HealthSelect MedicareRx Effective August, 1 2015€¦ · 01/08/2015 · SOLN 2mg/ml, 4mg/ml, 8mg/ml 3 B/D MORPHINE SULFATE SOLN 10mg/5ml, 20mg/5ml 1 morphine sulfate SOLN .5mg/ml,

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered under Medicare B or D LA - Limited Access

1

HealthSelect MedicareRx Effective August, 1 2015

Drug Name Drug Tier

Requirements/Limits

ANALGESICS GOUT allopurinol tab 1

ALOPRIM 3

colchicine w/ probenecid 1

COLCRYS 2

probenecid 1

ULORIC 2

MISCELLANEOUS diclofenac w/ misoprostol 1

DUEXIS 3

PRIALT 100mcg/ml, 500mcg/20ml

3 PA

VIMOVO 2

NSAIDS celecoxib CAPS 1

diclofenac potassium 1

diclofenac sodium TB24; TBEC

1

diflunisal 1

etodolac 1

etodolac er 1

fenoprofen calcium TABS 1

flurbiprofen TABS 1

ibuprofen SUSP 1

ibuprofen TABS 400mg, 600mg, 800mg

1

ketoprofen CAPS; CP24 1

mefenamic acid CAPS 1

MELOXICAM SUSP 1

meloxicam tabs 1

nabumetone TABS 1

NAPRELAN 3

naproxen SUSP; TABS; TBEC

1

NAPROXEN SOD TAB 500MG CR

1

naproxen sodium TABS 275mg, 550mg

1

oxaprozin 1

piroxicam CAPS 1

sulindac TABS 1

tolmetin sodium 1

Drug Name Drug Tier

Requirements/Limits

ZIPSOR 3

ZORVOLEX 3

OPIOID ANALGESICS acetaminophen w/ codeine SOLN

QL (5000 mL / 30 days)

1 QL

acetaminophen w/ codeine TABS

QL (400 tabs / 30 days)

1 QL

ASPIRIN-CAFFEINE-DIHYDROCODEINE BITARTRATE

1

butorphanol nasal spray QL (10 mL / 30 days)

1 QL

butorphanol tartrate SOLN 1

BUTRANS 2

capital and codeine QL (5000 mL / 30 days)

3 QL

CONZIP 3

hydrocodone-acetaminophen 2.5-325mg


1 QL

hydrocodone-acetaminophen 5-300mg


1 QL



1 QL



1 QL

hydrocodone-acetaminophen 7.5-325 mg/15ml

QL (5400 mL / 30 days)

1 QL



1 QL



1 QL

hydrocodone-acetaminophen tab 10-325mg


1 QL

hydrocodone-ibuprofen 2.5-200 mg

1

hydrocodone-ibuprofen tab 7.5-200 mg

1

ibudone 5-200 mg 1

ibudone tab 10-200mg 1

lorcet hd tab 10-325mg QL (360 tabs / 30 days)

1 QL


2

Drug Name Drug Tier

Requirements/Limits

lorcet plus tab 7.5-325 QL (360 tabs / 30 days)

1 QL

lorcet tab 5-325mg QL (360 tabs / 30 days)

1 QL

LORTAB ELIX QL (6000 mL / 30 days)

3 QL

lortab tab 5-325mg QL (360 tabs / 30 days)

1 QL

lortab tab 7.5-325 QL (360 tabs / 30 days)

1 QL

lortab tab 10-325mg QL (360 tabs / 30 days)

1 QL

reprexain 10/200 1

TRAMADOL HCL TB24 1

tramadol hcl er TB24 1

tramadol hcl er (biphasic) 100mg

1


1


1

tramadol hcl tab 50 mg 1

tramadol-acetaminophen QL (240 tabs / 30 days)

1 QL

trezix QL (360 caps / 30 days)

3 QL

vicodin QL (400 tabs / 30 days)

1 QL

vicodin es QL (400 tabs / 30 days)

1 QL

vicodin hp QL (400 tabs / 30 days)

1 QL

OPIOID ANALGESICS, CII ABSTRAL

QL (120 tabs / 30 days) 3 QL PA

CODEINE SULFATE 1

DILAUDID-HP INJ 250MG 3 B/D

DURAMORPH 1 B/D

EMBEDA CAPS 20-0.8MG 3


EMBEDA CAPS 50-2MG 3



EMBEDA CAPS 100-4MG 3

endocet QL (360 tabs / 30 days)

1 QL

ENDODAN TAB 1

Drug Name Drug Tier

Requirements/Limits

fentanyl citrate LPOP QL (120 lozenges / 30 days)

1 QL PA

fentanyl td patch 72hr 12 mcg/hr

1


1


1


1


1

FENTORA QL (120 tabs / 30 days)

2 QL PA

hydromorphone hcl LIQD 1

HYDROMORPHONE HCL SOLN 1mg/ml, 2mg/ml, 4mg/ml

1 B/D

hydromorphone hcl SOLN 500mg/50ml

1 B/D

hydromorphone hcl TABS 1

hydromorphone tab 8mg er 1



HYDROMORPHONE TABS 32MG

1

HYSINGLA ER 20mg, 30mg, 40mg, 60mg


3 QL

HYSINGLA ER 80mg, 100mg, 120mg


3 QL

INFUMORPH 200 3 B/D

INFUMORPH 500 3 B/D

KADIAN 40mg, 200mg 3

LAZANDA QL (30 bottles / 30 days)

2 QL PA

levorphanol tartrate TABS 1

methadone hcl CONC; SOLN; TABS

1

METHADONE INJ 10MG/ML 3

MORPHINE SUL 20MG/ML ORAL SOL

1

morphine sulfate CP24 1

MORPHINE SULFATE SOLN 1mg/ml, 10mg/ml, 15mg/ml

1 B/D


3

Drug Name Drug Tier

Requirements/Limits

MORPHINE SULFATE SOLN 2mg/ml, 4mg/ml, 8mg/ml

3 B/D

MORPHINE SULFATE SOLN 10mg/5ml, 20mg/5ml

1

morphine sulfate SOLN .5mg/ml, 1mg/ml

1 B/D

MORPHINE SULFATE TABS

1

morphine sulfate beads 1

morphine sulfate ext-rel tab 1

NUCYNTA 2

NUCYNTA ER 2

OPANA ER (CRUSH RESISTANT

2

OXECTA 3

OXYCODONE HCL CAPS; CONC

1

oxycodone hcl SOLN; TABS 1

oxycodone w/ acetaminophen 2.5-325mg


1 QL

oxycodone w/ acetaminophen 5-325mg


1 QL

oxycodone w/ acetaminophen 7.5-325mg


1 QL

oxycodone w/ acetaminophen 10-325mg


1 QL

oxycodone-aspirin 1

oxycodone-ibuprofen 1

OXYCONTIN 10mg, 15mg, 20mg, 30mg

2

OXYCONTIN 40mg, 60mg, 80mg


2 QL

oxymorphone hcl TABS 1

roxicet soln QL (1800 mL / 30 days)

2 QL

roxicet tabs QL (360 tabs / 30 days)

1 QL

SUBSYS QL (4 boxes / 30 days)

3 QL PA

XARTEMIS XR QL (120 tabs / 30 days)

3 QL

ZOHYDRO ER (ABUSE DETERRENT)

3

ANESTHETICS

Drug Name Drug Tier

Requirements/Limits

LOCAL ANESTHETICS lidocaine hcl (local anesth.) 1 B/D

lidocaine inj 0.5% 1 B/D

lidocaine inj 1% 1 B/D

lidocaine inj 1.5% 1 B/D

lidocaine inj 2% 1 B/D

ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 1

BETHKIS 3 B/D

gentamicin in saline inj 0.8 mg/ml

1


3

gentamicin in saline inj 1 mg/ml

1


1


3


1

gentamicin in saline inj 2 mg/ml

1

gentamicin sulfate SOLN 1

neomycin sulfate TABS 1

paromomycin sulfate CAPS 1

streptomycin sulfate SOLR 1

sulfadiazine TABS 3

TOBI PODHALER 3 PA

tobramycin NEBU 1 B/D

tobramycin sulfate SOLN; SOLR

1

tobramycin sulfate in saline 3

ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 2

ALINIA 2

atovaquone SUSP 1

AZACTAM 3

AZACTAM/DEX INJ 1GM 3

AZACTAM/DEX INJ 2GM 3

aztreonam 1

BILTRICIDE 2

CAYSTON 2 LA PA

clindamycin hcl CAPS 1

clindamycin palmitate hydrochloride

1


4

Drug Name Drug Tier

Requirements/Limits

clindamycin phosphate SOLN

1

clindamycin phosphate in d5w 1

colistimethate sodium SOLR 1

CUBICIN 3

DALVANCE 3

dapsone TABS 1

DARAPRIM 3

DORIBAX 3

FLAGYL ER 3

imipenem-cilastatin 1

INVANZ 3

ivermectin TABS 1

linezolid SOLN 1

MACRODANTIN 25mg 90 day limit if > 64 yr

2 PA

meropenem 1

methenamine hippurate 1

METRO IV 3

metronidazole CAPS; TABS 1

metronidazole inj 1

NEBUPENT 3 B/D

nitrofurantoin SUSP 90 day limit if > 64 yr

1 PA

nitrofurantoin macrocrystal 50mg

90 day limit if > 64 yr

1 PA

nitrofurantoin macrocrystal 100mg

90 day limit if >64 yr

1 PA

nitrofurantoin monohyd macro 90 day limit if > 64 yr

1 PA

PENTAM 300 3

polymyxin b sulfate SOLR 1

PRIMSOL SOL 50MG/5ML 3

SIVEXTRO 3

sulfamethoxazole-trimethop 1

sulfamethoxazole-trimethoprim inj

1

SYNERCID 3

trimethoprim TABS 1

TYGACIL 3

vancomycin hcl CAPS 1

vancomycin hcl SOLR 10gm, 500mg, 1000mg, 5000mg

1

vancomycin hcl SOLR 750mg

3

Drug Name Drug Tier

Requirements/Limits

XIFAXAN TAB 200MG 3

ZYVOX SUSR; TABS 2

ANTIFUNGALS ABELCET 3 B/D

AMBISOME 3 B/D

AMPHOTEC 3 B/D

amphotericin b SOLR 1 B/D

CANCIDAS 3

CRESEMBA 3

ERAXIS 3

fluconazole SUSR; TABS 1

fluconazole in dextrose 1

fluconazole inj nacl 100 3



flucytosine CAPS 1

griseofulvin microsize 1

griseofulvin ultramicrosize 1

itraconazole CAPS 1

ketoconazole TABS 1

LAMISIL PACK 3

MYCAMINE 3

NOXAFIL 3

nystatin TABS 1

ONMEL 3

SPORANOX SOL 10MG/ML 3

terbinafine hcl TABS 1

voriconazole SUSR; TABS 1

voriconazole inj 200mg 1

ANTIMALARIALS ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG

1

atovaquone-proguanil hcl tab 250-100 mg

1

chloroquine phosphate TABS

1

COARTEM 2

mefloquine hcl 1

PRIMAQUINE PHOSPHATE 3

quinine sulfate CAPS 1

ANTIRETROVIRAL AGENTS abacavir sulfate 1

APTIVUS 3

CRIXIVAN 3

didanosine 1

EDURANT 2


5

Drug Name Drug Tier

Requirements/Limits

EMTRIVA 2

EPIVIR SOL 10MG/ML 2

FUZEON 2

INTELENCE 2

INVIRASE 3

ISENTRESS 2

lamivudine 1

LEXIVA 3

NEVIRAPINE SUSP 1

nevirapine TABS; TB24 1

NORVIR 2

PREZISTA 2

RESCRIPTOR 2

RETROVIR IV INFUSION 3

REYATAZ 2

SELZENTRY 3

stavudine 1

SUSTIVA 2

TIVICAY 3

TYBOST 3

VIDEX PEDIATRIC 3

VIRACEPT 3

VIRAMUNE XR 100mg 2

VIREAD 2

VITEKTA 3

ZIAGEN SOLN 3

zidovudine 1

ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine-zidovudine

1

ATRIPLA 2

COMPLERA 3

EPZICOM 3

EVOTAZ 3

KALETRA SOL 2

KALETRA TAB 100-25MG 2

KALETRA TAB 200-50MG 2

lamivudine-zidovudine 1

PREZCOBIX 3

STRIBILD 2

TRIUMEQ 3

TRUVADA 2

ANTITUBERCULAR AGENTS CAPASTAT SULFATE 3

cycloserine CAPS 1

Drug Name Drug Tier

Requirements/Limits

ethambutol hcl TABS 1

isoniazid SOLN; SYRP 1

isoniazid tabs 1

paser d/r 3

PRIFTIN 3

pyrazinamide 1

rifabutin 1

rifamate 3

rifampin CAPS; SOLR 1

RIFATER 3

SIRTURO 3 LA

TRECATOR 3

ANTIVIRALS acyclovir CAPS; SUSP; TABS

1

acyclovir sodium 1 B/D

adefovir dipivoxil 1

BARACLUDE SOLN 2

cidofovir 1

entecavir 1

EPIVIR HBV SOLN 2

famciclovir TABS 1

foscarnet sodium 1

ganciclovir inj 500mg 1 B/D

HARVONI 2 PA

lamivudine (hbv) 1

moderiba pak 3 PA

moderiba tab 200mg 1 PA

OLYSIO 3 PA

REBETOL SOLN 2 PA

RELENZA DISKHALER 2

ribapak mis 600/day 3 PA

ribasphere 1 PA

ribasphere ribapak 800 3 PA



ribavirin 200mg 1 PA

rimantadine hydrochloride 1

SOVALDI 2 PA

TAMIFLU 2

TYZEKA 3

valacyclovir hcl TABS 1

VALCYTE SOLR 2

valganciclovir hcl 1

VICTRELIS 2 PA

CEPHALOSPORINS CEDAX SUSR 90mg/5ml 3


6

Drug Name Drug Tier

Requirements/Limits

cefaclor 1

cefaclor er tab 500mg 3

cefadroxil 1

cefazolin inj 1

cefazolin sodium 1gm, 20gm 1

cefazolin/dextrose 3

cefdinir 1

CEFEPIME 1GM SOLN 3

CEFEPIME 2GM SOLN 3

cefepime inj 1gm 1

cefepime inj 2gm 1

cefixime 1

cefotaxime sodium 1gm, 2gm, 500mg

1

cefotetan disodium 3

cefoxitin sodium 1

CEFOXITIN SODIUM IN DEXTROSE

3

cefpodoxime proxetil 1

cefprozil 1

ceftazidime 1gm, 2gm, 6gm 1

CEFTAZIDIME/DEXTROSE 3

ceftibuten 1

CEFTIN SUSR 3

ceftriaxone sodium SOLR 1gm, 2gm, 10gm, 250mg, 500mg

1

cefuroxime axetil 1

cefuroxime sodium 1.5gm, 7.5gm, 750mg

1

cefuroxime sodium soln iv 7.5 gm

3

cephalexin 1

claforan 1gm, 2gm 3

FORTAZ SOLN 3

FORTAZ SOLR 500mg 3

MAXIPIME 3

SUPRAX CAPS 2

suprax CHEW 2

suprax SUSR 100mg/5ml, 200mg/5ml

2

SUPRAX SUSR 500mg/5ml 2

tazicef SOLR 1

tazicef vial 1

TEFLARO 3

ZERBAXA 3

ZINACEF SOLR 750mg 3

Drug Name Drug Tier

Requirements/Limits

ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 1

azithromycin SOLR 500mg 1

azithromycin SUSR 1

azithromycin TABS 1

clarithromycin SUSR; TABS; TB24

1

DIFICID 2

e.e.s. 400 mg tab 1

E.E.S. GRANULES 3

ery-tab 3

ERYPED 200 3

ERYPED 400 3

erythrocin lactobionate 500mg

3

erythrocin stearate 1

erythromycin base 1

erythromycin cap 250mg ec 1

erythromycin ethylsuccinate 1

PCE 3

ZMAX 3

FLUOROQUINOLONES AVELOX SOLN 3

ciprofloxacin SOLN 200mg/20ml

1

ciprofloxacin SUSR 1

ciprofloxacin er 1

ciprofloxacin hcl TABS 1

ciprofloxacin in d5w 1

ciprofloxacn inj 1

FACTIVE 3

levofloxacin SOLN; TABS 1

levofloxacin in d5w 1

moxifloxacin hcl TABS 1

PENICILLINS amoxicillin 1

amoxicillin & pot clavulanate 1

ampicillin & sulbactam sodium 1

ampicillin cap 250mg 1

ampicillin cap 500 mg 1

ampicillin inj 1

ampicillin sodium 1

ampicillin susp 1

AUGMENTIN SUSR 3

BACTOCILL INJ DEX 1GM 3

BACTOCILL INJ DEX 2GM 3


7

Drug Name Drug Tier

Requirements/Limits

BICILLIN C-R 3

BICILLIN L-A 3

dicloxacillin sodium 1

nafcillin sodium 1

NALLPEN ISO-OSMOTIC IN DE

3

NALLPEN/DEXTROSE 3

oxacillin sodium 1

PENICILLIN G POT IN DEXTROSE

3

penicillin g potassium 1

penicillin g procaine 3

penicillin g sodium 1

penicillin v potassium 1

pfizerpen 1

piperacillin sodium-tazobactam sodium

1

ZOSYN SOLN 3

TETRACYCLINES demeclocycline hcl 1

DORYX 200mg 3

doxy inj 1

doxycycline (monohydrate) 1

doxycycline hyclate CAPS; SOLR; TABS; TBEC

1

minocycline hcl CAPS; TABS; TB24

1

SOLODYN 3

TETRACYCLINE HCL CAPS

1

VIBRAMYCIN SYRP 2

ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU 3 B/D

BUSULFEX 3 B/D

CYCLOPHOSPHAMIDE CAPS

2 B/D

cyclophosphamide SOLR 1 B/D

dacarbazine 200mg 1 B/D

EMCYT 2

GLEOSTINE 3

HEXALEN 2

IFEX 3gm 3 B/D

ifosfamide 1 B/D

ifosfamide for inj 1 gm 1 B/D

IFOSFAMIDE FOR INJ 3 GM 3 B/D

LEUKERAN 2

Drug Name Drug Tier

Requirements/Limits

LOMUSTINE 1

melphalan hcl 1 B/D

MUSTARGEN 3 B/D

TREANDA 3 B/D

ZANOSAR 3 B/D

ANTHRACYCLINES daunorubicin inj 5mg/ml 1 B/D

doxorubicin hcl 50mg 1 B/D

doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml

1 B/D

doxorubicin inj 50mg 1 B/D

EPIRUBICIN INJ 50MG 3 B/D

epirubicin inj 50mg/25ml 1 B/D

epirubicin inj 200mg 1 B/D

idarubicin hcl 1 B/D

VALSTAR 3 PA

ANTIBIOTICS bleomycin sulfate 1 B/D

COSMEGEN 3 B/D

mitomycin SOLR 1 B/D

ANTIMETABOLITES adrucil 1 B/D

ALIMTA 3 B/D

ARRANON 3 B/D

azacitidine 1 B/D

cladribine 1 B/D

CLOLAR 3 B/D

cytarabine inj 1 B/D

decitabine 1 B/D

fludarabine phosphate 1 B/D

fluorouracil SOLN 1 B/D

FOLOTYN 3 PA

GEMCITABINE INJ 1GM SOLN

3 B/D

gemcitabine inj 1gm SOLR 1 B/D

GEMCITABINE INJ 2GM SOLN

3 B/D

gemcitabine inj 2gm SOLR 1 B/D

GEMCITABINE INJ 200MG SOLN

3 B/D

gemcitabine inj 200mg SOLR

1 B/D

mercaptopurine TABS 1

methotrexate sodium inj 1 B/D

NIPENT 3 B/D

PURIXAN 3

TABLOID 2

ANTIMITOTIC, TAXOIDS ABRAXANE 3 B/D


8

Drug Name Drug Tier

Requirements/Limits

DOCETAXEL CONC 20mg/ml, 80mg/4ml

1 B/D

docetaxel CONC 140mg/7ml 3 B/D

DOCETAXEL SOLN 80mg/8ml, 200mg/20ml

3 B/D

paclitaxel 1 B/D

ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 1 B/D

vincasar 1 B/D

vincristine sulfate 1 B/D

vinorelbine tartrate 1 B/D

BIOLOGIC RESPONSE MODIFIERS ARZERRA 3 B/D

AVASTIN 3 B/D

ERBITUX 3 B/D

ERIVEDGE 3 LA PA

FARYDAK 3 LA PA

HERCEPTIN 3 B/D

IBRANCE 3 LA PA

ISTODAX 3 B/D

KADCYLA 3 B/D

LYNPARZA 3 PA

PERJETA 3 PA

PROLEUKIN 3 B/D

RITUXAN 2 PA

TORISEL 3 B/D

VECTIBIX 3 B/D

VELCADE 3 B/D

YERVOY 3 PA

ZALTRAP 3 PA

ZOLINZA 2 PA

HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS 1

bicalutamide 1

DEPO-PROVERA INJ 400/ML 3 B/D

ELIGARD INJ 7.5MG 3 B/D

ELIGARD INJ 22.5MG 3 B/D

ELIGARD INJ 30MG 3 B/D

ELIGARD INJ 45MG 3 B/D

exemestane 1

FARESTON 2

FASLODEX 2 B/D

FIRMAGON 3 B/D

flutamide 1

letrozole TABS 1

leuprolide acetate KIT 1 PA

LUPR DEP-PED INJ 15MG 2 PA

LUPR DEP-PED INJ 30MG (3-MONTH)

2 PA

Drug Name Drug Tier

Requirements/Limits

LUPRON DEP INJ 11.25MG 2 PA

LUPRON DEPOT 2 PA

LUPRON DEPOT INJ 22.5MG (3-MONTH)

2 PA

LUPRON DEPOT INJ 30MG (3-MONTH)

2 PA

LUPRON DEPOT INJ 45MG 2 PA

LUPRON DEPOT-PED 2 PA

LYSODREN 2

MEGACE ES 2

megestrol acetate SUSP; TABS

1 PA

NILANDRON 2

SOLTAMOX 3

tamoxifen citrate TABS 1

TRELSTAR MIXJECT 2 PA

VANTAS 3 PA

XTANDI 3 LA PA

ZOLADEX 2 PA

ZYTIGA 3 PA

KINASE INHIBITORS AFINITOR 2 PA

AFINITOR DISPERZ 2 PA

BOSULIF 2 PA

CAPRELSA 3 LA PA

COMETRIQ 3 PA

GILOTRIF TAB 20MG 3 LA PA



GLEEVEC 2 PA

ICLUSIG 2 LA PA

IMBRUVICA CAP 140MG 3 LA PA

INLYTA 3 LA PA

JAKAFI 3 LA PA

LENVIMA 10MG DAILY DOSE

3 LA PA


3 LA PA


3 LA PA


3 LA PA

MEKINIST 3 PA

NEXAVAR 2 LA PA

SPRYCEL 2 PA

STIVARGA 3 LA PA

SUTENT 2 PA

TAFINLAR 3 PA

TARCEVA 2 PA


9

Drug Name Drug Tier

Requirements/Limits

TASIGNA 2 PA

TYKERB 2 LA PA

VOTRIENT 2 PA

XALKORI 3 LA PA

ZELBORAF 3 LA PA

ZYDELIG 3 LA PA

ZYKADIA 3 LA PA

MISCELLANEOUS BLINCYTO 3 PA

CYRAMZA 100mg/10ml 3 PA

DROXIA 3

ERWINAZE 3 LA PA

GAZYVA 3 PA

HALAVEN 3 B/D

hydroxyurea CAPS 1

IXEMPRA KIT 3 B/D

JEVTANA 3 PA

KEYTRUDA SOLR 3 PA

MATULANE 2

mitoxantrone hcl 1 B/D

ONCASPAR 3 PA

OPDIVO 40mg/4ml 3 PA

POMALYST 2 LA PA

SYLATRON KIT 296MCG 2 PA



SYNRIBO 3 PA

TARGRETIN 2 PA

tretinoin CAPS 1

TRISENOX 3 B/D

UVADEX 3 B/D

PLATINUM-BASED AGENTS carboplatin 1 B/D

cisplatin 1 B/D

ELOXATIN 3 B/D

oxaliplatin 1 B/D

PROTECTIVE AGENTS amifostine crystalline 1 B/D

dexrazoxane 250mg 1 B/D

ELITEK 3 B/D

FUSILEV 3 PA

KEPIVANCE 3 B/D

leucovor ca inj 1 B/D

leucovorin calcium SOLR 1 B/D

leucovorin calcium TABS 1

leucovorin calcium 500 mg 3 B/D

mesna 1 B/D

MESNEX TABS 3

Drug Name Drug Tier

Requirements/Limits

TOPOISOMERASE INHIBITORS CAMPTOSAR 300mg/15ml 3 B/D

ETOPOPHOS 3 B/D

etoposide SOLN 500mg/25ml

1 B/D

irinotecan 1 B/D

irinotecan hcl 1 B/D

toposar 1gm/50ml 1 B/D

topotecan hcl SOLR 1 B/D

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl

1

benazepril & hydrochlorothiazide

1

captopril & hydrochlorothiazide

1

enalapril maleate & hydrochlorothiazide

1

fosinopril sodium & hydrochlorothiazide

1

lisinopril & hydrochlorothiazide

1

moexipril-hydrochlorothiazide 1

quinapril-hydrochlorothiazide 1

TARKA 2

trandolapril-verapamil hcl 1

ACE INHIBITORS benazepril hcl TABS 1

captopril TABS 1

enalapril maleate TABS 1

fosinopril sodium 1

lisinopril TABS 1

moexipril hcl 1

perindopril erbumine 1

quinapril hcl 1

ramipril 1

trandolapril 1

ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone 1

spironolactone TABS 1

ALPHA BLOCKERS doxazosin mesylate 1

prazosin hcl 1

terazosin hcl 1


10

Drug Name Drug Tier

Requirements/Limits

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan tab 5-160 mg

1

amlodipine besylate-valsartan tab 5-320 mg

1


1


1

amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg

1

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg

1

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg

1


1


1

AZOR 2

BENICAR HCT 2

candesartan cilexetil-hydrochlorothiazide

1

EDARBYCLOR 3

irbesartan-hydrochlorothiazide 1

losartan potassium & hydrochlorothiazide

1

telmisartan-amlodipine 1

telmisartan-hydrochlorothiazide

1

TEVETEN HCT 3

TRIBENZOR 2

valsartan-hydrochlorothiazide 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 2

candesartan cilexetil 1

EDARBI 3

eprosartan mesylate 1

irbesartan 1

losartan potassium 1

TELMISARTAN 1

valsartan 1

ANTIARRHYTHMICS amiodarone hcl 1

amiodarone inj 50mg/ml 1

disopyramide phosphate 1 PA

Drug Name Drug Tier

Requirements/Limits

flecainide acetate 1

mexiletine hcl 1

MULTAQ 3

NORPACE CR 2 PA

pacerone 1

propafenone hcl 1

quinidine gluconate er 1

quinidine sulfate TABS 1

sorine 1

sotalol hcl 1

sotalol hcl (afib/afl) 1

TIKOSYN 2

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 3

atorvastatin calcium TABS 1

CRESTOR 2

fluvastatin sodium 1

LESCOL XL 3

LIVALO 3

lovastatin 1

pravastatin sodium 1

simvastatin TABS 1

ANTILIPEMICS, MISCELLANEOUS ADVICOR 3

ANTARA 3

cholestyramine 1

cholestyramine light 1

choline fenofibrate 1

colestipol hcl 1

FENOFIBRATE CAPS 1

fenofibrate TABS 48mg, 54mg, 145mg, 160mg

1

fenofibrate micronized 1

FENOFIBRIC ACID 1

FENOGLIDE 3

gemfibrozil TABS 1

JUXTAPID 5mg, 10mg, 20mg

3 PA

KYNAMRO 3 PA

LIPTRUZET 3

niacin (antihyperlipidemic) 1

niacor 1

omega-3-acid ethyl esters 1

prevalite 1

SIMCOR 2


11

Drug Name Drug Tier

Requirements/Limits

TRIGLIDE 3

VASCEPA 3

VYTORIN 2

WELCHOL 2

ZETIA TAB 10MG 2

BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone 1

bisoprolol & hydrochlorothiazide

1

DUTOPROL 3

metoprolol & hctz tab 50-25mg

1


1


1

nadolol & bendroflumethiazide 1

propranolol & hydrochlorothiazide

1

BETA-BLOCKERS acebutolol hcl CAPS 1

atenolol TABS 1

betaxolol hcl 1

bisoprolol fumarate 1

BYSTOLIC 2

carvedilol 1

COREG CR 2

labetalol hcl SOLN; TABS 1

metoprolol succinate 1

metoprolol tartrate SOLN; TABS

1

nadolol TABS 1

pindolol 1

propranolol hcl er 1

propranolol inj 1mg/ml 1

propranolol sol 1

propranolol tab 1

SOTYLIZE 3

timolol maleate TABS 1

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS AMLODIPINE BESYLATE/ATORV

1

CALCIUM CHANNEL BLOCKERS afeditab cr 1

amlodipine besylate TABS 1

Drug Name Drug Tier

Requirements/Limits

CARDIZEM LA 120mg 3

cartia xt 1

dilt-cd cap 1

dilt-xr cap 1

diltiazem cap 120mg/24hr 1

diltiazem cap er/12hr 1

diltiazem hcl TABS 1

diltiazem hcl coated beads 1

diltiazem hcl er 1

diltiazem hcl extended release beads

1

diltiazem inj 25mg/5ml 1

diltiazem inj 50/10ml 1

diltiazem inj 100mg 3

diltiazem inj 125/25ml 1

diltzac 1

felodipine 1

isradipine 1

matzim la 1

nicardipine hcl CAPS 1

nifedical 1

nifedipine TB24 1

nifedipine er 1

nimodipine CAPS 1

nisoldipine 1

NYMALIZE 3

taztia xt 1

verapamil hcl CP24 100mg, 120mg, 180mg, 200mg, 240mg, 300mg

1

VERAPAMIL HCL CP24 360mg

1

verapamil hcl SOLN 1

verapamil hcl TABS 1

verapamil hcl TBCR 1

DIGITALIS GLYCOSIDES digitek 1

digoxin 1

digoxin inj 1

DIGOXIN SOL 50MCG/ML 1

LANOXIN PEDIATRIC 3

LANOXIN TAB 2

DIRECT RENIN INHIBITORS/COMBINATIONS TEKAMLO 2

TEKTURNA 2


12

Drug Name Drug Tier

Requirements/Limits

TEKTURNA HCT 2

DIURETICS acetazolamide CP12; TABS 1

acetazolamide sodium 1

ALDACTAZIDE TAB 50/50 3

amiloride & hydrochlorothiazide

1

amiloride hcl 1

bumetanide 1

chlorothiazide 1

chlorthalidone 25mg, 50mg 1

DIURIL SUS 250/5ML 3

DYRENIUM 3

EDECRIN 3

furosemide SOLN; TABS 1

furosemide inj 1

furosemide oral soln 8 mg/ml 2

hydrochlorothiazide CAPS; TABS

1

indapamide 1

methazolamide TABS 1

methyclothiazide 1

metolazone 1

spironolactone & hydrochlorothiazide

1

torsemide inj 20mg/2ml 3

torsemide inj 50mg/5ml 3

torsemide tabs 1

triamt/hctz cap 37.5-25 1

triamt/hctz cap 50-25mg 1

triamt/hctz tab 37.5-25 1

triamt/hctz tab 75-50mg 1

MISCELLANEOUS BIDIL 2

clonidine hcl PTWK; TABS 1

clorpres 1

DEMSER 3

DIBENZYLINE 3

hydralazine hcl SOLN; TABS 1

midodrine hcl 1

minoxidil TABS 1

RANEXA 2

NITRATES DILATRATE SR 3

ISORDIL TITRADOSE 40mg 2

isosorbide dinitrate 1

Drug Name Drug Tier

Requirements/Limits

isosorbide mononitrate 1

isosorbide mononitrate er 1

minitran 1

nitro-bid 3

NITRO-DUR .3mg/hr, .8mg/hr

2

NITROGLYCERIN .4mg/spray

1

NITROGLYCERIN LINGUAL 1

nitroglycerin patches 1

NITROLINGUAL SPR PUMPSPRA

2

NITROMIST 3

NITROSTAT 2

PULMONARY ARTERIAL HYPERTENSION ADCIRCA 2 PA

ADEMPAS 3 PA

FLOLAN 2 LA PA

LETAIRIS 2 LA PA

OPSUMIT 3 PA

ORENITRAM TAB 0.25MG 3 PA


ORENITRAM TAB 1MG 3 PA


REMODULIN 2 B/D LA

REVATIO SOLN 3 PA

REVATIO SUSR 2 PA

sildenafil citrate (pulmonary hypertension)

1 PA

TRACLEER 2 LA PA

TYVASO 2 B/D

VELETRI 3 LA PA

VENTAVIS 2 B/D

CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam CONC 3

alprazolam TABS 1

buspirone hcl TABS 1

fluvoxamine maleate 1

fluvoxamine maleate er 1

lorazepam CONC; SOLN; TABS

1

ANTICONVULSANTS APTIOM 3

BANZEL SUS 40MG/ML 3

BANZEL TAB 200MG 3

BANZEL TAB 400MG 3


13

Drug Name Drug Tier

Requirements/Limits

carbamazepine CHEW; CP12; SUSP; TABS; TB12

1

CELONTIN 3

clonazepam TABS; TBDP 1

clorazepate dipotassium 1

diazepam CONC; SOLN; TABS

1

DIAZEPAM GEL (ANTICONVULSANT)

1

dilantin 3

DILANTIN-125 3

divalproex sodium 1

epitol 1

ethosuximide CAPS; SOLN 1

felbamate 1

FYCOMPA 3

gabapentin CAPS; SOLN; TABS

1

GABITRIL 12mg, 16mg 2

LAMICTAL ODT 2

LAMICTAL STARTER 3

LAMICTAL XR KIT 2

lamotrigine CHEW; TABS; TB24; TBDP

1

levetiracetam SOLN; TABS; TB24

1

LEVETIRACETAM IN NACL 3

LYRICA 2

ONFI SUS 2.5MG/ML 3

ONFI TAB 10MG 3

oxcarbazepine 1

OXTELLAR XR 3

PEGANONE 3

phenobarbital ELIX; TABS 1 PA

PHENOBARBITAL SODIUM 65mg/ml

3 PA

phenobarbital sodium 130mg/ml

1 PA

phenytek 3

phenytoin CHEW; SUSP 1

phenytoin inj 50mg/ml 1

phenytoin sodium extended 1

POTIGA 3

primidone TABS 1

QUDEXY XR 3

SABRIL 3 LA PA

TEGRETOL 3

Drug Name Drug Tier

Requirements/Limits

TEGRETOL-XR 3

tiagabine hcl 1

topiramate CPSP; TABS 1

TOPIRAMATE CS24 1

TROKENDI XR 3

valproate sodium SOLN; SYRP

1

valproic acid CAPS 1

VIMPAT 2

zonisamide CAPS 1

ANTIDEMENTIA donepezil odt 5mg 1

donepezil odt 10mg 1

donepezil tab hcl 23mg 1

donepezil tabs 5mg 1

donepezil tabs 10mg 1

EXELON PATCHES 2

galantamine hydrobromide 1

NAMENDA SOL 10MG/5ML PA if <30 yr

2 PA

NAMENDA TAB PA if <30 yr

2 PA

NAMENDA XR PA if <30 yr

2 PA

NAMENDA XR TITRATION PACK

PA if <30 yr

2 PA

NAMZARIC 3

rivastigmine tartrate 1

ANTIDEPRESSANTS amitriptyline hcl TABS 1 PA

amoxapine 1

APLENZIN 3

BRINTELLIX 2

bupropion hcl TABS; TB12; TB24

1

citalopram hydrobromide 1

clomipramine hcl CAPS 1 PA

desipramine hcl TABS 1

doxepin hcl CAPS; CONC 1 PA

duloxetine hcl CPEP 20mg, 30mg, 60mg

1

EMSAM 3

escitalopram oxalate 1

FETZIMA 3

FETZIMA TITRATION PACK 3

fluoxetine hcl CAPS 1


14

Drug Name Drug Tier

Requirements/Limits

fluoxetine hcl CPDR 1

fluoxetine hcl SOLN 1

fluoxetine hcl TABS 10mg, 20mg

1

FLUOXETINE HCL TABS 60mg

2

FORFIVO XL 3

imipramine hcl TABS 1 PA

imipramine pamoate 1 PA

maprotiline hcl 1

MARPLAN 2

mirtazapine 1

nefazodone hcl 1

nortriptyline hcl CAPS; SOLN

1

paroxetine er tab 1

paroxetine hcl 1

PAXIL SUSP 3

PEXEVA 3

phenelzine sulfate TABS 1

PRISTIQ 2

protriptyline hcl 1

sertraline hcl CONC; TABS 1

SURMONTIL 3 PA

tranylcypromine sulfate 1

trazodone hcl TABS 1

venlafaxine cap er 1

venlafaxine hcl 1

venlafaxine tab 1

VENLAFAXINE TAB 225MG ER

1

venlafaxine tab er 1

VIIBRYD 2

ANTIPARKINSONIAN AGENTS amantadine hcl CAPS; SYRP; TABS

1

APOKYN 3 LA PA

AZILECT 2

benztropine mesylate SOLN 1

benztropine mesylate TABS 1 PA

bromocriptine mesylate CAPS; TABS

1

carbidopa TABS 1

carbidopa-levodopa 1

CARBIDOPA/LEVODOPA/ENTACAPONE

1

DUOPA 3 B/D

Drug Name Drug Tier

Requirements/Limits

entacapone 1

MIRAPEX .75mg 3

MIRAPEX ER 2

NEUPRO 2

pramipexole dihydrochloride 1

pramipexole dihydrochloride tab sr 24hr 0.75 mg

1


1


1

ropinirole hydrochloride 1

RYTARY 3

selegiline hcl CAPS; TABS 1

trihexyphenidyl hcl 1 PA

ZELAPAR 2

ANTIPSYCHOTICS ABILIFY 2

ABILIFY DISCMELT 2

ABILIFY INJ 9.75MG 2

ABILIFY MAINTENA 3

aripiprazole 1

chlorpromaz inj 25mg/ml 3

chlorpromazine hcl TABS 1

clozapine 1

CLOZAPINE ODT 1

CLOZAPINE ODT 150MG 1

CLOZAPINE ODT 200MG 1

FANAPT 3

FANAPT TITRATION PACK 3

FAZACLO 3

fluphenazine decanoate SOLN

1

fluphenazine hcl 1

GEODON INJ 3

haloperidol TABS 1

haloperidol decanoate SOLN 1

haloperidol lactate 1

INVEGA 3

INVEGA SUST INJ 39 MG/0.25 ML

3


3


3

INVEGA SUST INJ 156MG/ML

3


15

Drug Name Drug Tier

Requirements/Limits


3

INVEGA TRINZA 3

LATUDA 2

loxapine succinate 1

olanzapine 1

olanzapine odt 1

ORAP 3

perphenazine TABS 1

quetiapine fumarate 1

RISPERDAL INJ 12.5MG 2

RISPERDAL INJ 25MG 2

RISPERDAL INJ 37.5MG 2

RISPERDAL INJ 50MG 2

risperidone 1

risperidone odt 1

SAPHRIS 3

SEROQUEL XR 2

thioridazine hcl TABS 1 PA

thiothixene 1

trifluoperazine hcl 1

VERSACLOZ 3

ziprasidone hcl 1

ZYPREXA RELPREVV 3 B/D

ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine cap 10mg er 1

amphetamine cap 15mg er 1




amphetamine-dextroamphetamine cap sr 24hr 5 mg

1

amphetamine-dextroamphetamine tab 5 mg

1

amphetamine-dextroamphetamine tab 7.5 mg

1


1

amphetamine-dextroamphetamine tab 12.5 mg

1


1


1


1

Drug Name Drug Tier

Requirements/Limits

APTENSIO XR 3

DAYTRANA 2

guanfacine hcl (adhd) 1

metadate tab er 20 mg 1

METHYLIN CHEW TAB 2

methylphenidate hcl CHEW; CP24; CPCR; SOLN; TABS; TBCR

1

methylphenidate hcl er 1

QUILLIVANT XR 2

RITALIN LA 10mg, 60mg 3

STRATTERA 2

VYVANSE 2

HYPNOTICS ROZEREM 3

SILENOR 2

temazepam 7.5mg, 15mg 90 day limit if >64 yr

1

zolpidem tartrate TABS 90 day limit if >64 yr

1 PA

MIGRAINE ALSUMA 3

AXERT 3

cafergot tab 1-100mg 2

dihydroergotamine mesylate 1mg/ml

1

DIHYDROERGOTAMINE MESYLATE 4mg/ml

1

ergomar 3

FROVA TAB 2.5MG 3

migergot 1

naratriptan hcl 1

RELPAX 2

rizatriptan benzoate 1

SUMATRIPTAN SUCCINATE SOAJ

1

SUMATRIPTAN SUCCINATE SOCT

1

SUMATRIPTAN SUCCINATE SOLN 5mg/act, 20mg/act

1

sumatriptan succinate SOSY 1

sumatriptan succinate TABS 1

sumatriptan succinate inj SOAJ; SOLN

1

SUMATRIPTAN SUCCINATE INJ SOCT

1

SUMAVEL DOSEPRO 2

TREXIMET 2


16

Drug Name Drug Tier

Requirements/Limits

zolmitriptan TABS 1

zolmitriptan odt 1

ZOMIG NASAL SPRAY 2

MISCELLANEOUS BRISDELLE 2

EQUETRO 3

GRALISE 2

GRALISE STARTER 2

HETLIOZ 3 PA

HORIZANT 3

lithium carbonate CAPS; TABS; TBCR

1

LITHIUM CITRATE 3

MESTINON SYRUP 2

MESTINON TIMESPAN 2

NUEDEXTA 2

pyridostigmine bromide TABS

1

riluzole 1

SAVELLA 2

SAVELLA TITRATION PACK 2

XENAZINE 2 LA PA

MULTIPLE SCLEROSIS AGENTS AMPYRA 3 LA PA

AUBAGIO 3 PA

AVONEX 2 PA

AVONEX PEN 2 PA

BETASERON 3 PA

COPAXONE INJ 40MG/ML 2 PA

COPAXONE KIT 20MG/ML 2 PA

EXTAVIA 2 PA

GILENYA CAP 0.5MG 2 PA

LEMTRADA 3 LA PA

PLEGRIDY 2 PA

PLEGRIDY STARTER PACK 2 PA

REBIF 3 PA

REBIF REBIDOSE 3 PA

REBIF REBIDOSE TITRATION

3 PA

REBIF TITRATION PACK 3 PA

TECFIDERA CAP 120MG 2 PA

TECFIDERA CAP 240MG 2 PA

TECFIDERA MIS STARTER 2 PA

TYSABRI 3 LA PA

MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 1

cyclobenzaprine hcl TABS 5mg, 10mg

1 PA

Drug Name Drug Tier

Requirements/Limits

dantrolene sodium CAPS 1

tizanidine 1

NARCOLEPSY/CATAPLEXY modafinil 1

NUVIGIL 2

XYREM 2 LA PA

PSYCHOTHERAPEUTIC-MISC acamprosate calcium 1

BUNAVAIL MIS 2.1-0.3 3

BUNAVAIL MIS 4.2-0.7 3

BUNAVAIL MIS 6.3-1MG 3

buprenorphine hcl SUBL 1

buprenorphine hcl-naloxone hcl sl

1

buproban 1

CHANTIX 2 PA

CHANTIX CONTINUING MONTH

2 PA

CHANTIX STARTER PACK 2 PA

disulfiram TABS 1

naloxone hcl SOLN 1

naltrexone hcl TABS 1

NICOTROL INHALER 3

NICOTROL NS 3

SARAFEM 3

SUBOXONE MIS 2-0.5MG 3

SUBOXONE MIS 4-1MG 3



VIVITROL 3 PA

ZUBSOLV 2

ZUBSOLV SUB 8.6-2.1 2

ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM 2 PA

ANDROGEL 3 PA

ANDROGEL 1% 3 PA

ANDROGEL 1.62% 3 PA

ANDROGEL GEL PUMP 1% 3 PA

ANDROGEL PUMP 3 PA

AVEED 3 PA

AXIRON 2 PA

depo-testosterone 100mg/ml 3

FORTESTA 2 PA

oxandrolone TABS 1 PA

STRIANT 3 PA

TESTIM 3 PA


17

Drug Name Drug Tier

Requirements/Limits

testosterone cypionate SOLN

1

testosterone enanthate SOLN

1

VOGELXO 3 PA

VOGELXO PUMP 3 PA

ANTIDIABETICS, INJECTABLE ALCOHOL SWABS 2

APIDRA 2

APIDRA SOLOSTAR 2

BYDUREON 2

BYETTA 3

GAUZE PADS 2X2 2

HUMALOG 3

HUMALOG MIX 50/50 3

HUMALOG MIX 50/50 KWIKPEN

3

HUMALOG MIX 75/25 3

HUMALOG MIX 75/25 KWIKPEN

3

HUMULIN 70/30 3

HUMULIN 70/30 KWIKPEN 3

HUMULIN N 3

HUMULIN N KWIKPEN 3

HUMULIN R 3

HUMULIN R U-500 (CONCENTRATE)

2 B/D

INSULIN PEN NEEDLES 2

INSULIN SAFETY NEEDLES 2

INSULIN SYRINGES 2

LANTUS 2

LANTUS SOLOSTAR 2

LEVEMIR 2

LEVEMIR FLEXTOUCH 2

NOVOLIN 70/30 2

NOVOLIN 70/30 RELION 3

NOVOLIN N 2

NOVOLIN N RELION 3

NOVOLIN R 2

NOVOLIN R RELION 3

NOVOLOG 2

NOVOLOG MIX 70/30 2

NOVOLOG MIX 70/30 PREFILL

2

NOVOLOG PENFILL 2

SYMLINPEN 60 2

SYMLINPEN 120 2

Drug Name Drug Tier

Requirements/Limits

TANZEUM 3

TOUJEO SOLOSTAR 3

TRULICITY 3 PA

VICTOZA 2

ANTIDIABETICS, ORAL acarbose 1

ACTOPLUS MET XR 15-1000MG

3

ACTOPLUS MET XR 30-1000MG

3

FARXIGA 3

glimepiride 1

glipizide TABS 1

glipizide er 1

glipizide-metformin 2.5-250 mg

1

glipizide-metformin 2.5-500 mg

1

glipizide-metformin 5-500mg 1

GLUMETZA 3

GLYSET 3

GLYXAMBI 3

INVOKAMET TAB 50-500MG 2

INVOKAMET TAB 50-1000 2



INVOKANA TAB 100MG 2

INVOKANA TAB 300MG 2

JANUMET 2

JANUMET XR TAB 50-500MG

2

JANUMET XR TAB 50-1000 2

JANUMET XR TAB 100-1000 2

JANUVIA 2

JARDIANCE 3

JENTADUETO 2

KAZANO 3

KOMBIGLYZE XR 2.5-1000MG

3

KOMBIGLYZE XR 5-500MG 3

KOMBIGLYZE XR 5-1000MG 3

metformin er 1

metformin hcl TABS; TB24 1

nateglinide 1

NESINA 3

ONGLYZA 3

OSENI TAB 12.5-15MG 3


18

Drug Name Drug Tier

Requirements/Limits



OSENI TAB 25-15MG 3

OSENI TAB 25-30MG 3

OSENI TAB 25-45MG 3

pioglitazone hcl 1

pioglitazone hcl-glimepiride 1

pioglitazone hcl-metformin hcl 1

PRANDIMET 3

repaglinide 1

RIOMET 3

TRADJENTA 2

XIGDUO XR TAB 5-500MG 3



XIGDUO XR TAB 10-1000 3

BISPHOSPHONATES ACTONEL 5mg, 30mg, 35mg

2

alendronate sodium 1

ATELVIA 2

BINOSTO 3

FOSAMAX PLUS D 3

ibandronate sodium 1 B/D

pamidronate inj 6mg/ml 3 B/D

pamidronate inj 30/10ml 1 B/D

pamidronate inj 90/10ml 1 B/D

risedronate sodium 1

zoledronic inj 4mg/5ml 1 B/D

zoledronic inj 5/100ml 1 B/D

ZOMETA SOLN 3 B/D

CALCIUM RECEPTOR AGONISTS SENSIPAR 2

CHELATING AGENTS CHEMET 3

DEPEN TITRATABS 3

EXJADE 3 LA PA

FERRIPROX 3 PA

kionex 1

sodium polystyrene sulfonate 1

SYPRINE 3

CONTRACEPTIVES altavera 1

amethia 91 day 1

amethyst 28 day 1

apri 28 day 1

Drug Name Drug Tier

Requirements/Limits

aranelle 28 1

ashlyna 91 day 1

aubra 28 day 1

aviane 28 1

balziva 28 day 1

BEYAZ 2

briellyn 28 day 1

camila 28 day 1

CAMRESE LO TAB 1

cryselle 28 1

cyclafem 1/35 28 day 1

cyclafem 7/7/7 28 day 1

deblitane 28 day 1

delyla 28 day 1

DEPO-SUBQ PROVERA 104 2

desogestrel-ethinyl estradiol (biphasic)

1

drospirenone-ethinyl estradiol 1

ELLA 2

emoquette 1

enpresse 28 day 1

errin 28 day 1

falmina 28 day 1

GENERESS FE 3

GIANVI TAB 3-0.02MG 1

gildagia 1

gildess 1.5/30 21 day 1

gildess 24 fe 28 day 1

heather 1

introvale 91 day 1

JOLESSA TAB 0.15-0.03 MG 1

JOLIVETTE 1

junel 1.5/30 21 day 1

junel 1/20 21 day 1

junel fe 1.5/30 28 day 1

junel fe 1/20 28 day 1

kariva 28 day 1

kelnor 1/35 28 day 1

larin 1.5/30 1

larin 1/20 1

larin fe 1.5/30 1

larin fe 1/20 1

LEENA TAB 1

lessina 28 day 1

levonest 28 day 1


19

Drug Name Drug Tier

Requirements/Limits

levonorgestrel & eth estradiol 1

levonorgestrel (emergency oc)

1

levonorgestrel-ethinyl estradiol (91-day)

1

levonorgestrel-ethinyl estradiol (continuous)

1

levora 0.15/30 28 day 1

LO LOESTRIN FE 2

lomedia 24 fe 1

loryna 28 day 1

low-ogestrel 28 day 1

lutera 28 day 1

lyza 1

marlissa 28 day 1

medroxyprogesterone acetate (contraceptive)

1

microgestin 1.5/30 21 day 1

microgestin 1/20 21 day 1

microgestin fe 1.5/30 28 day 1

microgestin fe 1/20 28 day 1

MINASTRIN 24 FE 2

MONONESSA 1

my way 1

myzilra 1

necon 0.5/35 28 day 1

necon 1/35 28 day 1

NECON 7/7/7 1

necon 10/11 28 day 3

NECON TAB 1/50-28 1

next choice tab 1.5mg 1

nikki 28 day 1

NORA-BE TAB 1

norethin acet & estrad-fe 1

norethindrone & ethinyl estradiol-fe

1

norethindrone (contraceptive) 1

norgestimate-ethinyl estradiol (triphasic)

1

norlyroc 28 day 1

nortrel 0.5/35 28 day 1

nortrel 1/35 21 day 1

nortrel 1/35 28 day 1

nortrel 7/7/7 28 day 1

NUVARING 2

OCELLA TAB 3-0.03MG 1

ogestrel 28 day 1

Drug Name Drug Tier

Requirements/Limits

orsythia 28 day 1

ORTHO TRI-CYCLEN LO 2

philith 1

pimtrea pack 1

pirmella 1/35 28 day 1

portia 28 day 1

previfem 28 day 1

QUARTETTE 3

quasense 91 day 1

reclipsen 28 day 1

sharobel 28 day 1

SOLIA 1

sprintec 28 day 1

sronyx 28 day 1

syeda 1

tarina fe tab 1/20 1

tri-legest 28 day 1

tri-previfem 28 day 1

tri-sprintec 28 day 1

TRINESSA 1

trivora 28 day 1

velivet 28 day 1

vestura 1

viorele 1

vyfemia 28 day 1

WYMZYA FE 1

xulane dis 150-35 1

zarah 1

zenchent fe 28 day 1

zenchent tab 1

zovia 1/35e 28 day 1

zovia 1/50e 28 day 1

ENDOMETRIOSIS danazol CAPS 1

LUPANETA PACK 3 PA

SYNAREL 2

ENZYME REPLACEMENTS ADAGEN 3 LA PA

ALDURAZYME 3 LA PA

CARBAGLU 3 LA PA

CERDELGA 3 PA

CEREZYME 3 PA

CYSTADANE 3

CYSTAGON 3 PA

ELAPRASE 3 PA

ELELYSO 3 PA


20

Drug Name Drug Tier

Requirements/Limits

FABRAZYME 3 PA

KUVAN 2 PA

levocarnitine (metabolic modifiers)

1 B/D

LUMIZYME 3 PA

MYOZYME 3 PA

NAGLAZYME 3 LA PA

ORFADIN 3 PA

PROCYSBI 3 LA PA

sodium phenylbutyrate 1

VIMIZIM 3 PA

VPRIV 3 PA

ZAVESCA 3 LA PA

ESTROGENS ALORA 3 PA

COMBIPATCH 3 PA

depo-estradiol 3

DUAVEE 2 PA

estrace CREA 2

estradiol PTTW; PTWK; TABS

1 PA

ESTRADIOL VALERATE OIL 10mg/ml, 40mg/ml

1

estradiol valerate OIL 20mg/ml

1

ESTRING 3

FEMRING 3

MENOSTAR 3 PA

MINIVELLE 2 PA

PREMARIN 2 PA

PREMARIN CREAM 2

PREMARIN INJ 3

PREMPHASE 2 PA

PREMPRO 2 PA

VAGIFEM 2

GLUCOCORTICOIDS a-hydrocort 1

cortisone acetate TABS 1

DEPO-MEDROL INJ 20MG/ML

3 B/D

dexamethasone CONC 3

dexamethasone ELIX; SOLN; TABS

1

dexamethasone sodium phosphate

1

dexpak taperpak 13 day 2

FLO-PRED SUS 3 B/D

Drug Name Drug Tier

Requirements/Limits

fludrocortisone acetate TABS

1

hydrocortisone TABS 1

MEDROL TAB 2MG 3 B/D

methylpr ace inj 40mg/ml 1 B/D

methylpr ace inj 80mg/ml 1 B/D

methylpr ss inj 1gm 1 B/D

methylpr ss inj 40mg 1 B/D

methylpr ss inj 125mg 1 B/D

methylpred pak 4mg 1 B/D

methylpred tab 4mg 1 B/D




millipred 3 B/D

ORAPRED ODT TAB 10MG 2 B/D

pred sod pho sol 5mg/5ml 1 B/D

prednisolone sodium phosphate

1 B/D

prednisolone sol 15mg/5ml 1 B/D

prednisolone sol 25mg/5ml 1 B/D

prednisolone syrup 15 mg/5ml 1 B/D

prednisone con 5mg/ml 3 B/D

prednisone pak 5mg 1 B/D

prednisone pak 10mg 1 B/D

prednisone sol 5mg/5ml 1 B/D

prednisone tab 1mg 1 B/D

prednisone tab 2.5mg 1 B/D





RAYOS TAB 1MG 3 B/D

RAYOS TAB 2MG 3 B/D

RAYOS TAB 5MG 3 B/D

SOLU-CORTEF 3

SOLU-MEDROL INJ 2GM 3 B/D

veripred 3 B/D

GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 2

GLUCAGON EMERGENCY KIT

2

PROGLYCEM SUS 50MG/ML 3

HUMAN GROWTH HORMONES GENOTROPIN 3 PA

GENOTROPIN MINIQUICK 3 PA

HUMATROPE 2 PA

HUMATROPE COMBO PACK 2 PA

NORDITROPIN FLEXPRO 2 PA


21

Drug Name Drug Tier

Requirements/Limits

NORDITROPIN NORDIFLEX PEN

2 PA

NUTROPIN AQ INJ 20MG/2ML

3 PA

NUTROPIN AQ NUSPIN 5 3 PA

NUTROPIN AQ PEN 3 PA

OMNITROPE 5.8MG 3 PA

OMNITROPE 5MG 3 PA

OMNITROPE 10MG 3 PA

SAIZEN 3 PA

SAIZEN CLICK.EASY 3 PA

SEROSTIM 3 PA

TEV-TROPIN 3 PA

ZOMACTON 3 PA

ZORBTIVE 3 PA

MISCELLANEOUS AFREZZA 3

cabergoline 1

calcitonin (salmon) nasal spray

1

CHORIONIC GONADOTROPIN SOLR

1 PA

EGRIFTA 3 PA

FORTICAL SPR 200/ACT 3

H.P. ACTHAR 3 PA

INCRELEX 3 LA PA

KORLYM 3 LA PA

methylergonovine maleate TABS

1

MIACALCIN INJ 200U/ML 2 B/D

MYALEPT 3 PA

NOVAREL INJ 10000UNT 1 PA

octreotide acetate 1 PA

PREGNYL W/DILUENT BENZYL

1 PA

PROLIA 3

raloxifene hcl 1

RAVICTI 3 LA PA

SAMSCA 3 PA

SANDOSTATIN LAR DEPOT 3 PA

SIGNIFOR 3 PA

SOMATULINE DEPOT 3 PA

SOMAVERT 3 LA PA

SUPPRELIN LA 3 PA

XGEVA 3 PA

PARATHYROID HORMONES FORTEO 2 PA

PHOSPHATE BINDER AGENTS AURYXIA 3

Drug Name Drug Tier

Requirements/Limits

calcium acetate (phosphate binder)

1

FOSRENOL 3

PHOSLYRA 2

RENAGEL 3

RENVELA PAK 2

RENVELA TAB 800MG 2

VELPHORO 2

PROGESTINS CRINONE 2

MAKENA 3 PA

medroxyprogesterone acetate 1

norethindrone acetate TABS 1

progesterone micronized CAPS

1

THYROID AGENTS levothyroxine sodium TABS 1

LEVOXYL 1

liothyronine sodium SOLN; TABS

1

methimazole TABS 1

propylthiouracil TABS 1

SYNTHROID 2

TIROSINT 3

UNITHROID 1

VASOPRESSINS DESMOPRESSIN ACETATE SOLN

1

desmopressin acetate TABS 1

desmopressin acetate inj 1

desmopressin acetate spray 1

desmopressin acetate spray refrigerated

1

STIMATE 3 PA

GASTROINTESTINAL ANTIEMETICS AKYNZEO 3 B/D

ALOXI 3

CESAMET 3 B/D

compro supp 1

dronabinol 1 B/D

EMEND CAP 40MG 3 B/D



EMEND PAK 80 & 125 3 B/D

granisetron hcl SOLN 1

granisetron hcl TABS 1 B/D


22

Drug Name Drug Tier

Requirements/Limits

meclizine hcl TABS 1

metoclopramide hcl SOLN; TABS; TBDP

1

metoclopramide hcl inj 5 mg/ml

1

METOZOLV ODT 3

ondansetron hcl SOLN 1

ondansetron hcl TABS 1 B/D

ondansetron hcl inj 1

ondansetron hcl oral soln 1 B/D

ondansetron odt 1 B/D

phenadoz 1 PA

phenadoz sup 1 PA

phenergan SUPP 1 PA

phenergan supp 1 PA

prochlorperazine inj 5 mg/ml 1

prochlorperazine maleate TABS

1

prochlorperazine supp 1

promethazine hcl SOLN; SUPP; SYRP; TABS

1 PA

promethegan 1 PA

SANCUSO 2

TRANSDERM-SCOP 2 PA

ZUPLENZ 3 B/D

ANTISPASMODICS ATROPINE SULFATE SOLN .05mg/ml, .1mg/ml

1

BENTYL SOLN 3

CANTIL 3

CUVPOSA 3

dicyclomine hcl 1

glycate 3

glycopyrrolate SOLN; TABS 1

methscopolamine bromide TABS

1

H2-RECEPTOR ANTAGONISTS cimetidine TABS 1

cimetidine sol 300/5ml 1

famotidine SOLN 20mg/2ml, 40mg/4ml, 200mg/20ml

1

famotidine SUSR 1

famotidine TABS 20mg, 40mg

1

nizatidine 1

ranitidine hcl CAPS 1

ranitidine hcl SOLN 1

ranitidine hcl SYRP 1

Drug Name Drug Tier

Requirements/Limits

ranitidine hcl TABS 150mg, 300mg

1

INFLAMMATORY BOWEL DISEASE APRISO 2

ASACOL HD 3

balsalazide disodium 1

budesonide CP24 1

CANASA 2

colocort 1

DELZICOL 3

DIPENTUM 3

ENTYVIO 3 PA

GIAZO 3

HYDROCORTISONE (INTRARECTAL)

1

LIALDA 2

mesalamine enema 1

PENTASA 2

SF-ROWASA 2

sulfasalazine dr 1

sulfasalazine ir 1

UCERIS 3

LAXATIVES COLYTE-FLAVOR PACKS 3

constulose 1

enulose 1

gaviltye-g 1

gavilyte-c 1

gavilyte-h 1

gavilyte-n 1

generlac 1

GOLYTELY 3

kristalose 3

lactulose 1

lactulose (encephalopathy) 1

MOVIPREP 2

NULYTELY/FLAVOR PACKS 3

OSMOPREP 3

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate

1

peg 3350-potassium chloride-sod bicarbonate-sod chloride

1

polyethylene glycol 3350 PACK; POWD

1

PREPOPIK 3

RELISTOR 2


23

Drug Name Drug Tier

Requirements/Limits

SUCLEAR 2

SUPREP BOWEL PREP 2

trilyte 1

MISCELLANEOUS alosetron hcl 1

AMITIZA 2

amoxicillin-clarithromycin w/ lansoprazole

1

CARAFATE SUSP 2

cromolyn sodium (mastocytosis)

1

diphenoxylate w/ atropine 1

GATTEX 3 LA PA

LINZESS 2

loperamide hcl CAPS 1

LOTRONEX 2

misoprostol TABS 1

MOVANTIK 3

OMECLAMOX-PAK 3

PYLERA 2

SUCRAID 3

sucralfate TABS 1

ursodiol CAPS; TABS 1

XIFAXAN TAB 550MG 2

PANCREATIC ENZYMES CREON 2

PANCREAZE 3

PERTZYE 3

ULTRESA 2

VIOKACE 10 2

VIOKACE 20 2

ZENPEP 2

PROTON PUMP INHIBITORS ACIPHEX SPR CAP 5MG 3

ACIPHEX SPR CAP 10MG 3

DEXILANT 3

esomeprazole sodium 1

lansoprazole CPDR 1

NEXIUM 3

NEXIUM GRA 2.5MG DR 3

NEXIUM GRA 5MG DR 3

NEXIUM GRA 10MG DR 3



omeprazole CPDR 1

Drug Name Drug Tier

Requirements/Limits

OMEPRAZOLE-SODIUM BICARBONATE

1

pantoprazole sodium 1

PREVACID SOLUTAB 3

PRILOSEC PACK 3

PROTONIX PACK 3

rabeprazole sodium 1

ZEGERID PACK 3

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl 1

AVODART 2

CARDURA XL 3

finasteride TABS 5mg 1

JALYN 3

RAPAFLO 2

tamsulosin hcl 1

MISCELLANEOUS bethanechol chloride TABS 1

ELMIRON 2

POTASSIUM CITRATE (ALKALINIZER) TAB

1

URINARY ANTISPASMODICS ENABLEX 3

GELNIQUE 2

MYRBETRIQ 2

oxybutynin chloride 1

OXYTROL 3

TOLTERODINE TARTRATE ER

1

tolterodine tartrate tab 1 mg 1

tolterodine tartrate tab 2 mg 1

TOVIAZ 3

trospium chloride 1

trospium chloride er 1

VESICARE 2

VAGINAL ANTI-INFECTIVES CLEOCIN VAG SUPP 100MG 2

clindamycin cre 2% vag 1

metronidazole vaginal 1

miconazole nitrate vaginal 1

NUVESSA 3

terconazole vaginal 1

VANDAZOLE 1

zazole .4% 1

ZAZOLE .8% 1


24

Drug Name Drug Tier

Requirements/Limits

HEMATOLOGIC ANTICOAGULANTS COUMADIN 3

ELIQUIS TAB 2.5MG 2

ELIQUIS TAB 5MG 2

enoxaparin sodium 1

fondaparinux sodium 1

FRAGMIN 2

HEP SOD/NACL INJ 25000 1

HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML

1

heparin sod inj 1000u/ml 1 B/D

HEPARIN SOD INJ 2000U/ML

3 B/D

HEPARIN SOD INJ 2500U/ML

3 B/D

heparin sod inj 5000u/0.5ml 1 B/D




HEPARIN SODIUM/D5W 1

HEPARIN SODIUM/NACL 0.45%

3

jantoven 1

PRADAXA 2

SAVAYSA 3

warfarin sodium 1

XARELTO 2

XARELTO STARTER PACK 2

HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 2 PA

EPOGEN 2 PA

GRANIX 3 PA

LEUKINE 3 PA

MIRCERA 3 PA

MOZOBIL 2 PA

NEULASTA 2 PA

NEUMEGA 3 PA

NEUPOGEN 2 PA

PROCRIT 2 PA

MISCELLANEOUS anagrelide hcl 1

BERINERT 3 PA

cilostazol 1

CINRYZE 3 LA PA

DESFERAL 2gm 3 PA

FIRAZYR 2 PA

Drug Name Drug Tier

Requirements/Limits

KALBITOR 3 PA

NPLATE 250mcg 3 PA

pentoxifylline TBCR 1

PROMACTA 2 LA PA

RUCONEST 3 PA

SOLIRIS 2 PA

tranexamic acid SOLN; TABS

1

PLATELET AGGREGATION INHIBITORS AGGRENOX 2

BRILINTA 2

clopidogrel bisulfate 1

EFFIENT 2

ZONTIVITY 3

IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ACTEMRA 3 PA

CIMZIA 3 PA

ENBREL 2 PA

ENBREL SURECLICK 2 PA

HUMIRA 2 PA

HUMIRA PEN 2 PA

HUMIRA PEN-CROHNS STARTER KIT

2 PA

HUMIRA PEN-PSORIASIS STARTER KIT

2 PA

hydroxychloroquine sulfate 1

KINERET 3 PA

leflunomide TABS 1

methotrexate sodium tabs 1

ORENCIA 3 PA

OTEZLA 3 PA

OTREXUP 3 PA

REMICADE 3 PA

RHEUMATREX 2

SIMPONI 3 PA

SIMPONI ARIA 3 PA

trexall 2 B/D

XELJANZ 3 PA

IMMUNOGLOBULINS BIVIGAM 3 PA

CARIMUNE NANOFILTERED 3 PA

CYTOGAM 3 PA

FLEBOGAMMA 3 PA

FLEBOGAMMA DIF 3 PA

GAMASTAN S/D 2 B/D

GAMMAGARD LIQUID 3 PA


25

Drug Name Drug Tier

Requirements/Limits

GAMMAGARD S/D 3 PA

GAMMAGARD S/D IGA LESS TH

3 PA

GAMMAKED 3 PA

GAMMAPLEX 2.5gm/50ml, 5gm/100ml, 10gm/200ml

3 PA

GAMUNEX-C 3 PA

GAMUNEX-C 1GM/10ML 3 PA

HIZENTRA 1gm/5ml 3 PA

HYQVIA 3 PA

OCTAGAM 1gm/20ml, 2gm/20ml, 2.5gm/50ml, 5gm/100ml, 10gm/200ml, 25gm/500ml

3 PA

PRIVIGEN 3 PA

IMMUNOMODULATORS ACTIMMUNE 3 LA PA

ARCALYST 3 PA

GRASTEK 2

ILARIS 2 PA

INTRON-A INJ 10MU 2 B/D




PEG-INTRON 2 PA

PEG-INTRON REDIPEN 2 PA

PEGASYS 2 PA

PEGASYS PROCLICK 2 PA

PEGINTRON 80mcg/0.5ml, 120mcg/0.5ml, 150mcg/0.5ml

2 PA

RAGWITEK 2

REVLIMID 2 LA PA

THALOMID 2 PA

IMMUNOSUPPRESSANTS ASTAGRAF XL 3 B/D

ATGAM 3 B/D

azasan 2 B/D

azathioprine TABS 1 B/D

CELLCEPT INTRAVENOUS 3 B/D

cyclosporine CAPS; SOLN 1 B/D

cyclosporine modified (for microemulsion)

1 B/D

gengraf 1 B/D

mycophenolate mofetil 1 B/D

mycophenolate sodium 1 B/D

NEORAL 2 B/D

NULOJIX 3 B/D

PROGRAF CAPS 2 B/D

PROGRAF SOLN 3 B/D

Drug Name Drug Tier

Requirements/Limits

RAPAMUNE SOLN 2 B/D

SANDIMMUNE CAPS 2 B/D

SANDIMMUNE SOLN 2 B/D

SIMULECT 3 B/D

SIROLIMUS TABS 1 B/D

sirolimus tab 0.5 mg 1 B/D

tacrolimus CAPS 1 B/D

THYMOGLOBULIN 3 B/D

ZORTRESS TAB 0.5MG 3 B/D



MISCELLANEOUS BENLYSTA 3 PA

SYLVANT 3 PA

VACCINES ACTHIB 3

ADACEL 3

BCG VACCINE 3

BEXSERO 3

BOOSTRIX 3

CERVARIX 3

COMVAX 3

DAPTACEL 3

DIPHTHERIA/TETANUS TOXOID

3 B/D

ENGERIX-B SUSP 3 B/D

GARDASIL 3

GARDASIL 9 3

HAVRIX 3

HIBERIX 3

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

INFANRIX 3

IPOL INACTIVATED IPV 2

IXIARO 3

M-M-R II W/DILUENT 10 DOS

3

MENACTRA 3

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

MENVEO 3

PEDVAX HIB 3

PROQUAD 3

RABAVERT 3

RECOMBIVAX HB 3 B/D

ROTARIX 2

ROTATEQ 3

SYNAGIS 3

TENIVAC 3 B/D


26

Drug Name Drug Tier

Requirements/Limits

TETANUS TOXOID ADSORBED

3 B/D

TETANUS/DIPHTHERIA TOXOID

3 B/D

TRUMENBA 3

TWINRIX INJ 3

TYPHIM VI 3

VAQTA 3

VARIVAX 3

YF-VAX 3

ZOSTAVAX 3

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES ammonium chloride SOLN 3

KLOR-CON 8 1

KLOR-CON 10 1

klor-con m15 3

klor-con m20 1

klor-con pow 20meq 1

MAGNESIUM SULFATE SOLN 40mg/ml, 80mg/ml

3

magnesium sulfate SOLN 50%

1

MAGNESIUM SULFATE SOLN 50%

1

MAGNESIUM SULFATE IN D5W

3

potassium chloride LIQD 1

POTASSIUM CHLORIDE TBCR

1

potassium chloride caps er 1

potassium chloride microencapsulated crystals cr

1

SODIUM CHLORIDE SOLN 2.5meq/ml

1

SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN

1

TPN ELECTROLYTES 1 B/D

IV NUTRITION AMINOSYN 3 B/D

AMINOSYN 7%/ELECTROLYTES

3 B/D

AMINOSYN II 3 B/D

AMINOSYN II 8.5%/ELECTROL

1 B/D

AMINOSYN INJ 8.5/LYTE 1 B/D

AMINOSYN M 3 B/D

Drug Name Drug Tier

Requirements/Limits

AMINOSYN-HBC 3 B/D

AMINOSYN-PF 3 B/D

AMINOSYN-PF 7% 3 B/D

AMINOSYN-RF 3 B/D

CLINIMIX 2.75%/DEXTROSE 5%

3 B/D


3 B/D


3 B/D


3 B/D


3 B/D

CLINIMIX 5%/DEXTROSE 15%

3 B/D


3 B/D


3 B/D

CLINIMIX E 2.75%/DEXTROSE 5%

3 B/D


3 B/D

CLINIMIX E 4.25%/DEXTROSE

3 B/D


3 B/D


3 B/D

CLINIMIX E 5%/DEXTROSE 15%

3 B/D


3 B/D


3 B/D

clinisol 15 1 B/D

FREAMINE HBC 6.9% 3 B/D

FREAMINE III 3 B/D

HEPATAMINE 1 B/D

INTRALIPID INJ 20% 1 B/D

INTRALIPID INJ 30% 3 B/D

LIPOSYN III INJ 10% 3 B/D

NEPHRAMINE 3 B/D

NUTRILIPID EMU 20% 1 B/D

premasol 6% 1 B/D

premasol 10% 3 B/D

PROCALAMINE 3 B/D

PROSOL 3 B/D

travasol 10 3 B/D


27

Drug Name Drug Tier

Requirements/Limits

TROPHAMINE INJ 10% 3 B/D

IV REPLACEMENT SOLUTIONS DEXTROSE SOLN 50% 1

dextrose SOLN 70% 1

DEXTROSE 2.5%/NACL 0.45%

1

DEXTROSE 5% 1

DEXTROSE 5% /ELECTROLYTE

3

DEXTROSE 5%/LACTATED RING

1

DEXTROSE 5%/NACL 0.2% 1





DEXTROSE 5%/NACL 0.225%

1

DEXTROSE 5%/POTASSIUM CHL

1

DEXTROSE 10% FLEX CONTAIN

1

DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%

3

DEXTROSE 10%/NACL 0.45%

1

ELECTROLYTE-R IN DEXTROSE

3

IONOSOL-B/DEXTROSE 5% 3

IONOSOL-MB/DEXTROSE 5%

3

ISOLYTE P 3

isolyte s 3

KCL0.15%/D5W/NACL0.2% 1

KCL0.15%/D5W/NACL0.225%

3

kcl 0.3%/d5w/lr iv lac ri 3

KCL 0.3%/D5W/NACL 0.9% 3

KCL 0.3%/D5W/NACL 0.45% 1

KCL 0.15%/D5W/LR 3

KCL 0.15%/D5W/NACL 0.9% 1

KCL 0.075%/D5W/NACL 0.45%

1

LACTATED RINGERS VIAFLEX

1

normosol-m 1

NORMOSOL-R 3

PLASMA-LYTE A 3

Drug Name Drug Tier

Requirements/Limits

PLASMA-LYTE-56/D5W 3

PLASMA-LYTE-148 3

potassium chloride SOLN 1

POTASSIUM CHLORIDE 0.3%/D

1

POTASSIUM CHLORIDE 0.15%

1

POTASSIUM CHLORIDE 0.22%

1

potassium chloride in nacl 1

POTASSIUM CHLORIDE IN NACL

1

RINGER'S 1

SODIUM CHLORIDE SOLN .9%, 3%, 5%

1

SODIUM CHLORIDE 0.45% VIA

1

VITAMINS calcitriol CAPS; SOLN 1 B/D

doxercalciferol 1 B/D

paricalcitol CAPS 1 B/D

PARICALCITOL SOLN 3 B/D

PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)

1

ZEMPLAR SOLN 3 B/D

OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc 1

blephamide OINT 3

BLEPHAMIDE SUSP 3

neomycin-polymy-dexameth 1

neomycin-polymyxin-hc (ophth)

1

PRED-G 3

PRED-G S.O.P. 3

sulfacetamide sod-prednisolone

1

TOBRADEX OINT 2

TOBRADEX ST 2

tobramycin-dexamethasone 1

ZYLET 2

ANTI-INFECTIVES AZASITE 3

bacitracin (ophthalmic) 1

bacitracin-polymyxin b (ophth) 1

BESIVANCE 2

CILOXAN OIN 0.3% OP 3

ciprofloxacin hcl (ophth) 1


28

Drug Name Drug Tier

Requirements/Limits

erythromycin (ophth) 1

gatifloxacin (ophth) 1

gentak 1

gentamicin sulfate (ophth) 1

ilotycin 1

levofloxacin (ophth) 1

MOXEZA 2

NATACYN 2

neomycin-bacitracin zn-polymyxin

1

neomycin-polymyxin-gramicidin

1

ofloxacin (ophth) 1

polymyxin b-trimethoprim 1

sulfacetamide sodium (ophth) 1

tobramycin (ophth) 1

TOBREX OINT 0.3% 3

trifluridine SOLN 1

VIGAMOX 2

ZIRGAN 3

ANTI-INFLAMMATORIES ACUVAIL 3

ALREX 2

bromfenac sodium (ophth) 1

BROMFENAC SODIUM (OPHTH)(ONCE-DAILY)

1

dexamethasone sodium phosphate (ophth)

1

diclofenac sodium (ophth) 1

DUREZOL 2

FLAREX 3

FLUOROMETHOLONE (OPHTH)

1

flurbiprofen sodium 1

FML 3

FML FORTE 3

ILEVRO 3

ketorolac tromethamine (ophth)

1

LOTEMAX 2

MAXIDEX 3

NEVANAC 3

PRED MILD 3

PREDNISOLONE ACETATE (OPHTH)

1

prednisolone sodium phosphate (ophth)

3

Drug Name Drug Tier

Requirements/Limits

VEXOL 3

ANTIALLERGICS ALOCRIL 3

ALOMIDE 3

azelastine hcl (ophth) 1

BEPREVE 3

cromolyn sodium (ophth) 1

EMADINE 3

epinastine hcl (ophth) 1

LASTACAFT 3

PATADAY 2

PATANOL 2

PAZEO 3

ANTIGLAUCOMA ALPHAGAN P 0.1% 2

ALPHAGAN P 0.15% 2

AZOPT 2

betaxolol hcl (ophth) 1

BETIMOL 2

BETOPTIC-S 2

brimonidine sol 0.2% 1

BRIMONIDINE SOL 0.15% 1

carteolol hcl (ophth) 1

COMBIGAN 2

COSOPT PF 2

dorzolamide hcl 1

dorzolamide hcl-timolol maleate

1

ISTALOL 3

latanoprost SOLN 1

levobunolol hcl .5% 1

LEVOBUNOLOL HCL .25% 1

LUMIGAN 3

metipranolol 1

PHOSPHOLINE IODIDE 3

PILOCARPINE HCL SOLN 1

SIMBRINZA SUS 1-0.2% 2

timolol maleate (ophth) 1

TIMOLOL MALEATE GEL 1

TIMOPTIC OCUDOSE 3

TRAVATAN Z 2

ZIOPTAN 2

MISCELLANEOUS BOTOX INJ 100UNIT 3 PA

BOTOX INJ 200UNIT 3 PA

CYSTARAN 3 PA


29

Drug Name Drug Tier

Requirements/Limits

DYSPORT 3 PA

EYLEA 3 PA

LACRISERT 3

LUCENTIS 3 PA

MYOBLOC 2500unit/0.5ml 3 PA

naphazoline 0.1% 1

PROLENSA 2

proparacaine hcl SOLN 1

RESTASIS 2

XEOMIN 3 PA

RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPT AER 62.5-25 2

COMBIVENT RESPIMAT 2

ipratropium-albuterol 1 B/D

ANTICHOLINERGICS ATROVENT HFA 3

INCRUSE ELLIPTA 3

ipratropium bromide (nasal) 1

ipratropium sol inhal 1 B/D

SPIRIVA HANDIHALER 2

SPIRIVA RESPIMAT 2

TUDORZA PRESSAIR 3

TUDORZA PRESSAIR (INSTITUTIONAL PACK) 400MCG/ACT

3

ANTIHISTAMINE COMBINATIONS CLARINEX-D TAB 2.5-120 3

DYMISTA SPR 137-50 3

SEMPREX-D 3

ANTIHISTAMINES ASTEPRO 2

azelastine spr 0.1% 1

azelastine spr 0.15% 1

cetirizine syrup 1

CLARINEX SYRP 3

desloratadine 1

diphenhydram inj 50mg/ml 1

hydroxyzine hcl SOLN; TABS

1 PA

hydroxyzine hcl inj 1 PA

hydroxyzine pamoate CAPS 1 PA

levocetirizine soln 2.5mg/5ml 1

levocetirizine tab 5 mg 1

olopatadine hcl (nasal) 1

BETA AGONISTS

Drug Name Drug Tier

Requirements/Limits

albuterol sulfate NEBU 1 B/D

albuterol sulfate SYRP; TABS

1

albuterol sulfate er 1

ARCAPTA NEOHALER 2

BROVANA 3 B/D

FORADIL AEROLIZER 2

levalbuterol conc 1.25mg/0.5ml

1 B/D

LEVALBUTEROL HCL NEBU 1.25mg/3ml

1 B/D

levalbuterol hcl NEBU .31mg/3ml, .63mg/3ml

1 B/D

PERFOROMIST 2 B/D

PROAIR HFA 2

PROAIR RESPICLICK 3

PROVENTIL HFA 2

SEREVENT DISKUS 2

STRIVERDI RESPIMAT 3

terbutaline sulfate SOLN; TABS

1

VENTOLIN HFA 3

XOPENEX HFA 3

LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium CHEW; PACK; TABS

1

zafirlukast 1

ZYFLO CR 3

MAST CELL STABILIZERS cromolyn sodium NEBU 1 B/D

MISCELLANEOUS acetylcysteine SOLN 10%, 20%

1 B/D

ARALAST NP 3 LA PA

AUVI-Q 2

DALIRESP 2

EPINEPHRINE SOAJ 1

EPIPEN 2-PAK 2

EPIPEN-JR 2-PAK 2

ESBRIET 3 PA

GLASSIA 3 LA PA

KALYDECO TABS 3 PA

OFEV 3 PA

PROLASTIN-C 3 LA PA

PULMOZYME 2 B/D

tyzine .05% 3

XOLAIR 2 LA PA


30

Drug Name Drug Tier

Requirements/Limits

ZEMAIRA 3 LA PA

NASAL STEROIDS BECONASE AQ 3

budesonide (nasal) 1

flunisolide (nasal) 1

fluticasone propionate (nasal) 1

NASONEX 2

OMNARIS 3

QNASL 3

triamcinolone acetonide (nasal)

1

VERAMYST 3

ZETONNA 3

STEROID INHALANTS AEROSPAN 3

ALVESCO 3

ARNUITY ELLIPTA 3

ASMANEX 2

ASMANEX HFA 2

ASMANEX TWISTHALER 14 MET

2

budesonide (inhalation) 1 B/D

FLOVENT DISKUS 2

FLOVENT HFA 2

PULMICORT FLEXHALER 2

PULMICORT INH SUSP 1MG/2ML

3 B/D

QVAR 2

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS 2

ADVAIR HFA 2

BREO ELLIPTA 3

DULERA 2

SYMBICORT 2

XANTHINES aminophylline inj 1

elixophyllin 2

lufyllin 200mg 3

theo-24 2

theophylline 1

TOPICAL DERMATOLOGY, ACNE ABSORICA 3

ACANYA 2

ACZONE 3

Drug Name Drug Tier

Requirements/Limits

adapalene CREA 1

adapalene GEL .1% 1

ADAPALENE GEL .3% 1

amnesteem 1

ATRALIN 2

AVITA 1

AZELEX 3

benzoyl peroxide-erythromycin

1

claravis 1

CLINDAGEL 3

clindamax 1

clindamycin phosphate (topical)

1

clindamycin phosphate-benzoyl peroxide

1

clindamycin phosphate-benzoyl peroxide (refrigerate)

1

DIFFERIN LOTN 2

EPIDUO 2

ery pad 2% 1

erythromycin (acne aid) 1

FABIOR 3

myorisan 1

neuac gel 1.2-5% 1

ONEXTON 3

RETIN-A MICRO PUMP .08%

2

sulfacetamide sodium (acne) 1

tretin-x CREA 3

tretinoin CREA; GEL 1

TRETINOIN MICROSPHERE 1

VELTIN 3

zenatane 1

ZIANA 3

DERMATOLOGY, ANTIBIOTICS ALTABAX 3

BACTROBAN NASAL 3

CENTANY 3

CORTISPORIN CREA; OINT

3

gentamicin sulfate (topical) 1

mupirocin OINT 1

mupirocin calcium (topical) 1

SILVER SULFADIAZINE CREA

1


31

Drug Name Drug Tier

Requirements/Limits

SSD 1

SULFAMYLON CREA 3

DERMATOLOGY, ANTIFUNGALS ciclopirox GEL 1

ciclopirox cre 0.77% 1

ciclopirox shampoo 1% 1

ciclopirox sus 0.77% 1

clotrimazole (topical) 1

econazole nitrate CREA 1

ERTACZO 3

EXELDERM 3

ketoconazole (topical) 1

ketodan aer 2% 1

LUZU 2

MENTAX 2

NAFTIFINE HCL 1

NAFTIN 2

nyamyc 1

nystatin (topical) 1

nystatin pow 100000 1

nystop 1

OXISTAT 3

DERMATOLOGY, ANTIPRURITIC CORTIFOAM 2

procto-pak 1

proctosol hc 2.5 % 1

proctozone hc 1

PRUDOXIN CRE 5% 1

DERMATOLOGY, ANTIPSORIATICS acitretin 1

calcipotriene CREA; OINT; SOLN

1

calcitrene oin 0.005% 1

CALCITRIOL OINT 1

COSENTYX 3 PA

COSENTYX SENSOREADY PEN

3 PA

methoxsalen rapid 1

8-MOP 3

SORILUX 2

STELARA 3 PA

TAZORAC 2

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 1

selenium sulfide LOTN 1

DERMATOLOGY, ANTIVIRALS

Drug Name Drug Tier

Requirements/Limits

acyclovir topical 1

DENAVIR 2

XERESE 3

ZOVIRAX CREA 3

DERMATOLOGY, CORTICOSTEROIDS ala-cort 1

alclometasone dipropionate 1

amcinonide CREA; LOTN 1

amcinonide OINT 3

apexicon CREA 3

apexicon OINT 1

betamethasone dipropionate (topical)

1

betamethasone dipropionate augmented

1

betamethasone valerate CREA; FOAM; LOTN; OINT

1

calcipotrien oin betameth 1

CAPEX 2

clobetasol propionate CREA; FOAM; GEL; LIQD; LOTN; OINT; SHAM; SOLN

1

clobetasol propionate emollient base

1

clobetasol propionate emulsion

1

clocortolone pivalate 1

clodan 1

CORDRAN TAPE 3

cormax 1

DESONATE 3

DESONIDE CREA 1

desonide LOTN; OINT 1

desoximetasone CREA 1

desoximetasone GEL 1

DESOXIMETASONE OINT .05%

1

desoximetasone OINT .25% 1

diflorasone diacetate 1

fluocinolone acetonide CREA; OIL; OINT; SOLN

1

fluocinonide CREA; GEL; OINT; SOLN

1

fluocinonide emulsified base 1

fluticasone propionate CREA; LOTN; OINT

1

halobetasol propionate 1

HALOG 3


32

Drug Name Drug Tier

Requirements/Limits

hydrocortisone (topical) 1

hydrocortisone butyrate 1

hydrocortisone butyrate hydrophilic lipo base

1

hydrocortisone valerate 1

KENALOG 3

LOCOID LOTN 2

LOKARA LOTN 0.05% 1

mometasone furoate CREA; OINT; SOLN

1

PANDEL 3

PREDNICARBATE CREA 1

prednicarbate OINT 1

TACLONEX SUSP 3

texacort 2

TOPICORT LIQD 3

triamcinolone acetonide (topical)

1

trianex 3

triderm 1

u-cort 1

DERMATOLOGY, LOCAL ANESTHETICS lidocaine OINT 1

lidocaine PTCH 1 PA

lidocaine hcl GEL 1

lidocaine hcl SOLN 4% 1

lidocaine-prilocaine 1 B/D

SYNERA 3

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ammonium lactate CREA; LOTN

1

CONDYLOX GEL 2

diclofenac gel 3% 1

diclofenac sol 1.5% 1

DOXYCYCLINE (ROSACEA) 1

ELIDEL 2

FINACEA 2

fluorouracil (topical) CREA 5%

1

FLUOROURACIL (TOPICAL) CREA .5%

1

fluorouracil (topical) SOLN 1

imiquimod CREA 1

laclotion lot 12% 1

metronidazole (topical) 1

NORITATE 3

Drug Name Drug Tier

Requirements/Limits

ORACEA 2

OXSORALEN 3

PANRETIN 3

PENNSAID 2

PICATO 2

podofilox SOLN 1

RECTIV 3

rosadan cre 0.75% 1

SOOLANTRA 3

tacrolimus (topical) 1 PA

TARGRETIN GEL 3 PA

VALCHLOR 3 LA PA

VOLTAREN GEL 1% 2

ZYCLARA 2

DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 3

malathion 1

permethrin CREA 1

SKLICE 3

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 1

neomycin/polymyxin b gu 1

REGRANEX 3

SANTYL 3

SODIUM CHLORIDE 0.9% 1

STERILE WATER IRRIGATION

1

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl 1

chlorhexidine gluconate (mouth-throat)

1

clotrimazole TROC 1

lidocaine hcl (mouth-throat) 1

nystatin (mouth-throat) 1

periogard soln 0.12% 1

pilocarpine hcl (oral) 1

triamcinolone acetonide (mouth)

1

OTIC acetasol hc 1

acetic acid (otic) 1

acetic acid sol/hc 1

acetic acid-aluminum acetate 1

CIPRO HC 3

CIPRODEX 2


33

Drug Name Drug Tier

Requirements/Limits

COLY-MYCIN S 3

CORTISPORIN-TC 3

fluocinolone acetonide (otic) 1

neomycin-polymyxin-hc (otic) 1

ofloxacin (otic) 1

34

Index 8 8-MOP .............................. 31 A abacavir sulfate ...................4 abacavir sulfate-lamivudine-zidovudine ..........................................5 ABELCET............................4 ABILIFY............................. 14 ABILIFY DISCMELT ......... 14 ABILIFY INJ 9.75MG ........ 14 ABILIFY MAINTENA ......... 14 ABRAXANE ........................7 ABSORICA ....................... 30 ABSTRAL............................2 acamprosate calcium ........ 16 ACANYA ........................... 30 acarbose ........................... 17 acebutolol hcl .................... 11 acetaminophen w/ codeine .1 acetasol hc ........................ 32 acetazolamide ................... 12 acetazolamide sodium ...... 12 acetic acid ......................... 32 acetic acid (otic) ................ 32 acetic acid sol/hc ............... 32 acetic acid-aluminum acetate .......................................... 32 acetylcysteine ................... 29 ACIPHEX SPR CAP 10MG .......................................... 23 ACIPHEX SPR CAP 5MG . 23 acitretin ............................. 31 ACTEMRA ........................ 24 ACTHIB ............................. 25 ACTIMMUNE .................... 25 ACTONEL ......................... 18 ACTOPLUS MET XR 15-1000MG ....................... 17 ACTOPLUS MET XR 30-1000MG ....................... 17 ACUVAIL........................... 28 acyclovir ..............................5 acyclovir sodium .................5 acyclovir topical ................. 31 ACZONE ........................... 30 ADACEL............................ 25 ADAGEN ........................... 19 adapalene ......................... 30

ADAPALENE .................... 30 ADCIRCA .......................... 12 adefovir dipivoxil ................. 5 ADEMPAS ........................ 12 adrucil ................................. 7 ADVAIR DISKUS .............. 30 ADVAIR HFA .................... 30 ADVICOR ......................... 10 AEROSPAN ...................... 30 afeditab cr ......................... 11 AFINITOR ........................... 8 AFINITOR DISPERZ........... 8 AFREZZA ......................... 21 AGGRENOX ..................... 24 a-hydrocort ........................ 20 AKYNZEO ......................... 21 ala-cort .............................. 31 ALBENZA ........................... 3 albuterol sulfate ................ 29 albuterol sulfate er ............ 29 alclometasone dipropionate .......................................... 31 ALCOHOL SWABS ........... 17 ALDACTAZIDE TAB 50/50 .......................................... 12 ALDURAZYME ................. 19 alendronate sodium .......... 18 alfuzosin hcl ...................... 23 ALIMTA ............................... 7 ALINIA ................................ 3 allopurinol tab ..................... 1 ALOCRIL .......................... 28 ALOMIDE .......................... 28 ALOPRIM ............................ 1 ALORA .............................. 20 alosetron hcl ..................... 23 ALOXI ............................... 21 ALPHAGAN P 0.1% .......... 28 ALPHAGAN P 0.15% ........ 28 alprazolam ........................ 12 ALREX .............................. 28 ALSUMA ........................... 15 ALTABAX .......................... 30 altavera ............................. 18 ALTOPREV ....................... 10 ALVESCO ......................... 30 amantadine hcl ................. 14 AMBISOME ........................ 4 amcinonide ....................... 31

amethia 91 day ................. 18 amethyst 28 day ............... 18 amifostine crystalline .......... 9 amikacin sulfate .................. 3 amiloride & hydrochlorothiazide ........... 12 amiloride hcl ..................... 12 aminophylline inj ............... 30 AMINOSYN ...................... 26 AMINOSYN 7%/ELECTROLYTES ....... 26 AMINOSYN II ................... 26 AMINOSYN II 8.5%/ELECTROL.............. 26 AMINOSYN INJ 8.5/LYTE 26 AMINOSYN M .................. 26 AMINOSYN-HBC .............. 26 AMINOSYN-PF ................. 26 AMINOSYN-PF 7% ........... 26 AMINOSYN-RF................. 26 amiodarone hcl ................. 10 amiodarone inj 50mg/ml ... 10 AMITIZA ........................... 23 amitriptyline hcl ................. 13 amlodipine besylate .......... 11 AMLODIPINE BESYLATE/ATORV .......... 11 amlodipine besylate-benazepril hcl ....... 9 amlodipine besylate-valsartan tab 10-160 mg ........................ 10 amlodipine besylate-valsartan tab 10-320 mg ........................ 10 amlodipine besylate-valsartan tab 5-160 mg ..................................... 10 amlodipine besylate-valsartan tab 5-320 mg ..................................... 10 amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg.......................................... 10 amlodipine-valsartan-hydrochlorothiazide 10-160-25mg.......................................... 10 amlodipine-valsartan-hydrochlorothiazide 10-320-25mg

35

.......................................... 10 amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg .......................................... 10 amlodipine-valsartan-hydrochlorothiazide 5-160-25mg . 10 ammonium chloride ........... 26 ammonium lactate ............. 32 amnesteem ....................... 30 amoxapine ........................ 13 amoxicillin ...........................6 amoxicillin & pot clavulanate ............................................6 amoxicillin-clarithromycin w/ lansoprazole ...................... 23 amphetamine cap 10mg er .......................................... 15 amphetamine cap 15mg er .......................................... 15 amphetamine cap 20mg er .......................................... 15 amphetamine cap 25mg er .......................................... 15 amphetamine cap 30mg er .......................................... 15 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 15 amphetamine-dextroamphetamine tab 10 mg ............... 15 amphetamine-dextroamphetamine tab 12.5 mg ............ 15 amphetamine-dextroamphetamine tab 15 mg ............... 15 amphetamine-dextroamphetamine tab 20 mg ............... 15 amphetamine-dextroamphetamine tab 30 mg ............... 15 amphetamine-dextroamphetamine tab 5 mg ................. 15 amphetamine-dextroamphetamine tab 7.5 mg .............. 15 AMPHOTEC ........................4 amphotericin b ....................4 ampicillin & sulbactam sodium ................................6 ampicillin cap 250mg ..........6 ampicillin cap 500 mg .........6 ampicillin inj .........................6 ampicillin sodium .................6 ampicillin susp .....................6

AMPYRA ........................... 16 anagrelide hcl ................... 24 anastrozole ......................... 8 ANDRODERM .................. 16 ANDROGEL ...................... 16 ANDROGEL 1% ............... 16 ANDROGEL 1.62% .......... 16 ANDROGEL GEL PUMP 1% .......................................... 16 ANDROGEL PUMP .......... 16 ANORO ELLIPT AER 62.5-25 .............................. 29 ANTARA ........................... 10 apexicon ........................... 31 APIDRA ............................ 17 APIDRA SOLOSTAR ........ 17 APLENZIN ........................ 13 APOKYN ........................... 14 apri 28 day ........................ 18 APRISO ............................ 22 APTENSIO XR .................. 15 APTIOM ............................ 12 APTIVUS ............................ 4 ARALAST NP ................... 29 aranelle 28 ........................ 18 ARANESP ALBUMIN FREE .......................................... 24 ARCALYST ....................... 25 ARCAPTA NEOHALER .... 29 aripiprazole ....................... 14 ARNUITY ELLIPTA ........... 30 ARRANON .......................... 7 ARZERRA ........................... 8 ASACOL HD ..................... 22 ashlyna 91 day .................. 18 ASMANEX ........................ 30 ASMANEX HFA ................ 30 ASMANEX TWISTHALER 14 MET ............................. 30 ASPIRIN-CAFFEINE-DIHYDROCODEINE BITARTRATE ............................................ 1 ASTAGRAF XL ................. 25 ASTEPRO ......................... 29 ATELVIA ........................... 18 atenolol ............................. 11 atenolol & chlorthalidone ... 11 ATGAM ............................. 25 atorvastatin calcium .......... 10 atovaquone ......................... 3

atovaquone-proguanil hcl tab 250-100 mg ........................ 4 ATOVAQUONE-PROGUANIL HCL TAB 62.5-25 MG ...... 4 ATRALIN .......................... 30 ATRIPLA ............................. 5 ATROPINE SULFATE ...... 22 ATROVENT HFA .............. 29 AUBAGIO ......................... 16 aubra 28 day ..................... 18 AUGMENTIN ...................... 6 AURYXIA .......................... 21 AUVI-Q ............................. 29 AVASTIN ............................ 8 AVEED ............................. 16 AVELOX ............................. 6 aviane 28 .......................... 18 AVITA ............................... 30 AVODART ........................ 23 AVONEX ........................... 16 AVONEX PEN .................. 16 AXERT .............................. 15 AXIRON ............................ 16 azacitidine ........................... 7 AZACTAM .......................... 3 AZACTAM/DEX INJ 1GM ... 3 AZACTAM/DEX INJ 2GM ... 3 azasan .............................. 25 AZASITE ........................... 27 azathioprine ...................... 25 azelastine hcl (ophth) ........ 28 azelastine spr 0.1% .......... 29 azelastine spr 0.15% ........ 29 AZELEX ............................ 30 AZILECT ........................... 14 azithromycin ....................... 6 AZITHROMYCIN ................ 6 AZOPT .............................. 28 AZOR ................................ 10 aztreonam ........................... 3 B bacitracin (ophthalmic) ...... 27 bacitracin-polymyxin b (ophth) .............................. 27 bacitracin-poly-neomycin-hc.......................................... 27 baclofen ............................ 16 BACTOCILL INJ DEX 1GM 6 BACTOCILL INJ DEX 2GM 6 BACTROBAN NASAL ....... 30

36

balsalazide disodium ......... 22 balziva 28 day ................... 18 BANZEL SUS 40MG/ML ... 12 BANZEL TAB 200MG ....... 12 BANZEL TAB 400MG ....... 12 BARACLUDE ......................5 BCG VACCINE ................. 25 BECONASE AQ ................ 30 benazepril & hydrochlorothiazide .............9 benazepril hcl ......................9 BENICAR .......................... 10 BENICAR HCT .................. 10 BENLYSTA ....................... 25 BENTYL ............................ 22 benzoyl peroxide-erythromycin ...... 30 benztropine mesylate ........ 14 BEPREVE ......................... 28 BERINERT ........................ 24 BESIVANCE ..................... 27 betamethasone dipropionate (topical) ............................. 31 betamethasone dipropionate augmented ........................ 31 betamethasone valerate ... 31 BETASERON .................... 16 betaxolol hcl ...................... 11 betaxolol hcl (ophth) .......... 28 bethanechol chloride ......... 23 BETHKIS.............................3 BETIMOL .......................... 28 BETOPTIC-S .................... 28 BEXSERO......................... 25 BEYAZ .............................. 18 bicalutamide ........................8 BICILLIN C-R ......................7 BICILLIN L-A .......................7 BICNU .................................7 BIDIL ................................. 12 BILTRICIDE ........................3 BINOSTO .......................... 18 bisoprolol & hydrochlorothiazide ........... 11 bisoprolol fumarate ........... 11 BIVIGAM ........................... 24 bleomycin sulfate ................7 blephamide ....................... 27 BLEPHAMIDE ................... 27 BLINCYTO ..........................9

BOOSTRIX ....................... 25 BOSULIF ............................ 8 BOTOX INJ 100UNIT........ 28 BOTOX INJ 200UNIT........ 28 BREO ELLIPTA ................ 30 briellyn 28 day ................... 18 BRILINTA .......................... 24 BRIMONIDINE SOL 0.15% .......................................... 28 brimonidine sol 0.2%......... 28 BRINTELLIX ..................... 13 BRISDELLE ...................... 16 bromfenac sodium (ophth) 28 BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) ... 28 bromocriptine mesylate ..... 14 BROVANA ........................ 29 budesonide ....................... 22 budesonide (inhalation) ..... 30 budesonide (nasal) ........... 30 bumetanide ....................... 12 BUNAVAIL MIS 2.1-0.3..... 16 BUNAVAIL MIS 4.2-0.7..... 16 BUNAVAIL MIS 6.3-1MG .. 16 buprenorphine hcl ............. 16 buprenorphine hcl-naloxone hcl sl.................................. 16 buproban ........................... 16 bupropion hcl .................... 13 buspirone hcl .................... 12 BUSULFEX ......................... 7 butorphanol nasal spray ...... 1 butorphanol tartrate ............ 1 BUTRANS ........................... 1 BYDUREON ..................... 17 BYETTA ............................ 17 BYSTOLIC ........................ 11 C cabergoline ....................... 21 cafergot tab 1-100mg ........ 15 calcipotrien oin betameth .. 31 calcipotriene ...................... 31 calcitonin (salmon) nasal spray ................................. 21 calcitrene oin 0.005%........ 31 calcitriol ............................. 27 CALCITRIOL ..................... 31 calcium acetate (phosphate binder) ............................... 21 camila 28 day .................... 18

CAMPTOSAR ..................... 9 CAMRESE LO TAB .......... 18 CANASA ........................... 22 CANCIDAS ......................... 4 candesartan cilexetil ......... 10 candesartan cilexetil-hydrochlorothiazide.......................................... 10 CANTIL ............................. 22 CAPASTAT SULFATE ........ 5 CAPEX ............................. 31 capital

and codeine .................... 1 CAPRELSA ........................ 8 captopril .............................. 9 captopril & hydrochlorothiazide ............. 9 CARAFATE ...................... 23 CARBAGLU ...................... 19 carbamazepine ................. 13 carbidopa .......................... 14 CARBIDOPA/LEVODOPA/ENTACAPONE ................... 14 carbidopa-levodopa .......... 14 carboplatin .......................... 9 CARDIZEM LA.................. 11 CARDURA XL .................. 23 CARIMUNE NANOFILTERED .............. 24 carteolol hcl (ophth) .......... 28 cartia xt ............................. 11 carvedilol .......................... 11 CAYSTON .......................... 3 CEDAX ............................... 5 cefaclor ............................... 6 cefaclor er tab 500mg ......... 6 cefadroxil ............................ 6 cefazolin inj ......................... 6 cefazolin sodium ................. 6 cefazolin/dextrose ............... 6 cefdinir ................................ 6 CEFEPIME 1GM SOLN ...... 6 CEFEPIME 2GM SOLN ...... 6 cefepime inj 1gm................. 6 cefepime inj 2gm................. 6 cefixime .............................. 6 cefotaxime sodium .............. 6 cefotetan disodium .............. 6 cefoxitin sodium .................. 6 CEFOXITIN SODIUM IN

37

DEXTROSE ........................6 cefpodoxime proxetil ...........6 cefprozil...............................6 ceftazidime ..........................6 CEFTAZIDIME/DEXTROSE ............................................6 ceftibuten ............................6 CEFTIN ...............................6 ceftriaxone sodium ..............6 cefuroxime axetil .................6 cefuroxime sodium ..............6 cefuroxime sodium soln iv 7.5 gm .................................6 celecoxib .............................1 CELLCEPT INTRAVENOUS .......................................... 25 CELONTIN ........................ 13 CENTANY ......................... 30 cephalexin ...........................6 CERDELGA ...................... 19 CEREZYME ...................... 19 CERVARIX ........................ 25 CESAMET ......................... 21 cetirizine syrup .................. 29 cevimeline hcl ................... 32 CHANTIX .......................... 16 CHANTIX CONTINUING MONTH ............................. 16 CHANTIX STARTER PACK .......................................... 16 CHEMET ........................... 18 chlorhexidine gluconate (mouth-throat) ................... 32 chloroquine phosphate ........4 chlorothiazide .................... 12 chlorpromaz inj 25mg/ml ... 14 chlorpromazine hcl ............ 14 chlorthalidone .................... 12 cholestyramine .................. 10 cholestyramine light .......... 10 choline fenofibrate ............. 10 CHORIONIC GONADOTROPIN ............ 21 ciclopirox ........................... 31 ciclopirox cre 0.77% .......... 31 ciclopirox shampoo 1% ..... 31 ciclopirox sus 0.77% ......... 31 cidofovir...............................5 cilostazol ........................... 24 CILOXAN OIN 0.3% OP ... 27

cimetidine .......................... 22 cimetidine sol 300/5ml ...... 22 CIMZIA .............................. 24 CINRYZE .......................... 24 CIPRO HC ........................ 32 CIPRODEX ....................... 32 ciprofloxacin ........................ 6 ciprofloxacin er .................... 6 ciprofloxacin hcl .................. 6 ciprofloxacin hcl (ophth) .... 27 ciprofloxacin in d5w ............ 6 ciprofloxacn inj .................... 6 cisplatin ............................... 9 citalopram hydrobromide .. 13 cladribine ............................ 7 claforan ............................... 6 claravis .............................. 30 CLARINEX ........................ 29 CLARINEX-D TAB 2.5-120 .......................................... 29 clarithromycin ...................... 6 CLEOCIN VAG SUPP 100MG .............................. 23 CLINDAGEL ..................... 30 clindamax .......................... 30 clindamycin cre 2% vag .... 23 clindamycin hcl ................... 3 clindamycin palmitate hydrochloride ...................... 3 clindamycin phosphate ....... 4 clindamycin phosphate (topical) ............................. 30 clindamycin phosphate in d5w ..................................... 4 clindamycin phosphate-benzoyl peroxide .......................................... 30 clindamycin phosphate-benzoyl peroxide (refrigerate) ....................... 30 CLINIMIX 2.75%/DEXTROSE 5% ..... 26 CLINIMIX 4.25%/DEXTROSE 10% ... 26 CLINIMIX 4.25%/DEXTROSE 20% ... 26 CLINIMIX 4.25%/DEXTROSE 25% ... 26 CLINIMIX 4.25%/DEXTROSE 5% ..... 26

CLINIMIX 5%/DEXTROSE 15% .................................. 26 CLINIMIX 5%/DEXTROSE 20% .................................. 26 CLINIMIX 5%/DEXTROSE 25% .................................. 26 CLINIMIX E 2.75%/DEXTROSE 10% ... 26 CLINIMIX E 2.75%/DEXTROSE 5% ..... 26 CLINIMIX E 4.25%/DEXTROSE ........... 26 CLINIMIX E 4.25%/DEXTROSE 25% ... 26 CLINIMIX E 4.25%/DEXTROSE 5% ..... 26 CLINIMIX E 5%/DEXTROSE 15% .................................. 26 CLINIMIX E 5%/DEXTROSE 20% .................................. 26 CLINIMIX E 5%/DEXTROSE 25% .................................. 26 clinisol 15 .......................... 26 clobetasol propionate ........ 31 clobetasol propionate emollient base .................. 31 clobetasol propionate emulsion ........................... 31 clocortolone pivalate ......... 31 clodan ............................... 31 CLOLAR ............................. 7 clomipramine hcl ............... 13 clonazepam ...................... 13 clonidine hcl ...................... 12 clopidogrel bisulfate .......... 24 clorazepate dipotassium ... 13 clorpres ............................. 12 clotrimazole ...................... 32 clotrimazole (topical) ......... 31 clozapine .......................... 14 CLOZAPINE ODT ............. 14 CLOZAPINE ODT 150MG 14 CLOZAPINE ODT 200MG 14 COARTEM .......................... 4 codeine

and capital ....................... 1 CODEINE SULFATE .......... 2 colchicine w/ probenecid ..... 1 COLCRYS .......................... 1 colestipol hcl ..................... 10

38

colistimethate sodium .........4 colocort ............................. 22 COLY-MYCIN S ................ 33 COLYTE-FLAVOR PACKS .......................................... 22 COMBIGAN ...................... 28 COMBIPATCH .................. 20 COMBIVENT RESPIMAT . 29 COMETRIQ .........................8 COMPLERA ........................5 compro supp ..................... 21 COMVAX .......................... 25 CONDYLOX ...................... 32 constulose ......................... 22 CONZIP ..............................1 COPAXONE INJ 40MG/ML .......................................... 16 COPAXONE KIT 20MG/ML .......................................... 16 CORDRAN ........................ 31 COREG CR ....................... 11 cormax .............................. 31 CORTIFOAM .................... 31 cortisone acetate ............... 20 CORTISPORIN ................. 30 CORTISPORIN-TC ........... 33 COSENTYX ...................... 31 COSENTYX SENSOREADY PEN .................................. 31 COSMEGEN .......................7 COSOPT PF ..................... 28 COUMADIN ...................... 24 CREON ............................. 23 CRESEMBA ........................4 CRESTOR ........................ 10 CRINONE ......................... 21 CRIXIVAN ...........................4 cromolyn sodium ............... 29 cromolyn sodium (mastocytosis) ................... 23 cromolyn sodium (ophth) .. 28 cryselle 28 ......................... 18 CUBICIN .............................4 CUVPOSA ........................ 22 cyclafem 1/35 28 day ........ 18 cyclafem 7/7/7 28 day ....... 18 cyclobenzaprine hcl .......... 16 cyclophosphamide ..............7 CYCLOPHOSPHAMIDE .....7 cycloserine ..........................5

cyclosporine ...................... 25 cyclosporine modified (for microemulsion) ................. 25 CYRAMZA .......................... 9 CYSTADANE .................... 19 CYSTAGON ...................... 19 CYSTARAN ...................... 28 cytarabine inj ....................... 7 CYTOGAM ........................ 24 D dacarbazine ........................ 7 DALIRESP ........................ 29 DALVANCE ........................ 4 danazol ............................. 19 dantrolene sodium ............ 16 dapsone .............................. 4 DAPTACEL ....................... 25 DARAPRIM ......................... 4 daunorubicin inj 5mg/ml ...... 7 DAYTRANA ...................... 15 deblitane 28 day ............... 18 decitabine ........................... 7 delyla 28 day ..................... 18 DELZICOL ........................ 22 demeclocycline hcl .............. 7 DEMSER .......................... 12 DENAVIR .......................... 31 DEPEN TITRATABS ......... 18 depo-estradiol ................... 20 DEPO-MEDROL INJ 20MG/ML .......................... 20 DEPO-PROVERA INJ 400/ML ................................ 8 DEPO-SUBQ PROVERA 104 .................................... 18 depo-testosterone ............. 16 DESFERAL ....................... 24 desipramine hcl ................. 13 desloratadine .................... 29 desmopressin acetate ....... 21 DESMOPRESSIN ACETATE .......................................... 21 desmopressin acetate inj .. 21 desmopressin acetate spray .......................................... 21 desmopressin acetate spray refrigerated ....................... 21 desogestrel-ethinyl estradiol (biphasic) .......................... 18 DESONATE ...................... 31

desonide ........................... 31 DESONIDE ....................... 31 desoximetasone................ 31 DESOXIMETASONE ........ 31 dexamethasone ................ 20 dexamethasone sodium phosphate ......................... 20 dexamethasone sodium phosphate (ophth)............. 28 DEXILANT ........................ 23 dexpak taperpak 13 day ... 20 dexrazoxane ....................... 9 dextrose ............................ 27 DEXTROSE ...................... 27 DEXTROSE 10% FLEX CONTAIN ......................... 27 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%.......................................... 27 DEXTROSE 10%/NACL 0.45% ............................... 27 DEXTROSE 2.5%/NACL 0.45% ............................... 27 DEXTROSE 5% ................ 27 DEXTROSE 5% /ELECTROLYTE ............... 27 DEXTROSE 5%/LACTATED RING ................................. 27 DEXTROSE 5%/NACL 0.2%.......................................... 27 DEXTROSE 5%/NACL 0.225% ............................. 27 DEXTROSE 5%/NACL 0.3%.......................................... 27 DEXTROSE 5%/NACL 0.33% ............................... 27 DEXTROSE 5%/NACL 0.45% ............................... 27 DEXTROSE 5%/NACL 0.9%.......................................... 27 DEXTROSE 5%/POTASSIUM CHL ...... 27 diazepam .......................... 13 DIAZEPAM GEL (ANTICONVULSANT) ....... 13 DIBENZYLINE .................. 12 diclofenac gel 3%.............. 32 diclofenac potassium .......... 1 diclofenac sodium ............... 1 diclofenac sodium (ophth) . 28

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diclofenac sol 1.5% ........... 32 diclofenac w/ misoprostol ....1 dicloxacillin sodium .............7 dicyclomine hcl .................. 22 didanosine...........................4 DIFFERIN ......................... 30 DIFICID ...............................6 diflorasone diacetate ......... 31 diflunisal ..............................1 digitek ............................... 11 digoxin .............................. 11 digoxin inj .......................... 11 DIGOXIN SOL 50MCG/ML .......................................... 11 dihydroergotamine mesylate .......................................... 15 DIHYDROERGOTAMINE MESYLATE ....................... 15 dilantin .............................. 13 DILANTIN-125 .................. 13 DILATRATE SR ................ 12 DILAUDID-HP INJ 250MG ..2 dilt-cd cap.......................... 11 diltiazem cap 120mg/24hr . 11 diltiazem cap er/12hr ......... 11 diltiazem hcl ...................... 11 diltiazem hcl coated beads 11 diltiazem hcl er .................. 11 diltiazem hcl extended release beads ................... 11 diltiazem inj 100mg ........... 11 diltiazem inj 125/25ml ....... 11 diltiazem inj 25mg/5ml ...... 11 diltiazem inj 50/10ml ......... 11 dilt-xr cap .......................... 11 diltzac ................................ 11 DIPENTUM ....................... 22 diphenhydram inj 50mg/ml 29 diphenoxylate w/ atropine . 23 DIPHTHERIA/TETANUS TOXOID ............................ 25 disopyramide phosphate ... 10 disulfiram........................... 16 DIURIL SUS 250/5ML ....... 12 divalproex sodium ............. 13 docetaxel.............................8 DOCETAXEL ......................8 donepezil odt 10mg ........... 13 donepezil odt 5mg ............. 13 donepezil tab hcl 23mg ..... 13

donepezil tabs 10mg ......... 13 donepezil tabs 5mg ........... 13 DORIBAX ............................ 4 DORYX ............................... 7 dorzolamide hcl ................. 28 dorzolamide hcl-timolol maleate ............................. 28 doxazosin mesylate ............ 9 doxepin hcl ........................ 13 doxercalciferol ................... 27 doxorubicin hcl .................... 7 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ....... 7 doxorubicin inj 50mg ........... 7 doxy inj ................................ 7 doxycycline (monohydrate) . 7 DOXYCYCLINE (ROSACEA) ...................... 32 doxycycline hyclate ............. 7 dronabinol ......................... 21 drospirenone-ethinyl estradiol ............................ 18 DROXIA .............................. 9 DUAVEE ........................... 20 DUEXIS .............................. 1 DULERA ........................... 30 duloxetine hcl .................... 13 DUOPA ............................. 14 DURAMORPH .................... 2 DUREZOL ......................... 28 DUTOPROL ...................... 11 DYMISTA SPR 137-50 ..... 29 DYRENIUM ....................... 12 DYSPORT ........................ 29 E e.e.s. 400 mg tab ................ 6 E.E.S. GRANULES ............. 6 econazole nitrate .............. 31 EDARBI ............................ 10 EDARBYCLOR ................. 10 EDECRIN .......................... 12 EDURANT .......................... 4 EFFIENT ........................... 24 EGRIFTA .......................... 21 ELAPRASE ....................... 19 ELECTROLYTE-R IN DEXTROSE ...................... 27 ELELYSO ......................... 19 ELIDEL ............................. 32 ELIGARD INJ 22.5MG ........ 8

ELIGARD INJ 30MG ........... 8 ELIGARD INJ 45MG ........... 8 ELIGARD INJ 7.5MG .......... 8 ELIQUIS TAB 2.5MG ........ 24 ELIQUIS TAB 5MG ........... 24 ELITEK ............................... 9 elixophyllin ........................ 30 ELLA ................................. 18 ELMIRON ......................... 23 ELOXATIN .......................... 9 EMADINE ......................... 28 EMBEDA CAPS 100-4MG .. 2 EMBEDA CAPS 20-0.8MG . 2 EMBEDA CAPS 30-1.2MG . 2 EMBEDA CAPS 50-2MG .... 2 EMBEDA CAPS 60-2.4MG . 2 EMBEDA CAPS 80-3.2MG . 2 EMCYT ............................... 7 EMEND CAP 125MG ........ 21 EMEND CAP 40MG .......... 21 EMEND CAP 80MG .......... 21 EMEND PAK 80 & 125 ..... 21 emoquette ......................... 18 EMSAM ............................ 13 EMTRIVA ............................ 5 ENABLEX ......................... 23 enalapril maleate ................ 9 enalapril maleate & hydrochlorothiazide ............. 9 ENBREL ........................... 24 ENBREL SURECLICK ...... 24 endocet ............................... 2 ENDODAN TAB .................. 2 ENGERIX-B ...................... 25 enoxaparin sodium ........... 24 enpresse 28 day ............... 18 entacapone ....................... 14 entecavir ............................. 5 ENTYVIO .......................... 22 enulose ............................. 22 EPIDUO ............................ 30 epinastine hcl (ophth) ....... 28 EPINEPHRINE ................. 29 EPIPEN 2-PAK ................. 29 EPIPEN-JR 2-PAK ............ 29 epirubicin inj 200mg ............ 7 EPIRUBICIN INJ 50MG ...... 7 epirubicin inj 50mg/25ml ..... 7 epitol ................................. 13 EPIVIR HBV ....................... 5

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EPIVIR SOL 10MG/ML .......5 eplerenone ..........................9 EPOGEN........................... 24 eprosartan mesylate ......... 10 EPZICOM............................5 EQUETRO ........................ 16 ERAXIS ...............................4 ERBITUX ............................8 ergomar............................. 15 ERIVEDGE .........................8 errin 28 day ....................... 18 ERTACZO ......................... 31 ERWINAZE .........................9 ery pad 2% ........................ 30 ERYPED 200 ......................6 ERYPED 400 ......................6 ery-tab .................................6 erythrocin lactobionate ........6 erythrocin stearate ..............6 erythromycin (acne aid) .... 30 erythromycin (ophth) ......... 28 erythromycin base ...............6 erythromycin cap 250mg ec 6 erythromycin ethylsuccinate 6 ESBRIET........................... 29 escitalopram oxalate ......... 13 esomeprazole sodium ....... 23 estrace .............................. 20 estradiol ............................ 20 estradiol valerate ............... 20 ESTRADIOL VALERATE .. 20 ESTRING .......................... 20 ethambutol hcl .....................5 ethosuximide ..................... 13 etodolac ..............................1 etodolac er ..........................1 ETOPOPHOS .....................9 etoposide ............................9 EURAX ............................. 32 EVOTAZ..............................5 EXELDERM ...................... 31 EXELON PATCHES ......... 13 exemestane ........................8 EXJADE ............................ 18 EXTAVIA ........................... 16 EYLEA .............................. 29 F FABIOR............................. 30 FABRAZYME .................... 20 FACTIVE .............................6

falmina 28 day .................. 18 famciclovir ........................... 5 famotidine ......................... 22 FANAPT ............................ 14 FANAPT TITRATION PACK .......................................... 14 FARESTON ........................ 8 FARXIGA .......................... 17 FARYDAK ........................... 8 FASLODEX ......................... 8 FAZACLO ......................... 14 felbamate .......................... 13 felodipine .......................... 11 FEMRING ......................... 20 fenofibrate ......................... 10 FENOFIBRATE ................. 10 fenofibrate micronized....... 10 FENOFIBRIC ACID........... 10 FENOGLIDE ..................... 10 fenoprofen calcium ............. 1 fentanyl citrate .................... 2 fentanyl td patch 72hr 100 mcg/hr ................................. 2 fentanyl td patch 72hr 12 mcg/hr ................................. 2 fentanyl td patch 72hr 25 mcg/hr ................................. 2 fentanyl td patch 72hr 50 mcg/hr ................................. 2 fentanyl td patch 72hr 75 mcg/hr ................................. 2 FENTORA ........................... 2 FERRIPROX ..................... 18 FETZIMA .......................... 13 FETZIMA TITRATION PACK .......................................... 13 FINACEA .......................... 32 finasteride ......................... 23 FIRAZYR .......................... 24 FIRMAGON ........................ 8 FLAGYL ER ........................ 4 FLAREX ............................ 28 FLEBOGAMMA ................ 24 FLEBOGAMMA DIF .......... 24 flecainide acetate .............. 10 FLOLAN ............................ 12 FLO-PRED SUS ............... 20 FLOVENT DISKUS ........... 30 FLOVENT HFA ................. 30 fluconazole .......................... 4

fluconazole in dextrose ....... 4 fluconazole inj nacl 100 ...... 4 fluconazole inj nacl 200 ...... 4 fluconazole inj nacl 400 ...... 4 flucytosine ........................... 4 fludarabine phosphate ........ 7 fludrocortisone acetate ..... 20 flunisolide (nasal) .............. 30 fluocinolone acetonide ...... 31 fluocinolone acetonide (otic).......................................... 33 fluocinonide ...................... 31 fluocinonide emulsified base.......................................... 31 FLUOROMETHOLONE (OPHTH) ........................... 28 fluorouracil .......................... 7 fluorouracil (topical) .......... 32 FLUOROURACIL (TOPICAL) ........................ 32 fluoxetine hcl ............... 13, 14 FLUOXETINE HCL ........... 14 fluphenazine decanoate .... 14 fluphenazine hcl ................ 14 flurbiprofen .......................... 1 flurbiprofen sodium ........... 28 flutamide ............................. 8 fluticasone propionate ....... 31 fluticasone propionate (nasal) ............................... 30 fluvastatin sodium ............. 10 fluvoxamine maleate ......... 12 fluvoxamine maleate er ..... 12 FML .................................. 28 FML FORTE ..................... 28 FOLOTYN ........................... 7 fondaparinux sodium ........ 24 FORADIL AEROLIZER ..... 29 FORFIVO XL .................... 14 FORTAZ ............................. 6 FORTEO ........................... 21 FORTESTA ...................... 16 FORTICAL SPR 200/ACT 21 FOSAMAX PLUS D .......... 18 foscarnet sodium ................ 5 fosinopril sodium ................. 9 fosinopril sodium & hydrochlorothiazide ............. 9 FOSRENOL ...................... 21 FRAGMIN ......................... 24

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FREAMINE HBC 6.9% ...... 26 FREAMINE III ................... 26 FROVA TAB 2.5MG .......... 15 furosemide ........................ 12 furosemide inj .................... 12 furosemide oral soln 8 mg/ml .......................................... 12 FUSILEV .............................9 FUZEON .............................5 FYCOMPA ........................ 13 G gabapentin ........................ 13 GABITRIL.......................... 13 galantamine hydrobromide 13 GAMASTAN S/D ............... 24 GAMMAGARD LIQUID ..... 24 GAMMAGARD S/D ........... 25 GAMMAGARD S/D IGA LESS TH ........................... 25 GAMMAKED ..................... 25 GAMMAPLEX ................... 25 GAMUNEX-C .................... 25 GAMUNEX-C 1GM/10ML . 25 ganciclovir inj 500mg ..........5 GARDASIL ........................ 25 GARDASIL 9 ..................... 25 gatifloxacin (ophth) ............ 28 GATTEX............................ 23 GAUZE PADS 2X2 ........... 17 gaviltye-g........................... 22 gavilyte-c ........................... 22 gavilyte-h........................... 22 gavilyte-n........................... 22 GAZYVA .............................9 GELNIQUE ....................... 23 gemcitabine inj 1gm ............7 GEMCITABINE INJ 1GM ....7 gemcitabine inj 200mg ........7 GEMCITABINE INJ 200MG 7 gemcitabine inj 2gm ............7 GEMCITABINE INJ 2GM ....7 gemfibrozil......................... 10 GENERESS FE ................ 18 generlac ............................ 22 gengraf .............................. 25 GENOTROPIN .................. 20 GENOTROPIN MINIQUICK .......................................... 20 gentak ............................... 28 gentamicin in saline inj 0.8

mg/ml .................................. 3 gentamicin in saline inj 0.9 mg/ml .................................. 3 gentamicin in saline inj 1 mg/ml .................................. 3 gentamicin in saline inj 1.2 mg/ml .................................. 3 gentamicin in saline inj 1.4 mg/ml .................................. 3 gentamicin in saline inj 1.6 mg/ml .................................. 3 gentamicin in saline inj 2 mg/ml .................................. 3 gentamicin sulfate ............... 3 gentamicin sulfate (ophth) . 28 gentamicin sulfate (topical) .......................................... 30 GEODON INJ ................... 14 GIANVI TAB 3-0.02MG ..... 18 GIAZO ............................... 22 gildagia ............................. 18 gildess 1.5/30 21 day ........ 18 gildess 24 fe 28 day .......... 18 GILENYA CAP 0.5MG ...... 16 GILOTRIF TAB 20MG......... 8 GILOTRIF TAB 30MG......... 8 GILOTRIF TAB 40MG......... 8 GLASSIA .......................... 29 GLEEVEC ........................... 8 GLEOSTINE ....................... 7 glimepiride ........................ 17 glipizide ............................. 17 glipizide er ......................... 17 glipizide-metformin 2.5-250 mg ..................................... 17 glipizide-metformin 2.5-500 mg ..................................... 17 glipizide-metformin 5-500mg .......................................... 17 GLUCAGEN HYPOKIT ..... 20 GLUCAGON EMERGENCY KIT .................................... 20 GLUMETZA ...................... 17 glycate .............................. 22 glycopyrrolate ................... 22 GLYSET ............................ 17 GLYXAMBI ....................... 17 GOLYTELY ....................... 22 GRALISE .......................... 16 GRALISE STARTER......... 16

granisetron hcl .................. 21 GRANIX ............................ 24 GRASTEK ........................ 25 griseofulvin microsize ......... 4 griseofulvin ultramicrosize .. 4 guanfacine hcl (adhd) ....... 15 H H.P. ACTHAR ................... 21 HALAVEN ........................... 9 halobetasol propionate ..... 31 HALOG ............................. 31 haloperidol ........................ 14 haloperidol decanoate ...... 14 haloperidol lactate............. 14 HARVONI ........................... 5 HAVRIX ............................ 25 heather ............................. 18 HEP SOD/NACL INJ 25000.......................................... 24 HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML ........................... 24 heparin sod inj 10000u/ml . 24 heparin sod inj 1000u/ml ... 24 heparin sod inj 20000u/ml . 24 HEPARIN SOD INJ 2000U/ML ......................... 24 HEPARIN SOD INJ 2500U/ML ......................... 24 heparin sod inj 5000u/0.5ml.......................................... 24 heparin sod inj 5000u/ml ... 24 HEPARIN SODIUM/D5W . 24 HEPARIN SODIUM/NACL 0.45% ............................... 24 HEPATAMINE .................. 26 HERCEPTIN ....................... 8 HETLIOZ .......................... 16 HEXALEN ........................... 7 HIBERIX ........................... 25 HIZENTRA ........................ 25 HORIZANT ....................... 16 HUMALOG ....................... 17 HUMALOG MIX 50/50 ...... 17 HUMALOG MIX 50/50 KWIKPEN ......................... 17 HUMALOG MIX 75/25 ...... 17 HUMALOG MIX 75/25 KWIKPEN ......................... 17 HUMATROPE ................... 20

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HUMATROPE COMBO PACK ................................ 20 HUMIRA ............................ 24 HUMIRA PEN ................... 24 HUMIRA PEN-CROHNS STARTER KIT ................... 24 HUMIRA PEN-PSORIASIS STARTER KIT ................... 24 HUMULIN 70/30 ................ 17 HUMULIN 70/30 KWIKPEN .......................................... 17 HUMULIN N ...................... 17 HUMULIN N KWIKPEN..... 17 HUMULIN R ...................... 17 HUMULIN R U-500 (CONCENTRATE) ............ 17 hydralazine hcl .................. 12 hydrochlorothiazide ........... 12 hydrocodone-acetaminophen 10-300mg ............................1 hydrocodone-acetaminophen 2.5-325mg ...........................1 hydrocodone-acetaminophen 5-300mg ..............................1 hydrocodone-acetaminophen 5-325mg ..............................1 hydrocodone-acetaminophen 7.5-300mg ...........................1 hydrocodone-acetaminophen 7.5-325 mg/15ml .................1 hydrocodone-acetaminophen 7.5-325mg ...........................1 hydrocodone-acetaminophen tab 10-325mg ......................1 hydrocodone-ibuprofen 2.5-200 mg ..........................1 hydrocodone-ibuprofen tab 7.5-200 mg ..........................1 hydrocortisone .................. 20 HYDROCORTISONE (INTRARECTAL) ............... 22 hydrocortisone (topical) ..... 32 hydrocortisone butyrate .... 32 hydrocortisone butyrate hydrophilic lipo base ......... 32 hydrocortisone valerate ..... 32 hydromorphone hcl .............2 HYDROMORPHONE HCL ..2 hydromorphone tab 12mg er ............................................2

hydromorphone tab 16mg er ............................................ 2 hydromorphone tab 8mg er . 2 HYDROMORPHONE TABS 32MG .................................. 2 hydroxychloroquine sulfate .......................................... 24 hydroxyurea ........................ 9 hydroxyzine hcl ................. 29 hydroxyzine hcl inj ............ 29 hydroxyzine pamoate ........ 29 HYQVIA ............................ 25 HYSINGLA ER .................... 2 I ibandronate sodium .......... 18 IBRANCE ............................ 8 ibudone 5-200 mg ............... 1 ibudone tab 10-200mg ........ 1 ibuprofen ............................. 1 ICLUSIG ............................. 8 idarubicin hcl ....................... 7 IFEX .................................... 7 ifosfamide ........................... 7 ifosfamide for inj 1 gm ......... 7 IFOSFAMIDE FOR INJ 3 GM ...................................... 7 ILARIS .............................. 25 ILEVRO ............................. 28 ilotycin ............................... 28 IMBRUVICA CAP 140MG ... 8 imipenem-cilastatin ............. 4 imipramine hcl ................... 14 imipramine pamoate ......... 14 imiquimod ......................... 32 IMOVAX RABIES (H.D.C.V.) .......................................... 25 INCRELEX ........................ 21 INCRUSE ELLIPTA .......... 29 indapamide ....................... 12 INFANRIX ......................... 25 INFUMORPH 200 ............... 2 INFUMORPH 500 ............... 2 INLYTA ............................... 8 INSULIN PEN NEEDLES .. 17 INSULIN SAFETY NEEDLES ......................... 17 INSULIN SYRINGES ........ 17 INTELENCE ........................ 5 INTRALIPID INJ 20%........ 26 INTRALIPID INJ 30%........ 26

INTRON-A INJ 10MU ....... 25 INTRON-A INJ 18MU ....... 25 INTRON-A INJ 25MU ....... 25 INTRON-A INJ 50MU ....... 25 introvale 91 day ................ 18 INVANZ .............................. 4 INVEGA ............................ 14 INVEGA SUST INJ 117 MG/0.75 ML ...................... 14 INVEGA SUST INJ 156MG/ML ........................ 14 INVEGA SUST INJ 234 MG/1.5 ML ........................ 15 INVEGA SUST INJ 39 MG/0.25 ML ...................... 14 INVEGA SUST INJ 78 MG/0.5 ML ........................ 14 INVEGA TRINZA .............. 15 INVIRASE ........................... 5 INVOKAMET TAB 150-1000.......................................... 17 INVOKAMET TAB 150-500.......................................... 17 INVOKAMET TAB 50-1000.......................................... 17 INVOKAMET TAB 50-500MG ......................... 17 INVOKANA TAB 100MG .. 17 INVOKANA TAB 300MG .. 17 IONOSOL-B/DEXTROSE 5% .................................... 27 IONOSOL-MB/DEXTROSE 5% .................................... 27 IPOL INACTIVATED IPV .. 25 ipratropium bromide (nasal).......................................... 29 ipratropium sol inhal .......... 29 ipratropium-albuterol ......... 29 irbesartan .......................... 10 irbesartan-hydrochlorothiazide........................................ 10 irinotecan ............................ 9 irinotecan hcl ...................... 9 ISENTRESS ....................... 5 ISOLYTE P ....................... 27 isolyte s ............................. 27 isoniazid .............................. 5 isoniazid tabs ...................... 5 ISORDIL TITRADOSE ...... 12 isosorbide dinitrate ............ 12

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isosorbide mononitrate ...... 12 isosorbide mononitrate er . 12 isradipine........................... 11 ISTALOL ........................... 28 ISTODAX ............................8 itraconazole .........................4 ivermectin............................4 IXEMPRA KIT .....................9 IXIARO .............................. 25 J JAKAFI ................................8 JALYN ............................... 23 jantoven ............................ 24 JANUMET ......................... 17 JANUMET XR TAB 100-1000 ........................... 17 JANUMET XR TAB 50-1000 .......................................... 17 JANUMET XR TAB 50-500MG ......................... 17 JANUVIA ........................... 17 JARDIANCE ...................... 17 JENTADUETO .................. 17 JEVTANA ............................9 JOLESSA TAB 0.15-0.03 MG .................................... 18 JOLIVETTE ....................... 18 junel 1.5/30 21 day ............ 18 junel 1/20 21 day ............... 18 junel fe 1.5/30 28 day ........ 18 junel fe 1/20 28 day ........... 18 JUXTAPID ......................... 10 K KADCYLA ...........................8 KADIAN...............................2 KALBITOR ........................ 24 KALETRA SOL ...................5 KALETRA TAB 100-25MG ..5 KALETRA TAB 200-50MG ..5 KALYDECO ...................... 29 kariva 28 day ..................... 18 KAZANO ........................... 17 KCL 0.075%/D5W/NACL 0.45% ................................ 27 KCL 0.15%/D5W/LR ......... 27 KCL 0.15%/D5W/NACL 0.9% .................................. 27 kcl 0.3%/d5w/lr iv lac ri ...... 27 KCL 0.3%/D5W/NACL 0.45% ................................ 27

KCL 0.3%/D5W/NACL 0.9% .......................................... 27 KCL0.15%/D5W/NACL0.2% .......................................... 27 KCL0.15%/D5W/NACL0.225% ...................................... 27 kelnor 1/35 28 day ............ 18 KENALOG ........................ 32 KEPIVANCE ....................... 9 ketoconazole ....................... 4 ketoconazole (topical) ....... 31 ketoconazole shampoo ..... 31 ketodan aer 2% ................. 31 ketoprofen ........................... 1 ketorolac tromethamine (ophth) .............................. 28 KEYTRUDA ........................ 9 KINERET .......................... 24 kionex ............................... 18 KLOR-CON 10 .................. 26 KLOR-CON 8 .................... 26 klor-con m15 ..................... 26 klor-con m20 ..................... 26 klor-con pow 20meq ......... 26 KOMBIGLYZE XR 2.5-1000MG ...................... 17 KOMBIGLYZE XR 5-1000MG ......................... 17 KOMBIGLYZE XR 5-500MG .......................................... 17 KORLYM ........................... 21 kristalose ........................... 22 KUVAN ............................. 20 KYNAMRO ........................ 10 L labetalol hcl ....................... 11 laclotion lot 12% ................ 32 LACRISERT ...................... 29 LACTATED RINGERS VIAFLEX ........................... 27 lactulose ............................ 22 lactulose (encephalopathy) .......................................... 22 LAMICTAL ODT ................ 13 LAMICTAL STARTER....... 13 LAMICTAL XR .................. 13 LAMISIL .............................. 4 lamivudine ........................... 5 lamivudine (hbv) ................. 5 lamivudine-zidovudine ........ 5

lamotrigine ........................ 13 LANOXIN PEDIATRIC ...... 11 LANOXIN TAB .................. 11 lansoprazole ..................... 23 LANTUS ........................... 17 LANTUS SOLOSTAR ....... 17 larin 1.5/30 ........................ 18 larin 1/20 ........................... 18 larin fe 1.5/30 .................... 18 larin fe 1/20 ....................... 18 LASTACAFT ..................... 28 latanoprost ........................ 28 LATUDA ........................... 15 LAZANDA ........................... 2 LEENA TAB ...................... 18 leflunomide ....................... 24 LEMTRADA ...................... 16 LENVIMA 10MG DAILY DOSE ................................. 8 LENVIMA 14MG DAILY DOSE ................................. 8 LENVIMA 20MG DAILY DOSE ................................. 8 LENVIMA 24MG DAILY DOSE ................................. 8 LESCOL XL ...................... 10 lessina 28 day ................... 18 LETAIRIS .......................... 12 letrozole .............................. 8 leucovor ca inj ..................... 9 leucovorin calcium .............. 9 leucovorin calcium 500 mg . 9 LEUKERAN ........................ 7 LEUKINE .......................... 24 leuprolide acetate ............... 8 levalbuterol conc 1.25mg/0.5ml .................... 29 levalbuterol hcl .................. 29 LEVALBUTEROL HCL ..... 29 LEVEMIR .......................... 17 LEVEMIR FLEXTOUCH ... 17 levetiracetam .................... 13 LEVETIRACETAM IN NACL.......................................... 13 levobunolol hcl .................. 28 LEVOBUNOLOL HCL ....... 28 levocarnitine (metabolic modifiers) .......................... 20 levocetirizine soln 2.5mg/5ml.......................................... 29

44

levocetirizine tab 5 mg ...... 29 levofloxacin .........................6 levofloxacin (ophth) ........... 28 levofloxacin in d5w ..............6 levonest 28 day ................. 18 levonorgestrel & eth estradiol .......................................... 19 levonorgestrel (emergency oc) ..................................... 19 levonorgestrel-ethinyl estradiol (91-day) .............. 19 levonorgestrel-ethinyl estradiol (continuous) ........ 19 levora 0.15/30 28 day ....... 19 levorphanol tartrate .............2 levothyroxine sodium ........ 21 LEVOXYL.......................... 21 LEXIVA ...............................5 LIALDA ............................. 22 lidocaine ............................ 32 lidocaine hcl ...................... 32 lidocaine hcl (local anesth.) .3 lidocaine hcl (mouth-throat) .......................................... 32 lidocaine inj 0.5% ................3 lidocaine inj 1% ...................3 lidocaine inj 1.5% ................3 lidocaine inj 2% ...................3 lidocaine-prilocaine ........... 32 linezolid ...............................4 LINZESS ........................... 23 liothyronine sodium ........... 21 LIPOSYN III INJ 10% ........ 26 LIPTRUZET ...................... 10 lisinopril ...............................9 lisinopril & hydrochlorothiazide .............9 lithium carbonate ............... 16 LITHIUM CITRATE ........... 16 LIVALO ............................. 10 LO LOESTRIN FE ............. 19 LOCOID ............................ 32 LOKARA LOTN 0.05% ...... 32 lomedia 24 fe .................... 19 LOMUSTINE .......................7 loperamide hcl ................... 23 lorazepam ......................... 12 lorcet hd tab 10-325mg .......1 lorcet plus tab 7.5-325 ........2 lorcet tab 5-325mg ..............2

LORTAB ELIX ..................... 2 lortab tab 10-325mg ............ 2 lortab tab 5-325mg .............. 2 lortab tab 7.5-325 ................ 2 loryna 28 day .................... 19 losartan potassium ............ 10 losartan potassium & hydrochlorothiazide ........... 10 LOTEMAX ......................... 28 LOTRONEX ...................... 23 lovastatin ........................... 10 low-ogestrel 28 day ........... 19 loxapine succinate ............ 15 LUCENTIS ........................ 29 lufyllin ................................ 30 LUMIGAN ......................... 28 LUMIZYME ....................... 20 LUPANETA PACK ............ 19 LUPR DEP-PED INJ 15MG 8 LUPR DEP-PED INJ 30MG (3-MONTH) ......................... 8 LUPRON DEP INJ 11.25MG ............................................ 8 LUPRON DEPOT ............... 8 LUPRON DEPOT INJ 22.5MG (3-MONTH) ........... 8 LUPRON DEPOT INJ 30MG (3-MONTH) ......................... 8 LUPRON DEPOT INJ 45MG ............................................ 8 LUPRON DEPOT-PED ....... 8 lutera 28 day ..................... 19 LUZU ................................ 31 LYNPARZA ......................... 8 LYRICA ............................. 13 LYSODREN ........................ 8 lyza ................................... 19 M MACRODANTIN ................. 4 magnesium sulfate ............ 26 MAGNESIUM SULFATE ... 26 MAGNESIUM SULFATE IN D5W .................................. 26 MAKENA ........................... 21 malathion .......................... 32 maprotiline hcl ................... 14 marlissa 28 day ................. 19 MARPLAN ........................ 14 MATULANE ........................ 9 matzim la .......................... 11

MAXIDEX ......................... 28 MAXIPIME .......................... 6 meclizine hcl ..................... 22 MEDROL TAB 2MG .......... 20 medroxyprogesterone acetate .............................. 21 medroxyprogesterone acetate (contraceptive) ..... 19 mefenamic acid................... 1 mefloquine hcl .................... 4 MEGACE ES ...................... 8 megestrol acetate ............... 8 MEKINIST ........................... 8 MELOXICAM ...................... 1 meloxicam tabs ................... 1 melphalan hcl ..................... 7 MENACTRA ..................... 25 MENOMUNE-A/C/Y/W-135.......................................... 25 MENOSTAR ..................... 20 MENTAX ........................... 31 MENVEO .......................... 25 mercaptopurine ................... 7 meropenem ........................ 4 mesalamine enema .......... 22 mesna ................................. 9 MESNEX ............................ 9 MESTINON SYRUP ......... 16 MESTINON TIMESPAN ... 16 metadate tab er 20 mg ...... 15 metformin er ..................... 17 metformin hcl .................... 17 methadone hcl .................... 2 METHADONE INJ 10MG/ML............................................ 2 methazolamide ................. 12 methenamine hippurate ...... 4 methimazole ..................... 21 methotrexate sodium inj ...... 7 methotrexate sodium tabs 24 methoxsalen rapid ............ 31 methscopolamine bromide 22 methyclothiazide ............... 12 methylergonovine maleate 21 METHYLIN CHEW TAB .... 15 methylphenidate hcl .......... 15 methylphenidate hcl er ...... 15 methylpr ace inj 40mg/ml .. 20 methylpr ace inj 80mg/ml .. 20 methylpr ss inj 125mg ....... 20

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methylpr ss inj 1gm ........... 20 methylpr ss inj 40mg ......... 20 methylpred pak 4mg ......... 20 methylpred tab 16mg ........ 20 methylpred tab 32mg ........ 20 methylpred tab 4mg .......... 20 methylpred tab 8mg .......... 20 metipranolol ...................... 28 metoclopramide hcl ........... 22 metoclopramide hcl inj 5 mg/ml ................................ 22 metolazone ....................... 12 metoprolol & hctz tab 100-25mg .......................... 11 metoprolol & hctz tab 100-50mg .......................... 11 metoprolol & hctz tab 50-25mg ............................ 11 metoprolol succinate ......... 11 metoprolol tartrate ............. 11 METOZOLV ODT .............. 22 METRO IV ...........................4 metronidazole .....................4 metronidazole (topical) ...... 32 metronidazole inj .................4 metronidazole vaginal ....... 23 mexiletine hcl .................... 10 MIACALCIN INJ 200U/ML. 21 miconazole nitrate vaginal. 23 microgestin 1.5/30 21 day . 19 microgestin 1/20 21 day .... 19 microgestin fe 1.5/30 28 day .......................................... 19 microgestin fe 1/20 28 day 19 midodrine hcl ..................... 12 migergot ............................ 15 millipred............................. 20 MINASTRIN 24 FE ............ 19 minitran ............................. 12 MINIVELLE ....................... 20 minocycline hcl ....................7 minoxidil ............................ 12 MIRAPEX .......................... 14 MIRAPEX ER .................... 14 MIRCERA ......................... 24 mirtazapine ....................... 14 misoprostol ........................ 23 mitomycin ............................7 mitoxantrone hcl ..................9 M-M-R II W/DILUENT 10

DOS .................................. 25 modafinil ........................... 16 moderiba pak ...................... 5 moderiba tab 200mg ........... 5 moexipril hcl ........................ 9 moexipril-hydrochlorothiazide .......................................... 9 mometasone furoate ......... 32 MONONESSA .................. 19 montelukast sodium .......... 29 MORPHINE SUL 20MG/ML ORAL SOL .......................... 2 morphine sulfate ............. 2, 3 MORPHINE SULFATE ... 2, 3 morphine sulfate beads....... 3 morphine sulfate ext-rel tab 3 MOVANTIK ....................... 23 MOVIPREP ....................... 22 MOXEZA ........................... 28 moxifloxacin hcl .................. 6 MOZOBIL .......................... 24 MULTAQ ........................... 10 mupirocin .......................... 30 mupirocin calcium (topical) 30 MUSTARGEN ..................... 7 my way .............................. 19 MYALEPT ......................... 21 MYCAMINE ........................ 4 mycophenolate mofetil ...... 25 mycophenolate sodium ..... 25 MYOBLOC ........................ 29 myorisan ........................... 30 MYOZYME ........................ 20 MYRBETRIQ .................... 23 myzilra .............................. 19 N nabumetone ........................ 1 nadolol .............................. 11 nadolol & bendroflumethiazide ......... 11 nafcillin sodium ................... 7 NAFTIFINE HCL ............... 31 NAFTIN ............................. 31 NAGLAZYME .................... 20 NALLPEN ISO-OSMOTIC IN DE ....................................... 7 NALLPEN/DEXTROSE ....... 7 naloxone hcl ...................... 16 naltrexone hcl ................... 16 NAMENDA SOL 10MG/5ML

.......................................... 13 NAMENDA TAB ................ 13 NAMENDA XR .................. 13 NAMENDA XR TITRATION PACK ................................ 13 NAMZARIC ....................... 13 naphazoline 0.1% ............. 29 NAPRELAN ........................ 1 naproxen ............................. 1 NAPROXEN SOD TAB 500MG CR .......................... 1 naproxen sodium ................ 1 naratriptan hcl ................... 15 NASONEX ........................ 30 NATACYN ........................ 28 nateglinide ........................ 17 NEBUPENT ........................ 4 necon 0.5/35 28 day ......... 19 necon 1/35 28 day ............ 19 necon 10/11 28 day .......... 19 NECON 7/7/7 .................... 19 NECON TAB 1/50-28 ........ 19 nefazodone hcl ................. 14 neomycin sulfate ................. 3 neomycin/polymyxin b gu . 32 neomycin-bacitracin zn-polymyxin ..................... 28 neomycin-polymy-dexameth.......................................... 27 neomycin-polymyxin-gramicidin ..................................... 28 neomycin-polymyxin-hc (ophth) .............................. 27 neomycin-polymyxin-hc (otic).......................................... 33 NEORAL ........................... 25 NEPHRAMINE .................. 26 NESINA ............................ 17 neuac gel 1.2-5% .............. 30 NEULASTA ....................... 24 NEUMEGA ....................... 24 NEUPOGEN ..................... 24 NEUPRO .......................... 14 NEVANAC ........................ 28 nevirapine ........................... 5 NEVIRAPINE ...................... 5 NEXAVAR .......................... 8 NEXIUM ............................ 23 NEXIUM GRA 10MG DR .. 23 NEXIUM GRA 2.5MG DR . 23

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NEXIUM GRA 20MG DR .. 23 NEXIUM GRA 40MG DR .. 23 NEXIUM GRA 5MG DR .... 23 next choice tab 1.5mg ....... 19 niacin (antihyperlipidemic). 10 niacor ................................ 10 nicardipine hcl ................... 11 NICOTROL INHALER ....... 16 NICOTROL NS ................. 16 nifedical ............................. 11 nifedipine........................... 11 nifedipine er ...................... 11 nikki 28 day ....................... 19 NILANDRON .......................8 nimodipine......................... 11 NIPENT ...............................7 nisoldipine ......................... 11 nitro-bid ............................. 12 NITRO-DUR ...................... 12 nitrofurantoin .......................4 nitrofurantoin macrocrystal ..4 nitrofurantoin monohyd macro ..................................4 NITROGLYCERIN ............ 12 NITROGLYCERIN LINGUAL .......................................... 12 nitroglycerin patches ......... 12 NITROLINGUAL SPR PUMPSPRA ...................... 12 NITROMIST ...................... 12 NITROSTAT ...................... 12 nizatidine ........................... 22 NORA-BE TAB .................. 19 NORDITROPIN FLEXPRO .......................................... 20 NORDITROPIN NORDIFLEX PEN ............. 21 norethin acet & estrad-fe ... 19 norethindrone & ethinyl estradiol-fe ........................ 19 norethindrone (contraceptive) .................. 19 norethindrone acetate ....... 21 norgestimate-ethinyl estradiol (triphasic) ............ 19 NORITATE ........................ 32 norlyroc 28 day ................. 19 normosol-m ....................... 27 NORMOSOL-R ................. 27 NORPACE CR .................. 10

nortrel 0.5/35 28 day ......... 19 nortrel 1/35 21 day ............ 19 nortrel 1/35 28 day ............ 19 nortrel 7/7/7 28 day ........... 19 nortriptyline hcl .................. 14 NORVIR .............................. 5 NOVAREL INJ 10000UNT 21 NOVOLIN 70/30 ................ 17 NOVOLIN 70/30 RELION . 17 NOVOLIN N ...................... 17 NOVOLIN N RELION ........ 17 NOVOLIN R ...................... 17 NOVOLIN R RELION ........ 17 NOVOLOG ........................ 17 NOVOLOG MIX 70/30 ...... 17 NOVOLOG MIX 70/30 PREFILL ........................... 17 NOVOLOG PENFILL ........ 17 NOXAFIL ............................ 4 NPLATE ............................ 24 NUCYNTA .......................... 3 NUCYNTA ER .................... 3 NUEDEXTA ...................... 16 NULOJIX ........................... 25 NULYTELY/FLAVOR PACKS .............................. 22 NUTRILIPID EMU 20% ..... 26 NUTROPIN AQ INJ 20MG/2ML ........................ 21 NUTROPIN AQ NUSPIN 5 21 NUTROPIN AQ PEN......... 21 NUVARING ....................... 19 NUVESSA ......................... 23 NUVIGIL ........................... 16 nyamyc ............................. 31 NYMALIZE ........................ 11 nystatin ............................... 4 nystatin (mouth-throat) ...... 32 nystatin (topical) ................ 31 nystatin pow 100000 ......... 31 nystop ............................... 31 O OCELLA TAB 3-0.03MG ... 19 OCTAGAM ........................ 25 octreotide acetate ............. 21 OFEV ................................ 29 ofloxacin (ophth) ............... 28 ofloxacin (otic) ................... 33 ogestrel 28 day ................. 19 olanzapine ........................ 15

olanzapine odt .................. 15 olopatadine hcl (nasal) ...... 29 OLYSIO .............................. 5 OMECLAMOX-PAK .......... 23 omega-3-acid ethyl esters 10 omeprazole ....................... 23 OMEPRAZOLE-SODIUM BICARBONATE ................ 23 OMNARIS ......................... 30 OMNITROPE 10MG ......... 21 OMNITROPE 5.8MG ........ 21 OMNITROPE 5MG ........... 21 ONCASPAR ....................... 9 ondansetron hcl ................ 22 ondansetron hcl inj............ 22 ondansetron hcl oral soln .. 22 ondansetron odt ................ 22 ONEXTON ........................ 30 ONFI SUS 2.5MG/ML ....... 13 ONFI TAB 10MG .............. 13 ONGLYZA ........................ 17 ONMEL ............................... 4 OPANA ER (CRUSH RESISTANT ....................... 3 OPDIVO .............................. 9 OPSUMIT ......................... 12 ORACEA .......................... 32 ORAP ............................... 15 ORAPRED ODT TAB 10MG.......................................... 20 ORENCIA ......................... 24 ORENITRAM TAB 0.125MG.......................................... 12 ORENITRAM TAB 0.25MG.......................................... 12 ORENITRAM TAB 1MG ... 12 ORENITRAM TAB 2.5MG 12 ORFADIN ......................... 20 orsythia 28 day ................. 19 ORTHO TRI-CYCLEN LO 19 OSENI TAB 12.5-15MG .... 17 OSENI TAB 12.5-30MG .... 18 OSENI TAB 12.5-45MG .... 18 OSENI TAB 25-15MG ....... 18 OSENI TAB 25-30MG ....... 18 OSENI TAB 25-45MG ....... 18 OSMOPREP ..................... 22 OTEZLA ............................ 24 OTREXUP ........................ 24 oxacillin sodium .................. 7

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oxaliplatin ............................9 oxandrolone ...................... 16 oxaprozin ............................1 oxcarbazepine ................... 13 OXECTA .............................3 OXISTAT........................... 31 OXSORALEN .................... 32 OXTELLAR XR ................. 13 oxybutynin chloride ........... 23 oxycodone hcl .....................3 OXYCODONE HCL ............3 oxycodone w/ acetaminophen 10-325mg ..3 oxycodone w/ acetaminophen 2.5-325mg .3 oxycodone w/ acetaminophen 5-325mg ....3 oxycodone w/ acetaminophen 7.5-325mg .3 oxycodone-aspirin ...............3 oxycodone-ibuprofen ..........3 OXYCONTIN .......................3 oxymorphone hcl .................3 OXYTROL ......................... 23 P pacerone ........................... 10 paclitaxel .............................8 pamidronate inj 30/10ml .... 18 pamidronate inj 6mg/ml ..... 18 pamidronate inj 90/10ml .... 18 PANCREAZE .................... 23 PANDEL............................ 32 PANRETIN ........................ 32 pantoprazole sodium ......... 23 paricalcitol ......................... 27 PARICALCITOL ................ 27 paromomycin sulfate ...........3 paroxetine er tab ............... 14 paroxetine hcl .................... 14 paser d/r ..............................5 PATADAY ......................... 28 PATANOL ......................... 28 PAXIL ................................ 14 PAZEO .............................. 28 PCE ....................................6 PEDVAX HIB .................... 25 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ........... 22 peg 3350-potassium chloride-sod bicarbonate-sod

chloride ............................. 22 PEGANONE ..................... 13 PEGASYS ......................... 25 PEGASYS PROCLICK ..... 25 PEGINTRON .................... 25 PEG-INTRON ................... 25 PEG-INTRON REDIPEN .. 25 PENICILLIN G POT IN DEXTROSE ........................ 7 penicillin g potassium .......... 7 penicillin g procaine ............ 7 penicillin g sodium .............. 7 penicillin v potassium .......... 7 PENNSAID ....................... 32 PENTAM 300 ...................... 4 PENTASA ......................... 22 pentoxifylline ..................... 24 PERFOROMIST ............... 29 perindopril erbumine ........... 9 periogard soln 0.12% ........ 32 PERJETA ............................ 8 permethrin ......................... 32 perphenazine .................... 15 PERTZYE ......................... 23 PEXEVA ........................... 14 pfizerpen ............................. 7 phenadoz .......................... 22 phenadoz sup ................... 22 phenelzine sulfate ............. 14 phenergan ......................... 22 phenergan supp ................ 22 phenobarbital .................... 13 phenobarbital sodium........ 13 PHENOBARBITAL SODIUM .......................................... 13 phenytek ........................... 13 phenytoin .......................... 13 phenytoin inj 50mg/ml ....... 13 phenytoin sodium extended .......................................... 13 philith ................................ 19 PHOSLYRA ...................... 21 PHOSPHOLINE IODIDE ... 28 PICATO ............................ 32 PILOCARPINE HCL.......... 28 pilocarpine hcl (oral).......... 32 pimtrea pack ..................... 19 pindolol ............................. 11 pioglitazone hcl ................. 18 pioglitazone hcl-glimepiride

.......................................... 18 pioglitazone hcl-metformin hcl ..................................... 18 piperacillin sodium-tazobactam sodium 7 pirmella 1/35 28 day ......... 19 piroxicam ............................ 1 PLASMA-LYTE A.............. 27 PLASMA-LYTE-148 .......... 27 PLASMA-LYTE-56/D5W ... 27 PLEGRIDY ....................... 16 PLEGRIDY STARTER PACK ................................ 16 podofilox ........................... 32 polyethylene glycol 3350 .. 22 polymyxin b sulfate ............. 4 polymyxin b-trimethoprim .. 28 POMALYST ........................ 9 portia 28 day ..................... 19 potassium chloride ...... 26, 27 POTASSIUM CHLORIDE . 26 POTASSIUM CHLORIDE 0.15% ............................... 27 POTASSIUM CHLORIDE 0.22% ............................... 27 POTASSIUM CHLORIDE 0.3%/D .............................. 27 potassium chloride caps er.......................................... 26 potassium chloride in nacl 27 POTASSIUM CHLORIDE IN NACL ................................ 27 potassium chloride microencapsulated crystals cr ....................................... 26 POTASSIUM CITRATE (ALKALINIZER) TAB ........ 23 POTIGA ............................ 13 PRADAXA ........................ 24 pramipexole dihydrochloride.......................................... 14 pramipexole dihydrochloride tab sr 24hr 0.375 mg ......... 14 pramipexole dihydrochloride tab sr 24hr 0.75 mg ........... 14 pramipexole dihydrochloride tab sr 24hr 1.5 mg............. 14 PRANDIMET .................... 18 pravastatin sodium ............ 10 prazosin hcl ........................ 9

48

PRED MILD ...................... 28 pred sod pho sol 5mg/5ml . 20 PRED-G ............................ 27 PRED-G S.O.P. ................ 27 prednicarbate .................... 32 PREDNICARBATE ........... 32 PREDNISOLONE ACETATE (OPHTH) ........................... 28 prednisolone sodium phosphate ......................... 20 prednisolone sodium phosphate (ophth) ............. 28 prednisolone sol 15mg/5ml .......................................... 20 prednisolone sol 25mg/5ml .......................................... 20 prednisolone syrup 15 mg/5ml .............................. 20 prednisone con 5mg/ml ..... 20 prednisone pak 10mg ....... 20 prednisone pak 5mg ......... 20 prednisone sol 5mg/5ml .... 20 prednisone tab 10mg ........ 20 prednisone tab 1mg .......... 20 prednisone tab 2.5mg ....... 20 prednisone tab 20mg ........ 20 prednisone tab 50mg ........ 20 prednisone tab 5mg .......... 20 PREGNYL W/DILUENT BENZYL ............................ 21 PREMARIN ....................... 20 PREMARIN CREAM ......... 20 PREMARIN INJ ................. 20 premasol 10% ................... 26 premasol 6% ..................... 26 PREMPHASE ................... 20 PREMPRO ........................ 20 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) .......................................... 27 PREPOPIK ........................ 22 PREVACID SOLUTAB ...... 23 prevalite ............................ 10 previfem 28 day ................ 19 PREZCOBIX .......................5 PREZISTA ..........................5 PRIALT ...............................1 PRIFTIN ..............................5 PRILOSEC ........................ 23 PRIMAQUINE PHOSPHATE

............................................ 4 primidone .......................... 13 PRIMSOL SOL 50MG/5ML . 4 PRISTIQ ........................... 14 PRIVIGEN ......................... 25 PROAIR HFA .................... 29 PROAIR RESPICLICK ...... 29 probenecid .......................... 1 PROCALAMINE ................ 26 prochlorperazine inj 5 mg/ml .......................................... 22 prochlorperazine maleate . 22 prochlorperazine supp ...... 22 PROCRIT .......................... 24 procto-pak ......................... 31 proctosol hc 2.5 % ............ 31 proctozone hc ................... 31 PROCYSBI ....................... 20 progesterone micronized .. 21 PROGLYCEM SUS 50MG/ML .......................... 20 PROGRAF ........................ 25 PROLASTIN-C .................. 29 PROLENSA ...................... 29 PROLEUKIN ....................... 8 PROLIA ............................. 21 PROMACTA ..................... 24 promethazine hcl .............. 22 promethegan ..................... 22 propafenone hcl ................ 10 proparacaine hcl ............... 29 propranolol & hydrochlorothiazide ........... 11 propranolol hcl er .............. 11 propranolol inj 1mg/ml....... 11 propranolol sol .................. 11 propranolol tab .................. 11 propylthiouracil .................. 21 PROQUAD ........................ 25 PROSOL ........................... 26 PROTONIX ....................... 23 protriptyline hcl .................. 14 PROVENTIL HFA ............. 29 PRUDOXIN CRE 5% ........ 31 PULMICORT FLEXHALER .......................................... 30 PULMICORT INH SUSP 1MG/2ML .......................... 30 PULMOZYME ................... 29 PURIXAN ............................ 7

PYLERA ........................... 23 pyrazinamide ...................... 5 pyridostigmine bromide ..... 16 Q QNASL ............................. 30 QUARTETTE .................... 19 quasense 91 day .............. 19 QUDEXY XR .................... 13 quetiapine fumarate .......... 15 QUILLIVANT XR ............... 15 quinapril hcl ........................ 9 quinapril-hydrochlorothiazide............................................ 9 quinidine gluconate er ....... 10 quinidine sulfate ................ 10 quinine sulfate .................... 4 QVAR ............................... 30 R RABAVERT ...................... 25 rabeprazole sodium .......... 23 RAGWITEK ...................... 25 raloxifene hcl .................... 21 ramipril ................................ 9 RANEXA ........................... 12 ranitidine hcl ..................... 22 RAPAFLO ......................... 23 RAPAMUNE ..................... 25 RAVICTI ........................... 21 RAYOS TAB 1MG ............ 20 RAYOS TAB 2MG ............ 20 RAYOS TAB 5MG ............ 20 REBETOL ........................... 5 REBIF ............................... 16 REBIF REBIDOSE ............ 16 REBIF REBIDOSE TITRATION ....................... 16 REBIF TITRATION PACK 16 reclipsen 28 day................ 19 RECOMBIVAX HB ............ 25 RECTIV ............................ 32 REGRANEX ..................... 32 RELENZA DISKHALER ...... 5 RELISTOR ........................ 22 RELPAX ........................... 15 REMICADE ....................... 24 REMODULIN .................... 12 RENAGEL ........................ 21 RENVELA PAK ................. 21 RENVELA TAB 800MG .... 21 repaglinide ........................ 18

49

reprexain 10/200 .................2 RESCRIPTOR ....................5 RESTASIS ........................ 29 RETIN-A MICRO PUMP ... 30 RETROVIR IV INFUSION ...5 REVATIO .......................... 12 REVLIMID ......................... 25 REYATAZ ...........................5 RHEUMATREX ................. 24 ribapak mis 600/day ............5 ribasphere ...........................5 ribasphere ribapak 1000 .....5 ribasphere ribapak 1200 .....5 ribasphere ribapak 800 .......5 ribavirin 200mg ...................5 rifabutin ...............................5 rifamate ...............................5 rifampin ...............................5 RIFATER.............................5 riluzole .............................. 16 rimantadine hydrochloride ...5 RINGER'S ......................... 27 RIOMET ............................ 18 risedronate sodium ........... 18 RISPERDAL INJ 12.5MG.. 15 RISPERDAL INJ 25MG .... 15 RISPERDAL INJ 37.5MG.. 15 RISPERDAL INJ 50MG .... 15 risperidone ........................ 15 risperidone odt .................. 15 RITALIN LA ....................... 15 RITUXAN ............................8 rivastigmine tartrate .......... 13 rizatriptan benzoate .......... 15 ropinirole hydrochloride ..... 14 rosadan cre 0.75% ............ 32 ROTARIX .......................... 25 ROTATEQ ......................... 25 roxicet soln ..........................3 roxicet tabs ..........................3 ROZEREM ........................ 15 RUCONEST ...................... 24 RYTARY ........................... 14 S SABRIL ............................. 13 SAIZEN ............................. 21 SAIZEN CLICK.EASY ....... 21 SAMSCA ........................... 21 SANCUSO ........................ 22 SANDIMMUNE CAPS ....... 25

SANDIMMUNE SOLN....... 25 SANDOSTATIN LAR DEPOT ............................. 21 SANTYL ............................ 32 SAPHRIS .......................... 15 SARAFEM ........................ 16 SAVAYSA ......................... 24 SAVELLA .......................... 16 SAVELLA TITRATION PACK ................................ 16 selegiline hcl ..................... 14 selenium sulfide ................ 31 SELZENTRY ....................... 5 SEMPREX-D .................... 29 SENSIPAR ........................ 18 SEREVENT DISKUS ........ 29 SEROQUEL XR ................ 15 SEROSTIM ....................... 21 sertraline hcl ..................... 14 SF-ROWASA .................... 22 sharobel 28 day ................ 19 SIGNIFOR ........................ 21 sildenafil citrate (pulmonary hypertension) .................... 12 SILENOR .......................... 15 SILVER SULFADIAZINE .. 30 SIMBRINZA SUS 1-0.2% .. 28 SIMCOR ........................... 10 SIMPONI ........................... 24 SIMPONI ARIA ................. 24 SIMULECT ........................ 25 simvastatin ........................ 10 SIROLIMUS ...................... 25 sirolimus tab 0.5 mg .......... 25 SIRTURO ............................ 5 SIVEXTRO .......................... 4 SKLICE ............................. 32 SODIUM CHLORIDE .. 26, 27 SODIUM CHLORIDE 0.45% VIA .................................... 27 SODIUM CHLORIDE 0.9% .......................................... 32 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN ................................ 26 sodium phenylbutyrate ...... 20 sodium polystyrene sulfonate .......................................... 18 SOLIA ............................... 19 SOLIRIS ............................ 24

SOLODYN .......................... 7 SOLTAMOX ........................ 8 SOLU-CORTEF ................ 20 SOLU-MEDROL INJ 2GM 20 SOMATULINE DEPOT ..... 21 SOMAVERT ..................... 21 SOOLANTRA ................... 32 SORILUX .......................... 31 sorine ................................ 10 sotalol hcl .......................... 10 sotalol hcl (afib/afl) ............ 10 SOTYLIZE ........................ 11 SOVALDI ............................ 5 SPIRIVA HANDIHALER ... 29 SPIRIVA RESPIMAT ........ 29 spironolactone .................... 9 spironolactone & hydrochlorothiazide ........... 12 SPORANOX SOL 10MG/ML............................................ 4 sprintec 28 day ................. 19 SPRYCEL ........................... 8 sronyx 28 day ................... 19 SSD .................................. 31 stavudine ............................ 5 STELARA ......................... 31 STERILE WATER IRRIGATION ..................... 32 STIMATE .......................... 21 STIVARGA ......................... 8 STRATTERA .................... 15 streptomycin sulfate ............ 3 STRIANT .......................... 16 STRIBILD ........................... 5 STRIVERDI RESPIMAT ... 29 SUBOXONE MIS 12-3MG 16 SUBOXONE MIS 2-0.5MG.......................................... 16 SUBOXONE MIS 4-1MG .. 16 SUBOXONE MIS 8-2MG .. 16 SUBSYS ............................. 3 SUCLEAR ......................... 23 SUCRAID ......................... 23 sucralfate .......................... 23 sulfacetamide sodium (acne).......................................... 30 sulfacetamide sodium (ophth) .............................. 28 sulfacetamide sod-prednisolone .............. 27

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sulfadiazine .........................3 sulfamethoxazole-trimethop 4 sulfamethoxazole-trimethoprim inj ....................................4 SULFAMYLON .................. 31 sulfasalazine dr ................. 22 sulfasalazine ir .................. 22 sulindac ...............................1 sumatriptan succinate ....... 15 SUMATRIPTAN SUCCINATE ..................... 15 sumatriptan succinate inj .. 15 SUMATRIPTAN SUCCINATE INJ ............... 15 SUMAVEL DOSEPRO ...... 15 SUPPRELIN LA ................ 21 suprax .................................6 SUPRAX .............................6 SUPREP BOWEL PREP... 23 SURMONTIL ..................... 14 SUSTIVA.............................5 SUTENT..............................8 syeda ................................ 19 SYLATRON KIT 296MCG ...9 SYLATRON KIT 444MCG ...9 SYLATRON KIT 888MCG ...9 SYLVANT.......................... 25 SYMBICORT ..................... 30 SYMLINPEN 120 .............. 17 SYMLINPEN 60 ................ 17 SYNAGIS .......................... 25 SYNAREL ......................... 19 SYNERA ........................... 32 SYNERCID .........................4 SYNRIBO ............................9 SYNTHROID ..................... 21 SYPRINE .......................... 18 T TABLOID.............................7 TACLONEX ....................... 32 tacrolimus.......................... 25 tacrolimus (topical) ............ 32 TAFINLAR ...........................8 TAMIFLU.............................5 tamoxifen citrate ..................8 tamsulosin hcl ................... 23 TANZEUM ......................... 17 TARCEVA ...........................8 TARGRETIN .......................9 TARGRETIN GEL ............. 32

tarina fe tab 1/20 ............... 19 TARKA ................................ 9 TASIGNA ............................ 9 tazicef ................................. 6 tazicef vial ........................... 6 TAZORAC ......................... 31 taztia xt ............................. 11 TECFIDERA CAP 120MG 16 TECFIDERA CAP 240MG 16 TECFIDERA MIS STARTER .......................................... 16 TEFLARO ........................... 6 TEGRETOL ...................... 13 TEGRETOL-XR ................ 13 TEKAMLO ......................... 11 TEKTURNA ...................... 11 TEKTURNA HCT .............. 12 TELMISARTAN ................. 10 telmisartan-amlodipine ...... 10 telmisartan-hydrochlorothiazide ...................................... 10 temazepam ....................... 15 TENIVAC .......................... 25 terazosin hcl ........................ 9 terbinafine hcl ..................... 4 terbutaline sulfate ............. 29 terconazole vaginal ........... 23 TESTIM ............................. 16 testosterone cypionate ...... 17 testosterone enanthate ..... 17 TETANUS TOXOID ADSORBED ...................... 26 TETANUS/DIPHTHERIA TOXOID ............................ 26 TETRACYCLINE HCL ........ 7 TEVETEN HCT ................. 10 TEV-TROPIN .................... 21 texacort ............................. 32 THALOMID ....................... 25 theo-24 .............................. 30 theophylline ....................... 30 thioridazine hcl .................. 15 thiothixene ........................ 15 THYMOGLOBULIN ........... 25 tiagabine hcl ...................... 13 TIKOSYN .......................... 10 timolol maleate .................. 11 timolol maleate (ophth) ..... 28 TIMOLOL MALEATE GEL 28 TIMOPTIC OCUDOSE ...... 28

TIROSINT ......................... 21 TIVICAY .............................. 5 tizanidine .......................... 16 TOBI PODHALER ............... 3 TOBRADEX ...................... 27 TOBRADEX ST ................ 27 tobramycin .......................... 3 tobramycin (ophth) ............ 28 tobramycin sulfate............... 3 tobramycin sulfate in saline 3 tobramycin-dexamethasone.......................................... 27 TOBREX OINT 0.3% ........ 28 tolmetin sodium................... 1 TOLTERODINE TARTRATE ER ..................................... 23 tolterodine tartrate tab 1 mg.......................................... 23 tolterodine tartrate tab 2 mg.......................................... 23 TOPICORT ....................... 32 topiramate ......................... 13 TOPIRAMATE .................. 13 toposar ................................ 9 topotecan hcl ...................... 9 TORISEL ............................ 8 torsemide inj 20mg/2ml ..... 12 torsemide inj 50mg/5ml ..... 12 torsemide tabs .................. 12 TOUJEO SOLOSTAR ....... 17 TOVIAZ ............................. 23 TPN ELECTROLYTES ..... 26 TRACLEER ...................... 12 TRADJENTA .................... 18 TRAMADOL HCL................ 2 tramadol hcl er .................... 2 tramadol hcl er (biphasic) 100mg ................................. 2 tramadol hcl er (biphasic) 200mg ................................. 2 tramadol hcl er (biphasic) 300mg ................................. 2 tramadol hcl tab 50 mg ....... 2 tramadol-acetaminophen .... 2 trandolapril .......................... 9 trandolapril-verapamil hcl .... 9 tranexamic acid................. 24 TRANSDERM-SCOP ........ 22 tranylcypromine sulfate ..... 14 travasol 10 ........................ 26

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TRAVATAN Z .................... 28 trazodone hcl .................... 14 TREANDA ...........................7 TRECATOR ........................5 TRELSTAR MIXJECT .........8 tretinoin ......................... 9, 30 TRETINOIN MICROSPHERE ............... 30 tretin-x ............................... 30 trexall ................................ 24 TREXIMET ........................ 15 trezix ...................................2 triamcinolone acetonide (mouth) ............................. 32 triamcinolone acetonide (nasal) ............................... 30 triamcinolone acetonide (topical) ............................. 32 triamt/hctz cap 37.5-25 ..... 12 triamt/hctz cap 50-25mg ... 12 triamt/hctz tab 37.5-25 ...... 12 triamt/hctz tab 75-50mg .... 12 trianex ............................... 32 TRIBENZOR ..................... 10 triderm ............................... 32 trifluoperazine hcl .............. 15 trifluridine .......................... 28 TRIGLIDE ......................... 11 trihexyphenidyl hcl ............ 14 tri-legest 28 day ................ 19 trilyte ................................. 23 trimethoprim ........................4 TRINESSA ........................ 19 tri-previfem 28 day ............ 19 TRISENOX ..........................9 tri-sprintec 28 day ............. 19 TRIUMEQ ...........................5 trivora 28 day .................... 19 TROKENDI XR ................. 13 TROPHAMINE INJ 10% ... 27 trospium chloride ............... 23 trospium chloride er .......... 23 TRULICITY ....................... 17 TRUMENBA ...................... 26 TRUVADA ...........................5 TUDORZA PRESSAIR ..... 29 TUDORZA PRESSAIR (INSTITUTIONAL PACK) 400MCG/ACT ................... 29 TWINRIX INJ .................... 26

TYBOST ............................. 5 TYGACIL ............................ 4 TYKERB ............................. 9 TYPHIM VI ........................ 26 TYSABRI .......................... 16 TYVASO ........................... 12 TYZEKA .............................. 5 tyzine ................................ 29 U UCERIS ............................ 22 u-cort................................. 32 ULORIC .............................. 1 ULTRESA ......................... 23 UNITHROID ...................... 21 ursodiol ............................. 23 UVADEX ............................. 9 V VAGIFEM .......................... 20 valacyclovir hcl .................... 5 VALCHLOR ...................... 32 VALCYTE ........................... 5 valganciclovir hcl ................. 5 valproate sodium .............. 13 valproic acid ...................... 13 valsartan ........................... 10 valsartan-hydrochlorothiazide ........................................ 10 VALSTAR ........................... 7 vancomycin hcl ................... 4 VANDAZOLE .................... 23 VANTAS ............................. 8 VAQTA .............................. 26 VARIVAX .......................... 26 VASCEPA ......................... 11 VECTIBIX ........................... 8 VELCADE ........................... 8 VELETRI ........................... 12 velivet 28 day .................... 19 VELPHORO ...................... 21 VELTIN ............................. 30 venlafaxine cap er ............. 14 venlafaxine hcl .................. 14 venlafaxine tab .................. 14 VENLAFAXINE TAB 225MG ER ..................................... 14 venlafaxine tab er ............. 14 VENTAVIS ........................ 12 VENTOLIN HFA ................ 29 VERAMYST ...................... 30 verapamil hcl ..................... 11

VERAPAMIL HCL ............. 11 veripred ............................. 20 VERSACLOZ .................... 15 VESICARE ....................... 23 vestura .............................. 19 VEXOL .............................. 28 VIBRAMYCIN ..................... 7 vicodin ................................ 2 vicodin es ............................ 2 vicodin hp ........................... 2 VICTOZA .......................... 17 VICTRELIS ......................... 5 VIDEX PEDIATRIC ............. 5 VIGAMOX ......................... 28 VIIBRYD ........................... 14 VIMIZIM ............................ 20 VIMOVO ............................. 1 VIMPAT ............................ 13 vinblastine sulfate ............... 8 vincasar .............................. 8 vincristine sulfate ................ 8 vinorelbine tartrate .............. 8 VIOKACE 10 ..................... 23 VIOKACE 20 ..................... 23 viorele ............................... 19 VIRACEPT .......................... 5 VIRAMUNE XR ................... 5 VIREAD .............................. 5 VITEKTA ............................. 5 VIVITROL ......................... 16 VOGELXO ........................ 17 VOGELXO PUMP ............. 17 VOLTAREN GEL 1% ........ 32 voriconazole ....................... 4 voriconazole inj 200mg ....... 4 VOTRIENT ......................... 9 VPRIV ............................... 20 vyfemia 28 day ................. 19 VYTORIN .......................... 11 VYVANSE ......................... 15 W warfarin sodium ................ 24 WELCHOL ........................ 11 WYMZYA FE .................... 19 X XALKORI ............................ 9 XARELTO ......................... 24 XARELTO STARTER PACK.......................................... 24 XARTEMIS XR ................... 3

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XELJANZ .......................... 24 XENAZINE ........................ 16 XEOMIN ............................ 29 XERESE ........................... 31 XGEVA ............................. 21 XIFAXAN TAB 200MG ........4 XIFAXAN TAB 550MG ...... 23 XIGDUO XR TAB 10-1000 18 XIGDUO XR TAB 10-500MG .......................................... 18 XIGDUO XR TAB 5-1000MG .......................................... 18 XIGDUO XR TAB 5-500MG .......................................... 18 XOLAIR ............................. 29 XOPENEX HFA ................ 29 XTANDI ...............................8 xulane dis 150-35 .............. 19 XYREM ............................. 16 Y YERVOY .............................8 YF-VAX ............................. 26 Z zafirlukast .......................... 29 ZALTRAP ............................8 ZANOSAR ...........................7 zarah ................................. 19 ZAVESCA ......................... 20 zazole ............................... 23

ZAZOLE ............................ 23 ZEGERID .......................... 23 ZELAPAR ......................... 14 ZELBORAF ......................... 9 ZEMAIRA .......................... 30 ZEMPLAR ......................... 27 zenatane ........................... 30 zenchent fe 28 day ........... 19 zenchent tab ..................... 19 ZENPEP ........................... 23 ZERBAXA ........................... 6 ZETIA TAB 10MG ............. 11 ZETONNA ......................... 30 ZIAGEN .............................. 5 ZIANA ............................... 30 zidovudine ........................... 5 ZINACEF ............................ 6 ZIOPTAN .......................... 28 ziprasidone hcl .................. 15 ZIPSOR .............................. 1 ZIRGAN ............................ 28 ZMAX .................................. 6 ZOHYDRO ER (ABUSE DETERRENT) ..................... 3 ZOLADEX ........................... 8 zoledronic inj 4mg/5ml ...... 18 zoledronic inj 5/100ml ....... 18 ZOLINZA ............................. 8 zolmitriptan ....................... 16

zolmitriptan odt ................. 16 zolpidem tartrate ............... 15 ZOMACTON ..................... 21 ZOMETA ........................... 18 ZOMIG NASAL SPRAY .... 16 zonisamide ....................... 13 ZONTIVITY ....................... 24 ZORBTIVE ........................ 21 ZORTRESS TAB 0.25MG 25 ZORTRESS TAB 0.5MG .. 25 ZORTRESS TAB 0.75MG 25 ZORVOLEX ........................ 1 ZOSTAVAX ...................... 26 ZOSYN ............................... 7 zovia 1/35e 28 day............ 19 zovia 1/50e 28 day............ 19 ZOVIRAX .......................... 31 ZUBSOLV ......................... 16 ZUBSOLV SUB 8.6-2.1 .... 16 ZUPLENZ ......................... 22 ZYCLARA ......................... 32 ZYDELIG ............................ 9 ZYFLO CR ........................ 29 ZYKADIA ............................ 9 ZYLET .............................. 27 ZYPREXA RELPREVV ..... 15 ZYTIGA ............................... 8 ZYVOX ............................... 4

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HealthSelect MedicareRx Effective August, 1 2015€¦ · 01/08/2015 · SOLN 2mg/ml, 4mg/ml, 8mg/ml 3 B/D MORPHINE SULFATE SOLN 10mg/5ml, 20mg/5ml 1 morphine sulfate SOLN .5mg/ml,