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2015 Rx Preferred Drug Guide (3-Tier) Please bring this guide with you to your next doctor visit.

30781(Ed. 10/2014)

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Do you have questions?

Call Assurant Health Customer Service at the phone number printed on the back of your medical identification card.

Dear Member,

To help you know how drugs are covered by your plan, we are pleased to provide you with a copy of our 2015 Rx Preferred Drug Guide.

This document provides helpful information on the Assurant Rx Preferred Drug Guide and your pharmacy benefit plan. You may want to take this guide with you when you see your doctor to talk about what is covered under your plan.

Many commonly prescribed drugs are listed in this guide. Please remember this is not a complete list of drugs covered under your plan. Because thousands of drugs are included in your pharmacy benefits plan, we only list the most commonly prescribed ones.

Most injectable medications are not covered under the prescription drug benefit but paid subject to the cost-sharing requirements (e.g. deductible and coinsurance) that apply to other medical services.

Wellness: If required by applicable law, certain medications that are deemed wellness benefits are provided with no cost-sharing to members.

Please note that not all drugs listed in this guide are covered by all pharmacy benefit programs. Check your benefit materials or contact Assurant Health by calling the number on the back of your medical identification card to determine if a drug would be covered.

Where required by applicable law, members who have coverage for medications which have changed status including tier (i.e drug changed from P (preferred) to NP (non-preferred) on the Rx Preferred Drug Guide, Prior Authorization List, Step Therapy List, or Quantity Limit during the plan year, will continue to have those medications covered at the same benefit level under their plan prior to the addition, removal or change, until January 1st of the following calendar year.

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What is the Assurant Rx Preferred Drug Guide? Our Rx Preferred Drug Guide is meant to give you a general view of drugs covered by your plan. Changes to the list are based on the latest medical findings as well as information from the Food and Drug Administration (FDA) and drug makers. This list includes both brand-name and generic drugs and is updated regularly. Assurant will generally cover the drugs listed on our Rx Preferred Drug Guide as long as they are medically necessary and plan rules are followed. Coverage is not limited to drugs on the Rx Preferred Drug Guide. Your plan has different copay or coinsurance tiers for generic, brand-name, preferred and non-preferred drugs. Usually, preferred drugs are covered at a lower copay or coinsurance tier, which means you pay less out of pocket for those drugs. The Rx Preferred Drug Guide is subject to change without notice. Drugs on the list are based on reliable medical data, safety and cost. When you talk to your doctor about what drug may be right for you, it is important to remember that you and your doctor are responsible for making the final decision on your drug therapy.

Why is the Rx Preferred Drug Guide subject to change? During the year, we may add or remove drugs from the Rx Preferred Drug Guide. These changes happen for various reasons and may move a drug from one coverage tier to another.

� As brand-name drugs lose their patents, generic versions may become available. When this happens, the brand-name drug may move to a higher copayment or coinsurance tier. The generic drug may be added to the list and available at a lower copayment or coinsurance tier.

� The FDA approves many new drugs throughout the year. Your plan generally covers new FDA-approved drugs; however, you may pay a higher copayment or coinsurance tier for these drugs. The new drug(s) also may be subject to prior authorization or step-therapy requirements.

� Some drugs may also no longer require a prescription. If your drug becomes available over-the-counter (OTC), the drug will generally no longer be covered under your prescription plan.

� If the FDA removes a drug from the market it will also no longer be covered under your prescription plan.

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Why do some drugs have quantity limits? Your plan may limit the amount of a drug you can receive at one time. These limits help your doctor and pharmacist check that the drugs are used appropriately while promoting patient safety. We use medical guidelines, FDA approval and guidance from drug makers to set these coverage limits. The quantity limits program includes:

� Dose Efficiency Edits – Limits coverage of prescriptions to one dose per day for drugs that are approved for once-daily dosing.

� Maximum Daily Dose – A message is sent to the pharmacy if a prescription is higher than the maximum allowed dose.

� Quantity Limits Over Time – Limits coverage of prescriptions to a specific number of units in a defined amount of time.

To get coverage for amounts over the allowed quantity, you, your doctor or the person you appoint to manage your care must request a coverage override by calling the phone number located on your ID card. The quantity limit list is subject to change.

What is step-therapy? With step-therapy you must try one or more alternate drugs before your plan will cover a step-therapy drug. These drugs are FDA-approved, treat the same condition(s) and, they may also be available to you at a lower copay or coinsurance tier. If it is necessary for you to use a drug on the step therapy list, you, your doctor, or the person you appoint to manage your care may request a coverage override by calling the phone number located on your ID card.

What is the Prior Authorization program? The Prior Authorization program encourages appropriate and cost-effective use of drugs by allowing coverage only when certain conditions are met.

• A physician, a patient, or a person appointed to manage the patient’s care must request prior authorization before drugs on the Prior Authorization List may be covered under a member’s pharmacy benefits plan. If the request is approved, the drug will then be covered at the applicable costs associated with the member’s plan.

• The Prior Authorization program is based upon current medical findings, FDA-approved manufacturer labeling information, and cost.

• To determine if a drug requires prior authorization, refer to the column titled Prior Authorization next to the list of drugs in this guide. The list of drugs requiring prior authorization is subject to change.

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To initiate a prior authorization request: • Call the phone number on the back of the member identification card to

obtain more information on the prior authorization review process.

What are generic drugs? Drug manufacturers develop and release new drugs under a brand name. When the patent expires, other manufacturers are then able to make duplicate versions of the same drug. Generic drugs are chemically the same as their branded counterparts. They are also the same in dosage, safety, strength, form and intended use. Plus, generics usually cost less than brand-name drugs. Generic drugs are only available after the FDA approves them. When filling your prescription, your pharmacist generally can substitute a generic drug for a brand-name drug when the generic is rated by the FDA as equivalent and also where it is permitted by your doctor and state law.

Table of Contents – Preferred Drugs by Therapeutic Class

Therapeutic Class Page(s)

*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS* 8

*AMEBICIDES* 9

*AMINOGLYCOSIDES 9

*ANALGESICS - ANTI-INFLAMMATORY* 9

*ANALGESICS - NONNARCOTIC* 11

*ANALGESICS - OPIOID* 12

*ANDROGENS-ANABOLIC* 14

*ANORECTAL AGENTS* 15

*ANTHELMINTICS* 15

*ANTIANGINAL AGENTS* 16

THERAPEUTIC CLASS LIST KEY (on following pages)

lower case– Generic medication – lowest co-payment

UPPERCASE – Brand-name medication – Higher co-payment

MED – Injectable medication that may be covered under the

medical benefit

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*ANTIANXIETY AGENTS* 16

*ANTIARRHYTHMICS* 17

*ANTIASTHMATIC AND BRONCHODILATOR AGENTS* 17

*ANTICOAGULANTS* 19

*ANTICONVULSANTS* 19

*ANTIDEPRESSANTS* 22

*ANTIDIABETICS* 24

*ANTIDIARRHEALS* 27

*ANTIDOTES* 27

*ANTIEMETICS* 27

*ANTIFUNGALS* 28

*ANTIHISTAMINES* 28

*ANTIHYPERLIPIDEMICS* 29

*ANTIHYPERTENSIVES* 31

*ANTI-INFECTIVE AGENTS - MISC.* 34

*ANTIMALARIALS* 35

*ANTIMYASTHENIC/CHOLINERGIC AGENTS* 35

*ANTIMYCOBACTERIAL AGENTS* 35

*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES* 35

*ANTIPARKINSON AGENTS* 39

*ANTIPSYCHOTICS/ANTIMANIC AGENTS* 40

*ANTIVIRALS* 42

*ASSORTED CLASSES* 44

*BETA BLOCKERS* 46

*BIOLOGICALS MISC* 46

*CALCIUM CHANNEL BLOCKERS* 47

*CARDIOTONICS* 48

*CARDIOVASCULAR AGENTS - MISC.* 48

*CEPHALOSPORINS* 49

*CONTRACEPTIVES* 49

*CORTICOSTEROIDS* 53

*COUGH/COLD/ALLERGY* 54

*DERMATOLOGICALS* 56

*DIAGNOSTIC PRODUCTS* 66

*DIGESTIVE AIDS* 67

*DIURETICS* 67

*ENDOCRINE AND METABOLIC AGENTS - MISC.* 68

*ESTROGENS* 71

*FLUOROQUINOLONES* 72

*GASTROINTESTINAL AGENTS - MISC.* 73

*GENERAL ANESTHETICS* 74

*GENITOURINARY AGENTS - MISCELLANEOUS* 74

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*GOUT AGENTS* 76

*HEMATOLOGICAL AGENTS - MISC.* 76

*HEMATOPOIETIC AGENTS* 78

*HEMOSTATICS* 78

*HYPNOTICS* 79

*LAXATIVES* 79

*MACROLIDES* 80

*MEDICAL DEVICES* 80

*MIGRAINE PRODUCTS* 81

*MINERALS & ELECTROLYTES* 82

*MOUTH/THROAT/DENTAL AGENTS* 83

*MUSCULOSKELETAL THERAPY AGENTS* 84

*NASAL AGENTS - SYSTEMIC AND TOPICAL* 85

*NEUROMUSCULAR AGENTS* 85

*OPHTHALMIC AGENTS* 85

*OTIC AGENTS* 90

*OXYTOCICS* 91

*PASSIVE IMMUNIZING AGENTS* 91

*PENICILLINS* 92

*PROGESTINS* 93

*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.* 93

*RESPIRATORY AGENTS - MISC.* 95

*TETRACYCLINES* 95

*THYROID AGENTS* 96

*ULCER DRUGS* 96

*URINARY ANTI-INFECTIVES* 98

*URINARY ANTISPASMODICS* 99

*VAGINAL PRODUCTS* 99

*VASOPRESSORS* 100

*VITAMINS* 100

Medication Name

3-Tier

G = Generic

P = Preferred Brand

NP = Non Preferred

Brand

MED = Medical

Benefit Pri

or

Au

tho

riza

tio

n

Ste

p T

he

rap

y

Qu

an

tity

Lim

it

*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*

*Amphetamines** - *Amphetamine Mixtures***

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ADDERALL NP N Y Y

ADDERALL XR CAPSULE NP N Y Y

amphetamine-dextroamphet ER G N N Y

amphetamine-dextroamphetamine G N N Y

*Amphetamines** - *Amphetamines***

DESOXYN NP N Y Y

DEXEDRINE NP N Y Y

dextroamphetamine G N N Y

dextroamphetamine ER G N N Y

dextroamphetamine sulfate solution G N N Y

methamphetamine G N N Y

PROCENTRA NP N Y Y

VYVANSE P N N Y

zenzedi G N N Y

*Analeptics** - *Analeptics***

CAFCIT NP N N Y

caffeine citrate solution G N N Y *Attention-Deficit/Hyperactivity Disorder (ADHD) Agents** - *ADHD

Agent - Selective Alpha Adrenergic Agonists***

clonidine ER G N N Y

INTUNIV NP N Y Y

KAPVAY NP N Y Y *Attention-Deficit/Hyperactivity Disorder (ADHD) Agents** - *ADHD

Agent - Selective Norepinephrine Reuptake Inhibitor***

STRATTERA P N N Y

*Stimulants - Misc.** - *Stimulants - Misc.***

CONCERTA NP N Y Y

DAYTRANA NP N Y Y

dexmethylphenidate G N N Y

dexmethylphenidate ER G N N Y

FOCALIN NP N Y Y

FOCALIN XR NP N Y Y

METADATE CD NP N Y Y

metadate ER G N N Y

methylin ER G N N Y

methylin solution NP N Y Y

methylin TABLET G N N Y

METHYLIN TABLET CHEWABLE NP N Y Y

methylphenidate solution G N N Y

methylphenidate ER G N N Y

methylphenidate ER (CD) G N N Y

methylphenidate ER (LA) G N N Y

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methylphenidate tablet G N N Y

modafinil G Y N Y

NUVIGIL NP Y N Y

PROVIGIL NP Y N Y

QUILLIVANT XR NP N Y Y

RITALIN LA NP N Y Y

RITALIN SR NP N Y Y

*AMEBICIDES*

*Amebicides** - *Amebicides***

YODOXIN NP N N Y

*AMINOGLYCOSIDES*

*Aminoglycosides** - *Aminoglycosides***

BETHKIS NP Y N Y

NEO-FRADIN NP N N Y

neomycin G N N Y

paromomycin G N N Y

TOBI NP Y N Y

TOBI PODHALER P Y N Y

tobramycin inhalation solution G Y N Y

*ANALGESICS - ANTI-INFLAMMATORY*

*Antirheumatic - Enzyme Inhibitors** - *Antirheumatic - Janus Kinase

(JAK) Inhibitors***

XELJANZ NP Y N Y *Antirheumatic Antimetabolites** - *Antirheumatic

Antimetabolites***

OTREXUP MED Y N Y

RHEUMATREX NP N N Y

RASUVO MED Y N Y *Anti-TNF-alpha - Monoclonal Antibodies** - *Anti-TNF-alpha -

Monoclonal Antibodies***

HUMIRA MED Y N Y *Anti-TNF-alpha - Monoclonoal Antibodies** - *Anti-TNF-alpha -

Monoclonoal Antibodies***

SIMPONI MED Y N Y

SIMPONI ARIA MED Y N Y

STELARA MED Y N Y

*Gold Compounds** - *Gold Compounds***

RIDAURA NP N N Y

*Interleukin-1 Blockers** - *Interleukin-1 Blockers***

ARCALYST MED Y N Y *Interleukin-1 Receptor Antagonist (IL-1Ra)** - *Interleukin-1 Receptor

Antagonist (IL-1Ra)***

KINERET MED Y N Y

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*Interleukin-1beta Blockers** - *Interleukin-1beta Blockers***

ILARIS MED Y N Y *Interleukin-6 Receptor Inhibitors** - *Interleukin-6 Receptor

Inhibitors***

ACTEMRA MED Y N Y *Nonsteroidal Anti-inflammatory Agents (NSAIDs)** - *Cyclooxygenase

2 (COX-2) Inhibitors***

CELEBREX NP N N Y *Nonsteroidal Anti-inflammatory Agents (NSAIDs)** - *Nonsteroidal

Anti-inflammatory Agent Combinations***

ARTHROTEC NP N N Y

diclofenac-misoprostol G N N Y

DUEXIS NP N Y Y

VIMOVO P N Y Y *Nonsteroidal Anti-inflammatory Agents (NSAIDs)** - *Nonsteroidal

Anti-inflammatory Agents (NSAIDs)***

ANAPROX NP N N Y

ANAPROX DS NP N N Y

CATAFLAM NP N N Y

DAYPRO NP N N Y

diclofenac potassium G N N Y

diclofenac sodium G N N Y

diclofenac sodium ER NP N N Y

EC-NAPROSYN NP N N Y

etodolac G N N Y

etodolac ER G N N Y

FELDENE NP N N Y

flurbiprofen G N N Y

ibuprofen G N N Y

INDOCIN NP N N Y

indomethacin G N N Y

indomethacin ER G N N Y

ketoprofen G N N Y

ketorolac G N N Y

mefenamic acid G N N Y

meloxicam G N N Y

MOBIC NP N N Y

nabumetone G N N Y

NALFON NP N N Y

NAPRELAN NP N N Y

NAPROSYN NP N N Y

naproxen G N N Y

naproxen delayed release G N N Y

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naproxen sodium G N N Y

oxaprozin G N N Y

piroxicam G N N Y

PONSTEL NP N N Y

SPRIX NP N N Y

sulindac G N N Y

tolmetin G N N Y

VOLTAREN-XR NP N N Y

ZIPSOR NP N N Y

ZORVOLEX NP N Y Y *Phosphodiesterase 4 (PDE4) Inhibitors** - *Phosphodiesterase 4

(PDE4) Inhibitors***

OTEZLA NP Y N Y

OTEZLA STARTER PACK NP Y N Y

*Pyrimidine Synthesis Inhibitors** - *Pyrimidine Synthesis Inhibitors***

leflunomide G N N Y *Selective Costimulation Modulators** - *Selective Costimulation

Modulators***

ORENCIA MED Y N Y *Soluble Tumor Necrosis Factor Receptor Agents** - *Soluble Tumor

Necrosis Factor Receptor Agents***

ENBREL MED Y N Y

*ANALGESICS - NonNarcotic*

*Analgesic Combinations** - *Analgesics-Sedatives***

alagesic capsule G N N Y

ALAGESIC LQ SOLUTION NP N N Y

anolor 300 CAPSULE 50-325-40 MG ORAL G N N Y

BUPAP NP N N Y

butalbital-acetaminophen G N N Y

butalbital-APAP-caffeine G N N Y

butalbital-ASA-caffeine G N N Y

capacet G N N Y

EQUAGESIC NP N N Y

ESGIC NP N N Y

FIORICET NP N N Y

FIORINAL NP N N Y

margesic G N N Y

marten-tab G N N Y

ORBIVAN CF NP N N Y

REPAN G N N Y

TENCON G N N Y

ZEBUTAL G N N Y

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*Analgesics-Peptide Channel Blockers** - *Selective N-Type Neuronal

Calcium Channel Blockers***

PRIALT MED Y N Y

*Salicylates** - *Salicylate Combinations***

choline & mag trisalicylate G N N Y

*Salicylates** - *Salicylates***

diflunisal G N N Y

MST 600 NP N N Y

salsalate G N N Y

*ANALGESICS - OPIOID*

*Opioid Agonists** - *Opioid Agonists***

ABSTRAL NP Y N Y

ACTIQ LOLLIPOP NP Y N Y

AVINZA NP N N Y

CONZIP NP N N Y

DEMEROL NP N N Y

DILAUDID NP N N Y

DOLOPHINE NP N N Y

DURAGESIC NP N N Y

EXALGO NP N Y Y

fentanyl citrate lollipop G Y N Y

fentanyl patch G N N Y

FENTORA NP Y N Y

hydromorphone G N N Y

KADIAN NP N N Y

LAZANDA NP Y N Y

meperidine G N N Y

meperitab G N N Y

methadone G N N Y

METHADOSE NP N N Y

morphine sulfate ER G N N Y

MS CONTIN NP N N Y

NUCYNTA P N N Y

NUCYNTA ER P N N Y

OPANA NP N N Y

OPANA ER P N N Y

OXECTA NP N N Y

oxycodone G N N Y

OXYCONTIN P N N Y

oxymorphone G N N Y

oxymorphone ER G N N Y

ROXICODONE NP N N Y

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SUBSYS NP Y Y Y

tramadol G N N Y

tramadol ER G N N Y

ULTRAM NP N N Y

ULTRAM ER NP N N Y

ZOHYDRO ER NP N N Y

*Opioid Combinations** - *Codeine Combinations***

acetaminophen-codeine G N N Y

ascomp-codeine G N N Y

butalbital compound/codeine G N N Y

butalbital-APAP-caff-codeine G N N Y

butalbital-ASA-caff-codeine G N N Y

CAPITAL/CODEINE P N N Y

FIORICET/CODEINE NP N N Y

FIORINAL/CODEINE NP N N Y

TYLENOL WITH CODEINE NP N N Y

*Opioid Combinations** - *Dihydrocodeine Combinations***

SYANLGOS-DC NP N N Y

*Opioid Combinations** - *Hydrocodone Combinations***

HYCET NP N N Y

hydrocodone-acetaminophen G N N Y

hydrocodone-ibuprofen G N N Y

IBUDONE NP N N Y

LORCET G N N Y

LORCET HD G N N Y

LORTAB NP N N Y

NORCO NP N N Y

reprexain G N N Y

vicodin G N N Y

vicodin es G N N Y

vicodin hp G N N Y

VICOPROFEN NP N N Y

XODOL NP N N Y

ZAMICET NP N N Y

ZOLVIT NP N N Y

*Opioid Combinations** - *Opioid Combinations***

endocet G N N Y

endodan G N N Y

oxycodone-acetaminophen G N N Y

oxycodone-aspirin G N N Y

oxycodone-ibuprofen G N N Y

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PERCOCET NP N N Y

PERCODAN NP N N Y

PRIMLEV NP N N Y

ROXICET SOLUTION P N N Y

roxicet tablet G N N Y

XARTEMIS XR NP N N Y

*Opioid Combinations** - *Tramadol Combinations***

tramadol-acetaminophen G N N Y

ULTRACET NP N N Y

*Opioid Partial Agonists** - *Opioid Partial Agonists***

BUNAVAIL NP Y Y Y

buprenorphine sublingual G Y N Y

buprenorphine-naloxone sublingual G Y N Y

butorphanol nasal spray G N N Y

BUTRANS PATCH P N N Y

SUBOXONE FILM NP Y N Y

SUBOXONE TABLET NP Y N Y

ZUBSOLV TABLET NP Y Y Y

*ANDROGENS-ANABOLIC*

*Anabolic Steroids** - *Anabolic Steroids***

ANADROL-50 NP Y N Y

OXANDRIN NP Y N Y

oxandrolone G Y N Y

*Androgens** - *Androgens***

ANDRODERM NP Y Y Y

ANDROGEL P Y N Y

ANDROID P Y N Y

androxy G Y N Y

AXIRON NP Y Y Y

danazol G N N Y

FIRST TESTOSTERONE CREAM NP Y Y Y

FIRST TESTOSTERONE OINTMENT NP Y Y Y

FORTESTA NP Y Y Y

METHITEST P Y N Y

STRIANT NP Y Y Y

TESTIM P Y N Y

testosterone gel G Y N Y

VOGELXO NP Y Y Y

AVEED MED Y N Y

*ANORECTAL AGENTS*

*Intrarectal Steroids** - *Intrarectal Steroids***

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colocort G N N Y

CORTENEMA NP N N Y

CORTIFOAM NP N N Y

hydrocortisone enema G N N Y

*Rectal Combinations** - *Rectal Anesthetic/Steroids***

ANALPRAM-HC NP N N Y

HC pram G N N Y

hydrocortisone-pramoxine G N N Y

lidazone HC G N N Y

lidocaine-hydrocortisone G N N Y

lidocort KIT G N N Y

pramcort G N N Y

PROCORT NP N N Y

PROCTOFOAM HC NP N N Y

*Rectal Steroids** - *Rectal Steroids***

anucort-HC G N N Y

ANUSOL-HC 2.5 % NP N N Y

GRx hicort G N N Y

hemorrhoidal-HC G N N Y

hemril-30 G N N Y

hydrocortisone acetate suppository G N N Y

proctocare-HC G N N Y

proctocream HC G N N Y

procto-pak G N N Y

proctosol HC G N N Y

proctozone-HC G N N Y

rectacort-HC G N N Y

*Vasodilating Agents** - *Nitrate Vasodilating Agents***

RECTIV NP N N Y

*ANTHELMINTICS*

*Anthelmintics** - *Anthelmintics***

ALBENZA NP N N Y

BILTRICIDE NP N N Y

STROMECTOL NP N N Y

*ANTIANGINAL AGENTS*

*Antianginals-Other** - *Antianginals-Other***

RANEXA P N Y Y

*Nitrates** - *Nitrates***

DILATRATE-SR NP N N Y

IMDUR NP N N Y

isochron G N N Y

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isoditrate ER G N N Y

ISORDIL NP N N Y

isosorbide dinitrate G N N Y

isosorbide dinitrate ER G N N Y

isosorbide mononitrate G N N Y

isosorbide mononitrate ER G N N Y

minitran G N N Y

NITRO-BID NP N N Y

NITRO-DUR NP N N Y

nitroglycerin ER G N N Y

nitroglycerin patch G N N Y

nitroglycerin translingual spray G N N Y

NITROLINGUAL SPRAY NP N N Y

NITROMIST SPRAY NP N N Y

NITROSTAT P N N Y

nitro-time G N N Y

*ANTIANXIETY AGENTS*

*Antianxiety Agents - Misc.** - *Antianxiety Agents - Misc.***

buspirone G N N Y

hydroxyzine HCL syrup G N N Y

hydroxyzine HCL tablet G N N Y

hydroxyzine pamoate G N N Y

meprobamate G N N Y

VISTRIL NP N N Y

*Benzodiazepines** - *Benzodiazepines***

alprazolam G N N Y

alprazolam dispersible tablet G N N Y

alprazolam ER G N N Y

ALPRAZOLAM INTENSOL CONCENTRATE NP N N Y

alprazolam XR G N N Y

ATIVAN NP N N Y

chlordiazepoxide G N N Y

clorazepate G N N Y

diazepam G N N Y

DIAZEPAM INTENSOL CONCENTRATE NP N N Y

lorazepam G N N Y

LORAZEPAM INTENSOL CONCENTRATE NP N N Y

lorazepam TABLET 0.5 MG ORAL G N N Y

NIRAVAM NP N N Y

oxazepam G N N Y

TRANXENE-T NP N N Y

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VALIUM NP N N Y

XANAX NP N N Y

XANAX XR NP N N Y

*ANTIARRHYTHMICS*

*Antiarrhythmics Type I-A** - *Antiarrhythmics Type I-A***

disopyramide G N N Y

NORPACE NP N N Y

NORPACE CR NP N N Y

quinidine gluconate ER G N N Y

quinidine sulfate G N N Y

*Antiarrhythmics Type I-B** - *Antiarrhythmics Type I-B***

mexiletine G N N Y

*Antiarrhythmics Type I-C** - *Antiarrhythmics Type I-C***

flecainide G N N Y

propafenone G N N Y

propafenone ER G N N Y

RYTHMOL NP N N Y

RYTHMOL SR NP N N Y

*Antiarrhythmics Type III** - *Antiarrhythmics Type III***

amiodarone G N N Y

CORDARONE NP N N Y

MULTAQ P N N Y

pacerone G N N Y

TIKOSYN NP Y N Y

*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*

*Antiasthmatic - Monoclonal Antibodies** - *Anti-IgE Monoclonal

Antibodies***

XOLAIR MED Y N Y

*Anti-Inflammatory Agents** - *Anti-Inflammatory Agents***

cromolyn sodium concentrate G N N Y *Asthma and Bronchodilator Agent Combinations** - *Xanthine-

Expectorants***

difil-G forte G N N Y *Bronchodilators - Anticholinergics** - *Bronchodilators -

Anticholinergics***

ATROVENT HFA NP N N Y

ipratropium inhalation solution G N N Y

SPIRIVA HANDIHALER P N N Y

TUDORZA PRESSAIR NP N Y Y

*Leukotriene Modulators** - *5-Lipoxygenase Inhibitors***

ZYFLO CR TABLET EXTENDED RELEASE 12 HR NP N N Y

ZYFLO TABLET NP N N Y

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*Leukotriene Modulators** - *Leukotriene Receptor Antagonists***

ACCOLATE TABLET NP N N Y

montelukast G N N Y

SINGULAIR NP N N Y

zafirlukast G N N Y *Selective Phosphodiesterase 4 (PDE4) Inhibitors** - *Selective

Phosphodiesterase 4 (PDE4) Inhibitors***

DALIRESP NP N Y Y

*Steroid Inhalants** - *Steroid Inhalants***

AEROSPAN NP N Y Y

ALVESCO NP N Y Y

ASMANEX P N N Y

budesonide inhalation suspension G N N Y

FLOVENT DISKUS P N N Y

FLOVENT HFA P N N Y

PULMICORT FLEXHALER NP N Y Y

PULMICORT INHALATION SUSPENSION NP N N Y

QVAR P N N Y

*Sympathomimetics** - *Adrenergic Combinations***

ADVAIR DISKUS P N N Y

ADVAIR HFA P N N Y

ANORO ELLIPTA NP N Y Y

BREO ELLIPTA NP N Y Y

COMBIVENT RESPIMAT P N N Y

DULERA AEROSOL P N N Y

DUONEB INHALATION SOLUTION NP N N Y

ipratropium-albuterol inhalation solution G N N Y

SYMBICORT P N N Y

*Sympathomimetics** - *Beta Adrenergics***

albuterol sulfate ER tablet G N N Y

albuterol sulfate inhalation solution G N N Y

albuterol sulfate syrup G N N Y

albuterol sulfate tablet G N N Y

ARCAPTA NEOHALER NP N Y Y

BROVANA NP N Y Y

FORADIL P N N Y

levalbuterol inhalation solution G N N Y

PERFOROMIST NP N Y Y

PROAIR HFA P N N Y

PROVENTIL HFA NP N Y Y

SEREVENT DISKUS P N N Y

terbutaline sulfate G N N Y

19

VENTOLIN HFA P N N Y

VOSPIRE ER NP N N Y

XOPENEX HFA NP N Y Y

XOPENEX INHALATION SOLUTION NP N N Y

*Xanthines** - *Xanthines***

ELIXOPHYLLIN NP N N Y

LUFYLLIN NP N N Y

THEO-24 NP N N Y

theochron G N N Y

theophylline ER G N N Y

theophylline solution G N N Y

*ANTICOAGULANTS*

*Coumarin Anticoagulants** - *Coumarin Anticoagulants***

COUMADIN NP N N Y

jantoven G N N Y

warfarin G N N Y

*Direct Factor Xa Inhibitors** - *Direct Factor Xa Inhibitors***

ELIQUIS P N N Y

XARELTO P N N Y *Heparins And Heparinoid-Like Agents** - *Low Molecular Weight

Heparins***

enoxaparin G N N Y

FRAGMIN NP N N Y

LOVENOX NP N N Y *Heparins And Heparinoid-Like Agents** - *Synthetic Heparinoid-Like

Agents***

ARIXTRA NP N N Y

fondaparinux G N N Y

*Thrombin Inhibitors** - *Thrombin Inhibitors - Hirudin Type***

IPRIVASK NP N N Y *Thrombin Inhibitors** - *Thrombin Inhibitors - Selective Direct &

Reversible***

PRADAXA P N N Y

*ANTICONVULSANTS*

*AMPA Glutamate Receptor Antagonists** - *AMPA Glutamate

Receptor Antagonists***

FYCOMPA NP N N Y *Anticonvulsants - Benzodiazepines** - *Anticonvulsants -

Benzodiazepines***

clonazepam G N N Y

clonazepam dispersible tablet G N N Y

DIASTAT ACUDIAL NP N N Y

KLONOPIN NP N N Y

20

ONFI NP N N Y

*Anticonvulsants - Misc.** - *Anticonvulsants - Misc.***

APTIOM NP N N Y

BANZEL NP N N Y

carbamazepine chewable tablet G N N Y

carbamazepine ER G N N Y

carbamazepine suspension G N N Y

carbamazepine tablet G N N Y

CARBATROL NP N N Y

epitol G N N Y

gabapentin G N N Y

KEPPRA SOLUTION NP N N Y

KEPPRA TABLET NP N N Y

KEPPRA XR NP N N Y

LAMICTAL NP N N Y

LAMICTAL CHEWABLE TABLET NP N N Y

LAMICTAL ODT NP N N Y

LAMICTAL ODT KIT NP N N Y

LAMICTAL STARTER KIT NP N N Y

LAMICTAL XR NP N N Y

LAMICTAL XR KIT NP N N Y

lamotrigine G N N Y

lamotrigine chewable tablet G N N Y

lamotrigine ER G N N Y

levetiracetam G N N Y

levetiracetam ER G N N Y

levetiracetam solution G N N Y

LYRICA NP N Y Y

MYSOLINE NP N N Y

NEURONTIN NP N N Y

NEURONTIN SOLUTION NP N N Y

oxcarbazepine G N N Y

oxcarbazepine suspension G N N Y

OXTELLAR XR NP N N Y

POTIGA TABLET NP N N Y

primidone G N N Y

ropiramate G N N Y

TEGRETOL NP N N Y

TEGRETOL SUSPENSION NP N N Y

TEGRETOL-XR NP N N Y

TOPAMAX NP N N Y

21

TOPAMAX SPRINKLE NP N N Y

topiragen G N N Y

topiramate sprinkle G N N Y

TRILEPTAL SUSPENSION NP N N Y

TRILEPTAL TABLET NP N N Y

TROKENDI XR NP N Y Y

VIMPAT NP N N Y

ZONEGRAN NP N N Y

zonisamide G N N Y

*Carbamates** - *Carbamates***

felbamate G N N Y

felbamate suspension G N N Y

FELBATOL SUSPENSION NP N N Y

FELBATOL TABLET NP N N Y

*GABA Modulators** - *GABA Modulators***

GABATRIL NP N N Y

SABRIL PACKET NP Y N Y

SABRIL TABLET NP Y N Y

tiagabine G N N Y

*Hydantoins** - *Hydantoins***

DILANTIN NP N N Y

DILANTIN INFATABS NP N N Y

DILANTIN SUSPENSION NP N N Y

PEGANONE NP N N Y

PHENYTEK NP N N Y

phenytoin chewable G N N Y

phenytoin ER G N N Y

phenytoin infatabs G N N Y

phenytoin suspension G N N Y

*Succinimides** - *Succinimides***

CELONTIN NP N N Y

ethosuximide G N N Y

ethosuximide solution G N N Y

ZARONTIN NP N N Y

ZARONTIN SOLUTION NP N N Y

*Valproic Acid** - *Valproic Acid***

DEPAKENE NP N N Y

DEPAKENE SYRUP NP N N Y

DEPAKOTE DR NP N N Y

DEPAKOTE ER NP N N Y

DEPAKOTE SPRINKLES NP N N Y

22

divalproex DR G N N Y

divalproex ER G N N Y

divalproex sprinkle G N N Y

STAVZOR NP N N Y

valproic acid G N N Y

valproic acid solution G N N Y

valproic acid syrup G N N Y

*ANTIDEPRESSANTS*

*Alpha-2 Receptor Antagonists (Tetracyclics)** - *Alpha-2 Receptor

Antagonists (Tetracyclics)***

mirtazapine G N N Y

REMERON NP N N Y

*Antidepressants - Misc.** - *Antidepressants - Misc.***

APLENZIN NP N Y Y

budeprion SR G N N Y

budeprion XL G N N Y

bupropion HCl G N N Y

bupropion HCL ER (SR) G N N Y

bupropion HCl ER (XL) G N N Y

FORFIVO XL NP N Y Y

WELLBUTRIN NP N N Y

WELLBUTRIN SR NP N N Y

WELLBUTRIN XL NP N N Y

*Modified Cyclics** - *Modified Cyclics***

BRINTELLIX NP N Y Y

VIIBRYD NP N Y Y

VIIBRYD KIT NP N Y Y *Monoamine Oxidase Inhibitors (MAOIs)** - *Monoamine Oxidase

Inhibitors (MAOIs)***

EMSAM NP N N Y

MARPLAN NP N N Y

NARDIL NP N N Y

PARNATE NP N N Y

phenelzine G N N Y

tranylcypromine G N N Y *Selective Serotonin Reuptake Inhibitors (SSRIs)** - *Selective

Serotonin Reuptake Inhibitors (SSRIs)***

CELEXA NP N N Y

citalopram G N N Y

citalopram solution G N N Y

escitalopram G N N Y

fluoxetine G N N Y

23

fluoxetine solution G N N Y

fluvoxamine G N N Y

fluvoxamine ER G N N Y

LEXAPRO NP N N Y

LUVOX CR NP N N Y

paroxetine G N N Y

paroxetine ER G N N Y

PAXIL NP N N Y

PAXIL CR NP N N Y

PEXEVA TABLET NP N Y Y

PROZAC NP N N Y

PROZAC WEEKLY CAPSULE DELAYED RELEASE NP N N Y

sertraline G N N Y

ZOLOFT NP N N Y

fluoxetine delayed release G N N Y

*Serotonin Modulators** - *Serotonin Modulators***

nefazodone NP N N Y

trazodone G N N Y *Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)** - *Serotonin-

Norepinephrine Reuptake Inhibitors (SNRIs)***

CYMBALTA NP N N Y

DESVENLAFAXINE ER TABLET NP N Y Y

duloxetine G N N Y

EFFEXOR XR NP N N Y

FETZIMA NP N Y Y

FETZIMA TITRATION PACK NP N Y Y

KHEDEZLA NP N Y Y

PRISTIQ NP N Y Y

venlafaxine G N N Y

venlafaxine er capsule G N N Y

VENLAFAXINE HCl ER TABLET NP N Y Y

*Tricyclic Agents** - *Tricyclic Agents***

amitriptyline G N N Y

ANAFRANIL NP N N Y

clomipramine G N N Y

desipramine G N N Y

doxepin G N N Y

imipramine hcl G N N Y

imipramine pamoate G N N Y

NORPRAMIN NP N N Y

nortriptyline G N N Y

PAMELOR NP N N Y

24

protriptyline G N N Y

SURMONTIL NP N N Y

TOFRANIL NP N N Y

TOFRANIL-PM NP N N Y

VIVACTIL NP N N Y

*ANTIDIABETICS*

*Alpha-Glucosidase Inhibitors** - *Alpha-Glucosidase Inhibitors***

acarbose G N N Y

GLYSET NP N N Y

PRECOSE NP N N Y

*Antidiabetic - Amylin Analogs** - *Antidiabetic - Amylin Analogs***

SYMLIN PEN P N N Y *Antidiabetic Combinations** - *Dipeptidyl Peptidase-4 Inhibitor-

Biguanide Combinations***

JANUMET P N N Y

JANUMET XR P N N Y

JENTADUETO P N N Y

KAZANO NP N Y Y

KOMBIGLYZE XR P N N Y *Antidiabetic Combinations** - *DPP-4 Inhibitor-Thiazolidinedione

Combinations***

OSENI NP N Y Y *Antidiabetic Combinations** - *Meglitinide-Biguanide

Combinations***

PRANDIMET NP N N Y *Antidiabetic Combinations** - *Sulfonylurea-Biguanide

Combinations***

glipizide-metformin G N N Y

GLUCOVANCE NP N N Y

glyburide-metformin G N N Y *Antidiabetic Combinations** - *Sulfonylurea-Thiazolidinedione

Combinations***

AVANDARYL NP N N Y

DUETACT NP N N Y

pioglitazone-glimepiride G N N Y *Antidiabetic Combinations** - *Thiazolidinedione-Biguanide

Combinations***

ACTOPLUS MET NP N N Y

ACTOPLUS MET XR NP N N Y

AVANDAMET NP N N Y

pioglitazone-metformin G N N Y

*Biguanides** - *Biguanides***

GLUCOPHAGE NP N N Y

GLUCOPHAGE XR NP N N Y

25

GLUMETZA NP N N Y

metformin G N N Y

metformin ER G N N Y

RIOMET NP N N Y

*Diabetic Other** - *Diabetic Other***

GLUCAGEN NP N N Y

GLUCAGON NP N N Y

PROGLYCEM P N N Y

*Diabetic Other** - *Progesterone Receptor Antagonists***

KORLYM NP Y N Y *Dipeptidyl Peptidase-4 (DPP-4) Inhibitors** - *Dipeptidyl Peptidase-4

(DPP-4) Inhibitors***

JANUVIA P N N Y

NESINA NP N Y Y

ONGLYZA P N N Y

TRADJENTA P N N Y *Dopamine Receptor Agonists - Antidiabetic** - *Dopamine Receptor

Agonists - Ergot Derivatives***

CYCLOSET P N N Y *Incretin Mimetic Agents (GLP-1 Receptor Agonists)** - *Incretin

Mimetic Agents (GLP-1 Receptor Agonists)***

BYDUREON P N N Y

BYETTA NP N N Y

TANZEUM NP N Y Y

VICTOZA P N N Y

TRULICITY NP N Y Y

*Insulin Sensitizing Agents** - *Thiazolidinediones***

ACTOS NP N N Y

AVANDIA NP N N Y

pioglitazone G N N Y

*Insulin** - *Human Insulin***

APIDRA NP N N Y

APIDRA SOLOSTAR NP N N Y

HUMALOG KWIKPEN P N N Y

HUMALOG MIX 50/50 P N N Y

HUMALOG MIX 50/50 KWIKPEN P N N Y

HUMALOG MIX 50/50 PEN P N N Y

HUMALOG MIX 75/25 P N N Y

HUMALOG Mix 75/25 KWIKPEN P N N Y

HUMALOG MIX 75/25 PEN P N N Y

HUMALOG PEN P N N Y

HUMULIN 70/30 KWIKPEN P N N Y

26

HUMULIN 70/30 PEN P N N Y

HUMULIN N KWIKPEN P N N Y

HUMULIN N Pen P N N Y

HUMULIN R U-500 P N N Y

LANTUS P N N Y

LANTUS SOLOSTAR P N N Y

LEVEMIR P N N Y

LEVEMIR FLEXPEN P N N Y

NOVOLOG P N N Y

NOVOLOG FLEXPEN P N N Y

NOVOLOG MIX 70/30 * P N N Y

NOVOLOG MIX 70/30 FLEXPEN P N N Y

*Meglitinide Analogues** - *Meglitinide Analogues***

nateglinide G N N Y

PRANDIN NP N N Y

repaglinide G N N Y

STARLIX NP N N Y *Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors** - *Sodium-

Glucose Co-Transporter 2 (SGLT2) Inhibitors***

FARXIGA NP N Y Y

INVOKANA P N Y Y

*Sulfonylureas** - *Sulfonylureas***

AMARYL NP N N Y

chlorpropamide G N N Y

DIABETA NP N N Y

glimepiride G N N Y

glipizide G N N Y

glipizide ER G N N Y

glipizide XL G N N Y

GLUCOTROL NP N N Y

GLUCOTROL XL NP N N Y

glyburide G N N Y

glyburide micronized G N N Y

glycron G N N Y

GLYNASE NP N N Y

tolazamide G N N Y

*ANTIDIARRHEALS*

*Antidiarrheal - Chloride Channel Antagonists** - *Antidiarrheal -

Chloride Channel Antagonists***

FULYZAQ NP N N Y

*Antiperistaltic Agents** - *Antiperistaltic Agents***

diphenatol G N N Y

27

diphenoxylate-atropine G N N Y

lofene G N N Y

LOMOTIL NP N N Y

lonox G N N Y

MOTOFEN NP N N Y

opium tincture 10 MG/ML G N N Y

*ANTIDOTES*

*Antidotes - Chelating Agents** - *Antidotes - Chelating Agents***

CHEMET P N N Y

EXJADE NP Y N Y

FERRIPROX NP Y N Y

*Antidotes** - *Antidotes***

deferoxamine mesylate MED Y N Y

DESFERAL MED Y N Y

RADIOGARDASE P N N Y

*Opioid Antagonists** - *Opioid Antagonists***

depade G N N Y

EVZIO NP N N Y

naltrexone tablet G N N Y

REVIA NP N N Y

VIVITROL MED Y N Y

*ANTIEMETICS*

*5-HT3 Receptor Antagonists** - *5-HT3 Receptor Antagonists***

ANZEMET NP N N Y

granisetron G N N Y

GRANISOL SOLUTION NP N N Y

ondansetron G N N Y

ondansetron odt G N N Y

SANCUSO NP N N Y

ZOFRAN NP N N Y

ZOFRAN ODT NP N N Y

ZUPLENZ NP N N Y

*Antiemetics - Anticholinergic** - *Antiemetics - Anticholinergic***

TIGAN NP N N Y

TRANSDERM-SCOP NP N N Y

trimethobenzamide G N N Y

*Antiemetics - Miscellaneous** - *Antiemetic Combinations***

DICLEGIS NP N N Y

AKYNZEO NP N Y Y

*Antiemetics - Miscellaneous** - *Antiemetics - Miscellaneous***

CESAMET NP N N Y

28

dronabinol G N N Y

MARINOL NP N N Y *Substance P/Neurokinin 1 (NK1) Receptor Antagonists** - *Substance

P/Neurokinin 1 (NK1) Receptor Antagonists***

EMEND P N N Y

*ANTIFUNGALS*

*Antifungals** - *Antifungals***

BIO-STATIN CAPSULE NP N N Y

bio-statin oral powder G N N Y

flucytosine G N N Y

GRIFULVIN V NP N N Y

griseofulvin microsize suspension G N N Y

griseofulvin microsize tablet G N N Y

griseofulvin ultramicrosize tablet G N N Y

GRIS-PEG NP N N Y

LAMISIL NP N N Y

NYSTATIN ORAL POWDER G N N Y

NYSTATIN TABLET G N N Y

terbinafine G N N Y

*Imidazole-Related Antifungals** - *Imidazoles***

ketoconazole G N N Y

*Imidazole-Related Antifungals** - *Triazoles***

DIFLUCAN 150 MG NP N N Y

DIFLUCAN SUSPENSION NP N N Y

Diflucan TABLET (all other strengths) NP N N Y

fluconazole 150 mg G N N Y

fluconazole suspension G N N Y

fluconazole tablet (all other strengths) G N N Y

itraconazole G N N Y

NOXAFIL NP N N Y

ONMEL NP N N Y

SPORANOX NP N N Y

VFEND NP N N Y

voriconazole G N N Y

*ANTIHISTAMINES*

*Antihistamines - Alkylamines** - *Antihistamines - Alkylamines***

ED-CHLOR-TAN NP N N Y

RESPA-BR NP N N Y *Antihistamines - Ethanolamines** - *Antihistamines -

Ethanolamines***

arbinoxa G N N Y

carbinoxamine Maleate G N N Y

29

clemastine fumarate G N N Y

DOXYTEK NP N N Y

KARBINAL ER NP N N Y

PALGIC NP N N Y

*Antihistamines - Non-Sedating** - *Antihistamines - Non-Sedating***

CLARINEX NP N N Y

CLARINEX REDITABS NP N N Y

desloratadine G N N Y

desloratadine odt G N N Y

levocetirizine G N N Y

XYZAL NP N N Y *Antihistamines - Phenothiazines** - *Antihistamines -

Phenothiazines***

phenadoz suppository G N N Y

promethazine hcl G N N Y

promethazine hcl suppository G N N Y

promethegan suppository 12.5 mg, 25 mg G N N Y

PROMETHEGAN SUPPOSITORY 50 MG NP N N Y

*Antihistamines - Piperidines** - *Antihistamines - Piperidines***

cyproheptadine G N N Y

*ANTIHYPERLIPIDEMICS*

*Antihyperlipidemics - Combinations** - *Intest Cholest Absorp Inhib-

HMG CoA Reductase Inhib Comb***

LIPTRUZET P N N Y

VYTORIN NP N N Y

*Antihyperlipidemics - Misc.** - *Antihyperlipidemics - Misc.***

KYNAMRO MED Y Y Y

LOVAZA NP N Y Y

omega-3-acid Ethyl Esters G N N Y

Vascepa P N N Y

*Bile Acid Sequestrants** - *Bile Acid Sequestrants***

cholestyramine light G N N Y

COLESTID NP N N Y

colestipol G N N Y

micronized colestipol G N N Y

prevalite G N N Y

QUESTRAN NP N N Y

QUESTRAN LIGHT NP N N Y

WELCHOL P N N Y

*Fibric Acid Derivatives** - *Fibric Acid Derivatives***

ANTARA NP N Y Y

fenofibrate G N N Y

30

fenofibrate micronized G N N Y

fenofibric acid G N N Y

FENOGLIDE NP N Y Y

FIBRICOR NP N Y Y

gemfibrozil G N N Y

LIPOFEN NP N Y Y

LOFIBRA NP N Y Y

LOPID NP N Y Y

TRICOR NP N Y Y

TRIGLIDE NP N Y Y

TRILIPIX NP N Y Y *HMG CoA Reductase Inhibitors** - *HMG CoA Reductase Inhibitor

Combinations***

ADVICOR NP N N Y

SIMCOR NP N N Y

*HMG CoA Reductase Inhibitors** - *HMG CoA Reductase Inhibitors***

ALTOPREV NP N Y Y

atorvastatin G N N Y

CRESTOR P N N Y

fluvastatin G N N Y

LESCOL NP N Y Y

LESCOL XL NP N Y Y

LIPITOR NP N Y Y

LIVALO NP N Y Y

lovastatin G N N Y

MEVACOR NP N N Y

PRAVACHOL NP N N Y

pravastatin G N N Y

simvastatin G N N Y

ZOCOR NP N N Y *Intestinal Cholesterol Absorption Inhibitors** - *Intestinal Cholesterol

Absorption Inhibitors***

ZETIA P N N Y *Microsomal Triglyceride Transfer Protein (MTP) Inhibitors** -

*Microsomal Triglyceride Transfer Protein Inhibitors***

JUXTAPID NP Y Y Y

*Nicotinic Acid Derivatives** - *Nicotinic Acid Derivatives***

niacin ER G N N Y

NIASPAN P N N Y

*ANTIHYPERTENSIVES*

*ACE Inhibitors** - *ACE Inhibitors***

ACCUPRIL NP N N Y

31

ACEON NP N N Y

ALTACE NP N N Y

benazepril G N N Y

captopril G N N Y

enalapril G N N Y

EPANED NP N N Y

fosinopril G N N Y

lisinopril G N N Y

LOTENSIN NP N N Y

MAVIK NP N N Y

moexipril G N N Y

perindopril G N N Y

PRINIVIL NP N N Y

quinapril G N N Y

ramipril G N N Y

trandolapril G N N Y

UNIVASC NP N N Y

VASOTEC NP N N Y

ZESTRIL NP N N Y *Agents for Pheochromocytoma** - *Agents for

Pheochromocytoma***

DEMSER NP N N Y

DIBENZYLINE P N N Y *Angiotensin II Receptor Antagonists** - *Angiotensin II Receptor

Antagonists***

ATACAND NP N N Y

AVAPRO NP N N Y

BENICAR NP N Y Y

candesartan G N N Y

COZAAR NP N N Y

DIOVAN NP N N Y

EDARBI NP N Y Y

eprosartan G N N Y

irbesartan G N N Y

losartan G N N Y

TEVETEN NP N N Y *Antiadrenergic Antihypertensives** - *Antiadrenergics - Centrally

Acting***

CATAPRES NP N N Y

CATAPRES-TTS NP N N Y

clonidine G N N Y

clonidine patch G N N Y

32

guanfacine G N N Y

methyldopa G N N Y

TENEX NP N N Y *Antiadrenergic Antihypertensives** - *Antiadrenergics - Peripherally

Acting***

CARDURA NP N N Y

doxazosin G N N Y

MINIPRESS NP N N Y

prazosin G N N Y

terazosin G N N Y *Antihypertensive Combinations** - *ACE Inhibitor & Calcium Channel

Blocker Combinations***

amlodipine-benazepril G N N Y

LOTREL NP N Y Y

TARKA NP N N Y *Antihypertensive Combinations** - *ACE Inhibitors &

Thiazide/Thiazide-Like***

ACCURETIC NP N N Y

benazepril-hydrochlorothiazide G N N Y

enalapril-hydrochlorothiazide G N N Y

fosinopril-HCTZ G N N Y

lisinopril-hydrochlorothiazide G N N Y

LOTENSIN HCT NP N N Y

moexipril-hydrochlorothiazide G N N Y

PRINZIDE NP N N Y

quinapril-hydrochlorothiazide G N N Y

UNIRETIC NP N N Y

VASERETIC NP N N Y

ZESTORETIC NP N N Y *Antihypertensive Combinations** - *Adrenolytics-Central &

Thiazide/Thiazide-Like Comb***

CLORPRES NP N N Y *Antihypertensive Combinations** - *Angiotensin II Receptor Antag &

Ca Channel Blocker Comb***

AZOR NP N Y Y

EXFORGE P N N Y

amlodipine-valsartan P N N Y *Antihypertensive Combinations** - *Angiotensin II Receptor Antag &

Thiazide/Thiazide-Like***

ATACAND HCT NP N N Y

AVALIDE NP N N Y

BENICAR HCT NP N Y Y

candesartan-HCTZ G N N Y

DIOVAN HCT NP N Y Y

33

EDARBYCLOR NP N Y Y

HYZAAR NP N N Y

irbesartan-HCTZ G N N Y

losartan-HCTZ G N N Y

TEVETEN HCT NP N N Y

valsartan-HCTZ G N N Y *Antihypertensive Combinations** - *Angiotensin II Receptor Ant-Ca

Channel Blocker-Thiazides***

EXFORGE HCT P N N Y

TRIBENZOR NP N Y Y *Antihypertensive Combinations** - *Beta Blocker & Diuretic

Combinations***

atenolol-chlorthalidone G N N Y

bisoprolol-hydrochlorothiazide G N N Y

CORZIDE NP N N Y

DUTOPROL P N N Y

LOPRESSOR HCT NP N N Y

metoprolol-hydrochlorothiazide G N N Y

nadolol-bendroflumethiazide G N N Y

TENORETIC NP N N Y

ZIAC NP N N Y *Antihypertensive Combinations** - *Direct Renin Inhibitors & Calcium

Channel Blocker Comb***

TEKAMLO NP N N Y *Antihypertensive Combinations** - *Direct Renin Inhibitors &

Thiazide/Thiazide-Like Comb***

TEKTURNA HCT NP N N Y *Antihypertensive Combinations** - *Direct Renin Inhibitors-Ca

Channel Blocker-Thiazide Comb***

AMTURNIDE NP N N Y

*Antihypertensives - Misc.** - *Antihypertensives - Misc.***

VECAMYL NP N Y Y

*Direct Renin Inhibitors** - *Direct Renin Inhibitors***

TEKTURNA NP N N Y *Selective Aldosterone Receptor Antagonists (SARAs)** - *Selective

Aldosterone Receptor Antagonists (SARAs)***

eplerenone G N N Y

INSPRA NP N N Y

*Vasodilators** - *Vasodilators***

hydralazine G N N Y

minoxidil G N N Y

*ANTI-INFECTIVE AGENTS - MISC.*

*Anti-infective Agents - Misc.** - *Anti-infective Agents - Misc.***

CAYSTON NP Y N Y

34

colistimethate sodium G N N Y

COLY-MYCIN M NP N N Y

FIRST-VANCOMYCIN NP N N Y

FLAGYL NP N N Y

FLAGYL ER NP N N Y

metronidazole G N N Y

NEBUPENT P N N Y

PRIMSOL NP N N Y

TINDAMAX NP N N Y

tinidazole G N N Y

trimethoprim G N N Y

VANCOCIN NP N N Y

vancomycin G N N Y

XIFAXAN NP N N Y *Anti-infective Misc. - Combinations** - *Anti-infective Misc. -

Combinations***

BACTRIM NP N N Y

BACTRIM DS NP N N Y

E.S.P. suspension G N N Y

erythromycin-sulfisoxazole suspension G N N Y

SEPTRA NP N N Y

SEPTRA DS NP N N Y

SMZ-TMP DS G N N Y

sulfamethoxazole-TMP DS G N N Y

sulfamethoxazole-trimethoprim suspension G N N Y

sulfamethoxazole-trimethoprim tablet G N N Y

sulfatrim pediatric suspension G N N Y

*Antiprotozoal Agents** - *Antiprotozoal Agents***

ALINIA NP N N Y

*Ketolides** - *Ketolides***

KETEK NP N N Y

*Lincosamides** - *Lincosamides***

CLEOCIN NP N N Y

clindamycin G N N Y

*Oxazolidinones** - *Oxazolidinones***

SIVEXTRO NP N N Y

ZYVOX P N N Y

*ANTIMALARIALS*

*Antimalarial Combinations** - *Antimalarial Combinations***

atovaquone-proguanil G N N Y

COARTEM NP N N Y

MALARONE NP N N Y

35

*Antimalarials** - *Antimalarials***

ARALEN NP N N Y

chloroquine G N N Y

DARAPRIM NP N N Y

hydroxychloroquine G N N Y

mefloquine G N N Y

PLAQUENIL NP N N Y

QUALAQUIN NP N N Y

quinine sulfate G N N Y

*ANTIMYASTHENIC AGENTS*

*Antimyasthenic Agents** - *Antimyasthenic Agents***

MESTINON P N N Y

*ANTIMYASTHENIC/CHOLINERGIC AGENTS*

*Antimyasthenic/Cholinergic Agents** - *Antimyasthenic/Cholinergic

Agents***

pyridostigmine bromide G N N Y

*ANTIMYCOBACTERIAL AGENTS*

*Anti TB Combinations** - *Anti TB Combinations***

RIFAMATE NP N N Y

RIFATER NP N N Y

*Antimycobacterial Agents** - *Antimycobacterial Agents***

ethambutol G N N Y

isoniazid G N N Y

MYAMBUTOL P N N Y

PASER PACKET NP N N Y

PRIFTIN NP N N Y

pyrazinamide G N N Y

RIFADIN NP N N Y

rifampin G N N Y

SIRTURO NP N N Y

TRECATOR NP N N Y

*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*

*Alkylating Agents** - *Alkylating Agents***

HEXALEN P N N Y

MYLERAN P N N Y

TREANDA MED Y N Y

*Alkylating Agents** - *Imidazotetrazines***

TEMODAR NP Y N Y

temozolomide G Y N Y

*Alkylating Agents** - *Nitrogen Mustards***

ALKERAN P N N Y

LEUKERAN P N N Y

36

*Antimetabolites** - *Antimetabolites***

capecitabine G Y N Y

mercaptopurine G N N Y

methotrexate G N N Y

PURINETHOL NP N N Y

TABLOID P N N Y

TREXALL NP N N Y

XELODA NP Y N Y

azacitidine G Y N Y

DACOGEN MED Y N Y

decitabine MED Y N Y

FOLOTYN MED Y N Y

PURIXAN NP N Y Y

VIDAZA MED Y N Y *Antineoplastic - Hedgehog Pathway Inhibitors** - *Antineoplastic -

Hedgehog Pathway Inhibitors***

ERIVEDGE NP Y N Y *Antineoplastic - Hormonal and Related Agents** - *Androgen

Biosynthesis Inhibitors***

ZYTIGA P Y N Y

*Antineoplastic - Hormonal and Related Agents** - *Antiadrenals***

LYSODREN NP N N Y

*Antineoplastic - Hormonal and Related Agents** - *Antiandrogens***

bicalutamide G N N Y

CASODEX NP N N Y

flutamide G N N Y

NILANDRON P N N Y

XTANDI NP Y N Y

*Antineoplastic - Hormonal and Related Agents** - *Antiestrogens***

FARESTON NP N N Y

SOLTAMOX NP N N Y

tamoxifen G N N Y *Antineoplastic - Hormonal and Related Agents** - *Aromatase

Inhibitors***

anastrozole G N N Y

ARIMIDEX NP N Y Y

AROMASIN NP N N Y

exemestane G N N Y

FEMARA NP N Y Y

letrozole G N N Y *Antineoplastic - Hormonal and Related Agents** - *Estrogen Receptor

Antagonist***

FASLODEX MED N N Y

37

*Antineoplastic - Hormonal and Related Agents** - *Estrogens-

Antineoplastic***

EMCYT P N N Y *Antineoplastic - Hormonal and Related Agents** - *Gonadotropin

Releasing Hormone (GnRH) Antagonists***

FIRMAGON MED Y N Y

*Antineoplastic - Hormonal and Related Agents** - *LHRH Analogs***

ELIGARD KIT MED Y N Y

leuprolide acetate kit MED Y N Y

LUPRON DEPOT KIT MED Y N Y

TRELSTAR DEPOT MED Y N Y

TRELSTAR LA MED Y N Y

TRELSTAR LA MIXJECT MED Y N Y

VANTAS KIT MED Y N Y

ZOLADEX IMPLANT MED Y N Y *Antineoplastic - Hormonal and Related Agents** - *Progestins-

Antineoplastic***

MEGACE NP N N Y

megestrol acetate G N N Y *Antineoplastic - Immunomodulators** - *Antineoplastic -

Immunomodulators***

POMALYST NP Y N Y *Antineoplastic Enzyme Inhibitors** - *Antineoplastic - BRAF Kinase

Inhibitors***

TAFINLAR NP Y N Y

ZELBORAF NP Y N Y *Antineoplastic Enzyme Inhibitors** - *Antineoplastic - Histone

Deacetylase Inhibitors***

ZOLINZA NP Y N Y

BELEODAQ MED Y N Y *Antineoplastic Enzyme Inhibitors** - *Antineoplastic - MEK

Inhibitors***

MEKINIST NP Y N Y *Antineoplastic Enzyme Inhibitors** - *Antineoplastic - mTOR Kinase

Inhibitors***

AFINITOR NP Y N Y

AFINITOR DISPERZ NP Y N Y

TORISEL NP Y N Y *Antineoplastic Enzyme Inhibitors** - *Antineoplastic - Multikinase

Inhibitors***

NEXAVAR NP Y N Y

STIVARGA NP Y N Y

SUTENT P Y N Y *Antineoplastic Enzyme Inhibitors** - *Antineoplastic - Tyrosine Kinase

Inhibitors***

38

BOSULIF NP Y N Y

CAPRELSA NP Y N Y

COMETRIQ KIT NP Y N Y

GILOTRIF NP Y N Y

GLEEVEC P Y N Y

ICLUSIG NP Y Y Y

IMBRUVICA NP Y N Y

INLYTA NP Y N Y

SPRYCEL NP Y Y Y

TARCEVA P Y N Y

TASIGNA NP Y Y Y

TYKERB NP Y N Y

VOTRIENT NP Y N Y

XALKORI NP Y N Y

ZYKADIA NP Y N Y *Antineoplastic Enzyme Inhibitors** - *Janus Associated Kinase (JAK)

Inhibitors***

JAKAFI NP Y N Y

*Antineoplastics Misc.** - *Antineoplastics Misc.***

ACTIMMUNE MED Y N Y

ALFERON N MED Y N Y

hydroxyurea G N N Y

INTRON-A MED Y N Y

MATULANE P N N Y

SYLATRON KIT MED Y N Y

KEYTRUDA MED Y N Y

PROLEUKIN MED Y N Y

SYNRIBO MED Y N Y

*Antineoplastics Misc.** - *Retinoids***

tretinoin capsule G N N Y

*Antineoplastics Misc.** - *Selective Retinoid X Receptor Agonists***

TARGRETIN P Y N Y *Chemotherapy Rescue/Antidote Agents** - *Folic Acid Antagonists

Rescue Agents***

leucovorin calcium MED N N Y

FUSILEV MED Y N Y *Chemotherapy Rescue/Antidote Agents** - *Urinary Tract Protective

Agents***

MESNEX MED N N Y

*Topoisomerase I Inhibitors** - *Topoisomerase I Inhibitors***

HYCAMTIN CAPSULE NP Y N Y

*Antineoplastic- Angiogenesis Inhibitors**

39

AVASTIN MED Y N Y

*Antineoplastic- Antibodies***

CYRAMZA MED Y N Y

ZALTRAP MED Y N Y

RITUXAN MED Y N Y

ADCETRIS MED Y N Y

ARZERRA MED Y N Y

ERBITUX MED Y N Y

GAZYVA MED Y N Y

HERCEPTIN MED Y N Y

PERJETA MED Y N Y

VECTIBIX MED Y N Y

YERVOY MED Y N Y

KADCYLA MED Y N Y

*Antineoplastic- Enzymes***

ERWINAZE MED Y N Y

ONCASPAR MED Y N Y

*Antineoplastic Mitotic Inhibitor***

HALAVEN MED Y N Y

IXEMPRA MED Y N Y

JEVTANA NP Y N Y

*Antineoplastic-Antibiotics***

mitoxantrone MED Y N Y

VALSTAR MED Y N Y *Antineoplastic Enzyme Inhibitors** - *Antineoplastic - Proteasome

Inhibitors***

KYPROLIS MED Y N Y

VELCADE MED Y N Y *Antineoplastic Enzyme Inhibitors** - *Antineoplastic -

Phosphatidylinositol 3-Kinase Inhibitor***

ZYDELIG NP Y N Y

*ANTIPARKINSON AGENTS*

*Antiparkinson Anticholinergics** - *Antiparkinson Anticholinergics***

benztropine mesylate G N N Y

trihexyphenidyl G N N Y *Antiparkinson COMT Inhibitors** - *Central/Peripheral COMT

Inhibitors***

TASMAR NP N N Y

*Antiparkinson COMT Inhibitors** - *Peripheral COMT Inhibitors***

COMTAN NP N N Y

entacapone G N N Y

*Antiparkinson Dopaminergics** - *Antiparkinson Dopaminergics***

40

amantadine G N N Y

bromocriptine mesylate G N N Y

PARLODEL NP N N Y

APOKYN MED Y N Y

*Antiparkinson Dopaminergics** - *Levodopa Combinations***

carbidopa-levodopa G N N Y

carbidopa-levodopa dispersible G N N Y

carbidopa-levodopa ER G N N Y

SINEMET CR NP N N Y

STALEVO NP N N Y *Antiparkinson Dopaminergics** - *Nonergoline Dopamine Receptor

Agonists***

MIRAPEX P N N Y

MIRAPEX ER NP N Y Y

NEUPRO PATCH NP N N Y

pramipexole G N N Y

REQUIP NP N N Y

REQUIP XL NP N N Y

ropinirole G N N Y

ropinirole ER G N N Y *Antiparkinson Monoamine Oxidase Inhibitors** - *Antiparkinson

Monoamine Oxidase Inhibitors***

AZILECT P N N Y

ELDEPRYL NP N N Y

selegiline G N N Y

ZELAPAR NP N N Y

*ANTIPSYCHOTICS/ANTIMANIC AGENTS*

*Antimanic Agents** - *Antimanic Agents***

lithium carbonate G N N Y

lithium carbonate ER G N N Y

LITHOBID NP N N Y

*Antipsychotics - Misc.** - *Antipsychotics - Misc.***

EQUETRO NP N N Y

GEODON NP N Y Y

LATUDA P N N Y

ziprasidone G N N Y

*Benzisoxazoles** - *Benzisoxazoles***

FANAPT NP N Y Y

FANAPT TITRATION PACK NP N Y Y

INVEGA NP N Y Y

RISPERDAL NP N Y Y

RISPERDAL M NP N Y Y

41

RISPERDAL SOLUTION NP N Y Y

risperidone G N N Y

risperidone ODT G N N Y

risperidone solution G N N Y

*Butyrophenones** - *Butyrophenones***

haloperidol G N N Y

haloperidol concentrate G N N Y

*Dibenzapines** - *Dibenzodiazepines***

clozapine G N N Y

CLOZARIL NP N N Y

FAZACLO NP N N Y

VERSACLOZ NP N Y Y

*Dibenzapines** - *Dibenzo-oxepino Pyrroles***

SAPHRIS NP N Y Y

*Dibenzapines** - *Dibenzothiazepines***

quetiapine G N N Y

SEROQUEL NP N Y Y

SEROQUEL XR P N N Y

*Dibenzapines** - *Dibenzoxazepines***

loxapine G N N Y

*Dibenzapines** - *Thienbenzodiazepines***

olanzapine G N N Y

olanzapine ODT G N N Y

ZYPREXA NP N Y Y

ZYPREXA ZYDIS NP N Y Y

*Phenothiazines** - *Phenothiazines***

chlorpromazine G N N Y

compazine suppository G N N Y

compro suppository G N N Y

fluphenazine G N N Y

perphenazine G N N Y

prochlorperazine G N N Y

thioridazine G N N Y

trifluoperazine G N N Y

*Quinolinone Derivatives** - *Quinolinone Derivatives***

ABILIFY NP N Y Y

ABILIFY MAINTENA INJ MED N N Y

ABILIFY SOLUTION NP N Y Y

*Thioxanthenes** - *Thioxanthenes***

thiothixene G N N Y

*ANTIVIRALS*

42

*Antiretrovirals** - *Antiretroviral Combinations***

ATRIPLA NP N N Y

COMBIVIR NP N N Y

COMPLERA NP N N Y

EPZICOM NP N N Y

KALETRA P N N Y

lamivudine-zidovudine G N N Y

STRIBILD NP N N Y

TRUVADA P N N Y

TRIUMEQ NP N N Y *Antiretrovirals** - *Antiretrovirals - CCR5 Antagonists (Entry

Inhibitor)***

SELZENTRY NP N N Y

*Antiretrovirals** - *Antiretrovirals - Fusion Inhibitors***

FUZEON MED Y N Y

*Antiretrovirals** - *Antiretrovirals - Integrase Inhibitors***

ISENTRESS NP N N Y

TIVICAY NP N N Y

*Antiretrovirals** - *Antiretrovirals - Protease Inhibitors***

APTIVUS P N N Y

CRIXIVAN NP N N Y

INVIRASE NP N N Y

LEXIVA P N N Y

NORVIR P N N Y

PREZISTA P N N Y

REYATAZ P N N Y

VIRACEPT NP N N Y

*Antiretrovirals** - *Antiretrovirals - RTI-Non-Nucleoside Analogues***

EDURANT NP N N Y

INTELENCE NP N N Y

nevirapine G N N Y

RESCRIPTOR NP N N Y

SUSTIVA P N N Y

VIRAMUNE SUSPENSION NP N N Y

VIRAMUNE TABLET NP N N Y

VIRAMUNE XR TABLET NP N N Y *Antiretrovirals** - *Antiretrovirals - RTI-Nucleoside Analogues-

Purines***

abacavir G N N Y

didanosine G N N Y

VIDEX EC NP N N Y

VIDEX SOLUTION P N N Y

43

ZIAGEN SOLUTION NP N N Y

ZIAGEN TABLET NP N N Y *Antiretrovirals** - *Antiretrovirals - RTI-Nucleoside Analogues-

Pyrimidines***

EMTRIVA P N N Y

EMTRIVA SOLUTION P N N Y

EPIVIR HBV SOLUTION NP N N Y

EPIVIR TABLET NP N N Y

lamivudine G N N Y *Antiretrovirals** - *Antiretrovirals - RTI-Nucleoside Analogues-

Thymidines***

RETROVIR NP N N Y

RETROVIR SYRUP NP N N Y

stavudine capsule G N N Y

stavudine solution G N N Y

ZERIT NP N N Y

zidovudine G N N Y

zidovudine syrup G N N Y

*Antiretrovirals** - *Antiretrovirals - RTI-Nucleotide Analogues***

VIREAD P N N Y

*CMV Agents** - *CMV Agents***

cidofovir MED N N Y

CYTOVENE MED Y N Y

FOSCAVIR MED N N Y

ganciclovir MED N N Y

VALCYTE SOLUTION P N N Y

VALCYTE TABLET P N N Y

VISTIDE MED N N Y

*Hepatitis Agents** - *Hepatitis B Agents***

adefovir G N N Y

BARACLUDE NP N N Y

BARACLUDE SOLUTION NP N N Y

HEPSERA NP N N Y

TYZEKA NP N N Y

entecavir P N N Y

*Hepatitis Agents** - *Hepatitis C Agents***

COPEGUS NP Y N Y

HARVONI NP Y N Y

INCIVEK P Y N Y

MODERIBA NP Y N Y

OLYSIO NP Y N Y

PEGASYS MED Y N Y

44

PEG-INTRON MED Y N Y

REBETOL NP Y N Y

RIBASPHERE CAPSULE P Y N Y

RIBASPHERE TABLET 200 MG ORAL P Y N Y

RIBASPHERE TABLET 400 MG, 600 MG NP Y N Y

RIBATAB NP Y N Y

ribavirin G Y N Y

SOVALDI NP Y N Y

VICTRELIS NP Y N Y

RIBAPAK NP Y N Y

*Herpes Agents** - *Herpes Agents - Purine Analogues***

acyclovir G N N Y

valacyclovir G N N Y

VALTREX NP N N Y

ZOVIRAX NP N N Y

*Herpes Agents** - *Herpes Agents - Thymidine Analogues***

famciclovir G N N Y

FAMVIR NP N N Y

*Influenza Agents** - *Influenza Agents***

FLUMADINE NP N N Y

rimantadine G N N Y

*Influenza Agents** - *Neuraminidase Inhibitors***

RELENZA NP N N Y

TAMIFLU NP N N Y *Respiratory Syncytial Virus (RSV) Agents** - *RSV Agents - Nucleoside

Analogues***

VIRAZOLE NP N N Y

*Antiretrovirals** -

TYBOST NP N N Y

*ASSORTED CLASSES*

*Chelating Agents** - *Chelating Agents***

CUPRIMINE NP N N Y

DEPEN TITRATABS P N N Y

SYPRINE NP N N Y

*Enzymes** - *Enzymes***

XIAFLEX MED N N Y

*Immunomodulators** - *Antileprotics***

THALOMID NP Y N Y *Immunomodulators** - *Immunomodulators for Myelodysplastic

Syndromes***

REVLIMID NP Y N Y

*Immunosuppressive Agents** - *Cyclosporine Analogs***

45

cyclosporine G N N Y

cyclosporine modified G N N Y

gengraf G N N Y

NEORAL NP N N Y

SANDIMMUNE NP N N Y *Immunosuppressive Agents** - *Immune Globulin

Immunosuppressants***

ATGAM MED N N Y

THYMOGLOBULIN MED N N Y *Immunosuppressive Agents** - *Inosine Monophosphate

Dehydrogenase Inhibitors***

CELLCEPT NP N N Y

mycophenolate mofetil G N N Y

mycophenolic acid G N N Y

*Immunosuppressive Agents** - *Macrolide Immunosuppressants***

ASTAGRAF XL NP N N Y

HECORIA P N N Y

PROGRAF NP N N Y

RAPAMUNE NP N N Y

tacrolimus G N N Y

ZORTRESS NP N N Y

*Immunosuppressive Agents** - *Monoclonal Antibodies***

SIMULECT MED N N Y

*Immunosuppressive Agents** - *Purine Analogs***

AZASAN NP N N Y

azathioprine G N N Y

IMURAN NP N N Y *Immunosuppressive Agents** - *Selective T-Cell Costimulation

Blockers***

NULOJIX MED N N Y

*Potassium Removing Resins** - *Potassium Removing Resins***

kalexate G N N Y

KAYEXALATE NP N N Y

kionex G N N Y

sodium polystyrene sulfonate G N N Y

SPS SUSPENSION NP N N Y *Systemic Lupus Erythematosus Agents** - *B-Lymphocyte Stimulator

(BLyS)-Specific Inhibitors***

BENLYSTA MED Y N Y

*Lymphatic Agents***

SYLVANT MED Y N Y

*BETA BLOCKERS*

*Alpha-Beta Blockers** - *Alpha-Beta Blockers***

46

carvedilol G N N Y

COREG NP N N Y

COREG CR P N N Y

labetalol G N N Y

TRANDATE NP N N Y

*Beta Blockers Cardio-Selective** - *Beta Blockers Cardio-Selective***

acebutolol G N N Y

atenolol G N N Y

betaxolol G N N Y

bisoprolol G N N Y

BYSTOLIC P N N Y

KERLONE NP N N Y

LOPRESSOR NP N N Y

metoprolol Succinate ER NP N N Y

metoprolol tartrate G N N Y

SECTRAL NP N N Y

TENORMIN NP N N Y

TOPROL XL NP N N Y

ZEBETA NP N N Y

*Beta Blockers Non-Selective** - *Beta Blockers Non-Selective***

BETAPACE NP N N Y

BETAPACE AF NP N N Y

CORGARD NP N N Y

INDERAL LA NP N N Y

INDERAL XL NP N N Y

LEVATOL NP N N Y

nadolol G N N Y

propranolol G N N Y

propranolol ER G N N Y

sorine G N N Y

sotalol G N N Y

*BIOLOGICALS MISC*

*Biologicals Misc** - *Biologicals Misc***

ADAGEN NP Y N Y

*Allergenic Extracts***

GRASTEK NP Y N Y

ORALAIR NP Y N Y

RAGWITEK NP Y N Y

*CALCIUM CHANNEL BLOCKERS*

*Calcium Channel Blockers** - *Calcium Channel Blockers***

ADALAT CC NP N N Y

47

afeditab G N N Y

amlodipine G N N Y

CALAN NP N N Y

CALAN SR NP N N Y

CARDENE SR NP N N Y

CARDIZEM NP N N Y

CARDIZEM CD NP N N Y

CARDIZEM LA NP N N Y

cartia XT G N N Y

DILACOR XT NP N N Y

dilt-CD G N N Y

diltiazem G N N Y

diltiazem CD G N N Y

diltiazem ER G N N Y

dilt-XR G N N Y

diltzac G N N Y

felodipine G N N Y

ISOPTIN SR NP N N Y

matzim LA G N N Y

nicardipine G N N Y

nifediac CC G N N Y

nifedical XL G N N Y

nifedipine G N N Y

nifedipine ER G N N Y

nimodipine G N N Y

nisoldipine G N N Y

nisoldipine ER G N N Y

NORVASC NP N N Y

NYMALYZE NP N N Y

PROCARDIA NP N N Y

PROCARDIA XL NP N N Y

SULAR NP N N Y

taztia XT G N N Y

TIAZAC NP N N Y

verapamil G N N Y

verapamil ER G N N Y

VERELAN NP N N Y

VERELAN PM NP N N Y

*CARDIOTONICS*

*Cardiac Glycosides** - *Cardiac Glycosides***

digox G N N Y

48

digoxin G N N Y

LANOXIN NP N N Y

*CARDIOVASCULAR AGENTS – MISC.*

*Cardiovascular Agents Misc. – Combinations** - *Nitrate & Vasodilator

Combinations***

BIDIL NP N N Y

*Impotence Agents** - *Prostaglandin – Impotence Agents***

CAVERJECT (applies only to plans with ED coverage) NP N N Y

EDEX (applies only to plans with ED coverage) NP N N Y

MUSE (applies only to plans with ED coverage) NP N N Y

*Prostaglandin Vasodilators** - *Prostaglandin Vasodilators***

epoprostenol MED Y N Y

REMODULIN MED Y N Y

TYVASO NP Y N Y

VELETRI MED Y N Y

VENTAVIS NP Y N Y

FLOLAN MED Y N Y

ORENITRAM NP Y N Y *Pulmonary Hypertension – Endothelin Receptor Antagonists** -

*Pulmonary Hypertension – Endothelin Receptor Antagonists***

LETAIRIS P Y N Y

OPSUMIT NP Y N Y

TRACLEER P Y N Y *Pulmonary Hypertension – Phosphodiesterase Inhibitors** -

*Pulmonary Hypertension – Phosphodiesterase Inhibitors***

ADCIRCA NP Y N Y

REVATIO NP Y N Y

sildenafil citrate G Y N Y *Pulmonary Hypertension – Sol Guanylate Cyclase Stimulator** - *Pulm

Hyperten-Soluble Guanylate Cyclase Stimulator (sGC)***

ADEMPAS NP Y N Y *Impotence Agents** - *Selective cGMP Phosphodiesterase Type 5

Inhibitor Agents***

CIALIS (applies only to plans with ED coverage) P N N Y

LEVITRA (applies only to plans with ED coverage) NP N N Y

STAXYN (applies only to plans with ED coverage) NP N N Y

STENDRA (applies only to plans with ED coverage) NP N N Y

VIAGRA (applies only to plans with ED coverage) NP N N Y

*CEPHALOSPORINS*

*Cephalosporins – 1st

Generation** - *Cephalosporins – 1st

Generation***

cefadroxil G N N Y

cephalexin G N N Y

KEFLEX NP N N Y

49

*Cephalosporins – 2nd

Generation** - *Cephalosporins – 2nd

Generation***

cefaclor G N N Y

cefprozil G N N Y

CEFTIN NP N N Y

cefuroxime G N N Y *Cephalosporins – 3

rd Generation** - *Cephalosporins – 3

rd

Generation***

CEDAX NP N N Y

cefdinir G N N Y

cefpodoxime G N N Y

SPECTRACEF NP N N Y

SUPRAX NP N N Y

*CONTRACEPTIVES*

*Combination Contraceptives – Oral** - *Biphasic Contraceptives –

Oral***

azurette G N N Y

desogestrel-ethinyl estradiol G N N Y

kariva G N N Y

LO LOESTRIN FE NP N Y Y

MIRCETTE NP N Y Y

pimtrea G N N Y

viorele G N N Y *Combination Contraceptives – Oral** - *Combination Contraceptives –

Oral***

altavera G N N Y

alyacen G N N Y

apri G N N Y

aubra G N N Y

aviane G N N Y

balziva G N N Y

BEYAZ NP N Y Y

BREVICON NP N Y Y

briellyn G N N Y

chateal G N N Y

cryselle G N N Y

cyclafem G N N Y

dasetta G N N Y

DESOGEN NP N Y Y

drospirenone-ethinyl estradiol G N N Y

elinest G N N Y

emoquette G N N Y

enskyce G N N Y

50

estarylla G N N Y

FALESSA NP N Y Y

falmina G N N Y

FEMCON FE NP N Y Y

GENERESS FE NP N Y Y

gianvi G N N Y

gildagia G N N Y

gildess G N N Y

gildess FE G N N Y

junel G N N Y

junel FE G N N Y

kelnor G N N Y

kurvelo G N N Y

larin G N N Y

larin Fe G N N Y

lessina G N N Y

levonorgestrel-ethinyl estradiol G N N Y

levora G N N Y

LOESTRIN NP N Y Y

LOESTRIN FE NP N Y Y

loryna G N N Y

low-ogestrel G N N Y

lutera G N N Y

marlissa G N N Y

microgestin G N N Y

microgestin FE G N N Y

MINASTRIN 24 FE NP N Y Y

MODICON NP N Y Y

mono-linyah G N N Y

mononessa G N N Y

necon G N N Y

NECON 1/50 NP N Y Y

NECON 10/11 NP N Y Y

norgestimate-eth estradiol G N N Y

NORINYL NP N Y Y

nortrel G N N Y

ocella G N N Y

orsythia G N N Y

ORTHO-CEPT NP N Y Y

ORTHO-CYCLEN NP N Y Y

ORTHO-NOVUM NP N Y Y

51

OVCON NP N Y Y

philith G N N Y

pirmella G N N Y

portia G N N Y

previfem G N N Y

reclipsen G N N Y

SAFYRAL NP N Y Y

solia G N N Y

sprintec G N N Y

sronyx G N N Y

syeda G N N Y

vestura G N N Y

vyfemla G N N Y

wera G N N Y

wymzya Fe G N N Y

YASMIN NP N Y Y

YAZ NP N Y Y

zarah G N N Y

zenchent G N N Y

zenchent FE G N N Y

zeosa G N N Y

zovia G N N Y *Combination Contraceptives – Oral** - *Extended-Cycle

Contraceptives – Oral***

amethia G N N Y

amethia Lo G N N Y

camrese G N N Y

camrese Lo G N N Y

daysee G N N Y

introvale G N N Y

jolessa G N N Y

levonorgest-Eth Estrad 91-Day G N N Y

LOSEASONIQUE NP N Y Y

Quartette NP N Y Y

quasense G N N Y

SEASONIQUE NP N Y Y *Combination Contraceptives – Oral** - *Four Phase Contraceptives –

Oral***

NATAZIA NP N Y Y *Combination Contraceptives – Oral** - *Triphasic Contraceptives –

Oral***

alyacen G N N Y

52

aranelle G N N Y

caziant G N N Y

cesia G N N Y

cyclafem G N N Y

CYCLESSA NP N Y Y

dasetta G N N Y

enpresse G N N Y

ESTROSTEP FE NP N Y Y

leena G N N Y

levonest G N N Y

myzilra G N N Y

necon G N N Y

norgestim-eth estrad G N N Y

nortrel G N N Y

ORTHO- NOVUM NP N Y Y

ORTHO TRI-CYCLEN NP N Y Y

ORTHO TRI-CYCLEN LO NP N Y Y

pirmella G N N Y

tilia Fe G N N Y

tri-estarylla G N N Y

tri-legest Fe G N N Y

tri-linyah G N N Y

trinessa G N N Y

TRI-NORINYL NP N Y Y

tri-previfem G N N Y

tri-sprintec G N N Y

trivora G N N Y

velivet G N N Y *Combination Contraceptives – Transdermal** - *Combination

Contraceptives – Transdermal***

ORTHO EVRA PATCH NP N Y Y

xulane patch G N N Y *Combination Contraceptives - Vaginal** - *Combination

Contraceptives - Vaginal***

NUVARING NP N Y Y

*Copper Contraceptives - IUD** - *Copper Contraceptives - IUD***

Paragard Intrauterine Copper INTRAUTERINE DEVICE INTRAUTERINE MED N N Y *Progestin Contraceptives - Implants** - *Progestin Contraceptives -

Implants***

Implanon IMPLANT 68 MG SUBCUTANEOUS* MED N N Y

Nexplanon IMPLANT 68 MG SUBCUTANEOUS* MED N N Y *Progestin Contraceptives - Injectable** - *Progestin Contraceptives -

Injectable***

53

DEPO PROVERA INJ MED N N Y

DEPO-SUBQ PROVERA INJ MED N N Y

medroxyprogesterone acetate inj MED N N Y

*Progestin Contraceptives - IUD** - *Progestin Contraceptives - IUD***

Mirena INTRAUTERINE DEVICE 20 MCG/24HR INTRAUTERINE MED N N Y

Skyla INTRAUTERINE DEVICE 13.5 MG INTRAUTERINE MED N N Y *Progestin Contraceptives - Oral** - *Progestin Contraceptives -

Oral***

camila G N N Y

errin G N N Y

heather G N N Y

jencycla G N N Y

jolivette G N N Y

lyza G N N Y

nora-be G N N Y

norethindrone G N N Y

NOR-QD NP N Y Y

ORTHO MICRONOR NP N Y Y

*CORTICOSTEROIDS*

*Glucocorticosteroids** - *Glucocorticosteroids***

asmalpred G N N Y

asmalpred plus G N N Y

baycadron G N N Y

budesonide ER G N N Y

CORTEF NP N N Y

dexamethasone elixir G N N Y

dexamethasone intensol concentrate NP N N Y

dexamethasone tablet G N N Y

DEXPAK NP N N Y

ENTOCORT EC NP N Y Y

FLO-PRED NP N N Y

hydrocortisone tablet G N N Y

MEDROL PAK NP N N Y

MEDROLTABLET NP N N Y

methylprednisolone pak G N N Y

methylprednisolone tablet G N N Y

MILLIPRED NP N N Y

MILLIPRED DP NP N N Y

ORAPRED ODT NP N N Y

ORAPRED SOLUTION NP N N Y

PEDIAPRED SOLUTION NP N N Y

prednisolone sodium phosphate solution G N N Y

54

prednisolone solution G N N Y

prednisolone syrup G N N Y

prednisone G N N Y

PREDNISONE INTENSOL CONCENTRATE NP N N Y

prednisone pak G N N Y

PRELONE SYRUP NP N N Y

RAYOS NP N Y Y

UCERIS NP N N Y

VERIPRED NP N N Y

*Mineralocorticoids** - *Mineralocorticoids***

fludrocortisone G N N Y

*COUGH/COLD/ALLERGY*

*Antitussives** - *Antitussive - Nonnarcotic***

benzonatate G N N Y

TESSALON PERLES NP N N Y

ZONATUSS NP N N Y

*Antitussives** - *Antitussive - Opioid***

hydrocodone-homatropine syrup G N N Y

hydrocodone-homatropine tablet G N N Y

hydromet syrup G N N Y

tussigon G N N Y *Cough/Cold/Allergy Combinations** - *Antitussive-Expectorant -

Decongest-Antihist***

ALBATUSSIN NN LIQUID NP N N Y

NEOTUSS-D LIQUID NP N N Y

*Cough/Cold/Allergy Combinations** - *Antitussive-Expectorant***

cheratussin AC G N N Y

gani-tuss NR liquid G N N Y

guaiatussin ac syrup G N N Y

guaifenesin AC syrup G N N Y

guaifenesin-codeine solution G N N Y

guaifenesin-codeine syrup G N N Y

guiatuss AC syrup G N N Y

iophen C-NR liquid G N N Y

m-clear WC solution G N N Y

myci-GC solution G N N Y

mytussin AC syrup G N N Y

NORTUSS-EX LIQUID NP N N Y

relcof C solution G N N Y

robafen AC syrup G N N Y

romilar AC solution G N N Y

virtussin A/C solution G N N Y

55

*Cough/Cold/Allergy Combinations** - *Antitussive-Expectorants-

Antihistamine***

TUSNEL NP N N Y *Cough/Cold/Allergy Combinations** - *Antitussive-Expectorants-

Decongestant***

ALBATUSSIN NP N N Y

cheratussin DAC solution G N N Y

EXACTUSS LIQUID NP N N Y

GILTUSS LIQUID NP N N Y

GILTUSS PED-C LIQUID NP N N Y

GILTUSS TR NP N N Y

guaifenesin DAC syrup G N N Y

mytussin DAC solution G N N Y

TGQ 30PSE/150GFN/15DM SYRUP NP N N Y

TUSNEL Ped-C SYRUP NP N N Y

TUSSO-DMR NP N N Y

Z-COF I SUSPENSION NP N N Y *Cough/Cold/Allergy Combinations** - *Decongestant &

Antihistamine***

CLARINEX-D 12 Hour NP N N Y

CLARINEX-D 24 Hour NP N N Y

DECON-A ELIXIR NP N N Y

RELHIST NP N N Y

RESCON-JR NP N N Y

RESCON-MX NP N N Y

SEMPREX-D NP N N Y *Cough/Cold/Allergy Combinations** - *Decongestant w/

Expectorant***

GILPHEX TR NP N N Y *Cough/Cold/Allergy Combinations** - *Decongestant-Antihistamine

w/ Expectorant***

DECON-G LIQUID NP N N Y *Cough/Cold/Allergy Combinations** - *Non-Narc Antitussive-

Antihistamine***

promethazine-DM SYRUP G N N Y *Cough/Cold/Allergy Combinations** - *Non-Narc Antitussive-

Decongestant-Antihistamine***

bromfed DM syrup G N N Y

CARBAPEH 12 Ped SUSPENSION NP N N Y

CARBAPHEN PED SUSPENSION NP N N Y

dimetane DX syrup G N N Y

NEOTUSS PLUS LIQUID NP N N Y

PEDIATEX TDM SUSPENSION NP N N Y

pseudoeph-bromphen-DM syrup G N N Y

56

TGQ 30PSE/3BRM/15DM SYRUP NP N N Y *Cough/Cold/Allergy Combinations** - *Opioid Antitussive-

Antihistamine***

hydrocod Polst-CPM polst ER LIQUID G N N Y

promethazine-codeine syrup G N N Y

TUSSICAPS NP N N Y

TUSSIONEX NP N N Y

VITUZ SOLUTION NP N N Y *Cough/Cold/Allergy Combinations** - *Opioid Antitussive-

Decongestant***

REZIRA SOLUTION NP N N Y *Cough/Cold/Allergy Combinations** - *Opioid Antitussive-

Decongestant-Antihistamine***

CPB WC LIQUID NP N N Y

PHENYLHISTINE DH LIQUID NP N N Y

TRICODE AR LIQUID NP N N Y

*Misc. Respiratory Inhalants** - *Misc. Respiratory Inhalants***

HYPERSAL NEBULIZATION SOLUTION NP N N Y

nebusal nebulization solution G N N Y

pulmosal nebulization solution G N N Y

sodium chloride nebulization solution G N N Y

*Mucolytics** - *Mucolytics***

acetylcysteine solution G N N Y

*DERMATOLOGICALS*

*Acne Products** - *Acne Antibiotics***

ACZONE NP N N Y

AKNE-MYCIN NP N N Y

CLEOCIN-T NP N N Y

clindacin ETZ G N N Y

clindacin-P G N N Y

CLINDAGEL NP N N Y

clindamax G N N Y

clindamycin external G N N Y

ery pad G N N Y

ERYGEL NP N N Y

erythromycin external G N N Y

erythromycin pad G N N Y

EVOCLIN NP N N Y

KLARON NP N N Y

sulfacetamide sodium external G N N Y

*Acne Products** - *Acne Combinations***

ACANYA NP N Y Y

57

avar cleanser G N N Y

AVAR LS CLEANSER LIQUID NP N N Y

AVAR LS PAD NP N N Y

AVAR PAD NP N N Y

avar-e emollient cream G N N Y

avar-e green G N N Y

AVAR-E LS CREAM NP N N Y

BENZAMYCIN NP N Y Y

benzoyl peroxide-erythromycin G N N Y

bp 10-1 G N N Y

bp cleansing wash emulsion G N N Y

cerisa wash emulsion G N N Y

claris clarifying wash emulsion G N N Y

clenia G N N Y

clindamycin phos-benzoyl perox external G N N Y

DUAC NP N Y Y

EPIDUO P N N Y

PLEXION NP N Y Y

prascion emulsion G N N Y

prascion fc pad G N N Y

prascion ra cream G N N Y

rosaderm emulsion G N N Y

rosanil cleanser emulsion G N N Y

SE 10-5 SS G N N Y

sulfacetamide sodium-sulfur external G N N Y

sulfacleanse 8/4 suspension G N N Y

suphera cream G N N Y

topisulf cream G N N Y

VANOXIDE-HC LOTION NP N N Y

virti-sulf cream G N N Y

zencia liquid G N N Y

*Acne Products** - *Acne Products***

ABSORICA NP N Y Y

adapalene G N N Y

amnesteem G N Y Y

ATRALIN NP N Y Y

avita G N N Y

AZELEX NP N N Y

benzepro foam G N N Y

benzepro short contact foam G N N Y

BENZIQ NP N N Y

58

BENZIQ LS NP N N Y

benzoyl peroxide external G N N Y

BP foam external G N N Y

BPO EXTERNAL NP N N Y

claravis G N Y Y

DIFFERIN NP N Y Y

FABIOR NP N Y Y

myorisan G N Y Y

NUOX EXTERNAL NP N N Y

RETIN-A NP N Y Y

RETIN-A MICRO P N N Y

RIAX FOAM NP N Y Y

sotret G N Y Y

SULFOAM SHAMPOO NP N N Y

tretinoin external G N N Y

tretinoin microsphere external G N N Y

TRETIN-X NP N Y Y

ZACLIR CLEANSING LOTION NP N N Y

zenatane G N Y Y *Agents for External Genital and Perianal Warts** - *Agents for External

Genital and Perianal Warts***

VEREGEN OINTMENT NP N N Y

*Antibiotics - Topical** - *Antibiotic Steroid Combinations - Topical***

CORTISPORIN NP N N Y

*Antibiotics - Topical** - *Antibiotics - Topical***

ALTABAX OINTMENT NP N N Y

BACTROBAN NP N N Y

CENTANY NP N N Y

gentamicin sulfate G N N Y

mupirocin external G N N Y

*Antifungals - Topical** - *Antifungals - Topical Combinations***

ALA QUIN CREAM NP N N Y

ALCORTIN A NP N N Y

ALOQUIN NP N N Y

clotrimazole-betamethasone G N N Y

DERMASORB AF KIT NP N N Y

dermazene G N N Y

exoderm G N N Y

hydrocortisone-iodoquinol G N N Y

LOTROSONE NP N N Y

nystatin-triamcinolone G N N Y

versiclear LOTION 25-1 % EXTERNAL G N N Y

59

VUSION NP N N Y

VYTONE NP N N Y

*Antifungals - Topical** - *Antifungals - Topical***

ciclodan G N N Y

ciclopirox G N N Y

CNL8 NAIL KIT NP N N Y

HALOTIN NP N N Y

LOPROX NP N N Y

NAFTIN NP N N Y

nyamyc powder G N N Y

nystatin G N N Y

nystop powder G N N Y

pedi-dri powder G N N Y

PENLAC NP N N Y

*Antifungals - Topical** - *Imidazole-Related Antifungals - Topical***

antifungal cream G N N Y

baza antifungal cream G N N Y

carrington antifungal cream G N N Y

econazole G N N Y

ECOZA FOAM NP N N Y

ERTACZA NP N N Y

EXELDERM NP N N Y

EXTINA FOAM NP N N Y

JUBLIA NP N N Y

ketoconazole G N N Y

ketodan foam G N N Y

KP miconazole nitrate G N N Y

kuric G N N Y

LUZU NP N N Y

micaderm G N N Y

MICATIN NP N N Y

miconazole nitrate G N N Y

micro guard G N N Y

neosporin AF cream G N N Y

NIZORAL SHAMPOO NP N N Y

nuzole G N N Y

OXISTAT NP N N Y

podactin G N N Y

RA antifungal cream G N N Y

remedy antifungal cream G N N Y

secura antifungal cream G N N Y

60

secura antifungal extra thick cream G N N Y

SM antifungal miconazole cream G N N Y

soothe & cool INZO antifungal cream G N N Y

XOLEGEL NP N N Y *Anti-inflammatory Agents - Topical** - *Anti-inflammatory Agents -

Topical***

FLECTOR PATCH P N N Y

PENNSAID SOLUTION NP N Y Y

VOLTAREN GEL P N Y Y *Antineoplastic or Premalignant Lesion Agents - Topical** -

*Antineoplastic Alkylating Agents - Topical***

VALCHLOR NP Y N Y *Antineoplastic or Premalignant Lesion Agents - Topical** -

*Antineoplastic Antimetabolites - Topical***

CARAC NP N N Y

EFUDEX NP N N Y

FLUOROPLEX NP N N Y

fluorouracil G N N Y *Antineoplastic or Premalignant Lesion Agents - Topical** -

*Antineoplastic or Premalignant Lesions - Topical Misc.***

PICATO P N N Y *Antineoplastic or Premalignant Lesion Agents - Topical** -

*Antineoplastic or Premalignant Lesions - Topical NSAID's***

diclofenac Sodium 3 % transdermal G N N Y

SOLARAZE 3 % TRANSDERMAL NP N N Y *Antineoplastic or Premalignant Lesion Agents - Topical** -

*Antineoplastic Retinoids - Topical***

PANRETIN P N N Y *Antineoplastic or Premalignant Lesion Agents - Topical** -

*Photodynamic Therapy Agents - Topical***

LEVULAN KERASTICK NP N N Y

METVIXIA NP N N Y *Antineoplastic or Premalignant Lesion Agents - Topical** - *Topical

Selective Retinoid X Receptor Agonists***

TARGRETIN P Y N Y

*Antipruritics - Topical** - *Antipruritics - Topical***

PRUDOXIN NP N N Y

ZONALON NP N N Y

*Antipsoriatics** - *Antipsoriatics - Systemic***

8-MOP NP N N Y

acitretin G N N Y

OXSORALEN ULTRA NP N N Y

SORIATANE P N N Y

*Antipsoriatics** - *Antipsoriatics***

61

calcipotriene G N N Y

DOVONEX NP N N Y

DRITHO-CRÈME HP NP N N Y

SORILUX FOAM NP N N Y

TAZORAC P N N Y

VECTICAL NP N N Y

ZITHRANOL SHAMPOO NP N N Y

ZITHRANOL-RR CREAM NP N N Y

*Antiseborrheic Products** - *Antiseborrheic Combinations***

SELRX SHAMPOO NP N N Y

SODIUM SULFACETAMIDE WASH NP N N Y

*Antiseborrheic Products** - *Antiseborrheic Products***

mexar wash G N N Y

OVACE NP N N Y

OVACE PLUS NP N N Y

RE 10 wash G N N Y

SEB-PREV NP N N Y

SEB-PREV WASH G N N Y

selenium sulfide lotion G N N Y

sodium sulfacetamide shampoo G N N Y

sulfacetamide sodium 10 % (cleans) G N N Y

sulfacetamide sodium liquide 10 % external G N N Y

TERSI FOAM NP N N Y

*Antivirals - Topical** - *Antiviral Topical Combinations***

XERESE NP N N Y

*Antivirals - Topical** - *Antivirals - Topical***

acyclovir ointment G N N Y

DENAVIR NP N N Y

ZOVIRAX CREAM NP N N Y

ZOVIRAX OINTMENT NP N N Y

*Burn Products** - *Burn Products***

mafenide acetate packet G N N Y

SILVADENE CREAM NP N N Y

silver sulfadiazine cream G N N Y

SSD AF cream G N N Y

SSD cream G N N Y

SULFAMYLON NP N N Y

thermazene G N N Y

*Cauterizing Agents** - *Cauterizing Agent Combinations***

grafco silver nit applicator G N N Y

*Cauterizing Agents** - *Cauterizing Agents***

62

TRI-CHLOR LIQUID NP N N Y

*Corticosteroids - Topical** - *Corticosteroids - Topical***

ACLOVATE NP N N Y

alclometasone G N N Y

alphatrex G N N Y

amcinonide G N N Y

apexicon G N N Y

APEXICON E NP N N Y

betamethasone dipropionate G N N Y

betamethasone dipropionate aug G N N Y

betamethasone valerate G N N Y

beta-val G N N Y

CAPEX SHAMPOO NP N N Y

clobetasol propionate G N N Y

clobetasol propionate E G N N Y

clobetasol propionate emulsion foam G N N Y

clobetasol propionate foam G N N Y

CLOBEX NP N N Y

CORDRAN LOTION NP N N Y

CORDRAN TAPE NP N N Y

cormax G N N Y

CUTIVATE NP N N Y

DERMA-SMOOTHE/FS BODY OIL NP N N Y

DERMA-SMOOTHE/FS SCALP OIL NP N N Y

DERMATOPP NP N N Y

DESONATE NP N N Y

desonide G N N Y

DESOWEN NP N N Y

desoximetasone G N N Y

diflorasone G N N Y

DIPROLENE NP N N Y

DIPROLENE AF NP N N Y

ELOCON NP N N Y

fluocinolone acetonide G N N Y

fluocinolone acetonide body oil G N N Y

fluocinolone acetonide scalp oil G N N Y

fluocinonide G N N Y

fluocinonide-E G N N Y

fluticasone propionate external G N N Y

halobetasol propionate G N N Y

HALOG NP N N Y

63

hydrocortisone G N N Y

hydrocortisone butyr lipo base G N N Y

hydrocortisone butyrate G N N Y

hydrocortisone valerate G N N Y

isovate G N N Y

KENALOG NP N N Y

LOCOID NP N N Y

LOCOID LIPOCREAM NP N N Y

lokara G N N Y

LUXIQ NP N N Y

mometasone furoate G N N Y

NUCORT NP N N Y

OLUX NP N N Y

OLUX-E NP N N Y

PANDEL NP N N Y

prednicarbate G N N Y

scalacort G N N Y

SYNALAR NP N N Y

TEMOVATE NP N N Y

TEMOVATE E NP N N Y

TEXACORT NP N N Y

TOPICORT NP N N Y

triamcinolone acetonide G N N Y

TRIANEX NP N N Y

triderm G N N Y

ULTRAVATE NP N N Y

VERDESO NP N N Y

WESTCORT NP N N Y *Corticosteroids - Topical** - *Steroid-Local Anesthetic

Combinations***

CORTANE-B NP N N Y

EPIFOAM NP N N Y

hydrocortisone ace-pramoxine cream G N N Y

NOVACORT NP N N Y

PRAMOSONE NP N N Y

PRAMOSONE E NP N N Y

*Corticosteroids - Topical** - *Topical Steroid Combinations***

cortalo G N N Y

hydrocortisone acetate-aloe G N N Y

TACLONEX NP N N Y

u-Cort G N N Y

*Emollient/Keratolytic Agents** - *Emollient/Keratolytic Agents***

64

ALUVEA NP N N Y

carmol 40 G N N Y

CEM-UREA NP N N Y

cerovel G N N Y

cerovel G N N Y

DERMASORB XM KIT NP N N Y

GORDONS UREA NP N N Y

KERALAC NP N N Y

KERFOAM 42 NP N N Y

RE 40 G N N Y

RE urea 40 G N N Y

remeven G N N Y

TL urea G N N Y

U-kera E G N N Y

UMECTA NP N N Y

urea external G N N Y

urea nail G N N Y

urea-C40 G N N Y

UTOPIC NP N N Y

X-viate G N N Y *Emollient/Keratolytic Agents** - *Emollient/Keratolytic

Combinations***

latrix G N N Y

RE urea 50 G N N Y

UMECTA PD NP N N Y

URAMAXIN FOAM NP N N Y

urea hydrating foam G N N Y

urea in zn undecyl-lactic acid G N N Y

UREA Nail KIT 40 & 0.2 % NP N N Y

UREA Nail STICK 50 % NP N N Y

*Emollients** - *Emollients***

hygel G N N Y

HYLIRA NP N N Y

lactic acid external G N N Y

sodium hyaluronate external G N N Y

*Enzymes - Topical** - *Enzymes - Topical***

OPTASE NP N N Y

revina G N N Y

SANTYL NP N N Y

TBC aerosol G N N Y

vasolex G N N Y

*Immunomodulating Agents - Topical** - *Immunomodulators

65

Imidazoquinolinamines - Topical***

ALDARA NP N N Y

imiquimod G N N Y

ZYCLARA NP N N Y *Immunosuppressive Agents - Topical** - *Macrolide

Immunosuppressants - Topical***

ELIDEL P Y N Y

PROTOPIC P Y N Y *Keratolytic/Antimitotic Agents** - *Keratolytic and/or Antimitotic

Combinations***

BENSAL HP NP N N Y

GORDOFILM SOLUTION NP N N Y

SALKERA FOAM NP N N Y

SALVAX DUO PLUS KIT NP N N Y

*Keratolytic/Antimitotic Agents** - *Keratolytic/Antimitotic Agents***

aliclen G N N Y

CONDYLOX EXTERNAL NP N N Y

PODOCON EXTERNAL NP N N Y

podofilox external G N N Y

RE SA G N N Y

salacyn G N N Y

Salicylic acid external G N N Y

*Local Anesthetics - Topical** - *Local Anesthetics - Topical***

ANACAINE NP N N Y

lidocaine HCl external G N N Y

lidocaine patch G N N Y

LIDODERM PATCH NP N N Y

LIDORX NP N N Y

QUTENZA PATCH KIT NP N N Y

XYLOCAINE SOLUTION NP N N Y

*Local Anesthetics - Topical** - *Topical Anesthetic Combinations***

EMLA NP N N Y

lidocaine-prilocaine G N N Y

PLIAGLIS NP N N Y

SYNERA PATCH NP N N Y

*Misc. Topical** - *Astringents***

XERAC AC NP N N Y

*Misc. Topical** - *Misc. Topical***

hypercare G N N Y

*Rosacea Agents** - *Rosacea Agents***

FINACEA NP N N Y

METROCREAM NP N N Y

66

METROGEL NP N N Y

METROLOTION NP N N Y

metronidazole external cream, lotion G N N Y

MIRVASO NP N Y Y

NORITATE NP N N Y

ORACEA ORAL P N N Y

rosadan external G N N Y

vitazol G N N Y

*Scabicides & Pediculicides** - *Scabicides & Pediculicides***

acticin G N N Y

ELIMITE NP N N Y

EURAX NP N N Y

lindane external G N N Y

malathion external G N N Y

NATROBA EXTERNAL NP N N Y

OVIDE EXTERNAL NP N N Y

permethrin external G N N Y

SKLICE EXTERNAL NP N N Y

ULESFIA EXTERNAL NP N N Y

*Wound Care Products** - *Wound Care - Growth Factor Agents***

REGRANEX EXTERNAL NP N N Y

*Wound Care Products** - *Wound Care Combinations***

REGENECARE EXTERNAL NP N N Y *Wound Care Products** - *Wound Cleansers/Decubitus Ulcer

Therapy***

LAVARE WOULD WASH EXTERNAL NP N N Y

*DIAGNOSTIC PRODUCTS*

*Diagnostic Biologicals** - *Multiple Skin Tests***

GLUCOSE TEST STRIP (ANY OTHER BRAND NAME) NP N Y Y

*Diagnostic Drugs** - *Diagnostic Drugs***

Thyrogen SOLUTION RECONSTITUTED 1.1 MG INTRAMUSCULAR* MED N N Y

*Diagnostic Products, Misc.** - *Diagnostic Products, Misc.***

Hyskon SOLUTION 32-10 % MED N N Y

*Diagnostic Tests** - *Diagnostic Tests***

EXACTECH P N N Y

EXACTECH R-S-G P N N Y

FreeStyle InsuLinx Test STRIP IN VITRO P N N Y

FreeStyle Lite Test STRIP IN VITRO P N N Y

FreeStyle Test STRIP IN VITRO P N N Y

OneTouch Test STRIP IN VITRO P N N Y

OneTouch Ultra Blue STRIP IN VITRO P N N Y

OneTouch Verio STRIP IN VITRO P N N Y

67

Precision PCX Plus Test STRIP IN VITRO P N N Y

Precision PCx STRIP IN VITRO P N N Y

Precision Point of Care Test STRIP IN VITRO P N N Y

Precision QID Test STRIP IN VITRO P N N Y

Precision Sof-Tact Test STRIP IN VITRO P N N Y

Precision Xtra Blood Glucose STRIP IN VITRO P N N Y

*DIGESTIVE AIDS*

*Digestive Enzymes** - *Digestive Enzymes***

CREON P N N Y

PANCREAZE NP N N Y

PERTZYE NP N Y Y

SUCRAID NP N N Y

ULTRESA NP N Y Y

VIOKASE NP N Y Y

ZENPEP P N N Y

*DIURETICS*

*Carbonic Anhydrase Inhibitors** - *Carbonic Anhydrase Inhibitors***

acetazolamide G N N Y

acetazolamide ER G N N Y

DIAMOX NP N N Y

methazolamide G N N Y

NEPTAZANE NP N N Y

*Diuretic Combinations** - *Diuretic Combinations***

ALDACTAZIDE NP N N Y

amiloride-hydrochlorothiazide G N N Y

DYAZIDE NP N N Y

MAXZIDE NP N N Y

MAXZIDE-25 NP N N Y

spironolactone-HCTZ G N N Y

triamterene-HCTZ G N N Y

*Loop Diuretics** - *Loop Diuretics***

bumetanide G N N Y

DEMADEX NP N N Y

EDECRIN NP N N Y

furosemide G N N Y

LASIX NP N N Y

torsemide G N N Y

*Osmotic Diuretics** - *Osmotic Diuretics***

INTROL NP N N Y

*Potassium Sparing Diuretics** - *Potassium Sparing Diuretics***

ALDACTONE NP N N Y

68

amiloride G N N Y

DYRENIUM NP N N Y

spironolactone G N N Y *Thiazides and Thiazide-Like Diuretics** - *Thiazides and Thiazide-Like

Diuretics***

chlorothiazide G N N Y

DIURIL NP N N Y

hydrochlorothiazide G N N Y

indapamide G N N Y

metolazone G N N Y

MICROZIDE NP N N Y

ZAROXOLYN NP N N Y

*ENDOCRINE AND METABOLIC AGENTS - MISC.*

*Bone Density Regulators** - *Bisphosphonates***

ACTONEL NP N N Y

alendronate G N N Y

ATELVIA P N N Y

BINOSTRO NP N Y Y

BONIVA NP N Y Y

FOSAMAX NP N N Y

FOSAMAX PLUS D NP N Y Y

ibandronate G N N Y

pamidronate G N N Y

RECLAST NP Y N Y

risedronate G N N Y

SKELID NP N N Y

zoledronic acid G Y N Y

ZOMETA NP Y N Y

*Bone Density Regulators** - *Calcitonins***

calcitonin (salmon) nasal solution G N N Y

MIACALCIN NASAL SOLUTION NP N N Y

MIACALCIN SOLUTUION INJECTABLE MED N N Y

*Bone Density Regulators** - *Calcium Regulators - Misc.***

GANITE MED N N Y *Bone Density Regulators** - *Parathyroid Hormone And

Derivatives***

FORTEO MED Y N Y

*Bone Density Regulators** - *RANK Ligand (RANKL) Inhibitors***

PROLIA MED Y N Y

XGEVA MED Y N Y

*Corticotropin** - *Corticotropin***

ACTHAR HP MED Y N Y

69

*Fertility Regulators** - *Ovulation Stimulants-Synthetic***

CLOMID NP N N Y

serophene G N N Y

clomiphene citrate G N N Y *Growth Hormone Receptor Antagonists** - *Growth Hormone


SOMAVERT MED Y N Y

*Growth Hormones** - *Growth Hormones***

GENOTROPIN MED Y N Y

HUMATROPE MED Y N Y

NORDITROPIN MED Y N Y

NUTROPIN AQ, NUTROPIN MED Y N Y

OMNITROPE MED Y N Y

SAIZEN MED Y N Y

SEROSTIM MED Y N Y

TEV-TROPIN MED Y N Y

ZORBTIVE MED Y N Y *Hormone Receptor Modulators** - *Selective Estrogen Receptor

Modulators (SERMs)***

EVISTA P N N Y *Insulin-Like Growth Factors (Somatomedins)** - *Insulin-Like Growth

Factors (Somatomedins)***

INCRELEX MED Y N Y *LHRH/GnRH Agonist Analog Pituitary Suppressants** - *LHRH/GnRH

Agonist Analog Combinations***

LUPANETA PACK MED Y N Y *LHRH/GnRH Agonist Analog Pituitary Suppressants** - *LHRH/GnRH

Agonist Analog Pituitary Suppressants***

LUPRON DEPOT-PED KIT MED Y N Y

SUPPRELIN LA KIT MED Y N Y

SYNAREL NP N N Y

*Metabolic Modifiers** - *Calcimimetic Agents***

SENSIPAR NP Y N Y

*Metabolic Modifiers** - *Carnitine Replenisher - Agents***

CARNITOR NP N N Y

CARNITOR SF NP N N Y

levocarnitine G N N Y

*Metabolic Modifiers** - *Fabry Disease - Agents***

FABRAZYME MED Y N Y *Metabolic Modifiers** - *Hereditary Tyrosinemia Type 1 (HT-1)

Treatment - Agents***

ORFADIN P Y N Y

*Metabolic Modifiers** - *Homocystinuria Treatment - Agents***

CYSTADANE P N N Y

70

*Metabolic Modifiers** - *Hyperammonemia Treatment - Agents***

CARBAGLU NP Y N Y *Metabolic Modifiers** - *Hyperparathyroid Treatment - Vitamin D

Analogs***

calcitriol oral G N N Y

paricalcitol oral G N N Y

ROCALTROL ORAL NP N N Y

ZEMPLAR INTRAVENOUS MED N N Y

ZEMPLAR ORAL P N N Y

*Metabolic Modifiers** - *Mucopolysaccharidosis I (MPS I) - Agents***

ALDURAZYME MED Y N Y *Metabolic Modifiers** - *Mucopolysaccharidosis II (MPS II) -

Agents***

ELAPRASE MED Y N Y *Metabolic Modifiers** - *Mucopolysaccharidosis IV (MPS IV) -

Agents***

VIMIZIM MED Y N Y *Metabolic Modifiers** - *Mucopolysaccharidosis VI (MPS VI) -

Agents***

NAGLAZYME MED Y N Y

*Metabolic Modifiers** - *Phenylketonuria Treatment - Agents***

KUVAN P Y N Y

*Metabolic Modifiers** - *Urea Cycle Disorder - Agents***

AMMONUL SOLUTION INTRAVENOUS MED N N Y

BUPHENYL P Y N Y

RAVICTI NP Y N Y

sodium phenylbutyrate G N N Y

*Posterior Pituitary Hormones** - *Vasopressin***

DDAVP SOLUTION NP N N Y

DDAVP TABLET NP N N Y

desmopressin ace rhinal tube nasal G N N Y

desmopressin ace spray refrig solution nasal G N N Y

desmopressin acetate spray solution nasal G N N Y

desmopressin acetate tablet G N N Y

minirin solution nasal G N N Y

STIMATE SOLUTION NASAL NP Y N Y

*Prolactin Inhibitors** - *Dopamine Receptor Agonists***

cabergoline G N N Y

*Somatostatic Agents** - *Somatostatic Agents***

octreotide acetate injection MED Y N Y

SANDOSTATIN MED Y N Y

SANDOSTATIN LAR DEPOT MED Y N Y

SIGNIFOR MED Y N Y

71

SOMATULINE DEPOT MED Y N Y *Vasopressin Receptor Antagonists** - *Selective Vasopressin V2-


SAMSCA P Y N Y

*Fertility Regulators** -

BRAVELLE MED Y N Y

GONAL-F MED Y N Y

FOLLISTIM AQ MED Y N Y

chorionic gonadotropin MED Y N Y

NOVAREL MED Y N Y

OVIDREL MED Y N Y

PREGNYL MED Y N Y

MENOPUR MED Y N Y

REPRONEX MED Y N Y

*Growth Hormones Releasing Hormones (GHRH)***

EGRIFTA MED Y N Y

*GnRH/LHRH Antagonists**

CETROTIDE MED Y N Y

GANIRELIX ACETATE MED Y N Y

*Metabolic Modifiers** - *GAA Deficiency Treatment- Agents***

LUMIZYME MED Y N Y

MYOZYME MED Y N Y

*Metabolic Modifiers** - *Leptin Analogues***

MYALEPT NP Y N Y

*ESTROGENS*

*Estrogen Combinations** - *Estrogen & Androgen***

covaryx G N N Y

covaryx HS G N N Y

EEMT G N N Y

EEMT HS G N N Y

essian H.S. TABLET 0.625-1.25 MG ORAL G N N Y

essian TABLET 1.25-2.5 MG ORAL G N N Y

est estrogens-methyltest G N N Y

est estrogens-methyltest DS G N N Y

est estrogens-methyltest HS G N N Y

methyltest-est estrogens G N N Y

methyltest-est estrogens HS G N N Y

*Estrogen Combinations** - *Estrogen & Progestin***

ACTIVELLA NP N N Y

ANGELIQ NP N N Y

CLIMARA PRO NP N N Y

COMBIPATCH NP N N Y

72

estradiol-norethindrone acet G N N Y

FEMHRT LOW DOSE NP N N Y

mimvey G N N Y

PREFEST NP N N Y

PREMPHASE P N N Y

PREMPRO P N N Y *Estrogen Combinations** - *Estrogen-Selective Estrogen Receptor

Modulator Comb***

DUAVEE P N N Y

*Estrogens** - *Estrogens***

ALORA NP N N Y

CENESTIN NP N N Y

CLIMARA NP N N Y

DIVIGEL NP N N Y

ELESTRIN NP N N Y

ENJUVIA NP N N Y

ESTRACE TABLET NP N N Y

ESTRADERM NP N N Y

estradiol patch G N N Y

estradiol tablet G N N Y

ESTRAGEL NP N N Y

ESTRASORB NP N N Y

estropipate G N N Y

EVAMIST NP N N Y

MENEST NP N N Y

MENOSTAR NP N N Y

MINIVELLE NP N N Y

ortho-est G N N Y

PREMARIN TABLET P N N Y

VIVELLE-DOT P N N Y

*FLUOROQUINOLONES*

*Fluoroquinolones** - *Fluoroquinolones***

CIPRO ORAL NP N N Y

CIPRO XR NP N N Y

ciprofloxacin oral G N N Y

ciprofloxacin-ciproflox HCl ER G N N Y

FACTIVE NP N N Y

LEVAQUIN ORAL NP N N Y

levofloxacin oral G N N Y

NOROXIN NP N N Y

ofloxacin G N N Y

*GASTROINTESTINAL AGENTS - MISC.*

73

*Gallstone Solubilizing Agents** - *Gallstone Solubilizing Agents***

ACTIGALL NP N N Y

CHENODAL NP N N Y

URSO NP N N Y

URSO FORTE NP N N Y

ursodiol G N N Y *Gastrointestinal Antiallergy Agents** - *Gastrointestinal Antiallergy

Agents***

cromolyn sodium concentrate oral G N N Y

GASTROCROM CONCENTRATE ORAL NP N N Y *Gastrointestinal Chloride Channel Activators** - *Gastrointestinal

Chloride Channel Activators***

AMITIZA P N Y Y

*Gastrointestinal Stimulants** - *Gastrointestinal Stimulants***

metoclopramide G N N Y

METOZOLV ODT NP N N Y

REGLAN NP N N Y

*Inflammatory Bowel Agents** - *Inflammatory Bowel Agents***

APRISO P N N Y

ASACOL HD P N N Y

AZULFIDINE NP N Y Y

AZULFIDINE ENTAB NP N Y Y

balsalazide disodium CAPSULE G N N Y

CANASA P N N Y

COLAZAL NP N Y Y

DELZICOL P N N Y

DIPENTUM NP N Y Y

GIAZO NP N Y Y

LIALDA P N N Y

mesalamine enema G N N Y

PENTASA P N N Y

SF ROWASA ENEMA NP N N Y

sulfasalazine G N N Y

sulfasalazine delayed release G N N Y

sulfazine EC G N N Y

CIMZIA NP Y N Y

REMICADE NP Y N Y

ENTYVIO NP Y N Y

*Intestinal Acidifiers** - *Intestinal Acidifiers***

enulose G N N Y

generlac G N N Y

lactulose encephalopathy G N N Y

74

*Irritable Bowel Syndrome (IBS) Agents** - *IBS Agent - Guanylate

Cyclase-C (GC-C) Agonists***

LINZESS P N Y Y *Irritable Bowel Syndrome (IBS) Agents** - *IBS Agent - Selective 5-HT3


LOTRONEX NP Y N Y *Peripheral Opioid Receptor Antagonists** - *Peripheral Opioid


RELISTOR P Y N Y

RELISTOR KIT P Y N Y

*Phosphate Binder Agents** - *Phosphate Binder Agents***

calcium acetate (phos binder) G N N Y

calcium acetate oral capsule G N N Y

ELIPHOS NP N N Y

FORSRENOL P N N Y

PHOSLO NP N Y Y

PHOSLYRA P N N Y

RENAGEL NP N Y Y

RENVELA P N N Y

VELPHORO NP N N Y *Short Bowel Syndrome (SBS) Agents** - *Glucagon-Like Peptide-2

(GLP-2) Analogs***

GATTEX KIT MED Y N Y

*GENERAL ANESTHETICS*

*Volatile Anesthetics** - *Volatile Anesthetics***

FORANE MED N N Y

isoflurane MED N N Y

sevoflurane MED N N Y

sojourn MED N N Y

SUPRANE MED N N Y

terrell MED N N Y

ULTANE MED N N Y

*GENITOURINARY AGENTS - MISCELLANEOUS*

*Acidifiers** - *Phosphates***

K-PHOS No 2 NP N N Y

*Alkalinizers** - *Citrates***

citric acid-sodium citrate solution oral G N N Y

CITROLITH NP N N Y

cytra K crystals G N N Y

cytra-2 solution G N N Y

CYTRA-3 SYRUP NP N N Y

CYTRA-K SOLUTION NP N N Y

ORACIT NP N N Y

75

potassium citrate-citric acid packet G N N Y

POTASSIUM CITRATE-CITRIC ACID SOLUTION NP N N Y

taron-crystals packet G N N Y

UROCIT-K 10 NP N N Y

UROCIT-K 5 NP N N Y

*Cystinosis Agents** - *Cystinosis Agents***

CYSTAGON NP Y N Y

PROCYSBI NP Y Y Y

*Genitourinary Irrigants** - *Anti-infective Genitourinary Irrigants***

neomycin-polymyxin b gu irrigation G N N Y

NEOPORIN GU IRRIGATION MED N N Y

*Genitourinary Irrigants** - *Genitourinary Irrigants***

acetic acid irrigation MED N N Y

aminoacetic acid irrigation MED N N Y

argyle sterile saline irrigation MED N N Y

curity sterile saline irrigation MED N N Y

glycine irrigation MED N N Y

glycine urologic irrigation MED N N Y

RENACIDIN SOLUTION IRRIGATION MED N N Y

RESECTISOL SOLUTION IRRIGATION MED N N Y

sodium chloride solution irrigation MED N N Y

*Interstitial Cystitis Agents** - *Interstitial Cystitis Agents***

ELMIRON P N N Y

*Prostatic Hypertrophy Agents** - *5-Alpha Reductase Inhibitors***

AVODART P N N Y

finasteride G N N Y

PROSCAR NP N N Y *Prostatic Hypertrophy Agents** - *Alpha 1-Adrenoceptor

Antagonists***

alfuzosin G N N Y

CARDURA XL NP N N Y

FLOMAX NP N N Y

RAPAFLO P N N Y

tamsulosin G N N Y

UROXATRAL NP N N Y *Prostatic Hypertrophy Agents** - *Prostatic Hypertrophy Agent

Combinations***

JALYN P N N Y

*Urinary Analgesics** - *Urinary Analgesics***

phenazo G N N Y

phenazopyridine G N N Y

*Urinary Stone Agents** - *Urinary Stone Agents***

76

LITOSTAT NP N N Y

THIOLA NP N N Y *Prostatic Hypertrophy Agents** - *Selective cGMP Phosphodiesterase

Type 5 Inhibitor***

CIALIS 2.5MG, CIALIS 5MG (for BPH use) P Y N Y

*GOUT AGENTS*

*Gout Agent Combinations** - *Gout Agent Combinations***

colchicine-probenecid G N N Y

*Gout Agents** - *Gout Agents***

allopurinol G N N Y

COLCRYS P N N Y

KRYSTEXXA NP Y N Y

ULORIC NP N Y Y

ZYLOPRIM NP N N Y

MITIGARE NP N Y Y

*Uricosurics** - *Uricosurics***

probenecid G N N Y

*HEMATOLOGICAL AGENTS - MISC.*

*Antihemophilic Products** - *Antihemophilic Products***

ADVATE MED Y N Y

ALPHANATE/VWF MED Y N Y

ALPHANINE SD MED Y N Y

BEBULIN MED Y N Y

BEBULIN VH MED Y N Y

BENEFIX MED Y N Y

CORIFACT MED Y N Y

FEIBA NF MED Y N Y

FEIBA VH MED Y N Y

HELIXATE FS MED Y N Y

HEMOFIL M MED Y N Y

HUMATE-P MED Y N Y

KCENTRA MED Y N Y

KOATE-DVI MED Y N Y

KOGENATE FS MED Y N Y

KOGENATE FS BIO-SET MED Y N Y

MONOCLATE-P MED Y N Y

MONONINE MED Y N Y

NOVOSEVEN RT MED Y N Y

PROFILNINE SD MED Y N Y

RECOMBINATE MED Y N Y

RIASTAP MED Y N Y

RIXUBIS MED Y N Y

77

TRETTEN MED Y N Y

WILATE MED Y N Y

XYNTHA MED Y N Y

XYNTHA SOLOFUSE KIT MED Y N Y

ALPROLIX MED Y N Y

ELOCTATE MED Y N Y *Bradykinin B2 Receptor Antagonists** - *Bradykinin B2 Receptor

Antagonists***

FIRAZYR MED Y N Y

*Complement Inhibitors** - *C1 Inhibitors***

BERINERT MED Y N Y

CINRYZE MED Y N Y

RUCONEST MED Y N Y

*Complement Inhibitors** - *Complement Inhibitors***

SOLIRIS MED Y N Y

*Hematorheologic Agents** - *Hematorheologic Agents***

pentopak G N N Y

pentoxifylline G N N Y

*Plasma Kallikrein Inhibitors** - *Plasma Kallikrein Inhibitors***

KALBITOR MED Y N Y *Platelet Aggregation Inhibitors** - *Cyclopentyltriazolopyrimidine

(CPTP) Derivatives***

BRILINTA NP N N Y *Platelet Aggregation Inhibitors** - *Phosphodiesterase III

Inhibitors***

cilostazol G N N Y

PLETAL NP N N Y *Platelet Aggregation Inhibitors** - *Platelet Aggregation Inhibitor

Combinations***

AGGRENOX P N N Y

*Platelet Aggregation Inhibitors** - *Platelet Aggregation Inhibitors***

dipyridamole G N N Y

PERSANTIN NP N N Y

*Platelet Aggregation Inhibitors** - *Quinazoline Agents***

AGRYLIN NP N N Y

anagrelide G N N Y

*Platelet Aggregation Inhibitors** - *Thienopyridine Derivatives***

clopidogrel G N N Y

EFFIENT P N N Y

PLAVIX NP N N Y

ticlopidine G N N Y

*Thrombolytic Enzymes**

ACTIVASE MED Y N Y

78

*Human Protein C***

CEPROTIN MED Y N Y

*HEMATOPOIETIC AGENTS*

*Agents for Gaucher Disease** - *Agents for Gaucher Disease***

CEREZYME MED Y N Y

ELELYSO MED Y N Y

VPRIV MED Y N Y

ZAVESCA NP Y N Y

*Agents for Sickle Cell Anemia** - *Cytotoxic Agents***

DROXIA NP N N Y

*Hematopoietic Growth Factors** - *Erythropoietins***

ARANESP (ALBUMIN FREE) MED Y N Y

OMONTYS MED Y N Y

PROCRIT MED Y N Y

EPOGEN MED Y N Y *Hematopoietic Growth Factors** - *Granulocyte Colony-Stimulating

Factors (G-CSF)***

GRANIX MED Y N Y

NEULASTA MED Y N Y

NEUPOGEN MED Y N Y *Hematopoietic Growth Factors** - *Granulocyte/Macrophage Colony-

Stimulating Factor(GM-CSF)***

LEUKINE MED Y N Y

*Hematopoietic Growth Factors** - *Interleukins***

NEUMEGA MED Y N Y *Hematopoietic Growth Factors** - *Thrombopoietin (TPO) Receptor

Agonists***

NPLATE MED Y N Y

PROMACTA NP Y N Y

*Stem Cell Mobilizers***

MOZOBIL MED Y N Y

*HEMOSTATICS*

*Hemostatics - Systemic** - *Hemostatics - Systemic***

AMICAR NP N N Y

aminocaproic acid G N N Y

LYSTEDA NP N N Y

tranexamic acid G N N Y

*HYPNOTICS*

*Barbiturate Hypnotics** - *Barbiturate Hypnotics***

BUTISOL NP N N Y

phenobarbital soution, tablet G N N Y

SECONAL NP N N Y

79

*Hypnotics - Tricyclic Agents** - *Hypnotics - Tricyclic Agents***

SILENOR NP N Y Y

*Non-Barbiturate Hypnotics** - *Benzodiazepine Hypnotics***

DORAL NP N N Y

estazolam G N N Y

flurazepam G N N Y

HALCION NP N N Y

midazolam syrup G N N Y

RESTORIL NP N N Y

temazepam G N N Y

triazolam G N N Y *Non-Barbiturate Hypnotics** - *Non-Benzodiazepine - GABA-Receptor

Modulators***

AMBIEN NP N N Y

AMBIEN CR NP N N Y

EDLUAR NP N Y Y

eszopiclone G N N Y

INTERMEZZO NP N Y Y

LUNESTA NP N Y Y

SONATA NP N Y Y

zaleplon G N N Y

zolpidem G N N Y

zolpidem ER G N N Y

ZOLPIMIST NP N Y Y *Selective Melatonin Receptor Agonists** - *Selective Melatonin

Receptor Agonists***

HETLIOZ NP Y N Y

ROZEREM NP N Y Y

*LAXATIVES*

*Laxative Combinations** - *Bowel Evacuant Combinations***

COLYTE WITH FLAVOR PACKS NP N N Y

gaviLyte-C G N N Y

gaviLyte-G G N N Y

gaviLyte-N with flavor pack G N N Y

GOLYTELY NP N N Y

MOVIPREP P N N Y

NULYTELY WITH FLAVOR PACKS NP N N Y

peg 3350/electrolytes G N N Y

peg3350-kcl-na bicarb-nacl G N N Y

PREPOPIK PACKET NP N N Y

SUCLEAR KIT NP N N Y

SUPREP BOWEL PREP NP N N Y

80

triLyte G N N Y

*Laxatives - Miscellaneous** - *Laxatives - Miscellaneous***

constulose G N N Y

KRISTALOSE NP N N Y

lactulose G N N Y

*Saline Laxatives** - *Saline Laxative Mixtures***

OSMOPREP NP N N Y

*MACROLIDES*

*Azithromycin** - *Azithromycin***

azithromycin G N N Y

ZITHROMAX NP N N Y

ZMAX NP N N Y

*Clarithromycin** - *Clarithromycin***

BIAXIN NP N N Y

BIAXIN XL NP N N Y

BIAXIN XL PAC NP N N Y

clarithromycin G N N Y

clarithromycin ER G N N Y

*Erythromycins** - *Erythromycins***

E.E.S. 400 TABLET NP N N Y

E.E.S. GRANULES NP N N Y

ERYPED 200 NP N N Y

ERYPED 400 NP N N Y

ERY-TAB NP N N Y

ERYTHROCIN STEARATE NP N N Y

erythromycin base G N N Y

PCE NP N N Y

*Fidaxomicin** - *Fidaxomicin***

DIFICID NP N N Y

*MEDICAL DEVICES*

*Contraceptives** - *Cervical Caps***

FemCap DEVICE 22 MM VAGINAL NP N N Y



Prentif Cavity-Rim Cerv Cap DEVICE 22 MM VAGINAL NP N N Y




Prentif Fitting Set VAGINAL NP N N Y

*Contraceptives** - *Diaphragms***

Omniflex Diaphragm DIAPHRAGM VAGINAL NP N N Y

81

Ortho Diaphragm Coil KIT 100 MM VAGINAL NP N N Y



Ortho Diaphragm Flat KIT 55 MM VAGINAL NP N N Y









Wide-Seal Diaphragm 60 DIAPHRAGM 2 % VAGINAL NP N N Y








*Diabetic Supplies** - *Glucose Monitoring Test Supplies***

BD LANCETS P N N Y

BRAND LANCETS (any other brand name) NP N N Y

lancets (any generic) G N N Y

*Parenteral Therapy Supplies** - *Needles & Syringes***

insulin syringes (any generic) G N N Y

pen needles (any generic) G N N Y

BD PEN NEEDLES P N N Y

BD INSULIN SYRINGES P N N Y

BRAND PEN NEEDLES (any other brand name) NP N N Y

BRAND INSULIN SYRINGES (any other brand name) NP N N Y

*MIGRAINE PRODUCTS*

*Migraine Combinations** - *Ergot Combinations***

CAFERGOT NP N N Y

MIGERGOT NP N N Y

*Migraine Combinations** - *Migraine Combinations***

epidrin G N N Y

isometheptene-APAP-dichloral G N N Y

migragesic IDA G N N Y

MIGRALAM NP N N Y

nodolor G N N Y

82

PRODRIN NP N N Y *Migraine Combinations** - *Selective Serotonin Agonist-NSAID

Combinations***

TREXIMET NP N Y Y

*Migraine Products - NSAIDs** - *Migraine Products - NSAIDs***

CAMBIA NP N N Y

*Migraine Products** - *Migraine Products***

D.H.E. 45 SOLUTION NP N N Y

dihydroergotamine mesylate solution G N N Y

ERGOMAR NP N N Y

MIGRAL NP N N Y

MIGRANAL NP N N Y

*Serotonin Agonists** - *Selective Serotonin Agonists 5-HT(1)***

ALSUMA NP N Y Y

AMERGE NP N N Y

AXERT NP N Y Y

FROVA NP N Y Y

IMITREX NP N N Y

MAXALT NP N N Y

MAXALT-MLT NP N N Y

naratriptan G N N Y

RELPAX NP N Y Y

rizatriptan G N N Y

rizatriptan MLT G N N Y

sumatriptan G N N Y

SUMAVEL NP N Y Y

zolmitriptan G N N Y

zolmitriptan ZMT G N N Y

ZOMIG NP N N Y

ZOMIG NASAL SPRAY NP N Y Y

ZOMIG ZMT NP N N Y

*MINERALS & ELECTROLYTES*

*Iodine Products** - *Iodine Products***

SSKI SOLUTION NP N N Y

*Phosphate** - *Phosphate***

K-PHOS NP N N Y

phospha 250 neutral G N N Y

*Potassium** - *Potassium Combinations***

EFFER-K NP N N Y

effervescent pot chloride G N N Y

pot bicarb-pot chloride G N N Y

*Potassium** - *Potassium***

83

EFFER-K G N N Y

epiklor G N N Y

kaon-Cl-10 G N N Y

K-effervescent G N N Y

klor-con M10 G N N Y

KLOR-CON M15 NP N N Y

klor-con M20 G N N Y

klor-con packet 20meq G N N Y

KLOR-CON PACKET 25 MEQ ORAL NP N N Y

klor-con tablet extended release G N N Y

klor-con/EF G N N Y

k-prime G N N Y

k-vescent G N N Y

MICRO-K NP N N Y

potassium bicarbonate oral G N N Y

potassium chloride crys ER G N N Y

potassium chloride liquid 20 MEQ/15ML G N N Y

potassium chloride packet G N N Y

potassium chloride solution 20 MEQ/15ML G N N Y

*MOUTH/THROAT/DENTAL AGENTS*

*Anesthetics Topical Oral** - *Anesthetics Topical Oral***

lidocaine hcl mouth/throat G N N Y

lidocaine viscous G N N Y

LTA 360 kit NP N N Y

*Anti-infectives - Throat** - *Anti-infectives - Throat***

clotrimazole lozenge mouth/throat G N N Y

nystatin suspension mouth/throat G N N Y

ORAVIG NP N N Y

*Antiseptics - Mouth/Throat** - *Antiseptics - Mouth/Throat***

chlorhexidine gluconate solution mouth/throat G N N Y

PERIDEX MOUTH/THROAT NP N N Y

periogard mouth/throat G N N Y

*Steroids - Mouth/Throat** - *Steroids - Mouth/Throat***

oralone paste dental G N N Y

triamcinolone acetonide paste dental G N N Y

*Throat Products - Misc.** - *Saliva Stimulants***

cevimeline G N N Y

EVOXAC NP N N Y

pilocarpine oral G N N Y

SALAGEN NP N N Y

*MUSCULOSKELETAL THERAPY AGENTS*

84

*Central Muscle Relaxants** - *Central Muscle Relaxants***

AMRIX NP N Y Y

baclofen oral G N N Y

carisoprodol oral G N N Y

chlorzoxazone oral G N N Y

cyclobenzaprine oral G N N Y

ed baclofen G N N Y

FEXMID NP N Y Y

LORZONE NP N N Y

metaxalone oral G N N Y

methocarbamol oral G N N Y

orphenadrine ER oral G N N Y

PARAFON FORTE DSC NP N N Y

ROBAXIN NP N N Y

SKELAXIN NP N N Y

SOMA NP N N Y

tizanidine oral G N N Y

ZANAFLEX NP N N Y

*Direct Muscle Relaxants** - *Direct Muscle Relaxants***

DANTRIUM NP N N Y

dantrolene oral G N N Y

*Muscle Relaxant Combinations** - *Muscle Relaxant Combinations***

carisoprodol-aspirin oral G N N Y

carisoprodol-aspirin-codeine oral G N N Y

orphenadrine-aspirin-caffeine oral G N N Y

*Viscosupplements** - *Viscosupplements***

GEL-ONE MED Y N Y

ORTHOVISC MED Y N Y

SUPARTZ MED Y N Y

SYNVISC ONE MED Y N Y

EUFLEXXA MED Y N Y

HYALGAN MED Y N Y

MONOVISC MED Y N Y

*NASAL AGENTS - SYSTEMIC AND TOPICAL*

*Nasal Agent Combinations** - *Antihistamine-Steroid***

DYMISTA NP N N Y

*Nasal Antiallergy** - *Nasal Antihistamines***

ASTEPRO NP N N Y

azelastine nasal G N N Y

PATANASE NASAL NP N N Y

olopatadine nasal G N N Y

85

*Nasal Anticholinergics** - *Nasal Anticholinergics***

ATROVENT NASAL NP N N Y

ipratropium bromide nasal G N N Y

*Nasal Anti-infectives** - *Nasal Antibiotics***

BACTROBAN OINTMENT NASAL NP N N Y

*Nasal Steroids** - *Nasal Steroids***

BECONASE AQ NASAL NP N Y Y

budesonide suspension nasal G N N Y

FLONASE NASAL NP N Y Y

flunisolide solution nasal G N N Y

fluticasone propionate suspension nasal G N N Y

NASACORT AQ SUSPENSION NASAL NP N Y Y

NASONEX SUSPENSION NASAL P N N Y

OMNARIS SUSPENSION NASAL NP N N Y

QNASL SOLUTION NASAL NP N N Y

RHINOCORT AQUA SUSPENSION NASAL NP N Y Y

triamcinolone acetonide nasal G N N Y

VERAMYST SUSPENSION NASAL P N N Y

ZETONNA SOLUTION NASAL NP N Y Y

*Sympathomimetic Decongestants** - *Topical Decongestants***

ADRENALIN SOLUTION NASAL NP N N Y

TYZINE SOLUTION NASAL NP N N Y

*NEUROMUSCULAR AGENTS*

*ALS Agents** - *Benzathiazoles***

RILUTEK NP N N Y

riluzole G N N Y *Neuromuscular Blocking Agent - Neurotoxins** - *Neuromuscular

Blocking Agent - Neurotoxins***

BOTOX SOLUTION INJECTION MED Y N Y

DYSPORT SOLUTION INTRAMUSCULAR MED Y N Y

XEOMIN SOLUTION INTRAMUSCULAR MED Y N Y

MYOBLOC MED Y N Y

*OPHTHALMIC AGENTS*

*Beta-blockers - Ophthalmic** - *Beta-blockers - Ophthalmic

Combinations***

COMBIGAN OPHTHALMIC P N N Y

COSOPT OPHTHALMIC NP N N Y

COSOPT PF OPHTHALMIC NP N N Y

dorzolamide HCl-timolol mal ophthalmic G N N Y

*Beta-blockers - Ophthalmic** - *Beta-blockers - Ophthalmic***

BETAGAN OPHTHALMIC NP N N Y

betaxolol ophthalmic G N N Y

86

BETIMOL OPHTHALMIC NP N N Y

BETOPTIC-S OPHTHALMIC NP N N Y

carteolol HCl ophthalmic G N N Y

ISTALOL OPHTHALMIC NP N N Y

levobunolol HCl ophthalmic G N N Y

METIPRANOLOL OPHTHALMIC NP N N Y

OPTIPRANOLOL OPHTHALMIC NP N N Y

timolol maleate gel forming solution ophthalmic G N N Y

timolol maleate ophthalmic G N N Y

TIMOPTIC OCUDOSE PHTHALMIC NP N N Y

TIMOPTIC OPHTHALMIC NP N N Y

TIMOPTIC-XE GEL FORMING OPHTHALMIC NP N N Y

*Cycloplegic Mydriatics** - *Cycloplegic Mydriatic Combinations***

CYCLOMYDRIL OPHTHALMIC NP N N Y

*Cycloplegic Mydriatics** - *Cycloplegic Mydriatics***

AK-pentolate ophthalmic G N N Y

atropine sulfate ophthalmic G N N Y

atropine-care ophthalmic G N N Y

CYCLOGYL OPHTHALMIC NP N N Y

cyclopentolate ophthalmic G N N Y

cylate ophthalmic G N N Y

homatropaire ophthalmic G N N Y

homatropine ophthalmic G N N Y

ISOPTO HOMATROPINE OPHTHALMIC NP N N Y

ISOPTO HYOSINE OPHTHALMIC NP N N Y

mydral ophthalmic G N N Y

MYDRIACYL OPHTHALMIC NP N N Y

tropicamide ophthalmic G N N Y

*Miotics** - *Miotics - Cholinesterase Inhibitors***

PHOSPHOLINE IODIDE OPHTHALMIC NP N N Y

*Miotics** - *Miotics - Direct Acting***

ISOPTO CARBACHOL OPHTHALMIC NP N N Y

pilocarpine ophthalmic G N N Y

PILOPINE OPHTHALMIC NP N N Y *Ophthalmic - Angiogenesis Inhibitors** - *Vascular Endothelial Growth

Factor (VEGF) Antagonists***

EYLEA INTRAOCULAR P Y N Y

LUCENTIS INTRAOCULAR P Y N Y

MACUGEN INTRAOCULAR NP Y N Y *Ophthalmic Adrenergic Agents** - *Alpha Adrenergic Agonist &

Carbonic Anhydrase Inhib Comb***

SIMBRINZA OPHTHALMIC NP N N Y

87

*Ophthalmic Adrenergic Agents** - *Ophthalmic Selective Alpha

Adrenergic Agonists***

ALPHAGAN P OPHTHALMIC P N N Y

apraclonidine ophthalmic G N N Y

brimonidine ophthalmic G N N Y

IOPIDINE OPHTHALMIC NP N N Y

*Ophthalmic Anti-infectives** - *Ophthalmic Antibiotics***

AZASITE OPHTHALMIC P N N Y

BESIVANCE OPHTHALMIC NP N N Y

CILOXIN OPHTHALMIC NP N N Y

ciprofloxacin ophthalmic G N N Y

erythromycin ophthalmic G N N Y

garamycin ointment ophthalmic G N N Y

GARAMYCIN SOLUTION OPHTHALMIC NP N N Y

gatifloxacin ophthalmic G N N Y

gentak ophthalmic G N N Y

gentamicin ophthalmic G N N Y

gentasol ophthalmic G N N Y

ilotycin ophthalmic G N N Y

levofloxacin ophthalmic G N N Y

MITOSOL KIT OPHTHALMIC NP N N Y

MOXEZA OPHTHALMIC NP N N Y

OCUFLOX OPHTHALMIC NP N N Y

ofloxacin ophthalmic G N N Y

romycin ophthalmic G N N Y

tobramycin ophthalmic G N N Y

tobrasol ophthalmic G N N Y

TOBREX OPHTHALMIC NP N N Y

VIGAMOX OPHTHALMIC NP N N Y

ZYMAXID OPHTHALMIC NP N N Y

*Ophthalmic Anti-infectives** - *Ophthalmic Antifungal***

NATACYN OPHTHALMIC NP N N Y *Ophthalmic Anti-infectives** - *Ophthalmic Anti-infective

Combinations***

ak-poly-bac ophthalmic G N N Y

bacitracin-polymyxin B ophthalmic G N N Y

neomycin-bacitracin zn-polymyx ophthalmic G N N Y

neomycin-polymyxin-gramicidin ophthalmic G N N Y

neo-polycin ophthalmic G N N Y

NEOSPORIN NP N N Y

polycin b ophthalmic G N N Y

polycin ophthalmic G N N Y

88

polymyxin B-trimethoprim ophthalmic G N N Y

POLYTRIM NP N N Y

triple antibiotic ophthalmic G N N Y

*Ophthalmic Anti-infectives** - *Ophthalmic Antiseptics***

BETADINE OPHTHALMIC PREP SOLUTION NP N N Y

*Ophthalmic Anti-infectives** - *Ophthalmic Antivirals***

trifluridine ophthalmic G N N Y

VIROPTIC OPHTHALMIC NP N N Y

ZIRGAN OPHTHALMIC NP N N Y

*Ophthalmic Anti-infectives** - *Ophthalmic Sulfonamides***

sulfacetamide sodium ophthalmic G N N Y *Ophthalmic Immunomodulators** - *Ophthalmic

Immunomodulators***

RESTASIS OPHTHALMIC P N N Y

*Ophthalmic Local Anesthetics** - *Ophthalmic Local Anesthetics***

AKTEN OPHTHALMIC NP N N Y

ALCAINE OPHTHALMIC NP N N Y

altacaine ophthalmic G N N Y

parcaine ophthalmic G N N Y

proparacaine ophthalmic G N N Y

tetcaine ophthalmic G N N Y

tetravisc forte ophthalmic G N N Y

tetravisc ophthalmic G N N Y *Ophthalmic Photodynamic Therapy Agents** - *Ophthalmic

Photodynamic Therapy Agents***

VISUDYNE NP Y N Y

*Ophthalmic Steroids** - *Ophthalmic Steroid Combinations***

bacitra-neomycin-polymyxin-hc ophthalmic G N N Y

BLEPHAMIDE OPHTHALMIC NP N N Y

BLEPHAMIDE S.O.P. OPHTHALMIC NP N N Y

MAXITROL OPHTHALMIC NP N N Y

neomycin-polymyxin-dexameth ophthalmic G N N Y

neo-polycin HC ophthalmic G N N Y

poly-dex ophthalmic G N N Y

PRED-G OPHTHALMIC NP N N Y

PRED-G S.O.P. OPHTHALMIC NP N N Y

sulfacetamide-prednisolone ophthalmic G N N Y

TOBRADEX OPHTHALMIC NP N N Y

TOBRADEX ST NP N N Y

tobramycin-dexamethasone ophthalmic G N N Y

ZYLET OPHTHALMIC NP N N Y

*Ophthalmic Steroids** - *Ophthalmic Steroids***

89

ALREX OPHTHALMIC P N N Y

dexamethasone ophthalmic G N N Y

DUREZOL OPHTHALMIC NP N N Y

FLAREX OPHTHALMIC NP N N Y

fluorometholone ophthalmic G N N Y

fluor-op ophthalmic G N N Y

FML FORTE OPHTHALMIC NP N N Y

FML LIQUIFILM OPHTHALMIC NP N N Y

FML OINTMENT OPHTHALMIC NP N N Y

LOTEMAX OPHTHALMIC P N N Y

MAXIDEX OPHTHALMIC NP N N Y

OMNIPRED OPHTHALMIC NP N N Y

OZUDEX IMPLANT INTRAOCULAR MED N N Y

PRED FORTE OPHTHALMIC NP N N Y

PRED MILD OPHTHALMIC NP N N Y

prednisolone ophthalmic G N N Y

VEXOL OPHTHALMIC NP N N Y

*Ophthalmic Surgical Aids** - *Ophthalmic Surgical Aids***

GELFILM OPHTHALMIC NP N N Y

*Ophthalmics - Misc.** - *Ophthalmic Antiallergic***

ALOCRIL OPHTHALMIC NP N N Y

ALOMIDE OPHTHALMIC NP N N Y

azelastine ophthalmic G N N Y

BEPREVE OPHTHALMIC NP N N Y

cromolyn sodium ophthalmic G N N Y

ELESTAT OPHTHALMIC NP N N Y

EMADINE OPHTHALMIC NP N N Y

epinastine ophthalmic G N N Y

LASTACAFT OPHTHALMIC NP N N Y

OPTIVAR OPHTHALMIC NP N N Y

PATADAY OPHTHALMIC P N N Y

PATANOL OPHTHALMIC NP N Y Y *Ophthalmics - Misc.** - *Ophthalmic Carbonic Anhydrase

Inhibitors***

AZOPT OPHTHALMIC P N N Y

dorzolamide ophthalmic G N N Y

TRUSOPT OPHTHALMIC NP N N Y

*Ophthalmics - Misc.** - *Ophthalmic Enzymes***

JETREA SOLUTION INTRAOCULAR MED N N Y *Ophthalmics - Misc.** - *Ophthalmic Nonsteroidal Anti-inflammatory

Agents***

ACULAR LS OPHTHALMIC NP N N Y

90

ACUVAIL OPHTHALMIC NP N N Y

diclofenac ophthalmic G N N Y

flurbiprofen ophthalmic G N N Y

ILVERO OPHTHALMIC NP N N Y

ketorolac ophthalmic G N N Y

NEVANAC OPHTHALMIC NP N N Y

OCUFEN OPHTHALMIC NP N N Y

PROLENSA OPHTHALMIC NP N N Y

*Ophthalmics - Misc.** - *Ophthalmics - Cystinosis Agents**

CYSTARAN OPHTHALMIC NP Y N Y

*Prostaglandins - Ophthalmic** - *Prostaglandins - Ophthalmic***

latanoprost ophthalmic G N N Y

LUMIGAN OPHTHALMIC P N N Y

RESCULA OPHTHALMIC NP N Y Y

TRAVATAN Z OPHTHALMIC P N N Y

travoprost ophthalmic G N N Y

XALATAN OPHTHALMIC NP N Y Y

ZIOPTAN OPTHALMIC NP N Y Y

*OTIC AGENTS*

*Otic Agents - Miscellaneous** - *Otic Agents - Miscellaneous***

acetic acid otic G N N Y

CRESYLATE OTIC NP N N Y

*Otic Analgesics** - *Otic Analgesics***

PINNACAINE OTIC NP N N Y

RE BENZOTIC OTIC NP N N Y

*Otic Anti-infectives** - *Otic Anti-infectives***

CETRAXAL OTIC NP N N Y

ofloxacin otic G N N Y

*Otic Combinations** - *Otic Analgesic Combinations***

a/b otic G N N Y

aero otic HC G N N Y

antipyrine-benzocaine otic G N N Y

AURALGAN OTIC NP N N Y

aurax otic G N N Y

aurodex otic G N N Y

auroguard otic G N N Y

auroto otic G N N Y

CORTANE-B OTIC NP N N Y

cortic-nd otic G N N Y

cyotic otic G N N Y

exotic-hc otic G N N Y

91

MYOXIN OTIC NP N N Y

otic care otic G N N Y

OTIC EDGE OTIC NP N N Y

OTICIN HC NR OTIC NP N N Y

oticin OTIC G N N Y

otirx otic G N N Y

oto-end 10 otic G N N Y

otomar otic G N N Y

otomax-hc solution G N N Y

OTOZIN OTIC NP N N Y

pramoxine-chloroxylenol otic G N N Y

pramoxine-hc-chloroxylenol aq otic G N N Y

RE pramoxine-hc otic G N N Y

zotane hc otic G N N Y

*Otic Combinations** - *Otic Steroid-Anti-infective Combinations***

antibiotic ear solution G N N Y

CIPRO HC OTIC NP N N Y

CIPRODEX OTIC P N N Y

COLY-MYCIN S OTIC NP N N Y

CORTISPORIN OTIC NP N N Y

CORTISPORIN-TC OTIC NP N N Y

cortomycin otic G N N Y

neomycin-polymyxin-hc otic G N N Y

*Otic Steroids** - *Otic Steroids***

acetasol hc otic G N N Y

DERMOTIC OIL OTIC NP N N Y

fluocinolone acetonide oil otic G N N Y

hydrocortisone-acetic otic G N N Y

VOSOL HC OTIC NP N N Y

*OXYTOCICS*

*Oxytocics** - *Oxytocics***

methylergonovine maleate G N N Y

*PASSIVE IMMUNIZING AGENTS*

*Immune Serums** - *Immune Serums***

CARIMUNE NF SOLUTION RECONSTITUTED INTRAVENOUS MED Y N Y

CYTOGAM INJECTABLE INTRAVENOUS MED Y N Y

FLEBOGAMMA DIF SOLUTION INTRAVENOUS MED Y N Y

FLEBOGAMMA SOLUTION INTRAVENOUS MED Y N Y

GAMASTAN S/D INJECTABLE INTRAMUSCULAR MED Y N Y

GAMMAGARD INJECTION MED Y N Y

GAMMAGARD S/D SOLUTION INTRAVENOUS MED Y N Y

92

GAMMAKED SOLUTION MED Y N Y

GAMMAPLEX SOLUTION INTRAVENOUS MED Y N Y

GAMUNEX SOLUTION INTRAVENOUS MED Y N Y

HEPAGAM B SOLUTION INJECTION MED N N Y

HIZENTRA SOLUTION SUBCUTANEOUS MED Y N Y

HYPERHEP B S/D SOLUTION INTRAMUSCULAR MED Y N Y

HYPERRHO S/D INJECTABLE INTRAMUSCULAR MED Y N Y

HYPERTET S/D INJECTABLE INTRAMUSCULAR MED N N Y

MICRHOGAM ULTRA-FILTERED PLUS INJECTABLE INTRAMUSCULAR MED N N Y

NABI-HB SOLUTION INTRAMUSCULAR MED N N Y

OCTAGAM SOLUTION INTRAVENOUS MED Y N Y

PRIVIGEN SOLUTION INTRAVENOUS MED Y N Y

RHOGAM ULTRA-FILTERED PLUS INJECTABLE INTRAMUSCULAR MED N N Y

RHOPHYLAC SOLUTION INJECTION MED N N Y

VARIZIG SOLUTION RECONSTITUTED INJECTION MED N N Y

WINRHO SDF SOLUTION INJECTION MED Y N Y

HYQVIA INJECTABLE MED N N Y

BIVIGAM MED Y N Y

*Monoclonal Antibodies** - *Antiviral Monoclonal Antibodies***

SYNAGIS SOLUTION INTRAMUSCULAR MED Y N Y

*PENICILLINS*

*Aminopenicillins** - *Aminopenicillins***

amoxicillin G N N Y

ampicillin G N N Y

MOXATAG NP N N Y

*Natural Penicillins** - *Natural Penicillins***

penicillin v potassium G N N Y

*Penicillin Combinations** - *Penicillin Combinations***

amoxicillin-pot clavulanate G N N Y

amoxicillin-pot clavulanate ER G N N Y

AUGMENTIN NP N N Y

AUGMENTIN ES NP N N Y

AUGMENTIN XR NP N N Y *Penicillinase-Resistant Penicillins** - *Penicillinase-Resistant

Penicillins***

dicloxacillin sodium G N N Y

*PROGESTINS*

*Progestins** - *Progestins***

AYGESTIN NP N N Y

MAKENA OIL INTRAMUSCULAR MED Y N Y

medroxyprogesterone acetate G N N Y

MEGACE ES NP N N Y

93

norethindrone acetate TABLET 5 MG ORAL G N N Y

progesterone micronized capsule oral G N N Y

progesterone oil intramuscular MED N N Y

PROMETRIUM ORAL NP N N Y

PROVERA NP N N Y

*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*

*Agents for Chemical Dependency** - *Alcohol Deterrents***

acamprosate calcium G N N Y

ANTABUSE NP N N Y

CAMPRAL NP N N Y

disulfiram G N N Y

*Anti-Cataplectic Agents** - *Anti-Cataplectic Agents***

XYREM NP Y N Y

*Antidementia Agents** - *Cholinomimetics - ACHE Inhibitors***

ARICEPT NP N N Y

ARICEPT ODT NP N N Y

donepezil G N N Y

donepezil odt G N N Y

EXELON ORAL NP N N Y

EXELON PATCH P N N Y

galantamine G N N Y

galantamine er G N N Y

RAZADYNE NP N N Y

RAZADYNE ER NP N N Y

rivastigmine G N N Y *Antidementia Agents** - *N-Methyl-D-Aspartate (NMDA) Receptor

Antagonists***

NAMENDA P N N Y

NAMENDA TITRATION PACK P N N Y

NAMENDA XR P N N Y

NAMENDA XR TITRATION PACK P N N Y *Combination Psychotherapeutics** - *Thienbenzodiazepines &

SSRIs***

olanzapine-fluoxetine G N N Y

SYMBAX NP N N Y

*Fibromyalgia Agents** - *Fibromyalgia Agent - SNRIs***

SAVELLA P N N Y

SAVELLA TITRATION PACK P N N Y *Movement Disorder Drug Therapy** - *Movement Disorder Drug

Therapy***

XENAZINE P Y N Y *Multiple Sclerosis Agents** - *MS Agents - Pyrimidine Synthesis

Inhibitors***

94

AUBAGIO NP Y N Y *Multiple Sclerosis Agents** - *Multiple Sclerosis Agents -

Interferons***

AVONEX MED Y N Y

BETASERON MED Y N Y

EXTAVIA MED Y N Y

REBIF MED Y N Y

REBIF REBIDOSE MED Y N Y

REBIF TITRATION PACK MED Y N Y

PLEGRIDY MED Y Y Y *Multiple Sclerosis Agents** - *Multiple Sclerosis Agents - Monoclonal

Antibodies***

TYSABRI MED Y N Y *Multiple Sclerosis Agents** - *Multiple Sclerosis Agents - Nrf2 Pathway

Activators***

TECFIDERA MED Y Y Y

TECFIDERA 120 & 240 MG MED Y Y Y *Multiple Sclerosis Agents** - *Multiple Sclerosis Agents - Potassium

Channel Blockers***

AMPYRA NP Y N Y

*Multiple Sclerosis Agents** - *Multiple Sclerosis Agents***

COPAXONE MED Y N Y

COPAXONE KIT MED Y N Y *Multiple Sclerosis Agents** - *Sphingosine 1-Phosphate (S1P) Receptor

Modulators***

GILENYA NP Y N Y *Postherpetic Neuralgia (PHN) Agents** - *Postherpetic Neuralgia

(PHN) Agents***

GRALISE NP N Y Y

GRALISE STARTER PACK NP N Y Y *Premenstrual Dysphoric Disorder (PMDD) Agents** - *Premenstrual

Dysphoric Disorder (PMDD) Agents - SSRIs***

fluoxetine (PMDD) G N N Y

SARAFEM G N N Y *Pseudobulbar Affect (PBA) Agents** - *Pseudobulbar Affect Agent

Combinations***

NUEDEXTA NP N N Y *Psychotherapeutic and Neurological Agents - Misc.** -

*Psychotherapeutic and Neurological Agents - Misc.***

ORAP NP N N Y *Restless Leg Syndrome (RLS) Agents** - *Restless Leg Syndrome (RLS)

Agents***

HORIZANT NP N Y Y

*Smoking Deterrents** - *Smoking Deterrents***

bupropion ER (Smoking Det) EXTENDED RELEASE 12 HR G N N Y

95

CHANTIX NP N N Y

NICORETTE GUM NP N N Y

NICORETTE LOZENGE NP N N Y

NICORETTE STARTER KIT NP N N Y

NICOTROL INHALER NP N N Y

NICOTROL NASAL SPRAY NP N N Y

ZYBAN EXTENDED RELEASE 12 HR NP N N Y *Vasomotor Symptom Agents** - *Vasomotor Symptom Agents -

SSRIs***

BRISDELLE NP N N Y

*RESPIRATORY AGENTS - MISC.*

*Alpha-Proteinase Inhibitor (Human)** - *Alpha-Proteinase Inhibitor

(Human)***

ARALAST NP SOLUTION INTRAVENOUS MED Y N Y

GLASSIA SOLUTION INTRAVENOUS MED Y N Y

PROLASTIN SOLUTION INTRAVENOUS MED Y N Y

PROLASTIN-C SOLUTION INTRAVENOUS MED Y N Y

ZEMAIRA SOLUTION INTRAVENOUS MED Y N Y

*Cystic Fibrosis Agents** - *CFTR Potentiators***

KALYDECO NP Y N Y

*Cystic Fibrosis Agents** - *Hydrolytic Enzymes***

PULMOZYME P Y N Y

*Pleural Sclerosing Agents** - *Pleural Sclerosing Agents***

SCLEROSOL INTRAPLEURAL AEROSOL MED N N Y

STERILE TALC POWDER INTRAPLEURAL MED N N Y

*Respiratory Agents - Misc.** - *Respiratory Agents - Misc.***

CUROSULF SUSPENSION INHALATION MED N N Y

INFASURF SUSPENSION 35-0.9 MG/ML-% INHALATION MED N N Y

*Pulmonary Fibrosis Agents***

ESBRIET NP Y N Y

OFEV NP Y N Y

*TETRACYCLINES*

*Tetracyclines** - *Tetracyclines***

ADOXA NP N N Y

ADOXA PAK NP N N Y

avidoxy G N N Y

demeclocycline G N N Y

DORYX NP N N Y

doxycycline hyclate G N N Y

doxycycline monohydrate G N N Y

MINOCIN NP N N Y

minocycline G N N Y

96

minocycline ER G N N Y

MONODOX NP N N Y

morgidox G N N Y

SOLODYN NP N N Y

tetracycline G N N Y

VIBRAMYCIN NP N N Y

*THYROID AGENTS*

*Antithyroid Agents** - *Antithyroid Agents***

methimazole G N N Y

propylthiouracil G N N Y

TAPAZOLE NP N N Y

*Thyroid Hormones** - *Thyroid Hormones***

ARMOUR THYROID NP N N Y

CYTOMEL NP N N Y

levothroid G N N Y

levothyroxine sodium G N N Y

levoxyl G N N Y

liothyronine sodium G N N Y

NATURE-THROID NP N N Y

np thyroid G N N Y

SYNTHROID NP N N Y

THYROLAR NP N N Y

TIROSINT NP N N Y

unithroid G N N Y

unithroid direct G N N Y

WESTHROID NP N N Y

WESTHROID-P NP N N Y

WP THYROID NP N N Y

*ULCER DRUGS*

*Antispasmodics** - *Anticholinergic Combinations***

clidinium-chlordiazepoxide G N N Y

DONNATAL NP N N Y

GASTRINEX NF CAPSULE NP N N Y

RE chlordiazepoxide/clidinium G N N Y

*Antispasmodics** - *Antispasmodics***

BENTYL NP N N Y

dicyclomine G N N Y

*Antispasmodics** - *Belladonna Alkaloids***

colidrops solution oral G N N Y

ed-spaz G N N Y

hyomax G N N Y

97

hyomax-ft G N N Y

hyomax-sl G N N Y

hyomax-sr G N N Y

hyoscyamine sulfate ER G N N Y

hyoscyamine sulfate oral G N N Y

hyoscyamine sulfate sublingual G N N Y

hyosyne G N N Y

nulev odt G N N Y

oscimin oral G N N Y

oscimin SR G N N Y

oscimin sublingual G N N Y

SYMAX DUOTAB NP N N Y

symax fastabs G N N Y

symax-SL G N N Y

symax-SR G N N Y

*Antispasmodics** - *Quaternary Anticholinergics***

CANTIL NP N N Y

CUVPOSA NP N N Y

GLYCATE NP N Y Y

glycopyrrolate G N N Y

methscopolamine bromide G N N Y

PAMINE NP N N Y

PAMINE FORTE NP N N Y

ROBINUL ORAL NP N N Y

RONINUL-FORTE ORAL NP N N Y

*Misc. Anti-Ulcer** - *Misc. Anti-Ulcer***

CARAFATE SUSPENSION NP N N Y

CARAFATE TABLET NP N N Y

sucralfate tablet G N N Y

*Proton Pump Inhibitors** - *Proton Pump Inhibitors***

ACIPHEX SPRINKLE NP N Y Y

ACIPHEX TABLET NP N Y Y

DEXILANT P N N Y

ESOMEPRAZOLE STRONTIUM NP N Y Y

KP omeprazole magnesium capsule G N N Y

lansoprazole G N N Y

NEXIUM P N N Y

omeprazole G N N Y

pantoprazole G N N Y

PREVACID NP N Y Y

PREVACID SOLUTAB NP N Y Y

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PRILOSEC NP N Y Y

PROTONIX NP N Y Y

rabeprazole G N N Y

*Ulcer Drugs - Prostaglandins** - *Ulcer Drugs - Prostaglandins***

CYTOTEC NP N N Y

misoprostol tablet G N N Y *Ulcer Therapy Combinations** - *Proton Pump Inhibitor-Antacid

Combinations***

omeprazole-sodium bicarbonate G N N Y

ZEGERID NP N Y Y *Ulcer Therapy Combinations** - *Ulcer Anti-Infective w/ Bismuth

Combinations***

PYLERA P N N Y *Ulcer Therapy Combinations** - *Ulcer Anti-Infective w/ Proton Pump

Inhibitors***

amoxicill-clarithro-lansopraz G N N Y

OMECLAMOX-PAK P N N Y

PREVPAK NP N Y Y

*URINARY ANTI-INFECTIVES*

*Urinary Anti-infective Combinations** - *Methenamine Combos***

UROQID #2 NP N N Y *Urinary Anti-infective Combinations** - *Urinary Antiseptic-

Antispasmodic &/or Analgesics***

hyophen G N N Y

phosenamine G N N Y

phosphasal G N N Y

ur n-c G N N Y

URELLE NP N N Y

URIBEL NP N N Y

URIMAR-T NP N N Y

urin ds G N N Y

uryl G N N Y

ustell G N N Y

uta G N N Y

uticap G N N Y

utira-c G N N Y

utrona-c G N N Y

*Urinary Anti-infectives** - *Urinary Anti-infectives***

FURADANTAN SUSPENSION NP N N Y

HIPREX NP N N Y

MACROBID NP N N Y

MACRODANTIN NP N N Y

methenamine hippurate G N N Y

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methenamine mandelate TABLET 1 GM ORAL G N N Y

MONUROL PACKET NP N N Y

nitrofurantoin macrocrystal G N N Y

nitrofurantoin monohyd macro G N N Y

nitrofurantoin suspension G N N Y

UREX NP N N Y

*URINARY ANTISPASMODICS*

*Beta-3 Adrenergic Agonists** - *Beta-3 Adrenergic Agonists***

MYRBETRIQ P N Y Y *Urinary Antispasmodic - Antimuscarinics (Anticholinergic)** - *Urinary

Antispasmodic - Antimuscarinic (Anticholinergic)***

DETROL LA NP N Y Y

oxybutynin G N N Y

SANCTURA, SANCTURA XR NP N Y Y

VESICARE P N Y Y *Urinary Antispasmodics - Cholinergic Agonists** - *Urinary

Antispasmodics - Cholinergic Agonists***

bethanechol chloride G N N Y

*Urinary Antispasmodics** - *Urinary Antispasmodics***

DETROL NP N Y Y

DITROPAN XL NP N Y Y

P N Y Y

GELNIQUE NP N Y Y

oxybutynin chloride er G N N Y

tolterodine G N N Y

TOVIAZ NP N Y Y

trospium G N N Y

trospium er G N N Y

URECHOLINE NP N N Y

*VAGINAL PRODUCTS*

*Vaginal Anti-infectives** - *Imidazole-Related Antifungals***

GYNAZOLE-1 NP N N Y

TERAZOLE 3 NP N N Y

TERAZOLE 7 NP N N Y

terconazole G N N Y

zazole G N N Y

*Vaginal Anti-infectives** - *Vaginal Anti-infectives***

AVC NP N N Y

CLEOCIN VAGINAL NP N N Y

clindamycin vaginal G N N Y

CLINDESSE NP N N Y

METRO-GEL VAGINAL NP N N Y

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metronidazole vaginal G N N Y

vandazole G N N Y

*Vaginal Estrogens** - *Vaginal Estrogens***

ESTRACE CREAM VAGINAL NP N N Y

ESTRING NP N N Y

FEMRING NP N N Y

PREMARIN CREAM VAGINAL P N N Y

VAGIFEM NP N N Y

*Vaginal Progestins** - *Vaginal Progestins***

CRINONE P N N Y

ENDOMETRIN P N N Y

PROCHIEVE P N N Y

*VASOPRESSORS*

*Anaphylaxis Therapy Agents** - *Anaphylaxis Therapy Agents***

ADRENACLICK NP N Y Y

AUVI-Q P N N Y

EPIPEN P N N Y

EPIPEN JR P N N Y

TWINJECT NP N N Y

*Vasopressors** - *Vasopressors***

midodrine G N N Y

*Neurogenic Orthostatic Hypotension Agent***

NORTHERA NP Y N Y

*VITAMINS*

*Oil Soluble Vitamins** - *Vitamin D***

DRISDOL NP N N Y

ergocalciferol G N N Y

vitamin D (ergocalciferol) G N N Y

*Oil Soluble Vitamins** - *Vitamin K***

MEPHYTON P N N Y

*Water Soluble Vitamins** - *PABA***

POTABA NP N N Y

2015 Rx Preferred Drug Guide (3-Tier) doctor visit. - Caremark€¦ · 3 What is the Assurant Rx...

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Transcript of 2015 Rx Preferred Drug Guide (3-Tier) doctor visit. - Caremark€¦ · 3 What is the Assurant Rx...