Cigna Medicare Select Plus Rx (HMO) 2014 Comprehensive ......2014. To get updated information about the drugs covered by Cigna Medicare Select Plus Rx, please contact us. Our contact

This formulary was updated on 09/2013.

For more recent information or other questions, please contact Cigna Medicare Select Plus

Rx Customer Service at 1-800-627-7534 or, for TTY users, 711, 7 days a week, 8 am–8 pm

(hours apply Monday – Friday, February 15 – September 30). Or visit www.cignamedicare.com.

Note to existing members: This formulary has changed since last year. Please review this

document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our” it means Cigna HealthCare of Arizona,

Inc. When it refers to “plan” or “our plan” it means Cigna Medicare Select Plus Rx.

This document includes a list of the drugs (formulary) for our plan which is current as of

09/2013. For an updated formulary, please contact us. Our contact information, along with the

date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits,

formulary, pharmacy network, premium and/or copayments/coinsurance may change on

January 1, 2015.

823704 f 09/13

2014 Comprehensive Formulary(List of Covered Drugs)PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Cigna Medicare Select Plus Rx® (HMO)

Last Updated 09/2013

H0354_1262009e AcceptedHPMS Approved Formulary File Submission ID Version Number 14317.v07

1

2014 Comprehensive Formulary

you chose our plan, except for cases in which

you can save additional money or we can ensure

your safety.

If we remove drugs from our formulary, or

add prior authorization, quantity limits and/

or step therapy restrictions on a drug or move

a drug to a higher cost-sharing tier, we must

notify affected members of the change at least

60 days before the change becomes effective, or

at the time the member requests a refill of the

drug, at which time the member will receive a

60-day supply of the drug. If the Food and Drug

Administration deems a drug on our formulary

to be unsafe or the drug’s manufacturer removes

the drug from the market, we will immediately

remove the drug from our formulary and provide

notice to members who take the drug. The

enclosed formulary is current as of January 1,

2014. To get updated information about the

drugs covered by Cigna Medicare Select Plus Rx,

please contact us. Our contact information

appears on the front and back cover pages.

Our plan’s printed formulary document will be

updated for any mid-year, non maintenance

changes via errata sheets in the event that

we 1) remove a drug from our formulary,

2) increase the cost share of a formulary drug,

or 3) add utilization management edits to a

formulary drug and no new alternate drug is

offered by our plan as a possible replacement

for any of the previously described formulary

changes. All affected members currently taking

What is the Cigna Medicare Rx Select Plus Rx Formulary?

A formulary is a list of covered drugs selected by

Cigna Medicare Select Plus Rx in consultation

with a team of health care providers, which

represents the prescription therapies believed

to be a necessary part of a quality treatment

program. Cigna Medicare Select Plus Rx will

generally cover the drugs listed in our formulary

as long as the drug is medically necessary, the

prescription is filled at a Cigna Medicare Select

Plus Rx network pharmacy, and other plan rules

are followed. For more information on how to fill

your prescriptions, please review your Evidence

of Coverage.

Can the Formulary (drug list) change?

Generally, if you are taking a drug on our 2014

formulary that was covered at the beginning

of the year, we will not discontinue or reduce

coverage of the drug during the 2014 coverage

year except when a new, less expensive generic

drug becomes available or when new adverse

information about the safety or effectiveness

of a drug is released. Other types of formulary

changes, such as removing a drug from our

formulary, will not affect members who are

currently taking the drug. It will remain available

at the same cost-sharing for those members

taking it for the remainder of the coverage year.

We feel it is important that you have continued

access for the remainder of the coverage year to

the formulary drugs that were available when

2


What are generic drugs?

Cigna Medicare Select Plus Rx covers both brand

name drugs and generic drugs. A generic drug is

approved by the FDA as having the same active

ingredient as the brand name drug. Generally,

generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?

Some covered drugs may have additional

requirements or limits on coverage. These

requirements and limits may include:

• Prior Authorization: Cigna Medicare Select

Plus Rx requires you or your physician to get

prior authorization for certain drugs. This

means that you will need to get approval from

Cigna Medicare Select Plus Rx before you fill

your prescriptions. If you don’t get approval,

Cigna Medicare Select Plus Rx may not cover

the drug.

• Quantity Limits: For certain drugs, Cigna

Medicare Select Plus Rx limits the amount

of the drug that we will cover. For example,

Cigna Medicare Select Plus Rx provides

coverage for up to 1 tablet per day per

prescription for Crestor 10 mg tablets. This

may be in addition to a standard one month

or three month supply.

• Step Therapy: In some cases, Cigna Medicare

Select Plus Rx requires you to first try certain

drugs to treat your medical condition before

we will cover another drug for that condition.

a formulary drug which will have one or more of

the previously described formulary changes will

be exempt from the formulary change(s) for the

remainder of the coverage year.

How do I use the Formulary?

There are two ways to find your drug within

the formulary:

Medical Condition

The formulary begins on page 7. The drugs

in this formulary are grouped into categories

depending on the type of medical conditions

that they are used to treat. For example, drugs

used to treat a heart condition are listed under

the category, Cardiovascular Agents – Blood

Pressure/ Cholesterol/Heart Medications. If

you know what your drug is used for, look for

the category name in the list that begins on

page 7. Then look under the category name for

your drug.

Alphabetical Listing

If you are not sure what category to look under,

you should look for your drug in the Index

that begins on page 77. The Index provides an

alphabetical list of all of the drugs included in

this document. Both brand name drugs and

generic drugs are listed in the Index. Look in the

Index and find your drug. Next to your drug, you

will see the page number where you can find

coverage information. Turn to the page listed in

the Index and find the name of your drug in the

first column of the list.

3


list, show it to your doctor and ask him or her

to prescribe a similar drug that is covered by

Cigna Medicare Select Plus Rx.

• YoucanaskCignaMedicareSelectPlusRx

to make an exception and cover your drug.

See below for information about how to

request an exception.

How do I request an exception to the Cigna Medicare Select Plus Rx Formulary?

You can ask Cigna Medicare Select Plus Rx to

make an exception to our coverage rules. There

are several types of exceptions that you can ask

us to make.

• Youcanaskustocoveryourdrugevenifitis

not on our formulary. If approved, this drug

will be covered at a pre-determined cost-

sharing level, and you would not be able to

ask us to provide the drug at a lower cost-

sharing level.

• Youcanaskustocoveraformularydrugat

a lower cost-sharing level (if this drug is not

on the specialty tier). If approved this would

lower the amount you must pay for your drug.

• Youcanaskustowaivecoveragerestrictions

or limits on your drug. For example, for certain

drugs, Cigna Medicare Select Plus Rx limits the

amount of the drug that we will cover. If your

drug has a quantity limit, you can ask us to

waive the limit and cover a greater amount.

For example, if Drug A and Drug B both treat

your medical condition, Cigna Medicare Select

Plus Rx may not cover Drug B unless you try

Drug A first. If Drug A does not work for you,

Cigna Medicare Select Plus Rx will then cover

Drug B.

You can find out if your drug has any additional

requirements or limits by looking in the

formulary that begins on page 7. You can also

get more information about the restrictions

applied to specific covered drugs by visiting our

website. Our contact information, along with the

date we last updated the formulary, appears on

the front and back cover pages.

You can ask Cigna Medicare Select Plus Rx to

make an exception to these restrictions or limits

or for a list of other, similar drugs that may treat

your health condition. See the section, “How do

I request an exception to the Cigna Medicare

Select Plus Rx formulary?” on page 3 for

information about how to request an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary

(list of covered drugs), you should first contact

Customer Service and ask if your drug is covered.

If you learn that Cigna Medicare Select Plus Rx

does not cover your drug, you have two options:

• YoucanaskCustomerServiceforalistof

similar drugs that are covered by Cigna

Medicare Select Plus Rx. When you receive the

4


Generally, Cigna Medicare Select Plus Rx will

only approve your request for an exception if

the alternative drugs included on the plan’s

formulary, the lower cost-sharing drug or

additional utilization restrictions would not be as

effective in treating your condition and/or would

cause you to have adverse medical effects.

You should contact us to ask us for an initial

coverage decision for a formulary, tiering or

utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must

make our decision within 72 hours of getting

your prescribing physician’s supporting

statement. You can request an expedited (fast)

exception if you or your doctor believe that your

health could be seriously harmed by waiting

up to 72 hours for a decision. If your request to

expedite is granted, we must give you a decision

no later than 24 hours after we get a supporting

statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

As a new or continuing member in our plan,

you may be taking a drug that is not on our

formulary. Or, you may be taking a drug that

is on our formulary but your ability to get it

is limited. For example, you may need a prior

authorization from us before you can fill your

prescription. You should talk to your doctor to

decide if you should switch to an appropriate

drug that we cover or request a formulary

exception so that we will cover the drug you

take. While you talk to your doctor to determine

the right course of action for you, we may cover

your drug in certain cases during the first 90 days

you are a member of our plan.

For each of your drugs that is not on our

formulary or if your ability to get your drugs is

limited, we will cover a temporary 31-day supply

(unless you have a prescription written for fewer

days) when you go to a network pharmacy. After

your first 31-day supply, we will not pay for these

drugs, even if you have been a member of the

plan less than 90 days.

If you are a resident of a long-term care facility,

we will allow you to refill your prescription until

we have provided you with a 102-day transition

supply, consistent with dispensing increment,

(unless you have a prescription written for fewer

days). We will cover more than one refill of these

drugs for the first 90 days you are a member of

our plan. If you need a drug that is not on our

formulary or if your ability to get your drugs

is limited, but you are past the first 90 days of

membership in our plan, we will cover a 31-day

emergency supply of that drug (unless you have

a prescription for fewer days) while you pursue a

formulary exception.

5


Cigna Medicare Select Plus Rx’s Formulary

The formulary that begins on the next page

provides coverage information about the drugs

covered by Cigna Medicare Select Plus Rx. If you

have trouble finding your drug in the list, turn to

the Index that begins on page 77.

The first column of the chart lists the drug name.

Brand name drugs are capitalized (e.g., NEXIUM)

and generic drugs are listed in lower-case italics

(e.g., omeprazole).

The information in the Requirements/Limits

column tells you if Cigna Medicare Select Plus Rx

has any special requirements for coverage of

your drug.

An extended transition process is provided to

circumstances involving level of care changes

in which a beneficiary is changing from one

treatment setting to another. An override for

refill too soon edit would be provided to allow

appropriate coverage. Since there may exist

some period of time in which beneficiaries with

level of care changes have a temporary gap in

coverage while going through a process, our

transition policy would allow coverage for one

fill with up to a 31-day supply of medication.

For more information

For more detailed information about your

Cigna Medicare Select Plus Rx prescription

drug coverage, please review your Evidence of

Coverage and other plan materials.

If you have questions about Cigna Medicare

Select Plus Rx, please contact us. Our contact

information, along with the date we last updated

the formulary, appears on the front and back

cover pages.

If you have general questions about Medicare

prescription drug coverage, please call Medicare

at 1-800-MEDICARE (1-800-633-4227) 24 hours

a day/seven days a week. TTY/TDD users should

call 1-877-486-2048. Or, visit medicare.gov.

6


Initial Coverage Level Copays/Coinsurance

Cigna Medicare Select Plus Rx® – Standard (HMO)

Tiers

30-Day Retail

Preferred/Non-Preferred

90-Day Retail


30-Day Mail Order

90-Day Mail Order

30-Day Out-of-

Network31-Day

LTC

1* $3/$10 $9/$30 $3 $6 $3 $3

2* $10/$17 $30/$51 $10 $20 $10 $10

3 $40/$45 $120/$135 $40 $80 $40 $40

4 $75/$95 $225/$285 $75 $150 $75 $75

5 33% 33% 33% 33% 33% 33%

* We provide coverage of this prescription drug in the coverage gap. Please refer to the Evidence of Coverage for more information about this coverage.

Cigna Medicare Select Plus Rx® – Diabetes Heart (HMO SNP)

Tiers

30-Day Retail


90-Day Retail


30-Day Mail Order

90-Day Mail Order

30-Day Out-of-

Network31-Day

LTC

1* $2/$9 $6/$27 $2 $4 $2 $2

2* $9/$16 $27/$48 $9 $18 $9 $9

3 $40/$45 $120/$135 $40 $80 $40 $40

4 $75/$95 $225/$285 $75 $150 $75 $75

5 33% 33% 33% 33% 33% 33%

* We provide coverage of this prescription drug in the coverage gap. Please refer to the Evidence of Coverage for more information about this coverage.

7


Covered Drugs By Category

Cost-Sharing Tier Description. Please refer to page 6 for applicable copay/cost-share amounts.Tier 1: Preferred Generic Drugs. This grouping of prescription drugs represents the lowest cost sharing.

Tier 2: Non-Preferred Generic Drugs.

Tier 3: Preferred Brand Drugs.

Tier 4: Non-Preferred Brand Drugs.

Tier 5: Specialty Tier. This grouping of prescription drugs represents the highest cost sharing.

Symbol Key – Utilization Management Requirements/LimitsB vs D: Coverage determination for Part B or Part D required. Note: Inhalant solutions used in a nebulizer are only

covered under Part D when the member is located in a long term care (LTC) setting.

GC: Gap coverage. We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.

HI: This prescription drug may be covered under our medical benefit. For more information, call Customer Service at 1-800-627-7534, seven days a week, (hours apply Monday – Friday, February 15 – September 30). TTY users should call 711.

PA: Prior authorization is required.

QL: Quantity limits apply.

RA : Restricted Access. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at 1-800-627-7534, seven days a week, 8 am–8 pm (hours apply Monday – Friday, February 15 – September 30). TTY users should call 711.

ST: Step therapy is required.

Generally all medications on the formulary are available through mail order except when special circumstances or situations prohibit mailing a particular medication to your home.

Drug Name Drug Tier Requirements/Limits

Analgesics

acetaminophen/codeine solution 2 QL (5000 ML per 30 days) GC

acetaminophen/codeine tablet 300mg/15mg, 300mg/30mg 2 QL (360 EA per 30 days) GC

acetaminophen/codeine tablet 300mg/60mg 2 QL (240 EA per 30 days) GC

ascomp/codeine 2 QL (180 EA per 30 days) PA GC

astramorph 2 GC

AVINzA 4 QL (60 EA per 30 days)

butalbital/acetaminophen/caffeine/codeine 2 QL (180 EA per 30 days) PA GC

butorphanol tartrate injection 2 GC

butorphanol tartrate nasal solution 2 QL (5 ML per 30 days) GC

8




BUTRANS 3 QL (4 EA per 28 days)

CAPITAL/CODEINE 3 QL (5000 ML per 30 days)

co-gesic 2 QL (240 EA per 30 days) GC

codeine sulfate tablet 15mg 2 QL (720 EA per 30 days) GC



DEMEROL INJECTION 25MG/ML, 50MG/ML, 75MG/ML, 100MG/ML

4 PA

DILAUDID-5 4 QL (1200 ML per 30 days)

DURAMORPH 4

endocet tablet 325mg/5mg, 325mg/7.5mg, 325mg/10mg 2 QL (360 EA per 30 days) GC

endocet tablet 500mg/7.5mg 2 QL (240 EA per 30 days) GC

endocet tablet 650mg/10mg 2 QL (180 EA per 30 days) GC

fentanyl patch 2 QL (20 EA per 30 days) GC

fentanyl citrate injection 2 BvsD GC

fentanyl citrate oral transmucosal lollipop 200mcg 2 QL (120 EA per 30 days) PA GC

fentanyl citrate oral transmucosal lollipop 400mcg, 600mcg, 800mcg, 1200mcg, 1600mcg

5 QL (120 EA per 30 days) PA

HYCET 4 QL (5400 ML per 30 days)

hydrocodone bitartrate/acetaminophen solution 7.5mg & 325mg/15ml

2 QL (5400 ML per 30 days) GC

hydrocodone bitartrate/acetaminophen tablet 10mg/750mg 2 QL (150 EA per 30 days) GC

hydrocodone/acetaminophen solution 7.5mg & 500mg/15ml 2 QL (3600 ML per 30 days) GC

hydrocodone/acetaminophen tablet 5mg/325mg, 7.5mg/325mg, 10mg/325mg

2 QL (360 EA per 30 days) GC

hydrocodone/acetaminophen tablet 2.5mg/500mg, 5mg/500mg, 7.5mg/500mg, 10mg/500mg


hydrocodone/acetaminophen tablet 7.5mg/650mg,10mg/ 650mg, 10mg/660mg


hydrocodone/acetaminophen tablet 7.5mg/750mg 2 QL (150 EA per 30 days) GC

hydrocodone/ibuprofen tablet 7.5mg/200mg 2 QL (180 EA per 30 days) GC

hydromorphone hcl injection 500mg/50ml 2 GC

hydromorphone hcl tablet 2 QL (240 EA per 30 days) GC

9




LAzANDA 4 QL (43.96 GM per 28 days) PA

levorphanol tartrate 2 QL (180 EA per 30 days) GC

maxidone 2 QL (150 EA per 30 days) GC

meperidine hcl injection 25mg/ml, 50mg/ml, 100mg/ml 2 PA GC

meperidine hcl oral solution 2 QL (900 ML per 30 days) PA GC

meperitab 2 QL (180 EA per 30 days) PA GC

methadone hcl concentrate 2 QL (500 ML per 30 days) GC

methadone hcl injection 2 GC

methadone hcl oral solution 5mg/5ml 2 QL (4000 ML per 30 days) GC

methadone hcl oral solution 10mg/5ml 2 QL (2000 ML per 30 days) GC

methadone hcl tablet 5mg, 10mg 2 QL (360 EA per 30 days) GC

methadone hcl tablet soluble 40mg 2 QL (90 EA per 30 days) GC

methadose concentrate 2 QL (500 ML per 30 days) GC

methadose tablet soluble 40mg 2 QL (90 EA per 30 days) GC

morphine sulfate er capsule 20mg, 30mg, 50mg, 60mg, 80mg, 100mg


morphine sulfate er tablet 15mg, 30mg 2 QL (180 EA per 30 days) GC

morphine sulfate er tablet 60mg, 100mg, 200mg 2 QL (120 EA per 30 days) GC

morphine sulfate injection 0.5mg/ml, 1mg/ml, 4mg/ml, 10mg/ml, 15mg/ml

2 GC

morphine sulfate oral solution 10mg/5ml 2 QL (5400 ML per 30 days) GC

morphine sulfate oral solution 20mg/5ml 2 QL (2700 ML per 30 days) GC

morphine sulfate oral solution 20mg/ml 2 QL (540 ML per 30 days) GC

morphine sulfate tablet 15mg, 30mg 2 QL (360 EA per 30 days) GC

nalbuphine hcl 2 BvsD GC

ONSOLIS 5 QL (120 EA per 30 days) PA

OPANA ER TABLET 5MG, 7.5MG, 10MG, 15MG, 20MG, 30MG 3 QL (60 EA per 30 days)

OPANA ER TABLET 40MG 3 QL (120 EA per 30 days)

oxycodone hcl capsule, tablet 2 QL (300 EA per 30 days) GC

oxycodone hcl concentrate 2 QL (360 ML per 30 days) GC

oxycodone/acetaminophen capsule 2 QL (240 EA per 30 days) GC

10




oxycodone/acetaminophen tablet 2.5mg/325mg, 5mg/325mg, 7.5mg/325mg, 10/325mg


oxycodone/acetaminophen tablet 7.5mg/500mg 2 QL (240 EA per 30 days) GC

oxycodone/acetaminophen tablet 10mg /650mg 2 QL (180 EA per 30 days) GC

oxycodone/aspirin 2 QL (360 EA per 30 days) GC

oxycodone/ibuprofen 2 QL (150 EA per 30 days) GC

OXYCONTIN ER TABLET 10MG, 15MG, 20MG, 30MG, 40MG, 60MG

3 QL (90 EA per 30 days)

OXYCONTIN ER TABLET 80MG 3 QL (120 EA per 30 days)

oxymorphone hcl 2 QL (180 EA per 30 days) GC

oxymorphone hcl er tablet 5mg, 7.5mg, 10mg, 15mg, 20mg, 30mg


oxymorphone hcl er tablet 40mg 2 QL (120 EA per 30 days) GC

pentazocine/acetaminophen 2 QL (180 EA per 30 days) PA GC

pentazocine/naloxone hcl 2 QL (360 EA per 30 days) PA GC

reprexain 2 QL (180 EA per 30 days) GC

roxicet solution 2 QL (1800 ML per 30 days) GC

roxicet tablet 2 QL (360 EA per 30 days) GC

ROXICODONE TABLET 15MG, 30MG 4 QL (300 EA per 30 days)

stagesic 2 QL (240 EA per 30 days) GC

SYNALGOS-DC 3 QL (330 EA per 30 days)

TALWIN 4 PA

tramadol hcl er capsule 150mg 2 QL (60 EA per 30 days) GC

tramadol hcl er tablet 100mg 2 QL (90 EA per 30 days) GC

tramadol hcl er tablet 200mg, 300mg 2 QL (30 EA per 30 days) GC

tramadol hcl tablet 50mg 2 QL (240 EA per 30 days) GC

tramadol hcl/acetaminophen 2 QL (240 EA per 30 days) GC

Anesthetics

lidocaine hcl external solution 2 GC

lidocaine hcl injection 0.5%, 1% 2 GC

lidocaine hcl jelly gel 2% 2 GC

lidocaine ointment 2 BvsD GC

11




lidocaine viscous 2 GC

lidocaine/prilocaine cream 2 BvsD GC

LIDODERM 4 QL (90 EA per 30 days)

SYNERA 4 BvsD

Anti-Addiction/Substance Abuse Treatment Agents

BUPRENEX 4

buprenorphine hcl injection 2 GC

buprenorphine hcl tablet sublingual 2 QL (24 EA per 30 days) GC

buprenorphine hcl/naloxone hcl 2 GC

buproban 2 QL (60 EA per 30 days) GC

CAMPRAL 4 QL (180 EA per 30 days)

CHANTIX TABLET 0.5MG, 1MG 3 QL (336 EA per 365 days)

CHANTIX TABLET STARTING MONTH 3 QL (106 EA per 365 days)

depade 2 GC

disulfiram 2 GC

naloxone hcl 2 GC

naltrexone hcl 2 GC

NICOTROL INHALER 3

NICOTROL NS 3

REVIA 4

SUBOXONE 3

VIVITROL 5 PA

Anti-inflammatory Agents

ARTHROTEC 4

CAMBIA 4

CELEBREX 3 QL (60 EA per 30 days)

diclofenac potassium 2 GC

diclofenac sodium dr 2 GC

diclofenac sodium er 2 GC

diclofenac sodium/misoprostol 2 GC

diflunisal 2 GC

12




etodolac 2 GC

etodolac er 2 GC

fenoprofen calcium 2 GC

flurbiprofen 2 GC

ibuprofen suspension 2 GC

ibuprofen tablet 400mg, 600mg, 800mg 2 GC

indomethacin & indomethacin er 2 PA GC

ketoprofen 2 GC

ketoprofen er 2 GC

ketorolac tromethamine injection 2 PA GC

ketorolac tromethamine tablet 10mg 2 QL (20 EA per 30 days) PA GC

meclofenamate sodium 2 GC

meloxicam 2 GC

nabumetone 2 GC

naproxen 2 GC

naproxen dr 2 GC

naproxen sodium tablet 275mg, 550mg 2 GC

oxaprozin 2 GC

piroxicam 2 GC

salsalate 2 GC

sulindac 2 GC

tolmetin sodium 2 GC

Antibacterials

AkNE-MYCIN 3

ALTABAX 4

amikacin sulfate 2 HI

amoxicillin 2 GC

amoxicillin/potassium clavulanate 2 GC

ampicillin 2 GC

ampicillin sodium 2 GC

ampicillin-sulbactam 2 HI

13




AVELOX INJECTION 3

AVELOX TABLET 3 QL (30 EA per 30 days)

AzACTAM 1GM, 2GM 4 HI

AzACTAM IN ISO-OSMOTIC DEXTROSE 1GM 4 HI

AzACTAM IN ISO-OSMOTIC DEXTROSE 2GM 5 HI

AzASITE 3

azithromycin 2 GC

aztreonam 2 HI

baciim 2 GC

bacitracin 2 GC

bacitracin/polymyxin b 2 GC

bactocill in dextrose 2 HI

BICILLIN C-R 4

BICILLIN L-A 4

BLEPH-10 4

CAYSTON 5

CEDAX CAPSULE 4

cefaclor & cefaclor er 2 GC

cefadroxil 2 GC

cefazolin sodium 2 HI

cefdinir 2 GC

cefepime 2 HI

cefotaxime sodium 2 GC

cefotetan 2 GC

cefoxitin sodium 2 GC

cefpodoxime proxetil 2 GC

cefprozil 2 GC

ceftazidime 2 GC

ceftriaxone sodium 2 GC

cefuroxime axetil 2 GC

cefuroxime sodium 2 GC

14




cephalexin 2 GC

chloramphenicol sodium succinate 2 GC

CILOXAN OINTMENT 3

CIPRO HC 3

CIPRO I.V. 4

CIPRODEX 3

ciprofloxacin er 2 GC

ciprofloxacin hcl 2 GC

ciprofloxacin i.v. 2 GC

CLAFORAN 4

clarithromycin 2 GC

clarithromycin er 2 GC

clindamycin hcl 2 GC

clindamycin phosphate 2 GC

colistimethate sodium 2 GC

COLY-MYCIN M 4

CORTISPORIN OINTMENT 3

CUBICIN 5 HI

demeclocycline hcl 2 GC

dicloxacillin sodium 2 GC

DIFICID 3 QL (20 EA per 30 days) PA

DORIBAX 4 HI

doxycycline hyclate 2 GC

doxycycline monohydrate 2 GC

e.e.s. 2 GC

ery 2 GC

ery-tab 2 GC

ERYPED 3

erythrocin lactobionate 2 GC

erythrocin stearate 2 GC

erythromycin base 2 GC

15




erythromycin ethylsuccinate 2 GC

erythromycin gel, ointment, solution 2 GC

FLAGYL ER 4

FORTAz 4

FURADANTIN 4 PA

gentak ointment 2 GC

gentamicin sulfate 2 GC

HELIDAC 4

imipenem/cilastatin 2 HI

INVANz 4 HI

kETEk 4

levofloxacin injection, ophthalmic solution, oral solution 2 GC

levofloxacin tablet 2 QL (30 EA per 30 days) GC

LINCOCIN 3

MACRODANTIN CAPSULE 25MG 4 PA

mafenide acetate 2 GC

MAXIPIME 4 HI

meropenem 2 HI

MERREM 4 HI

methenamine hippurate 2 GC

METROGEL 4

METROGEL-VAGINAL 4

metronidazole cream, lotion, tablet 2 GC

metronidazole gel 0.75% 2 GC

metronidazole injection 2 GC

metronidazole vaginal 2 GC

minocycline hcl 2 GC

MONUROL 4

MOXEzA 3

mupirocin 2 GC

nafcillin sodium 2 HI

16




NALLPEN 3 HI

neomycin sulfate tablet 2 GC

neomycin/bacitracin/polymyxin 2 GC

neomycin/polymyxin b sulfates 2 GC

neomycin/polymyxin/bacitracin/hydrocortisone 2 GC

neomycin/polymyxin/gramicidin 2 GC

neomycin/polymyxin/hydrocortisone ophthalmic suspension 2 GC

nitrofurantoin 2 PA GC

nitrofurantoin macrocrystalline 2 PA GC

nitrofurantoin monohydrate 2 PA GC

NOROXIN 4

ofloxacin 2 GC

ORACEA 4

oxacillin sodium 2 HI

paromomycin sulfate 2 GC

PCE 3

penicillin g potassium 2 HI

penicillin g procaine 2 GC

penicillin g sodium 2 GC

penicillin v potassium 2 GC

pfizerpen-g 2 HI

PHISOHEX 4

piperacillin sodium/tazobactam sodium 2 HI

polymyxin b sulfate 2 GC

PREVPAC 4 QL (224 EA per 30 days)

PRIMAXIN IV 4 HI

PRIMSOL 4

RELAGARD 4

SILVADENE 4

silver sulfadiazine 2 GC

sodium sulfacetamide 2 GC

17




ssd 2 GC

streptomycin sulfate 2 GC

sulfacetamide sodium ointment 10% 2 GC

sulfadiazine 2 GC

sulfamethoxazole/trimethoprim 2 GC

sulfamethoxazole/trimethoprim ds 2 GC

SULFAMYLON 4

SUPRAX 4

SYNERCID 5

tazicef 2 GC

TEFLARO 4 HI

tetracycline hcl 2 GC

TIMENTIN 4 HI

TOBI 5 BvsD

TOBI PODHALER 5

tobramycin sulfate 2 GC

tobramycin sulfate/sodium chloride 2 GC

TOBREX OINTMENT 3

trimethoprim 2 GC

trimethoprim sulfate/polymyxin b sulfate 2 GC

TYGACIL 4 HI

UNASYN 3 HI

vancomycin hcl capsule 125mg 5 QL (40 EA per 10 days)

vancomycin hcl capsule 250mg 5 QL (80 EA per 10 days)

vancomycin hcl injection 500mg, 750mg, 5000mg 2 BvsD GC

vancomycin hcl injection 1gm, 10gm 2 HI

VANDAzOLE 4

VIBATIV 4 HI

VIGAMOX 3

XIFAXAN TABLET 200MG 4 QL (90 EA per 30 days) PA

XIFAXAN TABLET 550MG 5 QL (60 EA per 30 days) PA

18




zMAX 4 QL (120 ML per 30 days)

zOSYN 3 HI

zYVOX INJECTION 5

zYVOX SUSPENSION 5 QL (1680 ML per 60 days)

zYVOX TABLET 5 QL (56 EA per 60 days)

Anticonvulsants

BANzEL SUSPENSION 4

BANzEL TABLET 200MG 4

BANzEL TABLET 400MG 5

carbamazepine 2 GC

carbamazepine er 2 GC

CARBATROL 4

CELONTIN 4

clonazepam odt 0.125mg, 0.25mg, 0.5mg, 1mg 2 QL (120 EA per 30 days) GC

clonazepam odt 2mg 2 QL (300 EA per 30 days) GC

clonazepam tablet 0.5mg, 1mg 2 QL (120 EA per 30 days) GC

clonazepam tablet 2mg 2 QL (300 EA per 30 days) GC

clorazepate dipotassium tablet 3.75mg, 7.5mg 2 QL (90 EA per 30 days) GC

clorazepate dipotassium tablet 15mg 2 QL (120 EA per 30 days) GC

DEPACON 4

diazepam gel 2.5mg 2 QL (10 ML per 30 days) GC

diazepam gel 10mg 2 QL (20 ML per 30 days) GC

diazepam gel 20mg 2 QL (40 ML per 30 days) GC

DILANTIN 4

DILANTIN INFATABS 4

divalproex sodium 2 GC

divalproex sodium er 2 GC

epitol 2 GC

ethosuximide 2 GC

felbamate suspension 5

felbamate tablet 2 GC

19




FELBATOL 5

fosphenytoin sodium 2 GC

gabapentin 2 GC

LAMICTAL ODT 3

lamotrigine 2 GC

lamotrigine er 2 GC

levetiracetam 2 GC

levetiracetam er 2 GC

LYRICA CAPSULE 25MG, 225MG, 300MG 3 QL (60 EA per 30 days)

LYRICA CAPSULE 50MG, 75MG, 100MG, 150MG, 200MG 3 QL (90 EA per 30 days)

LYRICA SOLUTION 3 QL (900 ML per 30 days)

magnesium sulfate injection 2 GC

NEURONTIN SOLUTION 4

ONFI TABLET 5MG, 10MG 4 QL (60 EA per 30 days)

ONFI TABLET 20MG 4 QL (120 EA per 30 days)

oxcarbazepine 2 GC

PEGANONE 4

phenobarbital 2 PA GC

PHENYTEk 4

phenytoin 2 GC

phenytoin sodium 2 GC

phenytoin sodium extended 2 GC

POTIGA TABLET 50MG 4 QL (270 EA per 30 days)

POTIGA TABLET 200MG, 300MG, 400MG 4 QL (90 EA per 30 days)

primidone 2 GC

SABRIL TABLET 5 QL (180 EA per 30 days)

SABRIL PACkET 5 QL (200 EA per 30 days)

tiagabine hcl 2 GC

topiramate 2 GC

valproate sodium 2 GC

valproic acid 2 GC

20




VIMPAT INJECTION 3

VIMPAT ORAL SOLUTION 3 QL (1200 ML per 30 days)

VIMPAT TABLET 3 QL (60 EA per 30 days)

zonisamide 2 GC

Antidementia Agents

donepezil hcl odt 5mg 2 QL (30 EA per 30 days) GC

donepezil hcl odt 10mg 2 QL (60 EA per 30 days) GC

donepezil hcl tablet 5mg 2 QL (30 EA per 30 days) GC

donepezil hcl tablet 10mg 2 QL (60 EA per 30 days) GC

ergoloid mesylates 2 PA GC

EXELON PATCH 3 QL (30 EA per 30 days)

EXELON SOLUTION 4 QL (180 ML per 30 days)

galantamine hydrobromide solution 2 QL (200 ML per 30 days) GC

galantamine hydrobromide er capsule 2 QL (30 EA per 30 days) GC

galantamine hydrobromide tablet 2 QL (60 EA per 30 days) GC

NAMENDA SOLUTION 3 QL (300 ML per 30 days)

NAMENDA TABLET 5MG 3 QL (90 EA per 30 days)

NAMENDA TABLET 10MG 3 QL (60 EA per 30 days)

NAMENDA TITRATION PAk 3 QL (49 EA per 30 days)

rivastigmine tartrate 2 QL (60 EA per 30 days) GC

Antidepressants

amitriptyline hcl 2 PA GC

amoxapine 2 GC

APLENzIN 4 QL (30 EA per 30 days)

budeprion sr tablet 100mg 2 QL (60 EA per 30 days) GC

budeprion sr tablet 150mg 2 QL (90 EA per 30 days) GC

bupropion hcl 2 GC

bupropion hcl sr tablet 100mg, 200mg 2 QL (60 EA per 30 days) GC

bupropion hcl sr tablet 150mg 2 QL (90 EA per 30 days) GC

bupropion hcl xl tablet 150mg 2 QL (90 EA per 30 days) GC

bupropion hcl xl tablet 300mg 2 QL (30 EA per 30 days) GC

21




chlordiazepoxide/amitriptyline 2 PA GC

citalopram hydrobromide solution 2 QL (600 ML per 30 days) GC

citalopram hydrobromide tablet 10mg, 20mg 2 QL (60 EA per 30 days) GC

citalopram hydrobromide tablet 40mg 2 QL (30 EA per 30 days) GC

clomipramine hcl 2 PA GC

CYMBALTA 4 QL (60 EA per 30 days)

desipramine hcl 2 GC

doxepin hcl 2 PA GC

EMSAM 5

escitalopram oxalate solution 2 QL (600 ML per 30 days) GC

escitalopram oxalate tablet 2 QL (60 EA per 30 days) GC

fluoxetine hcl capsule 10mg, 20mg, 40mg 2 GC

fluoxetine hcl tablet 10mg, 20mg, 60mg 2 GC

fluoxetine hcl solution 20mg/5ml 2 GC

fluvoxamine maleate 2 GC

imipramine hcl 2 PA GC

imipramine pamoate 2 PA GC

maprotiline hcl 2 GC

MARPLAN 4

mirtazapine 2 GC

mirtazapine odt 2 GC

nefazodone hcl 2 GC

nortriptyline hcl capsule 2 GC

olanzapine/fluoxetine 2 QL (30 EA per 30 days) GC

PARNATE 4

paroxetine hcl 2 QL (60 EA per 30 days) GC

PAXIL SUSPENSION 4 QL (900 ML per 30 days)

perphenazine/amitriptyline 2 PA GC

phenelzine sulfate 2 GC

PRISTIQ 3 QL (30 EA per 30 days)

protriptyline hcl 2 GC

22




sertraline hcl concentrate 2 QL (300 ML per 30 days) GC

sertraline hcl tablet 25mg, 50mg 2 QL (90 EA per 30 days) GC

sertraline hcl tablet 100mg 2 QL (60 EA per 30 days) GC

tranylcypromine sulfate 2 GC

trazodone hcl 2 GC

trimipramine maleate 2 PA GC

venlafaxine hcl 2 GC

venlafaxine hcl er capsule 37.5mg 2 QL (30 EA per 30 days) GC

venlafaxine hcl er capsule 75mg 2 QL (90 EA per 30 days) GC

venlafaxine hcl er capsule 150mg 2 QL (60 EA per 30 days) GC

VENLAFAXINE HCL ER TABLET 37.5MG, 150MG, 225MG 4 QL (30 EA per 30 days)

VENLAFAXINE HCL ER TABLET 75MG 4 QL (90 EA per 30 days)

VIIBRYD 3 QL (30 EA per 30 days)

Antiemetics

ALOXI 4 BvsD

ANzEMET INJECTION 4 PA

ANzEMET TABLET 4 QL (5 EA per 30 days) BvsD

CESAMET 4 BvsD

dronabinol capsule 2.5mg, 5mg 2 BvsD GC

dronabinol capsule 10mg 5 BvsD

EMEND CAPSULE 40MG 3 QL (2 EA per 30 days) BvsD



EMEND CAPSULE TRIFOLD PACk 3 QL (12 EA per 30 days) BvsD

granisetron hcl injection 2 HI

granisetron hcl tablet 2 QL (60 EA per 30 days) BvsD GC

granisol 2 QL (300 ML per 30 days) BvsD GC

meclizine hcl tablet rx 2 GC

ondansetron hcl injection 2 BvsD GC

ondansetron hcl oral solution 2 QL (900 ML per 30 days) BvsD GC

ondansetron hcl tablet 4mg, 8mg 2 QL (90 EA per 30 days) BvsD GC

23




ondansetron hcl tablet 24mg 2 QL (5 EA per 30 days) BvsD GC

ondansetron odt 4mg, 8mg 2 QL (90 EA per 30 days) BvsD GC

phenadoz suppository 12.5mg, 25mg 2 PA GC

promethazine hcl suppository 12.5mg, 25mg 2 PA GC

promethegan suppository 12.5mg, 25mg, 50mg 2 PA GC

SANCUSO 4 QL (4 EA per 30 days) PA

TIGAN INJECTION 3 PA

TRANSDERM-SCOP 4

trimethobenzamide hcl 2 PA GC

Antifungals

ABELCET 5 BvsD

AMBISOME 5 BvsD

amphotericin b 2 BvsD GC

ANCOBON 5

CANCIDAS 5 HI

ciclopirox 2 GC

ciclopirox nail lacquer 2 GC

ciclopirox olamine 2 GC

clotrimazole rx 2 GC

clotrimazole/betamethasone dipropionate 2 GC

econazole nitrate 2 GC

ERAXIS 3

fluconazole 2 GC

fluconazole in dextrose 2 HI

fluconazole in nacl 2 HI

flucytosine 5

GRIFULVIN V 3

GRIS-PEG 3

griseofulvin microsize 2 GC

griseofulvin ultramicrosize 2 GC

GYNAzOLE-1 4

24




itraconazole 2 GC

ketoconazole cream, shampoo, tablet 2 GC

miconazole 3 rx 2 GC

MYCAMINE 5 HI

NAFTIN 4

NATACYN 4

NOXAFIL 5

nyamyc 2 GC

nystatin 2 GC

nystatin/triamcinolone 2 GC

nystop 2 GC

OXISTAT 3

pedi-dri 2 GC

SPORANOX SOLUTION 5

terbinafine hcl tablet 2 GC

terconazole 2 GC

VFEND 5

VFEND IV 4

voriconazole injection 2 GC

voriconazole tablet 5

zazole cream 2 GC

Antigout Agents

allopurinol 2 GC

allopurinol sodium 2 GC

ALOPRIM 4

COLCRYS 3

probenecid 2 GC

probenecid/colchicine 2 GC

ULORIC 3 QL (30 EA per 30 days) ST

25




Antimigraine Agents

AXERT TABLET 6.25MG 4 QL (18 EA per 30 days) ST

AXERT TABLET 12.5MG 4 QL (12 EA per 30 days) ST

D.H.E. 45 5

dihydroergotamine mesylate injection 2 GC

ERGOMAR 4

FROVA 4 QL (18 EA per 30 days) ST

migergot 2 GC

MIGRANAL 4 QL (8 ML per 30 days)

naratriptan hcl tablet 1mg 2 QL (18 EA per 30 days) ST GC

naratriptan hcl tablet 2.5mg 2 QL (9 EA per 30 days) ST GC

RELPAX TABLET 20MG 4 QL (12 EA per 30 days) ST

RELPAX TABLET 40MG 4 QL (6 EA per 30 days) ST

rizatriptan benzoate odt 5mg 2 QL (27 EA per 30 days) GC

rizatriptan benzoate odt 10mg 2 QL (18 EA per 30 days) GC

rizatriptan benzoate tablet 5mg 2 QL (27 EA per 30 days) GC

rizatriptan benzoate tablet 10mg 2 QL (18 EA per 30 days) GC

sumatriptan solution 5mg/act 2 QL (36 EA per 30 days) GC

sumatriptan solution 20mg/act 2 QL (12 EA per 30 days) GC

sumatriptan succinate injection 4mg/0.5ml, 6mg/0.5ml cartridge, syringe

2 QL (4 ML per 30 days) GC

sumatriptan succinate injection 6mg/0.5ml vial 2 QL (8 ML per 30 days) GC

sumatriptan succinate tablet 25mg 2 QL (36 EA per 30 days) GC



Antimyasthenic Agents

guanidine hcl 2 GC

MESTINON SYRUP 3

MESTINON TIMESPAN 3

pyridostigmine bromide 2 GC

REGONOL 4

26




Antimycobacterials

CAPASTAT SULFATE 3

dapsone 2 GC

ethambutol hcl 2 GC

isoniazid 2 GC

MYCOBUTIN 3

PASER 4

PRIFTIN 4

pyrazinamide 2 GC

RIFADIN INJECTION 3

rifampin 2 GC

RIFATER 4

SEROMYCIN 3

SIRTURO 5

TRECATOR 3

Antineoplastics

ABRAXANE 5 BvsD

ADRIAMYCIN 4 BvsD

AFINITOR TABLET 2.5MG, 5MG, 7.5MG 5 QL (30 EA per 30 days)

AFINITOR TABLET 10MG 5 QL (60 EA per 30 days)

ALIMTA 5 BvsD

ALkERAN INJECTION 4 BvsD

amifostine 5 BvsD

anastrozole 2 QL (30 EA per 30 days) GC

ARRANON 5 BvsD

ARzERRA 5 BvsD

AVASTIN 5 BvsD

BICNU 3 BvsD

bleomycin sulfate 2 BvsD GC

BOSULIF 5

BUSULFEX 3 BvsD

27




CAMPTOSAR 4 BvsD

CAPRELSA 5

carboplatin 2 BvsD GC

CEENU 3

CERUBIDINE 4 BvsD

cisplatin 2 BvsD GC

cladribine 5 BvsD

CLOLAR 5 BvsD

COMETRIQ 5

COSMEGEN 5 BvsD

cyclophosphamide tablet 2 BvsD GC

cytarabine 2 BvsD GC

cytarabine aqueous 2 BvsD GC

dacarbazine 2 BvsD GC

DACOGEN 5 BvsD

daunorubicin hcl 2 BvsD GC

DAUNOXOME 4 BvsD

dexrazoxane 5 BvsD

DOCEFREz 5 BvsD

docetaxel 5 BvsD

DOXIL 5 BvsD

doxorubicin hcl 2 BvsD GC

DROXIA 3

ELITEk 5

ELLENCE 5 BvsD

ELOXATIN 5 BvsD

ELSPAR 3 BvsD

EMCYT 3

epirubicin hcl 2 BvsD GC

ERBITUX 5 BvsD

ERIVEDGE 5

28




ETOPOPHOS 4 BvsD

etoposide injection 2 BvsD GC

exemestane 2 GC

FARESTON 5

FASLODEX 5 BvsD

FLUDARA 5 BvsD

fludarabine phosphate 2 BvsD GC

fluorouracil injection 2 BvsD GC

gemcitabine hcl 5 BvsD

GEMzAR 5 BvsD

GLEEVEC 5

HALAVEN 5

HERCEPTIN 5 BvsD

HEXALEN 5

HYCAMTIN INJECTION 5 BvsD

HYDREA 4

hydroxyurea 2 GC

ICLUSIG 5

IDAMYCIN PFS 5 BvsD

idarubicin hcl 5 BvsD

IFEX 4 BvsD

ifosfamide 2 BvsD GC

ifosfamide/mesna 5 BvsD

INLYTA 5

irinotecan 5 BvsD

ISTODAX 5 BvsD

IXEMPRA kIT 5 BvsD

JAkAFI 5

JEVTANA 5 BvsD

kADCYLA 5 BvsD

letrozole 2 GC

29




leucovorin calcium injection 2 BvsD GC

leucovorin calcium tablet 2 GC

LEUkERAN 3

MATULANE 5

MEkINIST 5

melphalan hcl 2 BvsD GC

mercaptopurine 2 GC

mesna 2 BvsD GC

MESNEX INJECTION 4 BvsD

MESNEX TABLET 5

mitomycin 2 BvsD GC

mitoxantrone hcl 2 BvsD GC

MUSTARGEN 3 BvsD

NAVELBINE 5 BvsD

NEXAVAR 5 RA

NIPENT 5 BvsD

ONTAk 5 BvsD

oxaliplatin 5 BvsD

paclitaxel 2 BvsD GC

PANRETIN 5

pentostatin 5 BvsD

PERJETA 5 BvsD

POMALYST 5

PROLEUkIN 5

REVLIMID 5 QL (28 EA per 28 days) RA

RITUXAN 5 PA

SOLTAMOX 4

SPRYCEL 5

STIVARGA 5

SUTENT 5

SYLATRON 5 PA

30




SYNRIBO 5 BvsD

TABLOID 4

TAFINLAR 5

tamoxifen citrate 2 GC

TARCEVA 5

TARGRETIN 5

TASIGNA 5

TAXOTERE 5 BvsD

THALOMID 5

thiotepa 2 BvsD GC

toposar 2 BvsD GC

topotecan hcl 5 BvsD

TREANDA 5 BvsD

tretinoin capsule 10mg 5

TRISENOX 4 BvsD

TYkERB 5

VECTIBIX 5 BvsD

VELCADE 5 BvsD

VIDAzA 3

vinblastine sulfate 2 BvsD GC

vincasar pfs 2 BvsD GC

vincristine sulfate 2 BvsD GC

vinorelbine tartrate 2 BvsD GC

VOTRIENT 5

VUMON 4 PA

XALkORI 5

YERVOY 5 BvsD

zALTRAP 5 BvsD

zANOSAR 4 BvsD

zELBORAF 5

zINECARD 5 BvsD

31




zOLINzA 5

zYTIGA 5

Antiparasitics

ALBENzA 4

ALINIA 4

atovaquone/proguanil hcl 2 GC

chloroquine phosphate 2 GC

COARTEM 4 QL (24 EA per 30 days)

DARAPRIM 4

EURAX 4

hydroxychloroquine sulfate 2 GC

lindane 2 GC

malathion 2 GC

mefloquine hcl 2 GC

MEPRON 5

NEBUPENT 4 BvsD

PENTAM 300 4

permethrin cream rx 2 GC

PRIMAQUINE PHOSPHATE 4

QUALAQUIN 4 PA

quinine sulfate 2 PA GC

SkLICE 4

STROMECTOL 3

tinidazole 2 GC

Antiparkinson Agents

APOkYN 5

AzILECT 3

benztropine mesylate injection 2 GC

benztropine mesylate tablet 2 PA GC

bromocriptine mesylate 2 GC

carbidopa/levodopa 2 GC

32




carbidopa/levodopa er 2 GC

carbidopa/levodopa odt 2 GC

entacapone 2 GC

LODOSYN 3

pramipexole dihydrochloride 2 GC

ropinirole hcl 2 GC

ropinirole hcl er 2 GC

selegiline hcl 2 GC

TASMAR 3

trihexyphenidyl hcl 2 PA GC

zELAPAR 4

Antipsychotics

ABILIFY DISCMELT 3 QL (60 EA per 30 days)

ABILIFY INJECTION 4

ABILIFY MAINTENA 5

ABILIFY ORAL SOLUTION 3 QL (900 ML per 30 days)

ABILIFY TABLET 3 QL (30 EA per 30 days)

chlorpromazine hcl injection, tablet 2 GC

clozapine 2 GC

compro 2 GC

FANAPT 4 QL (60 EA per 30 days)

FANAPT TITRATION PACk 4 QL (16 EA per 30 days)

FAzACLO 4

fluphenazine decanoate 2 GC

fluphenazine hcl 2 GC

GEODON INJECTION 4

haloperidol 2 GC

haloperidol decanoate 2 GC

haloperidol lactate 2 GC

INVEGA SUSTENNA 39MG/0.25ML, 78MG/0.5ML 4

INVEGA SUSTENNA 117MG/0.75ML, 156MG/ML, 234MG/1.5ML 5

33




INVEGA TABLET ER 1.5MG, 3MG 4 QL (30 EA per 30 days)

INVEGA TABLET ER 6MG 4 QL (60 EA per 30 days)

INVEGA TABLET ER 9MG 5 QL (30 EA per 30 days)

LATUDA TABLET 20MG, 40MG, 120MG 3 QL (30 EA per 30 days)

LATUDA TABLET 80MG 3 QL (60 EA per 30 days)

loxapine succinate 2 GC

olanzapine odt 2 QL (30 EA per 30 days) GC

olanzapine injection 2 GC

olanzapine tablet 2 QL (60 EA per 30 days) GC

ORAP 4

perphenazine 2 GC

prochlorperazine 2 GC

prochlorperazine edisylate 2 GC

prochlorperazine maleate 2 GC

quetiapine fumarate tablet 25mg, 50mg, 100mg, 200mg 2 QL (120 EA per 30 days) GC

quetiapine fumarate tablet 300mg, 400mg 2 QL (90 EA per 30 days) GC

RISPERDAL CONSTA INJECTION 12.5MG, 25MG 4

RISPERDAL CONSTA INJECTION 37.5MG, 50MG 5

risperidone odt 0.25mg, 0.5mg, 1mg, 2mg, 3mg 2 QL (90 EA per 30 days) GC

risperidone odt 4mg 2 QL (120 EA per 30 days) GC

risperidone solution 2 QL (360 ML per 30 days) GC

risperidone tablet 0.25mg, 0.5mg, 1mg, 2mg, 3mg 2 QL (90 EA per 30 days) GC

risperidone tablet 4mg 2 QL (120 EA per 30 days) GC

SAPHRIS 3 QL (60 EA per 30 days)

SEROQUEL XR TABLET 50MG, 300MG, 400MG 3 QL (60 EA per 30 days)

SEROQUEL XR TABLET 150MG, 200MG 3 QL (30 EA per 30 days)

thioridazine hcl 2 PA GC

thiothixene 2 GC

trifluoperazine hcl 2 GC

ziprasidone hcl 2 QL (60 EA per 30 days) GC

34




Antispasticity Agents

baclofen 2 GC

dantrolene sodium capsule 2 GC

tizanidine hcl 2 GC

Antivirals

abacavir 2 GC

acyclovir 2 GC

acyclovir sodium injection 500mg 2 BvsD GC

amantadine hcl 2 GC

APTIVUS 5

ATRIPLA 5

BARACLUDE 3

cidofovir 5

COMPLERA 5

COPEGUS 5

CRIXIVAN 3

DENAVIR 3

didanosine 2 GC

EDURANT 5

EMTRIVA 4

EPIVIR HBV 4

EPIVIR SOLUTION 4

EPzICOM 5

famciclovir 2 GC

foscarnet sodium 2 BvsD GC

FUzEON 5

ganciclovir 2 BvsD GC

HEPSERA 5

INCIVEk 5 PA

INFERGEN 5 PA

INTELENCE TABLET 25MG 4

35




INTELENCE TABLET 100MG, 200MG 5

INTRON-A 4

INVIRASE CAPSULE 200MG 4

INVIRASE TABLET 500MG 5

ISENTRESS TABLET CHEWABLE 25MG, 100MG 3

ISENTRESS TABLET 400MG 5

kALETRA 5

lamivudine 2 GC

lamivudine/zidovudine 5

LEXIVA SUSPENSION 4

LEXIVA TABLET 5

nevirapine tablet 2 GC

NORVIR 4

PEG-INTRON 5 PA

PREzISTA SUSPENSION 4

PREzISTA TABLET 75MG, 150MG 4

PREzISTA TABLET 400MG, 600MG, 800MG 5

REBETOL CAPSULE 5

REBETOL SOLUTION 3

RELENzA DISkHALER 4 QL (120 EA per 365 days)

RESCRIPTOR 4

RETROVIR IV INFUSION 4

REYATAz 3

ribapak tablet 5

ribasphere capsule 200mg 2 GC

ribasphere tablet 200mg, 400mg 2 GC

ribasphere tablet 600mg 5

ribavirin capsule, tablet 200mg 2 GC

rimantadine hcl 2 GC

SELzENTRY 5

stavudine 2 GC

36




STRIBILD 5

SUSTIVA 3

TAMIFLU CAPSULE 30MG 3 QL (120 EA per 365 days)



TAMIFLU SUSPENSION 3

trifluridine 2 GC

TRIzIVIR 5

TRUVADA 5

TYzEkA 5

valacyclovir hcl 2 GC

VICTRELIS 5 PA

VIDEX PEDIATRIC 3

VIRACEPT 5

VIRAMUNE 4

VIRAMUNE XR 4

VIREAD 5

VISTIDE 5

zERIT SOLUTION 4

zIAGEN SOLUTION 4

zidovudine 2 GC

zIRGAN 4

zOVIRAX CREAM, OINTMENT 4

Anxiolytics

alprazolam er tablet 0.5mg, 1mg, 2mg, 3mg 2 QL (90 EA per 30 days) GC

alprazolam intensol 2 QL (300 ML per 30 days) GC

alprazolam odt 0.25mg, 0.5mg, 1mg 2 QL (120 EA per 30 days) GC

alprazolam odt 2mg 2 QL (150 EA per 30 days) GC

alprazolam tablet 0.25mg, 0.5mg, 1mg 2 QL (120 EA per 30 days) GC

alprazolam tablet 2mg 2 QL (150 EA per 30 days) GC

buspirone hcl 2 GC

37




diazepam intensol 2 QL (240 ML per 30 days) GC

diazepam injection 10mg/2ml, 5mg/ml 2 GC

diazepam oral solution 1mg/ml 2 QL (1200 ML per 30 days) GC

diazepam tablet 2mg, 5mg, 10mg 2 QL (120 EA per 30 days) GC

lorazepam injection 2 GC

lorazepam intensol 2 QL (150 ML per 30 days) GC

lorazepam tablet 2 QL (120 EA per 30 days) GC

meprobamate 2 PA GC

oxazepam 2 QL (120 EA per 30 days) GC

Bipolar Agents

EQUETRO 4

lithium carbonate 2 GC

lithium carbonate er 2 GC

lithium citrate 2 GC

LITHOBID 4

Blood Glucose Regulators

acarbose 2 GC

ALCOHOL PREP PADS 3

AVANDIA TABLET 2MG, 4MG 4 QL (60 EA per 30 days)

AVANDIA TABLET 8MG 4 QL (30 EA per 30 days)

BD INSULIN SYRINGE 3

BD PEN NEEDLE 3

BYDUREON 3 QL (2.6 ML per 28 days)

BYETTA 3 QL (3 ML per 30 days)

chlorpropamide 1 PA GC

GAUzE PADS 2”X2” 3

glimepiride 1 GC

glipizide 1 GC

glipizide er 1 GC

glipizide/metformin hcl 1 GC

GLUCAGEN HYPOkIT 3

38




GLUCAGON EMERGENCY kIT 3

glyburide 1 PA GC

glyburide micronized 1 PA GC

glyburide/metformin hcl 1 PA GC

GLYSET 4

HUMALOG 3

HUMALOG MIX 50/50 3

HUMALOG MIX 75/25 3

HUMULIN 70/30 3

HUMULIN N 3

HUMULIN R 3

HUMULIN R U-500 (CONCENTRATED) 3

INSULIN SYRINGE & PEN NEEDLE 3

JANUMET 3 QL (60 EA per 30 days)

JANUMET XR TABLET 500MG/50MG, 1000MG/50MG 3 QL (60 EA per 30 days)

JANUMET XR TABLET 1000MG/100MG 3 QL (30 EA per 30 days)

JANUVIA 3 QL (30 EA per 30 days)

JENTADUETO 3 QL (60 EA per 30 days)

JUVISYNC 3 QL (30 EA per 30 days)

LANTUS 3

LANTUS SOLOSTAR 3

LEVEMIR 3

LEVEMIR FLEXPEN 3

metformin hcl 1 GC

metformin hcl er 1 GC

nateglinide 1 GC

NOVOFINE & NOVOTWIST PEN NEEDLE 3

NOVOLIN 70/30 4 ST

NOVOLIN N 4 ST

NOVOLIN R 4 ST

NOVOLOG 4 ST

39




NOVOLOG MIX 70/30 4 ST

pioglitazone hcl 1 QL (30 EA per 30 days) GC

pioglitazone hcl/glimepiride 1 QL (30 EA per 30 days) GC

pioglitazone hcl/metformin hcl 1 QL (90 EA per 30 days) GC

PRANDIN 4

PROGLYCEM 4

RIOMET 3

SYMLINPEN 60 4 QL (12 ML per 30 days)

SYMLINPEN 120 4 QL (10.8 ML per 30 days)

tolazamide 1 GC

tolbutamide 1 GC

TRADJENTA 3 QL (30 EA per 30 days)

V-GO 4

VICTOzA 3 QL (9 ML per 30 days)

Blood Products/Modifiers/Volume Expanders

AGGRENOX 3 QL (60 EA per 30 days)

aminocaproic acid tablet 2 GC

anagrelide hcl 2 GC

ARANESP 25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML, 60MCG/0.3ML, 60MCG/ML

3 PA

ARANESP 100MCG/0.5ML, 100MCG/ML, 150MCG/0.3ML, 150MCG/0.75ML, 200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML

5 PA

BRILINTA 3 QL (60 EA per 30 days)

cilostazol 2 GC

clopidogrel tablet 75mg 2 GC

clopidogrel tablet 300mg 2 QL (1 EA per 30 days) GC

COUMADIN 4

CYkLOkAPRON 3

dipyridamole tablet 2 PA GC

EFFIENT TABLET 5MG 3 QL (42 EA per 30 days)

EFFIENT TABLET 10MG 3 QL (36 EA per 30 days)

40




ELIQUIS 3 QL (60 EA per 30 days)

enoxaparin sodium 30mg/0.3ml 2 QL (18 ML per 365 days) GC




enoxaparin sodium 100mg/ml 2 QL (60 ML per 365 days) GC

enoxaparin sodium 120mg/0.8ml 5 QL (48 ML per 365 days)

enoxaparin sodium 150mg/ml 5 QL (60 ML per 365 days)

enoxaparin sodium 300mg/3ml 2 QL (90 ML per 30 days) GC

EPOGEN 4 PA

fondaparinux sodium 2.5mg/0.5ml 2 QL (32 ML per 365 days) GC

fondaparinux sodium 5mg/0.4ml 5 QL (12 ML per 365 days)

fondaparinux sodium 7.5mg/0.6ml 5 QL (18 ML per 365 days)

fondaparinux sodium 10mg/0.8ml 5 QL (24 ML per 365 days)

FRAGMIN 2500UNIT/0.2ML, 5000UNIT/0.2ML 4 QL (6 ML per 365 days) ST

FRAGMIN 7500UNIT/0.3ML 5 QL (54 ML per 365 days) ST

FRAGMIN 10000UNIT/ML 5 QL (180 ML per 365 days) ST



FRAGMIN 18000UNT/0.72ML 5 QL (21.6 ML per 365 days) ST

FRAGMIN 25000UNIT/ML 4 QL (133 ML per 365 days) ST

heparin sodium 1000unit/ml 2 BvsD GC

heparin sodium 2000unit/ml, 2500unit/ml, 5000unit/ml, 10000unit/ml, 20000unit/ml

2 GC

heparin sodium/d5w injection 5%; 40unit/ml 2 GC

heparin sodium/nacl 0.45% 2 GC

heparin sodium/sodium chloride 0.9% premix 2 GC

jantoven 2 GC

LEUkINE 5

MOzOBIL 5

NEULASTA 5

NEUMEGA 5 PA

41




NEUPOGEN 5

PRADAXA 4 QL (60 EA per 30 days)

PROCRIT 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML, 10000UNIT/ML

3 PA

PROCRIT 20000UNIT/ML, 40000UNIT/ML 5 PA

PROMACTA 5

ticlopidine hcl 2 PA GC

tranexamic acid injection 2 GC

warfarin sodium 2 GC

XARELTO TABLET 10MG, 20MG 3 QL (30 EA per 30 days)

XARELTO TABLET 15MG 3 QL (60 EA per 30 days)

Cardiovascular Agents

acebutolol hcl 2 GC

acetazolamide sodium 2 GC

ADVICOR 4 QL (30 EA per 30 days)

afeditab cr 2 GC

amiloride hcl 2 GC

amiloride/hctz 2 GC

amiodarone hcl 2 GC

amlodipine besylate tablet 2.5mg 2 QL (90 EA per 30 days) GC

amlodipine besylate tablet 5mg , 10mg 2 QL (60 EA per 30 days) GC

amlodipine besylate/atorvastatin calcium 1 QL (30 EA per 30 days) GC

amlodipine besylate/benazepril hcl 2 QL (30 EA per 30 days) GC

AMTURNIDE 4 QL (30 EA per 30 days)

ATACAND 4 QL (30 EA per 30 days) ST

ATACAND HCT 4 QL (30 EA per 30 days) ST

atenolol 2 GC

atenolol/chlorthalidone 2 GC

atorvastatin calcium 1 QL (30 EA per 30 days) GC

benazepril hcl 1 GC

benazepril hcl/hctz 1 GC

42




BENICAR 3 QL (30 EA per 30 days)

BENICAR HCT 3 QL (30 EA per 30 days)

betaxolol hcl tablet 10mg, 20mg 2 GC

BIDIL 4

bisoprolol fumarate 2 GC

bisoprolol fumarate/hctz 2 GC

bumetanide 2 GC

BYSTOLIC TABLET 2.5MG, 5MG 3 QL (90 EA per 30 days)

BYSTOLIC TABLET 10MG 3 QL (120 EA per 30 days)

BYSTOLIC TABLET 20MG 3 QL (60 EA per 30 days)

candesartan cilexetil/hctz 1 QL (30 EA per 30 days) GC

captopril 1 GC

captopril/hctz 1 GC

cartia xt 2 GC

carvedilol 2 GC

chlorothiazide 2 GC

chlorothiazide sodium 2 GC

chlorthalidone 2 GC

cholestyramine light packet 2 GC

clonidine hcl tablet 2 GC

clonidine hcl patch weekly 0.1mg/24hr, 0.2mg/24hr 2 QL (4 EA per 28 days) GC

clonidine hcl patch weekly 0.3mg/24hr 2 QL (8 EA per 28 days) GC

clorpres 2 GC

colestipol hcl 2 GC

COREG CR 3 QL (30 EA per 30 days)

CRESTOR 3 QL (30 EA per 30 days)

DEMSER 3

DIBENzYLINE 3

digoxin 2 PA GC

dilacor xr 2 GC

dilt-cd 2 GC

43




dilt-xr 2 GC

diltiazem cd 2 GC

diltiazem hcl er 2 GC

diltiazem hcl injection, tablet 2 GC

diltzac 2 GC

DIOVAN TABLET 40MG, 80MG, 160MG 4 QL (60 EA per 30 days)

DIOVAN TABLET 320MG 4 QL (30 EA per 30 days)

disopyramide phosphate 2 PA GC

DIURIL 3

doxazosin mesylate 2 GC

DUTOPROL 4 QL (60 EA per 30 days)

DYRENIUM 4

EDECRIN 3

enalapril maleate 1 GC

enalapril maleate/hctz 1 GC

eplerenone 2 GC

eprosartan mesylate 2 QL (30 EA per 30 days) GC

EXFORGE 3 QL (30 EA per 30 days)

EXFORGE HCT 3 QL (30 EA per 30 days)

felodipine er 2 QL (60 EA per 30 days) GC

fenofibrate micronized 2 QL (30 EA per 30 days) GC

fenofibrate tablet 48mg, 54mg 2 QL (60 EA per 30 days) GC

fenofibrate tablet 145mg, 160mg 2 QL (30 EA per 30 days) GC

flecainide acetate 2 GC

fluvastatin capsule 20mg 1 QL (30 EA per 30 days) GC

fluvastatin capsule 40mg 1 QL (60 EA per 30 days) GC

fosinopril sodium 1 GC

fosinopril sodium/hctz 1 GC

furosemide 2 GC

gemfibrozil 2 GC

guanfacine hcl 2 PA GC

44




hydralazine hcl 2 GC

hydrochlorothiazide 2 GC

indapamide 2 GC

INNOPRAN XL 4

irbesartan 1 QL (30 EA per 30 days) GC

irbesartan/hctz 1 QL (30 EA per 30 days) GC

isosorbide dinitrate 2 GC

isosorbide dinitrate er 2 GC

isosorbide mononitrate 2 GC

isosorbide mononitrate er 2 GC

isradipine 2 GC

JUXTAPID 5

kYNAMRO 5

labetalol hcl 2 GC

LANOXIN 3 PA

LANOXIN PEDIATRIC 3 PA

LESCOL XL 4 QL (30 EA per 30 days)

LIPOFEN CAPSULE 50MG 4 QL (60 EA per 30 days) ST

LIPOFEN CAPSULE 150MG 4 QL (30 EA per 30 days) ST

lisinopril 1 GC

lisinopril/hctz 1 GC

LOFIBRA CAPSULE 4 QL (30 EA per 30 days) ST

LOFIBRA TABLET 54MG 4 QL (60 EA per 30 days) ST

LOFIBRA TABLET 160MG 4 QL (30 EA per 30 days) ST

losartan potassium/hctz tablet 50mg/12.5mg 1 QL (60 EA per 30 days) GC

losartan potassium/hctz tablet 100mg/12.5mg, 100mg/25mg 1 QL (30 EA per 30 days) GC

losartan potassium tablet 25mg 1 QL (90 EA per 30 days) GC



lovastatin tablet 10mg, 20mg 1 QL (90 EA per 30 days) GC

lovastatin tablet 40mg 1 QL (60 EA per 30 days) GC

45




LOVAzA 3

methazolamide 2 GC

methyclothiazide 2 GC

methyldopa 2 PA GC

methyldopa/hctz 2 PA GC

methyldopate hcl 2 PA GC

metolazone 2 GC

metoprolol succinate er tablet 25mg, 50mg, 100mg 2 QL (90 EA per 30 days) GC

metoprolol succinate er tablet 200mg 2 QL (60 EA per 30 days) GC

metoprolol tartrate 2 GC

metoprolol/hctz 2 GC

mexiletine hcl 2 GC

MICARDIS 4 QL (30 EA per 30 days)

MICARDIS HCT 4 QL (30 EA per 30 days)

midodrine hcl 2 GC

minitran 2 GC

minoxidil 2 GC

moexipril hcl 1 GC

moexipril/hctz 1 GC

MULTAQ 3 QL (60 EA per 30 days)

nadolol 2 GC

nadolol/bendroflumethiazide 2 GC

NIACOR 4

nicardipine hcl 2 GC

nifediac cc 2 GC

nifedical xl 2 GC

nifedipine 2 PA GC

nifedipine er 2 GC

nimodipine 2 GC

nisoldipine 2 QL (30 EA per 30 days) GC

nisoldipine er 2 QL (30 EA per 30 days) GC

46




NITRO-BID 4

NITRO-DUR PATCH 0.3MG/HR, 0.8MG/HR 4

nitroglycerin injection 2 GC

nitroglycerin transdermal patch 2 GC

NITROLINGUAL PUMPSPRAY 3

NITROSTAT 3

NORPACE CR 4

pacerone 2 GC

pentoxifylline er 2 GC

perindopril erbumine 1 GC

pindolol 2 GC

pravastatin sodium tablet 10mg, 20mg 1 QL (90 EA per 30 days) GC

pravastatin sodium tablet 40mg 1 QL (60 EA per 30 days) GC

pravastatin sodium tablet 80mg 1 QL (30 EA per 30 days) GC

prazosin hcl 2 GC

prevalite powder 2 GC

procainamide hcl 2 GC

propafenone hcl 2 GC

propafenone hcl er 2 GC

propranolol hcl 2 GC

propranolol hcl er 2 GC

propranolol hcl/hctz 2 GC

quinapril hcl 1 GC

quinapril hcl/hctz 1 GC

quinidine gluconate 2 GC

quinidine gluconate cr 2 GC

quinidine sulfate 2 GC

quinidine sulfate er 2 GC

ramipril 1 GC

RANEXA 3

RECTIV 4

47




reserpine 2 PA GC

SIMCOR TABLET ER 500MG/20MG, 500MG/40MG, 1000MG/40MG

3 QL (30 EA per 30 days)

SIMCOR TABLET ER 750MG/20MG, 1000MG/20MG 3 QL (60 EA per 30 days)

simvastatin tablet 5mg, 10mg, 20mg 1 QL (90 EA per 30 days) GC

simvastatin tablet 40mg 1 QL (45 EA per 30 days) GC

simvastatin tablet 80mg 1 QL (30 EA per 30 days) GC

SODIUM EDECRIN 3

sorine 2 GC

sotalol hcl 2 GC

sotalol hcl (af) 2 GC

spironolactone 2 GC

spironolactone/hctz 2 GC

TARkA TABLET 1MG/240MG, 2MG/180MG, 2MG/240MG 4 QL (30 EA per 30 days)

TARkA TABLET 4MG/240MG 4 QL (60 EA per 30 days)

taztia xt 2 GC

TEkAMLO 4 QL (30 EA per 30 days)

TEkTURNA 4 QL (30 EA per 30 days)

TEkTURNA HCT 4 QL (30 EA per 30 days)

terazosin hcl 2 GC

TEVETEN TABLET 400MG 4 QL (60 EA per 30 days)

TEVETEN HCT 4 QL (30 EA per 30 days)

TIkOSYN 4

timolol maleate tablet 2 GC

TOPROL XL TABLET ER 25MG, 50MG, 100MG 4 QL (90 EA per 30 days)

TOPROL XL TABLET ER 200MG 4 QL (60 EA per 30 days)

torsemide 2 GC

trandolapril 1 GC

triamterene/hctz 2 GC

TRILIPIX CAPSULE DELAYED RELEASE 45MG 4 QL (60 EA per 30 days)

TRILIPIX CAPSULE DELAYED RELEASE 135MG 4 QL (30 EA per 30 days)

48




valsartan/hctz 1 QL (30 EA per 30 days) GC

verapamil hcl 2 GC

verapamil hcl er 2 GC

verapamil hcl sr 2 GC

VYTORIN 4 QL (30 EA per 30 days)

WELCHOL 3

zETIA 3 QL (30 EA per 30 days)

Central Nervous System Agents

amphetamine/dextroamphetamine capsule er 5mg, 10mg, 15mg 2 QL (30 EA per 30 days) GC

amphetamine/dextroamphetamine capsule er 20mg, 25mg, 30mg 2 QL (60 EA per 30 days) GC

amphetamine/dextroamphetamine tablet 2 GC

AMPYRA 5 QL (60 EA per 30 days) PA

AUBAGIO 5 QL (30 EA per 30 days) PA

AVONEX 5 PA

COPAXONE 5 PA

DAYTRANA 4 QL (30 EA per 30 days)

dexmethylphenidate hcl 2 GC

dextroamphetamine sulfate er 2 GC

dextroamphetamine sulfate tablet 2 GC

EXTAVIA 5 PA

GILENYA 5 QL (30 EA per 30 days) PA

INTUNIV 4 QL (30 EA per 30 days) PA

metadate er 2 GC

methamphetamine hcl 2 PA GC

METHYLIN TABLET CHEWABLE 4

methylphenidate hcl 2 GC

methylphenidate hcl cd capsule 10mg, 20mg, 30mg, 40mg, 50mg, 60mg

2 GC

methylphenidate hcl er capsule 20mg, 30mg, 40mg 2 GC

methylphenidate hcl er tablet 10mg, 20mg 2 GC

methylphenidate hcl er tablet 18mg, 27mg, 36mg, 54mg 2 QL (30 EA per 30 days) GC

49




NUEDEXTA 3 QL (60 EA per 30 days)

procentra 2 GC

REBIF 5 PA

REBIF TITRATION PACk 5 PA

riluzole 2 GC

SAVELLA 3 QL (60 EA per 30 days)

SAVELLA TITRATION PACk 3 QL (55 EA per 30 days)

STRATTERA CAPSULE 10MG, 18MG, 25MG, 40MG 3 QL (60 EA per 30 days)

STRATTERA CAPSULE 60MG, 80MG, 100MG 3 QL (30 EA per 30 days)

XENAzINE 5 RA

Dental and Oral Agents

cevimeline hcl 2 GC

chlorhexidine gluconate oral rinse 2 GC

EVOXAC 4

kEPIVANCE 5

periogard 2 GC

pilocarpine hcl tablet 2 GC

triamcinolone in orabase 2 GC

Dermatological Agents

8-MOP 3

adapalene 2 GC

ammonium lactate rx 2 GC

amnesteem 2 GC

AzELEX 3

calcipotriene 2 GC

CARAC 4

claravis 2 GC

CLINDAGEL 4

clindamycin phosphate foam 1% 2 GC

clindamycin phosphate gel 1% 2 GC

clindamycin phosphate lotion 1% 2 GC

50




clindamycin phosphate solution 1% 2 GC

clindamycin phosphate swab 1% 2 GC

clindamycin/benzoyl peroxide gel 5%/1% 2 GC

CONDYLOX GEL 4

CORTISPORIN CREAM 3

ELIDEL 4

erythromycin/benzoyl peroxide 2 GC

FINACEA 3

fluorouracil cream 5% 2 GC

fluorouracil topical solution 2%, 5% 2 GC

imiquimod 2 GC

myorisan 2 GC

OXSORALEN 4

OXSORALEN ULTRA 3

podofilox 2 GC

PRUDOXIN 3

REGRANEX 5 QL (30 GM per 30 days) PA

RETIN-A MICRO 4 PA

SANTYL 3

selenium sulfide lotion 2 GC

SOLARAzE 3

SORIATANE 5

sulfacetamide sodium suspension 10% 2 GC

TAzORAC 4

tretinoin cream 0.025%, 0.05%, 0.1% 2 PA GC

tretinoin gel 0.01%, 0.025% 2 PA GC

UVADEX 3 BvsD

VELTIN 4

VOLTAREN 3

zIANA 4

zONALON 3

51




zYCLARA 3

zYCLARA PUMP 3

Enzyme Replacement/Modifiers

ADAGEN 5

ALDURAzYME 5

BUPHENYL 5

CEREzYME 5

CREON 3

CYSTADANE 5

CYSTAGON 3

ELAPRASE 5

ELELYSO 5

FABRAzYME 5

kUVAN 5

LUMIzYME 5

MYOzYME 5

NAGLAzYME 5

ORFADIN 5

PANCRELIPASE 4

RAVICTI 5

sodium phenylbutyrate 2 GC

SUCRAID 5

VPRIV 5 BvsD

XIAFLEX 5 PA

zAVESCA 5

zENPEP 3

Gastrointestinal Agents

ACIPHEX 4 QL (60 EA per 30 days)

AMITIzA 3 QL (60 EA per 30 days)

atropine sulfate 2 GC

CANTIL 3

52




CARAFATE SUSPENSION 4

CHENODAL 5

cimetidine 2 GC

cimetidine hcl 2 GC

constulose 2 GC

cromolyn sodium concentrate 100mg/5ml 2 GC

CUVPOSA 4

DEXILANT 4 QL (60 EA per 30 days)

dicyclomine hcl 2 GC

diphenoxylate/atropine 2 GC

enulose 2 GC

famotidine injection 2 GC

famotidine tablet 20mg, 40mg rx 2 GC

GATTEX 5 PA

gavilyte-c 2 GC

gavilyte-g 2 GC

gavilyte-n/flavor pack 2 GC

generlac 2 GC

glycopyrrolate 2 GC

GOLYTELY 3

HALFLYTELY BOWEL PREP/FLAVOR PACkS 3

kRISTALOSE 4

lactulose 2 GC

lansoprazole 2 QL (60 EA per 30 days) GC

loperamide hcl capsule rx 2 GC

LOTRONEX 5 PA

methscopolamine bromide 2 GC

metoclopramide hcl 2 GC

misoprostol 2 GC

MOTOFEN 3

MOVIPREP 4

53




NEXIUM 3 QL (60 EA per 30 days)

NEXIUM I.V. 3

nizatidine capsule 2 GC

NULYTELY/FLAVOR PACkS 3

omeprazole capsule delayed release rx 2 QL (60 EA per 30 days) GC

OSMOPREP 4

pantoprazole sodium injection 2 GC

pantoprazole sodium tablet delayed release 2 QL (60 EA per 30 days) GC

polyethylene glycol 3350 powder 2 GC

propantheline bromide 2 GC

ranitidine hcl capsule, injection, syrup 2 GC

ranitidine hcl tablet 150mg, 300mg rx 2 GC

RELISTOR 3

sucralfate tablet 2 GC

trilyte 2 GC

ursodiol 2 GC

zEGERID 4 QL (60 EA per 30 days)

Genitourinary Agents

alfuzosin hcl er 2 QL (30 EA per 30 days) GC

AVODART 3 QL (30 EA per 30 days)

bethanechol chloride 2 GC

calcium acetate capsule 2 GC

CIALIS TABLET 2.5MG, 5MG 3 QL (30 EA per 30 days) PA

eliphos 2 GC

ELMIRON 4

finasteride tablet 5mg 2 GC

flavoxate hcl 2 GC

FOSRENOL 3

GELNIQUE GEL 3% 3 QL (92 GM per 30 days)

GELNIQUE GEL 10% 3 QL (30 GM per 30 days)

JALYN 3 QL (30 EA per 30 days)

54




MYRBETRIQ 4 QL (30 EA per 30 days)

oxybutynin chloride 2 GC

oxybutynin chloride er tablet 5mg 2 QL (30 EA per 30 days) GC

oxybutynin chloride er tablet 10mg, 15mg 2 QL (60 EA per 30 days) GC

PHOSLO 3

PHOSLYRA 3

RAPAFLO 3 QL (30 EA per 30 days) ST

RENVELA 3

tamsulosin hcl 2 GC

tolterodine tartrate 2 QL (60 EA per 30 days) GC

trospium chloride 2 QL (60 EA per 30 days) GC

trospium chloride er 2 QL (30 EA per 30 days) GC

VESICARE 3 QL (30 EA per 30 days)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

a-hydrocort 2 BvsD GC

a-methapred 2 BvsD GC

ala cort 2 GC

ala scalp 2 GC

alclometasone dipropionate 2 GC

amcinonide 2 GC

ARISTOSPAN INTRA-ARTICULAR 4

ARISTOSPAN INTRALESIONAL 4

augmented betamethasone dipropionate 2 GC

betamethasone dipropionate 2 GC

betamethasone valerate 2 GC

CELESTONE 3

clobetasol propionate foam, gel, lotion, ointment, shampoo, solution

2 GC

clobetasol propionate e cream 2 GC

CLODERM PUMP 3

CORDRAN SP 3

55




CORDRAN TAPE 3

CORTIFOAM 4

cortisone acetate 2 GC

CUTIVATE LOTION 4

DEPO-MEDROL 4 BvsD

DESONATE 4

desonide 2 GC

desoximetasone 2 GC

dexamethasone elixir, tablet 2 GC

dexamethasone intensol 2 GC

dexamethasone sodium phosphate injection 2 GC

diflorasone diacetate 2 GC

fludrocortisone acetate 2 GC

fluocinolone acetonide 2 GC

fluocinolone acetonide body 2 GC

fluocinonide 2 GC

fluocinonide-e 2 GC

fluticasone propionate cream 0.05% 2 GC

fluticasone propionate lotion 0.05% 2 GC

fluticasone propionate ointment 0.005% 2 GC

halobetasol propionate 2 GC

hydrocortisone butyrate 2 GC

hydrocortisone valerate 2 GC

hydrocortisone cream 1%, 2.5% 2 GC

hydrocortisone lotion 2.5% 2 GC

hydrocortisone ointment 1%, 2.5% 2 GC

hydrocortisone tablet 2 GC

kENALOG 4

lokara 2 GC

LUXIQ 4

methylprednisolone 2 GC

56




methylprednisolone acetate 2 BvsD GC

methylprednisolone dose pack 2 GC

methylprednisolone sodiumsuccinate 40mg, 125mg 2 BvsD GC

methylprednisolone sodiumsuccinate 1000mg 2 HI

mometasone furoate cream, ointment, solution 2 GC

OLUX-E 4

ORAPRED ODT 4

PANDEL 3

prednicarbate 2 GC

prednisolone sodium phosphate oral solution 5mg/5ml, 15mg/5ml

2 GC

prednisone 2 GC

prednisone intensol 2 GC

procto-pak 2 GC

PROCTOCORT CREAM 4

proctocream hc 2 GC

proctosol hc 2 GC

proctozone-hc 2 GC

SOLU-CORTEF 3 BvsD

SOLU-MEDROL 40MG, 125MG, 500MG 3 BvsD

SOLU-MEDROL 1000MG, 2GM 3 HI

triamcinolone acetonide cream 0.025%, 0.1%, 0.5% 2 GC

triamcinolone acetonide lotion 0.025%, 0.1% 2 GC

triamcinolone acetonide ointment 0.025%, 0.1%, 0.5% 2 GC

triderm 2 GC

u-cort 2 GC

VANOS 4

VERDESO 4

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

ACTHAR HP 5 PA

DDAVP SOLUTION 4

57




desmopressin acetate 2 GC

EGRIFTA INJECTION 1MG 5 QL (60 EA per 30 days) PA

EGRIFTA INJECTION 2MG 5 QL (30 EA per 30 days) PA

GENOTROPIN 5MG, 12MG 5 PA

GENOTROPIN MINIQUICk INJECTION 0.2MG 4 PA

GENOTROPIN MINIQUICk INJECTION 0.4MG, 0.6MG, 0.8MG, 1MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 2MG

5 PA

HUMATROPE INJECTION 5MG, 6MG, 12MG, 24MG 5 PA

HUMATROPE COMBO PACk 5 PA

INCRELEX 5 PA

NORDITROPIN FLEXPRO 5 PA

NORDITROPIN NORDIFLEX 5 PA

NUTROPIN 5 PA

NUTROPIN AQ 5 PA

OMNITROPE INJECTION 5MG/1.5ML, 10MG/1.5ML 4 PA

OMNITROPE INJECTION 5.8MG 5 PA

SAIzEN INJECTION 5MG, 8.8MG 5 PA

SAIzEN INJECTION CLICk.EASY 8.8MG 5 PA

SEROSTIM 5 PA

STIMATE 3

TEV-TROPIN 4 PA

zORBTIVE 5 PA

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

ALORA 4 PA

amethia 2 GC

amethyst 2 GC

ANADROL-50 5

ANDRODERM 3

ANDROGEL 3

ANDROGEL PUMP 3

ANDROXY 4

58




ANGELIQ 4 PA

apri 2 GC

aranelle 2 GC

aviane 2 GC

balziva 2 GC

briellyn 2 GC

camila 2 GC

CENESTIN 4 PA

CLIMARA PRO 4 QL (4 EA per 28 days) PA

COMBIPATCH 4 PA

cryselle 2 GC

cyclafem 2 GC

CYCLESSA 4

DEPO-ESTRADIOL 3

DEPO-PROVERA 3

DEPO-SUBQ PROVERA 104 3

DIVIGEL 4 PA

drospirenone/ethinyl estradiol 2 GC

ELLA 3

emoquette 2 GC

ENJUVIA 3 PA

enpresse 2 GC

errin 2 GC

ESTRACE CREAM 4

estradiol/norethindrone acetate 2 PA GC

estradiol tablet 2 PA GC

ESTRASORB 4 QL (97.44 GM per 28 days) PA

ESTRING 4

estropipate 2 PA GC

ESTROSTEP FE 4

EVISTA 3

59




FEMCON FE 4

FEMRING 4 QL (1 EA per 90 days)

GENERESS FE 3

gianvi 2 GC

gildagia 2 GC

introvale 2 GC

jinteli 2 PA GC

jolivette 2 GC

junel 2 GC

junel fe 2 GC

kariva 2 GC

kelnor 2 GC

leena 2 GC

lessina 2 GC

levonest 2 GC

levonorgestrel/ethinyl estradiol 2 GC

levora 2 GC

LOESTRIN 24 FE 4

loryna 2 GC

LOSEASONIQUE 4

low-ogestrel 2 GC

lutera 2 GC

MAkENA 5 PA

marlissa 2 GC

medroxyprogesterone acetate 2 GC

MEGACE ES 3 PA

MEGACE ORAL 4 PA

megestrol acetate suspension 2 PA GC

megestrol acetate tablet 2 PA GC

MENEST 4 PA

MENOSTAR 4 QL (4 EA per 28 days) PA

60




methitest 2 GC

microgestin 2 GC

microgestin fe 2 GC

mimvey 2 PA GC

mononessa 2 GC

necon 2 GC

NOR-QD 4

nora-be 2 GC

norethindrone acetate 2 GC

nortrel 2 GC

NUVARING 4

ocella 2 GC

ogestrel 2 GC

orsythia 2 GC

ORTHO EVRA 4

ORTHO TRI-CYCLEN LO 4

OXANDRIN 5

oxandrolone tablet 2.5mg 2 GC

oxandrolone tablet 10mg 5

PLAN B ONE-STEP 4

portia 2 GC

PREFEST 4 PA

PREMARIN CREAM 3

PREMARIN INJECTION 4

PREMARIN TABLET 4 PA

PREMPHASE 4 PA

PREMPRO 4 PA

previfem 2 GC

progesterone capsule 2 GC

quasense 2 GC

reclipsen 2 GC

61




SEASONIQUE 4

sprintec 2 GC

sronyx 2 GC

TESTIM 3

testosterone cypionate 2 GC

testosterone enanthate 2 GC

tri-legest fe 2 GC

tri-previfem 2 GC

tri-sprintec 2 GC

trinessa 2 GC

trivora 2 GC

VAGIFEM 4

velivet 2 GC

YAz 4

zenchent fe 2 GC

zovia 2 GC

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

ARMOUR THYROID 3 PA

LEVOTHROID 3

levothyroxine sodium tablet 2 GC

LEVOXYL 3

liothyronine sodium 2 GC

nature-throid 2 PA GC

nature-throid nt 2 PA GC

np thyroid 2 PA GC

SYNTHROID 4

THYROLAR 4

UNITHROID 3

westhroid 2 PA GC

westhroid-p 2 PA GC

62




Hormonal Agents, Suppressant (Adrenal)

LYSODREN 3

Hormonal Agents, Suppressant (Parathyroid)

SENSIPAR TABLET 30MG 3 QL (60 EA per 30 days)



Hormonal Agents, Suppressant (Pituitary)

cabergoline 2 GC

ELIGARD INJECTION 7.5MG 4 QL (1 EA per 30 days) PA

ELIGARD INJECTION 22.5MG 4 QL (1 EA per 90 days) PA

ELIGARD INJECTION 30MG 4 QL (1 EA per 120 days) PA

ELIGARD INJECTION 45MG 4 QL (1 EA per 180 days) PA

FIRMAGON 4 BvsD

leuprolide acetate 2 PA GC

LUPRON DEPOT 5 PA

LUPRON DEPOT-PED 5 PA

octreotide acetate injection 50mcg/ml, 100mcg/ml, 200mcg/ml 2 GC

octreotide acetate injection 1000mcg/ml, 500mcg/ml 5

SANDOSTATIN INJECTION 50MCG/ML 4

SANDOSTATIN INJECTION 100MCG/ML, 200MCG/ML, 500MCG/ML, 1000MCG/ML

5

SANDOSTATIN LAR DEPOT 5

SIGNIFOR 5

SOMATULINE DEPOT 5

SOMAVERT 5

SYNAREL 5 PA

TRELSTAR DEPOT 3.75MG 3 QL (1 EA per 28 days) PA

TRELSTAR LA 11.25MG 3 QL (1 EA per 84 days) PA

TRELSTAR 22.5MG 3 QL (1 EA per 168 days) PA

zOLADEX 4 PA

63




Hormonal Agents, Suppressant (Sex Hormones/Modifiers)

bicalutamide 2 GC

flutamide 2 GC

NILANDRON 4

XTANDI 5

Hormonal Agents, Suppressant (Thyroid)

methimazole 2 GC

propylthiouracil 2 GC

Immunological Agents

ACTEMRA 5 PA

ACTHIB 3

ACTIMMUNE 5

ADACEL 3

ARCALYST 5 PA RA

ATGAM 5

azathioprine 2 GC

azathioprine sodium 2 GC

BENLYSTA 5 PA

BOOSTRIX 3

CARIMUNE NF 5 PA

CELLCEPT CAPSULE 4 BvsD

CELLCEPT INTRAVENOUS 4 BvsD

CELLCEPT SUSPENSION, TABLET 5 BvsD

CERVARIX 3

COMVAX 3

CUPRIMINE 3

cyclosporine 2 BvsD GC

cyclosporine modified 2 BvsD GC

DAPTACEL 3

DEPEN TITRATABS 3

64




ENBREL 5 PA

ENBREL SURECLICk 5 PA

ENGERIX-B 3 BvsD

GAMASTAN S/D 3 PA

GAMMAGARD LIQUID 5 PA

GAMMAPLEX 5 PA

GAMUNEX-C 5 PA

GARDASIL 3

gengraf 2 BvsD GC

HAVRIX 3

HIzENTRA 5 PA

HUMIRA 5 PA

ILARIS 5 PA

IMOVAX RABIES (H.D.C.V.) 3

INFANRIX 3

IPOL INACTIVATED IPV 3

IXIARO 3

JE-VAX 3

leflunomide 2 GC

M-M-R II 3

MENACTRA 3

MENOMUNE-A/C/Y/W-135 3

MENVEO 3

methotrexate 2 GC

methotrexate sodium 2 GC

mycophenolate mofetil 2 BvsD GC

MYFORTIC 3 BvsD

NEORAL 4 BvsD

NULOJIX 5 BvsD

ORENCIA IV 250MG 5 PA

PEDIARIX 3

65




PEDVAX HIB 3

PRIVIGEN 5 PA

PROGRAF CAPSULE 0.5MG, 1MG 4 BvsD

PROGRAF CAPSULE 5MG 5 BvsD

PROGRAF INJECTION 4 BvsD

PROQUAD 3

RABAVERT 3

RAPAMUNE SOLUTION 5 BvsD

RAPAMUNE TABLET 0.5MG 4 BvsD

RAPAMUNE TABLET 1MG, 2MG 5 BvsD

RECOMBIVAX HB 3 BvsD

REMICADE 5 PA

RHEUMATREX 4

RIDAURA 5

ROTATEQ 3

SANDIMMUNE 3 BvsD

SIMULECT 5 BvsD

SYNAGIS 5 PA

tacrolimus 2 BvsD GC

tetanus toxoid adsorbed 2 GC

TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT 2 GC

THYMOGLOBULIN 5

TORISEL 5 BvsD

TREXALL 4

TWINRIX 3

TYPHIM VI 4

TYSABRI 5 PA RA

VAQTA 3

VARIVAX 3

YF-VAX 3

zORTRESS TABLET 0.25MG 4 BvsD

66




zORTRESS TABLET 0.5MG, 0.75MG 5 BvsD

zOSTAVAX 3

Inflammatory Bowel Disease Agents

APRISO 3

ASACOL 4 ST

ASACOL HD 4 ST

balsalazide disodium 2 GC

budesonide capsule er 3mg 2 GC

CANASA 3

colocort 2 GC

DIPENTUM 3

hydrocortisone enema 100mg/60ml 2 GC

LIALDA 3

mesalamine kit 2 GC

PENTASA 3

sulfasalazine tablet 2 GC

sulfazine ec 2 GC

Metabolic Bone Disease Agents

ACTONEL 4

alendronate sodium 2 GC

ATELVIA 4

BONIVA INJECTION 4 BvsD

calcitonin-salmon 2 BvsD GC

calcitriol 2 BvsD GC

etidronate disodium 2 GC

FORTEO 5

FORTICAL 2 BvsD GC

FOSAMAX PLUS D 4 QL (4 EA per 28 days) ST

HECTOROL 4 ST BvsD

ibandronate sodium 2 GC

MIACALCIN 4 BvsD

67




pamidronate disodium 2 BvsD GC

PROLIA 4

SkELID 4

XGEVA 5 PA

zEMPLAR 3 BvsD

zoledronic acid injection 4mg/5ml 5 PA

zoledronic acid injection 5mg/100ml 2 BvsD GC

zOMETA 5 PA

Miscellaneous Therapeutic Agents

BERINERT 5 PA

BOTOX 4 PA

CINRYzE 5 PA

DYSPORT 4 PA

FERRIPROX 5

FIRAzYR 5 PA

fomepizole 5

HORIzANT 4

kALBITOR 5 PA

kORLYM 5 QL (120 EA per 30 days) PA

LACTATED RINGERS IRRIGATION 3

levocarnitine 2 BvsD GC

methylergonovine maleate tablet 2 GC

PHYSIOLYTE 3 BvsD

PHYSIOSOL IRRIGATION 3 BvsD

RINGERS IRRIGATION 3

sodium chloride 0.9% irrigation 2 GC

sterile water irrigation 2 GC

XEOMIN 4 PA

Ophthalmic Agents

acetazolamide 2 GC

acetazolamide er 2 GC

68




ALOCRIL 4

ALOMIDE 4

ALPHAGAN P SOLUTION 0.1% 3

apraclonidine 2 GC

azelastine hcl ophthalmic solution 0.05% 2 GC

AzOPT 3

betaxolol hcl solution 0.5% 2 GC

BETIMOL 4

BETOPTIC-S 3

BLEPHAMIDE 4

BLEPHAMIDE S.O.P. 4

brimonidine tartrate 2 GC

bromfenac 2 GC

carteolol hcl 2 GC

COMBIGAN 3

COSOPT 4

cromolyn sodium solution 4% 2 GC

CYSTARAN 5

dexamethasone sodium phosphate solution 0.1% 2 GC

diclofenac sodium 2 GC

dorzolamide hcl 2 GC

dorzolamide hcl/timolol maleate 2 GC

DUREzOL 3

EMADINE 4

epinastine hcl 2 GC

FLAREX 4

fluorometholone 2 GC

flurbiprofen sodium 2 GC

FML 4

FML FORTE 4

ILEVRO 3

69




IOPIDINE 4

isopto carpine 2 GC

ISTALOL 4

ketorolac tromethamine ophthalmic solution 0.4%, 0.5% 2 GC

LACRISERT 4

latanoprost 2 GC

levobunolol hcl 2 GC

LOTEMAX 4

LUMIGAN 3 QL (2.5 ML per 28 days)

MAXIDEX 4

metipranolol 2 GC

naphazoline hcl rx 2 GC

neomycin/polymyxin/dexamethasone 2 GC

NEVANAC 3

OCUFEN 4

OPTIVAR 4

PATADAY 3

PATANOL 4 ST

PHOSPHOLINE IODIDE 4

pilocarpine hcl solution 1%, 2%, 4% 2 GC

PILOPINE HS 4

PRED MILD 4

PRED-G 3

PRED-G S.O.P. 3

prednisolone acetate 2 GC

prednisolone sodium phosphate ophthalmic solution 1% 2 GC

proparacaine hcl 2 GC

RESTASIS 3

SIMBRINzA 3

sulfacetamide sodium/prednisolone sodium phosphate 2 GC

timolol maleate gel 2 GC

70




timolol maleate solution 2 GC

TOBRADEX OINTMENT 4

TOBRADEX ST 4

tobramycin/dexamethasone 2 GC

TRAVATAN z 3 QL (2.5 ML per 28 days)

travoprost 2 QL (2.5 ML per 28 days) GC

TRUSOPT 4

VEXOL 4

zYLET 4

Otic Agents

acetasol hc 2 GC

acetic acid 2 GC

COLY-MYCIN S 4

CORTISPORIN-TC 4

DERMOTIC 4

hydrocortisone/acetic acid 2 GC

neomycin/polymyxin/hc 2 GC

Respiratory Tract Agents

acetylcysteine solution 2 BvsD GC

ADCIRCA 5 QL (60 EA per 30 days) PA

ADVAIR DISkUS 3

ADVAIR HFA 3

albuterol sulfate er 2 GC

albuterol sulfate inhalation solution 2 BvsD GC

albuterol sulfate syrup, tablet 2 GC

ALVESCO 4

aminophylline 2 GC

ARALAST NP 5 PA

ARCAPTA NEOHALER 4

ASMANEX 3

ASTEPRO 3

71




ATROVENT HFA 4 ST

AUVI-Q 4 QL (2 EA per 1 day)

azelastine hcl nasal solution 137mcg/spray 2 GC

BROVANA 4 BvsD

budesonide suspension 0.25mg/2ml, 0.5mg/2ml 2 BvsD GC

carbinoxamine maleate 2 PA GC

CLARINEX-D 12 HOUR 4 QL (60 EA per 30 days)

CLARINEX-D 24 HOUR 4 QL (30 EA per 30 days)

clemastine fumarate tablet 2.68mg 2 PA GC

COMBIVENT RESPIMAT 3

cromolyn sodium inhalation solution 20mg/2ml 2 BvsD GC

cyproheptadine hcl 2 PA GC

DALIRESP 3

desloratadine 2 QL (30 EA per 30 days) GC

desloratadine odt 2 QL (30 EA per 30 days) GC

dexchlorpheniramine maleate 2 PA GC

diphenhydramine hcl capsule 50mg 2 PA GC

diphenhydramine hcl injection 2 PA GC

DULERA 4

DYMISTA 3

ELIXOPHYLLIN 4

EPIPEN 3 QL (2 EA per 1 day)

EPIPEN-JR 3 QL (2 EA per 1 day)

FLOVENT DISkUS 3

FLOVENT HFA 3

flunisolide solution 29mcg/act 2 GC

fluticasone propionate suspension 50mcg/act 2 GC

FORADIL AEROLIzER 3

GLASSIA 5 PA

hydroxyzine hcl 2 PA GC

hydroxyzine pamoate 2 PA GC

72




ipratropium bromide inhalation solution 2 BvsD GC

ipratropium bromide nasal solution 2 GC

ipratropium bromide/albuterol sulfate inhalation solution 2 BvsD GC

kALYDECO 5 QL (60 EA per 30 days) PA

LETAIRIS 5

levalbuterol hcl inhalation solution 2 BvsD GC

levocetirizine dihydrochloride solution 2 QL (300 ML per 30 days) GC

levocetirizine dihydrochloride tablet 2 QL (30 EA per 30 days) GC

LUFYLLIN 4

metaproterenol sulfate 2 GC

montelukast sodium 2 GC

NASONEX 4 ST

OMNARIS 3

palgic liquid 2 PA GC

PERFOROMIST 4 BvsD

PROAIR HFA 3

PROLASTIN-C 5 PA

promethazine hcl injection 25mg/ml, 50mg/ml 2 PA GC

promethazine hcl syrup 6.25mg/5ml 2 PA GC

promethazine hcl tablet 12.5mg, 25mg, 50mg 2 PA GC

promethazine vc 2 PA GC

PROVENTIL HFA 4

PULMICORT INHALATION SUSPENSION 4 BvsD

PULMICORT FLEXHALER 4 ST

PULMOzYME 5 BvsD

QVAR 3

REMODULIN 5 BvsD

SEMPREX-D 4

SEREVENT DISkUS 3

sildenafil citrate tablet 20mg 2 PA GC

SPIRIVA HANDIHALER 3

73




SYMBICORT 3

terbutaline sulfate 2 GC

THEO-24 CAPSULE ER 3

theochron 2 GC

theophylline cr 2 GC

theophylline er 2 GC

TRACLEER 5 RA

triamcinolone acetonide inhaler 55mcg/act 2 GC

TUDORzA PRESSAIR 3

TYVASO 5 BvsD

TYzINE 4

TYzINE PEDIATRIC 4

VENTAVIS 5 PA

VERAMYST 3

VIRAzOLE 5 BvsD

XOLAIR 5 PA

XOPENEX 4 BvsD

XOPENEX CONCENTRATE 4 BvsD

XOPENEX HFA 4

zafirlukast 2 GC

zEMAIRA 5 PA

zETONNA 3

Skeletal Muscle Relaxants

carisoprodol tablet 350mg 2 PA GC

carisoprodol/aspirin 2 PA GC

carisoprodol/aspirin/codeine 2 PA GC

chlorzoxazone 2 PA GC

cyclobenzaprine hcl tablet 5mg, 10mg 2 PA GC

metaxalone 2 PA GC

methocarbamol 2 PA GC

orphenadrine citrate 2 PA GC

74




orphenadrine citrate er 2 PA GC

orphenadrine/asa/caffeine 2 PA GC

Sleep Disorder Agents

LUNESTA 4 PA

modafinil tablet 100mg 2 QL (30 EA per 30 days) PA GC

modafinil tablet 200mg 2 QL (60 EA per 30 days) PA GC

PROVIGIL TABLET 100MG 4 QL (30 EA per 30 days) PA

PROVIGIL TABLET 200MG 4 QL (60 EA per 30 days) PA

SILENOR 4 QL (30 EA per 30 days)

temazepam 2 QL (30 EA per 30 days) GC

XYREM 5 RA

zaleplon 2 QL (60 EA per 30 days) PA GC

zolpidem tartrate tablet 5mg 2 QL (60 EA per 30 days) PA GC

zolpidem tartrate tablet 10mg 2 QL (30 EA per 30 days) PA GC

Therapeutic Nutrients/Minerals/Electrolytes

AMINOSYN 3 BvsD

AMINOSYN II 3 BvsD

AMINOSYN M 3 BvsD

AMINOSYN-HBC 3 BvsD

AMINOSYN-PF 3 BvsD

ammonium chloride 2 GC

CARBAGLU 5

CHEMET 4

CLINIMIX 3 BvsD

CLINIMIX E 3 BvsD

CLINISOL SF 15% 3 BvsD

dextrose 2 BvsD GC

DEXTROSE 5%/LACTATED RINGERS 3 BvsD

dextrose/nacl 2 BvsD GC

dextrose/potassium chloride 2 BvsD GC

EXJADE 5

75




FREAMINE HBC 3 BvsD

FREAMINE III 3 BvsD

HEPATAMINE 3 BvsD

HEPATASOL 3 BvsD

INTRALIPID 3 BvsD

IONOSOL-B/DEXTROSE 5% 3 BvsD

IONOSOL-MB/DEXTROSE 5% 3 BvsD

ISOLYTE-M/DEXTROSE 5% 3 BvsD

ISOLYTE-P/DEXTROSE 5% 3 BvsD

ISOLYTE-S 3 BvsD

k-TABS 2 GC

kCL/D5W/LR 3 BvsD

kCL/D5W/NACL 3 BvsD

kionex powder 2 GC

klor-con 2 GC

klor-con m 2 GC

LACTATED RINGERS VIAFLEX 3

LIPOSYN II 3 BvsD

LIPOSYN III 3 BvsD

magnesium sulfate injection 2 BvsD GC

NEPHRAMINE 3 BvsD

NORMOSOL-M IN D5W 3 BvsD

NORMOSOL-R 3 BvsD

NORMOSOL-R IN D5W 3 BvsD

PLASMA-LYTE A 3 BvsD

PLASMA-LYTE-148 3 BvsD

PLASMA-LYTE-56/D5W 3 BvsD

potassium chloride er 2 GC

potassium chloride injection 2 BvsD GC

potassium chloride sr 2 GC

potassium chloride/d5w 2 BvsD GC

76




potassium chloride/d5w/nacl 2 BvsD GC

potassium chloride/nacl 2 BvsD GC

potassium citrate tablet er 2 GC

PREMASOL 3 BvsD

PRENATAL TABLET 3

PROCALAMINE 3 BvsD

PROSOL 4 BvsD

RINGERS INJECTION 3

SAMSCA TABLET 15MG 5 QL (90 EA per 30 days)

SAMSCA TABLET 30MG 5 QL (60 EA per 30 days)

sodium chloride injection 2 BvsD GC

sodium fluoride tablet 2 GC

SODIUM LACTATE 3 BvsD

sodium polystyrene sulfonate suspension 2 GC

SYPRINE 3

TPN ELECTROLYTES 3 BvsD

TRAVASOL 4 BvsD

TROPHAMINE 3 BvsD

UROCIT-k 15 4

77

Drug Page Drug Page Drug Page


Covered Drugs Index

8-MOP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

Aabacavir . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

ABILIFY DISCMELT . . . . . . . . . . . . . . . . .32

ABILIFY INJECTION . . . . . . . . . . . . . . . .32

ABILIFY MAINTENA . . . . . . . . . . . . . . . .32

ABILIFY ORAL SOLUTION . . . . . . . . .32

ABILIFY TABLET . . . . . . . . . . . . . . . . . . . .32

ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . . .26

acarbose. . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

acebutolol hcl . . . . . . . . . . . . . . . . . . . . . . .41

acetaminophen/codeine solution. . . 7

acetaminophen/codeine tablet 300mg/15mg, 300mg/30mg . . . . . . . . 7

acetaminophen/codeine tablet 300mg/60mg . . . . . . . . . . . . . . . . . . . . . . . . 7

acetasol hc . . . . . . . . . . . . . . . . . . . . . . . . . .70

acetazolamide . . . . . . . . . . . . . . . . . . . . . .67

acetazolamide er. . . . . . . . . . . . . . . . . . . .67

acetazolamide sodium . . . . . . . . . . . . .41

acetic acid . . . . . . . . . . . . . . . . . . . . . . . . . . .70

acetylcysteine solution. . . . . . . . . . . . . .70

ACIPHEX . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

ACTEMRA . . . . . . . . . . . . . . . . . . . . . . . . . . .63

ACTHAR HP . . . . . . . . . . . . . . . . . . . . . . . . .56

ACTHIB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . . .63

ACTONEL . . . . . . . . . . . . . . . . . . . . . . . . . . .66

acyclovir . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

acyclovir sodium injection 500mg . .34

ADACEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

ADAGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

adapalene . . . . . . . . . . . . . . . . . . . . . . . . . . .49

ADCIRCA . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

ADRIAMYCIN . . . . . . . . . . . . . . . . . . . . . . .26

ADVAIR DISkUS . . . . . . . . . . . . . . . . . . . .70

ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . . .70

ADVICOR . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

afeditab cr . . . . . . . . . . . . . . . . . . . . . . . . . . .41

AFINITOR TABLET 2.5MG, 5MG, 7.5MG . . . . . . . . . . . . . . . . . . . . . . . .26

AFINITOR TABLET 10MG . . . . . . . . . .26

AGGRENOX . . . . . . . . . . . . . . . . . . . . . . . . .39

a-hydrocort. . . . . . . . . . . . . . . . . . . . . . . . . .54

AkNE-MYCIN . . . . . . . . . . . . . . . . . . . . . . .12

ala cort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

ala scalp . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

ALBENzA . . . . . . . . . . . . . . . . . . . . . . . . . . .31

albuterol sulfate er . . . . . . . . . . . . . . . . . .70

albuterol sulfate inhalation solution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

albuterol sulfate syrup, tablet . . . . . .70

alclometasone dipropionate . . . . . . .54

ALCOHOL PREP PADS . . . . . . . . . . . . .37

ALDURAzYME . . . . . . . . . . . . . . . . . . . . . .51

alendronate sodium . . . . . . . . . . . . . . . .66

alfuzosin hcl er . . . . . . . . . . . . . . . . . . . . . .53

ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

ALINIA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

ALkERAN INJECTION . . . . . . . . . . . . . .26

allopurinol. . . . . . . . . . . . . . . . . . . . . . . . . . .24

allopurinol sodium. . . . . . . . . . . . . . . . . .24

ALOCRIL. . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

ALOMIDE . . . . . . . . . . . . . . . . . . . . . . . . . . .68

ALOPRIM . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

ALOXI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

ALPHAGAN P SOLUTION 0.1% . . .68

alprazolam er tablet 0.5mg, 1mg, 2mg, 3mg . . . . . . . . . . . . . . . . . . . . .36

alprazolam intensol. . . . . . . . . . . . . . . . .36

alprazolam odt 0.25mg, 0.5mg, 1mg. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

alprazolam odt 2mg . . . . . . . . . . . . . . . .36

alprazolam tablet 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . . . . . . . . . . .36

alprazolam tablet 2mg . . . . . . . . . . . . .36

ALTABAX . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

ALVESCO . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

amantadine hcl . . . . . . . . . . . . . . . . . . . . .34

AMBISOME . . . . . . . . . . . . . . . . . . . . . . . . .23

amcinonide . . . . . . . . . . . . . . . . . . . . . . . . .54

a-methapred . . . . . . . . . . . . . . . . . . . . . . . .54

amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

amethyst . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

amifostine . . . . . . . . . . . . . . . . . . . . . . . . . . .26

amikacin sulfate . . . . . . . . . . . . . . . . . . . .12

amiloride hcl . . . . . . . . . . . . . . . . . . . . . . . .41

amiloride/hctz . . . . . . . . . . . . . . . . . . . . . .41

aminocaproic acid tablet . . . . . . . . . . .39

aminophylline. . . . . . . . . . . . . . . . . . . . . . .70

AMINOSYN . . . . . . . . . . . . . . . . . . . . . . . . .74

AMINOSYN-HBC . . . . . . . . . . . . . . . . . . .74

78



CoveredDrugsIndex

AMINOSYN II . . . . . . . . . . . . . . . . . . . . . . .74

AMINOSYN M . . . . . . . . . . . . . . . . . . . . . .74

AMINOSYN-PF . . . . . . . . . . . . . . . . . . . . .74

amiodarone hcl . . . . . . . . . . . . . . . . . . . . .41

AMITIzA . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

amitriptyline hcl. . . . . . . . . . . . . . . . . . . . .20

amlodipine besylate/atorvastatin calcium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

amlodipine besylate/ benazepril hcl . . . . . . . . . . . . . . . . . . . . . . .41

amlodipine besylate tablet 2.5mg .41

amlodipine besylate tablet 5mg , 10mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

ammonium chloride . . . . . . . . . . . . . . . .74

ammonium lactate rx. . . . . . . . . . . . . . .49

amnesteem. . . . . . . . . . . . . . . . . . . . . . . . . .49

amoxapine . . . . . . . . . . . . . . . . . . . . . . . . . .20

amoxicillin. . . . . . . . . . . . . . . . . . . . . . . . . . .12

amoxicillin/potassium clavulanate. . . . . . . . . . . . . . . . . . . . . . . . . .12

amphetamine/dextroamphetamine capsule er 5mg, 10mg, 15mg. . . . . . .48

amphetamine/dextroamphetamine capsule er 20mg, 25mg, 30mg . . . . .48

amphetamine/dextroamphetamine tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

amphotericin b. . . . . . . . . . . . . . . . . . . . . .23

ampicillin. . . . . . . . . . . . . . . . . . . . . . . . . . . .12

ampicillin sodium . . . . . . . . . . . . . . . . . .12

ampicillin-sulbactam . . . . . . . . . . . . . . .12

AMPYRA . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

AMTURNIDE . . . . . . . . . . . . . . . . . . . . . . . .41

ANADROL-50 . . . . . . . . . . . . . . . . . . . . . . .57

anagrelide hcl . . . . . . . . . . . . . . . . . . . . . . .39

anastrozole. . . . . . . . . . . . . . . . . . . . . . . . . .26

ANCOBON . . . . . . . . . . . . . . . . . . . . . . . . . .23

ANDRODERM. . . . . . . . . . . . . . . . . . . . . . .57

ANDROGEL . . . . . . . . . . . . . . . . . . . . . . . . .57

ANDROGEL PUMP . . . . . . . . . . . . . . . . .57

ANDROXY. . . . . . . . . . . . . . . . . . . . . . . . . . .57

ANGELIQ . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

ANzEMET INJECTION . . . . . . . . . . . . .22

ANzEMET TABLET. . . . . . . . . . . . . . . . . .22

APLENzIN. . . . . . . . . . . . . . . . . . . . . . . . . . .20

APOkYN. . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

apraclonidine . . . . . . . . . . . . . . . . . . . . . . .68

apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

APRISO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

APTIVUS . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

ARALAST NP. . . . . . . . . . . . . . . . . . . . . . . .70

aranelle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

ARANESP 25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML, 60MCG/0.3ML, 60MCG/ML . . . . . . . . . . . . . . . . . . . . . . . . .39

ARANESP 100MCG/0.5ML, 100MCG/ML, 150MCG/0.3ML, 150MCG/0.75ML, 200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML . . . . . . . .39

ARCALYST. . . . . . . . . . . . . . . . . . . . . . . . . . .63

ARCAPTA NEOHALER. . . . . . . . . . . . . .70

ARISTOSPAN INTRA-ARTICULAR. . . . . . . . . . . . . . . . .54

ARISTOSPAN INTRALESIONAL. . . .54

ARMOUR THYROID . . . . . . . . . . . . . . . .61

ARRANON . . . . . . . . . . . . . . . . . . . . . . . . . .26

ARTHROTEC . . . . . . . . . . . . . . . . . . . . . . . .11

ARzERRA. . . . . . . . . . . . . . . . . . . . . . . . . . . .26

ASACOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

ASACOL HD . . . . . . . . . . . . . . . . . . . . . . . . .66

ascomp/codeine . . . . . . . . . . . . . . . . . . . . . 7

ASMANEX . . . . . . . . . . . . . . . . . . . . . . . . . .70

ASTEPRO . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

astramorph. . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ATACAND . . . . . . . . . . . . . . . . . . . . . . . . . . .41

ATACAND HCT . . . . . . . . . . . . . . . . . . . . .41

ATELVIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

atenolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

atenolol/chlorthalidone . . . . . . . . . . . .41

ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

atorvastatin calcium. . . . . . . . . . . . . . . .41

atovaquone/proguanil hcl . . . . . . . . .31

ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

atropine sulfate . . . . . . . . . . . . . . . . . . . . .51

ATROVENT HFA . . . . . . . . . . . . . . . . . . . .71

AUBAGIO . . . . . . . . . . . . . . . . . . . . . . . . . . .48

augmented betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . .54

AUVI-Q . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71

AVANDIA TABLET 2MG, 4MG . . . . .37

AVANDIA TABLET 8MG . . . . . . . . . . . .37

AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

AVELOX INJECTION . . . . . . . . . . . . . . . .13

AVELOX TABLET . . . . . . . . . . . . . . . . . . . .13

aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

AVINzA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

AVODART . . . . . . . . . . . . . . . . . . . . . . . . . . .53

79



Covered Drugs Index

AVONEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

AXERT TABLET 6.25MG . . . . . . . . . . . .25

AXERT TABLET 12.5MG . . . . . . . . . . . .25

AzACTAM 1GM, 2GM . . . . . . . . . . . . . .13

AzACTAM IN ISO-OSMOTIC DEXTROSE 1GM . . . . . . . . . . . . . . . . . . . .13

AzACTAM IN ISO-OSMOTIC DEXTROSE 2GM . . . . . . . . . . . . . . . . . . . .13

AzASITE . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

azathioprine. . . . . . . . . . . . . . . . . . . . . . . . .63

azathioprine sodium. . . . . . . . . . . . . . . .63

azelastine hcl nasal solution 137mcg/spray. . . . . . . . . . . . . . . . . . . . . . .71

azelastine hcl ophthalmic solution 0.05% . . . . . . . . . . . . . . . . . . . . . .68

AzELEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

AzILECT . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

azithromycin . . . . . . . . . . . . . . . . . . . . . . . .13

AzOPT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

aztreonam . . . . . . . . . . . . . . . . . . . . . . . . . .13

Bbaciim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

bacitracin. . . . . . . . . . . . . . . . . . . . . . . . . . . .13

bacitracin/polymyxin b . . . . . . . . . . . . .13

baclofen . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

bactocill in dextrose. . . . . . . . . . . . . . . . .13

balsalazide disodium . . . . . . . . . . . . . . .66

balziva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

BANzEL SUSPENSION . . . . . . . . . . . . .18

BANzEL TABLET 200MG . . . . . . . . . . .18

BANzEL TABLET 400MG . . . . . . . . . . .18

BARACLUDE . . . . . . . . . . . . . . . . . . . . . . . .34

BD INSULIN SYRINGE . . . . . . . . . . . . .37

BD PEN NEEDLE . . . . . . . . . . . . . . . . . . . .37

benazepril hcl . . . . . . . . . . . . . . . . . . . . . . .41

benazepril hcl/hctz. . . . . . . . . . . . . . . . . .41

BENICAR . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

BENICAR HCT. . . . . . . . . . . . . . . . . . . . . . .42

BENLYSTA . . . . . . . . . . . . . . . . . . . . . . . . . . .63

benztropine mesylate injection . . . .31

benztropine mesylate tablet. . . . . . . .31

BERINERT . . . . . . . . . . . . . . . . . . . . . . . . . . .67

betamethasone dipropionate . . . . . .54

betamethasone valerate. . . . . . . . . . . .54

betaxolol hcl solution 0.5%. . . . . . . . .68

betaxolol hcl tablet 10mg, 20mg. . .42

bethanechol chloride . . . . . . . . . . . . . . .53

BETIMOL . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

BETOPTIC-S . . . . . . . . . . . . . . . . . . . . . . . . .68

bicalutamide . . . . . . . . . . . . . . . . . . . . . . . .63

BICILLIN C-R . . . . . . . . . . . . . . . . . . . . . . . .13

BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . . .13

BICNU . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

bisoprolol fumarate. . . . . . . . . . . . . . . . .42

bisoprolol fumarate/hctz . . . . . . . . . . .42

bleomycin sulfate . . . . . . . . . . . . . . . . . . .26

BLEPH-10 . . . . . . . . . . . . . . . . . . . . . . . . . . .13

BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . . .68

BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . . .68

BONIVA INJECTION . . . . . . . . . . . . . . . .66

BOOSTRIX . . . . . . . . . . . . . . . . . . . . . . . . . .63

BOSULIF . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

BOTOX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

briellyn. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

brimonidine tartrate . . . . . . . . . . . . . . . .68

bromfenac. . . . . . . . . . . . . . . . . . . . . . . . . . .68

bromocriptine mesylate . . . . . . . . . . . .31

BROVANA . . . . . . . . . . . . . . . . . . . . . . . . . . .71

budeprion sr tablet 100mg . . . . . . . . .20

budeprion sr tablet 150mg . . . . . . . . .20

budesonide capsule er 3mg . . . . . . . .66

budesonide suspension 0.25mg/2ml, 0.5mg/2ml. . . . . . . . . . . .71

bumetanide . . . . . . . . . . . . . . . . . . . . . . . . .42

BUPHENYL . . . . . . . . . . . . . . . . . . . . . . . . . .51

BUPRENEX . . . . . . . . . . . . . . . . . . . . . . . . . .11

buprenorphine hcl injection . . . . . . . .11

buprenorphine hcl/naloxone hcl . . .11

buprenorphine hcl tablet sublingual . . . . . . . . . . . . . . . . . . . . . . . . . . .11

buproban. . . . . . . . . . . . . . . . . . . . . . . . . . . .11

bupropion hcl . . . . . . . . . . . . . . . . . . . . . . .20

bupropion hcl sr tablet 100mg, 200mg . . . . . . . . . . . . . . . . . . . . . .20

bupropion hcl sr tablet 150mg . . . . .20

bupropion hcl xl tablet 150mg . . . . .20

bupropion hcl xl tablet 300mg . . . . .20

buspirone hcl . . . . . . . . . . . . . . . . . . . . . . . .36

BUSULFEX . . . . . . . . . . . . . . . . . . . . . . . . . .26

butalbital/acetaminophen/ caffeine/codeine . . . . . . . . . . . . . . . . . . . . . 7

butorphanol tartrate injection . . . . . . 7

butorphanol tartrate nasal solution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

80



CoveredDrugsIndex

BUTRANS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

BYDUREON . . . . . . . . . . . . . . . . . . . . . . . . .37

BYETTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

BYSTOLIC TABLET 2.5MG, 5MG . . .42

BYSTOLIC TABLET 10MG . . . . . . . . . .42

BYSTOLIC TABLET 20MG . . . . . . . . . .42

Ccabergoline. . . . . . . . . . . . . . . . . . . . . . . . . .62

calcipotriene . . . . . . . . . . . . . . . . . . . . . . . .49

calcitonin-salmon. . . . . . . . . . . . . . . . . . .66

calcitriol . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

calcium acetate capsule . . . . . . . . . . . .53

CAMBIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

CAMPRAL . . . . . . . . . . . . . . . . . . . . . . . . . . .11

CAMPTOSAR . . . . . . . . . . . . . . . . . . . . . . .27

CANASA. . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

CANCIDAS . . . . . . . . . . . . . . . . . . . . . . . . . .23

candesartan cilexetil/hctz . . . . . . . . . .42

CANTIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

CAPASTAT SULFATE . . . . . . . . . . . . . . . .26

CAPITAL/CODEINE . . . . . . . . . . . . . . . . . . 8

CAPRELSA . . . . . . . . . . . . . . . . . . . . . . . . . .27

captopril . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

captopril/hctz . . . . . . . . . . . . . . . . . . . . . . .42

CARAC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

CARAFATE SUSPENSION . . . . . . . . . .52

CARBAGLU. . . . . . . . . . . . . . . . . . . . . . . . . .74

carbamazepine . . . . . . . . . . . . . . . . . . . . .18

carbamazepine er. . . . . . . . . . . . . . . . . . .18

CARBATROL . . . . . . . . . . . . . . . . . . . . . . . .18

carbidopa/levodopa . . . . . . . . . . . . . . . .31

carbidopa/levodopa er . . . . . . . . . . . . .32

carbidopa/levodopa odt. . . . . . . . . . . .32

carbinoxamine maleate . . . . . . . . . . . .71

carboplatin . . . . . . . . . . . . . . . . . . . . . . . . . .27

CARIMUNE NF . . . . . . . . . . . . . . . . . . . . . .63

carisoprodol/aspirin . . . . . . . . . . . . . . . .73

carisoprodol/aspirin/codeine. . . . . . .73

carisoprodol tablet 350mg . . . . . . . . .73

carteolol hcl . . . . . . . . . . . . . . . . . . . . . . . . .68

cartia xt. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . . . .13

CEDAX CAPSULE . . . . . . . . . . . . . . . . . . .13

CEENU. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

cefaclor & cefaclor er . . . . . . . . . . . . . . .13

cefadroxil . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

cefazolin sodium . . . . . . . . . . . . . . . . . . . .13

cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

cefepime. . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

cefotaxime sodium. . . . . . . . . . . . . . . . . .13

cefotetan . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

cefoxitin sodium . . . . . . . . . . . . . . . . . . . .13

cefpodoxime proxetil. . . . . . . . . . . . . . . .13

cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . .13

ceftriaxone sodium . . . . . . . . . . . . . . . . .13

cefuroxime axetil . . . . . . . . . . . . . . . . . . . .13

cefuroxime sodium. . . . . . . . . . . . . . . . . .13

CELEBREX . . . . . . . . . . . . . . . . . . . . . . . . . . .11

CELESTONE . . . . . . . . . . . . . . . . . . . . . . . . .54

CELLCEPT CAPSULE . . . . . . . . . . . . . . .63

CELLCEPT INTRAVENOUS . . . . . . . . .63

CELLCEPT SUSPENSION, TABLET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

CELONTIN. . . . . . . . . . . . . . . . . . . . . . . . . . .18

CENESTIN . . . . . . . . . . . . . . . . . . . . . . . . . . .58

cephalexin. . . . . . . . . . . . . . . . . . . . . . . . . . .14

CEREzYME . . . . . . . . . . . . . . . . . . . . . . . . . .51

CERUBIDINE . . . . . . . . . . . . . . . . . . . . . . . .27

CERVARIX . . . . . . . . . . . . . . . . . . . . . . . . . . .63

CESAMET . . . . . . . . . . . . . . . . . . . . . . . . . . .22

cevimeline hcl . . . . . . . . . . . . . . . . . . . . . . .49

CHANTIX TABLET 0.5MG, 1MG . . .11

CHANTIX TABLET STARTING MONTH . . . . . . . . . . . . . . . .11

CHEMET . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

CHENODAL . . . . . . . . . . . . . . . . . . . . . . . . .52

chloramphenicol sodium succinate . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

chlordiazepoxide/amitriptyline . . . .21

chlorhexidine gluconate oral rinse. . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

chloroquine phosphate . . . . . . . . . . . . .31

chlorothiazide. . . . . . . . . . . . . . . . . . . . . . .42

chlorothiazide sodium . . . . . . . . . . . . . .42

chlorpromazine hcl injection, tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

chlorpropamide . . . . . . . . . . . . . . . . . . . . .37

chlorthalidone . . . . . . . . . . . . . . . . . . . . . .42

chlorzoxazone. . . . . . . . . . . . . . . . . . . . . . .73

cholestyramine light packet . . . . . . . .42

CIALIS TABLET 2.5MG, 5MG . . . . . . .53

ciclopirox . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

ciclopirox nail lacquer . . . . . . . . . . . . . .23

81



Covered Drugs Index

ciclopirox olamine . . . . . . . . . . . . . . . . . .23

cidofovir . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

CILOXAN OINTMENT . . . . . . . . . . . . . .14

cimetidine . . . . . . . . . . . . . . . . . . . . . . . . . . .52

cimetidine hcl . . . . . . . . . . . . . . . . . . . . . . .52

CINRYzE . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . . . .14

ciprofloxacin er. . . . . . . . . . . . . . . . . . . . . .14

ciprofloxacin hcl. . . . . . . . . . . . . . . . . . . . .14

ciprofloxacin i.v. . . . . . . . . . . . . . . . . . . . . .14

CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . . . . .14

CIPRO I.V. . . . . . . . . . . . . . . . . . . . . . . . . . . .14

cisplatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

citalopram hydrobromide solution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

citalopram hydrobromide tablet 10mg, 20mg. . . . . . . . . . . . . . . . . . . . . . . . .21

citalopram hydrobromide tablet 40mg . . . . . . . . . . . . . . . . . . . . . . . . .21

cladribine. . . . . . . . . . . . . . . . . . . . . . . . . . . .27

CLAFORAN . . . . . . . . . . . . . . . . . . . . . . . . .14

claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

CLARINEX-D 12 HOUR. . . . . . . . . . . . .71

CLARINEX-D 24 HOUR. . . . . . . . . . . . .71

clarithromycin. . . . . . . . . . . . . . . . . . . . . . .14

clarithromycin er . . . . . . . . . . . . . . . . . . . .14

clemastine fumarate tablet 2.68mg . . . . . . . . . . . . . . . . . . . . . . .71

CLIMARA PRO . . . . . . . . . . . . . . . . . . . . . .58

CLINDAGEL . . . . . . . . . . . . . . . . . . . . . . . . .49

clindamycin/benzoyl peroxide gel 5%/1%. . . . . . . . . . . . . . . . . . . . . . . . . . .50

clindamycin hcl . . . . . . . . . . . . . . . . . . . . .14

clindamycin phosphate . . . . . . . . . . . .14

clindamycin phosphate foam 1% . .49

clindamycin phosphate gel 1%. . . . .49

clindamycin phosphate lotion 1% . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

clindamycin phosphate solution 1%. . . . . . . . . . . . . . . . . . . . . . . . . .50

clindamycin phosphate swab 1% . .50

CLINIMIX . . . . . . . . . . . . . . . . . . . . . . . . . . .74

CLINIMIX E . . . . . . . . . . . . . . . . . . . . . . . . .74

CLINISOL SF 15% . . . . . . . . . . . . . . . . . .74

clobetasol propionate e cream . . . . .54

clobetasol propionate foam, gel, lotion, ointment, shampoo, solution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

CLODERM PUMP . . . . . . . . . . . . . . . . . . .54

CLOLAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

clomipramine hcl . . . . . . . . . . . . . . . . . . .21

clonazepam odt 0.125mg, 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . .18

clonazepam odt 2mg . . . . . . . . . . . . . . .18

clonazepam tablet 0.5mg, 1mg . . . .18

clonazepam tablet 2mg . . . . . . . . . . . .18

clonidine hcl patch weekly 0.1mg/24hr, 0.2mg/24hr . . . . . . . . . . .42

clonidine hcl patch weekly 0.3mg/24hr. . . . . . . . . . . . . . . . . . . . . . . . . .42

clonidine hcl tablet. . . . . . . . . . . . . . . . . .42

clopidogrel tablet 75mg . . . . . . . . . . . .39

clopidogrel tablet 300mg. . . . . . . . . . .39

clorazepate dipotassium tablet 3.75mg, 7.5mg . . . . . . . . . . . . . . . . . . . . . .18

clorazepate dipotassium tablet 15mg . . . . . . . . . . . . . . . . . . . . . . . . .18

clorpres . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

clotrimazole/betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . .23

clotrimazole rx . . . . . . . . . . . . . . . . . . . . . .23

clozapine . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

COARTEM . . . . . . . . . . . . . . . . . . . . . . . . . . .31

codeine sulfate tablet 15mg . . . . . . . . . 8



co-gesic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

COLCRYS . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

colestipol hcl . . . . . . . . . . . . . . . . . . . . . . . .42

colistimethate sodium . . . . . . . . . . . . . .14

colocort. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

COLY-MYCIN M . . . . . . . . . . . . . . . . . . . . .14

COLY-MYCIN S. . . . . . . . . . . . . . . . . . . . . .70

COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . . .68

COMBIPATCH . . . . . . . . . . . . . . . . . . . . . . .58

COMBIVENT RESPIMAT. . . . . . . . . . . .71

COMETRIQ . . . . . . . . . . . . . . . . . . . . . . . . . .27

COMPLERA . . . . . . . . . . . . . . . . . . . . . . . . .34

compro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

COMVAX . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

CONDYLOX GEL . . . . . . . . . . . . . . . . . . . .50

constulose . . . . . . . . . . . . . . . . . . . . . . . . . . .52

COPAXONE . . . . . . . . . . . . . . . . . . . . . . . . .48

COPEGUS . . . . . . . . . . . . . . . . . . . . . . . . . . .34

CORDRAN SP . . . . . . . . . . . . . . . . . . . . . . .54

CORDRAN TAPE . . . . . . . . . . . . . . . . . . . .55

COREG CR. . . . . . . . . . . . . . . . . . . . . . . . . . .42

82



CoveredDrugsIndex

CORTIFOAM . . . . . . . . . . . . . . . . . . . . . . . .55

cortisone acetate. . . . . . . . . . . . . . . . . . . .55

CORTISPORIN CREAM . . . . . . . . . . . .50

CORTISPORIN OINTMENT . . . . . . . .14

CORTISPORIN-TC . . . . . . . . . . . . . . . . . .70

COSMEGEN . . . . . . . . . . . . . . . . . . . . . . . . .27

COSOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

COUMADIN . . . . . . . . . . . . . . . . . . . . . . . . .39

CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

CRESTOR . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

CRIXIVAN . . . . . . . . . . . . . . . . . . . . . . . . . . .34

cromolyn sodium concentrate 100mg/5ml. . . . . . . . . . . . . . . . . . . . . . . . . .52

cromolyn sodium inhalation solution 20mg/2ml . . . . . . . . . . . . . . . . .71

cromolyn sodium solution 4%. . . . . .68

cryselle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

CUBICIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

CUPRIMINE . . . . . . . . . . . . . . . . . . . . . . . . .63

CUTIVATE LOTION . . . . . . . . . . . . . . . . .55

CUVPOSA . . . . . . . . . . . . . . . . . . . . . . . . . . .52

cyclafem . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

CYCLESSA. . . . . . . . . . . . . . . . . . . . . . . . . . .58

cyclobenzaprine hcl tablet 5mg, 10mg . . . . . . . . . . . . . . . . . . . . . . . . . .73

cyclophosphamide tablet . . . . . . . . . .27

cyclosporine . . . . . . . . . . . . . . . . . . . . . . . . .63

cyclosporine modified . . . . . . . . . . . . . .63

CYkLOkAPRON . . . . . . . . . . . . . . . . . . . .39

CYMBALTA . . . . . . . . . . . . . . . . . . . . . . . . . .21

cyproheptadine hcl . . . . . . . . . . . . . . . . .71

CYSTADANE . . . . . . . . . . . . . . . . . . . . . . . .51

CYSTAGON. . . . . . . . . . . . . . . . . . . . . . . . . .51

CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . . . .68

cytarabine . . . . . . . . . . . . . . . . . . . . . . . . . . .27

cytarabine aqueous. . . . . . . . . . . . . . . . .27

Ddacarbazine . . . . . . . . . . . . . . . . . . . . . . . . .27

DACOGEN. . . . . . . . . . . . . . . . . . . . . . . . . . .27

DALIRESP . . . . . . . . . . . . . . . . . . . . . . . . . . .71

dantrolene sodium capsule. . . . . . . . .34

dapsone . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

DAPTACEL . . . . . . . . . . . . . . . . . . . . . . . . . .63

DARAPRIM. . . . . . . . . . . . . . . . . . . . . . . . . .31

daunorubicin hcl . . . . . . . . . . . . . . . . . . . .27

DAUNOXOME . . . . . . . . . . . . . . . . . . . . . .27

DAYTRANA . . . . . . . . . . . . . . . . . . . . . . . . .48

DDAVP SOLUTION . . . . . . . . . . . . . . . . .56

demeclocycline hcl . . . . . . . . . . . . . . . . . .14

DEMEROL INJECTION 25MG/ML, 50MG/ML, 75MG/ML, 100MG/ML . . . . . . . . . . . . . . 8

DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

DENAVIR . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

DEPACON . . . . . . . . . . . . . . . . . . . . . . . . . . .18

depade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

DEPEN TITRATABS . . . . . . . . . . . . . . . . .63

DEPO-ESTRADIOL . . . . . . . . . . . . . . . . .58

DEPO-MEDROL . . . . . . . . . . . . . . . . . . . .55

DEPO-PROVERA. . . . . . . . . . . . . . . . . . . .58

DEPO-SUBQ PROVERA 104 . . . . . . .58

DERMOTIC . . . . . . . . . . . . . . . . . . . . . . . . . .70

desipramine hcl . . . . . . . . . . . . . . . . . . . . .21

desloratadine . . . . . . . . . . . . . . . . . . . . . . .71

desloratadine odt . . . . . . . . . . . . . . . . . . .71

desmopressin acetate. . . . . . . . . . . . . . .57

DESONATE . . . . . . . . . . . . . . . . . . . . . . . . . .55

desonide. . . . . . . . . . . . . . . . . . . . . . . . . . . . .55

desoximetasone. . . . . . . . . . . . . . . . . . . . .55

dexamethasone elixir, tablet . . . . . . .55

dexamethasone intensol . . . . . . . . . . .55

dexamethasone sodium phosphate injection. . . . . . . . . . . . . . . . .55

dexamethasone sodium phosphate solution 0.1% . . . . . . . . . . .68

dexchlorpheniramine maleate . . . . .71

DEXILANT . . . . . . . . . . . . . . . . . . . . . . . . . . .52

dexmethylphenidate hcl . . . . . . . . . . . .48

dexrazoxane. . . . . . . . . . . . . . . . . . . . . . . . .27

dextroamphetamine sulfate er . . . . .48

dextroamphetamine sulfate tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

dextrose . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

DEXTROSE 5%/LACTATED RINGERS . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

dextrose/nacl. . . . . . . . . . . . . . . . . . . . . . . .74

dextrose/potassium chloride . . . . . . .74

D.H.E. 45 . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

diazepam gel 2.5mg . . . . . . . . . . . . . . . .18

diazepam gel 10mg. . . . . . . . . . . . . . . . .18

diazepam gel 20mg. . . . . . . . . . . . . . . . .18

diazepam injection 10mg/2ml, 5mg/ml . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

diazepam intensol . . . . . . . . . . . . . . . . . .37

diazepam oral solution 1mg/ml. . . .37

83



Covered Drugs Index

diazepam tablet 2mg, 5mg, 10mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

DIBENzYLINE . . . . . . . . . . . . . . . . . . . . . . .42

diclofenac potassium . . . . . . . . . . . . . . .11

diclofenac sodium . . . . . . . . . . . . . . . . . .68

diclofenac sodium dr . . . . . . . . . . . . . . .11

diclofenac sodium er. . . . . . . . . . . . . . . .11

diclofenac sodium/misoprostol . . . .11

dicloxacillin sodium. . . . . . . . . . . . . . . . .14

dicyclomine hcl. . . . . . . . . . . . . . . . . . . . . .52

didanosine . . . . . . . . . . . . . . . . . . . . . . . . . .34

DIFICID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

diflorasone diacetate . . . . . . . . . . . . . . .55

diflunisal. . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

digoxin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

dihydroergotamine mesylate injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

dilacor xr . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

DILANTIN . . . . . . . . . . . . . . . . . . . . . . . . . . .18

DILANTIN INFATABS . . . . . . . . . . . . . . .18

DILAUDID-5 . . . . . . . . . . . . . . . . . . . . . . . . . 8

dilt-cd. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

diltiazem cd . . . . . . . . . . . . . . . . . . . . . . . . .43

diltiazem hcl er . . . . . . . . . . . . . . . . . . . . . .43

diltiazem hcl injection, tablet. . . . . . .43

dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

diltzac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

DIOVAN TABLET 40MG, 80MG, 160MG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

DIOVAN TABLET 320MG . . . . . . . . . . .43

DIPENTUM . . . . . . . . . . . . . . . . . . . . . . . . . .66

diphenhydramine hcl capsule 50mg . . . . . . . . . . . . . . . . . . . . . . .71

diphenhydramine hcl injection. . . . .71

diphenoxylate/atropine . . . . . . . . . . . .52

dipyridamole tablet . . . . . . . . . . . . . . . . .39

disopyramide phosphate . . . . . . . . . . .43

disulfiram. . . . . . . . . . . . . . . . . . . . . . . . . . . .11

DIURIL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

divalproex sodium . . . . . . . . . . . . . . . . . .18

divalproex sodium er. . . . . . . . . . . . . . . .18

DIVIGEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

DOCEFREz . . . . . . . . . . . . . . . . . . . . . . . . . .27

docetaxel . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

donepezil hcl odt 5mg . . . . . . . . . . . . . .20

donepezil hcl odt 10mg . . . . . . . . . . . . .20

donepezil hcl tablet 5mg . . . . . . . . . . .20

donepezil hcl tablet 10mg . . . . . . . . . .20

DORIBAX . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

dorzolamide hcl . . . . . . . . . . . . . . . . . . . . .68

dorzolamide hcl/timolol maleate . .68

doxazosin mesylate . . . . . . . . . . . . . . . . .43

doxepin hcl . . . . . . . . . . . . . . . . . . . . . . . . . .21

DOXIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

doxorubicin hcl. . . . . . . . . . . . . . . . . . . . . .27

doxycycline hyclate . . . . . . . . . . . . . . . . .14

doxycycline monohydrate . . . . . . . . . .14

dronabinol capsule 2.5mg, 5mg . . .22

dronabinol capsule 10mg . . . . . . . . . .22

drospirenone/ethinyl estradiol . . . . .58

DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

DULERA . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71

DURAMORPH . . . . . . . . . . . . . . . . . . . . . . . 8

DUREzOL . . . . . . . . . . . . . . . . . . . . . . . . . . .68

DUTOPROL . . . . . . . . . . . . . . . . . . . . . . . . .43

DYMISTA . . . . . . . . . . . . . . . . . . . . . . . . . . . .71

DYRENIUM. . . . . . . . . . . . . . . . . . . . . . . . . .43

DYSPORT. . . . . . . . . . . . . . . . . . . . . . . . . . . .67

Eeconazole nitrate. . . . . . . . . . . . . . . . . . . .23

EDECRIN . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

EDURANT . . . . . . . . . . . . . . . . . . . . . . . . . . .34

e.e.s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

EFFIENT TABLET 5MG . . . . . . . . . . . . .39

EFFIENT TABLET 10MG . . . . . . . . . . . .39

EGRIFTA INJECTION 1MG . . . . . . . . .57

EGRIFTA INJECTION 2MG . . . . . . . . .57

ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . . . .51

ELELYSO. . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

ELIDEL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

ELIGARD INJECTION 7.5MG . . . . . .62

ELIGARD INJECTION 22.5MG . . . . .62

ELIGARD INJECTION 30MG . . . . . . .62

ELIGARD INJECTION 45MG . . . . . . .62

eliphos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

ELIQUIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

ELITEk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

ELIXOPHYLLIN . . . . . . . . . . . . . . . . . . . . .71

ELLA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

ELLENCE . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

ELMIRON. . . . . . . . . . . . . . . . . . . . . . . . . . . .53

ELOXATIN . . . . . . . . . . . . . . . . . . . . . . . . . .27

ELSPAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

EMADINE . . . . . . . . . . . . . . . . . . . . . . . . . . .68

84



CoveredDrugsIndex

EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

EMEND CAPSULE 40MG. . . . . . . . . . .22

EMEND CAPSULE 80MG. . . . . . . . . . .22

EMEND CAPSULE 125MG . . . . . . . . .22

EMEND CAPSULE TRIFOLD PACk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

emoquette. . . . . . . . . . . . . . . . . . . . . . . . . . .58

EMSAM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

EMTRIVA . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

enalapril maleate . . . . . . . . . . . . . . . . . . .43

enalapril maleate/hctz . . . . . . . . . . . . .43

ENBREL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

ENBREL SURECLICk. . . . . . . . . . . . . . . .64

endocet tablet 325mg/5mg, 325mg/7.5mg, 325mg/10mg . . . . . . . 8

endocet tablet 500mg/7.5mg . . . . . . . 8

endocet tablet 650mg/10mg . . . . . . . . 8

ENGERIX-B . . . . . . . . . . . . . . . . . . . . . . . . . .64

ENJUVIA . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

enoxaparin sodium 30mg/0.3ml . . .40




enoxaparin sodium 100mg/ml . . . . .40

enoxaparin sodium 120mg/0.8ml . .40

enoxaparin sodium 150mg/ml . . . . .40

enoxaparin sodium 300mg/3ml . . .40

enpresse . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

entacapone . . . . . . . . . . . . . . . . . . . . . . . . .32

enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

epinastine hcl . . . . . . . . . . . . . . . . . . . . . . .68

EPIPEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71

EPIPEN-JR . . . . . . . . . . . . . . . . . . . . . . . . . .71

epirubicin hcl . . . . . . . . . . . . . . . . . . . . . . . .27

epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

EPIVIR HBV . . . . . . . . . . . . . . . . . . . . . . . . .34

EPIVIR SOLUTION . . . . . . . . . . . . . . . . . .34

eplerenone . . . . . . . . . . . . . . . . . . . . . . . . . .43

EPOGEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

eprosartan mesylate . . . . . . . . . . . . . . . .43

EPzICOM . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

EQUETRO . . . . . . . . . . . . . . . . . . . . . . . . . . .37

ERAXIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

ERBITUX. . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

ergoloid mesylates . . . . . . . . . . . . . . . . . .20

ERGOMAR . . . . . . . . . . . . . . . . . . . . . . . . . .25

ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . . . . .27

errin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

ery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

ERYPED . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

ery-tab. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14

erythrocin lactobionate. . . . . . . . . . . . .14

erythrocin stearate. . . . . . . . . . . . . . . . . .14

erythromycin base . . . . . . . . . . . . . . . . . .14

erythromycin/benzoyl peroxide . . . .50

erythromycin ethylsuccinate . . . . . . .15

erythromycin gel, ointment, solution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

escitalopram oxalate solution . . . . . .21

escitalopram oxalate tablet . . . . . . . .21

ESTRACE CREAM . . . . . . . . . . . . . . . . . . .58

estradiol/norethindrone acetate . . .58

estradiol tablet . . . . . . . . . . . . . . . . . . . . . .58

ESTRASORB. . . . . . . . . . . . . . . . . . . . . . . . .58

ESTRING . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

estropipate . . . . . . . . . . . . . . . . . . . . . . . . . .58

ESTROSTEP FE . . . . . . . . . . . . . . . . . . . . . .58

ethambutol hcl. . . . . . . . . . . . . . . . . . . . . .26

ethosuximide. . . . . . . . . . . . . . . . . . . . . . . .18

etidronate disodium . . . . . . . . . . . . . . . .66

etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

etodolac er . . . . . . . . . . . . . . . . . . . . . . . . . .12

ETOPOPHOS . . . . . . . . . . . . . . . . . . . . . . . .28

etoposide injection. . . . . . . . . . . . . . . . . .28

EURAX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

EVISTA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58

EVOXAC . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

EXELON PATCH . . . . . . . . . . . . . . . . . . . . .20

EXELON SOLUTION . . . . . . . . . . . . . . . .20

exemestane . . . . . . . . . . . . . . . . . . . . . . . . .28

EXFORGE. . . . . . . . . . . . . . . . . . . . . . . . . . . .43

EXFORGE HCT . . . . . . . . . . . . . . . . . . . . . .43

EXJADE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

EXTAVIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

FFABRAzYME . . . . . . . . . . . . . . . . . . . . . . . .51

famciclovir . . . . . . . . . . . . . . . . . . . . . . . . . .34

famotidine injection . . . . . . . . . . . . . . . .52

famotidine tablet 20mg, 40mg rx. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

FANAPT . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

FANAPT TITRATION PACk . . . . . . . . .32

FARESTON . . . . . . . . . . . . . . . . . . . . . . . . . .28

FASLODEX . . . . . . . . . . . . . . . . . . . . . . . . . .28

FAzACLO . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

85



Covered Drugs Index

fluvoxamine maleate . . . . . . . . . . . . . . .21

FML . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

FML FORTE . . . . . . . . . . . . . . . . . . . . . . . . .68

fomepizole . . . . . . . . . . . . . . . . . . . . . . . . . .67

fondaparinux sodium 2.5mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . .40

fondaparinux sodium 5mg/0.4ml . . . . . . . . . . . . . . . . . . . . . . . . . .40

fondaparinux sodium 7.5mg/0.6ml . . . . . . . . . . . . . . . . . . . . . . . .40

fondaparinux sodium 10mg/0.8ml . . . . . . . . . . . . . . . . . . . . . . . . .40

FORADIL AEROLIzER . . . . . . . . . . . . . .71

FORTAz . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

FORTEO . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

FORTICAL . . . . . . . . . . . . . . . . . . . . . . . . . . .66

FOSAMAX PLUS D . . . . . . . . . . . . . . . . .66

foscarnet sodium. . . . . . . . . . . . . . . . . . . .34

fosinopril sodium . . . . . . . . . . . . . . . . . . .43

fosinopril sodium/hctz. . . . . . . . . . . . . .43

fosphenytoin sodium . . . . . . . . . . . . . . .19

FOSRENOL . . . . . . . . . . . . . . . . . . . . . . . . . .53

FRAGMIN 2500UNIT/0.2ML, 5000UNIT/0.2ML . . . . . . . . . . . . . . . . . . .40

FRAGMIN 7500UNIT/0.3ML . . . . . . .40

FRAGMIN 10000UNIT/ML . . . . . . . . .40

FRAGMIN 12500UNIT/0.5ML . . . . .40

FRAGMIN 15000UNIT/0.6ML . . . . .40

FRAGMIN 18000UNT/0.72ML. . . . .40

FRAGMIN 25000UNIT/ML . . . . . . . . .40

FREAMINE HBC . . . . . . . . . . . . . . . . . . . .75

FREAMINE III . . . . . . . . . . . . . . . . . . . . . . .75

FROVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

felbamate suspension . . . . . . . . . . . . . .18

felbamate tablet . . . . . . . . . . . . . . . . . . . .18

FELBATOL . . . . . . . . . . . . . . . . . . . . . . . . . . .19

felodipine er . . . . . . . . . . . . . . . . . . . . . . . . .43

FEMCON FE . . . . . . . . . . . . . . . . . . . . . . . . .59

FEMRING. . . . . . . . . . . . . . . . . . . . . . . . . . . .59

fenofibrate micronized. . . . . . . . . . . . . .43

fenofibrate tablet 48mg, 54mg. . . . .43

fenofibrate tablet 145mg, 160mg . .43

fenoprofen calcium . . . . . . . . . . . . . . . . .12

fentanyl citrate injection. . . . . . . . . . . . . 8

fentanyl citrate oral transmucosal lollipop 200mcg . . . . . . . . . . . . . . . . . . . . . . 8

fentanyl citrate oral transmucosal lollipop 400mcg, 600mcg, 800mcg, 1200mcg, 1600mcg. . . . . . . . 8

fentanyl patch. . . . . . . . . . . . . . . . . . . . . . . . 8

FERRIPROX . . . . . . . . . . . . . . . . . . . . . . . . .67

FINACEA . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

finasteride tablet 5mg . . . . . . . . . . . . . .53

FIRAzYR. . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

FIRMAGON . . . . . . . . . . . . . . . . . . . . . . . . .62

FLAGYL ER . . . . . . . . . . . . . . . . . . . . . . . . . .15

FLAREX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

flavoxate hcl. . . . . . . . . . . . . . . . . . . . . . . . .53

flecainide acetate . . . . . . . . . . . . . . . . . . .43

FLOVENT DISkUS . . . . . . . . . . . . . . . . . .71

FLOVENT HFA . . . . . . . . . . . . . . . . . . . . . .71

fluconazole . . . . . . . . . . . . . . . . . . . . . . . . . .23

fluconazole in dextrose . . . . . . . . . . . . .23

fluconazole in nacl . . . . . . . . . . . . . . . . . .23

flucytosine. . . . . . . . . . . . . . . . . . . . . . . . . . .23

FLUDARA . . . . . . . . . . . . . . . . . . . . . . . . . . .28

fludarabine phosphate . . . . . . . . . . . . .28

fludrocortisone acetate . . . . . . . . . . . . .55

flunisolide solution 29mcg/act . . . . .71

fluocinolone acetonide . . . . . . . . . . . . .55

fluocinolone acetonide body . . . . . . .55

fluocinonide . . . . . . . . . . . . . . . . . . . . . . . . .55

fluocinonide-e. . . . . . . . . . . . . . . . . . . . . . .55

fluorometholone . . . . . . . . . . . . . . . . . . . .68

fluorouracil cream 5% . . . . . . . . . . . . . .50

fluorouracil injection . . . . . . . . . . . . . . .28

fluorouracil topical solution 2%, 5% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

fluoxetine hcl capsule 10mg, 20mg, 40mg. . . . . . . . . . . . . . . . . . . . . . . . .21

fluoxetine hcl solution 20mg/5ml . .21

fluoxetine hcl tablet 10mg, 20mg, 60mg. . . . . . . . . . . . . . . . . . . . . . . . .21

fluphenazine decanoate. . . . . . . . . . . .32

fluphenazine hcl . . . . . . . . . . . . . . . . . . . .32

flurbiprofen. . . . . . . . . . . . . . . . . . . . . . . . . .12

flurbiprofen sodium. . . . . . . . . . . . . . . . .68

flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

fluticasone propionate cream 0.05% . . . . . . . . . . . . . . . . . . . . . . . .55

fluticasone propionate lotion 0.05%. . . . . . . . . . . . . . . . . . . . . . . . .55

fluticasone propionate ointment 0.005% . . . . . . . . . . . . . . . . . . .55

fluticasone propionate suspension 50mcg/act. . . . . . . . . . . . . .71

fluvastatin capsule 20mg. . . . . . . . . . .43

fluvastatin capsule 40mg. . . . . . . . . . .43

86



CoveredDrugsIndex

GRIS-PEG . . . . . . . . . . . . . . . . . . . . . . . . . . .23

guanfacine hcl . . . . . . . . . . . . . . . . . . . . . .43

guanidine hcl. . . . . . . . . . . . . . . . . . . . . . . .25

GYNAzOLE-1 . . . . . . . . . . . . . . . . . . . . . . .23

HHALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . . .28

HALFLYTELY BOWEL PREP/FLAVOR PACkS . . . . . . . . . . . . . .52

halobetasol propionate. . . . . . . . . . . . .55

haloperidol . . . . . . . . . . . . . . . . . . . . . . . . . .32

haloperidol decanoate. . . . . . . . . . . . . .32

haloperidol lactate. . . . . . . . . . . . . . . . . .32

HAVRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

HECTOROL. . . . . . . . . . . . . . . . . . . . . . . . . .66

HELIDAC . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

heparin sodium 1000unit/ml. . . . . . .40

heparin sodium 2000unit/ml, 2500unit/ml, 5000unit/ml, 10000unit/ml, 20000unit/ml . . . . . . .40

heparin sodium/d5w injection 5%; 40unit/ml . . . . . . . . . . . . . . . . . . . . . . .40

heparin sodium/nacl 0.45% . . . . . . . .40

heparin sodium/sodium chloride 0.9% premix . . . . . . . . . . . . . . .40

HEPATAMINE . . . . . . . . . . . . . . . . . . . . . . .75

HEPATASOL . . . . . . . . . . . . . . . . . . . . . . . . .75

HEPSERA . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

HERCEPTIN . . . . . . . . . . . . . . . . . . . . . . . . .28

HEXALEN . . . . . . . . . . . . . . . . . . . . . . . . . . .28

HIzENTRA . . . . . . . . . . . . . . . . . . . . . . . . . .64

HORIzANT . . . . . . . . . . . . . . . . . . . . . . . . . .67

HUMALOG . . . . . . . . . . . . . . . . . . . . . . . . . .38

GENOTROPIN MINIQUICk INJECTION 0.2MG . . . . . . . . . . . . . . . . . .57

GENOTROPIN MINIQUICk INJECTION 0.4MG, 0.6MG, 0.8MG, 1MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 2MG . . . . . . . . . . . . . . .57

gentak ointment . . . . . . . . . . . . . . . . . . . .15

gentamicin sulfate . . . . . . . . . . . . . . . . . .15

GEODON INJECTION . . . . . . . . . . . . . .32

gianvi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

gildagia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

GILENYA . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

GLASSIA . . . . . . . . . . . . . . . . . . . . . . . . . . . .71

GLEEVEC . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

glimepiride . . . . . . . . . . . . . . . . . . . . . . . . . .37

glipizide . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

glipizide er. . . . . . . . . . . . . . . . . . . . . . . . . . .37

glipizide/metformin hcl. . . . . . . . . . . . .37

GLUCAGEN HYPOkIT . . . . . . . . . . . . . .37

GLUCAGON EMERGENCY kIT . . . . .38

glyburide . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

glyburide/metformin hcl . . . . . . . . . . .38

glyburide micronized . . . . . . . . . . . . . . .38

glycopyrrolate. . . . . . . . . . . . . . . . . . . . . . .52

GLYSET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

GOLYTELY . . . . . . . . . . . . . . . . . . . . . . . . . . .52

granisetron hcl injection . . . . . . . . . . .22

granisetron hcl tablet . . . . . . . . . . . . . . .22

granisol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

GRIFULVIN V . . . . . . . . . . . . . . . . . . . . . . . .23

griseofulvin microsize. . . . . . . . . . . . . . .23

griseofulvin ultramicrosize . . . . . . . . .23

FURADANTIN. . . . . . . . . . . . . . . . . . . . . . .15

furosemide . . . . . . . . . . . . . . . . . . . . . . . . . .43

FUzEON . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

Ggabapentin. . . . . . . . . . . . . . . . . . . . . . . . . .19

galantamine hydrobromide er capsule. . . . . . . . . . . . . . . . . . . . . . . . . . . .20

galantamine hydrobromide solution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

galantamine hydrobromide tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

GAMASTAN S/D . . . . . . . . . . . . . . . . . . . .64

GAMMAGARD LIQUID . . . . . . . . . . . . .64

GAMMAPLEX . . . . . . . . . . . . . . . . . . . . . . .64

GAMUNEX-C . . . . . . . . . . . . . . . . . . . . . . .64

ganciclovir. . . . . . . . . . . . . . . . . . . . . . . . . . .34

GARDASIL . . . . . . . . . . . . . . . . . . . . . . . . . .64

GATTEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

GAUzE PADS 2”X2” . . . . . . . . . . . . . . . .37

gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

gavilyte-g. . . . . . . . . . . . . . . . . . . . . . . . . . . .52

gavilyte-n/flavor pack . . . . . . . . . . . . . .52

GELNIQUE GEL 3% . . . . . . . . . . . . . . . . .53

GELNIQUE GEL 10% . . . . . . . . . . . . . . .53

gemcitabine hcl . . . . . . . . . . . . . . . . . . . . .28

gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . . .43

GEMzAR . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

GENERESS FE . . . . . . . . . . . . . . . . . . . . . . .59

generlac . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

gengraf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

GENOTROPIN 5MG, 12MG . . . . . . . .57

87



Covered Drugs Index

imipenem/cilastatin . . . . . . . . . . . . . . . .15

imipramine hcl . . . . . . . . . . . . . . . . . . . . . .21

imipramine pamoate . . . . . . . . . . . . . . .21

imiquimod . . . . . . . . . . . . . . . . . . . . . . . . . .50

IMOVAX RABIES (H.D.C.V.) . . . . . . . .64

INCIVEk . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

INCRELEX . . . . . . . . . . . . . . . . . . . . . . . . . . .57

indapamide . . . . . . . . . . . . . . . . . . . . . . . . .44

indomethacin & indomethacin er . .12

INFANRIX . . . . . . . . . . . . . . . . . . . . . . . . . . .64

INFERGEN . . . . . . . . . . . . . . . . . . . . . . . . . .34

INLYTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

INNOPRAN XL . . . . . . . . . . . . . . . . . . . . . .44

INSULIN SYRINGE & PEN NEEDLE . . . . . . . . . . . . . . . . . . . . . . . .38

INTELENCE TABLET 25MG. . . . . . . . .34

INTELENCE TABLET 100MG, 200MG. . . . . . . . . . . . . . . . . . . . .35

INTRALIPID . . . . . . . . . . . . . . . . . . . . . . . . .75

INTRON-A. . . . . . . . . . . . . . . . . . . . . . . . . . .35

introvale . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

INTUNIV. . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

INVANz . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

INVEGA SUSTENNA 39MG/0.25ML, 78MG/0.5ML . . . . . .32

INVEGA SUSTENNA 117MG/0.75ML, 156MG/ML, 234MG/1.5ML . . . . . . . . . . . . . . . . . . . . . .32

INVEGA TABLET ER 1.5MG, 3MG . . . . . . . . . . . . . . . . . . . . . . . .33

INVEGA TABLET ER 6MG . . . . . . . . . .33

INVEGA TABLET ER 9MG . . . . . . . . . .33

INVIRASE CAPSULE 200MG . . . . . . .35

hydrocodone/ibuprofen tablet 7.5mg/200mg . . . . . . . . . . . . . . . . . . . . . . . . 8

hydrocortisone/acetic acid . . . . . . . . .70

hydrocortisone butyrate . . . . . . . . . . . .55

hydrocortisone cream 1%, 2.5% . . .55

hydrocortisone enema 100mg/60ml . . . . . . . . . . . . . . . . . . . . . . . .66

hydrocortisone lotion 2.5%. . . . . . . . .55

hydrocortisone ointment 1%, 2.5% . . . . . . . . . . . . . . . . . . . . . . . . . . . .55

hydrocortisone tablet . . . . . . . . . . . . . .55

hydrocortisone valerate . . . . . . . . . . . .55

hydromorphone hcl injection 500mg/50ml . . . . . . . . . . . . . . . . . . . . . . . . . 8

hydromorphone hcl tablet. . . . . . . . . . . 8

hydroxychloroquine sulfate . . . . . . . .31

hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . . .28

hydroxyzine hcl . . . . . . . . . . . . . . . . . . . . .71

hydroxyzine pamoate. . . . . . . . . . . . . . .71

Iibandronate sodium . . . . . . . . . . . . . . . .66

ibuprofen suspension . . . . . . . . . . . . . . .12

ibuprofen tablet 400mg, 600mg, 800mg . . . . . . . . . . . . . . . . . . . . . .12

ICLUSIG . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

IDAMYCIN PFS . . . . . . . . . . . . . . . . . . . . .28

idarubicin hcl. . . . . . . . . . . . . . . . . . . . . . . .28

IFEX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

ifosfamide . . . . . . . . . . . . . . . . . . . . . . . . . . .28

ifosfamide/mesna . . . . . . . . . . . . . . . . . .28

ILARIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

ILEVRO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

HUMALOG MIX 50/50 . . . . . . . . . . . . .38

HUMALOG MIX 75/25 . . . . . . . . . . . . .38

HUMATROPE COMBO PACk . . . . . .57

HUMATROPE INJECTION 5MG, 6MG, 12MG, 24MG . . . . . . . . . .57

HUMIRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

HUMULIN 70/30. . . . . . . . . . . . . . . . . . . .38

HUMULIN N . . . . . . . . . . . . . . . . . . . . . . . .38

HUMULIN R . . . . . . . . . . . . . . . . . . . . . . . . .38

HUMULIN R U-500 (CONCENTRATED) . . . . . . . . . . . . . . . . .38

HYCAMTIN INJECTION . . . . . . . . . . . .28

HYCET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

hydralazine hcl . . . . . . . . . . . . . . . . . . . . . .44

HYDREA . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

hydrochlorothiazide . . . . . . . . . . . . . . . .44

hydrocodone/acetaminophen solution 7.5mg & 500mg/15ml. . . . . . 8

hydrocodone/acetaminophen tablet 2.5mg/500mg, 5mg/500mg, 7.5mg/500mg, 10mg/500mg . . . . . . . 8

hydrocodone/acetaminophen tablet 5mg/325mg, 7.5mg/325mg, 10mg/325mg . . . . . . . . . . . . . . . . . . . . . . . . 8

hydrocodone/acetaminophen tablet 7.5mg/650mg,1 0mg/ 650mg, 10mg/660mg . . . . . . . . . 8

hydrocodone/acetaminophen tablet 7.5mg/750mg. . . . . . . . . . . . . . . . . 8

hydrocodone bitartrate/acetaminophen solution 7.5mg & 325mg/15ml . . . . . . . . . . . . . . . 8

hydrocodone bitartrate/acetaminophen tablet 10mg/750mg . . . . . . . . . . . . . . . . . . . . . . . . 8

88



CoveredDrugsIndex

ketoconazole cream, shampoo, tablet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

ketoprofen. . . . . . . . . . . . . . . . . . . . . . . . . . .12

ketoprofen er . . . . . . . . . . . . . . . . . . . . . . . .12

ketorolac tromethamine injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

ketorolac tromethamine ophthalmic solution 0.4%, 0.5% . . .69

ketorolac tromethamine tablet 10mg . . . . . . . . . . . . . . . . . . . . . . . . .12

kionex powder . . . . . . . . . . . . . . . . . . . . . .75

klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75

klor-con m. . . . . . . . . . . . . . . . . . . . . . . . . . .75

kORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

kRISTALOSE . . . . . . . . . . . . . . . . . . . . . . . .52

k-TABS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .75

kUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

kYNAMRO . . . . . . . . . . . . . . . . . . . . . . . . . .44

Llabetalol hcl . . . . . . . . . . . . . . . . . . . . . . . . .44

LACRISERT . . . . . . . . . . . . . . . . . . . . . . . . . .69

LACTATED RINGERS IRRIGATION . . . . . . . . . . . . . . . . . . . . . . . . .67

LACTATED RINGERS VIAFLEX . . . . .75

lactulose. . . . . . . . . . . . . . . . . . . . . . . . . . . . .52

LAMICTAL ODT . . . . . . . . . . . . . . . . . . . .19

lamivudine . . . . . . . . . . . . . . . . . . . . . . . . . .35

lamivudine/zidovudine . . . . . . . . . . . . .35

lamotrigine. . . . . . . . . . . . . . . . . . . . . . . . . .19

lamotrigine er . . . . . . . . . . . . . . . . . . . . . . .19

LANOXIN. . . . . . . . . . . . . . . . . . . . . . . . . . . .44

LANOXIN PEDIATRIC . . . . . . . . . . . . . .44

JJAkAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

JALYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

JANUMET . . . . . . . . . . . . . . . . . . . . . . . . . . .38

JANUMET XR TABLET 500MG/50MG, 1000MG/50MG . . .38

JANUMET XR TABLET 1000MG/100MG . . . . . . . . . . . . . . . . . . .38

JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

JENTADUETO . . . . . . . . . . . . . . . . . . . . . . .38

JE-VAX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

JEVTANA . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

jinteli. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

jolivette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

junel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

junel fe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

JUVISYNC . . . . . . . . . . . . . . . . . . . . . . . . . . .38

JUXTAPID . . . . . . . . . . . . . . . . . . . . . . . . . . .44

KkADCYLA . . . . . . . . . . . . . . . . . . . . . . . . . . .28

kALBITOR . . . . . . . . . . . . . . . . . . . . . . . . . . .67

kALETRA . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

kALYDECO . . . . . . . . . . . . . . . . . . . . . . . . . .72

kariva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

kCL/D5W/LR. . . . . . . . . . . . . . . . . . . . . . . .75

kCL/D5W/NACL . . . . . . . . . . . . . . . . . . . .75

kelnor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

kENALOG . . . . . . . . . . . . . . . . . . . . . . . . . . .55

kEPIVANCE . . . . . . . . . . . . . . . . . . . . . . . . .49

kETEk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

INVIRASE TABLET 500MG . . . . . . . . .35

IONOSOL-B/DEXTROSE 5% . . . . . . .75

IONOSOL-MB/DEXTROSE 5%. . . . .75

IOPIDINE . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

IPOL INACTIVATED IPV . . . . . . . . . . . .64

ipratropium bromide/albuterol sulfate inhalation solution . . . . . . . . .72

ipratropium bromide inhalation solution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72

ipratropium bromide nasal solution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72

irbesartan . . . . . . . . . . . . . . . . . . . . . . . . . . .44

irbesartan/hctz. . . . . . . . . . . . . . . . . . . . . .44

irinotecan . . . . . . . . . . . . . . . . . . . . . . . . . . .28

ISENTRESS TABLET 400MG. . . . . . . .35

ISENTRESS TABLET CHEWABLE 25MG, 100MG . . . . . . . . . . . . . . . . . . . . . .35

ISOLYTE-M/DEXTROSE 5%. . . . . . . .75

ISOLYTE-P/DEXTROSE 5% . . . . . . . .75

ISOLYTE-S. . . . . . . . . . . . . . . . . . . . . . . . . . .75

isoniazid . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

isopto carpine . . . . . . . . . . . . . . . . . . . . . . .69

isosorbide dinitrate . . . . . . . . . . . . . . . . .44

isosorbide dinitrate er. . . . . . . . . . . . . . .44

isosorbide mononitrate . . . . . . . . . . . . .44

isosorbide mononitrate er . . . . . . . . . .44

isradipine . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

ISTALOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

ISTODAX . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

itraconazole . . . . . . . . . . . . . . . . . . . . . . . . .24

IXEMPRA kIT . . . . . . . . . . . . . . . . . . . . . . .28

IXIARO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

89



Covered Drugs Index

LODOSYN . . . . . . . . . . . . . . . . . . . . . . . . . . .32

LOESTRIN 24 FE . . . . . . . . . . . . . . . . . . . .59

LOFIBRA CAPSULE . . . . . . . . . . . . . . . . .44

LOFIBRA TABLET 54MG . . . . . . . . . . .44

LOFIBRA TABLET 160MG . . . . . . . . . .44

lokara. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55

loperamide hcl capsule rx. . . . . . . . . . .52

lorazepam injection. . . . . . . . . . . . . . . . .37

lorazepam intensol . . . . . . . . . . . . . . . . .37

lorazepam tablet. . . . . . . . . . . . . . . . . . . .37

loryna. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

losartan potassium/hctz tablet 50mg/12.5mg . . . . . . . . . . . . . . . . . . . . . . .44

losartan potassium/hctz tablet 100mg/12.5mg, 100mg/25mg . . . . .44

losartan potassium tablet 25mg . . .44

losartan potassium tablet 50mg . . .44

losartan potassium tablet 100mg. .44

LOSEASONIQUE . . . . . . . . . . . . . . . . . . . .59

LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . . . .69

LOTRONEX . . . . . . . . . . . . . . . . . . . . . . . . . .52

lovastatin tablet 10mg, 20mg . . . . . .44

lovastatin tablet 40mg . . . . . . . . . . . . .44

LOVAzA . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

low-ogestrel . . . . . . . . . . . . . . . . . . . . . . . . .59

loxapine succinate . . . . . . . . . . . . . . . . . .33

LUFYLLIN . . . . . . . . . . . . . . . . . . . . . . . . . . .72

LUMIGAN . . . . . . . . . . . . . . . . . . . . . . . . . . .69

LUMIzYME . . . . . . . . . . . . . . . . . . . . . . . . . .51

LUNESTA . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

LUPRON DEPOT . . . . . . . . . . . . . . . . . . . .62

LUPRON DEPOT-PED . . . . . . . . . . . . . .62

levofloxacin tablet . . . . . . . . . . . . . . . . . .15

levonest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

levonorgestrel/ethinyl estradiol . . . .59

levora . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

levorphanol tartrate . . . . . . . . . . . . . . . . . 9

LEVOTHROID . . . . . . . . . . . . . . . . . . . . . . .61

levothyroxine sodium tablet. . . . . . . .61

LEVOXYL . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

LEXIVA SUSPENSION . . . . . . . . . . . . . .35

LEXIVA TABLET . . . . . . . . . . . . . . . . . . . . .35

LIALDA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

lidocaine hcl external solution . . . . .10

lidocaine hcl injection 0.5%, 1%. . . .10

lidocaine hcl jelly gel 2% . . . . . . . . . . . .10

lidocaine ointment. . . . . . . . . . . . . . . . . .10

lidocaine/prilocaine cream . . . . . . . . .11

lidocaine viscous . . . . . . . . . . . . . . . . . . . .11

LIDODERM. . . . . . . . . . . . . . . . . . . . . . . . . .11

LINCOCIN . . . . . . . . . . . . . . . . . . . . . . . . . . .15

lindane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

liothyronine sodium . . . . . . . . . . . . . . . .61

LIPOFEN CAPSULE 50MG . . . . . . . . .44

LIPOFEN CAPSULE 150MG . . . . . . . .44

LIPOSYN II . . . . . . . . . . . . . . . . . . . . . . . . . .75

LIPOSYN III . . . . . . . . . . . . . . . . . . . . . . . . .75

lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

lisinopril/hctz. . . . . . . . . . . . . . . . . . . . . . . .44

lithium carbonate. . . . . . . . . . . . . . . . . . .37

lithium carbonate er . . . . . . . . . . . . . . . .37

lithium citrate . . . . . . . . . . . . . . . . . . . . . . .37

LITHOBID . . . . . . . . . . . . . . . . . . . . . . . . . . .37

lansoprazole . . . . . . . . . . . . . . . . . . . . . . . .52

LANTUS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

LANTUS SOLOSTAR . . . . . . . . . . . . . . . .38

latanoprost. . . . . . . . . . . . . . . . . . . . . . . . . .69

LATUDA TABLET 20MG, 40MG, 120MG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

LATUDA TABLET 80MG . . . . . . . . . . . .33

LAzANDA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

leena. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

leflunomide . . . . . . . . . . . . . . . . . . . . . . . . .64

LESCOL XL . . . . . . . . . . . . . . . . . . . . . . . . . .44

lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

LETAIRIS . . . . . . . . . . . . . . . . . . . . . . . . . . . .72

letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

leucovorin calcium injection. . . . . . . .29

leucovorin calcium tablet. . . . . . . . . . .29

LEUkERAN . . . . . . . . . . . . . . . . . . . . . . . . . .29

LEUkINE . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

leuprolide acetate. . . . . . . . . . . . . . . . . . .62

levalbuterol hcl inhalation solution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72

LEVEMIR . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

LEVEMIR FLEXPEN . . . . . . . . . . . . . . . . .38

levetiracetam. . . . . . . . . . . . . . . . . . . . . . . .19

levetiracetam er . . . . . . . . . . . . . . . . . . . . .19

levobunolol hcl . . . . . . . . . . . . . . . . . . . . . .69

levocarnitine . . . . . . . . . . . . . . . . . . . . . . . .67

levocetirizine dihydrochloride solution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72

levocetirizine dihydrochloride tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72

levofloxacin injection, ophthalmic solution, oral solution. . . . . . . . . . . . . . .15

90



CoveredDrugsIndex

methadone hcl oral solution 10mg/5ml . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

methadone hcl tablet 5mg, 10mg. . . 9

methadone hcl tablet soluble 40mg . . . . . . . . . . . . . . . . . . . . . . . . . 9

methadose concentrate . . . . . . . . . . . . . 9

methadose tablet soluble 40mg . . . . 9

methamphetamine hcl . . . . . . . . . . . . .48

methazolamide . . . . . . . . . . . . . . . . . . . . .45

methenamine hippurate . . . . . . . . . . .15

methimazole . . . . . . . . . . . . . . . . . . . . . . . .63

methitest . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

methocarbamol. . . . . . . . . . . . . . . . . . . . .73

methotrexate. . . . . . . . . . . . . . . . . . . . . . . .64

methotrexate sodium. . . . . . . . . . . . . . .64

methscopolamine bromide. . . . . . . . .52

methyclothiazide . . . . . . . . . . . . . . . . . . .45

methyldopa . . . . . . . . . . . . . . . . . . . . . . . . .45

methyldopa/hctz. . . . . . . . . . . . . . . . . . . .45

methyldopate hcl . . . . . . . . . . . . . . . . . . .45

methylergonovine maleate tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

METHYLIN TABLET CHEWABLE . . .48

methylphenidate hcl . . . . . . . . . . . . . . . .48

methylphenidate hcl cd capsule 10mg, 20mg, 30mg, 40mg, 50mg, 60mg. . . . . . . . . . . . . . . . . . . . . . . . .48

methylphenidate hcl er capsule 20mg, 30mg, 40mg . . . . . . . . . . . . . . . . .48

methylphenidate hcl er tablet 10mg, 20mg. . . . . . . . . . . . . . . . . . . . . . . . .48

methylphenidate hcl er tablet 18mg, 27mg, 36mg, 54mg . . . . . . . . .48

meloxicam . . . . . . . . . . . . . . . . . . . . . . . . . .12

melphalan hcl . . . . . . . . . . . . . . . . . . . . . . .29

MENACTRA . . . . . . . . . . . . . . . . . . . . . . . . .64

MENEST . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

MENOMUNE-A/C/Y/W-135 . . . . . . .64

MENOSTAR . . . . . . . . . . . . . . . . . . . . . . . . .59

MENVEO . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

meperidine hcl injection 25mg/ml, 50mg/ml, 100mg/ml. . . . . . . . . . . . . . . . . 9

meperidine hcl oral solution. . . . . . . . . 9

meperitab . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

meprobamate. . . . . . . . . . . . . . . . . . . . . . .37

MEPRON . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

mercaptopurine . . . . . . . . . . . . . . . . . . . . .29

meropenem . . . . . . . . . . . . . . . . . . . . . . . . .15

MERREM . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

mesalamine kit. . . . . . . . . . . . . . . . . . . . . .66

mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

MESNEX INJECTION . . . . . . . . . . . . . . .29

MESNEX TABLET . . . . . . . . . . . . . . . . . . .29

MESTINON SYRUP . . . . . . . . . . . . . . . . .25

MESTINON TIMESPAN . . . . . . . . . . . . .25

metadate er . . . . . . . . . . . . . . . . . . . . . . . . .48

metaproterenol sulfate . . . . . . . . . . . . .72

metaxalone . . . . . . . . . . . . . . . . . . . . . . . . .73

metformin hcl . . . . . . . . . . . . . . . . . . . . . . .38

metformin hcl er . . . . . . . . . . . . . . . . . . . .38

methadone hcl concentrate . . . . . . . . . 9

methadone hcl injection. . . . . . . . . . . . . 9

methadone hcl oral solution 5mg/5ml . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

lutera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

LUXIQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55

LYRICA CAPSULE 25MG, 225MG, 300MG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19

LYRICA CAPSULE 50MG, 75MG, 100MG, 150MG, 200MG . . . . . . . . . . .19

LYRICA SOLUTION . . . . . . . . . . . . . . . . .19

LYSODREN . . . . . . . . . . . . . . . . . . . . . . . . . .62

MMACRODANTIN CAPSULE 25MG 15

mafenide acetate . . . . . . . . . . . . . . . . . . .15

magnesium sulfate injection . . . . . . .19

magnesium sulfate injection . . . . . . .75

MAkENA . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

malathion . . . . . . . . . . . . . . . . . . . . . . . . . . .31

maprotiline hcl . . . . . . . . . . . . . . . . . . . . . .21

marlissa . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59

MARPLAN. . . . . . . . . . . . . . . . . . . . . . . . . . .21

MATULANE . . . . . . . . . . . . . . . . . . . . . . . . .29

MAXIDEX . . . . . . . . . . . . . . . . . . . . . . . . . . .69

maxidone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

MAXIPIME . . . . . . . . . . . . . . . . . . . . . . . . . .15

meclizine hcl tablet rx. . . . . . . . . . . . . . .22

meclofenamate sodium . . . . . . . . . . . .12

medroxyprogesterone acetate . . . . .59

mefloquine hcl . . . . . . . . . . . . . . . . . . . . . .31

MEGACE ES . . . . . . . . . . . . . . . . . . . . . . . . .59

MEGACE ORAL . . . . . . . . . . . . . . . . . . . . .59

megestrol acetate suspension . . . . . .59

megestrol acetate tablet. . . . . . . . . . . .59

MEkINIST . . . . . . . . . . . . . . . . . . . . . . . . . . .29

91



Covered Drugs Index

morphine sulfate tablet 15mg, 30mg. . . . . . . . . . . . . . . . . . . . . . . . . . 9

MOTOFEN. . . . . . . . . . . . . . . . . . . . . . . . . . .52

MOVIPREP . . . . . . . . . . . . . . . . . . . . . . . . . .52

MOXEzA . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

MOzOBIL . . . . . . . . . . . . . . . . . . . . . . . . . . .40

MULTAQ. . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

mupirocin . . . . . . . . . . . . . . . . . . . . . . . . . . .15

MUSTARGEN . . . . . . . . . . . . . . . . . . . . . . .29

MYCAMINE . . . . . . . . . . . . . . . . . . . . . . . . .24

MYCOBUTIN . . . . . . . . . . . . . . . . . . . . . . . .26

mycophenolate mofetil . . . . . . . . . . . . .64

MYFORTIC . . . . . . . . . . . . . . . . . . . . . . . . . .64

myorisan . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

MYOzYME . . . . . . . . . . . . . . . . . . . . . . . . . .51

MYRBETRIQ. . . . . . . . . . . . . . . . . . . . . . . . .54

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . .12

nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

nadolol/bendroflumethiazide. . . . . .45

nafcillin sodium . . . . . . . . . . . . . . . . . . . . .15

NAFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

NAGLAzYME . . . . . . . . . . . . . . . . . . . . . . .51

nalbuphine hcl . . . . . . . . . . . . . . . . . . . . . . . 9

NALLPEN. . . . . . . . . . . . . . . . . . . . . . . . . . . .16

naloxone hcl. . . . . . . . . . . . . . . . . . . . . . . . .11

naltrexone hcl . . . . . . . . . . . . . . . . . . . . . . .11

NAMENDA SOLUTION . . . . . . . . . . . . .20

NAMENDA TABLET 5MG . . . . . . . . . .20

NAMENDA TABLET 10MG . . . . . . . . .20

NAMENDA TITRATION PAk . . . . . . .20

mimvey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

minocycline hcl. . . . . . . . . . . . . . . . . . . . . .15

minoxidil . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

mirtazapine . . . . . . . . . . . . . . . . . . . . . . . . .21

mirtazapine odt . . . . . . . . . . . . . . . . . . . . .21

misoprostol. . . . . . . . . . . . . . . . . . . . . . . . . .52

mitomycin . . . . . . . . . . . . . . . . . . . . . . . . . . .29

mitoxantrone hcl. . . . . . . . . . . . . . . . . . . .29

M-M-R II . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

modafinil tablet 100mg . . . . . . . . . . . .74

modafinil tablet 200mg . . . . . . . . . . . .74

moexipril hcl . . . . . . . . . . . . . . . . . . . . . . . .45

moexipril/hctz. . . . . . . . . . . . . . . . . . . . . . .45

mometasone furoate cream, ointment, solution . . . . . . . . . . . . . . . . . .56

mononessa . . . . . . . . . . . . . . . . . . . . . . . . . .60

montelukast sodium . . . . . . . . . . . . . . . .72

MONUROL . . . . . . . . . . . . . . . . . . . . . . . . . .15

morphine sulfate er capsule 20mg, 30mg, 50mg, 60mg, 80mg, 100mg . . 9

morphine sulfate er tablet 15mg, 30mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

morphine sulfate er tablet 60mg, 100mg, 200mg . . . . . . . . . . . . . . . . . . . . . . . 9

morphine sulfate injection 0.5mg/ml, 1mg/ml, 4mg/ml, 10mg/ml, 15mg/ml . . . . . . . . . . . . . . . . . . 9

morphine sulfate oral solution 10mg/5ml . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

morphine sulfate oral solution 20mg/5ml . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

morphine sulfate oral solution 20mg/ml . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

methylprednisolone . . . . . . . . . . . . . . . .55

methylprednisolone acetate. . . . . . . .56

methylprednisolone dose pack . . . . .56

methylprednisolone sodiumsuccinate 40mg, 125mg . . . .56

methylprednisolone sodiumsuccinate 1000mg . . . . . . . . . .56

metipranolol . . . . . . . . . . . . . . . . . . . . . . . .69

metoclopramide hcl . . . . . . . . . . . . . . . .52

metolazone. . . . . . . . . . . . . . . . . . . . . . . . . .45

metoprolol/hctz . . . . . . . . . . . . . . . . . . . . .45

metoprolol succinate er tablet 25mg, 50mg, 100mg. . . . . . . . .45

metoprolol succinate er tablet 200mg . . . . . . . . . . . . . . . . . . . . . . . .45

metoprolol tartrate . . . . . . . . . . . . . . . . .45

METROGEL . . . . . . . . . . . . . . . . . . . . . . . . .15

METROGEL-VAGINAL. . . . . . . . . . . . . .15

metronidazole cream, lotion, tablet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

metronidazole gel 0.75% . . . . . . . . . . .15

metronidazole injection . . . . . . . . . . . .15

metronidazole vaginal. . . . . . . . . . . . . .15

mexiletine hcl . . . . . . . . . . . . . . . . . . . . . . .45

MIACALCIN . . . . . . . . . . . . . . . . . . . . . . . . .66

MICARDIS . . . . . . . . . . . . . . . . . . . . . . . . . . .45

MICARDIS HCT . . . . . . . . . . . . . . . . . . . . .45

miconazole 3 rx . . . . . . . . . . . . . . . . . . . . .24

microgestin . . . . . . . . . . . . . . . . . . . . . . . . .60

microgestin fe . . . . . . . . . . . . . . . . . . . . . . .60

midodrine hcl . . . . . . . . . . . . . . . . . . . . . . .45

migergot. . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

MIGRANAL. . . . . . . . . . . . . . . . . . . . . . . . . .25

92



CoveredDrugsIndex

NORDITROPIN FLEXPRO . . . . . . . . . .57

NORDITROPIN NORDIFLEX . . . . . . .57

norethindrone acetate . . . . . . . . . . . . . .60

NORMOSOL-M IN D5W . . . . . . . . . . .75

NORMOSOL-R . . . . . . . . . . . . . . . . . . . . . .75

NORMOSOL-R IN D5W . . . . . . . . . . . .75

NOROXIN . . . . . . . . . . . . . . . . . . . . . . . . . . .16

NORPACE CR . . . . . . . . . . . . . . . . . . . . . . .46

NOR-QD. . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

nortrel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

nortriptyline hcl capsule . . . . . . . . . . . .21

NORVIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

NOVOFINE & NOVOTWIST PEN NEEDLE . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

NOVOLIN 70/30 . . . . . . . . . . . . . . . . . . . .38

NOVOLIN N . . . . . . . . . . . . . . . . . . . . . . . . .38

NOVOLIN R . . . . . . . . . . . . . . . . . . . . . . . . .38

NOVOLOG . . . . . . . . . . . . . . . . . . . . . . . . . .38

NOVOLOG MIX 70/30 . . . . . . . . . . . . . .39

NOXAFIL . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

np thyroid . . . . . . . . . . . . . . . . . . . . . . . . . . .61

NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . . . .49

NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

NULYTELY/FLAVOR PACkS . . . . . . . .53

NUTROPIN . . . . . . . . . . . . . . . . . . . . . . . . . .57

NUTROPIN AQ . . . . . . . . . . . . . . . . . . . . . .57

NUVARING . . . . . . . . . . . . . . . . . . . . . . . . . .60

nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

nystatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

nystatin/triamcinolone . . . . . . . . . . . . .24

nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

NEURONTIN SOLUTION . . . . . . . . . . .19

NEVANAC . . . . . . . . . . . . . . . . . . . . . . . . . . .69

nevirapine tablet . . . . . . . . . . . . . . . . . . . .35

NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . . .29

NEXIUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

NEXIUM I.V. . . . . . . . . . . . . . . . . . . . . . . . . .53

NIACOR . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

nicardipine hcl . . . . . . . . . . . . . . . . . . . . . .45

NICOTROL INHALER . . . . . . . . . . . . . . .11

NICOTROL NS . . . . . . . . . . . . . . . . . . . . . .11

nifediac cc . . . . . . . . . . . . . . . . . . . . . . . . . . .45

nifedical xl . . . . . . . . . . . . . . . . . . . . . . . . . . .45

nifedipine. . . . . . . . . . . . . . . . . . . . . . . . . . . .45

nifedipine er . . . . . . . . . . . . . . . . . . . . . . . . .45

NILANDRON . . . . . . . . . . . . . . . . . . . . . . . .63

nimodipine . . . . . . . . . . . . . . . . . . . . . . . . . .45

NIPENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

nisoldipine. . . . . . . . . . . . . . . . . . . . . . . . . . .45

nisoldipine er . . . . . . . . . . . . . . . . . . . . . . . .45

NITRO-BID . . . . . . . . . . . . . . . . . . . . . . . . . .46

NITRO-DUR PATCH 0.3MG/HR, 0.8MG/HR . . . . . . . . . . . . . . . . . . . . . . . . . . .46

nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . .16

nitrofurantoin macrocrystalline. . . .16

nitrofurantoin monohydrate . . . . . . .16

nitroglycerin injection . . . . . . . . . . . . . .46

nitroglycerin transdermal patch . . .46

NITROLINGUAL PUMPSPRAY . . . . .46

NITROSTAT. . . . . . . . . . . . . . . . . . . . . . . . . .46

nizatidine capsule. . . . . . . . . . . . . . . . . . .53

nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

naphazoline hcl rx . . . . . . . . . . . . . . . . . .69

naproxen . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

naproxen dr . . . . . . . . . . . . . . . . . . . . . . . . .12

naproxen sodium tablet 275mg, 550mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

naratriptan hcl tablet 1mg . . . . . . . . .25

naratriptan hcl tablet 2.5mg . . . . . . .25

NASONEX . . . . . . . . . . . . . . . . . . . . . . . . . . .72

NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . . .24

nateglinide . . . . . . . . . . . . . . . . . . . . . . . . . .38

nature-throid. . . . . . . . . . . . . . . . . . . . . . . .61

nature-throid nt. . . . . . . . . . . . . . . . . . . . .61

NAVELBINE . . . . . . . . . . . . . . . . . . . . . . . . .29

NEBUPENT . . . . . . . . . . . . . . . . . . . . . . . . . .31

necon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

nefazodone hcl. . . . . . . . . . . . . . . . . . . . . .21

neomycin/bacitracin/polymyxin . . .16

neomycin/polymyxin/bacitracin/hydrocortisone . . . . . . . . . . . . . . . . . . . . . .16

neomycin/polymyxin b sulfates . . . .16

neomycin/polymyxin/ dexamethasone . . . . . . . . . . . . . . . . . . . . .69

neomycin/polymyxin/gramicidin . .16

neomycin/polymyxin/hc. . . . . . . . . . . .70

neomycin/polymyxin/ hydrocortisone ophthalmic suspension . . . . . . . . . . . . . . . . . . . . . . . . . .16

neomycin sulfate tablet. . . . . . . . . . . . .16

NEORAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . .64

NEPHRAMINE . . . . . . . . . . . . . . . . . . . . . .75

NEULASTA . . . . . . . . . . . . . . . . . . . . . . . . . .40

NEUMEGA . . . . . . . . . . . . . . . . . . . . . . . . . .40

NEUPOGEN . . . . . . . . . . . . . . . . . . . . . . . . .41

93



Covered Drugs Index

oxycodone/acetaminophen tablet 2.5mg/325mg, 5mg/325mg, 7.5mg/325mg, 10/325mg . . . . . . . . . .10

oxycodone/acetaminophen tablet 7.5mg/500mg . . . . . . . . . . . . . . . . . . . . . . .10

oxycodone/acetaminophen tablet 10mg /650mg . . . . . . . . . . . . . . . . . . . . . . .10

oxycodone/aspirin . . . . . . . . . . . . . . . . . .10

oxycodone hcl capsule, tablet . . . . . . . 9

oxycodone hcl concentrate . . . . . . . . . . 9

oxycodone/ibuprofen. . . . . . . . . . . . . . .10

OXYCONTIN ER TABLET 10MG, 15MG, 20MG, 30MG, 40MG, 60MG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

OXYCONTIN ER TABLET 80MG . . . .10

oxymorphone hcl . . . . . . . . . . . . . . . . . . .10

oxymorphone hcl er tablet 5mg, 7.5mg, 10mg, 15mg, 20mg, 30mg. .10

oxymorphone hcl er tablet 40mg . .10

Ppacerone . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

paclitaxel . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

palgic liquid . . . . . . . . . . . . . . . . . . . . . . . . .72

pamidronate disodium . . . . . . . . . . . . .67

PANCRELIPASE . . . . . . . . . . . . . . . . . . . . .51

PANDEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . . . .29

pantoprazole sodium injection. . . . .53

pantoprazole sodium tablet delayed release. . . . . . . . . . . . . . . . . . . . . .53

PARNATE . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

paromomycin sulfate . . . . . . . . . . . . . . .16

paroxetine hcl . . . . . . . . . . . . . . . . . . . . . . .21

OPANA ER TABLET 40MG . . . . . . . . . . 9

OPTIVAR . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

ORACEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

ORAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

ORAPRED ODT . . . . . . . . . . . . . . . . . . . . .56

ORENCIA IV 250MG . . . . . . . . . . . . . . . .64

ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

orphenadrine/asa/caffeine. . . . . . . . .74

orphenadrine citrate . . . . . . . . . . . . . . . .73

orphenadrine citrate er . . . . . . . . . . . . .74

orsythia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

ORTHO EVRA . . . . . . . . . . . . . . . . . . . . . . .60

ORTHO TRI-CYCLEN LO. . . . . . . . . . . .60

OSMOPREP . . . . . . . . . . . . . . . . . . . . . . . . .53

oxacillin sodium. . . . . . . . . . . . . . . . . . . . .16

oxaliplatin . . . . . . . . . . . . . . . . . . . . . . . . . . .29

OXANDRIN. . . . . . . . . . . . . . . . . . . . . . . . . .60

oxandrolone tablet 2.5mg . . . . . . . . . .60

oxandrolone tablet 10mg . . . . . . . . . .60

oxaprozin. . . . . . . . . . . . . . . . . . . . . . . . . . . .12

oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . . .37

oxcarbazepine. . . . . . . . . . . . . . . . . . . . . . .19

OXISTAT . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

OXSORALEN . . . . . . . . . . . . . . . . . . . . . . . .50

OXSORALEN ULTRA . . . . . . . . . . . . . . .50

oxybutynin chloride. . . . . . . . . . . . . . . . .54

oxybutynin chloride er tablet 5mg .54

oxybutynin chloride er tablet 10mg, 15mg. . . . . . . . . . . . . . . . . . . . . . . . .54

oxycodone/acetaminophen capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Oocella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

octreotide acetate injection 50mcg/ml, 100mcg/ml, 200mcg/ml . . . . . . . . . . . . . . . . . . . . . . . . . .62

octreotide acetate injection 1000mcg/ml, 500mcg/ml . . . . . . . . . .62

OCUFEN . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

ofloxacin. . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

ogestrel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

olanzapine/fluoxetine . . . . . . . . . . . . . .21

olanzapine injection . . . . . . . . . . . . . . . .33

olanzapine odt . . . . . . . . . . . . . . . . . . . . . .33

olanzapine tablet . . . . . . . . . . . . . . . . . . .33

OLUX-E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

omeprazole capsule delayed release rx . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

OMNARIS . . . . . . . . . . . . . . . . . . . . . . . . . . .72

OMNITROPE INJECTION 5.8MG . .57

OMNITROPE INJECTION 5MG/1.5ML, 10MG/1.5ML. . . . . . . . .57

ondansetron hcl injection . . . . . . . . . .22

ondansetron hcl oral solution . . . . . .22

ondansetron hcl tablet 4mg, 8mg. .22

ondansetron hcl tablet 24mg . . . . . .23

ondansetron odt 4mg, 8mg . . . . . . . .23

ONFI TABLET 5MG, 10MG . . . . . . . . .19

ONFI TABLET 20MG . . . . . . . . . . . . . . . .19

ONSOLIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

ONTAk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

OPANA ER TABLET 5MG, 7.5MG, 10MG, 15MG, 20MG, 30MG . . . . . . . . 9

94



CoveredDrugsIndex

potassium chloride er . . . . . . . . . . . . . . .75

potassium chloride injection . . . . . . .75

potassium chloride/nacl . . . . . . . . . . . .76

potassium chloride sr . . . . . . . . . . . . . . .75

potassium citrate tablet er. . . . . . . . . .76

POTIGA TABLET 50MG. . . . . . . . . . . . .19

POTIGA TABLET 200MG, 300MG, 400MG. . . . . . . . . . . . . . . . . . . . .19

PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . . . .41

pramipexole dihydrochloride. . . . . . .32

PRANDIN . . . . . . . . . . . . . . . . . . . . . . . . . . .39

pravastatin sodium tablet 10mg, 20mg. . . . . . . . . . . . . . . . . . . . . . . . .46

pravastatin sodium tablet 40mg . . .46

pravastatin sodium tablet 80mg . . .46

prazosin hcl . . . . . . . . . . . . . . . . . . . . . . . . .46

PRED-G. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

PRED-G S.O.P. . . . . . . . . . . . . . . . . . . . . . . .69

PRED MILD . . . . . . . . . . . . . . . . . . . . . . . . .69

prednicarbate . . . . . . . . . . . . . . . . . . . . . . .56

prednisolone acetate . . . . . . . . . . . . . . .69

prednisolone sodium phosphate ophthalmic solution 1% . . . . . . . . . . . .69

prednisolone sodium phosphate oral solution 5mg/5ml, 15mg/5ml . . . . . . . . . . . . . . . . . . . . . . . . . . .56

prednisone . . . . . . . . . . . . . . . . . . . . . . . . . .56

prednisone intensol . . . . . . . . . . . . . . . . .56

PREFEST. . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

PREMARIN CREAM. . . . . . . . . . . . . . . . .60

PREMARIN INJECTION . . . . . . . . . . . .60

PREMARIN TABLET. . . . . . . . . . . . . . . . .60

PREMASOL . . . . . . . . . . . . . . . . . . . . . . . . .76

PHENYTEk . . . . . . . . . . . . . . . . . . . . . . . . . .19

phenytoin . . . . . . . . . . . . . . . . . . . . . . . . . . .19

phenytoin sodium. . . . . . . . . . . . . . . . . . .19

phenytoin sodium extended. . . . . . . .19

PHISOHEX . . . . . . . . . . . . . . . . . . . . . . . . . .16

PHOSLO . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . . . . .54

PHOSPHOLINE IODIDE . . . . . . . . . . . .69

PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . . . . .67

PHYSIOSOL IRRIGATION . . . . . . . . . .67

pilocarpine hcl solution 1%, 2%, 4% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

pilocarpine hcl tablet . . . . . . . . . . . . . . .49

PILOPINE HS . . . . . . . . . . . . . . . . . . . . . . . .69

pindolol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

pioglitazone hcl . . . . . . . . . . . . . . . . . . . . .39

pioglitazone hcl/glimepiride . . . . . . .39

pioglitazone hcl/metformin hcl . . . .39

piperacillin sodium/tazobactam sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

piroxicam. . . . . . . . . . . . . . . . . . . . . . . . . . . .12

PLAN B ONE-STEP . . . . . . . . . . . . . . . . .60

PLASMA-LYTE-56/D5W . . . . . . . . . . .75

PLASMA-LYTE-148. . . . . . . . . . . . . . . . .75

PLASMA-LYTE A. . . . . . . . . . . . . . . . . . . .75

podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

polyethylene glycol 3350 powder . .53

polymyxin b sulfate . . . . . . . . . . . . . . . . .16

POMALYST . . . . . . . . . . . . . . . . . . . . . . . . . .29

portia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

potassium chloride/d5w. . . . . . . . . . . .75

potassium chloride/d5w/nacl . . . . . .76

PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

PATADAY . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

PATANOL . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

PAXIL SUSPENSION . . . . . . . . . . . . . . . .21

PCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

PEDIARIX . . . . . . . . . . . . . . . . . . . . . . . . . . .64

pedi-dri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

PEDVAX HIB . . . . . . . . . . . . . . . . . . . . . . . .65

PEGANONE . . . . . . . . . . . . . . . . . . . . . . . . .19

PEG-INTRON. . . . . . . . . . . . . . . . . . . . . . . .35

penicillin g potassium . . . . . . . . . . . . . .16

penicillin g procaine . . . . . . . . . . . . . . . .16

penicillin g sodium . . . . . . . . . . . . . . . . . .16

penicillin v potassium. . . . . . . . . . . . . . .16

PENTAM 300 . . . . . . . . . . . . . . . . . . . . . . . .31

PENTASA . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

pentazocine/acetaminophen . . . . . .10

pentazocine/naloxone hcl . . . . . . . . . .10

pentostatin . . . . . . . . . . . . . . . . . . . . . . . . . .29

pentoxifylline er . . . . . . . . . . . . . . . . . . . . .46

PERFOROMIST . . . . . . . . . . . . . . . . . . . . .72

perindopril erbumine . . . . . . . . . . . . . . .46

periogard . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

permethrin cream rx . . . . . . . . . . . . . . . .31

perphenazine . . . . . . . . . . . . . . . . . . . . . . .33

perphenazine/amitriptyline . . . . . . . .21

pfizerpen-g . . . . . . . . . . . . . . . . . . . . . . . . . .16

phenadoz suppository 12.5mg, 25mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

phenelzine sulfate. . . . . . . . . . . . . . . . . . .21

phenobarbital. . . . . . . . . . . . . . . . . . . . . . .19

95



Covered Drugs Index

PROQUAD . . . . . . . . . . . . . . . . . . . . . . . . . .65

PROSOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76

protriptyline hcl . . . . . . . . . . . . . . . . . . . . .21

PROVENTIL HFA . . . . . . . . . . . . . . . . . . . .72

PROVIGIL TABLET 100MG . . . . . . . . .74

PROVIGIL TABLET 200MG . . . . . . . . .74

PRUDOXIN . . . . . . . . . . . . . . . . . . . . . . . . . .50

PULMICORT FLEXHALER . . . . . . . . . .72

PULMICORT INHALATION SUSPENSION . . . . . . . . . . . . . . . . . . . . . . .72

PULMOzYME . . . . . . . . . . . . . . . . . . . . . . .72

pyrazinamide . . . . . . . . . . . . . . . . . . . . . . .26

pyridostigmine bromide . . . . . . . . . . . .25

QQUALAQUIN . . . . . . . . . . . . . . . . . . . . . . . .31

quasense . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

quetiapine fumarate tablet 25mg, 50mg, 100mg, 200mg. . . . . . .33

quetiapine fumarate tablet 300mg, 400mg . . . . . . . . . . . . . . . . . . . . . .33

quinapril hcl . . . . . . . . . . . . . . . . . . . . . . . . .46

quinapril hcl/hctz . . . . . . . . . . . . . . . . . . .46

quinidine gluconate . . . . . . . . . . . . . . . .46

quinidine gluconate cr . . . . . . . . . . . . . .46

quinidine sulfate . . . . . . . . . . . . . . . . . . . .46

quinidine sulfate er . . . . . . . . . . . . . . . . .46

quinine sulfate . . . . . . . . . . . . . . . . . . . . . .31

QVAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72

RRABAVERT . . . . . . . . . . . . . . . . . . . . . . . . . .65

ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

proctocream hc . . . . . . . . . . . . . . . . . . . . .56

procto-pak . . . . . . . . . . . . . . . . . . . . . . . . . .56

proctosol hc . . . . . . . . . . . . . . . . . . . . . . . . .56

proctozone-hc. . . . . . . . . . . . . . . . . . . . . . .56

progesterone capsule . . . . . . . . . . . . . . .60

PROGLYCEM . . . . . . . . . . . . . . . . . . . . . . . .39

PROGRAF CAPSULE 0.5MG, 1MG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65

PROGRAF CAPSULE 5MG . . . . . . . . .65

PROGRAF INJECTION. . . . . . . . . . . . . .65

PROLASTIN-C . . . . . . . . . . . . . . . . . . . . . .72

PROLEUkIN . . . . . . . . . . . . . . . . . . . . . . . . .29

PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

PROMACTA . . . . . . . . . . . . . . . . . . . . . . . . .41

promethazine hcl injection 25mg/ml, 50mg/ml . . . . . . . . . . . . . . . . .72

promethazine hcl suppository 12.5mg, 25mg. . . . . . . . . . . . . . . . . . . . . . .23

promethazine hcl syrup 6.25mg/5ml . . . . . . . . . . . . . . . . . . . . . . . . .72

promethazine hcl tablet 12.5mg, 25mg, 50mg. . . . . . . . . . . . . . . . . . . . . . . . .72

promethazine vc . . . . . . . . . . . . . . . . . . . .72

promethegan suppository 12.5mg, 25mg, 50mg . . . . . . . . . . . . . . .23

propafenone hcl . . . . . . . . . . . . . . . . . . . .46

propafenone hcl er . . . . . . . . . . . . . . . . . .46

propantheline bromide . . . . . . . . . . . . .53

proparacaine hcl . . . . . . . . . . . . . . . . . . . .69

propranolol hcl . . . . . . . . . . . . . . . . . . . . . .46

propranolol hcl er . . . . . . . . . . . . . . . . . . .46

propranolol hcl/hctz . . . . . . . . . . . . . . . .46

propylthiouracil . . . . . . . . . . . . . . . . . . . . .63

PREMPHASE . . . . . . . . . . . . . . . . . . . . . . . .60

PREMPRO . . . . . . . . . . . . . . . . . . . . . . . . . . .60

PRENATAL TABLET . . . . . . . . . . . . . . . . .76

prevalite powder . . . . . . . . . . . . . . . . . . . .46

previfem . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

PREVPAC . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

PREzISTA SUSPENSION . . . . . . . . . . .35

PREzISTA TABLET 75MG, 150MG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

PREzISTA TABLET 400MG, 600MG, 800MG. . . . . . . . . . . . . . . . . . . . .35

PRIFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

PRIMAQUINE PHOSPHATE . . . . . . . .31

PRIMAXIN IV . . . . . . . . . . . . . . . . . . . . . . . .16

primidone . . . . . . . . . . . . . . . . . . . . . . . . . . .19

PRIMSOL . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

PRISTIQ . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

PRIVIGEN . . . . . . . . . . . . . . . . . . . . . . . . . . .65

PROAIR HFA . . . . . . . . . . . . . . . . . . . . . . . .72

probenecid . . . . . . . . . . . . . . . . . . . . . . . . . .24

probenecid/colchicine . . . . . . . . . . . . . .24

procainamide hcl . . . . . . . . . . . . . . . . . . .46

PROCALAMINE . . . . . . . . . . . . . . . . . . . . .76

procentra . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

prochlorperazine. . . . . . . . . . . . . . . . . . . .33

prochlorperazine edisylate . . . . . . . . .33

prochlorperazine maleate . . . . . . . . . .33

PROCRIT 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML, 10000UNIT/ML . . . . . . . . . . . . . . . . . . . . .41

PROCRIT 20000UNIT/ML, 40000UNIT/ML . . . . . . . . . . . . . . . . . . . . .41

PROCTOCORT CREAM . . . . . . . . . . . . .56

96



CoveredDrugsIndex

rizatriptan benzoate odt 5mg . . . . . .25

rizatriptan benzoate odt 10mg. . . . .25

rizatriptan benzoate tablet 5mg . . .25

rizatriptan benzoate tablet 10mg . .25

ropinirole hcl . . . . . . . . . . . . . . . . . . . . . . . .32

ropinirole hcl er. . . . . . . . . . . . . . . . . . . . . .32

ROTATEQ . . . . . . . . . . . . . . . . . . . . . . . . . . . .65

roxicet solution . . . . . . . . . . . . . . . . . . . . . .10

roxicet tablet . . . . . . . . . . . . . . . . . . . . . . . .10

ROXICODONE TABLET 15MG, 30MG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

SSABRIL PACkET. . . . . . . . . . . . . . . . . . . . .19

SABRIL TABLET . . . . . . . . . . . . . . . . . . . . .19

SAIzEN INJECTION 5MG, 8.8MG .57

SAIzEN INJECTION CLICk.EASY 8.8MG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

salsalate . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

SAMSCA TABLET 15MG . . . . . . . . . . .76

SAMSCA TABLET 30MG . . . . . . . . . . .76

SANCUSO . . . . . . . . . . . . . . . . . . . . . . . . . . .23

SANDIMMUNE . . . . . . . . . . . . . . . . . . . . .65

SANDOSTATIN INJECTION 50MCG/ML . . . . . . . . . . . . . . . . . . . . . . . . .62

SANDOSTATIN INJECTION 100MCG/ML, 200MCG/ML, 500MCG/ML, 1000MCG/ML. . . . . . .62

SANDOSTATIN LAR DEPOT . . . . . . .62

SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

SAVELLA . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

SAVELLA TITRATION PACk . . . . . . . .49

RETROVIR IV INFUSION . . . . . . . . . . .35

REVIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

REVLIMID . . . . . . . . . . . . . . . . . . . . . . . . . . .29

REYATAz . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

RHEUMATREX . . . . . . . . . . . . . . . . . . . . . .65

ribapak tablet . . . . . . . . . . . . . . . . . . . . . . .35

ribasphere capsule 200mg . . . . . . . . .35

ribasphere tablet 200mg, 400mg . .35

ribasphere tablet 600mg . . . . . . . . . . .35

ribavirin capsule, tablet 200mg . . . .35

RIDAURA . . . . . . . . . . . . . . . . . . . . . . . . . . . .65

RIFADIN INJECTION. . . . . . . . . . . . . . . .26

rifampin . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

RIFATER . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

riluzole. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

rimantadine hcl . . . . . . . . . . . . . . . . . . . . .35

RINGERS INJECTION . . . . . . . . . . . . . . .76

RINGERS IRRIGATION . . . . . . . . . . . . . .67

RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

RISPERDAL CONSTA INJECTION 12.5MG, 25MG . . . . . . . . . . . . . . . . . . . . .33

RISPERDAL CONSTA INJECTION 37.5MG, 50MG . . . . . . . . . . . . . . . . . . . . .33

risperidone odt 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . . . . . . . . . . . . . . . . . .33

risperidone odt 4mg . . . . . . . . . . . . . . . .33

risperidone solution. . . . . . . . . . . . . . . . .33

risperidone tablet 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . . . . . . . . . . . . . . . . . .33

risperidone tablet 4mg . . . . . . . . . . . . .33

RITUXAN . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

rivastigmine tartrate. . . . . . . . . . . . . . . .20

RANEXA . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

ranitidine hcl capsule, injection, syrup. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

ranitidine hcl tablet 150mg, 300mg rx . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

RAPAFLO . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

RAPAMUNE SOLUTION . . . . . . . . . . . .65

RAPAMUNE TABLET 0.5MG . . . . . . .65

RAPAMUNE TABLET 1MG, 2MG . .65

RAVICTI . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

REBETOL CAPSULE . . . . . . . . . . . . . . . .35

REBETOL SOLUTION . . . . . . . . . . . . . . .35

REBIF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

REBIF TITRATION PACk . . . . . . . . . . . .49

reclipsen . . . . . . . . . . . . . . . . . . . . . . . . . . . . .60

RECOMBIVAX HB . . . . . . . . . . . . . . . . . . .65

RECTIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

REGONOL . . . . . . . . . . . . . . . . . . . . . . . . . . .25

REGRANEX . . . . . . . . . . . . . . . . . . . . . . . . . .50

RELAGARD. . . . . . . . . . . . . . . . . . . . . . . . . .16

RELENzA DISkHALER . . . . . . . . . . . . .35

RELISTOR . . . . . . . . . . . . . . . . . . . . . . . . . . .53

RELPAX TABLET 20MG . . . . . . . . . . . . .25

RELPAX TABLET 40MG . . . . . . . . . . . . .25

REMICADE . . . . . . . . . . . . . . . . . . . . . . . . . .65

REMODULIN . . . . . . . . . . . . . . . . . . . . . . . .72

RENVELA . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

reprexain . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

RESCRIPTOR . . . . . . . . . . . . . . . . . . . . . . . .35

reserpine. . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

RETIN-A MICRO . . . . . . . . . . . . . . . . . . . .50

97



Covered Drugs Index

ssd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

stagesic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

stavudine . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

sterile water irrigation . . . . . . . . . . . . . .67

STIMATE . . . . . . . . . . . . . . . . . . . . . . . . . . . .57

STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . . . .29

STRATTERA CAPSULE 10MG, 18MG, 25MG, 40MG . . . . . . . . . . . . . . .49

STRATTERA CAPSULE 60MG, 80MG, 100MG . . . . . . . . . . . . . . . . . . . . . .49

streptomycin sulfate . . . . . . . . . . . . . . . .17

STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

STROMECTOL . . . . . . . . . . . . . . . . . . . . . .31

SUBOXONE . . . . . . . . . . . . . . . . . . . . . . . . .11

SUCRAID . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

sucralfate tablet. . . . . . . . . . . . . . . . . . . . .53

sulfacetamide sodium ointment 10% . . . . . . . . . . . . . . . . . . . . . . .17

sulfacetamide sodium/ prednisolone sodium phosphate . . .69

sulfacetamide sodium suspension 10% . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . . .17

sulfamethoxazole/trimethoprim . . .17

sulfamethoxazole/ trimethoprim ds. . . . . . . . . . . . . . . . . . . . .17

SULFAMYLON . . . . . . . . . . . . . . . . . . . . . .17

sulfasalazine tablet . . . . . . . . . . . . . . . . .66

sulfazine ec . . . . . . . . . . . . . . . . . . . . . . . . . .66

sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

sumatriptan solution 5mg/act . . . . .25

sumatriptan solution 20mg/act. . . .25

simvastatin tablet 80mg. . . . . . . . . . . .47

SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

SkELID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

SkLICE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

sodium chloride 0.9% irrigation. . . .67

sodium chloride injection . . . . . . . . . .76

SODIUM EDECRIN . . . . . . . . . . . . . . . . .47

sodium fluoride tablet . . . . . . . . . . . . . .76

SODIUM LACTATE. . . . . . . . . . . . . . . . . .76

sodium phenylbutyrate . . . . . . . . . . . . .51

sodium polystyrene sulfonate suspension . . . . . . . . . . . . . . . . . . . . . . . . . .76

sodium sulfacetamide . . . . . . . . . . . . . .16

SOLARAzE . . . . . . . . . . . . . . . . . . . . . . . . . .50

SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . . .29

SOLU-CORTEF . . . . . . . . . . . . . . . . . . . . . .56

SOLU-MEDROL 40MG, 125MG, 500MG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

SOLU-MEDROL 1000MG, 2GM . . .56

SOMATULINE DEPOT . . . . . . . . . . . . . .62

SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . . .62

SORIATANE . . . . . . . . . . . . . . . . . . . . . . . . .50

sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

sotalol hcl . . . . . . . . . . . . . . . . . . . . . . . . . . .47

sotalol hcl (af). . . . . . . . . . . . . . . . . . . . . . .47

SPIRIVA HANDIHALER . . . . . . . . . . . . .72

spironolactone . . . . . . . . . . . . . . . . . . . . . .47

spironolactone/hctz . . . . . . . . . . . . . . . .47

SPORANOX SOLUTION . . . . . . . . . . . .24

sprintec . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

sronyx. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

SEASONIQUE . . . . . . . . . . . . . . . . . . . . . . .61

selegiline hcl. . . . . . . . . . . . . . . . . . . . . . . . .32

selenium sulfide lotion. . . . . . . . . . . . . .50

SELzENTRY . . . . . . . . . . . . . . . . . . . . . . . . .35

SEMPREX-D. . . . . . . . . . . . . . . . . . . . . . . . .72

SENSIPAR TABLET 30MG . . . . . . . . . .62



SEREVENT DISkUS . . . . . . . . . . . . . . . . .72

SEROMYCIN . . . . . . . . . . . . . . . . . . . . . . . .26

SEROQUEL XR TABLET 50MG, 300MG, 400MG. . . . . . . . . . . . . . . . . . . . .33

SEROQUEL XR TABLET 150MG, 200MG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

SEROSTIM . . . . . . . . . . . . . . . . . . . . . . . . . .57

sertraline hcl concentrate. . . . . . . . . . .22

sertraline hcl tablet 25mg, 50mg. . .22

sertraline hcl tablet 100mg . . . . . . . . .22

SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . . . .62

sildenafil citrate tablet 20mg . . . . . . .72

SILENOR . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

SILVADENE. . . . . . . . . . . . . . . . . . . . . . . . . .16

silver sulfadiazine . . . . . . . . . . . . . . . . . . .16

SIMBRINzA . . . . . . . . . . . . . . . . . . . . . . . . .69

SIMCOR TABLET ER 500MG/20MG, 500MG/40MG, 1000MG/40MG . . . . . . . . . . . . . . . . . . . . .47

SIMCOR TABLET ER 750MG/20MG, 1000MG/20MG . . .47

SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . . .65

simvastatin tablet 5mg, 10mg, 20mg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

simvastatin tablet 40mg. . . . . . . . . . . .47

98



CoveredDrugsIndex

TEVETEN HCT . . . . . . . . . . . . . . . . . . . . . .47

TEVETEN TABLET 400MG. . . . . . . . . .47

TEV-TROPIN . . . . . . . . . . . . . . . . . . . . . . . .57

THALOMID. . . . . . . . . . . . . . . . . . . . . . . . . .30

THEO-24 CAPSULE ER . . . . . . . . . . . . .73

theochron . . . . . . . . . . . . . . . . . . . . . . . . . . .73

theophylline cr . . . . . . . . . . . . . . . . . . . . . .73

theophylline er . . . . . . . . . . . . . . . . . . . . . .73

thioridazine hcl . . . . . . . . . . . . . . . . . . . . .33

thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

thiothixene . . . . . . . . . . . . . . . . . . . . . . . . . .33

THYMOGLOBULIN . . . . . . . . . . . . . . . . .65

THYROLAR . . . . . . . . . . . . . . . . . . . . . . . . . .61

tiagabine hcl . . . . . . . . . . . . . . . . . . . . . . . .19

ticlopidine hcl . . . . . . . . . . . . . . . . . . . . . . .41

TIGAN INJECTION . . . . . . . . . . . . . . . . . .23

TIkOSYN . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

TIMENTIN . . . . . . . . . . . . . . . . . . . . . . . . . . .17

timolol maleate gel . . . . . . . . . . . . . . . . .69

timolol maleate solution . . . . . . . . . . .70

timolol maleate tablet . . . . . . . . . . . . . .47

tinidazole. . . . . . . . . . . . . . . . . . . . . . . . . . . .31

tizanidine hcl . . . . . . . . . . . . . . . . . . . . . . . .34

TOBI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

TOBI PODHALER . . . . . . . . . . . . . . . . . . .17

TOBRADEX OINTMENT . . . . . . . . . . . .70

TOBRADEX ST . . . . . . . . . . . . . . . . . . . . . .70

tobramycin/dexamethasone . . . . . . .70

tobramycin sulfate . . . . . . . . . . . . . . . . . .17

tobramycin sulfate/sodium chloride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

TOBREX OINTMENT. . . . . . . . . . . . . . . .17

TAMIFLU CAPSULE 45MG . . . . . . . . .36


TAMIFLU SUSPENSION . . . . . . . . . . .36

tamoxifen citrate. . . . . . . . . . . . . . . . . . . .30

tamsulosin hcl. . . . . . . . . . . . . . . . . . . . . . .54

TARCEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

TARGRETIN . . . . . . . . . . . . . . . . . . . . . . . . .30

TARkA TABLET 1MG/240MG, 2MG/180MG, 2MG/240MG . . . . . . .47

TARkA TABLET 4MG/240MG . . . . . .47

TASIGNA . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

TASMAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

TAXOTERE. . . . . . . . . . . . . . . . . . . . . . . . . . .30

tazicef . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

TAzORAC . . . . . . . . . . . . . . . . . . . . . . . . . . .50

taztia xt. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

TEkAMLO . . . . . . . . . . . . . . . . . . . . . . . . . . .47

TEkTURNA . . . . . . . . . . . . . . . . . . . . . . . . . .47

TEkTURNA HCT . . . . . . . . . . . . . . . . . . . .47

temazepam . . . . . . . . . . . . . . . . . . . . . . . . .74

terazosin hcl . . . . . . . . . . . . . . . . . . . . . . . . .47

terbinafine hcl tablet. . . . . . . . . . . . . . . .24

terbutaline sulfate . . . . . . . . . . . . . . . . . .73

terconazole . . . . . . . . . . . . . . . . . . . . . . . . . .24

TESTIM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

testosterone cypionate . . . . . . . . . . . . .61

testosterone enanthate . . . . . . . . . . . . .61

TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT . . . . .65

tetanus toxoid adsorbed. . . . . . . . . . . .65

tetracycline hcl . . . . . . . . . . . . . . . . . . . . . .17

sumatriptan succinate injection 4mg/0.5ml, 6mg/0.5ml cartridge, syringe. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

sumatriptan succinate injection 6mg/0.5ml vial . . . . . . . . . . . . . . . . . . . . . .25

sumatriptan succinate tablet 25mg . . . . . . . . . . . . . . . . . . . . . . . . .25

sumatriptan succinate tablet 50mg . . . . . . . . . . . . . . . . . . . . . . . . .25

sumatriptan succinate tablet 100mg . . . . . . . . . . . . . . . . . . . . . . . .25

SUPRAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

SUSTIVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

SYLATRON . . . . . . . . . . . . . . . . . . . . . . . . .29

SYMBICORT. . . . . . . . . . . . . . . . . . . . . . . . .73

SYMLINPEN 60 . . . . . . . . . . . . . . . . . . . . .39

SYMLINPEN 120 . . . . . . . . . . . . . . . . . . . .39

SYNAGIS . . . . . . . . . . . . . . . . . . . . . . . . . . . .65

SYNALGOS-DC . . . . . . . . . . . . . . . . . . . . .10

SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . . . . .62

SYNERA . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

SYNERCID . . . . . . . . . . . . . . . . . . . . . . . . . . .17

SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

SYNTHROID . . . . . . . . . . . . . . . . . . . . . . . .61

SYPRINE. . . . . . . . . . . . . . . . . . . . . . . . . . . . .76

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

tacrolimus . . . . . . . . . . . . . . . . . . . . . . . . . . .65

TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . . . .30

TALWIN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10


99



Covered Drugs Index

TRISENOX . . . . . . . . . . . . . . . . . . . . . . . . . . .30

tri-sprintec. . . . . . . . . . . . . . . . . . . . . . . . . . .61

trivora . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

TRIzIVIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

TROPHAMINE . . . . . . . . . . . . . . . . . . . . . .76

trospium chloride . . . . . . . . . . . . . . . . . . .54

trospium chloride er . . . . . . . . . . . . . . . .54

TRUSOPT. . . . . . . . . . . . . . . . . . . . . . . . . . . .70

TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . . . .36

TUDORzA PRESSAIR. . . . . . . . . . . . . . .73

TWINRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . .65

TYGACIL. . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

TYkERB. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . . .65

TYSABRI. . . . . . . . . . . . . . . . . . . . . . . . . . . . .65

TYVASO . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73

TYzEkA . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

TYzINE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73

TYzINE PEDIATRIC . . . . . . . . . . . . . . . .73

Uu-cort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

ULORIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

UNASYN . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

UNITHROID . . . . . . . . . . . . . . . . . . . . . . . .61

UROCIT-k 15. . . . . . . . . . . . . . . . . . . . . . . .76

ursodiol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

UVADEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

VVAGIFEM . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

valacyclovir hcl. . . . . . . . . . . . . . . . . . . . . .36

TRELSTAR DEPOT 3.75MG . . . . . . . .62

TRELSTAR LA 11.25MG . . . . . . . . . . . .62

tretinoin capsule 10mg . . . . . . . . . . . . .30

tretinoin cream 0.025%, 0.05%, 0.1% . . . . . . . . . . . . . . . . . . . . . . . . .50

tretinoin gel 0.01%, 0.025% . . . . . . . .50

TREXALL . . . . . . . . . . . . . . . . . . . . . . . . . . . .65

triamcinolone acetonide cream 0.025%, 0.1%, 0.5% . . . . . . . . . . . . . . . . .56

triamcinolone acetonide inhaler 55mcg/act. . . . . . . . . . . . . . . . . . . . . . . . . . .73

triamcinolone acetonide lotion 0.025%, 0.1%. . . . . . . . . . . . . . . . . . . . . . . .56

triamcinolone acetonide ointment 0.025%, 0.1%, 0.5% . . . . . . . . . . . . . . . . .56

triamcinolone in orabase . . . . . . . . . . .49

triamterene/hctz . . . . . . . . . . . . . . . . . . . .47

triderm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

trifluoperazine hcl. . . . . . . . . . . . . . . . . . .33

trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . . .36

trihexyphenidyl hcl. . . . . . . . . . . . . . . . . .32

tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . . .61

TRILIPIX CAPSULE DELAYED RELEASE 45MG . . . . . . . . . . . . . . . . . . . . .47

TRILIPIX CAPSULE DELAYED RELEASE 135MG . . . . . . . . . . . . . . . . . . .47

trilyte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

trimethobenzamide hcl. . . . . . . . . . . . .23

trimethoprim. . . . . . . . . . . . . . . . . . . . . . . .17

trimethoprim sulfate/polymyxin b sulfate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

trimipramine maleate . . . . . . . . . . . . . .22

trinessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

tri-previfem. . . . . . . . . . . . . . . . . . . . . . . . . .61

tolazamide . . . . . . . . . . . . . . . . . . . . . . . . . .39

tolbutamide . . . . . . . . . . . . . . . . . . . . . . . . .39

tolmetin sodium . . . . . . . . . . . . . . . . . . . .12

tolterodine tartrate . . . . . . . . . . . . . . . . .54

topiramate . . . . . . . . . . . . . . . . . . . . . . . . . .19

toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

topotecan hcl. . . . . . . . . . . . . . . . . . . . . . . .30

TOPROL XL TABLET ER 25MG, 50MG, 100MG . . . . . . . . . . . . . .47

TOPROL XL TABLET ER 200MG . . .47

TORISEL . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65

torsemide. . . . . . . . . . . . . . . . . . . . . . . . . . . .47

TPN ELECTROLYTES . . . . . . . . . . . . . . .76

TRACLEER. . . . . . . . . . . . . . . . . . . . . . . . . . .73

TRADJENTA . . . . . . . . . . . . . . . . . . . . . . . . .39

tramadol hcl/acetaminophen. . . . . .10

tramadol hcl er capsule 150mg . . . .10

tramadol hcl er tablet 100mg . . . . . .10

tramadol hcl er tablet 200mg, 300mg . . . . . . . . . . . . . . . . . . . . . .10

tramadol hcl tablet 50mg . . . . . . . . . .10

trandolapril . . . . . . . . . . . . . . . . . . . . . . . . .47

tranexamic acid injection. . . . . . . . . . .41

TRANSDERM-SCOP . . . . . . . . . . . . . . . .23

tranylcypromine sulfate . . . . . . . . . . . .22

TRAVASOL . . . . . . . . . . . . . . . . . . . . . . . . . .76

TRAVATAN z . . . . . . . . . . . . . . . . . . . . . . . .70

travoprost . . . . . . . . . . . . . . . . . . . . . . . . . . .70

trazodone hcl. . . . . . . . . . . . . . . . . . . . . . . .22

TREANDA . . . . . . . . . . . . . . . . . . . . . . . . . . .30

TRECATOR . . . . . . . . . . . . . . . . . . . . . . . . . .26

TRELSTAR 22.5MG . . . . . . . . . . . . . . . . .62

100



CoveredDrugsIndex

VYTORIN . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

Wwarfarin sodium . . . . . . . . . . . . . . . . . . . .41

WELCHOL . . . . . . . . . . . . . . . . . . . . . . . . . . .48

westhroid. . . . . . . . . . . . . . . . . . . . . . . . . . . .61

westhroid-p . . . . . . . . . . . . . . . . . . . . . . . . .61

XXALkORI . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

XARELTO TABLET 10MG, 20MG . . .41

XARELTO TABLET 15MG . . . . . . . . . . .41

XENAzINE . . . . . . . . . . . . . . . . . . . . . . . . . .49

XEOMIN . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

XIAFLEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

XIFAXAN TABLET 200MG . . . . . . . . . .17

XIFAXAN TABLET 550MG . . . . . . . . . .17

XOLAIR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73

XOPENEX . . . . . . . . . . . . . . . . . . . . . . . . . . .73

XOPENEX CONCENTRATE . . . . . . . . .73

XOPENEX HFA . . . . . . . . . . . . . . . . . . . . . .73

XTANDI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63

XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

YYAz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

YERVOY . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

YF-VAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . . .73

zaleplon . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

VEXOL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

VFEND. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

VFEND IV. . . . . . . . . . . . . . . . . . . . . . . . . . . .24

V-GO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

VIBATIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

VICTOzA . . . . . . . . . . . . . . . . . . . . . . . . . . . .39

VICTRELIS . . . . . . . . . . . . . . . . . . . . . . . . . . .36

VIDAzA . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

VIDEX PEDIATRIC . . . . . . . . . . . . . . . . . .36

VIGAMOX . . . . . . . . . . . . . . . . . . . . . . . . . . .17

VIIBRYD . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

VIMPAT INJECTION . . . . . . . . . . . . . . . .20

VIMPAT ORAL SOLUTION . . . . . . . . .20

VIMPAT TABLET . . . . . . . . . . . . . . . . . . . .20

vinblastine sulfate . . . . . . . . . . . . . . . . . .30

vincasar pfs. . . . . . . . . . . . . . . . . . . . . . . . . .30

vincristine sulfate . . . . . . . . . . . . . . . . . . .30

vinorelbine tartrate . . . . . . . . . . . . . . . . .30

VIRACEPT . . . . . . . . . . . . . . . . . . . . . . . . . . .36

VIRAMUNE. . . . . . . . . . . . . . . . . . . . . . . . . .36

VIRAMUNE XR . . . . . . . . . . . . . . . . . . . . . .36

VIRAzOLE . . . . . . . . . . . . . . . . . . . . . . . . . . .73

VIREAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

VISTIDE . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

VIVITROL . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

VOLTAREN . . . . . . . . . . . . . . . . . . . . . . . . . .50

voriconazole injection . . . . . . . . . . . . . .24

voriconazole tablet . . . . . . . . . . . . . . . . .24

VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . . . .30

VPRIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

VUMON . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

valproate sodium . . . . . . . . . . . . . . . . . . .19

valproic acid. . . . . . . . . . . . . . . . . . . . . . . . .19

valsartan/hctz . . . . . . . . . . . . . . . . . . . . . .48

vancomycin hcl capsule 125mg . . . .17

vancomycin hcl capsule 250mg . . . .17

vancomycin hcl injection 1gm, 10gm . . . . . . . . . . . . . . . . . . . . . . . . . .17

vancomycin hcl injection 500mg, 750mg, 5000mg . . . . . . . . . . . . . . . . . . . .17

VANDAzOLE . . . . . . . . . . . . . . . . . . . . . . . .17

VANOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .56

VAQTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .65

VARIVAX . . . . . . . . . . . . . . . . . . . . . . . . . . . .65

VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

VELCADE . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

velivet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

VELTIN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

venlafaxine hcl . . . . . . . . . . . . . . . . . . . . . .22

venlafaxine hcl er capsule 37.5mg. .22

venlafaxine hcl er capsule 75mg . . .22

venlafaxine hcl er capsule 150mg . .22

VENLAFAXINE HCL ER TABLET 37.5MG, 150MG, 225MG . . . . . . . . . .22

VENLAFAXINE HCL ER TABLET 75MG . . . . . . . . . . . . . . . . . . . . . .22

VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . . . .73

VERAMYST . . . . . . . . . . . . . . . . . . . . . . . . . .73

verapamil hcl. . . . . . . . . . . . . . . . . . . . . . . .48

verapamil hcl er . . . . . . . . . . . . . . . . . . . . .48

verapamil hcl sr . . . . . . . . . . . . . . . . . . . . .48

VERDESO . . . . . . . . . . . . . . . . . . . . . . . . . . .56

VESICARE . . . . . . . . . . . . . . . . . . . . . . . . . . .54

101



Covered Drugs Index

zORBTIVE . . . . . . . . . . . . . . . . . . . . . . . . . . .57

zORTRESS TABLET 0.5MG, 0.75MG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66

zORTRESS TABLET 0.25MG . . . . . . .65

zOSTAVAX . . . . . . . . . . . . . . . . . . . . . . . . . .66

zOSYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

zovia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61

zOVIRAX CREAM, OINTMENT . . . .36

zYCLARA. . . . . . . . . . . . . . . . . . . . . . . . . . . .51

zYCLARA PUMP . . . . . . . . . . . . . . . . . . . .51

zYLET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

zYTIGA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

zYVOX INJECTION . . . . . . . . . . . . . . . . .18

zYVOX SUSPENSION . . . . . . . . . . . . . .18

zYVOX TABLET . . . . . . . . . . . . . . . . . . . . .18

zALTRAP . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

zANOSAR . . . . . . . . . . . . . . . . . . . . . . . . . . .30

zAVESCA . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

zazole cream . . . . . . . . . . . . . . . . . . . . . . . .24

zEGERID . . . . . . . . . . . . . . . . . . . . . . . . . . . .53

zELAPAR . . . . . . . . . . . . . . . . . . . . . . . . . . . .32

zELBORAF . . . . . . . . . . . . . . . . . . . . . . . . . .30

zEMAIRA . . . . . . . . . . . . . . . . . . . . . . . . . . . .73

zEMPLAR . . . . . . . . . . . . . . . . . . . . . . . . . . .67

zenchent fe . . . . . . . . . . . . . . . . . . . . . . . . . .61

zENPEP . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51

zERIT SOLUTION . . . . . . . . . . . . . . . . . .36

zETIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48

zETONNA . . . . . . . . . . . . . . . . . . . . . . . . . . .73

zIAGEN SOLUTION . . . . . . . . . . . . . . . .36

zIANA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

zidovudine . . . . . . . . . . . . . . . . . . . . . . . . . .36

zINECARD . . . . . . . . . . . . . . . . . . . . . . . . . .30

ziprasidone hcl . . . . . . . . . . . . . . . . . . . . . .33

zIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

zMAX. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

zOLADEX . . . . . . . . . . . . . . . . . . . . . . . . . . .62

zoledronic acid injection 4mg/5ml . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

zoledronic acid injection 5mg/100ml. . . . . . . . . . . . . . . . . . . . . . . . . .67

zOLINzA . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

zolpidem tartrate tablet 5mg. . . . . . .74

zolpidem tartrate tablet 10mg . . . . .74

zOMETA. . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

zONALON. . . . . . . . . . . . . . . . . . . . . . . . . . .50

zonisamide . . . . . . . . . . . . . . . . . . . . . . . . . .20

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823704 f 09/13 © 2013 Cigna. Some content provided under license.

This formulary was updated on 09/2013. For more recent information or other questions, please contact Cigna Medicare Select Plus Rx Customer Service at 1-800-627-7534 or, for TTY users, 711, 7 days a week, 8 am–8 pm (hours apply Monday – Friday, February 15 – September 30). Or visit www.cignamedicare.com.

This information is available for free in other languages. Please call our Customer Service number at 1-800-627-7534 (TTY 711), 8 am–8 pm, seven days a week (hours apply Monday – Friday, February 15 – September 30).

Esta información está disponible de forma gratuita en otros idiomas. Favor de contactar a nuestro Departamento de servicio al cliente al 1-800-627-7534 (TTY 711), de 8 a.m. a 8 p.m, siete días a la semana (horario se aplica de lunes – viernes, del 15 de febrero – 30 de septiembre).

Documents

Cigna Medicare Select Plus Rx (HMO) 2014 Comprehensive ......2014. To get updated information about the drugs covered by Cigna Medicare Select Plus Rx, please contact us. Our contact