2013 Blue Shield Medicare Enhanced Plan Formulary

Blue Shield Medicare Enhanced Plan (PDP)

2013 Formulary (List of Covered Drugs)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2014. A Medicare-approved Part D sponsor. This information is available for free in other languages. Please contact our Member Services number at (888) 239-6469 [TTY (888) 239-6482], 7 a.m. to 8 p.m., seven days a week, from October 1 through February 14. However, after February 14, your call will be handled by our automated phone system on weekends and holidays. Esta información está disponible gratis en otros idiomas. Comuníquese con nuestro Servicio para Miembros al (888) 239-6469 [TTY (888) 239-6482] de 7 a.m. a 8 p.m., los siete días de la semana, desde el 1 de octubre hasta el 14 de febrero. Sin embargo, después del 14 de febrero, nuestro sistema telefónico automático atenderá su llamada durante los fines de semana y los días feriados. S2468_12_220B CMS Accepted 09012012 Formulary ID 00013143 Version 33 blueshieldca.com/med_formulary

PDP00005-ENH_11_15_13

What is the Blue Shield Medicare Enhanced Plan (PDP) Formulary?

A formulary is a list of covered drugs selected by Blue Shield Medicare Enhanced Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Blue Shield Medicare Enhanced Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Blue Shield Medicare Enhanced Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary change? Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2013 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. You may use this written notification as an update to your printed formulary. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of November 7, 2013. To get updated information about the drugs covered by Blue Shield Medicare Enhanced Plan, please visit our Web site at blueshieldca.com/med_formulary or call Member Services (888) 239-6469, seven days a week, 7:00 a.m. - 8:00 p.m. TTY users should call (888) 239-6482.

How do I use the Formulary?

There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents”. If you know what your drug is used for, look for the category name in the list that begins on page number 1. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 37. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?

Blue Shield Medicare Enhanced Plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

Prior Authorization: Blue Shield Medicare Enhanced Plan requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from Blue Shield Medicare Enhanced Plan before you fill your prescriptions. If you don’t get approval, Blue Shield Medicare Enhanced Plan may not cover the drug.

Quantity Limits: For certain drugs, Blue Shield Medicare Enhanced Plan limits the amount of the drug that Blue Shield Medicare Enhanced Plan will cover. For example, Blue Shield Medicare Enhanced Plan provides 18 tablets per 30 days for sumatriptan (generic for IMITREX). This may be in addition to a standard one month or three month supply.

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

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site at blueshieldca.com/med_formulary.

You can ask Blue Shield Medicare Enhanced Plan to make an exception to these restrictions or limits. See the section, “How do I request an exception to the Blue Shield Medicare Enhanced Plan formulary?” on page iii for information about how to request an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary, you should first contact Member Services and confirm that your drug is not covered. If you learn that Blue Shield Medicare Enhanced Plan does not cover your drug, you have two options:

You can ask Member Services for a list of similar drugs that are covered by Blue Shield Medicare Enhanced Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Blue Shield Medicare Enhanced Plan.

You can ask Blue Shield Medicare Enhanced Plan to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Blue Shield Medicare Enhanced Plan Formulary?

You can ask Blue Shield Medicare Enhanced Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

You can ask us to cover your drug even if it is not on our formulary. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,

Blue Shield Medicare Enhanced Plan limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our Non-Preferred Brand Drug tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the Preferred Brand Drug tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in Specialty Tier Drugs tier.

Generally, Blue Shield Medicare Enhanced Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary, in the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you are requesting a formulary, tiering, or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s or 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 must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement.

What do I do before I can 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 on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that 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, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 91-day transition supply, consistent with the dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Our transition policy applies to the member categories listed below whom are stabilized on:

Medicare Part D drugs not on the formulary Medicare Part D drugs on the formulary with a prior authorization, step therapy or quantity limit

requirement, or Medicare Part D drugs as listed above, where a distinction cannot be made at point of service

whether it is a new or ongoing prescription drug

And are members in any of the following scenarios:

new members at the beginning of a contract year, newly eligible members transitioning from other coverage at the beginning of a contract year, transitioning individuals who switch from one plan to another after the beginning of a contract

year, enrollees residing in long-term care (LTC) facilities, or in some cases, current enrollees affected by formulary changes from one contract year to the next

For more information

For more detailed information about your Blue Shield Medicare Enhanced Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Blue Shield Medicare Enhanced Plan please call Member Services at (888) 239-6469, seven days a week, 7:00 a.m. - 8:00 p.m. TTY users should call (888) 239-6482. Or visit www.blueshieldca.com/findamedicareplan.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov.

Blue Shield Medicare Enhanced Plan Formulary

The formulary that begins on page 1 provides coverage information about some of the drugs covered by Blue Shield Medicare Enhanced Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 37.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., AUGMENTIN) and generic drugs are listed in lower-case italics (e.g., amoxicillin).

The information in the Requirements/Limits column tells you if Blue Shield Medicare Enhanced Plan has any special requirements for coverage of your drug.

Key to Formulary Abbreviations Drug Tiers

Tier Supply Blue Shield Medicare

Enhanced Plan

1 Preferred Generic Drugs

Network Preferred or Other Network Pharmacy or Out-of-Network Pharmacy (30-day supply)

$5 Copay

Network Preferred or Mail Service Pharmacy (90-day supply)

$10 Copay

Other Network Pharmacy (90-day supply)

$15 Copay

Network Long-Term Care Pharmacy (31-day supply)

$5 Copay

2 Preferred

Brand Drugs


$45 Copay


$90 Copay


$135 Copay


$45 Copay

3 Non-

Preferred Brand Drugs


$90 Copay


$180 Copay


$270 Copay


$90 Copay

Tier Supply Blue Shield Medicare

Enhanced Plan

4 Injectable

Drugs

Network Preferred or Other Network Pharmacy (30-day supply)

25% of Blue Shield's

contracted rate

Network Preferred or Other Network Pharmacy or Mail Service Pharmacy (90-day supply)


contracted rate

Out-of-Network Pharmacy (30-day supply)

25% of submitted cost



contracted rate

5 Specialty

Tier Drugs

Network Preferred or Other Network Pharmacy (30-day supply)


contracted rate

Network Preferred or Other Network Pharmacy or Mail Service Pharmacy (90-day supply)


contracted rate

Out-of-Network Pharmacy (30-day supply)

33% of submitted cost



contracted rate

Requirements/Limit Codes Code Definition AG This prescription drug has coverage limits based on age groups. The limits may be based

upon how the U.S. Food and Drug Administration (FDA) approved the drug for use or special cautions for use by people in certain age groups. For new prescriptions, discuss alternatives with your physician. Your pharmacy or physician may call Blue Shield for assistance with coverage for ongoing use.

B/D This prescription drug requires prior authorization review to determine whether coverage is under Part B or Part D of the Medicare benefit, based on Medicare coverage rules. Call Blue Shield to provide the necessary information to determine coverage.

ED This prescription drug is not normally covered in a Medicare Prescription Drug Plan; however, Blue Shield covers this drug as a supplemental benefit. The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help from Medicare or Social Security to pay for your prescriptions, you will not get any extra help to pay for this drug.

LA This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call Member Services at (888) 239-6469, seven days a week, 7:00 a.m. - 8:00 p.m. TTY/TDD users should call (888) 239-6482.

QL This medication has a dosing or prescription quantity limit. Maximum daily dose limits are defined by the FDA and listed in the drug package insert. Other quantity limits encourage consolidated dosing when possible.

PA Coverage for this prescription requires prior authorization from Blue Shield. Call Blue Shield to provide the necessary information to determine coverage.

ST Coverage for this prescription is provided when other first-line or preferred drug therapies have been tried (step therapy).

† Medication is NOT available through Blue Shield’s mail service pharmacy.

Form Codes

Abbreviation Definition Abbreviation Definition AERS Aerosol PACK Pack

CAPS Capsule PTTW Patch - Biweekly

CHEW Chewable PTWK Patch - Weekly

CONC Concentrate SOLN Solution

CP24 Capsule - Extended Release 24-hour SOLR Solution - Reconstituted

CPDR Capsule - Delayed-Release SUSP Suspension

CREA Cream SUSR Suspension - Reconstituted

ELIX Elixir SYRP Syrup

FOAM Foam TABS Tablet

GEL Gel TB24 Tablet - Extended Release 24-hour

LOTN Lotion TBDP Tablet - Dispersible OIL Oil TBEC Tablet - Enteric Coated

OINT Ointment TBEF Tablet - Effervescent

1

Drug Name DrugTier

Requirements/ Limits

Analgesics Analgesics butalbital/acetaminophen/caffeine tabs

1 QL(180 EA per 30 days)

butalbital/acetaminophen/caffeine/codeine

1 †QL(180 EA per 30 days)

Nonsteroidal Anti-inflammatory Drugs diclofenac sodium/misoprostol

2

meclofenamate sodium 2 mefenamic acid 1 NALFON 3 naproxen sodium tabs 275mg, 550mg

1

oxycodone/ibuprofen 1 †QL(120 EA per 30 days)

Opioid Analgesics, Long-acting AVINZA CP24 120MG 3 †QL(13 EA per 1

days) AVINZA CP24 30MG, 45MG, 60MG, 75MG


AVINZA CP24 90MG 3 †QL(90 EA per 30 days)

DURAMORPH 4 †B/D fentanyl (patch) 2 †QL(20 EA per

30 days) KADIAN CP24 10MG 3 †QL(60 EA per

30 days) KADIAN CP24 200MG 3 †QL(90 EA per

30 days) levorphanol tartrate 1 †QL(270 EA per

30 days) methadone hcl conc 1 †QL(540 ML per

30 days) methadone hcl inj 4 †B/D methadone hcl oral soln 10mg/5ml

1 †QL(2700 ML per 30 days)

methadone hcl oral soln 5mg/5ml


methadone hcl tabs 10mg


methadone hcl tabs 5mg 1 †QL(1080 EA per 30 days)

methadose tabs 1 †QL(540 EA per 30 days)

morphine sulfate er cp24 10mg


Drug Name DrugTier


morphine sulfate er cp24 100mg, 50mg, 60mg, 80mg






morphine sulfate er tbcr 100mg, 200mg


morphine sulfate er tbcr 60mg


morphine sulfate er tbcr 15mg, 30mg


morphine sulfate inj 0.5mg/ml

4 †B/D

morphine sulfate oral soln 20mg/ml


morphine sulfate oral soln 20mg/5ml


morphine sulfate oral soln 10mg/5ml


morphine sulfate supp 30mg








morphine sulfate tabs 30mg


morphine sulfate tabs 15mg


OXYCONTIN T12A 60MG


OXYCONTIN T12A 40MG, 80MG


OXYCONTIN T12A 15MG, 20MG, 30MG


OXYCONTIN T12A 10MG


oxymorphone hcl er tb12 10mg, 15mg, 20mg, 30mg, 5mg, 7.5mg


oxymorphone hcl er tb12 40mg


tramadol hcl er tb24 2 †

2

Drug Name DrugTier


Opioid Analgesics, Short-acting acetaminophen/caffeine/dihydrocodeine bitartrate


acetaminophen/codeine oral soln


acetaminophen/codeine tabs 300mg; 60mg






butalbital/aspirin/caffeine/codeine


butorphanol tartrate inj 4 †B/D butorphanol tartrate nasal soln


CAPITAL/CODEINE 3 †QL(2700 ML per 30 days)

co-gesic 1 †QL(240 EA per 30 days)

codeine sulfate tabs 60mg






endocet tabs 650mg; 10mg


endocet tabs 500mg; 7.5mg


endocet tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg


fentanyl citrate 4 †B/D fentanyl citrate oral transmucosal

5 †PA QL(120 EA per 30 days)

HYCET 3 †QL(5400 ML per 30 days)

hydrocodone/acetaminophen oral soln 500mg/15ml; 7.5mg/15ml


hydrocodone/acetaminophen oral soln 325mg/15ml; 7.5mg/15ml


Drug Name DrugTier


hydrocodone/acetaminophen tabs 750mg; 10mg, 750mg; 7.5mg


hydrocodone/acetaminophen tabs 650mg; 10mg, 650mg; 7.5mg, 660mg; 10mg


hydrocodone/acetaminophen tabs 500mg; 10mg, 500mg; 2.5mg, 500mg; 5mg, 500mg; 7.5mg


hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg


hydrocodone/acetaminophen tabs 300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg


hydrocodone/ibuprofen tabs 7.5mg; 200mg


hydromorphone hcl inj 500mg/50ml

4 †B/D

hydromorphone hcl tabs 8mg






NUCYNTA TABS 50MG


NUCYNTA TABS 100MG, 75MG


oxycodone hcl caps 1 †QL(360 EA per 30 days)

oxycodone hcl conc 1 †QL(180 ML per 30 days)

oxycodone hcl oral soln 1 †QL(7200 ML per 30 days)

oxycodone hcl tabs 30mg, 5mg


oxycodone hcl tabs 20mg






oxycodone/acetaminophen caps


3

Drug Name DrugTier


oxycodone/acetaminophen tabs 650mg; 10mg


oxycodone/acetaminophen tabs 500mg; 7.5mg


oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg


oxycodone/aspirin 1 †QL(360 EA per 30 days)

oxymorphone hcl 1 †QL(360 EA per 30 days)

reprexain tabs 10mg; 200mg


REPREXAIN TABS 2.5MG; 200MG


REPREXAIN TABS 5MG; 200MG


ROXICET ORAL SOLN


ROXICET TABS 500MG; 5MG


roxicet tabs 325mg; 5mg 1 †QL(360 EA per 30 days)

roxicodone tabs 5mg 1 †QL(360 EA per 30 days)

stagesic 1 †QL(240 EA per 30 days)

SYNALGOS-DC 3 † tramadol hcl 1 † tramadol hcl/acetaminophen


ZYDONE 3 †QL(300 EA per 30 days)

Anesthetics Local Anesthetics lidocaine hcl (gel) gel 2%

1

lidocaine hcl (gel) gel 2%

1 †

lidocaine hcl external soln

1 †

lidocaine hcl inj 1% 4 †B/D lidocaine oint 1 † lidocaine viscous 1 † lidocaine/prilocaine crea

1 †

LIDODERM 3 †QL(90 EA per 30 days)

Drug Name DrugTier


Anti-Addiction/Substance Abuse Treatment Agents Alcohol Deterrents/Anti-craving acamprosate calcium dr 2 CAMPRAL 3 disulfiram 1 naltrexone hcl 1 Opioid Antagonists buprenorphine hcl subl 8mg

2 PA QL(120 EA per 30 days)

buprenorphine hcl subl 2mg


buprenorphine hcl/naloxone hcl subl 8mg; 2mg


buprenorphine hcl/naloxone hcl subl 2mg; 0.5mg


naloxone hcl 4 †B/D SUBOXONE FILM 3 PA ZUBSOLV 3 PA QL(90 EA

per 30 days) Smoking Cessation Agents buproban 1 QL(60 EA per 30

days) CHANTIX 2 QL(60 EA per 30

days) CHANTIX PAK 2 QL(60 EA per 30

days) NICOTROL INHALER 2 NICOTROL NS 2 Anti-inflammatory Agents Nonsteroidal Anti-inflammatory Drugs CELEBREX 3 PA diclofenac potassium 1 diclofenac sodium dr 1 diclofenac sodium er 1 diflunisal 1 etodolac 1 etodolac er 1 fenoprofen calcium 1 flurbiprofen 1 ibuprofen susp 1 ibuprofen tabs 400mg, 600mg, 800mg

1

INDOCIN SUSP 3 indomethacin caps 1 indomethacin er 2

4

Drug Name DrugTier


ketoprofen 1 ketoprofen er 1 meloxicam 1 nabumetone 1 NALFON 3 naproxen 1 naproxen dr 1 oxaprozin 1 piroxicam 1 sulindac 1 tolmetin sodium 1 Antibacterials Aminoglycosides gentamicin sulfate crea 1 † gentamicin sulfate oint 0.1%

1 †

gentamicin sulfate ophthalmic soln

1 †

neomycin sulfate tabs 1 † paromomycin sulfate 1 † TOBI 5 †PA QL(280 ML

per 30 days) TOBI PODHALER 5 †PA QL(224 EA

per 28 days) tobramycin sulfate inj 10mg/ml, 80mg/2ml

4 †B/D

tobramycin sulfate ophthalmic soln

1 †

TOBREX OINT 2 † Antibacterials, Other ak-poly-bac 1 † alcohol preps pads 1 † bacitracin ophthalmic oint

1 †

bacitracin/polymyxin b 1 † BACTROBAN NASAL 3 † CLEOCIN CAPS 75MG 2 † CLEOCIN SUPP 2 † clindamycin hcl 1 † clindamycin palmitate hcl

1 †

clindamycin phosphate crea

1 †

clindamycin phosphate in d5w

4 †B/D

colistimethate sodium 4 †B/D CORTISPORIN OINT 3 † CUBICIN 5 †B/D HELIDAC 3 †

Drug Name DrugTier


MACRODANTIN CAPS 25MG

2 †PA

mafenide acetate 2 † methenamine hippurate 2 † METROGEL 2 † metronidazole caps 1 † metronidazole crea 1 † metronidazole gel 0.75%

1 †

metronidazole gel 1% 2 † metronidazole in nacl 0.79%

4 †B/D

metronidazole lotn 2 † metronidazole tabs 1 † MONUROL 3 † mupirocin crea 2 † mupirocin oint 1 † neomycin/bacitracin/polymyxin

1 †

neomycin/polymyxin/bacitracin/hydrocortisone

1 †

neomycin/polymyxin/gramicidin

1 †

neomycin/polymyxin/hydrocortisone

1 †

nitrofurantoin 1 †PA nitrofurantoin macrocrystalline

1 †PA

nitrofurantoin monohydrate

1 †PA

polycin b 1 † polymyxin b sulfate 4 †B/D PREVPAC 3 † PRIMSOL 3 † silver sulfadiazine 1 † ssd 1 † SULFAMYLON CREA 3 † trimethoprim 1 † trimethoprim sulfate/polymyxin b sulfate

1 †

vancomycin hcl caps 5 † VANCOMYCIN HCL INJ 500MG

4 †B/D

vancomycin hcl inj 1000mg, 10gm

4 †B/D

vandazole 1 † XIFAXAN TABS 200MG


5

Drug Name DrugTier


XIFAXAN TABS 550MG


ZYVOX 5 †PA Beta-lactam, Cephalosporins CEDAX CAPS 3 † cefaclor caps 1 † cefaclor er 1 † cefadroxil 1 † cefazolin sodium inj 500mg

4 †B/D

cefdinir 1 † cefditoren pivoxil 1 † cefepime inj 1gm, 2gm 4 †B/D cefotaxime sodium 4 †B/D cefoxitin sodium inj 10gm, 1gm, 2gm

4 †B/D

cefpodoxime proxetil 1 † cefprozil 1 † ceftazidime/dextrose 4 †B/D ceftriaxone sodium 4 †B/D cefuroxime axetil 1 † cefuroxime sodium inj 1.5gm, 7.5gm, 750mg

4 †B/D

cephalexin caps 250mg, 500mg

1 †

cephalexin susr 1 † SUPRAX 3 † tazicef inj 1gm, 2gm, 6gm

4 †B/D

Beta-lactam, Other CAYSTON 5 †PA QL(84 ML

per 30 days) INVANZ 4 †B/D Beta-lactam, Penicillins amoxicillin 1 † amoxicillin/potassium clavulanate

1 †

amoxicillin/potassium clavulanate er

1 †

ampicillin 1 † ampicillin sodium inj 10gm, 125mg, 1gm

4 †B/D

AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML

2 †

BICILLIN C-R 4 †B/D BICILLIN L-A 4 †B/D dicloxacillin sodium 1 †

Drug Name DrugTier


NAFCILLIN SODIUM INJ 10GM, 1GM

4 †B/D

oxacillin sodium inj 10gm, 1gm

4 †B/D

penicillin g potassium inj 5mu

4 †B/D

penicillin g procaine 4 †B/D penicillin g sodium 4 †B/D penicillin v potassium 1 † piperacillin sodium/tazobactam sodium inj 3gm; 0.375gm, 4gm; 0.5gm

4 †B/D

Macrolides AKNE-MYCIN 3 † azithromycin inj 500mg 4 †B/D azithromycin susr 1 † azithromycin tabs 500mg


azithromycin tabs 250mg


azithromycin tabs 600mg


clarithromycin er 1 †QL(42 EA per 14 days)

clarithromycin susr 1 † clarithromycin tabs 1 †QL(42 EA per

14 days) ery 1 † ERY-TAB 2 † ERYPED 2 † erythrocin lactobionate inj 500mg

4 †B/D

ERYTHROCIN STEARATE

2 †

erythromycin base 1 † erythromycin cpep 1 † erythromycin ethylsuccinate

1 †

erythromycin external soln

1 †

erythromycin gel 1 † erythromycin oint 1 † erythromycin/sulfisoxazole

1 †

KETEK TABS 400MG 2 †QL(20 EA per 10 days)

KETEK TABS 300MG 2 †QL(20 EA per 30 days)

6

Drug Name DrugTier


PCE 2 † romycin 1 † ZITHROMAX PACK 2 †QL(2 EA per 1

days) ZMAX 3 †QL(60 EA per

30 days) Quinolones AVELOX ABC PACK 2 †QL(10 EA per

10 days) AVELOX TABS 2 †QL(10 EA per

10 days) CILOXAN OINT 2 † CIPRO HC 3 † CIPRO SUSR 2 † CIPRODEX 3 † ciprofloxacin er tb24 500mg; 0


ciprofloxacin er tb24 1000mg; 0


ciprofloxacin hcl 1 † ciprofloxacin i.v.-in d5w inj 200mg/100ml; 5%

4 †B/D

ciprofloxacin inj 400mg/40ml

4 †B/D

FACTIVE 3 † levofloxacin in d5w inj 5%; 500mg/100ml

4 †B/D

levofloxacin inj 4 †B/D levofloxacin ophthalmic soln

1 †

levofloxacin oral soln 1 † levofloxacin tabs 1 †QL(10 EA per

10 days) MOXEZA 2 † NOROXIN 3 † ofloxacin 1 † VIGAMOX 2 † Sulfonamides sodium sulfacetamide ophthalmic soln

1 †

sulfacetamide sodium oint

1 †

sulfacetamide sodium ophthalmic soln

1 †

sulfadiazine 1 † sulfamethoxazole/trimethoprim ds

1 †

sulfamethoxazole/trimethoprim inj

4 †B/D

Drug Name DrugTier


sulfamethoxazole/trimethoprim susp

1 †

sulfamethoxazole/trimethoprim tabs

1 †

Tetracyclines demeclocycline hcl 2 † doxycycline caps 75mg 1 † doxycycline hyclate caps 1 † doxycycline hyclate dr tbec 100mg, 75mg

2 †

doxycycline hyclate dr tbec 150mg


doxycycline hyclate inj 4 †B/D doxycycline hyclate tabs 1 † doxycycline monohydrate caps

1 †

doxycycline monohydrate tabs 100mg

1 †

doxycycline monohydrate tabs 150mg, 50mg, 75mg

2 †

doxycycline susr 2 † minocycline hcl caps 1 † minocycline hcl tabs 2 † ORACEA 2 † tetracycline hcl 1 † VIBRAMYCIN SYRP 3 † Anticonvulsants Anticonvulsants, Other levetiracetam er tb24 750mg


levetiracetam er tb24 500mg


levetiracetam inj 500mg/5ml

4 †B/D

levetiracetam oral soln 1 levetiracetam tabs 1 phenobarbital 1 POTIGA TABS 200MG, 300MG, 400MG


POTIGA TABS 50MG 3 QL(270 EA per 30 days)

Calcium Channel Modifying Agents CELONTIN 2 ethosuximide 1

7

Drug Name DrugTier


LYRICA CAPS 200MG, 225MG, 300MG


LYRICA CAPS 100MG, 150MG, 25MG, 50MG, 75MG


LYRICA ORAL SOLN 3 PA QL(900 ML per 30 days)

zonisamide 1 Gamma-aminobutyric Acid (GABA) Augmenting Agents clonazepam odt tbdp 2mg


clonazepam odt tbdp 1mg


clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg


clonazepam tabs 2mg 1 QL(300 EA per 30 days)

clonazepam tabs 1mg 1 QL(600 EA per 30 days)

clonazepam tabs 0.5mg 1 QL(1200 EA per 30 days)

clorazepate dipotassium tabs 15mg


clorazepate dipotassium tabs 7.5mg


clorazepate dipotassium tabs 3.75mg


diazepam gel 1 QL(2 EA per 5 days)

divalproex sodium 1 divalproex sodium dr 1 divalproex sodium er 1 gabapentin 1 GABITRIL TABS 12MG, 16MG

3 PA

HORIZANT 3 PA QL(30 EA per 30 days)

ONFI SUSP 3 PA QL(480 ML per 30 days)

ONFI TABS 3 PA QL(60 EA per 30 days)

primidone 1 SABRIL 5 †QL(180 EA per

30 days) STAVZOR 3 PA tiagabine hydrochloride 2 PA valproate sodium 4 †B/D

Drug Name DrugTier


valproic acid 1 Glutamate Reducing Agents felbamate 1 LAMICTAL STARTER KIT

2

lamotrigine 1 lamotrigine er tb24 100mg, 25mg, 50mg

2 QL(30 EA per 30 days) ST

lamotrigine er tb24 250mg, 300mg


lamotrigine er tb24 200mg


topiramate 1 PA Sodium Channel Agents BANZEL SUSP 2 PA QL(2400 ML

per 30 days) BANZEL TABS 200MG


BANZEL TABS 400MG


carbamazepine chew 1 carbamazepine er cp12 1 carbamazepine er tb12 2 carbamazepine susp 2 carbamazepine tabs 1 DILANTIN CAPS 30MG

2

DILANTIN INFATABS 2 epitol 1 EQUETRO 3 oxcarbazepine 1 PA PEGANONE 2 phenytoin 1 phenytoin sodium extended

1

TEGRETOL-XR TB12 100MG

2

TRILEPTAL SUSP 3 PA VIMPAT INJ 4 †PA VIMPAT ORAL SOLN 3 PA QL(1200 ML

per 30 days) VIMPAT TABS 3 PA QL(60 EA

per 30 days) Antidementia Agents Cholinesterase Inhibitors ARICEPT TABS 23MG 2 QL(30 EA per 30

days) ST donepezil hcl tabs 23mg 2 ST

8

Drug Name DrugTier


donepezil hcl tabs 10mg, 5mg

1

donepezil hcl tbdp 2 EXELON ORAL SOLN 2 EXELON PT24 2 galantamine hydrobromide cp24


galantamine hydrobromide oral soln

2

galantamine hydrobromide tabs

2

rivastigmine tartrate 2 N-methyl-D-aspartate (NMDA) Receptor Antagonist NAMENDA ORAL SOLN

2 QL(360 ML per 30 days)

NAMENDA TABS 2 QL(60 EA per 30 days)

NAMENDA TITRATION PAK


NAMENDA XR 2 QL(30 EA per 30 days)

NAMENDA XR TITRATION PACK


Antidepressants Antidepressants, Other budeprion sr tb12 150mg


budeprion sr tb12 100mg


bupropion hcl sr tb12 200mg






bupropion hcl tabs 100mg


bupropion hcl tabs 75mg


bupropion hcl xl tb24 300mg


bupropion hcl xl tb24 150mg


FORFIVO XL 3 PA QL(30 EA per 30 days)

maprotiline hcl 1 mirtazapine 1

Drug Name DrugTier


mirtazapine odt tbdp 30mg, 45mg

1

nefazodone hcl 1 trazodone hcl tabs 100mg, 150mg, 50mg

1

trazodone hcl tabs 300mg

2

Monoamine Oxidase Inhibitors EMSAM 3 PA MARPLAN 2 phenelzine sulfate 1 selegiline hcl caps 2 selegiline hcl tabs 1 tranylcypromine sulfate 2 Serotonin/Norepinephrine Reuptake Inhibitors citalopram hydrobromide

1

CYMBALTA CPEP 60MG


CYMBALTA CPEP 20MG, 30MG


DESVENLAFAXINE ER


escitalopram oxalate oral soln


escitalopram oxalate tabs 20mg, 5mg


escitalopram oxalate tabs 10mg


fluoxetine dr 2 QL(4 EA per 28 days)

fluoxetine hcl caps 1 fluoxetine hcl oral soln 1 fluoxetine hcl tabs 10mg, 20mg

1

fluvoxamine maleate 1 fluvoxamine maleate er 2 ST olanzapine/fluoxetine 2 paroxetine hcl 1 paroxetine hcl er 2 PAXIL SUSP 3 FDA Max Dose

900ml/30 days PEXEVA TABS 10MG 3 ST FDA Max

Dose 180/30 days PEXEVA TABS 40MG 3 ST FDA Max

Dose 30/30 days PEXEVA TABS 30MG 3 ST FDA Max

Dose 60/30 days

9

Drug Name DrugTier


PEXEVA TABS 20MG 3 ST FDA Max Dose 90/30 days

PRISTIQ TB24 50MG 3 QL(30 EA per 30 days) ST

PRISTIQ TB24 100MG 3 QL(120 EA per 30 days) ST

sertraline hcl conc 2 sertraline hcl tabs 1 venlafaxine hcl 1 venlafaxine hcl er cp24 150mg, 37.5mg


venlafaxine hcl er cp24 75mg


venlafaxine hcl er tb24 150mg, 37.5mg, 75mg


VENLAFAXINE HCL ER TB24 225MG


VIIBRYD KIT 3 QL(1 EA per 30 days) ST

VIIBRYD TABS 3 QL(30 EA per 30 days) ST

Tricyclics amitriptyline hcl 1 amoxapine 1 clomipramine hcl 1 desipramine hcl 2 doxepin hcl 1 imipramine hcl 1 imipramine pamoate 2 nortriptyline hcl 1 perphenazine/amitriptyline

1

protriptyline hcl 1 trimipramine maleate 1 Antiemetics Antiemetics, Other ANTIVERT TABS 50MG

3 †

hydroxyzine hcl oral soln

1 †

hydroxyzine hcl tabs 10mg, 25mg

1 †

meclizine hcl tabs 1 † TRANSDERM-SCOP 3 † Emetogenic Therapy Adjuncts ANZEMET INJ 4 †PA ANZEMET TABS 2 †PA QL(1 EA

per 5 days)

Drug Name DrugTier


dronabinol caps 2.5mg, 5mg


dronabinol caps 10mg 5 †PA QL(180 EA per 30 days)

EMEND CAPS 40MG, 80MG, 125MG

3 †PA

granisetron hcl inj 0.1mg/ml, 1mg/ml

4 †PA

granisetron hcl tabs 2 †PA QL(60 EA per 30 days)

granisol 2 †PA QL(300 ML per 30 days)

ondansetron hcl inj 4mg/2ml

4 †B/D

ondansetron hcl oral soln

1 †B/D QL(450 ML per 30 days)

ondansetron hcl tabs 24mg

1 †B/D QL(15 EA per 30 days)

ondansetron hcl tabs 4mg, 8mg

1 †B/D QL(90 EA per 30 days)

ondansetron odt 1 †B/D QL(90 EA per 30 days)

Antifungals Antifungals amphotericin b 4 †B/D BIO-STATIN CAPS 3 † CANCIDAS 5 †PA ciclopirox gel 2 † ciclopirox nail lacquer 1 † ciclopirox olamine 1 † ciclopirox sham 2 † ciclopirox susp 1 † clotrimazole external crea

1 †

clotrimazole external soln

1 †

clotrimazole troc 1 † econazole nitrate 1 † EXELDERM 3 † fluconazole 1 † fluconazole in dextrose inj 56mg/ml; 400mg/200ml

4 †B/D

flucytosine 1 † griseofulvin microsize susp

1 †

griseofulvin microsize tabs

2 †

10

Drug Name DrugTier


griseofulvin ultramicrosize

2 †

gynazole-1 1 † itraconazole 2 †PA ketoconazole 1 † LAMISIL SPRAY 3 † MENTAX 3 † miconazole 3 1 † MYCAMINE 4 †B/D NAFTIN CREA 1% 3 † NAFTIN GEL 3 † NATACYN 2 † NOXAFIL 5 †PA nyamyc 1 † nystatin crea 1 † nystatin oint 1 † nystatin powd 100000unit/gm

1 †

nystatin susp 1 † nystatin tabs 1 † nystatin/triamcinolone 1 † nystop 1 † OXISTAT 3 † pedi-dri 1 † SPORANOX ORAL SOLN

3 †PA

terbinafine hcl tabs 1 †QL(30 EA per 30 days)

terconazole 1 † VFEND SUSR 3 †PA voriconazole inj 4 †B/D voriconazole tabs 5 †PA zazole crea 1 † Antigout Agents Antigout Agents allopurinol (tablet) 1 COLCRYS 2 KRYSTEXXA 5 †PA probenecid 1 probenecid/colchicine 1 ULORIC 2 QL(30 EA per 30

days) ST Antimigraine Agents Abortive butalbital/acetaminophen/caffeine tabs


esgic caps 1 QL(180 EA per 30 days)

Drug Name DrugTier


Ergot Alkaloids dihydroergotamine mesylate inj

4 †PA

migergot 2 † MIGRANAL 3 †QL(8 ML per 30

days) Serotonin (5-HT) 1b/1d Receptor Agonists naratriptan hcl 1 †QL(18 EA per

30 days) RELPAX 3 †QL(18 EA per

30 days) rizatriptan benzoate 2 †QL(24 EA per

30 days) rizatriptan benzoate odt 2 †QL(24 EA per

30 days) sumatriptan nasal soln 1 †QL(18 EA per

30 days) sumatriptan succinate inj 4mg/0.5ml, 6mg/0.5ml


sumatriptan succinate inj 6mg/0.5ml


sumatriptan succinate refill inj 4mg/0.5ml


sumatriptan succinate tabs


SUMAVEL DOSEPRO 4 †QL(16 ML per 30 days)

ZOMIG 3 †QL(18 EA per 30 days)

ZOMIG ZMT 3 †QL(18 EA per 30 days)

Antimyasthenic Agents Parasympathomimetics guanidine hcl 1 MESTINON SYRP 3 MESTINON TIMESPAN

3

MYTELASE 3 pyridostigmine bromide 1 Antimycobacterials Antimycobacterials, Other dapsone 1 MYCOBUTIN 3 Antituberculars cycloserine 1 ethambutol hcl 1 ISONIAZID INJ 4 †B/D

11

Drug Name DrugTier


isoniazid syrp 1 isoniazid tabs 1 PASER 3 PRIFTIN 2 pyrazinamide 1 rifampin caps 1 rifampin inj 4 †B/D RIFATER 3 SEROMYCIN 3 TRECATOR 3 Antineoplastics Alkylating Agents ALKERAN INJ 4 †B/D BICNU 4 †B/D BUSULFEX 4 †B/D CEENU 2 cyclophosphamide inj 4 †B/D cyclophosphamide tabs 1 PA dacarbazine 4 †B/D HEXALEN 5 † ifosfamide 4 †B/D ifosfamide/mesna 4 †B/D LEUKERAN 2 MATULANE 5 † melphalan hcl 4 †B/D MUSTARGEN 4 †B/D thiotepa 4 †B/D TREANDA 5 †B/D ZANOSAR 4 †B/D Antiangiogenic Agents CAPRELSA TABS 300MG


CAPRELSA TABS 100MG


REVLIMID CAPS 15MG, 2.5MG, 25MG


REVLIMID CAPS 10MG


REVLIMID CAPS 5MG 5 †PA QL(150 EA per 30 days)

THALOMID CAPS 150MG, 200MG


THALOMID CAPS 100MG


THALOMID CAPS 50MG


Antiestrogens/Modifiers EMCYT 2

Drug Name DrugTier


FARESTON 5 † FASLODEX 4 †B/D SOLTAMOX 3 tamoxifen citrate 1 Antimetabolites ALIMTA 4 †B/D cladribine 4 †B/D CLOLAR 4 †B/D cytarabine aqueous 4 †B/D cytarabine inj 100mg, 1gm, 500mg

4 †B/D

DROXIA 2 ELITEK 5 †B/D floxuridine 4 †B/D FLUOROURACIL INJ 2.5GM/50ML

4 †

hydroxyurea 1 mercaptopurine 1 pentostatin 4 †B/D TABLOID 2 Antineoplastics TAFINLAR 5 †PA QL(120 EA

per 30 days) Antineoplastics, Other ABRAXANE 4 †B/D adriamycin inj 10mg, 20mg, 50mg

4 †B/D

amifostine 4 †B/D ARRANON 5 †B/D bleomycin sulfate 4 †B/D carboplatin inj 150mg/15ml

4 †B/D

cisplatin inj 100mg/100ml

4 †B/D

COMETRIQ KIT 5 †PA QL(56 EA per 28 days)

COMETRIQ KIT 20MG


COMETRIQ KIT 5 †PA QL(112 EA per 28 days)

DACOGEN 5 †PA daunorubicin hcl inj 5mg/ml

4 †B/D

decitabine 5 † dexrazoxane inj 500mg 4 †B/D docetaxel inj 80mg/4ml, 80mg/8ml

4 †B/D

doxorubicin hcl inj 2mg/ml

4 †B/D

12

Drug Name DrugTier


ELLENCE INJ 200MG/100ML

4 †B/D

ELSPAR 4 †B/D EPIRUBICIN HCL INJ 50MG

4 †B/D

epirubicin hcl inj 50mg/25ml

4 †B/D

ERIVEDGE 5 †PA QL(30 EA per 30 days)

fludarabine phosphate 4 †B/D FUSILEV 4 †B/D GILOTRIF 5 †PA QL(30 EA

per 30 days) HALAVEN 5 †B/D IDAMYCIN PFS INJ 20MG/20ML

4 †B/D

idarubicin hcl inj 10mg/10ml

4 †B/D

irinotecan inj 100mg/5ml

4 †B/D

ISTODAX 5 †B/D IXEMPRA KIT 5 †B/D JAKAFI 5 †PA QL(60 EA

per 30 days) JEVTANA 5 †B/D leucovorin calcium inj 100mg, 350mg

4 †B/D

leucovorin calcium tabs 1 MEKINIST 5 †PA MENEST 3 PA mesna 4 †B/D MESNEX TABS 2 mitomycin 4 †B/D mitoxantrone hcl 4 †B/D ONCASPAR 4 †B/D ONTAK 5 †B/D oxaliplatin inj 100mg/20ml

5 †B/D

paclitaxel inj 300mg/50ml

4 †B/D

POMALYST 5 †PA QL(30 EA per 30 days)

PROLEUKIN 5 †B/D SYLATRON 5 †PA SYNRIBO 5 †B/D TRISENOX 4 †B/D VELCADE 5 †B/D VIDAZA 5 †B/D vinblastine sulfate 4 †B/D

Drug Name DrugTier


vincasar pfs 4 †B/D vincristine sulfate 4 †B/D vinorelbine tartrate inj 50mg/5ml

4 †B/D

ZOLINZA 5 †PA QL(120 EA per 30 days)

ZYTIGA 5 †PA QL(120 EA per 30 days)

Aromatase Inhibitors, 3rd Generation anastrozole 1 exemestane 2 letrozole 2 Enzyme Inhibitors ETOPOPHOS 4 †B/D etoposide inj 500mg/25ml

4 †B/D

topotecan hcl inj 4mg 4 †B/D Molecular Target Inhibitors AFINITOR DISPERZ TBSO 5MG


AFINITOR DISPERZ TBSO 2MG


AFINITOR DISPERZ TBSO 3MG


AFINITOR TABS 2.5MG, 5MG


AFINITOR TABS 10MG, 7.5MG


BOSULIF TABS 500MG


BOSULIF TABS 100MG


GLEEVEC TABS 400MG


GLEEVEC TABS 100MG


INLYTA TABS 5MG 5 †PA QL(120 EA per 30 days)

INLYTA TABS 1MG 5 †PA QL(180 EA per 30 days)

NEXAVAR 5 †PA QL(120 EA per 30 days)

SPRYCEL TABS 100MG, 140MG


SPRYCEL TABS 70MG, 80MG


SPRYCEL TABS 50MG


13

Drug Name DrugTier


SPRYCEL TABS 20MG


STIVARGA 5 †PA QL(120 EA per 30 days)

SUTENT CAPS 50MG 5 †PA QL(30 EA per 30 days)

SUTENT CAPS 25MG 5 †PA QL(90 EA per 30 days)

SUTENT CAPS 12.5MG


TARCEVA TABS 100MG, 150MG


TARCEVA TABS 25MG


TASIGNA 5 †PA QL(120 EA per 30 days)

TYKERB 5 †PA QL(660 EA per 30 days)

VOTRIENT 5 †PA QL(120 EA per 30 days)

XALKORI 5 †PA QL(60 EA per 30 days)

ZELBORAF 5 †PA QL(240 EA per 30 days)

Monoclonal Antibodies ARZERRA INJ 100MG/5ML

5 †PA

AVASTIN INJ 100MG/4ML

5 †B/D

CAMPATH 5 †B/D ERBITUX INJ 100MG/50ML

5 †B/D

HERCEPTIN 5 †B/D RITUXAN 5 †PA VECTIBIX INJ 100MG/5ML

5 †B/D

ZALTRAP INJ 100MG/4ML

5 †PA

Retinoids PANRETIN 5 †PA TARGRETIN 5 † tretinoin caps 5 † Antiparasitics Anthelmintics ALBENZA 3 BILTRICIDE 2 STROMECTOL 3

Drug Name DrugTier


Antiprotozoals ALINIA SUSR 3 †QL(180 ML per

3 days) ALINIA TABS 3 †QL(6 EA per 3

days) atovaquone/proguanil hcl tabs 250mg; 100mg

1 †

chloroquine phosphate 1 † COARTEM 2 †QL(24 EA per 2

days) DARAPRIM 2 † hydroxychloroquine sulfate

1 †

MALARONE TABS 62.5MG; 25MG

3 †

mefloquine hcl 1 † MEPRON 5 †PA NEBUPENT 2 †B/D PENTAM 300 4 †B/D primaquine phosphate 1 † quinine sulfate 2 †PA tinidazole tabs 500mg 2 †QL(20 EA per

30 days) tinidazole tabs 250mg 2 †QL(40 EA per

30 days) Pediculicides/Scabicides acticin 1 EURAX 2 lindane 1 malathion 2 permethrin crea 1 spinosad 2 Antiparkinson Agents Anticholinergics benztropine mesylate tabs

1

trihexyphenidyl hcl 1 Antiparkinson Agents, Other entacapone 2 TASMAR 3 Dopamine Agonists APOKYN 4 †PA bromocriptine mesylate 1 MIRAPEX ER 3 QL(30 EA per 30

days) pramipexole dihydrochloride

1

ropinirole er 2

14

Drug Name DrugTier


ropinirole hcl 1 Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors carbidopa/levodopa 1 carbidopa/levodopa er 1 carbidopa/levodopa odt 1 carbidopa/levodopa sr tbcr 25mg; 100mg

1

LODOSYN 3 STALEVO 2 Monoamine Oxidase B (MAO-B) Inhibitors AZILECT 2 QL(30 EA per 30

days) Antipsychotics 1st Generation/Typical chlorpromazine hcl inj 4 †B/D chlorpromazine hcl tabs 1 † compro 1 † fluphenazine decanoate 4 †B/D fluphenazine hcl conc 1 fluphenazine hcl elix 1 fluphenazine hcl inj 4 †B/D fluphenazine hcl tabs 1 haloperidol 1 haloperidol decanoate 4 †B/D haloperidol lactate 4 †B/D loxapine succinate 1 ORAP 2 perphenazine 1 † prochlorperazine 1 † prochlorperazine edisylate

4 †B/D

prochlorperazine maleate

1 †

thioridazine hcl 1 PA thiothixene 1 trifluoperazine hcl 1 2nd Generation/Atypical ABILIFY 3 ABILIFY 4 †B/D ABILIFY DISCMELT 3 PA ABILIFY MAINTENA INJ 300MG

5 †PA

FANAPT 3 QL(60 EA per 30 days)

FANAPT TITRATION PACK


GEODON INJ 4 †B/D

Drug Name DrugTier


INVEGA 3 PA INVEGA SUSTENNA INJ 39MG/0.25ML, 78MG/0.5ML

4 †PA

INVEGA SUSTENNA INJ 117MG/0.75ML, 156MG/ML, 234MG/1.5ML

5 †PA

LATUDA TABS 120MG, 20MG, 40MG


LATUDA TABS 80MG 3 QL(60 EA per 30 days)

olanzapine inj 4 †B/D olanzapine odt 1 olanzapine tabs 1 quetiapine fumarate 1 RISPERDAL CONSTA 4 †B/D risperidone 1 risperidone odt 1 SAPHRIS 3 QL(60 EA per 30

days) SEROQUEL XR 2 ziprasidone hcl 2 Treatment-Resistant clozapine 1 FAZACLO 3 Antispasticity Agents Antispasticity Agents baclofen 1 dantrolene sodium caps 2 tizanidine hcl caps 2 tizanidine hcl tabs 1 Antivirals Anti-cytomegalovirus (CMV) Agents cidofovir 4 †B/D foscarnet sodium 4 †B/D ganciclovir 4 †B/D VALCYTE 5 † Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors ATRIPLA 5 † COMPLERA 5 † EDURANT 3 INTELENCE TABS 25MG

3 †

INTELENCE TABS 100MG, 200MG

5 †

nevirapine tabs 1

15

Drug Name DrugTier


RESCRIPTOR 3 STRIBILD 5 † SUSTIVA 2 VIRAMUNE SUSP 3 VIRAMUNE XR 3 Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors abacavir 2 didanosine 1 EMTRIVA 3 EPIVIR HBV ORAL SOLN

2 PA

EPIVIR HBV TABS 2 PA EPIVIR ORAL SOLN 2 EPZICOM 5 † lamivudine 1 lamivudine/zidovudine 2 RETROVIR IV INFUSION

4 †

stavudine 1 TRIZIVIR 5 † TRUVADA 5 † VIDEX PEDIATRIC 2 VIREAD POWD 3 QL(180 GM per

30 days) VIREAD TABS 200MG, 250MG, 300MG


VIREAD TABS 150MG 3 QL(60 EA per 30 days)

ZERIT ORAL SOLN 3 ZIAGEN ORAL SOLN 2 zidovudine 1 Anti-HIV Agents, Other FUZEON 5 † ISENTRESS CHEW 100MG

5 †

ISENTRESS CHEW 25MG

3

ISENTRESS TABS 5 † SELZENTRY 5 † TIVICAY 5 †QL(60 EA per

30 days) Anti-HIV Agents, Protease Inhibitors APTIVUS 5 † CRIXIVAN 2 INVIRASE CAPS 3 INVIRASE TABS 5 †

Drug Name DrugTier


KALETRA ORAL SOLN

5 †

KALETRA TABS 200MG; 50MG

5 †

KALETRA TABS 100MG; 25MG

3

LEXIVA SUSP 3 LEXIVA TABS 5 † NORVIR 3 PREZISTA SUSP 5 † PREZISTA TABS 150MG, 400MG, 600MG, 800MG

5 †

PREZISTA TABS 75MG

3

REYATAZ 2 VIRACEPT 5 † Anti-influenza Agents amantadine hcl 1 RELENZA DISKHALER


rimantadine hcl 1 TAMIFLU CAPS 75MG


TAMIFLU CAPS 45MG


TAMIFLU CAPS 30MG


TAMIFLU SUSR 2 QL(1080 ML per 365 days)

Antihepatitis Agents BARACLUDE ORAL SOLN


BARACLUDE TABS 5 †QL(30 EA per 30 days)

HEPSERA 5 †QL(30 EA per 30 days)

INCIVEK 5 †PA QL(168 EA per 28 days)

INFERGEN INJ 15MCG/0.5ML

5 †PA

INTRON-A INJ 10MU/ML, 5MU/0.2ML, 6000000UNIT/ML

5 †PA

INTRON-A INJ 10MU/0.2ML, 3MU/0.2ML

4 †PA

16

Drug Name DrugTier


INTRON-A W/DILUENT INJ 10MU

4 †PA

INTRON-A W/DILUENT INJ 18MU, 50MU

5 †PA

PEG-INTRON 5 †PA PEG-INTRON REDIPEN

5 †PA

PEG-INTRON REDIPEN PAK 4

5 †PA

PEGASYS 5 †PA PEGASYS PROCLICK INJ 135MCG/0.5ML

5 †PA QL(2 ML per 28 days)

REBETOL ORAL SOLN

3 PA

ribapak tabs 5 †PA ribasphere 2 PA ribavirin 2 PA TYZEKA 5 †QL(30 EA per

30 days) VICTRELIS 5 †PA QL(336 EA

per 28 days) Antiherpetic Agents acyclovir caps, susp, tabs

1

acyclovir oint 2 QL(30 GM per 7 days)

acyclovir sodium inj 500mg

4 †B/D

DENAVIR 3 famciclovir 2 trifluridine 2 valacyclovir hcl 2 ZOVIRAX CREA 3 QL(5 GM per 30

days) ZOVIRAX OINT 3 QL(30 GM per

30 days) Anxiolytics Anxiolytics, Other alprazolam er tb24 3mg 1 QL(90 EA per 30

days) alprazolam er tb24 2mg 1 QL(150 EA per

30 days) alprazolam er tb24 1mg 1 QL(300 EA per

30 days) alprazolam er tb24 0.5mg


Drug Name DrugTier


alprazolam intensol 1 QL(300 ML per 30 days)

alprazolam tabs 2mg 1 QL(150 EA per 30 days)

alprazolam tabs 1mg 1 QL(300 EA per 30 days)

alprazolam tabs 0.5mg 1 QL(600 EA per 30 days)

alprazolam tabs 0.25mg 1 QL(1200 EA per 30 days)

buspirone hcl 1 diazepam intensol 1 QL(360 ML per

30 days) diazepam oral soln 1 QL(1800 ML per

30 days) diazepam tabs 10mg 1 QL(180 EA per



30 days) estazolam tabs 2mg 1 QL(30 EA per 30

days) estazolam tabs 1mg 1 QL(60 EA per 30

days) lorazepam intensol 1 QL(150 ML per

30 days) lorazepam tabs 2mg 1 QL(150 EA per

30 days) lorazepam tabs 1mg 1 QL(300 EA per

30 days) lorazepam tabs 0.5mg 1 QL(600 EA per

30 days) oxazepam caps 30mg 1 QL(120 EA per



30 days) Bipolar Agents Mood Stabilizers lithium carbonate 1 lithium carbonate er 1 lithium citrate 1 Blood Glucose Regulators Antidiabetic Agents acarbose 2

17

Drug Name DrugTier


BYDUREON 4 †PA QL(4 EA per 30 days)

BYETTA 4 †PA glimepiride 1 glipizide 1 glipizide er 1 glipizide/metformin hcl 1 glyburide 1 glyburide micronized 1 glyburide/metformin hcl 1 GLYSET 3 JANUMET 2 QL(60 EA per 30

days) ST JANUMET XR TB24 1000MG; 100MG, 500MG; 50MG


JANUMET XR TB24 1000MG; 50MG


JANUVIA 2 QL(30 EA per 30 days) ST

JUVISYNC 2 QL(30 EA per 30 days) ST

metformin hcl (GLUCOPHAGE)

1

metformin hcl er (GLUCOPHAGE XR)

1

nateglinide tabs 120mg 1 QL(90 EA per 30 days)

nateglinide tabs 60mg 1 QL(180 EA per 30 days)

pioglitazone hcl 2 ST pioglitazone hcl-glimepiride

2 ST

pioglitazone hcl/metformin hcl

2 ST

PRANDIN TABS 0.5MG, 1MG


PRANDIN TABS 2MG 3 QL(240 EA per 30 days)

repaglinide tabs 0.5mg, 1mg


repaglinide tabs 2mg 2 QL(240 EA per 30 days)

RIOMET 3 SYMLINPEN 120 4 †PA QL(12 ML

per 30 days) SYMLINPEN 60 4 †PA QL(12 ML

per 30 days) tolazamide 1

Drug Name DrugTier


tolbutamide 1 Glycemic Agents dextrose 10%/nacl 0.45%

4 †B/D

dextrose 10% flex container

4 †B/D

dextrose 10%/nacl 0.2% 4 †B/D dextrose 2.5%/sodium chloride 0.45%

4 †B/D

dextrose 5% 4 †B/D dextrose 5%/nacl 0.2% 4 †B/D dextrose 5%/nacl 0.225%

4 †B/D

dextrose 5%/nacl 0.33% 4 †B/D dextrose 5%/nacl 0.45% 4 †B/D dextrose 5%/nacl 0.9% 4 †B/D GLUCAGEN HYPOKIT


GLUCAGON EMERGENCY KIT


kcl 0.15%/d5w/lr 4 †B/D kcl 0.3%/d5w/nacl 0.9% 4 †B/D PROGLYCEM 3 Insulins HUMALOG (VIAL) 2 If Part B covered,

call Blue Shield HUMALOG KWIKPEN 2 HUMULIN (VIAL) 2 If Part B covered,

call Blue Shield LANTUS (VIAL) 2 QL(40 ML per 30

days) If Part B covered, call Blue

Shield LANTUS SOLOSTAR 2 QL(45 ML per 30

days) LEVEMIR (VIAL) 2 QL(40 ML per 30

days) If Part B covered, call Blue

Shield LEVEMIR FLEXPEN 2 QL(45 ML per 30

days) NOVOLIN (VIAL) 3 If Part B covered,

call Blue Shield NOVOLOG (VIAL) 3 If Part B covered,

call Blue Shield Blood Products/Modifiers/Volume Expanders Anticoagulants COUMADIN INJ 4 †B/D

18

Drug Name DrugTier


COUMADIN TABS 3 ELIQUIS TABS 2.5MG 2 PA QL(60 EA

per 30 days) enoxaparin sodium inj 30mg/0.3ml

4 †QL(8.4 ML per 30 days)

enoxaparin sodium inj 40mg/0.4ml






enoxaparin sodium inj 300mg/3ml




enoxaparin sodium inj 100mg/ml, 150mg/ml


fondaparinux sodium inj 5mg/0.4ml


fondaparinux sodium inj 7.5mg/0.6ml


fondaparinux sodium inj 10mg/0.8ml


fondaparinux sodium inj 2.5mg/0.5ml


FRAGMIN INJ 2500UNIT/0.2ML, 5000UNIT/0.2ML


FRAGMIN INJ 25000UNIT/ML


FRAGMIN INJ 7500UNIT/0.3ML


FRAGMIN INJ 10000UNIT/ML, 12500UNIT/0.5ML


FRAGMIN INJ 15000UNIT/0.6ML


FRAGMIN INJ 18000UNT/0.72ML


heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 5000unit/ml

4 †B/D

jantoven 1 PRADAXA 3 PA warfarin sodium 1 XARELTO TABS 10MG


Drug Name DrugTier


XARELTO TABS 15MG, 20MG


Blood Formation Modifiers anagrelide hcl 1 ARANESP ALBUMIN FREE INJ 25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML, 60MCG/ML

4 †PA

ARANESP ALBUMIN FREE INJ 100MCG/0.5ML, 100MCG/ML, 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML, 60MCG/0.3ML

5 †PA

LEUKINE INJ 250MCG

5 †PA

NEULASTA 5 †PA NEUMEGA 5 †PA NEUPOGEN INJ 300MCG/0.5ML, 480MCG/0.8ML, 480MCG/1.6ML

5 †PA

PROCRIT INJ 20000UNIT/ML, 40000UNIT/ML

5 †PA

PROCRIT INJ 10000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

4 †PA

PROCRIT INJ 2000UNIT/ML

2 †PA

PROMACTA TABS 12.5MG, 50MG, 75MG


PROMACTA TABS 25MG


Blood Products/Modifiers/Volume Expanders CINRYZE 5 †B/D Coagulants BRILINTA 2 QL(60 EA per 30

days) CYKLOKAPRON 4 †B/D

19

Drug Name DrugTier


tranexamic acid tabs 2 PA QL(30 EA per 30 days)

Platelet Modifying Agents AGGRENOX 3 cilostazol 1 clopidogrel tabs 75mg 1 EFFIENT 2 QL(30 EA per 30

days) Cardiovascular Agents Alpha-adrenergic Agonists clonidine hcl ptwk 2 clonidine hcl tabs 1 CLORPRES 2 guanfacine hcl 1 methyldopa 1 methyldopa/hydrochlorothiazide

1

midodrine hcl 1 Alpha-adrenergic Blocking Agents prazosin hcl 1 reserpine 1 Angiotensin II Receptor Antagonists candesartan cilexetil tabs 32mg


candesartan cilexetil tabs 16mg






DIOVAN TABS 320MG, 40MG


DIOVAN TABS 160MG, 80MG


EDARBI 2 ST EDARBYCLOR 2 ST eprosartan mesylate 1 QL(30 EA per 30

days) ST irbesartan 2 QL(30 EA per 30

days) ST irbesartan/hydrochlorothiazide tabs 12.5mg; 300mg


irbesartan/hydrochlorothiazide tabs 12.5mg; 150mg


losartan potassium 1 QL(30 EA per 30 days)

Drug Name DrugTier


losartan potassium/hydrochlorothiazide


valsartan/hydrochlorothiazide tabs 12.5mg; 320mg, 12.5mg; 80mg, 25mg; 320mg


valsartan/hydrochlorothiazide tabs 12.5mg; 160mg, 25mg; 160mg


Angiotensin-converting Enzyme (ACE) Inhibitors benazepril hcl tabs 10mg, 20mg, 5mg


benazepril hcl tabs 40mg


benazepril hcl/hydrochlorothiazide

1

captopril 1 captopril/hydrochlorothiazide

1

enalapril maleate 1 enalapril maleate/hydrochlorothiazide

1

fosinopril sodium tabs 10mg, 20mg

1

fosinopril sodium tabs 40mg

1

fosinopril sodium/hydrochlorothiazide


lisinopril 1 lisinopril/hydrochlorothiazide

1

moexipril hcl tabs 7.5mg 1 moexipril hcl tabs 15mg 1 moexipril/hydrochlorothiazide tabs 12.5mg; 7.5mg


moexipril/hydrochlorothiazide tabs 12.5mg; 15mg, 25mg; 15mg


perindopril erbumine tabs 2mg, 4mg


perindopril erbumine tabs 8mg


quinapril hcl 1 QL(60 EA per 30 days)

20

Drug Name DrugTier


quinapril/hydrochlorothiazide


ramipril caps 10mg 1 QL(60 EA per 30 days)

ramipril caps 1.25mg, 2.5mg, 5mg


TARKA 3 trandolapril tabs 1mg, 2mg


trandolapril tabs 4mg 1 QL(60 EA per 30 days)

Antiarrhythmics amiodarone hcl inj 50mg/ml

4 †B/D

amiodarone hcl tabs 200mg, 400mg

1

disopyramide phosphate 1 flecainide acetate 1 mexiletine hcl 1 MULTAQ 2 PA QL(60 EA

per 30 days) NORPACE CR 2 PACERONE TABS 100MG

2

propafenone hcl 1 propafenone hcl er 2 quinidine gluconate cr 1 quinidine sulfate 1 quinidine sulfate er 1 sorine 1 sotalol hcl (af) 1 sotalol hcl tabs 160mg, 240mg, 80mg

1

TIKOSYN 3 Beta-adrenergic Blocking Agents acebutolol hcl 1 atenolol 1 atenolol/chlorthalidone 1 betaxolol hcl tabs 20mg 1 bisoprolol fumarate 1 bisoprolol fumarate/hydrochlorothiazide

1

carvedilol 1 COREG CR 3 ST INNOPRAN XL 3 labetalol hcl tabs 1 LEVATOL 3 metoprolol succinate er 1

Drug Name DrugTier


metoprolol tartrate inj 4 †B/D metoprolol tartrate tabs 1 metoprolol/hydrochlorothiazide

1

nadolol 1 nadolol/bendroflumethiazide

1

pindolol 1 propranolol hcl er 1 propranolol hcl inj 4 †B/D propranolol hcl oral soln

1

propranolol hcl tabs 1 propranolol/hydrochlorothiazide

1

timolol maleate 1 Calcium Channel Blocking Agents afeditab cr 1 amlodipine besylate 1 amlodipine besylate/benazepril hcl

2

CARDIZEM CD CP24 360MG

3

CARDIZEM LA TB24 120MG

3

cartia xt 1 COVERA-HS 3 dilt-xr cp24 180mg 1 diltiazem cd cp24 120mg, 240mg, 300mg

1

diltiazem hcl cp24 120mg, 180mg, 240mg, 300mg

1

diltiazem hcl er cp12 1 diltiazem hcl er cp24 180mg, 360mg, 420mg

1

diltiazem hcl inj 100mg 4 †B/D diltiazem hcl tabs 1 diltzac cp24 120mg, 180mg, 300mg

1

EXFORGE 3 QL(30 EA per 30 days) ST

EXFORGE HCT 3 QL(30 EA per 30 days) ST

felodipine er 1 isradipine 2 matzim la 2 nicardipine hcl caps 1 nifediac cc tb24 90mg 1

21

Drug Name DrugTier


nifedical xl 1 nifedipine er 1 nimodipine 2 nisoldipine 2 nisoldipine er 2 taztia xt 1 verapamil hcl er 1 verapamil hcl inj 4 †B/D verapamil hcl sr cp24 360mg

1

verapamil hcl tabs 1 Cardiovascular Agents, Other DEMSER 3 digoxin inj 4 †B/D digoxin oral soln 1 digoxin tabs 1 LANOXIN TABS 3 pentoxifylline er 1 RANEXA 3 PA Diuretics, Carbonic Anhydrase Inhibitors acetazolamide 1 Diuretics, Loop bumetanide tabs 1 EDECRIN 3 furosemide inj 4 †B/D furosemide oral soln 1 furosemide tabs 1 torsemide inj 20mg/2ml 4 †B/D torsemide tabs 1 Diuretics, Potassium-sparing ALDACTAZIDE TABS 50MG; 50MG

3

amiloride hcl 1 amiloride/hydrochlorothiazide

1

DYRENIUM 3 eplerenone 2 spironolactone 1 spironolactone/hydrochlorothiazide

1

triamterene/hydrochlorothiazide

1

Diuretics, Thiazide candesartan cilexetil/hydrochlorothiazide


chlorothiazide 1 chlorthalidone 1

Drug Name DrugTier


DIURIL 3 hydrochlorothiazide 1 indapamide 1 methyclothiazide 1 metolazone 1 THALITONE 2 Dyslipidemics, Fibric Acid Derivatives fenofibrate caps 130mg 2 QL(30 EA per 30

days) fenofibrate caps 43mg 2 QL(60 EA per 30

days) fenofibrate micronized 1 QL(30 EA per 30

days) fenofibrate tabs 160mg 1 QL(30 EA per 30




days) fenofibric acid dr 2 QL(30 EA per 30

days) gemfibrozil 1 QL(75 EA per 30

days) TRIGLIDE 3 QL(30 EA per 30

days) TRILIPIX 2 QL(30 EA per 30

days) Dyslipidemics, HMG CoA Reductase Inhibitors ADVICOR TB24 40MG; 1000MG


ADVICOR TB24 20MG; 1000MG, 20MG; 500MG, 20MG; 750MG


atorvastatin calcium 1 QL(30 EA per 30 days)

fluvastatin 2 QL(60 EA per 30 days)

LESCOL XL 3 QL(30 EA per 30 days)

lovastatin 1 pravastatin sodium tabs 80mg


pravastatin sodium tabs 10mg, 20mg, 40mg


22

Drug Name DrugTier


SIMCOR TB24 1000MG; 40MG, 500MG; 20MG, 500MG; 40MG


SIMCOR TB24 1000MG; 20MG, 750MG; 20MG


simvastatin 1 QL(30 EA per 30 days)

Dyslipidemics, Other cholestyramine 1 cholestyramine light 1 colestipol hcl for oral suspension

1

colestipol hcl gran 2 colestipol hcl tabs 1 JUXTAPID CAPS 10MG, 5MG


JUXTAPID CAPS 20MG


LOVAZA 3 PA NIASPAN TBCR 1000MG, 750MG


NIASPAN TBCR 500MG


prevalite pack 1 prevalite powd 2 WELCHOL 2 ZETIA 3 PA Vasodilators, Direct-acting Arterial hydralazine hcl inj 4 †B/D hydralazine hcl tabs 1 minoxidil tabs 1 Vasodilators, Direct-acting Arterial/Venous BIDIL 3 PA QL(180 EA

per 30 days) DILATRATE SR 3 ISORDIL TITRADOSE TABS 40MG

3

isosorbide dinitrate 1 isosorbide dinitrate er 1 isosorbide mononitrate 1 isosorbide mononitrate er

1

minitran 1 NITRO-BID 2 nitroglycerin inj 4 †B/D nitroglycerin lingual translingual soln

1

Drug Name DrugTier


nitroglycerin pt24 1 NITROSTAT 2 Central Nervous System Agents Attention Deficit Hyperactivity Disorder Agents, Amphetamines amphetamine/dextroamphetamine cp24


amphetamine/dextroamphetamine tabs 30mg


amphetamine/dextroamphetamine tabs 20mg


amphetamine/dextroamphetamine tabs 5mg, 7.5mg, 10mg, 15mg


amphetamine/dextroamphetamine tabs 12.5mg


dextroamphetamine sulfate er cp24 15mg






dextroamphetamine sulfate tabs 10mg


methamphetamine hcl 1 QL(240 EA per 30 days)

VYVANSE 3 QL(30 EA per 30 days)

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines dexmethylphenidate hcl 1 QL(60 EA per 30

days) FOCALIN XR 3 QL(30 EA per 30

days) KAPVAY 3 PA METHYLIN CHEW 3 QL(180 EA per

30 days) methylphenidate hcl cd cpcr 50mg, 60mg


methylphenidate hcl cd cpcr 10mg


methylphenidate hcl er cp24 40mg


methylphenidate hcl er cp24 20mg, 30mg


methylphenidate hcl er tbcr 18mg, 27mg, 36mg, 54mg


23

Drug Name DrugTier


methylphenidate hcl er tbcr 20mg


methylphenidate hcl oral soln 10mg/5ml


methylphenidate hcl oral soln 5mg/5ml


methylphenidate hcl tabs 20mg






STRATTERA CAPS 100MG, 60MG, 80MG


STRATTERA CAPS 10MG, 18MG, 25MG, 40MG


Central Nervous System Agents butalbital/acetaminophen


butalbital/asa/caffeine 1 QL(180 EA per 30 days)

butalbital/aspirin/caffeine


Central Nervous System, Other NUEDEXTA 2 QL(60 EA per 30

days) riluzole 5 † XENAZINE TABS 25MG


XENAZINE TABS 12.5MG


Multiple Sclerosis Agents AMPYRA 5 †PA QL(60 EA

per 30 days) AUBAGIO 5 †PA QL(30 EA

per 30 days) COPAXONE 5 † GILENYA 5 †PA QL(30 EA

per 30 days) Dental and Oral Agents Dental and Oral Agents APHTHASOL 3 cevimeline hcl 2 chlorhexidine gluconate mouth/throat soln

1

chlorhexidine gluconate oral rinse

1

Drug Name DrugTier


KEPIVANCE 5 †B/D periogard 1 pilocarpine hcl tabs 2 triamcinolone in orabase

1

Dermatological Agents Dermatological Agents 8-MOP 3 acitretin 5 † adapalene 1 PA ammonium lactate 1 amnesteem 2 AZELEX 3 calcipotriene crea 2 calcipotriene external soln

2

calcipotriene oint 1 calcitrene 1 CARAC 3 CLARAVIS CAPS 10MG, 20MG, 40MG

3

claravis caps 30mg 5 † clindamycin phosphate external soln

1

clindamycin phosphate foam

1 QL(100 GM per 30 days)

clindamycin phosphate gel

1

clindamycin phosphate lotn

1

clindamycin phosphate swab

1

clindamycin/benzoyl peroxide gel 5%; 1%

1

CONDYLOX GEL 3 CORTISPORIN CREA 3 DIFFERIN GEL 0.3% 3 PA DIFFERIN LOTN 3 PA ELIDEL 3 QL(100 GM per

30 days) ST erythromycin/benzoyl peroxide

1

FINACEA 3 FLUOROPLEX 3 fluorouracil crea 2 fluorouracil external soln

1

gauze pads 1

24

Drug Name DrugTier


imiquimod 1 QL(24 EA per 30 days)

laclotion 1 myorisan 2 OXSORALEN 3 OXSORALEN ULTRA 5 † podofilox 1 PROTOPIC 3 QL(100 GM per

30 days) ST REGRANEX 5 †PA SANTYL 2 selenium sulfide lotn 1 SOLARAZE 3 SORIATANE 5 † STELARA 5 †PA sulfacetamide sodium susp

1

TAZORAC 3 PA tretinoin crea 1 PA tretinoin gel 1 PA ZONALON 3 QL(45 GM per

30 days) ZYCLARA 2 QL(28 EA per 30

days) Enzyme Replacement/Modifiers Enzyme Replacement/Modifiers ADAGEN 4 †B/D ALDURAZYME 5 †B/D BUPHENYL 5 †PA CARBAGLU 5 †PA CEREZYME 5 †PA CREON 2 CYSTADANE 3 CYSTAGON 3 ELAPRASE 5 †B/D FABRAZYME 5 †B/D KUVAN 5 †PA LUMIZYME 5 †B/D MYOZYME 5 †B/D NAGLAZYME 5 †B/D ORFADIN 3 PA PANCREAZE 2 RAVICTI 5 †PA QL(525 ML

per 30 days) sodium phenylbutyrate 5 †PA SUCRAID 5 † VPRIV 5 †B/D ZAVESCA 5 † ZENPEP 3

Drug Name DrugTier


Gastrointestinal Agents Antispasmodics, Gastrointestinal atropine sulfate inj 0.05mg/ml, 0.1mg/ml, 1mg/ml

4 †B/D

CANTIL 3 dicyclomine hcl 1 glycopyrrolate tabs 1 methscopolamine bromide

1

propantheline bromide 1 Gastrointestinal Agents GATTEX 5 †PA QL(30 EA

per 30 days) Gastrointestinal Agents, Other cromolyn sodium conc 2 diphenoxylate/atropine 1 GASTROCROM 3 loperamide hcl caps 1 metoclopramide hcl inj 4 †B/D metoclopramide hcl oral soln

1 †

metoclopramide hcl tabs 1 † RELISTOR INJ 12MG/0.6ML

4 †PA

ursodiol caps 1 ursodiol tabs 2 VISICOL 3 Histamine2 (H2) receptor Antagonists cimetidine 1 cimetidine hcl inj 4 †B/D cimetidine hcl oral soln 1 famotidine inj 4 †B/D famotidine susr 1 famotidine tabs 20mg, 40mg

1

nizatidine 1 ranitidine hcl caps 1 ranitidine hcl inj 150mg/6ml

4 †B/D

ranitidine hcl syrp 1 ranitidine hcl tabs 150mg, 300mg

1

ZANTAC TBEF 3 Irritable Bowel Syndrome Agents AMITIZA 3 PA QL(60 EA

per 30 days)

25

Drug Name DrugTier


LINZESS 3 PA QL(30 EA per 30 days)

LOTRONEX 2 PA Laxatives enulose 1 gavilyte-c 1 gavilyte-g 1 gavilyte-n/flavor pack 1 GOLYTELY ORAL SOLN 227.1GM; 2.82GM; 6.36GM; 5.53GM; 21.5GM

3

KRISTALOSE PACK 10GM

3

lactulose 1 peg 3350/electrolytes 1 polyethylene glycol 3350 powd

1

SUPREP BOWEL PREP

2

trilyte 1 Protectants CYTOTEC TABS 100MCG

3

misoprostol 1 sucralfate tabs 1 Proton Pump Inhibitors DEXILANT 2 QL(30 EA per 30

days) ST lansoprazole 2 NEXIUM I.V. 4 †B/D omeprazole cpdr 1 omeprazole/sodium bicarbonate

2 ST

pantoprazole sodium inj 4 †B/D pantoprazole sodium tbec

1

PRILOSEC PACK 10MG


PRILOSEC PACK 2.5MG


PROTONIX PACK 3 ZEGERID PACK 3 QL(30 EA per 30

days) Genitourinary Agents Antispasmodics, Urinary DETROL LA 3 QL(30 EA per 30

days) ST

Drug Name DrugTier


ENABLEX TB24 15MG


ENABLEX TB24 7.5MG


flavoxate hcl 1 GELNIQUE GEL 10% 2 oxybutynin chloride 1 oxybutynin chloride er 1 tolterodine tartrate 2 QL(60 EA per 30

days) ST TOVIAZ 3 QL(30 EA per 30

days) ST trospium chloride 2 QL(60 EA per 30

days) trospium chloride er 2 QL(30 EA per 30

days) VESICARE TABS 10MG


VESICARE TABS 5MG


Benign Prostatic Hypertrophy Agents alfuzosin hcl er 1 QL(30 EA per 30

days) AVODART 3 QL(30 EA per 30

days) ST doxazosin mesylate 1 finasteride (tablet) tabs 5mg

1

RAPAFLO 3 QL(30 EA per 30 days) ST

tamsulosin hcl 1 terazosin hcl 1 Genitourinary Agents, Other bethanechol chloride 1 ELMIRON 2 Phosphate Binders FOSRENOL 5 † RENVELA PACK 2 QL(180 EA per

30 days) RENVELA TABS 2 Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) Glucocorticoids/Mineralocorticoids ALA SCALP 3 ala-cort 1 alclometasone dipropionate

1

amcinonide 1

26

Drug Name DrugTier


ANUSOL-HC CREA 3 augmented betamethasone dipropionate crea

1

augmented betamethasone dipropionate gel

1

augmented betamethasone dipropionate lotn

1

augmented betamethasone dipropionate oint

2

betamethasone dipropionate

1

betamethasone valerate crea

1

betamethasone valerate foam

2

betamethasone valerate lotn

1

betamethasone valerate oint

1

CAPEX 3 CELESTONE 3 clobetasol propionate crea

1

clobetasol propionate e 1 clobetasol propionate emollient crea

1

clobetasol propionate external soln

1

clobetasol propionate foam

2 PA

clobetasol propionate gel

1

clobetasol propionate lotn

2 PA

clobetasol propionate oint

1

clobetasol propionate sham

2 PA

CLODERM PUMP 3 clotrimazole/betamethasone dipropionate

1 †

CORDRAN 3 CORDRAN SP 3 CORDRAN TAPE 3 CORTIFOAM 2

Drug Name DrugTier


cortisone acetate 1 desonide crea 1 desonide lotn 2 desonide oint 1 desoximetasone crea 2 desoximetasone gel 2 desoximetasone oint 0.25%

2

desoximetasone oint 0.05%

1

dexamethasone 1 dexamethasone intensol 1 dexamethasone sodium phosphate inj 4mg/ml

4 †B/D

diflorasone diacetate 2 DIPROLENE LOTN 3 fludrocortisone acetate 1 fluocinolone acetonide 1 fluocinolone acetonide body oil

1

fluocinonide 1 fluocinonide-e 1 fluticasone propionate crea

1

fluticasone propionate lotn

2

fluticasone propionate oint

1

halobetasol propionate 1 HALOG 3 hydrocortisone butyrate 1 hydrocortisone crea 1%, 2.5%

1

hydrocortisone in absorbase

1

hydrocortisone lotn 1 hydrocortisone oint 1%, 2.5%

1

hydrocortisone tabs 1 hydrocortisone valerate 1 KENALOG 3 LOCOID LIPOCREAM 3 lokara 2 MEDROL TABS 2MG, 4MG

2

methylprednisolone (tablet)

1

methylprednisolone acetate (injection)

4 †B/D

27

Drug Name DrugTier


methylprednisolone dose pack

1

methylprednisolone sodiumsuccinate inj 125mg, 1gm, 40mg

4 †B/D

mometasone furoate crea

1

mometasone furoate external soln

1

mometasone furoate oint 1 ORAPRED ODT 3 PANDEL 3 prednicarbate 1 prednisolone sodium phosphate

1

prednisone 1 prednisone intensol 1 proctocream hc 1 proctosol hc 1 TACLONEX OINT 3 PA TEXACORT 3 triamcinolone acetonide crea

1

triamcinolone acetonide lotn

1

triamcinolone acetonide oint

1

triderm 1 u-cort 1 VANOS 3 PA VERDESO 3 Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) ACTHAR HP 5 †PA chorionic gonadotropin 4 †B/D desmopressin acetate nasal soln

2

desmopressin acetate tabs

1

EGRIFTA INJ 1MG 5 †PA QL(60 EA per 30 days)

GENOTROPIN 5 †PA

Drug Name DrugTier


GENOTROPIN MINIQUICK INJ 0.4MG, 0.6MG, 0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG

5 †PA

GENOTROPIN MINIQUICK INJ 0.2MG

4 †PA

HUMATROPE INJ 6MG

4 †PA

HUMATROPE INJ 12MG, 24MG, 5MG

5 †PA

INCRELEX 5 †PA NORDITROPIN FLEXPRO

5 †PA

NORDITROPIN NORDIFLEX PEN

5 †PA

NUTROPIN 5 †PA NUTROPIN AQ 5 †PA OMNITROPE INJ 5.8MG

5 †PA

OMNITROPE INJ 10MG/1.5ML, 5MG/1.5ML

4 †PA

SAIZEN 5 †PA SEROSTIM 5 †PA STIMATE 3 ZORBTIVE 5 †PA Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) KORLYM 5 †PA QL(120 EA

per 30 days) Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) Anabolic Steroids ANADROL-50 3 oxandrolone 2 PA Androgens ANDRODERM 3 QL(30 EA per 30

days) ST ANDROGEL GEL 50MG/5GM


28

Drug Name DrugTier


ANDROGEL PUMP GEL 1.62%


ANDROGEL PUMP GEL 1%


androxy 2 AXIRON 3 QL(180 ML per

30 days) danazol 2 DEPO-TESTOSTERONE INJ 100MG/ML

4 †B/D

STRIANT 3 TESTIM 3 QL(300 GM per

30 days) testosterone cypionate inj 200mg/ml

4 †B/D

testosterone enanthate 4 †B/D Estrogens ACTIVELLA TABS 0.5MG; 0.1MG

2

ALORA 3 QL(8 EA per 28 days)

amethia 1 amethyst 1 apri 1 aranelle 1 aviane 1 balziva 1 briellyn 1 cesia 1 CLIMARA PRO 2 QL(4 EA per 28

days) COMBIPATCH 2 QL(8 EA per 28

days) cryselle 1 cyclafem 1/35 1 cyclafem 7/7/7 1 DELESTROGEN INJ 20MG/ML, 40MG/ML

4 †B/D

DEPO-ESTRADIOL 4 †B/D drospirenone/ethinyl estradiol

1

emoquette 1 ENJUVIA 2 PA enpresse 1 ESTRACE CREA 2 estradiol ptwk 1 QL(16 EA per 30

days) estradiol tabs 1

Drug Name DrugTier


estradiol valerate 4 †B/D estradiol/norethindrone acetate

1

ESTRING 2 QL(1 EA per 84 days)

estropipate 1 PA FEMHRT LOW DOSE 3 FDA Max Dose

28/28 days FEMRING 3 QL(1 EA per 84

days) FEMTRACE 3 gianvi 1 gildagia 1 introvale 1 jinteli 1 junel 1 junel fe 1 kariva 1 kelnor 1 lessina 1 levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg

1

levora 1 LOESTRIN FE TABS 20MCG; 75MG; 1MG

3

low-ogestrel 1 lutera 1 MENOSTAR 3 QL(4 EA per 28

days) microgestin 1 microgestin fe 1 mononessa 1 necon 1/35 1 necon 1/50-28 1 NECON TABS 35MCG; 0

2

necon tabs 0; 0, 35mcg; 0.5mg

1

nortrel 1 nortrel 1/35 1 NUVARING 2 QL(1 EA per 28

days) ocella 1 ogestrel 1 orsythia 1 ORTHO EVRA 2 OVCON-50 28 3 portia 1

29

Drug Name DrugTier


PREFEST 3 FDA Max Dose 30 tabs/30 days

PREMARIN CREA 2 PREMPHASE 2 PA QL(28 EA

per 28 days) PREMPRO 2 PA QL(28 EA

per 28 days) previfem 1 quasense 1 reclipsen 1 solia 1 sprintec 1 tri-legest fe 1 tri-previfem 1 tri-sprintec 1 trinessa 1 trivora 1 VAGIFEM 2 velivet 1 vestura 1 VIVELLE-DOT PTTW 0.05MG/24HR


VIVELLE-DOT PTTW 0.025MG/24HR, 0.0375MG/24HR, 0.075MG/24HR, 0.1MG/24HR


zenchent fe 1 zeosa 1 zovia 1 Progestins camila 1 CRINONE 3 PA DEPO-PROVERA INJ 400MG/ML

4 †B/D

ENDOMETRIN 3 PA errin 1 jolivette 1 medroxyprogesterone acetate inj

4 †B/D

medroxyprogesterone acetate tabs

1

MEGACE ES 3 PA megestrol acetate 1 PA nora-be 1 norethindrone acetate 1 PLAN B 2 progesterone caps 1

Drug Name DrugTier


Selective Estrogen Receptor Modifying Agents EVISTA 2 QL(30 EA per 30

days) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) levothroid 1 levothyroxine sodium tabs

1

levoxyl 1 liothyronine sodium tabs 1 SYNTHROID 3 THYROLAR-1/2 2 TIROSINT 3 unithroid tabs 100mcg, 112mcg, 125mcg, 150mcg, 175mcg, 200mcg, 25mcg, 300mcg, 50mcg, 75mcg, 88mcg

1

Hormonal Agents, Suppressant (Adrenal) Hormonal Agents, Suppressant (Adrenal) LYSODREN 2 Hormonal Agents, Suppressant (Parathyroid) Hormonal Agents, Suppressant (Parathyroid) SENSIPAR TABS 30MG

2 PA

SENSIPAR TABS 60MG, 90MG

5 †PA

Hormonal Agents, Suppressant (Pituitary) Hormonal Agents, Suppressant (Pituitary) cabergoline 2 QL(16 EA per 30

days) ELIGARD INJ 22.5MG, 7.5MG

4 †B/D

leuprolide acetate 4 †B/D LUPRON DEPOT INJ 22.5MG, 3.75MG, 30MG, 45MG, 7.5MG

4 †B/D

LUPRON DEPOT-PED INJ 11.25MG, 15MG, 7.5MG

4 †B/D

octreotide acetate 4 †PA SANDOSTATIN LAR DEPOT

5 †PA

SOMATULINE DEPOT 4 †PA

30

Drug Name DrugTier


SOMAVERT 5 †PA SYNAREL 5 † Hormonal Agents, Suppressant (Sex Hormones/Modifiers) Antiandrogens bicalutamide 1 flutamide 2 NILANDRON 2 XTANDI 5 †PA QL(120 EA

per 30 days) Hormonal Agents, Suppressant (Thyroid) Antithyroid Agents methimazole 1 propylthiouracil 1 Immunological Agents Immune Suppressants ASTAGRAF XL 3 B/D AZASAN 3 B/D azathioprine 1 B/D azathioprine sodium 4 †B/D BENLYSTA INJ 120MG

5 †PA

CELLCEPT INTRAVENOUS

4 †PA

CELLCEPT SUSR 2 PA cyclosporine caps 1 B/D cyclosporine inj 4 †B/D cyclosporine modified 1 B/D ENBREL 5 †PA gengraf 2 B/D HUMIRA 5 †PA HUMIRA PEN 5 †PA HUMIRA STARTER KIT

5 †PA

KINERET 5 †PA methotrexate (tablet) 1 methotrexate sodium 4 †B/D mycophenolate mofetil 1 PA MYFORTIC 2 PA NULOJIX 5 †B/D ORENCIA INJ 250MG 5 †PA ORENCIA INJ 125MG/ML

5 †PA QL(4 ML per 28 days)

PROGRAF INJ 4 †B/D RAPAMUNE 3 PA REMICADE 5 †PA SANDIMMUNE ORAL SOLN

3 B/D

Drug Name DrugTier


SIMPONI INJ 50MG/0.5ML

5 †PA QL(0.5 ML per 30 days)

tacrolimus 1 B/D TORISEL 5 †B/D TREXALL 3 ZORTRESS TABS 0.25MG, 0.75MG

2 B/D QL(60 EA per 30 days)

ZORTRESS TABS 0.5MG

2 B/D QL(120 EA per 30 days)

Immunizing Agents, Passive CARIMUNE NANOFILTERED

5 †PA

GAMASTAN S/D 4 †PA GAMMAGARD LIQUID

5 †PA

GAMMAGARD S/D 5 †PA GAMUNEX-C 5 †PA PRIVIGEN INJ 20GM/200ML

5 †PA

Immunomodulators ACTIMMUNE 5 †PA ARCALYST 5 †PA AVONEX 5 †QL(4 EA per 28

days) BETASERON 5 †PA QL(15 EA

per 30 days) EXTAVIA 5 †PA QL(15 EA

per 30 days) ILARIS 5 †PA leflunomide 1 REBIF 5 †QL(12 ML per

30 days) REBIF TITRATION PACK


RIDAURA 2 TECFIDERA 5 †PA QL(60 EA

per 30 days) TECFIDERA STARTER PACK


TYSABRI 5 †PA XELJANZ 5 †PA QL(60 EA

per 30 days) Vaccines ACTHIB 4 † ADACEL 4 † BIOTHRAX 4 † BOOSTRIX 4 † CERVARIX 4 † COMVAX 4 †

31

Drug Name DrugTier


DAPTACEL 4 † DECAVAC 4 †B/D ENGERIX-B 4 †B/D GARDASIL 4 † HAVRIX 4 †B/D IMOVAX RABIES (H.D.C.V.)

4 †B/D

INFANRIX 4 † IPOL 4 † IXIARO 4 † JE-VAX 4 † M-M-R II 4 † MENACTRA 4 † MENOMUNE-A/C/Y/W-135

4 †

MENVEO 4 † PEDVAX HIB 4 † PROQUAD 4 † RABAVERT 4 †B/D RECOMBIVAX HB INJ 10MCG/ML, 40MCG/ML

4 †B/D

ROTARIX 3 B/D ROTATEQ 2 tetanus toxoid adsorbed 4 †B/D TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT

4 †B/D

TWINRIX 4 †B/D TYPHIM VI 4 † VAQTA INJ 25UNIT/0.5ML

4 †B/D

VARIVAX 4 † YF-VAX 4 † ZOSTAVAX 4 † Inflammatory Bowel Disease Agents Aminosalicylates APRISO 2 QL(120 EA per

30 days) ASACOL 2 QL(360 EA per

30 days) ASACOLHD 2 QL(180 EA per

30 days) balsalazide disodium 2 CANASA 3 LIALDA 2 QL(120 EA per

30 days) mesalamine kit 1

Drug Name DrugTier


Glucocorticoids budesonide cp24 5 † colocort 1 hydrocortisone enem 1 methylprednisolone (tablet)

1

millipred tabs 1 Sulfonamides sulfasalazine 1 sulfazine 1 sulfazine ec 1 Metabolic Bone Disease Agents Metabolic Bone Disease Agents ACTONEL TABS 30MG

2 PA

ACTONEL TABS 150MG


ACTONEL TABS 35MG


ACTONEL TABS 5MG 3 QL(30 EA per 30 days) ST

alendronate sodium oral soln


alendronate sodium tabs 35mg, 70mg


alendronate sodium tabs 10mg, 40mg, 5mg


ATELVIA 3 QL(4 EA per 30 days) ST

BONIVA INJ 4 †PA calcitonin-salmon 1 QL(3.7 ML per

30 days) calcitriol caps 1 B/D calcitriol inj 4 †B/D calcitriol oral soln 2 B/D etidronate disodium 2 FORTEO 5 †PA FORTICAL 2 FOSAMAX PLUS D 3 QL(4 EA per 28

days) HECTOROL CAPS 2 HECTOROL INJ 4 †B/D ibandronate sodium 2 QL(1 EA per 30

days) ST MIACALCIN INJ 4 †PA PROLIA 4 †PA SKELID 3

32

Drug Name DrugTier


XGEVA 5 †PA QL(1.7 ML per 28 days)

ZEMPLAR CAPS 2 ZEMPLAR INJ 4 †B/D zoledronic acid inj 4mg/5ml

4 †PA

ZOMETA INJ 4MG/100ML

4 †PA

Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents BD NEEDLE/30G X 1/2"

2

FERRIPROX 5 †PA QL(540 EA per 30 days)

FIRAZYR 5 †PA QL(6 ML per 1 days)

INSULIN SYRINGES, NEEDLES

2

INTRALIPID INJ 1.7%; 30%

4 †B/D

lactated ringers irrigation

4 †B/D

levocarnitine tabs 1 methylergonovine maleate tabs

1

physiolyte 1 physiosol irrigation 1 sodium chloride 0.9% 4 †B/D Ophthalmic Agents Ophthalmic Prostaglandin and Prostamide Analogs latanoprost 1 LUMIGAN OPHTHALMIC SOLN 0.01%

2 QL(2.5 ML per 30 days)

LUMIGAN OPHTHALMIC SOLN 0.03%

2 QL(7.5 ML per 30 days)

TRAVATAN Z 2 QL(5 ML per 30 days)

travoprost 2 QL(5 ML per 30 days)

Ophthalmic Agents, Other atropine sulfate ophthalmic soln

1

CYSTARAN 5 †PA QL(60 ML per 28 days)

LACRISERT 3

Drug Name DrugTier


mydral 1 naphazoline hcl 1 RESTASIS 2 QL(64 EA per 30

days) tropicamide 1 Ophthalmic Anti-allergy Agents ALOCRIL 3 ALOMIDE 2 azelastine hcl ophthalmic soln

1

BEPREVE 3 cromolyn sodium ophthalmic soln

1

EMADINE 3 ST epinastine hcl 1 LASTACAFT 3 QL(3 ML per 30

days) PATADAY 2 PATANOL 2 QL(10 ML per 30

days) Ophthalmic Anti-inflammatories ALREX 2 BLEPHAMIDE 2 † BLEPHAMIDE S.O.P. 2 † bromfenac 1 dexamethasone sodium phosphate ophthalmic soln

1

diclofenac sodium 1 DUREZOL 3 FLAREX 3 fluorometholone 1 flurbiprofen sodium 1 FML 2 FML FORTE 3 ILEVRO 3 QL(1.7 ML per

30 days) ketorolac tromethamine ophthalmic soln

1

LOTEMAX GEL 2 LOTEMAX SUSP 2 MAXIDEX 3 neomycin/polymyxin/dexamethasone

1 †

NEVANAC 3 poly-dex 1 † PRED MILD 3 PRED-G 3 † PRED-G S.O.P. 3 †

33

Drug Name DrugTier


prednisolone acetate 1 prednisolone sodium phosphate

1

sulfacetamide sodium/prednisolone sodium phosphate

1 †

TOBRADEX OINT 2 † tobramycin/dexamethasone

1 †

VEXOL 3 VOLTAREN OPHTHALMIC SOLN

3

ZYLET 2 † Ophthalmic Antiglaucoma Agents acetazolamide er 1 ALPHAGAN P 2 apraclonidine 1 AZOPT 2 betaxolol hcl ophthalmic soln

1

BETIMOL 2 BETOPTIC-S 3 brimonidine tartrate 1 carteolol hcl 1 dorzolamide hcl 1 dorzolamide hcl/timolol maleate

1

ISOPTO CARPINE 3 levobunolol hcl 1 methazolamide 2 metipranolol 1 PHOSPHOLINE IODIDE

3

PILOPINE HS 2 timolol maleate 1 Otic Agents Otic Agents acetic acid otic soln 1 acetic acid/aluminum acetate

1

COLY-MYCIN S 2 † CORTISPORIN-TC 2 † hydrocortisone/acetic acid

1

neomycin/polymyxin/hydrocortisone

1 †

Drug Name DrugTier


Respiratory Tract Agents Anti-inflammatories, Inhaled Corticosteroids ADVAIR DISKUS 2 QL(60 EA per 30

days) ADVAIR HFA 2 QL(12 GM per

30 days) ASMANEX 7 METERED DOSES

2 QL(0.54 EA per 30 days)

ASMANEX AEPB 110MCG/INH






BECONASE AQ 3 QL(50 GM per 30 days)

budesonide susp 2 B/D QL(120 ML per 30 days)

FLOVENT DISKUS AEPB 100MCG/BLIST, 50MCG/BLIST


FLOVENT DISKUS AEPB 250MCG/BLIST


FLOVENT HFA AERO 44MCG/ACT


FLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT


flunisolide 1 QL(50 ML per 30 days)

fluticasone propionate susp


NASONEX 2 QL(34 GM per 30 days)

OMNARIS 3 QL(12.5 GM per 30 days) ST

PULMICORT FLEXHALER


PULMICORT SUSP 1MG/2ML

2 B/D QL(60 ML per 30 days)

PULMICORT SUSP 0.25MG/2ML, 0.5MG/2ML


QVAR AERS 80MCG/ACT

2 QL(21.9 GM per 30 days)

QVAR AERS 40MCG/ACT


RHINOCORT AQUA 3 QL(17.2 GM per 30 days) ST

34

Drug Name DrugTier


SYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT


SYMBICORT AERO 160MCG/ACT; 4.5MCG/ACT


triamcinolone acetonide inha


Antihistamines ASTEPRO 2 QL(30 ML per 25

days) azelastine hcl nasal soln 1 QL(30 ML per 30

days) carbinoxamine maleate 1 CLARINEX SYRP 3 QL(473 ML per

30 days) ST CLARINEX-D TB12 3 QL(60 EA per 30

days) ST CLARINEX-D TB24 3 QL(30 EA per 30

days) ST clemastine fumarate syrp

1

clemastine fumarate tabs 2.68mg

1

desloratadine 2 QL(30 EA per 30 days) ST

desloratadine odt 2 ST diphenhydramine hcl caps 50mg

1 †

diphenhydramine hcl elix

1 †

diphenhydramine hcl inj 4 †B/D hydroxyzine hcl tabs 50mg

1

hydroxyzine pamoate 1 levocetirizine dihydrochloride

1

SEMPREX-D 3 Antileukotrienes montelukast sodium 1 QL(30 EA per 30

days) SINGULAIR PACK 2 QL(30 EA per 30

days) zafirlukast 1 ZYFLO CR 3 Bronchodilators, Anticholinergic ATROVENT HFA 3 QL(52 GM per

30 days)

Drug Name DrugTier


COMBIVENT RESPIMAT


ipratropium bromide inhalation soln


ipratropium bromide nasal soln 0.03%


ipratropium bromide nasal soln 0.06%


ipratropium bromide/albuterol sulfate


SPIRIVA HANDIHALER


TUDORZA PRESSAIR 2 QL(1 EA per 30 days)

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) aminophylline 4 †B/D ELIXOPHYLLIN 3 THEO-24 3 theochron 1 theophylline er 1 Bronchodilators, Sympathomimetic albuterol sulfate nebu 0.5%


albuterol sulfate nebu 1.25mg/3ml


albuterol sulfate nebu 0.083%


albuterol sulfate nebu 0.63mg/3ml


ARCAPTA NEOHALER


AUVI-Q 2 QL(4 EA per 2 days)

COMBIVENT 3 QL(29.4 GM per 30 days)

epinephrine hcl inj 0.1mg/ml

4 †

EPIPEN 2 QL(4 EA per 2 days)

levalbuterol 1 PA QL(90 EA per 30 days)

levalbuterol hcl nebu 0.31mg/3ml, 0.63mg/3ml

1 PA QL(288 ML per 30 days)

MAXAIR AUTOHALER


PROAIR HFA 2 QL(17 GM per 30 days)

35

Drug Name DrugTier


SEREVENT DISKUS 2 QL(60 EA per 30 days)

terbutaline sulfate inj 4 †B/D terbutaline sulfate tabs 1 TWINJECT 2 QL(2 EA per 2

days) VENTOLIN HFA 2 QL(36 GM per

30 days) XOPENEX CONCENTRATE


XOPENEX HFA 3 QL(30 GM per 30 days)

XOPENEX NEBU 1.25MG/3ML

3 PA QL(288 ML per 30 days)

Mast Cell Stabilizers cromolyn sodium nebu 1 B/D QL(240 ML

per 30 days) Pulmonary Antihypertensives ADCIRCA 5 †PA LETAIRIS TABS 10MG


LETAIRIS TABS 5MG 5 †PA QL(60 EA per 30 days)

sildenafil citrate 5 †PA TRACLEER TABS 125MG


TRACLEER TABS 62.5MG


VENTAVIS INHALATION SOLN 10MCG/ML

5 †B/D QL(540 ML per 30 days)

Respiratory Tract Agents, Other acetylcysteine inhalation soln

1 B/D

ARALAST NP INJ 400MG

5 †B/D

GLASSIA 5 †B/D KALYDECO 5 †PA QL(60 EA

per 30 days) PROLASTIN-C 5 †B/D PULMOZYME 5 †B/D QL(150

ML per 30 days) TYZINE 2 XOLAIR 5 †PA ZEMAIRA 5 †B/D

Drug Name DrugTier


Skeletal Muscle Relaxants Skeletal Muscle Relaxants carisoprodol tabs 250mg


orphenadrine citrate er 1 PA SOMA TABS 250MG 3 QL(120 EA per

30 days) Sleep Disorder Agents GABA Receptor Modulators temazepam caps 22.5mg, 30mg


temazepam caps 15mg 1 QL(60 EA per 30 days)

temazepam caps 7.5mg 1 QL(120 EA per 30 days)

triazolam tabs 0.25mg 1 QL(60 EA per 30 days)

triazolam tabs 0.125mg 1 QL(120 EA per 30 days)

zaleplon caps 10mg 1 QL(60 EA per 30 days)

zaleplon caps 5mg 1 QL(120 EA per 30 days)

zolpidem tartrate er tbcr 12.5mg


zolpidem tartrate er tbcr 6.25mg


zolpidem tartrate tabs 10mg


zolpidem tartrate tabs 5mg


Sleep Disorders, Other modafinil tabs 200mg 1 PA QL(60 EA

per 30 days) modafinil tabs 100mg 1 PA QL(90 EA

per 30 days) NUVIGIL TABS 150MG, 250MG


NUVIGIL TABS 50MG 2 PA QL(60 EA per 30 days)

ROZEREM 3 QL(30 EA per 30 days) ST

SILENOR 3 QL(30 EA per 30 days)

XYREM 5 †PA Therapeutic Nutrients/Minerals/Electrolytes Electrolyte/Mineral Modifiers CHEMET 2

36

Drug Name DrugTier


CUPRIMINE 2 DEPEN TITRATABS 2 EXJADE 5 † kionex powd 2 sodium polystyrene sulfonate susp 15gm/60ml

2

SYPRINE 3 Electrolyte/Mineral Replacement AMINOSYN II INJ 71.8MEQ/L; 993MG/100ML; 1018MG/100ML; 700MG/100ML; 738MG/100ML; 500MG/100ML; 300MG/100ML; 660MG/100ML; 1000MG/100ML; 1050MG/100ML; 172MG/100ML; 298MG/100ML; 722MG/100ML; 530MG/100ML; 45.3MEQ/L; 400MG/100ML; 200MG/100ML; 270MG/100ML; 500MG/100ML

4 †B/D

calcium acetate caps 1 dextrose 5% /electrolyte #48 viaflex

4 †B/D

DEXTROSE 5%/POTASSIUM CHLORIDE 0.15%

4 †B/D

eliphos 1 ISOLYTE-M/DEXTROSE 5%

4 †B/D

KLOR-CON 10 2 KLOR-CON 8 2 klor-con m10 1 klor-con m15 1 LACTATED RINGERS VIAFLEX

4 †B/D

NORMOSOL-M IN D5W

4 †B/D

potassium chloride 0.224%/dextrose 5% viaflex

4 †B/D

Drug Name DrugTier


potassium chloride 0.3%/d5w

4 †B/D

potassium chloride er cpcr

1

potassium chloride er tbcr 10meq, 20meq

1

potassium chloride inj 0.4meq/ml, 10meq/100ml, 10meq/50ml, 2meq/ml, 30meq/100ml

4 †B/D

potassium chloride sr 1 potassium citrate tbcr 1 sodium chloride 0.45% viaflex

4 †B/D

sodium chloride inj 0.9%, 2.5meq/ml, 3%, 5%

4 †B/D

sodium fluoride tabs 1 tpn electrolytes 4 †B/D UROCIT-K 15 2 Vitamins niacor 1 prenatal low iron tabs 120mg; 0; 200mg; 400unit; 2mg; 12mcg; 27mg; 1mg; 20mg; 10mg; 3mg; 1.84mg; 22unit; 4000unit; 25mg

1

prenatal vitamins tabs 120mg; 200mg; 400unit; 8mcg; 1mg; 29mg; 20mg; 150mcg; 3mg; 3mg; 3mg; 30unit; 15mg

1

triveen-u 1

Index Drug Name Page #

Drug Name Page #

37

1st Generation/Typical ......................................... 14 2nd Generation/Atypical ...................................... 14 8-MOP................................................................... 23 abacavir ................................................................ 15 ABILIFY ............................................................... 14 ABILIFY DISCMELT .......................................... 14 ABILIFY MAINTENA ........................................ 14 Abortive................................................................. 10 ABRAXANE ........................................................ 11 acamprosate calcium dr .......................................... 3 acarbose ................................................................ 16 acebutolol hcl ........................................................ 20 acetaminophen/caffeine/dihydrocodeine bitartrate 2 acetaminophen/codeine ........................................... 2 acetazolamide ....................................................... 21 acetazolamide er ................................................... 33 acetic acid ............................................................. 33 acetic acid/aluminum acetate ............................... 33 acetylcysteine ........................................................ 35 acitretin ................................................................. 23 ACTHAR HP ........................................................ 27 ACTHIB ................................................................ 30 acticin .................................................................... 13 ACTIMMUNE ...................................................... 30 ACTIVELLA ........................................................ 28 ACTONEL ............................................................ 31 acyclovir ................................................................ 16 acyclovir sodium ................................................... 16 ADACEL .............................................................. 30 ADAGEN .............................................................. 24 adapalene .............................................................. 23 ADCIRCA............................................................. 35 adriamycin ............................................................ 11 ADVAIR DISKUS................................................ 33 ADVAIR HFA ...................................................... 33 ADVICOR ............................................................ 21 afeditab cr ............................................................. 20 AFINITOR ............................................................ 12 AFINITOR DISPERZ ........................................... 12 AGGRENOX ........................................................ 19 AKNE-MYCIN ....................................................... 5

ak-poly-bac ............................................................. 4 ALA SCALP ......................................................... 25 ala-cort .................................................................. 25 ALBENZA ............................................................ 13 albuterol sulfate .................................................... 34 alclometasone dipropionate .................................. 25 Alcohol Deterrents/Anti-craving ........................... 3 alcohol preps ........................................................... 4 ALDACTAZIDE .................................................. 21 ALDURAZYME ................................................... 24 alendronate sodium ............................................... 31 alfuzosin hcl er ...................................................... 25 ALIMTA ............................................................... 11 ALINIA ................................................................. 13 ALKERAN ........................................................... 11 Alkylating Agents ................................................. 11 allopurinol (tablet) ................................................ 10 ALOCRIL ............................................................. 32 ALOMIDE ............................................................ 32 ALORA ................................................................. 28 Alpha-adrenergic Agonists .................................. 19 Alpha-adrenergic Blocking Agents ..................... 19 ALPHAGAN P ..................................................... 33 alprazolam ............................................................ 16 alprazolam er ........................................................ 16 alprazolam intensol ............................................... 16 ALREX ................................................................. 32 amantadine hcl ...................................................... 15 amcinonide ............................................................ 25 amethia .................................................................. 28 amethyst ................................................................ 28 amifostine .............................................................. 11 amiloride hcl ......................................................... 21 amiloride/hydrochlorothiazide ............................. 21 Aminoglycosides ..................................................... 4 aminophylline ........................................................ 34 Aminosalicylates................................................... 31 AMINOSYN II ..................................................... 36 amiodarone hcl ..................................................... 20 AMITIZA .............................................................. 24 amitriptyline hcl ...................................................... 9

Drug Name Page #

Drug Name Page #

38

amlodipine besylate .............................................. 20 amlodipine besylate/benazepril hcl....................... 20 ammonium lactate ................................................. 23 amnesteem ............................................................. 23 amoxapine ............................................................... 9 amoxicillin............................................................... 5 amoxicillin/potassium clavulanate.......................... 5 amoxicillin/potassium clavulanate er ..................... 5 amphetamine/dextroamphetamine ........................ 22 amphotericin b ........................................................ 9 ampicillin ................................................................ 5 ampicillin sodium .................................................... 5 AMPYRA ............................................................. 23 Anabolic Steroids ................................................. 27 ANADROL-50 ...................................................... 27 anagrelide hcl ....................................................... 18 Analgesics............................................................... 1 Analgesics ............................................................... 1 anastrozole ............................................................ 12 ANDRODERM ..................................................... 27 ANDROGEL......................................................... 27 ANDROGEL PUMP ............................................. 28 Androgens............................................................. 27 androxy ................................................................. 28 Anesthetics ............................................................. 3 Angiotensin II Receptor Antagonists .................. 19 Angiotensin-converting Enzyme (ACE) Inhibitors

........................................................................... 19 Anthelmintics ....................................................... 13 Anti-Addiction/Substance Abuse Treatment

Agents ................................................................. 3 Antiandrogens ...................................................... 30 Antiangiogenic Agents ......................................... 11 Antiarrhythmics ................................................... 20 Antibacterials ........................................................ 4 Antibacterials, Other .............................................. 4 Anticholinergics ................................................... 13 Anticoagulants ..................................................... 17 Anticonvulsants ..................................................... 6 Anticonvulsants, Other .......................................... 6 Anti-cytomegalovirus (CMV) Agents .................. 14

Antidementia Agents ............................................ 7 Antidepressants ..................................................... 8 Antidepressants, Other ........................................... 8 Antidiabetic Agents .............................................. 16 Antiemetics ............................................................ 9 Antiemetics, Other .................................................. 9 Antiestrogens/Modifiers ....................................... 11 Antifungals............................................................. 9 Antigout Agents ................................................... 10 Antihepatitis Agents ............................................. 15 Antiherpetic Agents .............................................. 16 Antihistamines ...................................................... 34 Anti-HIV Agents, Non-nucleoside Reverse

Transcriptase Inhibitors .................................. 14 Anti-HIV Agents, Nucleoside and Nucleotide

Reverse Transcriptase Inhibitors..................... 15 Anti-HIV Agents, Other ....................................... 15 Anti-HIV Agents, Protease Inhibitors ................. 15 Anti-inflammatories, Inhaled Corticosteroids .... 33 Anti-inflammatory Agents ................................... 3 Anti-influenza Agents .......................................... 15 Antileukotrienes ................................................... 34 Antimetabolites ..................................................... 11 Antimigraine Agents ........................................... 10 Antimyasthenic Agents ....................................... 10 Antimycobacterials ............................................. 10 Antimycobacterials, Other ................................... 10 Antineoplastics .................................................... 11 Antineoplastics, Other .......................................... 11 Antiparasitics....................................................... 13 Antiparkinson Agents ......................................... 13 Antiparkinson Agents, Other ............................... 13 Antiprotozoals....................................................... 13 Antipsychotics ..................................................... 14 Antispasmodics, Gastrointestinal ........................ 24 Antispasmodics, Urinary ...................................... 25 Antispasticity Agents .......................................... 14 Antithyroid Agents ............................................... 30 Antituberculars..................................................... 10 ANTIVERT............................................................. 9 Antivirals ............................................................. 14

Drug Name Page #

Drug Name Page #

39

ANUSOL-HC ....................................................... 26 Anxiolytics ........................................................... 16 Anxiolytics, Other................................................. 16 ANZEMET ............................................................. 9 APHTHASOL ....................................................... 23 APOKYN .............................................................. 13 apraclonidine ........................................................ 33 apri ........................................................................ 28 APRISO ................................................................ 31 APTIVUS .............................................................. 15 ARALAST NP ...................................................... 35 aranelle ................................................................. 28 ARANESP ALBUMIN FREE .............................. 18 ARCALYST ......................................................... 30 ARCAPTA NEOHALER ..................................... 34 ARICEPT ................................................................ 7 Aromatase Inhibitors, 3rd Generation ................ 12 ARRANON ........................................................... 11 ARZERRA ............................................................ 13 ASACOL............................................................... 31 ASACOLHD ......................................................... 31 ASMANEX ........................................................... 33 ASMANEX 7 METERED DOSES ...................... 33 ASTAGRAF XL ................................................... 30 ASTEPRO ............................................................. 34 ATELVIA ............................................................. 31 atenolol ................................................................. 20 atenolol/chlorthalidone ......................................... 20 atorvastatin calcium.............................................. 21 atovaquone/proguanil hcl ..................................... 13 ATRIPLA .............................................................. 14 atropine sulfate ............................................... 24, 32 ATROVENT HFA ................................................ 34 Attention Deficit Hyperactivity Disorder Agents,

Amphetamines .................................................. 22 Attention Deficit Hyperactivity Disorder Agents,

Non-amphetamines .......................................... 22 AUBAGIO ............................................................ 23 augmented betamethasone dipropionate .............. 26 AUGMENTIN ........................................................ 5 AUVI-Q ................................................................ 34

AVASTIN ............................................................. 13 AVELOX ................................................................ 6 AVELOX ABC PACK ........................................... 6 aviane .................................................................... 28 AVINZA ................................................................. 1 AVODART ........................................................... 25 AVONEX .............................................................. 30 AXIRON ............................................................... 28 AZASAN .............................................................. 30 azathioprine .......................................................... 30 azathioprine sodium .............................................. 30 azelastine hcl ................................................... 32, 34 AZELEX ............................................................... 23 AZILECT .............................................................. 14 azithromycin ............................................................ 5 AZOPT .................................................................. 33 bacitracin ................................................................ 4 bacitracin/polymyxin b............................................ 4 baclofen ................................................................. 14 BACTROBAN NASAL ......................................... 4 balsalazide disodium ............................................. 31 balziva ................................................................... 28 BANZEL ................................................................. 7 BARACLUDE ...................................................... 15 BD NEEDLE/30G X 1/2 ...................................... 32 BECONASE AQ ................................................... 33 benazepril hcl ........................................................ 19 benazepril hcl/hydrochlorothiazide ...................... 19 Benign Prostatic Hypertrophy Agents ................. 25 BENLYSTA .......................................................... 30 benztropine mesylate ............................................. 13 BEPREVE ............................................................. 32 Beta-adrenergic Blocking Agents ........................ 20 Beta-lactam, Cephalosporins ................................. 5 Beta-lactam, Other ................................................. 5 Beta-lactam, Penicillins ......................................... 5 betamethasone dipropionate ................................. 26 betamethasone valerate ........................................ 26 BETASERON ....................................................... 30 betaxolol hcl .................................................... 20, 33 bethanechol chloride ............................................. 25

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BETIMOL ............................................................. 33 BETOPTIC-S ........................................................ 33 bicalutamide .......................................................... 30 BICILLIN C-R ........................................................ 5 BICILLIN L-A ........................................................ 5 BICNU .................................................................. 11 BIDIL .................................................................... 22 BILTRICIDE ........................................................ 13 BIO-STATIN .......................................................... 9 BIOTHRAX .......................................................... 30 Bipolar Agents ..................................................... 16 bisoprolol fumarate ............................................... 20 bisoprolol fumarate/hydrochlorothiazide ............. 20 bleomycin sulfate .................................................. 11 BLEPHAMIDE ..................................................... 32 BLEPHAMIDE S.O.P. ......................................... 32 Blood Formation Modifiers ................................. 18 Blood Glucose Regulators .................................. 16 Blood Products/Modifiers/Volume Expanders 17,

18 BONIVA ............................................................... 31 BOOSTRIX........................................................... 30 BOSULIF .............................................................. 12 briellyn .................................................................. 28 BRILINTA ............................................................ 18 brimonidine tartrate .............................................. 33 bromfenac ............................................................. 32 bromocriptine mesylate ......................................... 13 Bronchodilators, Anticholinergic ........................ 34 Bronchodilators, Phosphodiesterase Inhibitors

(Xanthines) ....................................................... 34 Bronchodilators, Sympathomimetic .................... 34 budeprion sr ............................................................ 8 budesonide ...................................................... 31, 33 bumetanide ............................................................ 21 BUPHENYL ......................................................... 24 buprenorphine hcl ................................................... 3 buprenorphine hcl/naloxone hcl ............................. 3 buproban ................................................................. 3 bupropion hcl .......................................................... 8 bupropion hcl sr ...................................................... 8

bupropion hcl xl ...................................................... 8 buspirone hcl ......................................................... 16 BUSULFEX .......................................................... 11 butalbital/acetaminophen ..................................... 23 butalbital/acetaminophen/caffeine .................... 1, 10 butalbital/acetaminophen/caffeine/codeine ............ 1 butalbital/asa/caffeine........................................... 23 butalbital/aspirin/caffeine ..................................... 23 butalbital/aspirin/caffeine/codeine ......................... 2 butorphanol tartrate................................................ 2 BYDUREON ........................................................ 17 BYETTA ............................................................... 17 cabergoline ........................................................... 29 calcipotriene ......................................................... 23 calcitonin-salmon .................................................. 31 calcitrene............................................................... 23 calcitriol ................................................................ 31 calcium acetate ..................................................... 36 Calcium Channel Blocking Agents ..................... 20 Calcium Channel Modifying Agents ..................... 6 camila .................................................................... 29 CAMPATH ........................................................... 13 CAMPRAL ............................................................. 3 CANASA .............................................................. 31 CANCIDAS ............................................................ 9 candesartan cilexetil ............................................. 19 candesartan cilexetil/hydrochlorothiazide ............ 21 CANTIL ................................................................ 24 CAPEX ................................................................. 26 CAPITAL/CODEINE ............................................. 2 CAPRELSA .......................................................... 11 captopril ................................................................ 19 captopril/hydrochlorothiazide .............................. 19 CARAC ................................................................. 23 CARBAGLU......................................................... 24 carbamazepine ........................................................ 7 carbamazepine er .................................................... 7 carbidopa/levodopa .............................................. 14 carbidopa/levodopa er .......................................... 14 carbidopa/levodopa odt ........................................ 14 carbidopa/levodopa sr .......................................... 14

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carbinoxamine maleate ......................................... 34 carboplatin ............................................................ 11 Cardiovascular Agents ....................................... 19 Cardiovascular Agents, Other ............................. 21 CARDIZEM CD ................................................... 20 CARDIZEM LA ................................................... 20 CARIMUNE NANOFILTERED .......................... 30 carisoprodol .......................................................... 35 carteolol hcl .......................................................... 33 cartia xt ................................................................. 20 carvedilol .............................................................. 20 CAYSTON .............................................................. 5 CEDAX ................................................................... 5 CEENU ................................................................. 11 cefaclor ................................................................... 5 cefaclor er ............................................................... 5 cefadroxil ................................................................ 5 cefazolin sodium...................................................... 5 cefdinir .................................................................... 5 cefditoren pivoxil .................................................... 5 cefepime .................................................................. 5 cefotaxime sodium ................................................... 5 cefoxitin sodium ...................................................... 5 cefpodoxime proxetil ............................................... 5 cefprozil................................................................... 5 ceftazidime/dextrose ................................................ 5 ceftriaxone sodium .................................................. 5 cefuroxime axetil ..................................................... 5 cefuroxime sodium .................................................. 5 CELEBREX ............................................................ 3 CELESTONE ........................................................ 26 CELLCEPT ........................................................... 30 CELLCEPT INTRAVENOUS ............................. 30 CELONTIN............................................................. 6 Central Nervous System Agents .................. 22, 23 Central Nervous System, Other ........................... 23 cephalexin ............................................................... 5 CEREZYME ......................................................... 24 CERVARIX .......................................................... 30 cesia ...................................................................... 28 cevimeline hcl ........................................................ 23

CHANTIX............................................................... 3 CHANTIX PAK...................................................... 3 CHEMET .............................................................. 35 chlorhexidine gluconate ........................................ 23 chlorhexidine gluconate oral rinse ....................... 23 chloroquine phosphate .......................................... 13 chlorothiazide ....................................................... 21 chlorpromazine hcl ............................................... 14 chlorthalidone ....................................................... 21 cholestyramine ...................................................... 22 cholestyramine light .............................................. 22 Cholinesterase Inhibitors ....................................... 7 chorionic gonadotropin ........................................ 27 ciclopirox ................................................................ 9 ciclopirox nail lacquer ............................................ 9 ciclopirox olamine .................................................. 9 cidofovir ................................................................ 14 cilostazol ............................................................... 19 CILOXAN............................................................... 6 cimetidine .............................................................. 24 cimetidine hcl ........................................................ 24 CINRYZE ............................................................. 18 CIPRO ..................................................................... 6 CIPRO HC .............................................................. 6 CIPRODEX............................................................. 6 ciprofloxacin ........................................................... 6 ciprofloxacin er ....................................................... 6 ciprofloxacin hcl ..................................................... 6 ciprofloxacin i.v.-in d5w ......................................... 6 cisplatin ................................................................. 11 citalopram hydrobromide ....................................... 8 cladribine .............................................................. 11 CLARAVIS........................................................... 23 CLARINEX .......................................................... 34 CLARINEX-D ...................................................... 34 clarithromycin ......................................................... 5 clarithromycin er .................................................... 5 clemastine fumarate .............................................. 34 CLEOCIN ............................................................... 4 CLIMARA PRO ................................................... 28 clindamycin hcl ....................................................... 4

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clindamycin palmitate hcl ....................................... 4 clindamycin phosphate ...................................... 4, 23 clindamycin phosphate in d5w ................................ 4 clindamycin/benzoyl peroxide ............................... 23 clobetasol propionate............................................ 26 clobetasol propionate e ......................................... 26 clobetasol propionate emollient ............................ 26 CLODERM PUMP ............................................... 26 CLOLAR............................................................... 11 clomipramine hcl .................................................... 9 clonazepam ............................................................. 7 clonazepam odt ....................................................... 7 clonidine hcl .......................................................... 19 clopidogrel ............................................................ 19 clorazepate dipotassium.......................................... 7 CLORPRES .......................................................... 19 clotrimazole............................................................. 9 clotrimazole/betamethasone dipropionate ............ 26 clozapine ............................................................... 14 Coagulants ............................................................ 18 COARTEM ........................................................... 13 codeine sulfate ........................................................ 2 co-gesic ................................................................... 2 COLCRYS ............................................................ 10 colestipol hcl ......................................................... 22 colestipol hcl for oral suspension ......................... 22 colistimethate sodium.............................................. 4 colocort ................................................................. 31 COLY-MYCIN S .................................................. 33 COMBIPATCH .................................................... 28 COMBIVENT ....................................................... 34 COMBIVENT RESPIMAT .................................. 34 COMETRIQ .......................................................... 11 COMPLERA ......................................................... 14 compro .................................................................. 14 COMVAX ............................................................. 30 CONDYLOX ........................................................ 23 COPAXONE ......................................................... 23 CORDRAN ........................................................... 26 CORDRAN SP...................................................... 26 CORDRAN TAPE ................................................ 26

COREG CR ........................................................... 20 CORTIFOAM ....................................................... 26 cortisone acetate ................................................... 26 CORTISPORIN ................................................ 4, 23 CORTISPORIN-TC .............................................. 33 COUMADIN................................................... 17, 18 COVERA-HS ........................................................ 20 CREON ................................................................. 24 CRINONE ............................................................. 29 CRIXIVAN ........................................................... 15 cromolyn sodium ....................................... 24, 32, 35 cryselle .................................................................. 28 CUBICIN ................................................................ 4 CUPRIMINE......................................................... 36 cyclafem 1/35 ........................................................ 28 cyclafem 7/7/7 ....................................................... 28 cyclophosphamide ................................................. 11 cycloserine ............................................................ 10 cyclosporine .......................................................... 30 cyclosporine modified ........................................... 30 CYKLOKAPRON ................................................ 18 CYMBALTA .......................................................... 8 CYSTADANE ...................................................... 24 CYSTAGON ......................................................... 24 CYSTARAN ......................................................... 32 cytarabine ............................................................. 11 cytarabine aqueous ............................................... 11 CYTOTEC ............................................................ 25 dacarbazine ........................................................... 11 DACOGEN ........................................................... 11 danazol .................................................................. 28 dantrolene sodium ................................................. 14 dapsone ................................................................. 10 DAPTACEL .......................................................... 31 DARAPRIM ......................................................... 13 daunorubicin hcl ................................................... 11 DECAVAC ........................................................... 31 decitabine .............................................................. 11 DELESTROGEN .................................................. 28 demeclocycline hcl .................................................. 6 DEMSER .............................................................. 21

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DENAVIR............................................................. 16 Dental and Oral Agents ...................................... 23 DEPEN TITRATABS ........................................... 36 DEPO-ESTRADIOL ............................................. 28 DEPO-PROVERA ................................................ 29 DEPO-TESTOSTERONE .................................... 28 Dermatological Agents........................................ 23 desipramine hcl ....................................................... 9 desloratadine......................................................... 34 desloratadine odt .................................................. 34 desmopressin acetate ............................................ 27 desonide ................................................................ 26 desoximetasone ..................................................... 26 DESVENLAFAXINE ER ....................................... 8 DETROL LA ........................................................ 25 dexamethasone ...................................................... 26 dexamethasone intensol ........................................ 26 dexamethasone sodium phosphate .................. 26, 32 DEXILANT .......................................................... 25 dexmethylphenidate hcl ......................................... 22 dexrazoxane .......................................................... 11 dextroamphetamine sulfate ................................... 22 dextroamphetamine sulfate er ............................... 22 dextrose 10%/nacl 0.45% .................................... 17 dextrose 5% /electrolyte #48 viaflex .................... 36 dextrose 10% flex container.................................. 17 dextrose 10%/nacl 0.2% ....................................... 17 dextrose 2.5%/sodium chloride 0.45% ................. 17 dextrose 5% ........................................................... 17 dextrose 5%/nacl 0.2% ......................................... 17 dextrose 5%/nacl 0.225% ..................................... 17 dextrose 5%/nacl 0.33% ....................................... 17 dextrose 5%/nacl 0.45% ....................................... 17 dextrose 5%/nacl 0.9% ......................................... 17 DEXTROSE 5%/POTASSIUM CHLORIDE 0.15%

........................................................................... 36 diazepam ........................................................... 7, 16 diazepam intensol.................................................. 16 diclofenac potassium ............................................... 3 diclofenac sodium ................................................. 32 diclofenac sodium dr ............................................... 3

diclofenac sodium er ............................................... 3 diclofenac sodium/misoprostol ............................... 1 dicloxacillin sodium ................................................ 5 dicyclomine hcl ..................................................... 24 didanosine ............................................................. 15 DIFFERIN............................................................. 23 diflorasone diacetate ............................................. 26 diflunisal ................................................................. 3 digoxin................................................................... 21 dihydroergotamine mesylate ................................. 10 DILANTIN ............................................................. 7 DILANTIN INFATABS ......................................... 7 DILATRATE SR .................................................. 22 diltiazem cd ........................................................... 20 diltiazem hcl .......................................................... 20 diltiazem hcl er ...................................................... 20 dilt-xr..................................................................... 20 diltzac .................................................................... 20 DIOVAN ............................................................... 19 diphenhydramine hcl ............................................. 34 diphenoxylate/atropine ......................................... 24 DIPROLENE ........................................................ 26 disopyramide phosphate ....................................... 20 disulfiram ................................................................ 3 Diuretics, Carbonic Anhydrase Inhibitors .......... 21 Diuretics, Loop ..................................................... 21 Diuretics, Potassium-sparing .............................. 21 Diuretics, Thiazide ............................................... 21 DIURIL ................................................................. 21 divalproex sodium ................................................... 7 divalproex sodium dr .............................................. 7 divalproex sodium er............................................... 7 docetaxel ............................................................... 11 donepezil hcl ....................................................... 7, 8 Dopamine Agonists .............................................. 13 Dopamine Precursors/L- Amino Acid

Decarboxylase Inhibitors ................................. 14 dorzolamide hcl ..................................................... 33 dorzolamide hcl/timolol maleate........................... 33 doxazosin mesylate ................................................ 25 doxepin hcl .............................................................. 9

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doxorubicin hcl ..................................................... 11 doxycycline .............................................................. 6 doxycycline hyclate ................................................. 6 doxycycline hyclate dr ............................................. 6 doxycycline monohydrate........................................ 6 dronabinol ............................................................... 9 drospirenone/ethinyl estradiol .............................. 28 DROXIA ............................................................... 11 DURAMORPH ....................................................... 1 DUREZOL ............................................................ 32 DYRENIUM ......................................................... 21 Dyslipidemics, Fibric Acid Derivatives ............... 21 Dyslipidemics, HMG CoA Reductase Inhibitors 21 Dyslipidemics, Other ............................................ 22 econazole nitrate ..................................................... 9 EDARBI ................................................................ 19 EDARBYCLOR ................................................... 19 EDECRIN ............................................................. 21 EDURANT ........................................................... 14 EFFIENT............................................................... 19 EGRIFTA .............................................................. 27 ELAPRASE .......................................................... 24 Electrolyte/Mineral Modifiers ............................. 35 Electrolyte/Mineral Replacement ........................ 36 ELIDEL................................................................. 23 ELIGARD ............................................................. 29 eliphos ................................................................... 36 ELIQUIS ............................................................... 18 ELITEK................................................................. 11 ELIXOPHYLLIN ................................................. 34 ELLENCE ............................................................. 12 ELMIRON ............................................................ 25 ELSPAR ................................................................ 12 EMADINE ............................................................ 32 EMCYT................................................................. 11 EMEND .................................................................. 9 Emetogenic Therapy Adjuncts............................... 9 emoquette .............................................................. 28 EMSAM .................................................................. 8 EMTRIVA ............................................................ 15 ENABLEX ............................................................ 25

enalapril maleate .................................................. 19 enalapril maleate/hydrochlorothiazide ................. 19 ENBREL ............................................................... 30 endocet .................................................................... 2 ENDOMETRIN .................................................... 29 ENGERIX-B ......................................................... 31 ENJUVIA .............................................................. 28 enoxaparin sodium ................................................ 18 enpresse................................................................. 28 entacapone ............................................................ 13 enulose .................................................................. 25 Enzyme Inhibitors ................................................ 12 Enzyme Replacement/Modifiers ........................ 24 epinastine hcl ........................................................ 32 epinephrine hcl ...................................................... 34 EPIPEN ................................................................. 34 EPIRUBICIN HCL ............................................... 12 epitol ....................................................................... 7 EPIVIR .................................................................. 15 EPIVIR HBV ........................................................ 15 eplerenone ............................................................. 21 eprosartan mesylate .............................................. 19 EPZICOM ............................................................. 15 EQUETRO .............................................................. 7 ERBITUX ............................................................. 13 Ergot Alkaloids ..................................................... 10 ERIVEDGE........................................................... 12 errin....................................................................... 29 ery ........................................................................... 5 ERYPED ................................................................. 5 ERY-TAB ............................................................... 5 erythrocin lactobionate ........................................... 5 ERYTHROCIN STEARATE ................................. 5 erythromycin ........................................................... 5 erythromycin base ................................................... 5 erythromycin ethylsuccinate ................................... 5 erythromycin/benzoyl peroxide ............................. 23 erythromycin/sulfisoxazole ..................................... 5 escitalopram oxalate ............................................... 8 esgic ...................................................................... 10 estazolam............................................................... 16

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ESTRACE ............................................................. 28 estradiol ................................................................ 28 estradiol valerate .................................................. 28 estradiol/norethindrone acetate ............................ 28 ESTRING .............................................................. 28 Estrogens .............................................................. 28 estropipate............................................................. 28 ethambutol hcl ....................................................... 10 ethosuximide ........................................................... 6 etidronate disodium .............................................. 31 etodolac ................................................................... 3 etodolac er .............................................................. 3 ETOPOPHOS ....................................................... 12 etoposide ............................................................... 12 EURAX ................................................................. 13 EVISTA ................................................................ 29 EXELDERM ........................................................... 9 EXELON................................................................. 8 exemestane ............................................................ 12 EXFORGE ............................................................ 20 EXFORGE HCT ................................................... 20 EXJADE ............................................................... 36 EXTAVIA ............................................................. 30 FABRAZYME ...................................................... 24 FACTIVE ................................................................ 6 famciclovir ............................................................ 16 famotidine ............................................................. 24 FANAPT ............................................................... 14 FANAPT TITRATION PACK ............................. 14 FARESTON .......................................................... 11 FASLODEX .......................................................... 11 FAZACLO ............................................................ 14 felbamate ................................................................. 7 felodipine er .......................................................... 20 FEMHRT LOW DOSE ......................................... 28 FEMRING............................................................. 28 FEMTRACE ......................................................... 28 fenofibrate ............................................................. 21 fenofibrate micronized .......................................... 21 fenofibric acid dr ................................................... 21 fenoprofen calcium .................................................. 3

fentanyl (patch) ....................................................... 1 fentanyl citrate ........................................................ 2 fentanyl citrate oral transmucosal .......................... 2 FERRIPROX......................................................... 32 FINACEA ............................................................. 23 finasteride (tablet) ................................................. 25 FIRAZYR ............................................................. 32 FLAREX ............................................................... 32 flavoxate hcl .......................................................... 25 flecainide acetate .................................................. 20 FLOVENT DISKUS ............................................. 33 FLOVENT HFA ................................................... 33 floxuridine ............................................................. 11 fluconazole .............................................................. 9 fluconazole in dextrose ........................................... 9 flucytosine ............................................................... 9 fludarabine phosphate .......................................... 12 fludrocortisone acetate ......................................... 26 flunisolide .............................................................. 33 fluocinolone acetonide .......................................... 26 fluocinolone acetonide body oil ............................ 26 fluocinonide........................................................... 26 fluocinonide-e ....................................................... 26 fluorometholone .................................................... 32 FLUOROPLEX..................................................... 23 FLUOROURACIL .......................................... 11, 23 fluoxetine dr ............................................................ 8 fluoxetine hcl ........................................................... 8 fluphenazine decanoate ......................................... 14 fluphenazine hcl .................................................... 14 flurbiprofen ............................................................. 3 flurbiprofen sodium ............................................... 32 flutamide ............................................................... 30 fluticasone propionate .................................... 26, 33 fluvastatin .............................................................. 21 fluvoxamine maleate ............................................... 8 fluvoxamine maleate er ........................................... 8 FML ...................................................................... 32 FML FORTE ......................................................... 32 FOCALIN XR ....................................................... 22 fondaparinux sodium ............................................ 18

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FORFIVO XL ......................................................... 8 FORTEO ............................................................... 31 FORTICAL ........................................................... 31 FOSAMAX PLUS D ............................................ 31 foscarnet sodium ................................................... 14 fosinopril sodium .................................................. 19 fosinopril sodium/hydrochlorothiazide ................. 19 FOSRENOL .......................................................... 25 FRAGMIN ............................................................ 18 furosemide ............................................................. 21 FUSILEV .............................................................. 12 FUZEON ............................................................... 15 GABA Receptor Modulators ................................ 35 gabapentin............................................................... 7 GABITRIL .............................................................. 7 galantamine hydrobromide ..................................... 8 GAMASTAN S/D ................................................. 30 Gamma-aminobutyric Acid (GABA) Augmenting

Agents ................................................................. 7 GAMMAGARD LIQUID ..................................... 30 GAMMAGARD S/D ............................................ 30 GAMUNEX-C ...................................................... 30 ganciclovir ............................................................ 14 GARDASIL .......................................................... 31 GASTROCROM ................................................... 24 Gastrointestinal Agents ...................................... 24 Gastrointestinal Agents, Other ............................ 24 GATTEX............................................................... 24 gauze pads ............................................................. 23 gavilyte-c ............................................................... 25 gavilyte-g............................................................... 25 gavilyte-n/flavor pack ........................................... 25 GELNIQUE .......................................................... 25 gemfibrozil ............................................................ 21 gengraf .................................................................. 30 Genitourinary Agents ......................................... 25 Genitourinary Agents, Other ............................... 25 GENOTROPIN ..................................................... 27 GENOTROPIN MINIQUICK .............................. 27 gentamicin sulfate ................................................... 4 GEODON .............................................................. 14

gianvi..................................................................... 28 gildagia ................................................................. 28 GILENYA ............................................................. 23 GILOTRIF ............................................................ 12 GLASSIA .............................................................. 35 GLEEVEC ............................................................ 12 glimepiride ............................................................ 17 glipizide ................................................................. 17 glipizide er ............................................................ 17 glipizide/metformin hcl ......................................... 17 GLUCAGEN HYPOKIT ...................................... 17 GLUCAGON EMERGENCY KIT....................... 17 Glucocorticoids ..................................................... 31 Glucocorticoids/Mineralocorticoids .................... 25 Glutamate Reducing Agents .................................. 7 glyburide ............................................................... 17 glyburide micronized ............................................ 17 glyburide/metformin hcl ........................................ 17 Glycemic Agents ................................................... 17 glycopyrrolate ....................................................... 24 GLYSET ............................................................... 17 GOLYTELY ......................................................... 25 granisetron hcl ........................................................ 9 granisol ................................................................... 9 griseofulvin microsize ............................................. 9 griseofulvin ultramicrosize ................................... 10 guanfacine hcl ....................................................... 19 guanidine hcl ......................................................... 10 gynazole-1 ............................................................. 10 HALAVEN ........................................................... 12 halobetasol propionate ......................................... 26 HALOG................................................................. 26 haloperidol ............................................................ 14 haloperidol decanoate .......................................... 14 haloperidol lactate ................................................ 14 HAVRIX ............................................................... 31 HECTOROL ......................................................... 31 HELIDAC ............................................................... 4 heparin sodium...................................................... 18 HEPSERA ............................................................. 15 HERCEPTIN......................................................... 13

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HEXALEN ............................................................ 11 Histamine2 (H2) receptor Antagonists................ 24 HORIZANT ............................................................ 7 Hormonal Agents,

Stimulant/Replacement/Modifying (Adrenal)........................................................................... 25

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)........................................................................... 27

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) .............................................. 27

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) ...................................... 27

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)........................................................................... 29

Hormonal Agents, Suppressant (Adrenal) ....... 29 Hormonal Agents, Suppressant (Parathyroid) 29 Hormonal Agents, Suppressant (Pituitary) ...... 29 Hormonal Agents, Suppressant (Sex

Hormones/Modifiers) ...................................... 30 Hormonal Agents, Suppressant (Thyroid) ....... 30 HUMALOG (VIAL) ............................................. 17 HUMALOG KWIKPEN ....................................... 17 HUMATROPE ...................................................... 27 HUMIRA .............................................................. 30 HUMIRA PEN ...................................................... 30 HUMIRA STARTER KIT .................................... 30 HUMULIN (VIAL) .............................................. 17 HYCET ................................................................... 2 hydralazine hcl ...................................................... 22 hydrochlorothiazide .............................................. 21 hydrocodone/acetaminophen .................................. 2 hydrocodone/ibuprofen ........................................... 2 hydrocortisone ................................................ 26, 31 hydrocortisone butyrate ........................................ 26 hydrocortisone in absorbase ................................. 26 hydrocortisone valerate ........................................ 26 hydrocortisone/acetic acid .................................... 33

hydromorphone hcl ................................................. 2 hydroxychloroquine sulfate ................................... 13 hydroxyurea .......................................................... 11 hydroxyzine hcl ................................................. 9, 34 hydroxyzine pamoate ............................................ 34 ibandronate sodium .............................................. 31 ibuprofen ................................................................. 3 IDAMYCIN PFS .................................................. 12 idarubicin hcl ........................................................ 12 ifosfamide .............................................................. 11 ifosfamide/mesna................................................... 11 ILARIS .................................................................. 30 ILEVRO ................................................................ 32 imipramine hcl ........................................................ 9 imipramine pamoate ............................................... 9 imiquimod ............................................................. 24 Immune Suppressants .......................................... 30 Immunizing Agents, Passive ................................ 30 Immunological Agents ........................................ 30 Immunomodulators .............................................. 30 IMOVAX RABIES (H.D.C.V.) ............................ 31 INCIVEK .............................................................. 15 INCRELEX ........................................................... 27 indapamide ............................................................ 21 INDOCIN ................................................................ 3 indomethacin ........................................................... 3 indomethacin er ...................................................... 3 INFANRIX ........................................................... 31 INFERGEN ........................................................... 15 Inflammatory Bowel Disease Agents ................. 31 INLYTA ................................................................ 12 INNOPRAN XL.................................................... 20 INSULIN SYRINGES, NEEDLES ...................... 32 Insulins ................................................................. 17 INTELENCE......................................................... 14 INTRALIPID ........................................................ 32 INTRON-A ........................................................... 15 INTRON-A W/DILUENT .................................... 16 introvale ................................................................ 28 INVANZ ................................................................. 5 INVEGA ............................................................... 14

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INVEGA SUSTENNA ......................................... 14 INVIRASE ............................................................ 15 IPOL ...................................................................... 31 ipratropium bromide ............................................. 34 ipratropium bromide/albuterol sulfate ................. 34 irbesartan .............................................................. 19 irbesartan/hydrochlorothiazide ............................ 19 irinotecan .............................................................. 12 Irritable Bowel Syndrome Agents........................ 24 ISENTRESS .......................................................... 15 ISOLYTE-M/DEXTROSE 5% ............................. 36 ISONIAZID .................................................... 10, 11 ISOPTO CARPINE .............................................. 33 ISORDIL TITRADOSE........................................ 22 isosorbide dinitrate ............................................... 22 isosorbide dinitrate er ........................................... 22 isosorbide mononitrate ......................................... 22 isosorbide mononitrate er ..................................... 22 isradipine .............................................................. 20 ISTODAX ............................................................. 12 itraconazole........................................................... 10 IXEMPRA KIT ..................................................... 12 IXIARO................................................................. 31 JAKAFI ................................................................. 12 jantoven ................................................................. 18 JANUMET ............................................................ 17 JANUMET XR ..................................................... 17 JANUVIA ............................................................. 17 JE-VAX................................................................. 31 JEVTANA............................................................. 12 jinteli ..................................................................... 28 jolivette .................................................................. 29 junel....................................................................... 28 junel fe ................................................................... 28 JUVISYNC ........................................................... 17 JUXTAPID ........................................................... 22 KADIAN ................................................................. 1 KALETRA ............................................................ 15 KALYDECO ......................................................... 35 KAPVAY .............................................................. 22 kariva .................................................................... 28

kcl 0.15%/d5w/lr ................................................... 17 kcl 0.3%/d5w/nacl 0.9% ....................................... 17 kelnor .................................................................... 28 KENALOG ........................................................... 26 KEPIVANCE ........................................................ 23 KETEK ................................................................... 5 ketoconazole .......................................................... 10 ketoprofen ............................................................... 4 ketoprofen er ........................................................... 4 ketorolac tromethamine ........................................ 32 KINERET ............................................................. 30 kionex .................................................................... 36 KLOR-CON 10 ..................................................... 36 KLOR-CON 8 ....................................................... 36 klor-con m10 ......................................................... 36 klor-con m15 ......................................................... 36 KORLYM ............................................................. 27 KRISTALOSE ...................................................... 25 KRYSTEXXA ...................................................... 10 KUVAN ................................................................ 24 labetalol hcl .......................................................... 20 laclotion ................................................................ 24 LACRISERT ......................................................... 32 lactated ringers irrigation..................................... 32 LACTATED RINGERS VIAFLEX ..................... 36 lactulose ................................................................ 25 LAMICTAL STARTER KIT ................................. 7 LAMISIL SPRAY ................................................ 10 lamivudine ............................................................. 15 lamivudine/zidovudine .......................................... 15 lamotrigine .............................................................. 7 lamotrigine er.......................................................... 7 LANOXIN ............................................................ 21 lansoprazole .......................................................... 25 LANTUS ............................................................... 17 LANTUS SOLOSTAR ......................................... 17 LASTACAFT ....................................................... 32 latanoprost ............................................................ 32 LATUDA .............................................................. 14 Laxatives ............................................................... 25 leflunomide ............................................................ 30

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LESCOL XL ......................................................... 21 lessina ................................................................... 28 LETAIRIS ............................................................. 35 letrozole................................................................. 12 leucovorin calcium ................................................ 12 LEUKERAN ......................................................... 11 LEUKINE ............................................................. 18 leuprolide acetate .................................................. 29 levalbuterol ........................................................... 34 levalbuterol hcl ..................................................... 34 LEVATOL ............................................................ 20 LEVEMIR ............................................................. 17 LEVEMIR FLEXPEN .......................................... 17 levetiracetam ........................................................... 6 levetiracetam er ...................................................... 6 levobunolol hcl ...................................................... 33 levocarnitine ......................................................... 32 levocetirizine dihydrochloride .............................. 34 levofloxacin ............................................................. 6 levofloxacin in d5w ................................................. 6 levonorgestrel/ethinyl estradiol ............................ 28 levora .................................................................... 28 levorphanol tartrate ................................................ 1 levothroid .............................................................. 29 levothyroxine sodium ............................................ 29 levoxyl ................................................................... 29 LEXIVA ................................................................ 15 LIALDA ................................................................ 31 lidocaine .................................................................. 3 lidocaine hcl ............................................................ 3 lidocaine hcl (gel) ................................................... 3 lidocaine viscous ..................................................... 3 lidocaine/prilocaine ................................................ 3 LIDODERM ........................................................... 3 lindane................................................................... 13 LINZESS............................................................... 25 liothyronine sodium .............................................. 29 lisinopril ................................................................ 19 lisinopril/hydrochlorothiazide .............................. 19 lithium carbonate .................................................. 16 lithium carbonate er .............................................. 16

lithium citrate ........................................................ 16 Local Anesthetics ................................................... 3 LOCOID LIPOCREAM ....................................... 26 LODOSYN ........................................................... 14 LOESTRIN FE...................................................... 28 lokara .................................................................... 26 loperamide hcl ...................................................... 24 lorazepam .............................................................. 16 lorazepam intensol ................................................ 16 losartan potassium ................................................ 19 losartan potassium/hydrochlorothiazide .............. 19 LOTEMAX ........................................................... 32 LOTRONEX ......................................................... 25 lovastatin ............................................................... 21 LOVAZA .............................................................. 22 low-ogestrel........................................................... 28 loxapine succinate ................................................. 14 LUMIGAN ............................................................ 32 LUMIZYME ......................................................... 24 LUPRON DEPOT ................................................. 29 LUPRON DEPOT-PED ........................................ 29 lutera ..................................................................... 28 LYRICA .................................................................. 7 LYSODREN ......................................................... 29 MACRODANTIN................................................... 4 Macrolides .............................................................. 5 mafenide acetate ..................................................... 4 MALARONE ........................................................ 13 malathion .............................................................. 13 maprotiline hcl ........................................................ 8 MARPLAN ............................................................. 8 Mast Cell Stabilizers............................................. 35 MATULANE ........................................................ 11 matzim la ............................................................... 20 MAXAIR AUTOHALER ..................................... 34 MAXIDEX ............................................................ 32 meclizine hcl............................................................ 9 meclofenamate sodium ............................................ 1 MEDROL .............................................................. 26 medroxyprogesterone acetate ............................... 29 mefenamic acid ....................................................... 1

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mefloquine hcl ....................................................... 13 MEGACE ES ........................................................ 29 megestrol acetate .................................................. 29 MEKINIST ........................................................... 12 meloxicam ............................................................... 4 melphalan hcl ........................................................ 11 MENACTRA ........................................................ 31 MENEST............................................................... 12 MENOMUNE-A/C/Y/W-135 ............................... 31 MENOSTAR......................................................... 28 MENTAX ............................................................. 10 MENVEO ............................................................. 31 MEPRON .............................................................. 13 mercaptopurine ..................................................... 11 mesalamine ........................................................... 31 mesna .................................................................... 12 MESNEX .............................................................. 12 MESTINON .......................................................... 10 MESTINON TIMESPAN ..................................... 10 Metabolic Bone Disease Agents ......................... 31 metformin hcl ........................................................ 17 metformin hcl er .................................................... 17 methadone hcl ......................................................... 1 methadose ............................................................... 1 methamphetamine hcl ........................................... 22 methazolamide ...................................................... 33 methenamine hippurate ........................................... 4 methimazole .......................................................... 30 methotrexate (tablet) ............................................. 30 methotrexate sodium ............................................. 30 methscopolamine bromide .................................... 24 methyclothiazide ................................................... 21 methyldopa ............................................................ 19 methyldopa/hydrochlorothiazide .......................... 19 methylergonovine maleate .................................... 32 METHYLIN .......................................................... 22 methylphenidate hcl .............................................. 23 methylphenidate hcl cd ......................................... 22 methylphenidate hcl er .................................... 22, 23 methylprednisolone (tablet) ............................ 26, 31 methylprednisolone acetate (injection) ................. 26

methylprednisolone dose pack .............................. 27 methylprednisolone sodiumsuccinate ................... 27 metipranolol .......................................................... 33 metoclopramide hcl ............................................... 24 metolazone ............................................................ 21 metoprolol succinate er......................................... 20 metoprolol tartrate ................................................ 20 metoprolol/hydrochlorothiazide ........................... 20 METROGEL ........................................................... 4 metronidazole .......................................................... 4 metronidazole in nacl 0.79% .................................. 4 mexiletine hcl ........................................................ 20 MIACALCIN ........................................................ 31 miconazole 3 ......................................................... 10 microgestin ............................................................ 28 microgestin fe ........................................................ 28 midodrine hcl ........................................................ 19 migergot ................................................................ 10 MIGRANAL ......................................................... 10 millipred ................................................................ 31 minitran ................................................................. 22 minocycline hcl ....................................................... 6 minoxidil ............................................................... 22 MIRAPEX ER ...................................................... 13 mirtazapine ............................................................. 8 mirtazapine odt ....................................................... 8 Miscellaneous Therapeutic Agents .................... 32 misoprostol ............................................................ 25 mitomycin .............................................................. 12 mitoxantrone hcl ................................................... 12 M-M-R II .............................................................. 31 modafinil ............................................................... 35 moexipril hcl ......................................................... 19 moexipril/hydrochlorothiazide .............................. 19 Molecular Target Inhibitors ................................ 12 mometasone furoate .............................................. 27 Monoamine Oxidase B (MAO-B) Inhibitors ...... 14 Monoamine Oxidase Inhibitors ............................. 8 Monoclonal Antibodies ........................................ 13 mononessa ............................................................. 28 montelukast sodium ............................................... 34

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MONUROL ............................................................ 4 Mood Stabilizers ................................................... 16 morphine sulfate ...................................................... 1 morphine sulfate er ................................................. 1 MOXEZA ............................................................... 6 MULTAQ ............................................................. 20 Multiple Sclerosis Agents .................................... 23 mupirocin ................................................................ 4 MUSTARGEN ...................................................... 11 MYCAMINE ........................................................ 10 MYCOBUTIN ...................................................... 10 mycophenolate mofetil .......................................... 30 mydral ................................................................... 32 MYFORTIC .......................................................... 30 myorisan ................................................................ 24 MYOZYME .......................................................... 24 MYTELASE ......................................................... 10 nabumetone ............................................................. 4 nadolol .................................................................. 20 nadolol/bendroflumethiazide ................................ 20 NAFCILLIN SODIUM ........................................... 5 NAFTIN ................................................................ 10 NAGLAZYME ..................................................... 24 NALFON ............................................................ 1, 4 naloxone hcl ............................................................ 3 naltrexone hcl .......................................................... 3 NAMENDA ............................................................ 8 NAMENDA TITRATION PAK ............................. 8 NAMENDA XR...................................................... 8 NAMENDA XR TITRATION PACK.................... 8 naphazoline hcl ..................................................... 32 naproxen ................................................................. 4 naproxen dr ............................................................. 4 naproxen sodium ..................................................... 1 naratriptan hcl ...................................................... 10 NASONEX ........................................................... 33 NATACYN ........................................................... 10 nateglinide............................................................. 17 NEBUPENT .......................................................... 13 NECON ................................................................. 28 necon 1/35 ............................................................. 28

necon 1/50-28........................................................ 28 nefazodone hcl ........................................................ 8 neomycin sulfate ...................................................... 4 neomycin/bacitracin/polymyxin .............................. 4 neomycin/polymyxin/bacitracin/hydrocortisone ..... 4 neomycin/polymyxin/dexamethasone .................... 32 neomycin/polymyxin/gramicidin ............................. 4 neomycin/polymyxin/hydrocortisone ................ 4, 33 NEULASTA ......................................................... 18 NEUMEGA........................................................... 18 NEUPOGEN ......................................................... 18 NEVANAC ........................................................... 32 nevirapine ............................................................. 14 NEXAVAR ........................................................... 12 NEXIUM I.V. ....................................................... 25 niacor .................................................................... 36 NIASPAN ............................................................. 22 nicardipine hcl ...................................................... 20 NICOTROL INHALER .......................................... 3 NICOTROL NS ...................................................... 3 nifediac cc ............................................................. 20 nifedical xl ............................................................. 21 nifedipine er .......................................................... 21 NILANDRON ....................................................... 30 nimodipine............................................................. 21 nisoldipine ............................................................. 21 nisoldipine er ........................................................ 21 NITRO-BID .......................................................... 22 nitrofurantoin .......................................................... 4 nitrofurantoin macrocrystalline .............................. 4 nitrofurantoin monohydrate .................................... 4 nitroglycerin .......................................................... 22 nitroglycerin lingual ............................................. 22 NITROSTAT ........................................................ 22 nizatidine ............................................................... 24 N-methyl-D-aspartate (NMDA) Receptor

Antagonist........................................................... 8 Nonsteroidal Anti-inflammatory Drugs ............ 1, 3 nora-be .................................................................. 29 NORDITROPIN FLEXPRO ................................. 27 NORDITROPIN NORDIFLEX PEN ................... 27

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norethindrone acetate ........................................... 29 NORMOSOL-M IN D5W .................................... 36 NOROXIN .............................................................. 6 NORPACE CR...................................................... 20 nortrel ................................................................... 28 nortrel 1/35 ........................................................... 28 nortriptyline hcl ...................................................... 9 NORVIR ............................................................... 15 NOVOLIN (VIAL) ............................................... 17 NOVOLOG (VIAL).............................................. 17 NOXAFIL ............................................................. 10 NUCYNTA ............................................................. 2 NUEDEXTA ......................................................... 23 NULOJIX .............................................................. 30 NUTROPIN .......................................................... 27 NUTROPIN AQ.................................................... 27 NUVARING ......................................................... 28 NUVIGIL .............................................................. 35 nyamyc .................................................................. 10 nystatin .................................................................. 10 nystatin/triamcinolone .......................................... 10 nystop .................................................................... 10 ocella ..................................................................... 28 octreotide acetate .................................................. 29 ofloxacin .................................................................. 6 ogestrel .................................................................. 28 olanzapine ............................................................. 14 olanzapine odt ....................................................... 14 olanzapine/fluoxetine .............................................. 8 omeprazole ............................................................ 25 omeprazole/sodium bicarbonate ........................... 25 OMNARIS ............................................................ 33 OMNITROPE ....................................................... 27 ONCASPAR ......................................................... 12 ondansetron hcl ....................................................... 9 ondansetron odt ...................................................... 9 ONFI ....................................................................... 7 ONTAK................................................................. 12 Ophthalmic Prostaglandin and Prostamide

Analogs ............................................................. 32 Ophthalmic Agents ............................................. 32

Ophthalmic Agents, Other ................................... 32 Ophthalmic Anti-allergy Agents .......................... 32 Ophthalmic Antiglaucoma Agents ...................... 33 Ophthalmic Anti-inflammatories ........................ 32 Opioid Analgesics, Long-acting ............................ 1 Opioid Analgesics, Short-acting ............................ 2 Opioid Antagonists ................................................. 3 ORACEA ................................................................ 6 ORAP .................................................................... 14 ORAPRED ODT ................................................... 27 ORENCIA ............................................................. 30 ORFADIN ............................................................. 24 orphenadrine citrate er ......................................... 35 orsythia ................................................................. 28 ORTHO EVRA ..................................................... 28 Otic Agents .......................................................... 33 OVCON-50 28 ...................................................... 28 oxacillin sodium ...................................................... 5 oxaliplatin ............................................................. 12 oxandrolone .......................................................... 27 oxaprozin................................................................. 4 oxazepam............................................................... 16 oxcarbazepine ......................................................... 7 OXISTAT ............................................................. 10 OXSORALEN ...................................................... 24 OXSORALEN ULTRA ........................................ 24 oxybutynin chloride ............................................... 25 oxybutynin chloride er .......................................... 25 oxycodone hcl .......................................................... 2 oxycodone/acetaminophen .................................. 2, 3 oxycodone/aspirin ................................................... 3 oxycodone/ibuprofen ............................................... 1 OXYCONTIN ......................................................... 1 oxymorphone hcl ..................................................... 3 oxymorphone hcl er................................................. 1 PACERONE ......................................................... 20 paclitaxel ............................................................... 12 PANCREAZE ....................................................... 24 PANDEL ............................................................... 27 PANRETIN ........................................................... 13 pantoprazole sodium ............................................. 25

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Parasympathomimetics ........................................ 10 paromomycin sulfate ............................................... 4 paroxetine hcl .......................................................... 8 paroxetine hcl er ..................................................... 8 PASER .................................................................. 11 PATADAY ........................................................... 32 PATANOL ............................................................ 32 PAXIL ..................................................................... 8 PCE ......................................................................... 6 Pediculicides/Scabicides ...................................... 13 pedi-dri .................................................................. 10 PEDVAX HIB ...................................................... 31 peg 3350/electrolytes ............................................ 25 PEGANONE ........................................................... 7 PEGASYS ............................................................. 16 PEGASYS PROCLICK ........................................ 16 PEG-INTRON....................................................... 16 PEG-INTRON REDIPEN ..................................... 16 PEG-INTRON REDIPEN PAK 4 ......................... 16 penicillin g potassium ............................................. 5 penicillin g procaine ............................................... 5 penicillin g sodium .................................................. 5 penicillin v potassium ............................................. 5 PENTAM 300 ....................................................... 13 pentostatin ............................................................. 11 pentoxifylline er .................................................... 21 perindopril erbumine ............................................ 19 periogard............................................................... 23 permethrin ............................................................. 13 perphenazine ......................................................... 14 perphenazine/amitriptyline ..................................... 9 PEXEVA ............................................................. 8, 9 phenelzine sulfate .................................................... 8 phenobarbital .......................................................... 6 phenytoin ................................................................. 7 phenytoin sodium extended ..................................... 7 Phosphate Binders ............................................... 25 PHOSPHOLINE IODIDE .................................... 33 physiolyte .............................................................. 32 physiosol irrigation ............................................... 32 pilocarpine hcl ...................................................... 23

PILOPINE HS ....................................................... 33 pindolol ................................................................. 20 pioglitazone hcl ..................................................... 17 pioglitazone hcl/metformin hcl ............................. 17 pioglitazone hcl-glimepiride ................................. 17 piperacillin sodium/tazobactam sodium ................. 5 piroxicam ................................................................ 4 PLAN B ................................................................ 29 Platelet Modifying Agents .................................... 19 podofilox ............................................................... 24 polycin b .................................................................. 4 poly-dex ................................................................. 32 polyethylene glycol 3350....................................... 25 polymyxin b sulfate ................................................. 4 POMALYST ......................................................... 12 portia ..................................................................... 28 potassium chloride ................................................ 36 potassium chloride 0.224%/dextrose 5% viaflex .. 36 potassium chloride 0.3%/d5w ............................... 36 potassium chloride er ............................................ 36 potassium chloride sr ............................................ 36 potassium citrate ................................................... 36 POTIGA .................................................................. 6 PRADAXA ........................................................... 18 pramipexole dihydrochloride ................................ 13 PRANDIN ............................................................. 17 pravastatin sodium ................................................ 21 prazosin hcl ........................................................... 19 PRED MILD ......................................................... 32 PRED-G ................................................................ 32 PRED-G S.O.P. ..................................................... 32 prednicarbate ........................................................ 27 prednisolone acetate ............................................. 33 prednisolone sodium phosphate ...................... 27, 33 prednisone ............................................................. 27 prednisone intensol ............................................... 27 PREFEST .............................................................. 29 PREMARIN .......................................................... 29 PREMPHASE ....................................................... 29 PREMPRO ............................................................ 29 prenatal low iron................................................... 36

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prenatal vitamins .................................................. 36 prevalite ................................................................ 22 previfem................................................................. 29 PREVPAC............................................................... 4 PREZISTA ............................................................ 15 PRIFTIN ............................................................... 11 PRILOSEC ............................................................ 25 primaquine phosphate ........................................... 13 primidone ................................................................ 7 PRIMSOL ............................................................... 4 PRISTIQ ................................................................. 9 PRIVIGEN ............................................................ 30 PROAIR HFA ....................................................... 34 probenecid............................................................. 10 probenecid/colchicine ........................................... 10 prochlorperazine ................................................... 14 prochlorperazine edisylate.................................... 14 prochlorperazine maleate ..................................... 14 PROCRIT .............................................................. 18 proctocream hc ..................................................... 27 proctosol hc ........................................................... 27 progesterone ......................................................... 29 Progestins ............................................................. 29 PROGLYCEM ...................................................... 17 PROGRAF ............................................................ 30 PROLASTIN-C..................................................... 35 PROLEUKIN ........................................................ 12 PROLIA ................................................................ 31 PROMACTA ........................................................ 18 propafenone hcl .................................................... 20 propafenone hcl er ................................................ 20 propantheline bromide .......................................... 24 propranolol hcl ..................................................... 20 propranolol hcl er ................................................. 20 propranolol/hydrochlorothiazide .......................... 20 propylthiouracil .................................................... 30 PROQUAD ........................................................... 31 Protectants ............................................................ 25 Proton Pump Inhibitors ....................................... 25 PROTONIX .......................................................... 25 PROTOPIC ........................................................... 24

protriptyline hcl ...................................................... 9 PULMICORT ....................................................... 33 PULMICORT FLEXHALER ............................... 33 Pulmonary Antihypertensives .............................. 35 PULMOZYME ..................................................... 35 pyrazinamide ......................................................... 11 pyridostigmine bromide ........................................ 10 quasense ................................................................ 29 quetiapine fumarate .............................................. 14 quinapril hcl .......................................................... 19 quinapril/hydrochlorothiazide .............................. 20 quinidine gluconate cr .......................................... 20 quinidine sulfate .................................................... 20 quinidine sulfate er ............................................... 20 quinine sulfate ....................................................... 13 Quinolones ............................................................. 6 QVAR ................................................................... 33 RABAVERT ......................................................... 31 ramipril ................................................................. 20 RANEXA .............................................................. 21 ranitidine hcl ......................................................... 24 RAPAFLO ............................................................ 25 RAPAMUNE ........................................................ 30 RAVICTI .............................................................. 24 REBETOL............................................................. 16 REBIF ................................................................... 30 REBIF TITRATION PACK ................................. 30 reclipsen ................................................................ 29 RECOMBIVAX HB ............................................. 31 REGRANEX ......................................................... 24 RELENZA DISKHALER ..................................... 15 RELISTOR ........................................................... 24 RELPAX ............................................................... 10 REMICADE .......................................................... 30 RENVELA ............................................................ 25 repaglinide ............................................................ 17 reprexain ................................................................. 3 RESCRIPTOR ...................................................... 15 reserpine ............................................................... 19 Respiratory Tract Agents ................................... 33 Respiratory Tract Agents, Other .......................... 35

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RESTASIS ............................................................ 32 Retinoids ............................................................... 13 RETROVIR IV INFUSION .................................. 15 REVLIMID ........................................................... 11 REYATAZ ............................................................ 15 RHINOCORT AQUA ........................................... 33 ribapak .................................................................. 16 ribasphere ............................................................. 16 ribavirin ................................................................ 16 RIDAURA ............................................................ 30 rifampin ................................................................. 11 RIFATER .............................................................. 11 riluzole .................................................................. 23 rimantadine hcl ..................................................... 15 RIOMET ............................................................... 17 RISPERDAL CONSTA ........................................ 14 risperidone ............................................................ 14 risperidone odt ...................................................... 14 RITUXAN............................................................. 13 rivastigmine tartrate ............................................... 8 rizatriptan benzoate .............................................. 10 rizatriptan benzoate odt ........................................ 10 romycin ................................................................... 6 ropinirole er .......................................................... 13 ropinirole hcl ........................................................ 14 ROTARIX ............................................................. 31 ROTATEQ ............................................................ 31 ROXICET ............................................................... 3 roxicodone............................................................... 3 ROZEREM ........................................................... 35 SABRIL .................................................................. 7 SAIZEN ................................................................ 27 SANDIMMUNE ................................................... 30 SANDOSTATIN LAR DEPOT ............................ 29 SANTYL ............................................................... 24 SAPHRIS .............................................................. 14 Selective Estrogen Receptor Modifying Agents .. 29 selegiline hcl ........................................................... 8 selenium sulfide ..................................................... 24 SELZENTRY ........................................................ 15 SEMPREX-D ........................................................ 34

SENSIPAR ............................................................ 29 SEREVENT DISKUS ........................................... 35 SEROMYCIN ....................................................... 11 SEROQUEL XR ................................................... 14 SEROSTIM ........................................................... 27 Serotonin (5-HT) 1b/1d Receptor Agonists ......... 10 Serotonin/Norepinephrine Reuptake Inhibitors ... 8 sertraline hcl ........................................................... 9 sildenafil citrate .................................................... 35 SILENOR .............................................................. 35 silver sulfadiazine ................................................... 4 SIMCOR ............................................................... 22 SIMPONI .............................................................. 30 simvastatin ............................................................ 22 SINGULAIR ......................................................... 34 Skeletal Muscle Relaxants .................................. 35 SKELID ................................................................ 31 Sleep Disorder Agents......................................... 35 Sleep Disorders, Other ......................................... 35 Smoking Cessation Agents .................................... 3 Sodium Channel Agents ........................................ 7 sodium chloride ..................................................... 36 sodium chloride 0.45% viaflex .............................. 36 sodium chloride 0.9% ........................................... 32 sodium fluoride ..................................................... 36 sodium phenylbutyrate .......................................... 24 sodium polystyrene sulfonate ................................ 36 sodium sulfacetamide .............................................. 6 SOLARAZE .......................................................... 24 solia ....................................................................... 29 SOLTAMOX ........................................................ 11 SOMA ................................................................... 35 SOMATULINE DEPOT ....................................... 29 SOMAVERT......................................................... 30 SORIATANE ........................................................ 24 sorine..................................................................... 20 sotalol hcl .............................................................. 20 sotalol hcl (af) ....................................................... 20 spinosad ................................................................ 13 SPIRIVA HANDIHALER .................................... 34 spironolactone....................................................... 21

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spironolactone/hydrochlorothiazide ..................... 21 SPORANOX ......................................................... 10 sprintec .................................................................. 29 SPRYCEL ....................................................... 12, 13 ssd ........................................................................... 4 stagesic .................................................................... 3 STALEVO ............................................................ 14 stavudine ............................................................... 15 STAVZOR .............................................................. 7 STELARA............................................................. 24 STIMATE ............................................................. 27 STIVARGA .......................................................... 13 STRATTERA ....................................................... 23 STRIANT .............................................................. 28 STRIBILD............................................................. 15 STROMECTOL .................................................... 13 SUBOXONE ........................................................... 3 SUCRAID ............................................................. 24 sucralfate............................................................... 25 sulfacetamide sodium ........................................ 6, 24 sulfacetamide sodium/prednisolone sodium

phosphate .......................................................... 33 sulfadiazine ............................................................. 6 sulfamethoxazole/trimethoprim ............................... 6 sulfamethoxazole/trimethoprim ds .......................... 6 SULFAMYLON ..................................................... 4 sulfasalazine .......................................................... 31 sulfazine ................................................................ 31 sulfazine ec ............................................................ 31 Sulfonamides .................................................... 6, 31 sulindac ................................................................... 4 sumatriptan ........................................................... 10 sumatriptan succinate ........................................... 10 sumatriptan succinate refill .................................. 10 SUMAVEL DOSEPRO ........................................ 10 SUPRAX ................................................................. 5 SUPREP BOWEL PREP ...................................... 25 SUSTIVA .............................................................. 15 SUTENT ............................................................... 13 SYLATRON ......................................................... 12 SYMBICORT ....................................................... 34

SYMLINPEN 120 ................................................. 17 SYMLINPEN 60 ................................................... 17 SYNALGOS-DC .................................................... 3 SYNAREL ............................................................ 30 SYNRIBO ............................................................. 12 SYNTHROID ....................................................... 29 SYPRINE .............................................................. 36 TABLOID ............................................................. 11 TACLONEX ......................................................... 27 tacrolimus ............................................................. 30 TAFINLAR ........................................................... 11 TAMIFLU ............................................................. 15 tamoxifen citrate ................................................... 11 tamsulosin hcl ....................................................... 25 TARCEVA ............................................................ 13 TARGRETIN ........................................................ 13 TARKA ................................................................. 20 TASIGNA ............................................................. 13 TASMAR .............................................................. 13 tazicef ...................................................................... 5 TAZORAC ............................................................ 24 taztia xt .................................................................. 21 TECFIDERA......................................................... 30 TECFIDERA STARTER PACK .......................... 30 TEGRETOL-XR ..................................................... 7 temazepam............................................................. 35 terazosin hcl .......................................................... 25 terbinafine hcl ....................................................... 10 terbutaline sulfate ................................................. 35 terconazole ............................................................ 10 TESTIM ................................................................ 28 testosterone cypionate ........................................... 28 testosterone enanthate .......................................... 28 tetanus toxoid adsorbed ........................................ 31 TETANUS/DIPHTHERIA TOXOIDS-

ADSORBED ADULT ...................................... 31 tetracycline hcl ........................................................ 6 Tetracyclines........................................................... 6 TEXACORT ......................................................... 27 THALITONE ........................................................ 21 THALOMID ......................................................... 11

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THEO-24............................................................... 34 theochron .............................................................. 34 theophylline er ...................................................... 34 Therapeutic Nutrients/Minerals/Electrolytes ... 35 thioridazine hcl ..................................................... 14 thiotepa ................................................................. 11 thiothixene ............................................................. 14 THYROLAR-1/2 .................................................. 29 tiagabine hydrochloride .......................................... 7 TIKOSYN ............................................................. 20 timolol maleate ................................................ 20, 33 tinidazole ............................................................... 13 TIROSINT ............................................................ 29 TIVICAY .............................................................. 15 tizanidine hcl ......................................................... 14 TOBI ....................................................................... 4 TOBI PODHALER ................................................. 4 TOBRADEX ......................................................... 33 tobramycin sulfate ................................................... 4 tobramycin/dexamethasone ................................... 33 TOBREX................................................................. 4 tolazamide ............................................................. 17 tolbutamide ........................................................... 17 tolmetin sodium ....................................................... 4 tolterodine tartrate ................................................ 25 topiramate ............................................................... 7 topotecan hcl ......................................................... 12 TORISEL .............................................................. 30 torsemide ............................................................... 21 TOVIAZ ................................................................ 25 tpn electrolytes ...................................................... 36 TRACLEER .......................................................... 35 tramadol hcl ............................................................ 3 tramadol hcl er ........................................................ 1 tramadol hcl/acetaminophen .................................. 3 trandolapril ........................................................... 20 tranexamic acid ..................................................... 19 TRANSDERM-SCOP............................................. 9 tranylcypromine sulfate .......................................... 8 TRAVATAN Z ..................................................... 32 travoprost .............................................................. 32

trazodone hcl ........................................................... 8 TREANDA ........................................................... 11 Treatment-Resistant ............................................. 14 TRECATOR ......................................................... 11 tretinoin ........................................................... 13, 24 TREXALL ............................................................ 30 triamcinolone acetonide .................................. 27, 34 triamcinolone in orabase ...................................... 23 triamterene/hydrochlorothiazide .......................... 21 triazolam ............................................................... 35 Tricyclics................................................................. 9 triderm................................................................... 27 trifluoperazine hcl ................................................. 14 trifluridine ............................................................. 16 TRIGLIDE ............................................................ 21 trihexyphenidyl hcl ................................................ 13 tri-legest fe ............................................................ 29 TRILEPTAL ........................................................... 7 TRILIPIX .............................................................. 21 trilyte ..................................................................... 25 trimethoprim ........................................................... 4 trimethoprim sulfate/polymyxin b sulfate ................ 4 trimipramine maleate .............................................. 9 trinessa .................................................................. 29 tri-previfem ........................................................... 29 TRISENOX ........................................................... 12 tri-sprintec............................................................. 29 triveen-u ................................................................ 36 trivora ................................................................... 29 TRIZIVIR ............................................................. 15 tropicamide ........................................................... 32 trospium chloride .................................................. 25 trospium chloride er .............................................. 25 TRUVADA ........................................................... 15 TUDORZA PRESSAIR ........................................ 34 TWINJECT ........................................................... 35 TWINRIX ............................................................. 31 TYKERB............................................................... 13 TYPHIM VI .......................................................... 31 TYSABRI ............................................................. 30 TYZEKA............................................................... 16

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TYZINE ................................................................ 35 u-cort ..................................................................... 27 ULORIC ................................................................ 10 unithroid ................................................................ 29 UROCIT-K 15 ...................................................... 36 ursodiol ................................................................. 24 Vaccines ................................................................ 30 VAGIFEM ............................................................ 29 valacyclovir hcl ..................................................... 16 VALCYTE ............................................................ 14 valproate sodium ..................................................... 7 valproic acid ........................................................... 7 valsartan/hydrochlorothiazide .............................. 19 vancomycin hcl ........................................................ 4 vandazole ................................................................ 4 VANOS ................................................................. 27 VAQTA................................................................. 31 VARIVAX ............................................................ 31 Vasodilators, Direct-acting Arterial .................... 22 Vasodilators, Direct-acting Arterial/Venous ....... 22 VECTIBIX ............................................................ 13 VELCADE ............................................................ 12 velivet .................................................................... 29 venlafaxine hcl ........................................................ 9 venlafaxine hcl er .................................................... 9 VENTAVIS........................................................... 35 VENTOLIN HFA ................................................. 35 verapamil hcl ........................................................ 21 verapamil hcl er .................................................... 21 verapamil hcl sr .................................................... 21 VERDESO ............................................................ 27 VESICARE ........................................................... 25 vestura ................................................................... 29 VEXOL ................................................................. 33 VFEND ................................................................. 10 VIBRAMYCIN ....................................................... 6 VICTRELIS .......................................................... 16 VIDAZA ............................................................... 12 VIDEX PEDIATRIC ............................................ 15 VIGAMOX ............................................................. 6 VIIBRYD ................................................................ 9

VIMPAT ................................................................. 7 vinblastine sulfate ................................................. 12 vincasar pfs ........................................................... 12 vincristine sulfate .................................................. 12 vinorelbine tartrate ............................................... 12 VIRACEPT ........................................................... 15 VIRAMUNE ......................................................... 15 VIRAMUNE XR .................................................. 15 VIREAD ............................................................... 15 VISICOL ............................................................... 24 Vitamins ................................................................ 36 VIVELLE-DOT .................................................... 29 VOLTAREN ......................................................... 33 voriconazole .......................................................... 10 VOTRIENT........................................................... 13 VPRIV................................................................... 24 VYVANSE ........................................................... 22 warfarin sodium .................................................... 18 WELCHOL ........................................................... 22 XALKORI............................................................. 13 XARELTO ............................................................ 18 XELJANZ ............................................................. 30 XENAZINE .......................................................... 23 XGEVA................................................................. 32 XIFAXAN........................................................... 4, 5 XOLAIR ............................................................... 35 XOPENEX ............................................................ 35 XOPENEX CONCENTRATE .............................. 35 XOPENEX HFA ................................................... 35 XTANDI ............................................................... 30 XYREM ................................................................ 35 YF-VAX ............................................................... 31 zafirlukast .............................................................. 34 zaleplon ................................................................. 35 ZALTRAP............................................................. 13 ZANOSAR ............................................................ 11 ZANTAC .............................................................. 24 ZAVESCA ............................................................ 24 zazole..................................................................... 10 ZEGERID ............................................................. 25 ZELBORAF .......................................................... 13

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ZEMAIRA ............................................................ 35 ZEMPLAR ............................................................ 32 zenchent fe ............................................................. 29 ZENPEP ................................................................ 24 zeosa ...................................................................... 29 ZERIT ................................................................... 15 ZETIA ................................................................... 22 ZIAGEN ................................................................ 15 zidovudine ............................................................. 15 ziprasidone hcl ...................................................... 14 ZITHROMAX......................................................... 6 ZMAX ..................................................................... 6 zoledronic acid ...................................................... 32 ZOLINZA ............................................................. 12 zolpidem tartrate ................................................... 35 zolpidem tartrate er............................................... 35 ZOMETA .............................................................. 32

ZOMIG ................................................................. 10 ZOMIG ZMT ........................................................ 10 ZONALON ........................................................... 24 zonisamide............................................................... 7 ZORBTIVE ........................................................... 27 ZORTRESS........................................................... 30 ZOSTAVAX ......................................................... 31 zovia ...................................................................... 29 ZOVIRAX............................................................. 16 ZUBSOLV .............................................................. 3 ZYCLARA ............................................................ 24 ZYDONE ................................................................ 3 ZYFLO CR ........................................................... 34 ZYLET .................................................................. 33 ZYTIGA ................................................................ 12 ZYVOX................................................................... 5

2013 Blue Shield Medicare Enhanced Plan Formulary

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