Your Guide to Prescription Drug Benefits Preferred Formulary and Prescription Drug List

Your Guide to Prescription Drug Benefits 2016 Preferred Formulary and Prescription Drug List CURRENT AS OF 7/1/2016 Table of Contents Abbreviations...
Author: Gilbert Mosley
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Your Guide to Prescription Drug Benefits 2016 Preferred Formulary and Prescription Drug List

CURRENT AS OF 7/1/2016

Table of Contents Abbreviations and Key to Drug Tiers ….…………………………………………………………………… 1-2 Drug Classes: ANTI - INFECTIVES .......................................................................................................................................... 3 ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS .......................................................................... 13 AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ........................................................................... 17 CARDIOVASCULAR, HYPERTENSION & LIPIDS ..................................................................................... 38 DERMATOLOGICALS/TOPICAL THERAPY ............................................................................................... 51 DIAGNOSTICS & MISCELLANEOUS AGENTS .......................................................................................... 67 EAR, NOSE & THROAT MEDICATIONS...................................................................................................... 69 ENDOCRINE/DIABETES ................................................................................................................................ 71 GASTROENTEROLOGY ................................................................................................................................. 88 IMMUNOLOGY, VACCINES & BIOTECHNOLOGY .................................................................................. 95 MUSCULOSKELETAL & RHEUMATOLOGY ........................................................................................... 101 OBSTETRICS & GYNECOLOGY ................................................................................................................. 102 OPHTHALMOLOGY...................................................................................................................................... 111 RESPIRATORY, ALLERGY, COUGH & COLD.......................................................................................... 117 UROLOGICALS .............................................................................................................................................. 124 VITAMINS, HEMATINICS & ELECTROLYTES ........................................................................................ 127 Index ................................................................................................................................................................. 140

List of Abbreviations: #: Some plans do not cover these medications. Check with BlueCross BlueShield of Tennessee Member Services to determine coverage at the phone number listed on your BlueCross BlueShield of Tennessee member ID card. ACA: Affordable Care Act AGE-A: Age edit is applicable. Prior authorization is required for members 17 years of age and younger. Your network provider must call Express Scripts at 1-877-916-2271 to request a coverage review. AGE-B: Age edit is applicable. Prior authorization is required for males 30 years of age and younger; prior authorization is required for all females. Your network physician must call Express Scripts at 1-877-9162271 to request a coverage review. GEN: Only applies to two and three tiered plans with flat copays under the retail benefit. The brand name drug will process at the generic copay tier. The brand name drug’s generic equivalent is a non-covered drug. If your plan has a coinsurance or percentage benefit for drugs, the brand name drug will be covered at the assigned brand copay and the generic equivalent will be a covered benefit. LD: Limited Distribution. This medication may be available only at certain pharmacies. For more information, please call BlueCross BlueShield Member Services at the phone number listed on your BlueCross BlueShield of Tennessee member ID card. OTC: Over the Counter. An OTC drug is a medication that can be purchased without a prescription from your physician. PA: Prior Authorization. The plan requires your physician to obtain prior authorization for certain drugs. This means that you will need to get approval before you may fill your prescription. Your network provider must call Express Scripts at 1-877-916-2271 to request a coverage review for a drug that requires prior authorization. QL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that will be covered. Please visit the following link for additional details regarding quantity limits: http://www.bcbst.com/docs/providers/Essential-Quantity-Limit-021516.pdf SPRx: Product is on the Specialty Drug List. Please visit the following link for additional details regarding the Specialty Drug List: http://www.bcbst.com/docs/pharmacy/Specialty-Drug-List-2016.pdf ST: Step Therapy. In some cases, your plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. Your network provider must call Express Scripts at 1-877-916-2271 to request a coverage review. Please visit the following link for additional details regarding the Step Therapy list: http://www.bcbst.com/docs/providers/Essential-Step-Therapy-List-122315.pdf

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Drug Tier Key: Tier 1: Lowest member copayment: Includes generic prescription drugs. Tier 2: Reduced member copayment: Includes selected branded products that are more cost-effective than similar drugs within a common drug class. Tier 3: Highest member copayment: Includes branded products listed in this guide not selected for Tier 2. In many cases, there is a reasonable alternative drug in Tier 1 or Tier 2 for the Tier 3 products.

Pharmacy Appeals: To appeal a denial based on the Prior Authorization criteria or to request a medical exception to the quantity limit, please FAX a written request to: Pharmacy Management Appeals BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN 37402-2555 Fax: 1-888-343-4232 Please provide the following information with your written request: 1. Patient name and cardholder ID number 2. Physician name and phone number 3. Drug and diagnosis information

2

Drug Name

Drug Tier

Requirements / Limits

ANTI - INFECTIVES ANTIFUNGAL AGENTS ANCOBON ORAL CAPSULE

3

clotrimazole mucous membrane troche

1

CRESEMBA ORAL CAPSULE

3

DIFLUCAN ORAL SUSPENSION FOR RECONSTITUTION

3

DIFLUCAN ORAL TABLET

3

fluconazole oral suspension for reconstitution

1

fluconazole oral tablet

1

flucytosine oral capsule

1

griseofulvin microsize oral suspension

1

griseofulvin microsize oral tablet

1

griseofulvin ultramicrosize oral tablet

1

GRIS-PEG (ULTRAMICROSIZE) ORAL TABLET

3

itraconazole oral capsule

1

ketoconazole oral tablet

1

NOXAFIL ORAL SUSPENSION

3

NOXAFIL ORAL TABLET,DELAYED RELEASE (DR/EC)

3

nystatin oral powder

1

nystatin oral suspension

1

nystatin oral tablet

1

ONMEL ORAL TABLET

3

ORAVIG BUCCAL MUCO-ADHESIVE BUCCAL TABLET

3

SPORANOX ORAL SOLUTION

3

SPORANOX PULSEPAK ORAL CAPSULE

3

terbinafine hcl oral tablet

1

VFEND ORAL SUSPENSION FOR RECONSTITUTION

3

VFEND ORAL TABLET

3

voriconazole oral suspension for reconstitution

1 3

#

Drug Name

Drug Tier

voriconazole oral tablet

Requirements / Limits

1

ANTIVIRALS abacavir oral tablet

1

abacavir-lamivudine-zidovudine oral tablet

1

acyclovir oral capsule

1

acyclovir oral suspension

1

acyclovir oral tablet

1

adefovir oral tablet

1

amantadine hcl oral capsule

1

amantadine hcl oral solution

1

amantadine hcl oral tablet

1

APTIVUS ORAL CAPSULE

3

APTIVUS ORAL SOLUTION

3

ATRIPLA ORAL TABLET

3

BARACLUDE ORAL SOLUTION

3

BARACLUDE ORAL TABLET

3

COMBIVIR ORAL TABLET

3

COMPLERA ORAL TABLET

3

CRIXIVAN ORAL CAPSULE

3

didanosine oral capsule,delayed release(dr/ec)

1

EDURANT ORAL TABLET

3

EMTRIVA ORAL CAPSULE

3

EMTRIVA ORAL SOLUTION

3

entecavir oral tablet

1

EPIVIR HBV ORAL SOLUTION

3

EPIVIR HBV ORAL TABLET

3

EPIVIR ORAL SOLUTION

3

EPIVIR ORAL TABLET

3

EPZICOM ORAL TABLET

3

EVOTAZ ORAL TABLET

3

famciclovir oral tablet

1

FAMVIR ORAL TABLET

3

FLUMADINE ORAL TABLET

3 4

SPRx

SPRx

SPRx

Drug Name

Drug Tier

Requirements / Limits

FUZEON SUBCUTANEOUS RECON SOLN

3

SPRx

GENVOYA ORAL TABLET

3

SPRx

HARVONI ORAL TABLET

2

PA; SPRx

HEPSERA ORAL TABLET

3

INTELENCE ORAL TABLET

3

INVIRASE ORAL CAPSULE

3

INVIRASE ORAL TABLET

3

ISENTRESS ORAL POWDER IN PACKET

3

ISENTRESS ORAL TABLET

3

ISENTRESS ORAL TABLET,CHEWABLE

3

KALETRA ORAL SOLUTION

3

KALETRA ORAL TABLET

3

lamivudine oral solution

1

lamivudine oral tablet

1

lamivudine-zidovudine oral tablet

1

LEXIVA ORAL SUSPENSION

3

LEXIVA ORAL TABLET

3

nevirapine oral suspension

1

nevirapine oral tablet

1

nevirapine oral tablet extended release 24 hr

1

NORVIR ORAL CAPSULE

3

NORVIR ORAL SOLUTION

3

NORVIR ORAL TABLET

3

ODEFSEY ORAL TABLET

3

SPRx

PREZCOBIX ORAL TABLET

3

SPRx

PREZISTA ORAL SUSPENSION

3

PREZISTA ORAL TABLET

3

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE

3

RESCRIPTOR ORAL TABLET

3

RESCRIPTOR ORAL TABLET, DISPERSIBLE

3

RETROVIR ORAL CAPSULE

3

REYATAZ ORAL CAPSULE

3 5

QL (20 per 180 days)

Drug Name

Drug Tier

Requirements / Limits

REYATAZ ORAL POWDER IN PACKET

3

rimantadine oral tablet

1

SELZENTRY ORAL TABLET

3

SOVALDI ORAL TABLET

2

stavudine oral capsule

1

stavudine oral recon soln

1

STRIBILD ORAL TABLET

3

SUSTIVA ORAL CAPSULE

3

SUSTIVA ORAL TABLET

3

TAMIFLU ORAL CAPSULE 30 MG

3

QL (20 per 180 days)

TAMIFLU ORAL CAPSULE 45 MG, 75 MG

3

QL (10 per 180 days)

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION

3

QL (180 per 180 days)

TIVICAY ORAL TABLET

3

SPRx

TRIUMEQ ORAL TABLET

3

SPRx

TRIZIVIR ORAL TABLET

3

TRUVADA ORAL TABLET

3

TYBOST ORAL TABLET

3

TYZEKA ORAL TABLET

3

valacyclovir oral tablet

1

VALCYTE ORAL RECON SOLN

3

VALCYTE ORAL TABLET

3

valganciclovir oral tablet

1

VALTREX ORAL TABLET

3

VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN

3

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

3

VIRACEPT ORAL TABLET

3

VIRAMUNE ORAL SUSPENSION

3

VIRAMUNE ORAL TABLET

3

VIRAMUNE XR ORAL TABLET EXTENDED RELEASE 24 HR

3

VIRAZOLE INHALATION RECON SOLN

3 6

PA; SPRx

SPRx

Drug Name

Drug Tier

VIREAD ORAL POWDER

3

VIREAD ORAL TABLET

3

VITEKTA ORAL TABLET

3

ZERIT ORAL CAPSULE

3

ZERIT ORAL RECON SOLN

3

ZIAGEN ORAL SOLUTION

3

ZIAGEN ORAL TABLET

3

zidovudine oral capsule

1

zidovudine oral syrup

1

zidovudine oral tablet

1

ZOVIRAX ORAL CAPSULE

3

ZOVIRAX ORAL SUSPENSION

3

ZOVIRAX ORAL TABLET

3

CEPHALOSPORINS CEDAX ORAL CAPSULE

3

CEDAX ORAL SUSPENSION FOR RECONSTITUTION

3

cefaclor oral capsule

1

cefaclor oral suspension for reconstitution

1

cefaclor oral tablet extended release 12 hr

1

cefadroxil oral capsule

1

cefadroxil oral suspension for reconstitution

1

cefadroxil oral tablet

1

cefdinir oral capsule

1

cefdinir oral suspension for reconstitution

1

cefditoren pivoxil oral tablet

1

cefixime oral suspension for reconstitution

1

cefpodoxime oral suspension for reconstitution

1

cefpodoxime oral tablet

1

cefprozil oral suspension for reconstitution

1

cefprozil oral tablet

1

ceftibuten oral capsule

1

ceftibuten oral suspension for reconstitution

1 7

Requirements / Limits

SPRx

Drug Name

Drug Tier

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION

3

CEFTIN ORAL TABLET

3

cefuroxime axetil oral tablet

1

cephalexin oral capsule

1

cephalexin oral suspension for reconstitution

1

cephalexin oral tablet

1

KEFLEX ORAL CAPSULE

3

SPECTRACEF ORAL TABLET

3

SUPRAX ORAL CAPSULE

3

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION

3

SUPRAX ORAL TABLET,CHEWABLE

3

ERYTHROMYCINS & OTHER MACROLIDES azithromycin oral packet

1

azithromycin oral suspension for reconstitution

1

azithromycin oral tablet

1

BIAXIN ORAL SUSPENSION FOR RECONSTITUTION

3

BIAXIN ORAL TABLET

3

clarithromycin oral suspension for reconstitution

1

clarithromycin oral tablet

1

clarithromycin oral tablet extended release 24 hr

1

DIFICID ORAL TABLET

3

e.e.s. 400 oral tablet

1

E.E.S. GRANULES ORAL SUSPENSION FOR RECONSTITUTION

3

ERYPED 200 ORAL SUSPENSION FOR RECONSTITUTION

3

ERYPED 400 ORAL SUSPENSION FOR RECONSTITUTION

3

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

1

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

3

erythrocin (as stearate) oral tablet

1 8

Requirements / Limits

Drug Name

Drug Tier

erythromycin ethylsuccinate oral tablet

1

erythromycin oral capsule,delayed release(dr/ec)

1

erythromycin oral tablet

1

PCE ORAL TABLET, PARTICLES/CRYSTALS

3

ZITHROMAX ORAL PACKET

3

ZITHROMAX ORAL SUSPENSION FOR RECONSTITUTION

3

ZITHROMAX ORAL TABLET

3

ZMAX ORAL SUSPENSION,EXTENDED REL RECON

3

Requirements / Limits

MISCELLANEOUS ANTIINFECTIVES ALBENZA ORAL TABLET

3

ALINIA ORAL SUSPENSION FOR RECONSTITUTION

3

ALINIA ORAL TABLET

3

atovaquone oral suspension

1

atovaquone-proguanil oral tablet

1

BILTRICIDE ORAL TABLET

3

CAYSTON INHALATION SOLUTION FOR NEBULIZATION

3

chloroquine phosphate oral tablet

1

CLEOCIN ORAL CAPSULE

3

CLEOCIN ORAL RECON SOLN

3

clindamycin hcl oral capsule

1

clindamycin palmitate hcl oral recon soln

1

clindamycin pediatric oral recon soln

1

COARTEM ORAL TABLET

3

CYCLOSERINE ORAL CAPSULE

3

dapsone oral tablet

1

DARAPRIM ORAL TABLET

3

ethambutol oral tablet

1

FLAGYL ER ORAL TABLET EXTENDED RELEASE

3

FLAGYL ORAL CAPSULE

3

FLAGYL ORAL TABLET

3 9

PA; SPRx

PA; SPRx

Drug Name

Drug Tier

Requirements / Limits

hydroxychloroquine oral tablet

1

isoniazid oral solution

1

isoniazid oral tablet

1

ivermectin oral tablet

1

KETEK ORAL TABLET

3

linezolid oral suspension for reconstitution

1

QL (14 per 30 days)

linezolid oral tablet

1

QL (14 per 30 days)

MALARONE ORAL TABLET

3

MALARONE PEDIATRIC ORAL TABLET

3

mefloquine oral tablet

1

MEPRON ORAL SUSPENSION

3

metronidazole oral capsule

1

metronidazole oral tablet

1

MYAMBUTOL ORAL TABLET

3

MYCOBUTIN ORAL CAPSULE

3

NEBUPENT INHALATION RECON SOLN

3

neomycin oral tablet

1

paromomycin oral capsule

1

PASER ORAL GRANULES DR FOR SUSP IN PACKET

3

PLAQUENIL ORAL TABLET

3

PRIFTIN ORAL TABLET

3

PRIMAQUINE ORAL TABLET

3

pyrazinamide oral tablet

1

QUALAQUIN ORAL CAPSULE

3

quinine sulfate oral capsule

1

rifabutin oral capsule

1

RIFADIN ORAL CAPSULE

3

RIFAMATE ORAL CAPSULE

3

rifampin oral capsule

1

RIFATER ORAL TABLET

3

SIRTURO ORAL TABLET

3

STROMECTOL ORAL TABLET

3 10

Drug Name

Drug Tier

Requirements / Limits

TINDAMAX ORAL TABLET

3

tinidazole oral tablet

1

TOBI INHALATION SOLUTION FOR NEBULIZATION

3

SPRx; QL (56 per 30 days)

TOBI PODHALER INHALATION CAPSULE

2

SPRx; QL (224 per 30 days)

TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE

2

SPRx; QL (224 per 30 days)

tobramycin in 0.225 % nacl inhalation solution for nebulization

1

SPRx; QL (56 per 30 days)

TRECATOR ORAL TABLET

3

XIFAXAN ORAL TABLET 200 MG

3

XIFAXAN ORAL TABLET 550 MG

2

ZYVOX ORAL SUSPENSION FOR RECONSTITUTION

3

QL (14 per 30 days)

ZYVOX ORAL TABLET

3

QL (14 per 30 days)

PENICILLINS amoxicillin oral capsule

1

amoxicillin oral suspension for reconstitution

1

amoxicillin oral tablet

1

amoxicillin oral tablet,chewable

1

amoxicillin-pot clavulanate oral suspension for reconstitution

1

amoxicillin-pot clavulanate oral tablet

1

amoxicillin-pot clavulanate oral tablet extended release 12 hr

1

amoxicillin-pot clavulanate oral tablet,chewable

1

ampicillin oral capsule

1

ampicillin oral suspension for reconstitution

1

AUGMENTIN ES-600 ORAL SUSPENSION FOR RECONSTITUTION

3

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION

3

AUGMENTIN ORAL TABLET

3

AUGMENTIN XR ORAL TABLET EXTENDED RELEASE 12 HR

3

dicloxacillin oral capsule

1 11

Drug Name

Drug Tier

penicillin v potassium oral recon soln

1

penicillin v potassium oral tablet

1

QUINOLONES AVELOX ABC PACK ORAL TABLET

3

AVELOX ORAL TABLET

3

CIPRO ORAL SUSPENSION,MICROCAPSULE RECON

3

CIPRO ORAL TABLET

3

CIPRO XR ORAL TABLET, ER MULTIPHASE 24 HR

3

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr

1

ciprofloxacin hcl oral tablet

1

ciprofloxacin oral suspension,microcapsule recon

1

FACTIVE ORAL TABLET

3

LEVAQUIN ORAL TABLET

3

levofloxacin oral solution

1

levofloxacin oral tablet

1

moxifloxacin oral tablet

1

ofloxacin oral tablet

1

SULFA'S & RELATED AGENTS BACTRIM DS ORAL TABLET

3

BACTRIM ORAL TABLET

3

sulfadiazine oral tablet

1

sulfamethoxazole-trimethoprim oral suspension

1

sulfamethoxazole-trimethoprim oral tablet

1

sulfatrim oral suspension

1

TETRACYCLINES ADOXA ORAL CAPSULE

3

AVIDOXY DK KIT

3

avidoxy oral tablet

1

demeclocycline oral tablet

1

doxycycline hyclate oral capsule

1

doxycycline hyclate oral tablet

1 12

Requirements / Limits

Drug Name

Drug Tier

doxycycline hyclate oral tablet,delayed release (dr/ec)

1

doxycycline monohydrate oral capsule

1

doxycycline monohydrate oral suspension for reconstitution

1

doxycycline monohydrate oral tablet

1

minocycline oral capsule

1

minocycline oral tablet

1

tetracycline oral capsule

1

VIBRAMYCIN ORAL CAPSULE

3

VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION

3

VIBRAMYCIN ORAL SYRUP

3

Requirements / Limits

URINARY TRACT AGENTS FURADANTIN ORAL SUSPENSION

3

HIPREX ORAL TABLET

3

MACROBID ORAL CAPSULE

3

MACRODANTIN ORAL CAPSULE

3

methenamine hippurate oral tablet

1

methenamine mandelate oral tablet

1

MONUROL ORAL PACKET

3

nitrofurantoin macrocrystal oral capsule

1

nitrofurantoin monohyd/m-cryst oral capsule

1

nitrofurantoin oral suspension

1

PRIMSOL ORAL SOLUTION

3

trimethoprim oral tablet

1

VANCOMYCIN VANCOCIN ORAL CAPSULE

3

vancomycin oral capsule

1

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ADJUNCTIVE AGENTS leucovorin calcium oral tablet

1

MESNEX ORAL TABLET

3

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS 13

Drug Name

Drug Tier

Requirements / Limits

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION

3

PA; SPRx

AFINITOR ORAL TABLET

3

PA; SPRx

ALECENSA ORAL CAPSULE

3

PA; SPRx

ALKERAN ORAL TABLET

2

anastrozole oral tablet

1

ARIMIDEX ORAL TABLET

3

AROMASIN ORAL TABLET

3

ASTAGRAF XL ORAL CAPSULE,EXTENDED RELEASE 24HR

3

AZASAN ORAL TABLET

3

azathioprine oral tablet

1

bexarotene oral capsule

1

bicalutamide oral tablet

1

BOSULIF ORAL TABLET

3

PA; SPRx

capecitabine oral tablet

1

SPRx

CAPRELSA ORAL TABLET

3

PA; SPRx

CASODEX ORAL TABLET

3

CELLCEPT ORAL CAPSULE

3

CELLCEPT ORAL SUSPENSION FOR RECONSTITUTION

3

COMETRIQ ORAL CAPSULE

3

SPRx

COTELLIC ORAL TABLET

3

PA; SPRx

CYCLOPHOSPHAMIDE ORAL CAPSULE

3

cyclosporine modified oral capsule

1

cyclosporine modified oral solution

1

cyclosporine oral capsule

1

DROXIA ORAL CAPSULE

3

EMCYT ORAL CAPSULE

3

ERIVEDGE ORAL CAPSULE

3

etoposide oral capsule

1

exemestane oral tablet

1

FARESTON ORAL TABLET

3

FARYDAK ORAL CAPSULE

3 14

SPRx

SPRx

PA; SPRx

PA; SPRx

Drug Name

Drug Tier

Requirements / Limits

FEMARA ORAL TABLET

3

flutamide oral capsule

1

gengraf oral capsule

1

gengraf oral solution

1

GILOTRIF ORAL TABLET

3

PA; SPRx

GLEEVEC ORAL TABLET

3

SPRx

GLEOSTINE ORAL CAPSULE

3

HEXALEN ORAL CAPSULE

3

HYCAMTIN ORAL CAPSULE

3

HYDREA ORAL CAPSULE

3

hydroxyurea oral capsule

1

IBRANCE ORAL CAPSULE

3

PA; SPRx

ICLUSIG ORAL TABLET

3

PA; SPRx

imatinib oral tablet

1

SPRx

IMBRUVICA ORAL CAPSULE

3

PA; SPRx

IMURAN ORAL TABLET

3

INLYTA ORAL TABLET

3

PA; SPRx

IRESSA ORAL TABLET

3

PA; SPRx

JAKAFI ORAL TABLET

3

PA; SPRx

LENVIMA ORAL CAPSULE

3

PA; SPRx

letrozole oral tablet

1

LEUKERAN ORAL TABLET

2

leuprolide subcutaneous kit

1

SPRx

LONSURF ORAL TABLET

3

PA; SPRx

LYNPARZA ORAL CAPSULE

3

PA; SPRx

LYSODREN ORAL TABLET

3

MATULANE ORAL CAPSULE

3

MEGACE ES ORAL SUSPENSION

3

MEGACE ORAL SUSPENSION

3

megestrol oral suspension

1

megestrol oral tablet

1

MEKINIST ORAL TABLET

3

mercaptopurine oral tablet

1 15

SPRx

PA; SPRx

Drug Name

Drug Tier

Requirements / Limits

methotrexate sodium (pf) injection recon soln

1

methotrexate sodium (pf) injection solution

1

methotrexate sodium injection solution

1

methotrexate sodium oral tablet

1

mitoxantrone intravenous concentrate

1

mycophenolate mofetil oral capsule

1

mycophenolate mofetil oral suspension for reconstitution

1

mycophenolate mofetil oral tablet

1

mycophenolate sodium oral tablet,delayed release (dr/ec)

1

MYFORTIC ORAL TABLET,DELAYED RELEASE (DR/EC)

3

MYLERAN ORAL TABLET

3

NEORAL ORAL CAPSULE

3

NEORAL ORAL SOLUTION

3

NEXAVAR ORAL TABLET

3

NILANDRON ORAL TABLET

3

NINLARO ORAL CAPSULE

3

PA; SPRx

octreotide acetate injection solution

1

SPRx

octreotide acetate injection syringe

1

SPRx

ODOMZO ORAL CAPSULE

3

PA; SPRx

PROGRAF ORAL CAPSULE

3

PURIXAN ORAL SUSPENSION

3

RAPAMUNE ORAL SOLUTION

3

RAPAMUNE ORAL TABLET

3

RHEUMATREX ORAL TABLETS,DOSE PACK

3

SANDIMMUNE ORAL CAPSULE

3

SANDIMMUNE ORAL SOLUTION

3

SANDOSTATIN INJECTION SOLUTION

3

SPRx

SIGNIFOR SUBCUTANEOUS SOLUTION

3

PA; SPRx

sirolimus oral tablet

1

SOLTAMOX ORAL SOLUTION

3

ACA

SPRYCEL ORAL TABLET

3

SPRx

16

SPRx

PA; SPRx

Drug Name

Drug Tier

Requirements / Limits

STIVARGA ORAL TABLET

3

PA; SPRx

SUTENT ORAL CAPSULE

3

PA; SPRx

TABLOID ORAL TABLET

3

tacrolimus oral capsule

1

TAFINLAR ORAL CAPSULE

3

PA; SPRx

TAGRISSO ORAL TABLET

3

PA; SPRx

tamoxifen oral tablet

1

ACA

TARCEVA ORAL TABLET

3

PA; SPRx

TARGRETIN ORAL CAPSULE

3

SPRx

TARGRETIN TOPICAL GEL

3

PA; SPRx

TASIGNA ORAL CAPSULE

3

SPRx

TEMODAR ORAL CAPSULE

3

PA; SPRx

temozolomide oral capsule

1

PA; SPRx

THALOMID ORAL CAPSULE

3

PA; SPRx

tretinoin (chemotherapy) oral capsule

1

TREXALL ORAL TABLET

3

TYKERB ORAL TABLET

3

PA; SPRx

VOTRIENT ORAL TABLET

3

PA; SPRx

XALKORI ORAL CAPSULE

3

PA; SPRx

XELODA ORAL TABLET

3

SPRx

XTANDI ORAL CAPSULE

3

PA; SPRx

ZELBORAF ORAL TABLET

3

PA; SPRx

ZOLINZA ORAL CAPSULE

3

SPRx

ZORTRESS ORAL TABLET

3

ZYDELIG ORAL TABLET

3

PA; SPRx

ZYKADIA ORAL CAPSULE

3

PA; SPRx

ZYTIGA ORAL TABLET

3

SPRx

AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ANTICONVULSANTS APTIOM ORAL TABLET

3

BANZEL ORAL SUSPENSION

3

BANZEL ORAL TABLET

3

carbamazepine oral capsule, er multiphase 12 hr

1 17

Drug Name

Drug Tier

carbamazepine oral suspension

1

carbamazepine oral tablet

1

carbamazepine oral tablet extended release 12 hr

1

carbamazepine oral tablet,chewable

1

CARBATROL ORAL CAPSULE, ER MULTIPHASE 12 HR

3

CELONTIN ORAL CAPSULE

3

clonazepam oral tablet

1

clonazepam oral tablet,disintegrating

1

DEPAKENE ORAL CAPSULE

3

DEPAKENE ORAL SOLUTION

3

DEPAKOTE ER ORAL TABLET EXTENDED RELEASE 24 HR

3

DEPAKOTE ORAL TABLET,DELAYED RELEASE (DR/EC)

3

DEPAKOTE SPRINKLES ORAL CAPSULE, SPRINKLE

3

DIASTAT ACUDIAL RECTAL KIT

3

DIASTAT RECTAL KIT

3

diazepam rectal kit

1

DILANTIN EXTENDED ORAL CAPSULE

2

DILANTIN INFATABS ORAL TABLET,CHEWABLE

2

DILANTIN ORAL CAPSULE

2

DILANTIN-125 ORAL SUSPENSION

2

divalproex oral capsule, sprinkle

1

divalproex oral tablet extended release 24 hr

1

divalproex oral tablet,delayed release (dr/ec)

1

epitol oral tablet

1

EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR

3

ethosuximide oral capsule

1

ethosuximide oral solution

1

felbamate oral suspension

1

felbamate oral tablet

1 18

Requirements / Limits

Drug Name

Drug Tier

FELBATOL ORAL SUSPENSION

3

FELBATOL ORAL TABLET

3

FYCOMPA ORAL TABLET

3

gabapentin oral capsule

1

gabapentin oral solution

1

gabapentin oral tablet

1

GABITRIL ORAL TABLET

3

KEPPRA ORAL SOLUTION

3

KEPPRA ORAL TABLET

3

KEPPRA XR ORAL TABLET EXTENDED RELEASE 24 HR

3

KLONOPIN ORAL TABLET

3

LAMICTAL ODT ORAL TABLET,DISINTEGRATING

3

LAMICTAL ODT STARTER (BLUE) ORAL TABLET DISINTEGRATING, DOSE PK

3

LAMICTAL ODT STARTER (GREEN) ORAL TABLET DISINTEGRATING, DOSE PK

3

LAMICTAL ODT STARTER (ORANGE) ORAL TABLET DISINTEGRATING, DOSE PK

3

LAMICTAL ORAL TABLET

3

LAMICTAL ORAL TABLET, CHEWABLE DISPERSIBLE

3

LAMICTAL STARTER (BLUE) KIT ORAL TABLETS,DOSE PACK

3

LAMICTAL STARTER (GREEN) KIT ORAL TABLETS,DOSE PACK

3

LAMICTAL STARTER (ORANGE) KIT ORAL TABLETS,DOSE PACK

3

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR

3

LAMICTAL XR STARTER (BLUE) ORAL TABLET EXTENDED REL,DOSE PACK

3

LAMICTAL XR STARTER (GREEN) ORAL TABLET EXTENDED REL,DOSE PACK

3

LAMICTAL XR STARTER (ORANGE) ORAL TABLET EXTENDED REL,DOSE PACK

3

19

Requirements / Limits

Drug Name

Drug Tier

Requirements / Limits

lamotrigine oral tablet

1

lamotrigine oral tablet disintegrating, dose pk

1

lamotrigine oral tablet extended release 24hr

1

lamotrigine oral tablet, chewable dispersible

1

lamotrigine oral tablet,disintegrating

1

levetiracetam oral solution

1

levetiracetam oral tablet

1

levetiracetam oral tablet extended release 24 hr

1

LYRICA ORAL CAPSULE

2

LYRICA ORAL SOLUTION

2

MYSOLINE ORAL TABLET

3

NEURONTIN ORAL CAPSULE

3

NEURONTIN ORAL SOLUTION

3

NEURONTIN ORAL TABLET

3

ONFI ORAL SUSPENSION

3

ONFI ORAL TABLET

3

oxcarbazepine oral suspension

1

oxcarbazepine oral tablet

1

OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HR

2

PEGANONE ORAL TABLET

3

phenobarbital oral elixir

1

phenobarbital oral tablet

1

PHENYTEK ORAL CAPSULE

3

phenytoin oral suspension

1

phenytoin oral tablet,chewable

1

phenytoin sodium extended oral capsule

1

POTIGA ORAL TABLET

3

primidone oral tablet

1

QUDEXY XR ORAL CAPSULE,SPRINKLE,ER 24HR

2

roweepra oral tablet

1

SABRIL ORAL POWDER IN PACKET

3

SPRx

SABRIL ORAL TABLET

3

SPRx

20

Drug Name

Drug Tier

SPRITAM ORAL TABLET FOR SUSPENSION

3

TEGRETOL ORAL SUSPENSION

3

TEGRETOL ORAL TABLET

3

TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR

3

tiagabine oral tablet

1

TOPAMAX ORAL CAPSULE, SPRINKLE

3

TOPAMAX ORAL TABLET

3

topiramate oral capsule, sprinkle

1

TOPIRAMATE ORAL CAPSULE,SPRINKLE,ER 24HR

3

topiramate oral tablet

1

TRILEPTAL ORAL SUSPENSION

3

TRILEPTAL ORAL TABLET

3

TROKENDI XR ORAL CAPSULE,EXTENDED RELEASE 24HR

2

valproic acid (as sodium salt) oral solution

1

valproic acid oral capsule

1

VIMPAT ORAL SOLUTION

2

VIMPAT ORAL TABLET

2

ZARONTIN ORAL CAPSULE

3

ZARONTIN ORAL SOLUTION

3

ZONEGRAN ORAL CAPSULE

3

zonisamide oral capsule

1

Requirements / Limits

ANTIPARKINSONISM AGENTS APOKYN SUBCUTANEOUS CARTRIDGE

3

AZILECT ORAL TABLET

3

benztropine oral tablet

1

bromocriptine oral capsule

1

bromocriptine oral tablet

1

carbidopa oral tablet

1

carbidopa-levodopa oral tablet

1

carbidopa-levodopa oral tablet extended release

1

carbidopa-levodopa oral tablet,disintegrating

1 21

SPRx

Drug Name

Drug Tier

carbidopa-levodopa-entacapone oral tablet

1

COMTAN ORAL TABLET

3

DUOPA J-TUBE INTESTINAL PUMP SUSPENSION

3

ELDEPRYL ORAL CAPSULE

3

entacapone oral tablet

1

LODOSYN ORAL TABLET

3

MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR

3

MIRAPEX ORAL TABLET

3

NEUPRO TRANSDERMAL PATCH 24 HOUR

3

PARLODEL ORAL CAPSULE

3

PARLODEL ORAL TABLET

3

pramipexole oral tablet

1

pramipexole oral tablet extended release 24 hr

1

REQUIP ORAL TABLET

3

REQUIP XL ORAL TABLET EXTENDED RELEASE 24 HR

3

ropinirole oral tablet

1

ropinirole oral tablet extended release 24 hr

1

selegiline hcl oral capsule

1

selegiline hcl oral tablet

1

SINEMET CR ORAL TABLET EXTENDED RELEASE

3

SINEMET ORAL TABLET

3

STALEVO 100 ORAL TABLET

3

STALEVO 125 ORAL TABLET

3

STALEVO 150 ORAL TABLET

3

STALEVO 200 ORAL TABLET

3

STALEVO 50 ORAL TABLET

3

STALEVO 75 ORAL TABLET

3

TASMAR ORAL TABLET

3

tolcapone oral tablet

1

trihexyphenidyl oral elixir

1 22

Requirements / Limits

PA; SPRx

Drug Name

Drug Tier

trihexyphenidyl oral tablet

1

ZELAPAR ORAL TABLET,DISINTEGRATING

3

Requirements / Limits

MIGRAINE & CLUSTER HEADACHE THERAPY almotriptan malate oral tablet

1

QL (18 per 30 days)

ALSUMA SUBCUTANEOUS PEN INJECTOR

3

QL (8 per 30 days)

AMERGE ORAL TABLET

3

QL (18 per 30 days)

CAFERGOT ORAL TABLET

3

D.H.E.45 INJECTION SOLUTION

3

dihydroergotamine injection solution

1

dihydroergotamine nasal spray,non-aerosol

1

ERGOMAR SUBLINGUAL TABLET

3

frovatriptan oral tablet

1

QL (18 per 30 days)

IMITREX NASAL SPRAY,NON-AEROSOL

3

QL (12 per 30 days)

IMITREX ORAL TABLET

3

QL (18 per 30 days)

IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 4 MG/0.5 ML

3

QL (12 per 30 days)

IMITREX STATDOSE KIT REFILL SUBCUTANEOUS CARTRIDGE 6 MG/0.5 ML

3

QL (8 per 30 days)

IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 4 MG/0.5 ML

3

QL (12 per 30 days)

IMITREX STATDOSE PEN SUBCUTANEOUS PEN INJECTOR 6 MG/0.5 ML

3

QL (8 per 30 days)

IMITREX SUBCUTANEOUS SOLUTION

3

QL (8 per 30 days)

isometh-dichloral-acetaminophn oral capsule

1

isomethepten-caf-acetaminophen oral tablet

1

migergot rectal suppository

1

MIGRANAL NASAL SPRAY,NON-AEROSOL

3

QL (8 per 30 days)

naratriptan oral tablet

1

QL (18 per 30 days)

nodolor oral capsule

1

RELPAX ORAL TABLET

2

QL (18 per 30 days)

rizatriptan oral tablet

1

QL (18 per 30 days)

rizatriptan oral tablet,disintegrating

1

QL (18 per 30 days)

sumatriptan nasal spray,non-aerosol

1

QL (12 per 30 days)

sumatriptan succinate oral tablet

1

QL (18 per 30 days)

23

QL (8 per 30 days)

Drug Name

Drug Tier

Requirements / Limits

sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml

1

QL (12 per 30 days)

sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml

1

QL (8 per 30 days)

sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml

1

QL (12 per 30 days)

sumatriptan succinate subcutaneous pen injector 6 mg/0.5 ml

1

QL (8 per 30 days)

sumatriptan succinate subcutaneous solution

1

QL (8 per 30 days)

sumatriptan succinate subcutaneous syringe

1

QL (8 per 30 days)

SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 4 MG/0.5 ML

3

QL (12 per 30 days)

SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML

3

QL (8 per 30 days)

zolmitriptan oral tablet

1

QL (18 per 30 days)

zolmitriptan oral tablet,disintegrating

1

QL (18 per 30 days)

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR

2

PA; SPRx

ARICEPT ORAL TABLET

3

donepezil oral tablet

1

donepezil oral tablet,disintegrating

1

EXELON ORAL CAPSULE

3

EXELON TRANSDERMAL PATCH 24 HOUR

3

galantamine oral capsule,ext rel. pellets 24 hr

1

galantamine oral solution

1

galantamine oral tablet

1

HORIZANT ORAL TABLET EXTENDED RELEASE

3

KEVEYIS ORAL TABLET

3

memantine oral solution

1

memantine oral tablet

1

MEMANTINE ORAL TABLETS,DOSE PACK

3

NAMENDA ORAL SOLUTION

3

NAMENDA ORAL TABLET

3

MISCELLANEOUS NEUROLOGICAL THERAPY

24

PA; SPRx

Drug Name

Drug Tier

Requirements / Limits

NAMENDA TITRATION PAK ORAL TABLETS,DOSE PACK

3

NAMENDA XR ORAL CAP,SPRINKLE,ER 24HR DOSE PACK

2

NAMENDA XR ORAL CAPSULE,SPRINKLE,ER 24HR

2

NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR

3

NUEDEXTA ORAL CAPSULE

3

RAZADYNE ER ORAL CAPSULE,EXT REL. PELLETS 24 HR

3

RAZADYNE ORAL TABLET

3

rivastigmine tartrate oral capsule

1

rivastigmine transdermal patch 24 hour

1

tetrabenazine oral tablet

1

PA; SPRx

XENAZINE ORAL TABLET

3

PA; SPRx

MUSCLE RELAXANTS & ANTISPASMODIC THERAPY baclofen oral tablet

1

carisoprodol oral tablet

1

carisoprodol-asa-codeine oral tablet

1

carisoprodol-aspirin oral tablet

1

chlorzoxazone oral tablet

1

cyclobenzaprine oral tablet

1

DANTRIUM ORAL CAPSULE

3

dantrolene oral capsule

1

FEXMID ORAL TABLET

3

MESTINON ORAL SYRUP

3

MESTINON ORAL TABLET

3

MESTINON TIMESPAN ORAL TABLET EXTENDED RELEASE

3

metaxalone oral tablet

1

methocarbamol oral tablet

1

orphenadrine citrate oral tablet extended release

1

PARAFON FORTE DSC ORAL TABLET

3

pyridostigmine bromide oral tablet

1 25

Drug Name

Drug Tier

pyridostigmine bromide oral tablet extended release

1

ROBAXIN ORAL TABLET

3

ROBAXIN-750 ORAL TABLET

3

SKELAXIN ORAL TABLET

3

SOMA ORAL TABLET

3

tizanidine oral capsule

1

tizanidine oral tablet

1

ZANAFLEX ORAL CAPSULE

3

ZANAFLEX ORAL TABLET

3

Requirements / Limits

NARCOTIC ANALGESICS ABSTRAL SUBLINGUAL TABLET

3

acetaminophen-codeine oral solution

1

acetaminophen-codeine oral tablet

1

QL (180 per 30 days)

ACTIQ BUCCAL LOZENGE ON A HANDLE

3

QL (16 per 30 days)

ascomp with codeine oral capsule

1

QL (180 per 30 days)

BUPAP ORAL TABLET

3

QL (180 per 30 days)

butalbital compound w/codeine oral capsule

1

QL (180 per 30 days)

butalbital-acetaminop-caf-cod oral capsule

1

QL (180 per 30 days)

butalbital-acetaminophen oral tablet

1

QL (180 per 30 days)

butalbital-acetaminophen-caff oral capsule

1

QL (180 per 30 days)

butalbital-acetaminophen-caff oral tablet

1

QL (180 per 30 days)

butalbital-aspirin-caffeine oral capsule

1

QL (180 per 30 days)

BUTRANS TRANSDERMAL PATCH WEEKLY

3

PA

capacet oral capsule

1

QL (180 per 30 days)

CAPITAL WITH CODEINE ORAL SUSPENSION

3

codeine sulfate oral tablet

1

QL (180 per 30 days)

codeine-butalbital-asa-caff oral capsule

1

QL (180 per 30 days)

DEMEROL ORAL TABLET

3

QL (180 per 30 days)

dihydrocode-acetaminophen-caff oral capsule

1

QL (360 per 30 days)

dihydrocodeine-aspirin-caff oral capsule

1

DILAUDID ORAL LIQUID

3

DILAUDID ORAL TABLET

3 26

QL (16 per 30 days)

QL (180 per 30 days)

Drug Name

Drug Tier

Requirements / Limits

diskets oral tablet,soluble

1

QL (180 per 30 days); PA

DOLOPHINE ORAL TABLET

3

QL (180 per 30 days); PA

DURAGESIC TRANSDERMAL PATCH 72 HOUR

3

PA

endocet oral tablet

1

QL (240 per 30 days)

ESGIC ORAL CAPSULE

3

QL (180 per 30 days)

ESGIC ORAL TABLET

3

QL (180 per 30 days)

fentanyl citrate buccal lozenge on a handle

1

QL (16 per 30 days); PA

fentanyl transdermal patch 72 hour

1

PA

FENTORA BUCCAL TABLET, EFFERVESCENT

3

QL (16 per 30 days)

FIORICET ORAL CAPSULE

3

QL (180 per 30 days)

FIORICET WITH CODEINE ORAL CAPSULE

3

QL (180 per 30 days)

FIORINAL ORAL CAPSULE

3

QL (180 per 30 days)

FIORINAL-CODEINE #3 ORAL CAPSULE

3

QL (180 per 30 days)

HYCET ORAL SOLUTION

3

hydrocodone-acetaminophen oral solution

1

hydrocodone-acetaminophen oral tablet

1

QL (240 per 30 days)

hydrocodone-ibuprofen oral tablet

1

QL (150 per 30 days)

hydromorphone oral liquid

1

hydromorphone oral tablet

1

hydromorphone rectal suppository

1

IBUDONE ORAL TABLET

3

QL (150 per 30 days)

ibuprofen-oxycodone oral tablet

1

QL (150 per 30 days)

KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS

3

QL (120 per 30 days); PA

levorphanol tartrate oral tablet

1

QL (180 per 30 days)

lorcet (hydrocodone) oral tablet

1

QL (240 per 30 days)

lorcet hd oral tablet

1

QL (240 per 30 days)

lorcet plus oral tablet

1

QL (240 per 30 days)

lortab 10-325 oral tablet

1

QL (240 per 30 days)

lortab 5-325 oral tablet

1

QL (240 per 30 days)

lortab 7.5-325 oral tablet

1

QL (240 per 30 days)

LORTAB ELIXIR ORAL SOLUTION

3 27

QL (180 per 30 days)

Drug Name

Drug Tier

Requirements / Limits

margesic oral capsule

1

QL (180 per 30 days)

marten-tab oral tablet

1

QL (180 per 30 days)

meperidine oral solution

1

meperidine oral tablet

1

QL (180 per 30 days)

methadone oral concentrate

1

PA

methadone oral solution

1

PA

methadone oral tablet

1

QL (180 per 30 days); PA

methadone oral tablet,soluble

1

QL (180 per 30 days); PA

methadose oral concentrate

1

methadose oral tablet,soluble

1

morphine concentrate oral solution

1

morphine oral capsule, er multiphase 24 hr

1

QL (120 per 30 days); PA

morphine oral capsule,extend.release pellets

1

QL (120 per 30 days); PA

morphine oral solution

1

morphine oral tablet

1

QL (180 per 30 days)

morphine oral tablet extended release

1

QL (90 per 30 days); PA

morphine rectal suppository

1

MS CONTIN ORAL TABLET EXTENDED RELEASE

3

QL (90 per 30 days); PA

NORCO ORAL TABLET

3

QL (240 per 30 days)

OPANA ER ORAL TABLET,ORAL ONLY,EXT.REL.12 HR

2

QL (120 per 30 days); PA

OPANA ORAL TABLET

3

QL (120 per 30 days)

oxycodone oral capsule

1

QL (120 per 30 days)

oxycodone oral concentrate

1

oxycodone oral solution

1

oxycodone oral tablet

1

QL (120 per 30 days)

oxycodone-acetaminophen oral tablet

1

QL (240 per 30 days)

oxycodone-aspirin oral tablet

1

QL (240 per 30 days)

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

2

QL (120 per 30 days); PA

oxymorphone oral tablet

1

QL (120 per 30 days)

oxymorphone oral tablet extended release 12 hr

1

QL (120 per 30 days); PA

PERCOCET ORAL TABLET

3

QL (240 per 30 days)

28

QL (180 per 30 days)

Drug Name

Drug Tier

Requirements / Limits

PRIMLEV ORAL TABLET

3

QL (240 per 30 days)

reprexain oral tablet

1

QL (150 per 30 days)

ROXICODONE ORAL TABLET

3

QL (120 per 30 days)

SYNALGOS-DC ORAL CAPSULE

3

tencon oral tablet

1

QL (180 per 30 days)

TREZIX ORAL CAPSULE

3

QL (360 per 30 days)

TYLENOL-CODEINE #3 ORAL TABLET

3

QL (180 per 30 days)

TYLENOL-CODEINE #4 ORAL TABLET

3

QL (180 per 30 days)

VANATOL LQ ORAL SOLUTION

3

verdrocet oral tablet

1

QL (240 per 30 days)

vicodin es oral tablet

1

QL (240 per 30 days)

vicodin hp oral tablet

1

QL (240 per 30 days)

vicodin oral tablet

1

QL (240 per 30 days)

VICOPROFEN ORAL TABLET

3

QL (150 per 30 days)

XODOL 10/300 ORAL TABLET

3

QL (240 per 30 days)

XODOL 5/300 ORAL TABLET

3

QL (240 per 30 days)

XODOL 7.5/300 ORAL TABLET

3

QL (240 per 30 days)

xylon 10 oral tablet

1

QL (150 per 30 days)

zamicet oral solution

1

zebutal oral capsule

1

QL (180 per 30 days)

NON-NARCOTIC ANALGESICS ANAPROX DS ORAL TABLET

3

ARTHROTEC 50 ORAL TABLET,IR,DELAYED REL,BIPHASIC

3

ARTHROTEC 75 ORAL TABLET,IR,DELAYED REL,BIPHASIC

3

BUNAVAIL BUCCAL FILM

3

#; QL (90 per 30 days)

buprenorphine-naloxone sublingual tablet

1

#; QL (90 per 30 days)

butorphanol tartrate nasal spray,non-aerosol

1

CELEBREX ORAL CAPSULE

3

celecoxib oral capsule

1

choline,magnesium salicylate oral liquid

1

DAYPRO ORAL TABLET

3

diclofenac potassium oral tablet

1 29

Drug Name

Drug Tier

diclofenac sodium oral tablet extended release 24 hr

1

diclofenac sodium oral tablet,delayed release (dr/ec)

1

diclofenac sodium topical gel

1

diclofenac-misoprostol oral tablet,ir,delayed rel,biphasic

1

diflunisal oral tablet

1

DISALCID ORAL TABLET

3

EC-NAPROSYN ORAL TABLET,DELAYED RELEASE (DR/EC)

3

etodolac oral capsule

1

etodolac oral tablet

1

etodolac oral tablet extended release 24 hr

1

FELDENE ORAL CAPSULE

3

fenoprofen oral tablet

1

FLECTOR TRANSDERMAL PATCH 12 HOUR

3

flurbiprofen oral tablet

1

ibuprofen oral suspension

1

ibuprofen oral tablet

1

INDOCIN ORAL SUSPENSION

3

INDOCIN RECTAL SUPPOSITORY

3

indomethacin oral capsule

1

indomethacin oral capsule, extended release

1

ketoprofen oral capsule

1

ketoprofen oral capsule,ext rel. pellets 24 hr

1

ketorolac oral tablet

1

meclofenamate oral capsule

1

mefenamic acid oral capsule

1

meloxicam oral suspension

1

meloxicam oral tablet

1

MOBIC ORAL SUSPENSION

3

MOBIC ORAL TABLET

3

nabumetone oral tablet

1 30

Requirements / Limits

Drug Name

Drug Tier

Requirements / Limits

NALFON ORAL CAPSULE

3

naltrexone oral tablet

1

NAPRELAN CR ORAL TABLET, ER MULTIPHASE 24 HR

3

NAPROSYN ORAL TABLET

3

naproxen oral tablet

1

naproxen oral tablet,delayed release (dr/ec)

1

naproxen sodium oral tablet

1

NUCYNTA ER ORAL TABLET EXTENDED RELEASE 12 HR

2

QL (180 per 30 days); PA

NUCYNTA ORAL TABLET

2

QL (180 per 30 days)

oxaprozin oral tablet

1

pentazocine-naloxone oral tablet

1

piroxicam oral capsule

1

PONSTEL ORAL CAPSULE

3

REVIA ORAL TABLET

3

salsalate oral tablet

1

SPRIX NASAL SPRAY,NON-AEROSOL

3

SUBOXONE SUBLINGUAL FILM

2

sulindac oral tablet

1

tolmetin oral capsule

1

tolmetin oral tablet

1

tramadol oral tablet

1

tramadol oral tablet extended release 24 hr

1

PA

tramadol oral tablet, er multiphase 24 hr

1

PA

tramadol-acetaminophen oral tablet

1

ULTRACET ORAL TABLET

3

ULTRAM ER ORAL TABLET EXTENDED RELEASE 24 HR

3

ULTRAM ORAL TABLET

3

VOLTAREN TOPICAL GEL

3

VOLTAREN-XR ORAL TABLET EXTENDED RELEASE 24 HR

3

ZUBSOLV SUBLINGUAL TABLET

3 31

#

#

#; QL (90 per 30 days)

PA

#; QL (90 per 30 days)

Drug Name

Drug Tier

Requirements / Limits

PSYCHOTHERAPEUTIC DRUGS ABILIFY ORAL TABLET

3

ADDERALL ORAL TABLET

3

ADDERALL XR ORAL CAPSULE,EXTENDED RELEASE 24HR

3

alprazolam intensol oral concentrate

1

alprazolam oral tablet

1

alprazolam oral tablet extended release 24 hr

1

alprazolam oral tablet,disintegrating

1

AMBIEN CR ORAL TABLET,EXT RELEASE MULTIPHASE

3

AMBIEN ORAL TABLET

3

amitriptyline oral tablet

1

amitriptyline-chlordiazepoxide oral tablet

1

amoxapine oral tablet

1

amphetamine mix er

1

ANAFRANIL ORAL CAPSULE

3

aripiprazole oral solution

1

AGE-A

aripiprazole oral tablet

1

AGE-A

aripiprazole oral tablet,disintegrating

1

AGE-A

ATIVAN ORAL TABLET

3

bupropion hcl oral tablet

1

bupropion hcl oral tablet extended release

1

bupropion hcl oral tablet extended release 24 hr

1

buspirone oral tablet

1

BUTISOL ORAL TABLET

3

CELEXA ORAL TABLET

3

chlordiazepoxide hcl oral capsule

1

chlorpromazine oral tablet

1

citalopram oral tablet, oral solution

1

clomipramine oral capsule

1

clonidine hcl oral tablet extended release 12 hr

1

clorazepate dipotassium oral tablet

1

clozapine oral tablet

1 32

AGE-A GEN

GEN

AGE-A

Drug Name

Drug Tier

Requirements / Limits

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

1

AGE-A

CLOZAPINE ORAL TABLET,DISINTEGRATING 150 MG, 200 MG

3

AGE-A

CLOZARIL ORAL TABLET

3

AGE-A

CONCERTA ORAL TABLET EXTENDED RELEASE 24HR

3

GEN

CYMBALTA ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

DAYTRANA TRANSDERMAL PATCH 24 HOUR

3

desipramine oral tablet

1

DESOXYN ORAL TABLET

3

dexedrine oral tablet

1

DEXEDRINE SPANSULE ORAL CAPSULE, EXTENDED RELEASE

3

dexmethylphenidate oral capsule,er biphasic 5050

1

dexmethylphenidate oral tablet

1

dextroamphetamine oral capsule, extended release

1

dextroamphetamine oral solution

1

dextroamphetamine oral tablet

1

dextroamphetamine-amphetamine oral tablet

1

diazepam intensol oral concentrate

1

diazepam oral solution

1

diazepam oral tablet

1

doxepin oral capsule

1

doxepin oral concentrate

1

duloxetine oral capsule,delayed release(dr/ec)

1

EFFEXOR XR ORAL CAPSULE,EXTENDED RELEASE 24HR

3

EMSAM TRANSDERMAL PATCH 24 HOUR

3

ergoloid oral tablet

1

escitalopram oxalate oral solution

1

escitalopram oxalate oral tablet

1

estazolam oral tablet

1 33

Drug Name

Drug Tier

Requirements / Limits

eszopiclone oral tablet

1

FANAPT ORAL TABLET

3

AGE-A

FANAPT ORAL TABLETS,DOSE PACK

3

AGE-A

FAZACLO ORAL TABLET,DISINTEGRATING

3

AGE-A

fluoxetine oral capsule

1

fluoxetine oral capsule,delayed release(dr/ec)

1

fluoxetine oral solution

1

fluoxetine oral tablet 10 mg, 20 mg

1

FLUOXETINE ORAL TABLET 60 MG

3

fluphenazine hcl oral concentrate

1

fluphenazine hcl oral elixir

1

fluphenazine hcl oral tablet

1

flurazepam oral capsule

1

fluvoxamine oral capsule,extended release 24hr

1

fluvoxamine oral tablet

1

FOCALIN ORAL TABLET

3

FOCALIN XR ORAL CAPSULE,ER BIPHASIC 50-50

3

GEODON ORAL CAPSULE

3

guanfacine oral tablet extended release 24 hr

1

guanidine oral tablet

1

HALCION ORAL TABLET

3

haloperidol lactate oral concentrate

1

haloperidol oral tablet

1

imipramine hcl oral tablet

1

imipramine pamoate oral capsule

1

INTUNIV ER ORAL TABLET EXTENDED RELEASE 24 HR

3

INVEGA ORAL TABLET EXTENDED RELEASE 24HR

3

KAPVAY ORAL TABLET EXTENDED RELEASE 12 HR

3

LATUDA ORAL TABLET

2

LEXAPRO ORAL SOLUTION

3 34

AGE-A

AGE-A

AGE-A

Drug Name

Drug Tier

LEXAPRO ORAL TABLET

3

lithium carbonate oral capsule

1

lithium carbonate oral tablet

1

lithium carbonate oral tablet extended release

1

lithium citrate oral solution

1

LITHOBID ORAL TABLET EXTENDED RELEASE

3

lorazepam intensol oral concentrate

1

lorazepam oral concentrate

1

lorazepam oral tablet

1

loxapine succinate oral capsule

1

LUNESTA ORAL TABLET

3

maprotiline oral tablet

1

MARPLAN ORAL TABLET

3

METADATE CD ORAL CAPSULE, ER BIPHASIC 30-70

3

metadate er oral tablet extended release

1

methamphetamine oral tablet

1

METHYLIN ORAL SOLUTION

3

METHYLIN ORAL TABLET,CHEWABLE

3

methylphenidate oral capsule, er biphasic

1

methylphenidate oral solution

1

methylphenidate oral tablet

1

methylphenidate oral tablet er, 24 hr

1

methylphenidate oral tablet extended release

1

methylphenidate oral tablet,chewable

1

midazolam oral syrup

1

mirtazapine oral tablet

1

mirtazapine oral tablet,disintegrating

1

modafinil oral tablet

1

NARDIL ORAL TABLET

3

nefazodone oral tablet

1

NORPRAMIN ORAL TABLET

3

nortriptyline oral capsule

1 35

Requirements / Limits

GEN

PA

Drug Name

Drug Tier

Requirements / Limits

nortriptyline oral solution

1

NUVIGIL ORAL TABLET

2

PA

olanzapine oral tablet

1

AGE-A

olanzapine oral tablet,disintegrating

1

AGE-A

olanzapine-fluoxetine oral capsule 12-25 mg, 1250 mg, 6-25 mg, 6-50 mg

1

olanzapine-fluoxetine oral capsule 3-25 mg

1

ORAP ORAL TABLET

3

oxazepam oral capsule

1

paliperidone oral tablet extended release 24hr

1

PAMELOR ORAL CAPSULE

3

PARNATE ORAL TABLET

3

paroxetine hcl oral tablet

1

paroxetine hcl oral tablet extended release 24 hr

1

PAXIL CR ORAL TABLET EXTENDED RELEASE 24 HR

3

PAXIL ORAL SUSPENSION

3

PAXIL ORAL TABLET

3

perphenazine oral tablet

1

perphenazine-amitriptyline oral tablet

1

PEXEVA ORAL TABLET

3

phenelzine oral tablet

1

pimozide oral tablet

1

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR

2

procentra oral solution

1

protriptyline oral tablet

1

PROZAC ORAL CAPSULE

3

PROZAC WEEKLY ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

quazepam oral tablet

1

quetiapine oral tablet

1

QUILLIVANT XR ORAL SUSPENSION,EXT REL 24HR,RECON

2

REMERON ORAL TABLET

3 36

PA

AGE-A

AGE-A

Drug Name

Drug Tier

Requirements / Limits

REMERON SOLTAB ORAL TABLET,DISINTEGRATING

3

RESTORIL ORAL CAPSULE

3

RISPERDAL M-TAB ORAL TABLET,DISINTEGRATING

3

AGE-A

RISPERDAL ORAL SOLUTION

3

AGE-A

RISPERDAL ORAL TABLET

3

AGE-A

risperidone oral solution

1

AGE-A

risperidone oral tablet

1

AGE-A

risperidone oral tablet,disintegrating

1

AGE-A

RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50

3

RITALIN ORAL TABLET

3

ROZEREM ORAL TABLET

3

SAPHRIS (BLACK CHERRY) SUBLINGUAL TABLET

3

SARAFEM ORAL TABLET

3

seconal sodium oral capsule

1

SEROQUEL ORAL TABLET

3

AGE-A

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR

2

AGE-A

sertraline oral concentrate

1

sertraline oral tablet

1

SONATA ORAL CAPSULE

3

STRATTERA ORAL CAPSULE

2

SURMONTIL ORAL CAPSULE

3

SYMBYAX ORAL CAPSULE

3

temazepam oral capsule

1

thioridazine oral tablet

1

thiothixene oral capsule

1

TOFRANIL ORAL TABLET

3

TRANXENE T-TAB ORAL TABLET

3

tranylcypromine oral tablet

1

trazodone oral tablet

1

triazolam oral tablet

1 37

AGE-A

Drug Name

Drug Tier

Requirements / Limits

trifluoperazine oral tablet

1

trimipramine oral capsule

1

VALIUM ORAL TABLET

3

venlafaxine oral capsule,extended release 24hr

1

venlafaxine oral tablet

1

VYVANSE ORAL CAPSULE

2

WELLBUTRIN SR ORAL TABLET EXTENDED RELEASE

3

WELLBUTRIN XL ORAL TABLET EXTENDED RELEASE 24 HR

3

XANAX ORAL TABLET

3

XANAX XR ORAL TABLET EXTENDED RELEASE 24 HR

3

XYREM ORAL SOLUTION

3

zaleplon oral capsule

1

zenzedi oral tablet 10 mg, 5 mg

1

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

3

ziprasidone hcl oral capsule

1

ZOLOFT ORAL CONCENTRATE

3

ZOLOFT ORAL TABLET

3

zolpidem oral tablet

1

zolpidem oral tablet,ext release multiphase

1

ZYPREXA ORAL TABLET

3

AGE-A

ZYPREXA ZYDIS ORAL TABLET,DISINTEGRATING

3

AGE-A

CARDIOVASCULAR, HYPERTENSION & LIPIDS ANTIARRHYTHMIC AGENTS amiodarone oral tablet

1

BETAPACE AF ORAL TABLET

3

BETAPACE ORAL TABLET

3

CORDARONE ORAL TABLET

3

disopyramide phosphate oral capsule

1

flecainide oral tablet

1 38

PA

AGE-A

Drug Name

Drug Tier

mexiletine oral capsule

1

MULTAQ ORAL TABLET

3

NORPACE CR ORAL CAPSULE, EXTENDED RELEASE

3

NORPACE ORAL CAPSULE

3

pacerone oral tablet

1

propafenone oral capsule,extended release 12 hr

1

propafenone oral tablet

1

quinidine gluconate oral tablet extended release

1

quinidine sulfate oral tablet

1

RYTHMOL ORAL TABLET

3

RYTHMOL SR ORAL CAPSULE,EXTENDED RELEASE 12 HR

3

sorine oral tablet

1

sotalol af oral tablet

1

sotalol oral tablet

1

SOTYLIZE ORAL SOLUTION

3

TIKOSYN ORAL CAPSULE

3

ANTIHYPERTENSIVE THERAPY ACCUPRIL ORAL TABLET

3

ACCURETIC ORAL TABLET

3

acebutolol oral capsule

1

ACEON ORAL TABLET

3

ADALAT CC ORAL TABLET EXTENDED RELEASE

3

afeditab cr oral tablet extended release

1

ALDACTAZIDE ORAL TABLET

3

ALDACTONE ORAL TABLET

3

ALTACE ORAL CAPSULE

3

amiloride oral tablet

1

amiloride-hydrochlorothiazide oral tablet

1

amlodipine oral tablet

1

amlodipine-benazepril oral capsule

1

amlodipine-valsartan oral tablet

1 39

Requirements / Limits

Drug Name

Drug Tier

amlodipine-valsartan-hcthiazid oral tablet

1

ATACAND HCT ORAL TABLET

3

ATACAND ORAL TABLET

3

atenolol oral tablet

1

atenolol-chlorthalidone oral tablet

1

AVALIDE ORAL TABLET

3

AVAPRO ORAL TABLET

3

AZOR ORAL TABLET

2

benazepril oral tablet

1

benazepril-hydrochlorothiazide oral tablet

1

BENICAR HCT ORAL TABLET

2

BENICAR ORAL TABLET

2

betaxolol oral tablet

1

BIDIL ORAL TABLET

3

bisoprolol fumarate oral tablet

1

bisoprolol-hydrochlorothiazide oral tablet

1

bumetanide oral tablet

1

BYSTOLIC ORAL TABLET

2

CALAN ORAL TABLET

3

CALAN SR ORAL TABLET EXTENDED RELEASE

3

candesartan oral tablet

1

candesartan-hydrochlorothiazid oral tablet

1

captopril oral tablet

1

captopril-hydrochlorothiazide oral tablet

1

CARDIZEM CD ORAL CAPSULE,EXTENDED RELEASE 24HR

3

CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24 HR

3

CARDIZEM ORAL TABLET

3

CARDURA ORAL TABLET

3

CARDURA XL ORAL TABLET EXTENDED RELEASE 24HR

3

carvedilol oral tablet

1 40

Requirements / Limits

Drug Name

Drug Tier

Requirements / Limits

CATAPRES ORAL TABLET

3

CATAPRES-TTS-1 TRANSDERMAL PATCH WEEKLY

3

CATAPRES-TTS-2 TRANSDERMAL PATCH WEEKLY

3

CATAPRES-TTS-3 TRANSDERMAL PATCH WEEKLY

3

chlorothiazide oral tablet

1

chlorthalidone oral tablet

1

clonidine hcl oral tablet

1

clonidine transdermal patch weekly

1

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

1

CLORPRES ORAL TABLET 0.3-15 MG

3

COREG CR ORAL CAPSULE, ER MULTIPHASE 24 HR

2

COREG ORAL TABLET

3

CORGARD ORAL TABLET

3

CORZIDE ORAL TABLET

3

COZAAR ORAL TABLET

3

DEMADEX ORAL TABLET

3

DEMSER ORAL CAPSULE

3

DIBENZYLINE ORAL CAPSULE

3

diltiazem hcl oral capsule,extended release 24hr

1

DIOVAN HCT ORAL TABLET

3

DIOVAN ORAL TABLET

3

DIURIL ORAL SUSPENSION

3

doxazosin oral tablet

1

DUTOPROL ORAL TABLET EXTENDED RELEASE 24 HR

3

DYAZIDE ORAL CAPSULE

3

DYRENIUM ORAL CAPSULE

3

EDARBI ORAL TABLET

3

ST

EDARBYCLOR ORAL TABLET

3

ST

EDECRIN ORAL TABLET

3

enalapril maleate oral tablet

1 41

Drug Name

Drug Tier

enalapril-hydrochlorothiazide oral tablet

1

EPANED ORAL RECON SOLN

3

eplerenone oral tablet

1

epoprostenol (glycine) intravenous recon soln

1

eprosartan oral tablet

1

EXFORGE HCT ORAL TABLET

3

EXFORGE ORAL TABLET

3

felodipine oral tablet extended release 24 hr

1

FLOLAN INTRAVENOUS RECON SOLN

3

fosinopril oral tablet

1

fosinopril-hydrochlorothiazide oral tablet

1

furosemide oral solution

1

furosemide oral tablet

1

guanfacine oral tablet

1

hydralazine oral tablet

1

hydrochlorothiazide oral capsule

1

hydrochlorothiazide oral tablet

1

HYZAAR ORAL TABLET

3

indapamide oral tablet

1

INDERAL LA ORAL CAPSULE,EXTENDED RELEASE 24 HR

3

INDERAL XL ORAL CAPSULE,EXTENDED RELEASE 24HR

3

INNOPRAN XL ORAL CAPSULE,EXTENDED RELEASE 24HR

3

INSPRA ORAL TABLET

3

irbesartan oral tablet

1

irbesartan-hydrochlorothiazide oral tablet

1

isradipine oral capsule

1

labetalol oral tablet

1

LASIX ORAL TABLET

3

LEVATOL ORAL TABLET

3

lisinopril oral tablet

1

lisinopril-hydrochlorothiazide oral tablet

1 42

Requirements / Limits

PA; SPRx

PA; SPRx

Drug Name

Drug Tier

LOPRESSOR HCT ORAL TABLET

3

LOPRESSOR ORAL TABLET

3

losartan oral tablet

1

losartan-hydrochlorothiazide oral tablet

1

LOTENSIN HCT ORAL TABLET

3

LOTENSIN ORAL TABLET

3

LOTREL ORAL CAPSULE

3

MAVIK ORAL TABLET

3

MAXZIDE ORAL TABLET

3

MAXZIDE-25MG ORAL TABLET

3

methyclothiazide oral tablet

1

methyldopa oral tablet

1

methyldopa-hydrochlorothiazide oral tablet

1

metolazone oral tablet

1

metoprolol succinate oral tablet extended release 24 hr

1

metoprolol ta-hydrochlorothiaz oral tablet

1

metoprolol tartrate oral tablet

1

MICARDIS HCT ORAL TABLET

3

MICARDIS ORAL TABLET

3

MICROZIDE ORAL CAPSULE

3

MINIPRESS ORAL CAPSULE

3

minoxidil oral tablet

1

moexipril oral tablet

1

moexipril-hydrochlorothiazide oral tablet

1

nadolol oral tablet

1

nadolol-bendroflumethiazide oral tablet

1

nicardipine oral capsule

1

nifedical xl oral tablet extended release 24hr

1

nifedipine oral capsule

1

nifedipine oral tablet extended release

1

nifedipine oral tablet extended release 24hr

1

nimodipine oral capsule

1 43

Requirements / Limits

Drug Name

Drug Tier

nisoldipine oral tablet extended release 24 hr

1

NORVASC ORAL TABLET

3

ORENITRAM ORAL TABLET EXTENDED RELEASE

3

perindopril erbumine oral tablet

1

phenoxybenzamine oral capsule

1

pindolol oral tablet

1

prazosin oral capsule

1

PRINIVIL ORAL TABLET

3

PROCARDIA ORAL CAPSULE

3

PROCARDIA XL ORAL TABLET EXTENDED RELEASE 24HR

3

propranolol oral capsule,extended release 24 hr

1

propranolol oral solution

1

propranolol oral tablet

1

propranolol-hydrochlorothiazid oral tablet

1

quinapril oral tablet

1

quinapril-hydrochlorothiazide oral tablet

1

ramipril oral capsule

1

REMODULIN INJECTION SOLUTION

3

reserpine oral tablet

1

SECTRAL ORAL CAPSULE

3

spironolactone oral tablet

1

spironolacton-hydrochlorothiaz oral tablet

1

SULAR ORAL TABLET EXTENDED RELEASE 24 HR

3

TARKA ORAL TABLET, IR - ER, BIPHASIC 24HR

3

TEKTURNA HCT ORAL TABLET

3

TEKTURNA ORAL TABLET

3

telmisartan oral tablet

1

telmisartan-amlodipine oral tablet

1

telmisartan-hydrochlorothiazid oral tablet

1

TENEX ORAL TABLET

3 44

Requirements / Limits

PA; SPRx

PA; SPRx

Drug Name

Drug Tier

TENORETIC 100 ORAL TABLET

3

TENORETIC 50 ORAL TABLET

3

TENORMIN ORAL TABLET

3

terazosin oral capsule

1

TIAZAC ORAL CAPSULE, EXTENDED RELEASE

3

timolol maleate oral tablet

1

TOPROL XL ORAL TABLET EXTENDED RELEASE 24 HR

3

torsemide oral tablet

1

trandolapril oral tablet

1

trandolapril-verapamil oral tablet, ir - er, biphasic 24hr

1

triamterene-hydrochlorothiazid oral capsule

1

triamterene-hydrochlorothiazid oral tablet

1

TRIBENZOR ORAL TABLET

2

TWYNSTA ORAL TABLET

3

valsartan oral tablet

1

valsartan-hydrochlorothiazide oral tablet

1

VASERETIC ORAL TABLET

3

VASOTEC ORAL TABLET

3

veletri intravenous recon soln

1

verapamil oral capsule, 24 hr er pellet ct

1

verapamil oral capsule,ext rel. pellets 24 hr

1

verapamil oral tablet

1

verapamil oral tablet extended release

1

VERELAN ORAL CAPSULE,EXT REL. PELLETS 24 HR

3

VERELAN PM ORAL CAPSULE, 24 HR ER PELLET CT

3

ZEBETA ORAL TABLET

3

ZESTORETIC ORAL TABLET

3

ZESTRIL ORAL TABLET

3

ZIAC ORAL TABLET

3

CARDIAC GLYCOSIDES 45

Requirements / Limits

PA; SPRx

Drug Name

Drug Tier

digitek oral tablet

1

digox oral tablet

1

digoxin oral solution

1

digoxin oral tablet

1

LANOXIN ORAL TABLET

2

Requirements / Limits

COAGULATION THERAPY ADVATE INTRAVENOUS RECON SOLN

3

AGGRENOX ORAL CAPSULE, ER MULTIPHASE 12 HR

3

ALPHANATE INTRAVENOUS RECON SOLN

3

SPRx

ALPHANINE SD INTRAVENOUS RECON SOLN

3

SPRx

ALPROLIX INTRAVENOUS RECON SOLN

3

SPRx

AMICAR ORAL SOLUTION

3

AMICAR ORAL TABLET

3

ARIXTRA SUBCUTANEOUS SYRINGE

3

aspirin-dipyridamole oral capsule, er multiphase 12 hr

1

BENEFIX INTRAVENOUS KIT

3

BRILINTA ORAL TABLET

2

cilostazol oral tablet

1

clopidogrel oral tablet

1

COAGADEX INTRAVENOUS RECON SOLN

3

PA; SPRx

CORIFACT INTRAVENOUS KIT

3

SPRx

COUMADIN ORAL TABLET

3

dipyridamole oral tablet

1

EFFIENT ORAL TABLET

2

ELIQUIS ORAL TABLET

2

enoxaparin subcutaneous solution

1

QL (42 per 365 days)

enoxaparin subcutaneous syringe

1

QL (42 per 365 days)

FEIBA NF INTRAVENOUS RECON SOLN

3

SPRx

fondaparinux subcutaneous syringe

1

QL (42 per 365 days)

FRAGMIN SUBCUTANEOUS SOLUTION

3

QL (42 per 365 days)

FRAGMIN SUBCUTANEOUS SYRINGE

3

QL (42 per 365 days)

46

SPRx

QL (42 per 365 days)

SPRx

Drug Name

Drug Tier

Requirements / Limits

HELIXATE FS INTRAVENOUS RECON SOLN

3

SPRx

HEMOFIL M HIGH INTRAVENOUS RECON SOLN

3

SPRx

HEMOFIL M LOW INTRAVENOUS RECON SOLN

3

SPRx

HEMOFIL M MID INTRAVENOUS RECON SOLN

3

SPRx

HEMOFIL M SUPER HIGH INTRAVENOUS RECON SOLN

3

SPRx

hep flush-10 (pf) intravenous solution

1

heparin (porcine) injection solution

1

heparin lock flush (porcine) intravenous solution

1

heparin lock flush (porcine) intravenous syringe

1

heparin lock flush intravenous solution

1

heparin lockflush(porcine)(pf) intravenous syringe

1

heparin, porcine (pf) injection solution

1

heparin, porcine (pf) injection syringe

1

heparin, porcine (pf) intravenous solution

1

heparin, porcine (pf) intravenous syringe

1

HUMATE-P INTRAVENOUS KIT

3

jantoven oral tablet

1

KOATE-DVI INTRAVENOUS RECON SOLN

3

SPRx

KOGENATE FS INTRAVENOUS RECON SOLN

3

SPRx

LOVENOX SUBCUTANEOUS SOLUTION

3

QL (42 per 365 days)

LOVENOX SUBCUTANEOUS SYRINGE

3

QL (42 per 365 days)

MEPHYTON ORAL TABLET

3

MONOCLATE-P INTRAVENOUS KIT

3

monoject prefill (pf) intravenous syringe

1

monoject prefill advanced (pf) intravenous syringe

1

MONONINE INTRAVENOUS KIT

3

SPRx

NOVOSEVEN RT INTRAVENOUS RECON SOLN

3

SPRx

pentoxifylline oral tablet extended release

1

PERSANTINE ORAL TABLET

3 47

SPRx

SPRx

Drug Name

Drug Tier

Requirements / Limits

PLAVIX ORAL TABLET

3

PRADAXA ORAL CAPSULE

2

PROFILNINE INTRAVENOUS RECON SOLN

3

SPRx

PROMACTA ORAL TABLET

3

SPRx

RECOMBINATE INTRAVENOUS RECON SOLN

3

SPRx

RIXUBIS INTRAVENOUS RECON SOLN

3

SPRx

ticlopidine oral tablet

1

warfarin oral tablet

1

WILATE INTRAVENOUS RECON SOLN

3

XARELTO ORAL TABLET

2

XARELTO ORAL TABLETS,DOSE PACK

2

XYNTHA INTRAVENOUS SOLUTION

3

SPRx

XYNTHA SOLOFUSE INTRAVENOUS SYRINGE

3

SPRx

ZONTIVITY ORAL TABLET

3

LIPID/CHOLESTEROL LOWERING AGENTS ALTOPREV ORAL TABLET EXTENDED RELEASE 24 HR

3

amlodipine-atorvastatin oral tablet

1

ANTARA ORAL CAPSULE

3

atorvastatin oral tablet

1

CADUET ORAL TABLET

3

cholestyramine (with sugar) oral powder

1

cholestyramine (with sugar) oral powder in packet

1

cholestyramine light oral powder

1

cholestyramine light oral powder in packet

1

COLESTID FLAVORED ORAL PACKET

3

COLESTID ORAL GRANULES

3

COLESTID ORAL TABLET

3

colestipol oral granules

1

colestipol oral packet

1

colestipol oral tablet

1

CRESTOR ORAL TABLET

2 48

SPRx

Drug Name

Drug Tier

Requirements / Limits

fenofibrate micronized oral capsule 43 mg, 67 mg, 130 mg, 134 mg, 200 mg

1

fenofibrate nanocrystallized tablet 145 mg, 48 mg

1

fenofibrate oral tablet 54 mg, 160 mg

1

fenofibric acid (choline) oral capsule,delayed release(dr/ec)

1

fenofibric acid oral tablet

1

FENOGLIDE ORAL TABLET

3

FIBRICOR ORAL TABLET

3

fluvastatin oral capsule

1

fluvastatin oral tablet extended release 24 hr

1

gemfibrozil oral tablet

1

JUXTAPID ORAL CAPSULE

3

PA; SPRx

KYNAMRO SUBCUTANEOUS SYRINGE

3

PA; SPRx

LESCOL ORAL CAPSULE

3

LESCOL XL ORAL TABLET EXTENDED RELEASE 24 HR

3

LIPITOR ORAL TABLET

3

LIPOFEN ORAL CAPSULE

3

LIVALO ORAL TABLET

3

LOFIBRA ORAL CAPSULE

3

LOFIBRA ORAL TABLET

3

LOPID ORAL TABLET

3

lovastatin oral tablet

1

niacin oral tablet extended release 24 hr

1

NIACOR ORAL TABLET

3

NIASPAN EXTENDED-RELEASE ORAL TABLET EXTENDED RELEASE 24 HR

2

PRALUENT PEN SUBCUTANEOUS PEN INJECTOR

2

PA; SPRx

PRALUENT SYRINGE SUBCUTANEOUS SYRINGE

2

PA; SPRx

PRAVACHOL ORAL TABLET

3

pravastatin oral tablet

1

prevalite oral powder, oral powder in packet

1 49

Drug Name

Drug Tier

Requirements / Limits

QUESTRAN LIGHT ORAL POWDER

3

QUESTRAN ORAL POWDER

3

QUESTRAN ORAL POWDER IN PACKET

3

REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR

2

PA; SPRx

REPATHA SYRINGE SUBCUTANEOUS SYRINGE

2

PA; SPRx

simvastatin oral tablet

1

TRICOR ORAL TABLET

3

TRIGLIDE ORAL TABLET

3

TRILIPIX ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

VYTORIN 10-10 ORAL TABLET

2

VYTORIN 10-20 ORAL TABLET

2

VYTORIN 10-40 ORAL TABLET

2

VYTORIN 10-80 ORAL TABLET

2

WELCHOL ORAL POWDER IN PACKET

3

WELCHOL ORAL TABLET

3

ZETIA ORAL TABLET

2

ZOCOR ORAL TABLET

3

MISCELLANEOUS CARDIOVASCULAR AGENTS CORLANOR ORAL TABLET

3

ENTRESTO ORAL TABLET

3

RANEXA ORAL TABLET EXTENDED RELEASE 12 HR

3

NITRATES DILATRATE-SR ORAL CAPSULE, EXTENDED RELEASE

3

ISOCHRON ORAL TABLET EXTENDED RELEASE

3

ISORDIL ORAL TABLET

3

ISORDIL TITRADOSE ORAL TABLET

3

isosorbide dinitrate oral tablet

1

isosorbide dinitrate oral tablet extended release

1

isosorbide mononitrate oral tablet

1 50

Drug Name

Drug Tier

isosorbide mononitrate oral tablet extended release 24 hr

1

MINITRAN TRANSDERMAL PATCH 24 HOUR

3

nitro-bid transdermal ointment

1

NITRO-DUR TRANSDERMAL PATCH 24 HOUR

3

nitroglycerin oral capsule, extended release

1

nitroglycerin transdermal patch 24 hour

1

nitroglycerin translingual aerosol,spray

1

nitroglycerin translingual spray,non-aerosol

1

NITROLINGUAL TRANSLINGUAL SPRAY,NON-AEROSOL

3

NITROMIST TRANSLINGUAL AEROSOL,SPRAY

3

NITROSTAT SUBLINGUAL TABLET

3

nitro-time oral capsule, extended release

1

DERMATOLOGICALS/TOPICAL THERAPY ANTIPSORIATIC / ANTISEBORRHEIC acitretin oral capsule

1

ANALPRAM-HC TOPICAL LOTION

3

calcipotriene scalp solution

1

calcipotriene topical cream

1

calcipotriene topical ointment

1

calcipotriene-betamethasone topical ointment

1

calcitrene topical ointment

1

calcitriol topical ointment

1

COAL TAR TOPICAL SOLUTION

3

DOVONEX TOPICAL CREAM

3

drithocreme hp topical cream

1

EPIFOAM TOPICAL FOAM

3

hydrocortisone-pramoxine topical cream

1

OVACE PLUS SHAMPOO TOPICAL SHAMPOO

3

51

Requirements / Limits

Drug Name

Drug Tier

OVACE PLUS TOPICAL CLEANSER,EXTENDED RELEASE

3

OVACE PLUS TOPICAL CREAM

3

OVACE PLUS TOPICAL LOTION

3

OVACE PLUS WASH TOPICAL CLEANSER,GEL EXTENDED RELEASE

3

OVACE TOPICAL CLEANSER

3

PRAMOSONE E TOPICAL CREAM

3

PRAMOSONE TOPICAL CREAM

3

PRAMOSONE TOPICAL LOTION

3

PRAMOSONE TOPICAL OINTMENT

3

seb-prev topical cleanser

1

selenium sulfide topical lotion

1

selenium sulfide topical shampoo

1

SELRX TOPICAL SHAMPOO

3

SORIATANE ORAL CAPSULE

3

SORILUX TOPICAL FOAM

3

sulfacetamide sodium topical cleanser

1

sulfacetamide sodium topical shampoo

1

TACLONEX TOPICAL SUSPENSION

3

TERSI FOAM TOPICAL FOAM

3

VECTICAL TOPICAL OINTMENT

3

ZITHRANOL TOPICAL SHAMPOO

3

ZITHRANOL-RR TOPICAL CREAM, RAPID RELEASE

3

BURN THERAPY SILVADENE TOPICAL CREAM

3

silver sulfadiazine topical cream

1

ssd topical cream

1

thermazene topical cream

1

KERATOLYTICS BENSAL HP TOPICAL OINTMENT

3

INOVA 4-1 TOPICAL COMBO PACK

3

INOVA 8-2 TOPICAL COMBO PACK

3 52

Requirements / Limits

Drug Name

Drug Tier

KERALYT RX TOPICAL GEL

3

KERALYT SCALP COMPLETE TOPICAL KIT,SHAMPOO AND GEL

3

PODOCON TOPICAL LIQUID

3

POTASSIUM HYDROXIDE TOPICAL SOLUTION

3

salacyn topical cream

1

salacyn topical lotion

1

SALEX TOPICAL COMBO PACK

3

SALEX TOPICAL KIT,CLEANSER AND CREAM ER

3

SALEX TOPICAL SHAMPOO

3

salicylic acid er-ceramides topical combo pack

1

salicylic acid er-ceramides topical kit,cleanser and cream er

1

salicylic acid topical cream

1

salicylic acid topical cream,extended release

1

salicylic acid topical film forming liquid w/appl

1

salicylic acid topical foam

1

salicylic acid topical gel

1

salicylic acid topical liquid

1

salicylic acid topical lotion

1

salicylic acid topical lotion,extended release

1

salicylic acid topical shampoo

1

SALKERA TOPICAL FOAM

3

SALVAX DUO PLUS TOPICAL FOAM

3

salvax topical foam

1

VIRASAL TOPICAL FILM FORMING LIQUID W/APPL

3

MISCELLANEOUS DERMATOLOGICALS 8-MOP ORAL CAPSULE

3

ALUVEA TOPICAL CREAM

3

ATOPICLAIR TOPICAL CREAM

3

ATRAPRO CP TOPICAL COMBO PACK,CREAM AND GEL

3 53

Requirements / Limits

Drug Name

Drug Tier

avo cream topical emulsion

1

BIAFINE EMULSION TOPICAL EMULSION

3

bp-50% urea topical emulsion

1

cem-urea topical gel

1

CONDYLOX TOPICAL GEL

3

CORTANE-B TOPICAL LOTION

3

DERMASORB XM COMPLETE KIT TOPICAL CREAM

3

diclofenac sodium topical gel

1

doxepin topical cream

1

EFUDEX TOPICAL CREAM

3

eletone topical cream

1

ELIDEL TOPICAL CREAM

2

emulsion sb topical emulsion

1

EPICERAM TOPICAL EMULSION, EXTENDED RELEASE

3

FLUOROPLEX TOPICAL CREAM

3

fluorouracil topical cream

1

fluorouracil topical solution

1

GORDONS UREA TOPICAL OINTMENT

3

hpr plus hydrogel topical kit,cream and gel

1

hpr plus topical cream

1

hpr plus topical foam

1

HPR PLUS-MB HYDROGEL TOPICAL COMBO PACK,GEL AND FOAM

3

hpr topical foam

1

HYDRO 35 TOPICAL FOAM

3

HYDRO 40 TOPICAL FOAM

3

HYLATOPIC PLUS TOPICAL CREAM

3

HYLATOPIC PLUS TOPICAL FOAM

3

HYLATOPIC TOPICAL FOAM

3

KERAFOAM TOPICAL FOAM

3

KERALAC TOPICAL CREAM

3

lactic acid e topical cream

1 54

Requirements / Limits

Drug Name

Drug Tier

lactic acid topical lotion

1

latrix topical suspension

1

LEVULAN TOPICAL SOLUTION

3

LOUTREX TOPICAL CREAM

3

methoxsalen rapid oral capsule

1

NEOSALUS TOPICAL CREAM

3

NEOSALUS TOPICAL FOAM

3

NEOSALUS TOPICAL LOTION

3

nivatopic plus topical cream

1

OXSORALEN TOPICAL LOTION

3

OXSORALEN ULTRA ORAL CAPSULE

3

PANRETIN TOPICAL GEL

3

PICATO TOPICAL GEL

3

podofilox topical solution

1

PROMISEB TOPICAL CREAM

3

PROTOPIC TOPICAL OINTMENT

3

pruclair topical cream

1

prudoxin topical cream

1

prutect topical emulsion

1

rea lo 39 topical cream

1

rea lo 40 topical cream

1

rea lo 40 topical lotion

1

REGRANEX TOPICAL GEL

3

remeven topical cream

1

silver nitrate applicators topical stick

1

silver nitrate topical solution

1

SOLARAZE TOPICAL GEL

3

sonafine topical emulsion

1

tacrolimus topical ointment

1

TROPAZONE LOTION TOPICAL LOTION

3

UMECTA PD TOPICAL EMULSION, ADHESIVE

3

UMECTA PD TOPICAL SUSPENSION,ADHESIVE

3 55

Requirements / Limits

#

#

Drug Name

Drug Tier

umecta topical foam

1

URAMAXIN GT TOPICAL GEL

3

URAMAXIN GT TOPICAL KIT,CREAM AND GEL

3

URAMAXIN TOPICAL FOAM

3

URAMAXIN TOPICAL GEL

3

urea nail stick topical solution

1

urea topical cream

1

urea topical foam

1

urea topical gel

1

urea topical lotion

1

urea topical nail film suspension

1

urea-hyaluronate sodium topical kit

1

UTOPIC TOPICAL CREAM

3

VALCHLOR TOPICAL GEL

3

VEREGEN TOPICAL OINTMENT

3

XCLAIR TOPICAL CREAM

3

ZONALON TOPICAL CREAM

3

Requirements / Limits

PA; SPRx

THERAPY FOR ACNE ACANYA TOPICAL GEL

2

ACZONE TOPICAL GEL

3

adapalene topical cream

1

adapalene topical gel

1

adapalene topical gel with pump

1

ATRALIN TOPICAL GEL

2

AVAR LS TOPICAL CLEANSER

3

AVAR LS TOPICAL FOAM

3

AVAR LS TOPICAL PADS, MEDICATED

3

avar topical cleanser

1

AVAR TOPICAL FOAM

3

AVAR TOPICAL PADS, MEDICATED

3

AVAR-E GREEN TOPICAL CREAM

3

AVAR-E LS TOPICAL CREAM

3 56

PA

Drug Name

Drug Tier

avita topical cream

1

AZELEX TOPICAL CREAM

3

BENZACLIN PUMP TOPICAL GEL

3

BENZAMYCIN TOPICAL GEL

3

BENZAMYCINPAK TOPICAL GEL

3

BENZEFOAM TOPICAL FOAM

3

BENZEFOAM ULTRA TOPICAL FOAM

3

BENZEPRO (MICROSPHERES) TOPICAL CLEANSER

3

benzepro topical towelette

1

benzoyl peroxide topical cleanser

1

benzoyl peroxide topical foam

1

bp 10-1 topical cleanser

1

bpo topical gel

1

bpo topical towelette

1

claravis oral capsule

1

cleansing wash topical cleanser

1

CLEOCIN T TOPICAL GEL

3

CLEOCIN T TOPICAL LOTION

3

CLEOCIN T TOPICAL SOLUTION

3

CLEOCIN T TOPICAL SWAB

3

clindacin p topical swab

1

CLINDAGEL TOPICAL GEL

3

clindamycin phosphate topical foam

1

clindamycin phosphate topical gel

1

clindamycin phosphate topical lotion

1

clindamycin phosphate topical solution

1

clindamycin phosphate topical swab

1

clindamycin-benzoyl peroxide topical gel

1

DIFFERIN TOPICAL GEL

3

DIFFERIN TOPICAL GEL WITH PUMP

3

DIFFERIN TOPICAL LOTION

3

DUAC TOPICAL GEL

3 57

Requirements / Limits PA

Drug Name

Drug Tier

EPIDUO FORTE TOPICAL GEL WITH PUMP

2

EPIDUO TOPICAL GEL

2

EPIDUO TOPICAL GEL WITH PUMP

2

ery pads topical swab

1

erygel topical gel

1

erythromycin with ethanol topical gel

1

erythromycin with ethanol topical solution

1

erythromycin with ethanol topical swab

1

erythromycin-benzoyl peroxide topical gel

1

EVOCLIN TOPICAL FOAM

3

FABIOR TOPICAL FOAM

3

FINACEA TOPICAL FOAM

3

FINACEA TOPICAL GEL

3

INOVA TOPICAL COMBO PACK

3

METROCREAM TOPICAL CREAM

3

METROGEL TOPICAL GEL

3

METROGEL TOPICAL GEL WITH PUMP

3

METROLOTION TOPICAL LOTION

3

metronidazole topical cream

1

metronidazole topical gel

1

metronidazole topical gel with pump

1

metronidazole topical lotion

1

myorisan oral capsule

1

neuac topical gel

1

NORITATE TOPICAL CREAM

3

NUOX TOPICAL GEL

3

PACNEX TOPICAL CLEANSER

3

PLEXION CLEANSING CLOTHS TOPICAL PADS, MEDICATED

3

PLEXION TOPICAL CLEANSER

3

PLEXION TOPICAL CREAM

3

PLEXION TOPICAL LOTION

3

RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.04 %, 0.1 %

3 58

Requirements / Limits

PA

PA; GEN

Drug Name

Drug Tier

Requirements / Limits

RETIN-A MICRO PUMP TOPICAL GEL WITH PUMP 0.08 %

3

PA; GEN

RETIN-A MICRO TOPICAL GEL

3

PA; GEN

RETIN-A TOPICAL CREAM

3

PA

RETIN-A TOPICAL GEL

3

PA

rosadan topical cream

1

rosadan topical gel

1

ROSANIL TOPICAL CLEANSER

3

rosula cleansing cloths topical pads, medicated

1

ROSULA TOPICAL CLEANSER

3

ss 10-2 topical cleanser

1

sss 10-5 topical foam, topical cream

1

sulfacetamide sodium-sulfur topical cleanser

1

sulfacetamide sodium-sulfur topical cream

1

sulfacetamide sodium-sulfur topical lotion

1

sulfacetamide sodium-sulfur topical pads, medicated

1

sulfacetamide sodium-sulfur topical suspension

1

sulfacetamide sod-sulfur-urea topical cleanser

1

sulfacleanse 8-4 topical suspension

1

sulfact na-sul-avobnz-otn-ocsa topical combo pack,cleanser and cream

1

SUMADAN XLT TOPICAL COMBO PACK,CLEANSER AND CREAM

3

SUMAXIN TOPICAL CLEANSER

3

SUMAXIN TOPICAL PADS, MEDICATED

3

SUMAXIN TS TOPICAL SUSPENSION

3

TAZORAC TOPICAL CREAM

3

PA

TAZORAC TOPICAL GEL

3

PA

tretinoin microspheres topical gel

1

PA; GEN

tretinoin topical cream

1

PA

tretinoin topical gel

1

PA

TRETIN-X CREAM KIT TOPICAL COMBO PACK

3

PA

TRETIN-X TOPICAL CREAM

3

PA

59

Drug Name

Drug Tier

VANOXIDE-HC TOPICAL SUSPENSION

3

zenatane oral capsule

1

zencia topical cleanser

1

TOPICAL ANESTHETICS BUCALSEP MUCOUS MEMBRANE AEROSOL,SPRAY

3

BUCALSEP MUCOUS MEMBRANE SOLUTION

3

ethyl chloride topical aerosol,spray

1

glydo mucous membrane jelly in applicator

1

lidocaine hcl mucous membrane gel

1

lidocaine hcl mucous membrane jelly in applicator

1

lidocaine hcl mucous membrane solution

1

lidocaine hcl-hydrocortison ac topical cream

1

lidocaine viscous mucous membrane solution

1

lidocaine-prilocaine topical cream

1

lidocaine-prilocaine topical kit

1

NOVACORT TOPICAL GEL

3

relador pak plus topical kit

1

relador pak topical kit

1

SYNERA TOPICAL PATCH, MEDICATED SELF-HEATING

3

TOPICAL ANTIBACTERIALS ALTABAX TOPICAL OINTMENT

3

CENTANY AT TOPICAL OINTMENT KIT

3

CENTANY TOPICAL OINTMENT

3

CORTISPORIN TOPICAL CREAM

3

CORTISPORIN TOPICAL OINTMENT

3

gentamicin topical cream

1

gentamicin topical ointment

1

KLARON TOPICAL SUSPENSION

3

mupirocin calcium topical cream

1

mupirocin topical ointment

1

NEO-SYNALAR KIT TOPICAL CREAM

3 60

Requirements / Limits

Drug Name

Drug Tier

NEO-SYNALAR TOPICAL CREAM

3

sulfacetamide sodium (acne) topical suspension

1

SULFAMYLON TOPICAL CREAM

3

SULFAMYLON TOPICAL PACKET

3

TOPICAL ANTIFUNGALS ciclodan topical cream

1

ciclodan topical solution

1

ciclopirox topical cream

1

ciclopirox topical gel

1

ciclopirox topical shampoo

1

ciclopirox topical solution

1

ciclopirox topical suspension

1

ciclopirox-ure-camph-menth-euc topical solution

1

clotrimazole-betamethasone topical cream

1

clotrimazole-betamethasone topical lotion

1

CNL 8 NAIL TOPICAL KIT

3

econazole topical cream

1

ERTACZO TOPICAL CREAM

3

EXELDERM TOPICAL CREAM

3

EXELDERM TOPICAL SOLUTION

3

EXODERM TOPICAL LOTION

3

EXTINA TOPICAL FOAM

3

ketoconazole topical cream

1

ketoconazole topical foam

1

ketoconazole topical shampoo

1

LOPROX TOPICAL SHAMPOO

3

LOTRISONE TOPICAL CREAM

3

NAFTIFINE TOPICAL CREAM 1 %

3

naftifine topical cream 2 %

1

NAFTIN TOPICAL GEL

3

NIZORAL TOPICAL SHAMPOO

3

nyamyc topical powder

1

nystatin topical cream

1 61

Requirements / Limits

Drug Name

Drug Tier

nystatin topical ointment

1

nystatin topical powder

1

nystatin-triamcinolone topical cream

1

nystatin-triamcinolone topical ointment

1

nystop topical powder

1

oxiconazole topical cream

1

OXISTAT TOPICAL LOTION

3

PEDIADERM AF TOPICAL CREAM

3

PENLAC TOPICAL SOLUTION

3

TRIACETIN LIQUID

3

TRIPLE DYE TOPICAL SWAB

3

VUSION TOPICAL OINTMENT

3

XOLEGEL TOPICAL GEL

3

Requirements / Limits

TOPICAL ANTIVIRALS acyclovir topical ointment

1

DENAVIR TOPICAL CREAM

3

ZOVIRAX TOPICAL CREAM

2

ZOVIRAX TOPICAL OINTMENT

3

TOPICAL CORTICOSTEROIDS ALA-SCALP TOPICAL LOTION

3

alclometasone topical cream, ointment

1

amcinonide topical cream, ointment

1

amcinonide topical lotion

1

apexicon e topical cream

1

AQUA GLYCOLIC HC TOPICAL COMBO PACK

3

betamethasone dipropionate topical cream

1

betamethasone dipropionate topical lotion

1

betamethasone dipropionate topical ointment

1

betamethasone valerate topical cream

1

betamethasone valerate topical foam

1

betamethasone valerate topical lotion

1

betamethasone valerate topical ointment

1 62

GEN

GEN

Drug Name

Drug Tier

betamethasone, augmented topical cream

1

betamethasone, augmented topical gel

1

betamethasone, augmented topical lotion

1

betamethasone, augmented topical ointment

1

CAPEX TOPICAL SHAMPOO

3

clobetasol scalp solution

1

clobetasol topical cream

1

clobetasol topical foam

1

clobetasol topical gel

1

clobetasol topical lotion

1

clobetasol topical ointment

1

clobetasol topical shampoo

1

clobetasol topical spray,non-aerosol

1

clobetasol-emollient topical cream

1

clobetasol-emollient topical foam

1

CLOBEX TOPICAL LOTION

3

CLOBEX TOPICAL SHAMPOO

3

CLOBEX TOPICAL SPRAY,NON-AEROSOL

3

CLOCORTOLONE PIVALATE TOPICAL CREAM

3

clodan topical shampoo

1

CLODERM TOPICAL CREAM

3

CORDRAN TAPE SMALL ROLL TOPICAL TAPE

3

CORDRAN TOPICAL CREAM

3

CORDRAN TOPICAL LOTION

3

CORDRAN TOPICAL OINTMENT

3

cormax scalp solution

1

CUTIVATE TOPICAL CREAM

3

CUTIVATE TOPICAL LOTION

3

DERMA-SMOOTHE/FS BODY OIL TOPICAL OIL

3

DERMA-SMOOTHE/FS SCALP OIL SCALP OIL

3

63

Requirements / Limits

Drug Name

Drug Tier

DERMASORB HC COMPLETE KIT TOPICAL COMBO PACK,CLEANSER AND LOTION

3

DERMASORB TA COMPLETE KIT TOPICAL CREAM

3

DERMATOP TOPICAL CREAM

3

DERMATOP TOPICAL OINTMENT

3

DESONATE TOPICAL GEL

3

desonide topical cream

1

desonide topical lotion

1

desonide topical ointment

1

DESOWEN TOPICAL CREAM

3

DESOWEN TOPICAL LOTION

3

desoximetasone topical cream

1

desoximetasone topical gel

1

desoximetasone topical ointment

1

diflorasone topical cream

1

diflorasone topical ointment

1

DIPROLENE AF TOPICAL CREAM

3

DIPROLENE TOPICAL LOTION

3

DIPROLENE TOPICAL OINTMENT

3

ELOCON TOPICAL CREAM

3

ELOCON TOPICAL OINTMENT

3

ELOCON TOPICAL SOLUTION

3

fluocinolone and shower cap scalp oil

1

fluocinolone topical cream

1

fluocinolone topical oil

1

fluocinolone topical ointment

1

fluocinolone topical solution

1

fluocinonide topical cream

1

fluocinonide topical gel

1

fluocinonide topical ointment

1

fluocinonide topical solution

1

fluocinonide-e topical cream

1

flurandrenolide topical cream

1 64

Requirements / Limits

Drug Name

Drug Tier

fluticasone topical cream

1

fluticasone topical lotion

1

fluticasone topical ointment

1

halobetasol propionate topical cream

1

halobetasol propionate topical ointment

1

HALOG TOPICAL CREAM

3

HALOG TOPICAL OINTMENT

3

hydrocortisone butyrate topical cream

1

hydrocortisone butyrate topical ointment

1

hydrocortisone butyrate topical solution

1

hydrocortisone butyr-emollient topical cream

1

hydrocortisone topical cream

1

hydrocortisone topical lotion

1

hydrocortisone topical ointment

1

hydrocortisone valerate topical cream

1

hydrocortisone valerate topical ointment

1

hydrocortisone-min oil-wht pet topical ointment

1

KENALOG TOPICAL AEROSOL

3

LOCOID LIPOCREAM TOPICAL CREAM

3

LOCOID TOPICAL LOTION

3

LUXIQ TOPICAL FOAM

3

mometasone topical cream

1

mometasone topical ointment

1

mometasone topical solution

1

OLUX TOPICAL FOAM

3

OLUX-E TOPICAL FOAM

3

PANDEL TOPICAL CREAM

3

PEDIADERM TA TOPICAL CREAM

3

prednicarbate topical cream

1

prednicarbate topical ointment

1

PSORCON TOPICAL CREAM

3

SCALACORT DK TOPICAL COMBO PACK

3

scalacort topical lotion

1 65

Requirements / Limits

Drug Name

Drug Tier

SYNALAR CREAM KIT TOPICAL CREAM

3

SYNALAR OINTMENT KIT TOPICAL COMBO PACK,OINTMENT AND CREAM

3

SYNALAR TOPICAL SOLUTION

3

SYNALAR TS TOPICAL KIT

3

TEMOVATE E TOPICAL CREAM

3

TEMOVATE TOPICAL CREAM

3

TEMOVATE TOPICAL OINTMENT

3

TEXACORT TOPICAL SOLUTION

3

TOPICORT TOPICAL CREAM

3

TOPICORT TOPICAL GEL

3

TOPICORT TOPICAL OINTMENT

3

TOPICORT TOPICAL SPRAY,NON-AEROSOL

3

triamcinolone acetonide topical aerosol

1

triamcinolone acetonide topical cream

1

triamcinolone acetonide topical lotion

1

triamcinolone acetonide topical ointment

1

trianex topical ointment

1

triderm topical cream

1

ULTRAVATE X TOPICAL COMBO PACK

3

ULTRAVATE X TOPICAL COMBO PACK,OINTMENT AND CREAM

3

VANOS TOPICAL CREAM

3

VERDESO TOPICAL FOAM

3

TOPICAL ENZYMES SANTYL TOPICAL OINTMENT

3

TOPICAL SCABICIDES / PEDICULICIDES ELIMITE TOPICAL CREAM

3

EURAX TOPICAL CREAM

3

EURAX TOPICAL LOTION

3

lindane topical shampoo

1

malathion topical lotion

1

NATROBA TOPICAL SUSPENSION

3

OVIDE TOPICAL LOTION

3 66

Requirements / Limits

Drug Name

Drug Tier

permethrin topical cream

1

spinosad topical suspension

1

ULESFIA TOPICAL LOTION

3

Requirements / Limits

DIAGNOSTICS & MISCELLANEOUS AGENTS ANOREXIANTS ADIPEX-P ORAL CAPSULE

3

#

ADIPEX-P ORAL TABLET

3

#

BELVIQ ORAL TABLET

3

#

benzphetamine oral tablet

1

#

CONTRAVE ORAL TABLET EXTENDED RELEASE

3

#

diethylpropion oral tablet

1

#

diethylpropion oral tablet extended release

1

#

phendimetrazine tartrate oral capsule, extended release

1

#

phendimetrazine tartrate oral tablet

1

#

phentermine oral capsule

1

#

phentermine oral tablet

1

#

QSYMIA ORAL CAPSULE, ER MULTIPHASE 24 HR

3

#

REGIMEX ORAL TABLET

3

#

SAXENDA SUBCUTANEOUS PEN INJECTOR

3

#

XENICAL ORAL CAPSULE

3

#

IRRIGATING SOLUTIONS lactated ringers irrigation solution

1

neomycin-polymyxin b gu irrigation solution

1

NEOSPORIN GU IRRIGANT IRRIGATION SOLUTION

3

PHYSIOLYTE IRRIGATION SOLUTION

3

PHYSIOSOL IRRIGATION IRRIGATION SOLUTION

3

ringers irrigation solution

1

SORBITOL IRRIGATION SOLUTION

3

SORBITOL-MANNITOL URETHRAL SOLUTION

3 67

Drug Name

Drug Tier

Requirements / Limits

MISCELLANEOUS AGENTS acamprosate oral tablet,delayed release (dr/ec)

1

acetic acid irrigation solution

1

ACTONEL ORAL TABLET

3

AGRYLIN ORAL CAPSULE

3

alendronate oral tablet

1

anagrelide oral capsule

1

ANTABUSE ORAL TABLET

3

bd pre-filled normal saline injection syringe

1

BUPHENYL ORAL POWDER

3

caffeine citrated oral solution

1

CARBAGLU ORAL TABLET, DISPERSIBLE

3

CARNITOR (SUGAR-FREE) ORAL SOLUTION

3

CARNITOR ORAL SOLUTION

3

CARNITOR ORAL TABLET

3

cevimeline oral capsule

1

CHEMET ORAL CAPSULE

3

disulfiram oral tablet

1

etidronate disodium oral tablet

1

EVOXAC ORAL CAPSULE

3

EXJADE ORAL TABLET, DISPERSIBLE

3

SPRx

FERRIPROX ORAL TABLET

3

SPRx

INFASURF INTRATRACHEAL SUSPENSION

3

JADENU ORAL TABLET

3

levocarnitine (with sugar) oral solution

1

levocarnitine oral tablet

1

LIPOCHOL PLUS ORAL TABLET

3

LITHOSTAT ORAL TABLET

3

METOPIRONE ORAL CAPSULE

3

midodrine oral tablet

1

monoject 0.9% sodium chloride injection syringe

1

monoject prefill advanced ns injection syringe

1

monoject prefill saline flush injection syringe

1 68

#

#

#

SPRx

Drug Name

Drug Tier

Requirements / Limits

normal saline flush injection syringe

1

NORTHERA ORAL CAPSULE

3

PA; SPRx

ORFADIN ORAL CAPSULE

3

SPRx

pilocarpine hcl oral tablet

1

RADIOGARDASE ORAL CAPSULE

3

RAVICTI ORAL LIQUID

3

RILUTEK ORAL TABLET

3

riluzole oral tablet

1

risedronate oral tablet

1

SALAGEN ORAL TABLET

3

sodium chlor 0.9% bacteriostat injection solution

1

sodium chloride 0.9 % injection syringe

1

sodium chloride irrigation solution

1

sodium phenylbutyrate oral powder

1

SURVANTA INTRATRACHEAL SUSPENSION

3

SYPRINE ORAL CAPSULE

3

syrex sodium chloride 0.9% injection syringe

1

THIOLA ORAL TABLET

3

water for irrigation, sterile irrigation solution

1

SPRx

SMOKING DETERRENTS CHANTIX CONTINUING MONTH BOX ORAL TABLET

3

#; ACA

CHANTIX ORAL TABLET

3

#; ACA

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK

3

#; ACA

NICOTROL INHALATION CARTRIDGE

3

#

NICOTROL NS NASAL SPRAY,NONAEROSOL

3

#

ZYBAN ORAL TABLET EXTENDED RELEASE

3

#

EAR, NOSE & THROAT MEDICATIONS MISCELLANEOUS AGENTS ARESTIN DENTAL CARTRIDGE

3

ASTEPRO NASAL SPRAY,NON-AEROSOL

2 69

Drug Name

Drug Tier

ATROVENT NASAL SPRAY,NON-AEROSOL

3

azelastine nasal aerosol,spray

1

azelastine nasal spray,non-aerosol

1

BACTROBAN NASAL NASAL OINTMENT

3

chlorhexidine gluconate mucous membrane mouthwash

1

CLINPRO 5000 DENTAL PASTE

3

DEBACTEROL MUCOUS MEMBRANE SOLUTION

3

DEBACTEROL MUCOUS MEMBRANE SWAB

3

denta 5000 plus dental cream

1

dentagel dental gel

1

fluoridex daily defense dental gel

1

FLUORIDEX SENSITIVITY RELIEF DENTAL GEL

3

GELCLAIR MUCOUS MEMBRANE GEL IN PACKET

3

ipratropium bromide nasal spray,non-aerosol

1

MUGARD MUCOUS MEMBRANE SOLUTION

3

olopatadine nasal spray,non-aerosol

1

oralone dental paste

1

ORAMAGICRX MUCOUS MEMBRANE MOUTHWASH

3

PATANASE NASAL SPRAY,NON-AEROSOL

3

PERIDEX MUCOUS MEMBRANE MOUTHWASH

3

periogard mucous membrane mouthwash

1

pilocarpine hcl oral tablet

1

PREVIDENT 5000 BOOSTER PLUS DENTAL PASTE

3

PREVIDENT 5000 DRY MOUTH DENTAL GEL

3

PREVIDENT 5000 ENAMEL PROTECT DENTAL PASTE

3

PREVIDENT 5000 SENSITIVE DENTAL PASTE

3

70

Requirements / Limits

Drug Name

Drug Tier

PREVIDENT DENTAL SOLUTION

3

SALAGEN ORAL TABLET

3

sf 5000 plus dental cream

1

sf dental gel

1

sodium fluoride dental solution

1

triamcinolone acetonide dental paste

1

TYZINE NASAL DROPS

3

TYZINE NASAL SPRAY,NON-AEROSOL

3

Requirements / Limits

MISCELLANEOUS OTIC PREPARATIONS acetasol hc otic drops

1

acetic acid otic solution

1

acetic acid-aluminum acetate otic drops

1

ciprofloxacin hcl otic dropperette

1

DERMOTIC OIL OTIC DROPS

3

fluocinolone acetonide oil otic drops

1

hydrocortisone-acetic acid otic drops

1

ofloxacin otic drops

1

OTIC STEROID / ANTIBIOTIC CIPRO HC OTIC DROPS,SUSPENSION

3

CIPRODEX OTIC DROPS,SUSPENSION

2

COLY-MYCIN S OTIC DROPS,SUSPENSION

3

neomycin-polymyxin-hc otic drops,suspension

1

neomycin-polymyxin-hc otic solution

1

ENDOCRINE/DIABETES ADRENAL HORMONES ACTHAR H.P. INJECTION GEL

3

CORTEF ORAL TABLET

3

cortisone oral tablet

1

deltasone oral tablet

1

dexamethasone intensol oral drops

1

dexamethasone oral elixir

1

dexamethasone oral solution

1

dexamethasone oral tablet

1 71

PA; SPRx

Drug Name

Drug Tier

DEXPAK 10 DAY ORAL TABLETS,DOSE PACK

3

DEXPAK 13 DAY ORAL TABLETS,DOSE PACK

3

DEXPAK 6 DAY ORAL TABLETS,DOSE PACK

3

fludrocortisone oral tablet

1

hydrocortisone oral tablet

1

MEDROL (PAK) ORAL TABLETS,DOSE PACK

3

MEDROL ORAL TABLET

3

methylprednisolone oral tablet

1

methylprednisolone oral tablets,dose pack

1

millipred dp oral tablets,dose pack

1

MILLIPRED ORAL SOLUTION

3

millipred oral tablet

1

ORAPRED ODT ORAL TABLET,DISINTEGRATING

3

PEDIAPRED ORAL SOLUTION

3

prednisolone oral solution

1

prednisolone sodium phosphate oral solution

1

prednisolone sodium phosphate oral tablet,disintegrating

1

prednisone intensol oral concentrate

1

prednisone oral solution

1

prednisone oral tablet

1

prednisone oral tablets,dose pack

1

TRIESENCE (PF) INTRAOCULAR SUSPENSION

3

veripred 20 oral solution

1

ANTITHYROID AGENTS methimazole oral tablet

1

propylthiouracil oral tablet

1

SSKI ORAL SOLUTION

3

TAPAZOLE ORAL TABLET

3 72

Requirements / Limits

Drug Name

Drug Tier

Requirements / Limits

BLOOD GLUCOSE MONITORING DEVICES & SUPPLIES ACCU-CHEK AVIVA PLUS TEST STRP STRIP

3

ST; OTC; QL (306 per 30 days)

ACCU-CHEK AVIVA STRIP

3

ST; OTC; QL (306 per 30 days)

ACCU-CHEK COMPACT TEST STRIP

3

ST; OTC; QL (306 per 30 days)

ACCU-CHEK SMARTVIEW TEST STRIP STRIP

3

ST; OTC; QL (306 per 30 days)

ACCUTREND GLUCOSE STRIP

3

ST; OTC; QL (306 per 30 days)

ACURA TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

ADVANCED GLUC METER TEST STRIP STRIP

3

OTC; QL (306 per 30 days)

ADVOCATE REDI-CODE STRIP

3

OTC; QL (306 per 30 days)

ADVOCATE TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

AGAMATRIX AMP TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

ASSURE 4 STRIPS STRIP

3

OTC; QL (306 per 30 days)

ASSURE PLATINUM STRIP

3

OTC; QL (306 per 30 days)

ASSURE PRISM MULTI STRIP STRIP

3

OTC; QL (306 per 30 days)

BG-STAR STRIP

3

OTC; QL (306 per 30 days)

BIONIME RIGHTEST TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

BLOOD GLUCOSE TEST STRIP

3

OTC; QL (306 per 30 days)

BREEZE 2 TEST STRIPS STRIP

2

OTC; QL (306 per 30 days)

CARESENS N TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

CLEVER CHOICE MICRO TEST STRIP STRIP

3

OTC; QL (306 per 30 days)

CLEVER CHOICE PRO STRIP

3

OTC; QL (306 per 30 days)

CLEVER CHOICE TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

CLEVER CHOICE VOICE+ TEST STRIP

3

OTC; QL (306 per 30 days)

CONTOUR NEXT STRIPS STRIP

2

OTC; QL (306 per 30 days)

CONTOUR TEST STRIPS STRIP

2

OTC; QL (306 per 30 days)

CONTROL G3 STRIP

3

OTC; QL (306 per 30 days)

COOL GLUCOSE TEST STRIP STRIP

3

OTC; QL (306 per 30 days)

DIATRUE PLUS TEST STRIP STRIP

3

OTC; QL (306 per 30 days)

EASY PLUS II TEST STRIP

3

OTC; QL (306 per 30 days)

EASY STEP STRIP

3

OTC; QL (306 per 30 days)

EASY TALK GLUCOSE TEST STRIP

3

OTC; QL (306 per 30 days)

EASY TOUCH STRIP

3

OTC; QL (306 per 30 days)

73

Drug Name

Drug Tier

Requirements / Limits

EASY TRAK GLUCOSE TEST STRIP

3

OTC; QL (306 per 30 days)

EASYGLUCO PLUS STRIP

3

OTC; QL (306 per 30 days)

EASYGLUCO TEST STRIP

3

OTC; QL (306 per 30 days)

EASYMAX STRIP

3

OTC; QL (306 per 30 days)

ELEMENT COMPACT TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

ELEMENT TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

EMBRACE BLOOD GLUCOSE SYSTEM STRIP

3

OTC; QL (306 per 30 days)

EMBRACE EVO TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

EMBRACE PRO TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

EVENCARE G2 STRIP

3

OTC; QL (306 per 30 days)

EVENCARE G3 TEST STRIP

3

OTC; QL (306 per 30 days)

EVENCARE MINI GLUCOSE TEST STR STRIP

3

OTC; QL (306 per 30 days)

EVOLUTION TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

EZ SMART PLUS TEST STRIP

3

OTC; QL (306 per 30 days)

EZ SMART TEST STRIP

3

OTC; QL (306 per 30 days)

FIFTY50 TEST STRIP STRIP

3

OTC; QL (306 per 30 days)

FORA D10 STRIP

3

OTC; QL (306 per 30 days)

FORA D15G STRIP

3

OTC; QL (306 per 30 days)

FORA D20 STRIP

3

OTC; QL (306 per 30 days)

FORA D40-G31 TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

FORA G20 STRIP

3

OTC; QL (306 per 30 days)

FORA G30A STRIP

3

OTC; QL (306 per 30 days)

FORA GD50 TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

FORA TEST STRIP STRIP

3

OTC; QL (306 per 30 days)

FORA TN'G VOICE TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

FORA V10 STRIP

3

OTC; QL (306 per 30 days)

FORA V12 GLUCOSE STRIP

3

OTC; QL (306 per 30 days)

FORA V20 STRIP

3

OTC; QL (306 per 30 days)

FORACARE GD20 STRIP

3

OTC; QL (306 per 30 days)

FORACARE GD40 STRIP

3

OTC; QL (306 per 30 days)

FORTISCARE GLUCOSE TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

FREESTYLE INSULINX STRIP

3

ST; OTC; QL (306 per 30 days)

74

Drug Name

Drug Tier

Requirements / Limits

FREESTYLE INSULINX TEST STRIPS STRIP

3

ST; OTC; QL (306 per 30 days)

FREESTYLE LITE STRIPS STRIP

3

ST; OTC; QL (306 per 30 days)

FREESTYLE PRECISION NEO STRIPS STRIP

3

ST; OTC; QL (306 per 30 days)

FREESTYLE TEST STRIP

3

ST; OTC; QL (306 per 30 days)

G-4 TEST STRIP

3

OTC; QL (306 per 30 days)

GE100 BLOOD GLUCOSE TEST STRIP STRIP

3

OTC; QL (306 per 30 days)

GENSTRIP TEST STRIP STRIP

3

OTC; QL (306 per 30 days)

GLUCO NAVII TEST STRIP STRIP

3

OTC; QL (306 per 30 days)

GLUCOCARD 01 SENSOR PLUS STRIP

3

OTC; QL (306 per 30 days)

GLUCOCARD EXPRESSION STRIP

3

OTC; QL (306 per 30 days)

GLUCOCARD SHINE TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

GLUCOCARD VITAL SENSOR STRIP

3

OTC; QL (306 per 30 days)

GLUCOCARD VITAL TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

GLUCOCOM GLUCOSE STRIP

3

OTC; QL (306 per 30 days)

GM100 STRIP

3

OTC; QL (306 per 30 days)

GMATE TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

HEALTHPRO TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

INFINITY TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

LIBERTY TEST STRIP

3

OTC; QL (306 per 30 days)

MAXIMA STRIP

3

OTC; QL (306 per 30 days)

MICRO BLOOD GLUCOSE STRIP

3

OTC; QL (306 per 30 days)

MICRODOT BLOOD GLUCOSE SYSTEM STRIP

3

OTC; QL (306 per 30 days)

MYGLUCOHEALTH STRIP

3

OTC; QL (306 per 30 days)

NEUTEK 2TEK TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

NOVA MAX GLUCOSE TEST STRIP

3

OTC; QL (306 per 30 days)

ON CALL EXPRESS TEST STRIP STRIP

3

OTC; QL (306 per 30 days)

ON CALL PLUS TEST STRIP STRIP

3

OTC; QL (306 per 30 days)

ON CALL VIVID TEST STRIP STRIP

3

OTC; QL (306 per 30 days)

ONETOUCH ULTRA TEST STRIP

2

OTC; QL (306 per 30 days)

ONETOUCH VERIO STRIP

2

OTC; QL (306 per 30 days)

OPTIUM EZ STRIP

3

ST; OTC; QL (306 per 30 days)

OPTIUM TEST STRIP

3

ST; OTC; QL (306 per 30 days)

75

Drug Name

Drug Tier

Requirements / Limits

OPTUMRX STRIP

3

OTC; QL (306 per 30 days)

PHARMACIST CHOICE STRIP

3

OTC; QL (306 per 30 days)

PRECISION PCX PLUS TEST STRIP

3

ST; OTC; QL (306 per 30 days)

PRECISION PCX TEST STRIP

3

ST; OTC; QL (306 per 30 days)

PRECISION POINT OF CARE TEST STRIP

3

ST; OTC; QL (306 per 30 days)

PRECISION Q-I-D TEST STRIP

3

ST; OTC; QL (306 per 30 days)

PRECISION XTRA TEST STRIP

3

ST; OTC; QL (306 per 30 days)

PREMIUM V10 STRIP

3

OTC; QL (306 per 30 days)

PRODIGY NO CODING STRIP

3

OTC; QL (306 per 30 days)

QUINTET AC STRIP

3

OTC; QL (306 per 30 days)

REFUAH PLUS STRIP

3

OTC; QL (306 per 30 days)

RELION CONFIRM-MICRO STRIP

3

OTC; QL (306 per 30 days)

RELION PRIME TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

REVEAL TEST STRIP STRIP

3

OTC; QL (306 per 30 days)

RIGHTEST GS550 TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

SMART SENSE TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

SMARTEST TEST STRIP

3

OTC; QL (306 per 30 days)

SOLUS V2 TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

SURE-TEST EASYPLUS MINI STRIP

3

OTC; QL (306 per 30 days)

TELCARE TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

TEST N'GO TEST STRIP

3

OTC; QL (306 per 30 days)

TRUE METRIX GLUCOSE TEST STRIP STRIP

3

OTC; QL (306 per 30 days)

TRUETEST TEST STRIPS STRIP

3

OTC; QL (306 per 30 days)

TRUETRACK TEST STRIP

3

OTC; QL (306 per 30 days)

ULTIMA TEST STRIPS STRIP

3

ST; OTC; QL (306 per 30 days)

ULTRATRAK STRIP

3

OTC; QL (306 per 30 days)

ULTRATRAK ULTIMATE STRIP

3

OTC; QL (306 per 30 days)

UNISTRIP1 TEST STRIP STRIP

3

OTC; QL (306 per 30 days)

WAVESENSE JAZZ STRIP

3

OTC; QL (306 per 30 days)

WAVESENSE PRESTO STRIP

3

OTC; QL (306 per 30 days)

DIABETES, SUPPLIES, & DURABLE MEDICAL EQUIPMENT GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN

2

76

Drug Name

Drug Tier

Requirements / Limits

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT INJECTION RECON SOLN

2

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT

2

PROGLYCEM ORAL SUSPENSION

3

INSULIN SYRINGES/MISCELLANEOUS DURABLE MEDICAL EQU 1ST TIER UNIFINE PENTIPS NEEDLE

2

OTC; QL (1000 per 30 days)

1ST TIER UNILET COMFORTOUCH

2

OTC

ACCU-CHEK FASTCLIX

2

OTC

ACCU-CHEK SAFE-T-PRO

2

OTC

ACCU-CHEK SOFTCLIX LANCETS

2

OTC

ACTI-LANCE LANCETS

2

OTC

ADVANCED TRAVEL LANCETS

2

OTC

ADVOCATE LANCET

2

OTC

ADVOCATE PEN NEEDLES NEEDLE

2

OTC; QL (1000 per 30 days)

ALTERNATE SITE LANCET

2

OTC

ASSURE HAEMOLANCE PLUS

3

OTC

ASSURE LANCE

2

OTC

ASSURE LANCE PLUS

2

OTC

BD AUTOSHIELD PEN NEEDLE NEEDLE

2

OTC; QL (1000 per 30 days)

BD CURVED TONSIL REUSABLE NEEDLE

2

QL (1000 per 30 days)

BD ECLIPSE NEEDLE

2

QL (1000 per 30 days)

BD FILTER NEEDLE-5 MICRON NEEDLE

2

QL (1000 per 30 days)

BD INSULIN PEN NEEDLE UF SHORT NEEDLE

2

QL (1000 per 30 days)

BD INTEGRA NEEDLE NEEDLE

2

QL (1000 per 30 days)

BD MICROTAINER LANCET

2

OTC

BD NOKOR ADMIX NEEDLE NEEDLE

2

QL (1000 per 30 days)

BD PRECISIONGLIDE NEEDLE

2

QL (1000 per 30 days)

BD PRECISIONGLIDE NON-STERILE NEEDLE

2

QL (1000 per 30 days)

BD SAFETYGLIDE NEEDLE NEEDLE

2

QL (1000 per 30 days)

BD SPECIALTY USE NEEDLES NEEDLE

2

QL (1000 per 30 days)

77

Drug Name

Drug Tier

Requirements / Limits

BD ULTRA FINE LANCETS

2

OTC

BD ULTRA-FINE NANO PEN NEEDLES NEEDLE

2

OTC; QL (1000 per 30 days)

BD YALE REUSABLE REG METAL NEEDLE

2

QL (1000 per 30 days)

BLUNT NEEDLE, DISPOSABLE NEEDLE

2

QL (1000 per 30 days)

BULLSEYE MINI SAFETY LANCETS

2

OTC

CAREFINE PEN NEEDLE NEEDLE

3

OTC; QL (1000 per 30 days)

CAREONE THIN LANCET

2

OTC

CLEVER CHEK LANCETS

2

OTC

CLICKFINE NEEDLE

2

OTC; QL (1000 per 30 days)

COAGUCHEK LANCETS

2

OTC

COLOR LANCETS

2

OTC

COMFORT EZ PEN NEEDLES NEEDLE

2

OTC; QL (1000 per 30 days)

COMFORT LANCETS

2

OTC

DROPLET LANCETS

2

OTC

EASY COMFORT LANCETS

2

OTC

EASY COMFORT PEN NEEDLES NEEDLE

3

OTC; QL (1000 per 30 days)

EASY TOUCH FLIPLOCK NEEDLE NEEDLE

3

QL (1000 per 30 days)

EASY TOUCH HYPODERMIC NEEDLE NEEDLE

3

QL (1000 per 30 days)

EXEL HYPODERMIC NEEDLES NEEDLE

2

QL (1000 per 30 days)

e-z ject lancets

1

OTC

EZ SMART LANCETS

2

OTC

FIFTY50 SAFETY SEAL LANCETS

2

OTC

FINE 30 UNIVERSAL LANCETS

2

OTC

FINGERSTIX LANCETS

2

OTC

FIRST CHOICE LANCETS THIN

2

OTC

FLOW-EZE VENTED NEEDLE NEEDLE

2

QL (1000 per 30 days)

FORA V10-V12-D10-D20 COMBO PACK

3

OTC

FORACARE LANCETS

2

OTC

FREESTYLE LANCETS

2

OTC

FREESTYLE UNISTIK 2

2

OTC

GLUCOCOM LANCETS

2

OTC

GMATE LANCETS

2

OTC

78

Drug Name

Drug Tier

Requirements / Limits

HEALTHY ACCENTS UNIFINE PENTIP NEEDLE

2

OTC; QL (1000 per 30 days)

HEALTHY ACCENTS UNILET LANCET

2

OTC

huber safety needles (disp.) needle

1

QL (1000 per 30 days)

INCONTROL PEN NEEDLE NEEDLE

2

OTC; QL (1000 per 30 days)

INCONTROL SUPER THIN LANCETS

2

OTC

INCONTROL ULTRA THIN LANCETS

2

OTC

INJECT EASE LANCETS

2

OTC

INSUPEN NEEDLE

2

OTC; QL (1000 per 30 days)

INVACARE LANCETS

2

OTC

KINNEY BRAND LANCETS

2

OTC

LANCETS

2

OTC

LANCETS,THIN

2

OTC

LIFESHIELD BLUNT CANNULA NEEDLE

2

QL (1000 per 30 days)

LITE TOUCH LANCETS

2

OTC

MEDISENSE THIN LANCETS

2

OTC

MEDLANCE PLUS LANCETS

2

OTC

MEDLANCE PLUS SPECIAL BLADE

3

OTC

MICRO THIN LANCETS

2

OTC

MICROLET LANCET

2

OTC

MINI ULTRA-THIN II NEEDLE

2

OTC; QL (1000 per 30 days)

MONOJECT BLOOD COLLECTION NEEDLE

3

QL (1000 per 30 days)

MONOJECT HYPODERMIC NEEDLES NEEDLE

2

QL (1000 per 30 days)

MONOJECT MEDICATION TRANSF NDL NEEDLE

2

QL (1000 per 30 days)

MONOLET THIN LANCETS

2

OTC

MULTI-DRAW NEEDLE NEEDLE

2

QL (1000 per 30 days)

MYGLUCOHEALTH LANCETS

2

OTC

NEEDLES, HUBER DISPOSABLE NEEDLE

2

QL (1000 per 30 days)

NOKOR NEEDLE NEEDLE

2

QL (1000 per 30 days)

NOVA SAFETY LANCETS

2

OTC

NOVA SUREFLEX LANCETS

2

OTC

NOVOFINE 32 NEEDLE

2

OTC; QL (1000 per 30 days)

79

Drug Name

Drug Tier

Requirements / Limits

NOVOFINE AUTOCOVER NEEDLE

2

OTC; QL (1000 per 30 days)

NOVOFINE PLUS NEEDLE

3

OTC; QL (1000 per 30 days)

NOVOPEN ECHO SUBCUTANEOUS INSULIN PEN

3

NOVOTWIST NEEDLE

2

OTC; QL (1000 per 30 days)

ON CALL LANCET

2

OTC

ON CALL PLUS LANCET

2

OTC

ONETOUCH ULTRASOFT LANCETS

2

OTC

ON-THE-GO LANCETS

2

OTC

PEN NEEDLE NEEDLE

2

OTC; QL (1000 per 30 days)

PEN NEEDLE, DIABETIC NEEDLE

2

OTC; QL (1000 per 30 days)

PENTIPS NEEDLE

2

OTC; QL (1000 per 30 days)

PHASEAL PROTECTOR DEVICE

2

QL (1000 per 30 days)

POLY HUB NEEDLE NEEDLE

3

QL (1000 per 30 days)

PRESSURE ACTIVATED LANCETS

2

OTC

PRODIGY LANCETS

2

OTC

PRODIGY TWIST TOP LANCET

2

OTC

RELIAMED LANCET

2

OTC

RELIAMED SAFETY SEAL LANCETS

2

OTC

RELION NEEDLES NEEDLE

2

OTC; QL (1000 per 30 days)

RELION PEN NEEDLES NEEDLE

3

OTC; QL (1000 per 30 days)

RELION THIN LANCETS

2

OTC

RELION ULTRA THIN PLUS LANCETS

2

OTC

RIGHTEST GL300 LANCETS

2

OTC

SAFETY LANCETS

2

OTC

SAFETY SEAL LANCETS

2

OTC

SAFETY-LET LANCETS

2

OTC

SINGLE-LET

2

OTC

SMART SENSE LANCETS

2

OTC

SMARTEST LANCET

2

OTC

SOFT TOUCH LANCETS

2

OTC

SOLUS V2 LANCETS

2

OTC

STERILANCE TL

2

OTC

80

Drug Name

Drug Tier

Requirements / Limits

SUPER THIN LANCETS

2

OTC

SURE COMFORT LANCETS

2

OTC

SURE COMFORT PEN NEEDLE NEEDLE

2

OTC; QL (1000 per 30 days)

SURE-FINE PEN NEEDLES NEEDLE

2

OTC; QL (1000 per 30 days)

SURE-LANCE

2

OTC

SURE-TOUCH LANCET

2

OTC

SURGUARD2 SAFETY NEEDLE

2

QL (1000 per 30 days)

TECHLITE LANCETS

2

OTC

TECHLITE PEN NEEDLE NEEDLE

2

OTC; QL (1000 per 30 days)

TITUS NEEDLE NEEDLE

2

QL (1000 per 30 days)

TOPCARE UNIVERSAL1 LANCET

2

OTC

TRUEPLUS LANCETS

2

OTC

ULTICARE PEN NEEDLE NEEDLE

2

OTC; QL (1000 per 30 days)

ULTILET BASIC LANCETS

2

OTC

ULTILET CLASSIC LANCETS

2

OTC

ULTILET LANCETS

2

OTC

ULTILET PEN NEEDLE NEEDLE

2

OTC; QL (1000 per 30 days)

ULTILET SAFETY LANCETS

2

OTC

ULTRA THIN LANCETS

2

OTC

ULTRA THIN PLUS LANCETS

2

OTC

ULTRA TLC LANCETS

2

OTC

ULTRALANCE LANCETS

2

OTC

ULTRA-THIN II INS PEN NEEDLES NEEDLE

2

OTC; QL (1000 per 30 days)

UNIFINE PENTIPS NEEDLE

2

OTC; QL (1000 per 30 days)

UNIFINE PENTIPS PLUS NEEDLE

3

OTC; QL (1000 per 30 days)

UNILET COMFORTOUCH LANCET

2

OTC

UNILET EXCELITE II LANCET

2

OTC

UNILET EXCELITE LANCET

2

OTC

UNILET GP LANCET

2

OTC

UNILET LANCET

2

OTC

UNISTIK 3 EXTRA LANCET

2

OTC

UNISTIK CZT LANCET

2

OTC

UNISTIK SAFETY

2

OTC

81

Drug Name

Drug Tier

Requirements / Limits

UNISTIK TOUCH LANCETS

2

OTC

UNIVERSAL 1 LANCETS

2

OTC

VGO 20 DEVICE

2

VGO 30 DEVICE

2

VGO 40 DEVICE

2

INSULIN THERAPY AFREZZA INHALATION CARTRIDGE, W/INHALATION DEVICE

3

APIDRA SOLOSTAR SUBCUTANEOUS INSULIN PEN

3

ST

APIDRA SUBCUTANEOUS SOLUTION

3

ST

HUMALOG KWIKPEN SUBCUTANEOUS INSULIN PEN

3

ST

HUMALOG MIX 50-50 KWIKPEN SUBCUTANEOUS INSULIN PEN

3

HUMALOG MIX 50-50 SUBCUTANEOUS SUSPENSION

3

HUMALOG MIX 75-25 KWIKPEN SUBCUTANEOUS INSULIN PEN

3

ST

HUMALOG MIX 75-25 SUBCUTANEOUS SUSPENSION

3

ST

HUMALOG SUBCUTANEOUS CARTRIDGE

3

ST

HUMALOG SUBCUTANEOUS SOLUTION

3

ST

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN

3

ST

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION

3

ST

HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN

3

ST

HUMULIN N SUBCUTANEOUS SUSPENSION

3

ST

HUMULIN R INJECTION SOLUTION

3

ST

HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN

2

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION

2

LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN

2

82

Drug Name

Drug Tier

LANTUS SUBCUTANEOUS SOLUTION

2

LEVEMIR FLEXTOUCH SUBCUTANEOUS INSULIN PEN

2

LEVEMIR SUBCUTANEOUS SOLUTION

2

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION

2

NOVOLIN N SUBCUTANEOUS SUSPENSION

2

NOVOLIN R INJECTION SOLUTION

2

NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN

2

NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN

2

NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION

2

NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE

2

NOVOLOG SUBCUTANEOUS SOLUTION

2

TOUJEO SOLOSTAR SUBCUTANEOUS INSULIN PEN

2

Requirements / Limits

MISCELLANEOUS HORMONES ANADROL-50 ORAL TABLET

3

PA; #

ANDRODERM TRANSDERMAL PATCH 24 HOUR

3

PA; #; AGE-B

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP

2

PA; #; AGE-B

ANDROGEL TRANSDERMAL GEL IN PACKET

2

PA; #; AGE-B

ANDROID ORAL CAPSULE

3

PA; #

androxy oral tablet

1

PA; #

BRAVELLE INJECTION RECON SOLN

3

#

cabergoline oral tablet

1

calcitonin (salmon) nasal spray,non-aerosol

1

calcitriol oral capsule

1

calcitriol oral solution

1

CERDELGA ORAL CAPSULE

3

PA; SPRx

CETROTIDE SUBCUTANEOUS KIT

3

#

83

Drug Name

Drug Tier

Requirements / Limits

chorionic gonadotropin, human intramuscular recon soln

1

#

clomiphene citrate oral tablet

1

#

danazol oral capsule

1

#

DDAVP NASAL AEROSOL,SPRAY

3

DDAVP NASAL SOLUTION

3

DDAVP ORAL TABLET

3

DEPO-TESTOSTERONE INTRAMUSCULAR OIL

3

desmopressin nasal solution

1

desmopressin nasal spray,non-aerosol

1

desmopressin oral tablet

1

doxercalciferol oral capsule

1

FOLLISTIM AQ INJECTION SOLUTION

3

#

FOLLISTIM AQ SUBCUTANEOUS CARTRIDGE

3

#

fortical nasal spray,non-aerosol

1

GANIRELIX SUBCUTANEOUS SYRINGE

3

#

GONAL-F RFF REDI-JECT SUBCUTANEOUS PEN INJECTOR

3

#

GONAL-F RFF SUBCUTANEOUS RECON SOLN

3

#

GONAL-F SUBCUTANEOUS RECON SOLN

3

#

HECTOROL ORAL CAPSULE

3

KORLYM ORAL TABLET

3

PA; SPRx

KUVAN ORAL POWDER IN PACKET

3

SPRx

KUVAN ORAL TABLET,SOLUBLE

3

SPRx

MENOPUR SUBCUTANEOUS RECON SOLN

3

#

METHITEST ORAL TABLET

3

PA; #

methyltestosterone oral capsule

1

PA; #

MIACALCIN INJECTION SOLUTION

2

MIACALCIN NASAL SPRAY,NON-AEROSOL

3

MYALEPT SUBCUTANEOUS RECON SOLN

3

PA; SPRx

NATPARA SUBCUTANEOUS CARTRIDGE

3

PA; SPRx

novarel intramuscular recon soln

1

#

84

PA; #; AGE-B

Drug Name

Drug Tier

Requirements / Limits

OVIDREL SUBCUTANEOUS SYRINGE

3

#

OXANDRIN ORAL TABLET

3

PA; #

oxandrolone oral tablet

1

PA; #

paricalcitol oral capsule

1

PREGNYL INTRAMUSCULAR RECON SOLN

3

ROCALTROL ORAL CAPSULE

3

ROCALTROL ORAL SOLUTION

3

SAMSCA ORAL TABLET

3

SPRx

SENSIPAR ORAL TABLET

3

SPRx

SOMAVERT SUBCUTANEOUS RECON SOLN

3

SPRx

STIMATE NASAL SPRAY,NON-AEROSOL

3

SPRx

STRIANT BUCCAL MUCOADHESIVE SYSTEM ER 12 HR

3

PA; #; AGE-B

SYNAREL NASAL SPRAY,NON-AEROSOL

3

testosterone cypionate intramuscular oil

1

PA; #; AGE-B

testosterone enanthate intramuscular oil

1

PA; #; AGE-B

testosterone transdermal gel in metered-dose pump

1

PA; #; AGE-B

testosterone transdermal gel in packet

1

PA; #; AGE-B

TESTRED ORAL CAPSULE

3

PA; #

ZAVESCA ORAL CAPSULE

3

PA; SPRx

ZEMPLAR ORAL CAPSULE

3

NON-INSULIN HYPOGLYCEMIC AGENTS acarbose oral tablet

1

ACTOPLUS MET ORAL TABLET

3

ACTOPLUS MET XR ORAL TABLET, ER MULTIPHASE 24 HR

3

ACTOS ORAL TABLET

3

AMARYL ORAL TABLET

3

AVANDIA ORAL TABLET

3

BYDUREON SUBCUTANEOUS PEN INJECTOR

2

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON

2

BYETTA SUBCUTANEOUS PEN INJECTOR

2 85

#

Drug Name

Drug Tier

chlorpropamide oral tablet

1

CYCLOSET ORAL TABLET

3

DUETACT ORAL TABLET

3

FARXIGA ORAL TABLET

2

FORTAMET ORAL TABLET EXTENDED RELEASE 24HR

3

glimepiride oral tablet

1

glipizide oral tablet

1

glipizide oral tablet extended release 24hr

1

glipizide-metformin oral tablet

1

GLUCOPHAGE ORAL TABLET

3

GLUCOPHAGE XR ORAL TABLET EXTENDED RELEASE 24 HR

3

GLUCOTROL ORAL TABLET

3

GLUCOTROL XL ORAL TABLET EXTENDED RELEASE 24HR

3

GLUCOVANCE ORAL TABLET

3

glyburide micronized oral tablet

1

glyburide oral tablet

1

glyburide-metformin oral tablet

1

GLYNASE ORAL TABLET

3

GLYSET ORAL TABLET

3

GLYXAMBI ORAL TABLET

2

INVOKAMET ORAL TABLET

2

INVOKANA ORAL TABLET

2

JANUMET ORAL TABLET

2

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR

2

JANUVIA ORAL TABLET

2

JENTADUETO ORAL TABLET

2

metformin oral tablet

1

metformin oral tablet extended release 24 hr

1

metformin oral tablet extended release 24hr

1

nateglinide oral tablet

1 86

Requirements / Limits

Drug Name

Drug Tier

pioglitazone oral tablet

1

pioglitazone-glimepiride oral tablet

1

pioglitazone-metformin oral tablet

1

PRANDIN ORAL TABLET

3

PRECOSE ORAL TABLET

3

repaglinide oral tablet

1

repaglinide-metformin oral tablet

1

RIOMET ORAL SOLUTION

3

STARLIX ORAL TABLET

3

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR

3

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR

3

tolazamide oral tablet

1

tolbutamide oral tablet

1

TRADJENTA ORAL TABLET

2

VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR

2

XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR

2

THYROID HORMONES ARMOUR THYROID ORAL TABLET

3

CYTOMEL ORAL TABLET

3

levothyroxine oral tablet

1

levoxyl oral tablet

1

liothyronine oral tablet

1

nature-throid oral tablet

1

np thyroid oral tablet

1

SYNTHROID ORAL TABLET

3

THYROLAR-1 ORAL TABLET

3

THYROLAR-1/2 ORAL TABLET

3

THYROLAR-1/4 ORAL TABLET

3

THYROLAR-2 ORAL TABLET

3

THYROLAR-3 ORAL TABLET

3 87

Requirements / Limits

Drug Name

Drug Tier

unithroid oral tablet

1

westhroid oral tablet

1

WP THYROID ORAL TABLET

3

GASTROENTEROLOGY ANTIDIARRHEALS & ANTISPASMODICS anaspaz oral tablet,disintegrating

1

belladonna alkaloids-opium rectal suppository

1

belladonna-opium rectal suppository

1

BENTYL ORAL CAPSULE

3

BENTYL ORAL TABLET

3

chlordiazepoxide-clidinium oral capsule

1

CUVPOSA ORAL SOLUTION

3

dicyclomine oral capsule

1

dicyclomine oral solution

1

dicyclomine oral tablet

1

diphenoxylate-atropine oral liquid

1

diphenoxylate-atropine oral tablet

1

DONNATAL ORAL ELIXIR

3

DONNATAL ORAL TABLET

3

ed-spaz oral tablet,disintegrating

1

glycopyrrolate oral tablet

1

hyoscyamine sulfate oral drops

1

hyoscyamine sulfate oral elixir

1

hyoscyamine sulfate oral tablet

1

hyoscyamine sulfate oral tablet extended release 12 hr

1

hyoscyamine sulfate oral tablet,disintegrating

1

hyoscyamine sulfate sublingual tablet

1

hyosyne oral drops

1

hyosyne oral elixir

1

LEVBID ORAL TABLET EXTENDED RELEASE 12 HR

3

LEVSIN ORAL TABLET

3 88

Requirements / Limits

Drug Name

Drug Tier

LEVSIN/SL SUBLINGUAL TABLET

3

LIBRAX (WITH CLIDINIUM) ORAL CAPSULE

3

LOMOTIL ORAL TABLET

3

methscopolamine oral tablet

1

MOTOFEN ORAL TABLET

3

NULEV ORAL TABLET,DISINTEGRATING

3

opium tincture oral tincture

1

oscimin oral tablet

1

oscimin oral tablet,disintegrating

1

oscimin sl sublingual tablet

1

oscimin sr oral tablet extended release 12 hr

1

paregoric oral liquid

1

propantheline oral tablet

1

ROBINUL FORTE ORAL TABLET

3

ROBINUL ORAL TABLET

3

SYMAX DUOTAB ORAL TABLET,EXT RELEASE MULTIPHASE

3

symax fastabs oral tablet,disintegrating

1

symax-sl sublingual tablet

1

symax-sr oral tablet extended release 12 hr

1

MISCELLANEOUS GASTROINTESTINAL AGENTS ACTIGALL ORAL CAPSULE

3

alosetron oral tablet

1

AMITIZA ORAL CAPSULE

2

ANA-LEX KIT RECTAL KIT

3

ANALPRAM-HC RECTAL CREAM

2

ANALPRAM-HC SINGLES RECTAL CREAM

2

anucort-hc rectal suppository

1

ANUSOL-HC RECTAL CREAM

3

ANUSOL-HC RECTAL SUPPOSITORY

3

ANZEMET ORAL TABLET

3

APRISO ORAL CAPSULE,EXTENDED RELEASE 24HR

2

AURYXIA ORAL TABLET

3 89

Requirements / Limits

Drug Name

Drug Tier

Requirements / Limits

AZULFIDINE EN-TABS ORAL TABLET,DELAYED RELEASE (DR/EC)

3

AZULFIDINE ORAL TABLET

3

balsalazide oral capsule

1

bisacodyl oral tablet,delayed release (dr/ec)

1

budesonide oral capsule,delayed,extend.release

1

calcium acetate oral capsule

1

calcium acetate oral tablet

1

CANASA RECTAL SUPPOSITORY

2

CESAMET ORAL CAPSULE

3

CHENODAL ORAL TABLET

3

CHOLBAM ORAL CAPSULE

3

PA; SPRx

CIMZIA SUBCUTANEOUS SYRINGE KIT

3

PA; ST; SPRx

citrate of magnesia oral solution

1

ACA; OTC

COLAZAL ORAL CAPSULE

3

colocort rectal enema

1

COLYTE WITH FLAVOR PACKS ORAL RECON SOLN

3

COMPAZINE ORAL TABLET

3

COMPAZINE RECTAL SUPPOSITORY

3

compro rectal suppository

1

constulose oral solution

1

CORTENEMA RECTAL ENEMA

3

CORTIFOAM RECTAL FOAM

3

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC)

2

cromolyn oral concentrate

1

CYSTADANE ORAL POWDER

3

DIPENTUM ORAL CAPSULE

3

dronabinol oral capsule

1

eliphos oral tablet

1

EMEND ORAL CAPSULE

3

EMEND ORAL CAPSULE,DOSE PACK

3

ENTEREG ORAL CAPSULE

3 90

ACA; OTC

SPRx

Drug Name

Drug Tier

Requirements / Limits

ENTOCORT EC ORAL CAPSULE,DELAYED,EXTEND.RELEASE

3

enulose oral solution

1

FOSRENOL ORAL POWDER IN PACKET

3

FOSRENOL ORAL TABLET,CHEWABLE

3

GASTROCROM ORAL CONCENTRATE

3

GATTEX 30-VIAL SUBCUTANEOUS KIT

3

PA; SPRx

gavilyte-c oral recon soln

1

ACA

gavilyte-g oral recon soln

1

ACA

gavilyte-h and bisacodyl oral kit

1

ACA

gavilyte-n oral recon soln

1

ACA

generlac oral solution

1

GIAZO ORAL TABLET

3

GOLYTELY ORAL POWDER IN PACKET

3

GOLYTELY ORAL RECON SOLN

3

granisetron hcl oral tablet

1

hemmorex-hc rectal suppository

1

hydrocortisone acetate rectal suppository

1

hydrocortisone rectal cream

1

hydrocortisone rectal enema

1

hydrocortisone-pramoxine rectal cream

1

KAYEXALATE ORAL POWDER

3

kionex oral powder

1

kionex oral suspension

1

KRISTALOSE ORAL PACKET

2

lactulose oral solution

1

laxative peg 3350 oral powder

1

LIALDA ORAL TABLET,DELAYED RELEASE (DR/EC)

2

lidocaine hcl-hydrocortison ac rectal cream

1

lidocaine hcl-hydrocortison ac rectal kit

1

lidocaine-hydrocortisone-aloe rectal gel

1

lidocaine-hydrocortisone-aloe rectal kit

1

LINZESS ORAL CAPSULE

2 91

ACA

ACA; OTC

Drug Name

Drug Tier

Requirements / Limits

LOTRONEX ORAL TABLET

3

MAGNEBIND 400 ORAL TABLET

3

MARINOL ORAL CAPSULE

3

mesalamine rectal enema

1

mesalamine with cleansing wipe rectal enema kit

1

metoclopramide hcl oral solution

1

metoclopramide hcl oral tablet

1

MOVIPREP ORAL POWDER IN PACKET

3

NULYTELY WITH FLAVOR PACKS ORAL RECON SOLN

3

ondansetron hcl oral solution

1

ondansetron hcl oral tablet

1

ondansetron oral tablet,disintegrating

1

OSMOPREP ORAL TABLET

3

ACA

peg 3350-electrolytes oral recon soln

1

ACA

peg-3350 with flavor packs oral recon soln

1

ACA

peg-electrolyte soln oral recon soln

1

ACA

peg-prep oral kit

1

ACA

PENTASA ORAL CAPSULE, EXTENDED RELEASE

2

PHOSLO ORAL CAPSULE

3

PHOSLYRA ORAL SOLUTION

3

phosphate laxative oral liquid

1

ACA; OTC

polyethylene glycol 3350 oral powder

1

ACA

polyethylene glycol 3350 oral powder in packet

1

ACA

pramcort rectal cream

1

PREPOPIK ORAL POWDER IN PACKET

2

prochlorperazine maleate oral tablet

1

prochlorperazine rectal suppository

1

PROCORT RECTAL CREAM

3

PROCTOCORT RECTAL CREAM

3

PROCTOCORT RECTAL SUPPOSITORY

3

PROCTOFOAM HC RECTAL FOAM

3

procto-med hc rectal cream

1 92

ACA

ACA

Drug Name

Drug Tier

procto-pak rectal cream

1

proctosol hc rectal cream

1

proctozone-hc rectal cream

1

REGLAN ORAL TABLET

3

RELISTOR SUBCUTANEOUS SOLUTION

3

RELISTOR SUBCUTANEOUS SYRINGE

3

RENAGEL ORAL TABLET

3

RENVELA ORAL POWDER IN PACKET

3

RENVELA ORAL TABLET

3

ROWASA RECTAL ENEMA KIT

3

SFROWASA RECTAL ENEMA

3

sodium polystyrene sulfonate oral powder

1

sodium polystyrene sulfonate oral suspension

1

sodium polystyrene sulfonate rectal enema 30 gram/120 ml

1

SODIUM POLYSTYRENE SULFONATE RECTAL ENEMA 50 GRAM/200 ML

3

SOLESTA IMPLANT GEL FOR IMPLANT IN SYRINGE

3

sps oral suspension

1

sps rectal enema

1

SUCRAID ORAL SOLUTION

3

sulfasalazine oral tablet

1

sulfasalazine oral tablet,delayed release (dr/ec)

1

SUPREP BOWEL PREP KIT ORAL RECON SOLN

2

TIGAN ORAL CAPSULE

3

TRANSDERM-SCOP TRANSDERMAL PATCH 3 DAY

3

trilyte with flavor packets oral recon soln

1

trimethobenzamide oral capsule

1

UCERIS ORAL TABLET,DELAYED AND EXT.RELEASE

2

URSO 250 ORAL TABLET

3

URSO FORTE ORAL TABLET

3 93

Requirements / Limits

ACA

ACA

Drug Name

Drug Tier

ursodiol oral capsule

1

ursodiol oral tablet

1

VELPHORO ORAL TABLET,CHEWABLE

3

VIOKACE ORAL TABLET

3

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC)

2

ZOFRAN (AS HYDROCHLORIDE) ORAL SOLUTION

3

ZOFRAN (AS HYDROCHLORIDE) ORAL TABLET

3

ZOFRAN ODT ORAL TABLET,DISINTEGRATING

3

Requirements / Limits

ULCER THERAPY amoxicil-clarithromy-lansopraz oral combo pack

1

carafate oral suspension

1

CARAFATE ORAL TABLET

3

cimetidine hcl oral solution

1

cimetidine oral tablet

1

CYTOTEC ORAL TABLET

3

esomeprazole magnesium

1

famotidine oral tablet, oral suspension

1

lansoprazole oral capsule,delayed release(dr/ec)

1

misoprostol oral tablet

1

NEXIUM ORAL CAPSULE

2

NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET

2

nizatidine oral capsule, oral solution

1

OMECLAMOX-PAK ORAL COMBO PACK

3

omeprazole oral capsule,delayed release(dr/ec)

1

pantoprazole oral tablet,delayed release (dr/ec)

1

PEPCID ORAL SUSPENSION

3

PEPCID ORAL TABLET

3

PREVACID SOLUTAB ORAL TABLET,DISINTEGRAT, DELAY REL

3

PREVPAC ORAL COMBO PACK

3 94

GEN

GEN

Drug Name

Drug Tier

PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON

3

PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET

3

PROTONIX ORAL TABLET,DELAYED RELEASE (DR/EC)

3

PYLERA ORAL CAPSULE

3

ranitidine hcl oral capsule

1

ranitidine hcl oral syrup

1

ranitidine hcl oral tablet

1

sucralfate oral tablet

1

ZANTAC ORAL TABLET

3

Requirements / Limits

IMMUNOLOGY, VACCINES & BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ARANESP (IN POLYSORBATE) INJECTION SOLUTION

3

PA; SPRx

ARANESP (IN POLYSORBATE) INJECTION SYRINGE

3

PA; SPRx

EPOGEN INJECTION SOLUTION

3

PA; SPRx

MIRCERA INJECTION SYRINGE

3

PA; SPRx

MOZOBIL SUBCUTANEOUS SOLUTION

3

SPRx

NEULASTA SUBCUTANEOUS SYRINGE

3

SPRx

NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR

3

SPRx

NEUPOGEN INJECTION SOLUTION

3

SPRx

NEUPOGEN INJECTION SYRINGE

3

SPRx

PROCRIT INJECTION SOLUTION

3

PA; SPRx

ZARXIO INJECTION SYRINGE

3

SPRx

3

PA; SPRx; #

AUBAGIO ORAL TABLET

3

PA; SPRx

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT

2

SPRx

GROWTH HORMONES NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR

INTERFERONS

95

Drug Name

Drug Tier

Requirements / Limits

AVONEX INTRAMUSCULAR PEN INJECTOR KIT

2

SPRx

AVONEX INTRAMUSCULAR SYRINGE

2

SPRx

AVONEX INTRAMUSCULAR SYRINGE KIT

2

SPRx

BETASERON SUBCUTANEOUS KIT

3

ST; SPRx

COPAXONE SUBCUTANEOUS SYRINGE

2

SPRx

COPEGUS ORAL TABLET

3

PA; SPRx

EXTAVIA SUBCUTANEOUS KIT

3

SPRx

EXTAVIA SUBCUTANEOUS RECON SOLN

3

SPRx

GILENYA ORAL CAPSULE

2

PA; SPRx

glatopa subcutaneous syringe

1

SPRx

moderiba dose pack oral tablets,dose pack

1

PA; SPRx

moderiba oral tablet

1

PA; SPRx

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR

2

PA; SPRx

PEGASYS SUBCUTANEOUS SOLUTION

2

PA; SPRx

PEGASYS SUBCUTANEOUS SYRINGE

2

PA; SPRx

PEGINTRON REDIPEN SUBCUTANEOUS PEN INJECTOR KIT

3

PA; SPRx

PEGINTRON SUBCUTANEOUS KIT

3

PA; SPRx

PLEGRIDY SUBCUTANEOUS PEN INJECTOR

3

SPRx

PLEGRIDY SUBCUTANEOUS SYRINGE

3

SPRx

POMALYST ORAL CAPSULE

3

PA; SPRx

REBETOL ORAL SOLUTION

3

PA; SPRx

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE

2

SPRx

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR

2

SPRx

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE

2

SPRx

REVLIMID ORAL CAPSULE

3

PA; SPRx

ribasphere oral capsule

1

PA; SPRx

ribasphere oral tablet

1

PA; SPRx

ribavirin oral capsule

1

PA; SPRx

ribavirin oral tablet

1

PA; SPRx

96

Drug Name

Drug Tier

Requirements / Limits

SYLATRON SUBCUTANEOUS KIT

3

PA; SPRx

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC)

2

PA; SPRx

ACTIMMUNE SUBCUTANEOUS SOLUTION

3

PA; SPRx

ALDARA TOPICAL CREAM IN PACKET

3

ARCALYST SUBCUTANEOUS RECON SOLN

3

imiquimod topical cream in packet

1

INTRON A INJECTION RECON SOLN

3

PA; SPRx

INTRON A INJECTION SOLUTION

3

PA; SPRx

KINERET SUBCUTANEOUS SYRINGE

3

PA; ST; SPRx

INTERLEUKINS

SPRx

VACCINES & MISCELLANEOUS IMMUNOLOGICALS ACTHIB (PF) INTRAMUSCULAR RECON SOLN

3

ACA

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SUSPENSION

3

ACA

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE

3

ACA

AFLURIA 2015-2016 (PF) INTRAMUSCULAR SYRINGE

3

ACA

AFLURIA 2015-2016 INTRAMUSCULAR SUSPENSION

3

ACA

BCG VACCINE, LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

ACA

BEXSERO (PF) INTRAMUSCULAR SYRINGE

3

ACA

BIOTHRAX INTRAMUSCULAR SUSPENSION

3

ACA

BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION

3

ACA

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE

3

ACA

CERVARIX VACCINE (PF) INTRAMUSCULAR SYRINGE

3

ACA

DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION

3

ACA

97

Drug Name

Drug Tier

Requirements / Limits

ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION

3

ACA

ENGERIX-B (PF) INTRAMUSCULAR SYRINGE

3

ACA

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION

3

ACA

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE

3

ACA

EZ FLU 2015-16 (FLUVIRIN) (PF) INTRAMUSCULAR SYRINGE KIT

3

ACA

EZ FLU 2015-16(FLUCELVAX)(PF) INTRAMUSCULAR SYRINGE KIT

3

ACA

FLUARIX QUAD 2015-2016 (PF) INTRAMUSCULAR SYRINGE

3

ACA

FLUBLOK 2015-2016 (PF) INTRAMUSCULAR SOLUTION

3

ACA

FLUCELVAX 2015-2016 (PF) INTRAMUSCULAR SYRINGE

3

ACA

FLULAVAL QUAD 2015-2016 INTRAMUSCULAR SUSPENSION

3

ACA

FLUMIST QUAD 2015-2016 NASAL NASAL SPRAY SYRINGE

3

ACA

FLUVIRIN 2015-2016 (PF) INTRAMUSCULAR SYRINGE

3

ACA

FLUVIRIN 2015-2016 INTRAMUSCULAR SUSPENSION

3

ACA

FLUZONE 2015-2016 INTRAMUSCULAR SUSPENSION

3

ACA

FLUZONE HIGH-DOSE 2015-16 (PF) INTRAMUSCULAR SYRINGE

3

ACA

FLUZONE INTRADERM QUAD 2015-16 INTRADERMAL SYRINGE

3

ACA

FLUZONE QUAD 2015-2016 (PF) INTRAMUSCULAR SUSPENSION

3

ACA

FLUZONE QUAD 2015-2016 (PF) INTRAMUSCULAR SYRINGE

3

ACA

FLUZONE QUAD 2015-2016 INTRAMUSCULAR SUSPENSION

3

ACA

98

Drug Name

Drug Tier

Requirements / Limits

FLUZONE QUAD PEDI 2015-16 (PF) INTRAMUSCULAR SYRINGE

3

ACA

GAMMAGARD LIQUID INJECTION SOLUTION

3

PA; SPRx

GAMUNEX-C INJECTION SOLUTION

3

PA; SPRx

GARDASIL (PF) INTRAMUSCULAR SUSPENSION

3

ACA

GARDASIL (PF) INTRAMUSCULAR SYRINGE

3

ACA

GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION

3

ACA

GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE

3

ACA

GRASTEK SUBLINGUAL TABLET

3

PA

HAVRIX (PF) INTRAMUSCULAR SUSPENSION

3

ACA

HAVRIX (PF) INTRAMUSCULAR SYRINGE

3

ACA

HIZENTRA SUBCUTANEOUS SOLUTION

3

PA; SPRx

HYQVIA SUBCUTANEOUS SOLUTION

3

PA; SPRx

IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN

3

ACA

INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION

3

ACA

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

3

ACA

IPOL INJECTION SUSPENSION

3

ACA

IXIARO (PF) INTRAMUSCULAR SYRINGE

3

ACA

KINRIX (PF) INTRAMUSCULAR SUSPENSION

3

ACA

KINRIX (PF) INTRAMUSCULAR SYRINGE

3

ACA

MENACTRA (PF) INTRAMUSCULAR SOLUTION

3

ACA

MENHIBRIX (PF) INTRAMUSCULAR RECON SOLN

3

ACA

MENOMUNE - A/C/Y/W-135 (PF) SUBCUTANEOUS RECON SOLN

3

ACA

MENOMUNE - A/C/Y/W-135 SUBCUTANEOUS RECON SOLN

3

ACA

99

Drug Name

Drug Tier

Requirements / Limits

MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT

3

ACA

M-M-R II (PF) SUBCUTANEOUS RECON SOLN

3

ACA

ORALAIR SUBLINGUAL TABLET

3

PA; SPRx

PEDIARIX (PF) INTRAMUSCULAR SYRINGE

3

ACA

PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION

3

ACA

PENTACEL (PF) INTRAMUSCULAR KIT

3

ACA

PNEUMOVAX 23 INJECTION SOLUTION

3

ACA

PNEUMOVAX 23 INJECTION SYRINGE

3

ACA

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE

3

ACA

PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

ACA

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION

3

ACA

RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION

3

ACA

RAGWITEK SUBLINGUAL TABLET

3

PA

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION

3

ACA

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE

3

ACA

ROTARIX ORAL SUSPENSION FOR RECONSTITUTION

3

ACA

ROTATEQ VACCINE ORAL SUSPENSION

3

ACA

TENIVAC (PF) INTRAMUSCULAR SUSPENSION

3

ACA

TENIVAC (PF) INTRAMUSCULAR SYRINGE

3

ACA

TETANUS,DIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION

3

ACA

TETANUS-DIPHTHERIA TOXOIDS-TD INTRAMUSCULAR SUSPENSION

3

ACA

TRUMENBA INTRAMUSCULAR SYRINGE

3

ACA

TWINRIX (PF) INTRAMUSCULAR SUSPENSION

3

ACA

100

Drug Name

Drug Tier

Requirements / Limits

TWINRIX (PF) INTRAMUSCULAR SYRINGE

3

ACA

TYPHIM VI INTRAMUSCULAR SOLUTION

3

ACA

TYPHIM VI INTRAMUSCULAR SYRINGE

3

ACA

VAQTA (PF) INTRAMUSCULAR SUSPENSION

3

ACA

VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

ACA

VIVOTIF BERNA VACCINE ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

ACA

VIVOTIF ORAL CAPSULE,DELAYED RELEASE(DR/EC)

3

ACA

YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

ACA

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION

3

ACA

MUSCULOSKELETAL & RHEUMATOLOGY GOUT THERAPY allopurinol oral tablet

1

colchicine-probenecid oral tablet

1

COLCRYS ORAL TABLET

2

probenecid oral tablet

1

ULORIC ORAL TABLET

2

ZYLOPRIM ORAL TABLET

3

OSTEOPOROSIS THERAPY ACTONEL ORAL TABLET

3

alendronate oral solution

1

alendronate oral tablet

1

ATELVIA ORAL TABLET,DELAYED RELEASE (DR/EC)

3

BINOSTO ORAL TABLET, EFFERVESCENT

3

BONIVA ORAL TABLET

3

EVISTA ORAL TABLET

3

FORTEO SUBCUTANEOUS PEN INJECTOR

2

FOSAMAX ORAL TABLET

3

FOSAMAX PLUS D ORAL TABLET

3 101

SPRx

Drug Name

Drug Tier

ibandronate oral tablet

1

raloxifene oral tablet

1

risedronate oral tablet

1

risedronate oral tablet,delayed release (dr/ec)

1

Requirements / Limits ACA

OTHER RHEUMATOLOGICALS ACTEMRA SUBCUTANEOUS SYRINGE

3

ARAVA ORAL TABLET

3

DEPEN TITRATABS ORAL TABLET

3

ENBREL SUBCUTANEOUS RECON SOLN

3

PA; SPRx

ENBREL SUBCUTANEOUS SYRINGE

3

PA; SPRx

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR

3

PA; SPRx

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT

3

PA; SPRx; QL (2 per 30 days)

HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT

3

PA; SPRx; QL (2 per 30 days)

HUMIRA SUBCUTANEOUS SYRINGE KIT

3

PA; SPRx; QL (2 per 30 days)

leflunomide oral tablet

1

ORENCIA SUBCUTANEOUS SYRINGE

3

PA; ST; SPRx; QL (4 per 30 days)

OTEZLA ORAL TABLET

3

PA; ST; SPRx

OTEZLA STARTER ORAL TABLETS,DOSE PACK

3

PA; ST; SPRx

RIDAURA ORAL CAPSULE

3

SAVELLA ORAL TABLET

2

SAVELLA ORAL TABLETS,DOSE PACK

2

SIMPONI SUBCUTANEOUS PEN INJECTOR

3

PA; ST; SPRx

SIMPONI SUBCUTANEOUS SYRINGE

3

PA; ST; SPRx

XELJANZ ORAL TABLET

3

PA; ST; SPRx

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR

3

PA; ST; SPRx

OBSTETRICS & GYNECOLOGY ESTROGENS & PROGESTINS ALORA TRANSDERMAL PATCH SEMIWEEKLY

3

ANGELIQ ORAL TABLET

3 102

PA; SPRx

Drug Name

Drug Tier

Requirements / Limits

AYGESTIN ORAL TABLET

3

camila oral tablet

1

CLIMARA PRO TRANSDERMAL PATCH WEEKLY

3

CLIMARA TRANSDERMAL PATCH WEEKLY

3

COMBIPATCH TRANSDERMAL PATCH SEMIWEEKLY

3

covaryx h.s. oral tablet

1

covaryx oral tablet

1

CRINONE VAGINAL GEL

3

#

deblitane oral tablet

1

ACA

DELESTROGEN INTRAMUSCULAR OIL

3

DEPO-ESTRADIOL INTRAMUSCULAR OIL

3

DEPO-PROVERA INTRAMUSCULAR SOLUTION

3

DEPO-PROVERA INTRAMUSCULAR SUSPENSION

3

ACA

DEPO-PROVERA INTRAMUSCULAR SYRINGE

3

ACA

DEPO-SUBQ PROVERA 104 SUBCUTANEOUS SYRINGE

3

ACA

DIVIGEL TRANSDERMAL GEL IN PACKET

2

DUAVEE ORAL TABLET

3

eemt hs oral tablet

1

eemt oral tablet

1

ELESTRIN TRANSDERMAL GEL IN METERED-DOSE PUMP

3

ENJUVIA ORAL TABLET

2

errin oral tablet

1

ESTRACE ORAL TABLET

3

ESTRACE VAGINAL CREAM

3

estradiol oral tablet

1

estradiol transdermal patch semiweekly

1

estradiol transdermal patch weekly

1

estradiol valerate intramuscular oil

1 103

ACA

ACA

Drug Name

Drug Tier

Requirements / Limits

estradiol-norethindrone acet oral tablet

1

ESTRING VAGINAL RING

3

ESTROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP

3

estrogens-methyltestosterone oral tablet

1

estropipate oral tablet

1

EVAMIST TRANSDERMAL SPRAY,NONAEROSOL

2

FEMHRT LOW DOSE ORAL TABLET

3

FEMRING VAGINAL RING

3

fyavolv oral tablet

1

heather oral tablet

1

ACA

jencycla oral tablet

1

ACA

jevantique lo oral tablet

1

ACA

jinteli oral tablet

1

ACA

jolivette oral tablet

1

ACA

lopreeza oral tablet

1

lyza oral tablet

1

ACA

medroxyprogesterone intramuscular suspension

1

ACA

medroxyprogesterone intramuscular syringe

1

ACA

medroxyprogesterone oral tablet

1

MENEST ORAL TABLET

3

MENOSTAR TRANSDERMAL PATCH WEEKLY

3

mimvey lo oral tablet

1

mimvey oral tablet

1

MINIVELLE TRANSDERMAL PATCH SEMIWEEKLY

3

nora-be oral tablet

1

ACA

norethindrone (contraceptive) oral tablet

1

ACA

norethindrone acetate oral tablet

1

norethindrone ac-eth estradiol oral tablet

1

ACA

norlyroc oral tablet

1

ACA

NOR-QD ORAL TABLET

3

ACA

104

Drug Name

Drug Tier

ORTHO MICRONOR ORAL TABLET

3

PREFEST ORAL TABLET

3

PREMARIN ORAL TABLET

2

PREMARIN VAGINAL CREAM

2

PREMPHASE ORAL TABLET

2

PREMPRO ORAL TABLET

2

progesterone micronized oral capsule

1

PROMETRIUM ORAL CAPSULE

3

PROVERA ORAL TABLET

3

sharobel oral tablet

1

VAGIFEM VAGINAL TABLET

2

VIVELLE-DOT TRANSDERMAL PATCH SEMIWEEKLY

3

Requirements / Limits ACA

ACA

MISCELLANEOUS OB/GYN AVC VAGINAL VAGINAL CREAM

3

CLEOCIN VAGINAL CREAM

3

CLEOCIN VAGINAL SUPPOSITORY

2

clindamycin phosphate vaginal cream

1

CLINDESSE VAGINAL CREAM,EXTENDED RELEASE

3

fem ph vaginal gel

1

GYNAZOLE-1 VAGINAL CREAM

3

isoxsuprine oral tablet

1

LUPANETA PACK (1 MONTH) KIT. SYRINGE AND TABLET

3

PA; SPRx

LUPANETA PACK (3 MONTH) KIT. SYRINGE AND TABLET

3

PA; SPRx

LYSTEDA ORAL TABLET

3

METROGEL VAGINAL VAGINAL GEL

3

metronidazole vaginal gel

1

miconazole-3 vaginal suppository

1

NUVARING VAGINAL RING

2

NUVESSA VAGINAL GEL

3

OSPHENA ORAL TABLET

2 105

ACA

Drug Name

Drug Tier

Requirements / Limits

RELAGARD VAGINAL GEL

3

TERAZOL 3 VAGINAL CREAM

3

TERAZOL 7 VAGINAL CREAM

3

terconazole vaginal cream

1

terconazole vaginal suppository

1

tranexamic acid oral tablet

1

vandazole vaginal gel

1

xulane transdermal patch weekly

1

ACA

altavera (28) oral tablet

1

ACA

alyacen 1/35 (28) oral tablet

1

ACA

alyacen 7/7/7 (28) oral tablet

1

ACA

amethia lo oral tablets,dose pack,3 month

1

ACA

amethia oral tablets,dose pack,3 month

1

ACA

amethyst oral tablet

1

ACA

apri oral tablet

1

ACA

aranelle (28) oral tablet

1

ACA

ashlyna oral tablets,dose pack,3 month

1

ACA

aubra oral tablet

1

ACA

aviane oral tablet

1

ACA

azurette (28) oral tablet

1

ACA

balziva (28) oral tablet

1

ACA

bekyree (28) oral tablet

1

ACA

BEYAZ ORAL TABLET

3

ACA

blisovi 24 fe oral tablet

1

ACA

blisovi fe 1.5/30 (28) oral tablet

1

ACA

blisovi fe 1/20 (28) oral tablet

1

ACA

BREVICON (28) ORAL TABLET

3

briellyn oral tablet

1

ACA

camrese lo oral tablets,dose pack,3 month

1

ACA

camrese oral tablets,dose pack,3 month

1

ACA

caziant (28) oral tablet

1

ACA

chateal oral tablet

1

ACA

ORAL CONTRACEPTIVES & RELATED AGENTS

106

Drug Name

Drug Tier

Requirements / Limits

cryselle (28) oral tablet

1

ACA

cyclafem 1/35 (28) oral tablet

1

ACA

cyclafem 7/7/7 (28) oral tablet

1

ACA

CYCLESSA (28) ORAL TABLET

3

cyred oral tablet

1

ACA

dasetta 1/35 (28) oral tablet

1

ACA

dasetta 7/7/7 (28) oral tablet

1

ACA

daysee oral tablets,dose pack,3 month

1

ACA

delyla (28) oral tablet

1

ACA

desog-e.estradiol/e.estradiol oral tablet

1

ACA

DESOGEN ORAL TABLET

3

desogestrel-ethinyl estradiol oral tablet

1

ACA

drospirenone-ethinyl estradiol oral tablet

1

ACA

elinest oral tablet

1

ACA

ELLA ORAL TABLET

3

ACA; QL (2 per 1 day)

emoquette oral tablet

1

ACA

enpresse oral tablet

1

ACA

enskyce oral tablet

1

ACA

estarylla oral tablet

1

ACA

ESTROSTEP FE-28 ORAL TABLET

3

falmina (28) oral tablet

1

FEMCON FE ORAL TABLET,CHEWABLE

3

GENERESS FE ORAL TABLET,CHEWABLE

3

gianvi (28) oral tablet

1

ACA

gildagia oral tablet

1

ACA

gildess 1.5/30 (21) oral tablet

1

ACA

gildess 1/20 (21) oral tablet

1

ACA

gildess 24 fe oral tablet

1

ACA

gildess fe 1.5/30 (28) oral tablet

1

ACA

gildess fe 1/20 (28) oral tablet

1

ACA

introvale oral tablets,dose pack,3 month

1

ACA

jolessa oral tablets,dose pack,3 month

1

ACA

juleber oral tablet

1

ACA

107

ACA

Drug Name

Drug Tier

Requirements / Limits

junel 1.5/30 (21) oral tablet

1

ACA

junel 1/20 (21) oral tablet

1

ACA

junel fe 1.5/30 (28) oral tablet

1

ACA

junel fe 1/20 (28) oral tablet

1

ACA

junel fe 24 oral tablet

1

ACA

kaitlib fe oral tablet,chewable

1

ACA

kariva (28) oral tablet

1

ACA

kelnor 1/35 (28) oral tablet

1

ACA

kimidess (28) oral tablet

1

ACA

kurvelo oral tablet

1

ACA

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month

1

ACA

larin 1.5/30 (21) oral tablet

1

ACA

larin 1/20 (21) oral tablet

1

ACA

larin 24 fe oral tablet

1

ACA

larin fe 1.5/30 (28) oral tablet

1

ACA

larin fe 1/20 (28) oral tablet

1

ACA

layolis fe oral tablet,chewable

1

ACA

leena 28 oral tablet

1

ACA

lessina oral tablet

1

ACA

levonest (28) oral tablet

1

ACA

levonorgestrel-ethinyl estrad oral tablet

1

ACA

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month

1

ACA

levonorg-eth estrad triphasic oral tablet

1

ACA

levora-28 oral tablet

1

ACA

LO LOESTRIN FE ORAL TABLET

2

ACA

LOESTRIN 1.5/30 (21) ORAL TABLET

3

LOESTRIN 1/20 (21) ORAL TABLET

3

LOESTRIN FE 1.5/30 (28-DAY) ORAL TABLET

3

LOESTRIN FE 1/20 (28-DAY) ORAL TABLET

3

lomedia 24 fe oral tablet

1

ACA

loryna (28) oral tablet

1

ACA

108

Drug Name

Drug Tier

Requirements / Limits

LOSEASONIQUE ORAL TABLETS,DOSE PACK,3 MONTH

3

low-ogestrel (28) oral tablet

1

ACA

lutera (28) oral tablet

1

ACA

marlissa oral tablet

1

ACA

microgestin 1.5/30 (21) oral tablet

1

ACA

microgestin 1/20 (21) oral tablet

1

ACA

MICROGESTIN 24 FE ORAL TABLET

3

microgestin fe 1.5/30 (28) oral tablet

1

ACA

microgestin fe 1/20 (28) oral tablet

1

ACA

MINASTRIN 24 FE ORAL TABLET,CHEWABLE

2

ACA

MIRCETTE (28) ORAL TABLET

3

MODICON (28) ORAL TABLET

3

mono-linyah oral tablet

1

ACA

mononessa (28) oral tablet

1

ACA

myzilra oral tablet

1

ACA

NATAZIA ORAL TABLET

3

ACA

necon 0.5/35 (28) oral tablet

1

ACA

necon 1/35 (28) oral tablet

1

ACA

necon 1/50 (28) oral tablet

1

ACA

necon 10/11 (28) oral tablet

1

ACA

necon 7/7/7 (28) oral tablet

1

ACA

nikki (28) oral tablet

1

ACA

noreth-ethinyl estradiol-iron oral tablet,chewable

1

ACA

norethindrone ac-eth estradiol oral tablet

1

ACA

norethindrone-e.estradiol-iron oral tablet

1

ACA

norgestimate-ethinyl estradiol oral tablet

1

ACA

NORINYL 1+35 (28) ORAL TABLET

3

NORINYL 1+50 (28) ORAL TABLET

3

nortrel 0.5/35 (28) oral tablet

1

ACA

nortrel 1/35 (21) oral tablet

1

ACA

nortrel 7/7/7 (28) oral tablet

1

ACA

ocella oral tablet

1

ACA

109

Drug Name

Drug Tier

Requirements / Limits

ogestrel (28) oral tablet

1

ACA

orsythia oral tablet

1

ACA

ORTHO TRI-CYCLEN (28) ORAL TABLET

3

ORTHO TRI-CYCLEN LO (28) ORAL TABLET

3

ORTHO-CYCLEN (28) ORAL TABLET

3

ORTHO-NOVUM 1/35 (28) ORAL TABLET

3

ORTHO-NOVUM 7/7/7 (28) ORAL TABLET

3

OVCON-35 (28) ORAL TABLET

3

philith oral tablet

1

ACA

pimtrea (28) oral tablet

1

ACA

pirmella oral tablet

1

ACA

portia oral tablet

1

ACA

previfem oral tablet

1

ACA

QUARTETTE ORAL TABLETS,DOSE PACK,3 MONTH

3

ACA

quasense oral tablets,dose pack,3 month

1

ACA

reclipsen (28) oral tablet

1

ACA

SAFYRAL ORAL TABLET

3

ACA

SEASONIQUE ORAL TABLETS,DOSE PACK,3 MONTH

3

setlakin oral tablets,dose pack,3 month

1

ACA

sprintec (28) oral tablet

1

ACA

sronyx oral tablet

1

ACA

syeda oral tablet

1

ACA

tarina fe 1/20 (28) oral tablet

1

ACA

tilia fe oral tablet

1

ACA

tri-estarylla oral tablet

1

ACA

tri-legest fe oral tablet

1

ACA

tri-linyah oral tablet

1

ACA

tri-lo-estarylla oral tablet

1

ACA

tri-lo-marzia oral tablet

1

ACA

tri-lo-sprintec oral tablet

1

ACA

trinessa (28) oral tablet

1

ACA

trinessa lo oral tablet

1

ACA

110

ACA

Drug Name

Drug Tier

Requirements / Limits

TRI-NORINYL (28) ORAL TABLET

3

tri-previfem (28) oral tablet

1

ACA

tri-sprintec (28) oral tablet

1

ACA

trivora (28) oral tablet

1

ACA

velivet triphasic regimen (28) oral tablet

1

ACA

vestura (28) oral tablet

1

ACA

vienva oral tablet

1

ACA

viorele (28) oral tablet

1

ACA

vyfemla (28) oral tablet

1

ACA

wera (28) oral tablet

1

ACA

wymzya fe oral tablet,chewable

1

ACA

YASMIN (28) ORAL TABLET

3

YAZ (28) ORAL TABLET

3

zarah oral tablet

1

ACA

zenchent (28) oral tablet

1

ACA

zenchent fe oral tablet,chewable

1

ACA

zovia 1/35e (28) oral tablet

1

ACA

zovia 1/50e (28) oral tablet

1

ACA

OXYTOCICS methylergonovine oral tablet

1

OPHTHALMOLOGY ANTIBIOTICS AZASITE OPHTHALMIC DROPS

3

bacitracin ophthalmic ointment

1

bacitracin-polymyxin b ophthalmic ointment

1

BETADINE OPHTHALMIC PREP OPHTHALMIC SOLUTION

3

CILOXAN OPHTHALMIC OINTMENT

3

ciprofloxacin hcl ophthalmic drops

1

erythromycin ophthalmic ointment

1

gatifloxacin ophthalmic drops

1

gentak ophthalmic ointment

1

gentamicin ophthalmic drops

1 111

Drug Name

Drug Tier

gentamicin ophthalmic ointment

1

ILOTYCIN OPHTHALMIC OINTMENT

3

levofloxacin ophthalmic drops

1

MOXEZA OPHTHALMIC DROPS, VISCOUS

2

NATACYN OPHTHALMIC DROPS,SUSPENSION

3

neomycin-bacitracin-polymyxin ophthalmic ointment

1

neomycin-polymyxin-gramicidin ophthalmic drops

1

neo-polycin ophthalmic ointment

1

NEOSPORIN (NEO-POLYM-GRAMICID) OPHTHALMIC DROPS

3

OCUFLOX OPHTHALMIC DROPS

3

ofloxacin ophthalmic drops

1

polycin ophthalmic ointment

1

polymyxin b sulf-trimethoprim ophthalmic drops

1

POLYTRIM OPHTHALMIC DROPS

3

tobramycin ophthalmic drops

1

TOBREX OPHTHALMIC OINTMENT

3

VIGAMOX OPHTHALMIC DROPS

2

ANTIVIRALS trifluridine ophthalmic drops

1

VIROPTIC OPHTHALMIC DROPS

3

ZIRGAN OPHTHALMIC GEL

3

BETA-BLOCKERS BETAGAN OPHTHALMIC DROPS

3

betaxolol ophthalmic drops

1

BETIMOL OPHTHALMIC DROPS

2

BETOPTIC S OPHTHALMIC DROPS,SUSPENSION

3

carteolol ophthalmic drops

1

ISTALOL OPHTHALMIC DROPS, ONCE DAILY

3

levobunolol ophthalmic drops

1

metipranolol ophthalmic drops

1 112

Requirements / Limits

Drug Name

Drug Tier

timolol maleate ophthalmic drops

1

timolol maleate ophthalmic gel forming solution

1

TIMOPTIC OCUDOSE (PF) OPHTHALMIC DROPPERETTE

3

TIMOPTIC OPHTHALMIC DROPS

3

TIMOPTIC-XE OPHTHALMIC GEL FORMING SOLUTION

3

CHOLINESTERASE INHIBITOR MIOTICS PHOSPHOLINE IODIDE OPHTHALMIC DROPS

3

CYCLOPLEGIC MYDRIATICS atropine ophthalmic drops

1

atropine ophthalmic ointment

1

CYCLOGYL OPHTHALMIC DROPS

3

cyclopentolate ophthalmic drops

1

homatropaire ophthalmic drops

1

homatropine hbr ophthalmic drops

1

ISOPTO ATROPINE OPHTHALMIC DROPS

3

MYDRIACYL OPHTHALMIC DROPS

3

PAREMYD OPHTHALMIC DROPS

3

tropicamide ophthalmic drops

1

DIRECT ACTING MIOTICS ISOPTO CARPINE OPHTHALMIC DROPS

3

MIOCHOL-E INTRAOCULAR KIT

3

pilocarpine hcl ophthalmic drops

1

MISCELLANEOUS OPHTHALMOLOGICS acuicyn topical spray,non-aerosol

1

AKTEN (PF) OPHTHALMIC GEL

3

ALCAINE OPHTHALMIC DROPS

3

ALOCRIL OPHTHALMIC DROPS

3

ALOMIDE OPHTHALMIC DROPS

3

altacaine ophthalmic drops

1

altafluor ophthalmic drops

1

AVENOVA TOPICAL SPRAY,NON-AEROSOL

3 113

Requirements / Limits

Drug Name

Drug Tier

azelastine ophthalmic drops

1

BEPREVE OPHTHALMIC DROPS

2

cromolyn ophthalmic drops

1

CYSTARAN OPHTHALMIC DROPS

3

ELESTAT OPHTHALMIC DROPS

3

EMADINE OPHTHALMIC DROPS

3

epinastine ophthalmic drops

1

flucaine ophthalmic drops

1

fluorescein-benoxinate ophthalmic drops

1

fluorescein-proparacaine ophthalmic drops

1

flurox ophthalmic drops

1

LASTACAFT OPHTHALMIC DROPS

3

olopatadine ophthalmic drops

1

PATADAY OPHTHALMIC DROPS

2

PATANOL OPHTHALMIC DROPS

2

PAZEO OPHTHALMIC DROPS

2

proparacaine ophthalmic drops

1

RESTASIS OPHTHALMIC DROPPERETTE

2

tetcaine ophthalmic drops

1

tetracaine hcl (pf) ophthalmic drops

1

tetracaine hcl ophthalmic drops

1

TETRAVISC FORTE OPHTHALMIC DROPS,HYPERVISCOUS

3

TETRAVISC OPHTHALMIC DROPPERETTE,VISCOUS

3

TETRAVISC OPHTHALMIC DROPS, VISCOUS

3

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS ACULAR LS OPHTHALMIC DROPS

3

ACULAR OPHTHALMIC DROPS

3

bromfenac ophthalmic drops

1

diclofenac sodium ophthalmic drops

1

flurbiprofen sodium ophthalmic drops

1

ketorolac ophthalmic drops

1 114

Requirements / Limits

Drug Name

Drug Tier

OCUFEN OPHTHALMIC DROPS

3

PROLENSA OPHTHALMIC DROPS

2

Requirements / Limits

ORAL DRUGS FOR GLAUCOMA acetazolamide oral capsule, extended release

1

acetazolamide oral tablet

1

DIAMOX SEQUELS ORAL CAPSULE, EXTENDED RELEASE

3

methazolamide oral tablet

1

NEPTAZANE ORAL TABLET

3

OTHER GLAUCOMA DRUGS AZOPT OPHTHALMIC DROPS,SUSPENSION

2

bimatoprost ophthalmic drops

1

COMBIGAN OPHTHALMIC DROPS

3

COSOPT (PF) OPHTHALMIC DROPPERETTE

3

COSOPT OPHTHALMIC DROPS

3

dorzolamide ophthalmic drops

1

dorzolamide-timolol ophthalmic drops

1

latanoprost ophthalmic drops

1

LUMIGAN OPHTHALMIC DROPS

2

miostat intraocular solution

1

MITOSOL OPHTHALMIC KIT

3

RESCULA OPHTHALMIC DROPS

3

SIMBRINZA OPHTHALMIC DROPS,SUSPENSION

3

TRAVATAN Z OPHTHALMIC DROPS

2

travoprost (benzalkonium) ophthalmic drops

1

TRUSOPT OPHTHALMIC DROPS

3

XALATAN OPHTHALMIC DROPS

3

ST

ZIOPTAN (PF) OPHTHALMIC DROPPERETTE

3

ST

STEROID-ANTIBIOTIC COMBINATIONS MAXITROL OPHTHALMIC DROPS,SUSPENSION

3

MAXITROL OPHTHALMIC OINTMENT

3

neomycin-bacitracin-poly-hc ophthalmic ointment

1 115

ST

Drug Name

Drug Tier

neomycin-polymyxin b-dexameth ophthalmic drops,suspension

1

neomycin-polymyxin b-dexameth ophthalmic ointment

1

neomycin-polymyxin-hc ophthalmic drops,suspension

1

neo-polycin hc ophthalmic ointment

1

PRED-G OPHTHALMIC DROPS,SUSPENSION

3

PRED-G S.O.P. OPHTHALMIC OINTMENT

3

TOBRADEX OPHTHALMIC OINTMENT

2

TOBRADEX ST OPHTHALMIC DROPS,SUSPENSION

2

tobramycin-dexamethasone ophthalmic drops,suspension

1

ZYLET OPHTHALMIC DROPS,SUSPENSION

2

STEROIDS ALREX OPHTHALMIC DROPS,SUSPENSION

2

dexamethasone sodium phosphate ophthalmic drops

1

DUREZOL OPHTHALMIC DROPS

2

FLAREX OPHTHALMIC DROPS,SUSPENSION

3

fluorometholone ophthalmic drops,suspension

1

FML FORTE OPHTHALMIC DROPS,SUSPENSION

3

FML LIQUIFILM OPHTHALMIC DROPS,SUSPENSION

3

FML S.O.P. OPHTHALMIC OINTMENT

3

LOTEMAX OPHTHALMIC DROPS,GEL

2

LOTEMAX OPHTHALMIC DROPS,SUSPENSION

2

LOTEMAX OPHTHALMIC OINTMENT

2

MAXIDEX OPHTHALMIC DROPS,SUSPENSION

3

OMNIPRED OPHTHALMIC DROPS,SUSPENSION

3

PRED FORTE OPHTHALMIC DROPS,SUSPENSION

3 116

Requirements / Limits

Drug Name

Drug Tier

PRED MILD OPHTHALMIC DROPS,SUSPENSION

3

prednisolone acetate ophthalmic drops,suspension

1

prednisolone sodium phosphate ophthalmic drops

1

VEXOL OPHTHALMIC DROPS,SUSPENSION

3

Requirements / Limits

STEROID-SULFONAMIDE COMBINATIONS BLEPHAMIDE OPHTHALMIC DROPS,SUSPENSION

3

BLEPHAMIDE S.O.P. OPHTHALMIC OINTMENT

3

sulfacetamide-prednisolone ophthalmic drops

1

SULFONAMIDES BLEPH-10 OPHTHALMIC DROPS

3

sulfacetamide sodium ophthalmic ointment

1

SYMPATHOMIMETICS ALPHAGAN P OPHTHALMIC DROPS

3

apraclonidine ophthalmic drops

1

brimonidine ophthalmic drops

1

IOPIDINE OPHTHALMIC DROPPERETTE

3

IOPIDINE OPHTHALMIC DROPS

3

VASOCONSTRICTOR DECONGESTANTS CYCLOMYDRIL OPHTHALMIC DROPS

3

naphazoline ophthalmic drops

1

phenylephrine hcl ophthalmic drops

1

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

2

adrenalin injection solution

1

arbinoxa oral liquid

1

arbinoxa oral tablet

1

carbinoxamine maleate oral liquid

1

carbinoxamine maleate oral tablet

1

CLARINEX ORAL SYRUP

3 117

QL (4 per 30 days)

Drug Name

Drug Tier

Requirements / Limits

CLARINEX ORAL TABLET

3

clemastine oral tablet

1

cyproheptadine oral syrup

1

cyproheptadine oral tablet

1

desloratadine oral tablet

1

desloratadine oral tablet,disintegrating

1

diphenhydramine hcl injection solution

1

diphenhydramine hcl injection syringe

1

epinephrine injection auto-injector

1

epinephrine injection solution

1

epinephrine injection syringe

1

EPIPEN 2-PAK INJECTION AUTO-INJECTOR

2

QL (4 per 30 days)

EPIPEN JR 2-PAK INJECTION AUTOINJECTOR

2

QL (4 per 30 days)

hydroxyzine hcl oral solution

1

hydroxyzine hcl oral tablet

1

hydroxyzine pamoate oral capsule

1

levocetirizine oral solution

1

levocetirizine oral tablet

1

phenadoz rectal suppository

1

phenergan rectal suppository

1

promethazine oral syrup

1

promethazine oral tablet

1

promethazine rectal suppository

1

promethegan rectal suppository

1

VISTARIL ORAL CAPSULE

3

XYZAL ORAL SOLUTION

3

XYZAL ORAL TABLET

3

COUGH & COLD THERAPY benzonatate oral capsule

1

BROMFED DM ORAL SYRUP

3

brompheniramine-pseudoeph-dm oral syrup

1

CAPCOF ORAL LIQUID

3 118

QL (4 per 30 days)

Drug Name

Drug Tier

centergy oral drops

1

cheratussin ac oral liquid

1

cheratussin dac oral syrup

1

CLARINEX-D 12 HOUR ORAL TABLET, ER MULTIPHASE 12 HR

3

codeine-guaifenesin oral liquid

1

guaifenesin ac oral liquid

1

guaifenesin dac oral syrup

1

hydrocodone-chlorpheniramine oral suspension,extended rel 12 hr

1

hydrocodone-cpm-pseudoephed oral solution

1

hydrocodone-homatropine oral syrup

1

hydrocodone-homatropine oral tablet

1

hydromet oral syrup

1

iophen c-nr oral liquid

1

lortuss ex oral syrup

1

MAR-COF BP ORAL LIQUID

3

MAR-COF CG ORAL LIQUID

3

m-clear wc oral liquid

1

M-END MAX D ORAL LIQUID

3

M-END PE ORAL LIQUID

3

phenylhistine dh oral liquid

1

promethazine vc oral syrup

1

promethazine vc-codeine oral syrup

1

promethazine-codeine oral syrup

1

promethazine-dm oral syrup

1

promethazine-phenyleph-codeine oral syrup

1

PRO-RED AC (W/ DEXCHLORPHENIR) ORAL LIQUID

3

relcof c oral liquid

1

RESPA-AR ORAL TABLET EXTENDED RELEASE 12 HR

3

REZIRA ORAL SOLUTION

3

rydex oral liquid

1 119

Requirements / Limits

Drug Name

Drug Tier

SEMPREX-D ORAL CAPSULE

3

TESSALON PERLES ORAL CAPSULE

3

tusnel c oral syrup

1

TUSNEL PEDIATRIC ORAL LIQUID

3

TUSSICAPS ORAL CAPSULE,EXTENDED RELEASE 12 HR

3

tussigon oral tablet

1

TUSSIONEX PENNKINETIC ER ORAL SUSPENSION,EXTENDED REL 12 HR

3

virtussin ac oral liquid

1

ZODRYL AC 25 ORAL SUSPENSION

3

ZODRYL AC 30 ORAL SUSPENSION

3

ZODRYL AC 35 ORAL SUSPENSION

3

ZODRYL AC 40 ORAL SUSPENSION

3

ZODRYL AC 50 ORAL SUSPENSION

3

ZODRYL AC 60 ORAL SUSPENSION

3

ZODRYL AC 80 ORAL SUSPENSION

3

ZODRYL DAC 25 ORAL SUSPENSION

3

ZODRYL DAC 30 ORAL SUSPENSION

3

ZODRYL DAC 35 ORAL SUSPENSION

3

ZODRYL DAC 40 ORAL SUSPENSION

3

ZODRYL DAC 50 ORAL SUSPENSION

3

ZODRYL DAC 60 ORAL SUSPENSION

3

ZODRYL DAC 80 ORAL SUSPENSION

3

ZODRYL DEC 25 ORAL SUSPENSION

3

ZODRYL DEC 30 ORAL SUSPENSION

3

ZODRYL DEC 35 ORAL SUSPENSION

3

ZODRYL DEC 40 ORAL SUSPENSION

3

ZODRYL DEC 50 ORAL SUSPENSION

3

ZODRYL DEC 60 ORAL SUSPENSION

3

ZODRYL DEC 80 ORAL SUSPENSION

3

ZONATUSS ORAL CAPSULE

3

Z-TUSS AC ORAL LIQUID

3

ZUTRIPRO ORAL SOLUTION

3 120

Requirements / Limits

Drug Name

Drug Tier

Requirements / Limits

PULMONARY AGENTS ACCOLATE ORAL TABLET

3

acetylcysteine solution

1

ADCIRCA ORAL TABLET

2

PA; SPRx

ADEMPAS ORAL TABLET

3

PA; SPRx

ADVAIR DISKUS INHALATION BLISTER WITH DEVICE

2

ADVAIR HFA INHALATION HFA AEROSOL INHALER

2

AEROSPAN INHALATION HFA AEROSOL INHALER

3

albuterol sulfate inhalation solution for nebulization

1

albuterol sulfate oral syrup

1

albuterol sulfate oral tablet

1

albuterol sulfate oral tablet extended release 12 hr

1

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE

2

ARCAPTA NEOHALER INHALATION CAPSULE, W/INHALATION DEVICE

2

ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE

2

ASMANEX HFA INHALATION HFA AEROSOL INHALER

2

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

2

ATROVENT HFA INHALATION HFA AEROSOL INHALER

3

BERINERT INTRAVENOUS KIT

3

BREO ELLIPTA INHALATION BLISTER WITH DEVICE

2

BROVANA INHALATION SOLUTION FOR NEBULIZATION

2

budesonide inhalation suspension for nebulization

1

budesonide nasal spray,non-aerosol

1

CINRYZE INTRAVENOUS RECON SOLN

3

COMBIVENT RESPIMAT INHALATION MIST

2 121

PA; SPRx

PA; SPRx

Drug Name

Drug Tier

Requirements / Limits

cromolyn inhalation solution for nebulization

1

CUROSURF INTRATRACHEAL SUSPENSION

3

DALIRESP ORAL TABLET

2

DULERA INHALATION HFA AEROSOL INHALER

2

ELIXOPHYLLIN ORAL ELIXIR

3

ESBRIET ORAL CAPSULE

3

PA; SPRx

FIRAZYR SUBCUTANEOUS SYRINGE

3

PA; SPRx

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE

2

FLOVENT HFA INHALATION HFA AEROSOL INHALER

2

flunisolide nasal spray,non-aerosol

1

fluticasone nasal spray,suspension

1

FORADIL AEROLIZER INHALATION CAPSULE, W/INHALATION DEVICE

2

HYPER-SAL INHALATION SOLUTION FOR NEBULIZATION

3

ipratropium bromide inhalation solution

1

ipratropium-albuterol inhalation solution for nebulization

1

KALYDECO ORAL GRANULES IN PACKET

3

PA; SPRx

KALYDECO ORAL TABLET

3

PA; SPRx

levalbuterol hcl inhalation solution for nebulization

1

metaproterenol oral syrup

1

metaproterenol oral tablet

1

mometasone nasal spray,non-aerosol

1

montelukast oral granules in packet

1

montelukast oral tablet

1

montelukast oral tablet,chewable

1

NEBUSAL INHALATION SOLUTION FOR NEBULIZATION

3

OFEV ORAL CAPSULE

3

PA; SPRx

OPSUMIT ORAL TABLET

3

PA; SPRx

ORKAMBI ORAL TABLET

3

PA; SPRx

122

Drug Name

Drug Tier

Requirements / Limits

PERFOROMIST INHALATION SOLUTION FOR NEBULIZATION

2

PROAIR HFA INHALATION HFA AEROSOL INHALER

2

PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED

2

PROVENTIL HFA INHALATION HFA AEROSOL INHALER

3

PULMICORT FLEXHALER INHALATION AEROSOL POWDR BREATH ACTIVATED

3

PULMICORT INHALATION SUSPENSION FOR NEBULIZATION

3

pulmosal inhalation solution for nebulization

1

PULMOZYME INHALATION SOLUTION

3

QVAR INHALATION AEROSOL

2

REVATIO INTRAVENOUS SOLUTION

3

PA; SPRx

REVATIO ORAL SUSPENSION FOR RECONSTITUTION

3

PA; SPRx

REVATIO ORAL TABLET

3

PA; SPRx

SEREVENT DISKUS INHALATION BLISTER WITH DEVICE

2

sildenafil intravenous solution

1

PA; SPRx

sildenafil 20 mg oral tablet

1

PA; SPRx

SINGULAIR ORAL GRANULES IN PACKET

3

SINGULAIR ORAL TABLET

3

SINGULAIR ORAL TABLET,CHEWABLE

3

sodium chloride inhalation solution for nebulization

1

SPIRIVA RESPIMAT INHALATION MIST

2

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE

2

STIOLTO RESPIMAT INHALATION MIST

3

SYMBICORT INHALATION HFA AEROSOL INHALER

2

terbutaline oral tablet

1

terbutaline subcutaneous solution

1 123

ST

SPRx

Drug Name

Drug Tier

Requirements / Limits

THEO-24 ORAL CAPSULE,EXTENDED RELEASE 24HR

3

theochron oral tablet extended release 12 hr

1

theophylline oral solution

1

theophylline oral tablet extended release

1

theophylline oral tablet extended release 12 hr

1

TRACLEER ORAL TABLET

3

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED

2

TYVASO INHALATION SOLUTION FOR NEBULIZATION

3

PA; SPRx

TYVASO REFILL KIT INHALATION SOLUTION FOR NEBULIZATION

3

PA; SPRx

TYVASO STARTER KIT INHALATION SOLUTION FOR NEBULIZATION

3

PA; SPRx

VENTAVIS INHALATION SOLUTION FOR NEBULIZATION

3

PA; SPRx

VENTOLIN HFA INHALATION HFA AEROSOL INHALER

3

ST

VOSPIRE ER ORAL TABLET EXTENDED RELEASE 12 HR

3

XOPENEX CONCENTRATE INHALATION SOLUTION FOR NEBULIZATION

3

XOPENEX HFA INHALATION HFA AEROSOL INHALER

3

XOPENEX INHALATION SOLUTION FOR NEBULIZATION

3

zafirlukast oral tablet

1

UROLOGICALS ANTICHOLINERGICS & ANTISPASMODICS darifenacin oral tablet extended release 24 hr

1

DETROL LA ORAL CAPSULE,EXTENDED RELEASE 24HR

3

DETROL ORAL TABLET

3

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR

3

124

PA; SPRx

ST

Drug Name

Drug Tier

ENABLEX ORAL TABLET EXTENDED RELEASE 24 HR

2

flavoxate oral tablet

1

GELNIQUE TRANSDERMAL GEL IN PACKET

2

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR

2

oxybutynin chloride oral syrup

1

oxybutynin chloride oral tablet

1

oxybutynin chloride oral tablet extended release 24hr

1

OXYTROL TRANSDERMAL PATCH SEMIWEEKLY

3

tolterodine oral capsule,extended release 24hr

1

tolterodine oral tablet

1

trospium oral capsule,extended release 24hr

1

trospium oral tablet

1

VESICARE ORAL TABLET

2

Requirements / Limits

BENIGN PROSTATIC HYPERPLASIA (BPH) THERAPY alfuzosin oral tablet extended release 24 hr

1

AVODART ORAL CAPSULE

3

CIALIS ORAL TABLET 2.5 MG

3

#; QL (8 per 30 days)

CIALIS ORAL TABLET 5 MG

3

#; QL (15 per 60 days)

dutasteride oral capsule

1

dutasteride-tamsulosin oral capsule, er multiphase 24 hr

1

finasteride 5 mg oral tablet

1

FLOMAX ORAL CAPSULE,EXTENDED RELEASE 24HR

3

JALYN ORAL CAPSULE, ER MULTIPHASE 24 HR

3

PROSCAR ORAL TABLET

3

RAPAFLO ORAL CAPSULE

3

tamsulosin oral capsule,extended release 24hr

1

UROXATRAL ORAL TABLET EXTENDED RELEASE 24 HR

3

125

Drug Name

Drug Tier

Requirements / Limits

CHOLINERGIC STIMULANTS bethanechol chloride oral tablet

1

URECHOLINE ORAL TABLET

3

MISCELLANEOUS UROLOGICALS alprostadil injection solution

1

CAVERJECT IMPULSE INTRACAVERNOSAL KIT

3

#; QL (8 per 30 days)

CAVERJECT INTRACAVERNOSAL RECON SOLN

3

#; QL (8 per 30 days)

CIALIS ORAL TABLET

3

#; QL (8 per 30 days)

CYSTAGON ORAL CAPSULE

3

cytra k crystals oral packet

1

cytra-2 oral solution

1

cytra-3 oral solution

1

cytra-k oral solution

1

EDEX INTRACAVERNOSAL KIT

3

ELMIRON ORAL CAPSULE

3

hyolev mb oral tablet

1

hyophen oral tablet

1

K-PHOS NO 2 ORAL TABLET

3

K-PHOS ORIGINAL ORAL TABLET,SOLUBLE

3

LEVITRA ORAL TABLET

3

methen-sod phos-meth blue-hyos oral tablet

1

MUSE URETHRAL SUPPOSITORY

3

ORACIT ORAL SOLUTION

3

phosphasal oral tablet

1

pot,sodium citrate-citric acid oral solution

1

potassium citrate oral tablet extended release

1

potassium citrate-citric acid oral packet

1

potassium citrate-citric acid oral solution

1

PROCYSBI ORAL CAPSULE, DELAYED REL SPRINKLE

3

PROSTIN VR PEDIATRIC INJECTION SOLUTION

3

126

#; QL (8 per 30 days)

#; QL (8 per 30 days) #; QL (8 per 30 days)

PA; SPRx

Drug Name

Drug Tier

Requirements / Limits

SHOHL'S MODIFIED ORAL SOLUTION

3

sodium citrate-citric acid oral solution

1

STAXYN ORAL TABLET,DISINTEGRATING

3

#; QL (8 per 30 days)

STENDRA ORAL TABLET

3

#

tricitrates oral solution

1

ur n-c oral tablet

1

uramit mb oral capsule

1

URELLE ORAL TABLET

3

uretron d-s oral tablet

1

URIBEL ORAL CAPSULE

3

urimar-t oral tablet

1

urin ds oral tablet

1

uro-blue oral tablet

1

UROCIT-K 10 ORAL TABLET EXTENDED RELEASE

3

UROCIT-K 15 ORAL TABLET EXTENDED RELEASE

3

UROCIT-K 5 ORAL TABLET EXTENDED RELEASE

3

urogesic-blue oral tablet

1

uro-l oral tablet

1

uro-mp oral capsule

1

UROQID-ACID NO.2 ORAL TABLET

3

uryl oral tablet

1

ustell oral capsule

1

utira-c oral tablet

1

VIAGRA ORAL TABLET

3

virtrate-2 oral solution

1

virtrate-3 oral solution

1

virtrate-k oral solution

1

URINARY ANESTHETICS phenazopyridine oral tablet

1

PYRIDIUM ORAL TABLET

3

VITAMINS, HEMATINICS & ELECTROLYTES 127

#; QL (8 per 30 days)

Drug Name

Drug Tier

Requirements / Limits

ELECTROLYTES calcium 500 with d oral tablet

1

ACA; OTC

calcium citrate + d oral tablet

1

ACA; OTC

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

3

effer-k oral tablet, effervescent 25 meq

1

GALZIN ORAL CAPSULE

3

k-effervescent oral tablet, effervescent

1

klor-con 10 oral tablet extended release

1

klor-con 8 oral tablet extended release

1

klor-con m10 oral tablet,er particles/crystals

1

klor-con m15 oral tablet,er particles/crystals

1

klor-con m20 oral tablet,er particles/crystals

1

klor-con oral packet

1

klor-con sprinkle oral capsule, extended release

1

KLOR-CON/25 ORAL PACKET

3

klor-con/ef oral tablet, effervescent

1

k-phos-neutral oral tablet

1

k-sol oral liquid

1

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

3

k-tab oral tablet extended release 8 meq

1

lugols oral solution

1

phospha 250 neutral oral tablet

1

POTABA ORAL CAPSULE

3

potassium bicarb and chloride oral tablet, effervescent

1

potassium bicarb-citric acid oral tablet, effervescent

1

potassium chloride oral capsule, extended release

1

potassium chloride oral liquid

1

potassium chloride oral packet

1

potassium chloride oral tablet extended release

1

potassium chloride oral tablet,er particles/crystals

1 128

Drug Name

Drug Tier

strong iodine oral solution

1

virt-phos 250 neutral oral tablet

1

Requirements / Limits

MISCELLANEOUS VITAMINS, HEMATINICS, & ELECTROLYTES FORTAVIT ORAL CAPSULE

3

VITAMINS & HEMATINICS ACTIVE FE ORAL TABLET

3

ACTIVE OB ORAL CAPSULE

3

ANIMI-3 WITH VITAMIN D ORAL CAPSULE

3

ATABEX EC ORAL TABLET,DELAYED RELEASE (DR/EC)

3

b complex-vitamin b12 oral tablet

1

BACMIN ORAL TABLET

3

BAL-CARE DHA ESSENTIAL ORAL COMBO PACK,TABLET AND CAP,DR

3

bal-care dha oral combo pack,tablet and cap,dr

1

b-complex with vitamin c oral tablet

1

BIFERA RX ORAL TABLET

3

calcium pnv oral capsule

1

calcium-folic acid-vitamin d oral wafer

1

CARDIOTEK-RX (BIOPERINE) ORAL TABLET

3

centratex oral capsule

1

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

1

CITRANATAL 90 DHA (ALGAL OIL) ORAL COMBO PACK

3

CITRANATAL ASSURE ORAL COMBO PACK

3

CITRANATAL B-CALM (FE GLUC) ORAL TABLETS, SEQUENTIAL

3

CITRANATAL DHA (ALGAL OIL) ORAL COMBO PACK

3

CITRANATAL HARMONY (IRON FUM) ORAL CAPSULE

3

c-nate dha oral capsule

1

complete natal dha oral combo pack

1

completenate oral tablet,chewable

1 129

ACA; OTC

ACA; OTC

Drug Name

Drug Tier

Requirements / Limits

CONCEPT DHA ORAL CAPSULE

3

CONCEPT OB ORAL CAPSULE

3

corvita 150 oral tablet

1

corvita oral tablet

1

CORVITE 150 ORAL TABLET

3

CORVITE FE ORAL TABLET

3

CORVITE FREE ORAL TABLET

3

CORVITE ORAL TABLET

3

cyanocobalamin (vitamin b-12) injection solution

1

DIALYVITE 800 WITH IRON ORAL TABLET

3

dialyvite oral tablet

1

DIALYVITE SUPREME D ORAL TABLET

3

dothelle dha oral capsule

1

DRISDOL ORAL CAPSULE

3

DUET DHA BALANCED ORAL COMBO PACK

3

DUET DHA WITH OMEGA-3 ORAL COMBO PACK

3

ELDERCAPS ORAL CAPSULE

3

ergocalciferol (vitamin d2) oral capsule

1

ESCAVITE ORAL TABLET,CHEWABLE

3

EXTRA-VIRT PLUS DHA ORAL CAPSULE

3

fabb oral tablet

1

fe c plus oral tablet

1

ferocon oral capsule

1

FERRALET 90 DUAL-IRON DELIVERY ORAL TABLET

3

ferraplus 90 oral tablet

1

ferrocite plus oral tablet

1

ferrogels forte oral capsule

1

FLUORABON ORAL DROPS

3

ACA

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

1

ACA

130

Drug Name

Drug Tier

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

1

FLUOR-A-DAY ORAL DROPS

3

FLUORITAB ORAL DROPS

3

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

1

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

1

FLURA-DROPS ORAL DROPS

3

focalgin 90 dha oral combo pack

1

focalgin ca oral combo pack

1

focalgin dss oral tablet

1

folbecal oral tablet, er multiphase 24 hr

1

folbee oral tablet

1

folbee plus oral tablet

1

FOLGARD OS ORAL TABLET

3

FOLGARD RX ORAL TABLET

3

folic acid oral tablet

1

folic acid-vit b6-vit b12 oral tablet

1

folivane-f oral capsule

1

folivane-ob oral capsule

1

folivane-plus oral capsule

1

folplex 2.2 oral tablet

1

FOLTRATE ORAL TABLET

3

hematinic plus vit/minerals oral tablet

1

hematinic/folic acid oral tablet

1

hematogen fa oral capsule

1

hematogen forte oral capsule

1

hematogen oral capsule

1

HEMATRON ORAL LIQUID

3

HEMATRON-AF ORAL TABLET EXTENDED RELEASE 24 HR

3

HEMAX ORAL TABLET EXTENDED RELEASE 24 HR

3

hemenatal ob + dha oral combo pack

1 131

Requirements / Limits

ACA

ACA

Drug Name

Drug Tier

Requirements / Limits

hemenatal ob oral tablet

1

hemetab oral tablet

1

HEMOCYTE-F ORAL TABLET

3

HEMOCYTE-PLUS ORAL CAPSULE

3

ICAR-C PLUS ORAL TABLET

3

inatal advance oral tablet

1

inatal ultra oral tablet

1

INTEGRA F ORAL CAPSULE

3

INTEGRA PLUS ORAL CAPSULE

3

IROSPAN 24/6 ORAL TABLET

3

levomefolate dha oral capsule

1

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

1

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

1

macnatal cn dha oral capsule

1

MARNATAL-F ORAL CAPSULE

3

MAXARON FORTE ORAL TABLET

3

MAXINATE ORAL TABLET

3

multigen folic oral tablet

1

multigen plus oral tablet

1

multi-vit with fluoride-iron oral drops

1

ACA

multi-vitamin with fluoride oral drops

1

ACA

multi-vitamin with fluoride oral tablet,chewable 0.25 mg, 0.5 mg

1

ACA

multi-vitamin with fluoride oral tablet,chewable 1 mg

1

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

1

multivitamins with fluoride oral tablet,chewable 1 mg

1

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

1

mvc-fluoride oral tablet,chewable 1 mg

1

M-VIT ORAL TABLET

3

132

ACA

ACA

ACA

Drug Name

Drug Tier

MYKIDZ IRON FLUORIDE ORAL SUSPENSION

3

mynatal advance oral tablet

1

mynatal oral capsule

1

mynatal oral tablet

1

mynatal plus oral tablet

1

mynatal-z oral tablet

1

mynate 90 plus oral tablet extended release

1

mynephrocaps oral capsule

1

NATACHEW (FE BIS-GLYCINATE) ORAL TABLET,CHEWABLE

3

NATALVIT ORAL TABLET

3

NATELLE ONE ORAL CAPSULE

3

nephplex rx oral tablet

1

NEPHROCAPS ORAL CAPSULE

3

NEPHROCAPS QT ORAL TABLET,DISINTEGRATING

3

NEPHRON FA ORAL TABLET

3

nephro-vite rx oral tablet

1

NESTABS ABC ORAL COMBO PACK

3

NESTABS DHA ORAL COMBO PACK

3

NESTABS ORAL TABLET

3

NEURIN-SL SUBLINGUAL TABLET

3

newgen oral tablet

1

NEXA PLUS ORAL CAPSULE

3

NIVA-PLUS ORAL TABLET

3

NUTRICAP ORAL TABLET

3

OB COMPLETE ONE ORAL CAPSULE

3

OB COMPLETE ORAL TABLET

3

OB COMPLETE PETITE ORAL CAPSULE

3

OB COMPLETE PREMIER ORAL TABLET

3

OB COMPLETE WITH DHA ORAL CAPSULE

3

obstetrix dha oral combo pack,tablet and cap,dr

1

133

Requirements / Limits

Drug Name

Drug Tier

OBSTETRIX EC ORAL TABLET,DELAYED RELEASE (DR/EC)

3

OBTREX DHA ORAL COMBO PACK,TABLET AND CAP,DR

3

O-CAL FA ORAL TABLET

3

PAIRE OB PLUS DHA ORAL COMBO PACK

3

PED MULTIVITAMINS-A,B,D,E,K,ZN ORAL DROPS

3

pnv 29-1 oral tablet

1

pnv ob+dha oral combo pack

1

pnv-dha + docusate oral capsule

1

pnv-dha oral capsule

1

pnv-ferrous fumarate-docu-fa oral tablet

1

pnv-omega oral capsule

1

pnv-select oral tablet

1

pnv-vp-u oral capsule

1

POLY-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC

3

POLY-VI-FLOR ORAL TABLET,CHEWABLE

3

POLY-VI-FLOR WITH IRON ORAL DROPS,SUSPENSION BIPHASIC

3

POLY-VI-FLOR WITH IRON ORAL TABLET,CHEWABLE

3

pr natal 400 ec oral combo pack,tablet and cap,dr

1

pr natal 400 oral combo pack

1

pr natal 430 ec oral combo pack,tablet and cap,dr

1

pr natal 430 oral combo pack

1

PREFERA-OB ONE ORAL CAPSULE

3

PREFERA-OB ORAL TABLET

3

prena1 chew oral tablet,chew,ir - dr,biphase

1

prena1 pearl oral capsule,ir - delay rel,biphase

1

prenaissance next oral tablet

1

prenaissance oral capsule

1

prenaissance plus oral capsule

1

PRENATA ORAL TABLET,CHEWABLE

3 134

Requirements / Limits

Drug Name

Drug Tier

Requirements / Limits

prenatabs fa oral tablet

1

prenatabs rx oral tablet

1

prenatal multi-dha (algal oil) oral capsule

1

ACA; OTC

prenatal one daily oral tablet

1

ACA; OTC

prenatal oral tablet

1

ACA; OTC

prenatal plus (calcium carb) oral tablet

1

prenatal plus oral tablet

1

prenatal vitamin oral tablet

1

prenatal vitamin plus low iron oral tablet

1

prenatal-u oral capsule

1

PRENATE AM ORAL TABLET

3

PRENATE CHEWABLE ORAL TABLET,CHEWABLE

3

PRENATE DHA (FERR ASP GLYCIN) ORAL CAPSULE

3

PRENATE ENHANCE ORAL CAPSULE

3

PRENATE MINI ORAL CAPSULE

3

PRENATE RESTORE ORAL CAPSULE

3

PRENATE STAR ORAL TABLET

3

preplus oral tablet

1

PREQUE 10 ORAL TABLET

3

pretab oral tablet

1

PROFERRIN-FORTE ORAL TABLET

3

PROTECT IRON ORAL TABLET

3

PROVIDA OB ORAL CAPSULE

3

PUREFE OB PLUS ORAL CAPSULE

3

PUREFE PLUS ORAL CAPSULE

3

purevit dualfe plus oral capsule

1

relnate dha oral capsule

1

renal caps oral capsule

1

rena-vite rx oral tablet

1

reno caps oral capsule

1

risacal-d oral tablet

1

R-NATAL OB ORAL CAPSULE

3 135

ACA; OTC

ACA; OTC

Drug Name

Drug Tier

Requirements / Limits

rulavite dha oral capsule

1

SELECT-OB + DHA ORAL COMBO PACK

3

SELECT-OB ORAL TABLET,CHEWABLE

3

se-natal 19 (with docusate) oral tablet

1

se-natal 19 oral tablet,chewable

1

se-tan dha oral capsule

1

se-tan plus oral capsule

1

sodium fluoride oral drops

1

ACA

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

1

ACA

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

1

SOFTGELS MULTIVIT-A,B,D,E,K,ZN ORAL CAPSULE

3

STROVITE FORTE ORAL TABLET

3

STROVITE ONE ORAL TABLET

3

SUPERVITE (EC) ORAL TABLET,DELAYED RELEASE (DR/EC)

3

SUPERVITE ORAL LIQUID

3

TANDEM PLUS ORAL CAPSULE

3

taron forte oral capsule

1

taron-c dha oral capsule

1

taron-prex prenatal-dha oral capsule

1

THRIVITE RX ORAL TABLET

3

thrivite-19 oral tablet

1

tl gard rx oral tablet

1

tl g-fol os oral tablet

1

tl icon oral capsule

1

tl-hem 150 oral tablet extended release 24 hr

1

TRICARE ORAL TABLET

3

TRICARE PRENATAL DHA ONE ORAL CAPSULE

3

tricon oral capsule

1

trigels-f forte oral capsule

1

trinatal gt oral tablet

1 136

Drug Name

Drug Tier

Requirements / Limits

trinatal rx 1 oral tablet

1

trinate oral tablet

1

triphrocaps oral capsule

1

triple vitamin with fluoride oral drops

1

TRISTART DHA ORAL CAPSULE

3

tri-tabs dha oral combo pack

1

triveen-duo dha oral combo pack

1

TRI-VI-FLOR ORAL DROPS,SUSPENSION BIPHASIC

3

tri-vit with fluoride and iron oral drops

1

ACA

tri-vitamin with fluoride oral drops

1

ACA

trust natal dha oral combo pack

1

UDAMIN SP ORAL TABLET

3

ultimatecare one nf oral capsule

1

ultimatecare one oral capsule

1

v-c forte oral capsule

1

vemavite-prx-2 oral capsule

1

vic-forte oral capsule

1

vinate care oral tablet,chewable

1

vinate dha oral capsule

1

VINATE DHA RF ORAL CAPSULE

3

vinate ii oral tablet

1

vinate m oral tablet

1

vinate one oral tablet

1

vinate ultra oral tablet

1

virt nate oral tablet

1

virt-advance oral tablet

1

virt-c dha oral capsule

1

VIRT-CAPS ORAL CAPSULE

3

virt-care one oral capsule

1

virt-gard oral tablet

1

virt-nate dha oral capsule

1

virt-pn dha oral capsule

1 137

ACA

Drug Name

Drug Tier

Requirements / Limits

virt-pn oral tablet

1

virt-pn plus oral capsule

1

virt-select oral capsule

1

virt-vite gt oral tablet

1

virt-vite oral tablet

1

VIRT-VITE PLUS ORAL TABLET

3

vit 3 oral capsule

1

VITAFOL NANO ORAL TABLET

3

VITAFOL ORAL TABLET

3

VITAFOL ULTRA ORAL CAPSULE

3

vitafol-ob oral tablet

1

VITAFOL-OB+DHA ORAL COMBO PACK

3

VITAFOL-ONE ORAL CAPSULE

3

VITAL-D RX ORAL TABLET

3

VITAMED MD ONE RX ORAL CAPSULE

3

VITAMED MD PLUS RX ORAL COMBO PACK

3

VITAMEDMD REDICHEW RX ORAL TABLET,CHEW,IR - DR,BIPHASE

3

vitamin d3 oral tablet

1

ACA; OTC

vitamins a,c,d and fluoride oral drops

1

ACA

VITAPEARL ORAL CAPSULE,IR - DELAY REL,BIPHASE

3

VITA-RESPA ORAL TABLET

3

VIVA DHA ORAL CAPSULE

3

vol-care rx oral tablet

1

vol-nate oral tablet

1

vol-plus oral tablet

1

vol-tab rx oral tablet

1

vp-ch plus oral capsule

1

vp-ch-pnv oral capsule

1

vp-ggr-b6 oral tablet

1

vp-heme ob + dha oral combo pack

1

vp-heme ob oral tablet

1 138

Drug Name

Drug Tier

vp-heme one oral capsule

1

VP-PNV-DHA ORAL CAPSULE

3

vp-vite rx oral tablet

1

zatean-ch oral capsule

1

zatean-pn dha oral capsule

1

zatean-pn plus oral capsule

1

zingiber oral tablet

1

139

Requirements / Limits

Index 1 1ST TIER UNIFINE PENTIPS .......................................... 77 1ST TIER UNILET COMFORTOUCH ........... 77 8 8-MOP .................................. 53 A abacavir .................................. 4 abacavir-lamivudinezidovudine .......................... 4 ABILIFY .............................. 32 ABSTRAL............................ 26 acamprosate .......................... 68 ACANYA ............................. 56 acarbose ................................ 85 ACCOLATE....................... 121 ACCU-CHEK AVIVA......... 73 ACCU-CHEK AVIVA PLUS TEST STRP ...................... 73 ACCU-CHEK COMPACT TEST ................................ 73 ACCU-CHEK FASTCLIX .. 77 ACCU-CHEK SAFE-T-PRO .......................................... 77 ACCU-CHEK SMARTVIEW TEST STRIP .................... 73 ACCU-CHEK SOFTCLIX LANCETS ........................ 77 ACCUPRIL .......................... 39 ACCURETIC ....................... 39 ACCUTREND GLUCOSE .. 73 acebutolol ............................. 39 ACEON ................................ 39 acetaminophen-codeine ........ 26 acetasol hc ............................ 71 acetazolamide ..................... 115 acetic acid ....................... 68, 71 acetic acid-aluminum acetate71 acetylcysteine ..................... 121 acitretin ................................. 51 ACTEMRA ........................ 102 ACTHAR H.P. ..................... 71 ACTHIB (PF) ....................... 97 ACTIGALL .......................... 89 ACTI-LANCE LANCETS ... 77 ACTIMMUNE ..................... 97 ACTIQ.................................. 26

ACTIVE FE ........................ 129 ACTIVE OB ....................... 129 ACTONEL ................... 68, 101 ACTOPLUS MET ................ 85 ACTOPLUS MET XR ......... 85 ACTOS ................................. 85 acuicyn................................ 113 ACULAR............................ 114 ACULAR LS ...................... 114 ACURA TEST STRIPS ....... 73 acyclovir ................................. 4 ACZONE .............................. 56 ADACEL(TDAP ADOLESN/ADULT)(PF) 97 ADALAT CC ....................... 39 adapalene .............................. 56 ADCIRCA .......................... 121 ADDERALL ........................ 32 ADDERALL XR .................. 32 adefovir ................................... 4 ADEMPAS ......................... 121 ADIPEX-P ............................ 67 ADOXA................................ 12 ADRENACLICK ............... 117 adrenalin ............................. 117 ADVAIR DISKUS ............. 121 ADVAIR HFA ................... 121 ADVANCED GLUC METER TEST STRIP..................... 73 ADVANCED TRAVEL LANCETS ........................ 77 ADVATE.............................. 46 ADVOCATE LANCET ....... 77 ADVOCATE PEN NEEDLES .......................................... 77 ADVOCATE REDI-CODE . 73 ADVOCATE TEST STRIPS73 AEROSPAN ....................... 121 afeditab cr ............................. 39 AFINITOR ........................... 14 AFINITOR DISPERZ .......... 14 AFLURIA 2015-2016 .......... 97 AFLURIA 2015-2016 (PF) .. 97 AFREZZA ............................ 82 AGAMATRIX AMP TEST STRIPS ............................. 73 AGGRENOX........................ 46 AGRYLIN ............................ 68 140

AKTEN (PF) ...................... 113 ALA-SCALP ........................ 62 ALBENZA ............................. 9 albuterol sulfate .................. 121 ALCAINE........................... 113 alclometasone ....................... 62 ALDACTAZIDE ..................39 ALDACTONE ......................39 ALDARA ............................. 97 ALECENSA ......................... 14 alendronate ................... 68, 101 alfuzosin ............................. 125 ALINIA .................................. 9 ALKERAN ........................... 14 allopurinol........................... 101 almotriptan malate ................ 23 ALOCRIL ........................... 113 ALOMIDE .......................... 113 ALORA .............................. 102 alosetron ............................... 89 ALPHAGAN P ................... 117 ALPHANATE ...................... 46 ALPHANINE SD ................. 46 alprazolam ............................ 32 alprazolam intensol ............... 32 ALPROLIX .......................... 46 alprostadil ........................... 126 ALREX ............................... 116 ALSUMA ............................. 23 ALTABAX ........................... 60 altacaine .............................. 113 ALTACE .............................. 39 altafluor............................... 113 altavera (28) ........................ 106 ALTERNATE SITE LANCET .......................................... 77 ALTOPREV ......................... 48 ALUVEA .............................. 53 alyacen 1/35 (28) ................ 106 alyacen 7/7/7 (28) ............... 106 amantadine hcl ........................ 4 AMARYL ............................. 85 AMBIEN .............................. 32 AMBIEN CR ........................ 32 amcinonide ........................... 62 AMERGE ............................. 23 amethia ............................... 106 amethia lo ........................... 106

amethyst ............................. 106 AMICAR .............................. 46 amiloride............................... 39 amiloride-hydrochlorothiazide .......................................... 39 amiodarone ........................... 38 AMITIZA ............................. 89 amitriptyline ......................... 32 amitriptyline-chlordiazepoxide .......................................... 32 amlodipine ............................ 39 amlodipine-atorvastatin ........ 48 amlodipine-benazepril .......... 39 amlodipine-valsartan ............ 40 amlodipine-valsartan-hcthiazid .......................................... 40 amoxapine ............................ 32 amoxicil-clarithromy-lansopraz .......................................... 94 amoxicillin............................ 11 amoxicillin-pot clavulanate .. 11 ampicillin.............................. 11 AMPYRA ............................. 24 ANADROL-50 ..................... 83 ANAFRANIL ....................... 32 anagrelide ............................. 68 ANA-LEX KIT .................... 89 ANALPRAM-HC........... 51, 89 ANALPRAM-HC SINGLES89 ANAPROX DS .................... 29 anaspaz ................................. 88 anastrozole............................ 14 ANCOBON ............................ 3 ANDRODERM .................... 83 ANDROGEL ........................ 83 ANDROID ........................... 83 androxy ................................. 83 ANGELIQ .......................... 102 ANIMI-3 WITH VITAMIN D ........................................ 129 ANORO ELLIPTA ............ 121 ANTABUSE......................... 68 ANTARA ............................. 48 anucort-hc ............................. 89 ANUSOL-HC ....................... 89 ANZEMET ........................... 89 apexicon e............................. 62 APIDRA ............................... 82 APIDRA SOLOSTAR ......... 82 APOKYN ............................. 21

apraclonidine ...................... 117 apri ...................................... 106 APRISO ................................ 89 APTIOM ............................... 17 APTIVUS ............................... 4 AQUA GLYCOLIC HC ....... 62 aranelle (28) ........................ 106 ARANESP (IN POLYSORBATE) ............ 95 ARAVA .............................. 102 arbinoxa .............................. 117 ARCALYST ......................... 97 ARCAPTA NEOHALER ... 121 ARESTIN ............................. 69 ARICEPT ............................. 24 ARIMIDEX .......................... 14 aripiprazole ........................... 32 ARIXTRA ............................ 46 ARMOUR THYROID ......... 87 ARNUITY ELLIPTA ......... 121 AROMASIN ......................... 14 ARTHROTEC 50 ................. 29 ARTHROTEC 75 ................. 29 ascomp with codeine ............ 26 ashlyna ................................ 106 ASMANEX HFA ............... 121 ASMANEX TWISTHALER ........................................ 121 aspirin-dipyridamole ............ 46 ASSURE 4 STRIPS.............. 73 ASSURE HAEMOLANCE PLUS ................................ 77 ASSURE LANCE ................ 77 ASSURE LANCE PLUS...... 77 ASSURE PLATINUM ......... 73 ASSURE PRISM MULTI STRIP ............................... 73 ASTAGRAF XL................... 14 ASTEPRO ............................ 69 ATABEX EC ...................... 129 ATACAND .......................... 40 ATACAND HCT ................. 40 ATELVIA ........................... 101 atenolol ................................. 40 atenolol-chlorthalidone ......... 40 ATIVAN ............................... 32 ATOPICLAIR ...................... 53 atorvastatin ........................... 48 atovaquone.............................. 9 atovaquone-proguanil ............. 9 141

ATRALIN............................. 56 ATRAPRO CP...................... 53 ATRIPLA ............................... 4 atropine ............................... 113 ATROVENT......................... 70 ATROVENT HFA.............. 121 AUBAGIO ............................ 95 aubra ................................... 106 AUGMENTIN ...................... 11 AUGMENTIN ES-600 ......... 11 AUGMENTIN XR ............... 11 AURYXIA ............................ 89 AVALIDE ............................ 40 AVANDIA ........................... 85 AVAPRO .............................. 40 avar ....................................... 56 AVAR ................................... 56 AVAR LS ............................. 56 AVAR-E GREEN ................. 56 AVAR-E LS ......................... 56 AVC VAGINAL ................ 105 AVELOX .............................. 12 AVELOX ABC PACK ......... 12 AVENOVA ........................ 113 aviane .................................. 106 avidoxy ................................. 12 AVIDOXY DK ..................... 12 avita ...................................... 57 avo cream.............................. 54 AVODART......................... 125 AVONEX ............................. 96 AVONEX (WITH ALBUMIN) .......................................... 95 AYGESTIN ........................ 103 AZASAN .............................. 14 AZASITE ........................... 111 azathioprine .......................... 14 azelastine ...................... 70, 114 AZELEX............................... 57 AZILECT ............................. 21 azithromycin ........................... 8 AZOPT ............................... 115 AZOR ................................... 40 AZULFIDINE ...................... 90 AZULFIDINE EN-TABS .... 90 azurette (28) ........................ 106 B b complex-vitamin b12 ....... 129 bacitracin ............................ 111 bacitracin-polymyxin b ....... 111

baclofen ................................ 25 BACMIN ............................ 129 BACTRIM ............................ 12 BACTRIM DS...................... 12 BACTROBAN NASAL ....... 70 bal-care dha ........................ 129 BAL-CARE DHA ESSENTIAL................... 129 balsalazide ............................ 90 balziva (28)......................... 106 BANZEL .............................. 17 BARACLUDE ....................... 4 BCG VACCINE, LIVE (PF) 97 b-complex with vitamin c... 129 BD AUTOSHIELD PEN NEEDLE .......................... 77 BD CURVED TONSIL REUSABLE ..................... 77 BD ECLIPSE........................ 77 BD FILTER NEEDLE-5 MICRON .......................... 77 BD INSULIN PEN NEEDLE UF SHORT....................... 77 BD INTEGRA NEEDLE ..... 77 BD MICROTAINER LANCET .......................... 77 BD NOKOR ADMIX NEEDLE .......................... 77 BD PRECISIONGLIDE....... 77 BD PRECISIONGLIDE NONSTERILE .......................... 77 bd pre-filled normal saline ... 68 BD SAFETYGLIDE NEEDLE .......................................... 77 BD SPECIALTY USE NEEDLES ........................ 77 BD ULTRA FINE LANCETS .......................................... 78 BD ULTRA-FINE NANO PEN NEEDLES................ 78 BD YALE REUSABLE REG METAL ............................ 78 bekyree (28)........................ 106 belladonna alkaloids-opium . 88 belladonna-opium ................. 88 BELVIQ ............................... 67 benazepril ............................. 40 benazepril-hydrochlorothiazide .......................................... 40 BENEFIX ............................. 46

BENICAR ............................ 40 BENICAR HCT ................... 40 BENSAL HP ........................ 52 BENTYL .............................. 88 BENZACLIN PUMP ........... 57 BENZAMYCIN ................... 57 BENZAMYCINPAK ........... 57 BENZEFOAM...................... 57 BENZEFOAM ULTRA ....... 57 benzepro ............................... 57 BENZEPRO (MICROSPHERES) ......... 57 benzonatate ......................... 118 benzoyl peroxide .................. 57 benzphetamine ...................... 67 benztropine ........................... 21 BEPREVE .......................... 114 BERINERT ........................ 121 BETADINE OPHTHALMIC PREP .............................. 111 BETAGAN ......................... 112 betamethasone dipropionate . 62 betamethasone valerate......... 62 betamethasone, augmented ... 63 BETAPACE ......................... 38 BETAPACE AF ................... 38 BETASERON ...................... 96 betaxolol ....................... 40, 112 bethanechol chloride........... 126 BETIMOL .......................... 112 BETOPTIC S ...................... 112 bexarotene ............................ 14 BEXSERO (PF) .................... 97 BEYAZ............................... 106 BG-STAR ............................. 73 BIAFINE EMULSION......... 54 BIAXIN .................................. 8 bicalutamide ......................... 14 BIDIL ................................... 40 BIFERA RX ....................... 129 BILTRICIDE .......................... 9 bimatoprost ......................... 115 BINOSTO ........................... 101 BIONIME RIGHTEST TEST STRIPS ............................. 73 BIOTHRAX ......................... 97 bisacodyl ............................... 90 bisoprolol fumarate............... 40 bisoprolol-hydrochlorothiazide .......................................... 40 142

BLEPH-10 .......................... 117 BLEPHAMIDE .................. 117 BLEPHAMIDE S.O.P. ....... 117 blisovi 24 fe ........................ 106 blisovi fe 1.5/30 (28) ..........106 blisovi fe 1/20 (28) .............106 BLOOD GLUCOSE TEST .. 73 BLUNT NEEDLE, DISPOSABLE .................. 78 BONIVA............................. 101 BOOSTRIX TDAP ............... 97 BOSULIF ............................. 14 bp 10-1 .................................. 57 bp-50% urea.......................... 54 bpo ........................................ 57 BRAVELLE ......................... 83 BREEZE 2 TEST STRIPS ...73 BREO ELLIPTA ................ 121 BREVICON (28) ................ 106 briellyn ................................ 106 BRILINTA ........................... 46 brimonidine......................... 117 BROMFED DM ................. 118 bromfenac ........................... 114 bromocriptine ....................... 21 brompheniramine-pseudoephdm ................................... 118 BROVANA ........................ 121 BUCALSEP .......................... 60 budesonide .................... 90, 121 BULLSEYE MINI SAFETY LANCETS ........................ 78 bumetanide ........................... 40 BUNAVAIL ......................... 29 BUPAP ................................. 26 BUPHENYL ......................... 68 buprenorphine-naloxone ....... 29 bupropion hcl ........................ 32 buspirone .............................. 32 butalbital compound w/codeine .......................................... 26 butalbital-acetaminop-caf-cod .......................................... 26 butalbital-acetaminophen ..... 26 butalbital-acetaminophen-caff .......................................... 26 butalbital-aspirin-caffeine..... 26 BUTISOL ............................. 32 butorphanol tartrate .............. 29 BUTRANS ........................... 26

BYDUREON........................ 85 BYETTA .............................. 85 BYSTOLIC .......................... 40 C cabergoline ........................... 83 CADUET.............................. 48 CAFERGOT ......................... 23 caffeine citrated .................... 68 CALAN ................................ 40 CALAN SR .......................... 40 calcipotriene ......................... 51 calcipotriene-betamethasone 51 calcitonin (salmon) ............... 83 calcitrene .............................. 51 calcitriol .......................... 51, 83 calcium 500 with d ............. 128 calcium acetate ..................... 90 calcium citrate + d .............. 128 calcium pnv ........................ 129 calcium-folic acid-vitamin d ........................................ 129 camila ................................. 103 camrese ............................... 106 camrese lo ........................... 106 CANASA ............................. 90 candesartan ........................... 40 candesartan-hydrochlorothiazid .......................................... 40 capacet .................................. 26 CAPCOF ............................ 118 capecitabine .......................... 14 CAPEX ................................. 63 CAPITAL WITH CODEINE .......................................... 26 CAPRELSA ......................... 14 captopril ................................ 40 captopril-hydrochlorothiazide .......................................... 40 carafate ................................. 94 CARAFATE ......................... 94 CARBAGLU ........................ 68 carbamazepine ................ 17, 18 CARBATROL...................... 18 carbidopa .............................. 21 carbidopa-levodopa .............. 21 carbidopa-levodopaentacapone ........................ 22 carbinoxamine maleate ....... 117 CARDIOTEK-RX (BIOPERINE) ................ 129

CARDIZEM ......................... 40 CARDIZEM CD................... 40 CARDIZEM LA ................... 40 CARDURA .......................... 40 CARDURA XL .................... 40 CAREFINE PEN NEEDLE . 78 CAREONE THIN LANCET 78 CARESENS N TEST STRIPS .......................................... 73 carisoprodol .......................... 25 carisoprodol-asa-codeine ...... 25 carisoprodol-aspirin .............. 25 CARNITOR.......................... 68 CARNITOR (SUGAR-FREE) .......................................... 68 carteolol .............................. 112 carvedilol .............................. 41 CASODEX ........................... 14 CATAPRES.......................... 41 CATAPRES-TTS-1 .............. 41 CATAPRES-TTS-2 .............. 41 CATAPRES-TTS-3 .............. 41 CAVERJECT ..................... 126 CAVERJECT IMPULSE ... 126 CAYSTON ............................. 9 caziant (28) ......................... 106 CEDAX .................................. 7 cefaclor ................................... 7 cefadroxil ................................ 7 cefdinir.................................... 7 cefditoren pivoxil ................... 7 cefixime .................................. 7 cefpodoxime ........................... 7 cefprozil .................................. 7 ceftibuten ................................ 7 CEFTIN .................................. 8 cefuroxime axetil .................... 8 CELEBREX ......................... 29 celecoxib............................... 29 CELEXA .............................. 32 CELLCEPT .......................... 14 CELONTIN .......................... 18 cem-urea ............................... 54 CENTANY ........................... 60 CENTANY AT..................... 60 centergy .............................. 119 centratex ............................. 129 cephalexin ............................... 8 CERDELGA ......................... 83 143

CERVARIX VACCINE (PF) .......................................... 97 CESAMET ........................... 90 CETROTIDE ........................ 83 cevimeline............................. 68 CHANTIX ............................ 69 CHANTIX CONTINUING MONTH BOX .................. 69 CHANTIX STARTING MONTH BOX .................. 69 chateal ................................. 106 CHEMET .............................. 68 CHENODAL ........................ 90 cheratussin ac...................... 119 cheratussin dac.................... 119 chewable multivit-a,b,d,e,k,zn ........................................ 129 chlordiazepoxide hcl ............. 32 chlordiazepoxide-clidinium ..88 chlorhexidine gluconate........70 chloroquine phosphate ............9 chlorothiazide .......................41 chlorpromazine .....................32 chlorpropamide .....................86 chlorthalidone .......................41 chlorzoxazone .......................25 CHOLBAM ..........................90 cholestyramine (with sugar) .48 cholestyramine light ............. 48 choline,magnesium salicylate ..........................................29 chorionic gonadotropin, human ..........................................84 CIALIS .......................125, 126 ciclodan.................................61 ciclopirox ..............................61 ciclopirox-ure-camph-mentheuc.....................................61 cilostazol ...............................46 CILOXAN ..........................111 cimetidine .............................94 cimetidine hcl .......................94 CIMZIA ................................90 CINRYZE ...........................121 CIPRO ..................................12 CIPRO HC ............................71 CIPRO XR ............................12 CIPRODEX ..........................71 ciprofloxacin .........................12 ciprofloxacin (mixture) .........12

ciprofloxacin hcl ..... 12, 71, 111 citalopram ............................. 32 CITRANATAL 90 DHA (ALGAL OIL) ................ 129 CITRANATAL ASSURE .. 129 CITRANATAL B-CALM (FE GLUC)............................ 129 CITRANATAL DHA (ALGAL OIL) ................ 129 CITRANATAL HARMONY (IRON FUM) .................. 129 citrate of magnesia ............... 90 claravis ................................. 57 CLARINEX................ 117, 118 CLARINEX-D 12 HOUR .. 119 clarithromycin ........................ 8 cleansing wash...................... 57 clemastine ........................... 118 CLEOCIN....................... 9, 105 CLEOCIN T ......................... 57 CLEVER CHEK LANCETS 78 CLEVER CHOICE MICRO TEST STRIP .................... 73 CLEVER CHOICE PRO...... 73 CLEVER CHOICE TEST STRIPS ............................. 73 CLEVER CHOICE VOICE+ TEST ................................ 73 CLICKFINE ......................... 78 CLIMARA ......................... 103 CLIMARA PRO................. 103 clindacin p ............................ 57 CLINDAGEL ....................... 57 clindamycin hcl ...................... 9 clindamycin palmitate hcl ...... 9 clindamycin pediatric ............. 9 clindamycin phosphate . 57, 105 clindamycin-benzoyl peroxide .......................................... 57 CLINDESSE ...................... 105 CLINPRO 5000 .................... 70 clobetasol .............................. 63 clobetasol-emollient ............. 63 CLOBEX .............................. 63 CLOCORTOLONE PIVALATE ...................... 63 clodan ................................... 63 CLODERM .......................... 63 clomiphene citrate ................ 84 clomipramine........................ 32

clonazepam ........................... 18 clonidine ............................... 41 clonidine hcl ................... 32, 41 clopidogrel ............................ 46 clorazepate dipotassium ....... 32 clorpres ................................. 41 CLORPRES .......................... 41 clotrimazole ............................ 3 clotrimazole-betamethasone . 61 clozapine......................... 32, 33 CLOZAPINE ........................ 33 CLOZARIL .......................... 33 c-nate dha ........................... 129 CNL 8 NAIL ........................ 61 COAGADEX........................ 46 COAGUCHEK LANCETS .. 78 COAL TAR .......................... 51 COARTEM ............................ 9 codeine sulfate ...................... 26 codeine-butalbital-asa-caff ... 26 codeine-guaifenesin ............ 119 COLAZAL ........................... 90 colchicine-probenecid ........ 101 COLCRYS.......................... 101 COLESTID ........................... 48 COLESTID FLAVORED .... 48 colestipol .............................. 48 colocort ................................. 90 COLOR LANCETS ............. 78 COLY-MYCIN S ................. 71 COLYTE WITH FLAVOR PACKS ............................. 90 COMBIGAN ...................... 115 COMBIPATCH .................. 103 COMBIVENT RESPIMAT 121 COMBIVIR ............................ 4 COMETRIQ ......................... 14 COMFORT EZ PEN NEEDLES ........................ 78 COMFORT LANCETS ........ 78 COMPAZINE ....................... 90 COMPLERA .......................... 4 complete natal dha .............. 129 completenate ....................... 129 compro .................................. 90 COMTAN............................. 22 CONCEPT DHA ................ 130 CONCEPT OB ................... 130 CONCERTA ........................ 33 CONDYLOX........................ 54 144

constulose ............................. 90 CONTOUR NEXT STRIPS . 73 CONTOUR TEST STRIPS .. 73 CONTRAVE ........................67 CONTROL G3 .....................73 COOL GLUCOSE TEST STRIP ...............................73 COPAXONE ........................96 COPEGUS ............................ 96 CORDARONE ..................... 38 CORDRAN........................... 63 CORDRAN TAPE SMALL ROLL ................................ 63 COREG................................. 41 COREG CR .......................... 41 CORGARD........................... 41 CORIFACT .......................... 46 CORLANOR ........................ 50 cormax .................................. 63 CORTANE-B ....................... 54 CORTEF ............................... 71 CORTENEMA ..................... 90 CORTIFOAM....................... 90 cortisone ............................... 71 CORTISPORIN .................... 60 corvita ................................. 130 corvita 150 .......................... 130 CORVITE ........................... 130 CORVITE 150 .................... 130 CORVITE FE ..................... 130 CORVITE FREE ................ 130 CORZIDE ............................. 41 COSOPT ............................. 115 COSOPT (PF) ..................... 115 COTELLIC ........................... 14 COUMADIN ........................ 46 covaryx ............................... 103 covaryx h.s. ......................... 103 COZAAR .............................. 41 CREON................................. 90 CRESEMBA........................... 3 CRESTOR ............................ 49 CRINONE .......................... 103 CRIXIVAN............................. 4 cromolyn ............... 90, 114, 122 cryselle (28) ........................ 107 CUROSURF ....................... 122 CUTIVATE .......................... 63 CUVPOSA ........................... 88

cyanocobalamin (vitamin b-12) ........................................ 130 cyclafem 1/35 (28) ............. 107 cyclafem 7/7/7 (28) ............ 107 CYCLESSA (28) ................ 107 cyclobenzaprine .................... 25 CYCLOGYL ...................... 113 CYCLOMYDRIL............... 117 cyclopentolate..................... 113 CYCLOPHOSPHAMIDE .... 14 CYCLOSERINE .................... 9 CYCLOSET ......................... 86 cyclosporine ......................... 14 cyclosporine modified .......... 14 CYMBALTA ....................... 33 cyproheptadine ................... 118 cyred ................................... 107 CYSTADANE...................... 90 CYSTAGON ...................... 126 CYSTARAN ...................... 114 CYTOMEL........................... 87 CYTOTEC ........................... 94 cytra k crystals .................... 126 cytra-2................................. 126 cytra-3................................. 126 cytra-k................................. 126 D D.H.E.45............................... 23 DALIRESP ......................... 122 danazol ................................. 84 DANTRIUM ........................ 25 dantrolene ............................. 25 dapsone ................................... 9 DAPTACEL (DTAP PEDIATRIC) (PF)............ 97 DARAPRIM ........................... 9 darifenacin .......................... 124 dasetta 1/35 (28) ................. 107 dasetta 7/7/7 (28) ................ 107 DAYPRO ............................. 29 daysee ................................. 107 DAYTRANA ....................... 33 DDAVP ................................ 84 DEBACTEROL ................... 70 deblitane ............................. 103 DELESTROGEN ............... 103 deltasone ............................... 71 delyla (28) .......................... 107 DEMADEX .......................... 41 demeclocycline ..................... 12

DEMEROL........................... 26 DEMSER .............................. 41 DENAVIR ............................ 62 denta 5000 plus ..................... 70 dentagel ................................ 70 DEPAKENE ......................... 18 DEPAKOTE ......................... 18 DEPAKOTE ER ................... 18 DEPAKOTE SPRINKLES .. 18 DEPEN TITRATABS ........ 102 DEPO-ESTRADIOL .......... 103 DEPO-PROVERA.............. 103 DEPO-SUBQ PROVERA 104 ........................................ 103 DEPO-TESTOSTERONE .... 84 DERMA-SMOOTHE/FS BODY OIL ....................... 63 DERMA-SMOOTHE/FS SCALP OIL ...................... 63 DERMASORB HC COMPLETE KIT ............. 64 DERMASORB TA COMPLETE KIT ............. 64 DERMASORB XM COMPLETE KIT ............. 54 DERMATOP ........................ 64 DERMOTIC OIL ................. 71 desipramine .......................... 33 desloratadine ....................... 118 desmopressin ........................ 84 desog-e.estradiol/e.estradiol ........................................ 107 DESOGEN ......................... 107 desogestrel-ethinyl estradiol ........................................ 107 DESONATE ......................... 64 desonide ................................ 64 DESOWEN .......................... 64 desoximetasone .................... 64 DESOXYN ........................... 33 DETROL ............................ 124 DETROL LA ...................... 124 dexamethasone ..................... 71 dexamethasone intensol ........ 71 dexamethasone sodium phosphate ........................ 116 dexedrine .............................. 33 DEXEDRINE SPANSULE .. 33 dexmethylphenidate.............. 33 DEXPAK 10 DAY ............... 72 145

DEXPAK 13 DAY ............... 72 DEXPAK 6 DAY ................. 72 dextroamphetamine .............. 33 dextroamphetamineamphetamine.....................33 dialyvite ..............................130 DIALYVITE 800 WITH IRON ........................................130 DIALYVITE SUPREME D ........................................130 DIAMOX SEQUELS ......... 115 DIASTAT ............................. 18 DIASTAT ACUDIAL ..........18 DIATRUE PLUS TEST STRIP ..........................................73 diazepam .........................18, 33 diazepam intensol ................. 33 DIBENZYLINE ................... 41 diclofenac potassium ............ 29 diclofenac sodium ... 30, 54, 114 diclofenac-misoprostol ......... 30 dicloxacillin .......................... 11 dicyclomine .......................... 88 didanosine ............................... 4 diethylpropion....................... 67 DIFFERIN ............................ 57 DIFICID ................................. 8 diflorasone ............................ 64 DIFLUCAN ............................ 3 diflunisal ............................... 30 digitek ................................... 46 digox ..................................... 46 digoxin .................................. 46 dihydrocode-acetaminophencaff ....................................26 dihydrocodeine-aspirin-caff .26 dihydroergotamine ................23 DILANTIN ........................... 18 DILANTIN EXTENDED ..... 18 DILANTIN INFATABS ...... 18 DILANTIN-125 .................... 18 DILATRATE-SR ................. 50 DILAUDID........................... 26 diltiazem hcl ......................... 41 DIOVAN .............................. 41 DIOVAN HCT ..................... 41 DIPENTUM ......................... 90 diphenhydramine hcl .......... 118 diphenoxylate-atropine ......... 88 DIPROLENE ........................ 64

DIPROLENE AF.................. 64 dipyridamole......................... 46 DISALCID ........................... 30 diskets ................................... 27 disopyramide phosphate ....... 38 disulfiram ............................. 68 DITROPAN XL ................. 124 DIURIL ................................ 41 divalproex ............................. 18 DIVIGEL............................ 103 DOLOPHINE ....................... 27 donepezil .............................. 24 DONNATAL........................ 88 dorzolamide ........................ 115 dorzolamide-timolol ........... 115 dothelle dha ........................ 130 DOVONEX .......................... 51 doxazosin.............................. 41 doxepin ........................... 33, 54 doxercalciferol ...................... 84 doxycycline hyclate ........ 12, 13 doxycycline monohydrate .... 13 DRISDOL........................... 130 drithocreme hp...................... 51 dronabinol............................. 90 DROPLET LANCETS ......... 78 drospirenone-ethinyl estradiol ........................................ 107 DROXIA .............................. 14 DUAC................................... 57 DUAVEE ........................... 103 DUET DHA BALANCED . 130 DUET DHA WITH OMEGA-3 ........................................ 130 DUETACT ........................... 86 DULERA............................ 122 duloxetine ............................. 33 DUOPA ................................ 22 DURAGESIC ....................... 27 DUREZOL ......................... 116 dutasteride .......................... 125 dutasteride-tamsulosin........ 125 DUTOPROL......................... 41 DYAZIDE ............................ 41 DYRENIUM ........................ 41 E e.e.s. 400 ................................. 8 E.E.S. GRANULES ............... 8 EASY COMFORT LANCETS .......................................... 78

EASY COMFORT PEN NEEDLES ........................ 78 EASY PLUS II TEST........... 73 EASY STEP ......................... 73 EASY TALK GLUCOSE TEST ................................ 73 EASY TOUCH ..................... 73 EASY TOUCH FLIPLOCK NEEDLE .......................... 78 EASY TOUCH HYPODERMIC NEEDLE .......................................... 78 EASY TRAK GLUCOSE TEST ................................ 74 EASYGLUCO PLUS ........... 74 EASYGLUCO TEST ........... 74 EASYMAX .......................... 74 EC-NAPROSYN .................. 30 econazole .............................. 61 EDARBI ............................... 41 EDARBYCLOR ................... 41 EDECRIN ............................. 41 EDEX ................................. 126 ed-spaz .................................. 88 EDURANT ............................. 4 eemt .................................... 103 eemt hs ................................ 103 effer-k ................................. 128 EFFER-K ............................ 128 EFFEXOR XR ...................... 33 EFFIENT .............................. 46 EFUDEX .............................. 54 ELDEPRYL.......................... 22 ELDERCAPS ..................... 130 ELEMENT COMPACT TEST STRIPS ............................. 74 ELEMENT TEST STRIPS... 74 ELESTAT ........................... 114 ELESTRIN ......................... 103 eletone .................................. 54 ELIDEL ................................ 54 ELIMITE .............................. 66 elinest.................................. 107 eliphos .................................. 90 ELIQUIS .............................. 46 ELIXOPHYLLIN ............... 122 ELLA .................................. 107 ELMIRON .......................... 126 ELOCON .............................. 64 EMADINE.......................... 114 146

EMBRACE BLOOD GLUCOSE SYSTEM ....... 74 EMBRACE EVO TEST STRIPS ............................. 74 EMBRACE PRO TEST STRIPS ............................. 74 EMCYT ................................ 14 EMEND ................................ 90 emoquette ........................... 107 EMSAM ............................... 33 EMTRIVA .............................. 4 emulsion sb ........................... 54 ENABLEX ......................... 125 enalapril maleate ................... 42 enalapril-hydrochlorothiazide .......................................... 42 ENBREL............................. 102 ENBREL SURECLICK .....102 endocet ..................................27 ENGERIX-B (PF) ................ 98 ENGERIX-B PEDIATRIC (PF) ................................... 98 ENJUVIA ........................... 103 enoxaparin ............................ 46 enpresse .............................. 107 enskyce ............................... 107 entacapone ............................ 22 entecavir ................................. 4 ENTEREG ............................ 90 ENTOCORT EC ................... 91 ENTRESTO .......................... 50 enulose .................................. 91 EPANED .............................. 42 EPICERAM .......................... 54 EPIDUO ............................... 58 EPIDUO FORTE .................. 58 EPIFOAM............................. 51 epinastine ............................ 114 epinephrine ......................... 118 EPIPEN 2-PAK .................. 118 EPIPEN JR 2-PAK ............. 118 epitol ..................................... 18 EPIVIR ................................... 4 EPIVIR HBV .......................... 4 eplerenone............................. 42 EPOGEN .............................. 95 epoprostenol (glycine) ..........42 eprosartan .............................42 EPZICOM...............................4 EQUETRO ........................... 18

ergocalciferol (vitamin d2) . 130 ergoloid................................. 33 ERGOMAR .......................... 23 ERIVEDGE .......................... 14 errin .................................... 103 ERTACZO ........................... 61 ery pads ................................ 58 erygel .................................... 58 ERYPED 200 ......................... 8 ERYPED 400 ......................... 8 ery-tab..................................... 8 ERY-TAB............................... 8 erythrocin (as stearate) ........... 8 erythromycin .................. 9, 111 erythromycin ethylsuccinate .. 9 erythromycin with ethanol ... 58 erythromycin-benzoyl peroxide .......................................... 58 ESBRIET............................ 122 ESCAVITE......................... 130 escitalopram oxalate ............. 33 ESGIC .................................. 27 estarylla .............................. 107 estazolam .............................. 33 ESTRACE .......................... 103 estradiol .............................. 103 estradiol valerate ................ 103 estradiol-norethindrone acet ........................................ 104 ESTRING ........................... 104 ESTROGEL ....................... 104 estrogens-methyltestosterone ........................................ 104 estropipate .......................... 104 ESTROSTEP FE-28 ........... 107 eszopiclone ........................... 34 ethambutol .............................. 9 ethosuximide ........................ 18 ethyl chloride ........................ 60 etidronate disodium .............. 68 etodolac ................................ 30 etoposide............................... 14 EURAX ................................ 66 EVAMIST .......................... 104 EVENCARE G2................... 74 EVENCARE G3 TEST ........ 74 EVENCARE MINI GLUCOSE TEST STR..... 74 EVISTA.............................. 101 EVOCLIN ............................ 58

EVOLUTION TEST STRIPS .......................................... 74 EVOTAZ ................................ 4 EVOXAC ............................. 68 EXEL HYPODERMIC NEEDLES ........................ 78 EXELDERM ........................ 61 EXELON .............................. 24 exemestane ........................... 14 EXFORGE............................ 42 EXFORGE HCT................... 42 EXJADE ............................... 68 EXODERM .......................... 61 EXTAVIA ............................ 96 EXTINA ............................... 61 EXTRA-VIRT PLUS DHA 130 EZ FLU 2015-16 (FLUVIRIN) (PF) ................................... 98 EZ FLU 201516(FLUCELVAX)(PF) .... 98 e-z ject lancets ...................... 78 EZ SMART LANCETS ....... 78 EZ SMART PLUS TEST ..... 74 EZ SMART TEST ................ 74 F fabb ..................................... 130 FABIOR ............................... 58 FACTIVE ............................. 12 falmina (28) ........................ 107 famciclovir.............................. 4 famotidine............................. 94 FAMVIR ................................ 4 FANAPT .............................. 34 FARESTON ......................... 14 FARXIGA ............................ 86 FARYDAK ........................... 14 FAZACLO............................ 34 fe c plus .............................. 130 FEIBA NF ............................ 46 felbamate .............................. 18 FELBATOL.......................... 19 FELDENE ............................ 30 felodipine .............................. 42 fem ph ................................. 105 FEMARA ............................. 15 FEMCON FE ...................... 107 FEMHRT LOW DOSE ...... 104 FEMRING .......................... 104 fenofibrate ............................ 49 fenofibrate micronized ......... 49 147

fenofibrate nanocrystallized .49 fenofibric acid .......................49 fenofibric acid (choline) .......49 FENOGLIDE ........................ 49 fenoprofen............................. 30 fentanyl ................................. 27 fentanyl citrate ...................... 27 FENTORA ............................ 27 ferocon ................................ 130 FERRALET 90 DUAL-IRON DELIVERY .................... 130 ferraplus 90 ......................... 130 FERRIPROX ........................ 68 ferrocite plus ....................... 130 ferrogels forte ..................... 130 FEXMID ............................... 25 FIBRICOR ............................ 49 FIFTY50 SAFETY SEAL LANCETS ........................ 78 FIFTY50 TEST STRIP......... 74 FINACEA ............................. 58 finasteride ........................... 125 FINE 30 UNIVERSAL LANCETS ........................ 78 FINGERSTIX LANCETS .... 78 FIORICET ............................ 27 FIORICET WITH CODEINE .......................................... 27 FIORINAL ........................... 27 FIORINAL-CODEINE #3....27 FIRAZYR ........................... 122 FIRST CHOICE LANCETS THIN................................. 78 FLAGYL ................................ 9 FLAGYL ER .......................... 9 FLAREX............................. 116 flavoxate ............................. 125 flecainide .............................. 39 FLECTOR ............................ 30 FLOLAN .............................. 42 FLOMAX ........................... 125 FLOVENT DISKUS .......... 122 FLOVENT HFA ................. 122 FLOW-EZE VENTED NEEDLE........................... 78 FLUARIX QUAD 2015-2016 (PF) ...................................98 FLUBLOK 2015-2016 (PF) .98 flucaine ...............................114

FLUCELVAX 2015-2016 (PF) .......................................... 98 fluconazole ............................. 3 flucytosine .............................. 3 fludrocortisone ..................... 72 FLULAVAL QUAD 20152016 .................................. 98 FLUMADINE ........................ 4 FLUMIST QUAD 2015-2016 .......................................... 98 flunisolide ........................... 122 fluocinolone.......................... 64 fluocinolone acetonide oil .... 71 fluocinolone and shower cap 64 fluocinonide.......................... 64 fluocinonide-e....................... 64 FLUORABON ................... 130 FLUOR-A-DAY................. 131 fluor-a-day (with xylitol)... 130, 131 fluorescein-benoxinate ....... 114 fluorescein-proparacaine .... 114 fluoridex daily defense ......... 70 FLUORIDEX SENSITIVITY RELIEF ............................ 70 fluoritab .............................. 131 FLUORITAB ..................... 131 fluorometholone ................. 116 FLUOROPLEX .................... 54 fluorouracil ........................... 54 fluoxetine.............................. 34 FLUOXETINE ..................... 34 fluphenazine hcl ................... 34 FLURA-DROPS ................ 131 flurandrenolide ..................... 64 flurazepam ............................ 34 flurbiprofen........................... 30 flurbiprofen sodium ............ 114 flurox .................................. 114 flutamide............................... 15 fluticasone .................... 65, 122 fluvastatin ............................. 49 FLUVIRIN 2015-2016 ......... 98 FLUVIRIN 2015-2016 (PF) . 98 fluvoxamine.......................... 34 FLUZONE 2015-2016 ......... 98 FLUZONE HIGH-DOSE 2015-16 (PF) .................... 98 FLUZONE INTRADERM QUAD 2015-16 ................ 98

FLUZONE QUAD 2015-2016 .......................................... 98 FLUZONE QUAD 2015-2016 (PF) ................................... 98 FLUZONE QUAD PEDI 2015-16 (PF)..................... 99 FML FORTE ...................... 116 FML LIQUIFILM .............. 116 FML S.O.P. ........................ 116 focalgin 90 dha ................... 131 focalgin ca .......................... 131 focalgin dss ......................... 131 FOCALIN ............................. 34 FOCALIN XR ...................... 34 folbecal ............................... 131 folbee .................................. 131 folbee plus .......................... 131 FOLGARD OS ................... 131 FOLGARD RX................... 131 folic acid ............................. 131 folic acid-vit b6-vit b12 ...... 131 folivane-f ............................ 131 folivane-ob.......................... 131 folivane-plus ....................... 131 FOLLISTIM AQ .................. 84 folplex 2.2........................... 131 FOLTRATE........................ 131 fondaparinux ......................... 46 FORA D10 ........................... 74 FORA D15G......................... 74 FORA D20 ........................... 74 FORA D40-G31 TEST STRIPS ............................. 74 FORA G20 ........................... 74 FORA G30A......................... 74 FORA GD50 TEST STRIPS 74 FORA TEST STRIP ............. 74 FORA TN'G VOICE TEST STRIPS ............................. 74 FORA V10 ........................... 74 FORA V10-V12-D10-D20 ... 78 FORA V12 GLUCOSE ........ 74 FORA V20 ........................... 74 FORACARE GD20 .............. 74 FORACARE GD40 .............. 74 FORACARE LANCETS ...... 78 FORADIL AEROLIZER ... 122 FORTAMET ........................ 86 FORTAVIT ........................ 129 FORTEO ............................ 101 148

fortical................................... 84 FORTISCARE GLUCOSE TEST STRIPS .................. 74 FOSAMAX.........................101 FOSAMAX PLUS D .......... 101 fosinopril............................... 42 fosinopril-hydrochlorothiazide .......................................... 42 FOSRENOL ......................... 91 FRAGMIN ...................... 46, 47 FREESTYLE INSULINX ....74 FREESTYLE INSULINX TEST STRIPS .................. 75 FREESTYLE LANCETS ..... 78 FREESTYLE LITE STRIPS 75 FREESTYLE PRECISION NEO STRIPS .................... 75 FREESTYLE TEST ............. 75 FREESTYLE UNISTIK 2 .... 78 frovatriptan ........................... 23 FURADANTIN .................... 13 furosemide ............................ 42 FUZEON ................................ 5 fyavolv ................................ 104 FYCOMPA ........................... 19 G G-4 TEST ............................. 75 gabapentin............................. 19 GABITRIL ........................... 19 galantamine........................... 24 GALZIN ............................. 128 GAMMAGARD LIQUID .... 99 GAMUNEX-C ...................... 99 GANIRELIX ........................ 84 GARDASIL (PF) .................. 99 GARDASIL 9 (PF) ............... 99 GASTROCROM .................. 91 gatifloxacin ......................... 111 GATTEX 30-VIAL .............. 91 gavilyte-c .............................. 91 gavilyte-g .............................. 91 gavilyte-h and bisacodyl ....... 91 gavilyte-n .............................. 91 GE100 BLOOD GLUCOSE TEST STRIP ..................... 75 GELCLAIR .......................... 70 GELNIQUE ........................ 125 gemfibrozil ........................... 49 GENERESS FE .................. 107 generlac................................. 91

gengraf .................................. 15 GENSTRIP TEST STRIP .... 75 gentak ................................. 111 gentamicin ............ 60, 111, 112 GENVOYA ............................ 5 GEODON ............................. 34 gianvi (28) .......................... 107 GIAZO ................................. 91 gildagia ............................... 107 gildess 1.5/30 (21) .............. 107 gildess 1/20 (21) ................. 107 gildess 24 fe........................ 107 gildess fe 1.5/30 (28) .......... 107 gildess fe 1/20 (28) ............. 107 GILENYA ............................ 96 GILOTRIF ............................ 15 glatopa .................................. 96 GLEEVEC ............................ 15 GLEOSTINE ........................ 15 glimepiride ........................... 86 glipizide ................................ 86 glipizide-metformin.............. 86 GLUCAGEN DIAGNOSTIC KIT ................................... 76 GLUCAGEN HYPOKIT ..... 77 GLUCAGON EMERGENCY KIT (HUMAN) ................ 77 GLUCO NAVII TEST STRIP .......................................... 75 GLUCOCARD 01 SENSOR PLUS ................................ 75 GLUCOCARD EXPRESSION .......................................... 75 GLUCOCARD SHINE TEST STRIPS ............................. 75 GLUCOCARD VITAL SENSOR........................... 75 GLUCOCARD VITAL TEST STRIPS ............................. 75 GLUCOCOM GLUCOSE.... 75 GLUCOCOM LANCETS .... 78 GLUCOPHAGE ................... 86 GLUCOPHAGE XR ............ 86 GLUCOTROL...................... 86 GLUCOTROL XL ............... 86 GLUCOVANCE .................. 86 glyburide............................... 86 glyburide micronized............ 86 glyburide-metformin ............ 86 glycopyrrolate....................... 88

glydo ..................................... 60 GLYNASE ........................... 86 GLYSET............................... 86 GLYXAMBI ........................ 86 GM100.................................. 75 GMATE LANCETS ............. 78 GMATE TEST STRIPS ....... 75 GOLYTELY ......................... 91 GONAL-F ............................ 84 GONAL-F RFF .................... 84 GONAL-F RFF REDI-JECT 84 GORDONS UREA ............... 54 granisetron hcl ...................... 91 GRASTEK............................ 99 griseofulvin microsize ............ 3 griseofulvin ultramicrosize ..... 3 GRIS-PEG (ULTRAMICROSIZE) ...... 3 guaifenesin ac ..................... 119 guaifenesin dac ................... 119 guanfacine ...................... 34, 42 guanidine .............................. 34 GYNAZOLE-1 ................... 105 H HALCION ............................ 34 halobetasol propionate .......... 65 HALOG ................................ 65 haloperidol ............................ 34 haloperidol lactate ................ 34 HARVONI.............................. 5 HAVRIX (PF) ...................... 99 HEALTHPRO TEST STRIPS .......................................... 75 HEALTHY ACCENTS UNIFINE PENTIP ........... 79 HEALTHY ACCENTS UNILET LANCET ........... 79 heather ................................ 104 HECTOROL......................... 84 HELIXATE FS ..................... 47 hematinic plus vit/minerals 131 hematinic/folic acid ............ 131 hematogen .......................... 131 hematogen fa ...................... 131 hematogen forte .................. 131 HEMATRON ..................... 131 HEMATRON-AF ............... 131 HEMAX ............................. 131 hemenatal ob....................... 132 hemenatal ob + dha ............ 131 149

hemetab...............................132 hemmorex-hc ........................ 91 HEMOCYTE-F .................. 132 HEMOCYTE-PLUS ........... 132 HEMOFIL M HIGH ............. 47 HEMOFIL M LOW .............. 47 HEMOFIL M MID ............... 47 HEMOFIL M SUPER HIGH47 hep flush-10 (pf) ................... 47 heparin (porcine) .................. 47 heparin lock flush ................. 47 heparin lock flush (porcine)..47 heparin lockflush(porcine)(pf) ..........................................47 heparin, porcine (pf) ............. 47 HEPSERA .............................. 5 HEXALEN ........................... 15 HIPREX ................................ 13 HIZENTRA .......................... 99 homatropaire ....................... 113 homatropine hbr.................. 113 HORIZANT .......................... 24 hpr ......................................... 54 hpr plus ................................. 54 hpr plus hydrogel .................. 54 HPR PLUS-MB HYDROGEL .......................................... 54 huber safety needles (disp.) .. 79 HUMALOG .......................... 82 HUMALOG KWIKPEN ...... 82 HUMALOG MIX 50-50....... 82 HUMALOG MIX 50-50 KWIKPEN ........................ 82 HUMALOG MIX 75-25....... 82 HUMALOG MIX 75-25 KWIKPEN ........................ 82 HUMATE-P ......................... 47 HUMIRA ............................ 102 HUMIRA PEDIATRIC CROHN'S START.......... 102 HUMIRA PEN CROHN'SUC-HS START .............. 102 HUMULIN 70/30 ................. 82 HUMULIN 70/30 KWIKPEN .......................................... 82 HUMULIN N ....................... 82 HUMULIN N KWIKPEN .... 82 HUMULIN R........................ 82 HUMULIN R U-500 (CONC) KWIKPEN ........................ 82

HUMULIN R U-500 (CONCENTRATED) ....... 82 HYCAMTIN ........................ 15 HYCET................................. 27 hydralazine ........................... 42 HYDREA ............................. 15 HYDRO 35........................... 54 HYDRO 40........................... 54 hydrochlorothiazide.............. 42 hydrocodone-acetaminophen 27 hydrocodone-chlorpheniramine ........................................ 119 hydrocodone-cpmpseudoephed ................... 119 hydrocodone-homatropine . 119 hydrocodone-ibuprofen ........ 27 hydrocortisone .......... 65, 72, 91 hydrocortisone acetate .......... 91 hydrocortisone butyrate ........ 65 hydrocortisone butyr-emollient .......................................... 65 hydrocortisone valerate ........ 65 hydrocortisone-acetic acid.... 71 hydrocortisone-min oil-wht pet .......................................... 65 hydrocortisone-pramoxine .. 51, 91 hydromet............................. 119 hydromorphone .................... 27 hydroxychloroquine ............. 10 hydroxyurea .......................... 15 hydroxyzine hcl .................. 118 hydroxyzine pamoate ......... 118 HYLATOPIC ....................... 54 HYLATOPIC PLUS ............ 54 hyolev mb ........................... 126 hyophen .............................. 126 hyoscyamine sulfate ............. 88 hyosyne................................. 88 HYPER-SAL ...................... 122 HYQVIA .............................. 99 HYZAAR ............................. 42 I ibandronate ......................... 102 IBRANCE ............................ 15 IBUDONE ............................ 27 ibuprofen .............................. 30 ibuprofen-oxycodone ........... 27 ICAR-C PLUS.................... 132 ICLUSIG .............................. 15

ILOTYCIN ......................... 112 imatinib................................. 15 IMBRUVICA ....................... 15 imipramine hcl ...................... 34 imipramine pamoate ............. 34 imiquimod ............................ 97 IMITREX ............................. 23 IMITREX STATDOSE KIT REFILL ............................ 23 IMITREX STATDOSE PEN23 IMOVAX RABIES VACCINE (PF) ................................... 99 IMURAN .............................. 15 inatal advance ..................... 132 inatal ultra ........................... 132 INCONTROL PEN NEEDLE .......................................... 79 INCONTROL SUPER THIN LANCETS ........................ 79 INCONTROL ULTRA THIN LANCETS ........................ 79 indapamide ........................... 42 INDERAL LA ...................... 42 INDERAL XL ...................... 42 INDOCIN ............................. 30 indomethacin ........................ 30 INFANRIX (DTAP) (PF)..... 99 INFASURF........................... 68 INFINITY TEST STRIPS .... 75 INJECT EASE LANCETS... 79 INLYTA ............................... 15 INNOPRAN XL ................... 42 INOVA ................................. 58 INOVA 4-1 ........................... 52 INOVA 8-2 ........................... 52 INSPRA ................................ 42 INSUPEN ............................. 79 INTEGRA F ....................... 132 INTEGRA PLUS ................ 132 INTELENCE .......................... 5 INTRON A ........................... 97 introvale .............................. 107 INTUNIV ER ....................... 34 INVACARE LANCETS ...... 79 INVEGA ............................... 34 INVIRASE ............................. 5 INVOKAMET ...................... 86 INVOKANA ........................ 86 iophen c-nr .......................... 119 IOPIDINE ........................... 117 150

IPOL ..................................... 99 ipratropium bromide ..... 70, 122 ipratropium-albuterol .......... 122 irbesartan .............................. 42 irbesartan-hydrochlorothiazide .......................................... 42 IRESSA ................................ 15 IROSPAN 24/6 ................... 132 ISENTRESS ........................... 5 ISOCHRON .......................... 50 isometh-dichloralacetaminophn .................... 23 isomethepten-cafacetaminophen .................. 23 isoniazid ................................ 10 ISOPTO ATROPINE ......... 113 ISOPTO CARPINE ............113 ISORDIL .............................. 50 ISORDIL TITRADOSE ....... 50 isosorbide dinitrate ............... 50 isosorbide mononitrate ......... 51 isoxsuprine.......................... 105 isradipine .............................. 42 ISTALOL ........................... 112 itraconazole............................. 3 ivermectin ............................. 10 IXIARO (PF) ........................ 99 J JADENU............................... 68 JAKAFI ................................ 15 JALYN ............................... 125 jantoven ................................ 47 JANUMET ........................... 86 JANUMET XR ..................... 86 JANUVIA ............................. 86 jencycla ............................... 104 JENTADUETO .................... 86 jevantique lo ....................... 104 jinteli ................................... 104 jolessa ................................. 107 jolivette ............................... 104 juleber ................................. 107 junel 1.5/30 (21) ................. 108 junel 1/20 (21) .................... 108 junel fe 1.5/30 (28) ............. 108 junel fe 1/20 (28) ................ 108 junel fe 24 ........................... 108 JUXTAPID ........................... 49 K KADIAN .............................. 27

kaitlib fe.............................. 108 KALETRA ............................. 5 KALYDECO ...................... 122 KAPVAY ............................. 34 kariva (28) .......................... 108 KAYEXALATE ................... 91 k-effervescent ..................... 128 KEFLEX................................. 8 kelnor 1/35 (28) .................. 108 KENALOG........................... 65 KEPPRA............................... 19 KEPPRA XR ........................ 19 KERAFOAM ....................... 54 KERALAC ........................... 54 KERALYT RX..................... 53 KERALYT SCALP COMPLETE ..................... 53 KETEK ................................. 10 ketoconazole ..................... 3, 61 ketoprofen............................. 30 ketorolac ....................... 30, 114 KEVEYIS ............................. 24 kimidess (28) ...................... 108 KINERET ............................. 97 KINNEY BRAND LANCETS .......................................... 79 KINRIX (PF) ........................ 99 kionex ................................... 91 KLARON ............................. 60 KLONOPIN ......................... 19 klor-con .............................. 128 klor-con 10 ......................... 128 klor-con 8 ........................... 128 klor-con m10 ...................... 128 klor-con m15 ...................... 128 klor-con m20 ...................... 128 klor-con sprinkle ................ 128 KLOR-CON/25 .................. 128 klor-con/ef .......................... 128 KOATE-DVI ........................ 47 KOGENATE FS ................... 47 KORLYM............................. 84 K-PHOS NO 2.................... 126 K-PHOS ORIGINAL ......... 126 k-phos-neutral..................... 128 KRISTALOSE ..................... 91 k-sol .................................... 128 k-tab.................................... 128 K-TAB................................ 128 kurvelo................................ 108

KUVAN................................ 84 KYNAMRO ......................... 49 L l norgest/e.estradiol-e.estrad ........................................ 108 labetalol ................................ 42 lactated ringers ..................... 67 lactic acid .............................. 55 lactic acid e ........................... 54 lactulose ................................ 91 LAMICTAL ......................... 19 LAMICTAL ODT ................ 19 LAMICTAL ODT STARTER (BLUE) ............................. 19 LAMICTAL ODT STARTER (GREEN) .......................... 19 LAMICTAL ODT STARTER (ORANGE) ....................... 19 LAMICTAL STARTER (BLUE) KIT ..................... 19 LAMICTAL STARTER (GREEN) KIT .................. 19 LAMICTAL STARTER (ORANGE) KIT ............... 19 LAMICTAL XR ................... 19 LAMICTAL XR STARTER (BLUE) ............................. 19 LAMICTAL XR STARTER (GREEN) .......................... 19 LAMICTAL XR STARTER (ORANGE) ....................... 19 lamivudine .............................. 5 lamivudine-zidovudine ........... 5 lamotrigine............................ 20 LANCETS ............................ 79 LANCETS,THIN ................. 79 LANOXIN ............................ 46 lansoprazole .......................... 94 LANTUS .............................. 83 LANTUS SOLOSTAR......... 82 larin 1.5/30 (21) .................. 108 larin 1/20 (21) ..................... 108 larin 24 fe............................ 108 larin fe 1.5/30 (28) .............. 108 larin fe 1/20 (28) ................. 108 LASIX .................................. 42 LASTACAFT ..................... 114 latanoprost .......................... 115 latrix...................................... 55 LATUDA.............................. 34 151

laxative peg 3350 .................. 91 layolis fe ............................. 108 leena 28 ............................... 108 leflunomide ......................... 102 LENVIMA ............................ 15 LESCOL ............................... 49 LESCOL XL ......................... 49 lessina ................................. 108 letrozole ................................ 15 leucovorin calcium ............... 13 LEUKERAN......................... 15 leuprolide .............................. 15 levalbuterol hcl ................... 122 LEVAQUIN ......................... 12 LEVATOL ............................ 42 LEVBID ............................... 88 LEVEMIR ............................ 83 LEVEMIR FLEXTOUCH....83 levetiracetam.........................20 LEVITRA ........................... 126 levobunolol ......................... 112 levocarnitine ......................... 68 levocarnitine (with sugar) ..... 68 levocetirizine ...................... 118 levofloxacin .................. 12, 112 levomefolate dha ................ 132 levonest (28) ....................... 108 levonorgestrel-ethinyl estrad ........................................ 108 levonorg-eth estrad triphasic ........................................ 108 levora-28 ............................. 108 levorphanol tartrate ............... 27 levothyroxine ........................ 87 levoxyl .................................. 87 LEVSIN ................................ 88 LEVSIN/SL .......................... 89 LEVULAN ........................... 55 LEXAPRO ............................ 35 LEXIVA ................................. 5 LIALDA ............................... 91 LIBERTY TEST ................... 75 LIBRAX (WITH CLIDINIUM) ................... 89 lidocaine hcl.......................... 60 lidocaine hcl-hydrocortison ac .................................... 60, 91 lidocaine viscous .................. 60 lidocaine-hydrocortisone-aloe .......................................... 91

lidocaine-prilocaine .............. 60 LIFESHIELD BLUNT CANNULA ...................... 79 lindane .................................. 66 linezolid ................................ 10 LINZESS .............................. 91 liothyronine .......................... 87 LIPITOR............................... 49 LIPOCHOL PLUS ............... 68 LIPOFEN ............................. 49 lisinopril ............................... 42 lisinopril-hydrochlorothiazide .......................................... 43 LITE TOUCH LANCETS ... 79 lithium carbonate .................. 35 lithium citrate ....................... 35 LITHOBID ........................... 35 LITHOSTAT ........................ 68 LIVALO ............................... 49 LO LOESTRIN FE............. 108 LOCOID ............................... 65 LOCOID LIPOCREAM ....... 65 LODOSYN ........................... 22 LOESTRIN 1.5/30 (21) ...... 108 LOESTRIN 1/20 (21) ......... 108 LOESTRIN FE 1.5/30 (28DAY) .............................. 108 LOESTRIN FE 1/20 (28-DAY) ........................................ 108 LOFIBRA ............................. 49 lomedia 24 fe ...................... 108 LOMOTIL ............................ 89 LONSURF............................ 15 LOPID .................................. 49 lopreeza .............................. 104 LOPRESSOR ....................... 43 LOPRESSOR HCT .............. 43 LOPROX .............................. 61 lorazepam ............................. 35 lorazepam intensol................ 35 lorcet (hydrocodone) ............ 27 lorcet hd ................................ 27 lorcet plus ............................. 27 lortab 10-325 ........................ 27 lortab 5-325 .......................... 27 lortab 7.5-325 ....................... 27 LORTAB ELIXIR ................ 27 lortuss ex ............................ 119 loryna (28) .......................... 108 losartan ................................. 43

losartan-hydrochlorothiazide 43 LOSEASONIQUE.............. 109 LOTEMAX ........................ 116 LOTENSIN .......................... 43 LOTENSIN HCT ................. 43 LOTREL............................... 43 LOTRISONE ........................ 61 LOTRONEX ........................ 92 LOUTREX ........................... 55 lovastatin .............................. 49 LOVENOX ........................... 47 low-ogestrel (28) ................ 109 loxapine succinate ................ 35 ludent fluoride .................... 132 lugols .................................. 128 LUMIGAN ......................... 115 LUNESTA ............................ 35 LUPANETA PACK (1 MONTH) ........................ 105 LUPANETA PACK (3 MONTH) ........................ 105 lutera (28) ........................... 109 LUXIQ.................................. 65 LYNPARZA ......................... 15 LYRICA ............................... 20 LYSODREN ......................... 15 LYSTEDA .......................... 105 lyza ..................................... 104 M macnatal cn dha .................. 132 MACROBID ........................ 13 MACRODANTIN ................ 13 MAGNEBIND 400............... 92 MALARONE ....................... 10 MALARONE PEDIATRIC . 10 malathion .............................. 66 maprotiline............................ 35 MAR-COF BP .................... 119 MAR-COF CG ................... 119 margesic................................ 28 MARINOL ........................... 92 marlissa............................... 109 MARNATAL-F .................. 132 MARPLAN .......................... 35 marten-tab ............................. 28 MATULANE........................ 15 MAVIK ................................ 43 MAXARON FORTE.......... 132 MAXIDEX ......................... 116 MAXIMA ............................. 75 152

MAXINATE ....................... 132 MAXITROL ....................... 115 MAXZIDE ............................ 43 MAXZIDE-25MG ................ 43 m-clear wc .......................... 119 meclofenamate ...................... 30 MEDISENSE THIN LANCETS ........................ 79 MEDLANCE PLUS LANCETS ........................ 79 MEDLANCE PLUS SPECIAL BLADE ............................. 79 MEDROL ............................. 72 MEDROL (PAK).................. 72 medroxyprogesterone ......... 104 mefenamic acid ..................... 30 mefloquine ............................ 10 MEGACE ............................. 15 MEGACE ES........................ 15 megestrol .............................. 15 MEKINIST ........................... 15 meloxicam ............................ 30 memantine ............................ 24 MEMANTINE ...................... 24 MENACTRA (PF)................ 99 M-END MAX D ................. 119 M-END PE ......................... 119 MENEST ............................ 104 MENHIBRIX (PF) ............... 99 MENOMUNE - A/C/Y/W-135 ..........................................99 MENOMUNE - A/C/Y/W-135 (PF) ...................................99 MENOPUR...........................84 MENOSTAR ......................104 MENVEO A-C-Y-W-135-DIP (PF) .................................100 meperidine ............................28 MEPHYTON ........................47 MEPRON .............................10 mercaptopurine .....................15 mesalamine ...........................92 mesalamine with cleansing wipe ..................................92 MESNEX ..............................13 MESTINON .........................25 MESTINON TIMESPAN ....25 METADATE CD..................35 metadate er............................35 metaproterenol ....................122

metaxalone ........................... 25 metformin ............................. 86 methadone ............................ 28 methadose ............................. 28 methamphetamine ................ 35 methazolamide ................... 115 methenamine hippurate ........ 13 methenamine mandelate ....... 13 methen-sod phos-meth bluehyos ................................ 126 methimazole ......................... 72 METHITEST........................ 84 methocarbamol ..................... 25 methotrexate sodium ............ 16 methotrexate sodium (pf) ..... 16 methoxsalen rapid ................ 55 methscopolamine.................. 89 methyclothiazide .................. 43 methyldopa ........................... 43 methyldopahydrochlorothiazide.......... 43 methylergonovine ............... 111 METHYLIN ......................... 35 methylphenidate ................... 35 methylprednisolone .............. 72 methyltestosterone ................ 84 metipranolol ....................... 112 metoclopramide hcl .............. 92 metolazone ........................... 43 METOPIRONE .................... 68 metoprolol succinate ............ 43 metoprolol ta-hydrochlorothiaz .......................................... 43 metoprolol tartrate ................ 43 METROCREAM.................. 58 METROGEL ........................ 58 METROGEL VAGINAL ... 105 METROLOTION ................. 58 metronidazole ......... 10, 58, 105 mexiletine ............................. 39 MIACALCIN ....................... 84 MICARDIS .......................... 43 MICARDIS HCT ................. 43 miconazole-3 ...................... 105 MICRO BLOOD GLUCOSE .......................................... 75 MICRO THIN LANCETS ... 79 MICRODOT BLOOD GLUCOSE SYSTEM....... 75 microgestin 1.5/30 (21) ...... 109

microgestin 1/20 (21) ......... 109 MICROGESTIN 24 FE ...... 109 microgestin fe 1.5/30 (28) .. 109 microgestin fe 1/20 (28) ..... 109 MICROLET LANCET ......... 79 MICROZIDE ........................ 43 midazolam ............................ 35 midodrine.............................. 68 migergot................................ 23 MIGRANAL ........................ 23 millipred ............................... 72 MILLIPRED ......................... 72 millipred dp .......................... 72 mimvey ............................... 104 mimvey lo ........................... 104 MINASTRIN 24 FE ........... 109 MINI ULTRA-THIN II ........ 79 MINIPRESS ......................... 43 MINITRAN .......................... 51 MINIVELLE ...................... 104 minocycline .......................... 13 minoxidil .............................. 43 MIOCHOL-E...................... 113 miostat ................................ 115 MIRAPEX ............................ 22 MIRAPEX ER ...................... 22 MIRCERA ............................ 95 MIRCETTE (28) ................ 109 mirtazapine ........................... 35 misoprostol ........................... 94 MITOSOL .......................... 115 mitoxantrone......................... 16 M-M-R II (PF) .................... 100 MOBIC ................................. 30 modafinil .............................. 35 moderiba ............................... 96 moderiba dose pack .............. 96 MODICON (28) ................. 109 moexipril .............................. 43 moexipril-hydrochlorothiazide .......................................... 43 mometasone .................. 65, 122 MONOCLATE-P ................. 47 monoject 0.9% sodium chloride ............................. 68 MONOJECT BLOOD COLLECTION ................. 79 MONOJECT HYPODERMIC NEEDLES ........................ 79 153

MONOJECT MEDICATION TRANSF NDL.................. 79 monoject prefill (pf) ............. 47 monoject prefill advanced (pf) .......................................... 47 monoject prefill advanced ns 68 monoject prefill saline flush . 68 MONOLET THIN LANCETS .......................................... 79 mono-linyah ........................ 109 mononessa (28) ................... 109 MONONINE ........................ 47 montelukast......................... 122 MONUROL .......................... 13 morphine ............................... 28 morphine concentrate ........... 28 MOTOFEN ........................... 89 MOVIPREP .......................... 92 MOXEZA ........................... 112 moxifloxacin ......................... 12 MOZOBIL ............................ 95 MS CONTIN ........................ 28 MUGARD ............................ 70 MULTAQ ............................. 39 MULTI-DRAW NEEDLE ... 79 multigen folic...................... 132 multigen plus ...................... 132 multi-vit with fluoride-iron. 132 multi-vitamin with fluoride 132 multivitamins with fluoride 132 mupirocin .............................. 60 mupirocin calcium ................ 60 MUSE ................................. 126 mvc-fluoride ....................... 132 M-VIT................................. 132 MYALEPT ........................... 84 MYAMBUTOL .................... 10 MYCOBUTIN ...................... 10 mycophenolate mofetil ......... 16 mycophenolate sodium ......... 16 MYDRIACYL .................... 113 MYFORTIC ......................... 16 MYGLUCOHEALTH .......... 75 MYGLUCOHEALTH LANCETS ........................ 79 MYKIDZ IRON FLUORIDE ........................................ 133 MYLERAN .......................... 16 mynatal ............................... 133 mynatal advance ................. 133

mynatal plus ....................... 133 mynatal-z ............................ 133 mynate 90 plus ................... 133 mynephrocaps..................... 133 myorisan ............................... 58 MYRBETRIQ .................... 125 MYSOLINE ......................... 20 myzilra ................................ 109 N nabumetone .......................... 30 nadolol .................................. 43 nadolol-bendroflumethiazide 43 naftifine ................................ 61 NAFTIFINE ......................... 61 NAFTIN ............................... 61 NALFON.............................. 31 naltrexone ............................. 31 NAMENDA ......................... 24 NAMENDA TITRATION PAK .................................. 25 NAMENDA XR ................... 25 NAMZARIC......................... 25 naphazoline......................... 117 NAPRELAN CR .................. 31 NAPROSYN ........................ 31 naproxen ............................... 31 naproxen sodium .................. 31 naratriptan............................. 23 NARDIL ............................... 35 NATACHEW (FE BISGLYCINATE) ................ 133 NATACYN ........................ 112 NATALVIT ........................ 133 NATAZIA .......................... 109 nateglinide ............................ 86 NATELLE ONE ................. 133 NATPARA ........................... 84 NATROBA........................... 66 nature-throid ......................... 87 NEBUPENT ......................... 10 NEBUSAL ......................... 122 necon 0.5/35 (28)................ 109 necon 1/35 (28)................... 109 necon 1/50 (28)................... 109 necon 10/11 (28)................. 109 necon 7/7/7 (28) ................. 109 NEEDLES, HUBER DISPOSABLE.................. 79 nefazodone ........................... 35 neomycin .............................. 10

neomycin-bacitracin-poly-hc ........................................ 115 neomycin-bacitracinpolymyxin....................... 112 neomycin-polymyxin b gu.... 67 neomycin-polymyxin bdexameth ........................ 116 neomycin-polymyxingramicidin....................... 112 neomycin-polymyxin-hc ..... 71, 116 neo-polycin ......................... 112 neo-polycin hc .................... 116 NEORAL .............................. 16 NEOSALUS ......................... 55 NEOSPORIN (NEO-POLYMGRAMICID) .................. 112 NEOSPORIN GU IRRIGANT .......................................... 67 NEO-SYNALAR.................. 61 NEO-SYNALAR KIT .......... 60 nephplex rx ......................... 133 NEPHROCAPS .................. 133 NEPHROCAPS QT............ 133 NEPHRON FA ................... 133 nephro-vite rx ..................... 133 NEPTAZANE .................... 115 NESTABS .......................... 133 NESTABS ABC ................. 133 NESTABS DHA................. 133 neuac ..................................... 58 NEULASTA ......................... 95 NEUPOGEN ........................ 95 NEUPRO .............................. 22 NEURIN-SL ....................... 133 NEURONTIN ....................... 20 NEUTEK 2TEK TEST STRIPS ............................. 75 nevirapine ............................... 5 newgen................................ 133 NEXA PLUS ...................... 133 NEXAVAR .......................... 16 NEXIUM PACKET ............. 94 niacin .................................... 49 NIACOR ............................... 49 NIASPAN EXTENDEDRELEASE ........................ 49 nicardipine ............................ 43 NICOTROL .......................... 69 NICOTROL NS .................... 69 154

nifedical xl ............................ 43 nifedipine .............................. 43 nikki (28) ............................ 109 NILANDRON ...................... 16 nimodipine ............................ 44 NINLARO ............................ 16 nisoldipine ............................44 nitro-bid ................................ 51 NITRO-DUR ........................ 51 nitrofurantoin ........................ 13 nitrofurantoin macrocrystal .. 13 nitrofurantoin monohyd/mcryst .................................. 13 nitroglycerin ......................... 51 NITROLINGUAL ................ 51 NITROMIST ........................ 51 NITROSTAT ........................ 51 nitro-time .............................. 51 NIVA-PLUS ....................... 133 nivatopic plus........................ 55 nizatidine .............................. 94 NIZORAL............................. 61 nodolor .................................. 23 NOKOR NEEDLE ............... 79 nora-be ................................ 104 NORCO ................................ 28 NORDITROPIN FLEXPRO 95 noreth-ethinyl estradiol-iron ........................................ 109 norethindrone (contraceptive) ........................................ 104 norethindrone acetate..........104 norethindrone ac-eth estradiol ................................104, 109 norethindrone-e.estradiol-iron ........................................109 norgestimate-ethinyl estradiol ........................................109 NORINYL 1+35 (28) ......... 109 NORINYL 1+50 (28) ......... 109 NORITATE ..........................58 norlyroc...............................104 normal saline flush ...............69 NORPACE ...........................39 NORPACE CR .....................39 NORPRAMIN ......................35 NOR-QD.............................104 NORTHERA ........................69 nortrel 0.5/35 (28) ...............109 nortrel 1/35 (21) ..................109

nortrel 7/7/7 (28) ................ 109 nortriptyline .......................... 36 NORVASC ........................... 44 NORVIR................................. 5 NOVA MAX GLUCOSE TEST ................................ 75 NOVA SAFETY LANCETS79 NOVA SUREFLEX LANCETS ........................ 79 NOVACORT........................ 60 novarel .................................. 84 NOVOFINE 32 .................... 79 NOVOFINE AUTOCOVER 80 NOVOFINE PLUS ............... 80 NOVOLIN 70/30.................. 83 NOVOLIN N ........................ 83 NOVOLIN R ........................ 83 NOVOLOG .......................... 83 NOVOLOG FLEXPEN........ 83 NOVOLOG MIX 70-30 ....... 83 NOVOLOG MIX 70-30 FLEXPEN ........................ 83 NOVOLOG PENFILL ......... 83 NOVOPEN ECHO ............... 80 NOVOSEVEN RT ............... 47 NOVOTWIST ...................... 80 NOXAFIL .............................. 3 np thyroid ............................. 87 NUCYNTA .......................... 31 NUCYNTA ER .................... 31 NUEDEXTA ........................ 25 NULEV ................................ 89 NULYTELY WITH FLAVOR PACKS ............................. 92 NUOX .................................. 58 NUTRICAP ........................ 133 NUVARING....................... 105 NUVESSA ......................... 105 NUVIGIL ............................. 36 nyamyc ................................. 61 nystatin ....................... 3, 61, 62 nystatin-triamcinolone .......... 62 nystop ................................... 62 O OB COMPLETE ................ 133 OB COMPLETE ONE ....... 133 OB COMPLETE PETITE .. 133 OB COMPLETE PREMIER ........................................ 133

OB COMPLETE WITH DHA ........................................ 133 obstetrix dha ....................... 133 OBSTETRIX EC ................ 134 OBTREX DHA .................. 134 O-CAL FA .......................... 134 ocella .................................. 109 octreotide acetate .................. 16 OCUFEN ............................ 115 OCUFLOX ......................... 112 ODEFSEY .............................. 5 ODOMZO ............................ 16 OFEV.................................. 122 ofloxacin ................. 12, 71, 112 ogestrel (28) ........................ 110 olanzapine............................. 36 olanzapine-fluoxetine ........... 36 olopatadine ................... 70, 114 OLUX ................................... 65 OLUX-E ............................... 65 OMECLAMOX-PAK .......... 94 omeprazole ........................... 94 OMNIPRED ....................... 116 ON CALL EXPRESS TEST STRIP ............................... 75 ON CALL LANCET ............ 80 ON CALL PLUS LANCET . 80 ON CALL PLUS TEST STRIP .......................................... 75 ON CALL VIVID TEST STRIP ............................... 75 ondansetron .......................... 92 ondansetron hcl..................... 92 ONETOUCH ULTRA TEST .......................................... 75 ONETOUCH ULTRASOFT LANCETS ........................ 80 ONETOUCH VERIO ........... 75 ONFI..................................... 20 ONMEL .................................. 3 ON-THE-GO LANCETS ..... 80 OPANA ................................ 28 OPANA ER .......................... 28 opium tincture....................... 89 OPSUMIT .......................... 122 OPTIUM EZ ......................... 75 OPTIUM TEST .................... 75 OPTUMRX .......................... 76 ORACIT ............................. 126 ORALAIR .......................... 100 155

oralone .................................. 70 ORAMAGICRX ................... 70 ORAP ................................... 36 ORAPRED ODT .................. 72 ORAVIG................................. 3 ORENCIA .......................... 102 ORENITRAM ...................... 44 ORFADIN ............................ 69 ORKAMBI ......................... 122 orphenadrine citrate .............. 25 orsythia ............................... 110 ORTHO MICRONOR ........ 105 ORTHO TRI-CYCLEN (28) ........................................ 110 ORTHO TRI-CYCLEN LO (28) ................................. 110 ORTHO-CYCLEN (28) ..... 110 ORTHO-NOVUM 1/35 (28) ........................................ 110 ORTHO-NOVUM 7/7/7 (28) ........................................ 110 oscimin ................................. 89 oscimin sl .............................. 89 oscimin sr.............................. 89 OSMOPREP ......................... 92 OSPHENA .......................... 105 OTEZLA............................. 102 OTEZLA STARTER .......... 102 OVACE ................................ 52 OVACE PLUS...................... 52 OVACE PLUS SHAMPOO . 51 OVACE PLUS WASH ......... 52 OVCON-35 (28) ................. 110 OVIDE .................................. 66 OVIDREL............................. 85 OXANDRIN ......................... 85 oxandrolone .......................... 85 oxaprozin .............................. 31 oxazepam .............................. 36 oxcarbazepine ....................... 20 oxiconazole ........................... 62 OXISTAT ............................. 62 OXSORALEN ...................... 55 OXSORALEN ULTRA........55 OXTELLAR XR .................. 20 oxybutynin chloride ............ 125 oxycodone............................. 28 oxycodone-acetaminophen ... 28 oxycodone-aspirin ................ 28 OXYCONTIN ...................... 28

oxymorphone........................ 28 OXYTROL ......................... 125 P pacerone ............................... 39 PACNEX .............................. 58 PAIRE OB PLUS DHA ..... 134 paliperidone .......................... 36 PAMELOR ........................... 36 PANDEL .............................. 65 PANRETIN .......................... 55 pantoprazole ......................... 94 PARAFON FORTE DSC ..... 25 paregoric ............................... 89 PAREMYD ........................ 113 paricalcitol ............................ 85 PARLODEL ......................... 22 PARNATE ........................... 36 paromomycin ........................ 10 paroxetine hcl ....................... 36 PASER ................................. 10 PATADAY ......................... 114 PATANASE ......................... 70 PATANOL ......................... 114 PAXIL .................................. 36 PAXIL CR ............................ 36 PAZEO ............................... 114 PCE......................................... 9 PED MULTIVITAMINSA,B,D,E,K,ZN ................ 134 PEDIADERM AF ................ 62 PEDIADERM TA ................ 65 PEDIAPRED ........................ 72 PEDIARIX (PF) ................. 100 PEDVAX HIB (PF)............ 100 peg 3350-electrolytes ........... 92 peg-3350 with flavor packs .. 92 PEGANONE ........................ 20 PEGASYS ............................ 96 PEGASYS PROCLICK ....... 96 peg-electrolyte soln .............. 92 PEGINTRON ....................... 96 PEGINTRON REDIPEN ..... 96 peg-prep ................................ 92 PEN NEEDLE ...................... 80 PEN NEEDLE, DIABETIC . 80 penicillin v potassium........... 12 PENLAC .............................. 62 PENTACEL (PF) ............... 100 PENTASA ............................ 92 pentazocine-naloxone ........... 31

PENTIPS .............................. 80 pentoxifylline........................ 47 PEPCID ................................ 94 PERCOCET.......................... 28 PERFOROMIST ................ 123 PERIDEX ............................. 70 perindopril erbumine ............ 44 periogard ............................... 70 permethrin ............................ 67 perphenazine ......................... 36 perphenazine-amitriptyline... 36 PERSANTINE...................... 48 PEXEVA .............................. 36 PHARMACIST CHOICE .... 76 PHASEAL PROTECTOR.... 80 phenadoz ............................. 118 phenazopyridine ................. 127 phendimetrazine tartrate ....... 67 phenelzine............................. 36 phenergan ........................... 118 phenobarbital ........................ 20 phenoxybenzamine ............... 44 phentermine .......................... 67 phenylephrine hcl ............... 117 phenylhistine dh ................. 119 PHENYTEK ......................... 20 phenytoin .............................. 20 phenytoin sodium extended .. 20 philith.................................. 110 PHOSLO .............................. 92 PHOSLYRA ......................... 92 phospha 250 neutral............ 128 phosphasal .......................... 126 phosphate laxative ................ 92 PHOSPHOLINE IODIDE .. 113 PHYSIOLYTE ..................... 67 PHYSIOSOL IRRIGATION 67 PICATO................................ 55 pilocarpine hcl ........ 69, 70, 113 pimozide ............................... 36 pimtrea (28) ........................ 110 pindolol................................. 44 pioglitazone .......................... 87 pioglitazone-glimepiride ...... 87 pioglitazone-metformin ........ 87 pirmella............................... 110 piroxicam .............................. 31 PLAQUENIL........................ 10 PLAVIX ............................... 48 PLEGRIDY .......................... 96 156

PLEXION ............................. 58 PLEXION CLEANSING CLOTHS........................... 58 PNEUMOVAX 23.............. 100 pnv 29-1 .............................. 134 pnv ob+dha ......................... 134 pnv-dha ............................... 134 pnv-dha + docusate ............. 134 pnv-ferrous fumarate-docu-fa ........................................134 pnv-omega .......................... 134 pnv-select ............................ 134 pnv-vp-u ............................. 134 PODOCON ........................... 53 podofilox............................... 55 POLY HUB NEEDLE ..........80 polycin ................................112 polyethylene glycol 3350 .....92 polymyxin b sulf-trimethoprim ........................................112 POLYTRIM ........................112 POLY-VI-FLOR................. 134 POLY-VI-FLOR WITH IRON ........................................ 134 POMALYST......................... 96 PONSTEL............................. 31 portia ................................... 110 pot,sodium citrate-citric acid ........................................ 126 POTABA ............................ 128 potassium bicarb and chloride ........................................ 128 potassium bicarb-citric acid 128 potassium chloride .............. 128 potassium citrate ................. 126 potassium citrate-citric acid 126 POTASSIUM HYDROXIDE .......................................... 53 POTIGA ............................... 20 pr natal 400 ......................... 134 pr natal 400 ec .................... 134 pr natal 430 ......................... 134 pr natal 430 ec .................... 134 PRADAXA ........................... 48 PRALUENT PEN ................. 49 PRALUENT SYRINGE ....... 49 pramcort ................................ 92 pramipexole .......................... 22 PRAMOSONE ..................... 52 PRAMOSONE E .................. 52

PRANDIN ............................ 87 PRAVACHOL ..................... 49 pravastatin ............................ 49 prazosin ................................ 44 PRECISION PCX PLUS TEST .......................................... 76 PRECISION PCX TEST ...... 76 PRECISION POINT OF CARE TEST..................... 76 PRECISION Q-I-D TEST .... 76 PRECISION XTRA TEST ... 76 PRECOSE ............................ 87 PRED FORTE .................... 116 PRED MILD ...................... 117 PRED-G ............................. 116 PRED-G S.O.P. .................. 116 prednicarbate ........................ 65 prednisolone ......................... 72 prednisolone acetate ........... 117 prednisolone sodium phosphate .................................. 72, 117 prednisone ............................ 72 prednisone intensol ............... 72 PREFERA-OB ................... 134 PREFERA-OB ONE .......... 134 PREFEST ........................... 105 PREGNYL ........................... 85 PREMARIN ....................... 105 PREMIUM V10 ................... 76 PREMPHASE .................... 105 PREMPRO ......................... 105 prena1 chew........................ 134 prena1 pearl ........................ 134 prenaissance ....................... 134 prenaissance next................ 134 prenaissance plus ................ 134 PRENATA ......................... 134 prenatabs fa ........................ 135 prenatabs rx ........................ 135 prenatal ............................... 135 prenatal multi-dha (algal oil) ........................................ 135 prenatal one daily ............... 135 prenatal plus ....................... 135 prenatal plus (calcium carb)135 prenatal vitamin .................. 135 prenatal vitamin plus low iron ........................................ 135 prenatal-u ............................ 135 PRENATE AM .................. 135

PRENATE CHEWABLE ... 135 PRENATE DHA (FERR ASP GLYCIN)........................ 135 PRENATE ENHANCE ...... 135 PRENATE MINI ................ 135 PRENATE RESTORE ....... 135 PRENATE STAR ............... 135 preplus ................................ 135 PREPOPIK ........................... 92 PREQUE 10 ....................... 135 PRESSURE ACTIVATED LANCETS ........................ 80 pretab .................................. 135 PREVACID SOLUTAB....... 94 prevalite ................................ 50 PREVIDENT ........................ 71 PREVIDENT 5000 BOOSTER PLUS ................................ 70 PREVIDENT 5000 DRY MOUTH ........................... 70 PREVIDENT 5000 ENAMEL PROTECT ........................ 70 PREVIDENT 5000 SENSITIVE ...................... 70 previfem.............................. 110 PREVNAR 13 (PF) ............ 100 PREVPAC ............................ 94 PREZCOBIX .......................... 5 PREZISTA ............................. 5 PRIFTIN ............................... 10 PRILOSEC ........................... 95 PRIMAQUINE ..................... 10 primidone.............................. 20 PRIMLEV ............................ 29 PRIMSOL............................. 13 PRINIVIL ............................. 44 PRISTIQ ............................... 36 PROAIR HFA .................... 123 PROAIR RESPICLICK ..... 123 probenecid .......................... 101 PROCARDIA ....................... 44 PROCARDIA XL................. 44 procentra ............................... 36 prochlorperazine ................... 92 prochlorperazine maleate ..... 92 PROCORT............................ 92 PROCRIT ............................. 95 PROCTOCORT.................... 92 PROCTOFOAM HC ............ 92 procto-med hc ....................... 92 157

procto-pak ............................. 93 proctosol hc .......................... 93 proctozone-hc ....................... 93 PROCYSBI......................... 126 PRODIGY LANCETS ......... 80 PRODIGY NO CODING ..... 76 PRODIGY TWIST TOP LANCET .......................... 80 PROFERRIN-FORTE ........ 135 PROFILNINE ....................... 48 progesterone micronized .... 105 PROGLYCEM ..................... 77 PROGRAF ............................ 16 PROLENSA ....................... 115 PROMACTA ........................ 48 promethazine ...................... 118 promethazine vc.................. 119 promethazine vc-codeine .... 119 promethazine-codeine......... 119 promethazine-dm ................ 119 promethazine-phenylephcodeine ............................ 119 promethegan ....................... 118 PROMETRIUM ................. 105 PROMISEB .......................... 55 propafenone .......................... 39 propantheline ........................ 89 proparacaine ....................... 114 propranolol ........................... 44 propranolol-hydrochlorothiazid .......................................... 44 propylthiouracil .................... 72 PROQUAD (PF) ................. 100 PRO-RED AC (W/ DEXCHLORPHENIR)... 119 PROSCAR .......................... 125 PROSTIN VR PEDIATRIC ........................................ 126 PROTECT IRON................ 135 PROTONIX .......................... 95 PROTOPIC ........................... 55 protriptyline .......................... 36 PROVENTIL HFA ............. 123 PROVERA ......................... 105 PROVIDA OB .................... 135 PROZAC .............................. 36 PROZAC WEEKLY ............ 36 pruclair .................................. 55 prudoxin................................ 55 prutect ................................... 55

PSORCON ........................... 65 PULMICORT ..................... 123 PULMICORT FLEXHALER ........................................ 123 pulmosal ............................. 123 PULMOZYME................... 123 PUREFE OB PLUS ............ 135 PUREFE PLUS .................. 135 purevit dualfe plus .............. 135 PURIXAN ............................ 16 PYLERA .............................. 95 pyrazinamide ........................ 10 PYRIDIUM ........................ 127 pyridostigmine bromide . 25, 26 Q QSYMIA .............................. 67 QUADRACEL (PF) ........... 100 QUALAQUIN ...................... 10 QUARTETTE .................... 110 quasense ............................. 110 quazepam .............................. 36 QUDEXY XR ...................... 20 QUESTRAN......................... 50 QUESTRAN LIGHT............ 50 quetiapine ............................. 36 QUILLIVANT XR ............... 36 quinapril ............................... 44 quinapril-hydrochlorothiazide .......................................... 44 quinidine gluconate .............. 39 quinidine sulfate ................... 39 quinine sulfate ...................... 10 QUINTET AC ...................... 76 QVAR................................. 123 R RABAVERT (PF) .............. 100 RADIOGARDASE .............. 69 RAGWITEK....................... 100 raloxifene............................ 102 ramipril ................................. 44 RANEXA ............................. 50 ranitidine hcl ......................... 95 RAPAFLO.......................... 125 RAPAMUNE ....................... 16 RAVICTI.............................. 69 RAZADYNE ........................ 25 RAZADYNE ER .................. 25 rea lo 39 ................................ 55 rea lo 40 ................................ 55 REBETOL ............................ 96

REBIF (WITH ALBUMIN) . 96 REBIF REBIDOSE .............. 96 REBIF TITRATION PACK. 96 reclipsen (28) ...................... 110 RECOMBINATE ................. 48 RECOMBIVAX HB (PF) .. 100 REFUAH PLUS ................... 76 REGIMEX ............................ 67 REGLAN .............................. 93 REGRANEX ........................ 55 relador pak ............................ 60 relador pak plus .................... 60 RELAGARD ...................... 106 relcof c ................................ 119 RELENZA DISKHALER ...... 5 RELIAMED LANCET......... 80 RELIAMED SAFETY SEAL LANCETS ........................ 80 RELION CONFIRM-MICRO .......................................... 76 RELION NEEDLES............. 80 RELION PEN NEEDLES .... 80 RELION PRIME TEST STRIPS ............................. 76 RELION THIN LANCETS .. 80 RELION ULTRA THIN PLUS LANCETS ........................ 80 RELISTOR ........................... 93 relnate dha .......................... 135 RELPAX .............................. 23 REMERON .......................... 37 REMERON SOLTAB .......... 37 remeven ................................ 55 REMODULIN ...................... 44 RENAGEL ........................... 93 renal caps ............................ 135 rena-vite rx ......................... 135 reno caps ............................. 135 RENVELA ........................... 93 repaglinide ............................ 87 repaglinide-metformin .......... 87 REPATHA SURECLICK .... 50 REPATHA SYRINGE ......... 50 reprexain ............................... 29 REQUIP................................ 22 REQUIP XL ......................... 22 RESCRIPTOR ........................ 5 RESCULA .......................... 115 reserpine ............................... 44 RESPA-AR......................... 119 158

RESTASIS ..........................114 RESTORIL ...........................37 RETIN-A .............................. 59 RETIN-A MICRO ................ 59 RETIN-A MICRO PUMP ... 58, 59 RETROVIR ............................ 5 REVATIO........................... 123 REVEAL TEST STRIP ........ 76 REVIA .................................. 31 REVLIMID........................... 96 REYATAZ ......................... 5, 6 REZIRA .............................. 119 RHEUMATREX .................. 16 ribasphere ............................. 96 ribavirin ................................ 96 RIDAURA .......................... 102 rifabutin ................................ 10 RIFADIN .............................. 10 RIFAMATE .......................... 10 rifampin ................................ 10 RIFATER ............................. 10 RIGHTEST GL300 LANCETS .......................................... 80 RIGHTEST GS550 TEST STRIPS ............................. 76 RILUTEK ............................. 69 riluzole .................................. 69 rimantadine ............................. 6 ringers ................................... 67 RIOMET ............................... 87 risacal-d .............................. 135 risedronate .................... 69, 102 RISPERDAL ........................ 37 RISPERDAL M-TAB .......... 37 risperidone ............................ 37 RITALIN .............................. 37 RITALIN LA ........................ 37 rivastigmine .......................... 25 rivastigmine tartrate .............. 25 RIXUBIS .............................. 48 rizatriptan .............................. 23 R-NATAL OB .................... 135 ROBAXIN ............................ 26 ROBAXIN-750..................... 26 ROBINUL ............................ 89 ROBINUL FORTE ............... 89 ROCALTROL ...................... 85 ropinirole .............................. 22 rosadan .................................. 59

ROSANIL............................. 59 ROSULA .............................. 59 rosula cleansing cloths ......... 59 ROTARIX .......................... 100 ROTATEQ VACCINE ...... 100 ROWASA............................. 93 roweepra ............................... 20 ROXICODONE ................... 29 ROZEREM ........................... 37 rulavite dha ......................... 136 rydex ................................... 119 RYTHMOL .......................... 39 RYTHMOL SR .................... 39 S SABRIL................................ 20 SAFETY LANCETS ............ 80 SAFETY SEAL LANCETS . 80 SAFETY-LET LANCETS ... 80 SAFYRAL.......................... 110 salacyn .................................. 53 SALAGEN ..................... 69, 71 SALEX ................................. 53 salicylic acid ......................... 53 salicylic acid er-ceramides ... 53 SALKERA ........................... 53 salsalate ................................ 31 salvax.................................... 53 SALVAX DUO PLUS ......... 53 SAMSCA ............................. 85 SANDIMMUNE .................. 16 SANDOSTATIN .................. 16 SANTYL .............................. 66 SAPHRIS (BLACK CHERRY) ........................ 37 SARAFEM ........................... 37 SAVELLA .......................... 102 SAXENDA ........................... 67 scalacort ................................ 65 SCALACORT DK ............... 65 SEASONIQUE ................... 110 seb-prev ................................ 52 seconal sodium ..................... 37 SECTRAL ............................ 44 SELECT-OB ...................... 136 SELECT-OB + DHA ......... 136 selegiline hcl ......................... 22 selenium sulfide.................... 52 SELRX ................................. 52 SELZENTRY ......................... 6 SEMPREX-D ..................... 120

se-natal 19........................... 136 se-natal 19 (with docusate) . 136 SENSIPAR ........................... 85 SEREVENT DISKUS ........ 123 SEROQUEL ......................... 37 SEROQUEL XR................... 37 sertraline ............................... 37 se-tan dha ............................ 136 se-tan plus ........................... 136 setlakin................................ 110 sf 71 sf 5000 plus .......................... 71 SFROWASA ........................ 93 sharobel .............................. 105 SHOHL'S MODIFIED ....... 127 SIGNIFOR............................ 16 sildenafil ............................. 123 SILVADENE........................ 52 silver nitrate .......................... 55 silver nitrate applicators ....... 55 silver sulfadiazine ................. 52 SIMBRINZA ...................... 115 SIMPONI............................ 102 simvastatin ............................ 50 SINEMET ............................. 22 SINEMET CR ...................... 22 SINGLE-LET ....................... 80 SINGULAIR ...................... 123 sirolimus ............................... 16 SIRTURO ............................. 10 SKELAXIN .......................... 26 SMART SENSE LANCETS 80 SMART SENSE TEST STRIPS ............................. 76 SMARTEST LANCET ........ 80 SMARTEST TEST............... 76 sodium chlor 0.9% bacteriostat .......................................... 69 sodium chloride ............ 69, 123 sodium chloride 0.9 % .......... 69 sodium citrate-citric acid .... 127 sodium fluoride............. 71, 136 sodium phenylbutyrate ......... 69 sodium polystyrene sulfonate .......................................... 93 SODIUM POLYSTYRENE SULFONATE ................... 93 SOFT TOUCH LANCETS .. 80 SOFTGELS MULTIVITA,B,D,E,K,ZN ................ 136 159

SOLARAZE ......................... 55 SOLESTA............................. 93 SOLTAMOX ........................ 16 SOLUS V2 LANCETS......... 80 SOLUS V2 TEST STRIPS ... 76 SOMA................................... 26 SOMAVERT ........................ 85 sonafine................................. 55 SONATA .............................. 37 SORBITOL........................... 67 SORBITOL-MANNITOL .... 67 SORIATANE ....................... 52 SORILUX ............................. 52 sorine .................................... 39 sotalol ................................... 39 sotalol af ............................... 39 SOTYLIZE ........................... 39 SOVALDI............................... 6 SPECTRACEF ....................... 8 spinosad ................................ 67 SPIRIVA RESPIMAT ........ 123 SPIRIVA WITH HANDIHALER .............. 123 spironolactone....................... 44 spironolacton-hydrochlorothiaz .......................................... 44 SPORANOX........................... 3 SPORANOX PULSEPAK ..... 3 sprintec (28) ........................ 110 SPRITAM ............................. 21 SPRIX ................................... 31 SPRYCEL............................. 16 sps ......................................... 93 sronyx ................................. 110 ss 10-2 ................................... 59 ssd ......................................... 52 SSKI ..................................... 72 sss 10-5 ................................. 59 STALEVO 100 ..................... 22 STALEVO 125 ..................... 22 STALEVO 150 ..................... 22 STALEVO 200 ..................... 22 STALEVO 50 ....................... 22 STALEVO 75 ....................... 22 STARLIX ............................. 87 stavudine ................................. 6 STAXYN ............................ 127 STENDRA .......................... 127 STERILANCE TL ................ 80 STIMATE ............................. 85

STIOLTO RESPIMAT ...... 123 STIVARGA.......................... 17 STRATTERA ....................... 37 STRIANT ............................. 85 STRIBILD .............................. 6 STROMECTOL ................... 10 strong iodine ....................... 129 STROVITE FORTE ........... 136 STROVITE ONE ............... 136 SUBOXONE ........................ 31 SUCRAID ............................ 93 sucralfate .............................. 95 SULAR ................................. 44 sulfacetamide sodium ... 52, 117 sulfacetamide sodium (acne) 61 sulfacetamide sodium-sulfur 59 sulfacetamide sod-sulfur-urea .......................................... 59 sulfacetamide-prednisolone 117 sulfacleanse 8-4 .................... 59 sulfact na-sul-avobnz-otn-ocsa .......................................... 59 sulfadiazine........................... 12 sulfamethoxazole-trimethoprim .......................................... 12 SULFAMYLON................... 61 sulfasalazine ......................... 93 sulfatrim ............................... 12 sulindac................................. 31 SUMADAN XLT ................. 59 sumatriptan ........................... 23 sumatriptan succinate ..... 23, 24 SUMAVEL DOSEPRO ....... 24 SUMAXIN ........................... 59 SUMAXIN TS...................... 59 SUPER THIN LANCETS .... 81 SUPERVITE ...................... 136 SUPERVITE (EC).............. 136 SUPRAX ................................ 8 SUPREP BOWEL PREP KIT .......................................... 93 SURE COMFORT LANCETS .......................................... 81 SURE COMFORT PEN NEEDLE .......................... 81 SURE-FINE PEN NEEDLES .......................................... 81 SURE-LANCE ..................... 81 SURE-TEST EASYPLUS MINI ................................. 76

SURE-TOUCH LANCET .... 81 SURGUARD2 SAFETY ...... 81 SURMONTIL....................... 37 SURVANTA ........................ 69 SUSTIVA ............................... 6 SUTENT............................... 17 syeda ................................... 110 SYLATRON ......................... 97 SYMAX DUOTAB .............. 89 symax fastabs ....................... 89 symax-sl................................ 89 symax-sr ............................... 89 SYMBICORT..................... 123 SYMBYAX .......................... 37 SYMLINPEN 120 ................ 87 SYMLINPEN 60 .................. 87 SYNALAR ........................... 66 SYNALAR CREAM KIT .... 66 SYNALAR OINTMENT KIT .......................................... 66 SYNALAR TS ..................... 66 SYNALGOS-DC .................. 29 SYNAREL............................ 85 SYNERA .............................. 60 SYNTHROID ....................... 87 SYPRINE ............................. 69 syrex sodium chloride 0.9% . 69 T TABLOID ............................ 17 TACLONEX ........................ 52 tacrolimus ....................... 17, 55 TAFINLAR .......................... 17 TAGRISSO .......................... 17 TAMIFLU .............................. 6 tamoxifen .............................. 17 tamsulosin........................... 125 TANDEM PLUS ................ 136 TAPAZOLE ......................... 72 TARCEVA ........................... 17 TARGRETIN ....................... 17 tarina fe 1/20 (28) ............... 110 TARKA ................................ 44 taron forte ........................... 136 taron-c dha .......................... 136 taron-prex prenatal-dha ...... 136 TASIGNA ............................ 17 TASMAR ............................. 22 TAZORAC ........................... 59 TECFIDERA ........................ 97 TECHLITE LANCETS ........ 81 160

TECHLITE PEN NEEDLE .. 81 TEGRETOL ......................... 21 TEGRETOL XR ................... 21 TEKTURNA......................... 44 TEKTURNA HCT................ 44 TELCARE TEST STRIPS ... 76 telmisartan ............................ 44 telmisartan-amlodipine ......... 44 telmisartan-hydrochlorothiazid .......................................... 44 temazepam ............................ 37 TEMODAR .......................... 17 TEMOVATE ........................ 66 TEMOVATE E ..................... 66 temozolomide ....................... 17 tencon ................................... 29 TENEX ................................. 45 TENIVAC (PF) .................. 100 TENORETIC 100 ................. 45 TENORETIC 50 ................... 45 TENORMIN ......................... 45 TERAZOL 3 ....................... 106 TERAZOL 7 ....................... 106 terazosin ................................ 45 terbinafine hcl ......................... 3 terbutaline ........................... 123 terconazole .......................... 106 TERSI FOAM ...................... 52 TESSALON PERLES ........ 120 TEST N'GO TEST................ 76 testosterone ........................... 85 testosterone cypionate .......... 85 testosterone enanthate ........... 85 TESTRED............................. 85 TETANUS,DIPHTHERIA TOX PED(PF) ................ 100 TETANUS-DIPHTHERIA TOXOIDS-TD ................ 100 tetcaine ................................ 114 tetrabenazine ......................... 25 tetracaine hcl ....................... 114 tetracaine hcl (pf) ................ 114 tetracycline ........................... 13 TETRAVISC ...................... 114 TETRAVISC FORTE ........ 114 TEXACORT ......................... 66 THALOMID ......................... 17 THEO-24 ............................ 124 theochron ............................ 124 theophylline ........................ 124

thermazene ........................... 52 THIOLA ............................... 69 thioridazine ........................... 37 thiothixene ............................ 37 THRIVITE RX ................... 136 thrivite-19 ........................... 136 THYROLAR-1 ..................... 87 THYROLAR-1/2.................. 87 THYROLAR-1/4.................. 87 THYROLAR-2 ..................... 87 THYROLAR-3 ..................... 87 tiagabine ............................... 21 TIAZAC ............................... 45 ticlopidine ............................. 48 TIGAN ................................. 93 TIKOSYN ............................ 39 tilia fe.................................. 110 timolol maleate ............. 45, 113 TIMOPTIC ......................... 113 TIMOPTIC OCUDOSE (PF) ........................................ 113 TIMOPTIC-XE .................. 113 TINDAMAX ........................ 11 tinidazole .............................. 11 TITUS NEEDLE .................. 81 TIVICAY ............................... 6 tizanidine .............................. 26 tl gard rx ............................. 136 tl g-fol os ............................ 136 tl icon .................................. 136 tl-hem 150 .......................... 136 TOBI..................................... 11 TOBI PODHALER .............. 11 TOBRADEX ...................... 116 TOBRADEX ST ................ 116 tobramycin .......................... 112 tobramycin in 0.225 % nacl . 11 tobramycin-dexamethasone 116 TOBREX ............................ 112 TOFRANIL .......................... 37 tolazamide ............................ 87 tolbutamide ........................... 87 tolcapone .............................. 22 tolmetin................................. 31 tolterodine........................... 125 TOPAMAX .......................... 21 TOPCARE UNIVERSAL1 LANCET .......................... 81 TOPICORT .......................... 66 topiramate ............................. 21

TOPIRAMATE .................... 21 TOPROL XL ........................ 45 torsemide .............................. 45 TOUJEO SOLOSTAR ......... 83 TRACLEER ....................... 124 TRADJENTA ....................... 87 tramadol ................................ 31 tramadol-acetaminophen ...... 31 trandolapril ........................... 45 trandolapril-verapamil .......... 45 tranexamic acid................... 106 TRANSDERM-SCOP .......... 93 TRANXENE T-TAB ............ 37 tranylcypromine.................... 37 TRAVATAN Z................... 115 travoprost (benzalkonium) . 115 trazodone .............................. 37 TRECATOR ......................... 11 tretinoin ................................ 59 tretinoin (chemotherapy) ...... 17 TRETIN-X............................ 59 TRETIN-X CREAM KIT..... 59 TREXALL ............................ 17 TREZIX ................................ 29 TRIACETIN ......................... 62 triamcinolone acetonide . 66, 71 triamterene-hydrochlorothiazid .......................................... 45 trianex ................................... 66 triazolam ............................... 38 TRIBENZOR........................ 45 TRICARE ........................... 136 TRICARE PRENATAL DHA ONE ................................ 136 tricitrates ............................. 127 tricon ................................... 136 TRICOR ............................... 50 triderm .................................. 66 TRIESENCE (PF) ................ 72 tri-estarylla.......................... 110 trifluoperazine ...................... 38 trifluridine........................... 112 trigels-f forte ....................... 136 TRIGLIDE............................ 50 trihexyphenidyl ............... 22, 23 tri-legest fe .......................... 110 TRILEPTAL......................... 21 tri-linyah ............................. 110 TRILIPIX ............................. 50 tri-lo-estarylla ..................... 110 161

tri-lo-marzia ........................ 110 tri-lo-sprintec ...................... 110 trilyte with flavor packets ..... 93 trimethobenzamide ............... 93 trimethoprim ......................... 13 trimipramine ......................... 38 trinatal gt ............................. 136 trinatal rx 1 ......................... 137 trinate ..................................137 trinessa (28) ........................110 trinessa lo ............................110 TRI-NORINYL (28) ...........111 triphrocaps ..........................137 TRIPLE DYE .......................62 triple vitamin with fluoride .137 tri-previfem (28) .................111 tri-sprintec (28) ...................111 TRISTART DHA ...............137 tri-tabs dha ..........................137 TRIUMEQ ..............................6 triveen-duo dha ................... 137 TRI-VI-FLOR..................... 137 tri-vit with fluoride and iron ........................................ 137 tri-vitamin with fluoride ..... 137 trivora (28) .......................... 111 TRIZIVIR ............................... 6 TROKENDI XR ................... 21 TROPAZONE LOTION ...... 55 tropicamide ......................... 113 trospium .............................. 125 TRUE METRIX GLUCOSE TEST STRIP ..................... 76 TRUEPLUS LANCETS .......81 TRUETEST TEST STRIPS .76 TRUETRACK TEST............76 TRUMENBA ......................100 TRUSOPT ..........................115 trust natal dha ..................... 137 TRUVADA............................. 6 TUDORZA PRESSAIR ..... 124 tusnel c ................................ 120 TUSNEL PEDIATRIC ....... 120 TUSSICAPS ....................... 120 tussigon ............................... 120 TUSSIONEX PENNKINETIC ER ...................................120 TWINRIX (PF) ...........100, 101 TWYNSTA........................... 45 TYBOST................................. 6

TYKERB .............................. 17 TYLENOL-CODEINE #3.... 29 TYLENOL-CODEINE #4.... 29 TYPHIM VI ....................... 101 TYVASO............................ 124 TYVASO REFILL KIT ..... 124 TYVASO STARTER KIT . 124 TYZEKA ................................ 6 TYZINE ............................... 71 U UCERIS ................................ 93 UDAMIN SP ...................... 137 ULESFIA ............................. 67 ULORIC ............................. 101 ULTICARE PEN NEEDLE . 81 ULTILET BASIC LANCETS .......................................... 81 ULTILET CLASSIC LANCETS ........................ 81 ULTILET LANCETS .......... 81 ULTILET PEN NEEDLE .... 81 ULTILET SAFETY LANCETS ........................ 81 ULTIMA TEST STRIPS ...... 76 ultimatecare one ................. 137 ultimatecare one nf ............. 137 ULTRA THIN LANCETS ... 81 ULTRA THIN PLUS LANCETS ........................ 81 ULTRA TLC LANCETS ..... 81 ULTRACET ......................... 31 ULTRALANCE LANCETS 81 ULTRAM ............................. 31 ULTRAM ER ....................... 31 ULTRA-THIN II INS PEN NEEDLES ........................ 81 ULTRATRAK...................... 76 ULTRATRAK ULTIMATE 76 ULTRAVATE X .................. 66 umecta .................................. 56 UMECTA PD ....................... 55 UNIFINE PENTIPS ............. 81 UNIFINE PENTIPS PLUS .. 81 UNILET COMFORTOUCH LANCET .......................... 81 UNILET EXCELITE II LANCET .......................... 81 UNILET EXCELITE LANCET .......................... 81 UNILET GP LANCET......... 81

UNILET LANCET ............... 81 UNISTIK 3 EXTRA LANCET .......................................... 81 UNISTIK CZT LANCET..... 81 UNISTIK SAFETY .............. 81 UNISTIK TOUCH LANCETS .......................................... 82 UNISTRIP1 TEST STRIP ... 76 unithroid ............................... 88 UNIVERSAL 1 LANCETS . 82 ur n-c................................... 127 URAMAXIN ........................ 56 URAMAXIN GT .................. 56 uramit mb ........................... 127 urea ....................................... 56 urea nail stick........................ 56 urea-hyaluronate sodium ...... 56 URECHOLINE .................. 126 URELLE ............................. 127 uretron d-s........................... 127 URIBEL.............................. 127 urimar-t ............................... 127 urin ds ................................. 127 uro-blue .............................. 127 UROCIT-K 10 .................... 127 UROCIT-K 15 .................... 127 UROCIT-K 5 ...................... 127 urogesic-blue ...................... 127 uro-l .................................... 127 uro-mp ................................ 127 UROQID-ACID NO.2........ 127 UROXATRAL ................... 125 URSO 250 ............................ 93 URSO FORTE...................... 93 ursodiol ................................. 94 uryl...................................... 127 ustell ................................... 127 utira-c.................................. 127 UTOPIC................................ 56 V VAGIFEM .......................... 105 valacyclovir ............................ 6 VALCHLOR ........................ 56 VALCYTE ............................. 6 valganciclovir ......................... 6 VALIUM .............................. 38 valproic acid ......................... 21 valproic acid (as sodium salt) .......................................... 21 valsartan................................ 45 162

valsartan-hydrochlorothiazide .......................................... 45 VALTREX ............................. 6 VANATOL LQ .................... 29 VANCOCIN .........................13 vancomycin........................... 13 vandazole ............................ 106 VANOS ................................ 66 VANOXIDE-HC .................. 60 VAQTA (PF) ...................... 101 VARIVAX (PF).................. 101 VASERETIC ........................ 45 VASOTEC ............................ 45 v-c forte .............................. 137 VECTICAL .......................... 52 veletri .................................... 45 velivet triphasic regimen (28) ........................................ 111 VELPHORO ......................... 94 vemavite-prx-2 ................... 137 venlafaxine ........................... 38 VENTAVIS ........................ 124 VENTOLIN HFA ............... 124 verapamil .............................. 45 VERDESO ............................ 66 verdrocet ............................... 29 VEREGEN ........................... 56 VERELAN ........................... 45 VERELAN PM ..................... 45 veripred 20 ............................ 72 VESICARE......................... 125 vestura (28) ......................... 111 VEXOL............................... 117 VFEND ................................... 3 VGO 20 ................................ 82 VGO 30 ................................ 82 VGO 40 ................................ 82 VIAGRA............................. 127 VIBRAMYCIN .................... 13 vic-forte .............................. 137 vicodin .................................. 29 vicodin es .............................. 29 vicodin hp ............................. 29 VICOPROFEN ..................... 29 VICTOZA 2-PAK ................ 87 VIDEX 2 GRAM PEDIATRIC ............................................ 6 VIDEX EC.............................. 6 vienva ................................. 111 VIGAMOX ......................... 112

VIMPAT............................... 21 vinate care .......................... 137 vinate dha ........................... 137 VINATE DHA RF ............. 137 vinate ii ............................... 137 vinate m .............................. 137 vinate one ........................... 137 vinate ultra .......................... 137 VIOKACE ............................ 94 viorele (28) ......................... 111 VIRACEPT ............................ 6 VIRAMUNE .......................... 6 VIRAMUNE XR .................... 6 VIRASAL............................. 53 VIRAZOLE ............................ 6 VIREAD ................................. 7 VIROPTIC ......................... 112 virt nate............................... 137 virt-advance ........................ 137 virt-c dha ............................ 137 VIRT-CAPS ....................... 137 virt-care one........................ 137 virt-gard .............................. 137 virt-nate dha........................ 137 virt-phos 250 neutral .......... 129 virt-pn ................................. 138 virt-pn dha .......................... 137 virt-pn plus ......................... 138 virtrate-2 ............................. 127 virtrate-3 ............................. 127 virtrate-k ............................. 127 virt-select ............................ 138 virtussin ac.......................... 120 virt-vite ............................... 138 virt-vite gt ........................... 138 VIRT-VITE PLUS ............. 138 VISTARIL.......................... 118 vit 3..................................... 138 VITAFOL ........................... 138 VITAFOL NANO .............. 138 VITAFOL ULTRA ............ 138 vitafol-ob ............................ 138 VITAFOL-OB+DHA ......... 138 VITAFOL-ONE ................. 138 VITAL-D RX ..................... 138 VITAMED MD ONE RX .. 138 VITAMED MD PLUS RX. 138 VITAMEDMD REDICHEW RX .................................. 138 vitamin d3........................... 138

vitamins a,c,d and fluoride . 138 VITAPEARL ...................... 138 VITA-RESPA..................... 138 VITEKTA ............................... 7 VIVA DHA ........................ 138 VIVELLE-DOT.................. 105 VIVOTIF ............................ 101 VIVOTIF BERNA VACCINE ........................................ 101 vol-care rx........................... 138 vol-nate ............................... 138 vol-plus ............................... 138 vol-tab rx ............................ 138 VOLTAREN ........................ 31 VOLTAREN-XR.................. 31 voriconazole ....................... 3, 4 VOSPIRE ER ..................... 124 VOTRIENT .......................... 17 vp-ch plus ........................... 138 vp-ch-pnv............................ 138 vp-ggr-b6 ............................ 138 vp-heme ob ......................... 138 vp-heme ob + dha ............... 138 vp-heme one ....................... 139 VP-PNV-DHA.................... 139 vp-vite rx ............................ 139 VUSION ............................... 62 vyfemla (28) ....................... 111 VYTORIN 10-10 .................. 50 VYTORIN 10-20 .................. 50 VYTORIN 10-40 .................. 50 VYTORIN 10-80 .................. 50 VYVANSE ........................... 38 W warfarin ................................ 48 water for irrigation, sterile .... 69 WAVESENSE JAZZ ........... 76 WAVESENSE PRESTO ...... 76 WELCHOL .......................... 50 WELLBUTRIN SR .............. 38 WELLBUTRIN XL.............. 38 wera (28)............................. 111 westhroid .............................. 88 WILATE ............................... 48 WP THYROID ..................... 88 wymzya fe .......................... 111 X XALATAN ......................... 115 XALKORI ............................ 17 XANAX................................ 38 163

XANAX XR ......................... 38 XARELTO ........................... 48 XCLAIR ............................... 56 XELJANZ........................... 102 XELJANZ XR .................... 102 XELODA .............................. 17 XENAZINE ..........................25 XENICAL............................. 67 XIFAXAN ............................ 11 XIGDUO XR ........................ 87 XODOL 10/300 .................... 29 XODOL 5/300 ...................... 29 XODOL 7.5/300 ...................29 XOLEGEL ............................62 XOPENEX .........................124 XOPENEX CONCENTRATE ........................................124 XOPENEX HFA ................124 XTANDI ...............................17 xulane .................................106 xylon 10 ................................29 XYNTHA ............................. 48 XYNTHA SOLOFUSE ........48 XYREM ................................38 XYZAL...............................118 Y YASMIN (28) ..................... 111 YAZ (28) ............................ 111 YF-VAX (PF) .....................101 Z zafirlukast ...........................124 zaleplon.................................38 zamicet ..................................29 ZANAFLEX ......................... 26 ZANTAC .............................. 95 zarah ...................................111 ZARONTIN ..........................21 ZARXIO ............................... 95 zatean-ch ............................. 139 zatean-pn dha ...................... 139 zatean-pn plus ..................... 139 ZAVESCA ............................ 85 ZEBETA ............................... 45 zebutal................................... 29 ZELAPAR ............................ 23 ZELBORAF ......................... 17 ZEMPLAR ........................... 85 zenatane ................................ 60 zenchent (28) ...................... 111 zenchent fe .......................... 111

zencia.................................... 60 ZENPEP ............................... 94 zenzedi.................................. 38 ZENZEDI ............................. 38 ZERIT..................................... 7 ZESTORETIC ...................... 45 ZESTRIL .............................. 45 ZETIA .................................. 50 ZIAC..................................... 45 ZIAGEN ................................. 7 zidovudine .............................. 7 zingiber ............................... 139 ZIOPTAN (PF)................... 115 ziprasidone hcl...................... 38 ZIRGAN ............................. 112 ZITHRANOL ....................... 52 ZITHRANOL-RR ................ 52 ZITHROMAX ........................ 9 ZMAX .................................... 9 ZOCOR ................................ 50 ZODRYL AC 25 ................ 120 ZODRYL AC 30 ................ 120 ZODRYL AC 35 ................ 120 ZODRYL AC 40 ................ 120

ZODRYL AC 50 ................ 120 ZODRYL AC 60 ................ 120 ZODRYL AC 80 ................ 120 ZODRYL DAC 25 ............. 120 ZODRYL DAC 30 ............. 120 ZODRYL DAC 35 ............. 120 ZODRYL DAC 40 ............. 120 ZODRYL DAC 50 ............. 120 ZODRYL DAC 60 ............. 120 ZODRYL DAC 80 ............. 120 ZODRYL DEC 25 .............. 120 ZODRYL DEC 30 .............. 120 ZODRYL DEC 35 .............. 120 ZODRYL DEC 40 .............. 120 ZODRYL DEC 50 .............. 120 ZODRYL DEC 60 .............. 120 ZODRYL DEC 80 .............. 120 ZOFRAN (AS HYDROCHLORIDE) ...... 94 ZOFRAN ODT ..................... 94 ZOLINZA ............................. 17 zolmitriptan .......................... 24 ZOLOFT ............................... 38 zolpidem ............................... 38

164

ZONALON ........................... 56 ZONATUSS ....................... 120 ZONEGRAN ........................ 21 zonisamide ............................ 21 ZONTIVITY......................... 48 ZORTRESS .......................... 17 ZOSTAVAX (PF) .............. 101 zovia 1/35e (28) .................. 111 zovia 1/50e (28) .................. 111 ZOVIRAX ........................ 7, 62 Z-TUSS AC ........................ 120 ZUBSOLV ............................ 31 ZUTRIPRO......................... 120 ZYBAN ................................ 69 ZYDELIG ............................. 17 ZYKADIA ............................ 17 ZYLET ............................... 116 ZYLOPRIM ........................ 101 ZYPREXA ............................ 38 ZYPREXA ZYDIS ............... 38 ZYTIGA ............................... 17 ZYVOX ................................ 11

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