SAN FRANCISCO HEALTH PLAN Medicare/ Medi-Cal …diphenhydramine hcl oral tablet 25 mg T1 ED...

San Francisco Health Plan Medicare/Medi-Cal Formulary AS OF May 2020

SAN FRANCISCO HEALTH PLAN

Medicare/ Medi-Cal Formulary

A s of May 2020


San Francisco Health Plan Medicare/Medi-Cal Formulary The San Francisco Health Plan (SFHP), with the direction from the Pharmacy and Therapeutics Committee (P&T), has developed a formulary to be used by members, clinicians, and pharmacists. The P&T Committee is composed of the SFHP Chief Medical Officer, the SFHP Pharmacy Director, physicians from various medical specialties and clinics, and community clinical pharmacists. The P&T meets quarterly to review formulary changes based on quality of care considerations and sound pharmacoeconomic principles.

The formulary is a list of drug products designed to reflect the most appropriate, high quality and cost-effective drug therapies. The formulary is updated regularly and is subject to change without notice.

The formulary requires the continuous support of all our providers and pharmacists. Please contact us at (415) 547-7818 x 7085 option 3 or [email protected] if you have any questions regarding theformulary. The SFHP formulary can be easily accessed online from our website athttp://www.sfhp.org/providers/formulary/sfhp-formulary/.

Request for Addition or Deletion of a Drug to the Formulary SFHP providers may request evaluation of drugs for addition to or deletion from the Formulary by submitting the Formulary Modification Request Form available on our website at http://www.sfhp.org/providers/formulary/prior-authorization-requests/.

Request for Non-Preferred Medications Non-preferred or non-formulary medications may be authorized when there is clinical justification for doing so. Providers can submit a prior authorization (PA) request in one of three different ways:

1. Online: Submit using the Online Pharmacy Prior Authorization Request Form.2. Fax: Download a Prior Authorization Request Form and fax to 1(855) 811-9331 for both

standard and urgent requests. Urgent requests should be clearly labeled “URGENT” at the topof the prior authorization request form.

3. Phone: Pharmacy Benefits Manager (PBM) PerformRx at (888) 989-0091 to submit a verbalrequest.

The Prior Authorization Request Form and the Online Pharmacy Prior Authorization Request Form can be accessed from our website at http://www.sfhp.org/providers/formulary/prior-authorization-requests/.

mailto:[email protected]

http://www.sfhp.org/providers/formulary/sfhp-formulary/

http://www.sfhp.org/files/providers/formulary/formulary_modification_form.pdf

http://www.sfhp.org/providers/formulary/prior-authorization-requests/

https://ppa.performrx.com/PublicUser/CaliforniaForm/OnlineForm.aspx?cucu_id=8WNE9dA4crj04kitEF%2bZ1A%3d%3d

http://www.sfhp.org/files/providers/forms/UniversalPAForm.pdf

http://www.sfhp.org/files/providers/forms/UniversalPAForm.pdf

https://ppa.performrx.com/PublicUser/CaliforniaForm/OnlineForm.aspx?cucu_id=8WNE9dA4crj04kitEF%2bZ1A%3d%3d




Brand Medication Policy SFHP has a mandatory generic policy and requires generic substitution when an equivalent AB-rated generic product is available. Dispensing of brand name medications when generic equivalent is available is allowed only in certain cases:

• Pharmacy bills brand medication as DAW 5 (i.e. billed as a generic product).• Pharmacy bills brand medication as DAW 8 (i.e. generic formulation is not currently available).• Pharmacy is dispensing one (1) of the following narrow therapeutic index drugs/classes: Dilantin

(phenytoin), thyroid hormones, coumarin type anticoagulants.• For all other brand name medication requests, prior authorization with documentation that two

(2) generic medications from different manufacturers were tried and did not meet the medicalneeds of the member.

All brand name medication prior authorization requests are reviewed by an SFHP pharmacist or Medical Director. In all other cases, a prior authorization (PA) request should be submitted using the instructions above. Detailed PA criteria for brand name medication requests can be found at http://www.sfhp.org/files/providers/formulary/Prior_Auth_Criteria.pdf under “Brand Medication Requests” section.

Medicare/Medi-Cal Formulary Provisions Medicare/Medi-Cal formulary is designed for members with both Medicare and Medi-Cal coverage (dual-eligibles). Medicare/Medi-Cal formulary only covers the following products:

• Medications excluded by Medicare Part D and covered by SFHP Medi-Cal formulary• Supplies excluded by Medicare Part B and covered by SFHP Medi-Cal formulary

Day Supply Policy SFHP standard day supply policy is 30 day supply for brand and 90 day supply for generic medications. Exceptions can be made to the 90 day supply policy for specific generic medications. Refills are allowed when 75% of the medication has been used.

Formulary Restrictions (DUR edits) Standard formulary restrictions applicable to SFHP formularies are medication quantity and age limitations. All formulary restrictions are based on FDA approved indications, standards of practice and safety and abuse potential considerations.

Therapeutic Interchange Policy Per American College of Clinical Pharmacy (AACP), therapeutic interchange is defined as the dispensing of a drug that is therapeutically equivalent to but chemically different from the drug originally prescribed by a physician or other authorized prescriber. SFHP follows ACCP’s definition of therapeutic interchange and will only employ therapeutic interchange with prescriber’s approval. Criteria for

http://www.sfhp.org/files/providers/formulary/Prior_Auth_Criteria.pdf


consideration in therapeutic interchange include availability of agents within a therapeutic class, therapeutic equivalence, safety data, and costs.

Home Blood Pressure Monitors Effective 2/6/16, Omron Series 3, 5, and 10 home blood pressure monitors are covered as a pharmacy benefit for a quantity of 1 monitor per member every 5 years.

Formulary Document Details The SFHP formulary document is listed by drug class and includes the following information: drug name, dosage form, drug tier, quantity limit and prior authorization, or step therapy requirements. Brand products are listed in all uppercase letters and generic products are listed in all lowercase letters. Tier 1 drugs are formulary and will pay at the point of sale, if quantity limits and age limitations are met (see “Formulary Restrictions” above). Tier 2 drugs may require a Prior Authorization (see “Request for Non-Preferred Medications” above).

**Some medications may be listed as both Tier 1 and Tier 2 due to a particular strength being formulary and another strength of the same medication requiring a prior authorization.

If you are hearing impaired, please call the TDD/TYY line at 1(415) 547-7830, toll-free at 1(888) 883-7347 or through the California Relay Service at 711. You may request this document in alternative formats like Braille, large size print, and audio. To request other formats, or for help with reading this document and other SFHP materials, please call Customer Service at 1(415) 547-7800 or toll-free at 1(800) 288-5555.

1

Drug Generic drugs = lowercase italics

Brand name drugs = UPPERCASE

Tier T1= Formulary, Generic T2= Formulary, Brand T3= Formulary, Prior Authorization or Step Therapy T4= Specialty Pharmacy, Prior Authorization T5= Non-Formulary, Carve Out, or Obtain through the Medical Benefit

Notes AL= Age Limit PA= Prior Authorization QL= Quantity Limit ST= Step Therapy

Drug Tier Notes

Antihistamine Drugs

Ethanolamine Derivatives

carbinoxamine maleate oral liquid T5

carbinoxamine maleate oral tablet 4 mg T5

CHILDREN'S ALLERGY (DIPHENHYD) ORAL ELIXIR

T1

clemastine oral syrup T5

dimenhydrinate oral T1

DIPHENHIST ORAL TABLET 50 MG T1

diphenhydramine hcl oral capsule T1

diphenhydramine hcl oral tablet 25 mg T1

Q-DRYL ORAL LIQUID T1

First Gen. Antihist. Derivatives, Misc. cyproheptadine T5

First Generation Antihistamines




T1

chlorpheniramine maleate oral tablet T1

chlorpheniramine maleate oral tablet extended release

T1


cyproheptadine T5

dexchlorpheniramine maleate oral syrup T5

2

Drug Tier Notes





ED-CHLORPED T5


Phenothiazine Derivatives

promethazine oral T1 AL

promethazine rectal suppository 12.5 mg, 25 mg T1 AL

PROMETHAZINE VC T1 AL

Piperazine Derivatives

hydroxyzine hcl intramuscular T5

hydroxyzine hcl oral solution 10 mg/5 ml T5

hydroxyzine hcl oral tablet T5

hydroxyzine pamoate T5

meclizine oral tablet 12.5 mg, 25 mg T1

meclizine oral tablet,chewable T1

Propylamine Derivatives

APRODINE T1 AL



T1


ED A-HIST (NEW DOSING) T5

ED-CHLORPED T5

KIDKARE COUGH/COLD T1 AL

PHENABID T5

Second Generation Antihistamines

ALAVERT T1

cetirizine oral tablet T1

cetirizine oral tablet,chewable T1

CHILDREN'S ALLEGRA ALLERGY ORAL TABLET,DISINTEGRATING

T1

CHILD'S ALL DAY ALLERGY(CETIR) T1

3

Drug Tier Notes

CLARINEX ORAL SYRUP T5

CLARINEX-D 12 HOUR T5

desloratadine oral tablet T5

fexofenadine oral suspension T1

fexofenadine oral tablet 180 mg, 60 mg T1

levocetirizine T5

loratadine oral solution T1

loratadine oral tablet T1

LORATADINE-D T1 AL

SEMPREX-D T5

Anti-Infective Agents

1St Generation Cephalosporin Antibiotics

cefadroxil oral capsule T5

cefadroxil oral suspension for reconstitution 250 mg/5 ml, 500 mg/5 ml

T5

cefadroxil oral tablet T5

cefazolin injection recon soln 100 gram, 300 g T5

cephalexin oral capsule 250 mg, 500 mg T5

cephalexin oral suspension for reconstitution T5

cephalexin oral tablet T5

KEFLEX ORAL CAPSULE 750 MG T5

2Nd Generation Cephalosporin Antibiotics

cefaclor oral capsule T5

cefotetan T5

cefoxitin T5

cefoxitin in dextrose, iso-osm T5

cefprozil T5

CEFTIN ORAL SUSPENSION FOR RECONSTITUTION

T5

CEFTIN ORAL TABLET 250 MG, 500 MG T5

cefuroxime sodium injection T5

cefuroxime sodium intravenous recon soln 7.5 gram

T5

cefuroxime-dextrose (iso-osm) T5

4

Drug Tier Notes

MEFOXIN IN DEXTROSE (ISO-OSM) T5

ZINACEF IN STERILE WATER T5

ZINACEF INTRAVENOUS RECON SOLN 750 MG

T5

3Rd Generation Cephalosporin Antibiotics

CEDAX T5

cefdinir T5

cefditoren pivoxil oral tablet 200 mg T5

cefotaxime T5

cefpodoxime T5

ceftriaxone in dextrose,iso-os T5

CLAFORAN INTRAVENOUS RECON SOLN T5

FORTAZ IN DEXTROSE 5 % T5

FORTAZ INTRAVENOUS T5

SUPRAX ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML, 200 MG/5 ML

T5

SUPRAX ORAL TABLET T5

4Th Generation Cephalosporin Antibiotics

cefepime in dextrose,iso-osm intravenous piggyback 1 gram/50 ml

T5

cefepime injection T5

5Th Generation Cephalosporin Antibiotics

TEFLARO T5

Adamantane Antivirals

amantadine hcl T5

rimantadine T5

Allylamine Antifungals

LAMISIL T5

TERBINEX T5

Amebicides

FLAGYL ER T5

FLAGYL ORAL CAPSULE T5

HELIDAC T5

5

Drug Tier Notes

METRO I.V. T5

metronidazole in nacl (iso-os) T5

metronidazole oral tablet T5

paromomycin T5

PYLERA T5

YODOXIN T5

Aminoglycoside Antibiotics

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 100 mg/50 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml

T5

gentamicin sulfate (pf) intravenous solution 80 mg/8 ml

T5

NEO-FRADIN T5

neomycin T5

paromomycin T5

tobramycin in 0.225 % nacl T5

tobramycin in 0.9 % nacl T5

Aminopenicillin Antibiotics

amoxicillin oral capsule T5

amoxicillin oral suspension for reconstitution T5

amoxicillin oral tablet T5

amoxicillin oral tablet,chewable 125 mg, 250 mg T5

amoxicillin-pot clavulanate T5

ampicillin T5

ampicillin sodium intravenous T5

ampicillin-sulbactam T5

AUGMENTIN ORAL SUSPENSION FOR RECONSTITUTION 125-31.25 MG/5 ML

T5

MOXATAG T5

OMECLAMOX-PAK T5

PREVPAC T5

UNASYN INJECTION RECON SOLN 15 GRAM

T5

Anthelmintics

6

Drug Tier Notes

ALBENZA T5

BILTRICIDE T5

PIN-X ORAL SUSPENSION T5

STROMECTOL T5

Antifungals, Miscellaneous

GRIFULVIN V ORAL TABLET T5

griseofulvin microsize oral suspension T5

GRIS-PEG (ULTRAMICROSIZE) T5

SSKI T5

THYROSHIELD T5

Antimalarials

ARALEN T5

chloroquine phosphate oral tablet 250 mg T5

COARTEM T5

DARAPRIM T5

HELIDAC T5

hydroxychloroquine T5

MALARONE T5

MALARONE PEDIATRIC T5

mefloquine T5

primaquine T5

PYLERA T5

QUALAQUIN T5

quinidine gluconate T5

quinidine sulfate T5

Antimycobacterials, Miscellaneous

dapsone oral T5

Antiprotozoals, Miscellaneous

ALINIA T5

atovaquone T5

dapsone oral T5

FLAGYL ER T5

FLAGYL ORAL CAPSULE T5

7

Drug Tier Notes

HELIDAC T5

METRO I.V. T5

metronidazole in nacl (iso-os) T5

metronidazole oral tablet T5

NEBUPENT T5

PENTAM T5

PYLERA T5

tinidazole T5

Antituberculosis Agents

AVELOX T5

AVELOX IN NACL (ISO-OSMOTIC) T5

BIAXIN ORAL SUSPENSION FOR RECONSTITUTION 250 MG/5 ML

T5

BIAXIN ORAL TABLET T5

CAPASTAT T5

CIPRO ORAL SUSPENSION,MICROCAPSULE RECON

T5

ciprofloxacin (mixture) T5

ciprofloxacin hcl oral T5

ciprofloxacin in 5 % dextrose T5

ciprofloxacin lactate intravenous solution 400 mg/40 ml

T5

clarithromycin oral suspension for reconstitution 125 mg/5 ml

T5

cycloserine T5

ethambutol T5

isoniazid oral T5

LEVAQUIN IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK 250 MG/50 ML, 500 MG/100 ML

T5

levofloxacin in d5w intravenous piggyback 250 mg/50 ml, 750 mg/150 ml

T5

levofloxacin intravenous T5

levofloxacin oral T5

MYCOBUTIN T5

PASER T5

8

Drug Tier Notes

pretomanid T5

PRIFTIN T5

pyrazinamide T5

RIFADIN T5

RIFAMATE T5

RIFATER T5

TRECATOR T5

Antivirals, Miscellaneous

foscarnet T5

Azole Antifungals

fluconazole T5

fluconazole in dextrose(iso-o) T5

fluconazole in nacl (iso-osm) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml

T5

itraconazole oral capsule T5

ketoconazole oral T5

NOXAFIL ORAL SUSPENSION T5

SPORANOX ORAL SOLUTION T5

VFEND ORAL SUSPENSION FOR RECONSTITUTION

T5

voriconazole intravenous T5

voriconazole oral tablet T5

Bacitracin Antibiotics

BACIIM T5

Carbapenem Antibiotics

DORIBAX T5

imipenem-cilastatin T5

INVANZ T5

meropenem T5

Cephamycin Antibiotics

cefotetan T5

cefoxitin T5

cefoxitin in dextrose, iso-osm T5

MEFOXIN IN DEXTROSE (ISO-OSM) T5

9

Drug Tier Notes

Chloramphenicol Antibiotics

chloramphenicol sod succinate T5

Cyclic Lipopeptide Antibiotics

CUBICIN T5

Echinocandin Antifungals

CANCIDAS T5

ERAXIS(WATER DILUENT) T5

MYCAMINE T5

Erythromycin Antibiotics

E.E.S. 400 ORAL TABLET T5

E.E.S. GRANULES T5

ERYPED 400 T5

ERY-TAB T5

ERYTHROCIN T5

ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG

T5

erythromycin oral capsule,delayed release(dr/ec) T5

erythromycin oral tablet T5

erythromycin-sulfisoxazole T5

PCE T5

Extended-Spectrum Penicillins

piperacillin-tazobactam intravenous recon soln 3.375 gram, 4.5 gram, 40.5 gram

T5

TIMENTIN T5

ZOSYN IN DEXTROSE (ISO-OSM) INTRAVENOUS PIGGYBACK 2.25 GRAM/50 ML, 3.375 GRAM/50 ML

T5

Glycopeptide Antibiotics

VANCOCIN T5

vancomycin in dextrose 5 % intravenous piggyback 1 gram/200 ml

T5

vancomycin intravenous recon soln 750 mg T5

VIBATIV INTRAVENOUS RECON SOLN 750 MG

T5

Glycylcycline Antibiotics

10

Drug Tier Notes

TYGACIL T5

Hcv Protease Inhibitor Antivirals

INCIVEK T5

VICTRELIS T5

Hiv Entry And Fusion Inhibitors

FUZEON SUBCUTANEOUS KIT T5

SELZENTRY ORAL TABLET 150 MG, 300 MG T5

Hiv Integrase Inhibitor Antiretrovirals

ISENTRESS ORAL TABLET T5

Hiv Nonnucleoside Rev.Transcrip. Inhib.

ATRIPLA T5

INTELENCE T5

nevirapine oral tablet extended release 24 hr 400 mg

T5

RESCRIPTOR T5

SUSTIVA T5

VIRAMUNE T5

Hiv Nucleoside, Nucleotide Rt Inhibitors

abacavir oral tablet T5

abacavir-lamivudine-zidovudine T5

ATRIPLA T5

didanosine T5

EMTRIVA T5

EPIVIR HBV ORAL SOLUTION T5

EPIVIR ORAL SOLUTION T5

EPZICOM T5

lamivudine oral tablet T5

lamivudine-zidovudine T5

RETROVIR INTRAVENOUS T5

stavudine T5

TRUVADA ORAL TABLET 200-300 MG T5

VIDEX 2 GRAM PEDIATRIC T5

VIDEX 4 GRAM PEDIATRIC T5

VIREAD ORAL TABLET 300 MG T5

11

Drug Tier Notes

ZIAGEN ORAL SOLUTION T5

zidovudine T5

Hiv Protease Inhibitor Antiretrovirals

APTIVUS T5

APTIVUS (WITH VITAMIN E) T5

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG T5

INVIRASE T5

KALETRA T5

LEXIVA T5

NORVIR ORAL CAPSULE T5

NORVIR ORAL SOLUTION T5

NORVIR ORAL TABLET T5

PREZISTA ORAL TABLET 150 MG, 400 MG, 600 MG, 75 MG

T5

REYATAZ ORAL CAPSULE 150 MG, 200 MG, 300 MG

T5

VIRACEPT ORAL TABLET T5

Interferon Antivirals

ALFERON N T5

INFERGEN SUBCUTANEOUS SOLUTION 15 MCG/0.5 ML

T5

INTRON A INJECTION T5

PEGASYS CONVENIENCE PACK T5

PEGINTRON T5

Ketolide Antibiotics

KETEK T5

Lincomycin Antibiotics

CLEOCIN HCL ORAL CAPSULE 75 MG T5

CLEOCIN IN 5 % DEXTROSE T5

CLEOCIN PEDIATRIC T5

clindamycin hcl oral capsule 150 mg, 300 mg T5

LINCOCIN T5

Macrolide Antibiotics

E.E.S. 400 ORAL TABLET T5

12

Drug Tier Notes

E.E.S. GRANULES T5

ERYPED 400 T5

ERY-TAB T5

ERYTHROCIN T5

ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG

T5

erythromycin oral capsule,delayed release(dr/ec) T5

erythromycin oral tablet T5

PCE T5

Monobactam Antibiotics

AZACTAM IN DEXTROSE (ISO-OSM) T5

aztreonam T5

CAYSTON T5

Monoclonal Antibody Antivirals

SYNAGIS T5

Natural Penicillin Antibiotics

BICILLIN C-R T5

penicillin g pot in dextrose T5

penicillin g sodium T5

penicillin v potassium T5

Neuraminidase Inhibitor Antivirals

RELENZA DISKHALER T5

TAMIFLU ORAL CAPSULE T5

Nucleoside And Nucleotide Antivirals

acyclovir oral capsule T5

acyclovir oral suspension 200 mg/5 ml T5

acyclovir oral tablet T5

acyclovir sodium T5

adefovir T5

BARACLUDE T5

COPEGUS T5

CYTOVENE T5

famciclovir T5

REBETOL T5

13

Drug Tier Notes

TYZEKA T5

valacyclovir T5

VALCYTE T5

VIRAZOLE T5

VISTIDE T5

Other Macrolide Antibiotics

azithromycin T5

BIAXIN ORAL SUSPENSION FOR RECONSTITUTION 250 MG/5 ML

T5

BIAXIN ORAL TABLET T5

clarithromycin oral suspension for reconstitution 125 mg/5 ml

T5

OMECLAMOX-PAK T5

PREVPAC T5

ZMAX T5

Other Misc. Antibacterial Agents

HELIDAC T5

PYLERA T5

Oxazolidinone Antibiotics

ZYVOX INTRAVENOUS PIGGYBACK 200 MG/100 ML

T5

ZYVOX ORAL T5

Penicillinase-Resistant Penicillins

dicloxacillin T5

nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml

T5

oxacillin in dextrose(iso-osm) T5

oxacillin injection recon soln 10 gram T5

oxacillin intravenous T5

Polyene Antifungals

ABELCET T5

AMBISOME T5

AMPHOTEC T5

amphotericin b T5

nystatin oral powder 50 million unit T5

14

Drug Tier Notes

nystatin oral suspension T5

nystatin oral tablet T5

Polymyxin Antibiotics

colistin (colistimethate na) T5

polymyxin b sulfate T5

Quinolone Antibiotics

AVELOX T5

AVELOX IN NACL (ISO-OSMOTIC) T5

CIPRO ORAL SUSPENSION,MICROCAPSULE RECON

T5

ciprofloxacin (mixture) T5

ciprofloxacin hcl oral T5

ciprofloxacin in 5 % dextrose T5

ciprofloxacin lactate intravenous solution 400 mg/40 ml

T5

FACTIVE T5

LEVAQUIN IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK 250 MG/50 ML, 500 MG/100 ML

T5

levofloxacin in d5w intravenous piggyback 250 mg/50 ml, 750 mg/150 ml

T5

levofloxacin intravenous T5

levofloxacin oral T5

NOROXIN T5

ofloxacin oral T5

Rifamycin Antibiotics

MYCOBUTIN T5

PRIFTIN T5

RIFADIN T5

RIFAMATE T5

RIFATER T5

XIFAXAN T5

Streptogramin Antibiotics

SYNERCID T5

Sulfonamide Antibiotics (Systemic)

15

Drug Tier Notes

AZULFIDINE T5

AZULFIDINE EN-TABS T5

BACTRIM T5

BACTRIM DS T5

erythromycin-sulfisoxazole T5

sulfadiazine T5

sulfamethoxazole-trimethoprim intravenous T5

sulfamethoxazole-trimethoprim oral suspension T5

Tetracycline Antibiotics

ALODOX T5

AVIDOXY DK T5

demeclocycline T5

doxycycline hyclate intravenous T5

doxycycline hyclate oral capsule T5

doxycycline hyclate oral tablet 100 mg T5

doxycycline hyclate oral tablet,delayed release (dr/ec) 100 mg, 150 mg, 75 mg

T5

doxycycline monohydrate oral capsule T5

doxycycline monohydrate oral tablet T5

HELIDAC T5

MINOCIN INTRAVENOUS T5

MINOCIN KIT WITH WIPES T5

minocycline oral capsule T5

minocycline oral tablet T5

minocycline oral tablet extended release 24 hr 135 mg, 45 mg, 90 mg

T5

ORACEA T5

PYLERA T5

SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG

T5

tetracycline T5

VIBRAMYCIN ORAL SUSPENSION FOR RECONSTITUTION

T5

VIBRAMYCIN ORAL SYRUP T5

16

Drug Tier Notes

Urinary Anti-Infectives

FURADANTIN T5

HIPREX T5

MACRODANTIN ORAL CAPSULE 25 MG T5

MONUROL T5

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

T5

nitrofurantoin monohyd/m-cryst T5

trimethoprim T5

Antineoplastic Agents

Antineoplastic Agents

ABRAXANE T5

ADRIAMYCIN INTRAVENOUS RECON SOLN T5

ADRIAMYCIN INTRAVENOUS SOLUTION 10 MG/5 ML

T5

ADRUCIL INTRAVENOUS SOLUTION 500 MG/10 ML

T5

AFINITOR DISPERZ T5

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG

T5

ALFERON N T5

ALIMTA T5

ALKERAN T5

anastrozole T5

AROMASIN T5

ARRANON T5

ARZERRA INTRAVENOUS SOLUTION 1,000 MG/50 ML

T5

AVASTIN T5

BEXXAR DOSIMETRIC T5

bicalutamide T5

BICNU T5

bleomycin T5

CARAC T5

carboplatin T5

17

Drug Tier Notes

cisplatin intravenous solution T5

cladribine T5

CLOLAR T5

COMETRIQ T5

COSMEGEN T5

cyclophosphamide intravenous T5

cyclophosphamide oral tablet T5

cytarabine T5

cytarabine (pf) injection recon soln T5

cytarabine (pf) injection solution 2 gram/20 ml (100 mg/ml), 20 mg/ml

T5

dacarbazine T5

DACOGEN T5

daunorubicin T5

DAUNOXOME T5

DEPOCYT (PF) T5

diclofenac sodium topical gel 3 % T5

docetaxel intravenous solution 20 mg/2 ml (final), 80 mg/8 ml (final)

T5

DROXIA T5

EFUDEX TOPICAL CREAM T5

ELIGARD T5

ELIGARD (3 MONTH) T5



ELOXATIN T5

ELSPAR T5

EMCYT T5

epirubicin intravenous recon soln 50 mg T5

epirubicin intravenous solution 50 mg/25 ml T5

ERBITUX T5

ERIVEDGE T5

ETOPOPHOS T5

etoposide T5

18

Drug Tier Notes

FARESTON T5

FASLODEX T5

FIRMAGON T5

floxuridine T5

fludarabine T5

FLUOROPLEX T5

fluorouracil intravenous T5

fluorouracil topical solution T5

flutamide T5

FOLOTYN INTRAVENOUS SOLUTION 20 MG/ML (1 ML)

T5

gemcitabine intravenous recon soln 1 gram, 200 mg

T5

GLEEVEC T5

HALAVEN T5

HERCEPTIN INTRAVENOUS RECON SOLN 440 MG

T5

HEXALEN T5

HYCAMTIN ORAL T5

HYDREA T5

IDAMYCIN PFS T5

IFEX T5

ifosfamide intravenous solution 1 gram/20 ml T5

ifosfamide-mesna intravenous kit 1-1 gram T5


irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml

T5

ISTODAX T5

IXEMPRA T5

JEVTANA T5

letrozole T5

LEUKERAN T5

leuprolide subcutaneous kit T5

LIPODOX T5

lomustine T5

19

Drug Tier Notes

LUPRON DEPOT T5

LUPRON DEPOT (3 MONTH) T5


LUPRON DEPOT-PED T5

LYSODREN T5

MATULANE T5

MEGACE ES T5

megestrol oral suspension 400 mg/10 ml (40 mg/ml)

T5

megestrol oral tablet T5

melphalan hcl T5

mercaptopurine T5

methotrexate sodium T5

methotrexate sodium (pf) T5

mitomycin intravenous T5

mitoxantrone T5

MUSTARGEN T5

MYLERAN T5

NEXAVAR T5

NILANDRON T5

ONCASPAR T5

ONTAK T5

oxaliplatin intravenous recon soln 100 mg T5

paclitaxel T5

PANRETIN T5

pentostatin T5

PHOTOFRIN T5

POMALYST T5

PROLEUKIN T5

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG

T5

RHEUMATREX T5

RITUXAN T5

SPRYCEL T5

20

Drug Tier Notes

SUPPRELIN LA T5

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 50 MG

T5

TABLOID T5

tamoxifen T5

TARCEVA T5

TARGRETIN T5

TASIGNA ORAL CAPSULE 150 MG, 200 MG T5

TAXOTERE INTRAVENOUS SOLUTION 20 MG/ML (1 ML), 80 MG/4 ML (20 MG/ML)

T5

TEMODAR T5

THERACYS T5

thiotepa injection recon soln 15 mg T5

TICE BCG T5

topotecan intravenous recon soln T5

TORISEL T5

TREANDA INTRAVENOUS RECON SOLN 100 MG

T5

TRELSTAR INTRAMUSCULAR SYRINGE T5

tretinoin (chemotherapy) T5

TREXALL T5

TRISENOX INTRAVENOUS SOLUTION 1 MG/ML

T5

TYKERB T5

VALCHLOR T5

VALSTAR T5

VANTAS T5

VECTIBIX T5

VELCADE T5

VIDAZA T5

vinblastine T5

VINCASAR PFS INTRAVENOUS SOLUTION 1 MG/ML

T5

vinorelbine T5

VOTRIENT T5

21

Drug Tier Notes

VUMON T5

XELODA T5

ZALTRAP T5

ZANOSAR T5

ZEVALIN (Y-90) T5

ZOLADEX T5

ZOLINZA T5

Antitoxins,Immune Glob,Toxoids,Vaccines

Allergenic Extracts (Therapeutic)

HONEY BEE TREATMENT T5

Antitoxins And Immune Globulins

CARIMUNE NF NANOFILTERED T5

CROFAB T5

DIGIFAB T5

FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 %

T5

GAMASTAN S/D T5

GAMMAGARD LIQUID T5

GAMMAGARD S/D INTRAVENOUS RECON SOLN 2.5 GRAM

T5

GAMMAGARD S-D (IGA < 1 MCG/ML) T5

GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 5 GRAM/50 ML (10 %)

T5

HEPAGAM B INJECTION SOLUTION GREATR THAN 312 UNIT/ML (5 ML)

T5

HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %)

T5

HYPERHEP B S-D NEONATAL T5

HYPERRAB S/D (PF) T5

HYPERRHO S/D T5

HYPERTET S/D (PF) T5

RHOPHYLAC T5

WINRHO SDF T5

Toxoids

22

Drug Tier Notes

ADACEL(TDAP ADOLESN/ADULT)(PF) INTRAMUSCULAR SYRINGE

T5

BOOSTRIX TDAP INTRAMUSCULAR SYRINGE

T5

DAPTACEL (DTAP PEDIATRIC) (PF) T5

INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE

T5

PEDIARIX (PF) T5

tetanus toxoid,adsorbed (pf) T5

tetanus-diphtheria toxoids-td T5

Vaccines

ACTHIB (PF) T5

BIOTHRAX T5

CERVARIX VACCINE (PF) T5

COMVAX (PF) T5

ENGERIX-B (PF) T5

ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SUSPENSION

T5

FLUBLOK 2013-2014 (PF) T5

FLUCELVAX 2013-2014 (PF) T5

FLULAVAL QUAD 2013-2014 T5

FLUMIST 2012-2013 T5

FLUVIRIN 2012-2013 T5

FLUVIRIN 2012-2013 (PF) T5

FLUVIRIN 2013-2014 T5

FLUVIRIN 2013-2014 (PF) T5

FLUZONE HIGH-DOSE 2012-13 (PF) T5

GARDASIL (PF) INTRAMUSCULAR SYRINGE

T5

HAVRIX (PF) INTRAMUSCULAR SUSPENSION 720 ELISA UNIT/0.5 ML

T5

HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440 ELISA UNIT/ML

T5

IMOVAX RABIES VACCINE (PF) T5

IPOL T5

IXIARO (PF) T5

23

Drug Tier Notes

KINRIX (PF) INTRAMUSCULAR SUSPENSION

T5

MENACTRA (PF) INTRAMUSCULAR SYRINGE

T5

MENHIBRIX (PF) T5

MENOMUNE - A/C/Y/W-135 (PF) T5

MENVEO A-C-Y-W-135-DIP (PF) T5

M-M-R II (PF) T5

PEDIARIX (PF) T5

PEDVAX HIB (PF) T5

PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF/0.5 ML

T5

PNEUMOVAX-23 INJECTION SOLUTION T5

PREVNAR 13 (PF) T5

PROQUAD (PF) T5

RABAVERT (PF) T5

RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 40 MCG/ML, 5 MCG/0.5 ML

T5

RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCG/ML

T5

ROTARIX T5

ROTATEQ VACCINE T5

SINGLE USE EZ FLU 2013-14 (PF) INTRAMUSCULAR SYRINGE KIT 45 MCG (15 MCG X 3)/0.5 ML

T5

THERACYS T5

TICE BCG T5

TWINRIX (PF) INTRAMUSCULAR SYRINGE T5

TYPHIM VI INTRAMUSCULAR SYRINGE T5

VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT/0.5 ML

T5

VAQTA (PF) INTRAMUSCULAR SYRINGE 50 UNIT/ML

T5

VARIVAX (PF) T5

VIVOTIF BERNA VACCINE T5

YF-VAX (PF) T5

ZOSTAVAX (PF) T5

24

Drug Tier Notes

Autonomic Drugs

Alpha- And Beta-Adrenergic Agonists

ADRENALIN INJECTION SOLUTION 1 MG/ML

T5

APRODINE T1 AL

bupivacaine-epinephrine (pf) T5

CHILDREN'S SILFEDRINE T1 AL


CONGEST-EZE T1

ephedrine sulfate injection solution T5

ephedrine sulfate oral T5

epinephrine injection syringe 0.1 mg/ml T5

EPIPEN 2-PAK T5

EPIPEN JR 2-PAK T5


lidocaine-epinephrine (pf) T5

lidocaine-epinephrine injection solution 0.5 %-1:200,000, 1 %-1:100,000, 2 %-1:100,000

T5

LORATADINE-D T1 AL

NASAL DECONGESTANT (PSEUDOEPH) ORAL LIQUID

T1 AL

norepinephrine bitartrate T5

pseudoephedrine hcl oral tablet T1 AL

pseudoephedrine hcl oral tablet extended release T1 AL

pseudoephedrine-guaifenesin oral tablet extended release 12 hr 60-600 mg

T1 AL

racepinephrine T5

REZIRA T5

SEMPREX-D T5

SENSORCAINE-EPINEPHRINE T5

SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 0.75 %-1:200,000

T5

SUDAFED 24 HOUR T1

SUDOGEST 12-HOUR T1 AL

SUDOGEST ORAL TABLET 60 MG T1 AL

25

Drug Tier Notes

XYLOCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 1 %-1:200,000

T5

Alpha-Adrenergic Agonists

clonidine T5

clonidine (pf) T5

clonidine hcl oral tablet T5

CLORPRES T5


methyldopa T5

methyldopate T5

midodrine T5

NEO-SYNEPHRINE (PHENYLEPHRINE) INJECTION

T5

PHENABID T5


Antimuscarinics/Antispasmodics

ANASPAZ T5

ANORO ELLIPTA T5

ATROPEN INTRAMUSCULAR PEN INJECTOR 0.5 MG/0.7 ML, 1 MG/0.7 ML, 2 MG/0.7 ML

T5

atropine injection syringe 0.1 mg/ml T5

ATROVENT HFA T5

belladonna tincture (bulk) T5

BENTYL INTRAMUSCULAR T5

BENTYL ORAL CAPSULE T5

BENTYL ORAL TABLET T5

CANTIL T5

chlordiazepoxide-clidinium T5

COMBIVENT T5

CUVPOSA T5

dicyclomine oral solution T5

diphenoxylate-atropine oral tablet T5

glycopyrrolate oral tablet 1 mg, 2 mg T5

hyoscyamine sulfate oral drops T5

26

Drug Tier Notes

hyoscyamine sulfate oral elixir T5

hyoscyamine sulfate oral tablet T5

hyoscyamine sulfate oral tablet extended release 12 hr

T1

hyoscyamine sulfate sublingual T1

ipratropium bromide inhalation T5

ipratropium-albuterol T5

LEVSIN INJECTION T5

methscopolamine T5

phenobarb-hyoscy-atropine-scop oral tablet T5

propantheline T5

scopolamine hbr T5

SPIRIVA WITH HANDIHALER T5

SYMAX DUOTAB T5

Antiparkinsonian Agents

benztropine T5

trihexyphenidyl T5

Autonomic Drugs, Miscellaneous

CHANTIX CONTINUING MONTH BOX T5

CHANTIX ORAL TABLET 0.5 MG T5

CHANTIX STARTING MONTH BOX T5

nicotine (polacrilex) buccal gum 2 mg T1 QL (360 EA per 30 days)

nicotine (polacrilex) buccal gum 4 mg T1 QL (360 QY per 30 DYs)

nicotine (polacrilex) buccal lozenge T1 QL (360 EA per 30 days)

nicotine transdermal patch 24 hour 14 mg/24 hr, 21 mg/24 hr, 7 mg/24 hr

T1 QL (30 QY per 30 DYs)

NICOTROL T5

NICOTROL NS T5

Centrally Acting Skeletal Muscle Relaxnt

AMRIX T5

carisoprodol oral tablet 250 mg T5

carisoprodol-aspirin T5

carisoprodol-aspirin-codeine T5

chlorzoxazone oral tablet 500 mg T5

27

Drug Tier Notes

cyclobenzaprine oral tablet T5

metaxalone oral tablet 800 mg T5

methocarbamol oral T5

ROBAXIN INJECTION T5

tizanidine T5

Direct-Acting Skeletal Muscle Relaxants

REVONTO T5

Gaba-Derivative Skeletal Muscle Relaxant

baclofen oral tablet 10 mg, 20 mg T5

GABLOFEN INTRATHECAL SOLUTION 40,000 MCG/20ML (2,000 MCG/ML)

T5

LIORESAL T5

Neuromuscular Blocking Agents

ANECTINE T5

Non-Sel. Beta-Adrenergic Blocking Agents

BYSTOLIC T5

carvedilol T5

COREG CR T5

INNOPRAN XL T5

labetalol intravenous syringe 20 mg/4 ml (5 mg/ml)

T5

labetalol oral T5

nadolol T5

nadolol-bendroflumethiazide T5

pindolol T5

propranolol oral T5

propranolol-hydrochlorothiazid T5

sotalol T5

Non-Sel.Alpha-1-Adrenergic Blocking Agts

doxazosin T5

prazosin T5

terazosin T5

Non-Sel.Alpha-Adrenergic Blocking Agents

CAFERGOT T5

28

Drug Tier Notes

D.H.E.45 T5

DIBENZYLINE T5

ergoloid T5

ERGOMAR T5

MIGRANAL T5

phentolamine injection recon soln T5

Non-Selective Beta-Adrenergic Agonists

ISUPREL T5

Parasympathomimetic (Cholinergic Agents)

bethanechol chloride T5

donepezil T5

EVOXAC T5

EXELON ORAL SOLUTION T5

EXELON TRANSDERMAL PATCH 24 HOUR 4.6 MG/24 HR, 9.5 MG/24 HR

T5

galantamine T5

guanidine T5

MESTINON ORAL T5

MESTINON TIMESPAN T5

neostigmine methylsulfate injection T5

physostigmine salicylate T5

pilocarpine hcl oral T5

PROSTIGMIN T5

REGONOL T5

rivastigmine tartrate T5

Selective Alpha-1-Adrenergic Block.Agent

carvedilol T5

COREG CR T5

FLOMAX T5

JALYN T5


T5

labetalol oral T5

RAPAFLO T5

29

Drug Tier Notes

UROXATRAL T5

Selective Beta-1-Adrenergic Agonists

dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml)

T5

dobutamine intravenous solution 250 mg/20 ml (12.5 mg/ml)

T5

dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 800 mg/250 ml (3,200 mcg/ml)

T5

dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 800 mg/10 ml (80 mg/ml), 800 mg/5 ml (160 mg/ml)

T5

Selective Beta-2-Adrenergic Agonists

ADVAIR DISKUS T5

ADVAIR HFA T5

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml

T5

albuterol sulfate oral syrup T5

albuterol sulfate oral tablet T5

ANORO ELLIPTA T5

BROVANA T5

budesonide-formoterol T5

COMBIVENT T5

DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION

T5

FORADIL AEROLIZER T5


levalbuterol hcl inhalation solution for nebulization 1.25 mg/0.5 ml

T5

MAXAIR AUTOHALER T5

metaproterenol T5

PERFOROMIST T5

PROAIR HFA T5

SEREVENT DISKUS T5

30

Drug Tier Notes

terbutaline T5

XOPENEX T5

XOPENEX HFA T5

Selective Beta-Adrenergic Blocking Agent

atenolol T5

atenolol-chlorthalidone T5

bisoprolol fumarate T5

bisoprolol-hydrochlorothiazide T5

metoprolol succinate T5

metoprolol ta-hydrochlorothiaz T5

metoprolol tartrate intravenous solution T5

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

T5

Skeletal Muscle Relaxants, Miscellaneous

BOTOX T5

BOTOX COSMETIC T5

DYSPORT T5

MYOBLOC INTRAMUSCULAR SOLUTION 10,000 UNIT/2 ML

T5

orphenadrine citrate injection T5

ORPHENADRINE COMPOUND-DS T5

XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT, 50 UNIT

T5

Blood Derivatives

Blood Derivatives

ALBUMINAR 25 % T5

ALBUMINAR 5 % T5

Blood Formation, Coagulation, Thrombosis

Anticoagulants

TRICITRASOL T5

Anticoagulants, Miscellaneous

ACD-A T5

anticoag citrate phos dextrose T5

CEPROTIN (BLUE BAR) T5

31

Drug Tier Notes

CEPROTIN (GREEN BAR) T5

fondaparinux T5

THROMBATE III T5

Antiheparin Agents

protamine T5

Coumarin Derivatives

COUMADIN INTRAVENOUS T5

warfarin T5

Direct Factor Xa Inhibitors

fondaparinux T5

Direct Thrombin Inhibitors

ANGIOMAX T5

argatroban T5

IPRIVASK T5

PRADAXA ORAL CAPSULE 150 MG, 75 MG T5

Hematopoietic Agents

ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML

T5

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 40 MCG/0.4 ML, 60 MCG/0.3 ML

T5

EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

T5

GRANIX SUBCUTANEOUS SYRINGE T5

LEUKINE INJECTION RECON SOLN T5

MOZOBIL T5

NEUMEGA T5

NEUPOGEN T5

NPLATE SUBCUTANEOUS RECON SOLN 250 MCG, 500 MCG

T5

PROCRIT INJECTION SOLUTION 40,000 UNIT/ML

T5

32

Drug Tier Notes

PROMACTA ORAL TABLET 25 MG, 50 MG, 75 MG

T5

Hemorrheologic Agents

pentoxifylline T5

Hemostatics

ADVATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

T5

ALPHANATE INTRAVENOUS RECON SOLN 1,000 (400 VWF) UNIT/10 ML, 1,500 (600 VWF) UNIT/10 ML, 250 (100 VWF) UNIT/5 ML, 500 (200 VWF) UNIT/5 ML

T5

ALPHANINE SD INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 500 (+/-) UNIT

T5

aminocaproic acid intravenous T5

BENEFIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 500 UNIT

T5

CYKLOKAPRON T5

DDAVP INJECTION T5

DDAVP NASAL SOLUTION T5

DDAVP ORAL T5

desmopressin nasal spray,non-aerosol T5

FEIBA NF INTRAVENOUS RECON SOLN 1,750-3,250 UNIT

T5

HELIXATE FS T5

HEMOFIL M HIGH T5

HEMOFIL M LOW T5

HEMOFIL M MID T5

HEMOFIL M SUPER HIGH T5

HUMATE-P T5

KOATE-DVI INTRAVENOUS KIT T5

KOATE-DVI INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 250 (+/-) UNIT

T5

LYSTEDA T5

MONOCLATE-P INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT

T5

NOVOSEVEN RT T5

33

Drug Tier Notes

PROFILNINE INTRAVENOUS RECON SOLN 500 (+/-) UNIT

T5

RECOMBINATE T5

RECOTHROM SPRAY KIT T5

RECOTHROM TOPICAL RECON SOLN 5,000 UNIT

T5

RIASTAP T5

RIXUBIS T5

STIMATE T5

THROMBIN-JMI NASAL T5

THROMBIN-JMI TOPICAL RECON SOLN T5

THROMBIN-JMI TOPICAL SPRAY,NON-AEROSOL

T5

XYNTHA T5

XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 3,000 (+/-) UNIT

T5

Heparins

enoxaparin T5

FRAGMIN SUBCUTANEOUS SYRINGE 10,000 ANTI-XA UNIT/ML, 12,500 ANTI-XA UNIT/0.5 ML, 2,500 ANTI-XA UNIT/0.2 ML

T5

heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml)

T5

heparin (porcine) injection solution 10,000 unit/ml, 20,000 unit/ml

T5

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml

T5

heparin, porcine (pf) intravenous solution 25,000 unit/10 ml

T5

Iron Preparations

ATABEX EC T5

BAL-CARE DHA T5

BAL-CARE DHA ESSENTIAL T5

CAVAN-EC SOD DHA T5

CENTRUM COMPLETE T1

34

Drug Tier Notes

CLASSIC PRENATAL T2

COMPLETENATE T5

CONCEPT DHA T5

CONCEPT OB T5

DUET DHA BALANCED ORAL COMBO PACK 26 MG IRON- 1 MG-278 MG

T5

DUET DHA EC-OM 3 T5

DUET DHA WITH OMEGA-3 T5

ELITE-OB 400 T5

EXTRA-VIRT PLUS DHA T5

EZFE FORTE T1 QL (30 QY per 30 DYs)

ferrous fumarate oral tablet 324 mg (106 mg iron) T1

ferrous gluconate oral tablet 240 mg (27 mg iron), 324 mg (38 mg iron), 325 mg (36 mg iron)

T1

ferrous sulfate oral drops T1

ferrous sulfate oral elixir T1

ferrous sulfate oral liquid T1

ferrous sulfate oral solution T1

ferrous sulfate oral tablet 325 mg (65 mg iron) T1

ferrous sulfate oral tablet extended release T1

ferrous sulfate oral tablet,delayed release (dr/ec) T1

FLINTSTONES COMPLETE (IRON) ORAL TABLET,CHEWABLE 18 MG IRON

T2

FOLCAL DHA T5

FOLIVANE-PRX DHA NF T5

GESTICARE DHA T5

IROSPAN 24/6 T5

KPN ORAL TABLET 9 MG IRON- 267 MCG T2 QL (30 QY per 30 DYs)

LEVOMEFOLATEPNV T5

L-METHYLFOLATE PNV DHA T5

NATACHEW (FE BIS-GLYCINATE) T5

NATAFORT (NEW FORMULA 2011) T5

NATELLE ONE T5

OB COMPLETE 400 T5

OB COMPLETE ONE T5

35

Drug Tier Notes

OB COMPLETE ORAL TABLET T5

OB COMPLETE PREMIER T5

OBSTETRIX EC T5

OBTREX T5

ONE DAILY MULTI-VIT W-MINERAL ORAL TABLET

T1

PAIRE OB PLUS DHA T5

PNV FOLIC ACID + IRON T5

POLY-VI-SOL WITH IRON T2

POLYVITAMIN WITH IRON T1

POLY-VITAMIN WITH IRON T1

PREFERA-OB ONE T5

PRENA1 T5

PRENA1 PLUS T5

PRENAISSANCE 90 DHA T5

PRENATA T5

PRENATABS FA T5

PRENATABS RX T5

PRENATAL VITAMIN ORAL TABLET 27 MG IRON- 0.8 MG

T1

PRENATE DHA T5

PRENATE ELITE T5

PRENATE ESSENTIAL T5

PRENATE MINI T5

PREQUE 10 T5

PUREFE OB PLUS T5

SELECT-OB (FOLIC ACID) T5

SE-TAN DHA T5

SETONET T5

SETONET-EC T5

TARON-BC T5

THERA-M ORAL TABLET , 9 MG IRON-400 MCG

T1

THEREMS-M T2

TRIADVANCE T5

36

Drug Tier Notes

TRINATE T5

TRIVEEN-DUO DHA T5

TRIVEEN-ONE T5

TRIVEEN-PRX RNF T5

TRIVEEN-TEN T5

TRI-VI-SOL WITH IRON T2

ULTIMATECARE ONE NF T5

VINATE AZ T5

VINATE DHA T5

VINATE M T5

VINATE ONE T5

VIRT-BAL DHA T5

VIRT-PN T5

VIRT-PN DHA T5

VIRT-SELECT T5

VITAFOL-PLUS T5

VITASPIRE T5

VIVA DHA T5

VP-CH PLUS T5

VP-CH-PNV T5

VP-ERA OB PLUS T5

VP-PNV-DHA T5

ZATEAN-CH T5

ZATEAN-PN PLUS T5

Platelet-Aggregation Inhibitors

AGGRASTAT IN SODIUM CHLORIDE INTRAVENOUS SOLUTION 5 MG/100 ML (50 MCG/ML)

T5

AGGRENOX T5

ASCRIPTIN T1

aspirin oral tablet T1

aspirin oral tablet,chewable T1

aspirin oral tablet,delayed release (dr/ec) 325 mg, 81 mg

T1

aspirin rectal suppository 600 mg T1

37

Drug Tier Notes

BAYER PLUS EXTRA STRENGTH T1

cilostazol T5

clopidogrel T5

dipyridamole T5

EFFERVESCENT ANTACID T1

EFFIENT T5

HALFPRIN T2

INTEGRILIN T5

MIGRAINE FORMULA T1

REOPRO T5

SYNALGOS-DC T5

ticlopidine T5

TRI-BUFFERED ASPIRIN T1

Platelet-Reducing Agents

AGRYLIN T5

anagrelide oral capsule 1 mg T5

Thrombolytic Agents

ACTIVASE INTRAVENOUS RECON SOLN 50 MG

T5

ASCRIPTIN T1




T1




HALFPRIN T2

MIGRAINE FORMULA T1

RETAVASE INTRAVENOUS KIT T5

SYNALGOS-DC T5


Cardiovascular Drugs

Alpha-Adrenergic Blocking Agents

38

Drug Tier Notes

carvedilol T5

COREG CR T5

doxazosin T5


T5

labetalol oral T5

prazosin T5

terazosin T5

Alpha-Adrenergic Blocking Agt.(Hypoten)

doxazosin T5


T5

labetalol oral T5

prazosin T5

terazosin T5

Angiotensin Ii Receptor Antagon.(Hypotn)

AVAPRO T5

AZOR T5

DIOVAN T5

EXFORGE T5

EXFORGE HCT T5

irbesartan-hydrochlorothiazide T5

losartan T5

losartan-hydrochlorothiazide T5

olmesartan T5

telmisartan T5

telmisartan-amlodipine T5

TEVETEN HCT T5

TRIBENZOR T5

valsartan-hydrochlorothiazide T5

Angiotensin Ii Receptor Antagonists

AVAPRO T5

AZOR T5

DIOVAN T5

39

Drug Tier Notes

EXFORGE T5

EXFORGE HCT T5


losartan T5


olmesartan T5

telmisartan T5


TEVETEN HCT T5

TRIBENZOR T5


Angiotensin-Convert.Enzyme Inhib(Hypotn)

amlodipine-benazepril T5

benazepril T5

benazepril-hydrochlorothiazide T5

captopril T5

captopril-hydrochlorothiazide T5

enalapril maleate T5

enalaprilat intravenous solution T5

enalapril-hydrochlorothiazide T5

fosinopril T5

fosinopril-hydrochlorothiazide T5

lisinopril T5

lisinopril-hydrochlorothiazide T5

moexipril T5

moexipril-hydrochlorothiazide T5

quinapril T5

quinapril-hydrochlorothiazide T5

ramipril T5

TARKA T5

Angiotensin-Converting Enzyme Inhibitors


benazepril T5


40

Drug Tier Notes

captopril T5


enalapril maleate T5

enalaprilat intravenous solution T5


fosinopril T5


lisinopril T5


moexipril T5


quinapril T5


ramipril T5

TARKA T5

Antiarrhythmic Agents

ADENOCARD T5

Antiarrhythmics, Miscellaneous

digoxin injection solution T5

digoxin oral solution 50 mcg/ml (0.05 mg/ml) T5

digoxin oral tablet T5

LANOXIN PEDIATRIC T5

magnesium sulfate in d5w intravenous piggyback 1 gram/100 ml

T5

magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %)

T5

magnesium sulfate in water intravenous piggyback 4 gram/50 ml (8 %)

T5

magnesium sulfate injection syringe T5

Antilipemic Agents, Miscellaneous

FISH OIL ORAL CAPSULE 340-1,000 MG T1 QL (120 QY per 30 DYs)

JUXTAPID ORAL CAPSULE 10 MG, 20 MG T5

LOVAZA T5

niacin oral capsule, extended release 250 mg, 500 mg

T1

41

Drug Tier Notes

niacin oral tablet 100 mg, 500 mg T1

niacin oral tablet extended release 500 mg T1

NIACOR T5

NIASPAN EXTENDED-RELEASE T5

omega-3 fatty acids-fish oil oral capsule 300-1,000 mg

T1 QL (120 QY per 30 DYs)

Beta-Adrenergic Blocking Agents

atenolol T5




BYSTOLIC T5

carvedilol T5

COREG CR T5

INNOPRAN XL T5


T5

labetalol oral T5

LEVATOL T5





T5

nadolol T5


pindolol T5

propranolol oral T5


sotalol T5

Beta-Adrenergic Blocking Agt.(Hypoten)

atenolol T5




42

Drug Tier Notes

INNOPRAN XL T5


T5

labetalol oral T5





T5

nadolol T5


pindolol T5

propranolol oral T5


sotalol T5

Bile Acid Sequestrants

cholestyramine (with sugar) T5

CHOLESTYRAMINE LIGHT T5

COLESTID FLAVORED ORAL PACKET T5

COLESTID ORAL TABLET T5

colestipol oral granules T5

WELCHOL T5

Calcium-Channel Block.Agt,Misc(Hypoten)

diltiazem hcl intravenous T5

diltiazem hcl oral capsule,ext.rel 24h degradable T5

diltiazem hcl oral capsule,extended release 12 hr T5


diltiazem hcl oral capsule,extended release 24hr T5

diltiazem hcl oral tablet T5

TARKA T5

verapamil intravenous solution T5

verapamil oral T5

Calcium-Channel Blocking Agents

amlodipine T5

43

Drug Tier Notes


AMTURNIDE T5

AZOR T5

CADUET T5

CARDENE SR T5

CLEVIPREX INTRAVENOUS EMULSION 25 MG/50 ML

T5







EXFORGE T5

EXFORGE HCT T5

felodipine T5

isradipine T5

nicardipine intravenous solution T5

nicardipine oral T5

NIFEDICAL XL T5

nifedipine oral capsule T5

nifedipine oral tablet extended release T5

nifedipine oral tablet extended release 24hr 90 mg T5

nimodipine T5

nisoldipine oral tablet extended release 24 hr 20 mg, 30 mg, 40 mg

T5

TARKA T5

TEKAMLO T5


TRIBENZOR T5


verapamil oral T5

Calcium-Channel Blocking Agents(Hypoten)


44

Drug Tier Notes







verapamil oral T5

Calcium-Channel Blocking Agents, Misc.







TARKA T5


verapamil oral T5

Carbonic Anhydrase Inhibitors(Hypoten)

acetazolamide T5

acetazolamide sodium T5

Cardiac Drugs, Miscellaneous

RANEXA T5

Cardiotonic Agents

digoxin injection solution T5

digoxin oral solution 50 mcg/ml (0.05 mg/ml) T5

digoxin oral tablet T5

dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml)

T5

dobutamine intravenous solution 250 mg/20 ml (12.5 mg/ml)

T5

dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 800 mg/250 ml (3,200 mcg/ml)

T5

45

Drug Tier Notes

dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 800 mg/10 ml (80 mg/ml), 800 mg/5 ml (160 mg/ml)

T5

LANOXIN PEDIATRIC T5

milrinone T5

milrinone in 5 % dextrose intravenous piggyback 40 mg/200 ml (200 mcg/ml)

T5

Central Alpha-Agonists

clonidine T5

clonidine (pf) T5

clonidine hcl oral tablet T5

CLORPRES T5

guanfacine oral tablet T5

INTUNIV ER T5

methyldopa T5

methyldopate T5

Cholesterol Absorption Inhibitors

VYTORIN 10-10 T5

VYTORIN 10-20 T5

VYTORIN 10-40 T5

VYTORIN 10-80 T5

ZETIA T5

Class Ia Antiarrhythmics

disopyramide phosphate oral capsule T5

NORPACE CR T5

procainamide injection T5

quinidine gluconate T5

quinidine sulfate T5

Class Ib Antiarrhythmics

DILANTIN T5

lidocaine (pf) intravenous syringe T5

mexiletine T5

phenytoin oral suspension 125 mg/5 ml T5

phenytoin oral tablet,chewable T5

46

Drug Tier Notes

phenytoin sodium extended T5

phenytoin sodium intravenous solution T5

Class Ic Antiarrhythmics

flecainide T5

propafenone T5

Class Ii Antiarrhythmics

atenolol T5




carvedilol T5

COREG CR T5

INNOPRAN XL T5


T5

labetalol oral T5





T5

nadolol T5


pindolol T5

propranolol oral T5


sotalol T5

Class Iii Antiarrhythmics

amiodarone intravenous solution T5

amiodarone oral tablet 200 mg, 400 mg T5

CORVERT T5

MULTAQ T5

PACERONE ORAL TABLET 100 MG T5

sotalol T5

47

Drug Tier Notes

TIKOSYN T5

Class Iv Antiarrhythmics

ADENOCARD T5

ADENOSCAN T5








verapamil oral T5

Dihydropyridines

amlodipine T5


AMTURNIDE T5

AZOR T5

CADUET T5

CARDENE SR T5


T5

EXFORGE T5

EXFORGE HCT T5

felodipine T5

isradipine T5


nicardipine oral T5

NIFEDICAL XL T5




nimodipine T5


T5

48

Drug Tier Notes

TEKAMLO T5


TRIBENZOR T5

Dihydropyridines (Antihypertensive)

amlodipine T5


AMTURNIDE T5

AZOR T5

CADUET T5

CARDENE SR T5


T5

EXFORGE T5

EXFORGE HCT T5

felodipine T5

isradipine T5


nicardipine oral T5

NIFEDICAL XL T5




nimodipine T5


T5

TEKAMLO T5


TRIBENZOR T5

Direct Vasodilators

BIDIL T5

hydralazine T5

minoxidil oral T5

Diuretics, Miscellaneous (Hypotensive)

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML T5

49

Drug Tier Notes

THEO-24 T5

THEOCHRON T5

theophylline oral tablet extended release T5

Fibric Acid Derivatives

ANTARA ORAL CAPSULE 43 MG T5

fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 67 mg

T5

fenofibrate oral tablet 160 mg, 54 mg T5

fenofibric acid T5

fenofibric acid (choline) T5

FENOGLIDE T5

gemfibrozil T5

LIPOFEN T5

TRICOR T5

Hmg-Coa Reductase Inhibitors

ADVICOR T5

ALTOPREV T5

atorvastatin T5

CADUET T5

CRESTOR T5

fluvastatin oral capsule T5

LESCOL XL T5

LIVALO T5

lovastatin T5

pravastatin T5

SIMCOR T5

simvastatin oral tablet T5

VYTORIN 10-10 T5

VYTORIN 10-20 T5

VYTORIN 10-40 T5

VYTORIN 10-80 T5

Hypotensive Agents, Miscellaneous

amlodipine T5


50

Drug Tier Notes

AZOR T5

CARDENE SR T5

carvedilol T5


T5

COREG CR T5

CORLOPAM T5

DIBENZYLINE T5

doxazosin T5

EXFORGE T5

felodipine T5

INNOPRAN XL T5

isradipine T5


nicardipine oral T5

NIFEDICAL XL T5




nimodipine T5


T5

phentolamine injection recon soln T5

pindolol T5

propranolol oral T5

sotalol T5

terazosin T5

Loop Diuretics (Hypotensive Agents)

bumetanide T5

DEMADEX T5

furosemide injection syringe T5

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

T5

furosemide oral tablet T5

SODIUM EDECRIN T5

51

Drug Tier Notes

torsemide intravenous solution 20 mg/2 ml (10 mg/ml)

T5

Mineralocorticoid (Aldosterone) Antagnts

ALDACTAZIDE ORAL TABLET 25-25 MG T5

eplerenone T5

spironolactone T5

Mineralocorticoid(Aldoster.)Antag(Hypot)


eplerenone T5

spironolactone T5

Nitrates And Nitrites

amyl nitrite inhalation solution 0.3 ml T5

BIDIL T5

DILATRATE-SR T5

IMDUR T5

ISORDIL T5

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg

T5

isosorbide dinitrate oral tablet extended release T5

isosorbide mononitrate oral tablet T5

NITRO-BID T5

NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR

T5

nitroglycerin in 5 % dextrose intravenous solution 100 mg/250 ml (400 mcg/ml), 50 mg/250 ml (200 mcg/ml)

T5

nitroglycerin intravenous T5

nitroglycerin oral T5

nitroglycerin transdermal patch 24 hour T5

NITROLINGUAL T5

NITROMIST T5

NITROSTAT T5

Osmotic Diuretics (Hypotensive Agents)

mannitol 10 % T5

mannitol 20 % T5

52

Drug Tier Notes

mannitol 25 % intravenous solution T5

mannitol 5 % T5

Peripheral Adrenergic Inhibitors

reserpine T5

Phosphodiesterase Type 5 Inhibitors

ADCIRCA T5

CIALIS T5

cilostazol T5

LEVITRA T5

REVATIO INTRAVENOUS T5

REVATIO ORAL TABLET T5

STAXYN T5

STENDRA T5

VIAGRA T5

Potassium-Sparing Diuretics (Hypoten)


amiloride T5

amiloride-hydrochlorothiazide T5

DYRENIUM T5

eplerenone T5

spironolactone T5

triamterene-hydrochlorothiazid oral capsule 37.5-25 mg

T5

triamterene-hydrochlorothiazid oral tablet T5

Renin Inhibitors

AMTURNIDE T5

TEKAMLO T5

TEKTURNA T5

TEKTURNA HCT T5

Sclerosing Agents

ETHAMOLIN T5

morrhuate sodium T5

SOTRADECOL T5

53

Drug Tier Notes

Thiazide Diuretics(Hypotensive Agents)



AMTURNIDE T5




chlorothiazide T5

chlorothiazide sodium T5

DIURIL T5


EXFORGE HCT T5


hydrochlorothiazide T5




methyclothiazide T5






TEKTURNA HCT T5

TEVETEN HCT T5


T5


TRIBENZOR T5


Thiazide-Like Diuretics(Hypotensive Agt)


chlorthalidone oral tablet 25 mg, 50 mg T5

CLORPRES T5

54

Drug Tier Notes

indapamide T5

metolazone T5

Vasodilating Agents, Miscellaneous

AGGRENOX T5

alprostadil T5

ambrisentan T5

amlodipine T5


AMTURNIDE T5

AZOR T5

CADUET T5

CARDENE SR T5

CAVERJECT IMPULSE T5

CAVERJECT INTRACAVERNOSAL RECON SOLN

T5


T5







dipyridamole T5

EDEX INTRACAVERNOSAL KIT 40 MCG T5

epoprostenol (glycine) T5

EXFORGE T5

felodipine T5

isradipine T5

MUSE T5

NATRECOR T5


nicardipine oral T5

NIFEDICAL XL T5

55

Drug Tier Notes




nimodipine T5


T5

papaverine injection solution T5

REMODULIN T5

TARKA T5

TEKAMLO T5


TRACLEER ORAL TABLET T5

TRIBENZOR T5

TYVASO T5

VENTAVIS T5


verapamil oral T5

Cellular And Gene Therapy

Cellular And Gene Therapy

PROVENGE T5

Cellular Therapy

PROVENGE T5

Central Nervous System Agents

Adamantanes (Cns)

amantadine hcl T5

Amphetamines

benzphetamine oral tablet 50 mg T5

DESOXYN T5

dextroamphetamine oral capsule, extended release T5

dextroamphetamine oral tablet T5

dextroamphetamine-amphetamine oral capsule,extended release 24hr

T5

PROCENTRA T5

56

Drug Tier Notes

VYVANSE ORAL CAPSULE 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG

T5

Analgesics And Antipyretics, Misc.

acetaminophen oral drops 100 mg/ml T1

acetaminophen oral liquid 500 mg/5 ml T1

acetaminophen oral tablet 500 mg T1

acetaminophen-codeine oral solution 120-12 mg/5 ml

T5

acetaminophen-codeine oral tablet T5

butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg

T5

butalbital-acetaminophen-caff oral capsule 50-325-40 mg

T5

butalbital-acetaminophen-caff oral tablet 50-325-40 mg

T5

CHILDREN'S NON-ASPIRIN ORAL TABLET,CHEWABLE

T1

CHILDREN'S PAIN RELIEF ORAL SUSPENSION

T1

clonidine (pf) T5

ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG

T5

FEVERALL RECTAL SUPPOSITORY 325 MG, 650 MG

T1

FEVERALL RECTAL SUPPOSITORY 80 MG T2

gabapentin oral capsule T5

gabapentin oral solution 250 mg/5 ml T5

gabapentin oral tablet 600 mg, 800 mg T5

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml, 7.5-500 mg/15 ml

T5

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

T5

LYRICA ORAL CAPSULE T5

MAGNACET T5

MAPAP (ACETAMINOPHEN) ORAL LIQUID 160 MG/5 ML

T1

MIGRAINE FORMULA T1

57

Drug Tier Notes

oxycodone-acetaminophen oral tablet 2.5-325 mg T5

PRIALT T5

PRIMLEV T5

Q-PAP ORAL LIQUID T1

ROXICET ORAL SOLUTION T5

TENSION HEADACHE RELIEF T1

tramadol-acetaminophen T5

XOLOX T5

ZAMICET T5

ZYDONE T5

Anticholinergic Agents (Cns)

benztropine T5

trihexyphenidyl T5

Anticonvulsants, Miscellaneous

APTIOM T5

BANZEL T5

carbamazepine oral capsule, er multiphase 12 hr T5

carbamazepine oral suspension 100 mg/5 ml T5

carbamazepine oral tablet T5

carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg

T5

carbamazepine oral tablet,chewable T5

DEPACON T5

DEPAKENE T5

DEPAKOTE T5

DEPAKOTE ER T5

DEPAKOTE SPRINKLES T5

EQUETRO T5

felbamate T5

FYCOMPA ORAL TABLET T5

gabapentin oral capsule T5

gabapentin oral solution 250 mg/5 ml T5

gabapentin oral tablet 600 mg, 800 mg T5

GABITRIL ORAL TABLET 12 MG, 16 MG T5

58

Drug Tier Notes

LAMICTAL ODT T5

LAMICTAL ODT STARTER (BLUE) T5

LAMICTAL ODT STARTER (GREEN) T5

LAMICTAL ODT STARTER (ORANGE) T5

LAMICTAL STARTER (BLUE) KIT T5

LAMICTAL STARTER (GREEN) KIT T5

LAMICTAL STARTER (ORANGE) KIT T5

LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 100 MG, 200 MG, 25 MG, 50 MG

T5

LAMICTAL XR STARTER (BLUE) T5

LAMICTAL XR STARTER (GREEN) T5

LAMICTAL XR STARTER (ORANGE) T5

lamotrigine oral tablet T5

lamotrigine oral tablet, chewable dispersible T5

levetiracetam intravenous T5

levetiracetam oral solution 100 mg/ml T5

levetiracetam oral tablet T5

levetiracetam oral tablet extended release 24 hr T5



T5


T5


T5


oxcarbazepine T5

OXTELLAR XR T5

SABRIL T5

STAVZOR T5

TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG

T5

tiagabine oral tablet 2 mg, 4 mg T5

topiramate oral capsule, sprinkle T5

topiramate oral tablet T5

59

Drug Tier Notes

VIMPAT INTRAVENOUS T5

VIMPAT ORAL SOLUTION T5

VIMPAT ORAL TABLET T5

ZONEGRAN ORAL CAPSULE 100 MG, 25 MG T5

zonisamide oral capsule 50 mg T5

Antidepressants, Miscellaneous

APLENZIN T5

BUDEPRION SR ORAL TABLET SUSTAINED-RELEASE 12 HR 150 MG

T5

BUPROBAN T5

bupropion hcl oral tablet T5

bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg

T5

bupropion hcl oral tablet sustained-release 12 hr 100 mg, 200 mg

T5

mirtazapine T5

Antimanic Agents

ABILIFY T5

ABILIFY DISCMELT T5

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

T5

carbamazepine oral capsule, er multiphase 12 hr T5

carbamazepine oral suspension 100 mg/5 ml T5

carbamazepine oral tablet T5

carbamazepine oral tablet extended release 12 hr 200 mg, 400 mg

T5

carbamazepine oral tablet,chewable T5

DEPACON T5

DEPAKENE T5

DEPAKOTE T5

DEPAKOTE ER T5


EQUETRO T5

GEODON INTRAMUSCULAR T5

LAMICTAL ODT T5

60

Drug Tier Notes

LAMICTAL ODT STARTER (BLUE) T5

LAMICTAL ODT STARTER (GREEN) T5

LAMICTAL ODT STARTER (ORANGE) T5

LAMICTAL STARTER (BLUE) KIT T5

LAMICTAL STARTER (GREEN) KIT T5

LAMICTAL STARTER (ORANGE) KIT T5

lamotrigine oral tablet T5

lamotrigine oral tablet, chewable dispersible T5

lithium carbonate T5

lithium citrate oral solution 8 meq/5 ml T5

olanzapine T5

quetiapine oral tablet T5

RISPERDAL CONSTA T5

risperidone oral solution T5

risperidone oral tablet T5

risperidone oral tablet,disintegrating T5

SAPHRIS SUBLINGUAL TABLET 10 MG, 5 MG

T5

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR

T5

STAVZOR T5

TEGRETOL XR ORAL TABLET EXTENDED RELEASE 12 HR 100 MG

T5

ziprasidone hcl T5

ZYPREXA RELPREVV T5

Antimigraine Agents, Miscellaneous

ASCOMP WITH CODEINE T5

ASCRIPTIN T1




T1



61

Drug Tier Notes


T5


T5


T5

CAFERGOT T5

CAMBIA T5

D.H.E.45 T5

DEPACON T5

DEPAKENE T5

DEPAKOTE T5

DEPAKOTE ER T5



ERGOMAR T5

HALFPRIN T2

INNOPRAN XL T5

MIGRAINE FORMULA T1

MIGRANAL T5

propranolol oral T5

STAVZOR T5

SYNALGOS-DC T5



Antipsychotics, Miscellaneous

loxapine succinate T5

ORAP T5

Anxiolytics,Sedatives,And Hypnotics,Misc

buspirone T5

droperidol injection solution T5

EDLUAR T5

eszopiclone T5

hydroxyzine hcl intramuscular T5

hydroxyzine hcl oral solution 10 mg/5 ml T5

62

Drug Tier Notes

hydroxyzine hcl oral tablet T5

hydroxyzine pamoate T5

meprobamate T5


promethazine rectal suppository 12.5 mg, 25 mg T1 AL

propofol intravenous emulsion T5

ROZEREM T5

SONATA T5

zolpidem oral T5

ZOLPIMIST T5

Atypical Antipsychotics

ABILIFY T5

ABILIFY DISCMELT T5

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON

T5

clozapine oral tablet T5

FANAPT T5

FAZACLO T5

GEODON INTRAMUSCULAR T5

INVEGA T5

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML

T5

LATUDA ORAL TABLET 40 MG, 60 MG, 80 MG

T5

olanzapine T5

olanzapine-fluoxetine T5

quetiapine oral tablet T5

RISPERDAL CONSTA T5

risperidone oral solution T5

risperidone oral tablet T5

risperidone oral tablet,disintegrating T5

SAPHRIS SUBLINGUAL TABLET 10 MG, 5 MG

T5

SEROQUEL XR ORAL TABLET EXTENDED RELEASE 24 HR

T5

63

Drug Tier Notes

ziprasidone hcl T5

ZYPREXA RELPREVV T5

Barbiturates (Anticonvulsants)

BREVITAL INJECTION RECON SOLN 2.5 GRAM, 500 MG

T5


primidone T5

Barbiturates (Anxiolytic, Sedative/Hyp)



T5


T5


T5


Barbiturates (General Anesthetics)

BREVITAL INJECTION RECON SOLN 2.5 GRAM, 500 MG

T5

Benzodiazepines (Anticonvulsants)

clonazepam T5

clorazepate dipotassium T5

DIASTAT T5

DIASTAT ACUDIAL T5

DIAZEPAM INTENSOL T5

diazepam oral solution 5 mg/5 ml (1 mg/ml) T5

diazepam oral tablet T5

lorazepam injection solution 4 mg/ml T5

lorazepam injection syringe T5

lorazepam oral T5

ONFI T5

Benzodiazepines (Anxiolytic,Sedativ/Hyp)

alprazolam T5

ALPRAZOLAM INTENSOL T5

amitriptyline-chlordiazepoxide T5

64

Drug Tier Notes

chlordiazepoxide hcl T5

chlordiazepoxide-clidinium T5

clonazepam T5

clorazepate dipotassium T5

DIASTAT T5

DIASTAT ACUDIAL T5

DIAZEPAM INTENSOL T5

diazepam oral solution 5 mg/5 ml (1 mg/ml) T5

diazepam oral tablet T5

DORAL T5

estazolam T5

flurazepam T5

lorazepam injection solution 4 mg/ml T5

lorazepam injection syringe T5

lorazepam oral T5

midazolam (pf) injection cartridge T5

midazolam oral syrup 2 mg/ml T5

ONFI T5

temazepam T5

triazolam T5

Butyrophenones

haloperidol T5

haloperidol decanoate T5

haloperidol lactate injection T5

haloperidol lactate oral T5

Catechol-O-Methyltransferase(Comt)Inhib.

COMTAN T5

STALEVO 100 T5

STALEVO 125 T5

STALEVO 150 T5

STALEVO 200 T5

STALEVO 50 T5

STALEVO 75 T5

TASMAR ORAL TABLET 100 MG T5

65

Drug Tier Notes

Central Nervous System Agents, Misc.

CAMPRAL T5

flumazenil T5

guanfacine oral tablet T5

INTUNIV ER T5

LODOSYN T5

NAMENDA T5

NAMENDA TITRATION PAK T5

NUEDEXTA T5

RILUTEK T5

STRATTERA T5

XENAZINE T5

XYREM T5

Cyclooxygenase-2 (Cox-2) Inhibitors

CELEBREX T5

Dopamine Precursors

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg

T5

carbidopa-levodopa oral tablet extended release T5

carbidopa-levodopa oral tablet,disintegrating T5

STALEVO 100 T5

STALEVO 125 T5

STALEVO 150 T5

STALEVO 200 T5

STALEVO 50 T5

STALEVO 75 T5

Ergot-Deriv. Dopamine Receptor Agonists

bromocriptine T5

cabergoline T5

CYCLOSET T5

Fibromyalgia Agents

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg

T5


66

Drug Tier Notes

SAVELLA T5

General Anesthetics, Miscellaneous

AMIDATE INTRAVENOUS SOLUTION T5

ketamine injection T5

propofol intravenous emulsion T5

Hydantoins

DILANTIN T5

fosphenytoin injection solution 100 mg pe/2 ml T5

PEGANONE T5

phenytoin oral suspension 125 mg/5 ml T5

phenytoin oral tablet,chewable T5

phenytoin sodium extended T5

phenytoin sodium intravenous solution T5

Monoamine Oxidase B Inhibitors

AZILECT T5

ELDEPRYL T5

EMSAM T5

selegiline hcl oral tablet T5

ZELAPAR T5

Monoamine Oxidase Inhibitors

AZILECT T5

ELDEPRYL T5

EMSAM T5

MARPLAN T5

NARDIL T5

selegiline hcl oral tablet T5

tranylcypromine T5

ZELAPAR T5

Nonergot-Deriv.Dopamine Receptor Agonist

APOKYN T5

MIRAPEX ER ORAL TABLET EXTENDED RELEASE 24 HR 0.375 MG, 0.75 MG, 1.5 MG, 3 MG, 4.5 MG

T5

pramipexole oral tablet T5

67

Drug Tier Notes

ropinirole T5

Opiate Agonists

ABSTRAL T5

acetaminophen-codeine oral solution 120-12 mg/5 ml

T5

acetaminophen-codeine oral tablet T5

alfentanil T5


AVINZA T5


T5


codeine sulfate oral tablet T5

DEMEROL (PF) INJECTION SOLUTION 100 MG/ML

T5

DEMEROL (PF) INJECTION SYRINGE 25 MG/ML, 75 MG/ML

T5

DEMEROL ORAL TABLET 50 MG T5

DEPODUR (PF) EPIDURAL SUSPENSION 10 MG/ML

T5

DILAUDID-HP (PF) INJECTION RECON SOLN T5

DISKETS T5

DOLOPHINE ORAL T5

ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG

T5

ENDODAN T5

EXALGO ER ORAL TABLET EXTENDED RELEASE 24 HR 12 MG, 16 MG, 8 MG

T5

fentanyl citrate (pf) injection solution T5

fentanyl citrate buccal lozenge on a handle T5

fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

T5

FENTORA T5

hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml, 7.5-500 mg/15 ml

T5

68

Drug Tier Notes

hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg

T5

hydrocodone-ibuprofen oral tablet 2.5-200 mg, 5-200 mg, 7.5-200 mg

T5

hydromorphone (pf) injection solution 1 mg/ml, 2 mg/ml, 4 mg/ml

T5

hydromorphone oral liquid T5

hydromorphone oral tablet T5

hydromorphone rectal T5

ibuprofen-oxycodone T5

KADIAN ORAL CAPSULE,EXTEND.RELEASE PELLETS 10 MG, 200 MG

T5

levorphanol tartrate oral tablet 2 mg T5

MAGNACET T5

meperidine (pf) injection solution 50 mg/ml T5

meperidine injection cartridge T5

meperidine oral solution T5

meperidine oral tablet 100 mg T5

methadone injection solution T5

methadone oral concentrate T5

methadone oral solution T5

morphine injection solution 5 mg/ml T5

morphine injection syringe 15 mg/ml T5

morphine oral capsule,extend.release pellets 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg

T5

morphine oral tablet T5

morphine oral tablet extended release T5

NUCYNTA T5

opium tincture T5

oxycodone oral capsule T5

oxycodone oral tablet T5

oxycodone-acetaminophen oral tablet 2.5-325 mg T5

OXYCONTIN ORAL TABLET EXTENDED RELEASE 12 HR

T5

oxymorphone oral tablet T5

69

Drug Tier Notes

oxymorphone oral tablet extended release 12 hr 15 mg, 7.5 mg

T5

PRIMLEV T5

REPREXAIN ORAL TABLET 10-200 MG T5

REZIRA T5

ROXICET ORAL SOLUTION T5

SUFENTA T5

SYNALGOS-DC T5

tramadol oral tablet 50 mg T5

tramadol oral tablet extended release 24 hr T5

tramadol oral tablet, er multiphase 24 hr T5


TREZIX ORAL CAPSULE 356.4-30-16 MG T5

ULTIVA T5

XOLOX T5

ZAMICET T5

ZYDONE T5

Opiate Antagonists

naloxone injection solution T5

naloxone injection syringe T5

naltrexone T5

VIVITROL T5

Opiate Partial Agonists

BUPRENEX T5

buprenorphine hcl sublingual T5

buprenorphine-naloxone sublingual tablet T5

butorphanol tartrate T5

BUTRANS TRANSDERMAL PATCH WEEKLY 10 MCG/HOUR, 20 MCG/HOUR, 5 MCG/HOUR

T5

nalbuphine T5

pentazocine-naloxone T5

SUBOXONE SUBLINGUAL FILM 2-0.5 MG, 8-2 MG

T5

TALWIN T5

70

Drug Tier Notes

ZUBSOLV SUBLINGUAL TABLET 1.4-0.36 MG, 5.7-1.4 MG

T5

Other Nonsteroidal Anti-Inflam. Agents

ARTHROTEC 50 T5

ARTHROTEC 75 T5

CALDOLOR INTRAVENOUS RECON SOLN 400 MG/4 ML (100 MG/ML)

T5

CAMBIA T5

CATAFLAM T5

CLINORIL T5

diclofenac sodium oral T5

diflunisal T5

etodolac T5

FELDENE T5

fenoprofen oral tablet T5

FLECTOR T5

flurbiprofen T5

hydrocodone-ibuprofen oral tablet 2.5-200 mg, 5-200 mg, 7.5-200 mg

T5

IBUPROFEN JR STRENGTH T1

ibuprofen oral capsule T5

ibuprofen oral suspension T1

ibuprofen oral tablet 100 mg, 200 mg T1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg T5

ibuprofen-oxycodone T5

INDOCIN T5

indomethacin oral T5

INFANT'S IBUPROFEN T5

ketoprofen oral capsule 50 mg, 75 mg T5

ketoprofen oral capsule,ext rel. pellets 24 hr 200 mg

T5

ketorolac injection cartridge T5

ketorolac injection solution 30 mg/ml (1 ml) T5

ketorolac oral T5

meclofenamate T5

71

Drug Tier Notes

mefenamic acid T5

meloxicam T5

nabumetone T5

NALFON ORAL CAPSULE 400 MG T5

NAPRELAN CR T5

naproxen T5

naproxen sodium oral tablet 220 mg T1

naproxen sodium oral tablet 275 mg, 550 mg T5

NEOPROFEN (IBUPROFEN LYSN)(PF) T5

oxaprozin T5

PENNSAID TOPICAL DROPS T5

REPREXAIN ORAL TABLET 10-200 MG T5

sulindac oral tablet 150 mg T5

tolmetin T5

TREXIMET ORAL TABLET 85-500 MG T5

VIMOVO T5

VOLTAREN TOPICAL T5

ZIPSOR T5

ZORVOLEX T5

Phenothiazines

chlorpromazine T5

COMPRO T5

fluphenazine decanoate T5

fluphenazine hcl T5

perphenazine T5

perphenazine-amitriptyline T5

prochlorperazine edisylate injection solution 5 mg/ml

T5

prochlorperazine maleate T5

thioridazine T5

trifluoperazine T5

Respiratory And Cns Stimulants


72

Drug Tier Notes


T5


T5


T5

CONCERTA T5

DAYTRANA T5

dexmethylphenidate oral capsule,er biphasic 50-50 15 mg, 30 mg, 40 mg

T5

dexmethylphenidate oral tablet T5

FOCALIN XR ORAL CAPSULE,ER BIPHASIC 50-50 10 MG, 20 MG, 5 MG

T5

METADATE ER T5

METHYLIN ORAL TABLET,CHEWABLE T5

methylphenidate hcl oral capsule, er biphasic 30-70

T5

methylphenidate hcl oral capsule,er biphasic 50-50 20 mg, 30 mg, 40 mg

T5

methylphenidate hcl oral solution T5

methylphenidate hcl oral tablet T5

methylphenidate hcl oral tablet extended release 10 mg

T5

MIGRAINE FORMULA T1

QUILLIVANT XR T5

RITALIN LA ORAL CAPSULE,ER BIPHASIC 50-50 10 MG

T5

SYNALGOS-DC T5

TENSION HEADACHE RELIEF T1

Salicylates

AGGRENOX T5


ASCRIPTIN T1

ASPER-FLEX T1



73

Drug Tier Notes


T1



carisoprodol-aspirin T5


choline,magnesium salicylate T5


ENDODAN T5

HALFPRIN T2

MIGRAINE FORMULA T1

MUSCLE RUB (WITH CAMPHOR) T1

ORPHENADRINE COMPOUND-DS T5

SALONPAS TOPICAL ADHESIVE PATCH,MEDICATED

T1 QL (40 QY per 30 DYs); AL

salsalate T5

SYNALGOS-DC T5

THERA-GESIC TOPICAL CREAM 15-1 % T5


ULTRACIN T T1

Sel.Serotonin,Norepi Reuptake Inhibitor

duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg

T5

PRISTIQ ORAL TABLET EXTENDED RELEASE 24 HR 100 MG, 50 MG

T5

SAVELLA T5

venlafaxine T5

Selective Serotonin Agonists

ALSUMA T5

AMERGE T5

AXERT T5

FROVA T5

IMITREX NASAL T5

MAXALT T5

MAXALT-MLT T5

74

Drug Tier Notes

RELPAX T5

sumatriptan succinate oral T5

sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml

T5

sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml

T5

sumatriptan succinate subcutaneous solution T5

SUMAVEL DOSEPRO SUBCUTANEOUS NEEDLE-FREE INJECTOR 6 MG/0.5 ML

T5

TREXIMET ORAL TABLET 85-500 MG T5

ZOMIG NASAL SPRAY,NON-AEROSOL 5 MG T5

ZOMIG ORAL T5

ZOMIG ZMT T5

Selective-Serotonin Reuptake Inhibitors

citalopram T5

escitalopram oxalate T5

fluoxetine oral capsule T5

fluoxetine oral capsule,delayed release(dr/ec) T5

fluoxetine oral solution T5

fluoxetine oral tablet 10 mg, 20 mg T5

fluvoxamine oral tablet T5

LUVOX CR T5

olanzapine-fluoxetine T5

paroxetine hcl oral tablet T5

paroxetine hcl oral tablet extended release 24 hr T5

PAXIL ORAL SUSPENSION T5

PEXEVA T5

SARAFEM ORAL TABLET 10 MG, 20 MG T5

sertraline T5

Serotonin Modulators

nefazodone T5

trazodone T5

VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)-20 MG (7)-40 MG (16)

T5

Succinimides

75

Drug Tier Notes

CELONTIN ORAL CAPSULE 300 MG T5

ethosuximide T5

Thioxanthenes

thiothixene T5

Tricyclics, Other Norepi-Ru Inhibitors

amitriptyline T5

amitriptyline-chlordiazepoxide T5

amoxapine T5

ANAFRANIL T5

desipramine T5

doxepin oral capsule T5

doxepin oral concentrate T5

imipramine hcl T5

imipramine pamoate T5

maprotiline T5

nortriptyline oral capsule T5

perphenazine-amitriptyline T5

protriptyline T5

SILENOR T5

SURMONTIL T5

Vesicular Monoamine Transport2 Inhibitor

XENAZINE T5

Wakefulness-Promoting Agents

NUVIGIL T5

PROVIGIL T5

Contraceptives (E.G. Foams, Devices)

Contraceptives (E.G. Foams, Devices)

AIMSCO LATEX CONDOM T1

CONDOMS-PREM LUBRICATED T1

GYNOL II T1

TODAY CONTRACEPTIVE SPONGE T2

VAGINAL CONTRACEPTIVE FILM T2

VAGINAL CONTRACEPTIVE FOAM T1

76

Drug Tier Notes

Devices

Devices

AMVISC T5

AMVISC PLUS T5

BIOTENE DRY MOUTH ORAL RINSE T2

BLOOD PRESSURE KIT T1 QL (1 EA per 5 yrs)

blood pressure kit med and lrg T1 QL (1 EA per 5 yrs)

blood pressure monitor T1 QL (1 EA per 5 yrs)

EUFLEXXA T5

HYPER-SAL INHALATION SOLUTION FOR NEBULIZATION 7 %

T5

ORTHOVISC T5

PROVISC T5

sodium chloride inhalation solution for nebulization 0.9 %, 10 %, 3 %

T5

SUPARTZ T5

SYNVISC T5

VISCOAT T5

Diagnostic Agents

Adrenocortical Insufficiency

ACTHAR H.P. T5

ACTHREL T5

CORTROSYN T5

cosyntropin intravenous T5

Allergenic Extracts (Diagnostic)


Diabetes Mellitus

TRUETEST TEST STRIPS T5

TRUETRACK TEST T5

Diagnostic Agents

GASTROMARK T5

Drug Hypersensitivity

PRE-PEN T5

77

Drug Tier Notes

Ketones

ACETEST T1

Kidney Function

mannitol 10 % T5

mannitol 20 % T5


mannitol 5 % T5

Myasthenia Gravis

ENLON T5

ENLON-PLUS T5

neostigmine methylsulfate injection T5

Ocular Disorders

ALTAFLUOR T5

FLUORETS T5

MEMBRANEBLUE T5

Pituitary Function

ACTHREL T5

R-GENE 10 T5

Roentgenography And Other Imaging Agents

ENTERO VU ORAL PACKET T5

ESOPHO-CAT T5

E-Z-CAT DRY T5

E-Z-HD BARIUM T5

E-Z-PAQUE T5

GASTROGRAFIN T5

ISOVUE-300 T5

ISOVUE-M 300 T5

LIQUID E-Z PAQUE T5

LIQUID POLIBAR T5

MAXIBAR T5

MULTIHANCE T5

OMNIPAQUE 240 T5

OMNIPAQUE 300 T5

78

Drug Tier Notes

PROHANCE INTRAVENOUS SOLUTION T5

READI-CAT T5

READI-CAT 2 ORAL SUSPENSION 2.1 % (W/V), 2.0 % (W/W)

T5

TAGITOL V T5

VARIBAR THIN LIQUID T5

VISIPAQUE INTRAVENOUS SOLUTION 270 MG IODINE/ML

T5

VOLUMEN T5

Sugar

CLINITEST REAGENT T1

Electrolytic, Caloric, And Water Balance

Acidifying Agents

ammonium chloride T5

Alkalinizing Agents

CYTRA K CRYSTALS T5


NEUT T5

potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg)

T5

sodium bicarbonate intravenous syringe 10 meq/10 ml (8.4 %), 4.2 % (0.5 meq/ml), 7.5 % (0.9 meq/ml)

T5

sodium citrate-citric acid T1 QL (120 ML per 1 day)

sodium lactate T5

TRICITRASOL T5

Ammonia Detoxicants

AMMONUL T5

BUPHENYL ORAL TABLET T5

CARBAGLU T5

KRISTALOSE T5

lactulose oral solution 10 gram/15 ml T5

LITHOSTAT T5

Caloric Agents

AMINOSYN 10 % T5

79

Drug Tier Notes

AMINOSYN 3.5 % T5

AMINOSYN 7 % T5

AMINOSYN 7 % WITH ELECTROLYTES T5

AMINOSYN 8.5 %-ELECTROLYTES T5

AMINOSYN II 15 % T5

AMINOSYN II 5%/DEXTROSE 25% T5

AMINOSYN II 8.5 % T5

AMINOSYN M 3.5 % T5

AMINOSYN-RF 5.2 % T5

BOOST ORAL LIQUID T3 PA

CLINIMIX 5%/D15W SULFITE FREE T5

CLINIMIX 5%/D25W SULFITE-FREE T5

CLINIMIX 2.75%/D5W SULFIT FREE T5

CLINIMIX 4.25%/D10W SULF FREE T5

CLINIMIX 4.25%/D5W SULFIT FREE T5

CLINIMIX 4.25%-D20W SULF-FREE T5

CLINIMIX 5%-D20W(SULFITE-FREE) T5

CLINIMIX E 2.75%/D10W SUL FREE T5

CLINIMIX E 2.75%/D5W SULF FREE T5

CLINIMIX E 4.25%/D25W SUL FREE T5

CLINIMIX E 4.25%/D5W SULF FREE T5

CLINIMIX E 5%/D15W SULFIT FREE T5



d10 %-0.45 % sodium chloride T5

d2.5 %-0.45 % sodium chloride T5

d5 % and 0.9 % sodium chloride T5

d5 %-0.45 % sodium chloride T5

dextrose 10 % and 0.2 % nacl T5

dextrose 10 % in water (d10w) T5




80

Drug Tier Notes

dextrose 5 % in water (d5w) intravenous parenteral solution

T5

dextrose 5%-0.2 % sod chloride T5

dextrose 5%-0.3 % sod.chloride T5

dextrose 50 % in water (d50w) intravenous parenteral solution

T5


ENFAMIL GLUCOSE T5

ENSURE MUSCLE HEALTH ORAL LIQUID 0.05-1.05 GRAM-KCAL/ML

T3 PA

ENSURE PLUS T3 PA

FREAMINE HBC 6.9 % T5

FREAMINE III 3 %-ELECTROLYTES T5

glucose oral tablet,chewable 4 gram T1

INTRALIPID INTRAVENOUS EMULSION 20 %, 30 %

T5

NEPHRAMINE 5.4 % T5

NEPRO CARB STEADY T3 PA

NUTRAMIGEN WITH ENFLORA LGG T3 PA

PEDIASURE ORAL LIQUID 0.03-1 GRAM-KCAL/ML

T3 PA

PKU 2 T3 PA

PKU TRIO T3 PA

POLYCOSE T5

PREMASOL 6 % T5

PROSOL 20 % T5

SIMILAC ALIMENTUM T3 PA

SIMILAC EXPERT CARE NEOSURE T3 PA

Carbonic Anhydrase Inhibitors

acetazolamide T5


Diuretics, Miscellaneous


THEO-24 T5

THEOCHRON T5

81

Drug Tier Notes


Irrigating Solutions

acetic acid irrigation T5

DELFLEX-LC/1.5% DEXTROSE T5



DIANEAL LOW CALCIUM/1.5% DEX T5

DIANEAL PD-2 WITH 2.5 % DEX T5

DIANEAL PD-2 WITH 4.25 % DEX T5

DIANEAL WITH 2.5 % DEXTROSE T5

GLYCINE UROLOGIC T5

lactated ringers irrigation T5

PHYSIOLYTE T5

RENACIDIN IRRIGATION SOLUTION 6.602-0.198 GRAM/100 ML

T5

RESECTISOL T5

RIMSO-50 T5

ringer's irrigation T5

STERILE SALINE IRRIGATION T5

water for irrigation, sterile T5

Loop Diuretics

bumetanide T5

DEMADEX T5

furosemide injection syringe T5

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

T5

furosemide oral tablet T5

SODIUM EDECRIN T5

torsemide intravenous solution 20 mg/2 ml (10 mg/ml)

T5

Osmotic Diuretics

mannitol 10 % T5

mannitol 20 % T5


82

Drug Tier Notes

mannitol 5 % T5

Phosphate-Removing Agents

calcium acetate(phosphat bind) T5

FOSRENOL ORAL TABLET,CHEWABLE T5

RENAGEL T5

RENVELA ORAL POWDER IN PACKET T5

sevelamer carbonate oral tablet T5

Potassium-Removing Agents

KIONEX T5

KIONEX (WITH SORBITOL) T5

Potassium-Sparing Diuretics


amiloride T5


DYRENIUM T5

spironolactone T5


T5


Replacement Preparations

ANTACID EXTRA-STRENGTH ORAL TABLET,CHEWABLE 168 MG CALCIUM (420 MG), 200 MG CALCIUM (500 MG)

T1

ATABEX EC T5

BAL-CARE DHA T5

B-NEXA T5

CALCI-CHEW T1

CALCI-MIX T2

CALCIONATE T2

CALCIUM 500 WITH D T1

CALCIUM 600 T1

CALCIUM 600 WITH VITAMIN D3 ORAL CAPSULE 600 MG(1,500MG) -400 UNIT

T1

CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG (750 MG)

T1

83

Drug Tier Notes

CALCIUM ANTACID ULTRA MAX ST T1

calcium carbonate oral suspension T1

calcium carbonate oral tablet 260 mg calcium (648 mg), 500 mg calcium (1,250 mg)

T1

calcium carbonate-vitamin d2 T1

calcium carbonate-vitamin d3 oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit

T1

calcium citrate-vitamin d3 oral tablet 200-125 mg-unit

T1

calcium gluconate oral tablet 45 mg (500 mg) T1

calcium lactate oral tablet 650 mg, 84 mg (648 mg)

T1

dextrose 5 % in ringer's T5

dextrose 5 %-lactated ringers T5

EFFER-K T5

electrolyte-48 in d5w T5

FLORICAL T5

FOLBECAL T5

FOLCAL DHA T5

HESPAN 6 % IN NS T5

HEXTEND T5

HYPERLYTE CR T5

HYPER-SAL INHALATION SOLUTION FOR NEBULIZATION 7 %

T5

IONOSOL-B IN D5W T5

IONOSOL-MB IN D5W T5

ISOLYTE M IN 5 % DEXTROSE T5

ISOLYTE S PH 7.4 T5

ISOLYTE-P IN 5 % DEXTROSE T5

ISOLYTE-S T5

KLOR-CON T5

KLOR-CON 8 T5

KLOR-CON M10 T5

KLOR-CON M15 T5

KLOR-CON M20 T5

84

Drug Tier Notes

KLOR-CON/25 T5

lactated ringers intravenous T5

LEVOMEFOLATEPNV T5


MACNATAL CN DHA T5

magnesium oral tablet 200 mg T1

MAGONATE T1

MARNATAL-F T5

MONOCAL T5

MYNATAL ORAL CAPSULE T5

MYNATAL PLUS T5

NATALVIRT CA T5

NATALVIT T5

NATELLE ONE T5

NORMOSOL-R T5

NORMOSOL-R IN 5 % DEXTROSE T5

NORMOSOL-R PH 7.4 T5

NUTRILYTE II T5

OB COMPLETE ONE T5


O-CAL PRENATAL T5

OS-CAL 500 + D3 ORAL TABLET 500 MG(1,250MG) -200 UNIT

T1

OYSCO 500/D ORAL TABLET,CHEWABLE T1

OYSTER SHELL + D3 T1

OYSTER SHELL CALCIUM-VIT D2 ORAL TABLET 250 (625)-125 MG-UNIT

T1

PARVA-CAL 500 T2

PEDIATRIC ELECTROLYTE ORAL SOLUTION

T1

PHOS-NAK T2

PLASMA-LYTE 148 T5

PLASMA-LYTE A T5

PLASMA-LYTE-56 IN 5 % DEXTROSE T5

potassium acetate T5

85

Drug Tier Notes

potassium bicarb and chloride T5

potassium chlorid-d5-0.45%nacl T5

potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

T5

potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l

T5

potassium chloride in lr-d5 T5

potassium chloride in water intravenous piggyback

T5

potassium chloride intravenous T5

potassium chloride oral liquid T5

potassium chloride oral tablet extended release 10 meq

T5

potassium chloride oral tablet extended release 20 meq

T1

potassium chloride-0.45 % nacl T5

potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l

T5

potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l

T5

potassium chloride-d5-0.9%nacl T5

potassium gluconate oral tablet 2.5 meq, 550 mg (90 mg)

T5

potassium phosphate m-/d-basic intravenous solution 3 mmol/ml

T5

PR NATAL 430 EC T5


PRENATABS FA T5

PRENATABS RX T5

PRENATAL LOW IRON T5

PRENATAL PLUS WITH IRON (CA) T5


T1

PRENATAL VITAMIN PLUS LOW IRON T5

PROTECT NATAL T5

ringer's intravenous T5

RISACAL-D T1

86

Drug Tier Notes

SETONET T5

SETONET-EC T5

sodium acetate T5

sodium chloride 0.45 % intravenous parenteral solution

T5

sodium chloride 0.9 % intravenous parenteral solution

T5

sodium chloride 3 % T5

sodium chloride 5 % T5

sodium chloride inhalation solution for nebulization 0.9 %, 10 %, 3 %

T5

sodium chloride intravenous T5

sodium chloride oral T1

sodium phosphate T5

TARON-BC T5

THERA-M ORAL TABLET 9 MG IRON-400 MCG

T1

TRIADVANCE T5

TRINATAL ULTRA T5

TRINATE T5

TRIVEEN-DUO DHA T5

TRIVEEN-ONE T5

TRIVEEN-PRX RNF T5


VENATAL COMPLETE DHA T5

VINATE AZ T5

VINATE DHA T5

VINATE ONE T5

VIRT-BAL DHA T5

VIRT-SELECT T5

VOLUVEN 6 % T5

VP-GGR-B6 T5

ZATEAN-CH T5

ZATEAN-PN PLUS T5

zinc gluconate oral T1

87

Drug Tier Notes

zinc sulfate oral T1

ZINC-15 T2

Thiazide Diuretics



AMTURNIDE T5




chlorothiazide T5

chlorothiazide sodium T5

DIURIL T5


EXFORGE HCT T5


hydrochlorothiazide T5




methyclothiazide T5






TEKTURNA HCT T5

TEVETEN HCT T5


T5


TRIBENZOR T5


Thiazide-Like Diuretics


88

Drug Tier Notes

chlorthalidone oral tablet 25 mg, 50 mg T5

CLORPRES T5

indapamide T5

metolazone T5

Uricosuric Agents

probenecid T5

Vasopressin Antagonists

SAMSCA T5

Enzymes

Enzymes

ACTIVASE INTRAVENOUS RECON SOLN 50 MG

T5

ADAGEN T5

ALDURAZYME T5

CEREZYME T5

ELAPRASE T5

ELELYSO T5

ELITEK T5

FABRAZYME T5

HYLENEX T5

LUMIZYME T5

NAGLAZYME T5

PULMOZYME T5

RETAVASE INTRAVENOUS KIT T5

VITRASE T5

VPRIV T5

XIAFLEX T5

Eye, Ear, Nose And Throat (Eent) Preps.

Alpha-Adrenergic Agonists (Eent)

ALPHAGAN P T5

brimonidine ophthalmic (eye) drops 0.2 % T5

COMBIGAN T5

Antiallergic Agents

89

Drug Tier Notes

ALOCRIL T5

ASTELIN T5

ASTEPRO NASAL SPRAY,NON-AEROSOL T5

azelastine ophthalmic (eye) T5

BEPREVE T5

cromolyn nasal T1 AL

cromolyn ophthalmic (eye) T5

ELESTAT T5

ketotifen fumarate T1

LASTACAFT T5

PATADAY OPHTHALMIC (EYE) DROPS 0.2 % T5

PATANASE T5

PATANOL T5

Antibacterials (Eent)

AK-POLY-BAC T5

ALODOX T5

bacitracin ophthalmic (eye) T5

BACTROBAN NASAL T5

BESIVANCE T5

BLEPH-10 T5

BLEPHAMIDE T5

BLEPHAMIDE S.O.P. T5

CILOXAN T5

CIPRO HC T5

CIPRODEX T5

COLY-MYCIN S T5

doxycycline hyclate oral tablet 20 mg T5

erythromycin ophthalmic (eye) T5

GARAMYCIN OPHTHALMIC (EYE) OINTMENT

T5

GENTAK OPHTHALMIC (EYE) DROPS T5

levofloxacin ophthalmic (eye) T5

MAXITROL T5

neomycin-bacitracin-poly-hc T5

90

Drug Tier Notes

neomycin-bacitracin-polymyxin T5

neomycin-polymyxin-gramicidin T5

neomycin-polymyxin-hc T5

OCUFLOX T5

ofloxacin otic (ear) T5

polymyxin b sulf-trimethoprim T5

PRED-G T5

PRED-G S.O.P. T5

sulfacetamide-prednisolone T5

TOBRADEX T5

TOBRADEX ST T5

tobramycin T5

TOBREX OPHTHALMIC (EYE) OINTMENT T5

ZYLET T5

ZYMAXID T5

Antifungals (Eent)

NATACYN T5

Antivirals (Eent)

trifluridine T5

ZIRGAN T5

Beta-Adrenergic Blocking Agents (Eent)

BETAGAN OPHTHALMIC (EYE) DROPS 0.5 % T5

betaxolol ophthalmic (eye) T5

carteolol T5

COMBIGAN T5

COSOPT T5

ISTALOL T5

levobunolol ophthalmic (eye) drops 0.25 % T5

metipranolol T5

timolol maleate ophthalmic (eye) drops T5

timolol maleate ophthalmic (eye) gel forming solution

T5

Carbonic Anhydrase Inhibitors (Eent)

acetazolamide T5

91

Drug Tier Notes


COSOPT T5

dorzolamide T5

Corticosteroids (Eent)

ACETASOL HC T5

AERO OTIC HC T5

CIPRO HC T5

CIPRODEX T5

CORTANE-B AQUEOUS T5

DERMOTIC OIL T5

dexamethasone sodium phosphate ophthalmic (eye)

T5

DUREZOL T5

FLAREX T5

FLONASE T5

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)

T5

fluorometholone T5

FML S.O.P. T5

ILUVIEN T5

MAXITROL T5

neomycin-bacitracin-poly-hc T5

neomycin-polymyxin-hc ophthalmic (eye) T5

OMNARIS T5

OMNIPRED T5

OZURDEX T5

PRED MILD T5

PRED-G T5

PRED-G S.O.P. T5

prednisolone sodium phosphate ophthalmic (eye) T5

RETISERT T5

RHINOCORT ALLERGY T2 QL (8.43 ML per 30 days)

RHINOCORT AQUA T5

TOBRADEX T5

92

Drug Tier Notes

TOBRADEX ST T5

triamcinolone acetonide nasal T1 QL (16.9 ML per 30 days)

VERAMYST T5

VEXOL T5

ZYLET T5

Eent Anti-Infectives, Miscellaneous

ACETASOL HC T5

acetic acid otic (ear) T5

acetic acid-aluminum acetate T5

BETADINE OPHTHALMIC PREP T5

chlorhexidine gluconate mucous membrane T5

EAR WAX DROPS T1

OTICIN T5

Eent Anti-Inflammatory Agents, Misc.

RESTASIS T5

Eent Drugs, Miscellaneous

ALODOX T5

ALTALUBE T1

ARTIFICIAL TEARS (POLYVIN ALC) T1

ARTIFICIAL TEARS(DEXT70-HYPRO) OPHTHALMIC (EYE) DROPS

T1

BABY AYR SALINE T2

DEEP SEA NASAL T1 QL (90 QY per 30 DYs)

ENUCLENE T5

EYLEA INTRAVITREAL SOLUTION T5

HYPOTEARS T1

IOPIDINE OPHTHALMIC (EYE) DROPPERETTE

T5

ipratropium bromide nasal spray,non-aerosol 0.03 %

T1 QL (30 ML per 30 days)

ipratropium bromide nasal spray,non-aerosol 42 mcg (0.06 %)

T1 QL (15 ML per 30 days)

ISOPTO TEARS T2

JETREA (PF) INTRAVITREAL SOLUTION 0.5 MG/0.2 ML

T5

93

Drug Tier Notes

LACRISERT T5

LUBRICANT EYE OPHTHALMIC (EYE) OINTMENT 83-15 %

T1

LUCENTIS INTRAVITREAL SOLUTION T5

MACUGEN T5

MURO 128 OPHTHALMIC (EYE) DROPS 2 % T1

NATURE'S TEARS (HYPROMELLOSE) T1

PURE AND GENTLE EYE T1

REFRESH LIQUIGEL T2

sodium chloride ophthalmic (eye) T1

TEARS NATURALE FREE (PF) T1

THERATEARS OPHTHALMIC (EYE) DROPPERETTE,GEL

T1

THERATEARS OPHTHALMIC (EYE) DROPS T2

ULTRA FRESH T1

VISUDYNE T5

Eent Nonsteroidal Anti-Inflam. Agents

ACULAR T5

ACULAR LS T5

ACUVAIL (PF) T5

BROMDAY T5

bromfenac T5

diclofenac sodium ophthalmic (eye) T5

flurbiprofen sodium T5

NEVANAC T5

Local Anesthetics (Eent)

AKTEN (PF) T5

ALCAINE T5

ALTAFLUOR T5

cocaine T5

lidocaine hcl mucous membrane jelly T5

lidocaine hcl mucous membrane solution 4 % (40 mg/ml)

T5

LIDOCAINE VISCOUS T5

OTICIN T5

94

Drug Tier Notes

OTOZIN T5

PINNACAINE T5

TETCAINE T5

Miotics

ISOPTO CARBACHOL T5

PHOSPHOLINE IODIDE T5

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %

T5

PILOPINE HS T5

Mydriatics

atropine ophthalmic (eye) drops T5

atropine ophthalmic (eye) ointment T5

CYCLOGYL OPHTHALMIC (EYE) DROPS 0.5 %, 2 %

T5

CYCLOMYDRIL T5

cyclopentolate ophthalmic (eye) drops 1 % T5

HOMATROPAIRE T5

ISOPTO HOMATROPINE OPHTHALMIC (EYE) DROPS 2 %

T5

ISOPTO HYOSCINE T5

tropicamide ophthalmic (eye) drops 1 % T5

Prostaglandin Analogs

latanoprost T5

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %

T5

Vasoconstrictors

EYE ALLERGY RELIEF T1

naphazoline T5

phenylephrine hcl ophthalmic (eye) T5

TYZINE NASAL DROPS T5

Gastrointestinal Drugs

5-Ht3 Receptor Antagonists

ANZEMET INTRAVENOUS SOLUTION 100 MG/5 ML

T5

granisetron (pf) intravenous solution 100 mcg/ml T5

95

Drug Tier Notes

granisetron hcl intravenous solution 1 mg/ml (1 ml)

T5

granisetron hcl oral T5

GRANISOL T5

ondansetron T5

ondansetron hcl T5

ondansetron hcl (pf) injection solution T5

ZUPLENZ T5

Antacids And Adsorbents

aluminum hydroxide gel oral suspension 320 mg/5 ml

T1

alum-mag hydroxide-simeth oral suspension 200-200-20 mg/5 ml

T1

ANTACID ANTI-GAS ORAL SUSPENSION 400-400-40 MG/5 ML

T1

ANTACID EXTRA-STRENGTH ORAL TABLET,CHEWABLE 168 MG CALCIUM (420 MG), 200 MG CALCIUM (500 MG)

T1

CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG (750 MG)

T1

CALCIUM ANTACID ULTRA MAX ST T1

calcium carbonate oral tablet 260 mg calcium (648 mg)

T1


GAVISCON EXTRA STRENGTH ORAL SUSPENSION

T2

MAG-AL T2

magnesium oxide oral tablet 250 mg magnesium, 400 mg (241.3 mg magnesium)

T1

PEPTIC RELIEF ORAL TABLET,CHEWABLE T1

PINK BISMUTH ORAL SUSPENSION 262 MG/15 ML

T1

PINK BISMUTH ORAL TABLET T1

ROLAIDS T2

ROLAIDS EXTRA STRENGTH T2

sodium bicarbonate oral T1

STOMACH RELIEF MAX STRENGTH T1

96

Drug Tier Notes

Antidiarrhea Agents

ANTI-DIARRHEAL (LOPERAMIDE) ORAL TABLET

T1 QL (30 EA per 30 days)


FULYZAQ T5

loperamide oral capsule T5

loperamide oral liquid 1 mg/5 ml T1 QL (150 ML per 30 days)

MOTOFEN T5

opium tincture T5

PEPTIC RELIEF ORAL TABLET,CHEWABLE T1

PINK BISMUTH ORAL SUSPENSION 262 MG/15 ML

T1

PINK BISMUTH ORAL TABLET T1

STOMACH RELIEF MAX STRENGTH T1

Antiemetics, Miscellaneous

ANTI-NAUSEA T1

CESAMET T5

dronabinol T5

TRANSDERM-SCOP T5

Antiflatulents

alum-mag hydroxide-simeth oral suspension 200-200-20 mg/5 ml

T1

ANTACID ANTI-GAS ORAL SUSPENSION 400-400-40 MG/5 ML

T1

BICARSIM T2

BICARSIM FORTE T1

simethicone oral capsule 180 mg T1

simethicone oral drops,suspension T1

simethicone oral tablet,chewable T1

Antihistamines (Gi Drugs)

COMPRO T5


meclizine oral tablet 12.5 mg, 25 mg T1

meclizine oral tablet,chewable T1

97

Drug Tier Notes

prochlorperazine edisylate injection solution 5 mg/ml

T5

prochlorperazine maleate T5

TIGAN INTRAMUSCULAR T5

TIGAN ORAL CAPSULE 300 MG T5

Anti-Inflammatory Agents (Gi Drugs)

APRISO T5

ASACOL HD T5

AZULFIDINE T5


balsalazide T5

CANASA T5

DELZICOL ORAL CAPSULE,DELAYED RELEASE(DR/EC)

T5

DIPENTUM T5

LIALDA T5

LOTRONEX T5

mesalamine rectal enema T5

mesalamine with cleansing wipe T5

SFROWASA T5

Antiulcer Agents And Acid Suppress.,Misc

HELIDAC T5

PYLERA T5

Cathartics And Laxatives

AMITIZA T5

ATABEX EC T5

bisacodyl T1

COLYTE WITH FLAVOR PACKS ORAL RECON SOLN 227.1-21.5-6.36 GRAM

T5

COMPLETE-RF PRENATAL T5

DAILY FIBER (PSYLLIUM-SUCROSE) ORAL POWDER 3.4 GRAM/12 GRAM

T1

docusate sodium oral capsule T1

docusate sodium oral tablet T1

ENEMA DISPOSABLE T1

98

Drug Tier Notes

FIBER SMOOTH T1

FOLCAL DHA T5


GAVILYTE-G T5

GAVILYTE-N T5

GERI-MUCIL (ASPARTAME) T1

glycerin (adult) T1

glycerin (child) T1

GOLYTELY ORAL POWDER IN PACKET T5

HALFLYTELY-BISACODYL W-FLAV PK T5

karaya gum (bulk) T1

KONSYL (SUGAR) ORAL POWDER IN PACKET

T1

LAXATIVE (BISACODYL) ORAL TABLET T1

LO-SO PREP T5

MACNATAL CN DHA T5

magnesium citrate oral solution T1

MILK OF MAGNESIA T1

MINERAL OIL LAXATIVE T1

MOVIPREP T5

OBSTETRIX EC T5

OBTREX T5

OSMOPREP T5

peg 3350-electrolytes oral recon soln 240-22.72-6.72 -5.84 gram

T5

polyethylene glycol 3350 T1 QL (527 QY per 30 DYs)


PREQUE 10 T5

psyllium husk oral powder T1

SENNA ORAL SYRUP 8.8 MG/5 ML T1

SENNA ORAL TABLET T1

sennosides-docusate sodium T1

SILACE ORAL SYRUP T1

STOOL SOFTENER ORAL CAPSULE 50 MG T1

99

Drug Tier Notes

SUPREP BOWEL PREP KIT T5

TRICARE PRENATAL DHA ONE(DSS) T5

TRINATAL ULTRA T5

TRIVEEN-PRX RNF T5

VIRT-SELECT T5

VP-CH PLUS T5

ZATEAN-CH T5

Cholelitholytic Agents

CHENODAL T5

URSO FORTE T5

ursodiol oral capsule T5

ursodiol oral tablet 250 mg T5

Digestants

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 6,000-19,000 -30,000 UNIT

T5

lactase T1

PANCRELIPASE 5000 T5

ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC) 10,000-34,000 -55,000 UNIT, 15,000-51,000 -82,000 UNIT, 20,000-68,000 -109,000 UNIT

T5

Emetics

ipecac T1

Gi Drugs, Miscellaneous

ALLI T2

CIMZIA T5

CIMZIA POWDER FOR RECONST T5

CIMZIA STARTER KIT T5

CULTURELLE KIDS PROBIOTICS ORAL POWDER IN PACKET

T2

CULTURELLE ORAL CAPSULE, SPRINKLE T2

ENTEREG T5

HUMIRA PEN T5

100

Drug Tier Notes

HUMIRA SUBCUTANEOUS SYRINGE KIT 20 MG/0.4 ML

T5

PROBIOTIC (S.BOULARDII) T1

RELISTOR SUBCUTANEOUS KIT T5

RELISTOR SUBCUTANEOUS SOLUTION T5

REMICADE T5

SIMPONI SUBCUTANEOUS PEN INJECTOR T5

VSL#3 ORAL CAPSULE T3 PA

XENICAL T5

Histamine H2-Antagonists

ACID REDUCER (FAMOTIDINE) ORAL TABLET 20 MG

T1

AXID ORAL SOLUTION T5

cimetidine hcl T5

cimetidine oral tablet 200 mg T1

cimetidine oral tablet 300 mg, 400 mg, 800 mg T5

famotidine (pf)-nacl (iso-os) T5

famotidine intravenous solution T5

famotidine oral suspension T5

famotidine oral tablet 10 mg T1

famotidine oral tablet 40 mg T5

nizatidine oral capsule T5

ranitidine hcl injection solution 25 mg/ml T5

ranitidine hcl oral capsule T5

ranitidine hcl oral syrup T5

ranitidine hcl oral tablet 150 mg, 75 mg T1

ranitidine hcl oral tablet 300 mg T5

Neurokinin-1 Receptor Antagonists

EMEND ORAL CAPSULE T5

EMEND ORAL CAPSULE,DOSE PACK T5

Prokinetic Agents

metoclopramide hcl injection solution T5

metoclopramide hcl oral solution T5

metoclopramide hcl oral tablet T5

101

Drug Tier Notes

METOZOLV ODT ORAL TABLET,DISINTEGRATING 5 MG

T5

Prostaglandins

ARTHROTEC 50 T5

ARTHROTEC 75 T5

misoprostol T5

Protectants

CARAFATE ORAL SUSPENSION T5

sucralfate oral tablet T5

Proton-Pump Inhibitors

ACIPHEX T5

ACIPHEX SPRINKLE T5

DEXILANT T5

lansoprazole oral capsule,delayed release(dr/ec) T5

NEXIUM T5

NEXIUM IV T5

NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN PACKET 10 MG, 20 MG, 40 MG

T5

OMECLAMOX-PAK T5

omeprazole oral capsule,delayed release(dr/ec) T5

omeprazole oral tablet,delayed release (dr/ec) T5

omeprazole-sodium bicarbonate oral capsule T5

pantoprazole T5

PREVACID SOLUTAB T5

PREVPAC T5

PRILOSEC ORAL SUSP,DELAYED RELEASE FOR RECON

T5

PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET

T5

VIMOVO T5

ZEGERID ORAL PACKET 20-1,680 MG T5

Gold Compounds

Gold Compounds

RIDAURA T5

102

Drug Tier Notes

Heavy Metal Antagonists

Heavy Metal Antagonists

CHEMET T5

CUPRIMINE T5

deferoxamine T5

DEPEN TITRATABS T5

EXJADE T5

SYPRINE T5

Hormones And Synthetic Substitutes

Adrenals

ADVAIR DISKUS T5

ADVAIR HFA T5

A-HYDROCORT T5

ALVESCO T5

A-METHAPRED T5

ARISTOSPAN INTRA-ARTICULAR T5

ARISTOSPAN INTRALESIONAL T5

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (14)

T5

BAYCADRON T5

betamethasone acet,sod phos T5


CELESTONE T5

CORTEF T5

cortisone T5

DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML

T5

DEXAMETHASONE INTENSOL T5

dexamethasone oral solution T5

dexamethasone oral tablet T5

dexamethasone sodium phosphate injection solution

T5

DEXPAK 10 DAY T5

103

Drug Tier Notes


T5

ENTOCORT EC T5

FLOVENT DISKUS T5

FLOVENT HFA T5

fludrocortisone T5

KENALOG INJECTION T5

MEDROL ORAL TABLET 2 MG T5

methylprednisolone T5

methylprednisolone acetate T5

methylprednisolone sodium succ intravenous recon soln 1,000 mg

T5

MILLIPRED T5

MILLIPRED DP ORAL TABLETS,DOSE PACK 5 MG (21 TABS)

T5

ORAPRED ODT T5

prednisolone oral solution 15 mg/5 ml T5

prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

T5

prednisone T5

PREDNISONE INTENSOL T5

PULMICORT FLEXHALER T5

PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG/2 ML

T5

QVAR T5

SOLU-CORTEF ACT-O-VIAL (PF) INJECTION RECON SOLN 1,000 MG/8 ML, 250 MG/2 ML, 500 MG/4 ML

T5

SOLU-MEDROL INTRAVENOUS RECON SOLN 2 GRAM

T5

VERIPRED 20 T5

Alpha-Glucosidase Inhibitors

acarbose T5

GLYSET T5

Amylinomimetics

104

Drug Tier Notes

SYMLINPEN 120 T5

Androgens

ANADROL-50 T5

ANDRODERM T5

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP

T5

ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)

T5

ANDROID T5

ANDROXY T5

AXIRON T5

COVARYX T5

COVARYX H.S. T5

danazol T5

DEPO-TESTOSTERONE T5

FORTESTA T5

METHITEST T5

OXANDRIN T5

STRIANT T5

TESTOPEL T5

testosterone enanthate T5

Antidiabetic Agents, Miscellaneous

WELCHOL T5

Antiestrogens

anastrozole T5

AROMASIN T5

letrozole T5

Antigonadtropins

CETROTIDE SUBCUTANEOUS KIT 0.25 MG T5

FIRMAGON T5

ganirelix T5

Antihypoglycemic Agents, Miscellaneous

PROGLYCEM T5

105

Drug Tier Notes

Antiparathyroid Agents

calcitonin (salmon) T5

MIACALCIN INJECTION T5

SENSIPAR T5

Antithyroid Agents

IODOPEN T5

methimazole oral tablet 10 mg, 5 mg T5

propylthiouracil T5

SSKI T5

THYROSHIELD T5

Biguanides

ACTOPLUS MET XR T5

AVANDAMET T5

glipizide-metformin T5

GLUMETZA T5

glyburide-metformin T5

JANUMET T5

JENTADUETO T5

KOMBIGLYZE XR T5

metformin oral tablet T5

metformin oral tablet extended release 24 hr T5

metformin oral tablet extended release 24hr T5

PRANDIMET T5

Contraceptives

ALTAVERA (28) T5

AMETHYST (28) T5

APRI T5

ARANELLE (28) T5

AVIANE T5

AZURETTE (28) T5

BALZIVA (28) T5

BEYAZ T5

BREVICON (28) T5

106

Drug Tier Notes

CAMILA T5

CAZIANT (28) T5

CRYSELLE (28) T5

CYCLAFEM 1/35 (28) T5

CYCLAFEM 7/7/7 (28) T5

ELLA T5

ENPRESSE T5

ESTROSTEP FE-28 T5

FEMCON FE T5

GIANVI (28) T5

GILDESS FE 1.5/30 (28) T5

GILDESS FE 1/20 (28) T5

IMPLANON T5

INTROVALE T5

JUNEL 1.5/30 (21) T5

JUNEL 1/20 (21) T5

KELNOR 1/35 (28) T5

levonorgestrel oral tablet 0.75 mg T5

LO LOESTRIN FE T5

LOSEASONIQUE T5

MIRENA T5

MONONESSA (28) T5

NATAZIA T5

NECON 1/50 (28) T5

NECON 10/11 (28) T5

NEXT CHOICE ONE DOSE T5

NUVARING T5

OCELLA T5

OGESTREL (28) T5

ORTHO TRI-CYCLEN (28) T5

ORTHO TRI-CYCLEN LO (28) T5

SAFYRAL T5

SEASONIQUE T5

XULANE T5

107

Drug Tier Notes

ZOVIA 1/50E (28) T5

Dipeptidyl Peptidase-4(Dpp-4) Inhibitors

JANUMET T5

JANUVIA T5

JENTADUETO T5

KOMBIGLYZE XR T5

ONGLYZA T5

Estrogen Agonist-Antagonists

EVISTA T5

FARESTON T5

tamoxifen T5

Estrogens

ACTIVELLA T5

ALORA T5

ANGELIQ ORAL TABLET 0.5-1 MG T5

CENESTIN T5

CLIMARA PRO T5

COMBIPATCH T5

COVARYX T5

COVARYX H.S. T5

DEPO-ESTRADIOL T5

DIVIGEL TRANSDERMAL GEL IN PACKET 0.25 MG/0.25 GRAM (0.1 %)

T5

ELESTRIN T5

ENJUVIA T5

ESTRACE VAGINAL T5

estradiol oral T5

estradiol transdermal patch weekly T5

estradiol vaginal tablet T5

estradiol valerate T5

ESTRASORB T5

ESTRING T5

ESTROGEL T5

estropipate T5

108

Drug Tier Notes

EVAMIST T5

FEMHRT LOW DOSE T5

FEMRING T5

JINTELI T5

MENEST T5

MENOSTAR T5

PREFEST T5

PREMARIN T5

PREMPHASE T5

PREMPRO T5

VIVELLE-DOT TRANSDERMAL PATCH SEMIWEEKLY 0.0375 MG/24 HR

T5

Glycogenolytic Agents

GLUCAGEN HYPOKIT T5

GLUCAGON EMERGENCY KIT (HUMAN) T5

Gonadotropins

BRAVELLE T5

chorionic gonadotropin, human intramuscular T5

ELIGARD T5




FOLLISTIM AQ T5

GONAL-F T5

GONAL-F RFF T5

GONAL-F RFF PEN SUBCUTANEOUS PEN INJECTOR 300/0.5 UNIT/ML

T5


LUPRON DEPOT T5



LUPRON DEPOT-PED T5

MENOPUR T5

OVIDREL T5

109

Drug Tier Notes

REPRONEX T5

SUPPRELIN LA T5

SYNAREL T5

TRELSTAR INTRAMUSCULAR SYRINGE T5

VANTAS T5

ZOLADEX T5

Gonadotropins And Antigonadotropins

BRAVELLE T5

chorionic gonadotropin, human intramuscular T5

ELIGARD T5




FOLLISTIM AQ T5

GONAL-F T5

GONAL-F RFF T5

GONAL-F RFF PEN SUBCUTANEOUS PEN INJECTOR 300/0.5 UNIT/ML

T5


LUPRON DEPOT T5



LUPRON DEPOT-PED T5

MENOPUR T5

OVIDREL T5

REPRONEX T5

SUPPRELIN LA T5

SYNAREL T5

VANTAS T5

ZOLADEX T5

Incretin Mimetics

BYETTA T5

VICTOZA 2-PAK T5

Insulins

110

Drug Tier Notes

APIDRA SOLOSTAR U-100 INSULIN T5

APIDRA U-100 INSULIN T5

HUMALOG MIX 50-50 KWIKPEN T5


HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE

T5

HUMULIN 70/30 INSULIN PEN T5

HUMULIN N PEN T5

HUMULIN R REGULAR U-100 INSULN T5

HUMULIN R U-500 (CONC) INSULIN T5

LANTUS SOLOSTAR U-100 INSULIN T5

LEVEMIR U-100 INSULIN T5

NOVOLOG MIX 70-30FLEXPEN U-100 T5

NOVOLOG PENFILL U-100 INSULIN T5

Intermediate-Acting Insulins




HUMULIN N PEN T5


Long-Acting Insulins

LANTUS SOLOSTAR U-100 INSULIN T5

LEVEMIR U-100 INSULIN T5

Meglitinides

nateglinide T5

PRANDIMET T5

PRANDIN ORAL TABLET 0.5 MG T5

repaglinide oral tablet 1 mg, 2 mg T5

Parathyroid Agents

FORTEO T5

Parathyroid And Antiparathyroid Agents


FORTEO T5


111

Drug Tier Notes

Pituitary

ACTHAR H.P. T5

DDAVP T5

desmopressin nasal spray,non-aerosol T5

GENOTROPIN T5

GENOTROPIN MINIQUICK T5

HUMATROPE T5

NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG/1.5 ML (6.7 MG/ML), 15 MG/1.5 ML (10 MG/ML)

T5

NORDITROPIN NORDIFLEX T5

NUTROPIN T5

NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 5 MG/2 ML (2.5 MG/ML)

T5

NUTROPIN AQ SUBCUTANEOUS CARTRIDGE 20 MG/2 ML (10 MG/ML)

T5

OMNITROPE SUBCUTANEOUS CARTRIDGE 5 MG/1.5 ML (3.3 MG/ML)

T5

OMNITROPE SUBCUTANEOUS RECON SOLN

T5

PITRESSIN T5

SAIZEN CLICK.EASY T5

SAIZEN SUBCUTANEOUS RECON SOLN 5 MG

T5

SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG

T5

STIMATE T5

ZORBTIVE T5

Progestins

ACTIVELLA T5

ANGELIQ ORAL TABLET 0.5-1 MG T5

AYGESTIN T5

COMBIPATCH T5

CRINONE T5

DEPO-PROVERA INTRAMUSCULAR SUSPENSION

T5

112

Drug Tier Notes

DEPO-SUBQ PROVERA 104 T5

ENDOMETRIN T5

FEMHRT LOW DOSE T5

JINTELI T5

MAKENA INTRAMUSCULAR OIL 250 MG/ML

T5

medroxyprogesterone oral T5

MEGACE ES T5

megestrol oral suspension 400 mg/10 ml (40 mg/ml)

T5

megestrol oral tablet T5

progesterone T5

PROMETRIUM T5

Rapid-Acting Insulins

APIDRA SOLOSTAR U-100 INSULIN T5

APIDRA U-100 INSULIN T5



HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE

T5


NOVOLOG PENFILL U-100 INSULIN T5

Short-Acting Insulins


HUMULIN R REGULAR U-100 INSULN T5

HUMULIN R U-500 (CONC) INSULIN T5

Somatostatin Agonists

octreotide acetate injection solution T5

SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT

T5

SOMATULINE DEPOT T5

Somatotropin Agonists

INCRELEX T5

Somatotropin Antagonists

113

Drug Tier Notes

SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG, 15 MG, 20 MG

T5

Sulfonylureas

AVANDARYL T5

chlorpropamide T5

DIABETA T5

DUETACT T5

glimepiride T5

glipizide T5

glipizide-metformin T5

glyburide micronized T5

glyburide-metformin T5

tolazamide T5

Thiazolidinediones

ACTOPLUS MET XR T5

AVANDAMET T5

AVANDARYL T5

AVANDIA T5

DUETACT T5

pioglitazone T5

Thyroid Agents

ARMOUR THYROID T5

CYTOMEL T5

levothyroxine oral T5

liothyronine intravenous T5

NATURE-THROID ORAL TABLET 130 MG, 16.25 MG, 195 MG, 260 MG, 32.5 MG, 325 MG, 65 MG, 97.5 MG

T5

THYROLAR-1 T5

THYROLAR-1/2 T5

THYROLAR-1/4 T5

THYROLAR-2 T5

THYROLAR-3 T5

114

Drug Tier Notes

TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG, 137 MCG, 150 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

T5

Local Anesthetics (Parenteral)

Local Anesthetics (Parenteral)

bupivacaine T5

bupivacaine (pf) injection solution T5

bupivacaine-dextrose-water(pf) T5

bupivacaine-epinephrine (pf) T5

CARBOCAINE (PF) T5

CARBOCAINE INJECTION SOLUTION T5

chloroprocaine (pf) T5

lidocaine (pf) in d7.5w T5

lidocaine (pf) injection solution T5

lidocaine hcl injection solution 10 mg/ml (1 %), 5 mg/ml (0.5 %)

T5

lidocaine-epinephrine (pf) T5

lidocaine-epinephrine injection solution 0.5 %-1:200,000, 1 %-1:100,000, 2 %-1:100,000

T5

NAROPIN (PF) T5

NESACAINE INJECTION SOLUTION 10 MG/ML (1 %)

T5

PONTOCAINE (PF) T5

SENSORCAINE-EPINEPHRINE T5

SENSORCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 0.75 %-1:200,000

T5

XYLOCAINE-MPF/EPINEPHRINE INJECTION SOLUTION 1 %-1:200,000

T5

Miscellaneous Therapeutic Agents

5-Alpha-Reductase Inhibitors

AVODART T5

finasteride oral tablet 5 mg T5

JALYN T5

Alcohol Deterrents

disulfiram T5

115

Drug Tier Notes

naltrexone T5

VIVITROL T5

Antidotes

amyl nitrite inhalation solution 0.3 ml T5


T5

CHEMET T5

CROFAB T5

deferoxamine T5

DIGIFAB T5

flumazenil T5

fomepizole T5

FOSRENOL ORAL TABLET,CHEWABLE T5

FUSILEV T5

GLUCAGEN HYPOKIT T5

GLUCAGON EMERGENCY KIT (HUMAN) T5

KIONEX T5

KIONEX (WITH SORBITOL) T5

leucovorin calcium injection recon soln T5

leucovorin calcium injection solution 500 mg/50 ml

T5

leucovorin calcium oral T5


T5


T5


T5


MEPHYTON T2

methylene blue (antidote) T5

naloxone injection solution T5

naloxone injection syringe T5

physostigmine salicylate T5

protamine T5

116

Drug Tier Notes

PROTOPAM CHLORIDE T5

RENAGEL T5

RENVELA ORAL POWDER IN PACKET T5

sevelamer carbonate oral tablet T5

sodium thiosulfate intravenous solution 1 gram/10 ml (100 mg/ml), 12.5 gram/50 ml (250 mg/ml)

T5

SSKI T5

THYROSHIELD T5

Antigout Agents

allopurinol T5

allopurinol sodium T5

COLCRYS T5

INDOCIN T5

indomethacin oral T5

KRYSTEXXA T5

NAPRELAN CR T5

naproxen T5

naproxen sodium oral tablet 220 mg T1

naproxen sodium oral tablet 275 mg, 550 mg T5

probenecid T5

ULORIC T5

Bone Anabolic Agents

FORTEO T5

Bone Resorption Inhibitors

ACTONEL T5

alendronate oral tablet T5

ATELVIA T5

BONIVA INTRAVENOUS T5


etidronate disodium T5

EVISTA T5

FOSAMAX PLUS D T5

ibandronate intravenous solution T5

ibandronate oral T5

117

Drug Tier Notes


pamidronate T5

PROLIA T5

RECLAST T5

SKELID T5

XGEVA T5

ZOMETA INTRAVENOUS SOLUTION T5

Cariostatic Agents

FLUORABON T5

FLUOR-A-DAY T5

FLUOR-A-DAY (WITH XYLITOL) T5

fluoride (sodium) oral drops T5

fluoride (sodium) oral tablet,chewable 0.5 mg (1.1 mg sodium fluorid)

T5

FLUORIDEX DAILY DEFENSE DENTAL GEL T5

FLURA-DROPS T5

TRIPLE VITAMIN WITH FLUORIDE T5

Complement Inhibitors

BERINERT INTRAVENOUS KIT T5

CINRYZE T5

FIRAZYR T5

KALBITOR T5

SOLIRIS T5

Disease-Modifying Antirheumatic Agents

ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML)

T5

ACTEMRA SUBCUTANEOUS T5

ARAVA T5

AZASAN T5

azathioprine T5

azathioprine sodium T5

AZULFIDINE T5


118

Drug Tier Notes

CIMZIA T5



CUPRIMINE T5

cyclosporine intravenous T5

cyclosporine modified T5

cyclosporine oral capsule T5

DEPEN TITRATABS T5

ENBREL SUBCUTANEOUS RECON SOLN T5

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5 ML (0.5)

T5

HUMIRA PEN T5


T5


KINERET T5



ORENCIA (WITH MALTOSE) T5

OTEZLA T5

OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG(19)

T5

REMICADE T5

RHEUMATREX T5

RIDAURA T5

SANDIMMUNE ORAL SOLUTION T5


STELARA SUBCUTANEOUS SYRINGE T5

TREXALL T5

Gonadotropin-Releasing Hormone Antagnts

CETROTIDE SUBCUTANEOUS KIT 0.25 MG T5

FIRMAGON T5

ganirelix T5

Immunomodulatory Agents

119

Drug Tier Notes

ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML)

T5

ACTEMRA SUBCUTANEOUS T5

ACTIMMUNE T5

ARAVA T5

AVONEX (WITH ALBUMIN) T5

AVONEX INTRAMUSCULAR SYRINGE KIT T5

AZASAN T5

azathioprine T5


AZULFIDINE T5


BETASERON SUBCUTANEOUS KIT T5

CIMZIA T5



COPAXONE SUBCUTANEOUS SYRINGE T5






T5

GILENYA ORAL CAPSULE 0.5 MG T5

HUMIRA PEN T5


T5



KINERET T5



ORENCIA (WITH MALTOSE) T5

OTEZLA T5

120

Drug Tier Notes


T5

POMALYST T5

PROLEUKIN T5

REBIF (WITH ALBUMIN) T5

REBIF REBIDOSE T5

REBIF TITRATION PACK T5

REMICADE T5

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG

T5

RHEUMATREX T5

RIDAURA T5




THALOMID T5

TREXALL T5

TYSABRI T5

Immunosuppressive Agents

ASTAGRAF XL T5

ATGAM T5

AZASAN T5

azathioprine T5


BENLYSTA INTRAVENOUS T5

CELLCEPT T5

CELLCEPT INTRAVENOUS T5

cyclophosphamide intravenous T5

cyclophosphamide oral tablet T5




ELIDEL T5

mercaptopurine T5

121

Drug Tier Notes



mycophenolate sodium T5

PROGRAF INTRAVENOUS T5

PROGRAF ORAL CAPSULE T5

RAPAMUNE T5

RHEUMATREX T5


SIMULECT T5

THYMOGLOBULIN T5

TREXALL T5

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG

T5

Other Miscellaneous Therapeutic Agents

acetylcysteine T5

AMPYRA T5

ARCALYST T5

BOTOX T5

BOTOX COSMETIC T5

CARNITOR INTRAVENOUS T5

CARNITOR ORAL TABLET T5

CARTICEL T5

CYSTADANE T5

CYSTAGON T5

DEMSER T5

DYSPORT T5

ethanol (ethyl alcohol) T5


KUVAN ORAL POWDER IN PACKET 100 MG T5

KUVAN ORAL TABLET,SOLUBLE T5

levocarnitine (with sugar) T5

melatonin oral liquid 5 mg/15 ml T1

melatonin oral tablet 1 mg, 3 mg, 5 mg T1

melatonin oral tablet,disintegrating 3 mg, 5 mg T1

122

Drug Tier Notes

MYOBLOC INTRAMUSCULAR SOLUTION 10,000 UNIT/2 ML

T5

octreotide acetate injection solution T5

OCUVITE LUTEIN AND ZEAXANTHIN T2

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG

T5

PANHEMATIN INTRAVENOUS RECON SOLN 313 MG

T5

REMICADE T5

SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT

T5

SENSIPAR T5

THIOLA T5

XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT, 50 UNIT

T5

ZAVESCA T5

Protective Agents

amifostine crystalline T5

dexrazoxane hcl T5

ELMIRON T5

mesna T5

MESNEX ORAL T5

Oxytocics

Oxytocics

CERVIDIL T5

HEMABATE T5

methylergonovine T5

oxytocin injection solution T5

PREPIDIL T5

PROSTIN E2 T5

Pharmaceutical Aids

Pharmaceutical Aids

DILUENT FOR EPOPROSTENOL/FLOLA T5

PLACEBO #00 T4

water for inject, bacteriostat T5

123

Drug Tier Notes

Radioactive Agents

Radioactive Agents

METASTRON T5

QUADRAMET T5

Respiratory Tract Agents

Alpha And Beta Adrenergic Agonist(Respr)

ADRENALIN INJECTION SOLUTION 1 MG/ML

T5

APRODINE T1 AL

CHILDREN'S SILFEDRINE T1 AL


CONGEST-EZE T1

ephedrine sulfate injection solution T5

ephedrine sulfate oral T5

epinephrine injection syringe 0.1 mg/ml T5

EPIPEN 2-PAK T5

EPIPEN JR 2-PAK T5


LORATADINE-D T1 AL

NASAL DECONGESTANT (PSEUDOEPH) ORAL LIQUID

T1 AL

pseudoephedrine hcl oral tablet T1 AL

pseudoephedrine hcl oral tablet extended release T1 AL


T1 AL

racepinephrine T5

REZIRA T5

SEMPREX-D T5

SUDAFED 24 HOUR T1

SUDOGEST 12-HOUR T1 AL

SUDOGEST ORAL TABLET 60 MG T1 AL

Anticholinergic Agents (Respir.Tract)

ANORO ELLIPTA T5

124

Drug Tier Notes


T5

atropine injection syringe 0.1 mg/ml T5

ATROVENT HFA T5

COMBIVENT T5


ipratropium bromide inhalation T5


SPIRIVA WITH HANDIHALER T5

Antitussives

ADULT ROBITUSSIN PEAK COLD DM T1 AL

ADULT TUSSIN COUGH CONGEST DM T1 AL

benzonatate oral capsule 100 mg, 200 mg T1

codeine sulfate oral tablet T5

codeine-guaifenesin T1 AL

CREO-TERPIN (DM-GUAIFENESIN) T1

dextromethorphan polistirex T1 AL

dextromethorphan-guaifenesin oral syrup T1 AL

DIABETIC TUSSIN DM ORAL LIQUID 10-200 MG/5 ML

T1 AL


NUEDEXTA T5

promethazine-dm T1 AL

REZIRA T5

SCOT-TUSSIN SENIOR T2

SYNALGOS-DC T5

VICKS 44 CUSTOM CARE DRY COUGH T2

Cystic Fibrosis (Cftr) Potentiators

KALYDECO ORAL TABLET T5

Expectorants

ADULT ROBITUSSIN PEAK COLD DM T1 AL

ADULT TUSSIN CHEST CONGESTION T1 AL

ADULT TUSSIN COUGH CONGEST DM T1 AL

125

Drug Tier Notes

codeine-guaifenesin T1 AL

CONGEST-EZE T1

CREO-TERPIN (DM-GUAIFENESIN) T1

dextromethorphan-guaifenesin oral syrup T1 AL

DIABETIC TUSSIN DM ORAL LIQUID 10-200 MG/5 ML

T1 AL

guaifenesin oral tablet 200 mg T1 AL

guaifenesin oral tablet extended release 12hr T1 AL

MUCINEX ORAL TABLET EXTENDED RELEASE 12HR 1,200 MG

T1 AL


T1 AL

SCOT-TUSSIN SENIOR T2

SSKI T5

THYROSHIELD T5

TUSSIN ORAL LIQUID T1

First Generation Antihist.(Respir Tract)

APRODINE T1 AL




T1



T1


cyproheptadine T5







ED-CHLORPED T5


126

Drug Tier Notes

PHENABID T5



promethazine-dm T1 AL


Leukotriene Modifiers

ACCOLATE T5

montelukast T5

ZYFLO T5

ZYFLO CR T5

Mast-Cell Stabilizers

ALOCRIL T5

cromolyn inhalation T5

cromolyn nasal T1 AL

cromolyn ophthalmic (eye) T5

cromolyn oral T5

Mucolytic Agents

acetylcysteine T5

PULMOZYME T5

Nasal Preparations (Steroids)

FLONASE T5

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)

T5

OMNARIS T5

RHINOCORT ALLERGY T2 QL (8.43 ML per 30 days)

RHINOCORT AQUA T5

triamcinolone acetonide nasal T1 QL (16.9 ML per 30 days)

VERAMYST T5

Non-Select.Beta-Adrenergic Agont(Respir)

ISUPREL T5

Orally Inhaled Preparations (Steroids)

ADVAIR DISKUS T5

ADVAIR HFA T5

127

Drug Tier Notes

ALVESCO T5

ASMANEX TWISTHALER INHALATION AEROSOL POWDR BREATH ACTIVATED 110 MCG/ ACTUATION (30), 220 MCG/ ACTUATION (14)

T5



T5

FLOVENT DISKUS T5

FLOVENT HFA T5

PULMICORT FLEXHALER T5

PULMICORT INHALATION SUSPENSION FOR NEBULIZATION 1 MG/2 ML

T5

QVAR T5

Respiratory Tract Agents, Miscellaneous

ARALAST NP T5

GLASSIA T5

XOLAIR SUBCUTANEOUS RECON SOLN T5

Second Generation Antihist(Respir Tract)

ALAVERT T1

cetirizine oral tablet T1

cetirizine oral tablet,chewable T1

CHILDREN'S ALLEGRA ALLERGY T1

CHILD'S ALL DAY ALLERGY(CETIR) T1

CLARINEX ORAL SYRUP T5


desloratadine oral tablet T5

fexofenadine oral suspension T1

fexofenadine oral tablet 180 mg, 60 mg T1

levocetirizine T5

loratadine oral solution T1

loratadine oral tablet T1

LORATADINE-D T1 AL

SEMPREX-D T5

128

Drug Tier Notes

Select.Beta-2-Adrenergic Agonist(Respir)

ADVAIR DISKUS T5

ADVAIR HFA T5

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml

T5

albuterol sulfate oral syrup T5

albuterol sulfate oral tablet T5

ANORO ELLIPTA T5

BROVANA T5


COMBIVENT T5


T5

FORADIL AEROLIZER T5


levalbuterol hcl inhalation solution for nebulization 1.25 mg/0.5 ml

T5

MAXAIR AUTOHALER T5

metaproterenol T5

PERFOROMIST T5

PROAIR HFA T5

SEREVENT DISKUS T5

terbutaline T5

XOPENEX T5

XOPENEX HFA T5

Vasodilating Agents (Respiratory Tract)

ADCIRCA T5

ambrisentan T5

epoprostenol (glycine) T5

REMODULIN T5

REVATIO INTRAVENOUS T5

REVATIO ORAL TABLET T5

TRACLEER ORAL TABLET T5

129

Drug Tier Notes

TYVASO T5

VENTAVIS T5

Xanthine Derivatives

aminophylline intravenous solution 250 mg/10 ml T5


LUFYLLIN T5

THEO-24 T5

THEOCHRON T5


Skin And Mucous Membrane Agents

Allylamines (Skin And Mucous Membrane)

NAFTIN TOPICAL CREAM 1 % T5

NAFTIN TOPICAL GEL 1 % T5

terbinafine hcl topical T1 QL (120 GM per 30 days)

Antibacterials (Skin, Mucous Membrane)

ACZONE TOPICAL GEL T5

AKNE-MYCIN T5

ALTABAX T5

bacitracin topical ointment T1

bacitracin zinc topical ointment T1

BACTROBAN T5

BENZAMYCINPAK T5

CENTANY AT T5

clindamycin phosphate topical foam T5

clindamycin phosphate topical gel T5

clindamycin phosphate topical lotion T5

clindamycin phosphate topical solution T5

clindamycin phosphate topical swab T5

clindamycin phosphate vaginal T5

clindamycin-benzoyl peroxide topical gel T5

CORTISPORIN TOPICAL T5

ERY PADS T5

erythromycin with ethanol topical gel T5

130

Drug Tier Notes

erythromycin with ethanol topical solution T5

erythromycin-benzoyl peroxide T5

gentamicin topical T5

metronidazole topical cream T5

metronidazole topical gel T5

metronidazole topical lotion T5

metronidazole vaginal T5

neomycin-polymyxin b gu T5

NORITATE T5

ROSADAN TOPICAL KIT, CLEANSER AND GEL

T5

TRIPLE ANTIBIOTIC TOPICAL OINTMENT T1

VELTIN T5

Antifulgals (Skin, Mucous Membrane),Misc

EXODERM T5

Anti-Inflammatory Agents (Skin, Mucous)

ALA-SCALP T5

alclometasone T5

ALCORTIN A TOPICAL GEL IN PACKET T5

amcinonide T5

ANALPRAM ADVANCED T5

ANALPRAM-HC RECTAL LOTION T5

ANUSOL-HC RECTAL CREAM WITH APPLICATOR

T5

APEXICON T5

APEXICON E T5

betamethasone dipropionate T5

betamethasone valerate topical cream T5

betamethasone valerate topical lotion T5

betamethasone valerate topical ointment T5

betamethasone, augmented T5

CAPEX T5

CARMOL HC T5

clobetasol scalp T5

131

Drug Tier Notes

clobetasol topical cream T5

clobetasol topical foam T5

clobetasol topical gel T5

clobetasol topical ointment T5

clobetasol-emollient topical cream T5

CLOBEX T5

CLODERM T5

clotrimazole-betamethasone T5

COLOCORT T5

CORDRAN TAPE SMALL ROLL T5

CORDRAN TOPICAL CREAM 0.05 % T5

CORDRAN TOPICAL LOTION T5

CUTIVATE TOPICAL OINTMENT T5

DERMA-SMOOTHE/FS BODY OIL T5

DERMATOP T5

DESONATE T5

desonide T5

DESOWEN OINTMENT AND LOTION T5

desoximetasone topical cream T5

desoximetasone topical gel T5

desoximetasone topical ointment 0.25 % T5

diflorasone topical cream T5

ELOCON TOPICAL CREAM T5

ELOCON TOPICAL OINTMENT T5

EPIFOAM T5

fluocinolone and shower cap T5

fluocinolone topical cream T5

fluocinolone topical ointment T5

fluocinolone topical solution T5

fluocinonide topical cream 0.05 % T5

fluocinonide topical gel T5

fluocinonide topical ointment T5

fluocinonide topical solution T5

FLUOCINONIDE-E T5

132

Drug Tier Notes

fluticasone propionate topical cream T5

fluticasone propionate topical lotion T5

halobetasol propionate topical cream T5

halobetasol propionate topical ointment T5

HALOG T5

HALONATE T5

HC-1% HEMORRHOID T1

hydrocortisone acetate rectal suppository 25 mg T5

hydrocortisone acetate topical cream 1 % T1 QL (240 GM per 30 days)

hydrocortisone butyrate topical cream T5

hydrocortisone butyrate topical ointment T5

hydrocortisone butyrate topical solution T5

hydrocortisone topical cream 1 % T1 QL (240 QY per 30 DYs)

hydrocortisone topical cream 2.5 % T5

hydrocortisone topical lotion 1 % T1 QL (240 GM per 30 days)

hydrocortisone topical lotion 2.5 % T5

hydrocortisone topical ointment 0.5 %, 2.5 % T5

hydrocortisone topical ointment 1 % T1 QL (240 QY per 30 DYs)

hydrocortisone valerate T5

hydrocortisone-aloe vera topical cream 1 % T1 QL (240 QY per 30 DYs)

hydrocortisone-pramox-e-pram.1 rectal kit,cream and towelette 2.5 %-1 % (4 gram)-1 %

T5

hydrocortisone-pramoxine rectal cream 1-1 %, 2.5-1 %

T5

hydrocortisone-pramoxine topical T5

KENALOG TOPICAL T5

lidocaine hcl-hydrocortison ac rectal kit 3-0.5 %, 3-1 % (7 gram)

T5

lidocaine hcl-hydrocortison ac topical T5

lidocaine-hydrocortisone-aloe T5

LOCOID LIPOCREAM T5

LOCOID TOPICAL LOTION T5

LUXIQ T5

mometasone topical solution T5

NUCORT T5

133

Drug Tier Notes

OLUX-E T5

ORALONE T5

PANDEL T5

PEDIADERM HC T5

PROCTOCORT TOPICAL T5

PROCTOFOAM HC T5

RIMSO-50 T5

TACLONEX T5

TEXACORT T5

triamcinolone acetonide topical cream T5

triamcinolone acetonide topical lotion T5

triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %

T5

TRIANEX T5

ULTRAVATE PAC T5

VANOS T5

XERESE T5

Antipruritics And Local Anesthetics



ANECREAM (WITH DRESSINGS) T5

ANTI-ITCH (DIPHENHYDRAMINE) TOPICAL GEL

T1

EPIFOAM T5


T5


T5


lidocaine hcl topical cream 3 % T5

lidocaine hcl topical lotion T5


T5


LIDOCAINE PAIN RELIEF T1

134

Drug Tier Notes

lidocaine topical cream 5 % T1

lidocaine topical ointment T5


lidocaine-prilocaine T5

LIDODERM T5

phenazopyridine oral tablet 95 mg T1

PRAMEGEL ANTI-ITCH T5

pramoxine T1

PROCTOFOAM HC T5

PRUDOXIN T5

SYNERA T5

VAGISIL TOPICAL CREAM 20-3 % T5

Antivirals (Skin And Mucous Membrane)

ABREVA T2 QL (2 QY per 30 DYs)

acyclovir topical cream T5

DENAVIR T5

XERESE T5

ZOVIRAX TOPICAL OINTMENT T5

Astringents

HEMORRHOIDAL (WITCH HAZEL) T1

Azoles (Skin And Mucous Membrane)

ALOE VESTA ANTIFUNGAL (MICON) T1

AZOLEN TINCTURE T1

clotrimazole mucous membrane T5

clotrimazole topical solution T5

clotrimazole vaginal cream T1


econazole T5

ECOZA T5

ERTACZO T5

EXELDERM T5

EXTINA T5

FUNGI CURE T2

GYNE-LOTRIMIN T1

135

Drug Tier Notes

ketoconazole topical cream T5

ketoconazole topical shampoo T5

LOTRIMIN AF T1

LOTRIMIN AF POWDER T1

miconazole nitrate topical cream T1

miconazole nitrate vaginal cream T1

miconazole nitrate vaginal suppository T1

MICONAZOLE-3 VAGINAL SUPPOSITORY T5

MONISTAT 3 VAGINAL CREAM T2

NIZORAL A-D T2

OXISTAT T5

terconazole vaginal cream T5

tioconazole T1

VUSION T5

XOLEGEL T5

Basic Lotions And Liniments

GERI-HYDROLAC TOPICAL LOTION 12 % T2

GERI-HYDROLAC TOPICAL LOTION 5 % T1

LAC-HYDRIN FIVE T2

lactic acid T5

Basic Oils And Other Solvents

MINERAL OIL LIGHT T1

Basic Ointments And Protectants

ammonium lactate topical cream T1

HYDROPHOR T5

MINERIN CREME T1

Benzylamines (Skin And Mucous Membrane)

LOTRIMIN ULTRA T5

Cell Stimulants And Proliferants

ATRALIN T5

AVITA T5

KEPIVANCE T5

REGRANEX T5

136

Drug Tier Notes

RENOVA TOPICAL CREAM 0.02 % T5

RETIN-A MICRO T5

RETIN-A TOPICAL CREAM 0.05 %, 0.1 % T5

RETIN-A TOPICAL GEL 0.01 % T5

tretinoin (emollient) T5

TRETIN-X (GEL) T5

TRETIN-X CREAM KIT T5

TRETIN-X TOPICAL CREAM 0.0375 % T5

VELTIN T5

Corticosteroids (Skin, Mucous Membrane)

ALA-SCALP T5

alclometasone T5


amcinonide T5



ANUSOL-HC RECTAL CREAM WITH APPLICATOR

T5

APEXICON T5

APEXICON E T5

betamethasone dipropionate T5

betamethasone valerate topical cream T5

betamethasone valerate topical lotion T5

betamethasone valerate topical ointment T5

betamethasone, augmented T5

CAPEX T5

CARMOL HC T5

clobetasol scalp T5

clobetasol topical cream T5

clobetasol topical foam T5

clobetasol topical gel T5

clobetasol topical ointment T5

clobetasol-emollient topical cream T5

CLOBEX T5

137

Drug Tier Notes

CLODERM T5


COLOCORT T5

CORDRAN TAPE SMALL ROLL T5

CORDRAN TOPICAL CREAM 0.05 % T5

CORDRAN TOPICAL LOTION T5

CORTISPORIN TOPICAL T5

CUTIVATE TOPICAL OINTMENT T5

DERMA-SMOOTHE/FS BODY OIL T5

DERMATOP T5

DESONATE T5

desonide T5

DESOWEN OINTMENT AND LOTION T5

desoximetasone topical cream T5

desoximetasone topical gel T5

desoximetasone topical ointment 0.25 % T5

diflorasone topical cream T5

ELOCON TOPICAL CREAM T5

ELOCON TOPICAL OINTMENT T5

EPIFOAM T5

fluocinolone and shower cap T5

fluocinolone topical cream T5

fluocinolone topical ointment T5

fluocinolone topical solution T5

fluocinonide topical cream 0.05 % T5

fluocinonide topical gel T5

fluocinonide topical ointment T5

fluocinonide topical solution T5

FLUOCINONIDE-E T5

fluticasone propionate topical cream T5

fluticasone propionate topical lotion T5

halobetasol propionate topical cream T5

halobetasol propionate topical ointment T5

HALOG T5

138

Drug Tier Notes

HALONATE T5

HC-1% HEMORRHOID T1

hydrocortisone acetate rectal suppository 25 mg T5

hydrocortisone acetate topical cream 1 % T1 QL (240 GM per 30 days)

hydrocortisone butyrate topical cream T5

hydrocortisone butyrate topical ointment T5

hydrocortisone butyrate topical solution T5

hydrocortisone topical cream 1 % T1 QL (240 QY per 30 DYs)

hydrocortisone topical cream 2.5 % T5

hydrocortisone topical lotion 1 % T1 QL (240 GM per 30 days)

hydrocortisone topical lotion 2.5 % T5

hydrocortisone topical ointment 0.5 %, 2.5 % T5

hydrocortisone topical ointment 1 % T1 QL (240 QY per 30 DYs)

hydrocortisone valerate T5

hydrocortisone-aloe vera topical cream 1 % T1 QL (240 QY per 30 DYs)


T5


T5


KENALOG TOPICAL T5


T5



LOCOID LIPOCREAM T5

LOCOID TOPICAL LOTION T5

LUXIQ T5

mometasone topical solution T5

NUCORT T5

OLUX-E T5

ORALONE T5

PANDEL T5

PEDIADERM HC T5

PROCTOCORT TOPICAL T5

139

Drug Tier Notes

PROCTOFOAM HC T5

TACLONEX T5

TEXACORT T5

triamcinolone acetonide topical cream T5

triamcinolone acetonide topical lotion T5

triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 %

T5

TRIANEX T5

ULTRAVATE PAC T5

VANOS T5

XERESE T5

Depigmenting Agents

TRI-LUMA T5

Detergents

PERIFRESH T1

Hydroxypyridones (Skin, Mucous Membrane)

ciclopirox T5

ciclopirox-vite-nail lacq remo T5

CNL 8 NAIL T5

Keratolytic Agents

ACNE MEDICATION TOPICAL LOTION 5 % T1

benzoyl peroxide topical cleanser 10 %, 4 %, 5 % T1

benzoyl peroxide topical gel 10 %, 2.5 % T1 QL (60 QY per 30 DYs)

benzoyl peroxide topical gel 5 % T1

benzoyl peroxide topical lotion 10 % T1

BP-50% UREA T5

clindamycin-benzoyl peroxide topical gel T5

GORDONS UREA T5

HYDRO 35 T5

HYDRO 40 T5

KERAFOAM T5

LATRIX XM T5

NEUTROGENA T-GEL CONDITNER(SA) T2

PRASCION RA T5

140

Drug Tier Notes

salicylic acid topical liquid 17 % T1 QL (15 QY per 30 DYs)

UMECTA NAIL FILM PEN T5

UMECTA PD T5

URAMAXIN TOPICAL CREAM T5

URAMAXIN TOPICAL FOAM T5

URAMAXIN TOPICAL GEL T5

UREA (WITH LACTIC,SALICY ACID) T5

urea topical cream 20 % T1 QL (85 QY per 30 DYs)

urea topical cream 40 %, 50 % T5

urea topical gel 40 % T5

urea topical lotion T5

WART REMOVER TOPICAL LIQUID T1 QL (14.8 QY per 30 DYs)

Keratoplastic Agents

coal tar (bulk) T5

CUTAR T2

ELTA LITE TAR T1

ELTA TAR T1

THERA-GEL T1

X-SEB T PLUS T1

Local Anti-Infectives, Miscellaneous

ALCOHOL PREP PADS T5


ALOQUIN T5

ANTISEPTIC WOUND-SKIN T1

DY-O-DERM T5

KLARON T5

PHISOHEX T5

PRASCION RA T5

selenium sulfide topical shampoo 2.25 %, 2.5 % T5

SILVADENE T5

SULFAMYLON T5

ULESFIA T5

Nonsteroidal Anti-Inflammat.Agents(Skin)


141

Drug Tier Notes

FLECTOR T5


VOLTAREN TOPICAL T5

Pigmenting Agents

8-MOP T5

OXSORALEN T5

OXSORALEN ULTRA T5

UVADEX T5

Polyenes (Skin And Mucous Membrane)

NYAMYC T5

nystatin topical cream T5

nystatin topical ointment T5

nystatin-triamcinolone T5

Scabicides And Pediculicides

ACTICIN T5

EURAX T5

lindane T5

malathion T5

NATROBA T5

permethrin topical liquid T1

PYRETHRIN LICE TREATMENT M T1

RID LICE KILLING T1

ULESFIA T5

Skin And Mucous Membrane Agents, Misc.

acitretin T5

ACZONE TOPICAL GEL T5

adapalene topical cream T5

adapalene topical gel 0.1 % T5

ALOE VESTA CLEANSING T1

AVAGE T5

AZELEX T5

calcipotriene scalp T5

calcipotriene topical cream T5

142

Drug Tier Notes

calcipotriene topical ointment T5

capsaicin topical cream 0.025 % T1

CARAC T5

CETAPHIL GENTLE CLEANSER T1

CLARAVIS T5

CONDYLOX T5


DIFFERIN TOPICAL GEL 0.3 % T5

DIFFERIN TOPICAL LOTION T5

EFUDEX TOPICAL CREAM T5

ELIDEL T5



T5

EPIDUO TOPICAL GEL T5

FINACEA TOPICAL GEL T5

FLECTOR T5

FLUOROPLEX T5

fluorouracil topical solution T5

GRX RINSE-FREE T1

HIGH POTENCY CAPSAICIN T1 QL (42.5 QY per 30 DYs)

HUMIRA PEN T5


T5

imiquimod topical cream in packet T5

K-Y LUBRICATING T1

LEVULAN T5

METVIXIA T5

minocycline oral tablet extended release 24 hr 135 mg, 45 mg, 90 mg

T5

ORACEA T5

ORAL RELIEF DRY MOUTH T2

OTEZLA T5


T5

143

Drug Tier Notes

PANRETIN T5


PROSHIELD SPRAY CLEANSER T1

PROTOPIC T5

QUTENZA T5

REGRANEX T5

REMICADE T5

SANTYL T5

SOLODYN ORAL TABLET EXTENDED RELEASE 24 HR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG

T5


TACLONEX T5

TARGRETIN TOPICAL T5

TAZORAC T5

TRIXAICIN T1

TRIXAICIN HP T1

VALCHLOR T5

VANIQA T5

VECTICAL T5

VEREGEN T5

VOLTAREN TOPICAL T5

ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP 2.5 %

T5

ZYCLARA TOPICAL CREAM IN PACKET T5

Thiocarbamates(Skin And Mucous Membrane)

LAMISIL AF TOPICAL POWDER T1

TINACTIN TOPICAL AEROSOL POWDER T1

TINACTIN TOPICAL AEROSOL,SPRAY T2

tolnaftate topical cream T1

tolnaftate topical solution T1

Smooth Muscle Relaxants

Antimuscarinics

DITROPAN XL ORAL TABLET EXTENDED RELEASE 24HR 5 MG

T5

144

Drug Tier Notes

ENABLEX T5

flavoxate T5

GELNIQUE TRANSDERMAL GEL IN METERED-DOSE PUMP 28 MG/0.92 GRAM (3 %)

T5

oxybutynin chloride oral syrup T5

oxybutynin chloride oral tablet T5

oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg

T5

OXYTROL T5

SANCTURA T5

SANCTURA XR T5

solifenacin T5

tolterodine T5

TOVIAZ T5

Respiratory Smooth Muscle Relaxants

aminophylline intravenous solution 250 mg/10 ml T5


LUFYLLIN T5

THEO-24 T5

THEOCHRON T5


Vitamins

Multivitamin Preparations

ANIMAL SHAPES COMPLETE ORAL TABLET,CHEWABLE

T1

APETIMAR/IRON T2

AQUADEKS ORAL TABLET,CHEWABLE T2

ATABEX EC T5

BAL-CARE DHA T5


B-NEXA T5

CAVAN-EC SOD DHA T5

CENTRUM COMPLETE T1

CENTRUM SILVER ORAL TABLET T1

145

Drug Tier Notes

CHEWABLE-VITE T2

CITRANATAL B-CALM (FE GLUC) T5

CLASSIC PRENATAL T2

COMPLETE SENIOR ORAL TABLET T1

COMPLETENATE T5


CONCEPT DHA T5

CONCEPT OB T5

DAILY MULTIPLE FOR MEN 50+ T1

DAILY-VITE T1


T5

DUET DHA EC-OM 3 T5


ELITE OB WITH DHA T5

ELITE-OB 400 T5



FLINTSTONES COMPLETE (IRON) ORAL TABLET,CHEWABLE 18 MG IRON

T2

FOLBECAL T5

FOLCAL DHA T5


GESTICARE DHA T5

HEMENATAL OB T5

HEMENATAL OB + DHA T5


LEVOMEFOLATEPNV T5


MACNATAL CN DHA T5

MACULAR VITAMIN ORAL TABLET 0.5 MG T2

MARNATAL-F T5

MULTI-DELYN T1

mv-min-folic acid-lutein T1

146

Drug Tier Notes


MYNATAL PLUS T5

MYNATE 90 PLUS T5



NATALVIRT CA T5

NATALVIT T5

NATELLE ONE T5

OB COMPLETE 400 T5

OB COMPLETE ONE T5



OBSTETRIX EC T5

OBTREX T5

O-CAL PRENATAL T5

OCUVITE WITH LUTEIN T1

ONE DAILY MULTI-VIT W-MINERAL ORAL TABLET

T1



POLY-VI-SOL ORAL DROPS T2 AL

POLY-VI-SOL WITH IRON T2

POLY-VITAMIN T1

POLYVITAMIN WITH IRON T1

POLY-VITAMIN WITH IRON T1

PR NATAL 430 EC T5

PREFERA-OB ONE T5

PRENA1 T5

PRENA1 CHEW (QUATREFOLIC) T5

PRENA1 PLUS T5


PRENATA T5

PRENATABS FA T5

PRENATABS RX T5

147

Drug Tier Notes

PRENATAL 19 (WITH DOCUSATE) T5




T1


PRENATAL-U T5

PRENATE DHA T5

PRENATE ELITE T5


PRENATE MINI T5

PREQUE 10 T5

PROTECT NATAL T5

PUREFE OB PLUS T5


SE-TAN DHA T5

SETONET T5

SETONET-EC T5

TARON-BC T5

THERA ORAL TABLET T1

THERA-M ORAL TABLET , 9 MG IRON-400 MCG

T1

THERATRUM COMPLETE 50 PLUS/LUT T1

THEREMS-M T2

TRIADVANCE T5


TRINATAL GT T5

TRINATAL ULTRA T5

TRINATE T5


TRIVEEN-DUO DHA T5

TRIVEEN-ONE T5

TRIVEEN-PRX RNF T5

TRIVEEN-TEN T5

148

Drug Tier Notes


TRI-VITAMIN T1



VINATE AZ T5

VINATE CALCIUM T5

VINATE DHA T5

VINATE IC T5

VINATE II T5

VINATE M T5

VINATE ONE T5

VINATE PN CARE T5

VIRT-BAL DHA T5

VIRT-PN T5

VIRT-PN DHA T5

VIRT-SELECT T5

VITAFOL-PLUS T5

VITALETS ORAL TABLET,CHEWABLE T1

VITAMENT T2

VITASPIRE T5

VIVA DHA T5

VP-CH PLUS T5

VP-CH-PNV T5

VP-ERA OB PLUS T5

VP-GGR-B6 T5

VP-PNV-DHA T5

ZATEAN-CH T5

ZATEAN-PN PLUS T5

Vitamin A



TRI-VITAMIN T1

vitamin a oral capsule 10,000 unit T1

Vitamin B Complex

149

Drug Tier Notes

ADVICOR T5

AQUADEKS ORAL TABLET,CHEWABLE T2

ATABEX EC T5

BAL-CARE DHA T5


biotin oral capsule 5 mg T1

B-NEXA T5

CAVAN-EC SOD DHA T5

CENTRUM COMPLETE T1

CENTRUM SILVER ORAL TABLET T1

CITRANATAL B-CALM (FE GLUC) T5

CLASSIC PRENATAL T2

COMPLETENATE T5


CONCEPT DHA T5

CONCEPT OB T5

cyanocobalamin (vitamin b-12) injection T1

cyanocobalamin (vitamin b-12) oral tablet 500 mcg

T1

cyanocobalamin (vitamin b-12) oral tablet extended release 1,000 mcg

T1

DAILY MULTIPLE FOR MEN 50+ T1

DIALYVITE 800 ORAL TABLET T1

DIALYVITE 800-ULTRA D T2


T5

DUET DHA EC-OM 3 T5


ELITE-OB 400 T5



FOLBECAL T5

FOLCAL DHA T5

folic acid injection T5

folic acid oral tablet T1

150

Drug Tier Notes


GESTICARE DHA T5

HEMENATAL OB T5

HEMENATAL OB + DHA T5

IROSPAN 24/6 T5


LEVOMEFOLATEPNV T5

L-METHYLFOLATE T1 QL (30 EA per 30 days)


MACNATAL CN DHA T5

MACULAR VITAMIN ORAL TABLET 0.5 MG T2

MARNATAL-F T5

mv-min-folic acid-lutein T1


MYNATAL PLUS T5



NATALVIRT CA T5

NATALVIT T5

NATELLE ONE T5

NEPHROCAPS T5

OB COMPLETE 400 T5

OB COMPLETE ONE T5



OBSTETRIX EC T5

OBTREX T5

O-CAL PRENATAL T5



PR NATAL 430 EC T5

PREFERA-OB ONE T5

PRENA1 T5

PRENA1 CHEW (QUATREFOLIC) T5

151

Drug Tier Notes

PRENA1 PLUS T5


PRENATA T5

PRENATABS FA T5

PRENATABS RX T5

PRENATAL 19 (WITH DOCUSATE) T5




T1


PRENATE DHA T5

PRENATE ELITE T5


PRENATE MINI T5

PREQUE 10 T5

PROTECT NATAL T5

PUREFE OB PLUS T5

PYRI 500 T1

pyridoxine (vitamin b6) oral tablet 100 mg, 25 mg, 50 mg

T1

RENA-VITE RX T1


SE-TAN DHA T5

SETONET T5

SETONET-EC T5

SIMCOR T5

TARON-BC T5

THERA-M ORAL TABLET 9 MG IRON-400 MCG

T1

thiamine mononitrate (vit b1) T1

TRIADVANCE T5


TRINATAL GT T5

TRINATAL ULTRA T5

152

Drug Tier Notes

TRINATE T5

TRIVEEN-DUO DHA T5

TRIVEEN-ONE T5

TRIVEEN-PRX RNF T5

TRIVEEN-TEN T5



VINATE AZ T5

VINATE DHA T5

VINATE M T5

VINATE ONE T5

VIRT-BAL DHA T5

VIRT-PN T5

VIRT-PN DHA T5

VIRT-SELECT T5

VITAFOL-PLUS T5

VITAMENT T2

VITAMIN B-1 ORAL TABLET 100 MG, 50 MG T1

VITAMIN B-12 ORAL TABLET 1,000 MCG T1

VITAMIN B-12 ORAL TABLET 100 MCG T1 QL (100 QY per 30 DYs)

VITAMIN B-6 ORAL TABLET 50 MG T1

VITASPIRE T5

VIVA DHA T5

VP-CH PLUS T5

VP-CH-PNV T5

VP-ERA OB PLUS T5

VP-GGR-B6 T5

VP-PNV-DHA T5

ZATEAN-CH T5

ZATEAN-PN PLUS T5

Vitamin C

ascorbic acid (vitamin c) oral tablet 250 mg, 500 mg

T1

DIALYVITE 800 ORAL TABLET T1

153

Drug Tier Notes


IROSPAN 24/6 T5

NEPHROCAPS T5



TRI-VITAMIN T1

VITAMIN C ORAL TABLET 1,000 MG T1

VITAMIN C ORAL TABLET,CHEWABLE 500 MG

T1

Vitamin D

calcitriol intravenous solution 1 mcg/ml T5

calcitriol oral T5

CALCIUM 500 WITH D T1

CALCIUM 600 WITH VITAMIN D3 ORAL CAPSULE 600 MG(1,500MG) -400 UNIT

T1

calcium carbonate-vitamin d2 T1

calcium carbonate-vitamin d3 oral tablet 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 unit

T1

calcium citrate-vitamin d3 oral tablet 200-125 mg-unit

T1

cholecalciferol (vitamin d3) oral capsule 1,250 mcg (50,000 unit), 125 mcg (5,000 unit)

T1

cholecalciferol (vitamin d3) oral tablet 125 mcg (5,000 unit), 25 mcg (1,000 unit), 50 mcg (2,000 unit)

T1


ergocalciferol (vitamin d2) oral capsule 1,250 mcg (50,000 unit)

T1

ergocalciferol (vitamin d2) oral drops T1 AL

FOSAMAX PLUS D T5

HECTOROL INTRAVENOUS SOLUTION 2 MCG/ML

T5

OS-CAL 500 + D3 ORAL TABLET 500 MG(1,250MG) -200 UNIT

T1

OYSCO 500/D ORAL TABLET,CHEWABLE T1

OYSTER SHELL + D3 T1

154

Drug Tier Notes

OYSTER SHELL CALCIUM-VIT D2 ORAL TABLET 250 (625)-125 MG-UNIT

T1

PARVA-CAL 500 T2

RISACAL-D T1



TRI-VITAMIN T1

VITAMIN D3 ORAL CAPSULE 10 MCG (400 UNIT), 25 MCG (1,000 UNIT), 50 MCG (2,000 UNIT)

T1

VITAMIN D3 ORAL TABLET 10 MCG (400 UNIT)

T1

VITAMIN D3 ORAL TABLET,CHEWABLE 10 MCG (400 UNIT)

T1

ZEMPLAR T5

Vitamin E

vitamin e (dl, acetate) oral capsule 100 unit, 400 unit

T1

vitamin e (dl, acetate) oral drops 100 unit/0.25 ml T1

Vitamin K Activity

MEPHYTON T2

155

Index

8 8-MOP ................................ 140 A abacavir ................................ 10 abacavir-lamivudine-

zidovudine ........................ 10 ABELCET ............................ 13 ABILIFY ........................ 59, 62 ABILIFY DISCMELT ... 59, 62 ABILIFY MAINTENA .. 59, 62 ABRAXANE ........................ 16 ABREVA ........................... 133 ABSTRAL ............................ 66 acarbose .............................. 103 ACCOLATE....................... 125 ACD-A ................................. 30 acetaminophen ...................... 55 acetaminophen-codeine .. 55, 66 ACETASOL HC ............ 90, 91 acetazolamide ........... 44, 80, 90 acetazolamide sodium ... 44, 80,

90 ACETEST ............................ 76 acetic acid ....................... 80, 91 acetic acid-aluminum acetate 91 acetylcysteine ............. 120, 126 ACID REDUCER

(FAMOTIDINE) .............. 99 ACIPHEX........................... 100 ACIPHEX SPRINKLE ...... 100 acitretin ............................... 141 ACNE MEDICATION ....... 139 ACTEMRA ................ 117, 118 ACTHAR H.P. ............. 76, 110 ACTHIB (PF) ....................... 22 ACTHREL ..................... 76, 77 ACTICIN ............................ 140 ACTIMMUNE ................... 118 ACTIVASE .................... 37, 87 ACTIVELLA ............. 106, 111 ACTONEL ......................... 116 ACTOPLUS MET XR 104, 113 ACULAR ............................. 93 ACULAR LS ........................ 93 ACUVAIL (PF) .................... 93 acyclovir ....................... 12, 133 acyclovir sodium .................. 12 ACZONE .................... 128, 141

ADACEL(TDAP ADOLESN/ADULT)(PF) 21

ADAGEN ............................. 88 adapalene ............................ 141 ADCIRCA .................... 51, 128 adefovir ................................. 12 ADENOCARD ............... 40, 46 ADENOSCAN ..................... 46 ADRENALIN ............... 23, 122 ADRIAMYCIN .................... 16 ADRUCIL ............................ 16 ADULT ROBITUSSIN PEAK

COLD DM .............. 123, 124 ADULT TUSSIN CHEST

CONGESTION .............. 124 ADULT TUSSIN COUGH

CONGEST DM ...... 123, 124 ADVAIR DISKUS ...... 29, 101,

126, 127 ADVAIR HFA .... 29, 101, 126,

127 ADVATE.............................. 31 ADVICOR .................... 49, 148 AERO OTIC HC .................. 90 AFINITOR ........................... 16 AFINITOR DISPERZ .......... 16 AGGRASTAT IN SODIUM

CHLORIDE ...................... 36 AGGRENOX............ 36, 53, 72 AGRYLIN ............................ 37 A-HYDROCORT ............... 102 AIMSCO LATEX CONDOM

.......................................... 75 AKNE-MYCIN .................. 128 AK-POLY-BAC ................... 89 AKTEN (PF) ........................ 93 ALA-SCALP .............. 129, 135 ALAVERT ..................... 2, 127 ALBENZA ............................. 5 ALBUMINAR 25 % ............ 30 ALBUMINAR 5 % .............. 30 albuterol sulfate ............ 29, 127 ALCAINE ............................ 93 alclometasone ............. 129, 135 ALCOHOL PREP PADS ... 140 ALCORTIN A .... 130, 135, 140 ALDACTAZIDE ..... 50, 51, 52,

81, 86 ALDURAZYME .................. 88

alendronate ......................... 116 alfentanil ............................... 66 ALFERON N .................. 11, 16 ALIMTA ............................... 16 ALINIA .................................. 6 ALKERAN ........................... 16 ALLI ..................................... 99 allopurinol ........................... 115 allopurinol sodium .............. 115 ALOCRIL ..................... 88, 125 ALODOX ................. 15, 89, 92 ALOE VESTA

ANTIFUNGAL (MICON) ........................................ 134

ALOE VESTA CLEANSING ........................................ 141

ALOQUIN .......................... 140 ALORA .............................. 107 ALPHAGAN P ..................... 88 ALPHANATE ...................... 32 ALPHANINE SD ................. 32 alprazolam ............................ 63 ALPRAZOLAM INTENSOL

.......................................... 63 alprostadil ............................. 53 ALSUMA ............................. 73 ALTABAX ......................... 129 ALTAFLUOR ................ 77, 93 ALTALUBE ......................... 92 ALTAVERA (28) ............... 105 ALTOPREV ......................... 49 aluminum hydroxide gel ....... 94 alum-mag hydroxide-simeth 95,

96 ALVESCO .................. 102, 126 amantadine hcl .................. 4, 55 AMBISOME ......................... 13 ambrisentan ................... 53, 128 amcinonide ................. 130, 135 AMERGE ............................. 73 A-METHAPRED ............... 102 AMETHYST (28) ............... 105 AMIDATE ............................ 65 amifostine crystalline .......... 122 amiloride ......................... 52, 81 amiloride-hydrochlorothiazide

.............................. 52, 82, 86 aminocaproic acid ................. 32 aminophylline ............. 128, 143

156

AMINOSYN 10 % ............... 78 AMINOSYN 3.5 % .............. 78 AMINOSYN 7 % ................. 78 AMINOSYN 7 % WITH

ELECTROLYTES ........... 78 AMINOSYN 8.5 %-

ELECTROLYTES ........... 78 AMINOSYN II 15 % ........... 78 AMINOSYN II

5%/DEXTROSE 25% ...... 78 AMINOSYN II 8.5 % .......... 78 AMINOSYN M 3.5 % ......... 78 AMINOSYN-RF 5.2 % ........ 78 amiodarone ........................... 46 AMITIZA ............................. 97 amitriptyline ......................... 74 amitriptyline-chlordiazepoxide

.................................... 63, 74 amlodipine .......... 42, 47, 49, 53 amlodipine-benazepril ... 39, 42,

47, 49, 54 ammonium chloride.............. 78 ammonium lactate .............. 135 AMMONUL ......................... 78 amoxapine ............................ 74 amoxicillin .............................. 5 amoxicillin-pot clavulanate .... 5 AMPHOTEC ........................ 13 amphotericin b ...................... 13 ampicillin ................................ 5 ampicillin sodium ................... 5 ampicillin-sulbactam .............. 5 AMPYRA ........................... 120 AMRIX................................. 26 AMTURNIDE ... 42, 47, 52, 54,

86 AMVISC .............................. 75 AMVISC PLUS ................... 75 amyl nitrite ................... 51, 114 ANADROL-50 ................... 103 ANAFRANIL ....................... 74 anagrelide ............................. 37 ANALPRAM ADVANCED

........................ 130, 133, 135 ANALPRAM-HC...... 130, 133,

135 ANASPAZ ........................... 25 anastrozole .................... 16, 104 ANDRODERM .................. 103 ANDROGEL ...................... 103 ANDROID ......................... 103

ANDROXY ........................ 103 ANECREAM (WITH

DRESSINGS) ................. 133 ANECTINE .......................... 27 ANGELIQ .................. 107, 111 ANGIOMAX ........................ 31 ANIMAL SHAPES

COMPLETE ................... 144 ANORO ELLIPTA 25, 29, 123,

127 ANTACID ANTI-GAS .. 95, 96 ANTACID EXTRA-

STRENGTH ............... 82, 95 ANTARA ............................. 48 anticoag citrate phos dextrose

.......................................... 30 ANTI-DIARRHEAL

(LOPERAMIDE).............. 95 ANTI-ITCH

(DIPHENHYDRAMINE) ........................................ 133

ANTI-NAUSEA ................... 96 ANTISEPTIC WOUND-SKIN

........................................ 140 ANUSOL-HC ............. 130, 135 ANZEMET ........................... 94 APETIMAR/IRON ............. 144 APEXICON ................ 130, 135 APEXICON E ............ 130, 136 APIDRA SOLOSTAR U-100

INSULIN ................ 109, 112 APIDRA U-100 INSULIN 109,

112 APLENZIN .......................... 58 APOKYN ............................. 66 APRI ................................... 105 APRISO ................................ 96 APRODINE ...... 2, 23, 122, 124 APTIOM ............................... 57 APTIVUS ............................. 10 APTIVUS (WITH VITAMIN

E) ...................................... 10 AQUADEKS .............. 144, 148 ARALAST NP ................... 126 ARALEN ................................ 6 ARANELLE (28) ............... 105 ARANESP (IN

POLYSORBATE) ............ 31 ARAVA ...................... 117, 118 ARCALYST ....................... 121 argatroban ............................. 31

ARISTOSPAN INTRA-ARTICULAR ................. 102

ARISTOSPAN INTRALESIONAL ........ 102

ARMOUR THYROID ........ 113 AROMASIN ................. 16, 104 ARRANON .......................... 16 ARTHROTEC 50 ......... 69, 100 ARTHROTEC 75 ......... 69, 100 ARTIFICIAL TEARS

(POLYVIN ALC) ............. 92 ARTIFICIAL

TEARS(DEXT70-HYPRO) .......................................... 92

ARZERRA ........................... 16 ASACOL HD ....................... 96 ASCOMP WITH CODEINE

.................. 60, 63, 66, 71, 72 ascorbic acid (vitamin c) .... 152 ASCRIPTIN ....... 36, 37, 60, 72 ASMANEX TWISTHALER

................................ 102, 126 ASPER-FLEX ...................... 72 aspirin ................. 36, 37, 60, 72 ASTAGRAF XL ................. 120 ASTELIN ............................. 88 ASTEPRO ............................ 88 ATABEX EC ... 33, 82, 97, 144,

148 ATELVIA ........................... 116 atenolol ..................... 29, 41, 45 atenolol-chlorthalidone .. 29, 41,

46, 53, 87 ATGAM ............................. 120 atorvastatin ........................... 49 atovaquone .............................. 6 ATRALIN ........................... 135 ATRIPLA ............................. 10 ATROPEN ............ 25, 114, 123 atropine ................... 25, 93, 123 ATROVENT HFA ........ 25, 123 AUGMENTIN ........................ 5 AVAGE .............................. 141 AVANDAMET .......... 105, 113 AVANDARYL ........... 112, 113 AVANDIA ......................... 113 AVAPRO .............................. 38 AVASTIN ............................. 16 AVELOX .......................... 7, 14 AVELOX IN NACL (ISO-

OSMOTIC) ................... 7, 14

157

AVIANE............................. 105 AVIDOXY DK .................... 15 AVINZA............................... 67 AVITA ............................... 135 AVODART ........................ 114 AVONEX ........................... 118 AVONEX (WITH ALBUMIN)

........................................ 118 AXERT................................. 73 AXID .................................. 100 AXIRON ............................ 103 AYGESTIN ........................ 111 AZACTAM IN DEXTROSE

(ISO-OSM) ....................... 12 AZASAN ............ 117, 118, 120 azathioprine ........ 117, 118, 120 azathioprine sodium .. 117, 118,

120 azelastine .............................. 88 AZELEX ............................ 141 AZILECT ............................. 66 azithromycin ......................... 12 AZOLEN TINCTURE ....... 134 AZOR ..... 38, 42, 47, 48, 49, 54 aztreonam ............................. 12 AZULFIDINE 14, 96, 117, 118 AZULFIDINE EN-TABS ... 14,

96, 117, 118 AZURETTE (28)................ 105 B BABY AYR SALINE .......... 92 BACIIM ................................. 8 bacitracin ...................... 89, 129 bacitracin zinc .................... 129 baclofen ................................ 27 BACTRIM ............................ 14 BACTRIM DS...................... 14 BACTROBAN ................... 129 BACTROBAN NASAL ....... 89 BAL-CARE DHA . 33, 82, 144,

148 BAL-CARE DHA

ESSENTIAL..... 33, 144, 148 balsalazide ............................ 96 BALZIVA (28) ................... 105 BANZEL .............................. 57 BARACLUDE ..................... 12 BAYCADRON................... 102 BAYER PLUS EXTRA

STRENGTH ... 36, 37, 60, 72 belladonna tincture (bulk) .... 25

benazepril ............................. 39 benazepril-hydrochlorothiazide

.............................. 39, 52, 86 BENEFIX ............................. 32 BENLYSTA ....................... 120 BENTYL .............................. 25 BENZAMYCINPAK ......... 129 benzonatate ......................... 123 benzoyl peroxide ................ 139 benzphetamine ...................... 55 benztropine ..................... 26, 57 BEPREVE ............................ 88 BERINERT ........................ 117 BESIVANCE........................ 89 BETADINE OPHTHALMIC

PREP ................................ 91 BETAGAN ........................... 90 betamethasone acet,sod phos

........................................ 102 betamethasone dipropionate

................................ 130, 136 betamethasone valerate...... 130,

136 betamethasone, augmented 130,

136 BETASERON .................... 118 betaxolol ............................... 90 bethanechol chloride............. 28 BEXXAR DOSIMETRIC .... 16 BEYAZ ............................... 105 BIAXIN ............................ 7, 13 bicalutamide ......................... 16 BICARSIM ........................... 96 BICARSIM FORTE ............. 96 BICILLIN C-R ..................... 12 BICNU.................................. 16 BIDIL ............................. 48, 51 BILTRICIDE .......................... 5 BIOTENE DRY MOUTH

ORAL RINSE................... 75 BIOTHRAX ......................... 22 biotin ................................... 148 bisacodyl ............................... 97 bisoprolol fumarate... 30, 41, 46 bisoprolol-hydrochlorothiazide

.................. 30, 41, 46, 52, 86 bleomycin ............................. 16 BLEPH-10 ............................ 89 BLEPHAMIDE .................... 89 BLEPHAMIDE S.O.P. ......... 89 BLOOD PRESSURE KIT .... 75

blood pressure kit med and lrg .......................................... 75

blood pressure monitor ......... 75 B-NEXA ............... 82, 144, 148 BONIVA ............................. 116 BOOST ................................. 78 BOOSTRIX TDAP ............... 21 BOTOX ........................ 30, 121 BOTOX COSMETIC ... 30, 121 BP-50% UREA ................... 139 BRAVELLE ....................... 108 BREVICON (28) ................ 105 BREVITAL .................... 62, 63 brimonidine ........................... 88 BROMDAY .......................... 93 bromfenac ............................. 93 bromocriptine ....................... 65 BROVANA .................. 29, 127 BUDEPRION SR ................. 59 budesonide-formoterol 29, 102,

126, 127 bumetanide ..................... 50, 81 BUPHENYL ......................... 78 bupivacaine ......................... 113 bupivacaine (pf) .................. 113 bupivacaine-dextrose-water(pf)

........................................ 113 bupivacaine-epinephrine (pf)

.................................. 23, 113 BUPRENEX ......................... 69 buprenorphine hcl ................. 69 buprenorphine-naloxone ....... 69 BUPROBAN ........................ 59 bupropion hcl ........................ 59 buspirone .............................. 61 butalbital-acetaminop-caf-cod

.................. 56, 60, 63, 67, 71 butalbital-acetaminophen-caff

........................ 56, 60, 63, 71 butorphanol tartrate .............. 69 BUTRANS ........................... 69 BYETTA ............................ 109 BYSTOLIC ..................... 27, 41 C cabergoline ........................... 65 CADUET ...... 42, 47, 48, 49, 54 CAFERGOT ................... 27, 60 CALCI-CHEW ..................... 82 CALCI-MIX ......................... 82 CALCIONATE ..................... 82 calcipotriene ....................... 141

158

calcitonin (salmon) .... 104, 110, 116

calcitriol .............................. 152 CALCIUM 500 WITH D .... 82,

152 CALCIUM 600 .................... 82 CALCIUM 600 WITH

VITAMIN D3 ........... 82, 152 calcium acetate(phosphat bind)

.......................................... 81 CALCIUM ANTACID .. 82, 95 CALCIUM ANTACID

ULTRA MAX ST....... 82, 95 calcium carbonate ........... 82, 95 calcium carbonate-vitamin d2

.................................. 82, 152 calcium carbonate-vitamin d3

.................................. 82, 153 calcium citrate-vitamin d3 ... 82,

153 calcium gluconate ................. 82 calcium lactate ...................... 82 CALDOLOR ........................ 69 CAMBIA ........................ 60, 69 CAMILA ............................ 105 CAMPRAL........................... 64 CANASA ............................. 97 CANCIDAS ........................... 8 CANTIL ............................... 25 CAPASTAT ........................... 7 CAPEX ....................... 130, 136 capsaicin ............................. 141 captopril ................................ 39 captopril-hydrochlorothiazide

.............................. 39, 52, 86 CARAC ........................ 16, 141 CARAFATE ....................... 100 CARBAGLU ........................ 78 carbamazepine ................ 57, 59 carbidopa-levodopa .............. 65 carbinoxamine maleate ... 1, 125 CARBOCAINE .................. 113 CARBOCAINE (PF) .......... 113 carboplatin ............................ 16 CARDENE SR .. 42, 47, 48, 49,

54 CARIMUNE NF

NANOFILTERED ........... 21 carisoprodol .......................... 26 carisoprodol-aspirin ........ 26, 72

carisoprodol-aspirin-codeine .............................. 26, 67, 72

CARMOL HC ............ 130, 136 CARNITOR........................ 121 carteolol ................................ 90 CARTICEL ........................ 121 carvedilol 27, 28, 37, 41, 46, 49 CATAFLAM ........................ 69 CAVAN-EC SOD DHA ...... 33,

144, 148 CAVERJECT ....................... 54 CAVERJECT IMPULSE ..... 54 CAYSTON ........................... 12 CAZIANT (28) ................... 105 CEDAX .................................. 3 cefaclor ................................... 3 cefadroxil ................................ 3 cefazolin ................................. 3 cefdinir.................................... 3 cefditoren pivoxil ................... 3 cefepime ................................. 4 cefepime in dextrose,iso-osm . 4 cefotaxime .............................. 4 cefotetan ............................. 3, 8 cefoxitin .............................. 3, 8 cefoxitin in dextrose, iso-osm 3,

8 cefpodoxime ........................... 4 cefprozil .................................. 3 CEFTIN .................................. 3 ceftriaxone in dextrose,iso-os . 4 cefuroxime sodium ................. 3 cefuroxime-dextrose (iso-osm)

............................................ 3 CELEBREX ......................... 65 CELESTONE ..................... 102 CELLCEPT ........................ 120 CELLCEPT INTRAVENOUS

........................................ 120 CELONTIN .......................... 74 CENESTIN ......................... 107 CENTANY AT................... 129 CENTRUM COMPLETE ... 33,

144, 148 CENTRUM SILVER . 144, 148 cephalexin ............................... 3 CEPROTIN (BLUE BAR) ... 30 CEPROTIN (GREEN BAR) 30 CEREZYME ........................ 88 CERVARIX VACCINE (PF)

.......................................... 22

CERVIDIL ......................... 122 CESAMET ........................... 96 CETAPHIL GENTLE

CLEANSER ................... 141 cetirizine ......................... 2, 127 CETROTIDE .............. 104, 118 CHANTIX ............................ 26 CHANTIX CONTINUING

MONTH BOX .................. 26 CHANTIX STARTING

MONTH BOX .................. 26 CHEMET .................... 101, 114 CHENODAL ........................ 98 CHEWABLE-VITE ........... 144 CHILDREN'S ALLEGRA

ALLERGY ................. 2, 127 CHILDREN'S ALLERGY

(DIPHENHYD) .......... 1, 125 CHILDREN'S NON-ASPIRIN

.......................................... 56 CHILDREN'S PAIN RELIEF

.......................................... 56 CHILDREN'S SILFEDRINE

.................................. 23, 122 CHILD'S ALL DAY

ALLERGY(CETIR) ... 2, 127 chloramphenicol sod succinate

............................................ 8 chlordiazepoxide hcl ............. 63 chlordiazepoxide-clidinium . 25,

63 chlorhexidine gluconate ........ 91 chloroprocaine (pf) ............. 113 chloroquine phosphate ............ 6 chlorothiazide ................. 53, 86 chlorothiazide sodium .... 53, 86 chlorpheniramine maleate . 1, 2,

125 chlorpromazine ..................... 71 chlorpropamide ................... 112 chlorthalidone ................. 53, 87 chlorzoxazone ....................... 26 cholecalciferol (vitamin d3) 153 cholestyramine (with sugar) . 42 CHOLESTYRAMINE LIGHT

.......................................... 42 choline,magnesium salicylate

.......................................... 72 chorionic gonadotropin, human

........................................ 108 CIALIS ................................. 52

159

ciclopirox ............................ 138 ciclopirox-vite-nail lacq remo

........................................ 138 cilostazol......................... 36, 52 CILOXAN ............................ 89 cimetidine ........................... 100 cimetidine hcl ..................... 100 CIMZIA ................ 99, 117, 118 CIMZIA POWDER FOR

RECONST ........ 99, 117, 118 CIMZIA STARTER KIT .... 99,

117, 119 CINRYZE........................... 117 CIPRO .............................. 7, 14 CIPRO HC...................... 89, 90 CIPRODEX .................... 89, 90 ciprofloxacin (mixture) .... 7, 14 ciprofloxacin hcl ............... 7, 14 ciprofloxacin in 5 % dextrose 7,

14 ciprofloxacin lactate ......... 7, 14 cisplatin ................................ 16 citalopram ............................. 74 CITRANATAL B-CALM (FE

GLUC) .................... 144, 148 cladribine .............................. 16 CLAFORAN .......................... 4 CLARAVIS ........................ 141 CLARINEX .................... 2, 127 CLARINEX-D 12 HOUR2, 23,

122, 127 clarithromycin .................. 7, 13 CLASSIC PRENATAL ...... 33,

144, 148 clemastine ....................... 1, 125 CLEOCIN HCL.................... 11 CLEOCIN IN 5 %

DEXTROSE ..................... 11 CLEOCIN PEDIATRIC ....... 11 CLEVIPREX 42, 47, 48, 49, 54 CLIMARA PRO ................. 107 clindamycin hcl .................... 11 clindamycin phosphate ....... 129 clindamycin-benzoyl peroxide

................................ 129, 139 CLINIMIX 5%/D15W

SULFITE FREE ............... 78 CLINIMIX 5%/D25W

SULFITE-FREE ............... 78 CLINIMIX 2.75%/D5W

SULFIT FREE.................. 79

CLINIMIX 4.25%/D10W SULF FREE ..................... 79

CLINIMIX 4.25%/D5W SULFIT FREE .................. 79

CLINIMIX 4.25%-D20W SULF-FREE ..................... 79

CLINIMIX 5%-D20W(SULFITE-FREE).. 79

CLINIMIX E 2.75%/D10W SUL FREE ........................ 79

CLINIMIX E 2.75%/D5W SULF FREE ..................... 79

CLINIMIX E 4.25%/D25W SUL FREE ........................ 79

CLINIMIX E 4.25%/D5W SULF FREE ..................... 79

CLINIMIX E 5%/D15W SULFIT FREE .................. 79



CLINITEST REAGENT ...... 77 CLINORIL ........................... 69 clobetasol .................... 130, 136 clobetasol-emollient ... 130, 136 CLOBEX .................... 130, 136 CLODERM ................ 130, 136 CLOLAR .............................. 16 clonazepam ........................... 63 clonidine ......................... 24, 45 clonidine (pf) ............ 24, 45, 56 clonidine hcl ................... 24, 45 clopidogrel ............................ 36 clorazepate dipotassium ....... 63 CLORPRES ........ 24, 45, 53, 87 clotrimazole ........................ 134 clotrimazole-betamethasone

........................ 130, 134, 136 clozapine ............................... 62 CNL 8 NAIL ...................... 139 coal tar (bulk) ..................... 139 COARTEM ............................ 6 cocaine .................................. 93 codeine sulfate .............. 67, 123 codeine-guaifenesin .... 123, 124 COLCRYS.......................... 115 COLESTID ........................... 42 COLESTID FLAVORED .... 42 colestipol .............................. 42 colistin (colistimethate na) ... 13

COLOCORT ............... 130, 136 COLY-MYCIN S ................. 89 COLYTE WITH FLAVOR

PACKS ............................. 97 COMBIGAN .................. 88, 90 COMBIPATCH .......... 107, 111 COMBIVENT 25, 29, 123, 127 COMETRIQ ......................... 16 COMPLETE SENIOR ........ 144 COMPLETENATE ..... 33, 144,

148 COMPLETE-RF PRENATAL

.......................... 97, 144, 148 COMPRO ....................... 71, 96 COMTAN ............................. 64 COMVAX (PF) .................... 22 CONCEPT DHA .. 33, 144, 148 CONCEPT OB ..... 33, 144, 148 CONCERTA ......................... 71 CONDOMS-PREM

LUBRICATED ................. 75 CONDYLOX ...................... 141 CONGEST-EZE ... 24, 122, 124 COPAXONE ...................... 119 COPEGUS ............................ 12 CORDRAN ................. 130, 136 CORDRAN TAPE SMALL

ROLL ...................... 130, 136 COREG CR . 27, 28, 37, 41, 46,

49 CORLOPAM ........................ 49 CORTANE-B AQUEOUS ... 90 CORTEF ............................. 102 cortisone ............................. 102 CORTISPORIN .......... 129, 136 CORTROSYN ...................... 76 CORVERT ........................... 46 COSMEGEN ........................ 16 COSOPT ............................... 90 cosyntropin ........................... 76 COUMADIN ........................ 31 COVARYX ................ 103, 107 COVARYX H.S. ........ 104, 107 CREON ................................. 99 CREO-TERPIN (DM-

GUAIFENESIN) .... 123, 124 CRESTOR ............................ 49 CRINONE .......................... 111 CRIXIVAN ........................... 10 CROFAB ...................... 21, 114 cromolyn ....................... 88, 125

160

CRYSELLE (28) ................ 105 CUBICIN ............................... 8 CULTURELLE .................... 99 CULTURELLE KIDS

PROBIOTICS................... 99 CUPRIMINE .............. 101, 117 CUTAR .............................. 139 CUTIVATE ................ 130, 136 CUVPOSA ........................... 25 cyanocobalamin (vitamin b-12)

........................................ 149 CYCLAFEM 1/35 (28) ...... 105 CYCLAFEM 7/7/7 (28) ..... 105 cyclobenzaprine .................... 26 CYCLOGYL ........................ 94 CYCLOMYDRIL................. 94 cyclopentolate....................... 94 cyclophosphamide ........ 16, 120 cycloserine .............................. 7 CYCLOSET ......................... 65 cyclosporine ....... 117, 119, 120 cyclosporine modified ....... 117,

119, 120 CYKLOKAPRON ................ 32 cyproheptadine ............... 1, 125 CYSTADANE .................... 121 CYSTAGON ...................... 121 cytarabine ............................. 17 cytarabine (pf) ...................... 17 CYTOMEL......................... 113 CYTOVENE ........................ 12 CYTRA K CRYSTALS ....... 78 D D.H.E.45 ......................... 27, 60 d10 %-0.45 % sodium chloride

.......................................... 79 d2.5 %-0.45 % sodium

chloride ............................. 79 d5 % and 0.9 % sodium

chloride ............................. 79 d5 %-0.45 % sodium chloride

.......................................... 79 dacarbazine ........................... 17 DACOGEN .......................... 17 DAILY FIBER (PSYLLIUM-

SUCROSE)....................... 97 DAILY MULTIPLE FOR

MEN 50+ ................ 144, 149 DAILY-VITE ..................... 144 danazol ............................... 104 dapsone ................................... 6

DAPTACEL (DTAP PEDIATRIC) (PF) ............ 21

DARAPRIM ........................... 6 daunorubicin ......................... 17 DAUNOXOME .................... 17 DAYTRANA........................ 71 DDAVP ........................ 32, 110 DEEP SEA NASAL ............. 92 deferoxamine .............. 101, 114 DELFLEX-LC/1.5%

DEXTROSE ..................... 80 DELFLEX-LC/2.5%

DEXTROSE ..................... 80 DELFLEX-LC/4.25%

DEXTROSE ..................... 80 DELZICOL .......................... 97 DEMADEX .................... 50, 81 demeclocycline ..................... 15 DEMEROL ........................... 67 DEMEROL (PF)................... 67 DEMSER ............................ 121 DENAVIR .......................... 133 DEPACON ............... 57, 59, 61 DEPAKENE ............. 57, 59, 61 DEPAKOTE ............. 57, 59, 61 DEPAKOTE ER ....... 57, 59, 61 DEPAKOTE SPRINKLES . 57,

59, 61 DEPEN TITRATABS 101, 117 DEPOCYT (PF) ................... 17 DEPODUR (PF) ................... 67 DEPO-ESTRADIOL .......... 107 DEPO-MEDROL ............... 102 DEPO-PROVERA.............. 111 DEPO-SUBQ PROVERA 104

........................................ 111 DEPO-TESTOSTERONE .. 104 DERMA-SMOOTHE/FS

BODY OIL ............. 130, 136 DERMATOP .............. 130, 136 DERMOTIC OIL ................. 90 desipramine .......................... 74 desloratadine ................... 2, 127 desmopressin ................ 32, 110 DESONATE ............... 130, 136 desonide ...................... 130, 136 DESOWEN OINTMENT

AND LOTION ....... 130, 136 desoximetasone .......... 131, 136 DESOXYN ........................... 55 dexamethasone ................... 102

DEXAMETHASONE INTENSOL ..................... 102

dexamethasone sodium phosphate .................. 90, 102

dexchlorpheniramine maleate 1, 2, 125

DEXILANT ........................ 101 dexmethylphenidate .............. 71 DEXPAK 10 DAY ............. 102 dexrazoxane hcl .................. 122 dextroamphetamine .............. 55 dextroamphetamine-

amphetamine ..................... 55 dextromethorphan polistirex

........................................ 124 dextromethorphan-guaifenesin

........................................ 124 dextrose 10 % and 0.2 % nacl

.......................................... 79 dextrose 10 % in water (d10w)




.......................................... 79 dextrose 5 % in ringer's ........ 82 dextrose 5 % in water (d5w) . 79 dextrose 5 %-lactated ringers82 dextrose 5%-0.2 % sod

chloride ............................. 79 dextrose 5%-0.3 %

sod.chloride ...................... 79 dextrose 50 % in water (d50w)


.......................................... 79 DIABETA ........................... 112 DIABETIC TUSSIN DM ... 124 DIALYVITE 800 ........ 149, 152 DIALYVITE 800-ULTRA D

........................ 149, 152, 153 DIANEAL LOW

CALCIUM/1.5% DEX ..... 80 DIANEAL PD-2 WITH 2.5 %

DEX .................................. 80 DIANEAL PD-2 WITH 4.25

% DEX .............................. 80 DIANEAL WITH 2.5 %

DEXTROSE ..................... 80

161

DIASTAT ............................. 63 DIASTAT ACUDIAL .......... 63 diazepam......................... 63, 64 DIAZEPAM INTENSOL ..... 63 DIBENZYLINE ............. 27, 50 diclofenac sodium ... 17, 69, 93,

140, 141 dicloxacillin .......................... 13 dicyclomine .......................... 25 didanosine............................. 10 DIFFERIN .......................... 141 diflorasone .................. 131, 136 diflunisal ............................... 70 DIGIFAB ...................... 21, 114 digoxin ............................ 40, 44 DILANTIN ..................... 45, 65 DILATRATE-SR ................. 51 DILAUDID-HP (PF) ............ 67 diltiazem hcl 42, 43, 44, 46, 47,

54 DILUENT FOR

EPOPROSTENOL/FLOLA ........................................ 122

dimenhydrinate ......... 1, 96, 125 DIOVAN .............................. 38 DIPENTUM ......................... 97 DIPHENHIST ................ 1, 125 diphenhydramine hcl ...... 1, 125 diphenoxylate-atropine .. 25, 95,

123 dipyridamole................... 36, 54 DISKETS ............................. 67 disopyramide phosphate ....... 45 disulfiram ........................... 114 DITROPAN XL ................. 143 DIURIL .......................... 53, 86 DIVIGEL ............................ 107 dobutamine ..................... 28, 44 dobutamine in d5w ......... 28, 44 docetaxel............................... 17 docusate sodium ................... 97 DOLOPHINE ....................... 67 donepezil .............................. 28 dopamine ........................ 29, 44 dopamine in 5 % dextrose ... 29,

44 DORAL ................................ 64 DORIBAX .............................. 8 dorzolamide .......................... 90 doxazosin ............ 27, 37, 38, 50 doxepin ................................. 74

doxycycline hyclate ........ 15, 89 doxycycline monohydrate .... 15 dronabinol ............................. 96 droperidol ............................. 61 DROXIA .............................. 17 DUET DHA BALANCED .. 33,

144, 149 DUET DHA EC-OM 3 33, 144,

149 DUET DHA WITH OMEGA-3

.......................... 33, 144, 149 DUETACT ................. 112, 113 DULERA ...... 29, 102, 126, 127 duloxetine ....................... 65, 73 DUREZOL ........................... 90 DY-O-DERM ..................... 140 DYRENIUM .................. 52, 82 DYSPORT .................... 30, 121 E E.E.S. 400 ......................... 9, 11 E.E.S. GRANULES.......... 9, 11 EAR WAX DROPS.............. 91 econazole ............................ 134 ECOZA ............................... 134 ED A-HIST (NEW DOSING)

.............................. 2, 24, 125 ED-CHLORPED ........ 1, 2, 125 EDEX ................................... 54 EDLUAR .............................. 61 EFFER-K .............................. 83 EFFERVESCENT ANTACID

............ 36, 37, 61, 72, 78, 95 EFFIENT .............................. 36 EFUDEX ...................... 17, 141 ELAPRASE .......................... 88 ELDEPRYL.......................... 66 electrolyte-48 in d5w ............ 83 ELELYSO ............................ 88 ELESTAT ............................. 88 ELESTRIN ......................... 107 ELIDEL ...................... 120, 141 ELIGARD .................... 17, 108 ELIGARD (3 MONTH) ...... 17,

108 ELIGARD (4 MONTH) ...... 17,

108 ELIGARD (6 MONTH) ...... 17,

108 ELITE OB WITH DHA ..... 144 ELITEK ................................ 88 ELITE-OB 400 ..... 34, 144, 149

ELIXOPHYLLIN .. 48, 80, 128, 143

ELLA .................................. 105 ELMIRON .......................... 122 ELOCON .................... 131, 136 ELOXATIN .......................... 17 ELSPAR ............................... 17 ELTA LITE TAR ............... 139 ELTA TAR ......................... 139 EMCYT ................................ 17 EMEND .............................. 100 EMSAM ............................... 66 EMTRIVA ............................ 10 ENABLEX ......................... 143 enalapril maleate ................... 39 enalaprilat ............................. 39 enalapril-hydrochlorothiazide

.............................. 39, 53, 87 ENBREL ............. 117, 119, 141 ENDOCET ..................... 56, 67 ENDODAN .................... 67, 72 ENDOMETRIN .................. 111 ENEMA DISPOSABLE ....... 97 ENFAMIL GLUCOSE ......... 79 ENGERIX-B (PF) ................ 22 ENGERIX-B PEDIATRIC

(PF) ................................... 22 ENJUVIA ........................... 107 ENLON ................................. 76 ENLON-PLUS ..................... 76 enoxaparin ............................ 33 ENPRESSE ......................... 105 ENSURE MUSCLE HEALTH

.......................................... 79 ENSURE PLUS .................... 79 ENTEREG ............................ 99 ENTERO VU ........................ 77 ENTOCORT EC ................. 102 ENUCLENE ......................... 92 ephedrine sulfate ........... 24, 122 EPIDUO ............................. 141 EPIFOAM ........... 131, 133, 137 epinephrine ................... 24, 122 EPIPEN 2-PAK ............ 24, 123 EPIPEN JR 2-PAK ....... 24, 123 epirubicin .............................. 17 EPIVIR ................................. 10 EPIVIR HBV ........................ 10 eplerenone ................. 50, 51, 52 EPOGEN .............................. 31 epoprostenol (glycine) .. 54, 128

162

EPZICOM ............................ 10 EQUETRO ..................... 57, 59 ERAXIS(WATER DILUENT)

............................................ 8 ERBITUX............................. 17 ergocalciferol (vitamin d2) . 153 ergoloid................................. 27 ERGOMAR .................... 27, 61 ERIVEDGE .......................... 17 ERTACZO ......................... 134 ERY PADS ......................... 129 ERYPED 400 ................... 9, 11 ERY-TAB......................... 9, 11 ERYTHROCIN ................ 9, 11 ERYTHROCIN (AS

STEARATE) ................ 9, 11 erythromycin .............. 9, 11, 89 erythromycin with ethanol . 129 erythromycin-benzoyl peroxide

........................................ 129 erythromycin-sulfisoxazole ... 9,

14 escitalopram oxalate ............. 74 ESOPHO-CAT ..................... 77 estazolam .............................. 64 ESTRACE .......................... 107 estradiol .............................. 107 estradiol valerate ................ 107 ESTRASORB ..................... 107 ESTRING ........................... 107 ESTROGEL ....................... 107 estropipate .......................... 107 ESTROSTEP FE-28 ........... 105 eszopiclone ........................... 61 ethambutol .............................. 7 ETHAMOLIN ...................... 52 ethanol (ethyl alcohol) ........ 121 ethosuximide ........................ 74 etidronate disodium ............ 116 etodolac ................................ 70 ETOPOPHOS ....................... 17 etoposide............................... 17 EUFLEXXA ......................... 75 EURAX .............................. 140 EVAMIST .......................... 107 EVISTA ...................... 106, 116 EVOXAC ............................. 28 EXALGO ER ....................... 67 EXELDERM ...................... 134 EXELON .............................. 28

EXFORGE... 38, 43, 47, 48, 50, 54

EXFORGE HCT 38, 43, 47, 48, 53, 87

EXJADE ............................. 101 EXODERM ........................ 129 EXTINA ............................. 134 EXTRA-VIRT PLUS DHA. 34,

144, 149 EYE ALLERGY RELIEF .... 94 EYLEA ................................. 92 E-Z-CAT DRY ..................... 77 EZFE FORTE ....... 34, 145, 149 E-Z-HD BARIUM ................ 77 E-Z-PAQUE ......................... 77 F FABRAZYME ..................... 88 FACTIVE ............................. 14 famciclovir............................ 12 famotidine ........................... 100 famotidine (pf)-nacl (iso-os)

........................................ 100 FANAPT .............................. 62 FARESTON ................. 17, 106 FASLODEX ......................... 17 FAZACLO............................ 62 FEIBA NF ............................ 32 felbamate .............................. 57 FELDENE ............................ 70 felodipine ...... 43, 47, 48, 50, 54 FEMCON FE ...................... 105 FEMHRT LOW DOSE ..... 107,

111 FEMRING .......................... 107 fenofibrate ............................ 49 fenofibrate micronized ......... 48 fenofibric acid....................... 49 fenofibric acid (choline) ....... 49 FENOGLIDE........................ 49 fenoprofen ............................ 70 fentanyl ................................. 67 fentanyl citrate ...................... 67 fentanyl citrate (pf) ............... 67 FENTORA............................ 67 ferrous fumarate ................... 34 ferrous gluconate .................. 34 ferrous sulfate ....................... 34 FEVERALL.......................... 56 fexofenadine ................... 2, 127 FIBER SMOOTH ................. 97 FINACEA ........................... 141

finasteride ........................... 114 FIRAZYR ........................... 117 FIRMAGON ......... 17, 104, 118 FISH OIL .............................. 40 FLAGYL ............................ 4, 6 FLAGYL ER ...................... 4, 6 FLAREX ............................... 91 flavoxate ............................. 143 FLEBOGAMMA DIF .......... 21 flecainide .............................. 45 FLECTOR ............ 70, 140, 141 FLINTSTONES COMPLETE

(IRON) ...................... 34, 145 FLOMAX ............................. 28 FLONASE .................... 91, 126 FLORICAL ........................... 83 FLOVENT DISKUS .. 102, 126 FLOVENT HFA ......... 102, 126 floxuridine ............................ 17 FLUBLOK 2013-2014 (PF) . 22 FLUCELVAX 2013-2014 (PF)

.......................................... 22 fluconazole ............................. 8 fluconazole in dextrose(iso-o) 8 fluconazole in nacl (iso-osm) . 8 fludarabine ............................ 17 fludrocortisone .................... 102 FLULAVAL QUAD 2013-

2014 .................................. 22 flumazenil ..................... 64, 114 FLUMIST 2012-2013 ........... 22 flunisolide ..................... 91, 126 fluocinolone ................ 131, 137 fluocinolone and shower cap

................................ 131, 137 fluocinonide ................ 131, 137 FLUOCINONIDE-E ... 131, 137 FLUORABON .................... 116 FLUOR-A-DAY ................. 116 FLUOR-A-DAY (WITH

XYLITOL) ..................... 116 FLUORETS .......................... 77 fluoride (sodium) ................ 116 FLUORIDEX DAILY

DEFENSE ....................... 117 fluorometholone ................... 91 FLUOROPLEX ............ 17, 141 fluorouracil ............. 17, 18, 142 fluoxetine .............................. 74 fluphenazine decanoate ........ 71 fluphenazine hcl .................... 71

163

FLURA-DROPS ................ 117 flurazepam ............................ 64 flurbiprofen........................... 70 flurbiprofen sodium .............. 93 flutamide............................... 18 fluticasone propionate 131, 137 fluvastatin ............................. 49 FLUVIRIN 2012-2013 ......... 22 FLUVIRIN 2012-2013 (PF) . 22 FLUVIRIN 2013-2014 ......... 22 FLUVIRIN 2013-2014 (PF) . 22 fluvoxamine .......................... 74 FLUZONE HIGH-DOSE

2012-13 (PF) .................... 22 FML S.O.P. .......................... 91 FOCALIN XR ...................... 71 FOLBECAL ......... 83, 145, 149 FOLCAL DHA 34, 83, 97, 145,

149 folic acid ............................. 149 FOLIVANE-PRX DHA NF 34,

97, 145, 149 FOLLISTIM AQ ........ 108, 109 FOLOTYN ........................... 18 fomepizole .......................... 114 fondaparinux................... 30, 31 FORADIL AEROLIZER .... 29,

127 FORTAZ ................................ 4 FORTAZ IN DEXTROSE 5 %

............................................ 4 FORTEO .................... 110, 116 FORTESTA ........................ 104 FOSAMAX PLUS D .. 116, 153 foscarnet ................................. 8 fosinopril .............................. 39 fosinopril-hydrochlorothiazide

.............................. 39, 53, 87 fosphenytoin ......................... 65 FOSRENOL ................. 81, 114 FRAGMIN ........................... 33 FREAMINE HBC 6.9 % ...... 79 FREAMINE III 3 %-

ELECTROLYTES ........... 79 FROVA ................................ 73 FULYZAQ ........................... 95 FUNGI CURE .................... 134 FURADANTIN .................... 15 furosemide ...................... 50, 81 FUSILEV ........................... 114 FUZEON ................................ 9

FYCOMPA ........................... 57 G gabapentin ...................... 56, 57 GABITRIL ........................... 57 GABLOFEN ......................... 27 galantamine .......................... 28 GAMASTAN S/D ................ 21 GAMMAGARD LIQUID .... 21 GAMMAGARD S/D ............ 21 GAMMAGARD S-D (IGA < 1

MCG/ML) ........................ 21 GAMUNEX-C...................... 21 ganirelix ...................... 104, 118 GARAMYCIN ..................... 89 GARDASIL (PF) .................. 22 GASTROGRAFIN ............... 77 GASTROMARK .................. 76 GAVILYTE-G...................... 97 GAVILYTE-N...................... 97 GAVISCON EXTRA

STRENGTH ..................... 95 GELNIQUE ........................ 143 gemcitabine .......................... 18 gemfibrozil ........................... 49 GENOTROPIN .................. 110 GENOTROPIN MINIQUICK

........................................ 110 GENTAK.............................. 89 gentamicin .......................... 129 gentamicin in nacl (iso-osm) .. 5 gentamicin sulfate (pf)............ 5 GEODON ....................... 59, 62 GERI-HYDROLAC ........... 134 GERI-MUCIL

(ASPARTAME) ............... 97 GESTICARE DHA ..... 34, 145,

149 GIANVI (28) ...................... 105 GILDESS FE 1.5/30 (28) ... 105 GILDESS FE 1/20 (28) ...... 105 GILENYA .......................... 119 GLASSIA ........................... 126 GLEEVEC ............................ 18 glimepiride.......................... 112 glipizide .............................. 112 glipizide-metformin .... 105, 112 GLUCAGEN HYPOKIT .. 108,

115 GLUCAGON EMERGENCY

KIT (HUMAN)....... 108, 115 glucose .................................. 79

GLUMETZA ...................... 105 glyburide micronized .......... 112 glyburide-metformin ... 105, 112 glycerin (adult) ..................... 97 glycerin (child) ..................... 97 GLYCINE UROLOGIC ....... 80 glycopyrrolate ....................... 25 GLYSET ............................. 103 GOLYTELY ......................... 97 GONAL-F ................... 108, 109 GONAL-F RFF .......... 108, 109 GONAL-F RFF PEN .. 108, 109 GORDONS UREA ............. 139 granisetron (pf) ..................... 94 granisetron hcl ...................... 94 GRANISOL .......................... 94 GRANIX ............................... 31 GRIFULVIN V ....................... 5 griseofulvin microsize ............ 5 GRIS-PEG

(ULTRAMICROSIZE) ....... 6 GRX RINSE-FREE ............ 142 guaifenesin .......................... 124 guanfacine ....................... 45, 64 guanidine .............................. 28 GYNE-LOTRIMIN ............ 134 GYNOL II ............................ 75 H HALAVEN ........................... 18 HALFLYTELY-BISACODYL

W-FLAV PK .................... 97 HALFPRIN ......... 36, 37, 61, 72 halobetasol propionate 131, 137 HALOG ...................... 131, 137 HALONATE .............. 131, 137 haloperidol ............................ 64 haloperidol decanoate ........... 64 haloperidol lactate ................ 64 HAVRIX (PF) ...................... 22 HC-1% HEMORRHOID ... 131,

137 HECTOROL ....................... 153 HELIDAC ......... 4, 6, 13, 15, 97 HELIXATE FS ..................... 32 HEMABATE ...................... 122 HEMENATAL OB ..... 145, 149 HEMENATAL OB + DHA

................................ 145, 149 HEMOFIL M HIGH ............. 32 HEMOFIL M LOW .............. 32 HEMOFIL M MID ............... 32

164

HEMOFIL M SUPER HIGH32 HEMORRHOIDAL (WITCH

HAZEL) ......................... 134 HEPAGAM B ...................... 21 heparin (porcine) .................. 33 heparin (porcine) in 5 % dex 33 heparin(porcine) in 0.45% nacl

.......................................... 33 heparin, porcine (pf) ............. 33 HERCEPTIN ........................ 18 HESPAN 6 % IN NS ............ 83 HEXALEN ........................... 18 HEXTEND ........................... 83 HIGH POTENCY

CAPSAICIN ................... 142 HIPREX ............................... 15 HIZENTRA .......................... 21 HOMATROPAIRE .............. 94 HONEY BEE TREATMENT

............................ 21, 76, 121 HUMALOG MIX 50-50

KWIKPEN ..... 109, 110, 112 HUMALOG MIX 75-25

KWIKPEN ..... 109, 110, 112 HUMALOG U-100 INSULIN

................................ 109, 112 HUMATE-P ......................... 32 HUMATROPE ................... 110 HUMIRA ...... 99, 117, 119, 142 HUMIRA PEN .... 99, 117, 119,

142 HUMULIN 70/30 INSULIN

PEN ................ 109, 110, 112 HUMULIN N PEN..... 109, 110 HUMULIN R REGULAR U-

100 INSULN .......... 109, 112 HUMULIN R U-500 (CONC)

INSULIN ................ 109, 112 HYCAMTIN ........................ 18 hydralazine ........................... 48 HYDREA ............................. 18 HYDRO 35 ......................... 139 HYDRO 40 ......................... 139 hydrochlorothiazide ........ 53, 87 hydrocodone-acetaminophen

.................................... 56, 67 hydrocodone-ibuprofen .. 67, 70 hydrocortisone ............ 131, 137 hydrocortisone acetate 131, 137 hydrocortisone butyrate ..... 131,

137

hydrocortisone valerate ..... 132, 137

hydrocortisone-aloe vera ... 132, 137

hydrocortisone-pramox-e-pram.1 ............. 132, 133, 137

hydrocortisone-pramoxine . 132, 133, 137, 138

hydromorphone .................... 67 hydromorphone (pf) ............. 67 HYDROPHOR ................... 135 hydroxychloroquine 6, 117, 119 hydroxyzine hcl ................ 2, 61 hydroxyzine pamoate ....... 2, 61 HYLENEX ........................... 88 hyoscyamine sulfate ............. 25 HYPERHEP B S-D

NEONATAL .................... 21 HYPERLYTE CR ................ 83 HYPERRAB S/D (PF) ......... 21 HYPERRHO S/D ................. 21 HYPER-SAL .................. 75, 83 HYPERTET S/D (PF) .......... 21 HYPOTEARS ...................... 92 I ibandronate ......................... 116 ibuprofen .............................. 70 IBUPROFEN JR STRENGTH

.......................................... 70 ibuprofen-oxycodone...... 67, 70 IDAMYCIN PFS .................. 18 IFEX ..................................... 18 ifosfamide ............................. 18 ifosfamide-mesna ................. 18 ILUVIEN .............................. 91 IMDUR ................................. 51 imipenem-cilastatin ................ 8 imipramine hcl ...................... 75 imipramine pamoate ............. 75 imiquimod .......................... 142 IMITREX ............................. 73 IMOVAX RABIES VACCINE

(PF) ................................... 22 IMPLANON ....................... 105 INCIVEK................................ 9 INCRELEX ........................ 112 indapamide ..................... 53, 87 INDOCIN ..................... 70, 115 indomethacin ................ 70, 115 INFANRIX (DTAP) (PF) ..... 21 INFANT'S IBUPROFEN ..... 70

INFERGEN .......................... 11 INNOPRAN XL 27, 41, 46, 50,

61 INTEGRILIN ....................... 37 INTELENCE ........................ 10 INTRALIPID ........................ 80 INTRON A ............. 11, 18, 119 INTROVALE ..................... 106 INTUNIV ER ................. 45, 64 INVANZ ................................. 8 INVEGA ............................... 62 INVEGA SUSTENNA ......... 62 INVIRASE ........................... 10 IODOPEN ........................... 104 IONOSOL-B IN D5W .......... 83 IONOSOL-MB IN D5W ...... 83 IOPIDINE ............................. 92 ipecac .................................... 99 IPOL ..................................... 22 ipratropium bromide ...... 25, 92,

123 ipratropium-albuterol ..... 25, 29,

123, 127 IPRIVASK ............................ 31 irbesartan-hydrochlorothiazide

.............................. 38, 53, 87 irinotecan .............................. 18 IROSPAN 24/6 ..... 34, 149, 152 ISENTRESS ......................... 10 ISOLYTE M IN 5 %

DEXTROSE ..................... 83 ISOLYTE S PH 7.4 .............. 83 ISOLYTE-P IN 5 %

DEXTROSE ..................... 83 ISOLYTE-S .......................... 83 isoniazid .................................. 7 ISOPTO CARBACHOL ...... 93 ISOPTO HOMATROPINE .. 94 ISOPTO HYOSCINE ........... 94 ISOPTO TEARS .................. 92 ISORDIL .............................. 51 isosorbide dinitrate ............... 51 isosorbide mononitrate ......... 51 ISOVUE-300 ........................ 77 ISOVUE-M 300 .................... 77 isradipine ...... 43, 47, 48, 50, 54 ISTALOL ............................. 90 ISTODAX ............................. 18 ISUPREL ...................... 27, 126 itraconazole ............................. 8 IXEMPRA ............................ 18

165

IXIARO (PF) ........................ 22 J JALYN ......................... 28, 114 JANUMET ................. 105, 106 JANUVIA........................... 106 JENTADUETO .......... 105, 106 JETREA (PF) ....................... 92 JEVTANA ............................ 18 JINTELI ..................... 107, 111 JUNEL 1.5/30 (21) ............. 106 JUNEL 1/20 (21) ................ 106 JUXTAPID ........................... 40 K KADIAN .............................. 68 KALBITOR ........................ 117 KALETRA ........................... 10 KALYDECO ...................... 124 karaya gum (bulk) ................ 97 KEFLEX................................. 3 KELNOR 1/35 (28) ............ 106 KENALOG......... 102, 132, 138 KEPIVANCE ..................... 135 KERAFOAM ..................... 139 ketamine ............................... 65 KETEK ................................. 11 ketoconazole ................... 8, 134 ketoprofen............................. 70 ketorolac ............................... 70 ketotifen fumarate ................ 88 KIDKARE COUGH/COLD .. 2,

24, 123, 124, 125 KINERET ................... 118, 119 KINRIX (PF) ........................ 22 KIONEX....................... 81, 115 KIONEX (WITH SORBITOL)

.................................. 81, 115 KLARON ........................... 140 KLOR-CON ......................... 83 KLOR-CON 8 ...................... 83 KLOR-CON M10 ................. 83 KLOR-CON M15 ................. 83 KLOR-CON M20 ................. 83 KLOR-CON/25 .................... 83 KOATE-DVI ........................ 32 KOMBIGLYZE XR ... 105, 106 KONSYL (SUGAR) ............ 98 KPN ...................... 34, 145, 149 KRISTALOSE ..................... 78 KRYSTEXXA .................... 116 KUVAN ............................. 121 K-Y LUBRICATING ......... 142

L labetalol .. 27, 28, 37, 38, 41, 46 LAC-HYDRIN FIVE ......... 135 LACRISERT ........................ 92 lactase ................................... 99 lactated ringers ............... 80, 83 lactic acid ............................ 135 lactulose ................................ 78 LAMICTAL ODT .......... 57, 59 LAMICTAL ODT STARTER

(BLUE) ....................... 57, 59 LAMICTAL ODT STARTER

(GREEN) .................... 57, 59 LAMICTAL ODT STARTER

(ORANGE) ................. 57, 59 LAMICTAL STARTER

(BLUE) KIT ............... 57, 59 LAMICTAL STARTER

(GREEN) KIT ............ 57, 59 LAMICTAL STARTER

(ORANGE) KIT ......... 57, 59 LAMICTAL XR ................... 58 LAMICTAL XR STARTER

(BLUE) ............................. 58 LAMICTAL XR STARTER

(GREEN) .......................... 58 LAMICTAL XR STARTER

(ORANGE) ....................... 58 LAMISIL ................................ 4 LAMISIL AF ...................... 143 lamivudine ............................ 10 lamivudine-zidovudine ......... 10 lamotrigine................ 58, 59, 60 LANOXIN PEDIATRIC 40, 44 lansoprazole ........................ 101 LANTUS SOLOSTAR U-100

INSULIN ................ 109, 110 LASTACAFT ....................... 88 latanoprost ............................ 94 LATRIX XM ...................... 139 LATUDA.............................. 62 LAXATIVE (BISACODYL)98 LESCOL XL......................... 49 letrozole ........................ 18, 104 leucovorin calcium ............. 115 LEUKERAN ........................ 18 LEUKINE ............................. 31 leuprolide .............. 18, 108, 109 levalbuterol hcl ............. 29, 127 LEVAQUIN IN 5 %

DEXTROSE ................. 7, 14

LEVATOL ............................ 41 LEVEMIR U-100 INSULIN

................................ 109, 110 levetiracetam ......................... 58 LEVITRA ............................. 52 levobunolol ........................... 90 levocarnitine (with sugar) ... 121 levocetirizine .................. 2, 127 levofloxacin ................ 7, 14, 89 levofloxacin in d5w .......... 7, 14 LEVOMEFOLATEPNV ..... 34,

83, 145, 149 levonorgestrel ..................... 106 levorphanol tartrate ............... 68 levothyroxine ...................... 113 LEVSIN ................................ 25 LEVULAN ......................... 142 LEXIVA ............................... 11 LIALDA ............................... 97 lidocaine ............................. 133 lidocaine (pf) in d7.5w ...... 113 lidocaine (pf) ................ 45, 113 lidocaine hcl .......... 93, 114, 133 lidocaine hcl-hydrocortison ac

........................ 132, 133, 138 LIDOCAINE PAIN RELIEF

........................................ 133 LIDOCAINE VISCOUS ...... 93 lidocaine-epinephrine ... 24, 114 lidocaine-epinephrine (pf) ... 24,

114 lidocaine-hydrocortisone-aloe

........................ 132, 133, 138 lidocaine-prilocaine ............ 133 LIDODERM ....................... 133 LINCOCIN ........................... 11 lindane ................................ 140 LIORESAL ........................... 27 liothyronine ......................... 113 LIPODOX ............................. 18 LIPOFEN .............................. 49 LIQUID E-Z PAQUE ........... 77 LIQUID POLIBAR .............. 77 lisinopril .......................... 39, 40 lisinopril-hydrochlorothiazide

........................ 39, 40, 53, 87 lithium carbonate .................. 60 lithium citrate ........................ 60 LITHOSTAT ........................ 78 LIVALO ............................... 49 L-METHYLFOLATE ........ 149

166

L-METHYLFOLATE PNV DHA ........... 34, 83, 145, 149

LO LOESTRIN FE............. 106 LOCOID ..................... 132, 138 LOCOID LIPOCREAM .... 132,

138 LODOSYN ........................... 64 lomustine .............................. 18 loperamide ............................ 95 loratadine .................... 2, 3, 127 LORATADINE-D ... 3, 24, 123,

127 lorazepam ....................... 63, 64 losartan ................................. 38 losartan-hydrochlorothiazide

.............................. 38, 53, 87 LOSEASONIQUE ............. 106 LO-SO PREP........................ 98 LOTRIMIN AF .................. 134 LOTRIMIN AF POWDER 134 LOTRIMIN ULTRA .......... 135 LOTRONEX ........................ 97 lovastatin .............................. 49 LOVAZA ............................. 40 loxapine succinate ................ 61 LUBRICANT EYE .............. 92 LUCENTIS........................... 92 LUFYLLIN ................ 128, 144 LUMIGAN ........................... 94 LUMIZYME ........................ 88 LUPRON DEPOT 18, 108, 109 LUPRON DEPOT (3

MONTH) .......... 18, 108, 109 LUPRON DEPOT (4

MONTH) .......... 18, 108, 109 LUPRON DEPOT-PED ...... 18,

108, 109 LUVOX CR.......................... 74 LUXIQ ....................... 132, 138 LYRICA ................... 56, 58, 65 LYSODREN......................... 18 LYSTEDA ............................ 32 M MACNATAL CN DHA 83, 98,

145, 149 MACRODANTIN ................ 15 MACUGEN .......................... 92 MACULAR VITAMIN..... 145,

149 MAG-AL .............................. 95 MAGNACET ................. 56, 68

magnesium............................ 83 magnesium citrate................. 98 magnesium oxide .................. 95 magnesium sulfate .. 40, 58, 115 magnesium sulfate in d5w ... 40,

58, 115 magnesium sulfate in water . 40,

58, 115 MAGONATE ....................... 83 MAKENA .......................... 111 MALARONE ......................... 6 MALARONE PEDIATRIC ... 6 malathion ............................ 141 mannitol 10 % .......... 51, 76, 81 mannitol 20 % .......... 51, 76, 81 mannitol 25 % .......... 51, 76, 81 mannitol 5 % ............ 51, 76, 81 MAPAP

(ACETAMINOPHEN) ..... 56 maprotiline............................ 75 MARNATAL-F .... 83, 145, 149 MARPLAN .......................... 66 MATULANE........................ 18 MAXAIR AUTOHALER ... 29,

128 MAXALT ............................. 73 MAXALT-MLT ................... 73 MAXIBAR ........................... 77 MAXITROL ................... 89, 91 meclizine .......................... 2, 96 meclofenamate...................... 70 MEDROL ........................... 102 medroxyprogesterone ......... 111 mefenamic acid..................... 70 mefloquine .............................. 6 MEFOXIN IN DEXTROSE

(ISO-OSM) ..................... 3, 8 MEGACE ES ............... 18, 111 megestrol ...................... 19, 111 melatonin ............................ 121 meloxicam ............................ 70 melphalan hcl ....................... 19 MEMBRANEBLUE ............ 77 MENACTRA (PF) ............... 22 MENEST ............................ 107 MENHIBRIX (PF) ............... 22 MENOMUNE - A/C/Y/W-135

(PF) ................................... 22 MENOPUR ................ 108, 109 MENOSTAR ...................... 107

MENVEO A-C-Y-W-135-DIP (PF) ................................... 22

meperidine ............................ 68 meperidine (pf) ..................... 68 MEPHYTON .............. 115, 154 meprobamate ........................ 61 mercaptopurine ............. 19, 120 meropenem ............................. 8 mesalamine ........................... 97 mesalamine with cleansing

wipe .................................. 97 mesna .................................. 122 MESNEX ............................ 122 MESTINON ......................... 28 MESTINON TIMESPAN .... 28 METADATE ER .................. 72 metaproterenol .............. 29, 128 METASTRON .................... 122 metaxalone ............................ 26 metformin ........................... 105 methadone ............................. 68 methimazole ....................... 104 METHITEST ...................... 104 methocarbamol ..................... 26 methotrexate sodium ... 19, 118,

119, 120 methotrexate sodium (pf) .... 19,

118, 119, 120 methscopolamine .................. 26 methyclothiazide ............. 53, 87 methyldopa ..................... 25, 45 methyldopate .................. 25, 45 methylene blue (antidote) ... 115 methylergonovine ............... 122 METHYLIN ......................... 72 methylphenidate hcl .............. 72 methylprednisolone ............ 102 methylprednisolone acetate 102 methylprednisolone sodium

succ ................................. 102 metipranolol .......................... 90 metoclopramide hcl ............ 100 metolazone ...................... 53, 87 metoprolol succinate . 30, 41, 46 metoprolol ta-hydrochlorothiaz

.................. 30, 41, 46, 53, 87 metoprolol tartrate ... 30, 41, 42,

46 METOZOLV ODT ............. 100 METRO I.V. ....................... 4, 6 metronidazole ............. 4, 6, 129

167

metronidazole in nacl (iso-os) ........................................ 4, 6

METVIXIA ........................ 142 mexiletine ............................. 45 MIACALCIN ..... 104, 110, 116 miconazole nitrate .............. 134 MICONAZOLE-3 .............. 134 midazolam ............................ 64 midazolam (pf) ..................... 64 midodrine ............................. 25 MIGRAINE FORMULA .... 37,

56, 61, 72 MIGRANAL .................. 27, 61 MILK OF MAGNESIA ....... 98 MILLIPRED....................... 103 MILLIPRED DP ................ 103 milrinone .............................. 44 milrinone in 5 % dextrose .... 44 MINERAL OIL LAXATIVE

.......................................... 98 MINERAL OIL LIGHT ..... 135 MINERIN CREME ............ 135 MINOCIN ............................ 15 MINOCIN KIT WITH WIPES

.......................................... 15 minocycline .................. 15, 142 minoxidil .............................. 48 MIRAPEX ER ...................... 66 MIRENA ............................ 106 mirtazapine ........................... 59 misoprostol ......................... 100 mitomycin............................. 19 mitoxantrone......................... 19 M-M-R II (PF) ...................... 22 moexipril ........................ 39, 40 moexipril-hydrochlorothiazide

........................ 39, 40, 53, 87 mometasone ................ 132, 138 MONISTAT 3 .................... 134 MONOCAL .......................... 83 MONOCLATE-P ................. 32 MONONESSA (28) ........... 106 montelukast ........................ 125 MONUROL .......................... 15 morphine............................... 68 morrhuate sodium ................. 52 MOTOFEN........................... 95 MOVIPREP .......................... 98 MOXATAG ........................... 5 MOZOBIL ............................ 31 MUCINEX ......................... 124

MULTAQ ............................. 46 MULTI-DELYN ................ 145 MULTIHANCE.................... 77 MURO 128 ........................... 92 MUSCLE RUB (WITH

CAMPHOR) ..................... 72 MUSE ................................... 54 MUSTARGEN ..................... 19 mv-min-folic acid-lutein.... 145,

149 MYCAMINE .......................... 8 MYCOBUTIN .................. 7, 14 mycophenolate sodium ....... 120 MYLERAN .......................... 19 MYNATAL .......... 83, 145, 149 MYNATAL PLUS83, 145, 149 MYNATE 90 PLUS ........... 145 MYOBLOC .................. 30, 121 N nabumetone .......................... 70 nadolol ................ 27, 41, 42, 46 nadolol-bendroflumethiazide

............ 27, 41, 42, 46, 53, 87 nafcillin in dextrose iso-osm 13 NAFTIN ............................. 128 NAGLAZYME ..................... 88 nalbuphine ............................ 69 NALFON .............................. 70 naloxone ....................... 69, 115 naltrexone ..................... 69, 114 NAMENDA.......................... 64 NAMENDA TITRATION

PAK .................................. 64 naphazoline ........................... 94 NAPRELAN CR .......... 70, 116 naproxen ....................... 70, 116 naproxen sodium .......... 70, 116 NARDIL ............................... 66 NAROPIN (PF) .................. 114 NASAL DECONGESTANT

(PSEUDOEPH) ........ 24, 123 NATACHEW (FE BIS-

GLYCINATE) .. 34, 145, 149 NATACYN .......................... 90 NATAFORT (NEW

FORMULA 2011) ... 34, 145, 150

NATALVIRT CA. 83, 145, 150 NATALVIT .......... 83, 145, 150 NATAZIA .......................... 106 nateglinide .......................... 110

NATELLE ONE .... 34, 84, 145, 150

NATRECOR ......................... 54 NATROBA ......................... 141 NATURE'S TEARS

(HYPROMELLOSE) ....... 92 NATURE-THROID ........... 113 NEBUPENT ........................... 6 NECON 1/50 (28) ............... 106 NECON 10/11 (28) ............. 106 nefazodone ............................ 74 NEO-FRADIN ........................ 5 neomycin ................................ 5 neomycin-bacitracin-poly-hc

.................................... 89, 91 neomycin-bacitracin-

polymyxin ......................... 89 neomycin-polymyxin b gu .. 129 neomycin-polymyxin-

gramicidin ......................... 89 neomycin-polymyxin-hc . 89, 91 NEOPROFEN (IBUPROFEN

LYSN)(PF) ....................... 70 neostigmine methylsulfate ... 28,

76 NEO-SYNEPHRINE

(PHENYLEPHRINE) ....... 25 NEPHRAMINE 5.4 % .......... 80 NEPHROCAPS .......... 150, 152 NEPRO CARB STEADY .... 80 NESACAINE ..................... 114 NEUMEGA .......................... 31 NEUPOGEN ......................... 31 NEUT ................................... 78 NEUTROGENA T-GEL

CONDITNER(SA) ......... 139 NEVANAC ........................... 93 nevirapine ............................. 10 NEXAVAR ........................... 19 NEXIUM ............................ 101 NEXIUM IV ....................... 101 NEXIUM PACKET ............ 101 NEXT CHOICE ONE DOSE

........................................ 106 niacin .................................... 40 NIACOR ............................... 40 NIASPAN EXTENDED-

RELEASE ......................... 40 nicardipine .... 43, 47, 48, 50, 54 nicotine ................................. 26 nicotine (polacrilex) .............. 26

168

NICOTROL .......................... 26 NICOTROL NS.................... 26 NIFEDICAL XL 43, 47, 48, 50,

54 nifedipine ...... 43, 47, 48, 50, 54 NILANDRON ...................... 19 nimodipine .... 43, 47, 48, 50, 54 nisoldipine .... 43, 47, 48, 50, 54 NITRO-BID ......................... 51 NITRO-DUR ........................ 51 nitrofurantoin macrocrystal .. 15 nitrofurantoin monohyd/m-

cryst .................................. 16 nitroglycerin ......................... 51 nitroglycerin in 5 % dextrose 51 NITROLINGUAL ................ 51 NITROMIST ........................ 51 NITROSTAT ........................ 51 nizatidine ............................ 100 NIZORAL A-D .................. 134 NORDITROPIN FLEXPRO

........................................ 110 NORDITROPIN NORDIFLEX

........................................ 110 norepinephrine bitartrate ...... 24 NORITATE ........................ 129 NORMOSOL-R ................... 84 NORMOSOL-R IN 5 %

DEXTROSE ..................... 84 NORMOSOL-R PH 7.4 ....... 84 NOROXIN ........................... 14 NORPACE CR ..................... 45 nortriptyline .......................... 75 NORVIR............................... 11 NOVOLOG MIX 70-

30FLEXPEN U-100 ...... 109, 110, 112

NOVOLOG PENFILL U-100 INSULIN ................ 110, 112

NOVOSEVEN RT ............... 32 NOXAFIL .............................. 8 NPLATE............................... 31 NUCORT ................... 132, 138 NUCYNTA .......................... 68 NUEDEXTA ................ 65, 124 NUTRAMIGEN WITH

ENFLORA LGG .............. 80 NUTRILYTE II .................... 84 NUTROPIN ........................ 110 NUTROPIN AQ ................. 111 NUTROPIN AQ NUSPIN . 111

NUVARING ....................... 106 NUVIGIL ............................. 75 NYAMYC .......................... 140 nystatin ......................... 13, 140 nystatin-triamcinolone ........ 140 O OB COMPLETE .. 34, 145, 150 OB COMPLETE 400 .. 34, 145,

150 OB COMPLETE ONE .. 34, 84,

145, 150 OB COMPLETE PREMIER

.................... 34, 84, 145, 150 OBSTETRIX EC ... 34, 98, 145,

150 OBTREX ........ 34, 98, 145, 150 O-CAL PRENATAL ... 84, 145,

150 OCELLA ............................ 106 octreotide acetate ........ 112, 121 OCUFLOX ........................... 89 OCUVITE LUTEIN AND

ZEAXANTHIN .............. 121 OCUVITE WITH LUTEIN 145 ofloxacin ......................... 14, 89 OGESTREL (28) ................ 106 olanzapine ....................... 60, 62 olanzapine-fluoxetine ..... 62, 74 olmesartan ............................ 38 OLUX-E ..................... 132, 138 OMECLAMOX-PAK ..... 5, 13,

101 omega-3 fatty acids-fish oil .. 40 omeprazole ......................... 101 omeprazole-sodium

bicarbonate ..................... 101 OMNARIS.................... 91, 126 OMNIPAQUE 240 ............... 77 OMNIPAQUE 300 ............... 77 OMNIPRED ......................... 91 OMNITROPE ..................... 111 ONCASPAR ......................... 19 ondansetron .......................... 94 ondansetron hcl..................... 94 ondansetron hcl (pf).............. 94 ONE DAILY MULTI-VIT W-

MINERAL ................ 34, 146 ONFI ............................... 63, 64 ONGLYZA ......................... 106 ONTAK ................................ 19 opium tincture................. 68, 95

ORACEA ...................... 15, 142 ORAL RELIEF DRY MOUTH

........................................ 142 ORALONE ................. 132, 138 ORAP ................................... 61 ORAPRED ODT ................ 103 ORENCIA (WITH

MALTOSE) ............ 118, 119 ORFADIN .......................... 121 orphenadrine citrate .............. 30 ORPHENADRINE

COMPOUND-DS ....... 30, 73 ORTHO TRI-CYCLEN (28)

........................................ 106 ORTHO TRI-CYCLEN LO

(28) ................................. 106 ORTHOVISC ....................... 75 OS-CAL 500 + D3........ 84, 153 OSMOPREP ......................... 98 OTEZLA ............. 118, 119, 142 OTEZLA STARTER . 118, 119,

142 OTICIN ........................... 91, 93 OTOZIN ............................... 93 OVIDREL ................... 108, 109 oxacillin ................................ 13 oxacillin in dextrose(iso-osm)

.......................................... 13 oxaliplatin ............................. 19 OXANDRIN ....................... 104 oxaprozin .............................. 70 oxcarbazepine ....................... 58 OXISTAT ........................... 134 OXSORALEN .................... 140 OXSORALEN ULTRA ...... 140 OXTELLAR XR .................. 58 oxybutynin chloride ............ 143 oxycodone ............................. 68 oxycodone-acetaminophen .. 56,

68 OXYCONTIN ...................... 68 oxymorphone ........................ 68 oxytocin .............................. 122 OXYTROL ......................... 143 OYSCO 500/D .............. 84, 153 OYSTER SHELL + D3 84, 153 OYSTER SHELL CALCIUM-

VIT D2 ...................... 84, 153 OZURDEX ........................... 91 P PACERONE ......................... 46

169

paclitaxel .............................. 19 PAIRE OB PLUS DHA ...... 34,

146, 150 pamidronate ........................ 116 PANCRELIPASE 5000 ....... 99 PANDEL .................... 132, 138 PANHEMATIN ................. 121 PANRETIN .................. 19, 142 pantoprazole ....................... 101 papaverine ............................ 54 paromomycin ...................... 4, 5 paroxetine hcl ....................... 74 PARVA-CAL 500 ........ 84, 153 PASER ................................... 7 PATADAY ........................... 88 PATANASE ......................... 88 PATANOL ........................... 88 PAXIL .................................. 74 PCE................................... 9, 11 PEDIADERM HC ...... 132, 138 PEDIARIX (PF) ............. 21, 22 PEDIASURE ........................ 80 PEDIATRIC ELECTROLYTE

.......................................... 84 PEDVAX HIB (PF) .............. 23 peg 3350-electrolytes ........... 98 PEGANONE ........................ 66 PEGASYS CONVENIENCE

PACK ............................... 11 PEGINTRON ....................... 11 penicillin g pot in dextrose ... 12 penicillin g sodium ............... 12 penicillin v potassium........... 12 PENNSAID .......... 71, 140, 142 PENTACEL (PF) ................. 23 PENTAM ............................... 6 pentazocine-naloxone ........... 69 pentostatin ............................ 19 pentoxifylline ....................... 31 PEPTIC RELIEF .................. 95 PERFOROMIST .......... 29, 128 PERIFRESH ....................... 138 permethrin .......................... 141 perphenazine......................... 71 perphenazine-amitriptyline.. 71,

75 PEXEVA .............................. 74 PHENABID .............. 2, 25, 125 phenazopyridine ................. 133 phenobarb-hyoscy-atropine-

scop....................... 26, 62, 63

phentolamine .................. 27, 50 phenylephrine hcl ................. 94 phenytoin ........................ 45, 66 phenytoin sodium ........... 45, 66 phenytoin sodium extended . 45,

66 PHISOHEX ........................ 140 PHOS-NAK .......................... 84 PHOSPHOLINE IODIDE .... 93 PHOTOFRIN........................ 19 PHYSIOLYTE ..................... 80 physostigmine salicylate...... 28,

115 pilocarpine hcl ................ 28, 93 PILOPINE HS ...................... 93 pindolol ......... 27, 41, 42, 46, 50 PINK BISMUTH ............ 95, 96 PINNACAINE...................... 93 PIN-X ..................................... 5 pioglitazone ........................ 113 piperacillin-tazobactam .......... 9 PITRESSIN ........................ 111 PKU 2 ................................... 80 PKU TRIO ............................ 80 PLACEBO #00 ................... 122 PLASMA-LYTE 148 ........... 84 PLASMA-LYTE A .............. 84 PLASMA-LYTE-56 IN 5 %

DEXTROSE ..................... 84 PNEUMOVAX-23 ............... 23 PNV FOLIC ACID + IRON 34,

146, 150 POLYCOSE ......................... 80 polyethylene glycol 3350 ..... 98 polymyxin b sulfate .............. 13 polymyxin b sulf-trimethoprim

.......................................... 89 POLY-VI-SOL ................... 146 POLY-VI-SOL WITH IRON

.................................. 35, 146 POLY-VITAMIN ............... 146 POLYVITAMIN WITH IRON

.................................. 35, 146 POLY-VITAMIN WITH

IRON ................................ 35 POLY-VITAMIN WITH

IRON .............................. 146 POMALYST ................ 19, 119 PONTOCAINE (PF) .......... 114 potassium acetate .................. 84

potassium bicarb and chloride .......................................... 84

potassium chlorid-d5-0.45%nacl ......................... 84

potassium chloride .......... 84, 85 potassium chloride in 0.9%nacl

.......................................... 84 potassium chloride in 5 % dex

.......................................... 84 potassium chloride in lr-d5 ... 84 potassium chloride in water .. 84 potassium chloride-0.45 % nacl

.......................................... 85 potassium chloride-d5-

0.2%nacl ........................... 85 potassium chloride-d5-

0.3%nacl ........................... 85 potassium chloride-d5-

0.9%nacl ........................... 85 potassium citrate ................... 78 potassium gluconate ............. 85 potassium phosphate m-/d-

basic .................................. 85 PR NATAL 430 EC ..... 85, 146,

150 PRADAXA ........................... 31 PRAMEGEL ANTI-ITCH . 133 pramipexole .......................... 66 pramoxine ........................... 133 PRANDIMET ............. 105, 110 PRANDIN .......................... 110 PRASCION RA .......... 139, 140 pravastatin ............................. 49 prazosin ..................... 27, 37, 38 PRED MILD ......................... 91 PRED-G .......................... 89, 91 PRED-G S.O.P. .............. 89, 91 prednisolone ....................... 103 prednisolone sodium phosphate

.................................. 91, 103 prednisone ........................... 103 PREDNISONE INTENSOL

........................................ 103 PREFERA-OB ONE ... 35, 146,

150 PREFEST ........................... 107 PREMARIN ....................... 107 PREMASOL 6 % ................. 80 PREMPHASE ..................... 107 PREMPRO ......................... 107 PRENA1 ............... 35, 146, 150

170

PRENA1 CHEW (QUATREFOLIC) . 146, 150

PRENA1 PLUS .... 35, 146, 150 PRENAISSANCE 90 DHA 35,

85, 98, 146, 150 PRENATA ........... 35, 146, 150 PRENATABS FA . 35, 85, 146,

150 PRENATABS RX . 35, 85, 146,

150 PRENATAL 19 (WITH

DOCUSATE) ......... 146, 150 PRENATAL LOW IRON ... 85,

146, 150 PRENATAL PLUS WITH

IRON (CA) ....... 85, 146, 150 PRENATAL VITAMIN 35, 85,

146, 150 PRENATAL VITAMIN PLUS

LOW IRON ...... 85, 146, 150 PRENATAL-U ................... 146 PRENATE DHA .. 35, 146, 150 PRENATE ELITE 35, 146, 150 PRENATE ESSENTIAL..... 35,

146, 150 PRENATE MINI .. 35, 146, 150 PRE-PEN .............................. 76 PREPIDIL .......................... 122 PREQUE 10 ... 35, 98, 146, 150 pretomanid .............................. 7 PREVACID SOLUTAB .... 101 PREVNAR 13 (PF) .............. 23 PREVPAC ................ 5, 13, 101 PREZISTA ........................... 11 PRIALT ................................ 56 PRIFTIN ........................... 7, 14 PRILOSEC ......................... 101 primaquine .............................. 6 primidone ............................. 62 PRIMLEV ...................... 56, 68 PRISTIQ ............................... 73 PROAIR HFA .............. 29, 128 probenecid .................... 87, 116 PROBIOTIC (S.BOULARDII)

.......................................... 99 procainamide ........................ 45 PROCENTRA ...................... 55 prochlorperazine edisylate... 71,

96 prochlorperazine maleate 71, 96 PROCRIT ............................. 31

PROCTOCORT.......... 132, 138 PROCTOFOAM HC . 132, 133,

138 PROFILNINE ....................... 32 progesterone ....................... 111 PROGLYCEM ................... 104 PROGRAF.......................... 120 PROHANCE ........................ 77 PROLEUKIN ............... 19, 119 PROLIA.............................. 116 PROMACTA ........................ 31 promethazine ............ 2, 61, 125 PROMETHAZINE VC ... 2, 25,

125 promethazine-dm ........ 124, 125 PROMETRIUM ................. 112 propafenone .......................... 45 propantheline ........................ 26 propofol .......................... 61, 65 propranolol .. 27, 41, 42, 46, 50,

61 propranolol-hydrochlorothiazid

............ 27, 41, 42, 46, 53, 87 propylthiouracil .................. 104 PROQUAD (PF)................... 23 PROSHIELD SPRAY

CLEANSER ................... 142 PROSOL 20 % ..................... 80 PROSTIGMIN...................... 28 PROSTIN E2 ...................... 122 protamine ...................... 30, 115 PROTECT NATAL ..... 85, 146,

151 PROTONIX ........................ 101 PROTOPAM CHLORIDE . 115 PROTOPIC ......................... 142 protriptyline .......................... 75 PROVENGE ......................... 55 PROVIGIL ........................... 75 PROVISC ............................. 76 PRUDOXIN ....................... 133 pseudoephedrine hcl ..... 24, 123 pseudoephedrine-guaifenesin

.......................... 24, 123, 124 psyllium husk ....................... 98 PULMICORT ............. 103, 126 PULMICORT FLEXHALER

................................ 103, 126 PULMOZYME ............. 88, 126 PURE AND GENTLE EYE . 92

PUREFE OB PLUS ..... 35, 146, 151

PYLERA ........... 4, 6, 13, 15, 97 pyrazinamide .......................... 7 PYRETHRIN LICE

TREATMENT M ........... 141 PYRI 500 ............................ 151 pyridoxine (vitamin b6) ...... 151 Q Q-DRYL ......................... 1, 125 Q-PAP ................................... 56 QUADRAMET ................... 122 QUALAQUIN ........................ 6 quetiapine ....................... 60, 62 QUILLIVANT XR ............... 72 quinapril .......................... 39, 40 quinapril-hydrochlorothiazide

........................ 39, 40, 53, 87 quinidine gluconate .......... 6, 45 quinidine sulfate ............... 6, 45 QUTENZA ......................... 142 QVAR ......................... 103, 126 R RABAVERT (PF) ................ 23 racepinephrine .............. 24, 123 ramipril ........................... 39, 40 RANEXA ............................. 44 ranitidine hcl ....................... 100 RAPAFLO ............................ 28 RAPAMUNE ...................... 120 READI-CAT ......................... 77 READI-CAT 2 ...................... 77 REBETOL ............................ 12 REBIF (WITH ALBUMIN)

........................................ 119 REBIF REBIDOSE ............ 119 REBIF TITRATION PACK

........................................ 119 RECLAST .......................... 116 RECOMBINATE ................. 32 RECOMBIVAX HB (PF) ..... 23 RECOTHROM ..................... 32 RECOTHROM SPRAY KIT 32 REFRESH LIQUIGEL ......... 92 REGONOL ........................... 28 REGRANEX .............. 135, 142 RELENZA DISKHALER .... 12 RELISTOR ........................... 99 RELPAX ............................... 73 REMICADE 99, 118, 119, 121,

142

171

REMODULIN .............. 54, 128 RENACIDIN ........................ 81 RENAGEL ................... 81, 115 RENA-VITE RX ................ 151 RENOVA ........................... 135 RENVELA ................... 81, 115 REOPRO .............................. 37 repaglinide .......................... 110 REPREXAIN ................. 68, 71 REPRONEX ............... 108, 109 RESCRIPTOR ...................... 10 RESECTISOL ...................... 81 reserpine ............................... 51 RESTASIS ........................... 92 RETAVASE ................... 37, 88 RETIN-A ............................ 135 RETIN-A MICRO .............. 135 RETISERT ........................... 91 RETROVIR .......................... 10 REVATIO .................... 52, 128 REVLIMID .................. 19, 119 REVONTO ........................... 26 REYATAZ ........................... 11 REZIRA ......... 24, 68, 123, 124 R-GENE 10 .......................... 77 RHEUMATREX . 19, 118, 119,

120 RHINOCORT ALLERGY .. 91,

126 RHINOCORT AQUA .. 91, 126 RHOPHYLAC ..................... 21 RIASTAP ............................. 32 RID LICE KILLING .......... 141 RIDAURA .......... 101, 118, 119 RIFADIN .......................... 7, 14 RIFAMATE ..................... 7, 14 RIFATER ......................... 7, 14 RILUTEK ............................. 65 rimantadine ............................. 4 RIMSO-50 .................... 81, 132 ringer's ............................ 81, 85 RISACAL-D................. 85, 153 RISPERDAL CONSTA . 60, 62 risperidone ...................... 60, 62 RITALIN LA........................ 72 RITUXAN ............................ 19 rivastigmine tartrate.............. 28 RIXUBIS .............................. 32 ROBAXIN ............................ 26 ROLAIDS............................. 95

ROLAIDS EXTRA STRENGTH ..................... 95

ropinirole .............................. 66 ROSADAN ......................... 129 ROTARIX ............................ 23 ROTATEQ VACCINE......... 23 ROXICET ....................... 56, 68 ROZEREM ........................... 61 S SABRIL ................................ 58 SAFYRAL .......................... 106 SAIZEN .............................. 111 SAIZEN CLICK.EASY ..... 111 salicylic acid ....................... 139 SALONPAS ......................... 73 salsalate ................................ 73 SAMSCA.............................. 87 SANCTURA ...................... 143 SANCTURA XR ................ 143 SANDIMMUNE 118, 119, 120 SANDOSTATIN LAR

DEPOT ................... 112, 121 SANTYL ............................ 142 SAPHRIS........................ 60, 62 SARAFEM ........................... 74 SAVELLA ...................... 65, 73 scopolamine hbr ................... 26 SCOT-TUSSIN SENIOR ... 124 SEASONIQUE ................... 106 SELECT-OB (FOLIC ACID)

.......................... 35, 146, 151 selegiline hcl ......................... 66 selenium sulfide .................. 140 SELZENTRY ......................... 9 SEMPREX-D ... 3, 24, 123, 127 SENNA ................................. 98 sennosides-docusate sodium. 98 SENSIPAR ................. 104, 121 SENSORCAINE-

EPINEPHRINE ........ 24, 114 SENSORCAINE-

MPF/EPINEPHRINE ...... 24, 114

SEREVENT DISKUS .. 29, 128 SEROQUEL XR............. 60, 62 SEROSTIM ........................ 111 sertraline ............................... 74 SE-TAN DHA ...... 35, 146, 151 SETONET ...... 35, 85, 147, 151 SETONET-EC 35, 85, 147, 151 sevelamer carbonate ..... 81, 115

SFROWASA ........................ 97 SILACE ................................ 98 SILENOR ............................. 75 SILVADENE ...................... 140 SIMCOR ....................... 49, 151 simethicone ........................... 96 SIMILAC ALIMENTUM .... 80 SIMILAC EXPERT CARE

NEOSURE ........................ 80 SIMPONI .............. 99, 118, 119 SIMULECT ........................ 120 simvastatin ............................ 49 SINGLE USE EZ FLU 2013-

14 (PF) .............................. 23 SKELID .............................. 116 sodium acetate ...................... 85 sodium bicarbonate ......... 78, 95 sodium chloride ........ 76, 85, 92 sodium chloride 0.45 % ........ 85 sodium chloride 0.9 % .......... 85 sodium chloride 3 % ............. 85 sodium chloride 5 % ............. 85 sodium citrate-citric acid ...... 78 SODIUM EDECRIN ...... 50, 81 sodium lactate ....................... 78 sodium phosphate ................. 86 sodium thiosulfate .............. 115 solifenacin ........................... 143 SOLIRIS ............................. 117 SOLODYN ................... 15, 142 SOLU-CORTEF ACT-O-

VIAL (PF) ...................... 103 SOLU-MEDROL ............... 103 SOMATULINE DEPOT .... 112 SOMAVERT ...................... 112 SONATA .............................. 61 sotalol ........... 27, 41, 42, 46, 50 SOTRADECOL .................... 52 SPIRIVA WITH

HANDIHALER ........ 26, 123 spironolactone ..... 50, 51, 52, 82 SPORANOX ........................... 8 SPRYCEL ............................. 19 SSKI ............... 6, 104, 115, 124 STALEVO 100 ............... 64, 65 STALEVO 125 ............... 64, 65 STALEVO 150 ............... 64, 65 STALEVO 200 ............... 64, 65 STALEVO 50 ................. 64, 65 STALEVO 75 ................. 64, 65 stavudine ............................... 10

172

STAVZOR ............... 58, 60, 61 STAXYN .............................. 52 STELARA .......... 118, 119, 142 STENDRA ........................... 52 STERILE SALINE ............... 81 STIMATE..................... 33, 111 STOMACH RELIEF MAX

STRENGTH ............... 95, 96 STOOL SOFTENER ............ 98 STRATTERA ....................... 65 STRIANT ........................... 104 STROMECTOL ..................... 5 SUBOXONE ........................ 69 sucralfate ............................ 100 SUDAFED 24 HOUR .. 24, 123 SUDOGEST ................. 24, 123 SUDOGEST 12-HOUR 24, 123 SUFENTA ............................ 68 sulfacetamide-prednisolone .. 89 sulfadiazine........................... 14 sulfamethoxazole-trimethoprim

.......................................... 15 SULFAMYLON................. 140 sulindac................................. 71 sumatriptan succinate ........... 73 SUMAVEL DOSEPRO ....... 73 SUPARTZ ............................ 76 SUPPRELIN LA .. 19, 108, 109 SUPRAX ................................ 4 SUPREP BOWEL PREP KIT

.......................................... 98 SURMONTIL....................... 75 SUSTIVA ............................. 10 SUTENT............................... 19 SYMAX DUOTAB .............. 26 SYMLINPEN 120 .............. 103 SYNAGIS............................. 12 SYNALGOS-DC ..... 37, 61, 68,

72, 73, 124 SYNAREL ................. 108, 109 SYNERA ............................ 133 SYNERCID .......................... 14 SYNVISC ............................. 76 SYPRINE ........................... 101 T TABLOID ............................ 19 TACLONEX ...... 132, 138, 142 TAGITOL V ......................... 77 TALWIN .............................. 69 TAMIFLU ............................ 12 tamoxifen ...................... 19, 106

TARCEVA ........................... 19 TARGRETIN ............... 19, 142 TARKA .. 39, 40, 42, 43, 44, 55 TARON-BC.... 35, 86, 147, 151 TASIGNA ............................ 19 TASMAR ............................. 64 TAXOTERE ......................... 20 TAZORAC ......................... 142 TEARS NATURALE FREE

(PF) ................................... 92 TEFLARO .............................. 4 TEGRETOL XR ............. 58, 60 TEKAMLO .. 43, 47, 48, 52, 55 TEKTURNA ........................ 52 TEKTURNA HCT ... 52, 53, 87 telmisartan ............................ 38 telmisartan-amlodipine .. 38, 39,

43, 47, 48, 55 temazepam ............................ 64 TEMODAR .......................... 20 TENSION HEADACHE

RELIEF ...................... 56, 72 terazosin.................... 27, 38, 50 terbinafine hcl ..................... 128 TERBINEX ............................ 4 terbutaline ..................... 29, 128 terconazole.......................... 134 TESTOPEL ........................ 104 testosterone enanthate......... 104 tetanus toxoid,adsorbed (pf) . 21 tetanus-diphtheria toxoids-td 22 TETCAINE .......................... 93 tetracycline ........................... 15 TEVETEN HCT . 38, 39, 53, 87 TEXACORT ............... 132, 138 THALOMID ....................... 119 THEO-24 ........ 48, 80, 128, 144 THEOCHRON 48, 80, 128, 144 theophylline .... 48, 80, 128, 144 THERA ............................... 147 THERACYS ................... 20, 23 THERA-GEL...................... 139 THERA-GESIC .................... 73 THERA-M ...... 35, 86, 147, 151 THERATEARS .................... 92 THERATRUM COMPLETE

50 PLUS/LUT ................ 147 THEREMS-M .............. 35, 147 thiamine mononitrate (vit b1)

........................................ 151 THIOLA ............................. 121

thioridazine ........................... 71 thiotepa ................................. 20 thiothixene ............................ 74 THROMBATE III ................ 30 THROMBIN-JMI ................. 33 THYMOGLOBULIN ......... 120 THYROLAR-1 ................... 113 THYROLAR-1/2 ................ 113 THYROLAR-1/4 ................ 113 THYROLAR-2 ................... 113 THYROLAR-3 ................... 113 THYROSHIELD ... 6, 104, 115,

124 tiagabine ............................... 58 TICE BCG ...................... 20, 23 ticlopidine ............................. 37 TIGAN .................................. 96 TIKOSYN ............................. 46 TIMENTIN ............................. 9 timolol maleate ..................... 90 TINACTIN ......................... 143 tinidazole ................................ 6 tioconazole .......................... 134 TIROSINT .......................... 113 tizanidine .............................. 26 TOBRADEX .................. 89, 91 TOBRADEX ST ............. 89, 91 tobramycin ............................ 89 tobramycin in 0.225 % nacl .... 5 tobramycin in 0.9 % nacl ........ 5 TOBREX .............................. 89 TODAY CONTRACEPTIVE

SPONGE ........................... 75 tolazamide ........................... 113 tolmetin ................................. 71 tolnaftate ............................. 143 tolterodine ........................... 143 topiramate ............................. 58 topotecan ............................... 20 TORISEL .............................. 20 torsemide ........................ 50, 81 TOVIAZ ............................. 143 TRACLEER ................. 55, 128 tramadol .......................... 68, 69 tramadol-acetaminophen56, 61,

69 TRANSDERM-SCOP .......... 96 tranylcypromine .................... 66 trazodone .............................. 74 TREANDA ........................... 20 TRECATOR ........................... 7

173

TRELSTAR .................. 20, 108 tretinoin (chemotherapy) ...... 20 tretinoin (emollient)............ 135 TRETIN-X ......................... 135 TRETIN-X (GEL) .............. 135 TRETIN-X CREAM KIT... 135 TREXALL ............ 20, 118, 120 TREXIMET .................... 71, 73 TREZIX ................................ 69 TRIADVANCE ..... 35, 86, 147,

151 triamcinolone acetonide ...... 91,

126, 132, 138 triamterene-hydrochlorothiazid

........................ 52, 53, 82, 87 TRIANEX .................. 132, 138 triazolam ............................... 64 TRIBENZOR .... 38, 39, 43, 47,

48, 53, 55, 87 TRI-BUFFERED ASPIRIN 37,

61, 73 TRICARE PRENATAL DHA

ONE(DSS) ........ 98, 147, 151 TRICITRASOL .............. 30, 78 TRICOR ............................... 49 trifluoperazine ...................... 71 trifluridine............................. 90 trihexyphenidyl............... 26, 57 TRI-LUMA ........................ 138 trimethoprim ......................... 16 TRINATAL GT.......... 147, 151 TRINATAL ULTRA..... 86, 98,

147, 151 TRINATE ....... 35, 86, 147, 151 TRIPLE ANTIBIOTIC ...... 129 TRIPLE VITAMIN WITH

FLUORIDE ... 117, 147, 148, 152, 153

TRISENOX .......................... 20 TRIVEEN-DUO DHA .. 35, 86,

147, 151 TRIVEEN-ONE .... 35, 86, 147,

151 TRIVEEN-PRX RNF .... 35, 86,

98, 147, 151 TRIVEEN-TEN .... 35, 147, 151 TRI-VI-SOL WITH IRON .. 35,

147, 148, 152, 153 TRI-VITAMIN .. 147, 148, 152,

153 TRIXAICIN ....................... 142

TRIXAICIN HP ................. 142 tropicamide ........................... 94 TRUETEST TEST STRIPS . 76 TRUETRACK TEST ........... 76 TRUVADA .......................... 10 TUSSIN .............................. 124 TWINRIX (PF)..................... 23 TYGACIL .............................. 9 TYKERB .............................. 20 TYPHIM VI ......................... 23 TYSABRI ........................... 120 TYVASO ...................... 55, 128 TYZEKA .............................. 12 TYZINE................................ 94 U ULESFIA.................... 140, 141 ULORIC ............................. 116 ULTIMATECARE ONE NF

.................... 35, 86, 147, 151 ULTIVA ............................... 69 ULTRA FRESH ................... 93 ULTRACIN T ...................... 73 ULTRAVATE PAC ... 132, 138 UMECTA NAIL FILM PEN

........................................ 139 UMECTA PD ..................... 139 UNASYN ............................... 5 URAMAXIN ...................... 139 urea ..................................... 139 UREA (WITH

LACTIC,SALICY ACID) ........................................ 139

UROXATRAL ..................... 28 URSO FORTE ...................... 98 ursodiol ........................... 98, 99 UVADEX ........................... 140 V VAGINAL

CONTRACEPTIVE FILM .......................................... 75

VAGINAL CONTRACEPTIVE FOAM .......................................... 75

VAGISIL ............................ 133 valacyclovir .......................... 12 VALCHLOR ................ 20, 142 VALCYTE ........................... 12 valsartan-hydrochlorothiazide

........................ 38, 39, 53, 87 VALSTAR............................ 20 VANCOCIN ........................... 9

vancomycin ............................. 9 vancomycin in dextrose 5 % ... 9 VANIQA ............................ 143 VANOS ...................... 132, 138 VANTAS .............. 20, 108, 109 VAQTA (PF) ........................ 23 VARIBAR THIN LIQUID ... 77 VARIVAX (PF) .................... 23 VECTIBIX ........................... 20 VECTICAL ........................ 143 VELCADE ........................... 20 VELTIN ...................... 129, 135 VENATAL COMPLETE DHA

.......................... 86, 147, 151 venlafaxine ........................... 73 VENTAVIS .................. 55, 128 VERAMYST ................ 91, 126 verapamil ...... 42, 43, 44, 47, 55 VEREGEN ......................... 143 VERIPRED 20 .................... 103 VEXOL ................................. 91 VFEND ................................... 8 VIAGRA ............................... 52 VIBATIV ................................ 9 VIBRAMYCIN .................... 15 VICKS 44 CUSTOM CARE

DRY COUGH ................ 124 VICTOZA 2-PAK .............. 109 VICTRELIS ............................ 9 VIDAZA ............................... 20 VIDEX 2 GRAM PEDIATRIC

.......................................... 10 VIDEX 4 GRAM PEDIATRIC

.......................................... 10 VIIBRYD ............................. 74 VIMOVO ...................... 71, 101 VIMPAT ............................... 58 VINATE AZ ... 36, 86, 147, 151 VINATE CALCIUM .......... 147 VINATE DHA 36, 86, 147, 151 VINATE IC ........................ 147 VINATE II .......................... 147 VINATE M ........... 36, 147, 151 VINATE ONE 36, 86, 147, 151 VINATE PN CARE ........... 147 vinblastine ............................. 20 VINCASAR PFS .................. 20 vinorelbine ............................ 20 VIRACEPT ........................... 11 VIRAMUNE ......................... 10 VIRAZOLE .......................... 12

174

VIREAD ............................... 10 VIRT-BAL DHA... 36, 86, 147,

151 VIRT-PN .............. 36, 147, 151 VIRT-PN DHA .... 36, 147, 151 VIRT-SELECT 36, 86, 98, 147,

151 VISCOAT............................. 76 VISIPAQUE ......................... 77 VISTIDE .............................. 12 VISUDYNE ......................... 93 VITAFOL-PLUS .. 36, 148, 152 VITALETS ......................... 148 VITAMENT ............... 148, 152 vitamin a ............................. 148 VITAMIN B-1.................... 152 VITAMIN B-12.................. 152 VITAMIN B-6.................... 152 VITAMIN C ....................... 152 VITAMIN D3 ..................... 153 vitamin e (dl, acetate) ......... 154 VITASPIRE ......... 36, 148, 152 VITRASE ............................. 88 VIVA DHA .......... 36, 148, 152 VIVELLE-DOT ................. 107 VIVITROL ................... 69, 114 VIVOTIF BERNA VACCINE

.......................................... 23 VOLTAREN ........ 71, 140, 143 VOLUMEN .......................... 77 VOLUVEN 6 % ................... 86 voriconazole ........................... 8 VOTRIENT .......................... 20 VP-CH PLUS . 36, 98, 148, 152 VP-CH-PNV......... 36, 148, 152 VP-ERA OB PLUS ..... 36, 148,

152 VP-GGR-B6 ......... 86, 148, 152 VP-PNV-DHA ..... 36, 148, 152 VPRIV .................................. 88 VSL#3 .................................. 99 VUMON ............................... 20 VUSION ............................. 134 VYTORIN 10-10............ 45, 49 VYTORIN 10-20............ 45, 49

VYTORIN 10-40 ............ 45, 49 VYTORIN 10-80 ............ 45, 49 VYVANSE ........................... 55 W warfarin ................................ 31 WART REMOVER ............ 139 water for inject, bacteriostat

........................................ 122 water for irrigation, sterile .... 81 WELCHOL .................. 42, 104 WINRHO SDF ..................... 21 X XELODA.............................. 20 XENAZINE .................... 65, 75 XENICAL ............................ 99 XEOMIN ...................... 30, 121 XERESE ............. 132, 133, 138 XGEVA .............................. 116 XIAFLEX ............................. 88 XIFAXAN ............................ 14 XOLAIR ............................. 126 XOLEGEL.......................... 134 XOLOX .......................... 56, 69 XOPENEX ................... 29, 128 XOPENEX HFA .......... 29, 128 X-SEB T PLUS .................. 140 XULANE............................ 106 XYLOCAINE-

MPF/EPINEPHRINE ...... 24, 114

XYNTHA ............................. 33 XYNTHA SOLOFUSE ........ 33 XYREM................................ 65 Y YF-VAX (PF) ....................... 23 YODOXIN ............................. 4 Z ZALTRAP ............................ 20 ZAMICET ...................... 57, 69 ZANOSAR ........................... 20 ZATEAN-CH .. 36, 86, 98, 148,

152 ZATEAN-PN PLUS ...... 36, 86,

148, 152 ZAVESCA.......................... 121

ZEGERID ........................... 101 ZELAPAR ............................ 66 ZEMPLAR ......................... 153 ZENPEP ............................... 99 ZETIA ................................... 45 ZEVALIN (Y-90) ................. 20 ZIAGEN ............................... 10 zidovudine ............................ 10 ZINACEF ............................... 3 ZINACEF IN STERILE

WATER .............................. 3 zinc gluconate ....................... 86 zinc sulfate ............................ 86 ZINC-15 ............................... 86 ziprasidone hcl ................ 60, 62 ZIPSOR ................................ 71 ZIRGAN ............................... 90 ZMAX .................................. 13 ZOLADEX ........... 20, 108, 109 ZOLINZA ............................. 20 zolpidem ............................... 62 ZOLPIMIST ......................... 62 ZOMETA ........................... 116 ZOMIG ................................. 73 ZOMIG ZMT ........................ 73 ZONEGRAN ........................ 58 zonisamide ............................ 58 ZORBTIVE ........................ 111 ZORTRESS ........................ 120 ZORVOLEX ......................... 71 ZOSTAVAX (PF) ................ 23 ZOSYN IN DEXTROSE (ISO-

OSM) .................................. 9 ZOVIA 1/50E (28) ............. 106 ZOVIRAX .......................... 133 ZUBSOLV ............................ 69 ZUPLENZ ............................ 94 ZYCLARA ......................... 143 ZYDONE ........................ 57, 69 ZYFLO ............................... 125 ZYFLO CR ......................... 125 ZYLET ........................... 90, 91 ZYMAXID ........................... 90 ZYPREXA RELPREVV 60, 62 ZYVOX ................................ 13

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Transcript of SAN FRANCISCO HEALTH PLAN Medicare/ Medi-Cal …diphenhydramine hcl oral tablet 25 mg T1 ED...