Lista de medicamentos cubiertos

Comprehensive Care Management Corporation
Summary of Benefits 2011
CCM Direct Complete Plan (HMO)
Formulario CCM Direct 2011
Lista de medicamentos cubiertos
January 1, 2011 – December 31, 2011
Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk and
Westchester Counties, State of New York
H5989_2011_SB_001 CMS Approved MMYYYY
Del 1 de enero de 2011 al 31 de diciembre de 2011
Condados de Bronx, Kings, Nassau, Nueva York, Queens,
Richmond, Suffolk y Westchester; Estado de Nueva York
H5989_2011_FORM_001_S CMS Approved 09272010
Comprehensive Care Management
Formulario 2011
(Lista de medicamentos cubiertos)
TENGA EN CUENTA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS
MEDICAMENTOS CUBIERTOS POR ESTE PLAN.
Nota para miembros actuales: este formulario ha cambiado desde el año pasado. Revise este
documento para asegurarse de que aún contenga los medicamentos que usted toma.
Comprehensive Care Management es un plan de salud con un contrato de Medicare.
Esta información está disponible en diferentes formatos, por ejemplo, en otros idiomas, en letra grande y en
cintas de audio. Si necesita información sobre el plan en otro formato o idioma, comuníquese con el servicio
de atención para miembros al número indicado arriba.
H5989_2011_FORM_001_S CMS Approved 09272010
i
¿Qué es el formulario Comprehensive Care Management?
Un formulario es una lista de los medicamentos cubiertos seleccionados por Comprehensive Care
Management y un equipo de proveedores de atención médica, y constituye los tratamientos recetados que se
consideran una parte necesaria de un programa de tratamiento de calidad. Comprehensive Care Management
generalmente cubrirá los medicamentos de la lista de nuestro formulario siempre que el medicamento sea
necesario, que la receta se llena en una farmacia de la red de Comprehensive Care Management y que se
sigan otras normas del plan. Para obtener más información sobre cómo llenar su receta, relea su Evidencia
de cobertura.
¿El formulario puede cambiar?
Generalmente, si está tomando un medicamento del formulario 2011 que se cubría a principios de año,
no suspenderemos ni reduciremos la cobertura de éste durante la cobertura del 2011, a menos que se
lance un nuevo medicamento genérico a un precio más reducido, o que se revele información que ponga
en duda la seguridad o efectividad del medicamento. Otros cambios en los formularios, como la
eliminación de un medicamento del formulario, no afectarán a los miembros que estén actualmente
tomando el medicamento. Se mantendrá al mismo costo compartido para los miembros que lo tomen
durante lo que quede de cobertura en el año. Sentimos que es importante que tenga acceso permanente
a los medicamentos del formulario que estaban disponibles cuando eligió el plan durante el tiempo que
queda de cobertura en el año, con excepción de los casos en los que pueda ahorrar dinero adicional o en
los que nosotros podamos garantizar su seguridad.
Si eliminamos medicamentos del formulario, agregamos el requisito de autorización previa, límites de
cantidad o restricciones a tratamientos escalonados de un medicamento, o ubicamos un medicamento a
un nivel superior de costo compartido, debemos notificar a los miembros afectados por el cambio al
menos 60 días antes de que se haga efectivo ese cambio,o en el momento en el que el miembro solicite
una nueva receta del medicamento y se le entregue un suministro del medicamento para 60 días. Si la
Administración de Drogas y Alimentos (Food and Drug Administration, FDA) considera que algún
medicamento del formulario no es seguro o si el fabricante del medicamento lo retira del mercado,
nosotros lo retiraremos del formulario inmediatamente y lo comunicaremos a aquellos miembros que
toman el medicamento. El formulario adjunto rige a partir del 1 de enero de 2011. Para obtener
información sobre los medicamentos que cubre Comprehensive Care Management, visite nuestro sitio
web en www.ccmny.org o llame al servicio de atención para miembros al 1-877-226-8500, los 7 días de
la semana, de 8:00 a. m. a 8:00 p. m. Los usuarios de TTY deben llamar al: 1-800-650-2774. Si surge
un cambio en el formulario a mitad de año que no afecte a medicamentos de mantenimiento,
agregaremos una hoja de fe de erratas al formulario para explicar el cambio.
¿Cómo uso el formulario?
Hay dos formas de encontrar su medicamento en el formulario:
ii
Afección médica
El formulario comienza en la página 1. Los medicamentos de este formulario están agrupados en
categorías de acuerdo con el tipo de afecciones médicas para las que se usan. Por ejemplo, los
medicamentos que se usan para tratar una afección cardíaca se detallan en la categoría, "Afecciones
cardiovasculares, hipertensión y lípidos". Si sabe para qué se usa su medicamento, busque el nombre de
la categoría en la lista que comienza en la página 1. Luego busque su medicamento bajo el nombre de la
categoría
Lista alfabética
Si no está seguro bajo qué categoría buscar, deberá buscar su medicamento en el índice de la página 32.
El índice proporciona una lista alfabética de todos los medicamentos que están incluidos en este
documento. En el índice aparecen tanto los medicamentos de marca como los genéricos. Busque en el
índice y encuentre su medicamento. Al lado del nombre de su medicamento, encontrará el número de
página en la que hay información sobre la cobertura. Diríjase a la página que indica el índice y encuentre
el nombre del medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos?
Comprehensive Care Management cubre tanto los medicamentos de marca como los genéricos. La FDA
aprueba un medicamento genérico que tenga el mismo ingrediente activo que un medicamento de marca.
Generalmente, el costo de los medicamentos genéricos es menor al de los medicamentos de marca.
¿Hay alguna restricción en mi cobertura?
Algunos medicamentos cubiertos pueden tener requisitos especiales o límites de cobertura. Estos requisitos y
límites pueden incluir:

Autorización previa: Comprehensive Care Management exige que usted o su médico obtengan
autorización previa para ciertos medicamentos. Esto significa que necesitará obtener aprobación de
Comprehensive Care Management antes de llenar sus recetas. Si no obtiene la aprobación,
Comprehensive Care Management no cubrirá el medicamento.

Límites de cantidad: para algunos medicamentos, Comprehensive Care Management limita la
cantidad del medicamento a cubrir. Por ejemplo, Comprehensive Care Management proporciona 31
unidades por receta para CRESTOR. Esto puede sumarse al suministro estándar de uno o tres meses.

Tratamiento escalonado: en algunos casos, Comprehensive Care Management exige que pruebe
algunos medicamentos para tratar su afección médica antes de cubrir otro medicamento para ésa
afección. Por ejemplo, si ambos medicamentos, A y B, sirven para tratar su afección médica,
Comprehensive Care Management no cubrirá el medicamento B a menos que usted pruebe el
medicamento A primero. Si el medicamento A no le da resultado, entonces Comprehensive Care
Management cubrirá el medicamento B.
iii
Puede averiguar si su medicamento tiene requisitos adicionales o límites consultando el formulario que
comienza en la página 1. También puede obtener más información sobre las restricciones que se
aplican a medicamentos específicos cubiertos visitando nuestro sitio web en www.ccmny.org.
Puede solicitar que Comprehensive Care Management haga una excepción a estos límites y restricciones.
Consulte la sección, "¿Cómo solicito a Comprehensive Care Management que haga una excepción al
formulario?" en la página IV para obtener información sobre cómo solicitar una excepción.
¿Qué sucede en caso de que mi medicamento no esté en el formulario?
Si su medicamento no está incluido en este formulario, debe ponerse en contacto con servicios de atención al
miembro para que le confirmen si su medicamento no está cubierto. Si le confirman que Comprehensive
Care Management no cubre su medicamento, tiene dos opciones:

Puede solicitar a servicios de atención al miembro una lista de medicamentos similares cubiertos por
Comprehensive Care Management. Cuando reciba la lista, muéstresela a su médico y pídale que le
recete un medicamento similar cubierto por Comprehensive Care Management.

Puede solicitar a Comprehensive Care Management que haga una excepción y cubra su
medicamento. Más abajo, encontrará información sobre cómo solicitar una excepción.
¿Cómo solicito una excepción al formulario de Comprehensive Care Management?
Puede solicitar que Comprehensive Care Management haga una excepción a las normas de cobertura.
Existen varios tipos de excepciones que puede solicitarnos.

Puede solicitarnos la cobertura de su medicamento incluso si no está en el formulario.

Puede solicitarnos que no apliquemos una restricción a la cobertura o limitaciones a su medicamento.
Por ejemplo, para algunos medicamentos, Comprehensive Care Management limita la cantidad de
medicamentos que cubre. Si su medicamento tiene un límite de cantidad, puede solicitarnos que
anulemos ese límite y cubramos una mayor cantidad.

Para nuestro plan CCM Direct Value, puede solicitarnos que le brindemos un nivel mayor de
cobertura para su medicamento. Si su medicamento está incluido en el nivel de medicamentos no
preferidos, puede solicitarnos la cobertura al monto del costo compartido que se aplica a
iv
medicamentos del nivel de medicamentos preferidos. Esto reducirá el monto que debe pagar por su
medicamento.. Tenga en cuenta que si accedemos a su solicitud de cobertura de un medicamento que
no está en el formulario, no podrá solicitar un nivel mayor de cobertura para el medicamento.
Tampoco podrá solicitar un nivel mayor de cobertura para medicamentos que están en el nivel de
medicamentos especiales.
Generalmente, Comprehensive Care Management sólo aprobará su solicitud de excepción si los
medicamentos alternativos que están incluidos en el formulario del plan u otras restricciones adicionales de
utilización no serán tan efectivas para tratar su afección o pueden causarle efectos médicos adversos.
Debe comunicarse con nosotros para solicitar una decisión de cobertura inicial para un formulario, o una
excepción de restricción de utilización. Al solicitar una excepción de restricción de utilización, de nivel o
de formulario, debe presentar una declaración de su médico que apoye su solicitud. Generalmente,
debemos decidirnos dentro de las 72 horas de haber recibido la declaración de su médico autorizado. Puede
solicitar una excepción acelerada (rápida) si usted o su médico consideran que su salud puede verse
seriamente afectada por una espera de hasta 72 horas. Si se concede la solicitud de excepción acelerada,
debemos comunicarle nuestra decisión 24 horas después de recibir la declaración de su médico autorizado.
¿Qué hago antes de hablar con mi médico sobre cambiar mis medicamentos o solicitar
una excepción?
Como miembro nuevo o permanente de nuestro plan, puede estar tomando medicamentos que no están en el
formulario. O, puede estar tomando un medicamento que está en el formulario pero tiene capacidad limitada
para obtenerlo. Por ejemplo, puede necesitar nuestra autorización previa antes de que pueda llenar su receta.
Debe hablar con su médico para decidir si debe cambiar a un medicamento determinado que esté cubierto o
solicitar una excepción al formulario para que cubramos el medicamento que está tomando. Mientras habla
con su médico para determinar la medida correcta para usted, cubriremos su medicamento en ciertos casos
durante los primeros 90 días que es miembro del plan.
Para cada medicamento que no esté en nuestro formulario o si su capacidad para obtenerlo es limitada,
cubriremos un suministro temporal de 31 días (a menos que tenga una receta para menos días) cuando vaya a
una farmacia de la red. Después de su suministro de 31 días, no cubriremos esos medicamentos, aunque haya
sido miembro del plan durante menos de 90 días.
Si usted es residente en una institución de cuidado a largo plazo, cubriremos un suministro de transición
temporal por 31 días (a menos que tenga una receta por menos días) Cubriremos más de una renovación de
estos medicamentos durante los primeros 90 días que usted sea miembro de nuestro plan. Si necesita un
medicamento que no está en nuestro formulario o si su capacidad para obtenerlo es limitada, pero han pasado
los primeros 90 días de afiliación a nuestro plan, cubriremos un suministro de emergencia por 31 días (a
menos que tenga una prescripción para menos días) mientras solicita una excepción de formulario.
v
Para obtener más información
Para obtener más información detallada sobre su cobertura de medicamentos recetados Comprehensive Care
Management revise su Evidencia de cobertura y otros materiales del plan.
Si quiere hacer preguntas sobre Comprehensive Care Management, llame al servicio de atención para
miembros al
1-877-226-8500, los 7 días de la semana, de 8:00 a. m. a 8:00 p m. Los usuarios de TTY deben llamar al 1800-650-2774, o visitar www.ccmny.org.
Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, llame a Medicare al
1-800-MEDICARE (1-800-633-4227), los 7 días de la semana, las 24 horas del día. Los usuarios de
TTY/TDD deben llamar al: 1-877-486-2048. O, visitar www.medicare.gov.
Formulario de Comprehensive Care Management
El formulario comienza en la página siguiente y proporciona información sobre la cobertura de algunos de
los medicamentos cubiertos por Comprehensive Care Management. Si tiene dificultades para encontrar su
medicamento en la lista, diríjase al índice de la página 32.
En la primera columna de la tabla encontrará la lista con los nombres de los medicamentos. Los
medicamentos de marca se escriben con mayúscula (p. ej., ZOSYN) y los genéricos se detallan en minúscula
itálica (p. ej., amoxicilina).
Bajo la columna Notas podrá informarse si Comprehensive Care Management tiene algún requisito especial
para cubrir su medicamento.
Abajo figura una lista de abreviaturas que pueden aparecer en las páginas siguientes, en la columna
Requisitos/Límites
y que indican si existen requisitos especiales para la cobertura del medicamento.
Lista de abreviaturas
LC: límite de cantidad Para algunos medicamentos, el Plan limita la cantidad de medicamento que cubre.
Por
ejemplo, el plan proporciona 34 comprimidos por receta de CRESTOR®.
TE: tratamiento escalonado. En algunos casos, el plan exige que pruebe ciertos medicamentos para tratar su
afección
médica antes de cubrir otro medicamento para esa afección. Por ejemplo, si ambos medicamentos, A y B,
sirven para tratar
su afección médica, no cubriremos el medicamento B a menos que pruebe el medicamento A primero. Si el
medicamento A no funciona en su
vi
caso, entonces cubriremos el B.
AP: autorización previa. El plan exige que usted o su médico obtengan autorización previa para ciertos
medicamentos.
Lo que significa que necesitará obtener la aprobación antes de completar sus recetas. Si no obtiene la
aprobación, no cubriremos el medicamento.
ID: infusión a domicilio A este medicamento recetado lo puede cubrir nuestro beneficio médico. Para
obtener más información,
llame al servicio de atención al cliente.
IC: intervalo en la cobertura Brindamos cobertura de este medicamento recetado en el período de intervalo
en la cobertura. Consulte nuestra
información de evidencia de cobertura para conocer más detalles. El intervalo de cobertura se aplica sólo a
los miembros del plan CCM Direct Value (HMO).
DL: disponibilidad limitada. Esta receta puede estar disponible sólo en ciertas farmacias. Para obtener más
información, llame al servicio de atención al cliente.
PR: primera receta gratuita. La receta de este medicamento se la proporcionamos a un monto menor al costo
compartido la primera vez
que la llene.
CS: cobertura superior La receta de este medicamento generalmente no se cubre en un plan de
medicamentos recetados de Medicare.
El monto que paga cuando llena una receta para este medicamento no cuenta como el costo total de
medicamentos
(esto quiere decir que el monto que paga no lo ayuda a reunir los requisitos para pasar a la cobertura
catastrófica). Además, si está
recibiendo ayuda adicional para pagar sus recetas, no obtendrá ayuda adicional para pagar el medicamento.
BC: beneficio cubierto La receta de este medicamento tiene un límite al beneficio cubierto.
PM: pedido de medicamentos. Esta receta de medicamentos está disponible mediante nuestro servicio de
envío por correo y
en las farmacias minoristas de nuestra red. Considere usar el sistema de pedidos para los medicamentos a
largo plazo (mantenimiento) (por ejemplo, los medicamentos para la presión arterial alta). Las farmacias
minoristas de la red pueden ser más apropiadas para las recetas de medicamentos a corto plazo (por ejemplo,
los antibióticos).
vii
Commonly Prescribed Therapeutic
Drug Categories
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
Drug
Name
amphotericin b
ANCOBON
clotrimazole troc
DIFLUCAN IN NACL INJ
200MG/100ML; 0.9%
ERAXIS INJ 100MG
fluconazole in dextrose inj 0;
400mg/200ml
fluconazole susr
fluconazole tabs
GRIS-PEG
griseofulvin microsize
itraconazole
ketoconazole
NOXAFIL
nystatin susp
nystatin tabs
SPORANOX ORAL SOLN
terbinafine tabs
VFEND
VFEND IV
Drug
Tier Notes
1 GC PA MO
2
MO
1
GC MO
2
MO
2
1
GC
1
1
3
1
1
1
2
1
1
2
1
2
2
GC MO
GC MO
MO
GC MO
GC MO
GC MO
MO
GC MO
GC MO
MO
GC MO
MO
MO
acyclovir caps
acyclovir inj 500mg
acyclovir susp
acyclovir tabs
amantadine
APTIVUS CAPS
APTIVUS ORAL SOLN
ATRIPLA
BARACLUDE ORAL SOLN
1
1
1
1
1
4
4
4
2
GC MO
GC MO
GC MO
GC MO
GC MO
MO
BARACLUDE TABS
2
COMBIVIR
CRIXIVAN CAPS 100MG
4
2
ANTIVIRALS
MO
QL(1890
per 90 days)
MO
QL(90 per
90 days)
MO
MO
1
Drug
Name
CRIXIVAN CAPS 200MG,
333MG, 400MG
didanosine
EMTRIVA CAPS
EMTRIVA ORAL SOLN
EPIVIR
EPIVIR HBV
EPZICOM
famciclovir
foscarnet sodium
FUZEON
ganciclovir caps
HEPSERA
Drug
Tier
2
INTELENCE
INVIRASE
ISENTRESS
KALETRA ORAL SOLN
KALETRA TABS 200MG;
50MG
KALETRA TABS 100MG;
25MG
LEXIVA SUSP
LEXIVA TABS
NORVIR
PREZISTA TABS 75MG
PREZISTA TABS 400MG,
600MG
REBETOL ORAL SOLN
RELENZA DISKHALER
4
4
4
4
4
MO
MO
MO
GC MO
GC PA MO
MO
GC MO
QL(90 per
90 days)
MO
MO
MO
MO
MO
MO
2
MO
2
4
2
2
4
MO
MO
MO
MO
MO
2
2
RESCRIPTOR
RETROVIR IV INFUSION
REYATAZ
ribapak
ribasphere caps
ribasphere tabs 400mg
ribasphere tabs 600mg
ribasphere tabs 200mg
ribavirin caps
ribavirin tabs 200mg
rimantadine hcl
3
2
4
4
4
4
4
1
4
1
1
PA MO
QL(300 per
365 days)
MO
MO
MO
MO
PA MO
PA MO
PA
PA MO
GC PA MO
PA
GC PA
GC MO
1
2
2
2
2
4
1
1
4
1
4
Notes
MO
GC MO
MO
Drug
Drug
Name
Tier Notes
SELZENTRY
4
MO
stavudine
1
GC MO
SUSTIVA
2
MO
TAMIFLU CAPS 45MG, 75MG
2 QL(56 per
365 days)
MO
TAMIFLU CAPS 30MG
2 QL(112 per
365 days)
MO
TAMIFLU SUSR
2
MO
TRIZIVIR
4
MO
TRUVADA
4
MO
TYZEKA
4
MO
valacyclovir hcl
1
GC MO
VALCYTE ORAL SOLN
4
VALCYTE TABS
4
MO
VIDEX PEDIATRIC ORAL
2
MO
SOLN 2GM
VIRACEPT POWD
2
MO
VIRACEPT TABS
4
MO
VIRAMUNE
2
MO
VIREAD
2
MO
ZIAGEN
2
MO
zidovudine
1
GC MO
Drug
Drug
Name
Tier Notes
cefuroxime sodium inj 7.5gm
1
GC
cefuroxime sodium inj 1.5gm,
1
GC MO
750mg
CEFUROXIME/DEXTROSE
2
cephalexin
1
GC MO
FORTAZ INJ 1GM, 1GM/50ML; 2
5%, 2GM/50ML; 5%, 6GM
FORTAZ INJ 2GM
2
MO
MAXIPIME
3
MO
SUPRAX
3
MO
TAZICEF INJ 1GM, 2GM, 6GM 2
ZINACEF IN ISO-OSMOTIC
2
DEXTROSE
ZINACEF IN ISO-OSMOTIC
2
DILUENT
ZINACEF INJ 1.5GM, 750MG
2
ERYTHROMYCINS / OTHER
MACROLIDES
azithromycin inj 500mg
azithromycin susr
azithromycin tabs
clarithromycin
clarithromycin er
e.e.s. 400
E.E.S. GRANULES
ERY-TAB
ERYTHROCIN
LACTOBIONATE INJ 500MG
erythrocin stearate
erythromycin / sulfisoxazole
ERYTHROMYCIN BASE
ZMAX
CEPHALOSPORINS
cefaclor
cefadroxil
cefazolin inj 1gm; 5%, 20gm,
500mg
cefazolin inj 1gm
cefdinir
cefepime inj 2gm
cefepime inj 1gm
cefotaxime sodium inj 10gm, 1gm,
500mg
cefotaxime sodium inj 2gm
cefoxitin sodium inj 10gm, 2gm
cefoxitin sodium inj 1gm
cefpodoxime proxetil
ceftriaxone sodium inj 10gm
ceftriaxone sodium inj 250mg,
500mg
CEFTRIAXONE/DEXTROSE
cefuroxime axetil
1
1
1
GC MO
GC MO
GC
1
1
1
1
1
GC MO
GC MO
GC
GC MO
GC
1
1
1
1
1
1
GC MO
GC
GC MO
GC MO
GC
GC MO
2
1
GC MO
1
1
1
1
1
1
2
2
2
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
MO
1
1
2
2
GC MO
GC MO
MO
MO
MISCELLANEOUS ANTIINFECTIVES
ALBENZA
ALINIA
amikacin sulfate inj 250mg/ml
amikacin sulfate inj 50mg/ml
AZACTAM IN DEXTROSE
AZACTAM IN ISO-OSMOTIC
DEXTROSE INJ 1GM; 0
AZACTAM INJ 2GM
BILTRICIDE
CAPASTAT SULFATE
chloroquine
2
2
2
1
1
2
2
MO
MO
GC
GC MO
2
2
3
1
MO
MO
GC MO
Drug
Drug
Name
Tier Notes
CLEOCIN GALAXY
2
CLEOCIN PEDIATRIC
2
MO
GRANULES
clindamycin hcl
1
GC MO
clindamycin phosphate add1
GC
vantage
COARTEM
2
MO
colistimethate sodium
1
GC MO
CUBICIN
2
MO
DAPSONE
2
MO
DARAPRIM
2
MO
ethambutol tabs 400mg
1
GC
ethambutol tabs 100mg
1
GC MO
gentamicin sulfate inj 10mg/ml
1
GC
gentamicin sulfate inj 40mg/ml
1
GC MO
gentamicin sulfate/0.9% sodium
1
GC
chloride
gentamicin sulfate/sodium
1
GC
chloride inj 1.2mg/ml; 0.9%
hydroxychloroquine
1
GC MO
isonarif
1
GC MO
ISONIAZID SYRP
2
MO
isoniazid tabs
1
GC MO
isotonic gentamicin inj 0.6mg/ml; 1
GC
0.9%, 0.8mg/ml; 0.9%
KETEK
2 QL(20 per
30 days)
MO
MALARONE
2
MO
mebendazole
1
GC MO
mefloquine hcl
1
GC MO
MEPRON
4
MO
metronidazole
1
GC MO
metronidazole in nacl 0.79%
1
GC MO
MYCOBUTIN
2
MO
NEBUPENT
2
PA MO
neomycin sulfate
1
GC MO
paromomycin
1
GC MO
PASER
2
MO
PRIMAQUINE
2
MO
PRIMAXIN I.M.
2
MO
PRIMAXIN IV
2
MO
pyrazinamide
1
GC MO
QUALAQUIN
2
MO
Drug
Name
rifampin
SEROMYCIN
STREPTOMYCIN SULFATE
STROMECTOL
TOBI
tobramycin inj 10mg/ml
tobramycin inj 80mg/2ml
TOBRAMYCIN SULFATE /
SODIUM CHLORIDE
TRECATOR
TYGACIL
XIFAXAN TABS 200MG
Drug
Tier Notes
1
GC MO
2
MO
2
MO
2
MO
4
PA MO
1
GC
1
GC MO
2
2
2
3
ZYVOX INJ
ZYVOX SUSR
2
2
ZYVOX TABS
2
MO
MO
QL(9 per 30
days) MO
MO
QL(1800
per 30 days)
MO
QL(56 per
30 days)
MO
PENICILLINS
amoxicillin
amoxicillin/clavulanate potassium
amoxicillin/clavulanate potassium
er
amoxicillin/potassium clavulanate
tabs
ampicillin caps
ampicillin inj 10gm, 1gm
AMPICILLIN INJ 125MG
ampicillin susr
ampicillin-sulbactam inj 10gm;
5gm
ampicillin-sulbactam inj 2gm;
1gm
BICILLIN C-R
BICILLIN L-A
dicloxacillin sodium
nafcillin sodium inj 10gm
nafcillin sodium inj 1gm
NALLPEN/DEXTROSE INJ 0;
1GM/50ML
penicillin g potassium
PENICILLIN G POTASSIUM IN
ISO-OSMOTIC DEXTROSE
3
1
1
1
GC MO
GC MO
GC MO
1
GC MO
1
1
2
1
1
GC MO
GC
1
GC MO
2
2
1
1
1
2
MO
MO
GC MO
GC
GC MO
1
2
GC
GC MO
GC
Drug
Drug
Name
Tier Notes
PENICILLIN G PROCAINE
2
MO
PENICILLIN G SODIUM
2
penicillin v potassium
1
GC MO
pfizerpen-g inj 20mu
1
GC
piperacillin sodium/ tazobactam
1
GC MO
sodium inj 3gm; 0.375gm
UNASYN INJ 2GM; 1GM
2
MO
ZOSYN INJ 5%; 2GM/50ML;
2
0.25GM/50ML, 5%; 3GM/50ML;
0.375GM/50ML
ZOSYN INJ 3GM; 0.375GM
2
MO
Drug
Drug
Name
Tier Notes
MACRODANTIN CAPS 25MG
2
MO
methenamine hippurate
1
GC MO
nitrofurantoin macrocrystalline
1
GC MO
caps 50mg
nitrofurantoin monohydrate
1
GC MO
PRIMSOL
3
MO
trimethoprim
1
GC MO
VANCOMYCIN
VANCOCIN ORAL
VANCOMYCIN HCL ISOOSMOTIC DEXTROSE
vancomycin inj 10gm
vancomycin inj 1000mg
VIBATIV INJ 250MG
QUINOLONES
AVELOX ABC PACK
AVELOX INJ
AVELOX TABS
CIPRO I.V.-IN D5W
ciprofloxacin inj
ciprofloxacin tabs
LEVAQUIN INJ 5%;
750MG/150ML
LEVAQUIN INJ 25MG/ML
LEVAQUIN ORAL SOLN
LEVAQUIN TABS
NOROXIN
ofloxacin
2
2
2
2
1
1
2
3
3
3
3
1
MO
MO
MO
GC
GC MO
GC MO
GC MO
GC MO
GC MO
amifostine
dexrazoxane inj 500mg
ELITEK INJ 1.5MG
leucovorin calcium inj 100mg,
350mg
leucovorin calcium tabs 25mg,
5mg
LEUCOVORIN CALCIUM
TABS 10MG, 15MG
mesna
MESNEX TABS
ZINECARD INJ 250MG
1
1
1
1
1
GC MO
GC MO
GC MO
GC MO
GC MO
1
1
1
2
GC MO
GC MO
GC MO
MO
2
MO
URINARY TRACT AGENTS
FURADANTIN
GC
GC MO
4
1
4
1
MO
GC MO
1
GC MO
2
MO
1
2
2
GC MO
MO
MO
GC MO
ANTINEOPLASTIC /
IMMUNOSUPPRESSANT DRUGS
TETRACYCLINES
demeclocycline hcl
doxycycline hyclate caps
doxycycline hyclate inj
doxycycline hyclate tabs
doxycycline monohydrate tabs
150mg, 50mg, 75mg
minocycline hcl
minocycline hcl er
tetracycline hcl
VIBRAMYCIN SYRP
1
1
2
ADJUNCTIVE AGENTS
MO
MO
MO
MO
GC MO
1
1
1
1
MO
ANTINEOPLASTIC /
IMMUNOSUPPRESSANT DRUGS
SULFA'S / RELATED AGENTS
sulfadiazine
sulfamethoxazole / trimethoprim
sulfamethoxazole/trimethoprim ds
sulfatrim
2
2
4
ABRAXANE
adriamycin inj 2mg/ml
AFINITOR TABS 5MG
3
1
4
AFINITOR TABS 10MG
4
ALIMTA INJ 500MG
ALKERAN INJ
ARIMIDEX
AROMASIN
ARRANON
3
3
2
2
3
MO
GC
PA QL(90
per 90 days)
MO
PA QL(180
per 90 days)
MO
MO
MO
MO
Drug
Drug
Name
Tier Notes
ARZERRA
2
MO
AVASTIN
3
MO
azathioprine
1 GC PA MO
azathioprine sodium
1 GC PA MO
bicalutamide
1
GC MO
BICNU
3
MO
bleomycin sulfate inj 30unit
1
GC
BUSULFEX
2
CAMPATH
3
MO
carboplatin inj 150mg/15ml
1
GC MO
CEENU
2
MO
CELLCEPT
2
PA MO
CELLCEPT INTRAVENOUS
2
cisplatin
1
GC MO
cladribine
1
GC MO
CLOLAR
3
COSMEGEN
3
MO
cyclophosphamide tabs
1 GC PA MO
cyclosporine caps 100mg, 25mg
1 GC PA MO
CYCLOSPORINE CAPS 50MG
2
PA
cyclosporine inj
1
GC PA
cyclosporine oral soln
1 GC PA MO
CYTARABINE AQUEOUS INJ
2
MO
100MG/ML
cytarabine aqueous inj 20mg/ml
1
GC MO
cytarabine inj 500mg
1
GC MO
dacarbazine inj 200mg
1
GC MO
DAUNORUBICIN HCL INJ
3
5MG/ML
DOXIL
2
MO
doxorubicin hcl
1
GC
DROXIA
2
MO
ELLENCE
3
MO
ELOXATIN
3
MO
ELSPAR
3
MO
EMCYT
2
MO
epirubicin hcl inj 50mg/25ml
1
GC
ERBITUX
3
MO
ETOPOPHOS
3
MO
etoposide inj
1
GC MO
FARESTON
3
MO
FASLODEX
4
MO
FEMARA
2
MO
Drug
Drug
Name
Tier Notes
FIRMAGON INJ 80MG
2
MO
FIRMAGON INJ 120MG
4
MO
fludarabine phosphate inj 50mg
1
GC MO
fluorouracil
1
GC MO
flutamide
1
GC MO
GEMZAR INJ 1GM
3
MO
gengraf
1 GC PA MO
GLEEVEC
4
MO
HERCEPTIN
3
MO
HEXALEN
4
MO
HYCAMTIN INJ
3
MO
hydroxyurea
1
GC MO
idarubicin hcl
1
GC
IFEX INJ 3GM
3
MO
ifosfamide inj 1gm
1
GC
ifosfamide/mesna
4
irinotecan
1
GC MO
ISTODAX
2
MO
IXEMPRA KIT INJ 45MG
4
MO
LEUKERAN
2
MO
leuprolide acetate
1
GC MO
LEUSTATIN
2
MO
LUPRON DEPOT INJ 3.75MG
2
MO
LUPRON DEPOT INJ 11.25MG, 4
MO
22.5MG, 30MG, 7.5MG
LUPRON DEPOT-PED INJ
4
MO
11.25MG, 15MG
LYSODREN
2
MO
MATULANE
4
MO
MEGACE ES
3
MO
megestrol acetate
1
GC MO
melphalan hydrochloride
1
GC
mercaptopurine
1
GC MO
methotrexate
1 GC PA MO
methotrexate sodium inj 25mg/ml 1
GC MO
METHOTREXATE SODIUM
3
INJ 1GM
mitomycin inj 20mg
1
GC MO
mitoxantrone hcl
1
GC MO
MUSTARGEN
3
MO
mycophenolate mofetil
1 GC PA MO
MYFORTIC
2
PA MO
NEORAL
2
PA MO
5
Drug
Name
NEXAVAR
Drug
Tier
4
NILANDRON
NIPENT
octreotide
ONCASPAR
ONTAK
ORTHOCLONE OKT3
oxaliplatin inj 100mg/20ml
paclitaxel
pentostatin
PHOTOFRIN
PROGRAF INJ
RAPAMUNE ORAL SOLN
RAPAMUNE TABS 1MG, 2MG
REVLIMID
RHEUMATREX
RITUXAN
SANDIMMUNE CAPS
SANDIMMUNE INJ
SANDIMMUNE ORAL SOLN
SANDOSTATIN INJ
100MCG/ML, 500MCG/ML,
50MCG/ML
SANDOSTATIN LAR DEPOT
SIMULECT INJ 20MG
SOMATULINE DEPOT
SPRYCEL TABS 100MG,
50MG, 70MG
3
3
1
3
3
2
1
1
1
3
2
2
2
4
3
2
2
2
2
4
SPRYCEL TABS 20MG
4
3
2
4
4
SUTENT
4
TABLOID
tacrolimus
tamoxifen citrate
TARCEVA TABS 100MG,
150MG
2
1
1
4
Drug
Name
TARCEVA TABS 25MG
Notes
LA PA
QL(360 per
90 days)
MO
MO
MO
GC MO
MO
TARGRETIN
TASIGNA CAPS 200MG
TAXOTERE INJ 80MG/2ML
THALOMID
thiotepa
toposar
TORISEL
TREANDA INJ 100MG
TRELSTAR DEPOT MIXJECT
TRELSTAR LA MIXJECT
tretinoin
TRISENOX
TYKERB
GC MO
GC MO
GC
PA
PA MO
PA MO
LA MO
PA MO
PA MO
PA MO
PA
PA MO
MO
VECTIBIX
VELCADE
VIDAZA
vinblastine sulfate inj 10mg
vincasar pfs
vincristine sulfate
vinorelbine tartrate
VOTRIENT
ZANOSAR
ZOLINZA
MO
MO
MO
QL(180 per
90 days)
MO
QL(360 per
90 days)
MO
PA QL(90
per 90 days)
MO
MO
GC PA MO
GC MO
PA QL(90
per 90 days)
MO
Drug
Tier Notes
4 PA QL(180
per 90 days)
MO
2
MO
4
MO
4
MO
4
PA MO
1
GC MO
1
GC MO
4
PA MO
4
MO
3
MO
3
MO
1
GC MO
2
MO
4 LA QL(540
per 90 days)
MO
4
MO
3
MO
4
QL(4200
per 90 days)
MO
1
GC
1
GC
1
GC
1
GC MO
4
MO
3
MO
4
MO
AUTONOMIC / CNS DRUGS,
NEUROLOGY / PSYCH
ANTICONVULSANTS
BANZEL
carbamazepine chew
carbamazepine er
carbamazepine susp
carbamazepine tabs
CARBATROL
CELONTIN
DILANTIN INFATABS
divalproex sodium cpsp
divalproex sodium er
6
2
1
1
1
1
2
2
2
1
1
MO
GC MO
GC MO
GC
GC MO
MO
MO
MO
GC MO
GC MO
Drug
Drug
Name
Tier Notes
divalproex sodium tbec
1
GC MO
epitol
1
GC MO
EQUETRO
2
MO
ethosuximide
1
GC MO
FELBATOL
2
MO
gabapentin
1
GC MO
GABITRIL
2
MO
KEPPRA INJ
2
LAMICTAL ODT TBDP
2
MO
LAMICTAL XR
2
MO
lamotrigine
1
GC MO
levetiracetam oral soln
1
GC MO
levetiracetam tabs
1
GC MO
LYRICA CAPS 225MG, 300MG 2 QL(180 per
90 days)
MO
LYRICA CAPS 100MG, 150MG, 2 QL(270 per
200MG, 25MG, 50MG, 75MG
90 days)
MO
NEURONTIN ORAL SOLN
2
MO
oxcarbazepine
1
GC MO
PEGANONE
2
MO
phenytoin
1
GC MO
PHENYTOIN SODIUM
2
phenytoin sodium extended
1
GC MO
primidone
1
GC MO
SABRIL
2
MO
TEGRETOL-XR TB12 100MG
2
MO
topiramate
1
GC MO
valproate sodium
1
GC MO
valproic acid
1
GC MO
VIMPAT INJ
2
VIMPAT ORAL SOLN
2
MO
VIMPAT TABS
2
MO
zonisamide
1
GC MO
Drug
Drug
Name
Tier Notes
carbidopa/levodopa odt
1
GC MO
carbidopa/levodopa sr tbcr 50mg; 1
GC MO
200mg
COMTAN
2
MO
LODOSYN
2
MO
MIRAPEX ER
2
MO
pramipexole dihydrochloride tabs 1
GC
0.125mg, 0.25mg, 0.5mg, 1.5mg,
1mg
REQUIP XL
2
MO
ropinirole
1
GC MO
selegiline
1
GC MO
STALEVO 100
2
MO
STALEVO 125
2
MO
STALEVO 150
2
MO
STALEVO 200
2
MO
STALEVO 50
2
MO
STALEVO 75
2
MO
trihexyphenidyl
1
GC MO
ZELAPAR
2
MO
MIGRAINE / CLUSTER HEADACHE
THERAPY
ANTIPARKINSONISM AGENTS
APOKYN
AZILECT
benztropine mesylate inj
benztropine mesylate tabs
bromocriptine mesylate
carbidopa / levodopa
carbidopa/levodopa cr
2
2
1
1
1
1
1
LA MO
MO
GC
GC MO
GC MO
GC MO
GC MO
dihydroergotamine mesylate
ergotamine tartrate / caffeine
MAXALT
1
1
2
MAXALT-MLT
2
migergot
MIGRANAL
1
3
sumatriptan succinate inj
6mg/0.5ml
1
sumatriptan succinate tabs 100mg
1
sumatriptan succinate tabs 25mg,
50mg
1
GC MO
GC MO
QL(36 per
90 days)
MO
QL(36 per
90 days)
MO
GC MO
QL(24 per
90 days)
MO
GC QL(12
per 90 days)
MO
GC QL(27
per 90 days)
MO
GC QL(54
per 90 days)
MO
MISCELLANEOUS NEUROLOGICAL
THERAPY
7
Drug
Name
ARICEPT ODT
Drug
Tier Notes
2 QL(90 per
90 days)
MO
ARICEPT TABS 10MG, 5MG
2 QL(90 per
90 days)
MO
COPAXONE
4 PA QL(90
per 90 days)
MO
EXELON CAPS
2 QL(180 per
90 days)
MO
EXELON ORAL SOLN
2
MO
EXELON PT24
2 QL(90 per
90 days)
MO
galantamine hydrobromide cp24
1 GC QL(90
per 90 days)
MO
galantamine hydrobromide oral
1
GC MO
soln
galantamine hydrobromide tabs
1 GC QL(180
per 90 days)
MO
MYTELASE
2
MO
NAMENDA ORAL SOLN
2
MO
NAMENDA TABS 10MG
2 QL(180 per
90 days)
MO
NAMENDA TABS 5MG
2 QL(270 per
90 days)
MO
NAMENDA TITRATION PAK
2
MO
XENAZINE
4
LA MO
Drug
Name
orphenadrine /asa /caffeine
orphenadrine citrate
orphenadrine citrate er
orphenadrine compound ds
pyridostigmine bromide
regonol
tizanidine hcl
1
1
1
1
1
1
2
2
1
1
Notes
GC MO
GC MO
GC MO
GC MO
GC MO
GC
GC MO
acetaminophen / codeine oral
soln
acetaminophen / codeine tabs
300mg; 15mg
acetaminophen/codeine #3
acetaminophen/codeine #4
ascomp/codeine
BUPRENEX
buprenorphine hcl inj
buprenorphine hcl subl
codeine sulfate tabs 30mg, 60mg
DILAUDID INJ
DILAUDID-5
DILAUDID-HP INJ 10MG/ML
duramorph
EMBEDA CPCR 20MG; 0.8MG,
30MG; 1.2MG, 50MG; 2MG
endocet
fentanyl citrate
fentanyl citrate oral transmucosal
1
GC MO
1
GC MO
1
1
1
2
1
1
1
2
2
2
1
3
GC MO
GC MO
GC
MO
GC
GC MO
GC MO
MO
MO
1
1
1
fentanyl patches
hydrocodone / acetaminophen
hydrocodone / ibuprofen
hydrocodone /acetaminophen-hs
hydrocodone
bitartrate/acetaminophen
hydromorphone hcl inj 10mg/ml
hydromorphone hcl tabs
INFUMORPH 200
INFUMORPH 500
KADIAN
levorphanol tartrate
margesic-h
1
1
1
1
1
GC MO
GC
GC PA
QL(360 per
90 days)
MO
GC MO
GC MO
GC MO
GC MO
GC MO
1
1
2
2
2
1
1
GC MO
GC MO
MO
MO
MO
GC MO
GC MO
NARCOTIC ANALGESICS
MUSCLE RELAXANTS /
ANTISPASMODIC THERAPY
baclofen
carisoprodol /aspirin
carisoprodol tabs 350mg
chlorzoxazone
cyclobenzaprine hcl
dantrolene sodium
MESTINON SYRP
MESTINON TIMESPAN
metaxalone
methocarbamol
Drug
Tier
1
1
1
1
1
1
1
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
MO
GC
GC MO
8
GC MO
MO
Drug
Drug
Name
Tier Notes
meperidine hcl inj 10mg/ml,
1
GC
50mg/ml
meperidine hcl inj 25mg/ml,
1
GC MO
75mg/ml
meperidine hcl oral soln
1
GC MO
methadone hcl conc
1
GC MO
methadone hcl inj
1
GC
METHADONE HCL ORAL
2
MO
SOLN
methadone hcl tabs
1
GC MO
methadose tabs 10mg
1
GC
methadose tabs 5mg
1
GC MO
morphine sulfate er
1
GC MO
morphine sulfate inj 0.5mg/ml,
1
GC
5mg/ml
morphine sulfate inj 1mg/ml
1
GC MO
morphine sulfate oral soln
1
GC MO
morphine sulfate tabs
1
GC MO
ONSOLIS
2
OPANA ER
2
MO
oxycodone /acetaminophen caps
1
GC MO
oxycodone /acetaminophen tabs
1
GC
325mg; 5mg
oxycodone /acetaminophen tabs
1
GC MO
325mg; 2.5mg, 650mg; 10mg
oxycodone /apap tabs 500mg;
1
GC MO
7.5mg
oxycodone /aspirin
1
GC MO
oxycodone hcl tabs 15mg, 30mg,
1
GC MO
5mg
oxycodone-apap
1
GC MO
OXYCONTIN
2
MO
reprexain tabs 10mg; 200mg
1
GC MO
ROXICET ORAL SOLN
2
MO
roxicet tabs 325mg; 5mg
1
GC MO
stagesic
1
GC MO
zerlor
1
GC MO
Drug
Name
CELEBREX
depade
diclofenac potassium
diclofenac sodium
diclofenac sodium ec
diclofenac sodium xr
diflunisal
etodolac
fenoprofen calcium
FLECTOR
flurbiprofen
ibuprofen susp
ibuprofen tabs 400mg, 600mg,
800mg
indomethacin caps
indomethacin er
ketoprofen
ketoprofen er
meclofenamate sodium
meloxicam
nabumetone
naloxone
naltrexone
naproxen sodium tabs 275mg,
550mg
naproxen susp
naproxen tabs 250mg, 375mg
naproxen tbec
oxaprozin
piroxicam
SUBOXONE SUBL
sulindac
tolmetin sodium
tramadol
tramadol hcl er
VOLTAREN GEL
NON-NARCOTIC ANALGESICS
ARTHROTEC 50
ARTHROTEC 75
butorphanol tartrate nasal soln
3
3
1
MO
MO
GC PA
QL(30 per
90 days)
MO
Drug
Tier Notes
2 QL(180 per
90 days)
MO
1
GC MO
1
GC MO
1
GC MO
1
GC MO
1
GC MO
1
GC MO
1
GC MO
1
GC MO
3
MO
1
GC MO
1
GC MO
1
GC MO
1
1
1
1
1
1
1
1
1
1
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC
GC MO
GC MO
1
1
1
1
1
2
1
1
1
1
2
GC MO
GC MO
GC MO
GC MO
GC MO
MO
GC MO
GC MO
GC MO
GC MO
MO
1
1
1
1
GC MO
GC MO
GC MO
GC MO
PROPOXYPHENE
balacet 325
propoxyphene /acetaminophen
propoxyphene hcl
propoxyphene-n /acetaminophen
9
Drug
Name
Drug
Tier
Drug
Name
citalopram tabs 10mg
Notes
PSYCHOTHERAPEUTIC DRUGS
ABILIFY DISCMELT TBDP
15MG
3
ABILIFY DISCMELT TBDP
10MG
3
ABILIFY INJ
ABILIFY ORAL SOLN
ABILIFY TABS 20MG, 2MG,
30MG, 5MG
3
3
3
ABILIFY TABS 15MG
3
ABILIFY TABS 10MG
3
amitriptyline
amoxapine
amphetamine
/dextroamphetamine tabs
budeprion sr
1
1
1
budeprion xl tb24 300mg
1
budeprion xl tb24 150mg
1
1
bupropion hcl
bupropion hcl sr tb12 100mg,
200mg
1
1
bupropion hcl sr tb12 150mg
1
buspirone hcl
chlordiazepoxide /amitriptyline
chlorpromazine
citalopram oral soln
citalopram tabs 40mg
1
1
1
1
1
QL(180 per
90 days) ST
MO
QL(270 per
90 days) ST
MO
ST
ST MO
QL(90 per
90 days) ST
MO
QL(180 per
90 days) ST
MO
QL(270 per
90 days) ST
MO
GC MO
GC MO
GC PA MO
citalopram tabs 20mg
clomipramine
clozapine tabs 100mg, 25mg,
50mg
CLOZAPINE TABS 200MG
CYMBALTA CPEP 60MG
GC QL(180
per 90 days)
MO
GC QL(90
per 90 days)
MO
GC QL(270
per 90 days)
MO
GC MO
GC QL(180
per 90 days)
MO
GC PA
QL(180 per
90 days)
MO
GC MO
GC MO
GC MO
GC MO
GC QL(90
per 90 days)
MO
10
Drug
Tier Notes
1 GC QL(180
per 90 days)
MO
1 GC QL(270
per 90 days)
MO
1
GC MO
1
GC
2
2
CYMBALTA CPEP 20MG,
30MG
2
desipramine
dexmethylphenidate
dextroamphetamine sulfate
dextroamphetamine sulfate er
doxepin caps 100mg, 10mg,
25mg, 50mg, 75mg
doxepin conc
EMSAM
1
1
1
1
1
FANAPT TABS 1MG, 2MG,
4MG
3
FANAPT TABS 10MG, 12MG,
6MG, 8MG
3
FANAPT TITRATION PACK
FAZACLO TBDP 100MG,
12.5MG, 25MG
fluoxetine caps 40mg
3
3
fluoxetine caps 20mg
1
fluoxetine caps 10mg
1
fluoxetine dr
1
1
3
1
QL(90 per
90 days)
MO
QL(180 per
90 days)
MO
GC MO
GC PA MO
GC PA MO
GC PA MO
GC MO
GC MO
QL(90 per
90 days)
MO
QL(90 per
90 days)
MO
QL(180 per
90 days)
MO
MO
GC QL(180
per 90 days)
MO
GC QL(360
per 90 days)
MO
GC QL(720
per 90 days)
MO
GC QL(12
per 90 days)
MO
Drug
Name
fluoxetine oral soln
fluoxetine tabs 20mg
fluoxetine tabs 10mg
fluphenazine conc
fluphenazine decanoate inj
fluphenazine elix
fluphenazine inj
fluphenazine tabs
fluvoxamine
FOCALIN XR CP24 10MG,
15MG, 20MG, 5MG
GEODON CAPS
Drug
Tier Notes
1
GC MO
1 GC QL(360
per 90 days)
MO
1 GC QL(720
per 90 days)
MO
1
GC
1
GC MO
1
GC MO
1
GC MO
1
GC MO
1 GC QL(270
per 90 days)
MO
2
PA MO
2
GEODON INJ
HALDOL
HALDOL DECANOATE 100
HALDOL DECANOATE 50
haloperidol
haloperidol decanoate inj
haloperidol lactate inj
imipramine
imipramine pamoate
INVEGA SUSTENNA
INVEGA TB24 1.5MG, 3MG,
9MG
2
2
2
2
1
1
1
1
1
2
2
INVEGA TB24 6MG
2
LEXAPRO ORAL SOLN
LEXAPRO TABS
2
2
lithium carbonate
lithium carbonate er
lithium citrate
loxapine
maprotiline
1
1
1
1
1
QL(180 per
90 days)
MO
MO
MO
MO
MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
QL(90 per
90 days)
MO
QL(180 per
90 days)
MO
MO
QL(90 per
90 days)
MO
GC MO
GC MO
GC MO
GC MO
GC MO
11
Drug
Name
MARPLAN
METADATE CD
metadate er
methamphetamine hcl
METHYLIN CHEW
methylin er
METHYLIN ORAL SOLN
methylin tabs
methylphenidate hcl
methylphenidate hcl sr
mirtazapine
Drug
Tier Notes
2
MO
3
PA MO
1 GC PA MO
1 GC PA MO
3
PA MO
1 GC PA MO
3
PA MO
1 GC PA MO
1
GC PA
1
GC PA
1 GC QL(90
per 90 days)
MO
mirtazapine odt tbdp 30mg, 45mg 1 GC QL(90
per 90 days)
MO
NARDIL
2
MO
NAVANE CAPS 20MG
2
MO
nefazodone
1 GC QL(180
per 90 days)
MO
nortriptyline
1
GC MO
ORAP
2
MO
paroxetine er tb24 12.5mg
1 GC QL(180
per 90 days)
MO
paroxetine er tb24 25mg
1 GC QL(270
per 90 days)
MO
paroxetine susp
1
GC MO
paroxetine tabs 20mg, 40mg
1 GC QL(90
per 90 days)
MO
paroxetine tabs 10mg, 30mg
1 GC QL(180
per 90 days)
MO
PAXIL SUSP
2
MO
perphenazine
1
GC MO
PRISTIQ
2 QL(90 per
90 days)
MO
protriptyline hcl
1
GC MO
PROVIGIL
2 PA QL(90
per 90 days)
MO
RISPERDAL CONSTA
2
MO
Drug
Name
risperidone odt
risperidone oral soln
risperidone tabs
RITALIN LA
ROZEREM
SAPHRIS
SEROQUEL TABS 25MG,
300MG, 400MG
SEROQUEL TABS 100MG,
200MG, 50MG
SEROQUEL XR TB24 150MG,
300MG, 400MG
SEROQUEL XR TB24 200MG,
50MG
sertraline conc
sertraline tabs 100mg, 25mg
sertraline tabs 50mg
STRATTERA
SURMONTIL
SYMBYAX
thioridazine
thiothixene
tranylcypromine
trazodone
trifluoperazine
venlafaxine hcl
XYREM
zaleplon
Drug
Tier Notes
1 GC QL(180
per 90 days)
MO
1
GC MO
1 GC QL(180
per 90 days)
MO
3
PA MO
3
MO
3 QL(180 per
90 days)
MO
2 QL(180 per
90 days)
MO
2 QL(270 per
90 days)
MO
2 QL(180 per
90 days)
MO
2 QL(270 per
90 days)
MO
1
GC MO
1 GC QL(180
per 90 days)
MO
1 GC QL(270
per 90 days)
MO
2
MO
3
MO
3 QL(90 per
90 days)
MO
1
GC MO
1
GC MO
1
GC MO
1
GC MO
1
GC MO
1 GC QL(270
per 90 days)
MO
4
PA
1
GC MO
12
Drug
Name
zolpidem
ZYPREXA INJ
ZYPREXA TABS
ZYPREXA ZYDIS
Drug
Tier Notes
1
GC MO
2
MO
2 QL(90 per
90 days)
MO
2 QL(90 per
90 days)
MO
CARDIOVASCULAR,
HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone inj
amiodarone tabs
disopyramide phosphate
flecainide acetate
mexiletine
MULTAQ
NORPACE CR CP12 100MG
PACERONE TABS 100MG,
400MG
pacerone tabs 200mg
procainamide
propafenone hcl
quinidine gluconate cr
quinidine sulfate
quinidine sulfate er
sorine
sotalol
TIKOSYN
1
1
1
1
1
2
2
2
GC
GC MO
GC MO
GC MO
GC MO
MO
MO
MO
1
1
1
1
1
1
1
1
3
GC MO
GC
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
ANTIHYPERTENSIVE THERAPY
acebutolol
afeditab cr
amiloride
amiloride / hydrochlorothiazide
amlodipine / benazepril
1
1
1
1
1
amlodipine besylate
atenolol
atenolol / chlorthalidone
benazepril
benazepril / hydrochlorothiazide
tabs 20mg; 12.5mg, 20mg; 25mg
1
1
1
1
1
GC MO
GC MO
GC MO
GC MO
GC QL(90
per 90 days)
MO
GC MO
GC MO
GC MO
GC MO
GC QL(360
per 90 days)
MO
Drug
Drug
Name
Tier Notes
benazepril / hydrochlorothiazide
1 GC QL(720
tabs 10mg; 12.5mg
per 90 days)
MO
benazepril / hydrochlorothiazide
1
GC
tabs 5mg; 6.25mg
QL(1440
per 90 days)
MO
betaxolol hcl tabs
1
GC
BIDIL
2 QL(540 per
90 days)
MO
bisoprolol fumarate
1
GC MO
bisoprolol fumarate /
1
GC MO
hydrochlorothiazide
bumetanide
1
GC MO
BYSTOLIC
2
MO
captopril
1
GC MO
captopril / hydrochlorothiazide
1 GC QL(90
tabs 25mg; 15mg, 25mg; 25mg,
per 90 days)
50mg; 15mg
MO
captopril / hydrochlorothiazide
1 GC QL(270
tabs 50mg; 25mg
per 90 days)
MO
cartia xt
1
GC MO
carvedilol
1
GC MO
chlorothiazide
1
GC MO
chlorothiazide sodium
1
GC MO
chlorthalidone tabs 25mg, 50mg
1
GC MO
clonidine ptwk
1
GC
clonidine tabs
1
GC MO
COREG CR
2
MO
DEMSER
2
MO
DIBENZYLINE
3
MO
dilt-cd cp24 120mg, 300mg
1
GC MO
dilt-xr cp24 180mg, 240mg
1
GC
diltiazem cd cp24 120mg, 240mg, 1
GC MO
300mg
diltiazem hcl cp24 360mg
1
GC MO
diltiazem hcl er cp12
1
GC MO
diltiazem hcl er cp24 420mg
1
GC MO
diltiazem hcl er tb24
1
GC
diltiazem hcl inj 25mg/5ml
1
GC
DILTIAZEM HCL INJ 100MG
2
diltiazem hcl tabs
1
GC MO
diltzac
1
GC MO
13
Drug
Name
DIOVAN HCT
Drug
Tier Notes
2 QL(90 per
90 days)
MO
DIOVAN TABS 320MG
2 QL(90 per
90 days)
MO
DIOVAN TABS 160MG, 40MG, 2 QL(180 per
80MG
90 days)
MO
doxazosin
1 GC QL(180
per 90 days)
MO
EDECRIN
2
MO
enalapril
1
GC MO
enalapril / hydrochlorothiazide
1 GC QL(90
tabs 5mg; 12.5mg
per 90 days)
MO
enalapril / hydrochlorothiazide
1 GC QL(180
tabs 10mg; 25mg
per 90 days)
MO
eplerenone
1
GC MO
EXFORGE
2 QL(90 per
90 days)
MO
EXFORGE HCT
2 QL(90 per
90 days)
MO
felodipine er
1
GC MO
fosinopril
1
GC MO
fosinopril / hydrochlorothiazide
1 GC QL(90
tabs 10mg; 12.5mg
per 90 days)
MO
fosinopril / hydrochlorothiazide
1 GC QL(360
tabs 20mg; 12.5mg
per 90 days)
MO
furosemide inj
1
GC MO
furosemide oral soln 10mg/ml
1
GC MO
FUROSEMIDE ORAL SOLN
2
MO
8MG/ML
furosemide tabs
1
GC MO
guanfacine hcl
1
GC MO
hydralazine
1
GC MO
hydrochlorothiazide
1
GC MO
indapamide
1
GC MO
isradipine
1
GC MO
labetalol inj
1
GC
Drug
Name
labetalol tabs
lisinopril / hydrochlorothiazide
tabs 12.5mg; 10mg, 12.5mg;
20mg
lisinopril / hydrochlorothiazide
tabs 25mg; 20mg
lisinopril tabs 5mg
lisinopril tabs 10mg, 2.5mg,
20mg, 30mg, 40mg
losartan potassium tabs 100mg
Drug
Tier Notes
1
GC MO
1 GC QL(90
per 90 days)
MO
1 GC QL(360
per 90 days)
MO
1
GC
1
GC MO
1
losartan potassium tabs 25mg,
50mg
1
losartan
potassium/hydrochlorothiazide
1
LOTREL CAPS 10MG; 40MG,
5MG; 40MG
2
methyclothiazide
metolazone
metoprolol / hydrochlorothiazide
metoprolol succinate er
metoprolol tartrate inj
metoprolol tartrate tabs
MICARDIS
1
1
1
1
1
1
2
MICARDIS HCT
2
minoxidil tabs
moexipril
moexipril / hydrochlorothiazide
tabs 12.5mg; 15mg, 12.5mg;
7.5mg
moexipril / hydrochlorothiazide
tabs 25mg; 15mg
1
1
1
nadolol / bendroflumethiazide
nadolol tabs 20mg, 40mg, 80mg
nicardipine caps
nifediac cc
1
1
1
1
1
GC QL(90
per 90 days)
MO
GC QL(180
per 90 days)
MO
GC QL(90
per 90 days)
MO
QL(90 per
90 days)
MO
GC MO
GC MO
GC MO
GC
GC
GC MO
QL(90 per
90 days)
MO
QL(90 per
90 days)
MO
GC MO
GC MO
GC QL(90
per 90 days)
MO
GC QL(180
per 90 days)
MO
GC MO
GC MO
GC MO
GC MO
14
Drug
Name
nifedical xl
nifedipine
nifedipine er tb24 30mg, 60mg
nifedipine er tb24 90mg
nimodipine
nisoldipine tb24 20mg, 30mg,
40mg
perindopril erbumine
pindolol
prazosin
Drug
Tier
1
1
1
1
4
1
1
1
1
propranolol /hydrochlorothiazide
propranolol hcl er
propranolol hcl inj
propranolol hcl oral soln
propranolol hcl tabs
quinapril
quinapril / hydrochlorothiazide
1
1
1
1
1
1
1
ramipril
reserpine
SODIUM EDECRIN
spironolactone
spironolactone /
hydrochlorothiazide
SULAR
taztia xt
TEKTURNA
1
1
2
1
1
TEKTURNA HCT
2
terazosin hcl
1
timolol maleate
torsemide tabs
trandolapril
trandolapril/verapamil hcl tbcr
2mg; 180mg, 2mg; 240mg
trandolapril/verapamil hcl tbcr
4mg; 240mg
1
1
1
1
2
1
2
1
Notes
GC MO
GC MO
GC
GC MO
MO
GC MO
GC MO
GC MO
GC QL(360
per 90 days)
MO
GC MO
GC MO
GC
GC MO
GC MO
GC MO
GC QL(90
per 90 days)
MO
GC MO
GC MO
GC MO
GC MO
MO
GC MO
QL(90 per
90 days)
MO
QL(90 per
90 days)
MO
GC QL(180
per 90 days)
MO
GC MO
GC MO
GC MO
GC QL(90
per 90 days)
GC QL(180
per 90 days)
Drug
Drug
Name
Tier Notes
triamterene / hydrochlorothiazide 1
GC MO
TWYNSTA
2 QL(90 per
90 days)
MO
VALTURNA
2 QL(90 per
90 days)
MO
verapamil er
1
GC MO
verapamil inj
1
GC
verapamil tabs
1
GC MO
Drug
Name
LOVENOX INJ 100MG/ML,
120MG/0.8ML, 150MG/ML,
300MG/3ML, 60MG/0.6ML,
80MG/0.8ML
pentopak
pentoxifylline er
PLAVIX
PROMACTA TABS 50MG
CARDIAC GLYCOSIDES
digoxin inj
digoxin oral soln
digoxin tabs
LANOXIN INJ
LANOXIN TABS
1
1
1
2
2
GC
GC MO
GC MO
MO
COAGULATION THERAPY
AGGRENOX
ARIXTRA INJ 2.5MG/0.5ML
ARIXTRA INJ 10MG/0.8ML,
5MG/0.4ML, 7.5MG/0.6ML
cilostazol
CYKLOKAPRON
dipyridamole tabs
EFFIENT
FRAGMIN
heparin sodium dcu
HEPARIN SODIUM INJ
2500UNIT/ML
HEPARIN SODIUM INJ
2000UNIT/ML
heparin sodium inj 10000unit/ml,
1000unit/ml, 5000unit/ml
heparin sodium/d5w inj 5%;
40unit/ml
HEPARIN SODIUM/NACL
0.45%
heparin sodium/sodium chloride
0.9% premix
jantoven
LOVENOX INJ 30MG/0.3ML,
40MG/0.4ML
2
2
4
MO
MO
MO
1
2
1
2
2
1
2
GC MO
MO
GC MO
MO
MO
GC MO
2
MO
1
GC MO
1
GC
Drug
Tier
4
1
1
2
4
PROMACTA TABS 25MG
4
ticlopidine hcl
warfarin
1
1
GC
1
2
GC MO
MO
GC MO
GC MO
MO
LA PA
QL(90 per
90 days)
MO
LA PA
QL(270 per
90 days)
MO
GC MO
GC MO
LIPID/CHOLESTEROL LOWERING
AGENTS
CADUET
2
cholestyramine light pack
COLESTID GRAN
colestipol
CRESTOR
1
2
1
2
fenofibrate
fenofibrate micronized
gemfibrozil
LIPITOR
1
1
1
2
lovastatin tabs 10mg
1
lovastatin tabs 20mg, 40mg
1
LOVAZA
NIASPAN
pravastatin tabs 10mg, 20mg,
80mg
2
2
1
2
1
Notes
MO
15
QL(90 per
90 days)
MO
GC MO
MO
GC MO
QL(90 per
90 days)
MO
GC MO
GC MO
GC MO
QL(90 per
90 days)
MO
GC QL(90
per 90 days)
MO
GC QL(180
per 90 days)
MO
MO
MO
GC QL(90
per 90 days)
MO
Drug
Name
pravastatin tabs 40mg
Drug
Tier Notes
1 GC QL(180
per 90 days)
MO
prevalite powd
1
GC MO
SIMCOR TB24 1000MG; 20MG, 2 QL(180 per
500MG; 20MG, 750MG; 20MG
90 days)
MO
simvastatin
1 GC QL(90
per 90 days)
MO
TRICOR
2
MO
TRILIPIX
2
MO
ZETIA
2 QL(90 per
90 days)
MO
MISCELLANEOUS CARDIOVASCULAR
AGENTS
RANEXA
2
MO
1
1
1
1
1
1
1
GC MO
GC MO
GC MO
GC MO
GC MO
GC PA
GC
1
1
GC MO
GC MO
2
2
MO
MO
NITRATES
isosorbide dinitrate
isosorbide dinitrate er
isosorbide mononitrate
isosorbide mononitrate er
nitro-bid
nitroglycerin inj
nitroglycerin pt24 0.2mg/hr,
0.6mg/hr
nitroglycerin pt24 0.4mg/hr
nitroglycerin transdermal pt24
0.1mg/hr
NITROLINGUAL PUMPSPRAY
NITROSTAT
amnesteem
avita crea
AZELEX
claravis
clindamycin phosphate external
soln
clindamycin phosphate foam
clindamycin phosphate gel
clindamycin phosphate lotn
clindamycin phosphate swab
clindamycin/benzoyl peroxide
ery
erythromycin / benzoyl peroxide
erythromycin external soln
erythromycin gel
FINACEA
METROGEL
metronidazole
sotret
tretinoin
ANTIPSORIATIC / ANTISEBORRHEIC
1
1
2
GC MO
GC MO
MO
1
1
1
GC MO
GC MO
GC MO
BURN THERAPY
silver sulfadiazine
ssd
thermazene
Drug
Tier
2
1
2
2
2
3
2
1
1
1
4
2
1
3
2
2
3
2
Notes
MO
GC MO
MO
MO
MO
MO
MO
GC MO
GC MO
GC
MO
MO
GC MO
MO
PA MO
MO
MO
MO
1
1
2
1
1
GC
GC MO
MO
GC
GC MO
1
1
1
1
1
1
1
1
1
2
2
1
1
1
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
MO
GC MO
GC
GC MO
1
1
GC MO
GC MO
THERAPY FOR ACNE
DERMATOLOGICALS/TOPICAL
THERAPY
calcipotriene external soln
selenium sulfide lotn 2.5%
SORIATANE CAPS 17.5MG,
22.5MG
Drug
Name
8-MOP
ammonium lactate
CARAC
CARMOL-HC
CONDYLOX GEL
ELIDEL
FLUOROPLEX
fluorouracil
imiquimod
laclotion
OXSORALEN ULTRA
PANRETIN
podofilox
PROTOPIC
REGRANEX
SOLARAZE
VEREGEN
ZONALON
TOPICAL ANESTHETICS
lidocaine / prilocaine crea
lidocaine external soln
MISCELLANEOUS DERMATOLOGICALS
16
Drug
Name
lidocaine gel
lidocaine inj 0.5%, 1%
lidocaine oint
lidocaine viscous
LIDODERM
Drug
Tier
1
1
1
1
3
Drug
Drug
Name
Tier Notes
amcinonide oint
1
GC
augmented betamethasone
1
GC MO
dipropionate
beta-val crea
1
GC MO
betamethasone dipropionate crea 1
GC MO
betamethasone dipropionate oint
1
GC MO
betamethasone valerate crea
1
GC MO
betamethasone valerate lotn
1
GC
betamethasone valerate oint
1
GC MO
CAPEX
2
MO
clobetasol propionate e
1
GC MO
clobetasol propionate external
1
GC
soln
clobetasol propionate foam
1
GC MO
clobetasol propionate gel
1
GC MO
clobetasol propionate oint
1
GC MO
CLOBEX LOTN
2
MO
CLOBEX SHAM
2
MO
CORDRAN TAPE
2
MO
DERMA-SMOOTHE / FS BODY 2
MO
OIL
desonide
1
GC MO
desoximetasone
1
GC MO
diflorasone diacetate
1
GC MO
fluocinolone acetonide
1
GC MO
fluocinonide emollient base
1
GC
fluocinonide external soln
1
GC MO
fluocinonide gel
1
GC MO
fluocinonide oint
1
GC MO
fluticasone propionate
1
GC MO
halobetasol propionate
1
GC MO
hydrocortisone butyrate
1
GC MO
hydrocortisone crea 1%, 2.5%
1
GC MO
hydrocortisone lotn
1
GC MO
hydrocortisone oint 1%, 2.5%
1
GC MO
hydrocortisone valerate
1
GC MO
LOCOID LOTN
2
MO
LUXIQ
2
MO
mometasone furoate
1
GC MO
PANDEL
2
MO
prednicarbate
1
GC MO
triamcinolone acetonide crea
1
GC MO
triamcinolone acetonide lotn
1
GC MO
Notes
GC MO
GC
GC MO
GC MO
PA MO
TOPICAL ANTIBACTERIALS
ALTABAX
BACTROBAN CREA
gentamicin sulfate crea
gentamicin sulfate oint
mupirocin
PHISOHEX
sodium sulfacetamide
SULFAMYLON
2
2
1
1
1
2
1
2
MO
MO
GC MO
GC MO
GC MO
MO
GC MO
MO
1
1
1
1
1
1
1
1
1
2
1
1
1
1
1
1
1
2
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
MO
2
3
3
MO
MO
MO
TOPICAL ANTIFUNGALS
ciclopirox
ciclopirox nail lacquer
ciclopirox olamine
clotrimazole / betamethasone
clotrimazole external crea
clotrimazole external soln
econazole nitrate
ketoconazole
kuric
NAFTIN
nyamyc
nystatin / triamcinolone
nystatin crea
nystatin external powd
nystatin oint
nystop
pedi-dri
XOLEGEL
TOPICAL ANTIVIRALS
DENAVIR
ZOVIRAX CREA
ZOVIRAX OINT
TOPICAL CORTICOSTEROIDS
ala cort
alclometasone dipropionate
amcinonide crea
amcinonide lotn
1
1
1
1
GC MO
GC MO
GC MO
GC MO
17
Drug
Name
triamcinolone acetonide oint
triderm crea
Drug
Tier Notes
1
GC MO
1
GC MO
TOPICAL ENZYMES
SANTYL
2
MO
TOPICAL SCABICIDES / PEDICULICIDES
acticin
EURAX
LINDANE
malathion
OVIDE
permethrin crea
ULESFIA
1
2
2
1
2
1
3
GC MO
MO
MO
GC MO
MO
GC MO
DIAGNOSTICS / MISCELLANEOUS
AGENTS
sodium chloride 0.9%
sodium chloride inj 0.9%
sodium polystyrene sulfonate
powd
SYPRINE
MISCELLANEOUS AGENTS
ACTONEL TABS 30MG
ADAGEN
alcohol 5%/dextrose 5%
alendronate sodium tabs 40mg
anagrelide hydrochloride
ANTABUSE TABS 250MG
BUPHENYL
CAMPRAL
3
4
1
1
1
2
2
2
CHEMET
CLINIMIX / DEXTROSE
DEXTROSE 10%/NACL 0.45%
dextrose 10% flex container
DEXTROSE 10%/NACL 0.2%
dextrose 2.5%/sodium chloride
0.45%
dextrose 5%
dextrose 5%/nacl 0.2%
dextrose 5%/nacl 0.225%
DEXTROSE 5%/NACL 0.33%
dextrose 5%/nacl 0.45%
dextrose 5%/nacl 0.9%
etidronate disodium
EVOXAC
EXJADE
FOSRENOL
2
2
2
1
2
1
1
1
1
2
1
1
1
3
4
2
Drug
Name
INCRELEX
kionex powd
levocarnitine oral soln
levocarnitine tabs
midodrine
ORFADIN
pilocarpine hcl tabs
PROLASTIN INJ 500MG
RENAGEL
RENVELA
RILUTEK
SKELID
PA MO
LA MO
GC
GC PA MO
GC MO
MO
MO
QL(540 per
90 days)
MO
MO
Drug
Tier Notes
4 LA PA MO
1
GC MO
1
GC MO
1
GC MO
1
GC MO
4
LA MO
1
GC MO
4
LA
2
MO
2
MO
4
MO
3 PA QL(180
per 90 days)
MO
1
GC MO
1
GC MO
1
GC MO
2
MO
buproban
1
CHANTIX TABS
2
CHANTIX TABS 0.5MG, 1MG
2
NICOTROL INHALER
3
NICOTROL NASAL
3
GC PA
QL(180 per
90 days)
MO
PA QL(1
per 3 days)
MO
PA QL(168
per 90 days)
MO
PA QL(504
per 90 days)
MO
PA QL(90
per 90 days)
MO
SMOKING DETERRENTS
GC
GC
GC MO
GC
GC
EAR, NOSE / THROAT
MEDICATIONS
MISCELLANEOUS AGENTS
GC MO
GC MO
GC MO
MO
LA MO
MO
ASTELIN
ASTEPRO
azelastine hcl nasal soln
BACTROBAN NASAL
chlorhexidine gluconate oral
rinse
18
2
2
1
2
1
MO
MO
GC MO
MO
GC MO
Drug
Name
ipratropium bromide nasal soln
periogard
triamcinolone in orabase
TYZINE
TYZINE PEDIATRIC NASAL
DROPS
Drug
Tier Notes
1
GC MO
1
GC MO
1
GC MO
2
MO
2
Drug
Name
METHYLPREDNISOLONE
SODIUMSUCCINATE INJ
1000MG
methylprednisolone tabs 32mg
methylprednisolone tabs 16mg,
4mg, 8mg
prednisolone sodium phosphate
oral soln 15mg/5ml
prednisolone syrp
prednisone
PREDNISONE INTENSOL
SOLU-CORTEF INJ 100MG
SOLU-CORTEF INJ 250MG
SOLU-MEDROL INJ 2GM,
40MG
SOLU-MEDROL INJ 125MG
solu-medrol inj 500mg
MISCELLANEOUS OTIC
PREPARATIONS
acetasol hc
acetic acid
acetic acid / hydrocortisone
borofair
DERMOTIC
ofloxacin
1
1
1
1
2
1
GC MO
GC MO
GC MO
GC MO
MO
GC MO
OTIC STEROID / ANTIBIOTIC
CIPRO HC
CIPRODEX
COLY-MYCIN S
CORTISPORIN-TC
cortomycin
neomycin /polymyxin /hc
neomycin /polymyxin
/hydrocortisone otic susp
3
2
2
2
1
1
1
MO
MO
MO
MO
GC MO
GC MO
GC MO
Drug
Tier Notes
2
PA MO
1
1
GC PA
GC PA MO
1
GC PA MO
1
1
2
2
2
2
GC PA
GC PA MO
PA MO
2
1
PA MO
GC PA
1
1
GC MO
GC MO
acarbose
1
ACTOPLUS MET
2
ACTOS
2
GC QL(270
per 90 days)
MO
QL(270 per
90 days)
MO
QL(90 per
90 days)
MO
ALCOHOL PREPS
AVANDAMET
2
2
AVANDARYL TABS 2MG;
8MG, 4MG; 4MG, 4MG; 8MG
2
AVANDARYL TABS 1MG;
4MG, 2MG; 4MG
2
AVANDIA TABS 8MG
2
AVANDIA TABS 2MG, 4MG
2
ANTITHYROID AGENTS
methimazole
propylthiouracil
DIABETES THERAPY
ENDOCRINE/DIABETES
ADRENAL HORMONES
a-hydrocort
a-methapred
cortisone acetate
DEPO-MEDROL
dexamethasone elix
dexamethasone inj 4mg/ml
DEXAMETHASONE
INTENSOL
dexamethasone tabs 0.5mg,
0.75mg, 1.5mg, 4mg, 6mg
DEXAMETHASONE TABS
1MG, 2MG
fludrocortisone acetate
hydrocortisone tabs
methylprednisolone acetate
methylprednisolone
sodiumsuccinate inj 125mg, 40mg
1
1
1
2
1
1
2
GC MO
GC PA MO
GC MO
PA MO
GC MO
GC MO
MO
1
GC MO
2
MO
1
1
1
1
GC MO
GC MO
GC PA MO
GC PA
MO
PA
19
QL(180 per
90 days)
MO
QL(90 per
90 days)
MO
QL(180 per
90 days)
MO
QL(90 per
90 days)
MO
QL(180 per
90 days)
MO
Drug
Drug
Name
Tier Notes
BD INSULIN SYRINGE
2
MO
SAFETYGLIDE/1ML/29G X
1/2"
BD INSULIN SYRINGE
2
MO
ULTRAFINE/0.3ML/31G X
5/16"
BD INSULIN SYRINGE
2
MO
ULTRAFINE/0.5ML/30G X 1/2"
BD INSULIN SYRINGE
2
MO
ULTRAFINE/1ML/31G X 5/16"
BD PEN
2
MO
NEEDLE/ULTRAFINE/29G X
12.7MM
BYETTA
3 QL(7.2 per
90 days) ST
MO
CURITY GAUZE PADS 2"X2"
2
MO
DUETACT
2 QL(90 per
90 days)
MO
glimepiride tabs 1mg, 2mg
1 GC QL(90
per 90 days)
MO
glimepiride tabs 4mg
1 GC QL(180
per 90 days)
MO
glipizide / metformin
1 GC QL(360
per 90 days)
MO
glipizide er tb24 2.5mg
1 GC QL(90
per 90 days)
glipizide tabs 10mg
1 GC QL(360
per 90 days)
MO
glipizide tabs 5mg
1 GC QL(720
per 90 days)
MO
glipizide xl tb24 5mg
1 GC QL(90
per 90 days)
MO
glipizide xl tb24 10mg
1 GC QL(180
per 90 days)
MO
GLUCAGEN HYPOKIT
2
MO
GLUCAGON EMERGENCY
2
MO
KIT
20
Drug
Name
glyburide / metformin tabs
1.25mg; 250mg, 2.5mg; 500mg
Drug
Tier Notes
1 GC QL(180
per 90 days)
MO
glyburide / metformin tabs 5mg;
1 GC QL(360
500mg
per 90 days)
MO
glyburide micronized tabs 1.5mg, 1 GC QL(90
3mg
per 90 days)
MO
glyburide micronized tabs 6mg
1 GC QL(180
per 90 days)
MO
glyburide tabs 1.25mg, 2.5mg
1 GC QL(180
per 90 days)
MO
glyburide tabs 5mg
1 GC QL(360
per 90 days)
MO
glycron tabs 1.5mg, 3mg
1 GC QL(180
per 90 days)
MO
GLYCRON TABS 4.5MG
2 QL(360 per
90 days)
HUMALOG
2
MO
HUMALOG MIX 50/50
2
MO
HUMALOG MIX 50/50 PEN
2
MO
HUMALOG MIX 75/25
2
MO
HUMALOG MIX 75/25 PEN
2
MO
HUMALOG PEN
2
MO
HUMULIN 70/30
2
MO
HUMULIN 70/30 PEN
2
MO
HUMULIN N
2
MO
HUMULIN N U-100 PEN
2
MO
HUMULIN R
2
MO
HUMULIN R U-500
2
MO
(CONCENTRATED)
JANUMET
2 QL(180 per
90 days)
MO
JANUVIA
2 QL(90 per
90 days)
MO
LANTUS
2
MO
LANTUS SOLOSTAR
2
MO
metformin hcl er tb24 750mg
1 GC QL(270
per 90 days)
MO
Drug
Name
metformin hcl er tb24 500mg
metformin hcl tabs 1000mg
metformin hcl tabs 850mg
metformin hcl tabs 500mg
nateglinide
NOVOLIN 70/30
NOVOLIN 70/30 INNOLET
NOVOLIN N
NOVOLIN N INNOLET
NOVOLIN R
NOVOLOG
NOVOLOG FLEXPEN
NOVOLOG MIX 70/30
NOVOLOG MIX 70/30
PREFILLED FLEXPEN
ONGLYZA
PRANDIN TABS 0.5MG, 1MG
Drug
Tier Notes
1 GC QL(450
per 90 days)
MO
1 GC QL(180
per 90 days)
MO
1 GC QL(270
per 90 days)
MO
1 GC QL(360
per 90 days)
MO
1 GC QL(270
per 90 days)
MO
2
MO
2
MO
2
MO
2
MO
2
MO
2
MO
2
MO
2
MO
2
MO
2
2
PRANDIN TABS 2MG
2
PROGLYCEM
RELION R
SYMLIN
2
2
3
SYMLINPEN 120
3
SYMLINPEN 60
3
tolazamide
tolbutamide
1
1
QL(90 per
90 days)
MO
QL(360 per
90 days)
MO
QL(720 per
90 days)
MO
MO
MO
QL(60 per
90 days)
MO
QL(33 per
90 days)
MO
QL(33 per
90 days)
MO
GC MO
GC MO
Drug
Name
Drug
Tier
Notes
MISCELLANEOUS HORMONES
ALDURAZYME
ANADROL-50
ANDROGEL
cabergoline
calcitonin-salmon
4
3
2
1
1
calcitriol caps
calcitriol inj 1mcg/ml
calcitriol oral soln
CEREZYME INJ 200UNIT
danazol
desmopressin acetate
FABRAZYME INJ 35MG
fortical
1
1
1
4
1
1
4
1
HECTOROL
KUVAN
NAGLAZYME
oxandrolone
SAMSCA TABS 30MG
2
4
4
1
4
SAMSCA TABS 15MG
4
SENSIPAR TABS 60MG, 90MG
SENSIPAR TABS 30MG
SOMAVERT
4
2
2
STIMATE
SYNAREL
testosterone cypionate inj
100mg/ml
testosterone enanthate
ZAVESCA
ZEMPLAR
ZOMETA
2
3
1
LA PA MO
PA MO
PA MO
GC MO
GC QL(12
per 90 days)
MO
GC MO
GC MO
GC MO
LA PA MO
GC MO
GC MO
LA PA MO
GC QL(12
per 90 days)
MO
MO
LA MO
LA MO
GC PA MO
QL(730 per
365 days)
MO
QL(1460
per 365
days) MO
MO
MO
PA QL(90
per 90 days)
MO
MO
MO
GC PA MO
1
2
2
4
GC PA MO
LA
MO
MO
1
1
GC
GC MO
THYROID HORMONES
levothyroxine tabs
levoxyl
21
Drug
Name
liothyronine sodium tabs
SYNTHROID
unithroid
Drug
Tier Notes
1
GC MO
2
MO
1
GC MO
Drug
Name
gavilyte-n/flavor pack
generlac
granisetron inj
GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
atropine sulfate inj 0.1mg/ml
ATROPINE SULFATE INJ
0.05MG/ML
dicyclomine hcl caps
dicyclomine hcl oral soln
dicyclomine hcl tabs
diphenoxylate / atropine
glycopyrrolate
loperamide hcl caps
1
2
GC
1
1
1
1
1
1
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
granisetron tabs
hydrocortisone enem
lactulose
LOTRONEX
MISCELLANEOUS GASTROINTESTINAL
AGENTS
AMITIZA
ASACOL
ASACOL HD
balsalazide
CANASA
compro
constulose
CREON
CYSTADANE
DIPENTUM
dronabinol
EMEND CAPS 40MG
2
2
2
1
2
1
1
3
2
3
1
2
EMEND CAPS 125MG
2
EMEND CAPS
2
EMEND CAPS 80MG
2
ENTOCORT EC
enulose
GASTROCROM
gavilyte-c
gavilyte-g
2
1
2
1
1
MO
MO
MO
GC
MO
GC MO
GC MO
MO
MO
MO
GC PA MO
PA QL(3
per 90 days)
MO
PA QL(6
per 90 days)
MO
PA QL(18
per 90 days)
MO
PA QL(24
per 90 days)
MO
MO
GC MO
MO
GC MO
GC MO
22
meclizine hcl
mesalamine enem
metoclopramide
ondansetron hcl inj 4mg/2ml
ondansetron hcl oral soln
ondansetron hcl tabs 24mg
ondansetron hcl tabs 4mg, 8mg
ondansetron odt
PENTASA
polyethylene glycol 3350 powd
prochlorperazine
prochlorperazine edisylate
prochlorperazine maleate
procto-pak
proctosol hc
proctozone-hc
RELISTOR
REMICADE
sulfasalazine tabs
sulfazine ec
TRANSDERM-SCOP
trilyte
URSO 250
URSO FORTE
Drug
Tier Notes
1
GC MO
1
GC MO
1 GC QL(42
per 90 days)
MO
1
GC PA
QL(180 per
90 days)
1
GC MO
1
GC MO
2 QL(180 per
90 days)
MO
1
GC MO
1
GC MO
1
GC MO
1
GC MO
1 GC PA MO
1
GC PA
QL(21 per
90 days)
1
GC PA
QL(135 per
90 days)
MO
1
GC PA
QL(135 per
90 days)
MO
2
MO
1
GC MO
1
GC
1
GC MO
1
GC MO
1
GC
1
GC MO
1
GC MO
2
MO
4
PA MO
1
GC MO
1
GC
3
MO
1
GC MO
2
MO
2
MO
Drug
Name
ursodiol caps
ursodiol tabs
ZENPEP
Drug
Tier Notes
1
GC MO
1
GC
2
MO
ULCER THERAPY
CARAFATE SUSP
famotidine inj
famotidine premixed
famotidine tabs 20mg, 40mg
lansoprazole
2
1
1
1
1
misoprostol
NEXIUM
1
2
NEXIUM I.V. INJ 20MG
NEXIUM I.V. INJ 40MG
nizatidine
omeprazole cpdr 40mg
2
2
1
1
omeprazole cpdr 10mg, 20mg
1
PEPCID SUSR
PREVPAC
PYLERA
ranitidine hcl caps
ranitidine hcl syrp
ranitidine hcl tabs
sucralfate
ZANTAC INJ 50MG/50ML;
0.45%
2
3
2
1
1
1
1
2
MO
GC MO
GC
GC MO
GC QL(180
per 90 days)
MO
GC MO
QL(90 per
90 days)
MO
MO
GC MO
GC QL(90
per 90 days)
MO
GC QL(180
per 90 days)
MO
MO
MO
MO
GC MO
GC MO
GC MO
GC MO
MO
IMMUNOLOGY, VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ACTIMMUNE
ARANESP INJ 500MCG/ML
4
2
ARANESP INJ 150MCG/0.3ML
2
LA PA MO
PA QL(3
per 90 days)
MO
PA QL(3.6
per 90 days)
MO
23
Drug
Drug
Name
Tier Notes
ARANESP INJ 200MCG/0.4ML 2 PA QL(4.8
per 90 days)
MO
ARANESP INJ 100MCG/0.5ML 2
PA QL(6
per 90 days)
MO
ARANESP INJ 300MCG/0.6ML, 2 PA QL(7.2
60MCG/0.3ML
per 90 days)
MO
ARANESP INJ 40MCG/0.4ML
2 PA QL(9.6
per 90 days)
MO
ARANESP INJ 25MCG/0.42ML 2
PA
QL(10.08
per 90 days)
MO
ARANESP INJ 100MCG/ML,
2 PA QL(12
200MCG/ML, 300MCG/ML
per 90 days)
MO
ARANESP INJ 25MCG/ML,
2 PA QL(24
40MCG/ML, 60MCG/ML
per 90 days)
MO
ARCALYST
4
LA MO
AVONEX
4 PA QL(12
per 90 days)
MO
BETASERON
4 PA QL(45
per 90 days)
MO
EPOGEN INJ 20000UNIT/ML
4 PA QL(36
per 90 days)
MO
EPOGEN INJ 40000UNIT/ML
3 PA QL(12
per 90 days)
EPOGEN INJ 2000UNIT/ML,
3 PA QL(36
3000UNIT/ML, 4000UNIT/ML
per 90 days)
MO
EPOGEN INJ 10000UNIT/ML
3 PA QL(72
per 90 days)
MO
INTRON-A INJ 3MU/0.2ML
2
PA MO
INTRON-A INJ 10MU/0.2ML,
4
PA MO
5MU/0.2ML, 6000000UNIT/ML
INTRON-A WITH DILUENT
4
PA MO
INJ 10MU
LEUKINE
4
PA MO
Drug
Name
MOZOBIL
NEULASTA
NEUMEGA
NEUPOGEN INJ
300MCG/0.5ML
NEUPOGEN INJ
480MCG/0.8ML
NEUPOGEN INJ
480MCG/1.6ML
NORDITROPIN CARTRIDGE
NORDITROPIN NORDIFLEX
PEN
omnitrope inj 5mg/1.5ml
PEG-INTRON INJ
50MCG/0.5ML
Drug
Tier Notes
4 QL(4.8 per
90 days)
MO
3 PA QL(3.6
per 90 days)
MO
4 PA QL(63
per 90 days)
MO
4 PA QL(21
per 90 days)
MO
4 PA QL(33.6
per 90 days)
MO
4 PA QL(67.2
per 90 days)
MO
4
PA MO
4
PA MO
1
4
PEG-INTRON REDIPEN
4
PEGASYS INJ 180MCG/0.5ML
4
PROCRIT INJ 40000UNIT/ML
2
PROCRIT INJ 10000UNIT/ML,
20000UNIT/ML, 2000UNIT/ML,
3000UNIT/ML, 4000UNIT/ML
PROLEUKIN
REBIF
2
REBIF TITRATION PACK
TEV-TROPIN
4
4
4
4
GC PA MO
PA QL(12
per 90 days)
MO
PA QL(12
per 90 days)
MO
PA QL(6
per 90 days)
MO
PA QL(18
per 90 days)
MO
PA QL(36
per 90 days)
MO
MO
PA QL(18
per 90 days)
MO
PA MO
PA MO
VACCINES / MISCELLANEOUS
IMMUNOLOGICALS
ACTHIB
ADACEL
2
2
MO
24
Drug
Drug
Name
Tier Notes
ATTENUVAX
2
MO
BOOSTRIX
2
MO
CERVARIX
2
PA
COMVAX
2
PA MO
DAPTACEL
2
MO
DECAVAC
2
MO
DIPHTHERIA/TETANUS
2
TOXOID PEDIATRIC
ENGERIX-B
2
PA
GARDASIL
2
PA MO
HAVRIX INJ 720ELU/0.5ML
2
HAVRIX INJ 1440ELU/ML
2
MO
IMOVAX RABIES (H.D.C.V.)
2
INFANRIX
2
MO
IPOL INACTIVATED IPV
2
MO
IXIARO
2
JE-VAX
2
MO
M-M-R II W/DILUENT 10
2
MO
DOSE
MENACTRA
2
MENOMUNE-A/C/Y/W-135
2
MO
MERUVAX II W/DILUENT 10
2
MO
DOSE
PEDIARIX
2
PA
PEDVAX HIB
2
MO
PRIVIGEN
4
PA MO
PROQUAD
2
RABAVERT
2
MO
RECOMBIVAX HB
2
PA
ROTATEQ
2
TETANUS / DIPHTHERIA
2
MO
TOXOIDS-ADSORBED ADULT
TETANUS TOXOID
2
ADSORBED
THYMOGLOBULIN
2
PA
TRIHIBIT
2
TRIPEDIA
2
TWINRIX
2
PA MO
TYPHIM VI
2
VAQTA
2
MO
VARIVAX
2
VIVAGLOBIN
4
PA MO
YF-VAX
2
Drug
Name
ZOSTAVAX
Drug
Tier
2
Notes
PA
1
2
1
1
2
GC MO
MO
GC MO
GC MO
MO
ACTONEL TABS 150MG,
35MG, 5MG
alendronate sodium tabs 10mg,
35mg, 5mg, 70mg
BONIVA TABS
EVISTA
3
ST MO
1
GC MO
2
2
FORTEO
4
MO
QL(90 per
90 days)
MO
QL(7.2 per
90 days)
MO
MUSCULOSKELETAL /
RHEUMATOLOGY
GOUT THERAPY
allopurinol
COLCRYS
probenecid
probenecid /colchicine
ULORIC
OSTEOPOROSIS THERAPY
OTHER RHEUMATOLOGICALS
CUPRIMINE
DEPEN TITRATABS
ENBREL
2
2
4
HUMIRA INJ 20MG/0.4ML
4
HUMIRA INJ 40MG/0.8ML
4
HUMIRA PEN-CROHNS
DISEASE STARTER
leflunomide
4
1
RIDAURA
SAVELLA
3
2
SAVELLA TITRATION PACK
2
MO
MO
PA QL(600
per 90 days)
MO
PA QL(2.4
per 90 days)
MO
PA QL(4.8
per 90 days)
MO
PA MO
GC QL(90
per 90 days)
MO
MO
QL(180 per
90 days)
MO
MO
OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
25
Drug
Drug
Name
Tier Notes
ALORA
2
MO
camila
1
GC MO
CLIMARA PRO
2
MO
COMBIPATCH
2
MO
CRINONE
2
PA MO
DEPO-PROVERA
2
MO
DEPO-SUBQ PROVERA 104
3
MO
DIVIGEL
2
MO
errin
1
GC MO
ESTRADERM
2
MO
estradiol / norethindrone acetate
1
GC MO
estradiol ptwk
1
GC
estradiol tabs
1
GC MO
ESTRING
3
MO
estropipate
1
GC MO
FEMHRT 1/5
3
MO
FEMHRT LOW DOSE
3
MO
GYNODIOL
3
jolivette
1
GC MO
medroxyprogesterone acetate
1
GC MO
MENEST
3
MO
MENOSTAR
3
MO
nora-be
1
GC MO
norethindrone tabs 5mg
1
GC MO
ortho-est
1
GC
PREFEST
3
MO
PREMARIN TABS
2
MO
PREMARIN W/APPLICATOR
2
MO
PREMPHASE
2
MO
PREMPRO
2
MO
PROMETRIUM
2
MO
VAGIFEM
2
MO
VIVELLE-DOT
2
MO
MISCELLANEOUS OB/GYN
CLEOCIN SUPP
clindamycin phosphate crea
GYNAZOLE-1
metronidazole vaginal
miconazole 3
NUVARING
ORTHO EVRA
terconazole
2
1
2
1
1
3
3
1
MO
GC MO
GC MO
GC MO
MO
MO
GC MO
Drug
Name
vandazole
zazole crea 0.4%
zazole supp
Drug
Tier Notes
1
GC MO
1
GC MO
1
GC
Drug
Name
sprintec 28
sronyx
tri-legest fe
tri-previfem
tri-sprintec
trinessa
trivora-28
velivet
zovia 1/35e
zovia 1/50e
ORAL CONTRACEPTIVES / RELATED
AGENTS
apri
aranelle
aviane
balziva
cesia
cryselle-28
enpresse-28
junel
junel fe 1.5/30
junel fe 1/20
kariva
kelnor 1/35
leena
lessina-28
levora
low-ogestrel
lutera
microgestin 1.5/30
microgestin 1/20
microgestin fe
microgestin fe 1.5/30
mononessa
necon 0.5/35-28
necon 1/35-28
necon 10/11-28
necon 7/7/7
next choice
nortrel 0.5/35 (28)
nortrel 1/35 (21)
nortrel 1/35 (28)
nortrel 7/7/7
ogestrel
portia-28
previfem
quasense
reclipsen
solia
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
GC MO
GC
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
Drug
Tier
1
1
1
1
1
1
1
1
1
1
Notes
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
GC MO
OXYTOCICS
METHERGINE TABS
2
OPHTHALMOLOGY
ANTIBIOTICS
ak-tob
AZASITE
bacitracin / polymyxin b
bacitracin ophthalmic oint
CILOXAN OINT
ciprofloxacin ophthalmic soln
erythromycin oint
gentak
gentamicin sulfate ophthalmic
soln
gentasol
NATACYN
neomycin /bacitracin /polymyxin
neomycin /polymyxin /gramicidin
ofloxacin
polycin b
romycin
tobramycin ophthalmic soln
tobrasol
TOBREX OINT
trimethoprim sulfate/polymyxin b
sulfate
VIGAMOX
ZYMAR
1
2
1
1
2
1
1
1
1
GC
MO
GC MO
GC MO
MO
GC MO
GC MO
GC MO
GC MO
1
2
1
1
1
1
1
1
1
2
1
GC MO
MO
GC MO
GC MO
GC MO
GC
GC MO
GC MO
GC
MO
GC MO
2
2
MO
MO
1
3
GC MO
MO
ANTIVIRALS
trifluridine
ZIRGAN
BETA-BLOCKERS
26
Drug
Name
betaxolol hcl ophthalmic soln
carteolol hcl
ISTALOL
levobunolol hcl
metipranolol
timolol maleate
timolol maleate ophthalmic gel
forming
TIMOPTIC OCUDOSE
Drug
Tier
1
1
2
1
1
1
1
Notes
GC MO
GC MO
MO
GC MO
GC MO
GC MO
GC MO
2
MO
Drug
Name
dorzolamide hcl/timolol maleate
TRAVATAN Z
XALATAN
STEROID-ANTIBIOTIC COMBINATIONS
neomycin /polymyxin /bacitracin
/hydrocortisone
neomycin /polymyxin
/dexamethasone
neomycin /polymyxin
/hydrocortisone ophthalmic susp
poly-dex oint
poly-dex susp
tobramycin /dexamethasone
ZYLET
CYCLOPLEGIC MYDRIATICS
mydral ophthalmic soln 1%
mydral ophthalmic soln 0.5%
tropicamide
1
1
1
GC
GC MO
GC MO
2
MO
DIRECT ACTING MIOTICS
PILOPINE HS
MISCELLANEOUS OPHTHALMOLOGICS
ALOCRIL
azelastine hcl ophthalmic soln
cromolyn sodium ophthalmic soln
LACRISERT
parcaine
PATADAY
PATANOL
proparacaine hcl
RESTASIS
3
1
1
2
1
2
2
1
2
MO
GC
GC MO
MO
GC MO
MO
MO
GC MO
MO
2
1
1
1
MO
GC MO
GC MO
GC MO
2
2
MO
MO
1
1
1
2
2
1
1
GC MO
1
GC MO
1
1
1
2
GC MO
GC
GC MO
MO
sulfacetamide sodium /
prednisolone sodium phospha
1
GC MO
2
1
1
2
2
2
1
1
MO
GC MO
GC MO
MO
MO
MO
GC MO
GC MO
2
1
MO
GC MO
2
1
1
MO
GC MO
GC MO
3
MO
SULFONAMIDES
BLEPH-10
sodium sulfacetamide
SYMPATHOMIMETICS
ALPHAGAN P
apraclonidine
brimonidine tartrate ophthalmic
soln 0.2%
IOPIDINE
GC MO
GC
GC MO
VASOCONSTRICTOR DECONGESTANTS
ak-con
naphazoline hcl
OTHER GLAUCOMA DRUGS
AZOPT
COMBIGAN
dorzolamide hcl
GC MO
STEROID-SULFONAMIDE
COMBINATIONS
ALREX
dexamethasone ophthalmic soln
fluorometholone
FML
FML FORTE
LOTEMAX
prednisolone acetate
prednisolone sodium phosphate
ophthalmic soln
ORAL DRUGS FOR GLAUCOMA
acetazolamide
acetazolamide sodium
methazolamide
1
STEROIDS
NON-STEROIDAL ANTIINFLAMMATORY AGENTS
ACUVAIL
diclofenac sodium
flurbiprofen sodium
ketorolac tromethamine
ophthalmic soln
NEVANAC
XIBROM
Drug
Tier Notes
1
GC MO
2
MO
2
MO
MO
MO
GC MO
1
1
GC MO
GC
RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC
AGENTS
27
Drug
Name
carbinoxamine maleate
cetirizine hcl syrp
CLARINEX REDITABS
Drug
Tier Notes
1
GC MO
1
GC MO
2 QL(90 per
90 days)
MO
CLARINEX SYRP
2
MO
CLARINEX TABS
2 QL(90 per
90 days)
MO
CLARINEX-D 12 HOUR
2 QL(180 per
90 days)
MO
CLARINEX-D 24 HOUR
2 QL(90 per
90 days)
MO
clemastine fumarate syrp
1
GC MO
clemastine fumarate tabs 2.68mg
1
GC MO
diphenhydramine hcl caps 50mg
1
GC MO
diphenhydramine hcl inj
1
GC MO
epinephrine hcl inj 0.1mg/ml
1
GC
EPIPEN
2
MO
EPIPEN-JR
2
MO
fexofenadine hcl tabs 180mg
1 GC QL(90
per 90 days)
MO
fexofenadine hcl tabs 30mg, 60mg 1 GC QL(180
per 90 days)
MO
hydroxyzine hcl inj 25mg/ml
1
GC
hydroxyzine hcl inj 50mg/ml
1
GC MO
hydroxyzine hcl syrp
1 GC PA MO
hydroxyzine hcl tabs
1 GC PA MO
palgic liqd
1
GC MO
phenadoz
1
GC
promethazine hcl inj 25mg/ml
1
GC
promethazine hcl inj 50mg/ml
1
GC MO
promethazine hcl supp
1
GC MO
promethazine hcl syrp
1 GC PA MO
promethazine hcl tabs
1 GC PA MO
promethegan supp 25mg
1
GC
promethegan supp 50mg
1
GC MO
TWINJECT
2
MO
Drug
Name
ACCOLATE
PULMONARY AGENTS
ipratropium bromide inhalation
soln
28
acetylcysteine
ADVAIR DISKUS
ADVAIR HFA
albuterol sulfate er
albuterol sulfate nebu
albuterol sulfate syrp
albuterol sulfate tabs
aminophylline inj
aminophylline tabs
ASMANEX 120 METERED
DOSES
ASMANEX 14 METERED
DOSES
ASMANEX 30 METERED
DOSES
ASMANEX 60 METERED
DOSES
ATROVENT HFA
budesonide
COMBIVENT
cromolyn sodium nebu
ELIXOPHYLLIN
FLOVENT DISKUS
FLOVENT HFA
flunisolide nasal soln 0.025%
fluticasone propionate
FORADIL AEROLIZER
Drug
Tier Notes
3 QL(180 per
90 days)
MO
1 GC PA MO
2 QL(180 per
90 days)
MO
2 QL(36 per
90 days)
MO
1
GC MO
1 GC PA MO
1
GC MO
1
GC MO
1
GC
1
GC MO
2 QL(3 per 90
days) MO
2 QL(3 per 90
days)
2 QL(3 per 90
days) MO
2 QL(3 per 90
days) MO
2 QL(77.4 per
90 days)
MO
1 GC PA MO
2 QL(88.2 per
90 days)
MO
1 GC PA MO
3
MO
2 QL(180 per
90 days)
MO
2 QL(72 per
90 days)
MO
1
GC MO
1
GC MO
2 QL(180 per
90 days)
MO
1 GC PA MO
Drug
Name
ipratropium bromide/albuterol
sulfate
LETAIRIS
metaproterenol sulfate
NASONEX
PERFOROMIST
PROAIR HFA
PULMICORT SUSP 1MG/2ML
PULMOZYME
REVATIO TABS
SEREVENT DISKUS
Drug
Tier Notes
1 GC PA MO
4
1
2
2
2
2
4
4
2
SINGULAIR
2
SPIRIVA HANDIHALER
2
SYMBICORT AERO
80MCG/ACT; 4.5MCG/ACT
SYMBICORT AERO
160MCG/ACT; 4.5MCG/ACT
2
terbutaline sulfate
THEO-24
theochron
theophylline er
TRACLEER
1
3
1
1
4
2
VENTOLIN HFA
2
VERAMYST
ZYFLO CR
2
3
Drug
Name
LA PA
QL(90 per
90 days)
MO
GC MO
MO
PA MO
QL(51 per
90 days)
MO
PA MO
PA MO
PA QL(270
per 90 days)
MO
QL(180 per
90 days)
MO
QL(90 per
90 days)
MO
QL(90 per
90 days)
MO
QL(30.6 per
90 days)
QL(30.6 per
90 days)
MO
GC MO
MO
GC MO
GC MO
LA PA
QL(180 per
90 days)
MO
QL(108 per
90 days)
MO
MO
QL(360 per
90 days)
MO
29
Notes
ANTICHOLINERGICS /
ANTISPASMODICS
DETROL
2
DETROL LA
2
ENABLEX
2
flavoxate hcl
oxybutynin
oxybutynin er tb24 5mg
1
1
1
oxybutynin er tb24 10mg, 15mg
1
OXYTROL
2
QL(180 per
90 days)
MO
QL(90 per
90 days)
MO
QL(90 per
90 days)
MO
GC MO
GC MO
GC QL(90
per 90 days)
MO
GC QL(180
per 90 days)
MO
QL(32 per
90 days)
MO
BENIGN PROSTATIC
HYPERPLASIA(BPH) THERAPY
AVODART
2
finasteride
1
tamsulosin hcl
1
UROXATRAL
2
QL(90 per
90 days)
MO
GC QL(90
per 90 days)
MO
GC QL(180
per 90 days)
MO
QL(90 per
90 days)
MO
CHOLINERGIC STIMULANTS
bethanechol chloride
1
GC MO
MISCELLANEOUS UROLOGICALS
CYSTAGON
ELMIRON
potassium citrate extendedrelease
2
2
1
VITAMINS, HEMATINICS /
ELECTROLYTES
ELECTROLYTES
UROLOGICALS
Drug
Tier
LA
MO
GC MO
Drug
Drug
Name
Tier
calcium acetate
1
eliphos
1
K-TABS
3
KAON-CL-10
3
kcl 0.075%/d5w/nacl 0.45%
1
kcl 0.15%/d5w/lr
1
KCL 0.15%/D5W/NACL 0.2%
2
KCL 0.15%/D5W/NACL 0.225% 2
kcl 0.15%/d5w/nacl 0.9%
1
kcl 0.3%/d5w/lr iv lac ring
1
KCL 0.3%/D5W/NACL 0.2%
2
kcl 0.3%/d5w/nacl 0.45%
1
kcl 0.3%/d5w/nacl 0.9%
1
klor-con 10
1
klor-con 8
1
KLOR-CON M15
3
klor-con m20
1
LACTATED RINGERS
2
MAGNESIUM SULFATE IN
2
D5W INJ 5%; 10MG/ML
MAGNESIUM SULFATE INJ
2
NORMOSOL
2
POTASSIUM CHLORIDE
2
0.075%/D5W/NACL 0.225%
POTASSIUM CHLORIDE 0.15% 2
/NACL 0.45% VIAFLEX
potassium chloride 0.15%
1
d5w/nacl 0.33%
potassium chloride 0.15%
1
d5w/nacl 0.45% viaflex
potassium chloride 0.15% nacl
1
0.9%
POTASSIUM CHLORIDE
2
0.15%/D5W
POTASSIUM CHLORIDE 0.22% 2
D5W/NACL 0.45%
potassium chloride 0.224%/d5w
1
POTASSIUM CHLORIDE 0.3%/ 2
NACL 0.9%
potassium chloride 0.3%/d5w
1
potassium chloride cr
1
potassium chloride er cpcr
1
potassium chloride er tbcr 20meq 1
Drug
Name
potassium chloride inj
10meq/100ml, 10meq/50ml,
2meq/ml
POTASSIUM CHLORIDE INJ
0.4MEQ/ML, 30MEQ/100ML
potassium chloride sr
ringers injection
sodium bicarbonate inj 7.5%,
8.4%
sodium chloride 0.45% viaflex
sodium chloride inj 3%, 5%
sodium chloride inj 2.5meq/ml
Notes
GC
GC MO
MO
MO
GC
GC
GC
GC
GC
GC
GC MO
GC MO
MO
GC MO
MO
Drug
Tier
1
Notes
GC
2
1
1
1
GC
GC
GC
1
1
1
GC MO
GC
GC MO
MISCELLANEOUS NUTRITION
PRODUCTS
AMINOSYN
AMINOSYN II
AMINOSYN II M
AMINOSYN-HBC
AMINOSYN-HF
AMINOSYN-PF
AMINOSYN-PF 7%
CLINIMIX / DEXTROSE
CLINISOL SF
DEXTROSE 5%
/ELECTROLYTE #48 VIAFLEX
FREAMINE HBC
FREAMINE III
HEPATAMINE
HEPATASOL
INTRALIPID INJ 1.7%; 30%
intralipid inj 2.25%; 20%
IONOSOL
ISOLYTE
KCL 0.15%/D10W/NACL 0.2%
LIPOSYN III INJ 1.8%; 2.5%;
30%
NEPHRAMINE
NORMOSOL
novamine
PLASMA-LYTE
PREMASOL INJ
premasol inj
RENAMIN
TRAVASOL
GC
GC MO
GC
GC
GC
GC
GC MO
GC MO
30
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
2
2
2
2
1
2
2
1
2
2
MO
GC
GC
GC
Drug
Name
TROPHAMINE
Drug
Tier
2
Notes
1
1
GC
GC
VITAMINS / HEMATINICS
prenatabs obn
sodium fluoride tabs
31
Index of Drugs
alclometasone dipropionate.................................17
alcohol 5%/dextrose 5% ......................................18
ALCOHOL PREPS..............................................19
ALDURAZYME..................................................21
alendronate sodium........................................18, 25
ALIMTA ................................................................4
ALINIA..................................................................2
ALKERAN ............................................................4
allopurinol............................................................25
ALOCRIL ............................................................27
ALORA................................................................25
ALPHAGAN P ....................................................27
ALREX ................................................................27
ALTABAX ..........................................................17
amantadine.............................................................1
amcinonide...........................................................17
a-methapred .........................................................19
amifostine...............................................................4
amikacin sulfate .....................................................2
amiloride ..............................................................12
amiloride / hydrochlorothiazide ..........................12
aminophylline.......................................................28
AMINOSYN ........................................................30
AMINOSYN II ....................................................30
AMINOSYN II M................................................30
AMINOSYN-HBC ..............................................30
AMINOSYN-HF..................................................30
AMINOSYN-PF ..................................................30
AMINOSYN-PF 7%............................................30
amiodarone ..........................................................12
AMITIZA.............................................................22
amitriptyline.........................................................10
amlodipine / benazepril........................................12
amlodipine besylate .............................................12
ammonium lactate................................................16
amnesteem............................................................16
amoxapine ............................................................10
amoxicillin..............................................................3
amoxicillin/clavulanate potassium.........................3
amoxicillin/clavulanate potassium er ....................3
amoxicillin/potassium clavulanate.........................3
amphetamine /dextroamphetamine ......................10
8
8-MOP................................................................. 16
A
ABILIFY ............................................................. 10
ABILIFY DISCMELT ........................................ 10
ABRAXANE......................................................... 4
acarbose .............................................................. 19
ACCOLATE........................................................ 28
acebutolol ............................................................ 12
acetaminophen / codeine....................................... 8
acetaminophen/codeine #3.................................... 8
acetaminophen/codeine #4.................................... 8
acetasol hc........................................................... 19
acetazolamide...................................................... 27
acetazolamide sodium ......................................... 27
acetic acid ........................................................... 19
acetic acid / hydrocortisone ................................ 19
acetylcysteine ...................................................... 28
ACTHIB .............................................................. 24
acticin .................................................................. 18
ACTIMMUNE .................................................... 23
ACTONEL .................................................... 18, 25
ACTOPLUS MET............................................... 19
ACTOS................................................................ 19
ACUVAIL........................................................... 27
acyclovir ................................................................ 1
ADACEL............................................................. 24
ADAGEN ............................................................ 18
adriamycin............................................................. 4
ADVAIR DISKUS.............................................. 28
ADVAIR HFA .................................................... 28
afeditab cr ........................................................... 12
AFINITOR ............................................................ 4
AGGRENOX ...................................................... 15
a-hydrocort.......................................................... 19
ak-con .................................................................. 27
ak-tob................................................................... 26
ala cort ................................................................ 17
ALBENZA ............................................................ 2
albuterol sulfate................................................... 28
albuterol sulfate er .............................................. 28
32
amphotericin b....................................................... 1
ampicillin............................................................... 3
ampicillin-sulbactam............................................. 3
ANADROL-50 .................................................... 21
anagrelide hydrochloride.................................... 18
ANCOBON ........................................................... 1
ANDROGEL....................................................... 21
ANTABUSE........................................................ 18
APOKYN .............................................................. 7
apraclonidine ...................................................... 27
apri ...................................................................... 26
APTIVUS .............................................................. 1
aranelle................................................................ 26
ARANESP........................................................... 23
ARCALYST........................................................ 23
ARICEPT .............................................................. 8
ARICEPT ODT ..................................................... 8
ARIMIDEX........................................................... 4
ARIXTRA ........................................................... 15
AROMASIN.......................................................... 4
ARRANON ........................................................... 4
ARTHROTEC 50.................................................. 9
ARTHROTEC 75.................................................. 9
ARZERRA ............................................................ 5
ASACOL............................................................. 22
ASACOL HD ...................................................... 22
ascomp/codeine ..................................................... 8
ASMANEX 120 METERED DOSES ................ 28
ASMANEX 14 METERED DOSES................... 28
ASMANEX 30 METERED DOSES................... 28
ASMANEX 60 METERED DOSES................... 28
ASTELIN ............................................................ 18
ASTEPRO ........................................................... 18
atenolol................................................................ 12
atenolol / chlorthalidone ..................................... 12
ATRIPLA .............................................................. 1
atropine sulfate.................................................... 22
ATROVENT HFA .............................................. 28
ATTENUVAX .................................................... 24
augmented betamethasone dipropionate............. 17
AVANDAMET ................................................... 19
AVANDARYL.................................................... 19
AVANDIA .......................................................... 19
AVASTIN ..............................................................5
AVELOX ...............................................................4
AVELOX ABC PACK ..........................................4
aviane...................................................................26
avita......................................................................16
AVODART ..........................................................29
AVONEX.............................................................23
AZACTAM............................................................2
AZACTAM IN DEXTROSE.................................2
AZACTAM IN ISO-OSMOTIC DEXTROSE......2
AZASITE.............................................................26
azathioprine ...........................................................5
azathioprine sodium...............................................5
azelastine hcl..................................................18, 27
AZELEX ..............................................................16
AZILECT...............................................................7
azithromycin...........................................................2
AZOPT.................................................................27
B
bacitracin .............................................................26
bacitracin / polymyxin b.......................................26
baclofen..................................................................8
BACTROBAN.....................................................17
BACTROBAN NASAL.......................................18
balacet 325.............................................................9
balsalazide ...........................................................22
balziva ..................................................................26
BANZEL................................................................6
BARACLUDE .......................................................1
BD INSULIN SYRINGE
SAFETYGLIDE/1ML/29G X 1/2 ...................20
BD INSULIN SYRINGE
ULTRAFINE/0.3ML/31G X 5/16 ...................20
BD INSULIN SYRINGE
ULTRAFINE/0.5ML/30G X 1/2 .....................20
BD INSULIN SYRINGE ULTRAFINE/1ML/31G
X 5/16...............................................................20
BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM
..........................................................................20
benazepril.............................................................12
benazepril / hydrochlorothiazide ...................12, 13
benztropine mesylate..............................................7
33
betamethasone dipropionate ............................... 17
betamethasone valerate....................................... 17
BETASERON ..................................................... 23
beta-val................................................................ 17
betaxolol hcl .................................................. 13, 27
bethanechol chloride ........................................... 29
bicalutamide .......................................................... 5
BICILLIN C-R ...................................................... 3
BICILLIN L-A ...................................................... 3
BICNU .................................................................. 5
BIDIL .................................................................. 13
BILTRICIDE......................................................... 2
bisoprolol fumarate............................................. 13
bisoprolol fumarate / hydrochlorothiazide ......... 13
bleomycin sulfate................................................... 5
BLEPH-10........................................................... 27
BONIVA ............................................................. 25
BOOSTRIX......................................................... 24
borofair................................................................ 19
brimonidine tartrate ............................................ 27
bromocriptine mesylate ......................................... 7
budeprion sr ........................................................ 10
budeprion xl......................................................... 10
budesonide........................................................... 28
bumetanide .......................................................... 13
BUPHENYL........................................................ 18
BUPRENEX.......................................................... 8
buprenorphine hcl ................................................. 8
buproban ............................................................. 18
bupropion hcl ...................................................... 10
bupropion hcl sr .................................................. 10
buspirone hcl ....................................................... 10
BUSULFEX .......................................................... 5
butorphanol tartrate.............................................. 9
BYETTA ............................................................. 20
BYSTOLIC ......................................................... 13
calcium acetate ....................................................30
camila...................................................................25
CAMPATH ............................................................5
CAMPRAL ..........................................................18
CANASA .............................................................22
CAPASTAT SULFATE ........................................2
CAPEX ................................................................17
captopril...............................................................13
captopril / hydrochlorothiazide ...........................13
CARAC................................................................16
CARAFATE ........................................................23
carbamazepine .......................................................6
carbamazepine er...................................................6
CARBATROL .......................................................6
carbidopa / levodopa .............................................7
carbidopa/levodopa cr ...........................................7
carbidopa/levodopa odt .........................................7
carbidopa/levodopa sr ...........................................7
carbinoxamine maleate........................................28
carboplatin.............................................................5
carisoprodol...........................................................8
carisoprodol /aspirin .............................................8
CARMOL-HC......................................................16
carteolol hcl .........................................................27
cartia xt ................................................................13
carvedilol .............................................................13
CEENU ..................................................................5
cefaclor ..................................................................2
cefadroxil ...............................................................2
cefazolin .................................................................2
cefdinir ...................................................................2
cefepime .................................................................2
cefotaxime sodium..................................................2
cefoxitin sodium .....................................................2
cefpodoxime proxetil..............................................2
ceftriaxone sodium .................................................2
CEFTRIAXONE/DEXTROSE..............................2
cefuroxime axetil....................................................2
cefuroxime sodium .................................................2
CEFUROXIME/DEXTROSE................................2
CELEBREX...........................................................9
CELLCEPT............................................................5
CELLCEPT INTRAVENOUS ..............................5
C
cabergoline.......................................................... 21
CADUET............................................................. 15
calcipotriene........................................................ 16
calcitonin-salmon ................................................ 21
calcitriol .............................................................. 21
34
CELONTIN........................................................... 6
cephalexin.............................................................. 2
CEREZYME ....................................................... 21
CERVARIX ........................................................ 24
cesia..................................................................... 26
cetirizine hcl ........................................................ 28
CHANTIX........................................................... 18
CHEMET ............................................................ 18
chlordiazepoxide /amitriptyline........................... 10
chlorhexidine gluconate oral rinse ..................... 18
chloroquine............................................................ 2
chlorothiazide...................................................... 13
chlorothiazide sodium ......................................... 13
chlorpromazine.................................................... 10
chlorthalidone ..................................................... 13
chlorzoxazone........................................................ 8
cholestyramine light ............................................ 15
ciclopirox............................................................. 17
ciclopirox nail lacquer ........................................ 17
ciclopirox olamine............................................... 17
cilostazol.............................................................. 15
CILOXAN........................................................... 26
CIPRO HC........................................................... 19
CIPRO I.V.-IN D5W............................................. 4
CIPRODEX......................................................... 19
ciprofloxacin.................................................... 4, 26
cisplatin ................................................................. 5
citalopram ........................................................... 10
cladribine .............................................................. 5
claravis ................................................................ 16
CLARINEX......................................................... 28
CLARINEX REDITABS .................................... 28
CLARINEX-D 12 HOUR ................................... 28
CLARINEX-D 24 HOUR ................................... 28
clarithromycin ....................................................... 2
clarithromycin er................................................... 2
clemastine fumarate ............................................ 28
CLEOCIN............................................................ 25
CLEOCIN GALAXY............................................ 3
CLEOCIN PEDIATRIC GRANULES ................. 3
CLIMARA PRO.................................................. 25
clindamycin hcl ..................................................... 3
clindamycin phosphate.................................. 16, 25
clindamycin phosphate add-vantage......................3
clindamycin/benzoyl peroxide..............................16
CLINIMIX / DEXTROSE .............................18, 30
CLINISOL SF......................................................30
clobetasol propionate...........................................17
clobetasol propionate e........................................17
CLOBEX..............................................................17
CLOLAR................................................................5
clomipramine .......................................................10
clonidine...............................................................13
clotrimazole......................................................1, 17
clotrimazole / betamethasone ..............................17
clozapine ..............................................................10
COARTEM ............................................................3
codeine sulfate .......................................................8
COLCRYS ...........................................................25
COLESTID ..........................................................15
colestipol ..............................................................15
colistimethate sodium.............................................3
COLY-MYCIN S.................................................19
COMBIGAN........................................................27
COMBIPATCH ...................................................25
COMBIVENT......................................................28
COMBIVIR............................................................1
compro .................................................................22
COMTAN ..............................................................7
COMVAX............................................................24
CONDYLOX .......................................................16
constulose.............................................................22
COPAXONE..........................................................8
CORDRAN TAPE ...............................................17
COREG CR..........................................................13
cortisone acetate ..................................................19
CORTISPORIN-TC.............................................19
cortomycin............................................................19
COSMEGEN..........................................................5
CREON ................................................................22
CRESTOR............................................................15
CRINONE............................................................25
CRIXIVAN ............................................................1
cromolyn sodium............................................27, 28
cryselle-28............................................................26
CUBICIN ...............................................................3
35
CUPRIMINE....................................................... 25
CURITY GAUZE PADS 2 ................................. 20
cyclobenzaprine hcl............................................... 8
cyclophosphamide ................................................. 5
cyclosporine .......................................................... 5
CYKLOKAPRON............................................... 15
CYMBALTA ...................................................... 10
CYSTADANE..................................................... 22
CYSTAGON ....................................................... 29
cytarabine.............................................................. 5
CYTARABINE AQUEOUS ................................. 5
DEXTROSE 10%/NACL 0.45% ........................18
DEXTROSE 5% /ELECTROLYTE #48
VIAFLEX ........................................................30
dextrose 10% flex container.................................18
DEXTROSE 10%/NACL 0.2% ...........................18
dextrose 2.5%/sodium chloride 0.45% ................18
dextrose 5%..........................................................18
dextrose 5%/nacl 0.2% ........................................18
dextrose 5%/nacl 0.225% ....................................18
DEXTROSE 5%/NACL 0.33% ...........................18
dextrose 5%/nacl 0.45% ......................................18
dextrose 5%/nacl 0.9% ........................................18
DIBENZYLINE...................................................13
diclofenac potassium..............................................9
diclofenac sodium ............................................9, 27
diclofenac sodium ec..............................................9
diclofenac sodium xr ..............................................9
dicloxacillin sodium ...............................................3
dicyclomine hcl ....................................................22
didanosine ..............................................................1
diflorasone diacetate............................................17
DIFLUCAN IN NACL ..........................................1
diflunisal ................................................................9
digoxin..................................................................15
dihydroergotamine mesylate..................................7
DILANTIN INFATABS........................................6
DILAUDID ............................................................8
DILAUDID-5.........................................................8
DILAUDID-HP......................................................8
dilt-cd ...................................................................13
diltiazem cd ..........................................................13
diltiazem hcl .........................................................13
diltiazem hcl er.....................................................13
dilt-xr....................................................................13
diltzac...................................................................13
DIOVAN..............................................................13
DIOVAN HCT.....................................................13
DIPENTUM.........................................................22
diphenhydramine hcl............................................28
diphenoxylate / atropine ......................................22
DIPHTHERIA/TETANUS TOXOID PEDIATRIC
..........................................................................24
dipyridamole ........................................................15
D
dacarbazine ........................................................... 5
danazol ................................................................ 21
dantrolene sodium ................................................. 8
DAPSONE ............................................................ 3
DAPTACEL........................................................ 24
DARAPRIM.......................................................... 3
DAUNORUBICIN HCL....................................... 5
DECAVAC.......................................................... 24
demeclocycline hcl ................................................ 4
DEMSER............................................................. 13
DENAVIR........................................................... 17
depade ................................................................... 9
DEPEN TITRATABS ......................................... 25
DEPO-MEDROL ................................................ 19
DEPO-PROVERA .............................................. 25
DEPO-SUBQ PROVERA 104............................ 25
DERMA-SMOOTHE / FS BODY OIL .............. 17
DERMOTIC ........................................................ 19
desipramine ......................................................... 10
desmopressin acetate........................................... 21
desonide............................................................... 17
desoximetasone.................................................... 17
DETROL ............................................................. 29
DETROL LA....................................................... 29
dexamethasone .............................................. 19, 27
DEXAMETHASONE INTENSOL .................... 19
dexmethylphenidate............................................. 10
dexrazoxane........................................................... 4
dextroamphetamine sulfate ................................. 10
dextroamphetamine sulfate er ............................. 10
36
disopyramide phosphate...................................... 12
divalproex sodium ............................................. 6, 7
divalproex sodium er............................................. 6
DIVIGEL............................................................. 25
dorzolamide hcl ................................................... 27
dorzolamide hcl/timolol maleate......................... 27
doxazosin............................................................. 13
doxepin ................................................................ 10
DOXIL .................................................................. 5
doxorubicin hcl...................................................... 5
doxycycline hyclate ............................................... 4
doxycycline monohydrate...................................... 4
dronabinol ........................................................... 22
DROXIA ............................................................... 5
DUETACT .......................................................... 20
duramorph............................................................. 8
ENTOCORT EC ..................................................22
enulose .................................................................22
epinephrine hcl.....................................................28
EPIPEN ................................................................28
EPIPEN-JR ..........................................................28
epirubicin hcl .........................................................5
epitol ......................................................................7
EPIVIR...................................................................1
EPIVIR HBV .........................................................1
eplerenone............................................................13
EPOGEN..............................................................23
EPZICOM ..............................................................1
EQUETRO.............................................................7
ERAXIS .................................................................1
ERBITUX ..............................................................5
ergotamine tartrate / caffeine ................................7
errin......................................................................25
ery ........................................................................16
ERY-TAB ..............................................................2
ERYTHROCIN LACTOBIONATE......................2
erythrocin stearate .................................................2
erythromycin ..................................................16, 26
erythromycin / benzoyl peroxide..........................16
erythromycin / sulfisoxazole ..................................2
ERYTHROMYCIN BASE ....................................2
ESTRADERM .....................................................25
estradiol ...............................................................25
estradiol / norethindrone acetate.........................25
ESTRING.............................................................25
estropipate............................................................25
ethambutol..............................................................3
ethosuximide ..........................................................7
etidronate disodium .............................................18
etodolac..................................................................9
ETOPOPHOS ........................................................5
etoposide ................................................................5
EURAX................................................................18
EVISTA ...............................................................25
EVOXAC.............................................................18
EXELON................................................................8
EXFORGE ...........................................................13
EXFORGE HCT ..................................................13
EXJADE ..............................................................18
E
e.e.s. 400................................................................ 2
E.E.S. GRANULES .............................................. 2
econazole nitrate ................................................. 17
EDECRIN............................................................ 13
EFFIENT............................................................. 15
ELIDEL............................................................... 16
eliphos ................................................................. 30
ELITEK................................................................. 4
ELIXOPHYLLIN................................................ 28
ELLENCE ............................................................. 5
ELMIRON........................................................... 29
ELOXATIN........................................................... 5
ELSPAR ................................................................ 5
EMBEDA .............................................................. 8
EMCYT................................................................. 5
EMEND............................................................... 22
EMSAM .............................................................. 10
EMTRIVA............................................................. 1
ENABLEX .......................................................... 29
enalapril .............................................................. 13
enalapril / hydrochlorothiazide........................... 13
ENBREL ............................................................. 25
endocet .................................................................. 8
ENGERIX-B ....................................................... 24
enpresse-28.......................................................... 26
37
fluphenazine .........................................................11
fluphenazine decanoate inj ..................................11
flurbiprofen ............................................................9
flurbiprofen sodium..............................................27
flutamide ................................................................5
fluticasone propionate ...................................17, 28
fluvoxamine ..........................................................11
FML .....................................................................27
FML FORTE........................................................27
FOCALIN XR......................................................11
FORADIL AEROLIZER .....................................28
FORTAZ ................................................................2
FORTEO ..............................................................25
fortical..................................................................21
foscarnet sodium ....................................................1
fosinopril ..............................................................13
fosinopril / hydrochlorothiazide ..........................13
FOSRENOL.........................................................18
FRAGMIN ...........................................................15
FREAMINE HBC................................................30
FREAMINE III ....................................................30
FURADANTIN......................................................4
furosemide............................................................13
FUZEON................................................................1
F
FABRAZYME .................................................... 21
famciclovir............................................................. 1
famotidine............................................................ 23
famotidine premixed............................................ 23
FANAPT ............................................................. 10
FANAPT TITRATION PACK ........................... 10
FARESTON .......................................................... 5
FASLODEX .......................................................... 5
FAZACLO .......................................................... 10
FELBATOL .......................................................... 7
felodipine er......................................................... 13
FEMARA .............................................................. 5
FEMHRT 1/5....................................................... 25
FEMHRT LOW DOSE ....................................... 25
fenofibrate ........................................................... 15
fenofibrate micronized......................................... 15
fenoprofen calcium................................................ 9
fentanyl citrate....................................................... 8
fentanyl citrate oral transmucosal ........................ 8
fentanyl patches..................................................... 8
fexofenadine hcl................................................... 28
FINACEA............................................................ 16
finasteride............................................................ 29
FIRMAGON.......................................................... 5
flavoxate hcl ........................................................ 29
flecainide acetate................................................. 12
FLECTOR ............................................................. 9
FLOVENT DISKUS ........................................... 28
FLOVENT HFA.................................................. 28
fluconazole ............................................................ 1
fluconazole in dextrose.......................................... 1
fludarabine phosphate........................................... 5
fludrocortisone acetate........................................ 19
flunisolide............................................................ 28
fluocinolone acetonide ........................................ 17
fluocinonide......................................................... 17
fluocinonide emollient base................................. 17
fluorometholone .................................................. 27
FLUOROPLEX................................................... 16
fluorouracil...................................................... 5, 16
fluoxetine ....................................................... 10, 11
fluoxetine dr......................................................... 10
G
gabapentin..............................................................7
GABITRIL.............................................................7
galantamine hydrobromide....................................8
ganciclovir .............................................................1
GARDASIL .........................................................24
GASTROCROM..................................................22
gavilyte-c..............................................................22
gavilyte-g..............................................................22
gavilyte-n/flavor pack ..........................................22
gemfibrozil ...........................................................15
GEMZAR...............................................................5
generlac................................................................22
gengraf ...................................................................5
gentak...................................................................26
gentamicin sulfate ......................................3, 17, 26
gentamicin sulfate/0.9% sodium chloride..............3
gentamicin sulfate/sodium chloride .......................3
38
gentasol ............................................................... 26
GEODON ............................................................ 11
GLEEVEC............................................................. 5
glimepiride .......................................................... 20
glipizide ............................................................... 20
glipizide / metformin............................................ 20
glipizide er........................................................... 20
glipizide xl ........................................................... 20
GLUCAGEN HYPOKIT .................................... 20
GLUCAGON EMERGENCY KIT..................... 20
glyburide.............................................................. 20
glyburide / metformin .......................................... 20
glyburide micronized........................................... 20
glycopyrrolate ..................................................... 22
glycron................................................................. 20
granisetron .......................................................... 22
griseofulvin microsize ........................................... 1
GRIS-PEG............................................................. 1
guanfacine hcl ..................................................... 13
GYNAZOLE-1.................................................... 25
GYNODIOL........................................................ 25
HUMALOG MIX 50/50 ......................................20
HUMALOG MIX 50/50 PEN..............................20
HUMALOG MIX 75/25 ......................................20
HUMALOG MIX 75/25 PEN..............................20
HUMALOG PEN.................................................20
HUMIRA .............................................................25
HUMIRA PEN-CROHNS DISEASE STARTER
..........................................................................25
HUMULIN 70/30.................................................20
HUMULIN 70/30 PEN ........................................20
HUMULIN N.......................................................20
HUMULIN N U-100 PEN ...................................20
HUMULIN R .......................................................20
HUMULIN R U-500 (CONCENTRATED)........20
HYCAMTIN ..........................................................5
hydralazine...........................................................13
hydrochlorothiazide .............................................13
hydrocodone / acetaminophen ...............................8
hydrocodone / ibuprofen ........................................8
hydrocodone /acetaminophen-hs ...........................8
hydrocodone bitartrate/acetaminophen.................8
hydrocortisone .........................................17, 19, 22
hydrocortisone butyrate .......................................17
hydrocortisone valerate .......................................17
hydromorphone hcl ................................................8
hydroxychloroquine ...............................................3
hydroxyurea ...........................................................5
hydroxyzine hcl ....................................................28
H
HALDOL ............................................................ 11
HALDOL DECANOATE 100 ............................ 11
HALDOL DECANOATE 50 .............................. 11
halobetasol propionate........................................ 17
haloperidol .......................................................... 11
haloperidol decanoate inj.................................... 11
haloperidol lactate inj ......................................... 11
HAVRIX ............................................................. 24
HECTOROL........................................................ 21
HEPARIN SODIUM........................................... 15
heparin sodium dcu ............................................. 15
heparin sodium/d5w ............................................ 15
HEPARIN SODIUM/NACL 0.45% ................... 15
heparin sodium/sodium chloride 0.9% premix ... 15
HEPATAMINE................................................... 30
HEPATASOL...................................................... 30
HEPSERA ............................................................. 1
HERCEPTIN......................................................... 5
HEXALEN ............................................................ 5
HUMALOG ........................................................ 20
I
ibuprofen ................................................................9
idarubicin hcl .........................................................5
IFEX.......................................................................5
ifosfamide...............................................................5
ifosfamide/mesna....................................................5
imipramine ...........................................................11
imipramine pamoate ............................................11
imiquimod ............................................................16
IMOVAX RABIES (H.D.C.V.)...........................24
INCRELEX..........................................................18
indapamide...........................................................13
indomethacin..........................................................9
indomethacin er .....................................................9
39
INFANRIX.......................................................... 24
INFUMORPH 200 ................................................ 8
INFUMORPH 500 ................................................ 8
INTELENCE......................................................... 1
INTRALIPID ...................................................... 30
INTRON-A.......................................................... 23
INTRON-A WITH DILUENT............................ 23
INVEGA.............................................................. 11
INVEGA SUSTENNA........................................ 11
INVIRASE ............................................................ 1
IONOSOL ........................................................... 30
IOPIDINE............................................................ 27
IPOL INACTIVATED IPV ................................ 24
ipratropium bromide ..................................... 19, 28
ipratropium bromide/albuterol sulfate................ 29
irinotecan .............................................................. 5
ISENTRESS .......................................................... 1
ISOLYTE ............................................................ 30
isonarif .................................................................. 3
ISONIAZID........................................................... 3
isosorbide dinitrate ............................................. 16
isosorbide dinitrate er ......................................... 16
isosorbide mononitrate........................................ 16
isosorbide mononitrate er ................................... 16
isotonic gentamicin ............................................... 3
isradipine............................................................. 13
ISTALOL ............................................................ 27
ISTODAX ............................................................. 5
itraconazole........................................................... 1
IXEMPRA KIT ..................................................... 5
IXIARO............................................................... 24
KALETRA.............................................................1
KAON-CL-10 ......................................................30
kariva ...................................................................26
kcl 0.075%/d5w/nacl 0.45% ................................30
KCL 0.15%/D10W/NACL 0.2% .........................30
kcl 0.15%/d5w/lr ..................................................30
KCL 0.15%/D5W/NACL 0.2% ...........................30
KCL 0.15%/D5W/NACL 0.225% .......................30
kcl 0.15%/d5w/nacl 0.9% ....................................30
kcl 0.3%/d5w/lr iv lac ring...................................30
KCL 0.3%/D5W/NACL 0.2% .............................30
kcl 0.3%/d5w/nacl 0.45% ....................................30
kcl 0.3%/d5w/nacl 0.9% ......................................30
kelnor 1/35 ...........................................................26
KEPPRA ................................................................7
KETEK ..................................................................3
ketoconazole.....................................................1, 17
ketoprofen ..............................................................9
ketoprofen er ..........................................................9
ketorolac tromethamine .......................................27
kionex ...................................................................18
klor-con 10 ...........................................................30
klor-con 8 .............................................................30
KLOR-CON M15 ................................................30
klor-con m20 ........................................................30
K-TABS ...............................................................30
kuric .....................................................................17
KUVAN ...............................................................21
L
labetalol .........................................................13, 14
laclotion ...............................................................16
LACRISERT........................................................27
LACTATED RINGERS ......................................30
lactulose ...............................................................22
LAMICTAL ODT..................................................7
LAMICTAL XR ....................................................7
lamotrigine.............................................................7
LANOXIN ...........................................................15
lansoprazole.........................................................23
LANTUS..............................................................20
LANTUS SOLOSTAR ........................................20
leena.....................................................................26
J
jantoven ............................................................... 15
JANUMET .......................................................... 20
JANUVIA............................................................ 20
JE-VAX............................................................... 24
jolivette ................................................................ 25
junel..................................................................... 26
junel fe 1.5/30...................................................... 26
junel fe 1/20......................................................... 26
K
KADIAN ............................................................... 8
40
leflunomide .......................................................... 25
lessina-28 ............................................................ 26
LETAIRIS ........................................................... 29
leucovorin calcium ................................................ 4
LEUKERAN ......................................................... 5
LEUKINE............................................................ 23
leuprolide acetate.................................................. 5
LEUSTATIN......................................................... 5
LEVAQUIN .......................................................... 4
levetiracetam ......................................................... 7
levobunolol hcl .................................................... 27
levocarnitine........................................................ 18
levora................................................................... 26
levorphanol tartrate .............................................. 8
levothyroxine ....................................................... 21
levoxyl.................................................................. 21
LEXAPRO .......................................................... 11
LEXIVA ................................................................ 1
lidocaine ........................................................ 16, 17
lidocaine / prilocaine .......................................... 16
lidocaine viscous ................................................. 17
LIDODERM........................................................ 17
LINDANE ........................................................... 18
liothyronine sodium............................................. 22
LIPITOR.............................................................. 15
LIPOSYN III ....................................................... 30
lisinopril .............................................................. 14
lisinopril / hydrochlorothiazide........................... 14
lithium carbonate ................................................ 11
lithium carbonate er ............................................ 11
lithium citrate ...................................................... 11
LOCOID.............................................................. 17
LODOSYN............................................................ 7
loperamide hcl..................................................... 22
losartan potassium .............................................. 14
losartan potassium/hydrochlorothiazide............. 14
LOTEMAX ......................................................... 27
LOTREL.............................................................. 14
LOTRONEX ....................................................... 22
lovastatin ............................................................. 15
LOVAZA ............................................................ 15
LOVENOX.......................................................... 15
low-ogestrel......................................................... 26
loxapine................................................................11
LUPRON DEPOT..................................................5
LUPRON DEPOT-PED.........................................5
lutera ....................................................................26
LUXIQ .................................................................17
LYRICA.................................................................7
LYSODREN ..........................................................5
M
MACRODANTIN..................................................4
MAGNESIUM SULFATE ..................................30
MAGNESIUM SULFATE IN D5W ...................30
MALARONE.........................................................3
malathion .............................................................18
maprotiline...........................................................11
margesic-h..............................................................8
MARPLAN ..........................................................11
MATULANE .........................................................5
MAXALT ..............................................................7
MAXALT-MLT.....................................................7
MAXIPIME ...........................................................2
mebendazole...........................................................3
meclizine hcl.........................................................22
meclofenamate sodium...........................................9
medroxyprogesterone acetate ..............................25
mefloquine hcl........................................................3
MEGACE ES .........................................................5
megestrol acetate ...................................................5
meloxicam ..............................................................9
melphalan hydrochloride .......................................5
MENACTRA .......................................................24
MENEST..............................................................25
MENOMUNE-A/C/Y/W-135..............................24
MENOSTAR........................................................25
meperidine hcl........................................................9
MEPRON...............................................................3
mercaptopurine ......................................................5
MERUVAX II W/DILUENT 10 DOSE ..............24
mesalamine ..........................................................22
mesna .....................................................................4
MESNEX ...............................................................4
MESTINON...........................................................8
MESTINON TIMESPAN......................................8
41
METADATE CD ................................................ 11
metadate er.......................................................... 11
metaproterenol sulfate......................................... 29
metaxalone ............................................................ 8
metformin hcl....................................................... 21
metformin hcl er ............................................ 20, 21
methadone hcl ....................................................... 9
methadose.............................................................. 9
methamphetamine hcl.......................................... 11
methazolamide..................................................... 27
methenamine hippurate ......................................... 4
METHERGINE................................................... 26
methimazole......................................................... 19
methocarbamol...................................................... 8
methotrexate .......................................................... 5
methotrexate sodium ............................................. 5
methyclothiazide.................................................. 14
METHYLIN ........................................................ 11
methylin er........................................................... 11
methylphenidate hcl............................................. 11
methylphenidate hcl sr ........................................ 11
methylprednisolone ............................................. 19
methylprednisolone acetate................................. 19
methylprednisolone sodiumsuccinate.................. 19
metipranolol ........................................................ 27
metoclopramide................................................... 22
metolazone........................................................... 14
metoprolol / hydrochlorothiazide........................ 14
metoprolol succinate er....................................... 14
metoprolol tartrate .............................................. 14
METROGEL ....................................................... 16
metronidazole .................................................. 3, 16
metronidazole in nacl 0.79%................................. 3
metronidazole vaginal ......................................... 25
mexiletine ............................................................ 12
MICARDIS ......................................................... 14
MICARDIS HCT ................................................ 14
miconazole 3........................................................ 25
microgestin 1.5/30............................................... 26
microgestin 1/20.................................................. 26
microgestin fe ...................................................... 26
microgestin fe 1.5/30 ........................................... 26
midodrine ............................................................ 18
migergot .................................................................7
MIGRANAL ..........................................................7
minocycline hcl ......................................................4
minocycline hcl er ..................................................4
minoxidil ..............................................................14
MIRAPEX ER .......................................................7
mirtazapine ..........................................................11
mirtazapine odt ....................................................11
misoprostol...........................................................23
mitomycin...............................................................5
mitoxantrone hcl ....................................................5
M-M-R II W/DILUENT 10 DOSE......................24
moexipril ..............................................................14
moexipril / hydrochlorothiazide...........................14
mometasone furoate .............................................17
mononessa............................................................26
morphine sulfate.....................................................9
morphine sulfate er ................................................9
MOZOBIL ...........................................................24
MULTAQ ............................................................12
mupirocin .............................................................17
MUSTARGEN.......................................................5
MYCOBUTIN .......................................................3
mycophenolate mofetil ...........................................5
mydral ..................................................................27
MYFORTIC...........................................................5
MYTELASE ..........................................................8
N
nabumetone ............................................................9
nadolol .................................................................14
nadolol / bendroflumethiazide .............................14
nafcillin sodium......................................................3
NAFTIN...............................................................17
NAGLAZYME ....................................................21
NALLPEN/DEXTROSE .......................................3
naloxone.................................................................9
naltrexone ..............................................................9
NAMENDA ...........................................................8
NAMENDA TITRATION PAK............................8
naphazoline hcl ....................................................27
naproxen ................................................................9
naproxen sodium....................................................9
42
NARDIL.............................................................. 11
NASONEX.......................................................... 29
NATACYN ......................................................... 26
nateglinide........................................................... 21
NAVANE ............................................................ 11
NEBUPENT .......................................................... 3
necon 0.5/35-28................................................... 26
necon 1/35-28...................................................... 26
necon 10/11-28.................................................... 26
necon 7/7/7 .......................................................... 26
nefazodone........................................................... 11
neomycin /bacitracin /polymyxin ........................ 26
neomycin /polymyxin /bacitracin /hydrocortisone
......................................................................... 27
neomycin /polymyxin /dexamethasone ................ 27
neomycin /polymyxin /gramicidin ....................... 26
neomycin /polymyxin /hc ..................................... 19
neomycin /polymyxin /hydrocortisone........... 19, 27
neomycin sulfate.................................................... 3
NEORAL............................................................... 5
NEPHRAMINE................................................... 30
NEULASTA........................................................ 24
NEUMEGA......................................................... 24
NEUPOGEN ....................................................... 24
NEURONTIN........................................................ 7
NEVANAC ......................................................... 27
NEXAVAR ........................................................... 6
NEXIUM............................................................. 23
NEXIUM I.V....................................................... 23
next choice........................................................... 26
NIASPAN............................................................ 15
nicardipine .......................................................... 14
NICOTROL INHALER ...................................... 18
NICOTROL NASAL .......................................... 18
nifediac cc ........................................................... 14
nifedical xl ........................................................... 14
nifedipine............................................................. 14
nifedipine er......................................................... 14
NILANDRON ....................................................... 6
nimodipine........................................................... 14
NIPENT................................................................. 6
nisoldipine ........................................................... 14
nitro-bid............................................................... 16
nitrofurantoin macrocrystalline.............................4
nitrofurantoin monohydrate...................................4
nitroglycerin.........................................................16
nitroglycerin transdermal ....................................16
NITROLINGUAL PUMPSPRAY.......................16
NITROSTAT .......................................................16
nizatidine..............................................................23
nora-be.................................................................25
NORDITROPIN CARTRIDGE ..........................24
NORDITROPIN NORDIFLEX PEN ..................24
norethindrone.......................................................25
NORMOSOL .......................................................30
NOROXIN .............................................................4
NORPACE CR.....................................................12
nortrel 0.5/35 (28)................................................26
nortrel 1/35 (21)...................................................26
nortrel 1/35 (28)...................................................26
nortrel 7/7/7 .........................................................26
nortriptyline .........................................................11
NORVIR ................................................................1
novamine ..............................................................30
NOVOLIN 70/30 .................................................21
NOVOLIN 70/30 INNOLET...............................21
NOVOLIN N .......................................................21
NOVOLIN N INNOLET .....................................21
NOVOLIN R........................................................21
NOVOLOG..........................................................21
NOVOLOG FLEXPEN .......................................21
NOVOLOG MIX 70/30.......................................21
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
..........................................................................21
NOXAFIL ..............................................................1
NUVARING ........................................................25
nyamyc .................................................................17
nystatin.............................................................1, 17
nystatin / triamcinolone .......................................17
nystop ...................................................................17
O
octreotide ...............................................................6
ofloxacin.....................................................4, 19, 26
ogestrel.................................................................26
omeprazole...........................................................23
43
omnitrope ............................................................ 24
ONCASPAR ......................................................... 6
ondansetron hcl ................................................... 22
ondansetron odt................................................... 22
ONGLYZA.......................................................... 21
ONSOLIS .............................................................. 9
ONTAK................................................................. 6
OPANA ER ........................................................... 9
ORAP .................................................................. 11
ORFADIN ........................................................... 18
orphenadrine /asa /caffeine................................... 8
orphenadrine citrate.............................................. 8
orphenadrine citrate er ......................................... 8
orphenadrine compound ds................................... 8
ORTHO EVRA ................................................... 25
ORTHOCLONE OKT3......................................... 6
ortho-est .............................................................. 25
OVIDE ................................................................ 18
oxaliplatin.............................................................. 6
oxandrolone......................................................... 21
oxaprozin............................................................... 9
oxcarbazepine........................................................ 7
OXSORALEN ULTRA ...................................... 16
oxybutynin ........................................................... 29
oxybutynin er ....................................................... 29
oxycodone /acetaminophen ................................... 9
oxycodone /apap.................................................... 9
oxycodone /aspirin ................................................ 9
oxycodone hcl........................................................ 9
oxycodone-apap .................................................... 9
OXYCONTIN ....................................................... 9
OXYTROL.......................................................... 29
PASER ...................................................................3
PATADAY ..........................................................27
PATANOL...........................................................27
PAXIL..................................................................11
PEDIARIX...........................................................24
pedi-dri.................................................................17
PEDVAX HIB .....................................................24
PEGANONE ..........................................................7
PEGASYS............................................................24
PEG-INTRON......................................................24
PEG-INTRON REDIPEN....................................24
penicillin g potassium ............................................3
PENICILLIN G POTASSIUM IN ISO-OSMOTIC
DEXTROSE.......................................................3
PENICILLIN G PROCAINE.................................4
PENICILLIN G SODIUM.....................................4
penicillin v potassium ............................................4
PENTASA............................................................22
pentopak...............................................................15
pentostatin..............................................................6
pentoxifylline er ...................................................15
PEPCID................................................................23
PERFOROMIST ..................................................29
perindopril erbumine ...........................................14
periogard..............................................................19
permethrin............................................................18
perphenazine ........................................................11
pfizerpen-g .............................................................4
phenadoz ..............................................................28
phenytoin................................................................7
PHENYTOIN SODIUM........................................7
phenytoin sodium extended ....................................7
PHISOHEX..........................................................17
PHOTOFRIN .........................................................6
pilocarpine hcl .....................................................18
PILOPINE HS......................................................27
pindolol ................................................................14
piperacillin sodium/ tazobactam sodium ...............4
piroxicam ...............................................................9
PLASMA-LYTE..................................................30
PLAVIX...............................................................15
podofilox ..............................................................16
polycin b...............................................................26
P
PACERONE........................................................ 12
paclitaxel ............................................................... 6
palgic................................................................... 28
PANDEL ............................................................. 17
PANRETIN ......................................................... 16
parcaine............................................................... 27
paromomycin......................................................... 3
paroxetine............................................................ 11
paroxetine er ....................................................... 11
44
poly-dex ............................................................... 27
polyethylene glycol 3350..................................... 22
portia-28.............................................................. 26
potassium chloride .............................................. 30
POTASSIUM CHLORIDE 0.075%/D5W/NACL
0.225%............................................................. 30
POTASSIUM CHLORIDE 0.15% /NACL 0.45%
VIAFLEX........................................................ 30
potassium chloride 0.15% d5w/nacl 0.33% ........ 30
potassium chloride 0.15% d5w/nacl 0.45% viaflex
......................................................................... 30
potassium chloride 0.15% nacl 0.9%.................. 30
POTASSIUM CHLORIDE 0.15%/D5W............ 30
POTASSIUM CHLORIDE 0.22% D5W/NACL
0.45%............................................................... 30
potassium chloride 0.224%/d5w ......................... 30
POTASSIUM CHLORIDE 0.3%/ NACL 0.9% . 30
potassium chloride 0.3%/d5w ............................. 30
potassium chloride cr .......................................... 30
potassium chloride er .......................................... 30
potassium chloride sr .......................................... 30
potassium citrate extended-release ..................... 29
pramipexole dihydrochloride ................................ 7
PRANDIN ........................................................... 21
pravastatin..................................................... 15, 16
prazosin ............................................................... 14
prednicarbate ...................................................... 17
prednisolone ........................................................ 19
prednisolone acetate ........................................... 27
prednisolone sodium phosphate .................... 19, 27
prednisone ........................................................... 19
PREDNISONE INTENSOL ............................... 19
PREFEST ............................................................ 25
PREMARIN ........................................................ 25
PREMARIN W/APPLICATOR.......................... 25
PREMASOL........................................................ 30
PREMPHASE ..................................................... 25
PREMPRO .......................................................... 25
prenatabs obn...................................................... 31
prevalite............................................................... 16
previfem............................................................... 26
PREVPAC........................................................... 23
PREZISTA ............................................................ 1
PRIMAQUINE ......................................................3
PRIMAXIN I.M.....................................................3
PRIMAXIN IV.......................................................3
primidone ...............................................................7
PRIMSOL ..............................................................4
PRISTIQ ..............................................................11
PRIVIGEN...........................................................24
PROAIR HFA......................................................29
probenecid............................................................25
probenecid /colchicine .........................................25
procainamide .......................................................12
prochlorperazine..................................................22
prochlorperazine edisylate...................................22
prochlorperazine maleate ....................................22
PROCRIT.............................................................24
procto-pak ............................................................22
proctosol hc..........................................................22
proctozone-hc.......................................................22
PROGLYCEM.....................................................21
PROGRAF .............................................................6
PROLASTIN........................................................18
PROLEUKIN.......................................................24
PROMACTA .......................................................15
promethazine hcl..................................................28
promethegan ........................................................28
PROMETRIUM...................................................25
propafenone hcl ...................................................12
proparacaine hcl..................................................27
propoxyphene /acetaminophen ..............................9
propoxyphene hcl ...................................................9
propoxyphene-n /acetaminophen ...........................9
propranolol /hydrochlorothiazide........................14
propranolol hcl ....................................................14
propranolol hcl er ................................................14
propylthiouracil ...................................................19
PROQUAD ..........................................................24
PROTOPIC ..........................................................16
protriptyline hcl ...................................................11
PROVIGIL...........................................................11
PULMICORT ......................................................29
PULMOZYME ....................................................29
PYLERA ..............................................................23
pyrazinamide..........................................................3
45
pyridostigmine bromide......................................... 8
RIDAURA ...........................................................25
rifampin..................................................................3
RILUTEK ............................................................18
rimantadine hcl ......................................................1
ringers injection ...................................................30
RISPERDAL CONSTA.......................................11
risperidone ...........................................................12
risperidone odt .....................................................12
RITALIN LA .......................................................12
RITUXAN..............................................................6
romycin ................................................................26
ropinirole ...............................................................7
ROTATEQ...........................................................24
ROXICET ..............................................................9
ROZEREM ..........................................................12
Q
QUALAQUIN....................................................... 3
quasense .............................................................. 26
quinapril .............................................................. 14
quinapril / hydrochlorothiazide .......................... 14
quinidine gluconate cr......................................... 12
quinidine sulfate .................................................. 12
quinidine sulfate er.............................................. 12
R
RABAVERT ....................................................... 24
ramipril................................................................ 14
RANEXA ............................................................ 16
ranitidine hcl ....................................................... 23
RAPAMUNE ........................................................ 6
REBETOL............................................................. 1
REBIF.................................................................. 24
REBIF TITRATION PACK ............................... 24
reclipsen .............................................................. 26
RECOMBIVAX HB ........................................... 24
regonol .................................................................. 8
REGRANEX ....................................................... 16
RELENZA DISKHALER ..................................... 1
RELION R........................................................... 21
RELISTOR.......................................................... 22
REMICADE ........................................................ 22
RENAGEL .......................................................... 18
RENAMIN .......................................................... 30
RENVELA .......................................................... 18
reprexain ............................................................... 9
REQUIP XL .......................................................... 7
RESCRIPTOR....................................................... 1
reserpine.............................................................. 14
RESTASIS .......................................................... 27
RETROVIR IV INFUSION .................................. 1
REVATIO ........................................................... 29
REVLIMID ........................................................... 6
REYATAZ ............................................................ 1
RHEUMATREX ................................................... 6
ribapak .................................................................. 1
ribasphere.............................................................. 1
ribavirin................................................................. 1
S
SABRIL .................................................................7
SAMSCA .............................................................21
SANDIMMUNE ....................................................6
SANDOSTATIN....................................................6
SANDOSTATIN LAR DEPOT.............................6
SANTYL..............................................................18
SAPHRIS .............................................................12
SAVELLA ...........................................................25
SAVELLA TITRATION PACK .........................25
selegiline ................................................................7
selenium sulfide....................................................16
SELZENTRY.........................................................2
SENSIPAR...........................................................21
SEREVENT DISKUS..........................................29
SEROMYCIN ........................................................3
SEROQUEL.........................................................12
SEROQUEL XR ..................................................12
sertraline ..............................................................12
silver sulfadiazine ................................................16
SIMCOR ..............................................................16
SIMULECT............................................................6
simvastatin ...........................................................16
SINGULAIR ........................................................29
SKELID ...............................................................18
sodium bicarbonate..............................................30
sodium chloride..............................................18, 30
46
sodium chloride 0.9%......................................... 18
sodium chloride 0.45% viaflex ............................ 30
SODIUM EDECRIN........................................... 14
sodium fluoride.................................................... 31
sodium polystyrene sulfonate .............................. 18
sodium sulfacetamide .................................... 17, 27
SOLARAZE ........................................................ 16
solia ..................................................................... 26
SOLU-CORTEF.................................................. 19
SOLU-MEDROL ................................................ 19
SOMATULINE DEPOT ....................................... 6
SOMAVERT....................................................... 21
SORIATANE ...................................................... 16
sorine................................................................... 12
sotalol .................................................................. 12
sotret.................................................................... 16
SPIRIVA HANDIHALER .................................. 29
spironolactone..................................................... 14
spironolactone / hydrochlorothiazide ................. 14
SPORANOX ......................................................... 1
sprintec 28 ........................................................... 26
SPRYCEL ............................................................. 6
sronyx .................................................................. 26
ssd........................................................................ 16
stagesic .................................................................. 9
STALEVO 100...................................................... 7
STALEVO 125...................................................... 7
STALEVO 150...................................................... 7
STALEVO 200...................................................... 7
STALEVO 50........................................................ 7
STALEVO 75........................................................ 7
stavudine................................................................ 2
STIMATE............................................................ 21
STRATTERA...................................................... 12
STREPTOMYCIN SULFATE.............................. 3
STROMECTOL .................................................... 3
SUBOXONE ......................................................... 9
sucralfate............................................................. 23
SULAR................................................................ 14
sulfacetamide sodium / prednisolone sodium
phospha ........................................................... 27
sulfadiazine............................................................ 4
sulfamethoxazole / trimethoprim........................... 4
sulfamethoxazole/trimethoprim ds .........................4
SULFAMYLON ..................................................17
sulfasalazine.........................................................22
sulfatrim .................................................................4
sulfazine ec...........................................................22
sulindac ..................................................................9
sumatriptan succinate ............................................7
SUPRAX................................................................2
SURMONTIL ......................................................12
SUSTIVA...............................................................2
SUTENT ................................................................6
SYMBICORT ......................................................29
SYMBYAX..........................................................12
SYMLIN ..............................................................21
SYMLINPEN 120................................................21
SYMLINPEN 60..................................................21
SYNAREL ...........................................................21
SYNTHROID ......................................................22
SYPRINE.............................................................18
T
TABLOID ..............................................................6
tacrolimus ..............................................................6
TAMIFLU..............................................................2
tamoxifen citrate ....................................................6
tamsulosin hcl ......................................................29
TARCEVA.............................................................6
TARGRETIN.........................................................6
TASIGNA ..............................................................6
TAXOTERE ..........................................................6
TAZICEF ...............................................................2
taztia xt.................................................................14
TEGRETOL-XR ....................................................7
TEKTURNA ........................................................14
TEKTURNA HCT ...............................................14
terazosin hcl .........................................................14
terbinafine ..............................................................1
terbutaline sulfate ................................................29
terconazole...........................................................25
testosterone cypionate..........................................21
testosterone enanthate .........................................21
TETANUS / DIPHTHERIA TOXOIDSADSORBED ADULT .....................................24
47
TETANUS TOXOID ADSORBED.................... 24
tetracycline hcl ...................................................... 4
TEV-TROPIN ..................................................... 24
THALOMID.......................................................... 6
THEO-24............................................................. 29
theochron............................................................. 29
theophylline er..................................................... 29
thermazene .......................................................... 16
thioridazine.......................................................... 12
thiotepa.................................................................. 6
thiothixene ........................................................... 12
THYMOGLOBULIN.......................................... 24
ticlopidine hcl...................................................... 15
TIKOSYN ........................................................... 12
timolol maleate.............................................. 14, 27
timolol maleate ophthalmic gel forming ............. 27
TIMOPTIC OCUDOSE ...................................... 27
tizanidine hcl ......................................................... 8
TOBI...................................................................... 3
tobramycin....................................................... 3, 26
tobramycin /dexamethasone................................ 27
TOBRAMYCIN SULFATE / SODIUM
CHLORIDE....................................................... 3
tobrasol................................................................ 26
TOBREX............................................................. 26
tolazamide ........................................................... 21
tolbutamide.......................................................... 21
tolmetin sodium ..................................................... 9
topiramate ............................................................. 7
toposar................................................................... 6
TORISEL .............................................................. 6
torsemide ............................................................. 14
TRACLEER ........................................................ 29
tramadol ................................................................ 9
tramadol hcl er ...................................................... 9
trandolapril ......................................................... 14
trandolapril/verapamil hcl .................................. 14
TRANSDERM-SCOP......................................... 22
tranylcypromine .................................................. 12
TRAVASOL........................................................ 30
TRAVATAN Z ................................................... 27
trazodone............................................................. 12
TREANDA............................................................ 6
TRECATOR ..........................................................3
TRELSTAR DEPOT MIXJECT............................6
TRELSTAR LA MIXJECT ...................................6
tretinoin............................................................6, 16
triamcinolone acetonide.................................17, 18
triamcinolone in orabase .....................................19
triamterene / hydrochlorothiazide .......................15
TRICOR...............................................................16
triderm..................................................................18
trifluoperazine......................................................12
trifluridine............................................................26
trihexyphenidyl.......................................................7
TRIHIBIT ............................................................24
tri-legest fe ...........................................................26
TRILIPIX.............................................................16
trilyte ....................................................................22
trimethoprim ..........................................................4
trimethoprim sulfate/polymyxin b sulfate.............26
trinessa.................................................................26
TRIPEDIA ...........................................................24
tri-previfem ..........................................................26
TRISENOX............................................................6
tri-sprintec............................................................26
trivora-28 .............................................................26
TRIZIVIR ..............................................................2
TROPHAMINE ...................................................31
tropicamide ..........................................................27
TRUVADA ............................................................2
TWINJECT ..........................................................28
TWINRIX ............................................................24
TWYNSTA ..........................................................15
TYGACIL ..............................................................3
TYKERB................................................................6
TYPHIM VI .........................................................24
TYZEKA................................................................2
TYZINE ...............................................................19
TYZINE PEDIATRIC NASAL DROPS .............19
U
ULESFIA .............................................................18
ULORIC...............................................................25
UNASYN...............................................................4
unithroid...............................................................22
48
UROXATRAL .................................................... 29
URSO 250 ........................................................... 22
URSO FORTE..................................................... 22
ursodiol................................................................ 23
VIVAGLOBIN ....................................................24
VIVELLE-DOT ...................................................25
VOLTAREN ..........................................................9
VOTRIENT............................................................6
V
W
VAGIFEM........................................................... 25
valacyclovir hcl ..................................................... 2
VALCYTE ............................................................ 2
valproate sodium ................................................... 7
valproic acid.......................................................... 7
VALTURNA....................................................... 15
VANCOCIN ORAL.............................................. 4
vancomycin............................................................ 4
VANCOMYCIN HCL ISO-OSMOTIC
DEXTROSE ...................................................... 4
vandazole............................................................. 26
VAQTA............................................................... 24
VARIVAX .......................................................... 24
VECTIBIX ............................................................ 6
VELCADE ............................................................ 6
velivet .................................................................. 26
venlafaxine hcl..................................................... 12
VENTOLIN HFA................................................ 29
VERAMYST....................................................... 29
verapamil............................................................. 15
verapamil er ........................................................ 15
VEREGEN .......................................................... 16
VFEND.................................................................. 1
VFEND IV ............................................................ 1
VIBATIV .............................................................. 4
VIBRAMYCIN ..................................................... 4
VIDAZA................................................................ 6
VIDEX PEDIATRIC............................................. 2
VIGAMOX.......................................................... 26
VIMPAT................................................................ 7
vinblastine sulfate.................................................. 6
vincasar pfs ........................................................... 6
vincristine sulfate .................................................. 6
vinorelbine tartrate ............................................... 6
VIRACEPT ........................................................... 2
VIRAMUNE ......................................................... 2
VIREAD................................................................ 2
warfarin................................................................15
X
XALATAN ..........................................................27
XENAZINE ...........................................................8
XIBROM..............................................................27
XIFAXAN..............................................................3
XOLEGEL ...........................................................17
XYREM ...............................................................12
Y
YF-VAX ..............................................................24
Z
zaleplon ................................................................12
ZANOSAR.............................................................6
ZANTAC .............................................................23
ZAVESCA ...........................................................21
zazole....................................................................26
ZELAPAR..............................................................7
ZEMPLAR...........................................................21
ZENPEP...............................................................23
zerlor ......................................................................9
ZETIA ..................................................................16
ZIAGEN.................................................................2
zidovudine ..............................................................2
ZINACEF...............................................................2
ZINACEF IN ISO-OSMOTIC DEXTROSE.........2
ZINACEF IN ISO-OSMOTIC DILUENT ............2
ZINECARD ...........................................................4
ZIRGAN ..............................................................26
ZMAX....................................................................2
ZOLINZA ..............................................................6
zolpidem ...............................................................12
ZOMETA.............................................................21
ZONALON ..........................................................16
zonisamide..............................................................7
ZOSTAVAX ........................................................25
49
ZOSYN.................................................................. 4
zovia 1/35e........................................................... 26
zovia 1/50e........................................................... 26
ZOVIRAX........................................................... 17
ZYFLO CR.......................................................... 29
ZYLET.................................................................27
ZYMAR ...............................................................26
ZYPREXA ...........................................................12
ZYPREXA ZYDIS ..............................................12
ZYVOX..................................................................3
50