Commercial Health Net’s Three-Tier Recommended Drug List...ANTIFUNGALS CONTINUED VFEND TABLETS...

Commercial

Jesus HaoHealth Net

Health Net’s Three-Tier Recommended Drug List

2013–2014

TABLE OF CONTENTS

SECTION 1 ...................................................................................................................................................... 2 QUESTIONS AND ANSWERS ABOUT YOUR PRESCRIPTION BENEFITS ............................. 2

SECTION 2 ...................................................................................................................................................... 4 HEALTH NET’S THREE-TIER RECOMMENDED DRUG LIST ................................................... 4

ANALGESICS ........................................................................................................................................... 4 ANALGESICS CONTINUED .................................................................................................................... 5 ANTIFUNGALS ......................................................................................................................................... 5 ANTIFUNGALS CONTINUED .................................................................................................................. 6 ANTIHISTAMINES .................................................................................................................................... 6 ANTIHISTAMINE DECONGESTANT COMBINATIONS .......................................................................... 6 ANTI-INFECTIVES ................................................................................................................................... 6 ANTINEOPLASTICS ............................................................................................................................... 11 ANTINEOPLASTICS CONTINUED ........................................................................................................ 12 ANTITUSSIVES – NARCOTIC ............................................................................................................... 12 ANTITUSSIVES – NON-NARCOTIC ...................................................................................................... 12 ANTITUSSIVES – NON-NARCOTIC CONTINUED ............................................................................... 13 EXPECTORANTS ................................................................................................................................... 13 CARDIOVASCULAR MEDICATIONS .................................................................................................... 13 CENTRAL NERVOUS SYSTEM MEDICATIONS .................................................................................. 18 ELECTROLYTIC, CALORIC AND WATER BALANCE MEDICATIONS ................................................ 22 ENDOCRINE MEDICATIONS ................................................................................................................ 23 EYE, EAR, NOSE AND THROAT MEDICATIONS ................................................................................ 27 GASTROINTESTINAL MEDICATIONS .................................................................................................. 31 GENITOURINARY MEDICATIONS ........................................................................................................ 33 IMMUNOSUPPRESSANTS (MEDICATIONS FOR TRANSPLANTS) ................................................... 34 JOINT / CONNECTIVE TISSUE / MUSCULOSKELETAL MEDICATIONS ........................................... 34 NEUROLOGICAL MEDICATIONS ......................................................................................................... 37 OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS .................................................................... 39 RESPIRATORY MEDICATIONS ............................................................................................................ 42 SKIN AND MUCOUS MEMBRANE MEDICATIONS .............................................................................. 44 VITAMINS ............................................................................................................................................... 48 DRUGS FOR THE TREATMENT OF OBESITY .................................................................................... 49 DRUGS FOR THE TREATMENT OF OBESITY CONTINUED .............................................................. 50 DRUGS FOR THE TREATMENT OF SMOKING CESSATION ............................................................. 50 SPECIALTY DRUGS .............................................................................................................................. 51 PREVENTIVE DRUGS ........................................................................................................................... 55

SECTION 3 .................................................................................................................................................... 58 DRUGS SUBJECT TO PRIOR AUTHORIZATION OR STEP THERAPY .................................. 58

SECTION 4 .................................................................................................................................................... 67 DRUGS SUBJECT TO QUANTITY LIMITATIONS .................................................................... 67

SECTION 5 .................................................................................................................................................... 78 ALTERNATIVE MEDICATIONS ON THE RECOMMENDED DRUG LIST ................................ 78

INDEX ............................................................................................................................................................ 85 INDEX OF DRUGS ON THE RECOMMENDED DRUG LIST .................................................... 85

2 Health Net Three-Tier Drug List (Revised 9/1/13)

QUESTIONS AND ANSWERS ABOUT YOUR PRESCRIPTION BENEFITS

1. How can I lower my prescription drug costs?

The choices you and your doctor make regarding prescription medications affect your health care costs. Usually, more than one drug is available to effectively treat a medical problem. When your doctor prescribes a medication for you, be sure to inquire about generic, brand-name and other alternative drug choices.

Always ask your doctor to refer to the Health Net Recommended Drug List when prescribing drugs so you are assured of obtaining medications with the lowest possible copayment. To view the most current list, visit www.healthnet.com.

2. What is the Health Net Recommended Drug List?

The Health Net Recommended Drug List is developed and updated regularly by the Health Net Pharmacy and Therapeutics (P&T) Committee comprised of actively participating physicians and clinical pharmacists throughout California. The list includes a broad selection of drugs that are covered under your pharmacy benefits, and identifies alternatives to common drugs not on the list. It provides a three-tier copayment program.

3. What are the three tiers?

The three tiers, from lowest copayment level to highest copayment level, are:

• Tier I – Preferred Generic, indicated by “1” on the list.

• Tier II – Preferred Brand-name, indicated by “2” on the list.

• Tier III – Nonformulary or nonpreferred, indicated by “3” on the list.

4. What is a generic drug?

A generic drug contains the same active ingredient in the same dosage forms and strengths as a brand- name drug. The Food and Drug Administration (FDA) performs safety, quality and effectiveness tests to ensure that the generic equivalent works

the same as the brand-name drug. Although generic drugs are lower priced than brand-name drugs, they offer the same therapeutic outcomes. Please refer to your Evidence of Coverage or Certificate of Insurance for the specific copayment differences between generic and brand drugs.

Talk to your doctor about using generic medications whenever possible. If there are no generic drugs available, ask your doctor if a brand-name drug is appropriate.

5. When does a medication require prior authorization?

The plan requires prior authorization to determine if a drug is medically necessary and being prescribed according to treatment guidelines consistent with good professional practice. In this case, your doctor must contact Health Net to provide information on the medical reasons for prescribing the medication. If clinical criteria are met, Health Net will issue an authorization for coverage of the medication.

6. What factors determine whether prior authorization is necessary for a particular medication?

• Laboratory or safety monitoring of the drug is necessary.

• There is evidence for experimental use.

• There are usage indications that may not meet Food and Drug Administration (FDA) criteria or Health Net prior authorization guidelines.

• There is potential for misuse.

• Quantity or duration limits are necessary.

• Benefit exclusions may apply.

• Step-care protocol is necessary and must be met.

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QUESTIONS AND ANSWERS ABOUT YOUR PRESCRIPTION BENEFITS

Health Net Three-Tier Drug List (Revised 9/1/13) 3

7. What is step-care protocol?

Step-care protocol is another type of prior authorization. In some cases, you need to try one or more prerequisite drugs before a step-care drug will be covered. If it is medically necessary for you to use a step-care medication without trying a prerequisite drug first, your doctor can contact Health Net to request coverage for the drug as a medical exception.

8. I have a two-tier prescription drug benefit plan. What medications are available to me?

Members with a two-tier plan have access to Tier I and Tier II medications. Prior authorization is required for designated medications. Drugs on Tier III are not covered, and require prior authorization from your physician to establish medical necessity for coverage.

9. What medications are available to members with a three-tier prescription drug benefit plan?

Members with a three-tier plan have access to Tier I, Tier II and Tier III medications. Some medications may require a prior authorization.

10. How is the list organized?

• Section 2: Drugs are listed by therapeutic class so you can identify similar medications within a treatment category

• Section 3: Drugs Subject to Prior Authorization

• Section 4: Drugs Subject to Quantity Limits

• Section 5: Alternative Medications on the Recommended Drug List

• Index

The last section is an alphabetical listing of all drugs with corresponding page numbers in the Therapeutic Class Section.

Generic names appear in lower case. Brand names are listed in upper case for reference only. If a medication is available generically, the generic will be dispensed. Brand-name medications noted in BOLD are available as a generic.

Information contained in the Health Net Recommended Drug List is subject to change.

The medication list may not be comprehensive. Quantity and dosage strength limitations may apply. Prior authorization and specific brands may be required on certain products. The presence of a medication on the Recommended Drug List does not guarantee that a physician will prescribe that drug for a Member with a particular medical condition. Consult your Evidence of Coverage or Certificate of Insurance for further information, or call the Customer Contact Center number listed on your Summary of Benefits and on your ID card.

11. What is the “Specialty Tier”?

Some plans may also have a Specialty Tier which is covered under the pharmacy benefit. Most of these drugs require prior authorization. Please consult your plan documents to determine whether your pharmacy benefit includes the Specialty Tier as part of the RDL for coverage.

Specialty medications are typically injectable medications administered either by you or a health care professional and are drugs that have significantly higher cost than traditional pharmacy benefit drugs. They often require special handling through a Specialty Pharmacy.

12. Are contraceptives covered under the Accountable Care Act?

Effective 8/1/12, some plans will cover most female prescription contraceptives and other preventive medications at $0 cost-share.¹ Coverage on some drugs may not follow the generic and brand tier system. Please refer to your plan documents1 and Health Net’s Recommended Drug List for coverage, cost-share and tier information. Refer to your Evidence of Coverage (EOC) or Certificate of Insurance (COI) for additional coverage information.

1 EOC or COI are legal binding documents. If the information in this brochure differs from the information in the EOC or COI, the EOC or COI applies.


HEALTH NET’S THREE-TIER RECOMMENDED DRUG LIST

TIER 1 TIER 2 TIER 3

(NOT ON FORMULARY) ANALGESICS

Acetaminophen / Codeine Tablets AVINZA CAPSULES ABSTRAL SUBLINGUAL

TABLETS (PA)

Acetaminophen 2.5 / Hydrocodone 1.67 Elixir CODEINE TABLETS ACTIQ LOZENGES (PA)

Acetaminophen 325 / Hydrocodone 5 Tablets NUCYNTA ER TABLETS (QL) BUCCAL FILM (PA) (QL)

Acetaminophen 500 / Hydrocodone 5 Tablets NUCYNTA TABLETS (QL) Butorphanol Nasal Spray (QL)

Acetaminophen 7.5 / Hydrocodone 650 Tablets OPANA ER CRUSH RESISTANT

TABLETS (QL) BUTRANS PATCH (QL)

Butalbital 50 / Acetaminophen 325 / Caffeine 40 Tablets COMBUNOX TABLETS (QL)

Butalbital 50 / Aspirin 325 / Caffeine 40 Tablets / Capsules CONZIP CAPSULES

Butalbital 50 / Aspirin 650 Tablets EXALGO SR TABLETS

Butalbital 50 / Aspirin 650 Tablets Fentanyl Lozenges (PA) (QL)

Codeine / Aspirin Tablets FENTORA BUCCAL TABLETS (PA) (QL)

Codeine Tablets FIORINAL CODEINE CAPSULES

DEMEROL TABLETS KADIAN CR CAPSULES 10MG, 40MG, 70MG,130MG, 150MG, 200MG (QL)

DILAUDID TABLETS LAZANDA NASAL SPRAY (PA)

DOLOPHINE TABLETS (QL) OPANA TABLETS DURAGESIC PATCHES (QL) ORBIVAN CF TABLETS EMPIRIN TABLETS #2, #3, #4 OXECTA TABLETS (QL)

ESGIC CAPSULES Oxycodone 5-Ibuprofen Tablets 400 (QL)

Fentanyl patches (QL)-USE BRAND DURAGESIC OXYCONTIN TABLETS (QL)

FIORICET TABLETS Pentazocine / Acetaminophen Tablets

FIORINAL TABLETS / CAPSULES PERCOCET (ALL

STRENGTHS EXCEPT 5/325)

Hydrocodone / Ibuprofen Tablets PERCOCET TABLETS (All

Strengths Except 5/325) Hydromorphone Tablets RYBIX ODT

KADIAN 20MG, 30MG, 50MG, 80MG, 100MG CAPSULES (QL

RYZOLT SR TABLETS (QL)

LORCET PLUS 7.5/650 TABLETS SPRIX NASAL SPRAY (QL)

LORCET TABLETS STADOL NASAL SPRAY (QL) LORTAB 5/500 TABLETS SUBSYS SPRAY (PA) LORTAB ELIXIR TALWIN NX TABLETS

Meperidine Tablets Tramadol / Acetaminophen Tablets

Methadone Tablets (QL) Tramadol Tablets 24 HR Morphine Solution ULTRACET TABLETS Morphine SR Tablets (QL) ULTRAM ER TABLETS

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BOLD = Brand Name LD=Limited Distribution SP = Refer to Specialty Tier PA= Requires Prior Authorization Brand is for reference only generics-will be used if available N=Not Available Through Mail Order

EST= Step Therapy Required for Coverage Health Net Three-Tier Drug List (Revised 9/1/13) 5


(NOT ON FORMULARY) ANALGESICS CONTINUED

Morphine Sulfate Extended Release Capsules (QL)

Morphine Suppositories MS CONTIN TABLETS (QL) MSIR TABLETS NORCO TABLETS ORAMORPH TABLETS (QL)

Oxycodone 4.5 / Aspirin 325 Tablets

Oxycodone 5 / Acetaminophen 325 Tablets

Oxycodone 7.5 / Ibuprofen 200 mg Tablets

Oxycodone 5 / Acetaminophen 500 Capsules

PERCOCET 5/325 TABLETS

PERCODAN FULL STRENGTH TABLETS

REPREXAIN TABLETS RMS SUPPOSITORIES ROXICET 5 / 325 TABLETS ROXICODONE TABLETS SEDAPAP TABLETS Tramadol Tablets (QL)

TYLENOL CODEINE TABLETS #2, #3, #4

TYLOX 5 / 500 CAPSULES ULTRAM TABLETS (QL) VICODIN 5 / 500 TABLETS

VICODIN ES 7.5 / 750 TABLETS

VICODIN HP TABLETS VICOPROFEN TABLETS XODOL TABLETS ANTIFUNGALS

Clotrimazole Troches LAMISIL GRANULES (PA) DIFLUCAN Tablets NOXAFIL SUSPENSION Fluconazole Tablets OMNEL TABLETS (PA) Griseofulvin Ultramicrosize

Tablets ORAVIG BUCCAL TABLETS

GRIS-PEG TABLETS Itraconazole Capsules (PA) Ketoconazole Tablets LAMISIL TABLETS (PA) MYCELEX TROCHES MYCOSTATIN TABLETS NIZORAL TABLETS Nystatin Oral Suspension Nystatin Tablets SPORANOX CAPSULES (PA) Terbinafine Tablets (PA)




(NOT ON FORMULARY) ANTIFUNGALS CONTINUED VFEND TABLETS (QL) Voriconazole Tablets (QL) ANTIHISTAMINES

ASTELIN NASAL SPRAY (QL) ASTEPRO 0.15% NASAL SPRAY (QL) CLARINEX REDI-TABSS (PA)

(QL)

ATARAX TABLETS CLARINEX TABLETS (PA) (QL)

Azelastine Nasal Spray (QL) Desloratadine Orally Disintegrating Tablets (PA) (QL)

Carbinoxamine Solution Desloratadine Tablets (PA) (QL)

Clemastine Tablets Levocitirize Tablets (PA) (QL)

Cyproheptadine 4 mg Tablets / Syrup XYZAL TABLETS (PA) (QL)

Hydroxyzine HCl Tablets Hydroxyzine Pamoate Capsules PALGIC SOLUTION PERIACTIN TABLETS 4 mg

PERIACTIN 2 MG/ 5 ML SYRUP

Promethazine Syrup TAVIST TABLETS VISTARIL CAPSULES ANTIHISTAMINE DECONGESTANT COMBINATIONS

Chlorpheniramine /Phenylephrine /methscopolamine 2/10/1.25 Syrup

Chlorpheniramine 4.5 / Phenylephrine 5 Suspension

Chlorpheniramine 8 / Phenylephrine 20/ Methscopolamine 2.5 Capsules

EXTENDRYL SR CAPSULES EXTENDRYL SYRUP

Promethazine & Phenylephrine Syrup

ANTI-INFECTIVES Amebicides HUMATIN CAPSULES YODOXIN TABLETS TINDAMAX TABLETS (PA) Paromomycin Capsules Tinidazole Tablets (PA) Anthelmintics Mebendazole Tablets (QL) BILTRICIDE TABLETS ALBENZA TABLETS VERMOX TABLETS (QL)

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(NOT ON FORMULARY) Antimalarials

ARALEN TABLETS COARTEM TABLETS (QL) Atovaquone-Proguanil Tablets

Chloroquine Tablets FANSIDAR TABLETS MALARONE TABLETS

Hydroxychloroquine Tablets PRIMAQUINE TABLETS QUALAQUIN CAPSULES (QL) (PA)

LARIAM TABLETS (QL) Mefloquine Tablets (QL) PLAQUENIL TABLETS Antituberculosis Medication

Ethambutol Tablets MYCOBUTIN CAPSULES Cycloserine Capsules

Isoniazid Tablets RIFAMATE CAPSULES DARAPRIM TABLETS MYAMBUTOL TABLETS TRECATOR TABLETS SEROMYCIN CAPSULES Pyrazinamide Tablets SIRTURO TABLETS (PA) RIFADIN CAPSULES Rifampin Capsules Antivirals and HIV Medications Abacavir Tablets APTIVUS CAPSULES DENAVIR CREAM (QL)

Acyclovir Oral Tablets / Capsules / Suspension ATRIPLA TABLETS EPIVIR HBV TABLETS

Amantadine Capsules BARACLUDE TABLETS FLUMADINE TABLETS Rimantadine Tablets

COMBIVIR TABLETS COMPLERA TABLETS INCIVEK TABLETS (PA (N) COPEGUS TABLETS (PA) CRIXIVAN CAPSULES RELENZA DISKHALER (QL) CYTOVENE CAPSULES EDURANT TABLETS TAMIFLU CAPSULES (QL)

Didansoine Delayed Chewable Tablets EMTRIVA CAPSULES 200MG TYZEKA TABLETS (PA)

Didansoine Delayed Release Capsules EPZICOM TABLETS VICTRELIS CAPSULES (PA)

(N) EPIVIR TABLETS HEPSERA TABLETS VIRAMUNE XR TABLETS Famciclovir Tablets HIVID TABLETS XERESE CREAM (QL) FAMVIR TABLETS INTELENCE TABLETS Ganciclovir Capsules INVIRASE CAPSULES

Lamivudine - Zidovudine Tablets

ISENTRESS TABLETS

Lamivudine Tablets KALETRA CAPSULES Nevirapin Tablets LEXIVA TABLETS REBETOL CAPSULES (PA) NEBUPENT SOLUTION

RETROVIR CAPSULES/ TABLETS NORVIR CAPSULES / TABLETS

Ribavirin Tablets / Capsules (PA) PREZISTA CAPSULES

Stavudine Capsules RESCRIPTOR TABLETS Valacyclovir Tablets (QL) REYATAZ CAPSULES VALTREX TABLETS (QL) SELZENTRY TABLETS

VIAGEN TABLETS STRIBILD TABLETS

VIDEX EC CAPSULES SUSTIVA CAPSULES / TABLETS VIRAMUNE TABLETS TRIZIVIR TABLETS ZERIT CAPSULES TRUVADA TABLETS




(NOT ON FORMULARY) Antivirals and HIV Medications Continued ZIAGEN TABLETS VALCYTE TABLETS (N) Zidovudine Capsules / Tablets VIDEX TABLETS ZOVIRAX ORAL TABLETS /

CAPSULES / SUSPENSION VIRACEPT TABLETS

ZOVIRAX ORAL SUSPENSIONn

VIREAD TABLETS

Cephalosporins

CECLOR CAPSULES / SUSPENSION CEDAX CAPSULES /

SUSPENSION Cefaclor Capsules / Suspension Cefditoren pivoxil Tablets Cefadroxil Capsules KEFLEX 750MG CAPSULES Cefdinir Capsules / Suspension SPECTRACEF TABLETS

Cefprozil Capsules / Suspension SUPRAX SUSPENSION /

CHEW TABLETS

CEFTIN CAPSULES /SUSPENSION SUPRAX 400 MG CAPSULES

(PA)

Cefuroxime Capsules /Suspension

CEFZIL CAPSULES / SUSPENSION

Cephalexin Capsules / Suspension

DURICEF CAPSULES

KEFLEX CAPSULES / SUSPENSION

OMNICEF CAPSULES / SUSPENSION

VANTIN TABLETS VANTIN SUSPENSION Erythromycins / Macrolides Azithromycin Tablets (QL) ERYPED TABLETS BIAXIN SUSPENSION ERY-TAB BIAXIN TABLETS ZMAX ORAL SUSPENSION (QL) BIAXIN XL TABLETS (QL)

Clarithromycin Extended Release Tablets

Clarithromycin Suspension Clarithromycin Tablets EES SUSPENSION E-MYCIN TABLETS ERYTHROCIN TABLETS

Erythromycin / Sulfisoxazole Suspension

Erythromycin Base Tablets

Erythromycin Ethylsuccinate Suspension

Erythromycin Stearate Tablets PEDIAZOLE SUSPENSION ZITHROMAX TABLETS (QL)

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(NOT ON FORMULARY) Fluoroquinolones CIPRO TABLETS AVELOX CAPSULES FACTIVE TABLETS CIPRO XR TABLETS (QL) NOROXIN TABLETS

Ciprofloxacin Extended Release Tablets

Ciprofloxacin Tablets

LEVAQUIN TABLETS / ORAL SOLUTION (QL

Levofloxacin Tablets / Oral Solution (QL)

Penicillins Amoxicillin Capsules,

Suspension, Chewable Tablets AMOXICILLIN 400MG

CHEWABLE TABLETS MOXATAG TABLETS (PA)

Amoxicillin / Clavulanate Potassium Tablets / Suspension

AMOXIL CAPSULES, SUSPENSION

Ampicillin Capsules / Suspension

AUGMENTIN CAPSULES / SUSPENSION

AUGMENTIN XR TABLETS BEEPEN-VK TABLETS /

SUSPENSION

Dicloxacillin Capsules / Suspension

Penicillin VK Tablets / Suspension

TRIMOX VEETIDS TABLETS /

SUSPENSION

WYMOX TABLETS / SUSPENSION

Sulfonamides BACTRIM TABLETS BACTRIM DS TABLETS Erythromycin / Sulfisoxazole

Suspension

PEDIAZOLE SUSPENSION SEPTRA TABLETS SEPTRA DS TABLETS Sulfamethoxazole /

Trimethoprim (SMZ / TMP) Tablets

Sulfamethoxazole / Trimethoprim DS (SMZ / TMP DS) Tablets




(NOT ON FORMULARY) Tetracyclines ACHROMYCIN V CAPSULES ADOXA TABLETS (EST)

DECLOMYCIN TABLETS DORYX CAPSULES (PA) (NOT COVERED USE DOXYCYCLINE- NON-PELLETS)

Demeclocycline Tablets Doxycycine Hyclate 20mg, 40mg Capsules / Tablets

Doxycycline Hyclate Capsules / Tablets

DYNACIN-NOT COVERED USE MINOCYCLINE CAPSULES

MINOCIN 50 MG, 100 MG CAPS ONLY- PELLETS NOT COVERED

Minocycline Tablets (PA) - Use Minocycline Capsules

Minocycline 50 mg,100 mg Capsules Only-Pellets not Covered

MONODOX CAPSULES (EST)

SUMYCIN CAPSULES NUTRIDOX CAPSULES (PA) Tetracycline Capsules ORACEA CAPSULES (EST)

VIBRAMYCIN CAPSULES SOLODYN SR TABS (EST) USE MINOCYCLINE CAPSULES

VIBRA-TABS Other Anti-Infectives

CLEOCIN CAPSULES DAPSONE TABLETS ALINIA SUSPENSION / TABLETS

Clindamycin Capsules MEPRON SUSPENSION CAYSTON INHALATION SOLUTION (QL) (N)

FLAGYL TABLETS 250 mg or 500 mg NEO-FRADIN ORAL SOLUTION DIFICID TABLETS

MACRODANTIN CAPSULES ZYVOX TABLETS HIPREX TABLETS

Methenamine Mandelate Tablets KETEK CAPSULES

Metronidazole Tablets 250 mg, 500 mg Methenamine Hippurate Enteric

Coated Tablets Neomycin Tablets THALOMID CAPSULES (N)

Nitrofurantoin Macrocrystals Capsule TOBI NEBULIZER SOLUTION

(N)

Trimethoprim Tablets VANCOCIN CAPSULES (PA) (QL)

Vancomycin Capsules (PA) (QL)

XIFAXAN 200MG TABLETS (QL)

XIFAXAN 550MG TABLETS (PA)

Topical Antibacterials A/T/S SOLUTION (SWABS,

PADS & PLEDGETS EXCLUDED)

CLEOCIN T SOLN (SWABS, PADS & PLEDGETS EXCLUDED)

Clindamycin Solution 1% (Swabs, Pads & Pledgets Excluded)

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(NOT ON FORMULARY) Topical Antibacterials Continued ERYCETTE SOLN (SWABS,

PADS & PLEDGETS EXCLUDED)

ERYDERM SOLN (SWABS, PADS & PLEDGETS EXCLUDED)

Erythromycin 2.0 % Soln (Swabs, Pads & Pledgets Excluded)

GARAMYCIN CREAM / OINTMENT

Gentamicin Sulfate Cream / Ointment

MYCOLOG II CREAM / OINTMENT

MYCOTRIACET CREAM / OINTMENT

Triamcinolone / Nystatin Cream / Ointment

ANTINEOPLASTICS

Anastrolzole Tablets ALKERAN TABLETS AFINITOR DISPERZ (PA) (N) (LD)

ARIMIDEX TABLETS ANDROXY TABLETS AFINITOR TABLETS (PA) (N) (LD)

AROMASIN TABLETS CAPRELSA TABLETS (N) BOSULIF TABLETS (PA) (N) (LD)

Bicalutamide Tablets COMETRIQ CAPSULES (PA) (N) (LD)

CASODEX TABLETS EMCYT CAPSULES DROXIA CAPSULES

CEENU CAPSULES ERIVEDGE CAPSULES (N) ICLUSIG TABLETS (PA) (N) (LD)

Cyclophosphamide Tablets FARESTON TABLETS INLYTA TABLETS (PA) (N)

CYTOXAN TABLETS GLEEVEC TABLETS (N) JUXTAPID CAPSULES (PA) (LD) (N) (LD)

EFUDEX CREAM / SOLUTION HEXALEN CAPSULES MEKINIST TABLETS (PA)

Etoposide Capsules HYCAMTIN CAPSULES (N) REVLIMID CAPSULES (PA) (N)

EULEXIN CAPSULES IRESSA TABLETS SOLTAMOX SOLUTION FEMARA TABLETS JAKAFI TABLETS (N) STIVARGA TABLETS (PA) (N) Fluoxymesterone Tablets LEUKERAN TABLETS TAFINLAR CAPSULES (PA) Flurouracil Cream / Solution LYSODREN TABLETS XTANDI CAPSULES (PA) (N) Flutamide Capsules MATULANE CAPSULES HYDREA TABLETS MYLERAN TABLETS Hydroxyurea Tablets NEXAVAR TABLETS (N) (LD) Ilomustine Capsules NILANDRON TABLETS Letrozole Tablets OFORTA TABLETS (N) LEUCOVORIN TABLETS POMALYST CAPSULES (N) Mercaptopurine Tablets SPRYCEL TABLETS (N) Methotrexate Tablets SUTENT CAPSULES (N) NOLVADEX TABLETS TABLOID TABLETS PURINETHOL TABLETS TARCEVA TABLETS (PA) (N) RHEUMATREX TABLETS TARGRETIN CAPSULES (N) Tamoxifen Citrate Tablets TASIGNA CAPSULES (PA) (N)




(NOT ON FORMULARY) ANTINEOPLASTICS CONTINUED TEMODAR CAPSULES (QL)

(N) TYKERB TABLETS (N)

Temozolide Capsules (QL) (N) VOTRIENT TABLETS (N) Tretinoin Capsules XALKORI CAPSULES (PA) (N) VEPESID CAPSULES XELODA TABLETS (N) VESANOID CAPSULES ZELBORAF TABLETS (PA) (NA) WELLCOVORIN TABLETS ZOLINZA CAPSULES (PA) (N) ZYTIGA TABLETS (PA) (N) ANTITUSSIVES – NARCOTIC CHERATUSSIN AC SYRUP CHERATUSSIN DAC SYRUP

Codeine 10 / Chlorpheniramine 2 / Pseudoephedrine 30 Liq

Codeine 10 / Pseudoephedrine 30 / Guaifenesin 100 Solution

Codeine 10/ Guaifenesin 100 Syrup

HISTUSSIN HC SYRUP

Guaifenesin 100 / Codeine 10 / Pseudoephedrine 30

Guaifenesin 100 / Codeine 10 Syrup

HYCODAN SYRUP HYCOTUSS EXPECTORANT

Hydrocodone 2.5 / Guaifenesin 100 /Pseudoephedrine 30 Soln

Hydrocodone 2.5 / Phenylephrine 5 / Chlorpheniramine 2 Syrup

Hydrocodone 5 / Guaifenesin 100 Expectorant

Hydrocodone 5 / Homatropine 1.5 Syrup

NOVAHISTINE DH LIQUID PHENERGAN VC CODEINE PHENERGAN/ CODEINE Promethazine / Codeine Syrup

Promethazine / Phenylephrine / Codeine Syrup

TUSSEND SYRUP TUSSIONEX SUSPENSION ANTITUSSIVES – NON-NARCOTIC Benzonatate Capsules Carbinoxamine 4 /

Pseudoephedrine 60 / DM 15 Syrup

Guaifenesin 600 / Pseudoephedrine 120 Tablets

Iodinated Glycerol / Dextromethorphan Syrup

IOPHEN-DM SYRUP PHENERGAN / DM SYRUP

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(NOT ON FORMULARY) ANTITUSSIVES – NON-NARCOTIC CONTINUED Promethazine / DM Syrup RONDEC DM SYRUP TESSALON PERLES ZEPHREX LA TABLETS EXPECTORANTS Guaifenesin 400 /

Pseudoephedrine 120 Tablets

PIMA SOLUTION Potassium Iodide Solution SSKI SOLUTION CARDIOVASCULAR MEDICATIONS Alpha-Beta Adrenergics Acebutolol Capsules BYSTOLIC TABLETS Carvedilol Tablets (QL) COREG CR CAPSULES COREG TABLETS (QL) Labetalol Tablets SECTRAL CAPSULES TRANDATE TABLETS Angiotensin Converting Enzyme Inhibitors (ACEI) ACCUPRIL TABLETS ACEON TABLETS ALTACE CAPSULES Benazepril Capsules CAPOTEN TABLETS Captopril Capsules Enalapril Tablets Fosinopril Capsules Lisinopril Tablets LOTENSIN TABLETS MAVIK TABLETS MONOPRIL TABLETS Perindopril Tablets Quinapril Tablets Ramipril Capsules Trandolapril Tablets UNIVASC TABLETS VASOTEC TABLETS ZESTRIL TABLETS Angiotensin II Receptor Blockers AVALIDE TABLETS BENICAR HCT TABLETS ATACAND HCT TABLETS

(EST) (QL) AVAPRO TABLETS BENICAR TABLETS ATACAND TABLETS (EST)

(QL) COZAAR TABLETS DIOVAN TABLETS Candesartan cilexetil-

hydrochlorothiazide (EST) DIOVAN HCT TABLETS TRIBENZOR TABLETS (EST) EDARBI TABLETS (EST)




(NOT ON FORMULARY) Angiotensin II Receptor Blockers Continued

Eprosartan 600 mg Tablets (EST)

EDARBYCHLOR TABLETS (EST)

HYZAAR TABLETS MICARDIS HCT TABLETS (EST) (QL)

Irbesartan Tablets MICARDIS TABLETS (EST) (QL)

Irbesartan-Hydrochlorothiazde Tablets TEVETEN HCT TABLETS

(EST)

Losartan / Hydrochlorothiazide Tablets TEVETEN 400 MG TABLETS

(EST) Losartan Tablets

TEVETEN 600 MG TABLETS (EST)

Valsartan / HCTZ Tablets Antiarrhythmics Amiodarone Tablets MULTAQ TABLETS CORDARONE TABLETS NORPACE CR CAPSULES Disopyramide Capsules TIKOSYN CAPSULES Flecainide Tablets Mexiletine Capsules Mexiletine SR Capsules MEXITIL CAPSULES NORPACE CAPSULES Propafenone Tablets (QL) Propafenone SR Capsules QUINAGLUTE TABLETS QUINIDEX TABLETS Quinidine Gluconate Tablets

Quinidine Sulfate Sustained Release Tablets

Quinidine Sulfate Tablets QUINIDINE TABLETS RYTHMOL TABLETS (QL) RYTHMOL SR CAPSULES TAMBOCOR TABLETS Antihyperlipidemics Atorvastatin Tablets (QL) ADVICOR TABLETS (QL) ALTOPREV TABLETS

Cholestyramine - Bulk Powder Only NIASPAN TABLETS Amlodipine / Atorvastatin

Tablets (PA)

Cholestyramine Lite- Bulk Powder Only

SIMCOR EXTENDED RELEASE TABLETS LIPTRUZET TABLETS (QL)

ANTARA CAPSULES 43 MG, 130 MG

Choline Fenofibrate Capsules VYTORIN TABLETS (QL) (EST) (10/10) CADUET TABLETS (PA)

COLESTID GRANULES ZETIA TABLETS CRESTOR TABLETS (EST)

COLESTID TABLETS Fenofibrate Micronized 43 mg, 130 mg

COLESTID TABLETS FIBRICOR TABLETS Colestipol Granules Fluvastatin Capsules (QL) (PA)

Colestipol Tablets LESCOL CAPSULES (QL) (PA)

Fenofibrate Micronized Capsules 67mg, 134 mg, 200 mg

LESCOL XL TABLETS (QL) ) (PA)

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(NOT ON FORMULARY) Antihyperlipidemics Continued

Fenofibrate Tablets 48 mg, 54 mg, 145 mg, 160 mg LIVALO TABLETS (EST) (QL)

Gemfibrozil Tablets LOVAZA CAPSULES LIPITOR TABLETS (QL) NIACOR TABLETS LOFIBRA CAPSULES TRIGLIDE TABLETS 50 MG LOPID TABLETS VASCEPA CAPSULES Lovastatin Tablets (QL) WELCHOL TABLETS MEVACOR TABLETS (QL) PRAVACHOL TABLETS (QL) Pravastatin Capsules (QL) QUESTRAN BULK - POWDER

ONLY

QUESTRAN LIGHT - POWDER ONLY

Simvastatin Tablets (QL) TRICOR TABLETS 48 mg,

145mg

TRILIPIX CAPSULES ZOCOR TABLETS (QL) Beta Adrenergic Antagonists Atenolol Tablets DUTOPROL SR TABLETS BETAPACE AF TABLETS INNOPRAN XL CAPSULES BETAPACE TABLETS Betaxolol Tablets Bisoprolol Tablets BLOCADREN TABLETS CORGARD TABLETS INDERAL LA CAPSULES INDERAL TABLETS KERLONE TABLETS LOPRESSOR HCT TABLETS LOPRESSOR TABLETS Metoprolol / HCTZ Tablets Metoprolol SR Tablets Metoprolol Tablets Nadolol Tablets Pindolol Tablets Propranolol Tablets Sotalol Tablets TENORMIN TABLETS Timolol Tablets TOPROL XL TABLETS ZEBETA TABLETS Calcium Channel Blockers ADALAT CC TABLETS CARDENE CAPSULES ADALAT TABLETS CARDENE SR CAPSULES Amlodipine Tablets COVERA -HS TABLETS CALAN SR TABLETS DYNACIRC CR TABLETS CALAN TABLETS Nicardipine Capsules CARDIZEM LA TABLETS VERELAN PM CAPSULES




(NOT ON FORMULARY) Calcium Channel Blockers Continued CARDIZEM CD CAPSULES CARDIZEM SR CAPSULES CARDIZEM TABLETS DILACOR XR CAPSULES

Diltiazem Coated Beads SR 24hr Tablets

Diltiazem Extended Release Capsules

Diltiazem Immediate Release Tablets

Diltiazem SR Capsules ISOPTIN SR TABLETS ISOPTIN TABLETS

Nifedipine Immediate Release Tablets

Nifedipine, Sustained Release Tablets

Nimodine Capsules NIMOTOP CAPSULES Nislodipine SR Tablets NORVASC TABLETS (QL) PLENDIL TABLETS PROCARDIA TABLETS PROCARDIA XL TABLETS SULAR ER TABLETS TIAZAC CAPSULES Verapamil SA Tablets Verapamil SR Capsules Verapamil Tablets VERELAN CAPSULES Cardiac Glycosides Digoxin Tablets LANOXIN TABLETS Combination Antihypertensives ACCURETIC TABLETS AMTURNIDE TABLETS (EST) TARKA TABLETS

ALDORIL TABLETS AZOR TABLETS (EST) TWYNSTA TABLETS (EST) (QL)

Amlodipine / Benazepril Tablets (QL) EXFORGE HCT TABLETS (EST)

Atenolol / Chlorthalidone Tablets EXFORGE TABLETS (EST)

Benazepril / HCTZ Tablets TEKAMLO TABLETS (EST)

Bisoprolol / Hydrochlorothiazide Tablets

CAPOZIDE TABLETS Captopril / HCTZ Tablets

Enalapril / Hydrochlorothiazide Tablets

INDERIDE TABLETS Lisinopril / HCTZ Tablets LOTENSIN HCT TABLETS LOTREL TABLETS (QL)

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(NOT ON FORMULARY) Combination Antihypertensives Continued

Methyldopa / Hydrochlorothiazide Tablets

MONOPRIL / HCT TABLETS

Propranolol / Hydrochlorothiazide Tablets

TENORETIC TABLETS UNIRETIC TABLETS VASERETIC TABLETS Anti-Adrenergic Medications ZESTORETIC TABLETS RESERPINE TABLETS CATAPRES-TTS PATCHES ZIAC TABLETS Clonidine Patches Clonidine (Tablets only) NEXICLON XR TABLETS ALDOMET TABLETS CATAPRES -TABLETS ONLY Guanfacine Tablets Guanabenz Tablets TENEX TABLETS WYTENSIN TABLETS Direct Renin Inhibitors TEKTURNA TABLETS (EST) TEKTURNA HCT TABLETS

(EST)

Vasodilating Medications APRESOLINE TABLETS ADCIRCA TABLETS (PA) BIDIL TABLETS

CARDURA TABLETS LETAIRIS (N) CIALIS TABLETS 2.5 MG, 5 MG (PA) (FOR BPH ONLY)

Doxazosin Mesylate Tablets NITROLINGUAL SPRAY NITROMIST SPRAY

Hydralazine Tablets TRACLEER TABLETS (N) (LD PROGLYCEM SUSPENSION

HYTRIN CAPSULES / TABLETS RANEXA TABLETS (QL)

IMDUR TABLETS REVATIO TABLETS (PA) ISORDIL TABLETS Sildenafil 20mg Tablets (PA) Isosorbide Dinitrate Tablets Isosorbide Mononitrate Tablets LONITEN TABLETS MINIPRESS CAPSULES Minoxidil Tablets NITRO-BID CAPSULES NITRO-DUR PATCHES (QL) Nitroglycerin Ointment Nitroglycerin Oral Capsules Nitroglycerin Patches (QL) NITRO-DUR PATCHES (QL) Nitroglycerin Ointment Nitroglycerin Oral CAPSULES Nitroglycerin Patches (QL) Nitroglycerin Sublingual Tablets




(NOT ON FORMULARY) Hematological Medications NITROSTAT SL TABLETS Prazosin Capsules Terazosin Tablets / Capsules AGRYLIN CAPSULES BRILINTA TABLETS (QL) AGGRENOX CAPSULES Anagrelide Capsules EFFIENT TABLETS ELIQUIS TABLETS Cilostazol Tablets EXJADE TABLETS LYSTEDA TABLETS (QL) Clopidogrel Tablets (QL) KUVAN TABLETS (PA) Tranexamic Acid Tablets (QL) COUMADIN TABLETS MEPHYTON TABLETS Dipyridamole Tablets PRADAXA CAPSULES Pentoxifylline Tablets XARELTO TABLETS (QL) PERSANTINE TABLETS PLAVIX TABLETS (QL) PLETAL TABLETS (QL) TICLID TABLETS Ticlopidine Tablets TRENTAL TABLETS Warfarin Sodium Tablets Pheochromcytoma Medications DIBENZYLINE CAPSULES CENTRAL NERVOUS SYSTEM MEDICATIONS Antidepressants

Amitriptyline Tablets AMOXAPINE TABLETS Amitriptyline /Perphenazine Tablets

Desipramine Tablets CYMBALTA CAPSULES (EST) (QL) APLENZIN SR 24 HR

TABLETS (EST) (QL) ANAFRANIL CAPSULES BRISDELLE TABLETS

AVENTYL CAPSULES Bupropion Sustained Release Capsules

Bupropion Sustained Release Tablets CELEXA ORAL SOLUTION

Bupropion Tablets Citalopram Oral Soultion

CELEXA TABLETS (QL) Desvenlafaxine 24 HR (EST) (QL)

Citalopram Tablets (QL) Fluoxetine Delayed Release Capsules 90 mg

Clomipramine Tablets Fluvoxamine SR Capsules DESYREL TABLETS Fluvoxamine Tablets Doxepin Capsules FORFIVO XL TABLETS (EST) EFFEXOR TABLETS Imipramine Pamoate Capsules EFFEXOR XR CAPSULES LUVOX CR CAPSULES ELAVIL TABLETS Nefazodone Tablets Escitalopram Tablets OLEPTRO TABLETS 24 HR Fluoxetine Capsules PEXEVA TABLETS Fluoxetine Tablets PRISTIQ TABLETS (EST) (QL) Imipramine HCL Tablets PROZAC 60 MG TABLETS

LEXAPRO TABLETS PROZAC WEEKLY CAPSULES

Maprotiline Tablets SILENOR TABLETS (EST) (QL)

Mirtazapine Soluble Tablets SURMONTIL CAPSULES

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(NOT ON FORMULARY) Antidepressants Continued Mirtazapine Tablets TOFRANIL PM TABLETS NORPRAMIN TABLETS Trimipramine Capsules Nortriptyline Tablets VIIBRYD TABLETS (EST) PAMELOR CAPSULES VIVACTIL TABLETS Paroxetine Tablets Paroxetine CR Tablets PAXIL TABLETS PAXIL CR TABLETS

PROZAC CAPSULES ONLY - 10 MG ,20 mg & 40 MG ONLY

REMERON SOLTABS REMERON TABLETS Sertraline Tablets SINEQUAN CAPSULES TOFRANIL TABLETS Trazodone Tablets Venlafaxine Tablets

Venlafaxine Extended Release Tablets

WELLBUTRIN SR TABLETS WELLBUTRIN TABLETS WELLBUTRIN XL TABLETS ZOLOFT TABLETS Antianxiety Medications ATIVAN TABLETS Alprazolam SR 24 hr Tablets Alprazolam Tablets Meprobamate Tablets BUSPAR TABLETS MILTOWN TABLETS Buspirone Tablets XANAX XR TABLETS Chlordiazepoxide Capsules Clorazepate Capsules Diazepam Tablets LIBRIUM CAPSULES Lorazepam Tablets Oxazepam Capsules SERAX CAPSULES TRANXENE CAPSULES VALIUM TABLETS XANAX TABLETS Anti-Mania Medications ESKALITH CAPSULES LITHOBID CAPSULES Lithium Carbonate Tablets /

Capsules

Antipsychotic Medications Chlorpromazine Tablets ABILIFY TABLETS / SOLUTION ABILIFY DISCMELT Clozapine Tablets SAPHRIS SL TABLETS (QL) EMSAM PATCHES (PA) CLOZARIL TABLETS FANAPT TABLETS (PA) Fluphenazine Tablets INVEGA TABLETS




(NOT ON FORMULARY) Antipsychotic Medications Continued GEODON CAPSULES LATUDA TABLETS

Haloperidol Tablets Olanzapine / Fluoxetine Capsules (PA)

Loxapine Capsules Olanzapine Orally Disintegrating Tablet

LOXITANE CAPSULES Olanzapine-Fluoxetine Capsules

NAVANE CAPSULES ORAP TABLETS Olanzapine Tablets RISPERDAL–M TABLETS

Perphenazine Tablets Risperidone Orally Disintegrating Tablets

PROLIXIN TABLETS SEROQUEL XR TABLETS Quetiapine Fumarate Tablets SYMBYAX CAPSULES RISPERDAL TABLETS ZYPREXA ZYDIS Risperidone Tablets SEROQUEL TABLETS Thiothixene Capsules Trifluoperazine Tablets Ziprasidone Capsules ZYPREXA TABLETS Barbiturates Phenobarbital Tablets Sedatives / Hypnotics AMBIEN TABLETS (QL) AMBIEN CR TABLETS (QL) Chloral Hydrate Capsules DORAL TABLETS

DALMANE CAPSULES (QL) EDLUAR SUBLINGUAL TABLETS (QL) (EST)

Estazolam Tablets INTERMEZZO SL TABLETS (PA)

Flurazepam Capsules (QL) LUNESTA TABLETS (EST) (QL)

HALCION TABLETS (QL) RESTORIL 22.5 MG

PROSOM TABLETS ROZEREM TABLETS (EST) (QL)

RESTORIL 7.5 MG, 15 MG, 30 MG CAPSULES Temazepam 22.5 mg Capsules

SONATA CAPSULES (EST) (QL) Zolpidem CR Tablets (QL)

(EST)

Temazepam 7.5 mg, 15 mg, 30 mg Capsules ZOLPIMIST SPRAY (EST)

Triazolam Tablets (QL) Zolpidem Tablets (QL) Monoamine Oxidase Inhibitors (MAOI) PARNATE TABLETS Tranylcypromine Tablets NARDIL TABLETS Phenelzine Tablets

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(NOT ON FORMULARY) Central Nervous System (CNS) Stimulants ADDERALL TABLETS VYVANSE (QL) DAYTRANA PATCH

ADDERALL XR CAPSULES (QL) DESOXYN TABLETS (PA)

Amphetamine Dextroamphetamine 24 HR SR Capsules (QL)

FOCALIN XR CAPSULES

Amphetamine Dextroamphetamine Tablets METADATE CD CAPSULES

CONCERTA SA TABLETS (QL) Methylphenidate LA Capsules

DEXEDRINE SPANSULES Modafanil Tablets (PA) (QL) DEXEDRINE TABLETS NUVIGILTABLETS (PA)

Dexmethylphenidate Tablets PROVIGIL TABLETS (QL) (PA)

Dextroamphetamine Sustained Release Capsules QUILLIVANT XR

SUSPENSION (QL) Dextroamphetamine Tablets RITALIN LA CAPSULES FOCALIN TABLETS ZENZEDI TABLETS METHYLIN SOLUTION

Methylphenidate Hcl Tablet SA OSM

METADATE CR Methylphenidate Solution Methylphenidate SR Tablets Methylphenidate Tablets RITALIN SR TABLETS RITALIN TABLETS Miscellaneous CNS Medications ANTABUSE TABLETS GUANIDINE TABLETS AUBAGIO TABLETS (PA) (SP) Disulfiram Tablets NUEDEXTA CAPSULES CAMPRAL TABLETS (PA) Naltrexone Tablets (PA) GILENYA TABLETS (PA) (SP) REVIA TABLETS INTUNIV TABLETS (QL) KAPVAY SR TABLETS RILUTEK TABLETS Riluzole Tablets SAVELLA TABLETS (PA) (QL) STRATTERA TABLETS (QL)

SUBOXONE SL TABLETS (PA) (QL)

SUBUTEX SL TABLETS (PA) (QL)

TECFIDERA CAPSULE (PA) (N) (SP)

XYREM SOLUTION (PA) ZUBSOLV SL TABLETS (PA)




(NOT ON FORMULARY) ELECTROLYTIC, CALORIC AND WATER BALANCE MEDICATIONS Alkalinizing Medications CITRA K CRYSTALS /

SOLUTION UROCIT K-15

Citric Acid / Potassium Citrate / Sodium Citrate Syrup / Crystals

CYTRA-2 SOLUTION CYTRA-3 SYRUP POLY-CITRA K CRYSTALS /

SYRUP

Potassium Citrate Tablets UROCIT-K-10 TABLETS UROCIT-K-5 TABLETS Electrolyte Depleters Calcium Acetate Capsules K-PHOS TABLETS FOSRENOL TABLETS KAYEXALATE PHOSLYRA SOLUTION RENAGEL TABLETS PHOSLO TABLETS /

CAPSULES RENVELA TABLETS

Sodium Polystyrene Sulfonate Powder

Sodium Polystyrene Sulfonate Solution

SPS SUSPENSION Ammonia Detoxicants CEPHULAC SOLUTION CARBAGLU TABLETS KRISTALOSE CRYSTALS Lactulose Solution LITHOSTAT TABLETS RAVICTI LIQUID (PA) (N) (LD) Potassium Medications K-DUR TABLETS KLOR-CON K-LYTE (DS) PACKETS K-TABS MICRO-K Potassium Chloride 8 mEq, 10

mEq, 20 mEq

Potassium Chloride Effervescent Tablets

Potassium Chloride Liquid Potassium Chloride Packets. SLOW K Loop Diuretics Bumetanide Tablets EDECRIN TABLETS BUMEX TABLETS DEMADEX TABLETS Torsemide Tablets Furosemide Tablets LASIX TABLETS

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(NOT ON FORMULARY) Potassium Sparing Diuretics ALDACTAZIDE TABLETS SAMSCA TABLETS (QL) DYRENNIUM CAPSULES ALDACTONE TABLETS Eplerenone Tablets Amiloride / Hydrochlorothiazide

Tablets INSPRA TABLETS

DYAZIDE CAPSULES MAXZIDE TABLETS MODURETIC TABLETS Spironolactone / HCTZ Tablets Spironolactone Tablets Triamterene / HCTZ Capsules Triamterene / HCTZ Tablets Thiazide and Related Diuretics

Chlorthalidone Tablets Hydrochlorothiazide (HCTZ)

12.5 mg Tablets HCTZ TABLETS / CAPSULES Hydrochlorothiazide (HCTZ) 25

mg, 50 mg Tablets

Hydrochlorothiazide (HCTZ) 12.5 mg Capsules

HYDRODIURIL TABLETS HYGROTON TABLETS Indapamide Tablets LOZOL TABLETS Metolazone Tablets MICROZIDE CAPSULES ZAROXOLYN TABLETS ENDOCRINE MEDICATIONS Androgens ANDROID CAPSULES ANDROGEL (QL) ANDRODERM PATCHES Danazol Capsules METHITEST TABLETS AXIRON SOLUTION (QL)

(EST) DANOCRINE CAPSULES FORTESTA GEL (QL) (EST) Fluoxymesterone Tablets STRIANT BUCCAL TABLETS Methyltestosterone Capsules TESTIM GEL (QL) – USE

ANDROGEL Oxandralone Tablets OXANDRIN TABLETS TESTRED CAPSULES Antidiabetic Medications Acarbose Tablets AVANDAMET TABLETS ACTOPLUS MET XR

TABLETS ACTOPLUS MET TABLETS AVANDARYL TABLETS FORTAMET TABLETS ACTOS TABLETS AVANDIA TABLETS GLUMETZA TABLETS DIABETA TABLETS JANUMET TABLETS GLYSET TABLETS Glimepiride Tablets JANUMET XR TABLETS INVOKANA TABLETS Glipizide Long Acting JANUVIA TABLETS KAZANO TABLETS (PA) AMARYL TABLETS JENTADUETO TABLETS Metformin ER Osmotic Glipizide Tablets JUVISYNC TABLETS (QL) NESINA TABLETS (PA) GLUCOPHAGE TABLETS KOMBIGLYZE XR OSENI TABLETS (PA)




(NOT ON FORMULARY) Antidiabetic Medications Continued GLUCOPHAGE XR TABLETS ONGLYZA TABLETS PRANDIMET TABLETS GLUCOTROL TABLETS PRANDIN TABLETS RIOMET SOLUTION DUETACT TABLETS TRADJENTA TABLETS GLUCOTROL XL TABLETS GLUCOVANCE TABLETS Glyburide Micronized Tablets GLYNASE TABLETS METAGLIP TABLETS Metformin / Glipizide Tablets Metformin / Glyburide Tablets Metformin Tablets Metformin XR Tablets MICRONASE TABLETS Nataglenide Tablets Pioglitazone / Glimepiride

Tablets

Pioglitazone Tablets Pioglitazone-Metformin Tablets STARLIX TABLETS Tolazamide Tablets PRECOSE TABLETS TOLBUTAMIDE TABLETS TOLINASE TABLETS Insulins HUMALOG INSULIN (QL) APIDRA INSULIN (QL)

HUMALOG INSULIN KWIKPENS (QL) APIDRA SOLOSTAR (QL) (PA)

HUMALOG INSULIN PENS (QL) NOVOLIN (VIALS OR CARTRIDGES ONLY)

HUMALOG MIX 50/50 INSULIN (QL) NOVOLOG (PA) (VIALS OR

CARTRIDGES ONLY)

HUMALOG MIX 50/50 INSULIN KWIKPENS (QL) NOVOLOG MIX (VIALS OR

CARTRIDGES. ONLY)

HUMALOG MIX 50/50 INSULIN PENS (QL)

HUMALOG MIX 75/25 INSULIN (QL)

HUMALOG MIX 75/25 INSULIN KWIKPENS (QL)

HUMALOG MIX 75/25 INSULIN PENS (QL)

HUMULIN INSULIN 50/50 (QL) HUMULIN N INSULIN (QL) HUMULIN R INSULIN (QL) LANTUS VIALS (QL) LANTUS CARTRIDGES (QL) LANTUS SOLOSTAR (QL)

LEVEMIR INSULIN (VIALS ONLY) (QL)

REGULAR ILETIN (QL)

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(NOT ON FORMULARY) Blood Glucose Test Strips (Not Covered By All Plans Under The Pharmacy Benefit)

ONETOUCH ULTRA BLUE TEST STRIPS (QL)

ACCU-CHEK COMFORT CURVE TEST STRIPS (QL) (PA

ONETOUCH VERIO IQ TEST STRIPS (QL) ACCU-CHEK ADVANTAGE

TEST STRIPS (QL) (PA

FREESTYLE LITE TEST STRIPS (QL) ACCU-CHEK AVIVA PLUS

TEST STRIPS (QL) (PA)

FREESTYLE TEST STRIPS (QL) ACCU-CHEK AVIVA TEST STRIPS (QL) (PA)

PRECISION XTRA TEST STRIPS (QL) ACCU-CHEK COMPACT TEST

STRIPS (QL) (PA)

ACCU-CHEK SMARTVIEW TEST STRIPS (PA) (QL)

ASCENCIA TEST STRIPS (PA) (QL)

FASTTAKE TEST STRIPS (PA) (QL)

NOVA MAX TEST STRIPS (PA) (QL)

ONETOUCH TEST STRIPS (PA) (QL)

PRESTIGE TEST STRIPS (PA) (QL)

SURESTEP TEST STRIPS (PA) (QL)

TRUETRAK TEST STRIPS (PA) (QL)

Insulin Needles and Syringes DISPOSABLE INSULIN

NEEDLES & SYRINGES

PEN NEEDLES PEN NEEDLES SHORT PEN NEEDLES MINI Estrogens CLIMARA PATCHES (QL) ESTRACE VAGINAL CREAM ALORA PATCHES ESTRACE TABLETS ESTRADERM PATCHES (QL) CENESTIN TABLETS Estradiol Patches - Weekly MENEST TABLETS ELESTRIN VAGINAL CREAM Estradiol Tablets PREMARIN TABLETS ENJUVIA TABLETS

Estradiol Patches - Biweekly PREMARIN VAGINAL CREAM ESTRASORB TOPICAL EMULSION

Estropipate Tablets VIVELLE-DOT PATCHES ESTRING (3 Month's Supply) OGEN TABLETS ESTROGEL (QL) ORTHO-EST TABLETS FEMRING (3 months Supply) MENOSTAR PATCH MINIVELLE PATCHES (QL) VAGIFEM VAGINAL TABLETS




(NOT ON FORMULARY) Hormone Combination Products ACTIVELLA TABLETS CLIMARA PRO PATCH ANGELIQ TABLETS

Esterified Estrogens /Methyltestosterone Tablets PREMPHASE TABLETS COMBIPATCH TABLETS

Esterified Estrogens /Methyltestosterone HS Tablets PREMPRO TABLETS PREFEST TABLETS

Estradiol & Norethindrone Acetate Tablet

ESTRATEST HS TABLETS ESTRATEST TABLETS FEMHRT TABLETS Osteoporosis Medications Alendronate Tablets (QL) EVISTA TABLETS (QL) ACTONEL TABLETS (PA) (QL

Calcitonin (Salmon) Nasal Solution ACTONEL with CALCIUM

TABLETS (PA) (QL) FORTICAL NASAL SPRAY ATELVIA TABLETS (EST) (QL)

FOSAMAX TABLETS (QL) BINOSTO EFFERVESCENT TABLETS (PA)

MIACALCIN NASAL SPRAY BONIVA TABLETS (QL) DIDRONEL TABLETS ETIDRONATE TABLETS

FOSAMAX-D TABLETS (PA) (QL)

Ibandronate Tablets (QL) Thyroid Hormones

ARMOUR THYROID 30 MG, 60 MG, 90 MG TABLETS ARMOUR THYROID 15 MG, 180

MG, 240 MG, 300 MG TABLETS THYROLAR TABLETS

CYTOMEL TABLETS TIROSINT CAPSULES LEVOTHROID TABLETS Levothyroxine Tablets LEVOXYL TABLETS Liothyronine Tablets SYNTHROID TABLETS Thyroid, Dessicated Tablets Anti-Thyroid Hormones Propylthiouracil (PTU) Tablets Methimazole Tablets TAPAZOLE TABLETS Miscellaneous Endocrine Medications DDAVP TABLETS/ SPRAY SYNAREL NASAL SOLUTION Cabergoline Tablets (QL) Desmopressin Tablets / Spray DOSTINEX TABLETS (QL)

MEGACE ORAL SUSPENSION MEGACE ES SUSPENSION

Megestrol Tablets OSPHENA TABLETS (PA) PROCYSBI CAPSULES (N) SENSIPAR TABLETS ZAVESCA CAPSULES (PA)

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(NOT ON FORMULARY) EYE, EAR, NOSE AND THROAT MEDICATIONS Anti-Glaucoma Medications

Acetazolamide SR Capsules ALPHAGAN P 0.1% OPHTHALMIC SOLUTION COMBIGAN OPHTHALMIC

SOLUTION

Acetazolamide Tablets AZOPT OPHTHALMIC SOLUTION COSOPT PF OPHTHALMIC

SOLUTION

ALPHAGAN OPHTHALMIC SOLUTION BETIMOL OPHTHALMIC

SOLUTION ISTALOL OPHTHALMIC SOLUTION

ALPHAGAN P OPHTHALMIC SOLUTION BETOPTIC OPHTHALMIC

SOLUTION MetiPranolol Ophthalmic Solution

BETAGAN OPHTHALMIC SOLUTION LUMIGAN OPHTHALMIC (QL) RESCULA OPHTHALMIC

SOLUTION (QL)

Betaxolol Ophthalmic Solution PHOSPHOLINE IODIDE OPHTHALMIC SOLUTION TIMOPTIC OCUDOSE

PRESERVATIVE FREE

Brimonidine Ophthalmic Solution PILOPINE HS GEL ZIOPTAN OPHTHALMIC

SOLUTION (QL)

COSOPT OPHTHALMIC SOLUTION TIMOPTIC XE GEL

DIAMOX SEQUELS/ TABLETS TRAVATAN Z OPHTHALMIC SOLUTION (QL)

Dipivefrin Ophthalmic Solution

Dorzolamide / Timolol Ophthalmic Solution

Dorzolamide Ophthalmic Solution

Epinephrine HCl Ophthalmic Solution

ISOPTOCARPINE OPHTHALMIC SOLUTION

Latanoprost Ophthalmic Solution (QL)

Levobunolol Ophthalmic Solution

Methazolamide Tablets NEPTAZANE TABLETS

PILOCAR OPHTHALMIC SOLUTION

Pilocarpine HCL Ophthalmic Solution

PROPINE OPHTHALMIC SOLUTION

Timolol Maleate Ophthalmic Solution

Timolol XE Ophthalmic Gel

TIMOPTIC OPHTHALMIC GEL SOLUTION

TIMOPTIC OPHTHALMIC SOLUTION

TRUSOPT OPHTHALMIC SOLUTION

XALATAN OPHTHALMIC SOLUTION (QL)




(NOT ON FORMULARY) Ophthalmic Antibiotics AK-TOB OPHTHALMIC

SOLUTION MOXEZA OPHTHALMIC SOLUTION AZASITE OPHTALMIC

SOLUTION (QL) BLEPH 10 OPHTHALMIC

OINTMENT / SOLUTION NATACYN OPHTHALMIC SUSPENSION BESIVANCE OPHTHALMIC

SOLUTION CILOXAN OPHTHALMIC

SOLUTION VIGAMOX OPHTHALMIC SOLUTION Levofloxacin Ophthalmic

Solution Ciprofloxacin Ophthalmic

Solution QUIXIN OPHTHALMIC SOLUTION

Erythromycin Base Ophthalmic Ointment ZYMAR OPHTHALMIC

SOLUTION GARAMYCIN OPHTHALMIC

OINTMENT/ SOLUTION ZYMAXID OPHTHALMIC SOLUTION

GENOPTIC OPHTHALMIC OINTMENT/ SOLUTION

GENTACIDIN OPHTHALMIC SOLUTION

Gentamicin Ophthalmic Solution & Ointment

Neomycin / Bacitracin / Polymyxin Ophthalmic Solution & Ointment

NEOSPORIN OPHTHALMIC OINTMENT

NEOSPORIN OPHTHALMIC SOLN.

OCUFLOX OPHTHALMIC SOLUTION

Ofloxacin Ophthalmic Solution Polymixin B Sulfate /

Trimethoprim Ophthalmic Solution

POLYTRIM OPHTHALMIC SOLUTION

Sulfacetamide Ophthalmic Solution

Tobramycin Ophthalmic Solution & Ointment

TOBREX OPHTHALMIC OINTMENT/ SOLUTION

Ophthalmic Anti-Inflammatory Medications

ACULAR LS OPHTHALMIC SOLUTION FLAREX OPHTHALMIC

SOLUTION ACUVAIL OPHTHALMIC SOLUTION

ACULAR OPHTHALMIC SOLUTION FML FORTE OPHTHALMIC

SOLUTION ALREX OPHTHALMIC SUSPENSION

DECADRON OPHTHALMIC SOLUTION & OINTMENT BROMDAY OPHTHALMIC

SOLUTION

Dexamethasone Ophthalmic Solution & Ointment Bromfenac Sodium Ophthalmic

Solution

Diclofenac Sodium Ophthalmic Solution DUREZOL OPHTHALMIC

EMULSION

Fluorometholone Ophthalmic Suspension LOTEMAX OPHTHALMIC

SUSPENSION/ GEL

Fluorometholone Ophthalmic Suspension & Ointment NEVANAC OPHTHALMIC

SUSPENSION

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(NOT ON FORMULARY) Ophthalmic Anti-Inflammatory Medications Continued

FLUOR-OP OPHTHALMIC SOLUTION PROLENSA OPHTHALMIC

SOLUTION

Flurbiprofen Ophthalmic Solution VEXOL OPHTHALMIC

SUSPENSION

FML OPHTHALMIC SOLUTION & OINTMENT XIBROM OPHTHALMIC

SUSPENSION

INFLAMASE FORTE OPHTHALMIC SOLUTION & OINTMENT

Ketorolac Ophthalmic Solution

MAXIDEX OPHTHALMIC SOLUTION

OCUFEN OPHTHALMIC SOLUTION

PRED FORTE OPHTHALMIC SUSPENSION

PRED MILD OPHTHALMIC SUSPENSION

Prednisolone Acetate Ophthalmic Suspension

Prednisolone Phosphate Ophthalmic Solution

VOLTAREN OPHTHALMIC SOLUTION

Ophthalmic Anti-Inflammatory / Anti-Infective Combinations CORTISPORIN OPHTHALMIC

SOLUTION & OINTMENT BLEPHAMIDE OPHTHALMIC

OINTMENT TOBRADEX ST OPHTHALMIC

SOLUTION Dexamethasone / Neomycin /

Polymyxin Ophth. Solution & Ointment

ISOPTO CETAPRED OPHTHALMIC SOLUTION/ OINTMENT

TOBRADEX OPHTHALMIC OINTMENT

Hydrocortisone / Neomycin / Polymyxin Ophth. Susp & Oint

ZYLET OPHTHALMIC SUSPENSION (QL)

MAXITROL OPHTHALMIC SOLUTION & OINTMENT

Ophthalmic Anti-Inflammatory / Anti-Infective Combinations Continued Neomycin / Polymyxin /

Prednisone Ophthalmic Solution

Sulfacetamide / Prednisolone Acetate Susp. & Ointment

Sulfacetamide / Prednisolone Ophthalmic Ointment

TOBRADEX OPHTHALMIC SUSPENSION (QL)

Ophthalmic Antivirals Trifluridine Ophthalmic Solution ZIRGAN OPHTHALMIC GEL VIROPTIC OPHTHALMIC

SOLUTION




(NOT ON FORMULARY) Other Ophthalmic Medications

Atropine Sulfate Ophthalmic Solution & Ointment ALOMIDE OPHTHALMIC

SOLUTION ALAMAST OPHTHALMIC SOLUTION

Cromolyn Sodium Ophthalmic Solution LASTACAFT OPHTHALMIC

SOLUTION ALOCRIL OPHTHALMIC SOLUTION

Cyclopentolate Ophthalmic Solution PATADAY OPHTHALMIC

SOLUTION BEPREVE OPHTHALMIC SOLUTION (QL)

Homatropine Ophthalmic Solution CYSTARAN OPHTHALMIC

SOLUTION

MYDFRIN OPHTHALMIC SOLUTION ELESTAT OPHTHALMIC

SOLUTION

Phenylephrine 2.5% Ophthalmic Solution Epinastine HCl Ophthalmic

Solution 0.05%

Scopolamine HBr Ophthalmic Solution LACRISERT INSERTS

LIVOSTIN OPHTHALMIC SOLUTION

OPTIVAR OPHTHALMIC SOLUTION

PATANOL OPHTHALMIC SOLUTION

RESTASIS OPHTHALMIC EMULSION (QL)

Ear Medications Acetic Acid 2% Otic Solution CIPRODEX OTIC SOLUTION ACETASOL HC (QL)

Acetic Acid Otic Aluminum Acetate Solution AURALGAN OTIC SOLUTION

AUROTO OTIC SOLUTION CETRAXAL OTIC SOLUTION

Benzocaine / Antipyrine Otic Solution CIPRO HC OTIC SOLUTION

CORTISPORIN OTIC SOLUTION / SUSPENSION VOSOL HC OTIC SOLUTION

DOMEBORO OTIC SOLUTION FLOXIN OTIC SOLUTION

Hydrocortisone / Chloroxylenol / Pramoxine hydrochloride Otic Solution

Hydrocortisone / Neomycin / Polymyxin Otic Solution/ Susp.

Ofloxacin Otic Solution OTICIN HC OTIC SOLUTION VOSOL OTIC SOLUTION Nasal Medications ASTELIN NASAL SPRAY (QL) ASTEPRO NASAL SPRAY (QL) BECONASE AQ (QL) Azelastine Nasal Spray (QL) NASONEX (QL) DYMISTA NASAL SPRAY (QL)

FLONASE (QL) VERAMYST NASAL SUSPENSION (QL) PATANASE NASAL SPRAY

Fluticasone Nasal Spray (QL) NASACORT AQ (QL)

NASALIDE NASAL SOLUTION NASAREL NASAL SOLUTION

QNASL AEROSOL RHINOCORT AQUA (QL)

Triamcinolone Acetonide Nasal Inhaler (QL)

ZETONNA NASAL AEROSOL (QL)

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(NOT ON FORMULARY) Throat and Mouth Medications

Chlorhexidine Gluconate (Covered Only If Dental Rider) Cevimeline Capsules

KENALOG IN ORABASE EVOXAC CAPSULES Lidocaine, Viscous

PERIDEX (Covered Only With Dental Rider)

SALAGEN TABLETS Triamcinolone 0.1% in Orabase Viscous Xylocaine GASTROINTESTINAL MEDICATIONS Anti-Diarrheal Medications

LOMOTIL TABLETS FULYZAQ DELAYED RELEASE TABLETS (PA) (QL)

Diphenoxylate / Atropine Tablets LINZESS CAPSULES (PA)

Anti-Emetic / Anti-Vertigo Medications

COMPAZINE TABLETS / SUPPOSITORIES ANZEMET (PA) (QL)

Ondansetron Orally disintegrating Tablets (QL) CESAMET CAPSULES (PA)

(QL) Ondansetron Tablets (QL) DICLEGIS TABLETS (PA) PHENERGAN TABLETS Dronabinol Capsules (PA)

Prochlorperazine Tablets / Supositories EMEND CAPSULES (QL)

Promethazine Tablets Granisetron Tablets (PA) (QL) TIGAN CAPSULES KYTRIL TABLETS (PA) (QL) Trimethobenzamide Capsules MARINOL CAPSULES (PA)

ZOFRAN ODT (QL) SANCUSO PATCHES (PA) (QL)

ZOFRAN TABLETS (QL) ZUPLENZ ORAL FILM (QL) Anti-Ulcer and Anti-Peptic Medications AXID CAPSULES / SOLUTION ACIPHEX TABLETS (QL) AXID TABLETS

CARAFATE TABLETS DEXILANT CAPSULES (EST) (QL)

Cimetidine 300 MG, 400 MG, 800 MG Tablets Famotidine Tablets

CYTOTEC TABLETS Lansoprazole Delayed Release Tablets (QL)

Misoprostol Tablets NEXIUM CAPSULES (PA) (QL) Nizatadine Capsules NEXIUM PACKETS (PA) Nizatadine Solution Nizatidine Tablets Omeprazole Capsules PEPCID TABLETS

Pantoprazole Tablets (QL) PREVACID CAPSULES (PA) (QL)

Ranitidine 300mg Tablets Only PREVACID SOLUTABS (PA) (QL)

Ranitidine 75mg/5ml Syrup PREVPAC (PA) (QL)

Sucralfate Tablets PRILOSEC SUSPENSION (PA)

TAGAMET 300 mg, 400 MG, 800 MG TABLETS

ZANTAC 300 MG TABLETS




(NOT ON FORMULARY) Antispasmodic and GI Motility Medications

Belladonna / Phenobarbital Tablets / Elixir CUVPOSA SOLUTION LOTRONEX TABLETS

ANASPAZ TABLETS DONNATAL EXTENTABS BENTYL CAPSULES

Clidinium / Chlordiazepoxide Capsules

Dicyclomine Capsules

DONNATAL TABLETS / ELIXIR

Ergotamine/ Belladonna/ Phenobarbital

Glycopyrrolate Tablets

Hyoscyamine Sulfate CR Tablets

Hyoscyamine Sulfate Tablets LEVSIN TABLETS LEVSINEX TABLETS LIBRAX CAPSULES Methscopolamine Tablets Metoclopramide Tablets PAMINE FORTE TABLETS PAMINE TABLETS ROBINUL FORTE TABLETS ROBINUL TABLETS Other GI Medications REGLAN TABLETS AMITIZA CAPSULES APRISO CAPSULES ACTIGALL CAPSULES ASACOL HD TABLETS CHENODAL TABLETS

ANUSOL-HC SUPP ASACOL TABLETS (QL) Budesonide SR Capsule 24 Hr 3mg

AZULFIDINE TABS (ENTERIC COATED NOT COVERED) CANASA SUPPOSITORIES DIPENTUM CAPSULES

Balsalazide Capsules (QL) CORTIFOAM ENTOCORT EC CAPSULES Bethanechol Tablets LIALDA TABLETS GIAZO TABLETS (EST) COLAZAL TABLETS (QL) PROCTOFOAM HC PENTASA TABLETS COLYTE SOLUTION UCERIS SR TABLETS (PA) CORTENEMA GOLYTELY SOLUTION

Hydrocortisone Retention Enema

Hydrocortisone Suppositories Mesalamine Enema MIRALAX POWDER (QL) NULYTELY SOLUTION Oral Colon Lavage Solution Polyethylene Glycol 3350/

Sodium Carb/Potassium For Soln 240 gm

Polyethylene Glycol 3350/Sod Carb / Potassium For Soln 420 gm

ROWASA ENEMA Sulfasalazine Tablets (Enteric

Coated Tablets Not Covered)

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(NOT ON FORMULARY) Other GI Medications Continued URECHOLINE URSO CAPSULES URSO FORTE CAPSULES Ursodiol 300 mg Capsules Digestive Enzymes COTAZYM (S) PERTZYE CAPSULES CREON CAPSULES PANCREAZE CAPSULES PANCRELIPASE CAPSULES ULTRESA CASULES ULTRASE MT CAPSULES VIOKASE POWDER ZENPEP CAPSULES GENITOURINARY MEDICATIONS Benign Prostatic Hyperplasia (BPH) Medications CARDURA TABLETS Alfuzosin Tablets Doxazosin Mesylate Tablets AVODART CAPSULES (EST) Finasteride (Age Limit) JALYN CAPSULES (EST) FLOMAX CAPSULES (QL) RAPAFLO CAPSULES

HYTRIN CAPSULES / TABLETS UROXATRAL TABLETS (QL)

PROSCAR TABLETS (AGE LIMIT) (QL)

Tamsulosin Capsules (QL) Terazosin Capsules / Tablets Overactive Bladder Medications DETROL TABLETS (QL) DETROL LA CAPSULES (QL) DITROPAN XL TABLETS DITROPAN TABLETS TOVIAZ 24 HR TABLETS (QL) ENABLEX TABLETS

Oxybutynin Immediate Release Tablets GELNIQUE GEL (QL)

Tolterodine Tablets (QL) MYRBETRIQ TABLET SR 24HR (QL)

Oxybutynin Extended Release Tablets

OXYTROL PATCHES SANCTURA TABLETS SANCTURA XR CAPSULES Trospium SR Capsules Trospium Tablets 20 mg VESICARE TABLETS Drugs To Treat Impotence (Not Covered By All Plans - Check Benefits for Coverage and Copayment) CIALIS TABLETS (PA) (QL) LEVITRA TABLETS (PA) (QL) STAXYN TABLETS (PA) (QL) VIAGRA TABLETS (PA) (QL)




(NOT ON FORMULARY) Miscellaneous Genitourinary Medications Bethanecol Tablets ELMIRON CAPSULES Flavoxate Tablets MACROBID CAPSULES MACRODANTIN CAPSULES

Methenamine / Methylene Blue / Atropine Tablets

Nitrofurantoin Macrocrystals Nitrofurantoin Suspension Phenazopyridine Tablets PYRIDIUM TABLETS Trimethoprim Tablets URISPAS TABLETS URECHOLINE TABLETS IMMUNOSUPPRESSANTS (MEDICATIONS FOR TRANSPLANTS) Azathioprine Tablets ASTRAGRAF XL CAPSULES

CELLCEPT TABLETS / CAPSULES MYFORTIC CAPSULES

Cyclosporine Capsules RAPAMUNE TABLETS

Cyclosporine Modified Capsules ZORTRESS TABLETS

DELTASONE TABLETS IMURAN TABLETS

GENGRAF CAPSULES /SOLUTION

HECORIA CAPSULES

Mycophenolate Capsules / Tablets

NEORAL CAPSULES Prednisone Tablets PROGRAF CAPSULES SANDIMMUNE CAPSULES Tacrolimus Capsules JOINT / CONNECTIVE TISSUE / MUSCULOSKELETAL MEDICATIONS Adrenal Corticosteroids (Steroids) CORTEF TABLETS RAYOS TABLETS Cortisone Tablets CORTONE TABLETS DECADRON TABLETS DELTASONE TABLETS Dexamethasone Tablets DEXONE TABLETS FLORINEF TABLETS Fludrocortisone Tablets Hydrocortisone Tablets HYDROCORTONE TABLETS LIQUID PRED SOLUTION MEDROL TABLETS Methylprednisolone Tablets ORASONE TABLETS Prednisolone Tablets Prednisone Tablets PRELONE SYRUP

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(NOT ON FORMULARY) Antirheumatics ARAVA TABLETS CUPRIMINE CAPSULES XELJANZ TABLETS (PA) (QL) Leflunomide Tablets DEPEN TABLETS Hydroxychloroquine Tablets RIDAURA CAPSULES Methotrexate Tablets PLAQUENIL TABLETS RHEUMATREX TABLETS Gout Medications Allopurinol Tablets COLCRYS TABLETS BENEMID TABLETS ULORIC TABLETS COL-BENEMID TABLETS Colchicine Tablets Probenecid Tablets Probenecid / Colchicine Tablets ZYLOPRIM TABLETS Non-Steroidal Anti-Inflammatory Medications (NSAIDs) ANAPROX DS TABLETS ARTHROTEC TABLETS ANAPROX TABLETS CAMBIA PACKETS (QL) CLINORIL TABLETS CATAFLAM TABLETS DAYPRO TABLETS CELEBREX (PA) (QL) Diclofenac Sodium Tablets Diclofenac Sodium Extended

Release Tablets Etodolac Tablets / Capsules DUEXIS TABLETS Etodolac XR Tablets FLECTOR PADS (QL) FELDENE CAPSULES Mefenamic Acid Capsules Fenoprofen Capsules PONSTEL CAPSULES Flurbiprofen 50 mg Tablets Diclofenac / Misoprostil Tablets Ibuprofen Tablets VIMOVO TABLETS (PA) INDOCIN CAPSULES VOLTAREN GEL INDOCIN SR CAPSULES VOLTAREN XR Indomethacin Capsules ZIPSOR CAPSULES (QL)

(EST) Indomethacin, Sustained

Release Capsules

Ketoprofen Capsules / Tablets (QL)

Ketorolac Tablets (QL) LODINE TABLETS /

CAPSULES

Meloxicam Tablets (QL) MOBIC TABLETS (QL) MOTRIN TABLETS Nabumetone Tablets NALFON CAPSULES NAPROSYN TABLETS Naproxen Sodium Tablets Naproxen Sodium, DS Tablets Naproxen Tablets (Enteric

Coated Not Covered)

ORUDIS CAPSULES Oxaprozin Tablets




(NOT ON FORMULARY) Non-Steroidal Anti-Inflammatory Medications (NSAIDs) Continued Piroxicam Capsules RELAFEN TABLETS Sulindac Tablets TOLECTIN DS CAPSULES TOLECTIN TABLETS Tolmetin (DS) Capsules TORADOL TABLETS (QL) VOLTAREN IMMEDIATE

RELEASE TABLETS

Salicylates

Aspirin, Sustained Release Tablets Diflunisal Tablets

Choline Magnesium Salicylate Tablets / Liquid DOLOBID TABLETS

Salsalate Tablets

TRILISATE TABLETS / LIQUID

Skeletal Muscle Relaxants

Baclofen Tablets AMRIX CAPSULES (EST) (QL)

LIORESAL TABLETS Carisoprodol 250 MG Tablets Carisoprodol 350 MG Tablets Chlorzoxazone Tablets Cyclobenzaprine Tablets Cyclobenazprine SR Capsules DANTRIUM CAPSULES LORZONE TABLETS NORGESIC TABLETS Metaxolone Tablets Methocarbamol Tablets PARAFON FORTE TABLETS NORFLEX TABLETS SKELAXIN TABLETS Diazepam Tablets SOMA 250MG TABLETS NORGESIC FORTE TABLETS Tizanidine Tablets Skeletal Muscle Relaxants Continued FLEXERIL TABLETS ZANAFLEX TABLETS

Carisoprodol / Aspirin 250 / 325 mg Tablets

Orphenadrine / Aspirin / Caffeine Tablets

Orphenadrine Citrate Tablets ROBAXIN TABLETS SOMA TABLETS SOMA COMPOUND TABLETS VALIUM TABLETS Miscellaneous Muscle Relaxants

MESTINON TABLETS MESTINON TIMESPAN TABLETS

Pyridostigmine Tablets PROSTIGMIN CR TABLETS

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(NOT ON FORMULARY) NEUROLOGICAL MEDICATIONS Alzheimers Disease Medication

ARICEPT 5 MG, 10 MG, 23 mg TABLETS EXELON PATCHES Galantamine Capsules (PA)

ARICEPT ODT 5 MG, 10 MG TABLETS Galantamine Tablets (PA)

Donepezil Orally Disintegrating Tablets NAMENDA TABLETS (PA)

Donepezil Tablets NAMENDA XR CAPSULES (PA)

EXELON CAPSULES RAZADYNE ER CAPSULES (PA)

Rivastigmine Capsules RAZADYNE TABLETS (PA) Anticonvulsants

Carbamazepine SR Capsules / SR Tablets 12 Hr BANZEL TABLETS GABITRIL TABLETS

Carbamazepine Tablets CELONTIN CAPSULES GRALISE TABELTS (PA) CARBATROL CAPSULES POTIGA TABLETS KEPPRA XR TABLETS Clonazepam Tablets SABRIL PACKETS (N) KLONOPIN WAFERS DEPAKENE CAPSULES SABRIL TABLETS (N) LAMICTAL ODT (PA) DEPAKOTE TABLETS VIMPAT TABLETS LAMICTAL XR KIT (PA) DILANTIN CAPSULES LAMICTAL XR TABLET (QL)

DILANTIN CHEWABLE TABLETS Lamotrigine XR Tablets

Ethosuximide Capsules Levetiracetam XR Tablets (QL)

Felbamate Tablets LYRICA SOLUTION (PA) (QL) FELBATOL TABLETS LYRICA TABLETS (QL) (PA)

Gabapentin Capsules / Tablets / Solution ONFI TABLETS

GABARONE TABLETS OXTELLAR XR SR 24 Hr. TABLETS (EST)

KEPPRA TABLETS STAVZOR CAPSULES DEPAKOTE ER TABLETS Tiagabine Tablets PHENYTEK CAPSULES KLONOPIN TABLETS Divalproex SR Tablets TEGRETOL XR TABLETS LAMICTAL TABLETS Lamotrigine Tablets Levetiracetam Tablets MYSOLINE TABLETS

NEURONTIN CAPSULES / TABLETS

Oxcarbazepine Tablets / Suspension

Phenytoin Capsules Phenytoin Chewable Tablets Primidone Tablets TEGRETOL TABLETS TOPAMAX TABLETS Topiramate Tablets

TRILEPTAL TABLETS / SUSPENSION




(NOT ON FORMULARY) Anticonvulsants Continued Valproic Acid Capsules ZARONTIN CAPSULES ZONEGRAN CAPSULES Zonisamide Capsules Migraine Treatment Medications

AMERGE TABLETS (QL) ERGOMAR SUBLINGUAL TABLETS AXERT TABLETS (QL)

APAP / Dichloralphenazone / Isometheptene Capsules FROVA TABLETS (QL)

CAFERGOT TABLETS MIGRANAL NASAL SPRAY (QL)

DURADRIN CAPSULES RELPAX TABLETS (QL)

Ergotamine / Caffeine Tablets / Suppositories TREXIMET TABLETS (QL)

(PA)

Ergotamine Tartrate Tablets Zolmitriptan Orally Disintegrating Tablets (QL)

IMITREX NASAL SPRAY (QL) Zolmitriptan Tablets (QL) IMITREX TABLETS (QL) ZOMIG NASAL SPRAY (QL) ZOMIG TABLETS (QL MAXALT TABLETS (QL) ZOMIG ZMT TABLETS (QL) MAXALT-MLT TABLETS (QL) MIDRIN CAPSULES Naratriptan Tablets (QL)

Rizatriptan Orally Disintegrating Tablets (QL)

Rizatriptan Tablets (QL)

Sumatriptan Tablets /Nasal Spray (QL)

Anti-Parkinsonism Medications

Amantadine Capsules AZILECT TABLETS Carbidopa-Levodopa Orally Disintegrating Tablets

ARTANE TABLETS COMTAN TABLETS Benztropine Mesylate Tablets Entacapone Tablets

Bromocriptine Capsules/ Tablets LODOSYN TABLETS

Carbidopa / Levodopa CR Tablets MIRAPEX ER TABLETS

Carbidopa / Levodopa Tablets NEUPRO PATCHES

Carbidopa-levodopa-entacapone Tablets

PARCOPA TABLETS

COGENTIN TABLETS REQUIP XL

ELDEPRYL CAPSULES Ropinirole Extended Release Tablets

LARODOPA TABLETS TASMAR TABLETS

Levodopa Tablets ZELAPAR DISINTEGRATING TABLETS

MIRAPEX TABLETS

PARLODEL CAPSULES / TABLETS

Pramipexole Tablets REQUIP TABLETS Ropinirole Tablets Selegiline Tablets

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(NOT ON FORMULARY) Anti-Parkinsonism Medications Continued SINEMET CR TABLETS SINEMET TABLETS STALEVO TABLETS SYMMETREL CAPSULES Trihexyphenidyl Tablets Miscellaneous Neurological Medications

AMPYRA TABLETS (QL) (PA) (SP) HORIZANT SR TABLETS (QL)

OBSTETRICAL AND GYNECOLOGICAL MEDICATIONS Contraceptives: Monophasic (Brand Equivalent Bolded and In Parens) Altavera (NORDETTE) Femcon Fe (OVCON Fe) Apri (ORTHO-CEPT) FEMCON-Fe

Aviane (ALESSE) Introvale (SEASONALE) 3 month supply

Balzia (OVCON-35) Jolessa (SEASONALE) 3 month supply

BREVICON LO LOESTRIN Briellyn (OVCON-35) LOESTRIN 24 Fe

Chateal (NORDETTE) MINASTRIN 24 FE CHEWABLE

Cryselle (LO/OVRAL) OVCON Fe

DEMULEN Quasense (SEASONALE) 3 month supply

DESOGEN (ORTHO-CEPT) SEASONALE (3 month supply)

Emoquette (ORTHO-CEPT) Wymzya Fe (FEMCON FE) Falmina (ALESSE) Zenchent Fe (FEMCON FE)

Gianvi (YAZ) Zeosa Chew Tabs (FEMCON FE

Elinest-28 (LO/OVRAL) Gildagia (OVCON) Kurvelo (NORDETTE) Gildess (LOESTRIN) Junel (LOESTRIN 21) Junel Fe (LOESTRIN Fe) Kelnor (DEMULEN) Lessina (ALESSE) Levora (NORDETTE) LO/OVRAL LOESTRIN 21 LOESTRIN FE Loryna (YAZ) Low-Ogestrel (LO/OVRAL) Lutera (ALESSE) Marlissa (NORDETTE) Microgestin (LOESTRIN 21) Microgestin Fe (LOESTRIN Fe) MODICON Mononessa (ORTHO-CYCLEN)




(NOT ON FORMULARY) Contraceptives: Monophasic (Brand Equivalent Bolded and In Parens) Continued Necon (MODICON)

Alyacen (ORTHO NOVUM 1/35)

Cyclafem 1/35 (ORTHO NOVUM 1/35)

Dasetta 1-35 (ORTHO NOVUM 1/35)

Necon 1/35 (ORTHO NOVUM 1/35)

Necon 1/50 (ORTHO NOVUM 1/50)

NORDETTE NORINYL 1+35 NORINYL 1+50 Nortrel (MODICON)

Nortrel 1/35 (ORTHO NOVUM 1/35)

Ocella (YASMIN) OGESTREL TABLETS Orsythia (ALESSE) ORTHO NOVUM 1/35 ORTHO NOVUM 1/50 ORTHO-CEPT ORTHO-CYCLEN OVRAL Philith (OVCON-35) Portia (NORDETTE) Previfem (ORTHO-CYCLEN) Reclipsen (ORTHO-CEPT) Solia (ORTHO-CEPT) Sprintec (ORTHO-CYCLEN) Sronyx (ALESSE) Syeda (YASMIN) Vestura (YAZ) Wera (MODICON) YASMIN YAZ Zarah (YASMIN) Zenchent (OVCON-35) Zovia (DEMULEN) Contraceptives: Biphasic Amethia (SEAONIQUE) (3

MONTH SUPPLY)

Azurette (MIRCETTE) Camrese (SEAONIQUE) (3

MONTH SUPPLY)

Kariva (MIRCETTE) MIRCETTE ORTHO-NOVUM 10/11

(NECON10/11)

SEASONIQUE (3 MONTH SUPPLY)

Viorele (MIRCETTE)

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(NOT ON FORMULARY) Contraceptives: Triphasic (Brand Equivalent Bolded and In Parens)

Alyacen 7/7/7 (ORTHO NOVUM 7/7/7) ORTHO TRI-CYCLEN LO ESTROSTEP Fe

Aranelle (TRI-NORINYL) TILIA Fe (ESTROSTEP Fe)

Caziant (CYCLESSA) Tri Legest Fe (ESTROSTEP Fe)

Cesia (CYCLESSA) CYCLESSA Enpresse (TRI-LEVLEN) Leena (TRI-NORINYL) Levenost (TRI-LEVLEN)

Dasetta 7/7/7 (ORTHO-NOVUM 7/7/7)

Myzilra 7/7/7 (ORTHO-NOVUM 7/7/7)

Necon 7/7/7 (ORTHO-NOVUM 7/7/7)

Nortrel 7/7/7 (ORTHO-NOVUM 7/7/7)

ORTHO TRI-CYCLEN ORTHO-NOVUM 7/7/7

Pirmella 7/7/7 (ORTHO-NOVUM 7/7/7)

TRI-LEVLEN

Tri-Lynya (ORTHO TRI-CYCLEN)

Trinessa (ORTHO TRI-CYCLEN)

TRI-NORINYL

Tri-previfem (ORTHO TRI-CYCLEN)

Tri-sprintec (ORTHO TRI-CYCLEN)

Trivora (TRI-LEVLEN) Velivet (CYCLESSA) Other Contraceptives (Brand Equivalent Bolded and In Parens) Amethia Lo (LOSEASONIQUE) BEYAZ Amethyst (LYBREL)

Camila (ORTHO-MICRONOR) NATAZIA GENERESS FE CHEWABLE TABLET

Camrese Lo (LOSEASONIQUE) NUVARING LYBREL TABLETS

Errin (ORTHO-MICRONOR) ORTHO DIAPHRAGM QUARTETTE TABLETS (3 Month Supply)

Heather (ORTHO-MICRONOR) ORTHO EVRA PATCH Other Contraceptives (Brand Equivalent Bolded and In Parens)

Jolivette (ORTHO-MICRONOR) PRENTIF CAVITY-RIM CERVICAL CAP

LOSEASONIQUE TABLETS (QL) (3 MONTH SUPPLY) SAFYRAL TABLETS

Nora-B (ORTHO-MICRONOR) NOR-QD ORTHO MICRONOR




(NOT ON FORMULARY) Emergency Contraceptives

Levonorgestrel 0.75mg (AGE RESTRICTION-OTC FOR 18 AND OLDER)

ELLA TABLETS (QL)

NEXT CHOICE (AGE RESTRICTION - OTC FOR 18 AND OLDER)

NEXT CHOICE ONE-STEP 1.5 MG (AGE RESTRICTION-OTC FOR 18 AND OLDER)

PLAN B TABLETS 0.75 mg (AGE RESTRICTION - OTC FOR 18 AND OLDER)

PLAN B ONE STEP TABLETS (AGE RESTRICTION-OTC FOR 18 AND OLDER)

Progestins

AYGESTIN TABLETS ENDOMETRIN SUPPOSITORIES

Medroxyprogesterone Tablets Progesterone Micronized Capsules (QL)

Norethindrone Tablets PROMETRIUM CAPSULES (QL)

PROVERA TABLETS Vaginal Anti-Infectives CLEOCIN VAGINAL CREAM Clindamycin Vaginal Cream DIFLUCAN TABLETS Fluconazole Tablets METROGEL VAGINAL GEL

Metronidazole Vaginal Gel 0.75%

TERAZOL VAGINAL CREAM / TABLETS

Terconazole Vaginal Cream / Tablets

Vandazole Vaginal Gel Other Obstetrical and Gynecologicals Drugs

CLOMID TABLETS (PA) (QL) CRINONE 8% VAGINAL CREAM (PA)

Clomiphene Tablets (PA) (QL) ERGOTRATE TABLETS Ergonovine Maleate Tablets METHERGINE TABLETS (QL) RESPIRATORY MEDICATIONS Inhaled Steroids

Budesonide Inhalation Suspension 0.25mg, 0.5mg(QL) ASMANEX AEROSOL (QL) AEROBID INHALER

PULMICORT INHALATION SUSPENSION 0.25MG, 0.5MG(QL)

FLOVENT DISKUS (QL) AEROBID-M INHALER

FLOVENT HFA (QL) ALVESCO AERSOL

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(NOT ON FORMULARY) Inhaled Steroids Continued

PULMICORT 1 MG RESPULES (QL) BREO ELLIPTA INHALER

PULMICORT FLEXHALER (QL) QVAR INHALER (QL) Devices For Use In Asthma AEROCHAMBER INSPIREASE PEAK FLOW METER Inhaled Respiratory Medications Acetylcysteine Solution ADVAIR DISKUS (QL) ARCAPTA NEOHALER

Albuterol Nebulized Solution ADVAIR HFA (QL) BROVANA INHALATION SOLUTION

Cromolyn Sodium Inhaler ATROVENT HFA INHALER (QL) COMBIVENT INHALER Ipratropium Inhaler DULERA AEROSOL (QL) COMBIVENT RESPIMAT Levalbuterol Nebulizer Solution MAXAIR AUTOHALER (QL) DUONEB INHALTION SOLN. MUCOMYST PROVENTIL HFA INHALER (QL) FORADIL AEROLIZER (QL)

PROVENTIL NEBULIZED SOLUTION PULMOZYME (QL) Ipratropium-Albuterol Nebulizer

Solution

XOPENEX NEBULIZER SOLUTION SEREVENT DISKUS (QL) Levalbuterol Nebulizer Solution

SPIRIVA HANDIHALER (QL) PERFOROMIST NEBULIZER SOLUTION 20MCG

SYMBICORT AEROSOL (QL) PROAIR HFA INHALER (QL)

TUDORZA PRESSAIR INHALATION (QL) VENTOLIN HFA INHALER

(QL)

XOPENEX HFA AEROSOL XOPENEX NEBULIZER SOLUTION

Oral Medications for Asthma or Lung Problems ACCOLATE TABLETS KALYDECO TABLETS (PA (N) DALIRESP TABLETS (QL)

Albuterol ER Tablets THEO-24 CAPSULES Theophylline Elixir 80 mg/ 15cc (Alcohol Free)

Albuterol Tablets ZYFLO TABLETS Aminophylline Tablets ZYFLO CR TABLETS BRETHINE TABLETS CAFCIT ORAL SOLUTION Caffeine Oral Solution Montelukast Tablets PROVENTIL TABLETS SINGULAIR TABLETS SLO-BID CAPSULES Terbutaline Sulfate Tablets THEODUR TABLETS Theophylline Liquid

Theophylline, Immediate Release Tablets

Theophylline, Sustained Release Capsules




(NOT ON FORMULARY) Oral Medications for Asthma or Lung Problems Continued

Theophylline, Sustained Release Capsules

UNIPHYL TABLETS VOSPIRE ER TABLETS Zafirlukast Tablets SKIN AND MUCOUS MEMBRANE MEDICATIONS Acne Treatment Medications

A/T/S SOLUTION (SWABS, PADS & PLEDGETS EXCLUDED)

DIFFERIN 0.3% GEL (QL) ABSORICA CAPSULES (PA)

ACCUTANE CAPSULES (QL) DRITHO-CRÈME HP ACZONE GEL Adapalene Cream FINACEA GEL ATRALIN GEL (QL) AMNESTEEM CAPSULES(QL) METROGEL TOPICAL GEL AZELEX CREAM

BENZAMYCIN GEL RETIN-A MICRO CREAM BENZACLIN GEL (Pump excluded)

CLARIFOAM EF TAZORAC CRM / GEL (QL) CLENIA CREAM

CLEOCIN T SOLUTION (SWABS, PADS & PLEDGETS EXCLUDED)

Clindamycin Phosphate 1% Foam

Clindamycin 1% / Benzoyl Peroxide 5% Gel (QL) Clindaymycin / Benzoyl

Peroxide Gel (Pump Excluded)

Clindamycin Solution 1% (Swabs, Pads & Pledgets Excluded)

DIFFERIN LOTION (QL)

DIFFERIN 0.1% CREAM OR GEL (QL) EPIDUO GEL (QL)

DUAC GEL (QL) EVOCLIN FOAM

ERYCETTE SOLN (SWABS, PADS & PLEDGETS EXCLUDED)

GASTROCROM CONCENTRATE

ERYDERM SOLN (SWABS, PADS & PLEDGETS EXCLUDED)

KLARON LOTION

Erythromycin / Benzoyl Peroxide Cream PLEXION CREAM

Erythromycin 1.5 % Soln (Swabs, Pads & Pledgets Excluded)

ROSAC CREAM

Erythromycin 2 % Gel ROSULA GEL

Erythromycin 2 % Soln (Swabs, Pads & Pledgets Excluded) TRETIN-X CREAM

Isotretinoin Caps (QL) ULESFIA LOTION 5%

METROCREAM TOPICAL CREAM ZIANA GEL (QL)

METROGEL TOPICAL GEL 1% ZONALON CREAM

METROLOTION 0.75% Metronidazole Lotion 0.75%

Metronidazole Topical Cream / Gel

OVACE WASH PLEXION CLEANSER PLEXION SCT CREAM PRASCION EMULSION

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(NOT ON FORMULARY) Acne Treatment Medications Continued RETIN-A CREAM / GEL (QL) ROSULA CLARIFYING WASH SALEX CREAM Salicylic Acid Cream

Sodium Sulfacetamide/Sulfur Foam

SOTRET CAPSULES (QL) Sulfacetamide sodium liq.10%

Sulfacetamide Sodium w/ Sulfur Cream 10-5%

Sulfacetamide Sodium w/ Sulfur Emulsion 10-5%

Sulfacetamide Sodium w/ Sulfur Emulsion 10-5%

Sulfacetamide Sodium w/ Sulfur Suspension 8%-4%


Sulfacetamide Sodium-Sulfur in Urea Emulsion 10-4%

SULFACET-R LOTION (QL) SUMAXIN TS SUSPENSION SUMAXIN WASH Tretinoin Cream / Gel (QL)


ZENATANE CAPSULES (QL) Topical Antifungal Medications Ciclopirox Cream / GEL Ciclopirox 8% Solution

Clotrimazole / Betamethasone Cream / Lotion (QL) ERTACZO CREAM

Econazole Cream EXELDERM CREAM / SOLUTION

Ketoconazole Cream (QL) Ketoconazole Shampoo LOPROX CREAM / GEL LOPROX SHAMPOO

LOTRISONE CREAM / LOTION (QL) NAFTIN CREAM

MYCOSTATIN CREAM / OINTMENT OXISTAT CREAM

NIZORAL CREAM (QL) PENLAC NAIL LACQUER NYAMYC POWDER Nystatin Cream / Ointment Nystatin Powder NYSTOP POWDER SPECTAZOLE CREAM Topical Anti-Infectives Acyclovir Ointment (QL) ALTABAX OINTMENT

BACTROBAN CREAM / OINTMENT PANRETIN GEL (PA)

Mupirocin Cream / Ointment SULFAMYLON CREAM




(NOT ON FORMULARY) Topical Anti-Infectives Continued SILVADENE CREAM ZOVIRAX CREAM (QL) Silver Sulfadiazine cream SSD CREAM ZOVIRAX OINTMENT (QL) Topical Anti-Inflammatory / Steroids: Low Potency

Aclometasone Dipropionate Cream / Ointment

ACLOVATE CREAM / OINTMENT

Desonide Cream / Ointment / Lotion

DESOWEN CREAM / OINTMENT/ LOTION

Fluocinolone Acetonide 0.01% Cream / Ointment / Solution

Hydrocortisone 2.5% Cream / Ointment / Lotion

HYTONE CREAM / OINTMENT

SYNALAR 0.01% CREAM / OINTMENT / SOLUTION

Topical Anti-Inflammatory / Steroids: Medium Potency

ARISTOCORT CREAM / OINTMENT CORDRAN CREAM /

OINTMENT / TAPE

CUTIVATE CREAM / OINTMENT WESTCORT CREAM /

OINTMENT

DERMATOP CREAM Hydrocortisone Valerate Cream / Ointment

ELOCON CREAM / OINTMENT Hydrocortisone Butyrate

Ointment

Fluocinolone Acetonide 0.025% Cream / Ointment LOCOID OINTMENT

Fluticasone Cream / Ointment

Hydrocortisone Butyrate Cream / Ointment

KENALOG CREAM / OINTMENT

LOCOID CREAM / OINTMENT Mometasone Furoate Cream /

Ointment / Lotion

Prednicarbate Cream SYNALAR 0.025% CREAM /

OINTMENT

Triamcinolone Acetonide Cream / Ointment / Lotion

Topical Anti-Inflammatory / Steroids: High Potency Amcinonide Cream HALOG CREAM / OINTMENT Betamethasone Dipropionate

Cream / Ointment TOPICORT SPRAY (EST)

CYCLORT CREAM Desoximetasone 0.05%

CREAM

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(NOT ON FORMULARY) Topical Anti-Inflammatory / Steroids: High Potency Continued

Diflorasone Diacetate, Emollient Cream

DIPROSONE CREAM / OINTMENT

Fluocinolone Acetonide 0.2% HP Cream

Fluocinonide Cream/ Ointment LIDEX CREAM / OINTMENT LIDEX E CREAM

MAXIVATE CREAM / OINTMENT

SYNALAR HP CREAM TOPICORT LP CREAM Topical Anti-Inflammatory / Steroids: Very High Potency Augmented Betamethasone

Dipropionate Cream Clobetasol propionate Lotion / Shampoo

Clobetasol Propionate Cream / Ointment/ Gel / Solution/ Emollient

CLOBEX LOTION

Diflorasone Diacetate Cream / Ointment CLOBEX SHAMPOO

DIPROLENE AF CREAM FLORONE CREAM MAXIFLOR CREAM /

OINTMENT

PSORCON CREAM / OINTMENT/ Emollient

TEMOVATE CREAM / OINTMENT/ GEL/ SOLUTION / EMOLLIENT

ULTRAVATE CREAM / OINTMENT

Antipsoriasis Medications Calcipotriene Cream / Solution TAZORAC CREAM / GEL (QL) Acitretin Capsules Calcitriol Ointment (QL) SORIATANE CAPSULES

DOVONEX Cream / SOLUTION SORILUX AEROSOL

SEBIZON LOTION TACLONEX OINTMENT (EST) (QL)

Selenium Sulfide 2.5% Lotion

Selenium sulfide-pyrithione zinc in Urea Shampoo

SELSEB SHAMPOO SELSUN LOTION VECTICAL OINTMENT (QL) Scabicides ACTICIN CREAM (QL) EURAX CREAM / LOTION Malathion Lotion ELIMITE CREAM (QL) NATROBA TOPICAL

SUSPENSION (Age Limit) Permethrin Cream (QL) OVIDE LOTION SKLICE LOTION




(NOT ON FORMULARY) Miscellaneous Skin and Mucous Membrane Medications ALDARA CREAM CONDYLOX – GEL Doxepin Cream

Aluminum Chloride Hexahydrate FLUOROPLEX CREAM /

SOLUTION ELIDEL CREAM

CARAC CREAM OXSORALEN ULTRA TABLETS ONLY EMLA CREAM

DRYSOL PROTOPIC OINTMENT (PA) (QL) FLECTOR PADS (QL)

EFUDEX CREAM / SOLUTION KERALAC CREAM / LOTION Fluorouracil Cream LIDODERM PATCHES Imiquimod Cream PENNSAID SOLUTION (QL) PICATO GEL PLIAGLIS CREAM REGRANEX GEL (PA) (QL) SOLARAZE GEL SYNERA PATCHES ULESFIA LOTION 5% VEREGEN OINTMENT (QL) VOLTAREN GEL ZONALON CREAM ZYCLARA CREAM (QL) ZYCLARA CREAM PUMP (QL) Anorectal Medications ANALPRAM CREAM 1%-1% CORTIFOAM ANALPRAM CREAM 2.5%-1% ANALPRAM CREAM 2.5%-1% PROCTOFOAM NS Hydrocortisone (Rectal Cream)

Hydrocortisone Cream / Pramoxine Cream

PROCTO-CREAM VITAMINS Prenatal Vitamins CAVAN-EC SOD DHA B-NEXA CITRANATAL 90 DHA CITRANATAL B-CALM CITRANATAL ASSURE CITRANATAL B-CALM CITRANATAL DHA CITRANATAL HARMONY CITRANATAL RX CITRANATAL HARMONY COMPLETENATE CITRANATAL HARMONY CONCEPT DHA DUET DHA FOLBECAL DUET DHA BALANCED GESTICARE DHA DUET DHA EC HEMENATAL OB + DHA FOLCAL DHA NESTABS DHA FOLCAPS OMEGA 3 NUTRI-TAB OB + DHA NATELLE ONE PNV OB+DHA NEEVO DHA PR NATAL 400 NESTABS PR NATAL 430 NEXA PLUS PR NATAL 430 EC NEXA SELECT PREFERA OB + DHA PNV-DHA PRENAPLUS PREFERA OB

PRENATA PRENA1

PLUS/QUATREFOLIC

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(NOT ON FORMULARY) Prenatal Vitamins Continued PRENATABS FA PRENAISSANCE PRENATABS RX PRENATAL 19 PRENATAL AD PRENATE MINI PRENATAL PLUS PRENEXA PRENATAL PLUS IRON SELECT-OB+DHA PRENATAL VITAMINS PLUS TARON-BC PRENATE DHA TARON-PREX PRENATE ELITE TL-SELECT PRENATE ESSENTIAL ULTIMATECARE ONE SETON ET-EC VIRT-PN DHA

TRIVEEN-DUO DHA VITAMEDMD ONE

RX/QUATREFO

VINACAL VITAMEDMD PLUS

RX/QUATRE VINATE CALCIUM ZATEAN-CH VINATE ONE ZATEAN-PN VINATE ULTRA ZATEAN-PN DHA VOL-PLUS ZATEAN-PN PLUS VOL-TAB RX Vitamin and Fluoride Medications / Miscellaneous Supplements Calcitriol Capsules FERRIPROX TABLETS (QL) DRISDOL CAPSULES HECTOROL CAPSULES

Ergocalciferol Capsules POLY-VI-FLOR SOLUTION BIPHASIC (age limit 6 years and younger)

Fluoride / Polyvitamins (Without Iron; Drops & Tabs) (age limit 6)

POLY-VI-FLOR TABLETS BIPHASIC (age limit 6 years and younger)

Fluoride / Vitamins A,D,C (Without Iron; Drops & Tabs) (age limit 6 years and younger)

ZEMPLAR CAPSULES

Folic Acid 1 mg Tablets LURIDE TABLETS

POLY-VI-FLOR TABLETS / DROPS (age limit 6 years)

ROCALTROL CAPSULES

Sodium Fluoride Tablets and Drops

TRI-VI-FLOR TABLETS / DROPS (age limit 6 years and younger)

DRUGS FOR THE TREATMENT OF OBESITY BENEFIT EXCLUSION* - *Some Plans May Cover Morbid Obesity – Refer To Plan Documents Phentermine Capsules (PA) -

BENEFIT EXCLUSION* Phentermine Tablets (PA) -

BENEFIT EXCLUSION* QSYMIA CAPSULES (PA)-

BENEFIT EXCLUSION REGIMEX TABLETS (PA)

BENEFIT EXCLUSION* XENICAL CAPSULES OTC -

BENEFIT EXCLUSION*




(NOT ON FORMULARY) DRUGS FOR THE TREATMENT OF OBESITY CONTINUED

BELVIQ tablets (PA) (QL)

DRUGS FOR THE TREATMENT OF SMOKING CESSATION BENEFIT EXCLUSION* +Some Plans May Have Coverage For Smoking Cessation Products – Refer To Plan Documents For Coverage and Copayment / Coinsurance

Buproban Tablets (PA) (QL) - BENEFIT EXCLUSION+ CHANTIX TABLETS (PA) (QL) - BENEFIT EXCLUSION+ NICOTROL NASAL SPRAY (PA) (QL) - BENEFIT EXCLUSION+ ZYBAN TABLETS (PA) (QL) - BENEFIT EXCLUSION+

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N = Not available through mail order Health Net Three-Tier Drug List (Revised 9/1/13) 51 LD = Limited Distribution EST = Electronic Step Edit

SPECIALTY DRUGS

SPECIALTY DRUGS2 Arthritis / Psoriasis

Brand Generic Comments

ENBREL (N) PREFERRED PRODUCT ETANERCEPT PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

HUMIRA (N) PREFERRED PRODUCT ADALIMUMAB PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

SIMPONI (N) PREFERRED PRODUCT GOLIMUMAB PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

CIMZIA (N) (EST) PREFERRED PRODUCT CERTOLIZUMAB PEGOL

PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

KINERET (N) (EST) ANAKINRA PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

METHOTREXATE INJECTION METHOTREXATE INJECTION PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

ORENCIA SUB Q 125MG/ML (N) (EST) PREFERRED PRODUCT ABATACEPT


Blood Modifiers


PROCRIT (N) PREFERRED PRODUCT EPOETIN ALFA PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

ARANESP (EST) (N) DARBEPOETIN ALFA-ALBUMIN PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

EPOGEN (EST) (N) EPOETIN ALFA PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

NEULASTA (EST) (N) PEGFILGRASTIM PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

NEUMEGA (N) OPRELVEKIN PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

NEUPOGEN (N) FILGRASTIM PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

Blood Thinners


ARIXTRA (N) FONDAPARINUX SODIUM

PRIOR AUTHORIZATION REQUIRED-QUANTITY LIMITATIONS- MAY REQUIRE A COINSURANCE

FRAGMIN (N) DALTEPARIN SODIUM


LOVENOX (N) ENOXAPARIN SODIUM


Multiple Sclerosis

Brand Generic Comments AUBAGIO TABLETS (N) TERIFLUNOMIDE PRIOR AUTHORIZATION REQUIRED AVONEX (N) PREFERRED PRODUCT INTERFERON BETA-1A PRIOR AUTHORIZATION REQUIRED

BETASERON (N) PREFERRED PRODUCT INTERFERON BETA-1B

PRIOR AUTHORIZATION REQUIRED

COPAXONE (N) PREFERRED PRODUCT GLATIRAMER ACETATE

PRIOR AUTHORIZATION REQUIRED

EXTAVIA (N) INTERFERON BETA-1B PRIOR AUTHORIZATION REQUIRED

GILENYA CAPSULES (N) FINGOLIMOD PRIOR AUTHORIZATION REQUIRED

REBIF (N) INTERFERON BETA-1A PRIOR AUTHORIZATION REQUIRED



Growth Hormones Brand Generic Name Comments

HUMATROPE(N) (LD) PREFERRED PRODUCT SOMATROPIN


NUTROPIN (N) (LD) SOMATROPIN PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

NUTROPIN AQ (N) (LD) SOMATROPIN PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

GENOTROPIN (N) (LD) SOMATROPIN PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

INCRELEX (N) (LD) MECASERMIN PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

NORDITROPIN (N) (LD) PREFERRED PRODUCT SOMATROPIN


OMNITROPE (N) (LD) SOMATROPIN PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

SAIZEN (N) (LD) SOMATROPIN PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

SEROSTIM (N) (LD) SOMATROPIN PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

SOMAVERT (N) (LD) PEGVISOMANT PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

TEV-TROPIN (N) (LD) SOMATROPIN PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

ZORBTIVE (N) (LD) SOMATROPIN PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

Migraine Medications

Brand Generic Name Comments

SUMITRIPTAN INJ / SYRINGE (N) SUMITRIPTAN


IMITREX INJ / SYRINGE( N) SUMITRIPTAN


D.H.E. 45 (N) DIHYDROERGOTAMINE


DIHYDROERGOTAMINE (N) DIHYDROERGOTAMINE


Osteoporosis Treatment Brand Generic Name Comments

FORTEO (N) TERIPARATIDE (RECOMBINANT) PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

MIACALCIN (N) CALCITONIN (SALMON) PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

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Antivirals / Immune System Enhancers Brand Generic Name Comments

ACTIMMUNE (N) INTERFERON GAMMA-1B PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

FUZEON (N) ENFUVIRTIDE PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

INFERGEN (N) INTERFERON ALFACON-1 PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

INTRON-A (N) INTERFERON ALFA-2B PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

PEGASYS (N) PREFERRED PRODUCT PEGINTERFERON ALFA-2A


PEG-INTRON (N) PREFERRED PRODUCT PEGINTERFERON ALFA-2B


Miscellaneous


APOKYN (N) APOMORPHINE PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

LUPRON (N) - Not the Depot form LEUPROLIDE ACETATE PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

ALFERON N (N) INTERFERON ALFA-N3 PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

ARCALYST (N) RILONACEPT PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

Octreotide (N) - Not the Depot form OCTREOTIDE ACETATE PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

RELISTOR (N) METHYLNALTREXONE BROMIDE PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

SANDOSTATIN - Not the Depot / LAR (N) form OCTREOTIDE ACETATE



CAVERJECT INJECTION (QL) (N) ALPROSTADIL

PRIOR AUTHORIZATION REQUIRED-CHECK PLAN FOR COVERAGE- MAY REQUIRE A COINSURANCE

EDEX INJECTION (QL) (N) ALPROSTADIL

PRIOR AUTHORIZATION REQUIRED-CHECK PLAN FOR COVERAGE- MAY REQUIRE A COINSURANCE

Other Self-Administered Drugs (May be obtained from a retail pharmacy-Not covered by all plans)

Tier 1 Tier 2 Tier 3 AUV-Q (QL) (N) BYDUREON (PA) (N) EPIPEN (QL) (N) BYETTA (PA) (N) EPIPEN, JR. (QL) (N) SYMLIN (PA) (N) GLUCAGEN (QL) (N) VICTOZA (PA) (N) GLUCAGON (QL (N))



Drugs for Hemophilia (Check Plan Documents for Coverage) Brand Generic Name Comments

ADVATE (N) (LD) Factor VIII (antihemophilic factor [recombinant]) per IU


ALPHANATE VWF (N) (LD) Von Willebrand factor complex, human, ristocetin cofactor , per I.U.


ALPHANINE SD (N) (LD) Factor IX (antihemophilic factor, purified, non-recombinant) per IU


BEBULIN VH (N) (LD) Factor IX, complex, per IU PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

BENEFIX (N) (LD) Factor IX (antihemophilic factor, recombinant) per IU


CEPROTIN (N) (LD) Protein C concentrate, intravenous, human, 10 IU


FEIBA VH IMMUNO (ANTI-INHIBITOR COAGULANT COMPLEX) (N) (LD) Anti-inhibitor, per IU


HELIXATE FS (N) (LD) Factor VIII (antihemophilic factor [recombinant]) per IU


HEMOFIL M (N) (LD) Factor VIII (antihemophilic factor [human]) per IU


HUMATE-P (N) (LD) Von Willebrand factor complex, human, ristocetin cofactor, per IU, VWF:RCO


KOATE-DVI (N) (LD) Factor VIII (antihemophilic factor [human]) per IU


KOGENATE FS (N) (LD) Factor VIII (antihemophilic factor, recombinant) per IU


MONOCLATE-P (N) (LD) Factor VIII (antihemophilic factor [human]) per IU


MONONINE (N) (LD) Factor IX (antihemophilic factor, purified, non-recombinant) per IU


NOVOSEVEN (N) (LD) Factor VIIa (antihemophilic factor, recombinant), per 1 microgram


PROFILNINE SD (N) (LD) Factor IX, complex, per IU PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

RECOMBINATE (N) (LD) Factor VIII (antihemophilic factor [recombinant]) per IU


REFACTO (N) (LD) Factor VIII (antihemophilic factor [recombinant]) per IU


THROMBATE III (N) (LD) Antithrombin III (human), per IU PRIOR AUTHORIZATION REQUIRED-MAY REQUIRE A COINSURANCE

XYNTHA KIT (N) (LD) Injection, factor VIII (antihemophilic factor, recombinant), per IU


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PREVENTIVE DRUGS (REQUIRED UNDER AFFORDABLE CARE ACT FOR NON-GRANDFATHERED PLANS)

CONTRACEPTIVES COVERED UNDER PHARMACY (COVERAGE IS FOR THE GENERIC PRODUCT WHEN AVAILABLE)

ALTAVERA ALYACEN AMETHIA AMETHIA LO AMETHYST APRI ARANELLE AVIANE AZURETTE BALZIVA BEYAZ BRIELLYN CAMILA CAMRESE CAMRESE LO CAZIANT CHATEAL CRYSELLE CYCLAFEM CYCLESSA DASETTA DAYSEE DESOGEN DROSPIRENONE-ETHINYL ESTRADIOL ELINEST ELLA EMOQUETTE ENPRESSE ERRIN ESTARYLLA ESTROSTEP FE FALMINA FEMCON FE

GENERESS FE

GIANVI

GILDAGIA

GILDESS

GILDESS FE

HEATHER

INTROVALE

JOLESSA

JOLIVETTE

JUNEL

JUNEL FE

KARIVA

KELNOR 1/35

KELNOR 1-35

LEENA

LESSINA

LEVONEST

LEVONORGESTREL

LEVONORGESTREL-ETH ESTRADIOL

LEVONORG-ETH ESTRAD ETH ESTRAD

LEVORA-28

LO LOESTRIN FE

LOESTRIN

LOESTRIN 24 FE

LOESTRIN FE

LO-OVRAL-28

LORYNA

LOSEASONIQUE

LOW-OGESTREL

LUTERA

LYBREL

MARLISSA

MICROGESTIN



CONTRACEPTIVES COVERED UNDER PHARMACY (COVERAGE IS FOR THE GENERIC PRODUCT WHEN AVAILABLE)

MICROGESTIN FE

MICRONOR

MIRCETTE

MONO-LINYAH

MONONESSA

MY WAY

MYZILRA

NATAZIA

NECON NEXT CHOICE NEXT CHOICE ONE DOSE

NORA-BE

NORDETTE-28

NORETHINDRONE

NORETHINDRONE-ETHINYL ESTRADIOL

NORGESTIMATE-ETHINYL ESTRADIOL

NORGESTREL-ETHINY ESTRADIOL NORINYL 1+35 NORINYL 1+50

NOR-Q-D

NORTREL

NUVARING OCELLA OGESTREL ORSYTHIA

ORTHO ALL-FLEX DIAPHRAGM ORTHO EVRA

ORTHO TRI-CYCLEN

ORTHO TRI-CYCLEN LO ORTHO-CEPT ORTHO-CYCLEN

ORTHO-NOVUM

OVCON

PHILITH

PLAN B

PLAN B ONE-STEP

PORTIA

PREVIFEM

PRIMELLA

QUARTETTEQUASENSERECLIPSENSAFYRALSEASONALESEASONIQUE

SOLIA

SPRINTECSRONYXSYEDATILIA FETRI-ESTARYLLATRI-LEGEST FETRI-LINYAHTRINESSA

TRI-NORINYLTRI-PREVIFEMTRI-SPRINTECTRIVORA-28VELIVETVESTURAVIORELEWERA

WYMZYA FEYASMIN 28YAZZARAHZENCHENTZENCHENT FEZEOSAZOVIA 1-35EZOVIA 1-50E

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OTHER CONTRACEPTIVES (COVERAGE IS FOR THE GENERIC PRODUCT WHEN AVAILABLE

FC FEMALE CONDOM

FC2 FEMALE CONDOM

FEMCAP CERVICAL CAP

PRENTIF CAVITY-RIM CERVICAL CAP

CONCEPTROL GEL

CONCEPTROL VAGINAL INSERTS

ENCARE GEL

ENCARE VAGINAL SUPPOSITORIES

GYNOL II GEL

ORTHO-GYNOL GEL

SHUR-SEAL GEL

TODAY SPONGE

VCF VAGINAL AEROSOL FOAM

VCF VAGINAL CONTRACEPTIVE FILM

CONTRACEPTIVES COVERED UNDER THE MEDICAL BENEFIT (COVERAGE IS FOR THE GENERIC PRODUCT WHEN AVAILABLE)

DEPO-PROVERA 150 MG/ML SYRINGE

DEPO-PROVERA 150 MG/ML VIAL

DEPO-SUBQ PROVERA 104 SYRINGE IMPLANON 68 MG IMPLANT

MEDROXYPROGESTERONE 150 MG/ML

MIRENA SYSTEM

NEXPLANON 68 MG IMPLANT

PARAGARD IUD

ASPIRIN PRODUCTS TO PREVENT CVD COVERED FOR MEN AGES 45 TO 79 AND WOMEN AGES 55 TO 79

ASPIRIN TAB 81 MG

ASPIRIN TAB 325 MG

ASPIRIN CHEW TAB 81 MG

ASPIRIN TAB DELAYED RELEASE 81 MG

ASPIRIN TAB DELAYED RELEASE 325 MG

ASPIRIN-AL HYDRO-MG HYDRO-CA CARB TAB 325 MG

ASPIRIN BUFFERED TAB 325 MG

FOLIC ACID SUPPLEMENTATION FOR WOMEN OF CHILD BEARING AGE

FOLIC ACID TAB 400 MCG FOLIC ACID TAB 800 MCG

ORAL FLUORIDE SUPPLEMENTS FOR CHILDREN 6 MONTHS THROUGH 5 YEARS OF AGE

SOD. FLUORIDE CHEW TAB 0.25 MG

SODIUM FLUORIDE CHEW TAB 0.5MG

SODIUM FLUORIDE CHEW TAB 1 MG

SODIUM FLUORIDE SOLN 0.5 MG/ML

SOD.FLUORIDE SOLN 0.125MG/DROP

SODIUM FLUORIDE SOLN 0.25 MG/DROP

SOD. FLUORIDE SOLN 0.25 MG/0.6ML

SODIUM FLUORIDE SOLN 0.5 MG/ML

IRON SUPPLEMENTATION FOR CHILDREN 6 MONTHS TO 12 MONTHS OF AGE

FERROUS SULFATE SOLN 75 MG/ML FERROUS SULFATE SOLN 75 MG/0.6ML

Health Net Three Tier Recommended Drug List (Revised 9/1/13) 58

DRUGS SUBJECT TO PRIOR AUTHORIZATION OR STEP THERAPY

TIER GENERIC BRAND NAME GENERIC NAME COMMENTS

3 ABSORICA CAPSULES (PA)

Tretoin TRY ISOTRETINOIN CAPSULES FIRST

3 ABSTRAL SUBLINGUAL TABLETS

Fentanyl Sublingual Tablet SPECIFIC DIAGNOSIS WITH TREATMENT PLAN REQUIRED

3 YES ACTIQ LOZENGES Fentanyl

3 ACTONEL Risedronate MUST HAVE FAILED Alendronate (FOSAMAX)

3 ACTONEL WITH CALCIUM

Risedronate / Calcium MUST HAVE FAILED Alendronate (FOSAMAX)

2 ADCIRCA TABLETS

Tadalafil Tablets MUST HAVE CONFIRMED DIAGNOSIS OF PAH

3 ADOXA TABLETS Doxycycline monohydrate capsules

Use Doxycycline Hyclate (Immediate release)

3 AFINITOR Everolimus

2 AMPYRA TABLETS

Dalfampridine Tab SR 12hr

3 YES AMRIX CAPSULES Cyclobenzaprine SR Capsules

MUST HAVE TRIED CYCLOBENZAPRINE AND ANOTHER MUSCLE RELAXANT

2 AMTURNIDE Aliskiren, Amlodipine, HCTZ

MUST HAVE FAILED AN ACEI OR AN ARB

3 ANZEMET Dolasetron USE ONDANSETRON (ZOFRAN)

3 APIDRA (SOLOSTAR)

Insulin glulisine

MUST BE USED IN REGIMENS THAT INCLUDE A LONGER ACTING INSULIN OR A BASAL INSULIN ANALOG

3 APLENZIN Bupropion SR 24 hr Tablet REQUIRES TRIAL AND FAILURE OF SSRI ANTIDEPRESSANTS

3 ASCENCIA TEST STRIPS

Blood Glucose Test Strips

USE ONETOUCH ULTRA BLUE, ONETOUCH VERIO IQ, FREESTYLE LITE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS

3 YES ATACAND (HCT) Candesartan / HCTZ

Losartan – HCT (HYZAAR), Irbesartan / HCTZ (AVALIDE), BENICAR HCT, DIOVAN HCT

3 ATELVIA Risedronate Delayed Release

Alendronate (FOSAMAX)

3 AUBAGIO TABLETS

Teriflunomide

SE

CT

ION

3




3 AVODART Dutasteride

Failure of terazosin (HYTRIN) or doxazosin (CARDURA) or tamsulosin (FLOMAX) AND Finasteride (PROSCAR)

3 AXIRON SOLUTION

Testosterone TD Soln 30 MG/ACT

REQUIRES TRIAL & FAILURE OF ANDROGEL

2 AZOR Olmesartan / Amlodipine REQUIRES TRIAL & FAILURE OF AN ACE INHIBITOR OR ARB

3 BINOSTO EFFERVESCENT TABLETS

Alendronate Alendronate (FOSAMAX)

3 BOSULIF TABLETS

Bosutinib

3 YES Buproban Tablets Bupropion 150 mg MUST BE ENROLLED IN AN APPROVED SUPPORT PROGRAM

3 YES CADUET TABLETS

Atorvastatin / Amlodipine INDIVIDUAL DRUGS RECOMMENDED

3 CAMPRAL Acamprosate Calcium

MEMBER MUST BE ENROLLED IN AN APPROVED SUPPORT PROGRAM

3 CELEBREX Celecoxib

MUST HAVE HISTORY OF GI BLEEDING AND/OR TAKING ORAL prednisone, prednisolone, dexamethasone, warfarin (COUMADIN), platelet inhibitors (PLAVIX, TICLID) or other anticoagulants

3 CESAMET CAPSULES

Nabilone Capsules

SP CIALIS TABLETS Taladafil

CHECK BENEFITS FOR COVERAGE

3 YES CLARINEX Desloratadine

MUST TRY OTC Fexofenadine (ALLEGRA), Loratadine (CLARITIN), Cetirizine (ZYRTEC)

3 COMETRIQ CAPSULES

Cabozantinib S-Malate

3 COPEGUS Ribavirin MUST BE USING INTERFERON CONCOMITANTLY

2 CRINONE 8% Progesterone Gel 8% MAY NOT BE COVERED BY ALL PLANS

2 CYMBALTA CAPSULES

Duloxetine EC Capsules REQUIRES TRIAL AND FAILURE OF SSRI ANTIDEPRESSANTS

3 Desvenlafaxine 24 HR

Desvenlafaxine 24 HR USE PRISTIQ (PA)




3 DESOXYN TABLETS

Methamphetamine

3 DEXILANT CAPSULES

Dexlansoprazole FAILURE OF Omeprazole (PRILOSEC), Pantoprazole (PROTONIX), OR ACIPHEX

3 DORYX TABLETS Doxycycline Delayed Release

USE DOXYCYCLINE HCL CAPSULES

3 DYNACIN TABLETS

Minocycline Tablets USE MINOCYCLINE CAPSULES 50 MG, 100 MG

3 EDARI TABLETS Azilsartan Medoxomil

Losartan (COZAAR), Benazepril (LOTENSIN), Lisinopril (ZESTRIL), BENICAR, DIOVAN

3 EDLUAR SUBLINGUAL TABLETS

Zolpidem Sublingual Tablets MUST HAVE FAILED ZOLPIDEM ORAL AND LUNESTA

3 ENDOMETRIN SUPPOSITORIES

Progesterone Vaginal Suppositories


2 EXFORGE Amlodipine / Valsartan REQUIRES TRIAL AND FAILURE OF SSRI ANTIDEPRESSANTS

2 EXFORGE HCT Amlodipine / Valsartan / HCTZ

REQUIRES TRIAL AND FAILURE OF AN ACE INHIBITOR

3 FANAPT TABLETS Iloperidone

MAXIMUM 2 PER DAY

3 FASTTAKE TEST STRIPS

BLOOD GLUCOSE TEST STRIPS


3 FENTORA BUCCAL TABLETS

Fentanyl Citrate

MAXIMUM 3 PER DAY

3 FERRIPROX TABLETS

Deferiprone

3 FORFIVO XL TABLETS

Bupropion SR 450mg USE GENERIC SSRIs OR BUPROPION SR GENERIC

3 FORTESTA Testosterone REQUIRES TRIAL AND FAILURE OF ANDROGEL

3 FOSAMAX-D TABLETS

Alendronate / Vitamin D

USE Alendronate (FOSAMAX) PLUS VITAMIN D (vitamin is OTC - NOT COVERED)

3

FULYZAQ DELAYED RELEASE TABLETS

Crofelemer Tab Delayed Release FOR HIV DIARHHEA ONLY

3 GIAZO TABLETS Balsalazide Disodium MUST HAVE TRIED AND

FAILED 750 MG

3 GILENYA CAPSULES

Fingolimod

SE

CT

ION

3




3 GRALISE TABLETS

Gabapentin Tablets (PHN) TRIED AND FAILED

GABAPENTIN 3 INCIVEK TABLETS Telaprevir Tablets 375 MG

3 ICLUSIG TABLETS Ponatinib

3 INLYTA TABLETS Axitinib Tablets

3 INTERMEZZO SL TABLETS

Zolpidem Tartrate SL

3 JALYN Dutasteride / Tamsulosin

Failure of Terazosin (HYTRIN) or Doxazosin (CARDURA) or Tamsulosin (FLOMAX) AND Finasteride (PROSCAR)

2 KALYDECO Ivacaftor

3 KAZANO TABLETS

Alogliptin / Metformin

2 KUVAN TABLETS Sapropterin Dihydrochloride Soluble Tab 100 Mg

3 KYTRIL Granisetron

3 LAMICTAL ODT Lamotrigine Orally Disintegrating Tablets USE ORAL TABLETS

3 LAMICTAL KIT Lamotrigine LIMITED TO 1 KIT FOR TITRATION ONLY

3 LAMICTAL XR Lamotrigine Extended Release USE IMMEDIATE

RELEASE ORAL TABLETS

1 YES LAMISIL Terbinafine Tablets SPECIFIC DIAGNOSIS WITH LAB TESTS REQUIRED

3 LAZANDA NASAL SPRAY

Fentanyl Nasal Spray

3 YES LESCOL FLUVASTATIN MUST TRY GENERIC STATINS OR VYTORIN FIRST

3 LESCOL XL FLUVASTATIN MUST TRY GENERIC STATINS OR VYTORIN FIRST

SP LEVITRA TABLETS

Vardenafil

CHECK BENEFITS FOR COVERAGE-MUST HAVE FAILED CIALIS AND VIAGRA

3 LINZESS CAPSULES

Linaclotide

3 LIVALO Pitavastatin MUST TRY GENERIC STATINS OR VYTORIN FIRST

3 LOTRONEX Alosetron

3 LUNESTA Eszopiclone MUST HAVE FAILED ZOLPIDEM ORAL TABLETS

3 LYRICA Pregabalin

3 YES MARINOL CAPSULES

Dronabinol

3 MEKINIST Trmetinib




3 MICARDIS Telmisartan Losartan (COZAAR), Irbesartan (AVAPRO), BENICAR, DIOVAN

3 MICARDIS HCT Telmisartan / HCTZ

Losartan / HCTZ (HYZAAR), Irbesartan / HCTZ (AVALIDE), BENICAR HCT, VALSARTAN / HCTZ(DIOVAN HCT)

3 MOXATAG TABLETS

Amoxicillin 24 HRs USE AMOXICILLIN

SP MUSE INSERTS Alprostadil Suppositories


3 NAMENDA Memantine REQUIRES INITIAL MMSE

3 NAMENDA XR Memantine Extended Release

REQUIRES INITIAL MMSE

3 NESINA TABLETS Alogliptin Benzoate

3 NEXIUM Esomeprazole TRY Omeprazole, Pantoprazole (PROTONIX), ACIPHEX,

3 NOVOLOG Insulin aspart (rDNA) USE HUMALOG

3 NUTRIDOX Doxycycline monohydrate capsules

USE DOXYCYCLINE HYCLATE

3 NUVIGIL TABLETS Armodafinil

3 OMNEL TABLETS Itraconazole 200mg SPECIFIC DIAGNOSIS WITH LAB TESTS REQUIRED

3 ONE TOUCH TEST STRIPS


USE ONETOUCH ULTRA BLUE, ONETOUCH VERIO IQ, FREESTYLE LITE, FREESTYLE INSULINX, PRECISION XTRA

3 ONSOLIS BUCCAL FILM

Fentanyl Citrate Buccal Film

Morphine Sulfate (MSIR, MS CONTIN), MORPHINE SULFATE EXTENDED RELEASE (KADIAN), OPANA ER, Meperidine (DEMEROL), Methadone, Codeine, Oxycodone Immediate Release, PERCOCET 5/325, PERCODAN 5/325

3 ORACEA CAPSULES

Doxycycline Delayed Release Capsules 40mg USE DOXYCLINE

HYCLATE CAPSULES 3 OSENI TABLETS Alogliptin-Pioglitazone

3 OSPHENA TABLETS

Ospemifene Tab

3 OXTELLAR XR SR 24 Hr. TABLETS

Oxcarbazepine SR 24 Hr FAILURE OF TRILEPTAL

3 PANRETIN GEL Alitretinoin

3 PENNSAID SOLUTION

Diclofenac Sodium LIMITED TO 5 MLS DAILY

SE

CT

ION

3




3 PRESTIGE TEST STRIPS



3 YES PREVACID Lansoprazole (Generic does not require a PA)

TRY Omeprazole (PRILOSEC), Pantoprazole (Protonix), ACIPHEX

3 PREVPAC Lansoprazole/Biaxin/ Amoxicillin

USE INDIVIDUAL DRUGS

3 PRILOSEC SUSPENSION

Omeprazole Suspension LIMITED TO PATIENTS THAT CANNOT USE CAPSULES

3 PRISTIQ TABLETS Desvenlafaxine 24 HR REQUIRES TRIAL AND FAILURE OF GENERIC SSRI ANTIDEPRESSANTS

3 PROMACTA TABLETS

Eltrombopag Olamine REQUIRES CONFIRMATION OF DIAGNOSIS

1 YES PROSCAR Finasteride AGE 50 AND OLDER NO AUTHORIZATION REQUIRED

2 PROTOPIC Tacrolimus Ointment 3 YES PROVIGIL Modafinil

3 QUALAQUIN CAPSULES

Quinine

FOR TREATMENT OF MALARIA ONLY – NOT COVERED FOR LEG CRAMPS

3 QSYMIA CAPSULES

Phentermine HCl-Topiramate Cap SR 24HR

MUST MEET BMI QUALIFICATIONS

3 RAVICTI LIQUID Glycerol Phenylbutyrate Liquid

3 YES RAZADYNE (ER) Galantamine (SR) REQUIRES INITIAL MMSE

3 REGRANEX GEL Becaplermin 3 YES REVATIO Sildenafil 2 REVLIMID Lenalidomide

2 YES Ribavirin Capsules / Tablets

Ribavirin LIMITED TO USE WITH PEGASYS OR PEG-INTRON

3 ROZEREM Ramelteon Tablets

MUST HAVE FAILED ZOLPIDEM UNLESS HISTORY OF SUBSTANCE ABUSE

2 SAMSCA TABS Tolvaptan

3 SANCUSO PATCH Granisetron MUST FAIL ONDANSETRON (ZOFRAN)

3 SAVELLA Milnacipran CONFIRMED DIAGNOSIS OF FIBROMYALGIA AND FAILURE OF CYMBALTA




YES SEROPHENE TABLETS

Clomiphene Citrate Tablets CHECK PLAN DOCUMENTS FOR COVERAGE

3 SILENOR Doxepin MUST HAVE FAILED ZOLPIDEM

3 SIRTURO Bedaquiline

2 SINGULAIR 10 MG Montelukast

3 YES SOLODYN Minocycline Tab SR 24HR USE MINOCYCLINE HCl CAPSULES

1 YES SPORANOX Itraconazole

3 YES STADOL NASAL SPRAY

Butorphanol Nasal Spray MAXIMUM 3 CANNISTERS PER MONTH

SP STAXYN TABLETS Vardenafil Orally Disintegrating Tablets CHECK BENEFITS FOR

COVERAGE

3 STIVARGA TABLETS

Regorafenib

3 SUBOXONE Buprenorphine / Naloxone 3 SUBSYS SPRAY Fentanyl Sublingual Spray 3 YES SUBUTEX Buprenorphine

3 SUPRAX CAPSULES

Cefixime

3 SURESTEP TEST STRIPS



3 YES SYMBYAX Olanzapine / Fluoxetine ZYPREXA PLUS Fluoxetine (PROZAC)

3 TACLONEX OINTMENT

Calcipotriene-betamethasone dipropionate MUST HAVE FAILED

DOVONEX OR VECTICAL

3 TAFINLAR CAPSULES

Dabrafenib

2 TARCEVA Erlotinib 3 TASIGNA Nilotinib

3/SP TECFIDERA

Dimethyl Fumarate Capsule Delayed Release Dimethyl Fumarate Capsule Delayed Release

2 TEKAMLO Aliskiren and Amlodipine


2 TEKTURNA Aliskiren


2 TEKTURNA HCT Aliskiren / HCTZ


3 TESTIM Testosterone REQUIRES TRIAL AND FAILURE OF ANDROGEL

3 TEVETEN HCT Eprosartan Mesylate / HCTZ

Losartan / HCTZ (HYZAAR), Irbesartan / HCTZ (AVALIDE), BENICAR HCT, Valsartan / HCTZ( DIOVAN HCT)

SE

CT

ION

3




3 YES TINDAMAX TABLETS

Tinidazole

3 TOPICORT SPRAY

Desoximetasone Spray 0.25%

3 TREXIMET Sumatriptan-naproxen sodium tab 85-500 mg USE IMITREX PLUS

NAPROXEN SODIUM

2 TRIBENZOR TABLETS

Olmesartan / Amlodipine / Hydrochlorthiazide

Losartan / HCTZ (HYZAAR), Irbesartan / HCTZ (AVALIDE), BENICAR HCT, VALSARTAN / HCTZ(DIOVAN HCT)

3 TRUETRACK TEST STRIPS



3 TWYNSTA TABLETS (EST)

Telmisartan / Amlodipine MUST HAVE FAILED AN ACEI OR AN ARB

3 TYZEKA TABLETS Telbivudine Tab 600 mg 3 YES VANCOCIN Vancomycin

SP VIAGRA Sildenafil CHECK BENEFITS FOR COVERAGE

3 VICTRELIS CAPSULES

Boceprevir Capsules

3 VIIBRYD TABLETS Vilazodone HCl Tablets

2 XALKORI CAPSULES

Crizotinib

2 VYTORIN 10/10 Ezetimibe-Simvastatin MUST HAVE TRIED AND FAILED GENERIC STATINS

3 XELJANZ TABLETS

Tofacitinib Citrate

3 XIFAXAN 550MG Rifaximin

3 XTANDI CAPSULES

Rivaroxaban

3 XYREM ORAL SOLUTION

Sodium Oxybate

3 YES XYZAL TABLETS Levocetirizine

MUST TRY OTC Fexofenadine (ALLEGRA), Loratadine (CLARITIN), Cetirizine (ZYRTEC)

3 ZAVESCA CAPSULES

Miglustat MUST HAVE FAILED 2 FORMULARY DRUGS WITHIN CLASS

2 ZELBORAF TABLETS

Vemurafenib Tablets

3 ZETIONNA AEROSOL

Ciclesonide




3 ZIPSOR CAPSULES

Diclofenac Potassium MUST HAVE FAILED DICLOFENAC SODIUM (VOLTAREN)

2 ZOLINZA CAPSULES

Vorinostat MUST HAVE FAILED 2 FORMULARY DRUGS WITHIN CLASS

3 ZOLPIMIST SPRAY

Zolpidem MUST HAVE TRIED AND FAILED ZOLPIDEM TARTRATE

3 ZUBSOLV SL TABLETS

Buprenorphine HCl-Naloxone

2 ZYTIGA TABLETS Abiraterone Acetate

SE

CT

ION

4


DRUGS SUBJECT TO QUANTITY LIMITATIONS

TIER

GENERIC

BRAND NAME

GENERIC NAME LIMITATIONS OR

COMMENTS

3

ACCU-CHEK ACTIVE TEST STRIPS


MAXIMUM 200 PER MONTH WITHOUT PRIOR AUTHORIZATION

3

ACCU-CHEK ADVANTAGE TEST STRIPS



3

ACCU-CHEK AVIVA TEST STRIPS



3

ACCU-CHEK AVIVA PLUS TEST STRIPS



3

ACCU-CHEK COMFORT CURVE TEST STRIPS



3

ACCU-CHEK COMPACT TEST STRIPS



1

YES

ACCUTANE

Isotretinoin Capsules MAXIMUM 5 MONTHS

CONTINUOUS THERAPY

3

YES

ACETASOL OTIC

Acetic Acid / Hydrocortisone

MAXIMUM 10 ML PER SCRIPT

2

ACIPHEX

Rabeprazole

MAXIMUM 12 WEEKS & 1 PER DAY WITHOUT PRIOR AUTHORIZATION

1 YES ACTICIN Permethrin cream MAXIMUM 60 GMS / MONTH

3

ACTONEL

Risedronate

5 MG: MAXIMUM 1 PER DAY; 35 MG MAXIMUM 1 PER WEEK

3

ACTONEL 75 mg

Risedronate MAXIMUM 2 TABLETS PER

MONTH

3

ACTONEL 150 mg

Risedronate MAXIMUM 1 TABLET PER

MONTH

3

ACTONEL WITH

CALCIUM

Risedronate / Calcium MAXIMUM 1 PACKAGE 28-

DAY SUPPLY PER MONTH

1

YES ADDERALL XR

CAPSULES

Amphetamine Salt Combo

MAXIMUM 1 PER DAY

2

ADVAIR DISKUS Salmeterol / Fluticasone Powder

Diskus MAXIMUM 1 INHALER PER

MONTH

2

ADVAIR HFA Salmeterol / Fluticasone Powder

Diskus MAXIMUM 1 INHALER PER

MONTH

2 ADVICOR Niacin ER/ Lovastatin Tablet MAXIMUM 1 PER DAY

3

ALORA PATCHES

Estradiol Transdermal - Bi-Weekly MAXIMUM 8 PATCHES PER

MONTH

1

YES

ALTACE CAPSULES

Ramipril

1.25 MG, 2.5 MG, 5 MG: MAXIMUM 1 PER DAY; 10 MG: MAXIMUM 2 PER DAY

1

YES AMBIEN Zolpidem – For Short Term Use

Only

MAXIMUM 1 PER DAY



TIER

GENERIC

BRAND NAME

GENERIC NAME

LIMITATIONS OR COMMENTS

3 YES AMBIEN CR Zolpidem Extensed-Release MAXIMUM 1 PER DAY

1 YES AMERGE Naratriptan MAXIMUM 9 TABLETS PER MONTH

3 YES AMRIX CAPSULES Cyclobenzaprine SR MAXIMUM 1 PER DAY

2 ANDROGEL Testosterone Gel MAXIMUM 150 GM PER MONTH

3 AMPYRA TABLETS Dalfampridine Tab SR 12hr MAXIMUM 2 PER DAY

3 YES ANZEMET Dolasetron Mesylate MAXIMUM 2 TABLETS PER COURSE OF THERAPY

3 APLENZIN Bupropion SR 24 hr MAXIMUM 1 PER DAY

2 ASACOL TABLETS Mesalamine (5-ASA) MAXIMUM 6 PER DAY

2 ASMANEX AEROSOL

Mometasone Furoate MAXIMUM 1 INHALER PER MONTH

1 YES ASTELIN NASAL SPRAY

Azelastine MAXIMUM 1 INHALER PER MONTH

2 ASTEPRO NASAL SPRAY

Azelastine MAXIMUM 1 INHALER PER MONTH

3 ATELVIA Risedronate Delayed release MAXIMUM 1 PER WEEK

3 ATRALIN GEL Tretinoin Gel 0.05% MAXIMUM 45 GM PER MONTH

2 ATROVENT HFA Ipratropium MAXIMUM 1 INHALER / 30 DAYS SUPPLY

3 AZASITE OPHTHALMIC SOLUTION

Azithromycin Ophthalmic Solution MAXIMUM 6 ML PER MONTH

2 AVELOX TABLETS Moxifloxacin MAXIMUM 14 TABLETS IN 3 MONTHS

2 AVINZA ER CAPS Morphine Sulate ER Caps MAXIMUM 1 PER DAY

3 AXERT TABLETS Almotriptan MAXIMUM 6 TABLETS PER MONTH

3 AXIRON SOLUTION Testosterone TD Soln 30 MG/ACT MAXIMUM 3 ML PER MONTH

3 BECONASE AQ Beclomethasone Inahler MAXIMUM 2 INHALERS PER MONTH

2 BENICAR Olmesartan Medoxomil MAXIMUM 1 PER DAY

2 BENICAR HCT Olmesartan Medoxomil / HCTZ MAXIMUM 1 PER DAY

3 BEPREVE OPHTHALMIC SOLUTION

Bepotastine Besilate MAXIMUM 10ML PER MONTH

1 YES BIAXIN XL Clarithromycin XL MAXIMUM 14 TABLETS PER PRESCRIPTION

3 YES BONIVA Ibandronate MAXIMUM 1 PER MONTH

3 BRILINTA TABLETS Ticagrelor Tab 90 MG MAXIMUM 2 TABLETS PER DAY

3 BUTRANS PATCHES Buphrenorphine MAXIMUM 4 PER MONTH

3 CAMBIA PACKETS Diclofenac Potassium Pkt 50 MG MAXIMUM 9 PER 30 DAYS

SE

CT

ION

4



TIER

GENERIC

BRAND NAME

GENERIC NAME


3 CAYSTON INHALATION SOLUTION

Aztreonam for Inhalation Solution MAXIMUM DAYS SUPPLY 28

1 YES CELEXA Citalopram MAXIMUM 40MG PER DAY

3 CELEBREX Celecoxib PA REQUIRED: 1 PER DAY

3 CESAMET CAPSULES

Nabilone MAXIMUM 60 CAPSULES PER MONTH

SP CIALIS Tadalafil CHECK SPECIFIC PLAN FOR COVERAGE, QUANTITY AND COINSURANCE

1 YES CIPRO XR 1000 MG Ciprofloxacin XR 1000 MG MAXIMUM 14 DAYS PER PRESCRIPTION

1 YES CIPRO XR 500 MG Ciprofloxacin XR 500 MG MAXIMUM 3 TABLETS PER PRESCRIPTION

2 CIPRODEX OTIC SUSPENSION

Ciprofloxacin / Hydrocortisone MAXIMUM 8 ML PER SCRIPT

3 YES CLARINEX TABLETS Desloratadine MAXIMUM 1 PER DAY

1 YES CLIMARA PATCHES Estradiol Transdermal - Weekly MAXIMUM 4 PATCHES PER MONTH

2 COARTEM TABLETS Artemether / lumefantrine MAXIMUM 3 DAYS TREATMENT

1 YES CLOMID Clomiphene NOT COVERED BY ALL PLANS – MAXIMUM 15 TABLETS

1 YES COLAZAL Balsalazide Disodium MAXIMUM 280 PER MONTH

3 YES COMBUNOX Oxycodone / Ibuprofen MAXIMUM 4 PER DAY

1 YES CONCERTA Methylphenidate Extended Release Tablets OSM

MAXIMUM 1 PER DAY - 36 MG MAXIMUM 2 PER DAY

1 YES COREG Carvedilol MAXIMUM 2 PER DAY

3 CRESTOR Rosuvastatin MAXIMUM 1 PER DAY

2 CYMBALTA Duloxetine MAXIMUM 2 PER DAY for 15 MG and 30 MG: 2 DAILY for 60 MG

3 DALIRESP Roflumilast Tablets MAXIMUM 1 PER DAY

1 YES DALMANE Flurazepam MAXIMUM 1 PER DAY

3 DENAVIR CREAM Penciclovir MAXIMUM 1.5 GM PER PRESCRIPTION

3 Desvenlafaxine 24 HR

Desvenlafaxine 24 HR MAXIMUM 1 PER DAY

2 YES DETROL Tolterodine Tartrate MAXIMUM 2 PER DAY

2 DETROL LA Tolterodine Tartrate Long Acting MAXIMUM 1 PER DAY

3 DEXILANT Dexlansoprazole Capsule Delayed Release

MAXIMUM 1 PER DAY

2 DIFFERIN GEL / CR / SOLUTION

Adapalene QTY MAXIMUM 45 GM, 30 ML or 60 PADS PER PRESCRIPTION



TIER

GENERIC

BRAND NAME

GENERIC NAME


3 DIFFERIN LOTION Adapalene QTY MAXIMUM 60 ML PER PRESCRIPTION

1 YES

DOLOPHINE Methadone Tablets 5 MG, 10 MG, 40 MG TABLETS ONLY

3 YES DOSTINEX

TABLETS Cabergoline MAXIMUM 8 PER 30 DAYS

2 YES

DOVONEX Calcipotriene MAXIMUM 120 GMS PER MONTH

2

DUAC KIT Benzoyl Peroxide 5%/ Clindamycin 1%

QTY MAXIMUM 1 KIT PER MONTH

1 YES DUETACT TABLETS Pioglitazone / Glimepiride MAXIMUM 1 PER DAY

2

DULERA AEROSOL Mometasone furoate-formoterol fumarate

MAXIMUM 1 INHALER PER MONTH

1

YES DURAGESIC

PATCHES Fentanyl Transdermal Patch

QTY MAXIMUM 10 PATCHES PER MONTH

3

DYMISTA NASAL

SPRAY

Azelastine Hcl-Fluticasone Proprionate

MAXIMUM 1 SPRAYER PER MONTH

2

ELIMITE CREAM Permethrin Cream

AGE LIMIT 2 MONTHS; MAXIMUM TO 60 GM PER PRESCRIPTION

3

ELLA Ulipristal LIMITED TO 5 DAY COURSE OF THERAPY

3

EMEND Aprepitant MAXIMUM A 3-DAY TRIPACK PER COURSE OF THERAPY

3 EPIDUO GEL Adapalene-Benzoyl Peroxide Gel MAXIMUM 1.5 GM DAILY

2

ESTRADERM Estradiol Transdermal - Bi-Weekly MAXIMUM 8 PATCHES PER MONTH

3

ESTROGEL Estradiol Gel QTY MAXIMUM 50 GM PER MONTH

2 EVISTA Raloxifene MAXIMUM 1 PER DAY

3

FACTIVE Gemifloxacin Mesylate MAXIMUM 7 DAYS PER COURSE OF THERAPY

3

YES FENTORA BUCCAL

TABLETS Fentanyl Citrate MAXIMUM 3 PER DAY

3 FLECTOR PATCHES Diclofenac Epolamine 1% MAXIMUM 1 PER DAY

1 YES FLOMAX TABLETS Tamsulosin MAXIMUM 2 PER DAY

1

YES FLONASE NASAL

SPRAY Fluticasone Nasal Inhaler

MAXIMUM 2 SPRAYERS PER MONTH

2

FLOVENT HFA

AEROSOL Fluticasone Inhaler

MAXIMUM 2 INHALERS PER MONTH

2

FLOVENT DISCKUS Fluticasone

MAXIMUM DAILY DOSE 40 FOR 50MG; 20 FOR 100MG; 8 FOR 250MG

1 YES FOCALIN Dexmethylphenidate MAXIMUM 2 PER DAY

3

FORADIL

AEROLIZER Formoterol Fumarate

MAXIMUM 2 CAPSULES PER DAY

3 FORTESTA GEL Testosterone gel LIMITED TO 2.4GM / DAY

SE

CT

ION

4



TIER

GENERIC

BRAND NAME

GENERIC NAME


1

YES

FOSAMAX Alendronate

5 MG & 10 MG MAXIMUM 1 PER DAY: 70 MG MAXIMUM 1 PER WEEK

3 YES FOSAMAX-D Alendronate / Vitamin D MAXIMUM 4 PER MONTH

2

FREESTYLE TEST STRIPS

Blood Glucose Test Strips MAXIMUM 200 PER MONTH WITHOUT PRIOR AUTHORIZATION

2

FREESTYLE LITE TEST STRIPS


3

FROVA TABETS Frovatriptan Succinate MAXIMUM 9 TABLETS PER MONTH

3

FULYZAQ DELAYED

RELEASE TABLETS Crofelemer Tab Delayed Release MAXIMUM 2 PER DAY

3 GELNIQUE GEL Oxybutynin Chloride Gel MAXIMUM 1 PKG PER DAY

3

HORIZANT SR

Gabapentin Enacarbil Tab SR 24HR 600 MG MAXIMUM 1 PER DAY

2

HUMALOG INSULIN Insulin, Lispro MAXIMUM 40 ML PER PRESCRIPTION

2

HUMALOG INSULIN

PENS Insulin, Lispro

MAXIMUM 45 ML PER PRESCRIPTION

2

HUMULIN INSULIN Insulin, Human mfg Lilly MAXIMUM 40 ML PER PRESCRIPTION

2

HUMULIN INSULIN

PENS Insulin, Human mfg Lilly


1

YES

IMITREX TABLETS Sumatriptan Tablets MAXIMUM 9 TABLETS PER MONTH

1

YES IMITREX NASAL

SPRAY Sumatriptan Nasal Spray

MAXIMUM 1 PKG OF 6 DOSES PER MONTH

3 INTUNIV TABLETS Guanfacine 24 HR Tablets MAXIMUM 1 PER DAY

3

JOLESSA Levonorgestrel and ethinyl estradiol

MAXIMUM 3 MONTH SUPPLY

2 JUVISYNC TABLETS Sitagliptin-Simvastatin MAXIMUM 1 PER DAY

1

YES

KADIAN CR CAPSULES 20MG, 30MG, 50MG, 80MG, 100MG

Morphine Sulfate Extended Release Capsules MAXIMUM 2 PER DAY

3

KAPIDEX Dexlansoprazole Capsule Delayed Release

MAXIMUM 1 PER DAY

1

YES Ketoconazole 2%

Cream Ketoconazole 2% Cream (QL)

MAXIMUM 60 GM PER MONTH

3

YES

KYTRIL Granisetron MAXIMUM 2 TABLETS COURSE OF THERAPY

3 YES LAMICTAL XR Lamotrigine SR 24 hr Tablet MAXIMUM 1 PER DAY

2

LANTUS Insulin Glargine MAXIMUM 40 ML PER PRESCRIPTION

2

LANTUS SOLOSTAR Insulin Glargine Pen MAXIMUM 45 ML PER PRESCRIPTION

1

YES

LARIAM Mefloquine MAXIMUM 6 TABLETS PER MONTH



TIER

GENERIC

BRAND NAME

GENERIC NAME


3 YES LESCOL Fluvastatin MAXIMUM 1 PER DAY

3 LESCOL XL

Fluvastatin Extended Release Capsules MAXIMUM 1 PER DAY

1 YES LEVAQUIN Levofloxacin MAXIMUM 14 TABLETS

2

LEVEMIR Insulin Detemir MAXIMUM 45 ML PER MONTH

1 YES LIPITOR Atorvastatin MAXIMUM 1 PER DAY

2 LIPTRUZET Ezetimibe-Atorvastatin MAXIMUM 1 PER DAY

3 LIVALO Pitavastatin MAXIMUM 1 PER DAY

2

LOTEMAX Loteprednol etabonate ophth susp 0.5%

MAXIMUM 2.5 ML PER MONTH

1 YES LOTREL Amlodipine / Benazepril MAXIMUM 1 PER DAY

1

YES

LOTRISONE Clotrimazole / Betamethasone MAXIMUM 45 GM PER MONTH

2

LUMIGAN Bimatoprost MAXIMUM 2.5 ML PER MONTH

3 LUNESTA Eszopiclone MAXIMUM 1 PER DAY

3 LYRICA Pregabalin Capsules MAXIMUM 3 PER DAY

3 LYRICA Pregabalin Solution MAXIMUM 30 ML PER DAY

3

YES

LYSTEDA Tranexamic Acid MAXIMUM 6 PER DAY FOR 5 DAYS

2

MAXAIR

AUTOHALER Pirbuterol


1

YES

MAXALT Rizatriptan MAXIMUM 12 TABLETS PER MONTH

1

YES

MAXALT-MLT Rizatriptan Orally Disintegrating Tablet

MAXIMUM 12TABLETS PER MONTH

3

MENOSTAR Estradiol Patch - weekly MAXIMU 4 PATCHES PER MONTH

2

METHERGINE Methylergonovine MAXIMUM 28 TABLETS PER PRESCRIPTION

1 YES MEVACOR Lovastatin MAXIMUM 1 PER DAY

3

MIGRANAL NASAL

SPRAY Dihydroergotamine

MAXIMUM 4 UNITS PER MONTH

1

YES

MIRALAX POWDER Polyethylene Glycol 3350 MAXIMUM 527 GM. PER MONTH

1 YES MOBIC TABLETS Meloxicam Tablets MAXIMUM 1 PER DAY

3

MOXATAG TABLETS Amoxicillin Extended Release Tablets

MAXIMUM 1 PER DAY X 10 DAYS

1

YES MS CONTIN

TABLETS Morphine Sulfate Sustained

Release Tablets MAXIMUM 3 PER DAY

SP

MUSE INSERTS Alprostadil Suppositories

MAXIMUM 6 SUPPOSITORIES PER MONTH

3

MYRBETRIQ

TABLETS Mirabegron MAXIMUM 1 PER DAY

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TIER

GENERIC

BRAND NAME

GENERIC NAME


3

YES NASACORT AQ

NASAL INHALATION Triamcinolone Nasal Inhalation


2

NASONEX NASAL

SUSPENSION

Mometasone Furoate Nasal Suspension

MAXIMUM 2 SPRAYERS PER MONTH

3

NATROBA

SUSPENSION Spinosad Topical Suspension MINIMUM 4 YEARS OF AGE

3 NEXIUM CAPSULES Esomeprazole MAXIM,UM 1 PER DAY

1

YES

Nitroglycerin Patches Nitroglycerin Patches MAXIMUM 30 PATCHES PER MONTH

1

YES NIZORAL 2%

CREAM Ketoconazole Cream


1 YES NORVASC Amlodipine MAXIMUM 2 PER DAY

2

NUCYNTA ER

TABLETS Tapentadol ER MAXIMUM 2 PER DAY

2 NUCYNTA TABLETS Tapentadol MAXIMUM 6 PER DAY

1

YES

OCUFLOX OPHTHALMIC SOLUTION

Ofloxacin MAXIMUM 60 GM PER MONTH

3

ONSOLIS BUCCAL

FILM Fentanyl Buccal Film MAXIMUM 3 PER DAY

3

ONE TOUCH TEST STRIPS


3

ONE TOUCH ULTRA TEST STRIPS


2

OPANA ER CRUSH

RESISITANT Oxymorphone Extended Release MAXIMUM 2 PER DAY

3 OXECTA TABLETS

Oxycodone hcl tab 5 mg (abuse deterrent) MAXIMUM 3 PER DAY

3

OXYCONTIN

TABLETS

Oxycodone Extended Release Tablet MAXIMUM 3 PER DAY

2

PATADAY OPHTHALMIC SOLUTION

Olopatadine 0.2% MAX 2.5 ML PER MONTH

1 YES PLAVIX TABLETS Clopidogrel MAXIMUM 2 PER DAY

1 YES PLETAL TABLETS Cilostazol MAXIMUM 2 PER DAY

1

YES

POLY-VI-FLOR Fluoride / Polyvitamins (Without Iron; Drops & Tablets)

MAXIMUM 5 YEARS OF AGE OR YOUNGER

1

YES

PRAVACHOL TABLETS

Pravastatin 10 MG, 20 MG, 80 MG: MAXIMUM 1 PER DAY; 40 MG: MAXIMUM 2 PER DAY

2

PRECISION Q.I.D. TEST STRIPS


2

PRECISION XTRA TEST STRIPS




TIER

GENERIC

BRAND NAME

GENERIC NAME


3

YES

PREVACID CAPSULES

Lansoprazole Tablets TABLETS NOT COVERED- USE SOLUTABS - PA REQUIRED

3

PREVACID

SOLUTABS Lansoprazole MAXIMUM 1 PER DAY

3

PROMACTA

TABLETS Eltrombopag Olamine

MAXIMUM 1 PER DAY

1

YES PRILOSEC

CAPSULES Omeprazole

PA REQUIRED: MAXIMUM 12 WEEKS & 1 PER DAY

3 PRISTIQ TABLETS Desvenlafaxine 24 Hr Tablets MAXIMUM 1 PER DAY

3 YES

PROMETRIUM CAPSULES

Progesterone Micronized MAXIMUM 2 PER DAY

1

YES

PROTONIX TABLETS

Pantoprazole MAXIMUM 12 WEEKS & 1 PER DAY WITHOUT PRIOR AUTHORIZATION

2

PROTOPIC

OINTMENT Tacrolimus Ointment

MAXIMUM 60 GMS PER FILL; 2 FILLS IN 6 MONTHS

2

PROVENTIL HFA Albutreol Inhaler QTY. LIMIT UP TO 1 INHALER / 30 DAYS SUPPLY

3 YES PROVIGIL Modafinil Tablets MAXIMUM 1 PER DAY

1

YES

PULMICORT INHALATION SUSPENSION

Budesonide Inhalation Suspension MAXIMUM 8 YEARS OF AGE OR YOUNGER

2

PULMICORT

FLEXHALER Budesonide Turbuhaler

MAXIMUM 2 INHALER PER 30 DAYS

2

PULMOZYME Dornase Alfa MAXIMUM 3O AMPS PER MONTH

3

QUALAQUIN TABLETS

Quinine

FOR TREATMENT OF MALARIA ONLY-NOT COVERED FOR LEG CRAMPS

3

QUILLIVANT

XR SUSPENSION Methylphenidate ER Suspension MAXIMUM 12 ML PER DAY

2

QVAR INHALER Beclomethasone Dipronate Aerosol


3

RANEXA TABLETS Ranolazine MAXIMUM 4 PER DAY FOR 500MG

3

YES

RAZADYNE ER Galantamine ER capsules MAXIMUM 1 CAPSULE PER DAY

3 REGRANEX Becaplermin Gel MAXIMUM 15 GMS PER FILL

1

YES

RELAFEN TABLETS Nabumetone Tablets

MAX. 4 PER DAY FOR 500MG; MAX. 3 PER DAY FOR 750MG

3

RELPAX TABLETS Eletriptan MAXIMUM 6 TABLETS FOR MONTH

RESCULA OPHTHALMIC SOLUTION

Unoprostone Isopropyl

MAXIMUM 1 BOTTLE PER MONTH

1

YES

RETIN-A Tretinoin MAXIMUM 20 GM PER PRESCRIPTION

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TIER

GENERIC

BRAND NAME

GENERIC NAME


3

RHINOCORT AQUA

SUSPENSION Budesonide Nasal Suspension


3 ROZEREM TABLETS Ramelteon MAXIMUM 1 PER DAY

1

YES

RYTHMOL TABLETS Propafenone

150 MG: MAXIMUM 6 PER DAY; 225 MG, 300 MG: MAXIMUM 3 PER DAY

2 SAMSCA TABLETS Tolvaptan Tablets MAXIMUM 1 PER DAY

3

SANCUSO

PATCHES Granisetron MAXIMUM 1 PER 21 DAYS

2 SAPHRIS SL TABS Asenapine MAXIMUM 2 PER DAY

3 SAVELLA TABLETS Milnacipran MAXIMUM 2 PER DAY

2

SEREVENT DISKUS Salmeterol MAXIMUM TO 2 BLISTERS PER DAY

1

YES

SEROPHENE TABLETS

Clomiphene NOT COVERED BY ALL PLANS – MAXIMUM 15 TABLETS

3 SILENOR TABLETS Doxepin MAXIMUM 1 PER DAY

1 YES SONATA CAPSULES Zaleplon MAXIMUM 1 PER DAY

3

SORIATANE CK KIT Acitretin Capsules plus Moisturizer MAXIMUM 1 KIT PER MONTH

3 SORILUX AEROSOL Calcipotriene MAXIMUM 4 GM PER DAY

2

SPIRIVA INHALER Tiotropium MAXIMUM 1 CAPSULE PER DAY

3

SPRIX NASAL

SPRAY

Ketorolac Tromethamine Nasal Spray 15.75 MG/SPRAY

MAXIMUM 5 DAYS TREATMENT

3

YES STADOL NASAL

SPRAY Butorphanol Nasal Spray

MAXIMUM 3 CANNISTERS PER MONTH

STAXYN TABLETS Vardenafil HCl Orally Disintegrating Tab 10 MG

MAXIMUM 8 TABLETS PER MONTH

3

STRATTERA

TABLETS Atomoxtine Tablets MAXIMUM 1 PER DAY

3

SUBOXONE TABLETS

Buprenorphine / Naloxone 2/0.5 MG: MAXIMUM 3 PER DAY; 8/2 MG: MAXIMUM 4 PER DAY

3 SUBOXONE FILM Buprenorphine / Naloxone MAXIMUM 1 PER DAY

3

YES SUBUTEX SL

TABLETS Buprenorphine

2 MG: MAXIMUM 3 PER DAY; 8 MG: MAXIMUM 4 PER DAY

1

YES SULFACET-R

LOTION

Sulfacetamide 10%/ Sulfur 5% Lotion


1

YES SUMATRIPTAN

TABLETS Sumatriptan Tablets


2 SYMBICORT

AEROSOL

Budesonide / Formoterol fumurate dihydrate MAXIMUM 1 PER MONTH

2

TAMIFLU Oseltamivir MAXIMUM 10 CAPSULES PER PRESCRIPTION

3

TACLONEX Calcipotriene-betamethasone dipropionate

MAXIMUM 60 GM PER PRESCRIPTION



TIER

GENERIC

BRAND NAME

GENERIC NAME


2

TAZORAC CREAM /

GEL Tazarotene


2 TEMODAR TABLETS Temozolomide MAXIMUM 15 PER MONTH

1

YES

TOBRADEX OPHTHALMIC SOLUTION

Tobramycin / Dexamethasone MAXIMUM 5 ML PER MAXIMUM 15 PER MONTH PRESCRIPTION

1

YES

TORADOL TABLETS Ketorolac Oral Tablets MAXIMUM 20 TABLETS PER PRESCRIPTION

2 TOVIAZ TABLETS

Fesoterodine Fumarate Tab SR 24HR MAXIMUM 1 PER DAY

2

TRAVATAN Z OPHTHALMIC SOLUTION

Travoprost MAXIMUM 2.5 ML PER MONTH

3

TREXIMET TABLETS Sumatriptan / Naproxen MAXIMUM 9 TABLETS PER MONTH

1

YES TRI-VI-FLOR

TABLETS

Fluoride / Vitamins A,D,C (Without Iron; Drops & Tablets)

MAXIMUM 5 YEARS OF AGE OR YOUNGER

3

TRUETRACK TEST STRIPS


2

TUDORZA

PRESSAIR Aclidinium Bromide Aerosol

MAXIMUM 1 INHALER PER MONTH

3 TWYNSTA TABLETS Telmisartan / Amlodipine MAXIMUM 1 PER DAY

1

YES ULTRAM TABLETS

50MG Tramadol 50 MG Tablets MAXIMUM 8 PER DAY

3

YES UROXATRAL

TABLETS Alfuzosin MAXIMUM 1 PER DAY

2

VALCYTE

CAPSULES Valganciclovir MAXIMUM 4 PER DAY

1 YES VALTREX TABLETS Valacyclovir MAXIMUM 30 PER MONTH

1

YES VECTICAL

OINTMENT Calcitriol Ointment

MAXIMUM 200 GMS PER PRESCRIPTION

2

VERAMYST Fluticasone Furoate MAXIMUM 1 INHALER PER MONTH

3

VEREGEN

OINTMENT Sinevcatechins


1

YES

VERMOX Mebendazole MAXIMUM 6 TABLETS PER PRESCRIPTION

1 YES VFEND Voriconazole MAXIMUM 2 TABLETS PER DAY

SP

VIAGRA TABLETS Sildenafil

CHECK SPECIFIC PLAN FOR COVERAGE, QUANTITY AND COINSURANCE

1

YES VI-DAYLIN/F

TABLETS

Fluoride / Polyvitamins (Without Iron; Drops & Tablets)

AGE LIMIT 5 YEARS OR YOUNGER

2

VIGAMOX Moxifloxacin MAXIMUM 3 ML PER PRESCRIPTION

1

YES VOSPIRE ER

TABLETS Albuterol Sulfate ER Tablets MAXIMUM 2 PER DAY

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TIER

GENERIC

BRAND NAME

GENERIC NAME


2 VYTORIN TABLETS Simvastatin / Ezetimibe MAXIMUM 1 PER DAY

2

VYVANSE

CAPSULES Lisdexamfetamine MAXIMUM 1 PER DAY

1

YES WELLBUTRIN XL

TABLETS Bupropion Extended Release MAXIMUM 1 PER DAY

3

YES

XALATAN Latanoprost MAXIMUM 2.5 ML PER MONTH

2

XARELTO

CAPSULES Rivaroxaban MAXIMUM 2 PER DAY

3 XELJANZ TABLETS Tofacitinib Citrate MAXIMUM 2 PER DAY

3

XIFAXAN TABLETS Rifaximin MAXIMUM 9 TABLETS PER PRESCRIPTION

3

XERESE CREAM Acyclovir-Hydrocortisone Cream

MAXIMUM 5 GM TUBE PER PRESCRIPTION

2

XOPENEX HFA

AEROSOL Levalbuterol

QTY. LIMIT UP TO 1 INHALER / 30 DAYS SUPPLY

3 YES XYZAL TABLETS Levocetirizine MAXIMUM 1 PER DAY

3 ZIANA GEL Clindamycin- Tretinoin Gel MAXIMUM 1 GM DAILY

3

ZIOPTAN Tafluprost ophthalmic solution MAXIMUM 1 CONTAINER PER DAY

3

ZIPSOR CAPSULES Diclofenac Potassium MAXIMUM 4 TABLETS PER DAY-MAXIMUM 7 DAYS

1

YES ZITHROMAX

TABLETS Azithromycin

MAXIMUM 6 TABLETS PER PRESCRIPTION

2

ZMAX SUSPENSION Azithromycin Extended Release for oral susp 2 gm

MAXIMUM 1 PER DAY (Equals 2 Gm dose Per day)

1 YES ZOCOR TABLETS Simvastatin MAXIMUM 1 PER DAY

1

YES

ZOFRAN TABLETS Ondansetron MAXIMUM 20 TABLETS PER PRESCRIPTION

1

YES

ZOFRAN ODT Ondansetron ODT MAXIMUM 20 TABLETS PER PRESCRIPTION

3

ZOMIG NASAL

SPRAY Zolmitriptan

MAXIMUM 1 PKG OF 6 DOSES PER MONTH

3

YES ZOMIG TABLETS /

ZMT Zolmitriptan


1

YES ZOVIRAX

OINTMENT Acyclovir Ointment


3

ZOVIRAX CREAM Acyclovir Cream MAXIMUM 30 GM PER PRESCRIPTION

3

ZUPLENZ ORAL

FILM Ondansetron Oral Film MAXIMUM 20 PER MONTH

3 ZYCLARA CREAM Imiquimod Cream 3.75% MAXIMUM 28 PER 28 DAYS

3

ZYCLARA PUMP Imiquimod Cream MAXIMUM 15 GM PER MONTH

2

ZYLET OPHTHALMIC SUSPENSION

Loteprednol etabonate / Tobramycin



ALTERNATIVE MEDICATIONS ON THE RECOMMENDED DRUG LIST

DRUG NAME SUGGESTED ALTERNATIVE DRUGS

ACTIQ LOZENGES

Acetaminophen /Codeine (TYLENOL/CODEINE), Fentanyl (DURAGESIC), Hydrocodone/Acetaminophen (LORTAB/LORCET/VICODIN/VICODIN ES), Hydrormorphone (DILAUDID), Meperidine (DEMEROL), Methadone (DOLOPHINE), Morphine sulfate (MSIR), Morphine Sulfate Controlled Release (MS CONTIN), Oxycodone/ Acetaminophen (PERCOCET), Oxycodone/ Aspirin (PERCODAN)

ACTONEL Alendronate (FOSAMAX)

ACTONEL WITH CALCIUM Alendronate (FOSAMAX)

AGGRENOX CAPSULES Clopidogrel (PLAVIX), Ticlopidine (TICLID) ALAMAST OPHTHALMIC DROPS Cromolyn (CROLOM), ALOMIDE, PATADAY ALOCRIL OPHTHALMIC SOLN. Cromolyn (CROLOM), ALOMIDE, PATADAY

ALORA PATCHES ESTRADERM, Estradiol Patches (CLIMARA), VIVELLE-DOT

ALREX OPHTHALMIC SUSPENSION

Dexamethasone (Decadron), Prednisolone (Pred Mild, Inflamase Mild)

ALTOPREV TABLETS Lovastatin Tablets AMBIEN CR TABLETS

Lorazepam (ATIVAN), Temazepam (RESTORIL), Flurazepam (DALMANE), Zolpidem (AMBIEN)

Amitriptyline / Perphenazine Tablets

Amitriptyline Tablets AND Perphenazine Tablets

ANGELIQ TABLETS PREMPRO, PREMPHASE, CLIMARA PRO, PREMARIN / Estradiol Patches (CLIMARA) / VIVELLE/ESTRADERM AND Medroxyprogesterone (PROVERA)

ANZEMET Ondansetron (ZOFRAN) TABLETS, metoclopramide, prochlorperazine, promethazine, trimethobenzamide,

ARTHROTEC TABLETS Misoprostil (CYTOTEC) AND Diclofenac (VOLTAREN) ATACAND Losaratan (COZAAR), Irbesartan (AVAPRO), BENICAR, DIOVAN

ATACAND HCT Losartan / HCTZ (HYZAAR), Irbesartan / hctz (AVALIDE), BENICAR HCT, Valsartan / HCTZ (DIOVAN HCT)

AVODART CAPSULES Finasteride (PROSCAR), Doxazosin (CARDURA), Terazosin (HYTRIN)

AXERT TABLETS Sumatriptan (IMITREX TABLETS), Rizatriptan (MAXALT), Naratriptan (AMERGE TABLETS)

AZELEX CREAM Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A MICRO), Adapalene (DIFFERIN), DUAC, TAZORAC, Sulfacetamide/sulfur (SULFACET-R)

BECONASE AQ Fluticasone (FLONASE), NASONEX, VERAMYST

BENZACLIN GEL Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A, RETIN A MICRO), ADAPALENE (DIFFERIN), DUAC, TAZORAC, Sulfacetamide/sulfur (SULFACET-R)

BEPREVE OPHTHALMIC SOLUTION

Cromolyn (CROLOM), ALOMIDE, PATADAY

BIDIL TABLETS Hydralazine (APRESOLINE) AND Isosorbide (ISORDIL) BONIVA TABLETS Alendronate (FOSAMAX)

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Butorphanol Nasal Spray FIORICET, FIORINAL, ISOYLL, Acetaminophen and codeine (TYLENOL/CODEINE), Hydrocodone 5mg and Acetaminophen 500 mg (VICODIN, LORTAB)

CAMPRAL TABLETS Naltrexone, Disulfiram (ANTABUSE)

CARDENE CAPSULES Nifedipine SR (ADALAT CC), Felodipine (PLENDIL), Nislodipine (SULAR), Verapamil SA Tabs (CALAN SR), Amlodipine (NORVASC), Diltiazem (CARDIZEM, TIAZAC, DILACOR)

CARDIZEM LA TABLETS

Nifedipine SR (ADALAT CC), Felodipine (PLENDIL), NISLODIPINE (SULAR), Verapamil SA Tabs (CALAN SR), Amlodipine (NORVASC), Diltiazem (CARDIZEM, TIAZAC, DILACOR)

CATAFLAM TABLETS

Ibuprofen (MOTRIN), Naproxen (NAPROSYN), Etodolac (LODINE), Oxaprozin (DAYPRO), Nabumetone (RELAFEN), Sulindac (CLINORIL), Diclofenac (VOLTAREN), Piroxicam (FELDENE), Ketoprofen (ORUDIS)

CATAPRES-TTS PATCHES Clonidine Tablets (CATAPRES)

CELEBREX

Ibuprofen (MOTRIN), Meloxicam (MOBIC), Naproxen (NAPROSYN), Etodolac (LODINE), Oxaprozin (DAYPRO), Nabumetone (RELAFEN), Sulindac (CLINORIL), Diclofenac (VOLTAREN), Piroxicam (FELDENE), Ketoprofen (ORUDIS), Tramadol (ULTRAM)

CENESTIN TABLETS PREMARIN, Estropipate (OGEN, ORTHO-EST), Esterified Estrogens (MENEST, ESTRATAB), Estradiol (ESTRACE)

CESAMET CAPSULES Ondansetron (ZOFRAN) Tablets, metoclopramide, prochlorperazine, promethazine, trimethobenzamide,

Chlorzoxazone Tablets Methocarbamol (ROBAXIN), Carisoprodol 350 MG (SOMA), Cyclobenzaprine (FLEXERIL)

CIPRO HC OTIC SOLUTION Cortisporin Otic, TOBRADEX, ZYLET SUSPENSION CLARINEX TABLETS CLARITIN (AVAILABLE OTC - NOT COVERED)

CLENIA CREAM Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A MICRO), DIFFERIN, DUAC, TAZORAC, Sulfacetamide/sulfur (SULFACET-R)

CLOBEX LOTION Betamethasone Dip. Augmented (DIPROLENE), clobetasol (TEMOVATE), Desoxymethasone (TOPICORT LP)

COMBIPATCH CLIMARA PRO, PREMPRO, PREMPHASE, PREMARIN and Medroxyprogesterone (PROVERA)

COMBIVENT INHALER/ RESPIMAT

PROVENTIL HFA AND Ipratropium (ATROVENT)

COMBUNOX TABLETS


CORDRAN CREAM / OINTMENT / TAPE

Betamethasone Dip. (DIPROSONE), Betamethasone Val. (VALISONE), Fluocinolone (SYNALAR), ELOCON, Triamcinolone (KENALOG, ARISTOCORT)

COVERA -HS TABLETS Verapamil SA Tabs (CALAN SR)

DENAVIR CREAM ABREVA ((AVAILABLE OTC - NOT COVERED), Acyclovir (ZOVIRAX (oral)), Valacyclovir (VALTREX)



DRUG NAME SUGGESTED ALTERNATIVE DRUGS DIDRONEL TABLETS Alendronate (FOSAMAX)

DITROPAN XL TABLETS Oxybutynin Immediate Release Tablets (DITROPAN), Tolterodine Tablets (DETROL), DETROL LA

DORAL TABLETS Zolpidem (AMBIEN), Lorazepam (ATIVAN), Temazepam (RESTORIL), Flurazepam (DALMANE)

DORYX TABLETS Doxycycline Hyclate (Immediate release) DYNACIN - USE MINOCYCLINE Minocycline (MINOCIN)

DYNACIRC CR TABLETS ADALAT CC, Felodipine (PLENDIL), NISLODIPINE (SULAR), Verapamil SA Tabs (CALAN SR)

EDECRIN TABLETS Furosemide (LASIX), Bumetanide (BUMEX), Metolazone (ZAROXOLYN)

ELESTAT OPHTHALMIC SOLUTION

Cromolyn (CROLOM), Lodoxamide (ALOMIDE), Olopatadine (PATANOL)

ELIDEL CREAM PROTOPIC (PA)

EMEND CAPSULES Ondansetron (ZOFRAN) Tablets, Metoclopramide (REGLAN), Prochlorperazine (COMPAZINE), Promethazine (PHENERGAN), Trimethobenzamide Capsules (TIGAN)

ENABLEX TABLETS Oxybutynin Immediate Release Tablets (DITROPAN), Tolterodine Tablets (DETROL), DETROL LA

ERTACZO CREAM Nystatin (MYCOSTATIN), Econazole (SPECTAZOLE), LAMISIL AT (OTC)

ESTRASORB TOPICAL EMULSION

ESTRADERM, Estradiol Patches (CLIMARA), VIVELLE-DOT

ESTRING PREMARIN, Estropipate (OGEN, ORTHO-EST), Esterified Estrogens (MENEST, ESTRATAB), Estradiol (ESTRACE), CLIMARA, ESTRADERM

ESTROGEL PREMARIN, Estropipate (OGEN, ORTHO-EST), Esterified Estrogens (MENEST, ESTRATAB), Estradiol (ESTRACE), Estradiol Patches (CLIMARA), ESTRADERM

EXELDERM Nystatin, Econazole (SPECTAZOLE), LAMISIL AT (OTC) FACTIVE TABLETS Ciprofloxacin (CIPRO)

FASTTAKE TEST STRIPS USE ONETOUCH ULTRA BLUE, ONETOUCH VERIO IQ, FREESTYLE LITE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS

FEMRING (3 Month Supply) PREMARIN VAGINAL Cream, ESTRACE VAGINAL Cream, ESTRADERM, Estradiol Patches (CLIMARA), VIVELLE-DOT

Fentanyl Lozenges


FENTORA BUCCAL Fentanyl Transdermal Patch

FOCALIN XR CAPSULES Methylphenidate SR (Ritalin SR), Dextroamphetamine SR (DEXEDRINE), VYVANSE, Methylphenidate SR OSM (CONCERTA)

FROVA Sumatriptan (IMITREX TABLETS), Rizatriptan (MAXALT), Naratriptan (AMERGE TABLETS)

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GLYSET TABLETS Tolazamide (TOLINASE), TOLBUTAMIDE, Glipizide Extended Release (GLUCOTROL XL), Glipizide (GLUCOTROL), Glyburide (DIABETA, MICRONASE)

HALOG CREAM / OINTMENT

Betamethasone Dipropionate Cream & Ointment (DIPROSONE), Betamethasone Valerate Ointment (BETA-VAL, Augmented betamethasone dipropionate. (DIPROLENE AF), Desoximetasone (TOPICORT), Diflorasone Cream (APEXICON E, PSORCON E), Fluocinonide (LIDEX, LIDEX E)

INNOPRAN XL CAPSULES INDERAL LA CAPSULES INSPRA TABLETS Spironolactone Ketoconazole Cream Econazole (SPECTAZOLE) Cream

KLARON LOTION Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A MICRO), DIFFERIN, DUAC, TAZORAC, Sulfacetamide/sulfur (SULFACET-R)

KRISTALOSE CRYSTALS Lactulose Solution (CHRONULAC), (Polethylene Glycol 3350 (MIRALAX- Available OTC)

KYTRIL TABLETS Ondansetron (ZOFRAN) Tablets, Metoclopramide, Prochlorperazine, Promethazine, Trimethobenzamide,

LIVOSTIN OPHTHALMIC SOLUTION

ALOMIDE, Cromolyn (CROLOM)

LOPROX GEL / SUSPENSION Nystatin, Econazole (SPECTAZOLE), LAMISIL AT (OTC) LORABID CAPSULES / SUSPENSION

OMNICEF, Cefprozil (CEFZIL), Cefuroxime (CEFTIN), Cefuroxime (CEFTIN), Cefadroxil (DURICEF)

LUNESTA TABLETS (EST) Zolpidem (AMBIEN), Lorazepam (ATIVAN), Temazepam (RESTORIL), Flurazepam (DALMANE)

LYRICA TABLETS Gabapentin (NEURONTIN) MALARONE TABLETS FANSIDAR

MARINOL CAPSULES Ondansetron (ZOFRAN) Tablets,Metoclopramide (REGLAN), Prochlorperazine (COMPAZINE), Promethazine (PHENERGAN), Trimethobenzamide (TIGAN)

Meprobamate Tablets Lorazepam (ATIVAN), Diazepam (VALIUM)

METADATE CD TABLETS Methylphenidate SR (Ritalin SR), Dextroamphetamine SR (DEXEDRINE), Amphetamine Mixture (ADDERALL), METHYLPHENIDATE SR OSM (CONCERTA)

MICARDIS Losaratan (COZAAR), Benazepril (LOTENSIN), Lisinopril (ZESTRIL), Irbesartan (AVAPRO), BENICAR, DIOVAN

MICARDIS HCT Losaratan (COZAAR), Benazepril (LOTENSIN), Lisinopril (ZESTRIL), BENICAR, VALSARTAN / HCTZ(DIOVAN HCT), Irbesartan / HCTZ (AVALIDE)

MIGRANAL NASAL SPRAY IMITREX NASAL SPRAY MILTOWN TABLETS Lorazepam (ATIVAN), Diazepam (VALIUM) MONODOX Doxycycline Hyclate (VIBRAMYCIN) NAMENDA Donezpil (ARICEPT), Rivastigmine (EXELON) NEXIUM CAPSULES Omeprazole (PRILOSEC), Pantoprazole (Protonix), ACIPHEX

Nicardipine Capsules

Nifedipine SR (ADALAT CC), Felodipine (PLENDIL), NISLODIPINE (SULAR), Verapamil SA Tabs (CALAN SR), Amlodipine (NORVASC), Diltiazem (CARDIZEM, TIAZAC, DILACOR)

NOROXIN TABLETS Ciprofloxacin (CIPRO), AVELOX NOVOLIN (VIALS OR CARTRIDGES ONLY)

USE HUMULIN

NOVOLOG (VIALS OR USE HUMALOG



DRUG NAME SUGGESTED ALTERNATIVE DRUGS CARTRIDGES ONLY) Ofloxacin Tablets Ciprofloxacin (CIPRO)

ONE TOUCH TEST STRIPS USE ONETOUCH ULTRA BLUE, ONETOUCH VERIO IQ, FREESTYLE LITE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS

OPTIVAR OPHTHALMIC SOLUTION

ALOMIDE, PATANAOL, PATADAY, ZADITOR ( OTC AVAILABLE - NOT COVERED)

ORAMORPH TABLETS Morphine Sulfate, MS CONTIN, MSIR, DILAUDID, Morphine Sulfate Extended Release (KADIAN)

OVCON ORTHO-NOVUM, MODICON, ORTHO-CEPT, MICROGESTIN (LOESTRIN), ORTHO-CYCLEN, ORTHO TRI-CYCLEN

OVIDE LOTION EURAX, Permethrin (ELIMITE, ACTICIN)

OXISTAT CREAM Nystatin, Econazole (SPECTAZOLE), LAMISIL AT (AVAILABLE OTC - NOT COVERED)

OXYCONTIN

Tramadol (ULTRAM), Morphine Sulfate (MS CONTIN, MSIR), Hydromorphone (DILAUDID), MORPHINE SULFATE EXTENDED RELEASE (MORPHINE SULFATE SUSTAINED RELEASE CAPSULES (KADIAN)), Meperidine (DEMEROL), Methadone, Codeine, Oxycodone Immediate Release, Fentanyl Patches (DURAGESIC), PERCOCET 5/325, PERCODAN 5/325

OXYTROL PATCHES Oxybutynin Immediate Release Tablets (DITROPAN), Tolterodine Tablets (DETROL), DETROL LA

PENTASA CAPSULES Sulfasalazine, ASACOL PLETAL TABLETS Pentoxifylline (TRENTAL)

PLEXION CREAM Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A MICRO), ADAPALENE (DIFFERIN), DUAC, TAZORAC, Sulfacetamide/sulfur (SULFACET-R)

PONSTEL CAPSULES

Ibuprofen (MOTRIN), Naproxen (NAPROSYN), Etodolac (LODINE), Oxaprozin (DAYPRO), Nabumetone (RELAFEN), Sulindac (CLINORIL), Diclofenac (VOLTAREN), Piroxicam (FELDENE), Ketoprofen (ORUDIS)

PREFEST TABLETS PREMPRO, PREMPHASE, CLIMARA PRO, PREMARIN/Estradiol Patches (CLIMARA)/VIVELLE/ESTRADERM AND Medroxyprogesterone (PROVERA)

PREVACID TABLETS / SOLUTABS

ACIPHEX, Omeprazole (PRILOSEC), Pantoprazole (PROTONIX)

PROMETRIUM CAPSULES Medroxyprogesterone (PROVERA)

PROSOM TABLETS Zolpidem (AMBIEN), Lorazepam (ATIVAN), Temazepam (RESTORIL), Flurazepam (DALMANE), Oxazepam (SERAX)

PROVIGIL Methylphenidate (RITALIN, RITALIN SR), Dextroamphetamine (DEXEDRINE, DEXEDRINE SPANSULE), Amphetamine mixture (ADDERALL), METHYLPHENIDATE SR OSM (CONCERTA)

PROZAC WEEKLY CAPSULES Fluoxetine Capsules (PROZAC), Citalopram (CELEXA), Paroxetine (PAXIL), VENLAFAXINE SR (EFFEXOR XR), Bupropion (WELLBUTRIN, WELLBUTRIN SR)

QUIXIN OPHTHALMIC SOLN. Ciprofloxacin (CILOXAN), OCUFLOX RAZADYNE ER CAPSULES Donezpil (ARICEPT), RIVASTIGMINE (EXELON) RAZADYNE TABLETS Donezpil (ARICEPT), RIVASTIGMINE (EXELON)

RELPAX Sumatriptan (IMITREX TABLETS), Rizatriptan (MAXALT), Naratriptan (AMERGE TABLETS)

RHINOCORT AQUA NASONEX, Fluticasone (FLONASE), VERAMYST

SE

CT

ION

5




RITALIN LA CAPSULES Methylphenidate SR (Ritalin SR), Dextroamphetamine SR (DEXEDRINE), METHYLPHENIDATE SR OSM (CONCERTA), VYNASE

ROBINUL TABLETS Dicyclomine (BENTYL)

ROSAC CREAM Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A MICRO), DIFFERIN, DUAC, TAZORAC, Sulfacetamide/sulfur (SULFACET-R)

ROSULA GEL Erythromycin Topical, Clindamycin Topical, Tretinoin (RETIN-A), RETIN A MICRO), DIFFERIN, DUAC, TAZORAC, Sulfacetamide/sulfur(SULFACET-R)

ROZEREM TABLETS Lorazepam (ATIVAN), Temazepam (RESTORIL), Flurazepam (DALMANE), Zolpidem (AMBIEN)

SANCTURA TABLETS Oxybutynin Immediate Release Tablets, Tolterodine Tablets (DETROL), DETROL LA

SEASONALE TABLETS (3 month supply)

ORTHO-NOVUM, MODICON, ORTHO-CEPT, MICROGESTIN (LOESTRIN), ORTHO-CYCLEN, ORTHO TRI-CYCLEN

SKELAXIN TABLETS Methocarbamol (ROBAXIN), Carisoprodol 350 MG (SOMA), Cyclobenzaprine (FLEXERIL 10mg)

SOLODYN TABLETS Minocycline Immediate Release (MINOCIN)

SPECTRACEF TABLETS OMNICEF

STADOL NASAL SPRAY FIORICET, FIORINAL , ISOYLL, Acetaminophen and codeine (TYLENOL / CODEINE), Hydrocodone 5mg and Acetaminophen 500 mg (VICODIN, LORTAB), Tramadol (ULTRAM)

STRATTERA Methylphenidate SR (Ritalin SR), Dextroamphetamine SR (DEXEDRINE SPANSULE), Amphetamine Mixture (ADDERALL), Methylphenidate SR OSM (CONCERTA)

SURESTEP TEST STRIPS USE ONETOUCH ULTRA BLUE, ONETOUCH VERIO IQ, FREESTYLE LITE, FREESTYLE INSULINX, PRECISION XTRA TEST STRIPS

SURMONTIL CAPSULES Amitriptyline (ELAVIL), Doxepin (SINEQUAN), AMOXAPINE, Nortriptyline (PAMELOR), Imipramine (TOFRANIL), Paroxetine (PAXIL), Citalopram (CELEXA), Fluoxetine (PROZAC),

TACLONEX OINTMENT DOVONEX OR VECTICAL

TALWIN NX TABLETS Hydrocodone and Acetaminophen (VICODIN, LORTAB)

TAMIFLU Amantadine (SYMMETREL)

TARKA TABLETS

Benazepril (LOTENSIN), Lisinopril (ZESTRIL), Captopril (CAPOTEN) AND Verapamil SA Tabs Tabs (CALAN SR), Felodipine (PLENDIL), NISLODIPINE (SULAR) or Nifedipine SR (ADALAT CC)

TERAZOL VAGINAL CREAM / TABLETS

MONISTAT (AVAILABLE OTC - NOT COVERED), GYNE LOTRIMIN (AVAILABLE OTC - NOT COVERED), VAGISTAT (AVAILABLE OTC - NOT COVERED), Fluconazole (DIFLUCAN 150mg)

TEVETEN HCT CAPSULES Benazepril / HCTZ (LOTENSIN HCT), Lisinopril / HCTZ (ZESTORETIC), BENICAR HCT , VALSARTAN / HCTZ(DIOVAN HCT), Irbesartan / HCTZ (AVALIDE),




TEVETEN TABLETS Losaratan (COZAAR), Benazepril (LOTENSIN), Lisinopril (ZESTRIL), Irbesartan (AVAPRO), BENICAR, DIOVAN

THYROLAR TABLETS Levothyroxine (SYNTHROID, LEVOXYL), Liothyronine (CYTOMEL)

Tizanidine Tablets Methocarbamol (ROBAXIN), Carisoprodol 350 MG (SOMA), Cyclobenzaprine (FLEXERIL)

TOFRANIL PM CAPSULES Imipramine (TOFRANIL) Torsemide Tablets Furosemide (LASIX), Bumetanide (BUMEX)

TWYNSTA CAPSULES Losartan (COZAAR), Irbesartan (AVAPRO), BENICAR OR DIOVAN AND Amodipine (NORVASC)

ULTRACET TABLETS Tramadol (ULTRAM) AND Acetaminophen (TYLENOL)

UROXATRAL TABLETS Oxybutynin Immediate Release Tabs, Tolterodine Tablets (DETROL), DETROL LA

VAGIFEM VAGINAL TABLETS PREMARIN VAGINAL CR, ESTRACE VAGINAL CR

VERELAN PM CAPSULES Verapamil SA Tabs (CALAN SR), Felodipine (PLENDIL), Nifedipine SA (ADALAT CC)

VESICARE TABLETS Oxybutynin Immediate Release Tablets (DITROPAN), Tolterodine Tablets (DETROL), DETROL LA, TOVIAZ

VEXOL OPHTHALMIC SUSPENSION

Dexamethasone (Decadron), Prednisolone (Pred Mild, Inflamase Mild)

VIVACTIL TABLETS Desipramine (NORPRAMIN), Nortriptyline (PAMELOR)

WELCHOL TABLETS Cholestyramine Powder (QUESTRAN, QUESTRAN LIGHT) -BULK POWDER ONLY

XANAX XR TABLETS Lorazepam (ATIVAN), Alprazolam (XANAX)

ZANAFLEX TABLETS Methocarbamol (ROBAXIN), Carisoprodol 350 MG (SOMA), Cyclobenzaprine (FLEXERIL)

ZOMIG TABLETS / NASAL SPRAY

Sumatriptan (IMITREX TABLETS), Rizatriptan (MAXALT), Naratriptan (AMERGE TABLETS), IMITREX NASAL SPRAY

ZOMIG ZMT TABLETS Sumatriptan (IMITREX), Rizatriptan (MAXALT), Naratriptan (AMERGE)

ZONALON CREAM OTC BENADRYL CREAM ZYFLO CR TABLETS SINGULAIR, Zafirlukast (ACCOLATE) ZYMAR OPHTHALMIC SOLN. Ciprofloxacin (CILOXAN), OCUFLOX

ZYPREXA ZYDIS Risperdone (RISPERDAL), Olanzapine (ZYPREXA), Quetiapine Fumarate (SEROQUEL)

ZYRTEC TABLETS ZYRTEC (AVAILABLE OTC - NOT COVERED), CLARITIN

(AVAILABLE OTC - NOT COVERED)


INDEX OF DRUGS ON THE RECOMMENDED DRUG LIST (FEMCON FE, 39 (ORTHO NOVUM 7/7/7), 41 A/T/S SOLUTION (SWABS, PADS & PLEDGETS

EXCLUDED), 10, 44 Abacavir Tablets, 7 ABILIFY DISCMELT, 19 ABILIFY TABLETS / SOLUTION, 19 ABSTRAL SUBLINGUAL TABLETS, 4 ACCOLATE TABLETS, 43 ACCU-CHEK COMFORT CURVE TEST STRIPS (QL) (PA,

25 ACCU-CHEK ADVANTAGE TEST STRIPS (QL) (PA, 25 ACCU-CHEK AVIVA PLUS TEST STRIPS (QL) (PA), 25 ACCU-CHEK AVIVA TEST STRIPS (QL) (PA), 25 ACCU-CHEK COMPACT TEST STRIPS (QL) (PA), 25 ACCU-CHEK SMARTVIEW TEST STRIPS (PA) (QL), 25 ACCUPRIL TABLETS, 13 ACCURETIC TABLETS, 16 ACCUTANE Capsules (QL), 44 Acebutolol Capsules, 13 ACEON TABLETS, 13 Acetaminophen / Codeine Tablets, 4 Acetaminophen 2.5 / Hydrocodone 1.67 Elixir, 4 Acetaminophen 325 / Hydrocodone 5 Tablets, 4 Acetaminophen 500 / Hydrocodone 5 Tablets, 4 Acetaminophen 7.5 / Hydrocodone 650 Tablets, 4 ACETASOL HC (QL), 30 Acetazolamide SR Capsules, 27 Acetazolamide Tablets, 27 Acetic Acid 2% Otic Solution, 30 Acetic Acid Otic Aluminum Acetate Solution, 30 Acetylcysteine Solution, 43 ACHROMYCIN V CAPSULES, 10 ACIPHEX TABLETS (QL), 31 Acitretin Capsules, 47 Aclometasone Dipropionate Cream / Ointment, 46 ACLOVATE CREAM / OINTMENT, 46 ACTICIN CREAM (QL), 47 ACTIGALL CAPSULES, 32 ACTIMMUNE, 53 ACTIQ LOZENGES (PA), 4 ACTIVELLA TABLETS, 26 ACTONEL TABLETS (PA) (QL, 26 ACTONEL with CALCIUM TABLETS (PA) (QL), 26 ACTOPLUS MET TABLETS, 23 ACTOPLUS MET XR TABLETS, 23 ACTOS TABLETS, 23 ACULAR LS OPHTHALMIC SOLUTION, 28 ACULAR OPHTHALMIC SOLUTION, 28 ACUVAIL OPHTHALMIC SOLUTION, 28 Acyclovir Ointment (QL), 45 Acyclovir Oral Tablets / Capsules / Suspension, 7 ACZONE GEL, 44 ADALAT CC TABLETS, 15 ADALAT TABLETS, 15 Adapalene Cream, 44

ADCIRCA TABLETS (PA), 17 ADDERALL TABLETS, 21 ADDERALL XR CAPSULES, 21 ADOXA TABLETS (EST), 10 ADVAIR DISKUS (QL), 43 ADVAIR HFA (QL), 43 ADVATE, 54 ADVICOR TABLETS (QL), 14 AEROBID INHALER, 42 AEROBID-M INHALER, 42 AEROCHAMBER, 43 AFINITOR DISPERZ (PA) (N), 11 AFINITOR TABLETS (PA), 11 AGGRENOX CAPSULES, 18 AGRYLIN CAPSULES, 18 AK-TOB OPHTHALMIC SOLUTION, 28 ALAMAST OPHTHALMIC SOLUTION, 30 ALBENZA TABLETS, 6 Albuterol ER Tablets, 43 Albuterol Nebulized Solution, 43 Albuterol Tablets, 43 ALDACTAZIDE TABLETS, 23 ALDACTONE TABLETS, 23 ALDARA CREAM, 48 ALDOMET TABLETS, 17 ALDORIL TABLETS, 16 Alendronate Tablets (QL), 26 ALFERON N, 53 Alfuzosin Tablets, 33 ALINIA SUSPENSION / TABLETS, 10 ALKERAN TABLETS, 11 Allopurinol Tablets, 35 ALOCRIL OPHTHALMIC SOLUTION, 30 ALOMIDE OPHTHALMIC SOLUTION, 30 ALORA PATCHES, 25 ALPHAGAN OPHTHALMIC SOLN., 27 ALPHAGAN P 0.1% OPHTHALMIC SOLUTION, 27 ALPHAGAN P OPHTHALMIC SOLN., 27 ALPHANATE VWF, 54 ALPHANINE SD, 54 Alprazolam SR 24 hr Tablets, 19 Alprazolam Tablets, 19 ALREX OPHTHALMIC SUSPENSION, 28 ALTABAX OINTMENT, 45 ALTACE CAPSULES, 13 Altavera (NORDETTE), 39 ALTOPREV TABLETS, 14 Aluminum Chloride Hexahydrate, 48 ALVESCO AERSOL, 42 Alyacen, 40 Alyacen 7/7/7, 41 Amantadine Capsules, 7, 38 AMARYL TABLETS, 23 AMBIEN CR TABLETS (QL), 20 AMBIEN TABLETS (QL), 20 Amcinonide Cream, 46

INDEX OF DRUGS ON THE RECOMMENDED DRUG LIST


AMERGE TABLETS (QL), 38 Amethia (SEAONIQUE), 40 Amethia Lo (LOSEASONIQUE), 41 Amethyst (LYBREL), 41 Amiloride / Hydrochlorothiazide Tablets, 23 Aminophylline Tablets, 43 Amiodarone Tablets, 14 AMITIZA CAPSULES, 32 Amitriptyline Tablets, 18 Amlodipine / Atorvastatin Tablets (PA), 14 Amlodipine / Benazepril Tablets (QL), 16 Amlodipine Tablets, 15 AMNESTEEM CAPSULES (QL), 44 AMOXAPINE TABLETS, 18 AMOXICILLIN 400MG CHEWABLE TABLETS, 9 Amoxicillin Capsules, Suspension, Chewable Tablets, 9 AMOXIL Capsules, Suspension, 9 Amphetamine Dextroamphetamine 24 HR SR Capsules (, 21 Ampicillin Capsules / Suspension, 9 AMPYRA TABLETS (QL) (PA), 39 AMRIX CAPSULES (EST) (QL), 36 AMTURNIDE TABLETS (EST), 16 ANAFRANIL CAPSULES, 18 Anagrelide Capsules, 18 ANALPRAM CREAM 1%-1%, 48 ANALPRAM CREAM 2.5%-1%, 48 ANAPROX DS TABLETS, 35 ANAPROX TABLETS, 35 ANASPAZ TABLETS, 32 Anastrolzole Tablets, 11 ANDRODERM PATCHES, 23 ANDROGEL (QL), 23 ANDROID CAPSULES, 23 ANDROXY TABLETS, 11 ANGELIQ TABLETS, 26 ANTABUSE TABLETS, 21 ANTARA CAPSULES 43 MG, 130 MG, 14 ANUSOL-HC SUPP, 32 ANZEMET (PA) (QL), 31 APAP / Dichloralphenazone / Isometheptene Capsules, 38 APIDRA INSULIN, 24 APIDRA SOLOSTAR (QL) (PA), 24 APLENZIN 24 HR TABLETS, 18 APOKYN, 53 APRESOLINE TABLETS, 17 Apri (ORTHO-CEPT), 39 APRISO CAPSULES, 32 APTIVUS CAPSULES, 7 ARALEN TABLETS, 7 Aranelle, 41 ARANELLE, 41 ARANESP, 51 ARAVA TABLETS, 35 ARCALYST, 53 ARCAPTA NEOHALER, 43 ARICEPT 5 MG, 10 MG TABLETS, 37 ARICEPT ODT 5 MG, 10 MG TABLETS, 37 ARIMIDEX TABLETS, 11 ARISTOCORT CREAM / OINTMENT, 46 ARIXTRA, 51 ARMOUR THYROID 30 MG, 60 MG, 90 MG TABLETS, 26 ARMOUR THYROID TABLETS, 26

AROMASIN TABLETS, 11 ARTANE TABLETS, 38 ARTHROTEC TABLETS, 35 ASACOL HD TABLETS, 32 ASACOL TABLETS (QL), 32 ASCENCIA TEST STRIPS (PA) (QL), 25 ASMANEX TWISTHALER (QL), 42 Aspirin, Sustained Release Tablets, 36 ASTELIN NASAL SPRAY, 6, 30 ASTEPRO NASAL SPRAY, 30 ASTRAGRAF XL CAPSULES, 34 ATACAND (EST) (QL), 13 ATARAX TABLETS, 6 ATELVIA TABLETS (EST) (QL), 26 Atenolol / Chlorthalidone Tablets, 16 Atenolol Tablets, 15 ATIVAN TABLETS, 19 Atorvastatin Tablets, 14 Atovaquone-Proguanil Tablets, 7 ATRALIN GEL (QL), 44 ATRIPLA TABLETS, 7 Atropine Sulfate Ophthalmic Solution & Ointment, 30 ATROVENT HFA INHALER, 43 AUBAGIO TABLETS (PA), 21 Augmented Betamethasone, 47 AUGMENTIN XR TABLETS, 9 AURALGAN OTIC SOLUTION, 30 AUROTO OTIC SOLUTION OTIC SOLUTION, 30 AUV-Q (QL) (N), 53 AVALIDE TABLETS, 13 AVANDAMET TABLETS, 23 AVANDARYL TABLETS, 23 AVANDIA TABLETS, 23 AVAPRO TABLETS, 13 AVELOX CAPSULES, 9 AVENTYL CAPSULES, 18 Aviane (ALESSE), 39 AVINZA CAPSULES, 4 AVODART CAPSULES (EST), 33 AVONEX, 51 AXERT TABLETS (QL), 38 AXID CAPSULES / SOLUTION, 31 AXID TABLETS, 31 AXIRON SOLUTION (QL) (EST), 23 AYGESTIN TABLETS, 42 AZASITE OPHTALMIC SOLUTION, 28 Azathioprine Tablets, 34 Azelastine Nasal Spray, 6, 30 AZELEX CREAM, 44 AZILECT TABLETS, 38 Azithromycin Tablets, 8 AZOR TABLETS (EST), 16 AZULFIDINE TABS (ENTERIC COATED NOT COVERED),

32 Azurette (MIRCETTE), 40 Baclofen Tablets, 36 BACTRIM DS TABLETS, 9 BACTRIM TABLETS, 9 BACTROBAN CREAM / OINTMENT, 45 Balsalazide Capsules (QL), 32 Balzia (OVCON-35), 39 BANZEL TABLETS, 37



BARACLUDE TABLETS, 7 BEBULIN VH, 54 BECONASE AQ (QL), 30 BEEPEN-VK TABLETS / SUSPENSION, 9 Belladonna / Phenobarbital Tablets/ Elixir, 32 BELVIQ tablets (PA) (QL), 50 Benazepril / HCTZ Tablets, 16 Benazepril Capsules, 13 BENEFIX, 54 BENEMID TABLETS, 35 BENICAR HCT TABLETS, 13 BENICAR TABLETS, 13 BENTYL CAPSULES, 32 BENZACLIN GEL (Pump excluded), 44 BENZAMYCIN GEL, 44 Benzocaine 1.5%/ Antipyrine 5.4%Otic Solution, 30 Benzonatate Capsules, 12 Benztropine Mesylate Tablets, 38 BEPREVE OPHTHALMIC SOLUTION (QL), 30 BESIVANCE OPHTHALMIC SOLUTION, 28 BETAGAN OPHTHALMIC SOLN., 27 Betamethasone Dipropionate Cream / Ointment, 46 BETAPACE AF TABLETS, 15 BETAPACE TABLETS, 15 BETASERON, 51 Betaxolol Ophthalmic Solution, 27 Betaxolol Tablets, 15 Bethanechol Tablets, 32 Bethanecol Tablets, 34 BETIMOL OPHTHALMIC SOLN., 27 BETOPTIC OPHTHALMIC SOLN., 27 BEYAZ, 41 BIAXIN SUSPENSION, 8 BIAXIN TABLETS, 8 BIAXIN XL TABLETS (QL), 8 Bicalutamide Tablets, 11 BIDIL TABLETS, 17 BILTRICIDE TABLETS, 6 BINOSTO EFFERVESCENT TABLETS (PA), 26 Bisoprolol / Hydrochlorothiazide Tablets, 16 Bisoprolol Tablets, 15 BLEPH 10 OPHTHALMIC OINT./ SOLUTION, 28 BLEPHAMIDE OPHTHALMIC OINTMENT, 29 BLOCADREN TABLETS, 15 BONIVA TABLETS (N) (QL, 26 BOSULIF TABLETS (PA), 11 BREO ELLIPTA INHALER, 43 BRETHINE TABLETS, 43 BREVICON, 39 Briellen (OVCON-35), 39 BRILINTA TABLETS, 18 Brimonidine Ophthalmic Solution, 27 BRISDELLE TABLETS, 18 BROMDAY OPHTHALMIC SOLUTION, 28 Bromfenac Sodium Ophthalmic Solution, 28 Bromocriptine Capsules/ Tablets, 38 BROVANA INHALATION SOLUTION, 43 Budesonide SR Capsule 24 Hr 3mg, 32 Bumetanide Tablets, 22 BUMEX TABLETS, 22 Buproban Tablets (PA) (QL), 50 Bupropion Sustained Release Capsules, 18

Bupropion Sustained Release Tablets, 18 Bupropion Tablets, 18 BUSPAR TABLETS, 19 Buspirone Tablets, 19 Butalbital 50 / Acetaminophen 325 / Caffeine 40 Tablets, 4 Butalbital 50 / Aspirin 325 / Caffeine 40 Tablets / Capsules, 4 Butalbital 50 / Aspirin 650 Tablets, 4 Butorphanol Nasal Spray (QL) (QL), 4 BUTRANS PATCH (QL) (PA), 4 BYDUREON (PA), 53 BYETTA (PA), 53 BYSTOLIC TABLETS, 13 Cabergoline Tablets (QL), 26 CADUET TABLETS (PA), 14 CAFCIT ORAL SOLUTION, 43 CAFERGOT TABLETS, 38 Caffeine Oral Solution, 43 CALAN SR TABLETS, 15 CALAN TABLETS, 15 Calcipotriene Solution, 47 Calcitonin (Salmon) Nasal Solution, 26 Calcitriol Capsules, 49 Calcitriol Ointment, 47 Calcium Acetate Capsules, 22 CAMBIA PACKETS (QL), 35 Camila (ORTHO-MICRONOR), 41 CAMPRAL TABLETS (PA), 21 Camrese Lo (LOSEASONIQUE), 41 CANASA SUPPOSITORIES, 32 Candesartan cilexetil-hydrochlorothiazide (EST), 13 CAPOTEN TABLETS, 13 CAPOZIDE TABLETS, 16 CAPRELSA TABLETS, 11 Captopril / HCTZ Tablets, 16 Captopril Capsules, 13 CARAC CREAM, 48 CARAFATE TABLETS, 31 CARBAGLU TABLETS (PA), 22 Carbamazepine SR Capsules / SR Tablets12 Hr, 37 Carbamazepine Tablets, 37 CARBATROL CAPSULES, 37 Carbidopa / Levodopa CR Tablets, 38 Carbidopa / Levodopa Tablets, 38 Carbidopa-Levodopa Orally Disintegrating Tablets, 38 Carbidopa-levodopa-entacapone Tablets, 38 Carbinoxamine 4 / Pseudoephedrine 60 / DM 15 Syrup, 12 Carbinoxamine Solution, 6 CARDENE CAPSULES, 15 CARDENE SR CAPSULES, 15 CARDIZEM CD CAPSULES, 16 CARDIZEM LA TABLETS, 15 CARDIZEM SR CAPSULES, 16 CARDIZEM TABLETS, 16 CARDURA TABLETS, 17, 33 Carisoprodol / Aspirin 250/325 mg Tablets, 36 Carisoprodol 250 MG Tablets, 36 Carisoprodol 350 MG Tablets, 36 Carvedilol Tablets (QL), 13 CASODEX TABLETS, 11 CATAFLAM TABLETS, 35 CATAPRES -TABLETS ONLY, 17 CATAPRES-TTS PATCHES, 17



CAVERJECT INJECTION, 53 CAYSTON INHALATION SOLUTION (QL), 10 Caziant (CYCLESSA), 41 CEDAX CAPSULES / SUSPENSION, 8 CEENU CAPSULES, 11 Cefadroxil Capsules, 8 Cefdinir Capsules / Suspension, 8 Cefprozil Capsules / Suspension, 8 CEFTIN CAPSULES, 8 Cefuroxime Capsules, 8 CEFZIL CAPSULES / SUSPENSION, 8 CELEBREX (PA) (QL), 35 CELEXA ORAL SOLUTION, 18 CELEXA TABLETS ), 18 CELLCEPT TABLETS /CAPSULES, 34 CELONTIN CAPSULES, 37 CENESTIN TABLETS, 25 Cephalexin Capsules / Suspension, 8 CEPHULAC SOLUTION, 22 CEPROTIN, 54 CESAMET CAPSULES (PA) (QL), 31 Cesia, 41 CETRAXAL OTIC SOLUTION, 30 Cevimeline Capsules, 31 CHANTIX TABLETS (PA) (QL), 50 Chateal, 39 CHENODAL TABLETS, 32 CHERATUSSIN AC SYRUP, 12 CHERATUSSIN DAC SYRUP, 12 Chloral Hydrate Capsules, 20 Chlordiazepoxide Capsules, 19 Chlorhexidine Gluconate (Covered Only If Dental Rider), 31 Chloroquine Tabelts, 7 Chlorpheniramine 8 / Phenylephrine 20/ Methscopolamine

2.5 Capsules, 6 Chlorpromazine Tablets, 19 Chlorthalidone Tablets, 23 Chlorzoxazone Tablets, 36 Cholestyramine - Bulk Powder Only, 14 Cholestyramine Lite- Bulk Powder Only, 14 Choline Magnesium Salicylate Tablets, 36 CIALIS TABLETS (PA) (QL), 33 CIALIS TABLETS 2.5 MG, 5 MG (PA) (FOR BPH ONLY), 17 Ciclopirox 8% Solution, 45 Ciclopirox Cream / GEL, 45 CILOXAN OPHTHALMIC SOLUTION, 28 Cimetidine 300 MG, 400 MG, 800 MG Tablets, 31 CIMZIA, 51 CIPRO HC OTIC SOLUTION, 30 CIPRO TABLETS, 9 CIPRO XR TABLETS (QL), 9 CIPRODEX OTIC SOLUTION, 30 Ciprofloxacin Extended Release Tablets, 9 Ciprofloxacin Ophthalmic Solution, 28 Ciprofloxacin Tablets, 9 Citalopram Oral Soultion, 18 Citalopram Tablets ), 18 CITRA K CRYSTALS / SOLUTION, 22 Citric Acid / Potassium Citrate / Sodium Citrate Syrup /

Crystals, 22 CLARIFOAM EF, 44 CLARINEX REDI-TABSS (PA) (QL), 6

CLARINEX TABLETS (PA), 6 Clarithromycin Extended Release Tablets, 8 Clarithromycin Suspension, 8 Clarithromycin Tablets, 8 Clemastine Tablets, 6 CLENIA CREAM, 44 CLEOCIN CAPSULES, 10 CLEOCIN T SOLN (SWABS, PADS & PLEDGETS

EXCLUDED), 10 CLEOCIN T SOLUTION, 44 CLEOCIN VAGINAL CREAM, 42 Clidinium / Chlordiazepoxide Capsules, 32 CLIMARA PATCHES, 25 CLIMARA PRO PATCH, 26 Clindamycin 1% / Benzoyl Peroxide 5% Gel, 44 Clindamycin Capsules, 10 Clindamycin Phosphate 1% Foam, 44 Clindamycin Solution 1% (Swabs, Pads & Pledgets

Excluded), 10, 44 Clindamycin Vaginal Cream, 42 Clindaymycin / Benzoyl Peroxide Gel (Pump Excluded), 44 CLINORIL TABLETS, 35 Clobetasol Propionate Cream / Ointment/ Gel / Solution/

Emollient, 47 Clobetasol propionate Lotion / Shampoo, 47 CLOBEX LOTION, 47 CLOBEX SHAMPOO, 47 CLOMID TABLETS (PA) (QL), 42 Clomiphene Tablets (PA) (QL), 42 Clomipramine Tablets, 18 Clonazepam Tablets, 37 Clonidine (Tablets only), 17 Clonidine Patches, 17 Clorazepate Capsules, 19 Clotrimazole / Betamethasone Cream / Lotion (QL), 45 Clotrimazole Troches, 5 Clozapine Tablets, 19 CLOZARIL TABLETS, 19 COARTEM TABLETS (QL), 7 Codeine / Aspirin Tablets, 4 Codeine 10 / Chlorpheniramine 2 / Pseudoephedrine 30 Liq,

12 Codeine 10 / Pseudoephedrine 30 / Guaifenesin 100

Solution, 12 Codeine 10/ Guaifenesin 100 Syrup, 12 Codeine Tablets, 4 CODEINE TABLETS, 4 COGENTIN TABLETS, 38 COLAZAL TABLETS, 32 COL-BENEMID TABLETS, 35 Colchicine Tablets, 35 COLCRYS TABLETS, 35 COLESTID GRANULES, 14 COLESTID TABLETS, 14 Colestipol Granules, 14 Colestipol Tablets, 14 COLYTE SOLUTION, 32 COMBIGAN OPHTHALMIC SOLN, 27 COMBIPATCH TABLETS, 26 COMBIVENT INHALER, 43 COMBIVENT RESPIMAT, 43 COMBIVIR TABLETS, 7



COMBUNOX TABLETS, 4 COMETRIQ CAPSULES (PA), 11 COMPAZINE TABLETS / SUPPOSITORIES, 31 COMPLERA TABLETS, 7 COMTAN TABLETS, 38 CONCERTA SA TABLETS, 21 CONDYLOX – GEL, 48 CONZIP CAPSULES, 4 COPAXONE, 51 COPEGUS TABLETS (PA), 7 CORDARONE TABLETS, 14 CORDRAN CREAM / OINTMENT / TAPE, 46 COREG CR CAPSULES, 13 COREG TABLETS (QL), 13 CORGARD TABLETS, 15 CORTEF TABLETS, 34 CORTENEMA, 32 CORTIFOAM, 32, 48 Cortisone Tablets, 34 CORTISPORIN OPHTHALMIC SOLUTION & OINTMENT,

29 CORTISPORIN OTIC SOLUTION / SUSPENSION, 30 CORTONE TABLETS, 34 COSOPT OPHTHALMIC SOLN., 27 COTAZYM (S), 33 COUMADIN TABLETS, 18 COVERA -HS TABLETS, 15 COZAAR TABLETS, 13 CREON CAPSULES, 33 CRESTOR TABLETS (EST), 14 CRINONE 8% VAGINAL CREAM (PA), 42 CRIXIVAN CAPSULES, 7 Cromolyn Sodium Inhaler, 43 CRYSELLE, 39 Cryselle (LO/OVRAL), 39 CUPRIMINE CAPSULES, 35 CUTIVATE CREAM / OINTMENT, 46 CUVPOSA SOLUTION, 32 Cyclafem 1/35 (ORTHO NOVUM 1/35), 40 CYCLESSA, 41 Cyclobenazprine SR Capsules, 36 Cyclobenzaprine Tablets, 36 Cyclopentolate Ophthalmic Solution, 30 CYCLORT CREAM, 46 Cycloserine Capsules, 7 Cyclosporine Capsules, 34 Cyclosporine Modified Capsules, 34 CYMBALTA CAPSULES (QL), 18 Cyproheptadine 4 mg Tablets & SYRUP, 6 CYSTARAN OPHTHALMIC SOLUTION, 30 CYTOMEL TABLETS, 26 CYTOTEC TABLETS, 31 CYTOVENE CAPSULES, 7 CYTRA-2 SOLUTION, 22 CYTRA-3 SYRUP, 22 D.H.E. 45, 52 DALIRESP TABLETS (QL), 43 DALMANE CAPSULES (QL), 20 Danazol Capsules, 23 DANOCRINE CAPSULES, 23 DANTRIUM CAPSULES, 36 DAPSONE TABLETS, 10

DARAPRIM TABLETS, 7 Dasetta 1-35, 40 Dasetta 7/7/7, 41 DAYPRO TABLETS, 35 DAYTRANA PATCH, 21 DDAVP TABLETS/ SPRAY, 26 DECADRON OPHTHALMIC SOLUTION & OINTMENT, 28 DECADRON TABLETS, 34 DELTASONE TABLETS, 34 DEMADEX TABLETS, 22 Demeclocycline Tablets, 10 DEMEROL TABLETS, 4 DEMULEN, 39 DENAVIR CREAM (QL), 7 DEPAKENE CAPSULES, 37 DEPAKOTE ER TABLETS, 37 DEPAKOTE TABLETS, 37 DEPEN TABLETS, 35 DERMATOP CREAM, 46 Desipramine Tablets, 18 Desloratadine Orally Disintegrating Tablets (PA) (QL), 6 Desloratadine Tablets (PA) (QL), 6 Desmopressin Tablets / Spray, 26 DESOGEN, 39 Desonide Cream / Ointment / Lotion, 46 DESOWEN CREAM / OINTMENT/ LOTION, 46 Desoximetasone 0.05% CREAM, 46 DESOXYN TABLETS, 21 Desvenlafaxine 24 HR (EST) (QL), 18 DESYREL TABLETS, 18 DETROL LA CAPSULES, 33 DETROL TABLETS, 33 Dexamethasone / Neomycin / Polymyxin Ophth. Soln & Oint,

29 Dexamethasone Ophthalmic Solution & Ointment, 28 Dexamethasone Tablets, 34 DEXEDRINE SPANSULES, 21 DEXEDRINE TABLETS, 21 DEXILANT CAPSULES (EST) (QL), 31 Dexmethylphenidate Tablets, 21 DEXONE TABLETS, 34 Dextroamphetamine Sustained Release Capsules, 21 Dextroamphetamine Tablets, 21 DIABETA TABLETS, 23 DIAMOX SEQUELS / TABLETS, 27 Diazepam Tablets, 19, 36 DIBENZYLINE CAPSULES, 18 DICLEGIS TABLETS (PA), 31 Diclofenac / Misoprostil Tablets, 35 Diclofenac Sodium Extended Release Tablets, 35 Diclofenac Sodium Ophthalmic Solution, 28 Diclofenac Sodium Tablets, 35 Dicloxacillin Capsules / Suspension, 9 Dicyclomine Capsules, 32 Didansoine Delayed Chewable Tablets, 7 Didansoine Delayed Release Capsules, 7 DIDRONEL TABLETS, 26 DIFFERIN 0.1% CREAM OR GEL, 44 DIFFERIN 0.3% GEL, 44 DIFFERIN LOTION, 44 DIFICID TABLETS, 10 Diflorasone Diacetate Cream / Ointment, 47



Diflorasone Diacetate, Emollient Cream, 47 DIFLUCAN 150 MG TAB ONLY, 42 DIFLUCAN Tablets, 5 Diflunisal Tablets, 36 Digoxin Tablets, 16 DIHYDROERGOTAMINE, 52 DILACOR XR CAPSULES, 16 DILANTIN CAPSULES / TABLETS, 37 DILANTIN CHEWABLE TABLETS, 37 DILAUDID TABLETS, 4 Diltiazem Extended Release Capsules, 16 Diltiazem Immediate Release Tablets, 16 Diltiazem SR Capsules, 16 DIOVAN HCT TABLETS, 13 DIOVAN TABLETS, 13 DIPENTUM CAPSULES, 32 Diphenoxylate / Atropine Tablets, 31 Dipivefrin Ophthalmic Solution, 27 DIPROLENE AF CREAM, 47 Dipropionate Cream, 47 DIPROSONE CREAM / OINTMENT, 47 Dipyridamole Tablets, 18 Disopyramide Capsules, 14 DISPOSABLE INSULIN NEEDLES & SYRINGES, 25 Disulfiram Tablets, 21 DITROPAN TABLETS, 33 DITROPAN XL TABLETS, 33 Divalproex SR Tablets, 37 DOLOBID TABLETS, 36 DOLOPHINE TABLETS (QL), 4 DOMEBORO OTIC SOLUTION, 30 Donepezil Orally Disintegrating Tablets, 37 Donepezil Tablets, 37 DONNATAL EXTENTABS, 32 DONNATAL TABLETS / ELIXIR, 32 DORAL TABLETS, 20 DORYX (PA), 10 Dorzolamide / Timolol Ophthalmic Solution, 27 DOSTINEX TABLETS, 26 DOVONEX Cream / SOLUTION, 47 Doxazosin Mesylate Tablets, 17, 33 Doxepin Capsules, 18 Doxepin Cream, 48 Doxycycine Hyclate 20mg, 40mg Capsules / Tablets, 10 Doxycycline Hyclate Capsules / Tablets, 10 DRISDOL CAPSULES, 49 DRITHO-CRÈME HP, 44 Dronabinol Capsules (PA), 31 Fluoride / Polyvitamins (Without Iron, 49 Iron, 49 DROXIA CAPSULES, 11 DRYSOL, 48 DUAC GEL, 44 DUEXIS TABLETS, 35 DULERA AEROSOL (QL), 43 DUONEB INHALTION SOLN., 43 DURADRIN CAPSULES, 38 DURAGESIC PATCHES (QL), 4 DUREZOL OPHTHALMIC EMULSION, 28 DURICEF, 8 DUTOPROL SR TABLETS, 15 DYAZIDE CAPSULES, 23

DYMISTA NASAL SPRAY, 30 DYNACIN-NOT COVERED USE MINOCYCLINE

CAPSULES, 10 DYNACIRC CR TABLETS, 15 DYRENNIUM CAPSULES, 23 Econazole Cream, 45 EDARBI TABLETS (EST), 13 EDARBYCHLOR TABLETS (EST), 14 EDECRIN TABLETS, 22 EDEX INJECTION, 53 EDLUAR SUBLINGUAL TABLETS (QL) (EST), 20 EDURANT TABLETS, 7 EES SUSPENSION, 8 EFFEXOR TABLETS, 18 EFFEXOR XR CAPSULES, 18 EFFIENT TABLETS, 18 EFUDEX CREAM / SOLUTION, 11 EFUDEX CREAM / SOLUTION, 48 ELAVIL TABLETS, 18 ELDEPRYL CAPSULES, 38 ELESTAT OPHTHALMIC SOLUTION, 30 ELIDEL CREAM, 48 ELIMITE CREAM (QL), 47 Elinest-28, 39 ELIQUIS TABLETS, 18 ELLA TABLETS (QL), 42 ELMIRON CAPSULES, 34 ELOCON CREAM / OINTMENT, 46 EMCYT CAPSULES, 11 EMEND CAPSULES (QL), 31 EMLA CREAM, 48 Emoquette (ORTHO-CEPT), 39 EMPIRIN TABLETS #2, #3, #4, 4 EMSAM PATCHES (PA), 19 EMTRIVA CAPSULES 200MG, 7 E-MYCIN TABLETS, 8 ENABLEX TABLETS, 33 Enalapril / Hydrochlorothiazide Tablets, 16 Enalapril Tablets, 13 ENBREL, 51 ENDOMETRIN SUPPOSITORIES, 42 ENJUVIA TABLETS, 25 Enpresse (TRI-LEVLEN), 41 Entacapone Tablets, 38 ENTOCORT EC CAPSULES, 32 EPIDUO GEL (QL), 44 Epinastine HCl Ophthalmic Solution 0.05%, 30 Epinephrine HCl Ophthalmic Solution, 27 EPIPEN (QL), 53 EPIPEN, JR. (QL), 53 EPIVIR HBV TABLETS, 7 EPIVIR TABLETS, 7 Eplerenone Tablets, 23 EPOGEN, 51 Eprosartan 600 mg Tablets (EST), 14 EPZICOM TABLETS, 7 Ergocalciferol Capsules, 49 ERGOMAR SUBLINGUAL TABLETS, 38 Ergonovine Maleate Tablets, 42 Ergotamine / Caffeine Tablets / Suppositories, 38 Ergotamine Tartrate Tablets, 38 Ergotamine/ Belladonna/ Phenobarbital, 32



ERGOTRATE TABLETS, 42 ERIVEDGE CAPSULES, 11 Errin (ORTHO-MICRONOR), 41 ERTACZO CREAM, 45 ERYCETTE SOLN (SWABS, PADS & PLEDGETS

EXCLUDED), 11, 44 ERYDERM SOLN (SWABS, PADS & PLEDGETS

EXCLUDED), 11, 44 ERYPED TABLETS, 8 ERY-TAB, 8 ERYTHROCIN TABLETS, 8 Erythromycin / Benzoyl Peroxide Cream, 44 Erythromycin / Sulfisoxazole, 8, 9 Erythromycin / Sulfisoxazole Suspension, 9 Erythromycin 1.5 % Soln (Swabs, Pads & Pledgets

Excluded), 44 Erythromycin 2 % Gel, 44 Erythromycin 2.0 % Soln (Swabs, Pads & Pledgets

Excluded), 11, 44 Erythromycin Base Ophthalmic Ointment, 28 Erythromycin Base Tablets, 8 Erythromycin Ethylsuccinate, 8 Erythromycin Stearate TABLETS, 8 Escitalopram Tablets, 18 ESGIC CAPSULES, 4 ESKALITH CAPSULES, 19 Estazolam Tablets, 20 Esterified Estrogens/Methyltestosterone, 26 Esterified Estrogens/Methyltestosterone HS tablets, 26 ESTRACE TABLETS, 25 ESTRACE VAGINAL CREAM, 25 ESTRADERM PATCHES, 25 Estradiol Patches - Biweekly, 25 Estradiol Patches - Weekly, 25 Estradiol Tablets, 25 ESTRASORB TOPICAL EMULSION, 25 ESTRATEST HS TABLETS, 26 ESTRING ( 3 Month's Supply), 25 ESTROGEL (2 month's Supply), 25 Estropipate Tablets, 25 ESTROSTEP Fe, 41 Ethambutol Tablets, 7 Ethosuximide Capsules, 37 ETIDRONATE TABLETS, 26 Etodolac Tablets / Capsules, 35 Etodolac XR Tablets, 35 EULEXIN CAPSULES, 11 EURAX CREAM / LOTION, 47 EVISTA TABLETS (QL), 26 EVOCLIN FOAM, 44 EVOXAC CAPSULES, 31 EXALGO SR TABLETS, 4 EXELDERM CREAM / SOLUTION, 45 EXELON CAPSULES, 37 EXELON PATCHES, 37 EXFORGE HCT TABLETS (EST), 16 EXFORGE TABLETS (EST), 16 EXJADE TABLETS, 18 EXTAVIA, 51 EXTENDRYL SR CAPSULES, 6 EXTENDRYL SYRUP, 6 FACTIVE TABLETS, 9

Falmina, 39 Famciclovir Tablets, 7 Famotidine Tablets, 31 FAMVIR TABLETS, 7 FANAPT TABLETS (PA), 19 FANSIDAR TABLETS, 7 FARESTON TABLETS, 11 FASTTAKE TEST STRIPS (PA) (QL), 25 FEIBA VH IMMUNO (ANTI-INHIBITOR COAGULANT

COMPLEX), 54 Felbamate Tablets, 37 FELBATOL TABLETS, 37 FELDENE CAPSULES, 35 FEMARA TABLETS, 11 FEMCON FE, 39 Femcon Fe (OVCON Fe), 39 FEMCON-Fe, 39 FEMRING (3 months Supply), 25 Fenofibrate Micronized 43 mg, 130 mg, 14 Fenofibrate Micronized Capsules 67mg, 134 mg, 200 mg, 14 Fenofibrate Tablets 48 mg, 54 mg, 145 mg, 160 mg, 15 Fenoprofen Capsules, 35 Fentanyl Lozenges (PA), 4 Fentanyl patches (QL), 4 FENTORA BUCCAL TABLETS (PA), 4 FERRIPROX TABLETS (QL), 49 FIBRICOR TABLETS, 14 FINACEA GEL, 44 Finasteride (Age Limit), 33 FIORICET TABLETS, 4 FIORINAL CODEINE CAPSULES, 4 FIORINAL TABLETS / CAPSULES, 4 FLAGYL TABLETS 250 mg or 500 mg, 10 FLAREX OPHTHALMIC SOLUTION, 28 Flavoxate Tablets, 34 Flecainide Tablets, 14 FLECTOR PADS (QL), 35, 48 FLEXERIL TABLETS, 36 FLOMAX CAPSULES, 33 FLONASE (QL), 30 FLORINEF TABLETS, 34 FLORONE CREAM, 47 FLOVENT DISKUS (QL), 42 FLOVENT HFA (QL), 42 FLOXIN OTIC SOLUTION, 30 Fluconazole Tablets, 42 Fluconazole Tablets ), 5 Fludrocortisone Tablets, 34 FLUMADINE TABLETS, 7 Fluocinolone Acetonide 0.01% Cream / Ointment / Solution,

46 Fluocinolone Acetonide 0.025% Cream / Ointment, 46 Fluocinolone Acetonide 0.2% HP Cream, 47 Fluocinonide Cream/ Ointment, 47 Fluoride / Vitamins A,D,C (Without, 49 Fluorometholone Ophthalmic Suspension, 28 Fluorometholone Ophthalmic Suspension & Ointment, 28 FLUOR-OP OPHTHALMIC SOLUTION, 29 FLUOROPLEX CREAM / SOLUTION, 48 Fluorouracil Cream / Solution, 48 Fluoxetine Capsules, 18 Fluoxetine Delayed Release Capsules 90 mg, 18



Fluoxetine Tablets, 18 Fluoxymesterone Tablets, 11, 23 Fluphenazine Tablets, 19 Flurazepam Capsules (QL), 20 Flurbiprofen 50 mg Tablets, 35 Flurbiprofen Ophthalmic Solution, 29 Flurouracil Cream / Solution, 11 Flutamide Capsules, 11 Fluticasone Cream / Ointment, 46 Fluticasone Nasal Spray (QL), 30 Fluvastatin Capsules (QL) (PA), 14 Fluvoxamine SR Capsules, 18 Fluvoxamine Tablets, 18 FML FORTE OPHTHALMIC SOLUTION, 28 FML OPHTHALMIC SOLUTION & OINTMENT, 29 FOCALIN TABLETS, 21 FOCALIN XR CAPSULES, 21 Folic Acid 1mg Tablets, 49 FORADIL AEROLIZER (QL), 43 FORFIVO XL TABLETS (EST), 18 FORTAMET TABLETS, 23 FORTEO, 52 FORTESTA GEL (QL) (EST), 23 FORTICAL NASAL SPRAY, 26 FOSAMAX TABLETS (QL), 26 FOSAMAX-D TABLETS (PA) (QL), 26 Fosinopril Capsules, 13 FOSRENOL TABLETS, 22 FRAGMIN, 51 FREESTYLE LITE TEST STRIPS (QL), 25 FREESTYLE TEST STRIPS (QL), 25 FROVA TABLETS (QL), 38 FULYZAQ DELAYED RELEASE TABLETS (PA), 31 Furosemide Tablets, 22 FUZEON, 53 Gabapentin Capsules / Tablets / Solution, 37 GABARONE TABLETS, 37 GABITRIL TABLETS, 37 Galantamine Capsules, 37 Galantamine Tablets, 37 Gangciclovir Capsules, 7 GARAMYCIN CREAM / OINTMENT, 11 GARAMYCIN OPHTHALMIC OINT./ SOLUTION, 28 GASTROCROM CONCENTRATE, 44 GELNIQUE GEL, 33 Gemfibrozil Tablets, 15 GENERESS FE CHEWABLE TABLET, 41 GENGRAF CAPSULES /SOLUTION, 34 GENOPTIC OPHTHALMIC OINT./ SOLUTION, 28 GENOTROPIN, 52 GENTACIDIN OPHTHALMIC SOLUTION, 28 Gentamicin Ophthalmic Solution & Ointment, 28 Gentamicin Sulfate Cream / Ointment, 11 GEODON CAPSULES, 20 Gianvi (YAZ), 39 GIAZO TABLETS (EST), 32 Gildagia, 39 Gildess, 39 GILENYA TABLETS (PA), 21 GLEEVEC TABLETS, 11 Glimepiride Tablets, 23 Glipizide Long Acting, 23

Glipizide Tablets, 23 GLUCAGEN (QL), 53 GLUCAGON (QL), 53 GLUCOPHAGE TABLETS, 23 GLUCOPHAGE XR TABLETS, 24 GLUCOTROL TABLETS, 24 GLUCOTROL XL TABLETS, 24 GLUCOVANCE TABLETS, 24 Glyburide Micronized Tablets, 24 Glycopyrrolate Tablets, 32 GLYNASE TABLETS, 24 GLYSET TABLETS, 23 GRALISE TABELTS (PA), 37 Granisetron Tablets (PA) (QL), 31 Griseofulvin Ultramicrosize Tablets, 5 GRIS-PEG TABLETS, 5 Guaifenesin 100 / Codeine 10 / Pseudoephedrine 30, 12 Guaifenesin 100 / Codeine 10 Expectorant, 12 Guaifenesin 400 / Pseudoephedrine 120 Tablets, 13 Guaifenesin 600 / Pseudoephedrine 120 Tab, 12 Guaifenesin 600 / Pseudoephedrine 120 Tablets, 12 Guanabenz Tablets, 17 Guanfacine Tablets, 17 GUANIDINE TABLETS, 21 HALCION TABLETS (QL), 20 HALOG CREAM / OINTMENT, 46 Haloperidol Tablets, 20 HCTZ TABLETS / CAPSULES, 23 Heather, 41 HECORIA CAPSULES, 34 HECTOROL CAPSULES, 49 HELIXATE FS, 54 HEMOFIL M, 54 HEPSERA, 7 HEXALEN CAPSULES, 11 HIPREX TABLETS, 10 HIVID TABLETS, 7 Homatropine Ophthalmic Solution, 30 HORIZANT SR TABLETS (QL), 39 HUMALOG INSULIN (QL), 24 HUMALOG INSULIN KWIKPENS (QL), 24 HUMALOG INSULIN PENS (QL), 24 HUMALOG MIX 50/50 INSULIN (QL), 24 HUMALOG MIX 50/50 INSULIN KWIKPENS (QL), 24 HUMALOG MIX 50/50 INSULIN PENS (QL), 24 HUMALOG MIX 75/25 INSULIN (QL), 24 HUMALOG MIX 75/25 INSULIN PENS(QL), 24 HUMALOG MIX 75/25 KWIKPENS (QL), 24 HUMATE-P, 54 HUMATIN CAPSULES, 6 HUMATROPE, 52 HUMIRA, 51 HUMULIN INSULIN 50/50 (QL), 24 HUMULIN N INSULIN (QL), 24 HUMULIN R INSULIN (QL), 24 HYCAMTIN CAPSULES, 11 HYCOTUSS Expectorant, 12 Hydralazine Tablets, 17 HYDREA TABLETS, 11 Hydrochlorothiazide (HCTZ) 12.5 mg Capsules, 23 Hydrochlorothiazide (HCTZ) 12.5 mg Tablets, 23 Hydrochlorothiazide (HCTZ) 25 mg, 50 mg Tablets, 23



Hydrocodone / Ibuprofen Tablets, 4 Hydrocodone 2.5 / Guaifenesin 100 /Pseudoephedrine 30

Soln, 12 Hydrocodone 2.5 / Phenylephrine 5 / Chlorpheniramine 2

Syrup, 12 Hydrocodone 5 / Guaifenesin 100 Expectorant, 12 Hydrocodone 5 / Homatropine 1.5 Syrup, 12 Hydrocortisone (Rectal Cream), 48 Hydrocortisone / Chloroxylenol / Pramoxine hydrochloride

Otic Sol., 30 Hydrocortisone / Neomycin / Polymyxin Ophth. Susp & Oint,

29 Hydrocortisone / Neomycin / Polymyxin Otic Solution/ Susp.,

30 Hydrocortisone 2.5% Cream / Ointment / Lotion, 46 Hydrocortisone Butyrate Cream / Ointment, 46 Hydrocortisone Butyrate Ointment, 46 Hydrocortisone Cream / Pramoxine Cream, 48 Hydrocortisone Retention Enema, 32 Hydrocortisone Suppositories, 32 Hydrocortisone Tablets, 34 Hydrocortisone Valerate Cream / Ointment, 46 HYDROCORTONE TABLETS, 34 HYDRODIURIL TABLETS, 23 Hydromorphone Tablets, 4 Hydroxychloroquine Tablets, 7, 35 Hydroxyurea Tablets, 11 Hydroxyzine HCl Tablets, 6 Hydroxyzine Pamoate Capsules, 6 HYGROTON TABLETS, 23 Hyoscyamine Sulfate CR Tablets, 32 Hyoscyamine Sulfate Tablets, 32 HYTONE CREAM / OINTMENT, 46 HYTRIN CAPSULES / TABLETS, 33 HYZAAR TABLETS, 14 Ibandronate Tablets, 26 Ibuprofen Tablets, 35 ICLUSIG TABLETS (PA), 11 IMDUR TABLETS, 17 Imipramine HCL Tablets, 18 Imipramine Pamoate Capsules, 18 Imiquimod Cream, 48 IMITREX INJ, 52 IMITREX NASAL SPRAY, 38 IMITREX TABLETS (QL), 38 IMURAN TABLETS, 34 INCIVEK TABLETS (PA (N), 7 INCRELEX, 52 Indapamide Tablets, 23 INDERAL LA CAPSULES, 15 INDERAL TABLETS, 15 INDERIDE TABLETS, 16 INDOCIN CAPSULES, 35 INDOCIN SR CAPSULES, 35 Indomethacin Capsules, 35 Indomethacin, Sustained Release Capsules, 35 INFERGEN, 53 INFLAMASE FORTE OPHTHALMIC SOLUTION &

OINTMENT, 29 INLYTA TABLETS (PA), 11 INNOPRAN XL CAPSULES, 15 INSPIREASE, 43

INSPRA TABLETS, 23 INTELENCE TABLETS, 7 INTERMEZZO SL TABLETS (PA), 20 INTRON-A, 53 Introvale (SEASONALE), 39 INTUNIV TABLETS (QL), 21 INVEGA TABLETS, 19 INVIRASE CAPSULES, 7 INVOKANA TABLETS, 23 Iodinated Glycerol / Dextromethorphan Syrup, 12 IOPHEN-DM SYRUP, 12 Ipratropium Inhaler, 43 Ipratropium-Albuterol Nebulizer Solution, 43 Irbesartan Tablets, 14 Irbesartan-Hydrochlorothiazde Tablets, 14 IRESSA TABLETS, 11 ISENTRESS TABLETS, 7 Isoniazid Tablets, 7 ISOPTIN SR TABLETS, 16 ISOPTIN TABLETS, 16 ISOPTO CETAPRED OPHTHALMIC SOLUTION/

OINTMENT, 29 ISOPTOCARPINE OPHTHALMIC SOLUTION, 27 ISORDIL TABLETS, 17 Isosorbide Dinitrate Tablets, 17 Isosorbide Mononitrate Tablets, 17 Isotretinoin Caps (QL), 44 ISTALOL OPHTHALMIC SOLUTION, 27 Itraconazole Capsules (PA), 5 JAKAFI TABLETS, 11 JALYN CAPSULES, 33 JANUMET TABLETS, 23 JANUMET XR TABLETS, 23 JANUVIA TABLETS, 23 JENTADUETO TABLETS, 23 Jolessa (SEASONALE), 39 Jolivette (ORTHO-MICRONOR), 41 Junel (LOESTRIN 21), 39 Junel Fe (LOESTRIN Fe), 39 JUVISYNC TABLETS (QL), 23 KADIAN 20MG, 30MG, 50MG, 80MG, 100MG CAPSULES

(QL, 4 KADIAN CR CAPSULES 10MG, 40MG, 70MG,130MG,

150MG, 200MG (QL), 4 KALETRA CAPSULES, 7 KALYDECO TABLETS (PA (N), 43 KAPVAY SR TABLETS, 21 Kariva (MIRCETTE), 40 KAYEXALATE, 22 KAZANO TABLETS (PA), 23 K-DUR TABLETS, 22 KEFLEX 750MG CAPSULES, 8 KEFLEX CAPSULES / SUSPENSION, 8 KELNOR, 39 Kelnor (DEMULEN), 39 KENALOG CREAM / OINTMENT, 46 KENALOG IN ORABASE, 31 KEPPRA TABLETS, 37 KEPPRA XR TABLETS, 37 KERALAC CREAM /LOTION, 48 KERLONE TABLETS, 15 KETEK CAPSULES, 10



Ketoconazole Cream (QL), 45 Ketoconazole Shampoo, 45 Ketoconazole Tablets, 5 Ketoprofen Capsules / Tablets (QL), 35 Ketorolac (QL), 35 Ketorolac Ophthalmic Solution, 29 KINERET, 51 KLARON LOTION, 44 KLONOPIN TABLETS, 37 KLONOPIN WAFERS, 37 KLOR-CON, 22 K-LYTE (DS) PACKETS, 22 KOATE-DVI, 54 KOGENATE FS, 54 KOMBIGLYZE XR, 23 K-PHOS TABLETS, 22 KRISTALOSE CRYSTALS, 22 K-TABS, 22 Kurvelo, 39 KUVAN TABLETS (PA), 18 KYTRIL TABLETS (PA) (QL), 31 Labetalol Tablets, 13 LACRISERT INSERTS, 30 Lactulose Solution, 22 LAMICTAL ODT (PA), 37 LAMICTAL TABLETS, 37 LAMICTAL XR KIT (PA), 37 LAMICTAL XR TABLET (QL), 37 LAMISIL TABLETS (PA), 5 LAMISIL GRANULES (PA), 5 Lamivudine - Zidovudine Tablets, 7 Lamivudine Tablets, 7 Lamotrigine Tablets, 37 Lamotrigine XR Tablets, 37 LANOXIN TABLETS, 16 Lansoprazole Delayed Release Tablets (QL), 31 LANTUS VIALS (QL), 24 LANTUS CARTRIDGES (QL), 24 LANTUS SOLOSTAR (QL), 24 LARIAM TABLETS (QL), 7 LARODOPA TABLETS, 38 LASIX TABLETS, 22 LASTACAFT OPHTHALMIC SOLUTION, 30 Latanoprost Ophthalmic Solution (QL), 27 LATUDA TABLETS, 20 LAZANDA NASAL SPRAY (PA), 4 Leena (TRI-NORINYL), 41 Leflunomide Tablets, 35 LESCOL CAPSULES (QL) (PA), 14 LESCOL XL TABLETS (QL) ) (PA), 14 Lessina (ALESSE), 39 LETAIRIS (N), 17 Letrozole Tablets, 11 LEUCOVORIN TABLETS, 11 LEUKERAN TABLETS, 11 Levalbuterol Nebulizer Solution, 43 LEVAQUIN TABLETS / ORAL SOLUTION (QL, 9 LEVEMIR INSULIN (VIALS ONLY) (QL), 24 Levenost, 41 Levetiracetam Tablets, 37 Levetiracetam XR Tablets, 37 LEVITRA TABLETS (PA) (QL), 33

LEVLEN, 40 Levobunolol Ophthalmic Solution, 27 Levocitirize Tablets (PA) (QL), 6 Levodopa Tablets, 38 Levofloxacin Ophthalmic Solution, 28 Levofloxacin Tablets / Oral Solution (QL), 9 Levonorgestrel 0.75mg, 42 Levora (NORDETTE), 39 LEVOTHROID TABLETS, 26 Levothyroxine Tablets, 26 LEVOXYL TABLETS, 26 LEVSIN TABLETS, 32 LEVSINEX TABLETS, 32 LEXAPRO TABLETS, 18 LEXIVA TABLETS, 7 LIALDA TABLETS, 32 LIBRAX CAPSULES, 32 LIBRIUM CAPSULES, 19 LIDEX CREAM / OINTMENT, 47 LIDEX E CREAM, 47 Lidocaine, Viscous, 31 LIDODERM PATCHES, 48 LINZESS CAPSULES (PA), 31 LIORESAL TABLETS, 36 Liothyronine Tablets, 26 LIPITOR TABLETS, 15 LIPTRUZET TABLETS (QL), 14 LIQUID PRED SOLUTION, 34 Lisinopril / HCTZ Tablets, 16 Lisinopril Tablets, 13 Lithium Carbonate Tablets / Capsules, 19 LITHOBID CAPSULES, 19 LITHOSTAT TABLETS, 22 LIVALO TABLETS (EST) (QL), 15 LIVOSTIN OPHTHALMIC SOLUTION, 30 LO LOESTRIN, 39 LO/OVRAL, 39 LOCOID CREAM / OINTMENT, 46 LOCOID OINTMENT, 46 LODINE TABLETS / CAPSULES, 35 LODOSYN TABLETS, 38 LOESTRIN, 39 LOESTRIN 21), 39 LOESTRIN 24 Fe, 39 LOESTRIN FE, 39 LOFIBRA CAPSULES, 15 LOMOTIL TABLETS, 31 LONITEN TABLETS, 17 LOPID TABLETS, 15 LOPRESSOR HCT TABLETS, 15 LOPRESSOR TABLETS, 15 LOPROX CREAM / GEL, 45 LOPROX SHAMPOO, 45 Lorazepam Tablets, 19 LORCET PLUS 7.5/650 TABLETS, 4 LORCET TABLETS, 4 LORTAB 5/500 TABLETS, 4 LORTAB ELIXIR, 4 Loryna (YAZ), 39 LORZONE TABLETS, 36 Losartan / Hydrochlorothiazide Tablets, 14 Losartan Tablets, 14



LOSEASONIQUE TABLETS (QL) (3 MONTH SUPPLY), 41 LOTEMAX OPHTHALMIC SUSPENSION/GEL, 28 LOTENSIN HCT TABLETS, 16 LOTENSIN TABLETS, 13 LOTREL TABLETS (QL), 16 LOTRISONE CREAM / LOTION (QL), 45 LOTRONEX TABLETS, 32 Lovastatin Tablets (QL), 15 LOVAZA CAPSULES, 15 LOVENOX, 51 LOW-Ogestrel, 39 Low-Ogestrel (LO/OVRAL), 39 Loxapine Capsules, 20 LOXITANE CAPSULES, 20 LOZOL TABLETS, 23 LUMIGAN OPHTHALMIC (QL), 27 LUNESTA TABLETS (EST) (QL), 20 LUPRON - Not the Depot form, 53 LURIDE TABLETS, 49 Lutera (ALESSE), 39 LUVOX CR CAPSULES, 18 LYBREL TABLETS, 41 LYRICA SOLUTION (PA) (QL), 37 LYRICA TABLETS (PA), 37 LYSODREN TABLETS, 11 LYSTEDA TABLETS, 18 MACROBID CAPSULES, 34 MACRODANTIN CAPSULES, 10, 34 MALARONE TABLETS, 7 Malathion Lotion, 47 Maprotiline Tablets, 18 MARINOL CAPSULES, 31 Marlissa, 39 MATULANE CAPSULES, 11 MAVIK TABLETS, 13 MAXAIR AUTOHALER, 43 MAXALT TABLETS (QL), 38 MAXALT-MLT TABLETS (QL), 38 MAXIDEX OPHTHALMIC SOLUTION, 29 MAXIFLOR CREAM / OINTMENT, 47 MAXITROL OPHTHALMIC SOLUTION & OINTMENT, 29 MAXIVATE CREAM / OINTMENT, 47 MAXZIDE TABLETS, 23 Mebendazole Tablets (QL), 6 MEDROL TABLETS, 34 Medroxyprogesterone Tablets, 42 Mefenamic Acid Capsules, 35 Mefloquine Tablets (QL), 7 MEGACE ES SUSPENSION, 26 MEGACE ORAL SUSPENSION, 26 Megestrol Tablets, 26 MEKINIST TABLETS (PA), 11 Meloxicam Tablets (QL), 35 MENEST TABLETS, 25 MENOSTAR PATCH, 25 Meperidine Tablets, 4 MEPHYTON TABLETS, 18 Meprobamate Tablets, 19 MEPRON SUSPENSION, 10 Mercaptopurine Tablets, 11 Mesalamine Enema, 32 MESTINON TABLETS, 36

MESTINON TIMESPAN TABLETS, 36 METADATE CD CAPSULES, 21 METADATE CR, 21 METAGLIP TABLETS, 24 Metaxolone Tablets, 36 Metformin / Glipizide Tablets, 24 Metformin / Glyburide Tablets, 24 Metformin ER Osmotic, 23 Metformin Tablets, 24 Metformin XR Tablets, 24 Methadone Tablets (QL), 4 Methazolamide Tablets, 27 Methenamine / Methylene Blue / Atropine Tablets, 34 Methenamine Hippurate Enteric Coated Tablets, 10 Methenamine Mandelate Tablets, 10 METHERGINE TABLETS (QL), 42 Methimazole Tablets, 26 METHITEST TABLETS, 23 Methocarbamol Tablets, 36 METHOTREXATE INJECTION, 51 Methotrexate Tablets, 11, 35 Methscopolamine Tablets, 32 Methyldopa / Hydrochlorothiazide Tablets, 17 METHYLIN SOLUTION, 21 Methylphenidate Hcl Tablet SA OSM, 21 Methylphenidate LA Capsules, 21 Methylphenidate Solution, 21 Methylphenidate SR Tablets, 21 Methylphenidate Tablets, 21 Methylprednisolone Tablets, 34 Methyltestosterone Capsules, 23 MetiPranolol Ophth. Soln., 27 Metoclopramide Tablets, 32 Metolazone Tablets, 23 Metoprolol HCTZ, 15 Metoprolol SR Tablets, 15 Metoprolol Tablets, 15 METROCREAM TOPICAL CREAM, 44 METROGEL TOPICAL GEL, 44 METROGEL TOPICAL GEL 1%, 44 METROGEL VAGINAL GEL, 42 METROLOTION 0.75%, 44 Metronidazole Lotion 0.75%, 44 Metronidazole Tablets 250 mg, 500 mg, 10 Metronidazole Topical Cream / Gel, 44 Metronidazole Vaginal Gel 0.75%, 42 MEVACOR TABLETS (QL), 15 Mexiletine Capsules, 14 Mexiletine SR Capsules, 14 MEXITIL CAPSULES, 14 MIACALCIN, 52 MIACALCIN NASAL SPRAY, 26 MICARDIS (EST) (QL), 14 MICARDIS HCT (EST) (QL), 14 Microgestin (LOESTRIN 21), 39 Microgestin Fe (LOESTRIN Fe), 39 MICRO-K, 22 MICRONASE TABLETS, 24 MICROZIDE CAPSULES, 23 MIDRIN CAPSULES, 38 MIGERGOT SUPPOSITORIES, 38 MIGRANAL NASAL SPRAY (QL), 38



MILTOWN TABLETS, 19 MINASTRIN 24 FE, 39 MINIPRESS CAPSULES, 17 MINIVELLE PATCHES, 25 MINOCIN 50 MG, 100 MG CAPS, 10 Minocycline 50 mg,100 mg Capsules, 10 Minocycline Tablets (PA) - Use Minocycline Capsules, 10 Minoxidil Tablets, 17 MINTEZOL CHEWABLE TABLETS, 6 MIRALAX POWDER (QL), 32 MIRAPEX ER TABLETS, 38 MIRAPEX TABLETS, 38 MIRCETTE, 40 Mirtazapine Soluble Tablets, 18 Mirtazapine Tablets, 19 Misoprostol Tablets, 31 MOBIC TABLETS (QL), 35 Modafanil Tablets (PA) (QL), 21 MODICON, 39 MODURETIC TABLETS, 23 Mometasone Furoate Cream / Ointment /Lotion, 46 MONOCLATE-P, 54 MONODOX (EST) CAPSULES, 10 Mononessa (ORTHO-CYCLEN), 39 MONONINE, 54 MONOPRIL / HCT TABLETS, 17 MONOPRIL TABLETS, 13 Montelukast Tablets, 43 Morphine Solution, 4 Morphine SR Tablets, 4 Morphine Sulfate Extended Release Capsules (QL, 5 Morphine Suppositories, 5 MOTRIN TABLETS, 35 MOXATAG TABLETS (PA), 9 MOXEZA OPHTHALMIC SOLUTION, 28 MS CONTIN TABLETS, 5 MSIR TABLETS, 5 MUCOMYST, 43 MULTAQ TABLETS, 14 Mupirocin Cream / Ointment, 45 MYAMBUTOL TABLETS, 7 MYCELEX TROCHES, 5 MYCOBUTIN CAPSULES, 7 MYCOLOG II CREAM / OINTMENT, 11 Mycophenolate Capsules, 34 MYCOSTATIN CREAM / OINTMENT, 45 MYCOSTATIN TABLETS, 5 MYCOTRIACET CREAM / OINTMENT, 11 MYDFRIN OPHTHALMIC SOLUTION, 30 MYFORTIC CAPSULES (PA), 34 MYLERAN TABLETS, 11 MYRBETRIQ TABLET SR 24 HR (QL), 33 MYSOLINE TABLETS, 37 Myzilra 7/7/7, 41 Nabumetone Tablets, 35 Nadolol Tablets, 15 NAFTIN CREAM, 45 NALFON CAPSULES, 35 Naltrexone Tablets (PA), 21 NAMENDA TABLETS (PA), 37 NAMENDA XR CAPSULES (PA), 37 NAPROSYN TABLETS, 35

Naproxen Sodium Tablets, 35 Naproxen Sodium, DS Tablets, 35 Naproxen Tablets (Enteric Coated Not Covered), 35 Naratriptan Tablets, 38 NARDIL TABLETS, 20 NASACORT AQ (QL), 30 NASALIDE NASAL SOLUTION, 30 NASAREL Nasal Solution, 30 NASONEX (QL), 30 NATACYN OPHTHALMIC SUSPENSION, 28 Nataglenide Tablets, 24 NATAZIA, 41 NATROBA TOPICAL SUSPENSION, 47 NEBUPENT SOLUTION, 7 Necon (MODICON), 40 Necon 1/35 (ORTHO NOVUM 1/35), 40 Necon 1/50 (Ortho novum 1/50), 40 Necon 7/7/7 (ORTHO-NOVUM 7/7/7), 41 Nefazodone Tablets, 18 NEO-FRADIN ORAL SOLUTION, 10 Neomycin / Bacitracin / Polymyxin Ophthalmic Solution &

Oint., 28 Neomycin / Polymyxin / Prednisone Ophth. Soln., 29 Neomycin Tablets, 10 NEORAL CAPSULES, 34 NEOSPORIN OPHTHALMIC OINTMENT, 28 NEOSPORIN OPHTHALMIC SOLN., 28 NEPTAZANE TABLETS, 27 NESINA TABLETS (PA), 23 NEULASTA, 51 NEUMEGA, 51 NEUPOGEN, 51 NEUPRO PATCHES, 38 NEURONTIN CAPSULES / TABLETS, 37 NEVANAC OPHTHALMIC SUSPENSION, 28 Nevirapin Tablets, 7 NEXAVAR TABLETS (N) (LD), 11 NEXICLON XR TABLETS, 17 NEXIUM CAPSULES (PA) (QL), 31 NEXIUM PACKETS (PA), 31 NEXT CHOICE TABLETS (AGE RESTRICTION-OTC FOR

18 AND OLDER), 42 NIACOR TABLETS, 15 NIASPAN TABLETS, 14 Nicardipine Capsules, 15 NICOTROL NASAL SPRAY (PA) (QL), 50 Nifedipine Immediate Release Tablets, 16 Nifedipine, Sustained Release Tablets, 16 NILANDRON TABLETS, 11 NIMOTOP CAPSULES, 16 Nislodipine SR Tablets, 16 NITRO-BID CAPSULES, 17 NITRO-DUR PATCHES (QL), 17 Nitrofurantoin Macrocrystals, 34 Nitrofurantoin Macrocrystals Capsule, 10 Nitrofurantoin Suspension, 34 Nitroglycerin Ointment, 17 Nitroglycerin Oral Capsules, 17 Nitroglycerin Oral CAPSULES, 17 Nitroglycerin Patches (QL), 17 Nitroglycerin Sublingual Tablets, 17 NITROLINGUAL SPRAY, 17



NITROMIST SPRAY, 17 NITROSTAT SL TABLETS, 18 Nizatadine Capsules, 31 Nizatadine Solution, 31 NizatIdine Tablets, 31 NIZORAL CREAM (QL), 45 NIZORAL TABLETS, 5 NOLVADEX TABLETS, 11 Nora-B (ORTHO-MICRONOR), 41 NORCO TABLETS, 5 NORDETTE, 39, 40 NORDITROPIN, 52 Norethindrone Tablets, 42 NORFLEX TABLETS, 36 NORGESIC FORTE TABLETS, 36 NORGESIC TABLETS, 36 NORINYL 1+35, 40 NORINYL 1+50, 40 NOROXIN TABLETS, 9 NORPACE CAPSULES, 14 NORPACE CR CAPSULES, 14 NORPRAMIN TABLETS, 19 NOR-QD, 41 Nortrel (MODICON), 40 Nortrel 1/35 (ORTHO NOVUM 1/35), 40 Nortriptyline Tablets, 19 NORVASC TABLETS (QL), 16 NORVIR CAPSULES/TABLETS, 7 NOVA MAX TEST STRIPS (PA) (QL), 25 NOVAHISTINE DH LIQUID, 12 NOVOLIN (VIALS OR CARTRIDGES ONLY), 24 NOVOLOG (PA) (VIALS OR CARTRIDGES ONLY), 24 NOVOLOG MIX (VIALS OR CARTS. ONLY), 24 NOVOSEVEN, 54 NOXAFIL SUSPENSION, 5 NUCYNTA ER TABLETS (QL), 4 NUCYNTA TABLETS (QL), 4 NUEDEXTA CAPSULES, 21 NULYTELY SOLUTION, 32 NUTRIDOX CAPSULES, 10 NUTROPIN, 52 NUTROPIN AQ, 52 NUVARING, 41 NUVIGILTABLETS (PA), 21 NYAMYC POWDER, 45 Nystatin Cream / Ointment, 45 Nystatin Oral Suspension, 5 Nystatin Powder, 45 Nystatin Tablets, 5 NYSTOP POWDER, 45 Ocella (YASMIN), 40 Octreotide - Not the Depot form, 53 OCUFEN OPHTHALMIC SOLUTION, 29 OCUFLOX OPHTHALMIC SOLUTION, 28 Ofloxacin Ophthalmic Solution, 28 Ofloxacin Otic Solution, 30 OFORTA TABLETS, 11 OGEN TABLETS, 25 OGESTREL, 40 OGESTREL TABLETS, 40 Olanzapine / Fluoxetine Capsules (PA), 20 Olanzapine Orally Disintegrating Tablet, 20

Olanzapine Tablets, 20 OLEPTRO TABLETS 24 HR, 18 Omeprazole Capsules, 31 OMNEL TABLETS (PA), 5 OMNICEF CAPSULES / SUSPENSION, 8 OMNITROPE, 52 Ondansetron Orally disintegrating Tablets (QL), 31 Ondansetron Tablets (QL), 31 ONETOUCH TEST STRIPS (PA) (QL), 25 ONFI TABLETS, 37 ONGLYZA TABLETS, 24 ONLY- PELLETS NOT COVERED, 10 ONSOLIS BUCCAL FILM (PA) (QL), 4 OPANA ER CRUSH RESISTANT TABLETS (QL), 4 OPANA TABLETS, 4 OPHTHALMIC SOLN., 27 OPHTHALMIC SOLUTION, 29 OPTIVAR OPHTHALMIC SOLUTION, 30 ORACEA CAPSULES (EST), 10 Oral Colon Lavage Solution, 32 ORAMORPH TABLETS, 5 ORAP TABLETS, 20 ORASONE TABLETS, 34 ORAVIG BUCCAL TABLETS, 5 ORBIVAN CF TABLETS, 4 Orphenadrine / Aspirin / Caffeine Tablets, 36 Orphenadrine Citrate Tablets, 36 Orsythia (ALESSE), 40 ORTHO DIAPHRAGM, 41 ORTHO EVRA PATCH, 41 ORTHO NOVUM 1/35, 40 ORTHO NOVUM 1/50, 40 ORTHO TRI-CYCLEN (BRAND AT TIER 1, 41 ORTHO TRI-CYCLEN LO, 41 ORTHO-CEPT, 40 ORTHO-CYCLEN, 40 ORTHO-EST TABLETS, 25 ORTHO-NOVUM 10/11), 40 ORTHO-NOVUM 7/7/7 (BRAND AT TIER 1, 41 ORUDIS CAPSULES, 35 OSENI TABLETS (PA), 23 OSPHENA TABLETS (PA), 26 OTICIN HC OTIC SOLUTION, 30 OVACE WASH, 44 OVCON Fe, 39 OVIDE LOTION, 47 OVRAL, 40 Oxandralone Tablets, 23 OXANDRIN TABLETS), 23 Oxaprozin Tablets, 35 Oxazepam Capsules, 19 Oxcarbazepine Tablets / Suspension, 37 OXECTA TABLETS, 4 OXISTAT CREAM, 45 OXSORALEN ULTRA TABLETS ONLY, 48 OXTELLAR XR SR 24 Hr. TABLETS (EST), 37 Oxybutynin Extended Release Tablets, 33 Oxybutynin Immediate Release Tablets, 33 Oxycodone / Ibuprofen Tablets, 5 Oxycodone 4.5 / Aspirin 325 Tablets, 5 Oxycodone 5 / Acetaminophen 325 Tablets, 5 Oxycodone 5 / Acetaminophen 500 Capsules, 5



Oxycodone 5-Ibuprofen 400 Tablets, 4 OXYCONTIN (QL), 4 OXYTROL PATCHES, 33 PAMELOR CAPSULES, 19 PAMINE FORTE TABLETS, 32 PAMINE TABLETS, 32 PANCREAZE CAPSULES, 33 PANCRELIPASE CAPSULES, 33 PANRETIN GEL (PA), 45 Pantoprazole Tablets (QL), 31 PARAFON FORTE TABLETS, 36 PARCOPA TABLETS, 38 PARLODEL CAPSULES / TABLETS, 38 PARNATE TABLETS, 20 Paromomycin Capsules, 6 Paroxetine CR Tablets, 19 Paroxetine Tablets, 19 PATADAY OPHTHALMIC SOLUTION, 30 PATANASE NASAL SPRAY, 30 PATANOL OPHTHALMIC SOLUTION, 30 PAXIL CR TABLETS, 19 PAXIL TABLETS, 19 PEAK FLOW METER, 43 PEDIAZOLE SUSPENSION, 8, 9 PEGASYS, 53 PEG-INTRON, 53 PEN NEEDLES, 25 PEN NEEDLES MINI, 25 PEN NEEDLES SHORT, 25 Penicillin VK Tablets / Suspension, 9 PENLAC NAIL LACQUER, 45 PENNSAID SOLUTION, 48 PENTASA TABLETS, 32 Pentazocine / Acetaminophen Tablets, 4 Pentoxifylline Tablets, 18 PEPCID TABLETS, 31 PERCOCET 5/325 TABLETS, 4, 5 PERCOCET TABLETS (All Strengths Except 5/325), 4 PERCODAN FULL STRENGTH TABLETS, 5 PERFOROMIST NEBULIZER SOLUTION, 43 PERIACTIN 2 MG/ 5 ML SYRUP, 6 PERIACTIN 4 mg TABLETS, 6 PERIDEX (Covered Only With Dental Rider), 31 Perindopril Tablets, 13 Permethrin Cream (QL), 47 Perphenazine Tablets, 20 PERSANTINE TABLETS, 18 PERTZYE CAPSULES, 33 PEXEVA TABLETS, 18 Phenazopyridine Tablets, 34 Phenelzine Tablets, 20 PHENERGAN / DM SYRUP, 12 PHENERGAN TABLETS, 31 PHENERGAN VC CODEINE, 12 PHENERGAN/ CODEINE, 12 Phenobarbital Tablets, 20 Phentermine Capsules (PA), 49 Phentermine Tablets (PA), 49 Phenylephrine 2.5% Ophthalmic Solution, 30 PHENYTEK CAPSULES, 37 Phenytoin Capsules, 37 Phenytoin Chewable Tablets, 37

Philith (OVCON-35), 40 PHOSLO TABLETS / CAPSULES, 22 PHOSLYRA SOLUTION, 22 PHOSPHOLINE IODIDE, 27 PICATO GEL, 48 PILOCAR OPHTHALMIC SOLN., 27 Pilocarpine HCL Ophthalmic Solution, 27 PILOPINE HS GEL, 27 PIMA SOLUTION, 13 Pindolol Tablets, 15 Pioglitazone / Glimepiride Tablets, 24 Pioglitazone Tablets, 24 Pioglitazone-Metformin Tablets, 24 Pirmella 7/7/7, 41 Piroxicam Capsules, 36 PLAN B ONE STEP, 42 PLAN B TABLETS (AGE RESTRICTION-OTC FOR 18 AND

OLDER), 42 PLAQUENIL, 35 PLAQUENIL TABLETS, 7, 35 PLAVIX TABLETS, 18 PLETAL TABLETS, 18 PLEXION CLEANSER, 44 PLEXION CREAM, 44 PLEXION SCT CREAM, 44 PLIAGLIS CREAM, 48 POLY-CITRA K CRYSTALS / SYRUP, 22 Polyethylene Glycol 3350/ Sodium Carb/ Potassium

ForSolution 240 gm, 32 Polyethylene Glycol 3350/ Sodium Carb/ Potassium

ForSolution 420 gm, 32 Polymixin B Sulfate / Trimethoprim Ophthalmic Solution, 28 POLYTRIM OPHTHALMIC SOLUTION, 28 POLY-VI-FLOR SOLUTION BIPHASIC, 49 POLY-VI-FLOR TABLETS / DROPS, 49 POLY-VI-FLOR TABLETS BIPHASIC, 49 PONSTEL CAPSULES, 35 Portia (NORDETTE), 40 Potassium Chloride 8 mEq, 10 mEq, 20 mEq, 22 Potassium Chloride Effervescent Tablets, 22 Potassium Chloride Liquid, 22 Potassium Chloride Packets., 22 Potassium Citrate Tablets, 22 Potassium Iodide Solution, 13 POTIGA TABLETS, 37 PRADAXA CAPSULES, 18 Pramipexole Tablets, 38 PRANDIMET TABLETS, 24 PRANDIN TABLETS, 24 PRAVACHOL TABLETS (QL), 15 Pravastatin Capsules (QL), 15 Prazosin Capsules, 18 PRECISION XTRA TEST STRIPS (QL), 25 PRED FORTE OPHTHALMIC SUSPENSION, 29 PRED MILD OPHTHALMIC SUSPENSION, 29 Prednicarbate Cream, 46 Prednisolone Acetate Ophthalmic Suspension, 29 Prednisolone Phosphate Ophthalmic Solution, 29 Prednisolone Tablets, 34 Prednisone Tablets, 34 PREFEST TABLETS, 26 PRELONE SYRUP, 34



PREMARIN TABLETS, 25 PREMARIN VAGINAL CREAM, 25 PREMPHASE TABLETS, 26 PREMPRO TABLETS, 26 PRENTIF CAVITY-RIM CERVICAL CAP, 41 PRESTIGE TEST STRIPS (PA) (QL), 25 PREVACID CAPSULES (PA) (QL), 31 PREVACID SOLUTABS (PA) (QL), 31 Previfem (ORTHO-CYCLEN), 40 PREVPAC (PA) (QL), 31 PREZISTA CAPSULES, 7 PRILOSEC SUSPENSION (PA), 31 PRIMAQUINE TABLETS, 7 Primidone Tablets, 37 PRISTIQ TABLETS (QL), 18 PROAIR HFA (QL), 43 Probenecid / Colchicine Tablets, 35 PROCARDIA TABLETS, 16 PROCARDIA XL TABLETS, 16 Prochlorperazine Tablets/ Supositories, 31 PROCRIT, 51 PROCTO-CREAM, 48 PROCTOFOAM HC, 32 PROCTOFOAM NS, 48 PROCYSBI CAPSULES (N), 26 PROFILNINE SD, 54 Progesterone Micronized Capsules, 42 PROGLYCEM SUSPENSION, 17 PROGRAF CAPSULES, 34 PROLENSA OPHTHALMIC SOLUTION, 29 PROLIXIN TABLETS, 20 Promethazine & Pheylephrine Syrup, 6 PROMETHAZINE / CODEINE, 12 Promethazine / DM Syrup, 13 Promethazine / Phenylephrine / Codeine Syrup, 12 Promethazine Syrup, 6 Promethazine Tablets, 31 PROMETRIUM CAPSULES, 42 Propafenone SR Capsules, 14 Propafenone Tablets, 14 PROPINE OPHTHALMIC SOLN., 27 Propranolol / Hydrochlorothiazide Tablets, 17 Propranolol Tablets, 15 Propylthiouracil (PTU) Tablets, 26 PROSCAR TABLETS (AGE LIMIT) (QL), 33 PROSOM TABLETS, 20 PROSTIGMIN CR TABLETS, 36 PROTOPIC OINTMENT (PA) (QL), 48 PROVENTIL HFA INHALER, 43 PROVENTIL NEBULIZED SOLUTION, 43 PROVENTIL TABLETS, 43 PROVERA TABLETS, 42 PROVIGIL TABLETS (QL) (PA), 21 PROZAC 60 MG TABLETS, 18 PROZAC CAPSULES ONLY - 10 MG ,20 mg & 400 MG

ONLY, 19 PROZAC WEEKLY CAPSULES, 18 PSORCON CREAM / OINTMENT, 47 PULMICORT FLEXIHALER (QL), 43 PULMICORT RESPULES (QL), 43 PULMOZYME (QL), 43 PURINETHOL TABLETS, 11

Pyrazinamide Tablets, 7 PYRIDIUM TABLETS, 34 Pyridostigmine Tablets, 36 QNASL AEROSOL, 30 QSYMIA CAPSULES (PA)-, 49 QUALAQUIN CAPSULES (QL) (PA), 7 QUARTETTE TABLETS (3 Month Supply), 41 Quasense (SEASONALE), 39 QUESTRAN BULK - POWDER ONLY, 15 QUESTRAN LIGHT - POWDER ONLY, 15 Quetiapine Fumarate Tablets, 20 QUILLIVANT XR SUSPENSION (QL), 21 QUINAGLUTE TABLETS, 14 Quinapril Tablets, 13 QUINIDEX TABLETS, 14 Quinidine Gluconate Tablets, 14 Quinidine Sulfate Sustained Release Tablets, 14 Quinidine Sulfate Tablets, 14 QUINIDINE TABLETS, 14 QUIXIN OPHTHALMIC SOLN., 28 QVAR (QL), 43 Ramipril Capsules, 13 RANEXA TABLETS, 17 Ranitidine 300 mg Tablets Only, 31 Ranitidine 75mg/5ml Syrup, 31 RAPAFLO CAPSULES, 33 RAPAMUNE TABLETS (PA), 34 RAVICTI LIQUID (PA) (N) (LD), 22 RAYOS TABLETS, 34 RAZADYNE ER CAPSULES (PA), 37 RAZADYNE TABLETS (PA), 37 REBETOL CAPSULES (PA), 7 REBIF, 51 Reclipsen (ORTHO-CEPT), 40 RECOMBINATE, 54 REFACTO, 54 REGIMEX TABLETS (PA), 49 REGLAN TABLETS, 32 REGRANEX GEL (PA), 48 REGULAR ILETIN, 24 RELAFEN TABLETS, 36 RELENZA DISKHALER (QL), 7 RELISTOR, 53 RELPAX TABLETS (QL), 38 REMERON SOLTABS, 19 REMERON TABLETS, 19 RENAGEL TABLETS, 22 RENVELA TABLETS, 22 REPREXAIN TABLETS, 5 REQUIP TABLETS, 38 REQUIP XL, 38 RESCRIPTOR TABLETS, 7 RESCULA OPHTHALMIC SOLN., 27 RESERPINE TABLETS, 17 RESTASIS OPHTHALMIC EMULSION, 30 RESTORIL 22.5 MG, 20 RESTORIL 7.5 MG, 15 MG, 30 MG CAPSULES, 20 RETIN-A CREAM / GEL, 45 RETIN-A MICRO, 44 RETROVIR CAPSULES/ TABLETS, 7 REVATIO TABLETS (PA), 17 REVIA TABLETS, 21



REVLIMID CAPSULES (PA), 11 REYATAZ CAPSULES, 7 RHEUMATREX TABLETS, 11, 35 RHINOCORT AQUA (QL), 30 Ribavirin Tablets / Capsules (PA), 7 RIDAURA CAPSULES, 35 RIFADIN CAPSULES, 7 RIFAMATE CAPSULES, 7 Rifampin Capsules, 7 RILUTEK TABLETS, 21 Riluzole Tablets, 21 Rimantadine Tablets, 7 RIOMET SOLUTION, 24 RISPERDAL TABLETS, 20 RISPERDAL–M TABLETS, 20 Risperidone Orally Disintegrating Tablets, 20 Risperidone Tablets, 20 RITALIN LA CAPSULES, 21 RITALIN SR TABLETS, 21 RITALIN TABLETS, 21 Rivastigmine Capsules, 37 Rizatriptan Orally Disintegrating Tablets (QL), 38 Rizatriptan Tablets (QL), 38 RMS SUPPOSITORIES, 5 ROBAXIN TABLETS, 36 ROBINUL TABLETS, 32 ROBINUL FORTE TABLETS, 32 ROCALTROL CAPSULES, 49 RONDEC DM SYRUP, 13 Ropinirole Extended Release Tablets, 38 Ropinirole Tablets, 38 ROSAC CREAM, 44 ROSULA CLARIFYING WASH, 45 ROSULA GEL, 44 ROWASA ENEMA, 32 ROXICET 5 / 325 TABLETS, 5 ROXICODONE TABLETS, 5 ROZEREM TABLETS (EST) (QL), 20 RYBIX ODT, 4 RYTHMOL SR CAPSULES, 14 RYTHMOL TABLETS, 14 RYZOLT SR TABLETS (QL), 4 SABRIL PACKETS, 37 SABRIL TABLETS, 37 SAFYRAL TABLETS, 41 SAIZEN, 52 SALAGEN TABLETS, 31 SALEX CREAM, 45 Salsalate Tablets / Liquid, 36 SAMSCA TABLETS (QL), 23 SANCTURA TABLETS, 33 SANCTURA XR CAPSULES, 33 SANCUSO PATCHES (PA) (QL), 31 SANDIMMUNE CAPSULES, 34 SANDOSTATIN - Not the Depot / LAR form, 53 SAPHRIS SL TABLETS, 19 SAVELLA TABLETS (PA) (QL), 21 Scopolamine HBr Ophthalmic Solution, 30 SEASONALE, 39 SEASONIQUE, 40 SEBIZON LOTION, 47 SECTRAL CAPSULES, 13

SEDAPAP TABLETS, 5 Selegiline Tablets, 38 Selenium Sulfide 2.5% Lotion, 47 Selenium sulfide-pyrithione zinc in Urea Shampoo, 47 SELSEB SHAMPOO, 47 SELSUN LOTION, 47 SELZENTRY TABLETS, 7 SENSIPAR TABLETS, 26 SEPTRA DS TABLETS, 9 SEPTRA TABLETS, 9 SERAX CAPSULES, 19 SEREVENT DISKUS (QL), 43 SEROMYCIN CAPSULES, 7 SEROQUEL TABLETS, 20 SEROQUEL XR TABLETS, 20 SEROSTIM, 52 Sertraline Tablets, 19 Sildenafil 20mg Tablets (PA), 17 SILENOR TABLETS (EST) (QL), 18 SILVADENE CREAM, 46 Silver Sulfadiazine cream, 46 SIMPONI, 51 Simvastatin Tablets (QL), 15 SINEMET CR TABLETS, 39 SINEMET TABLETS, 39 SINEQUAN CAPSULES, 19 SINGULAIR TABLETS, 43 SIRTURO TABLETS (PA), 7 SKELAXIN TABLETS, 36 SKLICE LOTION, 47 SLO-BID CAPSULES, 43 SLOW K, 22 Sodium Fluoride Tablets and Drops, 49 Sodium Polystyrene Sulfonate Powder, 22 Sodium Polystyrene Sulfonate Solution, 22 Sodium Sulfacetamide/Sulfur Foam, 45 SOLARAZE GEL, 48 Solia (ORTHO-CEPT, 40 SOLODYN SR TABS (EST) USE MINOCYCLINE

CAPSULES, 10 SOLTAMOX SOLUTION, 11 SOLUTION, 27 SOMA 250MG TABLETS, 36 SOMA 350 MG TABLETS, 36 SOMA COMPOUND TABLETS, 36 SOMAVERT, 52 SONATA CAPSULES (EST) (QL), 20 SORIATANE CAPSULES, 47 SORILUX AEROSOL, 47 Sotalol Tablets, 15 SOTRET CAPSULES (QL), 45 SPECTAZOLE CREAM, 45 SPECTRACEF TABLETS, 8 SPIRIVA HANDIHALER (QL), 43 Spironolactone / HCTZ Tablets, 23 Spironolactone Tablets, 23 SPORANOX CAPSULES (PA), 5 Sprintec (ORTHO-CYCLEN), 40 SPRIX NASAL SPRAY (QL), 4 SPRYCEL TABLETS (N), 11 SPS SUSPENSION, 22 Sronyx (ALESSE), 40



SSD CREAM, 46 SSKI SOLUTION, 13 STADOL NASAL SPRAY (QL), 4 STALEVO TABLETS, 39 STARLIX TABLETS, 24 Stavudine Capsules, 7 STAVZOR CAPSULES, 37 STAXYN TABLETS (PA) (QL), 33 STIVARGA TABLETS (PA), 11 STRATTERA, 21 STRIANT BUCCAL TABLETS, 23 STRIBILD TABLETS, 7 SUBOXONE SL TABLETS (PA) (QL), 21 SUBSYS SPRAY (PA), 4 SUBUTEX SL TABLETS (PA) (QL), 21 Sucralfate Tablets, 31 SULAR ER TABLETS, 16 Sulfacetamide / Prednisolone Acetate Susp. & Oint., 29 Sulfacetamide / Prednisolone Ophthalmic Ointment, 29 Sulfacetamide Ophthalmic Solution, 28 Sulfacetamide sodium liquid 10%, 45 Sulfacetamide Sodium w/ Sulfur Cream 10-5%, 45 Sulfacetamide Sodium w/ Sulfur Emulsion 10-5%, 45 Sulfacetamide Sodium w/ Sulfur Suspension 8%-4%, 45 Sulfacetamide Sodium w/ Sulfur Suspension 9%-4%, 45 Sulfacetamide Sodium-Sulfur in Urea Emulsion 10-4%, 45 SULFACET-R LOTION (QL), 45 Sulfamethoxazole / Trimethoprim (SMZ / TMP) Tablets, 9 Sulfamethoxazole / Trimethoprim DS (SMZ / TMP DS)

Tablets, 9 SULFAMYLON CREAM, 45 Sulfasalazine Tablets (Enteric Coated Tablets Not Covered),

32 Sulindac Tablets, 36 Sumatriptan Tablets (QL), 39 Sumatriptan Tablets /Nasal Spray (QL), 38 SUMAXIN TS SUSPENSION, 45 SUMAXIN WASH, 45 SUMITRIPTAN INJ, 52 SUMYCIN CAPSULES, 10 SUPRAX SUSPENSION / CHEW TABLETS, 8 SURESTEP TEST STRIPS (PA) (QL), 25 SURMONTIL CAPSULES, 18 Suspension, 6, 8 SUSPENSION, 8 SUSTIVA CAPSULES / TABLETS, 7 SUTENT CAPSULES (N), 11 Syeda (YASMIN), 40 SYMBICORT AEROSOL, 43, 75 SYMBYAX CAPSULES, 20 SYMLIN (PA), 53 SYMMETREL CAPSULES, 39 SYNALAR 0.01% CREAM / OINTMENT / SOLUTION, 46 SYNALAR 0.025% CREAM / OINTMENT, 46 SYNALAR HP CREAM, 47 SYNAREL NASAL SOLUTION, 26 SYNERA PATCHES, 48 SYNTHROID TABLETS, 26 SYRUP, 12 TABLOID TABLETS, 11 TACLONEX OINTMENT (EST), 47 Tacrolimus Capsules, 34

TAFINLAR CAPSULES (PA), 11 TAGAMET 300 mg, 400 MG, 800 MG TABLETS, 31 TALWIN NX TABLETS, 4 TAMBOCOR TABLETS, 14 TAMIFLU (QL), 7 Tamoxifen Citrate Tablets, 11 Tamsulosin Capsules (QL), 33 TAPAZOLE TABLETS, 26 TARCEVA TABLETS (PA), 11 TARGRETIN CAPSULES, 11 TARKA TABLETS, 16 TASIGNA CAPSULES (PA), 11 TASMAR TABLETS, 38 TAVIST TABLETS, 6 TAZORAC CREAM / GEL (QL), 47 TAZORAC CRM / GEL (QL), 44 TECFIDERA CAPSULE (PA) (N) (SP), 21 TEGRETOL TABLETS, 37 TEGRETOL XR TABLETS, 37 TEKAMLO TABLETS (EST), 16 TEKTURNA HCT TABLETS (EST), 17 TEKTURNA TABLETS, 17 Temazepam 22.5 mg Capsules ), 20 Temazepam 7.5 mg, 15 mg, 30 mg Capsules, 20 TEMODAR CAPSULES (QL), 12 TEMOVATE CREAM / OINTMENT/ GEL/ SOLUTION /

EMOLLIENT, 47 TENEX TABLETS, 17 TENORETIC TABLETS, 17 TENORMIN TABLETS, 15 TERAZOL VAGINAL CREAM / TABLETS, 42 Terazosin Capsules / Tablets, 33 Terazosin Tablets / Capsules, 18 Terbinafine Tablets (PA), 5 Terbutaline Sulfate Tablets, 43 Terconazole Vaginal Cream / Tablets, 42 TESSALON PERLES, 13 TESTIM GEL, 23 TESTRED CAPSULES, 23 Tetracycline Capsules, 10 TEVETEN 600 MG TABLETS (EST), 14 TEVETEN HCT TABLETS (EST) (QL), 14 TEVETEN TABLETS (PA) (QL), 14 TEV-TROPIN, 52 THALOMID CAPSULES [(N), 10 THEO-24 CAPSULES., 43 THEODUR TABLETS, 43 Theophylline Elixir 80 mg/ 15cc (Alcohol Free), 43 Theophylline Liquid, 43 Theophylline, Immediate Release Tablets, 43 Theophylline, Sustained Release Capsules, 43, 44 Thiothixene Capsules, 20 THROMBATE III, 54 Thyroid, Dessicated tablets, 26 THYROLAR TABLETS, 26 Tiagabine Tablets, 37 TIAZAC CAPSULES, 16 TICLID TABLETS, 18 Ticlopidine Tablets, 18 TIGAN CAPSULES, 31 TIKOSYN CAPSULES, 14 TILIA Fe, 41



Timolol Maleate OPHTHALMIC SOLN., 27 Timolol Tablets, 15 Timolol XE Gel, 27 TIMOPTIC OCUDOSE PRESERVATIVE FREE, 27 TIMOPTIC OPHTHALMIC GEL., 27 TIMOPTIC OPHTHALMIC SOLN.., 27 TIMOPTIC XE GEL, 27 TINDAMAX TABLETS (PA), 6 Tinidazole Tablets (PA), 6 TIROSINT CAPSULES, 26 Tizanidine Tablets, 36 TOBI NEBULIZER SOLUTION, 10 TOBRADEX OPHTHALMIC OINTMENT, 29 TOBRADEX OPHTHALMIC SUSPENSION, 29 TOBRADEX ST OPHTHALMIC SOLUTION, 29 Tobramycin Ophthalmic Solution & Ointment, 28 TOBREX OPHTHALMIC OINT./ SOLUTION, 28 TOFRANIL PM TABLETS, 19 TOFRANIL TABLETS, 19 Tolazamide Tablets, 24 TOLBUTAMIDE TABLETS, 24 TOLECTIN DS CAPSULES, 36 TOLECTIN TABLETS, 36 TOLINASE TABLETS, 24 Tolmetin (DS) Capsules, 36 Tolterodine Tablets, 33 TOPAMAX TABLETS, 37 TOPICORT LP CREAM, 47 TOPICORT SPRAY, 46 TOPROL XL TABLETS, 15 TORADOL TABLETS (QL), 36 Torsemide Tablets, 22 TOVIAZ 24 HR TABLETS, 33 TRACLEER TABLETS (N) (LD, 17 TRADJENTA TABLETS, 24 Tramadol / Acteaminophen Tablets, 4 Tramadol Tablets (QL), 5 Tramadol Tablets 24 HR, 4 TRANDATE TABLETS, 13 Trandolapril Tablets, 13 Tranexamic Acid Tablets (QL), 18 TRANXENE CAPSULES, 19 Tranylcypromine Tablets, 20 TRAVATAN Z OPHTHALMIC (QL), 27 Trazodone Tablets, 19 TRECATOR TABLETS, 7 TRENTAL TABLETS, 18 Tretinoin Capsules, 12 Tretinoin Cream / Gel, 45 TRETIN-X CREAM, 44 TREXIMET TABLETS (QL) (PA), 38 Tri Legest Fe (ESTROSTEP Fe), 41 Triamcinolone / Nystatin Cream / Ointment, 11 Triamcinolone 0.1% in Orabase, 31 Triamcinolone Acetonide Cream / Ointment / Lotion, 46 Triamcinolone Acetonide Nasal Inhaler, 30 Triamterene / HCTZ Capsules, 23 Triamterene / HCTZ Tablets, 23 Triazolam Tablets (QL), 20 TRIBENZOR TABLETS (EST), 13 Trifluoperazine Tablets, 20 Trifluridine Ophthalmic Solution, 29

TRIGLIDE TABLETS 50 MG, 15 TRILEPTAL TABLETS / SUSPENSION, 37 TRI-LEVLEN, 41 TRILIPIX CAPSULES, 15 TRILISATE TABLETS / LIQUID, 36 Tri-Lynya, 41 Trimethobenzamide Capsules, 31 Trimethoprim Tablets, 10, 34 Trimipramine Capsules, 19 TRIMOX, 9 Trinessa (ORTHO TRI-CYCLEN), 41 TRI-NORINYL), 41 Tri-previfem (ORTHO TRI-CYCLEN), 41 Tri-sprintec (ORTHO TRI-CYCLEN), 41 TRI-VI-FLOR TABLETS / DROPS, 49 Trivora (TRI-LEVLEN), 41 TRIZIVIR TABLETS, 7 Trospium SR Capsules, 33 Trospium Tablets 20 mg, 33 TRUETRAK TEST STRIPS (PA) (QL), 25 TRUSOPT OPHTHALMIC SOLN., 27 TRUVADA TABLETS, 7 TUDORZA PRESSAIR INHALATION (QL), 43 TUSSEND SYRUP, 12 TUSSIONEX SUSPENSION, 12 TWYNSTA TABLETS (EST) (QL), 14, 16 TYKERB TABLETS (N), 12 TYLENOL CODEINE TABLETS #2, #3, #4, 5 TYLOX 5 / 500 CAPSULES, 5 TYZEKA TABLETS (PA), 7 UCERIS SR TABLETS (PA), 32 ULESFIA LOTION 5%, 44, 48 ULORIC TABLETS (, 35 ULTRACET TABLETS, 4 ULTRAM ER TABLETS, 4 ULTRAM TABLETS (QL), 5 ULTRASE MT CAPSULES, 33 ULTRAVATE CREAM / OINTMENT, 47 ULTRESA CASULES, 33 UNIPHYL TABLETS, 44 UNIRETIC TABLETS, 17 UNIVASC TABLETS, 13 URECHOLINE, 33 URECHOLINE TABLETS, 34 URISPAS TABLETS, 34 UROCIT K-15, 22 UROCIT-K-10 TABLETS, 22 UROCIT-K-5 TABLETS, 22 UROXATRAL TABLETS, 33 URSO CAPSULES, 33 URSO FORTE CAPSULES, 33 Ursodiol 300 mg Capsules, 33 VAGIFEM VAGINAL TABLETS, 25 Valacyclovir Tablets (QL), 7 VALCYTE TABLETS, 8 VALIUM TABLETS, 19, 36 Valproic Acid Capsules, 38 Valsartan / HCTZ (DIOVAN HCT Tablets), 14 VALTREX TABLETS, 7 VANCOCIN CAPSULES (PA) (QL), 10 Vancomycin Capsules (PA) (QL), 10 Vandazole Vaginal Gel, 42



VANTIN SUSPENSION, 8 VANTIN TABLETS, 8 VASCEPA CAPSULES, 15 VASERETIC TABLETS, 17 VASOTEC TABLETS, 13 VECTICAL OINTMENT (QL), 47 VEETIDS TABLETS / SUSPENSION, 9 Velivet (CYCLESSA), 41 Venlafaxine Extended Release Tablets, 19 Venlafaxine Tablets, 19 VENTOLIN HFA, 43 VEPESID CAPSULES, 12 VERAMYST NASAL SUSPENSION, 30 Verapamil SA Tablets, 16 Verapamil SR Capsules, 16 Verapamil Tablets, 16 VEREGEN OINTMENT (QL), 48 VERELAN CAPSULES, 16 VERELAN PM CAPSULES, 15 VERMOX TABLETS (QL), 6 VESANOID CAPSULES, 12 VESICARE TABLETS, 33 Vestura (YAZ), 40 VEXOL OPHTHALMIC SUSPENSION, 29 VFEND TABLETS (QL), 6 VIAGEN TABLETS, 7 VIAGRA TABLETS (PA) (QL), 33 VIBRAMYCIN CAPSULES, 10 VIBRA-TABS, 10 VICODIN 5 / 500 TABLETS, 5 VICODIN ES 7.5 / 750 TABLETS, 5 VICODIN HP TABLETS, 5 VICOPROFEN TABLETS, 5 VICTOZA (PA), 53 VICTRELIS CAPSULES (PA) (N), 7 VIDEX EC CAPSULES, 7 VIDEX TABLETS, 8 VIGAMOX OPHTHALMIC SOLN., 28 VIIBRYD TABLETS (EST), 19 VIMOVO TABLETS (PA), 35 VIMPAT TABLETS), 37 VIOKASE POWDER, 33 Viorele, 40 VIRACEPT TABLETS, 8 VIRAMUNE TABLETS, 7 VIRAMUNE XR TABLETS, 7 VIREAD TABLETS, 8 Viscous Xylocaine, 31 VISTARIL CAPSULES, 6 VIVACTIL TABLETS, 19 VIVELLE-DOT PATCHES, 25 VOLTAREN GEL, 35, 48 VOLTAREN IMMEDIATE RELEASE TABLETS, 36 VOLTAREN OPHTHALMIC SOLUTION, 29 VOLTAREN XR, 35 Voriconazole Tablets (QL, 6 VOSOL HC OTIC SOLUTION, 30 VOSOL OTIC SOLUTION, 30 VOSPIRE ER TABLETS, 44 VOTRIENT TABLETS, 12 VYTORIN TABLETS (QL) (EST 10/10), 14 VYVANSE (QL), 21

Warfarin Sodium Tablets, 18 WELCHOL TABLETS, 15 WELLBUTRIN SR TABLETS, 19 WELLBUTRIN TABLETS, 19 WELLBUTRIN XL TABLETS, 19 WELLCOVORIN TABLETS, 12 Wera, 40 WESTCORT CREAM / OINTMENT, 46 WYMOX TABLETS / SUSPENSION, 9 Wymzya Fe, 39 WYTENSIN TABLETS, 17 XALATAN OPHTHALMIC (QL), 27 XALKORI CAPSULES (PA), 12 XANAX TABLETS, 19 XANAX XR TABLETS, 19 XARELTO TABLETS (QL), 18 XELJANZ TABLETS (PA) (QL), 35 XELODA TABLETS, 12 XENICAL CAPSULES OTC, 49 XERESE CREAM (QL), 7 XIBROM OPHTHALMIC SUSPENSION, 29 XIFAXAN 200MG TABLETS (QL), 10 XIFAXAN TABLETS 550MG (PA), 10 XODOL TABLETS, 5 XOPENEX HFA AEROSOL, 43 XOPENEX NEBULIZER SOLUTION, 43 XTANDI CAPSULES (PA), 11 XYNTHA KIT, 54 XYREM SOLUTION (PA), 21 XYZAL TABLETS (PA), 6 YASMIN, 40 YAZ, 40 YODOXIN TABLETS, 6 Zafirlukast Tablets, 44 ZANAFLEX TABLETS, 36 ZANTAC 300MG TABLETS, 31 ZARAH, 40 Zarah (YASMIN), 40 ZARONTIN CAPSULES, 38 ZAROXOLYN TABLETS, 23 ZAVESCA CAPSULES (PA), 26 ZEBETA TABLETS, 15 ZELAPAR DISENTEGRATING TABLETS, 38 ZELBORAF TABLETS (PA), 12 ZEMPLAR CAPSULES, 49 ZENATANE CAPSULES (QL), 45 Zenchent Fe, 39 ZENPEP CAPSULES, 33 ZENZEDI TABLETS, 21 Zeosa Chew Tabs, 39 ZEPHREX LA TABLETS, 13 ZERIT CAPSULES, 7 ZESTORETIC TABLETS, 17 ZESTRIL TABLETS, 13 ZETIA TABLETS, 14 ZETONNA NASAL AEROSOL, 30 ZIAC TABLETS, 17 ZIAGEN TABLETS, 8 ZIANA GEL, 44 Zidovudine Capsules / Tablets, 8 ZIOPTAN OPHTHALMIC SOLUTION, 27 ZIPSOR CAPSULES (QL) (EST), 35



ZIRGAN OPHTHALMIC GEL, 29 ZITHROMAX TABLETS (QL), 8 ZMAX ORAL SUSPENSION (QL), 8 ZOCOR TABLETS, 15 ZOFRAN ODT (QL), 31 ZOFRAN TABLETS (QL), 31 ZOLINZA CAPSULES (PA), 12 Zolmitriptan Orally Disintegrating Tablets (QL), 38 Zolmitriptan Tablets (QL), 38 ZOLOFT TABLETS, 18, 19 Zolpidem CR Tablets (QL) (EST), 20 Zolpidem Tablets (QL), 20 ZOLPIMIST SPRAY (EST), 20 ZOMIG TABLETS (QL, 38 ZOMIG ZMT TABLETS (QL), 38 ZONALON CREAM, 44, 48 ZONEGRAN CAPSULES, 38 Zonisamide Capsules, 38 ZORBTIVE, 52 ZORTRESS TABLETS, 34

Zovia (DEMULEN), 40 ZOVIRAX CREAM (QL), 10, 46 ZOVIRAX OINTMENT, 46 ZOVIRAX OINTMENT (QL), 10 ZOVIRAX ORAL SUSPENSIONn, 8 ZOVIRAX ORAL TABLETS / CAPSULES, 8 ZUBSOLV SL TABLETS (PA), 21 ZUPLENZ ORAL FILM, 31 ZYBAN TABLETS (PA) (QL), 50 ZYCLARA CREAM PUMP (QL), 48 ZYFLO CR TABLETS, 43 ZYFLO TABLETS, 43 ZYLET OPHTHALMIC SUSPENSION, 29 ZYLOPRIM TABLETS, 35 ZYMAR OPHTHALMIC SOLN., 28 ZYMAXID OPHTHALMIC SOLUTION, 28 ZYPREXA TABLETS), 20 ZYPREXA ZYDIS, 20 ZYTIGA TABLETS (PA) [Not available thru Mail Order], 12 ZYVOX TABLETS, 10

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