor (Vegf) Inhibitors*** AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML, 400 MG/16ML *Antineoplastic - Hedgehog Pathway Inhibitors** *Antineoplastic - Hedgehog Pathway Inhibitors*** ERIVEDGE ORAL CAPSULE 150 MG *Antineoplastic - Hormonal And Related Agents** *Antiadrenals***
30
Drug Name LYSODREN ORAL TABLET 500 MG
Preference Details Coverage Details P
PA
P
PA
*Antiandrogens*** XTANDI ORAL CAPSULE 40 MG *Antiestrogens*** Tamoxifen Citrate ORAL TABLET 10 MG, 20 MG
P
*Aromatase Inhibitors*** Anastrozole ORAL TABLET 1 MG
P
Letrozole ORAL TABLET 2.5 MG
P
*Estrogens-Antineoplastic*** EMCYT ORAL CAPSULE 140 MG
P
PA
TRELSTAR DEPOT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 3.75 MG
P
PA
TRELSTAR DEPOT MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 3.75 MG
P
PA
TRELSTAR LA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 11.25 MG
P
PA
TRELSTAR LA MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 11.25 MG
P
PA
TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 22.5 MG
P
PA
Megestrol Acetate ORAL SUSPENSION 40 MG/ML, 400 MG/10ML
P
QL (600 ML per 31 day(s))
Megestrol Acetate ORAL TABLET 20 MG, 40 MG
P
*Lhrh Analogs***
*Progestins-Antineoplastic***
*Antineoplastic Enzyme Inhibitors** *Antineoplastic - Braf Kinase Inhibitors*** ZELBORAF ORAL TABLET 240 MG
P
PA
P
PA
*Antineoplastic - Histone Deacetylase Inhibitors*** ZOLINZA ORAL CAPSULE 100 MG *Antineoplastic - Mtor Kinase Inhibitors***
31
Drug Name AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG
Preference Details Coverage Details P
PA
STIVARGA ORAL TABLET 40 MG
P
PA
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 50 MG
P
PA
BOSULIF ORAL TABLET 100 MG, 500 MG
P
PA
CAPRELSA ORAL TABLET 100 MG, 300 MG
P
PA
GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG
P
PA; QL (31 EA per 31 day(s))
GLEEVEC ORAL TABLET 100 MG, 400 MG
P
PA
ICLUSIG ORAL TABLET 15 MG, 45 MG
P
PA
SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG
P
PA
TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG
P
PA
TASIGNA ORAL CAPSULE 150 MG, 200 MG
P
PA
TYKERB ORAL TABLET 250 MG
P
PA
XALKORI ORAL CAPSULE 200 MG, 250 MG
P
PA
P
PA
P
PA
P
PA
*Antineoplastic - Multikinase Inhibitors***
*Antineoplastic - Tyrosine Kinase Inhibitors***
*Janus Associated Kinase (Jak) Inhibitors*** JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG *Antineoplastic Enzymes** *Antineoplastic Enzymes*** ERWINAZE INTRAMUSCULAR* SOLUTION RECONSTITUTED 10000 UNIT *Antineoplastics Misc.** *Antineoplastics Misc.*** Hydroxyurea ORAL CAPSULE 500 MG *Chemotherapy Rescue/Antidote Agents** *Folic Acid Antagonists Rescue Agents***
32
Drug Name
Preference Details Coverage Details
Leucovorin Calcium INJECTION SOLUTION RECONSTITUTED 100 MG, 200 MG, 350 MG
P
Leucovorin Calcium INTRAVENOUS* SOLUTION 10 MG/ML
P
Leucovorin Calcium ORAL TABLET 10 MG, 15 MG, 25 MG, 5 MG
P
*Mitotic Inhibitors** *Mitotic Inhibitors*** Etoposide ORAL CAPSULE 50 MG
P
PA
*Antiparkinson Agents* *Antiparkinson Anticholinergics** *Antiparkinson Anticholinergics*** Benztropine Mesylate ORAL TABLET 0.5 MG, 1 MG, 2 MG
P
Trihexyphenidyl HCl ORAL ELIXIR 0.4 MG/ML
P
Trihexyphenidyl HCl ORAL TABLET 2 MG, 5 MG
P
*Antiparkinson Dopaminergics** *Antiparkinson Dopaminergics*** Amantadine HCl ORAL CAPSULE 100 MG
P
Amantadine HCl ORAL SYRUP 50 MG/5ML
P
Amantadine HCl ORAL TABLET 100 MG
P
Bromocriptine Mesylate ORAL CAPSULE 5 MG
P
Bromocriptine Mesylate ORAL TABLET 2.5 MG
P
*Levodopa Combinations*** Carbidopa-Levodopa ORAL TABLET 10-100 MG, 25-100 MG, 25-250 MG
P
Carbidopa-Levodopa ER ORAL TABLET EXTENDEDRELEASE* 25-100 MG, 50-200 MG
P
*Nonergoline Dopamine Receptor Agonists*** Pramipexole Dihydrochloride ORAL TABLET 0.125 MG, 0.25 MG, 0.5 MG, 0.75 MG, 1 MG, 1.5 MG
P
ST
33
Drug Name ROPINIRole HCl ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG, 5 MG
Preference Details Coverage Details P
*Antiparkinson Monoamine Oxidase Inhibitors** *Antiparkinson Monoamine Oxidase Inhibitors*** Selegiline HCl ORAL CAPSULE 5 MG
P
Selegiline HCl ORAL TABLET 5 MG
P
*Antipsychotics/Antimanic Agents* *Antimanic Agents** *Antimanic Agents*** Lithium Carbonate ORAL CAPSULE 150 MG, 300 MG, 600 MG
P
Lithium Carbonate ORAL TABLET 300 MG
P
Lithium Carbonate ER ORAL TABLET EXTENDEDRELEASE* 300 MG, 450 MG
P
Lithium Citrate ORAL SOLUTION 8 MEQ/5ML
P
*Benzisoxazoles** *Benzisoxazoles*** INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML
P
PA; QL (1 ML per 28 day(s)); AL (Min 18 Years)
RisperiDONE ORAL SOLUTION 1 MG/ML
P
QL (496 ML per 31 day(s)); AL (Min 5 Years)
RisperiDONE ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG
P
QL (62 EA per 31 day(s)); AL (Min 5 Years)
RisperiDONE ORAL TABLET DISPERSIBLE 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG
P
QL (62 EA per 31 day(s)); AL (Min 5 Years)
RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG
P
QL (62 EA per 31 day(s)); AL (Min 5 Years)
*Butyrophenones** *Butyrophenones*** HALDOL DECANOATE INTRAMUSCULAR* SOLUTION 50 MG/ML
34
P
Drug Name
Preference Details Coverage Details
Haloperidol ORAL TABLET 0.5 MG, 1 MG, 10 MG, 2 MG, 5 MG
P
AL (Min 3 Years)
Haloperidol Decanoate INTRAMUSCULAR* SOLUTION 100 MG/ML, 50 MG/ML
P
AL (Min 18 Years)
Haloperidol Lactate INJECTION SOLUTION 5 MG/ML
P
AL (Min 3 Years)
Haloperidol Lactate ORAL CONCENTRATE 2 MG/ML
P
AL (Min 3 Years)
CloZAPine ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG
P
AL (Min 18 Years)
CloZAPine ORAL TABLET DISPERSIBLE 12.5 MG
P
QL (31 EA per 31 day(s)); AL (Min 18 Years)
P
ST; AL (Min 18 Years)
P
AL (Min 10 Years)
P
AL (Min 18 Years)
P
QL (31 EA per 31 day(s)); AL (Min 13 Years)
ChlorproMAZINE HCl ORAL TABLET 10 MG, 100 MG, 200 MG, 25 MG, 50 MG
P
AL (Min 6 Months)
FluPHENAZine Decanoate INJECTION SOLUTION 25 MG/ML
P
AL (Min 12 Years)
FluPHENAZine HCl ORAL CONCENTRATE 5 MG/ML
P
QL (248 ML per 31 day(s))
FluPHENAZine HCl ORAL ELIXIR 2.5 MG/5ML
P
QL (2480 ML per 31 day(s))
FluPHENAZine HCl ORAL TABLET 1 MG, 10 MG, 2.5 MG, 5 MG
P
*Dibenzapines** *Dibenzodiazepines***
*Dibenzo-Oxepino Pyrroles*** SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG *Dibenzothiazepines*** QUEtiapine Fumarate ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 400 MG, 50 MG *Dibenzoxazepines*** Loxapine Succinate ORAL CAPSULE 10 MG, 25 MG, 5 MG, 50 MG *Thienbenzodiazepines*** OLANZapine ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG *Phenothiazines** *Phenothiazines***
35
Drug Name
Preference Details Coverage Details
Perphenazine ORAL TABLET 16 MG, 2 MG, 4 MG, 8 MG
P
AL (Min 12 Years)
Prochlorperazine RE SUPPOSITORY 25 MG
P
AL (Min 2 Years)
Prochlorperazine Maleate ORAL TABLET 10 MG, 5 MG
P
AL (Min 2 Years)
Thioridazine HCl ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG
P
AL (Min 2 Years)
Trifluoperazine HCl ORAL TABLET 1 MG, 10 MG, 2 MG, 5 MG
P
AL (Min 6 Years)
P
AL (Min 12 Years)
P
OTC; QL (480 ML per 31 day(s))
*Thioxanthenes** *Thioxanthenes*** Thiothixene ORAL CAPSULE 1 MG, 10 MG, 2 MG, 5 MG *Antiseptics & Disinfectants* *Chlorine Antiseptics** *Chlorine Antiseptics*** Chlorhexidine Gluconate EXTERNAL LIQUID† 4 % *Antivirals* *Antiretrovirals** *Antiretroviral Combinations*** ATRIPLA ORAL TABLET 600-200-300 MG
P
COMPLERA ORAL TABLET 200-25-300 MG
P
EPZICOM ORAL TABLET 600-300 MG
P
KALETRA ORAL SOLUTION 400-100 MG/5ML
P
KALETRA ORAL TABLET 100-25 MG, 200-50 MG
P
Lamivudine-Zidovudine ORAL TABLET 150-300 MG
P
STRIBILD ORAL TABLET 150-150-200-300 MG
P
QL (31 EA per 31 day(s))
TRIZIVIR ORAL TABLET 300-150-300 MG
P
QL (62 EA per 31 day(s))
TRUVADA ORAL TABLET 200-300 MG
P
QL (31 EA per 31 day(s))
*Antiretrovirals - Ccr5 Antagonists (Entry Inhibitor)*** SELZENTRY ORAL TABLET 150 MG, 300 MG 36
P
QL (31 EA per 31 day(s))
Drug Name
Preference Details Coverage Details
*Antiretrovirals - Fusion Inhibitors*** FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED 90 MG
P
*Antiretrovirals - Integrase Inhibitors*** ISENTRESS ORAL TABLET 400 MG
P
ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG
P
TIVICAY ORAL TABLET 50 MG
P
QL (62 EA per 31 day(s))
*Antiretrovirals - Protease Inhibitors*** APTIVUS ORAL CAPSULE 250 MG
P
CRIXIVAN ORAL CAPSULE 200 MG, 400 MG
P
INVIRASE ORAL CAPSULE 200 MG
P
INVIRASE ORAL TABLET 500 MG
P
LEXIVA ORAL SUSPENSION 50 MG/ML
P
LEXIVA ORAL TABLET 700 MG
P
NORVIR ORAL CAPSULE 100 MG
P
NORVIR ORAL SOLUTION 80 MG/ML
P
NORVIR ORAL TABLET 100 MG
P
PREZISTA ORAL SUSPENSION 100 MG/ML
P
PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75 MG, 800 MG
P
REYATAZ ORAL CAPSULE 100 MG, 150 MG, 200 MG, 300 MG
P
QL (62 EA per 31 day(s))
VIRACEPT ORAL TABLET 250 MG, 625 MG
P
QL (310 EA per 31 day(s))
EDURANT ORAL TABLET 25 MG
P
QL (31 EA per 31 day(s))
INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG
P
Nevirapine ORAL SUSPENSION 50 MG/5ML
P
Nevirapine ORAL TABLET 200 MG
P
RESCRIPTOR ORAL TABLET 100 MG, 200 MG
P
SUSTIVA ORAL CAPSULE 200 MG, 50 MG
P
SUSTIVA ORAL TABLET 600 MG
P
QL (124 EA per 31 day(s))
*Antiretrovirals - Rti-Non-Nucleoside Analogues***
37
Drug Name
Preference Details Coverage Details
*Antiretrovirals - Rti-Nucleoside Analogues-Purines*** Abacavir Sulfate ORAL TABLET 300 MG
P
Didanosine ORAL CAPSULE DELAYED RELEASE 125 MG, 200 MG, 250 MG, 400 MG
P
VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM
P
ZIAGEN ORAL SOLUTION 20 MG/ML
P
*Antiretrovirals - Rti-Nucleoside Analogues-Pyrimidines*** EMTRIVA ORAL CAPSULE 200 MG
P
QL (31 EA per 31 day(s))
EMTRIVA ORAL SOLUTION 10 MG/ML
P
QL (170 ML per 31 day(s))
EPIVIR ORAL SOLUTION 10 MG/ML
P
EPIVIR HBV ORAL SOLUTION 5 MG/ML
P
EPIVIR HBV ORAL TABLET 100 MG
P
LamiVUDine ORAL TABLET 150 MG, 300 MG
P
*Antiretrovirals - Rti-Nucleoside Analogues-Thymidines*** Stavudine ORAL CAPSULE 15 MG, 20 MG, 30 MG, 40 MG
P
Stavudine ORAL SOLUTION RECONSTITUTED 1 MG/ML
P
Zidovudine ORAL CAPSULE 100 MG
P
Zidovudine ORAL SYRUP 50 MG/5ML
P
Zidovudine ORAL TABLET 300 MG
P
QL (1860 ML per 31 day(s))
*Antiretrovirals - Rti-Nucleotide Analogues*** VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG
P
*Hepatitis Agents** *Hepatitis B Agents*** BARACLUDE ORAL TABLET 0.5 MG, 1 MG
P
PA
INCIVEK ORAL TABLET 375 MG
P
PA; QL (504 EA per 365 day(s))
PEGASYS SUBCUTANEOUS* KIT 180 MCG/0.5ML
P
PA
*Hepatitis C Agents***
38
Drug Name
Preference Details Coverage Details
PEGASYS SUBCUTANEOUS* SOLUTION 180 MCG/0.5ML, 180 MCG/ML
P
PA
PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML
P
PA
RIBASPHERE ORAL TABLET 200 MG
P
Ribavirin ORAL TABLET 200 MG
P
*Herpes Agents** *Herpes Agents - Purine Analogues*** Acyclovir ORAL CAPSULE 200 MG
P
Acyclovir ORAL SUSPENSION 200 MG/5ML
P
Acyclovir ORAL TABLET 400 MG, 800 MG
P
ValACYclovir HCl ORAL TABLET 1 GM, 500 MG
P
QL (3500 ML per 31 day(s))
QL (62 EA per 31 day(s))
*Influenza Agents** *Influenza Agents*** Rimantadine HCl ORAL TABLET 100 MG
P
*Neuraminidase Inhibitors*** RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER
P
QL (40 EA per 365 day(s)); AL (Min 7 Years)
TAMIFLU ORAL CAPSULE 30 MG
P
QL (40 EA per 365 day(s))
TAMIFLU ORAL CAPSULE 45 MG, 75 MG
P
QL (20 EA per 365 day(s))
TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML
P
QL (360 ML per 365 day(s)); AL (Max 18 Years)
P
PA
P
PA
*Assorted Classes* *Immunomodulators** *Antileprotics*** THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG *Immunomodulators For Myelodysplastic Syndromes*** REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG *Immunosuppressive Agents** *Cyclosporine Analogs*** CycloSPORINE ORAL CAPSULE 100 MG, 25 MG
P
39
Drug Name
Preference Details Coverage Details
CycloSPORINE Modified ORAL CAPSULE 100 MG, 25 MG, 50 MG
P
CycloSPORINE Modified ORAL SOLUTION 100 MG/ML
P
GENGRAF ORAL CAPSULE 100 MG, 25 MG
P
GENGRAF ORAL SOLUTION 100 MG/ML
P
SANDIMMUNE ORAL SOLUTION 100 MG/ML
P
*Inosine Monophosphate Dehydrogenase Inhibitors*** CELLCEPT ORAL SUSPENSION RECONSTITUTED 200 MG/ML
P
Mycophenolate Mofetil ORAL CAPSULE 250 MG
P
Mycophenolate Mofetil ORAL TABLET 500 MG
P
*Macrolide Immunosuppressants*** HECORIA ORAL CAPSULE 0.5 MG, 1 MG, 5 MG
P
Tacrolimus ORAL CAPSULE 0.5 MG, 1 MG, 5 MG
P
*Purine Analogs*** AzaTHIOprine ORAL TABLET 50 MG
P
*Potassium Removing Resins** *Potassium Removing Resins*** Sodium Polystyrene Sulfonate ORAL POWDER
P
SPS ORAL SUSPENSION 15 GM/60ML
P
*Beta Blockers* *Alpha-Beta Blockers** *Alpha-Beta Blockers*** Carvedilol ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG
P
Labetalol HCl INTRAVENOUS* SOLUTION 5 MG/ML
P
Labetalol HCl ORAL TABLET 100 MG, 200 MG, 300 MG
P
*Beta Blockers Cardio-Selective** 40
QL (454 GM per 31 day(s))
Drug Name
Preference Details Coverage Details
*Beta Blockers Cardio-Selective*** Atenolol ORAL TABLET 100 MG, 25 MG, 50 MG
P
Bisoprolol Fumarate ORAL TABLET 10 MG, 5 MG
P
Metoprolol Succinate ER ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 200 MG, 25 MG, 50 MG
P
Metoprolol Tartrate INTRAVENOUS* SOLUTION 1 MG/ML
P
Metoprolol Tartrate ORAL TABLET 100 MG, 25 MG, 50 MG
P
*Beta Blockers Non-Selective** *Beta Blockers Non-Selective*** Nadolol ORAL TABLET 20 MG, 40 MG, 80 MG
P
Pindolol ORAL TABLET 10 MG, 5 MG
P
Propranolol HCl INTRAVENOUS* SOLUTION 1 MG/ML
P
Propranolol HCl ORAL TABLET 10 MG, 20 MG, 40 MG, 60 MG, 80 MG
P
Propranolol HCl ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 160 MG, 60 MG, 80 MG
P
SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG
P
Sotalol HCl ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG
P
Sotalol HCl (AF) ORAL TABLET 120 MG, 160 MG, 80 MG
P
Timolol Maleate ORAL TABLET 10 MG, 20 MG, 5 MG
P
*Calcium Channel Blockers* *Calcium Channel Blockers** *Calcium Channel Blockers*** AmLODIPine Besylate ORAL TABLET 10 MG, 2.5 MG, 5 MG
P
CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG
P
41
Drug Name
Preference Details Coverage Details
Dilt-XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG
P
Diltiazem HCl INTRAVENOUS* SOLUTION 125 MG/25ML, 25 MG/5ML, 50 MG/10ML
P
Diltiazem HCl ORAL TABLET 120 MG, 30 MG, 60 MG, 90 MG
P
Diltiazem HCl ER ORAL CAPSULE EXTENDED RELEASE 12 HOUR 120 MG, 60 MG, 90 MG
P
Diltiazem HCl ER Beads ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG
P
Diltiazem HCl ER Coated Beads ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG
P
MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 180 MG, 240 MG, 300 MG, 360 MG, 420 MG
P
NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG, 90 MG
P
NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG
P
NIFEdipine ORAL CAPSULE 10 MG
P
NIFEdipine ER Osmotic ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG, 90 MG
P
Verapamil HCl ORAL TABLET 120 MG, 40 MG, 80 MG
P
Verapamil HCl ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 120 MG, 180 MG, 200 MG, 240 MG, 300 MG, 360 MG
P
Verapamil HCl ER ORAL TABLET EXTENDEDRELEASE* 120 MG, 180 MG, 240 MG
P
*Cardiotonics* *Cardiac Glycosides** *Cardiac Glycosides*** 42
Drug Name
Preference Details Coverage Details
Digoxin INJECTION SOLUTION 0.25 MG/ML
P
Digoxin ORAL SOLUTION 0.05 MG/ML
P
Digoxin ORAL TABLET 0.125 MG, 0.25 MG
P
*Cardiovascular Agents - Misc.* *Pulmonary Hypertension - Endothelin Receptor Antagonists** *Pulmonary Hypertension - Endothelin Receptor Antagonists*** LETAIRIS ORAL TABLET 10 MG, 5 MG
P
PA
P
PA
*Pulmonary Hypertension - Phosphodiesterase Inhibitors** *Pulmonary Hypertension - Phosphodiesterase Inhibitors*** Sildenafil Citrate ORAL TABLET 20 MG *Cephalosporins* *Cephalosporins - 1St Generation** *Cephalosporins - 1St Generation*** Cefadroxil ORAL CAPSULE 500 MG
P
Cefadroxil ORAL SUSPENSION RECONSTITUTED 250 MG/5ML, 500 MG/5ML
P
Cefadroxil ORAL TABLET 1 GM
P
Cephalexin ORAL CAPSULE 250 MG, 500 MG, 750 MG
P
Cephalexin ORAL SUSPENSION RECONSTITUTED 125 MG/5ML
P
Cephalexin ORAL SUSPENSION RECONSTITUTED 250 MG/5ML
P
QL (300 ML per 31 day(s))
*Cephalosporins - 2Nd Generation** *Cephalosporins - 2Nd Generation*** Cefaclor ORAL CAPSULE 250 MG, 500 MG
P
Cefprozil ORAL SUSPENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML
P
Cefprozil ORAL TABLET 250 MG, 500 MG
P
Cefuroxime Axetil ORAL SUSPENSION RECONSTITUTED 125 MG/5ML
P
43
Drug Name Cefuroxime Axetil ORAL TABLET 250 MG, 500 MG
Preference Details Coverage Details P
*Cephalosporins - 3Rd Generation** *Cephalosporins - 3Rd Generation*** Cefdinir ORAL CAPSULE 300 MG
P
Cefdinir ORAL SUSPENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML
P
Cefpodoxime Proxetil ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 50 MG/5ML
P
Cefpodoxime Proxetil ORAL TABLET 100 MG, 200 MG
P
*Contraceptives* *Combination Contraceptives - Oral** *Biphasic Contraceptives - Oral*** KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5)
P
*Combination Contraceptives - Oral*** ALTAVERA ORAL TABLET 0.15-30 MG-MCG
P
APRI ORAL TABLET 0.15-30 MG-MCG
P
AVIANE ORAL TABLET 0.1-20 MG-MCG
P
BALZIVA ORAL TABLET 0.4-35 MG-MCG
P
Briellyn ORAL TABLET 0.4-35 MG-MCG
P
CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG
P
EMOQUETTE ORAL TABLET 0.15-30 MG-MCG
P
ESTARYLLA ORAL TABLET 0.25-35 MG-MCG
P
GIANVI ORAL TABLET 3-0.02 MG
P
JUNEL 1.5/30 ORAL TABLET 1.5-30 MG-MCG
P
JUNEL 1/20 ORAL TABLET 1-20 MG-MCG
P
JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG
P
JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG
P
44
Drug Name
Preference Details Coverage Details
KELNOR 1/35 ORAL TABLET 1-35 MG-MCG
P
LESSINA ORAL TABLET 0.1-20 MG-MCG
P
LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG
P
LORYNA ORAL TABLET 3-0.02 MG
P
LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG
P
LUTERA ORAL TABLET 0.1-20 MG-MCG
P
MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG
P
MICROGESTIN 1/20 ORAL TABLET 1-20 MG-MCG
P
MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG
P
MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG
P
MONONESSA ORAL TABLET 0.25-35 MG-MCG
P
NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG
P
NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG
P
NECON 1/50 (28) ORAL TABLET 1-50 MG-MCG
P
NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG
P
NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG
P
NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG
P
OCELLA ORAL TABLET 3-0.03 MG
P
PORTIA-28 ORAL TABLET 0.15-30 MG-MCG
P
PREVIFEM ORAL TABLET 0.25-35 MG-MCG
P
RECLIPSEN ORAL TABLET 0.15-30 MG-MCG
P
SOLIA ORAL TABLET 0.15-30 MG-MCG
P
45
Drug Name
Preference Details Coverage Details
SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG
P
SRONYX ORAL TABLET 0.1-20 MG-MCG
P
SYEDA ORAL TABLET 3-0.03 MG
P
ZENCHENT FE ORAL TABLET CHEWABLE 0.4-35 MG-MCG
P
ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG
P
ZOVIA 1/50E (28) ORAL TABLET 1-50 MG-MCG
P
*Extended-Cycle Contraceptives - Oral*** QUASENSE ORAL TABLET 0.15-0.03 MG
P
QL (91 EA per 91 day(s))
*Triphasic Contraceptives - Oral*** CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025 MG
P
ENPRESSE-28 ORAL TABLET
P
NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG
P
NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG
P
TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG
P
TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG
P
TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG
P
TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG
P
TRIVORA (28) ORAL TABLET
P
VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG
P
*Combination Contraceptives - Vaginal** *Combination Contraceptives - Vaginal*** NUVARING VAGINAL RING 0.12-0.015 MG/24HR
P
*Emergency Contraceptives** *Emergency Contraceptives*** Levonorgestrel ORAL TABLET 0.75 MG
46
P
QL (4 EA per 31 day(s))
Drug Name PLAN B ONE-STEP ORAL TABLET 1.5 MG
Preference Details Coverage Details P
OTC
P
QL (1 ML per 93 day(s))
*Progestin Contraceptives - Injectable** *Progestin Contraceptives - Injectable*** MedroxyPROGESTERone Acetate INTRAMUSCULAR* SUSPENSION 150 MG/ML *Progestin Contraceptives - Oral** *Progestin Contraceptives - Oral*** CAMILA ORAL TABLET 0.35 MG
P
ERRIN ORAL TABLET 0.35 MG
P
JOLIVETTE ORAL TABLET 0.35 MG
P
NORA-BE ORAL TABLET 0.35 MG
P
*Corticosteroids* *Glucocorticosteroids** *Glucocorticosteroids*** A-METHAPRED INJECTION SOLUTION RECONSTITUTED 125 MG, 40 MG
P
CELESTONE ORAL SOLUTION 0.6 MG/5ML
P
Cortisone Acetate ORAL TABLET 25 MG
P
Dexamethasone ORAL ELIXIR 0.5 MG/5ML
P
Dexamethasone ORAL SOLUTION 0.5 MG/5ML
P
Dexamethasone ORAL TABLET 0.5 MG, 0.75 MG, 1 MG, 1.5 MG, 2 MG, 4 MG, 6 MG
P
Dexamethasone Sodium Phosphate INJECTION SOLUTION 10 MG/ML, 4 MG/ML
P
Hydrocortisone ORAL TABLET 10 MG, 20 MG, 5 MG
P
MethylPREDNISolone ORAL TABLET 16 MG, 32 MG, 8 MG
P
MethylPREDNISolone (Pak) ORAL TABLET 4 MG
P
MethylPREDNISolone Acetate INJECTION SUSPENSION 40 MG/ML, 80 MG/ML
P
47
Drug Name
Preference Details Coverage Details
MethylPREDNISolone Sodium Succ INJECTION SOLUTION RECONSTITUTED 1 GM, 1000 MG, 125 MG, 40 MG
P
PrednisoLONE ORAL SOLUTION 15 MG/5ML
P
PrednisoLONE Sodium Phosphate ORAL SOLUTION 15 MG/5ML, 6.7 (5 Base) MG/5ML
P
PredniSONE ORAL SOLUTION 5 MG/5ML
P
PredniSONE ORAL TABLET 1 MG, 10 MG, 2.5 MG, 20 MG, 5 MG
P
*Mineralocorticoids** *Mineralocorticoids*** Fludrocortisone Acetate ORAL TABLET 0.1 MG
P
*Cough/Cold/Allergy* *Cough/Cold/Allergy Combinations** *Decongestant & Antihistamine*** ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG
P
OTC
ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HR* 60-120 MG
P
OTC
Allergy Relief/Nasal Decongest ORAL TABLET EXTENDED RELEASE 24 HR* 10-240 MG
P
OTC
Antihistamine Decongestant ORAL TABLET 2.5-60 MG
P
OTC
Cetirizine-Pseudoephedrine ER ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG
P
OTC
DELSYM NGHT TIME CGH/CLD CHILD ORAL LIQUID† 12.5-5 MG/5ML
P
OTC; AL (Max 20 Years)
DELSYM NIGHT TIME COUGH/COLD ORAL LIQUID† 6.25-2.5 MG/5ML
P
OTC; AL (Max 20 Years)
Fexofenadine-Pseudoephed ER ORAL TABLET EXTENDED RELEASE 24 HR* 180-240 MG
P
OTC
*Expectorants** 48
Drug Name
Preference Details Coverage Details
*Expectorants*** Mucus Relief ORAL TABLET 400 MG
P
OTC
Refenesen ORAL TABLET 200 MG
P
OTC
Refenesen 400 ORAL TABLET 400 MG
P
OTC
Robafen ORAL SYRUP 100 MG/5ML
P
OTC
BRONCHO SALINE INHALATION AEROSOL, SOLUTION 0.9 %
P
OTC
Sodium Chloride INHALATION NEBULIZATION SOLUTION 0.9 %
P
OTC
*Misc. Respiratory Inhalants** *Misc. Respiratory Inhalants***
*Mucolytics** *Mucolytics*** Acetylcysteine INHALATION SOLUTION 10 %, 20 %
P
*Dermatologicals* *Acne Products** *Acne Antibiotics*** Clindamycin Phosphate EXTERNAL GEL 1 %
P
Clindamycin Phosphate EXTERNAL LOTION 1%
P
Clindamycin Phosphate EXTERNAL SOLUTION 1 %
P
Ery EXTERNAL PAD 2 %
P
Erythromycin EXTERNAL GEL 2 %
P
Erythromycin EXTERNAL SOLUTION 2 %
P
Sulfacetamide Sodium EXTERNAL SUSPENSION 10 %
P
*Acne Combinations*** Benzoyl Peroxide-Erythromycin EXTERNAL GEL 5-3 %
P
*Acne Products*** Acne Medication EXTERNAL LOTION 10 %
P
OTC
Acne Medication 5 EXTERNAL LOTION 5 %
P
OTC
P
ST; QL (62 EA per 31 day(s)); AL (Min 12 Years and Max 20 Years)
AMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG
49
Drug Name
Preference Details Coverage Details
AVITA EXTERNAL CREAM 0.025 %
P
QL (45 GM per 31 day(s)); AL (Max 20 Years)
AVITA EXTERNAL GEL 0.025 %
P
QL (45 GM per 31 day(s)); AL (Max 20 Years)
Benzoyl Peroxide EXTERNAL GEL 10 %, 5 %
P
OTC
CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 40 MG
P
QL (62 EA per 31 day(s)); AL (Min 12 Years and Max 20 Years)
CLARAVIS ORAL CAPSULE 30 MG
P
ST; QL (62 EA per 31 day(s)); AL (Min 12 Years and Max 20 Years)
LAVOCLEN-4 CREAMY WASH EXTERNAL LIQUID† 4 %
P
LAVOCLEN-8 CREAMY WASH EXTERNAL LIQUID† 8 %
P
Tretinoin EXTERNAL CREAM 0.025 %, 0.05 %, 0.1 %
P
QL (45 GM per 31 day(s)); AL (Max 20 Years)
Tretinoin EXTERNAL GEL 0.01 %, 0.025 %
P
QL (45 GM per 31 day(s)); AL (Max 20 Years)
P
OTC
*Antibiotics - Topical** *Antibiotic Mixtures Topical*** Double Antibiotic EXTERNAL OINTMENT 500-10000 UNIT/GM *Antibiotic Steroid Combinations - Topical*** CORTISPORIN EXTERNAL OINTMENT 1 %
P
*Antibiotics - Topical*** Bacitracin Zinc EXTERNAL OINTMENT 500 UNIT/GM
P
Gentamicin Sulfate EXTERNAL CREAM 0.1 %
P
Gentamicin Sulfate EXTERNAL OINTMENT 0.1 %
P
Mupirocin EXTERNAL OINTMENT 2 %
P
*Antifungals - Topical** *Antifungals - Topical*** Ciclopirox EXTERNAL SOLUTION 8 %
P
Ciclopirox Olamine EXTERNAL CREAM 0.77 %
P
50
OTC
Drug Name
Preference Details Coverage Details
Ciclopirox Olamine EXTERNAL SUSPENSION 0.77 %
P
Nystatin EXTERNAL CREAM 100000 UNIT/GM
P
Nystatin EXTERNAL OINTMENT 100000 UNIT/GM
P
Nystatin EXTERNAL POWDER 100000 UNIT/GM
P
Terbinafine HCl EXTERNAL CREAM 1 %
P
OTC
Baza Antifungal EXTERNAL CREAM 2 %
P
OTC
Clotrimazole EXTERNAL CREAM 1 %
P
OTC
Clotrimazole EXTERNAL SOLUTION 1 %
P
OTC
Econazole Nitrate EXTERNAL CREAM 1 %
P
Ketoconazole EXTERNAL CREAM 2 %
P
Ketoconazole EXTERNAL SHAMPOO 2 %
P
*Imidazole-Related Antifungals - Topical***
*Anti-Inflammatory Agents - Topical** *Anti-Inflammatory Agents - Topical*** VOLTAREN TRANSDERMAL GEL 1 %
P
QL (300 GM per 31 day(s))
Fluorouracil EXTERNAL CREAM 5 %
P
PA
Fluorouracil EXTERNAL SOLUTION 2 %, 5 %
P
PA
*Antineoplastic Or Premalignant Lesion Agents - Topical** *Antineoplastic Antimetabolites - Topical***
*Antipsoriatics** *Antipsoriatics*** Calcipotriene EXTERNAL CREAM 0.005 %
P
Calcipotriene EXTERNAL OINTMENT 0.005 %
P
Calcipotriene EXTERNAL SOLUTION 0.005 %
P
DRITHO-CREME HP EXTERNAL CREAM 1 %
P
TAZORAC EXTERNAL CREAM 0.05 %, 0.1 %
P
QL (30 GM per 31 day(s)); AL (Max 20 Years)
TAZORAC EXTERNAL GEL 0.05 %, 0.1 %
P
QL (30 GM per 31 day(s)); AL (Max 20 Years)
51
Drug Name
Preference Details Coverage Details
*Antiseborrheic Products** *Antiseborrheic Products*** Selenium Sulfide EXTERNAL LOTION 2.5 %
P
*Antivirals - Topical** *Antivirals - Topical*** DENAVIR EXTERNAL CREAM 1 %
P
ST
ZOVIRAX EXTERNAL CREAM 5 %
P
ST
Silver Sulfadiazine EXTERNAL CREAM 1 %
P
QL (400 GM per 31 day(s))
SSD EXTERNAL CREAM 1 %
P
QL (400 GM per 31 day(s))
*Burn Products** *Burn Products***
*Corticosteroids - Topical** *Corticosteroids - Topical*** Alclometasone Dipropionate EXTERNAL CREAM 0.05 %
P
Alclometasone Dipropionate EXTERNAL OINTMENT 0.05 %
P
Betamethasone Dipropionate EXTERNAL CREAM 0.05 %
P
Betamethasone Dipropionate EXTERNAL LOTION 0.05 %
P
Betamethasone Dipropionate EXTERNAL OINTMENT 0.05 %
P
Betamethasone Dipropionate Aug EXTERNAL CREAM 0.05 %
P
Betamethasone Valerate EXTERNAL CREAM 0.1 %
P
Betamethasone Valerate EXTERNAL LOTION 0.1 %
P
Betamethasone Valerate EXTERNAL OINTMENT 0.1 %
P
Clobetasol Propionate EXTERNAL CREAM 0.05 %
P
Clobetasol Propionate EXTERNAL GEL 0.05 %
P
Clobetasol Propionate EXTERNAL OINTMENT 0.05 %
P
Desonide EXTERNAL CREAM 0.05 %
P
52
Drug Name
Preference Details Coverage Details
Fluocinolone Acetonide EXTERNAL CREAM 0.01 %, 0.025 %
P
Fluocinolone Acetonide EXTERNAL OINTMENT 0.025 %
P
Fluocinolone Acetonide EXTERNAL SOLUTION 0.01 %
P
Fluocinolone Acetonide Body EXTERNAL OIL 0.01 %
P
Fluocinolone Acetonide Scalp EXTERNAL OIL 0.01 %
P
Fluocinonide EXTERNAL CREAM 0.05 %
P
Fluocinonide EXTERNAL GEL 0.05 %
P
Fluocinonide EXTERNAL OINTMENT 0.05 %
P
Fluocinonide EXTERNAL SOLUTION 0.05 %
P
Fluocinonide-E EXTERNAL CREAM 0.05 %
P
Fluticasone Propionate EXTERNAL CREAM 0.05 %
P
Fluticasone Propionate EXTERNAL OINTMENT 0.005 %
P
Halobetasol Propionate EXTERNAL CREAM 0.05 %
P
Halobetasol Propionate EXTERNAL OINTMENT 0.05 %
P
Hydrocortisone EXTERNAL CREAM 1 %
P
OTC
Hydrocortisone EXTERNAL LOTION 1 %
P
OTC
Hydrocortisone EXTERNAL LOTION 2.5 %
P
Hydrocortisone EXTERNAL OINTMENT 1 %
P
Hydrocortisone EXTERNAL OINTMENT 2.5 %
P
Hydrocortisone Valerate EXTERNAL CREAM 0.2 %
P
Hydrocortisone Valerate EXTERNAL OINTMENT 0.2 %
P
Mometasone Furoate EXTERNAL CREAM 0.1 %
P
Mometasone Furoate EXTERNAL OINTMENT 0.1 %
P
OTC
53
Drug Name
Preference Details Coverage Details
Triamcinolone Acetonide EXTERNAL CREAM 0.025 %, 0.1 %, 0.5 %
P
Triamcinolone Acetonide EXTERNAL OINTMENT 0.1 %
P
*Emollient/Keratolytic Agents** *Emollient/Keratolytic Agents*** REMEVEN EXTERNAL CREAM 50 %
P
Urea EXTERNAL CREAM 40 %
P
X-VIATE EXTERNAL CREAM 40 %
P
*Emollients** *Emollients*** AMLACTIN EXTERNAL LOTION 12 %
P
OTC; QL (400 GM per 31 day(s))
Ammonium Lactate EXTERNAL CREAM 12 %
P
OTC; QL (400 GM per 31 day(s))
Ammonium Lactate EXTERNAL LOTION 12 %
P
OTC; QL (400 GM per 31 day(s))
P
PA
P
ST; QL (30 GM per 31 day(s))
CLEAR AWAY 1-STEP WART REMOVER EXTERNAL PAD 40 %
P
OTC
COMPOUND W EXTERNAL LIQUID† 17 %
P
OTC
COMPOUND W MAXIMUM STRENGTH EXTERNAL GEL 17 %
P
OTC
CONDYLOX EXTERNAL GEL 0.5 %
P
PA
FREEZONE EXTERNAL LIQUID† 17.6 %
P
OTC
Podofilox EXTERNAL SOLUTION 0.5 %
P
SALACTIC FILM EXTERNAL SOLUTION 17 %
P
*Enzymes - Topical** *Enzymes - Topical*** SANTYL EXTERNAL OINTMENT 250 UNIT/GM *Immunosuppressive Agents - Topical** *Macrolide Immunosuppressants - Topical*** ELIDEL EXTERNAL CREAM 1 % *Keratolytic/Antimitotic Agents** *Keratolytic/Antimitotic Agents***
*Local Anesthetics - Topical** 54
OTC
Drug Name
Preference Details Coverage Details
*Local Anesthetics - Topical*** Capsaicin EXTERNAL CREAM 0.025 %
P
Lidocaine EXTERNAL OINTMENT 5 %
P
Lidocaine HCl EXTERNAL GEL 2 %
P
Lidocaine HCl EXTERNAL SOLUTION 4 %
P
OTC
*Topical Anesthetic Combinations*** Lidocaine-Prilocaine EXTERNAL CREAM 2.5-2.5 %
P
Lidocaine-Prilocaine EXTERNAL KIT 2.5-2.5 %
P
*Misc. Topical** *Misc. Topical*** HYPERCARE EXTERNAL SOLUTION 20 %
P
*Rosacea Agents** *Rosacea Agents*** MetroNIDAZOLE EXTERNAL CREAM 0.75 %
P
MetroNIDAZOLE EXTERNAL GEL 1 %
P
*Scabicides & Pediculicides** *Scabicides & Pediculicides*** ACTICIN EXTERNAL CREAM 5 %
P
QL (60 GM per 31 day(s))
OVIDE EXTERNAL LOTION 0.5 %
P
QL (118 ML per 31 day(s)); AL (Min 7 Years)
Permethrin EXTERNAL CREAM 5 %
P
QL (60 GM per 31 day(s))
Permethrin EXTERNAL LOTION 1 %
P
OTC; QL (60 ML per 31 day(s))
*Diagnostic Products* *Diagnostic Drugs** *Diagnostic Drugs*** Dipyridamole INTRAVENOUS* SOLUTION 5 MG/ML
P
*Diagnostic Tests** *Diagnostic Tests*** ACCU-CHEK ACTIVE IN VITRO STRIP
P
OTC; QL (100 EA per 31 day(s))
ACCU-CHEK AVIVA PLUS IN VITRO STRIP
P
OTC; QL (100 EA per 31 day(s))
55
Drug Name
Preference Details Coverage Details
ACCU-CHEK COMFORT CURVE IN VITRO STRIP
P
OTC; QL (100 EA per 31 day(s))
ACCU-CHEK COMPACT IN VITRO STRIP
P
OTC; QL (102 EA per 31 day(s))
ACCU-CHEK COMPACT TEST DRUM IN VITRO STRIP
P
OTC; QL (102 EA per 31 day(s))
ACCU-CHEK SMARTVIEW IN VITRO STRIP
P
OTC; QL (100 EA per 31 day(s))
CLINISTIX IN VITRO STRIP
P
OTC; QL (100 EA per 31 day(s))
DIASTIX IN VITRO STRIP
P
OTC; QL (100 EA per 31 day(s))
FREESTYLE INSULINX TEST IN VITRO STRIP
P
OTC; QL (100 EA per 31 day(s))
FREESTYLE LITE TEST IN VITRO STRIP
P
OTC; QL (100 EA per 31 day(s))
FREESTYLE TEST IN VITRO STRIP
P
OTC; QL (100 EA per 31 day(s))
KETOSTIX IN VITRO STRIP
P
OTC; QL (100 EA per 31 day(s))
PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP
P
OTC; QL (100 EA per 31 day(s))
PRECISION XTRA KETONE IN VITRO STRIP
P
OTC
*Digestive Aids* *Digestive Enzymes** *Digestive Enzymes*** CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT
P
PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000 UNIT, 8000 UNIT
P
*Diuretics* *Carbonic Anhydrase Inhibitors** *Carbonic Anhydrase Inhibitors*** AcetaZOLAMIDE ORAL TABLET 125 MG, 250 MG
P
Methazolamide ORAL TABLET 25 MG, 50 MG
P
*Diuretic Combinations** *Diuretic Combinations*** Amiloride-Hydrochlorothiazide ORAL TABLET 5-50 MG 56
P
Drug Name
Preference Details Coverage Details
Spironolactone-HCTZ ORAL TABLET 25-25 MG
P
Triamterene-HCTZ ORAL CAPSULE 37.5-25 MG
P
Triamterene-HCTZ ORAL TABLET 37.5-25 MG, 75-50 MG
P
*Loop Diuretics** *Loop Diuretics*** Bumetanide INJECTION SOLUTION 0.25 MG/ML
P
Bumetanide ORAL TABLET 0.5 MG, 1 MG, 2 MG
P
Furosemide ORAL SOLUTION 10 MG/ML, 8 MG/ML
P
Furosemide ORAL TABLET 20 MG, 40 MG, 80 MG
P
Torsemide ORAL TABLET 10 MG, 100 MG, 20 MG, 5 MG
P
*Potassium Sparing Diuretics** *Potassium Sparing Diuretics*** Spironolactone ORAL TABLET 100 MG, 25 MG, 50 MG
P
*Thiazides And Thiazide-Like Diuretics** *Thiazides And Thiazide-Like Diuretics*** Chlorothiazide ORAL TABLET 250 MG, 500 MG
P
Chlorthalidone ORAL TABLET 25 MG, 50 MG
P
Hydrochlorothiazide ORAL CAPSULE 12.5 MG
P
Hydrochlorothiazide ORAL TABLET 12.5 MG, 25 MG, 50 MG
P
Indapamide ORAL TABLET 1.25 MG, 2.5 MG
P
Metolazone ORAL TABLET 10 MG, 2.5 MG, 5 MG
P
*Endocrine And Metabolic Agents - Misc.* *Bone Density Regulators** *Bisphosphonates***
57
Drug Name Alendronate Sodium ORAL TABLET 10 MG, 35 MG, 40 MG, 5 MG, 70 MG
Preference Details Coverage Details P
*Calcitonins*** Calcitonin (Salmon) NASAL SOLUTION 200 UNIT/ACT
P
FORTICAL NASAL SOLUTION 200 UNIT/ACT
P
*Rank Ligand (Rankl) Inhibitors*** PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML
P
PA
P
PA
*Growth Hormones** *Growth Hormones*** TEV-TROPIN SUBCUTANEOUS* SOLUTION RECONSTITUTED 5 MG *Hormone Receptor Modulators** *Selective Estrogen Receptor Modulators (Serms)*** EVISTA ORAL TABLET 60 MG
P
*Metabolic Modifiers** *Carnitine Replenisher - Agents*** LevOCARNitine INTRAVENOUS* SOLUTION 200 MG/ML
P
LevOCARNitine ORAL SOLUTION 1 GM/10ML
P
LevOCARNitine ORAL TABLET 330 MG
P
QL (900 ML per 31 day(s))
*Gaa Deficiency Treatment - Agents*** LUMIZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG
P
*Hyperparathyroid Treatment - Vitamin D Analogs*** Calcitriol INTRAVENOUS* SOLUTION 1 MCG/ML
P
Calcitriol ORAL CAPSULE 0.25 MCG, 0.5 MCG
P
Calcitriol ORAL SOLUTION 1 MCG/ML
P
*Posterior Pituitary Hormones** *Vasopressin*** Desmopressin Ace Rhinal Tube NASAL SOLUTION 0.01 % 58
P
PA
Drug Name
Preference Details Coverage Details
Desmopressin Ace Spray Refrig NASAL SOLUTION 0.01 %
P
Desmopressin Acetate ORAL TABLET 0.1 MG, 0.2 MG
P
Desmopressin Acetate Spray NASAL SOLUTION 0.01 %
P
*Estrogens* *Estrogen Combinations** *Estrogen & Progestin*** Estradiol-Norethindrone Acet ORAL TABLET 0.5-0.1 MG, 1-0.5 MG
P
PREMPHASE ORAL TABLET 0.625-5 MG
P
PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG
P
*Estrogens** *Estrogens*** CENESTIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG
P
ENJUVIA ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG
P
Estradiol ORAL TABLET 0.5 MG, 1 MG, 2 MG
P
Estradiol TRANSDERMAL PATCH WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.06 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR
P
Estropipate ORAL TABLET 0.75 MG, 1.5 MG, 3 MG
P
MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG
P
PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG
P
PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG
P
*Fluoroquinolones* *Fluoroquinolones** *Fluoroquinolones*** Ciprofloxacin HCl ORAL TABLET 250 MG, 500 MG, 750 MG
P
59
Drug Name Levofloxacin ORAL TABLET 250 MG, 500 MG, 750 MG
Preference Details Coverage Details P
QL (14 EA per 31 day(s))
Simethicone ORAL SUSPENSION 40 MG/0.6ML
P
OTC
Simethicone ORAL TABLET CHEWABLE 80 MG
P
OTC
*Gastrointestinal Agents - Misc.* *Antiflatulents** *Antiflatulents***
*Gallstone Solubilizing Agents** *Gallstone Solubilizing Agents*** Ursodiol ORAL CAPSULE 300 MG
P
*Gastrointestinal Stimulants** *Gastrointestinal Stimulants*** Metoclopramide HCl ORAL SOLUTION 5 MG/5ML
P
Metoclopramide HCl ORAL TABLET 10 MG, 5 MG
P
QL (1500 ML per 31 day(s))
*Inflammatory Bowel Agents** *Inflammatory Bowel Agents*** APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM
P
Balsalazide Disodium ORAL CAPSULE 750 MG
P
Mesalamine RE ENEMA 4 GM
P
SulfaSALAzine ORAL TABLET 500 MG
P
SulfaSALAzine ORAL TABLET DELAYED RELEASE 500 MG
P
QL (1800 ML per 31 day(s))
*Intestinal Acidifiers** *Intestinal Acidifiers*** P
QL (4185 ML per 31 day(s))
ELIPHOS ORAL TABLET 667 MG
P
QL (372 EA per 31 day(s))
RENVELA ORAL PACKET 0.8 GM, 2.4 GM
P
RENVELA ORAL TABLET 800 MG
P
Generlac ORAL SOLUTION 10 GM/15ML *Phosphate Binder Agents** *Phosphate Binder Agents***
*Genitourinary Agents - Miscellaneous* 60
Drug Name
Preference Details Coverage Details
*Alkalinizers** *Citrates*** Cytra-2 ORAL SOLUTION 500-334 MG/5ML
P
QL (3600 ML per 31 day(s))
CYTRA-3 ORAL SYRUP 550-500-334 MG/5ML
P
QL (3600 ML per 31 day(s))
Sodium Citrate ORAL GRANULES
P
*Genitourinary Irrigants** *Genitourinary Irrigants*** ARGYLE STERILE SALINE IRRIGATION SOLUTION 0.9 %
P
QL (1000 ML per 31 day(s))
Sodium Chloride IRRIGATION SOLUTION 0.9 %
P
QL (1000 ML per 31 day(s))
*Prostatic Hypertrophy Agents** *5-Alpha Reductase Inhibitors*** AVODART ORAL CAPSULE 0.5 MG
P
Finasteride ORAL TABLET 5 MG
P
*Alpha 1-Adrenoceptor Antagonists*** Tamsulosin HCl ORAL CAPSULE 0.4 MG
P
*Urinary Analgesics** *Urinary Analgesics*** Phenazopyridine HCl ORAL TABLET 100 MG, 200 MG
P
*Gout Agents* *Gout Agent Combinations** *Gout Agent Combinations*** Colchicine-Probenecid ORAL TABLET 0.5-500 MG
P
*Gout Agents** *Gout Agents*** Allopurinol ORAL TABLET 100 MG, 300 MG
P
COLCRYS ORAL TABLET 0.6 MG
P
*Uricosurics** *Uricosurics*** Probenecid ORAL TABLET 500 MG
P
*Hematological Agents - Misc.* *Bradykinin B2 Receptor Antagonists**
61
Drug Name
Preference Details Coverage Details
*Bradykinin B2 Receptor Antagonists*** FIRAZYR SUBCUTANEOUS* SOLUTION 30 MG/3ML
P
PA
*Hematorheologic Agents** *Hematorheologic Agents*** Pentoxifylline ER ORAL TABLET EXTENDEDRELEASE* 400 MG
P
*Platelet Aggregation Inhibitors** *Phosphodiesterase Iii Inhibitors*** Cilostazol ORAL TABLET 100 MG, 50 MG
P
*Platelet Aggregation Inhibitors*** Dipyridamole ORAL TABLET 25 MG, 50 MG, 75 MG
P
*Quinazoline Agents*** Anagrelide HCl ORAL CAPSULE 0.5 MG, 1 MG
P
*Thienopyridine Derivatives*** Clopidogrel Bisulfate ORAL TABLET 75 MG
P
*Hematopoietic Agents* *Cobalamins** *Cobalamins*** Cyanocobalamin INJECTION SOLUTION 1000 MCG/ML
P
Vitamin B-12 ORAL TABLET 1000 MCG
P
OTC
P
OTC
P
PA
*Folic Acid/Folates** *Folic Acid/Folates*** Folic Acid ORAL TABLET 1 MG, 400 MCG, 800 MCG *Hematopoietic Growth Factors** *Erythropoiesis-Stimulating Agents (Esas)*** PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML *Granulocyte Colony-Stimulating Factors (G-Csf)***
62
Drug Name NEUPOGEN INJECTION SOLUTION 300 MCG/0.5ML, 300 MCG/ML, 480 MCG/0.8ML, 480 MCG/1.6ML
Preference Details Coverage Details P
PA
*Hematopoietic Mixtures** *Iron Combinations*** CENTRATEX ORAL CAPSULE 106-1 MG
P
Ferrex 150 Forte ORAL CAPSULE 150-25-1 MG-MCG-MG
P
*Iron** *Iron*** Ferrex 150 ORAL CAPSULE 150 MG
P
OTC
Ferrous Sulfate ORAL ELIXIR 220 (44 Fe) MG/5ML
P
OTC
Ferrous Sulfate ORAL LIQUID† 220 (44 Fe) MG/5ML
P
OTC
Ferrous Sulfate ORAL SOLUTION 75 (15 Fe) MG/ML
P
OTC
Ferrous Sulfate ORAL TABLET 325 (65 Fe) MG
P
OTC
Ferrous Sulfate ORAL TABLET DELAYED RELEASE 324 (65 Fe) MG, 325 (65 Fe) MG
P
OTC
Slow Release Iron ORAL TABLET EXTENDEDRELEASE* 160 (50 Fe) MG
P
OTC
P
OTC
PHENobarbital ORAL ELIXIR 20 MG/5ML
P
QL (2000 ML per 31 day(s))
PHENobarbital ORAL TABLET 100 MG, 30 MG, 32.4 MG, 60 MG, 64.8 MG, 97.2 MG
P
PHENobarbital ORAL TABLET 15 MG
P
QL (310 EA per 31 day(s))
PHENobarbital ORAL TABLET 16.2 MG
P
QL (383 EA per 31 day(s))
PHENobarbital Sodium INJECTION SOLUTION 130 MG/ML, 65 MG/ML
P
*Hypnotics* *Antihistamine Hypnotics** *Antihistamine Hypnotics*** DiphenhydrAMINE HCl (Sleep) ORAL TABLET 50 MG *Barbiturate Hypnotics** *Barbiturate Hypnotics***
*Non-Barbiturate Hypnotics**
63
Drug Name
Preference Details Coverage Details
*Benzodiazepine Hypnotics*** Estazolam ORAL TABLET 1 MG, 2 MG
P
Temazepam ORAL CAPSULE 15 MG, 30 MG
P
Triazolam ORAL TABLET 0.125 MG, 0.25 MG
P
AL (Min 18 Years)
P
QL (31 EA per 31 day(s)); AL (Min 18 Years)
METAMUCIL ORAL CAPSULE 0.52 GM
P
OTC
METAMUCIL ORAL WAFER
P
OTC
METAMUCIL SMOOTH TEXTURE ORAL POWDER 28.3 %
P
OTC
GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM
P
QL (4000 ML per 31 day(s))
GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM
P
QL (4000 ML per 31 day(s))
GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM
P
QL (1 EA per 31 day(s))
PEG 3350-KCl-Na Bicarb-NaCl ORAL SOLUTION RECONSTITUTED 420 GM
P
QL (4000 ML per 31 day(s))
PEG 3350/Electrolytes ORAL SOLUTION RECONSTITUTED 240 GM
P
QL (4000 ML per 31 day(s))
PEG-3350/Electrolytes ORAL SOLUTION RECONSTITUTED 236 GM
P
QL (4000 ML per 31 day(s))
TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM
P
QL (4000 ML per 31 day(s))
P
OTC
P
QL (4185 ML per 31 day(s))
*Non-Benzodiazepine - Gaba-Receptor Modulators*** Zolpidem Tartrate ORAL TABLET 10 MG, 5 MG *Laxatives* *Bulk Laxatives** *Bulk Laxatives***
*Laxative Combinations** *Bowel Evacuant Combinations***
*Laxatives & Dss*** Senna S ORAL TABLET 8.6-50 MG *Laxatives - Miscellaneous** *Laxatives - Miscellaneous*** Lactulose ORAL SOLUTION 10 GM/15ML
64
Drug Name
Preference Details Coverage Details
Polyethylene Glycol 3350 ORAL POWDER
P
OTC; QL (527 GM per 31 day(s))
Sorbitol ORAL SOLUTION 70 %
P
OTC
Docusate Sodium ORAL TABLET 100 MG
P
OTC
Stool Softener ORAL CAPSULE 100 MG, 250 MG
P
OTC
Stool Softener Laxative DC ORAL CAPSULE 240 MG
P
OTC
*Surfactant Laxatives** *Surfactant Laxatives***
*Local Anesthetics-Parenteral* *Local Anesthetics - Amides** *Local Anesthetics - Amides*** Lidocaine HCl INJECTION SOLUTION 0.5 %, 1 %, 1.5 %
P
Lidocaine HCl (PF) INJECTION SOLUTION 2 %
P
*Macrolides* *Azithromycin** *Azithromycin*** Azithromycin INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG
P
Azithromycin ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML
P
Azithromycin ORAL TABLET 250 MG
P
Azithromycin ORAL TABLET 500 MG, 600 MG
P
Azithromycin Hydrogencitrate INTRAVENOUS* SOLUTION RECONSTITUTED 2.5 GM
P
QL (6 EA per 31 day(s))
*Clarithromycin** *Clarithromycin*** Clarithromycin ORAL SUSPENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML
P
Clarithromycin ORAL TABLET 250 MG, 500 MG
P
*Erythromycins** 65
Drug Name
Preference Details Coverage Details
*Erythromycins*** E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML
P
ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG
P
ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML
P
ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML
P
ERYTHROCIN STEARATE ORAL TABLET 250 MG
P
Erythromycin Base ORAL CAPSULE DELAYED RELEASE PARTICLES 250 MG
P
Erythromycin Base ORAL TABLET 250 MG, 500 MG
P
Erythromycin Ethylsuccinate ORAL TABLET 400 MG
P
*Medical Devices* *Diabetic Supplies** *Glucose Monitoring Test Supplies*** ACCU-CHEK AVIVA PLUS XX KIT W/DEVICE
P
OTC; QL (1 EA per 365 day(s))
ACCU-CHEK COMPACT PLUS CARE XX KIT
P
OTC; QL (1 EA per 365 day(s))
ACCU-CHEK NANO SMARTVIEW XX KIT W/DEVICE
P
OTC; QL (1 EA per 365 day(s))
FREESTYLE FREEDOM LITE XX KIT W/DEVICE
P
OTC; QL (1 EA per 365 day(s))
FREESTYLE INSULINX SYSTEM XX KIT W/DEVICE
P
OTC; QL (1 EA per 365 day(s))
FREESTYLE LITE XX DEVICE
P
OTC; QL (1 EA per 365 day(s))
Glucose Control IN VITRO SOLUTION
P
OTC
Lancet Device XX MISC
P
OTC
Lancets XX MISC
P
OTC
PRECISION XTRA XX DEVICE
P
OTC; QL (1 EA per 365 day(s))
P
OTC
*Misc. Devices** *Applicators,Cotton Balls,Etc*** Alcohol Pads XX PAD 70 % *Parenteral Therapy Supplies** 66
Drug Name
Preference Details Coverage Details
*Needles & Syringes*** BD INSULIN SYRINGE ULTRAFINE XX MISC 31G X 5/16" 1 ML
P
OTC; QL (100 EA per 31 day(s))
EXEL PEN NEEDLES 1/3" XX MISC 31G X 8 MM
P
OTC; QL (100 EA per 31 day(s))
Insulin Syringe XX MISC 29G X 1/2" 0.3 ML, 30G X 5/16" 0.3 ML
P
OTC; QL (100 EA per 31 day(s))
NOVOPEN 3 XX MISC
P
OTC
P
OTC; QL (2 EA per 365 day(s))
P
QL (2 EA per 365 day(s))
AEROCHAMBER PLUS FLO-VU XX MISC
P
QL (2 EA per 365 day(s))
AEROCHAMBER PLUS FLO-VU LARGE XX MISC
P
QL (2 EA per 365 day(s))
AEROCHAMBER PLUS FLO-VU SMALL XX MISC
P
QL (2 EA per 365 day(s))
AEROCHAMBER PLUS FLO-VU W/MASK XX MISC
P
QL (2 EA per 365 day(s))
E-Z SPACER XX DEVICE
P
QL (2 EA per 365 day(s))
MICROCHAMBER XX MISC
P
QL (2 EA per 365 day(s))
MICROSPACER XX MISC
P
QL (2 EA per 365 day(s))
OPTICHAMBER ADVANTAGE XX MISC
P
QL (2 EA per 365 day(s))
OPTICHAMBER ADVANTAGE-LG MASK XX MISC
P
QL (2 EA per 365 day(s))
OPTICHAMBER ADVANTAGE-MED MASK XX MISC
P
QL (2 EA per 365 day(s))
OPTICHAMBER ADVANTAGE-SM MASK XX MISC
P
QL (2 EA per 365 day(s))
OPTICHAMBER FACE MASK-LARGE XX MISC
P
OTC; QL (2 EA per 365 day(s))
OPTICHAMBER FACE MASK-MEDIUM XX MISC
P
OTC; QL (2 EA per 365 day(s))
*Respiratory Therapy Supplies** *Peak Flow Meters*** Peak Flow Meter XX DEVICE *Respiratory Therapy Supplies*** IN-CHECK DIAL FLOW TRAINER XX DEVICE *Spacer/Aerosol-Holding Chambers & Supplies***
67
Drug Name
Preference Details Coverage Details
OPTICHAMBER FACE MASK-SMALL XX MISC
P
OTC; QL (2 EA per 365 day(s))
OPTIHALER XX MISC
P
QL (2 EA per 365 day(s))
Naratriptan HCl ORAL TABLET 1 MG, 2.5 MG
P
ST; QL (9 EA per 31 day(s))
SUMAtriptan NASAL SOLUTION 20 MG/ACT, 5 MG/ACT
P
QL (12 EA per 31 day(s))
SUMAtriptan Succinate ORAL TABLET 100 MG, 25 MG, 50 MG
P
QL (9 EA per 31 day(s))
SUMAtriptan Succinate SUBCUTANEOUS* SOLUTION 4 MG/0.5ML, 6 MG/0.5ML
P
QL (4 ML per 31 day(s))
SUMAtriptan Succinate Refill SUBCUTANEOUS* SOLUTION 4 MG/0.5ML, 6 MG/0.5ML
P
QL (4 ML per 31 day(s))
P
OTC
Cal-Lac ORAL CAPSULE 500 MG
P
OTC
Calcium Acetate (Phos Binder) ORAL TABLET 667 MG
P
QL (372 EA per 31 day(s))
Calcium Carbonate ORAL SUSPENSION 1250 MG/5ML
P
OTC
Calcium Carbonate ORAL TABLET 1250 MG, 600 MG
P
OTC
Calcium Lactate ORAL TABLET 648 MG
P
OTC
ORALYTE ORAL SOLUTION
P
OTC; QL (4000 ML per 31 day(s))
ORALYTE FREEZER POPS ORAL SOLUTION
P
OTC; QL (4000 ML per 31 day(s))
*Migraine Products* *Serotonin Agonists** *Selective Serotonin Agonists 5-Ht(1)***
*Minerals & Electrolytes* *Calcium** *Calcium Combinations*** Calcium Carbonate-Vitamin D ORAL TABLET 600-400 MG-UNIT *Calcium***
*Electrolyte Mixtures** *Electrolytes Oral***
*Fluoride** *Fluoride Combinations*** 68
Drug Name FLUOR-A-DAY ORAL TABLET CHEWABLE 0.25 (F)-236.79 MG, 0.5 (F)-236.79 MG, 1 (F)-236.79 MG
Preference Details Coverage Details P
*Fluoride*** Sodium Fluoride ORAL SOLUTION 1.1 (0.5 F) MG/ML
P
Sodium Fluoride ORAL TABLET CHEWABLE 0.55 (0.25 F) MG, 1.1 (0.5 F) MG, 2.2 (1 F) MG
P
*Iodine Products** *Iodine Products*** SSKI ORAL SOLUTION 1 GM/ML
P
*Magnesium** *Magnesium*** Magnesium Oxide ORAL TABLET 500 MG
P
OTC
*Phosphate** *Phosphate*** K-PHOS-NEUTRAL ORAL TABLET 155-852-130 MG
P
*Potassium** *Potassium*** KLOR-CON ORAL TABLET EXTENDEDRELEASE* 8 MEQ
P
KLOR-CON 10 ORAL TABLET EXTENDEDRELEASE* 10 MEQ
P
KLOR-CON M10 ORAL TABLET EXTENDEDRELEASE* 10 MEQ
P
KLOR-CON M20 ORAL TABLET EXTENDEDRELEASE* 20 MEQ
P
Potassium Chloride INTRAVENOUS* SOLUTION 0.4 MEQ/ML, 10 MEQ/100ML, 2 MEQ/ML, 30 MEQ/100ML, 40 MEQ/100ML
P
Potassium Chloride ORAL LIQUID† 20 MEQ/15ML (10%), 40 MEQ/15ML (20%)
P
Potassium Chloride ORAL SOLUTION 20 MEQ/15ML (10%)
P
Potassium Chloride Crys ER ORAL TABLET EXTENDEDRELEASE* 10 MEQ, 20 MEQ
P
69
Drug Name Potassium Chloride ER ORAL TABLET EXTENDEDRELEASE* 10 MEQ, 8 MEQ
Preference Details Coverage Details P
*Sodium** *Sodium*** Normal Saline Flush INTRAVENOUS* SOLUTION 0.9 %
P
QL (310 ML per 31 day(s))
Saline Flush INTRAVENOUS* SOLUTION 0.9 %
P
QL (310 ML per 31 day(s))
Sodium Chloride INJECTION SOLUTION 0.9 %
P
QL (310 ML per 31 day(s))
Sodium Chloride INTRAVENOUS* SOLUTION 0.9 %
P
*Zinc** *Zinc*** Zinc Sulfate ORAL TABLET 220 (50 Zn) MG
P
OTC
*Mouth/Throat/Dental Agents* *Anesthetics Topical Oral** *Anesthetics Topical Oral*** Lidocaine Viscous MOUTH/THROAT SOLUTION 2 %
P
*Anti-Infectives - Throat** *Anti-Infectives - Throat*** Clotrimazole MOUTH/THROAT LOZENGE 10 MG
P
Clotrimazole MOUTH/THROAT TROCHE 10 MG
P
Nystatin MOUTH/THROAT SUSPENSION 100000 UNIT/ML
P
QL (300 ML per 31 day(s))
Chlorhexidine Gluconate MOUTH/THROAT SOLUTION 0.12 %
P
QL (480 ML per 31 day(s))
PERIOGARD MOUTH/THROAT SOLUTION 0.12 %
P
QL (480 ML per 31 day(s))
*Antiseptics - Mouth/Throat** *Antiseptics - Mouth/Throat***
*Dental Products** *Fluoride Dental Products*** CAVAREST DENTAL GEL 1.1 %
P
DENTAGEL DENTAL GEL 1.1 %
P
70
Drug Name
Preference Details Coverage Details
FLUORIDEX DAILY DEFENSE DENTAL GEL 1.1 %
P
KARIGEL DENTAL GEL 1.1 %
P
KARIGEL-N DENTAL GEL 1.1 %
P
NEUTRAGARD ADVANCED DENTAL GEL 1.1 %
P
PHOS-FLUR DENTAL GEL 1.1 %
P
SF DENTAL GEL 1.1 %
P
*Steroids - Mouth/Throat** *Steroids - Mouth/Throat*** Triamcinolone Acetonide MOUTH/THROAT PASTE 0.1 %
P
*Throat Products - Misc.** *Saliva Stimulants*** Pilocarpine HCl ORAL TABLET 5 MG, 7.5 MG
P
*Multivitamins* *B-Complex W/ C** *B-Complex W/ C*** Vitamin B Complex-C ORAL CAPSULE
P
OTC
P
OTC
P
OTC
P
AL (Max 12 Years)
P
AL (Max 12 Years)
P
AL (Max 12 Years)
*B-Complex W/ Folic Acid** *B-Complex W/ C & Folic Acid*** Rena-Vite ORAL TABLET *Multivitamins** *Multivitamins*** Multi-Vitamins ORAL TABLET *Ped Multi Vitamins W/Fl & Fe** *Ped Multi Vitamins W/Fl & Fe*** Multi-Vit/Fluoride/Iron ORAL SOLUTION 0.25-10 MG/ML *Ped Vitamins Acd Fluoride & Iron*** Tri-Vit/Fluoride/Iron ORAL SOLUTION 0.25-10 MG/ML *Ped Mv W/ Fluoride** *Ped Mv W/ Fluoride*** Multi-Vit/Fluoride ORAL SOLUTION 0.25 MG/ML, 0.5 MG/ML
71
Drug Name
Preference Details Coverage Details
Multi-Vitamin/Fluoride ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG
P
AL (Max 12 Years)
Multivitamin/Fluoride ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG
P
AL (Max 12 Years)
Tri-Vit/Fluoride ORAL SOLUTION 0.25 MG/ML
P
AL (Max 12 Years)
Tri-Vitamin/Fluoride ORAL SOLUTION 0.25 MG/ML, 0.5 MG/ML
P
AL (Max 12 Years)
Vitamins ACD-Fluoride ORAL SOLUTION 0.25 MG/ML
P
AL (Max 12 Years)
P
OTC
P
OTC
P
OTC
*Ped Vitamins Acd W/ Fluoride***
*Ped Mv W/ Iron** *Ped Mv W/ Iron*** Poly-Vitamin/Iron ORAL SOLUTION 10 MG/ML *Pediatric Multiple Vitamins** *Pediatric Multiple Vitamins W/ C*** Poly-Vitamin ORAL SOLUTION 35 MG/ML *Pediatric Vitamins** *Pediatric Vitamins A & D W/ C*** Tri-Vitamin ORAL SOLUTION 1500-400-35 *Prenatal Vitamins** *Prenatal Mv & Min W/Fe-Fa*** ELITE-OB ORAL TABLET 50-1.25 MG
P
MYNATAL ADVANCE ORAL TABLET
P
Mynatal-Z ORAL TABLET
P
Mynate 90 Plus ORAL TABLET EXTENDEDRELEASE*
P
Prenatabs OBN ORAL TABLET 29-1 MG
P
PRENATABS RX ORAL TABLET 29-1 MG
P
Prenatal Low Iron ORAL TABLET 27-0.8 MG
P
Prenatal Plus ORAL TABLET 27-1 MG
P
Prenatal Plus Iron ORAL TABLET 29-1 MG
P
Prenatal Vitamins ORAL TABLET 28-0.8 MG
P
Se-Natal 19 ORAL TABLET CHEWABLE 29-1 MG
P
Trinatal Rx 1 ORAL TABLET 60-1 MG
P
72
OTC
OTC
Drug Name
Preference Details Coverage Details
TRIVEEN-U ORAL CAPSULE 106.5-1 MG
P
UltimateCare Combo ORAL MISC 30-1 MG
P
VINATE AZ ORAL TABLET 27-1 MG
P
VINATE AZ EXTRA ORAL TABLET 29-1 MG
P
VINATE GT ORAL TABLET 90-1 MG
P
VINATE II ORAL TABLET 29-1 MG
P
VINATE M ORAL TABLET 27-1 MG
P
*Prenatal Mv & Min W/Fe-Fa-Ca-Omega 3 Fish Oil*** PR NATAL 400 EC ORAL MISC 29-1-200 & 400 MG (DR)
P
*Prenatal Vitamins*** FOLBECAL ORAL TABLET 1 MG
P
*Musculoskeletal Therapy Agents* *Central Muscle Relaxants** *Central Muscle Relaxants*** Baclofen ORAL TABLET 10 MG, 20 MG
P
Carisoprodol ORAL TABLET 350 MG
P
Chlorzoxazone ORAL TABLET 500 MG
P
Cyclobenzaprine HCl ORAL TABLET 10 MG, 5 MG
P
Methocarbamol ORAL TABLET 500 MG, 750 MG
P
QL (124 EA per 31 day(s))
QL (93 EA per 31 day(s))
*Direct Muscle Relaxants** *Direct Muscle Relaxants*** Dantrolene Sodium ORAL CAPSULE 100 MG, 25 MG, 50 MG
P
*Viscosupplements** *Viscosupplements*** SUPARTZ INTRA-ARTICULAR* SOLUTION 25 MG/2.5ML
P
PA
P
OTC
*Nasal Agents - Systemic And Topical* *Nasal Agents - Misc.** *Nasal Agents - Misc.*** Saline Mist Spray NASAL SOLUTION 0.65 %
73
Drug Name Saline Nasal Spray NASAL SOLUTION 0.65 %
Preference Details Coverage Details P
OTC
*Nasal Antiallergy** *Nasal Antihistamines*** Azelastine HCl NASAL SOLUTION 137 MCG/SPRAY
P
*Nasal Mast Cell Stabilizers*** Cromolyn Sodium NASAL AEROSOL, SOLUTION 5.2 MG/ACT
P
OTC
*Nasal Anticholinergics** *Nasal Anticholinergics*** Ipratropium Bromide NASAL SOLUTION 0.03 %, 0.06 %
P
*Nasal Steroids** *Nasal Steroids*** Flunisolide NASAL SOLUTION 25 MCG/ACT (0.025%)
P
Fluticasone Propionate NASAL SUSPENSION 50 MCG/ACT
P
*Sympathomimetic Decongestants** *Systemic Decongestants*** Pseudoephedrine HCl ORAL TABLET 30 MG, 60 MG
P
OTC
P
OTC; QL (15 ML per 31 day(s))
*Ophthalmic Agents* *Artificial Tears And Lubricants** *Artificial Tears And Lubricants*** Artificial Tears OPHTHALMIC SOLUTION 1.4 % *Beta-Blockers - Ophthalmic** *Beta-Blockers - Ophthalmic Combinations*** Dorzolamide HCl-Timolol Mal OPHTHALMIC SOLUTION 22.3-6.8 MG/ML
P
*Beta-Blockers - Ophthalmic*** Betaxolol HCl OPHTHALMIC SOLUTION 0.5 %
P
BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 %
P
74
Drug Name
Preference Details Coverage Details
Carteolol HCl OPHTHALMIC SOLUTION 1 %
P
Levobunolol HCl OPHTHALMIC SOLUTION 0.25 %, 0.5 %
P
Metipranolol OPHTHALMIC SOLUTION 0.3 %
P
Timolol Maleate OPHTHALMIC GEL FORMING SOLUTION 0.25 %, 0.5 %
P
Timolol Maleate OPHTHALMIC SOLUTION 0.25 %, 0.5 %
P
*Cycloplegic Mydriatics** *Cycloplegic Mydriatics*** Atropine Sulfate OPHTHALMIC OINTMENT 1 %
P
Atropine Sulfate OPHTHALMIC SOLUTION 1%
P
Atropine-Care OPHTHALMIC SOLUTION 1 %
P
ISOPTO HYOSCINE OPHTHALMIC SOLUTION 0.25 %
P
*Ophthalmic Adrenergic Agents** *Ophthalmic Selective Alpha Adrenergic Agonists*** Brimonidine Tartrate OPHTHALMIC SOLUTION 0.2 %
P
*Ophthalmic Anti-Infectives** *Ophthalmic Antibiotics*** Ciprofloxacin HCl OPHTHALMIC SOLUTION 0.3 %
P
Erythromycin OPHTHALMIC OINTMENT 5 MG/GM
P
Gentamicin Sulfate OPHTHALMIC OINTMENT 0.3 %
P
Gentamicin Sulfate OPHTHALMIC SOLUTION 0.3 %
P
Ofloxacin OPHTHALMIC SOLUTION 0.3 %
P
Tobramycin Sulfate OPHTHALMIC SOLUTION 0.3 %
P
*Ophthalmic Anti-Infective Combinations***
75
Drug Name
Preference Details Coverage Details
AK-Poly-Bac OPHTHALMIC OINTMENT 500-10000 UNIT/GM
P
Bacitracin-Polymyxin B OPHTHALMIC OINTMENT 500-10000 UNIT/GM
P
Neomycin-Bacitracin Zn-Polymyx OPHTHALMIC OINTMENT 5-400-10000
P
Neomycin-Polymyxin-Gramicidin OPHTHALMIC SOLUTION 1.75-10000-0.25
P
Polycin B OPHTHALMIC OINTMENT 500-10000 UNIT/GM
P
Polymyxin B-Trimethoprim OPHTHALMIC SOLUTION 10000-0.1 UNIT/ML-%
P
*Ophthalmic Antivirals*** Trifluridine OPHTHALMIC SOLUTION 1 %
P
*Ophthalmic Sulfonamides*** Sulfacetamide Sodium OPHTHALMIC SOLUTION 10 %
P
*Ophthalmic Immunomodulators** *Ophthalmic Immunomodulators*** RESTASIS OPHTHALMIC EMULSION 0.05 %
P
*Ophthalmic Steroids** *Ophthalmic Steroid Combinations*** Neomycin-Polymyxin-Dexameth OPHTHALMIC OINTMENT 3.5-10000-0.1
P
Neomycin-Polymyxin-Dexameth OPHTHALMIC SUSPENSION 3.5-10000-0.1
P
Neomycin-Polymyxin-HC OPHTHALMIC SUSPENSION 3.5-10000-1
P
Poly-Dex OPHTHALMIC OINTMENT 3.5-10000-0.1
P
PRED-G OPHTHALMIC SUSPENSION 0.3-1 %
P
Sulfacetamide-Prednisolone OPHTHALMIC SOLUTION 10-0.23 %
P
TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %
P
*Ophthalmic Steroids***
76
Drug Name
Preference Details Coverage Details
Dexamethasone Sodium Phosphate OPHTHALMIC SOLUTION 0.1 %
P
FLUOR-OP OPHTHALMIC SUSPENSION 0.1 %
P
Fluorometholone OPHTHALMIC SUSPENSION 0.1 %
P
FML FORTE OPHTHALMIC SUSPENSION 0.25 %
P
LOTEMAX OPHTHALMIC SUSPENSION 0.5 %
P
MAXIDEX OPHTHALMIC SUSPENSION 0.1 %
P
PrednisoLONE Acetate OPHTHALMIC SUSPENSION 1 %
P
VEXOL OPHTHALMIC SUSPENSION 1 %
P
*Ophthalmics - Misc.** *Ophthalmic Antiallergic*** Cromolyn Sodium OPHTHALMIC SOLUTION 4 %
P
Ketotifen Fumarate OPHTHALMIC SOLUTION 0.025 %
P
OTC
*Ophthalmic Carbonic Anhydrase Inhibitors*** AZOPT OPHTHALMIC SUSPENSION 1 %
P
Dorzolamide HCl OPHTHALMIC SOLUTION 2 %
P
*Ophthalmic Nonsteroidal Anti-Inflammatory Agents*** Diclofenac Sodium OPHTHALMIC SOLUTION 0.1 %
P
Flurbiprofen Sodium OPHTHALMIC SOLUTION 0.03 %
P
*Prostaglandins - Ophthalmic** *Prostaglandins - Ophthalmic*** Latanoprost OPHTHALMIC SOLUTION 0.005 %
P
QL (5 ML per 31 day(s))
*Otic Agents* *Otic Agents - Miscellaneous** *Otic Agents - Miscellaneous***
77
Drug Name Acetic Acid-Aluminum Acetate OTIC SOLUTION 2 %
Preference Details Coverage Details P
*Otic Anti-Infectives** *Otic Anti-Infectives*** Ofloxacin OTIC SOLUTION 0.3 %
P
*Otic Combinations** *Otic Analgesic Combinations*** Antipyrine-Benzocaine OTIC SOLUTION 5.4-1.4 %, 54-14 MG/ML
P
Oticin OTIC LIQUID† 1-0.1 %
P
*Otic Steroid-Anti-Infective Combinations*** CIPRODEX OTIC SUSPENSION 0.3-0.1 %
P
Neomycin-Polymyxin-HC OTIC SOLUTION 3.5-10000-1
P
Neomycin-Polymyxin-HC OTIC SUSPENSION 3.5-10000-1
P
ST; AL (Max 8 Years)
*Oxytocics* *Oxytocics** *Oxytocics*** Methylergonovine Maleate INJECTION SOLUTION 0.2 MG/ML
P
Methylergonovine Maleate ORAL TABLET 0.2 MG
P
*Passive Immunizing Agents* *Monoclonal Antibodies** *Antiviral Monoclonal Antibodies*** SYNAGIS INTRAMUSCULAR* SOLUTION 100 MG/ML, 50 MG/0.5ML
P
PA
*Penicillins* *Aminopenicillins** *Aminopenicillins*** Amoxicillin ORAL CAPSULE 250 MG, 500 MG
P
Amoxicillin ORAL SUSPENSION RECONSTITUTED 125 MG/5ML, 200 MG/5ML, 250 MG/5ML, 400 MG/5ML
P
Amoxicillin ORAL TABLET 500 MG, 875 MG
P
78
QL (300 ML per 31 day(s))
Drug Name
Preference Details Coverage Details
Amoxicillin ORAL TABLET CHEWABLE 125 MG, 250 MG
P
Ampicillin ORAL CAPSULE 250 MG, 500 MG
P
Ampicillin ORAL SUSPENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML
P
*Natural Penicillins** *Natural Penicillins*** BICILLIN L-A INTRAMUSCULAR* SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML
P
Penicillin G Procaine INTRAMUSCULAR* SUSPENSION 600000 UNIT/ML
P
Penicillin V Potassium ORAL SOLUTION RECONSTITUTED 125 MG/5ML, 250 MG/5ML
P
Penicillin V Potassium ORAL TABLET 250 MG, 500 MG
P
PFIZERPEN-G INJECTION SOLUTION RECONSTITUTED 20000000 UNIT, 5000000 UNIT
P
QL (300 ML per 31 day(s))
*Penicillin Combinations** *Penicillin Combinations*** Amoxicillin-Pot Clavulanate ORAL SUSPENSION RECONSTITUTED 200-28.5 MG/5ML, 250-62.5 MG/5ML, 400-57 MG/5ML, 600-42.9 MG/5ML
P
Amoxicillin-Pot Clavulanate ORAL TABLET 250-125 MG, 500-125 MG, 875-125 MG
P
Amoxicillin-Pot Clavulanate ORAL TABLET CHEWABLE 200-28.5 MG, 400-57 MG
P
BICILLIN C-R INTRAMUSCULAR* SUSPENSION 1200000 UNIT/2ML
P
BICILLIN C-R 900/300 INTRAMUSCULAR* SUSPENSION 900000-300000 UNIT/2ML
P
QL (300 ML per 31 day(s))
*Penicillinase-Resistant Penicillins** *Penicillinase-Resistant Penicillins*** Dicloxacillin Sodium ORAL CAPSULE 250 MG, 500 MG
P
79
Drug Name Oxacillin Sodium INJECTION SOLUTION RECONSTITUTED 1 GM, 10 GM, 2 GM
Preference Details Coverage Details P
*Progestins* *Progestins** *Progestins*** MAKENA INTRAMUSCULAR* OIL 250 MG/ML
P
MedroxyPROGESTERone Acetate ORAL TABLET 10 MG, 2.5 MG, 5 MG
P
Norethindrone Acetate ORAL TABLET 5 MG
P
PA
*Psychotherapeutic And Neurological Agents Misc.* *Agents For Chemical Dependency** *Alcohol Deterrents*** Acamprosate Calcium ORAL TABLET DELAYED RELEASE 333 MG
P
Disulfiram ORAL TABLET 250 MG, 500 MG
P
*Antidementia Agents** *Cholinomimetics - Ache Inhibitors*** Donepezil HCl ORAL TABLET 10 MG, 5 MG
P
EXELON TRANSDERMAL PATCH 24 HR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR
P
Rivastigmine Tartrate ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG
P
*N-Methyl-D-Aspartate (Nmda) Receptor Antagonists*** NAMENDA ORAL SOLUTION 10 MG/5ML
P
NAMENDA ORAL TABLET 10 MG, 5 MG
P
NAMENDA TITRATION PAK ORAL TABLET 5 (28)-10 (21) MG
P
*Combination Psychotherapeutics** *Benzodiazepines & Tricyclic Agents*** Chlordiazepoxide-Amitriptyline ORAL TABLET 10-25 MG, 5-12.5 MG *Phenothiazines & Tricyclic Agents***
80
P
QL (186 EA per 31 day(s))
Drug Name Perphenazine-Amitriptyline ORAL TABLET 2-10 MG, 2-25 MG, 4-10 MG, 4-25 MG, 4-50 MG
Preference Details Coverage Details P
*Fibromyalgia Agents** *Fibromyalgia Agent - Snris*** SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG
P
SAVELLA TITRATION PACK ORAL MISC 12.5 & 25 & 50 MG
P
*Multiple Sclerosis Agents** *Ms Agents - Pyrimidine Synthesis Inhibitors*** AUBAGIO ORAL TABLET 14 MG, 7 MG
P
PA
EXTAVIA SUBCUTANEOUS* KIT 0.3 MG
P
PA
REBIF SUBCUTANEOUS* SOLUTION 22 MCG/0.5ML, 44 MCG/0.5ML
P
PA
REBIF REBIDOSE SUBCUTANEOUS* SOLUTION 22 MCG/0.5ML, 44 MCG/0.5ML
P
PA
REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS* SOLUTION 6X8.8 & 6X22 MCG
P
PA
REBIF TITRATION PACK SUBCUTANEOUS* SOLUTION 6X8.8 & 6X22 MCG
P
PA
P
PA
P
AL (Min 12 Years)
Nicotine TRANSDERMAL PATCH 24 HR 14 MG/24HR, 21 MG/24HR, 7 MG/24HR
P
OTC; QL (140 EA per 365 day(s))
Nicotine Polacrilex MOUTH/THROAT GUM 2 MG, 4 MG
P
OTC; QL (4032 EA per 365 day(s))
*Multiple Sclerosis Agents - Interferons***
*Multiple Sclerosis Agents*** COPAXONE SUBCUTANEOUS* KIT 20 MG/ML *Psychotherapeutic And Neurological Agents Misc.** *Psychotherapeutic And Neurological Agents Misc.*** ORAP ORAL TABLET 1 MG, 2 MG *Smoking Deterrents** *Smoking Deterrents***
81
Drug Name
Preference Details Coverage Details
*Respiratory Agents - Misc.* *Cystic Fibrosis Agents** *Cftr Potentiators*** KALYDECO ORAL TABLET 150 MG
P
PA
P
PA
*Hydrolytic Enzymes*** PULMOZYME INHALATION SOLUTION 1 MG/ML *Tetracyclines* *Tetracyclines** *Tetracyclines*** DOXY 100 INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG
P
Doxycycline Hyclate ORAL CAPSULE 100 MG, 50 MG
P
PA
Doxycycline Hyclate ORAL TABLET 100 MG
P
PA
Doxycycline Hyclate ORAL TABLET 20 MG
P
Minocycline HCl ORAL CAPSULE 100 MG, 50 MG, 75 MG
P
Tetracycline HCl ORAL CAPSULE 250 MG, 500 MG
P
*Thyroid Agents* *Antithyroid Agents** *Antithyroid Agents*** Methimazole ORAL TABLET 10 MG, 5 MG
P
Propylthiouracil ORAL TABLET 50 MG
P
*Thyroid Hormones** *Thyroid Hormones*** ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG
P
Levothyroxine Sodium INTRAVENOUS* SOLUTION RECONSTITUTED 100 MCG, 500 MCG
P
Levothyroxine Sodium ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG
P
Liothyronine Sodium ORAL TABLET 25 MCG, 5 MCG, 50 MCG
P
82
QL (558 EA per 31 day(s))
Drug Name
Preference Details Coverage Details
NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG
P
NP Thyroid ORAL TABLET 30 MG, 60 MG, 90 MG
P
THYROLAR-1 ORAL TABLET 60 (12.5-50) MG (MCG)
P
THYROLAR-1/2 ORAL TABLET 30 (6.25-25) MG (MCG)
P
THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5) MG (MCG)
P
THYROLAR-2 ORAL TABLET 120 (25-100) MG (MCG)
P
THYROLAR-3 ORAL TABLET 180 (37.5-150) MG (MCG)
P
UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG
P
WESTHROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG
P
*Ulcer Drugs* *Antispasmodics** *Antispasmodics*** Dicyclomine HCl ORAL CAPSULE 10 MG
P
Dicyclomine HCl ORAL SOLUTION 10 MG/5ML
P
Dicyclomine HCl ORAL TABLET 20 MG
P
*Quaternary Anticholinergics*** Glycopyrrolate ORAL TABLET 1 MG, 2 MG
P
Propantheline Bromide ORAL TABLET 15 MG
P
*H-2 Antagonists** *H-2 Antagonists*** Acid Reducer ORAL TABLET 75 MG
P
OTC
Cimetidine ORAL TABLET 200 MG
P
OTC
83
Drug Name
Preference Details Coverage Details
Cimetidine ORAL TABLET 300 MG, 400 MG, 800 MG
P
Cimetidine HCl ORAL SOLUTION 300 MG/5ML
P
Famotidine INTRAVENOUS* SOLUTION 10 MG/ML
P
Famotidine ORAL TABLET 10 MG
P
Famotidine ORAL TABLET 20 MG, 40 MG
P
Famotidine Premixed INTRAVENOUS* SOLUTION 20-0.9 MG/50ML-%
P
Ranitidine Acid Reducer ORAL TABLET 75 MG
P
Ranitidine HCl INJECTION SOLUTION 1000 MG/40ML, 150 MG/6ML, 50 MG/2ML
P
Ranitidine HCl ORAL CAPSULE 150 MG, 300 MG
P
Ranitidine HCl ORAL SYRUP 15 MG/ML
P
QL (620 ML per 31 Day(s))
Ranitidine HCl ORAL TABLET 150 MG
P
OTC
Ranitidine HCl ORAL TABLET 300 MG
P
OTC
OTC
*Misc. Anti-Ulcer** *Misc. Anti-Ulcer*** CARAFATE ORAL SUSPENSION 1 GM/10ML
P
Sucralfate ORAL TABLET 1 GM
P
QL (1240 ML per 31 day(s))
*Proton Pump Inhibitors** *Proton Pump Inhibitors*** Lansoprazole ORAL CAPSULE DELAYED RELEASE 15 MG
P
ST; OTC
Lansoprazole ORAL CAPSULE DELAYED RELEASE 30 MG
P
ST
Omeprazole ORAL CAPSULE DELAYED RELEASE 10 MG, 20 MG, 40 MG
P
Pantoprazole Sodium ORAL TABLET DELAYED RELEASE 20 MG, 40 MG
P
*Ulcer Drugs - Prostaglandins** *Ulcer Drugs - Prostaglandins*** Misoprostol ORAL TABLET 100 MCG, 200 MCG *Urinary Anti-Infectives* 84
P
Drug Name
Preference Details Coverage Details
*Urinary Anti-Infective Combinations** *Urinary Antiseptic-Antispasmodic &/Or Analgesics*** URETRON D/S ORAL TABLET
P
Uticap ORAL CAPSULE 120 MG
P
*Urinary Anti-Infectives** *Urinary Anti-Infectives*** MACRODANTIN ORAL CAPSULE 25 MG
P
Nitrofurantoin Macrocrystal ORAL CAPSULE 100 MG, 50 MG
P
Nitrofurantoin Monohyd Macro ORAL CAPSULE 100 MG
P
AL (Max 8 Years)
*Urinary Antispasmodics* *Urinary Antispasmodics** *Urinary Antispasmodics*** Bethanechol Chloride ORAL TABLET 10 MG, 25 MG, 5 MG, 50 MG
P
Oxybutynin Chloride ORAL SYRUP 5 MG/5ML
P
Oxybutynin Chloride ORAL TABLET 5 MG
P
Oxybutynin Chloride ER ORAL TABLET EXTENDED RELEASE 24 HR* 10 MG, 15 MG, 5 MG
P
Trospium Chloride ORAL TABLET 20 MG
P
*Vaginal Products* *Vaginal Anti-Infectives** *Imidazole-Related Antifungals*** 3 Day Vaginal VAGINAL CREAM 2 %
P
OTC
Clotrimazole VAGINAL CREAM 1 %
P
OTC
Miconazole 3 VAGINAL SUPPOSITORY 200 MG
P
Miconazole 3 Combo Pack VAGINAL KIT 200-2 MG-% (9GM)
P
OTC
Miconazole Nitrate VAGINAL CREAM 2 %
P
OTC
Miconazole Nitrate VAGINAL SUPPOSITORY 100 MG
P
OTC
MONISTAT 1 COMBO PACK VAGINAL KIT 1200-2 MG-%
P
OTC
85
Drug Name
Preference Details Coverage Details
MONISTAT 3 VAGINAL CREAM 4 %
P
Terconazole VAGINAL CREAM 0.4 %, 0.8 %
P
Terconazole VAGINAL SUPPOSITORY 80 MG
P
OTC
*Vaginal Anti-Infectives*** Clindamycin Phosphate VAGINAL CREAM 2 %
P
MetroNIDAZOLE VAGINAL GEL 0.75 %
P
VANDAZOLE VAGINAL GEL 0.75 %
P
*Vaginal Estrogens** *Vaginal Estrogens*** PREMARIN VAGINAL CREAM 0.625 MG/GM
P
*Vaginal Progestins** *Vaginal Progestins*** ENDOMETRIN VAGINAL INSERT 100 MG
P
FIRST-PROGESTERONE VGS 100 VAGINAL SUPPOSITORY 100 MG
P
FIRST-PROGESTERONE VGS 200 VAGINAL SUPPOSITORY 200 MG
P
FIRST-PROGESTERONE VGS 25 VAGINAL SUPPOSITORY 25 MG
P
FIRST-PROGESTERONE VGS 400 VAGINAL SUPPOSITORY 400 MG
P
FIRST-PROGESTERONE VGS 50 VAGINAL SUPPOSITORY 50 MG
P
*Vasopressors* *Anaphylaxis Therapy Agents** *Anaphylaxis Therapy Agents*** EPIPEN 2-PAK INJECTION DEVICE 0.3 MG/0.3ML
P
QL (6 EA per 180 day(s))
EPIPEN JR 2-PAK INJECTION DEVICE 0.15 MG/0.3ML
P
QL (6 EA per 180 day(s))
*Vasopressors** *Vasopressors*** Midodrine HCl ORAL TABLET 10 MG, 2.5 MG, 5 MG
86
P
Drug Name
Preference Details Coverage Details
*Vitamins* *Oil Soluble Vitamins** *Vitamin A*** Vitamin A ORAL CAPSULE 10000 UNIT, 8000 UNIT
P
OTC
P
QL (4 EA per 28 Day(s))
*Vitamin D*** Vitamin D (Ergocalciferol) ORAL CAPSULE 50000 UNIT *Vitamin K*** MEPHYTON ORAL TABLET 5 MG
P
Vitamin K (Phytonadione) ORAL TABLET 100 MCG
P
OTC
Biotin ORAL CAPSULE 5 MG, 5000 MCG
P
OTC
Biotin 5000 ORAL CAPSULE 5 MG
P
OTC
Biotin Maximum Strength ORAL CAPSULE 5000 MCG
P
OTC
*Water Soluble Vitamins** *Biotin***
*Vitamin B-1*** Thiamine HCl INJECTION SOLUTION 100 MG/ML
P
Vitamin B-1 ORAL TABLET 100 MG, 250 MG, 50 MG
P
OTC
Niacin ORAL TABLET 100 MG, 250 MG, 50 MG, 500 MG
P
OTC
Niacin ER ORAL CAPSULE EXTENDED RELEASE* 500 MG
P
OTC
Niacin ER ORAL TABLET EXTENDEDRELEASE* 500 MG
P
OTC
NIACOR ORAL TABLET 500 MG
P
*Vitamin B-3***
*Vitamin B-6*** Vitamin B-6 ORAL TABLET 100 MG, 25 MG, 250 MG, 50 MG, 500 MG
P
OTC
Vitamin B-6 ER ORAL TABLET EXTENDEDRELEASE* 200 MG
P
OTC
87
88
Index
3 Day Vaginal VAGINAL CREAM 2 % ...................................................... 85 Abacavir Sulfate ORAL TABLET 300 MG ...................................... 38 Acamprosate Calcium ORAL TABLET DELAYED RELEASE 333 MG ...................................................................... 80 Acarbose ORAL TABLET 100 MG, 25 MG, 50 MG ................................ 19 ACCU-CHEK ACTIVE IN VITRO STRIP ............................................... 55 ACCU-CHEK AVIVA PLUS IN VITRO STRIP ............................................... 55 ACCU-CHEK AVIVA PLUS XX KIT W/DEVICE ............................ 66 ACCU-CHEK COMFORT CURVE IN VITRO STRIP ................................................................................................ 56 ACCU-CHEK COMPACT IN VITRO STRIP ............................................... 56 ACCU-CHEK COMPACT PLUS CARE XX KIT ........................ 66 ACCU-CHEK COMPACT TEST DRUM IN VITRO STRIP .......................................................................... 56 ACCU-CHEK NANO SMARTVIEW XX KIT W/DEVICE ......................................................... 66 ACCU-CHEK SMARTVIEW IN VITRO STRIP ..................................... 56 Acetaminophen ORAL SOLUTION 160 MG/5ML .............. 4 Acetaminophen ORAL TABLET 325 MG .......................................................................... 4 Acetaminophen ORAL TABLET 500 MG .......................................................................... 4 Acetaminophen-Codeine #2 ORAL TABLET 300-15 MG .................................................................................................... 6 Acetaminophen-Codeine #3 ORAL TABLET 300-30 MG .................................................................................................... 6 Acetaminophen-Codeine #4 ORAL TABLET 300-60 MG .................................................................................................... 6 Acetaminophen-Codeine ORAL SOLUTION 120-12 MG/5ML .................................................................................................... 6 AcetaZOLAMIDE ORAL TABLET 125 MG, 250 MG ................................................................................................ 56
Acetic Acid-Aluminum Acetate OTIC SOLUTION 2 % ...................... 78 Acetylcysteine INHALATION SOLUTION 10 %, 20 % ................... 49 Acid Reducer ORAL TABLET 75 MG ................................................................................... 83 Acne Medication 5 EXTERNAL LOTION 5 % .................................................... 49 Acne Medication EXTERNAL LOTION 10 % ................................................. 49 ACTICIN EXTERNAL CREAM 5 % ..................................................... 55 Acyclovir ORAL CAPSULE 200 MG ................................................................................... 39 Acyclovir ORAL SUSPENSION 200 MG/5ML .................................................... 39 Acyclovir ORAL TABLET 400 MG, 800 MG ...................................................... 39 ADDERALL XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 5 MG ...................................................................................... 1 ADRUCIL INTRAVENOUS* SOLUTION 500 MG/10ML ................................................................................................ 30 ADVAIR DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE ...................................................... 12 ADVAIR HFA INHALATION AEROSOL† 115-21 MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT ........................................................... 12 AEROCHAMBER PLUS FLO-VU LARGE XX MISC ................................................................................................ 67 AEROCHAMBER PLUS FLO-VU SMALL XX MISC ................................................................................................ 67 AEROCHAMBER PLUS FLO-VU W/MASK XX MISC ................................................................................................ 67 AEROCHAMBER PLUS FLO-VU XX MISC ................................ 67 AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG ................................................................................................ 32
AK-Poly-Bac OPHTHALMIC OINTMENT 500-10000 UNIT/GM .............................................................. 76 ALAVERT ALLERGY/SINUS ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG ................................................................................................ 48 ALBENZA ORAL TABLET 200 MG ...................................................................................... 8 Albuterol Sulfate INHALATION NEBULIZATION SOLUTION (2.5 MG/3ML) 0.083% ...................... 13 Albuterol Sulfate INHALATION NEBULIZATION SOLUTION (5 MG/ML) 0.5% ...................................... 13 Albuterol Sulfate INHALATION NEBULIZATION SOLUTION 0.63 MG/3ML, 1.25 MG/3ML ................................................................................................ 13 Albuterol Sulfate ORAL SYRUP 2 MG/5ML ........................................................... 13 Albuterol Sulfate ORAL TABLET 2 MG, 4 MG ........................ 13 Alclometasone Dipropionate EXTERNAL CREAM 0.05 % ................................................................................................ 52 Alclometasone Dipropionate EXTERNAL OINTMENT 0.05 % ......................................................................................... 52 Alcohol Pads XX PAD 70 % ................................................................................................ 66 Alendronate Sodium ORAL TABLET 10 MG, 35 MG, 40 MG, 5 MG, 70 MG ................................... 58 Aler-Dryl ORAL TABLET 50 MG ................................................................................... 24 ALKERAN ORAL TABLET 2 MG .................................................................................. 29 ALLEGRA ALLERGY CHILDRENS ORAL TABLET 30 MG ......................................................................... 24 ALLEGRA-D ALLERGY & CONGESTION ORAL TABLET EXTENDED RELEASE 12 HR* 60-120 MG ................................................................................................ 48 Allergy ORAL TABLET 4 MG ................................................................................................ 24 Allergy ORAL TABLET DISPERSIBLE 10 MG ...................... 24
89
Allergy Relief/Nasal Decongest ORAL TABLET EXTENDED RELEASE 24 HR* 10-240 MG ................................................................................................ 48 Allopurinol ORAL TABLET 100 MG, 300 MG ...................................................... 61 ALPRAZolam ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG ................................................................................................ 10 ALTAVERA ORAL TABLET 0.15-30 MG-MCG .................................... 44 Aluminum Hydroxide Gel ORAL SUSPENSION 320 MG/5ML .................................................................................................... 8 Amantadine HCl ORAL CAPSULE 100 MG ................................. 33 Amantadine HCl ORAL SYRUP 50 MG/5ML ........................................................ 33 Amantadine HCl ORAL TABLET 100 MG ...................................... 33 A-METHAPRED INJECTION SOLUTION RECONSTITUTED 125 MG, 40 MG .................................................................................. 47 Amiloride-Hydrochlorothiazide ORAL TABLET 5-50 MG ............. 56 Aminophylline INTRAVENOUS* SOLUTION 25 MG/ML .................. 13 Amiodarone HCl INTRAVENOUS* SOLUTION 150 MG/3ML .................................................... 11 Amiodarone HCl ORAL TABLET 200 MG, 400 MG ................................................................................................ 11 Amitriptyline HCl ORAL TABLET 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 MG ................................................................................................ 18 AMLACTIN EXTERNAL LOTION 12 % ................................................ 54 AmLODIPine Besylate ORAL TABLET 10 MG, 2.5 MG, 5 MG ................................................................................................ 41 Ammonium Lactate EXTERNAL CREAM 12 % .................................................. 54 Ammonium Lactate EXTERNAL LOTION 12 % ................................................. 54 AMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG .................................................................................. 49 Amoxapine ORAL TABLET 100 MG, 150 MG, 25 MG, 50 MG ................................................................................................ 19
90
Amoxicillin ORAL CAPSULE 250 MG, 500 MG ......................................... 78 Amoxicillin ORAL SUSPENSION RECONSTITUTED 125 MG/5ML, 200 MG/5ML, 250 MG/5ML, 400 MG/5ML .................. 78 Amoxicillin ORAL TABLET 500 MG, 875 MG ...................................................... 78 Amoxicillin ORAL TABLET CHEWABLE 125 MG, 250 MG ................................................................................................ 79 Amoxicillin-Pot Clavulanate ORAL SUSPENSION RECONSTITUTED 200-28.5 MG/5ML, 250-62.5 MG/5ML, 400-57 MG/5ML, 600-42.9 MG/5ML ................................................................. 79 Amoxicillin-Pot Clavulanate ORAL TABLET 250-125 MG, 500-125 MG, 875-125 MG .............. 79 Amoxicillin-Pot Clavulanate ORAL TABLET CHEWABLE 200-28.5 MG, 400-57 MG ............... 79 Amphetamine-Dextroamphetamin e ORAL TABLET 10 MG, 12.5 MG, 15 MG, 5 MG, 7.5 MG .................................................................................................... 1 Amphetamine-Dextroamphetamin e ORAL TABLET 20 MG ................. 1 Amphetamine-Dextroamphetamin e ORAL TABLET 30 MG ................. 1 Ampicillin ORAL CAPSULE 250 MG, 500 MG ...................................................... 79 Ampicillin ORAL SUSPENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML .................. 79 Anagrelide HCl ORAL CAPSULE 0.5 MG, 1 MG ............ 62 Anastrozole ORAL TABLET 1 MG ................................................................................... 31 Antihistamine Decongestant ORAL TABLET 2.5-60 MG ................................................................................................ 48 Antipyrine-Benzocaine OTIC SOLUTION 5.4-1.4 %, 54-14 MG/ML ..................................................................... 78 APIDRA INJECTION SOLUTION 100 UNIT/ML ................................................................................................ 21 APIDRA SOLOSTAR SUBCUTANEOUS* SOLUTION 100 UNIT/ML ................................................................................................ 21
APRI ORAL TABLET 0.15-30 MG-MCG ............................................................. 44 APRISO ORAL CAPSULE EXTENDED RELEASE 24 HOUR 0.375 GM ...................................... 60 APTIVUS ORAL CAPSULE 250 MG ..................................................................... 37 ARGYLE STERILE SALINE IRRIGATION SOLUTION 0.9 % ......................................................................................... 61 ARMOUR THYROID ORAL TABLET 120 MG, 15 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG .............................................. 82 Artificial Tears OPHTHALMIC SOLUTION 1.4 % .................................... 74 ASCOMP-CODEINE ORAL CAPSULE 50-325-40-30 MG .................................................................................................... 6 ASMANEX 120 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH ............................................................ 12 ASMANEX 14 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH ............................................................ 12 ASMANEX 30 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 110 MCG/INH, 220 MCG/INH ................................................................................................ 12 ASMANEX 60 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 220 MCG/INH ............................................................ 12 ASMANEX 7 METERED DOSES INHALATION AEROSOL POWDER, BREATH ACTIVATED 110 MCG/INH ............................................................ 12 Aspirin Low Dose ORAL TABLET 81 MG .............................................. 5 Aspirin ORAL TABLET 325 MG, 81 MG ............................................................. 5 Aspirin ORAL TABLET CHEWABLE 81 MG ................................ 5 Aspirin RE SUPPOSITORY 300 MG, 600 MG ......................................................... 5
Atenolol ORAL TABLET 100 MG, 25 MG, 50 MG ................................ 41 Atenolol-Chlorthalidone ORAL TABLET 100-25 MG, 50-25 MG ................................................................................................ 27 Atorvastatin Calcium ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG ......................................................... 25 Atovaquone-Proguanil HCl ORAL TABLET 250-100 MG, 62.5-25 MG .......................................................... 28 ATRIPLA ORAL TABLET 600-200-300 MG .......................................... 36 Atropine Sulfate OPHTHALMIC OINTMENT 1 % ........................................ 75 Atropine Sulfate OPHTHALMIC SOLUTION 1 % .......................................... 75 Atropine-Care OPHTHALMIC SOLUTION 1 % .......................................... 75 ATROVENT HFA INHALATION AEROSOL, SOLUTION 17 MCG/ACT ................................................................................................ 11 AUBAGIO ORAL TABLET 14 MG, 7 MG ........................................................... 81 AVANDAMET ORAL TABLET 2-1000 MG, 2-500 MG, 4-1000 MG, 4-500 MG ................................................................................................ 20 AVANDARYL ORAL TABLET 4-1 MG, 4-2 MG, 4-4 MG, 8-2 MG, 8-4 MG ........................ 20 AVANDIA ORAL TABLET 2 MG, 4 MG, 8 MG ..................................... 21 AVASTIN INTRAVENOUS* SOLUTION 100 MG/4ML, 400 MG/16ML ............................................................ 30 AVIANE ORAL TABLET 0.1-20 MG-MCG ........................................ 44 AVITA EXTERNAL CREAM 0.025 % ....................................................................... 50 AVITA EXTERNAL GEL 0.025 % ......................................................................................... 50 AVODART ORAL CAPSULE 0.5 MG ....................................................................... 61 AzaTHIOprine ORAL TABLET 50 MG .......................................................................... 40 Azelastine HCl NASAL SOLUTION 137 MCG/SPRAY ................................................................................................ 74 Azithromycin Hydrogencitrate INTRAVENOUS* SOLUTION RECONSTITUTED 2.5 GM ................................................................................................ 65
Azithromycin INTRAVENOUS* SOLUTION RECONSTITUTED 500 MG ................................................................................................ 65 Azithromycin ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML .................. 65 Azithromycin ORAL TABLET 250 MG ...................................................................... 65 Azithromycin ORAL TABLET 500 MG, 600 MG ......................................... 65 AZOPT OPHTHALMIC SUSPENSION 1 % .................................. 77 Bacitracin Zinc EXTERNAL OINTMENT 500 UNIT/GM ................................................................................................ 50 Bacitracin-Polymyxin B OPHTHALMIC OINTMENT 500-10000 UNIT/GM ............................ 76 Baclofen ORAL TABLET 10 MG, 20 MG ......................................................... 73 Balsalazide Disodium ORAL CAPSULE 750 MG ................................. 60 BALZIVA ORAL TABLET 0.4-35 MG-MCG ........................................ 44 BARACLUDE ORAL TABLET 0.5 MG, 1 MG ................................................ 38 Baza Antifungal EXTERNAL CREAM 2 % ...................................................... 51 BD INSULIN SYRINGE ULTRAFINE XX MISC 31G X 5/16" 1 ML ............................................................ 67 BENADRYL ALLERGY CHILDRENS ORAL LIQUID† 12.5 MG/5ML ................................................. 24 Benazepril HCl ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG ................................................................................................ 26 Benazepril-Hydrochlorothiazide ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG, 5-6.25 MG ................................................................................... 27 Benzoyl Peroxide EXTERNAL GEL 10 %, 5 % ................................................ 50 Benzoyl Peroxide-Erythromycin EXTERNAL GEL 5-3 % .................. 49 Benztropine Mesylate ORAL TABLET 0.5 MG, 1 MG, 2 MG ................................................................................................ 33 Betamethasone Dipropionate Aug EXTERNAL CREAM 0.05 % ................................................................................................ 52
Betamethasone Dipropionate EXTERNAL CREAM 0.05 % ................................................................................................
Betamethasone Dipropionate EXTERNAL LOTION 0.05 %
52
52 Betamethasone Dipropionate EXTERNAL OINTMENT 0.05 % ......................................................................................... 52 Betamethasone Valerate EXTERNAL CREAM 0.1 % ................................................................................................ 52 Betamethasone Valerate EXTERNAL LOTION 0.1 % ................................................................................................ 52 Betamethasone Valerate EXTERNAL OINTMENT 0.1 % ................................................................................................ 52 Betaxolol HCl OPHTHALMIC SOLUTION 0.5 % .................................... 74 Bethanechol Chloride ORAL TABLET 10 MG, 25 MG, 5 MG, 50 MG .......................................................................... 85 BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 % ........................ 74 BICILLIN C-R 900/300 INTRAMUSCULAR* SUSPENSION 900000-300000 UNIT/2ML .......................................................... 79 BICILLIN C-R INTRAMUSCULAR* SUSPENSION 1200000 UNIT/2ML .......................................................... 79 BICILLIN L-A INTRAMUSCULAR* SUSPENSION 1200000 UNIT/2ML, 2400000 UNIT/4ML, 600000 UNIT/ML ................................................................................................ 79 BILTRICIDE ORAL TABLET 600 MG ......................................................................... 8 Biotin 5000 ORAL CAPSULE 5 MG ................................................................................... 87 Biotin Maximum Strength ORAL CAPSULE 5000 MCG ........................ 87 Biotin ORAL CAPSULE 5 MG, 5000 MCG ............................................................. 87 Bisoprolol Fumarate ORAL TABLET 10 MG, 5 MG .................... 41 Bisoprolol-Hydrochlorothiazide ORAL TABLET 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG ................... 27 BOSULIF ORAL TABLET 100 MG, 500 MG .................................................... 32 ................................................................................................
91
Briellyn ORAL TABLET 0.4-35 MG-MCG ............................................................... 44 Brimonidine Tartrate OPHTHALMIC SOLUTION 0.2 % .............................................................................. 75 Bromocriptine Mesylate ORAL CAPSULE 5 MG ........................................ 33 Bromocriptine Mesylate ORAL TABLET 2.5 MG ........................................ 33 BRONCHO SALINE INHALATION AEROSOL, SOLUTION 0.9 % .................................... 49 BUDEPRION SR ORAL TABLET EXTENDED RELEASE 12 HR* 150 MG ................................................................................................ 17 Budesonide INHALATION SUSPENSION 0.25 MG/2ML, 0.5 MG/2ML ...................................................... 12 Bumetanide INJECTION SOLUTION 0.25 MG/ML ............ 57 Bumetanide ORAL TABLET 0.5 MG, 1 MG, 2 MG ....................................... 57 Buprenorphine HCl SUBLINGUAL TABLET SUBLINGUAL 2 MG, 8 MG .................................................................................................... 7 BuPROPion HCl ER (SR) ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG, 150 MG, 200 MG ...................................................... 17 BuPROPion HCl ER (XL) ORAL TABLET EXTENDED RELEASE 24 HR* 150 MG, 300 MG ................................................................................... 17 BuPROPion HCl ORAL TABLET 100 MG, 75 MG ............. 17 BusPIRone HCl ORAL TABLET 10 MG, 15 MG, 30 MG, 5 MG, 7.5 MG ........................................................................... 9 Butalbital-Acetaminophen ORAL TABLET 50-325 MG ................................ 4 Butalbital-APAP-Caff-Cod ORAL CAPSULE 50-325-40-30 MG ....................................................................................... 6 Butalbital-APAP-Caffeine ORAL CAPSULE 50-325-40 MG ................. 4 Butalbital-APAP-Caffeine ORAL TABLET 50-325-40 MG, 50-500-40 MG ...................................................... 4 Butalbital-ASA-Caff-Codeine ORAL CAPSULE 50-325-40-30 MG ....................................................................................... 6
92
Butalbital-ASA-Caffeine ORAL CAPSULE 50-325-40 MG ................. 4 Butorphanol Tartrate NASAL SOLUTION 10 MG/ML ..................... 7 BYDUREON SUBCUTANEOUS* SUSPENSION RECONSTITUTED 2 MG ................................................................................................ 20 Calcipotriene EXTERNAL CREAM 0.005 % ......................................... 51 Calcipotriene EXTERNAL OINTMENT 0.005 % ........................... 51 Calcipotriene EXTERNAL SOLUTION 0.005 % ............................. 51 Calcitonin (Salmon) NASAL SOLUTION 200 UNIT/ACT ................................................................................................ 58 Calcitriol INTRAVENOUS* SOLUTION 1 MCG/ML ................ 58 Calcitriol ORAL CAPSULE 0.25 MCG, 0.5 MCG ............................................. 58 Calcitriol ORAL SOLUTION 1 MCG/ML ............................................................... 58 Calcium Acetate (Phos Binder) ORAL TABLET 667 MG ............... 68 Calcium Carbonate Antacid ORAL TABLET CHEWABLE 500 MG .......................................................................... 8 Calcium Carbonate ORAL SUSPENSION 1250 MG/5ML ................................................................................................ 68 Calcium Carbonate ORAL TABLET 1250 MG, 600 MG ................................................................................................ 68 Calcium Carbonate-Vitamin D ORAL TABLET 600-400 MG-UNIT ............................................................. 68 Calcium Lactate ORAL TABLET 648 MG ...................................................................... 68 Cal-Lac ORAL CAPSULE 500 MG ................................................................................... 68 CAMILA ORAL TABLET 0.35 MG .................................................................................. 47 CAPRELSA ORAL TABLET 100 MG, 300 MG ....................................... 32 Capsaicin EXTERNAL CREAM 0.025 % ....................................................................... 55 Captopril ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG ................................................................................................ 26
Captopril-Hydrochlorothiazide ORAL TABLET 25-15 MG, 25-25 MG, 50-15 MG, 50-25 MG ................................................................................................ 27 CARAFATE ORAL SUSPENSION 1 GM/10ML ................................................................................................ 84 CarBAMazepine ORAL SUSPENSION 100 MG/5ML ................................................................................................ 15 CarBAMazepine ORAL TABLET 200 MG ...................................... 15 CarBAMazepine ORAL TABLET CHEWABLE 100 MG ................................................................................................ 15 Carbidopa-Levodopa ER ORAL TABLET EXTENDEDRELEASE* 25-100 MG, 50-200 MG ............................................ 33 Carbidopa-Levodopa ORAL TABLET 10-100 MG, 25-100 MG, 25-250 MG ............................................ 33 Carisoprodol ORAL TABLET 350 MG ...................................................................... 73 Carteolol HCl OPHTHALMIC SOLUTION 1 % .......................................... 75 CARTIA XT ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG .................................................... 41 Carvedilol ORAL TABLET 12.5 MG, 25 MG, 3.125 MG, 6.25 MG ................................................................................................ 40 CAVAREST DENTAL GEL 1.1 % ......................................................................................... 70 CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025 MG ................ 46 Cefaclor ORAL CAPSULE 250 MG, 500 MG ...................................................... 43 Cefadroxil ORAL CAPSULE 500 MG ...................................................................... 43 Cefadroxil ORAL SUSPENSION RECONSTITUTED 250 MG/5ML, 500 MG/5ML .................. 43 Cefadroxil ORAL TABLET 1 GM ................................................................................... 43 Cefdinir ORAL CAPSULE 300 MG ................................................................................... 44 Cefdinir ORAL SUSPENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML .................. 44
Cefpodoxime Proxetil ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 50 MG/5ML ..................... 44 Cefpodoxime Proxetil ORAL TABLET 100 MG, 200 MG ................................................................................................ 44 Cefprozil ORAL SUSPENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML .................. 43 Cefprozil ORAL TABLET 250 MG, 500 MG ...................................................... 43 Cefuroxime Axetil ORAL SUSPENSION RECONSTITUTED 125 MG/5ML ................................................................. 43 Cefuroxime Axetil ORAL TABLET 250 MG, 500 MG ................................................................................................ 44 CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG, 50 MG ...................................................................................... 3 CELESTONE ORAL SOLUTION 0.6 MG/5ML ........... 47 CELLCEPT ORAL SUSPENSION RECONSTITUTED 200 MG/ML .................................................................... 40 CENESTIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG .................................................................................. 59 CENTRATEX ORAL CAPSULE 106-1 MG .......................... 63 Cephalexin ORAL CAPSULE 250 MG, 500 MG, 750 MG ........... 43 Cephalexin ORAL SUSPENSION RECONSTITUTED 125 MG/5ML ................................................................. 43 Cephalexin ORAL SUSPENSION RECONSTITUTED 250 MG/5ML ................................................................. 43 Cetirizine HCl Childrens ORAL SOLUTION 1 MG/ML ..................... 24 Cetirizine HCl ORAL SYRUP 1 MG/ML, 5 MG/5ML ............................. 24 Cetirizine HCl ORAL TABLET 10 MG, 5 MG .................................................... 24 Cetirizine-Pseudoephedrine ER ORAL TABLET EXTENDED RELEASE 12 HR* 5-120 MG ................................................................................................ 48
Childrens Ibuprofen ORAL SUSPENSION 40 MG/ML ....................................................................................................
3
Childrens Loratadine ORAL SYRUP 5 MG/5ML ................................ 24 ChlordiazePOXIDE HCl ORAL CAPSULE 10 MG, 25 MG, 5 MG ................................................................................... 10 Chlordiazepoxide-Amitriptyline ORAL TABLET 10-25 MG, 5-12.5 MG .............................................................. 80 Chlorhexidine Gluconate EXTERNAL LIQUID† 4 % ................................................................................................ 36 Chlorhexidine Gluconate MOUTH/THROAT SOLUTION 0.12 % ........................................................................... 70 Chlorothiazide ORAL TABLET 250 MG, 500 MG ......................................... 57 ChlorproMAZINE HCl ORAL TABLET 10 MG, 100 MG, 200 MG, 25 MG, 50 MG ................................ 35 ChlorproPAMIDE ORAL TABLET 100 MG, 250 MG ................................................................................................ 22 Chlorthalidone ORAL TABLET 25 MG, 50 MG ................................................ 57 Chlorzoxazone ORAL TABLET 500 MG ...................................................................... 73 Cholestyramine Light ORAL PACKET 4 GM ............................................. 25 Cholestyramine Light ORAL POWDER 4 GM/DOSE ................... 25 Cholestyramine ORAL PACKET 4 GM ............................................................................. 25 Cholestyramine ORAL POWDER 4 GM/DOSE ................... 25 Choline & Mag Trisalicylate ORAL TABLET 1000 MG ............... 5 Choline-Mag Trisalicylate ORAL LIQUID† 500 MG/5ML ...................... 5 Ciclopirox EXTERNAL SOLUTION 8 % .......................................... 50 Ciclopirox Olamine EXTERNAL CREAM 0.77 % ............................................. 50 Ciclopirox Olamine EXTERNAL SUSPENSION 0.77 % ........................ 51 Cilostazol ORAL TABLET 100 MG, 50 MG ......................................................... 62 Cimetidine HCl ORAL SOLUTION 300 MG/5ML .......... 84 Cimetidine ORAL TABLET 200 MG ................................................................................... 83
Cimetidine ORAL TABLET 300 MG, 400 MG, 800 MG ........................ 84 CIPRODEX OTIC SUSPENSION 0.3-0.1 % ................ 78 Ciprofloxacin HCl OPHTHALMIC SOLUTION 0.3 % .............................................................................. 75 Ciprofloxacin HCl ORAL TABLET 250 MG, 500 MG, 750 MG ................................................................................... 59 Citalopram Hydrobromide ORAL TABLET 10 MG, 20 MG, 40 MG ................................................................................................ 18 CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 40 MG .................... 50 CLARAVIS ORAL CAPSULE 30 MG ......................................................................... 50 Clarithromycin ORAL SUSPENSION RECONSTITUTED 125 MG/5ML, 250 MG/5ML .................. 65 Clarithromycin ORAL TABLET 250 MG, 500 MG ......................................... 65 CLEAR AWAY 1-STEP WART REMOVER EXTERNAL PAD 40 % ................................................................................ 54 Clindamycin HCl ORAL CAPSULE 150 MG, 300 MG, 75 MG ................................................................................... 28 Clindamycin Palmitate HCl ORAL SOLUTION RECONSTITUTED 75 MG/5ML ................................................................. 28 Clindamycin Phosphate EXTERNAL GEL 1 % ........................ 49 Clindamycin Phosphate EXTERNAL LOTION 1 % ................................................................................................ 49 Clindamycin Phosphate EXTERNAL SOLUTION 1 % ................................................................................................ 49 Clindamycin Phosphate INJECTION SOLUTION 300 MG/2ML, 600 MG/4ML, 9 GM/60ML, 900 MG/6ML .............. 28 Clindamycin Phosphate INTRAVENOUS* SOLUTION 300 MG/2ML .................................................... 28 Clindamycin Phosphate VAGINAL CREAM 2 % ................. 86 CLINISTIX IN VITRO STRIP ................................................................................................ 56
93
Clobetasol Propionate EXTERNAL CREAM 0.05 % ................................................................................................
52
Clobetasol Propionate EXTERNAL GEL 0.05 % .............. 52 Clobetasol Propionate EXTERNAL OINTMENT 0.05 % ......................................................................................... 52 ClomiPRAMINE HCl ORAL CAPSULE 25 MG, 50 MG, 75 MG ................................................................................... 19 ClonazePAM ORAL TABLET 0.5 MG, 1 MG, 2 MG ............................ 15 CloNIDine HCl ORAL TABLET 0.1 MG, 0.2 MG, 0.3 MG ................ 26 Clopidogrel Bisulfate ORAL TABLET 75 MG .......................................... 62 Clorazepate Dipotassium ORAL TABLET 15 MG, 3.75 MG, 7.5 MG ................................................................................... 10 Clotrimazole EXTERNAL CREAM 1 % ...................................................... 51 Clotrimazole EXTERNAL SOLUTION 1 % .......................................... 51 Clotrimazole MOUTH/THROAT LOZENGE 10 MG ................................... 70 Clotrimazole MOUTH/THROAT TROCHE 10 MG ........................................ 70 Clotrimazole VAGINAL CREAM 1 % ...................................................... 85 CloZAPine ORAL TABLET 100 MG, 200 MG, 25 MG, 50 MG ................................................................................................ 35 CloZAPine ORAL TABLET DISPERSIBLE 12.5 MG ................ 35 Codeine Phosphate INJECTION SOLUTION 15 MG/ML, 30 MG/ML ........................................................................ 5 Codeine Sulfate ORAL TABLET 15 MG, 30 MG, 60 MG .......................... 5 Colchicine-Probenecid ORAL TABLET 0.5-500 MG .......................... 61 COLCRYS ORAL TABLET 0.6 MG .................................................................................. 61 COMBIVENT INHALATION AEROSOL† 18-103 MCG/ACT ................................................................................................ 13 COMBIVENT RESPIMAT INHALATION AEROSOL, SOLUTION 20-100 MCG/ACT ................................................................................................ 13 COMPLERA ORAL TABLET 200-25-300 MG .............................................. 36
94
COMPOUND W EXTERNAL LIQUID† 17 % .............................................. 54 COMPOUND W MAXIMUM STRENGTH EXTERNAL GEL 17 % ................................................................................ 54 CONDYLOX EXTERNAL GEL 0.5 % ............................................................ 54 COPAXONE SUBCUTANEOUS* KIT 20 MG/ML .................................................................... 81 Cortisone Acetate ORAL TABLET 25 MG .......................................... 47 CORTISPORIN EXTERNAL OINTMENT 1 % ....................................... 50 CREON ORAL CAPSULE DELAYED RELEASE PARTICLES 12000 UNIT, 24000 UNIT, 3000-9500 UNIT, 36000 UNIT, 6000 UNIT ............... 56 CRIXIVAN ORAL CAPSULE 200 MG, 400 MG ....................................... 37 Cromolyn Sodium INHALATION NEBULIZATION SOLUTION 20 MG/2ML ........................................................ 11 Cromolyn Sodium NASAL AEROSOL, SOLUTION 5.2 MG/ACT ................................................................. 74 Cromolyn Sodium OPHTHALMIC SOLUTION 4 % ......................................................................................... 77 CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG ................................................................................................ 44 Cyanocobalamin INJECTION SOLUTION 1000 MCG/ML ................................................................................................ 62 Cyclobenzaprine HCl ORAL TABLET 10 MG, 5 MG .................... 73 Cyclophosphamide ORAL TABLET 25 MG, 50 MG ................ 29 CycloSPORINE Modified ORAL CAPSULE 100 MG, 25 MG, 50 MG ................................................................................... 40 CycloSPORINE Modified ORAL SOLUTION 100 MG/ML .............. 40 CycloSPORINE ORAL CAPSULE 100 MG, 25 MG ................................................................................................ 39 Cyproheptadine HCl ORAL SYRUP 2 MG/5ML ................................ 25 Cyproheptadine HCl ORAL TABLET 4 MG .............................................. 25
Cytra-2 ORAL SOLUTION 500-334 MG/5ML ...................................... 61 CYTRA-3 ORAL SYRUP 550-500-334 MG/5ML ........................ 61 Danazol ORAL CAPSULE 100 MG, 200 MG, 50 MG ................................ 8 Dantrolene Sodium ORAL CAPSULE 100 MG, 25 MG, 50 MG ................................................................................... 73 Dapsone ORAL TABLET 100 MG, 25 MG ......................................................... 28 DARAPRIM ORAL TABLET 25 MG ......................................................................... 28 Deferoxamine Mesylate INJECTION SOLUTION RECONSTITUTED 2 GM, 500 MG ................................................................................... 22 DELSYM NGHT TIME CGH/CLD CHILD ORAL LIQUID† 12.5-5 MG/5ML ................................................................................................ 48 DELSYM NIGHT TIME COUGH/COLD ORAL LIQUID† 6.25-2.5 MG/5ML ................................................................................................ 48 DENAVIR EXTERNAL CREAM 1 % ..................................................... 52 DENTAGEL DENTAL GEL 1.1 % .............................................................................. 70 Desipramine HCl ORAL TABLET 10 MG, 100 MG, 150 MG, 25 MG, 50 MG, 75 MG ................................................................................................ 19 Desmopressin Ace Rhinal Tube NASAL SOLUTION 0.01 % ................................................................................................ 58 Desmopressin Ace Spray Refrig NASAL SOLUTION 0.01 % ................................................................................................ 59 Desmopressin Acetate ORAL TABLET 0.1 MG, 0.2 MG ............ 59 Desmopressin Acetate Spray NASAL SOLUTION 0.01 % ................................................................................................ 59 Desonide EXTERNAL CREAM 0.05 % ........................................................................... 52 Dexamethasone ORAL ELIXIR 0.5 MG/5ML ...................................................... 47 Dexamethasone ORAL SOLUTION 0.5 MG/5ML ............ 47 Dexamethasone ORAL TABLET 0.5 MG, 0.75 MG, 1 MG, 1.5 MG, 2 MG, 4 MG, 6 MG ................. 47
Dexamethasone Sodium Phosphate INJECTION SOLUTION 10 MG/ML, 4 MG/ML ..................................................................... 47 Dexamethasone Sodium Phosphate OPHTHALMIC SOLUTION 0.1 % .................................... 77 Dexmethylphenidate HCl ORAL TABLET 10 MG, 2.5 MG, 5 MG .................................................................................................... 2 Dextroamphetamine Sulfate ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 5 MG ................................................................. 1 Dextroamphetamine Sulfate ORAL TABLET 10 MG, 5 MG .................................................................................................... 1 DIASTIX IN VITRO STRIP ................................................................................................ 56 Diazepam INJECTION SOLUTION 5 MG/ML ..................... 10 Diazepam ORAL SOLUTION 1 MG/ML ..................................................................... 10 Diazepam ORAL TABLET 10 MG, 2 MG, 5 MG ....................................... 10 Diazepam RE GEL 10 MG, 2.5 MG, 20 MG ......................................................... 15 Diclofenac Potassium ORAL TABLET 50 MG .............................................. 3 Diclofenac Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG .................................................................................................... 3 Diclofenac Sodium OPHTHALMIC SOLUTION 0.1 % .............................................................................. 77 Diclofenac Sodium ORAL TABLET DELAYED RELEASE 25 MG, 50 MG, 75 MG .......................... 3 Dicloxacillin Sodium ORAL CAPSULE 250 MG, 500 MG ................................................................................................ 79 Dicyclomine HCl ORAL CAPSULE 10 MG .................................... 83 Dicyclomine HCl ORAL SOLUTION 10 MG/5ML .............. 83 Dicyclomine HCl ORAL TABLET 20 MG .......................................... 83 Didanosine ORAL CAPSULE DELAYED RELEASE 125 MG, 200 MG, 250 MG, 400 MG ........... 38 Diflunisal ORAL TABLET 500 MG ....................................................................................... 5
Digoxin INJECTION SOLUTION 0.25 MG/ML ............ 43 Digoxin ORAL SOLUTION 0.05 MG/ML ..................................................................... 43 Digoxin ORAL TABLET 0.125 MG, 0.25 MG .................................................... 43 DILANTIN ORAL CAPSULE 30 MG ......................................................................... 16 Diltiazem HCl ER Beads ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420 MG ...................................................... 42 Diltiazem HCl ER Coated Beads ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG ................................................................................... 42 Diltiazem HCl ER ORAL CAPSULE EXTENDED RELEASE 12 HOUR 120 MG, 60 MG, 90 MG ................................................ 42 Diltiazem HCl INTRAVENOUS* SOLUTION 125 MG/25ML, 25 MG/5ML, 50 MG/10ML ............................................................. 42 Diltiazem HCl ORAL TABLET 120 MG, 30 MG, 60 MG, 90 MG ................................................................................................ 42 Dilt-XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 180 MG, 240 MG ................................................................................... 42 DiphenhydrAMINE HCl (Sleep) ORAL TABLET 50 MG ................... 63 DiphenhydrAMINE HCl ORAL CAPSULE 25 MG, 50 MG ........... 24 DiphenhydrAMINE HCl ORAL TABLET 25 MG .......................................... 24 Diphenoxylate-Atropine ORAL LIQUID† 2.5-0.025 MG/5ML ................................................................................................ 22 Diphenoxylate-Atropine ORAL TABLET 2.5-0.025 MG ..................... 22 Dipyridamole INTRAVENOUS* SOLUTION 5 MG/ML ..................... 55 Dipyridamole ORAL TABLET 25 MG, 50 MG, 75 MG ................................ 62 Disopyramide Phosphate ORAL CAPSULE 100 MG, 150 MG ................................................................................................ 10 Disulfiram ORAL TABLET 250 MG, 500 MG ...................................................... 80
Divalproex Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 250 MG ................................................................................................
Divalproex Sodium ER ORAL TABLET EXTENDED RELEASE 24 HR* 500 MG
17
17 Divalproex Sodium ORAL CAPSULE SPRINKLE 125 MG ................................................................................................ 17 Divalproex Sodium ORAL TABLET DELAYED RELEASE 125 MG, 250 MG ......................................... 17 Divalproex Sodium ORAL TABLET DELAYED RELEASE 500 MG ...................................................................... 17 Docusate Sodium ORAL TABLET 100 MG ...................................... 65 Donepezil HCl ORAL TABLET 10 MG, 5 MG .................................................... 80 Dorzolamide HCl OPHTHALMIC SOLUTION 2 % ......................................................................................... 77 Dorzolamide HCl-Timolol Mal OPHTHALMIC SOLUTION 22.3-6.8 MG/ML .......................................... 74 Double Antibiotic EXTERNAL OINTMENT 500-10000 UNIT/GM .............................................................. 50 Doxazosin Mesylate ORAL TABLET 1 MG, 2 MG, 4 MG, 8 MG ................................................................................... 26 Doxepin HCl ORAL CAPSULE 10 MG, 100 MG, 25 MG, 50 MG, 75 MG .......................................................................... 19 Doxepin HCl ORAL CONCENTRATE 10 MG/ML ................................................................................................ 19 DOXY 100 INTRAVENOUS* SOLUTION RECONSTITUTED 100 MG ................................................................................................ 82 Doxycycline Hyclate ORAL CAPSULE 100 MG, 50 MG ................................................................................................ 82 Doxycycline Hyclate ORAL TABLET 100 MG ...................................... 82 Doxycycline Hyclate ORAL TABLET 20 MG .......................................... 82 DRITHO-CREME HP EXTERNAL CREAM 1 % ................................................................................................ 51 ................................................................................................
95
DULERA INHALATION AEROSOL† 100-5 MCG/ACT, 200-5 MCG/ACT ........................................ 13 E.E.S. GRANULES ORAL SUSPENSION RECONSTITUTED 200 MG/5ML ................................................................ 66 Econazole Nitrate EXTERNAL CREAM 1 % ...................................................... 51 EDURANT ORAL TABLET 25 MG .................................................................................. 37 ELIDEL EXTERNAL CREAM 1 % .................................................................................... 54 ELIPHOS ORAL TABLET 667 MG .................................................................................. 60 ELITE-OB ORAL TABLET 50-1.25 MG ......................................................... 72 ELIXOPHYLLIN ORAL ELIXIR 80 MG/15ML ....................... 14 EMCYT ORAL CAPSULE 140 MG .................................................................................. 31 EMOQUETTE ORAL TABLET 0.15-30 MG-MCG .................................... 44 EMTRIVA ORAL CAPSULE 200 MG ..................................................................... 38 EMTRIVA ORAL SOLUTION 10 MG/ML ........................................................... 38 Enalapril Maleate ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG ............................................................. 26 Enalapril-Hydrochlorothiazide ORAL TABLET 10-25 MG, 5-12.5 MG .............................................................. 27 ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG, 7.5-500 MG ............................................ 7 ENDOCET ORAL TABLET 10-650 MG ............................................................... 7 ENDOMETRIN VAGINAL INSERT 100 MG ....................................... 86 ENJUVIA ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG .................................................. 59 Enoxaparin Sodium INJECTION SOLUTION 300 MG/3ML .......... 14 Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 100 MG/ML, 150 MG/ML ..................................................................... 14 Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 120 MG/0.8ML, 80 MG/0.8ML ........................................................... 14
96
Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 30 MG/0.3ML, 40 MG/0.4ML ........................................................... 14 Enoxaparin Sodium SUBCUTANEOUS* SOLUTION 60 MG/0.6ML ................................................................................................ 14 ENPRESSE-28 ORAL TABLET ................................................................................................ 46 EPIPEN 2-PAK INJECTION DEVICE 0.3 MG/0.3ML ................ 86 EPIPEN JR 2-PAK INJECTION DEVICE 0.15 MG/0.3ML .......................................................... 86 EPITOL ORAL TABLET 200 MG .................................................................................. 15 EPIVIR HBV ORAL SOLUTION 5 MG/ML .................... 38 EPIVIR HBV ORAL TABLET 100 MG ..................................................................... 38 EPIVIR ORAL SOLUTION 10 MG/ML .................................................................... 38 EPZICOM ORAL TABLET 600-300 MG ........................................................ 36 ERIVEDGE ORAL CAPSULE 150 MG ..................................................................... 30 ERRIN ORAL TABLET 0.35 MG .................................................................................. 47 ERWINAZE INTRAMUSCULAR* SOLUTION RECONSTITUTED 10000 UNIT ............................................................................ 32 Ery EXTERNAL PAD 2 % ................................................................................................ 49 ERYPED 200 ORAL SUSPENSION RECONSTITUTED 200 MG/5ML ................................................................ 66 ERYPED 400 ORAL SUSPENSION RECONSTITUTED 400 MG/5ML ................................................................ 66 ERY-TAB ORAL TABLET DELAYED RELEASE 250 MG, 333 MG, 500 MG ....................................... 66 ERYTHROCIN STEARATE ORAL TABLET 250 MG ............. 66 Erythromycin Base ORAL CAPSULE DELAYED RELEASE PARTICLES 250 MG ................................................................................... 66
Erythromycin Base ORAL TABLET 250 MG, 500 MG ................................................................................................
66
Erythromycin Ethylsuccinate ORAL TABLET 400 MG ............... 66 Erythromycin EXTERNAL GEL 2 % .................................................................................... 49 Erythromycin EXTERNAL SOLUTION 2 % .......................................... 49 Erythromycin OPHTHALMIC OINTMENT 5 MG/GM ................... 75 Erythromycin-Sulfisoxazole ORAL SUSPENSION RECONSTITUTED 200-600 MG/5ML ................................................................. 28 Escitalopram Oxalate ORAL TABLET 10 MG, 20 MG, 5 MG ................................................................................................ 18 ESTARYLLA ORAL TABLET 0.25-35 MG-MCG .................................... 44 Estazolam ORAL TABLET 1 MG, 2 MG ............................................................. 64 Estradiol ORAL TABLET 0.5 MG, 1 MG, 2 MG ....................................... 59 Estradiol TRANSDERMAL PATCH WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.06 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR ................................................................................................ 59 Estradiol-Norethindrone Acet ORAL TABLET 0.5-0.1 MG, 1-0.5 MG .................................................................. 59 Estropipate ORAL TABLET 0.75 MG, 1.5 MG, 3 MG ................................. 59 Ethambutol HCl ORAL TABLET 100 MG, 400 MG ......................................... 29 Ethosuximide ORAL CAPSULE 250 MG ...................................................................... 16 Ethosuximide ORAL SOLUTION 250 MG/5ML .......... 16 Etodolac ORAL CAPSULE 200 MG, 300 MG ......................................................... 3 Etodolac ORAL TABLET 400 MG, 500 MG ......................................................... 3 Etoposide ORAL CAPSULE 50 MG ................................................................................... 33 EVISTA ORAL TABLET 60 MG .................................................................................. 58 EXEL PEN NEEDLES 1/3" XX MISC 31G X 8 MM ............................... 67
EXELON TRANSDERMAL PATCH 24 HR 13.3 MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR ................................................................................................ 80 EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG, 500 MG ..................................................................... 22 EXTAVIA SUBCUTANEOUS* KIT 0.3 MG ....................................................... 81 E-Z SPACER XX DEVICE ................................................................................................ 67 Famotidine INTRAVENOUS* SOLUTION 10 MG/ML .................. 84 Famotidine ORAL TABLET 10 MG ................................................................................... 84 Famotidine ORAL TABLET 20 MG, 40 MG ......................................................... 84 Famotidine Premixed INTRAVENOUS* SOLUTION 20-0.9 MG/50ML-% ................................ 84 Fenofibrate Micronized ORAL CAPSULE 134 MG, 200 MG, 67 MG ................................................................................... 25 Fenofibrate ORAL TABLET 160 MG, 54 MG ......................................................... 25 Fenoprofen Calcium ORAL TABLET 600 MG .......................................... 3 FentaNYL TRANSDERMAL PATCH 72 HR 100 MCG/HR, 12 MCG/HR, 25 MCG/HR, 50 MCG/HR, 75 MCG/HR ....................... 5 Ferrex 150 Forte ORAL CAPSULE 150-25-1 MG-MCG-MG ............................................... 63 Ferrex 150 ORAL CAPSULE 150 MG ...................................................................... 63 Ferrous Sulfate ORAL ELIXIR 220 (44 Fe) MG/5ML .......................... 63 Ferrous Sulfate ORAL LIQUID† 220 (44 Fe) MG/5ML .......................... 63 Ferrous Sulfate ORAL SOLUTION 75 (15 Fe) MG/ML ................................................................................................ 63 Ferrous Sulfate ORAL TABLET 325 (65 Fe) MG ............................................ 63 Ferrous Sulfate ORAL TABLET DELAYED RELEASE 324 (65 Fe) MG, 325 (65 Fe) MG .............. 63 Fexofenadine HCl ORAL TABLET 180 MG, 60 MG ............. 24 Fexofenadine-Pseudoephed ER ORAL TABLET EXTENDED RELEASE 24 HR* 180-240 MG ................................................................................................ 48
Finasteride ORAL TABLET 5 MG ................................................................................... 61 FIRAZYR SUBCUTANEOUS* SOLUTION 30 MG/3ML ............. 62 FIRST-PROGESTERONE VGS 100 VAGINAL SUPPOSITORY 100 MG ..................................................................... 86 FIRST-PROGESTERONE VGS 200 VAGINAL SUPPOSITORY 200 MG ..................................................................... 86 FIRST-PROGESTERONE VGS 25 VAGINAL SUPPOSITORY 25 MG ......................................................................... 86 FIRST-PROGESTERONE VGS 400 VAGINAL SUPPOSITORY 400 MG ..................................................................... 86 FIRST-PROGESTERONE VGS 50 VAGINAL SUPPOSITORY 50 MG ......................................................................... 86 Flecainide Acetate ORAL TABLET 100 MG, 150 MG, 50 MG ................................................................................... 10 FLOVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 100 MCG/BLIST, 250 MCG/BLIST, 50 MCG/BLIST ..................................................... 12 FLOVENT HFA INHALATION AEROSOL† 110 MCG/ACT, 220 MCG/ACT ................................................................................................ 12 FLOVENT HFA INHALATION AEROSOL† 44 MCG/ACT ........................................................... 12 Fluconazole ORAL SUSPENSION RECONSTITUTED 10 MG/ML, 40 MG/ML ........................................................... 23 Fluconazole ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG ................................................................................................ 23 Fludrocortisone Acetate ORAL TABLET 0.1 MG ........................................ 48 Flunisolide NASAL SOLUTION 25 MCG/ACT (0.025%) ................... 74 Fluocinolone Acetonide Body EXTERNAL OIL 0.01 % ................ 53 Fluocinolone Acetonide EXTERNAL CREAM 0.01 %, 0.025 % ....................................................................... 53 Fluocinolone Acetonide EXTERNAL OINTMENT 0.025 % ......................................................................................... 53
Fluocinolone Acetonide EXTERNAL SOLUTION 0.01 % ................................................................................................ 53 Fluocinolone Acetonide Scalp EXTERNAL OIL 0.01 % ................ 53 Fluocinonide EXTERNAL CREAM 0.05 % ............................................. 53 Fluocinonide EXTERNAL GEL 0.05 % ........................................................................... 53 Fluocinonide EXTERNAL OINTMENT 0.05 % ............................... 53 Fluocinonide EXTERNAL SOLUTION 0.05 % ................................. 53 Fluocinonide-E EXTERNAL CREAM 0.05 % ............................................. 53 FLUOR-A-DAY ORAL TABLET CHEWABLE 0.25 (F)-236.79 MG, 0.5 (F)-236.79 MG, 1 (F)-236.79 MG ......................... 69 FLUORIDEX DAILY DEFENSE DENTAL GEL 1.1 % ......................................................................................... 71 Fluorometholone OPHTHALMIC SUSPENSION 0.1 % .............................................................................. 77 FLUOR-OP OPHTHALMIC SUSPENSION 0.1 % ............................ 77 Fluorouracil EXTERNAL CREAM 5 % ...................................................... 51 Fluorouracil EXTERNAL SOLUTION 2 %, 5 % ........................... 51 Fluorouracil INTRAVENOUS* SOLUTION 500 MG/10ML ................................................................................................ 30 FLUoxetine HCl ORAL CAPSULE 10 MG, 20 MG, 40 MG ................................................................................... 18 FLUoxetine HCl ORAL SOLUTION 20 MG/5ML .............. 18 FLUoxetine HCl ORAL TABLET 10 MG, 20 MG ................ 18 FluPHENAZine Decanoate INJECTION SOLUTION 25 MG/ML ..................................................................... 35 FluPHENAZine HCl ORAL CONCENTRATE 5 MG/ML ................................................................................................ 35 FluPHENAZine HCl ORAL ELIXIR 2.5 MG/5ML .......................... 35 FluPHENAZine HCl ORAL TABLET 1 MG, 10 MG, 2.5 MG, 5 MG ............................................................................. 35 Flurbiprofen ORAL TABLET 100 MG, 50 MG ............................................................. 3 97
Flurbiprofen Sodium OPHTHALMIC SOLUTION 0.03 % ........................................................................... 77 Fluticasone Propionate EXTERNAL CREAM 0.05 % ................................................................................................ 53 Fluticasone Propionate EXTERNAL OINTMENT 0.005 % ......................................................................................... 53 Fluticasone Propionate NASAL SUSPENSION 50 MCG/ACT ................................................................................................ 74 FluvoxaMINE Maleate ORAL TABLET 100 MG, 25 MG, 50 MG ................................................................................... 18 FML FORTE OPHTHALMIC SUSPENSION 0.25 % ........................ 77 FOLBECAL ORAL TABLET 1 MG .................................................................................. 73 Folic Acid ORAL TABLET 1 MG, 400 MCG, 800 MCG .............. 62 Fondaparinux Sodium SUBCUTANEOUS* SOLUTION 10 MG/0.8ML ................................................................................................ 14 Fondaparinux Sodium SUBCUTANEOUS* SOLUTION 2.5 MG/0.5ML ................................................................................................ 14 Fondaparinux Sodium SUBCUTANEOUS* SOLUTION 5 MG/0.4ML ............ 15 Fondaparinux Sodium SUBCUTANEOUS* SOLUTION 7.5 MG/0.6ML ................................................................................................ 15 FORADIL AEROLIZER INHALATION CAPSULE 12 MCG ............................................................................. 13 FORTICAL NASAL SOLUTION 200 UNIT/ACT ................................................................................................ 58 Fosinopril Sodium ORAL TABLET 10 MG, 20 MG, 40 MG ................................................................................................ 26 Fosphenytoin Sodium INJECTION SOLUTION 100 MG PE/2ML ..................................................... 16 FREESTYLE FREEDOM LITE XX KIT W/DEVICE ............................ 66 FREESTYLE INSULINX SYSTEM XX KIT W/DEVICE ................................................................................................ 66
98
FREESTYLE INSULINX TEST IN VITRO STRIP ..................................... 56 FREESTYLE LITE TEST IN VITRO STRIP ............................................... 56 FREESTYLE LITE XX DEVICE .................................................................. 66 FREESTYLE TEST IN VITRO STRIP .......................................................................... 56 FREEZONE EXTERNAL LIQUID† 17.6 % ......................................... 54 Furosemide ORAL SOLUTION 10 MG/ML, 8 MG/ML ....................... 57 Furosemide ORAL TABLET 20 MG, 40 MG, 80 MG ................................ 57 FUZEON SUBCUTANEOUS* SOLUTION RECONSTITUTED 90 MG ................................................................................................ 37 Gabapentin ORAL CAPSULE 100 MG ...................................................................... 15 Gabapentin ORAL CAPSULE 300 MG ...................................................................... 15 Gabapentin ORAL CAPSULE 400 MG ...................................................................... 15 Gabapentin ORAL SOLUTION 250 MG/5ML .................................................... 15 Gabapentin ORAL TABLET 600 MG, 800 MG ...................................................... 15 GABITRIL ORAL TABLET 12 MG, 16 MG ........................................................ 16 GAVILYTE-G ORAL SOLUTION RECONSTITUTED 236 GM ................................................................................................ 64 GAVILYTE-N WITH FLAVOR PACK ORAL SOLUTION RECONSTITUTED 420 GM ................................................................................................ 64 Gemcitabine HCl INTRAVENOUS* SOLUTION 1 GM/26.3ML, 2 GM/52.6ML, 200 MG/5.26ML ........................................... 30 Gemcitabine HCl INTRAVENOUS* SOLUTION RECONSTITUTED 1 GM, 2 GM, 200 MG ...................................................... 30 Gemfibrozil ORAL TABLET 600 MG ................................................................................... 25 Generlac ORAL SOLUTION 10 GM/15ML ............................................................. 60 GENGRAF ORAL CAPSULE 100 MG, 25 MG ........................................... 40 GENGRAF ORAL SOLUTION 100 MG/ML ....................................................... 40
Gentamicin Sulfate EXTERNAL CREAM 0.1 % ................................................ 50 Gentamicin Sulfate EXTERNAL OINTMENT 0.1 % .................................. 50 Gentamicin Sulfate OPHTHALMIC OINTMENT 0.3 % .............................................................................. 75 Gentamicin Sulfate OPHTHALMIC SOLUTION 0.3 % .............................................................................. 75 GIANVI ORAL TABLET 3-0.02 MG .................................................................................. 44 GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG ............................. 32 GLEEVEC ORAL TABLET 100 MG, 400 MG .................................................... 32 Glimepiride ORAL TABLET 1 MG, 2 MG, 4 MG ....................................... 22 GlipiZIDE ER ORAL TABLET EXTENDED RELEASE 24 HR* 10 MG, 2.5 MG, 5 MG ........................ 22 GlipiZIDE ORAL TABLET 10 MG, 5 MG ............................................................. 22 GLIPIZIDE XL ORAL TABLET EXTENDED RELEASE 24 HR* 10 MG, 2.5 MG, 5 MG ........................................................... 22 GlipiZIDE-MetFORMIN HCl ORAL TABLET 2.5-250 MG, 2.5-500 MG, 5-500 MG ....................... 19 GLUCAGEN HYPOKIT INJECTION SOLUTION RECONSTITUTED 1 MG ................................................................................................ 20 GLUCAGEN INJECTION SOLUTION RECONSTITUTED 1 MG ................................................................................................ 20 GLUCAGON EMERGENCY INJECTION KIT 1 MG ................. 20 Glucose Control IN VITRO SOLUTION .................................................... 66 Glucose ORAL TABLET CHEWABLE 4 GM ................................ 20 GlyBURIDE Micronized ORAL TABLET 1.5 MG, 3 MG, 6 MG ................................................................................................ 22 GlyBURIDE ORAL TABLET 1.25 MG, 2.5 MG, 5 MG .................. 22 GlyBURIDE-MetFORMIN ORAL TABLET 1.25-250 MG, 2.5-500 MG, 5-500 MG ....................... 19 Glycopyrrolate ORAL TABLET 1 MG, 2 MG ....................................................... 83
GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM ................................................................................................ 64 Griseofulvin Microsize ORAL SUSPENSION 125 MG/5ML ................................................................................................ 23 Griseofulvin Microsize ORAL TABLET 500 MG ...................................... 23 Griseofulvin Ultramicrosize ORAL TABLET 125 MG, 250 MG ................................................................................... 23 GuanFACINE HCl ORAL TABLET 1 MG, 2 MG ........................ 26 HALDOL DECANOATE INTRAMUSCULAR* SOLUTION 50 MG/ML ................. 34 Halobetasol Propionate EXTERNAL CREAM 0.05 % ................................................................................................ 53 Halobetasol Propionate EXTERNAL OINTMENT 0.05 % ......................................................................................... 53 Haloperidol Decanoate INTRAMUSCULAR* SOLUTION 100 MG/ML, 50 MG/ML ..................................................................... 35 Haloperidol Lactate INJECTION SOLUTION 5 MG/ML ..................... 35 Haloperidol Lactate ORAL CONCENTRATE 2 MG/ML ................................................................................................ 35 Haloperidol ORAL TABLET 0.5 MG, 1 MG, 10 MG, 2 MG, 5 MG ................................................................................................ 35 HECORIA ORAL CAPSULE 0.5 MG, 1 MG, 5 MG ......................... 40 HEXALEN ORAL CAPSULE 50 MG ......................................................................... 29 HUMALOG KWIKPEN SUBCUTANEOUS* SOLUTION 100 UNIT/ML ................................................................................................ 21 HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS* SUSPENSION (50-50) 100 UNIT/ML ............................................................. 21 HUMALOG MIX 50/50 SUBCUTANEOUS* SUSPENSION (50-50) 100 UNIT/ML ............................................................. 21
HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS* SUSPENSION (75-25) 100 UNIT/ML ............................................................. 21 HUMALOG MIX 75/25 SUBCUTANEOUS* SUSPENSION (75-25) 100 UNIT/ML ............................................................. 21 HUMALOG SUBCUTANEOUS* SOLUTION 100 UNIT/ML ................................................................................................ 21 HUMIRA PEN SUBCUTANEOUS* KIT 40 MG/0.8ML .............................................................. 2 HUMIRA PEN-CROHNS STARTER SUBCUTANEOUS* KIT 40 MG/0.8ML ..................................... 2 HUMIRA SUBCUTANEOUS* KIT 20 MG/0.4ML, 40 MG/0.8ML .............................................................. 2 HUMULIN 70/30 PEN SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML ............................................................. 21 HUMULIN 70/30 SUBCUTANEOUS* SUSPENSION (70-30) 100 UNIT/ML ............................................................. 21 HUMULIN N PEN SUBCUTANEOUS* SUSPENSION 100 UNIT/ML ................................................................................................ 21 HUMULIN N SUBCUTANEOUS* SUSPENSION 100 UNIT/ML ................................................................................................ 21 HUMULIN R INJECTION SOLUTION 100 UNIT/ML ................................................................................................ 21 HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS* SOLUTION 500 UNIT/ML ................................................................................................ 21 HydrALAZINE HCl INJECTION SOLUTION 20 MG/ML ..................................................................... 27 HydrALAZINE HCl ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG ......................................................... 27 Hydrochlorothiazide ORAL CAPSULE 12.5 MG ............................... 57
Hydrochlorothiazide ORAL TABLET 12.5 MG, 25 MG, 50 MG ................................................................................... 57 Hydrocodone-Acetaminophen ORAL SOLUTION 7.5-325 MG/15ML, 7.5-500 MG/15ML .................................................................................................... 7 Hydrocodone-Acetaminophen ORAL TABLET 10-325 MG, 10-500 MG, 10-650 MG, 10-660 MG, 10-750 MG, 2.5-500 MG, 5-325 MG, 5-500 MG, 7.5-325 MG, 7.5-500 MG, 7.5-650 MG, 7.5-750 MG .............................................................. 7 Hydrocodone-Ibuprofen ORAL TABLET 7.5-200 MG .............................. 7 Hydrocortisone EXTERNAL CREAM 1 % ...................................................... 53 Hydrocortisone EXTERNAL LOTION 1 % .................................................... 53 Hydrocortisone EXTERNAL LOTION 2.5 % ............................................... 53 Hydrocortisone EXTERNAL OINTMENT 1 % ........................................ 53 Hydrocortisone EXTERNAL OINTMENT 2.5 % .................................. 53 Hydrocortisone ORAL TABLET 10 MG, 20 MG, 5 MG .......................... 47 Hydrocortisone RE ENEMA 100 MG/60ML ................................................................. 8 Hydrocortisone Valerate EXTERNAL CREAM 0.2 % ................................................................................................ 53 Hydrocortisone Valerate EXTERNAL OINTMENT 0.2 % ................................................................................................ 53 HYDROGESIC ORAL CAPSULE 5-500 MG ............................. 7 HYDROmorphone HCl ORAL LIQUID† 1 MG/ML ................................. 5 HYDROmorphone HCl ORAL TABLET 2 MG, 4 MG, 8 MG .................................................................................................... 5 HYDROmorphone HCl RE SUPPOSITORY 3 MG ......................... 5 Hydroxychloroquine Sulfate ORAL TABLET 200 MG ............... 28 Hydroxyurea ORAL CAPSULE 500 MG ...................................................................... 32 HydrOXYzine HCl ORAL SOLUTION 10 MG/5ML .................. 9 HydrOXYzine HCl ORAL SYRUP 10 MG/5ML ................................ 9
99
HydrOXYzine HCl ORAL TABLET 10 MG, 25 MG, 50 MG .................................................................................................... 9 HydrOXYzine Pamoate ORAL CAPSULE 100 MG, 25 MG, 50 MG ....................................................................................... 9 HYPERCARE EXTERNAL SOLUTION 20 % ...................................... 55 Ibuprofen ORAL SUSPENSION 100 MG/5ML ........................................................ 3 Ibuprofen ORAL TABLET 200 MG ....................................................................................... 3 Ibuprofen ORAL TABLET 400 MG, 600 MG, 800 MG ............................ 3 ICLUSIG ORAL TABLET 15 MG, 45 MG ........................................................ 32 Imipramine HCl ORAL TABLET 10 MG, 25 MG, 50 MG ...................... 19 IN-CHECK DIAL FLOW TRAINER XX DEVICE ............... 67 INCIVEK ORAL TABLET 375 MG .................................................................................. 38 Indapamide ORAL TABLET 1.25 MG, 2.5 MG ....................................................... 57 Indomethacin ORAL CAPSULE 25 MG, 50 MG .................................................... 3 Insulin Syringe XX MISC 29G X 1/2" 0.3 ML, 30G X 5/16" 0.3 ML ................................................................................................ 67 INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG ............. 37 INVEGA SUSTENNA INTRAMUSCULAR* SUSPENSION 117 MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39 MG/0.25ML, 78 MG/0.5ML ................................................................................................ 34 INVIRASE ORAL CAPSULE 200 MG ..................................................................... 37 INVIRASE ORAL TABLET 500 MG ..................................................................... 37 Ipratropium Bromide INHALATION SOLUTION 0.02 % ......................................................................................... 11 Ipratropium Bromide NASAL SOLUTION 0.03 %, 0.06 % ................................................................................................ 74 Ipratropium-Albuterol INHALATION SOLUTION 0.5-2.5 (3) MG/3ML ............................. 13 ISENTRESS ORAL TABLET 400 MG ..................................................................... 37
100
ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25 MG ................................................................................................ 37 Isoniazid INJECTION SOLUTION 100 MG/ML .............. 29 Isoniazid ORAL TABLET 100 MG, 300 MG ...................................................... 29 ISOPTO HYOSCINE OPHTHALMIC SOLUTION 0.25 % ........................................................................... 75 Isosorbide Dinitrate ER ORAL TABLET EXTENDEDRELEASE* 40 MG .................................................................................................... 9 Isosorbide Dinitrate ORAL TABLET 10 MG, 20 MG, 30 MG, 5 MG ................................................................. 9 Isosorbide Mononitrate ER ORAL TABLET EXTENDED RELEASE 24 HR* 120 MG, 30 MG, 60 MG ............................................................. 9 Isosorbide Mononitrate ORAL TABLET 10 MG, 20 MG .................... 9 JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG .................................................................................. 32 JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG .................................................................................. 14 JANUMET ORAL TABLET 50-1000 MG, 50-500 MG ................ 19 JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HR* 100-1000 MG, 50-1000 MG, 50-500 MG ................................................................................................ 19 JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG ............................. 20 JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG, 2.5-850 MG ........................................ 19 JOLIVETTE ORAL TABLET 0.35 MG ................................................................... 47 JUNEL 1.5/30 ORAL TABLET 1.5-30 MG-MCG ........................................ 44 JUNEL 1/20 ORAL TABLET 1-20 MG-MCG .............................................. 44 JUNEL FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG ................................................................................................ 44 JUNEL FE 1/20 ORAL TABLET 1-20 MG-MCG ............. 44
KALETRA ORAL SOLUTION 400-100 MG/5ML ...................................... 36 KALETRA ORAL TABLET 100-25 MG, 200-50 MG ................... 36 KALYDECO ORAL TABLET 150 MG ..................................................................... 82 KARIGEL DENTAL GEL 1.1 % ......................................................................................... 71 KARIGEL-N DENTAL GEL 1.1 % .............................................................................. 71 KARIVA ORAL TABLET 0.15-0.02/0.01 MG (21/5) ................. 44 KELNOR 1/35 ORAL TABLET 1-35 MG-MCG .............................................. 45 Ketoconazole EXTERNAL CREAM 2 % ...................................................... 51 Ketoconazole EXTERNAL SHAMPOO 2 % ........................................... 51 Ketoconazole ORAL TABLET 200 MG ...................................................................... 23 Ketoprofen ORAL CAPSULE 50 MG, 75 MG ............................................................. 3 Ketorolac Tromethamine ORAL TABLET 10 MG .............................................. 3 KETOSTIX IN VITRO STRIP ................................................................................................ 56 Ketotifen Fumarate OPHTHALMIC SOLUTION 0.025 % ....................................................................... 77 KLOR-CON 10 ORAL TABLET EXTENDEDRELEASE* 10 MEQ .............................................................................. 69 KLOR-CON M10 ORAL TABLET EXTENDEDRELEASE* 10 MEQ .............................................................................. 69 KLOR-CON M20 ORAL TABLET EXTENDEDRELEASE* 20 MEQ .............................................................................. 69 KLOR-CON ORAL TABLET EXTENDEDRELEASE* 8 MEQ .............................................................................. 69 K-PHOS-NEUTRAL ORAL TABLET 155-852-130 MG .......... 69 Labetalol HCl INTRAVENOUS* SOLUTION 5 MG/ML ..................... 40 Labetalol HCl ORAL TABLET 100 MG, 200 MG, 300 MG ........... 40 Lactulose ORAL SOLUTION 10 GM/15ML ............................................................. 64 LamiVUDine ORAL TABLET 150 MG, 300 MG ......................................... 38
Lamivudine-Zidovudine ORAL TABLET 150-300 MG ......................... 36 LamoTRIgine ORAL TABLET 100 MG, 150 MG, 200 MG ........... 15 LamoTRIgine ORAL TABLET 25 MG .......................................................................... 15 LamoTRIgine ORAL TABLET CHEWABLE 25 MG, 5 MG ................................................................................................ 15 Lancet Device XX MISC .............. 66 Lancets XX MISC .................................. 66 Lansoprazole ORAL CAPSULE DELAYED RELEASE 15 MG ................................................................................................ 84 Lansoprazole ORAL CAPSULE DELAYED RELEASE 30 MG ................................................................................................ 84 LANTUS SOLOSTAR SUBCUTANEOUS* SOLUTION 100 UNIT/ML ................................................................................................ 22 LANTUS SUBCUTANEOUS* SOLUTION 100 UNIT/ML ................................................................................................ 21 Latanoprost OPHTHALMIC SOLUTION 0.005 % ............................. 77 LAVOCLEN-4 CREAMY WASH EXTERNAL LIQUID† 4 % .................................................................................... 50 LAVOCLEN-8 CREAMY WASH EXTERNAL LIQUID† 8 % .................................................................................... 50 Leflunomide ORAL TABLET 10 MG, 20 MG ............................................................. 4 LESSINA ORAL TABLET 0.1-20 MG-MCG ........................................ 45 LETAIRIS ORAL TABLET 10 MG, 5 MG ........................................................... 43 Letrozole ORAL TABLET 2.5 MG ................................................................................... 31 Leucovorin Calcium INJECTION SOLUTION RECONSTITUTED 100 MG, 200 MG, 350 MG ......................................... 33 Leucovorin Calcium INTRAVENOUS* SOLUTION 10 MG/ML ........................................................... 33 Leucovorin Calcium ORAL TABLET 10 MG, 15 MG, 25 MG, 5 MG ............................................................. 33 LEUKERAN ORAL TABLET 2 MG .................................................................................. 30
LevETIRAcetam INTRAVENOUS* SOLUTION 500 MG/5ML .................................................... 15 LevETIRAcetam ORAL SOLUTION 100 MG/ML .............. 15 LevETIRAcetam ORAL TABLET 1000 MG, 500 MG, 750 MG ................................................................................... 15 LevETIRAcetam ORAL TABLET 250 MG ...................................... 15 Levobunolol HCl OPHTHALMIC SOLUTION 0.25 %, 0.5 % ..................................................... 75 LevOCARNitine INTRAVENOUS* SOLUTION 200 MG/ML ........................................................ 58 LevOCARNitine ORAL SOLUTION 1 GM/10ML .............. 58 LevOCARNitine ORAL TABLET 330 MG ...................................... 58 Levofloxacin ORAL TABLET 250 MG, 500 MG, 750 MG ........... 60 Levonorgestrel ORAL TABLET 0.75 MG .................................................................... 46 LEVORA 0.15/30 (28) ORAL TABLET 0.15-30 MG-MCG ................................................................................................ 45 Levothyroxine Sodium INTRAVENOUS* SOLUTION RECONSTITUTED 100 MCG, 500 MCG ................................................................. 82 Levothyroxine Sodium ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG .............................................................................. 82 LEXIVA ORAL SUSPENSION 50 MG/ML ........................................................... 37 LEXIVA ORAL TABLET 700 MG .................................................................................. 37 Lidocaine EXTERNAL OINTMENT 5 % ........................................ 55 Lidocaine HCl (Cardiac) INTRAVENOUS* SOLUTION 20 MG/ML ........................................................... 10 Lidocaine HCl (PF) INJECTION SOLUTION 2 % ................................................................................................ 65 Lidocaine HCl EXTERNAL GEL 2 % .................................................................................... 55 Lidocaine HCl EXTERNAL SOLUTION 4 % .......................................... 55
Lidocaine HCl INJECTION SOLUTION 0.5 %, 1 %, 1.5 % ................................................................................................
65
Lidocaine Viscous MOUTH/THROAT SOLUTION 2 % .................................................................................... 70 Lidocaine-Prilocaine EXTERNAL CREAM 2.5-2.5 % ................................................................................................ 55 Lidocaine-Prilocaine EXTERNAL KIT 2.5-2.5 % ................................................................................................ 55 Liothyronine Sodium ORAL TABLET 25 MCG, 5 MCG, 50 MCG .............................................................................. 82 Lisinopril ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30 MG, 40 MG, 5 MG ............................................................. 26 Lisinopril-Hydrochlorothiazide ORAL TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG ....................... 27 Lithium Carbonate ER ORAL TABLET EXTENDEDRELEASE* 300 MG, 450 MG ...................................................... 34 Lithium Carbonate ORAL CAPSULE 150 MG, 300 MG, 600 MG ...................................................................... 34 Lithium Carbonate ORAL TABLET 300 MG ...................................... 34 Lithium Citrate ORAL SOLUTION 8 MEQ/5ML ............ 34 Lomustine ORAL CAPSULE 10 MG, 100 MG, 40 MG ............................ 30 LONOX ORAL TABLET 2.5-0.025 MG .................................................... 22 Loperamide HCl ORAL CAPSULE 2 MG ........................................ 22 Loratadine ORAL TABLET 10 MG ................................................................................... 24 LORazepam INJECTION SOLUTION 2 MG/ML, 4 MG/ML ..................................................................... 10 LORazepam ORAL TABLET 0.5 MG, 1 MG, 2 MG ....................................... 10 LORYNA ORAL TABLET 3-0.02 MG ............................................................. 45 Losartan Potassium ORAL TABLET 100 MG, 25 MG, 50 MG ................................................................................... 26 Losartan Potassium-HCTZ ORAL TABLET 100-12.5 MG, 100-25 MG, 50-12.5 MG ................... 27
101
LOTEMAX OPHTHALMIC SUSPENSION 0.5 % ............................ 77 Lovastatin ORAL TABLET 10 MG, 20 MG, 40 MG ................................ 25 LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG ................................................................................................ 45 Loxapine Succinate ORAL CAPSULE 10 MG, 25 MG, 5 MG, 50 MG ......................................................... 35 LUMIZYME INTRAVENOUS* SOLUTION RECONSTITUTED 50 MG ................................................................................................ 58 LUTERA ORAL TABLET 0.1-20 MG-MCG ........................................ 45 LYSODREN ORAL TABLET 500 MG ..................................................................... 31 MACRODANTIN ORAL CAPSULE 25 MG .................................... 85 Magnesium Oxide ORAL TABLET 250 MG, 400 MG, 420 MG ....................................................................................... 8 Magnesium Oxide ORAL TABLET 500 MG ...................................... 69 MAKENA INTRAMUSCULAR* OIL 250 MG/ML .................................................................... 80 Mapap Infants ORAL SUSPENSION 160 MG/5ML .................................................................................................... 4 Mapap ORAL LIQUID† 160 MG/5ML ..................................................................... 4 Maprotiline HCl ORAL TABLET 25 MG, 50 MG, 75 MG ................................................................................................ 17 MATZIM LA ORAL TABLET EXTENDED RELEASE 24 HR* 180 MG, 240 MG, 300 MG, 360 MG, 420 MG ....................................... 42 MAXIDEX OPHTHALMIC SUSPENSION 0.1 % ............................ 77 Meclizine HCl ORAL TABLET 12.5 MG, 25 MG .......................................... 23 Meclizine HCl ORAL TABLET CHEWABLE 25 MG ............................ 23 MedroxyPROGESTERone Acetate INTRAMUSCULAR* SUSPENSION 150 MG/ML ................................................................................................ 47 MedroxyPROGESTERone Acetate ORAL TABLET 10 MG, 2.5 MG, 5 MG .................................................. 80
102
Mefloquine HCl ORAL TABLET 250 MG ...................................................................... 29 Megestrol Acetate ORAL SUSPENSION 40 MG/ML, 400 MG/10ML ............................................................. 31 Megestrol Acetate ORAL TABLET 20 MG, 40 MG ................ 31 Melatonin Maximum Strength ORAL TABLET 5 MG .......................... 2 Melatonin ORAL TABLET 5 MG ....................................................................................... 2 Meloxicam ORAL TABLET 15 MG, 7.5 MG ........................................................... 3 MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5 MG .................................................................................. 59 MEPHYTON ORAL TABLET 5 MG ............................................................................. 87 Meprobamate ORAL TABLET 200 MG, 400 MG ............................................ 9 MEPRON ORAL SUSPENSION 750 MG/5ML ................................................................................................ 28 Mercaptopurine ORAL TABLET 50 MG .......................................................................... 30 Mesalamine RE ENEMA 4 GM ................................................................................................ 60 MESTINON ORAL SYRUP 60 MG/5ML ................................................................ 29 MESTINON ORAL TABLET EXTENDEDRELEASE* 180 MG .................................................................................. 29 METAMUCIL ORAL CAPSULE 0.52 GM .............................. 64 METAMUCIL ORAL WAFER ................................................................................................ 64 METAMUCIL SMOOTH TEXTURE ORAL POWDER 28.3 % ........................................................................... 64 Metaproterenol Sulfate ORAL SYRUP 10 MG/5ML ............................ 13 MetFORMIN HCl ER (OSM) ORAL TABLET EXTENDED RELEASE 24 HR* 500 MG ................................................................................................ 20 MetFORMIN HCl ER ORAL TABLET EXTENDED RELEASE 24 HR* 500 MG, 750 MG ................................................................................... 20 MetFORMIN HCl ORAL TABLET 1000 MG, 500 MG, 850 MG ................................................................................... 20
Methadone HCl ORAL SOLUTION 10 MG/5ML, 5 MG/5ML ..................................................................... 5 Methadone HCl ORAL TABLET 10 MG, 5 MG ....................................................... 5 METHADOSE ORAL TABLET 10 MG ............................................................................. 5 Methazolamide ORAL TABLET 25 MG, 50 MG ................................................ 56 Methimazole ORAL TABLET 10 MG, 5 MG ............................................................. 82 Methitest ORAL TABLET 10 MG ....................................................................................... 8 Methocarbamol ORAL TABLET 500 MG, 750 MG ......................................... 73 Methotrexate ORAL TABLET 2.5 MG ........................................................................ 30 Methotrexate Sodium (PF) INJECTION SOLUTION 25 MG/ML ..................................................................... 30 Methotrexate Sodium INJECTION SOLUTION 25 MG/ML ..................................................................... 30 Methotrexate Sodium INJECTION SOLUTION RECONSTITUTED 1 GM .......... 30 Methyldopa ORAL TABLET 250 MG, 500 MG ...................................................... 26 Methylergonovine Maleate INJECTION SOLUTION 0.2 MG/ML ..................................................................... 78 Methylergonovine Maleate ORAL TABLET 0.2 MG ........................................ 78 METHYLIN ORAL TABLET CHEWABLE 10 MG, 2.5 MG, 5 MG ...................................................................................... 2 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 10 MG .................................................................................................... 2 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 18 MG, 27 MG, 36 MG ................................... 2 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 20 MG .................................................................................................... 2 Methylphenidate HCl ER ORAL TABLET EXTENDEDRELEASE* 54 MG .................................................................................................... 2 Methylphenidate HCl ORAL TABLET 10 MG, 5 MG ........................ 2
Methylphenidate HCl ORAL TABLET 20 MG .............................................. 2 MethylPREDNISolone (Pak) ORAL TABLET 4 MG ....................... 47 MethylPREDNISolone Acetate INJECTION SUSPENSION 40 MG/ML, 80 MG/ML ............................. 47 MethylPREDNISolone ORAL TABLET 16 MG, 32 MG, 8 MG ................................................................................................ 47 MethylPREDNISolone Sodium Succ INJECTION SOLUTION RECONSTITUTED 1 GM, 1000 MG, 125 MG, 40 MG ............................ 48 Metipranolol OPHTHALMIC SOLUTION 0.3 % .................................... 75 Metoclopramide HCl ORAL SOLUTION 5 MG/5ML .................. 60 Metoclopramide HCl ORAL TABLET 10 MG, 5 MG .................... 60 Metolazone ORAL TABLET 10 MG, 2.5 MG, 5 MG ................................. 57 Metoprolol Succinate ER ORAL TABLET EXTENDED RELEASE 24 HR* 100 MG, 200 MG, 25 MG, 50 MG ................................ 41 Metoprolol Tartrate INTRAVENOUS* SOLUTION 1 MG/ML ............................................................... 41 Metoprolol Tartrate ORAL TABLET 100 MG, 25 MG, 50 MG ................................................................................... 41 MetroNIDAZOLE EXTERNAL CREAM 0.75 % ............................................. 55 MetroNIDAZOLE EXTERNAL GEL 1 % ................................................................... 55 MetroNIDAZOLE ORAL TABLET 250 MG, 500 MG ................................................................................................ 27 MetroNIDAZOLE VAGINAL GEL 0.75 % .......................................................... 86 Mexiletine HCl ORAL CAPSULE 150 MG, 200 MG, 250 MG ...................................................................... 10 Miconazole 3 Combo Pack VAGINAL KIT 200-2 MG-% (9GM) ........................................................................ 85 Miconazole 3 VAGINAL SUPPOSITORY 200 MG .............. 85 Miconazole Nitrate VAGINAL CREAM 2 % ...................................................... 85 Miconazole Nitrate VAGINAL SUPPOSITORY 100 MG .............. 85
MICROCHAMBER XX MISC ................................................................................................ 67 MICROGESTIN 1.5/30 ORAL TABLET 1.5-30 MG-MCG ................................................................................................ 45 MICROGESTIN 1/20 ORAL TABLET 1-20 MG-MCG ............. 45 MICROGESTIN FE 1.5/30 ORAL TABLET 1.5-30 MG-MCG ............................................................. 45 MICROGESTIN FE 1/20 ORAL TABLET 1-20 MG-MCG ................................................................................................ 45 MICROSPACER XX MISC ................................................................................................ 67 Midodrine HCl ORAL TABLET 10 MG, 2.5 MG, 5 MG ........................ 86 Minocycline HCl ORAL CAPSULE 100 MG, 50 MG, 75 MG ................................................................................... 82 Minoxidil ORAL TABLET 10 MG, 2.5 MG ....................................................... 27 Mirtazapine ORAL TABLET 15 MG, 30 MG, 45 MG, 7.5 MG ................................................................................................ 17 Mirtazapine ORAL TABLET DISPERSIBLE 15 MG, 30 MG, 45 MG .......................................................................... 17 Misoprostol ORAL TABLET 100 MCG, 200 MCG ........................................... 84 Mometasone Furoate EXTERNAL CREAM 0.1 % ................................................................................................ 53 Mometasone Furoate EXTERNAL OINTMENT 0.1 % ................................................................................................ 53 MONISTAT 1 COMBO PACK VAGINAL KIT 1200-2 MG-% ................................................................................................ 85 MONISTAT 3 VAGINAL CREAM 4 % ..................................................... 86 MONONESSA ORAL TABLET 0.25-35 MG-MCG .................................... 45 Montelukast Sodium ORAL PACKET 4 MG ............................................. 11 Montelukast Sodium ORAL TABLET 10 MG .......................................... 11 Montelukast Sodium ORAL TABLET CHEWABLE 4 MG, 5 MG ................................................................................... 11 Morphine Sulfate (Concentrate) ORAL SOLUTION 20 MG/ML .................................................................................................... 6
Morphine Sulfate (PF) INJECTION SOLUTION 0.5 MG/ML ........................................................................ 6 Morphine Sulfate (PF) INTRAVENOUS* SOLUTION 8 MG/ML ................................................................... 6 Morphine Sulfate ER ORAL TABLET EXTENDEDRELEASE* 100 MG, 15 MG, 200 MG, 30 MG, 60 MG ....................................................................................... 6 Morphine Sulfate INJECTION SOLUTION 10 MG/ML, 15 MG/ML, 5 MG/ML, 8 MG/ML .................................................................................................... 5 Morphine Sulfate INTRAVENOUS* SOLUTION 1 MG/ML, 25 MG/ML, 50 MG/ML ........................................................................ 5 Morphine Sulfate ORAL SOLUTION 10 MG/5ML, 20 MG/5ML ..................................................................... 6 Morphine Sulfate ORAL TABLET 15 MG, 30 MG .................... 6 Morphine Sulfate RE SUPPOSITORY 10 MG, 20 MG, 30 MG, 5 MG ....................................................... 6 Mucus Relief ORAL TABLET 400 MG ...................................................................... 49 Multi-Vit/Fluoride ORAL SOLUTION 0.25 MG/ML, 0.5 MG/ML ..................................................................... 71 Multi-Vit/Fluoride/Iron ORAL SOLUTION 0.25-10 MG/ML ................................................................................................ 71 Multivitamin/Fluoride ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG ................................. 72 Multi-Vitamin/Fluoride ORAL TABLET CHEWABLE 0.25 MG, 0.5 MG, 1 MG ................................. 72 Multi-Vitamins ORAL TABLET ................................................................................................ 71 Mupirocin EXTERNAL OINTMENT 2 % ........................................ 50 MYCOBUTIN ORAL CAPSULE 150 MG ................................ 29 Mycophenolate Mofetil ORAL CAPSULE 250 MG ................................. 40 Mycophenolate Mofetil ORAL TABLET 500 MG ...................................... 40 MYLERAN ORAL TABLET 2 MG .................................................................................. 29
103
MYNATAL ADVANCE ORAL TABLET ................................................................. 72 Mynatal-Z ORAL TABLET ................................................................................................ 72 Mynate 90 Plus ORAL TABLET EXTENDEDRELEASE* ........... 72 Nabumetone ORAL TABLET 500 MG, 750 MG ............................................ 3 Nadolol ORAL TABLET 20 MG, 40 MG, 80 MG ................................................ 41 Naltrexone HCl ORAL TABLET 50 MG .......................................................................... 23 NAMENDA ORAL SOLUTION 10 MG/5ML ............. 80 NAMENDA ORAL TABLET 10 MG, 5 MG .................................................. 80 NAMENDA TITRATION PAK ORAL TABLET 5 (28)-10 (21) MG .................................................................................. 80 Naproxen DR ORAL TABLET DELAYED RELEASE 500 MG .................................................................................................... 4 Naproxen ORAL SUSPENSION 125 MG/5ML ........................................................ 3 Naproxen ORAL TABLET 250 MG, 375 MG, 500 MG ............................ 4 Naproxen Sodium ORAL TABLET 275 MG, 550 MG .................................................................................................... 4 Naratriptan HCl ORAL TABLET 1 MG, 2.5 MG .................. 68 NATURE-THROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG .............. 83 NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG ................................................................................................ 45 NECON 1/35 (28) ORAL TABLET 1-35 MG-MCG ............. 45 NECON 1/50 (28) ORAL TABLET 1-50 MG-MCG ............. 45 NECON 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG ................... 46 Nefazodone HCl ORAL TABLET 100 MG, 150 MG, 200 MG, 250 MG, 50 MG ............................ 17 Neomycin-Bacitracin Zn-Polymyx OPHTHALMIC OINTMENT 5-400-10000 ........................................................ 76
104
Neomycin-Polymyxin-Dexameth OPHTHALMIC OINTMENT 3.5-10000-0.1 .................................................... 76 Neomycin-Polymyxin-Dexameth OPHTHALMIC SUSPENSION 3.5-10000-0.1 .................................................... 76 Neomycin-Polymyxin-Gramicidin OPHTHALMIC SOLUTION 1.75-10000-0.25 ............................................ 76 Neomycin-Polymyxin-HC OPHTHALMIC SUSPENSION 3.5-10000-1 ......................................................... 76 Neomycin-Polymyxin-HC OTIC SOLUTION 3.5-10000-1 ................ 78 Neomycin-Polymyxin-HC OTIC SUSPENSION 3.5-10000-1 ................................................................................................ 78 NEUPOGEN INJECTION SOLUTION 300 MCG/0.5ML, 300 MCG/ML, 480 MCG/0.8ML, 480 MCG/1.6ML ................................................................................................ 63 NEUTRAGARD ADVANCED DENTAL GEL 1.1 % .......................... 71 Nevirapine ORAL SUSPENSION 50 MG/5ML ................................................................................................ 37 Nevirapine ORAL TABLET 200 MG ................................................................................... 37 Niacin ER ORAL CAPSULE EXTENDED RELEASE* 500 MG ................................................................................... 87 Niacin ER ORAL TABLET EXTENDEDRELEASE* 500 MG ................................................................................... 87 Niacin ORAL TABLET 100 MG, 250 MG, 50 MG, 500 MG ............... 87 NIACOR ORAL TABLET 500 MG .................................................................................. 26 NIACOR ORAL TABLET 500 MG .................................................................................. 87 Nicotine Polacrilex MOUTH/THROAT GUM 2 MG, 4 MG ............................................................................. 81 Nicotine TRANSDERMAL PATCH 24 HR 14 MG/24HR, 21 MG/24HR, 7 MG/24HR ................... 81 NIFEDIAC CC ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG, 90 MG ........................................................ 42
NIFEDICAL XL ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG .................................................................................. 42 NIFEdipine ER Osmotic ORAL TABLET EXTENDED RELEASE 24 HR* 30 MG, 60 MG, 90 MG ......................................................... 42 NIFEdipine ORAL CAPSULE 10 MG ................................................................................... 42 NITRO-BID TRANSDERMAL OINTMENT 2 % ........................................... 9 Nitrofurantoin Macrocrystal ORAL CAPSULE 100 MG, 50 MG ................................................................................... 85 Nitrofurantoin Monohyd Macro ORAL CAPSULE 100 MG ................................................................................................ 85 Nitroglycerin TRANSDERMAL PATCH 24 HR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR ......................................................................... 9 NITROSTAT SUBLINGUAL TABLET SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG ............................. 9 NORA-BE ORAL TABLET 0.35 MG ................................................................... 47 Norethindrone Acetate ORAL TABLET 5 MG .............................................. 80 Normal Saline Flush INTRAVENOUS* SOLUTION 0.9 % .............................................................................. 70 NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG ................................................................................................ 45 NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG ............. 45 NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG ............. 45 NORTREL 7/7/7 ORAL TABLET 0.5/0.75/1-35 MG-MCG ............................................................. 46 Nortriptyline HCl ORAL CAPSULE 10 MG, 25 MG, 50 MG, 75 MG ......................................................... 19 Nortriptyline HCl ORAL SOLUTION 10 MG/5ML .............. 19 NORVIR ORAL CAPSULE 100 MG .................................................................................. 37 NORVIR ORAL SOLUTION 80 MG/ML ........................................................... 37 NORVIR ORAL TABLET 100 MG .................................................................................. 37 NOVOPEN 3 XX MISC ................. 67
NP Thyroid ORAL TABLET 30 MG, 60 MG, 90 MG ................................ 83 NUVARING VAGINAL RING 0.12-0.015 MG/24HR ........................... 46 Nystatin EXTERNAL CREAM 100000 UNIT/GM ...................................... 51 Nystatin EXTERNAL OINTMENT 100000 UNIT/GM ................................................................................................ 51 Nystatin EXTERNAL POWDER 100000 UNIT/GM ...................................... 51 Nystatin MOUTH/THROAT SUSPENSION 100000 UNIT/ML .............................................................. 70 Nystatin ORAL TABLET 500000 UNIT ............................................................................ 23 OCELLA ORAL TABLET 3-0.03 MG ............................................................. 45 Ofloxacin OPHTHALMIC SOLUTION 0.3 % .................................... 75 Ofloxacin OTIC SOLUTION 0.3 % ......................................................................................... 78 OLANZapine ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG .................................................. 35 Omeprazole ORAL CAPSULE DELAYED RELEASE 10 MG, 20 MG, 40 MG ................................................ 84 Ondansetron HCl ORAL SOLUTION 4 MG/5ML .................. 23 Ondansetron HCl ORAL TABLET 4 MG, 8 MG ........................ 23 Ondansetron ORAL TABLET DISPERSIBLE 4 MG, 8 MG ................................................................................................ 23 OPTICHAMBER ADVANTAGE XX MISC ........... 67 OPTICHAMBER ADVANTAGE-LG MASK XX MISC ............................................................................ 67 OPTICHAMBER ADVANTAGE-MED MASK XX MISC ............................................................... 67 OPTICHAMBER ADVANTAGE-SM MASK XX MISC ............................................................................ 67 OPTICHAMBER FACE MASK-LARGE XX MISC ................................................................................................ 67 OPTICHAMBER FACE MASK-MEDIUM XX MISC ................................................................................................ 67
OPTICHAMBER FACE MASK-SMALL XX MISC
68 OPTIHALER XX MISC ................ 68 ORALYTE FREEZER POPS ORAL SOLUTION ............................... 68 ORALYTE ORAL SOLUTION ................................................................................................ 68 ORAP ORAL TABLET 1 MG, 2 MG .................................................................................. 81 Oticin OTIC LIQUID† 1-0.1 % ................................................................................................ 78 OVIDE EXTERNAL LOTION 0.5 % .............................................................................. 55 Oxacillin Sodium INJECTION SOLUTION RECONSTITUTED 1 GM, 10 GM, 2 GM ............................................................. 80 Oxandrolone ORAL TABLET 10 MG, 2.5 MG ........................................................... 7 Oxaprozin ORAL TABLET 600 MG ....................................................................................... 4 Oxazepam ORAL CAPSULE 10 MG, 15 MG, 30 MG ................................ 10 OXcarbazepine ORAL SUSPENSION 300 MG/5ML ................................................................................................ 15 OXcarbazepine ORAL TABLET 150 MG ...................................................................... 15 OXcarbazepine ORAL TABLET 300 MG ...................................................................... 16 OXcarbazepine ORAL TABLET 600 MG ...................................................................... 16 Oxybutynin Chloride ER ORAL TABLET EXTENDED RELEASE 24 HR* 10 MG, 15 MG, 5 MG ............................................................. 85 Oxybutynin Chloride ORAL SYRUP 5 MG/5ML ................................ 85 Oxybutynin Chloride ORAL TABLET 5 MG .............................................. 85 OxyCODONE HCl ORAL CAPSULE 5 MG ............................................ 6 OxyCODONE HCl ORAL SOLUTION 5 MG/5ML ..................... 6 OxyCODONE HCl ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG ................................................................. 6 OxyCODONE HCl ORAL TABLET 30 MG .............................................. 6 Oxycodone-Acetaminophen ORAL CAPSULE 5-500 MG .................................................................................................... 7 ................................................................................................
Oxycodone-Acetaminophen ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG, 7.5-500 MG ....................................................................................... 7 Oxycodone-Acetaminophen ORAL TABLET 10-650 MG .................................................................................................... 7 Oxycodone-Aspirin ORAL TABLET 4.8355-325 MG ................... 7 PACERONE ORAL TABLET 200 MG, 400 MG ....................................... 11 Pain & Fever Childrens ORAL SOLUTION 160 MG/5ML .............. 4 Pantoprazole Sodium ORAL TABLET DELAYED RELEASE 20 MG, 40 MG ................................................ 84 PARoxetine HCl ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG ......................................................... 18 Peak Flow Meter XX DEVICE ................................................................................................ 67 PEG 3350/Electrolytes ORAL SOLUTION RECONSTITUTED 240 GM ................................................................................................ 64 PEG 3350-KCl-Na Bicarb-NaCl ORAL SOLUTION RECONSTITUTED 420 GM ................................................................................................ 64 PEG-3350/Electrolytes ORAL SOLUTION RECONSTITUTED 236 GM ................................................................................................ 64 PEGANONE ORAL TABLET 250 MG ..................................................................... 16 PEGASYS PROCLICK SUBCUTANEOUS* SOLUTION 135 MCG/0.5ML, 180 MCG/0.5ML ........................................ 39 PEGASYS SUBCUTANEOUS* KIT 180 MCG/0.5ML ......................... 38 PEGASYS SUBCUTANEOUS* SOLUTION 180 MCG/0.5ML, 180 MCG/ML .................................................. 39 Penicillin G Procaine INTRAMUSCULAR* SUSPENSION 600000 UNIT/ML .............................................................. 79 Penicillin V Potassium ORAL SOLUTION RECONSTITUTED 125 MG/5ML, 250 MG/5ML .................. 79
105
Penicillin V Potassium ORAL TABLET 250 MG, 500 MG ................................................................................................
Pentazocine-Naloxone HCl ORAL TABLET 50-0.5 MG
79
7 Pentoxifylline ER ORAL TABLET EXTENDEDRELEASE* 400 MG ................................................................................... 62 PERIOGARD MOUTH/THROAT SOLUTION 0.12 % ................................ 70 Permethrin EXTERNAL CREAM 5 % ...................................................... 55 Permethrin EXTERNAL LOTION 1 % .................................................... 55 Perphenazine ORAL TABLET 16 MG, 2 MG, 4 MG, 8 MG ................. 36 Perphenazine-Amitriptyline ORAL TABLET 2-10 MG, 2-25 MG, 4-10 MG, 4-25 MG, 4-50 MG ................................................................................... 81 PERTZYE ORAL CAPSULE DELAYED RELEASE PARTICLES 16000 UNIT, 8000 UNIT ............................................................................ 56 PFIZERPEN-G INJECTION SOLUTION RECONSTITUTED 20000000 UNIT, 5000000 UNIT ........................ 79 Phenazopyridine HCl ORAL TABLET 100 MG, 200 MG ................................................................................................ 61 Phenelzine Sulfate ORAL TABLET 15 MG .......................................... 18 PHENobarbital ORAL ELIXIR 20 MG/5ML ........................................................ 63 PHENobarbital ORAL TABLET 100 MG, 30 MG, 32.4 MG, 60 MG, 64.8 MG, 97.2 MG .................... 63 PHENobarbital ORAL TABLET 15 MG .......................................................................... 63 PHENobarbital ORAL TABLET 16.2 MG .................................................................... 63 PHENobarbital Sodium INJECTION SOLUTION 130 MG/ML, 65 MG/ML ............................. 63 Phenytoin ORAL SUSPENSION 125 MG/5ML .................................................... 16 Phenytoin ORAL TABLET CHEWABLE 50 MG ............................ 16 ....................................................................................................
106
Phenytoin Sodium Extended ORAL CAPSULE 100 MG, 200 MG, 300 MG ...................................................... 16 Phenytoin Sodium INJECTION SOLUTION 50 MG/ML .................. 16 PHOS-FLUR DENTAL GEL 1.1 % .............................................................................. 71 Pilocarpine HCl ORAL TABLET 5 MG, 7.5 MG .................................................. 71 Pindolol ORAL TABLET 10 MG, 5 MG ............................................................. 41 Pioglitazone HCl ORAL TABLET 15 MG, 30 MG, 45 MG ................................................................................................ 21 Pioglitazone HCl-Metformin HCl ORAL TABLET 15-500 MG, 15-850 MG ............................................................ 20 Piroxicam ORAL CAPSULE 10 MG, 20 MG ............................................................. 4 PLAN B ONE-STEP ORAL TABLET 1.5 MG ....................................... 47 Podofilox EXTERNAL SOLUTION 0.5 % .................................... 54 Polycin B OPHTHALMIC OINTMENT 500-10000 UNIT/GM .............................................................. 76 Poly-Dex OPHTHALMIC OINTMENT 3.5-10000-0.1 ................................................................................................ 76 Polyethylene Glycol 3350 ORAL POWDER .......................................................... 65 Polymyxin B-Trimethoprim OPHTHALMIC SOLUTION 10000-0.1 UNIT/ML-% ..................... 76 Poly-Vitamin ORAL SOLUTION 35 MG/ML .................. 72 Poly-Vitamin/Iron ORAL SOLUTION 10 MG/ML .................. 72 PORTIA-28 ORAL TABLET 0.15-30 MG-MCG .................................... 45 Potassium Chloride Crys ER ORAL TABLET EXTENDEDRELEASE* 10 MEQ, 20 MEQ ............................................... 69 Potassium Chloride ER ORAL TABLET EXTENDEDRELEASE* 10 MEQ, 8 MEQ .................................................. 70 Potassium Chloride INTRAVENOUS* SOLUTION 0.4 MEQ/ML, 10 MEQ/100ML, 2 MEQ/ML, 30 MEQ/100ML, 40 MEQ/100ML .................................................... 69
Potassium Chloride ORAL LIQUID† 20 MEQ/15ML (10%), 40 MEQ/15ML (20%)
69 Potassium Chloride ORAL SOLUTION 20 MEQ/15ML (10%) ........................................................................... 69 PR NATAL 400 EC ORAL MISC 29-1-200 & 400 MG (DR) ................................................................................................ 73 Pramipexole Dihydrochloride ORAL TABLET 0.125 MG, 0.25 MG, 0.5 MG, 0.75 MG, 1 MG, 1.5 MG ........................................................................ 33 Pravastatin Sodium ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG ......................................................... 25 Prazosin HCl ORAL CAPSULE 1 MG, 2 MG, 5 MG ................................. 26 PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP ................................................................................................ 56 PRECISION XTRA KETONE IN VITRO STRIP ..................................... 56 PRECISION XTRA XX DEVICE .................................................................. 66 PRED-G OPHTHALMIC SUSPENSION 0.3-1 % ...................... 76 PrednisoLONE Acetate OPHTHALMIC SUSPENSION 1 % .................................................................................... 77 PrednisoLONE ORAL SOLUTION 15 MG/5ML .............. 48 PrednisoLONE Sodium Phosphate ORAL SOLUTION 15 MG/5ML, 6.7 (5 Base) MG/5ML ................................................................................................ 48 PredniSONE ORAL SOLUTION 5 MG/5ML ........................................................... 48 PredniSONE ORAL TABLET 1 MG, 10 MG, 2.5 MG, 20 MG, 5 MG ................................................................................... 48 PREMARIN INJECTION SOLUTION RECONSTITUTED 25 MG ................................................................................................ 59 PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG, 0.9 MG, 1.25 MG .................................................. 59 PREMARIN VAGINAL CREAM 0.625 MG/GM ................. 86 PREMPHASE ORAL TABLET 0.625-5 MG ......................................................... 59 ................................................................................................
PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG
59 Prenatabs OBN ORAL TABLET 29-1 MG .................................................................... 72 PRENATABS RX ORAL TABLET 29-1 MG ................................... 72 Prenatal Low Iron ORAL TABLET 27-0.8 MG .............................. 72 Prenatal Plus Iron ORAL TABLET 29-1 MG .................................... 72 Prenatal Plus ORAL TABLET 27-1 MG .................................................................... 72 Prenatal Vitamins ORAL TABLET 28-0.8 MG .............................. 72 PREVIFEM ORAL TABLET 0.25-35 MG-MCG .................................... 45 PREZISTA ORAL SUSPENSION 100 MG/ML ................................................................................................ 37 PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75 MG, 800 MG .................................................... 37 Primaquine Phosphate ORAL TABLET 26.3 MG .................................... 29 Primidone ORAL TABLET 250 MG ................................................................................... 16 Primidone ORAL TABLET 50 MG ................................................................................... 16 Probenecid ORAL TABLET 500 MG ................................................................................... 61 Procainamide HCl INJECTION SOLUTION 100 MG/ML, 500 MG/ML ..................................................................... 10 Prochlorperazine Maleate ORAL TABLET 10 MG, 5 MG .................... 36 Prochlorperazine RE SUPPOSITORY 25 MG .................. 36 PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML, 40000 UNIT/ML ............................................................. 62 PROCTOSOL HC RE CREAM 2.5 % .................................................................................. 8 PROCTOZONE-HC RE CREAM 2.5 % ................................................... 8 PROLIA SUBCUTANEOUS* SOLUTION 60 MG/ML ................. 58 Promethazine HCl ORAL SYRUP 6.25 MG/5ML ...................... 24 ................................................................................................
Promethazine HCl ORAL TABLET 12.5 MG, 25 MG, 50 MG ................................................................................... 24 Promethazine HCl RE SUPPOSITORY 25 MG .................. 24 PROMETHEGAN RE SUPPOSITORY 12.5 MG, 25 MG, 50 MG ........................................................ 24 Propafenone HCl ORAL TABLET 150 MG, 225 MG, 300 MG ................................................................................... 11 Propantheline Bromide ORAL TABLET 15 MG .......................................... 83 Propranolol HCl ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 160 MG, 60 MG, 80 MG ................... 41 Propranolol HCl INTRAVENOUS* SOLUTION 1 MG/ML ............................................................... 41 Propranolol HCl ORAL TABLET 10 MG, 20 MG, 40 MG, 60 MG, 80 MG ................................ 41 Propranolol-HCTZ ORAL TABLET 40-25 MG, 80-25 MG ................................................................................................ 27 Propylthiouracil ORAL TABLET 50 MG .......................................................................... 82 PROSTIGMIN ORAL TABLET 15 MG ......................................................................... 29 Protriptyline HCl ORAL TABLET 10 MG, 5 MG .................... 19 Pseudoephedrine HCl ORAL TABLET 30 MG, 60 MG ................ 74 PULMICORT INHALATION SUSPENSION 1 MG/2ML ................................................................................................ 12 PULMOZYME INHALATION SOLUTION 1 MG/ML .................... 82 Pyrazinamide ORAL TABLET 500 MG ...................................................................... 29 Pyridostigmine Bromide ORAL TABLET 60 MG .......................................... 29 QUASENSE ORAL TABLET 0.15-0.03 MG .................................................... 46 QUEtiapine Fumarate ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 400 MG, 50 MG ................................................................................................ 35 Quinapril HCl ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG ................................................................................................ 26
QuiNIDine Gluconate ER ORAL TABLET EXTENDEDRELEASE* 324 MG ................................................................................... 10 QuiNIDine Gluconate INJECTION SOLUTION 80 MG/ML ..................................................................... 10 QuiNIDine Sulfate ORAL TABLET 300 MG ...................................... 10 QVAR INHALATION AEROSOL, SOLUTION 40 MCG/ACT ........................................................... 12 QVAR INHALATION AEROSOL, SOLUTION 80 MCG/ACT ........................................................... 12 Ramipril ORAL CAPSULE 1.25 MG, 10 MG, 2.5 MG, 5 MG ................................................................................................ 26 Ranitidine Acid Reducer ORAL TABLET 75 MG .......................................... 84 Ranitidine HCl INJECTION SOLUTION 1000 MG/40ML, 150 MG/6ML, 50 MG/2ML ................................................................................................ 84 Ranitidine HCl ORAL CAPSULE 150 MG, 300 MG ................................................................................................ 84 Ranitidine HCl ORAL SYRUP 15 MG/ML ........................................................... 84 Ranitidine HCl ORAL TABLET 150 MG ...................................................................... 84 Ranitidine HCl ORAL TABLET 300 MG ...................................................................... 84 REBIF REBIDOSE SUBCUTANEOUS* SOLUTION 22 MCG/0.5ML, 44 MCG/0.5ML ..................................................... 81 REBIF REBIDOSE TITRATION PACK SUBCUTANEOUS* SOLUTION 6X8.8 & 6X22 MCG ............................................................................. 81 REBIF SUBCUTANEOUS* SOLUTION 22 MCG/0.5ML, 44 MCG/0.5ML ..................................................... 81 REBIF TITRATION PACK SUBCUTANEOUS* SOLUTION 6X8.8 & 6X22 MCG ............................................................................. 81 RECLIPSEN ORAL TABLET 0.15-30 MG-MCG .................................... 45 Reeses Pinworm Medicine ORAL SUSPENSION 144 MG/ML .................................................................................................... 9 107
Refenesen 400 ORAL TABLET 400 MG ...................................................................... 49 Refenesen ORAL TABLET 200 MG ................................................................................... 49 RELENZA DISKHALER INHALATION AEROSOL POWDER, BREATH ACTIVATED 5 MG/BLISTER ................................................................................................ 39 REMEVEN EXTERNAL CREAM 50 % ................................................. 54 Rena-Vite ORAL TABLET ................................................................................................ 71 RENVELA ORAL PACKET 0.8 GM, 2.4 GM ...................................................... 60 RENVELA ORAL TABLET 800 MG ..................................................................... 60 RESCRIPTOR ORAL TABLET 100 MG, 200 MG ....................................... 37 RESTASIS OPHTHALMIC EMULSION 0.05 % ............................... 76 REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG .................................................. 39 REYATAZ ORAL CAPSULE 100 MG, 150 MG, 200 MG, 300 MG .................................................................................. 37 RIBASPHERE ORAL TABLET 200 MG ..................................................................... 39 Ribavirin ORAL TABLET 200 MG ................................................................................... 39 RIDAURA ORAL CAPSULE 3 MG ...................................................................................... 3 Rifampin INTRAVENOUS* SOLUTION RECONSTITUTED 600 MG ................................................................................................ 29 Rifampin ORAL CAPSULE 150 MG, 300 MG ...................................................... 29 Rimantadine HCl ORAL TABLET 100 MG ...................................... 39 RIOMET ORAL SOLUTION 500 MG/5ML ................................................... 20 RISPERIDONE M-TAB ORAL TABLET DISPERSIBLE 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG ................................................................................................ 34 RisperiDONE ORAL SOLUTION 1 MG/ML ..................... 34 RisperiDONE ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG ....................................................... 34
108
RisperiDONE ORAL TABLET DISPERSIBLE 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG ................................................................................................ 34 Rivastigmine Tartrate ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG ............................................................. 80 Robafen ORAL SYRUP 100 MG/5ML ................................................................. 49 ROPINIRole HCl ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG, 5 MG ................................................................................................ 34 ROXICET ORAL TABLET 5-325 MG ................................................................... 7 SALACTIC FILM EXTERNAL SOLUTION 17 % ...................................... 54 Saline Flush INTRAVENOUS* SOLUTION 0.9 % .................................... 70 Saline Mist Spray NASAL SOLUTION 0.65 % ................................. 73 Saline Nasal Spray NASAL SOLUTION 0.65 % ................................. 74 Salsalate ORAL TABLET 500 MG, 750 MG ......................................................... 5 SANDIMMUNE ORAL SOLUTION 100 MG/ML ............. 40 SANTYL EXTERNAL OINTMENT 250 UNIT/GM ................................................................................................ 54 SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 5 MG ........................................................... 35 SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG ................................................................................................ 81 SAVELLA TITRATION PACK ORAL MISC 12.5 & 25 & 50 MG .................................................................................. 81 Selegiline HCl ORAL CAPSULE 5 MG ............................................................................. 34 Selegiline HCl ORAL TABLET 5 MG ................................................................................... 34 Selenium Sulfide EXTERNAL LOTION 2.5 % ............................................... 52 SELZENTRY ORAL TABLET 150 MG, 300 MG ....................................... 36 Se-Natal 19 ORAL TABLET CHEWABLE 29-1 MG ...................... 72 Senna S ORAL TABLET 8.6-50 MG ................................................................................... 64
SEREVENT DISKUS INHALATION AEROSOL POWDER, BREATH ACTIVATED 50 MCG/DOSE ................................................................................................ 13 Sertraline HCl ORAL TABLET 100 MG, 25 MG, 50 MG ................... 18 SF DENTAL GEL 1.1 % ................. 71 Sildenafil Citrate ORAL TABLET 20 MG .......................................... 43 Silver Sulfadiazine EXTERNAL CREAM 1 % ...................................................... 52 Simethicone ORAL SUSPENSION 40 MG/0.6ML ................................................................................................ 60 Simethicone ORAL TABLET CHEWABLE 80 MG ............................ 60 SIMPONI SUBCUTANEOUS* SOLUTION 100 MG/ML, 50 MG/0.5ML .............................................................. 3 Simvastatin ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG, 80 MG ................................................................................... 25 Slow Release Iron ORAL TABLET EXTENDEDRELEASE* 160 (50 Fe) MG ......................................................... 63 Sodium Chloride INHALATION NEBULIZATION SOLUTION 0.9 % .............................................................................. 49 Sodium Chloride INJECTION SOLUTION 0.9 % .................................... 70 Sodium Chloride INTRAVENOUS* SOLUTION 0.9 % .............................................................................. 70 Sodium Chloride IRRIGATION SOLUTION 0.9 % .................................... 61 Sodium Citrate ORAL GRANULES .................................................. 61 Sodium Fluoride ORAL SOLUTION 1.1 (0.5 F) MG/ML ................................................................................................ 69 Sodium Fluoride ORAL TABLET CHEWABLE 0.55 (0.25 F) MG, 1.1 (0.5 F) MG, 2.2 (1 F) MG ................................................................................................ 69 Sodium Polystyrene Sulfonate ORAL POWDER ................................... 40 SOLIA ORAL TABLET 0.15-30 MG-MCG ............................................................. 45 Sorbitol ORAL SOLUTION 70 % ......................................................................................... 65
SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG ................................................................................................ 41 Sotalol HCl (AF) ORAL TABLET 120 MG, 160 MG, 80 MG ................................................................................... 41 Sotalol HCl ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG ................................................................................................ 41 Spironolactone ORAL TABLET 100 MG, 25 MG, 50 MG ................... 57 Spironolactone-HCTZ ORAL TABLET 25-25 MG ................................ 57 SPRINTEC 28 ORAL TABLET 0.25-35 MG-MCG .................................... 46 SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG .............................................. 32 SPS ORAL SUSPENSION 15 GM/60ML ............................................................ 40 SRONYX ORAL TABLET 0.1-20 MG-MCG ........................................ 46 SSD EXTERNAL CREAM 1 % ................................................................................................ 52 SSKI ORAL SOLUTION 1 GM/ML .................................................................... 69 Stavudine ORAL CAPSULE 15 MG, 20 MG, 30 MG, 40 MG ................................................................................................ 38 Stavudine ORAL SOLUTION RECONSTITUTED 1 MG/ML ................................................................................................ 38 STIVARGA ORAL TABLET 40 MG .................................................................................. 32 Stool Softener Laxative DC ORAL CAPSULE 240 MG ................................................................................................ 65 Stool Softener ORAL CAPSULE 100 MG, 250 MG ......................................... 65 STRIBILD ORAL TABLET 150-150-200-300 MG ............................. 36 STROMECTOL ORAL TABLET 3 MG ................................................ 9 SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-1 MG, 8-2 MG ......................................................... 7 Sucralfate ORAL TABLET 1 GM ................................................................................... 84 Sulfacetamide Sodium EXTERNAL SUSPENSION 10 % ......................................................................................... 49 Sulfacetamide Sodium OPHTHALMIC SOLUTION 10 % ......................................................................................... 76
Sulfacetamide-Prednisolone OPHTHALMIC SOLUTION 10-0.23 % ................................................................. 76 Sulfamethoxazole-TMP DS ORAL TABLET 800-160 MG ................................................................................................ 28 Sulfamethoxazole-Trimethoprim ORAL SUSPENSION 200-40 MG/5ML ................................................................. 28 Sulfamethoxazole-Trimethoprim ORAL TABLET 400-80 MG ................................................................................................ 28 SulfaSALAzine ORAL TABLET 500 MG ...................................................................... 60 SulfaSALAzine ORAL TABLET DELAYED RELEASE 500 MG ................................................................................................ 60 Sulindac ORAL TABLET 150 MG, 200 MG ......................................................... 4 SUMAtriptan NASAL SOLUTION 20 MG/ACT, 5 MG/ACT ................................................................. 68 SUMAtriptan Succinate ORAL TABLET 100 MG, 25 MG, 50 MG ................................................................................... 68 SUMAtriptan Succinate Refill SUBCUTANEOUS* SOLUTION 4 MG/0.5ML, 6 MG/0.5ML ........................................................... 68 SUMAtriptan Succinate SUBCUTANEOUS* SOLUTION 4 MG/0.5ML, 6 MG/0.5ML ........................................................... 68 SUPARTZ INTRA-ARTICULAR* SOLUTION 25 MG/2.5ML ................................................................................................ 73 SUSTIVA ORAL CAPSULE 200 MG, 50 MG ........................................... 37 SUSTIVA ORAL TABLET 600 MG .................................................................................. 37 SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 50 MG .............. 32 SYEDA ORAL TABLET 3-0.03 MG .................................................................................. 46 SYMBICORT INHALATION AEROSOL† 160-4.5 MCG/ACT, 80-4.5 MCG/ACT ...................................... 13 SYNAGIS INTRAMUSCULAR* SOLUTION 100 MG/ML, 50 MG/0.5ML .......................................................... 78 TABLOID ORAL TABLET 40 MG .................................................................................. 30
Tacrolimus ORAL CAPSULE 0.5 MG, 1 MG, 5 MG ............................ 40 TAMIFLU ORAL CAPSULE 30 MG ......................................................................... 39 TAMIFLU ORAL CAPSULE 45 MG, 75 MG .............................................. 39 TAMIFLU ORAL SUSPENSION RECONSTITUTED 6 MG/ML ................................................................................................ 39 Tamoxifen Citrate ORAL TABLET 10 MG, 20 MG ................ 31 Tamsulosin HCl ORAL CAPSULE 0.4 MG .................................. 61 TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG ............. 32 TASIGNA ORAL CAPSULE 150 MG, 200 MG ....................................... 32 TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % ....................... 51 TAZORAC EXTERNAL GEL 0.05 %, 0.1 % ..................................................... 51 Temazepam ORAL CAPSULE 15 MG, 30 MG ................................................ 64 Temozolomide ORAL CAPSULE 100 MG, 140 MG, 180 MG, 20 MG, 250 MG, 5 MG ................................ 29 TENCON ORAL TABLET 50-650 MG ............................................................... 4 Terazosin HCl ORAL CAPSULE 1 MG, 10 MG, 2 MG, 5 MG ................................................................................................ 26 Terbinafine HCl EXTERNAL CREAM 1 % ...................................................... 51 Terbinafine HCl ORAL TABLET 250 MG ...................................................................... 23 Terbutaline Sulfate INJECTION SOLUTION 1 MG/ML ..................... 13 Terbutaline Sulfate ORAL TABLET 2.5 MG, 5 MG .................. 13 Terconazole VAGINAL CREAM 0.4 %, 0.8 % ......................................................... 86 Terconazole VAGINAL SUPPOSITORY 80 MG .................. 86 TESTIM TRANSDERMAL GEL 50 MG/5GM ........................................ 8 Testosterone Cypionate INTRAMUSCULAR* OIL 100 MG/ML, 200 MG/ML ............................. 8 Testosterone Enanthate INTRAMUSCULAR* OIL 200 MG/ML ........................................................................ 8
109
Tetracycline HCl ORAL CAPSULE 250 MG, 500 MG ................................................................................................
TEV-TROPIN SUBCUTANEOUS* SOLUTION RECONSTITUTED 5 MG
82
58 THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG .................................................................................. 39 Theophylline ER ORAL TABLET EXTENDED RELEASE 12 HR* 100 MG, 200 MG, 300 MG, 450 MG ........................ 14 Theophylline ER ORAL TABLET EXTENDED RELEASE 24 HR* 400 MG, 600 MG ................................................................................... 14 Theophylline ORAL SOLUTION 80 MG/15ML .................................................... 14 Thiamine HCl INJECTION SOLUTION 100 MG/ML .............. 87 Thioridazine HCl ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG ......................................................... 36 Thiothixene ORAL CAPSULE 1 MG, 10 MG, 2 MG, 5 MG ............. 36 THYROLAR-1 ORAL TABLET 60 (12.5-50) MG (MCG) ........................................................................ 83 THYROLAR-1/2 ORAL TABLET 30 (6.25-25) MG (MCG) ........................................................................ 83 THYROLAR-1/4 ORAL TABLET 15 (3.1-12.5) MG (MCG) ........................................................................ 83 THYROLAR-2 ORAL TABLET 120 (25-100) MG (MCG) ........................................................................ 83 THYROLAR-3 ORAL TABLET 180 (37.5-150) MG (MCG) ........................................................................ 83 TiaGABine HCl ORAL TABLET 2 MG, 4 MG ....................................................... 16 Timolol Maleate OPHTHALMIC GEL FORMING SOLUTION 0.25 %, 0.5 % .............................................................................. 75 Timolol Maleate OPHTHALMIC SOLUTION 0.25 %, 0.5 % ..................................................... 75 ................................................................................................
110
Timolol Maleate ORAL TABLET 10 MG, 20 MG, 5 MG ................................................................................................ 41 TIVICAY ORAL TABLET 50 MG .................................................................................. 37 TOBI INHALATION NEBULIZATION SOLUTION 300 MG/5ML ....................................................... 2 TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % ...................... 76 Tobramycin Sulfate OPHTHALMIC SOLUTION 0.3 % .............................................................................. 75 Tolmetin Sodium ORAL CAPSULE 400 MG .................................... 4 Topiramate ORAL CAPSULE SPRINKLE 15 MG, 25 MG ................................................................................................ 16 Topiramate ORAL TABLET 100 MG, 25 MG, 50 MG ................................ 16 Topiramate ORAL TABLET 200 MG ................................................................................... 16 Torsemide ORAL TABLET 10 MG, 100 MG, 20 MG, 5 MG ................................................................................................ 57 TRADJENTA ORAL TABLET 5 MG ............................................................................. 20 TraMADol HCl ORAL TABLET 50 MG ............................................................................. 6 Tranylcypromine Sulfate ORAL TABLET 10 MG .......................................... 18 Travel Sickness ORAL TABLET CHEWABLE 25 MG ............................ 23 TraZODone HCl ORAL TABLET 100 MG, 150 MG, 50 MG ................................................................................... 18 TRELSTAR DEPOT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 3.75 MG ................................................................................................ 31 TRELSTAR DEPOT MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 3.75 MG ................................................................................................ 31 TRELSTAR LA INTRAMUSCULAR* SUSPENSION RECONSTITUTED 11.25 MG ................................................................................................ 31
TRELSTAR LA MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 11.25 MG ................................................................................................ 31 TRELSTAR MIXJECT INTRAMUSCULAR* SUSPENSION RECONSTITUTED 22.5 MG ................................................................................................ 31 Tretinoin EXTERNAL CREAM 0.025 %, 0.05 %, 0.1 % ......................... 50 Tretinoin EXTERNAL GEL 0.01 %, 0.025 % ............................................................. 50 Triamcinolone Acetonide EXTERNAL CREAM 0.025 %, 0.1 %, 0.5 % ......................................................... 54 Triamcinolone Acetonide EXTERNAL OINTMENT 0.1 % ................................................................................................ 54 Triamcinolone Acetonide MOUTH/THROAT PASTE 0.1 % ......................................................................................... 71 Triamterene-HCTZ ORAL CAPSULE 37.5-25 MG ..................... 57 Triamterene-HCTZ ORAL TABLET 37.5-25 MG, 75-50 MG ................................................................................................ 57 Triazolam ORAL TABLET 0.125 MG, 0.25 MG .................................................... 64 TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG ............................................................................. 46 Trifluoperazine HCl ORAL TABLET 1 MG, 10 MG, 2 MG, 5 MG ................................................................................... 36 Trifluridine OPHTHALMIC SOLUTION 1 % .......................................... 76 Trihexyphenidyl HCl ORAL ELIXIR 0.4 MG/ML ............................. 33 Trihexyphenidyl HCl ORAL TABLET 2 MG, 5 MG ........................ 33 TRILYTE ORAL SOLUTION RECONSTITUTED 420 GM ................................................................................................ 64 Trimethoprim ORAL TABLET 100 MG ...................................................................... 27 Trinatal Rx 1 ORAL TABLET 60-1 MG .................................................................... 72 TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG ............................................................................. 46
TRI-PREVIFEM ORAL TABLET 0.18/0.215/0.25 MG-35 MCG ............................................................................. 46 TRI-SPRINTEC ORAL TABLET 0.18/0.215/0.25 MG-35 MCG ............................................................................. 46 TRIVEEN-U ORAL CAPSULE 106.5-1 MG ......................................................... 73 Tri-Vit/Fluoride ORAL SOLUTION 0.25 MG/ML ............ 72 Tri-Vit/Fluoride/Iron ORAL SOLUTION 0.25-10 MG/ML ................................................................................................ 71 Tri-Vitamin ORAL SOLUTION 1500-400-35 ........................................................ 72 Tri-Vitamin/Fluoride ORAL SOLUTION 0.25 MG/ML, 0.5 MG/ML ..................................................................... 72 TRIVORA (28) ORAL TABLET ................................................................................................ 46 TRIZIVIR ORAL TABLET 300-150-300 MG .......................................... 36 Trospium Chloride ORAL TABLET 20 MG .......................................... 85 TRUVADA ORAL TABLET 200-300 MG ........................................................ 36 TUDORZA PRESSAIR INHALATION AEROSOL POWDER, BREATH ACTIVATED 400 MCG/ACT ................................................................................................ 11 TYKERB ORAL TABLET 250 MG .................................................................................. 32 UltimateCare Combo ORAL MISC 30-1 MG .............................................. 73 UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG ................................................................................................ 83 Urea EXTERNAL CREAM 40 % ................................................................................................ 54 URETRON D/S ORAL TABLET ................................................................. 85 Ursodiol ORAL CAPSULE 300 MG ................................................................................... 60 Uticap ORAL CAPSULE 120 MG ................................................................................... 85 ValACYclovir HCl ORAL TABLET 1 GM, 500 MG ................ 39 Valproic Acid ORAL CAPSULE 250 MG ...................................................................... 17
Valproic Acid ORAL SOLUTION 250 MG/5ML .......... 17 Valproic Acid ORAL SYRUP 250 MG/5ML ................................................................. 17 Vancomycin HCl INTRAVENOUS* SOLUTION RECONSTITUTED 1000 MG, 500 MG, 750 MG ......................................... 27 Vancomycin HCl ORAL CAPSULE 125 MG, 250 MG ................................................................................................ 27 VANDAZOLE VAGINAL GEL 0.75 % ........................................................................... 86 VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG ................ 46 Venlafaxine HCl ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 150 MG, 37.5 MG, 75 MG .......................................... 18 Venlafaxine HCl ORAL TABLET 100 MG, 25 MG, 37.5 MG, 50 MG, 75 MG ................................ 18 VENTOLIN HFA INHALATION AEROSOL, SOLUTION 108 (90 BASE) MCG/ACT ........................................................... 13 Verapamil HCl ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 120 MG, 180 MG, 200 MG, 240 MG, 300 MG, 360 MG ........................ 42 Verapamil HCl ER ORAL TABLET EXTENDEDRELEASE* 120 MG, 180 MG, 240 MG ........................ 42 Verapamil HCl ORAL TABLET 120 MG, 40 MG, 80 MG ................... 42 VEXOL OPHTHALMIC SUSPENSION 1 % .................................. 77 VIDEX ORAL SOLUTION RECONSTITUTED 2 GM, 4 GM .................................................................................. 38 VINATE AZ EXTRA ORAL TABLET 29-1 MG ................................... 73 VINATE AZ ORAL TABLET 27-1 MG ................................................................... 73 VINATE GT ORAL TABLET 90-1 MG ................................................................... 73 VINATE II ORAL TABLET 29-1 MG ................................................................... 73 VINATE M ORAL TABLET 27-1 MG ................................................................... 73 VIRACEPT ORAL TABLET 250 MG, 625 MG ....................................... 37
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300 MG ................................................................................................ 38 Vitamin A ORAL CAPSULE 10000 UNIT, 8000 UNIT ................. 87 Vitamin B Complex-C ORAL CAPSULE ........................................................ 71 Vitamin B-1 ORAL TABLET 100 MG, 250 MG, 50 MG ............................ 87 Vitamin B-12 ORAL TABLET 1000 MCG ............................................................. 62 Vitamin B-6 ER ORAL TABLET EXTENDEDRELEASE* 200 MG ................................................................................... 87 Vitamin B-6 ORAL TABLET 100 MG, 25 MG, 250 MG, 50 MG, 500 MG ...................................................................... 87 Vitamin D (Ergocalciferol) ORAL CAPSULE 50000 UNIT ................................................................................................ 87 Vitamin K (Phytonadione) ORAL TABLET 100 MCG ................................................................................................ 87 Vitamins ACD-Fluoride ORAL SOLUTION 0.25 MG/ML ............ 72 VOLTAREN TRANSDERMAL GEL 1 % .................................................................. 51 VYTORIN ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG, 10-80 MG .............................................. 25 VYVANSE ORAL CAPSULE 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG .................................................. 1 Warfarin Sodium ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG ....................................................... 14 WESTHROID ORAL TABLET 113.75 MG, 130 MG, 146.25 MG, 16.25 MG, 162.5 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 48.75 MG, 65 MG, 81.25 MG, 97.5 MG .................................................. 83 XALKORI ORAL CAPSULE 200 MG, 250 MG ....................................... 32 XARELTO ORAL TABLET 10 MG .................................................................................. 14 XELODA ORAL TABLET 150 MG, 500 MG .................................................... 30 XOLAIR SUBCUTANEOUS* SOLUTION RECONSTITUTED 150 MG ................................................................................................ 11
111
XTANDI ORAL CAPSULE 40 MG .................................................................................. 31 X-VIATE EXTERNAL CREAM 40 % ................................................. 54 Zafirlukast ORAL TABLET 10 MG, 20 MG ......................................................... 11 ZEBUTAL ORAL CAPSULE 50-500-40 MG ..................................................... 4 ZELBORAF ORAL TABLET 240 MG ..................................................................... 31 ZENCHENT FE ORAL TABLET CHEWABLE 0.4-35 MG-MCG ............................................................. 46 ZETIA ORAL TABLET 10 MG ................................................................................................ 25 ZIAGEN ORAL SOLUTION 20 MG/ML .................................................................... 38 Zidovudine ORAL CAPSULE 100 MG ...................................................................... 38 Zidovudine ORAL SYRUP 50 MG/5ML ................................................................. 38 Zidovudine ORAL TABLET 300 MG ................................................................................... 38 Zinc Sulfate ORAL TABLET 220 (50 Zn) MG ....................................................... 70 ZOLINZA ORAL CAPSULE 100 MG ..................................................................... 31 Zolpidem Tartrate ORAL TABLET 10 MG, 5 MG .................... 64 Zonisamide ORAL CAPSULE 100 MG ...................................................................... 16 Zonisamide ORAL CAPSULE 25 MG ................................................................................... 16 Zonisamide ORAL CAPSULE 50 MG ................................................................................... 16 ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG ............. 46 ZOVIA 1/50E (28) ORAL TABLET 1-50 MG-MCG ............. 46 ZOVIRAX EXTERNAL CREAM 5 % ..................................................... 52
112
