Blue Rx Essentials Formulary · Blue Rx Essentials Formulary Effective 12/01/2016. INTRODUCTION The...

Blue Rx Essentials Formulary Effective 12/01/2016

INTRODUCTION The Blue Rx Essentials formulary is a list of drugs covered under your pharmacy benefit and developed to serve as a guide for physicians, pharmacists, healthcare professionals and members in the selection of cost-effective drug therapy. Wellmark recognizes that drug therapy is an integral part of effective health management. The vast availability of drug options, however, warrants a reasonable program for drug selection and use. Wellmark continually reviews new and existing drugs to ensure the formulary remains responsive to the needs of our members and health professionals. Criteria used to evaluate drug selection for the formulary includes, but is not limited to safety, efficacy and cost-effectiveness data, as well as comparison of relevant benefits of similar prescription or over-the-counter (OTC) agents while minimizing potential duplications. The formulary is a continually reviewed and modified document that represents covered drugs under your pharmacy benefit. This dynamic process does not allow this document to be completely accurate at all times. To accommodate regular changes, an updated electronic version of this formulary is available online at www.Wellmark.com. Wellmark welcomes your input and feedback on the information provided in this document.

FORMULARY OVERVIEW The Blue Rx Essentials formulary is continually changing to reflect new advances in drug treatment therapies and current practices of Wellmark providers. Due to the rapidly changing environment, this process ensures appropriate formulary review and tier placement. To continue to provide sustainable pharmacy benefits and access to needed cost-effective treatments, concentrated evaluation and analysis of drug products in formularies is accomplished through this process. Wellmark has developed the Pharmacy and Therapeutics Committee (P&T) to ensure all drugs in the Blue Rx Essentials formulary and new drugs approved by the United States Food and Drug Administration (FDA) are reviewed by licensed physicians actively practicing medicine in Iowa and South Dakota. In addition, the process allows P&T members the opportunity to receive evidence-based clinical data and make clinical recommendations for formulary placement and utilization management. The entire Wellmark formulary is reviewed annually by P&T including all new drugs approved by the FDA.

Wellmark Blue Cross and Blue Shield is an independent licensee of the Blue Cross and Blue Shield Association. Revision date 11/30/2016 ©2016 Wellmark, Inc.

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The P&T includes licensed physicians and pharmacists. These clinicians serve in an evaluation, education and advisory capacity to the Wellmark Pharmacy program specific to the coverage and limitations of drugs on the Wellmark formularies. Through review and discussion, P&T votes whether the drug or drug class is therapeutically unique, similar or inferior to existing treatment options. In addition, the P&T makes utilization management recommendations to Wellmark for consideration when there are therapeutically interchangeable alternatives. The P&T meets quarterly to evaluate drugs requested for addition to the Wellmark formularies, reviews existing drugs in the Wellmark formularies and establishes recommendations for utilization management.

HOW TO READ THE FORMULARY All drugs are listed by their generic names and/or most common proprietary (brand) name. Specific drug listings may be accessed either by generic (in lowercase) or brand name (in uppercase) and by therapeutic drug tier. Any drug not found in this formulary listing, or any formulary updates published by Wellmark, shall be considered excluded from your benefit. Once the product is located, the following items can be viewed: Drug Tier: Drugs are categorized within three tiers on the formulary. Each tier is assigned a cost, which is determined by the member's pharmacy benefit plan. You may refer to the formulary as a guide to select the most appropriate drugs and associated cost share.

Specialty Drugs (SP-P and SP-NP): Specialty drugs are high-cost injectable, infused, oral or inhaled drugs for the ongoing treatment of a chronic condition. These drugs generally require close supervision and monitoring of the patient's drug therapy. Specialty drugs may be categorized within tiers on the formulary or as drugs covered under your medical benefit.

• Specialty Drugs Preferred (SP-P): Drugs in this category will process with the preferred specialty drug cost-share.

• Specialty Drugs Non-Preferred (SP-NP): Drugs in this category will process with the non-preferred specialty cost-share, and will have a higher cost share than preferred specialty drugs.

Specialty pharmacies specialize in the delivery and clinical management of specialty drugs. Wellmark has two preferred specialty pharmacy providers: Caremark Specialty Pharmacy and Hy-Vee Pharmacy Solutions. You can find more information about their services at www.Wellmark.com. Drug Name: This lists the generic name for the product (lowercase) OR the brand name or common reference name for the product (UPPERCASE). Requirements/Limits: This lists Wellmark Pharmacy programs that may impact a particular drug or class of drugs and are described below:


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• Prior Authorization (PA): This indicates a drug requires prior authorization before it is covered under your benefit. Your health care provider will need to contact our Pharmacy program at 1-800-600-8065. Hours of operation are Monday - Friday: 8 a.m. to 6 p.m. CST Prior authorization review of prescribing guidelines will be evaluated utilizing the established drug review criteria approved by Wellmark. If the request does not meet the approved criteria, the request will not be approved and alternative therapy may be recommended along with the proper course of alternative action. A list of edits recommended by Wellmark is available upon request. Members should call Wellmark Customer Service at the number listed on the back of their ID card if they have questions regarding their specific coverage.

• Medical Necessity Prior Authorization (MN-PA): This indicates a

drug requires prior authorization before it is covered under your benefit. Your health care provider will need to contact our Pharmacy program at 1-800-600-8065. Hours of operation are Monday - Friday: 8 a.m. to 6 p.m. CST The intent of formulary medical necessity prior authorization is to confirm the appropriate coverage of the target drugs when evidence is provided documenting a trial and failure of the preferred formulary alternatives or a clinical reason such as expected adverse reaction or contraindication that prevents the patient from trying the formulary alternatives. These criteria apply to all medications subject to formulary medical necessity not otherwise managed through drug specific criteria. Members should call Wellmark Customer Service at the number listed on the back of their ID card if they have questions regarding their specific coverage.

• Quantity Limits (QL): Wellmark typically covers a 30-day supply for

prescriptions per co-pay. Some drugs, however, have a quantity limit. Amounts over the specified quantity limits are not a covered benefit. Quantity limits are in place to ensure the drug is being used correctly and other treatments are not appropriate. Most people would not need to take these drugs more often than what Wellmark allows. No special steps are necessary by the physician or member to have these drugs covered as long as the drugs prescribed do not exceed quantity limits. A few drugs may also require prior authorization (for example, Viagra). If you require one of these drugs in a larger quantity than is allowed, your physician may make a special request for coverage. Your physician may be asked to provide details about your medical condition and treatment plan. After reviewing the information, coverage will be evaluated based on medical necessity. Your benefits certificate, coverage manual, or policy has specific information about your plan's prior authorization requirements.


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• Preventive Drugs (PV): Preventive drugs are defined by the Internal Revenue Service. Preventive drugs are prescribed to prevent the occurrence of a disease or condition with risk factors such as high blood pressure, high cholesterol, diabetes, asthma, heart attack and stroke, or to prevent the recurrence of the disease or condition for individuals who have recovered. Preventive drugs do not include drugs used to treat an existing illness, injury or condition. For some pharmacy plans that require you to pay a certain amount before the plan coverage begins, preventive drugs may be covered before you reach that amount. To be sure, you should read your enrollment information to see how preventive drugs are covered specific to your plan.

• Generic Available (GA): Indicates a generic equivalent is available

for a brand name drug. In most cases, when you purchase a brand name drug that has an FDA-approved "A"-rated generic equivalent, Wellmark will pay only what it would have paid for the equivalent generic drug. You will be responsible for your payment obligation for the equivalent generic drug and any remaining cost difference up to the maximum allowed fee for the brand name drug.

HEALTH CARE REFORM PREVENTIVE DRUGS

Preventive drugs with an "A" or "B" rating in the current recommendations of the United States Preventive Services Task Force (USPSTF) and immunizations as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention are not associated with any cost share for members on plans with this benefit. A complete list of recommendations and guidelines related to preventive services can be found at Healthcare.gov. Recommended preventive items and services are subject to change and are subject to medical management.


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HOW TO READ YOUR FORMULARY

BENEFIT COVERAGE AND LIMITATIONS This printed formulary does not define benefit coverage and limitations. Many members have specific benefit inclusions, exclusions, copayments or a lack of coverage, which are not reflected in the Blue Rx Essentials formulary. Members should contact their Plan Sponsor or Wellmark Customer Service at the number on the back of their ID card if they have questions regarding their coverage. Please note that the formulary process is evolutionary and changes can occur throughout the year. The following topics may or may not be applicable depending on the parameters of your specific benefits.

FORMULARY EXCEPTION PROCESS Drugs not included in this list shall be considered non-formulary and are NOT COVERED. In some instances, Wellmark will consider coverage exceptions. Coverage of non-formulary drugs may be requested by the health professional through an exception request for a non-formulary prescription drug (outlined below). Generally, the following guidelines must be documented in order for an exception to be granted:

• All covered formulary drugs on any tier will be ineffective; OR • All covered formulary drugs on any tier have been ineffective; OR • All covered formulary drugs on any tier would not be as effective as

the non-formulary drug; OR • All covered formulary drugs would have adverse effects


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COMMON DRUG EXCLUSIONS Due to benefit design parameters, some plan sponsors may choose to exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded drugs may include, but are not limited to:

• OTC drugs or their equivalents unless otherwise specified in the formulary listing.

• Drug products used for cosmetic purposes • Experimental drug products, or any drug product used in an

experimental manner • Replacement of a lost or stolen drug • Foreign drugs or drugs not approved by the United States Food & Drug

Administration (FDA)

GENERIC DRUG SUBSTITUTION In most cases, Wellmark promotes the use of equally effective generic drugs whenever possible. If a member or physician requests a brand-name product when the prescription is filled and a generic equivalent is available, the member will typically be required to pay the difference in cost between the brand and the generic drug. When a brand-name drug becomes available as a generic, the brand-name product may move to a higher tier. Members may be required to pay more for a prescription when a higher-tier brand-name product is dispensed. Members will not be responsible for the cost difference between brands and generics when choosing one of the products listed below:

• Coumadin • Equetro • Tegretol/Tegretol XR • Cytomel • Lanoxin • Theophylline products • Depakene • Stavzor • Thyrolar • Depakote/Depakote ER • Synthroid • Tirosint • Dilantin

DRUG REQUESTS PROCEDURE Drug requests, questions or information regarding the drug requests, formulary status or other coverage may be requested.

1. The appropriate forms for drug review are available at Wellmark.com or by calling the Wellmark Pharmacy program at 1-800-600-8065.

2. Completed Wellmark Prior Authorization forms should be faxed to 1-888-836-0730

3. Completed Formulary Exception request forms should be faxed to 1-888-836-0730

The requesting provider will be provided written notification of Wellmark review decisions. Non-approved requests may be appealed. The physician must provide information to support the appeal on the basis of medical necessity.


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WELLMARK'S CLAIMS APPEAL AND EXTERNAL REVIEW PROCESS Finding out that a claim has been denied or paid differently than you expected can be frustrating. It's important you understand the reasons behind any decision to deny payment for a claim (also known as an adverse benefit determination). You can always contact Customer Service with a question about how a claim was decided, but for a full and fair review of a denied claim, use Wellmark's Claims Appeal and External Review Process. Here's how it works: Step 1: Filing an appeal for Review by Wellmark

• Whether you have coverage through your employer or you are an individual policyholder, you have a right to file an appeal when you receive an adverse benefit determination for payment of services under your benefit plan. (If your employer has a "self-funded" group health plan, the group is responsible for final claim determinations. However, your employer may have Wellmark review appeal requests on behalf of the self-funded plan.)

• Individuals applying for individual insurance policies may also file an appeal if their application for membership is initially denied through the medical underwriting process.

• The appeal must be filed in writing using a Wellmark Appeal/Review Form for Iowa or South Dakota and must be filed within 180 days of the date of the decision. However, if the situation is medically urgent, the appeal may be submitted verbally by calling Wellmark.

• More information is available in our How to Appeal notifications for Iowa and South Dakota.

Step 2: Filing a Request for External Review If you have exhausted our internal Appeal Process (Step 1) and you are not satisfied with the outcome (final adverse benefit determination) relating to a covered benefit that is denied, and the claim denial involves medical judgment or appropriateness, you may request an external review with the state's insurance division:

• The request must be filed in writing using an External Review Request Form for Iowa or South Dakota. External review may not be available for all members or for all types of claims, and is not available for Medicare Supplemental or most dental plans. Self-funded group health plans may use a different external review process.

• An expedited external review process is available if you have a medical condition where a delay in treatment could seriously jeopardize your life or health, or the ability to regain maximum function. Information regarding an expedited external review may be available from the state insurance division.

Please refer to your health plan benefits document, coverage manual or summary plan description for additional details on the Internal Appeal and External Review processes that is applicable to your specific plan.


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LEGEND

GA Generic Available MN-PA Medical Necessity-Prior Authorization PA Prior Authorization PV Preventive Medication QL Quantity Limit SP-P Specialty Preferred SP-NP Specialty Non-Preferred lowercase Indicates generic availability UPPERCASE Indicates brand availability

CONTACT INFORMATION The Blue Rx formulary is designed to assist physicians, members and other health care professionals in the selection of cost-effective agents. Wellmark encourages your input and feedback on how we can assist in improving this document and the formulary management process. Please direct your communications to: Wellmark Blue Cross and Blue Shield 1331 Grand Avenue P.O. Box 9232 Des Moines, IA 50306 In addition to the Blue Rx formulary, other quick-reference guides are available on our web site at Wellmark.com.


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Wellmark Essentials Drug Name Drug Tier Requirements/Limits ANALGESICS COX-II INHIBITORS CELEBREX 3 GA; QL celecoxib 1 QL GOUT allopurinol 1 colchicine 1 colchicine/probenecid 1 COLCRYS 3 GA MITIGARE 3 GA probenecid 1 ULORIC 2 PA; QL ZURAMPIC 3 PA ZYLOPRIM 3 GA NON-OPIOID ANALGESICS acetaminophen/salicylamide/phenyltoloxa

mine 1

BUPAP 3 butalbital/acetaminophen 1 butalbital/acetaminophen/caffeine 1 butalbital/aspirin/caffeine 1 EQUAGESIC 3 ESGIC 3 GA FIORICET 3 GA FIORINAL 3 GA LEVACET 3 VANATOL LQ 3 NSAIDS ANAPROX 3 GA ANAPROX DS 3 GA choline/magnesium trisalicylates 1 DAYPRO 3 GA diclofenac potassium 1 diclofenac sodium delayed-rel 1 diclofenac sodium ext-rel 1 diflunisal 1 EC-NAPROSYN 3 GA etodolac 1 etodolac ext-rel 1 FELDENE 3 GA fenoprofen 1 flurbiprofen 1

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Drug Name Drug Tier Requirements/Limits ibuprofen 1 INDOCIN SUPP 3 INDOCIN SUSP 2 indomethacin 1 indomethacin ext-rel 1 ketoprofen 1 ketoprofen ext-rel 1 ketorolac 1 meclofenamate sodium 1 mefenamic acid 1 meloxicam 1 MOBIC 3 GA nabumetone 1 NALFON 3 NAPRELAN 375MG, 500MG 3 GA NAPRELAN 750MG 3 NAPROSYN 3 GA naproxen 1 naproxen delayed-rel 1 naproxen sodium 1 naproxen sodium ext-rel 1 oxaprozin 1 piroxicam 1 PONSTEL 3 GA salsalate 1 SPRIX 3 sulindac 1 TIVORBEX 3 tolmetin sodium 1 ZIPSOR 3 NSAIDS, COMBINATIONS ARTHROTEC 3 GA diclofenac/misoprostol 1 NSAIDS, TOPICAL diclofenac sodium soln 3 FLECTOR 3 PENNSAID 3 REXAPHENAC 3 VOLTAREN GEL 3 OPIOID ANALGESICS ABSTRAL 3 PA ACTIQ 3 PA; GA alfentanil injection 1 butalbital/acetaminophen/caffeine/codeine 1 butalbital/aspirin/caffeine/codeine 1 butorphanol nasal spray 1 QL

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Drug Name Drug Tier Requirements/Limits BUTRANS 3 QL CAPITAL W/CODEINE 1 codeine 1 codeine/acetaminophen 1 CONZIP 3 GA DEMEROL 3 GA dihydrocodeine/acetaminophen/caffeine 1 dihydrocodeine/aspirin/caffeine 1 DILAUDID 3 GA DOLOPHINE 3 GA DURAGESIC 3 GA; QL EMBEDA 3 QL EXALGO 3 GA; QL fentanyl transdermal 12mcg, 25mcg,

50mcg, 75mcg, 100mcg 1 QL

FENTANYL TRANSDERMAL 37.5MCG, 62.5MCG, 87.5MCG

1 QL

fentanyl transmucosal lozenge 1 PA FENTORA 3 PA FIORICET W/CODEINE 3 GA FIORINAL W/CODEINE 3 GA HYCET 3 GA hydrocodone/acetaminophen 1 hydrocodone/ibuprofen 1 hydromorphone 1 hydromorphone ext-rel 1 QL HYDROMORPHONE SUPP 1 HYSINGLA ER 3 QL KADIAN 10MG, 20MG, 30MG, 50MG,

60MG, 80MG, 100MG 3 GA; QL

KADIAN 40MG, 200MG 3 QL LAZANDA 3 levorphanol 1 LORTAB ELIXIR 3 meperidine 1 methadone 1 METHADOSE CONCENTRATE 3 GA morphine 1 morphine ext-rel 1 QL morphine ext-rel beads 3 QL morphine supp 5mg, 10mg, 20mg 1 MORPHINE SUPP 30MG 1 MS CONTIN 3 GA; QL NORCO 3 GA NUCYNTA 3 NUCYNTA ER 3 QL OPANA 3 GA

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Drug Name Drug Tier Requirements/Limits OPANA ER 3 QL OXAYDO 3 oxycodone 1 oxycodone ext-rel 2 QL oxycodone/acetaminophen 1 oxycodone/aspirin 1 oxycodone/ibuprofen 1 OXYCONTIN 2 QL oxymorphone 1 oxymorphone ext-rel 1 QL pentazocine/naloxone 1 PERCOCET 3 GA PRIMLEV 3 REPREXAIN 3 GA ROXICET SOLN 3 ROXICODONE 3 GA SUBSYS 3 PA tramadol 1 tramadol ext-rel caps 100mg, 200mg,

300mg 3

TRAMADOL EXT-REL CAPS 150MG 3 tramadol ext-rel tabs 1 tramadol/acetaminophen 1 TREZIX 3 GA TYLENOL W/CODEINE 3 GA ULTRACET 3 GA ULTRAM 3 GA ULTRAM ER 3 GA VICOPROFEN 3 GA XARTEMIS XR 3 QL ZOHYDRO ER 3 QL ANTI-INFECTIVES AMINOGLYCOSIDES neomycin 1 paromomycin 1 ANTIBACTERIALS, CEPHALOSPORINS 1ST GEN cefadroxil 1 cephalexin 1 KEFLEX 3 GA ANTIBACTERIALS, CEPHALOSPORINS, 2ND GEN cefaclor 1 CEFACLOR ER 3 cefprozil 1 CEFTIN 3 GA CEFTIN SUSP 3 cefuroxime axetil 1

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Drug Name Drug Tier Requirements/Limits ANTIBACTERIALS, CEPHALOSPORINS, 3RD GEN CEDAX CAPS 3 GA CEDAX SUSP 90MG/5ML 3 CEDAX SUSP 180MG/5ML 3 GA cefdinir 1 cefditoren 3 cefixime 1 cefpodoxime 1 ceftibuten 1 ceftriaxone 1 SUPRAX 3 SUPRAX SUSP 3 GA SUPRAX SUSP 500MG/5ML 3 ANTIBACTERIALS, ERYTHROMYCINS/MACROLIDES azithromycin 1 BIAXIN 3 GA clarithromycin 1 clarithromycin ext-rel 1 DIFICID 3 e.e.s. 400 3 ERYPED SUS 200MG/5ML 3 GA ERYPED SUS 400MG/5ML 2 erythromycin base 1 erythromycin delayed-rel 1 erythromycin ethylsuccinate 1 erythromycin stearate 1 ZITHROMAX 3 GA ZMAX SUSP 3 ANTIBACTERIALS, FLUOROQUINOLONES AVELOX 3 GA CIPRO 3 GA CIPRO XR 3 GA ciprofloxacin 1 ciprofloxacin ext-rel 1 ciprofloxacin oral susp 1 FACTIVE 3 LEVAQUIN 3 GA levofloxacin 1 levofloxacin oral soln 1 moxifloxacin 1 ofloxacin 1 ANTIBACTERIALS, KETOLIDES KETEK 3 ANTIBACTERIALS, PENICILLINS amoxicillin 1 amoxicillin/clavulanate 1

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Drug Name Drug Tier Requirements/Limits amoxicillin/clavulanate ext-rel 1 ampicillin 1 AUGMENTIN 3 GA AUGMENTIN SUSP 3 GA AUGMENTIN SUSP 125MG/5ML 3 AUGMENTIN XR 3 GA dicloxacillin 1 penicillin vk 1 ANTIBACTERIALS, SULFONAMIDES BACTRIM 3 GA BACTRIM DS 3 GA SULFADIAZINE 1 sulfamethoxazole/trimethoprim 1 ANTIBACTERIALS, TETRACYCLINES ADOXA 3 PA; GA demeclocycline 1 DORYX 3 PA doxycycline hyclate 1 doxycycline hyclate delayed-rel 1 PA doxycycline monohydrate caps 50mg,

75mg, 100mg 1

doxycycline monohydrate caps 150mg 1 PA doxycycline monohydrate susp 1 doxycycline monohydrate tabs 1 PA MINOCIN 3 GA minocycline 1 minocycline ext-rel 1 PA MONODOX 3 GA SOLODYN 3 PA tetracycline 1 VIBRAMYCIN CAPS, SUSP 3 GA VIBRAMYCIN SYRUP 3 ANTIFUNGALS ANCOBON 3 GA BIO-STATIN 3 clotrimazole troche 1 CRESEMBA 3 DIFLUCAN 3 GA fluconazole 1 flucytosine 1 GRIS-PEG 3 GA griseofulvin microsize 1 griseofulvin ultramicrosize 1 itraconazole 1 PA ketoconazole tabs 1 LAMISIL 3 GA

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Drug Name Drug Tier Requirements/Limits NOXAFIL 3 nystatin oral 1 ONMEL 3 PA ORAVIG 3 SPORANOX 3 PA; GA SPORANOX SOLN 3 PA terbinafine 1 VFEND 3 GA voriconazole 1 ANTIMALARIALS ARALEN 3 GA atovaquone/proguanil 1 PV chloroquine 1 PV COARTEM 3 DARAPRIM 2 MALARONE 3 GA mefloquine 1 PV PRIMAQUINE 1 PV QUALAQUIN 3 GA quinine sulfate 1 ANTIRETROVIRALS, ANTIRETROVIRAL ADJUVANTS TYBOST 2 ANTIRETROVIRALS, ANTIRETROVIRAL COMBINATIONS abacavir/lamivudine 1 abacavir/lamivudine/zidovudine 1 ATRIPLA 2 COMBIVIR 3 GA COMPLERA 2 DESCOVY 2 EPZICOM 3 GA EVOTAZ 3 GENVOYA 2 lamivudine/zidovudine 1 ODEFSEY 2 PREZCOBIX 3 STRIBILD 2 TRIUMEQ 2 TRIZIVIR 3 GA TRUVADA 2 ANTIRETROVIRALS, CHEMOKINE RECEPTOR ANTAGONISTS SELZENTRY 2 ANTIRETROVIRALS, FUSION INHIBITORS FUZEON SP-P ANTIRETROVIRALS, INTEGRASE INHIBITORS ISENTRESS 2 ISENTRESS POWDER 3 15

Drug Name Drug Tier Requirements/Limits TIVICAY 2 VITEKTA 2 ANTIRETROVIRALS, PROTEASE INHIBITORS APTIVUS 2 APTIVUS SOLN 3 CRIXIVAN 2 INVIRASE 2 KALETRA 2 LEXIVA 2 LEXIVA SUSP 3 NORVIR 2 NORVIR SOLN 3 PREZISTA SUSP 3 PREZISTA TABS 2 REYATAZ 2 REYATAZ POWDER 3 VIRACEPT 2 ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS - NON-

NUCLEOSIDE EDURANT 2 INTELENCE 2 nevirapine 1 nevirapine ext-rel 1 RESCRIPTOR 2 SUSTIVA 2 VIRAMUNE 3 GA VIRAMUNE XR 3 GA ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS -

NUCLEOSIDE abacavir 1 didanosine 1 EMTRIVA 2 EPIVIR 3 GA lamivudine soln, tabs 1 RETROVIR 3 GA stavudine 1 VIDEX EC 3 GA VIDEX SOLN 3 ZERIT 3 GA ZIAGEN 3 GA ZIAGEN SOLN 2 zidovudine 1 ANTIRETROVIRALS, REVERSE TRANSCRIPTASE INHIBITORS -

NUCLEOTIDE VIREAD 2 VIREAD POWDER 3 16

Drug Name Drug Tier Requirements/Limits ANTITUBERCULAR AGENTS cycloserine 1 ethambutol 1 isoniazid 1 PASER GRANULES 1 PRIFTIN 3 pyrazinamide 1 RIFADIN 3 GA rifampin 1 RIFATER 3 SIRTURO 3 TRECATOR 3 ANTIVIRALS, CMV AGENTS VALCYTE 3 GA valganciclovir 1 ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS B adefovir dipivoxil 1 BARACLUDE SOLN 3 BARACLUDE TABS 3 GA entecavir 1 EPIVIR HBV 3 GA EPIVIR HBV SOLN 3 lamivudine tabs 1 TYZEKA SP-P ANTIVIRALS, HEPATITIS AGENTS - HEPATITIS C COPEGUS 3 GA DAKLINZA SP-NP PA; QL EPCLUSA SP-P PA; QL HARVONI SP-P PA; QL OLYSIO SP-NP PA; QL REBETOL CAPS 3 GA REBETOL SOLN 3 ribavirin 1 SOVALDI SP-P PA; QL TECHNIVIE SP-NP PA; QL VIEKIRA PAK SP-NP PA; QL VIEKIRA XR SP-NP PA; QL ZEPATIER SP-NP PA; QL ANTIVIRALS, HERPES AGENTS acyclovir 1 famciclovir 1 FAMVIR 3 GA SITAVIG 3 valacyclovir 1 VALTREX 3 GA ZOVIRAX 3 GA

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Drug Name Drug Tier Requirements/Limits ANTIVIRALS, INFLUENZA AGENTS FLUMADINE 3 GA RELENZA 2 rimantadine 1 TAMIFLU 2 MISCELLANEOUS ALBENZA 3 ALINIA 3 atovaquone 1 BILTRICIDE 3 CLEOCIN 3 GA clindamycin caps, oral soln 1 dapsone 1 FLAGYL 3 GA FLAGYL ER 3 FURADANTIN SUSP 3 GA IMPAVIDO 3 ivermectin 1 linezolid 1 MACROBID 3 GA MACRODANTIN 3 GA MEPRON SUSP 3 GA metronidazole 1 MONUROL 2 MYCOBUTIN 3 GA NEBUPENT 3 nitrofurantoin 1 PRIMSOL 3 rifabutin 1 SIVEXTRO 3 STROMECTOL 3 GA TINDAMAX 3 GA tinidazole 1 trimethoprim 1 VANCOCIN 3 GA vancomycin caps 1 vancomycin inj 500mg, 1000mg 1 VANCOMYCIN INJECTION 750MG 1 XIFAXAN 2 ZYVOX SUSP 3 GA ANTINEOPLASTIC AGENTS ALKYLATING AGENTS ALKERAN 2 CYCLOPHOSPHAMIDE CAPS 1 EMCYT SP-P GLEOSTINE 5MG 2

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Drug Name Drug Tier Requirements/Limits GLEOSTINE 10MG, 40MG, 100MG 3 HEXALEN 2 LEUKERAN 2 MYLERAN 2 TEMODAR SP-NP GA temozolomide SP-P VALCHLOR 2 ANTIMETABOLITES capecitabine SP-P mercaptopurine 1 methotrexate 1 TABLOID 2 TREXALL 3 XELODA SP-NP GA HORMONAL ANTINEOPLASTICS, ANTIANDROGENS bicalutamide 1 flutamide 1 NILANDRON 2 XTANDI SP-P ZYTIGA SP-P HORMONAL ANTINEOPLASTICS, ANTIESTROGENS FARESTON 2 SOLTAMOX 2 tamoxifen 1 PA; PV HORMONAL ANTINEOPLASTICS, AROMATASE INHIBITORS anastrozole 1 ARIMIDEX 3 GA AROMASIN 3 GA exemestane 1 FEMARA 3 GA letrozole 1 HORMONAL ANTINEOPLASTICS, PROGESTINS megestrol acetate 1 IMMUNOMODULATORS POMALYST SP-P REVLIMID SP-P THALOMID SP-P KINASE INHIBITORS AFINITOR SP-P QL AFINITOR DISPERZ SP-P ALECENSA SP-P BOSULIF SP-P CABOMETYX SP-P CAPRELSA 2 COMETRIQ 2

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Drug Name Drug Tier Requirements/Limits COTELLIC SP-P GILOTRIF 2 GLEEVEC SP-NP GA IBRANCE SP-P ICLUSIG SP-P imatinib mesylate SP-P IMBRUVICA SP-P INLYTA SP-P JAKAFI SP-P LENVIMA 2 MEKINIST SP-P NEXAVAR SP-P SPRYCEL SP-P STIVARGA SP-P SUTENT SP-P TAFINLAR SP-P TAGRISSO SP-P TARCEVA SP-P TASIGNA SP-P TYKERB SP-P QL VOTRIENT SP-P XALKORI SP-P ZELBORAF SP-P ZYDELIG 2 ZYKADIA SP-P MISCELLANEOUS bexarotene SP-P DROXIA 3 ERIVEDGE 2 etoposide SP-P FARYDAK SP-P HYDREA 3 GA hydroxyurea 1 leucovorin 1 LONSURF SP-P LYNPARZA 2 LYSODREN 2 MATULANE 2 NINLARO SP-P ODOMZO SP-P TARGRETIN CAPS SP-NP GA TARGRETIN GEL SP-P tretinoin caps 1 VENCLEXTA SP-P VISTOGARD SP-P ZOLINZA SP-P

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Drug Name Drug Tier Requirements/Limits TOPOISOMERASE INHIBITORS HYCAMTIN SP-P CARDIOVASCULAR ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS amlodipine/benazepril 1 PV LOTREL 3 GA PRESTALIA 3 TARKA 3 GA trandolapril/verapamil 1 PV ACE INHIBITOR/DIURETIC COMBINATIONS benazepril/hydrochlorothiazide 1 PV captopril/hydrochlorothiazide 1 PV enalapril/hydrochlorothiazide 1 PV fosinopril/hydrochlorothiazide 1 PV lisinopril/hydrochlorothiazide 1 PV LOTENSIN HCT 3 GA moexipril/hydrochlorothiazide 1 PV quinapril/hydrochlorothiazide 1 PV ZESTORETIC 3 GA ACE INHIBITORS ACCUPRIL 3 GA ALTACE 3 GA benazepril 1 PV captopril 1 PV enalapril 1 PV EPANED 3 fosinopril 1 PV lisinopril 1 PV LOTENSIN 3 GA MAVIK 3 GA moexipril 1 PV perindopril 1 PV PRINIVIL 3 GA QBRELIS 3 quinapril 1 PV ramipril 1 PV trandolapril 1 PV VASOTEC 3 GA ZESTRIL 3 GA ADRENOLYTICS, CENTRAL CATAPRES 3 GA CATAPRES-TTS 3 GA clonidine 1 PV clonidine transdermal 1 PV guanfacine 1 PV TENEX 3 GA 21

Drug Name Drug Tier Requirements/Limits ALDOSTERONE RECEPTOR ANTAGONISTS ALDACTONE 3 GA eplerenone 1 spironolactone 1 ALPHA BLOCKERS CARDURA 3 GA doxazosin 1 prazosin 1 terazosin 1 ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL

BLOCKER COMBINATIONS amlodipine/valsartan 1 PV AZOR 3 EXFORGE 3 GA telmisartan/amlodipine 1 PV TWYNSTA 3 GA ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL

BLOCKER/DIURETIC COMBINATIONS amlodipine/valsartan/hydrochlorothiazide 1 PV EXFORGE HCT 3 GA TRIBENZOR 3 ANGIOTENSIN II RECEPTOR ANTAGONIST/DIURETIC

COMBINATIONS ATACAND HCT 3 GA AVALIDE 3 GA BENICAR HCT 3 candesartan/hydrochlorothiazide 1 PV DIOVAN HCT 3 GA EDARBYCLOR 3 HYZAAR 3 GA irbesartan/hydrochlorothiazide 1 PV losartan/hydrochlorothiazide 1 PV MICARDIS HCT 3 GA telmisartan/hydrochlorothiazide 1 PV valsartan/hydrochlorothiazide 1 PV ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND 3 GA AVAPRO 3 GA BENICAR 3 candesartan 1 PV COZAAR 3 GA DIOVAN 3 GA EDARBI 3 eprosartan 1 PV irbesartan 1 PV

22

Drug Name Drug Tier Requirements/Limits losartan 1 PV MICARDIS 3 GA telmisartan 1 PV valsartan 1 PV ANTIARRHYTHMICS amiodarone 1 PV BETAPACE 3 GA disopyramide 1 PV dofetilide 1 flecainide 1 PV mexiletine 1 MULTAQ 3 NORPACE 3 GA NORPACE CR 3 propafenone 1 PV propafenone ext-rel 1 PV quinidine gluconate 1 quinidine sulfate 1 quinidine sulfate ext-rel 1 RYTHMOL 3 GA RYTHMOL SR 3 GA sotalol 1 PV sotalol af 1 PV TIKOSYN 3 GA ANTILIPEMICS, BILE ACID RESINS cholestyramine powder 1 PV cholestyramine powder light 1 PV COLESTID 3 GA colestipol 1 PV QUESTRAN 3 GA QUESTRAN LIGHT 3 GA WELCHOL 3 ANTILIPEMICS, CHOLESTEROL ABSORPTION INHIBITORS ZETIA 2 PV ANTILIPEMICS, FIBRATES ANTARA 3 fenofibrate caps, tabs 1 PV fenofibric acid 1 PV fenofibric acid delayed-rel 1 PV FENOGLIDE 3 GA gemfibrozil 1 PV LIPOFEN 3 GA LOFIBRA 3 GA TRICOR 3 GA TRIGLIDE 3 TRILIPIX 3 GA

23

Drug Name Drug Tier Requirements/Limits ANTILIPEMICS, HMG-COA REDUCTASE

INHIBITORS/COMBINATIONS ALTOPREV 3 atorvastatin 1 PV CRESTOR 2 PV fluvastatin 1 PV fluvastatin ext-rel 1 LESCOL XL 3 GA LIPITOR 3 GA LIVALO 2 PV lovastatin 1 PV MEVACOR 3 GA PRAVACHOL 3 GA pravastatin 1 PV simvastatin 1 PV VYTORIN 3 ZOCOR 3 GA ANTILIPEMICS, MISCELLANEOUS JUXTAPID SP-P PA; QL KYNAMRO SP-P PA; QL ANTILIPEMICS, NIACINS/COMBINATIONS ADVICOR 3 niacin 3 niacin ext-rel 1 PV NIASPAN 3 GA SIMCOR 3 ANTILIPEMICS, PCSK9 INHIBITORS PRALUENT SP-NP MN-PA; QL REPATHA SP-P PA; QL BETA-BLOCKER/DIURETIC COMBINATIONS atenolol/chlorthalidone 1 PV bisoprolol/hydrochlorothiazide 1 PV CORZIDE 3 GA DUTOPROL 3 LOPRESSOR HCT 3 GA metoprolol/hydrochlorothiazide 1 PV nadolol/bendroflumethiazide 1 PV propranolol/hydrochlorothiazide 1 PV ZIAC 3 GA BETA-BLOCKERS acebutolol 1 PV atenolol 1 PV betaxolol 1 PV bisoprolol 1 PV BYSTOLIC 3 carvedilol 1 PV 24

Drug Name Drug Tier Requirements/Limits COREG 3 GA COREG CR 3 CORGARD 3 GA HEMANGEOL 3 INDERAL LA 3 GA labetalol 1 PV LEVATOL 3 LOPRESSOR 3 GA metoprolol succinate ext-rel 1 PV metoprolol tartrate 1 PV nadolol 1 PV pindolol 1 PV propranolol 1 PV propranolol ext-rel 1 PV SECTRAL 3 GA TENORMIN 3 GA timolol 1 PV TOPROL-XL 3 GA TRANDATE 3 GA CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine/atorvastatin 1 PV CADUET 3 GA CALCIUM CHANNEL BLOCKERS, DIHYDROPYRIDINES ADALAT CC 3 GA amlodipine 1 PV felodipine ext-rel 1 PV isradipine 1 PV nicardipine 1 PV nifedipine 1 PV nifedipine ext-rel 1 PV nimodipine 1 nisoldipine ext-rel 1 PV NYMALIZE 3 PROCARDIA 3 GA PROCARDIA XL 3 GA CALCIUM CHANNEL BLOCKERS, NON DIHYDROPYRIDINES CALAN 3 GA CALAN SR 3 GA CARDIZEM 3 GA CARDIZEM CD 3 GA CARDIZEM LA 120MG 3 CARDIZEM LA 180MG, 240MG, 300MG,

360MG, 420MG 3 GA

diltiazem 1 PV diltiazem ext-rel 1 PV verapamil 1 PV

25

Drug Name Drug Tier Requirements/Limits verapamil ext-rel 1 PV VERELAN 3 GA VERELAN PM 3 GA DIGITALIS GLYCOSIDES digoxin 1 LANOXIN 62.5MCG, 187.5MCG 3 LANOXIN 125MCG, 250MCG 3 GA DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS TEKTURNA 3 TEKTURNA HCT 3 DIURETICS ALDACTAZIDE 25/25 3 GA ALDACTAZIDE 50/50 3 amiloride 1 amiloride/hydrochlorothiazide 1 PV bumetanide 1 chlorothiazide 1 PV chlorthalidone 1 PV DEMADEX 3 GA DIURIL 3 DYAZIDE 3 GA DYRENIUM 3 EDECRIN 3 furosemide 1 FUROSEMIDE SOLN 8 MG/ML 3 furosemide soln 10mg/ml 1 hydrochlorothiazide 1 PV indapamide 1 PV LASIX 3 GA MAXZIDE 3 GA methyclothiazide 1 PV metolazone 1 MICROZIDE 3 GA spironolactone/hydrochlorothiazide 1 PV torsemide 1 triamterene/hydrochlorothiazide 1 PV MISCELLANEOUS clonidine/chlorthalidone 3 CORLANOR 3 DEMSER 2 DIBENZYLINE 3 GA hydralazine 1 PV isoxsuprine 10mg 1 isoxsuprine 20mg 3 methyldopa 1 PV methyldopa/hydrochlorothiazide 1 PV

26

Drug Name Drug Tier Requirements/Limits midodrine 1 minoxidil 1 PV phenoxybenzamine 1 RANEXA 3 reserpine 1 PV NEPRILYSIN INHIBITOR/ANGIOTENSIN II RECEPTOR ANTAGONIST

COMBINATIONS ENTRESTO 3 PA; QL NITRATE/VASODILATOR COMBINATIONS BIDIL 3 NITRATES, ORAL DILATRATE SR 3 ISORDIL 5MG 3 GA ISORDIL 40MG 3 isosorbide dinitrate 1 PV isosorbide dinitrate ext-rel 1 PV isosorbide mononitrate 1 PV isosorbide mononitrate ext-rel 1 PV nitroglycerin caps 1 PV NITRATES, SUBLINGUAL/TRANSLINGUAL nitroglycerin lingual aerosol 1 nitroglycerin lingual spray 1 PV nitroglycerin sublingual 1 NITROLINGUAL SPRAY 3 GA NITROMIST 3 GA NITROSTAT 3 GA NITRATES, TRANSDERMAL NITRO-BID 3 NITRO-DUR 0.1MG, 0.2MG, 0.4MG, 0.6MG 3 GA NITRO-DUR 0.3MG, 0.8MG 3 nitroglycerin transdermal 1 PV PULMONARY ARTERIAL HYPERTENSION, ENDOTHELIN RECEPTOR

ANTAGONIST LETAIRIS SP-P PA; QL OPSUMIT SP-P PA; QL TRACLEER SP-P PA; QL PULMONARY ARTERIAL HYPERTENSION, PHOSPHODIESTERASE

INHIBITOR ADCIRCA SP-P PA; QL REVATIO INJ SP-NP PA; GA; QL REVATIO SUSP SP-NP PA; QL REVATIO TABS SP-NP PA; GA; QL sildenafil SP-P PA; QL PULMONARY ARTERIAL HYPERTENSION, PROSTACYCLIN RECEPTOR

AGONIST

27

Drug Name Drug Tier Requirements/Limits UPTRAVI SP-P PA; QL PULMONARY ARTERIAL HYPERTENSION, PROSTAGLANDIN

VASODILATORS ORENITRAM SP-P PA TYVASO SP-P PA; QL VENTAVIS SP-P PA; QL PULMONARY ARTERIAL HYPERTENSION, SOLUBLE GUANYLATE

CYCLASE STIMULATORS ADEMPAS SP-P PA; QL CENTRAL NERVOUS SYSTEM ANTIANXIETY, BENZODIAZEPINES alprazolam 1 alprazolam ext-rel 1 ALPRAZOLAM INTENSOL 1 ATIVAN 3 GA chlordiazepoxide 1 clonazepam 1 PV clorazepate 1 diazepam 1 KLONOPIN 3 GA lorazepam 1 NIRAVAM 3 GA oxazepam 1 VALIUM 3 GA XANAX 3 GA XANAX XR 3 GA ANTIANXIETY, MISCELLANEOUS ANAFRANIL 3 GA buspirone 1 clomipramine 1 PV fluvoxamine 1 PV fluvoxamine ext-rel 1 PA; PV meprobamate 1 ANTICONVULSANTS APTIOM 3 BANZEL 2 PA; PV; QL BRIVIACT 3 carbamazepine 1 PV carbamazepine ext-rel 1 PV CARBATROL 3 GA CELONTIN 2 PV DEPAKENE 3 GA DEPAKOTE 3 GA DEPAKOTE ER 3 GA DIASTAT 3 GA

28

Drug Name Drug Tier Requirements/Limits diazepam gel 1 DILANTIN 30MG 3 DILANTIN 100MG 3 GA DILANTIN CHEW 50MG 3 GA DILANTIN-125 SUSP 3 GA divalproex sodium 1 PV divalproex sodium delayed-rel 1 PV divalproex sodium ext-rel 1 PV ethosuximide 1 PV felbamate 1 PV FELBATOL 3 GA FYCOMPA 3 gabapentin 1 GABITRIL 2MG, 4MG 3 GA GABITRIL 12MG, 16MG 3 KEPPRA 3 GA KEPPRA XR 3 GA LAMICTAL 3 GA LAMICTAL CHEW 2MG 3 LAMICTAL CHEW 5MG, 25MG 3 GA LAMICTAL ODT 3 GA LAMICTAL XR 3 GA lamotrigine 1 PV lamotrigine ext-rel 1 PV levetiracetam 1 PV MYSOLINE 3 GA NEURONTIN 3 GA ONFI 3 PA; QL oxcarbazepine 1 PV OXTELLAR XR 3 PEGANONE 2 PV phenobarbital 1 PV PHENYTEK 3 GA phenytoin 1 PV phenytoin sodium extended 1 PV POTIGA 3 primidone 1 PV QUDEXY XR 3 GA SABRIL POWDER SP-P PA; QL SABRIL TABS SP-P QL STAVZOR 3 TEGRETOL 3 GA TEGRETOL-XR 100MG, 200MG, 400MG 3 GA tiagabine 1 PV TOPAMAX 3 GA TOPAMAX SPRINKLE 3 GA topiramate 1 PV 29

Drug Name Drug Tier Requirements/Limits TRILEPTAL 3 GA TROKENDI XR 3 valproic acid 1 PV VIMPAT 2 PV ZARONTIN 3 GA ZONEGRAN 3 GA zonisamide 1 PV ANTIDEMENTIA ARICEPT 3 GA donepezil 1 EXELON 3 GA galantamine 1 galantamine ext-rel 1 memantine 1 NAMENDA 3 GA NAMENDA XR 3 rivastigmine 1 rivastigmine transdermal 1 ANTIDEPRESSANTS, MAOIS EMSAM 3 MARPLAN 2 NARDIL 3 GA PARNATE 3 GA phenelzine 1 PV tranylcypromine 1 PV ANTIDEPRESSANTS, MISCELLANEOUS APLENZIN 3 bupropion 1 PV bupropion delayed-rel 1 PV bupropion ext-rel (12hr) 1 PV bupropion ext-rel (24hr) 1 PV chlordiazepoxide/amitriptyline 1 FORFIVO XL 3 maprotiline 1 PV mirtazapine 1 PV nefazodone 1 PV OLEPTRO 3 REMERON 3 GA trazodone 1 PV WELLBUTRIN 3 GA WELLBUTRIN SR 3 GA WELLBUTRIN XL 3 GA ANTIDEPRESSANTS, SNRIS CYMBALTA 3 GA DESVENLAFAXINE ER 50MG, 100MG 3 PA; QL desvenlafaxine ext-rel 50mg, 100mg 1 PA; PV; QL

30

Drug Name Drug Tier Requirements/Limits duloxetine 1 PV EFFEXOR XR 3 GA FETZIMA 3 PA; QL KHEDEZLA 3 PA; GA; QL PRISTIQ 50MG, 100MG 3 PA; QL venlafaxine 1 PV venlafaxine ext-rel 1 PV ANTIDEPRESSANTS, SSRIS CELEXA 3 GA citalopram 1 PV escitalopram 1 PV fluoxetine 1 PV FLUOXETINE 60MG 1 PV fluoxetine delayed-rel 1 PV LEXAPRO 3 GA paroxetine 1 PV paroxetine ext-rel 1 PV PAXIL 3 GA PAXIL CR 3 GA PAXIL SUSP 3 PEXEVA 3 PA PROZAC 3 GA PROZAC WEEKLY 3 GA SARAFEM 3 sertraline 1 PV VIIBRYD 3 PA ZOLOFT 3 GA ANTIDEPRESSANTS, TCAS amitriptyline 1 PV amoxapine 1 PV desipramine 1 PV doxepin 1 PV imipramine hcl 1 PV imipramine pamoate 1 PV nortriptyline 1 PV PAMELOR 3 GA protriptyline 1 PV SURMONTIL 25MG, 50MG 3 SURMONTIL 100MG 3 GA TOFRANIL 3 GA trimipramine 1 PV ANTIPARKINSONIAN AGENTS amantadine 1 AZILECT 2 benztropine 1 bromocriptine 1

31

Drug Name Drug Tier Requirements/Limits carbidopa 1 carbidopa/levodopa 1 carbidopa/levodopa ext-rel 1 carbidopa/levodopa/entacapone 1 COMTAN 3 GA ELDEPRYL 3 GA entacapone 1 LODOSYN 3 GA MIRAPEX 3 GA MIRAPEX ER 0.375MG, 0.75MG, 1.5MG,

2.25MG, 3MG, 4.5MG 3 PA; GA

MIRAPEX ER 3.75MG 3 PA NEUPRO 3 PARLODEL 3 GA pramipexole 1 pramipexole ext-rel 1 PA REQUIP 3 GA REQUIP XL 3 PA; GA ropinirole 1 ropinirole ext-rel 1 PA selegiline 1 SINEMET 3 GA SINEMET CR 3 GA STALEVO 3 GA TASMAR 3 GA tolcapone 1 trihexyphenidyl 1 ZELAPAR 3 ANTIPSYCHOTICS, ATYPICALS ABILIFY 3 GA ARIPIPRAZOLE ODT 3 aripiprazole soln 1 aripiprazole tabs 1 PV clozapine 1 PV CLOZARIL 3 GA FANAPT 3 QL FAZACLO 3 GA GEODON 3 GA INVEGA 3 GA LATUDA 3 loxapine 1 PV olanzapine 1 PV olanzapine/fluoxetine 1 paliperidone ext-rel 1 quetiapine 1 PV REXULTI 3 PA; QL RISPERDAL 3 GA 32

Drug Name Drug Tier Requirements/Limits RISPERDAL-M TAB 3 GA risperidone 1 PV SAPHRIS 3 SEROQUEL 3 GA SEROQUEL XR 3 SYMBYAX 3 GA VERSACLOZ 3 VRAYLAR 3 PA; QL ziprasidone 1 PV ZYPREXA 3 GA ZYPREXA ZYDIS 3 GA ANTIPSYCHOTICS, MISCELLANEOUS chlorpromazine 1 PV fluphenazine 1 PV haloperidol 1 PV ORAP 3 GA perphenazine 1 PV perphenazine/amitriptyline 1 pimozide 1 thioridazine 1 PV thiothixene 1 PV trifluoperazine 1 PV ATTENTION DEFICIT HYPERACTIVITY DISORDER ADDERALL 3 GA ADDERALL XR 3 PA; GA amphetamine/dextroamphetamine 1 amphetamine/dextroamphetamine ext-rel 1 PA APTENSIO XR 3 PA clonidine ext-rel 1 PA CONCERTA 3 PA; GA DAYTRANA 3 PA; QL DEXEDRINE CR 3 PA; GA dexmethylphenidate 1 dexmethylphenidate ext-rel 1 PA dextroamphetamine 2.5mg, 7.5mg, 15mg,

20mg, 30mg 3

dextroamphetamine 5mg, 10mg 1 dextroamphetamine ext-rel 5mg, 10mg,

15mg 1 PA

dextroamphetamine soln 1 FOCALIN 3 GA FOCALIN XR 5MG, 10MG, 15MG, 20MG,

30MG, 40MG 3 PA; GA

FOCALIN XR 25MG, 35MG 3 PA guanfacine ext-rel 1 INTUNIV 3 GA; QL KAPVAY 3 PA; GA 33

Drug Name Drug Tier Requirements/Limits METADATE CD 3 PA; GA methamphetamine tabs 5mg 1 METHYLIN CHEW 2.5MG, 5MG, 10MG 3 GA METHYLIN SOLN 3 GA methylphenidate chew 2.5mg, 5mg, 10mg 1 METHYLPHENIDATE ER 20MG, 30MG,

40MG 3 PA; GA

methylphenidate ext-rel 18mg, 27mg, 36mg, 54mg

1 PA

methylphenidate ext-rel caps 10mg, 20mg, 30mg, 40mg, 50mg, 60mg

1 PA

methylphenidate ext-rel caps 20mg, 30mg, 40mg

1 PA

methylphenidate ext-rel tabs 10mg, 20mg 1 PA methylphenidate soln 1 methylphenidate tabs 5mg, 10mg, 20mg 1 PROCENTRA 3 GA QUILLIVANT XR 3 PA; QL RITALIN 3 GA RITALIN LA 10MG, 60MG 3 PA RITALIN LA 20MG, 30MG, 40MG 3 PA; GA STRATTERA 2 PA; QL VYVANSE 3 PA FIBROMYALGIA LYRICA 3 SAVELLA 3 HUNTINGTON'S DISEASE AGENTS tetrabenazine SP-P QL XENAZINE SP-NP GA; QL HYPNOTICS, TRICYCLICS SILENOR 3 PA HYPNOTICS: BENZODIAZEPINES estazolam 1 flurazepam 1 HALCION 3 GA temazepam 1 triazolam 1 HYPNOTICS: NON-BENZODIAZEPINES AMBIEN 3 GA AMBIEN CR 3 PA; GA BELSOMRA 3 PA; QL BUTISOL SODIUM 3 EDLUAR 3 PA eszopiclone 1 PA HETLIOZ SP-P PA; QL INTERMEZZO 3 PA; GA

34

Drug Name Drug Tier Requirements/Limits LUNESTA 3 PA; GA ROZEREM 3 PA SECONAL 3 SONATA 3 GA zaleplon 1 zolpidem 1 zolpidem ext-rel 1 PA zolpidem sublingual 1 PA ZOLPIMIST 3 PA MIGRAINE, ERGOTAMINE DERIVATIVES CAFERGOT 3 D.H.E. 3 GA dihydroergotamine inj 1 dihydroergotamine nasal spray 1 QL ERGOMAR 3 migergot supp 1 MIGRANAL 3 GA; QL MIGRAINE, MISCELLANEOUS isometheptene/caffeine/acetaminophen 1 isometheptene/dichloralphenazone/acetam

inophen 1

PRODRIN 3 GA MIGRAINE, SELECTIVE SEROTONIN AGONIST/NSAID TREXIMET 3 PA; QL MIGRAINE, SELECTIVE SEROTONIN AGONISTS almotriptan 1 QL ALSUMA 3 PA; QL AMERGE 3 GA; QL AXERT 3 GA; QL FROVA 3 PA; GA; QL frovatriptan 1 PA; QL IMITREX 3 GA; QL MAXALT 3 GA; QL MAXALT-MLT 3 GA; QL naratriptan 1 QL RELPAX 3 PA; QL rizatriptan 1 QL sumatriptan 1 QL SUMAVEL DOSEPRO 3 PA; QL zolmitriptan 1 QL ZOMIG 3 GA; QL ZOMIG NASAL SPRAY 3 PA; QL ZOMIG ZMT 3 GA; QL MISCELLANEOUS ergoloid mesylates 1 GUANIDINE 3

35

Drug Name Drug Tier Requirements/Limits RILUTEK 3 GA riluzole 1 MOOD STABILIZERS EQUETRO 3 LITHIUM 3 lithium carbonate 1 lithium carbonate ext-rel 1 LITHOBID 3 GA MULTIPLE SCLEROSIS AMPYRA SP-P QL AUBAGIO SP-P PA; QL AVONEX SP-P PA; QL AVONEX PEN SP-P PA; QL AVONEX PREFILLED SYG SP-P PA; QL BETASERON SP-P PA; QL COPAXONE 20 MG SP-NP PA; GA; QL COPAXONE 40 MG SP-NP PA; QL EXTAVIA SP-P PA; QL GILENYA SP-P PA; QL glatopa 20 mg SP-P PA; QL PLEGRIDY SP-P PA; QL REBIF SP-P PA; QL TECFIDERA SP-P PA; QL ZINBRYTA SP-P PA MUSCULOSKELETAL THERAPY AGENTS AMRIX 3 baclofen 1 carisoprodol 1 carisoprodol/aspirin 1 carisoprodol/aspirin/codeine 1 chlorzoxazone 1 cyclobenzaprine 1 DANTRIUM 3 GA dantrolene 1 FEXMID 3 GA LORZONE 3 metaxalone 1 methocarbamol 1 orphenadrine ext-rel 1 orphenadrine/aspirin/caffeine 1 PARAFON FORTE DSC 3 GA ROBAXIN 3 GA ROBAXIN-750 3 GA SKELAXIN 3 GA SOMA 3 GA tizanidine 1

36

Drug Name Drug Tier Requirements/Limits ZANAFLEX 3 GA MYASTHENIA GRAVIS MESTINON 3 GA MESTINON SYRUP 3 MESTINON TIMESPAN 3 GA pyridostigmine 1 pyridostigmine ext-rel 1 NARCOLEPSY/CATAPLEXY armodafinil 1 PA; QL modafinil 1 PA; QL NUVIGIL 3 PA; GA; QL PROVIGIL 3 PA; GA; QL XYREM 2 PA; QL PSYCHOTHERAPEUTIC-MISC, ALCOHOL DETERRENTS acamprosate calcium 1 PV ANTABUSE 3 GA disulfiram 1 PV PSYCHOTHERAPEUTIC-MISC, OPIOID ANTAGONIST naltrexone 1 PV PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONIST/OPIOID

ANTAGONIST COMBINATIONS buprenorphine/naloxone sublingual 1 PV SUBOXONE 3 ZUBSOLV 3 PSYCHOTHERAPEUTIC-MISC, PARTIAL OPIOID AGONISTS buprenorphine sublingual 1 PV PSYCHOTHERAPEUTIC-MISC, PSEUDOBULBAR AFFECT NUEDEXTA 3 PSYCHOTHERAPEUTIC-MISC, SMOKING DETERRENTS bupropion ext-rel 1 CHANTIX 3 NICOTROL INHALER 3 NICOTROL NS 3 ZYBAN 3 GA ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 2 ANDRODERM 3 PA ANDROGEL 1% (25MG PAK) 3 PA; GA ANDROGEL 1% (50MG PAK) 3 PA ANDROGEL 1% PUMP 3 PA; GA ANDROGEL 1.62% 2 PA ANDROXY 3 AXIRON 3 PA DEPO-TESTOSTERONE 100MG/ML 3

37

Drug Name Drug Tier Requirements/Limits DEPO-TESTOSTERONE 200MG/ML 3 GA FORTESTA 3 PA; GA OXANDRIN 3 GA oxandrolone 1 STRIANT 3 PA TESTIM 3 PA; GA testosterone cypionate 1 testosterone enanthate 1 testosterone gel 1% 2 PA testosterone gel 10mg/act 2 PA VOGELXO 3 PA; GA ANTIDIABETICS, ALPHA-GLUCOSIDASE INHIBITOR acarbose 1 PV GLYSET 3 ANTIDIABETICS, AMYLIN ANALOGS SYMLINPEN 2 PV ANTIDIABETICS, BIGUANIDE/SULFONYLUREA COMBINATIONS glipizide/metformin 1 PV GLUCOVANCE 3 GA glyburide/metformin 1 PV ANTIDIABETICS, BIGUANIDES FORTAMET 3 GA GLUCOPHAGE 3 GA GLUCOPHAGE XR 3 GA metformin 1 PV metformin ext-rel 1 PV RIOMET 2 ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4)

INHIBITOR/BIGUANIDE COMBINATIONS JANUMET 2 PV JANUMET XR 2 PV JENTADUETO 2 PV KAZANO 3 MN-PA KOMBIGLYZE XR 3 MN-PA ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4)

INHIBITOR/INSULIN SENSITIZER COMBINATIONS OSENI 3 MN-PA ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS JANUVIA 2 PV NESINA 3 MN-PA ONGLYZA 3 MN-PA TRADJENTA 2 PV ANTIDIABETICS, INCRETIN MIMETIC AGENTS BYDUREON 2 PV; QL BYETTA 3 QL

38

Drug Name Drug Tier Requirements/Limits TANZEUM 3 MN-PA; QL TRULICITY 3 MN-PA; QL VICTOZA 2 PV; QL ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE COMBINATION ACTOPLUS MET 3 GA ACTOPLUS MET XR 3 pioglitazone/metformin 1 PV ANTIDIABETICS, INSULIN SENSITIZER/SULFONYLUREA COMBO pioglitazone/glimepiride 1 PV ANTIDIABETICS, INSULIN SENSITIZERS ACTOS 3 GA AVANDIA 3 pioglitazone 1 PV ANTIDIABETICS, INSULINS AFREZZA 3 PA; QL APIDRA 3 MN-PA HUMALOG 3 MN-PA HUMALOG MIX 3 MN-PA HUMULIN 70/30 3 MN-PA HUMULIN N 3 MN-PA HUMULIN R 3 MN-PA HUMULIN R U-500 2 PV LANTUS 2 PV LEVEMIR 2 PV NOVOLIN 70/30 2 PV NOVOLIN 70/30 RELION 2 PV NOVOLIN N 2 PV NOVOLIN N RELION 2 PV NOVOLIN R 2 PV NOVOLIN R RELION 2 PV NOVOLOG 2 PV NOVOLOG MIX 2 PV ANTIDIABETICS, MEGLITINIDE nateglinide 1 PV PRANDIN 3 GA repaglinide 1 PV STARLIX 3 GA ANTIDIABETICS, MEGLITINIDE/BIGUANIDE COMBINATIONS repaglinide/metformin 1 ANTIDIABETICS, MISCELLANEOUS CYCLOSET 3 ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)

INHIBITOR/BIGUANIDE COMBINATIONS INVOKAMET 3 INVOKAMET XR 3

39

Drug Name Drug Tier Requirements/Limits SYNJARDY 3 XIGDUO XR 3 MN-PA ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2)

INHIBITORS FARXIGA 3 MN-PA INVOKANA 3 JARDIANCE 3 ANTIDIABETICS, SODIUM-GLUCOSE CO-TRANSPORTER 2

INHIBITOR/DPP-4 INHIBITOR COMBINATIONS GLYXAMBI 3 ANTIDIABETICS, SULFONYLUREAS AMARYL 3 GA chlorpropamide 1 PV glimepiride 1 PV glipizide 1 PV glipizide ext-rel 1 PV GLUCOTROL 3 GA GLUCOTROL XL 3 GA glyburide 1 PV glyburide micronized 1 PV tolazamide 1 PV tolbutamide 1 PV ANTIDIABETICS, SUPPLIES ACCU-CHEK BLOOD GLUCOSE TEST

STRIPS 3 MN-PA; QL

ALL NON-PREFERRED BLOOD GLUCOSE TEST STRIPS

3 MN-PA; QL

ASCENSIA BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL BLOOD KETONE TEST STRIPS 2 PV BREEZE 2 BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL CONTOUR BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL CONTOUR NEXT BLOOD GLUCOSE TEST

STRIPS 3 MN-PA; QL

FREESTYLE BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL INSULIN SYRINGES 2 PV LANCETS 2 PV; QL ONETOUCH BLOOD GLUCOSE TEST STRIPS 2 PV; QL PEN NEEDLES 2 PV PRECISION XTRA BLOOD GLUCOSE TEST

STRIPS 3 MN-PA; QL

SURE-TEST BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL TRUETEST BLOOD GLUCOSE TEST STRIPS 3 MN-PA; QL TRUETRACK BLOOD GLUCOSE TEST

STRIPS 3 MN-PA; QL

URINE TEST STRIPS 2 PV CALCIUM RECEPTOR ANTAGONISTS

40

Drug Name Drug Tier Requirements/Limits SENSIPAR SP-P CALCIUM REGULATORS, BISPHOSPHONATES ACTONEL 3 GA alendronate 5mg, 10mg, 35mg, 70mg 1 PV alendronate 40mg 1 alendronate soln 3 ATELVIA 3 GA BONIVA TABS 3 GA etidronate 1 FOSAMAX 3 GA FOSAMAX PLUS D 3 ibandronate 1 PV risedronate 1 PV risedronate delayed-rel 1 PV CALCIUM REGULATORS, CALCITONINS calcitonin nasal spray 1 PV FORTICAL 3 MIACALCIN 3 GA CALCIUM REGULATORS, PARATHYROID HORMONES FORTEO SP-P CONTRACEPTIVES, BIPHASIC azurette 1 PV desogestrel/ethinyl estradiol 1 PV kariva 1 PV kimidess 1 PV MIRCETTE 3 GA NECON 10/11 3 pimtrea 1 PV viorele 1 PV CONTRACEPTIVES, CONTINUOUS amethyst 1 levonorgestrel/ethinyl estradiol 1 CONTRACEPTIVES, EMERGENCY CONTRACEPTION ELLA 3 CONTRACEPTIVES, EXTENDED CYCLE amethia 1 amethia lo 1 ashlyna 1 camrese 1 camrese lo 1 daysee 1 introvale 1 jolessa 1 levonorgestrel/ethinyl estradiol 1 LOSEASONIQUE 3 GA

41

Drug Name Drug Tier Requirements/Limits QUARTETTE 3 quasense 1 SEASONIQUE 3 GA setlakin 1 CONTRACEPTIVES, FOUR PHASE NATAZIA 3 CONTRACEPTIVES, INJECTABLE DEPO-PROVERA 3 GA DEPO-SUBQ PROVERA 104 3 medroxyprogesterone acetate 150mg/ml 1 CONTRACEPTIVES, MONOPHASIC altavera 1 alyacen 1 apri 1 PV aubra 1 aviane 1 balziva 1 BEYAZ 3 BREVICON 3 GA briellyn 1 chateal 1 cryselle 1 cyclafem 1 cyred 1 PV dasetta 1 delyla 1 DESOGEN 3 GA desogestrel/ethinyl estradiol 1 PV drospirenone/ethinyl estradiol 1 elinest 1 emoquette 1 PV enskyce 1 PV estarylla 1 FALESSA 3 falmina 1 FEMCON FE 3 GA GENERESS FE 3 GA gianvi 1 gildagia 1 gildess 1 PV gildess fe 1 PV gildess fe 24 1 juleber 1 PV junel 1 PV junel fe 1 PV junel fe 24 1

42

Drug Name Drug Tier Requirements/Limits kelnor 1 kurvelo 1 larin 1 PV larin fe 1 PV larin fe 24 1 layolis fe chew 1 lessina 1 levonorgestrel/ethinyl estradiol 1 levora 1 LO LOESTRIN 3 LOESTRIN 3 GA LOESTRIN FE 3 GA lomedia fe 24 1 loryna 1 low-ogestrel 1 lutera 1 marlissa 1 microgestin 1 PV microgestin fe 1 PV microgestin fe 24 1 MINASTRIN FE 24 3 MODICON 3 GA mono-linyah 1 mononessa 1 necon 1 necon 3 nikki 1 norethindrone/ethinyl estradiol 1 PV norethindrone/ethinyl estradiol fe 1 norethindrone/ethinyl estradiol fe 1 PV norethindrone/ethinyl estradiol fe chew 1 norgestimate/ethinyl estradiol 1 NORINYL 3 GA nortrel 1 ocella 1 ogestrel 1 orsythia 1 ORTHO-CYCLEN 3 GA ORTHO-NOVUM 3 GA OVCON-35 3 GA philith 1 pirmella 1 portia 1 previfem 1 reclipsen 1 PV SAFYRAL 3 sprintec 1 43

Drug Name Drug Tier Requirements/Limits sronyx 1 syeda 1 tarina fe 1 PV TAYTULLA 3 vestura 1 vyfemla 1 wera 1 wymzya fe chew 1 PV YASMIN 3 GA YAZ 3 GA zarah 1 zenchent 1 zenchent fe chew 1 PV zovia 1 CONTRACEPTIVES, PROGESTIN ONLY camila 1 deblitane 1 errin 1 heather 1 jencycla 1 jolivette 1 lyza 1 NOR-QD 3 GA nora-be 1 norethindrone 1 norlyroc 1 ORTHO MICRONOR 3 GA sharobel 1 CONTRACEPTIVES, TRANSDERMAL xulane 1 CONTRACEPTIVES, TRIPHASIC alyacen 1 aranelle 1 caziant 1 PV cyclafem 1 CYCLESSA 3 GA dasetta 1 enpresse 1 ESTROSTEP FE 3 GA leena 1 levonorgestrel/ethinyl estradiol 1 myzilra 1 necon 1 norgestimate/ethinyl estradiol 1 nortrel 1 ORTHO TRI-CYCLEN 3 GA

44

Drug Name Drug Tier Requirements/Limits ORTHO TRI-CYCLEN LO 3 GA ORTHO-NOVUM 7/7/7 3 GA pirmella 1 tilia fe 1 PV tri-estaryll 1 tri-legest fe 1 PV tri-linyah 1 tri-lo-sprintec 1 TRI-NORINYL 3 GA tri-previfem 1 tri-sprintec 1 trinessa 1 trivora 1 velivet 1 PV CONTRACEPTIVES, VAGINAL NUVARING 3 ENDOMETRIOSIS danazol 1 ESTROGEN/PROGESTIN, ORAL ACTIVELLA 3 GA ANGELIQ 3 estradiol/norethindrone 1 ethinyl estradiol/norethindrone 1 FEMHRT LOW DOSE 3 GA JEVANTIQUE LO 3 GA jinteli 1 lopreeza 1 mimvey 1 mimvey lo 1 PREFEST 3 PREMPHASE 2 PREMPRO 2 ESTROGEN/PROGESTIN, TRANSDERMAL CLIMARA PRO 3 COMBIPATCH 3 ESTROGEN/SELECTIVE ESTROGEN RECEPTOR MODULATOR

COMBINATIONS DUAVEE 3 ESTROGENS, ORAL covaryx 1 covaryx hs 1 eemt 1 eemt hs 1 ENJUVIA 3 esterified estrogens/methyltestosterone 1 ESTRACE 3 GA 45

Drug Name Drug Tier Requirements/Limits estradiol 1 estropipate 1 MENEST 3 PREMARIN 2 ESTROGENS, TRANSDERMAL CLIMARA 3 GA DIVIGEL 3 ELESTRIN 3 estradiol transdermal twice weekly 1 QL estradiol transdermal weekly 1 ESTROGEL 3 EVAMIST 3 MENOSTAR 3 MINIVELLE 3 QL VIVELLE-DOT 3 GA; QL ESTROGENS, VAGINAL ESTRACE CREAM 2 ESTRING 3 FEMRING 3 PREMARIN CREAM 2 VAGIFEM 3 GA yuvafem 1 GLUCOCORTICOIDS CORTEF 3 GA cortisone 3 dexamethasone 1 DEXAMETHASONE INTENSOL 1 dexamethasone oral soln 0.5mg/5ml 1 DEXPAK 3 FLO-PRED 3 fludrocortisone 1 hydrocortisone 1 KENALOG INJ 3 MEDROL 3 GA MEDROL 2MG 3 methylprednisolone 1 MILLIPRED 3 ORAPRED ODT 3 GA PEDIAPRED 3 GA prednisolone sodium phosphate odt, soln 1 prednisolone syrup 1 prednisone 1 PREDNISONE INTENSOL 1 RAYOS 3 VERIPRED 3 GLUCOSE ELEVATING AGENT

46

Drug Name Drug Tier Requirements/Limits GLUCAGEN HYPOKIT 2 GLUCAGON EMERGENCY KIT 2 HUMAN GROWTH HORMONES GENOTROPIN SP-NP PA HUMATROPE SP-NP PA NORDITROPIN SP-P PA NUTROPIN AQ SP-NP PA OMNITROPE SP-NP PA SAIZEN SP-NP PA SEROSTIM SP-NP PA ZOMACTON SP-NP PA ZORBTIVE SP-NP PA HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS calcitriol caps 1 calcitriol soln 3 doxercalciferol 1 HECTOROL 3 GA paricalcitol 1 RAYALDEE 3 ROCALTROL 3 GA ZEMPLAR 3 GA INSULIN-LIKE GROWTH FACTOR INCRELEX SP-P LYSOSOMAL STORAGE DISORDERS CERDELGA SP-P ZAVESCA SP-P MISCELLANEOUS cabergoline 1 CARBAGLU 3 CARNITOR 3 GA CYSTADANE 3 KORLYM 2 levocarnitine 1 methylergonovine 1 octreotide SP-P ORFADIN 3 ORFADIN SUSP 3 RAVICTI SP-P PA; QL SANDOSTATIN SP-NP GA SOMAVERT SP-P STRENSIQ SP-P SYPRINE 3 PHENYLKETONURIA TREATMENT AGENTS KUVAN SP-P PA PHOSPHATE BINDER AGENTS

47

Drug Name Drug Tier Requirements/Limits calcium acetate 1 ELIPHOS 3 GA FOSRENOL 3 PHOSLO 3 GA PHOSLYRA 3 RENAGEL 3 RENVELA 3 VELPHORO 3 PROGESTINS, INJECTABLE progesterone 50mg/ml 1 PROGESTINS, ORAL AYGESTIN 3 GA medroxyprogesterone acetate 1 MEGACE ES 3 GA megestrol susp 1 norethindrone acetate 1 progesterone micronized 1 PROMETRIUM 3 GA PROVERA 3 GA PROGESTINS, VAGINAL CRINONE GEL 4% 3 SELECTIVE ESTROGEN RECEPTOR MODULATOR EVISTA 3 PA; GA OSPHENA 3 raloxifene 1 PA; PV THYROID AGENTS, ANTITHYROID AGENTS iodine soln strong (lugol's) 3 methimazole 1 propylthiouracil 1 SSKI 3 THYROID SUPPLEMENTS ARMOUR THYROID 15MG, 120MG, 180MG,

240MG, 300MG 3

ARMOUR THYROID 30MG, 60MG, 90MG 3 GA CYTOMEL 3 GA levothyroxine 1 levoxyl 1 liothyronine 1 NATURE THROID 3 SYNTHROID 2 GA thyroid tab 1 THYROLAR 3 TIROSINT 3 unithroid 1 WESTHROID 3 WP THYROID 3 48

Drug Name Drug Tier Requirements/Limits VASOPRESSIN RECEPTOR ANTAGONISTS SAMSCA 3 QL VASOPRESSINS DDAVP 3 GA desmopressin 1 STIMATE 3 GASTROINTESTINAL ANTIDIARRHEALS diphenoxylate/atropine 1 LOMOTIL 3 GA MOTOFEN 3 opium tincture 1 ANTIEMETICS AKYNZEO 3 ANZEMET 2 CESAMET 2 COMPAZINE 3 GA dronabinol 1 EMEND 2 granisetron 1 MARINOL 3 GA metoclopramide 1 METOZOLV ODT 3 GA ondansetron 1 ondansetron soln 1 QL prochlorperazine 1 prochlorperazine supp 1 promethazine 1 promethazine supp 1 REGLAN 3 GA SANCUSO 3 PA; QL TIGAN 3 GA TRANSDERM-SCOP 3 trimethobenzamide 1 VARUBI 3 QL ZOFRAN 3 GA ZOFRAN SOLN 3 GA; QL ZUPLENZ 3 ANTISPASMODICS ANASPAZ 3 GA BELLADONNA/OPIUM SUPP 1 BENTYL 3 GA CANTIL 2 chlordiazepoxide/clidinium 1 CUVPOSA 3 dicyclomine 1 49

Drug Name Drug Tier Requirements/Limits DONNATAL 3 GASTRINEX NF 3 glycopyrrolate 1 hyoscyamine sulfate 1 hyoscyamine sulfate ext-rel 1 LEVBID 3 GA LEVSIN 3 GA LIBRAX 3 GA methscopolamine 1 propantheline 1 ROBINUL 3 GA ROBINUL FORTE 3 GA SYMAX DUOTAB 3 CHOLELITHOLYTICS ACTIGALL 3 GA CHENODAL 2 URSO 250 3 GA URSO FORTE 3 GA ursodiol 1 H2-RECEPTOR ANTAGONISTS cimetidine 1 famotidine 1 nizatidine 1 PEPCID 3 GA ranitidine 1 ZANTAC 3 GA INFLAMMATORY BOWEL DISEASE, ORAL AGENTS APRISO 3 ASACOL HD 3 AZULFIDINE 3 GA AZULFIDINE EN-TABS 3 GA balsalazide 1 budesonide caps 1 COLAZAL 3 GA DELZICOL 3 DIPENTUM 2 ENTOCORT EC 3 GA GIAZO 3 LIALDA 3 PENTASA 3 sulfasalazine 1 sulfasalazine delayed-rel 1 UCERIS 3 INFLAMMATORY BOWEL DISEASE, RECTAL AGENTS CANASA 2 CORTIFOAM 3

50

Drug Name Drug Tier Requirements/Limits hydrocortisone enema 1 mesalamine enema 1 SFROWASA 3 UCERIS FOAM 3 IRRITABLE BOWEL SYNDROME WITH CONSTIPATION AMITIZA 3 PA LINZESS 3 PA IRRITABLE BOWEL SYNDROME WITH DIARRHEA alosetron 1 LOTRONEX 3 GA VIBERZI 3 LAXATIVES/STOOL SOFTENERS CASCARA SAGRADA 2 COLYTE/FLAVOR PACKS 3 GA GOLYTELY 3 GOLYTELY 3 GA KRISTALOSE 1 lactulose 1 MOVIPREP 2 PV NULYTELY 3 GA OSMOPREP 2 PV peg 3350/electrolytes 1 PV PREPOPIK 3 SUPREP 2 PV MISCELLANEOUS BUPHENYL 3 BUPHENYL POWDER 3 GA CARAFATE 3 GA CARAFATE SUSP 3 cromolyn sodium 100mg/5ml 1 ENTEREG 3 GASTROCROM 3 GA lactulose (encephalopathy) 1 OCALIVA SP-P PA RECTIV 3 SUCRAID 2 sucralfate 1 OPIOID-INDUCED CONSTIPATION MOVANTIK 3 PA RELISTOR 3 MN-PA; QL PANCREATIC ENZYMES CREON 2 PANCREAZE 2 PERTZYE 2 VIOKACE 2 ZENPEP 2 51

Drug Name Drug Tier Requirements/Limits PROSTAGLANDINS CYTOTEC 3 GA misoprostol 1 PROTON PUMP INHIBITORS (PPI) ACIPHEX 3 GA; QL ACIPHEX SPRINKLE 3 PA; QL DEXILANT 3 PA; QL esomeprazole 1 PA; QL lansoprazole 1 QL NEXIUM 3 PA; GA; QL NEXIUM GRANULES 3 PA; QL omeprazole 1 QL pantoprazole 1 QL PREVACID 3 GA; QL PREVACID SOLUTAB 3 PA; QL PRILOSEC 3 GA; QL PRILOSEC POWDER 3 PA; QL PROTONIX 3 GA; QL PROTONIX PAK 3 PA; QL rabeprazole 1 QL SALIVA STIMULANTS cevimeline 1 EVOXAC 3 GA pilocarpine 1 SALAGEN 3 GA STEROIDS, RECTAL ANALPRAM-HC CREAM 3 GA ANALPRAM-HC LOTION 3 ANUSOL-HC 3 GA EPIFOAM 3 hydrocortisone acetate supp 1 hydrocortisone cream 1 hydrocortisone/pramoxine 1 lidazone 1 lidocaine/hydrocortisone 1 LIDOCAINE/HYDROCORTISONE GEL 1 PROCORT 3 PROCTOCORT 3 GA PROCTOFOAM HC 3 ULCER THERAPY COMBINATION lansoprazole/amoxicillin/clarithromycin 1 OMECLAMOX-PAK 3 PREVPAC 3 GA PYLERA 3 GENITOURINARY BENIGN PROSTATIC HYPERPLASIA 52

Drug Name Drug Tier Requirements/Limits alfuzosin 1 AVODART 3 GA CARDURA XL 3 dutasteride 1 dutasteride/tamsulosin 1 finasteride 1 FLOMAX 3 GA JALYN 3 GA PROSCAR 3 GA RAPAFLO 3 QL tamsulosin 1 UROXATRAL 3 GA ERECTILE DYSFUNCTION, ALPROSTADIL AGENTS CAVERJECT 3 QL EDEX 3 QL MUSE 3 QL ERECTILE DYSFUNCTION, PHOSPHODIESTERASE INHIBITORS CIALIS 3 PA; QL LEVITRA 3 PA; QL STAXYN 3 PA; QL STENDRA 3 PA; QL VIAGRA 2 PA; QL MISCELLANEOUS bethanechol 1 CYSTAGON 2 ELMIRON 3 LITHOSTAT 3 methenamine hippurate 1 methenamine mandelate 1 methenamine/hyoscyamine/methylene

blue/phenyl salicylate/benzoic acid 1

methenamine/hyoscyamine/methylene blue/phenyl salicylate/sodium bisphosphonate

1

methenamine/hyoscyamine/methylene blue/phenyl salicylate/sodium phosphate

1

methenamine/hyoscyamine/methylene blue/sodium phosphate

1

ORACIT 3 phenazopyridine 1 potassium citrate 1 potassium citrate/citric acid 1 potassium citrate/sodium citrate/citric acid 1 PROCYSBI 3 PYRIDIUM 3 GA RIMSO-50 3 SHOHLS SOLN MODIFIED 3 GA 53

Drug Name Drug Tier Requirements/Limits sodium citrate/citric acid 1 THIOLA 2 UROCIT-K 3 GA UROGESIC-BLUE 3 GA UROQID #2 2 URINARY ANTISPASMODICS darifenacin ext-rel 1 DETROL 3 GA DETROL LA 3 GA DITROPAN XL 3 GA ENABLEX 3 GA flavoxate 1 GELNIQUE 3 MYRBETRIQ 3 oxybutynin 1 oxybutynin ext-rel 1 tolterodine 1 tolterodine ext-rel 1 TOVIAZ 3 QL trospium 1 trospium ext-rel 1 VESICARE 3 VAGINAL ANTI-INFECTIVES AVC 3 CLEOCIN CREAM 3 GA CLEOCIN SUPP 3 clindamycin cream 1 CLINDESSE 3 GYNAZOLE-1 3 METROGEL-VAGINAL 3 GA metronidazole gel 0.75% 1 NUVESSA 3 TERAZOL 3 3 GA TERAZOL 7 3 GA terconazole cream 0.4% 1 terconazole cream 0.8% 1 PV terconazole supp 1 HEMATOLOGIC ANTICOAGULANTS, INJECTABLE ARIXTRA 3 GA enoxaparin 1 fondaparinux 1 FRAGMIN 2 LOVENOX 3 GA ANTICOAGULANTS, ORAL COUMADIN 2 GA; PV

54

Drug Name Drug Tier Requirements/Limits ELIQUIS 2 PV PRADAXA 2 PV SAVAYSA 3 MN-PA warfarin 1 PV XARELTO 2 PV HEMATOPOIETIC GROWTH FACTORS ARANESP SP-P EPOGEN SP-P GRANIX SP-P LEUKINE SP-P NEULASTA SP-P NEUPOGEN SP-P PROCRIT SP-P ZARXIO SP-P HEMOSTATICS, SYSTEMIC AMICAR 3 LYSTEDA 3 GA tranexamic acid 1 HEREDITARY ANGIOEDEMA AGENTS FIRAZYR SP-P PA IDIOPATHIC THROMBOCYTOPENIC PURPURA PROMACTA SP-P QL MISCELLANEOUS CHEMET 2 cilostazol 1 EXJADE 2 FERRIPROX 3 pentoxifylline 1 PLATELET AGGREGATION INHIBITORS AGGRENOX 3 GA aspirin/dipyridamole ext-rel 1 BRILINTA 3 clopidogrel 1 PV dipyridamole 1 PV EFFIENT 3 PLAVIX 3 GA PLATELET SYNTHESIS INHIBITORS anagrelide 1 IMMUNOLOGIC AGENTS ALLERGENIC EXTRACTS GRASTEK 3 PA; QL ORALAIR 3 PA; QL RAGWITEK 3 PA; QL BIOLOGIC DISEASE-MODIFYING AGENTS ACTEMRA SP-P PA; QL

55

Drug Name Drug Tier Requirements/Limits CIMZIA SP-NP PA; QL ENBREL SP-P PA; QL HUMIRA SP-P PA; QL KINERET SP-P PA; QL ORENCIA SP-P PA; QL SIMPONI SP-NP PA; QL DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDS) ARAVA 3 GA DEPEN 2 hydroxychloroquine 1 leflunomide 1 PLAQUENIL 3 GA RHEUMATREX 2 RIDAURA 2 XELJANX XR SP-P PA; QL XELJANZ SP-P PA; QL IMMUNOMODULATORS, INTERFERONS ACTIMMUNE SP-P PEGASYS SP-P PA; QL PEGINTRON SP-P PA; QL SYLATRON SP-P IMMUNOMODULATORS, MISCELLANEOUS OTEZLA SP-P PA; QL IMMUNOSUPPRESSANTS, ANTIMETABOLITES AZASAN 1 azathioprine 1 CELLCEPT 2 GA IMURAN 3 GA mycophenolate mofetil 1 PV mycophenolate sodium delayed-rel 1 PV MYFORTIC 3 GA IMMUNOSUPPRESSANTS, CALCINEURIN INHIBITORS ASTAGRAF XL 2 PV cyclosporine 1 PV cyclosporine modified 1 PV NEORAL 3 GA PROGRAF 3 GA SANDIMMUNE 3 GA SANDIMMUNE SOLN 3 tacrolimus 1 PV IMMUNOSUPPRESSANTS, RAPAMYCIN DERIVATIVE RAPAMUNE SOLN 2 PV RAPAMUNE TABS 3 GA sirolimus 1 PV ZORTRESS SP-P VACCINES 56

Drug Name Drug Tier Requirements/Limits ACTHIB 2 PV ADACEL 2 PV AFLURIA 2 PV BEXSERO 2 PV BOOSTRIX 2 PV CERVARIX 2 PV DAPTACEL 2 PV DIPHTHERIA/TETANUS TOXOID 2 PV ENGERIX-B 2 PV FLUAD 2 PV FLUARIX 2 PV FLUBLOK 2 PV FLUCELVAX 2 PV FLUCELVAX QUAD 2 PV FLULAVAL 2 PV FLUVIRIN 2 PV FLUZONE 2 PV GARDASIL 2 PV HAVRIX 2 PV HIBERIX 2 PV INFANRIX 2 PV IPOL INACTIVATED IPV 2 PV KINRIX 2 PV M-M-R II 2 PV MENACTRA 2 PV MENHIBRIX 2 PV MENOMUNE 2 PV MENVEO 2 PV PEDIARIX 2 PV PEDVAX HIB 2 PV PENTACEL 2 PV PNEUMOVAX 23 2 PV PREVNAR 13 2 PV PROQUAD 2 PV QUADRACEL 2 PV RECOMBIVAX HB 2 PV ROTARIX 2 PV ROTATEQ 2 PV TENIVAC 2 PV TRUMENBA 2 PV TWINRIX 2 PV VAQTA 2 PV VARIVAX 2 PV ZOSTAVAX 2 PV MISCELLANEOUS DIAGNOSTIC PRODUCTS

57

Drug Name Drug Tier Requirements/Limits CHEMSTRIP 2 PV COMBISTIX 2 PV HEMA-COMBISTIX 2 PV LABSTIX 2 PV MULTISTIX 2 PV URISTIX 2 PV NUTRITIONAL / SUPPLEMENTS ELECTROLYTES, MISCELLANEOUS K-PHOS 3 K-PHOS NEUTRAL 3 GA K-PHOS NO 2 3 potassium/sodium phosphates 1 ELECTROLYTES, POTASSIUM EFFER-K 3 K-TAB 3 GA KLOR-CON M15 1 KLOR-CON/25 3 MICRO-K 3 GA potassium bicarbonate effervescent 1 potassium bicarbonate/chloride

effervescent 1

potassium chloride ext-rel 1 potassium chloride powder 1 potassium chloride soln 1 ELECTROLYTES, POTASSIUM-REMOVING AGENTS sodium polystyrene sulfonate susp 1 VELTASSA SP-P VITAMINS AND MINERALS, FOLIC ACID / COMBINATIONS folic acid 1 VITAMINS AND MINERALS, MISCELLANEOUS MAGNEBIND 400 3 MEPHYTON 2 VITAMINS AND MINERALS, PRENATAL VITAMINS ACTIVE OB 2 PV ATABEX EC 2 PV BAL-CARE DHA 2 PV C-NATE DHA 2 PV CALCIUM PNV 2 PV CITRANATAL 2 PV CO-NATAL FA 2 PV COMPLETE NATAL DHA 2 PV COMPLETENATE 2 PV CONCEPT 2 PV DOTHELLE DHA 2 PV DUET DHA 2 PV elite-ob 2 PV 58

Drug Name Drug Tier Requirements/Limits ENBRACE HR 2 PV EXTRA-VIRT PLUS DHA 2 PV FOCALGIN 2 PV FOLCAL DHA 2 PV FOLCAPS OMEGA 3 2 PV FOLET 2 PV folinatal plus b 2 PV FOLIVANE-OB 2 PV HEMENATAL 2 PV inatal advance 2 PV inatal gt 2 PV inatal ultra 2 PV INFANATE BALANCE 2 PV LEVOMEFOLATE DHA 2 PV MACNATAL CN DHA 2 PV MARNATAL-F 2 PV multinatal plus 2 PV MYNATAL 2 PV MYNATE 90 PLUS 2 PV NATACHEW 2 PV NATALVIT 2 PV NATELLE ONE 2 PV NEEVO DHA 2 PV NESTABS 2 PV NEWGEN 2 PV NEXA PLUS 2 PV O-CAL PRENATAL 2 PV OB COMPLETE 2 PV OB COMPLETE GOLD 2 PV OBSTETRIX 2 PV PAIRE OB 2 PV PNV OB+DHA 2 PV PNV TABS 29-1 2 PV pnv-dha 2 PV PNV-DHA+DOCUSATE 2 PV PNV-OMEGA 2 PV pnv-select 2 PV PNV-TOTAL 2 PV PNV-VP-U 2 PV PR NATAL 2 PV PREFERAOB 2 PV PRENA1 2 PV PRENAISSANCE 2 PV PRENATA 2 PV prenatabs fa 2 PV prenatabs rx 2 PV PRENATAL 2 PV 59

Drug Name Drug Tier Requirements/Limits PRENATAL 19 CHEW 2 PV PRENATAL 19 TABS 2 PV PRENATAL VITAMINS/FERROUS

FUMARATE/DOCUSATE 2 PV

PRENATE 2 PV PREQUE 10 2 PV PRETAB 2 PV PROVIDA 2 PV PUREFE OB PLUS 2 PV R-NATAL OB 2 PV REDICHEW RX 2 PV RELNATE DHA 2 PV RULAVITE DHA 2 PV SE-NATAL 19 2 PV SE-TAN DHA 2 PV SELECT-OB 2 PV TARON-BC 2 PV TARON-C DHA 2 PV TARON-PREX 2 PV THRIVITE 2 PV TL FOLATE 2 PV TL-CARE DHA 2 PV TL-SELECT 2 PV TRI-TABS DHA 2 PV triadvance 2 PV TRICARE 2 PV TRINATAL 2 PV trinate 2 PV TRISTART DHA 2 PV TRIVEEN-DUO DHA 2 PV TRIVEEN-PRX 2 PV ULTIMATECARE 2 PV ultra tabs 2 PV VEMAVITE 2 PV VENA-BAL DHA 2 PV VINACAL B 2 PV VINATE 2 PV VIRT NATE 2 PV VIRT-ADVANCE 2 PV VIRT-C DHA 2 PV VIRT-CARE ONE 2 PV VIRT-PN 2 PV VIRT-SELECT 2 PV VIRT-VITE GT 2 PV VIRTPREX 2 PV VITA-PREN 2 PV VITAFOL 2 PV 60

Drug Name Drug Tier Requirements/Limits VITAMEDMD 2 PV VITAPEARL 2 PV VITATRUE 2 PV VIVA DHA 2 PV VOL-NATE 2 PV VOL-TAB RX 2 PV VP-CH 2 PV VP-GGR-B6 PRENATAL 2 PV VP-HEME 2 PV VP-PNV-DHA 2 PV ZATEAN 2 PV RESPIRATORY ANAPHYLAXIS TREATMENT AGENTS ADRENACLICK 3 GA epinephrine inj 3 EPIPEN 2 EPIPEN JR 2 ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPTA 3 COMBIVENT RESPIMAT 2 ipratropium/albuterol nebulizer soln 1 STIOLTO RESPIMAT 3 ANTICHOLINERGICS ATROVENT HFA 2 ipratropium nebulizer soln 1 SPIRIVA HANDIHALER 2 SPIRIVA RESPIMAT 3 TUDORZA PRESSAIR 3 ANTIHISTAMINE/DECONGESTANT COMBINATIONS CLARINEX-D 12 HOUR 3 DECON-A 3 promethazine/phenylephrine 1 RELHIST 3 RESCON-MX 3 SEMPREX-D 3 ANTIHISTAMINES, LOW-SEDATING levocetirizine 1 XYZAL 3 GA ANTIHISTAMINES, NONSEDATING CLARINEX 3 GA CLARINEX SYRUP 3 desloratadine 1 ANTIHISTAMINES, SEDATING brompheniramine 1 carbinoxamine 1

61

Drug Name Drug Tier Requirements/Limits clemastine 1 cyproheptadine 1 hydroxyzine hcl 1 hydroxyzine pamoate 1 KARBINAL ER 3 RESPA-BR 3 VISTARIL 3 GA ANTITUSSIVE COMBINATIONS, NON-OPIOID CARBAPHEN 3 DECON-G 3 dextromethorphan/brompheniramine/pseu

doephedrine 1

dextromethorphan/brompheniramine/pseudoephedrine

3

dextromethorphan/chlorpheniramine/phenylephrine

3

dextromethorphan/guaifenesin/phenylephrine

1

EXACTUSS 3 GA GILTUSS 3 GA giltuss pediatric 1 NEOTUSS PLUS 3 NORTUSS-EX 3 PEDIATEX TDM 3 promethazine/dextromethorphan 1 TGQ DM/BPM/PSE 3 TGQ DM/CPM/PE 3 TGQ DM/GFN/PSE 3 TUSNEL 3 ANTITUSSIVE COMBINATIONS, OPIOID FLOWTUSS 3 GILTUSS PED-C 3 HYCOFENIX 3 hydrocodone polistirex/chlorpheniramine 1 hydrocodone/chlorpheniramine/pseudoeph

edrine 1

hydrocodone/homatropine 1 OBREDON 3 promethazine/codeine 1 promethazine/phenylephrine/codeine 1 REZIRA 3 SUTTAR-2 3 GA SUTTAR-SF 3 GA TUSSICAPS 3 TUSSIONEX 3 GA TUZISTRA XR 3 VITUZ 3 62

Drug Name Drug Tier Requirements/Limits ZUTRIPRO 3 GA ANTITUSSIVES benzonatate 1 TESSALON PERLES 3 GA ZONATUSS 3 GA BETA AGONISTS, INHALANTS, LONG ACTING ARCAPTA NEOHALER 3 BROVANA 2 PV FORADIL AEROLIZER 2 PV PERFOROMIST 2 PV SEREVENT DISKUS 2 PV STRIVERDI RESPIMAT 3 BETA AGONISTS, INHALANTS, SHORT ACTING albuterol nebulizer soln 1 levalbuterol nebulizer soln 1 metaproterenol 1 PROAIR HFA 1 PROVENTIL HFA 2 VENTOLIN HFA 2 XOPENEX HFA 3 XOPENEX NEBULIZER 3 GA BETA AGONISTS, ORAL AGENTS albuterol 1 albuterol ext-rel 1 terbutaline 1 VOSPIRE ER 3 GA CYSTIC FIBROSIS CAYSTON 3 KALYDECO SP-P PA; QL ORKAMBI SP-P PA; QL PULMOZYME SP-P TOBI NEBULIZER SP-NP GA tobramycin nebulizer soln SP-P DECONGESTANT/EXPECTORANT COMBINATIONS phenylephrine/guaifenesin 1 LEUKOTRIENE MODIFIERS ACCOLATE 3 GA montelukast 1 PV SINGULAIR 3 GA zafirlukast 1 PV ZYFLO 3 ZYFLO CR 3 MAST CELL STABILIZERS cromolyn sodium nebulizer soln 1 PV MISCELLANEOUS

63

Drug Name Drug Tier Requirements/Limits acetylcysteine 1 ATROVENT NASAL 3 GA caffeine citrate 1 dyphylline-guaifenesin 1 HYPERSAL 3.5% 3 HYPERSAL 7% 3 GA ipratropium nasal spray 1 NEBUSAL 3 sodium chloride nebulizer soln 1 XOLAIR SP-P PA; QL NASAL ANTIHISTAMINE/STEROID COMBINATIONS DYMISTA 3 PA NASAL ANTIHISTAMINES ASTEPRO 3 GA azelastine spray 1 olopatadine spray 1 PATANASE 3 GA NASAL DECONGESTANTS ADRENALIN 3 TYZINE 3 NASAL STEROIDS BECONASE AQ 3 PA flunisolide spray 1 mometasone spray 1 PA NASONEX 3 PA; GA OMNARIS 3 PA QNASL 3 PA VERAMYST 3 PA ZETONNA 3 PA PHOSPHODIESTERASE-4 INHIBITORS DALIRESP 3 PULMONARY FIBROSIS AGENTS ESBRIET SP-P PA; QL OFEV SP-P PA; QL STEROID INHALANTS AEROSPAN 3 MN-PA ALVESCO 3 MN-PA ASMANEX 1 PV budesonide nebulizer susp 1 PV FLOVENT DISKUS 3 MN-PA FLOVENT HFA 3 MN-PA PULMICORT 3 GA PULMICORT FLEXHALER 3 MN-PA QVAR 1 PV STEROID/BETA AGONIST COMBINATIONS

64

Drug Name Drug Tier Requirements/Limits ADVAIR DISKUS 2 PV ADVAIR HFA 2 PV BREO ELLIPTA 3 DULERA 2 PV SYMBICORT 3 MN-PA XANTHINES ELIXOPHYLLIN 3 LUFYLLIN 3 THEO-24 1 theophylline ext-rel 1 theophylline soln 1 TOPICAL DERMATOLOGY, ACNE: ORAL claravis 1 myorisan 1 zenatane 1 DERMATOLOGY, ACNE: TOPICAL ACANYA 3 PA ACZONE 3 adapalene 1 ATRALIN 3 PA; GA AVAR 3 AVAR LS 3 AVAR LS CLEANSER 3 GA AVAR-E LS 3 GA AZELEX 3 BENZACLIN 3 PA BENZACLIN PUMP 3 PA; GA BENZAMYCIN 3 GA BENZAMYCIN PAK 3 BENZEFOAM 3 GA BENZIQ 3 benzoyl peroxide 1 BPO 1 CLEOCIN-T 3 GA clindamycin foam 1 PA clindamycin gel, lotn, soln, swab 1 clindamycin/benzoyl peroxide 1 PA DIFFERIN 3 GA DUAC GEL 3 PA; GA EPIDUO 3 ERYGEL 3 GA erythromycin gel, pads, soln 1 erythromycin/benzoyl peroxide 1 EVOCLIN 3 PA; GA KLARON 3 GA

65

Drug Name Drug Tier Requirements/Limits NUOX 3 PLEXION CLEANSER, CREAM, LOTION 3 GA PLEXION PADS 3 RETIN-A 3 PA; GA RIAX 3 ROSULA 3 sulfacetamide lotion 1 sulfacetamide/sulfur 1 SULFOAM 3 SUMADAN WASH 3 GA SUMAXIN 3 GA TAZORAC 3 TRETIN-X 3 tretinoin 1 PA VANOXIDE-HC 3 VELTIN 3 PA ZACLIR 3 ZIANA 3 PA DERMATOLOGY, ACTINIC KERATOSIS CARAC 3 PA; GA diclofenac gel 3% 1 PA EFUDEX 3 GA FLUOROPLEX 3 PA fluorouracil cream 0.5% 1 PA fluorouracil cream, drop, soln 5% 1 fluorouracil drop, soln 2% 1 LEVULAN KERASTICK 3 METVIXIA 3 PICATO 3 PA SOLARAZE 3 PA; GA ZYCLARA 3 PA DERMATOLOGY, ANTI-INFECTIVE/ANTI-INFLAMMATORY

COMBINATIONS CORTISPORIN CREAM 0.5% 3 CORTISPORIN OINT 1% 3 NEO-SYNALAR 3 DERMATOLOGY, ANTIBIOTICS ALTABAX 3 BACTROBAN 3 GA BACTROBAN NASAL 3 CENTANY 3 gentamicin 1 mupirocin 1 SILVADENE 3 GA silver sulfadiazine 1 DERMATOLOGY, ANTIFUNGALS 66

Drug Name Drug Tier Requirements/Limits ciclopirox 1 clotrimazole/betamethasone 1 econazole 1 ECOZA 3 ERTACZO 3 EXELDERM 3 EXTINA 3 GA HALOTIN 1 ketoconazole 1 LOPROX SHAMPOO 3 GA LOTRISONE 3 GA LUZU 3 naftifine cream 1 NAFTIN CREAM 3 GA NAFTIN GEL 3 NIZORAL 3 GA nystatin topical 1 nystatin/triamcinolone 1 oxiconazole cream 1 OXISTAT CREAM 3 GA OXISTAT LOTION 3 PENLAC 3 GA VUSION 3 DERMATOLOGY, ANTIPSORIATICS, INJECTABLE COSENTYX SP-P PA; QL COSENTYX PEN SP-P PA; QL DERMATOLOGY, ANTIPSORIATICS, ORAL acitretin 1 methoxsalen 1 8-MOP 3 OXSORALEN-ULTRA 3 GA SORIATANE 3 GA DERMATOLOGY, ANTIPSORIATICS, TOPICAL calcipotriene 1 calcitriol oint 1 DOVONEX 3 GA DRITHO-CREME HP 3 SORILUX 3 TACLONEX OINT 3 GA TACLONEX SUSP 3 VECTICAL 3 GA ZITHRANOL 3 ZITHRANOL-RR 3 DERMATOLOGY, ANTISEBORRHEICS OVACE PLUS CREAM, FOAM, LOTION 3 OVACE PLUS SHAMPOO, WASH 3 GA

67

Drug Name Drug Tier Requirements/Limits OVACE WASH 3 GA selenium sulfide 1 SELRX 3 sulfacetamide gel, shampoo, wash 1 DERMATOLOGY, ANTISEPTICS/DISINFECTANTS triple dye soln 3 DERMATOLOGY, CORTICOSTEROID COMBINATIONS PRAMOSONE CREAM 1-1% 1 PRAMOSONE CREAM 1-2.5% 3 GA PRAMOSONE E 3 PRAMOSONE LOTION 1 PRAMOSONE OINT 3 pramoxine/hydrocortisone 1-2.5% 1 DERMATOLOGY, CORTICOSTEROIDS: HIGH POTENCY amcinonide cream, lotion 0.1% 1 AMCINONIDE OINT 0.1% 1 APEXICON E 3 betamethasone dipropionate augmented

cream, lotion 0.05% 1

betamethasone dipropionate cream, lotion, oint 0.05%

1

desoximetasone cream, oint 0.25% 1 desoximetasone gel 0.05% 1 diflorasone 1 DIPROLENE 3 GA DIPROLENE AF 3 GA fluocinonide cream 0.1% 1 fluocinonide cream, gel, oint, soln 0.05% 1 fluocinonide-e cream 0.05% 1 HALOG 3 TOPICORT CREAM, OINT 0.25% 3 GA TOPICORT GEL 0.05% 3 GA TOPICORT SPRAY 0.25% 3 triamcinolone cream, oint 0.5% 1 VANOS 3 GA DERMATOLOGY, CORTICOSTEROIDS: LOW POTENCY ALA SCALP 3 GA alclometasone 1 CAPEX 3 DERMA-SMOOTHE/FS BODY, SCALP 3 GA DESONATE 3 desonide cream, lotion, oint 0.05% 1 DESOWEN CREAM, LOTION, OINT 0.05% 3 GA fluocinolone acetonide cream, soln 0.01% 1 fluocinolone acetonide oil body, scalp 1 hydrocortisone cream, lotion, oint 2.5% 1

68

Drug Name Drug Tier Requirements/Limits hydrocortisone lotion 2% 1 MICORT-HC 3 NUCORT 3 SYNALAR 3 GA TEXACORT 3 VERDESO 3 DERMATOLOGY, CORTICOSTEROIDS: MEDIUM POTENCY betamethasone valerate cream, lotion, oint

0.1% 1

betamethasone valerate foam 1 clocortolone cream 0.1% 3 CLODERM 3 GA CORDRAN CREAM, LOTION, OINT 0.05% 3 CORDRAN TAPE 3 CUTIVATE CREAM, LOTION 0.05% 3 GA desoximetasone cream, oint 0.05% 1 ELOCON CREAM, LOTION, OINT 0.1% 3 GA fluocinolone acetonide cream, oint 0.025% 1 fluticasone cream, lotion 0.05% 1 fluticasone oint 0.005% 1 hydrocortisone butyrate cream, oint, soln

0.1% 1

hydrocortisone valerate cream, oint 0.2% 1 KENALOG SPRAY 3 GA LOCOID CREAM, OINT, SOLN 0.1% 3 GA LOCOID LIPOCREAM 0.1% 3 GA LOCOID LOTION 0.1% 3 LUXIQ 3 GA mometasone cream, oint, soln 0.1% 1 PANDEL 3 prednicarbate cream, oint 0.1% 1 SYNALAR CREAM, OINT 0.025% 3 GA TOPICORT CREAM, OINT 0.05% 3 GA triamcinolone cream 0.1% 1 triamcinolone cream, lotion, oint 0.1% 1 triamcinolone cream, lotion, oint 0.025% 1 triamcinolone spray 1 TRIANEX 3 DERMATOLOGY, CORTICOSTEROIDS: VERY HIGH POTENCY betamethasone dipropionate augmented

gel, oint 0.05% 1

clobetasol cream, gel, lotion, oint, shampoo, soln, spray 0.05%

1

clobetasol emollient cream 0.05% 1 clobetasol foam 1 CLOBEX LOTION, SHAMPOO, SPRAY 0.05% 3 GA diflorasone oint 0.05% 1 69

Drug Name Drug Tier Requirements/Limits DIPROLENE OINT 0.05% 3 GA halobetasol cream, oint 0.05% 1 OLUX 3 GA OLUX-E 3 GA TEMOVATE CREAM, GEL, OINT, SOLN

0.05% 3 GA

TEMOVATE E CREAM 0.05% 3 GA ULTRAVATE CREAM, OINT 0.05% 3 GA ULTRAVATE LOTION 0.05% 3 DERMATOLOGY, EMOLLIENTS CEM-UREA 3 GORDONS UREA 3 HYDRO 40 FOAM 3 GA KERAFOAM 3 KERALAC 3 GA LATRIX XM 3 RYNODERM 3 UMECTA 3 UMECTA NAIL FILM 3 GA UMECTA PD 3 URAMAXIN 3 GA URAMAXIN FOAM 3 urea cream 1 urea emulsion 1 urea foam 1 urea gel 1 urea lotion 1 UREA NAIL 3 urea nail gel 45% 1 urea nail susp 1 urea susp 1 UTOPIC 3 DERMATOLOGY, IMMUNOMODULATORS ELIDEL 3 PROTOPIC 3 GA tacrolimus oint 1 DERMATOLOGY, LOCAL ANALGESIC lidocaine pad 5% 1 LIDODERM 3 GA DERMATOLOGY, LOCAL ANESTHETICS EMLA 3 GA lidocaine oint 5% 1 lidocaine soln 4% 1 lidocaine/prilocaine 1 DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir oint 1

70

Drug Name Drug Tier Requirements/Limits ALDARA 3 GA ARZOL SILVER NITRATE APPLICATORS 3 GA CONDYLOX GEL 3 PA CONDYLOX SOLN 3 GA DENAVIR 3 doxepin cream 5% 1 imiquimod 1 PA PANRETIN 3 PODOCON 25 1 podofilox soln 0.5% 1 PRUDOXIN CREAM 5% 3 GA SALICYLIC ACID 26% 1 salicylic acid soln 27.5% 1 SANTYL 3 silver nitrate applicators 1 SILVER NITRATE OINT, SOLN 10% 1 SILVER NITRATE SOLN 0.5%, 25%, 50% 1 SULFAMYLON CREAM 3 SULFAMYLON PAK 3 GA TRI-CHLOR 1 VEREGEN 3 PA VIRASAL 3 GA XERESE 3 ZONALON CREAM 5% 3 GA ZOVIRAX CREAM 3 ZOVIRAX OINT 3 GA DERMATOLOGY, ROSACEA DOXYCYCLINE DELAYED-REL 40MG 3 PA FINACEA 3 METROCREAM 3 GA METROGEL 3 GA METROLOTION 3 GA metronidazole cream, gel, lotion 0.75% 1 metronidazole gel 1% 1 MIRVASO 3 NORITATE 3 ORACEA 3 PA DERMATOLOGY, SCABICIDES AND PEDICULICIDES ELIMITE 3 GA EURAX 3 lindane 1 malathion 1 NATROBA 3 GA OVIDE 3 GA permethrin 1 SKLICE 3

71

Drug Name Drug Tier Requirements/Limits spinosad 3 ULESFIA 3 DERMATOLOGY, WOUND CARE PRODUCTS REGRANEX 3 MOUTH/THROAT/DENTAL AGENTS, MISCELLANEOUS ARESTIN 2 chlorhexidine gluconate 1 DEBACTEROL 3 PERIDEX 3 GA triamcinolone dental paste 1 viscous lidocaine 1 OPHTHALMIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY

COMBINATIONS BLEPHAMIDE 3 BLEPHAMIDE S.O.P. 3 MAXITROL 3 GA neomycin/polymyxin

b/bacitracin/hydrocortisone 1

neomycin/polymyxin b/dexamethasone 1 neomycin/polymyxin b/hydrocortisone 1 PRED-G 3 PRED-G S.O.P 3 sulfacetamide/prednisolone 1 TOBRADEX OINT 3 TOBRADEX ST 3 TOBRADEX SUSP 3 GA tobramycin/dexamethasone 1 ZYLET 3 OPHTHALMIC, ANTI-INFECTIVES AZASITE 3 bacitracin 1 bacitracin/polymyxin b 1 BESIVANCE 3 BETADINE OPHTHALMIC PREP 3 BLEPH-10 3 GA CILOXAN OINT 3 CILOXAN SOLN 3 GA ciprofloxacin ophth 1 erythromycin oint 1 GARAMYCIN 3 GA gatifloxacin 1 gentamicin ophth 1 levofloxacin soln 1 MOXEZA 3 neomycin/bacitracin/polymyxin b 1 neomycin/polymyxin b/gramicidin 1

72

Drug Name Drug Tier Requirements/Limits OCUFLOX 3 GA ofloxacin ophth 1 polymyxin b/trimethoprim 1 POLYTRIM 3 GA sulfacetamide ophth 1 tobramycin soln 1 TOBREX OINT 3 TOBREX SOLN 3 GA VIGAMOX 3 ZYMAXID 3 GA OPHTHALMIC, ANTI-INFLAMMATORY: NONSTEROIDAL ACULAR 3 GA ACULAR LS 3 GA ACUVAIL 3 bromfenac 1 diclofenac 1 flurbiprofen soln 1 ILEVRO 3 ketorolac soln 1 NEVANAC 3 PROLENSA 3 OPHTHALMIC, ANTI-INFLAMMATORY: STEROIDAL ALREX 3 dexamethasone soln 1 DUREZOL 3 FLAREX 3 fluorometholone 1 FML FORTE 3 FML LIQUIFILM 3 GA FML OINT 3 LOTEMAX 3 MAXIDEX 3 OMNIPRED 3 GA PRED FORTE 3 GA PRED MILD 3 prednisolone acetate 1% 1 PREDNISOLONE PHOSPHATE 1% 1 VEXOL 3 OPHTHALMIC, ANTIALLERGICS ALOCRIL 3 ALOMIDE 3 azelastine 1 BEPREVE 3 cromolyn sodium 1 ELESTAT 3 GA EMADINE 3

73

Drug Name Drug Tier Requirements/Limits epinastine 1 LASTACAFT 3 olopatadine 1 PATADAY 3 PATANOL 3 GA PAZEO 3 OPHTHALMIC, ANTIFUNGALS NATACYN 3 OPHTHALMIC, ANTIVIRAL trifluridine 1 VIROPTIC 3 GA ZIRGAN 3 OPHTHALMIC, BETA-BLOCKERS: NONSELECTIVE BETIMOL 2 carteolol 1 ISTALOL 3 levobunolol 1 metipranolol 1 timolol gel soln 1 timolol soln 1 TIMOPTIC 0.25%, 0.5% 3 GA TIMOPTIC OCUDOSE 0.25%, 0.5% 3 TIMOPTIC-XE 3 GA OPHTHALMIC, BETA-BLOCKERS: SELECTIVE betaxolol soln 1 BETOPTIC-S 2 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITOR/BETA-BLOCKER

COMBINATIONS COSOPT 3 GA COSOPT PF 3 dorzolamide/timolol 1 OPHTHALMIC, CARBONIC ANHYDRASE

INHIBITOR/SYMPATHOMIMETIC COMBINATIONS SIMBRINZA 3 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: ORAL acetazolamide 1 acetazolamide ext-rel 1 DIAMOX SEQUELS 3 GA methazolamide 1 OPHTHALMIC, CARBONIC ANHYDRASE INHIBITORS: TOPICAL AZOPT 3 dorzolamide 1 TRUSOPT 3 GA OPHTHALMIC, DRY EYE DISEASE RESTASIS 3

74

Drug Name Drug Tier Requirements/Limits XIIDRA 3 OPHTHALMIC, LOCAL ANESTHETIC AKTEN 3 OPHTHALMIC, MISCELLANEOUS CYSTARAN 2 LACRISERT 3 naphazoline 1 phenylephrine 1 proparacaine 1 tetracaine 1 OPHTHALMIC, MYDRIATICS ATROPINE OINT 1 atropine soln 1 CYCLOGYL 0.5%, 1%, 2% 3 GA CYCLOMYDRIL 3 cyclopentolate 1 homatropine 1 ISOPTO HOMATROPINE 2% 3 ISOPTO HOMATROPINE 5% 3 GA ISOPTO HYOSCINE 3 tropicamide 1 OPHTHALMIC, PARASYMPATHOMIMETICS ISOPTO CARBACHOL 3 MIOCHOL-E 3 pilocarpine soln 1 OPHTHALMIC, PROSTAGLANDINS bimatoprost 1 latanoprost 1 LUMIGAN 2 TRAVATAN Z 3 travoprost 3 XALATAN 3 GA ZIOPTAN 3 OPHTHALMIC, SYMPATHOMIMETIC/BETA-BLOCKER COMBINATIONS COMBIGAN 3 OPHTHALMIC, SYMPATHOMIMETICS ALPHAGAN P 0.1% 3 ALPHAGAN P 0.15% 3 GA apraclonidine 1 brimonidine 0.15%, 0.2% 1 IOPIDINE 0.5% 3 GA IOPIDINE 1% 3 PHOSPHOLINE IODIDE 3 OTIC, ANTI-INFECTIVE/ANTI-INFLAMMATORY COMBINATIONS CIPRO HC 3

75

Drug Name Drug Tier Requirements/Limits CIPRODEX 3 COLY-MYCIN S 3 CORTISPORIN 3 GA CORTISPORIN-TC 3 hydrocortisone/acetic acid 1 neomycin/polymyxin b/hydrocortisone soln 1 neomycin/polymyxin b/hydrocortisone susp 1 OTIC, ANTI-INFECTIVES acetic acid 1 acetic acid/aluminum acetate 1 CETRAXAL 3 GA ciprofloxacin otic 1 ofloxacin otic 1 OTIC, MISCELLANEOUS antipyrine/benzocaine 1 antipyrine/benzocaine/polycosanol 1 CORTANE-B 3 GA DERMOTIC 3 GA fluocinolone acetonide oil 0.01% 1 MYOXIN 1 OTICIN HC DRO 3 GA pramoxine/chloroxylenol 1 pramoxine/hydrocortisone/chloroxylenol 1 TREAGAN OTIC 3 GA

76

Index 8 8-MOP ............................................. 67 A abacavir .......................................... 16 abacavir/lamivudine .......................... 15 abacavir/lamivudine/zidovudine .......... 15 ABILIFY ........................................... 32 ABSTRAL ......................................... 10 acamprosate calcium ......................... 37 ACANYA ........................................... 65 acarbose .......................................... 38 ACCOLATE ....................................... 63 ACCU-CHEK BLOOD GLUCOSE TEST STRIPS ............................................ 40 ACCUPRIL ........................................ 21 acebutolol ........................................ 24 acetaminophen/salicylamide/phenyltoloxamine ............................................... 9 acetazolamide .................................. 74 acetazolamide ext-rel ........................ 74 acetic acid........................................ 76 acetic acid/aluminum acetate ............. 76 acetylcysteine .................................. 64 ACIPHEX .......................................... 52 ACIPHEX SPRINKLE ........................... 52 acitretin ........................................... 67 ACTEMRA ......................................... 55 ACTHIB ........................................... 57 ACTIGALL ........................................ 50 ACTIMMUNE ..................................... 56 ACTIQ ............................................. 10 ACTIVE OB ....................................... 58 ACTIVELLA ....................................... 45 ACTONEL ......................................... 41 ACTOPLUS MET................................. 39 ACTOPLUS MET XR ............................ 39 ACTOS ............................................. 39 ACULAR ........................................... 73 ACULAR LS....................................... 73 ACUVAIL .......................................... 73 acyclovir .......................................... 17 acyclovir oint .................................... 70 ACZONE .......................................... 65 ADACEL ........................................... 57 ADALAT CC ...................................... 25 adapalene ........................................ 65 ADCIRCA ......................................... 27

ADDERALL ....................................... 33 ADDERALL XR .................................. 33 adefovir dipivoxil .............................. 17 ADEMPAS ........................................ 28 ADOXA ........................................... 14 ADRENACLICK ................................. 61 ADRENALIN ..................................... 64 ADVAIR DISKUS ............................... 65 ADVAIR HFA .................................... 65 ADVICOR ........................................ 24 AEROSPAN ...................................... 64 AFINITOR ........................................ 19 AFINITOR DISPERZ .......................... 19 AFLURIA ......................................... 57 AFREZZA ......................................... 39 AGGRENOX ..................................... 55 AKTEN ............................................ 75 AKYNZEO ........................................ 49 ALA SCALP ...................................... 68 ALBENZA......................................... 18 albuterol ......................................... 63 albuterol ext-rel ............................... 63 albuterol nebulizer soln ..................... 63 alclometasone.................................. 68 ALDACTAZIDE 25/25 ........................ 26 ALDACTAZIDE 50/50 ........................ 26 ALDACTONE .................................... 22 ALDARA .......................................... 71 ALECENSA ....................................... 19 alendronate 40mg ............................ 41 alendronate 5mg, 10mg, 35mg, 70mg 41 alendronate soln .............................. 41 alfentanil injection ............................ 10 alfuzosin ......................................... 53 ALINIA ............................................ 18 ALKERAN ........................................ 18 ALL NON-PREFERRED BLOOD GLUCOSE TEST STRIPS ................................... 40 allopurinol ......................................... 9 almotriptan ..................................... 35 ALOCRIL ......................................... 73 ALOMIDE ........................................ 73 alosetron ......................................... 51 ALPHAGAN P 0.1% ........................... 75 ALPHAGAN P 0.15% ......................... 75 alprazolam ...................................... 28 alprazolam ext-rel ............................ 28

77

ALPRAZOLAM INTENSOL .................... 28 ALREX ............................................. 73 ALSUMA ........................................... 35 ALTABAX ......................................... 66 ALTACE ........................................... 21 altavera ........................................... 42 ALTOPREV ........................................ 24 ALVESCO ......................................... 64 alyacen ...................................... 42, 44 amantadine ...................................... 31 AMARYL ........................................... 40 AMBIEN ........................................... 34 AMBIEN CR ...................................... 34 amcinonide cream, lotion 0.1% .......... 68 AMCINONIDE OINT 0.1% ................... 68 AMERGE .......................................... 35 amethia ........................................... 41 amethia lo ....................................... 41 amethyst ......................................... 41 AMICAR ........................................... 55 amiloride ......................................... 26 amiloride/hydrochlorothiazide ............. 26 amiodarone ...................................... 23 AMITIZA .......................................... 51 amitriptyline ..................................... 31 amlodipine ....................................... 25 amlodipine/atorvastatin ..................... 25 amlodipine/benazepril ....................... 21 amlodipine/valsartan ......................... 22 amlodipine/valsartan/hydrochlorothiazide ...................................................... 22 amoxapine ....................................... 31 amoxicillin ....................................... 13 amoxicillin/clavulanate ...................... 13 amoxicillin/clavulanate ext-rel ............ 14 amphetamine/dextroamphetamine ...... 33 amphetamine/dextroamphetamine ext-rel ................................................... 33 ampicillin ......................................... 14 AMPYRA ........................................... 36 AMRIX ............................................. 36 ANADROL-50 .................................... 37 ANAFRANIL ...................................... 28 anagrelide ........................................ 55 ANALPRAM-HC CREAM ....................... 52 ANALPRAM-HC LOTION ...................... 52 ANAPROX .......................................... 9 ANAPROX DS ..................................... 9

ANASPAZ ........................................ 49 anastrozole ..................................... 19 ANCOBON ....................................... 14 ANDRODERM ................................... 37 ANDROGEL 1% (25MG PAK) .............. 37 ANDROGEL 1% (50MG PAK) .............. 37 ANDROGEL 1% PUMP ....................... 37 ANDROGEL 1.62% ............................ 37 ANDROXY ........................................ 37 ANGELIQ ......................................... 45 ANORO ELLIPTA ............................... 61 ANTABUSE ...................................... 37 ANTARA .......................................... 23 antipyrine/benzocaine ....................... 76 antipyrine/benzocaine/polycosanol ..... 76 ANUSOL-HC ..................................... 52 ANZEMET ........................................ 49 APEXICON E .................................... 68 APIDRA ........................................... 39 APLENZIN ....................................... 30 apraclonidine ................................... 75 apri ................................................ 42 APRISO ........................................... 50 APTENSIO XR .................................. 33 APTIOM ........................................... 28 APTIVUS ......................................... 16 APTIVUS SOLN ................................. 16 ARALEN .......................................... 15 aranelle .......................................... 44 ARANESP ........................................ 55 ARAVA ............................................ 56 ARCAPTA NEOHALER ........................ 63 ARESTIN ......................................... 72 ARICEPT ......................................... 30 ARIMIDEX ....................................... 19 ARIPIPRAZOLE ODT .......................... 32 aripiprazole soln ............................... 32 aripiprazole tabs .............................. 32 ARIXTRA ......................................... 54 armodafinil ...................................... 37 ARMOUR THYROID 15MG, 120MG, 180MG, 240MG, 300MG .................... 48 ARMOUR THYROID 30MG, 60MG, 90MG...................................................... 48 AROMASIN ...................................... 19 ARTHROTEC .................................... 10 ARZOL SILVER NITRATE APPLICATORS 71 ASACOL HD ..................................... 50

78

ASCENSIA BLOOD GLUCOSE TEST STRIPS ............................................ 40 ashlyna ........................................... 41 ASMANEX ........................................ 64 aspirin/dipyridamole ext-rel ............... 55 ASTAGRAF XL ................................... 56 ASTEPRO ......................................... 64 ATABEX EC ...................................... 58 ATACAND ......................................... 22 ATACAND HCT .................................. 22 ATELVIA .......................................... 41 atenolol ........................................... 24 atenolol/chlorthalidone ...................... 24 ATIVAN............................................ 28 atorvastatin ..................................... 24 atovaquone ...................................... 18 atovaquone/proguanil ........................ 15 ATRALIN .......................................... 65 ATRIPLA .......................................... 15 ATROPINE OINT ................................ 75 atropine soln .................................... 75 ATROVENT HFA ................................ 61 ATROVENT NASAL ............................. 64 AUBAGIO ......................................... 36 aubra .............................................. 42 AUGMENTIN ..................................... 14 AUGMENTIN SUSP ............................ 14 AUGMENTIN SUSP 125MG/5ML ........... 14 AUGMENTIN XR ................................ 14 AVALIDE .......................................... 22 AVANDIA ......................................... 39 AVAPRO ........................................... 22 AVAR ............................................... 65 AVAR LS .......................................... 65 AVAR LS CLEANSER .......................... 65 AVAR-E LS ....................................... 65 AVC ................................................ 54 AVELOX ........................................... 13 aviane ............................................. 42 AVODART......................................... 53 AVONEX .......................................... 36 AVONEX PEN .................................... 36 AVONEX PREFILLED SYG .................... 36 AXERT ............................................. 35 AXIRON ........................................... 37 AYGESTIN ........................................ 48 AZASAN ........................................... 56 AZASITE .......................................... 72

azathioprine .................................... 56 azelastine ........................................ 73 azelastine spray ............................... 64 AZELEX ........................................... 65 AZILECT .......................................... 31 azithromycin .................................... 13 AZOPT ............................................ 74 AZOR .............................................. 22 AZULFIDINE .................................... 50 AZULFIDINE EN-TABS ....................... 50 azurette .......................................... 41 B bacitracin ........................................ 72 bacitracin/polymyxin b ...................... 72 baclofen .......................................... 36 BACTRIM ......................................... 14 BACTRIM DS .................................... 14 BACTROBAN .................................... 66 BACTROBAN NASAL .......................... 66 BAL-CARE DHA ................................ 58 balsalazide ...................................... 50 balziva ............................................ 42 BANZEL .......................................... 28 BARACLUDE SOLN ............................ 17 BARACLUDE TABS ............................ 17 BECONASE AQ ................................. 64 BELLADONNA/OPIUM SUPP ................ 49 BELSOMRA ...................................... 34 benazepril ....................................... 21 benazepril/hydrochlorothiazide .......... 21 BENICAR ......................................... 22 BENICAR HCT .................................. 22 BENTYL ........................................... 49 BENZACLIN ..................................... 65 BENZACLIN PUMP ............................. 65 BENZAMYCIN ................................... 65 BENZAMYCIN PAK ............................ 65 BENZEFOAM .................................... 65 BENZIQ........................................... 65 benzonatate .................................... 63 benzoyl peroxide .............................. 65 benztropine ..................................... 31 BEPREVE ......................................... 73 BESIVANCE ..................................... 72 BETADINE OPHTHALMIC PREP ........... 72 betamethasone dipropionate augmented cream, lotion 0.05% ......................... 68 betamethasone dipropionate augmented

79

gel, oint 0.05% ................................ 69 betamethasone dipropionate cream, lotion, oint 0.05% ............................. 68 betamethasone valerate cream, lotion, oint 0.1% ........................................ 69 betamethasone valerate foam ............ 69 BETAPACE ........................................ 23 BETASERON ..................................... 36 betaxolol ......................................... 24 betaxolol soln ................................... 74 bethanechol ..................................... 53 BETIMOL .......................................... 74 BETOPTIC-S ..................................... 74 bexarotene ...................................... 20 BEXSERO ......................................... 57 BEYAZ ............................................. 42 BIAXIN ............................................ 13 bicalutamide .................................... 19 BIDIL .............................................. 27 BILTRICIDE ...................................... 18 bimatoprost ..................................... 75 BIO-STATIN ..................................... 14 bisoprolol ......................................... 24 bisoprolol/hydrochlorothiazide ............ 24 BLEPH-10 ........................................ 72 BLEPHAMIDE .................................... 72 BLEPHAMIDE S.O.P. .......................... 72 BLOOD KETONE TEST STRIPS............. 40 BONIVA TABS ................................... 41 BOOSTRIX ....................................... 57 BOSULIF .......................................... 19 BPO ................................................ 65 BREEZE 2 BLOOD GLUCOSE TEST STRIPS ............................................ 40 BREO ELLIPTA .................................. 65 BREVICON ....................................... 42 briellyn ............................................ 42 BRILINTA ......................................... 55 brimonidine 0.15%, 0.2% .................. 75 BRIVIACT ......................................... 28 bromfenac ....................................... 73 bromocriptine ................................... 31 brompheniramine ............................. 61 BROVANA ........................................ 63 budesonide caps ............................... 50 budesonide nebulizer susp ................. 64 bumetanide ...................................... 26 BUPAP .............................................. 9

BUPHENYL ....................................... 51 BUPHENYL POWDER ......................... 51 buprenorphine sublingual .................. 37 buprenorphine/naloxone sublingual .... 37 bupropion ....................................... 30 bupropion delayed-rel ....................... 30 bupropion ext-rel ............................. 37 bupropion ext-rel (12hr) ................... 30 bupropion ext-rel (24hr) ................... 30 buspirone ........................................ 28 butalbital/acetaminophen .................... 9 butalbital/acetaminophen/caffeine ........ 9 butalbital/acetaminophen/caffeine/codeine .................................................... 10 butalbital/aspirin/caffeine .................... 9 butalbital/aspirin/caffeine/codeine ...... 10 BUTISOL SODIUM ............................ 34 butorphanol nasal spray .................... 10 BUTRANS ........................................ 11 BYDUREON ...................................... 38 BYETTA ........................................... 38 BYSTOLIC ....................................... 24 C cabergoline ..................................... 47 CABOMETYX .................................... 19 CADUET .......................................... 25 CAFERGOT ...................................... 35 caffeine citrate ................................. 64 CALAN ............................................ 25 CALAN SR ....................................... 25 calcipotriene .................................... 67 calcitonin nasal spray ....................... 41 calcitriol caps ................................... 47 calcitriol oint .................................... 67 calcitriol soln ................................... 47 calcium acetate ................................ 48 CALCIUM PNV .................................. 58 camila............................................. 44 camrese .......................................... 41 camrese lo ...................................... 41 CANASA .......................................... 50 candesartan .................................... 22 candesartan/hydrochlorothiazide ........ 22 CANTIL ........................................... 49 capecitabine .................................... 19 CAPEX ............................................ 68 CAPITAL W/CODEINE ........................ 11 CAPRELSA ....................................... 19

80

captopril .......................................... 21 captopril/hydrochlorothiazide ............. 21 CARAC ............................................. 66 CARAFATE ........................................ 51 CARAFATE SUSP ............................... 51 CARBAGLU ....................................... 47 carbamazepine ................................. 28 carbamazepine ext-rel ....................... 28 CARBAPHEN ..................................... 62 CARBATROL ..................................... 28 carbidopa ......................................... 32 carbidopa/levodopa ........................... 32 carbidopa/levodopa ext-rel................. 32 carbidopa/levodopa/entacapone ......... 32 carbinoxamine .................................. 61 CARDIZEM ....................................... 25 CARDIZEM CD .................................. 25 CARDIZEM LA 120MG ........................ 25 CARDIZEM LA 180MG, 240MG, 300MG, 360MG, 420MG ................................. 25 CARDURA ........................................ 22 CARDURA XL .................................... 53 carisoprodol ..................................... 36 carisoprodol/aspirin ........................... 36 carisoprodol/aspirin/codeine ............... 36 CARNITOR ....................................... 47 carteolol .......................................... 74 carvedilol ......................................... 24 CASCARA SAGRADA .......................... 51 CATAPRES ....................................... 21 CATAPRES-TTS ................................. 21 CAVERJECT ...................................... 53 CAYSTON ......................................... 63 caziant ............................................ 44 CEDAX CAPS .................................... 13 CEDAX SUSP 180MG/5ML .................. 13 CEDAX SUSP 90MG/5ML .................... 13 cefaclor ........................................... 12 CEFACLOR ER ................................... 12 cefadroxil ......................................... 12 cefdinir ............................................ 13 cefditoren ........................................ 13 cefixime ........................................... 13 cefpodoxime..................................... 13 cefprozil........................................... 12 ceftibuten ........................................ 13 CEFTIN ............................................ 12 CEFTIN SUSP ................................... 12

ceftriaxone ...................................... 13 cefuroxime axetil ............................. 12 CELEBREX ......................................... 9 celecoxib ........................................... 9 CELEXA ........................................... 31 CELLCEPT ........................................ 56 CELONTIN ....................................... 28 CEM-UREA ....................................... 70 CENTANY ........................................ 66 cephalexin ....................................... 12 CERDELGA ...................................... 47 CERVARIX ....................................... 57 CESAMET ........................................ 49 CETRAXAL ....................................... 76 cevimeline ....................................... 52 CHANTIX ......................................... 37 chateal ........................................... 42 CHEMET .......................................... 55 CHEMSTRIP ..................................... 58 CHENODAL ...................................... 50 chlordiazepoxide .............................. 28 chlordiazepoxide/amitriptyline ........... 30 chlordiazepoxide/clidinium ................ 49 chlorhexidine gluconate .................... 72 chloroquine ..................................... 15 chlorothiazide .................................. 26 chlorpromazine ................................ 33 chlorpropamide ................................ 40 chlorthalidone .................................. 26 chlorzoxazone .................................. 36 cholestyramine powder ..................... 23 cholestyramine powder light .............. 23 choline/magnesium trisalicylates .......... 9 CIALIS ............................................ 53 ciclopirox ........................................ 67 cilostazol ......................................... 55 CILOXAN OINT ................................. 72 CILOXAN SOLN ................................ 72 cimetidine ....................................... 50 CIMZIA ........................................... 56 CIPRO ............................................. 13 CIPRO HC ........................................ 75 CIPRO XR ........................................ 13 CIPRODEX ....................................... 76 ciprofloxacin .................................... 13 ciprofloxacin ext-rel .......................... 13 ciprofloxacin ophth ........................... 72 ciprofloxacin oral susp ...................... 13

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ciprofloxacin otic ............................... 76 citalopram ....................................... 31 CITRANATAL .................................... 58 claravis ............................................ 65 CLARINEX ........................................ 61 CLARINEX SYRUP .............................. 61 CLARINEX-D 12 HOUR ....................... 61 clarithromycin .................................. 13 clarithromycin ext-rel ........................ 13 clemastine ....................................... 62 CLEOCIN .......................................... 18 CLEOCIN CREAM ............................... 54 CLEOCIN SUPP ................................. 54 CLEOCIN-T ....................................... 65 CLIMARA ......................................... 46 CLIMARA PRO ................................... 45 clindamycin caps, oral soln ................. 18 clindamycin cream ............................ 54 clindamycin foam .............................. 65 clindamycin gel, lotn, soln, swab ......... 65 clindamycin/benzoyl peroxide ............. 65 CLINDESSE ...................................... 54 clobetasol cream, gel, lotion, oint, shampoo, soln, spray 0.05% .............. 69 clobetasol emollient cream 0.05%....... 69 clobetasol foam ................................ 69 CLOBEX LOTION, SHAMPOO, SPRAY 0.05% ............................................. 69 clocortolone cream 0.1% ................... 69 CLODERM ........................................ 69 clomipramine ................................... 28 clonazepam ...................................... 28 clonidine .......................................... 21 clonidine ext-rel ................................ 33 clonidine transdermal ........................ 21 clonidine/chlorthalidone ..................... 26 clopidogrel ....................................... 55 clorazepate ...................................... 28 clotrimazole troche............................ 14 clotrimazole/betamethasone .............. 67 clozapine ......................................... 32 CLOZARIL ........................................ 32 C-NATE DHA .................................... 58 COARTEM ........................................ 15 codeine ........................................... 11 codeine/acetaminophen ..................... 11 COLAZAL ......................................... 50 colchicine .......................................... 9

colchicine/probenecid ......................... 9 COLCRYS .......................................... 9 COLESTID ....................................... 23 colestipol ........................................ 23 COLY-MYCIN S ................................. 76 COLYTE/FLAVOR PACKS .................... 51 COMBIGAN ...................................... 75 COMBIPATCH ................................... 45 COMBISTIX ..................................... 58 COMBIVENT RESPIMAT ..................... 61 COMBIVIR ....................................... 15 COMETRIQ ...................................... 19 COMPAZINE ..................................... 49 COMPLERA ...................................... 15 COMPLETE NATAL DHA ..................... 58 COMPLETENATE ............................... 58 COMTAN ......................................... 32 CO-NATAL FA................................... 58 CONCEPT ........................................ 58 CONCERTA ...................................... 33 CONDYLOX GEL ............................... 71 CONDYLOX SOLN ............................. 71 CONTOUR BLOOD GLUCOSE TEST STRIPS ........................................... 40 CONTOUR NEXT BLOOD GLUCOSE TEST STRIPS ........................................... 40 CONZIP ........................................... 11 COPAXONE 20 MG ............................ 36 COPAXONE 40 MG ............................ 36 COPEGUS ........................................ 17 CORDRAN CREAM, LOTION, OINT 0.05%...................................................... 69 CORDRAN TAPE ............................... 69 COREG ............................................ 25 COREG CR ....................................... 25 CORGARD ....................................... 25 CORLANOR ...................................... 26 CORTANE-B ..................................... 76 CORTEF .......................................... 46 CORTIFOAM ..................................... 50 cortisone ......................................... 46 CORTISPORIN .................................. 76 CORTISPORIN CREAM 0.5% .............. 66 CORTISPORIN OINT 1% .................... 66 CORTISPORIN-TC ............................. 76 CORZIDE ........................................ 24 COSENTYX ...................................... 67 COSENTYX PEN ................................ 67

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COSOPT ........................................... 74 COSOPT PF ...................................... 74 COTELLIC ........................................ 20 COUMADIN ...................................... 54 covaryx ........................................... 45 covaryx hs ....................................... 45 COZAAR .......................................... 22 CREON ............................................ 51 CRESEMBA ....................................... 14 CRESTOR ......................................... 24 CRINONE GEL 4% ............................. 48 CRIXIVAN ........................................ 16 cromolyn sodium .............................. 73 cromolyn sodium 100mg/5ml ............. 51 cromolyn sodium nebulizer soln .......... 63 cryselle ............................................ 42 CUTIVATE CREAM, LOTION 0.05% ...... 69 CUVPOSA ......................................... 49 cyclafem .................................... 42, 44 CYCLESSA ........................................ 44 cyclobenzaprine ................................ 36 CYCLOGYL 0.5%, 1%, 2% ................. 75 CYCLOMYDRIL .................................. 75 cyclopentolate .................................. 75 CYCLOPHOSPHAMIDE CAPS ................ 18 cycloserine ....................................... 17 CYCLOSET ....................................... 39 cyclosporine ..................................... 56 cyclosporine modified ........................ 56 CYMBALTA ....................................... 30 cyproheptadine ................................. 62 cyred............................................... 42 CYSTADANE ..................................... 47 CYSTAGON ....................................... 53 CYSTARAN ....................................... 75 CYTOMEL ......................................... 48 CYTOTEC ......................................... 52 D D.H.E. ............................................. 35 DAKLINZA ........................................ 17 DALIRESP ........................................ 64 danazol ........................................... 45 DANTRIUM ....................................... 36 dantrolene ....................................... 36 dapsone........................................... 18 DAPTACEL ........................................ 57 DARAPRIM ....................................... 15 darifenacin ext-rel ............................. 54

dasetta ...................................... 42, 44 DAYPRO ............................................ 9 daysee ............................................ 41 DAYTRANA ...................................... 33 DDAVP ............................................ 49 DEBACTEROL ................................... 72 deblitane ......................................... 44 DECON-A ........................................ 61 DECON-G ........................................ 62 delyla ............................................. 42 DELZICOL ....................................... 50 DEMADEX ........................................ 26 demeclocycline ................................ 14 DEMEROL ........................................ 11 DEMSER .......................................... 26 DENAVIR ......................................... 71 DEPAKENE....................................... 28 DEPAKOTE ...................................... 28 DEPAKOTE ER .................................. 28 DEPEN ............................................ 56 DEPO-PROVERA ............................... 42 DEPO-SUBQ PROVERA 104 ................ 42 DEPO-TESTOSTERONE 100MG/ML ...... 37 DEPO-TESTOSTERONE 200MG/ML ...... 38 DERMA-SMOOTHE/FS BODY, SCALP ... 68 DERMOTIC ...................................... 76 DESCOVY ........................................ 15 desipramine .................................... 31 desloratadine ................................... 61 desmopressin .................................. 49 DESOGEN ........................................ 42 desogestrel/ethinyl estradiol ......... 41, 42 DESONATE ...................................... 68 desonide cream, lotion, oint 0.05% .... 68 DESOWEN CREAM, LOTION, OINT 0.05%...................................................... 68 desoximetasone cream, oint 0.05% .... 69 desoximetasone cream, oint 0.25% .... 68 desoximetasone gel 0.05%................ 68 DESVENLAFAXINE ER 50MG, 100MG ... 30 desvenlafaxine ext-rel 50mg, 100mg .. 30 DETROL .......................................... 54 DETROL LA ...................................... 54 dexamethasone ............................... 46 DEXAMETHASONE INTENSOL ............. 46 dexamethasone oral soln 0.5mg/5ml .. 46 dexamethasone soln ......................... 73 DEXEDRINE CR ................................ 33

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DEXILANT ........................................ 52 dexmethylphenidate .......................... 33 dexmethylphenidate ext-rel ............... 33 DEXPAK ........................................... 46 dextroamphetamine 2.5mg, 7.5mg, 15mg, 20mg, 30mg .......................... 33 dextroamphetamine 5mg, 10mg ......... 33 dextroamphetamine ext-rel 5mg, 10mg, 15mg .............................................. 33 dextroamphetamine soln ................... 33 dextromethorphan/brompheniramine/pseudoephedrine ................................... 62 dextromethorphan/chlorpheniramine/phenylephrine........................................ 62 dextromethorphan/guaifenesin/phenylephrine ............................................... 62 DIAMOX SEQUELS ............................ 74 DIASTAT .......................................... 28 diazepam ......................................... 28 diazepam gel .................................... 29 DIBENZYLINE ................................... 26 diclofenac ........................................ 73 diclofenac gel 3% ............................. 66 diclofenac potassium .......................... 9 diclofenac sodium delayed-rel .............. 9 diclofenac sodium ext-rel .................... 9 diclofenac sodium soln ....................... 10 diclofenac/misoprostol ....................... 10 dicloxacillin ...................................... 14 dicyclomine ...................................... 49 didanosine ....................................... 16 DIFFERIN ......................................... 65 DIFICID ........................................... 13 diflorasone ....................................... 68 diflorasone oint 0.05% ...................... 69 DIFLUCAN ........................................ 14 diflunisal ........................................... 9 digoxin ............................................ 26 dihydrocodeine/acetaminophen/caffeine ...................................................... 11 dihydrocodeine/aspirin/caffeine .......... 11 dihydroergotamine inj ....................... 35 dihydroergotamine nasal spray ........... 35 DILANTIN 100MG .............................. 29 DILANTIN 30MG ............................... 29 DILANTIN CHEW 50MG ...................... 29 DILANTIN-125 SUSP ......................... 29 DILATRATE SR .................................. 27

DILAUDID ....................................... 11 diltiazem ......................................... 25 diltiazem ext-rel ............................... 25 DIOVAN .......................................... 22 DIOVAN HCT ................................... 22 DIPENTUM ....................................... 50 diphenoxylate/atropine ..................... 49 DIPHTHERIA/TETANUS TOXOID ......... 57 DIPROLENE ..................................... 68 DIPROLENE AF ................................. 68 DIPROLENE OINT 0.05% ................... 70 dipyridamole ................................... 55 disopyramide ................................... 23 disulfiram ........................................ 37 DITROPAN XL .................................. 54 DIURIL............................................ 26 divalproex sodium ............................ 29 divalproex sodium delayed-rel ........... 29 divalproex sodium ext-rel .................. 29 DIVIGEL .......................................... 46 dofetilide ......................................... 23 DOLOPHINE ..................................... 11 donepezil ........................................ 30 DONNATAL ...................................... 50 DORYX ............................................ 14 dorzolamide .................................... 74 dorzolamide/timolol .......................... 74 DOTHELLE DHA ................................ 58 DOVONEX ....................................... 67 doxazosin ........................................ 22 doxepin ........................................... 31 doxepin cream 5% ........................... 71 doxercalciferol ................................. 47 DOXYCYCLINE DELAYED-REL 40MG .... 71 doxycycline hyclate .......................... 14 doxycycline hyclate delayed-rel .......... 14 doxycycline monohydrate caps 150mg 14 doxycycline monohydrate caps 50mg, 75mg, 100mg .................................. 14 doxycycline monohydrate susp .......... 14 doxycycline monohydrate tabs ........... 14 DRITHO-CREME HP ........................... 67 dronabinol ....................................... 49 drospirenone/ethinyl estradiol ............ 42 DROXIA .......................................... 20 DUAC GEL ....................................... 65 DUAVEE .......................................... 45 DUET DHA ....................................... 58

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DULERA ........................................... 65 duloxetine ........................................ 31 DURAGESIC ..................................... 11 DUREZOL ......................................... 73 dutasteride ...................................... 53 dutasteride/tamsulosin ...................... 53 DUTOPROL ....................................... 24 DYAZIDE ......................................... 26 DYMISTA ......................................... 64 dyphylline-guaifenesin ....................... 64 DYRENIUM ....................................... 26 E e.e.s. 400 ........................................ 13 EC-NAPROSYN ................................... 9 econazole ........................................ 67 ECOZA ............................................ 67 EDARBI ........................................... 22 EDARBYCLOR ................................... 22 EDECRIN ......................................... 26 EDEX ............................................... 53 EDLUAR ........................................... 34 EDURANT ......................................... 16 eemt ............................................... 45 eemt hs ........................................... 45 EFFER-K .......................................... 58 EFFEXOR XR ..................................... 31 EFFIENT........................................... 55 EFUDEX ........................................... 66 ELDEPRYL ........................................ 32 ELESTAT .......................................... 73 ELESTRIN ........................................ 46 ELIDEL ............................................ 70 ELIMITE ........................................... 71 elinest ............................................. 42 ELIPHOS .......................................... 48 ELIQUIS .......................................... 55 elite-ob ............................................ 58 ELIXOPHYLLIN .................................. 65 ELLA ............................................... 41 ELMIRON ......................................... 53 ELOCON CREAM, LOTION, OINT 0.1% . 69 EMADINE ......................................... 73 EMBEDA .......................................... 11 EMCYT ............................................. 18 EMEND ............................................ 49 EMLA ............................................... 70 emoquette ....................................... 42 EMSAM ............................................ 30

EMTRIVA ......................................... 16 ENABLEX ......................................... 54 enalapril .......................................... 21 enalapril/hydrochlorothiazide ............. 21 ENBRACE HR ................................... 59 ENBREL ........................................... 56 ENGERIX-B ...................................... 57 ENJUVIA ......................................... 45 enoxaparin ...................................... 54 enpresse ......................................... 44 enskyce .......................................... 42 entacapone ..................................... 32 entecavir ......................................... 17 ENTEREG ........................................ 51 ENTOCORT EC ................................. 50 ENTRESTO ...................................... 27 EPANED .......................................... 21 EPCLUSA ......................................... 17 EPIDUO ........................................... 65 EPIFOAM ......................................... 52 epinastine ....................................... 74 epinephrine inj ................................. 61 EPIPEN ........................................... 61 EPIPEN JR ....................................... 61 EPIVIR ............................................ 16 EPIVIR HBV ..................................... 17 EPIVIR HBV SOLN ............................ 17 eplerenone ...................................... 22 EPOGEN .......................................... 55 eprosartan ...................................... 22 EPZICOM ......................................... 15 EQUAGESIC ....................................... 9 EQUETRO ........................................ 36 ergoloid mesylates ........................... 35 ERGOMAR ....................................... 35 ERIVEDGE ....................................... 20 errin ............................................... 44 ERTACZO ........................................ 67 ERYGEL ........................................... 65 ERYPED SUS 200MG/5ML .................. 13 ERYPED SUS 400MG/5ML .................. 13 erythromycin base............................ 13 erythromycin delayed-rel .................. 13 erythromycin ethylsuccinate .............. 13 erythromycin gel, pads, soln .............. 65 erythromycin oint ............................. 72 erythromycin stearate ....................... 13 erythromycin/benzoyl peroxide .......... 65

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ESBRIET .......................................... 64 escitalopram .................................... 31 ESGIC .............................................. 9 esomeprazole ................................... 52 estarylla .......................................... 42 estazolam ........................................ 34 esterified estrogens/methyltestosterone ...................................................... 45 ESTRACE ......................................... 45 ESTRACE CREAM .............................. 46 estradiol .......................................... 46 estradiol transdermal twice weekly ...... 46 estradiol transdermal weekly .............. 46 estradiol/norethindrone ..................... 45 ESTRING ......................................... 46 ESTROGEL ....................................... 46 estropipate ...................................... 46 ESTROSTEP FE ................................. 44 eszopiclone ...................................... 34 ethambutol ...................................... 17 ethinyl estradiol/norethindrone ........... 45 ethosuximide.................................... 29 etidronate ........................................ 41 etodolac ........................................... 9 etodolac ext-rel ................................. 9 etoposide ......................................... 20 EURAX ............................................. 71 EVAMIST.......................................... 46 EVISTA ............................................ 48 EVOCLIN .......................................... 65 EVOTAZ ........................................... 15 EVOXAC ........................................... 52 EXACTUSS ....................................... 62 EXALGO ........................................... 11 EXELDERM ....................................... 67 EXELON ........................................... 30 exemestane ..................................... 19 EXFORGE ......................................... 22 EXFORGE HCT .................................. 22 EXJADE ........................................... 55 EXTAVIA .......................................... 36 EXTINA ............................................ 67 EXTRA-VIRT PLUS DHA ...................... 59 F FACTIVE .......................................... 13 FALESSA .......................................... 42 falmina ............................................ 42 famciclovir ....................................... 17

famotidine ....................................... 50 FAMVIR ........................................... 17 FANAPT ........................................... 32 FARESTON ...................................... 19 FARXIGA ......................................... 40 FARYDAK ........................................ 20 FAZACLO ......................................... 32 felbamate ........................................ 29 FELBATOL ....................................... 29 FELDENE ........................................... 9 felodipine ext-rel .............................. 25 FEMARA .......................................... 19 FEMCON FE ..................................... 42 FEMHRT LOW DOSE .......................... 45 FEMRING ........................................ 46 fenofibrate caps, tabs ....................... 23 fenofibric acid .................................. 23 fenofibric acid delayed-rel ................. 23 FENOGLIDE ..................................... 23 fenoprofen ........................................ 9 fentanyl transdermal 12mcg, 25mcg, 50mcg, 75mcg, 100mcg .................... 11 FENTANYL TRANSDERMAL 37.5MCG, 62.5MCG, 87.5MCG .......................... 11 fentanyl transmucosal lozenge ........... 11 FENTORA ........................................ 11 FERRIPROX ..................................... 55 FETZIMA ......................................... 31 FEXMID ........................................... 36 FINACEA ......................................... 71 finasteride ....................................... 53 FIORICET .......................................... 9 FIORICET W/CODEINE ...................... 11 FIORINAL .......................................... 9 FIORINAL W/CODEINE ...................... 11 FIRAZYR ......................................... 55 FLAGYL ........................................... 18 FLAGYL ER ...................................... 18 FLAREX ........................................... 73 flavoxate ......................................... 54 flecainide ........................................ 23 FLECTOR ......................................... 10 FLOMAX .......................................... 53 FLO-PRED ....................................... 46 FLOVENT DISKUS ............................. 64 FLOVENT HFA .................................. 64 FLOWTUSS ...................................... 62 FLUAD ............................................ 57

86

FLUARIX .......................................... 57 FLUBLOK ......................................... 57 FLUCELVAX ...................................... 57 FLUCELVAX QUAD ............................. 57 fluconazole ....................................... 14 flucytosine ....................................... 14 fludrocortisone ................................. 46 FLULAVAL ........................................ 57 FLUMADINE ...................................... 18 flunisolide spray ............................... 64 fluocinolone acetonide cream, oint 0.025% ........................................... 69 fluocinolone acetonide cream, soln 0.01% ............................................. 68 fluocinolone acetonide oil 0.01% ......... 76 fluocinolone acetonide oil body, scalp .. 68 fluocinonide cream 0.1% ................... 68 fluocinonide cream, gel, oint, soln 0.05% ...................................................... 68 fluocinonide-e cream 0.05% ............... 68 fluorometholone ............................... 73 FLUOROPLEX .................................... 66 fluorouracil cream 0.5% .................... 66 fluorouracil cream, drop, soln 5% ....... 66 fluorouracil drop, soln 2% .................. 66 fluoxetine ........................................ 31 FLUOXETINE 60MG ........................... 31 fluoxetine delayed-rel ........................ 31 fluphenazine .................................... 33 flurazepam ....................................... 34 flurbiprofen ....................................... 9 flurbiprofen soln ............................... 73 flutamide ......................................... 19 fluticasone cream, lotion 0.05% .......... 69 fluticasone oint 0.005% ..................... 69 fluvastatin ........................................ 24 fluvastatin ext-rel ............................. 24 FLUVIRIN ......................................... 57 fluvoxamine ..................................... 28 fluvoxamine ext-rel ........................... 28 FLUZONE ......................................... 57 FML FORTE ....................................... 73 FML LIQUIFILM ................................. 73 FML OINT ......................................... 73 FOCALGIN ........................................ 59 FOCALIN .......................................... 33 FOCALIN XR 25MG, 35MG .................. 33 FOCALIN XR 5MG, 10MG, 15MG, 20MG,

30MG, 40MG ................................... 33 FOLCAL DHA .................................... 59 FOLCAPS OMEGA 3 ........................... 59 FOLET ............................................. 59 folic acid ......................................... 58 folinatal plus b ................................. 59 FOLIVANE-OB .................................. 59 fondaparinux ................................... 54 FORADIL AEROLIZER ........................ 63 FORFIVO XL..................................... 30 FORTAMET ...................................... 38 FORTEO .......................................... 41 FORTESTA ....................................... 38 FORTICAL ........................................ 41 FOSAMAX ........................................ 41 FOSAMAX PLUS D ............................. 41 fosinopril ......................................... 21 fosinopril/hydrochlorothiazide ............ 21 FOSRENOL ...................................... 48 FRAGMIN ........................................ 54 FREESTYLE BLOOD GLUCOSE TEST STRIPS ........................................... 40 FROVA ............................................ 35 frovatriptan ..................................... 35 FURADANTIN SUSP .......................... 18 furosemide ...................................... 26 furosemide soln 10mg/ml .................. 26 FUROSEMIDE SOLN 8 MG/ML ............. 26 FUZEON .......................................... 15 FYCOMPA ........................................ 29 G gabapentin ...................................... 29 GABITRIL 12MG, 16MG ..................... 29 GABITRIL 2MG, 4MG ......................... 29 galantamine .................................... 30 galantamine ext-rel .......................... 30 GARAMYCIN .................................... 72 GARDASIL ....................................... 57 GASTRINEX NF ................................ 50 GASTROCROM ................................. 51 gatifloxacin ...................................... 72 GELNIQUE ....................................... 54 gemfibrozil ...................................... 23 GENERESS FE .................................. 42 GENOTROPIN ................................... 47 gentamicin ...................................... 66 gentamicin ophth ............................. 72 GENVOYA ........................................ 15

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GEODON .......................................... 32 gianvi .............................................. 42 GIAZO ............................................. 50 gildagia ........................................... 42 gildess ............................................. 42 gildess fe ......................................... 42 gildess fe 24 ..................................... 42 GILENYA .......................................... 36 GILOTRIF ......................................... 20 GILTUSS .......................................... 62 GILTUSS PED-C ................................ 62 giltuss pediatric ................................ 62 glatopa 20 mg .................................. 36 GLEEVEC ......................................... 20 GLEOSTINE 10MG, 40MG, 100MG ....... 19 GLEOSTINE 5MG ............................... 18 glimepiride ....................................... 40 glipizide ........................................... 40 glipizide ext-rel ................................. 40 glipizide/metformin ........................... 38 GLUCAGEN HYPOKIT ......................... 47 GLUCAGON EMERGENCY KIT .............. 47 GLUCOPHAGE ................................... 38 GLUCOPHAGE XR .............................. 38 GLUCOTROL ..................................... 40 GLUCOTROL XL................................. 40 GLUCOVANCE ................................... 38 glyburide ......................................... 40 glyburide micronized ......................... 40 glyburide/metformin ......................... 38 glycopyrrolate .................................. 50 GLYSET ........................................... 38 GLYXAMBI ........................................ 40 GOLYTELY ........................................ 51 GORDONS UREA ............................... 70 granisetron ...................................... 49 GRANIX ........................................... 55 GRASTEK ......................................... 55 griseofulvin microsize ........................ 14 griseofulvin ultramicrosize.................. 14 GRIS-PEG ........................................ 14 guanfacine ....................................... 21 guanfacine ext-rel ............................. 33 GUANIDINE ...................................... 35 GYNAZOLE-1 .................................... 54 H HALCION ......................................... 34 halobetasol cream, oint 0.05% ........... 70

HALOG ............................................ 68 haloperidol ...................................... 33 HALOTIN ......................................... 67 HARVONI ........................................ 17 HAVRIX ........................................... 57 heather ........................................... 44 HECTOROL ...................................... 47 HEMA-COMBISTIX ............................ 58 HEMANGEOL .................................... 25 HEMENATAL .................................... 59 HETLIOZ ......................................... 34 HEXALEN ........................................ 19 HIBERIX .......................................... 57 homatropine .................................... 75 HUMALOG ....................................... 39 HUMALOG MIX ................................. 39 HUMATROPE .................................... 47 HUMIRA .......................................... 56 HUMULIN 70/30 ............................... 39 HUMULIN N ..................................... 39 HUMULIN R ..................................... 39 HUMULIN R U-500 ............................ 39 HYCAMTIN ....................................... 21 HYCET ............................................ 11 HYCOFENIX ..................................... 62 hydralazine ..................................... 26 HYDREA .......................................... 20 HYDRO 40 FOAM .............................. 70 hydrochlorothiazide .......................... 26 hydrocodone polistirex/chlorpheniramine...................................................... 62 hydrocodone/acetaminophen ............. 11 hydrocodone/chlorpheniramine/pseudoephedrine ........................................... 62 hydrocodone/homatropine ................. 62 hydrocodone/ibuprofen ..................... 11 hydrocortisone ................................. 46 hydrocortisone acetate supp .............. 52 hydrocortisone butyrate cream, oint, soln 0.1% .............................................. 69 hydrocortisone cream ....................... 52 hydrocortisone cream, lotion, oint 2.5%...................................................... 68 hydrocortisone enema ...................... 51 hydrocortisone lotion 2% .................. 69 hydrocortisone valerate cream, oint 0.2% .............................................. 69 hydrocortisone/acetic acid ................. 76

88

hydrocortisone/pramoxine ................. 52 hydromorphone ................................ 11 hydromorphone ext-rel ...................... 11 HYDROMORPHONE SUPP .................... 11 hydroxychloroquine ........................... 56 hydroxyurea ..................................... 20 hydroxyzine hcl ................................ 62 hydroxyzine pamoate ........................ 62 hyoscyamine sulfate .......................... 50 hyoscyamine sulfate ext-rel ............... 50 HYPERSAL 3.5% ............................... 64 HYPERSAL 7% .................................. 64 HYSINGLA ER ................................... 11 HYZAAR ........................................... 22 I ibandronate ..................................... 41 IBRANCE.......................................... 20 ibuprofen ......................................... 10 ICLUSIG .......................................... 20 ILEVRO ............................................ 73 imatinib mesylate ............................. 20 IMBRUVICA ...................................... 20 imipramine hcl .................................. 31 imipramine pamoate ......................... 31 imiquimod ........................................ 71 IMITREX .......................................... 35 IMPAVIDO ........................................ 18 IMURAN ........................................... 56 inatal advance .................................. 59 inatal gt ........................................... 59 inatal ultra ....................................... 59 INCRELEX ........................................ 47 indapamide ...................................... 26 INDERAL LA ..................................... 25 INDOCIN SUPP ................................. 10 INDOCIN SUSP ................................. 10 indomethacin ................................... 10 indomethacin ext-rel ......................... 10 INFANATE BALANCE .......................... 59 INFANRIX ........................................ 57 INLYTA ............................................ 20 INSULIN SYRINGES ........................... 40 INTELENCE ...................................... 16 INTERMEZZO ................................... 34 introvale .......................................... 41 INTUNIV .......................................... 33 INVEGA ........................................... 32 INVIRASE ........................................ 16

INVOKAMET ..................................... 39 INVOKAMET XR ................................ 39 INVOKANA ...................................... 40 iodine soln strong (lugol's) ................ 48 IOPIDINE 0.5% ................................ 75 IOPIDINE 1% .................................. 75 IPOL INACTIVATED IPV ..................... 57 ipratropium nasal spray .................... 64 ipratropium nebulizer soln ................. 61 ipratropium/albuterol nebulizer soln ... 61 irbesartan ....................................... 22 irbesartan/hydrochlorothiazide ........... 22 ISENTRESS ..................................... 15 ISENTRESS POWDER ........................ 15 isometheptene/caffeine/acetaminophen...................................................... 35 isometheptene/dichloralphenazone/acetaminophen ........................................ 35 isoniazid ......................................... 17 ISOPTO CARBACHOL ........................ 75 ISOPTO HOMATROPINE 2% ............... 75 ISOPTO HOMATROPINE 5% ............... 75 ISOPTO HYOSCINE ........................... 75 ISORDIL 40MG ................................ 27 ISORDIL 5MG .................................. 27 isosorbide dinitrate ........................... 27 isosorbide dinitrate ext-rel................. 27 isosorbide mononitrate ..................... 27 isosorbide mononitrate ext-rel ........... 27 isoxsuprine 10mg ............................. 26 isoxsuprine 20mg ............................. 26 isradipine ........................................ 25 ISTALOL .......................................... 74 itraconazole ..................................... 14 ivermectin ....................................... 18 J JAKAFI ............................................ 20 JALYN ............................................. 53 JANUMET ........................................ 38 JANUMET XR .................................... 38 JANUVIA ......................................... 38 JARDIANCE ..................................... 40 jencycla .......................................... 44 JENTADUETO ................................... 38 JEVANTIQUE LO ............................... 45 jinteli .............................................. 45 jolessa ............................................ 41 jolivette .......................................... 44

89

juleber ............................................ 42 junel ............................................... 42 junel fe ............................................ 42 junel fe 24 ....................................... 42 JUXTAPID ........................................ 24 K KADIAN 10MG, 20MG, 30MG, 50MG, 60MG, 80MG, 100MG ........................ 11 KADIAN 40MG, 200MG ...................... 11 KALETRA.......................................... 16 KALYDECO ....................................... 63 KAPVAY ........................................... 33 KARBINAL ER ................................... 62 kariva .............................................. 41 KAZANO .......................................... 38 KEFLEX ............................................ 12 kelnor.............................................. 43 KENALOG INJ ................................... 46 KENALOG SPRAY ............................... 69 KEPPRA ........................................... 29 KEPPRA XR....................................... 29 KERAFOAM ....................................... 70 KERALAC ......................................... 70 KETEK ............................................. 13 ketoconazole .................................... 67 ketoconazole tabs ............................. 14 ketoprofen ....................................... 10 ketoprofen ext-rel ............................. 10 ketorolac ......................................... 10 ketorolac soln ................................... 73 KHEDEZLA ....................................... 31 kimidess .......................................... 41 KINERET .......................................... 56 KINRIX ............................................ 57 KLARON ........................................... 65 KLONOPIN ....................................... 28 KLOR-CON M15 ................................ 58 KLOR-CON/25 .................................. 58 KOMBIGLYZE XR ............................... 38 KORLYM ........................................... 47 K-PHOS ........................................... 58 K-PHOS NEUTRAL ............................. 58 K-PHOS NO 2 ................................... 58 KRISTALOSE .................................... 51 K-TAB ............................................. 58 kurvelo ............................................ 43 KUVAN ............................................ 47 KYNAMRO ........................................ 24

L labetalol .......................................... 25 LABSTIX ......................................... 58 LACRISERT ...................................... 75 lactulose ......................................... 51 lactulose (encephalopathy) ................ 51 LAMICTAL ....................................... 29 LAMICTAL CHEW 2MG ....................... 29 LAMICTAL CHEW 5MG, 25MG ............. 29 LAMICTAL ODT ................................ 29 LAMICTAL XR ................................... 29 LAMISIL .......................................... 14 lamivudine soln, tabs ........................ 16 lamivudine tabs ............................... 17 lamivudine/zidovudine ...................... 15 lamotrigine ...................................... 29 lamotrigine ext-rel............................ 29 LANCETS ......................................... 40 LANOXIN 125MCG, 250MCG .............. 26 LANOXIN 62.5MCG, 187.5MCG .......... 26 lansoprazole .................................... 52 lansoprazole/amoxicillin/clarithromycin 52 LANTUS .......................................... 39 larin ............................................... 43 larin fe ............................................ 43 larin fe 24 ....................................... 43 LASIX ............................................. 26 LASTACAFT ..................................... 74 latanoprost ...................................... 75 LATRIX XM ...................................... 70 LATUDA .......................................... 32 layolis fe chew ................................. 43 LAZANDA ........................................ 11 leena .............................................. 44 leflunomide ..................................... 56 LENVIMA ......................................... 20 LESCOL XL ...................................... 24 lessina ............................................ 43 LETAIRIS ........................................ 27 letrozole .......................................... 19 leucovorin ....................................... 20 LEUKERAN ....................................... 19 LEUKINE ......................................... 55 LEVACET ........................................... 9 levalbuterol nebulizer soln ................. 63 LEVAQUIN ....................................... 13 LEVATOL ......................................... 25 LEVBID ........................................... 50

90

LEVEMIR .......................................... 39 levetiracetam ................................... 29 LEVITRA .......................................... 53 levobunolol ...................................... 74 levocarnitine .................................... 47 levocetirizine .................................... 61 levofloxacin ...................................... 13 levofloxacin oral soln ......................... 13 levofloxacin soln ............................... 72 LEVOMEFOLATE DHA ......................... 59 levonorgestrel/ethinyl estradiol 41, 43, 44 levora .............................................. 43 levorphanol ...................................... 11 levothyroxine ................................... 48 levoxyl ............................................ 48 LEVSIN ............................................ 50 LEVULAN KERASTICK ........................ 66 LEXAPRO ......................................... 31 LEXIVA ............................................ 16 LEXIVA SUSP.................................... 16 LIALDA ............................................ 50 LIBRAX ............................................ 50 lidazone ........................................... 52 lidocaine oint 5% .............................. 70 lidocaine pad 5% .............................. 70 lidocaine soln 4% .............................. 70 lidocaine/hydrocortisone .................... 52 LIDOCAINE/HYDROCORTISONE GEL .... 52 lidocaine/prilocaine ........................... 70 LIDODERM ....................................... 70 lindane ............................................ 71 linezolid ........................................... 18 LINZESS .......................................... 51 liothyronine ...................................... 48 LIPITOR ........................................... 24 LIPOFEN .......................................... 23 lisinopril ........................................... 21 lisinopril/hydrochlorothiazide .............. 21 LITHIUM .......................................... 36 lithium carbonate .............................. 36 lithium carbonate ext-rel ................... 36 LITHOBID ........................................ 36 LITHOSTAT ...................................... 53 LIVALO ............................................ 24 LO LOESTRIN ................................... 43 LOCOID CREAM, OINT, SOLN 0.1% ..... 69 LOCOID LIPOCREAM 0.1% ................. 69 LOCOID LOTION 0.1% ....................... 69

LODOSYN ........................................ 32 LOESTRIN ....................................... 43 LOESTRIN FE ................................... 43 LOFIBRA ......................................... 23 lomedia fe 24 .................................. 43 LOMOTIL ......................................... 49 LONSURF ........................................ 20 lopreeza .......................................... 45 LOPRESSOR..................................... 25 LOPRESSOR HCT .............................. 24 LOPROX SHAMPOO ........................... 67 lorazepam ....................................... 28 LORTAB ELIXIR ................................ 11 loryna ............................................. 43 LORZONE ........................................ 36 losartan .......................................... 23 losartan/hydrochlorothiazide .............. 22 LOSEASONIQUE ............................... 41 LOTEMAX ........................................ 73 LOTENSIN ....................................... 21 LOTENSIN HCT ................................ 21 LOTREL ........................................... 21 LOTRISONE ..................................... 67 LOTRONEX ...................................... 51 lovastatin ........................................ 24 LOVENOX ........................................ 54 low-ogestrel .................................... 43 loxapine .......................................... 32 LUFYLLIN ........................................ 65 LUMIGAN ........................................ 75 LUNESTA ......................................... 35 lutera ............................................. 43 LUXIQ ............................................. 69 LUZU .............................................. 67 LYNPARZA ....................................... 20 LYRICA ........................................... 34 LYSODREN ...................................... 20 LYSTEDA ......................................... 55 lyza ................................................ 44 M MACNATAL CN DHA .......................... 59 MACROBID ...................................... 18 MACRODANTIN ................................ 18 MAGNEBIND 400 .............................. 58 MALARONE ...................................... 15 malathion ........................................ 71 maprotiline ...................................... 30 MARINOL ........................................ 49

91

marlissa ........................................... 43 MARNATAL-F .................................... 59 MARPLAN ......................................... 30 MATULANE ....................................... 20 MAVIK ............................................. 21 MAXALT ........................................... 35 MAXALT-MLT .................................... 35 MAXIDEX ......................................... 73 MAXITROL ....................................... 72 MAXZIDE ......................................... 26 meclofenamate sodium ...................... 10 MEDROL .......................................... 46 MEDROL 2MG ................................... 46 medroxyprogesterone acetate ............ 48 medroxyprogesterone acetate 150mg/ml ...................................................... 42 mefenamic acid ................................ 10 mefloquine ....................................... 15 MEGACE ES ...................................... 48 megestrol acetate ............................. 19 megestrol susp ................................. 48 MEKINIST ........................................ 20 meloxicam ....................................... 10 memantine ...................................... 30 MENACTRA ....................................... 57 MENEST ........................................... 46 MENHIBRIX ...................................... 57 MENOMUNE ...................................... 57 MENOSTAR ...................................... 46 MENVEO .......................................... 57 meperidine ....................................... 11 MEPHYTON ....................................... 58 meprobamate ................................... 28 MEPRON SUSP .................................. 18 mercaptopurine ................................ 19 mesalamine enema ........................... 51 MESTINON ....................................... 37 MESTINON SYRUP ............................. 37 MESTINON TIMESPAN ....................... 37 METADATE CD .................................. 34 metaproterenol ................................. 63 metaxalone ...................................... 36 metformin ........................................ 38 metformin ext-rel ............................. 38 methadone ...................................... 11 METHADOSE CONCENTRATE .............. 11 methamphetamine tabs 5mg .............. 34 methazolamide ................................. 74

methenamine hippurate .................... 53 methenamine mandelate ................... 53 methenamine/hyoscyamine/methylene blue/phenyl salicylate/benzoic acid ..... 53 methenamine/hyoscyamine/methylene blue/phenyl salicylate/sodium bisphosphonate ................................ 53 methenamine/hyoscyamine/methylene blue/phenyl salicylate/sodium phosphate...................................................... 53 methenamine/hyoscyamine/methylene blue/sodium phosphate ..................... 53 methimazole .................................... 48 methocarbamol ................................ 36 methotrexate ................................... 19 methoxsalen .................................... 67 methscopolamine ............................. 50 methyclothiazide .............................. 26 methyldopa ..................................... 26 methyldopa/hydrochlorothiazide ........ 26 methylergonovine ............................ 47 METHYLIN CHEW 2.5MG, 5MG, 10MG . 34 METHYLIN SOLN .............................. 34 methylphenidate chew 2.5mg, 5mg, 10mg .............................................. 34 METHYLPHENIDATE ER 20MG, 30MG, 40MG ............................................. 34 methylphenidate ext-rel 18mg, 27mg, 36mg, 54mg .................................... 34 methylphenidate ext-rel caps 10mg, 20mg, 30mg, 40mg, 50mg, 60mg ...... 34 methylphenidate ext-rel caps 20mg, 30mg, 40mg .................................... 34 methylphenidate ext-rel tabs 10mg, 20mg .............................................. 34 methylphenidate soln ....................... 34 methylphenidate tabs 5mg, 10mg, 20mg...................................................... 34 methylprednisolone .......................... 46 metipranolol .................................... 74 metoclopramide ............................... 49 metolazone ..................................... 26 metoprolol succinate ext-rel .............. 25 metoprolol tartrate ........................... 25 metoprolol/hydrochlorothiazide .......... 24 METOZOLV ODT ............................... 49 METROCREAM .................................. 71 METROGEL ...................................... 71

92

METROGEL-VAGINAL ......................... 54 METROLOTION ................................. 71 metronidazole .................................. 18 metronidazole cream, gel, lotion 0.75% ...................................................... 71 metronidazole gel 0.75% ................... 54 metronidazole gel 1%........................ 71 METVIXIA ........................................ 66 MEVACOR ........................................ 24 mexiletine ........................................ 23 MIACALCIN ...................................... 41 MICARDIS ........................................ 23 MICARDIS HCT ................................. 22 MICORT-HC ...................................... 69 microgestin ...................................... 43 microgestin fe .................................. 43 microgestin fe 24 .............................. 43 MICRO-K ......................................... 58 MICROZIDE ...................................... 26 midodrine ........................................ 27 migergot supp .................................. 35 MIGRANAL ....................................... 35 MILLIPRED ....................................... 46 mimvey ........................................... 45 mimvey lo ........................................ 45 MINASTRIN FE 24 ............................. 43 MINIVELLE ....................................... 46 MINOCIN ......................................... 14 minocycline ...................................... 14 minocycline ext-rel ............................ 14 minoxidil .......................................... 27 MIOCHOL-E ...................................... 75 MIRAPEX.......................................... 32 MIRAPEX ER 0.375MG, 0.75MG, 1.5MG, 2.25MG, 3MG, 4.5MG ........................ 32 MIRAPEX ER 3.75MG ......................... 32 MIRCETTE ........................................ 41 mirtazapine ...................................... 30 MIRVASO ......................................... 71 misoprostol ...................................... 52 MITIGARE ......................................... 9 M-M-R II .......................................... 57 MOBIC ............................................. 10 modafinil ......................................... 37 MODICON ........................................ 43 moexipril ......................................... 21 moexipril/hydrochlorothiazide ............. 21 mometasone cream, oint, soln 0.1% ... 69

mometasone spray ........................... 64 MONODOX ...................................... 14 mono-linyah .................................... 43 mononessa ...................................... 43 montelukast .................................... 63 MONUROL ....................................... 18 morphine ........................................ 11 morphine ext-rel .............................. 11 morphine ext-rel beads ..................... 11 MORPHINE SUPP 30MG ..................... 11 morphine supp 5mg, 10mg, 20mg ...... 11 MOTOFEN ........................................ 49 MOVANTIK ...................................... 51 MOVIPREP ....................................... 51 MOXEZA.......................................... 72 moxifloxacin .................................... 13 MS CONTIN ..................................... 11 MULTAQ .......................................... 23 multinatal plus ................................. 59 MULTISTIX ...................................... 58 mupirocin ........................................ 66 MUSE ............................................. 53 MYCOBUTIN .................................... 18 mycophenolate mofetil ...................... 56 mycophenolate sodium delayed-rel..... 56 MYFORTIC ....................................... 56 MYLERAN ........................................ 19 MYNATAL ........................................ 59 MYNATE 90 PLUS ............................. 59 myorisan ......................................... 65 MYOXIN .......................................... 76 MYRBETRIQ ..................................... 54 MYSOLINE ....................................... 29 myzilra ........................................... 44 N nabumetone .................................... 10 nadolol ........................................... 25 nadolol/bendroflumethiazide .............. 24 naftifine cream ................................ 67 NAFTIN CREAM ................................ 67 NAFTIN GEL ..................................... 67 NALFON .......................................... 10 naltrexone ....................................... 37 NAMENDA ....................................... 30 NAMENDA XR................................... 30 naphazoline ..................................... 75 NAPRELAN 375MG, 500MG ................ 10 NAPRELAN 750MG ............................ 10

93

NAPROSYN ....................................... 10 naproxen ......................................... 10 naproxen delayed-rel ........................ 10 naproxen sodium .............................. 10 naproxen sodium ext-rel .................... 10 naratriptan ....................................... 35 NARDIL ........................................... 30 NASONEX ........................................ 64 NATACHEW ...................................... 59 NATACYN ......................................... 74 NATALVIT ........................................ 59 NATAZIA .......................................... 42 nateglinide ....................................... 39 NATELLE ONE ................................... 59 NATROBA ......................................... 71 NATURE THROID ............................... 48 NEBUPENT ....................................... 18 NEBUSAL ......................................... 64 necon ........................................ 43, 44 NECON 10/11 ................................... 41 NEEVO DHA ..................................... 59 nefazodone ...................................... 30 neomycin ......................................... 12 neomycin/bacitracin/polymyxin b ........ 72 neomycin/polymyxin b/bacitracin/hydrocortisone ................ 72 neomycin/polymyxin b/dexamethasone ...................................................... 72 neomycin/polymyxin b/gramicidin ....... 72 neomycin/polymyxin b/hydrocortisone 72 neomycin/polymyxin b/hydrocortisone soln................................................. 76 neomycin/polymyxin b/hydrocortisone susp ................................................ 76 NEORAL ........................................... 56 NEO-SYNALAR .................................. 66 NEOTUSS PLUS ................................ 62 NESINA ........................................... 38 NESTABS ......................................... 59 NEULASTA ....................................... 55 NEUPOGEN ...................................... 55 NEUPRO........................................... 32 NEURONTIN ..................................... 29 NEVANAC ......................................... 73 nevirapine ........................................ 16 nevirapine ext-rel ............................. 16 NEWGEN .......................................... 59 NEXA PLUS ...................................... 59

NEXAVAR ........................................ 20 NEXIUM .......................................... 52 NEXIUM GRANULES .......................... 52 niacin ............................................. 24 niacin ext-rel ................................... 24 NIASPAN ......................................... 24 nicardipine ...................................... 25 NICOTROL INHALER ......................... 37 NICOTROL NS .................................. 37 nifedipine ........................................ 25 nifedipine ext-rel .............................. 25 nikki ............................................... 43 NILANDRON .................................... 19 nimodipine ...................................... 25 NINLARO ......................................... 20 NIRAVAM ........................................ 28 nisoldipine ext-rel ............................ 25 NITRO-BID ...................................... 27 NITRO-DUR 0.1MG, 0.2MG, 0.4MG, 0.6MG ............................................ 27 NITRO-DUR 0.3MG, 0.8MG ................ 27 nitrofurantoin .................................. 18 nitroglycerin caps ............................. 27 nitroglycerin lingual aerosol ............... 27 nitroglycerin lingual spray ................. 27 nitroglycerin sublingual ..................... 27 nitroglycerin transdermal .................. 27 NITROLINGUAL SPRAY ...................... 27 NITROMIST ..................................... 27 NITROSTAT ..................................... 27 nizatidine ........................................ 50 NIZORAL ......................................... 67 nora-be ........................................... 44 NORCO ........................................... 11 NORDITROPIN ................................. 47 norethindrone .................................. 44 norethindrone acetate ....................... 48 norethindrone/ethinyl estradiol .......... 43 norethindrone/ethinyl estradiol fe ....... 43 norethindrone/ethinyl estradiol fe chew...................................................... 43 norgestimate/ethinyl estradiol ...... 43, 44 NORINYL ......................................... 43 NORITATE ....................................... 71 norlyroc .......................................... 44 NORPACE ........................................ 23 NORPACE CR ................................... 23 NOR-QD .......................................... 44

94

nortrel ....................................... 43, 44 nortriptyline ..................................... 31 NORTUSS-EX.................................... 62 NORVIR ........................................... 16 NORVIR SOLN .................................. 16 NOVOLIN 70/30 ................................ 39 NOVOLIN 70/30 RELION .................... 39 NOVOLIN N ...................................... 39 NOVOLIN N RELION .......................... 39 NOVOLIN R ...................................... 39 NOVOLIN R RELION .......................... 39 NOVOLOG ........................................ 39 NOVOLOG MIX .................................. 39 NOXAFIL .......................................... 15 NUCORT .......................................... 69 NUCYNTA ......................................... 11 NUCYNTA ER .................................... 11 NUEDEXTA ....................................... 37 NULYTELY ........................................ 51 NUOX .............................................. 66 NUTROPIN AQ .................................. 47 NUVARING ....................................... 45 NUVESSA ......................................... 54 NUVIGIL .......................................... 37 NYMALIZE ........................................ 25 nystatin oral ..................................... 15 nystatin topical ................................. 67 nystatin/triamcinolone ....................... 67 O OB COMPLETE .................................. 59 OB COMPLETE GOLD ......................... 59 OBREDON ........................................ 62 OBSTETRIX ...................................... 59 O-CAL PRENATAL .............................. 59 OCALIVA .......................................... 51 ocella .............................................. 43 octreotide ........................................ 47 OCUFLOX ......................................... 73 ODEFSEY ......................................... 15 ODOMZO ......................................... 20 OFEV ............................................... 64 ofloxacin .......................................... 13 ofloxacin ophth ................................. 73 ofloxacin otic .................................... 76 ogestrel ........................................... 43 olanzapine ....................................... 32 olanzapine/fluoxetine ........................ 32 OLEPTRO ......................................... 30

olopatadine ..................................... 74 olopatadine spray ............................. 64 OLUX .............................................. 70 OLUX-E ........................................... 70 OLYSIO ........................................... 17 OMECLAMOX-PAK ............................. 52 omeprazole ..................................... 52 OMNARIS ........................................ 64 OMNIPRED ...................................... 73 OMNITROPE .................................... 47 ondansetron .................................... 49 ondansetron soln ............................. 49 ONETOUCH BLOOD GLUCOSE TEST STRIPS ........................................... 40 ONFI .............................................. 29 ONGLYZA ........................................ 38 ONMEL ............................................ 15 OPANA ............................................ 11 OPANA ER ....................................... 12 opium tincture ................................. 49 OPSUMIT ........................................ 27 ORACEA .......................................... 71 ORACIT ........................................... 53 ORALAIR ......................................... 55 ORAP .............................................. 33 ORAPRED ODT ................................. 46 ORAVIG .......................................... 15 ORENCIA ......................................... 56 ORENITRAM..................................... 28 ORFADIN......................................... 47 ORFADIN SUSP ................................ 47 ORKAMBI ........................................ 63 orphenadrine ext-rel ......................... 36 orphenadrine/aspirin/caffeine ............ 36 orsythia .......................................... 43 ORTHO MICRONOR ........................... 44 ORTHO TRI-CYCLEN ......................... 44 ORTHO TRI-CYCLEN LO ..................... 45 ORTHO-CYCLEN ............................... 43 ORTHO-NOVUM ................................ 43 ORTHO-NOVUM 7/7/7 ....................... 45 OSENI ............................................ 38 OSMOPREP ...................................... 51 OSPHENA ........................................ 48 OTEZLA........................................... 56 OTICIN HC DRO ............................... 76 OVACE PLUS CREAM, FOAM, LOTION .. 67 OVACE PLUS SHAMPOO, WASH .......... 67

95

OVACE WASH ................................... 68 OVCON-35 ....................................... 43 OVIDE ............................................. 71 OXANDRIN ....................................... 38 oxandrolone ..................................... 38 oxaprozin ......................................... 10 OXAYDO .......................................... 12 oxazepam ........................................ 28 oxcarbazepine .................................. 29 oxiconazole cream ............................ 67 OXISTAT CREAM ............................... 67 OXISTAT LOTION .............................. 67 OXSORALEN-ULTRA .......................... 67 OXTELLAR XR ................................... 29 oxybutynin ....................................... 54 oxybutynin ext-rel ............................ 54 oxycodone ....................................... 12 oxycodone ext-rel ............................. 12 oxycodone/acetaminophen ................. 12 oxycodone/aspirin ............................. 12 oxycodone/ibuprofen ......................... 12 OXYCONTIN ..................................... 12 oxymorphone ................................... 12 oxymorphone ext-rel ......................... 12 P PAIRE OB ......................................... 59 paliperidone ext-rel ........................... 32 PAMELOR ......................................... 31 PANCREAZE ..................................... 51 PANDEL ........................................... 69 PANRETIN ........................................ 71 pantoprazole .................................... 52 PARAFON FORTE DSC ........................ 36 paricalcitol ....................................... 47 PARLODEL ....................................... 32 PARNATE ......................................... 30 paromomycin ................................... 12 paroxetine ....................................... 31 paroxetine ext-rel ............................. 31 PASER GRANULES ............................. 17 PATADAY ......................................... 74 PATANASE ....................................... 64 PATANOL ......................................... 74 PAXIL .............................................. 31 PAXIL CR ......................................... 31 PAXIL SUSP...................................... 31 PAZEO ............................................. 74 PEDIAPRED ...................................... 46

PEDIARIX ........................................ 57 PEDIATEX TDM ................................ 62 PEDVAX HIB .................................... 57 peg 3350/electrolytes ....................... 51 PEGANONE ...................................... 29 PEGASYS......................................... 56 PEGINTRON ..................................... 56 PEN NEEDLES .................................. 40 penicillin vk ..................................... 14 PENLAC ........................................... 67 PENNSAID ....................................... 10 PENTACEL ....................................... 57 PENTASA ......................................... 50 pentazocine/naloxone ....................... 12 pentoxifylline ................................... 55 PEPCID ........................................... 50 PERCOCET ....................................... 12 PERFOROMIST ................................. 63 PERIDEX ......................................... 72 perindopril ....................................... 21 permethrin ...................................... 71 perphenazine ................................... 33 perphenazine/amitriptyline ................ 33 PERTZYE ......................................... 51 PEXEVA ........................................... 31 phenazopyridine ............................... 53 phenelzine ....................................... 30 phenobarbital .................................. 29 phenoxybenzamine .......................... 27 phenylephrine .................................. 75 phenylephrine/guaifenesin................. 63 PHENYTEK ....................................... 29 phenytoin ........................................ 29 phenytoin sodium extended ............... 29 philith ............................................. 43 PHOSLO .......................................... 48 PHOSLYRA ....................................... 48 PHOSPHOLINE IODIDE ...................... 75 PICATO ........................................... 66 pilocarpine ...................................... 52 pilocarpine soln ................................ 75 pimozide ......................................... 33 pimtrea ........................................... 41 pindolol ........................................... 25 pioglitazone ..................................... 39 pioglitazone/glimepiride .................... 39 pioglitazone/metformin ..................... 39 pirmella ..................................... 43, 45

96

piroxicam ......................................... 10 PLAQUENIL ...................................... 56 PLAVIX ............................................ 55 PLEGRIDY ........................................ 36 PLEXION CLEANSER, CREAM, LOTION . 66 PLEXION PADS ................................. 66 PNEUMOVAX 23 ................................ 57 PNV OB+DHA ................................... 59 PNV TABS 29-1 ................................. 59 pnv-dha ........................................... 59 PNV-DHA+DOCUSATE ....................... 59 PNV-OMEGA ..................................... 59 pnv-select ........................................ 59 PNV-TOTAL ...................................... 59 PNV-VP-U ........................................ 59 PODOCON 25 ................................... 71 podofilox soln 0.5% .......................... 71 polymyxin b/trimethoprim .................. 73 POLYTRIM ........................................ 73 POMALYST ....................................... 19 PONSTEL ......................................... 10 portia .............................................. 43 potassium bicarbonate effervescent .... 58 potassium bicarbonate/chloride effervescent ..................................... 58 potassium chloride ext-rel .................. 58 potassium chloride powder ................. 58 potassium chloride soln ..................... 58 potassium citrate .............................. 53 potassium citrate/citric acid ............... 53 potassium citrate/sodium citrate/citric acid ................................................. 53 potassium/sodium phosphates ............ 58 POTIGA ........................................... 29 PR NATAL ........................................ 59 PRADAXA ......................................... 55 PRALUENT ........................................ 24 pramipexole ..................................... 32 pramipexole ext-rel ........................... 32 PRAMOSONE CREAM 1-1% ................. 68 PRAMOSONE CREAM 1-2.5% .............. 68 PRAMOSONE E ................................. 68 PRAMOSONE LOTION ........................ 68 PRAMOSONE OINT ............................ 68 pramoxine/chloroxylenol .................... 76 pramoxine/hydrocortisone 1-2.5% ...... 68 pramoxine/hydrocortisone/chloroxylenol ...................................................... 76

PRANDIN ......................................... 39 PRAVACHOL .................................... 24 pravastatin ...................................... 24 prazosin .......................................... 22 PRECISION XTRA BLOOD GLUCOSE TEST STRIPS ........................................... 40 PRED FORTE .................................... 73 PRED MILD ...................................... 73 PRED-G ........................................... 72 PRED-G S.O.P .................................. 72 prednicarbate cream, oint 0.1% ......... 69 prednisolone acetate 1% ................... 73 PREDNISOLONE PHOSPHATE 1% ....... 73 prednisolone sodium phosphate odt, soln...................................................... 46 prednisolone syrup ........................... 46 prednisone ...................................... 46 PREDNISONE INTENSOL ................... 46 PREFERAOB ..................................... 59 PREFEST ......................................... 45 PREMARIN ....................................... 46 PREMARIN CREAM ............................ 46 PREMPHASE .................................... 45 PREMPRO ........................................ 45 PRENA1 .......................................... 59 PRENAISSANCE ................................ 59 PRENATA ......................................... 59 prenatabs fa .................................... 59 prenatabs rx .................................... 59 PRENATAL ....................................... 59 PRENATAL 19 CHEW ......................... 60 PRENATAL 19 TABS .......................... 60 PRENATAL VITAMINS/FERROUS FUMARATE/DOCUSATE...................... 60 PRENATE ......................................... 60 PREPOPIK........................................ 51 PREQUE 10 ...................................... 60 PRESTALIA ...................................... 21 PRETAB ........................................... 60 PREVACID ....................................... 52 PREVACID SOLUTAB ......................... 52 previfem ......................................... 43 PREVNAR 13 .................................... 57 PREVPAC ......................................... 52 PREZCOBIX ..................................... 15 PREZISTA SUSP ............................... 16 PREZISTA TABS ............................... 16 PRIFTIN .......................................... 17

97

PRILOSEC ........................................ 52 PRILOSEC POWDER ........................... 52 PRIMAQUINE .................................... 15 primidone ........................................ 29 PRIMLEV .......................................... 12 PRIMSOL ......................................... 18 PRINIVIL .......................................... 21 PRISTIQ 50MG, 100MG ...................... 31 PROAIR HFA ..................................... 63 probenecid ........................................ 9 PROCARDIA ..................................... 25 PROCARDIA XL ................................. 25 PROCENTRA ..................................... 34 prochlorperazine ............................... 49 prochlorperazine supp ....................... 49 PROCORT ......................................... 52 PROCRIT .......................................... 55 PROCTOCORT ................................... 52 PROCTOFOAM HC.............................. 52 PROCYSBI ........................................ 53 PRODRIN ......................................... 35 progesterone 50mg/ml ...................... 48 progesterone micronized .................... 48 PROGRAF ......................................... 56 PROLENSA ....................................... 73 PROMACTA ....................................... 55 promethazine ................................... 49 promethazine supp ........................... 49 promethazine/codeine ....................... 62 promethazine/dextromethorphan ........ 62 promethazine/phenylephrine .............. 61 promethazine/phenylephrine/codeine .. 62 PROMETRIUM ................................... 48 propafenone ..................................... 23 propafenone ext-rel .......................... 23 propantheline ................................... 50 proparacaine .................................... 75 propranolol ...................................... 25 propranolol ext-rel ............................ 25 propranolol/hydrochlorothiazide .......... 24 propylthiouracil ................................. 48 PROQUAD ........................................ 57 PROSCAR ......................................... 53 PROTONIX ....................................... 52 PROTONIX PAK ................................. 52 PROTOPIC ........................................ 70 protriptyline ..................................... 31 PROVENTIL HFA ................................ 63

PROVERA ........................................ 48 PROVIDA ......................................... 60 PROVIGIL ........................................ 37 PROZAC .......................................... 31 PROZAC WEEKLY .............................. 31 PRUDOXIN CREAM 5% ...................... 71 PULMICORT ..................................... 64 PULMICORT FLEXHALER .................... 64 PULMOZYME .................................... 63 PUREFE OB PLUS .............................. 60 PYLERA ........................................... 52 pyrazinamide ................................... 17 PYRIDIUM ....................................... 53 pyridostigmine ................................. 37 pyridostigmine ext-rel ....................... 37 Q QBRELIS ......................................... 21 QNASL ............................................ 64 QUADRACEL .................................... 57 QUALAQUIN .................................... 15 QUARTETTE ..................................... 42 quasense ........................................ 42 QUDEXY XR ..................................... 29 QUESTRAN ...................................... 23 QUESTRAN LIGHT ............................ 23 quetiapine ....................................... 32 QUILLIVANT XR ............................... 34 quinapril ......................................... 21 quinapril/hydrochlorothiazide ............. 21 quinidine gluconate .......................... 23 quinidine sulfate .............................. 23 quinidine sulfate ext-rel .................... 23 quinine sulfate ................................. 15 QVAR .............................................. 64 R rabeprazole ..................................... 52 RAGWITEK ...................................... 55 raloxifene ........................................ 48 ramipril ........................................... 21 RANEXA .......................................... 27 ranitidine ........................................ 50 RAPAFLO ......................................... 53 RAPAMUNE SOLN ............................. 56 RAPAMUNE TABS.............................. 56 RAVICTI .......................................... 47 RAYALDEE ....................................... 47 RAYOS ............................................ 46 REBETOL CAPS ................................ 17

98

REBETOL SOLN ................................. 17 REBIF .............................................. 36 reclipsen .......................................... 43 RECOMBIVAX HB .............................. 57 RECTIV ............................................ 51 REDICHEW RX .................................. 60 REGLAN ........................................... 49 REGRANEX ....................................... 72 RELENZA ......................................... 18 RELHIST .......................................... 61 RELISTOR ........................................ 51 RELNATE DHA .................................. 60 RELPAX ........................................... 35 REMERON ........................................ 30 RENAGEL ......................................... 48 RENVELA ......................................... 48 repaglinide ....................................... 39 repaglinide/metformin ....................... 39 REPATHA ......................................... 24 REPREXAIN ...................................... 12 REQUIP ........................................... 32 REQUIP XL ....................................... 32 RESCON-MX ..................................... 61 RESCRIPTOR .................................... 16 reserpine ......................................... 27 RESPA-BR ........................................ 62 RESTASIS ........................................ 74 RETIN-A .......................................... 66 RETROVIR ........................................ 16 REVATIO INJ .................................... 27 REVATIO SUSP ................................. 27 REVATIO TABS ................................. 27 REVLIMID ........................................ 19 REXAPHENAC ................................... 10 REXULTI .......................................... 32 REYATAZ ......................................... 16 REYATAZ POWDER ............................ 16 REZIRA ............................................ 62 RHEUMATREX ................................... 56 RIAX ............................................... 66 ribavirin ........................................... 17 RIDAURA ......................................... 56 rifabutin .......................................... 18 RIFADIN .......................................... 17 rifampin ........................................... 17 RIFATER .......................................... 17 RILUTEK .......................................... 36 riluzole ............................................ 36

rimantadine ..................................... 18 RIMSO-50 ....................................... 53 RIOMET .......................................... 38 risedronate ...................................... 41 risedronate delayed-rel ..................... 41 RISPERDAL ...................................... 32 RISPERDAL-M TAB ........................... 33 risperidone ...................................... 33 RITALIN .......................................... 34 RITALIN LA 10MG, 60MG ................... 34 RITALIN LA 20MG, 30MG, 40MG ......... 34 rivastigmine .................................... 30 rivastigmine transdermal................... 30 rizatriptan ....................................... 35 R-NATAL OB .................................... 60 ROBAXIN ........................................ 36 ROBAXIN-750 .................................. 36 ROBINUL ......................................... 50 ROBINUL FORTE............................... 50 ROCALTROL ..................................... 47 ropinirole ........................................ 32 ropinirole ext-rel .............................. 32 ROSULA .......................................... 66 ROTARIX ......................................... 57 ROTATEQ ........................................ 57 ROXICET SOLN ................................ 12 ROXICODONE .................................. 12 ROZEREM ........................................ 35 RULAVITE DHA ................................ 60 RYNODERM ..................................... 70 RYTHMOL ........................................ 23 RYTHMOL SR ................................... 23 S SABRIL POWDER .............................. 29 SABRIL TABS ................................... 29 SAFYRAL ......................................... 43 SAIZEN ........................................... 47 SALAGEN ........................................ 52 SALICYLIC ACID 26% ....................... 71 salicylic acid soln 27.5% ................... 71 salsalate ......................................... 10 SAMSCA .......................................... 49 SANCUSO ........................................ 49 SANDIMMUNE .................................. 56 SANDIMMUNE SOLN ......................... 56 SANDOSTATIN ................................. 47 SANTYL ........................................... 71 SAPHRIS ......................................... 33

99

SARAFEM ......................................... 31 SAVAYSA ......................................... 55 SAVELLA .......................................... 34 SEASONIQUE ................................... 42 SECONAL ......................................... 35 SECTRAL ......................................... 25 SELECT-OB ...................................... 60 selegiline ......................................... 32 selenium sulfide ................................ 68 SELRX ............................................. 68 SELZENTRY ...................................... 15 SEMPREX-D...................................... 61 SE-NATAL 19 .................................... 60 SENSIPAR ........................................ 41 SEREVENT DISKUS ........................... 63 SEROQUEL ....................................... 33 SEROQUEL XR .................................. 33 SEROSTIM ....................................... 47 sertraline ......................................... 31 SE-TAN DHA .................................... 60 setlakin ........................................... 42 SFROWASA ...................................... 51 sharobel .......................................... 44 SHOHLS SOLN MODIFIED .................. 53 sildenafil .......................................... 27 SILENOR .......................................... 34 SILVADENE ...................................... 66 silver nitrate applicators .................... 71 SILVER NITRATE OINT, SOLN 10% ..... 71 SILVER NITRATE SOLN 0.5%, 25%, 50% ...................................................... 71 silver sulfadiazine ............................. 66 SIMBRINZA ...................................... 74 SIMCOR ........................................... 24 SIMPONI .......................................... 56 simvastatin ...................................... 24 SINEMET ......................................... 32 SINEMET CR ..................................... 32 SINGULAIR ...................................... 63 sirolimus .......................................... 56 SIRTURO ......................................... 17 SITAVIG .......................................... 17 SIVEXTRO ........................................ 18 SKELAXIN ........................................ 36 SKLICE ............................................ 71 sodium chloride nebulizer soln ............ 64 sodium citrate/citric acid .................... 54 sodium polystyrene sulfonate susp ...... 58

SOLARAZE ...................................... 66 SOLODYN ........................................ 14 SOLTAMOX ...................................... 19 SOMA ............................................. 36 SOMAVERT ...................................... 47 SONATA .......................................... 35 SORIATANE ..................................... 67 SORILUX ......................................... 67 sotalol ............................................ 23 sotalol af ......................................... 23 SOVALDI ......................................... 17 spinosad ......................................... 72 SPIRIVA HANDIHALER ...................... 61 SPIRIVA RESPIMAT........................... 61 spironolactone ................................. 22 spironolactone/hydrochlorothiazide .... 26 SPORANOX ...................................... 15 SPORANOX SOLN ............................. 15 sprintec .......................................... 43 SPRIX ............................................. 10 SPRYCEL ......................................... 20 sronyx ............................................ 44 SSKI ............................................... 48 STALEVO ......................................... 32 STARLIX ......................................... 39 stavudine ........................................ 16 STAVZOR ........................................ 29 STAXYN .......................................... 53 STENDRA ........................................ 53 STIMATE ......................................... 49 STIOLTO RESPIMAT .......................... 61 STIVARGA ....................................... 20 STRATTERA ..................................... 34 STRENSIQ ....................................... 47 STRIANT ......................................... 38 STRIBILD ........................................ 15 STRIVERDI RESPIMAT ....................... 63 STROMECTOL .................................. 18 SUBOXONE ...................................... 37 SUBSYS .......................................... 12 SUCRAID......................................... 51 sucralfate ........................................ 51 sulfacetamide gel, shampoo, wash ..... 68 sulfacetamide lotion ......................... 66 sulfacetamide ophth ......................... 73 sulfacetamide/prednisolone ............... 72 sulfacetamide/sulfur ......................... 66 SULFADIAZINE ................................ 14

100

sulfamethoxazole/trimethoprim .......... 14 SULFAMYLON CREAM......................... 71 SULFAMYLON PAK ............................. 71 sulfasalazine .................................... 50 sulfasalazine delayed-rel .................... 50 SULFOAM ......................................... 66 sulindac ........................................... 10 SUMADAN WASH .............................. 66 sumatriptan ..................................... 35 SUMAVEL DOSEPRO .......................... 35 SUMAXIN ......................................... 66 SUPRAX ........................................... 13 SUPRAX SUSP .................................. 13 SUPRAX SUSP 500MG/5ML ................. 13 SUPREP ........................................... 51 SURE-TEST BLOOD GLUCOSE TEST STRIPS ............................................ 40 SURMONTIL 100MG........................... 31 SURMONTIL 25MG, 50MG .................. 31 SUSTIVA .......................................... 16 SUTENT ........................................... 20 SUTTAR-2 ........................................ 62 SUTTAR-SF ...................................... 62 syeda .............................................. 44 SYLATRON ....................................... 56 SYMAX DUOTAB ................................ 50 SYMBICORT ..................................... 65 SYMBYAX ......................................... 33 SYMLINPEN ...................................... 38 SYNALAR ......................................... 69 SYNALAR CREAM, OINT 0.025% ......... 69 SYNJARDY ........................................ 40 SYNTHROID ..................................... 48 SYPRINE .......................................... 47 T TABLOID .......................................... 19 TACLONEX OINT ............................... 67 TACLONEX SUSP ............................... 67 tacrolimus ........................................ 56 tacrolimus oint ................................. 70 TAFINLAR ........................................ 20 TAGRISSO ....................................... 20 TAMIFLU .......................................... 18 tamoxifen ........................................ 19 tamsulosin ....................................... 53 TANZEUM ........................................ 39 TARCEVA ......................................... 20 TARGRETIN CAPS ............................. 20

TARGRETIN GEL ............................... 20 tarina fe .......................................... 44 TARKA ............................................ 21 TARON-BC ....................................... 60 TARON-C DHA ................................. 60 TARON-PREX ................................... 60 TASIGNA ......................................... 20 TASMAR .......................................... 32 TAYTULLA ....................................... 44 TAZORAC ........................................ 66 TECFIDERA ...................................... 36 TECHNIVIE ...................................... 17 TEGRETOL ....................................... 29 TEGRETOL-XR 100MG, 200MG, 400MG 29 TEKTURNA ...................................... 26 TEKTURNA HCT ................................ 26 telmisartan ...................................... 23 telmisartan/amlodipine ..................... 22 telmisartan/hydrochlorothiazide ......... 22 temazepam ..................................... 34 TEMODAR ........................................ 19 TEMOVATE CREAM, GEL, OINT, SOLN 0.05% ............................................ 70 TEMOVATE E CREAM 0.05% .............. 70 temozolomide .................................. 19 TENEX ............................................ 21 TENIVAC ......................................... 57 TENORMIN ...................................... 25 TERAZOL 3 ...................................... 54 TERAZOL 7 ...................................... 54 terazosin ......................................... 22 terbinafine....................................... 15 terbutaline ...................................... 63 terconazole cream 0.4% ................... 54 terconazole cream 0.8% ................... 54 terconazole supp .............................. 54 TESSALON PERLES ........................... 63 TESTIM ........................................... 38 testosterone cypionate ...................... 38 testosterone enanthate ..................... 38 testosterone gel 1% ......................... 38 testosterone gel 10mg/act ................. 38 tetrabenazine .................................. 34 tetracaine........................................ 75 tetracycline ..................................... 14 TEXACORT ...................................... 69 TGQ DM/BPM/PSE ............................ 62 TGQ DM/CPM/PE .............................. 62

101

TGQ DM/GFN/PSE ............................. 62 THALOMID ....................................... 19 THEO-24 .......................................... 65 theophylline ext-rel ........................... 65 theophylline soln............................... 65 THIOLA ............................................ 54 thioridazine ...................................... 33 thiothixene ....................................... 33 THRIVITE ......................................... 60 thyroid tab ....................................... 48 THYROLAR ....................................... 48 tiagabine ......................................... 29 TIGAN ............................................. 49 TIKOSYN.......................................... 23 tilia fe.............................................. 45 timolol ............................................. 25 timolol gel soln ................................. 74 timolol soln ...................................... 74 TIMOPTIC 0.25%, 0.5% .................... 74 TIMOPTIC OCUDOSE 0.25%, 0.5% ..... 74 TIMOPTIC-XE ................................... 74 TINDAMAX ....................................... 18 tinidazole ......................................... 18 TIROSINT ........................................ 48 TIVICAY ........................................... 16 TIVORBEX ........................................ 10 tizanidine ......................................... 36 TL FOLATE ....................................... 60 TL-CARE DHA ................................... 60 TL-SELECT ....................................... 60 TOBI NEBULIZER .............................. 63 TOBRADEX OINT ............................... 72 TOBRADEX ST .................................. 72 TOBRADEX SUSP .............................. 72 tobramycin nebulizer soln .................. 63 tobramycin soln ................................ 73 tobramycin/dexamethasone ............... 72 TOBREX OINT ................................... 73 TOBREX SOLN .................................. 73 TOFRANIL ........................................ 31 tolazamide ....................................... 40 tolbutamide ...................................... 40 tolcapone ......................................... 32 tolmetin sodium ................................ 10 tolterodine ....................................... 54 tolterodine ext-rel ............................. 54 TOPAMAX ......................................... 29 TOPAMAX SPRINKLE .......................... 29

TOPICORT CREAM, OINT 0.05% ......... 69 TOPICORT CREAM, OINT 0.25% ......... 68 TOPICORT GEL 0.05% ...................... 68 TOPICORT SPRAY 0.25% ................... 68 topiramate ...................................... 29 TOPROL-XL ...................................... 25 torsemide ........................................ 26 TOVIAZ ........................................... 54 TRACLEER ....................................... 27 TRADJENTA ..................................... 38 tramadol ......................................... 12 tramadol ext-rel caps 100mg, 200mg, 300mg ............................................ 12 TRAMADOL EXT-REL CAPS 150MG ...... 12 tramadol ext-rel tabs ........................ 12 tramadol/acetaminophen .................. 12 TRANDATE ...................................... 25 trandolapril...................................... 21 trandolapril/verapamil ...................... 21 tranexamic acid ............................... 55 TRANSDERM-SCOP ........................... 49 tranylcypromine ............................... 30 TRAVATAN Z .................................... 75 travoprost ....................................... 75 trazodone ........................................ 30 TREAGAN OTIC ................................ 76 TRECATOR ...................................... 17 tretinoin .......................................... 66 tretinoin caps .................................. 20 TRETIN-X ........................................ 66 TREXALL ......................................... 19 TREXIMET ....................................... 35 TREZIX ........................................... 12 triadvance ....................................... 60 triamcinolone cream 0.1% ................ 69 triamcinolone cream, lotion, oint 0.025%...................................................... 69 triamcinolone cream, lotion, oint 0.1% 69 triamcinolone cream, oint 0.5% ......... 68 triamcinolone dental paste ................ 72 triamcinolone spray .......................... 69 triamterene/hydrochlorothiazide ........ 26 TRIANEX ......................................... 69 triazolam......................................... 34 TRIBENZOR ..................................... 22 TRICARE ......................................... 60 TRI-CHLOR ...................................... 71 TRICOR ........................................... 23

102

tri-estaryll ........................................ 45 trifluoperazine .................................. 33 trifluridine ........................................ 74 TRIGLIDE ......................................... 23 trihexyphenidyl ................................. 32 tri-legest fe ...................................... 45 TRILEPTAL ....................................... 30 tri-linyah.......................................... 45 TRILIPIX .......................................... 23 tri-lo-sprintec ................................... 45 trimethobenzamide ........................... 49 trimethoprim .................................... 18 trimipramine .................................... 31 TRINATAL ........................................ 60 trinate ............................................. 60 trinessa ........................................... 45 TRI-NORINYL ................................... 45 triple dye soln .................................. 68 tri-previfem ...................................... 45 tri-sprintec ....................................... 45 TRISTART DHA ................................. 60 TRI-TABS DHA .................................. 60 TRIUMEQ ......................................... 15 TRIVEEN-DUO DHA ........................... 60 TRIVEEN-PRX ................................... 60 trivora ............................................. 45 TRIZIVIR ......................................... 15 TROKENDI XR .................................. 30 tropicamide ...................................... 75 trospium .......................................... 54 trospium ext-rel ................................ 54 TRUETEST BLOOD GLUCOSE TEST STRIPS ............................................ 40 TRUETRACK BLOOD GLUCOSE TEST STRIPS ............................................ 40 TRULICITY ....................................... 39 TRUMENBA....................................... 57 TRUSOPT ......................................... 74 TRUVADA ......................................... 15 TUDORZA PRESSAIR ......................... 61 TUSNEL ........................................... 62 TUSSICAPS ...................................... 62 TUSSIONEX ...................................... 62 TUZISTRA XR ................................... 62 TWINRIX ......................................... 57 TWYNSTA ........................................ 22 TYBOST ........................................... 15 TYKERB ........................................... 20

TYLENOL W/CODEINE ....................... 12 TYVASO .......................................... 28 TYZEKA ........................................... 17 TYZINE ........................................... 64 U UCERIS ........................................... 50 UCERIS FOAM .................................. 51 ULESFIA .......................................... 72 ULORIC ............................................. 9 ULTIMATECARE ................................ 60 ultra tabs ........................................ 60 ULTRACET ....................................... 12 ULTRAM .......................................... 12 ULTRAM ER ..................................... 12 ULTRAVATE CREAM, OINT 0.05% ....... 70 ULTRAVATE LOTION 0.05% ............... 70 UMECTA .......................................... 70 UMECTA NAIL FILM ........................... 70 UMECTA PD ..................................... 70 unithroid ......................................... 48 UPTRAVI ......................................... 28 URAMAXIN ...................................... 70 URAMAXIN FOAM ............................. 70 urea cream ...................................... 70 urea emulsion .................................. 70 urea foam ....................................... 70 urea gel .......................................... 70 urea lotion....................................... 70 UREA NAIL ...................................... 70 urea nail gel 45% ............................. 70 urea nail susp .................................. 70 urea susp ........................................ 70 URINE TEST STRIPS ......................... 40 URISTIX .......................................... 58 UROCIT-K ....................................... 54 UROGESIC-BLUE .............................. 54 UROQID #2 ..................................... 54 UROXATRAL .................................... 53 URSO 250 ....................................... 50 URSO FORTE ................................... 50 ursodiol .......................................... 50 UTOPIC ........................................... 70 V VAGIFEM ......................................... 46 valacyclovir ..................................... 17 VALCHLOR ...................................... 19 VALCYTE ......................................... 17 valganciclovir ................................... 17

103

VALIUM ........................................... 28 valproic acid ..................................... 30 valsartan ......................................... 23 valsartan/hydrochlorothiazide ............. 22 VALTREX .......................................... 17 VANATOL LQ ..................................... 9 VANCOCIN ....................................... 18 vancomycin caps .............................. 18 vancomycin inj 500mg, 1000mg ......... 18 VANCOMYCIN INJECTION 750MG ........ 18 VANOS ............................................ 68 VANOXIDE-HC .................................. 66 VAQTA ............................................. 57 VARIVAX .......................................... 57 VARUBI ........................................... 49 VASOTEC ......................................... 21 VECTICAL ........................................ 67 velivet ............................................. 45 VELPHORO ....................................... 48 VELTASSA ........................................ 58 VELTIN ............................................ 66 VEMAVITE ........................................ 60 VENA-BAL DHA ................................. 60 VENCLEXTA ...................................... 20 venlafaxine ...................................... 31 venlafaxine ext-rel ............................ 31 VENTAVIS ........................................ 28 VENTOLIN HFA ................................. 63 VERAMYST ....................................... 64 verapamil ........................................ 25 verapamil ext-rel .............................. 26 VERDESO ......................................... 69 VEREGEN ......................................... 71 VERELAN ......................................... 26 VERELAN PM .................................... 26 VERIPRED ........................................ 46 VERSACLOZ ..................................... 33 VESICARE ........................................ 54 vestura ............................................ 44 VEXOL ............................................. 73 VFEND ............................................. 15 VIAGRA ........................................... 53 VIBERZI .......................................... 51 VIBRAMYCIN CAPS, SUSP .................. 14 VIBRAMYCIN SYRUP .......................... 14 VICOPROFEN .................................... 12 VICTOZA ......................................... 39 VIDEX EC ......................................... 16

VIDEX SOLN .................................... 16 VIEKIRA PAK ................................... 17 VIEKIRA XR ..................................... 17 VIGAMOX ........................................ 73 VIIBRYD .......................................... 31 VIMPAT ........................................... 30 VINACAL B ...................................... 60 VINATE ........................................... 60 VIOKACE ......................................... 51 viorele ............................................ 41 VIRACEPT ........................................ 16 VIRAMUNE ...................................... 16 VIRAMUNE XR .................................. 16 VIRASAL ......................................... 71 VIREAD ........................................... 16 VIREAD POWDER ............................. 16 VIROPTIC ........................................ 74 VIRT NATE ...................................... 60 VIRT-ADVANCE ................................ 60 VIRT-C DHA .................................... 60 VIRT-CARE ONE ............................... 60 VIRT-PN .......................................... 60 VIRTPREX ........................................ 60 VIRT-SELECT ................................... 60 VIRT-VITE GT .................................. 60 viscous lidocaine .............................. 72 VISTARIL ........................................ 62 VISTOGARD..................................... 20 VITAFOL.......................................... 60 VITAMEDMD .................................... 61 VITAPEARL ...................................... 61 VITA-PREN ...................................... 60 VITATRUE ....................................... 61 VITEKTA ......................................... 16 VITUZ ............................................. 62 VIVA DHA ........................................ 61 VIVELLE-DOT ................................... 46 VOGELXO ........................................ 38 VOL-NATE ....................................... 61 VOL-TAB RX .................................... 61 VOLTAREN GEL ................................ 10 voriconazole .................................... 15 VOSPIRE ER .................................... 63 VOTRIENT ....................................... 20 VP-CH ............................................. 61 VP-GGR-B6 PRENATAL ...................... 61 VP-HEME ......................................... 61 VP-PNV-DHA .................................... 61

104

VRAYLAR ......................................... 33 VUSION ........................................... 67 vyfemla ........................................... 44 VYTORIN ......................................... 24 VYVANSE ......................................... 34 W warfarin ........................................... 55 WELCHOL ........................................ 23 WELLBUTRIN .................................... 30 WELLBUTRIN SR ............................... 30 WELLBUTRIN XL ............................... 30 wera ............................................... 44 WESTHROID ..................................... 48 WP THYROID .................................... 48 wymzya fe chew ............................... 44 X XALATAN ......................................... 75 XALKORI .......................................... 20 XANAX ............................................ 28 XANAX XR ........................................ 28 XARELTO ......................................... 55 XARTEMIS XR ................................... 12 XELJANX XR ..................................... 56 XELJANZ .......................................... 56 XELODA ........................................... 19 XENAZINE ........................................ 34 XERESE ........................................... 71 XIFAXAN .......................................... 18 XIGDUO XR ...................................... 40 XIIDRA ............................................ 75 XOLAIR ............................................ 64 XOPENEX HFA .................................. 63 XOPENEX NEBULIZER ........................ 63 XTANDI ........................................... 19 xulane ............................................. 44 XYREM ............................................. 37 XYZAL ............................................. 61 Y YASMIN ........................................... 44 YAZ ................................................. 44 yuvafem .......................................... 46 Z ZACLIR ............................................ 66 zafirlukast ........................................ 63 zaleplon ........................................... 35 ZANAFLEX ........................................ 37 ZANTAC ........................................... 50 zarah .............................................. 44

ZARONTIN ....................................... 30 ZARXIO........................................... 55 ZATEAN .......................................... 61 ZAVESCA ........................................ 47 ZELAPAR ......................................... 32 ZELBORAF ....................................... 20 ZEMPLAR ........................................ 47 zenatane ......................................... 65 zenchent ......................................... 44 zenchent fe chew ............................. 44 ZENPEP ........................................... 51 ZEPATIER ........................................ 17 ZERIT ............................................. 16 ZESTORETIC .................................... 21 ZESTRIL .......................................... 21 ZETIA ............................................. 23 ZETONNA ........................................ 64 ZIAC ............................................... 24 ZIAGEN ........................................... 16 ZIAGEN SOLN .................................. 16 ZIANA ............................................. 66 zidovudine ....................................... 16 ZINBRYTA ....................................... 36 ZIOPTAN ......................................... 75 ziprasidone ...................................... 33 ZIPSOR ........................................... 10 ZIRGAN .......................................... 74 ZITHRANOL ..................................... 67 ZITHRANOL-RR ................................ 67 ZITHROMAX .................................... 13 ZMAX SUSP ..................................... 13 ZOCOR ........................................... 24 ZOFRAN .......................................... 49 ZOFRAN SOLN ................................. 49 ZOHYDRO ER ................................... 12 ZOLINZA ......................................... 20 zolmitriptan ..................................... 35 ZOLOFT .......................................... 31 zolpidem ......................................... 35 zolpidem ext-rel ............................... 35 zolpidem sublingual .......................... 35 ZOLPIMIST ...................................... 35 ZOMACTON ..................................... 47 ZOMIG ............................................ 35 ZOMIG NASAL SPRAY ....................... 35 ZOMIG ZMT ..................................... 35 ZONALON CREAM 5% ....................... 71 ZONATUSS ...................................... 63

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ZONEGRAN ...................................... 30 zonisamide ....................................... 30 ZORBTIVE ........................................ 47 ZORTRESS ....................................... 56 ZOSTAVAX ....................................... 57 zovia ............................................... 44 ZOVIRAX ......................................... 17 ZOVIRAX CREAM .............................. 71 ZOVIRAX OINT ................................. 71 ZUBSOLV ......................................... 37 ZUPLENZ ......................................... 49 ZURAMPIC ........................................ 9 ZUTRIPRO ........................................ 63

ZYBAN ............................................ 37 ZYCLARA ......................................... 66 ZYDELIG ......................................... 20 ZYFLO ............................................. 63 ZYFLO CR ........................................ 63 ZYKADIA ......................................... 20 ZYLET ............................................. 72 ZYLOPRIM ......................................... 9 ZYMAXID ........................................ 73 ZYPREXA ......................................... 33 ZYPREXA ZYDIS ............................... 33 ZYTIGA ........................................... 19 ZYVOX SUSP ................................... 18

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Blue Rx Essentials Formulary · Blue Rx Essentials Formulary Effective 12/01/2016. INTRODUCTION The...

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