Health Partners Plans 2014 Formulary

HealthPartnersPlansFormulary
Updated1/2/2014
2014 Formulary
Introduction
Health Partners, Inc. is pleased to provide
the 2014 Formulary. This formulary covers
members under Health Partners Medicaid
plan. The drugs listed in the Health
Partners Formulary are intended to provide
sufficient options to treat the majority of
patients who require drug therapy in an
ambulatory setting. Excluded from
coverage are specific manufacturers who
have not contracted with the rebate program
of the Federal government.
The drugs listed in the Health Partners
Formulary have been reviewed and
approved by the Health Partners Pharmacy
and Therapeutics Committee. These drug
products have been selected to provide the
most clinically appropriate and costeffective medications for Health Partners
members. There may be occasions when
an unlisted drug is desired for medical
management of a specific patient. In those
instances, the unlisted medication may be
requested through Prior Authorization/
Medical Exception.
Preface
The Health Partners Formulary is organized
by sections, which refer to either a drug/
pharmacologic class or disease state. Each
section contains a list of drugs selected to
be on this formulary. Prescribing a drug
product that is available generically is
encouraged when appropriate.
Prescriptions for generically available nonprescription (OTC) drugs deemed medically
necessary by the plan are eligible for
coverage. Generally, OTC medications are
less costly than prescription alternatives and
their use can contribute to cost-effective
therapy. The over-the-counter (OTC)
products listed in the formulary are covered
with a prescription.
Pharmacy and Therapeutics

(P&T) Committee
The actions of the Health Partners P&T
Committee are communicated through
the Provider Newsletter to all physicians
and posted on our website. Pharmacy
providers in the Health Partners network
will be notified through correspondence
from the Health Partners pharmacy
department.
Product Selection Criteria
The Health Partners P&T Committee will
consider all FDA approved drugs for
inclusion in the formulary. The evaluation
process includes a literature review; expert
opinion by respected medical professionals
or through TEC (Technical Evaluation
Center) may also be sought. Formal reviews
are prepared which typically address the
following information:
1. Safety
2. Effectiveness
3. Comparison studies
4. Approved indications
5. Adverse effects
6. Contraindications
7. Pharmacokinetics
8. Patient compliance considerations
9. Medical outcome and
pharmacoeconomic studies
When a new drug is considered for
formulary inclusion an attempt will be made
to examine the drug relative to similar drugs
currently on formulary. In addition, entire
therapeutic classes are periodically
reviewed. This review process may result in
deletion of a drug(s) in a particular
therapeutic class in an effort to continually
promote the most clinically useful and costeffective agents.
Plan Limits
A maximum of 30-day supply of medication
is eligible for coverage. The prescriber is
urged to prescribe in amounts that adhere to

accepted standards of care. The days
supply must be accurately determined by
the dispensing pharmacist to assure
compliance with plan parameters.
Specific limits based on FDA guidelines,
medication package inserts and accepted
standards of care may apply to medication
treatments under clinical review.
Prescription quantities cannot be altered
unless approved by the physician, and must
be within the limits of the plans days supply.
Prescribed medications or regimens that are
non-formulary require prior authorization.
Immediate Need (5/15-day
Emergency Supply)
If a member presents at a pharmacy a
prescription which requires prior
authorization, whether for a non-formulary
drug or otherwise, and if the prior
authorization cannot be processed
immediately, Health Partners will allow the
pharmacy to dispense an interim supply of
the prescription under the following
circumstances:
If the recipient is in immediate need of the
medication in the professional judgment of
the pharmacist and if the prescription is for a
new medication (one that the recipient has
not taken before or that is taken for an acute
condition), Health Partners will allow the
pharmacy to dispense a 5-day supply of the
medication to afford the recipient or
pharmacy the opportunity to initiate the
request for prior authorization.
If the prescription is for an ongoing
medication (one that is continuously
prescribed for the treatment of an illness or
condition that is chronic in nature in which
there has not been a break in treatment for
greater than 34 Days), Health Partners will
allow the pharmacy to dispense a 15-day
supply of the medication automatically,
unless Health Partners mailed to the
member, with a copy to the prescriber, an
advanced written notice of the reduction or
termination of the medication at least 10

days prior to the end of the period for which
the medication was previously authorized.
Health Partners will respond to the request
for prior authorization within 24 hours from
when the request was received. If the prior
authorization is denied, the recipient is
entitled to appeal the decision through
several avenues. The 5-day or 15-day
requirement does not apply when the
pharmacist determines that taking the
medication, either alone or along with other
medication that the recipient may be taking,
would jeopardize the health and safety of
the recipient.
Formulary Product
Descriptions
This formulary lists all specific strengths and
dosage forms that are covered. When a
strength or dosage form is specified,
only the product identified will be
covered. Other strengths/ dosage forms
of the referenced product are not
covered.
For specific questions please contact the
Health Partners Pharmacy department at
215-991-4300.
Generic Substitution
Generic substitution is the process by which
a generic equivalent is dispensed rather
than the brand name product. The
appropriate use of generic drugs is one
method of providing cost conscious drug
therapy. Health Partners will not cover any
drugs by companies that do not participate
in the Federal Rebate Program or are DESI
drugs. Generic drugs must be prescribed
and dispensed when an A-rated generic
drug is available. Brand necessary
prescriptions for drugs with A-rated generics
require prior authorization.
The MAC list sets a ceiling price for the
reimbursement of certain multisource
prescription drugs. This price will typically
cover the acquisition of most generics but
not branded versions of the same drug. The
products selected for inclusion on the MAC
list are commonly prescribed and dispensed
and have usually gone through the FDAs
review and approval process. This process
assures the following requirements have
Updated1/2/2014
been met:
The generic drug will contain the same
active ingredient(s) and be the same
strength and dosage form as the brand
name counterpart.
The FDA has given the generic an A rating
compared to the branded counterpart
indicating bioequivalence and has
determined the generic is therapeutically
equivalent to the referenced brand. The
ratings of generic drugs are available by
referring to the FDA reference Approved
Drug Products with Therapeutic Equivalence
Evaluations (Orange Book).
When the above two criteria are met, a
generic can be substituted with the full
expectation that the substituted product will
produce the same clinical effect and safety
profile as the brand name product.
State laws or regulation may indicate the
ability to practice generic substitution for
selected products or categories of drugs.
There are now many brand name products
that are repackaged or distributed under a
generic label. These generic versions
should always be considered therapeutically
equivalent and substitutable for the source
branded product irrespective of rating.
To ensure that select medications are

utilized appropriately, Prior Authorization
may be required for the dispensing of
specific products. These medications may
require Prior Authorization for the following
reasons:
Non-formulary medications, or benefit
exceptions required by medical
necessity
All brand name medications when
there is an A-rated generic equivalent
available
Medications and/or treatments under
clinical investigation
Medications used for non-FDA
approved indications
Prescription costs that exceed $1000
per claim
Prescriptions that exceed set plan
limits (days supply, quantity, cost)
Prescriptions processed by nonnetwork pharmacies
New-to-market products
High end oral and self administered
injectable medications
Medications with Health Partners
P&T Committee approved treatment
guidelines
Drugs Efficacy Study

Implementation (DESI) Drugs
To request a prior authorization the

physician or a member of his/her staff
should contact Health Partners either by
fax at (866) 240-3712, or phone at (215)
991-4300. All non-emergency requests
can be faxed 24 hours per day; calls
should be placed from 9:00 A.M. to 5:00
P.M., Monday through Friday.
In the event of an immediate need after
business hours, the call should be made to
Health Partners Member Services at (800)
553-0784. The call will be evaluated and
routed to a pharmacist-on-call.
The physician may use the Health Partners
Prior Authorization/Medical Exception form
or a letter of request, but must include the
following information for quick and
appropriate review to take place:
Name and recipient number of member
Date of birth of member
Physicians name, license number, and
specialty
Physicians phone and fax numbers
Name of primary care physician if
different
Drug name, strength, and quantity of
medication
Health Partners does not reimburse for

DESI drugs. DESI drugs are those drugs
first marketed between 1938 and 1962
which were approved as safe, but not
required to show effectiveness for FDA
product approval. The DESI program
subsequently made a determination of fully
effective for most of these products and they
remain in the marketplace. A few DESI
products remain classified as less than fully
effective while awaiting final administrative
disposition. Also classified as DESI are
many products listed as identical, similar, or
related to actual DESI products.
Examples of DESI Drugs include:
Midrin
Vytone
Anusol HC
Donnatal
Tigan
Naldecon
Prior Authorization (PA)
ii
Days supply (duration of therapy) and

number of refills
Route of administration
Diagnosis
Medical rationale for request
Formulary medications used, duration
and therapy result
Additional clinical information that may
contribute to the review decision (e.g.,
labs)
Upon receiving the Prior Authorization
Medical Exception Request from the
prescriber, Health Partners will render a
decision within 24 hours. The Medical
Director will review each prior authorization
request and make the final decision of
approval or denial complete with a signature
and date. After Medical Director review, the
clinical pharmacist will prepare the request
for the denial/approval letter using The
Department of Public Welfare (DPW)
approved language. DPW approved
language is used for all denial letters and
mailed to the member or parent/guardian, in
the case of a child. A copy of the member
denial letter is also faxed to the prescribing
physician.
If the Prior Authorization Medical Exception
Request is denied, the prescriber can
submit a written appeal to Health Partners
Complaints & Grievances explaining the
medical necessity of the medical treatment
in question. At anytime during normal
business hours, the prescribing physician
can discuss the denial with a clinical
pharmacist or can have a peer to peer
discussion with the medical director.
Health Partners Specialty
and Injectable Medication
Program
Health Partners supports appropriate use of
injectables and has established procedures
for prescribing and suppliers. Under the
direction of the Health Partners Pharmacy
department, the physician provider has the
primary responsibility for obtaining Prior
Authorization for medications included in
this program. Call the Health Partners
Pharmacy department at 215-991-4300 for
authorization on specialty medications.
The following medications, although not
limited to, can be obtained through the retail

pharmacy benefit without prior authorization.
GENERIC NAME
ceftriaxone
cyanocobalamin
epinephrine
fluphenazine decanoate
glucagon
haloperidol decanoate
heparin sodium
Insulin
medroxyprogesterone
acetate 150 mg only
methylprednisolone
acetate
methylprednisolone
sod. succ.
penicillin g benzathine
penicillin g potassium
sumatriptan
triamcinolone acetonide
BRAND NAME
Rocephin
Vitamin B-12
Epipen, Epipen
Jr.
Prolixin Decanoate
Glucagon
Haldol Decanoate
Heparin
Depo-Provera
Depo-Medrol
Solu-Medrol
Bicillin L.A.
Pfizerpen
Imitrex
Kenalog-40
Quantity Limitations (QL)

All Food and Drug Administration (FDA)
quantities apply. Many drug products on the
Health Partners Formulary have quantity
limits based upon the dosage described in
product labeling.
Drugs subject to quantity limits may change.
Contact Health Partners Pharmacy
department at 215-991-4300 for more
information.
Recipient Restriction
Program
Health Partners participates in the
Pennsylvania Department of Public
Welfare Recipient Restriction Program.
Members identified through the DUR
program with suspected patterns of
abuse will be referred to the Recipient
Restriction Program. Providers
requesting information on this program
may contact Health Partners Pharmacy
department at 215-991-4300.
Editor
Your comments and suggestions regarding
the Health Partners 2014 Formulary are
Updated1/2/2014
encouraged. Your input is vital to this

formularys continued success. All
responses will be reviewed and considered.
Please send your comments to:
Health Partners
Attn: Pharmacy Director
901 Market Street
Suite 500
Philadelphia, PA 19107
Phone: (215) 991-4300
Internet: www.healthpart.com
Notice
The information contained in the Health
Partners Formulary and its appendices is
provided by Health Partners solely for the
convenience of medical providers. Neither
Health Partners warrants or assures
accuracy of such information, nor is it
intended to be comprehensive in nature.
This formulary is not intended to be a
substitute for the knowledge, expertise, skill
and judgment of the medical provider in their
choice of prescription drugs. Health
Partners does not assume responsibility for
the actions or omissions of any medical
provider based upon reliance, in whole or in
part, on the information contained herein.
The medical provider should consult the
drug manufacturer product literature or
standard references for more detailed
information.
The information contained in this document
is proprietary information subject to a
licensing agreement. The information may
not be copied in whole or in part without the
written permission of Health Partners. All
rights reserved.
Trade names are the intellectual property of
the respective product owners.
Legend
Y
GP
PA
QL
OTC
Yes drug is covered

Generic Preferred
Brand name drug with
AB-rated generic
available; use generic
Prior Authorization
required
Quantity Limits apply
Over the Counter (not
all covered OTC
products are listed)
iii
Health Partners of Philadelphia

2014 Formulary
Table of Contents
Antihistamine Drugs .................................................................................................................................................................................................................................................................................... 3

Anti-Infective Agents ................................................................................................................................................................................................................................................................................... 5
Antineoplastic Agents .............................................................................................................................................................................................................................................................................. 11
Autonomic Drugs ........................................................................................................................................................................................................................................................................................ 12
Blood Formation,Coagulation & Thrombosis ................................................................................................................................................................................................................ 16
Cardiovascular Drugs .............................................................................................................................................................................................................................................................................. 19
Central Nervous System Agents .................................................................................................................................................................................................................................................... 30
Devices .................................................................................................................................................................................................................................................................................................................... 43
Diagnostic Agents ........................................................................................................................................................................................................................................................................................ 43
Electrolytic, Caloric, And Water Balance ............................................................................................................................................................................................................................. 43
Eye, Ear, Nose And Throat (Eent) Preps. ............................................................................................................................................................................................................................ 47
Gastrointestinal Drugs ............................................................................................................................................................................................................................................................................ 52
Gold Compounds ......................................................................................................................................................................................................................................................................................... 57
Heavy Metal Antagonists ..................................................................................................................................................................................................................................................................... 57
Hormones And Synthetic Substitutes ....................................................................................................................................................................................................................................... 57
Miscellaneous Therapeutic Agents .............................................................................................................................................................................................................................................. 64
Pharmaceutical Aids .................................................................................................................................................................................................................................................................................. 66
Respiratory Tract Agents ..................................................................................................................................................................................................................................................................... 66
Serums, Toxoids, And Vaccines ..................................................................................................................................................................................................................................................... 73
Skin And Mucous Membrane Agents ...................................................................................................................................................................................................................................... 73
Smooth Muscle Relaxants ................................................................................................................................................................................................................................................................... 79
Vitamins ................................................................................................................................................................................................................................................................................................................ 80
Health Partners of Philadelphia

2014 Formulary
CURRENT AS OF 11/25/2013
UPPERCASE = Brand name drugs

lowercase italics = Generic drugs
Drug Name
Formulary Tier
GP = Generic Preferred
Products
BP = Brand Preferred
Products
S = Specialty Products
Formulary
Tier
Restrictions/Notes
PA = Prior Auth Applies
GR-M = Males Only
GR-F = Females Only
QL = Quantity Limit
Age = Age Restriction
OTC = Available over the counter
Formulary Restrictions/Notes
Tier
Antihistamine Drugs
Ethanolamine Derivatives
BENADRYL ALLERGY TABLET 25 MG
Retail; OTC; QL (100 EA per 26

day(s))
BP
clemastine tablet 1.34 mg
GP
Retail; OTC; QL (2 EA per 1 day(s))
dimenhydrinate tablet 50 mg
GP
diphenhydramine capsule 25 mg, 50 mg
GP

day(s))
diphenhydramine injection solution 50 mg/ml
GP
Retail
diphenhydramine oral elixir 12.5 mg/5 ml
GP
Retail; OTC; QL (240 ML per 15

day(s))
diphenhydramine oral liquid 12.5 mg/5 ml
GP

day(s))
diphenhydramine syrup 12.5 mg/5 ml
GP

day(s))
diphenhydramine tablet 25 mg, 50 mg
GP

day(s))
NYTOL TABLET 25 MG
GP

day(s))
SIMPLY SLEEP TABLET 25 MG
GP

day(s))
SOMINEX TABLET 25 MG
GP

day(s))
SOMINEX MAXIMUM STRENGTH TABLET 50

MG
GP
Retail; OTC
First Gen. Antihist. Derivatives, Misc.

GP
cyproheptadine syrup 2 mg/5 ml

www.healthpartnersplans.com
3
Retail
Drug Name
Formulary
Tier
Tier
GP
cyproheptadine tablet 4 mg
Retail
Phenothiazine Derivatives
PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25
MG
GP
Retail
promethazine rectal suppository 12.5 mg, 25 mg
GP
Retail; Age (Min 6 Years)
promethazine syrup 6.25 mg/5 ml
GP
promethazine tablet
GP
PROMETHAZINE VC SYRUP 6.25-5 MG/5 ML
GP
PROMETHAZINE VC-CODEINE SYRUP 6.25-5-10

MG/5 ML
GP
PROMETHEGAN
GP
Retail
GP
Retail; OTC
Piperazine Derivatives
DRAMAMINE LESS DROWSY TABLET 25 MG
hydroxyzine hcl syrup 10 mg/5 ml
GP
Retail
hydroxyzine hcl tablet
GP
Retail
hydroxyzine pamoate capsule
GP
Retail
meclizine chewable tablet 25 mg
GP
Retail; OTC
meclizine tablet 12.5 mg, 25 mg
GP
Retail; OTC
Propylamine Derivatives
ALLER-CHLOR SYRUP 2 MG/5 ML
GP

day(s))
ALLER-CHLOR TABLET 4 MG
GP

day(s))
ALLERGY (CHLORPHENIRAMINE) TABLET 4

MG
GP

day(s))
ALLERGY-TIME TABLET 4 MG
GP

day(s))
AMBI 60PSE-4CPM TABLET 4-60 MG
GP

day(s))
CHLOR-TRIMETON TABLET 4 MG
GP

day(s))
chlorpheniramine tablet 4 mg
GP

day(s))
dexchlorpheniramine maleate er tablet,extended release 6

mg
GP
Retail
ED-CHLORTAN TABLET 4 MG
GP

day(s))
LOHIST - D ORAL LIQUID 2-30 MG/5 ML
GP
Retail; OTC
RITIFED SYRUP 1.25-30 MG/5 ML
GP

day(s))
SUDOGEST COLD & ALLERGY TABLET 4-60 MG
GP

day(s))
SUDOGEST SINUS & ALLERGY TABLET 4-60 MG
GP

day(s))
4
Drug Name
Formulary
Tier
Tier
Second Generation Antihistamines

ALL DAY ALLERGY (CETIRIZINE) CHEWABLE
TABLET 10 MG, 5 MG
GP
ALL DAY ALLERGY (CETIRIZINE) ORAL SOLN

1 MG/ML
GP
Retail; OTC; QL (10 ML per 1 day(s))
ALL DAY ALLERGY (CETIRIZINE) TABLET 10

MG
GP
cetirizine chewable tablet 10 mg, 5 mg
GP
cetirizine oral solution 1 mg/ml
GP
cetirizine tablet 10 mg, 5 mg
GP
CHILDREN'S ALLER-TEC ORAL SOLN 1 MG/ML
GP
Retail; OTC
fexofenadine tablet 180 mg
GP
levocetirizine tablet 5 mg
GP
loratadine oral solution 5 mg/5 ml
GP
loratadine tablet 10 mg
GP
NON-DROWSY ALLERGY TABLET 10 MG
GP
OTC
Anti-Infective Agents
Adamantanes
amantadine hcl capsule 100 mg
GP
Retail
amantadine hcl syrup 50 mg/5 ml
GP
Retail
GP
Retail; QL (1 EA per 1 day(s))
metronidazole tablet 250 mg, 500 mg
GP
Retail
paromomycin capsule 250 mg
GP
neomycin tablet 500 mg
GP
Retail
paromomycin capsule 250 mg
GP
amoxicillin capsule 250 mg, 500 mg
GP
Retail
amoxicillin chewable tablet 125 mg, 250 mg
GP
Retail
amoxicillin oral suspension
GP
Retail
amoxicillin tablet 500 mg, 875 mg
GP
Retail
amoxicillin-potassium clavulanate chewable tablet

200-28.5 mg, 400-57 mg
GP
Retail
amoxicillin-potassium clavulanate oral suspension
GP
Retail
amoxicillin-potassium clavulanate tablet
GP
Retail
ampicillin capsule 250 mg, 500 mg
GP
Retail
ampicillin oral suspension 125 mg/5 ml, 250 mg/5 ml
GP
Retail
Allylamines
terbinafine tablet 250 mg
Amebicides
Aminoglycosides
Aminopenicillins
Antifungals, Miscellaneous
GRIFULVIN V TABLET 500 MG
BP
5
Retail
Drug Name
GRIS-PEG (ULTRAMICROSIZE) TABLET 125 MG,
250 MG
Formulary
Tier
Tier
GP
Retail
GP
Retail
chloroquine tablet 250 mg, 500 mg
GP
Retail
hydroxychloroquine tablet 200 mg
GP
Retail
mefloquine tablet 250 mg
GP
primaquine tablet 26.3 mg
GP
Retail
quinidine er tablet,extended release 324 mg
GP
Retail
quinidine sulfate er tablet,extended release 300 mg
GP
Retail
quinidine tablet 200 mg, 300 mg
GP
Retail
GP
Retail
dapsone tablet 100 mg, 25 mg
GP
Retail
GP
Retail
griseofulvin microsize oral suspension 125 mg/5 ml

Antimalarials
Antimycobacterials, Miscellaneous
dapsone tablet 100 mg, 25 mg
Antiprotozoals, Miscellaneous
Antituberculosis Agents
CIPRO ORAL SUSPENSION 250 MG/5 ML, 500
MG/5 ML
GP
Retail
ciprofloxacin tablet
GP
Retail
clarithromycin er tablet,extended release 24 hr 500 mg
GP
clarithromycin oral suspension 125 mg/5 ml, 250 mg/5 ml
GP
Retail
clarithromycin tablet 250 mg, 500 mg
GP
ethambutol tablet 100 mg, 400 mg
GP
Retail
isoniazid oral solution 50 mg/5 ml
GP
Retail
isoniazid tablet 100 mg, 300 mg
GP
Retail
levofloxacin oral solution 250 mg/10 ml
GP
Retail
levofloxacin tablet
GP
MYCOBUTIN CAPSULE 150 MG
BP
Retail
pyrazinamide tablet 500 mg
GP
Retail
rifampin capsule 150 mg, 300 mg
GP
Retail
fluconazole
GP
Retail
fluconazole oral suspension 10 mg/ml, 40 mg/ml
GP
Retail
ketoconazole tablet 200 mg
GP
Retail
GP
Retail
GP
Retail
Azoles
Erythromycins
erythromycin-sulfisoxazole oral suspension 200-600 mg/5
ml
First Generation Cephalosporins
cefadroxil capsule 500 mg
6
Drug Name
Formulary
Tier
Tier
cefadroxil oral suspension 250 mg/5 ml, 500 mg/5 ml
GP
Retail; QL (100 ML per 10 day(s)), QL

(75 ML per 7 day(s))
cefadroxil tablet 1 gram
GP
Retail
cephalexin capsule 250 mg, 500 mg
GP
Retail
cephalexin oral suspension 125 mg/5 ml, 250 mg/5 ml
GP
Retail
GP
Retail; QL (4 per 1 Day(s)), QL (8 per

1 Day(s))
Glycopeptides
vancomycin capsule 125 mg, 250 mg
Hcv Protease Inhibitors
INCIVEK TABLET 375 MG
PA; Specialty
VICTRELIS CAPSULE 200 MG
PA; Specialty
PA; QL (1 per 30 Day(s))
Hiv Entry And Fusion Inhibitors

FUZEON SUBCUTANEOUS SOLUTION 90 MG
SELZENTRY TABLET 150 MG, 300 MG
BP
APTIVUS CAPSULE 250 MG
BP
CRIXIVAN CAPSULE 200 MG, 400 MG
BP
Retail
INVIRASE CAPSULE 200 MG
BP
INVIRASE TABLET 500 MG
BP
KALETRA ORAL SOLUTION 400-100 MG/5 ML
BP
Retail; QL (400 ML per 30 day(s))
KALETRA TABLET 100-25 MG, 200-50 MG
BP
Retail; QL (300 EA per 30 day(s)), QL

(150 EA per 30 day(s))
LEXIVA TABLET 700 MG
BP
NORVIR CAPSULE 100 MG
BP
NORVIR ORAL SOLUTION 80 MG/ML
BP
NORVIR TABLET 100 MG
BP
PREZISTA ORAL SUSPENSION 100 MG/ML
BP
QL (12 per 1 Day(s))
PREZISTA TABLET 150 MG, 400 MG, 600 MG, 800

MG
BP
Retail,; QL (120 EA per 30 day(s)), QL

(60 EA per 30 day(s)), QL (1 per 1
Day(s))
REYATAZ CAPSULE 150 MG, 200 MG, 300 MG
BP

VIRACEPT TABLET 250 MG, 625 MG
BP

ISENTRESS CHEWABLE TABLET 100 MG, 25 MG
BP
Age (Min 2 Years and Max 12 Years)
ISENTRESS TABLET 400 MG
BP
Hiv Protease Inhibitors
Integrase Inhibitors
Interferons
PEGINTRON
PA; Specialty
PEGINTRON REDIPEN
PA; Specialty
Lincomycins
GP
clindamycin capsule 150 mg, 300 mg

7
Retail
Drug Name
Formulary
Tier
Tier
GP
clindamycin oral solution 75 mg/5 ml
Retail
Macrolides
E.E.S. 400 TABLET 400 MG
BP
Retail
erythromycin capsule,delayed release 250 mg
GP
Retail
erythromycin tablet 250 mg, 500 mg
GP
Retail
erythromycin ethylsuccinate tablet 400 mg
GP
Retail
Monoclonal Antibodies
SYNAGIS INTRAMUSCULAR SOLUTION 100
MG/ML, 50 MG/0.5 ML
PA; Specialty
Natural Penicillins
BICILLIN L-A INTRAMUSCULAR SYRINGE
1,200,000 UNIT/2 ML, 2,400,000 UNIT/4 ML, 600,000
UNIT/ML
Retail; QL (4 ML per 365 day(s)), QL

(12 ML per 365 day(s)),
GP
penicillin v potassium oral solution 125 mg/5 ml, 250 mg/5

ml
GP
Retail
penicillin v potassium tablet 250 mg, 500 mg
GP
Retail
Neuraminidase Inhibitors
TAMIFLU CAPSULE 30 MG, 45 MG, 75 MG
BP

(10 EA per 365 day(s)); Age (Min 1
Years)
TAMIFLU ORAL SUSPENSION 6 MG/ML
BP
Retail; QL (125 ML per 365 day(s));

Age (Min 1 Years)
ATRIPLA TABLET 600-200-300 MG
BP
COMPLERA TABLET 200-25-300 MG
BP
Retail; QL (1 EA per 1 Day(s))
EDURANT TABLET 25 MG
BP
INTELENCE TABLET 100 MG
BP
Retail
RESCRIPTOR DISPERSIBLE TABLET 100 MG
BP
RESCRIPTOR TABLET 200 MG
BP
SUSTIVA CAPSULE 200 MG, 50 MG
BP

SUSTIVA TABLET 600 MG
BP
VIRAMUNE ORAL SUSPENSION 50 MG/5 ML
BP
VIRAMUNE TABLET 200 MG
BP
VIRAMUNE XR TABLET,EXTENDED RELEASE

400 MG
BP
Nonnucleoside Rev.Transcriptase Inhib.
Nucleoside,Nucleotide Rev.Trnscrip.Inhib
GP
abacavir tablet 300 mg
Retail; QL (60 per 30 Day(s))
BP
COMPLERA TABLET 200-25-300 MG
BP
Retail; QL (1 EA per 1 Day(s))
didanosine capsule,delayed release 125 mg, 200 mg, 250

mg, 400 mg
EMTRIVA CAPSULE 200 MG
GP
BP
8

Drug Name
Formulary
Tier
Tier
EPIVIR ORAL SOLUTION 10 MG/ML
BP
EPZICOM TABLET 600-300 MG
BP
lamivudine tablet 150 mg, 300 mg
GP
Retail; QL (60 per 30 Day(s)), QL (30

per 30 Day(s))
lamivudine-zidovudine tablet 150-300 mg
GP
stavudine capsule 15 mg, 20 mg, 30 mg, 40 mg
GP

TRIZIVIR TABLET 300-150-300 MG
BP
TRUVADA TABLET 200-300 MG
BP
VIDEX 2 GRAM PEDIATRIC ORAL SOLUTION 10

MG/ML (FINAL)
BP
VIDEX 4 GRAM PEDIATRIC ORAL SOLUTION 10

MG/ML (FINAL)
BP
VIREAD ORAL POWDER 40 MG/SCOOP (40

MG/GRAM)
BP
PA; Retail
VIREAD TABLET 150 MG, 200 MG, 250 MG, 300

MG
BP
PA; Retail
ZERIT ORAL SOLUTION 1 MG/ML
BP
ZIAGEN ORAL SOLUTION 20 MG/ML
BP
zidovudine capsule 100 mg
GP
zidovudine syrup 10 mg/ml
GP
zidovudine tablet 300 mg
GP
acyclovir capsule 200 mg
GP
Retail
acyclovir oral suspension 200 mg/5 ml
GP
Retail
acyclovir tablet 400 mg, 800 mg
GP
Retail
Nucleosides And Nucleotides
BARACLUDE ORAL SOLUTION 0.05 MG/ML
BP
PA; Retail
BARACLUDE TABLET 0.5 MG, 1 MG
BP
PA; Retail
GP
famciclovir
Retail
ribavirin capsule 200 mg
PA; Specialty
ribavirin tablet 200 mg
PA; Specialty
GP
Retail
azithromycin oral packet 1 gram
GP
Retail
azithromycin oral suspension 100 mg/5 ml, 200 mg/5 ml
GP
Retail
azithromycin tablet 250 mg, 500 mg, 600 mg
GP
Retail; , QL (10 EA per 23 day(s))
clarithromycin er tablet,extended release 24 hr 500 mg
GP
clarithromycin oral suspension 125 mg/5 ml, 250 mg/5 ml
GP
Retail
GP
GP
Retail
valacyclovir tablet 1 g, 500 mg

Other Macrolides
Penicillinase-Resistant Penicillins
dicloxacillin capsule 250 mg, 500 mg
Polyenes
9
Drug Name
Formulary
Tier
Tier
nystatin oral powder
GP
Retail
nystatin tablet 500,000 unit
GP
Retail
Quinolones
CIPRO ORAL SUSPENSION 250 MG/5 ML, 500
MG/5 ML
GP
Retail
ciprofloxacin tablet
GP
Retail
GP
Retail
levofloxacin tablet
GP
ofloxacin tablet 200 mg, 300 mg, 400 mg
GP
Rifamycins
BP
Retail
GP
Retail
cefaclor capsule 250 mg, 500 mg
GP
Retail
cefaclor er tablet,extended release,12 hr 500 mg
GP
cefprozil oral suspension 125 mg/5 ml, 250 mg/5 ml
GP
cefprozil tablet 250 mg, 500 mg
GP
cefuroxime axetil tablet 250 mg, 500 mg
GP
Retail
sulfadiazine tablet 500 mg
GP
Retail
sulfamethoxazole-trimethoprim oral suspension 200-40

mg/5 ml
GP
Retail
sulfamethoxazole-trimethoprim tablet 400-80 mg, 800-160

mg
GP
Retail
sulfasalazine tablet 500 mg
GP
Retail
sulfasalazine tablet,delayed release 500 mg
GP
Retail
doxycycline hyclate capsule 100 mg, 50 mg
GP
Retail
doxycycline hyclate tablet 100 mg
GP
Retail
minocycline capsule 100 mg, 50 mg, 75 mg
GP
Retail; QL (2 EA per 1 day(s)), QL (30

EA per 23 day(s))
tetracycline capsule 250 mg, 500 mg
GP
Retail
cefdinir capsule 300 mg
GP
Retail
cefdinir oral suspension 125 mg/5 ml, 250 mg/5 ml
GP
Retail
cefpodoxime oral suspension 100 mg/5 ml, 50 mg/5 ml
GP
Retail
cefpodoxime tablet 100 mg, 200 mg
GP
Retail
ceftriaxone intravenous solution 1 gram, 2 gram
GP
Retail
ceftriaxone solution for injection
GP
Retail
ceftriaxone in dextrose (iso-osmotic) intravenous

piggyback 1 gram/50 ml, 2 gram/50 ml
GP
rifampin capsule 150 mg, 300 mg

Second Generation Cephalosporins
Sulfonamides (Systemic)
Tetracyclines
Third Generation Cephalosporins
10
Drug Name
Formulary
Tier
Tier
SUPRAX CAPSULE 400 MG
BP
SUPRAX TABLET 400 MG
BP
Urinary Anti-Infectives
MACRODANTIN CAPSULE 25 MG
BP
nitrofurantoin oral suspension 25 mg/5 ml
GP
Retail
nitrofurantoin macrocrystal capsule 100 mg, 50 mg
GP
Retail
nitrofurantoin monohydrate/macrocrystals capsule 100 mg
GP
Retail
trimethoprim tablet 100 mg
GP
Retail
Antineoplastic Agents
Antineoplastic Agents
ALKERAN TABLET 2 MG
BP
GP
anastrozole tablet 1 mg
AROMASIN TABLET 25 MG
BP
BP
Retail
Retail
GP
cyclophosphamide tablet 25 mg, 50 mg
Retail
Retail
GP
bicalutamide tablet 50 mg
CEENU CAPSULE
Retail
Retail
DROXIA
BP
Retail
EMCYT CAPSULE 140 MG
BP
Retail
GP
etoposide capsule 50 mg
Retail
FARESTON TABLET 60 MG
BP
FEMARA TABLET 2.5 MG
BP
Retail
GP
flutamide capsule 125 mg

HEXALEN CAPSULE 50 MG
LEUKERAN TABLET 2 MG
Specialty
GP
hydroxyurea capsule 500 mg

BP
Retail
Retail
leuprolide subcutaneous kit 1 mg/0.2 ml
Retail
PA; Specialty
LUPRON DEPOT INTRAMUSCULAR SYRINGE

KIT 3.75 MG
PA; Specialty
LUPRON DEPOT (3 MONTH) INTRAMUSCULAR

SYRINGE KIT 11.25 MG, 22.5 MG
PA; Specialty
LUPRON DEPOT (4 MONTH) INTRAMUSCULAR

SYRINGE KIT 30 MG
PA; Specialty
LUPRON DEPOT-PED
PA; Specialty
LYSODREN TABLET 500 MG
BP
MATULANE CAPSULE 50 MG
MEGACE ES ORAL SUSPENSION 625 MG/5 ML
Retail
Specialty
BP
PA; Retail
megestrol oral suspension 400 mg/10 ml (10 ml), 400

mg/10 ml (40 mg/ml)
GP
, Retail
megestrol tablet 20 mg, 40 mg
GP
Retail
mercaptopurine tablet 50 mg
GP
Retail
methotrexate sodium injection solution 25 mg/ml
GP
Retail
11
Drug Name
Formulary
Tier
Tier
methotrexate sodium tablet 2.5 mg
GP
Retail
methotrexate sodium (pf) injection solution 25 mg/ml
GP
Retail
MYLERAN TABLET 2 MG
NEXAVAR TABLET 200 MG
NILANDRON TABLET 150 MG
SUTENT
TABLOID TABLET 40 MG
BP
Retail
PA; Specialty
BP
Retail
PA; Specialty
BP
Retail
GP
tamoxifen tablet 10 mg, 20 mg
Retail
TARGRETIN CAPSULE 75 MG
PA; Specialty
TEMODAR CAPSULE
PA; Specialty
GP
tretinoin (chemotherapy) capsule 10 mg

XELODA TABLET 150 MG, 500 MG

PA; Specialty
Autonomic Drugs
Alpha- And Beta-Adrenergic Agonists
GP
QL (2 per 1 Day(s))
AMBI 60PSE-400GFN TABLET 60-400 MG
GP

day(s))
GP

day(s))
AUVI-Q INJECTION,AUTO-INJECTOR 0.15

MG/0.15 ML (1:1,000), 0.3 MG/0.3 ML (1:1,000)
BP
BROMFED DM SYRUP 2-30-10 MG/5 ML
GP
Retail
BROTAPP DM ORAL ELIXIR 1-15-5 MG/5 ML
GP
Retail; OTC
CHILDREN'S SUDAFED ORAL LIQUID 15 MG/5

ML
GP
Retail; OTC
CONGEST-EZE TABLET 60-400 MG
GP
Retail; OTC
CONGESTAC TABLET 60-400 MG
GP
Retail; OTC
EPIPEN 2-PAK INJECTION,AUTO-INJECTOR 0.3

MG/0.3 ML (1:1,000)
BP
EPIPEN JR 2-PAK INJECTION,AUTO-INJECTOR

0.15 MG/0.3 ML (1:2,000)
BP
EXEFEN-IR TABLET 60-400 MG
GP
Retail; OTC
GP
Retail; OTC
MUCINEX D TABLET,EXTENDED RELEASE

60-600 MG
BP
Retail; OTC
MUCINEX D MAXIMUM STRENGTH

TABLET,EXTENDED RELEASE 120-1,200 MG
BP
OTC
GP
pseudoephedrine tablet 30 mg, 60 mg

day(s))
Q-TAPP DM ORAL ELIXIR 1-15-5 MG/5 ML
GP
Retail; OTC
GP

day(s))
12
Drug Name
Formulary
Tier
Tier
GP

day(s))
GP

day(s))
Alpha-Adrenergic Agonists
methyldopa tablet 250 mg, 500 mg
GP
Retail
midodrine
GP
Retail
GP

MG/5 ML
GP
ATROVENT HFA AEROSOL INHALER 17

MCG/ACTUATION
BP
Retail
COMBIVENT RESPIMAT AEROSOL INHALER

20-100 MCG/ACTUATION
BP
PA; QL (14.7 per 30 Day(s)); Age

(Min 18 Years)
Antimuscarinics/Antispasmodics
dicyclomine capsule 10 mg
GP
Retail
dicyclomine tablet 20 mg
GP
Retail
diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml
GP
Retail
diphenoxylate-atropine tablet 2.5-0.025 mg
GP
Retail
glycopyrrolate tablet 1 mg, 2 mg
GP
Retail
hyoscyamine er tablet,extended release,12 hr 0.375 mg
GP
Retail
hyoscyamine oral drops 0.125 mg/ml
GP
Retail
hyoscyamine oral elixir 0.125 mg/5 ml
GP
Retail
hyoscyamine sublingual tablet 0.125 mg
GP
Retail
hyoscyamine sulfate tablet 0.125 mg
GP
Retail
HYOMAX-SL SUBLINGUAL TABLET 0.125 MG
GP
HYOSYNE ORAL DROPS 0.125 MG/ML
GP
Retail
HYOSYNE ORAL ELIXIR 0.125 MG/5 ML
GP
Retail
ipratropium bromide solution for inhalation 0.02 %
GP
Retail
propantheline tablet 15 mg
GP
Retail
SYMAX-SL SUBLINGUAL TABLET 0.125 MG
BP
Retail
SYMAX-SR TABLET,EXTENDED RELEASE 0.375

MG
BP
Retail
TUDORZA PRESSAIR BREATH ACTIVATED 400

MCG/ACTUATION
BP
PA; Retail; Age (Min 18 Years)
Antiparkinsonian Agents
benztropine oral
GP
Retail
trihexyphenidyl oral elixir 0.4 mg/ml
GP
Retail
trihexyphenidyl tablet 2 mg, 5 mg
GP
Retail
Autonomic Drugs, Miscellaneous

NICODERM CQ DAILY TRANSDERMAL PATCH
GP
Retail; OTC
NICORELIEF GUM 2 MG, 4 MG
GP
Retail; OTC
13
Drug Name
Formulary
Tier
Tier
nicotine daily transdermal patch
GP
Retail; OTC
nicotine daily transdermal patch,sequential 21-14-7 mg/24

hr
GP
Retail; OTC
nicotine (polacrilex) buccal lozenge 2 mg, 4 mg
GP
Retail; OTC
nicotine (polacrilex) gum 2 mg, 4 mg
GP
Retail; OTC
NICOTROL INHALATION CARTRIDGE 10 MG
GP
Retail
NICOTROL NS NASAL SPRAY 10 MG/ML
BP
Retail
Centrally Acting Skeletal Muscle Relaxnt

carisoprodol tablet 350 mg
GP
carisoprodol-asa-codeine tablet 200-325-16 mg
GP
carisoprodol-aspirin tablet 200-325 mg
GP
chlorzoxazone tablet 500 mg
GP
cyclobenzaprine tablet 10 mg, 5 mg
GP
Retail
methocarbamol tablet 500 mg, 750 mg
GP

tizanidine tablet 2 mg, 4 mg
GP

EA per 1 day(s))
GP
GP

EA per 1 day(s))
carvedilol tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg
GP

EA per 1 day(s))
labetalol oral
GP
Retail
nadolol tablet
GP
Retail
pindolol tablet 10 mg, 5 mg
GP
Retail
propranolol er capsule,24 hr,extended release
GP
Retail
propranolol oral solution 20 mg/5 ml, 40 mg/5 ml
GP
Retail
propranolol tablet
GP
Retail
propranolol-hydrochlorothiazide tablet 40-25 mg, 80-25

mg
GP
Retail
sotalol oral
GP
Retail
Direct-Acting Skeletal Muscle Relaxants

dantrolene oral
Gaba-Derivative Skeletal Muscle Relaxant
baclofen tablet 10 mg, 20 mg
Non-Sel. Beta-Adrenergic Blocking Agents
SOTALOL AF
GP
Retail
GP
Retail
doxazosin tablet 1 mg, 2 mg, 4 mg, 8 mg
GP

EA per 1 day(s))
prazosin oral
GP
terazosin capsule
GP
timolol maleate oral

Non-Sel.Alpha-1-Adrenergic Blocking Agts
Non-Sel.Alpha-Adrenergic Blocking Agents

14
Drug Name
Formulary
Tier
Tier
dihydroergotamine injection solution 1 mg/ml
GP
Retail
ergotamine-caffeine tablet 1-100 mg
GP
Retail
Parasympathomimetic (Cholinergic Agents)

ARICEPT
BP
bethanechol chloride oral
GP
Retail
donepezil tablet 10 mg, 5 mg
GP
EXELON ORAL SOLUTION 2 MG/ML
BP
EXELON TRANSDERMAL 24 HOUR PATCH 13.3

MG/24 HOUR, 4.6 MG/24 HOUR, 9.5 MG/24 HOUR
BP
, Retail; QL (1 per 1 Day(s)), QL (1

EA per 1 day(s))
pilocarpine tablet 5 mg, 7.5 mg
GP
Retail
pyridostigmine bromide tablet 60 mg
GP
Retail
rivastigmine capsule
GP
alfuzosin er tablet,extended release 24 hr 10 mg
GP
QL (1 per 1 Day(s))
GP

EA per 1 day(s))
labetalol oral
GP
Retail
tamsulosin er capsule,extended release 24 hr 0.4 mg
GP
Retail; GR-M
albuterol sulfate er tablet,extended release,12 hr 4 mg, 8

mg
GP
Retail
albuterol sulfate solution for nebulization 0.63 mg/3 ml,

1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml, 5
mg/ml
GP
Retail
albuterol sulfate syrup 2 mg/5 ml
GP
Retail
albuterol sulfate tablet 2 mg, 4 mg
GP
Retail
Selective Alpha-1-Adrenergic Block.Agent
Selective Beta-2-Adrenergic Agonists

BP

(Min 18 Years)
DULERA HFA AEROSOL INHALER 100-5

MCG/ACTUATION, 200-5 MCG/ACTUATION
BP
levalbuterol solution for nebulization
GP
Retail; Age (Max 12 Years)
metaproterenol syrup 10 mg/5 ml
GP
Retail
metaproterenol tablet 10 mg, 20 mg
GP
Retail
SEREVENT DISKUS POWDER FOR

INHALATION 50 MCG/DOSE
BP
SYMBICORT HFA AEROSOL INHALER 160-4.5

MCG/ACTUATION, 80-4.5 MCG/ACTUATION
BP

GP
terbutaline tablet 2.5 mg, 5 mg

VENTOLIN HFA AEROSOL INHALER 90
MCG/ACTUATION
GP
Retail
Retail; QL (34 GM per 34 day(s))
Selective Beta-Adrenergic Blocking Agent

acebutolol capsule 200 mg, 400 mg
GP
Retail
atenolol oral
GP
Retail
15
Drug Name
Formulary
Tier
Tier
atenolol-chlorthalidone tablet 100-25 mg, 50-25 mg
GP
Retail
betaxolol tablet 10 mg, 20 mg
GP
Retail
bisoprolol-hydrochlorothiazide
GP
Retail
metoprolol succinate er tablet,extended release 24 hr
GP
Retail
metoprolol tartrate oral
GP
Retail
Skeletal Muscle Relaxants, Miscellaneous

BOTOX INJECTION 100 UNIT, 200 UNIT
PA; Specialty
MYOBLOC
PA; Specialty
GP
orphenadrine citrate er tablet,extended release 100 mg
ORPHENADRINE COMPOUND TABLET 25-385-30

MG
GP
Retail
ORPHENADRINE COMPOUND-DS TABLET

50-770-60 MG
GP
Retail
COUMADIN ORAL
BP
Retail
JANTOVEN
GP
Retail
Blood Formation,Coagulation & Thrombosis

Coumarin Derivatives
GP
warfarin oral
Retail
Direct Factor Xa Inhibitors

XARELTO
BP
PA
Hematopoietic Agents
NEULASTA SUBCUTANEOUS SYRINGE 6
MG/0.6ML
PA; Specialty
NEUPOGEN INJECTION SOLUTION 300

MCG/ML, 480 MCG/1.6 ML
PA; Specialty
NEUPOGEN INJECTION SYRINGE 300 MCG/0.5

ML, 480 MCG/0.8 ML
PA; Specialty
NPLATE SUBCUTANEOUS SOLUTION 250 MCG,

500 MCG
PA; Specialty
PROCRIT
PA; Specialty
Hemorrheologic Agents
GP
pentoxifylline er tablet,extended release 400 mg
Retail
Hemostatics
aminocaproic acid oral solution 25 %
GP
aminocaproic acid tablet 500 mg
GP
DDAVP NASAL SOLUTION 0.1 MG/ML (REFRIG)
BP
Retail
Retail
desmopressin nasal solution 0.1 mg/ml (refrig)
GP
desmopressin nasal spray 10 mcg/spray (0.1 ml)
GP
desmopressin tablet 0.1 mg, 0.2 mg
GP
Retail
STIMATE NASAL SPRAY 150 MCG/SPRAY
BP
Age (Max 20 Years)
Heparins
GP
enoxaparin subcutaneous solution 300 mg/3 ml

16
Specialty
Drug Name
Formulary
Tier
Tier
enoxaparin subcutaneous syringe
GP
PA; Specialty
heparin (porcine) injection cartridge 5,000 unit/ml (1 ml)
GP
Retail
heparin (porcine) injection solution
GP
Retail
heparin (porcine) powder 100,000 unit, 25,000 unit
GP
Retail
heparin (porcine) (bulk) powder 1 million unit
GP
Retail
heparin (porcine) (bulk) powder 190,000 unit/gram
GP
Retail
heparin flush(porcine)-0.9 % sodium chloride intravenous

kit 100 unit/ml
GP
Retail
HEPARIN LOCK INTRAVENOUS SOLUTION 100

UNIT/ML
GP
Retail
HEPARIN LOCK FLUSH INTRAVENOUS

SOLUTION 10 UNIT/ML
GP
Retail
HEPARIN LOCK FLUSH INTRAVENOUS

SYRINGE 10 UNIT/ML
GP
Retail
heparin lock flush (porcine) intravenous solution 10

unit/ml, 100 unit/ml
GP
Retail
heparin lock flush (porcine) intravenous syringe 10

unit/ml, 100 unit/ml
GP
Retail
Iron Preparations
CENTAVITE A-Z COMPLETE-MINERAL TABLET
27-0.4 MG
GP

day(s))
CENTRUM COMPLETE TABLET 18-400 MG-MCG
GP

day(s))
CENTRUM SILVER ULTRA WOMEN'S TABLET
GP

day(s))
CENTRUM ULTRA WOMEN'S TABLET 18-400

MG-MCG
GP

day(s))
CEROVITE ADVANCED FORMULA TABLET

18-400 MG-MCG
GP

day(s))
CERTAVITE-ANTIOXIDANT TABLET 18-400

MG-MCG
GP

day(s))
FER-IRON ORAL DROPS 15 MG IRON (75

MG)/ML
GP

day(s))
FERGON TABLET 240 MG (27 MG IRON)
GP
Retail; OTC
FERRO-TIME TABLET 325 MG (65 MG IRON)
GP

day(s))
ferrous gluconate tablet 240 mg (27 mg iron), 324 mg (36

mg iron), 324 mg (38 mg iron), 325 mg (36 mg iron), 325
mg (37 mg iron)
GP
Retail; OTC; , QL (100 EA per 26

day(s))
ferrous sulfate oral drops 15 mg iron (75 mg)/ml
GP

day(s))
ferrous sulfate oral solution 220 mg (44 mg iron)/5 ml
GP
Retail; OTC
ferrous sulfate tablet 325 mg (65 mg iron)
GP

day(s))
17
Drug Name
Formulary
Tier
Tier
GP
ferrous sulfate tablet,delayed release 325 mg (65 mg iron)

day(s))
INATAL ADVANCE TABLET 90-1-50 MG
GP
Retail
MYNATAL ADVANCE TABLET 90-1-50 MG
GP
Retail
POLY-VI-SOL WITH IRON ORAL DROPS 1,500

UNIT-400 UNIT-10 MG/ML
BP
Retail; OTC
PRENAPLUS TABLET 27-1 MG
GP
Retail; GR-F; QL (1 per 1 Day(s))
PRENATABS RX TABLET 29 MG IRON- 1 MG
GP
Retail
PRENATAL TABLET 27-0.8 MG, 28-0.8 MG
GP
Retail; GR-F; OTC; QL (1 per 1

Day(s))
PRENATAL AD TABLET 90-1-50 MG
GP
PRENATAL LOW IRON TABLET 27-1 MG
GP
PRENATAL PLUS (CALCIUM CARBONATE)

TABLET 27-1 MG
GP
PRENATAL PLUS WITH IRON (CALCIUM

CARBONATE) TABLET 29 MG IRON- 1 MG
GP
PRENATAL VITAMIN TAB 27-0.8 MG
GP

Day(s))
RIGHT STEP PRENATAL VITAMINS TABLET

27-0.8 MG
GP
GR-F; OTC; QL (1 EA per 1 Day(s))
SE-NATAL 19 CHEWABLE TABLET 29 MG IRON1 MG
GP
GR-F; QL (1 EA per 1 Day(s))
STUART PRENATAL TABLET 28-0.8 MG
GP

Day(s))
TRI-VI-SOL WITH IRON ORAL DROPS 1,500

UNIT- 10 MG IRON/ML
BP
Retail; OTC
TRIADVANCE TABLET 90-1-50 MG
GP
Retail; GR-F; QL (1 EA per 1 Day(s))
TRICARE TABLET 27 MG IRON- 1 MG
GP
Retail
TRINATAL RX 1 TABLET 60 MG IRON-1 MG
GP
VINATE ONE TABLET 60 MG IRON-1 MG
GP
VOL-PLUS TABLET 27-1 MG
GP
VOL-TAB RX TABLET 29 MG IRON- 1 MG
GP
AGGRENOX CAPSULE, EXTENDED RELEASE

200-25 MG
BP
ASPIR-TRIN TABLET,DELAYED RELEASE 325

MG
GP

day(s))
Platelet-Aggregation Inhibitors
aspirin chewable tablet 81 mg
GP

day(s))
aspirin rectal suppository 300 mg, 600 mg
GP
Retail; OTC
aspirin tablet 325 mg
GP

day(s))
aspirin tablet,delayed release 325 mg, 500 mg, 650 mg, 81

mg, 975 mg
GP
Retail; OTC,; QL (100 EA per 26

day(s)),
18
Drug Name
BAYER ASPIRIN TABLET 325 MG
Formulary
Tier
Tier
day(s))
GP
butalbital-aspirin-caffeine capsule 50-325-40 mg
GP
Retail
butalbital-aspirin-caffeine tablet 50-325-40 mg
GP
Retail
cilostazol tablet 100 mg, 50 mg
GP
Retail
clopidogrel tablet 75 mg
GP
Retail
dipyridamole oral
GP
Retail
ECOTRIN TABLET,DELAYED RELEASE 325 MG
GP

day(s))
ECOTRIN LOW STRENGTH TABLET,DELAYED

RELEASE 81 MG
GP

day(s))
EXCEDRIN MENSTRUAL COMPLETE TABLET

250-250-65 MG
GP
Retail; OTC
GP
ticlopidine tablet 250 mg
Retail
Thrombolytic Agents
MG

day(s))
GP
GP

day(s))
GP
Retail; OTC
GP

day(s))

mg, 975 mg
GP

day(s)),

day(s))
GP
GP
Retail
GP
Retail
GP

day(s))

RELEASE 81 MG
GP

day(s))

250-250-65 MG
GP
Retail; OTC
Cardiovascular Drugs
Alpha-Adrenergic Blocking Agents
GP

EA per 1 day(s))
GP

EA per 1 day(s))
labetalol oral
GP
Retail
prazosin oral
GP
terazosin capsule
GP
Alpha-Adrenergic Blocking Agt.(Hypoten)

19
Drug Name
Formulary
Tier
Tier
GP

EA per 1 day(s))
labetalol oral
GP
Retail
prazosin oral
GP
terazosin capsule
GP
Angiotensin Ii Receptor Antagon.(Hypotn)

DIOVAN TABLET
BP
QL (1 per 1 Day(s))
irbesartan
GP
irbesartan-hydrochlorothiazide tablet 150-12.5 mg,

300-12.5 mg
GP
losartan
GP
losartan-hydrochlorothiazide
GP
valsartan-hydrochlorothiazide
GP
Angiotensin Ii Receptor Antagonists

DIOVAN TABLET
BP
QL (1 per 1 Day(s))
irbesartan
GP

300-12.5 mg
GP
losartan
GP
GP
GP
amlodipine-benazepril
GP
benazepril
GP
Retail
captopril
GP
captopril-hydrochlorothiazide
GP
Retail
enalapril maleate tablet
GP
enalapril-hydrochlorothiazide tablet 10-25 mg, 5-12.5 mg
GP

EA per 1 day(s))
fosinopril
GP
lisinopril tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg
GP

EA per 1 day(s))
lisinopril-hydrochlorothiazide tablet 10-12.5 mg, 20-12.5

mg, 20-25 mg
GP

EA per 1 day(s))
quinapril
GP
ramipril capsule
GP
GP
benazepril
GP
Retail
captopril
GP
GP
Retail
enalapril maleate tablet

GP
Angiotensin-Convert.Enzyme Inhib(Hypotn)
Angiotensin-Converting Enzyme Inhibitors
20
Drug Name
Formulary
Tier
Tier
GP

EA per 1 day(s))
fosinopril
GP
lisinopril tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg
GP

EA per 1 day(s))

mg, 20-25 mg
GP

EA per 1 day(s))
quinapril
GP
ramipril capsule
GP
digoxin oral solution 50 mcg/ml
GP
Retail
digoxin tablet 125 mcg, 250 mcg
GP
Retail
niacin er capsule,extended release
GP

day(s))
niacin er tablet,extended release 1,000 mg, 250 mg, 500

mg, 750 mg
GP

day(s))
niacin tablet
GP

day(s))
Antiarrhythmics, Miscellaneous
Antilipemic Agents, Miscellaneous
NIACOR TABLET 500 MG
BP
Retail
SLO-NIACIN TABLET,EXTENDED RELEASE 500

MG, 750 MG
GP

day(s))
Beta-Adrenergic Blocking Agents

GP
Retail
atenolol oral
GP
Retail
GP
Retail
GP
Retail
GP
Retail
GP

EA per 1 day(s))
labetalol oral
GP
Retail
GP
Retail
GP
Retail
nadolol tablet
GP
Retail
GP
Retail
GP
Retail
GP
Retail
propranolol tablet
GP
Retail

mg
GP
Retail
sotalol oral
GP
Retail
SOTALOL AF
GP
21
Retail
Drug Name
Formulary
Tier
Tier
GP
Retail
GP
Retail
atenolol oral
GP
Retail
GP
Retail
GP
Retail
GP
Retail
labetalol oral
GP
Retail
GP
Retail
GP
Retail
nadolol tablet
GP
Retail
GP
Retail
GP
Retail
GP
Retail
propranolol tablet
GP
Retail

mg
GP
Retail
sotalol oral
GP
Retail

Beta-Adrenergic Blocking Agt.(Hypoten)
SOTALOL AF
GP
Retail
GP
Retail
cholestyramine (with sugar) oral powder 4 gram
GP
Retail
cholestyramine (with sugar) powder for susp in a packet 4

gram
GP
Retail

Bile Acid Sequestrants
CHOLESTYRAMINE LIGHT ORAL POWDER 4

GRAM
GP
Retail
CHOLESTYRAMINE LIGHT POWDER FOR SUSP

IN A PACKET 4 GRAM
GP
Retail
PREVALITE ORAL POWDER 4 GRAM
GP
Retail
PREVALITE POWDER FOR SUSP IN A PACKET 4

GRAM
GP
Retail
CARDIZEM CD CAPSULE,EXTENDED RELEASE

360 MG
BP
CARDIZEM LA
BP
CARTIA XT CAPSULE,EXTENDED RELEASE 120

MG, 180 MG, 240 MG, 300 MG
BP

EA per 1 day(s))
DILT-CD CAPSULE,EXTENDED RELEASE 120

MG, 180 MG, 240 MG, 300 MG
BP

EA per 1 day(s))
DILT-XR CAPSULE, EXTENDED RELEASE 120

MG, 180 MG, 240 MG
GP

EA per 1 day(s))
DILTIA XT CAPSULE, EXTENDED RELEASE 120

MG, 180 MG, 240 MG
BP

EA per 1 day(s))
Calcium-Channel Block.Agt,Misc(Hypoten)
22
Drug Name
Formulary
Tier
Tier
diltiazem cd capsule,extended release 24 hr 120 mg, 180

mg, 240 mg, 300 mg
GP

EA per 1 day(s))
diltiazem er (xr/xt) capsule,extended release,controlled

120 mg, 180 mg, 240 mg
GP

EA per 1 day(s))
diltiazem er capsule,extended release 120 mg, 180 mg, 240

mg, 300 mg, 360 mg, 420 mg
GP

EA per 1 day(s))
diltiazem er capsule,extended release 12 hr
GP
diltiazem tablet 120 mg, 30 mg, 60 mg, 90 mg
GP

EA per 1 day(s)), QL (3 EA per 1
day(s))
DILTZAC ER CAPSULE,EXTENDED RELEASE

120 MG, 180 MG, 240 MG, 300 MG, 360 MG
BP

EA per 1 day(s))
MATZIM LA
BP
Retail
TAZTIA XT CAPSULE,EXTENDED RELEASE 120

MG, 180 MG, 240 MG, 300 MG, 360 MG
BP

EA per 1 day(s))
verapamil er (sr) tablet,extended release 120 mg, 180 mg,

240 mg
GP

EA per 1 day(s))
verapamil er 24 hr capsule,extended release
GP
Retail
verapamil tablet
GP
Retail
Calcium-Channel Blocking Agents, Misc.

360 MG
BP
CARDIZEM LA
BP

MG, 180 MG, 240 MG, 300 MG
BP

EA per 1 day(s))

MG, 180 MG, 240 MG, 300 MG
BP

EA per 1 day(s))

MG, 180 MG, 240 MG
GP

EA per 1 day(s))

MG, 180 MG, 240 MG
BP

EA per 1 day(s))

mg, 240 mg, 300 mg
GP

EA per 1 day(s))

120 mg, 180 mg, 240 mg
GP

EA per 1 day(s))

mg, 300 mg, 360 mg, 420 mg
GP

EA per 1 day(s))
GP
GP

day(s))

120 MG, 180 MG, 240 MG, 300 MG, 360 MG
BP

EA per 1 day(s))
MATZIM LA
BP
Retail

MG, 180 MG, 240 MG, 300 MG, 360 MG
BP

EA per 1 day(s))
23
Drug Name
Formulary
Tier
Tier

240 mg
GP

EA per 1 day(s))
GP
Retail
verapamil tablet
GP
Retail
acetazolamide er capsule,extended release 500 mg
GP
Retail
acetazolamide tablet 125 mg, 250 mg
GP
Retail
digoxin oral solution 50 mcg/ml
GP
Retail
digoxin tablet 125 mcg, 250 mcg
GP
Retail
clonidine tablet
GP
Retail
clonidine weekly transdermal patch
GP
Carbonic Anhydrase Inhibitors(Hypoten)
Cardiotonic Agents
Central Alpha-Agonists
CLORPRES
BP
Retail
guanfacine tablet 1 mg, 2 mg
GP
Retail
methyldopa tablet 250 mg, 500 mg
GP
Retail
disopyramide capsule 100 mg, 150 mg
GP
Retail
quinidine er tablet,extended release 324 mg
GP
Retail
quinidine sulfate er tablet,extended release 300 mg
GP
Retail
quinidine tablet 200 mg, 300 mg
GP
Retail
Class Ia Antiarrhythmics
Class Ib Antiarrhythmics
DILANTIN CAPSULE 30 MG
BP
Retail
DILANTIN EXTENDED CAPSULE 100 MG
BP
Retail
DILANTIN INFATABS CHEWABLE TABLET 50

MG
BP
Retail
DILANTIN-125 ORAL SUSPENSION 125 MG/5 ML
BP
Retail
GP
mexiletine
PHENYTEK CAPSULE 200 MG, 300 MG
BP
Retail
Retail
phenytoin oral suspension 125 mg/5 ml
GP
Retail
phenytoin sodium extended capsule
GP
Retail
flecainide
GP
Retail
propafenone tablet
GP
Retail
GP
Retail
atenolol oral
GP
Retail
GP
Retail
GP
Retail
GP
Retail
Class Ic Antiarrhythmics
Class Ii Antiarrhythmics
24
Drug Name
Formulary
Tier
Tier
GP

EA per 1 day(s))
labetalol oral
GP
Retail
GP
Retail
GP
Retail
nadolol tablet
GP
Retail
GP
Retail
GP
Retail
GP
Retail
propranolol tablet
GP
Retail

mg
GP
Retail
sotalol oral
GP
Retail
SOTALOL AF
GP
Retail
GP
Retail
GP
Retail
Class Iii Antiarrhythmics

amiodarone tablet 200 mg, 400 mg
PACERONE TABLET 200 MG
GP
GP
sotalol oral
SOTALOL AF
Retail
Retail
GP
Retail

360 MG
BP
CARDIZEM LA
BP

MG, 180 MG, 240 MG, 300 MG
BP

EA per 1 day(s))

MG, 180 MG, 240 MG, 300 MG
BP

EA per 1 day(s))

MG, 180 MG, 240 MG
GP

EA per 1 day(s))

MG, 180 MG, 240 MG
BP

EA per 1 day(s))
Class Iv Antiarrhythmics

mg, 240 mg, 300 mg
GP

EA per 1 day(s))

120 mg, 180 mg, 240 mg
GP

EA per 1 day(s))

mg, 300 mg, 360 mg, 420 mg
GP

EA per 1 day(s))
GP
GP

day(s))

120 MG, 180 MG, 240 MG, 300 MG, 360 MG
BP
25

EA per 1 day(s))
Drug Name
Formulary
Tier
Tier
MATZIM LA
BP
Retail

MG, 180 MG, 240 MG, 300 MG, 360 MG
BP

EA per 1 day(s))

240 mg
GP

EA per 1 day(s))
GP
Retail
verapamil tablet
GP
Retail
amlodipine
GP
GP
felodipine er tablet,extended release 24 hr
GP
nicardipine capsule 20 mg, 30 mg
GP
Retail
Dihydropyridines
NIFEDIAC CC TABLET,EXTENDED RELEASE 90

MG
GP
nifedipine capsule 10 mg, 20 mg
GP
Retail
nifedipine er tablet,extended release
GP
nifedipine er tablet,extended release 24 hr 30 mg, 60 mg,

90 mg
GP

EA per 1 day(s))
nisoldipine er tablet,extended release 24 hr 17 mg, 20 mg,

25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg
GP

EA per 1 day(s))
amlodipine
GP
GP
GP
GP
Retail
Dihydropyridines (Hypotensive Agents)

MG
GP
GP
Retail
GP

90 mg
GP

EA per 1 day(s))
nisoldipine er tablet,extended release 24 hr 17 mg, 20 mg,

25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg
GP

EA per 1 day(s))
hydralazine oral
GP
Retail
minoxidil tablet 10 mg, 2.5 mg
GP
Retail
Direct Vasodilators
Diuretics, Miscellaneous (Hypotensive)

ELIXOPHYLLIN ORAL ELIXIR 80 MG/15 ML
BP
Retail
THEOCHRON TABLET,EXTENDED RELEASE
BP
Retail
theophylline er tablet,extended release 400 mg, 600 mg
GP
Retail
theophylline er tablet,extended release,12 hr
GP
Retail
Fibric Acid Derivatives

26
Drug Name
Formulary
Tier
Tier
fenofibrate tablet 160 mg, 54 mg
GP
fenofibrate micronized capsule
GP
fenofibrate nanocrystallized tablet 145 mg, 48 mg
GP
Retail; QL (1 EA per 1 Day(s)), QL (1

per 1 Day(s))
gemfibrozil tablet 600 mg
GP
Retail
LOFIBRA
GP
LOFIBRA TABLET 160 MG, 54 MG
GP
Hmg-Coa Reductase Inhibitors

atorvastatin
GP
lovastatin tablet 10 mg, 20 mg, 40 mg
GP

EA per 1 day(s))
pravastatin
GP
simvastatin
GP
GP
Retail
GP
Retail
GP

EA per 1 day(s))
GP
QL (1 EA per 1 day(s)), QL (2 EA per

1 day(s))
GP
Retail
GP
Retail
GP
Retail
GP
Retail
propranolol tablet
GP
Retail
sotalol oral
GP
Retail
Hypotensive Agents, Miscellaneous
SOTALOL AF
GP
Retail
terazosin capsule
GP
GP
Retail
bumetanide oral
GP
Retail
furosemide oral solution 10 mg/ml, 40 mg/5 ml
GP
Retail
furosemide tablet
GP
Retail
spironolactone-hydrochlorothiazide tablet 25-25 mg
GP
Retail
spironolactone
GP
Retail
GP
Retail
spironolactone
GP
Retail
GP
Retail
Loop Diuretics (Hypotensive Agents)
Mineralocorticoid (Aldosterone) Antagnts
Mineralocorticoid(Aldoster.)Antag(Hypot)
Nitrates And Nitrites

isosorbide dinitrate er tablet,extended release 40 mg
27
Drug Name
Formulary
Tier
Tier
isosorbide dinitrate sublingual tablet 2.5 mg, 5 mg
GP
Retail
isosorbide dinitrate tablet
GP
Retail
isosorbide mononitrate er tablet,extended release 24 hr
GP
Retail
isosorbide mononitrate tablet 10 mg, 20 mg
GP
Retail
NITRO-BID TRANSDERMAL OINTMENT 2 %
BP
Retail
nitroglycerin oral
GP
Retail
nitroglycerin transdermal 24 hour patch
GP
NITROLINGUAL SPRAY 0.4 MG/DOSE
GP
Retail
NITROSTAT SUBLINGUAL
BP
Retail
Peripheral Adrenergic Inhibitors

GP
Retail
GP
Retail
amiloride tablet 5 mg
GP
Retail
amiloride-hydrochlorothiazide tablet 5-50 mg
GP
Retail
reserpine tablet 0.1 mg, 0.25 mg

Phosphodiesterase Type 5 Inhibitors
cilostazol tablet 100 mg, 50 mg
Potassium-Sparing Diuretics (Hypoten)
DYRENIUM CAPSULE 100 MG
GP
Retail
GP
Retail
spironolactone
GP
Retail
triamterene-hydrochlorothiazide capsule 37.5-25 mg
GP
Retail
triamterene-hydrochlorothiazide tablet 37.5-25 mg, 75-50

mg
GP
Retail
GP
Retail
GP
Retail
GP
Retail
chlorothiazide tablet 250 mg, 500 mg
GP
Retail
Thiazide Diuretics(Hypotensive Agents)
DIURIL ORAL SUSPENSION 250 MG/5 ML
BP
Retail
GP

EA per 1 day(s))
hydrochlorothiazide capsule 12.5 mg
GP
Retail
hydrochlorothiazide tablet 12.5 mg, 25 mg, 50 mg
GP
Retail

300-12.5 mg
GP

mg, 20-25 mg
GP

EA per 1 day(s))
GP
methyclothiazide tablet 5 mg
GP
Retail

mg
GP
Retail
GP
Retail
28
Drug Name
Formulary
Tier
Tier
GP
Retail

mg
GP
Retail
GP
GP
Retail
chlorthalidone tablet 25 mg, 50 mg
GP
Retail
Thiazide-Like Diuretics(Hypotensive Agt)
CLORPRES
BP
Retail
indapamide tablet 1.25 mg, 2.5 mg
GP
Retail
metolazone tablet
GP
Retail
Vasodilating Agents, Miscellaneous

200-25 MG
BP
amlodipine
GP
GP

360 MG
BP
CARDIZEM LA
BP

MG, 180 MG, 240 MG, 300 MG
BP

EA per 1 day(s))

MG, 180 MG, 240 MG, 300 MG
BP

EA per 1 day(s))

MG, 180 MG, 240 MG
GP

EA per 1 day(s))

MG, 180 MG, 240 MG
BP

EA per 1 day(s))

mg, 240 mg, 300 mg
GP

EA per 1 day(s))

120 mg, 180 mg, 240 mg
GP

EA per 1 day(s))

mg, 300 mg, 360 mg, 420 mg
GP

EA per 1 day(s))
GP
GP

day(s))

120 MG, 180 MG, 240 MG, 300 MG, 360 MG
GP
dipyridamole oral
MATZIM LA
BP
GP
29
Retail
GP
Retail
Retail
GP

MG

EA per 1 day(s))
BP
Retail
Drug Name
Formulary
Tier
Tier
GP

90 mg
GP

EA per 1 day(s))

MG, 180 MG, 240 MG, 300 MG, 360 MG

EA per 1 day(s))
BP

240 mg
GP

EA per 1 day(s))
GP
Retail
verapamil tablet
GP
Retail
amantadine hcl capsule 100 mg
GP
Retail
amantadine hcl syrup 50 mg/5 ml
GP
Retail
Central Nervous System Agents

Adamantanes (Cns)
Amphetamines
AMPHETAMINE SALT COMBO TABLET 10 MG,
12.5 MG, 15 MG, 20 MG, 30 MG, 5 MG, 7.5 MG

day(s)); Age (Max 21 Years)
GP
dextroamphetamine er capsule,extended release
GP
Retail; QL (1 EA per 1 day(s)); Age

(Max 21 Years)
dextroamphetamine tablet 10 mg, 5 mg
GP

EA per 1 day(s)); Age (Max 21 Years)
dextroamphetamine-amphetamine er 24hr capsule,extend

release
GP

(Max 21 Years)
acetaminophen chewable tablet 80 mg
GP
acetaminophen elixir 160 mg/5 ml
GP
OTC
acetaminophen oral liquid 500 mg/5 ml
GP
acetaminophen oral solution 160 mg/5 ml (5 ml)
GP

day(s))
acetaminophen rectal suppository 120 mg, 650 mg
GP
Retail; OTC
acetaminophen tablet 325 mg, 500 mg
GP

day(s))
acetaminophen-codeine tablet 300-15 mg, 300-30 mg,

300-60 mg
GP
Retail; , QL (12 EA per 1 day(s)), QL

(6 EA per 1 day(s))
Analgesics And Antipyretics, Misc.
BETATEMP ORAL SUSPENSION 160 MG/5 ML

day(s))
GP
butalbital-acetaminophen-caffeine-codeine capsule
50-325-40-30 mg
GP
Retail
butalbital-acetaminophen tablet 50-325 mg
GP
Retail
butalbital-acetaminophen-caffeine capsule 50-325-40 mg
GP
Retail
butalbital-acetaminophen-caffeine tablet 50-325-40 mg,

50-500-40 mg
GP
Retail
CHILDREN'S PAIN & FEVER RELIEF ORAL

ELIXIR 160 MG/5 ML
GP
30

day(s))
Drug Name
Formulary
Tier
Tier
CHILDREN'S TRIAMINIC FEVER REDUCER

ORAL LIQUID 160 MG/5 ML
GP

day(s))
ENDOCET TABLET 5-325 MG
GP
FEVERALL
GP
Retail; OTC
gabapentin capsule
GP
gabapentin oral solution 250 mg/5 ml
GP
gabapentin tablet 600 mg, 800 mg
GP

EA per 1 day(s))
hydrocodone-acetaminophen oral solution 7.5-500 mg/15

ml
GP
hydrocodone-acetaminophen tablet 10-325 mg, 10-500 mg,

10-650 mg, 10-660 mg, 10-750 mg, 2.5-500 mg, 5-325 mg,
5-500 mg, 7.5-325 mg, 7.5-500 mg, 7.5-650 mg, 7.5-750
mg
GP

day(s)), QL (12 EA per 1 day(s))
LORTAB TABLET 5-500 MG, 7.5-500 MG

EA per 1 day(s))
GP
oxycodone-acetaminophen capsule 5-500 mg
GP
oxycodone-acetaminophen tablet 2.5-325 mg, 5-325 mg
GP
PEDIACARE FEVER REDUCER ORAL

SUSPENSION 160 MG/5 ML

day(s))
GP
GP
pentazocine-acetaminophen tablet 25-650 mg
Retail
PHRENILIN FORTE CAPSULE 50-650 MG
GP
Retail
ROXICET ORAL SOLUTION 5-325 MG/5 ML
BP
Retail
ROXICET TABLET 5-325 MG
BP
Retail
GP
benztropine oral
GP
Retail
GP
Retail
trihexyphenidyl tablet 2 mg, 5 mg
GP
Retail
carbamazepine chewable tablet 100 mg
GP
Retail
carbamazepine er capsule,extended release mphase12hr
GP
Retail
carbamazepine er tablet,extended release,12 hr 200 mg,

400 mg
GP
Retail
carbamazepine oral suspension 100 mg/5 ml
GP
Retail
carbamazepine tablet 200 mg
GP
Retail
divalproex er tablet,extended release 24 hr 250 mg, 500

mg
GP
Retail
divalproex sprinkle capsule 125 mg
GP
Retail
divalproex tablet,delayed release
GP
Retail
felbamate oral suspension 600 mg/5 ml
GP
felbamate tablet 400 mg, 600 mg
GP
gabapentin capsule
GP
tramadol-acetaminophen tablet 37.5-325 mg

Anticholinergic Agents (Cns)
Anticonvulsants, Miscellaneous
31
Drug Name
Formulary
Tier
Tier
GP
gabapentin tablet 600 mg, 800 mg
GP

EA per 1 day(s))
GABITRIL TABLET
BP
Retail
LAMICTAL STARTER (BLUE) KIT TABLETS IN A

DOSE PACK 25 MG (35)
BP
Retail
LAMICTAL STARTER (ORANGE) KIT TABLETS,

DOSE PACK 25 MG (42) -100 MG (7)
BP
Retail
lamotrigine chewable dispersible tablet 25 mg, 5 mg
GP
Retail
lamotrigine tablet 100 mg, 150 mg, 200 mg, 25 mg
GP
Retail; QL (3 EA per 1 day(s)),
levetiracetam oral solution 100 mg/ml
GP
Retail
levetiracetam tablet 1,000 mg, 250 mg, 500 mg, 750 mg
GP

EA per 1 day(s))
oxcarbazepine oral suspension 300 mg/5 ml
GP
Retail
oxcarbazepine tablet
GP
Retail
TEGRETOL ORAL SUSPENSION 100 MG/5 ML
BP
Retail
TEGRETOL TABLET 200 MG
BP
Retail
TEGRETOL XR
BP
Retail
TOPIRAGEN
GP
topiramate sprinkle capsule 15 mg, 25 mg
GP
topiramate tablet
GP
valproic acid capsule 250 mg
GP
Retail
valproic acid (as sodium salt) oral solution 250 mg/5 ml,
250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml)
GP
Retail,
zonisamide
GP
Retail
Antidepressants, Miscellaneous
BUDEPRION SR TABLET,EXTENDED RELEASE
100 MG, 150 MG
GP
BUPROBAN TABLET,EXTENDED RELEASE 150

MG
GP
bupropion hcl sr tablet,sustained-release
GP
bupropion hcl tablet 100 mg, 75 mg
GP
bupropion hcl xl 24 hr tablet, extended release 150 mg,

300 mg
GP
mirtazapine
GP
Retail

mg
GP
Retail
GP
Retail
GP
Retail
lithium carbonate
GP
Retail
lithium carbonate er tablet,extended release 300 mg, 450

mg
GP
Retail
Antimanic Agents
32
Drug Name
Formulary
Tier
Tier
lithium carbonate tablet 300 mg
GP
Retail
GP
Retail
valproic acid (as sodium salt) oral solution 250 mg/5 ml,
250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml)
GP
Retail,
Antimigraine Agents, Miscellaneous

MG

day(s))
GP
GP

day(s))
GP
Retail; OTC
GP

day(s))

mg, 975 mg
GP

day(s)),
GP
BUTALBITAL COMPOUND W/CODEINE

CAPSULE 30-50-325-40 MG
GP

day(s))
50-325-40-30 mg
GP
GP

50-500-40 mg
GP
GP
Retail
GP
Retail
dihydroergotamine injection solution 1 mg/ml
GP
Retail

mg
GP
Retail
GP
Retail
GP
Retail
GP

day(s))

RELEASE 81 MG
GP

day(s))
GP

250-250-65 MG
GP
Retail
Retail; OTC
GP
Retail
GP
Retail
propranolol tablet
GP
Retail
GP
Retail
GP
GP
valproic acid (as sodium salt) oral solution
GP
33
Drug Name
Formulary
Tier
Tier
Antipsychotics, Miscellaneous
GP
loxapine succinate
Retail
LOXITANE CAPSULE 5 MG
GP
Retail
ORAP TABLET 1 MG, 2 MG
BP
Retail
Anxiolytics, Sedatives & Hypnotics,Misc.

buspirone
GP
Retail
diphenhydramine tablet 50 mg
GP

day(s))
hydroxyzine hcl syrup 10 mg/5 ml
GP
Retail
hydroxyzine hcl tablet
GP
Retail
hydroxyzine pamoate capsule
GP
Retail
meprobamate tablet 200 mg, 400 mg
GP
Retail
NYTOL TABLET 25 MG
GP

day(s))
PHENADOZ RECTAL SUPPOSITORY 12.5 MG, 25

MG
GP
Retail
promethazine rectal suppository 12.5 mg, 25 mg
GP
GP
promethazine tablet
GP
PROMETHEGAN
GP
Retail
GP

day(s))
GP

day(s))

MG
GP
Retail; OTC
zaleplon capsule 10 mg, 5 mg
GP
QL (2 per 1 Day(s))
zolpidem tablet 10 mg, 5 mg
GP
Atypical Antipsychotics
ABILIFY ORAL SOLUTION 1 MG/ML
BP
Retail; QL (10 ML per 1 day(s)); Age

(Min 6 Years)
ABILIFY TABLET
BP

(Min 6 Years)
ABILIFY DISCMELT DISINTEGRATING TABLET

10 MG, 15 MG
BP

(Min 6 Years)
ABILIFY MAINTENA INTRAMUSCULAR

SUSPENSION,EXTENDED RELEASE 300 MG, 400
MG
GP
clozapine tablet 100 mg, 200 mg, 25 mg, 50 mg

INVEGA SUSTENNA
PA
34

day(s)), QL (2 EA per 1 day(s)); Age
(Min 6 Years)
PA; Specialty
Drug Name
Formulary
Tier
Tier
olanzapine oral
GP

(Min 6 Years)
quetiapine tablet 100 mg, 200 mg, 25 mg, 300 mg, 400 mg,
50 mg
GP

day(s))
RISPERDAL CONSTA
PA; Specialty
risperidone disintegrating tablet 0.25 mg, 0.5 mg, 1 mg, 2

mg, 3 mg, 4 mg
GP

EA per 1 day(s)); Age (Min 6 Years)
risperidone oral solution 1 mg/ml
GP

(Min 6 Years)
risperidone tablet
GP

(Min 6 Years)
ziprasidone hcl
GP

(Min 6 Years)
ZYPREXA RELPREVV
PA; Specialty
Barbiturates (Anticonvulsants)
phenobarbital oral elixir 20 mg/5 ml
GP
Retail
phenobarbital tablet
GP
Retail
primidone tablet 250 mg, 50 mg
GP
Retail
Barbiturates (Anxiolytic, Sedative/Hyp)

CAPSULE 30-50-325-40 MG
GP
Retail
50-325-40-30 mg
GP
Retail
butalbital-acetaminophen tablet 50-325 mg
GP
Retail
GP
Retail

50-500-40 mg
GP
Retail
GP
Retail
GP
Retail
GP
Retail
phenobarbital tablet
GP
Retail
PHRENILIN FORTE CAPSULE 50-650 MG
GP
Retail
Benzodiazepines (Anticonvulsants)
clonazepam tablet
GP
clorazepate dipotassium tablet 15 mg, 3.75 mg, 7.5 mg
GP

EA per 1 day(s))
DIASTAT RECTAL KIT 2.5 MG
BP
DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20

MG, 5-7.5-10 MG
BP
diazepam oral solution 5 mg/5 ml
GP
Retail
diazepam rectal kit
GP
diazepam tablet
GP
35
Drug Name
Formulary
Tier
Tier
DIAZEPAM INTENSOL ORAL CONCENTRATE 5

MG/ML
GP
Retail
TRANXENE T-TAB
BP
Retail
Benzodiazepines (Anxiolytic,Sedativ/Hyp)
alprazolam tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg
GP

EA per 1 day(s))
amitriptyline-chlordiazepoxide tablet 12.5-5 mg, 25-10 mg
GP
chlordiazepoxide capsule 10 mg, 25 mg, 5 mg
GP
Retail; QL (10 EA per 1 day(s)),
clonazepam tablet
GP
clorazepate dipotassium tablet 15 mg, 3.75 mg, 7.5 mg
GP

EA per 1 day(s))
BP
DIASTAT ACUDIAL RECTAL KIT 12.5-15-17.5-20

MG, 5-7.5-10 MG
BP
diazepam oral solution 5 mg/5 ml
GP
Retail
diazepam rectal kit
GP
diazepam tablet
GP
DIAZEPAM INTENSOL ORAL CONCENTRATE 5

MG/ML
GP
Retail
estazolam tablet 1 mg, 2 mg
GP
flurazepam capsule 15 mg, 30 mg
GP
lorazepam oral concentrate 2 mg/ml
GP
Retail
lorazepam tablet 0.5 mg, 1 mg, 2 mg
GP

EA per 1 day(s))
LORAZEPAM INTENSOL ORAL CONCENTRATE

2 MG/ML
GP
Retail
oxazepam capsule 10 mg, 15 mg, 30 mg
GP

EA per 1 day(s))
temazepam capsule 15 mg, 30 mg
GP
TRANXENE T-TAB
BP
Retail
GP

EA per 1 day(s))
haloperidol
GP
Retail
haloperidol decanoate intramuscular solution 100 mg/ml,

50 mg/ml
GP
Retail
haloperidol injection solution 5 mg/ml
GP
Retail
haloperidol oral concentrate 2 mg/ml
GP
Retail
triazolam tablet 0.125 mg, 0.25 mg

Butyrophenones
Catechol-O-Methyltransferase(Comt)Inhib.
TASMAR TABLET 100 MG
BP
Central Nervous System Agents, Misc.

GP
guanfacine tablet 1 mg, 2 mg

NAMENDA ORAL SOLUTION 10 MG/5 ML
BP
36
Retail
Retail
Drug Name
Formulary
Tier
Tier
NAMENDA TABLET 10 MG, 5 MG
BP
NAMENDA TITRATION PAK TABLETS IN A

DOSE PACK 5-10 MG
BP
STRATTERA CAPSULE 10 MG, 100 MG, 18 MG, 25

MG, 40 MG, 60 MG, 80 MG
BP

day(s)); Age (Min 6 Years)
BP
PA; Retail
Cyclooxygenase-2 (Cox-2) Inhibitors

CELEBREX CAPSULE 100 MG, 200 MG
Dopamine Precursors
carbidopa-levodopa er tablet,extended release 25-100 mg,
50-200 mg
GP
Retail
carbidopa-levodopa tablet
GP
Retail
bromocriptine capsule 5 mg
GP
Retail
bromocriptine tablet 2.5 mg
GP
Retail
Ergot-Deriv. Dopamine Receptor Agonists
Hydantoins
DILANTIN CAPSULE 30 MG
BP
Retail
DILANTIN EXTENDED CAPSULE 100 MG
BP
Retail
DILANTIN INFATABS CHEWABLE TABLET 50

MG
BP
Retail
DILANTIN-125 ORAL SUSPENSION 125 MG/5 ML
BP
Retail
PHENYTEK CAPSULE 200 MG, 300 MG
BP
Retail
GP
Retail
GP
Retail
selegiline capsule 5 mg
GP
Retail
selegiline tablet 5 mg
GP
Retail
selegiline capsule 5 mg
GP
Retail
selegiline tablet 5 mg
GP
Retail
tranylcypromine tablet 10 mg
GP
Retail
pramipexole tablet
GP
ropinirole tablet
GP
GP
Retail; , QL (12 EA per 1 day(s)), QL

(6 EA per 1 day(s))
Monoamine Oxidase B Inhibitors
Monoamine Oxidase Inhibitors
Nonergot-Deriv.Dopamine Receptor Agonist
Opiate Agonists
acetaminophen-codeine tablet 300-15 mg, 300-30 mg,
300-60 mg
CAPSULE 30-50-325-40 MG
GP
Retail
50-325-40-30 mg
GP
Retail
GP
37
Drug Name
ENDOCET TABLET 5-325 MG
Formulary
Tier
Tier
GP
fentanyl transdermal patch
GP
hydrocodone-acetaminophen oral solution 7.5-500 mg/15

ml
GP
hydrocodone-acetaminophen tablet 10-325 mg, 10-500 mg,

10-650 mg, 10-660 mg, 10-750 mg, 2.5-500 mg, 5-325 mg,
5-500 mg, 7.5-325 mg, 7.5-500 mg, 7.5-650 mg, 7.5-750
mg
GP

day(s)), QL (12 EA per 1 day(s))
hydrocodone-ibuprofen tablet 7.5-200 mg
GP
hydromorphone rectal suppository 3 mg
GP
Retail
hydromorphone tablet
GP
Retail
LORTAB TABLET 5-500 MG, 7.5-500 MG

EA per 1 day(s))
GP
meperidine oral solution 50 mg/5 ml
GP
Retail
meperidine tablet 100 mg, 50 mg
GP
Retail
methadone oral concentrate 10 mg/ml
GP
Retail
methadone oral solution 10 mg/5 ml, 5 mg/5 ml
GP
Retail
methadone tablet 10 mg, 5 mg
GP
Retail
METHADONE INTENSOL ORAL CONCENTRATE

10 MG/ML
GP
Retail
morphine er tablet,extended release
GP
morphine oral solution 10 mg/5 ml, 20 mg/5 ml
GP
Retail
morphine rectal suppository 10 mg, 20 mg, 30 mg, 5 mg
GP
Retail
morphine tablet 15 mg, 30 mg
GP
Retail
morphine concentrate oral solution 100 mg/5 ml (20

mg/ml)
GP
Retail
oxycodone capsule 5 mg
GP
Retail
oxycodone oral concentrate 20 mg/ml
GP
Retail
oxycodone oral solution 5 mg/5 ml
GP
Retail
oxycodone tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg
GP
Retail
oxycodone-acetaminophen capsule 5-500 mg
GP
oxycodone-acetaminophen tablet 2.5-325 mg, 5-325 mg
GP
OXYCONTIN TABLET,EXTENDED RELEASE
GP
PA; Retail; QL (2 EA per 1 day(s))

MG/5 ML
GP
ROXICET ORAL SOLUTION 5-325 MG/5 ML
BP
Retail
ROXICET TABLET 5-325 MG
BP
Retail
tramadol tablet 50 mg
GP
Retail
GP
GP
Retail
Opiate Antagonists
naltrexone tablet 50 mg
REVIA TABLET 50 MG
BP
38
Retail
Drug Name
Formulary
Tier
Tier
BP
Retail
Opiate Partial Agonists

BUPRENEX INJECTION SOLUTION 0.3 MG/ML
buprenorphine sublingual tablet 2 mg, 8 mg
GP
PA; Retail
pentazocine-acetaminophen tablet 25-650 mg
GP
Retail
pentazocine-naloxone tablet 50-0.5 mg
GP
Retail
SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5

MG, 4-1 MG, 8-2 MG
BP
PA; , Retail; QL (1 per 1 Day(s)), QL

(2 per 1 Day(s))
GP

day(s))
Other Nonsteroidal Anti-Inflam. Agents

CHILDREN'S ADVIL ORAL SUSPENSION 100
MG/5 ML
diclofenac potassium tablet 50 mg
GP
Retail
diclofenac er tablet,extended release 24 hr 100 mg
GP
Retail
diclofenac sodium tablet,delayed release
GP
Retail
diflunisal tablet 500 mg
GP
Retail
etodolac capsule 200 mg, 300 mg
GP
Retail
etodolac tablet 400 mg, 500 mg
GP
Retail
fenoprofen tablet 600 mg
GP
Retail
flurbiprofen tablet 100 mg, 50 mg
GP
Retail
GP
ibuprofen oral suspension 100 mg/5 ml
GP

day(s))
ibuprofen tablet 200 mg, 400 mg, 600 mg, 800 mg
GP

day(s)),
indomethacin capsule 25 mg, 50 mg
GP
Retail
indomethacin er capsule,extended release 75 mg
GP
Retail
INFANT'S IBUPROFEN ORAL

DROPS,SUSPENSION 50 MG/1.25 ML
GP
INFANT'S MOTRIN ORAL DROPS,SUSPENSION

50 MG/1.25 ML
GP
ketoprofen capsule 50 mg, 75 mg
GP
Retail
ketoprofen er 24 hr capsule,extended release 200 mg
GP
Retail
ketorolac tablet 10 mg
GP
meclofenamate capsule 100 mg, 50 mg
GP
Retail
meloxicam tablet 15 mg, 7.5 mg
GP
Retail
MOTRIN TABLET 100 MG
BP

day(s))
MOTRIN IB TABLET 200 MG
BP

day(s))
nabumetone tablet 500 mg, 750 mg
GP
Retail
naproxen oral suspension 125 mg/5 ml
GP
Retail
naproxen tablet
GP
Retail
naproxen sodium tablet 220 mg, 275 mg, 550 mg
GP
Retail; OTC,; QL (3 EA per 1 day(s)),
39
Drug Name
Formulary
Tier
Tier
oxaprozin tablet 600 mg
GP
Retail
piroxicam capsule 10 mg, 20 mg
GP
sulindac tablet 150 mg, 200 mg
GP
Retail
tolmetin capsule 400 mg
GP
Retail
tolmetin tablet 200 mg, 600 mg
GP
Retail
VOLTAREN TOPICAL GEL 1 %
BP
Phenothiazines
GP
chlorpromazine tablet
COMPRO RECTAL SUPPOSITORY 25 MG
GP
Retail
Retail
fluphenazine decanoate injection solution 25 mg/ml
GP
fluphenazine injection solution 2.5 mg/ml
GP
Retail
fluphenazine oral concentrate 5 mg/ml
GP
Retail
fluphenazine oral elixir 2.5 mg/5 ml
GP
Retail
fluphenazine tablet
GP
Retail
perphenazine tablet
GP
Retail
perphenazine-amitriptyline
GP
Retail
prochlorperazine rectal suppository 25 mg
GP
Retail
prochlorperazine maleate tablet 10 mg, 5 mg
GP
Retail
thioridazine tablet
GP
Retail
trifluoperazine tablet
GP
Retail
Respiratory And Cns Stimulants

CAPSULE 30-50-325-40 MG
GP
50-325-40-30 mg
GP
GP

50-500-40 mg
GP
GP
GP
caffeine citrated oral solution 60 mg/3 ml (20 mg/ml)
GP
Age (Max 1 Years)
dexmethylphenidate tablet
GP
QL (2 per 1 Day(s)); Age (Max 21

Years)
METADATE ER TABLET,EXTENDED RELEASE

20 MG
QL (2 per 1 Day(s)); Age (Max 21

Years)
BP
methylphenidate er tablet,extended release 10 mg, 20 mg
GP
QL (3 EA per 1 Day(s)), QL (2 per 1

Day(s)); Age (Max 21 Years)
methylphenidate er tablet,extended release 24 hr 18 mg,

27 mg, 36 mg, 54 mg
GP
Retail; QL (1 EA per 1 Day(s)), QL (2

EA per 1 Day(s)); Age (Max 21 Years)
methylphenidate tablet
GP
Retail; QL (3 EA per 1 Day(s)); Age

(Max 21 Years)
Salicylates
40
Drug Name
Formulary
Tier
Tier

200-25 MG
BP

MG
GP

day(s))
GP

day(s))
GP
Retail; OTC
GP

day(s))

mg, 975 mg
GP

day(s)),
GP

day(s))
BENGAY ULTRA STRENGTH TOPICAL CREAM

4-30-10 %
GP
Retail; OTC

CAPSULE 30-50-325-40 MG
GP
Retail
GP
Retail
GP
Retail
GP
GP
GP

day(s))

RELEASE 81 MG
GP

day(s))

250-250-65 MG
GP
Retail; OTC
ICY HOT TOPICAL CREAM 30-10 %
GP
Retail; OTC; QL (90 GM per 180

day(s))
ORPHENADRINE COMPOUND TABLET 25-385-30

MG
GP
Retail
ORPHENADRINE COMPOUND-DS TABLET

50-770-60 MG
GP
Retail
GP
salsalate tablet 500 mg, 750 mg
Retail
Sel. Serotonin & Norepi Reuptake Inhibtr

CYMBALTA
BP
QL (2 per 1 Day(s))
venlafaxine er capsule,extended release 24 hr 150 mg, 37.5

mg, 75 mg
GP

EA per 1 day(s))
venlafaxine tablet
GP
naratriptan tablet 1 mg, 2.5 mg
GP
rizatriptan tablet 10 mg, 5 mg
GP
sumatriptan nasal spray 20 mg/actuation, 5 mg/actuation
GP
GP
Retail; , QL (2 per 26 Day(s))
Selective Serotonin Agonists
sumatriptan subcutaneous cartridge (refill) 4 mg/0.5 ml, 6

mg/0.5 ml
41
Drug Name
Formulary
Tier
Tier
sumatriptan subcutaneous pen injector 4 mg/0.5 ml, 6

mg/0.5 ml
GP
Retail; , QL (2 per 26 Day(s))
sumatriptan subcutaneous solution 6 mg/0.5 ml
GP
sumatriptan succinate oral
GP
citalopram oral solution 10 mg/5 ml
GP
citalopram tablet 10 mg, 20 mg, 40 mg
GP

(1.5 EA per 1 day(s))
escitalopram oral solution 5 mg/5 ml
GP
escitalopram tablet
GP
QL (1 per 1 Day(s))
fluoxetine capsule 10 mg, 20 mg, 40 mg
GP

day(s))
fluoxetine oral solution 20 mg/5 ml
GP
fluoxetine tablet 10 mg, 20 mg
GP

EA per 1 day(s))
fluvoxamine tablet 100 mg, 25 mg, 50 mg
GP

EA per 1 day(s)), QL (1.5 EA per 1
day(s))
paroxetine tablet 10 mg, 20 mg, 30 mg, 40 mg
GP

EA per 1 day(s))
sertraline oral concentrate 20 mg/ml
GP
Retail
sertraline tablet 100 mg, 25 mg, 50 mg
GP

EA per 1 day(s)), QL (1.5 EA per 1
day(s))
nefazodone
GP
Retail
trazodone tablet
GP
Retail
ethosuximide capsule 250 mg
GP
Retail
ethosuximide oral solution 250 mg/5 ml
GP
Retail
GP
Retail
amitriptyline oral
GP
Retail
amitriptyline-chlordiazepoxide tablet 12.5-5 mg, 25-10 mg
GP
amoxapine
GP
Retail
clomipramine
GP
Retail
desipramine oral
GP
Retail
doxepin capsule
GP
Retail
doxepin oral concentrate 10 mg/ml
GP
Retail
imipramine hcl
GP
Retail
maprotiline
GP
Retail
Selective-Serotonin Reuptake Inhibitors
Serotonin Modulators
Succinimides
Thioxanthenes
thiothixene capsule
Trycyclics & Other Norepineph.-Ru Inhib
42
Drug Name
Formulary
Tier
Tier
nortriptyline
GP
Retail
nortriptyline oral solution 10 mg/5 ml
GP
Retail
perphenazine-amitriptyline
GP
Retail
protriptyline tablet 10 mg, 5 mg
GP
Retail
Devices
Devices
CONTOUR METER KIT
GP
COOL MIST HUMIDIFIER 1 GALLON MISC
GP

EUFLEXXA INTRA-ARTICULAR SYRINGE 10

MG/ML
FINGERSTIX LANCETS
PA; Specialty
day(s))
GP
GP
humidifiers misc

MICROLET LANCET
GP

day(s))
SINGLE-LET MISC
GP

day(s))
sodium chloride for nebulization 7 %
GP
vaporizers misc
GP

Diagnostic Agents
Diabetes Mellitus
BREEZE 2 TEST STRIPS
GP

day(s))
CONTOUR TEST STRIPS
GP
Retail; OTC; QL (150 per 30 Day(s))
CHEK-STIX CONTROL STRIPS
GP
Retail; OTC
COMBISTIX REAGENT STRIPS
GP
Retail; OTC
HEMA-COMBISTIX STRIPS
GP
Retail; OTC
KETO-DIASTIX STRIPS
GP
Retail; OTC
LABSTIX REAGENT STRIPS
GP
Retail; OTC
MULTISTIX STRIPS
GP
Retail; OTC
MULTISTIX 5 STRIPS
GP
Retail; OTC
MULTISTIX 7 STRIPS
GP
Retail; OTC
MULTISTIX 8 SG STRIPS
GP
Retail; OTC
MULTISTIX 9 STRIPS
GP
Retail; OTC
MULTISTIX 9 SG STRIPS
GP
Retail; OTC
URISTIX 4 STRIPS
GP
Retail; OTC
URISTIX REAGENT STRIPS
GP
Retail; OTC
Urine And Feces Contents
Electrolytic, Caloric, And Water Balance

43
Drug Name
Formulary
Tier
Tier
GP
Retail
CYTRA-2 ORAL SOLUTION 500-334 MG/5 ML
GP
Retail
ORACIT ORAL SOLUTION 490-640 MG/5 ML
GP
Retail
Acidifying Agents
PHOSPHA 250 NEUTRAL TABLET 250 MG
Alkalinizing Agents
potassium citrate er tablet,extended release 10 meq, 5 meq
GP
Retail
sodium bicarbonate intravenous solution 8.4 %
GP
Retail
sodium bicarbonate intravenous syringe 8.4 % (1 meq/ml)
GP
Retail
sodium bicarbonate (antacid) powder
GP
Retail; OTC
sodium citrate-citric acid oral solution 500-334 mg/5 ml
GP
Retail
TARON-CRYSTALS ORAL PACKET 3,300-1,002

MG
GP
Retail
CONSTULOSE ORAL SOLUTION 10 GRAM/15 ML
GP
Retail
ENULOSE ORAL SOLUTION 10 GRAM/15 ML
GP
Retail
GENERLAC ORAL SOLUTION 10 GRAM/15 ML
GP
Retail
Ammonia Detoxicants
GP
Retail
GP
Retail; OTC
GP
Retail
GP
Retail
lactulose oral solution 10 gram/15 ml

Caloric Agents
glucose chewable tablet 4 gram
Carbonic Anhydrase Inhibitors
Diuretics, Miscellaneous
BP
Retail
BP
Retail
GP
Retail
GP
Retail
GP
Retail
bumetanide oral
GP
Retail
furosemide oral solution 10 mg/ml, 40 mg/5 ml
GP
Retail
furosemide tablet
GP
Retail
GP
Retail
Irrigating Solutions
sodium chloride irrigation solution 0.9 %
Loop Diuretics
Phosphate-Removing Agents
calcium acetate capsule 667 mg
CALPHRON TABLET 667 MG
GP
Retail; OTC
ELIPHOS TABLET 667 MG
GP
Retail
RENAGEL TABLET 400 MG, 800 MG
BP
RENVELA TABLET 800 MG
BP
Potassium-Removing Agents
44
Drug Name
Formulary
Tier
Tier
KALEXATE ORAL POWDER
GP
Retail
KIONEX ORAL POWDER
GP
Retail
KIONEX ORAL SUSPENSION 15 GRAM/60 ML
GP
Retail
MARLEXATE ORAL POWDER
GP
Retail
GP
sodium polystyrene sulfonate oral powder
Retail
SPS ENEMA 30 GRAM/120 ML
GP
Retail
SPS ORAL SUSPENSION 15 GRAM/60 ML
GP
Retail
Potassium-Sparing Diuretics
amiloride tablet 5 mg
GP
Retail
GP
Retail
GP
Retail
GP
Retail
spironolactone
GP
Retail
GP
Retail

mg
GP
Retail
Replacement Preparations
CALCIUM 500 + D TABLET 500 MG(1,250MG) -200
UNIT, 500 MG(1,250MG) -400 UNIT
GP

day(s))
CALCIUM 500 WITH D TABLET 500 MG(1,250MG)

-400 UNIT
GP

day(s))
CALCIUM 600 + D(3) TABLET 600 MG(1,500MG)

-200 UNIT, 600 MG(1,500MG) -400 UNIT
GP

day(s))
calcium carbonate-vitamin d3 chewable tablet 500-100

mg-unit
GP

day(s))
calcium carbonate-vitamin d3 tablet 500 mg(1,250mg)

-200 unit, 600 mg(1,500mg) -200 unit
GP

day(s))
calcium gluconate tablet 45 mg (500 mg)
GP
Retail; OTC
ENFALYTE ORAL SOLUTION
GP
Retail; OTC
GP
Retail
K-EFFERVESCENT TABLET 25 MEQ
GP
Retail
KLOR-CON ORAL PACKET 20 MEQ
GP
Retail
KLOR-CON TABLET,EXTENDED RELEASE 8

MEQ
GP
Retail
KLOR-CON 10 TABLET,EXTENDED RELEASE 10

MEQ
GP
Retail
KLOR-CON M10 TABLET,EXTENDED RELEASE

10 MEQ
GP
Retail
KLOR-CON M20 TABLET,EXTENDED RELEASE

20 MEQ
GP
Retail
GP
Retail
ORALYTE ORAL SOLUTION
GP
Retail; OTC
45
Drug Name
Formulary
Tier
Tier
OS-CAL 500 + D CHEWABLE TABLET 500

MG(1,250MG) -600 UNIT
GP

day(s))
OYSCO 500/D CHEWABLE TABLET 500

MG(1,250MG) -600 UNIT
GP

day(s))
OYSCO 500/D TABLET 500 MG(1,250MG) -200

UNIT
GP

day(s))
OYSCO D TABLET 250-125 MG-UNIT
GP

day(s))
OYSCO-500 TABLET 500 MG CALCIUM (1,250 MG)
GP

day(s))
OYSTER SHELL CALCIUM 500 TABLET 500 MG

CALCIUM (1,250 MG)
GP

day(s))
OYSTER SHELL CALCIUM-VIT D3 TABLET 500

MG(1,250MG) -200 UNIT, 500 MG(1,250MG) -400
UNIT
GP

day(s))
PHOS-NAK ORAL POWDER PACKET 280-160-250

MG
GP
Retail; OTC
potassium bicarbonate-citric acid effervescent tablet 25

meq
GP
Retail
potassium chloride er capsule,extended release 10 meq
GP
Retail
potassium chloride er tablet,extended release 10 meq, 8

meq
GP
Retail
potassium chloride er tablet,extended release(part/cryst)

10 meq, 20 meq
GP
Retail
potassium chloride oral liquid 10 %
GP
Retail
GP
Retail
GP
GP
Retail
GP

Day(s))
GP
GP

TABLET 27-1 MG
GP

GP
GP

Day(s))

27-0.8 MG
GP

GP

GP

Day(s))
GP
GP
46
Drug Name
Formulary
Tier
Tier
TUMS CHEWABLE TABLET 200 MG CALCIUM

(500 MG)
GP

day(s))
GP
GP
GP
Thiazide Diuretics
GP
Retail
GP
Retail
GP
Retail
GP
Retail
DIURIL ORAL SUSPENSION 250 MG/5 ML
BP
Retail
GP

EA per 1 day(s))
GP
Retail
hydrochlorothiazide tablet
GP
Retail

300-12.5 mg
GP

mg, 20-25 mg
GP

EA per 1 day(s))
GP
methyclothiazide tablet 5 mg
GP
Retail

mg
GP
Retail
GP
Retail
GP
Retail

mg
GP
Retail
GP
GP
Retail
chlorthalidone tablet 25 mg, 50 mg
GP
Retail
Thiazide-Like Diuretics
CLORPRES
BP
Retail
indapamide tablet 1.25 mg, 2.5 mg
GP
Retail
metolazone tablet
GP
Retail
GP
Retail
Uricosuric Agents
probenecid tablet 500 mg
Eye, Ear, Nose And Throat (Eent) Preps.
Alpha-Adrenergic Agonists (Eent)
ALPHAGAN P EYE DROPS 0.1 %
BP
brimonidine eye drops 0.15 %
GP
brimonidine eye drops 0.2 %
GP
Antiallergic Agents
47
Drug Name
Formulary
Tier
Tier
ALAWAY EYE DROPS 0.025 %
GP

day(s))
ALOCRIL EYE DROPS 2 %
BP
ALOMIDE EYE DROPS 0.1 %
BP
cromolyn eye drops 4 %
GP
cromolyn nasal spray 5.2 mg/spray (4 %)
GP

day(s))
ketotifen eye drops 0.025 %
GP

day(s))
ZADITOR EYE DROPS 0.025 %
GP

day(s))
GP
Retail
Antibacterials (Eent)
AK-POLY-BAC EYE OINTMENT 500-10,000
UNIT/GRAM
GP
bacitracin eye ointment 500 unit/gram
Retail
BLEPH-10 EYE DROPS 10 %
GP
BLEPHAMIDE EYE DROPS,SUSPENSION 10-0.2 %
GP
BLEPHAMIDE S.O.P. EYE OINTMENT 10-0.2 %
GP
Retail
CIPRODEX EAR DROPS,SUSPENSION 0.3-0.1 %
BP
Retail
ciprofloxacin eye drops 0.3 %
GP
erythromycin eye ointment 5 mg/gram (0.5 %)
GP
Retail
GENTAK EYE OINTMENT 0.3 % (3 MG/GRAM)
BP
Retail
gentamicin eye drops 0.3 %
GP
gentamicin eye ointment 0.3 % (3 mg/gram)
GP
Retail
neomycin-bacitracin-poly-hc eye ointment 3.5-400-10,000

mg-unit/g-1%
GP
Retail
neomycin-bacitracin-polymyxin eye ointment

3.5-400-10,000 mg-unit-unit/g
GP
Retail
neomycin-polymyxin-dexameth eye drops,suspension

3.5-10,000-0.1 mg/ml-unit/ml-%
GP
neomycin-polymyxin-dexameth eye ointment

3.5-10,000-0.1 mg-unit/g-%
GP
Retail
neomycin-polymyxin-gramicidin eye drops 1.75-10k-0.025

mg-unit-mg/ml
GP
neomycin-polymyxin-hydrocort ear drops,suspension

3.5-10,000-1 mg-unit/ml-%
GP
Retail
neomycin-polymyxin-hydrocort ear solution 3.5-10,000-1

mg-unit/ml-%
GP
Retail
neomycin-polymyxin-hydrocort eye drops,suspension

3.5-10,000-10 mg-unit-mg/ml
GP
NEOSPORIN (NEO-POLYM-GRAMICID) EYE

DROPS 1.75-10K-0.025 MG-UNIT-MG/ML
GP
ofloxacin ear drops 0.3 %
GP
Retail
ofloxacin eye drops 0.3 %
GP
48
Drug Name
Formulary
Tier
Tier
sulfacetamide sodium eye drops 10 %
GP
sulfacetamide-prednisolone eye drops 10 %-0.23 % (0.25

%)
GP
TOBRADEX EYE DROPS,SUSPENSION 0.3-0.1 %
BP
TOBRADEX EYE OINTMENT 0.3-0.1 %
BP
TOBRADEX ST EYE DROPS,SUSPENSION 0.3-0.05

%
BP
Retail; QL (3.5 GM per 18 day(s))
tobramycin eye drops 0.3 %
GP
tobramycin-dexamethasone eye drops,suspension 0.3-0.1

%
GP
TOBREX EYE OINTMENT 0.3 %
BP

GP
GP
Retail; QL (7.5 ML per 18 day(s))
dorzolamide-timolol eye drops 2-0.5 %
GP
levobunolol eye drops 0.25 %
GP
levobunolol eye drops 0.5 %
GP
timolol eye gel forming solution 0.25 %, 0.5 %
GP
timolol maleate eye drops 0.25 %, 0.5 %
GP
GP
Retail
GP
Retail
trimethoprim-polymyxin b eye drops 0.1-10,000 %-unit/ml

Antivirals (Eent)
trifluridine eye drops 1 %
Beta-Adrenergic Blocking Agents (Eent)
Carbonic Anhydrase Inhibitors (Eent)
AZOPT EYE DROPS,SUSPENSION 1 %
BP
dorzolamide eye drops 2 %
GP
GP
methazolamide tablet 25 mg, 50 mg
GP
Retail
Corticosteroids (Eent)
ALREX EYE DROPS,SUSPENSION 0.2 %
GP
GP
dexamethasone eye drops 0.1 %

FLAREX EYE DROPS,SUSPENSION 0.1 %
BP

fluorometholone eye drops,suspension 0.1 %
GP
fluticasone nasal spray,suspension 50 mcg/actuation
GP
FML FORTE EYE DROPS,SUSPENSION 0.25 %
BP
FML S.O.P. EYE OINTMENT 0.1 %
BP
neomycin-bacitracin-poly-hc eye ointment 3.5-400-10,000

mg-unit/g-1%
GP
Retail
neomycin-polymyxin-dexameth eye drops,suspension

3.5-10,000-0.1 mg/ml-unit/ml-%
GP
neomycin-polymyxin-dexameth eye ointment

3.5-10,000-0.1 mg-unit/g-%
GP
Retail
49
Drug Name
Formulary
Tier
neomycin-polymyxin-hydrocort eye drops,suspension

3.5-10,000-10 mg-unit-mg/ml
PRED MILD EYE DROPS,SUSPENSION 0.12 %
Tier
GP
GP

prednisolone acetate eye drops,suspension 1 %
GP
prednisolone sodium phosphate eye drops 1 %
GP
TOBRADEX EYE DROPS,SUSPENSION 0.3-0.1 %
BP
TOBRADEX EYE OINTMENT 0.3-0.1 %
BP
TOBRADEX ST EYE DROPS,SUSPENSION 0.3-0.05

%
BP
tobramycin-dexamethasone eye drops,suspension 0.3-0.1

%
GP
triamcinolone acetonide nasal spray aerosol 55 mcg
GP
Retail
TRIESENCE (PF) INTRAOCULAR SUSPENSION

40 MG/ML
BP
Retail
VEXOL EYE DROPS,SUSPENSION 1 %
BP
GP
Retail
Eent Anti-Infectives, Miscellaneous

ACETASOL HC EAR DROPS 1-2 %
GP
acetic acid ear solution 2 %

CARBAMOXIDE EAR DROPS 6.5 %

day(s))
GP
GP
chlorhexidine gluconate mouthwash 0.12 %
Retail
Retail
DEBROX EAR DROPS 6.5 %
GP

day(s))
EAR DROPS (CARBAMIDE PEROXIDE) 6.5 %
GP

day(s))
GP
hydrocortisone-acetic acid ear drops 1-2 %

PERIOGARD MOUTHWASH 0.12 %
Retail
GP
Retail
BP
PA; Retail; QL (2 EA per 1 day(s))
ALTACHLORE EYE DROPS 5 %
GP
Retail; OTC
ALTACHLORE EYE OINTMENT 5 %
GP
Retail; OTC
ARTIFICIAL TEARS EYE DROPS 1.4 %
GP

day(s))
ARTIFICIAL TEARS EYE OINTMENT
GP
OTC
ARTIFICIAL TEARS (PETROLATUM/MINERAL

OIL) EYE OINTMENT 83-15 %
GP
Retail; OTC; QL (3.5 GM per 7

day(s))
BION TEARS (PF) DROPS IN A DROPPERETTE

0.1-0.3 %
GP
Eent Anti-Inflammatory Agents, Misc.

RESTASIS EYE DROPS IN A DROPPERETTE 0.05
%
Eent Drugs, Miscellaneous
GP
ipratropium bromide nasal spray 0.03 %, 0.06 %
Retail
MURO 128 EYE DROPS 2 %, 5 %
GP
Retail; OTC
MURO 128 EYE OINTMENT 5 %
GP
Retail; OTC
50
Drug Name
Formulary
Tier
Tier
REFRESH CLASSIC (PF) EYE DROPS IN A

DROPPERETTE 1.4-0.6 %
GP
REFRESH LIQUIGEL EYE LIQUID GEL DROPS 1

%
GP
REFRESH P.M. EYE OINTMENT 57.3-42.5 %
GP

day(s))
REFRESH TEARS EYE DROPS 0.5 %
GP
SOCHLOR EYE DROPS 5 %
GP
Retail; OTC
SOCHLOR EYE OINTMENT 5 %
GP
Retail; OTC
sodium chloride eye drops 5 %
GP
Retail; OTC
sodium chloride eye ointment 5 %
GP
Retail; OTC
TEARS AGAIN EYE DROPS 1.4 %
GP

day(s))
TEARS AGAIN EYE OINTMENT
GP

day(s))
TEARS AGAIN MC EYE DROPS
GP

day(s))
TEARS NATURALE FREE (PF) DROPS IN A

DROPPERETTE 0.1-0.3 %
GP
TEARS NATURALE II EYE DROPS
GP

day(s))
Eent Nonsteroidal Anti-Inflam. Agents

diclofenac eye drops 0.1 %
GP
Retail
flurbiprofen eye drops 0.03 %
GP
ketorolac eye drops 0.4 %
GP
Retail
ketorolac eye drops 0.5 %
GP
GP
Retail
Local Anesthetics (Eent)

antipyrine-benzocaine ear drops 5.4-1.4 %
AURODEX EAR DROPS 5.4-1.4 %
GP
Retail
AUROGUARD EAR DROPS 5.4-1.4 %
GP
Retail
lidocaine mucosal gel 2 %
GP
Retail
lidocaine mucosal solution 2 %, 4 %
GP
Retail
LIDOCAINE VISCOUS MUCOSAL SOLUTION 2 %
GP
Retail
TREAGAN OTIC EAR DROPS 5.4-1.4 %
GP
Retail
GP
Miotics
ISOPTO CARBACHOL EYE DROPS 1.5 %, 3 %
GP
atropine eye drops 1 %
GP
atropine eye ointment 1 %
GP
Retail
pilocarpine eye drops

Mydriatics
HOMATROPAIRE EYE DROPS 5 %
GP
ISOPTO HOMATROPINE EYE DROPS 2 %
GP
51
Drug Name
ISOPTO HOMATROPINE EYE DROPS 5 %
Formulary
Tier
Tier
GP
tropicamide eye drops 0.5 %, 1 %

GP
GP
Prostaglandin Analogs
latanoprost eye drops 0.005 %
TRAVATAN Z EYE DROPS 0.004 %
BP
AFRIN NASAL SPRAY AEROSOL 0.05 %
GP
Retail; OTC
AFRIN SINUS NASAL SPRAY AEROSOL 0.05 %
GP
Retail; OTC
ALTAFRIN EYE DROPS 10 %, 2.5 %
GP
Retail
NAPHCON-A EYE DROPS 0.025-0.3 %
GP

day(s))
NEO-SYNEPHRINE (PHENYLEPHRINE) NASAL

SPRAY
GP

day(s))
NEOFRIN EYE DROPS 10 %, 2.5 %
GP
Retail
Vasoconstrictors
GP
Retail
ondansetron disintegrating tablet 4 mg, 8 mg
GP
ondansetron hcl oral solution 4 mg/5 ml
GP
ondansetron hcl tablet 4 mg, 8 mg
GP
aluminum hydroxide gel oral suspension 320 mg/5 ml, 600

mg/5 ml
GP
Retail; OTC
bismuth subsalicylate chewable tablet 262 mg
GP
calcium carbonate chewable tablet 200 mg calcium (500

mg)
GP

day(s))
phenylephrine eye drops 2.5 %

Gastrointestinal Drugs
5-Ht3 Receptor Antagonists
Antacids And Adsorbents
FOAMING ANTACID CHEWABLE TABLET 80-20

MG
GP
Retail; OTC
GAVISCON CHEWABLE TABLET 80-14.2 MG
GP
Retail; OTC
KAOPECTATE (BISMUTH SUBSALICYLATE)

ORAL SUSPENSION 262 MG/15 ML
GP

day(s))
KAOPECTATE EX STR (BISMUTH SS) ORAL

GP

day(s))
MAALOX ADVANCED CHEWABLE TABLET

1,000-60 MG
GP
Retail; OTC
MAALOX ADVANCED ORAL SUSPENSION

200-200-20 MG/5 ML
GP
Retail; OTC
MAALOX MAXIMUM STRENGTH ORAL

SUSPENSION 400-400-40 MG/5 ML
GP
Retail; OTC
GP
magnesium oxide tablet 400 mg
Retail; OTC
PEPTO-BISMOL CHEWABLE TABLET 262 MG
GP
PEPTO-BISMOL ORAL SUSPENSION 262 MG/15

ML
GP
Retail; OTC
52
Drug Name
Formulary
Tier
Tier
PEPTO-BISMOL TABLET 262 MG
GP
PEPTO-BISMOL MAX ST ORAL SUSPENSION 525

MG/15 ML
GP
Retail; OTC
RULOX ORAL SUSPENSION 200-200-20 MG/5 ML
GP
Retail; OTC
TUMS CHEWABLE TABLET 200 MG CALCIUM

(500 MG)
GP
Retail; OTC
GP
Retail; OTC
Antidiarrhea Agents
ANTI-DIARRHEAL (LOPERAMIDE) TABLET 2
MG
bismuth subsalicylate chewable tablet 262 mg
GP
GP
Retail
GP
Retail
KAOPECTATE (BISMUTH SUBSALICYLATE)

GP

day(s))
KAOPECTATE EX STR (BISMUTH SS) ORAL

GP

day(s))
loperamide capsule 2 mg
GP
Retail; OTC
loperamide oral liquid 1 mg/5 ml
GP

day(s))
loperamide tablet 2 mg
GP
PEPTO-BISMOL CHEWABLE TABLET 262 MG
GP
PEPTO-BISMOL ORAL SUSPENSION 262 MG/15

ML
GP
Retail; OTC
GP
PEPTO-BISMOL MAX ST ORAL SUSPENSION 525

MG/15 ML
GP
Retail; OTC
ULTRA A-D TABLET 2 MG
GP
Antiemetics, Miscellaneous
GP
dronabinol capsule 10 mg, 2.5 mg, 5 mg
PA; Retail; QL (3 EA per 1 day(s)),

QL (6 EA per 1 day(s))
EMEND CAPSULES IN A DOSE PACK 125-80-80

MG
BP
PA; Retail
EMEND ORAL
BP
PA; Retail
EMETROL ORAL SOLUTION
GP
Retail; OTC
GAS-X CHEWABLE TABLET 80 MG
GP

day(s))
GAS-X EXTRA STRENGTH CHEWABLE TABLET

125 MG
GP

day(s))
INFANTS GAS RELIEF ORAL

GP

day(s))
INFANTS' MYLICON ORAL DROPS,SUSPENSION

40 MG/0.6 ML
GP

day(s))
Antiflatulents
53
Drug Name
Formulary
Tier
Tier
MAALOX ADVANCED CHEWABLE TABLET

1,000-60 MG
GP
Retail; OTC
MAALOX ADVANCED ORAL SUSPENSION

200-200-20 MG/5 ML
GP
Retail; OTC
MAALOX MAXIMUM STRENGTH ORAL

GP
Retail; OTC
MINTOX PLUS CHEWABLE TABLET 200-200-25

MG
BP
OTC
MYLANTA GAS CHEWABLE TABLET 125 MG
GP
Retail; OTC
RULOX ORAL SUSPENSION 200-200-20 MG/5 ML
GP
Retail; OTC
simethicone chewable tablet 125 mg, 80 mg
GP
Retail; OTC
simethicone oral drops,suspension 40 mg/0.6 ml
GP

day(s))
Antihistamines (Gi Drugs)

COMPRO RECTAL SUPPOSITORY 25 MG
GP
GP
dimenhydrinate tablet 50 mg
DRAMAMINE LESS DROWSY TABLET 25 MG
Retail
GP

Retail; OTC
meclizine chewable tablet 25 mg
GP
Retail; OTC
meclizine tablet 12.5 mg, 25 mg
GP
Retail; OTC
prochlorperazine rectal suppository 25 mg
GP
Retail
prochlorperazine maleate tablet 10 mg, 5 mg
GP
Retail
trimethobenzamide capsule 300 mg
GP
Retail
GP
QL (9 per 1 Day(s))
Anti-Inflammatory Agents (Gi Drugs)

balsalazide capsule 750 mg
DELZICOL CAPSULE,DELAYED RELEASE 400
MG
BP
GP
mesalamine enema 4 gram/60 ml

PENTASA CAPSULE,EXTENDED RELEASE 250
MG, 500 MG
QL (6 per 1 Day(s))
BP
Retail
Retail
Cathartics And Laxatives

bisacodyl rectal suppository 10 mg
GP
Retail; OTC
bisacodyl tablet,delayed release 5 mg
GP

day(s))
COLACE CAPSULE 100 MG, 50 MG
GP
Retail; OTC
DOCUPRENE TABLET 100 MG
GP
Retail; OTC
docusate calcium capsule 240 mg
GP
Retail; OTC
docusate sodium capsule 100 mg, 250 mg
GP
docusate sodium oral liquid 50 mg/5 ml
GP
Retail; OTC
docusate sodium syrup 60 mg/15 ml
GP
Retail; OTC
docusate sodium tablet 100 mg
GP
DULCOLAX STOOL SOFTENER (DOCUSATE)

CAPSULE 100 MG
GP
54
Drug Name
Formulary
Tier
Tier
FIBER THERAPY (PSYLLIUM SEED) ORAL

POWDER 3.4 GRAM/5.8 GRAM
GP
Retail; OTC
FIBER-LAX TABLET 625 MG
GP

day(s))
FLEET BISACODYL ENEMA 10 MG/30 ML
GP
Retail; OTC
FLEET ENEMA 19-7 GRAM/118 ML
GP
Retail; OTC
FLEET GLYCERIN (ADULT) RECTAL

SUPPOSITORY
GP
FLEET GLYCERIN (CHILD) RECTAL

SUPPOSITORY
GP
FLEET LAXATIVE TABLET,DELAYED RELEASE

5 MG
GP

day(s))
FLEET MINERAL OIL ENEMA
GP
Retail; OTC
FLEET PEDIATRIC ENEMA 9.5-3.5 GRAM/59 ML
GP
Retail; OTC
GAVILAX ORAL POWDER 17 GRAM/DOSE
GP
Retail; OTC
glycerin (adult) rectal suppository
GP
glycerin (child) rectal suppository
GP
GOLYTELY ORAL POWDER PACKET

227.1-21.5-6.36 GRAM
BP
Retail
HALFLYTELY-BISACODYL W-FLAVOR PACK

ORAL KIT 5-210 MG-GRAM
BP
Retail
KAOPECTATE (DOCUSATE CALCIUM)

CAPSULE 240 MG
GP
Retail; OTC
KONSYL ORAL POWDER
GP
Retail; OTC
KONSYL (SUGAR) ORAL POWDER
GP
Retail; OTC
KONSYL (WITH ASPARTAME) ORAL POWDER
GP
Retail; OTC
KONSYL (WITH ASPARTAME) ORAL POWDER

PACKET 3.5 GRAM
GP
Retail; OTC
LAXATIVE STOOL SOFTENER WITH SENNA

TABLET 8.6-50 MG
GP

GP
magnesium citrate oral solution
Retail; OTC
METAMUCIL FIBER SINGLES ORAL POWDER

PACKET 3.4 GRAM
GP
Retail; OTC
METAMUCIL SUGAR-FREE (ASPARTAME)

ORAL POWDER 3.3 GRAM/5.95 GRAM
GP
Retail; OTC
mineral oil enema
GP
Retail; OTC
mineral oil oral
GP
Retail; OTC
MINERAL OIL HEAVY ORAL
GP
Retail; OTC
MINERAL OIL LAXATIVE ORAL
GP
Retail; OTC
MIRALAX ORAL POWDER 17 GRAM/DOSE
BP
Retail; OTC
MOVIPREP ORAL POWDER PACKET 100-7.5-2.691

GRAM
BP
Retail
peg 3350-electrolytes oral solution 236-22.74-6.74 gram,

240-22.72-6.72 gram
GP
55
Retail
Drug Name
PERI-COLACE TABLET 8.6-50 MG
Formulary
Tier
Tier
GP

GP
polyethylene glycol 3350 oral powder 17 gram/dose
Retail; OTC
REGULOID ORAL POWDER
GP
Retail; OTC
SENEXON-S TABLET 8.6-50 MG
GP
SENNA SYRUP 176 MG/5 ML
GP
Retail; OTC
SENNA SYRUP 8.8 MG/5 ML
GP
Retail; OTC
SENNA TABLET 8.6 MG
GP

day(s))
SENNA LAX TABLET 8.6 MG
GP

day(s))
SENNA LAXATIVE TABLET 8.6 MG
GP

day(s))
SENNA-GEN TABLET 8.6 MG
GP

day(s))
GP
sennosides-docusate sodium tablet 8.6-50 mg
SENOKOT-S TABLET 8.6-50 MG
GP
SOF-LAX CAPSULE 100 MG
GP
Cholelitholytic Agents
ursodiol capsule 300 mg
GP
Retail
ursodiol tablet 250 mg, 500 mg
GP
Retail
Digestants
CREON CAPSULE,DELAYED RELEASE
12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000
UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000
-30,000 UNIT
BP
Retail,
PANCRELIPASE 5000 CAPSULE,DELAYED

RELEASE 5,000-17,000 -27,000 UNIT
GP
Retail
Emetics
GP
ipecac syrup

day(s))
Gi Drugs, Miscellaneous
CIMZIA SUBCUTANEOUS SYRINGE KIT 400
MG/2 ML (200 MG/ML X 2)
PA; Specialty
CIMZIA POWDER FOR RECONSTITUTION

SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)
PA; Specialty
CIMZIA STARTER KIT SUBCUTANEOUS

SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2)
PA; Specialty
LINZESS CAPSULE 145 MCG, 290 MCG
BP
PA
Histamine H2-Antagonists
cimetidine oral solution 300 mg/5 ml
GP
Retail
cimetidine tablet 200 mg, 300 mg, 400 mg, 800 mg
GP
Retail; OTC,; QL (4 EA per 1 day(s)),
famotidine tablet 20 mg, 40 mg
GP
Retail; OTC,
PEPCID AC TABLET 20 MG
GP
56
Retail; OTC
Drug Name
Formulary
Tier
Tier
ranitidine capsule 150 mg, 300 mg
GP
Retail
ranitidine syrup 15 mg/ml
GP
Retail
ranitidine tablet 150 mg, 300 mg, 75 mg
GP
Retail; OTC,
metoclopramide oral solution 5 mg/5 ml
GP
Retail
metoclopramide tablet 10 mg, 5 mg
GP
Retail
GP
Retail
Prokinetic Agents
Prostaglandins
misoprostol tablet 100 mcg, 200 mcg
Protectants
CARAFATE ORAL SUSPENSION 100 MG/ML
GP
Retail
GP
Retail
omeprazole capsule,delayed release 10 mg, 20 mg, 40 mg
GP

EA per 1 day(s))
omeprazole magnesium capsule,delayed release 20 mg
GP
GP

EA per 1 day(s))
sucralfate tablet 1 gram

Proton-Pump Inhibitors
OMEPRAZOLE+SYRSPEND SF ALKA ORAL

SUSPENSION 2 MG/ML
GP
pantoprazole tablet,delayed release 20 mg, 40 mg

Gold Compounds
Gold Compounds
RIDAURA CAPSULE 3 MG
BP
Retail
CHEMET CAPSULE 100 MG
BP
Retail
CUPRIMINE CAPSULE 250 MG
BP
Retail
Heavy Metal Antagonists

Heavy Metal Antagonists
EXJADE
PA; Specialty
Hormones And Synthetic Substitutes

Adrenals
A-METHAPRED SOLUTION FOR INJECTION 125
MG/2 ML, 40 MG/ML
BP
Retail
BAYCADRON ORAL ELIXIR 0.5 MG/5 ML
GP
Retail
budesonide suspension for nebulization 0.25 mg/2 ml, 0.5

mg/2 ml
GP

(Min 1 Years and Max 8 Years)
cortisone tablet 25 mg
GP
Retail
DEPO-MEDROL INJ
BP
Retail
dexamethasone oral elixir 0.5 mg/5 ml
GP
Retail
dexamethasone oral solution 0.5 mg/5 ml
GP
Retail
dexamethasone tablet
GP
Retail
DEXAMETHASONE INTENSOL DROPS

(CONCENTRATE) 1 MG/ML
GP
Retail
GP
dexamethasone injection solution 4 mg/ml

57
Drug Name
Formulary
Tier
Tier
DEXPAK 13 DAY TABLETS IN A DOSE PACK 1.5

MG (51 TABS)
BP
Retail
DEXPAK 6 DAY TABLETS IN A DOSE PACK 1.5

MG (21 TABS)
BP
Retail

BP
FLOVENT DISKUS
BP
FLOVENT HFA AEROSOL INHALER 110

MCG/ACTUATION, 220 MCG/ACTUATION, 44
MCG/ACTUATION
BP
Retail; QL (12 GM per 20 day(s)), QL

(10.6 GM per 20 day(s))
fludrocortisone tablet 0.1 mg
GP
Retail
hydrocortisone oral
GP
Retail
MEDROL TABLET 2 MG
BP
Retail
methylprednisolone tablet
GP
Retail
methylprednisolone tablets in a dose pack 4 mg
GP
Retail
methylprednisolone acetate suspension for injection 40

mg/ml, 80 mg/ml
GP
Retail
methylprednisolone sodium succ intravenous solution

1,000 mg
GP
Retail
methylprednisolone sodium succ solution for injection 125

mg, 40 mg
GP
Retail
MILLIPRED TABLET 5 MG
BP
Retail
MILLIPRED DP TABLETS IN A DOSE PACK 5 MG

(21 TABS), 5 MG (48 TABS)
BP
Retail
prednisolone oral solution 15 mg/5 ml
GP
Retail
prednisolone sodium phosphate oral solution 15 mg/5 ml, 5

mg base/5 ml (6.7 mg/5 ml)
GP
Retail
prednisone oral solution 5 mg/5 ml
GP
Retail
prednisone tablet
GP
Retail
prednisone tablets in a dose pack 10 mg, 5 mg
GP
Retail
PREDNISONE INTENSOL ORAL CONCENTRATE

5 MG/ML
GP
Retail
PULMICORT SUSPENSION FOR NEBULIZATION

1 MG/2 ML
BP
Retail; Age (Min 1 Years and Max 8

Years)
PULMICORT FLEXHALER BREATH ACTIVATED

180 MCG/ACTUATION, 90 MCG/ACTUATION
BP
QVAR METERED AEROSOL ORAL INHALER 40

MCG/ACTUATION, 80 MCG/ACTUATION
BP

BP
Alpha-Glucosidase Inhibitors
GP
acarbose
Androgens
58
Retail
Drug Name
Formulary
Tier
Tier
ANDROGEL TRANSDERMAL GEL PACKET 1 %

(25 MG/2.5 G), 1 %(50 MG/5 GRAM), 1.62 % (20.25
MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)
BP
Retail,; QL (150 GM per 26 Day(s)),

QL (150 GM per 26 day(s)), QL (150
per 26 Day(s))
ANDROGEL TRANSDERMAL GEL PUMP 1.25

GRAM/ ACTUATION (1 %), 20.25 MG/1.25 GRAM
(1.62 %)
BP
Retail; QL (150 GM per 26 day(s)),

QL (150 GM per 26 Day(s))
GP
oxandrolone tablet 10 mg, 2.5 mg

TESTRED CAPSULE 10 MG
BP
PA; Retail
Retail
Antithyroid Agents
methimazole tablet 10 mg, 5 mg
GP
Retail
propylthiouracil tablet 50 mg
GP
Retail
SSKI ORAL SOLUTION 1 GRAM/ML
GP
Retail
Biguanides
glyburide-metformin
GP
Retail
metformin er tablet,extended release 24 hr 500 mg, 750

mg
GP

EA per 1 day(s))
metformin tablet 1,000 mg, 500 mg, 850 mg
GP

day(s))
pioglitazone-metformin tablet 15-500 mg, 15-850 mg
GP
Contraceptives
APRI TABLET 0.15-30 MG-MCG
GP
ARANELLE (28) TABLET 0.5/1/0.5-35 MG-MCG
GP
AVIANE TABLET 0.1-20 MG-MCG
GP
AZURETTE (28) TABLET 0.15-0.02MG X21 /0.01

MG X 5
GP
BALZIVA (28) TABLET 0.4-35 MG-MCG
GP
CAMILA TABLET 0.35 MG
GP
CAZIANT (28) TABLET 0.1/.125/.15-25 MG-MCG
GP
CRYSELLE (28) TABLET 0.3-30 MG-MCG
GP
CYCLAFEM 1/35 (28) TABLET 1-35 MG-MCG
GP
CYCLAFEM 7/7/7 (28) TABLET 0.5/0.75/1 MG- 35

MCG
GP
ENPRESSE TABLET 50-30 (6)/75-40 (5)/125-30(10)
GP
ERRIN TABLET 0.35 MG
GP
FEMCON FE CHEWABLE TABLET

0.4MG-35MCG(21) & 75 MG (7)
GP
GIANVI TABLET 3-20 MG-MCG
GP
GILDESS FE TABLET 1-20 MG-MCG, 1.5-30

MG-MCG
GP
HEATHER TABLET 0.35 MG
GP
JOLIVETTE TABLET 0.35 MG
GP
JUNEL 1.5/30 (21) TABLET 1.5-30 MG-MCG
GP
59
Drug Name
Formulary
Tier
Tier
JUNEL 1/20 (21) TABLET 1-20 MG-MCG
GP
JUNEL FE 1.5/30 (28) TABLET 1.5-30 MG-MCG
GP
JUNEL FE 1/20 (28) TABLET 1-20 MG-MCG
GP
KARIVA (28) TABLET 0.15-0.02MG X21 /0.01 MG X

5
GP
KELNOR 1/35 (28) TABLET 1-35 MG-MCG
GP
LEENA 28 TABLET 0.5/1/0.5-35 MG-MCG
GP
LESSINA TABLET 0.1-20 MG-MCG
GP
LEVORA-28 TABLET 0.15-30 MG-MCG
GP
LOW-OGESTREL (28) TABLET 0.3-30 MG-MCG
GP
LUTERA (28) TABLET 0.1-20 MG-MCG
GP
MICROGESTIN 1.5/30 (21) TABLET 1.5-30

MG-MCG
GP
MICROGESTIN 1/20 (21) TABLET 1-20 MG-MCG
GP
MICROGESTIN FE 1.5/30 (28) TABLET 1.5-30

MG-MCG
GP
MICROGESTIN FE 1/20 (28) TABLET 1-20

MG-MCG
GP
MONONESSA (28) TABLET 0.25-35 MG-MCG
GP
NECON 0.5/35 (28) TABLET 0.5-35 MG-MCG
GP
NECON 1/35 (28) TABLET 1-35 MG-MCG
GP
NECON 1/50 (28) TABLET 1-50 MG-MCG
GP
NECON 10/11 (28) TABLET 0.5-35/1-35

MG-MCG/MG-MCG
GP
NECON 7/7/7 (28) TABLET 0.5/0.75/1 MG- 35 MCG
GP
NORA-BE TABLET 0.35 MG
GP

GP
norethindrone (contraceptive) tablet 0.35 mg
NORTREL 0.5/35 (28) TABLET 0.5-35 MG-MCG
GP
NORTREL 1/35 (21) TABLET 1-35 MG-MCG
GP
NORTREL 1/35 (28) TABLET 1-35 MG-MCG
GP
NORTREL 7/7/7 (28) TABLET 0.5/0.75/1 MG- 35

MCG
GP
NUVARING VAGINAL 0.12-0.015 MG/24 HR
BP
OCELLA TABLET 3-0.03 MG
GP
OGESTREL (28) TABLET 0.5-50 MG-MCG
GP
ORTHO EVRA TRANSDERMAL PATCH 150-20

MCG/24 HR
BP
Retail
PLAN B ONE-STEP TABLET 1.5 MG
BP
Retail; OTC
PORTIA TABLET 0.15-30 MG-MCG
GP
PREVIFEM TABLET 0.25-35 MG-MCG
GP
RECLIPSEN (28) TABLET 0.15-30 MG-MCG
GP
SPRINTEC (28) TABLET 0.25-35 MG-MCG
GP
60
Drug Name
Formulary
Tier
Tier
SRONYX TABLET 0.1-20 MG-MCG
GP
TILIA FE TABLET 1-20(5)/1-30(7) /1MG-35MCG (9)
GP
TRI-LEGEST FE TABLET 1-20(5)/1-30(7)

/1MG-35MCG (9)
GP
TRI-PREVIFEM (28) TABLET 0.18/0.215/0.25 MG-35

MCG (28)
GP
TRI-SPRINTEC (28) TABLET 0.18/0.215/0.25 MG-35

MCG (28)
GP
TRINESSA (28) TABLET 0.18/0.215/0.25 MG-35

MCG (28)
GP
TRIVORA (28) TABLET 50-30 (6)/75-40 (5)/125-30(10)
GP
VELIVET TRIPHASIC REGIMEN (28) TABLET

0.1/.125/.15-25 MG-MCG
GP
ZARAH TABLET 3-0.03 MG
GP
ZENCHENT (28) TABLET 0.4-35 MG-MCG
GP
ZOVIA 1/35E (28) TABLET 1-35 MG-MCG
GP
ZOVIA 1/50E (28) TABLET 1-50 MG-MCG
GP
BP
GP
Retail
Estrogen Agonist-Antagonists
EVISTA TABLET 60 MG
Estrogens
ESTRACE TABLET 0.5 MG
estradiol tablet
GP
Retail
estradiol weekly transdermal patch
GP
Retail
estropipate tablet
GP
Retail
MENEST
GP
Retail
PREMARIN TABLET
GP
Retail
PREMARIN VAGINAL CREAM 0.625 MG/GRAM
GP
Retail
PREMPHASE TABLET 0.625 MG (14)/

0.625MG-5MG(14)
GP
Retail
PREMPRO
GP
Retail
VIVELLE-DOT TRANSDERMAL PATCH
GP
Retail
GLUCAGEN SOLUTION FOR INJECTION 1 MG
GP
Retail
GLUCAGEN HYPOKIT INJECTION 1 MG
GP
GLUCAGON EMERGENCY INJECTION KIT 1

MG
GP
BP
PA; Retail
BP
Glycogenolytic Agents
Incretin Mimetics
BYETTA SUBCUTANEOUS PEN INJECTOR 10
MCG/0.04 ML, 5 MCG/0.02 ML
Insulins
APIDRA SUBCUTANEOUS SOLUTION 100
UNIT/ML
61
Drug Name
Formulary
Tier
Tier
APIDRA SOLOSTAR SUBCUTANEOUS INSULIN

PEN 100 UNIT/ML
BP
HUMALOG SUBCUTANEOUS CARTRIDGE 100

UNIT/ML
BP
HUMALOG SUBCUTANEOUS SOLUTION 100

UNIT/ML
BP
HUMALOG KWIKPEN SUBCUTANEOUS 100

UNIT/ML
BP
HUMALOG MIX 50-50 SUBCUTANEOUS

SUSPENSION 100 UNIT/ML (50-50)
BP
HUMALOG MIX 50-50 KWIKPEN

SUBCUTANEOUS 100 UNIT/ML (50-50)
BP
HUMALOG MIX 75-25 SUBCUTANEOUS

BP

BP
HUMULIN 70/30 SUBCUTANEOUS SUSPENSION

100 UNIT/ML (70-30)
BP

day(s))
HUMULIN 70/30 PEN SUBCUTANEOUS 100

UNIT/ML (70-30)
BP

day(s))
HUMULIN N SUBCUTANEOUS SUSPENSION 100

UNIT/ML
BP

day(s))
HUMULIN N PEN SUBCUTANEOUS 100

UNIT/ML (3 ML)
BP

day(s))
HUMULIN R INJECTION SOLUTION 100

UNIT/ML
BP

day(s))
LANTUS SUBCUTANEOUS SOLUTION 100

UNIT/ML
BP
LANTUS SOLOSTAR SUBCUTANEOUS INSULIN

PEN 100 UNIT/ML (3 ML)
BP
LEVEMIR SUBCUTANEOUS SOLUTION 100

UNIT/ML
BP
LEVEMIR FLEXPEN SOLUTION

SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3
ML)
BP
NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION

100 UNIT/ML (70-30)
BP

day(s))
NOVOLIN N SUBCUTANEOUS SUSPENSION 100

UNIT/ML
BP

day(s))
NOVOLIN R INJECTION SOLUTION 100

UNIT/ML
BP

day(s))
NOVOLOG SUBCUTANEOUS SOLUTION 100

UNIT/ML
BP
NOVOLOG FLEXPEN SUBCUTANEOUS 100

UNIT/ML
BP
NOVOLOG MIX 70-30 SUBCUTANEOUS

SOLUTION 100 UNIT/ML (70-30)
BP
62
Drug Name
Formulary
Tier
Tier
NOVOLOG MIX 70-30 FLEXPEN

BP
NOVOLOG PENFILL SUBCUTANEOUS

CARTRIDGE 100 UNIT/ML
BP
Meglitinides
GP
nateglinide tablet 120 mg, 60 mg

PRANDIN TABLET 0.5 MG, 1 MG, 2 MG

EA per 1 day(s))
BP
Parathyroid
GP
calcitonin (salmon) nasal spray 200 unit/actuation
Retail
Pituitary
DDAVP NASAL SOLUTION 0.1 MG/ML (REFRIG)
BP
Retail
desmopressin nasal solution 0.1 mg/ml (refrig)
GP
desmopressin nasal spray 10 mcg/spray (0.1 ml)
GP
GP
Retail
NORDITROPIN FLEXPRO
PA; Specialty
NORDITROPIN NORDIFLEX SUBCUTANEOUS

PEN INJECTOR 30 MG/3 ML (10 MG/ML)
PA; Specialty
STIMATE NASAL SPRAY 150 MCG/SPRAY
BP
Age (Max 20 Years)
BP
Progestins
AYGESTIN TABLET 5 MG
medroxyprogesterone intramuscular suspension 150 mg/ml
GP
medroxyprogesterone intramuscular syringe 150 mg/ml
GP
medroxyprogesterone oral
GP
Retail
norethindrone acetate tablet 5 mg
GP
PROMETRIUM CAPSULE 100 MG, 200 MG
BP
Retail
Sulfonylureas
chlorpropamide tablet 100 mg, 250 mg
GP
Retail
glimepiride
GP
Retail
glipizide er tablet, extended release 24 hr
GP
Retail
glipizide tablet 10 mg, 5 mg
GP
Retail
glyburide tablet
GP
Retail
glyburide micronized tablet
GP
Retail
glyburide-metformin
GP
Retail
pioglitazone-glimepiride tablet 30-2 mg, 30-4 mg
GP
QL (1 per 1 Day(s))
tolazamide tablet 250 mg, 500 mg
GP
Retail
tolbutamide tablet 500 mg
GP
Retail
pioglitazone
GP
pioglitazone-glimepiride tablet 30-2 mg, 30-4 mg
GP
QL (1 per 1 Day(s))
pioglitazone-metformin tablet 15-500 mg, 15-850 mg
GP
Thiazolidinediones
63
Drug Name
Formulary
Tier
Tier
BP
Retail
Thyroid Agents
ARMOUR THYROID
levothyroxine tablet
GP
Retail
liothyronine oral
GP
Retail
NP THYROID
BP
Retail
Miscellaneous Therapeutic Agents

5-Alpha-Reductase Inhibitors
GP
finasteride tablet 5 mg
Retail
Alcohol Deterrents
GP
disulfiram tablet 250 mg, 500 mg

Antidotes
leucovorin calcium oral
GP
Retail
GP
Retail
Antigout Agents
allopurinol tablet 100 mg, 300 mg
COLCRYS TABLET 0.6 MG
BP
Retail
Bone Resorption Inhibitors

GP
alendronate tablet 10 mg, 35 mg, 40 mg, 5 mg, 70 mg

EA per 28 day(s))
Cariostatic Agents
FLUOR-A-DAY (WITH XYLITOL)
GP
Retail
MULTI-VITAMIN WITH FLUORIDE
GP
Retail
GP
pediatric multivitamin-fl oral drops 0.25 mg/ml, 0.5 mg/ml
Retail
PHOS-FLUR DENTAL SOLUTION 0.02 %

FLUORIDE (0.044 %)
GP
Retail; OTC
PREVIDENT GEL 1.1 %
GP
Retail
sodium fluoride chewable tablet
GP
Retail
sodium fluoride dental solution 0.2 %
GP
Retail
sodium fluoride oral drops 0.5 mg fluoride (1.1 mg)/ml
GP
Retail
sodium fluoride tablet 1 mg fluoride (2.2 mg)
GP
Retail
stannous fluoride dental solution 0.63 %
GP
Retail; QL (122 GM Max Qty Per Fill

Retail)
Complement Inhibitors
SOLIRIS INTRAVENOUS SOLUTION 300 MG/30
ML
PA; Specialty
CIMZIA SUBCUTANEOUS SYRINGE KIT 400

MG/2 ML (200 MG/ML X 2)
PA; Specialty
CIMZIA POWDER FOR RECONSTITUTION

SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)
PA; Specialty
CIMZIA STARTER KIT SUBCUTANEOUS

SYRINGE KIT 400 MG/2 ML (200 MG/ML X 2)
PA; Specialty
ENBREL SUBCUTANEOUS KIT 25 MG (1 ML)
PA; Specialty
Disease-Modifying Antirheumatic Agents
64
Drug Name
Formulary
Tier
Tier
ENBREL SUBCUTANEOUS SYRINGE 25

MG/0.5ML (0.51), 50 MG/ML (0.98 ML)
PA; Specialty
ENBREL SURECLICK SUBCUTANEOUS PEN

INJECTOR 50 MG/ML (0.98 ML)
PA; Specialty
HUMIRA SUBCUTANEOUS KIT 20 MG/0.4 ML, 40

MG/0.8 ML
PA; Specialty
HUMIRA CROHN'S DISEASE STARTER PACK

SUBCUTANEOUS PEN KIT 40 MG/0.8 ML
PA; Specialty
HUMIRA PEN SUBCUTANEOUS KIT 40 MG/0.8

ML
PA; Specialty
HUMIRA PSORIASIS STARTER PACK

SUBCUTANEOUS PEN KIT 40 MG/0.8 ML
PA; Specialty
leflunomide tablet 10 mg, 20 mg
GP
Retail
GP
Retail
GP
Retail
GP
Retail
Immunomodulatory Agents
AUBAGIO TABLET 14 MG, 7 MG
PA; Specialty
AVONEX INTRAMUSCULAR KIT 30 MCG
PA; Specialty
AVONEX INTRAMUSCULAR PEN INJECTOR 30

MCG/0.5 ML
PA
AVONEX INTRAMUSCULAR PEN KIT 30

MCG/0.5 ML
PA
AVONEX INTRAMUSCULAR SYRINGE 30

MCG/0.5 ML
PA
AVONEX ADMINISTRATION PACK

INTRAMUSCULAR KIT 30 MCG/0.5 ML
PA; Specialty
COPAXONE SUBCUTANEOUS SYRINGE KIT 20

MG/ML
PA; Specialty
GP
Retail
GP
Retail
GP
Retail
azathioprine tablet 50 mg
GP
Retail
cyclosporine capsule 100 mg, 25 mg
GP
Retail
cyclosporine modified
GP
Retail
cyclosporine modified oral solution 100 mg/ml
GP
Retail
Immunosuppressive Agents
GENGRAF CAPSULE 100 MG, 25 MG
BP
Retail
GENGRAF ORAL SOLUTION 100 MG/ML
BP
Retail
GP
Retail
GP
Retail
GP
Retail
mycophenolate mofetil capsule 250 mg
GP
Retail
65
Drug Name
Formulary
Tier
Tier
GP
mycophenolate mofetil tablet 500 mg
Retail
MYFORTIC TABLET,DELAYED RELEASE 180

MG, 360 MG
BP
Retail; , QL (120 EA per 26 day(s))
PROGRAF ORAL
BP
Retail
RAPAMUNE ORAL SOLUTION 1 MG/ML
BP
Retail
RAPAMUNE TABLET 1 MG, 2 MG
BP
Retail
SANDIMMUNE ORAL SOLUTION 100 MG/ML
BP
Retail
tacrolimus capsule
GP
Retail
GP
Retail
Other Miscellaneous Therapeutic Agents

acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20
%)
AMPYRA TABLET,EXTENDED RELEASE 10 MG
PA; Specialty
BOTOX INJECTION 100 UNIT, 200 UNIT
PA; Specialty
ELMIRON CAPSULE 100 MG
BP
MYOBLOC
PA; Specialty
NPLATE SUBCUTANEOUS SOLUTION 250 MCG,

500 MCG
PA; Specialty
OCUVITE CAPSULE 150-30-6-150

MG-UNIT-MG-MG
GP
Retail; OTC
REPHRESH VAGINAL GEL
BP
Retail; OTC
REPLENS VAGINAL GEL
BP
Retail; OTC
ORA-BLEND ORAL SUSPENSION
GP
Retail; OTC
ORA-PLUS ORAL SUSPENSION
GP
Retail; OTC
ORA-SWEET ORAL LIQUID
GP
Retail; OTC
Pharmaceutical Aids
Pharmaceutical Aids
GP
water for injection, sterile intravenous solution
Retail
Respiratory Tract Agents

Alpha And Beta Adrenergic Agonist(Respr)
GP
QL (2 per 1 Day(s))
GP

day(s))
GP

day(s))
AUVI-Q INJECTION,AUTO-INJECTOR 0.15

MG/0.15 ML (1:1,000), 0.3 MG/0.3 ML (1:1,000)
BP
GP
Retail
GP
Retail; OTC
CHILDREN'S SUDAFED ORAL LIQUID 15 MG/5

ML
GP
Retail; OTC
GP
Retail; OTC
GP
Retail; OTC
66
Drug Name
Formulary
Tier
Tier
EPIPEN 2-PAK INJECTION,AUTO-INJECTOR 0.3

MG/0.3 ML (1:1,000)
BP
EPIPEN JR 2-PAK INJECTION,AUTO-INJECTOR

0.15 MG/0.3 ML (1:2,000)
BP
GP
Retail; OTC
GP
Retail; OTC

60-600 MG
BP
Retail; OTC

BP
OTC
GP

day(s))
GP
Retail; OTC
GP

day(s))
GP

day(s))
GP

day(s))
ATROVENT HFA AEROSOL INHALER 17

MCG/ACTUATION
BP
Retail

BP

(Min 18 Years)
Anticholinergic Agents (Respir.Tract)
GP
Retail
GP
Retail
ipratropium bromide solution for inhalation 0.02 %
GP
Retail
TUDORZA PRESSAIR BREATH ACTIVATED 400

MCG/ACTUATION
BP
PA; Retail; Age (Min 18 Years)
Antitussives
GP
benzonatate capsule 100 mg, 200 mg
Retail
BIOCOTRON ORAL LIQUID 10-100 MG/5 ML
GP
Retail; OTC
GP
Retail
BRONCOTRON ORAL LIQUID 10-100 MG/5 ML
GP

day(s))
GP
Retail; OTC
CHERACOL D ORAL LIQUID 10-100 MG/5 ML
GP

day(s))
CHERATUSSIN AC ORAL LIQUID 10-100 MG/5

ML
GP
Retail; OTC
codeine-guaifenesin oral liquid 10-100 mg/5 ml
GP
Retail; OTC
dextromethorphan-guaifenesin syrup 10-100 mg/5 ml
GP

day(s))
DIABETIC TUSSIN DM ORAL LIQUID 10-100

MG/5 ML
GP
67

day(s))
Drug Name
Formulary
Tier
Tier
EXPECTORANT DM SYRUP 10-100 MG/5 ML
GP
Retail; OTC
GUAIATUSSIN AC ORAL LIQUID 10-100 MG/5

ML
GP
Retail; OTC
MUCINEX DM TABLET,EXTENDED RELEASE

60-1,200 MG
BP
Retail; OTC; QL (2 EA per 1 Day(s))
MUCINEX DM TABLET,EXTENDED RELEASE 12

HR 30-600 MG
BP

MG/5 ML
GP
promethazine-codeine syrup 6.25-10 mg/5 ml
GP
promethazine-dm syrup 6.25-15 mg/5 ml
GP
GP
Retail; OTC
Q-TUSSIN DM SYRUP 10-100 MG/5 ML
GP

day(s))
RI-TUSSIN DM SYRUP 10-100 MG/5 ML
GP

day(s))
ROBAFEN DM SYRUP 10-100 MG/5 ML
GP

day(s))
ROBITUSSIN PEDIATRIC SYRUP 7.5 MG/5 ML
GP
Retail; OTC
SILTUSSIN DM DAS ORAL LIQUID 10-100 MG/5

ML
GP

day(s))
SILTUSSIN-DM SYRUP 10-100 MG/5 ML
GP

day(s))
TUSNEL DIABETIC ORAL LIQUID 10-100 MG/5

ML
GP

day(s))
TUSSIGON TABLET 5-1.5 MG
BP
Retail
ULTRA DM FREE & CLEAR ORAL LIQUID 10-100

MG/5 ML
GP
Retail; OTC
GP

day(s))
BIOCOTRON ORAL LIQUID 10-100 MG/5 ML
GP
Retail; OTC
BRONCOTRON ORAL LIQUID 10-100 MG/5 ML
GP

day(s))
CHERACOL D ORAL LIQUID 10-100 MG/5 ML
GP

day(s))
CHERATUSSIN AC ORAL LIQUID 10-100 MG/5

ML
GP
Retail; OTC
CHILDREN'S MUCINEX ORAL LIQUID 100 MG/5

ML
BP

day(s))
Expectorants
GP
codeine-guaifenesin oral liquid 10-100 mg/5 ml
Retail; OTC
GP
Retail; OTC
GP
Retail; OTC
GP
dextromethorphan-guaifenesin syrup 10-100 mg/5 ml

68

day(s))
Drug Name
Formulary
Tier
Tier
DIABETIC TUSSIN DM ORAL LIQUID 10-100

MG/5 ML
GP

day(s))
DIABETIC TUSSIN EX ORAL LIQUID 100 MG/5

ML
GP

day(s))
GP
Retail; OTC
EXPECTORANT TABLET 200 MG
GP
Retail; OTC
EXPECTORANT DM SYRUP 10-100 MG/5 ML
GP
Retail; OTC
GUAIATUSSIN AC ORAL LIQUID 10-100 MG/5

ML
GP
Retail; OTC
guaifenesin oral liquid 100 mg/5 ml
GP

day(s))
guaifenesin tablet 200 mg
GP
Retail; OTC
MUCINEX TABLET,EXTENDED RELEASE 600

MG
BP
Retail; OTC
MUCINEX TABLET,EXTENDED RELEASE 12 HR

1,200 MG
BP
OTC

60-600 MG
BP
Retail; OTC

BP
OTC
MUCINEX DM TABLET,EXTENDED RELEASE

60-1,200 MG
BP
Retail; OTC; QL (2 EA per 1 Day(s))
MUCINEX DM TABLET,EXTENDED RELEASE 12

HR 30-600 MG
BP
ORGAN-I NR TABLET 200 MG
GP
Retail; OTC
Q-TUSSIN ORAL LIQUID 100 MG/5 ML
GP

day(s))
Q-TUSSIN DM SYRUP 10-100 MG/5 ML
GP

day(s))
REFENESEN TABLET 200 MG
GP
Retail; OTC
RI-TUSSIN ORAL LIQUID 100 MG/5 ML
GP

day(s))
RI-TUSSIN DM SYRUP 10-100 MG/5 ML
GP

day(s))
ROBAFEN ORAL LIQUID 100 MG/5 ML
GP

day(s))
ROBAFEN DM SYRUP 10-100 MG/5 ML
GP

day(s))
SCOT-TUSSIN EXPECTORANT ORAL LIQUID 100

MG/5 ML
GP

day(s))
SILTUSSIN DM DAS ORAL LIQUID 10-100 MG/5

ML
GP

day(s))
SILTUSSIN SA ORAL LIQUID 100 MG/5 ML
GP

day(s))
SILTUSSIN-DM SYRUP 10-100 MG/5 ML
GP

day(s))
69
Drug Name
Formulary
Tier
Tier
SSKI ORAL SOLUTION 1 GRAM/ML
GP
Retail
TUSNEL DIABETIC ORAL LIQUID 10-100 MG/5

ML
GP

day(s))
ULTRA DM FREE & CLEAR ORAL LIQUID 10-100

MG/5 ML
GP
Retail; OTC
GP

day(s))
GP

day(s))
ALLERGY (CHLORPHENIRAMINE) TABLET 4

MG
GP

day(s))
GP

day(s))
GP

day(s))
BENADRYL ALLERGY TABLET 25 MG
BP

day(s))
GP
Retail
GP
Retail; OTC
GP

day(s))
First Generation Antihist.(Respir Tract)
chlorpheniramine tablet 4 mg
GP

day(s))
clemastine tablet 1.34 mg
GP
cyproheptadine syrup 2 mg/5 ml
GP
Retail
cyproheptadine tablet 4 mg
GP
Retail
GP

day(s))
diphenhydramine injection solution 50 mg/ml
GP
Retail
GP

day(s))
GP

day(s))
GP

day(s))
GP

day(s))
GP

day(s))
GP
Retail; OTC
NYTOL TABLET 25 MG
GP

day(s))
GP
promethazine tablet
GP
70
Drug Name
Formulary
Tier
Tier
GP

MG/5 ML
GP
promethazine-codeine syrup 6.25-10 mg/5 ml
GP
GP
GP
Retail; OTC
GP

day(s))
GP

day(s))
GP

day(s))

MG
GP
Retail; OTC
GP

day(s))
GP

day(s))
Leukotriene Modifiers
montelukast chewable tablet 4 mg, 5 mg
GP
montelukast oral granules in packet 4 mg
GP
montelukast tablet 10 mg
GP
zafirlukast tablet 10 mg, 20 mg
GP
Retail
Mast-Cell Stabilizers
ALOCRIL EYE DROPS 2 %
BP
cromolyn eye drops 4 %
GP
GP

day(s))
cromolyn solution for nebulization 20 mg/2 ml
GP
Retail
GP
Retail
fluticasone nasal spray,suspension 50 mcg/actuation
GP
triamcinolone acetonide nasal spray aerosol 55 mcg
GP
Retail
GP

(Min 1 Years and Max 8 Years)
Mucolytic Agents
acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20
%)
Nasal Preparations (Steroids)
Orally Inhaled Preparations (Steroids)

budesonide suspension for nebulization 0.25 mg/2 ml, 0.5
mg/2 ml
BP
FLOVENT DISKUS
BP
FLOVENT HFA AEROSOL INHALER 110

MCG/ACTUATION, 220 MCG/ACTUATION, 44
MCG/ACTUATION
BP
Retail; QL (12 GM per 20 day(s)), QL

(10.6 GM per 20 day(s))
71
Drug Name
Formulary
Tier
Tier
PULMICORT SUSPENSION FOR NEBULIZATION

1 MG/2 ML
BP
Retail; Age (Min 1 Years and Max 8

Years)
PULMICORT FLEXHALER BREATH ACTIVATED

180 MCG/ACTUATION, 90 MCG/ACTUATION
BP
QVAR METERED AEROSOL ORAL INHALER 40

MCG/ACTUATION, 80 MCG/ACTUATION
BP

BP
Respiratory Tract Agents, Miscellaneous

XOLAIR SUBCUTANEOUS SOLUTION 150 MG
PA; Specialty
Second Generation Antihist(Respir Tract)

ALL DAY ALLERGY (CETIRIZINE) CHEWABLE
TABLET 10 MG, 5 MG
GP
ALL DAY ALLERGY (CETIRIZINE) ORAL SOLN

1 MG/ML
GP
ALL DAY ALLERGY (CETIRIZINE) TABLET 10

MG
GP
GP
cetirizine oral solution 1 mg/ml
GP
cetirizine tablet 10 mg, 5 mg
GP
CHILDREN'S ALLER-TEC ORAL SOLN 1 MG/ML
GP
Retail; OTC
fexofenadine tablet 180 mg
GP
levocetirizine tablet 5 mg
GP
loratadine oral solution 5 mg/5 ml
GP
loratadine tablet 10 mg
GP
NON-DROWSY ALLERGY TABLET 10 MG
GP
OTC
Select.Beta-2-Adrenergic Agonist(Respir)
albuterol sulfate er tablet,extended release,12 hr 4 mg, 8
mg
GP
Retail
albuterol sulfate solution for nebulization 0.63 mg/3 ml,

1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml, 5
mg/ml
GP
Retail
albuterol sulfate syrup 2 mg/5 ml
GP
Retail
albuterol sulfate tablet 2 mg, 4 mg
GP
Retail

BP

(Min 18 Years)

BP
GP
metaproterenol syrup 10 mg/5 ml
GP
Retail
GP
Retail

INHALATION 50 MCG/DOSE
BP
72
Drug Name
Formulary
Tier
BP

GP
terbutaline tablet 2.5 mg, 5 mg

VENTOLIN HFA AEROSOL INHALER 90
MCG/ACTUATION
Tier
Retail
GP
BP
Retail
LUFYLLIN TABLET 200 MG, 400 MG
BP
Retail
BP
Retail
Xanthine Derivatives
GP
Retail
GP
Retail
Serums, Toxoids, And Vaccines

Serums
HYPERRHO S/D INTRAMUSCULAR SYRINGE
1,500 UNIT (300 MCG)
BP
Retail
Vaccines
AFLURIA 2013-2014 INTRAMUSCULAR
SUSPENSION 45 MCG (15 MCG X 3)/0.5 ML
BP
AFLURIA 2013-2014 (PF) INTRAMUSCULAR

SYRINGE 45 MCG (15 MCG X 3)/0.5 ML
BP
FLUZONE 2013-2014 INTRAMUSCULAR

BP
FLUZONE 2013-2014 (PF) INTRAMUSCULAR

BP
FLUZONE 2013-2014 (PF) INTRAMUSCULAR

SYRINGE 45 MCG (15 MCG X 3)/0.5 ML
BP
FLUZONE HIGH-DOSE 2013-2014 (PF)

INTRAMUSCULAR SYRINGE 180 MCG/0.5 ML
BP
Age (Min 65 Years)
FLUZONE INTRADERM 2013-14 (PF)

INTRADERMAL SYRINGE 27 MCG/0.1 ML
BP
Age (Min 18 Years and Max 64 Years)
BP
Retail; OTC
Skin And Mucous Membrane Agents

Allylamines (Skin & Mucous Membrane)
LAMISIL AT TOPICAL CREAM 1 %
GP
Retail; OTC
bacitracin topical ointment 500 unit/gram
GP

day(s))
bacitracin-polymyxin b topical ointment 500-10,000

unit/gram
GP

day(s))
terbinafine topical cream 1 %

Antibacterials (Skin & Mucous Membrane)
BACTROBAN TOPICAL CREAM 2 %
BP
Retail
BENZAMYCINPAK TOPICAL GEL 3-5 %
BP
Retail
clindamycin lotion 1 %
GP
Retail
clindamycin phosphate topical swab 1 %
GP
Retail
73
Drug Name
Formulary
Tier
Tier
clindamycin topical gel 1 %
GP
Retail
clindamycin topical solution 1 %
GP
Retail
clindamycin vaginal cream 2 %
GP
Retail
clindamycin-benzoyl peroxide topical gel 1-5 %
GP
Retail
ERY PADS TOPICAL SWAB 2 %
BP
Retail
erythromycin with ethanol topical gel 2 %
GP
Retail
erythromycin with ethanol topical solution 2 %
GP
Retail
erythromycin with ethanol topical swab 2 %
GP
Retail
erythromycin-benzoyl peroxide topical gel 3-5 %
GP
Retail
gentamicin topical cream 0.1 %
GP
Retail
gentamicin topical ointment 0.1 %
GP
Retail
METROGEL VAGINAL 0.75 %
BP
Retail
metronidazole topical cream 0.75 %
GP
metronidazole topical gel 0.75 %
GP
metronidazole vaginal gel 0.75 %
GP
Retail
mupirocin topical ointment 2 %
GP
Retail
TRIPLE ANTIBIOTIC TOPICAL OINTMENT

3.5-400-5,000 MG-UNIT-UNIT/G
GP

day(s))
TRIPLE ANTIBIOTIC PLUS TOPICAL OINTMENT

3.5-500-10,000 MG-UNIT-UNIT/G
GP

day(s))
VANDAZOLE VAGINAL GEL 0.75 %
GP
Retail
Anti-Inflammatory Agents (Skin & Mucous)

GP
alclometasone topical cream 0.05 %
ANTI-ITCH (HYDROCORTISONE) TOPICAL

OINTMENT 1 %
GP
Retail; OTC; QL (30 GM per 7 day(s))
AQUANIL HC LOTION 1 %
GP
Retail; OTC
BETA-HC LOTION 1 %
GP
Retail; OTC
betamethasone dipropionate lotion 0.05 %
GP
Retail
betamethasone dipropionate topical ointment 0.05 %
GP
Retail
betamethasone valerate lotion 0.1 %
GP
Retail
betamethasone valerate topical ointment 0.1 %
GP
Retail
betamethasone, augmented topical cream 0.05 %
GP
CAPEX SHAMPOO 0.01 %
BP
Retail
clobetasol topical cream 0.05 %
GP
Retail
clobetasol topical gel 0.05 %
GP
Retail
clobetasol topical ointment 0.05 %
GP
Retail
clobetasol topical solution 0.05 %
GP
Retail
COLOCORT ENEMA 100 MG/60 ML
GP
Retail
CORMAX TOPICAL SOLUTION 0.05 %
BP
Retail
CORTIZONE-10 LOTION 1 %
BP
Retail; OTC
CORTIZONE-10 TOPICAL CREAM 1 %
BP
74
Drug Name
Formulary
Tier
Tier
CORTIZONE-10 TOPICAL GEL 1 %
BP
Retail; OTC
CORTIZONE-10 TOPICAL OINTMENT 1 %
BP
CORTIZONE-10 PLUS TOPICAL CREAM 1 %
BP
DERMA-SMOOTHE/FS BODY OIL 0.01 %
BP
DERMA-SMOOTHE/FS SCALP OIL 0.01 %
BP

GP
desonide topical ointment 0.05 %

DESOWEN LOTION 0.05 %
BP
Retail
Retail
diflorasone topical cream 0.05 %
GP
Retail
diflorasone topical ointment 0.05 %
GP
Retail
fluocinolone topical cream 0.025 %
GP
Retail
fluocinolone topical solution 0.01 %
GP
Retail
fluocinonide topical cream 0.05 %
GP
Retail
fluocinonide topical gel 0.05 %
GP
Retail
fluocinonide topical ointment 0.05 %
GP
Retail
fluocinonide topical solution 0.05 %
GP
Retail
fluticasone topical cream 0.05 %
GP
Retail
fluticasone topical ointment 0.005 %
GP
halobetasol propionate topical ointment 0.05 %
GP
HYDRO SKIN LOTION 1 %
GP
Retail; OTC
hydrocortisone enema 100 mg/60 ml
GP
Retail
hydrocortisone lotion 1 %
GP
Retail; OTC
hydrocortisone topical cream 0.5 %, 1 %, 2.5 %
GP
Retail; OTC,; QL (30 GM per 7

day(s)),
hydrocortisone topical ointment 0.5 %, 1 %, 2.5 %
GP
Retail; OTC,; QL (30 GM per 7

day(s)),
ITCH-X HC LOTION 1 %
BP
Retail; OTC
KENALOG TOPICAL AEROSOL 0.147 MG/GRAM
BP
Retail
mometasone lotion 0.1 %
GP
mometasone topical cream 0.1 %
GP
mometasone topical ointment 0.1 %
GP
PREPARATION H HYDROCORTISONE TOPICAL

CREAM 1 %
BP
PROCTOFOAM HC 1-1 %
BP
Retail
PROCTOSOL HC RECTAL CREAM 2.5 %
GP
Retail
RECORT PLUS TOPICAL CREAM 1 %
BP
triamcinolone acetonide dental paste 0.1 %
GP
Retail
triamcinolone acetonide lotion 0.025 %, 0.1 %
GP
Retail
triamcinolone acetonide topical cream
GP
Retail
triamcinolone acetonide topical ointment 0.025 %, 0.1 %
GP
Retail
Antipruritics And Local Anesthetics

ALLERGY CREAM TOPICAL 2 %
GP
75
Retail; OTC
Drug Name
Formulary
Tier
Tier
ANTI-ITCH (DIPHENHYDRAMINE) WITH ZINC

TOPICAL CREAM 2-0.1 %
GP
BANOPHEN ANTI-ITCH TOPICAL CREAM 2-0.1

%
GP
Retail; OTC
lidocaine topical ointment 5 %
GP
Retail
lidocaine-prilocaine topical cream 2.5-2.5 %
GP
Retail
lidocaine-prilocaine topical kit 2.5-2.5 %
GP
Retail
phenazopyridine tablet 100 mg, 200 mg
GP
Retail
PROCTOFOAM HC 1-1 %
BP
Retail
TUCKS OINTMENT 1-12.5 %
GP

day(s))
A-MANTLE TOPICAL CREAM
GP

day(s))
HEMORRHOIDAL HYGIENE TOPICAL PADS 50

%
GP
Retail; OTC
HYPERCARE TOPICAL SOLUTION 20 %
BP
Retail
Astringents
Azoles (Skin & Mucous Membrane)

GP
ANTIFUNGAL (CLOTRIMAZOLE) TOPICAL
CREAM 1 %
GP
ANTIFUNGAL CREAM TOPICAL 2 %
GP
CLOTRIM ANTIFUNGAL TOPICAL CREAM 1 %
GP
clotrimazole topical cream 1 %
GP
clotrimazole topical solution 1 %
GP

day(s))
clotrimazole troche 10 mg
GP
Retail
CLOTRIMAZOLE FOOT TOPICAL CREAM 1 %
GP
DESENEX TOPICAL CREAM 1 %
BP
DESENEX TOPICAL POWDER 2 %
BP

day(s))
DESENEX TOPICAL SPRAY 2 %
BP

day(s))
DESENEX SPRAY TOPICAL POWDER 2 %
BP

day(s))
ketoconazole shampoo 2 %
GP
Retail
ketoconazole topical cream 2 %
GP
Retail
LOTRIMIN AF TOPICAL POWDER 2 %
BP

day(s))
MICATIN TOPICAL CREAM 2 %
BP
MICONAZOLE 7 VAGINAL CREAM 2 %
GP
MICONAZOLE 7 VAGINAL SUPPOSITORY 100

MG
GP
76
Drug Name
Formulary
Tier
Tier
miconazole nitrate topical cream 2 %
GP
miconazole nitrate vaginal cream 2 %
GP
miconazole nitrate vaginal suppository 100 mg
GP
MICONAZOLE-3 VAGINAL KIT 200 MG- 2 % (9

GRAM)
GP
MICONAZOLE-3 VAGINAL SUPPOSITORY 200

MG
GP
NUZOLE TOPICAL CREAM 2 %
GP
VAGISTAT-3 VAGINAL KIT 200 MG- 2 % (9

GRAM)
GP
GP
Retail; OTC
Basic Lotions And Liniments

AMLACTIN LOTION 12 %
ammonium lactate lotion 12 %
GP
Retail; OTC
calamine lotion
GP

day(s))
LAC-HYDRIN TWELVE LOTION 12 %
GP
Retail; OTC
Basic Oils And Other Solvents

mineral oil topical
GP
Retail; OTC
GP
Retail; OTC
Basic Ointments And Protectants

ammonium lactate topical cream 12 %
RISABAL-PH TOPICAL CREAM
GP
Retail; OTC
vitamin a & d topical ointment
GP
Retail; OTC
zinc oxide topical ointment 20 %
GP
Retail; OTC
tretinoin topical cream
GP
Retail
tretinoin topical gel 0.01 %, 0.025 %
GP
Retail
ciclopirox topical cream 0.77 %
GP
Retail
ciclopirox topical gel 0.77 %
GP
Retail
ciclopirox topical solution 8 %
GP
ciclopirox topical suspension 0.77 %
GP
Retail
Cell Stimulants And Proliferants
Hydroxypyridones(Skin & Mucous Membrane)
Keratolytic Agents
BENZAC AC WASH TOPICAL CLEANSER 10 %
BP
Retail
BENZAC W WASH TOPICAL CLEANSER 10 %
BP
Retail
benzoyl peroxide topical cleanser 10 %, 5 %, 6 %
GP
, Retail; OTC
benzoyl peroxide topical gel 10 %, 5 %
GP
Retail; OTC
clindamycin-benzoyl peroxide topical gel 1-5 %
GP
Retail
DESQUAM-X TOPICAL CLEANSER 10 %, 5 %
BP
Retail; OTC
DUOFILM TOPICAL LIQUID 17 %
GP

day(s))
sulfacetamide sodium-sulfur topical cleanser 10-5 %

(w/w)
GP
77
Drug Name
Formulary
Tier
Tier
GP
urea topical cream 40 %
Retail
Keratoplastic Agents
BETATAR GEL SHAMPOO 2.5 %
GP
Retail; OTC
coal tar topical solution 20 %
GP
Retail
coal tar (bulk) topical solution 20 %
GP
Retail; OTC
IONIL T SHAMPOO 1 %
GP
Retail; OTC
PC-TAR SHAMPOO 1 %
GP
Retail; OTC
TERA-GEL TAR SHAMPOO 0.5 %
GP
Retail; OTC
THERA-GEL SHAMPOO 0.5 %
GP
Retail; OTC
X-SEB T PLUS SHAMPOO 2 %
GP
Retail; OTC
GP

day(s))
Local Anti-Infectives, Miscellaneous

BETASEPT SURGICAL SCRUB TOPICAL LIQUID
4%
selenium sulfide topical suspension 2.5 %
GP
Retail
silver sulfadiazine topical cream 1 %
GP
Retail
SSD TOPICAL CREAM 1 %
BP
Retail
sulfacetamide sodium (acne) topical suspension 10 %
GP
sulfacetamide sodium-sulfur topical cleanser 10-5 %

(w/w)
GP
ULESFIA LOTION 5 %
Retail
BP
Pigmenting Agents
8-MOP CAPSULE 10 MG
GP
Retail
GP
Retail
Polyenes (Skin & Mucous Membrane)

NYAMYC TOPICAL POWDER 100,000
UNIT/GRAM
nystatin topical cream 100,000 unit/gram
GP
Retail
nystatin topical ointment 100,000 unit/gram
GP
Retail
nystatin topical powder 100,000 unit/gram
GP
Retail
nystatin-triamcinolone topical cream 100,000-0.1 unit/g-%
GP
Retail
nystatin-triamcinolone topical ointment 100,000-0.1

unit/gram-%
GP
Retail
NYSTOP TOPICAL POWDER 100,000 UNIT/GRAM
GP
Retail
PEDI-DRI TOPICAL POWDER 100,000

UNIT/GRAM
GP
Retail
EURAX LOTION 10 %
BP
Retail
EURAX TOPICAL CREAM 10 %
BP
Retail
Scabicides And Pediculicides
lindane lotion 1 %
GP
Retail
lindane shampoo 1 %
GP
Retail
permethrin topical cream 5 %
GP
permethrin topical liquid 1 %
GP

day(s))
78
Drug Name
ULESFIA LOTION 5 %
Formulary
Tier
Tier
BP
Retail
Skin And Mucous Membrane Agents, Misc.

adapalene topical cream 0.1 %
GP
adapalene topical gel 0.1 %
GP
AMNESTEEM
GP
PA; Retail; Age (Max 20 Years)
calcipotriene topical ointment 0.005 %
GP
Retail
calcipotriene topical solution 0.005 %
GP
Retail
CALCITRENE TOPICAL OINTMENT 0.005 %
GP
Retail
capsaicin topical cream 0.025 %
GP

day(s))
capsaicin topical cream 0.075 %
GP

day(s))
CAPZASIN-HP TOPICAL CREAM 0.1 %
GP

day(s))
CLARAVIS
GP
CONDYLOX TOPICAL GEL 0.5 %
BP
Retail
ELIDEL TOPICAL CREAM 1 %
BP
PA; Retail
FLUOROPLEX TOPICAL CREAM 1 %
BP
Retail
fluorouracil topical cream 5 %
GP
Retail
fluorouracil topical solution 2 %, 5 %
GP
Retail
imiquimod topical cream packet 5 %
GP
PODOCON TOPICAL LIQUID 25 %
GP
Retail
GP
podofilox topical solution 0.5 %
Retail
SANTYL TOPICAL OINTMENT 250 UNIT/GRAM
GP
Retail
SOTRET CAPSULE 20 MG
GP
TUCKS RECTAL SUPPOSITORY 51 %
GP
ZOSTRIX TOPICAL CREAM 0.025 %
GP
Retail; OTC
ZOSTRIX DIABETIC TOPICAL CREAM 0.075 %
GP

day(s))
ZOSTRIX-HP TOPICAL CREAM 0.075 %
GP

day(s))
BP
Thiocarbamates (Skin & Mucous Membrane)

LAMISIL AF TOPICAL POWDER 1 %
tolnaftate topical cream 1 %
GP
tolnaftate topical powder 1 %
GP
tolnaftate topical solution 1 %
GP

day(s))
Smooth Muscle Relaxants

Antimuscarinics
DETROL LA CAPSULE,EXTENDED RELEASE 2
MG, 4 MG
BP
QL (1 per 1 Day(s))
GP
oxybutynin chloride er tablet,extended release 24 hr

79
QL (1 per 1 Day(s))
Drug Name
Formulary
Tier
Tier
oxybutynin chloride syrup 5 mg/5 ml
GP
oxybutynin chloride tablet 5 mg
GP
QL (4 per 1 Day(s))
tolterodine tablet 1 mg, 2 mg
GP
QL (2 per 1 Day(s))
trospium er capsule,extended release 24 hr 60 mg
GP
QL (1 per 1 Day(s))
trospium tablet 20 mg
GP
QL (2 per 1 Day(s))
Respiratory Smooth Muscle Relaxants

BP
Retail
LUFYLLIN TABLET 200 MG, 400 MG
BP
Retail
BP
Retail
GP
Retail
GP
Retail
Vitamins
Multivitamin Preparations
APATATE FORTE ORAL LIQUID
GP
Retail; OTC
BEE-ZEE TABLET
GP
Retail; OTC
BIOSUPP ORAL LIQUID
GP
Retail; OTC
BODY, HAIR, SKIN & NAILS CAPSULE 3-133

MG-MCG
GP
Retail; OTC
CENTAVITE A-Z COMPLETE-MINERAL TABLET

27-0.4 MG
GP

day(s))
GP

day(s))
CENTRUM SILVER ULTRA WOMEN'S TABLET
GP

day(s))

MG-MCG
GP

day(s))

18-400 MG-MCG
GP

day(s))

MG-MCG
GP

day(s))
I-VITE TABLET 1,000 UNIT-200 MG-60 UNIT-2 MG
GP
Retail; OTC
ICAPS PLUS TABLET
GP
Retail; OTC
GP
Retail
MEGA MULTIPLE/CHELATED MINERAL

TABLET
GP
Retail; OTC
MEGA MULTIVITAMIN W/MINERAL TAB
GP
OTC
MULTI VIT-FLUORIDE-IRON ORAL DROPS

0.25-10 MG/ML
GP
Retail
MULTI-VIT W/IRON & FLUORIDE ORAL DROPS

0.25-10 MG/ML
GP
Retail
MULTI-VITAMIN WITH FLUORIDE
GP
Retail
MULTI-VITAMINS/FLUORIDE ORAL DROPS 0.25

MG/ML
GP
Retail
80
Drug Name
MULTIPLE VITAMIN-MINERALS TABLET
Formulary
Tier
Tier
GP
Retail; OTC
GP
multivitamin with minerals tablet

day(s))
MULTIVITAMINS WITH FLUORIDE ORAL

DROPS 0.5 MG/ML
GP
Retail
MY-VITALIFE CAPSULE
GP
Retail; OTC
GP
Retail
OCUVITE WITH LUTEIN TABLET 1,000 UNIT-200

MG-60 UNIT-2 MG
GP
Retail; OTC
ONE-A-DAY MAXIMUM FORMULA TABLET
GP
Retail; OTC
GP
pediatric multivitamin-fl oral drops 0.25 mg/ml, 0.5 mg/ml
Retail
POLY-VI-SOL ORAL DROPS 1,500-35-400

UNIT-MG-UNIT/ML
BP
Retail; OTC
POLY-VI-SOL WITH IRON ORAL DROPS 1,500

UNIT-400 UNIT-10 MG/ML
BP
Retail; OTC
POLYVITAMIN/IRON CHEWABLE TABLET
GP
GP
GP
Retail
GP

Day(s))
GP
GP

TABLET 27-1 MG
GP

GP
GP

Day(s))
PRENATAL VITAMIN TABLET
GP

Day(s))

27-0.8 MG
GP
GR-F; OTC; QL (1 per 1 Day(s))
GP
GP

Day(s))
TAB-A-VITE-MINERALS TABLET
GP
Retail; OTC
TRI-VI-SOL ORAL DROPS 1,500-35-400

UNIT-MG-UNIT/ML
BP
Retail; OTC

UNIT- 10 MG IRON/ML
BP
Retail; OTC
GP
GP
Retail
GP
81
Drug Name
Formulary
Tier
Tier
GP
GP
GP
BP
Retail; OTC
Vitamin A
UNIT- 10 MG IRON/ML
GP

day(s))
b complex vitamins capsule
GP
Retail; OTC
b complex vitamins tablet
GP
Retail; OTC
vitamin a capsule
Vitamin B Complex
B COMPLEX-VITAMIN B12 TABLET
GP
Retail; OTC
B-PLEX TABLET 0.5 MG
GP
Retail
BALANCED B-100 TABLET 100 MG
GP
Retail; OTC
BALANCED B-50 TABLET
GP
Retail; OTC
GP

day(s))

MG-MCG
GP

day(s))

18-400 MG-MCG
GP

day(s))

MG-MCG
GP

day(s))
cyanocobalamin (vit b-12) er tablet,extended release

1,000 mcg
GP
Retail; OTC
cyanocobalamin (vit b-12) injection solution 1,000 mcg/ml
GP
Retail
cyanocobalamin (vit b-12) sublingual tablet 1,000 mcg
GP
Retail; OTC
folic acid tablet
GP

day(s))
GP
Retail
GP
Retail
NEPHROCAPS CAPSULE 1 MG
GP
Retail
GP
GP
Retail
GP

Day(s))
GP
GP

TABLET 27-1 MG
GP

GP
82
Drug Name
Formulary
Tier
Tier
GP

Day(s))
RENA-VITE RX TABLET 1-60-300 MG-MG-MCG
GP
Retail
RENAL CAPS CAPSULE 1 MG
GP
Retail
RENO CAPS CAPSULE 1 MG
GP
Retail

27-0.8 MG
GP
GP
GP

Day(s))
GP
GP
Retail
GP
TRIPHROCAPS CAPSULE 1 MG
GP
Retail
GP
VITAMIN B COMPLEX CAPSULE
GP
Retail; OTC
VITAMIN B COMPLEX TABLET
GP
Retail; OTC
VITAMIN B-1 TABLET 100 MG
GP
Retail; OTC
VITAMIN B-12 TABLET
GP
Retail; OTC
VITAMIN B-6 TABLET
GP

day(s))
VOL-CARE RX TABLET 1-60-300 MG-MG-MCG
GP
Retail
GP
GP
Vitamin C
GP
ascorbic acid tablet 250 mg, 500 mg

day(s))
SOOTHING PUREWAY-C TABLET 500 MG
GP

day(s))

UNIT- 10 MG IRON/ML
BP
Retail; OTC
VITAMIN C CHEWABLE TABLET 250 MG, 500 MG
GP

day(s))
VITAMIN C ER TABLET,EXTENDED RELEASE

1,000 MG, 500 MG
GP

day(s))
VITAMIN C ORAL LIQUID 500 MG/15 ML
GP
Retail; OTC
VITAMIN C SYRUP 500 MG/5 ML
GP
Retail; OTC
VITAMIN C TABLET
GP

day(s))
GP
QL (1 per 1 Day(s))
Vitamin D
GP
calcitriol capsule 0.25 mcg, 0.5 mcg

83
Retail
Drug Name
Formulary
Tier
Tier
GP
calcitriol oral solution 1 mcg/ml
Retail
CALCIUM 500 + D TABLET 500 MG(1,250MG) -200

UNIT, 500 MG(1,250MG) -400 UNIT
GP

day(s))
CALCIUM 500 WITH D TABLET 500 MG(1,250MG)

-400 UNIT
GP

day(s))
CALCIUM 600 + D(3) TABLET 600 MG(1,500MG)

-200 UNIT, 600 MG(1,500MG) -400 UNIT
GP

day(s))
calcium carbonate-vitamin d3 chewable tablet 500-100

mg-unit
GP

day(s))
calcium carbonate-vitamin d3 tablet 500 mg(1,250mg)

-200 unit, 600 mg(1,500mg) -200 unit
GP

day(s))
cholecalciferol (vitamin d3) capsule 50,000 unit
GP
Retail; OTC
cholecalciferol (vitamin d3) oral drops 400 unit/ml
GP
Retail; OTC
cholecalciferol (vitamin d3) tablet 1,000 unit, 2,000 unit
GP
Retail,; OTC; , QL (1 per 1 Day(s))
ergocalciferol (vitamin d2) capsule 50,000 unit
GP
Retail
ergocalciferol (vitamin d2) oral drops 8,000 unit/ml
GP
Retail; OTC
ergocalciferol (vitamin d2) tablet 400 unit
GP
Retail; OTC
OS-CAL 500 + D CHEWABLE TABLET 500

MG(1,250MG) -600 UNIT
GP
Retail; OTC
OYSCO 500/D CHEWABLE TABLET 500

MG(1,250MG) -600 UNIT
GP

day(s))
OYSCO 500/D TABLET 500 MG(1,250MG) -200

UNIT
GP

day(s))
OYSCO D TABLET 250-125 MG-UNIT
GP

day(s))
OYSTER SHELL CALCIUM-VIT D3 TABLET 500

MG(1,250MG) -200 UNIT, 500 MG(1,250MG) -400
UNIT
GP

day(s))

UNIT- 10 MG IRON/ML
BP
Retail; OTC
VITAMIN D2 CAPSULE 50,000 UNIT
GP
Retail
VITAMIN D3 CAPSULE 1,000 UNIT, 2,000 UNIT
GP
OTC
VITAMIN D3 TABLET 1,000 UNIT, 2,000 UNIT, 400

UNIT
GP
Retail,; OTC
Vitamin E
GP
vitamin e capsule

day(s))
Vitamin K Activity
MEPHYTON TABLET 5 MG
BP
84
Retail
Index
12
66
................................................................................................. 76
................................................................................................. 83
8-MOP CAPSULE 10 MG .......................... 78
abacavir tablet 300 mg .......................................... 8
ABILIFY DISCMELT
DISINTEGRATING TABLET 10
MG, 15 MG ................................................................ 34
ABILIFY MAINTENA
INTRAMUSCULAR
SUSPENSION,EXTENDED
RELEASE 300 MG, 400 MG ................... 34
ABILIFY ORAL SOLUTION 1
MG/ML .......................................................................... 34
ABILIFY TABLET ............................................ 34
acarbose ......................................................................... 58
acebutolol capsule 200 mg, 400 mg ......... 15
acetaminophen chewable tablet 80 mg
.................................................................................................. 30
acetaminophen elixir 160 mg/5 ml ........... 30
acetaminophen oral liquid 500 mg/5 ml
.................................................................................................. 30
acetaminophen oral solution 160 mg/5 ml
(5 ml) ................................................................................ 30
acetaminophen rectal suppository 120
mg, 650 mg ................................................................... 30
acetaminophen tablet 325 mg, 500 mg
.................................................................................................. 30
acetaminophen-codeine tablet 300-15 mg,
300-30 mg, 300-60 mg ........................................ 30
acetaminophen-codeine tablet 300-15 mg,
300-30 mg, 300-60 mg ........................................ 37
ACETASOL HC EAR DROPS 1-2 %
.................................................................................................. 50
acetazolamide er capsule,extended
release 500 mg ........................................................... 24
release 500 mg ........................................................... 44
release 500 mg ........................................................... 49
.................................................................................................. 24
.................................................................................................. 44
.................................................................................................. 49
acetic acid ear solution 2 % ............................ 50
acetylcysteine solution 100 mg/ml (10
%), 200 mg/ml (20 %) ....................................... 66
acetylcysteine solution 100 mg/ml (10
%), 200 mg/ml (20 %) ....................................... 71
acyclovir capsule 200 mg ..................................... 9
acyclovir oral suspension 200 mg/5 ml
..................................................................................................... 9
acyclovir tablet 400 mg, 800 mg ................... 9
adapalene topical cream 0.1 % .................... 79
adapalene topical gel 0.1 % ............................ 79
.................................................................................................
.................................................................................................
AFLURIA 2013-2014 (PF)

INTRAMUSCULAR SYRINGE 45
MCG (15 MCG X 3)/0.5 ML .................... 73
AFLURIA 2013-2014
INTRAMUSCULAR SUSPENSION
45 MCG (15 MCG X 3)/0.5 ML ............. 73
AFRIN NASAL SPRAY AEROSOL
0.05 % ................................................................................ 52
AFRIN SINUS NASAL SPRAY
AEROSOL 0.05 % ............................................... 52
AGGRENOX CAPSULE,
EXTENDED RELEASE 200-25 MG
.................................................................................................. 18
AGGRENOX CAPSULE,
.................................................................................................. 29
AGGRENOX CAPSULE,
.................................................................................................. 41
AK-POLY-BAC EYE OINTMENT
500-10,000 UNIT/GRAM ............................ 48
ALAWAY EYE DROPS 0.025 %
.................................................................................................. 48
albuterol sulfate er tablet,extended
release,12 hr 4 mg, 8 mg ................................... 15
albuterol sulfate er tablet,extended
release,12 hr 4 mg, 8 mg ................................... 72
albuterol sulfate solution for nebulization
0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml
(0.083 %), 2.5 mg/0.5 ml, 5 mg/ml ......... 15
albuterol sulfate solution for nebulization
0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml
(0.083 %), 2.5 mg/0.5 ml, 5 mg/ml ......... 72
albuterol sulfate syrup 2 mg/5 ml .............. 15
albuterol sulfate syrup 2 mg/5 ml .............. 72
albuterol sulfate tablet 2 mg, 4 mg .......... 15
albuterol sulfate tablet 2 mg, 4 mg .......... 72
alclometasone topical cream 0.05 %
.................................................................................................. 74
alendronate tablet 10 mg, 35 mg, 40 mg,
5 mg, 70 mg .................................................................. 64
alfuzosin er tablet,extended release 24 hr
10 mg .................................................................................. 15
ALKERAN TABLET 2 MG .................... 11
ALL DAY ALLERGY (CETIRIZINE)
CHEWABLE TABLET 10 MG, 5 MG
..................................................................................................... 5
CHEWABLE TABLET 10 MG, 5 MG
.................................................................................................. 72
ORAL SOLN 1 MG/ML .................................. 5
ORAL SOLN 1 MG/ML ............................... 72
TABLET 10 MG ....................................................... 5
TABLET 10 MG ................................................... 72
..................................................................................................... 4
.................................................................................................. 70
85
.....................................................................................................
70
ALLERGY
(CHLORPHENIRAMINE) TABLET 4
MG ......................................................................................... 4
ALLERGY
(CHLORPHENIRAMINE) TABLET 4
MG ...................................................................................... 70
ALLERGY CREAM TOPICAL 2 %
.................................................................................................. 75
..................................................................................................... 4
.................................................................................................. 70
allopurinol tablet 100 mg, 300 mg ............ 64
ALOCRIL EYE DROPS 2 % ................... 48
ALOCRIL EYE DROPS 2 % ................... 71
ALOMIDE EYE DROPS 0.1 % ............ 48
ALPHAGAN P EYE DROPS 0.1 %
.................................................................................................. 47
alprazolam tablet 0.25 mg, 0.5 mg, 1 mg,
2 mg ..................................................................................... 36
ALREX EYE DROPS,SUSPENSION
0.2 % ................................................................................... 49
ALTACHLORE EYE DROPS 5 %
.................................................................................................. 50
ALTACHLORE EYE OINTMENT 5
% ............................................................................................ 50
ALTAFRIN EYE DROPS 10 %, 2.5 %
.................................................................................................. 52
aluminum hydroxide gel oral suspension
320 mg/5 ml, 600 mg/5 ml ............................... 52
amantadine hcl capsule 100 mg ..................... 5
amantadine hcl capsule 100 mg .................. 30
amantadine hcl syrup 50 mg/5 ml ................ 5
amantadine hcl syrup 50 mg/5 ml ............. 30
A-MANTLE TOPICAL CREAM
.................................................................................................. 76
AMBI 60PSE-400GFN TABLET
60-400 MG ................................................................... 12
60-400 MG ................................................................... 66
60-400 MG ................................................................... 68
AMBI 60PSE-4CPM TABLET 4-60
MG ......................................................................................... 4
MG ...................................................................................... 12
MG ...................................................................................... 66
MG ...................................................................................... 70
A-METHAPRED SOLUTION FOR
INJECTION 125 MG/2 ML, 40
MG/ML .......................................................................... 57
amiloride tablet 5 mg ........................................... 28
amiloride tablet 5 mg ........................................... 45
amiloride-hydrochlorothiazide tablet 5-50
mg ......................................................................................... 28
..................................................................................................

mg ......................................................................................... 45
mg ......................................................................................... 47
aminocaproic acid oral solution 25 %
.................................................................................................. 16
aminocaproic acid tablet 500 mg .............. 16
amiodarone tablet 200 mg, 400 mg ......... 25
amitriptyline oral ................................................... 42
amitriptyline-chlordiazepoxide tablet
12.5-5 mg, 25-10 mg ............................................. 36
amitriptyline-chlordiazepoxide tablet
12.5-5 mg, 25-10 mg ............................................. 42
AMLACTIN LOTION 12 % ..................... 77
amlodipine .................................................................... 26
amlodipine .................................................................... 29
amlodipine-benazepril ........................................ 20
ammonium lactate lotion 12 % .................... 77
ammonium lactate topical cream 12 %
.................................................................................................. 77
AMNESTEEM ....................................................... 79
amoxapine .................................................................... 42
amoxicillin capsule 250 mg, 500 mg
..................................................................................................... 5
amoxicillin chewable tablet 125 mg, 250
mg ............................................................................................ 5
amoxicillin oral suspension .............................. 5
amoxicillin tablet 500 mg, 875 mg .............. 5
amoxicillin-potassium clavulanate
chewable tablet 200-28.5 mg, 400-57 mg
..................................................................................................... 5
amoxicillin-potassium clavulanate oral
suspension ........................................................................ 5
amoxicillin-potassium clavulanate tablet
..................................................................................................... 5
AMPHETAMINE SALT COMBO
TABLET 10 MG, 12.5 MG, 15 MG, 20
MG, 30 MG, 5 MG, 7.5 MG ..................... 30
ampicillin capsule 250 mg, 500 mg ............. 5
ampicillin oral suspension 125 mg/5 ml,
250 mg/5 ml ..................................................................... 5
AMPYRA TABLET,EXTENDED
RELEASE 10 MG ............................................... 66
anastrozole tablet 1 mg ...................................... 11
ANDROGEL TRANSDERMAL GEL
PACKET 1 % (25 MG/2.5 G), 1 %(50
MG/5 GRAM), 1.62 % (20.25 MG/1.25
GRAM), 1.62 % (40.5 MG/2.5 GRAM)
.................................................................................................. 59
ANDROGEL TRANSDERMAL GEL
PUMP 1.25 GRAM/ ACTUATION (1
%), 20.25 MG/1.25 GRAM (1.62 %)
.................................................................................................. 59
ANTI-DIARRHEAL
(LOPERAMIDE) TABLET 2 MG
.................................................................................................. 53
ANTIFUNGAL (CLOTRIMAZOLE)
TOPICAL CREAM 1 % ................................ 76
ANTIFUNGAL CREAM TOPICAL 2
% ............................................................................................ 76
ANTI-ITCH
(DIPHENHYDRAMINE) WITH
ZINC TOPICAL CREAM 2-0.1 %
76
ANTI-ITCH (HYDROCORTISONE)
TOPICAL OINTMENT 1 % ..................... 74
antipyrine-benzocaine ear drops 5.4-1.4
% ............................................................................................ 51
APATATE FORTE ORAL LIQUID
.................................................................................................. 80
APIDRA SOLOSTAR
SUBCUTANEOUS INSULIN PEN
100 UNIT/ML .......................................................... 62
APIDRA SUBCUTANEOUS
SOLUTION 100 UNIT/ML ....................... 61
APRI TABLET 0.15-30 MG-MCG
.................................................................................................. 59
APTIVUS CAPSULE 250 MG .................. 7
AQUANIL HC LOTION 1 % ................. 74
ARANELLE (28) TABLET 0.5/1/0.5-35
MG-MCG .................................................................... 59
ARICEPT ..................................................................... 15
ARMOUR THYROID ................................... 64
AROMASIN TABLET 25 MG .............. 11
ARTIFICIAL TEARS
(PETROLATUM/MINERAL OIL)
EYE OINTMENT 83-15 % ........................ 50
ARTIFICIAL TEARS EYE DROPS
1.4 % ................................................................................... 50
ARTIFICIAL TEARS EYE
OINTMENT ............................................................. 50
ascorbic acid tablet 250 mg, 500 mg
.................................................................................................. 83
aspirin chewable tablet 81 mg ...................... 18
.................................................................................................. 18
.................................................................................................. 19
.................................................................................................. 33
.................................................................................................. 41
aspirin tablet 325 mg ............................................ 18
aspirin tablet,delayed release 325 mg, 500
mg, 650 mg, 81 mg, 975 mg ........................... 18
mg, 650 mg, 81 mg, 975 mg ........................... 19
mg, 650 mg, 81 mg, 975 mg ........................... 33
mg, 650 mg, 81 mg, 975 mg ........................... 41
ASPIR-TRIN TABLET,DELAYED
RELEASE 325 MG ............................................ 18
RELEASE 325 MG ............................................ 19
RELEASE 325 MG ............................................ 33
RELEASE 325 MG ............................................ 41
..................................................................................................
86
atenolol oral ............................................................... 15

atenolol oral ............................................................... 21
atenolol oral ............................................................... 22
atenolol oral ............................................................... 24
atenolol-chlorthalidone tablet 100-25 mg,
50-25 mg ......................................................................... 16
50-25 mg ......................................................................... 21
50-25 mg ......................................................................... 22
50-25 mg ......................................................................... 24
50-25 mg ......................................................................... 29
50-25 mg ......................................................................... 47
atorvastatin ................................................................. 27
..................................................................................................... 8
atropine eye drops 1 % ....................................... 51
atropine eye ointment 1 % ............................... 51
ATROVENT HFA AEROSOL
INHALER 17 MCG/ACTUATION
.................................................................................................. 13
ATROVENT HFA AEROSOL
.................................................................................................. 67
AUBAGIO TABLET 14 MG, 7 MG
.................................................................................................. 65
AURODEX EAR DROPS 5.4-1.4 %
.................................................................................................. 51
AUROGUARD EAR DROPS 5.4-1.4
% ............................................................................................ 51
AUVI-Q
INJECTION,AUTO-INJECTOR 0.15
MG/0.15 ML (1:1,000), 0.3 MG/0.3 ML
(1:1,000) .......................................................................... 12
AUVI-Q
MG/0.15 ML (1:1,000), 0.3 MG/0.3 ML
(1:1,000) .......................................................................... 66
AVIANE TABLET 0.1-20 MG-MCG
.................................................................................................. 59
AVONEX ADMINISTRATION
PACK INTRAMUSCULAR KIT 30
MCG/0.5 ML ............................................................ 65
AVONEX INTRAMUSCULAR KIT
30 MCG .......................................................................... 65
AVONEX INTRAMUSCULAR PEN
INJECTOR 30 MCG/0.5 ML ................... 65
AVONEX INTRAMUSCULAR PEN
KIT 30 MCG/0.5 ML ....................................... 65
AVONEX INTRAMUSCULAR
SYRINGE 30 MCG/0.5 ML ...................... 65
AYGESTIN TABLET 5 MG ................... 63
azathioprine tablet 50 mg ................................ 65
azithromycin oral packet 1 gram ................. 9
azithromycin oral suspension 100 mg/5
ml, 200 mg/5 ml ........................................................... 9
azithromycin tablet 250 mg, 500 mg, 600
mg ............................................................................................ 9
AZOPT EYE DROPS,SUSPENSION 1
% ............................................................................................ 49
AZURETTE (28) TABLET
0.15-0.02MG X21 /0.01 MG X 5 ............ 59
b complex vitamins capsule ......................... 82

b complex vitamins tablet ............................. 82
B COMPLEX-VITAMIN B12
TABLET ........................................................................ 82
bacitracin eye ointment 500 unit/gram
.................................................................................................. 48
bacitracin topical ointment 500 unit/gram
.................................................................................................. 73
bacitracin-polymyxin b topical ointment
500-10,000 unit/gram .......................................... 73
baclofen tablet 10 mg, 20 mg ........................ 14
BACTROBAN TOPICAL CREAM 2
% ............................................................................................ 73
BALANCED B-100 TABLET 100 MG
.................................................................................................. 82
BALANCED B-50 TABLET .................... 82
balsalazide capsule 750 mg ............................. 54
BALZIVA (28) TABLET 0.4-35
MG-MCG .................................................................... 59
BANOPHEN ANTI-ITCH TOPICAL
CREAM 2-0.1 % .................................................... 76
BARACLUDE ORAL SOLUTION
0.05 MG/ML ................................................................. 9
BARACLUDE TABLET 0.5 MG, 1
MG ......................................................................................... 9
BAYCADRON ORAL ELIXIR 0.5
MG/5 ML ..................................................................... 57
.................................................................................................. 19
.................................................................................................. 33
.................................................................................................. 41
BEE-ZEE TABLET ............................................ 80
BENADRYL ALLERGY TABLET 25
MG ......................................................................................... 3
BENADRYL ALLERGY TABLET 25
MG ...................................................................................... 70
benazepril ..................................................................... 20
BENGAY ULTRA STRENGTH
TOPICAL CREAM 4-30-10 % ................ 41
BENZAC AC WASH TOPICAL
CLEANSER 10 % ................................................ 77
BENZAC W WASH TOPICAL
CLEANSER 10 % ................................................ 77
BENZAMYCINPAK TOPICAL GEL
3-5 % .................................................................................. 73
benzonatate capsule 100 mg, 200 mg
.................................................................................................. 67
benzoyl peroxide topical cleanser 10 %, 5
%, 6 % ............................................................................... 77
benzoyl peroxide topical gel 10 %, 5 %
.................................................................................................. 77
benztropine oral ...................................................... 13
benztropine oral ...................................................... 31
BETA-HC LOTION 1 % ............................... 74
betamethasone dipropionate lotion 0.05
% ............................................................................................ 74
betamethasone dipropionate topical
ointment 0.05 % ........................................................ 74
betamethasone valerate lotion 0.1 %
.................................................................................................. 74
betamethasone valerate topical ointment
0.1 % ................................................................................... 74
betamethasone, augmented topical cream

0.05 % ................................................................................ 74
BETASEPT SURGICAL SCRUB
TOPICAL LIQUID 4 % ................................ 78
BETATAR GEL SHAMPOO 2.5 %
.................................................................................................. 78
BETATEMP ORAL SUSPENSION
160 MG/5 ML ........................................................... 30
betaxolol tablet 10 mg, 20 mg ..................... 16
bethanechol chloride oral ................................ 15
bicalutamide tablet 50 mg ............................... 11
BICILLIN L-A INTRAMUSCULAR
SYRINGE 1,200,000 UNIT/2 ML,
2,400,000 UNIT/4 ML, 600,000
UNIT/ML ........................................................................ 8
BIOCOTRON ORAL LIQUID 10-100
MG/5 ML ..................................................................... 67
BIOCOTRON ORAL LIQUID 10-100
MG/5 ML ..................................................................... 68
BION TEARS (PF) DROPS IN A
DROPPERETTE 0.1-0.3 % ........................ 50
BIOSUPP ORAL LIQUID ......................... 80
bisacodyl rectal suppository 10 mg ......... 54
bisacodyl tablet,delayed release 5 mg
.................................................................................................. 54
bismuth subsalicylate chewable tablet 262
mg ......................................................................................... 52
bismuth subsalicylate chewable tablet 262
mg ......................................................................................... 53
bisoprolol-hydrochlorothiazide .................. 16
BLEPH-10 EYE DROPS 10 % ................ 48
BLEPHAMIDE EYE
DROPS,SUSPENSION 10-0.2 % ......... 48
BLEPHAMIDE S.O.P. EYE
OINTMENT 10-0.2 % ..................................... 48
BODY, HAIR, SKIN & NAILS
CAPSULE 3-133 MG-MCG ..................... 80
BOTOX INJECTION 100 UNIT, 200
UNIT ................................................................................ 16
BOTOX INJECTION 100 UNIT, 200
UNIT ................................................................................ 66
B-PLEX TABLET 0.5 MG ......................... 82
BREEZE 2 TEST STRIPS ........................... 43
brimonidine eye drops 0.15 % ...................... 47
brimonidine eye drops 0.2 % ......................... 47
BROMFED DM SYRUP 2-30-10
MG/5 ML ..................................................................... 12
MG/5 ML ..................................................................... 66
MG/5 ML ..................................................................... 67
MG/5 ML ..................................................................... 70
bromocriptine capsule 5 mg ........................... 37
bromocriptine tablet 2.5 mg ........................... 37
87
BRONCOTRON ORAL LIQUID

10-100 MG/5 ML .................................................. 67
BRONCOTRON ORAL LIQUID
10-100 MG/5 ML .................................................. 68
BROTAPP DM ORAL ELIXIR 1-15-5
MG/5 ML ..................................................................... 12
MG/5 ML ..................................................................... 66
MG/5 ML ..................................................................... 67
MG/5 ML ..................................................................... 70
BUDEPRION SR
TABLET,EXTENDED RELEASE 100
MG, 150 MG ............................................................. 32
budesonide suspension for nebulization
0.25 mg/2 ml, 0.5 mg/2 ml ............................... 57
budesonide suspension for nebulization
0.25 mg/2 ml, 0.5 mg/2 ml ............................... 71
bumetanide oral ....................................................... 27
bumetanide oral ....................................................... 44
BUPRENEX INJECTION
SOLUTION 0.3 MG/ML .............................. 39
buprenorphine sublingual tablet 2 mg, 8
mg ......................................................................................... 39
BUPROBAN TABLET,EXTENDED
RELEASE 150 MG ............................................ 32
bupropion hcl sr tablet,sustained-release
.................................................................................................. 32
bupropion hcl tablet 100 mg, 75 mg
.................................................................................................. 32
bupropion hcl xl 24 hr tablet, extended
release 150 mg, 300 mg ...................................... 32
buspirone ....................................................................... 34
BUTALBITAL COMPOUND
W/CODEINE CAPSULE 30-50-325-40
MG ...................................................................................... 33
BUTALBITAL COMPOUND
MG ...................................................................................... 35
BUTALBITAL COMPOUND
MG ...................................................................................... 37
BUTALBITAL COMPOUND
MG ...................................................................................... 40
BUTALBITAL COMPOUND
MG ...................................................................................... 41
butalbital-acetaminophen tablet 50-325
mg ......................................................................................... 30
butalbital-acetaminophen tablet 50-325
mg ......................................................................................... 35
butalbital-acetaminophen-caffeine
capsule 50-325-40 mg .......................................... 30
capsule 50-325-40 mg .......................................... 33
capsule 50-325-40 mg .......................................... 35
capsule 50-325-40 mg .......................................... 40
butalbital-acetaminophen-caffeine tablet
50-325-40 mg, 50-500-40 mg ........................ 30
50-325-40 mg, 50-500-40 mg ........................ 33
50-325-40 mg, 50-500-40 mg ........................ 35
50-325-40 mg, 50-500-40 mg ........................ 40
butalbital-acetaminophen-caffeine-codein
e capsule 50-325-40-30 mg ............................. 30
e capsule 50-325-40-30 mg ............................. 33
e capsule 50-325-40-30 mg ............................. 35
e capsule 50-325-40-30 mg ............................. 37
e capsule 50-325-40-30 mg ............................. 40
butalbital-aspirin-caffeine capsule
50-325-40 mg .............................................................. 19
50-325-40 mg .............................................................. 33
50-325-40 mg .............................................................. 35
50-325-40 mg .............................................................. 40
50-325-40 mg .............................................................. 41
butalbital-aspirin-caffeine tablet
50-325-40 mg .............................................................. 19
50-325-40 mg .............................................................. 33
50-325-40 mg .............................................................. 35
50-325-40 mg .............................................................. 40
50-325-40 mg .............................................................. 41
BYETTA SUBCUTANEOUS PEN
INJECTOR 10 MCG/0.04 ML, 5
MCG/0.02 ML ......................................................... 61
caffeine citrated oral solution 60 mg/3 ml
(20 mg/ml) ................................................................... 40
calamine lotion ....................................................... 77
calcipotriene topical ointment 0.005 %
.................................................................................................. 79
calcipotriene topical solution 0.005 %
.................................................................................................. 79
calcitonin (salmon) nasal spray 200
unit/actuation .............................................................. 63
CALCITRENE TOPICAL
OINTMENT 0.005 % ....................................... 79
calcitriol capsule 0.25 mcg, 0.5 mcg
.................................................................................................. 83
calcitriol oral solution 1 mcg/ml ................ 84
CALCIUM 500 + D TABLET 500
MG(1,250MG) -200 UNIT, 500
MG(1,250MG) -400 UNIT .......................... 45
CALCIUM 500 + D TABLET 500
MG(1,250MG) -200 UNIT, 500
MG(1,250MG) -400 UNIT .......................... 84
CALCIUM 500 WITH D TABLET 500
MG(1,250MG) -400 UNIT .......................... 45
CALCIUM 500 WITH D TABLET 500
MG(1,250MG) -400 UNIT .......................... 84
CALCIUM 600 + D(3) TABLET 600
MG(1,500MG) -200 UNIT, 600
MG(1,500MG) -400 UNIT .......................... 45
CALCIUM 600 + D(3) TABLET 600

MG(1,500MG) -200 UNIT, 600
MG(1,500MG) -400 UNIT .......................... 84
calcium acetate capsule 667 mg ................. 44
calcium carbonate chewable tablet 200
mg calcium (500 mg) .......................................... 52
calcium carbonate-vitamin d3 chewable
tablet 500-100 mg-unit ....................................... 45
calcium carbonate-vitamin d3 chewable
tablet 500-100 mg-unit ....................................... 84
calcium carbonate-vitamin d3 tablet 500
mg(1,250mg) -200 unit, 600
mg(1,500mg) -200 unit ..................................... 45
calcium carbonate-vitamin d3 tablet 500
mg(1,250mg) -200 unit, 600
mg(1,500mg) -200 unit ..................................... 84
calcium gluconate tablet 45 mg (500 mg)
.................................................................................................. 45
CALPHRON TABLET 667 MG .......... 44
CAMILA TABLET 0.35 MG ................... 59
CAPEX SHAMPOO 0.01 % ...................... 74
capsaicin topical cream 0.025 % ................ 79
capsaicin topical cream 0.075 % ................ 79
captopril ......................................................................... 20
captopril-hydrochlorothiazide .................... 20
CAPZASIN-HP TOPICAL CREAM
0.1 % ................................................................................... 79
CARAFATE ORAL SUSPENSION
100 MG/ML ............................................................... 57
carbamazepine chewable tablet 100 mg
.................................................................................................. 31
carbamazepine er capsule,extended
release mphase12hr .............................................. 31
carbamazepine er tablet,extended
release,12 hr 200 mg, 400 mg ....................... 31
carbamazepine oral suspension 100 mg/5
ml ........................................................................................... 31
carbamazepine tablet 200 mg ....................... 31
CARBAMOXIDE EAR DROPS 6.5 %
.................................................................................................. 50
carbidopa-levodopa er tablet,extended
release 25-100 mg, 50-200 mg ..................... 37
carbidopa-levodopa tablet .............................. 37
CARDIZEM CD
CAPSULE,EXTENDED RELEASE
360 MG ........................................................................... 22
CARDIZEM CD
360 MG ........................................................................... 23
CARDIZEM CD
360 MG ........................................................................... 25
CARDIZEM CD
360 MG ........................................................................... 29
CARDIZEM LA ................................................... 22
CARDIZEM LA ................................................... 23
CARDIZEM LA ................................................... 25
CARDIZEM LA ................................................... 29
carisoprodol tablet 350 mg ............................. 14
carisoprodol-asa-codeine tablet
200-325-16 mg ........................................................... 14
88
200-325-16 mg ........................................................... 37
200-325-16 mg ........................................................... 41
.................................................................................................. 14
.................................................................................................. 41
CARTIA XT CAPSULE,EXTENDED
RELEASE 120 MG, 180 MG, 240 MG,
300 MG ........................................................................... 22
300 MG ........................................................................... 23
300 MG ........................................................................... 25
300 MG ........................................................................... 29
carvedilol tablet 12.5 mg, 25 mg, 3.125
mg, 6.25 mg .................................................................. 14
mg, 6.25 mg .................................................................. 15
mg, 6.25 mg .................................................................. 19
mg, 6.25 mg .................................................................. 21
mg, 6.25 mg .................................................................. 25
mg, 6.25 mg .................................................................. 27
CAZIANT (28) TABLET
0.1/.125/.15-25 MG-MCG ............................. 59
CEENU CAPSULE ........................................... 11
cefaclor capsule 250 mg, 500 mg ............... 10
cefaclor er tablet,extended release,12 hr
500 mg ............................................................................... 10
cefadroxil capsule 500 mg .................................. 6
cefadroxil oral suspension 250 mg/5 ml,
500 mg/5 ml ..................................................................... 7
cefadroxil tablet 1 gram ....................................... 7
cefdinir capsule 300 mg ..................................... 10
cefdinir oral suspension 125 mg/5 ml, 250
mg/5 ml ............................................................................. 10
cefpodoxime oral suspension 100 mg/5
ml, 50 mg/5 ml ........................................................... 10
cefpodoxime tablet 100 mg, 200 mg
.................................................................................................. 10
cefprozil oral suspension 125 mg/5 ml,
250 mg/5 ml .................................................................. 10
cefprozil tablet 250 mg, 500 mg ................. 10
ceftriaxone in dextrose (iso-osmotic)
intravenous piggyback 1 gram/50 ml, 2
gram/50 ml .................................................................... 10
ceftriaxone intravenous solution 1 gram,
2 gram ............................................................................... 10
ceftriaxone solution for injection ............. 10
cefuroxime axetil tablet 250 mg, 500 mg
.................................................................................................. 10
CELEBREX CAPSULE 100 MG, 200
MG ...................................................................................... 37
CENTAVITE A-Z
COMPLETE-MINERAL TABLET
27-0.4 MG .................................................................... 17
CENTAVITE A-Z
COMPLETE-MINERAL TABLET
27-0.4 MG .................................................................... 80
CENTRUM COMPLETE TABLET
18-400 MG-MCG ................................................. 17
18-400 MG-MCG ................................................. 80
18-400 MG-MCG ................................................. 82
CENTRUM SILVER ULTRA
WOMEN'S TABLET ........................................ 17
CENTRUM SILVER ULTRA
WOMEN'S TABLET ........................................ 80
CENTRUM ULTRA WOMEN'S
TABLET 18-400 MG-MCG ....................... 17
TABLET 18-400 MG-MCG ....................... 80
TABLET 18-400 MG-MCG ....................... 82
cephalexin capsule 250 mg, 500 mg
..................................................................................................... 7
cephalexin oral suspension 125 mg/5 ml,
250 mg/5 ml ..................................................................... 7
CEROVITE ADVANCED
FORMULA TABLET 18-400
MG-MCG .................................................................... 17
CEROVITE ADVANCED
MG-MCG .................................................................... 80
CEROVITE ADVANCED
MG-MCG .................................................................... 82
CERTAVITE-ANTIOXIDANT
TABLET 18-400 MG-MCG ....................... 17
TABLET 18-400 MG-MCG ....................... 80
TABLET 18-400 MG-MCG ....................... 82
..................................................................................................... 5
.................................................................................................. 72
cetirizine oral solution 1 mg/ml ..................... 5
cetirizine oral solution 1 mg/ml .................. 72
cetirizine tablet 10 mg, 5 mg ............................ 5
cetirizine tablet 10 mg, 5 mg ......................... 72
CHEK-STIX CONTROL STRIPS
.................................................................................................. 43
CHEMET CAPSULE 100 MG ............... 57
CHERACOL D ORAL LIQUID
10-100 MG/5 ML .................................................. 67
CHERACOL D ORAL LIQUID
10-100 MG/5 ML .................................................. 68
CHERATUSSIN AC ORAL LIQUID
10-100 MG/5 ML .................................................. 67
CHERATUSSIN AC ORAL LIQUID
10-100 MG/5 ML .................................................. 68
CHILDREN'S ADVIL ORAL
SUSPENSION 100 MG/5 ML ................. 39
CHILDREN'S ALLER-TEC ORAL
SOLN 1 MG/ML ...................................................... 5
CHILDREN'S ALLER-TEC ORAL
SOLN 1 MG/ML ................................................... 72
CHILDREN'S MUCINEX ORAL
LIQUID 100 MG/5 ML ................................. 68
CHILDREN'S PAIN & FEVER

RELIEF ORAL ELIXIR 160 MG/5
ML ....................................................................................... 30
CHILDREN'S SUDAFED ORAL
LIQUID 15 MG/5 ML .................................... 12
CHILDREN'S SUDAFED ORAL
LIQUID 15 MG/5 ML .................................... 66
CHILDREN'S TRIAMINIC FEVER
REDUCER ORAL LIQUID 160 MG/5
ML ....................................................................................... 31
chlordiazepoxide capsule 10 mg, 25 mg, 5
mg ......................................................................................... 36
chlorhexidine gluconate mouthwash 0.12
% ............................................................................................ 50
chloroquine tablet 250 mg, 500 mg ............. 6
.................................................................................................. 28
.................................................................................................. 47
chlorpheniramine tablet 4 mg .......................... 4
chlorpheniramine tablet 4 mg ....................... 70
chlorpromazine tablet ........................................ 40
chlorpropamide tablet 100 mg, 250 mg
.................................................................................................. 63
chlorthalidone tablet 25 mg, 50 mg ......... 29
chlorthalidone tablet 25 mg, 50 mg ......... 47
..................................................................................................... 4
.................................................................................................. 70
chlorzoxazone tablet 500 mg ........................ 14
cholecalciferol (vitamin d3) capsule
50,000 unit ..................................................................... 84
cholecalciferol (vitamin d3) oral drops
400 unit/ml .................................................................... 84
cholecalciferol (vitamin d3) tablet 1,000
unit, 2,000 unit ........................................................... 84
cholestyramine (with sugar) oral powder
4 gram ............................................................................... 22
cholestyramine (with sugar) powder for
susp in a packet 4 gram ...................................... 22
CHOLESTYRAMINE LIGHT ORAL
POWDER 4 GRAM .......................................... 22
CHOLESTYRAMINE LIGHT
POWDER FOR SUSP IN A PACKET
4 GRAM ........................................................................ 22
ciclopirox topical cream 0.77 % ................. 77
ciclopirox topical gel 0.77 % ......................... 77
ciclopirox topical solution 8 % .................... 77
ciclopirox topical suspension 0.77 %
.................................................................................................. 77
cilostazol tablet 100 mg, 50 mg .................. 19
cilostazol tablet 100 mg, 50 mg .................. 28
cimetidine oral solution 300 mg/5 ml
.................................................................................................. 56
cimetidine tablet 200 mg, 300 mg, 400
mg, 800 mg ................................................................... 56
CIMZIA POWDER FOR
RECONSTITUTION
SUBCUTANEOUS KIT 400 MG (200
MG X 2 VIALS) .................................................... 56
CIMZIA POWDER FOR
RECONSTITUTION
SUBCUTANEOUS KIT 400 MG (200
MG X 2 VIALS) .................................................... 64
89
CIMZIA STARTER KIT

SUBCUTANEOUS SYRINGE KIT
400 MG/2 ML (200 MG/ML X 2)
..................................................................................................
CIMZIA STARTER KIT

SUBCUTANEOUS SYRINGE KIT
400 MG/2 ML (200 MG/ML X 2)
56
64
CIMZIA SUBCUTANEOUS
SYRINGE KIT 400 MG/2 ML (200
MG/ML X 2) ............................................................. 56
CIMZIA SUBCUTANEOUS
SYRINGE KIT 400 MG/2 ML (200
MG/ML X 2) ............................................................. 64
CIPRO ORAL SUSPENSION 250
MG/5 ML, 500 MG/5 ML ............................... 6
CIPRO ORAL SUSPENSION 250
MG/5 ML, 500 MG/5 ML ............................ 10
CIPRODEX EAR
DROPS,SUSPENSION 0.3-0.1 %
.................................................................................................. 48
ciprofloxacin eye drops 0.3 % ...................... 48
ciprofloxacin tablet ................................................. 6
ciprofloxacin tablet .............................................. 10
citalopram oral solution 10 mg/5 ml
.................................................................................................. 42
citalopram tablet 10 mg, 20 mg, 40 mg
.................................................................................................. 42
CLARAVIS ................................................................ 79
clarithromycin er tablet,extended release
24 hr 500 mg ................................................................... 6
clarithromycin er tablet,extended release
24 hr 500 mg ................................................................... 9
clarithromycin oral suspension 125 mg/5
ml, 250 mg/5 ml ........................................................... 6
clarithromycin oral suspension 125 mg/5
ml, 250 mg/5 ml ........................................................... 9
..................................................................................................... 6
..................................................................................................... 9
clemastine tablet 1.34 mg .................................... 3
clemastine tablet 1.34 mg ................................ 70
clindamycin capsule 150 mg, 300 mg
..................................................................................................... 7
clindamycin lotion 1 % ....................................... 73
clindamycin oral solution 75 mg/5 ml
..................................................................................................... 8
clindamycin phosphate topical swab 1 %
.................................................................................................. 73
clindamycin topical gel 1 % ............................ 74
clindamycin topical solution 1 % ............... 74
clindamycin vaginal cream 2 % .................. 74
clindamycin-benzoyl peroxide topical gel
1-5 % .................................................................................. 74
clindamycin-benzoyl peroxide topical gel
1-5 % .................................................................................. 77
clobetasol topical cream 0.05 % ................. 74
clobetasol topical gel 0.05 % ......................... 74
clobetasol topical ointment 0.05 % .......... 74
clobetasol topical solution 0.05 % ............ 74
clomipramine ............................................................. 42
clonazepam tablet .................................................. 35
clonazepam tablet .................................................. 36
clonidine tablet ......................................................... 24
..................................................................................................
clonidine weekly transdermal patch
24
clopidogrel tablet 75 mg .................................... 19
clorazepate dipotassium tablet 15 mg,
3.75 mg, 7.5 mg ........................................................ 35
clorazepate dipotassium tablet 15 mg,
3.75 mg, 7.5 mg ........................................................ 36
CLORPRES ............................................................... 24
CLORPRES ............................................................... 29
CLORPRES ............................................................... 47
CLOTRIM ANTIFUNGAL
TOPICAL CREAM 1 % ................................ 76
CLOTRIMAZOLE FOOT TOPICAL
CREAM 1 % .............................................................. 76
clotrimazole topical cream 1 % .................. 76
clotrimazole topical solution 1 % .............. 76
clotrimazole troche 10 mg ............................... 76
clozapine tablet 100 mg, 200 mg, 25 mg,
50 mg .................................................................................. 34
coal tar (bulk) topical solution 20 %
.................................................................................................. 78
coal tar topical solution 20 % ....................... 78
codeine-guaifenesin oral liquid 10-100
mg/5 ml ............................................................................. 67
codeine-guaifenesin oral liquid 10-100
mg/5 ml ............................................................................. 68
COLACE CAPSULE 100 MG, 50 MG
.................................................................................................. 54
COLCRYS TABLET 0.6 MG .................. 64
COLOCORT ENEMA 100 MG/60 ML
.................................................................................................. 74
COMBISTIX REAGENT STRIPS
.................................................................................................. 43
COMBIVENT RESPIMAT
AEROSOL INHALER 20-100
MCG/ACTUATION ........................................ 13
COMBIVENT RESPIMAT
MCG/ACTUATION ........................................ 15
COMBIVENT RESPIMAT
MCG/ACTUATION ........................................ 67
COMBIVENT RESPIMAT
MCG/ACTUATION ........................................ 72
COMPLERA TABLET 200-25-300
MG ......................................................................................... 8
COMPRO RECTAL SUPPOSITORY
25 MG .............................................................................. 40
COMPRO RECTAL SUPPOSITORY
25 MG .............................................................................. 54
CONDYLOX TOPICAL GEL 0.5 %
.................................................................................................. 79
.................................................................................................. 12
.................................................................................................. 66
.................................................................................................. 68
.................................................................................................. 12
.................................................................................................. 66
.................................................................................................. 68
..................................................................................................
CONSTULOSE ORAL SOLUTION 10

GRAM/15 ML ......................................................... 44
CONTOUR METER KIT .......................... 43
CONTOUR TEST STRIPS ........................ 43
COOL MIST HUMIDIFIER 1
GALLON MISC ................................................... 43
COPAXONE SUBCUTANEOUS
SYRINGE KIT 20 MG/ML ...................... 65
CORMAX TOPICAL SOLUTION
0.05 % ................................................................................ 74
cortisone tablet 25 mg ......................................... 57
CORTIZONE-10 LOTION 1 % ............. 74
CORTIZONE-10 PLUS TOPICAL
CREAM 1 % .............................................................. 75
CORTIZONE-10 TOPICAL CREAM
1 % ....................................................................................... 74
CORTIZONE-10 TOPICAL GEL 1 %
.................................................................................................. 75
CORTIZONE-10 TOPICAL
OINTMENT 1 % .................................................. 75
COUMADIN ORAL ........................................ 16
CREON CAPSULE,DELAYED
RELEASE 12,000-38,000 -60,000
UNIT, 24,000-76,000 -120,000 UNIT,
36,000-114,000- 180,000 UNIT,
6,000-19,000 -30,000 UNIT ......................... 56
CRIXIVAN CAPSULE 200 MG, 400
MG ......................................................................................... 7
cromolyn eye drops 4 % ..................................... 48
cromolyn eye drops 4 % ..................................... 71
.................................................................................................. 48
.................................................................................................. 71
cromolyn solution for nebulization 20
mg/2 ml ............................................................................. 71
CRYSELLE (28) TABLET 0.3-30
MG-MCG .................................................................... 59
CUPRIMINE CAPSULE 250 MG
.................................................................................................. 57
cyanocobalamin (vit b-12) er
tablet,extended release 1,000 mcg ........... 82
cyanocobalamin (vit b-12) injection
solution 1,000 mcg/ml ......................................... 82
cyanocobalamin (vit b-12) sublingual
tablet 1,000 mcg ....................................................... 82
CYCLAFEM 1/35 (28) TABLET 1-35
MG-MCG .................................................................... 59
CYCLAFEM 7/7/7 (28) TABLET
0.5/0.75/1 MG- 35 MCG ................................ 59
cyclobenzaprine tablet 10 mg, 5 mg
.................................................................................................. 14
cyclophosphamide tablet 25 mg, 50 mg
.................................................................................................. 11
cyclosporine capsule 100 mg, 25 mg
.................................................................................................. 65
cyclosporine modified ........................................ 65
cyclosporine modified oral solution 100
mg/ml ................................................................................. 65
CYMBALTA ............................................................ 41
cyproheptadine syrup 2 mg/5 ml ................... 3
cyproheptadine syrup 2 mg/5 ml ................ 70
cyproheptadine tablet 4 mg ............................... 4
cyproheptadine tablet 4 mg ............................ 70
90
CYTRA-2 ORAL SOLUTION 500-334

MG/5 ML ..................................................................... 44
dantrolene oral ......................................................... 14
dapsone tablet 100 mg, 25 mg ......................... 6
DDAVP NASAL SOLUTION 0.1
MG/ML (REFRIG) ........................................... 16
DDAVP NASAL SOLUTION 0.1
MG/ML (REFRIG) ........................................... 63
DEBROX EAR DROPS 6.5 % ............... 50
DELZICOL CAPSULE,DELAYED
RELEASE 400 MG ............................................ 54
DEPO-MEDROL INJ ..................................... 57
DERMA-SMOOTHE/FS BODY OIL
0.01 % ................................................................................ 75
DERMA-SMOOTHE/FS SCALP OIL
0.01 % ................................................................................ 75
DESENEX SPRAY TOPICAL
POWDER 2 % ......................................................... 76
DESENEX TOPICAL CREAM 1 %
.................................................................................................. 76
DESENEX TOPICAL POWDER 2 %
.................................................................................................. 76
DESENEX TOPICAL SPRAY 2 %
.................................................................................................. 76
desipramine oral ..................................................... 42
desmopressin nasal solution 0.1 mg/ml
(refrig) ............................................................................. 16
desmopressin nasal solution 0.1 mg/ml
(refrig) ............................................................................. 63
desmopressin nasal spray 10 mcg/spray
(0.1 ml) ........................................................................... 16
desmopressin nasal spray 10 mcg/spray
(0.1 ml) ........................................................................... 63
.................................................................................................. 16
.................................................................................................. 63
desonide topical ointment 0.05 % .............. 75
DESOWEN LOTION 0.05 % ................... 75
DESQUAM-X TOPICAL CLEANSER
10 %, 5 % ....................................................................... 77
DETROL LA
CAPSULE,EXTENDED RELEASE 2
MG, 4 MG ................................................................... 79
dexamethasone eye drops 0.1 % ................. 49
dexamethasone injection solution 4 mg/ml
.................................................................................................. 57
DEXAMETHASONE INTENSOL
DROPS (CONCENTRATE) 1 MG/ML
.................................................................................................. 57
dexamethasone oral elixir 0.5 mg/5 ml
.................................................................................................. 57
dexamethasone oral solution 0.5 mg/5 ml
.................................................................................................. 57
dexamethasone tablet ........................................ 57
dexchlorpheniramine maleate er
tablet,extended release 6 mg ............................ 4
dexmethylphenidate tablet ............................ 40
DEXPAK 13 DAY TABLETS IN A
DOSE PACK 1.5 MG (51 TABS)
.................................................................................................. 58
DEXPAK 6 DAY TABLETS IN A
DOSE PACK 1.5 MG (21 TABS)
.................................................................................................. 58
dextroamphetamine er capsule,extended
release .............................................................................. 30
dextroamphetamine tablet 10 mg, 5 mg
.................................................................................................. 30
dextroamphetamine-amphetamine er
24hr capsule,extend release .......................... 30
dextromethorphan-guaifenesin syrup
10-100 mg/5 ml .......................................................... 67
dextromethorphan-guaifenesin syrup
10-100 mg/5 ml .......................................................... 68
DIABETIC TUSSIN DM ORAL
LIQUID 10-100 MG/5 ML ......................... 67
DIABETIC TUSSIN DM ORAL
LIQUID 10-100 MG/5 ML ......................... 69
DIABETIC TUSSIN EX ORAL
LIQUID 100 MG/5 ML ................................. 69
DIASTAT ACUDIAL RECTAL KIT
12.5-15-17.5-20 MG, 5-7.5-10 MG
.................................................................................................. 35
DIASTAT ACUDIAL RECTAL KIT
12.5-15-17.5-20 MG, 5-7.5-10 MG
.................................................................................................. 36
.................................................................................................. 35
.................................................................................................. 36
DIAZEPAM INTENSOL ORAL
CONCENTRATE 5 MG/ML .................. 36
diazepam oral solution 5 mg/5 ml ............. 35
diazepam oral solution 5 mg/5 ml ............. 36
diazepam rectal kit ............................................... 35
diazepam rectal kit ............................................... 36
diazepam tablet ....................................................... 35
diazepam tablet ....................................................... 36
diclofenac er tablet,extended release 24
hr 100 mg ........................................................................ 39
diclofenac eye drops 0.1 % .............................. 51
diclofenac potassium tablet 50 mg ........... 39
diclofenac sodium tablet,delayed release
.................................................................................................. 39
dicloxacillin capsule 250 mg, 500 mg
..................................................................................................... 9
dicyclomine capsule 10 mg .............................. 13
dicyclomine tablet 20 mg .................................. 13
didanosine capsule,delayed release 125
mg, 200 mg, 250 mg, 400 mg ........................... 8
diflorasone topical cream 0.05 % .............. 75
diflorasone topical ointment 0.05 %
.................................................................................................. 75
diflunisal tablet 500 mg ..................................... 39
digoxin oral solution 50 mcg/ml ................. 21
digoxin oral solution 50 mcg/ml ................. 24
digoxin tablet 125 mcg, 250 mcg ............... 21
digoxin tablet 125 mcg, 250 mcg ............... 24
dihydroergotamine injection solution 1
mg/ml ................................................................................. 15
dihydroergotamine injection solution 1
mg/ml ................................................................................. 33
DILANTIN CAPSULE 30 MG ............. 24
DILANTIN CAPSULE 30 MG ............. 37
DILANTIN EXTENDED CAPSULE
100 MG ........................................................................... 24
DILANTIN EXTENDED CAPSULE
100 MG ........................................................................... 37
DILANTIN INFATABS CHEWABLE

TABLET 50 MG ................................................... 24
DILANTIN INFATABS CHEWABLE
TABLET 50 MG ................................................... 37
DILANTIN-125 ORAL SUSPENSION
125 MG/5 ML ........................................................... 24
DILANTIN-125 ORAL SUSPENSION
125 MG/5 ML ........................................................... 37
DILT-CD CAPSULE,EXTENDED
300 MG ........................................................................... 22
300 MG ........................................................................... 23
300 MG ........................................................................... 25
300 MG ........................................................................... 29
DILTIA XT CAPSULE, EXTENDED
RELEASE 120 MG, 180 MG, 240 MG
.................................................................................................. 22
.................................................................................................. 23
.................................................................................................. 25
.................................................................................................. 29
diltiazem cd capsule,extended release 24
hr 120 mg, 180 mg, 240 mg, 300 mg
.................................................................................................. 23
hr 120 mg, 180 mg, 240 mg, 300 mg
.................................................................................................. 25
hr 120 mg, 180 mg, 240 mg, 300 mg
.................................................................................................. 29
diltiazem er (xr/xt) capsule,extended
release,controlled 120 mg, 180 mg, 240
mg ......................................................................................... 23
mg ......................................................................................... 25
mg ......................................................................................... 29
diltiazem er capsule,extended release 12
hr .......................................................................................... 23
hr .......................................................................................... 25
hr .......................................................................................... 29
mg, 180 mg, 240 mg, 300 mg, 360 mg,
420 mg ............................................................................... 23
mg, 180 mg, 240 mg, 300 mg, 360 mg,
420 mg ............................................................................... 25
mg, 180 mg, 240 mg, 300 mg, 360 mg,
420 mg ............................................................................... 29
91
diltiazem tablet 120 mg, 30 mg, 60 mg,

90 mg .................................................................................. 23
90 mg .................................................................................. 25
90 mg .................................................................................. 29
DILT-XR CAPSULE, EXTENDED
.................................................................................................. 22
.................................................................................................. 23
.................................................................................................. 25
.................................................................................................. 29
DILTZAC ER
120 MG, 180 MG, 240 MG, 300 MG,
360 MG ........................................................................... 23
DILTZAC ER
120 MG, 180 MG, 240 MG, 300 MG,
360 MG ........................................................................... 25
DILTZAC ER
120 MG, 180 MG, 240 MG, 300 MG,
360 MG ........................................................................... 29
dimenhydrinate tablet 50 mg ............................ 3
dimenhydrinate tablet 50 mg ........................ 54
DIOVAN TABLET ............................................ 20
..................................................................................................... 3
.................................................................................................. 70
diphenhydramine injection solution 50
mg/ml .................................................................................... 3
diphenhydramine injection solution 50
mg/ml ................................................................................. 70
..................................................................................................... 3
.................................................................................................. 70
..................................................................................................... 3
.................................................................................................. 70
..................................................................................................... 3
.................................................................................................. 70
..................................................................................................... 3
.................................................................................................. 70
diphenhydramine tablet 50 mg .................... 34
diphenoxylate-atropine oral liquid
2.5-0.025 mg/5 ml ................................................... 13
2.5-0.025 mg/5 ml ................................................... 53
2.5-0.025 mg/5 ml ................................................... 67
diphenoxylate-atropine tablet 2.5-0.025

mg ......................................................................................... 13
mg ......................................................................................... 53
mg ......................................................................................... 67
dipyridamole oral ................................................... 19
dipyridamole oral ................................................... 29
disopyramide capsule 100 mg, 150 mg
.................................................................................................. 24
disulfiram tablet 250 mg, 500 mg ............. 64
DIURIL ORAL SUSPENSION 250
MG/5 ML ..................................................................... 28
DIURIL ORAL SUSPENSION 250
MG/5 ML ..................................................................... 47
divalproex er tablet,extended release 24
hr 250 mg, 500 mg .................................................. 31
hr 250 mg, 500 mg .................................................. 32
hr 250 mg, 500 mg .................................................. 33
.................................................................................................. 31
.................................................................................................. 32
.................................................................................................. 33
divalproex tablet,delayed release ............ 31
DOCUPRENE TABLET 100 MG
.................................................................................................. 54
docusate calcium capsule 240 mg .............. 54
docusate sodium capsule 100 mg, 250 mg
.................................................................................................. 54
docusate sodium oral liquid 50 mg/5 ml
.................................................................................................. 54
docusate sodium syrup 60 mg/15 ml
.................................................................................................. 54
docusate sodium tablet 100 mg ................... 54
donepezil tablet 10 mg, 5 mg ......................... 15
dorzolamide eye drops 2 % ............................. 49
.................................................................................................. 49
.................................................................................................. 14
.................................................................................................. 19
.................................................................................................. 20
.................................................................................................. 27
doxepin capsule ....................................................... 42
doxepin oral concentrate 10 mg/ml ......... 42
doxycycline hyclate capsule 100 mg, 50
mg ......................................................................................... 10
doxycycline hyclate tablet 100 mg ........... 10
DRAMAMINE LESS DROWSY
TABLET 25 MG ....................................................... 4
DRAMAMINE LESS DROWSY
TABLET 25 MG ................................................... 54
dronabinol capsule 10 mg, 2.5 mg, 5 mg
.................................................................................................. 53
DROXIA ....................................................................... 11
DULCOLAX STOOL SOFTENER

(DOCUSATE) CAPSULE 100 MG
54
DULERA HFA AEROSOL
INHALER 100-5 MCG/ACTUATION,
200-5 MCG/ACTUATION ......................... 15
DULERA HFA AEROSOL
200-5 MCG/ACTUATION ......................... 58
DULERA HFA AEROSOL
200-5 MCG/ACTUATION ......................... 71
DULERA HFA AEROSOL
200-5 MCG/ACTUATION ......................... 72
DUOFILM TOPICAL LIQUID 17 %
.................................................................................................. 77
.................................................................................................. 28
.................................................................................................. 45
E.E.S. 400 TABLET 400 MG ....................... 8
EAR DROPS (CARBAMIDE
PEROXIDE) 6.5 % .............................................. 50
ECOTRIN LOW STRENGTH
TABLET,DELAYED RELEASE 81
MG ...................................................................................... 19
MG ...................................................................................... 33
MG ...................................................................................... 41
ECOTRIN TABLET,DELAYED
RELEASE 325 MG ............................................ 19
RELEASE 325 MG ............................................ 33
RELEASE 325 MG ............................................ 41
..................................................................................................... 4
.................................................................................................. 70
EDURANT TABLET 25 MG .................... 8
ELIDEL TOPICAL CREAM 1 %
.................................................................................................. 79
ELIPHOS TABLET 667 MG ................... 44
ELIXOPHYLLIN ORAL ELIXIR 80
MG/15 ML .................................................................. 26
MG/15 ML .................................................................. 44
MG/15 ML .................................................................. 73
MG/15 ML .................................................................. 80
ELMIRON CAPSULE 100 MG ........... 66
EMCYT CAPSULE 140 MG ................... 11
EMEND CAPSULES IN A DOSE
PACK 125-80-80 MG ....................................... 53
EMEND ORAL ..................................................... 53
EMETROL ORAL SOLUTION .......... 53
EMTRIVA CAPSULE 200 MG ............... 8
enalapril maleate tablet .................................... 20
enalapril-hydrochlorothiazide tablet
10-25 mg, 5-12.5 mg ............................................. 20
..................................................................................................
92
10-25 mg, 5-12.5 mg ............................................. 21
10-25 mg, 5-12.5 mg ............................................. 28
10-25 mg, 5-12.5 mg ............................................. 47
ENBREL SUBCUTANEOUS KIT 25
MG (1 ML) ................................................................. 64
ENBREL SUBCUTANEOUS
SYRINGE 25 MG/0.5ML (0.51), 50
MG/ML (0.98 ML) .............................................. 65
ENBREL SURECLICK
SUBCUTANEOUS PEN INJECTOR
50 MG/ML (0.98 ML) ...................................... 65
ENDOCET TABLET 5-325 MG .......... 31
ENDOCET TABLET 5-325 MG .......... 38
ENFALYTE ORAL SOLUTION
.................................................................................................. 45
enoxaparin subcutaneous solution 300
mg/3 ml ............................................................................. 16
enoxaparin subcutaneous syringe ............ 17
ENPRESSE TABLET 50-30 (6)/75-40
(5)/125-30(10) ............................................................. 59
ENULOSE ORAL SOLUTION 10
GRAM/15 ML ......................................................... 44
EPIPEN 2-PAK
MG/0.3 ML (1:1,000) ........................................ 12
EPIPEN 2-PAK
MG/0.3 ML (1:1,000) ........................................ 67
EPIPEN JR 2-PAK
MG/0.3 ML (1:2,000) ........................................ 12
EPIPEN JR 2-PAK
MG/0.3 ML (1:2,000) ........................................ 67
EPIVIR ORAL SOLUTION 10
MG/ML ............................................................................. 9
EPZICOM TABLET 600-300 MG
..................................................................................................... 9
ergocalciferol (vitamin d2) capsule
50,000 unit ..................................................................... 84
ergocalciferol (vitamin d2) oral drops
8,000 unit/ml ................................................................ 84
ergocalciferol (vitamin d2) tablet 400
unit ....................................................................................... 84
.................................................................................................. 15
.................................................................................................. 33
ERRIN TABLET 0.35 MG ........................ 59
ERY PADS TOPICAL SWAB 2 %
.................................................................................................. 74
erythromycin capsule,delayed release 250
mg ............................................................................................ 8
erythromycin ethylsuccinate tablet 400
mg ............................................................................................ 8
erythromycin eye ointment 5 mg/gram
(0.5 %) ............................................................................. 48
erythromycin tablet 250 mg, 500 mg
..................................................................................................... 8
erythromycin with ethanol topical gel 2 %
.................................................................................................. 74
erythromycin with ethanol topical

solution 2 % .................................................................. 74
erythromycin with ethanol topical swab 2
% ............................................................................................ 74
erythromycin-benzoyl peroxide topical
gel 3-5 % ......................................................................... 74
erythromycin-sulfisoxazole oral
suspension 200-600 mg/5 ml ............................. 6
escitalopram oral solution 5 mg/5 ml
.................................................................................................. 42
escitalopram tablet ............................................... 42
estazolam tablet 1 mg, 2 mg .......................... 36
ESTRACE TABLET 0.5 MG ................... 61
estradiol tablet ......................................................... 61
estradiol weekly transdermal patch
.................................................................................................. 61
estropipate tablet ................................................... 61
ethambutol tablet 100 mg, 400 mg .............. 6
ethosuximide capsule 250 mg ....................... 42
ethosuximide oral solution 250 mg/5 ml
.................................................................................................. 42
etodolac capsule 200 mg, 300 mg .............. 39
etodolac tablet 400 mg, 500 mg .................. 39
etoposide capsule 50 mg .................................... 11
EUFLEXXA INTRA-ARTICULAR
SYRINGE 10 MG/ML ................................... 43
EURAX LOTION 10 % ................................. 78
EURAX TOPICAL CREAM 10 %
.................................................................................................. 78
EVISTA TABLET 60 MG ........................... 61
EXCEDRIN MENSTRUAL
COMPLETE TABLET 250-250-65 MG
.................................................................................................. 19
EXCEDRIN MENSTRUAL
.................................................................................................. 33
EXCEDRIN MENSTRUAL
.................................................................................................. 41
.................................................................................................. 12
.................................................................................................. 67
.................................................................................................. 69
EXELON ORAL SOLUTION 2
MG/ML .......................................................................... 15
EXELON TRANSDERMAL 24
HOUR PATCH 13.3 MG/24 HOUR,
4.6 MG/24 HOUR, 9.5 MG/24 HOUR
.................................................................................................. 15
EXJADE ........................................................................ 57
EXPECTORANT DM SYRUP 10-100
MG/5 ML ..................................................................... 68
EXPECTORANT DM SYRUP 10-100
MG/5 ML ..................................................................... 69
EXPECTORANT TABLET 200 MG
.................................................................................................. 69
famciclovir ...................................................................... 9
famotidine tablet 20 mg, 40 mg .................. 56
FARESTON TABLET 60 MG ............... 11
felbamate oral suspension 600 mg/5 ml
.................................................................................................. 31
felbamate tablet 400 mg, 600 mg .............. 31

................................................................................................. 26
FEMARA TABLET 2.5 MG .................... 11
FEMCON FE CHEWABLE TABLET
0.4MG-35MCG(21) & 75 MG (7) ......... 59
fenofibrate micronized capsule .................. 27
fenofibrate nanocrystallized tablet 145
mg, 48 mg ....................................................................... 27
fenofibrate tablet 160 mg, 54 mg .............. 27
fenoprofen tablet 600 mg .................................. 39
fentanyl transdermal patch ........................... 38
FERGON TABLET 240 MG (27 MG
IRON) .............................................................................. 17
FER-IRON ORAL DROPS 15 MG
IRON (75 MG)/ML ............................................ 17
FERRO-TIME TABLET 325 MG (65
MG IRON) ................................................................. 17
ferrous gluconate tablet 240 mg (27 mg
iron), 324 mg (36 mg iron), 324 mg (38
mg iron), 325 mg (36 mg iron), 325 mg
(37 mg iron) ................................................................ 17
ferrous sulfate oral drops 15 mg iron (75
mg)/ml .............................................................................. 17
ferrous sulfate oral solution 220 mg (44
mg iron)/5 ml .............................................................. 17
ferrous sulfate tablet 325 mg (65 mg
iron) .................................................................................... 17
ferrous sulfate tablet,delayed release 325
mg (65 mg iron) ...................................................... 18
FEVERALL ............................................................... 31
fexofenadine tablet 180 mg ............................... 5
fexofenadine tablet 180 mg ............................ 72
FIBER THERAPY (PSYLLIUM
SEED) ORAL POWDER 3.4
GRAM/5.8 GRAM ............................................. 55
FIBER-LAX TABLET 625 MG ............ 55
finasteride tablet 5 mg ........................................ 64
FINGERSTIX LANCETS .......................... 43
FLAREX EYE DROPS,SUSPENSION
0.1 % ................................................................................... 49
flecainide ....................................................................... 24
FLEET BISACODYL ENEMA 10
MG/30 ML .................................................................. 55
FLEET ENEMA 19-7 GRAM/118 ML
.................................................................................................. 55
FLEET GLYCERIN (ADULT)
RECTAL SUPPOSITORY ......................... 55
FLEET GLYCERIN (CHILD)
RECTAL SUPPOSITORY ......................... 55
FLEET LAXATIVE
MG ...................................................................................... 55
FLEET MINERAL OIL ENEMA
.................................................................................................. 55
FLEET PEDIATRIC ENEMA 9.5-3.5
GRAM/59 ML ......................................................... 55
FLOVENT DISKUS ......................................... 58
FLOVENT DISKUS ......................................... 71
FLOVENT HFA AEROSOL
INHALER 110 MCG/ACTUATION,
220 MCG/ACTUATION, 44
MCG/ACTUATION ........................................ 58
93
FLOVENT HFA AEROSOL

INHALER 110 MCG/ACTUATION,
220 MCG/ACTUATION, 44
MCG/ACTUATION ........................................ 71
fluconazole ...................................................................... 6
fluconazole oral suspension 10 mg/ml, 40
mg/ml .................................................................................... 6
fludrocortisone tablet 0.1 mg ........................ 58
fluocinolone topical cream 0.025 %
.................................................................................................. 75
fluocinolone topical solution 0.01 %
.................................................................................................. 75
fluocinonide topical cream 0.05 % ........... 75
fluocinonide topical gel 0.05 % ................... 75
fluocinonide topical ointment 0.05 %
.................................................................................................. 75
fluocinonide topical solution 0.05 %
.................................................................................................. 75
FLUOR-A-DAY (WITH XYLITOL)
.................................................................................................. 64
fluorometholone eye drops,suspension 0.1
% ............................................................................................ 49
FLUOROPLEX TOPICAL CREAM 1
% ............................................................................................ 79
fluorouracil topical cream 5 % .................... 79
fluorouracil topical solution 2 %, 5 %
.................................................................................................. 79
fluoxetine capsule 10 mg, 20 mg, 40 mg
.................................................................................................. 42
fluoxetine oral solution 20 mg/5 ml
.................................................................................................. 42
fluoxetine tablet 10 mg, 20 mg .................... 42
fluphenazine decanoate injection solution
25 mg/ml ......................................................................... 40
fluphenazine injection solution 2.5 mg/ml
.................................................................................................. 40
fluphenazine oral concentrate 5 mg/ml
.................................................................................................. 40
fluphenazine oral elixir 2.5 mg/5 ml
.................................................................................................. 40
fluphenazine tablet ............................................... 40
flurazepam capsule 15 mg, 30 mg ............. 36
flurbiprofen eye drops 0.03 % ...................... 51
flurbiprofen tablet 100 mg, 50 mg ............ 39
flutamide capsule 125 mg ................................. 11
fluticasone nasal spray,suspension 50
mcg/actuation ............................................................. 49
fluticasone nasal spray,suspension 50
mcg/actuation ............................................................. 71
fluticasone topical cream 0.05 % ............... 75
fluticasone topical ointment 0.005 %
.................................................................................................. 75
fluvoxamine tablet 100 mg, 25 mg, 50 mg
.................................................................................................. 42
FLUZONE 2013-2014 (PF)
45 MCG (15 MCG X 3)/0.5 ML ............. 73
FLUZONE 2013-2014 (PF)
INTRAMUSCULAR SYRINGE 45
MCG (15 MCG X 3)/0.5 ML .................... 73
FLUZONE 2013-2014
45 MCG (15 MCG X 3)/0.5 ML ............. 73
FLUZONE HIGH-DOSE 2013-2014

(PF) INTRAMUSCULAR SYRINGE
180 MCG/0.5 ML ................................................. 73
FLUZONE INTRADERM 2013-14
(PF) INTRADERMAL SYRINGE 27
MCG/0.1 ML ............................................................ 73
FML FORTE EYE
DROPS,SUSPENSION 0.25 % .............. 49
FML S.O.P. EYE OINTMENT 0.1 %
.................................................................................................. 49
FOAMING ANTACID CHEWABLE
TABLET 80-20 MG ........................................... 52
folic acid tablet ........................................................ 82
fosinopril ....................................................................... 20
fosinopril ....................................................................... 21
furosemide oral solution 10 mg/ml, 40
mg/5 ml ............................................................................. 27
furosemide oral solution 10 mg/ml, 40
mg/5 ml ............................................................................. 44
furosemide tablet .................................................... 27
furosemide tablet .................................................... 44
FUZEON SUBCUTANEOUS
SOLUTION 90 MG .............................................. 7
gabapentin capsule ............................................... 31
.................................................................................................. 31
.................................................................................................. 32
gabapentin tablet 600 mg, 800 mg ........... 31
gabapentin tablet 600 mg, 800 mg ........... 32
GABITRIL TABLET ....................................... 32
GAS-X CHEWABLE TABLET 80 MG
.................................................................................................. 53
GAS-X EXTRA STRENGTH
CHEWABLE TABLET 125 MG .......... 53
GAVILAX ORAL POWDER 17
GRAM/DOSE ......................................................... 55
GAVISCON CHEWABLE TABLET
80-14.2 MG ................................................................. 52
gemfibrozil tablet 600 mg ................................ 27
GENERLAC ORAL SOLUTION 10
GRAM/15 ML ......................................................... 44
GENGRAF CAPSULE 100 MG, 25
MG ...................................................................................... 65
GENGRAF ORAL SOLUTION 100
MG/ML .......................................................................... 65
GENTAK EYE OINTMENT 0.3 % (3
MG/GRAM) .............................................................. 48
gentamicin eye drops 0.3 % ............................ 48
gentamicin eye ointment 0.3 % (3
mg/gram) ....................................................................... 48
gentamicin topical cream 0.1 % ................. 74
gentamicin topical ointment 0.1 % ........... 74
GIANVI TABLET 3-20 MG-MCG
.................................................................................................. 59
GILDESS FE TABLET 1-20
MG-MCG, 1.5-30 MG-MCG ................... 59
glimepiride ................................................................... 63
glipizide er tablet, extended release 24 hr
.................................................................................................. 63
glipizide tablet 10 mg, 5 mg ........................... 63
GLUCAGEN HYPOKIT INJECTION
1 MG ................................................................................. 61
GLUCAGEN SOLUTION FOR
INJECTION 1 MG ............................................. 61
GLUCAGON EMERGENCY
INJECTION KIT 1 MG ................................ 61
glucose chewable tablet 4 gram .................. 44
glyburide micronized tablet .......................... 63
glyburide tablet ........................................................ 63
glyburide-metformin ........................................... 59
glyburide-metformin ........................................... 63
glycerin (adult) rectal suppository
.................................................................................................. 55
glycerin (child) rectal suppository
.................................................................................................. 55
glycopyrrolate tablet 1 mg, 2 mg .............. 13
GOLYTELY ORAL POWDER
PACKET 227.1-21.5-6.36 GRAM
.................................................................................................. 55
GRIFULVIN V TABLET 500 MG
..................................................................................................... 5
griseofulvin microsize oral suspension 125
mg/5 ml ................................................................................ 6
GRIS-PEG (ULTRAMICROSIZE)
TABLET 125 MG, 250 MG .......................... 6
GUAIATUSSIN AC ORAL LIQUID
10-100 MG/5 ML .................................................. 68
GUAIATUSSIN AC ORAL LIQUID
10-100 MG/5 ML .................................................. 69
guaifenesin oral liquid 100 mg/5 ml
.................................................................................................. 69
guaifenesin tablet 200 mg ................................ 69
guanfacine tablet 1 mg, 2 mg ........................ 24
guanfacine tablet 1 mg, 2 mg ........................ 36
HALFLYTELY-BISACODYL
W-FLAVOR PACK ORAL KIT 5-210
MG-GRAM ............................................................... 55
halobetasol propionate topical ointment
0.05 % ................................................................................ 75
haloperidol ................................................................... 36
haloperidol decanoate intramuscular
solution 100 mg/ml, 50 mg/ml ...................... 36
haloperidol injection solution 5 mg/ml
.................................................................................................. 36
haloperidol oral concentrate 2 mg/ml
.................................................................................................. 36
HEATHER TABLET 0.35 MG ............. 59
HEMA-COMBISTIX STRIPS ............... 43
HEMORRHOIDAL HYGIENE
TOPICAL PADS 50 % .................................... 76
heparin (porcine) (bulk) powder 1
million unit .................................................................... 17
heparin (porcine) (bulk) powder 190,000
unit/gram ........................................................................ 17
heparin (porcine) injection cartridge
5,000 unit/ml (1 ml) ............................................. 17
heparin (porcine) injection solution
.................................................................................................. 17
heparin (porcine) powder 100,000 unit,
25,000 unit ..................................................................... 17
heparin flush(porcine)-0.9 % sodium
chloride intravenous kit 100 unit/ml
.................................................................................................. 17
heparin lock flush (porcine) intravenous
solution 10 unit/ml, 100 unit/ml .................. 17
heparin lock flush (porcine) intravenous
syringe 10 unit/ml, 100 unit/ml .................... 17
94
HEPARIN LOCK FLUSH

INTRAVENOUS SOLUTION 10
UNIT/ML ..................................................................... 17
HEPARIN LOCK FLUSH
INTRAVENOUS SYRINGE 10
UNIT/ML ..................................................................... 17
HEPARIN LOCK INTRAVENOUS
SOLUTION 100 UNIT/ML ....................... 17
HEXALEN CAPSULE 50 MG .............. 11
HOMATROPAIRE EYE DROPS 5 %
.................................................................................................. 51
HUMALOG KWIKPEN
SUBCUTANEOUS 100 UNIT/ML
.................................................................................................. 62
(50-50) ............................................................................... 62
HUMALOG MIX 50-50
SUBCUTANEOUS SUSPENSION 100
UNIT/ML (50-50) ................................................. 62
(75-25) ............................................................................... 62
HUMALOG MIX 75-25
SUBCUTANEOUS SUSPENSION 100
UNIT/ML (75-25) ................................................. 62
HUMALOG SUBCUTANEOUS
CARTRIDGE 100 UNIT/ML ................. 62
HUMALOG SUBCUTANEOUS
SOLUTION 100 UNIT/ML ....................... 62
humidifiers misc ..................................................... 43
HUMIRA CROHN'S DISEASE
STARTER PACK SUBCUTANEOUS
PEN KIT 40 MG/0.8 ML ............................. 65
HUMIRA PEN SUBCUTANEOUS
KIT 40 MG/0.8 ML ............................................ 65
HUMIRA PSORIASIS STARTER
PACK SUBCUTANEOUS PEN KIT
40 MG/0.8 ML ......................................................... 65
HUMIRA SUBCUTANEOUS KIT 20
MG/0.4 ML, 40 MG/0.8 ML ..................... 65
HUMULIN 70/30 PEN
(70-30) ............................................................................... 62
HUMULIN 70/30 SUBCUTANEOUS
.................................................................................................. 62
HUMULIN N PEN
SUBCUTANEOUS 100 UNIT/ML (3
ML) ..................................................................................... 62
HUMULIN N SUBCUTANEOUS
SUSPENSION 100 UNIT/ML ................ 62
HUMULIN R INJECTION
SOLUTION 100 UNIT/ML ....................... 62
hydralazine oral ...................................................... 26
HYDRO SKIN LOTION 1 % ................. 75
.................................................................................................. 28
.................................................................................................. 47
hydrochlorothiazide tablet ............................. 47
hydrochlorothiazide tablet 12.5 mg, 25
mg, 50 mg ....................................................................... 28
hydrocodone-acetaminophen oral solution
7.5-500 mg/15 ml ..................................................... 31
hydrocodone-acetaminophen oral solution

7.5-500 mg/15 ml ..................................................... 38
hydrocodone-acetaminophen tablet
10-325 mg, 10-500 mg, 10-650 mg,
10-660 mg, 10-750 mg, 2.5-500 mg, 5-325
mg, 5-500 mg, 7.5-325 mg, 7.5-500 mg,
7.5-650 mg, 7.5-750 mg ..................................... 31
hydrocodone-acetaminophen tablet
10-325 mg, 10-500 mg, 10-650 mg,
10-660 mg, 10-750 mg, 2.5-500 mg, 5-325
mg, 5-500 mg, 7.5-325 mg, 7.5-500 mg,
7.5-650 mg, 7.5-750 mg ..................................... 38
.................................................................................................. 38
.................................................................................................. 39
hydrocortisone enema 100 mg/60 ml
.................................................................................................. 75
hydrocortisone lotion 1 % ................................ 75
hydrocortisone oral .............................................. 58
hydrocortisone topical cream 0.5 %, 1 %,
2.5 % ................................................................................... 75
hydrocortisone topical ointment 0.5 %, 1
%, 2.5 % .......................................................................... 75
hydrocortisone-acetic acid ear drops 1-2
% ............................................................................................ 50
hydromorphone rectal suppository 3 mg
.................................................................................................. 38
hydromorphone tablet ........................................ 38
hydroxychloroquine tablet 200 mg ............. 6
hydroxyurea capsule 500 mg ........................ 11
hydroxyzine hcl syrup 10 mg/5 ml ............... 4
hydroxyzine hcl syrup 10 mg/5 ml ............ 34
hydroxyzine hcl tablet .......................................... 4
hydroxyzine hcl tablet ....................................... 34
hydroxyzine pamoate capsule ........................ 4
hydroxyzine pamoate capsule ..................... 34
HYOMAX-SL SUBLINGUAL
TABLET 0.125 MG ............................................ 13
hyoscyamine er tablet,extended
release,12 hr 0.375 mg ........................................ 13
hyoscyamine oral drops 0.125 mg/ml
.................................................................................................. 13
hyoscyamine oral elixir 0.125 mg/5 ml
.................................................................................................. 13
hyoscyamine sublingual tablet 0.125 mg
.................................................................................................. 13
hyoscyamine sulfate tablet 0.125 mg
.................................................................................................. 13
HYOSYNE ORAL DROPS 0.125
MG/ML .......................................................................... 13
HYOSYNE ORAL ELIXIR 0.125
MG/5 ML ..................................................................... 13
HYPERCARE TOPICAL SOLUTION
20 % .................................................................................... 76
HYPERRHO S/D
INTRAMUSCULAR SYRINGE 1,500
UNIT (300 MCG) ................................................. 73
ibuprofen oral suspension 100 mg/5 ml
.................................................................................................. 39
ibuprofen tablet 200 mg, 400 mg, 600 mg,
800 mg ............................................................................... 39
ICAPS PLUS TABLET .................................. 80
ICY HOT TOPICAL CREAM 30-10 %
.................................................................................................. 41
imipramine hcl .......................................................... 42

imiquimod topical cream packet 5 %
.................................................................................................. 79
INATAL ADVANCE TABLET
90-1-50 MG ................................................................. 18
90-1-50 MG ................................................................. 45
90-1-50 MG ................................................................. 80
90-1-50 MG ................................................................. 82
INCIVEK TABLET 375 MG ...................... 7
indapamide tablet 1.25 mg, 2.5 mg .......... 29
indapamide tablet 1.25 mg, 2.5 mg .......... 47
indomethacin capsule 25 mg, 50 mg
.................................................................................................. 39
indomethacin er capsule,extended release
75 mg .................................................................................. 39
INFANTS GAS RELIEF ORAL
.................................................................................................. 53
INFANT'S IBUPROFEN ORAL
DROPS,SUSPENSION 50 MG/1.25
ML ....................................................................................... 39
INFANT'S MOTRIN ORAL
DROPS,SUSPENSION 50 MG/1.25
ML ....................................................................................... 39
INFANTS' MYLICON ORAL
.................................................................................................. 53
INTELENCE TABLET 100 MG ............ 8
INVEGA SUSTENNA ................................... 34
INVIRASE CAPSULE 200 MG .............. 7
INVIRASE TABLET 500 MG ................... 7
IONIL T SHAMPOO 1 % ............................ 78
ipecac syrup ............................................................... 56
ipratropium bromide nasal spray 0.03 %,
0.06 % ................................................................................ 50
ipratropium bromide solution for
inhalation 0.02 % ..................................................... 13
ipratropium bromide solution for
inhalation 0.02 % ..................................................... 67
irbesartan ...................................................................... 20
irbesartan-hydrochlorothiazide tablet
150-12.5 mg, 300-12.5 mg ............................... 20
150-12.5 mg, 300-12.5 mg ............................... 28
150-12.5 mg, 300-12.5 mg ............................... 47
ISENTRESS CHEWABLE TABLET
100 MG, 25 MG ........................................................ 7
ISENTRESS TABLET 400 MG ............... 7
isoniazid oral solution 50 mg/5 ml ............... 6
isoniazid tablet 100 mg, 300 mg .................... 6
ISOPTO CARBACHOL EYE DROPS
1.5 %, 3 % ...................................................................... 51
ISOPTO HOMATROPINE EYE
DROPS 2 % ................................................................ 51
ISOPTO HOMATROPINE EYE
DROPS 5 % ................................................................ 52
isosorbide dinitrate er tablet,extended
release 40 mg .............................................................. 27
isosorbide dinitrate sublingual tablet 2.5
mg, 5 mg .......................................................................... 28
isosorbide dinitrate tablet ............................... 28
95
isosorbide mononitrate er tablet,extended

release 24 hr ............................................................... 28
isosorbide mononitrate tablet 10 mg, 20
mg ......................................................................................... 28
ITCH-X HC LOTION 1 % ......................... 75
I-VITE TABLET 1,000 UNIT-200
MG-60 UNIT-2 MG .......................................... 80
JANTOVEN .............................................................. 16
JOLIVETTE TABLET 0.35 MG .......... 59
JUNEL 1.5/30 (21) TABLET 1.5-30
MG-MCG .................................................................... 59
JUNEL 1/20 (21) TABLET 1-20
MG-MCG .................................................................... 60
JUNEL FE 1.5/30 (28) TABLET 1.5-30
MG-MCG .................................................................... 60
JUNEL FE 1/20 (28) TABLET 1-20
MG-MCG .................................................................... 60
KALETRA ORAL SOLUTION
400-100 MG/5 ML .................................................. 7
KALETRA TABLET 100-25 MG,
200-50 MG ...................................................................... 7
KALEXATE ORAL POWDER ............ 45
KAOPECTATE (BISMUTH
SUBSALICYLATE) ORAL
SUSPENSION 262 MG/15 ML .............. 52
KAOPECTATE (BISMUTH
SUBSALICYLATE) ORAL
SUSPENSION 262 MG/15 ML .............. 53
KAOPECTATE (DOCUSATE
CALCIUM) CAPSULE 240 MG ......... 55
KAOPECTATE EX STR (BISMUTH
SS) ORAL SUSPENSION 525 MG/15
ML ....................................................................................... 52
KAOPECTATE EX STR (BISMUTH
SS) ORAL SUSPENSION 525 MG/15
ML ....................................................................................... 53
KARIVA (28) TABLET 0.15-0.02MG
X21 /0.01 MG X 5 ................................................ 60
K-EFFERVESCENT TABLET 25
MEQ .................................................................................. 45
KELNOR 1/35 (28) TABLET 1-35
MG-MCG .................................................................... 60
KENALOG TOPICAL AEROSOL
0.147 MG/GRAM ................................................ 75
ketoconazole shampoo 2 % ............................. 76
ketoconazole tablet 200 mg ............................... 6
ketoconazole topical cream 2 % ................. 76
KETO-DIASTIX STRIPS ........................... 43
ketoprofen capsule 50 mg, 75 mg .............. 39
ketoprofen er 24 hr capsule,extended
release 200 mg ........................................................... 39
ketorolac eye drops 0.4 % ................................ 51
ketorolac eye drops 0.5 % ................................ 51
ketorolac tablet 10 mg ........................................ 39
ketotifen eye drops 0.025 % ........................... 48
KIONEX ORAL POWDER ..................... 45
KIONEX ORAL SUSPENSION 15
GRAM/60 ML ......................................................... 45
KLOR-CON 10
MEQ .................................................................................. 45
KLOR-CON M10
MEQ .................................................................................. 45
KLOR-CON M20
MEQ .................................................................................. 45
KLOR-CON ORAL PACKET 20
MEQ .................................................................................. 45
KLOR-CON TABLET,EXTENDED
RELEASE 8 MEQ ............................................... 45
KONSYL (SUGAR) ORAL POWDER
.................................................................................................. 55
KONSYL (WITH ASPARTAME)
ORAL POWDER ................................................. 55
KONSYL (WITH ASPARTAME)
ORAL POWDER PACKET 3.5
GRAM ............................................................................ 55
KONSYL ORAL POWDER .................... 55
labetalol oral .............................................................. 14
labetalol oral .............................................................. 15
labetalol oral .............................................................. 19
labetalol oral .............................................................. 20
labetalol oral .............................................................. 21
labetalol oral .............................................................. 22
labetalol oral .............................................................. 25
LABSTIX REAGENT STRIPS ............. 43
LAC-HYDRIN TWELVE LOTION 12
% ............................................................................................ 77
lactulose oral solution 10 gram/15 ml
.................................................................................................. 44
LAMICTAL STARTER (BLUE) KIT
TABLETS IN A DOSE PACK 25 MG
(35) ....................................................................................... 32
LAMICTAL STARTER (ORANGE)
KIT TABLETS, DOSE PACK 25 MG
(42) -100 MG (7) ..................................................... 32
LAMISIL AF TOPICAL POWDER 1
% ............................................................................................ 79
LAMISIL AT TOPICAL CREAM 1 %
.................................................................................................. 73
lamivudine tablet 150 mg, 300 mg ............... 9
lamivudine-zidovudine tablet 150-300 mg
..................................................................................................... 9
lamotrigine chewable dispersible tablet 25
mg, 5 mg .......................................................................... 32
lamotrigine tablet 100 mg, 150 mg, 200
mg, 25 mg ....................................................................... 32
LANTUS SOLOSTAR
100 UNIT/ML (3 ML) ..................................... 62
LANTUS SUBCUTANEOUS
SOLUTION 100 UNIT/ML ....................... 62
latanoprost eye drops 0.005 % ..................... 52
LAXATIVE STOOL SOFTENER
WITH SENNA TABLET 8.6-50 MG
.................................................................................................. 55
LEENA 28 TABLET 0.5/1/0.5-35
MG-MCG .................................................................... 60
leflunomide tablet 10 mg, 20 mg ................ 65
LESSINA TABLET 0.1-20 MG-MCG
.................................................................................................. 60
leucovorin calcium oral ..................................... 64
LEUKERAN TABLET 2 MG ................ 11
leuprolide subcutaneous kit 1 mg/0.2 ml
.................................................................................................. 11
.................................................................................................. 15

..................................................................................................
72
LEVEMIR FLEXPEN SOLUTION

100 UNIT/ML (3 ML) ..................................... 62
LEVEMIR SUBCUTANEOUS
SOLUTION 100 UNIT/ML ....................... 62
levetiracetam oral solution 100 mg/ml
.................................................................................................. 32
levetiracetam tablet 1,000 mg, 250 mg,
500 mg, 750 mg ......................................................... 32
levobunolol eye drops 0.25 % ........................ 49
levobunolol eye drops 0.5 % ........................... 49
levocetirizine tablet 5 mg ..................................... 5
levocetirizine tablet 5 mg .................................. 72
..................................................................................................... 6
.................................................................................................. 10
levofloxacin tablet .................................................... 6
levofloxacin tablet ................................................. 10
LEVORA-28 TABLET 0.15-30
MG-MCG .................................................................... 60
levothyroxine tablet ............................................. 64
LEXIVA TABLET 700 MG ......................... 7
lidocaine mucosal gel 2 % ................................ 51
lidocaine mucosal solution 2 %, 4 %
.................................................................................................. 51
lidocaine topical ointment 5 % .................... 76
LIDOCAINE VISCOUS MUCOSAL
SOLUTION 2 % .................................................... 51
lidocaine-prilocaine topical cream 2.5-2.5
% ............................................................................................ 76
lidocaine-prilocaine topical kit 2.5-2.5 %
.................................................................................................. 76
lindane lotion 1 % ................................................... 78
lindane shampoo 1 % ............................................ 78
LINZESS CAPSULE 145 MCG, 290
MCG .................................................................................. 56
liothyronine oral ..................................................... 64
lisinopril tablet 10 mg, 2.5 mg, 20 mg, 30
mg, 40 mg, 5 mg ....................................................... 20
lisinopril tablet 10 mg, 2.5 mg, 20 mg, 30
mg, 40 mg, 5 mg ....................................................... 21
lisinopril-hydrochlorothiazide tablet
10-12.5 mg, 20-12.5 mg, 20-25 mg .......... 20
10-12.5 mg, 20-12.5 mg, 20-25 mg .......... 21
10-12.5 mg, 20-12.5 mg, 20-25 mg .......... 28
10-12.5 mg, 20-12.5 mg, 20-25 mg .......... 47
lithium carbonate ................................................... 32
lithium carbonate er tablet,extended
release 300 mg, 450 mg ...................................... 32
lithium carbonate tablet 300 mg ................ 33
LOFIBRA .................................................................... 27
LOFIBRA TABLET 160 MG, 54 MG
.................................................................................................. 27
LOHIST - D ORAL LIQUID 2-30
MG/5 ML ........................................................................ 4
MG/5 ML ..................................................................... 12
MG/5 ML ..................................................................... 67
96

MG/5 ML ..................................................................... 70
loperamide capsule 2 mg ................................... 53
loperamide oral liquid 1 mg/5 ml ............... 53
loperamide tablet 2 mg ....................................... 53
loratadine oral solution 5 mg/5 ml .............. 5
loratadine oral solution 5 mg/5 ml ........... 72
loratadine tablet 10 mg ......................................... 5
loratadine tablet 10 mg ...................................... 72
LORAZEPAM INTENSOL ORAL
lorazepam oral concentrate 2 mg/ml
.................................................................................................. 36
lorazepam tablet 0.5 mg, 1 mg, 2 mg
.................................................................................................. 36
LORTAB TABLET 5-500 MG, 7.5-500
MG ...................................................................................... 31
LORTAB TABLET 5-500 MG, 7.5-500
MG ...................................................................................... 38
losartan ........................................................................... 20
losartan-hydrochlorothiazide ...................... 20
LOTRIMIN AF TOPICAL POWDER
2 % ....................................................................................... 76
lovastatin tablet 10 mg, 20 mg, 40 mg
.................................................................................................. 27
LOW-OGESTREL (28) TABLET
0.3-30 MG-MCG ................................................... 60
loxapine succinate ................................................. 34
LOXITANE CAPSULE 5 MG ............... 34
LUFYLLIN TABLET 200 MG, 400
MG ...................................................................................... 73
LUFYLLIN TABLET 200 MG, 400
MG ...................................................................................... 80
LUPRON DEPOT (3 MONTH)
INTRAMUSCULAR SYRINGE KIT
11.25 MG, 22.5 MG ............................................ 11
LUPRON DEPOT (4 MONTH)
30 MG .............................................................................. 11
LUPRON DEPOT
3.75 MG .......................................................................... 11
LUPRON DEPOT-PED ............................... 11
LUTERA (28) TABLET 0.1-20
MG-MCG .................................................................... 60
LYSODREN TABLET 500 MG ........... 11
MAALOX ADVANCED
CHEWABLE TABLET 1,000-60 MG
.................................................................................................. 52
MAALOX ADVANCED
CHEWABLE TABLET 1,000-60 MG
.................................................................................................. 54
MAALOX ADVANCED ORAL
.................................................................................................. 52
MAALOX ADVANCED ORAL
.................................................................................................. 54
MAALOX MAXIMUM STRENGTH
ORAL SUSPENSION 400-400-40
MG/5 ML ..................................................................... 52
MAALOX MAXIMUM STRENGTH

ORAL SUSPENSION 400-400-40
MG/5 ML ..................................................................... 54
MACRODANTIN CAPSULE 25 MG
.................................................................................................. 11
magnesium citrate oral solution .............. 55
magnesium oxide tablet 400 mg ................. 52
maprotiline .................................................................. 42
MARLEXATE ORAL POWDER
.................................................................................................. 45
MATULANE CAPSULE 50 MG
.................................................................................................. 11
MATZIM LA ........................................................... 23
MATZIM LA ........................................................... 26
MATZIM LA ........................................................... 29
meclizine chewable tablet 25 mg ................... 4
meclizine chewable tablet 25 mg ................ 54
meclizine tablet 12.5 mg, 25 mg .................... 4
meclizine tablet 12.5 mg, 25 mg ................. 54
meclofenamate capsule 100 mg, 50 mg
.................................................................................................. 39
MEDROL TABLET 2 MG ........................ 58
medroxyprogesterone intramuscular
suspension 150 mg/ml .......................................... 63
medroxyprogesterone intramuscular
syringe 150 mg/ml ................................................... 63
medroxyprogesterone oral ............................. 63
mefloquine tablet 250 mg .................................... 6
MEGA MULTIPLE/CHELATED
MINERAL TABLET ....................................... 80
MEGA MULTIVITAMIN
W/MINERAL TAB ............................................ 80
MEGACE ES ORAL SUSPENSION
625 MG/5 ML ........................................................... 11
megestrol oral suspension 400 mg/10 ml
(10 ml), 400 mg/10 ml (40 mg/ml)
.................................................................................................. 11
megestrol tablet 20 mg, 40 mg .................... 11
meloxicam tablet 15 mg, 7.5 mg ................ 39
MENEST ...................................................................... 61
meperidine oral solution 50 mg/5 ml
.................................................................................................. 38
meperidine tablet 100 mg, 50 mg .............. 38
MEPHYTON TABLET 5 MG ............... 84
meprobamate tablet 200 mg, 400 mg
.................................................................................................. 34
mercaptopurine tablet 50 mg ........................ 11
mesalamine enema 4 gram/60 ml .............. 54
METADATE ER
MG ...................................................................................... 40
METAMUCIL FIBER SINGLES
ORAL POWDER PACKET 3.4
GRAM ............................................................................ 55
METAMUCIL SUGAR-FREE
(ASPARTAME) ORAL POWDER 3.3
GRAM/5.95 GRAM .......................................... 55
metaproterenol syrup 10 mg/5 ml ............. 15
metaproterenol syrup 10 mg/5 ml ............. 72
.................................................................................................. 15
.................................................................................................. 72
metformin er tablet,extended release 24
hr 500 mg, 750 mg .................................................. 59
metformin tablet 1,000 mg, 500 mg, 850

mg ......................................................................................... 59
METHADONE INTENSOL ORAL
CONCENTRATE 10 MG/ML ............... 38
methadone oral concentrate 10 mg/ml
.................................................................................................. 38
methadone oral solution 10 mg/5 ml, 5
mg/5 ml ............................................................................. 38
methadone tablet 10 mg, 5 mg ..................... 38
methazolamide tablet 25 mg, 50 mg
.................................................................................................. 49
methimazole tablet 10 mg, 5 mg ................ 59
methocarbamol tablet 500 mg, 750 mg
.................................................................................................. 14
methotrexate sodium (pf) injection
solution 25 mg/ml .................................................... 12
methotrexate sodium (pf) injection
solution 25 mg/ml .................................................... 65
methotrexate sodium injection solution 25
mg/ml ................................................................................. 11
methotrexate sodium injection solution 25
mg/ml ................................................................................. 65
methotrexate sodium tablet 2.5 mg ......... 12
methotrexate sodium tablet 2.5 mg ......... 65
methyclothiazide tablet 5 mg ........................ 28
methyclothiazide tablet 5 mg ........................ 47
methyldopa tablet 250 mg, 500 mg ......... 13
methyldopa tablet 250 mg, 500 mg ......... 24
methylphenidate er tablet,extended
release 10 mg, 20 mg ............................................ 40
methylphenidate er tablet,extended
release 24 hr 18 mg, 27 mg, 36 mg, 54 mg
.................................................................................................. 40
methylphenidate tablet ...................................... 40
methylprednisolone acetate suspension
for injection 40 mg/ml, 80 mg/ml .............. 58
methylprednisolone sodium succ
intravenous solution 1,000 mg ..................... 58
methylprednisolone sodium succ solution
for injection 125 mg, 40 mg ............................ 58
methylprednisolone tablet .............................. 58
methylprednisolone tablets in a dose pack
4 mg ..................................................................................... 58
metoclopramide oral solution 5 mg/5 ml
.................................................................................................. 57
metoclopramide tablet 10 mg, 5 mg
.................................................................................................. 57
metolazone tablet ................................................... 29
metolazone tablet ................................................... 47
metoprolol succinate er tablet,extended
release 24 hr ............................................................... 16
release 24 hr ............................................................... 21
release 24 hr ............................................................... 22
release 24 hr ............................................................... 25
metoprolol tartrate oral ................................... 16
METROGEL VAGINAL 0.75 % ......... 74
..................................................................................................... 5
97

.....................................................................................................
metronidazole topical cream 0.75 %
74
metronidazole topical gel 0.75 % .............. 74
metronidazole vaginal gel 0.75 % ............. 74
mexiletine ..................................................................... 24
MICATIN TOPICAL CREAM 2 %
.................................................................................................. 76
MICONAZOLE 7 VAGINAL
CREAM 2 % .............................................................. 76
MICONAZOLE 7 VAGINAL
SUPPOSITORY 100 MG ............................. 76
miconazole nitrate topical cream 2 %
.................................................................................................. 77
miconazole nitrate vaginal cream 2 %
.................................................................................................. 77
miconazole nitrate vaginal suppository
100 mg ............................................................................... 77
MICONAZOLE-3 VAGINAL KIT 200
MG- 2 % (9 GRAM) .......................................... 77
MICONAZOLE-3 VAGINAL
SUPPOSITORY 200 MG ............................. 77
MICROGESTIN 1.5/30 (21) TABLET
1.5-30 MG-MCG ................................................... 60
MICROGESTIN 1/20 (21) TABLET
1-20 MG-MCG ........................................................ 60
MICROGESTIN FE 1.5/30 (28)
TABLET 1.5-30 MG-MCG ........................ 60
MICROGESTIN FE 1/20 (28)
TABLET 1-20 MG-MCG ............................. 60
MICROLET LANCET .................................. 43
midodrine ...................................................................... 13
MILLIPRED DP TABLETS IN A
DOSE PACK 5 MG (21 TABS), 5 MG
(48 TABS) ..................................................................... 58
MILLIPRED TABLET 5 MG ................ 58
mineral oil enema ................................................. 55
MINERAL OIL HEAVY ORAL ......... 55
MINERAL OIL LAXATIVE ORAL
.................................................................................................. 55
mineral oil oral ....................................................... 55
mineral oil topical ................................................ 77
minocycline capsule 100 mg, 50 mg, 75
mg ......................................................................................... 10
minoxidil tablet 10 mg, 2.5 mg ................... 26
MINTOX PLUS CHEWABLE
TABLET 200-200-25 MG ............................. 54
MIRALAX ORAL POWDER 17
GRAM/DOSE ......................................................... 55
mirtazapine ................................................................. 32
misoprostol tablet 100 mcg, 200 mcg
.................................................................................................. 57
mometasone lotion 0.1 % ................................. 75
mometasone topical cream 0.1 % .............. 75
mometasone topical ointment 0.1 %
.................................................................................................. 75
MONONESSA (28) TABLET 0.25-35
MG-MCG .................................................................... 60
montelukast chewable tablet 4 mg, 5 mg
.................................................................................................. 71
montelukast oral granules in packet 4 mg
.................................................................................................. 71
montelukast tablet 10 mg ................................. 71
..................................................................................................
morphine concentrate oral solution 100

mg/5 ml (20 mg/ml) ............................................. 38
morphine er tablet,extended release
.................................................................................................. 38
morphine oral solution 10 mg/5 ml, 20
mg/5 ml ............................................................................. 38
morphine rectal suppository 10 mg, 20
mg, 30 mg, 5 mg ....................................................... 38
morphine tablet 15 mg, 30 mg ..................... 38
MOTRIN IB TABLET 200 MG ............ 39
MOTRIN TABLET 100 MG .................... 39
MOVIPREP ORAL POWDER
PACKET 100-7.5-2.691 GRAM ............ 55
MUCINEX D MAXIMUM
STRENGTH TABLET,EXTENDED
RELEASE 120-1,200 MG ............................ 12
MUCINEX D MAXIMUM
RELEASE 120-1,200 MG ............................ 67
MUCINEX D MAXIMUM
RELEASE 120-1,200 MG ............................ 69
MUCINEX D TABLET,EXTENDED
RELEASE 60-600 MG .................................... 12
RELEASE 60-600 MG .................................... 67
RELEASE 60-600 MG .................................... 69
MUCINEX DM
HR 30-600 MG ........................................................ 68
MUCINEX DM
HR 30-600 MG ........................................................ 69
MUCINEX DM
TABLET,EXTENDED RELEASE
60-1,200 MG .............................................................. 68
MUCINEX DM
60-1,200 MG .............................................................. 69
MUCINEX TABLET,EXTENDED
RELEASE 12 HR 1,200 MG ..................... 69
MUCINEX TABLET,EXTENDED
RELEASE 600 MG ............................................ 69
MULTI VIT-FLUORIDE-IRON
ORAL DROPS 0.25-10 MG/ML .......... 80
MULTIPLE VITAMIN-MINERALS
TABLET ........................................................................ 81
MULTISTIX 5 STRIPS ................................. 43
MULTISTIX 8 SG STRIPS ....................... 43
MULTISTIX 9 SG STRIPS ....................... 43
MULTISTIX STRIPS ..................................... 43
MULTI-VIT W/IRON & FLUORIDE
ORAL DROPS 0.25-10 MG/ML .......... 80
MULTI-VITAMIN WITH
FLUORIDE ............................................................... 64
MULTI-VITAMIN WITH
FLUORIDE ............................................................... 80
multivitamin with minerals tablet .......... 81
MULTIVITAMINS WITH
FLUORIDE ORAL DROPS 0.5
MG/ML .......................................................................... 81
MULTI-VITAMINS/FLUORIDE
ORAL DROPS 0.25 MG/ML ................... 80
mupirocin topical ointment 2 % .................. 74
MURO 128 EYE DROPS 2 %, 5 %
.................................................................................................. 50
MURO 128 EYE OINTMENT 5 %
.................................................................................................. 50
..................................................................................................... 6
.................................................................................................. 10
mycophenolate mofetil capsule 250 mg
.................................................................................................. 65
mycophenolate mofetil tablet 500 mg
.................................................................................................. 66
MYFORTIC TABLET,DELAYED
RELEASE 180 MG, 360 MG ................... 66
MYLANTA GAS CHEWABLE
TABLET 125 MG ................................................ 54
MYLERAN TABLET 2 MG ................... 12
MYNATAL ADVANCE TABLET
90-1-50 MG ................................................................. 18
90-1-50 MG ................................................................. 45
90-1-50 MG ................................................................. 81
90-1-50 MG ................................................................. 82
MYOBLOC ................................................................ 16
MYOBLOC ................................................................ 66
MY-VITALIFE CAPSULE ....................... 81
nabumetone tablet 500 mg, 750 mg
.................................................................................................. 39
nadolol tablet ............................................................. 14
nadolol tablet ............................................................. 21
nadolol tablet ............................................................. 22
nadolol tablet ............................................................. 25
naltrexone tablet 50 mg ..................................... 38
NAMENDA ORAL SOLUTION 10
MG/5 ML ..................................................................... 36
NAMENDA TABLET 10 MG, 5 MG
.................................................................................................. 37
NAMENDA TITRATION PAK
TABLETS IN A DOSE PACK 5-10
MG ...................................................................................... 37
NAPHCON-A EYE DROPS 0.025-0.3
% ............................................................................................ 52
naproxen oral suspension 125 mg/5 ml
.................................................................................................. 39
naproxen sodium tablet 220 mg, 275 mg,
550 mg ............................................................................... 39
naproxen tablet ........................................................ 39
naratriptan tablet 1 mg, 2.5 mg .................. 41
nateglinide tablet 120 mg, 60 mg .............. 63
NECON 0.5/35 (28) TABLET 0.5-35
MG-MCG .................................................................... 60
NECON 1/35 (28) TABLET 1-35
MG-MCG .................................................................... 60
NECON 1/50 (28) TABLET 1-50
MG-MCG .................................................................... 60
NECON 10/11 (28) TABLET
0.5-35/1-35 MG-MCG/MG-MCG
.................................................................................................. 60
NECON 7/7/7 (28) TABLET 0.5/0.75/1
MG- 35 MCG ........................................................... 60
98
nefazodone ................................................................... 42
NEOFRIN EYE DROPS 10 %, 2.5 %
.................................................................................................. 52
neomycin tablet 500 mg ........................................ 5
neomycin-bacitracin-poly-hc eye
ointment 3.5-400-10,000 mg-unit/g-1%
.................................................................................................. 48
neomycin-bacitracin-poly-hc eye
ointment 3.5-400-10,000 mg-unit/g-1%
.................................................................................................. 49
neomycin-bacitracin-polymyxin eye
ointment 3.5-400-10,000 mg-unit-unit/g
.................................................................................................. 48
neomycin-polymyxin-dexameth eye
drops,suspension 3.5-10,000-0.1
mg/ml-unit/ml-% ...................................................... 48
drops,suspension 3.5-10,000-0.1
mg/ml-unit/ml-% ...................................................... 49
ointment 3.5-10,000-0.1 mg-unit/g-%
.................................................................................................. 48
ointment 3.5-10,000-0.1 mg-unit/g-%
.................................................................................................. 49
neomycin-polymyxin-gramicidin eye
drops 1.75-10k-0.025 mg-unit-mg/ml
.................................................................................................. 48
neomycin-polymyxin-hydrocort ear
drops,suspension 3.5-10,000-1
mg-unit/ml-% .............................................................. 48
neomycin-polymyxin-hydrocort ear
solution 3.5-10,000-1 mg-unit/ml-%
.................................................................................................. 48
neomycin-polymyxin-hydrocort eye
mg-unit-mg/ml ........................................................... 48
neomycin-polymyxin-hydrocort eye
mg-unit-mg/ml ........................................................... 50
NEOSPORIN
(NEO-POLYM-GRAMICID) EYE
DROPS 1.75-10K-0.025
MG-UNIT-MG/ML .......................................... 48
NEO-SYNEPHRINE
(PHENYLEPHRINE) NASAL
SPRAY ............................................................................ 52
NEPHROCAPS CAPSULE 1 MG
.................................................................................................. 82
NEULASTA SUBCUTANEOUS
SYRINGE 6 MG/0.6ML ............................... 16
NEUPOGEN INJECTION
SOLUTION 300 MCG/ML, 480
MCG/1.6 ML ............................................................ 16
NEUPOGEN INJECTION SYRINGE
300 MCG/0.5 ML, 480 MCG/0.8 ML
.................................................................................................. 16
NEXAVAR TABLET 200 MG .............. 12
niacin er capsule,extended release .......... 21
niacin er tablet,extended release 1,000
mg, 250 mg, 500 mg, 750 mg ........................ 21
niacin tablet ................................................................ 21
NIACOR TABLET 500 MG ..................... 21
nicardipine capsule 20 mg, 30 mg ............. 26

NICODERM CQ DAILY
TRANSDERMAL PATCH ....................... 13
NICORELIEF GUM 2 MG, 4 MG
.................................................................................................. 13
nicotine (polacrilex) buccal lozenge 2
mg, 4 mg .......................................................................... 14
nicotine (polacrilex) gum 2 mg, 4 mg
.................................................................................................. 14
nicotine daily transdermal patch .............. 14
nicotine daily transdermal
patch,sequential 21-14-7 mg/24 hr ........... 14
NICOTROL INHALATION
CARTRIDGE 10 MG ..................................... 14
NICOTROL NS NASAL SPRAY 10
MG/ML .......................................................................... 14
NIFEDIAC CC
MG ...................................................................................... 26
NIFEDIAC CC
MG ...................................................................................... 29
nifedipine capsule 10 mg, 20 mg ................ 26
nifedipine capsule 10 mg, 20 mg ................ 29
.................................................................................................. 26
.................................................................................................. 30
nifedipine er tablet,extended release 24 hr
30 mg, 60 mg, 90 mg ............................................ 26
nifedipine er tablet,extended release 24 hr
30 mg, 60 mg, 90 mg ............................................ 30
NILANDRON TABLET 150 MG
.................................................................................................. 12
nisoldipine er tablet,extended release 24
hr 17 mg, 20 mg, 25.5 mg, 30 mg, 34 mg,
40 mg, 8.5 mg ............................................................. 26
NITRO-BID TRANSDERMAL
OINTMENT 2 % .................................................. 28
nitrofurantoin macrocrystal capsule 100
mg, 50 mg ....................................................................... 11
nitrofurantoin
monohydrate/macrocrystals capsule 100
mg ......................................................................................... 11
nitrofurantoin oral suspension 25 mg/5 ml
.................................................................................................. 11
nitroglycerin oral ................................................... 28
nitroglycerin transdermal 24 hour patch
.................................................................................................. 28
NITROLINGUAL SPRAY 0.4
MG/DOSE ................................................................... 28
NITROSTAT SUBLINGUAL ............... 28
NON-DROWSY ALLERGY TABLET
10 MG ................................................................................. 5
NON-DROWSY ALLERGY TABLET
10 MG .............................................................................. 72
NORA-BE TABLET 0.35 MG ................ 60
NORDITROPIN FLEXPRO ................... 63
NORDITROPIN NORDIFLEX
SUBCUTANEOUS PEN INJECTOR
30 MG/3 ML (10 MG/ML) ......................... 63
norethindrone (contraceptive) tablet 0.35
mg ......................................................................................... 60
norethindrone acetate tablet 5 mg ............ 63
NORTREL 0.5/35 (28) TABLET 0.5-35

MG-MCG .................................................................... 60
NORTREL 1/35 (21) TABLET 1-35
MG-MCG .................................................................... 60
NORTREL 1/35 (28) TABLET 1-35
MG-MCG .................................................................... 60
NORTREL 7/7/7 (28) TABLET
0.5/0.75/1 MG- 35 MCG ................................ 60
nortriptyline ................................................................ 43
nortriptyline oral solution 10 mg/5 ml
.................................................................................................. 43
NORVIR CAPSULE 100 MG .................... 7
NORVIR ORAL SOLUTION 80
MG/ML ............................................................................. 7
NORVIR TABLET 100 MG ........................ 7
NOVOLIN 70/30 SUBCUTANEOUS
.................................................................................................. 62
NOVOLIN N SUBCUTANEOUS
SUSPENSION 100 UNIT/ML ................ 62
NOVOLIN R INJECTION
SOLUTION 100 UNIT/ML ....................... 62
NOVOLOG FLEXPEN
.................................................................................................. 62
NOVOLOG MIX 70-30 FLEXPEN
(70-30) ............................................................................... 63
NOVOLOG MIX 70-30
SUBCUTANEOUS SOLUTION 100
UNIT/ML (70-30) ................................................. 62
NOVOLOG PENFILL
SUBCUTANEOUS CARTRIDGE 100
UNIT/ML ..................................................................... 63
NOVOLOG SUBCUTANEOUS
SOLUTION 100 UNIT/ML ....................... 62
NP THYROID ........................................................ 64
NPLATE SUBCUTANEOUS
SOLUTION 250 MCG, 500 MCG
.................................................................................................. 16
NPLATE SUBCUTANEOUS
SOLUTION 250 MCG, 500 MCG
.................................................................................................. 66
NUVARING VAGINAL 0.12-0.015
MG/24 HR ................................................................... 60
NUZOLE TOPICAL CREAM 2 %
.................................................................................................. 77
NYAMYC TOPICAL POWDER
100,000 UNIT/GRAM .................................... 78
nystatin oral powder ........................................... 10
nystatin tablet 500,000 unit ........................... 10
nystatin topical cream 100,000 unit/gram
.................................................................................................. 78
nystatin topical ointment 100,000
unit/gram ........................................................................ 78
nystatin topical powder 100,000
unit/gram ........................................................................ 78
nystatin-triamcinolone topical cream
100,000-0.1 unit/g-% ............................................ 78
nystatin-triamcinolone topical ointment
100,000-0.1 unit/gram-% .................................. 78
NYSTOP TOPICAL POWDER
100,000 UNIT/GRAM .................................... 78
NYTOL TABLET 25 MG .............................. 3
NYTOL TABLET 25 MG ........................... 34
99
NYTOL TABLET 25 MG ........................... 70

OCELLA TABLET 3-0.03 MG .............. 60
OCUVITE CAPSULE 150-30-6-150
MG-UNIT-MG-MG ......................................... 66
OCUVITE WITH LUTEIN TABLET
1,000 UNIT-200 MG-60 UNIT-2 MG
.................................................................................................. 81
ofloxacin ear drops 0.3 % ................................ 48
ofloxacin eye drops 0.3 % ................................ 48
ofloxacin tablet 200 mg, 300 mg, 400 mg
.................................................................................................. 10
OGESTREL (28) TABLET 0.5-50
MG-MCG .................................................................... 60
olanzapine oral ......................................................... 35
omeprazole capsule,delayed release 10
mg, 20 mg, 40 mg .................................................... 57
omeprazole magnesium capsule,delayed
release 20 mg .............................................................. 57
OMEPRAZOLE+SYRSPEND SF
ALKA ORAL SUSPENSION 2
MG/ML .......................................................................... 57
ondansetron disintegrating tablet 4 mg, 8
mg ......................................................................................... 52
ondansetron hcl oral solution 4 mg/5 ml
.................................................................................................. 52
ondansetron hcl tablet 4 mg, 8 mg ........... 52
ONE-A-DAY MAXIMUM
FORMULA TABLET ..................................... 81
ORA-BLEND ORAL SUSPENSION
.................................................................................................. 66
ORACIT ORAL SOLUTION 490-640
MG/5 ML ..................................................................... 44
ORALYTE ORAL SOLUTION ........... 45
ORAP TABLET 1 MG, 2 MG ................ 34
ORA-PLUS ORAL SUSPENSION
.................................................................................................. 66
ORA-SWEET ORAL LIQUID .............. 66
ORGAN-I NR TABLET 200 MG
.................................................................................................. 69
orphenadrine citrate er tablet,extended
release 100 mg ........................................................... 16
ORPHENADRINE COMPOUND
TABLET 25-385-30 MG ................................ 16
ORPHENADRINE COMPOUND
TABLET 25-385-30 MG ................................ 41
ORPHENADRINE COMPOUND-DS
TABLET 50-770-60 MG ................................ 16
ORPHENADRINE COMPOUND-DS
TABLET 50-770-60 MG ................................ 41
ORTHO EVRA TRANSDERMAL
PATCH 150-20 MCG/24 HR .................... 60
OS-CAL 500 + D CHEWABLE
TABLET 500 MG(1,250MG) -600
UNIT ................................................................................ 46
OS-CAL 500 + D CHEWABLE
TABLET 500 MG(1,250MG) -600
UNIT ................................................................................ 84
oxandrolone tablet 10 mg, 2.5 mg ............ 59
oxaprozin tablet 600 mg ................................... 40
oxazepam capsule 10 mg, 15 mg, 30 mg
.................................................................................................. 36
oxcarbazepine oral suspension 300 mg/5
ml ........................................................................................... 32
oxcarbazepine tablet ........................................... 32
oxybutynin chloride er tablet,extended

release 24 hr ............................................................... 79
oxybutynin chloride syrup 5 mg/5 ml
.................................................................................................. 80
oxybutynin chloride tablet 5 mg ................ 80
oxycodone capsule 5 mg .................................... 38
oxycodone oral concentrate 20 mg/ml
.................................................................................................. 38
oxycodone oral solution 5 mg/5 ml .......... 38
oxycodone tablet 10 mg, 15 mg, 20 mg,
30 mg, 5 mg .................................................................. 38
oxycodone-acetaminophen capsule 5-500
mg ......................................................................................... 31
oxycodone-acetaminophen capsule 5-500
mg ......................................................................................... 38
oxycodone-acetaminophen tablet 2.5-325
mg, 5-325 mg .............................................................. 31
oxycodone-acetaminophen tablet 2.5-325
mg, 5-325 mg .............................................................. 38
OXYCONTIN TABLET,EXTENDED
RELEASE .................................................................... 38
OYSCO 500/D CHEWABLE TABLET
500 MG(1,250MG) -600 UNIT ............... 46
OYSCO 500/D CHEWABLE TABLET
500 MG(1,250MG) -600 UNIT ............... 84
OYSCO 500/D TABLET 500
MG(1,250MG) -200 UNIT .......................... 46
OYSCO 500/D TABLET 500
MG(1,250MG) -200 UNIT .......................... 84
OYSCO D TABLET 250-125
MG-UNIT ................................................................... 46
OYSCO D TABLET 250-125
MG-UNIT ................................................................... 84
OYSCO-500 TABLET 500 MG
CALCIUM (1,250 MG) .................................. 46
OYSTER SHELL CALCIUM 500
TABLET 500 MG CALCIUM (1,250
MG) .................................................................................... 46
OYSTER SHELL CALCIUM-VIT D3
TABLET 500 MG(1,250MG) -200
UNIT, 500 MG(1,250MG) -400 UNIT
.................................................................................................. 46
OYSTER SHELL CALCIUM-VIT D3
TABLET 500 MG(1,250MG) -200
UNIT, 500 MG(1,250MG) -400 UNIT
.................................................................................................. 84
PACERONE TABLET 200 MG ........... 25
PANCRELIPASE 5000
CAPSULE,DELAYED RELEASE
5,000-17,000 -27,000 UNIT ......................... 56
pantoprazole tablet,delayed release 20
mg, 40 mg ....................................................................... 57
paromomycin capsule 250 mg ......................... 5
paroxetine tablet 10 mg, 20 mg, 30 mg,
40 mg .................................................................................. 42
PC-TAR SHAMPOO 1 % ............................ 78
PEDIACARE FEVER REDUCER
.................................................................................................. 31
pediatric multivitamin-fl oral drops 0.25
mg/ml, 0.5 mg/ml ..................................................... 64
pediatric multivitamin-fl oral drops 0.25
mg/ml, 0.5 mg/ml ..................................................... 81
PEDI-DRI TOPICAL POWDER
100,000 UNIT/GRAM .................................... 78
peg 3350-electrolytes oral solution

236-22.74-6.74 gram, 240-22.72-6.72
gram .................................................................................... 55
PEGINTRON ............................................................. 7
PEGINTRON REDIPEN ............................... 7
penicillin v potassium oral solution 125
mg/5 ml, 250 mg/5 ml ............................................. 8
penicillin v potassium tablet 250 mg, 500
mg ............................................................................................ 8
PENTASA CAPSULE,EXTENDED
RELEASE 250 MG, 500 MG ................... 54
pentazocine-acetaminophen tablet 25-650
mg ......................................................................................... 31
pentazocine-acetaminophen tablet 25-650
mg ......................................................................................... 39
pentazocine-naloxone tablet 50-0.5 mg
.................................................................................................. 39
pentoxifylline er tablet,extended release
400 mg ............................................................................... 16
PEPCID AC TABLET 20 MG ................ 56
PEPTO-BISMOL CHEWABLE
TABLET 262 MG ................................................ 52
PEPTO-BISMOL CHEWABLE
TABLET 262 MG ................................................ 53
PEPTO-BISMOL MAX ST ORAL
SUSPENSION 525 MG/15 ML .............. 53
PEPTO-BISMOL ORAL
SUSPENSION 262 MG/15 ML .............. 52
PEPTO-BISMOL ORAL
SUSPENSION 262 MG/15 ML .............. 53
.................................................................................................. 53
PERI-COLACE TABLET 8.6-50 MG
.................................................................................................. 56
PERIOGARD MOUTHWASH 0.12 %
.................................................................................................. 50
permethrin topical cream 5 % ...................... 78
permethrin topical liquid 1 % ....................... 78
perphenazine tablet .............................................. 40
perphenazine-amitriptyline ........................... 40
perphenazine-amitriptyline ........................... 43
PHENADOZ RECTAL
SUPPOSITORY 12.5 MG, 25 MG
..................................................................................................... 4
PHENADOZ RECTAL
SUPPOSITORY 12.5 MG, 25 MG
.................................................................................................. 34
phenazopyridine tablet 100 mg, 200 mg
.................................................................................................. 76
.................................................................................................. 35
phenobarbital tablet ............................................ 35
phenylephrine eye drops 2.5 % .................... 52
PHENYTEK CAPSULE 200 MG, 300
MG ...................................................................................... 24
PHENYTEK CAPSULE 200 MG, 300
MG ...................................................................................... 37
.................................................................................................. 24
.................................................................................................. 37
.................................................................................................. 24
.................................................................................................. 37
100
PHOS-FLUR DENTAL SOLUTION

0.02 % FLUORIDE (0.044 %) .................. 64
PHOS-NAK ORAL POWDER
PACKET 280-160-250 MG ......................... 46
PHOSPHA 250 NEUTRAL TABLET
250 MG ........................................................................... 44
PHRENILIN FORTE CAPSULE
50-650 MG ................................................................... 31
PHRENILIN FORTE CAPSULE
50-650 MG ................................................................... 35
pilocarpine eye drops .......................................... 51
pilocarpine tablet 5 mg, 7.5 mg .................. 15
pindolol tablet 10 mg, 5 mg ............................ 14
pioglitazone ................................................................. 63
pioglitazone-glimepiride tablet 30-2 mg,
30-4 mg ............................................................................ 63
pioglitazone-metformin tablet 15-500 mg,
15-850 mg ...................................................................... 59
pioglitazone-metformin tablet 15-500 mg,
15-850 mg ...................................................................... 63
piroxicam capsule 10 mg, 20 mg ............... 40
PLAN B ONE-STEP TABLET 1.5 MG
.................................................................................................. 60
PODOCON TOPICAL LIQUID 25 %
.................................................................................................. 79
podofilox topical solution 0.5 % ................. 79
polyethylene glycol 3350 oral powder 17
gram/dose ....................................................................... 56
POLY-VI-SOL ORAL DROPS
1,500-35-400 UNIT-MG-UNIT/ML
.................................................................................................. 81
POLY-VI-SOL WITH IRON ORAL
DROPS 1,500 UNIT-400 UNIT-10
MG/ML .......................................................................... 18
POLY-VI-SOL WITH IRON ORAL
DROPS 1,500 UNIT-400 UNIT-10
MG/ML .......................................................................... 81
POLYVITAMIN/IRON CHEWABLE
TABLET ........................................................................ 81
PORTIA TABLET 0.15-30 MG-MCG
.................................................................................................. 60
potassium bicarbonate-citric acid
effervescent tablet 25 meq ............................... 46
potassium chloride er capsule,extended
release 10 meq ............................................................ 46
potassium chloride er tablet,extended
release 10 meq, 8 meq ......................................... 46
potassium chloride er tablet,extended
release(part/cryst) 10 meq, 20 meq
.................................................................................................. 46
.................................................................................................. 46
.................................................................................................. 46
potassium citrate er tablet,extended
release 10 meq, 5 meq ......................................... 44
pramipexole tablet ................................................ 37
PRANDIN TABLET 0.5 MG, 1 MG, 2
MG ...................................................................................... 63
pravastatin ................................................................... 27
prazosin oral .............................................................. 14
prazosin oral .............................................................. 19

prazosin oral .............................................................. 20
PRED MILD EYE
DROPS,SUSPENSION 0.12 % .............. 50
prednisolone acetate eye drops,suspension
1 % ....................................................................................... 50
prednisolone oral solution 15 mg/5 ml
.................................................................................................. 58
prednisolone sodium phosphate eye drops
1 % ....................................................................................... 50
prednisolone sodium phosphate oral
solution 15 mg/5 ml, 5 mg base/5 ml (6.7
mg/5 ml) ......................................................................... 58
PREDNISONE INTENSOL ORAL
prednisone oral solution 5 mg/5 ml .......... 58
prednisone tablet .................................................... 58
prednisone tablets in a dose pack 10 mg,
5 mg ..................................................................................... 58
PREMARIN TABLET ................................... 61
PREMARIN VAGINAL CREAM
0.625 MG/GRAM ................................................ 61
PREMPHASE TABLET 0.625 MG
(14)/ 0.625MG-5MG(14) ................................ 61
PREMPRO ................................................................. 61
.................................................................................................. 18
.................................................................................................. 46
.................................................................................................. 81
.................................................................................................. 82
PRENATABS RX TABLET 29 MG
IRON- 1 MG ............................................................. 18
IRON- 1 MG ............................................................. 46
IRON- 1 MG ............................................................. 81
IRON- 1 MG ............................................................. 82
PRENATAL AD TABLET 90-1-50
MG ...................................................................................... 18
MG ...................................................................................... 46
MG ...................................................................................... 81
MG ...................................................................................... 82
PRENATAL LOW IRON TABLET
27-1 MG ......................................................................... 18
27-1 MG ......................................................................... 46
27-1 MG ......................................................................... 81
27-1 MG ......................................................................... 82
PRENATAL PLUS (CALCIUM
CARBONATE) TABLET 27-1 MG
.................................................................................................. 18
.................................................................................................. 46

..................................................................................................

81
82
PRENATAL PLUS WITH IRON
(CALCIUM CARBONATE) TABLET
29 MG IRON- 1 MG ........................................ 18
29 MG IRON- 1 MG ........................................ 46
29 MG IRON- 1 MG ........................................ 81
29 MG IRON- 1 MG ........................................ 82
PRENATAL TABLET 27-0.8 MG,
28-0.8 MG .................................................................... 18
28-0.8 MG .................................................................... 46
28-0.8 MG .................................................................... 81
28-0.8 MG .................................................................... 82
PRENATAL VITAMIN TAB 27-0.8
MG ...................................................................................... 18
MG ...................................................................................... 46
MG ...................................................................................... 81
MG ...................................................................................... 83
PRENATAL VITAMIN TABLET
.................................................................................................. 81
PREPARATION H
HYDROCORTISONE TOPICAL
CREAM 1 % .............................................................. 75
PREVALITE ORAL POWDER 4
GRAM ............................................................................ 22
PREVALITE POWDER FOR SUSP
IN A PACKET 4 GRAM ............................. 22
PREVIDENT GEL 1.1 % ............................. 64
PREVIFEM TABLET 0.25-35
MG-MCG .................................................................... 60
PREZISTA ORAL SUSPENSION 100
MG/ML ............................................................................. 7
PREZISTA TABLET 150 MG, 400
MG, 600 MG, 800 MG ....................................... 7
primaquine tablet 26.3 mg .................................. 6
primidone tablet 250 mg, 50 mg ................. 35
probenecid tablet 500 mg ................................. 47
prochlorperazine maleate tablet 10 mg, 5
mg ......................................................................................... 40
prochlorperazine maleate tablet 10 mg, 5
mg ......................................................................................... 54
prochlorperazine rectal suppository 25
mg ......................................................................................... 40
prochlorperazine rectal suppository 25
mg ......................................................................................... 54
PROCRIT .................................................................... 16
PROCTOFOAM HC 1-1 % ........................ 75
PROCTOFOAM HC 1-1 % ........................ 76
..................................................................................................
101
PROCTOSOL HC RECTAL CREAM

2.5 % ................................................................................... 75
PROGRAF ORAL ............................................. 66
promethazine rectal suppository 12.5 mg,
25 mg ..................................................................................... 4
promethazine rectal suppository 12.5 mg,
25 mg .................................................................................. 34
promethazine syrup 6.25 mg/5 ml ................ 4
promethazine syrup 6.25 mg/5 ml ............. 34
promethazine syrup 6.25 mg/5 ml ............. 70
promethazine tablet ................................................ 4
promethazine tablet ............................................. 34
promethazine tablet ............................................. 70
PROMETHAZINE VC SYRUP 6.25-5
MG/5 ML ........................................................................ 4
MG/5 ML ..................................................................... 13
MG/5 ML ..................................................................... 71
PROMETHAZINE VC-CODEINE
SYRUP 6.25-5-10 MG/5 ML ........................ 4
SYRUP 6.25-5-10 MG/5 ML .................... 13
SYRUP 6.25-5-10 MG/5 ML .................... 38
SYRUP 6.25-5-10 MG/5 ML .................... 68
SYRUP 6.25-5-10 MG/5 ML .................... 71
promethazine-codeine syrup 6.25-10 mg/5
ml ........................................................................................... 68
promethazine-codeine syrup 6.25-10 mg/5
ml ........................................................................................... 71
.................................................................................................. 68
.................................................................................................. 71
PROMETHEGAN ................................................. 4
PROMETHEGAN .............................................. 34
PROMETRIUM CAPSULE 100 MG,
200 MG ........................................................................... 63
propafenone tablet ................................................ 24
propantheline tablet 15 mg ............................. 13
propranolol er capsule,24 hr,extended
release .............................................................................. 14
release .............................................................................. 21
release .............................................................................. 22
release .............................................................................. 25
release .............................................................................. 27
release .............................................................................. 33
propranolol oral solution 20 mg/5 ml, 40
mg/5 ml ............................................................................. 14
mg/5 ml ............................................................................. 21
mg/5 ml ............................................................................. 22
mg/5 ml ............................................................................. 25
mg/5 ml ............................................................................. 27

mg/5 ml ............................................................................. 33
propranolol tablet .................................................. 14
propranolol-hydrochlorothiazide tablet
40-25 mg, 80-25 mg .............................................. 14
40-25 mg, 80-25 mg .............................................. 21
40-25 mg, 80-25 mg .............................................. 22
40-25 mg, 80-25 mg .............................................. 25
40-25 mg, 80-25 mg .............................................. 28
40-25 mg, 80-25 mg .............................................. 47
propylthiouracil tablet 50 mg ....................... 59
protriptyline tablet 10 mg, 5 mg ................ 43
.................................................................................................. 12
.................................................................................................. 67
PULMICORT FLEXHALER
BREATH ACTIVATED 180
MCG/ACTUATION, 90
MCG/ACTUATION ........................................ 58
PULMICORT FLEXHALER
BREATH ACTIVATED 180
MCG/ACTUATION, 90
MCG/ACTUATION ........................................ 72
PULMICORT SUSPENSION FOR
NEBULIZATION 1 MG/2 ML ............. 58
PULMICORT SUSPENSION FOR
NEBULIZATION 1 MG/2 ML ............. 72
pyrazinamide tablet 500 mg .............................. 6
pyridostigmine bromide tablet 60 mg
.................................................................................................. 15
Q-TAPP DM ORAL ELIXIR 1-15-5
MG/5 ML ..................................................................... 12
MG/5 ML ..................................................................... 67
MG/5 ML ..................................................................... 68
MG/5 ML ..................................................................... 71
Q-TUSSIN DM SYRUP 10-100 MG/5
ML ....................................................................................... 68
Q-TUSSIN DM SYRUP 10-100 MG/5
ML ....................................................................................... 69
Q-TUSSIN ORAL LIQUID 100 MG/5
ML ....................................................................................... 69
quetiapine tablet 100 mg, 200 mg, 25 mg,
300 mg, 400 mg, 50 mg ...................................... 35
quinapril ......................................................................... 20
quinapril ......................................................................... 21
quinidine er tablet,extended release 324
mg ............................................................................................ 6
quinidine er tablet,extended release 324
mg ......................................................................................... 24
quinidine sulfate er tablet,extended
release 300 mg .............................................................. 6
quinidine sulfate er tablet,extended

release 300 mg ........................................................... 24
quinidine tablet 200 mg, 300 mg ................... 6
quinidine tablet 200 mg, 300 mg ................ 24
QVAR METERED AEROSOL ORAL
INHALER 40 MCG/ACTUATION, 80
MCG/ACTUATION ........................................ 58
QVAR METERED AEROSOL ORAL
INHALER 40 MCG/ACTUATION, 80
MCG/ACTUATION ........................................ 72
ramipril capsule ....................................................... 20
ramipril capsule ....................................................... 21
ranitidine capsule 150 mg, 300 mg ........... 57
ranitidine syrup 15 mg/ml ................................ 57
ranitidine tablet 150 mg, 300 mg, 75 mg
.................................................................................................. 57
RAPAMUNE ORAL SOLUTION 1
MG/ML .......................................................................... 66
RAPAMUNE TABLET 1 MG, 2 MG
.................................................................................................. 66
RECLIPSEN (28) TABLET 0.15-30
MG-MCG .................................................................... 60
RECORT PLUS TOPICAL CREAM 1
% ............................................................................................ 75
REFENESEN TABLET 200 MG
.................................................................................................. 69
REFRESH CLASSIC (PF) EYE
DROPS IN A DROPPERETTE 1.4-0.6
% ............................................................................................ 51
REFRESH LIQUIGEL EYE LIQUID
GEL DROPS 1 % ................................................. 51
REFRESH P.M. EYE OINTMENT
57.3-42.5 % ................................................................... 51
REFRESH TEARS EYE DROPS 0.5
% ............................................................................................ 51
REGULOID ORAL POWDER ............ 56
RENAGEL TABLET 400 MG, 800
MG ...................................................................................... 44
RENAL CAPS CAPSULE 1 MG
.................................................................................................. 83
RENA-VITE RX TABLET 1-60-300
MG-MG-MCG ....................................................... 83
RENO CAPS CAPSULE 1 MG ............ 83
RENVELA TABLET 800 MG ................ 44
REPHRESH VAGINAL GEL ............... 66
REPLENS VAGINAL GEL ..................... 66
RESCRIPTOR DISPERSIBLE
TABLET 100 MG ................................................... 8
RESCRIPTOR TABLET 200 MG
..................................................................................................... 8
reserpine tablet 0.1 mg, 0.25 mg ................ 28
RESTASIS EYE DROPS IN A
DROPPERETTE 0.05 % ............................... 50
REVIA TABLET 50 MG .............................. 38
REYATAZ CAPSULE 150 MG, 200
MG, 300 MG ................................................................ 7
ribavirin capsule 200 mg ...................................... 9
ribavirin tablet 200 mg .......................................... 9
RIDAURA CAPSULE 3 MG ................. 57
rifampin capsule 150 mg, 300 mg ................ 6
rifampin capsule 150 mg, 300 mg ............. 10
RIGHT STEP PRENATAL
VITAMINS TABLET 27-0.8 MG
.................................................................................................. 18
102
RIGHT STEP PRENATAL

..................................................................................................
RIGHT STEP PRENATAL

..................................................................................................
RIGHT STEP PRENATAL

..................................................................................................
RISABAL-PH TOPICAL CREAM
46
81
83
77
RISPERDAL CONSTA ................................ 35
risperidone disintegrating tablet 0.25 mg,
0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg ................. 35
risperidone oral solution 1 mg/ml .............. 35
risperidone tablet ................................................... 35
..................................................................................................... 4
.................................................................................................. 12
.................................................................................................. 67
.................................................................................................. 71
RI-TUSSIN DM SYRUP 10-100 MG/5
ML ....................................................................................... 68
RI-TUSSIN DM SYRUP 10-100 MG/5
ML ....................................................................................... 69
RI-TUSSIN ORAL LIQUID 100 MG/5
ML ....................................................................................... 69
rivastigmine capsule ............................................ 15
rizatriptan tablet 10 mg, 5 mg ..................... 41
ROBAFEN DM SYRUP 10-100 MG/5
ML ....................................................................................... 68
ROBAFEN DM SYRUP 10-100 MG/5
ML ....................................................................................... 69
ROBAFEN ORAL LIQUID 100 MG/5
ML ....................................................................................... 69
ROBITUSSIN PEDIATRIC SYRUP
7.5 MG/5 ML ............................................................ 68
ropinirole tablet ....................................................... 37
ROXICET ORAL SOLUTION 5-325
MG/5 ML ..................................................................... 31
ROXICET ORAL SOLUTION 5-325
MG/5 ML ..................................................................... 38
ROXICET TABLET 5-325 MG ............ 31
ROXICET TABLET 5-325 MG ............ 38
RULOX ORAL SUSPENSION
200-200-20 MG/5 ML ....................................... 53
RULOX ORAL SUSPENSION
200-200-20 MG/5 ML ....................................... 54
salsalate tablet 500 mg, 750 mg ................. 41
SANDIMMUNE ORAL SOLUTION
100 MG/ML ............................................................... 66
SANTYL TOPICAL OINTMENT 250
UNIT/GRAM .......................................................... 79
SCOT-TUSSIN EXPECTORANT
ORAL LIQUID 100 MG/5 ML .............. 69
selegiline capsule 5 mg ........................................ 37
selegiline tablet 5 mg ............................................ 37
selenium sulfide topical suspension 2.5 %
.................................................................................................. 78
SELZENTRY TABLET 150 MG, 300
MG ......................................................................................... 7
..................................................................................................
SE-NATAL 19 CHEWABLE TABLET

29 MG IRON- 1 MG ........................................ 18
29 MG IRON- 1 MG ........................................ 81
29 MG IRON- 1 MG ........................................ 83
SENEXON-S TABLET 8.6-50 MG
.................................................................................................. 56
SENNA LAX TABLET 8.6 MG ........... 56
SENNA LAXATIVE TABLET 8.6 MG
.................................................................................................. 56
SENNA SYRUP 176 MG/5 ML ............ 56
SENNA SYRUP 8.8 MG/5 ML ............. 56
SENNA TABLET 8.6 MG .......................... 56
SENNA-GEN TABLET 8.6 MG .......... 56
sennosides-docusate sodium tablet 8.6-50
mg ......................................................................................... 56
SENOKOT-S TABLET 8.6-50 MG
.................................................................................................. 56
INHALATION 50 MCG/DOSE ........... 15
INHALATION 50 MCG/DOSE ........... 72
sertraline oral concentrate 20 mg/ml
.................................................................................................. 42
sertraline tablet 100 mg, 25 mg, 50 mg
.................................................................................................. 42
SILTUSSIN DM DAS ORAL LIQUID
10-100 MG/5 ML .................................................. 68
SILTUSSIN DM DAS ORAL LIQUID
10-100 MG/5 ML .................................................. 69
SILTUSSIN SA ORAL LIQUID 100
MG/5 ML ..................................................................... 69
SILTUSSIN-DM SYRUP 10-100 MG/5
ML ....................................................................................... 68
SILTUSSIN-DM SYRUP 10-100 MG/5
ML ....................................................................................... 69
silver sulfadiazine topical cream 1 %
.................................................................................................. 78
simethicone chewable tablet 125 mg, 80
mg ......................................................................................... 54
simethicone oral drops,suspension 40
mg/0.6 ml ........................................................................ 54
..................................................................................................... 3
.................................................................................................. 34
.................................................................................................. 71
simvastatin ................................................................... 27
SINGLE-LET MISC ......................................... 43
SLO-NIACIN TABLET,EXTENDED
RELEASE 500 MG, 750 MG ................... 21
SOCHLOR EYE DROPS 5 % ................. 51
SOCHLOR EYE OINTMENT 5 %
.................................................................................................. 51
sodium bicarbonate (antacid) powder
.................................................................................................. 44
sodium bicarbonate intravenous solution
8.4 % ................................................................................... 44
sodium bicarbonate intravenous syringe
8.4 % (1 meq/ml) .................................................... 44
sodium chloride eye drops 5 % ..................... 51
sodium chloride eye ointment 5 % ............ 51

..................................................................................................
43
46
sodium chloride irrigation solution 0.9 %
.................................................................................................. 44
sodium citrate-citric acid oral solution
500-334 mg/5 ml ...................................................... 44
sodium fluoride chewable tablet ................ 64
sodium fluoride dental solution 0.2 %
.................................................................................................. 64
sodium fluoride oral drops 0.5 mg
fluoride (1.1 mg)/ml ............................................ 64
sodium fluoride tablet 1 mg fluoride (2.2
mg) ...................................................................................... 64
sodium polystyrene sulfonate oral powder
................................................................................................ 45
SOF-LAX CAPSULE 100 MG ............... 56
SOLIRIS INTRAVENOUS
SOLUTION 300 MG/30 ML .................... 64
SOMINEX MAXIMUM STRENGTH
TABLET 50 MG ....................................................... 3
TABLET 50 MG ................................................... 34
TABLET 50 MG ................................................... 71
SOMINEX TABLET 25 MG ...................... 3
SOMINEX TABLET 25 MG ................... 34
SOMINEX TABLET 25 MG ................... 71
SOOTHING PUREWAY-C TABLET
500 MG ........................................................................... 83
SOTALOL AF ......................................................... 14
SOTALOL AF ......................................................... 21
SOTALOL AF ......................................................... 22
SOTALOL AF ......................................................... 25
SOTALOL AF ......................................................... 27
sotalol oral ................................................................... 14
sotalol oral ................................................................... 21
sotalol oral ................................................................... 22
sotalol oral ................................................................... 25
sotalol oral ................................................................... 27
SOTRET CAPSULE 20 MG .................... 79
spironolactone ........................................................... 27
spironolactone ........................................................... 28
spironolactone ........................................................... 45
spironolactone-hydrochlorothiazide tablet
25-25 mg ......................................................................... 27
25-25 mg ......................................................................... 28
25-25 mg ......................................................................... 45
25-25 mg ......................................................................... 47
SPRINTEC (28) TABLET 0.25-35
MG-MCG .................................................................... 60
SPS ENEMA 30 GRAM/120 ML
.................................................................................................. 45
SPS ORAL SUSPENSION 15
GRAM/60 ML ......................................................... 45
SRONYX TABLET 0.1-20 MG-MCG
.................................................................................................. 61
SSD TOPICAL CREAM 1 % ................... 78
SSKI ORAL SOLUTION 1
GRAM/ML ................................................................. 59
..................................................................................................
103
SSKI ORAL SOLUTION 1

GRAM/ML ................................................................. 70
stannous fluoride dental solution 0.63 %
.................................................................................................. 64
stavudine capsule 15 mg, 20 mg, 30 mg,
40 mg ..................................................................................... 9
STIMATE NASAL SPRAY 150
MCG/SPRAY .......................................................... 16
STIMATE NASAL SPRAY 150
MCG/SPRAY .......................................................... 63
STRATTERA CAPSULE 10 MG, 100
MG, 18 MG, 25 MG, 40 MG, 60 MG,
80 MG .............................................................................. 37
STUART PRENATAL TABLET
28-0.8 MG .................................................................... 18
28-0.8 MG .................................................................... 46
28-0.8 MG .................................................................... 81
28-0.8 MG .................................................................... 83
SUBOXONE SUBLINGUAL FILM
12-3 MG, 2-0.5 MG, 4-1 MG, 8-2 MG
.................................................................................................. 39
sucralfate tablet 1 gram .................................... 57
SUDOGEST COLD & ALLERGY
TABLET 4-60 MG ................................................. 4
TABLET 4-60 MG .............................................. 13
TABLET 4-60 MG .............................................. 67
TABLET 4-60 MG .............................................. 71
SUDOGEST SINUS & ALLERGY
TABLET 4-60 MG ................................................. 4
TABLET 4-60 MG .............................................. 13
TABLET 4-60 MG .............................................. 67
TABLET 4-60 MG .............................................. 71
sulfacetamide sodium (acne) topical
suspension 10 % ........................................................ 78
sulfacetamide sodium eye drops 10 %
.................................................................................................. 49
sulfacetamide sodium-sulfur topical
cleanser 10-5 % (w/w) ....................................... 77
sulfacetamide sodium-sulfur topical
cleanser 10-5 % (w/w) ....................................... 78
sulfacetamide-prednisolone eye drops 10
%-0.23 % (0.25 %) ............................................... 49
sulfadiazine tablet 500 mg ............................... 10
sulfamethoxazole-trimethoprim oral
suspension 200-40 mg/5 ml ............................. 10
sulfamethoxazole-trimethoprim tablet
400-80 mg, 800-160 mg ..................................... 10
sulfasalazine tablet 500 mg ............................ 10
sulfasalazine tablet,delayed release 500
mg ......................................................................................... 10
sulindac tablet 150 mg, 200 mg .................. 40
sumatriptan nasal spray 20 mg/actuation,
5 mg/actuation ........................................................... 41
sumatriptan subcutaneous cartridge
(refill) 4 mg/0.5 ml, 6 mg/0.5 ml .............. 41
sumatriptan subcutaneous pen injector 4

mg/0.5 ml, 6 mg/0.5 ml ....................................... 42
sumatriptan subcutaneous solution 6
mg/0.5 ml ........................................................................ 42
sumatriptan succinate oral ............................ 42
SUPRAX CAPSULE 400 MG ................ 11
SUPRAX TABLET 400 MG .................... 11
SUSTIVA CAPSULE 200 MG, 50 MG
..................................................................................................... 8
SUSTIVA TABLET 600 MG ...................... 8
SUTENT ....................................................................... 12
SYMAX-SL SUBLINGUAL TABLET
0.125 MG ...................................................................... 13
SYMAX-SR TABLET,EXTENDED
RELEASE 0.375 MG ........................................ 13
SYMBICORT HFA AEROSOL
INHALER 160-4.5
MCG/ACTUATION, 80-4.5
MCG/ACTUATION ........................................ 15
INHALER 160-4.5
MCG/ACTUATION ........................................ 58
INHALER 160-4.5
MCG/ACTUATION ........................................ 72
INHALER 160-4.5
MCG/ACTUATION ........................................ 73
SYNAGIS INTRAMUSCULAR
SOLUTION 100 MG/ML, 50 MG/0.5
ML .......................................................................................... 8
TAB-A-VITE-MINERALS TABLET
.................................................................................................. 81
TABLOID TABLET 40 MG ..................... 12
tacrolimus capsule ................................................. 66
TAMIFLU CAPSULE 30 MG, 45 MG,
75 MG ................................................................................. 8
TAMIFLU ORAL SUSPENSION 6
MG/ML ............................................................................. 8
tamoxifen tablet 10 mg, 20 mg ................... 12
tamsulosin er capsule,extended release 24
hr 0.4 mg ......................................................................... 15
TARGRETIN CAPSULE 75 MG
.................................................................................................. 12
TARON-CRYSTALS ORAL
PACKET 3,300-1,002 MG ........................... 44
TASMAR TABLET 100 MG ................... 36
TAZTIA XT CAPSULE,EXTENDED
300 MG, 360 MG .................................................. 23
300 MG, 360 MG .................................................. 26
300 MG, 360 MG .................................................. 30
TEARS AGAIN EYE DROPS 1.4 %
.................................................................................................. 51
TEARS AGAIN EYE OINTMENT
.................................................................................................. 51
TEARS AGAIN MC EYE DROPS
.................................................................................................. 51
TEARS NATURALE FREE (PF)

DROPS IN A DROPPERETTE 0.1-0.3
% ............................................................................................ 51
TEARS NATURALE II EYE DROPS
.................................................................................................. 51
TEGRETOL ORAL SUSPENSION
100 MG/5 ML ........................................................... 32
TEGRETOL TABLET 200 MG ............ 32
TEGRETOL XR ................................................... 32
temazepam capsule 15 mg, 30 mg ............ 36
TEMODAR CAPSULE ................................ 12
TERA-GEL TAR SHAMPOO 0.5 %
.................................................................................................. 78
terazosin capsule .................................................... 14
terbinafine tablet 250 mg .................................... 5
terbinafine topical cream 1 % ...................... 73
terbutaline tablet 2.5 mg, 5 mg ................... 15
terbutaline tablet 2.5 mg, 5 mg ................... 73
TESTRED CAPSULE 10 MG ................ 59
tetracycline capsule 250 mg, 500 mg
.................................................................................................. 10
THEOCHRON
.................................................................................................. 26
THEOCHRON
.................................................................................................. 44
THEOCHRON
.................................................................................................. 73
THEOCHRON
.................................................................................................. 80
theophylline er tablet,extended release
400 mg, 600 mg ......................................................... 26
400 mg, 600 mg ......................................................... 44
400 mg, 600 mg ......................................................... 73
400 mg, 600 mg ......................................................... 80
theophylline er tablet,extended release,12
hr .......................................................................................... 26
hr .......................................................................................... 44
hr .......................................................................................... 73
hr .......................................................................................... 80
THERA-GEL SHAMPOO 0.5 % ......... 78
thioridazine tablet ................................................. 40
thiothixene capsule ............................................... 42
ticlopidine tablet 250 mg .................................. 19
TILIA FE TABLET 1-20(5)/1-30(7)
/1MG-35MCG (9) ................................................. 61
timolol eye gel forming solution 0.25 %,
0.5 % ................................................................................... 49
timolol maleate eye drops 0.25 %, 0.5 %
.................................................................................................. 49
timolol maleate oral ............................................ 14
104

tizanidine tablet 2 mg, 4 mg ........................... 14
TOBRADEX EYE
.................................................................................................. 49
TOBRADEX EYE
.................................................................................................. 50
TOBRADEX EYE OINTMENT
0.3-0.1 % ......................................................................... 49
TOBRADEX EYE OINTMENT
0.3-0.1 % ......................................................................... 50
TOBRADEX ST EYE
.................................................................................................. 49
TOBRADEX ST EYE
.................................................................................................. 50
tobramycin eye drops 0.3 % ........................... 49
tobramycin-dexamethasone eye
drops,suspension 0.3-0.1 % ............................. 49
tobramycin-dexamethasone eye
drops,suspension 0.3-0.1 % ............................. 50
TOBREX EYE OINTMENT 0.3 %
.................................................................................................. 49
tolazamide tablet 250 mg, 500 mg ........... 63
tolbutamide tablet 500 mg ............................... 63
tolmetin capsule 400 mg .................................... 40
tolmetin tablet 200 mg, 600 mg .................. 40
tolnaftate topical cream 1 % ......................... 79
tolnaftate topical powder 1 % ...................... 79
tolnaftate topical solution 1 % ..................... 79
tolterodine tablet 1 mg, 2 mg ........................ 80
TOPIRAGEN .......................................................... 32
topiramate sprinkle capsule 15 mg, 25 mg
.................................................................................................. 32
topiramate tablet .................................................... 32
tramadol tablet 50 mg ......................................... 38
tramadol-acetaminophen tablet 37.5-325
mg ......................................................................................... 31
mg ......................................................................................... 33
mg ......................................................................................... 38
TRANXENE T-TAB ........................................ 36
tranylcypromine tablet 10 mg ...................... 37
TRAVATAN Z EYE DROPS 0.004 %
.................................................................................................. 52
trazodone tablet ...................................................... 42
TREAGAN OTIC EAR DROPS
5.4-1.4 % ......................................................................... 51
tretinoin (chemotherapy) capsule 10 mg
.................................................................................................. 12
tretinoin topical cream ...................................... 77
tretinoin topical gel 0.01 %, 0.025 %
.................................................................................................. 77
.................................................................................................. 18
.................................................................................................. 46
.................................................................................................. 81
.................................................................................................. 83
triamcinolone acetonide dental paste 0.1

% ............................................................................................ 75
triamcinolone acetonide lotion 0.025 %,
0.1 % ................................................................................... 75
triamcinolone acetonide nasal spray
aerosol 55 mcg ........................................................... 50
triamcinolone acetonide nasal spray
aerosol 55 mcg ........................................................... 71
triamcinolone acetonide topical cream
.................................................................................................. 75
triamcinolone acetonide topical ointment
0.025 %, 0.1 % ........................................................... 75
triamterene-hydrochlorothiazide capsule
37.5-25 mg ..................................................................... 28
37.5-25 mg ..................................................................... 29
37.5-25 mg ..................................................................... 45
37.5-25 mg ..................................................................... 47
triamterene-hydrochlorothiazide tablet
37.5-25 mg, 75-50 mg .......................................... 28
37.5-25 mg, 75-50 mg .......................................... 29
37.5-25 mg, 75-50 mg .......................................... 45
37.5-25 mg, 75-50 mg .......................................... 47
triazolam tablet 0.125 mg, 0.25 mg
.................................................................................................. 36
TRICARE TABLET 27 MG IRON- 1
MG ...................................................................................... 18
MG ...................................................................................... 81
MG ...................................................................................... 83
TRIESENCE (PF) INTRAOCULAR
SUSPENSION 40 MG/ML ........................ 50
trifluoperazine tablet .......................................... 40
trifluridine eye drops 1 % ................................. 49
.................................................................................................. 13
.................................................................................................. 31
trihexyphenidyl tablet 2 mg, 5 mg ............ 13
trihexyphenidyl tablet 2 mg, 5 mg ............ 31
TRI-LEGEST FE TABLET
1-20(5)/1-30(7) /1MG-35MCG (9)
.................................................................................................. 61
trimethobenzamide capsule 300 mg
.................................................................................................. 54
trimethoprim tablet 100 mg ........................... 11
trimethoprim-polymyxin b eye drops
0.1-10,000 %-unit/ml ............................................ 49
TRINATAL RX 1 TABLET 60 MG
IRON-1 MG .............................................................. 18
IRON-1 MG .............................................................. 46
IRON-1 MG .............................................................. 81
IRON-1 MG .............................................................. 83
TRINESSA (28) TABLET
0.18/0.215/0.25 MG-35 MCG (28)
.................................................................................................. 61
TRIPHROCAPS CAPSULE 1 MG
..................................................................................................
83
TRIPLE ANTIBIOTIC PLUS

TOPICAL OINTMENT 3.5-500-10,000
MG-UNIT-UNIT/G .......................................... 74
TRIPLE ANTIBIOTIC TOPICAL
OINTMENT 3.5-400-5,000
MG-UNIT-UNIT/G .......................................... 74
TRI-PREVIFEM (28) TABLET
0.18/0.215/0.25 MG-35 MCG (28)
.................................................................................................. 61
TRI-SPRINTEC (28) TABLET
0.18/0.215/0.25 MG-35 MCG (28)
.................................................................................................. 61
TRI-VI-SOL ORAL DROPS
1,500-35-400 UNIT-MG-UNIT/ML
.................................................................................................. 81
TRI-VI-SOL WITH IRON ORAL
DROPS 1,500 UNIT- 10 MG
IRON/ML .................................................................... 18
IRON/ML .................................................................... 81
IRON/ML .................................................................... 82
IRON/ML .................................................................... 83
IRON/ML .................................................................... 84
TRIVORA (28) TABLET 50-30
(6)/75-40 (5)/125-30(10) .................................... 61
TRIZIVIR TABLET 300-150-300 MG
..................................................................................................... 9
tropicamide eye drops 0.5 %, 1 % ............. 52
trospium er capsule,extended release 24
hr 60 mg ........................................................................... 80
trospium tablet 20 mg ......................................... 80
TRUVADA TABLET 200-300 MG
..................................................................................................... 9
TUCKS OINTMENT 1-12.5 % .............. 76
TUCKS RECTAL SUPPOSITORY 51
% ............................................................................................ 79
TUDORZA PRESSAIR BREATH
ACTIVATED 400
MCG/ACTUATION ........................................ 13
TUDORZA PRESSAIR BREATH
ACTIVATED 400
MCG/ACTUATION ........................................ 67
TUMS CHEWABLE TABLET 200
MG CALCIUM (500 MG) .......................... 47
TUMS CHEWABLE TABLET 200
MG CALCIUM (500 MG) .......................... 53
TUSNEL DIABETIC ORAL LIQUID
10-100 MG/5 ML .................................................. 68
TUSNEL DIABETIC ORAL LIQUID
10-100 MG/5 ML .................................................. 70
TUSSIGON TABLET 5-1.5 MG .......... 68
ULESFIA LOTION 5 % ............................... 78
ULESFIA LOTION 5 % ............................... 79
ULTRA A-D TABLET 2 MG ................. 53
ULTRA DM FREE & CLEAR ORAL
LIQUID 10-100 MG/5 ML ......................... 68
105
ULTRA DM FREE & CLEAR ORAL

LIQUID 10-100 MG/5 ML ......................... 70
urea topical cream 40 % .................................... 78
URISTIX 4 STRIPS .......................................... 43
URISTIX REAGENT STRIPS .............. 43
ursodiol capsule 300 mg .................................... 56
ursodiol tablet 250 mg, 500 mg ................... 56
VAGISTAT-3 VAGINAL KIT 200
MG- 2 % (9 GRAM) .......................................... 77
valacyclovir tablet 1 g, 500 mg ....................... 9
valproic acid (as sodium salt) oral
solution ........................................................................... 33
solution 250 mg/5 ml, 250 mg/5 ml (5
ml), 500 mg/10 ml (10 ml) ............................ 32
solution 250 mg/5 ml, 250 mg/5 ml (5
ml), 500 mg/10 ml (10 ml) ............................ 33
valproic acid capsule 250 mg ........................ 32
valproic acid capsule 250 mg ........................ 33
valsartan-hydrochlorothiazide ................... 20
vancomycin capsule 125 mg, 250 mg
..................................................................................................... 7
VANDAZOLE VAGINAL GEL 0.75
% ............................................................................................ 74
vaporizers misc ....................................................... 43
VELIVET TRIPHASIC REGIMEN
(28) TABLET 0.1/.125/.15-25
MG-MCG .................................................................... 61
venlafaxine er capsule,extended release
24 hr 150 mg, 37.5 mg, 75 mg ...................... 41
venlafaxine tablet .................................................. 41
VENTOLIN HFA AEROSOL
.................................................................................................. 15
VENTOLIN HFA AEROSOL
.................................................................................................. 73
verapamil er (sr) tablet,extended release
120 mg, 180 mg, 240 mg ................................... 23
120 mg, 180 mg, 240 mg ................................... 24
120 mg, 180 mg, 240 mg ................................... 26
120 mg, 180 mg, 240 mg ................................... 30
verapamil er 24 hr capsule,extended
release .............................................................................. 23
release .............................................................................. 24
release .............................................................................. 26
release .............................................................................. 30
verapamil tablet ...................................................... 23
VEXOL EYE DROPS,SUSPENSION
1 % ....................................................................................... 50
VICTRELIS CAPSULE 200 MG
..................................................................................................... 7
VIDEX 2 GRAM PEDIATRIC ORAL

SOLUTION 10 MG/ML (FINAL)
..................................................................................................... 9
VIDEX 4 GRAM PEDIATRIC ORAL
SOLUTION 10 MG/ML (FINAL)
..................................................................................................... 9
VINATE ONE TABLET 60 MG
IRON-1 MG .............................................................. 18
IRON-1 MG .............................................................. 47
IRON-1 MG .............................................................. 82
IRON-1 MG .............................................................. 83
VIRACEPT TABLET 250 MG, 625
MG ......................................................................................... 7
VIRAMUNE ORAL SUSPENSION 50
MG/5 ML ........................................................................ 8
VIRAMUNE TABLET 200 MG ............. 8
VIRAMUNE XR
MG ......................................................................................... 8
VIREAD ORAL POWDER 40
MG/SCOOP (40 MG/GRAM) ................... 9
VIREAD TABLET 150 MG, 200 MG,
250 MG, 300 MG ..................................................... 9
vitamin a & d topical ointment ................. 77
vitamin a capsule .................................................... 82
VITAMIN B COMPLEX CAPSULE
.................................................................................................. 83
VITAMIN B COMPLEX TABLET
.................................................................................................. 83
VITAMIN B-1 TABLET 100 MG
.................................................................................................. 83
VITAMIN B-12 TABLET ........................... 83
VITAMIN B-6 TABLET .............................. 83
VITAMIN C CHEWABLE TABLET
250 MG, 500 MG .................................................. 83
VITAMIN C ER
1,000 MG, 500 MG ............................................. 83
VITAMIN C ORAL LIQUID 500
MG/15 ML .................................................................. 83
VITAMIN C SYRUP 500 MG/5 ML
.................................................................................................. 83
VITAMIN C TABLET ................................... 83
VITAMIN D2 CAPSULE 50,000
UNIT ................................................................................ 84
VITAMIN D3 CAPSULE 1,000 UNIT,
2,000 UNIT ................................................................. 84
VITAMIN D3 TABLET 1,000 UNIT,
2,000 UNIT, 400 UNIT .................................. 84
vitamin e capsule .................................................... 84
VIVELLE-DOT TRANSDERMAL
PATCH ........................................................................... 61
VOL-CARE RX TABLET 1-60-300
MG-MG-MCG ....................................................... 83
VOL-PLUS TABLET 27-1 MG ............. 18
VOL-TAB RX TABLET 29 MG
IRON- 1 MG ............................................................. 18
IRON- 1 MG ............................................................. 47
IRON- 1 MG ............................................................. 82
IRON- 1 MG ............................................................. 83
VOLTAREN TOPICAL GEL 1 %
.................................................................................................. 40
warfarin oral .............................................................. 16
water for injection, sterile intravenous
solution .......................................................................... 66
XARELTO .................................................................. 16
XELODA TABLET 150 MG, 500 MG
.................................................................................................. 12
XOLAIR SUBCUTANEOUS
SOLUTION 150 MG ........................................ 72
X-SEB T PLUS SHAMPOO 2 % .......... 78
ZADITOR EYE DROPS 0.025 %
.................................................................................................. 48
zafirlukast tablet 10 mg, 20 mg .................. 71
zaleplon capsule 10 mg, 5 mg ....................... 34
ZARAH TABLET 3-0.03 MG ................. 61
ZENCHENT (28) TABLET 0.4-35
MG-MCG .................................................................... 61
ZERIT ORAL SOLUTION 1 MG/ML
..................................................................................................... 9
ZIAGEN ORAL SOLUTION 20
MG/ML ............................................................................. 9
zidovudine capsule 100 mg ................................. 9
zidovudine syrup 10 mg/ml ................................. 9
zidovudine tablet 300 mg ..................................... 9
zinc oxide topical ointment 20 % .............. 77
ziprasidone hcl .......................................................... 35
zolpidem tablet 10 mg, 5 mg .......................... 34
zonisamide ................................................................... 32
ZOSTRIX DIABETIC TOPICAL
CREAM 0.075 % ................................................... 79
ZOSTRIX TOPICAL CREAM 0.025 %
.................................................................................................. 79
ZOSTRIX-HP TOPICAL CREAM
0.075 % ............................................................................. 79
ZOVIA 1/35E (28) TABLET 1-35
MG-MCG .................................................................... 61
ZOVIA 1/50E (28) TABLET 1-50
MG-MCG .................................................................... 61
ZYPREXA RELPREVV .............................. 35
106

Health Partners Plans 2014 Formulary

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Health Partners Plans 2014 Formulary

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HealthPartnersPlansFormulary

Pharmacy and Therapeutics

urged to prescribe in amounts that adhere to

termination of the medication at least 10

To ensure that select medications are

Drugs Efficacy Study

To request a prior authorization the

Health Partners does not reimburse for

Days supply (duration of therapy) and

limited to, can be obtained through the retail

Quantity Limitations (QL)

encouraged. Your input is vital to this

Yes drug is covered

Health Partners of Philadelphia

Antihistamine Drugs .................................................................................................................................................................................................................................................................................... 3

Health Partners of Philadelphia

UPPERCASE = Brand name drugs

Retail; OTC; QL (100 EA per 26

clemastine tablet 1.34 mg

Retail; OTC; QL (2 EA per 1 day(s))

Retail; OTC; QL (12 EA per 7 day(s))

diphenhydramine capsule 25 mg, 50 mg

Retail; OTC; QL (100 EA per 26

diphenhydramine injection solution 50 mg/ml

diphenhydramine oral elixir 12.5 mg/5 ml

Retail; OTC; QL (240 ML per 15

diphenhydramine oral liquid 12.5 mg/5 ml

Retail; OTC; QL (240 ML per 15

diphenhydramine syrup 12.5 mg/5 ml

Retail; OTC; QL (240 ML per 15

diphenhydramine tablet 25 mg, 50 mg

Retail; OTC; QL (100 EA per 26

Retail; OTC; QL (100 EA per 26

SIMPLY SLEEP TABLET 25 MG

Retail; OTC; QL (100 EA per 26

Retail; OTC; QL (100 EA per 26

SOMINEX MAXIMUM STRENGTH TABLET 50

First Gen. Antihist. Derivatives, Misc.

cyproheptadine syrup 2 mg/5 ml

promethazine rectal suppository 12.5 mg, 25 mg

Retail; Age (Min 6 Years)

promethazine syrup 6.25 mg/5 ml

Retail; Age (Min 6 Years)

Retail; Age (Min 6 Years)

PROMETHAZINE VC SYRUP 6.25-5 MG/5 ML

Retail; Age (Min 6 Years)

PROMETHAZINE VC-CODEINE SYRUP 6.25-5-10

Retail; Age (Min 6 Years)

hydroxyzine hcl tablet

hydroxyzine pamoate capsule

meclizine chewable tablet 25 mg

meclizine tablet 12.5 mg, 25 mg

Retail; OTC; QL (240 ML per 15

Retail; OTC; QL (100 EA per 26

ALLERGY (CHLORPHENIRAMINE) TABLET 4

Retail; OTC; QL (100 EA per 26

Retail; OTC; QL (100 EA per 26

AMBI 60PSE-4CPM TABLET 4-60 MG

Retail; OTC; QL (240 EA per 10

Retail; OTC; QL (100 EA per 26

Retail; OTC; QL (100 EA per 26

dexchlorpheniramine maleate er tablet,extended release 6

Retail; OTC; QL (100 EA per 26

LOHIST - D ORAL LIQUID 2-30 MG/5 ML