HealthChoice Medicare formulary for high & low options : plan year... : for comprehensive guide use (complete formulary).

              Comprehensive
Medicare Formulary
Complete List of Prescribed Drugs
High and Low Option Medicare
Supplement Plans
With and Without Part D
Plan Year 2012
(Updated for January 1, 2012)
PLEASE READ: This document contains information
about the drugs covered under this plan.
Comprehensive Formulary
E7848_G6000
HPMS ID 00012423
1-1-12.Final
MDIS #2543
i
What is the HealthChoice Medicare Formulary?
The formulary is a list of drugs that are covered by HealthChoice. It includes both
brand-name and generic drugs. Generic drugs are approved by the FDA as having
the same active ingredient as brand-name drugs, but usually at a lower cost. This
formulary list represents the prescription therapies believed to be a necessary part
of a quality treatment program. Due to the Centers for Medicare and Medicaid
Services (CMS) regulations, a few differences can be noted between the formulary
for active and pre-Medicare members and the formulary for Medicare members.
Note: This formulary has changed since last year. Please review this document to
make sure the drugs you take are still listed.
What is a tier?
CMS requires each covered drug be placed in a tier. The HealthChoice tiers are:
Tier 1 — Generics (all covered generics are Preferred)
Tier 2 — Preferred brand-name
Tier 3 — non-Preferred brand-name
Tier 4 — Preferred, very high cost, and unique formulary drugs
Tier 5 — Tobacco cessation drugs
Can the formulary change?
Yes. HealthChoice may add or remove drugs from its formulary during the year.
When formulary changes occur, HealthChoice must notify members affected by
the change:
 At least 60 days before the date the change becomes effective, or
 At the time you request a refill of the drug. If you are notified of a
formulary change when refilling a prescription, you will be able to
receive a 60-day supply of the drug.
ii
How do I use the HealthChoice Medicare Formulary?
There are two ways to find your drugs within the formulary, by medical condition
or by drug name. Brand-name drugs appear in all capital letters (e.g., PROTONIX)
and generic drugs appear in lowercase italics (e.g., pantoprazole).
Locating your drug by medical condition
Drugs listed in this formulary are grouped by categories based on the medical
condition they treat. For example, drugs used to treat a heart condition are listed
under Cardiovascular Agents. If you know the condition your drug treats, you can
look for it under that category name.
Locating your drug by alphabetical listing
If you are not sure what category your drug falls under, you can look for it in the
Index located in the back of this formulary guide. The Index provides an
alphabetical list of all the brand-name and generic drugs included in this document.
Turn to the page listed in the Index to find your drug.
Are there any restrictions on coverage?
Some covered drugs have additional requirements or limits on coverage. Drugs
that are subject to additional requirements or limits are indicated by a two letter
code and can include:
 Quantity Limits (QL): For certain drugs, there are limits on the quantity
covered. The limit is an exception to the Plans’ standard benefit of a 34-
day supply or 100 units, whichever is greater.
 Step Therapy (ST): In some cases, HealthChoice requires you to try
plan Preferred drugs to treat your medical condition before we will cover
iii
another drug that treats the same condition. If you try drug A to treat your
medical condition and it does not work for you, the Plan may then cover
another drug for your condition.
 Prior Authorization (PA): Certain drugs require prior authorization. In
some cases, you must get prior authorization for drugs that are listed in
the HealthChoice Medicare Formulary. Drugs that are not listed in the
formulary also require prior authorization for coverage. If you don’t
receive approval of your prior authorization request, HealthChoice will
not cover your drug.
 Limited Availability (LA): Certain drugs may only be available at
certain pharmacies. For more information, call Medco Member Services
toll-free at 1-800-590-6828. TTY/TDD users call toll-free 1-800-716-
3231.
 Enhanced Drug (ED): These drugs are not normally covered by
Medicare prescription drug plans but, HealthChoice may cover the drugs
designated as ED drugs in this formulary. In some instances, a prior
authorization review may be required. The amounts you pay do not count
toward your total drug costs (i.e., the amounts you pay do not help you
qualify for catastrophic coverage). If you receive extra help paying for
your prescriptions, you will not receive help paying for an ED drug.
 Part B versus Part D Drug (B/D): These drugs may be covered under
Medicare Part B or Medicare Part D depending on the circumstances.
Prior authorization is required to determine how the drug must be billed.
Your physician must provide information about the use and setting of the
administration of the drug.
iv
What if my drug is not listed in the HealthChoice Medicare Formulary?
If your drug is not listed in this formulary, you should first contact Medco Member
Services and ask if your drug is covered. If you learn that HealthChoice does not
cover your drug, you have two options:
 You can ask Medco for a list of similar drugs that are covered by
HealthChoice. When you receive this list, you can show it to your doctor
and ask him/her to prescribe a drug that is covered by HealthChoice.
 You can ask HealthChoice to make an exception and cover your drug.
How do I request an exception to the HealthChoice Medicare
Formulary?
You can ask HealthChoice to make certain exceptions to its coverage rules. When
you or your doctor ask for an exception, it is called asking for a prior
authorization/exception. There are several types of exceptions you can ask us to
make.
 Certain drugs listed in the HealthChoice Medicare Formulary require a
Step Therapy prior authorization exception before they are covered. You
must first try a designated drug to treat your medical condition. If the
designated drug fails to treat your medical condition, you can request a
Step Therapy prior authorization exception. Your doctor must contact
Medco toll-free at 1-800-753-2851 and provide information to support
your request.
 You can ask us to cover your drug even if it is non-Formulary and not
listed in this guide. Please note, if we grant your request to cover a drug
that is not in our formulary, it will be covered at the non-Preferred
copay. To request a prior authorization/exception for a non-formulary
v
drug, your doctor must contact Medco toll-free at 1-800-753-2851 and
provide information to support your request.
 Due to approved therapy guidelines, certain medications have set
quantity limits. Quantity limits also apply if the drug form is other
than a tablet or capsule. To request a prior authorization/exception to the
quantity limitation rules, your doctor must contact Medco toll-free at 1-
800-753-2851 and provide information to support your request.
 Certain drugs listed in the HealthChoice Medicare Formulary require a
general prior authorization/exception before they are covered.
Generally, these drugs are very high cost, have specific prescribing
guidelines, are usually used for cosmetic purposes, or might be covered
under Medicare Part B. To request a prior authorization/exception for a
covered drug, your doctor must contact Medco toll-free at 1-800-753-
2851 and provide information to support your request.
 If you choose a non-Preferred medication when a Preferred medication
is available, you must pay the non-Preferred copay unless you request a
prior authorization/exception to receive a lower copay (a tier exception).
Be aware that medical guidelines must be met, and information supplied
by your doctor must justify your request. To request a prior
authorization/exception for a tier exception to receive a lower copay,
your doctor must contact Medco and provide information to support
your request. Your doctor can contact Medco toll-free at 1-800-841-
5409.
When requesting an exception, your doctor must submit a statement supporting the
request. Generally, we must make our decision within 72 hours of receiving your
prescribing physician’s supporting statement. You can request an expedited (fast)
exception if you or your doctor believe that your health could be seriously harmed
by waiting up to 72 hours for a decision. If your request to expedite is granted, we
vi
must give you a decision no later than 24 hours after we receive your prescriber’s
or prescribing physician’s supporting statement.
What do I do before I talk to my doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan, you may be taking drugs that are not
listed in our formulary; or you may be taking a drug that is listed in our formulary,
but your ability to get it is limited. For example, you may need a prior
authorization before you can fill your prescription. You should talk to your doctor
to decide if you should switch to an appropriate drug we cover or request a
formulary exception so that we will cover the drug you take. While you talk to
your doctor to determine the right course of action for you, HealthChoice may
cover your drug in certain cases.
For each of your drugs that is not listed in our formulary, or if your ability to get
your drugs is limited, we will cover a temporary 34-day supply (unless you have a
prescription written for fewer days) when you go to a HealthChoice Network
Pharmacy. After you receive your first 34-day supply, you will need to get a prior
authorization/exception before HealthChoice will continue to cover this
medication.
If you are a resident of a long-term care (LTC) facility, we will cover a temporary
34-day transition supply (unless you have a prescription written for fewer days). If
you need a drug that is not listed in our formulary or if your ability to get your drug
is limited, we will cover a 34-day emergency supply of that drug (unless you have
a prescription for fewer days) while you pursue a formulary exception. We will
cover up to two refills of these medications.
HealthChoice covers a transition supply if you have a level of care change such as
when you:
 Enter LTC facilities from hospitals or other settings;
vii
 Leave LTC facilities and return to the community;
 Are discharged from a hospital to a home;
 End a skilled nursing facility (SNF) stay covered under Medicare Part A
(where all pharmacy charges are covered), and must revert to coverage
under your Part D plan formulary;
 Revert from hospice status to standard Medicare Part A and B benefits;
or
 Are discharged from a psychiatric hospital with medication regimens that
are highly individualized.
For more information
For more detailed information about your prescription drug coverage, please
review your HealthChoice Medicare Supplement Handbook and other plan
materials or visit the HealthChoice website at www.healthchoiceok.com or
www.sib.ok.gov.
This Comprehensive Formulary is effective beginning January 1, 2012. If you have
questions about the prescription drug program, visit the HealthChoice website or
call Medco Member Services toll-free at 1-800-590-6828, 24 hours a day, 7 days a
week. TTY/TDD users call toll-free 1-800-716-3231.
If you have general questions about Medicare prescription drug coverage, please
call Medicare toll-free at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7
days a week or visit Medicare’s website at www.medicare.gov. TTY/TDD users
can call toll-free 1-877-486-2048.
This publication was printed by the Oklahoma State and Education Employees Group Insurance
Board, a division of the Office of State Finance, as authorized by 74 O.S. Section 1301, et seq;
34,000 copies have been printed at a cost of $.60 each. Copies have been deposited with the
Publications Clearinghouse of the Oklahoma Department of Libraries.
This page intentionally blank.
1
Commonly Prescribed Therapeutic
Drug Categories
ANTI - INFECTIVES
ANTIFUNGAL AGENTS
Drug
Name
Drug
Tier
Require-ments/
Limits
amphotericin b 1 B/D PA
ANCOBON 2
clotrimazole troc 1
DIFLUCAN IN NACL 2
ERAXIS INJ 100MG 2
fluconazole in dextrose inj 0;
400mg/200ml
1
fluconazole susr 1
fluconazole tabs 1
GRIS-PEG 3
griseofulvin microsize 1
itraconazole 1
ketoconazole 1
NOXAFIL 2
nystatin susp 1
nystatin tabs 1
ORAVIG 2
SPORANOX ORAL SOLN 2
terbinafine tabs 1
VFEND IV 2
VFEND SUSR 2
voriconazole 1
ANTIVIRALS
acyclovir caps 1
acyclovir inj 500mg 1
acyclovir susp 1
acyclovir tabs 1
amantadine 1
APTIVUS 4
ATRIPLA 4
BARACLUDE 2
COMBIVIR 4
CRIXIVAN 2
didanosine 1
EDURANT 4
EMTRIVA 2
Drug
Name
Drug
Tier
Require-ments/
Limits
EPIVIR 2
EPIVIR HBV 2
EPZICOM 4
famciclovir 1
foscarnet sodium 1 B/D PA
FUZEON 4
ganciclovir caps 1
HEPSERA 4
INTELENCE 4
INVIRASE CAPS 3
INVIRASE TABS 4
ISENTRESS 4
KALETRA ORAL SOLN 4
KALETRA TABS 200MG;
50MG
4
KALETRA TABS 100MG;
25MG
2
LEXIVA SUSP 2
LEXIVA TABS 4
NORVIR 2
PREZISTA TABS 150MG,
75MG
2
PREZISTA TABS 400MG,
600MG
4
REBETOL ORAL SOLN 2
RELENZA DISKHALER 2 QL(300 per
365 days)
RESCRIPTOR 3
RETROVIR IV INFUSION 2
REYATAZ 2
ribapak 4
ribasphere caps 1
ribasphere tabs 200mg 1
ribasphere tabs 400mg, 600mg 4
ribavirin 1
rimantadine hcl 1
SELZENTRY 4
stavudine 1
SUSTIVA 2
TAMIFLU CAPS 45MG, 75MG 2 QL(60 per
365 days)
TAMIFLU CAPS 30MG 2 QL(120 per
365 days)
2
Drug
Name
Drug
Tier
Require-ments/
Limits
TAMIFLU SUSR 12MG/ML 2
TRIZIVIR 4
TRUVADA 4
TYZEKA 4
valacyclovir hcl 1
VALCYTE 4
VIDEX PEDIATRIC ORAL
SOLN 2GM
2
VIRACEPT POWD 2
VIRACEPT TABS 4
VIRAMUNE 2
VIREAD 2
ZIAGEN 2
zidovudine 1
CEPHALOSPORINS
cefaclor 1
cefadroxil 1
cefazolin inj 1gm, 1gm; 5%,
20gm, 500mg
1
cefdinir 1
cefepime inj 1gm, 2gm 1
cefotaxime sodium 1
cefoxitin sodium inj 10gm, 1gm,
2gm
1
cefpodoxime proxetil 1
ceftazidime inj 1gm, 2gm, 6gm 1
ceftriaxone sodium 1
cefuroxime axetil 1
cefuroxime sodium inj 1.5gm,
7.5gm, 750mg
1
cephalexin 1
FORTAZ INJ 1GM/50ML; 5%,
2GM/50ML; 5%, 6GM
2
SUPRAX SUSR 3
TAZICEF INJ 1GM, 2GM, 6GM 2
TEFLARO 2
ZINACEF IN ISO-OSMOTIC
DEXTROSE
2
ZINACEF IN ISO-OSMOTIC
DILUENT
2
ZINACEF INJ 1.5GM, 750MG 2
ERYTHROMYCINS / OTHER
MACROLIDES
Drug
Name
Drug
Tier
Require-ments/
Limits
azithromycin inj 500mg 1
azithromycin susr 1
azithromycin tabs 1
clarithromycin 1
clarithromycin er 1
e.e.s. 400 1
E.E.S. GRANULES 2
ERY-TAB TBEC 500MG 2
ery-tab tbec 250mg, 333mg 1
ERYTHROCIN
LACTOBIONATE INJ 500MG
2
erythrocin stearate 1
ERYTHROMYCIN BASE 2
erythromycin ethylsuccinate 1
erythromycin/sulfisoxazole 1
ZMAX 2
MISCELLANEOUS ANTIINFECTIVES
ALBENZA 2
ALINIA 2
amikacin sulfate inj 500mg/2ml,
50mg/ml
1
AZACTAM IN ISO-OSMOTIC
DEXTROSE
2
AZACTAM INJ 2GM 2
aztreonam inj 1gm 1
BILTRICIDE 2
CAPASTAT SULFATE 3
CAYSTON 4 LA
chloroquine 1
CLEOCIN GALAXY 2
CLEOCIN PEDIATRIC
GRANULES
2
clindamycin hcl 1
clindamycin phosphate add-vantage
1
COARTEM 2
colistimethate sodium 1
CUBICIN 2 B/D PA
DAPSONE 2
DARAPRIM 2
ethambutol 1
gentamicin sulfate inj 1
3
Drug
Name
Drug
Tier
Require-ments/
Limits
gentamicin sulfate/0.9% sodium
chloride
1
gentamicin sulfate/sodium
chloride inj 1.2mg/ml; 0.9%
1
hydroxychloroquine 1
isonarif 1
ISONIAZID SYRP 2
isoniazid tabs 1
isotonic gentamicin inj 0.6mg/ml;
0.9%, 0.8mg/ml; 0.9%
1
KETEK 2
MALARONE 2
mebendazole 1
mefloquine hcl 1
MEPRON 4
meropenem inj 500mg 1
metronidazole 1
metronidazole in nacl 0.79% 1
MYCOBUTIN 2
NEBUPENT 2 B/D PA
neomycin sulfate 1
paromomycin 1
PASER 2
PRIMAQUINE 2
PRIMAXIN I.M. 2
PRIMAXIN IV 2
pyrazinamide 1
QUALAQUIN 2
rifampin 1
SEROMYCIN 2
STREPTOMYCIN SULFATE 2
STROMECTOL 2
TOBI 4 B/D PA
tobramycin inj 10mg/ml,
80mg/2ml
1
TOBRAMYCIN SULFATE /
SODIUM CHLORIDE
2
TRECATOR 2
TYGACIL 2
XIFAXAN 2
ZYVOX 2
PENICILLINS
Drug
Name
Drug
Tier
Require-ments/
Limits
amoxicillin 1
amoxicillin/clavulanate potassium 1
amoxicillin/clavulanate potassium
er
1
amoxicillin/potassium clavulanate
tabs
1
ampicillin caps 1
ampicillin inj 10gm, 1gm 1
AMPICILLIN INJ 125MG 2
ampicillin susr 1
ampicillin-sulbactam inj 10gm;
5gm, 2gm; 1gm
1
BICILLIN C-R 2
BICILLIN L-A 2
dicloxacillin sodium 1
nafcillin sodium inj 10gm, 1gm 1
NALLPEN/DEXTROSE INJ 0;
1GM/50ML
2
PENICILLIN G POTASSIUM IN
ISO-OSMOTIC DEXTROSE
2
penicillin g potassium inj 5mu 1
PENICILLIN G PROCAINE 2
PENICILLIN G SODIUM 2
penicillin v potassium 1
pfizerpen-g inj 20mu 1
piperacillin sodium/tazobactam
sodium inj 3gm; 0.375gm
1
ZOSYN INJ 5%; 2GM/50ML;
0.25GM/50ML, 5%; 3GM/50ML;
0.375GM/50ML
2
QUINOLONES
AVELOX 2
AVELOX ABC PACK 2
CIPRO I.V.-IN D5W INJ
200MG; 5%
2
ciprofloxacin inj 400mg/40ml 1
ciprofloxacin tabs 1
LEVAQUIN INJ 25MG/ML, 5%;
750MG/150ML
3
LEVAQUIN ORAL SOLN 3
LEVAQUIN TABS 3
NOROXIN 3
ofloxacin 1
SULFA'S / RELATED AGENTS
4
Drug
Name
Drug
Tier
Require-ments/
Limits
sulfadiazine 1
sulfamethoxazole/trimethoprim 1
sulfamethoxazole/trimethoprim ds 1
TETRACYCLINES
demeclocycline hcl 1
doxycycline hyclate caps 1
doxycycline hyclate inj 1
doxycycline hyclate tabs 1
doxycycline hyclate tbec 1
doxycycline monohydrate tabs
150mg, 50mg, 75mg
1
minocycline hcl 1
minocycline hcl er 1
tetracycline hcl 1
VIBRAMYCIN SYRP 2
URINARY TRACT AGENTS
MACRODANTIN CAPS 25MG 2
methenamine hippurate 1
nitrofurantoin 1
nitrofurantoin macrocrystalline
caps 50mg
1
nitrofurantoin monohydrate 1
PRIMSOL 3
trimethoprim 1
VANCOMYCIN
VANCOCIN ORAL 2
vancomycin inj 1000mg, 10gm,
500mg
1 B/D PA
VIBATIV INJ 250MG 2
ANTINEOPLASTIC /
IMMUNOSUPPRESSANT DRUGS
ADJUNCTIVE AGENTS
amifostine 4
dexrazoxane inj 500mg 1
ELITEK INJ 1.5MG 4
leucovorin calcium inj 100mg,
350mg
1
leucovorin calcium tabs 25mg,
5mg
1
LEUCOVORIN CALCIUM
TABS 10MG, 15MG
2
mesna 1
Drug
Name
Drug
Tier
Require-ments/
Limits
MESNEX TABS 2
XGEVA 4
ZINECARD INJ 250MG 2
ANTINEOPLASTIC /
IMMUNOSUPPRESSANT DRUGS
ABRAXANE 3
adriamycin inj 2mg/ml 1
AFINITOR TABS 10MG 4 PA QL(180
per 90 days)
AFINITOR TABS 2.5MG, 5MG 4 PA QL(270
per 90 days)
ALIMTA INJ 500MG 3
ALKERAN INJ 3
anastrozole 1
ARRANON 3
ARZERRA 2
AVASTIN INJ 100MG/4ML 3
azathioprine 1 B/D PA
azathioprine sodium 1 B/D PA
bicalutamide 1
BICNU 3
bleomycin sulfate inj 30unit 1
BUSULFEX 2
CAMPATH 3
carboplatin inj 150mg/15ml 1
CEENU 2
CELLCEPT INTRAVENOUS 2
CELLCEPT SUSR 2 B/D PA
cisplatin inj 100mg/100ml 1
cladribine 1
CLOLAR 3
COSMEGEN 3
cyclophosphamide tabs 1 B/D PA
cyclosporine caps 100mg, 25mg 1 B/D PA
CYCLOSPORINE CAPS 50MG 2 B/D PA
cyclosporine inj 1 B/D PA
cyclosporine oral soln 1 B/D PA
CYTARABINE AQUEOUS INJ
100MG/ML
2
cytarabine aqueous inj 20mg/ml 1
cytarabine inj 500mg 1
dacarbazine inj 200mg 1
5
Drug
Name
Drug
Tier
Require-ments/
Limits
DACOGEN 2
daunorubicin hcl inj 20mg 1
DAUNOXOME 3
DOCETAXEL INJ 80MG/8ML 2
DOXIL 2
doxorubicin hcl 1
DROXIA 2
ELLENCE INJ 200MG/100ML 3
ELOXATIN INJ 100MG/20ML 3
ELSPAR 3
EMCYT 2
epirubicin hcl inj 50mg/25ml 1
ERBITUX INJ 100MG/50ML 3
ETOPOPHOS 3
etoposide inj 1
exemestane 1
FARESTON 3
FASLODEX 4
FIRMAGON INJ 120MG 4
FIRMAGON INJ 80MG 2
fludarabine phosphate inj 50mg 1
fluorouracil inj 500mg/10ml 1
flutamide 1
gemcitabine hcl inj 1gm 4
gengraf 1 B/D PA
GLEEVEC 4
HALAVEN 4
HERCEPTIN 3
HEXALEN 4
hydroxyurea 1
idarubicin hcl inj 10mg/10ml 1
IFEX INJ 3GM 3
ifosfamide inj 1gm 1
ifosfamide/mesna 4
irinotecan inj 100mg/5ml 4
ISTODAX 2
IXEMPRA KIT INJ 45MG 4
JEVTANA 4
letrozole 1
LEUKERAN 2
leuprolide acetate 1
Drug
Name
Drug
Tier
Require-ments/
Limits
LUPRON DEPOT INJ 3.75MG 2
LUPRON DEPOT INJ 11.25MG,
22.5MG, 30MG, 7.5MG
4
LUPRON DEPOT-PED INJ
11.25MG, 15MG
4
LYSODREN 2
MATULANE 4
MEGACE ES 2
megestrol acetate 1
melphalan hydrochloride 1
mercaptopurine 1
methotrexate 1 B/D PA
methotrexate sodium inj 25mg/ml 1
METHOTREXATE SODIUM
INJ 1GM
3
mitomycin inj 20mg 1
mitoxantrone hcl 1
MUSTARGEN 3
mycophenolate mofetil 1 B/D PA
MYFORTIC 2 B/D PA
NEORAL 2 B/D PA
NEXAVAR 4 LA PA
QL(360 per
90 days)
NILANDRON 3
NIPENT 3
octreotide inj 100mcg/ml,
200mcg/ml, 50mcg/ml
1
octreotide inj 1000mcg/ml,
500mcg/ml
4
ONTAK 3
oxaliplatin inj 100mg/20ml 4
paclitaxel inj 300mg/50ml 1
pentostatin 1
PHOTOFRIN 3
PROGRAF INJ 2 B/D PA
RAPAMUNE 2 B/D PA
REVLIMID CAPS 15MG, 25MG 4 LA QL(21
per 28 days)
REVLIMID CAPS 10MG, 5MG 4 LA QL(30
per 30 days)
RHEUMATREX 3 B/D PA
RITUXAN 2 PA
SANDIMMUNE 2 B/D PA
6
Drug
Name
Drug
Tier
Require-ments/
Limits
SANDOSTATIN LAR DEPOT 3
SIMULECT INJ 20MG 2
SOMATULINE DEPOT 4
SPRYCEL TABS 100MG,
140MG, 50MG, 70MG, 80MG
4 QL(90 per
90 days)
SPRYCEL TABS 20MG 4 QL(180 per
90 days)
SUTENT 4 PA QL(90
per 90 days)
TABLOID 2
tacrolimus 1 B/D PA
tamoxifen citrate 1
TARCEVA TABS 100MG,
150MG
4 PA QL(90
per 90 days)
TARCEVA TABS 25MG 4 PA QL(180
per 90 days)
TARGRETIN 2
TASIGNA CAPS 200MG 4 QL(336 per
84 days)
TAXOTERE INJ 80MG/2ML,
80MG/4ML
4
THALOMID 4 PA
thiotepa 1
toposar 1
topotecan hcl inj 4mg 1
TORISEL 4 PA
TREANDA INJ 100MG 4
TRELSTAR DEPOT MIXJECT 3
TRELSTAR LA MIXJECT 3
TRELSTAR MIXJECT 3
tretinoin 1
TRISENOX 2
TYKERB 4 LA QL(540
per 90 days)
VANDETANIB TABS 300MG 4 QL(90 per
90 days)
VANDETANIB TABS 100MG 4 QL(180 per
90 days)
VECTIBIX INJ 100MG/5ML 4
VELCADE 3
VIDAZA 4 QL(4200
per 90 days)
vinblastine sulfate inj 10mg 1
vincasar pfs 1
Drug
Name
Drug
Tier
Require-ments/
Limits
vincristine sulfate 1
vinorelbine tartrate inj 50mg/5ml 1
VOTRIENT 4 QL(360 per
90 days)
ZANOSAR 3
ZOLINZA 4 QL(360 per
90 days)
ZORTRESS TABS 0.5MG,
0.75MG
4 B/D PA
ZORTRESS TABS 0.25MG 2 B/D PA
ZYTIGA 4 PA QL(360
per 90 days)
AUTONOMIC / CNS DRUGS,
NEUROLOGY / PSYCH
ANTICONVULSANTS
BANZEL 2
carbamazepine 1
carbamazepine er tb12 1
CARBATROL 2
CELONTIN 2
clonazepam 1 ED
DILANTIN CAPS 30MG 2
DILANTIN INFATABS 2
divalproex sodium cpsp 1
divalproex sodium er 1
divalproex sodium tbec 1
epitol 1
EQUETRO 2
ethosuximide 1
FELBATOL 2
gabapentin 1
GABITRIL 2
LAMICTAL ODT TBDP 2
LAMICTAL XR KIT 2
LAMICTAL XR TB24 100MG,
200MG, 25MG, 50MG
2
lamotrigine 1
levetiracetam 1
LYRICA 2
oxcarbazepine 1
PEGANONE 2
phenobarbital tabs 1 ED
7
Drug
Name
Drug
Tier
Require-ments/
Limits
phenytoin 1
PHENYTOIN SODIUM 2
phenytoin sodium extended 1
primidone 1
SABRIL 2
TEGRETOL-XR TB12 100MG 2
topiramate 1
valproate sodium 1
valproic acid 1
VIMPAT 2
zonisamide 1
ANTIPARKINSONISM AGENTS
APOKYN 2 LA
AZILECT 2
benztropine mesylate 1
bromocriptine mesylate 1
carbidopa / levodopa 1
carbidopa/levodopa cr 1
carbidopa/levodopa odt 1
carbidopa/levodopa sr tbcr 50mg;
200mg
1
COMTAN 2
LODOSYN 2
MIRAPEX ER TB24 0.375MG,
0.75MG, 1.5MG, 3MG, 4.5MG
2
pramipexole dihydrochloride 1
REQUIP XL 2
ropinirole 1
selegiline 1
STALEVO 100 2
STALEVO 125 2
STALEVO 150 2
STALEVO 200 2
STALEVO 50 2
STALEVO 75 2
trihexyphenidyl 1
ZELAPAR 2
ANXIOLYTICS
alprazolam 1 ED
diazepam tabs 1 ED
lorazepam tabs 1mg, 2mg 1 ED
oxazepam 1 ED
Drug
Name
Drug
Tier
Require-ments/
Limits
HYPNOTIC AGENTS
temazepam 1 ED
MIGRAINE / CLUSTER HEADACHE
THERAPY
dihydroergotamine mesylate 1
ergotamine tartrate / caffeine 1
MAXALT 3 QL(36 per
90 days)
MAXALT-MLT 3 QL(36 per
90 days)
migergot 1
MIGRANAL 3 QL(24 per
90 days)
naratriptan hcl tabs 2.5mg 1 QL(24 per
90 days)
naratriptan hcl tabs 1mg 1 QL(36 per
90 days)
RELPAX 3 QL(24 per
90 days)
sumatriptan succinate inj
6mg/0.5ml
1 QL(12 per
90 days)
sumatriptan succinate tabs 100mg 1 QL(27 per
90 days)
sumatriptan succinate tabs 25mg,
50mg
1 QL(54 per
90 days)
ZOMIG NASAL SOLN 3 QL(24 per
90 days)
ZOMIG TABS 5MG 3 QL(24 per
90 days)
ZOMIG TABS 2.5MG 3 QL(36 per
90 days)
ZOMIG ZMT TBDP 5MG 3 QL(24 per
90 days)
ZOMIG ZMT TBDP 2.5MG 3 QL(36 per
90 days)
MISCELLANEOUS NEUROLOGICAL
THERAPY
ARICEPT ODT 2
ARICEPT TABS 23MG 2
COPAXONE 4 PA QL(90
per 90 days)
donepezil hcl 1
EXELON ORAL SOLN 2
EXELON PT24 2
galantamine hydrobromide 1
8
Drug
Name
Drug
Tier
Require-ments/
Limits
GILENYA 4 PA QL(28
per 28 days)
MYTELASE 2
NAMENDA 2
NAMENDA TITRATION PAK 2
NUEDEXTA 2
rivastigmine tartrate 1
XENAZINE 4 LA
MUSCLE RELAXANTS /
ANTISPASMODIC THERAPY
baclofen 1
cyclobenzaprine hcl 1
dantrolene sodium caps 1
MESTINON SYRP 2
MESTINON TIMESPAN 2
pyridostigmine bromide 1
regonol 1
tizanidine hcl 1
NARCOTIC ANALGESICS
acetaminophen / codeine oral
soln
1
acetaminophen / codeine tabs
300mg; 15mg
1
acetaminophen/codeine #3 1
acetaminophen/codeine #4 1
ascomp/codeine 1
BUPRENEX 2
buprenorphine hcl 1
codeine sulfate 1
DILAUDID INJ 2
DILAUDID-5 2
DILAUDID-HP INJ 10MG/ML 2
duramorph 1
EMBEDA 3
endocet 1
EXALGO 3
fentanyl citrate 1
fentanyl citrate oral transmucosal
lpop 200mcg
1
fentanyl citrate oral transmucosal
lpop 1200mcg, 1600mcg, 400mcg,
600mcg, 800mcg
4
Drug
Name
Drug
Tier
Require-ments/
Limits
fentanyl patches 1 QL(45 per
90 days)
hydrocodone
bitartrate/acetaminophen tabs
1
hydrocodone/acetaminophen oral
soln 500mg/15ml; 7.5mg/15ml
1
hydrocodone/acetaminophen tabs 1
hydrocodone/ibuprofen 1
hydromorphone hcl inj 10mg/ml 1
hydromorphone hcl tabs 1
INFUMORPH 200 2
INFUMORPH 500 2
KADIAN 2
levorphanol tartrate 1
margesic-h 1
methadone hcl conc 1
methadone hcl inj 1
methadone hcl oral soln 5mg/5ml 1
METHADONE HCL ORAL
SOLN 10MG/5ML
2
methadone hcl tabs 1
methadose tabs 1
morphine sulfate er 1
morphine sulfate inj 0.5mg/ml,
1mg/ml
1
morphine sulfate oral soln 1
morphine sulfate tabs 1
ONSOLIS 2
OPANA ER 2
oxycodone / acetaminophen 1
oxycodone hcl caps 1
oxycodone hcl conc 1
oxycodone hcl tabs 15mg, 30mg,
5mg
1
oxycodone/aspirin 1
OXYCONTIN 3 ST
oxymorphone hydrochloride 1
reprexain tabs 10mg; 200mg 1
ROXICET ORAL SOLN 2
roxicet tabs 325mg; 5mg 1
stagesic 1
zerlor 1
NON-NARCOTIC ANALGESICS
9
Drug
Name
Drug
Tier
Require-ments/
Limits
ARTHROTEC 50 3
ARTHROTEC 75 3
butorphanol tartrate nasal soln 1 QL(30 per
90 days)
CELEBREX 2 PA
depade 1
diclofenac potassium 1
diclofenac sodium 1
diclofenac sodium ec 1
diclofenac sodium xr 1
diflunisal 1
etodolac 1
fenoprofen calcium 1
FLECTOR 3
flurbiprofen 1
ibuprofen susp 1
ibuprofen tabs 400mg, 600mg,
800mg
1
indomethacin caps 1
indomethacin er 1
ketoprofen 1
ketoprofen er 1
meclofenamate sodium 1
mefenamic acid 1
meloxicam 1
nabumetone 1
naloxone 1
naltrexone 1
naproxen sodium tabs 275mg,
550mg
1
naproxen susp 1
naproxen tabs 250mg, 375mg 1
naproxen tbec 1
oxaprozin 1
PENNSAID 2
piroxicam 1
SUBOXONE 2
sulindac 1
tolmetin sodium 1
tramadol 1
tramadol hcl er 1
VIMOVO 2
Drug
Name
Drug
Tier
Require-ments/
Limits
VOLTAREN GEL 2
PSYCHOTHERAPEUTIC DRUGS
ABILIFY 2
ABILIFY DISCMELT 2
amitriptyline 1
amoxapine 1
budeprion sr 1
budeprion xl 1
bupropion hcl 1
bupropion hcl sr 1
buspirone hcl 1
chlordiazepoxide/amitriptyline 1
chlorpromazine 1
citalopram 1
clomipramine 1
clozapine tabs 100mg, 25mg,
50mg
1
CLOZAPINE TABS 200MG 2
CYMBALTA 2
desipramine 1
dextroamphetamine sulfate 1 PA
dextroamphetamine sulfate er 1 PA
doxepin 1
EMSAM 3 QL(90 per
90 days)
FANAPT 3
FANAPT TITRATION PACK 3
FAZACLO 3
fluoxetine 1
fluoxetine dr 1
fluphenazine 1
fluphenazine decanoate inj 1
fluvoxamine 1
FOCALIN XR 2 PA
GEODON 2
HALDOL 2
HALDOL DECANOATE 100 2
HALDOL DECANOATE 50 2
haloperidol 1
haloperidol decanoate inj 1
haloperidol lactate inj 1
imipramine 1
10
Drug
Name
Drug
Tier
Require-ments/
Limits
imipramine pamoate 1
INVEGA 2
INVEGA SUSTENNA 2
LATUDA 2
lithium carbonate 1
lithium carbonate er 1
lithium citrate 1
loxapine 1
maprotiline 1
MARPLAN 2
METADATE CD CPCR 20MG,
30MG, 40MG, 50MG, 60MG
3 PA
methylphenidate hcl 1 PA
methylphenidate hydrochloride 1 PA
mirtazapine 1
mirtazapine odt tbdp 30mg, 45mg 1
nefazodone 1
nortriptyline 1
ORAP 2
paroxetine 1
paroxetine er 1
PAXIL SUSP 2
perphenazine 1
phenelzine sulfate 1
PRISTIQ 2
protriptyline hcl 1
PROVIGIL 2 PA QL(90
per 90 days)
RISPERDAL CONSTA 2
risperidone 1
risperidone odt 1
RITALIN LA 3 PA
SAPHRIS 2
SEROQUEL 2
SEROQUEL XR 2
sertraline 1
SILENOR 3
STRATTERA 2
SURMONTIL 3
SYMBYAX 3
thioridazine 1
thiothixene 1
Drug
Name
Drug
Tier
Require-ments/
Limits
tranylcypromine 1
trazodone 1
trifluoperazine 1
venlafaxine hcl 1
venlafaxine hcl er cp24 1
VIIBRYD 3
XYREM 4
zaleplon 1 QL(180 per
365 days)
zolpidem 1 QL(180 per
365 days)
zolpidem tartrate er tbcr 6.25mg 1
zolpidem tartrate er tbcr 12.5mg 1 QL(180 per
365 days)
ZYPREXA 2
ZYPREXA ZYDIS 2
CARDIOVASCULAR,
HYPERTENSION / LIPIDS
ANTIARRHYTHMIC AGENTS
amiodarone inj 50mg/ml 1
amiodarone tabs 1
disopyramide phosphate 1
flecainide acetate 1
mexiletine 1
MULTAQ 2
NORPACE CR CP12 100MG 2
PACERONE TABS 100MG 2
pacerone tabs 200mg 1
procainamide 1
propafenone hcl 1
propafenone hcl er 1
quinidine gluconate er 1
quinidine sulfate 1
quinidine sulfate er 1
sorine 1
sotalol 1
TIKOSYN 3
ANTIHYPERTENSIVE THERAPY
acebutolol 1
afeditab cr 1
amiloride 1
amiloride/hydrochlorothiazide 1
11
Drug
Name
Drug
Tier
Require-ments/
Limits
amlodipine 1
amlodipine / benazepril 1
AMTURNIDE 2
atenolol 1
atenolol / chlorthalidone 1
benazepril 1
benazepril / hydrochlorothiazide 1
BENICAR 2
BENICAR HCT 2
betaxolol hcl 1
BIDIL 2
bisoprolol fumarate 1
bisoprolol fumarate /
hydrochlorothiazide
1
bumetanide 1
BYSTOLIC 2
captopril 1
captopril/hydrochlorothiazide 1
cartia xt 1
carvedilol 1
chlorothiazide 1
chlorothiazide sodium 1
chlorthalidone tabs 25mg, 50mg 1
clonidine ptwk 1
clonidine tabs 1
COREG CR 2
DEMSER 2
DIBENZYLINE 3
dilt-cd cp24 120mg, 300mg 1
dilt-xr cp24 180mg, 240mg 1
diltiazem cd cp24 120mg, 240mg,
300mg
1
diltiazem hcl er cp12 1
diltiazem hcl er cp24 360mg,
420mg
1
diltiazem hcl inj 25mg/5ml 1
DILTIAZEM HCL INJ 100MG 2
diltiazem hcl tabs 1
diltzac cp24 120mg, 180mg,
240mg, 300mg
1
DIOVAN 2
DIOVAN HCT 2
Drug
Name
Drug
Tier
Require-ments/
Limits
doxazosin 1
EDECRIN 2
enalapril 1
enalapril / hydrochlorothiazide 1
eplerenone 1
EXFORGE 2
EXFORGE HCT 2
felodipine er 1
fosinopril 1
fosinopril / hydrochlorothiazide 1
furosemide inj 1
furosemide oral soln 10mg/ml 1
FUROSEMIDE ORAL SOLN
8MG/ML
2
furosemide tabs 1
guanfacine hcl 1
hydralazine 1
hydrochlorothiazide 1
indapamide 1
isradipine 1
labetalol 1
lisinopril 1
lisinopril/hydrochlorothiazide 1
losartan potassium 1
losartan
potassium/hydrochlorothiazide
1
matzim la 1
methyclothiazide 1
metolazone 1
metoprolol succinate er 1
metoprolol tartrate 1
metoprolol/hydrochlorothiazide 1
minoxidil tabs 1
moexipril 1
moexipril/hydrochlorothiazide 1
nadolol 1
nadolol/bendroflumethiazide 1
nicardipine caps 1
nifediac cc 1
nifedical xl 1
nifedipine 1
nifedipine er 1
12
Drug
Name
Drug
Tier
Require-ments/
Limits
nimodipine 1
nisoldipine 1
nisoldipine er 1
perindopril erbumine 1
pindolol 1
prazosin 1
propranolol hcl 1
propranolol hcl er 1
propranolol/hydrochlorothiazide 1
quinapril 1
quinapril/hydrochlorothiazide 1
ramipril 1
REMODULIN 4 PA
reserpine 1
SODIUM EDECRIN 2
spironolactone 1
spironolactone/hydrochlorothiazi
de
1
taztia xt 1
TEKAMLO 2
TEKTURNA 2
TEKTURNA HCT 2
terazosin hcl 1
timolol maleate 1
torsemide tabs 1
trandolapril 1
triamterene/hydrochlorothiazide 1
TWYNSTA 2
VALTURNA 2
verapamil 1
verapamil er 1
CARDIAC GLYCOSIDES
digoxin 1
LANOXIN 2
COAGULATION THERAPY
AGGRENOX 2
ARIXTRA 2
cilostazol 1
CYKLOKAPRON 2
EFFIENT 2
Drug
Name
Drug
Tier
Require-ments/
Limits
enoxaparin sodium inj
30mg/0.3ml, 40mg/0.4ml,
60mg/0.6ml, 80mg/0.8ml
1
enoxaparin sodium inj 100mg/ml,
120mg/0.8ml, 150mg/ml
4
FRAGMIN 2
HEPARIN SODIUM INJ
2000UNIT/ML
2
heparin sodium inj 10000unit/ml,
1000unit/ml, 20000unit/ml,
5000unit/ml
1
heparin sodium/d5w inj 5%;
40unit/ml
1
HEPARIN SODIUM/NACL
0.45%
2
heparin sodium/sodium chloride
0.9% premix
1
jantoven 1
LOVENOX INJ 300MG/3ML 2
pentopak 1
pentoxifylline er 1
PLAVIX 2
PRADAXA 2
PROMACTA 4 LA
ticlopidine hcl 1
warfarin 1
LIPID/CHOLESTEROL LOWERING
AGENTS
CADUET 2
cholestyramine light pack 1
colestipol 1
fenofibrate 1
fenofibrate micronized 1
gemfibrozil 1
LIPITOR 2
lovastatin 1
LOVAZA 2
NIASPAN 2
pravastatin 1
prevalite powd 1
simvastatin 1
TRICOR 2
TRILIPIX 2
13
Drug
Name
Drug
Tier
Require-ments/
Limits
WELCHOL 2
ZETIA 2
MISCELLANEOUS CARDIOVASCULAR
AGENTS
RANEXA 2
NITRATES
isosorbide dinitrate 1
isosorbide dinitrate er 1
isosorbide mononitrate 1
isosorbide mononitrate er 1
nitro-bid 1
NITRO-DUR PT24 0.3MG/HR,
0.8MG/HR
2
nitroglycerin inj 1 B/D PA
nitroglycerin pt24 1
nitroglycerin transdermal pt24
0.1mg/hr
1
NITROLINGUAL PUMPSPRAY 2
NITROSTAT 2
DERMATOLOGICALS/TOPICAL
THERAPY
ANTIPSORIATIC / ANTISEBORRHEIC
calcipotriene 1
selenium sulfide lotn 2.5% 1
SORIATANE 2
BURN THERAPY
silver sulfadiazine 1
ssd 1
thermazene 1
MISCELLANEOUS DERMATOLOGICALS
8-MOP 2
ammonium lactate 1
CARAC 2
CARMOL-HC 2
CONDYLOX GEL 2
ELIDEL 3
FLUOROPLEX 2
fluorouracil crea 1
fluorouracil external soln 1
imiquimod 1
laclotion 1
Drug
Name
Drug
Tier
Require-ments/
Limits
OXSORALEN ULTRA 4
PANRETIN 2
podofilox 1
PROTOPIC 3
REGRANEX 2
SOLARAZE 2
UVADEX 3
VEREGEN 3
ZONALON 2
THERAPY FOR ACNE
adapalene 1
amnesteem 1
avita crea 1
AZELEX 2
claravis caps 10mg, 20mg, 40mg 1
claravis caps 30mg 4
clindamycin phosphate external
soln
1
clindamycin phosphate foam 1
clindamycin phosphate gel 1
clindamycin phosphate lotn 1
clindamycin phosphate swab 1
clindamycin/benzoyl peroxide 1
DIFFERIN LOTN 2
ery 1
erythromycin / benzoyl peroxide 1
erythromycin external soln 1
erythromycin gel 1
FINACEA 2
METROGEL 2
metronidazole 1
sotret 1
TAZORAC 2
tretinoin 1
TOPICAL ANESTHETICS
lidocaine / prilocaine crea 1
lidocaine external soln 1
lidocaine gel 1
lidocaine inj 0.5%, 1% 1
lidocaine oint 1
lidocaine viscous 1
14
Drug
Name
Drug
Tier
Require-ments/
Limits
LIDODERM 2 QL(270 per
90 days)
TOPICAL ANTIBACTERIALS
ALTABAX 2
BACTROBAN CREA 2
gentamicin sulfate crea 1
gentamicin sulfate oint 0.1% 1
mupirocin 1
PHISOHEX 2
sodium sulfacetamide 1
SULFAMYLON 2
TOPICAL ANTIFUNGALS
ciclopirox 1
ciclopirox nail lacquer 1
ciclopirox olamine 1
clotrimazole / betamethasone 1
clotrimazole external crea 1
clotrimazole external soln 1
econazole nitrate 1
ketoconazole 1
NAFTIN 2
nyamyc 1
nystatin / triamcinolone 1
nystatin crea 1
nystatin external powd 1
nystatin oint 1
nystop 1
pedi-dri 1
TOPICAL ANTIVIRALS
DENAVIR 2
ZOVIRAX CREA 3
ZOVIRAX OINT 3
TOPICAL CORTICOSTEROIDS
ala cort 1
alclometasone dipropionate 1
amcinonide 1
augmented betamethasone
dipropionate crea
1
augmented betamethasone
dipropionate lotn
1
augmented betamethasone
dipropionate oint
1
Drug
Name
Drug
Tier
Require-ments/
Limits
betamethasone dipropionate 1
betamethasone valerate 1
CAPEX 2
clobetasol propionate e 1
clobetasol propionate external
soln
1
clobetasol propionate gel 1
clobetasol propionate oint 1
CLOBEX LOTN 2
CLOBEX SHAM 2
CORDRAN TAPE 2
DERMA-SMOOTHE / FS BODY
OIL
2
desonide 1
desoximetasone 1
diflorasone diacetate 1
fluocinolone acetonide 1
fluocinonide emollient base 1
fluocinonide external soln 1
fluocinonide gel 1
fluocinonide oint 1
fluticasone propionate crea 1
fluticasone propionate oint 1
halobetasol propionate 1
hydrocortisone butyrate 1
hydrocortisone crea 1%, 2.5% 1
hydrocortisone lotn 2.5% 1
hydrocortisone oint 1%, 2.5% 1
hydrocortisone valerate 1
LOCOID LOTN 2
LUXIQ 2
mometasone furoate 1
PANDEL 2
prednicarbate 1
triamcinolone acetonide crea 1
triamcinolone acetonide lotn 1
triamcinolone acetonide oint 1
triderm 1
TOPICAL ENZYMES
SANTYL 2
TOPICAL SCABICIDES / PEDICULICIDES
acticin 1
15
Drug
Name
Drug
Tier
Require-ments/
Limits
EURAX 2
LINDANE 2
malathion 1
permethrin crea 1
ULESFIA 3
DIAGNOSTICS / MISCELLANEOUS
AGENTS
MISCELLANEOUS AGENTS
ACTONEL TABS 30MG 3
ADAGEN 4 LA
alendronate sodium tabs 40mg 1 QL(90 per
90 days)
anagrelide hydrochloride 1
ANTABUSE TABS 250MG 2
ARALAST NP INJ 400MG 4 LA
BUPHENYL 2
CAMPRAL 2
CHEMET 2
CLINIMIX / DEXTROSE 2
DEXTROSE 10%/NACL 0.45% 2
dextrose 10% flex container 1
DEXTROSE 10%/NACL 0.2% 2
dextrose 2.5%/sodium chloride
0.45%
1
dextrose 5% 1
dextrose 5%/nacl 0.2% 1
dextrose 5%/nacl 0.225% 1
DEXTROSE 5%/NACL 0.33% 2
dextrose 5%/nacl 0.45% 1
dextrose 5%/nacl 0.9% 1
etidronate disodium 1
EVOXAC 3
EXJADE TBSO 125MG 2 LA
EXJADE TBSO 250MG, 500MG 4 LA
FOSRENOL 2
INCRELEX 4 LA
kionex powd 1
levocarnitine oral soln 1 B/D PA
levocarnitine tabs 1 B/D PA
midodrine 1
ORFADIN 4 LA
Drug
Name
Drug
Tier
Require-ments/
Limits
pilocarpine hcl tabs 1
PROLASTIN INJ 500MG 4 LA
PROLASTIN-C 4 LA
RENAGEL 2
RENVELA 2
RILUTEK 4
SKELID 3
sodium chloride 0.9% 1
sodium chloride inj 0.9% 1
sodium polystyrene sulfonate 1
SYPRINE 2
SMOKING DETERRENTS
BUPROBAN 5 QL(180 per
90 days)
CHANTIX TABS 5
CHANTIX TABS 0.5MG, 1MG 5 QL(336 per
365 days)
NICOTROL INHALER 5 QL(2688
per 365
days)
NICOTROL NASAL 5 QL(7200
per 365
days)
EAR, NOSE / THROAT
MEDICATIONS
MISCELLANEOUS AGENTS
ASTEPRO 2
azelastine hcl 1
BACTROBAN NASAL 2
chlorhexidine gluconate oral
rinse
1
ipratropium bromide nasal soln 1
periogard 1
triamcinolone in orabase 1
TYZINE 2
TYZINE PEDIATRIC NASAL
DROPS
2
MISCELLANEOUS OTIC
PREPARATIONS
acetasol hc 1
acetic acid 1
DERMOTIC 2
hydrocortisone/acetic acid 1
16
Drug
Name
Drug
Tier
Require-ments/
Limits
ofloxacin 1
OTIC STEROID / ANTIBIOTIC
CIPRO HC 3
CIPRODEX 2
COLY-MYCIN S 2
CORTISPORIN-TC 2
cortomycin 1
neomycin/polymyxin/hc 1
neomycin/polymyxin/hydrocortiso
ne otic susp
1
ENDOCRINE/DIABETES
ADRENAL HORMONES
a-hydrocort 1
a-methapred 1 B/D PA
cortisone acetate 1
DEPO-MEDROL 2 B/D PA
dexamethasone elix 1
dexamethasone inj 4mg/ml 1
DEXAMETHASONE
INTENSOL
2
DEXAMETHASONE TABS
1MG, 2MG
2
dexamethasone tabs 0.5mg,
0.75mg, 1.5mg, 4mg, 6mg
1
fludrocortisone acetate 1
hydrocortisone tabs 1
methylprednisolone 1 B/D PA
methylprednisolone acetate 1 B/D PA
methylprednisolone
sodiumsuccinate inj 125mg, 40mg
1 B/D PA
METHYLPREDNISOLONE
SODIUMSUCCINATE INJ
1000MG
2 B/D PA
prednisolone sodium phosphate
oral soln
1 B/D PA
prednisone 1 B/D PA
PREDNISONE INTENSOL 2 B/D PA
SOLU-CORTEF INJ 100MG,
250MG
2
SOLU-MEDROL INJ 125MG,
2GM, 40MG, 500MG
2 B/D PA
ANTITHYROID AGENTS
methimazole 1
Drug
Name
Drug
Tier
Require-ments/
Limits
propylthiouracil 1
DIABETES THERAPY
acarbose 1
ACTOPLUS MET 2
ACTOS 2
ALCOHOL PREPS 2
APIDRA 2 QL(120 per
90 days)
APIDRA SOLOSTAR 2 QL(120 per
90 days)
AVANDAMET 2
AVANDARYL 2
AVANDIA 2
BD INSULIN SYRINGE
SAFETYGLIDE/1ML/29G X
1/2"
2 QL(600 per
90 days)
BD INSULIN SYRINGE
ULTRAFINE/0.3ML/31G X
5/16"
2 QL(600 per
90 days)
BD INSULIN SYRINGE
ULTRAFINE/0.5ML/30G X 1/2"
2 QL(600 per
90 days)
BD INSULIN SYRINGE
ULTRAFINE/1ML/31G X 5/16"
2 QL(600 per
90 days)
BD PEN
NEEDLE/ULTRAFINE/29G X
12.7MM
2 QL(600 per
90 days)
BYETTA 3 QL(7.2 per
90 days)
DUETACT 2
GAUZE PADS 2"X2" 2
glimepiride 1
glipizide 1
glipizide / metformin 1
glipizide er 1
GLUCAGEN HYPOKIT 2
GLUCAGON EMERGENCY
KIT
2
glyburide 1
glyburide / metformin 1
glyburide micronized 1
glycron tabs 1.5mg 1
GLYCRON TABS 4.5MG 2
HUMALOG 2 QL(120 per
90 days)
17
Drug
Name
Drug
Tier
Require-ments/
Limits
HUMALOG KWIKPEN 2 QL(120 per
90 days)
HUMALOG MIX 50/50 2 QL(120 per
90 days)
HUMALOG MIX 50/50
KWIKPEN
2 QL(135 per
90 days)
HUMALOG MIX 75/25 2 QL(120 per
90 days)
HUMALOG MIX 75/25
KWIKPEN
2 QL(135 per
90 days)
HUMULIN 70/30 2 QL(120 per
90 days)
HUMULIN 70/30 PEN 2 QL(135 per
90 days)
HUMULIN N 2 QL(120 per
90 days)
HUMULIN N U-100 PEN 2 QL(135 per
90 days)
HUMULIN R 2 QL(120 per
90 days)
HUMULIN R U-500
(CONCENTRATED)
2
JANUMET 2
JANUVIA 2
KOMBIGLYZE XR 2
LANTUS 2 QL(120 per
90 days)
LANTUS SOLOSTAR 2 QL(120 per
90 days)
LEVEMIR 2 QL(120 per
90 days)
LEVEMIR FLEXPEN 2 QL(135 per
90 days)
metformin hcl 1
metformin hcl er 1
nateglinide 1
NOVOLIN 70/30 2 QL(120 per
90 days)
NOVOLIN N 2 QL(120 per
90 days)
NOVOLIN R 2 QL(120 per
90 days)
NOVOLOG 2 QL(120 per
90 days)
NOVOLOG FLEXPEN 2 QL(135 per
90 days)
Drug
Name
Drug
Tier
Require-ments/
Limits
NOVOLOG MIX 70/30 2 QL(120 per
90 days)
NOVOLOG MIX 70/30
PREFILLED FLEXPEN
2 QL(135 per
90 days)
ONGLYZA 2
PRANDIN 2
PROGLYCEM 2
SYMLIN 3 QL(60 per
90 days)
SYMLINPEN 120 3 QL(33 per
90 days)
SYMLINPEN 60 3 QL(33 per
90 days)
tolazamide 1
tolbutamide 1
MISCELLANEOUS HORMONES
ALDURAZYME 4 B/D LA PA
ANADROL-50 3 PA
ANDRODERM 2 PA QL(180
per 90 days)
ANDROGEL GEL 50MG/5GM 2 PA QL(900
per 90 days)
ANDROGEL PUMP GEL 1.62% 2 PA
ANDROID 2 PA
androxy 1 PA
cabergoline 1
calcitonin-salmon 1 QL(12 per
90 days)
calcitriol 1 B/D PA
CEREZYME INJ 200UNIT 4 B/D LA PA
danazol 1
desmopressin acetate 1
FABRAZYME INJ 35MG 4 B/D LA PA
fortical 1 QL(12 per
90 days)
HECTOROL 2
KUVAN 4 LA
NAGLAZYME 4 LA
oxandrolone tabs 10mg 4
oxandrolone tabs 2.5mg 1
SAMSCA 4
SENSIPAR TABS 60MG, 90MG 4
SENSIPAR TABS 30MG 2
18
Drug
Name
Drug
Tier
Require-ments/
Limits
SOMAVERT 2 PA QL(90
per 90 days)
STIMATE 2
SYNAREL 3
testosterone cypionate inj
100mg/ml
1 PA
testosterone enanthate 1 PA
ZAVESCA 2 LA
ZEMPLAR 2 B/D PA
ZOMETA 4
THYROID HORMONES
levothyroxine tabs 1
levoxyl 1
liothyronine sodium tabs 1
SYNTHROID 2
unithroid tabs 100mcg, 112mcg,
125mcg, 150mcg, 175mcg,
200mcg, 25mcg, 300mcg, 50mcg,
75mcg, 88mcg
1
GASTROENTEROLOGY
ANTIDIARRHEALS / ANTISPASMODICS
atropine sulfate inj 0.1mg/ml 1
ATROPINE SULFATE INJ
0.05MG/ML
2
dicyclomine hcl 1
glycopyrrolate 1
loperamide hcl caps 1
propantheline bromide 1
MISCELLANEOUS GASTROINTESTINAL
AGENTS
AMITIZA 2
ASACOL 2
ASACOL HD 2
balsalazide 1
CANASA 2
CIMZIA 4 PA QL(6
per 28 days)
compro 1
constulose 1
CORTIFOAM 2
Drug
Name
Drug
Tier
Require-ments/
Limits
CREON CPEP 120000UNIT;
24000UNIT; 76000UNIT,
30000UNIT; 6000UNIT;
19000UNIT, 60000UNIT;
12000UNIT; 38000UNIT
2
CYSTADANE 2
DIPENTUM 3
dronabinol 1 B/D PA
EMEND CAPS 40MG 2 B/D PA
QL(3 per 90
days)
EMEND CAPS 125MG 2 B/D PA
QL(6 per 90
days)
EMEND CAPS 2 B/D PA
QL(18 per
90 days)
EMEND CAPS 80MG 2 B/D PA
QL(24 per
90 days)
ENTOCORT EC 2
enulose 1
GASTROCROM 2
gavilyte-c 1
gavilyte-g 1
gavilyte-n/flavor pack 1
granisetron inj 0.1mg/ml, 1mg/ml 1
granisetron tabs 1 B/D PA
hydrocortisone enem 1
lactulose 1
LOTRONEX 2
meclizine hcl 1
mesalamine enem 1
metoclopramide 1
ondansetron hcl inj 4mg/2ml 1
ondansetron hcl oral soln 1 B/D PA
ondansetron hcl tabs 24mg 1 B/D PA
QL(21 per
90 days)
ondansetron hcl tabs 4mg, 8mg 1 B/D PA
QL(135 per
90 days)
ondansetron odt 1 B/D PA
QL(135 per
90 days)
19
Drug
Name
Drug
Tier
Require-ments/
Limits
PENTASA 2
polyethylene glycol 3350 powd 1
prochlorperazine 1
prochlorperazine edisylate 1
prochlorperazine maleate 1
procto-pak 1
proctosol hc 1
proctozone-hc 1
RELISTOR 2
REMICADE 4 PA
SANCUSO 2 QL(6 per 90
days)
sulfasalazine tabs 1
sulfazine ec 1
TRANSDERM-SCOP 3
trilyte 1
ursodiol 1
ZENPEP 2
ZUPLENZ 2 B/D PA
QL(135 per
90 days)
ULCER THERAPY
CARAFATE SUSP 2
famotidine inj 1
famotidine premixed 1
famotidine susr 1
famotidine tabs 20mg, 40mg 1
lansoprazole 1
lansoprazole odt 1
misoprostol 1
NEXIUM I.V. 2
nizatidine 1
omeprazole cpdr 1
pantoprazole 1
PREVPAC 3
PYLERA 2
ranitidine hcl caps 1
ranitidine hcl syrp 1
ranitidine hcl tabs 1
sucralfate 1
ZANTAC INJ 50MG/50ML;
0.45%
2
Drug
Name
Drug
Tier
Require-ments/
Limits
IMMUNOLOGY, VACCINES /
BIOTECHNOLOGY
BIOTECHNOLOGY DRUGS
ACTIMMUNE 4 LA
ARANESP INJ 100MCG/0.5ML,
100MCG/ML, 150MCG/0.3ML,
200MCG/0.4ML, 200MCG/ML,
25MCG/0.42ML, 25MCG/ML,
300MCG/0.6ML, 300MCG/ML,
40MCG/0.4ML, 40MCG/ML,
500MCG/ML, 60MCG/0.3ML,
60MCG/ML
2 PA
ARCALYST 4 LA
AVONEX 4 PA QL(12
per 90 days)
BETASERON 4 PA QL(45
per 90 days)
EPOGEN 3 PA
INTRON-A INJ 3MU/0.2ML,
6000000UNIT/ML
2
INTRON-A INJ 10MU/0.2ML,
5MU/0.2ML
4
INTRON-A WITH DILUENT
INJ 10MU
4
LEUKINE 4 PA
MOZOBIL 4
NEULASTA 3 PA
NEUMEGA 4 PA
NEUPOGEN INJ
300MCG/0.5ML,
480MCG/0.8ML,
480MCG/1.6ML
4 PA
NORDITROPIN FLEXPRO 4 PA
NORDITROPIN NORDIFLEX
PEN
4 PA
omnitrope inj 5mg/1.5ml 1 PA
PEG-INTRON INJ
50MCG/0.5ML
4
PEG-INTRON REDIPEN 4
PEGASYS 4
PROCRIT 2 PA
PROLEUKIN 4
REBIF 4 PA QL(18
per 90 days)
REBIF TITRATION PACK 4 PA
20
Drug
Name
Drug
Tier
Require-ments/
Limits
TEV-TROPIN 2 PA
VACCINES / MISCELLANEOUS
IMMUNOLOGICALS
ACTHIB 2
ADACEL 2
BOOSTRIX 2
CERVARIX 2
COMVAX 2
DAPTACEL 2
DECAVAC 2
DIPHTHERIA/TETANUS
TOXOID PEDIATRIC
2
ENGERIX-B 2 B/D PA
GARDASIL 2
HAVRIX 2
HIZENTRA INJ 1GM/5ML 4 PA
IMOVAX RABIES (H.D.C.V.) 2
INFANRIX 2
IPOL INACTIVATED IPV 2
IXIARO 2
JE-VAX 2
M-M-R II W/DILUENT 10
DOSE
2
MENACTRA 2
MENOMUNE-A/C/Y/W-135 2
MENVEO 2
PEDVAX HIB 2
PRIVIGEN INJ 20GM/200ML 4 PA
PROQUAD 2
RABAVERT 2
RECOMBIVAX HB INJ
10MCG/ML, 40MCG/ML
2 B/D PA
ROTATEQ 2
TETANUS / DIPHTHERIA
TOXOIDS-ADSORBED ADULT
2
TETANUS TOXOID
ADSORBED
2
THYMOGLOBULIN 2
TRIPEDIA 2
TWINRIX 2 B/D PA
TYPHIM VI 2
VAQTA 2
VARIVAX 2
Drug
Name
Drug
Tier
Require-ments/
Limits
VIVAGLOBIN 4 PA
YF-VAX 2
ZOSTAVAX 2
MUSCULOSKELETAL /
RHEUMATOLOGY
GOUT THERAPY
allopurinol 1
COLCRYS 2
probenecid 1
probenecid / colchicine 1
ULORIC 2
OSTEOPOROSIS THERAPY
alendronate sodium tabs 35mg,
70mg
1 QL(12 per
90 days)
alendronate sodium tabs 10mg,
5mg
1 QL(90 per
90 days)
BONIVA INJ 2
BONIVA TABS 3 B/D PA
QL(3 per 90
days)
EVISTA 2
FORTEO 2 QL(7.2 per
90 days)
OTHER RHEUMATOLOGICALS
CUPRIMINE 2
DEPEN TITRATABS 2
ENBREL 4 PA QL(600
per 90 days)
HUMIRA INJ 20MG/0.4ML 4 PA QL(2.4
per 90 days)
HUMIRA INJ 40MG/0.8ML 4 PA QL(4.8
per 90 days)
HUMIRA PEN-CROHNS
DISEASE STARTER
4 PA
leflunomide 1 QL(90 per
90 days)
RIDAURA 3
SAVELLA 2
SAVELLA TITRATION PACK 2
SIMPONI 4 PA QL(1
per 30 days)
OBSTETRICS / GYNECOLOGY
ESTROGENS / PROGESTINS
21
Drug
Name
Drug
Tier
Require-ments/
Limits
ALORA 2 QL(24 per
90 days)
camila 1
CLIMARA PRO 2 QL(12 per
90 days)
COMBIPATCH 2 QL(24 per
90 days)
CRINONE 2
DEPO-PROVERA 2
DEPO-SUBQ PROVERA 104 3
DIVIGEL GEL 1MG/GM 2 QL(90 per
90 days)
errin 1
ESTRADERM 2 QL(24 per
90 days)
estradiol / norethindrone acetate
tabs 1mg; 0.5mg
1
estradiol ptwk 1 QL(12 per
90 days)
estradiol tabs 1
ESTRING 3
estropipate 1
jinteli 1
jolivette 1
medroxyprogesterone acetate 1
MENOSTAR 3 QL(12 per
90 days)
nora-be 1
norethindrone tabs 5mg 1
ortho-est 1
PREFEST 3
PREMARIN TABS 2
PREMARIN W/APPLICATOR 2
PREMPHASE 2
PREMPRO 2
PROMETRIUM 2
VAGIFEM 2
VIVELLE-DOT 2 QL(24 per
90 days)
MISCELLANEOUS OB/GYN
CLEOCIN SUPP 2
clindamycin phosphate crea 1
GYNAZOLE-1 2
LYSTEDA 3
Drug
Name
Drug
Tier
Require-ments/
Limits
metronidazole vaginal 1
miconazole 3 1
NUVARING 3
ORTHO EVRA 3
terconazole 1
vandazole 1
zazole crea 0.4% 1
ORAL CONTRACEPTIVES / RELATED
AGENTS
apri 1
aranelle 1
aviane 1
balziva 1
cesia 1
cryselle-28 1
cyclafem 1/35 1
cyclafem 7/7/7 1
ELLA 2
enpresse-28 1
gianvi 1
junel 1
junel fe 1.5/30 1
junel fe 1/20 1
kariva 1
kelnor 1/35 1
leena 1
lessina-28 1
levora 1
low-ogestrel 1
lutera 1
microgestin 1.5/30 1
microgestin 1/20 1
microgestin fe 1
microgestin fe 1.5/30 1
mononessa 1
necon 0.5/35-28 1
necon 1/35-28 1
necon 10/11-28 1
necon 7/7/7 1
next choice 1
nortrel 0.5/35 (28) 1
22
Drug
Name
Drug
Tier
Require-ments/
Limits
nortrel 1/35 (21) 1
nortrel 1/35 (28) 1
nortrel 7/7/7 1
ocella 1
ogestrel 1
portia-28 1
previfem 1
quasense 1
reclipsen 1
solia 1
sprintec 28 1
sronyx 1
tri-legest fe 1
tri-previfem 1
tri-sprintec 1
trinessa 1
trivora-28 1
velivet 1
zeosa 1
zovia 1/35e 1
zovia 1/50e 1
OXYTOCICS
METHERGINE TABS 2
OPHTHALMOLOGY
ANTIBIOTICS
ak-tob 1
AZASITE 2
bacitracin / polymyxin b 1
bacitracin ophthalmic oint 1
BESIVANCE 2
CILOXAN OINT 2
ciprofloxacin ophthalmic soln 1
erythromycin oint 1
gentak 1
gentamicin sulfate ophthalmic
soln
1
gentasol 1
levofloxacin ophthalmic soln 1
MOXEZA 2
NATACYN 2
neomycin/bacitracin/polymyxin 1
Drug
Name
Drug
Tier
Require-ments/
Limits
neomycin/polymyxin/gramicidin 1
ofloxacin 1
romycin 1
tobramycin ophthalmic soln 1
tobrasol 1
TOBREX OINT 2
trimethoprim sulfate/polymyxin b
sulfate
1
VIGAMOX 2
ZYMAR 2
ZYMAXID 2
ANTIVIRALS
trifluridine 1
ZIRGAN 3
BETA-BLOCKERS
betaxolol hcl 1
BETOPTIC-S 2
carteolol hcl 1
ISTALOL 2
levobunolol hcl 1
metipranolol 1
timolol maleate 1
timolol maleate ophthalmic gel
forming
1
TIMOPTIC OCUDOSE 2
CYCLOPLEGIC MYDRIATICS
tropicamide 1
DIRECT ACTING MIOTICS
PILOPINE HS 2
MISCELLANEOUS OPHTHALMOLOGICS
ALOCRIL 3
azelastine hcl 1
BEPREVE 2
cromolyn sodium ophthalmic soln 1
epinastine hcl 1
LACRISERT 2
PATADAY 2
PATANOL 2
RESTASIS 2 QL(192 per
90 days)
23
Drug
Name
Drug
Tier
Require-ments/
Limits
NON-STEROIDAL ANTI-INFLAMMATORY
AGENTS
ACUVAIL 2
BROMDAY 2
bromfenac 1
diclofenac sodium 1
flurbiprofen sodium 1
ketorolac tromethamine
ophthalmic soln
1
NEVANAC 2
ORAL DRUGS FOR GLAUCOMA
acetazolamide 1
acetazolamide sodium 1
methazolamide 1
OTHER GLAUCOMA DRUGS
AZOPT 2
COMBIGAN 2
dorzolamide hcl 1
dorzolamide hcl/timolol maleate 1
latanoprost 1
LUMIGAN 2
TRAVATAN Z 2
STEROID-ANTIBIOTIC COMBINATIONS
neomycin/polymyxin/bacitracin/h
ydrocortisone
1
neomycin/polymyxin/dexamethaso
ne
1
neomycin/polymyxin/hydrocortiso
ne ophthalmic susp
1
poly-dex 1
TOBRADEX OINT 2
TOBRADEX ST 2
tobramycin/dexamethasone 1
ZYLET 2
STEROID-SULFONAMIDE
COMBINATIONS
sulfacetamide sodium /
prednisolone sodium phospha
1
STEROIDS
ALREX 2
dexamethasone ophthalmic soln 1
DUREZOL 2
Drug
Name
Drug
Tier
Require-ments/
Limits
fluorometholone 1
FML 2
FML FORTE 2
LOTEMAX 2
prednisolone acetate 1
prednisolone sodium phosphate
ophthalmic soln
1
SULFONAMIDES
BLEPH-10 2
sodium sulfacetamide 1
SYMPATHOMIMETICS
ALPHAGAN P 2
apraclonidine 1
brimonidine tartrate ophthalmic
soln 0.2%
1
IOPIDINE OPHTHALMIC
SOLN 1%
3
VASOCONSTRICTOR DECONGESTANTS
ak-con 1
RENAL / GENITOURINARY
IMPOTENCE AGENTS
CAVERJECT 2 ED PA
QL(6 per 30
days)
CAVERJECT IMPULSE 2 ED PA
QL(6 per 30
days)
CIALIS 3 ED PA
QL(6 per 30
days)
LEVITRA 2 ED PA
QL(6 per 30
days)
MUSE 2 ED PA
QL(6 per 30
days)
VIAGRA 2 ED PA
QL(6 per 30
days)
RESPIRATORY AND ALLERGY
ANTIHISTAMINE / ANTIALLERGENIC
AGENTS
carbinoxamine maleate 1
cetirizine hcl syrp 1
24
Drug
Name
Drug
Tier
Require-ments/
Limits
CLARINEX 3
CLARINEX REDITABS 3
CLARINEX-D 12 HOUR 3
CLARINEX-D 24 HOUR 3
clemastine fumarate syrp 1
clemastine fumarate tabs 2.68mg 1
epinephrine hcl inj 0.1mg/ml 1
EPIPEN 2
EPIPEN-JR 2
fexofenadine hcl 1
hydroxyzine hcl 1
levocetirizine dihydrochloride 1
palgic liqd 1
phenadoz 1
promethazine hcl 1
promethegan supp 25mg, 50mg 1
TWINJECT 2
PULMONARY AGENTS
acetylcysteine 1 B/D PA
ADVAIR DISKUS 2
ADVAIR HFA 2
albuterol sulfate er 1
albuterol sulfate nebu 1 B/D PA
albuterol sulfate syrp 1
albuterol sulfate tabs 1
aminophylline 1
ASMANEX 120 METERED
DOSES
2
ASMANEX 14 METERED
DOSES
2
ASMANEX 30 METERED
DOSES
2
ASMANEX 60 METERED
DOSES
2
ATROVENT HFA 2
budesonide susp 1 B/D PA
COMBIVENT 2
cromolyn sodium nebu 1 B/D PA
DULERA 3
ELIXOPHYLLIN 3
FLOVENT DISKUS 2
FLOVENT HFA 2
Drug
Name
Drug
Tier
Require-ments/
Limits
flunisolide nasal soln 0.025% 1 QL(200 per
90 days)
fluticasone propionate susp 1 QL(48 per
90 days)
FORADIL AEROLIZER 2
ipratropium bromide inhalation
soln
1 B/D PA
ipratropium bromide/albuterol
sulfate
1 B/D PA
LETAIRIS 4 LA
metaproterenol sulfate 1
PERFOROMIST 2 B/D PA
PROAIR HFA 2
PROVENTIL HFA 3
PULMICORT FLEXHALER 2
PULMICORT SUSP 1MG/2ML 2 B/D PA
PULMOZYME 4 B/D PA
QVAR 2
REVATIO 4
SEREVENT DISKUS 2
SINGULAIR 2
SPIRIVA HANDIHALER 2
SYMBICORT 2
terbutaline sulfate 1
THEO-24 3
theochron tb12 100mg, 300mg 1
theophylline er 1
TRACLEER 4 LA
VENTOLIN HFA 2
XOLAIR 4 PA QL(7.2
per 30 days)
zafirlukast 1
ZYFLO CR 3
UROLOGICALS
ANTICHOLINERGICS /
ANTISPASMODICS
DETROL 2
DETROL LA 2
ENABLEX 2
flavoxate hcl 1
GELNIQUE 2
oxybutynin 1
25
Drug
Name
Drug
Tier
Require-ments/
Limits
oxybutynin er 1
OXYTROL 2 QL(48 per
90 days)
TOVIAZ 2
trospium chloride 1
VESICARE 2
BENIGN PROSTATIC
HYPERPLASIA(BPH) THERAPY
AVODART 2
finasteride 1
JALYN 2
RAPAFLO 2
tamsulosin hcl 1
UROXATRAL 2
CHOLINERGIC STIMULANTS
bethanechol chloride 1
MISCELLANEOUS UROLOGICALS
CYSTAGON 2 LA
ELMIRON 2
potassium citrate extended-release
1
VITAMINS, HEMATINICS /
ELECTROLYTES
ELECTROLYTES
calcium acetate 1
eliphos 1
K-TABS 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
Drug
Name
Drug
Tier
Require-ments/
Limits
MAGNESIUM SULFATE IN
D5W INJ 5%; 10MG/ML
2
MAGNESIUM SULFATE INJ 2
NORMOSOL 2
POTASSIUM CHLORIDE
0.075%/D5W/NACL 0.225%
2
POTASSIUM CHLORIDE 0.15%
/NACL 0.45% VIAFLEX
2
potassium chloride 0.15%
d5w/nacl 0.33%
1
potassium chloride 0.15%
d5w/nacl 0.45% viaflex
1
potassium chloride 0.15% nacl
0.9%
1
POTASSIUM CHLORIDE
0.15%/D5W
2
POTASSIUM CHLORIDE 0.22%
D5W/NACL 0.45%
2
potassium chloride 0.224%/d5w 1
POTASSIUM CHLORIDE 0.3%/
NACL 0.9%
2
potassium chloride 0.3%/d5w 1
potassium chloride er cpcr 1
potassium chloride er tbcr 10meq,
20meq
1
potassium chloride inj
10meq/100ml, 10meq/50ml,
2meq/ml
1
POTASSIUM CHLORIDE INJ
0.4MEQ/ML, 30MEQ/100ML
2
ringers injection 1
sodium bicarbonate inj 7.5%,
8.4%
1
sodium chloride 0.45% viaflex 1
sodium chloride inj 2.5meq/ml,
3%, 5%
1
MISCELLANEOUS NUTRITION
PRODUCTS
AMINOSYN 2
AMINOSYN II 2
AMINOSYN II M 2
AMINOSYN-HBC 2
AMINOSYN-HF 2
AMINOSYN-PF 2
AMINOSYN-PF 7% 2
26
Drug
Name
Drug
Tier
Require-ments/
Limits
CLINIMIX / DEXTROSE 2
CLINISOL SF 2
DEXTROSE 5%
/ELECTROLYTE #48 VIAFLEX
2
FREAMINE III 2
HEPATAMINE 2
HEPATASOL 2
INTRALIPID INJ 1.7%; 30% 2
intralipid inj 2.25%; 20% 1
IONOSOL 2
ISOLYTE 2
KCL 0.15%/D10W/NACL 0.2% 2
LIPOSYN III INJ 1.8%; 2.5%;
30%
2
NEPHRAMINE 2
NORMOSOL 2
PLASMA-LYTE 2
PREMASOL INJ 56MEQ/L;
320MG/100ML; 730MG/100ML;
190MG/100ML; 3MEQ/L;
20MG/100ML; 300MG/100ML;
220MG/100ML; 290MG/100ML;
490MG/100ML; 840MG/100ML;
490MG/100ML; 200MG/100ML;
290MG/100ML; 410MG/100ML;
230MG/100ML; 5MEQ/L;
15MG/100ML; 250MG/100ML;
120MG/100ML; 140MG/100ML;
470MG/100ML
2
premasol inj 52meq/l;
1760mg/100ml; 880mg/100ml;
34meq/l; 1760mg/100ml;
372mg/100ml; 406mg/100ml;
526mg/100ml; 492mg/100ml;
492mg/100ml; 526mg/100ml;
356mg/100ml; 356mg/100ml;
390mg/100ml; 34mg/100ml;
152mg/100ml
1
TRAVASOL 2
TROPHAMINE 2
VITAMINS / HEMATINICS
prenatal vitamins (generic) 1
sodium fluoride tabs 1
27
Index of Drugs
8
8-MOP................................................................. 13
A
ABILIFY ............................................................... 9
ABILIFY DISCMELT .......................................... 9
ABRAXANE......................................................... 4
acarbose .............................................................. 16
acebutolol ............................................................ 10
acetaminophen / codeine....................................... 8
acetaminophen/codeine #3.................................... 8
acetaminophen/codeine #4.................................... 8
acetasol hc........................................................... 15
acetazolamide...................................................... 23
acetazolamide sodium ......................................... 23
acetic acid ........................................................... 15
acetylcysteine ...................................................... 24
ACTHIB .............................................................. 20
acticin.................................................................. 14
ACTIMMUNE .................................................... 19
ACTONEL .......................................................... 15
ACTOPLUS MET............................................... 16
ACTOS................................................................ 16
ACUVAIL........................................................... 23
acyclovir ................................................................ 1
ADACEL............................................................. 20
ADAGEN ............................................................ 15
adapalene ............................................................ 13
adriamycin............................................................. 4
ADVAIR DISKUS.............................................. 24
ADVAIR HFA .................................................... 24
afeditab cr ........................................................... 10
AFINITOR ............................................................ 4
AGGRENOX ...................................................... 12
a-hydrocort.......................................................... 16
ak-con.................................................................. 23
ak-tob................................................................... 22
ala cort ................................................................ 14
ALBENZA ........................................................... 2
albuterol sulfate................................................... 24
albuterol sulfate er .............................................. 24
alclometasone dipropionate ................................ 14
ALCOHOL PREPS..............................................16
ALDURAZYME..................................................17
alendronate sodium........................................15, 20
ALIMTA ................................................................4
ALINIA..................................................................2
ALKERAN ............................................................4
allopurinol............................................................20
ALOCRIL ............................................................22
ALORA................................................................21
ALPHAGAN P ....................................................23
alprazolam .............................................................7
ALREX ................................................................23
ALTABAX ..........................................................14
amantadine.............................................................1
amcinonide...........................................................14
a-methapred .........................................................16
amifostine...............................................................4
amikacin sulfate .....................................................2
amiloride..............................................................10
amiloride/hydrochlorothiazide ............................10
aminophylline.......................................................24
AMINOSYN ........................................................25
AMINOSYN II ....................................................25
AMINOSYN II M................................................25
AMINOSYN-HBC ..............................................25
AMINOSYN-HF..................................................25
AMINOSYN-PF ..................................................25
AMINOSYN-PF 7%............................................25
amiodarone ..........................................................10
AMITIZA.............................................................18
amitriptyline...........................................................9
amlodipine............................................................11
amlodipine / benazepril........................................11
ammonium lactate................................................13
amnesteem............................................................13
amoxapine..............................................................9
amoxicillin..............................................................3
amoxicillin/clavulanate potassium.........................3
amoxicillin/clavulanate potassium er ....................3
amoxicillin/potassium clavulanate.........................3
amphotericin b .......................................................1
ampicillin ...............................................................3
28
ampicillin-sulbactam............................................. 3
AMTURNIDE..................................................... 11
ANADROL-50 .................................................... 17
anagrelide hydrochloride.................................... 15
anastrozole ............................................................ 4
ANCOBON ........................................................... 1
ANDRODERM ................................................... 17
ANDROGEL....................................................... 17
ANDROGEL PUMP ........................................... 17
ANDROID .......................................................... 17
androxy................................................................ 17
ANTABUSE........................................................ 15
APIDRA .............................................................. 16
APIDRA SOLOSTAR ........................................ 16
APOKYN .............................................................. 7
apraclonidine ...................................................... 23
apri ...................................................................... 21
APTIVUS .............................................................. 1
ARALAST NP .................................................... 15
aranelle................................................................ 21
ARANESP........................................................... 19
ARCALYST........................................................ 19
ARICEPT .............................................................. 7
ARICEPT ODT ..................................................... 7
ARIXTRA ........................................................... 12
ARRANON ........................................................... 4
ARTHROTEC 50.................................................. 9
ARTHROTEC 75.................................................. 9
ARZERRA ............................................................ 4
ASACOL............................................................. 18
ASACOL HD ...................................................... 18
ascomp/codeine ..................................................... 8
ASMANEX 120 METERED DOSES ................ 24
ASMANEX 14 METERED DOSES................... 24
ASMANEX 30 METERED DOSES................... 24
ASMANEX 60 METERED DOSES................... 24
ASTEPRO ........................................................... 15
atenolol................................................................ 11
atenolol / chlorthalidone ..................................... 11
ATRIPLA .............................................................. 1
atropine sulfate.................................................... 18
ATROVENT HFA .............................................. 24
augmented betamethasone dipropionate............. 14
AVANDAMET....................................................16
AVANDARYL ....................................................16
AVANDIA...........................................................16
AVASTIN ..............................................................4
AVELOX ...............................................................3
AVELOX ABC PACK ..........................................3
aviane...................................................................21
avita......................................................................13
AVODART ..........................................................25
AVONEX.............................................................19
AZACTAM............................................................2
AZACTAM IN ISO-OSMOTIC DEXTROSE......2
AZASITE.............................................................22
azathioprine ...........................................................4
azathioprine sodium...............................................4
azelastine hcl..................................................15, 22
AZELEX ..............................................................13
AZILECT...............................................................7
azithromycin...........................................................2
AZOPT.................................................................23
aztreonam...............................................................2
B
bacitracin .............................................................22
bacitracin / polymyxin b.......................................22
baclofen..................................................................8
BACTROBAN.....................................................14
BACTROBAN NASAL.......................................15
balsalazide ...........................................................18
balziva..................................................................21
BANZEL................................................................6
BARACLUDE .......................................................1
BD INSULIN SYRINGE
SAFETYGLIDE/1ML/29G X 1/2 ...................16
BD INSULIN SYRINGE
ULTRAFINE/0.3ML/31G X 5/16 ...................16
BD INSULIN SYRINGE
ULTRAFINE/0.5ML/30G X 1/2 .....................16
BD INSULIN SYRINGE ULTRAFINE/1ML/31G
X 5/16...............................................................16
BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM
..........................................................................16
benazepril.............................................................11
29
benazepril / hydrochlorothiazide ........................ 11
BENICAR ........................................................... 11
BENICAR HCT .................................................. 11
benztropine mesylate ............................................. 7
BEPREVE ........................................................... 22
BESIVANCE ...................................................... 22
betamethasone dipropionate ............................... 14
betamethasone valerate....................................... 14
BETASERON .....................................................19
betaxolol hcl .................................................. 11, 22
bethanechol chloride........................................... 25
BETOPTIC-S ...................................................... 22
bicalutamide.......................................................... 4
BICILLIN C-R ...................................................... 3
BICILLIN L-A ...................................................... 3
BICNU .................................................................. 4
BIDIL .................................................................. 11
BILTRICIDE......................................................... 2
bisoprolol fumarate............................................. 11
bisoprolol fumarate / hydrochlorothiazide ......... 11
bleomycin sulfate................................................... 4
BLEPH-10........................................................... 23
BONIVA ............................................................. 20
BOOSTRIX......................................................... 20
brimonidine tartrate ............................................ 23
BROMDAY ........................................................ 23
bromfenac............................................................ 23
bromocriptine mesylate ......................................... 7
budeprion sr .......................................................... 9
budeprion xl........................................................... 9
budesonide........................................................... 24
bumetanide .......................................................... 11
BUPHENYL........................................................ 15
BUPRENEX.......................................................... 8
buprenorphine hcl ................................................. 8
BUPROBAN ....................................................... 15
bupropion hcl ........................................................ 9
bupropion hcl sr .................................................... 9
buspirone hcl ......................................................... 9
BUSULFEX .......................................................... 4
butorphanol tartrate.............................................. 9
BYETTA ............................................................. 16
BYSTOLIC ......................................................... 11
C
cabergoline ..........................................................17
CADUET .............................................................12
calcipotriene ........................................................13
calcitonin-salmon.................................................17
calcitriol...............................................................17
calcium acetate ....................................................25
camila...................................................................21
CAMPATH............................................................4
CAMPRAL ..........................................................15
CANASA .............................................................18
CAPASTAT SULFATE ........................................2
CAPEX ................................................................14
captopril...............................................................11
captopril/hydrochlorothiazide .............................11
CARAC................................................................13
CARAFATE ........................................................19
carbamazepine .......................................................6
carbamazepine er...................................................6
CARBATROL .......................................................6
carbidopa / levodopa .............................................7
carbidopa/levodopa cr ...........................................7
carbidopa/levodopa odt .........................................7
carbidopa/levodopa sr ...........................................7
carbinoxamine maleate........................................23
carboplatin.............................................................4
CARMOL-HC......................................................13
carteolol hcl .........................................................22
cartia xt ................................................................11
carvedilol .............................................................11
CAVERJECT.......................................................23
CAVERJECT IMPULSE.....................................23
CAYSTON.............................................................2
CEENU ..................................................................4
cefaclor ..................................................................2
cefadroxil ...............................................................2
cefazolin .................................................................2
cefdinir ...................................................................2
cefepime .................................................................2
cefotaxime sodium..................................................2
cefoxitin sodium .....................................................2
cefpodoxime proxetil..............................................2
ceftazidime .............................................................2
30
ceftriaxone sodium ................................................ 2
cefuroxime axetil ................................................... 2
cefuroxime sodium................................................. 2
CELEBREX .......................................................... 9
CELLCEPT ........................................................... 4
CELLCEPT INTRAVENOUS.............................. 4
CELONTIN........................................................... 6
cephalexin.............................................................. 2
CEREZYME ....................................................... 17
CERVARIX ........................................................ 20
cesia..................................................................... 21
cetirizine hcl ........................................................ 23
CHANTIX........................................................... 15
CHEMET ............................................................ 15
chlordiazepoxide/amitriptyline.............................. 9
chlorhexidine gluconate oral rinse ..................... 15
chloroquine............................................................ 2
chlorothiazide...................................................... 11
chlorothiazide sodium ......................................... 11
chlorpromazine...................................................... 9
chlorthalidone ..................................................... 11
cholestyramine light ............................................ 12
CIALIS ................................................................ 23
ciclopirox............................................................. 14
ciclopirox nail lacquer ........................................ 14
ciclopirox olamine............................................... 14
cilostazol.............................................................. 12
CILOXAN........................................................... 22
CIMZIA............................................................... 18
CIPRO HC........................................................... 16
CIPRO I.V.-IN D5W............................................. 3
CIPRODEX......................................................... 16
ciprofloxacin.....................................................3, 22
cisplatin ................................................................. 4
citalopram ............................................................. 9
cladribine .............................................................. 4
claravis ................................................................ 13
CLARINEX......................................................... 24
CLARINEX REDITABS .................................... 24
CLARINEX-D 12 HOUR ................................... 24
CLARINEX-D 24 HOUR ................................... 24
clarithromycin ....................................................... 2
clarithromycin er................................................... 2
clemastine fumarate .............................................24
CLEOCIN ............................................................21
CLEOCIN GALAXY ............................................2
CLEOCIN PEDIATRIC GRANULES ..................2
CLIMARA PRO ..................................................21
clindamycin hcl ......................................................2
clindamycin phosphate...................................13, 21
clindamycin phosphate add-vantage......................2
clindamycin/benzoyl peroxide..............................13
CLINIMIX / DEXTROSE .............................15, 26
CLINISOL SF......................................................26
clobetasol propionate...........................................14
clobetasol propionate e........................................14
CLOBEX..............................................................14
CLOLAR................................................................4
clomipramine .........................................................9
clonazepam ............................................................6
clonidine...............................................................11
clotrimazole......................................................1, 14
clotrimazole / betamethasone ..............................14
clozapine ................................................................9
COARTEM............................................................2
codeine sulfate .......................................................8
COLCRYS ...........................................................20
colestipol ..............................................................12
colistimethate sodium.............................................2
COLY-MYCIN S.................................................16
COMBIGAN........................................................23
COMBIPATCH ...................................................21
COMBIVENT......................................................24
COMBIVIR............................................................1
compro .................................................................18
COMTAN ..............................................................7
COMVAX............................................................20
CONDYLOX .......................................................13
constulose.............................................................18
COPAXONE..........................................................7
CORDRAN TAPE...............................................14
COREG CR..........................................................11
CORTIFOAM ......................................................18
cortisone acetate ..................................................16
CORTISPORIN-TC.............................................16
cortomycin............................................................16
31
COSMEGEN......................................................... 4
CREON ............................................................... 18
CRINONE ........................................................... 21
CRIXIVAN ........................................................... 1
cromolyn sodium ........................................... 22, 24
cryselle-28 ........................................................... 21
CUBICIN .............................................................. 2
CUPRIMINE....................................................... 20
cyclafem 1/35....................................................... 21
cyclafem 7/7/7 ..................................................... 21
cyclobenzaprine hcl............................................... 8
cyclophosphamide ................................................. 4
cyclosporine .......................................................... 4
CYKLOKAPRON............................................... 12
CYMBALTA ........................................................ 9
CYSTADANE..................................................... 18
CYSTAGON ....................................................... 25
cytarabine.............................................................. 4
CYTARABINE AQUEOUS ................................. 4
D
dacarbazine ........................................................... 4
DACOGEN ........................................................... 5
danazol ................................................................ 17
dantrolene sodium................................................. 8
DAPSONE ............................................................ 2
DAPTACEL........................................................ 20
DARAPRIM.......................................................... 2
daunorubicin hcl ................................................... 5
DAUNOXOME..................................................... 5
DECAVAC.......................................................... 20
demeclocycline hcl ................................................ 4
DEMSER............................................................. 11
DENAVIR........................................................... 14
depade ................................................................... 9
DEPEN TITRATABS ......................................... 20
DEPO-MEDROL ................................................ 16
DEPO-PROVERA .............................................. 21
DEPO-SUBQ PROVERA 104............................ 21
DERMA-SMOOTHE / FS BODY OIL .............. 14
DERMOTIC ........................................................ 15
desipramine ........................................................... 9
desmopressin acetate........................................... 17
desonide ...............................................................14
desoximetasone ....................................................14
DETROL..............................................................24
DETROL LA .......................................................24
dexamethasone...............................................16, 23
DEXAMETHASONE INTENSOL .....................16
dexrazoxane ...........................................................4
dextroamphetamine sulfate ....................................9
dextroamphetamine sulfate er................................9
DEXTROSE 10%/NACL 0.45% ........................15
DEXTROSE 5% /ELECTROLYTE #48
VIAFLEX ........................................................26
dextrose 10% flex container.................................15
DEXTROSE 10%/NACL 0.2% ...........................15
dextrose 2.5%/sodium chloride 0.45% ................15
dextrose 5%..........................................................15
dextrose 5%/nacl 0.2% ........................................15
dextrose 5%/nacl 0.225%....................................15
DEXTROSE 5%/NACL 0.33%...........................15
dextrose 5%/nacl 0.45% ......................................15
dextrose 5%/nacl 0.9% ........................................15
diazepam ................................................................7
DIBENZYLINE...................................................11
diclofenac potassium..............................................9
diclofenac sodium ............................................9, 23
diclofenac sodium ec..............................................9
diclofenac sodium xr ..............................................9
dicloxacillin sodium...............................................3
dicyclomine hcl ....................................................18
didanosine..............................................................1
DIFFERIN............................................................13
diflorasone diacetate............................................14
DIFLUCAN IN NACL ..........................................1
diflunisal ................................................................9
digoxin..................................................................12
dihydroergotamine mesylate..................................7
DILANTIN ............................................................6
DILANTIN INFATABS........................................6
DILAUDID ............................................................8
DILAUDID-5.........................................................8
DILAUDID-HP......................................................8
dilt-cd ...................................................................11
diltiazem cd ..........................................................11
32
diltiazem hcl ........................................................ 11
diltiazem hcl er .................................................... 11
dilt-xr................................................................... 11
diltzac .................................................................. 11
DIOVAN ............................................................. 11
DIOVAN HCT .................................................... 11
DIPENTUM ........................................................ 18
DIPHTHERIA/TETANUS TOXOID PEDIATRIC
......................................................................... 20
disopyramide phosphate...................................... 10
divalproex sodium ................................................. 6
divalproex sodium er............................................. 6
DIVIGEL............................................................. 21
DOCETAXEL....................................................... 5
donepezil hcl.......................................................... 7
dorzolamide hcl ................................................... 23
dorzolamide hcl/timolol maleate......................... 23
doxazosin............................................................. 11
doxepin .................................................................. 9
DOXIL .................................................................. 5
doxorubicin hcl...................................................... 5
doxycycline hyclate ............................................... 4
doxycycline monohydrate...................................... 4
dronabinol ........................................................... 18
DROXIA ............................................................... 5
DUETACT .......................................................... 16
DULERA............................................................. 24
duramorph............................................................. 8
DUREZOL .......................................................... 23
E
e.e.s. 400................................................................ 2
E.E.S. GRANULES .............................................. 2
econazole nitrate ................................................. 14
EDECRIN............................................................ 11
EDURANT............................................................ 1
EFFIENT............................................................. 12
ELIDEL............................................................... 13
eliphos ................................................................. 25
ELITEK................................................................. 4
ELIXOPHYLLIN................................................ 24
ELLA................................................................... 21
ELLENCE ............................................................. 5
ELMIRON ...........................................................25
ELOXATIN ...........................................................5
ELSPAR.................................................................5
EMBEDA...............................................................8
EMCYT..................................................................5
EMEND ...............................................................18
EMSAM.................................................................9
EMTRIVA .............................................................1
ENABLEX...........................................................24
enalapril...............................................................11
enalapril / hydrochlorothiazide ...........................11
ENBREL..............................................................20
endocet ...................................................................8
ENGERIX-B ........................................................20
enoxaparin sodium...............................................12
enpresse-28 ..........................................................21
ENTOCORT EC ..................................................18
enulose .................................................................18
epinastine hcl .......................................................22
epinephrine hcl.....................................................24
EPIPEN ................................................................24
EPIPEN-JR ..........................................................24
epirubicin hcl .........................................................5
epitol ......................................................................6
EPIVIR...................................................................1
EPIVIR HBV .........................................................1
eplerenone............................................................11
EPOGEN..............................................................19
EPZICOM ..............................................................1
EQUETRO.............................................................6
ERAXIS .................................................................1
ERBITUX ..............................................................5
ergotamine tartrate / caffeine ................................7
errin......................................................................21
ery ........................................................................13
ERY-TAB ..............................................................2
ERYTHROCIN LACTOBIONATE......................2
erythrocin stearate .................................................2
erythromycin ..................................................13, 22
erythromycin / benzoyl peroxide..........................13
ERYTHROMYCIN BASE ....................................2
erythromycin ethylsuccinate ..................................2
erythromycin/sulfisoxazole ....................................2
33
ESTRADERM...................................................... 21
estradiol................................................................ 21
estradiol / norethindrone acetate ......................... 21
ESTRING ............................................................. 21
estropipate............................................................ 21
ethambutol............................................................. 2
ethosuximide.......................................................... 6
etidronate disodium............................................. 15
etodolac ................................................................. 9
ETOPOPHOS........................................................ 5
etoposide................................................................ 5
EURAX ............................................................... 15
EVISTA............................................................... 20
EVOXAC ............................................................ 15
EXALGO .............................................................. 8
EXELON............................................................... 7
exemestane ............................................................ 5
EXFORGE ........................................................... 11
EXFORGE HCT .................................................. 11
EXJADE.............................................................. 15
F
FABRAZYME .................................................... 17
famciclovir............................................................. 1
famotidine.............................................................19
famotidine premixed.............................................19
FANAPT ............................................................... 9
FANAPT TITRATION PACK ............................. 9
FARESTON .......................................................... 5
FASLODEX .......................................................... 5
FAZACLO ............................................................ 9
FELBATOL .......................................................... 6
felodipine er......................................................... 11
fenofibrate ........................................................... 12
fenofibrate micronized......................................... 12
fenoprofen calcium................................................ 9
fentanyl citrate....................................................... 8
fentanyl citrate oral transmucosal ........................ 8
fentanyl patches..................................................... 8
fexofenadine hcl................................................... 24
FINACEA............................................................ 13
finasteride............................................................ 25
FIRMAGON.......................................................... 5
flavoxate hcl .........................................................24
flecainide acetate .................................................10
FLECTOR..............................................................9
FLOVENT DISKUS............................................24
FLOVENT HFA ..................................................24
fluconazole .............................................................1
fluconazole in dextrose ..........................................1
fludarabine phosphate ...........................................5
fludrocortisone acetate ........................................16
flunisolide.............................................................24
fluocinolone acetonide.........................................14
fluocinonide..........................................................14
fluocinonide emollient base .................................14
fluorometholone ...................................................23
FLUOROPLEX....................................................13
fluorouracil ......................................................5, 13
fluoxetine................................................................9
fluoxetine dr ...........................................................9
fluphenazine ...........................................................9
fluphenazine decanoate inj ....................................9
flurbiprofen ............................................................9
flurbiprofen sodium..............................................23
flutamide ................................................................5
fluticasone propionate ...................................14, 24
fluvoxamine............................................................9
FML .....................................................................23
FML FORTE........................................................23
FOCALIN XR........................................................9
FORADIL AEROLIZER .....................................24
FORTAZ................................................................2
FORTEO ..............................................................20
fortical..................................................................17
foscarnet sodium....................................................1
fosinopril..............................................................11
fosinopril / hydrochlorothiazide ..........................11
FOSRENOL.........................................................15
FRAGMIN ...........................................................12
FREAMINE III ....................................................26
furosemide............................................................11
FUZEON................................................................1
G
gabapentin..............................................................6
34
GABITRIL ............................................................ 6
galantamine hydrobromide ................................... 7
ganciclovir............................................................. 1
GARDASIL......................................................... 20
GASTROCROM ................................................. 18
GAUZE PADS 2 ................................................. 16
gavilyte-c ............................................................. 18
gavilyte-g............................................................. 18
gavilyte-n/flavor pack.......................................... 18
GELNIQUE......................................................... 24
gemcitabine hcl ..................................................... 5
gemfibrozil........................................................... 12
gengraf .................................................................. 5
gentak .................................................................. 22
gentamicin sulfate ......................................2, 14, 22
gentamicin sulfate/0.9% sodium chloride ............. 3
gentamicin sulfate/sodium chloride ...................... 3
gentasol ............................................................... 22
GEODON .............................................................. 9
gianvi................................................................... 21
GILENYA ............................................................. 8
GLEEVEC............................................................. 5
glimepiride .......................................................... 16
glipizide ............................................................... 16
glipizide / metformin............................................ 16
glipizide er........................................................... 16
GLUCAGEN HYPOKIT .................................... 16
GLUCAGON EMERGENCY KIT..................... 16
glyburide.............................................................. 16
glyburide / metformin.......................................... 16
glyburide micronized........................................... 16
glycopyrrolate ..................................................... 18
glycron................................................................. 16
granisetron .......................................................... 18
griseofulvin microsize ........................................... 1
GRIS-PEG............................................................. 1
guanfacine hcl ..................................................... 11
GYNAZOLE-1.................................................... 21
H
HALAVEN............................................................ 5
HALDOL .............................................................. 9
HALDOL DECANOATE 100 .............................. 9
HALDOL DECANOATE 50.................................9
halobetasol propionate ........................................14
haloperidol.............................................................9
haloperidol decanoate inj ......................................9
haloperidol lactate inj............................................9
HAVRIX ..............................................................20
HECTOROL ........................................................17
HEPARIN SODIUM ...........................................12
heparin sodium/d5w.............................................12
HEPARIN SODIUM/NACL 0.45% ....................12
heparin sodium/sodium chloride 0.9% premix ....12
HEPATAMINE....................................................26
HEPATASOL ......................................................26
HEPSERA..............................................................1
HERCEPTIN..........................................................5
HEXALEN.............................................................5
HIZENTRA..........................................................20
HUMALOG .........................................................16
HUMALOG KWIKPEN......................................17
HUMALOG MIX 50/50 ......................................17
HUMALOG MIX 50/50 KWIKPEN...................17
HUMALOG MIX 75/25 ......................................17
HUMALOG MIX 75/25 KWIKPEN...................17
HUMIRA .............................................................20
HUMIRA PEN-CROHNS DISEASE STARTER
..........................................................................20
HUMULIN 70/30.................................................17
HUMULIN 70/30 PEN ........................................17
HUMULIN N.......................................................17
HUMULIN N U-100 PEN...................................17
HUMULIN R .......................................................17
HUMULIN R U-500 (CONCENTRATED)........17
hydralazine...........................................................11
hydrochlorothiazide .............................................11
hydrocodone bitartrate/acetaminophen.................8
hydrocodone/acetaminophen .................................8
hydrocodone/ibuprofen..........................................8
hydrocortisone .........................................14, 16, 18
hydrocortisone butyrate .......................................14
hydrocortisone valerate .......................................14
hydrocortisone/acetic acid...................................15
hydromorphone hcl ................................................8
hydroxychloroquine ...............................................3
35
hydroxyurea........................................................... 5
hydroxyzine hcl.................................................... 24
I
ibuprofen ............................................................... 9
idarubicin hcl ........................................................ 5
IFEX ...................................................................... 5
ifosfamide .............................................................. 5
ifosfamide/mesna....................................................5
imipramine ............................................................ 9
imipramine pamoate............................................ 10
imiquimod............................................................ 13
IMOVAX RABIES (H.D.C.V.) .......................... 20
INCRELEX ......................................................... 15
indapamide.......................................................... 11
indomethacin ......................................................... 9
indomethacin er...................................................,, 9
INFANRIX.......................................................... 20
INFUMORPH 200 ................................................ 8
INFUMORPH 500 ................................................ 8
INTELENCE......................................................... 1
INTRALIPID ...................................................... 26
INTRON-A...........................................................19
INTRON-A WITH DILUENT.............................19
INVEGA.............................................................. 10
INVEGA SUSTENNA........................................ 10
INVIRASE ............................................................ 1
IONOSOL ........................................................... 26
IOPIDINE............................................................ 23
IPOL INACTIVATED IPV ................................ 20
ipratropium bromide ..................................... 15, 24
ipratropium bromide/albuterol sulfate................ 24
irinotecan .............................................................. 5
ISENTRESS .......................................................... 1
ISOLYTE ............................................................ 26
isonarif .................................................................. 3
ISONIAZID........................................................... 3
isosorbide dinitrate ............................................. 13
isosorbide dinitrate er ......................................... 13
isosorbide mononitrate........................................ 13
isosorbide mononitrate er ................................... 13
isotonic gentamicin ............................................... 3
isradipine............................................................. 11
ISTALOL.............................................................22
ISTODAX ..............................................................5
itraconazole............................................................1
IXEMPRA KIT......................................................5
IXIARO................................................................20
J
JALYN.................................................................25
jantoven................................................................12
JANUMET...........................................................17
JANUVIA ............................................................17
JE-VAX................................................................20
JEVTANA..............................................................5
jinteli ....................................................................21
jolivette.................................................................21
junel......................................................................21
junel fe 1.5/30.......................................................21
junel fe 1/20..........................................................21
K
KADIAN................................................................8
KALETRA.............................................................1
kariva ...................................................................21
kcl 0.075%/d5w/nacl 0.45% ................................25
KCL 0.15%/D10W/NACL 0.2% .........................26
kcl 0.15%/d5w/lr ..................................................25
KCL 0.15%/D5W/NACL 0.2% ...........................25
KCL 0.15%/D5W/NACL 0.225% .......................25
kcl 0.15%/d5w/nacl 0.9% ....................................25
kcl 0.3%/d5w/lr iv lac ring...................................25
KCL 0.3%/D5W/NACL 0.2% .............................25
kcl 0.3%/d5w/nacl 0.45% ....................................25
kcl 0.3%/d5w/nacl 0.9% ......................................25
kelnor 1/35 ...........................................................21
KETEK ..................................................................3
ketoconazole.....................................................1, 14
ketoprofen ..............................................................9
ketoprofen er ..........................................................9
ketorolac tromethamine .......................................23
kionex ...................................................................15
klor-con 10...........................................................25
klor-con 8.............................................................25
KLOR-CON M15 ................................................25
klor-con m20 ........................................................25
36
KOMBIGLYZE XR............................................ 17
K-TABS .............................................................. 25
KUVAN .............................................................. 17
L
labetalol............................................................... 11
laclotion............................................................... 13
LACRISERT ....................................................... 22
LACTATED RINGERS...................................... 25
lactulose .............................................................. 18
LAMICTAL ODT ................................................. 6
LAMICTAL XR.................................................... 6
lamotrigine ............................................................ 6
LANOXIN........................................................... 12
lansoprazole .........................................................19
lansoprazole odt ...................................................19
LANTUS ............................................................. 17
LANTUS SOLOSTAR ....................................... 17
latanoprost .......................................................... 23
LATUDA ............................................................ 10
leena .................................................................... 21
leflunomide.......................................................... 20
lessina-28 ............................................................ 21
LETAIRIS ........................................................... 24
letrozole................................................................. 5
leucovorin calcium................................................ 4
LEUKERAN ......................................................... 5
LEUKINE.............................................................19
leuprolide acetate.................................................. 5
LEVAQUIN .......................................................... 3
LEVEMIR ........................................................... 17
LEVEMIR FLEXPEN......................................... 17
levetiracetam......................................................... 6
LEVITRA............................................................ 23
levobunolol hcl .................................................... 22
levocarnitine........................................................ 15
levocetirizine dihydrochloride............................. 24
levofloxacin ......................................................... 22
levora................................................................... 21
levorphanol tartrate ...............................................8
levothyroxine ....................................................... 18
levoxyl.................................................................. 18
LEXIVA ................................................................ 1
lidocaine...............................................................13
lidocaine / prilocaine ...........................................13
lidocaine viscous..................................................13
LIDODERM ........................................................14
LINDANE............................................................15
liothyronine sodium .............................................18
LIPITOR ..............................................................12
LIPOSYN III........................................................26
lisinopril...............................................................11
lisinopril/hydrochlorothiazide .............................11
lithium carbonate.................................................10
lithium carbonate er.............................................10
lithium citrate.......................................................10
LOCOID ..............................................................14
LODOSYN ............................................................7
loperamide hcl .....................................................18
lorazepam...............................................................7
losartan potassium...............................................11
losartan potassium/hydrochlorothiazide .............11
LOTEMAX ..........................................................23
LOTRONEX ........................................................18
lovastatin..............................................................12
LOVAZA .............................................................12
LOVENOX ..........................................................12
low-ogestrel..........................................................21
loxapine................................................................10
LUMIGAN...........................................................23
LUPRON DEPOT..................................................5
LUPRON DEPOT-PED.........................................5
lutera....................................................................21
LUXIQ .................................................................14
LYRICA.................................................................6
LYSODREN ..........................................................5
LYSTEDA ...........................................................21
M
MACRODANTIN..................................................4
MAGNESIUM SULFATE ..................................25
MAGNESIUM SULFATE IN D5W ...................25
MALARONE.........................................................3
malathion .............................................................15
maprotiline...........................................................10
margesic-h..............................................................8
37
MARPLAN ......................................................... 10
MATULANE ........................................................ 5
matzim la ............................................................. 11
MAXALT.............................................................. 7
MAXALT-MLT .................................................... 7
mebendazole .......................................................... 3
meclizine hcl........................................................ 18
meclofenamate sodium.......................................... 9
medroxyprogesterone acetate ............................. 21
mefenamic acid...................................................... 9
mefloquine hcl ....................................................... 3
MEGACE ES ........................................................ 5
megestrol acetate................................................... 5
meloxicam.............................................................. 9
melphalan hydrochloride ...................................... 5
MENACTRA ...................................................... 20
MENOMUNE-A/C/Y/W-135 ............................. 20
MENOSTAR....................................................... 21
MENVEO............................................................ 20
MEPRON .............................................................. 3
mercaptopurine ..................................................... 5
meropenem............................................................ 3
mesalamine.......................................................... 18
mesna..................................................................... 4
MESNEX .............................................................. 4
MESTINON .......................................................... 8
MESTINON TIMESPAN ..................................... 8
METADATE CD ................................................ 10
metaproterenol sulfate......................................... 24
metformin hcl....................................................... 17
metformin hcl er .................................................. 17
methadone hcl ....................................................... 8
methadose.............................................................. 8
methazolamide..................................................... 23
methenamine hippurate ......................................... 4
METHERGINE................................................... 22
methimazole......................................................... 16
methotrexate .......................................................... 5
methotrexate sodium ............................................. 5
methyclothiazide.................................................. 11
methylphenidate hcl............................................. 10
methylphenidate hydrochloride........................... 10
methylprednisolone ............................................. 16
methylprednisolone acetate .................................16
methylprednisolone sodiumsuccinate ..................16
metipranolol.........................................................22
metoclopramide....................................................18
metolazone ...........................................................11
metoprolol succinate er........................................11
metoprolol tartrate...............................................11
metoprolol/hydrochlorothiazide ..........................11
METROGEL........................................................13
metronidazole...................................................3, 13
metronidazole in nacl 0.79% .................................3
metronidazole vaginal..........................................21
mexiletine .............................................................10
miconazole 3 ........................................................21
microgestin 1.5/30................................................21
microgestin 1/20...................................................21
microgestin fe.......................................................21
microgestin fe 1.5/30............................................21
midodrine .............................................................15
migergot .................................................................7
MIGRANAL..........................................................7
minocycline hcl ......................................................4
minocycline hcl er ..................................................4
minoxidil ..............................................................11
MIRAPEX ER .......................................................7
mirtazapine ..........................................................10
mirtazapine odt ....................................................10
misoprostol...........................................................19
mitomycin...............................................................5
mitoxantrone hcl ....................................................5
M-M-R II W/DILUENT 10 DOSE......................20
moexipril ..............................................................11
moexipril/hydrochlorothiazide.............................11
mometasone furoate .............................................14
mononessa............................................................21
morphine sulfate.....................................................8
morphine sulfate er ................................................8
MOXEZA ............................................................22
MOZOBIL ...........................................................19
MULTAQ ............................................................10
mupirocin .............................................................14
MUSE ..................................................................23
MUSTARGEN.......................................................5
38
MYCOBUTIN....................................................... 3
mycophenolate mofetil........................................... 5
MYFORTIC .......................................................... 5
MYTELASE.......................................................... 8
N
nabumetone ........................................................... 9
nadolol................................................................. 11
nadolol/bendroflumethiazide............................... 11
nafcillin sodium..................................................... 3
NAFTIN .............................................................. 14
NAGLAZYME.................................................... 17
NALLPEN/DEXTROSE....................................... 3
naloxone ................................................................ 9
naltrexone.............................................................. 9
NAMENDA .......................................................... 8
NAMENDA TITRATION PAK ........................... 8
naproxen................................................................ 9
naproxen sodium ................................................... 9
naratriptan hcl....................................................... 7
NATACYN ......................................................... 22
nateglinide........................................................... 17
NEBUPENT .......................................................... 3
necon 0.5/35-28.................................................... 21
necon 1/35-28....................................................... 21
necon 10/11-28..................................................... 21
necon 7/7/7 ........................................................... 21
nefazodone........................................................... 10
neomycin sulfate.................................................... 3
neomycin/bacitracin/polymyxin .......................... 22
neomycin/polymyxin/bacitracin/hydrocortisone . 23
neomycin/polymyxin/dexamethasone .................. 23
neomycin/polymyxin/gramicidin ......................... 22
neomycin/polymyxin/hc ....................................... 16
neomycin/polymyxin/hydrocortisone............. 16, 23
NEORAL............................................................... 5
NEPHRAMINE................................................... 26
NEULASTA.........................................................19
NEUMEGA..........................................................19
NEUPOGEN ........................................................19
NEVANAC ......................................................... 23
NEXAVAR ........................................................... 5
NEXIUM I.V........................................................19
next choice ...........................................................21
NIASPAN ............................................................12
nicardipine ...........................................................11
NICOTROL INHALER.......................................15
NICOTROL NASAL...........................................15
nifediac cc ............................................................11
nifedical xl............................................................11
nifedipine..............................................................11
nifedipine er .........................................................11
NILANDRON........................................................5
nimodipine............................................................12
NIPENT .................................................................5
nisoldipine............................................................12
nisoldipine er .......................................................12
nitro-bid ...............................................................13
NITRO-DUR........................................................13
nitrofurantoin.........................................................4
nitrofurantoin macrocrystalline.............................4
nitrofurantoin monohydrate...................................4
nitroglycerin.........................................................13
nitroglycerin transdermal ....................................13
NITROLINGUAL PUMPSPRAY.......................13
NITROSTAT .......................................................13
nizatidine..............................................................19
nora-be.................................................................21
NORDITROPIN FLEXPRO................................19
NORDITROPIN NORDIFLEX PEN ..................19
norethindrone.......................................................21
NORMOSOL .................................................25, 26
NOROXIN .............................................................3
NORPACE CR.....................................................10
nortrel 0.5/35 (28)................................................21
nortrel 1/35 (21)...................................................22
nortrel 1/35 (28)...................................................22
nortrel 7/7/7 .........................................................22
nortriptyline .........................................................10
NORVIR ................................................................1
NOVOLIN 70/30 .................................................17
NOVOLIN N .......................................................17
NOVOLIN R........................................................17
NOVOLOG..........................................................17
NOVOLOG FLEXPEN .......................................17
NOVOLOG MIX 70/30.......................................17
39
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
......................................................................... 17
NOXAFIL ............................................................. 1
NUEDEXTA ......................................................... 8
NUVARING........................................................ 21
nyamyc................................................................. 14
nystatin .............................................................1, 14
nystatin / triamcinolone....................................... 14
nystop .................................................................. 14
O
ocella ................................................................... 22
octreotide............................................................... 5
ofloxacin.....................................................3, 16, 22
ogestrel ................................................................ 22
omeprazole ...........................................................19
omnitrope .............................................................19
ondansetron hcl ................................................... 18
ondansetron odt................................................... 18
ONGLYZA.......................................................... 17
ONSOLIS .............................................................. 8
ONTAK................................................................. 5
OPANA ER ........................................................... 8
ORAP .................................................................. 10
ORAVIG ............................................................... 1
ORFADIN ........................................................... 15
ORTHO EVRA ................................................... 21
ortho-est .............................................................. 21
oxaliplatin.............................................................. 5
oxandrolone......................................................... 17
oxaprozin............................................................... 9
oxazepam............................................................... 7
oxcarbazepine........................................................ 6
OXSORALEN ULTRA .......................