Table of Contents - Blue Cross and Blue Shield of …...Vietnamese: Nếu quý vị, hay người...

1

Table of Contents

ANTI - INFECTIVES .......................................................................................................................................... 5

ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS .......................................................................... 12

AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ........................................................................... 17

CARDIOVASCULAR, HYPERTENSION & LIPIDS ..................................................................................... 31

DERMATOLOGICALS/TOPICAL THERAPY ............................................................................................... 39

DIAGNOSTICS & MISCELLANEOUS AGENTS .......................................................................................... 47

EAR, NOSE & THROAT MEDICATIONS...................................................................................................... 49

ENDOCRINE/DIABETES ................................................................................................................................ 50

GASTROENTEROLOGY ................................................................................................................................. 70

IMMUNOLOGY, VACCINES & BIOTECHNOLOGY .................................................................................. 75

MUSCULOSKELETAL & RHEUMATOLOGY ............................................................................................. 78

OBSTETRICS & GYNECOLOGY ................................................................................................................... 79

OPHTHALMOLOGY ........................................................................................................................................ 84

RESPIRATORY, ALLERGY, COUGH & COLD ............................................................................................ 88

UROLOGICALS ................................................................................................................................................ 92

VITAMINS, HEMATINICS & ELECTROLYTES .......................................................................................... 93

Index ................................................................................................................................................................. 103

2

List of Abbreviations

1: Generic

2: Preferred Brand

3: Non Preferred Brand and Specialty Drugs

4: Specialty Drugs

5: Zero Cost Share Preventive Drugs

6: Medical Service Drugs

ACA: Affordable Care Act.

LA: Limited Availability. This prescription may be available only at certain specialty pharmacies. For more

information, please call Customer Service.

M: Maintenance Medications

MSD: Medical Service Drug. This product is only covered under the medical benefit.

OTC: Over the Counter. An OTC drug is a non-prescription drug.

PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs.

This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we

may not cover the drug.

QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.

ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical

condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat

your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for

you, we will then cover Drug B.

3

Discrimination is Against the Law Blue KC complies with applicable Federal civil rights laws and does not discriminate on the basis of

race, color, national origin, age, disability, or sex. Blue KC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Blue KC: • Provides free aids and services to people with disabilities to communicate effectively with

us, such as: ○ Qualified sign language interpreters ○ Written information in other formats (large print, audio, accessible electronic formats,

other formats) • Provides free language services to people whose primary language is not English, such as:

○ Qualified interpreters

○ Information written in other languages

If you need these services, contact Customer Service, 844-395-7126 (Toll free), [email protected].

If you believe that Blue KC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the

Appeals Department, PO Box 419169, Kansas City, MO 64141-6169, 816-395-3537, TTY: 816-842-5607, [email protected]. You can file a grievance in person or by mail, or email. If you need help filing a grievance, the Appeals Department is available to help you. You can also file a civil rights

complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW

Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

If you, or someone you’re helping, has questions about Blue KC, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-844-395-7126.

Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Blue KC, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-844-395-7126.

Chinese: 如果您，或是您正在協助的對象，有關於 Blue KC方面的問題，您有權利免費以您的母語得到幫助和

訊息。洽詢一位翻譯員，請撥電話1-844-395-7126。

Vietnamese: Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Blue KC, quý vị sẽ có

quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-844-395-7126.

German: Falls Sie oder jemand, dem Sie helfen, Fragen zum Blue KC haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-844-395-7126 an.

mailto:[email protected]

http://www.hhs.gov/ocr/office/file/index.html

4

Korean: 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 [Blue KC]에 관해서 질문이 있다면 귀하는 그러한 도움과

정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1-844-

395-7126 로 전화하십시오.

Serbo-Croatian: Ukoliko Vi ili neko kome Vi pomažete ima pitanje o Blue KC, imate pravo da

besplatno dobijete pomoć i informacije na Vašem jeziku. Da biste razgovarali sa prevodiocem, nazovite 1-844-395-7126.

Arabic: الضرورية بلغتك من دون اية تكلفة. للتحدث ، فلديك الحق في الحصول على المساعدة والمعلومات Blue KC إن كان لديك أو لدى شخص تساعده أسئلة بخصوص

.7126-395-844-1. مع مترجم اتصل بـ

Russian: Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Blue KC, то

вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону1-844-395-7126.

French: Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Blue KC, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-844-395-7126.

Tagalog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Blue KC, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang

makausap ang isang tagasalin, tumawag sa1-844-395-7126.

Laotian: ຖ້ າທ່ ານ, ຫ ຼື ຄົນ ່່ ທທ່ ານກໍ າລັງຊ່ ວຍເຫ ຼື ອ, ມ ໍ່ ຄາຖາມກ່ ຽວກັບ Blue KC, ທ່ ານມ ່ ສດ ່່ ທຈະໄດ້ຮັບການຊ່

ວຍເຫ ຼື ອແລະ່ໍ ຂ້ ມູ ນຂ່ າວສານ ່່ ທເປັ ນພາສາຂອງທ່ ານໍ ່່ ບມ ຄ່ າໃຊ້ຈ່ າຍ. ການໂອ້ລົມກັບນາຍພາສາ, ໃຫ້ ໂທຫາ 1-

844-395-7126. Pennsylvanian Dutch: “Wann du hoscht en Froog, odder ebber, wu du helfscht, hot en Froog baut

Blue KC, hoscht du es Recht fer Hilf un Information in deinre eegne Schprooch griege, un die Hilf koschtet nix. Wann du mit me Interpreter schwetze witt, kannscht du 1-844-395-7126 uffrufe.

Persian: کمکو اطالعات بە زبان خود را بە طور رايگان ، داشتە باشيد حق اين را داريد کە Blue KC اگر شما، يا کسی کە شما بە او کمک ميکنيد ، سوال در مورد

.تماس حاصل نماييد 7126-395-844-1.دريافت نماييد

Cushite: Isin yookan namni biraa isin deeggartan Blue KC irratti gaaffii yo qabaattan, kaffaltii irraa bilisa haala ta’een afaan keessaniin odeeffannoo argachuu fi deeggarsa argachuuf mirga ni qabdu.

Nama isiniif ibsu argachuuf, lakkoofsa bilbilaa 1-844-395-7126 tiin bilbilaa. Portuguese: Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Blue KC, você

tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-844-395-7126.

For TTY services, please call 1-816-842-5607

You can get more information on our website at www.bluekc.com. Blue KC and Express Scripts are not

affiliated companies.

5

Drug Name Drug

Tier

Requirements

/ Limits

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

AMBISOME 6 MSD

amphotericin b 6 MSD

ANCOBON 3

CANCIDAS 6 MSD

clotrimazole 1

CRESEMBA

INTRAVENOUS

6 MSD

CRESEMBA ORAL 2

DIFLUCAN ORAL

SUSPENSION FOR

RECONSTITUTIO

N

3

DIFLUCAN ORAL

TABLET 100 MG,

200 MG, 50 MG

3

DIFLUCAN ORAL

TABLET 150 MG

3 QL

ERAXIS(WATER

DILUENT)

6 MSD

fluconazole in

dextrose(iso-o)

6 MSD

fluconazole in nacl

(iso-osm)

6 MSD

fluconazole oral

suspension for

reconstitution

1

fluconazole oral

tablet 100 mg, 200

mg, 50 mg

1

fluconazole oral

tablet 150 mg

1 QL

flucytosine 1

Drug Name Drug

Tier

Requirements

/ Limits

griseofulvin

microsize

1

griseofulvin

ultramicrosize

1

GRIS-PEG

(ULTRAMICROSIZ

E)

3

itraconazole 1 QL

ketoconazole 1

LAMISIL 3

NOXAFIL 2

nystatin 1

ONMEL 3 QL

ORAVIG 3

SPORANOX 2

SPORANOX

PULSEPAK

3 QL

terbinafine hcl 1

VFEND 3

voriconazole 1

ANTIVIRALS

abacavir 1 LA

abacavir-

lamivudine-

zidovudine

1 LA

acyclovir 1

adefovir 1

amantadine hcl 1 M

APTIVUS 2 LA

ATRIPLA 2 LA

BARACLUDE

ORAL SOLUTION

2



6

Drug Name Drug

Tier

Requirements

/ Limits

BARACLUDE

ORAL TABLET

3

cidofovir 6 MSD

COMBIVIR 3 LA

COMPLERA 2 LA

CRIXIVAN 2 LA

DAKLINZA 3 LA

DESCOVY 3 LA

didanosine 1 LA

EDURANT 2 LA

EMTRIVA 2 LA

entecavir 1

EPCLUSA 4 ST; LA

EPIVIR HBV

ORAL SOLUTION

2

EPIVIR HBV

ORAL TABLET

3

EPIVIR ORAL

SOLUTION

2 LA

EPIVIR ORAL

TABLET

3 LA

EPZICOM 2 LA

EVOTAZ 3 LA

famciclovir 1 QL

FAMVIR 3 QL

FLUMADINE 3

foscarnet 6 MSD

FOSCAVIR 6 MSD

FUZEON 3 LA

GENVOYA 2 LA

HARVONI 4 PA; ST; LA;

QL

Drug Name Drug

Tier

Requirements

/ Limits

HEPSERA 3

INTELENCE 2 LA

INVIRASE 2 LA

ISENTRESS 2 LA

KALETRA 2 LA

lamivudine oral

solution

1 LA

lamivudine oral

tablet 100 mg

1

lamivudine oral

tablet 150 mg, 300

mg

1 LA

lamivudine-

zidovudine

1 LA

LEXIVA 2 LA

nevirapine 1 LA

NORVIR 2 LA

ODEFSEY 3 LA

OLYSIO 3 ST; LA; QL

PREZCOBIX 3 LA

PREZISTA 2 LA

RELENZA

DISKHALER

2 QL

RESCRIPTOR 2 LA

RETROVIR 3 LA

REYATAZ 2 LA

rimantadine 1

SELZENTRY 2 PA; LA

SITAVIG 3 QL

SOVALDI 3 ST; LA; QL

stavudine 1 LA

STRIBILD 2 LA



7

Drug Name Drug

Tier

Requirements

/ Limits

SUSTIVA 2 LA

SYNAGIS 6 MSD

TAMIFLU 2 QL

TECHNIVIE 3 LA

TIVICAY ORAL

TABLET 10 MG, 25

MG

3 LA

TIVICAY ORAL

TABLET 50 MG

2 LA

TRIUMEQ 2 LA

TRIZIVIR 3 LA

TRUVADA 2 LA

TYBOST 3 LA

TYZEKA 2

valacyclovir 1 QL

VALCYTE ORAL

RECON SOLN

2

VALCYTE ORAL

TABLET

3

valganciclovir 1

VALTREX 3 QL

VIDEX 2 GRAM

PEDIATRIC

2 LA

VIDEX EC 3 LA

VIEKIRA PAK 3 PA; LA; QL

VIEKIRA XR 4 PA; LA

VIRACEPT 2 LA

VIRAMUNE 3 LA

VIRAMUNE XR 3 LA

VIRAZOLE 4 LA

VIREAD 2 LA

VITEKTA 3 LA

Drug Name Drug

Tier

Requirements

/ Limits

ZEPATIER 4 ST; LA

ZERIT 3 LA

ZIAGEN ORAL

SOLUTION

2 LA

ZIAGEN ORAL

TABLET

3 LA

zidovudine 1 LA

ZOVIRAX 3

CEPHALOSPORINS

AVYCAZ 6 MSD

CEDAX 3

cefaclor 1

cefadroxil 1

cefazolin 6 MSD

cefdinir 1

cefditoren pivoxil 1

cefepime 6 MSD

cefepime in

dextrose,iso-osm

6 MSD

cefixime 1

cefotaxime 6 MSD

cefotetan 6 MSD

cefoxitin 6 MSD

cefpodoxime 1

cefprozil 1

ceftibuten 1

CEFTIN 3

ceftriaxone in

dextrose,iso-os

6 MSD

ceftriaxone injection

recon soln 1 gram,

10 gram, 2 gram,

250 mg, 500 mg

6 MSD



8

Drug Name Drug

Tier

Requirements

/ Limits

CEFTRIAXONE

INJECTION

RECON SOLN 100

GRAM

6 MSD

cefuroxime axetil 1

cefuroxime sodium 6 MSD

cephalexin 1

CLAFORAN 6 MSD

CLAFORAN IN

DEXTROSE(ISO-

OSM)

6 MSD

KEFLEX 3

MAXIPIME 6 MSD

SPECTRACEF 3

SUPRAX 3

TAZICEF 6 MSD

TEFLARO 6 MSD

ZINACEF 6 MSD

ERYTHROMYCINS & OTHER

MACROLIDES

azithromycin 1

BIAXIN 3

clarithromycin 1

DIFICID 3

e.e.s. 400 1

E.E.S. GRANULES 2

ERYPED 200 2

ERYPED 400 2

ery-tab oral

tablet,delayed

release (dr/ec) 250

mg, 333 mg

1

Drug Name Drug

Tier

Requirements

/ Limits

ERY-TAB ORAL

TABLET,DELAYE

D RELEASE

(DR/EC) 500 MG

2

erythrocin (as

stearate)

1

erythromycin 1

erythromycin

ethylsuccinate

1

PCE 3

ZITHROMAX 3

ZMAX 3

MISCELLANEOUS

ANTIINFECTIVES

ALBENZA 2

ALINIA 2

amikacin 6 MSD

atovaquone 1

atovaquone-

proguanil

1

BETHKIS 6 MSD; QL

BILTRICIDE 3

CAPASTAT 6 MSD

CAYSTON 3 LA; QL

chloramphenicol sod

succinate

6 MSD

chloroquine

phosphate

1

CLEOCIN

INJECTION

6 MSD

CLEOCIN ORAL 3

clindamycin hcl 1

clindamycin

palmitate hcl

1



9

Drug Name Drug

Tier

Requirements

/ Limits

clindamycin

pediatric

1

clindamycin

phosphate

6 MSD

COARTEM 2

colistin

(colistimethate na)

6 MSD

COLY-MYCIN M

PARENTERAL

6 MSD

CUBICIN 6 MSD

CYCLOSERINE 3

dapsone 1 M

DARAPRIM 2 LA

DORIBAX 6 MSD

EMVERM 2

ethambutol 1

FLAGYL 3

FLAGYL ER 3

gentamicin 1 MSD

gentamicin in nacl

(iso-osm)

intravenous

piggyback 100

mg/100 ml, 60 mg/50

ml, 70 mg/50 ml, 80

mg/100 ml, 80 mg/50

ml, 90 mg/100 ml

1

GENTAMICIN IN

NACL (ISO-OSM)

INTRAVENOUS

PIGGYBACK 100

MG/50 ML, 120

MG/100 ML

3

gentamicin sulfate

(ped) (pf)

1

Drug Name Drug

Tier

Requirements

/ Limits

gentamicin sulfate

(pf) intravenous

solution 100 mg/10

ml

1

GENTAMICIN

SULFATE (PF)

INTRAVENOUS

SOLUTION 60

MG/6 ML

3

hydroxychloroquine 1 M

imipenem-cilastatin 6 MSD

IMPAVIDO 3 LA

INVANZ 6 MSD

isoniazid 1

ivermectin 1

KETEK 3

KITABIS PAK 3 LA

LINCOCIN 6 MSD

linezolid 1 PA

MALARONE 3

MALARONE

PEDIATRIC

3

mefloquine 1

MEPRON 3

meropenem 6 MSD

MERREM 6 MSD

metro i.v. 6 MSD

metronidazole 1

metronidazole in

nacl (iso-os)

6 MSD

MYAMBUTOL 3

MYCOBUTIN 3

NEBUPENT 2 QL



10

Drug Name Drug

Tier

Requirements

/ Limits

neomycin 1

paromomycin 1

PASER 3

PLAQUENIL 3 M

polymyxin b sulfate 6 MSD

PRIFTIN 2

PRIMAQUINE 3 M

PRIMAXIN IV 6 MSD

pyrazinamide 1

QUALAQUIN 3

quinine sulfate 1

rifabutin 1

RIFADIN 3

RIFAMATE 3

rifampin 1

RIFATER 3

SIRTURO 2

SIVEXTRO 3 PA

STREPTOMYCIN 6 MSD

STROMECTOL 2

TINDAMAX 3

tinidazole 1

TOBI 3 QL

TOBI PODHALER 2 QL

tobramycin in 0.225

% nacl

1 QL

TRECATOR 3

TYGACIL 6 MSD

XIFAXAN 2

ZYVOX

INTRAVENOUS

6 MSD

Drug Name Drug

Tier

Requirements

/ Limits

ZYVOX ORAL 2 PA

PENICILLINS

amoxicillin oral

capsule

1

amoxicillin oral

suspension for

reconstitution

1

amoxicillin oral

tablet

1

AMOXICILLIN

ORAL TABLET,

ER MULTIPHASE

24 HR

3

amoxicillin oral

tablet,chewable

1

amoxicillin-pot

clavulanate

1

ampicillin 1

ampicillin sodium 6 MSD

ampicillin-sulbactam 6 MSD

AUGMENTIN ES-

600

3

AUGMENTIN

ORAL

SUSPENSION FOR

RECONSTITUTIO

N 125-31.25 MG/5

ML

2

AUGMENTIN

ORAL

SUSPENSION FOR

RECONSTITUTIO

N 250-62.5 MG/5

ML

3

AUGMENTIN

ORAL TABLET

3

AUGMENTIN XR 3



11

Drug Name Drug

Tier

Requirements

/ Limits

BICILLIN C-R 6 MSD

dicloxacillin 1

MOXATAG 3

nafcillin 6 MSD

oxacillin 6 MSD

oxacillin in

dextrose(iso-osm)

6 MSD

penicillin g

potassium

6 MSD

penicillin v

potassium

1

pfizerpen-g 6 MSD

piperacillin-

tazobactam

6 MSD

UNASYN 6 MSD

QUINOLONES

AVELOX 3

AVELOX ABC

PACK

3

CIPRO 3

CIPRO XR 3

ciprofloxacin 1

ciprofloxacin

(mixture)

1

ciprofloxacin hcl 1

FACTIVE 3

LEVAQUIN 3

levofloxacin in d5w 6 MSD

levofloxacin

intravenous

6 MSD

levofloxacin oral 1

moxifloxacin 1

ofloxacin 1

Drug Name Drug

Tier

Requirements

/ Limits

SULFA'S & RELATED AGENTS

BACTRIM 3

BACTRIM DS 3

sulfadiazine 1

sulfamethoxazole-

trimethoprim

1

sulfatrim 1

TETRACYCLINES

ACTICLATE 3 ST

avidoxy 1

AVIDOXY DK 3 ST

BENZODOX 30 3

BENZODOX 60 3

demeclocycline 1

DORYX 3 ST

DORYX MPC 3 ST

doxycycline hyclate 1

doxycycline

monohydrate oral

capsule

1

DOXYCYCLINE

MONOHYDRATE

ORAL

CAPSULE,IR -

DELAY

REL,BIPHASE

3 ST

doxycycline

monohydrate oral

suspension for

reconstitution

1

doxycycline

monohydrate oral

tablet

1

MINOCIN 3 ST

minocycline 1



12

Drug Name Drug

Tier

Requirements

/ Limits

mondoxyne nl 1

MONODOX 3 ST

morgidox 1

MORGIDOX 2X100 3 ST

ORACEA 3 ST

SOLODYN 3 ST

tetracycline 1

VIBRAMYCIN

ORAL CAPSULE

3 ST

VIBRAMYCIN

ORAL

SUSPENSION FOR

RECONSTITUTIO

N

3

VIBRAMYCIN

ORAL SYRUP

3

URINARY TRACT AGENTS

FURADANTIN 3

MACROBID 3

MACRODANTIN 3

methenamine

hippurate

1

methenamine

mandelate

1

MONUROL 3

nitrofurantoin 1

nitrofurantoin

macrocrystal

1

nitrofurantoin

monohyd/m-cryst

1

PRIMSOL 3

trimethoprim 1

VANCOMYCIN

VANCOCIN 3

Drug Name Drug

Tier

Requirements

/ Limits

VANCOMYCIN IN

DEXTROSE 5 %

6 MSD

vancomycin

intravenous

6 MSD

vancomycin oral 1

VIBATIV 6 MSD

ANTINEOPLASTIC &

IMMUNOSUPPRESSANT

DRUGS

ADJUNCTIVE AGENTS

amifostine

crystalline

6 MSD

dexrazoxane hcl 6 MSD

ELITEK 6 MSD

FUSILEV 6 MSD

KEPIVANCE 6 MSD

leucovorin calcium

injection

1 LA

leucovorin calcium

oral

1

levoleucovorin

calcium

6 MSD

mesna 6 MSD

MESNEX

INTRAVENOUS

6 MSD

MESNEX ORAL 2

VISTOGARD 2

VORAXAZE 6 MSD

XGEVA 6 MSD

ZINECARD (AS

HCL)

6 MSD

ANTINEOPLASTIC &

IMMUNOSUPPRESSANT DRUGS



13

Drug Name Drug

Tier

Requirements

/ Limits

ABRAXANE 6 MSD

ADCETRIS 6 MSD

adrucil 6 MSD

AFINITOR 2

AFINITOR

DISPERZ

2

ALECENSA 3

ALKERAN

INTRAVENOUS

6 MSD

ALKERAN ORAL 2

anastrozole 1

ARIMIDEX 3

AROMASIN 3

ARRANON 6 MSD

ARZERRA 6 MSD

ASTAGRAF XL 3

AVASTIN 6 MSD

azacitidine 6 MSD

AZASAN 2

azathioprine 1

BELEODAQ 6 MSD

BENDEKA 6 MSD

bexarotene 1

bicalutamide 1

BICNU 6 MSD

bleomycin 6 MSD

BOSULIF 3 LA

BUSULFEX 6 MSD

CABOMETYX 3

CAMPATH 6 MSD

CAMPTOSAR 6 MSD

Drug Name Drug

Tier

Requirements

/ Limits

capecitabine 1

CAPRELSA 2

carboplatin 6 MSD

CASODEX 3

CELLCEPT

INTRAVENOUS

6 MSD

CELLCEPT ORAL

CAPSULE

3

CELLCEPT ORAL

SUSPENSION FOR

RECONSTITUTIO

N

2

cisplatin 6 MSD

cladribine 6 MSD

CLOLAR 6 MSD

COMETRIQ 3

COSMEGEN 6 MSD

COTELLIC 3

cyclophosphamide

intravenous

6 MSD

CYCLOPHOSPHA

MIDE ORAL

2

cyclosporine

intravenous

1 LA

cyclosporine

modified

1

cyclosporine oral 1

CYRAMZA 6 MSD

cytarabine 6 MSD

cytarabine (pf) 6 MSD

dacarbazine 6 MSD

DACOGEN 6 MSD

daunorubicin 6 MSD



14

Drug Name Drug

Tier

Requirements

/ Limits

decitabine 6 MSD

DOCEFREZ 6 MSD

docetaxel 6 MSD

DOXIL 6 MSD

doxorubicin 6 MSD

doxorubicin, peg-

liposomal

6 MSD

DROXIA 2

ELIGARD 3 LA

ELIGARD (3

MONTH)

3 LA

ELIGARD (4

MONTH)

3 LA

ELIGARD (6

MONTH)

3 LA

ELLENCE 6 MSD

EMCYT 2

ENVARSUS XR 3

epirubicin 6 MSD

ERBITUX 6 MSD

ERIVEDGE 2 LA

ERWINAZE 6 MSD

etoposide

intravenous

6 MSD

etoposide oral 1

EVOMELA 6 MSD

exemestane 1

FARESTON 2

FARYDAK 3

FASLODEX 6 MSD

FEMARA 3

Drug Name Drug

Tier

Requirements

/ Limits

FIRMAGON KIT W

DILUENT

SYRINGE

4 LA

floxuridine 6 MSD

fludarabine 6 MSD

fluorouracil 6 MSD

flutamide 1

FOLOTYN 6 MSD

GAZYVA 6 MSD

gemcitabine 6 MSD

GEMZAR 6 MSD

gengraf 1

GILOTRIF 2

GLEEVEC 3

GLEOSTINE 2

GLIADEL WAFER 3

HERCEPTIN 6 MSD

HEXALEN 2

HYCAMTIN

INTRAVENOUS

6 MSD

HYCAMTIN ORAL 3 LA

HYDREA 3

hydroxyurea 1

IBRANCE 2

ICLUSIG 3 LA

IDAMYCIN PFS 6 MSD

idarubicin 6 MSD

IFEX 6 MSD

ifosfamide 6 MSD

ifosfamide-mesna 6 MSD

imatinib 1

IMBRUVICA 3 LA



15

Drug Name Drug

Tier

Requirements

/ Limits

IMURAN 3

INLYTA 3 LA

IRESSA 2

irinotecan 6 MSD

ISTODAX 6 MSD

IXEMPRA 6 MSD

JAKAFI 3 LA

JEVTANA 6 MSD

KADCYLA 6 MSD

KYPROLIS 6 MSD

LENVIMA 2

letrozole 1

LEUKERAN 2

leuprolide 1 LA

lipodox 50 6 MSD

LONSURF 3

LUPRON DEPOT

(3 MONTH)

INTRAMUSCULA

R SYRINGE KIT

11.25 MG

3 LA

LUPRON DEPOT

(3 MONTH)

INTRAMUSCULA

R SYRINGE KIT

22.5 MG

4 LA

LUPRON DEPOT

(4 MONTH)

4 LA

LUPRON DEPOT

(6 MONTH)

4 LA

LUPRON DEPOT

INTRAMUSCULA

R SYRINGE KIT

3.75 MG

3 LA

Drug Name Drug

Tier

Requirements

/ Limits

LUPRON DEPOT

INTRAMUSCULA

R SYRINGE KIT

7.5 MG

4 LA

LUPRON DEPOT-

PED

3 LA

LYNPARZA 2 LA

LYSODREN 2

MARQIBO 6 MSD

MATULANE 2

MEGACE 3

MEGACE ES 3

megestrol 1

MEKINIST 2

melphalan hcl 6 MSD

mercaptopurine 1

methotrexate sodium 1

methotrexate sodium

(pf)

1

mitomycin 6 MSD

mitoxantrone 6 MSD

MUSTARGEN 6 MSD

mycophenolate

mofetil

1

mycophenolate

sodium

1

MYFORTIC 3

MYLERAN 3 LA

NAVELBINE 6 MSD

NEORAL 3

NEXAVAR 2

NILANDRON 3

NINLARO 2



16

Drug Name Drug

Tier

Requirements

/ Limits

NIPENT 6 MSD

NULOJIX 6 MSD

octreotide acetate 1 LA

ODOMZO 3

ONCASPAR 6 MSD

OPDIVO 6 MSD

oxaliplatin 6 MSD

paclitaxel 6 MSD

PERJETA 6 MSD

PORTRAZZA 6 MSD

PROGRAF 3

PURIXAN 3 LA

RAPAMUNE 2

RITUXAN 6 MSD

SANDIMMUNE

INTRAVENOUS

4 LA

SANDIMMUNE

ORAL CAPSULE

3

SANDIMMUNE

ORAL SOLUTION

2

SANDOSTATIN 4 LA

SANDOSTATIN

LAR DEPOT

6 MSD

SIGNIFOR 6 MSD

SIMULECT 6 MSD

sirolimus 1

SOLTAMOX 3

SOMATULINE

DEPOT

4 LA

SPRYCEL 2

STIVARGA 2

SUPPRELIN LA 6 MSD

Drug Name Drug

Tier

Requirements

/ Limits

SUTENT 2

SYLVANT 6 MSD

SYNRIBO 6 MSD

TABLOID 2

tacrolimus 1

TAFINLAR 2

TAGRISSO 2

tamoxifen 1

TARCEVA 2

TARGRETIN

ORAL

3

TARGRETIN

TOPICAL

2

TASIGNA 2

TAXOTERE 6 MSD

TEMODAR 3

temozolomide 1

TENIPOSIDE 6 MSD

THALOMID 2

thiotepa 6 MSD

toposar 6 MSD

topotecan 6 MSD

TORISEL 6 MSD

TREANDA 6 MSD

TRELSTAR 6 MSD

tretinoin

(chemotherapy)

1

TREXALL 2

TRISENOX 6 MSD

TYKERB 2

VANTAS 6 MSD

VECTIBIX 6 MSD



17

Drug Name Drug

Tier

Requirements

/ Limits

VELCADE 6 MSD

VENCLEXTA 2

VENCLEXTA

STARTING PACK

2

VIDAZA 6 MSD

vinblastine 6 MSD

vincasar pfs 6 MSD

vincristine 6 MSD

vinorelbine 6 MSD

VOTRIENT 2

XALKORI 2

XELODA 3

XTANDI 2

YERVOY 6 MSD

ZALTRAP 6 MSD

ZANOSAR 6 MSD

ZELBORAF 2

ZOLADEX 6 MSD

ZOLINZA 2

ZORTRESS 2

ZYDELIG 2

ZYKADIA 2 LA

ZYTIGA 2

AUTONOMIC & CNS DRUGS,

NEUROLOGY & PSYCH

ANTICONVULSANTS

ACTIVE-PAC 3 M

APTIOM 3

BANZEL 2

BRIVIACT 3 ST

carbamazepine 1

Drug Name Drug

Tier

Requirements

/ Limits

CARBATROL 3

CELONTIN 2

clonazepam 1

DEPAKENE 3 PA

DEPAKOTE 3 PA

DEPAKOTE ER 3 PA

DEPAKOTE

SPRINKLES

3 PA

DIASTAT 3

DIASTAT

ACUDIAL

3

diazepam 1

DILANTIN 2

DILANTIN

EXTENDED

3

DILANTIN

INFATABS

3

DILANTIN-125 3

divalproex 1

epitol 1

EQUETRO 3

ethosuximide 1

felbamate 1

FELBATOL 3

fosphenytoin 6 MSD

FYCOMPA 3

gabapentin 1

GABITRIL ORAL

TABLET 12 MG, 16

MG

2

GABITRIL ORAL

TABLET 2 MG, 4

MG

3



18

Drug Name Drug

Tier

Requirements

/ Limits

GRALISE 3 ST

GRALISE 30-DAY

STARTER PACK

3 ST

KEPPRA 3 ST

KEPPRA XR 3 ST

KLONOPIN 3

LAMICTAL 3 ST

LAMICTAL ODT 3 ST

LAMICTAL ODT

STARTER (BLUE)

3 ST

LAMICTAL ODT

STARTER

(GREEN)

3 ST

LAMICTAL ODT

STARTER

(ORANGE)

3 ST

LAMICTAL

STARTER (BLUE)

KIT

3 ST

LAMICTAL

STARTER

(GREEN) KIT

3 ST

LAMICTAL

STARTER

(ORANGE) KIT

3 ST

LAMICTAL XR 3 ST

LAMICTAL XR

STARTER (BLUE)

3 ST

LAMICTAL XR

STARTER

(GREEN)

3 ST

LAMICTAL XR

STARTER

(ORANGE)

3 ST

lamotrigine 1

levetiracetam 1

Drug Name Drug

Tier

Requirements

/ Limits

LYRICA 2 ST

MYSOLINE 3

NEURONTIN 3 ST

ONFI 2

oxcarbazepine 1

OXTELLAR XR 3 ST

PEGANONE 2

phenobarbital 1

PHENYTEK 3

phenytoin 1

phenytoin sodium

extended

1

POTIGA 2

primidone 1

QUDEXY XR 3

roweepra 1

SABRIL 3 LA

SMARTRX

GABAKIT

3 M

SMARTRX GABA-

V KIT

3 M

SPRITAM 3 ST

TEGRETOL 3

TEGRETOL XR 3

tiagabine 1

TOPAMAX 3

topiramate oral

capsule, sprinkle

1

TOPIRAMATE

ORAL

CAPSULE,SPRINK

LE,ER 24HR

3



19

Drug Name Drug

Tier

Requirements

/ Limits

topiramate oral

tablet

1

TRILEPTAL 3 ST

TROKENDI XR 3

valproic acid 1

valproic acid (as

sodium salt)

1

VIMPAT 2

ZARONTIN 3

ZONEGRAN 3

zonisamide 1

ANTIPARKINSONISM AGENTS

APOKYN 2 LA

AZILECT 3 M

benztropine 1

bromocriptine 1

carbidopa 1 M

carbidopa-levodopa 1 M

carbidopa-levodopa-

entacapone

1 M

COMTAN 3 M

DUOPA 6 MSD; M

ELDEPRYL 3 M

entacapone 1 M

LODOSYN 3 M

MIRAPEX 3 M

MIRAPEX ER 3 M

NEUPRO 3 M

PARLODEL 3

pramipexole 1 M

REQUIP 3 M

Drug Name Drug

Tier

Requirements

/ Limits

REQUIP XL 3 M

ropinirole 1 M

RYTARY 3 M

selegiline hcl 1 M

SINEMET 3 M

SINEMET CR 3 M

STALEVO 100 3 M

STALEVO 125 3 M

STALEVO 150 3 M

STALEVO 200 3 M

STALEVO 50 3 M

STALEVO 75 3 M

TASMAR 2 M

tolcapone 1 M

trihexyphenidyl 1

ZELAPAR 3 M

MIGRAINE & CLUSTER

HEADACHE THERAPY

almotriptan malate 1 QL

ALSUMA 3 QL

AMERGE 3 ST; QL

AXERT 3 ST; QL

CAFERGOT 3

D.H.E.45 3

dihydroergotamine

injection

1

dihydroergotamine

nasal

1 QL

ERGOMAR 3

frovatriptan 1 QL

IMITREX NASAL 3 QL



20

Drug Name Drug

Tier

Requirements

/ Limits

IMITREX ORAL 3 ST; QL

IMITREX

STATDOSE KIT

REFILL

3 QL

IMITREX

STATDOSE PEN

3 QL

IMITREX

SUBCUTANEOUS

3 QL

isometh-dichloral-

acetaminophn

1

isomethepten-caf-

acetaminophen

1

MAXALT 3 ST; QL

MAXALT-MLT 3 ST; QL

migergot 1

MIGRANAL 3 QL

MIGRANOW 3

naratriptan 1 QL

nodolor 1

ONZETRA XSAIL 3 QL

PRODRIN 3

RELPAX 3 ST; QL

rizatriptan 1 QL

sumatriptan 1 QL

sumatriptan

succinate

1 QL

SUMAVEL

DOSEPRO

3 QL

TREXIMET 3 ST; QL

ZEMBRACE

SYMTOUCH

3 QL

zolmitriptan 1 QL

ZOMIG 2 QL

Drug Name Drug

Tier

Requirements

/ Limits

ZOMIG ZMT 3 ST; QL

MISCELLANEOUS

NEUROLOGICAL THERAPY

AMPYRA 3 LA

ARICEPT 3 ST; M

donepezil oral tablet

10 mg, 5 mg

1 M

donepezil oral tablet

23 mg

1 ST; M

donepezil oral

tablet,disintegrating

1 M

EXELON 3 ST; M

galantamine 1 M

HORIZANT 3 ST

KEVEYIS 3 PA

memantine oral

solution

1 M

memantine oral

tablet

1 M

MEMANTINE

ORAL

TABLETS,DOSE

PACK

3 M

NAMENDA 3 ST; M

NAMENDA

TITRATION PAK

2 M

NAMENDA XR

ORAL

CAP,SPRINKLE,E

R 24HR DOSE

PACK

2 M

NAMENDA XR

ORAL

CAPSULE,SPRINK

LE,ER 24HR

2 ST; M

NAMZARIC 3 ST



21

Drug Name Drug

Tier

Requirements

/ Limits

NUEDEXTA 2 PA

RAZADYNE 3 ST; M

RAZADYNE ER 3 ST; M

rivastigmine 1 M

rivastigmine tartrate 1 M

tetrabenazine 1 PA

TYSABRI 6 MSD

XENAZINE 3 PA

MUSCLE RELAXANTS &

ANTISPASMODIC THERAPY

AMRIX 3

baclofen 1 M

carisoprodol 1

carisoprodol-asa-

codeine

1

carisoprodol-aspirin 1

chlorzoxazone 1

cyclobenzaprine 1

DANTRIUM 3 M

dantrolene 1 M

FEXMID 3

LORZONE 3

meprobamate 1

MESTINON ORAL

SYRUP

2 M

MESTINON ORAL

TABLET

3 M

MESTINON

TIMESPAN

2 M

metaxall 1

metaxalone 1

methocarbamol 1

Drug Name Drug

Tier

Requirements

/ Limits

orphenadrine citrate 1

PARAFON FORTE

DSC

3

pyridostigmine

bromide

1 M

ROBAXIN 3

ROBAXIN-750 3

SKELAXIN 3

SOMA 3

tizanidine 1 M

ZANAFLEX 3 M

NARCOTIC ANALGESICS

ABSTRAL 3 PA; QL

acetaminophen-caff-

dihydrocod

1

acetaminophen-

codeine

1

ACTIQ 3 PA; QL

ALLZITAL 3

ascomp with codeine 1

aspirin-caffeine-

dihydrocodein

1

BELBUCA 3

BUPAP 3

buprenorphine hcl 1

butalbital compound

w/codeine

1

butalbital-

acetaminop-caf-cod

1

butalbital-

acetaminophen

1

butalbital-

acetaminophen-caff

1



22

Drug Name Drug

Tier

Requirements

/ Limits

butalbital-aspirin-

caffeine

1

BUTRANS 3

capacet 1

CAPITAL WITH

CODEINE

3

codeine sulfate 1

codeine-butalbital-

asa-caff

1

DEMEROL 3

DILAUDID 3

diskets 1

DOLOPHINE 3

DURAGESIC 3

EMBEDA 3 ST; QL

endocet 1

ESGIC 3

EXALGO ER 3 ST; QL

fentanyl citrate 1 PA; QL

fentanyl transdermal

patch 72 hour 100

mcg/hr, 12 mcg/hr,

25 mcg/hr, 50

mcg/hr, 75 mcg/hr

1

FENTANYL

TRANSDERMAL

PATCH 72 HOUR

37.5 MCG/HOUR,

62.5 MCG/HOUR,

87.5 MCG/HOUR

3

FENTANYL-

BUPIVACAINE-

NACL (PF)

6 MSD

FENTORA 3 PA; QL

FIORICET 3

Drug Name Drug

Tier

Requirements

/ Limits

FIORICET WITH

CODEINE

3

FIORINAL 3

FIORINAL-

CODEINE #3

3

HYCET 3

hydrocodone-

acetaminophen

1

hydrocodone-

ibuprofen

1

hydromorphone oral

liquid

1

hydromorphone oral

tablet

1

hydromorphone oral

tablet extended

release 24 hr

1 QL

hydromorphone

rectal

1

HYSINGLA ER 3 ST; QL

IBUDONE 3

ibuprofen-oxycodone 1

IONSYS 3

KADIAN 3 ST; QL

LAZANDA 3 PA; QL

levorphanol tartrate 1

lorcet (hydrocodone) 1

lorcet hd 1

lorcet plus 1

lortab 10-325 1

lortab 5-325 1

lortab 7.5-325 1

LORTAB ELIXIR 3



23

Drug Name Drug

Tier

Requirements

/ Limits

margesic 1

marten-tab 1

meperidine 1

methadone 1

methadose 1

morphine

concentrate

1

morphine injection 6 MSD

morphine

intravenous

6 MSD

morphine oral

capsule, er

multiphase 24 hr

1 QL

morphine oral

capsule,extend.relea

se pellets

1 QL

morphine oral

solution

1

morphine oral tablet 1

morphine oral tablet

extended release

1 QL

morphine rectal 1

MS CONTIN 3 ST; QL

NORCO 3

OPANA 3

OPANA ER 3 ST; QL

OXAYDO 3

oxycodone oral

capsule

1

oxycodone oral

concentrate

1

oxycodone oral

solution

1

Drug Name Drug

Tier

Requirements

/ Limits

oxycodone oral

tablet

1

OXYCODONE

ORAL

TABLET,ORAL

ONLY,EXT.REL.12

HR

3 ST; QL

oxycodone-

acetaminophen

1

oxycodone-aspirin 1

OXYCONTIN 3 ST; QL

oxymorphone oral

tablet

1

oxymorphone oral

tablet extended

release 12 hr

1 QL

PERCOCET 3

PRIMLEV 3

PROBUPHINE 6 MSD

reprexain 1

ROXICODONE 3

SUBSYS 3 PA; QL

SYNALGOS-DC 3

tencon 1

TREZIX 3

TYLENOL-

CODEINE #3

3

TYLENOL-

CODEINE #4

3

VANATOL LQ 3

verdrocet 1

vicodin 1

vicodin es 1

vicodin hp 1



24

Drug Name Drug

Tier

Requirements

/ Limits

XARTEMIS XR 3

XODOL 10/300 3

XODOL 5/300 3

XODOL 7.5/300 3

XTAMPZA ER 3 ST; QL

xylon 10 1

zamicet 1

zebutal 1

ZOHYDRO ER 3 ST; QL

NON-NARCOTIC ANALGESICS

ANAPROX DS 3 ST; M

ARTHROTEC 50 3 ST; M

ARTHROTEC 75 3 ST; M

BUNAVAIL 3 PA; QL

buprenorphine-

naloxone

1 PA; QL

butorphanol tartrate

injection

6 MSD

butorphanol tartrate

nasal

1 QL

CAMBIA 3 ST; QL

CAPXIB 3

CELEBREX 3 ST; M

celecoxib 1 ST; M

choline,magnesium

salicylate

1

CONZIP 3 ST; QL

DAYPRO 3 ST; M

DERMACINRX

LEXITRAL

3 M

diclofenac potassium 1

Drug Name Drug

Tier

Requirements

/ Limits

diclofenac sodium

oral

1 M

diclofenac sodium

topical drops

1 M

diclofenac sodium

topical gel

1 ST; M

diclofenac-

misoprostol

1 M

DICLOTRAL 3 M

diflunisal 1 M

DISALCID 3

DS PREP PAK 3 M

DUEXIS 3 ST; M

EC-NAPROSYN 3 ST; M

etodolac 1 M

EVZIO 3 QL

FELDENE 3 ST; M

FENOPROFEN

ORAL CAPSULE

3 ST; M

fenoprofen oral

tablet

1 M

FENORTHO 3 ST; M

FLECTOR 3 ST; QL

flurbiprofen 1 M

ibuprofen 1 M

INDOCIN ORAL 3 ST

INDOCIN RECTAL 3

indomethacin 1

INFLAMMA-K 3 M

ketoprofen 1 M

ketorolac injection 6 MSD

ketorolac

intramuscular

6 MSD



25

Drug Name Drug

Tier

Requirements

/ Limits

ketorolac oral 1 QL

klofensaid ii 1 ST; M

LIDOXIB 3

meclofenamate 1 M

mefenamic acid 1

meloxicam oral

suspension

1 M

meloxicam oral

tablet 15 mg

1 M

meloxicam oral

tablet 7.5 mg

1 M; QL

MOBIC ORAL

TABLET 15 MG

3 ST; M

MOBIC ORAL

TABLET 7.5 MG

3 ST; M; QL

nabumetone 1 M

nalbuphine 6 MSD

NALFON 3 ST; M

naloxone 6 MSD

naltrexone 1

NAPRELAN CR 3 ST; M

NAPROSYN 3 ST; M

naproxen 1 M

naproxen sodium 1 M

NARCAN 2

NUCYNTA 3 QL

NUCYNTA ER 3 ST; QL

oxaprozin 1 M

PENNSAID 3 ST; M

pentazocine-

naloxone

1

piroxicam 1 M

Drug Name Drug

Tier

Requirements

/ Limits

PONSTEL 3 ST

REVIA 3

salsalate 1

SPRIX 3 ST; QL

SUBOXONE 3 PA; QL

sulindac 1 M

SURE RESULT

DSS PREMIUM

PACK

3 M

TALWIN 6 MSD

TIVORBEX 3 ST; M

tolmetin 1 M

TRAMADOL

ORAL

CAPSULE,ER

BIPHASE 24 HR

25-75

3 ST; QL

tramadol oral tablet 1 QL

tramadol oral tablet

extended release 24

hr

1 QL

tramadol oral tablet,

er multiphase 24 hr

1 QL

tramadol-

acetaminophen

1 QL

ULTRACET 3 ST; QL

ULTRAM 3 ST; QL

ULTRAM ER 3 ST; QL

VIMOVO 3 ST; M

VIVITROL 6 MSD

VIVLODEX 3 ST; M

VOLTAREN 3 ST; M

VOLTAREN-XR 3 ST; M

VOPAC MDS 3 M



26

Drug Name Drug

Tier

Requirements

/ Limits

XELITRAL 3 M

XRYLIX 3 M

ZIPSOR 3 ST

ZORVOLEX ORAL

CAPSULE 18 MG

3 ST; M; QL

ZORVOLEX ORAL

CAPSULE 35 MG

3 ST; M

ZUBSOLV 2 PA; QL

PSYCHOTHERAPEUTIC DRUGS

ABILIFY 3 QL

ABILIFY

MAINTENA

6 MSD

ADASUVE 3

ADDERALL 3

ADDERALL XR 3 PA

ADDYI 3 PA

ADZENYS XR-

ODT

3 ST

alprazolam 1

alprazolam intensol 1

AMBIEN 3 ST; QL

AMBIEN CR 3 ST; QL

amitriptyline 1

amitriptyline-

chlordiazepoxide

1

amoxapine 1

ANAFRANIL 3

APLENZIN 3 ST; M; QL

APTENSIO XR 3 PA

aripiprazole oral

solution

1

aripiprazole oral

tablet

1 QL

Drug Name Drug

Tier

Requirements

/ Limits

aripiprazole oral


1 QL

armodafinil 1 ST

ATIVAN 3

BELSOMRA 3 ST

BRISDELLE 3 ST; M; QL

bupropion hcl oral

tablet

1 M

bupropion hcl oral

tablet extended

release

1 M; QL

bupropion hcl oral

tablet extended

release 24 hr 150 mg

1 M

bupropion hcl oral

tablet extended

release 24 hr 300 mg

1 M; QL

buspirone 1 M

BUTISOL 3

CELEXA 3 ST; M; QL

chlordiazepoxide hcl 1

chlorpromazine 1

citalopram 1 M

clomipramine 1

clonidine hcl 1

clorazepate

dipotassium

1

clozapine oral tablet 1

clozapine oral


100 mg, 12.5 mg, 25

mg

1



27

Drug Name Drug

Tier

Requirements

/ Limits

CLOZAPINE

ORAL

TABLET,DISINTE

GRATING 150 MG,

200 MG

3

CLOZARIL 3

CONCERTA 3 PA

CYMBALTA 3 ST; M; QL

DAYTRANA 3 PA

desipramine 1

DESOXYN 3

DESVENLAFAXIN

E

3 ST; M; QL

DESVENLAFAXIN

E FUMARATE

3 ST; M

dexedrine 1

DEXEDRINE

SPANSULE

3 PA

dexmethylphenidate 1

dextroamphetamine 1

dextroamphetamine-

amphetamine

1

diazepam 1

diazepam intensol 1

DORAL 3

doxepin 1

duloxetine oral

capsule,delayed

release(dr/ec) 20

mg, 30 mg, 60 mg

1 M; QL

duloxetine oral

capsule,delayed

release(dr/ec) 40 mg

1 M

DYANAVEL XR 3 PA

EDLUAR 3 ST; QL

Drug Name Drug

Tier

Requirements

/ Limits

EFFEXOR XR 3 ST; M; QL

EMSAM 3 M

ergoloid 1 M

escitalopram oxalate 1 M

estazolam 1

eszopiclone 1 QL

EVEKEO 3

FANAPT 3 QL

FAZACLO 3

FETZIMA 3 ST; M; QL

fluoxetine oral

capsule 10 mg, 40

mg

1 M; QL

fluoxetine oral

capsule 20 mg

1 M

fluoxetine oral

capsule,delayed

release(dr/ec)

1 M; QL

fluoxetine oral

solution

1 M

fluoxetine oral tablet

10 mg

1 M; QL

fluoxetine oral tablet

20 mg

1 M

FLUOXETINE

ORAL TABLET 60

MG

3 ST

fluphenazine

decanoate

1

fluphenazine hcl 1

flurazepam 1

fluvoxamine 1 M; QL

FOCALIN 3



28

Drug Name Drug

Tier

Requirements

/ Limits

FOCALIN XR

ORAL

CAPSULE,ER

BIPHASIC 50-50 10

MG, 20 MG, 25

MG, 30 MG, 35

MG, 40 MG, 5 MG

3 PA

FOCALIN XR

ORAL

CAPSULE,ER

BIPHASIC 50-50 15

MG

3 PA; ST

FORFIVO XL 3 ST; M

GEODON

INTRAMUSCULA

R

3

GEODON ORAL 3 QL

guanfacine 1

guanidine 1

HALCION 3

HALDOL 3

HALDOL

DECANOATE

3

haloperidol 1

haloperidol

decanoate

1

haloperidol lactate 1

HETLIOZ 3 LA; QL

imipramine hcl 1

imipramine pamoate 1

INTERMEZZO 3 ST; QL

INTUNIV ER 3 ST

Drug Name Drug

Tier

Requirements

/ Limits

INVEGA ORAL

TABLET

EXTENDED

RELEASE 24HR

1.5 MG, 3 MG, 6

MG, 9 MG

3 QL

IRENKA 3 ST; M

KAPVAY 3 ST

KHEDEZLA 3 ST; M; QL

LATUDA 3 QL

LEXAPRO ORAL

SOLUTION

3 ST; M

LEXAPRO ORAL

TABLET

3 ST; M; QL

lithium carbonate 1

lithium citrate 1

LITHOBID 3

lorazepam 1

lorazepam intensol 1

loxapine succinate 1

LUNESTA 3 ST; QL

maprotiline 1

MARPLAN 3 M

METADATE CD 3 PA

metadate er 1

methamphetamine 1

METHYLIN 3

methylphenidate 1

mirtazapine 1

modafinil 1 PA

molindone 1

NARDIL 3 M

nefazodone 1 M



29

Drug Name Drug

Tier

Requirements

/ Limits

NORPRAMIN 3

nortriptyline 1

NUPLAZID 3 LA

NUVIGIL 3 PA

olanzapine

intramuscular

1 MSD

olanzapine oral

tablet 10 mg, 15 mg,

2.5 mg, 5 mg, 7.5 mg

1 QL

olanzapine oral

tablet 20 mg

1

olanzapine oral


1 QL

olanzapine-

fluoxetine

1

OLEPTRO ER 3

ORAP 3

oxazepam 1

paliperidone 1 QL

PAMELOR 3

PARNATE 3 M

paroxetine hcl 1 M; QL

PAXIL CR 3 ST; M; QL

PAXIL ORAL

SUSPENSION

3 ST; M

PAXIL ORAL

TABLET

3 ST; M; QL

perphenazine 1

perphenazine-

amitriptyline

1

PEXEVA 3 ST; M; QL

phenelzine 1 M

pimozide 1

Drug Name Drug

Tier

Requirements

/ Limits

PRISTIQ ORAL

TABLET

EXTENDED

RELEASE 24 HR

100 MG, 50 MG

3 ST; M; QL

PRISTIQ ORAL

TABLET

EXTENDED

RELEASE 24 HR

25 MG

3 ST; M

procentra 1

protriptyline 1

PROVIGIL 3 PA

PROZAC ORAL

CAPSULE 10 MG,

40 MG

3 ST; M; QL

PROZAC ORAL

CAPSULE 20 MG

3 ST; M

PROZAC WEEKLY 3 ST; M; QL

quazepam 1

quetiapine 1 QL

QUILLICHEW ER 3 ST

QUILLIVANT XR 3 PA

REMERON 3

REMERON

SOLTAB

3

RESTORIL 3

REXULTI 3

RISPERDAL M-

TAB

3 QL

RISPERDAL ORAL

SOLUTION

3

RISPERDAL ORAL

TABLET

3 QL

risperidone oral

solution

1



30

Drug Name Drug

Tier

Requirements

/ Limits

risperidone oral

tablet

1 QL

risperidone oral


1 QL

RITALIN 3

RITALIN LA 3 PA

ROZEREM 2 ST; QL

SAPHRIS (BLACK

CHERRY)

SUBLINGUAL

TABLET 2.5 MG

3

SAPHRIS (BLACK

CHERRY)

SUBLINGUAL

TABLET 5 MG

3 QL

SARAFEM ORAL

TABLET 10 MG

3 ST; M; QL

SARAFEM ORAL

TABLET 20 MG

3 ST; M

seconal sodium 1

SEROQUEL 3 QL

SEROQUEL XR 3 QL

sertraline oral

concentrate

1 M

sertraline oral tablet 1 M; QL

SILENOR 3 ST; QL

SONATA 3 ST; QL

STRATTERA 2 ST

SURMONTIL 3

SYMBYAX 3

temazepam 1

thioridazine 1

thiothixene 1

TOFRANIL 3

Drug Name Drug

Tier

Requirements

/ Limits

TRANXENE T-

TAB

3

tranylcypromine 1 M

trazodone 1

triazolam 1

trifluoperazine 1

trimipramine 1

TRINTELLIX 3 ST; QL

VALIUM 3

venlafaxine oral

capsule,extended

release 24hr 150 mg

1 M

venlafaxine oral

capsule,extended

release 24hr 37.5

mg, 75 mg

1 M; QL

venlafaxine oral

tablet

1 M; QL

venlafaxine oral

tablet extended

release 24hr

1 M; QL

VERSACLOZ 3

VIIBRYD ORAL

TABLET

3 ST; M; QL

VIIBRYD ORAL

TABLETS,DOSE

PACK

3 ST; QL

VRAYLAR 3

VYVANSE 2 PA

WELLBUTRIN SR 3 ST; M; QL

WELLBUTRIN XL 3 ST; M; QL

XANAX 3

XANAX XR 3

XYREM 3 LA



31

Drug Name Drug

Tier

Requirements

/ Limits

zaleplon 1 QL

zenzedi oral tablet

10 mg, 5 mg

1

ZENZEDI ORAL

TABLET 15 MG,

2.5 MG, 20 MG, 30

MG, 7.5 MG

3

ziprasidone hcl 1 QL

ZOLOFT ORAL

CONCENTRATE

3 ST; M

ZOLOFT ORAL

TABLET

3 ST; M; QL

zolpidem 1 QL

ZOLPIMIST 3 ST

ZYPREXA

INTRAMUSCULA

R

3 MSD

ZYPREXA ORAL

TABLET 10 MG, 15

MG, 2.5 MG, 5 MG,

7.5 MG

3 QL

ZYPREXA ORAL

TABLET 20 MG

3

ZYPREXA ZYDIS 3 QL

CARDIOVASCULAR,

HYPERTENSION & LIPIDS

ANTIARRHYTHMIC AGENTS

amiodarone 1 M

BETAPACE 3 M

BETAPACE AF 3 M

disopyramide

phosphate

1 M

dofetilide 1

flecainide 1 M

mexiletine 1 M

Drug Name Drug

Tier

Requirements

/ Limits

MULTAQ 3 M

NORPACE 3 M

NORPACE CR 3 M

pacerone 1 M

procainamide 6 MSD

propafenone 1 M

quinidine gluconate 1 M

quinidine sulfate 1 M

RYTHMOL 3 M

RYTHMOL SR 3 M

sotalol 1 M

sotalol af 1 M

SOTYLIZE 2 M

TIKOSYN 3

ANTIHYPERTENSIVE THERAPY

ACCUPRIL 3 M

ACCURETIC 3 M

acebutolol 1 M

ACEON 3 M

ADALAT CC 3 ST; M

afeditab cr 1 M

ALDACTAZIDE 3 M

ALDACTONE 3 M

ALTACE 3 M

amiloride 1 M

amiloride-

hydrochlorothiazide

1 M

amlodipine 1 M

amlodipine-

benazepril

1 M



32

Drug Name Drug

Tier

Requirements

/ Limits

amlodipine-

valsartan

1 M

amlodipine-

valsartan-hcthiazid

1 M

ATACAND 3 ST; M

ATACAND HCT 3 ST; M

atenolol 1 M

atenolol-

chlorthalidone

1 M

AVALIDE 3 ST; M

AVAPRO 3 ST; M

AZOR 3 ST; M

benazepril 1 M

benazepril-

hydrochlorothiazide

1 M

BENICAR 3 ST; M

BENICAR HCT 3 ST; M

betaxolol 1 M

BIDIL 3 M

bisoprolol fumarate 1 M

bisoprolol-

hydrochlorothiazide

1 M

BREVIBLOC 6 MSD

bumetanide 1 M

BYSTOLIC 3 ST; M

BYVALSON 3 M

CALAN 3 ST; M

CALAN SR 3 ST; M

candesartan 1 M

candesartan-

hydrochlorothiazid

1 M

captopril 1 M

Drug Name Drug

Tier

Requirements

/ Limits

captopril-

hydrochlorothiazide

1 M

CARDENE IV 6 MSD

CARDIZEM 3 M

CARDIZEM CD 3 M

CARDIZEM LA 3 M

CARDURA 3 ST; M; QL

CARDURA XL 3 ST; M; QL

carvedilol 1 M

CATAPRES 3 M

CATAPRES-TTS-1 3 M; QL



chlorothiazide 1 M

chlorothiazide

sodium

6 MSD

chlorthalidone 1 M

clonidine 1 M; QL

clonidine hcl 1 M

clorpres oral tablet

0.1-15 mg, 0.2-15

mg

1 M

CLORPRES ORAL

TABLET 0.3-15

MG

3 M

COREG 3 ST; M

COREG CR 3 ST; M

CORGARD 3 ST; M

CORZIDE 3 ST; M

COZAAR 3 ST; M

DEMADEX 3 M

DEMSER 2



33

Drug Name Drug

Tier

Requirements

/ Limits

DIBENZYLINE 3

diltiazem 1 M

DIOVAN 3 ST; M

DIOVAN HCT 3 ST; M

DIURIL 3 M

DIURIL IV 6 MSD

doxazosin 1 M; QL

DUTOPROL 2 ST; M

DYAZIDE 3 M

DYRENIUM 3 M

EDARBI 3 ST; M

EDARBYCLOR 3 ST; M

EDECRIN 3 M

enalapril maleate 1 M

enalapril-

hydrochlorothiazide

1 M

EPANED 3 M

eplerenone 1 M

epoprostenol

(glycine)

6 MSD

eprosartan 1 M

esmolol 6 MSD

EXFORGE 3 ST; M

EXFORGE HCT 2 ST; M

felodipine 1 M

FLOLAN 6 MSD

fosinopril 1 M

fosinopril-

hydrochlorothiazide

1 M

furosemide injection 6 MSD

furosemide oral 1 M

guanfacine 1 M

Drug Name Drug

Tier

Requirements

/ Limits

HEMANGEOL 3

hydralazine 1 M

hydrochlorothiazide 1 M

HYZAAR 3 ST; M

indapamide 1 M

INDERAL LA 3 ST; M

INDERAL XL 3 ST; M

INNOPRAN XL 3 ST; M

INSPRA 3 M

irbesartan 1 M

irbesartan-

hydrochlorothiazide

1 M

isradipine 1 M

labetalol 1 M

LASIX 3 M

LEVATOL 3 ST; M

lisinopril 1 M

lisinopril-

hydrochlorothiazide

1 M

LOPRESSOR 3 ST; M

LOPRESSOR HCT 3 ST; M

losartan 1 M

losartan-

hydrochlorothiazide

1 M

LOTENSIN 3 M

LOTENSIN HCT 3 M

LOTREL 3 M

MAVIK 3 M

MAXZIDE 3 M

MAXZIDE-25MG 3 M

methyclothiazide 1 M

methyldopa 1 M



34

Drug Name Drug

Tier

Requirements

/ Limits

methyldopa-

hydrochlorothiazide

1 M

methyldopate 6 MSD

metolazone 1 M

metoprolol succinate 1 M

metoprolol ta-

hydrochlorothiaz

1 M

metoprolol tartrate

oral tablet 100 mg,

25 mg, 50 mg

1 M

metoprolol tartrate

oral tablet 37.5 mg,

75 mg

2 M

MICARDIS 3 ST; M

MICARDIS HCT 3 ST; M

MICROZIDE 3 M

MINIPRESS 3 M

minoxidil 1 M

moexipril 1 M

moexipril-

hydrochlorothiazide

1 M

nadolol 1 M

nadolol-

bendroflumethiazide

1 M

nicardipine 1 M

nifedical xl 1 M

nifedipine 1 M

nimodipine 1

nisoldipine 1 M

NORVASC 3 ST; M

NYMALIZE 3

ORENITRAM 4 M; LA

Drug Name Drug

Tier

Requirements

/ Limits

perindopril

erbumine

1 M

phenoxybenzamine 1

pindolol 1 M

prazosin 1 M

PRESTALIA 3 ST; M

PRINIVIL 3 M

PROCARDIA 3 ST; M

PROCARDIA XL 3 ST; M

propranolol 1 M

propranolol-

hydrochlorothiazid

1 M

QBRELIS 3 M

quinapril 1 M

quinapril-

hydrochlorothiazide

1 M

ramipril 1 M

REMODULIN 6 MSD

reserpine 1 M

SECTRAL 3 ST; M

spironolactone 1 M

spironolacton-

hydrochlorothiaz

1 M

SULAR 3 ST; M

TARKA 3 M

TEKTURNA 3 M

TEKTURNA HCT 3 M

telmisartan 1 M

telmisartan-

amlodipine

1 M

telmisartan-

hydrochlorothiazid

1 M



35

Drug Name Drug

Tier

Requirements

/ Limits

TENEX 3 M

TENORETIC 100 3 ST; M

TENORETIC 50 3 ST; M

TENORMIN 3 ST; M

terazosin 1 M; QL

TIAZAC 3 M

timolol maleate 1 M

TOPROL XL 3 ST; M

torsemide 1 M

trandolapril 1 M

trandolapril-

verapamil

1 M

triamterene-

hydrochlorothiazid

1 M

TRIBENZOR 3 ST; M

TWYNSTA 3 ST; M

UPTRAVI 2 M

valsartan 1 M

valsartan-

hydrochlorothiazide

1 M

VASERETIC 3 M

VASOTEC 3 M

veletri 6 MSD

verapamil 1 M

VERELAN 3 ST; M

VERELAN PM 3 ST; M

ZEBETA 3 ST; M

ZESTORETIC 3 M

ZESTRIL 3 M

ZIAC 3 ST; M

CARDIAC GLYCOSIDES

Drug Name Drug

Tier

Requirements

/ Limits

digitek 1 M

digox 1 M

digoxin 1 M

LANOXIN 3 M

COAGULATION THERAPY

ADVATE 6 MSD

ADYNOVATE 6 MSD

AFSTYLA 6 MSD

AGGRENOX 2 M

ALPHANATE 6 MSD

ALPHANINE SD 6 MSD

ALPROLIX 6 MSD

AMICAR 2

ARGATROBAN 6 MSD

ARGATROBAN IN

0.9 % SOD CHLOR

6 MSD

ARGATROBAN IN

NACL (ISO-OS)

6 MSD

ARIXTRA 3 LA

aspirin-dipyridamole 1 M

BEBULIN 6 MSD

BENEFIX 6 MSD

BRILINTA ORAL

TABLET 60 MG

3 M

BRILINTA ORAL

TABLET 90 MG

2 M

CEPROTIN (BLUE

BAR)

6 MSD

CEPROTIN

(GREEN BAR)

6 MSD

cilostazol 1 M

clopidogrel oral

tablet 300 mg

1



36

Drug Name Drug

Tier

Requirements

/ Limits

clopidogrel oral

tablet 75 mg

1 M

COAGADEX 6 MSD

CORIFACT 6 MSD

COUMADIN 3

dipyridamole 1 M

DURLAZA 3 M

EFFIENT 3 M

ELIQUIS 2 PA

ELOCTATE 6 MSD

enoxaparin

subcutaneous

solution

6 MSD

enoxaparin

subcutaneous

syringe

1

FEIBA NF 6 MSD

fondaparinux 1 LA

FRAGMIN 3

HELIXATE FS 6 MSD

HEMOFIL M HIGH 6 MSD

HEMOFIL M LOW 6 MSD

HEMOFIL M MID 6 MSD

HEMOFIL M

SUPER HIGH

6 MSD

hep flush-10 (pf) 1

heparin (porcine) 1

HEPARIN

(PORCINE) IN

0.9% NACL

6

heparin (porcine) in

5 % dex

6 MSD

heparin (porcine) in

nacl (pf)

1

Drug Name Drug

Tier

Requirements

/ Limits

heparin flush 6

heparin

flush(porcine)-

0.9nacl

6

heparin lock flush 1

heparin lock flush

(porcine)

1

heparin

lockflush(porcine)(pf

)

1

HEPARIN(PORCIN

E) IN 0.45% NACL

INTRAVENOUS

PARENTERAL

SOLUTION 12,500

UNIT/250 ML

3

heparin(porcine) in

0.45% nacl

intravenous

parenteral solution

25,000 unit/250 ml,

25,000 unit/500 ml

1

heparin, porcine (pf) 1

HUMATE-P 6 MSD

IDELVION 6 MSD

IXINITY 6 MSD

jantoven 1

KOATE-DVI 6 MSD

KOGENATE FS 6 MSD

KOVALTRY 6 MSD

LOVENOX

SUBCUTANEOUS

SOLUTION

6 MSD

LOVENOX

SUBCUTANEOUS

SYRINGE

3

MEPHYTON 2



37

Drug Name Drug

Tier

Requirements

/ Limits

MONOCLATE-P 6 MSD

monoject prefill (pf) 1

MONONINE 6 MSD

NOVOEIGHT 6 MSD

NOVOSEVEN RT 6 MSD

NPLATE 6 MSD

NUWIQ 6 MSD

OBIZUR 6 MSD

pentoxifylline 1 M

PLAVIX ORAL

TABLET 300 MG

3

PLAVIX ORAL

TABLET 75 MG

3 M

PRADAXA 3 PA; M

PROFILNINE 6 MSD

PROMACTA 2 PA

RECOMBINATE 6 MSD

RIASTAP 6 MSD

RIXUBIS 6 MSD

SAVAYSA 3 PA

ticlopidine 1 M

tranexamic acid 6 MSD

TRETTEN 6 MSD

VONVENDI 6 MSD

warfarin 1

WILATE 6 MSD

XARELTO ORAL

TABLET 10 MG

2

XARELTO ORAL

TABLET 15 MG, 20

MG

2 PA

Drug Name Drug

Tier

Requirements

/ Limits

XARELTO ORAL

TABLETS,DOSE

PACK

2 PA

XYNTHA 6 MSD

XYNTHA

SOLOFUSE

6 MSD

ZONTIVITY 3 PA; M

LIPID/CHOLESTEROL LOWERING

AGENTS

ALTOPREV 3 ST; M; QL

amlodipine-

atorvastatin

1 M; QL

ANTARA 3 ST; M

atorvastatin 1 M; QL

CADUET 3 ST; M; QL

cholestyramine (with

sugar)

1 M

cholestyramine light 1 M

COLESTID 3 ST; M

COLESTID

FLAVORED

3 ST; M

colestipol 1 M

CRESTOR 3 ST; M; QL

fenofibrate

micronized

1 M

fenofibrate

nanocrystallized

1 M

FENOFIBRATE

ORAL CAPSULE

3 ST; M

fenofibrate oral

tablet

1 M

fenofibric acid 1 M

fenofibric acid

(choline)

1 M



38

Drug Name Drug

Tier

Requirements

/ Limits

FENOGLIDE 3 ST; M

FIBRICOR 3 ST; M

fluvastatin 1 M; QL

gemfibrozil 1 M

JUXTAPID 2

KYNAMRO 4 LA

LESCOL 3 ST; M; QL

LESCOL XL 3 ST; M; QL

LIPITOR 3 ST; M; QL

LIPOFEN 3 ST; M

LIVALO 3 ST; M; QL

LOFIBRA 3 ST; M

LOPID 3 M

lovastatin 1 M; QL

niacin 1 M

NIACOR 3 M

NIASPAN

EXTENDED-

RELEASE

3 M

omega-3 acid ethyl

esters

1 PA; M

PRALUENT PEN 3 PA; LA

PRALUENT

SYRINGE

3 PA; LA

PRAVACHOL 3 ST; M; QL

pravastatin 1 M; QL

prevalite 1 M

QUESTRAN 3 ST; M

QUESTRAN

LIGHT

3 ST; M

REPATHA

PUSHTRONEX

4 PA; LA

Drug Name Drug

Tier

Requirements

/ Limits

REPATHA

SURECLICK

3 PA; LA

REPATHA

SYRINGE

3 PA; LA

rosuvastatin 1 M; QL

simvastatin 1 M; QL

TRICOR 3 ST; M

TRIGLIDE 3 ST; M

TRILIPIX 3 ST; M

VASCEPA 2 PA; M

VYTORIN 10-10 3 ST; M; QL




WELCHOL 3 ST; M

ZETIA 2 ST; M

ZOCOR 3 ST; M; QL

MISCELLANEOUS

CARDIOVASCULAR AGENTS

CORLANOR 2 PA; M

ENTRESTO 2 PA; M

RANEXA 3 M

VECAMYL 3

NITRATES

DILATRATE-SR 3 M

ISOCHRON 3 M

ISORDIL 3 M

ISORDIL

TITRADOSE

3 M

isosorbide dinitrate 1 M

isosorbide

mononitrate

1 M



39

Drug Name Drug

Tier

Requirements

/ Limits

MINITRAN 3 M

nitro-bid 1 M

NITRO-DUR 3 M

nitroglycerin oral 1 M

nitroglycerin

transdermal

1 M

nitroglycerin

translingual

1

NITROLINGUAL 3

NITROMIST 3

NITROSTAT 2

nitro-time 1 M

DERMATOLOGICALS/TOPICA

L THERAPY

ANTIPSORIATIC /

ANTISEBORRHEIC

acitretin 1

calcipotriene 1

calcipotriene-

betamethasone

1

calcitrene 1

calcitriol 1

COAL TAR 2

COSENTYX 4 PA; LA

COSENTYX (2

SYRINGES)

4 PA; LA

COSENTYX PEN 4 PA; LA

COSENTYX PEN

(2 PENS)

4 PA; LA

DOVONEX 3

drithocreme hp 1

ENSTILAR 3

Drug Name Drug

Tier

Requirements

/ Limits

EPIFOAM 3 ST

hydrocortisone-

pramoxine

1

OVACE 3

OVACE PLUS

SHAMPOO

3

OVACE PLUS

TOPICAL

CLEANSER,EXTE

NDED RELEASE

3

OVACE PLUS

TOPICAL CREAM

3 ST

OVACE PLUS

TOPICAL FOAM

3

OVACE PLUS

TOPICAL LOTION

3 ST

OVACE PLUS

WASH

3

PRAMOSONE 3 ST

PRAMOSONE E 3 ST

PROMISEB

COMPLETE

3

seb-prev 1

selenium sulfide 1

SELRX 3

SORIATANE 3

SORILUX 3

STELARA 6 MSD

sulfacetamide

sodium

1

TACLONEX 3

TALTZ

AUTOINJECTOR

4 LA



40

Drug Name Drug

Tier

Requirements

/ Limits

TALTZ

AUTOINJECTOR

(2 PACK)

4 LA

TALTZ

AUTOINJECTOR

(3 PACK)

4 LA

TALTZ SYRINGE 4 LA

TALTZ SYRINGE

(2 PACK)

4 LA

TALTZ SYRINGE

(3 PACK)

4 LA

TERSI FOAM 3

VECTICAL 3

ZITHRANOL 3

ZITHRANOL-RR 3

BURN THERAPY

SILVADENE 3

silver sulfadiazine 1

ssd 1

thermazene 1

KERATOLYTICS

BENSAL HP 3

INOVA 4-1 3 ST

INOVA 8-2 3 ST

KERALYT RX 3

KERALYT SCALP

COMPLETE

3

PODOCON 3

POTASSIUM

HYDROXIDE

3

salacyn 1

SALEX 3

salicylic acid 1

Drug Name Drug

Tier

Requirements

/ Limits

salicylic acid er-

ceramides

1

SALKERA 3

salvax 1

SALVAX DUO

PLUS

3

ULTRASAL-ER 3

VIRASAL 3

MISCELLANEOUS

DERMATOLOGICALS

8-MOP 2

ALEVICYN

ANTIPRURITIC

3

ALEVICYN

ANTIPRURITIC SG

3

ALUVEA 3

ATOPICLAIR 3

ATRAPRO CP 3

ATRAPRO

HYDROGEL

3

avo cream 1

BIAFINE

EMULSION

3

bp-50% urea 1

CARAC 3

celacyn 1

cem-urea 1

CERACADE 3

CERAMAX 3

CONDYLOX 3

CORTANE-B 3

DERMASORB XM

COMPLETE KIT

3



41

Drug Name Drug

Tier

Requirements

/ Limits

diclofenac sodium 1 PA

doxepin 1

EFUDEX 3

eletone 1

ELIDEL 3 ST

emulsion sb 1

ENTTY 3

EPICERAM 3

FLUOROPLEX 3

FLUOROURACIL

TOPICAL CREAM

0.5 %

3

fluorouracil topical

cream 5 %

1

fluorouracil topical

solution

1

GORDONS UREA 3

hpr 1

hpr plus 1

hpr plus hydrogel 1

HPR PLUS-MB

HYDROGEL

3

HYDRO 35 3

HYDRO 40 3

HYLATOPIC 3

HYLATOPICPLUS 3

KERAFOAM 3

KERALAC 3

lactic acid 1

lactic acid e 1

latrix 1

LEVULAN 3

Drug Name Drug

Tier

Requirements

/ Limits

LOUTREX 3

luxamend 1

mb hydrogel 1

mb hydrogel

(cyclomethicone)

1

methoxsalen rapid 1

NEOSALUS 3

nivatopic plus 1

OXSORALEN 3

OXSORALEN

ULTRA

3

PANRETIN 3

PICATO 3

podofilox 1

PRESERA 3

PROMISEB 3

PROTOPIC 3 ST

pruclair 1

prudoxin 1

prumyx 1

prutect 1

QUTENZA 6 MSD

rea lo 39 1

rea lo 40 1

REGRANEX 2 QL

remeven 1

RESTIZAN 3

RYNODERM 3

silver nitrate 1

silver nitrate

applicators

1

SOLARAZE 3 PA



42

Drug Name Drug

Tier

Requirements

/ Limits

sonafine 1

tacrolimus 1 ST

TOLAK 3

TROPAZONE

LOTION

3

umecta 1

UMECTA PD 3

URAMAXIN 3

URAMAXIN GT 3

urea 1

urea nail stick 1

urea-hyaluronate

sodium

1

ure-k 1

UREVAZ 3

UTOPIC 3

VALCHLOR 2

VEREGEN 3

XCLAIR 3

ZANABIN 3

ZONALON 3

THERAPY FOR ACNE

ABSORICA 3

ACANYA 3 ST

ACZONE 3 ST

adapalene 1

ATRALIN 3

AVAR LS 3 ST

avar topical cleanser 1

AVAR TOPICAL

FOAM

3 ST

Drug Name Drug

Tier

Requirements

/ Limits

AVAR TOPICAL

PADS,

MEDICATED

3 ST

AVAR-E GREEN 3 ST

AVAR-E LS 3 ST

avita 1

AZELEX 3 ST

BENZACLIN 3 ST

BENZACLIN

PUMP

3 ST

BENZAMYCIN 3 ST

BENZAMYCINPA

K

3 ST

BENZEFOAM 3 ST

benzepro 1

benzoyl peroxide 1

bp 10-1 1

bpo 1

claravis 1

cleansing wash 1

CLEOCIN T 3 ST

CLINDACIN ETZ 3 ST

clindacin p 1

CLINDACIN PAC 3 ST

CLINDAGEL 3 ST

clindamycin

phosphate

1

clindamycin-benzoyl

peroxide

1

DIFFERIN 3 ST

DUAC 3 ST

EPIDUO 3 ST



43

Drug Name Drug

Tier

Requirements

/ Limits

EPIDUO FORTE 3 ST

ery pads 1

erygel 1

erythromycin with

ethanol

1

erythromycin-

benzoyl peroxide

1

EVOCLIN 3 ST

FABIOR 3 PA

FINACEA 3 ST

INOVA 3 ST

METROCREAM 3 ST

METROGEL 3 ST

METROLOTION 3 ST

metronidazole 1

MIRVASO 3

myorisan 1

neuac 1

NORITATE 3 ST

NUOX 3 ST

ONEXTON 3 ST

PLEXION 3 ST

PLEXION

CLEANSING

CLOTHS

3 ST

RETIN-A 3

RETIN-A MICRO 3

RETIN-A MICRO

PUMP

3

rosadan 1

ROSANIL 3 ST

ROSULA 3 ST

Drug Name Drug

Tier

Requirements

/ Limits

rosula cleansing

cloths

1

SOOLANTRA 3 ST

ss 10-2 1

sss 10-5 1

sulfacetamide

sodium-sulfur

1

sulfacetamide sod-

sulfur-urea

1

sulfacetamide-

sulfur-cleansr23

1

sulfacleanse 8-4 1

sulfact na-sul-

avobnz-otn-ocsa

1

SUMADAN 3 ST

SUMADAN XLT 3 ST

SUMAXIN 3 ST

SUMAXIN CP 3 ST

SUMAXIN TS 3 ST

TAZORAC 2 PA

tretinoin 1

tretinoin

microspheres

1

TRETIN-X 3

TRETIN-X CREAM

KIT

3

VANOXIDE-HC 3 ST

VELTIN 3 ST

zenatane 1

zencia 1

ZIANA 3 ST

TOPICAL ANESTHETICS

ASTERO 3



44

Drug Name Drug

Tier

Requirements

/ Limits

BUCALSEP 3

ethyl chloride 1

glydo 1

LDO PLUS 3

lidocaine hcl 1

lidocaine hcl-

hydrocortison ac

1

lidocaine topical

adhesive

patch,medicated

1 ST

lidocaine topical

ointment

1

lidocaine viscous 1

lidocaine-prilocaine 1

LIDOCAINE-

TETRACAINE

3

LIDODERM 3 PA

lido-k 1

lidopin topical

cream 3 %

1

LIDOPIN TOPICAL

CREAM 3.25 %

3

LIDORX 3

LIDOTRAL 3

LIDOVEX 3

LIVIXIL PAK 3

LP LITE PAK 3

lta pre-attached 1

NOVACORT

(WITH ALOE)

3

PLIAGLIS 3

relador pak 1

relador pak plus 1

Drug Name Drug

Tier

Requirements

/ Limits

SYNERA 3

TOPICAL ANTIBACTERIALS

ALTABAX 3

CENTANY 3

CENTANY AT 3

CORTISPORIN 3

gentamicin 1

KLARON 3 ST

mupirocin 1

mupirocin calcium 1

NEO-SYNALAR 3

NEO-SYNALAR

KIT

3

sulfacetamide

sodium (acne)

1

SULFAMYLON

TOPICAL CREAM

2

SULFAMYLON

TOPICAL PACKET

3

TOPICAL ANTIFUNGALS

ciclodan 1

ciclopirox 1

ciclopirox-ure-

camph-menth-euc

1

clotrimazole-

betamethasone

1

CNL 8 NAIL 3

econazole 1

ECOZA 3

ERTACZO 3

EXELDERM 3

EXODERM 3



45

Drug Name Drug

Tier

Requirements

/ Limits

EXTINA 3

JUBLIA 3

KERYDIN 3

ketoconazole 1

LOPROX 3

LOPROX KIT 3

LOTRISONE 3

LUZU 3

NAFTIFINE

TOPICAL CREAM

1 %

3

naftifine topical

cream 2 %

1

NAFTIN 3

NIZORAL 3

nyamyc 1

NYATA 3

nystatin 1

nystatin-

triamcinolone

1

nystop 1

oxiconazole 1

OXISTAT 3

PENLAC 3

TRIACETIN 2

TRIPLE DYE 3

VUSION 3

XOLEGEL 3

TOPICAL ANTIVIRALS

acyclovir 1

DENAVIR 3

XERESE 3

Drug Name Drug

Tier

Requirements

/ Limits

ZOVIRAX 2

TOPICAL CORTICOSTEROIDS

ADVANCED

ALLERGY

COLLECT KIT

3 ST

ALA-SCALP 3 ST

alclometasone 1

amcinonide 1

apexicon e 1

AQUA GLYCOLIC

HC

3 ST

betamethasone

dipropionate

1

betamethasone

valerate

1

betamethasone,

augmented

1

CAPEX 3 ST

clobetasol 1

clobetasol-emollient 1

CLOBEX 3 ST

CLOCORTOLONE

PIVALATE

3 ST

clodan 1

CLODERM 3 ST

CORDRAN 3 ST

cormax 1

CUTIVATE 3 ST

DERMACINRX

SILAPAK

3 ST

DERMACINRX

SILAZONE

3



46

Drug Name Drug

Tier

Requirements

/ Limits

DERMA-

SMOOTHE/FS

BODY OIL

3 ST

DERMA-

SMOOTHE/FS

SCALP OIL

3 ST

DERMASORB HC

COMPLETE KIT

3 ST

DERMASORB TA

COMPLETE KIT

3 ST

DERMATOP 3 ST

DERMAWERX

SDS

3 ST

DERMAZONE 3

DESONATE 3 ST

desonide 1

DESOWEN 3 ST

desoximetasone 1

diflorasone 1

DIPROLENE 3 ST

DIPROLENE AF 3 ST

ELOCON 3 ST

fluocinolone 1

fluocinolone and

shower cap

1

fluocinonide 1

fluocinonide-e 1

flurandrenolide 1

fluticasone 1

halobetasol

propionate

1

HALOG 3 ST

hydrocortisone 1

Drug Name Drug

Tier

Requirements

/ Limits

hydrocortisone

butyrate

1

hydrocortisone

butyr-emollient

1

hydrocortisone

valerate

1

hydrocortisone-min

oil-wht pet

1

KENALOG 3 ST

LOCOID 3 ST

LOCOID

LIPOCREAM

3 ST

LUXIQ 3 ST

mometasone 1

NOXIPAK 3

OLUX 3 ST

OLUX-E 3 ST

PANDEL 3 ST

prednicarbate 1

PSORCON 3 ST

SANADERMRX 3

scalacort 1

SCALACORT DK 3

SERNIVO 3 ST

SILAZONE-II 3

SURE RESULT

TAC PAK

3 ST

SYNALAR 3 ST

SYNALAR

CREAM KIT

3 ST

SYNALAR

OINTMENT KIT

3 ST

SYNALAR TS 3 ST



47

Drug Name Drug

Tier

Requirements

/ Limits

TEMOVATE 3 ST

TEXACORT 3 ST

TOPICORT 3 ST

triamcinolone

acetonide

1

trianex 1

triderm 1

TRI-SILA 3 ST

ULTRAVATE 3 ST

ULTRAVATE X 3 ST

VANOS 3 ST

VERDESO 3 ST

WHYTEDERM

TDPAK

3 ST

WHYTEDERM

TRILASIL PAK

3 ST

TOPICAL ENZYMES

SANTYL 2

TOPICAL SCABICIDES /

PEDICULICIDES

ELIMITE 3

EURAX 3

lindane 1

LYCELLE 3

malathion 1

NATROBA 3

OVIDE 3

permethrin 1

SKLICE 3

spinosad 1

ULESFIA 3

Drug Name Drug

Tier

Requirements

/ Limits

DIAGNOSTICS &

MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONS

lactated ringers 1

PHYSIOLYTE 3

PHYSIOSOL

IRRIGATION

3

ringers 1

SORBITOL-

MANNITOL

3

VASHE WOUND

THERAPY

3


acamprosate 1

ACTONEL 3 ST; QL

ADAGEN 6 MSD

AGRYLIN 3 M

alendronate 1 M; QL

AMMONUL 6 MSD

anagrelide 1 M

ANTABUSE 3

ARALAST NP 6 MSD

bd pre-filled normal

saline

6 MSD

BUPHENYL ORAL

POWDER

3

BUPHENYL ORAL

TABLET

2

caffeine citrated 1

CARBAGLU 2 LA

CARNITOR 3 M

CARNITOR

(SUGAR-FREE)

3 M



48

Drug Name Drug

Tier

Requirements

/ Limits

cevimeline 1 M

CHEMET 2

disulfiram 1

etidronate disodium 1 M

EVOXAC 3 M

EXJADE 3 LA

FERRIPROX ORAL

SOLUTION

3 LA

FERRIPROX ORAL

TABLET

2 LA

FERRLECIT 6 MSD

GLASSIA 6 MSD

INCRELEX 3 PA; LA

INFASURF 3

JADENU 3 LA

levocarnitine 1 M

levocarnitine (with

sugar)

1 M

LIPOCHOL PLUS 3

LITHOSTAT 3

METOPIRONE 3

midodrine 1

monoject 0.9%

sodium chloride

6 MSD

monoject prefill

advanced ns

6 MSD

monoject prefill

saline flush

6 MSD

normal saline flush 6 MSD

NORTHERA 3 LA

ORFADIN ORAL

CAPSULE

2 LA

Drug Name Drug

Tier

Requirements

/ Limits

ORFADIN ORAL

SUSPENSION

3 LA

pilocarpine hcl 1

PROLASTIN-C 6 MSD

RADIOGARDASE 3

RAVICTI 2 LA

RECLAST 6 MSD

RILUTEK 3

riluzole 1

risedronate 1 QL

SALAGEN 3

sodium benzoate-sod

phenylacet

6 MSD

sodium chlor 0.9%

bacteriostat

6 MSD

sodium chloride 0.9

% injection syringe

6 MSD

SODIUM

CHLORIDE 0.9 %

INJECTION

SYRINGE, WITH

SWAB CAP

6 MSD

sodium chloride 0.9

% intravenous

6 MSD

sodium ferric

gluconat-sucrose

6 MSD

sodium

phenylbutyrate

1

SOLIRIS 6 MSD

SURVANTA 3

SWABFLUSH 6 MSD

SYPRINE 3

syrex sodium

chloride 0.9%

6 MSD



49

Drug Name Drug

Tier

Requirements

/ Limits

THIOLA 3

water for irrigation,

sterile

1

XURIDEN 2

ZEMAIRA 6 MSD

zoledronic acid-

mannitol-water

6 MSD

SMOKING DETERRENTS

bupropion hcl

(smoking deter)

5 M

CHANTIX 5 ACA

CHANTIX

CONTINUING

MONTH BOX

5 ACA

CHANTIX

STARTING

MONTH BOX

5 ACA

NICODERM CQ

TRANSDERMAL

PATCH 24 HOUR

14 MG/24 HR, 7

MG/24 HR

5 ACA; OTC

NICODERM CQ

TRANSDERMAL

PATCH 24 HOUR

21 MG/24 HR

5 M; ACA; OTC

NICORETTE 5 ACA; OTC

nicotine 5 ACA; OTC

NICOTINE

(POLACRILEX)

5 ACA; OTC

NICOTROL 5 ACA

NICOTROL NS 5 ACA

QUIT 2 5 ACA; OTC

QUIT 4 5 ACA; OTC

ZYBAN 5 M; ACA

Drug Name Drug

Tier

Requirements

/ Limits

EAR, NOSE & THROAT

MEDICATIONS


ARESTIN 4 LA

ASTEPRO 3

azelastine nasal

aerosol,spray

1 QL

azelastine nasal

spray,non-aerosol

1

BACTROBAN

NASAL

2

chlorhexidine

gluconate

1

CLINPRO 5000 3 M

DEBACTEROL 2

denta 5000 plus 1 M

dentagel 1 M

EPISIL 3

fluoridex daily

defense

1 M

FLUORIDEX

SENSITIVITY

RELIEF

3 M

GELCLAIR 3

GELX 3

ipratropium bromide 1 QL

MUGARD 3

olopatadine 1 QL

ORAFATE 3

oralone 1

ORAMAGICRX 3

PATANASE 3 QL

PERIDEX 3



50

Drug Name Drug

Tier

Requirements

/ Limits

periogard 1

pilocarpine hcl 1

PREVIDENT 3 M

PREVIDENT 5000

BOOSTER PLUS

3 M

PREVIDENT 5000

DRY MOUTH

3 M

PREVIDENT 5000

ENAMEL

PROTECT

3 M

PREVIDENT 5000

SENSITIVE

3 M

PROTHELIAL 4 LA

Q-CARE RX Q4 3

SALAGEN 3

sf 1 M

sf 5000 plus 1 M

sodium fluoride 1 M

triamcinolone

acetonide

1

TYZINE 3

MISCELLANEOUS OTIC

PREPARATIONS

acetasol hc 1

acetic acid-

aluminum acetate

1

CETRAXAL 3

ciprofloxacin hcl 1

DERMOTIC OIL 3

fluocinolone

acetonide oil

1

hydrocortisone-

acetic acid

1

ofloxacin 1

Drug Name Drug

Tier

Requirements

/ Limits

OTIPRIO 3

OTIC STEROID / ANTIBIOTIC

CIPRO HC 3

CIPRODEX 2

COLY-MYCIN S 3

neomycin-

polymyxin-hc

1

OTOVEL 3

ENDOCRINE/DIABETES

ADRENAL HORMONES

ACTHAR H.P. 6 MSD

CORTEF 3 M

cortisone 1

deltasone 1

dexamethasone 1

dexamethasone

intensol

1

DEXPAK 10 DAY 3

DEXPAK 13 DAY 3

DEXPAK 6 DAY 3

fludrocortisone 1 M

hydrocortisone 1 M

MEDROL 3

MEDROL (PAK) 3

methylprednisolone 1

millipred dp 1

MILLIPRED ORAL

SOLUTION

3

millipred oral tablet 1

ORAPRED ODT 3

PEDIAPRED 3



51

Drug Name Drug

Tier

Requirements

/ Limits

prednisolone 1

prednisolone sodium

phosphate

1

prednisone 1

prednisone intensol 1

RAYOS 3

veripred 20 1

ANTITHYROID AGENTS

methimazole 1 M

propylthiouracil 1 M

SSKI 3 M

TAPAZOLE 3 M

BLOOD GLUCOSE MONITORING

DEVICES & SUPPLIES

ACCU-CHEK

AVIVA PLUS

TEST STRP

3 OTC

ACCU-CHEK

COMPACT TEST

3 OTC

ACCU-CHEK

SMARTVIEW

TEST STRIP

3 OTC

ACCUTREND

GLUCOSE

3 OTC

ADVANCED

GLUC METER

TEST STRIP

3 OTC

ADVOCATE REDI-

CODE

3 OTC

ADVOCATE TEST

STRIPS

3 OTC

AGAMATRIX

AMP TEST STRIPS

3 OTC

ASSURE 4 STRIPS 3 OTC

Drug Name Drug

Tier

Requirements

/ Limits

ASSURE

PLATINUM

3 OTC

ASSURE PRISM

MULTI STRIP

3 OTC

BIONIME

RIGHTEST TEST

STRIPS

3 OTC

BLOOD GLUCOSE

TEST

3 OTC

BREEZE 2 TEST

STRIPS

3 OTC

CARESENS N

TEST STRIPS

3 OTC

CLEVER CHOICE

MICRO TEST

STRIP

3 OTC

CLEVER CHOICE

PRO

3 OTC

CLEVER CHOICE

TEST STRIPS

3 OTC

CLEVER CHOICE

VOICE+ TEST

3 OTC

CONTOUR NEXT

STRIPS

3 OTC

CONTOUR TEST

STRIPS

3 OTC

CONTROL G3 3 OTC

COOL GLUCOSE

TEST STRIP

3 OTC

DIATRUE PLUS

TEST STRIP

3 OTC

EASY PLUS II

TEST

3 OTC

EASY STEP 3 OTC

EASY TALK

GLUCOSE TEST

3 OTC



52

Drug Name Drug

Tier

Requirements

/ Limits

EASY TOUCH

TEST STRIP

3 OTC

EASY TRAK

GLUCOSE TEST

3 OTC

EASYGLUCO

PLUS

3 OTC

EASYGLUCO

TEST

3 OTC

EASYMAX 3 OTC

ELEMENT

COMPACT TEST

STRIPS

3 OTC

ELEMENT TEST

STRIPS

3 OTC

EMBRACE

BLOOD GLUCOSE

SYSTEM

3 OTC

EMBRACE EVO

TEST STRIPS

3 OTC

EMBRACE PRO

TEST STRIPS

3 OTC

EVENCARE G2 3 OTC

EVENCARE G3

TEST

3 OTC

EVENCARE MINI

GLUCOSE TEST

STR

3 OTC

EVOLUTION TEST

STRIPS

3 OTC

EZ SMART PLUS

TEST

3 OTC

EZ SMART TEST 3 OTC

FIFTY50 TEST

STRIP

3 OTC

FORA D10 3 OTC

FORA D15G 3 OTC

Drug Name Drug

Tier

Requirements

/ Limits

FORA D20 3 OTC

FORA D40-G31

TEST STRIPS

3 OTC

FORA G20 3 OTC

FORA G30A 3 OTC

FORA GD50 TEST

STRIPS

3 OTC

FORA TEST STRIP 3 OTC

FORA TN'G VOICE

TEST STRIPS

3 OTC

FORA V10 3 OTC

FORA V12

GLUCOSE

3 OTC

FORA V20 3 OTC

FORACARE GD20 3 OTC

FORACARE GD40 3 OTC

FORTISCARE

GLUCOSE TEST

STRIPS

3 OTC

FREESTYLE

INSULINX

2 OTC

FREESTYLE

INSULINX TEST

STRIPS

2 OTC

FREESTYLE LITE

STRIPS

2 OTC

FREESTYLE

PRECISION NEO

STRIPS

3 OTC

FREESTYLE TEST 2 OTC

GE100 BLOOD

GLUCOSE TEST

STRIP

3 OTC

GENSTRIP TEST

STRIP

3 OTC



53

Drug Name Drug

Tier

Requirements

/ Limits

GLUCO NAVII

TEST STRIP

3 OTC

GLUCOCARD 01

SENSOR PLUS

3 OTC

GLUCOCARD

EXPRESSION

3 OTC

GLUCOCARD

SHINE TEST

STRIPS

3 OTC

GLUCOCARD

VITAL SENSOR

3 OTC

GLUCOCARD

VITAL TEST

STRIPS

3 OTC

GLUCOCOM

GLUCOSE

3 OTC

GM100 3 OTC

GMATE TEST

STRIPS

3 OTC

HEALTHPRO

TEST STRIPS

3 OTC

INFINITY TEST

STRIPS

3 OTC

LIBERTY TEST 3 OTC

MICRO BLOOD

GLUCOSE

3 OTC

MICRODOT

BLOOD GLUCOSE

SYSTEM

3 OTC

MYGLUCOHEALT

H

3 OTC

NEUTEK 2TEK

TEST STRIPS

3 OTC

NOVA MAX

GLUCOSE TEST

3 OTC

Drug Name Drug

Tier

Requirements

/ Limits

ON CALL

EXPRESS TEST

STRIP

3 OTC

ON CALL PLUS

TEST STRIP

3 OTC

ON CALL VIVID

TEST STRIP

3 OTC

ONETOUCH

ULTRA TEST

3 OTC

ONETOUCH

VERIO

3 OTC

OPTIUM EZ 3 OTC

OPTIUM TEST 3 OTC

OPTUMRX 3 OTC

PHARMACIST

CHOICE

3 OTC

PRECISION PCX

PLUS TEST

3 OTC

PRECISION PCX

TEST

3 OTC

PRECISION POINT

OF CARE TEST

3 OTC

PRECISION Q-I-D

TEST

3 OTC

PRECISION XTRA

TEST

3 OTC

PREMIUM V10 3 OTC

PRODIGY NO

CODING

3 OTC

QUINTET AC 3 OTC

REFUAH PLUS 3 OTC

RELION

CONFIRM-MICRO

3 OTC

RELION PRIME

TEST STRIPS

3 OTC



54

Drug Name Drug

Tier

Requirements

/ Limits

REVEAL TEST

STRIP

3 OTC

RIGHTEST GS550

TEST STRIPS

3 OTC

SMART SENSE

TEST STRIPS

3 OTC

SMARTEST TEST 3 OTC

SOLUS V2 TEST

STRIPS

3 OTC

SURE-TEST

EASYPLUS MINI

3 OTC

TELCARE TEST

STRIPS

3 OTC

TEST N'GO TEST 3 OTC

TRUE METRIX

GLUCOSE TEST

STRIP

3 OTC

TRUETEST TEST

STRIPS

3 OTC

TRUETRACK

TEST

3 OTC

ULTIMA TEST

STRIPS

3 OTC

ULTRATRAK 3 OTC

ULTRATRAK

ULTIMATE

3 OTC

UNISTRIP1 TEST

STRIP

3 OTC

WAVESENSE

JAZZ

3 OTC

WAVESENSE

PRESTO

3 OTC

DIABETES, SUPPLIES, & DURABLE

MEDICAL EQUIPMENT

GLUCAGEN

DIAGNOSTIC KIT

2

Drug Name Drug

Tier

Requirements

/ Limits

GLUCAGON HCL 3

GLUCOSE ELEVATING AGENTS

GLUCAGEN

HYPOKIT

2

GLUCAGON

EMERGENCY KIT

(HUMAN)

2

PROGLYCEM 2 M

INSULIN

SYRINGES/MISCELLANEOUS

DURABLE MEDICAL EQU

1ST TIER UNIFINE

PENTIPS

2 M; OTC

1ST TIER UNILET

COMFORTOUCH

2 OTC

2TEK

GLUCOSE/BLOOD

PRESSURE

3 OTC

ACCU-CHEK

AVIVA CONNECT

METER

3

ACCU-CHEK

AVIVA PLUS

METER

3 OTC

ACCU-CHEK

COMP BLUE

CONT, M-H

3 OTC

ACCU-CHEK

COMPACT PLUS

CONTROL

3 OTC

ACCU-CHEK

FASTCLIX

2 OTC

ACCU-CHEK

NANO

3 OTC

ACCU-CHEK

SAFE-T-PRO

2 OTC



55

Drug Name Drug

Tier

Requirements

/ Limits

ACCU-CHEK

SMARTVIEW

CONTRL SOL

3 OTC

ACCU-CHEK

SOFTCLIX

LANCET DEV

2 OTC

ACCU-CHEK

SOFTCLIX

LANCETS

2 OTC

ACCU-CHEK

VOICEMATE

3 OTC

ACCUTREND

GLUCOSE

CONTROL

3 OTC

ACTI-LANCE

LANCETS

2 OTC

ADJUSTABLE

LANCING DEVICE

2 OTC

ADVANCED

GLUCOSE METER

3 OTC

ADVANCED

LANCING DEVICE

2 OTC

ADVANCED

TRAVEL

LANCETS

2 OTC

ADVOCATE

BLOOD GLUCOSE

MONITOR

3 OTC

ADVOCATE DUO 3 OTC

ADVOCATE

LANCET

2 OTC

ADVOCATE LOW

CONTROL

3 OTC

ADVOCATE PEN

NEEDLES

2 M; OTC

ADVOCATE

RAPID-SAFE

LANCING

2 OTC

Drug Name Drug

Tier

Requirements

/ Limits

ADVOCATE REDI-

CODE DUO

METER

3 OTC

ADVOCATE REDI-

CODE GLU

MONITOR

3 OTC

ADVOCATE REDI-

CODE+ CTRL

LOW

3 OTC

AGAMATRIX

AMP GLUC

MONITOR SYS

3 OTC

AGAMATRIX

CONTROL HIGH

3 OTC

ALTERNATE SITE

LANCET

2 OTC

ALTERNATE SITE

LANCING DEVICE

2 OTC

AQUA LANCE

LANCING DEVICE

2 OTC

ASSURE 4

CONTROL

SOLUTION

3 OTC

ASSURE DOSE

NORMAL

CONTROL

3 OTC

ASSURE

HAEMOLANCE

PLUS

2 OTC

ASSURE LANCE 2 OTC

ASSURE LANCE

PLUS

2 OTC

ASSURE

PLATINUM

3 OTC

ASSURE PRISM

CONTROL 1-2

SOLN

3 OTC



56

Drug Name Drug

Tier

Requirements

/ Limits

ASSURE PRISM

MULTI METER

3 OTC

AUTOJECT 2

INJECTION

DEVICE

2 OTC

AUTO-LANCET

MINI

2 OTC

AUTOLET

IMPRESSION

LANC DEV

2 OTC

AUTOLET

LANCING DEVICE

2 OTC

AUTOPEN 2 TO 32

UNITS

2 OTC

BD AUTOSHIELD

PEN NEEDLE

2 M; OTC

BD INSULIN PEN

NEEDLE UF

SHORT

2 M

BD LANCET

DEVICE

2 OTC

BD

MICROTAINER

LANCET

2 OTC

BD ULTRA FINE

LANCETS

2 OTC

BD ULTRA-FINE

NANO PEN

NEEDLES

2 M; OTC

BIONIME

RIGHTEST GM300

SYSTEM

3 OTC

BLOOD GLUCOSE

CONTROL,

NORMAL

3 OTC

BLOOD-GLUCOSE

METER

3 OTC

Drug Name Drug

Tier

Requirements

/ Limits

BREEZE 2

CONTROL

SOLUTION,HIGH

3 OTC

BULLSEYE MINI

SAFETY

LANCETS

2 OTC

CAREFINE PEN

NEEDLE

2 M; OTC

CAREONE THIN

LANCET

2 OTC

CARESENS

CONTROL A

NORMAL

3 OTC

CARESENS N 3 OTC

CARESENS N

VOICE

3 OTC

CLEO 90

INFUSION SET 24"

2

CLEVER CHEK

BLOOD GLUCOSE

3 OTC

CLEVER CHEK

LANCETS

2 OTC

CLEVER CHOICE

GLUCOSE

MONITOR

3 OTC

CLEVER CHOICE

LEVEL 2

CONTROL

3 OTC

CLEVER CHOICE

MICRO

3 OTC

CLEVER CHOICE

PRO

3 OTC

CLICKFINE 2 M; OTC

COAGUCHEK

LANCETS

2 OTC

COLOR LANCETS 2 OTC



57

Drug Name Drug

Tier

Requirements

/ Limits

COMFORT EZ PEN

NEEDLES

2 M; OTC

COMFORT

LANCETS

2 OTC

COMFORT SHORT

INSULIN PUMP

23"

2

CONTOUR

CONTROL

SOLUTION, NML

3 OTC

CONTOUR LINK 3 OTC

CONTOUR NEXT

EZ METER

3 OTC

CONTOUR NEXT

LEV 2 CONTROL

SOL

3 OTC

CONTOUR NEXT

LINK

3 OTC

CONTOUR NEXT

METER

3 OTC

CONTOUR NEXT

USB METER

3 OTC

CONTROL

MONITORING

SYSTEM

3 OTC

COOL BLOOD

GLUCOSE METER

3 OTC

COOL CONTROL

A SOLUTION

3 OTC

DEXCOM G5

RECEIVER

3

DIATRUE

CONTROL SOLN

NORMAL

3 OTC

DIATRUE PLUS

BLOOD GLUCOSE

MET

3 OTC

Drug Name Drug

Tier

Requirements

/ Limits

DROPLET

LANCETS

2 OTC

DROPLET

LANCING DEVICE

2 OTC

DROPLET PEN

NEEDLE

2 M; OTC

EASY CLICK

LANCING DEVICE

2 OTC

EASY COMFORT

LANCETS

2 OTC

EASY COMFORT

PEN NEEDLES

2 M; OTC

EASY MINI EJECT

LANCING DEVICE

2 OTC

EASY PLUS II

BLOOD GLUCOSE

MET

3 OTC

EASY STEP

BLOOD GLUCOSE

METER

3 OTC

EASY TALK

BLOOD GLUCOSE

METER

3 OTC

EASY TOUCH

FLIPLOCK

NEEDLE

3 M

EASY TOUCH

GLUCOSE

MONITOR

3 OTC

EASY TOUCH

HYPODERMIC

NEEDLE

3 M

EASY TOUCH

LANCING DEVICE

2 OTC

EASY TRAK

BLOOD GLUCOSE

METER

3 OTC



58

Drug Name Drug

Tier

Requirements

/ Limits

EASYGLUCO

MONITORING

SYSTEM

3 OTC

EASYMAX L

BLOOD GLUCOSE

METER

3 OTC

EASYMAX LOW

CONTROL

3 OTC

EASYMAX NG 3 OTC

EASYMAX

NORMAL

CONTROL

3 OTC

EASYMAX V

SPEAKING

GLUCOSE SYS

3 OTC

EASYMAX V2

BLOOD GLUCOSE

METER

3 OTC

ELEMENT

COMPACT

GLUCOSE METER

3 OTC

ELEMENT

COMPACT

NORMAL

CONTROL

3 OTC

ELEMENT

COMPACT V

GLUCOSE MTR

3 OTC

ELEMENT

NORMAL

CONTROL

3 OTC

ELEMENT PLUS

BLOOD GLUCOSE

KIT

3 OTC

EMBRACE

BLOOD GLUCOSE

SYSTEM

3 OTC

EMBRACE EVO

LEVEL 1

3 OTC

Drug Name Drug

Tier

Requirements

/ Limits

EMBRACE

GLUCOSE

CONTROL LOW

3 OTC

EMBRACE PRO

GLUCOSE METER

3 OTC

EVENCARE G2 3 OTC

EVENCARE G3

GLUCOSE METER

3 OTC

EVENCARE MINI

MONITOR

SYSTEM

3 OTC

EVOLUTION

BLOOD GLUCOSE

METER

3 OTC

EVOLUTION

NORMAL

CONTROL

3 OTC

e-z ject lancets 1 OTC

EZ SMART

LANCETS

2 OTC

EZ SMART PLUS

SYSTEM

3 OTC

EZ SMART

SYSTEM

3 OTC

FIFTY50 SAFETY

SEAL LANCETS

2 OTC

FINE 30

UNIVERSAL

LANCETS

2 OTC

FINGERSTIX

LANCETS

2 OTC

FIRST CHOICE

LANCETS THIN

2 OTC

FORA D10 3 OTC

FORA D20 3 OTC

FORA G20 3 OTC



59

Drug Name Drug

Tier

Requirements

/ Limits

FORA G30A 3 OTC

FORA GD50

BLOOD GLUCOSE

SYSTEM

3 OTC

FORA LANCING

DEVICE

2 OTC

FORA NORMAL

CONTROL

3 OTC

FORA TEST N'GO

VOICE METER

3 OTC

FORA TN'G VOICE

METER

3 OTC

FORA V10 3 OTC

FORA V10-V12-

D10-D20

3 OTC

FORA V12 BLOOD

GLUCOSE

SYSTEM

3 OTC

FORA V20 3 OTC

FORA V30A 3 OTC

FORACARE GD20

GLUCOSE METER

3 OTC

FORACARE

GD40A GLUCOSE

METER

3 OTC

FORACARE

GD40B GLUCOSE

METER

3 OTC

FORACARE GDH

LOW CONTROL

3 OTC

FORACARE

LANCETS

2 OTC

FORTISCARE

BLOOD GLUCOSE

SYST

3 OTC

FORTISCARE

NORMAL

3 OTC

Drug Name Drug

Tier

Requirements

/ Limits

FREESTYLE

CONTROL

2 OTC

FREESTYLE

FLASH SYSTEM

2 OTC

FREESTYLE

FREEDOM

2 OTC

FREESTYLE

FREEDOM LITE

2 OTC

FREESTYLE

INSULINX

2 OTC

FREESTYLE

LANCETS

2 OTC

FREESTYLE LITE

METER

2 OTC

FREESTYLE

PRECISION NEO

METER

3 OTC

FREESTYLE

SIDEKICK II

2 OTC

FREESTYLE

SYSTEM KIT

2 OTC

FREESTYLE

UNISTIK 2

2 OTC

GE100 BLOOD

GLUCOSE

SYSTEM

3 OTC

GE100 CONTROL

SOLUTION

NORMAL

3 OTC

GLUCO NAVII

GLUCOSE

MONITOR

3 OTC

GLUCOCARD 01

METER

3 OTC

GLUCOCARD 01

NORMAL

CONTROL

3 OTC



60

Drug Name Drug

Tier

Requirements

/ Limits

GLUCOCARD

EXPRESSION

3 OTC

GLUCOCARD

SHINE METER

3 OTC

GLUCOCARD

VITAL

3 OTC

GLUCOCOM

BLOOD GLUCOSE

3 OTC

GLUCOCOM

CONTROL

NORMAL

3 OTC

GLUCOCOM

LANCETS

2 OTC

GLUCOSE

CONTROL

3 OTC

GM100 3 OTC

GMATE

CONTROL

SOLUTION,

NORMAL

3 OTC

GMATE LANCETS 2 OTC

GMATE LANCING

DEVICE

2 OTC

GMATE SMART

METER

3 OTC

GMATE SMART

STARTER

3 OTC

GMATE VOICE

METER

3 OTC

HEALTHPRO

GLUCOSE

MONITOR

3 OTC

HEALTHPRO

HIGH-LOW

CONTROL

3 OTC

Drug Name Drug

Tier

Requirements

/ Limits

HEALTHY

ACCENTS

AUTOLET

2 OTC

HEALTHY

ACCENTS

UNIFINE PENTIP

2 M; OTC

HEALTHY

ACCENTS UNILET

LANCET

2 OTC

HUMAPEN

LUXURA HD

2

HYPOLANCE AST

LANCING

2 OTC

INCONTROL

LANCING DEVICE

2 OTC

INCONTROL PEN

NEEDLE

2 M; OTC

INCONTROL

SUPER THIN

LANCETS

2 OTC

INCONTROL

ULTRA THIN

LANCETS

2 OTC

INFINITY

CONTROL

SOLUTION NORM

3 OTC

INFINITY

STARTER KIT

3 OTC

INJECT EASE

LANCETS

2 OTC

INSUPEN 2 M; OTC

INVACARE

LANCETS

2 OTC

JAZZ WIRELESS 2

METER KIT

3 OTC

KINNEY BRAND

LANCETS

2 OTC



61

Drug Name Drug

Tier

Requirements

/ Limits

LANCETS 2 OTC

LANCETS,THIN 2 OTC

LANCING DEVICE

WITH LANCETS

2 OTC

LANCING

SYSTEM

2 OTC

LANZO LANCING

DEVICE

2 OTC

LIBERTY LEV 1

GLUCOSE

CONTROL

3 OTC

LIBERTY LEV 2

GLUCOSE

CONTROL

3 OTC

LITE TOUCH

LANCETS

2 OTC

MEDISENSE 3 OTC

MEDISENSE

GLUCOSE

KETONE

3 OTC

MEDISENSE THIN

LANCETS

2 OTC

MEDLANCE PLUS

LANCETS

2 OTC

MEDLANCE PLUS

SPECIAL BLADE

2 OTC

MICRO THIN

LANCETS

2 OTC

MICRODOT

BLOOD GLUCOSE

SYSTEM

3 OTC

MICROLET

LANCET

2 OTC

MINI LANCING

DEVICE

2 OTC

MINI ULTRA-

THIN II

2 M; OTC

Drug Name Drug

Tier

Requirements

/ Limits

MONOLET THIN

LANCETS

2 OTC

MULTI-LANCET

DEVICE 2

2 OTC

MYGLUCOHEALT

H

3 OTC

MYGLUCOHEALT

H CONTROL

SOLUTION

3 OTC

MYGLUCOHEALT

H LANCETS

2 OTC

NOVA MAX

BLOOD GLUCOSE

METER

3 OTC

NOVA MAX

GLUCOSE

CONTROL

3 OTC

NOVA SAFETY

LANCETS

2 OTC

NOVA SUREFLEX

LANCETS

2 OTC

NOVAMAX PLUS

GLU-KET

3 OTC

NOVOFINE 32 2 M; OTC

NOVOFINE

AUTOCOVER

2 M; OTC

NOVOFINE PLUS 2 M; OTC

NOVOPEN ECHO 3

NOVOTWIST 2 M; OTC

ON CALL

EXPRESS

CONTROL

3 OTC

ON CALL

EXPRESS METER

3 OTC

ON CALL LANCET 2 OTC



62

Drug Name Drug

Tier

Requirements

/ Limits

ON CALL

LANCING DEVICE

2 OTC

ON CALL PLUS

CONTROL

3 OTC

ON CALL PLUS

LANCET

2 OTC

ON CALL PLUS

LANCING DEVICE

2 OTC

ON CALL PLUS

METER

3 OTC

ON CALL VIVID

CONTROL

3 OTC

ON CALL VIVID

METER

3 OTC

ON CALL VIVID

PAL METER

3 OTC

ONETOUCH

DELICA LANC

DEVICE

2 OTC

ONETOUCH

SURESOFT

LANCING DEV

2 OTC

ONETOUCH

ULTRA CONTROL

3 OTC

ONETOUCH

ULTRA2

3 OTC

ONETOUCH

ULTRAMINI

3 OTC

ONETOUCH

ULTRASOFT

LANCETS

2 OTC

ONETOUCH

VERIO FLEX

3 OTC

ONETOUCH

VERIO IQ METER

3 OTC

ONETOUCH

VERIO SYNC

3 OTC

Drug Name Drug

Tier

Requirements

/ Limits

ONETOUCH

VERIO SYSTEM

3 OTC

ON-THE-GO

LANCETS

2 OTC

OPTUMRX 3 OTC

PEN NEEDLE 2 M; OTC

PEN NEEDLE,

DIABETIC

2 M; OTC

PENTIPS 2 M; OTC

PENTIPS PEN

NEEDLE

2 M; OTC

PHARMACIST

CHOICE

GLUCOSE SYS

3 OTC

PHASEAL

PROTECTOR

3 M

POLY HUB

NEEDLE

2 M

PRECISION XTRA

MONITOR

3 OTC

PREMIUM BLOOD

GLUCOSE

MONITOR

3 OTC

PREMIUM V10 3 OTC

PRESSURE

ACTIVATED

LANCETS

2 OTC

PRESTO PRO

BLOOD GLUCOSE

METER

3 OTC

PRODIGY

AUTOCODE

METER

3 OTC

PRODIGY

AUTOCODE

MONITOR SYST

3 OTC



63

Drug Name Drug

Tier

Requirements

/ Limits

PRODIGY

CONTROL

SOLUTION, LOW

3 OTC

PRODIGY

CONTROL

SOLUTION,HIGH

3 OTC

PRODIGY

LANCETS

2 OTC

PRODIGY

LANCING DEVICE

2 OTC

PRODIGY

POCKET METER

3 OTC

PRODIGY TWIST

TOP LANCET

2 OTC

PRODIGY VOICE

GLUCOSE METER

3 OTC

QUINTET BLOOD

GLUCOSE METER

3 OTC

REFUAH PLUS

GLUCOSE

CONTROL

3 OTC

REFUAH PLUS

GLUCOSE

MONITOR

3 OTC

RELIAMED

LANCET

2 OTC

RELIAMED MINI

LANCING DEVICE

2 OTC

RELIAMED

SAFETY SEAL

LANCETS

2 OTC

RELION CONFIRM 3 OTC

RELION MICRO

GLUCOSE

MONITOR

3 OTC

RELION NEEDLES 2 M; OTC

Drug Name Drug

Tier

Requirements

/ Limits

RELION PEN

NEEDLES

2 M; OTC

RELION PRIME

METER

3 OTC

RELION THIN

LANCETS

2 OTC

RELION ULTRA

THIN PLUS

LANCETS

2 OTC

REVEAL BLOOD

GLUCOSE METER

3 OTC

RIGHTEST

CONTROL

SOLUTION HIGH

3 OTC

RIGHTEST GD500

LANCING DEVICE

2 OTC

RIGHTEST GL300

LANCETS

2 OTC

RIGHTEST GM550

SYSTEM

3 OTC

SAFETY

LANCETS

2 OTC

SAFETY SEAL

LANCETS

2 OTC

SAFETY-LET

LANCETS

2 OTC

SIDEKICK BLOOD

GLUCOSE

SYSTEM

3 OTC

SINGLE-LET 2 OTC

SMART SENSE

LANCETS

2 OTC

SMART SENSE

MONITORING

SYSTEM

3 OTC

SMARTDIABETES

VANTAGE

2 OTC



64

Drug Name Drug

Tier

Requirements

/ Limits

SMARTEST

CONTROL

3 OTC

SMARTEST EJECT 3 OTC

SMARTEST

LANCET

2 OTC

SMARTEST

PERSONA

STARTER

3 OTC

SMARTEST

PRONTO

STARTER

3 OTC

SMARTEST

PROTEGE

3 OTC

SNAP INSULIN

PUMP

CONTROLLER

2

SOFT TOUCH

LANCETS

2 OTC

SOLUS V2

AUDIBLE METER

3 OTC

SOLUS V2

CONTROL

SOLUTION,HIGH

3 OTC

SOLUS V2

LANCETS

2 OTC

SOLUS V2

LANCING DEVICE

2 OTC

STERILANCE TL 2 OTC

SUPER THIN

LANCETS

2 OTC

SURE COMFORT

LANCETS

2 OTC

SURE COMFORT

LANCING PEN

2 OTC

SURE COMFORT

PEN NEEDLE

2 M; OTC

Drug Name Drug

Tier

Requirements

/ Limits

SURE-FINE PEN

NEEDLES

2 M; OTC

SUREFLEX

LANCING DEVICE

2 OTC

SURE-LANCE 2 OTC

SURE-PEN

LANCING DEVICE

2 OTC

SURE-TEST

EASYPLUS MINI

METER

3 OTC

SURE-TOUCH

LANCET

2 OTC

T:30 INFUSION

SET

2

T:90 INFUSION

SET 23"

2

T:SLIM 2

T:SLIM G4 2

TECHLITE

LANCETS

2 OTC

TECHLITE PEN

NEEDLE

2 M; OTC

TELCARE BGM 3 OTC

TELCARE BLOOD

GLUCOSE KIT

3 OTC

TELCARE

CONTROL

3 OTC

TEST N'GO

BLOOD GLUCOSE

SYSTEM

3 OTC

TOPCARE

UNIVERSAL1

LANCET

2 OTC

TRUE METRIX

AIR GLUCOSE

METER

3 OTC



65

Drug Name Drug

Tier

Requirements

/ Limits

TRUE METRIX

GLUCOSE METER

3 OTC

TRUE METRIX

LEVEL 1

3 OTC

TRUE2GO BLOOD

GLUCOSE

SYSTEM

3 OTC

TRUECONTROL

LEVEL 0

3 OTC

TRUEDRAW

LANCING DEVICE

2 OTC

TRUEPLUS

LANCETS

2 OTC

TRUERESULT

BLOOD GLUCOSE

SYSTM

3 OTC

TRUETEST LOW

GLUCOSE

CONTROL

3 OTC

TRUETRACK

BLOOD GLUCOSE

SYSTEM

3 OTC

TRUETRACK

SMART SYSTEM

3 OTC

ULTICARE PEN

NEEDLE

2 M; OTC

ULTI-LANCE 2 OTC

ULTILET BASIC

LANCETS

2 OTC

ULTILET CLASSIC

LANCETS

2 OTC

ULTILET

LANCETS

2 OTC

ULTILET SAFETY

LANCETS

2 OTC

ULTIMA

MONITOR

3 OTC

Drug Name Drug

Tier

Requirements

/ Limits

ULTRA THIN

LANCETS

2 OTC

ULTRA THIN

PLUS LANCETS

2 OTC

ULTRA TLC

LANCETS

2 OTC

ULTRALANCE

LANCETS

2 OTC

ULTRA-THIN II

INS PEN NEEDLES

2 M; OTC

ULTRATRAK

GLUCOSE METER

3 OTC

ULTRATRAK

ULTIMATE

3 OTC

UNIFINE PENTIPS 2 M; OTC

UNIFINE PENTIPS

PLUS

2 M; OTC

UNILET

COMFORTOUCH

LANCET

2 OTC

UNILET

EXCELITE II

LANCET

2 OTC

UNILET

EXCELITE

LANCET

2 OTC

UNILET GP

LANCET

2 OTC

UNILET LANCET 2 OTC

UNISTIK 2

DEVICE

2 OTC

UNISTIK 2

NORMAL

LANCET,DEVICE

2 OTC

UNISTIK 3 2 OTC

UNISTIK 3 EXTRA

LANCET

2 OTC



66

Drug Name Drug

Tier

Requirements

/ Limits

UNISTIK CZT

LANCET

2 OTC

UNISTIK SAFETY 2 OTC

UNISTIK TOUCH

LANCETS

2 OTC

UNISTRIP LOW

CONTROL

3 OTC

UNIVERSAL 1

LANCETS

2 OTC

VGO 20 6 MSD

VGO 30 6 MSD

VGO 40 6 MSD

VOCALPOINT

GLUCOSE

CONTROL

3 OTC

WAVESENSE AMP 3 OTC

WAVESENSE

CONTROL

SOLUTION

3 OTC

WAVESENSE

PRESTO

3 OTC

INSULIN THERAPY

AFREZZA 3 M

APIDRA 3 M

APIDRA

SOLOSTAR

3 M

HUMALOG 2 M

HUMALOG

KWIKPEN

2 M

HUMALOG MIX

50-50

2 M

HUMALOG MIX

50-50 KWIKPEN

2 M

HUMALOG MIX

75-25

2 M

Drug Name Drug

Tier

Requirements

/ Limits

HUMALOG MIX

75-25 KWIKPEN

2 M

HUMULIN 70/30 2 M

HUMULIN 70/30

KWIKPEN

2 M

HUMULIN N 2 M

HUMULIN N

KWIKPEN

2 M

HUMULIN R 2 M

HUMULIN R U-500

(CONC) KWIKPEN

2 M

HUMULIN R U-500

(CONCENTRATED

)

2 M

LANTUS 2 M

LANTUS

SOLOSTAR

2 M

LEVEMIR 2 M

LEVEMIR

FLEXTOUCH

2 M

NOVOLIN 70/30 3 M

NOVOLIN N 3 M

NOVOLIN R 3 M

NOVOLOG 3 M

NOVOLOG

FLEXPEN

3 M

NOVOLOG MIX

70-30

3 M

NOVOLOG MIX

70-30 FLEXPEN

3 M

NOVOLOG

PENFILL

3 M

TOUJEO

SOLOSTAR

3 M



67

Drug Name Drug

Tier

Requirements

/ Limits

TRESIBA

FLEXTOUCH U-

100

3 M

TRESIBA

FLEXTOUCH U-

200

3 M

MISCELLANEOUS HORMONES

ALDURAZYME 6 MSD

ANADROL-50 3

ANDRODERM 3 PA

ANDROGEL 3 PA

ANDROID 3

androxy 1

AVEED 6 MSD

AXIRON 2 PA

cabergoline 1 M; QL

calcitriol 1 M

CERDELGA 3 LA

CEREZYME 6 MSD

danazol 1

DDAVP 3 M

DEPO-

TESTOSTERONE

3 PA

desmopressin 1 M

doxercalciferol

intravenous

6 MSD

doxercalciferol oral 1 M

ELAPRASE 6 MSD

ELELYSO 6 MSD

FABRAZYME 6 MSD

FORTESTA 3 PA

GANIRELIX 4 ST; LA

Drug Name Drug

Tier

Requirements

/ Limits

HECTOROL

INTRAVENOUS

6 MSD

HECTOROL ORAL 3 M

KORLYM 3 PA; LA

KUVAN 2 PA; LA

LUMIZYME 6 MSD

METHITEST 2

methyltestosterone 1

MIACALCIN

INJECTION

6 MSD

MIACALCIN

NASAL

3 M

MYALEPT 2 LA

MYOZYME 6 MSD

NAGLAZYME 6 MSD

NATESTO 3 PA

NATPARA 3 PA; LA

OXANDRIN 3

oxandrolone 1

pamidronate 6 MSD

PARICALCITOL

HEMODIALYSIS

PORT INJECTION

6 MSD; M

paricalcitol oral 1 M

ROCALTROL 3 M

SAMSCA 2 PA; QL

SENSIPAR 2 PA

SOMAVERT 3 LA

STIMATE 2 M

STRENSIQ 3 LA

STRIANT 3 PA

SYNAREL 3



68

Drug Name Drug

Tier

Requirements

/ Limits

TESTIM 3 PA

TESTONE CIK 3 PA

testosterone

cypionate

1 PA

testosterone

enanthate

1 PA

testosterone

transdermal gel in

metered-dose pump

1.25 gram/ actuation

(1 %)

1 PA

TESTOSTERONE

TRANSDERMAL

GEL IN

METERED-DOSE

PUMP 10 MG/0.5

GRAM

/ACTUATION

3 PA

testosterone

transdermal gel in

packet

1 PA

TESTRED 3

VIMIZIM 6 MSD

VOGELXO 3 PA

VPRIV 6 MSD

ZAVESCA 2

ZEMPLAR

INTRAVENOUS

6 MSD

ZEMPLAR ORAL 3 M

zoledronic acid 6 MSD

ZOLEDRONIC

ACID-MANNITOL-

WATER

6 MSD

ZOMETA 6 MSD

NON-INSULIN HYPOGLYCEMIC

AGENTS

Drug Name Drug

Tier

Requirements

/ Limits

acarbose 1 M

ACTOPLUS MET 3 ST; M; QL

ACTOPLUS MET

XR

2 ST; M; QL

ACTOS 3 ST; M; QL

ALOGLIPTIN 3 M; QL

ALOGLIPTIN-

METFORMIN

3 M; QL

ALOGLIPTIN-

PIOGLITAZONE

3 M; QL

AMARYL 3 M

AVANDIA 3 ST; M; QL

BYDUREON

SUBCUTANEOUS

PEN INJECTOR

2 PA; M

BYDUREON

SUBCUTANEOUS

SUSPENSION,EXT

ENDED REL

RECON

2 PA; M; QL

BYETTA 2 PA; M; QL

chlorpropamide 1 M

CYCLOSET 3 M

DUETACT 3 ST; M; QL

FARXIGA 3 M

FORTAMET 3 ST; M

glimepiride 1 M

glipizide 1 M

glipizide-metformin 1 M

GLUCOPHAGE 3 ST; M

GLUCOPHAGE XR 3 ST; M

GLUCOTROL 3 M

GLUCOTROL XL 3 M



69

Drug Name Drug

Tier

Requirements

/ Limits

GLUCOVANCE 3 M

GLUMETZA 3 ST; M

glyburide 1 M

glyburide

micronized

1 M

glyburide-metformin 1 M

GLYNASE 3 M

GLYSET 3 M

GLYXAMBI 3 M

INVOKAMET 2 M

INVOKANA 2 M; QL

JANUMET 2 M; QL

JANUMET XR 2 M; QL

JANUVIA 2 M; QL

JARDIANCE 3 M

JENTADUETO 2 M; QL

JENTADUETO XR 2 M

KAZANO 3 M; QL

KOMBIGLYZE XR 3 M; QL

metformin oral

tablet

1 M

metformin oral

tablet extended

release 24 hr

1 M

metformin oral

tablet extended

release 24hr

1 ST; M

metformin oral

tablet,er

gast.retention 24 hr

1 ST; M

miglitol 1 M

nateglinide 1 M

NESINA 3 M; QL

Drug Name Drug

Tier

Requirements

/ Limits

ONGLYZA 3 M; QL

OSENI 3 M; QL

pioglitazone 1 M; QL

pioglitazone-

glimepiride

1 M; QL

pioglitazone-

metformin

1 M; QL

PRANDIN 3 M

PRECOSE 3 M

repaglinide 1 M

repaglinide-

metformin

1 M; QL

RIOMET 2 ST; M

STARLIX 3 M

SYMLINPEN 120 2 PA; M; QL

SYMLINPEN 60 2 PA; M; QL

SYNJARDY 3 M

TANZEUM 3 PA; M; QL

tolazamide 1 M

tolbutamide 1 M

TRADJENTA 2 QL

TRULICITY 3 PA; M; QL

VICTOZA 2-PAK 3 PA; M; QL

VICTOZA 3-PAK 3 PA; M; QL

XIGDUO XR 3 M

THYROID HORMONES

ARMOUR

THYROID

2 M

CYTOMEL 3 M

levothyroxine 1 M

levoxyl 1 M

liothyronine 1 M



70

Drug Name Drug

Tier

Requirements

/ Limits

nature-throid 1 M

np thyroid 1 M

SYNTHROID 3 M

THYROLAR-1 2 M

THYROLAR-1/2 2 M

THYROLAR-1/4 2 M

THYROLAR-2 2 M

THYROLAR-3 2 M

TIROSINT 3 M

unithroid 1 M

westhroid 1 M

WP THYROID 3 M

GASTROENTEROLOGY

ANTIDIARRHEALS &

ANTISPASMODICS

anaspaz 1

atropine 6 MSD

belladonna

alkaloids-opium

1

belladonna-opium 1

BENTYL 3

chlordiazepoxide-

clidinium

1

CUVPOSA 3

dicyclomine 1

diphenoxylate-

atropine

1

DONNATAL 3

ed-spaz 1

FULYZAQ 3

glycopyrrolate 1

hyoscyamine sulfate 1

Drug Name Drug

Tier

Requirements

/ Limits

hyosyne 1

LEVBID 3

LEVSIN 3

LEVSIN/SL 3

LIBRAX (WITH

CLIDINIUM)

3

LOMOTIL 3

methscopolamine 1

MOTOFEN 3

NULEV 3

opium tincture 1

oscimin 1

oscimin sl 1

oscimin sr 1

paregoric 1

phenohytro 1

propantheline 1

ROBINUL 3

ROBINUL FORTE 3

SYMAX DUOTAB 3

symax fastabs 1

symax-sl 1

symax-sr 1

MISCELLANEOUS

GASTROINTESTINAL AGENTS

ACTIGALL 3 M

AKYNZEO 2 QL

alosetron 1 M

ALOXI 6 MSD; QL

AMITIZA 3

ANA-LEX KIT 3



71

Drug Name Drug

Tier

Requirements

/ Limits

ANALPRAM E 3

ANALPRAM-HC 3

ANALPRAM-HC

SINGLES

3

anucort-hc 1

ANUSOL-HC 3

APRISO 2 M

ASACOL HD 3 M

AURYXIA 3

AZULFIDINE 3 M

AZULFIDINE EN-

TABS

3 M

balsalazide 1

bisacodyl 5 ACA; OTC

budesonide 1

calcium acetate 1

CANASA 2 M

CESAMET 3 QL

CHENODAL 2 PA; LA

CHOLBAM 2

CIMZIA 4 PA; ST; LA

CIMZIA POWDER

FOR RECONST

4 PA; ST; LA

citrate of magnesia 5 ACA; OTC

COLAZAL 3

colocort 1

COLYTE WITH

FLAVOR PACKS

3

COMPAZINE 3

compro 1

constulose 1

CORTENEMA 3

Drug Name Drug

Tier

Requirements

/ Limits

CORTIFOAM 2

CREON 2

cromolyn 1

CYSTADANE 2

DELZICOL 3 M

DICLEGIS 3

DIPENTUM 3 M

dronabinol 1

eliphos 1

EMEND 2 QL

ENTOCORT EC 3

ENTYVIO 2 MSD

enulose 1

FOSRENOL 3

GASTROCROM 3

GATTEX 30-VIAL 3 LA

gavilyte-c 5 ACA

gavilyte-g 5 ACA

gavilyte-h and

bisacodyl

5 ACA

gavilyte-n 5 ACA

generlac 1

GIAZO 3

GOLYTELY ORAL

POWDER IN

PACKET

5 ACA

GOLYTELY ORAL

RECON SOLN

3

granisetron hcl 1 QL

hemmorex-hc 1

hydrocortisone 1



72

Drug Name Drug

Tier

Requirements

/ Limits

hydrocortisone

acetate

1

hydrocortisone-

pramoxine

1

KAYEXALATE 3

kionex 1

kionex (with

sorbitol)

1

KRISTALOSE 3 M

lactulose 1

laxative peg 3350 5 ACA; OTC

LIALDA 3 M

lidocaine hcl-

hydrocortison ac

rectal cream

1

LIDOCAINE HCL-

HYDROCORTISO

N AC RECTAL

GEL

3

lidocaine hcl-

hydrocortison ac

rectal kit

1

lidocaine-

hydrocortisone-aloe

1

LINZESS 2

LOTRONEX 3 M

MAGNEBIND 400 3

MARINOL 3

mesalamine 1

mesalamine with

cleansing wipe

1

metoclopramide hcl 1

METOZOLV ODT 3

milk of magnesia

concentrated

5 ACA; OTC

Drug Name Drug

Tier

Requirements

/ Limits

MOVANTIK 3

MOVIPREP 5 ACA

NULYTELY WITH

FLAVOR PACKS

3

OCALIVA 3 PA; LA

ondansetron 1 QL

ondansetron hcl (pf) 6 MSD

ondansetron hcl

intravenous

6 MSD

ondansetron hcl oral 1 QL

OSMOPREP 5 ACA

peg 3350-

electrolytes

5 ACA

peg-electrolyte soln 5 ACA

peg-prep 5 ACA

PENTASA 2 M

PERTZYE 3

PHOSLO 3

PHOSLYRA 3

phosphate laxative 5 ACA; OTC

polyethylene glycol

3350

5 ACA

pramcort 1

PREPOPIK 5 ACA

prochlorperazine 1

prochlorperazine

maleate

1

PROCORT 3

PROCTOCORT 3

PROCTOFOAM HC 3

procto-med hc 1

proctosol hc 1



73

Drug Name Drug

Tier

Requirements

/ Limits

proctozone-hc 1

RECTIV 2

REGLAN 3

RELISTOR 2

REMICADE 6 MSD

RENAGEL 3

RENVELA 2

ROWASA 3

SANCUSO 3 QL

sodium polystyrene

sulfonate oral

1

sodium polystyrene

sulfonate rectal

enema 30 gram/120

ml

1

SODIUM

POLYSTYRENE

SULFONATE

RECTAL ENEMA

50 GRAM/200 ML

3

SOLESTA 6 MSD

sps (with sorbitol) 1

SUCRAID 2 LA

sulfasalazine 1 M

SUPREP BOWEL

PREP KIT

5 ACA

TIGAN

INTRAMUSCULA

R

6 MSD

TIGAN ORAL 3

TRANSDERM-

SCOP

3

trilyte with flavor

packets

5 ACA

trimethobenzamide 1

Drug Name Drug

Tier

Requirements

/ Limits

UCERIS ORAL 2

UCERIS RECTAL 3

URSO 250 3 M

URSO FORTE 3 M

ursodiol 1 M

VARUBI 3

VELPHORO 3

VELTASSA 2

VIBERZI 2

VIOKACE 2

ZENPEP 3

ZOFRAN (AS

HYDROCHLORID

E) INTRAVENOUS

6 MSD

ZOFRAN (AS

HYDROCHLORID

E) ORAL

3 QL

ZOFRAN ODT 3 QL

ZUPLENZ 3 QL

ULCER THERAPY

ACIPHEX 3 ST; M

ACIPHEX

SPRINKLE

3 ST; M; QL

amoxicil-

clarithromy-

lansopraz

1

carafate oral

suspension

1 M

CARAFATE ORAL

TABLET

3 M

cimetidine 1 M

cimetidine hcl 1 M

CYTOTEC 3 M



74

Drug Name Drug

Tier

Requirements

/ Limits

DEXILANT 3 ST; M; QL

esomeprazole

magnesium oral

capsule,delayed


1 M; QL

esomeprazole

magnesium oral

capsule,delayed


1 M

esomeprazole

sodium

6 MSD

ESOMEPRAZOLE

STRONTIUM

3 ST; M

famotidine (pf) 6 MSD

famotidine

intravenous

6 MSD

famotidine oral 1 M

lansoprazole oral

capsule,delayed


1 M; QL

lansoprazole oral

capsule,delayed


1 M

misoprostol 1 M

NEXIUM PACKET

ORAL GRANULES

DR FOR SUSP IN

PACKET 10 MG,

2.5 MG, 20 MG, 5

MG

3 ST; M; QL

NEXIUM PACKET

ORAL GRANULES

DR FOR SUSP IN

PACKET 40 MG

3 ST; M

nizatidine 1 M

OMECLAMOX-

PAK

3 QL

Drug Name Drug

Tier

Requirements

/ Limits

omeprazole oral

capsule,delayed


1 M; QL

omeprazole oral

capsule,delayed

release(dr/ec) 20

mg, 40 mg

1 M

omeprazole-sodium

bicarbonate oral

capsule 20-1.1 mg-

gram

1 ST; M; QL

omeprazole-sodium

bicarbonate oral

capsule 40-1.1 mg-

gram

1 ST; M

pantoprazole oral

tablet,delayed

release (dr/ec) 20

mg

1 M; QL

pantoprazole oral

tablet,delayed

release (dr/ec) 40

mg

1 M

PEPCID 3 M

PREVACID

SOLUTAB ORAL

TABLET,DISINTE

GRAT, DELAY

REL 15 MG

3 ST; M; QL

PREVACID

SOLUTAB ORAL

TABLET,DISINTE

GRAT, DELAY

REL 30 MG

3 ST; M

PREVPAC 3

PRILOSEC 3 ST; M; QL

PROTONIX ORAL

GRANULES DR

FOR SUSP IN

PACKET

3 ST; M



75

Drug Name Drug

Tier

Requirements

/ Limits

PROTONIX ORAL

TABLET,DELAYE

D RELEASE

(DR/EC)

3 ST; M; QL

PYLERA 3

rabeprazole 1 M

ranitidine hcl 1 M

sucralfate 1 M

ZANTAC 3 M

ZEGERID ORAL

CAPSULE 20-1.1

MG-GRAM

3 ST; M; QL

ZEGERID ORAL

CAPSULE 40-1.1

MG-GRAM

3 ST; M

ZEGERID ORAL

PACKET 20-1,680

MG

3 ST; QL

ZEGERID ORAL

PACKET 40-1,680

MG

3 ST

IMMUNOLOGY, VACCINES &

BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

ARANESP (IN

POLYSORBATE)

6 MSD

EPOGEN 6 MSD

GRANIX 2 MSD

LEUKINE 6 MSD

MIRCERA 6 MSD

MOZOBIL 6 MSD

NEULASTA 6 MSD; QL

NEUPOGEN 6 MSD

PROCRIT 6 MSD

Drug Name Drug

Tier

Requirements

/ Limits

ZARXIO 6 MSD

GROWTH HORMONES

EGRIFTA 3 PA; LA

GENOTROPIN 4 PA; ST; LA

GENOTROPIN

MINIQUICK

4 PA; ST; LA

HUMATROPE 4 PA; ST; LA

NORDITROPIN

FLEXPRO

4 PA; ST; LA

NUTROPIN AQ 4 PA; ST; LA

NUTROPIN AQ

NUSPIN

4 PA; ST; LA

OMNITROPE 3 PA; LA

SAIZEN 4 PA; ST; LA

SAIZEN

CLICK.EASY

4 PA; ST; LA

SEROSTIM 4 PA; LA

ZOMACTON 3 PA; ST

ZORBTIVE 4 PA; LA

INTERFERONS

AUBAGIO 4 PA; LA

AVONEX 3 PA; LA; QL

AVONEX (WITH

ALBUMIN)

3 PA; LA; QL

BETASERON 4 PA; ST; LA;

QL

COPAXONE

SUBCUTANEOUS

SYRINGE 20

MG/ML

3 ST; LA; QL

COPAXONE

SUBCUTANEOUS

SYRINGE 40

MG/ML

4 ST; LA; QL



76

Drug Name Drug

Tier

Requirements

/ Limits

COPEGUS 4 ST; LA

EXTAVIA

SUBCUTANEOUS

KIT

3 PA; LA; QL

EXTAVIA

SUBCUTANEOUS

RECON SOLN

2 PA; QL

GILENYA 3 PA; LA

glatopa 1 LA; QL

LEMTRADA 6 MSD

moderiba 1 ST; LA

moderiba dose pack 1 ST; LA

PEGASYS 3 PA; LA; QL

PEGASYS

PROCLICK

3 PA; LA; QL

PEGINTRON 4 PA; LA; QL

PEGINTRON

REDIPEN

4 PA; LA; QL

PLEGRIDY 4 ST; LA; QL

POMALYST 2

REBETOL 4 ST; LA

REBIF (WITH

ALBUMIN)

3 PA; LA; QL

REBIF REBIDOSE 3 PA; LA; QL

REBIF TITRATION

PACK

3 PA; LA; QL

REVLIMID 2

ribasphere 1 ST; LA

ribasphere ribapak 1 ST; LA

ribavirin 1 ST; LA

SYLATRON 3 LA

TECFIDERA 3 PA; LA

ZINBRYTA 3 ST

Drug Name Drug

Tier

Requirements

/ Limits

INTERLEUKINS

ACTIMMUNE 3 LA

ALDARA 3

ALFERON N 6 MSD

ARCALYST 3 PA; ST; LA

ILARIS (PF) 6 MSD

imiquimod 1

INTRON A 3 LA

KINERET 4 PA; ST; LA

PROLEUKIN 6 MSD

ZYCLARA 3

VACCINES & MISCELLANEOUS

IMMUNOLOGICALS

AFLURIA 2016-

2017

2

AFLURIA 2016-

2017 (PF)

2

ATGAM 6 MSD

BCG VACCINE,

LIVE (PF)

6 MSD

BIVIGAM 6 MSD

BOOSTRIX TDAP 6 MSD

CARIMUNE NF

NANOFILTERED

6 MSD

DYSPORT 6 MSD

ENGERIX-B (PF) 6 MSD

ENGERIX-B

PEDIATRIC (PF)

6 MSD

FLEBOGAMMA

DIF

6 MSD

FLUAD 2016-2017

(65 YR UP)(PF)

3



77

Drug Name Drug

Tier

Requirements

/ Limits

FLUARIX QUAD

2016-2017 (PF)

2

FLUBLOK 2016-

2017 (PF)

3

FLUCELVAX

QUAD 2016-2017

(PF)

3

FLULAVAL QUAD

2016-2017

2

FLUVIRIN 2016-

2017

2

FLUVIRIN 2016-

2017 (PF)

2

FLUZONE HIGH-

DOSE 2016-17 (PF)

2

FLUZONE

INTRADERM

QUAD 2016-17

2

FLUZONE QUAD

2016-2017

2

FLUZONE QUAD

2016-2017 (PF)

2

FLUZONE QUAD

PEDI 2016-17 (PF)

2

GAMASTAN S/D 6 MSD

GAMMAGARD

LIQUID

6 MSD

GAMMAGARD S-

D (IGA < 1

MCG/ML)

6 MSD

GAMMAKED 6 MSD

GAMMAPLEX 6 MSD

GAMUNEX-C 6 MSD

GRASTEK 2 PA

HAVRIX (PF) 6 MSD

HEPAGAM B 6 MSD

Drug Name Drug

Tier

Requirements

/ Limits

HIBERIX (PF) 6 MSD

HIZENTRA 6 MSD

HYPERHEP B S/D 6 MSD

HYPERHEP B S-D

NEONATAL

6 MSD

HYPERRAB S/D

(PF)

6 MSD

HYQVIA 6 MSD

IMOGAM RABIES-

HT (PF)

6 MSD

KINRIX (PF) 6 MSD

MENACTRA (PF) 6 MSD

MENVEO A-C-Y-

W-135-DIP (PF)

6 MSD

MYOBLOC 6 MSD

NABI-HB 6 MSD

OCTAGAM 6 MSD

ORALAIR 3 PA; LA

PRIVIGEN 6 MSD

PROQUAD (PF) 6 MSD

PROVENGE 6 MSD

QUADRACEL (PF) 6 MSD

RAGWITEK 2 PA

RECOMBIVAX HB

(PF)

6 MSD

TENIVAC (PF) 6 MSD

TETANUS,DIPHTH

ERIA TOX

PED(PF)

6 MSD

TETANUS-

DIPHTHERIA

TOXOIDS-TD

6 MSD

THYMOGLOBULI

N

6 MSD



78

Drug Name Drug

Tier

Requirements

/ Limits

VAQTA (PF) 6 MSD

YF-VAX (PF) 6 MSD

MUSCULOSKELETAL &

RHEUMATOLOGY

GOUT THERAPY

allopurinol 1 M

COLCHICINE 3

colchicine-

probenecid

1

COLCRYS 2

KRYSTEXXA 6 MSD

MITIGARE 2

probenecid 1 M

ULORIC 2 PA; M

ZYLOPRIM 3 M

OSTEOPOROSIS THERAPY

ACTONEL 3 ST; M; QL

alendronate 1 M; QL

ATELVIA 3 ST; M; QL

BINOSTO 3 ST; M; QL

BONIVA 3 ST; M; QL

EVISTA 3 PA; M

FORTEO 2 PA; LA; QL

FOSAMAX 3 ST; M; QL

FOSAMAX PLUS

D

3 ST; M; QL

ibandronate 1 M; QL

PROLIA 6 MSD

raloxifene 1 PA; M

risedronate 1 M; QL

OTHER RHEUMATOLOGICALS

Drug Name Drug

Tier

Requirements

/ Limits

ACTEMRA

INTRAVENOUS

6 MSD

ACTEMRA

SUBCUTANEOUS

3 PA; ST; LA

ARAVA 3 QL

BENLYSTA 6 MSD

CUPRIMINE 2 M

DEPEN

TITRATABS

2 M

ENBREL 3 PA; ST; LA;

QL

ENBREL

SURECLICK

3 PA; ST; LA;

QL

HUMIRA 3 PA; ST; LA;

QL

HUMIRA

PEDIATRIC

CROHN'S START

2 PA; ST; QL

HUMIRA PEN

CROHN'S-UC-HS

START

3 PA; ST; LA;

QL

ORENCIA 3 PA; ST; LA

ORENCIA (WITH

MALTOSE)

6 MSD

ORENCIA

CLICKJECT

2 PA; ST

OTEZLA 3 ST; LA

OTEZLA

STARTER

3 ST; LA

OTREXUP (PF) 4 LA

RASUVO (PF) 4 LA

RIDAURA 2 M

SAVELLA ORAL

TABLET

2 ST; M; QL



79

Drug Name Drug

Tier

Requirements

/ Limits

SAVELLA ORAL

TABLETS,DOSE

PACK

2 ST; QL

SIMPONI 4 PA; ST; LA

SIMPONI ARIA 6 MSD

XELJANZ 4 ST; LA

XELJANZ XR 3 ST

OBSTETRICS &

GYNECOLOGY

DIAPHRAGMS AND OTHER NON-

ORAL CONTRACEPTIVES

CAYA

CONTOURED

5 ACA

FC2 FEMALE

CONDOM

5 ACA; OTC

FEMCAP 5 ACA

LILETTA 5 MSD

MIRENA 5 MSD

PARAGARD T

380A

5 MSD

SKYLA 5 MSD

WIDE-SEAL

DIAPHRAGM

5 ACA

ESTROGENS & PROGESTINS

ACTIVELLA 3 M

ALORA 3 M; QL

ANGELIQ 3 M

AYGESTIN 3 M

camila 5 M; ACA

CLIMARA 3 M; QL

CLIMARA PRO 3 M; QL

COMBIPATCH 3 M

covaryx 1

Drug Name Drug

Tier

Requirements

/ Limits

covaryx h.s. 1

CRINONE 3

deblitane 5 M; ACA

DELESTROGEN 3

DEPO-ESTRADIOL 3

DEPO-PROVERA 5 ACA; QL

DEPO-SUBQ

PROVERA 104

5 ACA; QL

DIVIGEL 3 M; QL

DUAVEE 3

eemt 1

eemt hs 1

ELESTRIN 3 M; QL

errin 5 M; ACA

ESTRACE 3 M

estradiol oral 1 M

estradiol

transdermal

1 M; QL

estradiol valerate 1

estradiol-

norethindrone acet

1 M

ESTRING 3 M

ESTROGEL 3 M; QL

estrogens-

methyltestosterone

1

estropipate 1 M

EVAMIST 3 QL

FEMHRT LOW

DOSE

3 M

FEMRING 3 M

fyavolv 1 M

heather 5 M; ACA



80

Drug Name Drug

Tier

Requirements

/ Limits

hydroxyprogesterone

caproate

6 PA; MSD

jencycla 5 M; ACA

jevantique lo 1 M

jinteli 1 M

jolivette 5 M; ACA

lopreeza 1 M

lyza 5 M; ACA

MAKENA 6 MSD

medroxyprogesteron

e intramuscular

5 ACA; QL

medroxyprogesteron

e oral

1 M

MENEST 2 M

MENOSTAR 3 M; QL

mimvey 1 M

mimvey lo 1 M

MINIVELLE 3 M; QL

nora-be 5 M; ACA

norethindrone

(contraceptive)

5 M; ACA

norethindrone

acetate

1 M

norethindrone ac-eth

estradiol

1 M

norlyroc 5 M; ACA

NOR-QD 5 ST; M; ACA

ORTHO

MICRONOR

5 ST; M; ACA

PREFEST 3 M

PREMARIN 3 M

PREMPHASE 3 M

PREMPRO 3 M

Drug Name Drug

Tier

Requirements

/ Limits

progesterone

micronized

1 M

PROMETRIUM 3 M

PROVERA 3 M

sharobel 5 M; ACA

VAGIFEM 2 M

VIVELLE-DOT 3 M; QL

MISCELLANEOUS OB/GYN

AVC VAGINAL 3

CERVIDIL 3

CLEOCIN 3

clindamycin

phosphate

1

CLINDESSE 3

CONCEPTROL 5 ACA; OTC

fem ph 1

GYNAZOLE-1 3

isoxsuprine 1 M

LUPANETA PACK

(1 MONTH)

3

LUPANETA PACK

(3 MONTH)

3

LYSTEDA 3

METROGEL

VAGINAL

3

metronidazole 1

MIFEPREX 4 LA

NEXPLANON 5 MSD

NUVARING 5 M; ACA

NUVESSA 3

OSPHENA 3

PREPIDIL 3



81

Drug Name Drug

Tier

Requirements

/ Limits

PROSTIN E2 3

RELAGARD 3

TERAZOL 3 3

TERAZOL 7 3

terconazole 1

TODAY

CONTRACEPTIVE

SPONGE

5 ACA; OTC

tranexamic acid 1

vaginal

contraceptive foam

5 ACA; OTC

vandazole 1

VCF

CONTRACEPTIVE

FILM

2 OTC

VCF

CONTRACEPTIVE

GEL

5 ACA; OTC

xulane 5 M; ACA

ORAL CONTRACEPTIVES &

RELATED AGENTS

AFTERA 5 ACA; OTC;

QL

altavera (28) 5 M; ACA

alyacen 1/35 (28) 5 M; ACA

alyacen 7/7/7 (28) 5 M; ACA

amethia 5 M; ACA

amethia lo 5 M; ACA

amethyst 5 M; ACA

apri 5 M; ACA

aranelle (28) 5 M; ACA

ashlyna 5 M; ACA

aubra 5 M; ACA

Drug Name Drug

Tier

Requirements

/ Limits

aviane 5 M; ACA

azurette (28) 5 M; ACA

balziva (28) 5 M; ACA

bekyree (28) 5 M; ACA

BEYAZ 5 ST; M; ACA

blisovi 24 fe 5 M; ACA

blisovi fe 1.5/30 (28) 5 M; ACA

blisovi fe 1/20 (28) 5 M; ACA

BREVICON (28) 5 ST; M; ACA

briellyn 5 M; ACA

camrese 5 M; ACA

camrese lo 5 M; ACA

caziant (28) 5 M; ACA

chateal 5 M; ACA

cryselle (28) 5 M; ACA

cyclafem 1/35 (28) 5 M; ACA

cyclafem 7/7/7 (28) 5 M; ACA

CYCLESSA (28) 5 ST; M; ACA

cyred 5 M; ACA

dasetta 1/35 (28) 5 M; ACA

dasetta 7/7/7 (28) 5 M; ACA

daysee 5 M; ACA

delyla (28) 5 M; ACA

desog-

e.estradiol/e.estradio

l

5 M; ACA

DESOGEN 5 ST; M; ACA

desogestrel-ethinyl

estradiol

5 M; ACA

drospirenone-ethinyl

estradiol

5 M; ACA



82

Drug Name Drug

Tier

Requirements

/ Limits

econtra ez 5 ACA; OTC;

QL

elinest 5 M; ACA

ELLA 5 ACA; QL

emoquette 5 M; ACA

enpresse 5 M; ACA

enskyce 5 M; ACA

estarylla 5 M; ACA

ESTROSTEP FE-28 5 ST; M; ACA

fallback solo 5 ACA; OTC;

QL

falmina (28) 5 M; ACA

FEMCON FE 5 ST; M; ACA

GENERESS FE 5 ST; ACA

gianvi (28) 5 M; ACA

gildagia 5 M; ACA

introvale 5 M; ACA

jolessa 5 M; ACA

juleber 5 M; ACA

junel 1.5/30 (21) 5 M; ACA

junel 1/20 (21) 5 M; ACA

junel fe 1.5/30 (28) 5 M; ACA

junel fe 1/20 (28) 5 M; ACA

junel fe 24 5 M; ACA

kaitlib fe 5 ACA

kariva (28) 5 M; ACA

kelnor 1/35 (28) 5 M; ACA

kimidess (28) 5 M; ACA

kurvelo 5 M; ACA

l norgest/e.estradiol-

e.estrad

5 M; ACA

larin 1.5/30 (21) 5 M; ACA

Drug Name Drug

Tier

Requirements

/ Limits

larin 1/20 (21) 5 M; ACA

larin 24 fe 5 M; ACA

larin fe 1.5/30 (28) 5 M; ACA

larin fe 1/20 (28) 5 M; ACA

layolis fe 5 ACA

leena 28 5 M; ACA

lessina 5 M; ACA

levonest (28) 5 M; ACA

levonorgestrel-

ethinyl estrad

5 M; ACA

levonorg-eth estrad

triphasic

5 M; ACA

levora-28 5 M; ACA

LO LOESTRIN FE 5 ST; M; ACA

LOESTRIN 1.5/30

(21)

5 ST; M; ACA

LOESTRIN 1/20

(21)

5 ST; M; ACA

LOESTRIN FE

1.5/30 (28-DAY)

5 ST; M; ACA

LOESTRIN FE 1/20

(28-DAY)

5 ST; M; ACA

lomedia 24 fe 5 M; ACA

loryna (28) 5 M; ACA

LOSEASONIQUE 5 ST; M; ACA

low-ogestrel (28) 5 M; ACA

lutera (28) 5 M; ACA

marlissa 5 M; ACA

microgestin 1.5/30

(21)

5 M; ACA

microgestin 1/20

(21)

5 M; ACA



83

Drug Name Drug

Tier

Requirements

/ Limits

MICROGESTIN 24

FE

5 ST; M; ACA

microgestin fe 1.5/30

(28)

5 M; ACA

microgestin fe 1/20

(28)

5 M; ACA

MINASTRIN 24 FE 5 ST; M; ACA

MIRCETTE (28) 5 ST; M; ACA

MODICON (28) 5 ST; M; ACA

mono-linyah 5 M; ACA

mononessa (28) 5 M; ACA

my way 5 ACA; OTC;

QL

myzilra 5 M; ACA

NATAZIA 5 ST; M; ACA

necon 0.5/35 (28) 5 M; ACA

necon 1/35 (28) 5 M; ACA

necon 1/50 (28) 5 M; ACA

necon 10/11 (28) 5 M; ACA

necon 7/7/7 (28) 5 M; ACA

next choice one dose 5 ACA; OTC;

QL

nikki (28) 5 M; ACA

noreth-ethinyl

estradiol-iron

5 ACA

norethindrone ac-eth

estradiol

5 M; ACA

norethindrone-

e.estradiol-iron

5 M; ACA

norgestimate-ethinyl

estradiol oral tablet

0.18/0.215/0.25 mg-

25 mcg

5 M

Drug Name Drug

Tier

Requirements

/ Limits

norgestimate-ethinyl

estradiol oral tablet

0.18/0.215/0.25 mg-

35 mcg (28), 0.25-35

mg-mcg

5 M; ACA

NORINYL 1+35

(28)

5 ST; M; ACA

nortrel 0.5/35 (28) 5 M; ACA

nortrel 1/35 (21) 5 M; ACA

nortrel 7/7/7 (28) 5 M; ACA

ocella 5 M; ACA

ogestrel (28) 5 M; ACA

opcicon one-step 5 ACA; OTC;

QL

orsythia 5 M; ACA

ORTHO TRI-

CYCLEN (28)

5 ST; M; ACA

ORTHO TRI-

CYCLEN LO (28)

5 ST; M; ACA

ORTHO-CYCLEN

(28)

5 ST; M; ACA

ORTHO-NOVUM

1/35 (28)

5 ST; M; ACA

ORTHO-NOVUM

7/7/7 (28)

5 ST; M; ACA

OVCON-35 (28) 5 ST; M; ACA

philith 5 M; ACA

pimtrea (28) 5 M; ACA

pirmella 5 M; ACA

PLAN B ONE-

STEP

5 ACA; QL

portia 5 M; ACA

previfem 5 M; ACA

QUARTETTE 5 ST; M; ACA



84

Drug Name Drug

Tier

Requirements

/ Limits

quasense 5 M; ACA

react 5 OTC; QL

reclipsen (28) 5 M; ACA

SAFYRAL 5 ST; M; ACA

SEASONIQUE 5 ST; M; ACA

setlakin 5 M; ACA

sprintec (28) 5 M; ACA

sronyx 5 M; ACA

syeda 5 M; ACA

TAKE ACTION 5 ACA; OTC;

QL

tarina fe 1/20 (28) 5 M; ACA

tilia fe 5 M; ACA

tri-estarylla 5 M; ACA

tri-legest fe 5 M; ACA

tri-linyah 5 M; ACA

tri-lo-estarylla 5 M; ACA

tri-lo-marzia 5 M; ACA

tri-lo-sprintec 5 M; ACA

trinessa (28) 5 M; ACA

trinessa lo 5 M; ACA

TRI-NORINYL (28) 5 ST; M; ACA

tri-previfem (28) 5 M; ACA

tri-sprintec (28) 5 M; ACA

trivora (28) 5 M; ACA

velivet triphasic

regimen (28)

5 M; ACA

vestura (28) 5 M; ACA

vienva 5 M; ACA

viorele (28) 5 M; ACA

vyfemla (28) 5 M; ACA

Drug Name Drug

Tier

Requirements

/ Limits

wera (28) 5 M; ACA

wymzya fe 5 M; ACA

YASMIN (28) 5 ST; M; ACA

YAZ (28) 5 ST; M; ACA

zarah 5 M; ACA

zenchent (28) 5 M; ACA

zenchent fe 5 M; ACA

zovia 1/35e (28) 5 M; ACA

zovia 1/50e (28) 5 M; ACA

OXYTOCICS

methergine 1

methylergonovine 1

OPHTHALMOLOGY

ANTIBIOTICS

AZASITE 3

bacitracin 1

bacitracin-

polymyxin b

1

BESIVANCE 3

BETADINE

OPHTHALMIC

PREP

3

CILOXAN 3

ciprofloxacin hcl 1

erythromycin 1

gatifloxacin 1

gentak 1

gentamicin 1

ILOTYCIN 3

levofloxacin 1

MOXEZA 3



85

Drug Name Drug

Tier

Requirements

/ Limits

NATACYN 2

neomycin-

bacitracin-

polymyxin

1 M

neomycin-

polymyxin-

gramicidin

1

neo-polycin 1 M

NEOSPORIN

(NEO-POLYM-

GRAMICID)

3

OCUFLOX 3

ofloxacin 1

polycin 1

polymyxin b sulf-

trimethoprim

1

POLYTRIM 3

tobramycin 1

TOBREX 3

VIGAMOX 3

ZYMAXID 3

ANTIVIRALS

trifluridine 1

VIROPTIC 3

ZIRGAN 3

BETA-BLOCKERS

BETAGAN 3 M

betaxolol 1 M

BETIMOL 3 M

BETOPTIC S 3 M

carteolol 1 M

ISTALOL 3 M

levobunolol 1 M

Drug Name Drug

Tier

Requirements

/ Limits

metipranolol 1 M

timolol maleate 1 M

TIMOPTIC 3 M

TIMOPTIC

OCUDOSE (PF)

3 M

TIMOPTIC-XE 3 M

CHOLINESTERASE INHIBITOR

MIOTICS

PHOSPHOLINE

IODIDE

2 M

CYCLOPLEGIC MYDRIATICS

atropine 1 M

CYCLOGYL 3 M

cyclopentolate 1 M

homatropaire 1 M

homatropine hbr 1 M

ISOPTO

ATROPINE

3 M

MYDRIACYL 3 M

PAREMYD 3

tropicamide 1 M

DIRECT ACTING MIOTICS

ISOPTO CARPINE 3 M

MIOCHOL-E 3

pilocarpine hcl 1 M

MISCELLANEOUS

OPHTHALMOLOGICS

acuicyn 1

AKTEN (PF) 3

ALCAINE 3

ALOCRIL 3

ALOMIDE 3



86

Drug Name Drug

Tier

Requirements

/ Limits

altacaine 1

altafluor 1

AVENOVA 3

azelastine 1

BEPREVE 3

cromolyn 1

CYSTARAN 2 LA

ELESTAT 3

EMADINE 3

epinastine 1

EYLEA 6 MSD

flucaine 1

fluorescein-

benoxinate

1

fluorescein-

proparacaine

1

flurox 1

JETREA (PF) 6 MSD

LACRISERT 3

LASTACAFT 3

LUCENTIS 6 MSD

MACUGEN 6 MSD

olopatadine 1

OMIDRIA 6 MSD

PATADAY 3

PATANOL 3

PAZEO 3

proparacaine 1

RESTASIS 2 PA; M; QL

tetcaine 1

tetracaine hcl 1

Drug Name Drug

Tier

Requirements

/ Limits

tetracaine hcl (pf) 1

TETRAVISC 3

TETRAVISC

FORTE

3

VISUDYNE 6 MSD

XIIDRA 3 M

NON-STEROIDAL ANTI-

INFLAMMATORY AGENTS

ACULAR 3

ACULAR LS 3

ACUVAIL (PF) 3

bromfenac 1

diclofenac sodium 1

flurbiprofen sodium 1

ILEVRO 3

ketorolac 1

NEVANAC 3

OCUFEN 3

PROLENSA 3

ORAL DRUGS FOR GLAUCOMA

acetazolamide 1 M

DIAMOX

SEQUELS

3 M

methazolamide 1 M

NEPTAZANE 3 M

OTHER GLAUCOMA DRUGS

AZOPT 3 M

bimatoprost 1 PA; M

COMBIGAN 3 M

COSOPT 3 M

COSOPT (PF) 3 M



87

Drug Name Drug

Tier

Requirements

/ Limits

dorzolamide 1 M

dorzolamide-timolol 1 M

latanoprost 1 PA; M

LUMIGAN 3 ST; M

MITOSOL 3

SIMBRINZA 3 M

TRAVATAN Z 3 ST; M

TRUSOPT 3 M

XALATAN 3 ST; M

ZIOPTAN (PF) 3 ST; M

STEROID-ANTIBIOTIC

COMBINATIONS

MAXITROL 3

neomycin-

bacitracin-poly-hc

1

neomycin-polymyxin

b-dexameth

1

neomycin-

polymyxin-hc

1

neo-polycin hc 1

PRED-G 3

PRED-G S.O.P. 3

TOBRADEX 3

TOBRADEX ST 3

tobramycin-

dexamethasone

1

ZYLET 3

STEROIDS

ALREX 3

dexamethasone

sodium phosphate

1

DUREZOL 3

Drug Name Drug

Tier

Requirements

/ Limits

FLAREX 3

fluorometholone 1

FML FORTE 3

FML LIQUIFILM 3

FML S.O.P. 3

ILUVIEN 6 MSD

LOTEMAX 3

MAXIDEX 3

OMNIPRED 3

OZURDEX 6 MSD

PRED FORTE 3

PRED MILD 2

prednisolone acetate 1

prednisolone sodium

phosphate

1

RETISERT 6 MSD

VEXOL 3

STEROID-SULFONAMIDE

COMBINATIONS

BLEPHAMIDE 3

BLEPHAMIDE

S.O.P.

3

sulfacetamide-

prednisolone

1

SULFONAMIDES

BLEPH-10 3

sulfacetamide

sodium

1

SYMPATHOMIMETICS

ALPHAGAN P

OPHTHALMIC

DROPS 0.1 %

2 M



88

Drug Name Drug

Tier

Requirements

/ Limits

ALPHAGAN P

OPHTHALMIC

DROPS 0.15 %

3 M

apraclonidine 1 M

brimonidine 1 M

IOPIDINE 3 M

VASOCONSTRICTOR

DECONGESTANTS

CYCLOMYDRIL 3 M

phenylephrine hcl 1

RESPIRATORY, ALLERGY,

COUGH & COLD

ANTIHISTAMINE &

ANTIALLERGENIC AGENTS

ADRENACLICK 3 QL

arbinoxa 1

carbinoxamine

maleate

1

cetirizine 1

CLARINEX ORAL

SYRUP

3

CLARINEX ORAL

TABLET

3 QL

clemastine 1

cyproheptadine 1

desloratadine 1 QL

diphenhydramine hcl 6 MSD

epinephrine 1 QL

EPIPEN 2-PAK 3 QL

EPIPEN JR 2-PAK 3 QL

hydroxyzine hcl 1

hydroxyzine

pamoate

1

Drug Name Drug

Tier

Requirements

/ Limits

KARBINAL ER 3

levocetirizine oral

solution

1

levocetirizine oral

tablet

1 QL

phenadoz 1

phenergan 1

promethazine 1

promethegan 1

VISTARIL 3

XYZAL ORAL

SOLUTION

3

XYZAL ORAL

TABLET

3 QL

COUGH & COLD THERAPY

benzonatate 1

BROMFED DM 3

brompheniramine-

pseudoeph-dm

1

CAPCOF 3

centergy 1

cheratussin ac 1

cheratussin dac 1

CLARINEX-D 12

HOUR

3 QL

codeine-guaifenesin 1

FLOWTUSS 3

guaifenesin ac 1

guaifenesin dac 1

HISTEX-AC 3

HYCOFENIX 3

hydrocodone-

chlorpheniramine

1



89

Drug Name Drug

Tier

Requirements

/ Limits

hydrocodone-cpm-

pseudoephed

1

hydrocodone-

homatropine

1

hydromet 1

iophen c-nr 1

lortuss ex 1

MAR-COF BP 3

MAR-COF CG 3

m-clear wc 1

M-END MAX D 3

M-END PE 3

NINJACOF-XG 3

OBREDON 3

phenylhistine dh 1

POLY-TUSSIN AC 3

promethazine vc 1

promethazine vc-

codeine

1

promethazine-

codeine

1

promethazine-dm 1

promethazine-

phenyleph-codeine

1

PRO-RED AC (W/

DEXCHLORPHENI

R)

3

relcof c 1

RESPA-AR 3

REZIRA 3

rydex 1

SEMPREX-D 3

Drug Name Drug

Tier

Requirements

/ Limits

TESSALON

PERLES

3

tusnel c 1

TUSNEL

PEDIATRIC

3

TUSSICAPS 3

tussigon 1

TUSSIONEX

PENNKINETIC ER

3

TUZISTRA XR 3

VITUZ 3

ZODRYL AC 25 3

ZODRYL AC 30 3

ZODRYL AC 35 3

ZODRYL AC 40 2

ZODRYL AC 50 3

ZODRYL AC 60 3

ZODRYL AC 80 3

ZODRYL DAC 25 3

ZODRYL DAC 30 3

ZODRYL DAC 35 3

ZODRYL DAC 40 3

ZODRYL DAC 50 3

ZODRYL DAC 60 3

ZODRYL DAC 80 3

ZODRYL DEC 25 3

ZODRYL DEC 30 2

ZODRYL DEC 35 3

ZODRYL DEC 40 3

ZODRYL DEC 50 3

ZODRYL DEC 60 3

ZODRYL DEC 80 3



90

Drug Name Drug

Tier

Requirements

/ Limits

ZONATUSS 3

Z-TUSS AC 3

ZUTRIPRO 3

PULMONARY AGENTS

ACCOLATE 3 M

acetylcysteine 1

ADCIRCA 4 PA; ST; LA;

QL

ADEMPAS 2 M; LA

ADVAIR DISKUS 3 PA; M; QL

ADVAIR HFA 3 PA; M; QL

AEROSPAN 3 M

albuterol sulfate

inhalation

1

albuterol sulfate oral 1 M

ALVESCO 3 M; QL

ANORO ELLIPTA 2 M; QL

ARCAPTA

NEOHALER

3 M; QL

ARNUITY

ELLIPTA

3 M

ASMANEX HFA 3 M

ASMANEX

TWISTHALER

3 M; QL

ATROVENT HFA 2 M; QL

BECONASE AQ 3 ST; QL

BERINERT 6 MSD

BEVESPI

AEROSPHERE

3 M

BREO ELLIPTA

INHALATION

BLISTER WITH

DEVICE 100-25

MCG/DOSE

3 PA; M; QL

Drug Name Drug

Tier

Requirements

/ Limits

BREO ELLIPTA

INHALATION

BLISTER WITH

DEVICE 200-25

MCG/DOSE

3 PA; M

BROVANA 3 M; QL

budesonide

inhalation

1 M; QL

budesonide nasal 1 QL

CINRYZE 6 MSD

COMBIVENT

RESPIMAT

2 QL

cromolyn 1 M

CUROSURF 3

DALIRESP 3 PA

DULERA 2 PA; M; QL

DYMISTA 3 ST; QL

ELIXOPHYLLIN 3 M

ESBRIET 3 PA; LA; QL

FIRAZYR 3 PA; LA

FLOVENT DISKUS 3 M; QL

FLOVENT HFA 3 M; QL

flunisolide 1 QL

fluticasone 1 QL

FORADIL

AEROLIZER

2 QL

HYPER-SAL 3

INCRUSE

ELLIPTA

2 M

ipratropium bromide 1 M

ipratropium-

albuterol

1 QL

KALBITOR 6 MSD



91

Drug Name Drug

Tier

Requirements

/ Limits

KALYDECO 3 PA; LA

LETAIRIS 3 PA; ST; M

levalbuterol hcl 1

metaproterenol 1 M

mometasone 1 QL

montelukast 1 M

NASONEX 3 ST; QL

NEBUSAL 3

OFEV 3 PA; LA; QL

OMNARIS 3 ST; QL

OPSUMIT 2 PA; ST; M

ORKAMBI 3 PA; LA

PERFOROMIST 2 M; QL

PROAIR HFA 2 QL

PROAIR

RESPICLICK

2

PROVENTIL HFA 3 QL

PULMICORT

FLEXHALER

3 M; QL

PULMICORT

INHALATION

SUSPENSION FOR

NEBULIZATION

0.25 MG/2 ML, 0.5

MG/2 ML

3 M; QL

PULMICORT

INHALATION

SUSPENSION FOR

NEBULIZATION 1

MG/2 ML

2 M; QL

pulmosal 1

PULMOZYME 2

Drug Name Drug

Tier

Requirements

/ Limits

QNASL NASAL

HFA AEROSOL

INHALER 40

MCG/ACTUATION

3 ST

QNASL NASAL

HFA AEROSOL

INHALER 80

MCG/ACTUATION

3 ST; QL

QVAR 2 M; QL

REVATIO

INTRAVENOUS

3 PA; LA

REVATIO ORAL

SUSPENSION FOR

RECONSTITUTIO

N

3 PA; ST; QL

REVATIO ORAL

TABLET

4 PA; ST; LA;

QL

RUCONEST 6 MSD

SEREVENT

DISKUS

3 M; QL

sildenafil 1 PA; LA; QL

SINGULAIR 3 M

sodium chloride 1

SPIRIVA

RESPIMAT

3 M

SPIRIVA WITH

HANDIHALER

3 M; QL

STIOLTO

RESPIMAT

3 M

STRIVERDI

RESPIMAT

3 M

SURFAXIN 3

SYMBICORT 2 PA; M; QL

terbutaline oral 1 M

terbutaline

subcutaneous

1



92

Drug Name Drug

Tier

Requirements

/ Limits

THEO-24 3 M

theochron 1 M

theophylline 1 M

TICANASE 3

TRACLEER 6 MSD; M

TUDORZA

PRESSAIR

2 M; QL

TYVASO 6 MSD

TYVASO REFILL

KIT

6 MSD

TYVASO

STARTER KIT

6 MSD

VENTAVIS 6 MSD

VENTOLIN HFA 3 QL

VERAMYST 3 ST; QL

VOSPIRE ER 3 M

XOLAIR 6 MSD; QL

XOPENEX 3

XOPENEX

CONCENTRATE

3

XOPENEX HFA 3

zafirlukast 1 M

ZETONNA 3 ST; QL

ZYFLO 3 M

ZYFLO CR 3 M

UROLOGICALS

ANTICHOLINERGICS &

ANTISPASMODICS

darifenacin 1 M

DETROL 3 ST; M

DETROL LA 3 ST; M

DITROPAN XL 3 ST; M

Drug Name Drug

Tier

Requirements

/ Limits

ENABLEX 3 ST; M

flavoxate 1 M

GELNIQUE 3 ST; M; QL

MYRBETRIQ 3 ST; M

oxybutynin chloride 1 M

OXYTROL 3 ST; M; QL

tolterodine 1 M

TOVIAZ 3 ST; M

trospium 1 M

VESICARE 3 ST; M

BENIGN PROSTATIC

HYPERPLASIA (BPH) THERAPY

alfuzosin 1 M

AVODART 3 ST; M

CIALIS 3 PA; QL

dutasteride 1 ST; M

dutasteride-

tamsulosin

1 ST; M

finasteride 1 M

FLOMAX 3 ST; M

JALYN 3 ST; M

PROSCAR 3 ST; M

RAPAFLO 3 ST; M

tamsulosin 1 M

UROXATRAL 3 ST; M

CHOLINERGIC STIMULANTS

bethanechol chloride 1

URECHOLINE 3

MISCELLANEOUS UROLOGICALS

AMMONIUM

CHLORIDE

6 MSD



93

Drug Name Drug

Tier

Requirements

/ Limits

azuphen mb 1

CYSTAGON 2 LA

cytra k crystals 1

cytra-2 1

cytra-3 1

cytra-k 1

ELMIRON 2

hyolev mb 1

hyophen 1

INDIOMIN MB 3

K-PHOS NO 2 2

K-PHOS

ORIGINAL

2

methen-sod phos-

meth blue-hyos

1

ORACIT 3

phosphasal 1

pot,sodium citrate-

citric acid

1

potassium citrate 1 M

potassium citrate-

citric acid

1

PROCYSBI 3 LA

SHOHL'S

MODIFIED

3

sodium citrate-citric

acid

1

tricitrates 1

ur n-c 1

uramit mb 1

URELLE 3

uretron d-s 1

Drug Name Drug

Tier

Requirements

/ Limits

URIBEL 3

urimar-t 1

urin ds 1

UROCIT-K 10 3 M

UROCIT-K 15 3 M

UROCIT-K 5 3 M

urogesic-blue 1

urolet mb 1

uro-mp 1

urophen mb 1

UROQID-ACID

NO.2

3

uryl 1

ustell 1

UTA 3

utira-c 1

URINARY ANESTHETICS

phenazopyridine 1

PYRIDIUM 3

VITAMINS, HEMATINICS &

ELECTROLYTES

ELECTROLYTES

calcium 500 with d 5 ACA; OTC

calcium carb and

citrate-vitd3

5 ACA; OTC

calcium citrate + d 5 ACA; OTC

calcium citrate-

vitamin d2

5 ACA; OTC

EFFER-K ORAL

TABLET,

EFFERVESCENT

10 MEQ, 20 MEQ

3 M



94

Drug Name Drug

Tier

Requirements

/ Limits

effer-k oral tablet,

effervescent 25 meq

1 M

GALZIN 3

k-effervescent 1 M

klor-con 1 M

klor-con 10 1 M

klor-con 8 1 M

klor-con m10 1 M

klor-con m15 1 M

klor-con m20 1 M

klor-con sprinkle 1 M

KLOR-CON/25 3 M

klor-con/ef 1 M

k-phos-neutral 1

k-sol 1 M

K-TAB ORAL

TABLET

EXTENDED

RELEASE 10 MEQ,

20 MEQ

3 M

k-tab oral tablet

extended release 8

meq

1 M

lugols 1

phospha 250 neutral 1

POTABA 3 M

potassium bicarb

and chloride

1 M

potassium bicarb-

citric acid

1 M

potassium chloride 1 M

potassium chloride

in 0.9%nacl

6 MSD

sodium chloride 6 MSD

Drug Name Drug

Tier

Requirements

/ Limits

sodium chloride 0.45

%

6 MSD

sodium chloride 3 % 6 MSD

sodium chloride 5 % 6 MSD

SODIUM

PHOSPHATE IN

0.9 % NACL

6 MSD

strong iodine 1

MISCELLANEOUS VITAMINS,

HEMATINICS, & ELECTROLYTES

FORTAVIT 3

ISOLYTE-S 6 MSD

VITAMINS & HEMATINICS

ACTIVE FE 3

ACTIVE OB 3

ANIMI-3 WITH

VITAMIN D

3

ATABEX EC 3

b complex-vitamin

b12

5 ACA; OTC

b complex-vitamin c-

folic acid

5 ACA; OTC

b-12 kit 6 MSD

BACMIN 3

balanced b-100

complex

1 OTC

bal-care dha 1

BAL-CARE DHA

ESSENTIAL

3

b-complex with

vitamin c oral tablet

5 ACA; OTC

b-complex with

vitamin c oral tablet

400-500 mcg-mg

1 OTC



95

Drug Name Drug

Tier

Requirements

/ Limits

BIFERA RX 3

CADEAU DHA 3

calcium pnv 1

calcium-folic acid-

vitamin d

1

centratex 1

chewable multivit-

a,b,d,e,k,zn

1 M

ciferex 1 M

CITRANATAL

(DUAL-IRON)

3

CITRANATAL 90

DHA (ALGAL OIL)

3

CITRANATAL

ASSURE

3

CITRANATAL B-

CALM (FE GLUC)

3

CITRANATAL

DHA (ALGAL OIL)

3

CITRANATAL

HARMONY (IRON

FUM)

3

classic prenatal 5 ACA; OTC

c-nate dha 1

COMPLETE

FORMULATION

D3000

3 M

COMPLETE

FORMULATION

PEDIATRIC

3 M

complete natal dha 1

completenate 1

CONCEPT DHA 3

CONCEPT OB 3

corvita 1

Drug Name Drug

Tier

Requirements

/ Limits

corvita 150 1

CORVITE 3

CORVITE 150 3

CORVITE FE 3

CORVITE FREE 3

cyanocobalamin

(vitamin b-12)

1

DERMACINRX

PUREFOLIX

3 M

dialyvite 1

DIALYVITE 3000 3

DIALYVITE 5000 3

dialyvite 800 5 ACA; OTC

DIALYVITE 800

WITH IRON

3

DIALYVITE

SUPREME D

3

dothelle dha 1

DRISDOL 3

DUET DHA

BALANCED

3

DUET DHA WITH

OMEGA-3

3

DURACHOL 3 M

ELDERCAPS 3

ENBRACE HR 3

ergocalciferol

(vitamin d2)

1

ESCAVITE 3

ESCAVITE D 3 M

ESCAVITE LQ 3 M

EXPECTA

PRENATAL

5 ACA; OTC



96

Drug Name Drug

Tier

Requirements

/ Limits

EXTRA-VIRT

PLUS DHA

2

FA-8 5 M; ACA; OTC

fabb 1

fe c plus 1

FERIVA 21-7

TABLET

3

ferocon 1

FERRALET 90

DUAL-IRON

DELIVERY

3

ferraplus 90 1

ferrocite plus 1

ferrogels forte 1

FLORIVA 3 M

FLORIVA

(FLUORIDE-

VITAMIN D3)

5 M; ACA

FLORIVA PLUS 3 M

FLUORABON 5 M; ACA

FLUOR-A-DAY 5 M; ACA

fluor-a-day (with

xylitol)

1 M

FLUORITAB

ORAL DROPS

5 M; ACA

fluoritab oral

tablet,chewable 0.5

mg fluoride (1.1 mg)

5 M; ACA

fluoritab oral

tablet,chewable 1


1 M

FLURA-DROPS 5 M; ACA

focalgin 90 dha 1

focalgin ca 1

Drug Name Drug

Tier

Requirements

/ Limits

focalgin dss 1

folbecal 1

folbee 1

folbee plus 1

FOLET DHA 3

FOLET ONE 3

FOLGARD OS 3

FOLGARD RX 3

folic acid oral tablet

1 mg

1 M

folic acid oral tablet

400 mcg, 800 mcg

5 M; ACA; OTC

folic acid-vit b6-vit

b12

1

folivane-f 1

folivane-ob 1

folivane-plus 1

FOLIXAPURE 3 M

folplex 2.2 1

foltabs 800 1 OTC

FOLTRATE 3

full spectrum b-

vitamin c

5 ACA; OTC

FUSION PLUS 3

FUSION

SPRINKLES

3

hematinic plus

vit/minerals

1

hematinic/folic acid 1

hematogen 1

hematogen fa 1

hematogen forte 1



97

Drug Name Drug

Tier

Requirements

/ Limits

HEMATRON 3

HEMATRON-AF 3

hemenatal ob 1

hemenatal ob + dha 1

hemetab 1

HEMOCYTE-F 3

HEMOCYTE-PLUS 3

ICAR-C PLUS 3

inatal advance 1

inatal ultra 1

INJECTAFER 6 MSD

INTEGRA F 3

INTEGRA PLUS 3

IROSPAN 24/6 3

levomefolate dha 1

ludent fluoride oral

tablet,chewable 0.25

mg fluorid (0.55

mg), 0.5 mg fluoride

(1.1 mg)

5 M; ACA

ludent fluoride oral

tablet,chewable 1


1 M

macnatal cn dha 1

MARNATAL-F 3

MAXARON

FORTE

3

MAXFE (FOLATE-

DOCUSATE)

3

MAXINATE 3

multigen folic 1

multigen plus 1

Drug Name Drug

Tier

Requirements

/ Limits

multi-vit with

fluoride-iron

5 ACA

multi-vitamin with

fluoride oral drops

5 ACA

multi-vitamin with

fluoride oral


mg, 0.5 mg

5 ACA

multi-vitamin with

fluoride oral

tablet,chewable 1

mg

1

multivitamins with

fluoride oral


mg, 0.5 mg

5 ACA

multivitamins with

fluoride oral

tablet,chewable 1

mg

1

mvc-fluoride oral


mg, 0.5 mg

5 ACA

mvc-fluoride oral

tablet,chewable 1

mg

1

M-VIT 3

mynatal 1

mynatal advance 1

mynatal plus 1

mynatal-z 1

mynate 90 plus 1

mynephrocaps 1

NASCOBAL 3 M

NATACHEW (FE

BIS-GLYCINATE)

3

NATELLE ONE 3



98

Drug Name Drug

Tier

Requirements

/ Limits

natural b-100

complex

5 ACA; OTC

NEEVODHA

(WITH ALGAL

OIL)

3

nephplex rx 1

NEPHROCAPS 3

NEPHROCAPS QT 3

NEPHRON FA 3

nephro-vite rx 1

NESTABS 3

NESTABS ABC 3

NESTABS DHA 3

NEURIN-SL 3

newgen 1

NEXA PLUS 3

NEXAVIR 3

NIVA-PLUS 3

NOXIFOL-D3 3 M

NUTRICAP 3

OB COMPLETE 3

OB COMPLETE

GOLD

3

OB COMPLETE

ONE

3

OB COMPLETE

PETITE

3

OB COMPLETE

PREMIER

3

OB COMPLETE

WITH DHA

3

obstetrix dha 1

OBSTETRIX EC 3

Drug Name Drug

Tier

Requirements

/ Limits

OBTREX DHA 3

O-CAL FA 3

O-CAL

PRENATAL

3

ONE A DAY

WOMEN'S

PRENATAL DHA

5 ACA; OTC

ONE DAILY

PRENATAL ORAL

COMBO PACK 28

MG IRON- 800

MCG

5 ACA; OTC

one daily prenatal

oral combo pack 28-

800-440 mg-mcg-mg

5 ACA; OTC

ortho d 1 M

PAIRE OB PLUS

DHA

3

PED

MULTIVITAMINS-

A,B,D,E,K,ZN

3 M

perry prenatal 5 ACA; OTC

PHYSICIANS EZ

USE B-12

3 MSD

pnv ob+dha 1

pnv-dha 1

pnv-dha + docusate 1

pnv-ferrous

fumarate-docu-fa

1

pnv-omega 1

pnv-select 1

pnv-vp-u 1

POLY-VI-FLOR 3

POLY-VI-FLOR FS 3 M



99

Drug Name Drug

Tier

Requirements

/ Limits

POLY-VI-FLOR

WITH IRON

3

poly-vitamin with

iron

1 OTC

pr natal 400 1

pr natal 400 ec 1

pr natal 430 1

pr natal 430 ec 1

PREFERA-OB 3

PREFERA-OB ONE 3

PREFERA-OB

PLUS DHA

3

prena1 chew 1

prena1 pearl 1

prena1 true 1

prenaissance 1

prenaissance next 1

prenaissance plus 1

PRENATA 3

prenatabs fa 1

prenatabs rx 1

prenatal 5 ACA; OTC

prenatal complete 5 ACA; OTC

prenatal formula 5 OTC

prenatal multi-dha

(algal oil)

1 OTC

prenatal one daily 5 ACA; OTC

prenatal plus 1

prenatal plus

(calcium carb)

1

prenatal vit#96-

ferrous fum-fa

5 ACA; OTC

Drug Name Drug

Tier

Requirements

/ Limits

prenatal vitamin 5 ACA; OTC

prenatal vitamin

plus low iron

1

prenatal-u 1

PRENATE AM 3

PRENATE

CHEWABLE

3

PRENATE DHA

(FERR ASP

GLYCIN)

3

PRENATE ELITE

(IRON ASP GLYC)

3

PRENATE

ENHANCE

3

PRENATE

ESSENTIAL(IRON-

ASP-GL)

3

PRENATE MINI

(FERR ASP

GLYCIN)

3

PRENATE PIXIE 3

PRENATE

RESTORE

3

PRENATE STAR 3

preplus 1

PREQUE 10 3

PROFERRIN-

FORTE

2

PROTECT IRON 3

PROVIDA DHA 3

PROVIDA OB 3

PURALOR CI 3 M

PUREFE OB PLUS 3

PUREFE PLUS 3



100

Drug Name Drug

Tier

Requirements

/ Limits

purevit dualfe plus 1

QUFLORA FE 3 M

QUFLORA

PEDIATRIC

3 M

QUFLORA

PEDIATRIC

DROPS

3 M

relnate dha 1

renal caps 1

rena-vite 5 ACA; OTC

rena-vite rx 1

reno caps 1

REVESTA 3 M

risacal-d 5 ACA; OTC

R-NATAL OB 3

rulavite dha 1

SELECT-OB 3

SELECT-OB +

DHA

3

se-natal 19 1

se-natal 19 (with

docusate)

1

se-tan dha 1

se-tan plus 1

sodium fluoride oral

drops

5 M; ACA



mg fluorid (0.55

mg), 0.5 mg fluoride

(1.1 mg)

5 M; ACA


tablet,chewable 1


1 M

Drug Name Drug

Tier

Requirements

/ Limits

SOFTGELS

MULTIVIT-

A,B,D,E,K,ZN

3 M

stress formula 5 ACA; OTC

stress formula with

iron

1 OTC

stress formula with

iron(sulf)

1 OTC

STROVITE FORTE 3

STROVITE ONE 3

SUPERVITE 3

SUPERVITE (EC) 3

TANDEM PLUS 3

taron forte 1

taron-c dha 1

taron-prex prenatal-

dha

1

TEXAVITE LQ 3 M

THRIVITE RX 3

thrivite-19 1

tl gard rx 1

tl g-fol os 1

tl icon 1

tl-hem 150 1

TRICARE 3

TRICARE

PRENATAL DHA

ONE

3

TRICARE

PRENATAL WITH

DHA

3

tricon 1

TRIFERIC 6 MSD



101

Drug Name Drug

Tier

Requirements

/ Limits

trigels-f forte 1

trinatal gt 1

trinatal rx 1 1

trinate 1

triphrocaps 1

TRISTART DHA 3

tri-tabs dha 1

triveen-duo dha 1

TRI-VI-FLOR 3

tri-vit with fluoride

and iron

5 ACA

tri-vitamin with

fluoride

5 ACA

trust natal dha 1

UDAMIN SP 3

ultimatecare one 1

ultimatecare one nf 1

v-c forte 1

vemavite-prx-2 1

vic-forte 1

vinate care 1

vinate dha 1

VINATE DHA RF 3

vinate ii 1

vinate m 1

vinate one 1

vinate ultra 1

virt-advance 1

virt-c dha 1

VIRT-CAPS 3

virt-gard 1

Drug Name Drug

Tier

Requirements

/ Limits

virt-nate 1

virt-nate dha 1

VIRTPREX 3

virt-select 1

virt-vite 1

virt-vite gt 1

VIRT-VITE PLUS 3 M

vit 3 1

vit b complex-folic

acid

5 ACA; OTC

VITA-BEE WITH C 5 ACA; OTC

VITAFOL 3

VITAFOL FE+

(WITH

DOCUSATE)

3

VITAFOL

GUMMIES

3

VITAFOL NANO 3

VITAFOL ULTRA 3

vitafol-ob 1

VITAFOL-

OB+DHA

3

VITAFOL-ONE 3

VITAL-D RX 3

VITAMED MD

ONE RX

3

VITAMED MD

PLUS RX

3

VITAMEDMD

REDICHEW RX

3

vitamin d3 5 ACA; OTC

vitamins a,c,d and

fluoride

5 ACA



102

Drug Name Drug

Tier

Requirements

/ Limits

VITAPEARL 3

VITA-RESPA 3

VITATRUE 3

VIVA DHA 3

vol-care rx 1

vol-nate 1

vol-plus 1

vol-tab rx 1

vp-ch plus 1

vp-ch-pnv 1

vp-ggr-b6 1

VP-PNV-DHA 3

vp-vite rx 1

zatean-ch 1

zatean-pn dha 1

zatean-pn plus 1

zavara 1 M

zingiber 1

103

Index

1 1ST TIER UNIFINE PENTIPS

.......................................... 52

1ST TIER UNILET

COMFORTOUCH ........... 52

2 2TEK GLUCOSE/BLOOD

PRESSURE ...................... 52

8 8-MOP .................................. 38

A abacavir .................................. 3

abacavir-lamivudine-

zidovudine .......................... 3

ABILIFY .............................. 24

ABILIFY MAINTENA ........ 24

ABRAXANE ........................ 11

ABSORICA .......................... 40

ABSTRAL ............................ 19

acamprosate .......................... 45

ACANYA ............................. 40

acarbose ................................ 66

ACCOLATE......................... 88

ACCU-CHEK AVIVA

CONNECT METER ........ 52

ACCU-CHEK AVIVA PLUS

METER ............................ 52

ACCU-CHEK AVIVA PLUS

TEST STRP ...................... 49

ACCU-CHEK COMP BLUE

CONT, M-H ..................... 52

ACCU-CHEK COMPACT

PLUS CONTROL ............ 52

ACCU-CHEK COMPACT

TEST ................................ 49

ACCU-CHEK FASTCLIX .. 52

ACCU-CHEK NANO .......... 52

ACCU-CHEK SAFE-T-PRO

.......................................... 52

ACCU-CHEK SMARTVIEW

CONTRL SOL ................. 53

ACCU-CHEK SMARTVIEW

TEST STRIP .................... 49

ACCU-CHEK SOFTCLIX

LANCET DEV ................. 53

ACCU-CHEK SOFTCLIX

LANCETS ........................ 53

ACCU-CHEK VOICEMATE

.......................................... 53

ACCUPRIL .......................... 29

ACCURETIC ....................... 29

ACCUTREND GLUCOSE .. 49

ACCUTREND GLUCOSE

CONTROL ....................... 53

acebutolol ............................. 29

ACEON ................................ 29

acetaminophen-caff-

dihydrocod ........................ 19

acetaminophen-codeine ........ 19

acetasol hc ............................ 48

acetazolamide ....................... 84

acetic acid-aluminum acetate 48

acetylcysteine ....................... 88

ACIPHEX ............................. 71

ACIPHEX SPRINKLE......... 71

acitretin ................................. 37

ACTEMRA .......................... 76

ACTHAR H.P. ..................... 48

ACTICLATE .......................... 9

ACTIGALL .......................... 68

ACTI-LANCE LANCETS ... 53

ACTIMMUNE ..................... 74

ACTIQ .................................. 19

ACTIVE FE .......................... 92

ACTIVE OB ......................... 92

ACTIVELLA........................ 77

ACTIVE-PAC ...................... 15

ACTONEL ..................... 45, 76

ACTOPLUS MET ................ 66

ACTOPLUS MET XR ......... 66

ACTOS ................................. 66

acuicyn.................................. 83

ACULAR.............................. 84

ACULAR LS ........................ 84

ACUVAIL (PF) .................... 84

acyclovir ........................... 3, 43

ACZONE .............................. 40

ADAGEN ............................. 45

ADALAT CC ....................... 29

adapalene .............................. 40

ADASUVE ........................... 24

ADCETRIS ........................... 11

ADCIRCA ............................ 88

ADDERALL ......................... 24

ADDERALL XR .................. 24

ADDYI ................................. 24

adefovir ................................... 3

ADEMPAS ........................... 88

ADJUSTABLE LANCING

DEVICE ........................... 53

ADRENACLICK ................. 86

adrucil ................................... 11

ADVAIR DISKUS ............... 88

ADVAIR HFA ...................... 88

ADVANCED ALLERGY

COLLECT KIT ................ 43

ADVANCED GLUC METER

TEST STRIP ..................... 49

ADVANCED GLUCOSE

METER ............................. 53

ADVANCED LANCING

DEVICE ........................... 53

ADVANCED TRAVEL

LANCETS ........................ 53

ADVATE .............................. 33

ADVOCATE BLOOD

GLUCOSE MONITOR .... 53

ADVOCATE DUO .............. 53

ADVOCATE LANCET ....... 53

ADVOCATE LOW

CONTROL ....................... 53

ADVOCATE PEN NEEDLES

.......................................... 53

ADVOCATE RAPID-SAFE

LANCING ........................ 53

ADVOCATE REDI-CODE .. 49

ADVOCATE REDI-CODE

DUO METER ................... 53

ADVOCATE REDI-CODE

GLU MONITOR .............. 53

ADVOCATE REDI-CODE+

CTRL LOW ...................... 53

ADVOCATE TEST STRIPS 49

ADYNOVATE ..................... 33

ADZENYS XR-ODT ........... 24

AEROSPAN ......................... 88

afeditab cr ............................. 29

104

AFINITOR ........................... 11

AFINITOR DISPERZ .......... 11

AFLURIA 2016-2017 .......... 74

AFLURIA 2016-2017 (PF) .. 74

AFREZZA ............................ 64

AFSTYLA ............................ 33

AFTERA .............................. 79

AGAMATRIX AMP GLUC

MONITOR SYS ............... 53

AGAMATRIX AMP TEST

STRIPS ............................. 49

AGAMATRIX CONTROL

HIGH ................................ 53

AGGRENOX ....................... 33

AGRYLIN ............................ 45

AKTEN (PF) ........................ 83

AKYNZEO........................... 68

ALA-SCALP ........................ 43

ALBENZA ............................. 6

albuterol sulfate .................... 88

ALCAINE ............................ 83

alclometasone ....................... 43

ALDACTAZIDE .................. 29

ALDACTONE ..................... 29

ALDARA ............................. 74

ALDURAZYME .................. 65

ALECENSA ......................... 11

alendronate ..................... 45, 76

ALEVICYN ANTIPRURITIC

.......................................... 38

ALEVICYN ANTIPRURITIC

SG ..................................... 38

ALFERON N........................ 74

alfuzosin ............................... 90

ALINIA .................................. 6

ALKERAN ........................... 11

allopurinol ............................ 76

ALLZITAL........................... 19

almotriptan malate ................ 17

ALOCRIL............................. 83

ALOGLIPTIN ...................... 66

ALOGLIPTIN-METFORMIN

.......................................... 66

ALOGLIPTIN-

PIOGLITAZONE ............. 66

ALOMIDE ........................... 83

ALORA ................................ 77

alosetron ............................... 68

ALOXI ................................. 68

ALPHAGAN P ............... 85, 86

ALPHANATE ...................... 33

ALPHANINE SD ................. 33

alprazolam ............................ 24

alprazolam intensol............... 24

ALPROLIX .......................... 33

ALREX ................................. 85

ALSUMA ............................. 17

ALTABAX ........................... 42

altacaine ................................ 84

ALTACE .............................. 29

altafluor ................................ 84

altavera (28) .......................... 79

ALTERNATE SITE LANCET

.......................................... 53

ALTERNATE SITE

LANCING DEVICE ........ 53

ALTOPREV ......................... 35

ALUVEA.............................. 38

ALVESCO............................ 88

alyacen 1/35 (28) .................. 79

alyacen 7/7/7 (28) ................. 79

amantadine hcl ........................ 3

AMARYL ............................. 66

AMBIEN .............................. 24

AMBIEN CR ........................ 24

AMBISOME .......................... 3

amcinonide ........................... 43

AMERGE ............................. 17

amethia ................................. 79

amethia lo ............................. 79

amethyst................................ 79

AMICAR .............................. 33

amifostine crystalline ........... 10

amikacin ................................. 6

amiloride ............................... 29

amiloride-hydrochlorothiazide

.......................................... 29

amiodarone ........................... 29

AMITIZA ............................. 68

amitriptyline ......................... 24

amitriptyline-chlordiazepoxide

.......................................... 24

amlodipine ............................ 29

amlodipine-atorvastatin ........ 35

amlodipine-benazepril .......... 29

amlodipine-valsartan ............ 30

amlodipine-valsartan-hcthiazid

.......................................... 30

AMMONIUM CHLORIDE . 90

AMMONUL ......................... 45

amoxapine ............................. 24

amoxicil-clarithromy-lansopraz

.......................................... 71

amoxicillin .............................. 8

AMOXICILLIN ..................... 8

amoxicillin-pot clavulanate .... 8

amphotericin b ........................ 3

ampicillin ................................ 8

ampicillin sodium ................... 8

ampicillin-sulbactam .............. 8

AMPYRA ............................. 18

AMRIX ................................. 19

ANADROL-50 ..................... 65

ANAFRANIL ....................... 24

anagrelide ............................. 45

ANA-LEX KIT ..................... 68

ANALPRAM E .................... 69

ANALPRAM-HC ................. 69

ANALPRAM-HC SINGLES69

ANAPROX DS ..................... 22

anaspaz ................................. 68

anastrozole ............................ 11

ANCOBON ............................ 3

ANDRODERM .................... 65

ANDROGEL ........................ 65

ANDROID ............................ 65

androxy ................................. 65

ANGELIQ ............................ 77

ANIMI-3 WITH VITAMIN D

.......................................... 92

ANORO ELLIPTA ............... 88

ANTABUSE ......................... 45

ANTARA ............................. 35

anucort-hc ............................. 69

ANUSOL-HC ....................... 69

apexicon e ............................. 43

APIDRA ............................... 64

APIDRA SOLOSTAR .......... 64

APLENZIN ........................... 24

APOKYN ............................. 17

apraclonidine ........................ 86

apri ........................................ 79

APRISO ................................ 69

APTENSIO XR .................... 24

APTIOM ............................... 15

APTIVUS ............................... 3

AQUA GLYCOLIC HC ....... 43

AQUA LANCE LANCING

DEVICE ........................... 53

ARALAST NP ...................... 45

105

aranelle (28).......................... 79

ARANESP (IN

POLYSORBATE) ............ 73

ARAVA ................................ 76

arbinoxa ................................ 86

ARCALYST ......................... 74

ARCAPTA NEOHALER ..... 88

ARESTIN ............................. 47

ARGATROBAN .................. 33

ARGATROBAN IN 0.9 %

SOD CHLOR ................... 33

ARGATROBAN IN NACL

(ISO-OS) .......................... 33

ARICEPT ............................. 18

ARIMIDEX .......................... 11

aripiprazole ........................... 24

ARIXTRA ............................ 33

armodafinil ........................... 24

ARMOUR THYROID ......... 67

ARNUITY ELLIPTA ........... 88

AROMASIN......................... 11

ARRANON .......................... 11

ARTHROTEC 50 ................. 22

ARTHROTEC 75 ................. 22

ARZERRA ........................... 11

ASACOL HD ....................... 69

ascomp with codeine ............ 19

ashlyna .................................. 79

ASMANEX HFA ................. 88

ASMANEX TWISTHALER 88

aspirin-caffeine-dihydrocodein

.......................................... 19

aspirin-dipyridamole ............ 33

ASSURE 4 CONTROL

SOLUTION ...................... 53

ASSURE 4 STRIPS ............. 49

ASSURE DOSE NORMAL

CONTROL ....................... 53

ASSURE HAEMOLANCE

PLUS ................................ 53

ASSURE LANCE ................ 53

ASSURE LANCE PLUS ..... 53

ASSURE PLATINUM ... 49, 53

ASSURE PRISM CONTROL

1-2 SOLN ......................... 53

ASSURE PRISM MULTI

METER ............................ 54

ASSURE PRISM MULTI

STRIP ............................... 49

ASTAGRAF XL .................. 11

ASTEPRO ............................ 47

ASTERO .............................. 41

ATABEX EC ........................ 92

ATACAND .......................... 30

ATACAND HCT ................. 30

ATELVIA ............................. 76

atenolol ................................. 30

atenolol-chlorthalidone ......... 30

ATGAM ............................... 74

ATIVAN ............................... 24

ATOPICLAIR ...................... 38

atorvastatin ........................... 35

atovaquone.............................. 6

atovaquone-proguanil ............. 6

ATRALIN ............................ 40

ATRAPRO CP ..................... 38

ATRAPRO HYDROGEL .... 38

ATRIPLA ............................... 3

atropine ........................... 68, 83

ATROVENT HFA ............... 88

AUBAGIO............................ 73

aubra ..................................... 79

AUGMENTIN ........................ 8

AUGMENTIN ES-600 ........... 8

AUGMENTIN XR ................. 8

AURYXIA............................ 69

AUTOJECT 2 INJECTION

DEVICE ........................... 54

AUTO-LANCET MINI ........ 54

AUTOLET IMPRESSION

LANC DEV ...................... 54

AUTOLET LANCING

DEVICE ........................... 54

AUTOPEN 2 TO 32 UNITS 54

AVALIDE ............................ 30

AVANDIA ........................... 66

AVAPRO.............................. 30

avar ....................................... 40

AVAR ................................... 40

AVAR LS ............................. 40

AVAR-E GREEN................. 40

AVAR-E LS ......................... 40

AVASTIN ............................ 11

AVC VAGINAL .................. 78

AVEED ................................ 65

AVELOX................................ 9

AVELOX ABC PACK ........... 9

AVENOVA .......................... 84

aviane.................................... 79

avidoxy ................................... 9

AVIDOXY DK ....................... 9

avita ...................................... 40

avo cream .............................. 38

AVODART ........................... 90

AVONEX ............................. 73

AVONEX (WITH ALBUMIN)

.......................................... 73

AVYCAZ ............................... 5

AXERT ................................. 17

AXIRON ............................... 65

AYGESTIN .......................... 77

azacitidine ............................. 11

AZASAN .............................. 11

AZASITE ............................. 82

azathioprine .......................... 11

azelastine ........................ 47, 84

AZELEX ............................... 40

AZILECT ............................. 17

azithromycin ........................... 6

AZOPT ................................. 84

AZOR ................................... 30

AZULFIDINE ...................... 69

AZULFIDINE EN-TABS .... 69

azuphen mb ........................... 91

azurette (28) .......................... 79

B b complex-vitamin b12 ......... 92

b complex-vitamin c-folic acid

.......................................... 92

b-12 kit .................................. 92

bacitracin .............................. 82

bacitracin-polymyxin b ......... 82

baclofen ................................ 19

BACMIN .............................. 92

BACTRIM .............................. 9

BACTRIM DS ........................ 9

BACTROBAN NASAL ....... 47

balanced b-100 complex ....... 92

bal-care dha .......................... 92

BAL-CARE DHA

ESSENTIAL ..................... 92

balsalazide ............................ 69

balziva (28) ........................... 79

BANZEL .............................. 15

BARACLUDE .................... 3, 4

BCG VACCINE, LIVE (PF) 74

b-complex with vitamin c ..... 92

BD AUTOSHIELD PEN

NEEDLE ........................... 54

106

BD INSULIN PEN NEEDLE

UF SHORT ....................... 54

BD LANCET DEVICE ........ 54

BD MICROTAINER

LANCET .......................... 54

bd pre-filled normal saline ... 45

BD ULTRA FINE LANCETS

.......................................... 54

BD ULTRA-FINE NANO

PEN NEEDLES................ 54

BEBULIN............................. 33

BECONASE AQ .................. 88

bekyree (28).......................... 79

BELBUCA ........................... 19

BELEODAQ ........................ 11

belladonna alkaloids-opium . 68

belladonna-opium ................. 68

BELSOMRA ........................ 24

benazepril ............................. 30

benazepril-hydrochlorothiazide

.......................................... 30

BENDEKA ........................... 11

BENEFIX ............................. 33

BENICAR ............................ 30

BENICAR HCT ................... 30

BENLYSTA ......................... 76

BENSAL HP ........................ 38

BENTYL .............................. 68

BENZACLIN ....................... 40

BENZACLIN PUMP ........... 40

BENZAMYCIN ................... 40

BENZAMYCINPAK ........... 40

BENZEFOAM ..................... 40

benzepro ............................... 40

BENZODOX 30 ..................... 9

BENZODOX 60 ..................... 9

benzonatate ........................... 86

benzoyl peroxide .................. 40

benztropine ........................... 17

BEPREVE ............................ 84

BERINERT .......................... 88

BESIVANCE ....................... 82

BETADINE OPHTHALMIC

PREP ................................ 82

BETAGAN ........................... 83

betamethasone dipropionate . 43

betamethasone valerate ........ 43

betamethasone, augmented... 43

BETAPACE ......................... 29

BETAPACE AF ................... 29

BETASERON ...................... 73

betaxolol ......................... 30, 83

bethanechol chloride............. 90

BETHKIS ............................... 6

BETIMOL ............................ 83

BETOPTIC S ........................ 83

BEVESPI AEROSPHERE ... 88

bexarotene ............................ 11

BEYAZ ................................. 79

BIAFINE EMULSION......... 38

BIAXIN .................................. 6

bicalutamide ......................... 11

BICILLIN C-R ....................... 9

BICNU.................................. 11

BIDIL ................................... 30

BIFERA RX ......................... 93

BILTRICIDE .......................... 6

bimatoprost ........................... 84

BINOSTO ............................. 76

BIONIME RIGHTEST

GM300 SYSTEM ............. 54

BIONIME RIGHTEST TEST

STRIPS ............................. 49

bisacodyl ............................... 69

bisoprolol fumarate............... 30

bisoprolol-hydrochlorothiazide

.......................................... 30

BIVIGAM ............................ 74

bleomycin ............................. 11

BLEPH-10 ............................ 85

BLEPHAMIDE .................... 85

BLEPHAMIDE S.O.P. ......... 85

blisovi 24 fe .......................... 79

blisovi fe 1.5/30 (28) ............ 79

blisovi fe 1/20 (28) ............... 79

BLOOD GLUCOSE

CONTROL, NORMAL .... 54

BLOOD GLUCOSE TEST .. 49

BLOOD-GLUCOSE METER

.......................................... 54

BONIVA .............................. 76

BOOSTRIX TDAP............... 74

BOSULIF ............................. 11

bp 10-1 .................................. 40

bp-50% urea ......................... 38

bpo ........................................ 40

BREEZE 2 CONTROL

SOLUTION,HIGH ........... 54

BREEZE 2 TEST STRIPS ... 49

BREO ELLIPTA .................. 88

BREVIBLOC ....................... 30

BREVICON (28) .................. 79

briellyn .................................. 79

BRILINTA ........................... 33

brimonidine ........................... 86

BRISDELLE ......................... 24

BRIVIACT ........................... 15

BROMFED DM ................... 86

bromfenac ............................. 84

bromocriptine ....................... 17

brompheniramine-pseudoeph-

dm ..................................... 86

BROVANA .......................... 88

BUCALSEP .......................... 42

budesonide ...................... 69, 88

BULLSEYE MINI SAFETY

LANCETS ........................ 54

bumetanide ........................... 30

BUNAVAIL ......................... 22

BUPAP ................................. 19

BUPHENYL ......................... 45

buprenorphine hcl ................. 19

buprenorphine-naloxone ....... 22

bupropion hcl ........................ 24

bupropion hcl (smoking deter)

.......................................... 47

buspirone .............................. 24

BUSULFEX ......................... 11

butalbital compound w/codeine

.......................................... 19

butalbital-acetaminop-caf-cod

.......................................... 19

butalbital-acetaminophen ..... 19

butalbital-acetaminophen-caff

.......................................... 19

butalbital-aspirin-caffeine ..... 20

BUTISOL ............................. 24

butorphanol tartrate .............. 22

BUTRANS ........................... 20

BYDUREON ........................ 66

BYETTA .............................. 66

BYSTOLIC ........................... 30

BYVALSON ........................ 30

C cabergoline ........................... 65

CABOMETYX ..................... 11

CADEAU DHA .................... 93

CADUET .............................. 35

CAFERGOT ......................... 17

caffeine citrated .................... 45

107

CALAN ................................ 30

CALAN SR .......................... 30

calcipotriene ......................... 37

calcipotriene-betamethasone 37

calcitrene .............................. 37

calcitriol .......................... 37, 65

calcium 500 with d ............... 91

calcium acetate ..................... 69

calcium carb and citrate-vitd3

.......................................... 91

calcium citrate + d ................ 91

calcium citrate-vitamin d2 .... 91

calcium pnv .......................... 93

calcium-folic acid-vitamin d 93

CAMBIA .............................. 22

camila ................................... 77

CAMPATH .......................... 11

CAMPTOSAR ..................... 11

camrese ................................. 79

camrese lo ............................. 79

CANASA ............................. 69

CANCIDAS ........................... 3

candesartan ........................... 30

candesartan-hydrochlorothiazid

.......................................... 30

capacet .................................. 20

CAPASTAT ........................... 6

CAPCOF .............................. 86

capecitabine .......................... 11

CAPEX ................................. 43

CAPITAL WITH CODEINE

.......................................... 20

CAPRELSA ......................... 11

captopril ................................ 30

captopril-hydrochlorothiazide

.......................................... 30

CAPXIB ............................... 22

CARAC ................................ 38

carafate ................................. 71

CARAFATE ......................... 71

CARBAGLU ........................ 45

carbamazepine ...................... 15

CARBATROL ...................... 15

carbidopa .............................. 17

carbidopa-levodopa .............. 17

carbidopa-levodopa-

entacapone ........................ 17

carbinoxamine maleate ......... 86

carboplatin ............................ 11

CARDENE IV ...................... 30

CARDIZEM ......................... 30

CARDIZEM CD................... 30

CARDIZEM LA ................... 30

CARDURA .......................... 30

CARDURA XL .................... 30

CAREFINE PEN NEEDLE . 54

CAREONE THIN LANCET 54

CARESENS CONTROL A

NORMAL ......................... 54

CARESENS N ...................... 54

CARESENS N TEST STRIPS

.......................................... 49

CARESENS N VOICE ........ 54

CARIMUNE NF

NANOFILTERED............ 74

carisoprodol .......................... 19

carisoprodol-asa-codeine ...... 19

carisoprodol-aspirin .............. 19

CARNITOR.......................... 45

CARNITOR (SUGAR-FREE)

.......................................... 45

carteolol ................................ 83

carvedilol .............................. 30

CASODEX ........................... 11

CATAPRES.......................... 30

CATAPRES-TTS-1 .............. 30

CATAPRES-TTS-2 .............. 30

CATAPRES-TTS-3 .............. 30

CAYA CONTOURED ......... 77

CAYSTON ............................. 6

caziant (28) ........................... 79

CEDAX .................................. 5

cefaclor ................................... 5

cefadroxil ................................ 5

cefazolin ................................. 5

cefdinir.................................... 5

cefditoren pivoxil ................... 5

cefepime ................................. 5

cefepime in dextrose,iso-osm . 5

cefixime .................................. 5

cefotaxime .............................. 5

cefotetan ................................. 5

cefoxitin .................................. 5

cefpodoxime ........................... 5

cefprozil .................................. 5

ceftibuten ................................ 5

CEFTIN .................................. 5

ceftriaxone .............................. 5

CEFTRIAXONE .................... 6

ceftriaxone in dextrose,iso-os . 5

cefuroxime axetil .................... 6

cefuroxime sodium ................. 6

celacyn .................................. 38

CELEBREX ......................... 22

celecoxib ............................... 22

CELEXA .............................. 24

CELLCEPT .......................... 11

CELLCEPT INTRAVENOUS

.......................................... 11

CELONTIN .......................... 15

cem-urea ............................... 38

CENTANY ........................... 42

CENTANY AT ..................... 42

centergy ................................ 86

centratex ............................... 93

cephalexin ............................... 6

CEPROTIN (BLUE BAR) ... 33

CEPROTIN (GREEN BAR) 33

CERACADE ......................... 38

CERAMAX .......................... 38

CERDELGA ......................... 65

CEREZYME ......................... 65

CERVIDIL ........................... 78

CESAMET ........................... 69

cetirizine ............................... 86

CETRAXAL ......................... 48

cevimeline ............................. 46

CHANTIX ............................ 47

CHANTIX CONTINUING

MONTH BOX .................. 47

CHANTIX STARTING

MONTH BOX .................. 47

chateal ................................... 79

CHEMET .............................. 46

CHENODAL ........................ 69

cheratussin ac ........................ 86

cheratussin dac ...................... 86

chewable multivit-a,b,d,e,k,zn

.......................................... 93

chloramphenicol sod succinate

............................................ 6

chlordiazepoxide hcl ............. 24

chlordiazepoxide-clidinium .. 68

chlorhexidine gluconate ........ 47

chloroquine phosphate ............ 6

chlorothiazide ....................... 30

chlorothiazide sodium .......... 30

chlorpromazine ..................... 24

chlorpropamide ..................... 66

chlorthalidone ....................... 30

108

chlorzoxazone....................... 19

CHOLBAM .......................... 69

cholestyramine (with sugar) . 35

cholestyramine light ............. 35

choline,magnesium salicylate

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

CIALIS ................................. 90

ciclodan ................................ 42

ciclopirox .............................. 42

ciclopirox-ure-camph-menth-

euc .................................... 42

cidofovir ................................. 4

ciferex ................................... 93

cilostazol............................... 33

CILOXAN ............................ 82

cimetidine ............................. 71

cimetidine hcl ....................... 71

CIMZIA ................................ 69

CIMZIA POWDER FOR

RECONST ........................ 69

CINRYZE............................. 88

CIPRO .................................... 9

CIPRO HC............................ 48

CIPRO XR.............................. 9

CIPRODEX .......................... 48

ciprofloxacin........................... 9

ciprofloxacin (mixture) .......... 9

ciprofloxacin hcl ......... 9, 48, 82

cisplatin ................................ 11

citalopram ............................. 24

CITRANATAL (DUAL-

IRON) ............................... 93

CITRANATAL 90 DHA

(ALGAL OIL) .................. 93

CITRANATAL ASSURE .... 93

CITRANATAL B-CALM (FE

GLUC) .............................. 93

CITRANATAL DHA

(ALGAL OIL) .................. 93

CITRANATAL HARMONY

(IRON FUM) .................... 93

citrate of magnesia ............... 69

cladribine .............................. 11

CLAFORAN .......................... 6

CLAFORAN IN

DEXTROSE(ISO-OSM) .... 6

claravis ................................. 40

CLARINEX .......................... 86

CLARINEX-D 12 HOUR .... 86

clarithromycin ........................ 6

classic prenatal ..................... 93

cleansing wash ...................... 40

clemastine ............................. 86

CLEO 90 INFUSION SET 24

.......................................... 54

CLEOCIN ......................... 6, 78

CLEOCIN T ......................... 40

CLEVER CHEK BLOOD

GLUCOSE........................ 54

CLEVER CHEK LANCETS 54

CLEVER CHOICE


CLEVER CHOICE LEVEL 2

CONTROL ....................... 54

CLEVER CHOICE MICRO 54

CLEVER CHOICE MICRO

TEST STRIP..................... 49

CLEVER CHOICE PRO 49, 54

CLEVER CHOICE TEST

STRIPS ............................. 49

CLEVER CHOICE VOICE+

TEST ................................ 49

CLICKFINE ......................... 54

CLIMARA............................ 77

CLIMARA PRO ................... 77

CLINDACIN ETZ ................ 40

clindacin p ............................ 40

CLINDACIN PAC ............... 40

CLINDAGEL ....................... 40

clindamycin hcl ...................... 6

clindamycin palmitate hcl ...... 6

clindamycin pediatric ............. 7

clindamycin phosphate .... 7, 40,

78

clindamycin-benzoyl peroxide

.......................................... 40

CLINDESSE ........................ 78

CLINPRO 5000 .................... 47

clobetasol .............................. 43

clobetasol-emollient ............. 43

CLOBEX .............................. 43

CLOCORTOLONE

PIVALATE ...................... 43

clodan ................................... 43

CLODERM .......................... 43

CLOLAR .............................. 11

clomipramine ........................ 24

clonazepam ........................... 15

clonidine ............................... 30

clonidine hcl ................... 24, 30

clopidogrel ...................... 33, 34

clorazepate dipotassium ........ 24

clorpres ................................. 30

CLORPRES .......................... 30

clotrimazole ............................ 3

clotrimazole-betamethasone . 42

clozapine ............................... 24

CLOZAPINE ........................ 25

CLOZARIL .......................... 25

c-nate dha .............................. 93

CNL 8 NAIL ......................... 42

COAGADEX ........................ 34

COAGUCHEK LANCETS .. 54

COAL TAR .......................... 37

COARTEM ............................. 7

codeine sulfate ...................... 20

codeine-butalbital-asa-caff ... 20

codeine-guaifenesin .............. 86

COLAZAL ........................... 69

COLCHICINE ...................... 76

colchicine-probenecid ........... 76

COLCRYS ............................ 76

COLESTID ........................... 35

COLESTID FLAVORED .... 35

colestipol ............................... 35

colistin (colistimethate na) ..... 7

colocort ................................. 69

COLOR LANCETS .............. 54

COLY-MYCIN M

PARENTERAL .................. 7

COLY-MYCIN S ................. 48

COLYTE WITH FLAVOR

PACKS ............................. 69

COMBIGAN ........................ 84

COMBIPATCH .................... 77

COMBIVENT RESPIMAT .. 88

COMBIVIR ............................ 4

COMETRIQ ......................... 11

COMFORT EZ PEN

NEEDLES ........................ 55

COMFORT LANCETS ........ 55

COMFORT SHORT INSULIN

PUMP 23 .......................... 55

COMPAZINE ....................... 69

COMPLERA .......................... 4

COMPLETE

FORMULATION D3000 . 93

COMPLETE

FORMULATION

PEDIATRIC ..................... 93

109

complete natal dha ................ 93

completenate......................... 93

compro .................................. 69

COMTAN............................. 17

CONCEPT DHA .................. 93

CONCEPT OB ..................... 93

CONCEPTROL .................... 78

CONCERTA ........................ 25

CONDYLOX ....................... 38

constulose ............................. 69

CONTOUR CONTROL

SOLUTION, NML ........... 55

CONTOUR LINK ................ 55

CONTOUR NEXT EZ

METER ............................ 55

CONTOUR NEXT LEV 2

CONTROL SOL .............. 55

CONTOUR NEXT LINK .... 55

CONTOUR NEXT METER 55

CONTOUR NEXT STRIPS . 49

CONTOUR NEXT USB

METER ............................ 55

CONTOUR TEST STRIPS .. 49

CONTROL G3 ..................... 49

CONTROL MONITORING

SYSTEM .......................... 55

CONZIP ............................... 22

COOL BLOOD GLUCOSE

METER ............................ 55

COOL CONTROL A

SOLUTION ...................... 55

COOL GLUCOSE TEST

STRIP ............................... 49

COPAXONE ........................ 73

COPEGUS ............................ 74

CORDRAN .......................... 43

COREG ................................ 30

COREG CR .......................... 30

CORGARD .......................... 30

CORIFACT .......................... 34

CORLANOR ........................ 36

cormax .................................. 43

CORTANE-B ....................... 38

CORTEF............................... 48

CORTENEMA ..................... 69

CORTIFOAM ...................... 69

cortisone ............................... 48

CORTISPORIN .................... 42

corvita ................................... 93

corvita 150 ............................ 93

CORVITE ............................. 93

CORVITE 150 ...................... 93

CORVITE FE ....................... 93

CORVITE FREE .................. 93

CORZIDE ............................. 30

COSENTYX ......................... 37

COSENTYX (2 SYRINGES)

.......................................... 37

COSENTYX PEN ................ 37

COSENTYX PEN (2 PENS) 37

COSMEGEN ........................ 11

COSOPT ............................... 84

COSOPT (PF)....................... 84

COTELLIC ........................... 11

COUMADIN ........................ 34

covaryx ................................. 77

covaryx h.s............................ 77

COZAAR.............................. 30

CREON ................................ 69

CRESEMBA .......................... 3

CRESTOR ............................ 35

CRINONE ............................ 77

CRIXIVAN ............................ 4

cromolyn ................... 69, 84, 88

cryselle (28) .......................... 79

CUBICIN................................ 7

CUPRIMINE ........................ 76

CUROSURF ......................... 88

CUTIVATE .......................... 43

CUVPOSA ........................... 68

cyanocobalamin (vitamin b-12)

.......................................... 93

cyclafem 1/35 (28)................ 79

cyclafem 7/7/7 (28) .............. 79

CYCLESSA (28) .................. 79

cyclobenzaprine .................... 19

CYCLOGYL ........................ 83

CYCLOMYDRIL ................. 86

cyclopentolate ....................... 83

cyclophosphamide ................ 11

CYCLOPHOSPHAMIDE .... 11

CYCLOSERINE .................... 7

CYCLOSET ......................... 66

cyclosporine.......................... 11

cyclosporine modified .......... 11

CYMBALTA........................ 25

cyproheptadine ..................... 86

CYRAMZA .......................... 11

cyred ..................................... 79

CYSTADANE ...................... 69

CYSTAGON ........................ 91

CYSTARAN ......................... 84

cytarabine ............................. 11

cytarabine (pf) ...................... 11

CYTOMEL ........................... 67

CYTOTEC ............................ 71

cytra k crystals ...................... 91

cytra-2 ................................... 91

cytra-3 ................................... 91

cytra-k ................................... 91

D D.H.E.45 ............................... 17

dacarbazine ........................... 11

DACOGEN ........................... 11

DAKLINZA ........................... 4

DALIRESP ........................... 88

danazol .................................. 65

DANTRIUM ......................... 19

dantrolene ............................. 19

dapsone ................................... 7

DARAPRIM ........................... 7

darifenacin ............................ 90

dasetta 1/35 (28) ................... 79

dasetta 7/7/7 (28) .................. 79

daunorubicin ......................... 11

DAYPRO .............................. 22

daysee ................................... 79

DAYTRANA ........................ 25

DDAVP ................................ 65

DEBACTEROL .................... 47

deblitane ............................... 77

decitabine .............................. 12

DELESTROGEN ................. 77

deltasone ............................... 48

delyla (28) ............................. 79

DELZICOL ........................... 69

DEMADEX .......................... 30

demeclocycline ....................... 9

DEMEROL ........................... 20

DEMSER .............................. 30

DENAVIR ............................ 43

denta 5000 plus ..................... 47

dentagel ................................. 47

DEPAKENE ......................... 15

DEPAKOTE ......................... 15

DEPAKOTE ER ................... 15

DEPAKOTE SPRINKLES ... 15

DEPEN TITRATABS .......... 76

DEPO-ESTRADIOL ............ 77

DEPO-PROVERA ................ 77

110

DEPO-SUBQ PROVERA 104

.......................................... 77

DEPO-TESTOSTERONE .... 65

DERMACINRX LEXITRAL

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

DERMACINRX PUREFOLIX

.......................................... 93

DERMACINRX SILAPAK . 43

DERMACINRX SILAZONE

.......................................... 43

DERMA-SMOOTHE/FS

BODY OIL ....................... 44

DERMA-SMOOTHE/FS

SCALP OIL ...................... 44

DERMASORB HC

COMPLETE KIT ............. 44

DERMASORB TA

COMPLETE KIT ............. 44

DERMASORB XM

COMPLETE KIT ............. 38

DERMATOP ........................ 44

DERMAWERX SDS ........... 44

DERMAZONE ..................... 44

DERMOTIC OIL ................. 48

DESCOVY ............................. 4

desipramine .......................... 25

desloratadine......................... 86

desmopressin ........................ 65

desog-e.estradiol/e.estradiol . 79

DESOGEN ........................... 79

desogestrel-ethinyl estradiol . 79

DESONATE ......................... 44

desonide ................................ 44

DESOWEN .......................... 44

desoximetasone .................... 44

DESOXYN ........................... 25

DESVENLAFAXINE .......... 25

DESVENLAFAXINE

FUMARATE .................... 25

DETROL .............................. 90

DETROL LA ........................ 90

dexamethasone ..................... 48

dexamethasone intensol........ 48

dexamethasone sodium

phosphate .......................... 85

DEXCOM G5 RECEIVER .. 55

dexedrine .............................. 25

DEXEDRINE SPANSULE .. 25

DEXILANT .......................... 72

dexmethylphenidate ............. 25

DEXPAK 10 DAY ............... 48

DEXPAK 13 DAY ............... 48

DEXPAK 6 DAY ................. 48

dexrazoxane hcl .................... 10

dextroamphetamine .............. 25

dextroamphetamine-

amphetamine .................... 25

dialyvite ................................ 93

DIALYVITE 3000 ............... 93

DIALYVITE 5000 ............... 93

dialyvite 800 ......................... 93

DIALYVITE 800 WITH IRON

.......................................... 93

DIALYVITE SUPREME D . 93

DIAMOX SEQUELS ........... 84

DIASTAT ............................. 15

DIASTAT ACUDIAL .......... 15

DIATRUE CONTROL SOLN

NORMAL ......................... 55

DIATRUE PLUS BLOOD

GLUCOSE MET .............. 55

DIATRUE PLUS TEST STRIP

.......................................... 49

diazepam ......................... 15, 25

diazepam intensol ................. 25

DIBENZYLINE ................... 31

DICLEGIS ............................ 69

diclofenac potassium ............ 22

diclofenac sodium..... 22, 39, 84

diclofenac-misoprostol ......... 22

DICLOTRAL ....................... 22

dicloxacillin ............................ 9

dicyclomine .......................... 68

didanosine ............................... 4

DIFFERIN ............................ 40

DIFICID ................................. 6

diflorasone ............................ 44

DIFLUCAN ............................ 3

diflunisal ............................... 22

digitek ................................... 33

digox ..................................... 33

digoxin .................................. 33

dihydroergotamine................ 17

DILANTIN ........................... 15

DILANTIN EXTENDED..... 15

DILANTIN INFATABS ...... 15

DILANTIN-125.................... 15

DILATRATE-SR ................. 36

DILAUDID .......................... 20

diltiazem ............................... 31

DIOVAN .............................. 31

DIOVAN HCT ..................... 31

DIPENTUM ......................... 69

diphenhydramine hcl ............ 86

diphenoxylate-atropine ......... 68

DIPROLENE ........................ 44

DIPROLENE AF .................. 44

dipyridamole ......................... 34

DISALCID ........................... 22

diskets ................................... 20

disopyramide phosphate ....... 29

disulfiram .............................. 46

DITROPAN XL .................... 90

DIURIL ................................. 31

DIURIL IV ........................... 31

divalproex ............................. 15

DIVIGEL .............................. 77

DOCEFREZ ......................... 12

docetaxel ............................... 12

dofetilide ............................... 29

DOLOPHINE ....................... 20

donepezil ............................... 18

DONNATAL ........................ 68

DORAL ................................ 25

DORIBAX .............................. 7

DORYX .................................. 9

DORYX MPC ........................ 9

dorzolamide .......................... 85

dorzolamide-timolol ............. 85

dothelle dha .......................... 93

DOVONEX .......................... 37

doxazosin .............................. 31

doxepin ........................... 25, 39

doxercalciferol ...................... 65

DOXIL .................................. 12

doxorubicin ........................... 12

doxorubicin, peg-liposomal .. 12

doxycycline hyclate ................ 9

doxycycline monohydrate ...... 9

DOXYCYCLINE

MONOHYDRATE ............. 9

DRISDOL ............................. 93

drithocreme hp ...................... 37

dronabinol ............................. 69

DROPLET LANCETS ......... 55

DROPLET LANCING

DEVICE ........................... 55

DROPLET PEN NEEDLE ... 55

drospirenone-ethinyl estradiol

.......................................... 79

111

DROXIA .............................. 12

DS PREP PAK ..................... 22

DUAC................................... 40

DUAVEE ............................. 77

DUET DHA BALANCED ... 93

DUET DHA WITH OMEGA-3

.......................................... 93

DUETACT ........................... 66

DUEXIS ............................... 22

DULERA .............................. 88

duloxetine ............................. 25

DUOPA ................................ 17

DURACHOL ........................ 93

DURAGESIC ....................... 20

DUREZOL ........................... 85

DURLAZA ........................... 34

dutasteride ............................ 90

dutasteride-tamsulosin .......... 90

DUTOPROL......................... 31

DYANAVEL XR ................. 25

DYAZIDE ............................ 31

DYMISTA ............................ 88

DYRENIUM ........................ 31

DYSPORT ............................ 74

E e.e.s. 400 ................................. 6

E.E.S. GRANULES ............... 6

EASY CLICK LANCING

DEVICE ........................... 55

EASY COMFORT LANCETS

.......................................... 55

EASY COMFORT PEN

NEEDLES ........................ 55

EASY MINI EJECT


EASY PLUS II BLOOD

GLUCOSE MET .............. 55

EASY PLUS II TEST .......... 49

EASY STEP ......................... 49

EASY STEP BLOOD

GLUCOSE METER ......... 55

EASY TALK BLOOD


EASY TALK GLUCOSE

TEST ................................ 49

EASY TOUCH FLIPLOCK

NEEDLE .......................... 55

EASY TOUCH GLUCOSE

MONITOR ....................... 55

EASY TOUCH

HYPODERMIC NEEDLE

.......................................... 55

EASY TOUCH LANCING

DEVICE ........................... 55

EASY TOUCH TEST STRIP

.......................................... 50

EASY TRAK BLOOD


EASY TRAK GLUCOSE

TEST ................................ 50

EASYGLUCO

MONITORING SYSTEM 56

EASYGLUCO PLUS ........... 50

EASYGLUCO TEST ........... 50

EASYMAX .......................... 50

EASYMAX L BLOOD


EASYMAX LOW CONTROL

.......................................... 56

EASYMAX NG ................... 56

EASYMAX NORMAL

CONTROL ....................... 56

EASYMAX V SPEAKING

GLUCOSE SYS ............... 56

EASYMAX V2 BLOOD


EC-NAPROSYN .................. 22

econazole .............................. 42

econtra ez .............................. 80

ECOZA ................................. 42

EDARBI ............................... 31

EDARBYCLOR ................... 31

EDECRIN ............................. 31

EDLUAR .............................. 25

ed-spaz .................................. 68

EDURANT ............................. 4

eemt ...................................... 77

eemt hs .................................. 77

effer-k ................................... 92

EFFER-K .............................. 91

EFFEXOR XR ...................... 25

EFFIENT .............................. 34

EFUDEX .............................. 39

EGRIFTA ............................. 73

ELAPRASE .......................... 65

ELDEPRYL.......................... 17

ELDERCAPS ....................... 93

ELELYSO ............................ 65

ELEMENT COMPACT


ELEMENT COMPACT

NORMAL CONTROL ..... 56

ELEMENT COMPACT TEST

STRIPS ............................. 50

ELEMENT COMPACT V

GLUCOSE MTR .............. 56

ELEMENT NORMAL

CONTROL ....................... 56

ELEMENT PLUS BLOOD

GLUCOSE KIT ................ 56

ELEMENT TEST STRIPS ... 50

ELESTAT ............................. 84

ELESTRIN ........................... 77

eletone ................................... 39

ELIDEL ................................ 39

ELIGARD ............................. 12

ELIGARD (3 MONTH) ....... 12



ELIMITE .............................. 45

elinest .................................... 80

eliphos ................................... 69

ELIQUIS ............................... 34

ELITEK ................................ 10

ELIXOPHYLLIN ................. 88

ELLA .................................... 80

ELLENCE ............................ 12

ELMIRON ............................ 91

ELOCON .............................. 44

ELOCTATE ......................... 34

EMADINE ............................ 84

EMBEDA ............................. 20

EMBRACE BLOOD

GLUCOSE SYSTEM . 50, 56

EMBRACE EVO LEVEL 1 . 56

EMBRACE EVO TEST

STRIPS ............................. 50

EMBRACE GLUCOSE

CONTROL LOW ............. 56

EMBRACE PRO GLUCOSE

METER ............................. 56

EMBRACE PRO TEST

STRIPS ............................. 50

EMCYT ................................ 12

EMEND ................................ 69

emoquette ............................. 80

EMSAM ............................... 25

EMTRIVA .............................. 4

112

emulsion sb ........................... 39

EMVERM .............................. 7

ENABLEX ........................... 90

enalapril maleate .................. 31

enalapril-hydrochlorothiazide

.......................................... 31

ENBRACE HR ..................... 93

ENBREL .............................. 76

ENBREL SURECLICK ....... 76

endocet ................................. 20

ENGERIX-B (PF) ................ 74

ENGERIX-B PEDIATRIC

(PF) ................................... 74

enoxaparin ............................ 34

enpresse ................................ 80

enskyce ................................. 80

ENSTILAR........................... 37

entacapone ............................ 17

entecavir ................................. 4

ENTOCORT EC .................. 69

ENTRESTO ......................... 36

ENTTY ................................. 39

ENTYVIO ............................ 69

enulose .................................. 69

ENVARSUS XR .................. 12

EPANED .............................. 31

EPCLUSA .............................. 4

EPICERAM .......................... 39

EPIDUO ............................... 40

EPIDUO FORTE.................. 41

EPIFOAM ............................ 37

epinastine .............................. 84

epinephrine ........................... 86

EPIPEN 2-PAK .................... 86

EPIPEN JR 2-PAK ............... 86

epirubicin .............................. 12

EPISIL .................................. 47

epitol ..................................... 15

EPIVIR ................................... 4

EPIVIR HBV.......................... 4

eplerenone ............................ 31

EPOGEN .............................. 73

epoprostenol (glycine) .......... 31

eprosartan ............................. 31

EPZICOM .............................. 4

EQUETRO ........................... 15

ERAXIS(WATER DILUENT)

............................................ 3

ERBITUX............................. 12

ergocalciferol (vitamin d2) ... 93

ergoloid ................................. 25

ERGOMAR .......................... 17

ERIVEDGE .......................... 12

errin ...................................... 77

ERTACZO............................ 42

ERWINAZE ......................... 12

ery pads................................. 41

erygel .................................... 41

ERYPED 200 ......................... 6

ERYPED 400 ......................... 6

ery-tab ..................................... 6

ERY-TAB ............................... 6

erythrocin (as stearate) ........... 6

erythromycin .................... 6, 82

erythromycin ethylsuccinate... 6

erythromycin with ethanol.... 41

erythromycin-benzoyl peroxide

.......................................... 41

ESBRIET .............................. 88

ESCAVITE ........................... 93

ESCAVITE D ....................... 93

ESCAVITE LQ .................... 93

escitalopram oxalate ............. 25

ESGIC .................................. 20

esmolol ................................. 31

esomeprazole magnesium..... 72

esomeprazole sodium ........... 72

ESOMEPRAZOLE

STRONTIUM ................... 72

estarylla ................................ 80

estazolam .............................. 25

ESTRACE ............................ 77

estradiol ................................ 77

estradiol valerate................... 77

estradiol-norethindrone acet . 77

ESTRING ............................. 77

ESTROGEL.......................... 77

estrogens-methyltestosterone 77

estropipate ............................ 77

ESTROSTEP FE-28 ............. 80

eszopiclone ........................... 25

ethambutol .............................. 7

ethosuximide ........................ 15

ethyl chloride ........................ 42

etidronate disodium .............. 46

etodolac ................................ 22

etoposide ............................... 12

EURAX ................................ 45

EVAMIST ............................ 77

EVEKEO .............................. 25

EVENCARE G2 ............. 50, 56

EVENCARE G3 GLUCOSE

METER ............................. 56

EVENCARE G3 TEST ........ 50

EVENCARE MINI

GLUCOSE TEST STR ..... 50

EVENCARE MINI

MONITOR SYSTEM ....... 56

EVISTA ................................ 76

EVOCLIN ............................. 41

EVOLUTION BLOOD


EVOLUTION NORMAL

CONTROL ....................... 56

EVOLUTION TEST STRIPS

.......................................... 50

EVOMELA ........................... 12

EVOTAZ ................................ 4

EVOXAC ............................. 46

EVZIO .................................. 22

EXALGO ER ........................ 20

EXELDERM ........................ 42

EXELON .............................. 18

exemestane ........................... 12

EXFORGE ............................ 31

EXFORGE HCT ................... 31

EXJADE ............................... 46

EXODERM .......................... 42

EXPECTA PRENATAL ...... 93

EXTAVIA ............................ 74

EXTINA ............................... 43

EXTRA-VIRT PLUS DHA .. 94

EYLEA ................................. 84

e-z ject lancets ...................... 56

EZ SMART LANCETS ....... 56

EZ SMART PLUS SYSTEM

.......................................... 56

EZ SMART PLUS TEST ..... 50

EZ SMART SYSTEM .......... 56

EZ SMART TEST ................ 50

F FA-8 ...................................... 94

fabb ....................................... 94

FABIOR ............................... 41

FABRAZYME ..................... 65

FACTIVE ............................... 9

fallback solo .......................... 80

falmina (28) .......................... 80

famciclovir .............................. 4

famotidine ............................. 72

113

famotidine (pf)...................... 72

FAMVIR ................................ 4

FANAPT .............................. 25

FARESTON ......................... 12

FARXIGA ............................ 66

FARYDAK........................... 12

FASLODEX ......................... 12

FAZACLO ........................... 25

FC2 FEMALE CONDOM ... 77

fe c plus ................................ 94

FEIBA NF ............................ 34

felbamate .............................. 15

FELBATOL ......................... 15

FELDENE ............................ 22

felodipine .............................. 31

fem ph ................................... 78

FEMARA ............................. 12

FEMCAP .............................. 77

FEMCON FE........................ 80

FEMHRT LOW DOSE ........ 77

FEMRING ............................ 77

fenofibrate ............................ 35

FENOFIBRATE ................... 35

fenofibrate micronized ......... 35

fenofibrate nanocrystallized . 35

fenofibric acid ...................... 35

fenofibric acid (choline) ....... 35

FENOGLIDE ....................... 36

fenoprofen ............................ 22

FENOPROFEN .................... 22

FENORTHO......................... 22

fentanyl ................................. 20

FENTANYL ......................... 20

fentanyl citrate ...................... 20

FENTANYL-

BUPIVACAINE-NACL

(PF) ................................... 20

FENTORA ........................... 20

FERIVA 21-7 TABLET ....... 94

ferocon .................................. 94

FERRALET 90 DUAL-IRON

DELIVERY ...................... 94

ferraplus 90 ........................... 94

FERRIPROX ........................ 46

FERRLECIT......................... 46

ferrocite plus ......................... 94

ferrogels forte ....................... 94

FETZIMA............................. 25

FEXMID............................... 19

FIBRICOR ........................... 36

FIFTY50 SAFETY SEAL

LANCETS ........................ 56

FIFTY50 TEST STRIP ........ 50

FINACEA ............................. 41

finasteride ............................. 90

FINE 30 UNIVERSAL

LANCETS ........................ 56

FINGERSTIX LANCETS .... 56

FIORICET ............................ 20

FIORICET WITH CODEINE

.......................................... 20

FIORINAL ........................... 20

FIORINAL-CODEINE #3 ... 20

FIRAZYR ............................. 88

FIRMAGON KIT W

DILUENT SYRINGE ...... 12

FIRST CHOICE LANCETS

THIN ................................ 56

FLAGYL ................................ 7

FLAGYL ER .......................... 7

FLAREX .............................. 85

flavoxate ............................... 90

FLEBOGAMMA DIF .......... 74

flecainide .............................. 29

FLECTOR ............................ 22

FLOLAN .............................. 31

FLOMAX ............................. 90

FLORIVA ............................. 94

FLORIVA (FLUORIDE-

VITAMIN D3) ................. 94

FLORIVA PLUS .................. 94

FLOVENT DISKUS ............ 88

FLOVENT HFA ................... 88

FLOWTUSS ......................... 86

floxuridine ............................ 12

FLUAD 2016-2017 (65 YR

UP)(PF) ............................ 74

FLUARIX QUAD 2016-2017

(PF) ................................... 75

FLUBLOK 2016-2017 (PF) . 75

flucaine ................................. 84

FLUCELVAX QUAD 2016-

2017 (PF) .......................... 75

fluconazole ............................. 3

fluconazole in dextrose(iso-o) 3

fluconazole in nacl (iso-osm) . 3

flucytosine .............................. 3

fludarabine ............................ 12

fludrocortisone...................... 48

FLULAVAL QUAD 2016-

2017 .................................. 75

FLUMADINE ......................... 4

flunisolide ............................. 88

fluocinolone .......................... 44

fluocinolone acetonide oil .... 48

fluocinolone and shower cap 44

fluocinonide .......................... 44

fluocinonide-e ....................... 44

FLUORABON ...................... 94

FLUOR-A-DAY ................... 94

fluor-a-day (with xylitol) ...... 94

fluorescein-benoxinate ......... 84

fluorescein-proparacaine ...... 84

fluoridex daily defense ......... 47

FLUORIDEX SENSITIVITY

RELIEF ............................. 47

fluoritab ................................ 94

FLUORITAB ........................ 94

fluorometholone ................... 85

FLUOROPLEX .................... 39

fluorouracil ..................... 12, 39

FLUOROURACIL ............... 39

fluoxetine .............................. 25

FLUOXETINE ..................... 25

fluphenazine decanoate ........ 25

fluphenazine hcl .................... 25

FLURA-DROPS ................... 94

flurandrenolide ..................... 44

flurazepam ............................ 25

flurbiprofen ........................... 22

flurbiprofen sodium .............. 84

flurox .................................... 84

flutamide ............................... 12

fluticasone ....................... 44, 88

fluvastatin ............................. 36

FLUVIRIN 2016-2017 ......... 75

FLUVIRIN 2016-2017 (PF) . 75

fluvoxamine .......................... 25

FLUZONE HIGH-DOSE

2016-17 (PF) ..................... 75

FLUZONE INTRADERM

QUAD 2016-17 ................ 75

FLUZONE QUAD 2016-2017

.......................................... 75

FLUZONE QUAD 2016-2017

(PF) ................................... 75

FLUZONE QUAD PEDI

2016-17 (PF) ..................... 75

FML FORTE ........................ 85

114

FML LIQUIFILM ................ 85

FML S.O.P. .......................... 85

focalgin 90 dha ..................... 94

focalgin ca ............................ 94

focalgin dss ........................... 94

FOCALIN............................. 25

FOCALIN XR ...................... 26

folbecal ................................. 94

folbee .................................... 94

folbee plus ............................ 94

FOLET DHA ........................ 94

FOLET ONE ........................ 94

FOLGARD OS ..................... 94

FOLGARD RX .................... 94

folic acid ............................... 94

folic acid-vit b6-vit b12 ........ 94

folivane-f .............................. 94

folivane-ob ........................... 94

folivane-plus ......................... 94

FOLIXAPURE ..................... 94

FOLOTYN ........................... 12

folplex 2.2............................. 94

foltabs 800 ............................ 94

FOLTRATE ......................... 94

fondaparinux......................... 34

FORA D10 ..................... 50, 56

FORA D15G ........................ 50

FORA D20 ..................... 50, 56

FORA D40-G31 TEST

STRIPS ............................. 50

FORA G20 ..................... 50, 56

FORA G30A .................. 50, 57

FORA GD50 BLOOD

GLUCOSE SYSTEM ....... 57

FORA GD50 TEST STRIPS 50

FORA LANCING DEVICE 57

FORA NORMAL CONTROL

.......................................... 57

FORA TEST N'GO VOICE

METER ............................ 57

FORA TEST STRIP ............. 50

FORA TN'G VOICE METER

.......................................... 57

FORA TN'G VOICE TEST

STRIPS ............................. 50

FORA V10 ..................... 50, 57

FORA V10-V12-D10-D20 ... 57

FORA V12 BLOOD


FORA V12 GLUCOSE ........ 50

FORA V20 ..................... 50, 57

FORA V30A......................... 57

FORACARE GD20 .............. 50

FORACARE GD20


FORACARE GD40 .............. 50

FORACARE GD40A


FORACARE GD40B


FORACARE GDH LOW

CONTROL ....................... 57

FORACARE LANCETS ...... 57

FORADIL AEROLIZER ..... 88

FORFIVO XL....................... 26

FORTAMET ........................ 66

FORTAVIT .......................... 92

FORTEO .............................. 76

FORTESTA .......................... 65

FORTISCARE BLOOD

GLUCOSE SYST ............. 57

FORTISCARE GLUCOSE

TEST STRIPS .................. 50

FORTISCARE NORMAL ... 57

FOSAMAX .......................... 76

FOSAMAX PLUS D ............ 76

foscarnet ................................. 4

FOSCAVIR ............................ 4

fosinopril .............................. 31

fosinopril-hydrochlorothiazide

.......................................... 31

fosphenytoin ......................... 15

FOSRENOL ......................... 69

FRAGMIN............................ 34

FREESTYLE CONTROL .... 57

FREESTYLE FLASH

SYSTEM .......................... 57

FREESTYLE FREEDOM .... 57

FREESTYLE FREEDOM

LITE ................................. 57

FREESTYLE INSULINX ... 50,

57

FREESTYLE INSULINX

TEST STRIPS .................. 50

FREESTYLE LANCETS ..... 57

FREESTYLE LITE METER 57

FREESTYLE LITE STRIPS 50

FREESTYLE PRECISION

NEO METER ................... 57

FREESTYLE PRECISION

NEO STRIPS .................... 50

FREESTYLE SIDEKICK II . 57

FREESTYLE SYSTEM KIT 57

FREESTYLE TEST ............. 50

FREESTYLE UNISTIK 2 .... 57

frovatriptan ........................... 17

full spectrum b-vitamin c ...... 94

FULYZAQ ........................... 68

FURADANTIN .................... 10

furosemide ............................ 31

FUSILEV .............................. 10

FUSION PLUS ..................... 94

FUSION SPRINKLES ......... 94

FUZEON ................................ 4

fyavolv .................................. 77

FYCOMPA ........................... 15

G gabapentin ............................. 15

GABITRIL ........................... 15

galantamine ........................... 18

GALZIN ............................... 92

GAMASTAN S/D ................ 75

GAMMAGARD LIQUID .... 75

GAMMAGARD S-D (IGA < 1

MCG/ML) ......................... 75

GAMMAKED ...................... 75

GAMMAPLEX .................... 75

GAMUNEX-C ...................... 75

GANIRELIX ........................ 65

GASTROCROM .................. 69

gatifloxacin ........................... 82

GATTEX 30-VIAL .............. 69

gavilyte-c .............................. 69

gavilyte-g .............................. 69

gavilyte-h and bisacodyl ....... 69

gavilyte-n .............................. 69

GAZYVA ............................. 12

GE100 BLOOD GLUCOSE

SYSTEM .......................... 57

GE100 BLOOD GLUCOSE

TEST STRIP ..................... 50

GE100 CONTROL

SOLUTION NORMAL .... 57

GELCLAIR .......................... 47

GELNIQUE .......................... 90

GELX ................................... 47

gemcitabine ........................... 12

gemfibrozil ........................... 36

GEMZAR ............................. 12

115

GENERESS FE .................... 80

generlac ................................ 69

gengraf .................................. 12

GENOTROPIN .................... 73

GENOTROPIN MINIQUICK

.......................................... 73

GENSTRIP TEST STRIP .... 50

gentak ................................... 82

gentamicin .................. 7, 42, 82

gentamicin in nacl (iso-osm) .. 7

GENTAMICIN IN NACL

(ISO-OSM) ......................... 7

gentamicin sulfate (ped) (pf) .. 7

gentamicin sulfate (pf) ........... 7

GENTAMICIN SULFATE

(PF) ..................................... 7

GENVOYA ............................ 4

GEODON ............................. 26

gianvi (28) ............................ 80

GIAZO ................................. 69

gildagia ................................. 80

GILENYA ............................ 74

GILOTRIF ............................ 12

GLASSIA ............................. 46

glatopa .................................. 74

GLEEVEC ............................ 12

GLEOSTINE ........................ 12

GLIADEL WAFER.............. 12

glimepiride ........................... 66

glipizide ................................ 66

glipizide-metformin .............. 66

GLUCAGEN DIAGNOSTIC

KIT ................................... 52

GLUCAGEN HYPOKIT ..... 52

GLUCAGON EMERGENCY

KIT (HUMAN) ................ 52

GLUCAGON HCL .............. 52

GLUCO NAVII GLUCOSE

MONITOR ....................... 57

GLUCO NAVII TEST STRIP

.......................................... 51

GLUCOCARD 01 METER . 57

GLUCOCARD 01 NORMAL

CONTROL ....................... 57

GLUCOCARD 01 SENSOR

PLUS ................................ 51

GLUCOCARD EXPRESSION

.................................... 51, 58

GLUCOCARD SHINE

METER ............................ 58

GLUCOCARD SHINE TEST

STRIPS ............................. 51

GLUCOCARD VITAL ........ 58

GLUCOCARD VITAL

SENSOR ........................... 51

GLUCOCARD VITAL TEST

STRIPS ............................. 51

GLUCOCOM BLOOD

GLUCOSE........................ 58

GLUCOCOM CONTROL

NORMAL ......................... 58

GLUCOCOM GLUCOSE .... 51

GLUCOCOM LANCETS .... 58

GLUCOPHAGE ................... 66

GLUCOPHAGE XR ............ 66

GLUCOSE CONTROL ........ 58

GLUCOTROL ...................... 66

GLUCOTROL XL ............... 66

GLUCOVANCE .................. 67

GLUMETZA ........................ 67

glyburide ............................... 67

glyburide micronized ............ 67

glyburide-metformin ............ 67

glycopyrrolate ....................... 68

glydo ..................................... 42

GLYNASE ........................... 67

GLYSET ............................... 67

GLYXAMBI ........................ 67

GM100............................ 51, 58

GMATE CONTROL

SOLUTION, NORMAL ... 58

GMATE LANCETS ............. 58

GMATE LANCING DEVICE

.......................................... 58

GMATE SMART METER .. 58

GMATE SMART STARTER

.......................................... 58

GMATE TEST STRIPS ....... 51

GMATE VOICE METER .... 58

GOLYTELY ......................... 69

GORDONS UREA ............... 39

GRALISE ............................. 16

GRALISE 30-DAY STARTER

PACK ............................... 16

granisetron hcl ...................... 69

GRANIX .............................. 73

GRASTEK............................ 75

griseofulvin microsize ............ 3

griseofulvin ultramicrosize ..... 3

GRIS-PEG

(ULTRAMICROSIZE) ....... 3

guaifenesin ac ....................... 86

guaifenesin dac ..................... 86

guanfacine ....................... 26, 31

guanidine .............................. 26

GYNAZOLE-1 ..................... 78

H HALCION ............................ 26

HALDOL .............................. 26

HALDOL DECANOATE .... 26

halobetasol propionate .......... 44

HALOG ................................ 44

haloperidol ............................ 26

haloperidol decanoate ........... 26

haloperidol lactate ................ 26

HARVONI .............................. 4

HAVRIX (PF) ...................... 75

HEALTHPRO GLUCOSE

MONITOR ....................... 58

HEALTHPRO HIGH-LOW

CONTROL ....................... 58

HEALTHPRO TEST STRIPS

.......................................... 51

HEALTHY ACCENTS

AUTOLET ........................ 58

HEALTHY ACCENTS

UNIFINE PENTIP ............ 58

HEALTHY ACCENTS

UNILET LANCET ........... 58

heather .................................. 77

HECTOROL ......................... 65

HELIXATE FS ..................... 34

HEMANGEOL ..................... 31

hematinic plus vit/minerals ... 94

hematinic/folic acid .............. 94

hematogen ............................. 94

hematogen fa ........................ 94

hematogen forte .................... 94

HEMATRON ....................... 95

HEMATRON-AF ................. 95

hemenatal ob ......................... 95

hemenatal ob + dha ............... 95

hemetab ................................. 95

hemmorex-hc ........................ 69

HEMOCYTE-F .................... 95

HEMOCYTE-PLUS ............. 95

HEMOFIL M HIGH ............. 34

HEMOFIL M LOW .............. 34

HEMOFIL M MID ............... 34

116

HEMOFIL M SUPER HIGH34

hep flush-10 (pf) ................... 34

HEPAGAM B ...................... 75

heparin (porcine) .................. 34

HEPARIN (PORCINE) IN

0.9% NACL ...................... 34

heparin (porcine) in 5 % dex 34

heparin (porcine) in nacl (pf) 34

heparin flush ......................... 34

heparin flush(porcine)-0.9nacl

.......................................... 34

heparin lock flush ................. 34

heparin lock flush (porcine) . 34

heparin lockflush(porcine)(pf)

.......................................... 34

heparin(porcine) in 0.45% nacl

.......................................... 34

HEPARIN(PORCINE) IN

0.45% NACL .................... 34

heparin, porcine (pf) ............. 34

HEPSERA .............................. 4

HERCEPTIN ........................ 12

HETLIOZ ............................. 26

HEXALEN ........................... 12

HIBERIX (PF)...................... 75

HISTEX-AC ......................... 86

HIZENTRA .......................... 75

homatropaire......................... 83

homatropine hbr ................... 83

HORIZANT ......................... 18

hpr......................................... 39

hpr plus ................................. 39

hpr plus hydrogel .................. 39

HPR PLUS-MB HYDROGEL

.......................................... 39

HUMALOG ......................... 64

HUMALOG KWIKPEN ...... 64

HUMALOG MIX 50-50 ...... 64

HUMALOG MIX 50-50

KWIKPEN ....................... 64

HUMALOG MIX 75-25 ...... 64

HUMALOG MIX 75-25

KWIKPEN ....................... 64

HUMAPEN LUXURA HD .. 58

HUMATE-P ......................... 34

HUMATROPE ..................... 73

HUMIRA .............................. 76

HUMIRA PEDIATRIC

CROHN'S START ........... 76

HUMIRA PEN CROHN'S-

UC-HS START ................ 76

HUMULIN 70/30 ................. 64

HUMULIN 70/30 KWIKPEN

.......................................... 64

HUMULIN N ....................... 64

HUMULIN N KWIKPEN .... 64

HUMULIN R ....................... 64

HUMULIN R U-500 (CONC)

KWIKPEN........................ 64

HUMULIN R U-500

(CONCENTRATED) ....... 64

HYCAMTIN ........................ 12

HYCET ................................. 20

HYCOFENIX ....................... 86

hydralazine ........................... 31

HYDREA ............................. 12

HYDRO 35 ........................... 39

HYDRO 40 ........................... 39

hydrochlorothiazide .............. 31

hydrocodone-acetaminophen 20

hydrocodone-chlorpheniramine

.......................................... 86

hydrocodone-cpm-

pseudoephed ..................... 87

hydrocodone-homatropine .... 87

hydrocodone-ibuprofen ........ 20

hydrocortisone .......... 44, 48, 69

hydrocortisone acetate .......... 70

hydrocortisone butyrate ........ 44

hydrocortisone butyr-emollient

.......................................... 44

hydrocortisone valerate ........ 44

hydrocortisone-acetic acid .... 48

hydrocortisone-min oil-wht pet

.......................................... 44

hydrocortisone-pramoxine ... 37,

70

hydromet ............................... 87

hydromorphone .................... 20

hydroxychloroquine................ 7

hydroxyprogesterone caproate

.......................................... 78

hydroxyurea .......................... 12

hydroxyzine hcl .................... 86

hydroxyzine pamoate ........... 86

HYLATOPIC ....................... 39

HYLATOPICPLUS.............. 39

hyolev mb ............................. 91

hyophen ................................ 91

hyoscyamine sulfate ............. 68

hyosyne ................................. 68

HYPERHEP B S/D ............... 75

HYPERHEP B S-D

NEONATAL .................... 75

HYPERRAB S/D (PF) ......... 75

HYPER-SAL ........................ 88

HYPOLANCE AST

LANCING ........................ 58

HYQVIA .............................. 75

HYSINGLA ER .................... 20

HYZAAR ............................. 31

I ibandronate ........................... 76

IBRANCE ............................. 12

IBUDONE ............................ 20

ibuprofen ............................... 22

ibuprofen-oxycodone ............ 20

ICAR-C PLUS ...................... 95

ICLUSIG .............................. 12

IDAMYCIN PFS .................. 12

idarubicin .............................. 12

IDELVION ........................... 34

IFEX ..................................... 12

ifosfamide ............................. 12

ifosfamide-mesna ................. 12

ILARIS (PF) ......................... 74

ILEVRO ............................... 84

ILOTYCIN ........................... 82

ILUVIEN .............................. 85

imatinib ................................. 12

IMBRUVICA ....................... 12

imipenem-cilastatin ................ 7

imipramine hcl ...................... 26

imipramine pamoate ............. 26

imiquimod ............................. 74

IMITREX ....................... 17, 18

IMITREX STATDOSE KIT

REFILL ............................. 18

IMITREX STATDOSE PEN 18

IMOGAM RABIES-HT (PF)

.......................................... 75

IMPAVIDO ............................ 7

IMURAN .............................. 13

inatal advance ....................... 95

inatal ultra ............................. 95

INCONTROL LANCING

DEVICE ........................... 58

INCONTROL PEN NEEDLE

.......................................... 58

117

INCONTROL SUPER THIN

LANCETS ........................ 58

INCONTROL ULTRA THIN

LANCETS ........................ 58

INCRELEX .......................... 46

INCRUSE ELLIPTA............ 88

indapamide ........................... 31

INDERAL LA ...................... 31

INDERAL XL ...................... 31

INDIOMIN MB.................... 91

INDOCIN ............................. 22

indomethacin ........................ 22

INFASURF .......................... 46

INFINITY CONTROL

SOLUTION NORM ......... 58

INFINITY STARTER KIT .. 58

INFINITY TEST STRIPS .... 51

INFLAMMA-K .................... 22

INJECT EASE LANCETS .. 58

INJECTAFER ...................... 95

INLYTA ............................... 13

INNOPRAN XL ................... 31

INOVA ................................. 41

INOVA 4-1 ........................... 38

INOVA 8-2 ........................... 38

INSPRA ................................ 31

INSUPEN ............................. 58

INTEGRA F ......................... 95

INTEGRA PLUS.................. 95

INTELENCE .......................... 4

INTERMEZZO .................... 26

INTRON A ........................... 74

introvale ................................ 80

INTUNIV ER ....................... 26

INVACARE LANCETS ...... 58

INVANZ................................. 7

INVEGA............................... 26

INVIRASE ............................. 4

INVOKAMET ...................... 67

INVOKANA ........................ 67

IONSYS ............................... 20

iophen c-nr............................ 87

IOPIDINE............................. 86

ipratropium bromide ....... 47, 88

ipratropium-albuterol ........... 88

irbesartan .............................. 31

irbesartan-hydrochlorothiazide

.......................................... 31

IRENKA ............................... 26

IRESSA ................................ 13

irinotecan .............................. 13

IROSPAN 24/6 ..................... 95

ISENTRESS ........................... 4

ISOCHRON.......................... 36

ISOLYTE-S .......................... 92

isometh-dichloral-

acetaminophn.................... 18

isomethepten-caf-

acetaminophen .................. 18

isoniazid.................................. 7

ISOPTO ATROPINE ........... 83

ISOPTO CARPINE .............. 83

ISORDIL .............................. 36

ISORDIL TITRADOSE ....... 36

isosorbide dinitrate ............... 36

isosorbide mononitrate ......... 36

isoxsuprine............................ 78

isradipine .............................. 31

ISTALOL ............................. 83

ISTODAX ............................ 13

itraconazole ............................ 3

ivermectin ............................... 7

IXEMPRA ............................ 13

IXINITY ............................... 34

J JADENU .............................. 46

JAKAFI ................................ 13

JALYN ................................. 90

jantoven ................................ 34

JANUMET ........................... 67

JANUMET XR ..................... 67

JANUVIA ............................. 67

JARDIANCE ........................ 67

JAZZ WIRELESS 2 METER

KIT ................................... 58

jencycla ................................. 78

JENTADUETO .................... 67

JENTADUETO XR .............. 67

JETREA (PF) ....................... 84

jevantique lo ......................... 78

JEVTANA ............................ 13

jinteli ..................................... 78

jolessa ................................... 80

jolivette ................................. 78

JUBLIA ................................ 43

juleber ................................... 80

junel 1.5/30 (21) ................... 80

junel 1/20 (21) ...................... 80

junel fe 1.5/30 (28) ............... 80

junel fe 1/20 (28) .................. 80

junel fe 24 ............................. 80

JUXTAPID ........................... 36

K KADCYLA ........................... 13

KADIAN .............................. 20

kaitlib fe ................................ 80

KALBITOR .......................... 88

KALETRA ............................. 4

KALYDECO ........................ 89

KAPVAY ............................. 26

KARBINAL ER ................... 86

kariva (28) ............................ 80

KAYEXALATE ................... 70

KAZANO ............................. 67

k-effervescent ....................... 92

KEFLEX ................................. 6

kelnor 1/35 (28) .................... 80

KENALOG ........................... 44

KEPIVANCE ....................... 10

KEPPRA ............................... 16

KEPPRA XR ........................ 16

KERAFOAM ........................ 39

KERALAC ........................... 39

KERALYT RX ..................... 38

KERALYT SCALP

COMPLETE ..................... 38

KERYDIN ............................ 43

KETEK ................................... 7

ketoconazole ..................... 3, 43

ketoprofen ............................. 22

ketorolac ................... 22, 23, 84

KEVEYIS ............................. 18

KHEDEZLA ......................... 26

kimidess (28) ........................ 80

KINERET ............................. 74

KINNEY BRAND LANCETS

.......................................... 58

KINRIX (PF) ........................ 75

kionex ................................... 70

kionex (with sorbitol) ........... 70

KITABIS PAK ....................... 7

KLARON ............................. 42

klofensaid ii .......................... 23

KLONOPIN .......................... 16

klor-con ................................. 92

klor-con 10 ............................ 92

klor-con 8 .............................. 92

klor-con m10 ........................ 92

klor-con m15 ........................ 92

klor-con m20 ........................ 92

118

klor-con sprinkle .................. 92

KLOR-CON/25 .................... 92

klor-con/ef ............................ 92

KOATE-DVI ........................ 34

KOGENATE FS ................... 34

KOMBIGLYZE XR ............. 67

KORLYM............................. 65

KOVALTRY ........................ 34

K-PHOS NO 2 ...................... 91

K-PHOS ORIGINAL ........... 91

k-phos-neutral....................... 92

KRISTALOSE ..................... 70

KRYSTEXXA ...................... 76

k-sol ...................................... 92

k-tab ...................................... 92

K-TAB .................................. 92

kurvelo .................................. 80

KUVAN ............................... 65

KYNAMRO ......................... 36

KYPROLIS .......................... 13

L l norgest/e.estradiol-e.estrad . 80

labetalol ................................ 31

LACRISERT ........................ 84

lactated ringers ..................... 45

lactic acid.............................. 39

lactic acid e ........................... 39

lactulose ................................ 70

LAMICTAL ......................... 16

LAMICTAL ODT ................ 16

LAMICTAL ODT STARTER

(BLUE) ............................. 16


(GREEN) .......................... 16


(ORANGE)....................... 16

LAMICTAL STARTER

(BLUE) KIT ..................... 16

LAMICTAL STARTER

(GREEN) KIT .................. 16

LAMICTAL STARTER

(ORANGE) KIT ............... 16

LAMICTAL XR ................... 16

LAMICTAL XR STARTER

(BLUE) ............................. 16

LAMICTAL XR STARTER

(GREEN) .......................... 16

LAMICTAL XR STARTER

(ORANGE)....................... 16

LAMISIL ................................ 3

lamivudine .............................. 4

lamivudine-zidovudine ........... 4

lamotrigine............................ 16

LANCETS ............................ 59

LANCETS,THIN ................. 59

LANCING DEVICE WITH

LANCETS ........................ 59

LANCING SYSTEM ........... 59

LANOXIN ............................ 33

lansoprazole .......................... 72

LANTUS .............................. 64

LANTUS SOLOSTAR......... 64

LANZO LANCING DEVICE

.......................................... 59

larin 1.5/30 (21) .................... 80

larin 1/20 (21) ....................... 80

larin 24 fe.............................. 80

larin fe 1.5/30 (28) ................ 80

larin fe 1/20 (28) ................... 80

LASIX .................................. 31

LASTACAFT ....................... 84

latanoprost ............................ 85

latrix...................................... 39

LATUDA.............................. 26

laxative peg 3350.................. 70

layolis fe ............................... 80

LAZANDA ........................... 20

LDO PLUS ........................... 42

leena 28................................. 80

LEMTRADA ........................ 74

LENVIMA............................ 13

LESCOL ............................... 36

LESCOL XL......................... 36

lessina ................................... 80

LETAIRIS ............................ 89

letrozole ................................ 13

leucovorin calcium ............... 10

LEUKERAN ........................ 13

LEUKINE ............................. 73

leuprolide .............................. 13

levalbuterol hcl ..................... 89

LEVAQUIN ........................... 9

LEVATOL............................ 31

LEVBID ............................... 68

LEVEMIR ............................ 64

LEVEMIR FLEXTOUCH ... 64

levetiracetam ........................ 16

levobunolol ........................... 83

levocarnitine ......................... 46

levocarnitine (with sugar) ..... 46

levocetirizine ........................ 86

levofloxacin ...................... 9, 82

levofloxacin in d5w ................ 9

levoleucovorin calcium ........ 10

levomefolate dha .................. 95

levonest (28) ......................... 80

levonorgestrel-ethinyl estrad 80

levonorg-eth estrad triphasic 80

levora-28 ............................... 80

levorphanol tartrate ............... 20

levothyroxine ........................ 67

levoxyl .................................. 67

LEVSIN ................................ 68

LEVSIN/SL .......................... 68

LEVULAN ........................... 39

LEXAPRO ............................ 26

LEXIVA ................................. 4

LIALDA ............................... 70

LIBERTY LEV 1 GLUCOSE

CONTROL ....................... 59

LIBERTY LEV 2 GLUCOSE

CONTROL ....................... 59

LIBERTY TEST ................... 51

LIBRAX (WITH

CLIDINIUM) ................... 68

lidocaine ............................... 42

lidocaine hcl .......................... 42

lidocaine hcl-hydrocortison ac

.................................... 42, 70

LIDOCAINE HCL-

HYDROCORTISON AC . 70

lidocaine viscous .................. 42

lidocaine-hydrocortisone-aloe

.......................................... 70

lidocaine-prilocaine .............. 42

LIDOCAINE-TETRACAINE

.......................................... 42

LIDODERM ......................... 42

lido-k ..................................... 42

lidopin ................................... 42

LIDOPIN .............................. 42

LIDORX ............................... 42

LIDOTRAL .......................... 42

LIDOVEX ............................ 42

LIDOXIB .............................. 23

LILETTA .............................. 77

LINCOCIN ............................. 7

lindane .................................. 45

linezolid .................................. 7

LINZESS .............................. 70

119

liothyronine .......................... 67

LIPITOR............................... 36

LIPOCHOL PLUS ............... 46

lipodox 50 ............................. 13

LIPOFEN ............................. 36

lisinopril ............................... 31

lisinopril-hydrochlorothiazide

.......................................... 31

LITE TOUCH LANCETS ... 59

lithium carbonate .................. 26

lithium citrate ....................... 26

LITHOBID ........................... 26

LITHOSTAT ........................ 46

LIVALO ............................... 36

LIVIXIL PAK ...................... 42

LO LOESTRIN FE............... 80

LOCOID ............................... 44

LOCOID LIPOCREAM ....... 44

LODOSYN ........................... 17

LOESTRIN 1.5/30 (21) ........ 80

LOESTRIN 1/20 (21) ........... 80

LOESTRIN FE 1.5/30 (28-

DAY) ................................ 80

LOESTRIN FE 1/20 (28-DAY)

.......................................... 80

LOFIBRA ............................. 36

lomedia 24 fe ........................ 80

LOMOTIL ............................ 68

LONSURF ............................ 13

LOPID .................................. 36

lopreeza ................................ 78

LOPRESSOR ....................... 31

LOPRESSOR HCT .............. 31

LOPROX .............................. 43

LOPROX KIT ...................... 43

lorazepam ............................. 26

lorazepam intensol................ 26

lorcet (hydrocodone) ............ 20

lorcet hd ................................ 20

lorcet plus ............................. 20

lortab 10-325 ........................ 20

lortab 5-325 .......................... 20

lortab 7.5-325 ....................... 20

LORTAB ELIXIR ................ 20

lortuss ex .............................. 87

loryna (28) ............................ 80

LORZONE ........................... 19

losartan ................................. 31

losartan-hydrochlorothiazide 31

LOSEASONIQUE ............... 80

LOTEMAX .......................... 85

LOTENSIN .......................... 31

LOTENSIN HCT ................. 31

LOTREL ............................... 31

LOTRISONE ........................ 43

LOTRONEX ........................ 70

LOUTREX ........................... 39

lovastatin .............................. 36

LOVENOX ........................... 34

low-ogestrel (28) .................. 80

loxapine succinate ................ 26

LP LITE PAK ....................... 42

lta pre-attached ..................... 42

LUCENTIS ........................... 84

ludent fluoride ...................... 95

lugols .................................... 92

LUMIGAN ........................... 85

LUMIZYME ........................ 65

LUNESTA ............................ 26

LUPANETA PACK (1

MONTH) .......................... 78

LUPANETA PACK (3

MONTH) .......................... 78

LUPRON DEPOT ................ 13

LUPRON DEPOT (3

MONTH) .......................... 13

LUPRON DEPOT (4

MONTH) .......................... 13

LUPRON DEPOT (6

MONTH) .......................... 13

LUPRON DEPOT-PED ....... 13

lutera (28) ............................. 80

luxamend .............................. 39

LUXIQ.................................. 44

LUZU ................................... 43

LYCELLE ............................ 45

LYNPARZA ......................... 13

LYRICA ............................... 16

LYSODREN ......................... 13

LYSTEDA ............................ 78

lyza ....................................... 78

M macnatal cn dha .................... 95

MACROBID ........................ 10

MACRODANTIN ................ 10

MACUGEN .......................... 84

MAGNEBIND 400............... 70

MAKENA ............................ 78

MALARONE ......................... 7

MALARONE PEDIATRIC ... 7

malathion .............................. 45

maprotiline ............................ 26

MAR-COF BP ...................... 87

MAR-COF CG ..................... 87

margesic ................................ 21

MARINOL ........................... 70

marlissa ................................. 80

MARNATAL-F .................... 95

MARPLAN ........................... 26

MARQIBO ........................... 13

marten-tab ............................. 21

MATULANE ........................ 13

MAVIK ................................. 31

MAXALT ............................. 18

MAXALT-MLT ................... 18

MAXARON FORTE ............ 95

MAXFE (FOLATE-

DOCUSATE) ................... 95

MAXIDEX ........................... 85

MAXINATE ......................... 95

MAXIPIME ............................ 6

MAXITROL ......................... 85

MAXZIDE ............................ 31

MAXZIDE-25MG ................ 31

mb hydrogel .......................... 39

mb hydrogel (cyclomethicone)

.......................................... 39

m-clear wc ............................ 87

meclofenamate ...................... 23

MEDISENSE ........................ 59

MEDISENSE GLUCOSE

KETONE .......................... 59

MEDISENSE THIN

LANCETS ........................ 59

MEDLANCE PLUS

LANCETS ........................ 59

MEDLANCE PLUS SPECIAL

BLADE ............................. 59

MEDROL ............................. 48

MEDROL (PAK) .................. 48

medroxyprogesterone ........... 78

mefenamic acid ..................... 23

mefloquine .............................. 7

MEGACE ............................. 13

MEGACE ES ........................ 13

megestrol .............................. 13

MEKINIST ........................... 13

meloxicam ............................ 23

melphalan hcl ........................ 13

memantine ............................ 18

120

MEMANTINE ..................... 18

MENACTRA (PF) ............... 75

M-END MAX D................... 87

M-END PE ........................... 87

MENEST .............................. 78

MENOSTAR ........................ 78

MENVEO A-C-Y-W-135-DIP

(PF) ................................... 75

meperidine ............................ 21

MEPHYTON ........................ 34

meprobamate ........................ 19

MEPRON ............................... 7

mercaptopurine ..................... 13

meropenem ............................. 7

MERREM............................... 7

mesalamine ........................... 70

mesalamine with cleansing

wipe .................................. 70

mesna .................................... 10

MESNEX ............................. 10

MESTINON ......................... 19

MESTINON TIMESPAN .... 19

METADATE CD ................. 26

metadate er ........................... 26

metaproterenol ...................... 89

metaxall ................................ 19

metaxalone ........................... 19

metformin ............................. 67

methadone ............................ 21

methadose ............................. 21

methamphetamine ................ 26

methazolamide ..................... 84

methenamine hippurate ........ 10

methenamine mandelate ....... 10

methen-sod phos-meth blue-

hyos .................................. 91

methergine ............................ 82

methimazole ......................... 49

METHITEST ........................ 65

methocarbamol ..................... 19

methotrexate sodium ............ 13

methotrexate sodium (pf) ..... 13

methoxsalen rapid ................ 39

methscopolamine .................. 68

methyclothiazide .................. 31

methyldopa ........................... 31

methyldopa-

hydrochlorothiazide .......... 32

methyldopate ........................ 32

methylergonovine ................. 82

METHYLIN ......................... 26

methylphenidate ................... 26

methylprednisolone .............. 48

methyltestosterone ................ 65

metipranolol.......................... 83

metoclopramide hcl .............. 70

metolazone............................ 32

METOPIRONE .................... 46

metoprolol succinate............. 32

metoprolol ta-hydrochlorothiaz

.......................................... 32

metoprolol tartrate ................ 32

METOZOLV ODT ............... 70

metro i.v.................................. 7

METROCREAM .................. 41

METROGEL ........................ 41

METROGEL VAGINAL ..... 78

METROLOTION ................. 41

metronidazole ............. 7, 41, 78

metronidazole in nacl (iso-os) 7

mexiletine ............................. 29

MIACALCIN ....................... 65

MICARDIS .......................... 32

MICARDIS HCT ................. 32

MICRO BLOOD GLUCOSE

.......................................... 51

MICRO THIN LANCETS ... 59

MICRODOT BLOOD

GLUCOSE SYSTEM . 51, 59

microgestin 1.5/30 (21) ........ 80

microgestin 1/20 (21) ........... 80

MICROGESTIN 24 FE ........ 81

microgestin fe 1.5/30 (28) .... 81

microgestin fe 1/20 (28) ....... 81

MICROLET LANCET ......... 59

MICROZIDE ........................ 32

midodrine.............................. 46

MIFEPREX .......................... 78

migergot................................ 18

miglitol ................................. 67

MIGRANAL ........................ 18

MIGRANOW ....................... 18

milk of magnesia concentrated

.......................................... 70

millipred ............................... 48

MILLIPRED ......................... 48

millipred dp .......................... 48

mimvey ................................. 78

mimvey lo ............................. 78

MINASTRIN 24 FE ............. 81

MINI LANCING DEVICE .. 59

MINI ULTRA-THIN II ........ 59

MINIPRESS ......................... 32

MINITRAN .......................... 37

MINIVELLE ........................ 78

MINOCIN ............................... 9

minocycline ............................ 9

minoxidil ............................... 32

MIOCHOL-E ........................ 83

MIRAPEX ............................ 17

MIRAPEX ER ...................... 17

MIRCERA ............................ 73

MIRCETTE (28) .................. 81

MIRENA .............................. 77

mirtazapine ........................... 26

MIRVASO ............................ 41

misoprostol ........................... 72

MITIGARE ........................... 76

mitomycin ............................. 13

MITOSOL ............................ 85

mitoxantrone ......................... 13

MOBIC ................................. 23

modafinil ............................... 26

moderiba ............................... 74

moderiba dose pack .............. 74

MODICON (28) ................... 81

moexipril ............................... 32

moexipril-hydrochlorothiazide

.......................................... 32

molindone ............................. 26

mometasone .................... 44, 89

mondoxyne nl ....................... 10

MONOCLATE-P ................. 35

MONODOX ......................... 10

monoject 0.9% sodium

chloride ............................. 46

monoject prefill (pf) ............. 35

monoject prefill advanced ns 46

monoject prefill saline flush . 46

MONOLET THIN LANCETS

.......................................... 59

mono-linyah .......................... 81

mononessa (28) ..................... 81

MONONINE ........................ 35

montelukast ........................... 89

MONUROL .......................... 10

morgidox ............................... 10

MORGIDOX 2X100 ............ 10

morphine ............................... 21

morphine concentrate ........... 21

121

MOTOFEN........................... 68

MOVANTIK ........................ 70

MOVIPREP .......................... 70

MOXATAG ........................... 9

MOXEZA ............................. 82

moxifloxacin........................... 9

MOZOBIL ............................ 73

MS CONTIN ........................ 21

MUGARD ............................ 47

MULTAQ ............................. 29

multigen folic ....................... 95

multigen plus ........................ 95

MULTI-LANCET DEVICE 2

.......................................... 59

multi-vit with fluoride-iron .. 95

multi-vitamin with fluoride .. 95

multivitamins with fluoride .. 95

mupirocin ............................. 42

mupirocin calcium ................ 42

MUSTARGEN ..................... 13

mvc-fluoride ......................... 95

M-VIT .................................. 95

my way ................................. 81

MYALEPT ........................... 65

MYAMBUTOL ...................... 7

MYCOBUTIN ........................ 7

mycophenolate mofetil ......... 13

mycophenolate sodium ......... 13

MYDRIACYL ...................... 83

MYFORTIC ......................... 13

MYGLUCOHEALTH .... 51, 59

MYGLUCOHEALTH

CONTROL SOLUTION .. 59

MYGLUCOHEALTH

LANCETS ........................ 59

MYLERAN .......................... 13

mynatal ................................. 95

mynatal advance ................... 95

mynatal plus ......................... 95

mynatal-z .............................. 95

mynate 90 plus ..................... 95

mynephrocaps....................... 95

MYOBLOC .......................... 75

myorisan ............................... 41

MYOZYME ......................... 65

MYRBETRIQ ...................... 90

MYSOLINE ......................... 16

myzilra .................................. 81

N NABI-HB ............................. 75

nabumetone .......................... 23

nadolol .................................. 32

nadolol-bendroflumethiazide 32

nafcillin ................................... 9

naftifine ................................ 43

NAFTIFINE ......................... 43

NAFTIN ............................... 43

NAGLAZYME ..................... 65

nalbuphine ............................ 23

NALFON .............................. 23

naloxone ............................... 23

naltrexone ............................. 23

NAMENDA.......................... 18

NAMENDA TITRATION

PAK .................................. 18

NAMENDA XR ................... 18

NAMZARIC ......................... 18

NAPRELAN CR .................. 23

NAPROSYN ........................ 23

naproxen ............................... 23

naproxen sodium .................. 23

naratriptan ............................. 18

NARCAN ............................. 23

NARDIL ............................... 26

NASCOBAL ........................ 95

NASONEX ........................... 89

NATACHEW (FE BIS-

GLYCINATE) .................. 95

NATACYN .......................... 83

NATAZIA ............................ 81

nateglinide ............................ 67

NATELLE ONE ................... 95

NATESTO ............................ 65

NATPARA ........................... 65

NATROBA ........................... 45

natural b-100 complex .......... 96

nature-throid ......................... 68

NAVELBINE ....................... 13

NEBUPENT ........................... 7

NEBUSAL............................ 89

necon 0.5/35 (28) .................. 81

necon 1/35 (28) ..................... 81

necon 1/50 (28) ..................... 81

necon 10/11 (28) ................... 81

necon 7/7/7 (28).................... 81

NEEVODHA (WITH ALGAL

OIL) .................................. 96

nefazodone............................ 26

neomycin ................................ 8

neomycin-bacitracin-poly-hc 85

neomycin-bacitracin-

polymyxin ......................... 83

neomycin-polymyxin b-

dexameth ........................... 85

neomycin-polymyxin-

gramicidin ......................... 83

neomycin-polymyxin-hc . 48, 85

neo-polycin ........................... 83

neo-polycin hc ...................... 85

NEORAL .............................. 13

NEOSALUS ......................... 39

NEOSPORIN (NEO-POLYM-

GRAMICID) ..................... 83

NEO-SYNALAR .................. 42

NEO-SYNALAR KIT .......... 42

nephplex rx ........................... 96

NEPHROCAPS .................... 96

NEPHROCAPS QT .............. 96

NEPHRON FA ..................... 96

nephro-vite rx ....................... 96

NEPTAZANE ....................... 84

NESINA ............................... 67

NESTABS ............................ 96

NESTABS ABC ................... 96

NESTABS DHA ................... 96

neuac ..................................... 41

NEULASTA ......................... 73

NEUPOGEN ......................... 73

NEUPRO .............................. 17

NEURIN-SL ......................... 96

NEURONTIN ....................... 16

NEUTEK 2TEK TEST

STRIPS ............................. 51

NEVANAC ........................... 84

nevirapine ............................... 4

newgen .................................. 96

NEXA PLUS ........................ 96

NEXAVAR ........................... 13

NEXAVIR ............................ 96

NEXIUM PACKET .............. 72

NEXPLANON ...................... 78

next choice one dose ............. 81

niacin .................................... 36

NIACOR ............................... 36

NIASPAN EXTENDED-

RELEASE ......................... 36

nicardipine ............................ 32

NICODERM CQ .................. 47

NICORETTE ........................ 47

nicotine ................................. 47

122

NICOTINE (POLACRILEX)

.......................................... 47

NICOTROL .......................... 47

NICOTROL NS.................... 47

nifedical xl ............................ 32

nifedipine .............................. 32

nikki (28) .............................. 81

NILANDRON ...................... 13

nimodipine ............................ 32

NINJACOF-XG ................... 87

NINLARO ............................ 13

NIPENT ................................ 14

nisoldipine ............................ 32

nitro-bid ................................ 37

NITRO-DUR ........................ 37

nitrofurantoin ........................ 10

nitrofurantoin macrocrystal .. 10

nitrofurantoin monohyd/m-

cryst .................................. 10

nitroglycerin ......................... 37

NITROLINGUAL ................ 37

NITROMIST ........................ 37

NITROSTAT ........................ 37

nitro-time .............................. 37

NIVA-PLUS ......................... 96

nivatopic plus ....................... 39

nizatidine .............................. 72

NIZORAL ............................ 43

nodolor ................................. 18

nora-be .................................. 78

NORCO ................................ 21

NORDITROPIN FLEXPRO 73

noreth-ethinyl estradiol-iron . 81

norethindrone (contraceptive)

.......................................... 78

norethindrone acetate ........... 78

norethindrone ac-eth estradiol

.................................... 78, 81

norethindrone-e.estradiol-iron

.......................................... 81

norgestimate-ethinyl estradiol

.......................................... 81

NORINYL 1+35 (28) ........... 81

NORITATE .......................... 41

norlyroc ................................ 78

normal saline flush ............... 46

NORPACE ........................... 29

NORPACE CR ..................... 29

NORPRAMIN ...................... 27

NOR-QD .............................. 78

NORTHERA ........................ 46

nortrel 0.5/35 (28)................. 81

nortrel 1/35 (21).................... 81

nortrel 7/7/7 (28) .................. 81

nortriptyline .......................... 27

NORVASC ........................... 32

NORVIR ................................. 4

NOVA MAX BLOOD


NOVA MAX GLUCOSE

CONTROL ....................... 59

NOVA MAX GLUCOSE

TEST ................................ 51

NOVA SAFETY LANCETS 59

NOVA SUREFLEX

LANCETS ........................ 59

NOVACORT (WITH ALOE)

.......................................... 42

NOVAMAX PLUS GLU-KET

.......................................... 59

NOVOEIGHT ...................... 35

NOVOFINE 32..................... 59

NOVOFINE AUTOCOVER 59

NOVOFINE PLUS ............... 59

NOVOLIN 70/30 .................. 64

NOVOLIN N ........................ 64

NOVOLIN R ........................ 64

NOVOLOG .......................... 64

NOVOLOG FLEXPEN ........ 64

NOVOLOG MIX 70-30 ....... 64

NOVOLOG MIX 70-30

FLEXPEN ........................ 64

NOVOLOG PENFILL ......... 64

NOVOPEN ECHO ............... 59

NOVOSEVEN RT ............... 35

NOVOTWIST ...................... 59

NOXAFIL .............................. 3

NOXIFOL-D3 ...................... 96

NOXIPAK ............................ 44

np thyroid ............................. 68

NPLATE ............................... 35

NUCYNTA .......................... 23

NUCYNTA ER .................... 23

NUEDEXTA ........................ 19

NULEV ................................ 68

NULOJIX ............................. 14

NULYTELY WITH FLAVOR

PACKS ............................. 70

NUOX .................................. 41

NUPLAZID .......................... 27

NUTRICAP .......................... 96

NUTROPIN AQ ................... 73

NUTROPIN AQ NUSPIN .... 73

NUVARING ......................... 78

NUVESSA ............................ 78

NUVIGIL ............................. 27

NUWIQ ................................ 35

nyamyc ................................. 43

NYATA ................................ 43

NYMALIZE ......................... 32

nystatin ............................. 3, 43

nystatin-triamcinolone .......... 43

nystop ................................... 43

O OB COMPLETE .................. 96

OB COMPLETE GOLD ...... 96

OB COMPLETE ONE ......... 96

OB COMPLETE PETITE .... 96

OB COMPLETE PREMIER 96

OB COMPLETE WITH DHA

.......................................... 96

OBIZUR ............................... 35

OBREDON ........................... 87

obstetrix dha ......................... 96

OBSTETRIX EC .................. 96

OBTREX DHA .................... 96

O-CAL FA ............................ 96

O-CAL PRENATAL ............ 96

OCALIVA ............................ 70

ocella ..................................... 81

OCTAGAM .......................... 75

octreotide acetate .................. 14

OCUFEN .............................. 84

OCUFLOX ........................... 83

ODEFSEY .............................. 4

ODOMZO ............................. 14

OFEV .................................... 89

ofloxacin ..................... 9, 48, 83

ogestrel (28) .......................... 81

olanzapine ............................. 27

olanzapine-fluoxetine ........... 27

OLEPTRO ER ...................... 27

olopatadine ..................... 47, 84

OLUX ................................... 44

OLUX-E ............................... 44

OLYSIO ................................. 4

OMECLAMOX-PAK ........... 72

omega-3 acid ethyl esters ..... 36

omeprazole ........................... 72

123

omeprazole-sodium

bicarbonate ....................... 72

OMIDRIA ............................ 84

OMNARIS ........................... 89

OMNIPRED ......................... 85

OMNITROPE....................... 73

ON CALL EXPRESS

CONTROL ....................... 59

ON CALL EXPRESS METER

.......................................... 59

ON CALL EXPRESS TEST

STRIP ............................... 51

ON CALL LANCET ............ 59

ON CALL LANCING

DEVICE ........................... 60

ON CALL PLUS CONTROL

.......................................... 60

ON CALL PLUS LANCET . 60

ON CALL PLUS LANCING

DEVICE ........................... 60

ON CALL PLUS METER ... 60

ON CALL PLUS TEST STRIP

.......................................... 51

ON CALL VIVID CONTROL

.......................................... 60

ON CALL VIVID METER .. 60

ON CALL VIVID PAL

METER ............................ 60

ON CALL VIVID TEST

STRIP ............................... 51

ONCASPAR ........................ 14

ondansetron .......................... 70

ondansetron hcl .................... 70

ondansetron hcl (pf) ............. 70

ONE A DAY WOMEN'S

PRENATAL DHA ........... 96

one daily prenatal ................. 96

ONE DAILY PRENATAL .. 96

ONETOUCH DELICA LANC

DEVICE ........................... 60

ONETOUCH SURESOFT

LANCING DEV ............... 60

ONETOUCH ULTRA

CONTROL ....................... 60

ONETOUCH ULTRA TEST

.......................................... 51

ONETOUCH ULTRA2........ 60

ONETOUCH ULTRAMINI 60

ONETOUCH ULTRASOFT

LANCETS ........................ 60

ONETOUCH VERIO ........... 51

ONETOUCH VERIO FLEX 60

ONETOUCH VERIO IQ

METER ............................ 60

ONETOUCH VERIO SYNC

.......................................... 60

ONETOUCH VERIO

SYSTEM .......................... 60

ONEXTON ........................... 41

ONFI ..................................... 16

ONGLYZA ........................... 67

ONMEL .................................. 3

ON-THE-GO LANCETS ..... 60

ONZETRA XSAIL............... 18

OPANA ................................ 21

OPANA ER .......................... 21

opcicon one-step ................... 81

OPDIVO ............................... 14

opium tincture....................... 68

OPSUMIT ............................ 89

OPTIUM EZ ......................... 51

OPTIUM TEST .................... 51

OPTUMRX .................... 51, 60

ORACEA.............................. 10

ORACIT ............................... 91

ORAFATE............................ 47

ORALAIR ............................ 75

oralone .................................. 47

ORAMAGICRX ................... 47

ORAP ................................... 27

ORAPRED ODT .................. 48

ORAVIG ................................ 3

ORENCIA ............................ 76

ORENCIA (WITH

MALTOSE) ...................... 76

ORENCIA CLICKJECT ...... 76

ORENITRAM ...................... 32

ORFADIN ............................ 46

ORKAMBI ........................... 89

orphenadrine citrate .............. 19

orsythia ................................. 81

ortho d................................... 96

ORTHO MICRONOR .......... 78

ORTHO TRI-CYCLEN (28) 81

ORTHO TRI-CYCLEN LO

(28) ................................... 81

ORTHO-CYCLEN (28) ....... 81

ORTHO-NOVUM 1/35 (28) 81

ORTHO-NOVUM 7/7/7 (28)

.......................................... 81

oscimin ................................. 68

oscimin sl .............................. 68

oscimin sr .............................. 68

OSENI .................................. 67

OSMOPREP ......................... 70

OSPHENA ............................ 78

OTEZLA ............................... 76

OTEZLA STARTER ............ 76

OTIPRIO .............................. 48

OTOVEL .............................. 48

OTREXUP (PF) .................... 76

OVACE ................................ 37

OVACE PLUS ...................... 37

OVACE PLUS SHAMPOO . 37

OVACE PLUS WASH ......... 37

OVCON-35 (28) ................... 81

OVIDE .................................. 45

oxacillin .................................. 9

oxacillin in dextrose(iso-osm) 9

oxaliplatin ............................. 14

OXANDRIN ......................... 65

oxandrolone .......................... 65

oxaprozin .............................. 23

OXAYDO ............................. 21

oxazepam .............................. 27

oxcarbazepine ....................... 16

oxiconazole ........................... 43

OXISTAT ............................. 43

OXSORALEN ...................... 39

OXSORALEN ULTRA ........ 39

OXTELLAR XR .................. 16

oxybutynin chloride .............. 90

oxycodone ............................. 21

OXYCODONE ..................... 21

oxycodone-acetaminophen ... 21

oxycodone-aspirin ................ 21

OXYCONTIN ...................... 21

oxymorphone ........................ 21

OXYTROL ........................... 90

OZURDEX ........................... 85

P pacerone ................................ 29

paclitaxel ............................... 14

PAIRE OB PLUS DHA ........ 96

paliperidone .......................... 27

PAMELOR ........................... 27

pamidronate .......................... 65

PANDEL .............................. 44

PANRETIN .......................... 39

pantoprazole ......................... 72

124

PARAFON FORTE DSC ..... 19

PARAGARD T 380A........... 77

paregoric ............................... 68

PAREMYD .......................... 83

paricalcitol ............................ 65

PARICALCITOL ................. 65

PARLODEL ......................... 17

PARNATE ........................... 27

paromomycin .......................... 8

paroxetine hcl ....................... 27

PASER ................................... 8

PATADAY ........................... 84

PATANASE ......................... 47

PATANOL ........................... 84

PAXIL .................................. 27

PAXIL CR ............................ 27

PAZEO ................................. 84

PCE......................................... 6

PED MULTIVITAMINS-

A,B,D,E,K,ZN .................. 96

PEDIAPRED ........................ 48

peg 3350-electrolytes ........... 70

PEGANONE ........................ 16

PEGASYS ............................ 74

PEGASYS PROCLICK ....... 74

peg-electrolyte soln .............. 70

PEGINTRON ....................... 74

PEGINTRON REDIPEN ..... 74

peg-prep ................................ 70

PEN NEEDLE ...................... 60

PEN NEEDLE, DIABETIC . 60

penicillin g potassium............. 9

penicillin v potassium............. 9

PENLAC .............................. 43

PENNSAID .......................... 23

PENTASA ............................ 70

pentazocine-naloxone ........... 23

PENTIPS .............................. 60

PENTIPS PEN NEEDLE ..... 60

pentoxifylline ....................... 35

PEPCID ................................ 72

PERCOCET ......................... 21

PERFOROMIST .................. 89

PERIDEX ............................. 47

perindopril erbumine ............ 32

periogard............................... 48

PERJETA ............................. 14

permethrin ............................ 45

perphenazine......................... 27

perphenazine-amitriptyline... 27

perry prenatal ........................ 96

PERTZYE ............................ 70

PEXEVA .............................. 27

pfizerpen-g.............................. 9

PHARMACIST CHOICE .... 51

PHARMACIST CHOICE

GLUCOSE SYS ............... 60

PHASEAL PROTECTOR .... 60

phenadoz ............................... 86

phenazopyridine ................... 91

phenelzine ............................. 27

phenergan ............................. 86

phenobarbital ........................ 16

phenohytro ............................ 68

phenoxybenzamine ............... 32

phenylephrine hcl ................. 86

phenylhistine dh ................... 87

PHENYTEK ......................... 16

phenytoin .............................. 16

phenytoin sodium extended .. 16

philith.................................... 81

PHOSLO .............................. 70

PHOSLYRA ......................... 70

phospha 250 neutral.............. 92

phosphasal ............................ 91

phosphate laxative ................ 70

PHOSPHOLINE IODIDE .... 83

PHYSICIANS EZ USE B-12

.......................................... 96

PHYSIOLYTE ..................... 45

PHYSIOSOL IRRIGATION 45

PICATO................................ 39

pilocarpine hcl .......... 46, 48, 83

pimozide ............................... 27

pimtrea (28) .......................... 81

pindolol ................................. 32

pioglitazone .......................... 67

pioglitazone-glimepiride ...... 67

pioglitazone-metformin ........ 67

piperacillin-tazobactam .......... 9

pirmella ................................. 81

piroxicam .............................. 23

PLAN B ONE-STEP ............ 81

PLAQUENIL.......................... 8

PLAVIX ............................... 35

PLEGRIDY .......................... 74

PLEXION ............................. 41

PLEXION CLEANSING

CLOTHS .......................... 41

PLIAGLIS ............................ 42

pnv ob+dha ........................... 96

pnv-dha ................................. 96

pnv-dha + docusate ............... 96

pnv-ferrous fumarate-docu-fa

.......................................... 96

pnv-omega ............................ 96

pnv-select .............................. 96

pnv-vp-u ............................... 96

PODOCON ........................... 38

podofilox ............................... 39

POLY HUB NEEDLE .......... 60

polycin .................................. 83

polyethylene glycol 3350 ..... 70

polymyxin b sulfate ................ 8

polymyxin b sulf-trimethoprim

.......................................... 83

POLYTRIM .......................... 83

POLY-TUSSIN AC .............. 87

POLY-VI-FLOR ................... 96

POLY-VI-FLOR FS ............. 96

POLY-VI-FLOR WITH IRON

.......................................... 97

poly-vitamin with iron .......... 97

POMALYST ......................... 74

PONSTEL ............................. 23

portia ..................................... 81

PORTRAZZA ....................... 14

pot,sodium citrate-citric acid 91

POTABA .............................. 92

potassium bicarb and chloride

.......................................... 92

potassium bicarb-citric acid .. 92

potassium chloride ................ 92

potassium chloride in 0.9%nacl

.......................................... 92

potassium citrate ................... 91

potassium citrate-citric acid .. 91

POTASSIUM HYDROXIDE

.......................................... 38

POTIGA ............................... 16

pr natal 400 ........................... 97

pr natal 400 ec ...................... 97

pr natal 430 ........................... 97

pr natal 430 ec ...................... 97

PRADAXA ........................... 35

PRALUENT PEN ................. 36

PRALUENT SYRINGE ....... 36

pramcort ................................ 70

pramipexole .......................... 17

PRAMOSONE ..................... 37

125

PRAMOSONE E .................. 37

PRANDIN ............................ 67

PRAVACHOL ..................... 36

pravastatin ............................ 36

prazosin ................................ 32

PRECISION PCX PLUS TEST

.......................................... 51

PRECISION PCX TEST ...... 51

PRECISION POINT OF

CARE TEST ..................... 51

PRECISION Q-I-D TEST .... 51

PRECISION XTRA

MONITOR ....................... 60

PRECISION XTRA TEST ... 51

PRECOSE ............................ 67

PRED FORTE ...................... 85

PRED MILD ........................ 85

PRED-G ............................... 85

PRED-G S.O.P. .................... 85

prednicarbate ........................ 44

prednisolone ......................... 49

prednisolone acetate ............. 85

prednisolone sodium phosphate

.................................... 49, 85

prednisone ............................ 49

prednisone intensol ............... 49

PREFERA-OB ..................... 97

PREFERA-OB ONE ............ 97

PREFERA-OB PLUS DHA . 97

PREFEST ............................. 78

PREMARIN ......................... 78

PREMIUM BLOOD


PREMIUM V10 ............. 51, 60

PREMPHASE ...................... 78

PREMPRO ........................... 78

prena1 chew.......................... 97

prena1 pearl .......................... 97

prena1 true ............................ 97

prenaissance ......................... 97

prenaissance next.................. 97

prenaissance plus .................. 97

PRENATA ........................... 97

prenatabs fa .......................... 97

prenatabs rx .......................... 97

prenatal ................................. 97

prenatal complete ................. 97

prenatal formula ................... 97

prenatal multi-dha (algal oil) 97

prenatal one daily ................. 97

prenatal plus ......................... 97

prenatal plus (calcium carb) . 97

prenatal vit#96-ferrous fum-fa

.......................................... 97

prenatal vitamin .................... 97

prenatal vitamin plus low iron

.......................................... 97

prenatal-u .............................. 97

PRENATE AM..................... 97

PRENATE CHEWABLE ..... 97

PRENATE DHA (FERR ASP

GLYCIN).......................... 97

PRENATE ELITE (IRON ASP

GLYC) .............................. 97

PRENATE ENHANCE ........ 97

PRENATE

ESSENTIAL(IRON-ASP-

GL) ................................... 97

PRENATE MINI (FERR ASP

GLYCIN).......................... 97

PRENATE PIXIE ................. 97

PRENATE RESTORE ......... 97

PRENATE STAR ................. 97

PREPIDIL ............................ 78

preplus .................................. 97

PREPOPIK ........................... 70

PREQUE 10 ......................... 97

PRESERA ............................ 39

PRESSURE ACTIVATED

LANCETS ........................ 60

PRESTALIA ........................ 32

PRESTO PRO BLOOD


PREVACID SOLUTAB....... 72

prevalite ................................ 36

PREVIDENT ........................ 48

PREVIDENT 5000 BOOSTER

PLUS ................................ 48

PREVIDENT 5000 DRY

MOUTH ........................... 48

PREVIDENT 5000 ENAMEL

PROTECT ........................ 48

PREVIDENT 5000

SENSITIVE ...................... 48

previfem................................ 81

PREVPAC ............................ 72

PREZCOBIX .......................... 4

PREZISTA ............................. 4

PRIFTIN ................................. 8

PRILOSEC ........................... 72

PRIMAQUINE ....................... 8

PRIMAXIN IV ....................... 8

primidone .............................. 16

PRIMLEV ............................. 21

PRIMSOL ............................. 10

PRINIVIL ............................. 32

PRISTIQ ............................... 27

PRIVIGEN ........................... 75

PROAIR HFA ...................... 89

PROAIR RESPICLICK ........ 89

probenecid ............................ 76

PROBUPHINE ..................... 21

procainamide ........................ 29

PROCARDIA ....................... 32

PROCARDIA XL ................. 32

procentra ............................... 27

prochlorperazine ................... 70

prochlorperazine maleate ...... 70

PROCORT ............................ 70

PROCRIT ............................. 73

PROCTOCORT .................... 70

PROCTOFOAM HC ............ 70

procto-med hc ....................... 70

proctosol hc .......................... 70

proctozone-hc ....................... 71

PROCYSBI ........................... 91

PRODIGY AUTOCODE

METER ............................. 60

PRODIGY AUTOCODE

MONITOR SYST ............. 60

PRODIGY CONTROL

SOLUTION, LOW ........... 61

PRODIGY CONTROL


PRODIGY LANCETS ......... 61

PRODIGY LANCING

DEVICE ........................... 61

PRODIGY NO CODING ..... 51

PRODIGY POCKET METER

.......................................... 61

PRODIGY TWIST TOP

LANCET .......................... 61

PRODIGY VOICE GLUCOSE

METER ............................. 61

PRODRIN ............................. 18

PROFERRIN-FORTE .......... 97

PROFILNINE ....................... 35

progesterone micronized ...... 78

PROGLYCEM ..................... 52

PROGRAF ............................ 14

126

PROLASTIN-C .................... 46

PROLENSA ......................... 84

PROLEUKIN ....................... 74

PROLIA ............................... 76

PROMACTA ........................ 35

promethazine ........................ 86

promethazine vc ................... 87

promethazine vc-codeine...... 87

promethazine-codeine .......... 87

promethazine-dm .................. 87

promethazine-phenyleph-

codeine ............................. 87

promethegan ......................... 86

PROMETRIUM ................... 78

PROMISEB .......................... 39

PROMISEB COMPLETE .... 37

propafenone .......................... 29

propantheline ........................ 68

proparacaine ......................... 84

propranolol ........................... 32

propranolol-hydrochlorothiazid

.......................................... 32

propylthiouracil .................... 49

PROQUAD (PF) .................. 75

PRO-RED AC (W/

DEXCHLORPHENIR) .... 87

PROSCAR ............................ 90

PROSTIN E2 ........................ 79

PROTECT IRON ................. 97

PROTHELIAL ..................... 48

PROTONIX .................... 72, 73

PROTOPIC........................... 39

protriptyline .......................... 27

PROVENGE......................... 75

PROVENTIL HFA ............... 89

PROVERA ........................... 78

PROVIDA DHA .................. 97

PROVIDA OB...................... 97

PROVIGIL ........................... 27

PROZAC .............................. 27

PROZAC WEEKLY ............ 27

pruclair ................................. 39

prudoxin ............................... 39

prumyx ................................. 39

prutect ................................... 39

PSORCON ........................... 44

PULMICORT ....................... 89

PULMICORT FLEXHALER

.......................................... 89

pulmosal ............................... 89

PULMOZYME ..................... 89

PURALOR CI ...................... 97

PUREFE OB PLUS .............. 97

PUREFE PLUS .................... 97

purevit dualfe plus ................ 98

PURIXAN ............................ 14

PYLERA .............................. 73

pyrazinamide .......................... 8

PYRIDIUM .......................... 91

pyridostigmine bromide ....... 19

Q QBRELIS ............................. 32

Q-CARE RX Q4 ................... 48

QNASL ................................. 89

QUADRACEL (PF) ............. 75

QUALAQUIN ........................ 8

QUARTETTE ...................... 81

quasense................................ 82

quazepam .............................. 27

QUDEXY XR....................... 16

QUESTRAN ......................... 36

QUESTRAN LIGHT ............ 36

quetiapine ............................. 27

QUFLORA FE ..................... 98

QUFLORA PEDIATRIC ..... 98

QUFLORA PEDIATRIC

DROPS ............................. 98

QUILLICHEW ER ............... 27

QUILLIVANT XR ............... 27

quinapril................................ 32

quinapril-hydrochlorothiazide

.......................................... 32

quinidine gluconate .............. 29

quinidine sulfate ................... 29

quinine sulfate ........................ 8

QUINTET AC ...................... 51

QUINTET BLOOD


QUIT 2 ................................. 47

QUIT 4 ................................. 47

QUTENZA ........................... 39

QVAR ................................... 89

R rabeprazole ........................... 73

RADIOGARDASE .............. 46

RAGWITEK ......................... 75

raloxifene .............................. 76

ramipril ................................. 32

RANEXA ............................. 36

ranitidine hcl ......................... 73

RAPAFLO ............................ 90

RAPAMUNE ........................ 14

RASUVO (PF) ...................... 76

RAVICTI .............................. 46

RAYOS ................................. 49

RAZADYNE ........................ 19

RAZADYNE ER .................. 19

rea lo 39 ................................ 39

rea lo 40 ................................ 39

react ...................................... 82

REBETOL ............................ 74

REBIF (WITH ALBUMIN) . 74

REBIF REBIDOSE .............. 74

REBIF TITRATION PACK . 74

RECLAST ............................ 46

reclipsen (28) ........................ 82

RECOMBINATE ................. 35

RECOMBIVAX HB (PF) ..... 75

RECTIV ................................ 71

REFUAH PLUS ................... 51

REFUAH PLUS GLUCOSE

CONTROL ....................... 61

REFUAH PLUS GLUCOSE

MONITOR ....................... 61

REGLAN .............................. 71

REGRANEX ........................ 39

relador pak ............................ 42

relador pak plus .................... 42

RELAGARD ........................ 79

relcof c .................................. 87

RELENZA DISKHALER ...... 4

RELIAMED LANCET ......... 61

RELIAMED MINI LANCING

DEVICE ........................... 61

RELIAMED SAFETY SEAL

LANCETS ........................ 61

RELION CONFIRM ............ 61

RELION CONFIRM-MICRO

.......................................... 51

RELION MICRO GLUCOSE

MONITOR ....................... 61

RELION NEEDLES ............. 61

RELION PEN NEEDLES .... 61

RELION PRIME METER .... 61

RELION PRIME TEST

STRIPS ............................. 51

RELION THIN LANCETS .. 61

RELION ULTRA THIN PLUS

LANCETS ........................ 61

RELISTOR ........................... 71

127

relnate dha ............................ 98

RELPAX .............................. 18

REMERON .......................... 27

REMERON SOLTAB .......... 27

remeven ................................ 39

REMICADE ......................... 71

REMODULIN ...................... 32

RENAGEL ........................... 71

renal caps .............................. 98

rena-vite ................................ 98

rena-vite rx ........................... 98

reno caps ............................... 98

RENVELA ........................... 71

repaglinide ............................ 67

repaglinide-metformin .......... 67

REPATHA PUSHTRONEX 36

REPATHA SURECLICK .... 36

REPATHA SYRINGE ......... 36

reprexain ............................... 21

REQUIP ............................... 17

REQUIP XL ......................... 17

RESCRIPTOR ........................ 4

reserpine ............................... 32

RESPA-AR........................... 87

RESTASIS ........................... 84

RESTIZAN........................... 39

RESTORIL ........................... 27

RETIN-A .............................. 41

RETIN-A MICRO ................ 41

RETIN-A MICRO PUMP .... 41

RETISERT ........................... 85

RETROVIR ............................ 4

REVATIO ............................ 89

REVEAL BLOOD GLUCOSE

METER ............................ 61

REVEAL TEST STRIP ........ 52

REVESTA ............................ 98

REVIA .................................. 23

REVLIMID .......................... 74

REXULTI ............................. 27

REYATAZ ............................. 4

REZIRA ............................... 87

RIASTAP ............................. 35

ribasphere ............................. 74

ribasphere ribapak ................ 74

ribavirin ................................ 74

RIDAURA ............................ 76

rifabutin .................................. 8

RIFADIN ................................ 8

RIFAMATE ........................... 8

rifampin .................................. 8

RIFATER ............................... 8

RIGHTEST CONTROL

SOLUTION HIGH ........... 61

RIGHTEST GD500


RIGHTEST GL300 LANCETS

.......................................... 61

RIGHTEST GM550 SYSTEM

.......................................... 61

RIGHTEST GS550 TEST

STRIPS ............................. 52

RILUTEK ............................. 46

riluzole .................................. 46

rimantadine ............................. 4

ringers ................................... 45

RIOMET ............................... 67

risacal-d ................................ 98

risedronate ...................... 46, 76

RISPERDAL ........................ 27

RISPERDAL M-TAB .......... 27

risperidone ...................... 27, 28

RITALIN .............................. 28

RITALIN LA ........................ 28

RITUXAN ............................ 14

rivastigmine .......................... 19

rivastigmine tartrate .............. 19

RIXUBIS .............................. 35

rizatriptan.............................. 18

R-NATAL OB ...................... 98

ROBAXIN ............................ 19

ROBAXIN-750 .................... 19

ROBINUL ............................ 68

ROBINUL FORTE............... 68

ROCALTROL ...................... 65

ropinirole .............................. 17

rosadan.................................. 41

ROSANIL ............................. 41

ROSULA .............................. 41

rosula cleansing cloths.......... 41

rosuvastatin ........................... 36

ROWASA ............................. 71

roweepra ............................... 16

ROXICODONE.................... 21

ROZEREM ........................... 28

RUCONEST ......................... 89

rulavite dha ........................... 98

rydex ..................................... 87

RYNODERM ....................... 39

RYTARY.............................. 17

RYTHMOL .......................... 29

RYTHMOL SR .................... 29

S SABRIL ................................ 16

SAFETY LANCETS ............ 61

SAFETY SEAL LANCETS . 61

SAFETY-LET LANCETS ... 61

SAFYRAL ............................ 82

SAIZEN ................................ 73

SAIZEN CLICK.EASY ....... 73

salacyn .................................. 38

SALAGEN ..................... 46, 48

SALEX ................................. 38

salicylic acid ......................... 38

salicylic acid er-ceramides ... 38

SALKERA ............................ 38

salsalate ................................. 23

salvax .................................... 38

SALVAX DUO PLUS ......... 38

SAMSCA .............................. 65

SANADERMRX .................. 44

SANCUSO ........................... 71

SANDIMMUNE ................... 14

SANDOSTATIN .................. 14

SANDOSTATIN LAR

DEPOT ............................. 14

SANTYL .............................. 45

SAPHRIS (BLACK

CHERRY) ......................... 28

SARAFEM ........................... 28

SAVAYSA ........................... 35

SAVELLA ...................... 76, 77

scalacort ................................ 44

SCALACORT DK ................ 44

SEASONIQUE ..................... 82

seb-prev ................................ 37

seconal sodium ..................... 28

SECTRAL ............................ 32

SELECT-OB ......................... 98

SELECT-OB + DHA ............ 98

selegiline hcl ......................... 17

selenium sulfide .................... 37

SELRX ................................. 37

SELZENTRY ......................... 4

SEMPREX-D ....................... 87

se-natal 19 ............................. 98

se-natal 19 (with docusate) ... 98

SENSIPAR ........................... 65

SEREVENT DISKUS .......... 89

SERNIVO ............................. 44

128

SEROQUEL ......................... 28

SEROQUEL XR .................. 28

SEROSTIM .......................... 73

sertraline ............................... 28

se-tan dha.............................. 98

se-tan plus ............................. 98

setlakin ................................. 82

sf 48

sf 5000 plus .......................... 48

sharobel ................................ 78

SHOHL'S MODIFIED ......... 91

SIDEKICK BLOOD


SIGNIFOR ........................... 14

SILAZONE-II ...................... 44

sildenafil ............................... 89

SILENOR ............................. 28

SILVADENE ....................... 38

silver nitrate .......................... 39

silver nitrate applicators ....... 39

silver sulfadiazine ................. 38

SIMBRINZA ........................ 85

SIMPONI ............................. 77

SIMPONI ARIA ................... 77

SIMULECT .......................... 14

simvastatin ............................ 36

SINEMET............................. 17

SINEMET CR ...................... 17

SINGLE-LET ....................... 61

SINGULAIR ........................ 89

sirolimus ............................... 14

SIRTURO ............................... 8

SITAVIG ................................ 4

SIVEXTRO ............................ 8

SKELAXIN .......................... 19

SKLICE ................................ 45

SKYLA................................. 77

SMART SENSE LANCETS 61

SMART SENSE

MONITORING SYSTEM 61

SMART SENSE TEST

STRIPS ............................. 52

SMARTDIABETES

VANTAGE....................... 61

SMARTEST CONTROL ..... 62

SMARTEST EJECT ............ 62

SMARTEST LANCET ........ 62

SMARTEST PERSONA

STARTER ........................ 62

SMARTEST PRONTO

STARTER ........................ 62

SMARTEST PROTEGE ...... 62

SMARTEST TEST............... 52

SMARTRX GABAKIT ........ 16

SMARTRX GABA-V KIT .. 16

SNAP INSULIN PUMP

CONTROLLER................ 62

sodium benzoate-sod

phenylacet ......................... 46

sodium chlor 0.9% bacteriostat

.......................................... 46

sodium chloride .............. 89, 92

sodium chloride 0.45 % ........ 92

sodium chloride 0.9 % .......... 46

SODIUM CHLORIDE 0.9 %

.......................................... 46

sodium chloride 3 % ............. 92

sodium chloride 5 % ............. 92

sodium citrate-citric acid ...... 91

sodium ferric gluconat-sucrose

.......................................... 46

sodium fluoride............... 48, 98

sodium phenylbutyrate ......... 46

SODIUM PHOSPHATE IN

0.9 % NACL ..................... 92

sodium polystyrene sulfonate

.......................................... 71

SODIUM POLYSTYRENE

SULFONATE ................... 71

SOFT TOUCH LANCETS .. 62

SOFTGELS MULTIVIT-

A,B,D,E,K,ZN .................. 98

SOLARAZE ......................... 39

SOLESTA ............................ 71

SOLIRIS ............................... 46

SOLODYN ........................... 10

SOLTAMOX ........................ 14

SOLUS V2 AUDIBLE

METER ............................ 62

SOLUS V2 CONTROL


SOLUS V2 LANCETS ........ 62

SOLUS V2 LANCING

DEVICE ........................... 62

SOLUS V2 TEST STRIPS ... 52

SOMA .................................. 19

SOMATULINE DEPOT ...... 14

SOMAVERT ........................ 65

sonafine ................................ 40

SONATA .............................. 28

SOOLANTRA ...................... 41

SORBITOL-MANNITOL .... 45

SORIATANE ....................... 37

SORILUX ............................. 37

sotalol ................................... 29

sotalol af ............................... 29

SOTYLIZE ........................... 29

SOVALDI ............................... 4

SPECTRACEF ....................... 6

spinosad ................................ 45

SPIRIVA RESPIMAT .......... 89

SPIRIVA WITH

HANDIHALER ................ 89

spironolactone ....................... 32

spironolacton-hydrochlorothiaz

.......................................... 32

SPORANOX ........................... 3

SPORANOX PULSEPAK ..... 3

sprintec (28) .......................... 82

SPRITAM ............................. 16

SPRIX ................................... 23

SPRYCEL ............................. 14

sps (with sorbitol) ................. 71

sronyx ................................... 82

ss 10-2 ................................... 41

ssd ......................................... 38

SSKI ..................................... 49

sss 10-5 ................................. 41

STALEVO 100 ..................... 17

STALEVO 125 ..................... 17

STALEVO 150 ..................... 17

STALEVO 200 ..................... 17

STALEVO 50 ....................... 17

STALEVO 75 ....................... 17

STARLIX ............................. 67

stavudine ................................. 4

STELARA ............................ 37

STERILANCE TL ................ 62

STIMATE ............................. 65

STIOLTO RESPIMAT ......... 89

STIVARGA .......................... 14

STRATTERA ....................... 28

STRENSIQ ........................... 65

STREPTOMYCIN ................. 8

stress formula ........................ 98

stress formula with iron ........ 98

stress formula with iron(sulf)98

STRIANT ............................. 65

STRIBILD .............................. 4

129

STRIVERDI RESPIMAT .... 89

STROMECTOL ..................... 8

strong iodine ......................... 92

STROVITE FORTE ............. 98

STROVITE ONE ................. 98

SUBOXONE ........................ 23

SUBSYS ............................... 21

SUCRAID ............................ 71

sucralfate .............................. 73

SULAR ................................. 32

sulfacetamide sodium ..... 37, 85

sulfacetamide sodium (acne) 42

sulfacetamide sodium-sulfur 41

sulfacetamide sod-sulfur-urea

.......................................... 41

sulfacetamide-prednisolone .. 85

sulfacetamide-sulfur-cleansr23

.......................................... 41

sulfacleanse 8-4 .................... 41

sulfact na-sul-avobnz-otn-ocsa

.......................................... 41

sulfadiazine............................. 9

sulfamethoxazole-trimethoprim

............................................ 9

SULFAMYLON................... 42

sulfasalazine ......................... 71

sulfatrim ................................. 9

sulindac................................. 23

SUMADAN .......................... 41

SUMADAN XLT ................. 41

sumatriptan ........................... 18

sumatriptan succinate ........... 18

SUMAVEL DOSEPRO ....... 18

SUMAXIN ........................... 41

SUMAXIN CP ..................... 41

SUMAXIN TS...................... 41

SUPER THIN LANCETS .... 62

SUPERVITE ........................ 98

SUPERVITE (EC)................ 98

SUPPRELIN LA .................. 14

SUPRAX ................................ 6

SUPREP BOWEL PREP KIT

.......................................... 71

SURE COMFORT LANCETS

.......................................... 62

SURE COMFORT LANCING

PEN .................................. 62

SURE COMFORT PEN

NEEDLE .......................... 62

SURE RESULT DSS

PREMIUM PACK ............ 23

SURE RESULT TAC PAK .. 44

SURE-FINE PEN NEEDLES

.......................................... 62

SUREFLEX LANCING

DEVICE ........................... 62

SURE-LANCE ..................... 62

SURE-PEN LANCING

DEVICE ........................... 62

SURE-TEST EASYPLUS

MINI ................................. 52

SURE-TEST EASYPLUS

MINI METER .................. 62

SURE-TOUCH LANCET .... 62

SURFAXIN .......................... 89

SURMONTIL ....................... 28

SURVANTA ........................ 46

SUSTIVA ............................... 5

SUTENT ............................... 14

SWABFLUSH ...................... 46

syeda ..................................... 82

SYLATRON ......................... 74

SYLVANT ........................... 14

SYMAX DUOTAB .............. 68

symax fastabs ....................... 68

symax-sl................................ 68

symax-sr ............................... 68

SYMBICORT ....................... 89

SYMBYAX .......................... 28

SYMLINPEN 120 ................ 67

SYMLINPEN 60 .................. 67

SYNAGIS ............................... 5

SYNALAR ........................... 44

SYNALAR CREAM KIT .... 44

SYNALAR OINTMENT KIT

.......................................... 44

SYNALAR TS ..................... 44

SYNALGOS-DC .................. 21

SYNAREL............................ 65

SYNERA .............................. 42

SYNJARDY ......................... 67

SYNRIBO ............................ 14

SYNTHROID ....................... 68

SYPRINE ............................. 46

syrex sodium chloride 0.9% . 46

T T

30 INFUSION SET .......... 62

90 INFUSION SET 23 ..... 62

SLIM ................................. 62

SLIM G4 ........................... 62

TABLOID ............................. 14

TACLONEX ......................... 37

tacrolimus ....................... 14, 40

TAFINLAR .......................... 14

TAGRISSO ........................... 14

TAKE ACTION ................... 82

TALTZ AUTOINJECTOR .. 37

TALTZ AUTOINJECTOR (2

PACK) .............................. 38

TALTZ AUTOINJECTOR (3

PACK) .............................. 38

TALTZ SYRINGE ............... 38

TALTZ SYRINGE (2 PACK)

.......................................... 38

TALTZ SYRINGE (3 PACK)

.......................................... 38

TALWIN .............................. 23

TAMIFLU .............................. 5

tamoxifen .............................. 14

tamsulosin ............................. 90

TANDEM PLUS .................. 98

TANZEUM ........................... 67

TAPAZOLE ......................... 49

TARCEVA ........................... 14

TARGRETIN ....................... 14

tarina fe 1/20 (28) ................. 82

TARKA ................................ 32

taron forte ............................. 98

taron-c dha ............................ 98

taron-prex prenatal-dha ........ 98

TASIGNA ............................. 14

TASMAR ............................. 17

TAXOTERE ......................... 14

TAZICEF ................................ 6

TAZORAC ........................... 41

TECFIDERA ........................ 74

TECHLITE LANCETS ........ 62

TECHLITE PEN NEEDLE .. 62

TECHNIVIE ........................... 5

TEFLARO .............................. 6

TEGRETOL ......................... 16

TEGRETOL XR ................... 16

TEKTURNA ......................... 32

TEKTURNA HCT ................ 32

TELCARE BGM .................. 62

TELCARE BLOOD

GLUCOSE KIT ................ 62

TELCARE CONTROL ........ 62

130

TELCARE TEST STRIPS ... 52

telmisartan ............................ 32

telmisartan-amlodipine ......... 32

telmisartan-hydrochlorothiazid

.......................................... 32

temazepam ............................ 28

TEMODAR .......................... 14

TEMOVATE ........................ 45

temozolomide ....................... 14

tencon ................................... 21

TENEX ................................. 33

TENIPOSIDE ....................... 14

TENIVAC (PF) .................... 75

TENORETIC 100 ................. 33

TENORETIC 50 ................... 33

TENORMIN ......................... 33

TERAZOL 3 ......................... 79

TERAZOL 7 ......................... 79

terazosin ............................... 33

terbinafine hcl ......................... 3

terbutaline ............................. 89

terconazole ........................... 79

TERSI FOAM ...................... 38

TESSALON PERLES .......... 87

TEST N'GO BLOOD


TEST N'GO TEST ............... 52

TESTIM ............................... 66

TESTONE CIK .................... 66

testosterone ........................... 66

TESTOSTERONE ............... 66

testosterone cypionate .......... 66

testosterone enanthate .......... 66

TESTRED ............................ 66

TETANUS,DIPHTHERIA

TOX PED(PF) .................. 75

TETANUS-DIPHTHERIA

TOXOIDS-TD .................. 75

tetcaine ................................. 84

tetrabenazine......................... 19

tetracaine hcl ........................ 84

tetracaine hcl (pf) ................. 84

tetracycline ........................... 10

TETRAVISC ........................ 84

TETRAVISC FORTE .......... 84

TEXACORT......................... 45

TEXAVITE LQ .................... 98

THALOMID......................... 14

THEO-24 .............................. 90

theochron .............................. 90

theophylline .......................... 90

thermazene............................ 38

THIOLA ............................... 47

thioridazine ........................... 28

thiotepa ................................. 14

thiothixene ............................ 28

THRIVITE RX ..................... 98

thrivite-19 ............................. 98

THYMOGLOBULIN ........... 75

THYROLAR-1 ..................... 68

THYROLAR-1/2 .................. 68

THYROLAR-1/4 .................. 68

THYROLAR-2 ..................... 68

THYROLAR-3 ..................... 68

tiagabine ............................... 16

TIAZAC ............................... 33

TICANASE .......................... 90

ticlopidine ............................. 35

TIGAN.................................. 71

TIKOSYN ............................ 29

tilia fe .................................... 82

timolol maleate ............... 33, 83

TIMOPTIC ........................... 83

TIMOPTIC OCUDOSE (PF)

.......................................... 83

TIMOPTIC-XE .................... 83

TINDAMAX .......................... 8

tinidazole ................................ 8

TIROSINT ............................ 68

TIVICAY................................ 5

TIVORBEX .......................... 23

tizanidine .............................. 19

tl gard rx ............................... 98

tl g-fol os .............................. 98

tl icon .................................... 98

tl-hem 150............................. 98

TOBI ....................................... 8

TOBI PODHALER ................ 8

TOBRADEX ........................ 85

TOBRADEX ST................... 85

tobramycin ............................ 83

tobramycin in 0.225 % nacl .... 8

tobramycin-dexamethasone .. 85

TOBREX .............................. 83

TODAY CONTRACEPTIVE

SPONGE .......................... 79

TOFRANIL .......................... 28

TOLAK ................................ 40

tolazamide ............................ 67

tolbutamide ........................... 67

tolcapone ............................... 17

tolmetin ................................. 23

tolterodine ............................. 90

TOPAMAX .......................... 16

TOPCARE UNIVERSAL1

LANCET .......................... 62

TOPICORT ........................... 45

topiramate ....................... 16, 17

TOPIRAMATE .................... 16

toposar .................................. 14

topotecan ............................... 14

TOPROL XL ........................ 33

TORISEL .............................. 14

torsemide .............................. 33

TOUJEO SOLOSTAR ......... 64

TOVIAZ ............................... 90

TRACLEER ......................... 90

TRADJENTA ....................... 67

tramadol ................................ 23

TRAMADOL ....................... 23

tramadol-acetaminophen ...... 23

trandolapril ........................... 33

trandolapril-verapamil .......... 33

tranexamic acid ............... 35, 79

TRANSDERM-SCOP .......... 71

TRANXENE T-TAB ............ 28

tranylcypromine .................... 28

TRAVATAN Z ..................... 85

trazodone .............................. 28

TREANDA ........................... 14

TRECATOR ........................... 8

TRELSTAR .......................... 14

TRESIBA FLEXTOUCH U-

100 .................................... 65

TRESIBA FLEXTOUCH U-

200 .................................... 65

tretinoin ................................. 41

tretinoin (chemotherapy) ...... 14

tretinoin microspheres .......... 41

TRETIN-X ............................ 41

TRETIN-X CREAM KIT ..... 41

TRETTEN ............................ 35

TREXALL ............................ 14

TREXIMET .......................... 18

TREZIX ................................ 21

TRIACETIN ......................... 43

triamcinolone acetonide .. 45, 48

triamterene-hydrochlorothiazid

.......................................... 33

trianex ................................... 45

131

triazolam ............................... 28

TRIBENZOR ....................... 33

TRICARE ............................. 98

TRICARE PRENATAL DHA

ONE .................................. 98

TRICARE PRENATAL WITH

DHA ................................. 98

tricitrates ............................... 91

tricon..................................... 98

TRICOR ............................... 36

triderm .................................. 45

tri-estarylla ........................... 82

TRIFERIC ............................ 98

trifluoperazine ...................... 28

trifluridine............................. 83

trigels-f forte ......................... 99

TRIGLIDE ........................... 36

trihexyphenidyl..................... 17

tri-legest fe............................ 82

TRILEPTAL......................... 17

tri-linyah ............................... 82

TRILIPIX ............................. 36

tri-lo-estarylla ....................... 82

tri-lo-marzia .......................... 82

tri-lo-sprintec ........................ 82

trilyte with flavor packets ..... 71

trimethobenzamide ............... 71

trimethoprim ......................... 10

trimipramine ......................... 28

trinatal gt .............................. 99

trinatal rx 1 ........................... 99

trinate .................................... 99

trinessa (28) .......................... 82

trinessa lo.............................. 82

TRI-NORINYL (28) ............ 82

TRINTELLIX....................... 28

triphrocaps ............................ 99

TRIPLE DYE ....................... 43

tri-previfem (28) ................... 82

TRISENOX .......................... 14

TRI-SILA ............................. 45

tri-sprintec (28) ..................... 82

TRISTART DHA ................. 99

tri-tabs dha ............................ 99

TRIUMEQ .............................. 5

triveen-duo dha ..................... 99

TRI-VI-FLOR ...................... 99

tri-vit with fluoride and iron . 99

tri-vitamin with fluoride ....... 99

trivora (28)............................ 82

TRIZIVIR ............................... 5

TROKENDI XR ................... 17

TROPAZONE LOTION ...... 40

tropicamide ........................... 83

trospium ................................ 90

TRUE METRIX AIR


TRUE METRIX GLUCOSE

METER ............................ 63

TRUE METRIX GLUCOSE

TEST STRIP..................... 52

TRUE METRIX LEVEL 1... 63

TRUE2GO BLOOD


TRUECONTROL LEVEL 0 63

TRUEDRAW LANCING

DEVICE ........................... 63

TRUEPLUS LANCETS ....... 63

TRUERESULT BLOOD

GLUCOSE SYSTM ......... 63

TRUETEST LOW GLUCOSE

CONTROL ....................... 63

TRUETEST TEST STRIPS . 52

TRUETRACK BLOOD


TRUETRACK SMART

SYSTEM .......................... 63

TRUETRACK TEST ........... 52

TRULICITY ......................... 67

TRUSOPT ............................ 85

trust natal dha ....................... 99

TRUVADA ............................ 5

TUDORZA PRESSAIR ....... 90

tusnel c .................................. 87

TUSNEL PEDIATRIC ......... 87

TUSSICAPS ......................... 87

tussigon ................................. 87

TUSSIONEX PENNKINETIC

ER ..................................... 87

TUZISTRA XR .................... 87

TWYNSTA .......................... 33

TYBOST ................................ 5

TYGACIL .............................. 8

TYKERB .............................. 14

TYLENOL-CODEINE #3 .... 21

TYLENOL-CODEINE #4 .... 21

TYSABRI ............................. 19

TYVASO .............................. 90

TYVASO REFILL KIT........ 90

TYVASO STARTER KIT ... 90

TYZEKA ................................ 5

TYZINE ................................ 48

U UCERIS ................................ 71

UDAMIN SP ........................ 99

ULESFIA .............................. 45

ULORIC ............................... 76

ULTICARE PEN NEEDLE . 63

ULTI-LANCE ...................... 63

ULTILET BASIC LANCETS

.......................................... 63

ULTILET CLASSIC

LANCETS ........................ 63

ULTILET LANCETS ........... 63

ULTILET SAFETY

LANCETS ........................ 63

ULTIMA MONITOR ........... 63

ULTIMA TEST STRIPS ...... 52

ultimatecare one .................... 99

ultimatecare one nf ............... 99

ULTRA THIN LANCETS ... 63

ULTRA THIN PLUS

LANCETS ........................ 63

ULTRA TLC LANCETS ..... 63

ULTRACET ......................... 23

ULTRALANCE LANCETS 63

ULTRAM ............................. 23

ULTRAM ER ....................... 23

ULTRASAL-ER ................... 38

ULTRA-THIN II INS PEN

NEEDLES ........................ 63

ULTRATRAK ...................... 52

ULTRATRAK GLUCOSE

METER ............................. 63

ULTRATRAK ULTIMATE 52,

63

ULTRAVATE ...................... 45

ULTRAVATE X .................. 45

umecta ................................... 40

UMECTA PD ....................... 40

UNASYN ............................... 9

UNIFINE PENTIPS ............. 63

UNIFINE PENTIPS PLUS ... 63

UNILET COMFORTOUCH

LANCET .......................... 63

UNILET EXCELITE II

LANCET .......................... 63

UNILET EXCELITE

LANCET .......................... 63

UNILET GP LANCET ......... 63

132

UNILET LANCET ............... 63

UNISTIK 2 DEVICE ........... 63

UNISTIK 2 NORMAL

LANCET,DEVICE .......... 63

UNISTIK 3 ........................... 63

UNISTIK 3 EXTRA LANCET

.......................................... 63

UNISTIK CZT LANCET..... 64

UNISTIK SAFETY .............. 64

UNISTIK TOUCH LANCETS

.......................................... 64

UNISTRIP LOW CONTROL

.......................................... 64

UNISTRIP1 TEST STRIP ... 52

unithroid ............................... 68

UNIVERSAL 1 LANCETS . 64

UPTRAVI............................. 33

ur n-c .................................... 91

URAMAXIN ........................ 40

URAMAXIN GT.................. 40

uramit mb ............................. 91

urea ....................................... 40

urea nail stick ....................... 40

urea-hyaluronate sodium ...... 40

URECHOLINE .................... 90

ure-k ..................................... 40

URELLE............................... 91

uretron d-s ............................ 91

UREVAZ .............................. 40

URIBEL ............................... 91

urimar-t ................................. 91

urin ds ................................... 91

UROCIT-K 10 ...................... 91

UROCIT-K 15 ...................... 91

UROCIT-K 5 ........................ 91

urogesic-blue ........................ 91

urolet mb .............................. 91

uro-mp .................................. 91

urophen mb ........................... 91

UROQID-ACID NO.2 ......... 91

UROXATRAL ..................... 90

URSO 250 ............................ 71

URSO FORTE...................... 71

ursodiol ................................. 71

uryl ....................................... 91

ustell ..................................... 91

UTA ...................................... 91

utira-c ................................... 91

UTOPIC ............................... 40

V VAGIFEM ............................ 78

vaginal contraceptive foam .. 79

valacyclovir ............................ 5

VALCHLOR ........................ 40

VALCYTE ............................. 5

valganciclovir ......................... 5

VALIUM .............................. 28

valproic acid ......................... 17

valproic acid (as sodium salt)

.......................................... 17

valsartan................................ 33

valsartan-hydrochlorothiazide

.......................................... 33

VALTREX ............................. 5

VANATOL LQ .................... 21

VANCOCIN ......................... 10

vancomycin .......................... 10

VANCOMYCIN IN

DEXTROSE 5 % .............. 10

vandazole .............................. 79

VANOS ................................ 45

VANOXIDE-HC .................. 41

VANTAS .............................. 14

VAQTA (PF) ........................ 76

VARUBI ............................... 71

VASCEPA ............................ 36

VASERETIC ........................ 33

VASHE WOUND THERAPY

.......................................... 45

VASOTEC............................ 33

v-c forte ................................ 99

VCF CONTRACEPTIVE

FILM ................................ 79

VCF CONTRACEPTIVE GEL

.......................................... 79

VECAMYL .......................... 36

VECTIBIX ........................... 14

VECTICAL .......................... 38

VELCADE ........................... 15

veletri .................................... 33

velivet triphasic regimen (28)

.......................................... 82

VELPHORO ......................... 71

VELTASSA.......................... 71

VELTIN................................ 41

vemavite-prx-2 ..................... 99

VENCLEXTA ...................... 15

VENCLEXTA STARTING

PACK ............................... 15

venlafaxine ........................... 28

VENTAVIS .......................... 90

VENTOLIN HFA ................. 90

VERAMYST ........................ 90

verapamil .............................. 33

VERDESO ............................ 45

verdrocet ............................... 21

VEREGEN ........................... 40

VERELAN ........................... 33

VERELAN PM ..................... 33

veripred 20 ............................ 49

VERSACLOZ ....................... 28

VESICARE ........................... 90

vestura (28) ........................... 82

VEXOL ................................. 85

VFEND ................................... 3

VGO 20 ................................ 64

VGO 30 ................................ 64

VGO 40 ................................ 64

VIBATIV .............................. 10

VIBERZI .............................. 71

VIBRAMYCIN .................... 10

vic-forte ................................ 99

vicodin .................................. 21

vicodin es .............................. 21

vicodin hp ............................. 21

VICTOZA 2-PAK ................ 67

VICTOZA 3-PAK ................ 67

VIDAZA ............................... 15

VIDEX 2 GRAM PEDIATRIC

............................................ 5

VIDEX EC .............................. 5

VIEKIRA PAK ....................... 5

VIEKIRA XR ......................... 5

vienva ................................... 82

VIGAMOX ........................... 83

VIIBRYD ............................. 28

VIMIZIM .............................. 66

VIMOVO .............................. 23

VIMPAT ............................... 17

vinate care ............................. 99

vinate dha .............................. 99

VINATE DHA RF ................ 99

vinate ii ................................. 99

vinate m ................................ 99

vinate one .............................. 99

vinate ultra ............................ 99

vinblastine ............................. 15

vincasar pfs ........................... 15

vincristine ............................. 15

133

vinorelbine ............................ 15

VIOKACE ............................ 71

viorele (28) ........................... 82

VIRACEPT ............................ 5

VIRAMUNE .......................... 5

VIRAMUNE XR .................... 5

VIRASAL............................. 38

VIRAZOLE ............................ 5

VIREAD ................................. 5

VIROPTIC ........................... 83

virt-advance .......................... 99

virt-c dha .............................. 99

VIRT-CAPS ......................... 99

virt-gard ................................ 99

virt-nate ................................ 99

virt-nate dha.......................... 99

VIRTPREX .......................... 99

virt-select .............................. 99

virt-vite ................................. 99

virt-vite gt ............................. 99

VIRT-VITE PLUS ............... 99

VISTARIL ............................ 86

VISTOGARD ....................... 10

VISUDYNE ......................... 84

vit 3 ....................................... 99

vit b complex-folic acid........ 99

VITA-BEE WITH C ............ 99

VITAFOL ............................. 99

VITAFOL FE+ (WITH

DOCUSATE) ................... 99

VITAFOL GUMMIES ......... 99

VITAFOL NANO ................ 99

VITAFOL ULTRA .............. 99

vitafol-ob .............................. 99

VITAFOL-OB+DHA ........... 99

VITAFOL-ONE ................... 99

VITAL-D RX ....................... 99

VITAMED MD ONE RX .... 99

VITAMED MD PLUS RX ... 99

VITAMEDMD REDICHEW

RX .................................... 99

vitamin d3 ............................. 99

vitamins a,c,d and fluoride ... 99

VITAPEARL ...................... 100

VITA-RESPA..................... 100

VITATRUE ........................ 100

VITEKTA............................... 5

VITUZ .................................. 87

VIVA DHA ........................ 100

VIVELLE-DOT ................... 78

VIVITROL ........................... 23

VIVLODEX ......................... 23

VOCALPOINT GLUCOSE

CONTROL ....................... 64

VOGELXO ........................... 66

vol-care rx........................... 100

vol-nate ............................... 100

vol-plus ............................... 100

vol-tab rx ............................ 100

VOLTAREN ........................ 23

VOLTAREN-XR.................. 23

VONVENDI ......................... 35

VOPAC MDS ....................... 23

VORAXAZE ........................ 10

voriconazole ........................... 3

VOSPIRE ER ....................... 90

VOTRIENT .......................... 15

vp-ch plus ........................... 100

vp-ch-pnv............................ 100

vp-ggr-b6 ............................ 100

VP-PNV-DHA.................... 100

VPRIV .................................. 66

vp-vite rx ............................ 100

VRAYLAR ........................... 28

VUSION ............................... 43

vyfemla (28) ......................... 82

VYTORIN 10-10 .................. 36

VYTORIN 10-20 .................. 36

VYTORIN 10-40 .................. 36

VYTORIN 10-80 .................. 36

VYVANSE ........................... 28

W warfarin ................................ 35

water for irrigation, sterile .... 47

WAVESENSE AMP ............ 64

WAVESENSE CONTROL

SOLUTION ...................... 64

WAVESENSE JAZZ ........... 52

WAVESENSE PRESTO 52, 64

WELCHOL .......................... 36

WELLBUTRIN SR .............. 28

WELLBUTRIN XL .............. 28

wera (28)............................... 82

westhroid .............................. 68

WHYTEDERM TDPAK ...... 45

WHYTEDERM TRILASIL

PAK .................................. 45

WIDE-SEAL DIAPHRAGM

.......................................... 77

WILATE ............................... 35

WP THYROID ..................... 68

wymzya fe ............................ 82

X XALATAN ........................... 85

XALKORI ............................ 15

XANAX ................................ 28

XANAX XR ......................... 28

XARELTO ........................... 35

XARTEMIS XR ................... 22

XCLAIR ............................... 40

XELITRAL ........................... 24

XELJANZ ............................. 77

XELJANZ XR ...................... 77

XELODA .............................. 15

XENAZINE .......................... 19

XERESE ............................... 43

XGEVA ................................ 10

XIFAXAN .............................. 8

XIGDUO XR ........................ 67

XIIDRA ................................ 84

XODOL 10/300 .................... 22

XODOL 5/300 ...................... 22

XODOL 7.5/300 ................... 22

XOLAIR ............................... 90

XOLEGEL ............................ 43

XOPENEX ........................... 90

XOPENEX CONCENTRATE

.......................................... 90

XOPENEX HFA .................. 90

XRYLIX ............................... 24

XTAMPZA ER ..................... 22

XTANDI ............................... 15

xulane ................................... 79

XURIDEN ............................ 47

xylon 10 ................................ 22

XYNTHA ............................. 35

XYNTHA SOLOFUSE ........ 35

XYREM ................................ 28

XYZAL ................................. 86

Y YASMIN (28) ....................... 82

YAZ (28) .............................. 82

YERVOY ............................. 15

YF-VAX (PF) ....................... 76

Z zafirlukast ............................. 90

zaleplon ................................. 29

ZALTRAP ............................ 15

zamicet .................................. 22

ZANABIN ............................ 40

134

ZANAFLEX ......................... 19

ZANOSAR ........................... 15

ZANTAC .............................. 73

zarah ..................................... 82

ZARONTIN ......................... 17

ZARXIO ............................... 73

zatean-ch............................. 100

zatean-pn dha...................... 100

zatean-pn plus ..................... 100

zavara ................................. 100

ZAVESCA ........................... 66

ZEBETA............................... 33

zebutal .................................. 22

ZEGERID ............................. 73

ZELAPAR ............................ 17

ZELBORAF ......................... 15

ZEMAIRA ............................ 47

ZEMBRACE SYMTOUCH . 18

ZEMPLAR ........................... 66

zenatane ................................ 41

zenchent (28) ........................ 82

zenchent fe............................ 82

zencia .................................... 41

ZENPEP ............................... 71

zenzedi .................................. 29

ZENZEDI ............................. 29

ZEPATIER ............................. 5

ZERIT..................................... 5

ZESTORETIC ...................... 33

ZESTRIL .............................. 33

ZETIA .................................. 36

ZETONNA ........................... 90

ZIAC..................................... 33

ZIAGEN ................................. 5

ZIANA ................................. 41

zidovudine .............................. 5

ZINACEF ............................... 6

ZINBRYTA .......................... 74

ZINECARD (AS HCL) ........ 10

zingiber ............................... 100

ZIOPTAN (PF) ..................... 85

ziprasidone hcl ...................... 29

ZIPSOR ................................ 24

ZIRGAN ............................... 83

ZITHRANOL ....................... 38

ZITHRANOL-RR ................ 38

ZITHROMAX ........................ 6

ZMAX .................................... 6

ZOCOR ................................ 36

ZODRYL AC 25 .................. 87

ZODRYL AC 30 .................. 87

ZODRYL AC 35 .................. 87

ZODRYL AC 40 .................. 87

ZODRYL AC 50 .................. 87

ZODRYL AC 60 .................. 87

ZODRYL AC 80 .................. 87

ZODRYL DAC 25 ............... 87

ZODRYL DAC 30 ............... 87

ZODRYL DAC 35 ............... 87

ZODRYL DAC 40 ............... 87

ZODRYL DAC 50 ............... 87

ZODRYL DAC 60 ............... 87

ZODRYL DAC 80 ............... 87

ZODRYL DEC 25 ................ 87

ZODRYL DEC 30 ................ 87

ZODRYL DEC 35 ................ 87

ZODRYL DEC 40 ................ 87

ZODRYL DEC 50 ................ 87

ZODRYL DEC 60 ................ 87

ZODRYL DEC 80 ................ 87

ZOFRAN (AS

HYDROCHLORIDE) ...... 71

ZOFRAN ODT ..................... 71

ZOHYDRO ER .................... 22

ZOLADEX ........................... 15

zoledronic acid ..................... 66

zoledronic acid-mannitol-water

.......................................... 47

ZOLEDRONIC ACID-

MANNITOL-WATER ..... 66

ZOLINZA ............................. 15

zolmitriptan ........................... 18

ZOLOFT ............................... 29

zolpidem ............................... 29

ZOLPIMIST ......................... 29

ZOMACTON ....................... 73

ZOMETA ............................. 66

ZOMIG ................................. 18

ZOMIG ZMT ........................ 18

ZONALON ........................... 40

ZONATUSS ......................... 88

ZONEGRAN ........................ 17

zonisamide ............................ 17

ZONTIVITY ......................... 35

ZORBTIVE .......................... 73

ZORTRESS .......................... 15

ZORVOLEX ......................... 24

zovia 1/35e (28) .................... 82

zovia 1/50e (28) .................... 82

ZOVIRAX ........................ 5, 43

Z-TUSS AC .......................... 88

ZUBSOLV ............................ 24

ZUPLENZ ............................ 71

ZUTRIPRO ........................... 88

ZYBAN ................................ 47

ZYCLARA ........................... 74

ZYDELIG ............................. 15

ZYFLO ................................. 90

ZYFLO CR ........................... 90

ZYKADIA ............................ 15

ZYLET ................................. 85

ZYLOPRIM .......................... 76

ZYMAXID ........................... 83

ZYPREXA ............................ 29

ZYPREXA ZYDIS ............... 29

ZYTIGA ............................... 15

ZYVOX .................................. 8

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