RDL Alpha List PDF

California
3-Tier Drug List

The 3-Tier Drug List includes a list of drugs covered by Health Net. This drug list is for California. The drug
list is updated often and may change. To get the most up-to-date information, you may view the latest drug
list on our website at www.healthnet.com or call us at the toll-free telephone number on your Health Net ID
card.
Welcome to Health Net

What is the 3-Tier Drug List?
The 3-Tier Drug List or formulary is a list of covered drugs used to treat common diseases or health
problems. The drug list is selected by a committee of doctors and pharmacists who meet regularly to decide
which drugs should be included. The committee reviews new drugs and new information about existing
drugs and chooses drugs based on:
Safety;
Effectiveness;
Side effects; and
Value (If two drugs are equally effective, the less costly drug will be preferred)
How much will I pay for my drugs?

To figure out how much you will pay for a drug, the abbreviations in the table below appear in the Drug Tier
column on the formulary. The copayment or coinsurance levels are defined in the table below. If you do not
know your copayment or coinsurance for each tier, please refer to your Summary of Benefits or other plan
documents.
Abbreviation
Description
Preferred generic drugs
Preferred brand drugs
Non-preferred brand drugs, covered drugs not on the drug list and covered brand
drugs that are approved as medically necessary by Health Net.
GP
Generic drugs are preferred. To get a brand drug that has a generic available, your
doctor must request prior authorization to show medical necessity. If we approve the
request, the drug may be covered at a higher copayment. Refer to your plan
documents for coverage details.
NF
Non-formulary drugs are those not included in the list of drugs approved by our
Pharmacy and Therapeutics Committee. We may cover a non-formulary drug if your
doctor provides a medical reason. If approved, the drug will be covered under the nonpreferred tier.
SP
Specialty and covered injectable drugs that may need to be filled by a Specialty
pharmacy. Prior authorization may be required. Some plans cover self-injectable drugs
under the medical benefit. Not all plans cover specialty drugs under the pharmacy
benefit. Refer to your plan documents for coverage and copayment/coinsurance.
ii
Are there any limits on my drug coverage?

Some drugs have limits on coverage. The table below provides a description of abbreviations that may
appear in the Limits column on the drug list:
Abbreviation Definition
Description
AC
Anti-Cancer
These oral cancer drugs are subject to a maximum $200

copayment per State law.
AL
Age Limit
These drugs may require prior authorization if your age does

not fall within manufacturer, FDA, or clinical recommendations.
PA
Prior Authorization
These drugs require prior authorization for coverage,

effectiveness, or safety reasons. This means that your doctor
must request approval from Health Net before the drug will be
covered.
PV
Preventive Drugs
QL
Quantity Limit
Preventive benefit drugs covered at no cost to members under

the Affordable Care Act. A deductible does not apply. To get a
brand drug that has a generic available, your doctor must
request prior authorization to show medical necessity. You will
be responsible for the difference in cost between the brand and
the generic drug.
These drugs have a limit on the amount that will be covered.
Your doctor must request approval for a higher quantity of the
drug from Health Net.
RX/OTC
Prescription &
Over-the-Counter
(OTC)
Certain drugs are available both in a prescription form and in an

OTC form. Only prescription drugs are covered by your plan
with the exception of some insulins, insulin supplies and some
covered preventive drugs.
ST
Step Therapy
You must first try and fail another specific drug(s) before these
drugs will be covered.
How can I get an exception to the rules for drug coverage?

Your doctor can ask for an exception to our rules for drug coverage.
Your doctor can ask us to cover your drug even if it is not on the drug list. If we approve an exception for
a drug thats not on the drug list, the non-preferred brand tier (Tier 3) applies.
Your doctor can ask us to make an exception for limits on your drug. For example, if your drug has a
quantity limit of 1 tablet per day, your doctor can ask us to cover more.
To request an exception, your doctor can fax a prior authorization form along with a written statement
supporting the request to us at 1-800-314-6223.
Can I go to any pharmacy?
To get the best benefit, you should use pharmacies that are in the network. These pharmacies have a contract
with Health Net. Most chain pharmacies and many independent pharmacies are in the network. To find a
iii
pharmacy near you, visit our website at www.healthnet.com or call us at the telephone number on your
Health Net ID card.
If you fill your prescription at an out-of-network pharmacy, the pharmacy may not be able to bill
Health Net online so you may have to pay the full cost of your drug. Unless it is an emergency your out-ofnetwork prescription drug may not be covered.
Some injectable and high cost drugs may be considered specialty drugs. Unless otherwise noted, these
drugs must be obtained from one of Health Nets Specialty Pharmacies.
Can I use a mail order pharmacy?
You can use the CVS Caremark Mail Order Pharmacy for the home delivery of most maintenance drugs.
Maintenance drugs are those that you take daily and are needed for a long term condition.
To use the mail order pharmacy, your doctor must provide new prescriptions that allow up to a 90-day
supply of each drug. Mail order forms are available on our website at www.healthnet.com or you may call us
at the telephone number on your Health Net ID card to request a form.
How can I save money on my prescription drugs?
You can save time and money with these simple steps:
Ask your doctor about generic drugs that may work for you.
Fill prescriptions at Health Net participating pharmacies.
Be sure your doctor prescribes drugs on the drug list
Fill your maintenance drugs through our mail order pharmacy program.
iv
Health Net Life Insurance Company (Health Net) complies with applicable federal civil rights
laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Health Net does not exclude people or treat them differently because of race, color, national
origin, age, disability, or sex.
Health Net:
Provides free aids and services to people with disabilities to communicate effectively with us,
such as qualified sign language interpreters and written information in other formats (large print,
accessible electronic formats, other formats).
Provides free language services to people whose primary language is not English, such as
qualified interpreters and information written in other languages.
If you need these services, contact Health Net's Customer Contact Center at:
On Exchange/Covered California 1-888-926-4988 (TTY: 711)
Off Exchange 1-800-522-0088 (TTY: 711)
If you believe that Health Net has failed to provide these services or discriminated in another
way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by
calling the number above and telling them you need help filing a grievance; Health Net's
Customer Contact Center is available to help you. You can also file a grievance by mail, fax or
online at:
Health Net Life Insurance Company
P.O. Box 10348
Van Nuys, CA 91410-0348
Fax: 1-877-831-6019
Online: healthnet.com
You can also file a civil rights complaint with the U.S. Department of Health and Human
Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint
Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S.
Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH
Building, Washington, DC 20201, 1-800-368-1019 (TDD: 1-8005377697).
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
NOLAFED34_2017
English
No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you
in your language. For help, call us at the number listed on your ID card or call 1-800-522-0088 (TTY: 711).
If you bought coverage through the California marketplace call 1-888-926-4988 (TTY: 711). For more help:
If you are enrolled in a PPO or EPO insurance policy from Health Net Life Insurance Company, call the
CA Dept. of Insurance at 1-800-927-4357. If you are enrolled in an HMO or HSP plan from Health Net of
California, Inc., call the DMHC Helpline at 1-888-HMO-2219.
Arabic
. . .
.)TTY: 711( 1-800-522-0088
:) TTY: 711( 1-888-926-4988
Health Net Life EPO PPO
.1-800-927-4357 Insurance Company
,.Health Net of California, Inc HSP HMO
.1-888-HMO-2219 DMHC
Armenian
: :
:
ID 1-800-522-0088 (TTY: 711)
:
, 1-888-926-4988 (TTY: 711) :
. Health Net Life Insurance Company- PPO EPO
,
1-800-927-4357 : Health Net of California, Inc.- HMO
HSP , DMHC 1-888-HMO-2219 :
Chinese
1-800-522-0088TTY711
1-888-926-4988TTY711 Health Net Life Insurance Company
PPO EPO 1-800-927-4357 Health Net of California, Inc.
HMO HSP DMHC 1-888-HMO-2219
Hindi

, ,
1-800-522-0088 (TTY: 711)
1-888-926-4988 (TTY: 711) : Health Net
Life Insurance Company PPO EPO ,
1-800-927-4357 Health Net of California, Inc.
HMO HSP , DMHC 1-888-HMO-2219

NOLAFED34_2017
Hmong
Kev Pab Txhais Lus Dawb. Koj xav tau neeg txhais lus los tau. Koj xav tau neeg nyeem cov ntaub ntawv kom
yog koj hom lus los tau. Kev pab, hu rau peb ntawm tus xov tooj teev nyob rau hauv koj daim ID card los yog
hu rau 1-800-522-0088 (TTY: 711). Yog tias koj yuav kev pov hwm ntawm California marketplace hu
1-888-926-4988 (TTY: 711). Xav tau kev pab ntxiv: Yog koj tau tsab ntawv tuav pov hwm PPO los yog EPO
los ntawm Health Net Life Insurance Company, hu mus rau CA Dept. of Insurance ntawm 1-800-927-4357.
Yog koj tau txoj kev pab kho mob HMO los yog HSP los ntawm Health Net of California, Inc., hu mus rau
DMHC tus xov tooj pab Helpline ntawm 1-888-HMO-2219.
Japanese
ID1-800-522-0088(TTY: 711)
()
1-888-926-4988 (TTY: 711) :Health Net Life
Insurance CompanyPPOEPO
1-800-927-4357 Health Net of California, Inc.HMOHSP
DMHC 1-888-HMO-2219
Khmer

1-800-522-0088 (TTY: 711)
1-888-926-4988 (TTY: 711)

PPO EPO
Health Net Life Insurance Company CA
1-800-927-4357 HMO HSP Health Net of California, Inc.

DMHC 1-888-HMO-2219
Korean
. . .
ID 1-800-522-0088 (TTY: 711)
. 1-888-926-4988 (TTY: 711)
. , Health Net Life Insurance Company PPO
EPO 1-800-927-4357 .
Health Net of California, Inc. HMO HSP DMHC
1-888-HMO-2219 .
Navajo
Saad Bee !k1 Eeyeed T11 J77ke. Ata halne7g77 h0l=. T11 h0 hazaad kehj7 naaltsoos hach8 w0ltah.
Sh7k1 adoowo[ n7n7zingo naaltsoos bee n47hod0lzin7g77 bik1agi b44sh bee hane7 bik11 1aj8
hod77lnih 47 doodaii 1-800-522-0088 (TTY: 711). California marketplace hooly4h7j7 b4eso 1ch33h
naanil7 ats77s baa 1h1y3 biniiy4 nah7n7[niigo 47 koj8 h0lne 1-888-926-4988 (TTY: 711). Sh7k1
an11doowo[ jin7zingo: PPO 47 doodaii EPO-j7 Health Net Life Insurance Company woly4h7j7 b4eso
1ch33h naanil biniiy4 hweiina bik44stigo 47 CA Dept. of Insurance bich8 hojilnih 1-800-927-4357.
HMO 47 doodaii HSP-j7 Health Net of California, Inc.-j7 b4eso 1ch33h naanil biniiy4 hats77s
bik44stigo 47 koj8 hojilnih DMHC Helpline 1-888-HMO-2219.
NOLAFED34_2017
Persian (Farsi)
. . .

.) TTY: 711( 1-800-522-0088
EPO PPO : .) TTY: 711( 1-888-926-4988
1-800-927-4357 CA Dept. of Insurance Health Net Life Insurance Company
.Health Net of California, Inc HSP HMO .
. 1-888-HMO-2219 DMHC
Panjabi (Punjabi)

,
1-800-522-0088 (TTY: 711)
1-888-926-4988 (TTY: 711) : Health Net Life Insurance
Company PPO EPO ,
1-800-927-4357 Healh Net of California, Inc. HMO
HSP DMHC 1-888-HMO-2219
Russian
. .
. ,
. ,
1-800-522-0088 (TTY: 711).
, 1-888-926-4988 (TTY: 711).
: PPO EPO Health Net
Life Insurance Company, (CA Dept. of Insurance),
1-800-927-4357. HMO HSP Health Net of
California, Inc.,
DMHC, 1-888-HMO-2219.
Spanish
Servicios de idiomas sin costo. Puede solicitar un intrprete. Puede obtener el servicio de lectura de
documentos y recibir algunos en su idioma. Para obtener ayuda, llmenos al nmero que figura en su
tarjeta de identificacin o comunquese con el Centro de Comunicacin Comercial de Health Net, al
1-800-522-0088 (TTY: 711). Si adquiri la cobertura a travs del mercado de California, llame al
1-888-926-4988 (TTY: 711). Para obtener ms ayuda, haga lo siguiente: Si est inscrito en una pliza de
seguro PPO o EPO de Health Net Life Insurance Company, llame al Departamento de Seguros de California,
al 1-800-927-4357. Si est inscrito en un plan HMO o HSP de Health Net of California, Inc., llame a la lnea
de ayuda del Departamento de Atencin Mdica Administrada, al 1-888-HMO-2219.
NOLAFED34_2017
Tagalog
Walang Bayad na Mga Serbisyo sa Wika. Makakakuha kayo ng isang interpreter. Makakakuha kayo ng mga
dokumento na babasahin sa inyo. Para sa tulong, tawagan kami sa nakalistang numero sa inyong ID card
o tawagan ang 1-800-522-0088 (TTY: 711). Kung bumili kayo ng pagsakop sa pamamagitan ng California
marketplace tawagan ang 1-888-926-4988 (TTY: 711). Para sa higit pang tulong: Kung nakatala kayo sa
insurance policy ng PPO o EPO mula sa Health Net Life Insurance Company, tawagan ang CA Dept. of
Insurance sa 1-800-927-4357. Kung nakatala kayo sa HMO o HSP na plan mula sa Health Net of California,
Inc., tawagan ang Helpline ng DMHC sa 1-888-HMO-2219.
Thai

1-800-522-0088 (TTY: 711)
California marketplace 1-888-926-4988 (TTY: 711)
PPO EPO Health Net Life Insurance Company
1-800-927-4357 HMO HSP Health Net of California, Inc.
DMHC 1-888-HMO-2219.
Vietnamese
Cc Dch V Ngn Ng Min Ph. Qu v c th c mt phin dch vin. Qu v c th yu cu c c

cho nghe ti liu. nhn tr gip, hy gi cho chng ti theo s c lit k trn th ID ca qu v hoc
gi 1-800-522-0088 (TTY: 711). Nu qu v mua khon bao tr thng qua th trng California
1-888-926-4988 (TTY: 711). nhn thm tr gip: Nu qu v ng k hp ng bo him PPO hoc
EPO t Health Net Life Insurance Company, vui lng gi S Y T CA theo s 1-800-927-4357. Nu qu
v ng k vo chng trnh HMO hoc HSP t Health Net of California, Inc., vui lng gi ng Dy
Tr Gip DMHC theo s 1-888-HMO-2219.
CA Commercial On and Off-Exchange Member Notice of Language Assistance

FLY007785EH00 (06/16)
NOLAFED34_2017
Drug Name
Drug Requirements/
Tier Limits
ADHD/ANTI-NARCOLEPSY/ANTIOBESITY/ANOREXIANTS - Drugs to Treat

ADHD, Sleep and Eating Disorders
Amphetamines
ADDERALL TABS (Use
AmphetamineDextroamphetamine)
ADDERALL XR CP24 (Use
AmphetamineDextroamphetamine)
ADZENYS XR-ODT TBED
amphetaminedextroamphetamine cp24
1.25mg-1.25mg-1.25mg1.25mg, 2.5mg-2.5mg2.5mg-2.5mg, 3.75mg3.75mg-3.75mg-3.75mg,
5mg-5mg-5mg-5mg,
6.25mg-6.25mg-6.25mg6.25mg, 7.5mg-7.5mg7.5mg-7.5mg
amphetaminedextroamphetamine tabs
1.25mg-1.25mg-1.25mg1.25mg, 1.875mg1.875mg-1.875mg1.875mg, 2.5mg-2.5mg2.5mg-2.5mg, 3.125mg3.125mg-3.125mg3.125mg, 3.75mg-3.75mg3.75mg-3.75mg, 5mg-5mg5mg-5mg, 7.5mg-7.5mg7.5mg-7.5mg
DESOXYN TABS (Use
Methamphetamine HCl)
DEXEDRINE CP24 (Use
Dextroamphetamine
Sulfate)
dextroamphetamine sulfate
cp24 10 mg, 15 mg, 5 mg
soln 5 mg/5ml
tabs 10 mg, 5 mg
DYANAVEL XR SUER
GP
QL(2 ea
GP daily,90 day(s)
limit)
3 PA; QL(1 ea
daily)
QL(2 ea
daily,90 day(s)
limit)
1
Drug Requirements/
Tier Limits
3 PA
methamphetamine hcl tabs
Drug Name
PROCENTRA SOLN (Use

Dextroamphetamine
Sulfate)
GP
VYVANSE CAPS 10 MG
VYVANSE CAPS 20 MG,

30 MG, 40 MG, 50 MG, 60
MG, 70 MG
ZENZEDI TABS
QL(1 ea daily)
Analeptics
caffeine citrate soln
Anorexiants Non-Amphetamine
ADIPEX-P CAPS (Use
SP PA
Phentermine HCl)
SP PA
benzphetamine hcl tabs
phentermine hcl caps
SP PA
QSYMIA CP24
SP PA
REGIMEX TABS (Use

Benzphetamine HCl)
SP PA
SUPRENZA TBDP
SP PA
Anti-Obesity Agents
BELVIQ TABS
SP PA
CONTRAVE TB12
SP PA
GP PA
XENICAL CAPS
SP PA
GP
Attention-Deficit/Hyperactivity Disorder (ADHD)

3 QL(4 ea daily)
clonidine hcl (adhd) tb12
guanfacine hcl (adhd) tb24
3
1
3
PA; QL(8 ml
daily)
QL(1 ea daily)
INTUNIV TB24 (Use

GP QL(1 ea daily)
Guanfacine HCl (ADHD))
KAPVAY TB12 (Use
GP QL(4 ea daily)
Clonidine HCl (ADHD))
STRATTERA CAPS 10
3 QL(2 ea daily)
MG, 18 MG, 25 MG, 40 MG
You can find information on what the symbols and abbreviations on this table mean by going to
page ii-iii.
California 3-Tier Drug List
1
Updated: January 1, 2017
Drug Name
STRATTERA CAPS 100
MG, 60 MG, 80 MG
Drug Requirements/
Tier Limits
3 QL(1 ea daily)
Stimulants - Misc.
APTENSIO XR CP24
armodafinil tabs
CONCERTA TBCR 18 MG,

27 MG, 54 MG (Use
Methylphenidate HCl)
CONCERTA TBCR 36 MG
(Use Methylphenidate HCl)
DAYTRANA PTCH
dexmethylphenidate hcl
cp24 10 mg, 15 mg, 20 mg,
30 mg, 40 mg, 5 mg
dexmethylphenidate hcl
tabs 10 mg, 2.5 mg, 5 mg
FOCALIN TABS (Use
Dexmethylphenidate HCl)
FOCALIN XR CP24 10
MG, 15 MG, 20 MG, 30
MG, 40 MG, 5 MG (Use
Dexmethylphenidate HCl)
FOCALIN XR CP24 25
MG, 35 MG
METADATE CD CPCR 10
MG, 40 MG, 50 MG, 60 MG
(Use Methylphenidate HCl)
METADATE CD CPCR 20
MG, 30 MG (Use
METHYLIN CHEW (Use
METHYLIN SOLN (Use
methylphenidate hcl chew
10 mg, 2.5 mg, 5 mg
methylphenidate hcl cp24
20 mg, 30 mg, 40 mg
methylphenidate hcl cpcr
10 mg, 40 mg, 50 mg, 60
mg
PA; QL(1 ea
daily)
PA
QL(1 ea
GP daily,90 day(s)
limit)
QL(2 ea
NF daily,90 day(s)
limit)
3
QL(1 ea daily)
3
1
Drug Name
methylphenidate hcl cpcr

20 mg, 30 mg
methylphenidate hcl soln
10 mg/5ml
methylphenidate hcl soln 5
mg/5ml
methylphenidate hcl tabs
10 mg, 20 mg, 5 mg
methylphenidate hcl tb24
18 mg, 27 mg, 54 mg
36 mg
54 mg
QL(2 ea daily)
GP QL(2 ea daily)
methylphenidate hcl tbcr 10

mg
QL(1 ea daily)
GP
3

mg, 20 mg, 27 mg, 54 mg
mg
GP
QL(2 ea
GP daily,90 day(s)
limit)

mg
GP
modafinil tabs
GP
3
3
NUVIGIL TABS (Use

Armodafinil)
PROVIGIL TABS (Use
Modafinil)
QUILLICHEW ER CHER
Drug Requirements/
Tier Limits
QL(2 ea
3 daily,90 day(s)
limit)
3
1
1
QL(1 ea
daily,90 day(s)
limit)
QL(2 ea
1 daily,90 day(s)
limit)
QL(1 ea
1 daily,90 day(s)
limit,3 copay(s)
per fill retail)
QL(1 ea
daily,90 ea per
1 fill retail,3
copay(s) per fill
retail)
QL(1 ea
1 daily,90 day(s)
limit)
QL(2 ea
1 daily,90 day(s)
limit)
QL(1 ea
daily,90 day(s)
1 limit,90 ea per
fill retail,3
copay(s) per fill
retail)
3 ST; QL(1 ea
daily)
GP PA
1
GP ST; QL(1 ea
daily)
3 PA
QUILLIVANT XR SUSR
RITALIN LA CP24 10 MG
PA; QL(12 ml
daily)
page ii-iii.

2
Drug Name
RITALIN LA CP24 20 MG,
30 MG, 40 MG (Use
Drug Requirements/
Tier Limits
GP
RITALIN LA CP24 60 MG
RITALIN TABS (Use
QL(1 ea
daily,90 ea per
fill retail,3
copay(s) per fill
retail)
GP
Drug Name
RASUVO SOAJ 10
MG/0.2ML, 12.5
MG/0.25ML, 15 MG/0.3ML,
17.5 MG/0.35ML, 22.5
MG/0.45ML, 25 MG/0.5ML,
27.5 MG/0.55ML, 30
MG/0.6ML, 7.5 MG/0.15ML
RHEUMATREX TABS
Drug Requirements/
Tier Limits
PA
SP
Gold Compounds
AMINOGLYCOSIDES - Drugs to Treat Bacterial

Infections
RIDAURA CAPS
Aminoglycosides
Nonsteroidal Anti-inflammatory Agents (NSAIDs)

ANAPROX DS TABS (Use GP
Naproxen Sodium)
ARTHROTEC 50 TBEC
GP
(Use Diclofenac w/
Misoprostol)
ARTHROTEC 75 TBEC
GP
(Use Diclofenac w/
Misoprostol)
CATAFLAM TABS (Use
GP
Diclofenac Potassium)
CELEBREX CAPS 100
ST; QL(1 ea
GP daily); AL
MG, 200 MG (Use
Celecoxib)
CELEBREX CAPS 400 MG GP PA; QL(2 ea
(Use Celecoxib)
daily); AL
CELEBREX CAPS 50 MG
GP PA; AL
(Use Celecoxib)
celecoxib caps 100 mg,
1 ST; QL(1 ea
200 mg
daily); AL
1 PA; QL(2 ea
celecoxib caps 400 mg
daily); AL
1 PA; AL
celecoxib caps 50 mg
BETHKIS NEBU
KITABIS PAK NEBU
neomycin sulfate tabs
paromomycin sulfate caps
TOBI NEBU (Use

Tobramycin)
GP
TOBI PODHALER CAPS
tobramycin nebu
TOBRAMYCIN NEBU
ANALGESICS - ANTI-INFLAMMATORY - Drugs

to Treat Pain, Swelling, Muscle and Joint
Conditions
Antirheumatic - Enzyme Inhibitors
XELJANZ TABS
XELJANZ XR TB24
PA; New
commercial
3 members to be
referred to
AcariaHealth
PA; New
commercial
SP members to be
referred to
AcariaHealth
Antirheumatic Antimetabolites
DAYPRO TABS (Use

Oxaprozin)
diclofenac potassium tabs

diclofenac sodium tb24 100
mg
diclofenac sodium tbec 25
mg, 50 mg, 75 mg
diclofenac w/ misoprostol
tbec
GP
3
3
1
3
page ii-iii.
3
Drug Name
DUEXIS TABS
Drug Requirements/
Tier Limits
3 PA
EC-NAPROSYN TBEC 500 GP

MG (Use Naproxen)
etodolac caps 200 mg, 300
1
mg
etodolac tabs 400 mg, 500
1
mg
etodolac tb24 400 mg, 500
1 QL(2 ea daily)
mg, 600 mg
FELDENE CAPS (Use
GP
Piroxicam)
FENOPROFEN CALCIUM
2
CAPS 200 MG
FENOPROFEN CALCIUM
3
CAPS 400 MG
fenoprofen calcium tabs
1
600 mg
FENORTHO CAPS 200
2
MG
FENORTHO CAPS 400
3
MG
Drug Name
meclofenamate sodium
caps
mefenamic acid caps
meloxicam susp 7.5

mg/5ml
meloxicam tabs 15 mg
QL(1 ea daily)
meloxicam tabs 7.5 mg
QL(2 ea daily)
MOBIC SUSP 7.5 MG/5ML
MOBIC TABS 15 MG (Use

Meloxicam)
MOBIC TABS 7.5 MG (Use
Meloxicam)
QL(4 ea daily)
nabumetone tabs 750 mg
QL(3 ea daily)
NALFON CAPS
flurbiprofen tabs 50 mg
NAPRELAN TB24 750 MG
ibuprofen tabs 400 mg, 600

mg, 800 mg
INDOCIN SUPP RE 50 MG
NAPROSYN SUSP (Use

Naproxen)
NAPROSYN TABS (Use
Naproxen)
naproxen sodium tabs 275
mg, 550 mg
naproxen sodium tb24 375
mg, 500 mg
NAPROXEN SUSP 125
MG/5ML
1
1
GP QL(2 ea daily)
1
flurbiprofen tabs 100 mg
GP QL(1 ea daily)
nabumetone tabs 500 mg
NAPRELAN TB24 375 MG,

500 MG (Use Naproxen
Sodium)
INDOCIN SUSP OR 25
MG/5ML
indomethacin caps or 25
mg, 50 mg
indomethacin cpcr or 75
mg
Drug Requirements/
Tier Limits
GP
3
GP
GP
1
3
2
ketoprofen caps
naproxen susp 125 mg/5ml
KETOPROFEN ER CP24
naproxen tabs 250 mg, 375

mg, 500 mg
naproxen tbec 500 mg
oxaprozin tabs
piroxicam caps
ketorolac tromethamine
tabs or 10 mg
LODINE TABS (Use
Etodolac)
1
GP
QL(20 ea per
fill retail,20 ea
per 30 days
retail)
page ii-iii.

4
Drug Name
PONSTEL CAPS (Use
Mefenamic Acid)
Drug Requirements/
Tier Limits
GP
SPRIX SOLN
sulindac tabs
TIVORBEX CAPS
TOLMETIN SODIUM
CAPS 400 MG
tolmetin sodium caps 400
mg
tolmetin sodium tabs 200
mg, 600 mg
VIMOVO TBEC
VOLTAREN-XR TB24 (Use
Diclofenac Sodium)
QL(1 ea daily,5
day(s) limit)
ST; QL(3 ea
daily)
2
1
1
3
PA
ZORVOLEX CAPS
ST; QL(4 ea
daily,7 day(s)
limit)
ST; QL(3 ea
daily)
Phosphodiesterase 4 (PDE4) Inhibitors

PA; New
commercial
SP members to be
OTEZLA TABS
referred to
AcariaHealth
PA; New
commercial
SP members to be
OTEZLA TBPK
referred to
AcariaHealth
Pyrimidine Synthesis Inhibitors
ARAVA TABS 10 MG (Use GP QL(2 ea daily)
Leflunomide)
ARAVA TABS 20 MG (Use GP QL(1 ea daily)
Leflunomide)
1 QL(2 ea daily)
leflunomide tabs 10 mg
leflunomide tabs 20 mg
QL(1 ea daily)
ANALGESICS - NonNarcotic - Drugs to Treat

Pain, Muscle and Joint Conditions
Analgesic Combinations
Drug Requirements/
Tier Limits
acetaminophensalicylamidephenyltoloxamine caps
BUPAP TABS
butalbital-acetaminophen
tabs
butalbital-acetaminophencaffeine caps 300mg50mg-40mg, 325mg-50mg40mg
butalbital-acetaminophencaffeine tabs 325mg-50mg40mg
butalbital-aspirin-caffeine
caps
DOLOGESIC TABS
GP
ZIPSOR CAPS
Drug Name
ESGIC TABS (Use

Butalbital-AcetaminophenCaffeine)
FIORICET CAPS (Use
Butalbital-AcetaminophenCaffeine)
FIORINAL CAPS (Use
Butalbital-Aspirin-Caffeine)
3
1
1
1
3
GP
GP
GP
LEVACET TABS
TENCON TABS
Salicylates
choline & mag salicylate
liqd
CHOLINE MAGNESIUM
TRISALICYLATE TABS
diflunisal tabs
1
2
3
ANALGESICS - OPIOID - Drugs to Treat Pain,

Muscle and Joint Conditions
Opioid Agonists
ABSTRAL SUBL
ACTIQ LPOP (Use
Fentanyl Citrate)
AVINZA CP24 (Use
Morphine Sulfate Beads)
PA
GP PA
GP QL(1 ea daily)
page ii-iii.
5
Drug Name
CODEINE SULFATE
SOLN 30 MG/5ML
codeine sulfate tabs 15 mg,
30 mg, 60 mg
CONZIP CP24 100 MG,
200 MG
DEMEROL TABS OR 100
MG, 50 MG (Use
Meperidine HCl)
DILAUDID LIQD (Use
Hydromorphone HCl)
DILAUDID TABS (Use
Hydromorphone HCl)
DOLOPHINE TABS (Use
Methadone HCl)
DURAGESIC PT72 (Use
Fentanyl)
EMBEDA CPCR
EXALGO T24A 12 MG, 16
MG, 8 MG (Use
Hydromorphone HCl)
EXALGO T24A 32 MG
(Use Hydromorphone HCl)
fentanyl citrate lpop
Drug Requirements/
Tier Limits
1
3
GP
GP
GP
GP QL(12 ea daily)
Limit 15 per
GP month;QL(0.5
ea daily)
3 PA
QL(4 ea daily)
GP
GP QL(2 ea daily)
fentanyl pt72 100 mcg/hr,

12 mcg/hr, 25 mcg/hr, 50
mcg/hr, 75 mcg/hr
FENTANYL PT72 37.5

MCG/HR, 62.5 MCG/HR,
87.5 MCG/HR
FENTORA TABS
hydromorphone hcl liqd 1

mg/ml
hydromorphone hcl t24a 12
mg, 16 mg, 8 mg, 8mg
hydromorphone hcl t24a 32
mg
hydromorphone hcl tabs 2
mg, 4 mg, 8 mg
HYSINGLA ER T24A
KADIAN CP24 10 MG (Use

Morphine Sulfate)
KADIAN CP24 100 MG, 20
MG, 30 MG, 50 MG, 60
MG, 80 MG (Use Morphine
Sulfate)
PA
Limit 15 per
month;QL(0.5
ea daily)
PA; Limit 15
patches per
month;QL(0.5
ea daily)
PA; QL(3 ea
daily)
1
1
QL(4 ea daily)
QL(2 ea daily)
1
3
Drug Name
PA
Drug Requirements/
Tier Limits
GP
QL(2 ea daily)
GP
KADIAN CP24 200 MG
KADIAN CP24 40 MG
QL(2 ea daily)
LAZANDA SOLN
PA
PA
LEVORPHANOL
TARTRATE TABS
meperidine hcl soln or 50
mg/5ml
meperidine hcl tabs or 100
mg, 50 mg
methadone hcl conc or 10
mg/ml
methadone hcl soln or 10
mg/5ml, 5 mg/5ml
methadone hcl tabs or 10
mg, 5 mg
methadone hcl tbso or 40
mg
METHADOSE CONC (Use
Methadone HCl)
METHADOSE SUGARFREE CONC (Use
Methadone HCl)
METHADOSE TBSO (Use
Methadone HCl)
morphine sulfate cp24 or
10 mg
morphine sulfate cp24 or
100 mg, 20 mg, 30 mg, 50
mg, 60 mg, 80 mg
MORPHINE SULFATE ER
CP24
morphine sulfate soln or 10
mg/5ml, 100 mg/5ml, 20
mg/5ml, 20 mg/ml
morphine sulfate supp re
10 mg, 20 mg, 5 mg
MORPHINE SULFATE
SUPP RE 30 MG
1
1
1
1
1
QL(12 ea daily)
1
GP
GP
GP
1
QL(2 ea daily)
1
2
QL(1 ea daily)
1
1
2
page ii-iii.

6
Drug Name
morphine sulfate tabs or 15

mg, 30 mg
morphine sulfate tbcr or
100 mg, 15 mg, 30 mg, 60
mg
MS CONTIN TBCR (Use
Morphine Sulfate)
NUCYNTA ER TB12
NUCYNTA TABS
OPANA ER (CRUSH
RESISTANT) T12A
OPANA TABS OR 10 MG,
5 MG (Use Oxymorphone
HCl)
Drug Requirements/
Tier Limits
QL(3 ea daily)
1
GP QL(3 ea daily)
2
QL(2 ea daily)
QL(6 ea daily)
QL(2 ea daily)
GP
3
oxycodone hcl caps
oxycodone hcl conc
OXYCODONE HCL ER
T12A
oxycodone hcl soln
oxycodone hcl tabs
OXYCONTIN T12A
oxymorphone hcl tabs 10

mg, 5 mg
oxymorphone hcl tb12 10
mg, 15 mg, 20 mg, 30 mg,
40 mg, 5 mg, 7.5 mg
OXYMORPHONE
HYDROCHLORIDE ER
TB12
ROXICODONE TABS (Use
Oxycodone HCl)
tramadol hcl tabs 50 mg
OXAYDO TABA
QL(4 ea daily)
QL(3 ea daily)
QL(3 ea daily)
3
QL(2 ea daily)
1
QL(2 ea daily)
2
GP
SUBSYS LIQD
tramadol hcl cp24 300 mg
TRAMADOL HCL ER
CP24 100 MG, 150 MG,
200 MG
Drug Name
PA
tramadol hcl tb24 100 mg,

200 mg, 300 mg
ULTRAM ER TB24 (Use
Tramadol HCl)
ULTRAM TABS (Use
Tramadol HCl)
Drug Requirements/
Tier Limits
1 QL(8 ea daily)
3
GP
GP QL(8 ea daily)
XTAMPZA ER C12A
PA
ZOHYDRO ER C12A
PA
ZOHYDRO ER CP12
PA
Opioid Combinations
acetaminophen w/ codeine
soln
tabs
acetaminophen-caffdihydrocod caps
ASPIRIN-CAFFEINEDIHYDROCODEINE CAPS
butalbital-acetaminophencaffeine w/ codeine caps
w/cod caps
CAPITAL/CODEINE SUSP
1
1
3
QL(12 ea daily)
3
3
3
3
FIORICET/CODEINE
CAPS (Use ButalbitalAcetaminophen-Caffeine w/ GP
Codeine)
FIORINAL/CODEINE #3
GP
CAPS (Use ButalbitalAspirin-Caffeine w/Cod)
HYCET SOLN (Use
GP
HydrocodoneAcetaminophen)
hydrocodoneacetaminophen soln
1
2.5mg/5ml-108mg/5ml,
5mg/10ml-217mg/10ml,
7.5mg/15ml-325mg/15ml
page ii-iii.
7
Drug Name
hydrocodoneacetaminophen tabs 10mg300mg, 5mg-300mg,

7.5mg-300mg
hydrocodoneacetaminophen tabs 10mg325mg, 5mg-325mg,
7.5mg-325mg
hydrocodoneacetaminophen tabs
2.5mg-325mg
hydrocodone-ibuprofen
tabs 200mg-10mg
tabs 200mg-10mg, 200mg7.5mg
tabs 200mg-2.5mg,
200mg-5mg
HYDROCODONE/ACETA
MINOPHEN SOLN
LORTAB ELIX
MEPERIDINE
HCL/PROMETHAZINE
HCL CAPS
NORCO TABS (Use
oxycodone w/
acetaminophen tabs 10mg325mg, 2.5mg-325mg,
7.5mg-325mg
oxycodone w/
acetaminophen tabs 5mg325mg
oxycodone-ibuprofen tabs
OXYCODONE/ACETAMIN
OPHEN SOLN
PERCOCET TABS (Use
Oxycodone w/
Acetaminophen)
PRIMLEV TABS
REPREXAIN TABS (Use
Hydrocodone-Ibuprofen)
Drug Requirements/
Tier Limits
1
QL(240 ea per
fill retail)
3
1
Not available
through mail
order
1
3
Drug Name
ROXICET SOLN (Use
Oxycodone w/
Acetaminophen)
GP
SYNALGOS-DC CAPS
tramadol-acetaminophen
tabs
TREZIX CAPS (Use
Acetaminophen-CaffDihydrocod)
TYLENOL/CODEINE #3
TABS (Use Acetaminophen
w/ Codeine)
TYLENOL/CODEINE #4
TABS (Use Acetaminophen
w/ Codeine)
ULTRACET TABS (Use
Tramadol-Acetaminophen)
VICOPROFEN TABS (Use
Hydrocodone-Ibuprofen)
XARTEMIS XR TBCR
XODOL TABS (Use

GP
3
QL(12 ea daily)
GP
GP
GP
GP
GP
3
PA
GP
BELBUCA FILM
QL(2 ea daily)
BUNAVAIL FILM
PA
buprenorphine hcl subl sl 2

mg
buprenorphine hcl subl sl 8
mg
buprenorphine hclnaloxone hcl dihydrate subl
Opioid Partial Agonists
QL(240 ea per
GP fill retail)
Drug Requirements/
Tier Limits
QL(4 ea daily)
butorphanol tartrate soln na

10 mg/ml
BUTRANS PTWK 10
MCG/HR, 20 MCG/HR, 5
MCG/HR
BUTRANS PTWK 15
MCG/HR
1
1
1
3
3
3
PA; QL(3 ea
daily)
PA; QL(4 ea
daily)
PA; QL(3 ea
daily)
Limit 7.5mls
per
month;QL(0.25
ml daily)
Limit 4 per
month;QL(0.15
ea daily)
QL(4 ea per 28
days retail)
GP
page ii-iii.

8
Drug Name
BUTRANS PTWK 7.5
MCG/HR
pentazocine w/ naloxone
tabs
SUBOXONE FILM 12MG3MG
SUBOXONE FILM 2MG0.5MG, 4MG-1MG, 8MG2MG
Drug Requirements/
Tier Limits
Limit 4 per
3 month;QL(0.14
3 ea daily)
3
Drug Name
FORTESTA GEL
Drug Requirements/
Tier Limits
ST; Limit
3 100gms per
month;QL(3.5
gm daily)
METHITEST TABS
methyltestosterone caps
methyltestosterone caps
ANDROGENS-ANABOLIC - Drugs to Regulate

Hormones
NATESTO GEL
Anabolic Steroids
STRIANT MISC
ZUBSOLV SUBL
ANADROL-50 TABS
OXANDRIN TABS (Use
Oxandrolone)
oxandrolone tabs
Androgens
ANDRODERM PT24 2
MG/24HR
ANDRODERM PT24 4
MG/24HR
ANDROGEL GEL 20.25
MG/1.25GM, 40.5
MG/2.5GM
ANDROGEL GEL 25
MG/2.5GM (Use
Testosterone)
ANDROGEL GEL 50
MG/5GM (Use
Testosterone)
ANDROGEL PUMP GEL 1
% (Use Testosterone)
ANDROGEL PUMP GEL
1.62 %
ANDROXY TABS
PA; QL(2 ea
daily)
PA; QL(3 ea
daily)
PA
TESTIM GEL (Use

Testosterone)
GP
testosterone gel 1 %
1
testosterone gel 1 %
QL(60 day(s)
limit)
QL(1 ea daily)
QL(10 gm
daily)
QL(10 gm
GP daily)
testosterone gel 1 %, 25
mg/2.5gm, 50 mg/5gm
testosterone gel 1 %, 50
mg/5gm
QL(10 gm
NF daily)
TESTOSTERONE GEL 10
MG/ACT
GP QL(10 gm
daily)
2 QL(10 gm
daily)
2 AC
testosterone gel 25
mg/2.5gm
testosterone gel 25
mg/2.5gm, 50 mg/5gm
TESTRED CAPS (Use
Methyltestosterone)
VOGELXO GEL (Use
Testosterone)
AXIRON SOLN
danazol caps
ST; QL(6 ml
daily)
VOGELXO PUMP GEL
Not available
through mail
order
PA; Limit 3
tubes per
month;QL(0.78
5 gm daily)
QL(2 ea daily)
GP PA; QL(10 gm
daily)
3 PA; QL(10 gm
daily)
PA; Limited to
3 300 gms per
month;QL(10
gm daily)
Limited to 300
1 gms per
month;QL(10
gm daily)
Limit 300gms
1 per
month;QL(10
gm daily)
ST; Limit
3 100gms per
month;QL(3.5
gm daily)
1 PA; QL(10 gm
daily)
1 QL(10 gm
daily)
GP
GP PA; QL(10 gm
daily)
3 PA; QL(10 gm
daily)
page ii-iii.
9
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
CORTIFOAM FOAM
FIRST-VANCOMYCIN 25
SOLN
FIRST-VANCOMYCIN 50
SOLN
FLAGYL CAPS (Use
Metronidazole)
FLAGYL TABS (Use
Metronidazole)
hydrocortisone (intrarectal)
enem
metronidazole caps
UCERIS FOAM
metronidazole tabs
NEBUPENT SOLR
PRIMSOL SOLN
TINDAMAX TABS (Use

Tinidazole)
ANORECTAL AGENTS - Rectal Drugs to Treat

Pain, Swelling and Itching
Intrarectal Steroids
CORTENEMA ENEM (Use
Hydrocortisone
(Intrarectal))
Rectal Combinations
ANALPRAM-HC LOTN
1%-2.5%
lidocaine-hydrocortisone
acetate (rectal) kit 3%2.5%
PROCTOFOAM HC FOAM
Rectal Steroids
ANUSOL-HC CREA (Use
Hydrocortisone (Rectal))
hydrocortisone (rectal) crea
GP
PA
GP
1
ANTHELMINTICS - Drugs to Treat Worm

Infections
Anthelmintics
ALBENZA TABS
BILTRICIDE TABS
ivermectin tabs
STROMECTOL TABS (Use GP

Ivermectin)
ANTI-INFECTIVE AGENTS - MISC. - Drugs to
Treat Bacterial Infections
Anti-infective Agents - Misc.
CAYSTON SOLR
3
GP
GP
GP PA
tinidazole tabs
trimethoprim tabs
PA
Vasodilating Agents
RECTIV OINT
VANCOCIN HCL CAPS

(Use Vancomycin HCl)
vancomycin hcl caps or
125 mg, 250 mg
GP PA
3
XIFAXAN TABS 200 MG
XIFAXAN TABS 550 MG
PA
PA; QL(9 ea
per fill retail)
PA; QL(2 ea
daily)
Anti-infective Misc. - Combinations

BACTRIM DS TABS (Use
GP
SulfamethoxazoleTrimethoprim)
BACTRIM TABS (Use
GP
SulfamethoxazoleTrimethoprim)
sulfamethoxazole1
trimethoprim susp
sulfamethoxazole1
trimethoprim tabs
Antiprotozoal Agents
ALINIA SUSR
ALINIA TABS
page ii-iii.

10
Drug Name
atovaquone susp
MEPRON SUSP (Use
Atovaquone)
Drug Requirements/
Tier Limits
ISORDIL TITRADOSE
TABS 5 MG (Use
Isosorbide Dinitrate)
ISOSORBIDE DINITRATE
ER TBCR
1
GP
Ketolides
KETEK TABS
Leprostatics
dapsone tabs
Lincosamides
CLEOCIN CAPS OR 150
Clindamycin HCl)
CLEOCIN PEDIATRIC
GRANULES SOLR (Use
Clindamycin Palmitate
Hydrochloride)
clindamycin hcl caps

clindamycin palmitate
hydrochloride solr
Oxazolidinones
linezolid susr 100 mg/5ml
linezolid tabs 600 mg
SIVEXTRO TABS
ZYVOX SUSR 100
MG/5ML (Use Linezolid)
ZYVOX TABS 600 MG
(Use Linezolid)
GP
GP
1
3
QL(210 ml per
90 days retail)
1 QL(20 ea per
90 days retail)
2 QL(6 ea per 90
days retail)
GP QL(210 ml per
90 days retail)
GP QL(20 ea per
90 days retail)
1
ANTIANGINAL AGENTS - Drugs to Treat Chest

Pain
Antianginals-Other
RANEXA TB12 1000 MG
RANEXA TB12 500 MG
Drug Name
Drug Requirements/
Tier Limits
GP
2
isosorbide dinitrate tabs
isosorbide mononitrate tabs
isosorbide mononitrate
tb24
NITRO-BID OINT
NITRO-DUR PT24 0.1

MG/HR, 0.2 MG/HR, 0.4
MG/HR, 0.6 MG/HR (Use
Nitroglycerin)
NITRO-DUR PT24 0.3
MG/HR, 0.8 MG/HR
nitroglycerin cpcr or 2.5
mg, 9 mg
NITROGLYCERIN
LINGUAL AERS
nitroglycerin pt24 td 0.1
mg/hr, 0.2 mg/hr, 0.4
mg/hr, 0.6 mg/hr
nitroglycerin soln tl 0.4
mg/spray
nitroglycerin subl sl 0.3 mg,
0.4 mg, 0.6 mg
NITROLINGUAL
PUMPSPRAY SOLN (Use
Nitroglycerin)
NITROMIST AERS
NITROSTAT SUBL (Use
Nitroglycerin)
QL(1 ea daily)
GP
2
QL(1 ea daily)
1
3
QL(1 ea daily)
1
1
1
GP
3
GP
ANTIANXIETY AGENTS - Drugs to Treat Anxiety

3
3
Nitrates
DILATRATE SR CPCR
ISORDIL TITRADOSE
TABS 40 MG
Antianxiety Agents - Misc.

QL(4 ea daily)
buspirone hcl tabs
hydroxyzine hcl soln
hydroxyzine hcl syrp
page ii-iii.
11
Drug Name
Drug Requirements/
Tier Limits
hydroxyzine hcl tabs
hydroxyzine pamoate caps
meprobamate tabs
VISTARIL CAPS (Use

Hydroxyzine Pamoate)
Benzodiazepines
ALPRAZOLAM INTENSOL
CONC
alprazolam tabs 0.25 mg,
0.5 mg, 1 mg, 2 mg
alprazolam tb24 0.5 mg, 1
mg, 2 mg, 3 mg
alprazolam tbdp 0.25 mg,
0.5 mg, 1 mg, 2 mg
ATIVAN TABS OR 0.5 MG,
1 MG, 2 MG (Use
Lorazepam)
GP
3
1
3
3
Antiarrhythmics Type I-A

disopyramide phosphate
caps
NORPACE CAPS (Use
Disopyramide Phosphate)
NORPACE CR CP12
quinidine gluconate tbcr or

324 mg
QUINIDINE SULFATE
TABS 200 MG
quinidine sulfate tabs 300
mg
quinidine sulfate tbcr 300
mg
Antiarrhythmics Type I-B
mexiletine hcl caps
Drug Requirements/
Tier Limits
1
GP
2
1
2
1
1
NF
Antiarrhythmics Type I-C
chlordiazepoxide hcl caps
clorazepate dipotassium
tabs
diazepam conc or 5 mg/ml
diazepam soln or 1 mg/ml
diazepam tabs or 10 mg, 2

mg, 5 mg
lorazepam conc or 2 mg/ml
lorazepam tabs or 0.5 mg,

1 mg, 2 mg
oxazepam caps
TRANXENE T TABS (Use

Clorazepate Dipotassium)
VALIUM TABS (Use
Diazepam)
XANAX TABS (Use
Alprazolam)
XANAX XR TB24 (Use
Alprazolam)
Drug Name
flecainide acetate tabs

propafenone hcl cp12 225
mg, 325 mg, 425 mg
propafenone hcl tabs 150
mg
propafenone hcl tabs 225
mg, 300 mg
RYTHMOL SR CP12 (Use
Propafenone HCl)
RYTHMOL TABS 150 MG
(Use Propafenone HCl)
RYTHMOL TABS 225 MG
(Use Propafenone HCl)
Antiarrhythmics Type III
1
1
1
QL(6 ea daily)
QL(3 ea daily)
GP
GP QL(6 ea daily)
GP QL(3 ea daily)
GP
amiodarone hcl tabs
GP
CORDARONE TABS (Use

Amiodarone HCl)
GP
dofetilide caps
MULTAQ TABS
GP
ANTIARRHYTHMICS - Drugs to treat abnormal

heart rhythms
TIKOSYN CAPS (Use

Dofetilide)
1
GP
GP
page ii-iii.

12
Drug Name
Drug Requirements/
Tier Limits
ANTIASTHMATIC AND BRONCHODILATOR

AGENTS - Drugs to Treat Lung Conditions
Anti-Inflammatory Agents
CROMOLYN SODIUM
NEBU
INCRUSE ELLIPTA AEPB
ipratropium bromide soln
SEEBRI NEOHALER
CAPS
SPIRIVA HANDIHALER
CAPS
SPIRIVA RESPIMAT
AERS 1.25 MCG/ACT
SPIRIVA RESPIMAT
AERS 2.5 MCG/ACT
TUDORZA PRESSAIR
AEPB
Limit 2 inhalers
per
month;QL(0.86
gm daily)
QL(1 ea daily)
3
2
2
Limit 1 Inhaler
per
month;QL(0.14
3 gm daily)
Limit 1 inhaler
per
month;QL(0.14
gm daily)
Limit 1 inhaler
per
month;QL(0.04
ea daily)
montelukast sodium chew
QL(1 ea daily)
montelukast sodium pack
QL(1 ea daily)
QL(1 ea daily)
SINGULAIR CHEW (Use

Montelukast Sodium)
SINGULAIR PACK (Use
Montelukast Sodium)
SINGULAIR TABS (Use
Montelukast Sodium)
Selective Phosphodiesterase 4 (PDE4) Inhibitors

3 QL(1 ea daily)
DALIRESP TABS
AEROSPAN AERS
ALVESCO AERS
ARNUITY ELLIPTA AEPB
GP QL(1 ea daily)
1
1
QL(4 ml daily)
QL(2 ml daily)
QL(20 ea daily)
ASMANEX HFA AERO
ASMANEX TWISTHALER
120 METERED DOSES
AEPB
ASMANEX TWISTHALER
14 METERED DOSES
AEPB
ASMANEX TWISTHALER
30 METERED DOSES
AEPB
ASMANEX TWISTHALER
60 METERED DOSES
AEPB
ASMANEX TWISTHALER
7 METERED DOSES
AEPB
GP QL(1 ea daily)
GP QL(1 ea daily)
ZYFLO CR TB12
ST
ZYFLO TABS
ST
budesonide (inhalation)
susp 0.25 mg/2ml
susp 0.5 mg/2ml
susp 1 mg/2ml
FLOVENT DISKUS AEPB
100 MCG/BLIST
Limit 2 inhalers
per
month;QL(0.6
gm daily)
Limit 2 inhalers
per
month;QL(0.41
gm daily)
QL(1 ea daily)
Limit 1 inhaler
per
month;QL(0.44
gm daily)
Limit 1 inhaler
per
month;QL(0.04
ea daily)
Limit 1 inhaler
per
month;QL(0.04
ea daily)
Limit 1 inhaler
per
month;QL(0.04
ea daily)
Limit 1 inhaler
per
month;QL(0.04
ea daily)
Limit 1 inhaler
per
month;QL(0.04
ea daily)
QL(8 ml daily)
QL(1 ea daily)
Leukotriene Modulators
montelukast sodium tabs
Drug Requirements/
Tier Limits
Steroid Inhalants
Bronchodilators - Anticholinergics
ATROVENT HFA AERS
Drug Name
page ii-iii.
13
Drug Name
FLOVENT DISKUS AEPB
250 MCG/BLIST
FLOVENT DISKUS AEPB
50 MCG/BLIST
FLOVENT HFA AERO 110
MCG/ACT, 220 MCG/ACT
FLOVENT HFA AERO 44
MCG/ACT
PULMICORT FLEXHALER
AEPB 180 MCG/ACT
PULMICORT FLEXHALER
AEPB 90 MCG/ACT
PULMICORT SUSP 0.25
MG/2ML (Use Budesonide
(Inhalation))
PULMICORT SUSP 0.5
(Inhalation))
PULMICORT SUSP 1
(Inhalation))
QVAR AERS 40 MCG/ACT
QVAR AERS 80 MCG/ACT
Drug Requirements/
Tier Limits
2 QL(8 ea daily)
2
2
QL(40 ea daily)
Limit 2 inhalers
per
month;QL(0.8
gm daily)
Limit 1 inhaler
per
month;QL(0.36
gm daily)
Limit 2 inhalers
per
month;QL(0.07
ea daily)
Limit 2 inhalers
per
month;QL(0.27
ea daily)
QL(8 ml daily)
GP
ADVAIR HFA AERO
albuterol sulfate nebu in

0.083 %, 0.5 %, 0.63
mg/3ml, 1.25 mg/3ml
albuterol sulfate syrp or 2
mg/5ml
albuterol sulfate tabs or 2
mg, 4 mg
albuterol sulfate tb12 or 4
mg, 8 mg
Drug Requirements/
Tier Limits
1
1
1
1
QL(2 ea daily)
ANORO ELLIPTA AEPB
QL(2 ea daily)
ARCAPTA NEOHALER
CAPS
QL(1 ea daily)
BEVESPI AERO
PA
BREO ELLIPTA AEPB
QL(2 ea daily)
BROVANA NEBU
COMBIVENT RESPIMAT
AERS
DULERA AERO
FORADIL AEROLIZER
CAPS
ipratropium-albuterol soln
levalbuterol hcl nebu
QL(4 ml daily)
GP
QL(2 ml daily)
GP
Limit 3 Inhalers
per Month-7.3g
pkg; 2 Inhalers
per Month-8.7g
pkg;QL(0.58
gm daily)
Limit 2 inhalers
per
month;QL(0.58
gm daily)
Sympathomimetics
ADVAIR DISKUS AEPB
Drug Name
QL(2 ea daily)
Limit 1 inhaler
per
month;QL(0.4
gm daily)
Limit 1 inhaler
per
month;QL(0.2
gm daily)
Limit 1 inhaler
per
month;QL(0.45
gm daily)
QL(2 ea daily)
Limit 18gms
per
month;QL(0.6
gm daily)
LEVALBUTEROL
TARTRATE HFA AERO
metaproterenol sulfate syrp
metaproterenol sulfate tabs
PERFOROMIST NEBU
QL(4 ml daily)
Limit 2 inhalers
per
month;QL(0.57
gm daily)
PROAIR HFA AERS
page ii-iii.

14
Drug Name
PROAIR RESPICLICK
AEPB
PROVENTIL HFA AERS

SEREVENT DISKUS
AEPB
STIOLTO RESPIMAT
AERS
STRIVERDI RESPIMAT
AERS
SYMBICORT AERO
terbutaline sulfate tabs or

2.5 mg, 5 mg
UTIBRON NEOHALER
CAPS
VENTOLIN HFA AERS
VENTOLIN HFA AERS

VOSPIRE ER TB12 (Use
Albuterol Sulfate)
XOPENEX
CONCENTRATE NEBU
(Use Levalbuterol HCl)
Drug Requirements/
Tier Limits
Limit 2 inhalers
3 per
month;QL(0.07
ea daily)
Limit 2 inhalers
2 per
month;QL(0.47
gm daily)
2 QL(2 ea daily)
2
Limit 1 inhaler
per
month;QL(0.14
gm daily)
Limit 1 inhaler
per
month;QL(0.14
gm daily)
Limit 1 inhaler
per
month;QL(0.34
gm daily)
1
3
Limit 2 inhalers
3 per
month;QL(1.2
gm daily)
Limit 2 inhalers
3 per
month;QL(0.47
gm daily)
GP QL(2 ea daily)
GP
XOPENEX HFA AERO
XOPENEX NEBU (Use

Levalbuterol HCl)
GP
Limit 18gms
per
month;QL(0.6
gm daily)
Drug Name
Drug Requirements/
Tier Limits
LUFYLLIN TABS
THEO-24 CP24
theophylline soln 80
mg/15ml
theophylline tb12 100 mg,
200 mg, 450 mg
3
1
theophylline tb12 300 mg
theophylline tb24 400 mg,

600 mg
ANTICOAGULANTS - Blood Thinners

Coumarin Anticoagulants
COUMADIN TABS (Use
Warfarin Sodium)
warfarin sodium tabs
GP
1
Direct Factor Xa Inhibitors

ELIQUIS TABS
SAVAYSA TABS
XARELTO STARTER
PACK TBPK
Heparins And Heparinoid-Like Agents

enoxaparin sodium soln ij
SP
300 mg/3ml
enoxaparin sodium soln sc SP
100 mg/ml
PA; QL(14 ml
enoxaparin sodium soln sc SP per fill retail,14
120 mg/0.8ml, 150 mg/ml
ml per 30 days
retail)
enoxaparin sodium soln sc
PA
30 mg/0.3ml, 40 mg/0.4ml, SP
60 mg/0.6ml, 80 mg/0.8ml
LOVENOX SOLN IJ 300
SP
MG/3ML (Use Enoxaparin
Sodium)
LOVENOX SOLN SC 100
SP
MG/ML (Use Enoxaparin
Sodium)
Xanthines
ELIXOPHYLLIN ELIX
page ii-iii.
15
Drug Name
Drug Requirements/
Tier Limits
PA; QL(14 ml
SP per fill retail,14
ml per 30 days
retail)
PA
Drug Name
Drug Requirements/
Tier Limits
BANZEL TABS
BRIVIACT SOLN
PA
BRIVIACT TABS
PA
carbamazepine chew
carbamazepine cp12
carbamazepine susp
carbamazepine tabs
AMPA Glutamate Receptor Antagonists
carbamazepine tb12
FYCOMPA SUSP
CARBATROL CP12 (Use

Carbamazepine)
FYCOMPA TABS
gabapentin caps
gabapentin soln
gabapentin tabs
LOVENOX SOLN SC 120

MG/0.8ML, 150 MG/ML
(Use Enoxaparin Sodium)
LOVENOX SOLN SC 30
MG/0.3ML, 40 MG/0.4ML,
60 MG/0.6ML, 80
MG/0.8ML (Use
Enoxaparin Sodium)
SP
Thrombin Inhibitors
PRADAXA CAPS
ANTICONVULSANTS - Drugs to Treat Seizures
Anticonvulsants - Benzodiazepines
clonazepam tabs
clonazepam tbdp
DIASTAT ACUDIAL GEL

DIASTAT PEDIATRIC GEL
3
3
DIAZEPAM GEL RE 10
MG, 2.5 MG, 20 MG
KLONOPIN TABS (Use

Clonazepam)
GP
ONFI SUSP
ONFI TABS
Anticonvulsants - Misc.
APTIOM TABS 200 MG,
400 MG, 600 MG
QL(4 ea per fill

retail,4 ea per
30 days retail)
QL(4 ea per fill
retail,4 ea per
30 days retail)
QL(4 ea per fill
retail,4 ea per
30 days retail)
QL(2 ea daily)
APTIOM TABS 800 MG
QL(1 ea daily)
BANZEL SUSP
KEPPRA SOLN OR 100

MG/ML (Use
Levetiracetam)
KEPPRA TABS OR 1000
MG, 250 MG, 500 MG, 750
MG (Use Levetiracetam)
KEPPRA XR TB24 (Use
Levetiracetam)
LAMICTAL CHEWABLE
DISPERSIBLE CHEW (Use
Lamotrigine)
LAMICTAL ODT KIT (Use
Lamotrigine)
LAMICTAL ODT TBDP
(Use Lamotrigine)
LAMICTAL STARTER/NOT
TAKING
CARBAMAZEPINE KIT
LAMICTAL
STARTER/TAKING
CARBAMAZEPINE/NOT
TAKING VALPROATE KIT
GP
GP
GP
GP
GP
GP PA
GP PA
2
page ii-iii.

16
Drug Name
LAMICTAL
STARTER/TAKING
VALPROATE KIT
LAMICTAL TABS (Use
Lamotrigine)
LAMICTAL XR KIT
LAMICTAL XR TB24 100
MG, 200 MG, 25 MG, 300
MG, 50 MG (Use
Lamotrigine)
LAMICTAL XR TB24 250
MG (Use Lamotrigine)
lamotrigine chew 25 mg, 5
mg
lamotrigine kit
lamotrigine tabs 100 mg,
150 mg, 200 mg, 25 mg
lamotrigine tb24 100 mg,
200 mg, 25 mg, 300 mg, 50
mg
lamotrigine tb24 250 mg
lamotrigine tbdp 100 mg,
200 mg, 25 mg, 50 mg
levetiracetam soln or 100
mg/ml, 500 mg/5ml
levetiracetam tabs or 1000
mg, 250 mg, 500 mg, 750
mg
levetiracetam tb24 or 500
mg, 750 mg
LYRICA CAPS 100 MG,
200 MG, 25 MG, 50 MG,
75 MG
LYRICA CAPS 150 MG,
225 MG, 300 MG
LYRICA SOLN 20 MG/ML
MYSOLINE TABS (Use
Primidone)
NEURONTIN CAPS (Use
Gabapentin)
NEURONTIN SOLN (Use
Gabapentin)
Drug Requirements/
Tier Limits
Drug Name
NEURONTIN TABS (Use
Gabapentin)
Drug Requirements/
Tier Limits
GP
oxcarbazepine susp
oxcarbazepine tabs
OXTELLAR XR TB24
POTIGA TABS
primidone tabs
QUDEXY XR CS24
PA
SPRITAM TB3D
PA
GP
3
PA
PA; QL(1 ea
GP daily)
GP PA
1
3
PA
1
3
PA; QL(1 ea
daily)
PA
PA
TEGRETOL SUSP (Use

Carbamazepine)
TEGRETOL TABS (Use
Carbamazepine)
TEGRETOL-XR TB12 (Use
Carbamazepine)
TOPAMAX SPRINKLE
CPSP (Use Topiramate)
TOPAMAX TABS (Use
Topiramate)
PA
GP
GP
GP
GP
GP
topiramate cpsp
TOPIRAMATE ER CS24
topiramate tabs
PA
1
1
3
3
3
GP
GP
GP
PA; QL(3 ea
daily)
PA; QL(2 ea
daily)
PA; QL(30 ml
daily)
TRILEPTAL SUSP (Use

Oxcarbazepine)
TRILEPTAL TABS (Use
Oxcarbazepine)
TROKENDI XR CP24
VIMPAT SOLN OR 10
MG/ML
VIMPAT TABS OR 100
MG, 150 MG, 200 MG, 50
MG
ZONEGRAN CAPS (Use
Zonisamide)
zonisamide caps
GP
GP
3
PA
2
2
GP
1
page ii-iii.
17
Drug Name
Drug Requirements/
Tier Limits
Carbamates
ethosuximide soln
felbamate susp
felbamate tabs
FELBATOL SUSP (Use

Felbamate)
FELBATOL TABS (Use
Felbamate)
Drug Name
GP
ZARONTIN CAPS (Use

Ethosuximide)
ZARONTIN SOLN (Use
Ethosuximide)
Drug Requirements/
Tier Limits
1
GP
GP
SABRIL PACK
SABRIL TABS
Valproic Acid
DEPAKENE CAPS (Use
Valproic Acid)
DEPAKENE SYRP (Use
Valproate Sodium)
DEPAKOTE ER TB24 (Use
Divalproex Sodium)
DEPAKOTE SPRINKLES
CSDR (Use Divalproex
Sodium)
DEPAKOTE TBEC (Use
Divalproex Sodium)
tiagabine hcl tabs
divalproex sodium csdr
divalproex sodium tb24
divalproex sodium tbec
STAVZOR CPDR
GABA Modulators
GABITRIL TABS 12 MG,
16 MG
GABITRIL TABS 2 MG, 4
MG (Use Tiagabine HCl)
Hydantoins
DILANTIN CAPS 100 MG
(Use Phenytoin Sodium
Extended)
DILANTIN CAPS 30 MG
DILANTIN INFATABS
CHEW (Use Phenytoin)
DILANTIN-125 SUSP (Use
Phenytoin)
PEGANONE TABS
PHENYTEK CAPS (Use
Phenytoin Sodium
Extended)
GP
3
GP
GP
2
GP
GP
3
valproate sodium soln or

250 mg/5ml
valproate sodium syrp or
250 mg/5ml
valproic acid caps
GP
GP
GP
GP
GP
1
1
1
ANTIDEPRESSANTS - Drugs to Treat Depression

GP
Alpha-2 Receptor Antagonists (Tetracyclics)
phenytoin chew
mirtazapine tabs
phenytoin sodium extended

caps
mirtazapine tbdp
phenytoin susp
Succinimides
REMERON SOLTAB TBDP GP

(Use Mirtazapine)
REMERON TABS (Use
GP
Mirtazapine)
CELONTIN CAPS
Antidepressants - Misc.
ethosuximide caps
APLENZIN TB24
PA; QL(1 ea
daily)
page ii-iii.

18
Drug Name
bupropion hcl tabs 100 mg,

75 mg
bupropion hcl tb12 100 mg,
150 mg, 200 mg
300 mg
300 mg
Drug Requirements/
Tier Limits
1
1
1
FORFIVO XL TB24
maprotiline hcl tabs
WELLBUTRIN SR TB12
(Use Bupropion HCl)
WELLBUTRIN TABS (Use
Bupropion HCl)
WELLBUTRIN XL TB24
(Use Bupropion HCl)
QL(1 ea daily)
Limited to 1
tablet per day
without prior
authorization;Q
L(1 ea daily)
ST; QL(1 ea
daily)
GP
GP
NF QL(1 ea daily)
Monoamine Oxidase Inhibitors (MAOIs)

3 QL(1 ea daily)
EMSAM PT24
MARPLAN TABS
NARDIL TABS (Use
Phenelzine Sulfate)
PARNATE TABS (Use
Tranylcypromine Sulfate)
phenelzine sulfate tabs
Drug Name
citalopram hydrobromide
tabs 10 mg
tabs 20 mg
tabs 40 mg
Drug Requirements/
Tier Limits
1 QL(4 ea daily)
1
QL(2 ea daily)
QL(1 ea daily)
escitalopram oxalate soln
escitalopram oxalate tabs
fluoxetine hcl caps 10 mg,

20 mg, 40 mg
fluoxetine hcl cpdr 90 mg
fluoxetine hcl soln 20

mg/5ml
fluoxetine hcl tabs 10 mg,
20 mg
FLUOXETINE HCL TABS
60 MG
1
1
3
fluvoxamine maleate cp24
fluvoxamine maleate tabs
GP
LEXAPRO SOLN (Use

Escitalopram Oxalate)
LEXAPRO TABS (Use
Escitalopram Oxalate)
GP
paroxetine hcl tabs
paroxetine hcl tb24
tranylcypromine sulfate
1
tabs
Selective Serotonin Reuptake Inhibitors (SSRIs)
CELEXA TABS 10 MG
QL(4 ea daily)
GP
(Use Citalopram
Hydrobromide)
CELEXA TABS 20 MG
QL(2 ea daily)
GP
(Use Citalopram
Hydrobromide)
CELEXA TABS 40 MG
QL(1 ea daily)
GP
(Use Citalopram
Hydrobromide)
3 QL(20 ml daily)
soln 10 mg/5ml
PAXIL CR TB24 (Use

Paroxetine HCl)
GP
GP
GP
PAXIL SUSP 10 MG/5ML
PAXIL TABS 10 MG, 20

Paroxetine HCl)
GP
PEXEVA TABS
PROZAC CAPS (Use
Fluoxetine HCl)
PROZAC WEEKLY CPDR
(Use Fluoxetine HCl)
sertraline hcl conc
ST; QL(1 ea
daily)
3
GP
GP
1
page ii-iii.
19
Drug Name
sertraline hcl tabs

ZOLOFT CONC (Use
Sertraline HCl)
ZOLOFT TABS (Use
Sertraline HCl)
Drug Requirements/
Tier Limits
FETZIMA TITRATION
PACK C4PK
NEFAZODONE HCL TABS

100 MG, 150 MG, 200 MG
nefazodone hcl tabs 250
mg, 50 mg
IRENKA CPEP
GP
KHEDEZLA TB24
PRISTIQ TB24
ST; QL(1 ea
daily)
1
1
QL(1 ea daily)
ST; QL(1 ea
daily)
PA
PA
amitriptyline hcl tabs
ST
AMOXAPINE TABS
3
3
3
trazodone hcl tabs
TRINTELLIX TABS
VIIBRYD KIT
Serotonin-Norepinephrine Reuptake Inhibitors

CYMBALTA CPEP (Use
GP QL(2 ea daily)
Duloxetine HCl)
DESVENLAFAXINE ER
3 PA
TB24 100 MG, 50 MG
DESVENLAFAXINE ER
3 ST; QL(1 ea
TB24 100 MG, 50 MG
daily)
duloxetine hcl cpep 20 mg,
1 QL(2 ea daily)
30 mg, 60 mg
DULOXETINE HCL CPEP
3 PA
40 MG
EFFEXOR XR CP24 150
GP QL(2 ea daily)
MG (Use Venlafaxine HCl)
EFFEXOR XR CP24 37.5
QL(1 ea daily)
GP
MG, 75 MG (Use
Venlafaxine HCl)
FETZIMA CP24 120 MG,
3 ST; QL(1 ea
40 MG, 80 MG
daily)
3 ST; QL(2 ea
FETZIMA CP24 20 MG
daily)
ANAFRANIL CAPS (Use

Clomipramine HCl)
2
1
1
GP
clomipramine hcl caps
desipramine hcl tabs
doxepin hcl caps
doxepin hcl conc
ELAVIL TABS (Use

Amitriptyline HCl)
GP
imipramine hcl tabs
imipramine pamoate caps
NORPRAMIN TABS (Use

Desipramine HCl)
nortriptyline hcl caps 10
mg, 25 mg, 50 mg, 75 mg
NORTRIPTYLINE HCL
SOLN 10 MG/5ML
PA
ST; QL(1 ea
daily)
ST; QL(1 ea
daily)
QL(2 ea daily)
venlafaxine hcl cp24 150

mg
venlafaxine hcl cp24 37.5
mg, 75 mg
VENLAFAXINE HCL ER
TB24
venlafaxine hcl tabs 100
mg, 25 mg, 37.5 mg, 50
mg, 75 mg
venlafaxine hcl tb24 150
mg, 37.5 mg, 75 mg
Tricyclic Agents
OLEPTRO TB24
VIIBRYD STARTER PACK

KIT
VIIBRYD TABS 10 MG, 20
MG, 40 MG
Drug Requirements/
Tier Limits
3 ST
GP
Serotonin Modulators
BRINTELLIX TABS
Drug Name
GP
1
2
page ii-iii.

20
Drug Name
Drug Requirements/
Tier Limits
PAMELOR CAPS (Use

Nortriptyline HCl)
protriptyline hcl tabs

SURMONTIL CAPS (Use
Trimipramine Maleate)
TOFRANIL TABS (Use
Imipramine HCl)
TOFRANIL-PM CAPS (Use
Imipramine Pamoate)
trimipramine maleate caps
INVOKAMET TABS
GP
INVOKAMET XR TB24
GP
JANUMET TABS
JANUMET XR TB24
JENTADUETO TABS
JENTADUETO XR TB24
KAZANO TABS
KOMBIGLYZE XR TB24
OSENI TABS
GP
3
Alpha-Glucosidase Inhibitors
GLYSET TABS (Use
Miglitol)
miglitol tabs
PRECOSE TABS (Use
Acarbose)
Antidiabetic Combinations
ACTOPLUS MET TABS
(Use Pioglitazone HClMetformin HCl)
ACTOPLUS MET XR TB24
ALOGLIPTIN/METFORMIN
HCL TABS
ALOGLIPTIN/PIOGLITAZO
NE TABS
1
GP
3
GP
GP
3
3
3
AVANDAMET TABS
AVANDARYL TABS
DUETACT TABS (Use

Pioglitazone HClGlimepiride)
glipizide-metformin hcl tabs
Drug Requirements/
Tier Limits
GLYXAMBI TABS
GP
ANTIDIABETICS - Drugs to Regulate Blood Sugar
acarbose tabs
Drug Name
GP
pioglitazone hcl-glimepiride
tabs
pioglitazone hcl-metformin
hcl tabs
PRANDIMET TABS (Use
Repaglinide-Metformin
HCl)
REPAGLINIDE/METFORM
IN HYDROCHLORIDE
TABS
1
1
GP
3
SYNJARDY TABS
XIGDUO XR TB24
Biguanides
FORTAMET TB24 (Use
Metformin HCl)
GLUCOPHAGE TABS
(Use Metformin HCl)
GLUCOPHAGE XR TB24
(Use Metformin HCl)
GP
GP
GP
metformin hcl tabs
GLUCOVANCE TABS (Use GP

Glyburide-Metformin)
metformin hcl tb24
glyburide-metformin tabs
RIOMET SOLN
Diabetic Other
page ii-iii.
21
Drug Name
KORLYM TABS
PROGLYCEM SUSP
Drug Requirements/
Tier Limits
3 PA
3
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

ALOGLIPTIN TABS
JANUVIA TABS
NESINA TABS
ONGLYZA TABS
TRADJENTA TABS
Dopamine Receptor Agonists - Antidiabetic

CYCLOSET TABS
Incretin Mimetic Agents (GLP-1 Receptor

SP PA
TANZEUM PEN
Insulin Sensitizing Agents
ACTOS TABS (Use
Pioglitazone HCl)
GP
AVANDIA TABS
pioglitazone hcl tabs
Insulin
AFREZZA POWD
AFREZZA POWD
APIDRA SOLN
APIDRA SOLOSTAR
SOPN
BASAGLAR KWIKPEN
SOPN
HUMALOG KWIKPEN
SOPN 100 UNIT/ML
Limit 3
cartridges per
day;QL(3 ea
daily)
QL(3 ea daily)
Limit 45 per
month;QL(1.34
ml daily)
Limit 45 per
month;QL(1.5
ml daily)
Limit 45mls per
month;QL(1.5
ml daily)
Limit 45mls per
month;QL(1.5
ml daily)
Drug Requirements/
Tier Limits
Limit 24mls per
HUMALOG KWIKPEN
2 month;QL(0.8
SOPN 200 UNIT/ML
ml daily)
PA; Limit 45mls
HUMALOG MIX 50/50
2 per
KWIKPEN SUPN
month;QL(1.5
ml daily)
Limit 45mls per
HUMALOG MIX 50/50
2 month;QL(1.5
SUSP
ml daily)
Limit 45mls per
HUMALOG MIX 75/25
2 month;QL(1.5
KWIKPEN SUPN
ml daily)
Limit 40mls per
HUMALOG MIX 75/25
2 month;QL(1.34
SUSP
ml daily)
Limit 45mls per
2 month;QL(1.5
HUMALOG SOCT
ml daily)
Limit 45 per
2 month;QL(1.5
HUMALOG SOLN
ml daily)
45mls per
HUMULIN 70/30 KWIKPEN 2 Limit
month;QL(1.5
SUPN
ml daily)
Limit 40mls per
2 month;QL(1.34
HUMULIN 70/30 SUSP
ml daily)
Limit 45mls per
HUMULIN N KWIKPEN
2 month;QL(1.5
SUPN
ml daily)
2 QL(1.34 ml
HUMULIN N SUSP
daily)
Limit 40mls per
2 month;QL(1.34
HUMULIN R SOLN
ml daily)
Limit 45mls per
2 month;QL(1.5
HUMULIN R SOLN
ml daily)
QL(40 ml per
HUMULIN R U-500
2 fill retail,40 ml
(CONCENTRATED) SOLN
per 30 days
retail)
QL(40 ml per
HUMULIN R U-500
2 fill retail,40 ml
KWIKPEN SOPN
per 30 days
retail)
Drug Name
page ii-iii.

22
Drug Name
LANTUS SOLN
LANTUS SOLOSTAR
SOPN
LEVEMIR FLEXTOUCH
SOPN
LEVEMIR SOLN
NOVOLIN 70/30 RELION
SUSP
NOVOLIN 70/30 SUSP
NOVOLIN N RELION
SUSP
NOVOLIN N SUSP
NOVOLIN R RELION
SOLN
NOVOLIN R SOLN
NOVOLOG FLEXPEN
SOPN
NOVOLOG MIX 70/30
PREFILLED FLEXPEN
SUPN
NOVOLOG MIX 70/30
SUSP
NOVOLOG PENFILL
SOCT
NOVOLOG SOLN
TOUJEO SOLOSTAR
SOPN
Drug Requirements/
Tier Limits
Limit 45 per
2 month;QL(1.5
ml daily)
Limit 45mls per
2 month;QL(1.5
ml daily)
2 QL(135 ml per
fill mail)
Limit 45mls per
2 month;QL(1.5
ml daily)
Limit 40mls per
3 month;QL(1.34
ml daily)
Limit 40mls per
3 month;QL(1.34
ml daily)
3 QL(1.34 ml
daily)
3 QL(1.34 ml
daily)
Limit 40mls per
3 month;QL(1.34
ml daily)
Limit 40mls per
3 month;QL(1.34
ml daily)
Limit 45mls per
3 month;QL(1.5
ml daily)
Limit 45 per
3 month;QL(1.50
49 ml daily)
Limit 40mls per
3 month;QL(1.34
ml daily)
Limit 45mls per
3 month;QL(1.5
ml daily)
Limit 40mls per
3 month;QL(1.34
ml daily)
Limit 3 pens
2 per
month;QL(0.5
ml daily)
Drug Name
TRESIBA FLEXTOUCH
SOPN 100 UNIT/ML
TRESIBA FLEXTOUCH
SOPN 200 UNIT/ML
Drug Requirements/
Tier Limits
Limit 45mls per
2 month;QL(1.5
ml daily)
Limit 27mls per
2 month;QL(0.9
ml daily)
Meglitinide Analogues
nateglinide tabs
PRANDIN TABS (Use
Repaglinide)
repaglinide tabs
STARLIX TABS (Use
Nateglinide)
1
GP
1
GP
Sodium-Glucose Co-Transporter 2 (SGLT2)

FARXIGA TABS
INVOKANA TABS
JARDIANCE TABS
Sulfonylureas
AMARYL TABS (Use
Glimepiride)
GP
chlorpropamide tabs
DIABETA TABS
glimepiride tabs
glipizide tabs
glipizide tb24
GLUCOTROL TABS (Use

Glipizide)
GLUCOTROL XL TB24
(Use Glipizide)
GP
GP
glyburide micronized tabs
glyburide tabs
GLYNASE TABS (Use

Glyburide Micronized)
tolazamide tabs
GP
1
page ii-iii.
23
Drug Name
Drug Requirements/
Tier Limits
tolbutamide tabs
Drug Name
NARCAN LIQD
Drug Requirements/
Tier Limits
3 QL(4 ea per 30
days retail)
ANTIDIARRHEALS - Drugs to Treat Diarrhea
REVIA TABS (Use

Naltrexone HCl)
Antidiarrheal - Chloride Channel Antagonists

3 PA; QL(2 ea
FULYZAQ TBEC
daily)
3 PA; QL(2 ea
MYTESI TBEC
daily)
ANTIEMETICS - Drugs to Treat Nausea and

Vomiting
Antiperistaltic Agents
diphenoxylate w/ atropine
liqd
diphenoxylate w/ atropine
tabs
IMODIUM A-D CAPS (Use
Loperamide HCl)
LOMOTIL TABS (Use
Diphenoxylate w/ Atropine)
1
GP RX/OTC
opium tincture tinc
PAREGORIC TINC
RX/OTC
Antidotes - Chelating Agents

CHEMET CAPS
EXJADE TBSO
FERRIPROX SOLN 100

MG/ML
FERRIPROX TABS 500

MG
JADENU TABS
Opioid Antagonists
1
SANCUSO PTCH
ZOFRAN ODT TBDP (Use
Ondansetron)
Not available
through mail
order
Antidotes and Specific Antagonists

3 PA
CETYLEV TBEF
3
ondansetron hcl tabs 4 mg,

8 mg
ondansetron tbdp
ANTIDOTES AND SPECIFIC ANTAGONISTS
naltrexone hcl tabs
ondansetron hcl soln 4

mg/5ml
GP
loperamide hcl caps
VISTOGARD PACK
5-HT3 Receptor Antagonists

ANZEMET TABS OR 100
3
MG, 50 MG
granisetron hcl tabs or 1

mg
GP
ZOFRAN SOLN 4 MG/5ML

(Use Ondansetron HCl)
ZOFRAN TABS 4 MG, 8
MG (Use Ondansetron
HCl)
ZUPLENZ FILM
PA; QL(2 ea
per fill retail)
PA; Limit 2
3 tablets per
day;QL(2 ea
daily)
Limit 50mls per
prescription;QL
1 (1.67 ml
daily,50 ml per
fill retail)
1 QL(20 ea per
fill retail)
1 QL(20 ea per
fill retail)
PA; QL(1 ea
per fill retail,1
3 ea per 21 days
retail,3 ea per
90 days mail)
GP QL(20 ea per
fill retail)
Limit 50mls per
prescription;QL
GP (1.67 ml
daily,50 ml per
fill retail)
QL(20 ea per
GP fill retail)
3
QL(20 ea per
fill retail)
Antiemetics - Anticholinergic
TIGAN CAPS (Use
GP
Trimethobenzamide HCl)
TRANSDERM-SCOP PT72
trimethobenzamide hcl
caps
page ii-iii.

24
Drug Name
Drug Requirements/
Tier Limits
Antiemetics - Miscellaneous
AKYNZEO CAPS
CESAMET CAPS
DICLEGIS TBEC
QL(2 ea per 28
days retail)
PA; QL(2 ea
daily)
QL(4 ea daily)
dronabinol caps
PA
MARINOL CAPS (Use

Dronabinol)
GP PA
Substance P/Neurokinin 1 (NK1) Receptor

QL(3 ea per fill
3 retail,3 ea per
EMEND CAPS
30 days retail)
QL(1 ea per fill
EMEND CAPS 125 MG, 80
3 retail,1 ea per
MG
30 days retail)
EMEND CAPS 40 MG
EMEND SUSR 125 MG
VARUBI TABS
QL(2 ea per 30
days retail)
QL(1 ea per 30
days retail)
QL(4 ea per fill
retail)
Drug Name
LAMISIL TABS 250 MG
(Use Terbinafine HCl)
Drug Requirements/
Tier Limits
GP QL(90 ea per
365 days retail)
nystatin powd
nystatin tabs
terbinafine hcl tabs
QL(90 ea per
365 days retail)
Not available
through mail
order
Imidazole-Related Antifungals
CRESEMBA CAPS
DIFLUCAN SUSR (Use
Fluconazole)
DIFLUCAN TABS (Use
Fluconazole)
GP
GP
fluconazole susr
fluconazole tabs
itraconazole caps
ketoconazole tabs
NOXAFIL SUSP
NOXAFIL TBEC
ONMEL TABS
PA
ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungals
ANCOBON CAPS (Use
Flucytosine)
GP
BIO-STATIN CAPS
flucytosine caps
SPORANOX CAPS 100

MG (Use Itraconazole)
SPORANOX PULSEPAK
CAPS (Use Itraconazole)
SPORANOX SOLN 10
MG/ML
VFEND SUSR 40 MG/ML
(Use Voriconazole)
VFEND TABS 200 MG, 50
MG (Use Voriconazole)
voriconazole susr or 40
mg/ml
voriconazole tabs or 200
mg, 50 mg
GRIFULVIN V TABS (Use

GP
Griseofulvin Microsize)
GRIS-PEG TABS (Use
Griseofulvin Ultramicrosize) GP
griseofulvin microsize susp
griseofulvin microsize tabs
griseofulvin ultramicrosize
tabs
LAMISIL PACK 125 MG,
187.5 MG
1
3
PA
PA
GP PA
GP PA
2
PA
GP
GP QL(2 ea daily)
1
1
QL(2 ea daily)
ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Alkylamines
page ii-iii.
25
Drug Name
BROMPHENIRAMINE
TANNATE CHEW
dexchlorpheniramine
maleate syrp
RESPA-BR TB12
Drug Requirements/
Tier Limits
promethazine hcl syrp or

6.25 mg/5ml
promethazine hcl tabs or
12.5 mg, 25 mg, 50 mg
Antihistamines - Piperidines
3
1
3
Antihistamines - Ethanolamines
carbinoxamine maleate
1
soln 4 mg/5ml
carbinoxamine maleate
3
tabs 4 mg
CLEMASTINE FUMARATE 2
SYRP 0.67 MG/5ML
clemastine fumarate tabs
1
2.68 mg
CLEMASTINE FUMARATE 2
TABS 2.68 MG
KARBINAL ER SUER
desloratadine tabs
Drug Requirements/
Tier Limits
1
1
cyproheptadine hcl syrp
cyproheptadine hcl tabs
ANTIHYPERLIPIDEMICS - Drugs to Treat High

Cholesterol
Antihyperlipidemics - Combinations
VYTORIN TABS 10MG2 ST; QL(1 ea
10MG
daily)
VYTORIN TABS 10MG2 QL(1 ea daily)
20MG, 40MG-10MG
VYTORIN TABS 80MG2 PA; QL(1 ea
10MG
daily)
Antihistamines - Non-Sedating
CLARINEX SYRP 0.5
3
MG/ML
CLARINEX TABS 5 MG
GP
(Use Desloratadine)
DESLORATADINE ODT
3
TBDP
Drug Name
PA
PA; QL(1 ea
daily)
PA
PA; QL(1 ea
daily)
PA
levocetirizine
3
dihydrochloride soln or 2.5
mg/5ml
levocetirizine
QL(1 ea daily)
3
dihydrochloride tabs or 5
mg
XYZAL SOLN 2.5 MG/5ML
PA
GP
(Use Levocetirizine
Dihydrochloride)
XYZAL TABS 5 MG (Use
QL(1 ea daily)
GP
Levocetirizine
Dihydrochloride)
Antihistamines - Phenothiazines
promethazine hcl soln or
1
6.25 mg/5ml
promethazine hcl supp re
1
12.5 mg, 25 mg, 50 mg
Antihyperlipidemics - Misc.
LOVAZA CAPS (Use
Omega-3-acid Ethyl Esters) GP
omega-3-acid ethyl esters
1
caps
VASCEPA CAPS 0.5 GM
VASCEPA CAPS 1 GM
Bile Acid Sequestrants

cholestyramine light pack 4
gm
cholestyramine light powd
4 gm/dose
cholestyramine pack or 4
gm
cholestyramine powd or 4
gm/dose
COLESTID FLAVORED
GRAN (Use Colestipol HCl)
COLESTID FLAVORED
PACK (Use Colestipol HCl)
COLESTID GRAN (Use
Colestipol HCl)
COLESTID PACK (Use
Colestipol HCl)
ST
3
1
3
1
GP
GP
GP
GP
page ii-iii.

26
Drug Name
Drug Requirements/
Tier Limits
COLESTID TABS (Use

Colestipol HCl)
GP
colestipol hcl gran 5 gm
colestipol hcl pack 5 gm
colestipol hcl tabs 1 gm
QUESTRAN LIGHT POWD

(Use Cholestyramine Light)
QUESTRAN PACK (Use
Cholestyramine)
QUESTRAN POWD (Use
Cholestyramine)
GP
GP
GP
WELCHOL PACK
WELCHOL TABS
Fibric Acid Derivatives
Drug Name
TRILIPIX CPDR (Use
Choline Fenofibrate)
Drug Requirements/
Tier Limits
GP
HMG CoA Reductase Inhibitors

ALTOPREV TB24
atorvastatin calcium tabs
CRESTOR TABS (Use

Rosuvastatin Calcium)
GP QL(1 ea daily)
fluvastatin sodium caps
QL(1 ea daily)
fluvastatin sodium tb24
QL(1 ea daily)
LESCOL CAPS (Use

Fluvastatin Sodium)
LESCOL XL TB24 (Use
Fluvastatin Sodium)
LIPITOR TABS (Use
Atorvastatin Calcium)
GP QL(1 ea daily)
GP QL(1 ea daily)
GP QL(1 ea daily)
ANTARA CAPS
LIVALO TABS
choline fenofibrate cpdr
lovastatin tabs
FENOFIBRATE CAPS 150

MG, 50 MG
fenofibrate micronized caps
MEVACOR TABS (Use

Lovastatin)
PRAVACHOL TABS 20
MG, 80 MG (Use
Pravastatin Sodium)
PRAVACHOL TABS 40
MG (Use Pravastatin
Sodium)
pravastatin sodium tabs 10
mg, 20 mg, 80 mg
pravastatin sodium tabs 40
mg
fenofibrate tabs 145 mg,

160 mg, 48 mg, 54 mg
FENOFIBRIC ACID TABS
FIBRICOR TABS
gemfibrozil tabs
LIPOFEN CAPS
LOFIBRA CAPS (Use

Fenofibrate Micronized)
LOFIBRA TABS (Use
Fenofibrate)
LOPID TABS (Use
Gemfibrozil)
TRICOR TABS (Use
Fenofibrate)
TRIGLIDE TABS
GP
QL(1 ea daily)
ST; QL(1 ea
daily)
GP
QL(1 ea daily)
GP
QL(2 ea daily)
GP
1
QL(1 ea daily)
QL(2 ea daily)
rosuvastatin calcium tabs
QL(1 ea daily)
simvastatin tabs
QL(1 ea daily)
GP
ZOCOR TABS (Use

Simvastatin)
GP
Intestinal Cholesterol Absorption Inhibitors
GP
ZETIA TABS
GP QL(1 ea daily)
Microsomal Triglyceride Transfer Protein (MTP)
page ii-iii.
27
Drug Name
JUXTAPID CAPS
Nicotinic Acid Derivatives
niacin (antihyperlipidemic)
tbcr
NIACOR TABS
NIASPAN TBCR (Use
Niacin (Antihyperlipidemic))
Drug Requirements/
Tier Limits
3 PA
VASOTEC TABS (Use

Enalapril Maleate)
ZESTRIL TABS (Use
Lisinopril)
3
GP
GP
GP QL(2 ea daily)
1
captopril tabs
enalapril maleate tabs
1
3
EPANED SOLR
fosinopril sodium tabs

lisinopril tabs
LOTENSIN TABS (Use
Benazepril HCl)
MAVIK TABS (Use
Trandolapril)
Drug Requirements/
Tier Limits
1 QL(2 ea daily)
1
GP QL(2 ea daily)
GP
Agents for Pheochromocytoma
GP
benazepril hcl tabs
EPANED SOLN
ramipril caps
trandolapril tabs
ANTIHYPERTENSIVES - Drugs to Treat High

Blood Pressure
ACE Inhibitors
ACCUPRIL TABS (Use
Quinapril HCl)
ACEON TABS (Use
Perindopril Erbumine)
ALTACE CAPS (Use
Ramipril)
Drug Name
DEMSER CAPS
DIBENZYLINE CAPS (Use
Phenoxybenzamine HCl)
phenoxybenzamine hcl
caps
3
GP
1
Angiotensin II Receptor Antagonists

ATACAND TABS (Use
GP
Candesartan Cilexetil)
AVAPRO TABS (Use
GP
Irbesartan)
BENICAR TABS (Use
GP
Olmesartan Medoxomil)
QL(2 ea daily)
candesartan cilexetil tabs
Limit 5mls daily

without
authorization;Q
L(5 ml daily)
QL(5 ml daily)
COZAAR TABS (Use

Losartan Potassium)
DIOVAN TABS (Use
Valsartan)
1
GP
GP
EDARBI TABS
EPROSARTAN
MESYLATE TABS
irbesartan tabs
GP
losartan potassium tabs
GP
MICARDIS TABS (Use

Telmisartan)
GP
moexipril hcl tabs
olmesartan medoxomil tabs
perindopril erbumine tabs
telmisartan tabs
PRINIVIL TABS (Use

Lisinopril)
quinapril hcl tabs
GP
1
TEVETEN TABS (Use

Eprosartan Mesylate)
valsartan tabs
GP
1
page ii-iii.

28
Drug Name
Drug Requirements/
Tier Limits
Antiadrenergic Antihypertensives
CARDURA TABS (Use
GP
Doxazosin Mesylate)
CATAPRES TABS (Use
GP
Clonidine HCl)
CATAPRES-TTS-1 PTWK
GP
(Use Clonidine HCl)
CATAPRES-TTS-2 PTWK
GP
(Use Clonidine HCl)
CATAPRES-TTS-3 PTWK
GP
(Use Clonidine HCl)
clonidine hcl ptwk td 0.1
3
mg/24hr, 0.2 mg/24hr, 0.3
mg/24hr
clonidine hcl tabs or 0.1
1
mg, 0.2 mg, 0.3 mg
doxazosin mesylate tabs
guanfacine hcl tabs
methyldopa tabs
MINIPRESS CAPS (Use

Prazosin HCl)
GP
prazosin hcl caps
reserpine tabs
TENEX TABS (Use

Guanfacine HCl)
terazosin hcl caps
GP
1
Antihypertensive Combinations
ACCURETIC TABS (Use
GP
QuinaprilHydrochlorothiazide)
amlodipine besylate1
benazepril hcl caps
amlodipine besylateST
olmesartan medoxomil tabs 1
amlodipine besylate1
valsartan tabs
amlodipine-valsartan1
hydrochlorothiazide tabs
2 ST
AMTURNIDE TABS
Drug Name
ATACAND HCT TABS
(Use Candesartan CilexetilHydrochlorothiazide)
atenolol & chlorthalidone
tabs
AVALIDE TABS (Use
IrbesartanHydrochlorothiazide)
AZOR TABS (Use
Amlodipine BesylateOlmesartan Medoxomil)
benazepril &
BENICAR HCT TABS (Use
Olmesartan MedoxomilHydrochlorothiazide)
bisoprolol &
BYVALSON TABS
candesartan cilexetilhydrochlorothiazide tabs

captopril &
CLORPRES TABS
CORZIDE TABS (Use
Nadolol &
Bendroflumethiazide)
DIOVAN HCT TABS (Use
ValsartanHydrochlorothiazide)
DUTOPROL TB24 100MG12.5MG, 25MG-12.5MG,
50MG-12.5MG
EDARBYCLOR TABS
enalapril maleate &

EXFORGE HCT TABS
(Use Amlodipine-ValsartanHydrochlorothiazide)
EXFORGE TABS (Use
Amlodipine BesylateValsartan)
fosinopril sodium &
Drug Requirements/
Tier Limits
GP
1
GP
ST
GP
1
GP
1
3
1
1
3
GP
GP
3
3
1
GP
GP
1
page ii-iii.
29
Drug Name
HYZAAR TABS (Use
Losartan Potassium &
Hydrochlorothiazide)
irbesartanhydrochlorothiazide tabs
lisinopril &
LOPRESSOR HCT TABS
(Use Metoprolol &
losartan potassium &
LOTENSIN HCT TABS
(Use Benazepril &
LOTREL CAPS (Use
Amlodipine BesylateBenazepril HCl)
methyldopa &
metoprolol &
METOPROLOL
SUCCINATE
ER/HYDROCHLOROTHIA
ZIDE TB24
MICARDIS HCT TABS
(Use TelmisartanHydrochlorothiazide)
moexiprilhydrochlorothiazide tabs
nadolol &
bendroflumethiazide tabs
olmesartan medoxomilamlodipinehydrochlorothiazide tabs
olmesartan medoxomilhydrochlorothiazide tabs
PRESTALIA TABS
propranolol &
quinaprilhydrochlorothiazide tabs
TARKA TBCR (Use
Trandolapril-Verapamil
HCl)
Drug Requirements/
Tier Limits
Drug Name
TEKAMLO TABS
GP
1
1
TEKTURNA HCT TABS
telmisartan-amlodipine tabs
telmisartanhydrochlorothiazide tabs
TENORETIC 100 TABS
(Use Atenolol &
Chlorthalidone)
TENORETIC 50 TABS
(Use Atenolol &
Chlorthalidone)
GP
1
GP
TEVETEN HCT TABS

GP
1
1
3
GP
1
3
ST
1
trandolapril-verapamil hcl
tbcr
TRIBENZOR TABS (Use
Olmesartan MedoxomilAmlodipineHydrochlorothiazide)
TWYNSTA TABS (Use
Telmisartan-Amlodipine)
valsartanhydrochlorothiazide tabs
VASERETIC TABS (Use
Enalapril Maleate &
ZESTORETIC TABS (Use
Lisinopril &
ZIAC TABS (Use Bisoprolol
& Hydrochlorothiazide)
Antihypertensives - Misc.
VECAMYL TABS
1
3
1
1
GP
Drug Requirements/
Tier Limits
2 ST
ST
1
GP
GP
3
ST
3
ST
GP
GP
1
GP
GP
GP
Direct Renin Inhibitors

ST
TEKTURNA TABS
ST
Selective Aldosterone Receptor Antagonists
eplerenone tabs
INSPRA TABS (Use
Eplerenone)
3
GP
Vasodilators
page ii-iii.

30
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
hydralazine hcl tabs or 10

mg, 100 mg, 25 mg, 50 mg
pyridostigmine bromide tbcr
minoxidil tabs
ANTIMYCOBACTERIAL AGENTS - Drugs to

Treat Tuberculosis (Bacterial Infections)
ANTIMALARIALS - Drugs to Treat Malaria

(Parasitic Infections)
Antimalarial Combinations
atovaquone-proguanil hcl
tabs
COARTEM TABS
MALARONE TABS (Use
Atovaquone-Proguanil HCl)
Antimalarials
chloroquine phosphate
tabs
3
2
GP
DARAPRIM TABS
hydroxychloroquine sulfate
tabs
mefloquine hcl tabs
PLAQUENIL TABS (Use

Hydroxychloroquine
Sulfate)
PRIMAQUINE
PHOSPHATE TABS
QUALAQUIN CAPS (Use
Quinine Sulfate)
quinine sulfate caps
QL(0.8 ea
daily)
PA
QL(6 ea per fill

retail)
GP
2
GP PA; QL(2 ea
daily)
3 PA; QL(2 ea
daily)
ANTIMYASTHENIC/CHOLINERGIC AGENTS
Antimyasthenic/Cholinergic Agents
GUANIDINE HCL TABS
MESTINON SYRP 60
MG/5ML
MESTINON TABS 60 MG
(Use Pyridostigmine
Bromide)
MESTINON TIMESPAN
TBCR (Use Pyridostigmine
Bromide)
pyridostigmine bromide
tabs
2
3
GP
PA
Anti TB Combinations
RIFAMATE CAPS
RIFATER TABS
Antimycobacterial Agents
CYCLOSERINE CAPS
ethambutol hcl tabs
isoniazid syrp or 50 mg/5ml
isoniazid tabs or 100 mg,

300 mg
MYAMBUTOL TABS (Use
Ethambutol HCl)
MYCOBUTIN CAPS (Use
Rifabutin)
1
GP
GP
PASER PACK
PRIFTIN TABS
pyrazinamide tabs
rifabutin caps
RIFADIN CAPS OR 150

MG, 300 MG (Use
Rifampin)
rifampin caps or 150 mg,
300 mg
GP
1
SIRTURO TABS
TRECATOR TABS
ANTINEOPLASTICS AND ADJUNCTIVE

THERAPIES - Drugs to Treat Cancer
Alkylating Agents
GP
1
ALKERAN TABS OR 2 MG
CYCLOPHOSPHAMIDE
CAPS OR 25 MG
AC
page ii-iii.
31
Drug Name
CYCLOPHOSPHAMIDE
CAPS OR 50 MG
Drug Requirements/
Tier Limits
2 AC
HEXALEN CAPS
New
commercial
members to be
referred to
AcariaHealth;A
C
AC
LEUKERAN TABS
AC
GLEOSTINE CAPS
LOMUSTINE CAPS
MYLERAN TABS
TEMODAR CAPS (Use
Temozolomide)
temozolomide caps
New
commercial
members to be
referred to
AcariaHealth;A
C
AC
GP AC
1
AC
Antimetabolites
capecitabine tabs
AC
mercaptopurine tabs
AC
AC
methotrexate sodium tabs

or 2.5 mg
PURINETHOL TABS (Use
Mercaptopurine)
GP AC
PURIXAN SUSP
AL; AC
TABLOID TABS
AC
TREXALL TABS
AC
XELODA TABS (Use

Capecitabine)
GP AC
Antineoplastic - BCL-2 Inhibitors

VENCLEXTA STARTING
2
PACK TBPK
PA; AC
VENCLEXTA TABS
PA; AC
Drug Name
ERIVEDGE CAPS
ODOMZO CAPS
Drug Requirements/
Tier Limits
2 AC
2
AC
Antineoplastic - Hormonal and Related Agents

1 AC
anastrozole tabs
ARIMIDEX TABS (Use
Anastrozole)
AROMASIN TABS (Use
Exemestane)
bicalutamide tabs
CASODEX TABS (Use
Bicalutamide)
GP AC
GP AC
1
AC
GP AC
EMCYT CAPS
AC
exemestane tabs
AC
FARESTON TABS
AC
FEMARA TABS (Use

Letrozole)
GP AC
flutamide caps
AC
letrozole tabs
AC
LYSODREN TABS
AC
MEGACE ORAL SUSP

(Use Megestrol Acetate)
GP AC
megestrol acetate susp
AC
megestrol acetate tabs
AC
NILANDRON TABS (Use

Nilutamide)
GP AC
nilutamide tabs
AC
SOLTAMOX SOLN
PV; AC
tamoxifen citrate tabs
PV; AC
Antineoplastic - Hedgehog Pathway Inhibitors

page ii-iii.

32
Drug Name
XTANDI CAPS
ZYTIGA TABS
Drug Requirements/
Tier Limits
PA; New
commercial
3 members to be
referred to
AcariaHealth;A
C
PA; New
commercial
2 members to be
referred to
AcariaHealth;A
C
Antineoplastic - Immunomodulators
3 AC
POMALYST CAPS
Antineoplastic Combinations
LONSURF TABS
PA; AC
Antineoplastic Enzyme Inhibitors

AFINITOR DISPERZ TBSO
PA; AC
AFINITOR TABS
PA; AC
PA; AC
PA; AC
PA; AC
CAPRELSA TABS
AC
COMETRIQ KIT
AC
COTELLIC TABS
PA; AC
FARYDAK CAPS
PA; AC
GILOTRIF TABS
PA; AC
ALECENSA CAPS
BOSULIF TABS
CABOMETYX TABS
GLEEVEC TABS (Use

Imatinib Mesylate)
IBRANCE CAPS
ICLUSIG TABS
Drug Name
imatinib mesylate tabs 100

mg
imatinib mesylate tabs 400
mg
Drug Requirements/
Tier Limits
1 AC
1
PV; AC
IMBRUVICA CAPS
PA; AC
INLYTA TABS
PA; AC
IRESSA TABS
AC
JAKAFI TABS
AC
PA; AC
PA; AC
PA; LA; AC
PA; AC
PA; AC
PA; LA; AC
LYNPARZA CAPS
PA; AC
MEKINIST TABS
PA; AC
LENVIMA 10 MG DAILY
DOSE CPPK
LENVIMA 14 MG DAILY
DOSE CPPK
LENVIMA 18 MG DAILY
DOSE CPPK
LENVIMA 20 MG DAILY
DOSE CPPK
LENVIMA 24 MG DAILY
DOSE CPPK
LENVIMA 8 MG DAILY
DOSE CPPK
NEXAVAR TABS
NINLARO CAPS
SPRYCEL TABS
STIVARGA TABS
GP AC
2
3
PA; Must use

AcariaHlth Sp
Rx 1-844-5384661;LA; AC
PA; AC
SUTENT CAPS
TAFINLAR CAPS
PA; Must use

AcariaHlth Sp
Rx 1-844-5384661;AC
PA; Limit 3
capsules per
month;QL(0.1
ea daily); AC
PA; Must use
AcariaHlth Sp
Rx 1-844-5384661;AC
PA; LA; AC
PA; Must use
AcariaHlth Sp
Rx 1-844-5384661;LA; AC
PA; AC
page ii-iii.
33
Drug Name
TAGRISSO TABS
Drug Requirements/
Tier Limits
2 PA; AC
PA; New
commercial
members to be
referred to
AcariaHealth;A
C
PA; New
commercial
members to be
referred to
AcariaHealth;A
C
PA; Must use
AcariaHlth Sp
Rx 1-844-5384661;AC
PA; Must use
AcariaHlth Sp
Rx 1-844-5384661;LA; AC
PA; AC
ZELBORAF TABS
PA; AC
ZOLINZA CAPS
PA; AC
ZYDELIG TABS
PA; AC
ZYKADIA CAPS
PA; AC
AC
TARCEVA TABS
TASIGNA CAPS
TYKERB TABS
VOTRIENT TABS
XALKORI CAPS
Antineoplastics Misc.
bexarotene caps
HYDREA CAPS (Use
Hydroxyurea)
hydroxyurea caps
MATULANE CAPS
TARGRETIN CAPS OR 75
MG (Use Bexarotene)
tretinoin (chemotherapy)
caps
GP AC
1
AC
AC
GP AC
1
AC
Chemotherapy Rescue/Antidote Agents

leucovorin calcium tabs or
AC
10 mg, 15 mg, 25 mg, 5 mg 1
Drug Name
MESNEX TABS OR 400
MG
Drug Requirements/
Tier Limits
3 AC
Mitotic Inhibitors
etoposide caps
Topoisomerase I Inhibitors
HYCAMTIN CAPS OR 0.25
MG, 1 MG
AC
PA; AC
ANTIPARKINSON AGENTS - Drugs to Treat

Parkinson's Disease
Antiparkinson Adjuvants
carbidopa tabs
LODOSYN TABS (Use
Carbidopa)
3
GP
Antiparkinson Anticholinergics
benztropine mesylate tabs
1
or 0.5 mg, 1 mg, 2 mg
trihexyphenidyl hcl elix
trihexyphenidyl hcl tabs
Antiparkinson COMT Inhibitors

COMTAN TABS (Use
GP
Entacapone)
entacapone tabs
TASMAR TABS (Use
Tolcapone)
tolcapone tabs
Antiparkinson Dopaminergics
amantadine hcl caps 100
mg
amantadine hcl syrp 50
mg/5ml
AMANTADINE HCL TABS
100 MG
bromocriptine mesylate
caps
tabs
carbidopa-levodopa tabs
10mg-100mg, 25mg100mg, 25mg-250mg
3
GP
3
1
1
3
1
1
1
page ii-iii.

34
Drug Name
carbidopa-levodopa tbcr
25mg-100mg, 50mg200mg
carbidopa-levodopa tbdp
10mg-100mg, 25mg100mg, 25mg-250mg
carbidopa-levodopaentacapone tabs
MIRAPEX ER TB24 (Use
Pramipexole
Dihydrochloride)
MIRAPEX TABS (Use
Pramipexole
Dihydrochloride)
NEUPRO PT24
PARLODEL TABS (Use
Bromocriptine Mesylate)
pramipexole
dihydrochloride tabs 0.125
mg, 0.25 mg, 0.5 mg, 0.75
mg, 1 mg, 1.5 mg
pramipexole
dihydrochloride tb24 0.375
mg, 0.75 mg, 1.5 mg, 2.25
mg, 3 mg, 3.75 mg, 4.5 mg
REQUIP TABS (Use
Ropinirole Hydrochloride)
REQUIP XL TB24 (Use
Ropinirole Hydrochloride)
ropinirole hydrochloride
tabs
tb24
RYTARY CPCR
SINEMET CR TBCR (Use
Carbidopa-Levodopa)
SINEMET TABS (Use
Carbidopa-Levodopa)
STALEVO 100 TABS (Use
Carbidopa-LevodopaEntacapone)
Drug Requirements/
Tier Limits
Drug Name
1
3
1
GP
Drug Requirements/
Tier Limits
GP
GP
GP
Antiparkinson Monoamine Oxidase Inhibitors

AZILECT TABS
GP
ELDEPRYL CAPS (Use

Selegiline HCl)
2
GP
selegiline hcl caps
GP
selegiline hcl tabs
ZELAPAR TBDP
1
ANTIPSYCHOTICS/ANTIMANIC AGENTS Drugs to Treat Mood Disorders
Antimanic Agents
3
GP
GP
1
GP
GP
GP
GP
lithium carbonate tabs
lithium carbonate tbcr
LITHIUM SOLN
LITHOBID TBCR (Use

Lithium Carbonate)
1
3
lithium carbonate caps
PA
GP
Antipsychotics - Misc.
EQUETRO CP12
GEODON CAPS (Use
Ziprasidone HCl)
3
GP
LATUDA TABS
PA
NUPLAZID TABS
PA
VRAYLAR CAPS
PA
VRAYLAR CPPK
PA
page ii-iii.
35
Drug Name
ziprasidone hcl caps
Drug Requirements/
Tier Limits
1
Benzisoxazoles
FANAPT TABS
FANAPT TITRATION
PACK TABS
INVEGA TB24 (Use
Paliperidone)
paliperidone tb24
RISPERDAL M-TAB TBDP
(Use Risperidone)
RISPERDAL SOLN (Use
Risperidone)
RISPERDAL TABS (Use
Risperidone)
PA
PA
GP
3
GP
GP
GP
1
risperidone tabs 0.25 mg,

0.5 mg, 1 mg, 2 mg, 3 mg,
4 mg
risperidone tbdp 0.25 mg
haloperidol tabs
1
1
Dibenzapines
CLOZAPINE ODT TBDP
clozapine tabs 100 mg, 200 1

mg, 25 mg, 50 mg
clozapine tbdp 100 mg, 25
3
mg
CLOZARIL TABS (Use
GP
Clozapine)
FAZACLO TBDP 100 MG,
GP
25 MG (Use Clozapine)
FAZACLO TBDP 12.5 MG,
3
150 MG, 200 MG
loxapine succinate caps
olanzapine tabs 10 mg, 15

mg, 2.5 mg, 20 mg, 5 mg,
7.5 mg
olanzapine tbdp 10 mg, 15
mg, 20 mg, 5 mg
QUETIAPINE FUMARATE
ER TB24
quetiapine fumarate tabs
100 mg, 200 mg, 25 mg,
300 mg, 400 mg, 50 mg
quetiapine fumarate tb24
400 mg
SAPHRIS SUBL
risperidone soln 1 mg/ml
risperidone tbdp 0.5 mg, 1

mg, 2 mg, 3 mg, 4 mg
Butyrophenones
haloperidol lactate conc or
2 mg/ml
Drug Name
SEROQUEL TABS (Use

Quetiapine Fumarate)
SEROQUEL XR TB24 150
MG, 200 MG, 300 MG, 50
MG
SEROQUEL XR TB24 400
MG (Use Quetiapine
Fumarate)
VERSACLOZ SUSP
ZYPREXA TABS (Use
Olanzapine)
ZYPREXA ZYDIS TBDP
(Use Olanzapine)
Dihydroindolones
MOLINDONE
HYDROCHLORIDE TABS
Phenothiazines
chlorpromazine hcl tabs or
10 mg, 100 mg, 200 mg, 25
mg, 50 mg
FLUPHENAZINE HCL
CONC OR 5 MG/ML
fluphenazine hcl elix or 2.5
mg/5ml
fluphenazine hcl tabs or 1
mg, 10 mg, 2.5 mg, 5 mg
Drug Requirements/
Tier Limits
1
3
3
PA
1
3
PA
PA
GP
PA
3
PA
GP
3
QL(18 ml daily)
GP
GP
1
3
1
1
perphenazine tabs
prochlorperazine maleate
tabs
page ii-iii.

36
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
prochlorperazine supp
COMBIVIR TABS (Use

Lamivudine-Zidovudine)
thioridazine hcl tabs
COMPLERA TABS
trifluoperazine hcl tabs
CRIXIVAN CAPS
DESCOVY TABS
didanosine cpdr
EDURANT TABS
GP
EMTRIVA CAPS
EMTRIVA SOLN
Quinolinone Derivatives
ABILIFY DISCMELT TBDP
ABILIFY SOLN 1 MG/ML
ABILIFY TABS 10 MG, 15

MG, 2 MG, 20 MG, 30 MG,
5 MG (Use Aripiprazole)
aripiprazole soln 1 mg/ml

aripiprazole tabs 10 mg, 15
mg, 2 mg, 20 mg, 30 mg, 5
mg
aripiprazole tbdp 10 mg, 15
mg
REXULTI TABS
PA
1
3
PA
PA
EPIVIR SOLN (Use

Lamivudine)
EPIVIR TABS (Use
Lamivudine)
EPZICOM TABS (Use
Abacavir SulfateLamivudine)
GP
GP
GP
GP
EVOTAZ TABS
GENVOYA TABS
ANTISEPTICS & DISINFECTANTS - Drugs to

Prevent Bacterial Skin Infections
INTELENCE TABS
Antiseptics & Disinfectants
INVIRASE CAPS
INVIRASE TABS
ISENTRESS CHEW
ISENTRESS PACK
ISENTRESS TABS
KALETRA SOLN
KALETRA TABS
lamivudine soln
lamivudine tabs
lamivudine-zidovudine tabs
Thioxanthenes
thiothixene caps
formaldehyde soln
ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals
abacavir sulfate tabs

abacavir sulfate-lamivudine
tabs
abacavir sulfatelamivudine-zidovudine tabs
1
1
1
APTIVUS CAPS
APTIVUS SOLN
ATRIPLA TABS
page ii-iii.
37
Drug Name
Drug Requirements/
Tier Limits
Drug Name
LEXIVA SUSP
TRIUMEQ TABS
LEXIVA TABS
nevirapine susp
TRIZIVIR TABS (Use

Abacavir SulfateLamivudine-Zidovudine)
nevirapine tabs
nevirapine tb24
NORVIR CAPS
NORVIR SOLN
NORVIR TABS
ODEFSEY TABS
PREZCOBIX TABS
PREZISTA SUSP 100

MG/ML
PREZISTA TABS 150 MG,
600 MG, 75 MG, 800 MG
RESCRIPTOR TABS
RETROVIR CAPS (Use
Zidovudine)
RETROVIR SYRP (Use
Zidovudine)
Drug Requirements/
Tier Limits
2
GP
TRUVADA TABS
TYBOST TABS
VIDEX EC CPDR (Use

Didanosine)
GP
VIDEXPEDIATRIC SOLR
VIRACEPT TABS
VIRAMUNE SUSP 50
MG/5ML
VIRAMUNE TABS 200 MG
(Use Nevirapine)
VIRAMUNE XR TB24 (Use
Nevirapine)
VIREAD POWD
VIREAD TABS
VITEKTA TABS
2
GP
GP
ZERIT CAPS (Use

Stavudine)
ZERIT SOLR (Use
Stavudine)
2
GP
GP
GP
GP
REYATAZ CAPS
REYATAZ PACK
SELZENTRY TABS
ZIAGEN TABS 300 MG

(Use Abacavir Sulfate)
stavudine caps
zidovudine caps
stavudine solr
zidovudine syrp
STRIBILD TABS
zidovudine tabs
SUSTIVA CAPS
CMV Agents
VALCYTE SOLR 50
MG/ML (Use Valganciclovir
HCl)
VALCYTE TABS 450 MG
(Use Valganciclovir HCl)
SUSTIVA TABS
TIVICAY TABS
ZIAGEN SOLN 20 MG/ML
2
GP
QL(21 ml daily)
GP
GP
page ii-iii.

38
Drug Name
valganciclovir hcl solr 50

mg/ml
valganciclovir hcl tabs 450
mg
Hepatitis Agents
adefovir dipivoxil tabs
BARACLUDE SOLN 0.05
MG/ML
BARACLUDE TABS 0.5
MG, 1 MG (Use Entecavir)
COPEGUS TABS (Use
Ribavirin (Hepatitis C))
DAKLINZA TABS 30 MG,
60 MG
Drug Requirements/
Tier Limits
1 QL(21 ml daily)
OLYSIO CAPS
1
PEG-INTRON KIT
1
2
GP
GP PA
3
PA
DAKLINZA TABS 90 MG
PA; LA
entecavir tabs
EPCLUSA TABS
EPIVIR HBV SOLN 5

MG/ML
EPIVIR HBV TABS 100
MG (Use Lamivudine
(HBV))
HARVONI TABS
HEPSERA TABS (Use
Adefovir Dipivoxil)
INCIVEK TABS
lamivudine (hbv) tabs

MODERIBA 1200 DOSE
PACK TABS
MODERIBA 800 DOSE
PACK TABS
Drug Name
PA; LA
3
GP
3
PA
GP
3
PA; Must use

AcariaHlth Sp
Rx 1-844-5384661
Drug Requirements/
Tier Limits
PA; Must use
3 AcariaHlth Sp
Rx 1-844-5384661
SP PA
PEG-INTRON REDIPEN
KIT
PEG-INTRON REDIPEN
PAK 4 KIT
PEGASYS PROCLICK
SOLN
SP PA
PEGASYS SOLN
SP PA
PEGINTRON KIT
SP PA
REBETOL CAPS 200 MG

(Use Ribavirin (Hepatitis
C))
REBETOL SOLN 40
MG/ML
RIBASPHERE RIBAPAK
TABS
SP PA
SP PA
PA
GP
2
PA
PA
ribavirin (hepatitis c) caps
PA
ribavirin (hepatitis c) misc
PA
ribavirin (hepatitis c) tabs
PA
SOVALDI TABS
PA
TECHNIVIE TABS
PA
TYZEKA TABS
ST
VEMLIDY TABS
VICTRELIS CAPS
VIEKIRA PAK TBPK
PA; Must use

AcariaHlth Sp
Rx 1-844-5384661
PA; Must use
AcariaHlth Sp
Rx 1-844-5384661
PA
VIEKIRA XR TB24
PA
ZEPATIER TABS
PA
3
2
PA
PA
MODERIBA MISC
PA
MODERIBA MISC
PA
page ii-iii.
39
Drug Name
Drug Requirements/
Tier Limits
Herpes Agents
CUPRIMINE CAPS
acyclovir caps
acyclovir susp
acyclovir tabs
famciclovir tabs
FAMVIR TABS (Use

Famciclovir)
DEPEN TITRATABS TABS
valacyclovir hcl tabs
TAMIFLU SUSR 6 MG/ML
PA
GP
REVLIMID CAPS
PA; AC
THALOMID CAPS
AC
ASTAGRAF XL CP24
PA
AZASAN TABS
azathioprine tabs or 50 mg
GP
GP
GP
3
3
QL(75 ml
daily,5 day(s)
limit); AL
ASSORTED CLASSES - Miscellaneous Drugs

Chelating Agents
Immunosuppressive Agents
Respiratory Syncytial Virus (RSV) Agents

VIRAZOLE SOLR
Immunomodulators
Influenza Agents
FLUMADINE TABS (Use
GP
Rimantadine
Hydrochloride)
RELENZA DISKHALER
3 QL(20 ea per
AEPB
fill retail)
rimantadine hydrochloride
3
tabs
TAMIFLU CAPS 30 MG, 45 3 QL(10 ea per
MG
fill retail); AL
TAMIFLU CAPS 75 MG
Drug Requirements/
Tier Limits
2 PA
PA; Must use

AcariaHlth Sp
Rx 1-844-5384661
SYPRINE CAPS
GP
SITAVIG TABS
VALTREX TABS (Use

Valacyclovir HCl)
ZOVIRAX CAPS OR 200
MG (Use Acyclovir)
ZOVIRAX SUSP OR 200
MG/5ML (Use Acyclovir)
ZOVIRAX TABS OR 400
MG, 800 MG (Use
Acyclovir)
Drug Name
CELLCEPT CAPS (Use

Mycophenolate Mofetil)
CELLCEPT SUSR (Use
CELLCEPT TABS (Use
cyclosporine caps or 100
mg, 25 mg
cyclosporine modified (for
microemulsion) caps
microemulsion) soln
CYCLOSPORINE
MODIFIED CAPS (Use
Cyclosporine Modified (For
Microemulsion))
ENVARSUS XR TB24
IMURAN TABS (Use
Azathioprine)
mycophenolate mofetil
caps
GP
GP
GP
1
1
1
GP
3
PA
GP
1
mycophenolate mofetil susr
mycophenolate mofetil tabs
page ii-iii.

40
Drug Name
mycophenolate sodium
tbec
MYFORTIC TBEC (Use
Mycophenolate Sodium)
NEORAL CAPS (Use
Microemulsion))
NEORAL SOLN (Use
Microemulsion))
PROGRAF CAPS OR 0.5
MG, 1 MG, 5 MG (Use
Tacrolimus)
RAPAMUNE SOLN 1
MG/ML
RAPAMUNE TABS 0.5
MG, 1 MG, 2 MG (Use
Sirolimus)
SANDIMMUNE CAPS OR
100 MG, 25 MG (Use
Cyclosporine)
SANDIMMUNE SOLN OR
100 MG/ML
Drug Requirements/
Tier Limits
3
GP
GP
GP
GP
GP
2
tacrolimus caps
ZORTRESS TABS
carvedilol tabs 3.125 mg
COREG CR CP24
QL(2 ea daily)
GP
GP QL(2 ea daily)
1
acebutolol hcl caps
atenolol tabs
betaxolol hcl tabs
bisoprolol fumarate tabs
BYSTOLIC TABS
metoprolol succinate tb24
ST
BETA BLOCKERS - Drugs to Treat High Blood

Pressure
Alpha-Beta Blockers
KERLONE TABS (Use

Betaxolol HCl)
LOPRESSOR TABS OR
100 MG, 50 MG (Use
Metoprolol Tartrate)
Potassium Removing Agents

KAYEXALATE POWD (Use
GP
Sodium Polystyrene
Sulfonate)
sodium polystyrene
1
sulfonate powd or
sodium polystyrene
1
sulfonate susp or 15
gm/60ml
sodium polystyrene
3
sulfonate susp re 30
gm/120ml, 50 gm/200ml
VELTASSA PACK
carvedilol tabs 12.5 mg, 25

mg, 6.25 mg
Beta Blockers Cardio-Selective
Drug Requirements/
Tier Limits
COREG TABS 12.5 MG,

25 MG, 6.25 MG (Use
Carvedilol)
COREG TABS 3.125 MG
(Use Carvedilol)
labetalol hcl tabs or 100
mg, 200 mg, 300 mg
GP
sirolimus tabs
Drug Name
metoprolol tartrate tabs or

100 mg, 25 mg, 50 mg
METOPROLOL
TARTRATE TABS OR 37.5
MG, 75 MG
SECTRAL CAPS (Use
Acebutolol HCl)
TENORMIN TABS (Use
Atenolol)
TOPROL XL TB24 (Use
Metoprolol Succinate)
ZEBETA TABS (Use
Bisoprolol Fumarate)
Beta Blockers Non-Selective
BETAPACE AF TABS (Use
Sotalol HCl (AFIB/AFL))
QL(1 ea daily)
GP
GP
1
1
2
GP
GP
GP
GP QL(1 ea daily)
GP
page ii-iii.
41
Drug Name
BETAPACE TABS (Use
Sotalol HCl)
CORGARD TABS (Use
Nadolol)
HEMANGEOL SOLN
INDERAL LA CP24 (Use
Propranolol HCl)
Drug Requirements/
Tier Limits
GP
GP
3
INNOPRAN XL CP24
nadolol tabs
pindolol tabs
sotalol hcl (afib/afl) tabs
1
1
1
1
sotalol hcl tabs
timolol maleate tabs
QL(60 ea per
fill retail)
BIOLOGICALS MISC - Drugs to Treat Low

Enzymes
Allergenic Extracts
ORALAIR ADULT SAMPLE
KIT SUBL
ORALAIR ADULT
STARTER PACK SUBL
ORALAIR
CHILDREN/ADOLESCENT
S SAMPLE KIT THPK
ORALAIR
CHILDREN/ADOLESCENT
S STARTER PACK SUBL
ORALAIR SUBL
PA
PA
PA
3
PA
3
3
Calcium Channel Blockers

ADALAT CC TB24 30 MG,
60 MG (Use Nifedipine)
ADALAT CC TB24 90 MG
(Use Nifedipine)
amlodipine besylate tabs
GP
INDERAL XL CP24
propranolol hcl cp24 or 120

mg, 160 mg, 60 mg, 80 mg
propranolol hcl soln or 20
mg/5ml, 40 mg/5ml
propranolol hcl tabs or 10
mg, 20 mg, 40 mg, 60 mg,
80 mg
AL
Drug Name
PA
CALCIUM CHANNEL BLOCKERS - Drugs to

Treat High Blood Pressure
CALAN SR TBCR (Use

Verapamil HCl)
CALAN TABS (Use
Verapamil HCl)
CARDIZEM CD CP24 (Use
Diltiazem HCl Coated
Beads)
CARDIZEM LA TB24 120
MG
CARDIZEM LA TB24 180
MG, 240 MG, 300 MG, 360
MG, 420 MG (Use
Diltiazem HCl Coated
Beads)
CARDIZEM TABS (Use
Diltiazem HCl)
diltiazem hcl coated beads
cp24 120 mg, 180 mg, 240
mg, 300 mg, 360 mg
diltiazem hcl coated beads
tb24 180 mg, 240 mg, 300
mg, 360 mg, 420 mg
diltiazem hcl cp12 or 120
mg, 60 mg, 90 mg
diltiazem hcl cp24 or 120
mg, 180 mg, 240 mg
diltiazem hcl extended
release beads cp24
diltiazem hcl tabs or 120
mg, 30 mg, 60 mg, 90 mg
Drug Requirements/
Tier Limits
GP
GP QL(1 ea daily)
1
GP
GP
QL(1 ea daily)
GP
2
GP
GP
QL(1 ea daily)
1
1
1
1
1
1
felodipine tb24
isradipine caps
nicardipine hcl caps or 20

mg, 30 mg
nifedipine caps 10 mg, 20
mg
nifedipine tb24 30 mg, 60
mg
QL(2 ea daily)
3
1
1
page ii-iii.

42
Drug Name
nifedipine tb24 30 mg, 60

mg, 90 mg
nimodipine caps
nisoldipine tb24 17 mg, 20
mg, 25.5 mg, 34 mg, 8.5
mg
NISOLDIPINE TB24 30
MG, 40 MG
NORVASC TABS (Use
Amlodipine Besylate)
NYMALIZE SOLN
PROCARDIA CAPS (Use
Nifedipine)
PROCARDIA XL TB24
(Use Nifedipine)
SULAR TB24 (Use
Nisoldipine)
TIAZAC CP24 (Use
Diltiazem HCl Extended
Release Beads)
verapamil hcl cp24 or 100
mg, 120 mg, 180 mg, 200
mg, 240 mg, 300 mg, 360
mg
verapamil hcl tabs or 120
mg, 40 mg, 80 mg
verapamil hcl tbcr or 120
mg, 180 mg, 240 mg
VERELAN CP24 (Use
Verapamil HCl)
VERELAN PM CP24 (Use
Verapamil HCl)
Drug Requirements/
Tier Limits
1 QL(1 ea daily)
Drug Name
LANOXIN TABS OR 187.5
MCG, 62.5 MCG
CARDIOVASCULAR AGENTS - MISC. - Drugs to

Treat Heart and Circulation Conditions
Cardiovascular Agents Misc. - Combinations

amlodipine besylate3 PA
atorvastatin calcium tabs
2
GP QL(2 ea daily)
3
BIDIL TABS
CADUET TABS (Use
Amlodipine BesylateAtorvastatin Calcium)
GP
ENTRESTO TABS
GP QL(1 ea daily)
Impotence Agents
CIALIS TABS 10 MG, 20
MG
CIALIS TABS 2.5 MG, 5
MG
GP
GP
LEVITRA TABS
1
1
MUSE PLLT
1
GP
STAXYN TBDP
GP
STENDRA TABS
Cardiac Glycosides
digoxin tabs or 0.125 mg,

0.25 mg, 125 mcg, 250
mcg
LANOXIN TABS OR 125
MCG, 250 MCG (Use
Digoxin)
CARDIOTONICS - Drugs to Treat Heart Failure

and Abnormal Heart Rhythm
digoxin soln or 0.05 mg/ml
Drug Requirements/
Tier Limits
VIAGRA TABS
Peripheral Vasodilators
GP
3
PA
GP
3
PA
SP PA; QL(0.27 ea
daily); AL
SP PA; QL(0.27 ea
daily)
SP PA; QL(0.27 ea
daily); AL
PA; Limit 6 per
month, Check
your plan
documents for
SP coverage,
benefits and
copayment/coin
surance.;QL(0.
2 ea daily)
ST; Limit 8 per
SP month;QL(0.27
ea daily); AL
PA; QL(8 ea
SP per 30 days
retail); AL
PA; QL(8 ea
SP per fill retail,8
ea per 30 days
retail); AL
isoxsuprine hcl tabs 10 mg
ISOXSUPRINE HCL TABS

20 MG
Prostaglandin Vasodilators
page ii-iii.
43
Drug Name
ORENITRAM TBCR
Drug Requirements/
Tier Limits
3 PA
Drug Name
Drug Requirements/
Tier Limits
cefadroxil susr
TYVASO REFILL SOLN
PA; LA
cefadroxil tabs
TYVASO SOLN
PA; LA
cephalexin caps 250 mg,

500 mg
TYVASO STARTER SOLN
PA; LA
cephalexin caps 750 mg
VENTAVIS SOLN
PA
Pulmonary Hypertension - Endothelin Receptor

LETAIRIS TABS
OPSUMIT TABS
TRACLEER TABS
PA
Pulmonary Hypertension - Phosphodiesterase

PA; New
commercial
2 members to be
ADCIRCA TABS
referred to
AcariaHealth
REVATIO SUSR 10
3 PA
MG/ML
REVATIO TABS 20 MG
PA
GP
(Use Sildenafil Citrate
(Pulmonary Hypertension))
sildenafil citrate (pulmonary 3 PA
hypertension) tabs
Pulmonary Hypertension - Prostacyclin Receptor
3 PA
UPTRAVI TABS
UPTRAVI TBPK
PA
cephalexin susr 125

1
mg/5ml, 250 mg/5ml
CEPHALEXIN TABS 250
3
MG, 500 MG
KEFLEX CAPS (Use
GP
Cephalexin)
Cephalosporins - 2nd Generation
cefaclor caps 250 mg, 500
1
mg
CEFACLOR ER TB12
CEFACLOR SUSR 125

MG/5ML, 250 MG/5ML,
375 MG/5ML
cefprozil susr
cefprozil tabs
CEFTIN SUSR 125

MG/5ML, 250 MG/5ML
CEFTIN TABS 250 MG,
500 MG (Use Cefuroxime
Axetil)
cefuroxime axetil tabs
2
GP
1
Cephalosporins - 3rd Generation

CEDAX CAPS
CEDAX SUSR
cefdinir caps
cefdinir susr
CEPHALOSPORINS - Drugs to Treat Bacterial

Infections
CEFDITOREN PIVOXIL
TABS 200 MG, 400 MG
Cephalosporins - 1st Generation
cefixime susr
Pulmonary Hypertension - Sol Guanylate Cyclase

3 PA; LA
ADEMPAS TABS
Sinus Node Inhibitors
CORLANOR TABS
cefadroxil caps
ST
page ii-iii.

44
Drug Name
Drug Requirements/
Tier Limits
cefpodoxime proxetil susr
cefpodoxime proxetil tabs
CEFTIBUTEN CAPS
CEFTIBUTEN SUSR
SPECTRACEF TABS
SUPRAX CAPS 400 MG
SUPRAX CHEW 100 MG,

200 MG
SUPRAX SUSR 100
MG/5ML, 200 MG/5ML
(Use Cefixime)
SUPRAX SUSR 500
MG/5ML
3
GP
3
CHEMICALS
Bulk Chemicals - C's
CALCITRIOL POWD XX
Bulk Chemicals - L's
LEVETIRACETAM POWD
XX
LEVOCETIRIZINE
DIHYDROCHLORIDE
POWD XX
Bulk Chemicals - S's
STEVIOL GLYCOSIDES
POWD
SULPIRIDE POWD
Bulk Chemicals - V's
VORICONAZOLE POWD
XX
3
PA
3
3
3
PA
CONTRACEPTIVES - Drugs to Prevent

Pregnancy
Combination Contraceptives - Oral
BEYAZ TABS (Use
QL(1 ea daily)
Drospirenone-Ethinyl
GP
Estradiol-Levomefolate
Calcium)
Drug Name
BREVICON-28 TABS (Use
Norethindrone & Eth
Estradiol)
CYCLESSA TABS (Use
Desogestrel-Ethinyl
Estradiol (Triphasic))
DESOGEN TABS (Use
Desogestrel & Ethinyl
Estradiol)
desogestrel & ethinyl
estradiol tabs
desogestrel-ethinyl
estradiol (biphasic) tabs
desogestrel-ethinyl
estradiol (triphasic) tabs
drospirenone-ethinyl
estradiol tabs 3mg-0.02mg
estradiol tabs 3mg-0.03mg
estradiol-levomefolate
calcium tabs
ESTROSTEP FE TABS
(Use Norethindrone
Acetate-Ethinyl EstradiolFe)
ethynodiol diacet & eth
estrad tabs 1mg-35mcg,
1mg-50mcg
ethynodiol diacet & eth
estrad tabs 1mg-50mcg
FEMCON FE CHEW (Use
Norethindrone & Ethinyl
Estradiol-Fe)
GENERESS FE CHEW
(Use Norethindrone &
Ethinyl Estradiol-Fe)
levonorgestrel & eth
estradiol tabs
levonorgestrel-eth estradiol
(triphasic) tabs
Drug Requirements/
Tier Limits
GP
GP
PV
GP
1
PV
1
1
1
1
QL(1 ea daily);
PV
QL(1 ea daily)
QL(1 ea daily)
1
PV
GP
1
1
PV
GP
QL(1 ea daily);
GP PV
1
1
levonorgestrel-ethinyl
estradiol (91-day) tabs
estradiol (91-day) tabs
QL(1 ea
daily,91 day(s)
limit)
QL(91 ea per
fill retail,91 ea
per fill mail)
page ii-iii.
45
Drug Name
estradiol (continuous) tabs
LO LOESTRIN FE TABS
LOESTRIN 1.5/30-21
TABS (Use Norethindrone
Acet & Eth Estra)
LOESTRIN 1/20-21 TABS
(Use Norethindrone Acet &
Eth Estra)
LOESTRIN FE 1.5/30
TABS (Use Norethin Acet &
Estrad-Fe)
LOESTRIN FE 1/20 TABS
(Use Norethin Acet &
Estrad-Fe)
LOSEASONIQUE TABS
(Use LevonorgestrelEthinyl Estradiol (91-Day))
MINASTRIN 24 FE CHEW
MIRCETTE TABS (Use
Desogestrel-Ethinyl
Estradiol (Biphasic))
MODICON TABS (Use
Norethindrone & Eth
Estradiol)
NATAZIA TABS
NECON 10/11-28 TABS
norethin acet & estrad-fe

tabs 75mg-20mcg-1mg
norethin acet & estrad-fe
tabs 75mg-20mcg-1mg,
75mg-30mcg-1.5mg
norethindrone & eth
estradiol tabs
norethindrone & ethinyl
estradiol-fe chew 0.4mg35mcg
norethindrone & ethinyl
estradiol-fe chew 75mg0.8mg-25mcg
norethindrone & mestranol
tabs
norethindrone acet & eth
estra tabs
Drug Requirements/
Tier Limits
3 PV
3
QL(1 ea daily)
GP
GP
GP
GP
QL(1 ea
GP daily,91 day(s)
limit)
3 PA; PV
GP
GP
2
QL(1 ea daily)
2
1
QL(1 ea daily);
PV
1
1
3
1
QL(1 ea daily);
PV
Drug Name
Drug Requirements/
Tier Limits
3 PV
norethindrone acetateethinyl estradiol-fe tabs

norethindrone-eth estradiol
1
(triphasic) tabs
1
(triphasic) tabs
norgestimate-ethinyl
1
1
1
estradiol tabs
norgestrel & ethinyl
1
estradiol tabs
NORINYL 1+35 TABS (Use
GP
Norethindrone & Eth
Estradiol)
NORINYL 1+50 TABS
ORTHO TRI-CYCLEN LO
TABS (Use NorgestimateEthinyl Estradiol
(Triphasic))
ORTHO TRI-CYCLEN
TABS (Use NorgestimateEthinyl Estradiol
(Triphasic))
ORTHO-CEPT TABS (Use
Desogestrel & Ethinyl
Estradiol)
ORTHO-CYCLEN TABS
(Use Norgestimate-Ethinyl
Estradiol)
ORTHO-NOVUM 1/35
& Eth Estradiol)
ORTHO-NOVUM 7/7/7
TABS (Use NorethindroneEth Estradiol (Triphasic))
OVCON-35 TABS (Use
Norethindrone & Eth
Estradiol)
PV
QL(1 ea daily)
QL(1 ea daily)
2
PV
GP
QL(1 ea daily)
GP
PV
GP
QL(1 ea daily)
GP
GP
QL(1 ea daily);
GP PV
GP
QUARTETTE TABS
SAFYRAL TABS
1
1
QL(1 ea daily);
PV
QL(1 ea
daily,91 day(s)
limit); PV
QL(1 ea daily)
page ii-iii.

46
Drug Requirements/
Tier Limits
SEASONIQUE TABS (Use
QL(1 ea
GP daily,91 day(s)
Levonorgestrel-Ethinyl
Estradiol (91-Day))
limit)
2 PV
TAYTULLA CAPS
Drug Name
TRI-NORINYL 28 TABS
(Use Norethindrone-Eth
Estradiol (Triphasic))
YASMIN 28 TABS (Use
Estradiol)
YAZ TABS (Use
Estradiol)
Drug Name
Drug Requirements/
Tier Limits
CORTICOSTEROIDS - Steroid Hormone Drugs to

Treat Systemic Swelling Conditions
Glucocorticosteroids
budesonide cpep
CORTEF TABS (Use

Hydrocortisone)
GP
cortisone acetate tabs
dexamethasone elix
DEXAMETHASONE
INTENSOL CONC
dexamethasone soln
dexamethasone tabs
DEXPAK 10 DAY TBPK
DEXPAK 13 DAY TBPK
DEXPAK 6 DAY TBPK
Combination Contraceptives - Vaginal

2 QL(1 ea per 30
NUVARING RING
days retail); PV
ENTOCORT EC CPEP
(Use Budesonide)
GP
Emergency Contraceptives
MEDROL DOSEPAK TBPK GP

(Use Methylprednisolone)
MEDROL TABS 16 MG, 32
GP
MG, 4 MG, 8 MG (Use
Methylprednisolone)
GP
QL(1 ea daily)
GP
QL(1 ea daily);
GP PV
Combination Contraceptives - Transdermal

Limit 4 patches
ORTHO EVRA PTWK (Use
GP per
Norelgestromin-Ethinyl
month;QL(0.14
Estradiol)
3 ea daily); PV
XULANE PTWK
ELLA TABS
levonorgestrel (emergency
1
oc) tabs
LEVONORGESTREL
2
TABS
PLAN B ONE-STEP TABS
GP
(Use Levonorgestrel
(Emergency OC))
Progestin Contraceptives - Oral
NOR-QD TABS (Use
GP
Norethindrone
(Contraceptive))
norethindrone
1
(contraceptive) tabs
ORTHO MICRONOR
GP
(Contraceptive))
Limit 4 patches
per
month;QL(0.14
3 ea daily); PV
PV
RX/OTC; PV
AL
RX/OTC; PV
QL(1 ea daily)
QL(1 ea daily)
QL(1 ea daily)
hydrocortisone tabs
MEDROL TABS 2 MG
methylprednisolone tabs
methylprednisolone tbpk
MILLIPRED DP TBPK
MILLIPRED SOLN 10
MG/5ML
MILLIPRED TABS 5 MG
ORAPRED ODT TBDP

(Use Prednisolone Sodium
Phosphate)
GP
page ii-iii.
47
Drug Name
prednisolone sodium
phosphate soln or 15
mg/5ml, 5 mg/5ml, 6.7
mg/5ml
PREDNISOLONE SODIUM
PHOSPHATE SOLN OR
25 MG/5ML
prednisolone sodium
phosphate tbdp or 10 mg,
15 mg, 30 mg
Drug Requirements/
Tier Limits
Drug Name
ZONATUSS CAPS (Use
Benzonatate)
Drug Requirements/
Tier Limits
GP
Cough/Cold/Allergy Combinations
ACTIDOM DMX LIQD
3
ACTINEL PEDIATRIC
LIQD
ALAHIST DM LIQD (Use
PhenylephrineBrompheniramine-DM)
prednisolone soln
prednisolone syrp
PREDNISONE INTENSOL
CONC
prednisone soln 5 mg/5ml
3
3
GP
ALBATUSSIN CAPS
ALBATUSSIN NN LIQD
AMBI
12.5CPD/100GFN/30PSE
LIQD
BIOBRON SF SYRP
BIODESP DM SYRP
BIONEL PEDIATRIC LIQD
PREDNISONE TBPK 5 MG
BIOSPEC DMX LIQD
RAYOS TBEC
PA
UCERIS TB24
PA
VERIPRED 20 SOLN
prednisone tabs 1 mg, 10

mg, 2.5 mg, 20 mg, 5 mg,
50 mg
PREDNISONE TBPK 10
MG
Mineralocorticoids
fludrocortisone acetate
tabs
brompheniramine &
phenyleph liqd
brompheniramine &
phenyleph susp
BRONKIDS LIQD
BROVEX PEB DM LIQD
(Use PhenylephrineBrompheniramine-DM)
3
3
3
GP
COUGH/COLD/ALLERGY - Drugs to Treat

Cough, Cold and Allergy Symptoms
BROVEX PSB LIQD
Antitussives
benzonatate caps 100 mg,
200 mg
BENZONATATE CAPS
150 MG
hydrocodone w/
homatropine syrp
hydrocodone w/
homatropine tabs
TESSALON PERLES
CAPS (Use Benzonatate)
CAPCOF SYRP
CARBAPHEN 12 LIQD
CARBAPHEN 12 PED
SUSP
CHERACOL PLUS LIQD
(Use DextromethorphanGuaifenesin)
1
1
3
GP
GP
page ii-iii.

48
Drug Name
CHERACOL-D COUGH
LIQD (Use
DextromethorphanGuaifenesin)
chlorpheniramine w/
codeine liqd
CLARINEX-D 12 HOUR
TB12
Drug Requirements/
Tier Limits
Drug Name
GILPHEX TR TABS
GP
GILTUSS LIQD (Use

Phenylephrine w/ DM-GG)
Drug Requirements/
Tier Limits
3 RX/OTC
GP RX/OTC
RX/OTC
GILTUSS TR TABS
PA
GLENMAX PEB LIQD
CODAR AR LIQD
CODAR D LIQD
CODITUSSIN AC LIQD
CPB WC LIQD
DALLERGY LIQD
DECON-G LIQD
guaifenesin-codeine liqd
100mg/5ml-10mg/5ml
guaifenesin-codeine liqd
200mg/5ml-8mg/5ml,
225mg/5ml-7.5mg/5ml
guaifenesin-codeine soln
100mg/5ml-10mg/5ml
guaifenesin-codeine soln
100mg/5ml-6.3mg/5ml
guaifenesin-codeine syrp
100mg/5ml-10mg/5ml
DESGEN DM SYRP
HISTEX-PE SYRP
HYCOFENIX SOLN
hydrocodone polistirexchlorpheniramine polistirex

suer
J-MAX SYRP
LEXUSS 210 LIQD
LUSAIR LIQD
M-END PE LIQD
MAR-COF BP LIQD
dextromethorphanguaifenesin liqd 10mg/5ml100mg/5ml, 10mg/5ml10mg/5ml-100mg/5ml100mg/5ml, 15mg/7.5ml150mg/7.5ml

dextromethorphanguaifenesin soln 10mg/5ml100mg/5ml, 20mg/10ml200mg/10ml
dextromethorphanguaifenesin tb12 30mg600mg, 60mg-1200mg
DOMETUSS-DMX LIQD
DURAFLU TABS
ED BRON GP LIQD
EXACTUSS LIQD (Use

Phenylephrine w/ DM-GG)
GP RX/OTC
EXACTUSS TR TABS
RX/OTC
EXAPHEX TR TABS
RX/OTC
FLOWTUSS SOLN
MAR-COF CG
EXPECTORANT LIQD
(Use Guaifenesin-Codeine)
MUCINEX D MAXIMUM
STRENGTH TB12 (Use
PseudoephedrineGuaifenesin)
MUCINEX D TB12 (Use
PseudoephedrineGuaifenesin)
RX/OTC
1
3
1
3
1
Limit 10mls per

day;QL(10 ml
daily); AL
RX/OTC
GP
GP
GP
page ii-iii.
49
Drug Name
MUCINEX DM MAXIMUM
STRENGTH TB12 (Use
MUCINEX DM TB12 (Use
NASOHIST DM LIQD (Use
Phenylephrine-ChlorphenDM)
Drug Requirements/
Tier Limits
promethazine-dm syrp
GP
GP
3
NINJACOF-XG LIQD
OBREDON SOLN
phenyleph-promethazine
w/ cod syrp
phenylephrine w/ dm-gg
liqd 28mg/5ml-388mg/5ml10mg/5ml, 7.5mg/ml88mg/ml-2.5mg/ml
liqd 30mg/5ml-200mg/5ml10mg/5ml, 5mg/5ml75mg/5ml-2.5mg/5ml
phenylephrinebrompheniramine-dm liqd
phenylephrinebrompheniramine-dm syrp
phenylephrine-chlorphendm liqd 15mg/5ml2mg/5ml-10mg/5ml,
15mg/5ml-4mg/5ml10mg/5ml
phenylephrine-chlorphendm liqd 3mg/ml-1mg/ml3.5mg/ml
phenylephrine-guaifenesin
liqd
PHENYLEPHRINE/GUAIF
ENESIN LIQD
promethazine &
phenylephrine syrp
promethazine w/codeine
syrp
GP
NEOTUSS PLUS LIQD
1
RX/OTC
3
3
3
3
Drug Name
PROMETHAZINE/PHENYL
EPHRINE SYRP
pseudoephed-bromphendm syrp
pseudoephed-cpm w/
hydrocod soln
pseudoephedrine w/
codeine-gg soln
pseudoephedrinebrompheniramine-codeine
liqd
pseudoephedrinedexchlorpheniraminechlophedianol liqd
pseudoephedrineguaifenesin tabs 40mg400mg
pseudoephedrineguaifenesin tb12 120mg1200mg
pseudoephedrineguaifenesin tb12 60mg600mg
pyrilamine maleatephenylephrine hcl tannate
susp
RELHIST CHEW
Drug Requirements/
Tier Limits
1
1
1
2
3
3
1
3
3
3
3
1
3
3
RESCON-GG LIQD (Use

PhenylephrineGuaifenesin)
RESCON-JR TB12
RESPA C&C IR TABS
RESPAIRE-30 CAPS
REZIRA SOLN
ROBITUSSIN CHILDRENS
COUGH & COLD CF LIQD
PHENYLHISTINE DH LIQD
PRO-CLEAR AC SYRP
PRO-RED AC SYRP
GP
page ii-iii.

50
Drug Name
Drug Requirements/
Tier Limits
Drug Name
RYDEX LIQD (Use

PseudoephedrineBrompheniramineCodeine)
GP
SEMPREX-D CAPS
VITUZ SOLN
SORBUTUSS NR LIQD
Z-TUSS AC LIQD
ZUTRIPRO SOLN (Use

Pseudoephed-CPM w/
Hydrocod)
Expectorants
TGQ 15DM/5PEH/2CPM
SYRP
TGQ
30PSE/150GFN/15DM
SYRP
TGQ 30PSE/3BRM/15DM
SYRP
TGQ 50PSE/3BRM/30DM
SYRP
VANACOF LIQD (Use

PseudoephedrineDexchlorpheniramineChlophedianol)
Drug Requirements/
Tier Limits
guaifenesin tabs 400 mg
3
3
3
TRICODE GF LIQD
TUSNEL C SYRP
HYPERSAL NEBU 7 %
(Use Sodium Chloride
(Inhalant))
TUSNEL CAPS 2MG15MG-200MG
NEBUSAL NEBU
TUSNEL PEDIATRIC LIQD
TUSSI-PRES PEDIATRIC
LIQD (Use Phenylephrine
w/ DM-GG)
sodium chloride (inhalant)

nebu
Mucolytics
GP
TUSSIONEX
PENNKINETIC
EXTENDED RELEASE
SUER (Use Hydrocodone
PolistirexChlorpheniramine
Polistirex)
acetylcysteine soln
Limit 10mls per

day;QL(10 ml
daily); AL
TUZISTRA XR SUER
VANACOF CD LIQD
VANACOF DX LIQD (Use

PseudoephedrineChlophedianolGuaifenesin)
HYPERSAL NEBU 3.5 %
GP
GP
GP
Misc. Respiratory Inhalants

HYPER-SAL NEBU (Use
Sodium Chloride (Inhalant)) GP
TRICODE AR LIQD
TUSSICAPS CP12
GP
3
GP
3
3
DERMATOLOGICALS - Drugs to Treat Skin

Conditions
Acne Products
ABSORICA CAPS
PA
ACZONE GEL 5 %
PA
ACZONE GEL 7.5 %
adapalene crea 0.1 %
adapalene gel 0.1 %
adapalene gel 0.3 %
PA; QL(2 gm
daily)
QL(45 gm per
fill retail)
QL(45 gm per
fill retail)
QL(45 gm per
fill retail,135 gm
per fill mail)
page ii-iii.
51
Drug Name
ADAPALENE LOTN 0.1 %
ATRALIN GEL (Use
Tretinoin)
AVAR FOAM
AVAR LS CLEANSER
LIQD (Use Sulfacetamide
Sodium w/ Sulfur)
Drug Requirements/
Tier Limits
Limit 59mls per
3 month;QL(1.97
ml daily)
Limit 45gms
GP per
month;QL(1.5
gm daily)
3
GP
AVAR LS FOAM
AVAR LS PADS
AVAR PADS
AVAR-E LS CREA (Use

Sulfacetamide Sodium w/
Sulfur)
AZELEX CREA
BENZACLIN GEL (Use
Clindamycin PhosphateBenzoyl Peroxide)
BENZACLIN WITH PUMP
GEL (Use Clindamycin
Phosphate-Benzoyl
Peroxide)
BENZAMYCIN GEL (Use
Benzoyl PeroxideErythromycin)
benzoyl peroxideerythromycin gel
BP CLEANSING WASH
EMUL
CLARIFOAM EF FOAM
(Use Sulfacetamide
Sodium w/ Sulfur)
CLEOCIN-T GEL (Use
Clindamycin Phosphate
(Topical))
CLEOCIN-T LOTN (Use
(Topical))
GP
3
GP
GP
QL(2 gm daily)
Drug Name
CLEOCIN-T SOLN (Use
(Topical))
CLEOCIN-T SWAB (Use
(Topical))
clindamycin phosphate
(topical) foam
(topical) gel
(topical) lotn
(topical) soln
(topical) swab
clindamycin phosphatebenzoyl peroxide
(refrigerate) gel
clindamycin phosphatebenzoyl peroxide gel
clindamycin phosphatetretinoin gel
DIFFERIN CREA 0.1 %
(Use Adapalene)
DIFFERIN GEL 0.1 % (Use
Adapalene)
DIFFERIN GEL 0.3 % (Use
Adapalene)
GP
1
2
QL(2 gm daily)
DIFFERIN LOTN 0.1 %

DUAC GEL (Use
Clindamycin PhosphateBenzoyl Peroxide
(Refrigerate))
Drug Requirements/
Tier Limits
GP
GP
3
1
1
1
3
1
3
3
GP QL(45 gm per
fill retail)
GP QL(45 gm per
fill retail)
QL(45 gm per
GP fill retail,135 gm
per fill mail)
Limit 59mls per
3 month;QL(1.97
ml daily)
GP
GP
EPIDUO FORTE GEL
EPIDUO GEL
GP
GP
ERYGEL GEL (Use

Erythromycin (Acne Aid))
QL(1 gm daily)
PA; Limit
45gms per
month;QL(1.5
gm daily)
Limit 45gms
per
month;QL(1.5
gm daily)
GP
page ii-iii.

52
Drug Name
erythromycin (acne aid) gel

erythromycin (acne aid)
pads
soln
EVOCLIN FOAM (Use
(Topical))
Drug Requirements/
Tier Limits
1
RETIN-A MICRO PUMP

GEL 0.04 %, 0.1 % (Use
Tretinoin Microsphere)
3
1
RETIN-A MICRO PUMP

GEL 0.08 %
GP
isotretinoin caps 10 mg
Limit 50gms
per
month;QL(1.67
gm daily)
QL(4 ea daily)
QL(5 ea daily)
FABIOR FOAM
isotretinoin caps 30 mg, 40

mg
KLARON LOTN (Use
Sulfacetamide Sodium
(Acne))
ONEXTON GEL
PLEXION CLEANSER
LIQD (Use Sulfacetamide
Sodium w/ Sulfur)
PLEXION CLEANSING
CLOTHS PADS
PLEXION CREA (Use
Sulfur)
PLEXION LOTN (Use
Sulfur)
RETIN-A CREA (Use
Tretinoin)
RETIN-A GEL (Use
Tretinoin)
Drug Name
QL(2 ea daily)
RIAX FOAM
ROSULA LIQD 4.5%-10%
SODIUM
SULFACETAMIDE/SULFU
R CLEANSER IN UREA
EMUL
SODIUM
SULFACETAMIDE/SULFU
R IN UREA GEL
SODIUM
SULFACETAMIDE/SULFU
R SUSP
SSS 10-5 FOAM
GP
PA
GP
3
GP
GP
GP
GP
Limit 50gms
RETIN-A MICRO GEL (Use GP per
Tretinoin Microsphere)
month;QL(1.7
gm daily)
Drug Requirements/
Tier Limits
Limit 50gms
GP per
month;QL(1.7
gm daily)
PA; Limit
3 50gms per
month;QL(1.7
gm daily)
sulfacetamide sodium
(acne) lotn
(acne) susp
sulfacetamide sodium w/
sulfur crea 2%-10%, 4.8%9.8%
sulfur crea 5%-10%
sulfur emul 1%-10%
sulfur emul 5%-10%
sulfur liqd 2%-10%, 2%2%-10%-10%, 4.5%-9%,
4.8%-9.8%
sulfur liqd 4%-9%
sulfur lotn 4.8%-9.8%
sulfur lotn 5%-10%
3
3
2
1
1
3
1
3
1
3
1
3
1
QL(30 gm per
fill retail)
page ii-iii.
53
Drug Name
sulfur soln 2%-10%
sulfur susp 4%-8%
sulfacetamide sodiumsulfur in urea vehicle emul
SULFOAM SHAM
SUMADAN WASH LIQD
(Use Sulfacetamide
Sodium w/ Sulfur)
SUMAXIN TS SUSP (Use
Sulfur)
SUMAXIN WASH LIQD
(Use Sulfacetamide
Sodium w/ Sulfur)
TRETIN-X CREA 0.038 %
TRETIN-X CREA 0.075 %
tretinoin crea 0.025 %, 0.05

%, 0.1 %
tretinoin gel 0.01 %, 0.025
%
tretinoin gel 0.05 %
Drug Requirements/
Tier Limits
diclofenac sodium (topical)

gel 1 %
diclofenac sodium (topical)
soln 1.5 %
3
1
1
FLECTOR PTCH
PENNSAID SOLN 1.5 %

(Use Diclofenac Sodium
(Topical))
GP
GP
GP
Drug Requirements/
Tier Limits
3
1
QL(5 ml daily)
3
QL(5 ml daily)
GP
PENNSAID SOLN 2 %
REXAPHENAC CREA
VOLTAREN GEL (Use

Diclofenac Sodium
(Topical))
GP
PA; QL(4 gm
daily)
Antibiotics - Topical
3
Limit 35gms
per
month;QL(1.2
gm daily)
3
1
1
3
tretinoin microsphere gel
VANOXIDE-HC LOTN
VELTIN GEL
ZIANA GEL (Use

Clindamycin PhosphateTretinoin)
Drug Name
Limit 45gms
per
month;QL(1.5
gm daily)
Limit 50gms
per
month;QL(1.7
gm daily)
ALTABAX OINT
BACTROBAN CREA (Use
Mupirocin Calcium
(Topical))
BACTROBAN OINT (Use
Mupirocin)
3
GP
GP
CENTANY AT KIT
CENTANY OINT
CORTISPORIN CREA
CORTISPORIN OINT
QL(1 gm daily)
gentamicin sulfate (topical)

crea
gentamicin sulfate (topical)
oint
mupirocin calcium (topical)
crea
QL(1 gm daily)
mupirocin oint
NEO-SYNALAR CREA
NEO-SYNALAR KIT KIT
1
1
1
GP
Agents for External Genital and Perianal Warts

3 QL(30 gm per
VEREGEN OINT
fill retail)
Anti-inflammatory Agents - Topical
Antifungals - Topical
ALA-QUIN CREA
page ii-iii.

54
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
ciclopirox gel 0.77 %
ketoconazole (topical) foam
ciclopirox olamine crea
ketoconazole (topical)
sham
ciclopirox olamine susp
LAMISIL AT SPRAY SOLN
ciclopirox sham 1 %
ciclopirox soln 8 %
LOPROX CREA (Use

Ciclopirox Olamine)
LOPROX SHAMPOO
SHAM (Use Ciclopirox)
clotrimazole (topical) soln
clotrimazole w/
betamethasone crea
clotrimazole w/
betamethasone lotn
econazole nitrate crea
ECOZA FOAM
QL(45 gm per
fill retail,45 gm
per 30 days
retail)
QL(60 ml per
fill retail,60 ml
per 30 days
retail)
1
3
ERTACZO CREA
EXELDERM CREA
EXELDERM SOLN
EXODERM LOTN
EXTINA FOAM (Use

Ketoconazole (Topical))
RX/OTC
Limit 70gms
per
month;QL(2.5
gm daily)
PA
GP
HALOTIN CREA
iodoquinol-hc crea
iodoquinol-hydrocortisone
in aloe vehicle crea
JUBLIA SOLN
PA
KERYDIN SOLN
PA
ketoconazole (topical) crea
QL(2 gm daily)
LOTRISONE CREA (Use

Clotrimazole w/
Betamethasone)
GP
GP
QL(45 gm per
GP fill retail,45 gm
per 30 days
retail)
LUZU CREA
NAFTIFINE HCL CREA 1

%
naftifine hcl crea 2 %
NAFTIN CREA 1 %, 2 %
(Use Naftifine HCl)
GP
NAFTIN GEL 1 %, 2 %
NIZORAL SHAM (Use

Ketoconazole (Topical))
GP
nystatin (topical) crea
nystatin (topical) oint
nystatin (topical) powd
nystatin-triamcinolone crea
nystatin-triamcinolone oint
oxiconazole nitrate crea
OXISTAT CREA (Use

Oxiconazole Nitrate)
OXISTAT LOTN
PENLAC NAIL LACQUER
SOLN (Use Ciclopirox)
VUSION OINT
PA
Limit 30gms
per month;QL(1
gm daily)
Limit 30gms
per month;QL(1
gm daily)
GP
3
GP
3
page ii-iii.
55
Drug Name
VYTONE CREA (Use
Iodoquinol-Hydrocortisone
in Aloe Vehicle)
XOLEGEL GEL
Drug Requirements/
Tier Limits
calcipotriene crea
GP
3
Antineoplastic or Premalignant Lesion Agents 2 QL(1 gm daily)

CARAC CREA
diclofenac sodium (actinic

keratoses) gel
EFUDEX CREA (Use
Fluorouracil (Topical))
FLUOROPLEX CREA
calcipotriene soln
calcitriol (topical) oint

DOVONEX CREA (Use
Calcipotriene)
GP
methoxsalen rapid caps
2
1
fluorouracil (topical) soln
FLUOROURACIL CREA
QL(1 gm daily)
PANRETIN GEL
PA
PICATO GEL
SOLARAZE GEL (Use

Diclofenac Sodium (Actinic
Keratoses))
GP
TARGRETIN GEL EX 1 %
VALCHLOR GEL
PA; LA
OXSORALEN ULTRA
CAPS (Use Methoxsalen
Rapid)
SORIATANE CAPS 10 MG
(Use Acitretin)
SORIATANE CAPS 17.5
MG (Use Acitretin)
SORIATANE CAPS 25 MG
(Use Acitretin)
QL(1 gm daily)
VECTICAL OINT (Use

Calcitriol (Topical))
OVACE PLUS LOTN 9.8 %
acitretin caps 25 mg
QL(2 ea daily)
GP QL(2 ea daily)
TAZORAC GEL
acitretin caps 17.5 mg
GP
QL(1 gm daily)
ZONALON CREA
QL(1 ea daily)
GP QL(1 ea daily)
Antiseborrheic Products
OVACE PLUS FOAM 9.8
%
GP
TAZORAC CREA
acitretin caps 10 mg
QL(4 gm daily)
PRUDOXIN CREA
Limit 100gms
1 per
month;QL(3.4
gm daily)
GP QL(5 gm daily)
ZITHRANOL-RR CREA
8-MOP CAPS
QL(5 gm daily)
SORILUX FOAM
Antipsoriatics
Drug Requirements/
Tier Limits
1 QL(5 gm daily)
calcipotriene oint
fluorouracil (topical) crea
Antipruritics - Topical
DOXEPIN
HYDROCHLORIDE CREA
Drug Name
Limit 100gms
GP per
month;QL(3.4
gm daily)
3
3
3
OVACE PLUS SHAM 10 %

GP
(Use Sulfacetamide
Sodium)
OVACE PLUS WASH LIQD
GP
(Use Sulfacetamide
Sodium)
OVACE WASH LIQD (Use GP
Sulfacetamide Sodium)
page ii-iii.

56
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
selenium sulfide lotn
selenium sulfide-pyrithione
zinc in urea vehicle sham
SELRX SHAM
SODIUM
SULFACETAMIDE WASH
LIQD
sulfacetamide sodium liqd
Corticosteroids - Topical
ACLOVATE CREA (Use
Alclometasone
Dipropionate)
ALA SCALP LOTN (Use
Hydrocortisone (Topical))
alclometasone dipropionate
crea
alclometasone dipropionate
oint
sham
AMCINONIDE CREA
TERSI FOAM FOAM
AMCINONIDE LOTN
AMCINONIDE OINT
APEXICON E CREA
Antivirals - Topical
acyclovir topical oint
QL(1 gm daily)
DENAVIR CREA
Limit 5gms per

month;QL(0.17
gm daily)
LIDOVIR OINT
XERESE CREA
ZOVIRAX CREA EX 5 %
ZOVIRAX OINT EX 5 %
(Use Acyclovir Topical)
PA; Limit 5gms

3 per
month;QL(0.17
gm daily)
PA; Limit 5gms
3 per
month;QL(0.17
gm daily)
GP QL(1 gm daily)
Burn Products
mafenide acetate pack

SILVADENE CREA (Use
Silver Sulfadiazine)
silver sulfadiazine crea

SULFAMYLON CREA 85
MG/GM
SULFAMYLON PACK 5 %
(Use Mafenide Acetate)
Cauterizing Agents
ARZOL SILVER NITRATE
APPLICATORS MISC
3
GP
1
3
GP
betamethasone
dipropionate (topical) crea
betamethasone
dipropionate (topical) lotn
betamethasone
dipropionate (topical) oint
betamethasone
dipropionate augmented
crea
betamethasone
gel
betamethasone
lotn
betamethasone
oint
betamethasone valerate
crea 0.1 %
foam 0.12 %
lotn 0.1 %
oint 0.1 %
calcipotrienebetamethasone
dipropionate oint
GP
GP
1
1
1
1
1
1
1
1
1
1
3
1
1
3
ST; QL(2 gm
daily)
page ii-iii.
57
Drug Name
Drug Requirements/
Tier Limits
CAPEX SHAM
clobetasol propionate crea
clobetasol propionate
emollient base crea
emulsion foam
3
3
clobetasol propionate gel
clobetasol propionate liqd
clobetasol propionate lotn
clobetasol propionate oint
clobetasol propionate sham
clobetasol propionate soln
CLOBEX LIQD (Use

Clobetasol Propionate)
CLOBEX LOTN (Use
CLOBEX SHAM (Use
CLOCORTOLONE
PIVALATE CREA
CLOCORTOLONE
PIVALATE PUMP CREA
GP
GP
3
3
3
CLODERM PUMP CREA
CORDRAN OINT 0.05 %
CORDRAN TAPE 4
MCG/SQCM
CORDRAN TAPE TAPE
CORTANE-B LOTN
GP
GP
GP
GP
desonide lotn
desonide oint
diflorasone diacetate crea

PA
GP
desonide crea
DESOXIMETASONE OINT
0.05 %
desoximetasone oint 0.25
%
GP PA
GP
desoximetasone gel 0.05 %
GP
Drug Requirements/
Tier Limits
DESONATE GEL
DESOWEN CREA (Use

Desonide)
DESOWEN LOTN (Use
Desonide)
DESOXIMETASONE
CREA 0.05 %
desoximetasone crea 0.25
%
GP
CLODERM CREA
CORDRAN CREA 0.05 %

(Use Flurandrenolide)
CORDRAN LOTN 0.05 %
(Use Flurandrenolide)
CUTIVATE CREA (Use

Fluticasone Propionate)
CUTIVATE LOTN (Use
Fluticasone Propionate)
DERMA-SMOOTHE/FS
BODY OIL (Use
Fluocinolone Acetonide)
DERMA-SMOOTHE/FS
SCALP OIL (Use
DERMATOP CREA (Use
Prednicarbate)
DERMATOP OINT (Use
Prednicarbate)
clobetasol propionate foam
Drug Name
DIFLORASONE
DIACETATE OINT
DIPROLENE AF CREA
(Use Betamethasone
Dipropionate Augmented)
DIPROLENE LOTN (Use
Betamethasone
GP
GP
2
1
1
3
1
1
2
GP
GP
page ii-iii.

58
Drug Name
DIPROLENE OINT (Use
Betamethasone
ELOCON CREA (Use
Mometasone Furoate)
ELOCON LOTN (Use
Mometasone Furoate)
ELOCON OINT (Use
Mometasone Furoate)
Drug Requirements/
Tier Limits
GP
GP
Drug Name
HALOG CREA
HALOG OINT
EPIFOAM FOAM
fluocinolone acetonide crea
fluocinolone acetonide oil
fluocinolone acetonide oint
fluocinolone acetonide soln
fluocinonide crea 0.05 %,

0.1 %
fluocinonide crea 0.1 %
hydrocortisone (topical)
crea 2.5 %
hydrocortisone (topical) lotn
2%
hydrocortisone (topical) lotn
2.5 %
hydrocortisone (topical) oint
2.5 %
hydrocortisone butyrate
crea
hydrophilic lipo base crea
oint
soln
hydrocortisone valerate
crea
fluocinonide emulsified
base crea
hydrocortisone valerate oint
fluocinonide gel 0.05 %
fluocinonide oint 0.05 %
fluocinonide soln 0.05 %
flurandrenolide crea
flurandrenolide lotn
fluticasone propionate crea

0.05 %
fluticasone propionate lotn
0.05 %
fluticasone propionate oint
0.005 %
HALAC KIT
GP
GP
PA
KENALOG AERS (Use

Triamcinolone Acetonide
(Topical))
LOCOID CREA (Use
Hydrocortisone Butyrate)
LOCOID LIPOCREAM
CREA (Use Hydrocortisone
Butyrate Hydrophilic Lipo
Base)
LOCOID LOTN
1
3
1
3
halobetasol propionate
crea
halobetasol propionate oint
Drug Requirements/
Tier Limits
LOCOID OINT (Use

LOCOID SOLN (Use
LUXIQ FOAM (Use
Betamethasone Valerate)
1
3
1
1
1
3
1
3
3
3
GP
GP
GP
3
PA
GP
GP
GP
mometasone furoate crea
mometasone furoate oint
mometasone furoate soln
page ii-iii.
59
Drug Name
NUCORT LOTN
OLUX FOAM (Use
OLUX-E FOAM (Use
Clobetasol Propionate
Emulsion)
Drug Requirements/
Tier Limits
GP
GP
3
PRAMOSONE E CREA
PRAMOSONE LOTN 1%1%, 1%-2.5%

PRAMOSONE OINT 1%1%, 1%-2.5%
3
1
prednicarbate oint
TACLONEX SUSP
TEMOVATE CREA (Use
TEMOVATE E CREA (Use
Clobetasol Propionate
Emollient Base)
TEMOVATE GEL (Use
TEMOVATE OINT (Use
TEMOVATE SOLN (Use
GP
GP
ST; QL(2 gm
GP daily)
3
GP
ST; QL(2 gm
daily)
GP
GP
3
TOPICORT OINT 0.05 %
ULTRAVATE LOTN
GP
Drug Requirements/
Tier Limits
TOPICORT LIQD 0.25 %
TOPICORT OINT 0.25 %

(Use Desoximetasone)
triamcinolone acetonide
(topical) aers
(topical) crea
(topical) lotn
(topical) oint
TRIDESILON CREA (Use
Desonide)
ULTRAVATE CREA (Use
Halobetasol Propionate)
prednicarbate crea
SYNALAR CREA (Use

SYNALAR OINT (Use
SYNALAR SOLN (Use
TACLONEX OINT (Use
CalcipotrieneBetamethasone
Dipropionate)
TOPICORT CREA 0.25 %

TOPICORT GEL 0.05 %
PANDEL CREA
Drug Name
ULTRAVATE OINT (Use

Halobetasol Propionate)
VANOS CREA (Use
Fluocinonide)
VERDESO FOAM
WESTCORT OINT (Use
Hydrocortisone Valerate)
PA
GP
1
1
1
1
GP
GP
3
PA
GP
NF
3
GP
Emollient/Keratolytic Agents
GP
ALUVEA CREA (Use Urea)
GP
CARB-O-LAC HP CREA
CARB-O-LAC5 CREA
CEM-UREA SOLN
GORDONS UREA OINT
GP
GP
TEXACORT SOLN
TOPICORT CREA 0.05 %
HYDRO 35 FOAM (Use

Urea in Lactic Acid Vehicle)
HYDRO 40 FOAM FOAM
(Use Urea)
GP
GP
GP
page ii-iii.

60
Drug Name
Drug Requirements/
Tier Limits
KERASAL ULTRA20
CREA
UMECTA EMUL
UMECTA NAIL FILM SUSP GP

(Use Urea)
UMECTA SUSP (Use
GP
Urea)
URAMAXIN CREA 45 %
GP
(Use Urea)
URAMAXIN FOAM 20%
URAMAXIN GEL 45 %
(Use Urea)
URAMAXIN GT GEL (Use
Urea)
URAMAXIN LOTN 45 %
(Use Urea)
3
GP
GP
GP
urea crea
urea foam
urea gel
urea in lactic acid vehicle

foam
urea in lactic acid-salicylic
acid vehicle susp
urea in zinc undecylenatelactic acid vehicle emul
3
3
3
Drug Name
LAC-HYDRIN CREA (Use
Lactic Acid (Ammonium
Lactate))
LAC-HYDRIN LOTN (Use
Lactic Acid (Ammonium
Lactate))
LAC-HYDRIN TWELVE
LOTN (Use Lactic Acid
(Ammonium Lactate))
lactic acid (ammonium
lactate) crea 12 %
lactate) lotn 10 %
lactate) lotn 12 %
Enzymes - Topical
GRANULEX AERS (Use
Trypsin w/ Castor Oil &
Peruvian Balsam)
RX/OTC
GP
trypsin w/ castor oil &

3
peruvian balsam oint
Immunomodulating Agents - Topical
ALDARA CREA (Use
GP
Imiquimod)
imiquimod crea
ZYCLARA CREA
3
3
3
urea susp
ZYCLARA PUMP CREA

2.5 %
UTOPIC CREA
ZYCLARA PUMP CREA

3.75 %
RX/OTC
HYLIRA LOTN 0.1 %
TBC AERS
UREA NAIL STCK
GP
RX/OTC
GP
RX/OTC
GP
SANTYL OINT
urea lotn
Emollients
hyaluronate sodium
(emollient) gel
HYLIRA GEL 0.2 % (Use
Hyaluronate Sodium
(Emollient))
Drug Requirements/
Tier Limits
RX/OTC
GP
PA; QL(1 gm
daily)
PA; Limit 1 per
month;QL(0.6
gm daily)
PA; QL(1 gm
daily)
Immunosuppressive Agents - Topical

3 QL(60 gm per
ELIDEL CREA
fill retail)
PROTOPIC OINT (Use
GP QL(2 gm daily);
Tacrolimus (Topical))
AL
1 QL(2 gm daily);
tacrolimus (topical) oint
AL
Keratolytic/Antimitotic Agents
page ii-iii.
61
Drug Name
Drug Requirements/
Tier Limits
Drug Name
BENSAL HP OINT
EMLA CREA (Use

Lidocaine-Prilocaine)
CONDYLOX GEL
ETHYL CHLORIDE AERO
GP
CONDYLOX SOLN (Use

Podofilox)
PODOCON 25 IN
BENZOIN TINCTURE
SOLN
salicylic acid crea 6 %
salicylic acid foam 6 %
SALICYLIC ACID LIQD 26

%
salicylic acid liqd 27.5 %
ETHYL CHLORIDE/FINE
PINPOINT AERO
ETHYL CHLORIDE/FINE
STREAM AERO
ETHYL
CHLORIDE/MEDIUM JET
STREAM AERO
ETHYL
CHLORIDE/MEDIUM
STREAM AERO
ETHYL CHLORIDE/MIST
AERO
GEBAUERS INSTANT ICE
AERO
GEBAUERS PAIN EASE
AERO
GEBAUERS SPRAY AND
STRETCH AERO
salicylic acid lotn 6 %
salicylic acid sham 6 %
salicylic acid soln 28.5 %
salicylic acid w/ cleanser kit
podofilox soln
SALEX LOTION KIT (Use
Salicylic Acid w/ Cleanser)
SALEX SHAM (Use
Salicylic Acid)
SALVAX FOAM (Use

Salicylic Acid)
ULTRASAL-ER SOLN
(Use Salicylic Acid)
VIRASAL LIQD (Use
Salicylic Acid)
3
1
GP
GP
3
3
3
3
3
3
RX/OTC
RX/OTC
RX/OTC
lidocaine hcl gel ex 2 %
RX/OTC
lidocaine hcl soln ex 4 %
lidocaine oint
lidocaine ptch
GP
lidocaine-prilocaine crea
GP PA
LIDODERM PTCH (Use

Lidocaine)
PA
NUMBONEX LOTN
GP
Local Anesthetics - Topical

ADAZIN CREA
ANASTIA LOTN
COCAINE HCL SOLN
GP
Liniments
MEDROX-RX OINT
Drug Requirements/
Tier Limits
PA
PREMIUM SCAR PATCH

PTCH
SCAR PATCH PTCH 30%4%-2%
GP QL(3 ea daily)
2
3
3
SYNERA PTCH
VEXA PTCH
XYLOCAINE SOLN EX 4
% (Use Lidocaine HCl)
QL(3 ea daily)
GP
Misc. Dermatological Products
page ii-iii.

62
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
3 PA; QL(1 gm
daily)
CERACADE EMUL
SOOLANTRA CREA
EMULSION SB EMUL
ENTTY SPRAY
EMULSION EMUL
Scabicides & Pediculicides

ELIMITE CREA (Use
Permethrin)
EPICERAM EMUL
EURAX CREA
SYNERDERM EMUL
EURAX LOTN
lindane lotn
Misc. Topical
GP QL(60 gm per
fill retail)
aluminum chloride soln
lindane sham
DRYSOL SOLN
malathion lotn
XERAC AC SOLN
NATROBA SUSP
Rosacea Agents
DOXYCYCLINE CPDR
FINACEA FOAM
FINACEA GEL
METROCREAM CREA
(Use Metronidazole
(Topical))
METROGEL GEL (Use
Metronidazole (Topical))
METROLOTION LOTN
(Use Metronidazole
(Topical))
metronidazole (topical)
crea 0.75 %
metronidazole (topical) gel
0.75 %
metronidazole (topical) gel
1%
metronidazole (topical) lotn
0.75 %
PA
GP
SKLICE LOTN
SPINOSAD SUSP
ULESFIA LOTN
Wound Care Products
QL(60 ml per
GP fill retail)
REGRANEX GEL
AL
GP
permethrin crea
GP
QL(60 gm per
fill retail)
AL
QL(15 gm per
fill retail)
DIAGNOSTIC PRODUCTS
1
1
Diagnostic Biologicals
QL(45 gm per
fill retail)
QL(60 ml per
fill retail)
PA
NORITATE CREA
PA
ORACEA CPDR
PA
MIRVASO GEL
OVIDE LOTN (Use

Malathion)
QL(60 ml per
fill retail)
T.R.U.E. TEST TEST

Diagnostic Drugs
GLUCAGEN DIAGNOSTIC
SOLR
METOPIRONE CAPS
3
3
Diagnostic Tests
ACCU-CHEK ACTIVE
STRIPS STRP
PA; Limit 200

per
month;QL(6.67
ea daily)
page ii-iii.
63
Drug Name
ACCU-CHEK AVIVA PLUS
STRP VI
ACCU-CHEK AVIVA STRP

ACCU-CHEK COMFORT
CURVE TEST STRIPS
STRP
ACCU-CHEK COMPACT
PLUS STRP
ACCU-CHEK COMPACT
TEST DRUM STRP
ACCU-CHEK SMARTVIEW
STRIPS STRP
ACCUTREND GLUCOSE
STRP
ACURA BLOOD
GLUCOSE TESTSTRIPS
STRP
ADVANCE INTUITION
TEST STRIPS STRP
ADVANCE MICRO-DRAW
TEST STRIPS STRP
ADVOCATE REDI-CODE
STRP VI
ADVOCATE REDI-CODE+
TESTSTRIPS STRP
Drug Requirements/
Tier Limits
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
Drug Requirements/
Tier Limits
PA; Limit 200
ADVOCATE TEST STRIPS 3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
AGAMATRIX AMP NO
3 per
CODE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
AGAMATRIX JAZZ TEST
3 per
STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
AGAMATRIX KEYNOTE
3 per
TEST STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
AGAMATRIX PRESTO
3 per
TEST STRIPS STRP
month;QL(6.67
ea daily)
PA; Use
Preferred
ASCENSIA AUTODISC
3 Abbott and
TEST STRIPS DISK
OneTouch
Product;QL(6.7
ea daily)
PA; Limit 200
ASSURE 3 TEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
ASSURE 4 TEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
ASSURE II CHECK STRIP
3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
3 per
ASSURE II STRP
month;QL(6.67
ea daily)
PA; Limit 200
ASSURE II TEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
Drug Name
page ii-iii.

64
Drug Requirements/
Tier Limits
PA; Limit 200
ASSURE PLATINUM TEST 3 per
STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
ASSURE PRO TEST
3 per
STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
AT LAST TEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
PA; Use
Preferred
BAYER BREEZE 2 TEST
3 Abbott and
DISC DISK
OneTouch
Product;QL(6.7
ea daily)
PA; Limit 200
BAYER CONTOUR
3 per
BLOOD GLUCOSE TEST
month;QL(6.67
STRIPS STRP
ea daily)
PA; Limit 200
BAYER CONTOUR NEXT
3 per
BLOODGLUCOSE TEST
month;QL(6.67
STRP
ea daily)
PA; Limit 200
BG STAR BLOOD
3 per
GLUCOSE TEST STRP
month;QL(6.67
ea daily)
PA; Limit 200
BIOSCANNER GLUCOSE
3 per
TEST STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
BLOOD GLUCOSE TEST
3 per
STRIPS PREMIUM STRP
month;QL(6.67
ea daily)
PA; Limit 200
BLOOD GLUCOSE TEST
3 per
STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
CAREONE BLOOD
3 per
GLUCOSE TEST
month;QL(6.67
STRIPS/PREMIUM STRP
ea daily)
Drug Name
Drug Requirements/
Tier Limits
PA; Limit 200
CAREONE BLOOD
3 per
GLUCOSE TEST
month;QL(6.67
STRIPS/VALUE STRP
ea daily)
PA; Limit 200
CARESENS N BLOOD
3 per
GLUCOSETEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
CLEVER CHEK AUTO3 per
CODE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
CLEVER CHEK AUTO3 per
CODE VOICE TEST
month;QL(6.67
STRIPS STRP
ea daily)
PA; Limit 200
CLEVER CHEK TEST
3 per
STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
CLEVER CHOICE AUTO3 per
CODE PRO TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
CLEVER CHOICE MICRO
3 per
TESTSTRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
3 per
CONTROL AST STRP
month;QL(6.67
ea daily)
PA; Limit 200
CONTROL TEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
DIATRUE PLUS BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
DUO-CARE TEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
EASY PLUS BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
Drug Name
page ii-iii.
65
Drug Requirements/
Tier Limits
PA; Limit 200
EASY PLUS II BLOOD
3 per
GLUCOSE TEST STRP
month;QL(6.67
ea daily)
PA; Limit 200
EASY STEP TEST STRIPS 3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
EASY TALK BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
EASY TOUCH GLUCOSE
3 per
TEST STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
EASY TRAK BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
3 per
EASYGLUCO STRP VI
month;QL(6.67
ea daily)
PA; Limit 200
EASYMAX 15 TEST
3 per
STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
EASYMAX TEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
EASYPLUS BLOOD
3 per
GLUCOSE TEST STRIP
month;QL(6.67
STRP
ea daily)
PA; Limit 200
EASYPRO BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
3 per
EASYPRO PLUS STRP VI
month;QL(6.67
ea daily)
PA; Limit 200
ELEMENT COMPACT
3 per
TEST STRIPS STRP
month;QL(6.67
ea daily)
Drug Name
Drug Requirements/
Tier Limits
PA; Limit 200
ELEMENT TEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
EMBRACE BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
EQL TRUETEST BLOOD
3 per
GLUCOSE TEST STRP
month;QL(6.67
ea daily)
PA; Limit 200
EQL TRUETRACK TEST
3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
EVENCARE + BLOOD
3 per
GLUCOSETEST STRIP
month;QL(6.67
STRP
ea daily)
PA; Limit 200
EVENCARE BLOOD
3 per
GLUCOSE TEST STRIP
month;QL(6.67
STRP
ea daily)
PA; Limit 200
EVENCARE G2 TEST
3 per
STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
EVENCARE G3 TEST
3 per
STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
EVOLUTION AUTOCODE
3 per
STRP VI
month;QL(6.67
ea daily)
PA; Limit 200
EXACTECH R-S-G TEST
3 per
STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
EXACTECH TEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
EZ SMART BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
Drug Name
page ii-iii.

66
Drug Requirements/
Tier Limits
PA; Limit 200
EZ SMART PLUS BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
FIFTY50 GLUCOSE TEST
3 per
STRIP 2.0 STRP
month;QL(6.67
ea daily)
PA; Limit 200
FORA D10 BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
FORA D15G BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
FORA D20 BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
FORA G20 BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
FORA G30A BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
FORA GD20 TEST
3 per
STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
FORA V10 BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
FORA V12 BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
FORA V20 BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
FORA V30A BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
Drug Name
Drug Name
FORACARE GD40 STRP
FORACARE PREMIUM
V10 TESTSTRIPS STRP
FORACARE TEST N GO
TEST STRIPS STRP
FREESTYLE INSULINX
BLOODGLUCOSE TEST
STRIPS STRP
FREESTYLE INSULINX
BLOODGLUCOSE TEST
STRP
FREESTYLE INSULINX
BLOODGLUCOSE TEST
STRP
FREESTYLE LITE TEST
STRIPS STRP
FREESTYLE LITE TEST
STRIPS STRP
FREESTYLE TEST
STRIPS STRP
GE100 BLOOD GLUCOSE
TESTSTRIPS STRP
GLUCO PERFECT 3 TEST
STRIPS STRP
GLUCOCARD 01 SENSOR
PLUS STRP
GLUCOCARD 01 SENSOR
PLUSTEST STRIPS STRP
Drug Requirements/
Tier Limits
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
Limit 200 per
2 month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
Limit 200 per
2 month;QL(6.67
ea daily)
Limit 200 per
2 month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
Limit 200 per
2 month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
page ii-iii.
67
Drug Requirements/
Tier Limits
GLUCOCARD
PA; Limit 200
EXPRESSION BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
GLUCOCARD VITAL TEST 3 per
STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
GLUCOCARD X-SENSOR
3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
GLUCOCOM TEST
3 per
STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
GLUCONAVII BLOOD
3 per
GLUCOSETEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
GMATE BLOOD
3 per
GLUCOSE TESTSTRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
INFINITY BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
KROGER BLOOD
3 per
GLUCOSE TESTSTRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
KROGER PREMIUM
3 per
BLOOD GLUCOSE TEST
month;QL(6.67
STRIPS STRP
ea daily)
PA; Limit 200
KROGER TEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
LIBERTY NEXT
PA; Limit 200
GENERATION BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
LIBERTY TEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
Drug Name
Drug Requirements/
Tier Limits
PA; Limit 200
MAXIMA BLOOD
3 per
GLUCOSE TESTSTRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
MEIJER BLOOD
3 per
GLUCOSE TESTSTRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
MEIJER PREMIUM
3 per
BLOOD GLUCOSE TEST
month;QL(6.67
STRIPS STRP
ea daily)
PA; Limit 200
MEIJER TRUETEST
3 per
BLOOD GLUCOSE TEST
month;QL(6.67
STRIPS STRP
ea daily)
PA; Limit 200
MEIJER TRUETRACK
3 per
BLOOD GLUCOSE TEST
month;QL(6.67
STRIPS STRP
ea daily)
PA; Limit 200
MICRODOT TEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
MYGLUCOHEALTH
3 per
BLOOD GLUCOSE TEST
month;QL(6.67
STRP
ea daily)
PA; Limit 200
NEUTEK 2TEK TEST
3 per
STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
NEXGEN TEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
NOVA MAX GLUCOSE
3 per
TEST STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
ON CALL PLUS BLOOD
3 per
GLUCOSE TEST STRP
month;QL(6.67
ea daily)
PA; Limit 200
ON CALL VIVID BLOOD
3 per
GLUCOSE TEST STRP
month;QL(6.67
ea daily)
Drug Name
page ii-iii.

68
Drug Requirements/
Tier Limits
200 per
ONETOUCH ULTRA BLUE 2 Limit
month;QL(6.67
STRP
ea daily)
Limit 200 per
ONETOUCH VERIO TEST
2 month;QL(6.67
STRIPS STRP
ea daily)
PA; Limit 200
OPTIUM TEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
OPTIUMEZ TEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
OPTUMRX BLOOD
3 per
GLUCOSE TEST STRP
month;QL(6.67
ea daily)
PHARMACIST CHOICE
PA; Limit 200
AUTOCODE BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
POCKETCHEM EZ
3 per
BLOOD GLUCOSE TEST
month;QL(6.67
STRIPS STRP
ea daily)
PA; Limit 200
PRECISION PCX PLUS
3 per
TEST STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
3 per
PRECISION PCX STRP
month;QL(6.67
ea daily)
PA; Limit 200
PRECISION POINT OF
3 per
CARE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
PRECISION QID TEST
3 per
STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
PRECISION SOF-TACT
3 per
TEST STRIPS STRP
month;QL(6.67
ea daily)
Drug Name
Drug Requirements/
Tier Limits
PRECISION XTRA BLOOD
Limit 200 per
2 month;QL(6.67
GLUCOSE TEST STRIPS
STRP
ea daily)
PA; Limit 200
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
PRODIGY NO CODING
3 per
BLOOD GLUCOSE TEST
month;QL(6.67
STRIPS STRP
ea daily)
PA; Limit 200
PTS PANELS GLUCOSE
3 per
TEST STRP
month;QL(6.67
ea daily)
PA; Limit 200
QUICKTEK TEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
QUINTET AC BLOOD
3 per
GLUCOSETEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
QUINTET BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
RA TRUETEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
REFUAH PLUS BLOOD
3 per
GLUCOSETEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
RELION BLOOD
3 per
GLUCOSE TESTSTRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
RELION CONFIRM/MICRO 3 per
TEST STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
RELION PRIME BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
Drug Name
page ii-iii.
69
Drug Name
RELION ULTIMA BLOOD
GLUCOSE TEST STRIPS
STRP
RELION ULTIMA TEST
STRIPS STRP
REVEAL BLOOD
GLUCOSE TEST STRP
REXALL BLOOD
GLUCOSE TEST STRIPS
STRP
RIGHTEST GS100 BLOOD
GLUCOSE TEST STRIPS
STRP
GLUCOSE TEST STRIPS
STRP
GLUCOSE TEST STRIPS
STRP
SMART DIABETES
XPRES BLOOD
GLUCOSE TEST STRIPS
STRP
SMART SENSE PREMIUM
BLOODGLUCOSE STRIPS
STRP
SMART SENSE VALUE
BLOOD GLUCOSE
STRIPS STRP
SMARTEST BLOOD
GLUCOSE TEST STRIPS
STRP
SOLUS V2 AUDIBLE TEST
STRP
Drug Requirements/
Tier Limits
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
Drug Requirements/
Tier Limits
PA; Limit 200
SUPREME TEST STRIPS
3 per
STRP
month;QL(6.67
ea daily)
PA; Limit 200
SURE EDGE BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
SURE-TEST EASYPLUS
3 per
MINI BLOOD GLUCOSE
month;QL(6.67
TEST STRIPS STRP
ea daily)
PA; Limit 200
SURECHEK BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
TELCARE BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
TGT BLOOD GLUCOSE
3 per
TEST STRIPS PREMIUM
month;QL(6.67
STRP
ea daily)
PA; Limit 200
TGT BLOOD GLUCOSE
3 per
TEST STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
TRUETEST BLOOD
3 per
GLUCOSE TEST STRIPS
month;QL(6.67
STRP
ea daily)
PA; Limit 200
TRUETEST BLOOD
3 per
GLUCOSE TEST STRP
month;QL(6.67
ea daily)
PA; Limit 200
3 per
TRUETEST STRIPS STRP
month;QL(6.67
ea daily)
PA; Limit 200
TRUETRACK BLOOD
3 per
GLUCOSE TEST STRP
month;QL(6.67
ea daily)
PA; Limit 200
3 per
TRUETRACK TEST STRP
month;QL(6.67
ea daily)
Drug Name
page ii-iii.

70
Drug Name
ULTIMA TEST STRIPS
STRP
ULTRATRAK PRO TEST
STRIPS STRP
ULTRATRAK ULTIMATE
TEST STRIPS STRP
VICTORY AGM-4000
TEST STRIPS STRP
VOCAL POINT BLOOD
GLUCOSE TEST STRIPS
STRP
WAVESENSE PRESTO
TEST STRIPS STRP
Drug Requirements/
Tier Limits
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
PA; Limit 200
3 per
month;QL(6.67
ea daily)
Radiographic Contrast Media

POLIBAR ACB KIT
Drug Name
ZENPEP CPEP
10000UNIT-3000UNIT16000UNIT, 136000UNIT40000UNIT-218000UNIT,
68000UNIT-20000UNIT109000UNIT, 85000UNIT25000UNIT-136000UNIT
ZENPEP CPEP
17000UNIT-5000UNIT27000UNIT (Use
Pancrelipase (LipaseProtease-Amylase))
Drug Requirements/
Tier Limits
GP
DIURETICS - Drugs to Treat Heart, Circulation

Conditions and Blood Pressure
Carbonic Anhydrase Inhibitors
acetazolamide cp12
acetazolamide tabs
DIAMOX CP12 (Use

Acetazolamide)
GP
KEVEYIS TABS
methazolamide tabs
PA
DIGESTIVE AIDS - Drugs to Treat Low Digestive

Enzymes
Digestive Enzymes
CREON CPEP
PANCREAZE CPEP
pancrelipase (lipaseprotease-amylase) cpep
PERTZYE CPEP
SUCRAID SOLN
ULTRESA CPEP
VIOKACE TABS
PA
NEPTAZANE TABS (Use

Methazolamide)
Diuretic Combinations
ALDACTAZIDE TABS
25MG-25MG (Use
Spironolactone &
ALDACTAZIDE TABS
50MG-50MG
amiloride &
DYAZIDE CAPS (Use
Triamterene &
MAXZIDE TABS (Use
Triamterene &
GP
GP
2
1
GP
GP
page ii-iii.
71
Drug Name
MAXZIDE-25 TABS (Use
Triamterene &
spironolactone &
triamterene &
hydrochlorothiazide caps
triamterene &
Loop Diuretics
bumetanide tabs or 0.5 mg,
1 mg, 2 mg
BUMEX TABS (Use
Bumetanide)
DEMADEX TABS (Use
Torsemide)
EDECRIN TABS (Use
Ethacrynic Acid)
ethacrynic acid tabs
Drug Requirements/
Tier Limits
GP
1
1
GP
GP
GP ST
ST
furosemide soln or 10
1
mg/ml
FUROSEMIDE SOLN OR 8 3
MG/ML
furosemide tabs or 20 mg,
1
40 mg, 80 mg
LASIX TABS (Use
GP
Furosemide)
torsemide tabs
Potassium Sparing Diuretics

ALDACTONE TABS (Use
GP
Spironolactone)
amiloride hcl tabs
DYRENIUM CAPS
spironolactone tabs
Drug Requirements/
Tier Limits
chlorthalidone tabs 25 mg,

50 mg
DIURIL SUSP
hydrochlorothiazide caps
12.5 mg
12.5 mg
hydrochlorothiazide tabs 25
mg, 50 mg
Drug Name
1
3
1
indapamide tabs
METHYCLOTHIAZIDE
TABS
metolazone tabs
MICROZIDE CAPS (Use

ZAROXOLYN TABS (Use
Metolazone)
GP
GP
ENDOCRINE AND METABOLIC AGENTS MISC. - Drugs to Treat Bone Disease and
Regulate Hormones
Bone Density Regulators
ACTONEL TABS 150 MG
(Use Risedronate Sodium)
ACTONEL TABS 30 MG, 5
MG (Use Risedronate
Sodium)
ACTONEL TABS 35 MG
(Use Risedronate Sodium)
ALENDRONATE SODIUM
SOLN 70 MG/75ML
alendronate sodium tabs
10 mg, 5 mg
alendronate sodium tabs
35 mg, 70 mg
ALENDRONATE SODIUM
TABS 40 MG
Thiazides and Thiazide-Like Diuretics

CHLOROTHIAZIDE TABS
3
250 MG
ATELVIA TBEC (Use

Risedronate Sodium)
chlorothiazide tabs 500 mg
BINOSTO TBEF
CHLORTHALIDONE TABS
100 MG
GP QL(0.04 ea
daily)
QL(1 ea daily)
GP
GP QL(0.15 ea
daily)
3
1
1
QL(1 ea daily)
QL(0.15 ea
daily)
2
Limit 4 per
GP month;QL(0.15
ea daily)
ST; Limit 4 per
3 month;QL(0.15
ea daily)
page ii-iii.

72
Drug Name
BONIVA TABS (Use
Ibandronate Sodium)
Drug Requirements/
Tier Limits
GP QL(0.04 ea
daily)
calcitonin (salmon) soln
ETIDRONATE DISODIUM
TABS
FOSAMAX PLUS D TABS

FOSAMAX TABS (Use
Alendronate Sodium)
ibandronate sodium tabs

MIACALCIN SOLN NA 200
UNIT/ACT (Use Calcitonin
(Salmon))
risedronate sodium tabs
150 mg
risedronate sodium tabs 30
mg, 5 mg
risedronate sodium tabs 35
mg
risedronate sodium tbec 35

mg
SYNAREL SOLN
PA; QL(0.15 ea
daily)
GP QL(0.15 ea
daily)
1 QL(0.04 ea
daily)
GP
3
3
1
QL(0.04 ea
daily)
QL(1 ea daily)
QL(0.15 ea
daily)
Limit 4 per
month;QL(0.15
ea daily)
Fertility Regulators
clomiphene citrate tabs
Growth Hormones
OMNITROPE SOLR 5.8
MG
SAIZEN CLICK.EASY
SOLR
raloxifene hcl tabs
Drug Requirements/
Tier Limits
1 PV
LHRH/GnRH Agonist Analog Pituitary
Drug Name
QL(15 ea per
fill retail,00 ea
per fill mail,15
ea per 30 days
retail)
SP PA
Metabolic Modifiers
BUPHENYL POWD 3
GM/TSP (Use Sodium
Phenylbutyrate)
GP
BUPHENYL TABS 500 MG
calcitriol caps or 0.25 mcg,

0.5 mcg
calcitriol soln or 1 mcg/ml
CARBAGLU TABS
CARNITOR SF SOLN (Use

Levocarnitine (Metabolic
Modifiers))
CARNITOR SOLN OR 1
GM/10ML (Use
Levocarnitine (Metabolic
Modifiers))
CARNITOR TABS OR 330
MG (Use Levocarnitine
(Metabolic Modifiers))
CYSTADANE POWD
doxercalciferol caps or 0.5

mcg, 1 mcg, 2.5 mcg
HECTOROL CAPS OR 0.5
MCG, 1 MCG, 2.5 MCG
(Use Doxercalciferol)
GP
GP
RX/OTC
GP
3
3
GP
SP PA
KUVAN PACK
SAIZEN SOLR
SP PA
KUVAN TBSO
ZOMACTON SOLR 10 MG
SP PA
ZORBTIVE SOLR
SP PA
levocarnitine (metabolic
modifiers) soln or 1
gm/10ml
modifiers) tabs or 330 mg
Hormone Receptor Modulators

EVISTA TABS (Use
GP PV
Raloxifene HCl)
OSPHENA TABS
3
3
RX/OTC
ORFADIN CAPS
PA
ORFADIN SUSP
PA
page ii-iii.
73
Drug Name
Drug Requirements/
Tier Limits
paricalcitol caps or 1 mcg,

2 mcg, 4 mcg
RAVICTI LIQD
ROCALTROL CAPS (Use

Calcitriol)
ROCALTROL SOLN (Use
Calcitriol)
PA
sodium phenylbutyrate
powd
STRENSIQ SOLN
ANGELIQ TABS
PA
GP
Posterior Pituitary Hormones

DDAVP SOLN NA 0.01 %
GP
(Use Desmopressin
Acetate Refrigerated)
DDAVP SOLN NA 0.01 %
GP
(Use Desmopressin
Acetate Spray)
DDAVP TABS OR 0.1 MG,
GP
0.2 MG (Use
Desmopressin Acetate)
desmopressin acetate
1
refrigerated soln
1
spray refrigerated soln
1
spray soln
desmopressin acetate tabs
1
or 0.1 mg, 0.2 mg
STIMATE SOLN
Prolactin Inhibitors
cabergoline tabs
Drug Requirements/
Tier Limits
2 QL(1 ea daily)
ESTROGENS - Hormone Replacement/Modifying

Drugs
Estrogen Combinations
ACTIVELLA TABS (Use
Estradiol & Norethindrone
Acetate)
GP
3
ZEMPLAR CAPS OR 1
MCG, 2 MCG (Use
Paricalcitol)
SAMSCA TABS
GP
SENSIPAR TABS
Drug Name
GP
3
CLIMARA PRO PTWK
COMBIPATCH PTTW
DUAVEE TABS
esterified estrogens &

methyltestosterone tabs
estradiol & norethindrone
acetate tabs
FEMHRT LOW DOSE
Acetate-Ethinyl Estradiol)
norethindrone acetateethinyl estradiol tabs
GP
1
3
PREMPHASE TABS
2
2
SP PA
SANDOSTATIN SOLN
(Use Octreotide Acetate)
SP PA
QL(1 ea daily)
Estrogens
ALORA PTTW 0.025
MG/24HR
ALORA PTTW 0.05

MG/24HR
Somatostatic Agents
octreotide acetate soln
QL(1 ea daily)
PREFEST TABS
PREMPRO TABS 0.3MG1.5MG

PREMPRO TABS 0.45MG1.5MG, 0.625MG-2.5MG,
0.625MG-5MG
Limit 4 patches
per
month;QL(0.14
3 ea daily)
Limit 8 patches
per
month;QL(0.29
ea daily)
Limit 8 patches
per
month;QL(0.27
ea daily)
Vasopressin Receptor Antagonists

page ii-iii.

74
Drug Name
ALORA PTTW 0.075
MG/24HR
ALORA PTTW 0.1
MG/24HR
CLIMARA PTWK (Use
Estradiol)
Drug Requirements/
Tier Limits
Limit 8 patches
3 per
month;QL(0.27
ea daily)
Limit 8 per 28
3 days;QL(0.29
ea daily)
QL(4 ea per fill
GP retail,4 ea per
30 days retail)
Drug Name
ESTROGEL GEL
ESTROPIPATE TABS 0.75
MG, 1.5 MG
estropipate tabs 0.75 mg,
1.5 mg, 3 mg
Drug Requirements/
Tier Limits
Limit 50gms
3 per
month;QL(1.67
gm daily)
2
1
EVAMIST SOLN
DIVIGEL GEL
MENEST TABS
ELESTRIN GEL
MENOSTAR PTWK
ENJUVIA TABS 0.3 MG,

0.45 MG, 0.625 MG, 1.25
MG
MINIVELLE PTTW 0.025

MG/24HR
ENJUVIA TABS 0.9 MG

MG/24HR
ESTRACE TABS OR 0.5

MG, 1 MG, 2 MG (Use
Estradiol)
estradiol pttw td 0.025

mg/24hr
mg/24hr
mg/24hr
mg/24hr, 0.1 mg/24hr
estradiol ptwk td 0.025
mg/24hr, 0.05 mg/24hr,
0.06 mg/24hr, 0.075
mg/24hr, 0.1 mg/24hr, 37.5
mcg/24hr
estradiol tabs or 0.5 mg, 1
mg, 2 mg
QL(1 ea daily)
GP
Limit 8 patches
per
month;QL(0.29
ea daily)
1
1
1
1
Limit 8 patches
per
month;QL(0.27
ea daily)
Limit 8 per
month;QL(0.29
ea daily)
Limit 8 per 28
days;QL(0.29
ea daily)
QL(4 ea per fill
retail,4 ea per
30 days retail)
MINIVELLE PTTW 0.05

MG/24HR

MG/24HR, 0.1 MG/24HR
PREMARIN TABS OR 0.3

MG, 0.45 MG, 0.625 MG,
0.9 MG, 1.25 MG
VIVELLE-DOT PTTW
0.025 MG/24HR (Use
Estradiol)
VIVELLE-DOT PTTW
0.0375 MG/24HR (Use
Estradiol)
VIVELLE-DOT PTTW 0.05
MG/24HR, 0.075
MG/24HR, 0.1 MG/24HR
(Use Estradiol)
QL(4 ea per 30
days retail)
Limit 8 patches
per
month;QL(0.29
ea daily)
Limit 8 patches
per
month;QL(0.27
ea daily)
Limit 8 per 28
days;QL(0.29
ea daily)
Limit 8 patches
GP per
month;QL(0.29
ea daily)
GP
Limit 8 patches
GP per
month;QL(0.27
ea daily)
FLUOROQUINOLONES - Drugs to Treat Bacterial

Infections
1
Fluoroquinolones
AVELOX ABC PACK TABS
(Use Moxifloxacin HCl)
GP
page ii-iii.
75
Drug Name
Drug Requirements/
Tier Limits
AVELOX TABS OR 400

MG (Use Moxifloxacin HCl)
CIPRO SUSR (Use
Ciprofloxacin)
CIPRO TABS (Use
Ciprofloxacin HCl)
CIPRO XR TB24 1000MG
(Use CiprofloxacinCiprofloxacin HCl)
CIPRO XR TB24 500MG
(Use CiprofloxacinCiprofloxacin HCl)
CIPROFLOXACIN HCL
TABS 100 MG
ciprofloxacin hcl tabs 250
mg, 500 mg, 750 mg
ciprofloxacin susr
ciprofloxacin-ciprofloxacin
hcl tb24 1000mg
ciprofloxacin-ciprofloxacin
hcl tb24 500mg
FACTIVE TABS
LEVAQUIN SOLN 25
MG/ML (Use Levofloxacin)
LEVAQUIN TABS 250 MG,
500 MG, 750 MG (Use
Levofloxacin)
levofloxacin soln or 25
mg/ml
levofloxacin tabs or 250
mg, 500 mg, 750 mg
moxifloxacin hcl tabs

OFLOXACIN TABS 300
MG
ofloxacin tabs 400 mg
GP
ACTIGALL CAPS (Use

Ursodiol)
GP
CHENODAL TABS
GP
QL(14 ea per
GP fill retail)
QL(3 ea per fill
GP retail)
2
1
1
1
1
3
QL(14 ea per
fill retail)
QL(3 ea per fill
retail)
QL(1 ea per 90
days retail)
GP
QL(14 ea per
GP fill retail)
1
1
QL(14 ea per
fill retail)
URSO 250 TABS (Use

Ursodiol)
URSO FORTE TABS (Use
Ursodiol)
Drug Requirements/
Tier Limits
GP
3
GP
GP
ursodiol caps
ursodiol tabs
Gastrointestinal Antiallergy Agents

cromolyn sodium
1
(mastocytosis) conc
GASTROCROM CONC
GP
(Use Cromolyn Sodium
(Mastocytosis))
Gastrointestinal Chloride Channel Activators
AMITIZA CAPS
Gastrointestinal Stimulants
metoclopramide hcl soln or
3
10 mg/10ml, 5 mg/5ml
metoclopramide hcl tabs or
1
10 mg, 5 mg
METOCLOPRAMIDE ODT
3
TBDP
METOZOLV ODT TBDP
GP
(Use Metoclopramide HCl)
REGLAN TABS (Use
GP
Metoclopramide HCl)
Inflammatory Bowel Agents
APRISO CP24
ASACOL HD TBEC
ST
2
3
QL(28 ea per
90 days retail)
GASTROINTESTINAL AGENTS - MISC. Miscellaneous Gastrointestinal Drugs

Farnesoid X Receptor (FXR) Agonists
3 PA
OCALIVA TABS
Gallstone Solubilizing Agents
Drug Name
AZULFIDINE EN-TABS
TBEC (Use Sulfasalazine)
AZULFIDINE TABS (Use
Sulfasalazine)
GP
GP
balsalazide disodium caps
CANASA SUPP
QL(280 ea per
fill retail)
page ii-iii.

76
Drug Name
COLAZAL CAPS (Use
Balsalazide Disodium)
DELZICOL CPDR
DIPENTUM CAPS
Drug Requirements/
Tier Limits
GP QL(280 ea per
fill retail)
2 QL(12 ea daily)
3
PA; Use
generic
BALSALAZIDE;
QL(6 ea daily)
Drug Name
calcium acetate (phosphate

binder) caps
binder) tabs
ELIPHOS TABS (Use
Calcium Acetate
(Phosphate Binder))
Drug Requirements/
Tier Limits
1
1
RX/OTC
RX/OTC
GP
GIAZO TABS
LIALDA TBEC
MESALAMINE DR TBEC
PHOSLO CAPS (Use

Calcium Acetate
(Phosphate Binder))
mesalamine enem
PHOSLYRA SOLN
PENTASA CPCR
RENAGEL TABS
SFROWASA ENEM
RENVELA PACK
sulfasalazine tabs
RENVELA TABS
sulfasalazine tbec
GENITOURINARY AGENTS - MISCELLANEOUS

- Miscellaneous Drugs to Treat Reproductive
Organs and Urinary System
Acidifiers
Intestinal Acidifiers
lactulose (encephalopathy)
soln
FOSRENOL CHEW
FOSRENOL PACK
Irritable Bowel Syndrome (IBS) Agents
K-PHOS NO 2 TABS
alosetron hcl tabs
Alkalinizers
LINZESS CAPS
ORACIT SOLN
LOTRONEX TABS (Use

Alosetron HCl)
VIBERZI TABS
GP
3
PA
Peripheral Opioid Receptor Antagonists

ENTEREG CAPS
MOVANTIK TABS
RELISTOR TABS OR 150

MG
PA
PA
Phosphate Binder Agents

AURYXIA TABS
pot & sod citrates w/citric

ac soln
potassium citrate
(alkalinizer) tbcr
potassium citrate-citric acid
pack
potassium citrate-citric acid
soln
SHOHLS SOLUTION
MODIFIED SOLN (Use
Sodium Citrate & Citric
Acid)
sodium citrate & citric acid
soln
GP
3
3
1
1
1
GP
1
page ii-iii.
77
Drug Name
UROCIT-K 10 TBCR (Use
Potassium Citrate
(Alkalinizer))
Potassium Citrate
(Alkalinizer))
Potassium Citrate
(Alkalinizer))
Drug Requirements/
Tier Limits
PYRIDIUM TABS (Use

Phenazopyridine HCl)
GP
GP
GP
CYSTAGON CAPS
PROCYSBI CPDR
ELMIRON CAPS
QL(3 ea daily)
Prostatic Hypertrophy Agents
CARDURA XL TB24
GP AL
3
1
dutasteride-tamsulosin hcl
caps
FLOMAX CAPS (Use

Tamsulosin HCl)
JALYN CAPS (Use
Dutasteride-Tamsulosin
HCl)
PROSCAR TABS (Use
Finasteride)
THIOLA TABS
Gout Agent Combinations

colchicine w/ probenecid
tabs
Gout Agents
allopurinol tabs
COLCHICINE CAPS
colchicine tabs
COLCRYS TABS
MITIGARE CAPS
ULORIC TABS
ZURAMPIC TABS
GP QL(1 ea daily);
AL
tamsulosin hcl caps
1
GP
ZYLOPRIM TABS (Use

Allopurinol)
GP
Uricosurics
probenecid tabs
QL(2 ea daily)
Antihemophilic Products
CORIFACT KIT
SP PA
Bradykinin B2 Receptor Antagonists

SP PA
FIRAZYR SOLN
Hematorheologic Agents
pentoxifylline tbcr
Urinary Analgesics
1
PA
HEMATOLOGICAL AGENTS - MISC. - Drugs to

Treat Blood Disorders
GP
phenazopyridine hcl tabs
AL
1 QL(1 ea daily);
AL
GP QL(2 ea daily)
RAPAFLO CAPS
UROXATRAL TB24 (Use

Alfuzosin HCl)
LITHOSTAT TABS
dutasteride caps
finasteride tabs
GP
GOUT AGENTS - Drugs to Treat Gout
Interstitial Cystitis Agents
AVODART CAPS (Use

Dutasteride)
Drug Requirements/
Tier Limits
Urinary Stone Agents
Cystinosis Agents
alfuzosin hcl tb24
Drug Name
Platelet Aggregation Inhibitors
page ii-iii.

78
Drug Name
AGGRENOX CP12
AGRYLIN CAPS (Use
Anagrelide HCl)
Drug Requirements/
Tier Limits
Drug Name
PROCRIT SOLN 40000
UNIT/ML
3
GP
PROMACTA TABS
anagrelide hcl caps
ASPIRIN/DIPYRIDAMOLE
CP12
BRILINTA TABS
cilostazol tabs
QL(2 ea daily)
clopidogrel bisulfate tabs
QL(2 ea daily)
dipyridamole tabs
EFFIENT TABS
Hemostatics - Systemic
AMICAR SOLN 0.25
GM/ML
GP
AMICAR TABS 1000 MG
GP QL(2 ea daily)
aminocaproic acid syrp or

25 %
AMINOCAPROIC ACID
TABS OR 1000 MG
LYSTEDA TABS (Use
Tranexamic Acid)
PERSANTINE TABS (Use

Dipyridamole)
PLAVIX TABS (Use
Clopidogrel Bisulfate)
PLETAL TABS (Use
Cilostazol)
ZONTIVITY TABS
Agents for Gaucher Disease

3
PA
PA
Agents for Sickle Cell Anemia

DROXIA CAPS 200 MG,
3
300 MG
AC
DROXIA CAPS 400 MG
folic acid tabs or 400 mcg,

1
800 mcg
Hematopoietic Growth Factors
INTEGRA F CAPS
HEMOSTATICS - Drugs to Stop Bleeding/Treat

Blood Disorders
RX/OTC
PV
3
3
3
3
GP QL(6 ea daily,5
day(s) limit)
1 QL(6 ea daily,5
day(s) limit)
HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
Barbiturate Hypnotics
BUTISOL SODIUM TABS
Folic Acid/Folates
folic acid tabs or 1 mg
FOLIVANE-F CAPS
tranexamic acid tabs
HEMATOPOIETIC AGENTS - Drugs to Treat

Blood Disorders
ZAVESCA CAPS
PA; New
commercial
members to be
referred to
AcariaHealth
Hematopoietic Mixtures
GP QL(2 ea daily)
ticlopidine hcl tabs
CERDELGA CAPS
Drug Requirements/
Tier Limits
SP PA
phenobarbital elix 20
mg/5ml
phenobarbital soln 20
mg/5ml
PHENOBARBITAL TABS
100 MG, 15 MG, 30 MG,
60 MG
phenobarbital tabs 16.2
mg, 32.4 mg, 64.8 mg, 97.2
mg
Hypnotics - Tricyclic Agents
SILENOR TABS
3
1
1
2
1
ST; QL(1 ea
daily)
page ii-iii.
79
Drug Name
Non-Barbiturate Hypnotics
AMBIEN CR TBCR (Use
Zolpidem Tartrate)
AMBIEN TABS (Use
Zolpidem Tartrate)
DORAL TABS
Drug Requirements/
Tier Limits
Drug Name
Orexin Receptor Antagonists

GP QL(1 ea daily)
BELSOMRA TABS
GP QL(1 ea daily)
Selective Melatonin Receptor Agonists

3 PA
HETLIOZ CAPS
estazolam tabs
eszopiclone tabs
PA; QL(1 ea
daily)
ROZEREM TABS
temazepam caps 22.5 mg
MOVIPREP SOLR
triazolam tabs
QUAZEPAM TABS
RESTORIL CAPS (Use
Temazepam)
SONATA CAPS (Use
Zaleplon)
temazepam caps 15 mg,
30 mg, 7.5 mg
zaleplon caps
zolpidem tartrate subl sl
1.75 mg, 3.5 mg
zolpidem tartrate tabs or 10
mg, 5 mg
zolpidem tartrate tbcr or
12.5 mg, 6.25 mg
ZOLPIMIST SOLN
QL(1 ea daily)
1
GP
GP PA
GP QL(1 ea daily)
3
3
GP
GP QL(1 ea daily)
QL(1 ea daily)
PA
QL(1 ea daily)
QL(1 ea daily)
Limit 1 bottle
per
month;QL(0.26
ml daily)
PA
ST; QL(1 ea
daily)
LAXATIVES - Bowel Treatment Drugs

Laxative Combinations
bisacodyl-peg 3350-pot
chloride-sod bicarb-sod
chloride kit
COLYTE-FLAVOR PACKS
SOLR 227.1GM-21.5GM5.53GM-2.82GM-6.36GM
COLYTE-FLAVOR PACKS
SOLR 240GM-22.72GM5.84GM-2.98GM-6.72GM
(Use PEG 3350-KCl-Sod
Bicarb-Sod Chloride-Sod
Sulfate)
GOLYTELY SOLR
227.1GM-21.5GM-5.53GM2.82GM-6.36GM
GOLYTELY SOLR 236GM22.74GM-5.86GM-2.97GM6.74GM (Use PEG 3350KCl-Sod Bicarb-Sod
Chloride-Sod Sulfate)
HALCION TABS (Use

Triazolam)
INTERMEZZO SUBL (Use
Zolpidem Tartrate)
LUNESTA TABS (Use
Eszopiclone)
midazolam hcl syrp or 2
mg/ml
EDLUAR SUBL
flurazepam hcl caps
Drug Requirements/
Tier Limits
NULYTELY/FLAVOR
PACKS SOLR (Use PEG
3350-Potassium ChlorideSod Bicarbonate-Sod
Chloride)
peg 3350-kcl-sod bicarbsod chloride-sod sulfate
solr
peg 3350-potassium
chloride-sod bicarbonatesod chloride solr
PREPOPIK PACK
QL(1 ea per fill

retail); PV
PV
2
QL(4000 ml per
fill retail); PV
GP
QL(4000 ea per
fill retail); PV
QL(4000 ml per
fill retail); PV
GP
Limit 1 per
month;QL(0.03
4 ea daily); PV
PV
GP
QL(4000 ml per
fill retail); PV
PV
1
2
PV
page ii-iii.

80
Drug Name
SUCLEAR KIT
SUPREP BOWEL PREP
SOLN
Drug Requirements/
Tier Limits
2 PV
2
PV
Drug Name
DULCOLAX TBEC (Use

Bisacodyl)
Laxatives - Miscellaneous
KRISTALOSE PACK
lactulose soln
MIRALAX POWD (Use

Polyethylene Glycol 3350)
polyethylene glycol 3350

powd
MACROLIDES - Drugs to Treat Bacterial

Infections
Limit 528gms
per
GP month;QL(17.6
gm daily);
RX/OTC
Limit 528gms
per
1 month;QL(17.6
gm daily);
RX/OTC
Saline Laxatives
OSMOPREP TABS
sodium phosphates soln
Available for
members in
nongrandfathered
plans ages 5074;AL; PV
Stimulant Laxatives
bisacodyl supp
bisacodyl tbec
DULCOLAX SUPP (Use

Bisacodyl)
Drug Requirements/
Tier Limits
Available for
members in
GP nongrandfathered
Available for
members in
1 nongrandfathered
Available for
members in
1 nongrandfathered
Available for
members in
GP nongrandfathered
Azithromycin
AZITHROMYCIN PACK
OR 1 GM
azithromycin susr or 100
mg/5ml, 200 mg/5ml
azithromycin tabs or 250
mg
mg
mg
ZITHROMAX PACK OR 1
GM
ZITHROMAX SUSR OR
100 MG/5ML, 200 MG/5ML
(Use Azithromycin)
ZITHROMAX TABS OR
250 MG (Use Azithromycin)
ZITHROMAX TABS OR
ZITHROMAX TABS OR
ZITHROMAX TRI-PAK
TABS (Use Azithromycin)
ZITHROMAX Z-PAK TABS
(Use Azithromycin)
ZMAX SUSR
Clarithromycin
BIAXIN SUSR (Use
Clarithromycin)
BIAXIN TABS (Use
Clarithromycin)
clarithromycin susr 125
mg/5ml, 250 mg/5ml
clarithromycin tabs 250 mg,
500 mg
2
1
1
1
1
QL(6 ea per fill

retail)
QL(3 ea daily)
QL(10 ea per
fill retail)
2
GP
GP QL(6 ea per fill
retail)
GP QL(3 ea daily)
GP QL(10 ea per
fill retail)
GP QL(3 ea daily)
GP QL(6 ea per fill
retail)
2 QL(2 ea daily)
GP
GP
1
1
page ii-iii.
81
Drug Requirements/
Tier Limits
1 QL(14 ea per
clarithromycin tb24 500 mg
fill retail)
Drug Name
Erythromycins
E.E.S. GRANULES SUSR
(Use Erythromycin
Ethylsuccinate)
ERY-TAB TBEC
ERYPED 200 SUSR (Use
Erythromycin
Ethylsuccinate)
GP
2
GP
ERYPED 400 SUSR
erythromycin base cpep
erythromycin base tabs
erythromycin
ethylsuccinate susr
erythromycin
ethylsuccinate tabs
1
1
erythromycin stearate tabs
PCE TBEC
Fidaxomicin
DIFICID TABS
MEDICAL DEVICES AND SUPPLIES

Blood Pressure Devices
ADVOCATE ARM BLOOD
PRESSURE
MONITOR/LARGE DEVI
Contraceptives
OMNIFLEX DIAPHRAGM
DPRH
ORTHO DIAPHRAGM
COIL SPRING KIT 100 KIT
ORTHO DIAPHRAGM
ORTHO DIAPHRAGM
ORTHO DIAPHRAGM
FLAT SPRING KIT 55 KIT
2
2
PA; QL(6.67 ea
daily)
Drug Name
ORTHO DIAPHRAGM
ORTHO DIAPHRAGM
ORTHO DIAPHRAGM
ORTHO DIAPHRAGM
ORTHO DIAPHRAGM
ORTHO DIAPHRAGM
ORTHO DIAPHRAGM
ORTHO DIAPHRAGM
WIDE-SEAL SILICONE
DIAPHRAGM KIT 60
DPRH
WIDE-SEAL SILICONE
DIAPHRAGM KIT 65
DPRH
WIDE-SEAL SILICONE
DIAPHRAGM KIT 70
DPRH
WIDE-SEAL SILICONE
DIAPHRAGM KIT 75
DPRH
WIDE-SEAL SILICONE
DIAPHRAGM KIT 80
DPRH
WIDE-SEAL SILICONE
DIAPHRAGM KIT 85
DPRH
WIDE-SEAL SILICONE
DIAPHRAGM KIT 90
DPRH
WIDE-SEAL SILICONE
DIAPHRAGM KIT 95
DPRH
Drug Requirements/
Tier Limits
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
Diabetic Supplies
BLUESTAR DEVI
PA
FREESTYLE FREEDOM
LITE KIT
QL(1 ea per
365 days
retail); RX/OTC
page ii-iii.

82
Drug Name
FREESTYLE INSULINX
BLOODGLUCOSE
MONITORING SYSTEM
KIT
FREESTYLE LITE BLOOD
GLUCOSE MONITORING
SYSTEM DEVI
Drug Requirements/
Tier Limits
QL(1 ea per
2 365 days
retail); RX/OTC
ONETOUCH ULTRA 2 KIT

ONETOUCH ULTRA MINI
KIT
ONETOUCH VERIO FLEX
BLOODGLUCOSE
MONITORING SYSTEM
KIT
ONETOUCH VERIO IQ
BLOOD GLUCOSE
MONITORING SYSTEM
KIT
ONETOUCH VERIO KIT
2
2
2
ONETOUCH VERIO SYNC

BLOODGLUCOSE
MONITORING SYSTEM
KIT
PRECISION XTRA DEVI
Parenteral Therapy Supplies

BD ECLIPSE NEEDLE
30G X1/2" MISC
BD INSULIN SYRINGE
ULTRAFINE/U100/1ML/31G X 15/64"
MISC
BD NEEDLE/30G X 1/2"
MISC
CLEVER CHOICE
COMFORT EZINSULIN
PEN NEEDLES 33GX4MM
MISC
CLEVER CHOICE
COMFORT EZPEN
NEEDLES 33GX4MM
MISC
QL(1 ea per
365 days retail)
QL(1 ea per
365 days
retail); RX/OTC
QL(1 ea per
365 days
retail); RX/OTC
QL(1 ea per
365 days
retail); RX/OTC
QL(1 ea per
365 days
retail); RX/OTC
QL(1 ea per
365 days
retail); RX/OTC
QL(1 ea per
365 days
retail); RX/OTC
QL(1 ea per
365 days retail)
Drug Name
CLEVER CHOICE
COMFORT EZPEN
NEEDLES 33GX5MM
MISC
CLEVER CHOICE
COMFORT EZPEN
NEEDLES 33GX6MM
MISC
CLEVER CHOICE
COMFORT EZPEN
NEEDLES 33GX8MM
MISC
EASY TOUCH FLIPLOCK
NEEDLES 30GX1/2" MISC
EASY TOUCH
HYPODERMIC NEEDLES
30GX1/2" MISC
HYPODERMIC NEEDLE
30GX1/2" MISC
INSULIN SYRINGES AND
PEN NEEDLES
Limit 200 per

month;QL(6.67
ea daily)
2
2
Limit 200 per

month;QL(6.67
ea daily)
Limit 200 per
month;QL(6.67
ea daily)
Limit 200 per

month;QL(6.67
ea daily)
Limit 200 per
month;QL(6.67
ea daily)
2
2
2
2
INSUPEN 33GX4MM MISC
POLY HUB NEEDLE/30G

X 1/2" MISC
MO
Limit 200 per
month;QL(6.67
ea daily)
MIGRAINE PRODUCTS - Drugs to Treat Migraine

Headaches
Migraine Combinations
CAFERGOT TABS
Drug Requirements/
Tier Limits
Limit 200 per
2 month;QL(6.67
ea daily)
isometheptene-caffeineacetaminophen tabs
isometheptenedichloralphenazoneacetaminophen caps
2
1
1
MIGERGOT SUPP
MIGRALAM CAPS
PRODRIN TABS (Use

Isometheptene-CaffeineAcetaminophen)
TREXIMET TABS 85MG500MG
GP
3
PA; QL(0.3 ea
daily)
Migraine Products - NSAIDs
page ii-iii.
83
Drug Name
CAMBIA PACK
Drug Requirements/
Tier Limits
Limit 9 per
3 month;QL(0.3
ea daily)
Migraine Products
Limit 8 inhalers
per
month;QL(0.27
ml daily)
Drug Name
MAXALT-MLT TBDP (Use
Rizatriptan Benzoate)
naratriptan hcl tabs
DIHYDROERGOTAMINE
MESYLATE SOLN NA 4
MG/ML
ERGOMAR SUBL
RELPAX TABS
MIGRAL TABS
rizatriptan benzoate tabs

10 mg, 5 mg
MIGRANAL SOLN
Limit 8 inhalers
per
month;QL(0.27
ml daily)
Serotonin Agonists
almotriptan malate tabs
1
GP
AXERT TABS (Use

Almotriptan Malate)
GP
FROVA TABS (Use

Frovatriptan Succinate)
GP
IMITREX SOLN NA 20
MG/ACT (Use
Sumatriptan)
IMITREX SOLN NA 5
MG/ACT (Use
Sumatriptan)
IMITREX TABS OR 100
Sumatriptan Succinate)
MAXALT TABS (Use
Rizatriptan Benzoate)
rizatriptan benzoate tbdp

10 mg, 5 mg
sumatriptan soln 20 mg/act
AMERGE TABS (Use

Naratriptan HCl)
frovatriptan succinate tabs
ONZETRA XSAIL EXHP
GP
GP
GP
QL(0.2 ea
daily)
QL(9 ea per fill
retail,9 ea per
30 days retail)
QL(0.2 ea
daily)
QL(9 ea per fill
retail,9 ea per
30 days
retail,27 ea per
60 days mail)
QL(9 ea per fill
retail,9 ea per
30 days
retail,27 ea per
60 days mail)
Limit 6
sprayers per
month;QL(0.2
ea daily)
QL(6 ea per fill
retail,6 ea per
30 days retail)
QL(0.3 ea
daily)
GP QL(0.6 ea
daily)
sumatriptan soln 5 mg/act

sumatriptan succinate tabs
or 100 mg, 25 mg, 50 mg
ZECUITY PTCH
zolmitriptan tabs 2.5 mg, 5

mg
zolmitriptan tbdp 2.5 mg, 5
mg
ZOMIG NASAL SPRAY
SOLN
ZOMIG SOLN NA 2.5 MG

ZOMIG TABS OR 2.5 MG,
5 MG (Use Zolmitriptan)
ZOMIG ZMT TBDP (Use
Zolmitriptan)
Drug Requirements/
Tier Limits
Limit 12 per
GP month;QL(0.4
ea daily)
QL(9 ea per fill
1 retail,9 ea per
30 days retail)
3 PA
QL(0.2 ea
daily)
1 QL(0.6 ea
daily)
Limit 12 per
1 month;QL(0.4
ea daily)
Limit 6
1 sprayers per
month;QL(0.2
ea daily)
QL(6 ea per fill
1 retail,6 ea per
30 days retail)
1 QL(0.3 ea
daily)
PA; Limit 4
3 patches per
month;QL(0.13
4 ea daily)
3 QL(0.2 ea
daily)
Limit 6 per
3 month;QL(0.2
ea daily)
QL(6 ea per 30
3 days retail,18
ea per 90 days
mail)
QL(6 ea per 30
3 days retail,18
ea per 90 days
mail)
GP QL(0.2 ea
daily)
Limit 6 per
GP month;QL(0.2
ea daily)
3
MINERALS & ELECTROLYTES

page ii-iii.

84
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
CALCIFOL WAFR
K-TAB TBCR 10 MEQ, 8

MEQ (Use Potassium
Chloride)
CALCIUM-FOLIC ACID
PLUS D WAFR
K-TAB TBCR 20 MEQ
KLOR-CON 25 PACK
KLOR-CON M15 TBCR
2
2
Calcium
Fluoride
GP
FLORIVA LIQD
FLUORABON SOLN
AL; PV
KLOR-CON/25 PACK
FLURA-DROPS SOLN
AL; PV
LOZI-FLUR LOZG
MICRO-K CPCR (Use

GP
Potassium Chloride)
potassium bicarb & chloride 1
tbef
LURIDE CHEW (Use

Sodium Fluoride)
LURIDE SOLN (Use
Sodium Fluoride)
GP AL; PV
GP AL; PV
sodium fluoride chew
AL; PV
sodium fluoride soln
AL; PV
sodium fluoride tabs
AL; PV
Iodine Products
IODINE STRONG SOLN
SSKI SOLN
Magnesium
MAGNEBIND 400 TABS
Phosphate
K-PHOS NEUTRAL TABS
(Use Pot Phosphate
Monobasic w/ Sod
Phosphate Dibasic &
Monobasic)
K-PHOS TABS
pot phosphate monobasic

w/ sod phosphate dibasic &
monobasic tabs
Potassium
EFFER-K TBEF
GP
2
1
potassium bicarbonate tbef

potassium chloride cpcr or
10 meq, 8 meq
POTASSIUM CHLORIDE
ER TBCR
potassium chloride
microencapsulated crystals
cr tbcr
potassium chloride pack or
20 meq
potassium chloride soln or
10 %, 20 %
potassium chloride tbcr or
10 meq, 8 meq
Zinc
1
1
3
1
1
1
1
GALZIN CAPS
zinc sulfate caps or 220 mg
MOUTH/THROAT/DENTAL AGENTS
Anesthetics Topical Oral
FIRST-MOUTHWASH BLM
SUSP
lidocaine hcl (mouth-throat)
soln
LIDOCAINE HCL SOLN
MT 4 %
3
1
3
Anti-infectives - Throat
page ii-iii.
85
Drug Name
Drug Requirements/
Tier Limits
Drug Name
clotrimazole lozg
SALAGEN TABS (Use

Pilocarpine HCl (Oral))
clotrimazole troc
MULTIVITAMINS
Ped MV w/ Fluoride
FIRST-BXN MOUTHWASH
SUSP
FIRST-DUKES
MOUTHWASH SUSP
FIRST-MARYS
MOUTHWASH SUSP
nystatin (mouth-throat)
susp
ORAVIG TABS
Dental Products
GEL-KAM ORAL CARE
RINSE CONC (Use
Stannous Fluoride)
NAFRINSE
DAILY/NEUTRAL SOLR
NAFRINSE WEEKLY
SOLR
PREVIDENT SOLN (Use
Sodium Fluoride (Dental))
sodium fluoride (dental)
soln
stannous fluoride conc mt
0.63 %
Steroids - Mouth/Throat
(mouth) pste
3
1
3
RX/OTC
GP
3
3
GP RX/OTC
3
RX/OTC
RX/OTC
Throat Products - Misc.
cevimeline hcl caps

EVOXAC CAPS (Use
Cevimeline HCl)
FLORIVA PLUS SOLN
3
GP
GELCLAIR GEL
MUCOTROL WAFR
ORAFATE PSTE
pilocarpine hcl (oral) tabs
PROTHELIAL PSTE
Drug Requirements/
Tier Limits
pediatric multivitamins w/fl

chew
pediatric multivitamins w/fl
soln
pediatric vitamins acd w/
fluoride soln
POLY-VI-FLOR CHEW
200MCG-0.25MG-15UNIT400UNIT, 200MCG-0.5MG15UNIT-400UNIT
POLY-VI-FLOR CHEW
200MCG-1MG-15UNIT400UNIT
POLY-VI-FLOR SUSP
200MCG/ML-0.25MG/ML
QUFLORA PEDIATRIC
CHEW
QUFLORA PEDIATRIC
SOLN
GP
AL
AL
AL
AL
AL
Use generic
polyvitamin
with floride;AL
3
2
AL
AL
TRI-VI-FLOR SUSP
TRI-VI-FLORO SUSP
Ped Multi Vitamins w/Fl & FE

ESCAVITE D CHEW
MYKIDZ IRON FL SUSP
ped multivitamins w/fl &

1
iron soln
pediatric vitamins acd
1 AL
fluoride & iron soln
POLY-VI-FLOR/IRON
AL
3
CHEW 200MCG-0.5MG10MG-15UNIT-400UNIT
POLY-VI-FLOR/IRON
3
SUSP 200MCG/ML7MG/ML-0.25MG/ML
Pediatric Multiple Vitamins & Minerals w/ Fluoride
page ii-iii.

86
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
FLORIVA CHEW
ENBRACE HR CAPS
TEXAVITE LQ LIQD
EXTRA-VIRT PLUS DHA

CAPS
FOCALGIN 90 DHA MISC
FOCALGIN CA MISC
FOCALGIN-B TABS
FOLCAL DHA CAPS
FOLCAPS OMEGA 3
CAPS
FOLET DHA THPK
FOLET ONE CAPS
FOLIVANE-OB CAPS
GESTICARE DHA MISC
CITRANATAL DHA MISC
CITRANATAL HARMONY
CAPS
HEMENATAL OB + DHA
MISC
HEMENATAL OB TABS
CITRANATAL RX TABS
INFANATE BALANCE
CAPS
COMPLETENATE CHEW
INFANATE PLUS CAPS
CONCEPT DHA CAPS
CONCEPT OB CAPS
MACNATAL CN DHA
CAPS
CVS WOMENS
PRENATAL+DHA MISC
MARNATAL-F CAPS
DOTHELLE DHA CAPS
DUET DHA 400 MISC
DUET DHA 400EC MISC
DUET DHA 430 MISC
Prenatal Vitamins
ACTIVE OB CAPS
ATABEX EC TBEC
BAL-CARE DHA MISC
C-NATE DHA CAPS
CALCIUM PNV CAPS
CITRANATAL 90 DHA
MISC
CITRANATAL ASSURE
MISC
CITRANATAL B-CALM
MISC
DUET DHA 430EC MISC

DUET DHA BALANCED
MISC
2
2
MYNATAL ADVANCE
TABS
MYNATAL ULTRACAPLET
TABS
2
2
MYNATE 90 PLUS TBCR
NATACHEW CHEW
NATALVIRT 90 DHA MISC
NATALVIRT CA MISC
NATELLE ONE CAPS
3
3
page ii-iii.
87
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
NEEVO DHA CAPS
PR NATAL 400 EC MISC
NESTABS ABC MISC
PR NATAL 430 EC MISC
NESTABS DHA MISC
PR NATAL 430 MISC
NESTABS TABS
PREFERA OB + DHA
MISC
NEWGEN TABS
PREFERA OB TABS
NEXA PLUS CAPS
PREFERAOB +DHA MISC
PREFOL-DHA CAPS
PRENA 1 TRUE MISC
PRENA1 CHEW CHEW
PRENA1 PEARL CPCR
OB COMPLETE GOLD
CAPS
OB COMPLETE ONE
CAPS
OB COMPLETE PETITE
CAPS
OB COMPLETE PREMIER
TABS
OB COMPLETE/DHA
CAPS
OBSTETRIX DHA MISC
OBSTETRIX ONE CAPS
OBTREX DHA MISC
PAIRE OB MISC
PNV FERROUS
FUMARATE/DOCUSATE/F
OLIC ACID TABS
PNV OB+DHA MISC
PNV TABS 29-1 TABS
PNV-DHA CAPS
PNV-DHA+DOCUSATE
CAPS
PNV-OMEGA CAPS
PNV-SELECT TABS
PNV-TOTAL CAPS
PNV-VP-U CAPS
RX/OTC
PRENAISSANCE 90 DHA
MISC
PRENAISSANCE
BALANCE CAPS
PRENAISSANCE CAPS
RX/OTC
PRENAISSANCE DHA
MISC
PRENAISSANCE
HARMONY DHA MISC
PRENAISSANCE NEXT
TABS
PRENAISSANCE NEXT-B
TABS
PRENAISSANCE PLUS
CAPS
PRENAISSANCE
PROMISE MISC
2
3
3
2
3
3
3
3
2
PRENATA CHEW
PRENATABS RX TABS
page ii-iii.

88
Drug Name
PRENATAL 19 CHEW
1000UNIT-400UNIT20MG-25MG-3MG-200MG29MG-7MG-6MG-3MG12MCG-1MG-30UNIT20MG-100MG, 30UNIT1000UNIT-20MG-3MG200MG-29MG-7MG-15MG3MG-12MCG-400UNIT1MG-20MG-100MG
PRENATAL 19 TABS
1000UNIT-30UNIT-20MG25MG-3MG-200MG-29MG15MG-3MG-7MG-12MCG400UNIT-20MG-1MG100MG, 30UNIT1000UNIT-20MG-25MG3MG-200MG-29MG-7MG15MG-3MG-12MCG400UNIT-1MG-20MG100MG
PRENATAL PLUS IRON
TABS
prenatal vit w/ docusateiron carbonyl-folic acid tabs
prenatal without a vit w/ fe
fumarate-folic acid tabs
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
PRENATE ELITE TABS

20MG-600MCG-40UNIT150MCG-2600UNIT1.5MG-15MG-25MG155MG-3MG-21MG3.5MG-13MCG-600UNIT400MCG-330MCG-21MG75MG
PRENATE ELITE TABS
600MCG-10UNIT150MCG-2600UNIT1.5MG-15MG-15MG25MG-3MG-100MG-26MG6MG-21MG-3.5MG13MCG-450UNIT400MCG-330MCG-21MG75MG, 600MCG-10UNIT150MCG-2600UNIT1.5MG-15MG-25MG-3MG100MG-26MG-6MG-21MG3.5MG-13MCG-450UNIT400MCG-330MCG-21MG75MG
PRENATE ENHANCE
CAPS
PRENATE ESSENTIAL
CAPS
PRENATAL+DHA MISC
PRENATE MINI CAPS
PRENATAL-U CAPS
PRENATE PIXIE CAPS
PRENATE AM TABS
PRENATE RESTORE
CAPS
PRENATE CHEW
PRENATE STAR TABS
PREQUE 10 TABS
PROVIDA DHA CAPS
PROVIDA OB CAPS
R-NATAL OB CAPS
RELNATE DHA CAPS
RULAVITE DHA CAPS
PRENATE DHA CAPS

18MG-600MCG-40UNIT300MG-50MG-155MG25MCG-400UNIT400MCG-26MG-90MG
PRENATE DHA CAPS
600MCG-10UNIT-300MG50MG-145MG-28MG13MCG-220UNIT400MCG-26MG-90MG
2
1
3
QL(1 ea daily)
2
3
3
page ii-iii.
89
Drug Name
SE-NATAL 19 CHEW
30UNIT-1000UNIT100MG-20MG-3MG200MG-29MG-7MG-15MG3MG-12MCG-400UNIT1MG-20MG
SE-NATAL 19 TABS
30UNIT-1000UNIT-20MG25MG-200MG-29MG-7MG15MG-3MG-12MCG400UNIT-3MG-20MG1MG-100MG
SELECT-OB CHEW
0.6MG-29MG-30UNIT15MG-25MG-1700UNIT15MG-1.8MG-5MCG400UNIT-1.6MG-0.4MG2.5MG-60MG
SELECT-OB CHEW
1700UNIT-29MG-30UNIT15MG-25MG-1.6MG15MG-1.8MG-5MCG400UNIT-1MG-2.5MG60MG
Drug Requirements/
Tier Limits
SELECT-OB+DHA MISC
TARON-BC MISC
TARON-C DHA CAPS
TARON-PREX CAPS
THRIVITE 19 TABS
THRIVITE RX TABS
TL-CARE DHA CAPS
TL-SELECT CAPS
TRI-TABS DHA MISC
TRICARE PRENATAL 1
CHEW
Drug Name
TRICARE PRENATAL
CHEW 1MG-60MCG-1MG32.5MCG-4.5MG37.5MCG-1MG-15UNIT7MG-1.25MG-5MG-10MG0.85MG-125MCG400UNIT-150MCG-2.5MG30MG
TRICARE PRENATAL
COMPLEAT MISC
TRICARE PRENATAL
DHA ONE CAPS
TRICARE PRENATAL
THPK 75MG-1MG37.5MG-60MCG-1MG32.5MCG-37.5MCG4.5MG-150MG-1MG15UNIT-7MG-1.25MG5MG-10MG-0.85MG125MCG-400UNIT150MCG-2.5MG-30MG
Drug Requirements/
Tier Limits
3
3
TRINATAL GT TABS
TRINATAL RX 1 TABS
TRISTART DHA CAPS
TRIVEEN-PRX RNF CAPS
ULTIMATECARE ONE
CAPS
ULTIMATECARE ONE NF
CAPS
3
3
VEMAVITE-PRX 2 CAPS
VENA-BAL DHA MISC
VINACAL B MISC
VINATE C TABS
VINATE CALCIUM TABS
VINATE DHA RF CAPS
VINATE ONE TABS
VIRT-ADVANCE TABS
page ii-iii.

90
Drug Name
Drug Requirements/
Tier Limits
Drug Name
Drug Requirements/
Tier Limits
VIRT-C DHA CAPS
VP-HEME OB + DHA MISC
VIRT-CARE ONE CAPS
VP-HEME OB TABS
VIRT-NATE DHA CAPS
VP-PNV-DHA CAPS
VIRT-PN DHA CAPS
WEGMANS COMPLETE
PRENATAL+DHA MISC
VIRT-PN PLUS CAPS
ZATEAN-CH CAPS
VIRT-PN TABS
ZATEAN-PN DHA CAPS
VIRT-SELECT CAPS
ZATEAN-PN PLUS CAPS
VIRT-VITE GT TABS
ZATEAN-PN TABS
VIRTPREX CAPS
MUSCULOSKELETAL THERAPY AGENTS Drugs to Treat Spasms
VITAFOL FE+ CPPK
Central Muscle Relaxants
VITAFOL GUMMIES
CHEW
AMRIX CP24
VITAFOL-NANO TABS
baclofen tabs
VITAFOL-ONE CAPS
carisoprodol tabs 250 mg
carisoprodol tabs 350 mg
chlorzoxazone tabs
VITAMEDMD ONE
RX/QUATREFOLIC CAPS
VITAMEDMD PLUS
RX/QUATREFOLIC MISC
VITAMEDMD REDICHEW
RX CHEW
VITAPEARL CPCR
VITATRUE MISC
VIVA DHA CAPS
VOL-TAB RX TABS
VP CH ULTRA CAPS
VP-CH PLUS CAPS
VP-CH-PNV CAPS
VP-GGR-B6 PRENATAL
TABS
cyclobenzaprine hcl tabs

10 mg, 5 mg
cyclobenzaprine hcl tabs
7.5 mg
ENOVARXCYCLOBENZAPRINE HCL
CREA
FEXMID TABS (Use
Cyclobenzaprine HCl)
1
3
3
GP
LORZONE TABS
metaxalone tabs
methocarbamol tabs or 500

mg, 750 mg
orphenadrine citrate tb12 or
100 mg
ST; QL(1 ea
daily)
1
1
page ii-iii.
91
Drug Name
PARAFON FORTE DSC
TABS (Use
Chlorzoxazone)
ROBAXIN TABS OR 500
MG (Use Methocarbamol)
ROBAXIN-750 TABS (Use
Methocarbamol)
SKELAXIN TABS (Use
Metaxalone)
SOMA TABS (Use
Carisoprodol)
tizanidine hcl caps 2 mg, 4
mg, 6 mg
tizanidine hcl tabs 2 mg, 4
mg
ZANAFLEX CAPS (Use
Tizanidine HCl)
ZANAFLEX TABS (Use
Tizanidine HCl)
Direct Muscle Relaxants
DANTRIUM CAPS (Use
Dantrolene Sodium)
dantrolene sodium caps or
100 mg, 25 mg, 50 mg
Drug Requirements/
Tier Limits
GP
azelastine hcl soln 0.1 %
GP
azelastine hcl soln 0.15 %
GP
GP
olopatadine hcl (nasal) soln
GP
PATANASE SOLN (Use

Olopatadine HCl (Nasal))
Nasal Anticholinergics
ATROVENT SOLN (Use
Ipratropium Bromide
(Nasal))
ipratropium bromide (nasal)
soln
1
GP
GP
BECONASE AQ SUSP
GP
1
budesonide (nasal) susp
NASAL AGENTS - SYSTEMIC AND TOPICAL Drugs to treat the Nose or Sinus
Nasal Agent Combinations
DYMISTA SUSP
Nasal Anti-infectives
BACTROBAN NASAL
OINT
Limit 1 bottle
per
month;QL(0.77
gm daily)
FLONASE ALLERGY
RELIEF CHILDRENS
SUSP (Use Fluticasone
Propionate (Nasal))
FLONASE ALLERGY
RELIEF SUSP (Use
Fluticasone Propionate
(Nasal))
FLONASE SUSP (Use
Fluticasone Propionate
(Nasal))
flunisolide (nasal) soln
3
GP
GP
1
QL(50 gm per
3 fill retail,50 gm
per 30 days
retail)
QL(18 ml per
1 fill retail);
RX/OTC
QL(32 ml per
GP fill retail,32 ml
per 30 days
retail); RX/OTC
QL(32 ml per
per 30 days
retail); RX/OTC
QL(32 ml per
per 30 days
retail); RX/OTC
1
Nasal Antiallergy
ASTEPRO SOLN (Use
Azelastine HCl)
Drug Requirements/
Tier Limits
Limit 1 inhaler
1 per
month;QL(1.2
ml daily)
Limit 1 bottle
1 per
month;QL(1.2
ml daily)
Nasal Steroids
Muscle Relaxant Combinations

carisoprodol w/ aspirin &
3
codeine tabs
carisoprodol w/ aspirin tabs
Drug Name
Limit 1 bottle
GP per
month;QL(1.2
ml daily)
fluticasone propionate
(nasal) susp
mometasone furoate
(nasal) susp
QL(32 ml per
fill retail,32 ml
per 30 days
retail); RX/OTC
Limit 2 inhalers
per
month;QL(1.22
gm daily)
page ii-iii.

92
Drug Requirements/
Tier Limits
Limit 1 inhaler
per
NASACORT ALLERGY
3 month;QL(1.2
24HR AERO
ml daily);
RX/OTC
Limit 1 inhaler
NASACORT ALLERGY
per
24HR AERO (Use
GP month;QL(1.2
Triamcinolone Acetonide
ml daily);
(Nasal))
RX/OTC
Limit 1 inhaler
NASACORT ALLERGY
24HR CHILDRENS AERO GP per
month;QL(1.2
(Use Triamcinolone
ml daily);
Acetonide (Nasal))
RX/OTC
Limit 2 inhalers
NASONEX SUSP (Use
GP per
Mometasone Furoate
month;QL(1.22
(Nasal))
gm daily)
Limit 1 sprayer
3 per
OMNARIS SUSP
month;QL(0.42
gm daily)
Limit 1 inhaler
3 per
QNASL AERS
month;QL(0.3
gm daily)
Limit 1 inhaler
QNASL CHILDRENS
3 per
AERS
month;QL(0.17
gm daily)
ml per
RHINOCORT AQUA SUSP GP QL(18
fill
retail);
(Use Budesonide (Nasal))
RX/OTC
Limit 1 inhaler
per
3 month;QL(1.2
(nasal) aero
ml daily);
RX/OTC
Limit 1 inhaler
3 per
VERAMYST SUSP
month;QL(0.34
gm daily)
Limit 1 inhaler
3 per
ZETONNA AERS
month;QL(0.3
gm daily)
Drug Name
Drug Name
Drug Requirements/
Tier Limits
NEUROMUSCULAR AGENTS - Drugs to

Relax/Paralyze Muscles
ALS Agents
RILUTEK TABS (Use
Riluzole)
GP
riluzole tabs
OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and Lubricants
LACRISERT INST
Beta-blockers - Ophthalmic
BETAGAN SOLN (Use
GP
Levobunolol HCl)
betaxolol hcl (ophth) soln
BETIMOL SOLN
BETOPTIC-S SUSP
carteolol hcl (ophth) soln
COMBIGAN SOLN
COSOPT PF SOLN
COSOPT SOLN (Use

Dorzolamide HCl-Timolol
Maleate)
dorzolamide hcl-timolol
maleate soln
GP
1
ISTALOL SOLN
levobunolol hcl soln
METIPRANOLOL SOLN
timolol maleate (ophth) solg
timolol maleate (ophth) soln
TIMOPTIC OCUDOSE
SOLN
TIMOPTIC SOLN (Use
Timolol Maleate (Ophth))
3
GP
page ii-iii.
93
Drug Name
TIMOPTIC-XE SOLG (Use
Timolol Maleate (Ophth))
Cycloplegic Mydriatics
atropine sulfate
(ophthalmic) soln
ATROPINE SULFATE
OINT OP 1 %
CYCLOGYL SOLN (Use
Cyclopentolate HCl)
Drug Requirements/
Tier Limits
GP
AZASITE SOLN
bacitracin (ophthalmic) oint
bacitracin-polymyxin b
(ophth) oint
BESIVANCE SUSP
GP
3
cyclopentolate hcl soln
homatropine hbr soln
tropicamide soln
Miotics
ISOPTO CARPINE SOLN
(Use Pilocarpine HCl)
PHOSPHOLINE IODIDE
SOLR
pilocarpine hcl soln
BETADINE OPHTHALMIC
PREP SOLN
BLEPH-10 SOLN (Use
Sulfacetamide Sodium
(Ophth))
CILOXAN OINT
GP
GP
3
GP
2
1
Ophthalmic Adrenergic Agents

ALPHAGAN P SOLN 0.1 %
Drug Requirements/
Tier Limits
QL(6 ml per 30
3 days retail,00
ml per 90 days
mail)
CYCLOMYDRIL SOLN
ISOPTO ATROPINE SOLN

(Use Atropine Sulfate
(Ophthalmic))
MYDRIACYL SOLN (Use
Tropicamide)
Drug Name
CILOXAN SOLN (Use

Ciprofloxacin HCl (Ophth))
ciprofloxacin hcl (ophth)
soln
3
GP
2
GP
1
erythromycin (ophth) oint
GARAMYCIN SOLN (Use

Gentamicin Sulfate
(Ophth))
GP
gatifloxacin (ophth) soln

gentamicin sulfate (ophth)
oint
gentamicin sulfate (ophth)
soln
1
1
1
levofloxacin (ophth) soln
GP
MOXEZA SOLN
apraclonidine hcl soln
NATACYN SUSP
brimonidine tartrate soln
IOPIDINE SOLN 0.5 %

(Use Apraclonidine HCl)
GP
ALPHAGAN P SOLN 0.15

% (Use Brimonidine
Tartrate)
IOPIDINE SOLN 1 %
SIMBRINZA SUSP
Ophthalmic Anti-infectives
neomycin-bacitracin znpolymyxin oint

neomycin-polymyxingramicidin soln
NEOSPORIN SOLN (Use
Neomycin-PolymyxinGramicidin)
OCUFLOX SOLN (Use
Ofloxacin (Ophth))
1
1
GP
GP QL(5 ml per fill
retail)
page ii-iii.

94
Drug Name
ofloxacin (ophth) soln

polymyxin b-trimethoprim
soln
POLYTRIM SOLN (Use
Polymyxin B-Trimethoprim)
(ophth) oint
(ophth) soln
Drug Requirements/
Tier Limits
1 QL(5 ml per fill
retail)
ALREX SUSP
GP
TOBREX OINT
VIGAMOX SOLN
QL(3 ml per fill

retail)
GP
ZIRGAN GEL
3
1
QL(4 gm per fill

retail)
BLEPHAMIDE SUSP
dexamethasone sodium
phosphate (ophth) soln
DUREZOL EMUL
FLAREX SUSP
fluorometholone (ophth)
susp
FML FORTE SUSP
FML LIQUIFILM SUSP

(Use Fluorometholone
(Ophth))
3
GP
Ophthalmic Decongestants
NAPHAZOLINE HCL
SOLN
phenylephrine hcl (ophth)
soln 10 %
phenylephrine hcl (ophth)
soln 2.5 %
GP
FML OINT
LOTEMAX GEL
LOTEMAX OINT
3
LOTEMAX SUSP
MAXIDEX SUSP
Ophthalmic Immunomodulators
RESTASIS EMUL
RESTASIS MULTIDOSE
EMUL
Ophthalmic Local Anesthetics

AKTEN GEL
GP
trifluridine soln
ZYMAXID SOLN (Use

Gatifloxacin (Ophth))
bacitracin-poly-neomycinhc oint
BLEPHAMIDE S.O.P.
OINT
VIROPTIC SOLN (Use

Trifluridine)
tetracaine hcl (ophth) soln
Drug Requirements/
Tier Limits
Ophthalmic Steroids
tobramycin (ophth) soln
TOBREX SOLN (Use

Tobramycin (Ophth))
Drug Name
ALCAINE SOLN (Use

Proparacaine HCl)
GP
proparacaine hcl soln
QL(64 ml per
fill retail)
QL(64 ml per
fill retail)
MAXITROL OINT (Use

Neomycin-PolymyDexameth)
MAXITROL SUSP (Use
Neomycin-PolymyDexameth)
neomycin-polymydexameth oint
neomycin-polymydexameth susp
neomycin-polymyxin-hc
(ophth) susp
Limit 1 bottle
per
month;QL(0.2
ml daily)
GP
GP
1
1
1
page ii-iii.
95
Drug Name
OMNIPRED SUSP (Use
Prednisolone Acetate
(Ophth))
PRED FORTE SUSP (Use
Prednisolone Acetate
(Ophth))
Drug Requirements/
Tier Limits
GP
GP
Drug Name
Drug Requirements/
Tier Limits
ALOCRIL SOLN
ALOMIDE SOLN
azelastine hcl (ophth) soln
AZOPT SUSP
PRED MILD SUSP
PRED-G S.O.P. OINT
PRED-G SUSP
BEPREVE SOLN
bromfenac sodium (ophth)

soln
BROMSITE SOLN
cromolyn sodium (ophth)

soln
prednisolone acetate
(ophth) susp
PREDNISOLONE SODIUM
PHOSPHATE SOLN OP 1
%
PREDNISOLONE/MOXIFL
OXACIN SOLN
sulfacetamide sodprednisolone soln
TOBRADEX OINT
TOBRADEX ST SUSP
TOBRADEX SUSP (Use

TobramycinDexamethasone)
tobramycindexamethasone susp
VEXOL SUSP
ZYLET SUSP
QL(5 ml per fill

GP retail)
1
3
3
Ophthalmic Surgical Aids

GELFILM OP FILM
Ophthalmics - Misc.
ACULAR LS SOLN (Use
Ketorolac Tromethamine
(Ophth))
ACULAR SOLN (Use
Ketorolac Tromethamine
(Ophth))
ACUVAIL SOLN
QL(5 ml per fill

retail)
GP
GP
3
QL(5 ml per fill

retail)
CYSTARAN SOLN
diclofenac sodium (ophth)

soln
dorzolamide hcl soln
ELESTAT SOLN (Use

Epinastine HCl (Ophth))
Limit 4 bottles
per
month;QL(2.15
ml daily)
GP
EMADINE SOLN
epinastine hcl (ophth) soln
EYEAID IRRIGATING
SOLUTION SOLN (Use
Ophthalmic Irrigation
Solution)
fluorescein sodium topical
strp
Limit 10mls per

month;QL(0.4
ml daily)
ST; Limit 10ml
per
month;QL(0.34
ml daily)
GP
3
flurbiprofen sodium soln
FUL-GLO STRP
ILEVRO SUSP
(ophth) soln
page ii-iii.

96
Drug Name
Drug Requirements/
Tier Limits
LASTACAFT SOLN
NEVANAC SUSP
Drug Name
TRAVATAN Z SOLN
OCUFEN SOLN (Use

Flurbiprofen Sodium)
olopatadine hcl soln

ophthalmic irrigation
solution soln
OPTIVAR SOLN (Use
Azelastine HCl (Ophth))
PAREMYD SOLN
PATADAY SOLN
PATANOL SOLN (Use
Olopatadine HCl)
PAZEO SOLN
PROLENSA SOLN
TRUSOPT SOLN (Use
Dorzolamide HCl)
GP
1
Limit 10mls per

month;QL(0.34
ml daily)
XALATAN SOLN (Use

Latanoprost)
3
GP
ZIOPTAN SOLN
3
ST; Limit
3 2.5mls per
month;QL(0.08
4 ml daily)
Limit 10mls per
GP month;QL(0.34
ml daily)
ST; Limit
3 2.5mls per
month;QL(0.08
4 ml daily)
3
GP
Prostaglandins - Ophthalmic
BIMATOPROST SOLN
latanoprost soln op
LUMIGAN SOLN
RESCULA SOLN
TRAVOPROST SOLN
Limit 2.5mls
per
month;QL(0.09
ml daily)
Limit 2.5mls
per
month;QL(0.09
ml daily)
Limit 2.5mls
per
month;QL(0.09
ml daily)
Limit 1 bottle
per
month;QL(0.17
ml daily)
Drug Requirements/
Tier Limits
Limit 2.5mls
2 per
month;QL(0.09
ml daily)
Limit 2.5mls
2 per
month;QL(0.09
ml daily)
Limit 2.5mls
GP per
month;QL(0.09
ml daily)
3 QL(1 ea daily)
OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous
acetic acid (otic) soln

acetic acid-aluminum
acetate soln
Otic Analgesics
PINNACAINE OTIC SOLN
Otic Anti-infectives
CETRAXAL SOLN (Use
Ciprofloxacin HCl (Otic))
1
1
GP
ciprofloxacin hcl (otic) soln
FLOXIN OTIC SOLN (Use

Ofloxacin (Otic))
GP
ofloxacin (otic) soln
Otic Combinations
CIPRO HC SUSP
CIPRODEX SUSP
COLY-MYCIN S SUSP
CORTANE-B AQUEOUS
SOLN
CORTANE-B-OTIC SOLN
(Use Pramoxine-HCChloroxylenol)
CORTISPORIN-TC SUSP
QL(8 ml per fill

retail)
3
GP
3
page ii-iii.
97
Drug Name
Drug Requirements/
Tier Limits
1
(otic) soln
1
(otic) susp
OTICIN HC NR SOLN (Use
GP
Pramoxine-HCChloroxylenol)
OTOVEL SOLN
PRAMOTIC LIQD
AMOXICILLIN ER TB24
Limit 15mls per

month;QL(0.5
ea daily)
amoxicillin susr
amoxicillin tabs
ampicillin caps
ampicillin susr
MOXATAG TB24
QL(10 ml per
fill retail,30 ml
per fill mail)
Abortifacients/Agents for Cervical Ripening

CERVIDIL INST
PREPIDIL GEL
PROSTIN E2 SUPP
PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins
amoxicillin caps
amoxicillin chew
PA; QL(1 ea
daily,10 ea per
fill retail)
Natural Penicillins
OXYTOCICS - Drugs to Prevent/Control Uterine

Bleeding
Oxytocics
methylergonovine maleate
tabs or 0.2 mg
Drug Requirements/
Tier Limits
PA; QL(1 ea
3 daily,10 ea per
fill retail)
pramoxine-chloroxylenol
3
liqd
pramoxine-hc-chloroxylenol 1
soln
Otic Steroids
DERMOTIC OIL (Use
GP
Fluocinolone Acetonide
(Otic))
fluocinolone acetonide
3
(otic) oil
hydrocortisone w/acetic
acid soln
Drug Name
penicillin v potassium solr
penicillin v potassium tabs
Penicillin Combinations
amoxicillin & pot
clavulanate chew
amoxicillin & pot
clavulanate susr
amoxicillin & pot
clavulanate tabs
amoxicillin & pot
clavulanate tb12
AUGMENTIN ES-600
SUSR (Use Amoxicillin &
Pot Clavulanate)
AUGMENTIN SUSR
125MG/5ML-31.25MG/5ML
AUGMENTIN SUSR
250MG/5ML-62.5MG/5ML
(Use Amoxicillin & Pot
Clavulanate)
AUGMENTIN TABS
500MG-125MG, 875MG125MG (Use Amoxicillin &
Pot Clavulanate)
AUGMENTIN XR TB12
(Use Amoxicillin & Pot
Clavulanate)
1
1
1
1
GP
2
GP
GP
GP
Penicillinase-Resistant Penicillins
dicloxacillin sodium caps
page ii-iii.

98
Drug Name
Drug Requirements/
Tier Limits
Drug Name
PHARMACEUTICAL ADJUVANTS
XYREM SOLN
Liquid Vehicles
BASE GELATIN GUMMY
TROCHE GEL
Antidementia Agents
ARICEPT ODT TBDP (Use
Donepezil Hydrochloride)
ARICEPT TABS (Use
Donepezil Hydrochloride)
donepezil hydrochloride
tabs
donepezil hydrochloride
tbdp
EXELON CAPS (Use
Rivastigmine Tartrate)
EXELON PT24 (Use
Rivastigmine)
galantamine hydrobromide
cp24 16 mg, 24 mg, 8 mg
GALANTAMINE
HYDROBROMIDE SOLN 4
MG/ML
galantamine hydrobromide
tabs 12 mg, 4 mg, 8 mg
GUM BASE GELATIN GEL

Semi Solid Vehicles
PLO GEL - MEDIFLO KIT
KIT
3
3
PROGESTINS - Hormone Replacement/Modifying

Drugs
Progestins
AYGESTIN TABS (Use
Norethindrone Acetate)
medroxyprogesterone
acetate tabs
MEGACE ES SUSP (Use
Megestrol Acetate
(Appetite))
megestrol acetate
(appetite) susp
norethindrone acetate tabs
GP
1
AC
GP
3
AC
progesterone micronized
3 QL(2 ea daily)
caps
PROMETRIUM CAPS (Use GP QL(2 ea daily)
Progesterone Micronized)
PROVERA TABS (Use
GP
Medroxyprogesterone
Acetate)
PSYCHOTHERAPEUTIC AND NEUROLOGICAL
AGENTS - MISC. - Drugs to Treat Mental and
Emotional Conditions
Agents for Chemical Dependency
acamprosate calcium tbec
ANTABUSE TABS (Use
Disulfiram)
CAMPRAL TBEC (Use
Acamprosate Calcium)
disulfiram tabs
Anti-Cataplectic Agents
1
GP
GP
1
Drug Requirements/
Tier Limits
3 PA
GP QL(1 ea daily)
GP QL(1 ea daily)
1
QL(1 ea daily)
QL(1 ea daily)
GP
GP
1
2
1
memantine hcl soln
memantine hcl tabs
NAMENDA SOLN (Use

Memantine HCl)
NAMENDA TABS (Use
Memantine HCl)
NAMENDA TITRATION
PAK TABS (Use
Memantine HCl)
QL(1 ea daily)
GP
GP
GP
NAMENDA XR CP24
PA
NAMENDA XR TITRATION
PACK CP24
PA
NAMZARIC C4PK
PA
NAMZARIC CP24
PA
RAZADYNE ER CP24 (Use

QL(1 ea daily)
GP
Galantamine
Hydrobromide)
RAZADYNE SOLN (Use
GP
Galantamine
Hydrobromide)
page ii-iii.
99
Drug Name
RAZADYNE TABS (Use
Galantamine
Hydrobromide)
Drug Requirements/
Tier Limits
TECFIDERA STARTER
PACK MISC
GP
rivastigmine pt24
rivastigmine tartrate caps
GRALISE TABS
SAVELLA TITRATION
PACK MISC
XENAZINE TABS (Use

Tetrabenazine)
PA; QL(2 ea
daily)
PA; QL(2 ea
daily)
3
GP
3
GP
NUEDEXTA CAPS
Psychotherapeutic and Neurological Agents -
ergoloid mesylates tabs
3
GP
3
Restless Leg Syndrome (RLS) Agents

3 QL(1 ea daily)
HORIZANT TBCR
PA; LA
AUBAGIO TABS
PA
PA; Must use

3 AcariaHlth Sp
Rx 1-844-5384661
SP PA
SP PA
3
fluoxetine hcl (pmdd) tabs
pimozide tabs
TECFIDERA CPDR
ORAP TABS (Use

Pimozide)
AMPYRA TB12
REBIF REBIDOSE
TITRATIONPACK SOAJ
REBIF TITRATION PACK
SOSY
PA
Pseudobulbar Affect (PBA) Agents
Multiple Sclerosis Agents
GILENYA CAPS
FLUOXETINE CAPS
SARAFEM TABS (Use

Fluoxetine HCl (PMDD))
Movement Disorder Drug Therapy
tetrabenazine tabs
Premenstrual Dysphoric Disorder (PMDD) Agents
Fibromyalgia Agents
3
Drug Requirements/
Tier Limits
PA; Must use
3 AcariaHlth Sp
Rx 1-844-5384661;LA
Postherpetic Neuralgia (PHN) Agents

3 PA
GRALISE STARTER MISC
Combination Psychotherapeutics
CHLORDIAZEPOXIDE/AMI 3
TRIPTYLINE TABS
olanzapine-fluoxetine hcl
3
caps
PERPHENAZINE/AMITRIP
3
TYLINE TABS
SYMBYAX CAPS (Use
GP
Olanzapine-Fluoxetine
HCl)
SAVELLA TABS
Drug Name
PA; Must use

AcariaHlth Sp
Rx 1-844-5384661;LA
Smoking Deterrents
bupropion hcl (smoking
deterrent) tb12
CHANTIX CONTINUING
MONTHPAK TABS
CHANTIX STARTING
MONTH PAK TABS
CHANTIX TABS
NICODERM CQ PT24 (Use
Nicotine)
NICORETTE GUM (Use
Nicotine Polacrilex)
NICORETTE LOZG (Use
Nicotine Polacrilex)
NICORETTE MINI LOZG
(Use Nicotine Polacrilex)
PV
PV
PV
PV
GP PV
GP PV
GP PV
GP PV
page ii-iii.

100
Drug Name
NICORETTE STARTER
KIT GUM (Use Nicotine
Polacrilex)
Drug Requirements/
Tier Limits
PV
GP
nicotine polacrilex gum
PV
nicotine polacrilex lozg
PV
nicotine pt24
PV
NICOTINE
TRANSDERMAL SYSTEM
KIT
NICOTROL INHALER
INHA
NICOTROL NS SOLN
ZYBAN TB12 (Use
Bupropion HCl (Smoking
Deterrent))
PV
3
3
PV
PV
PV
GP
Vasomotor Symptom Agents

BRISDELLE CAPS
RESPIRATORY AGENTS - MISC. - Drugs to

Treat Lung Conditions
Cystic Fibrosis Agents
KALYDECO PACK
PA
KALYDECO TABS
PA
PA
ORKAMBI TABS 100MG125MG

ORKAMBI TABS 200MG125MG
PULMOZYME SOLN
PA
PA; Must use
AcariaHlth Sp
Rx 1-844-5384661;QL(5 ml
daily)
Pulmonary Fibrosis Agents

ESBRIET CAPS
PA
OFEV CAPS
PA
SULFONAMIDES - Drugs to Treat Bacterial

Infections
Sulfonamides
Drug Name
SULFADIAZINE TABS
Drug Requirements/
Tier Limits
3
TETRACYCLINES - Drugs to Treat Bacterial

Infections
Tetracyclines
ACTICLATE TABS
ADOXA CAPS 150 MG
(Use Doxycycline
(Monohydrate))
ADOXA PAK 1/100 TABS
(Use Doxycycline
(Monohydrate))
(Use Doxycycline
(Monohydrate))
(Use Doxycycline
(Monohydrate))
ADOXA TABS 100 MG, 50
MG, 75 MG (Use
Doxycycline
(Monohydrate))
demeclocycline hcl tabs

DORYX TBEC 200 MG
(Use Doxycycline Hyclate)
doxycycline (monohydrate)
caps 100 mg, 50 mg, 75
mg
caps 150 mg
susr 25 mg/5ml
tabs 100 mg, 50 mg, 75 mg
tabs 150 mg
doxycycline hyclate caps or
100 mg, 50 mg
doxycycline hyclate tabs or
100 mg
doxycycline hyclate tabs or
20 mg
doxycycline hyclate tbec or
100 mg, 150 mg, 75 mg
PA
ST
GP
GP
ST
GP
GP
GP
1
GP PA
3
3
ST
1
3
3
ST
1
1
3
3
ST
page ii-iii.
101
Drug Requirements/
Tier Limits
doxycycline hyclate tbec or
3 PA
200 mg
MINOCIN CAPS (Use
NF
Minocycline HCl)
minocycline hcl caps 100
1
mg, 50 mg, 75 mg
minocycline hcl tabs 100
3 PA
mg, 50 mg, 75 mg
minocycline hcl tb24 135
3 ST
mg, 45 mg, 90 mg
MONODOX CAPS (Use
GP
Doxycycline
(Monohydrate))
3 PA
NUTRIDOX KIT
Drug Name
SOLODYN TB24
tetracycline hcl caps
PA
Drug Name
levothyroxine sodium tabs

liothyronine sodium tabs or
25 mcg, 5 mcg, 50 mcg
NATURE-THROID NT-2.5
TABS
NATURE-THROID TABS
113.75 MG, 130 MG,
146.25 MG, 16.25 MG, 195
MG, 260 MG, 32.5 MG,
325 MG, 65 MG, 81.25
MG, 97.5 MG
NATURE-THROID TABS
48.75 MG
SYNTHROID TABS (Use
Levothyroxine Sodium)
Drug Requirements/
Tier Limits
1
1
3
3
GP
thyroid tabs
THYROLAR-1 TABS
THYROLAR-1/2 TABS
THYROLAR-1/4 TABS
THYROLAR-2 TABS
THYROLAR-3 TABS
THYROID AGENTS - Drugs to Regulate Thyroid

Hormones
TIROSINT CAPS
Antithyroid Agents
WESTHROID TABS
113.75 MG, 130 MG,
146.25 MG, 16.25 MG, 195
MG, 260 MG, 32.5 MG,
325 MG, 65 MG, 81.25
MG, 97.5 MG
WESTHROID TABS 162.5
MG, 48.75 MG
WP THYROID TABS
113.75 MG, 130 MG, 16.25
MG, 32.5 MG, 65 MG,
81.25 MG, 97.5 MG
WP THYROID TABS 48.75
MG
VIBRAMYCIN CAPS 100

MG (Use Doxycycline
Hyclate)
VIBRAMYCIN SUSR 25
MG/5ML (Use Doxycycline
(Monohydrate))
VIBRAMYCIN SYRP 50
MG/5ML
GP
GP
2
methimazole tabs
propylthiouracil tabs
TAPAZOLE TABS (Use

Methimazole)
Thyroid Hormones
ARMOUR THYROID TABS
120 MG, 180 MG, 240 MG,
30 MG, 300 MG, 60 MG,
90 MG
ARMOUR THYROID TABS
15 MG (Use Thyroid)
CYTOMEL TABS (Use
Liothyronine Sodium)
GP
2
GP
GP
3
2
3
ULCER DRUGS - Drugs to Treat Bowel, Intestine

and Stomach Conditions
Antispasmodics
page ii-iii.

102
Drug Name
ANASPAZ TBDP (Use
Hyoscyamine Sulfate)
BELLADONNA & OPIUM
SUPP
BELLADONNA
ALKALOIDS & OPIUM
SUPP
BENTYL CAPS (Use
Dicyclomine HCl)
BENTYL TABS (Use
Dicyclomine HCl)
Drug Requirements/
Tier Limits
GP
3
3
GP
GP
Drug Name
methscopolamine bromide
tabs
PAMINE FORTE TABS
(Use Methscopolamine
Bromide)
PAMINE FQ KIT
PAMINE TABS (Use
Methscopolamine Bromide)
phenobarbitalhyoscyamine-atropinescopolamine tabs
Drug Requirements/
Tier Limits
1
GP
3
GP
1
CANTIL TABS
chlordiazepoxide hclclidinium bromide caps
CUVPOSA SOLN
dicyclomine hcl caps
dicyclomine hcl soln
cimetidine hcl soln
dicyclomine hcl tabs
cimetidine tabs 300 mg,

400 mg, 800 mg
famotidine susr 40 mg/5ml
famotidine tabs 20 mg
famotidine tabs 40 mg
DONNATAL ELIX
0.1037MG/5ML0.0065MG/5ML0.0194MG/5ML16.2MG/5ML
DONNATAL EXTENTABS
TBCR
DONNATAL TABS
0.1037MG-0.0065MG0.0194MG-16.2MG (Use
PhenobarbitalHyoscyamine-AtropineScopolamine)
glycopyrrolate tabs or 1
mg, 2 mg
ROBINUL FORTE TABS

(Use Glycopyrrolate)
ROBINUL TABS OR 1 MG
(Use Glycopyrrolate)
1
GP
GP
H-2 Antagonists
GP
hyoscyamine sulfate tb12
hyoscyamine sulfate tbdp
LEVBID TB12 (Use

Hyoscyamine Sulfate)
LIBRAX CAPS (Use
Chlordiazepoxide HClClidinium Bromide)
propantheline bromide tabs
GP
GP
nizatidine caps 150 mg,

300 mg
NIZATIDINE SOLN 15
MG/ML
PEPCID AC MAXIMUM
STRENGTH TABS (Use
Famotidine)
PEPCID SUSR 40 MG/5ML
(Use Famotidine)
PEPCID TABS 20 MG (Use
Famotidine)
PEPCID TABS 40 MG (Use
Famotidine)
ranitidine hcl caps 150 mg,
300 mg
ranitidine hcl syrp 15
mg/ml, 150 mg/10ml, 75
mg/5ml
QL(4 ea daily);
RX/OTC
QL(2 ea daily)
1
2
QL(4 ea daily);
GP RX/OTC
GP
GP QL(4 ea daily);
RX/OTC
GP QL(2 ea daily)
3
1
page ii-iii.
103
Drug Name
ranitidine hcl tabs 150 mg

ranitidine hcl tabs 300 mg
ZANTAC 150 MAXIMUM
STRENGTH TABS (Use
Ranitidine HCl)
ZANTAC TABS 150 MG
(Use Ranitidine HCl)
ZANTAC TABS 300 MG
(Use Ranitidine HCl)
Misc. Anti-Ulcer
CARAFATE SUSP 1
GM/10ML
CARAFATE TABS 1 GM
(Use Sucralfate)
sucralfate tabs
Proton Pump Inhibitors
ACIPHEX SPRINKLE
CPSP
ACIPHEX TBEC (Use
Rabeprazole Sodium)
DEXILANT CPDR
esomeprazole magnesium
cpdr 20 mg
esomeprazole magnesium
cpdr 40 mg
ESOMEPRAZOLE
STRONTIUM CPDR 24.65
MG, 49.3 MG
FIRST-LANSOPRAZOLE
SUSP
FIRST-OMEPRAZOLE
SUSP
Drug Requirements/
Tier Limits
1 RX/OTC
1
RX/OTC
GP
GP RX/OTC
2
GP
1
PA
GP PA; QL(2 ea
daily)
3 PA; QL(1 ea
daily)
3 PA; QL(1 ea
daily); RX/OTC
3 PA; QL(1 ea
daily)
PA; QL(1 ea
3 daily)
lansoprazole cpdr 30 mg
rabeprazole sodium tbec
PA
3
1
1
GP RX/OTC
GP RX/OTC
GP
3
QL(1 ea daily);
AL
GP
3
3
GP
3
PA; QL(2 ea
daily)
misoprostol tabs
RX/OTC
PA; QL(1 ea
daily); RX/OTC
PA; QL(1 ea
GP daily); RX/OTC
3
pantoprazole sodium tbec

or 20 mg, 40 mg
PREVACID 24HR CPDR
(Use Lansoprazole)
PREVACID CPDR 15 MG
(Use Lansoprazole)
PREVACID CPDR 30 MG
(Use Lansoprazole)
PREVACID SOLUTAB
TBDP
PRILOSEC CPDR 10 MG,
20 MG, 40 MG (Use
Omeprazole)
PRILOSEC PACK 10 MG,
2.5 MG
PROTONIX PACK OR 40
MG
PROTONIX TBEC OR 20
MG, 40 MG (Use
Pantoprazole Sodium)
Drug Requirements/
Tier Limits
PA; QL(1 ea
GP daily)
Ulcer Drugs - Prostaglandins

CYTOTEC TABS (Use
GP
Misoprostol)
NEXIUM CPDR 20 MG
(Use Esomeprazole
Magnesium)
NEXIUM CPDR 40 MG
(Use Esomeprazole
Magnesium)
NEXIUM PACK 10 MG, 2.5
MG, 20 MG, 40 MG, 5 MG
OMEPRAZOLE +
SYRSPEND SFALKA
SUSP
omeprazole cpdr
GP
lansoprazole cpdr 15 mg
NEXIUM 24HR CPDR
Drug Name
Ulcer Therapy Combinations

amoxicillin-clarithromycin
1
w/ lansoprazole misc
OMECLAMOX-PAK MISC
omeprazole-sodium
bicarbonate caps 40mg1100mg
PA
page ii-iii.

104
Drug Name
omeprazole-sodium
bicarbonate pack 20mg1680mg, 40mg-1680mg
PREVPAC MISC (Use
Amoxicillin-Clarithromycin
w/ Lansoprazole)
PYLERA CAPS
ZEGERID PACK 20MG1680MG, 40MG-1680MG
(Use Omeprazole-Sodium
Bicarbonate)
Drug Requirements/
Tier Limits
3
GP
3
GP
URINARY ANTI-INFECTIVES - Drugs to Treat

Bladder/Kidney Infections
Urinary Anti-infective Combinations
methenamine-hyosc3
methylene blue-benzoic
acid-phenyl sal tabs
methenamine-hyosc3
methylene blue-sod phosphenyl sal caps
methenamine-hyosc3
methylene blue-sod phosphenyl sal tabs
methenamine-hyoscamine3
methylene blue-sodium
phosphate caps
Drug Name
MONUROL PACK
nitrofurantoin macrocrystal
caps
nitrofurantoin monohyd
macro caps
nitrofurantoin susp
Drug Requirements/
Tier Limits
3
1
1
1
URINARY ANTISPASMODICS - Drugs to Treat

Miscellaneous Bladder Spasms
Urinary Antispasmodic - Antimuscarinics
darifenacin hydrobromide
3
tb24
DETROL LA CP24 (Use
GP QL(1 ea daily)
Tolterodine Tartrate)
DETROL TABS (Use
GP QL(2 ea daily)
Tolterodine Tartrate)
DITROPAN XL TB24 (Use
GP
Oxybutynin Chloride)
ENABLEX TB24 (Use
Darifenacin Hydrobromide) GP
GELNIQUE GEL
oxybutynin chloride syrp
oxybutynin chloride tabs
URETRON D/S TABS
oxybutynin chloride tb24
URIMAR-T TABS
OXYTROL FOR WOMEN

PTTW
RX/OTC
OXYTROL PTTW
RX/OTC
QL(1 ea daily)
QL(2 ea daily)
TOVIAZ TB24
QL(1 ea daily)
trospium chloride cp24
trospium chloride tabs
VESICARE TABS
Urinary Anti-infectives
FURADANTIN SUSP (Use
Nitrofurantoin)
HIPREX TABS (Use
Methenamine Hippurate)
MACROBID CAPS (Use
Nitrofurantoin Monohyd
Macro)
MACRODANTIN CAPS
(Use Nitrofurantoin
Macrocrystal)
methenamine hippurate
tabs
methenamine mandelate
tabs
GP
GP
GP
GP
3
1
tolterodine tartrate cp24 2

mg, 4 mg
tolterodine tartrate tabs 1
mg, 2 mg
Urinary Antispasmodics - Beta-3 Adrenergic
page ii-iii.
105
Drug Name
Drug Requirements/
Tier Limits
3 QL(1 ea daily)
Drug Name
Drug Requirements/
Tier Limits
GP
Urinary Antispasmodics - Cholinergic Agonists
METROGEL-VAGINAL
GEL (Use Metronidazole
Vaginal)
bethanechol chloride tabs
metronidazole vaginal gel
URECHOLINE TABS (Use

Bethanechol Chloride)
GP
MICONAZOLE 3 SUPP
Urinary Antispasmodics - Direct Muscle Relaxants
NUVESSA GEL
flavoxate hcl tabs
TERAZOL 3 CREA (Use

Terconazole Vaginal)
TERAZOL 7 CREA (Use
Terconazole Vaginal)
terconazole vaginal crea
0.4 %, 0.8 %
terconazole vaginal supp
80 mg
MYRBETRIQ TB24
VACCINES
Bacterial Vaccines
VIVOTIF BERNA CPDR
VIVOTIF CPDR
Viral Vaccines
FLUMIST
QUADRIVALENT SUSP
QL(4 ea per fill

retail)
QL(4 ea per fill
retail)
VAGINAL PRODUCTS - Drugs to Treat Vaginal

Infections and Low Hormones
Miscellaneous Vaginal Products
FEM PH GEL (Use Acetic
Acid-Oxyquinoline Vaginal) GP
RELAGARD GEL (Use
GP
Acetic Acid-Oxyquinoline
Vaginal)
Spermicides
TODAY SPONGE MISC
CLEOCIN CREA VA 2 %
(Use Clindamycin
Phosphate Vaginal)
CLEOCIN SUPP VA 100
MG
vaginal crea
GP
GP
1
3
estradiol vaginal tabs
ESTRING RING
FEMRING RING
PREMARIN CREA VA
0.625 MG/GM
VAGIFEM TABS (Use
Estradiol Vaginal)
QL(1 ea per 90
days retail)
2
GP
Vaginal Progestins
2
Vaginal Anti-infectives
AVC CREA
Vaginal Estrogens
ESTRACE CREA VA 0.1
MG/GM
PA
3
GP
3
1
CLINDESSE CREA
GYNAZOLE-1 CREA
CRINONE GEL 8 %
PA
ENDOMETRIN INST
PA
VASOPRESSORS - Drugs to Treat Heart and

Circulation Conditions
Neurogenic Orthostatic Hypotension (NOH) 3 PA
NORTHERA CAPS
Vasopressors
midodrine hcl tabs
VITAMINS
Oil Soluble Vitamins
page ii-iii.

106
Drug Name
DRISDOL CAPS (Use
Ergocalciferol)
Drug Requirements/
Tier Limits
GP
ergocalciferol caps
MEPHYTON TABS
Water Soluble Vitamins

AMINOBENZOATE
POTASSIUM PACK
POTABA CAPS
3
3
page ii-iii.
107
Index
8-MOP
56
abacavir sulfate
37
abacavir sulfate-lamivudine 37
abacavir sulfate-lamivudinezidovudine
37
ABILIFY 1 MG/ML
37
ABILIFY 10 MG, 15 MG, 2 MG,
20 MG, 30 MG, 5 MG
37
ABILIFY DISCMELT
37
ABSORICA
51
ABSTRAL
5
acamprosate calcium
99
acarbose
21
ACCU-CHEK ACTIVE
STRIPS
63
ACCU-CHEK AVIVA
64
ACCU-CHEK AVIVA PLUS 64
ACCU-CHEK COMFORT
CURVE TEST STRIPS
64
ACCU-CHEK COMPACT
PLUS
64
ACCU-CHEK COMPACT TEST
DRUM
64
ACCU-CHEK SMARTVIEW
STRIPS
64
ACCUPRIL
28
ACCURETIC
29
ACCUTREND GLUCOSE 64
acebutolol hcl
41
ACEON
28
7
acetaminophen-caffdihydrocod
7
acetaminophen-salicylamidephenyltoloxamine
5
acetazolamide
71
acetic acid (otic)
97
acetic acid-aluminum
acetate
97
acetylcysteine
51
ACIPHEX
104
ACIPHEX SPRINKLE
104
acitretin 10 mg
56
acitretin 17.5 mg
56
acitretin 25 mg
56
ACLOVATE
57
ACTICLATE
101
ACTIDOM DMX
48
ACTIGALL
76
ACTINEL PEDIATRIC
48
ACTIQ
5
ACTIVE OB
87
ACTIVELLA
74
ACTONEL 150 MG
72
ACTONEL 30 MG, 5 MG 72
ACTONEL 35 MG
72
ACTOPLUS MET
21
ACTOPLUS MET XR
21
ACTOS
22
ACULAR
96
ACULAR LS
96
ACURA BLOOD GLUCOSE
TESTSTRIPS
64
ACUVAIL
96
acyclovir
40
acyclovir topical
57
ACZONE 5 %
51
ACZONE 7.5 %
51
ADALAT CC 30 MG, 60
MG
42
ADALAT CC 90 MG
42
adapalene 0.1 %
51
ADAPALENE 0.1 %
52
adapalene 0.3 %
51
ADAZIN
62
ADCIRCA
44
ADDERALL
1
ADDERALL XR
1
adefovir dipivoxil
39
ADEMPAS
44
ADIPEX-P
1
ADOXA 100 MG, 50 MG, 75
MG
101
ADOXA 150 MG
101
ADOXA PAK 1/100
101
ADOXA PAK 1/150
101
ADOXA PAK 2/100
101
ADVAIR DISKUS
14
ADVAIR HFA
14
ADVANCE INTUITION TEST
STRIPS
64
ADVANCE MICRO-DRAW
TEST STRIPS
64
ADVOCATE ARM BLOOD
PRESSURE
MONITOR/LARGE
82
ADVOCATE REDI-CODE 64
ADVOCATE REDI-CODE+
TESTSTRIPS
64
ADVOCATE TEST STRIPS 64

ADZENYS XR-ODT
1
AEROSPAN
13
AFINITOR
33
AFINITOR DISPERZ
33
AFREZZA
22
AGAMATRIX AMP NO CODE
TEST STRIPS
64
AGAMATRIX JAZZ TEST
STRIPS
64
AGAMATRIX KEYNOTE TEST
STRIPS
64
AGAMATRIX PRESTO TEST
STRIPS
64
AGGRENOX
79
AGRYLIN
79
AKTEN
95
AKYNZEO
25
ALA SCALP
57
ALA-QUIN
54
ALAHIST DM
48
ALBATUSSIN
48
ALBATUSSIN NN
48
ALBENZA
10
albuterol sulfate 0.083 %, 0.5 %,
0.63 mg/3ml, 1.25 mg/3ml 14
albuterol sulfate 2 mg, 4 mg 14
albuterol sulfate 2 mg/5ml 14
albuterol sulfate 4 mg, 8 mg 14
ALCAINE
95
alclometasone dipropionate 57
ALDACTAZIDE 25MG25MG
71
ALDACTAZIDE 50MG50MG
71
ALDACTONE
72
ALDARA
61
ALECENSA
33
alendronate sodium 10 mg, 5
mg
72
alendronate sodium 35 mg, 70
mg
72
ALENDRONATE SODIUM 40
MG
72
ALENDRONATE SODIUM 70
MG/75ML
72
alfuzosin hcl
78
ALINIA
10
ALKERAN 2 MG
31
allopurinol
78
almotriptan malate
84
Index 1
ALOCRIL
96
ALOGLIPTIN
22
ALOGLIPTIN/METFORMIN
HCL
21
ALOGLIPTIN/PIOGLITAZONE
21
ALOMIDE
96
ALORA 0.025 MG/24HR
74
ALORA 0.05 MG/24HR
74
ALORA 0.075 MG/24HR
75
ALORA 0.1 MG/24HR
75
alosetron hcl
77
ALPHAGAN P 0.1 %
94
ALPHAGAN P 0.15 %
94
alprazolam 0.25 mg, 0.5 mg, 1
mg, 2 mg
12
alprazolam 0.5 mg, 1 mg, 2 mg, 3
mg
12
ALPRAZOLAM INTENSOL 12
ALREX
95
ALTABAX
54
ALTACE
28
ALTOPREV
27
aluminum chloride
63
ALUVEA
60
ALVESCO
13
amantadine hcl 100 mg
34
AMANTADINE HCL 100 MG 34
amantadine hcl 50 mg/5ml 34
AMARYL
23
AMBI 12.5CPD/100GFN/30PSE
48
AMBIEN
80
AMBIEN CR
80
AMCINONIDE
57
AMERGE
84
AMICAR 0.25 GM/ML
79
AMICAR 1000 MG
79
amiloride &
hydrochlorothiazide
71
amiloride hcl
72
AMINOBENZOATE
POTASSIUM
107
AMINOCAPROIC ACID 1000
MG
79
aminocaproic acid 25 %
79
amiodarone hcl
12
AMITIZA
76
amitriptyline hcl
20
amlodipine besylate
42
Index 2
amlodipine besylateatorvastatin calcium

43
amlodipine besylate-benazepril
hcl
29
amlodipine besylate-olmesartan
medoxomil
29
amlodipine besylatevalsartan
29
amlodipine-valsartanhydrochlorothiazide
29
AMOXAPINE
20
amoxicillin
98
amoxicillin & pot
clavulanate
98
AMOXICILLIN ER
98
amoxicillin-clarithromycin w/
lansoprazole
104
amphetaminedextroamphetamine 1.25mg1.25mg-1.25mg-1.25mg,
1.875mg-1.875mg-1.875mg1.875mg, 2.5mg-2.5mg-2.5mg2.5mg, 3.125mg-3.125mg3.125mg-3.125mg, 3.75mg3.75mg-3.75mg-3.75mg, 5mg5mg-5mg-5mg, 7.5mg-7.5mg7.5mg-7.5mg
1
amphetaminedextroamphetamine 1.25mg1.25mg-1.25mg-1.25mg,
2.5mg-2.5mg-2.5mg-2.5mg,
3.75mg-3.75mg-3.75mg3.75mg, 5mg-5mg-5mg-5mg,
6.25mg-6.25mg-6.25mg6.25mg, 7.5mg-7.5mg-7.5mg7.5mg
1
ampicillin
98
AMPYRA
100
AMRIX
91
AMTURNIDE
29
ANADROL-50
9
ANAFRANIL
20
anagrelide hcl
79
ANALPRAM-HC 1%-2.5% 10
ANAPROX DS
3
ANASPAZ
103
ANASTIA
62
anastrozole
32
ANCOBON
25
ANDRODERM 2 MG/24HR 9
ANDRODERM 4 MG/24HR 9
ANDROGEL 20.25
MG/1.25GM, 40.5
MG/2.5GM
9
ANDROGEL 25 MG/2.5GM 9
ANDROGEL 50 MG/5GM
9
ANDROGEL PUMP 1 %
9
ANDROGEL PUMP 1.62 % 9
ANDROXY
9
ANGELIQ
74
ANORO ELLIPTA
14
ANTABUSE
99
ANTARA
27
ANUSOL-HC
10
ANZEMET 100 MG, 50 MG 24
APEXICON E
57
APIDRA
22
APIDRA SOLOSTAR
22
APLENZIN
18
apraclonidine hcl
94
APRISO
76
APTENSIO XR
2
APTIOM 200 MG, 400 MG, 600
MG
16
APTIOM 800 MG
16
APTIVUS
37
ARAVA 10 MG
5
ARAVA 20 MG
5
ARCAPTA NEOHALER
14
ARICEPT
99
ARICEPT ODT
99
ARIMIDEX
32
aripiprazole 1 mg/ml
37
aripiprazole 10 mg, 15 mg 37
aripiprazole 10 mg, 15 mg, 2 mg,
20 mg, 30 mg, 5 mg
37
armodafinil
2
ARMOUR THYROID 120 MG,
180 MG, 240 MG, 30 MG, 300
MG, 60 MG, 90 MG
102
ARMOUR THYROID 15
MG
102
ARNUITY ELLIPTA
13
AROMASIN
32
ARTHROTEC 50
3
ARTHROTEC 75
3
ARZOL SILVER NITRATE
APPLICATORS
57
ASACOL HD
76
ASCENSIA AUTODISC TEST
STRIPS
64
ASMANEX HFA
13
ASMANEX TWISTHALER 120

METERED DOSES
13
METERED DOSES
13
METERED DOSES
13
METERED DOSES
13
METERED DOSES
13
ASPIRIN-CAFFEINEDIHYDROCODEINE
7
ASPIRIN/DIPYRIDAMOLE 79
ASSURE 3 TEST STRIPS 64
ASSURE 4 TEST STRIPS 64
ASSURE II
64
ASSURE II CHECK STRIP 64
ASSURE II TEST STRIPS 64
ASSURE PLATINUM TEST
STRIPS
65
ASSURE PRO TEST
STRIPS
65
ASTAGRAF XL
40
ASTEPRO
92
AT LAST TEST STRIPS
65
ATABEX EC
87
ATACAND
28
ATACAND HCT
29
ATELVIA
72
atenolol
41
atenolol & chlorthalidone
29
ATIVAN 0.5 MG, 1 MG, 2
MG
12
atorvastatin calcium
27
atovaquone
11
atovaquone-proguanil hcl
31
ATRALIN
52
ATRIPLA
37
atropine sulfate (ophthalmic) 94
ATROPINE SULFATE 1 % 94
ATROVENT
92
ATROVENT HFA
13
AUBAGIO
100
AUGMENTIN 125MG/5ML31.25MG/5ML
98
AUGMENTIN 250MG/5ML62.5MG/5ML
98
AUGMENTIN 500MG-125MG,
875MG-125MG
98
AUGMENTIN ES-600
98
AUGMENTIN XR
98
AURYXIA
77
AVALIDE
29
AVANDAMET
21
AVANDARYL
21
AVANDIA
22
AVAPRO
28
AVAR
52
AVAR LS
52
AVAR LS CLEANSER
52
AVAR-E LS
52
AVC
106
AVELOX 400 MG
76
AVELOX ABC PACK
75
AVINZA
5
AVODART
78
AXERT
84
AXIRON
9
AYGESTIN
99
AZASAN
40
AZASITE
94
azathioprine 50 mg
40
azelastine hcl (ophth)
96
azelastine hcl 0.1 %
92
azelastine hcl 0.15 %
92
AZELEX
52
AZILECT
35
AZITHROMYCIN 1 GM
81
azithromycin 100 mg/5ml, 200
mg/5ml
81
azithromycin 250 mg
81
azithromycin 500 mg
81
azithromycin 600 mg
81
AZOPT
96
AZOR
29
AZULFIDINE
76
AZULFIDINE EN-TABS
76
bacitracin (ophthalmic)
94
bacitracin-poly-neomycin-hc
95
bacitracin-polymyxin b
(ophth)
94
baclofen
91
BACTRIM
10
BACTRIM DS
10
BACTROBAN
54
BACTROBAN NASAL
92
BAL-CARE DHA
87
balsalazide disodium
76
BANZEL
16
BARACLUDE 0.05 MG/ML 39
BARACLUDE 0.5 MG, 1 MG 39
BASAGLAR KWIKPEN
22
BASE GELATIN GUMMY
TROCHE
99
BAYER BREEZE 2 TEST
DISC
65
BAYER CONTOUR BLOOD
GLUCOSE TEST STRIPS 65
BAYER CONTOUR NEXT
BLOODGLUCOSE TEST
65
BD ECLIPSE NEEDLE 30G
X1/2"
83
BD INSULIN SYRINGE
ULTRAFINE/U-100/1ML/31G X
15/64"
83
BD NEEDLE/30G X 1/2"
83
BECONASE AQ
92
BELBUCA
8
BELLADONNA & OPIUM 103
BELLADONNA ALKALOIDS &
OPIUM
103
BELSOMRA
80
BELVIQ
1
benazepril &
hydrochlorothiazide
29
benazepril hcl
28
BENICAR
28
BENICAR HCT
29
BENSAL HP
62
BENTYL
103
BENZACLIN
52
BENZACLIN WITH PUMP 52
BENZAMYCIN
52
benzonatate 100 mg, 200
mg
48
BENZONATATE 150 MG
48
benzoyl peroxideerythromycin
52
benzphetamine hcl
1
benztropine mesylate 0.5 mg, 1
mg, 2 mg
34
BEPREVE
96
BESIVANCE
94
BETADINE OPHTHALMIC
PREP
94
BETAGAN
93
betamethasone dipropionate
(topical)
57
Index 3
betamethasone dipropionate
augmented
57
betamethasone valerate 0.1
%
57
betamethasone valerate 0.12
%
57
BETAPACE
42
BETAPACE AF
41
betaxolol hcl
41
betaxolol hcl (ophth)
93
bethanechol chloride
106
BETHKIS
3
BETIMOL
93
BETOPTIC-S
93
BEVESPI
14
bexarotene
34
BEYAZ
45
BG STAR BLOOD GLUCOSE
TEST
65
BIAXIN
81
bicalutamide
32
BIDIL
43
BILTRICIDE
10
BIMATOPROST
97
BINOSTO
72
BIO-STATIN
25
BIOBRON SF
48
BIODESP DM
48
BIONEL PEDIATRIC
48
BIOSCANNER GLUCOSE TEST
STRIPS
65
BIOSPEC DMX
48
bisacodyl
81
bisacodyl-peg 3350-pot chloridesod bicarb-sod chloride
80
bisoprolol &
hydrochlorothiazide
29
bisoprolol fumarate
41
BLEPH-10
94
BLEPHAMIDE
95
BLEPHAMIDE S.O.P.
95
BLOOD GLUCOSE TEST
STRIPS
65
BLOOD GLUCOSE TEST
STRIPS PREMIUM
65
BLUESTAR
82
BONIVA
73
BOSULIF
33
BP CLEANSING WASH
52
BREO ELLIPTA
14
Index 4
BREVICON-28
45
BRILINTA
79
brimonidine tartrate
94
BRINTELLIX
20
BRISDELLE
101
BRIVIACT
16
bromfenac sodium (ophth) 96
34
brompheniramine &
phenyleph
48
BROMPHENIRAMINE
TANNATE
26
BROMSITE
96
BRONKIDS
48
BROVANA
14
BROVEX PEB DM
48
BROVEX PSB
48
budesonide
47
budesonide (inhalation) 0.25
mg/2ml
13
budesonide (inhalation) 0.5
mg/2ml
13
budesonide (inhalation) 1
mg/2ml
13
budesonide (nasal)
92
bumetanide 0.5 mg, 1 mg, 2
mg
72
BUMEX
72
BUNAVAIL
8
BUPAP
5
BUPHENYL 3 GM/TSP
73
BUPHENYL 500 MG
73
buprenorphine hcl 2 mg
8
buprenorphine hcl 8 mg
8
buprenorphine hcl-naloxone hcl
dihydrate
8
bupropion hcl (smoking
deterrent)
100
bupropion hcl 100 mg, 150 mg,
200 mg
19
bupropion hcl 100 mg, 75
mg
19
bupropion hcl 150 mg, 300
mg
19
buspirone hcl
11
butalbital-acetaminophen 5
butalbital-acetaminophencaffeine 300mg-50mg-40mg,
325mg-50mg-40mg
5
butalbital-acetaminophencaffeine 325mg-50mg-40mg 5
butalbital-acetaminophencaffeine w/ codeine
7
5
w/cod
7
BUTISOL SODIUM
79
butorphanol tartrate 10 mg/ml 8
BUTRANS 10 MCG/HR, 20
MCG/HR, 5 MCG/HR
8
BUTRANS 15 MCG/HR
8
BUTRANS 7.5 MCG/HR
9
BYSTOLIC
41
BYVALSON
29
C-NATE DHA
87
cabergoline
74
CABOMETYX
33
CADUET
43
CAFERGOT
83
caffeine citrate
1
CALAN
42
CALAN SR
42
CALCIFOL
85
calcipotriene
56
calcipotriene-betamethasone
dipropionate
57
calcitonin (salmon)
73
CALCITRIOL
45
calcitriol (topical)
56
calcitriol 0.25 mcg, 0.5 mcg 73
calcitriol 1 mcg/ml
73
binder)
77
CALCIUM PNV
87
CALCIUM-FOLIC ACID PLUS
D
85
CAMBIA
84
CAMPRAL
99
CANASA
76
candesartan cilexetil
28
candesartan cilexetilhydrochlorothiazide
29
CANTIL
103
CAPCOF
48
capecitabine
32
CAPEX
58
CAPITAL/CODEINE
7
CAPRELSA
33
captopril
28
captopril &
hydrochlorothiazide
29
CARAC
56
CARAFATE 1 GM
104
CARAFATE 1 GM/10ML
104
CARB-O-LAC HP
60
CARB-O-LAC5
60
CARBAGLU
73
carbamazepine
16
CARBAPHEN 12
48
CARBAPHEN 12 PED
48
CARBATROL
16
carbidopa
34
carbidopa-levodopa 10mg100mg, 25mg-100mg, 25mg250mg
34
carbidopa-levodopa 25mg100mg, 50mg-200mg
35
carbidopa-levodopa-entacapone
35
carbinoxamine maleate 4 mg26
carbinoxamine maleate 4
mg/5ml
26
CARDIZEM
42
CARDIZEM CD
42
CARDIZEM LA 120 MG
42
CARDIZEM LA 180 MG, 240 MG,
300 MG, 360 MG, 420 MG 42
CARDURA
29
CARDURA XL
78
CAREONE BLOOD GLUCOSE
TEST STRIPS/PREMIUM 65
CAREONE BLOOD GLUCOSE
TEST STRIPS/VALUE
65
CARESENS N BLOOD
GLUCOSETEST STRIPS
65
carisoprodol 250 mg
91
carisoprodol 350 mg
91
carisoprodol w/ aspirin
92
carisoprodol w/ aspirin &
codeine
92
CARNITOR 1 GM/10ML
73
CARNITOR 330 MG
73
CARNITOR SF
73
carteolol hcl (ophth)
93
carvedilol 12.5 mg, 25 mg, 6.25
mg
41
carvedilol 3.125 mg
41
CASODEX
32
CATAFLAM
3
CATAPRES
29
CATAPRES-TTS-1
29
CATAPRES-TTS-2
29
CATAPRES-TTS-3
29
CAYSTON
10
CEDAX
44
CEFACLOR 125 MG/5ML, 250
MG/5ML, 375 MG/5ML
44
cefaclor 250 mg, 500 mg 44
CEFACLOR ER
44
cefadroxil
44
cefdinir
44
CEFDITOREN PIVOXIL 200
MG, 400 MG
44
cefixime
44
cefpodoxime proxetil
45
cefprozil
44
CEFTIBUTEN
45
CEFTIN 125 MG/5ML, 250
MG/5ML
44
CEFTIN 250 MG, 500 MG 44
cefuroxime axetil
44
CELEBREX 100 MG, 200
MG
3
CELEBREX 400 MG
3
CELEBREX 50 MG
3
celecoxib 100 mg, 200 mg 3
celecoxib 400 mg
3
celecoxib 50 mg
3
CELEXA 10 MG
19
CELEXA 20 MG
19
CELEXA 40 MG
19
CELLCEPT
40
CELONTIN
18
CEM-UREA
60
CENTANY
54
CENTANY AT
54
cephalexin 125 mg/5ml, 250
mg/5ml
44
cephalexin 250 mg, 500
mg
44
CEPHALEXIN 250 MG, 500
MG
44
cephalexin 750 mg
44
CERACADE
63
CERDELGA
79
CERVIDIL
98
CESAMET
25
CETRAXAL
97
CETYLEV
24
cevimeline hcl
86
CHANTIX
100
CHANTIX CONTINUING
MONTHPAK
100
CHANTIX STARTING MONTH
PAK
100
CHEMET
24
CHENODAL
76
CHERACOL PLUS
48
CHERACOL-D COUGH
49
chlordiazepoxide hcl
12
chlordiazepoxide hcl-clidinium
bromide
103
CHLORDIAZEPOXIDE/AMITRIP
TYLINE
100
chloroquine phosphate
31
CHLOROTHIAZIDE 250 MG 72
chlorothiazide 500 mg
72
chlorpheniramine w/ codeine 49
chlorpromazine hcl 10 mg, 100
mg, 200 mg, 25 mg, 50 mg 36
chlorpropamide
23
CHLORTHALIDONE 100
MG
72
chlorthalidone 25 mg, 50 mg 72
chlorzoxazone
91
cholestyramine 4 gm
26
cholestyramine 4 gm/dose 26
cholestyramine light 4 gm
26
cholestyramine light 4
gm/dose
26
choline & mag salicylate
5
choline fenofibrate
27
CHOLINE MAGNESIUM
TRISALICYLATE
5
CIALIS 10 MG, 20 MG
43
CIALIS 2.5 MG, 5 MG
43
ciclopirox 0.77 %
55
ciclopirox 1 %
55
ciclopirox 8 %
55
ciclopirox olamine
55
cilostazol
79
CILOXAN
94
cimetidine 300 mg, 400 mg, 800
mg
103
cimetidine hcl
103
CIPRO
76
CIPRO HC
97
CIPRO XR 1000MG
76
CIPRO XR 500MG
76
CIPRODEX
97
ciprofloxacin
76
Index 5
ciprofloxacin hcl (ophth)

94
ciprofloxacin hcl (otic)
97
CIPROFLOXACIN HCL 100
MG
76
ciprofloxacin hcl 250 mg, 500 mg,
750 mg
76
ciprofloxacin-ciprofloxacin hcl
1000mg
76
ciprofloxacin-ciprofloxacin hcl
500mg
76
citalopram hydrobromide 10
mg
19
mg/5ml
19
mg
19
mg
19
CITRANATAL 90 DHA
87
CITRANATAL ASSURE
87
CITRANATAL B-CALM
87
CITRANATAL DHA
87
CITRANATAL HARMONY 87
CITRANATAL RX
87
CLARIFOAM EF
52
CLARINEX 0.5 MG/ML
26
CLARINEX 5 MG
26
CLARINEX-D 12 HOUR
49
clarithromycin 125 mg/5ml, 250
mg/5ml
81
clarithromycin 250 mg, 500
mg
81
clarithromycin 500 mg
82
CLEMASTINE FUMARATE 0.67
MG/5ML
26
clemastine fumarate 2.68 mg26
CLEMASTINE FUMARATE 2.68
MG
26
CLEOCIN 100 MG
106
CLEOCIN 150 MG, 300 MG, 75
MG
11
CLEOCIN 2 %
106
CLEOCIN PEDIATRIC
GRANULES
11
CLEOCIN-T
52
CLEVER CHEK AUTO-CODE
TEST STRIPS
65
CLEVER CHEK AUTO-CODE
VOICE TEST STRIPS
65
CLEVER CHEK TEST
STRIPS
65
CLEVER CHOICE AUTO-CODE
PRO TEST STRIPS
65
Index 6
CLEVER CHOICE COMFORT

EZINSULIN PEN NEEDLES
33GX4MM
83
EZPEN NEEDLES
33GX4MM
83
EZPEN NEEDLES
33GX5MM
83
EZPEN NEEDLES
33GX6MM
83
EZPEN NEEDLES
33GX8MM
83
CLEVER CHOICE MICRO
TESTSTRIPS
65
CLIMARA
75
CLIMARA PRO
74
clindamycin hcl
11
clindamycin palmitate
hydrochloride
11
(topical)
52
vaginal
106
clindamycin phosphate-benzoyl
peroxide
52
clindamycin phosphate-benzoyl
peroxide (refrigerate)
52
clindamycin phosphatetretinoin
52
CLINDESSE
106
58
clobetasol propionate emollient
base
58
emulsion
58
CLOBEX
58
CLOCORTOLONE
PIVALATE
58
CLOCORTOLONE PIVALATE
PUMP
58
CLODERM
58
CLODERM PUMP
58
clomiphene citrate
73
clomipramine hcl
20
clonazepam
16
clonidine hcl (adhd)
1
clonidine hcl 0.1 mg, 0.2 mg,
0.3 mg
29
clonidine hcl 0.1 mg/24hr, 0.2
29
clopidogrel bisulfate
79
clorazepate dipotassium 12
CLORPRES
29
clotrimazole
86
clotrimazole (topical)
55
clotrimazole w/
betamethasone
55
clozapine 100 mg, 200 mg, 25
mg, 50 mg
36
clozapine 100 mg, 25 mg
36
CLOZAPINE ODT
36
CLOZARIL
36
COARTEM
31
COCAINE HCL
62
CODAR AR
49
CODAR D
49
codeine sulfate 15 mg, 30 mg, 60
mg
6
CODEINE SULFATE 30
MG/5ML
6
CODITUSSIN AC
49
COLAZAL
77
COLCHICINE
78
colchicine
78
colchicine w/ probenecid
78
COLCRYS
78
COLESTID
26
COLESTID FLAVORED
26
colestipol hcl 1 gm
27
colestipol hcl 5 gm
27
COLY-MYCIN S
97
COLYTE-FLAVOR PACKS
227.1GM-21.5GM-5.53GM2.82GM-6.36GM
80
COLYTE-FLAVOR PACKS
240GM-22.72GM-5.84GM2.98GM-6.72GM
80
COMBIGAN
93
COMBIPATCH
74
COMBIVENT RESPIMAT
14
COMBIVIR
37
COMETRIQ
33
COMPLERA
37
COMPLETENATE
87
COMTAN
34
CONCEPT DHA
87
CONCEPT OB
87
CONCERTA 18 MG, 27 MG, 54
MG
2
CONCERTA 36 MG
2
CONDYLOX
62
CONTRAVE
1
CONTROL AST
65
CONTROL TEST STRIPS 65
CONZIP 100 MG, 200 MG
6
COPEGUS
39
CORDARONE
12
CORDRAN 0.05 %
58
CORDRAN 4 MCG/SQCM 58
CORDRAN TAPE
58
COREG 12.5 MG, 25 MG, 6.25
MG
41
COREG 3.125 MG
41
COREG CR
41
CORGARD
42
CORIFACT
78
CORLANOR
44
CORTANE-B
58
CORTANE-B AQUEOUS
97
CORTANE-B-OTIC
97
CORTEF
47
CORTENEMA
10
CORTIFOAM
10
cortisone acetate
47
CORTISPORIN
54
CORTISPORIN-TC
97
CORZIDE
29
COSOPT
93
COSOPT PF
93
COTELLIC
33
COUMADIN
15
COZAAR
28
CPB WC
49
CREON
71
CRESEMBA
25
CRESTOR
27
CRINONE 8 %
106
CRIXIVAN
37
CROMOLYN SODIUM
13
cromolyn sodium
(mastocytosis)
76
cromolyn sodium (ophth)
96
CUPRIMINE
40
CUTIVATE
58
CUVPOSA
103
CVS WOMENS
PRENATAL+DHA
87
CYCLESSA
45
cyclobenzaprine hcl 10 mg, 5
mg
91
cyclobenzaprine hcl 7.5

mg
91
CYCLOGYL
94
CYCLOMYDRIL
94
cyclopentolate hcl
94
CYCLOPHOSPHAMIDE 25
MG
31
CYCLOPHOSPHAMIDE 50
MG
32
CYCLOSERINE
31
CYCLOSET
22
cyclosporine 100 mg, 25
mg
40
CYCLOSPORINE
MODIFIED
40
microemulsion)
40
CYMBALTA
20
cyproheptadine hcl
26
CYSTADANE
73
CYSTAGON
78
CYSTARAN
96
CYTOMEL
102
CYTOTEC
104
DAKLINZA 30 MG, 60 MG 39
DAKLINZA 90 MG
39
DALIRESP
13
DALLERGY
49
danazol
9
DANTRIUM
92
dantrolene sodium 100 mg, 25
mg, 50 mg
92
dapsone
11
DARAPRIM
31
darifenacin hydrobromide 105
DAYPRO
3
DAYTRANA
2
DDAVP 0.01 %
74
DDAVP 0.1 MG, 0.2 MG 74
DECON-G
49
DELZICOL
77
DEMADEX
72
demeclocycline hcl
101
DEMEROL 100 MG, 50 MG 6
DEMSER
28
DENAVIR
57
DEPAKENE
18
DEPAKOTE
18
DEPAKOTE ER
18
DEPAKOTE SPRINKLES
18
DEPEN TITRATABS
40
DERMA-SMOOTHE/FS
BODY
58
DERMA-SMOOTHE/FS
SCALP
58
DERMATOP
58
DERMOTIC
98
DESCOVY
37
DESGEN DM
49
desipramine hcl
20
desloratadine
26
DESLORATADINE ODT
26
desmopressin acetate 0.1 mg,
0.2 mg
74
refrigerated
74
desmopressin acetate spray 74
desmopressin acetate spray
refrigerated
74
DESOGEN
45
desogestrel & ethinyl
estradiol
45
desogestrel-ethinyl estradiol
(biphasic)
45
desogestrel-ethinyl estradiol
(triphasic)
45
DESONATE
58
desonide
58
DESOWEN
58
DESOXIMETASONE 0.05 % 58
desoximetasone 0.05 %
58
desoximetasone 0.25 %
58
DESOXYN
1
DESVENLAFAXINE ER 100 MG,
50 MG
20
DETROL
105
DETROL LA
105
dexamethasone
47
DEXAMETHASONE
INTENSOL
47
dexamethasone sodium
phosphate (ophth)
95
dexchlorpheniramine
maleate
26
DEXEDRINE
1
DEXILANT
104
dexmethylphenidate hcl 10 mg,
15 mg, 20 mg, 30 mg, 40 mg, 5
mg
2
dexmethylphenidate hcl 10 mg,
2.5 mg, 5 mg
2
Index 7
DEXPAK 10 DAY
47
DEXPAK 13 DAY
47
DEXPAK 6 DAY
47
dextroamphetamine sulfate 10
mg, 15 mg, 5 mg
1
mg, 5 mg
1
mg/5ml
1
dextromethorphan-guaifenesin
10mg/5ml-100mg/5ml, 10mg/5ml10mg/5ml-100mg/5ml100mg/5ml, 15mg/7.5ml150mg/7.5ml
49
10mg/5ml-100mg/5ml,
20mg/10ml-200mg/10ml
49
30mg-600mg, 60mg1200mg
49
DIABETA
23
DIAMOX
71
DIASTAT ACUDIAL
16
DIASTAT PEDIATRIC
16
DIATRUE PLUS BLOOD
diazepam 1 mg/ml
12
diazepam 10 mg, 2 mg, 5
mg
12
DIAZEPAM 10 MG, 2.5 MG, 20
MG
16
diazepam 5 mg/ml
12
DIBENZYLINE
28
DICLEGIS
25
diclofenac potassium
3
diclofenac sodium (actinic
keratoses)
56
diclofenac sodium (ophth) 96
diclofenac sodium (topical) 1
%
54
diclofenac sodium (topical) 1.5
%
54
diclofenac sodium 100 mg
3
diclofenac sodium 25 mg, 50 mg,
75 mg
3
diclofenac w/ misoprostol
3
dicloxacillin sodium
98
dicyclomine hcl
103
didanosine
37
DIFFERIN 0.1 %
52
DIFFERIN 0.3 %
52
DIFICID
82
diflorasone diacetate
58
Index 8
DIFLORASONE
DIACETATE
58
DIFLUCAN
25
diflunisal
5
digoxin 0.05 mg/ml
43
digoxin 0.125 mg, 0.25 mg, 125
mcg, 250 mcg
43
DIHYDROERGOTAMINE
MESYLATE 4 MG/ML
84
DILANTIN 100 MG
18
DILANTIN 30 MG
18
DILANTIN INFATABS
18
DILANTIN-125
18
DILATRATE SR
11
DILAUDID
6
diltiazem hcl 120 mg, 180 mg,
240 mg
42
diltiazem hcl 120 mg, 30 mg, 60
mg, 90 mg
42
diltiazem hcl 120 mg, 60 mg, 90
mg
42
diltiazem hcl coated beads 120
mg, 180 mg, 240 mg, 300 mg,
360 mg
42
diltiazem hcl coated beads 180
mg, 240 mg, 300 mg, 360 mg,
420 mg
42
diltiazem hcl extended release
beads
42
DIOVAN
28
DIOVAN HCT
29
DIPENTUM
77
diphenoxylate w/ atropine 24
DIPROLENE
58
DIPROLENE AF
58
dipyridamole
79
disopyramide phosphate 12
disulfiram
99
DITROPAN XL
105
DIURIL
72
divalproex sodium
18
DIVIGEL
75
dofetilide
12
DOLOGESIC
5
DOLOPHINE
6
DOMETUSS-DMX
49
donepezil hydrochloride 99
DONNATAL 0.1037MG0.0065MG-0.0194MG-16.2MG
103
DONNATAL 0.1037MG/5ML0.0065MG/5ML-0.0194MG/5ML16.2MG/5ML
103
DONNATAL EXTENTABS 103
DORAL
80
DORYX 200 MG
101
dorzolamide hcl
96
dorzolamide hcl-timolol
maleate
93
DOTHELLE DHA
87
DOVONEX
56
doxazosin mesylate
29
doxepin hcl
20
DOXEPIN
HYDROCHLORIDE
56
doxercalciferol 0.5 mcg, 1 mcg,
2.5 mcg
73
DOXYCYCLINE
63
doxycycline (monohydrate) 100
mg, 50 mg, 75 mg
101
mg
101
mg/5ml
101
doxycycline hyclate 100 mg 101
doxycycline hyclate 100 mg, 150
mg, 75 mg
101
doxycycline hyclate 100 mg, 50
mg
101
DRISDOL
107
dronabinol
25
drospirenone-ethinyl estradiol
3mg-0.02mg
45
drospirenone-ethinyl estradiol
3mg-0.03mg
45
drospirenone-ethinyl estradiollevomefolate calcium
45
DROXIA 200 MG, 300 MG 79
DROXIA 400 MG
79
DRYSOL
63
DUAC
52
DUAVEE
74
DUET DHA 400
87
DUET DHA 400EC
87
DUET DHA 430
87
DUET DHA 430EC
87
DUET DHA BALANCED
87
DUETACT
21
DUEXIS
4
DULCOLAX
81
DULERA
14
duloxetine hcl 20 mg, 30 mg, 60
mg
20
DULOXETINE HCL 40 MG 20
DUO-CARE TEST STRIPS 65
DURAFLU
49
DURAGESIC
6
DUREZOL
95
dutasteride
78
dutasteride-tamsulosin hcl 78
DUTOPROL 100MG-12.5MG,
25MG-12.5MG, 50MG12.5MG
29
DYANAVEL XR
1
DYAZIDE
71
DYMISTA
92
DYRENIUM
72
E.E.S. GRANULES
82
EASY PLUS BLOOD GLUCOSE
TEST STRIPS
65
EASY PLUS II BLOOD
GLUCOSE TEST
66
EASY STEP TEST STRIPS 66
EASY TALK BLOOD GLUCOSE
TEST STRIPS
66
EASY TOUCH FLIPLOCK
NEEDLES 30GX1/2"
83
EASY TOUCH GLUCOSE TEST
STRIPS
66
EASY TOUCH HYPODERMIC
NEEDLES 30GX1/2"
83
EASY TRAK BLOOD GLUCOSE
TEST STRIPS
66
EASYGLUCO
66
EASYMAX 15 TEST
STRIPS
66
EASYMAX TEST STRIPS 66
EASYPLUS BLOOD GLUCOSE
TEST STRIP
66
EASYPRO BLOOD GLUCOSE
TEST STRIPS
66
EASYPRO PLUS
66
EC-NAPROSYN 500 MG
4
econazole nitrate
55
ECOZA
55
ED BRON GP
49
EDARBI
28
EDARBYCLOR
29
EDECRIN
72
EDLUAR
80
EDURANT
37
EFFER-K
85
EFFEXOR XR 150 MG
20
EFFEXOR XR 37.5 MG, 75
MG
20
EFFIENT
79
EFUDEX
56
ELAVIL
20
ELDEPRYL
35
ELEMENT COMPACT TEST
STRIPS
66
ELEMENT TEST STRIPS 66
ELESTAT
96
ELESTRIN
75
ELIDEL
61
ELIMITE
63
ELIPHOS
77
ELIQUIS
15
ELIXOPHYLLIN
15
ELLA
47
ELMIRON
78
ELOCON
59
EMADINE
96
EMBEDA
6
EMBRACE BLOOD GLUCOSE
TEST STRIPS
66
EMCYT
32
EMEND
25
EMEND 125 MG
25
EMEND 125 MG, 80 MG 25
EMEND 40 MG
25
EMLA
62
EMSAM
19
EMTRIVA
37
EMULSION SB
63
ENABLEX
105
enalapril maleate
28
enalapril maleate &
hydrochlorothiazide
29
ENBRACE HR
87
ENDOMETRIN
106
ENJUVIA 0.3 MG, 0.45 MG,
0.625 MG, 1.25 MG
75
ENJUVIA 0.9 MG
75
ENOVARXCYCLOBENZAPRINE
HCL
91
enoxaparin sodium 100
mg/ml
15
mg/0.8ml, 150 mg/ml
15
enoxaparin sodium 30 mg/0.3ml,

40 mg/0.4ml, 60 mg/0.6ml, 80
mg/0.8ml
15
mg/3ml
15
entacapone
34
entecavir
39
ENTEREG
77
ENTOCORT EC
47
ENTRESTO
43
ENTTY SPRAY EMULSION 63
ENVARSUS XR
40
EPANED
28
EPCLUSA
39
EPICERAM
63
EPIDUO
52
EPIDUO FORTE
52
EPIFOAM
59
epinastine hcl (ophth)
96
EPIVIR
37
EPIVIR HBV 100 MG
39
EPIVIR HBV 5 MG/ML
39
eplerenone
30
EPROSARTAN MESYLATE 28
EPZICOM
37
EQL TRUETEST BLOOD
GLUCOSE TEST
66
EQL TRUETRACK TEST
66
EQUETRO
35
ergocalciferol
107
ergoloid mesylates
100
ERGOMAR
84
ERIVEDGE
32
ERTACZO
55
ERY-TAB
82
ERYGEL
52
ERYPED 200
82
ERYPED 400
82
53
erythromycin (ophth)
94
erythromycin base
82
erythromycin ethylsuccinate 82
erythromycin stearate
82
ESBRIET
101
ESCAVITE D
86
escitalopram oxalate
19
ESGIC
5
Index 9
esomeprazole magnesium 20
mg
104
esomeprazole magnesium 40
mg
104
ESOMEPRAZOLE STRONTIUM
24.65 MG, 49.3 MG
104
estazolam
80
esterified estrogens &
methyltestosterone
74
ESTRACE 0.1 MG/GM
106
ESTRACE 0.5 MG, 1 MG, 2
MG
75
estradiol & norethindrone
acetate
74
estradiol 0.025 mg/24hr
75
estradiol 0.025 mg/24hr, 0.05
mg/24hr, 0.06 mg/24hr, 0.075
mg/24hr, 0.1 mg/24hr, 37.5
mcg/24hr
75
75
75
estradiol 0.075 mg/24hr, 0.1
mg/24hr
75
estradiol 0.5 mg, 1 mg, 2 mg 75
estradiol vaginal
106
ESTRING
106
ESTROGEL
75
ESTROPIPATE 0.75 MG, 1.5
MG
75
estropipate 0.75 mg, 1.5 mg, 3
mg
75
ESTROSTEP FE
45
eszopiclone
80
ethacrynic acid
72
ethambutol hcl
31
ethosuximide
18
ETHYL CHLORIDE
62
ETHYL CHLORIDE/FINE
PINPOINT
62
ETHYL CHLORIDE/FINE
STREAM
62
ETHYL CHLORIDE/MEDIUM
JET STREAM
62
ETHYL CHLORIDE/MEDIUM
STREAM
62
ETHYL CHLORIDE/MIST
62
ethynodiol diacet & eth estrad
1mg-35mcg, 1mg-50mcg
45
ethynodiol diacet & eth estrad
1mg-50mcg
45
ETIDRONATE DISODIUM 73
etodolac 200 mg, 300 mg
4
etodolac 400 mg, 500 mg
4
Index 10
etodolac 400 mg, 500 mg, 600

mg
4
etoposide
34
EURAX
63
EVAMIST
75
EVENCARE + BLOOD
GLUCOSETEST STRIP 66
EVENCARE BLOOD
GLUCOSE TEST STRIP 66
EVENCARE G2 TEST
STRIPS
66
EVENCARE G3 TEST
STRIPS
66
EVISTA
73
EVOCLIN
53
EVOLUTION AUTOCODE 66
EVOTAZ
37
EVOXAC
86
EXACTECH R-S-G TEST
STRIPS
66
EXACTECH TEST
STRIPS
66
EXACTUSS
49
EXACTUSS TR
49
EXALGO 12 MG, 16 MG, 8
MG
6
EXALGO 32 MG
6
EXAPHEX TR
49
EXELDERM
55
EXELON
99
exemestane
32
EXFORGE
29
EXFORGE HCT
29
EXJADE
24
EXODERM
55
EXTINA
55
EXTRA-VIRT PLUS DHA 87
EYEAID IRRIGATING
SOLUTION
96
EZ SMART BLOOD GLUCOSE
TEST STRIPS
66
EZ SMART PLUS BLOOD
FABIOR
53
FACTIVE
76
famciclovir
40
famotidine 20 mg
103
famotidine 40 mg
103
famotidine 40 mg/5ml
103
FAMVIR
40
FANAPT
36
FANAPT TITRATION PACK 36

FARESTON
32
FARXIGA
23
FARYDAK
33
FAZACLO 100 MG, 25 MG 36
FAZACLO 12.5 MG, 150 MG,
200 MG
36
felbamate
18
FELBATOL
18
FELDENE
4
felodipine
42
FEM PH
106
FEMARA
32
FEMCON FE
45
FEMHRT LOW DOSE
74
FEMRING
106
fenofibrate 145 mg, 160 mg, 48
mg, 54 mg
27
FENOFIBRATE 150 MG, 50
MG
27
fenofibrate micronized
27
FENOFIBRIC ACID
27
FENOPROFEN CALCIUM 200
MG
4
FENOPROFEN CALCIUM 400
MG
4
fenoprofen calcium 600 mg 4
FENORTHO 200 MG
4
FENORTHO 400 MG
4
fentanyl 100 mcg/hr, 12 mcg/hr,
25 mcg/hr, 50 mcg/hr, 75
mcg/hr
6
FENTANYL 37.5 MCG/HR, 62.5
MCG/HR, 87.5 MCG/HR
6
fentanyl citrate
6
FENTORA
6
FERRIPROX 100 MG/ML
24
FERRIPROX 500 MG
24
FETZIMA 120 MG, 40 MG, 80
MG
20
FETZIMA 20 MG
20
FETZIMA TITRATION PACK20
FEXMID
91
FIBRICOR
27
FIFTY50 GLUCOSE TEST
STRIP 2.0
67
FINACEA
63
finasteride
78
FIORICET
5
FIORICET/CODEINE
7
FIORINAL
5
FIORINAL/CODEINE #3
7
FIRAZYR
78
FIRST-BXN MOUTHWASH 86
FIRST-DUKES
MOUTHWASH
86
FIRST-LANSOPRAZOLE 104
FIRST-MARYS
MOUTHWASH
86
FIRST-MOUTHWASH BLM 85
FIRST-OMEPRAZOLE
104
FIRST-VANCOMYCIN 25
10
FIRST-VANCOMYCIN 50
10
FLAGYL
10
FLAREX
95
flavoxate hcl
106
flecainide acetate
12
FLECTOR
54
FLOMAX
78
FLONASE
92
FLONASE ALLERGY
RELIEF
92
FLONASE ALLERGY RELIEF
CHILDRENS
92
FLORIVA
85
FLORIVA PLUS
86
FLOVENT DISKUS 100
MCG/BLIST
13
FLOVENT DISKUS 250
MCG/BLIST
14
FLOVENT DISKUS 50
MCG/BLIST
14
FLOVENT HFA 110 MCG/ACT,
220 MCG/ACT
14
FLOVENT HFA 44
MCG/ACT
14
FLOWTUSS
49
FLOXIN OTIC
97
fluconazole
25
flucytosine
25
fludrocortisone acetate
48
FLUMADINE
40
FLUMIST QUADRIVALENT106
flunisolide (nasal)
92
fluocinolone acetonide
59
fluocinolone acetonide (otic) 98
fluocinonide 0.05 %
59
fluocinonide 0.05 %, 0.1 % 59
fluocinonide 0.1 %
59
fluocinonide emulsified base 59
FLUORABON
85
fluorescein sodium topical 96
fluorometholone (ophth) 95
FLUOROPLEX
56
FLUOROURACIL
56
fluorouracil (topical)
56
FLUOXETINE
100
fluoxetine hcl (pmdd)
100
fluoxetine hcl 10 mg, 20
mg
19
fluoxetine hcl 10 mg, 20 mg, 40
mg
19
fluoxetine hcl 20 mg/5ml 19
FLUOXETINE HCL 60 MG 19
fluoxetine hcl 90 mg
19
fluphenazine hcl 1 mg, 10 mg,
2.5 mg, 5 mg
36
fluphenazine hcl 2.5
mg/5ml
36
FLUPHENAZINE HCL 5
MG/ML
36
FLURA-DROPS
85
flurandrenolide
59
flurazepam hcl
80
flurbiprofen 100 mg
4
flurbiprofen 50 mg
4
flurbiprofen sodium
96
flutamide
32
fluticasone propionate
(nasal)
92
fluticasone propionate 0.005
%
59
fluticasone propionate 0.05
%
59
fluvastatin sodium
27
fluvoxamine maleate
19
FML
95
FML FORTE
95
FML LIQUIFILM
95
FOCALGIN 90 DHA
87
FOCALGIN CA
87
FOCALGIN-B
87
FOCALIN
2
FOCALIN XR 10 MG, 15 MG,
20 MG, 30 MG, 40 MG, 5
MG
2
FOCALIN XR 25 MG, 35
MG
2
FOLCAL DHA
87
FOLCAPS OMEGA 3
87
FOLET DHA
87
FOLET ONE
87
folic acid 1 mg
79
folic acid 400 mcg, 800 mcg 79
FOLIVANE-F
79
FOLIVANE-OB
87
FORA D10 BLOOD GLUCOSE
TEST STRIPS
67
FORA D15G BLOOD GLUCOSE
TEST STRIPS
67
FORA D20 BLOOD GLUCOSE
TEST STRIPS
67
FORA G20 BLOOD GLUCOSE
TEST STRIPS
67
FORA G30A BLOOD GLUCOSE
TEST STRIPS
67
FORA GD20 TEST STRIPS 67
FORA V10 BLOOD GLUCOSE
TEST STRIPS
67
TEST STRIPS
67
TEST STRIPS
67
FORA V30A BLOOD GLUCOSE
TEST STRIPS
67
FORACARE GD40
67
FORACARE PREMIUM V10
TESTSTRIPS
67
FORACARE TEST N GO TEST
STRIPS
67
FORADIL AEROLIZER
14
FORFIVO XL
19
formaldehyde
37
FORTAMET
21
FORTESTA
9
FOSAMAX
73
FOSAMAX PLUS D
73
fosinopril sodium
28
fosinopril sodium &
hydrochlorothiazide
29
FOSRENOL
77
FREESTYLE FREEDOM
LITE
82
FREESTYLE INSULINX
BLOODGLUCOSE
MONITORING SYSTEM
83
FREESTYLE INSULINX
BLOODGLUCOSE TEST
67
FREESTYLE INSULINX
BLOODGLUCOSE TEST
STRIPS
67
FREESTYLE LITE BLOOD
GLUCOSE MONITORING
SYSTEM
83
FREESTYLE LITE TEST
STRIPS
67
Index 11
FREESTYLE TEST STRIPS 67

FROVA
84
frovatriptan succinate
84
FUL-GLO
96
FULYZAQ
24
FURADANTIN
105
furosemide 10 mg/ml
72
furosemide 20 mg, 40 mg, 80
mg
72
FUROSEMIDE 8 MG/ML
72
FYCOMPA
16
gabapentin
16
GABITRIL 12 MG, 16 MG
18
GABITRIL 2 MG, 4 MG
18
galantamine hydrobromide 12
mg, 4 mg, 8 mg
99
galantamine hydrobromide 16
mg, 24 mg, 8 mg
99
GALANTAMINE
HYDROBROMIDE 4 MG/ML 99
GALZIN
85
GARAMYCIN
94
GASTROCROM
76
gatifloxacin (ophth)
94
GE100 BLOOD GLUCOSE
TESTSTRIPS
67
GEBAUERS INSTANT ICE 62
GEBAUERS PAIN EASE
62
GEBAUERS SPRAY AND
STRETCH
62
GEL-KAM ORAL CARE
RINSE
86
GELCLAIR
86
GELFILM OP
96
GELNIQUE
105
gemfibrozil
27
GENERESS FE
45
gentamicin sulfate (ophth) 94
gentamicin sulfate (topical) 54
GENVOYA
37
GEODON
35
GESTICARE DHA
87
GIAZO
77
GILENYA
100
GILOTRIF
33
GILPHEX TR
49
GILTUSS
49
GILTUSS TR
49
GLEEVEC
33
Index 12
GLENMAX PEB
49
GLEOSTINE
32
glimepiride
23
glipizide
23
glipizide-metformin hcl
21
GLUCAGEN
DIAGNOSTIC
63
GLUCO PERFECT 3 TEST
STRIPS
67
GLUCOCARD 01 SENSOR
PLUS
67
GLUCOCARD 01 SENSOR
PLUSTEST STRIPS
67
GLUCOCARD EXPRESSION
BLOOD GLUCOSE TEST
STRIPS
68
GLUCOCARD VITAL TEST
STRIPS
68
GLUCOCARD X-SENSOR 68
GLUCOCOM TEST
STRIPS
68
GLUCONAVII BLOOD
GLUCOSETEST STRIPS 68
GLUCOPHAGE
21
GLUCOPHAGE XR
21
GLUCOTROL
23
GLUCOTROL XL
23
GLUCOVANCE
21
glyburide
23
glyburide micronized
23
glyburide-metformin
21
glycopyrrolate 1 mg, 2 mg103
GLYNASE
23
GLYSET
21
GLYXAMBI
21
GMATE BLOOD GLUCOSE
TESTSTRIPS
68
GOLYTELY 227.1GM-21.5GM5.53GM-2.82GM-6.36GM 80
GOLYTELY 236GM-22.74GM5.86GM-2.97GM-6.74GM 80
GORDONS UREA
60
GRALISE
100
GRALISE STARTER
100
granisetron hcl 1 mg
24
GRANULEX
61
GRIFULVIN V
25
GRIS-PEG
25
griseofulvin microsize
25
griseofulvin ultramicrosize 25
guaifenesin 400 mg
51
guaifenesin-codeine 100mg/5ml10mg/5ml
49
guaifenesin-codeine 100mg/5ml6.3mg/5ml
49
guaifenesin-codeine 200mg/5ml8mg/5ml, 225mg/5ml7.5mg/5ml
49
guanfacine hcl
29
guanfacine hcl (adhd)
1
GUANIDINE HCL
31
GUM BASE GELATIN
99
GYNAZOLE-1
106
HALAC
59
HALCION
80
halobetasol propionate
59
HALOG
59
haloperidol
36
haloperidol lactate 2 mg/ml 36
HALOTIN
55
HARVONI
39
HECTOROL 0.5 MCG, 1 MCG,
2.5 MCG
73
HEMANGEOL
42
HEMENATAL OB
87
HEMENATAL OB + DHA
87
HEPSERA
39
HETLIOZ
80
HEXALEN
32
HIPREX
105
HISTEX-PE
49
homatropine hbr
94
HORIZANT
100
HUMALOG
22
HUMALOG KWIKPEN 100
UNIT/ML
22
HUMALOG KWIKPEN 200
UNIT/ML
22
HUMALOG MIX 50/50
22
HUMALOG MIX 50/50
KWIKPEN
22
HUMALOG MIX 75/25
22
HUMALOG MIX 75/25
KWIKPEN
22
HUMULIN 70/30
22
HUMULIN 70/30 KWIKPEN 22
HUMULIN N
22
HUMULIN N KWIKPEN
22
HUMULIN R
22
HUMULIN R U-500
(CONCENTRATED)
22
HUMULIN R U-500
KWIKPEN
22
hyaluronate sodium
(emollient)
61
HYCAMTIN 0.25 MG, 1 MG 34
HYCET
7
HYCOFENIX
49
hydralazine hcl 10 mg, 100 mg,
25 mg, 50 mg
31
HYDREA
34
HYDRO 35
60
HYDRO 40 FOAM
60
hydrochlorothiazide 12.5 mg 72
hydrochlorothiazide 25 mg, 50
mg
72
hydrocodone polistirexchlorpheniramine polistirex 49
hydrocodone w/
homatropine
48
hydrocodone-acetaminophen
10mg-300mg, 5mg-300mg,
7.5mg-300mg
8
10mg-325mg, 5mg-325mg,
7.5mg-325mg
8
2.5mg-325mg
8
2.5mg/5ml-108mg/5ml,
5mg/10ml-217mg/10ml,
7.5mg/15ml-325mg/15ml
7
hydrocodone-ibuprofen 200mg10mg
8
hydrocodone-ibuprofen 200mg10mg, 200mg-7.5mg
8
hydrocodone-ibuprofen 200mg2.5mg, 200mg-5mg
8
HYDROCODONE/ACETAMINOP
HEN
8
hydrocortisone
47
hydrocortisone (intrarectal) 10
hydrocortisone (rectal)
10
hydrocortisone (topical) 2 % 59
hydrocortisone (topical) 2.5
%
59
59
hydrophilic lipo base
59
hydrocortisone valerate
59
hydrocortisone w/acetic acid 98
hydromorphone hcl 1 mg/ml 6
hydromorphone hcl 12 mg, 16
mg, 8 mg, 8mg
6
hydromorphone hcl 2 mg, 4 mg, 8
mg
6
hydromorphone hcl 32 mg 6
hydroxychloroquine sulfate 31
hydroxyurea
34
hydroxyzine hcl
11
hydroxyzine pamoate
12
HYLIRA 0.1 %
61
HYLIRA 0.2 %
61
hyoscyamine sulfate
103
HYPER-SAL
51
HYPERSAL 3.5 %
51
HYPERSAL 7 %
51
HYPODERMIC NEEDLE
30GX1/2"
83
HYSINGLA ER
6
HYZAAR
30
ibandronate sodium
73
IBRANCE
33
ibuprofen 400 mg, 600 mg, 800
mg
4
ICLUSIG
33
ILEVRO
96
imatinib mesylate 100 mg 33
imatinib mesylate 400 mg 33
IMBRUVICA
33
imipramine hcl
20
imipramine pamoate
20
imiquimod
61
IMITREX 100 MG, 25 MG, 50
MG
84
IMITREX 20 MG/ACT
84
IMITREX 5 MG/ACT
84
IMODIUM A-D
24
IMURAN
40
INCIVEK
39
INCRUSE ELLIPTA
13
indapamide
72
INDERAL LA
42
INDERAL XL
42
INDOCIN 25 MG/5ML
4
INDOCIN 50 MG
4
indomethacin 25 mg, 50 mg 4
indomethacin 75 mg
4
INFANATE BALANCE
87
INFANATE PLUS
87
INFINITY BLOOD GLUCOSE
TEST STRIPS
68
INLYTA
33
INNOPRAN XL
42
INSPRA
30
INSULIN SYRINGES AND PEN
NEEDLES
83
INSUPEN 33GX4MM
83
INTEGRA F
79
INTELENCE
37
INTERMEZZO
80
INTUNIV
1
INVEGA
36
INVIRASE
37
INVOKAMET
21
INVOKAMET XR
21
INVOKANA
23
IODINE STRONG
85
iodoquinol-hc
55
iodoquinol-hydrocortisone in aloe
vehicle
55
IOPIDINE 0.5 %
94
IOPIDINE 1 %
94
ipratropium bromide
13
ipratropium bromide (nasal) 92
ipratropium-albuterol
14
irbesartan
28
irbesartan-hydrochlorothiazide
30
IRENKA
20
IRESSA
33
ISENTRESS
37
isometheptene-caffeineacetaminophen
83
isometheptenedichloralphenazoneacetaminophen
83
isoniazid 100 mg, 300 mg 31
isoniazid 50 mg/5ml
31
ISOPTO ATROPINE
94
ISOPTO CARPINE
94
ISORDIL TITRADOSE 40
MG
11
ISORDIL TITRADOSE 5 MG 11
isosorbide dinitrate
11
ISOSORBIDE DINITRATE
ER
11
isosorbide mononitrate
11
isotretinoin 10 mg
53
isotretinoin 20 mg
53
isotretinoin 30 mg
53
isotretinoin 30 mg, 40 mg
53
isoxsuprine hcl 10 mg
43
Index 13
ISOXSUPRINE HCL 20 MG 43
isradipine
42
ISTALOL
93
itraconazole
25
ivermectin
10
J-MAX
49
JADENU
24
JAKAFI
33
JALYN
78
JANUMET
21
JANUMET XR
21
JANUVIA
22
JARDIANCE
23
JENTADUETO
21
JENTADUETO XR
21
JUBLIA
55
JUXTAPID
28
K-PHOS
85
K-PHOS NEUTRAL
85
K-PHOS NO 2
77
K-TAB 10 MEQ, 8 MEQ
85
K-TAB 20 MEQ
85
KADIAN 10 MG
6
KADIAN 100 MG, 20 MG, 30 MG,
50 MG, 60 MG, 80 MG
6
KADIAN 200 MG
6
KADIAN 40 MG
6
KALETRA
37
KALYDECO
101
KAPVAY
1
KARBINAL ER
26
KAYEXALATE
41
KAZANO
21
KEFLEX
44
KENALOG
59
KEPPRA 100 MG/ML
16
KEPPRA 1000 MG, 250 MG, 500
MG, 750 MG
16
KEPPRA XR
16
KERASAL ULTRA20
61
KERLONE
41
KERYDIN
55
KETEK
11
ketoconazole
25
ketoconazole (topical)
55
ketoprofen
4
KETOPROFEN ER
4
Index 14
(ophth)
96
ketorolac tromethamine 10
mg
4
KEVEYIS
71
KHEDEZLA
20
KITABIS PAK
3
KLARON
53
KLONOPIN
16
KLOR-CON 25
85
KLOR-CON M15
85
KLOR-CON/25
85
KOMBIGLYZE XR
21
KORLYM
22
KRISTALOSE
81
KROGER BLOOD GLUCOSE
TESTSTRIPS
68
KROGER PREMIUM BLOOD
KROGER TEST STRIPS 68
KUVAN
73
labetalol hcl 100 mg, 200 mg,
300 mg
41
LAC-HYDRIN
61
LAC-HYDRIN TWELVE
61
LACRISERT
93
lactic acid (ammonium lactate)
10 %
61
lactic acid (ammonium lactate)
12 %
61
lactulose
81
lactulose (encephalopathy) 77
LAMICTAL
17
LAMICTAL CHEWABLE
DISPERSIBLE
16
LAMICTAL ODT
16
LAMICTAL STARTER/NOT
TAKING
CARBAMAZEPINE
16
LAMICTAL STARTER/TAKING
CARBAMAZEPINE/NOT
TAKING VALPROATE
16
LAMICTAL STARTER/TAKING
VALPROATE
17
LAMICTAL XR
17
LAMICTAL XR 100 MG, 200
MG, 25 MG, 300 MG, 50
MG
17
LAMICTAL XR 250 MG
17
LAMISIL 125 MG, 187.5
MG
25
LAMISIL 250 MG
25
LAMISIL AT SPRAY
55
lamivudine
37
lamivudine (hbv)
39
lamivudine-zidovudine
37
lamotrigine
17
lamotrigine 100 mg, 150 mg, 200
mg, 25 mg
17
mg, 300 mg, 50 mg
17
mg, 50 mg
17
lamotrigine 25 mg, 5 mg
17
lamotrigine 250 mg
17
LANOXIN 125 MCG, 250
MCG
43
LANOXIN 187.5 MCG, 62.5
MCG
43
lansoprazole 15 mg
104
lansoprazole 30 mg
104
LANTUS
23
LANTUS SOLOSTAR
23
LASIX
72
LASTACAFT
97
latanoprost
97
LATUDA
35
LAZANDA
6
leflunomide 10 mg
5
leflunomide 20 mg
5
LENVIMA 10 MG DAILY
DOSE
33
LENVIMA 14 MG DAILY
DOSE
33
LENVIMA 18 MG DAILY
DOSE
33
LENVIMA 20 MG DAILY
DOSE
33
LENVIMA 24 MG DAILY
DOSE
33
LENVIMA 8 MG DAILY
DOSE
33
LESCOL
27
LESCOL XL
27
LETAIRIS
44
letrozole
32
leucovorin calcium 10 mg, 15 mg,
25 mg, 5 mg
34
LEUKERAN
32
LEVACET
5
levalbuterol hcl
14
LEVALBUTEROL TARTRATE
HFA
14
LEVAQUIN 25 MG/ML
76
LEVAQUIN 250 MG, 500 MG,

750 MG
76
LEVBID
103
LEVEMIR
23
LEVEMIR FLEXTOUCH
23
LEVETIRACETAM
45
levetiracetam 100 mg/ml, 500
mg/5ml
17
levetiracetam 1000 mg, 250 mg,
500 mg, 750 mg
17
levetiracetam 500 mg, 750
mg
17
LEVITRA
43
levobunolol hcl
93
modifiers) 1 gm/10ml
73
modifiers) 330 mg
73
LEVOCETIRIZINE
DIHYDROCHLORIDE
45
levocetirizine dihydrochloride 2.5
mg/5ml
26
levocetirizine dihydrochloride 5
mg
26
levofloxacin (ophth)
94
levofloxacin 25 mg/ml
76
levofloxacin 250 mg, 500 mg, 750
mg
76
LEVONORGESTREL
47
levonorgestrel & eth
estradiol
45
levonorgestrel (emergency
oc)
47
levonorgestrel-eth estradiol
(triphasic)
45
levonorgestrel-ethinyl estradiol
(91-day)
45
levonorgestrel-ethinyl estradiol
(continuous)
46
LEVORPHANOL TARTRATE 6
levothyroxine sodium
102
LEXAPRO
19
LEXIVA
38
LEXUSS 210
49
LIALDA
77
LIBERTY NEXT GENERATION
BLOOD GLUCOSE TEST
STRIPS
68
LIBERTY TEST STRIPS
68
LIBRAX
103
lidocaine
62
lidocaine hcl (mouth-throat) 85
lidocaine hcl 2 %
62
lidocaine hcl 4 %
62
LIDOCAINE HCL 4 %
85
lidocaine-hydrocortisone
acetate (rectal) 3%-2.5% 10
lidocaine-prilocaine
62
LIDODERM
62
LIDOVIR
57
lindane
63
linezolid 100 mg/5ml
11
linezolid 600 mg
11
LINZESS
77
liothyronine sodium 25 mcg, 5
mcg, 50 mcg
102
LIPITOR
27
LIPOFEN
27
lisinopril
28
lisinopril &
hydrochlorothiazide
30
LITHIUM
35
lithium carbonate
35
LITHOBID
35
LITHOSTAT
78
LIVALO
27
LO LOESTRIN FE
46
LOCOID
59
LOCOID LIPOCREAM
59
LODINE
4
LODOSYN
34
LOESTRIN 1.5/30-21
46
LOESTRIN 1/20-21
46
LOESTRIN FE 1.5/30
46
LOESTRIN FE 1/20
46
LOFIBRA
27
LOMOTIL
24
LOMUSTINE
32
LONSURF
33
loperamide hcl
24
LOPID
27
LOPRESSOR 100 MG, 50
MG
41
LOPRESSOR HCT
30
LOPROX
55
LOPROX SHAMPOO
55
lorazepam 0.5 mg, 1 mg, 2
mg
12
lorazepam 2 mg/ml
12
LORTAB
8
LORZONE
91
losartan potassium
28
losartan potassium &
hydrochlorothiazide
30
LOSEASONIQUE
46
LOTEMAX
95
LOTENSIN
28
LOTENSIN HCT
30
LOTREL
30
LOTRISONE
55
LOTRONEX
77
lovastatin
27
LOVAZA
26
LOVENOX 100 MG/ML
15
LOVENOX 120 MG/0.8ML, 150
MG/ML
16
LOVENOX 30 MG/0.3ML, 40
MG/0.4ML, 60 MG/0.6ML, 80
MG/0.8ML
16
LOVENOX 300 MG/3ML
15
loxapine succinate
36
LOZI-FLUR
85
LUFYLLIN
15
LUMIGAN
97
LUNESTA
80
LURIDE
85
LUSAIR
49
LUXIQ
59
LUZU
55
LYNPARZA
33
LYRICA 100 MG, 200 MG, 25
MG, 50 MG, 75 MG
17
LYRICA 150 MG, 225 MG, 300
MG
17
LYRICA 20 MG/ML
17
LYSODREN
32
LYSTEDA
79
M-END PE
49
MACNATAL CN DHA
87
MACROBID
105
MACRODANTIN
105
mafenide acetate
57
MAGNEBIND 400
85
MALARONE
31
malathion
63
maprotiline hcl
19
MAR-COF BP
49
MAR-COF CG
EXPECTORANT
49
MARINOL
25
Index 15
MARNATAL-F
87
MARPLAN
19
MATULANE
34
MAVIK
28
MAXALT
84
MAXALT-MLT
84
MAXIDEX
95
MAXIMA BLOOD GLUCOSE
TESTSTRIPS
68
MAXITROL
95
MAXZIDE
71
MAXZIDE-25
72
meclofenamate sodium
4
MEDROL 16 MG, 32 MG, 4 MG,
8 MG
47
MEDROL 2 MG
47
MEDROL DOSEPAK
47
MEDROX-RX
62
medroxyprogesterone
acetate
99
mefenamic acid
4
mefloquine hcl
31
MEGACE ES
99
MEGACE ORAL
32
megestrol acetate
32
megestrol acetate (appetite) 99
MEIJER BLOOD GLUCOSE
TESTSTRIPS
68
MEIJER PREMIUM BLOOD
MEIJER TRUETEST BLOOD
MEIJER TRUETRACK BLOOD
MEKINIST
33
meloxicam 15 mg
4
meloxicam 7.5 mg
4
meloxicam 7.5 mg/5ml
4
memantine hcl
99
MENEST
75
MENOSTAR
75
meperidine hcl 100 mg, 50 mg6
meperidine hcl 50 mg/5ml
6
MEPERIDINE
HCL/PROMETHAZINE HCL 8
MEPHYTON
107
meprobamate
12
MEPRON
11
mercaptopurine
32
mesalamine
77
Index 16
MESALAMINE DR
77
MESNEX 400 MG
34
MESTINON 60 MG
31
MESTINON 60 MG/5ML 31
MESTINON TIMESPAN 31
METADATE CD 10 MG, 40
MG, 50 MG, 60 MG
2
METADATE CD 20 MG, 30
MG
2
metaproterenol sulfate
14
metaxalone
91
metformin hcl
21
methadone hcl 10 mg, 5 mg 6
methadone hcl 10 mg/5ml, 5
mg/5ml
6
methadone hcl 10 mg/ml
6
methadone hcl 40 mg
6
METHADOSE
6
METHADOSE SUGARFREE
6
methamphetamine hcl
1
methazolamide
71
methenamine hippurate 105
methenamine mandelate 105
methenamine-hyosc-methylene
blue-benzoic acid-phenyl
sal
105
methenamine-hyosc-methylene
blue-sod phos-phenyl sal 105
methenamine-hyoscaminemethylene blue-sodium
phosphate
105
methimazole
102
METHITEST
9
methocarbamol 500 mg, 750
mg
91
methotrexate sodium 2.5
mg
32
methoxsalen rapid
56
methscopolamine
bromide
103
METHYCLOTHIAZIDE
72
methyldopa
29
methyldopa &
hydrochlorothiazide
30
methylergonovine maleate 0.2
mg
98
METHYLIN
2
methylphenidate hcl 10 mg 2
methylphenidate hcl 10 mg, 2.5
mg, 5 mg
2
methylphenidate hcl 10 mg, 20
mg, 5 mg
2

mg, 50 mg, 60 mg
2
methylphenidate hcl 10
mg/5ml
2
mg, 27 mg, 54 mg
2
mg, 54 mg
2
mg
2
mg, 40 mg
2
methylphenidate hcl 5 mg/5ml 2
methylprednisolone
47
methyltestosterone
9
METIPRANOLOL
93
metoclopramide hcl 10 mg, 5
mg
76
metoclopramide hcl 10 mg/10ml,
5 mg/5ml
76
METOCLOPRAMIDE ODT 76
metolazone
72
METOPIRONE
63
metoprolol &
hydrochlorothiazide
30
metoprolol succinate
41
METOPROLOL SUCCINATE
ER/HYDROCHLOROTHIAZIDE
30
metoprolol tartrate 100 mg, 25
mg, 50 mg
41
METOPROLOL TARTRATE 37.5
MG, 75 MG
41
METOZOLV ODT
76
METROCREAM
63
METROGEL
63
METROGEL-VAGINAL
106
METROLOTION
63
metronidazole
10
metronidazole (topical) 0.75
%
63
metronidazole (topical) 1 % 63
metronidazole vaginal
106
MEVACOR
27
mexiletine hcl
12
MIACALCIN 200 UNIT/ACT 73
MICARDIS
28
MICARDIS HCT
30
MICONAZOLE 3
106
MICRO-K
85
MICRODOT TEST STRIPS 68

MICROZIDE
72
midazolam hcl 2 mg/ml
80
midodrine hcl
106
MIGERGOT
83
miglitol
21
MIGRAL
84
MIGRALAM
83
MIGRANAL
84
MILLIPRED 10 MG/5ML
47
MILLIPRED 5 MG
47
MILLIPRED DP
47
MINASTRIN 24 FE
46
MINIPRESS
29
MINIVELLE 0.025 MG/24HR 75
MINIVELLE 0.0375
MG/24HR
75
MINIVELLE 0.05 MG/24HR 75
MINIVELLE 0.075 MG/24HR, 0.1
MG/24HR
75
MINOCIN
102
minocycline hcl 100 mg, 50 mg,
75 mg
102
minocycline hcl 135 mg, 45 mg,
90 mg
102
minoxidil
31
MIRALAX
81
MIRAPEX
35
MIRAPEX ER
35
MIRCETTE
46
mirtazapine
18
MIRVASO
63
misoprostol
104
MITIGARE
78
MOBIC 15 MG
4
MOBIC 7.5 MG
4
MOBIC 7.5 MG/5ML
4
modafinil
2
MODERIBA
39
MODERIBA 1200 DOSE
PACK
39
MODERIBA 800 DOSE
PACK
39
MODICON
46
moexipril hcl
28
moexipril-hydrochlorothiazide
30
MOLINDONE
HYDROCHLORIDE
36
mometasone furoate
59
mometasone furoate
(nasal)
92
MONODOX
102
montelukast sodium
13
MONUROL
105
morphine sulfate 10 mg
6
morphine sulfate 10 mg, 20 mg,
5 mg
6
morphine sulfate 10 mg/5ml,
100 mg/5ml, 20 mg/5ml, 20
mg/ml
6
morphine sulfate 100 mg, 15
mg, 30 mg, 60 mg
7
mg, 30 mg, 50 mg, 60 mg, 80
mg
6
mg
7
MORPHINE SULFATE 30
MG
6
MORPHINE SULFATE ER 6
MOVANTIK
77
MOVIPREP
80
MOXATAG
98
MOXEZA
94
moxifloxacin hcl
76
MS CONTIN
7
MUCINEX D
49
MUCINEX D MAXIMUM
STRENGTH
49
MUCINEX DM
50
MUCINEX DM MAXIMUM
STRENGTH
50
MUCOTROL
86
MULTAQ
12
mupirocin
54
mupirocin calcium (topical) 54
MUSE
43
MYAMBUTOL
31
MYCOBUTIN
31
mycophenolate mofetil
40
mycophenolate sodium
41
MYDRIACYL
94
MYFORTIC
41
MYGLUCOHEALTH BLOOD
GLUCOSE TEST
68
MYKIDZ IRON FL
86
MYLERAN
32
MYNATAL ADVANCE
87
MYNATAL
ULTRACAPLET
87
MYNATE 90 PLUS
87
MYRBETRIQ
106
MYSOLINE
17
MYTESI
24
nabumetone 500 mg
4
nabumetone 750 mg
4
nadolol
42
nadolol &
bendroflumethiazide
30
NAFRINSE
DAILY/NEUTRAL
86
NAFRINSE WEEKLY
86
NAFTIFINE HCL 1 %
55
naftifine hcl 2 %
55
NAFTIN 1 %, 2 %
55
NALFON
4
naltrexone hcl
24
NAMENDA
99
NAMENDA TITRATION PAK99
NAMENDA XR
99
NAMENDA XR TITRATION
PACK
99
NAMZARIC
99
NAPHAZOLINE HCL
95
NAPRELAN 375 MG, 500 MG 4
NAPRELAN 750 MG
4
NAPROSYN
4
NAPROXEN 125 MG/5ML
4
naproxen 125 mg/5ml
4
naproxen 250 mg, 375 mg, 500
mg
4
naproxen 500 mg
4
naproxen sodium 275 mg, 550
mg
4
naproxen sodium 375 mg, 500
mg
4
naratriptan hcl
84
NARCAN
24
NARDIL
19
NASACORT ALLERGY
24HR
93
NASACORT ALLERGY 24HR
CHILDRENS
93
NASOHIST DM
50
NASONEX
93
NATACHEW
87
NATACYN
94
NATALVIRT 90 DHA
87
NATALVIRT CA
87
NATAZIA
46
Index 17
nateglinide
23
NATELLE ONE
87
NATESTO
9
NATROBA
63
NATURE-THROID 113.75 MG,
130 MG, 146.25 MG, 16.25 MG,
195 MG, 260 MG, 32.5 MG, 325
MG, 65 MG, 81.25 MG, 97.5
MG
102
NATURE-THROID 48.75
MG
102
NATURE-THROID NT-2.5 102
NEBUPENT
10
NEBUSAL
51
NECON 10/11-28
46
NEEVO DHA
88
NEFAZODONE HCL 100 MG,
150 MG, 200 MG
20
nefazodone hcl 250 mg, 50
mg
20
NEO-SYNALAR
54
NEO-SYNALAR KIT
54
neomycin sulfate
3
neomycin-bacitracin znpolymyxin
94
neomycin-polymy-dexameth 95
neomycin-polymyxin-gramicidin
94
(ophth)
95
(otic)
98
NEORAL
41
NEOSPORIN
94
NEOTUSS PLUS
50
NEPTAZANE
71
NESINA
22
NESTABS
88
NESTABS ABC
88
NESTABS DHA
88
NEUPRO
35
NEURONTIN
17
NEUTEK 2TEK TEST
STRIPS
68
NEVANAC
97
nevirapine
38
NEWGEN
88
NEXA PLUS
88
NEXAVAR
33
NEXGEN TEST STRIPS
68
Index 18
NEXIUM 10 MG, 2.5 MG, 20

MG, 40 MG, 5 MG
104
NEXIUM 20 MG
104
NEXIUM 24HR
104
NEXIUM 40 MG
104
niacin (antihyperlipidemic) 28
NIACOR
28
NIASPAN
28
nicardipine hcl 20 mg, 30
mg
42
NICODERM CQ
100
NICORETTE
100
NICORETTE MINI
100
NICORETTE STARTER
KIT
101
nicotine
101
nicotine polacrilex
101
NICOTINE TRANSDERMAL
SYSTEM
101
NICOTROL INHALER
101
NICOTROL NS
101
nifedipine 10 mg, 20 mg 42
nifedipine 30 mg, 60 mg 42
nifedipine 30 mg, 60 mg, 90
mg
43
NILANDRON
32
nilutamide
32
nimodipine
43
NINJACOF-XG
50
NINLARO
33
nisoldipine 17 mg, 20 mg, 25.5
mg, 34 mg, 8.5 mg
43
NISOLDIPINE 30 MG, 40
MG
43
NITRO-BID
11
NITRO-DUR 0.1 MG/HR, 0.2
MG/HR, 0.4 MG/HR, 0.6
MG/HR
11
NITRO-DUR 0.3 MG/HR, 0.8
MG/HR
11
nitrofurantoin
105
nitrofurantoin
macrocrystal
105
nitrofurantoin monohyd
macro
105
nitroglycerin 0.1 mg/hr, 0.2
mg/hr, 0.4 mg/hr, 0.6
mg/hr
11
nitroglycerin 0.3 mg, 0.4 mg,
0.6 mg
11
nitroglycerin 0.4 mg/spray 11
nitroglycerin 2.5 mg, 9 mg 11
NITROGLYCERIN LINGUAL 11
NITROLINGUAL
PUMPSPRAY
11
NITROMIST
11
NITROSTAT
11
NIZATIDINE 15 MG/ML
103
nizatidine 150 mg, 300 mg 103
NIZORAL
55
NOR-QD
47
NORCO
8
norethin acet & estrad-fe 75mg20mcg-1mg
46
norethin acet & estrad-fe 75mg20mcg-1mg, 75mg-30mcg1.5mg
46
norethindrone & eth estradiol46
norethindrone & ethinyl estradiolfe 0.4mg-35mcg
46
norethindrone & ethinyl estradiolfe 75mg-0.8mg-25mcg
46
norethindrone & mestranol 46
norethindrone
(contraceptive)
47
norethindrone acet & eth
estra
46
norethindrone acetate
99
norethindrone acetate-ethinyl
estradiol
74
norethindrone acetate-ethinyl
estradiol-fe
46
(triphasic)
46
estradiol
46
norgestimate-ethinyl estradiol
(triphasic)
46
norgestrel & ethinyl estradiol 46
NORINYL 1+35
46
NORINYL 1+50
46
NORITATE
63
NORPACE
12
NORPACE CR
12
NORPRAMIN
20
NORTHERA
106
nortriptyline hcl 10 mg, 25 mg, 50
mg, 75 mg
20
NORTRIPTYLINE HCL 10
MG/5ML
20
NORVASC
43
NORVIR
38
NOVA MAX GLUCOSE TEST
STRIPS
68
NOVOLIN 70/30
23
NOVOLIN 70/30 RELION

23
NOVOLIN N
23
NOVOLIN N RELION
23
NOVOLIN R
23
NOVOLIN R RELION
23
NOVOLOG
23
NOVOLOG FLEXPEN
23
NOVOLOG MIX 70/30
23
NOVOLOG MIX 70/30
PREFILLED FLEXPEN
23
NOVOLOG PENFILL
23
NOXAFIL
25
NUCORT
60
NUCYNTA
7
NUCYNTA ER
7
NUEDEXTA
100
NULYTELY/FLAVOR
PACKS
80
NUMBONEX
62
NUPLAZID
35
NUTRIDOX
102
NUVARING
47
NUVESSA
106
NUVIGIL
2
NYMALIZE
43
nystatin
25
nystatin (mouth-throat)
86
nystatin (topical)
55
nystatin-triamcinolone
55
OB COMPLETE GOLD
88
OB COMPLETE ONE
88
OB COMPLETE PETITE
88
OB COMPLETE PREMIER 88
OB COMPLETE/DHA
88
OBREDON
50
OBSTETRIX DHA
88
OBSTETRIX ONE
88
OBTREX DHA
88
OCALIVA
76
octreotide acetate
74
OCUFEN
97
OCUFLOX
94
ODEFSEY
38
ODOMZO
32
OFEV
101
ofloxacin (ophth)
95
ofloxacin (otic)
97
OFLOXACIN 300 MG
76
ofloxacin 400 mg
76
olanzapine 10 mg, 15 mg, 2.5
mg, 20 mg, 5 mg, 7.5 mg 36
olanzapine 10 mg, 15 mg, 20
mg, 5 mg
36
olanzapine-fluoxetine hcl 100
OLEPTRO
20
olmesartan medoxomil
28
olmesartan medoxomilamlodipine-hydrochlorothiazide
30
olmesartan medoxomilhydrochlorothiazide
30
olopatadine hcl
97
olopatadine hcl (nasal)
92
OLUX
60
OLUX-E
60
OLYSIO
39
OMECLAMOX-PAK
104
omega-3-acid ethyl esters 26
omeprazole
104
OMEPRAZOLE + SYRSPEND
SFALKA
104
omeprazole-sodium
bicarbonate 20mg-1680mg,
40mg-1680mg
105
omeprazole-sodium
bicarbonate 40mg1100mg
104
OMNARIS
93
OMNIFLEX DIAPHRAGM 82
OMNIPRED
96
OMNITROPE 5.8 MG
73
ON CALL PLUS BLOOD
GLUCOSE TEST
68
ON CALL VIVID BLOOD
GLUCOSE TEST
68
ondansetron
24
ondansetron hcl 4 mg, 8
mg
24
ondansetron hcl 4 mg/5ml 24
ONETOUCH ULTRA 2
83
ONETOUCH ULTRA
BLUE
69
ONETOUCH ULTRA MINI 83
ONETOUCH VERIO
83
ONETOUCH VERIO FLEX
BLOODGLUCOSE
MONITORING SYSTEM 83
ONETOUCH VERIO IQ
BLOOD GLUCOSE
MONITORING SYSTEM 83
ONETOUCH VERIO SYNC

BLOODGLUCOSE
MONITORING SYSTEM
83
ONETOUCH VERIO TEST
STRIPS
69
ONEXTON
53
ONFI
16
ONGLYZA
22
ONMEL
25
ONZETRA XSAIL
84
OPANA 10 MG, 5 MG
7
OPANA ER (CRUSH
RESISTANT)
7
ophthalmic irrigation solution 97
opium tincture
24
OPSUMIT
44
OPTIUM TEST STRIPS
69
OPTIUMEZ TEST STRIPS 69
OPTIVAR
97
OPTUMRX BLOOD GLUCOSE
TEST
69
ORACEA
63
ORACIT
77
ORAFATE
86
ORALAIR
42
ORALAIR ADULT SAMPLE
KIT
42
ORALAIR ADULT STARTER
PACK
42
ORALAIR
CHILDREN/ADOLESCENTS
SAMPLE KIT
42
ORALAIR
CHILDREN/ADOLESCENTS
STARTER PACK
42
ORAP
100
ORAPRED ODT
47
ORAVIG
86
ORENITRAM
44
ORFADIN
73
ORKAMBI 100MG-125MG 101
ORKAMBI 200MG-125MG 101
orphenadrine citrate 100 mg 91
ORTHO DIAPHRAGM COIL
SPRING KIT 100
82
SPRING KIT 105
82
SPRING KIT 50
82
ORTHO DIAPHRAGM FLAT
SPRING KIT 55
82
Index 19

SPRING KIT 60
82
SPRING KIT 65
82
SPRING KIT 70
82
SPRING KIT 75
82
SPRING KIT 80
82
SPRING KIT 85
82
SPRING KIT 90
82
SPRING KIT 95
82
ORTHO EVRA
47
ORTHO MICRONOR
47
ORTHO TRI-CYCLEN
46
ORTHO TRI-CYCLEN LO 46
ORTHO-CEPT
46
ORTHO-CYCLEN
46
ORTHO-NOVUM 1/35
46
ORTHO-NOVUM 7/7/7
46
OSENI
21
OSMOPREP
81
OSPHENA
73
OTEZLA
5
OTICIN HC NR
98
OTOVEL
98
OVACE PLUS 10 %
56
OVACE PLUS 9.8 %
56
OVACE PLUS WASH
56
OVACE WASH
56
OVCON-35
46
OVIDE
63
OXANDRIN
9
oxandrolone
9
oxaprozin
4
OXAYDO
7
oxazepam
12
oxcarbazepine
17
oxiconazole nitrate
55
OXISTAT
55
OXSORALEN ULTRA
56
OXTELLAR XR
17
oxybutynin chloride
105
oxycodone hcl
7
OXYCODONE HCL ER
7
Index 20
oxycodone w/ acetaminophen
10mg-325mg, 2.5mg-325mg,
7.5mg-325mg
8
oxycodone w/ acetaminophen
5mg-325mg
8
oxycodone-ibuprofen
8
OXYCODONE/ACETAMINOPH
EN
8
OXYCONTIN
7
oxymorphone hcl 10 mg, 15
mg, 20 mg, 30 mg, 40 mg, 5
mg, 7.5 mg
7
oxymorphone hcl 10 mg, 5
mg
7
OXYMORPHONE
HYDROCHLORIDE ER
7
OXYTROL
105
OXYTROL FOR WOMEN 105
PAIRE OB
88
paliperidone
36
PAMELOR
21
PAMINE
103
PAMINE FORTE
103
PAMINE FQ
103
PANCREAZE
71
pancrelipase (lipase-proteaseamylase)
71
PANDEL
60
PANRETIN
56
pantoprazole sodium 20 mg, 40
mg
104
PARAFON FORTE DSC 92
PAREGORIC
24
PAREMYD
97
paricalcitol 1 mcg, 2 mcg, 4
mcg
74
PARLODEL
35
PARNATE
19
paromomycin sulfate
3
paroxetine hcl
19
PASER
31
PATADAY
97
PATANASE
92
PATANOL
97
PAXIL 10 MG, 20 MG, 30 MG,
40 MG
19
PAXIL 10 MG/5ML
19
PAXIL CR
19
PAZEO
97
PCE
82
ped multivitamins w/fl & iron 86

pediatric multivitamins w/fl 86
pediatric vitamins acd fluoride &
iron
86
pediatric vitamins acd w/
fluoride
86
peg 3350-kcl-sod bicarb-sod
chloride-sod sulfate
80
peg 3350-potassium chloride-sod
bicarbonate-sod chloride
80
PEG-INTRON
39
PEG-INTRON REDIPEN
39
PEG-INTRON REDIPEN PAK
4
39
PEGANONE
18
PEGASYS
39
PEGASYS PROCLICK
39
PEGINTRON
39
penicillin v potassium
98
PENLAC NAIL LACQUER 55
PENNSAID 1.5 %
54
PENNSAID 2 %
54
PENTASA
77
pentazocine w/ naloxone
9
pentoxifylline
78
PEPCID 20 MG
103
PEPCID 40 MG
103
PEPCID 40 MG/5ML
103
PEPCID AC MAXIMUM
STRENGTH
103
PERCOCET
8
PERFOROMIST
14
perindopril erbumine
28
permethrin
63
perphenazine
36
PERPHENAZINE/AMITRIPTYLIN
E
100
PERSANTINE
79
PERTZYE
71
PEXEVA
19
PHARMACIST CHOICE
AUTOCODE BLOOD GLUCOSE
TEST STRIPS
69
phenazopyridine hcl
78
phenelzine sulfate
19
PHENOBARBITAL 100 MG, 15
MG, 30 MG, 60 MG
79
phenobarbital 16.2 mg, 32.4 mg,
64.8 mg, 97.2 mg
79
phenobarbital 20 mg/5ml
79
phenobarbital-hyoscyamineatropine-scopolamine
103
phenoxybenzamine hcl
28
phentermine hcl
1
phenyleph-promethazine w/
cod
50
phenylephrine hcl (ophth) 10
%
95
phenylephrine hcl (ophth) 2.5
%
95
28mg/5ml-388mg/5ml-10mg/5ml,
7.5mg/ml-88mg/ml-2.5mg/ml 50
5mg/5ml-75mg/5ml-2.5mg/5ml
50
phenylephrine-brompheniraminedm
50
phenylephrine-chlorphen-dm
15mg/5ml-4mg/5ml10mg/5ml
50
phenylephrine-chlorphen-dm
3mg/ml-1mg/ml-3.5mg/ml
50
phenylephrine-guaifenesin 50
PHENYLEPHRINE/GUAIFENESI
N
50
PHENYLHISTINE DH
50
PHENYTEK
18
phenytoin
18
phenytoin sodium extended 18
PHOSLO
77
PHOSLYRA
77
PHOSPHOLINE IODIDE
94
PICATO
56
pilocarpine hcl
94
pilocarpine hcl (oral)
86
pimozide
100
pindolol
42
PINNACAINE OTIC
97
pioglitazone hcl
22
pioglitazone hcl-glimepiride 21
pioglitazone hcl-metformin
hcl
21
piroxicam
4
PLAN B ONE-STEP
47
PLAQUENIL
31
PLAVIX
79
PLETAL
79
PLEXION
53
PLEXION CLEANSER
53
PLEXION CLEANSING
CLOTHS
53
PLO GEL - MEDIFLO KIT 99
PNV FERROUS
FUMARATE/DOCUSATE/FOLI
C ACID
88
PNV OB+DHA
88
PNV TABS 29-1
88
PNV-DHA
88
PNV-DHA+DOCUSATE 88
PNV-OMEGA
88
PNV-SELECT
88
PNV-TOTAL
88
PNV-VP-U
88
POCKETCHEM EZ BLOOD
PODOCON 25 IN BENZOIN
TINCTURE
62
podofilox
62
POLIBAR ACB
71
POLY HUB NEEDLE/30G X
1/2"
83
POLY-VI-FLOR 200MCG0.25MG-15UNIT-400UNIT,
200MCG-0.5MG-15UNIT400UNIT
86
POLY-VI-FLOR 200MCG-1MG15UNIT-400UNIT
86
POLY-VI-FLOR 200MCG/ML0.25MG/ML
86
POLY-VI-FLOR/IRON
200MCG-0.5MG-10MG15UNIT-400UNIT
86
POLY-VI-FLOR/IRON
200MCG/ML-7MG/ML0.25MG/ML
86
polyethylene glycol 3350 81
polymyxin b-trimethoprim 95
POLYTRIM
95
POMALYST
33
PONSTEL
5
pot & sod citrates w/citric
ac
77
pot phosphate monobasic w/
sod phosphate dibasic &
monobasic
85
POTABA
107
potassium bicarb &
chloride
85
potassium bicarbonate
85
potassium chloride 10 %, 20
%
85
potassium chloride 10 meq, 8
meq
85
potassium chloride 20 meq 85

POTASSIUM CHLORIDE
ER
85
potassium chloride
microencapsulated crystals
cr
85
potassium citrate
(alkalinizer)
77
potassium citrate-citric acid 77
POTIGA
17
PR NATAL 400 EC
88
PR NATAL 430
88
PR NATAL 430 EC
88
PRADAXA
16
pramipexole dihydrochloride
0.125 mg, 0.25 mg, 0.5 mg, 0.75
mg, 1 mg, 1.5 mg
35
pramipexole dihydrochloride
0.375 mg, 0.75 mg, 1.5 mg, 2.25
mg, 3 mg, 3.75 mg, 4.5 mg 35
PRAMOSONE 1%-1%, 1%2.5%
60
PRAMOSONE E
60
PRAMOTIC
98
pramoxine-chloroxylenol
98
pramoxine-hc-chloroxylenol 98
PRANDIMET
21
PRANDIN
23
PRAVACHOL 20 MG, 80
MG
27
PRAVACHOL 40 MG
27
pravastatin sodium 10 mg, 20
mg, 80 mg
27
pravastatin sodium 40 mg 27
prazosin hcl
29
PRECISION PCX
69
PRECISION PCX PLUS TEST
STRIPS
69
PRECISION POINT OF CARE
TEST STRIPS
69
PRECISION QID TEST
STRIPS
69
PRECISION SOF-TACT TEST
STRIPS
69
PRECISION XTRA
83
PRECOSE
21
PRED FORTE
96
PRED MILD
96
PRED-G
96
PRED-G S.O.P.
96
Index 21
prednicarbate
60
prednisolone
48
prednisolone acetate (ophth) 96
PREDNISOLONE SODIUM
PHOSPHATE 1 %
96
prednisolone sodium phosphate
10 mg, 15 mg, 30 mg
48
prednisolone sodium phosphate
15 mg/5ml, 5 mg/5ml, 6.7
mg/5ml
48
PREDNISOLONE SODIUM
PHOSPHATE 25 MG/5ML 48
PREDNISOLONE/MOXIFLOXAC
IN
96
prednisone 1 mg, 10 mg, 2.5 mg,
20 mg, 5 mg, 50 mg
48
PREDNISONE 10 MG
48
PREDNISONE 5 MG
48
prednisone 5 mg/5ml
48
PREDNISONE INTENSOL 48
PREFERA OB
88
PREFERA OB + DHA
88
PREFERAOB +DHA
88
PREFEST
74
PREFOL-DHA
88
PREMARIN 0.3 MG, 0.45 MG,
0.625 MG, 0.9 MG, 1.25 MG 75
PREMARIN 0.625 MG/GM 106
PREMIUM SCAR PATCH 62
PREMPHASE
74
PREMPRO 0.3MG-1.5MG 74
PREMPRO 0.45MG-1.5MG,
0.625MG-2.5MG, 0.625MG5MG
74
PRENA 1 TRUE
88
PRENA1 CHEW
88
PRENA1 PEARL
88
PRENAISSANCE
88
PRENAISSANCE 90 DHA 88
PRENAISSANCE BALANCE 88
PRENAISSANCE DHA
88
PRENAISSANCE HARMONY
DHA
88
PRENAISSANCE NEXT
88
PRENAISSANCE NEXT-B 88
PRENAISSANCE PLUS
88
PRENAISSANCE PROMISE 88
PRENATA
88
PRENATABS RX
88
Index 22
PRENATAL 19 1000UNIT30UNIT-20MG-25MG-3MG200MG-29MG-15MG-3MG7MG-12MCG-400UNIT-20MG1MG-100MG, 30UNIT1000UNIT-20MG-25MG-3MG200MG-29MG-7MG-15MG3MG-12MCG-400UNIT-1MG20MG-100MG

89
PRENATAL 19 1000UNIT400UNIT-20MG-25MG-3MG200MG-29MG-7MG-6MG-3MG12MCG-1MG-30UNIT-20MG100MG, 30UNIT-1000UNIT20MG-3MG-200MG-29MG7MG-15MG-3MG-12MCG400UNIT-1MG-20MG-100MG
89
PRENATAL PLUS IRON 89
prenatal vit w/ docusate-iron
carbonyl-folic acid
89
prenatal without a vit w/ fe
fumarate-folic acid
89
PRENATAL+DHA
89
PRENATAL-U
89
PRENATE
89
PRENATE AM
89
PRENATE DHA 18MG600MCG-40UNIT-300MG50MG-155MG-25MCG400UNIT-400MCG-26MG90MG
89
PRENATE DHA 600MCG10UNIT-300MG-50MG-145MG28MG-13MCG-220UNIT400MCG-26MG-90MG
89
PRENATE ELITE 20MG600MCG-40UNIT-150MCG2600UNIT-1.5MG-15MG25MG-155MG-3MG-21MG3.5MG-13MCG-600UNIT400MCG-330MCG-21MG75MG
89
PRENATE ELITE 600MCG10UNIT-150MCG-2600UNIT1.5MG-15MG-15MG-25MG3MG-100MG-26MG-6MG21MG-3.5MG-13MCG450UNIT-400MCG-330MCG21MG-75MG, 600MCG10UNIT-150MCG-2600UNIT1.5MG-15MG-25MG-3MG100MG-26MG-6MG-21MG3.5MG-13MCG-450UNIT400MCG-330MCG-21MG75MG
89
PRENATE ENHANCE
89
PRENATE ESSENTIAL
89
PRENATE MINI
89
PRENATE PIXIE
89
PRENATE RESTORE
89
PRENATE STAR
89
PREPIDIL
98
PREPOPIK
80
PREQUE 10
89
PRESTALIA
30
PREVACID 15 MG
104
PREVACID 24HR
104
PREVACID 30 MG
104
PREVACID SOLUTAB
104
PREVIDENT
86
PREVPAC
105
PREZCOBIX
38
PREZISTA 100 MG/ML
38
PREZISTA 150 MG, 600 MG, 75
MG, 800 MG
38
PRIFTIN
31
PRILOSEC 10 MG, 2.5 MG 104
PRILOSEC 10 MG, 20 MG, 40
MG
104
PRIMAQUINE PHOSPHATE 31
primidone
17
PRIMLEV
8
PRIMSOL
10
PRINIVIL
28
PRISTIQ
20
PRO-CLEAR AC
50
PRO-RED AC
50
PROAIR HFA
14
PROAIR RESPICLICK
15
probenecid
78
PROCARDIA
43
PROCARDIA XL
43
PROCENTRA
1
prochlorperazine
37
prochlorperazine maleate
36
PROCRIT 40000 UNIT/ML 79
PROCTOFOAM HC
10
PROCYSBI
78
PRODIGY NO CODING BLOOD
PRODRIN
83
progesterone micronized
99
PROGLYCEM
22
PROGRAF 0.5 MG, 1 MG, 5

MG
41
PROLENSA
97
PROMACTA
79
promethazine &
phenylephrine
50
promethazine hcl 12.5 mg, 25
mg, 50 mg
26
promethazine hcl 6.25
mg/5ml
26
promethazine w/codeine
50
promethazine-dm
50
PROMETHAZINE/PHENYLEPHR
INE
50
PROMETRIUM
99
propafenone hcl 150 mg
12
propafenone hcl 225 mg, 300
mg
12
propafenone hcl 225 mg, 325 mg,
425 mg
12
propantheline bromide
103
proparacaine hcl
95
propranolol &
hydrochlorothiazide
30
propranolol hcl 10 mg, 20 mg, 40
mg, 60 mg, 80 mg
42
propranolol hcl 120 mg, 160 mg,
60 mg, 80 mg
42
propranolol hcl 20 mg/5ml, 40
mg/5ml
42
propylthiouracil
102
PROSCAR
78
PROSTIN E2
98
PROTHELIAL
86
PROTONIX 20 MG, 40 MG 104
PROTONIX 40 MG
104
PROTOPIC
61
protriptyline hcl
21
PROVENTIL HFA
15
PROVERA
99
PROVIDA DHA
89
PROVIDA OB
89
PROVIGIL
2
PROZAC
19
PROZAC WEEKLY
19
PRUDOXIN
56
pseudoephed-bromphen-dm 50
pseudoephed-cpm w/
hydrocod
50
pseudoephedrine w/ codeinegg
50
pseudoephedrinebrompheniramine-codeine 50
pseudoephedrinedexchlorpheniraminechlophedianol
50
pseudoephedrine-guaifenesin
120mg-1200mg
50
40mg-400mg
50
60mg-600mg
50
PTS PANELS GLUCOSE
TEST
69
PULMICORT 0.25
MG/2ML
14
PULMICORT 0.5 MG/2ML 14
PULMICORT 1 MG/2ML 14
PULMICORT FLEXHALER 180
MCG/ACT
14
PULMICORT FLEXHALER 90
MCG/ACT
14
PULMOZYME
101
PURINETHOL
32
PURIXAN
32
PYLERA
105
pyrazinamide
31
PYRIDIUM
78
pyridostigmine bromide
31
pyrilamine maleatephenylephrine hcl tannate 50
QNASL
93
QNASL CHILDRENS
93
QSYMIA
1
QUALAQUIN
31
QUARTETTE
46
QUAZEPAM
80
QUDEXY XR
17
QUESTRAN
27
QUESTRAN LIGHT
27
quetiapine fumarate 100 mg,
200 mg, 25 mg, 300 mg, 400
mg, 50 mg
36
quetiapine fumarate 400
mg
36
QUETIAPINE FUMARATE
ER
36
QUFLORA PEDIATRIC
86
QUICKTEK TEST STRIPS 69
QUILLICHEW ER
2
QUILLIVANT XR
2
quinapril hcl
28
quinapril-hydrochlorothiazide
30
quinidine gluconate 324 mg 12

QUINIDINE SULFATE 200
MG
12
quinidine sulfate 300 mg
12
quinine sulfate
31
QUINTET AC BLOOD
GLUCOSETEST STRIPS
69
QUINTET BLOOD GLUCOSE
TEST STRIPS
69
QVAR 40 MCG/ACT
14
QVAR 80 MCG/ACT
14
R-NATAL OB
89
RA TRUETEST STRIPS
69
rabeprazole sodium
104
raloxifene hcl
73
ramipril
28
RANEXA 1000 MG
11
RANEXA 500 MG
11
ranitidine hcl 15 mg/ml, 150
mg/10ml, 75 mg/5ml
103
ranitidine hcl 150 mg
104
ranitidine hcl 150 mg, 300
mg
103
ranitidine hcl 300 mg
104
RAPAFLO
78
RAPAMUNE 0.5 MG, 1 MG, 2
MG
41
RAPAMUNE 1 MG/ML
41
RASUVO 10 MG/0.2ML, 12.5
MG/0.25ML, 15 MG/0.3ML, 17.5
MG/0.35ML, 22.5 MG/0.45ML, 25
MG/0.5ML, 27.5 MG/0.55ML, 30
MG/0.6ML, 7.5 MG/0.15ML 3
RAVICTI
74
RAYOS
48
RAZADYNE
99
RAZADYNE ER
99
REBETOL 200 MG
39
REBETOL 40 MG/ML
39
REBIF REBIDOSE
TITRATIONPACK
100
REBIF TITRATION PACK 100
RECTIV
10
REFUAH PLUS BLOOD
GLUCOSETEST STRIPS
69
REGIMEX
1
REGLAN
76
REGRANEX
63
RELAGARD
106
RELENZA DISKHALER
40
RELHIST
50
Index 23
RELION BLOOD GLUCOSE

TESTSTRIPS
69
RELION CONFIRM/MICRO
TEST STRIPS
69
RELION PRIME BLOOD
RELION ULTIMA BLOOD
RELION ULTIMA TEST
STRIPS
70
RELISTOR 150 MG
77
RELNATE DHA
89
RELPAX
84
REMERON
18
REMERON SOLTAB
18
RENAGEL
77
RENVELA
77
repaglinide
23
REPAGLINIDE/METFORMIN
HYDROCHLORIDE
21
REPREXAIN
8
REQUIP
35
REQUIP XL
35
RESCON-GG
50
RESCON-JR
50
RESCRIPTOR
38
RESCULA
97
reserpine
29
RESPA C&C IR
50
RESPA-BR
26
RESPAIRE-30
50
RESTASIS
95
RESTASIS MULTIDOSE
95
RESTORIL
80
RETIN-A
53
RETIN-A MICRO
53
RETIN-A MICRO PUMP 0.04 %,
0.1 %
53
RETIN-A MICRO PUMP 0.08
%
53
RETROVIR
38
REVATIO 10 MG/ML
44
REVATIO 20 MG
44
REVEAL BLOOD GLUCOSE
TEST
70
REVIA
24
REVLIMID
40
REXALL BLOOD GLUCOSE
TEST STRIPS
70
REXAPHENAC
54
Index 24
REXULTI
37
REYATAZ
38
REZIRA
50
RHEUMATREX
3
RHINOCORT AQUA
93
RIAX
53
RIBASPHERE RIBAPAK 39
ribavirin (hepatitis c)
39
RIDAURA
3
rifabutin
31
RIFADIN 150 MG, 300 MG 31
RIFAMATE
31
rifampin 150 mg, 300 mg 31
RIFATER
31
RILUTEK
93
riluzole
93
rimantadine hydrochloride 40
RIOMET
21
risedronate sodium 150
mg
73
risedronate sodium 30 mg, 5
mg
73
risedronate sodium 35 mg 73
RISPERDAL
36
RISPERDAL M-TAB
36
risperidone 0.25 mg
36
risperidone 0.25 mg, 0.5 mg, 1
mg, 2 mg, 3 mg, 4 mg
36
risperidone 0.5 mg, 1 mg, 2 mg,
3 mg, 4 mg
36
risperidone 1 mg/ml
36
RITALIN
3
RITALIN LA 10 MG
2
RITALIN LA 20 MG, 30 MG, 40
MG
3
RITALIN LA 60 MG
3
rivastigmine
100
rivastigmine tartrate
100
rizatriptan benzoate 10 mg, 5
mg
84
ROBAXIN 500 MG
92
ROBAXIN-750
92
ROBINUL 1 MG
103
ROBINUL FORTE
103
ROBITUSSIN CHILDRENS
COUGH & COLD CF
50
ROCALTROL
74
35
ROSULA 4.5%-10%
53
rosuvastatin calcium
27
ROXICET
8
ROXICODONE
7
ROZEREM
80
RULAVITE DHA
89
RYDEX
51
RYTARY
35
RYTHMOL 150 MG
12
RYTHMOL 225 MG
12
RYTHMOL SR
12
SABRIL
18
SAFYRAL
46
SAIZEN
73
SAIZEN CLICK.EASY
73
SALAGEN
86
SALEX
62
SALEX LOTION
62
SALICYLIC ACID 26 %
62
salicylic acid 27.5 %
62
salicylic acid 28.5 %
62
salicylic acid 6 %
62
salicylic acid w/ cleanser
62
SALVAX
62
SAMSCA
74
SANCUSO
24
SANDIMMUNE 100 MG, 25
MG
41
SANDIMMUNE 100 MG/ML 41
SANDOSTATIN
74
SANTYL
61
SAPHRIS
36
SARAFEM
100
SAVAYSA
15
SAVELLA
100
SAVELLA TITRATION
PACK
100
SCAR PATCH 30%-4%-2% 62
SE-NATAL 19 30UNIT1000UNIT-100MG-20MG-3MG200MG-29MG-7MG-15MG-3MG12MCG-400UNIT-1MG-20MG
90
SE-NATAL 19 30UNIT1000UNIT-20MG-25MG-200MG29MG-7MG-15MG-3MG-12MCG400UNIT-3MG-20MG-1MG100MG
90
SEASONIQUE
47
SECTRAL
41
SEEBRI NEOHALER
13
SELECT-OB 0.6MG-29MG30UNIT-15MG-25MG-1700UNIT15MG-1.8MG-5MCG-400UNIT1.6MG-0.4MG-2.5MG-60MG
90
SELECT-OB 1700UNIT-29MG30UNIT-15MG-25MG-1.6MG15MG-1.8MG-5MCG-400UNIT1MG-2.5MG-60MG
90
SELECT-OB+DHA
90
selegiline hcl
35
selenium sulfide
57
selenium sulfide-pyrithione zinc in
urea vehicle
57
SELRX
57
SELZENTRY
38
SEMPREX-D
51
SENSIPAR
74
SEREVENT DISKUS
15
SEROQUEL
36
SEROQUEL XR 150 MG, 200
MG, 300 MG, 50 MG
36
SEROQUEL XR 400 MG
36
sertraline hcl
19
SFROWASA
77
SHOHLS SOLUTION
MODIFIED
77
sildenafil citrate (pulmonary
hypertension)
44
SILENOR
79
SILVADENE
57
silver sulfadiazine
57
SIMBRINZA
94
simvastatin
27
SINEMET
35
SINEMET CR
35
SINGULAIR
13
sirolimus
41
SIRTURO
31
SITAVIG
40
SIVEXTRO
11
SKELAXIN
92
SKLICE
63
SMART DIABETES XPRES

BLOOD GLUCOSE TEST
STRIPS
70
SMART SENSE PREMIUM
BLOODGLUCOSE
STRIPS
70
SMART SENSE VALUE
BLOOD GLUCOSE
STRIPS
70
SMARTEST BLOOD
sodium chloride (inhalant) 51
sodium citrate & citric acid 77
sodium fluoride
85
sodium fluoride (dental)
86
sodium phenylbutyrate
74
sodium phosphates
81
sodium polystyrene
sulfonate
41
sodium polystyrene sulfonate
15 gm/60ml
41
sodium polystyrene sulfonate
30 gm/120ml, 50
gm/200ml
41
SODIUM SULFACETAMIDE
WASH
57
SODIUM
SULFACETAMIDE/SULFUR
53
SODIUM
SULFACETAMIDE/SULFUR
CLEANSER IN UREA
53
SODIUM
SULFACETAMIDE/SULFUR IN
UREA
53
SOLARAZE
56
SOLODYN
102
SOLTAMOX
32
SOLUS V2 AUDIBLE
TEST
70
SOMA
92
SONATA
80
SOOLANTRA
63
SORBUTUSS NR
51
SORIATANE 10 MG
56
SORIATANE 17.5 MG
56
SORIATANE 25 MG
56
SORILUX
56
sotalol hcl
42
sotalol hcl (afib/afl)
42
SOVALDI
39
SPECTRACEF
45
SPINOSAD
63
SPIRIVA HANDIHALER
13
SPIRIVA RESPIMAT 1.25
MCG/ACT
13
SPIRIVA RESPIMAT 2.5
MCG/ACT
13
spironolactone
72
spironolactone &
hydrochlorothiazide
72
SPORANOX 10 MG/ML
25
SPORANOX 100 MG
25
SPORANOX PULSEPAK
25
SPRITAM
17
SPRIX
5
SPRYCEL
33
SSKI
85
SSS 10-5
53
STALEVO 100
35
STALEVO 125
35
STALEVO 150
35
STALEVO 50
35
STALEVO 75
35
stannous fluoride 0.63 %
86
STARLIX
23
stavudine
38
STAVZOR
18
STAXYN
43
STENDRA
43
STEVIOL GLYCOSIDES
45
STIMATE
74
STIOLTO RESPIMAT
15
STIVARGA
33
STRATTERA 10 MG, 18 MG, 25
MG, 40 MG
1
STRATTERA 100 MG, 60 MG, 80
MG
2
STRENSIQ
74
STRIANT
9
STRIBILD
38
STRIVERDI RESPIMAT
15
STROMECTOL
10
SUBOXONE 12MG-3MG
9
SUBOXONE 2MG-0.5MG, 4MG1MG, 8MG-2MG
9
SUBSYS
7
SUCLEAR
81
SUCRAID
71
sucralfate
104
SULAR
43
Index 25
sulfacetamide sodprednisolone
96
57
sulfacetamide sodium (acne) 53
(ophth)
95
sulfacetamide sodium w/ sulfur
1%-10%
53
2%-10%
54
2%-10%, 2%-2%-10%-10%,
4.5%-9%, 4.8%-9.8%
53
2%-10%, 4.8%-9.8%
53
4%-8%
54
4%-9%
53
4.8%-9.8%
53
5%-10%
53
sulfacetamide sodium-sulfur in
urea vehicle
54
SULFADIAZINE
101
sulfamethoxazole-trimethoprim
10
SULFAMYLON 5 %
57
SULFAMYLON 85 MG/GM 57
sulfasalazine
77
SULFOAM
54
sulindac
5
SULPIRIDE
45
SUMADAN WASH
54
sumatriptan 20 mg/act
84
sumatriptan 5 mg/act
84
sumatriptan succinate 100 mg, 25
mg, 50 mg
84
SUMAXIN TS
54
SUMAXIN WASH
54
SUPRAX 100 MG, 200 MG 45
SUPRAX 100 MG/5ML, 200
MG/5ML
45
SUPRAX 400 MG
45
SUPRAX 500 MG/5ML
45
SUPREME TEST STRIPS 70
SUPRENZA
1
SUPREP BOWEL PREP
81
SURE EDGE BLOOD GLUCOSE
TEST STRIPS
70
SURE-TEST EASYPLUS MINI
BLOOD GLUCOSE TEST
STRIPS
70
Index 26
SURECHEK BLOOD
SURMONTIL
21
SUSTIVA
38
SUTENT
33
SYMBICORT
15
SYMBYAX
100
SYNALAR
60
SYNALGOS-DC
8
SYNAREL
73
SYNERA
62
SYNERDERM
63
SYNJARDY
21
SYNTHROID
102
SYPRINE
40
T.R.U.E. TEST
63
TABLOID
32
TACLONEX
60
tacrolimus
41
tacrolimus (topical)
61
TAFINLAR
33
TAGRISSO
34
TAMIFLU 30 MG, 45 MG 40
TAMIFLU 6 MG/ML
40
TAMIFLU 75 MG
40
tamoxifen citrate
32
tamsulosin hcl
78
TANZEUM
22
TAPAZOLE
102
TARCEVA
34
TARGRETIN 1 %
56
TARGRETIN 75 MG
34
TARKA
30
TARON-BC
90
TARON-C DHA
90
TARON-PREX
90
TASIGNA
34
TASMAR
34
TAYTULLA
47
TAZORAC
56
TBC
61
TECFIDERA
100
TECFIDERA STARTER
PACK
100
TECHNIVIE
39
TEGRETOL
17
TEGRETOL-XR
17
TEKAMLO
30
TEKTURNA
30
TEKTURNA HCT
30
TELCARE BLOOD GLUCOSE
TEST STRIPS
70
telmisartan
28
telmisartan-amlodipine
30
telmisartan-hydrochlorothiazide
30
temazepam 15 mg, 30 mg, 7.5
mg
80
temazepam 22.5 mg
80
TEMODAR
32
TEMOVATE
60
TEMOVATE E
60
temozolomide
32
TENCON
5
TENEX
29
TENORETIC 100
30
TENORETIC 50
30
TENORMIN
41
TERAZOL 3
106
TERAZOL 7
106
terazosin hcl
29
terbinafine hcl
25
terbutaline sulfate 2.5 mg, 5
mg
15
terconazole vaginal 0.4 %, 0.8
%
106
terconazole vaginal 80 mg 106
TERSI FOAM
57
TESSALON PERLES
48
TESTIM
9
testosterone 1 %
9
testosterone 1 %, 25 mg/2.5gm,
50 mg/5gm
9
testosterone 1 %, 50 mg/5gm 9
TESTOSTERONE 10
MG/ACT
9
testosterone 25 mg/2.5gm
9
testosterone 25 mg/2.5gm, 50
mg/5gm
9
TESTRED
9
tetrabenazine
100
tetracaine hcl (ophth)
95
tetracycline hcl
102
TEVETEN
28
TEVETEN HCT
30
TEXACORT
60
TEXAVITE LQ
87
TGQ 15DM/5PEH/2CPM
51
TGQ 30PSE/150GFN/15DM 51
TGQ 30PSE/3BRM/15DM 51
TGQ 50PSE/3BRM/30DM 51
TGT BLOOD GLUCOSE TEST
STRIPS
70
TGT BLOOD GLUCOSE TEST
STRIPS PREMIUM
70
THALOMID
40
THEO-24
15
theophylline 100 mg, 200 mg,
450 mg
15
theophylline 300 mg
15
theophylline 400 mg, 600 mg15
theophylline 80 mg/15ml
15
THIOLA
78
thioridazine hcl
37
thiothixene
37
THRIVITE 19
90
THRIVITE RX
90
thyroid
102
THYROLAR-1
102
THYROLAR-1/2
102
THYROLAR-1/4
102
THYROLAR-2
102
THYROLAR-3
102
tiagabine hcl
18
TIAZAC
43
ticlopidine hcl
79
TIGAN
24
TIKOSYN
12
timolol maleate
42
timolol maleate (ophth)
93
TIMOPTIC
93
TIMOPTIC OCUDOSE
93
TIMOPTIC-XE
94
TINDAMAX
10
tinidazole
10
TIROSINT
102
TIVICAY
38
TIVORBEX
5
tizanidine hcl 2 mg, 4 mg
92
tizanidine hcl 2 mg, 4 mg, 6
mg
92
TL-CARE DHA
90
TL-SELECT
90
TOBI
3
TOBI PODHALER
3
TOBRADEX
96
TOBRADEX ST
96
tobramycin
3
TOBRAMYCIN
3
tobramycin (ophth)
95
tobramycindexamethasone
96
TOBREX
95
TODAY SPONGE
106
TOFRANIL
21
TOFRANIL-PM
21
tolazamide
23
tolbutamide
24
tolcapone
34
tolmetin sodium 200 mg, 600
mg
5
TOLMETIN SODIUM 400
MG
5
tolmetin sodium 400 mg
5
tolterodine tartrate 1 mg, 2
mg
105
tolterodine tartrate 2 mg, 4
mg
105
TOPAMAX
17
TOPAMAX SPRINKLE
17
TOPICORT 0.05 %
60
TOPICORT 0.25 %
60
topiramate
17
TOPIRAMATE ER
17
TOPROL XL
41
torsemide
72
TOUJEO SOLOSTAR
23
TOVIAZ
105
TRACLEER
44
TRADJENTA
22
tramadol hcl 100 mg, 200 mg,
300 mg
7
tramadol hcl 300 mg
7
tramadol hcl 50 mg
7
TRAMADOL HCL ER 100 MG,
150 MG, 200 MG
7
tramadol-acetaminophen
8
trandolapril
28
trandolapril-verapamil hcl 30
tranexamic acid
79
TRANSDERM-SCOP
24
TRANXENE T
12
tranylcypromine sulfate
19
TRAVATAN Z
97
TRAVOPROST
97
trazodone hcl
20
TRECATOR
31
TRESIBA FLEXTOUCH 100
UNIT/ML
23
TRESIBA FLEXTOUCH 200
UNIT/ML
23
TRETIN-X 0.038 %
54
TRETIN-X 0.075 %
54
tretinoin (chemotherapy)
34
tretinoin 0.01 %, 0.025 %
54
tretinoin 0.025 %, 0.05 %, 0.1
%
54
tretinoin 0.05 %
54
tretinoin microsphere
54
TREXALL
32
TREXIMET 85MG-500MG 83
TREZIX
8
TRI-NORINYL 28
47
TRI-TABS DHA
90
TRI-VI-FLOR
86
TRI-VI-FLORO
86
(mouth)
86
(nasal)
93
(topical)
60
triamterene &
hydrochlorothiazide
72
triazolam
80
TRIBENZOR
30
TRICARE PRENATAL 1
90
TRICARE PRENATAL 1MG60MCG-1MG-32.5MCG-4.5MG37.5MCG-1MG-15UNIT-7MG1.25MG-5MG-10MG-0.85MG125MCG-400UNIT-150MCG2.5MG-30MG
90
TRICARE PRENATAL 75MG1MG-37.5MG-60MCG-1MG32.5MCG-37.5MCG-4.5MG150MG-1MG-15UNIT-7MG1.25MG-5MG-10MG-0.85MG125MCG-400UNIT-150MCG2.5MG-30MG
90
TRICARE PRENATAL
COMPLEAT
90
TRICARE PRENATAL DHA
ONE
90
TRICODE AR
51
TRICODE GF
51
TRICOR
27
Index 27
TRIDESILON
60
trifluoperazine hcl
37
trifluridine
95
TRIGLIDE
27
trihexyphenidyl hcl
34
TRILEPTAL
17
TRILIPIX
27
trimethobenzamide hcl
24
trimethoprim
10
trimipramine maleate
21
TRINATAL GT
90
TRINATAL RX 1
90
TRINTELLIX
20
TRISTART DHA
90
TRIUMEQ
38
TRIVEEN-PRX RNF
90
TRIZIVIR
38
TROKENDI XR
17
tropicamide
94
trospium chloride
105
TRUETEST BLOOD GLUCOSE
TEST
70
TRUETEST BLOOD GLUCOSE
TEST STRIPS
70
TRUETEST STRIPS
70
TRUETRACK BLOOD
GLUCOSE TEST
70
TRUETRACK TEST
70
TRUSOPT
97
TRUVADA
38
trypsin w/ castor oil & peruvian
balsam
61
TUDORZA PRESSAIR
13
TUSNEL 2MG-15MG200MG
51
TUSNEL C
51
TUSNEL PEDIATRIC
51
TUSSI-PRES PEDIATRIC 51
TUSSICAPS
51
TUSSIONEX PENNKINETIC
EXTENDED RELEASE
51
TUZISTRA XR
51
TWYNSTA
30
TYBOST
38
TYKERB
34
TYLENOL/CODEINE #3
8
TYLENOL/CODEINE #4
8
TYVASO
44
TYVASO REFILL
44
Index 28
TYVASO STARTER
44
TYZEKA
39
UCERIS
10
ULESFIA
63
ULORIC
78
ULTIMA TEST STRIPS
71
ULTIMATECARE ONE
90
ULTIMATECARE ONE NF 90
ULTRACET
8
ULTRAM
7
ULTRAM ER
7
ULTRASAL-ER
62
ULTRATRAK PRO TEST
STRIPS
71
ULTRATRAK ULTIMATE TEST
STRIPS
71
ULTRAVATE
60
ULTRESA
71
UMECTA
61
UMECTA NAIL FILM
61
UPTRAVI
44
URAMAXIN 20%
61
URAMAXIN 45 %
61
URAMAXIN GT
61
urea
61
urea in lactic acid vehicle 61
urea in lactic acid-salicylic acid
vehicle
61
urea in zinc undecylenate-lactic
acid vehicle
61
UREA NAIL
61
URECHOLINE
106
URETRON D/S
105
URIMAR-T
105
UROCIT-K 10
78
UROCIT-K 15
78
UROCIT-K 5
78
UROXATRAL
78
URSO 250
76
URSO FORTE
76
ursodiol
76
UTIBRON NEOHALER
15
UTOPIC
61
VAGIFEM
106
valacyclovir hcl
40
VALCHLOR
56
VALCYTE 450 MG
38
VALCYTE 50 MG/ML
38
valganciclovir hcl 450 mg

39
valganciclovir hcl 50 mg/ml 39
VALIUM
12
valproate sodium 250
mg/5ml
18
valproic acid
18
valsartan
28
valsartan-hydrochlorothiazide
30
VALTREX
40
VANACOF
51
VANACOF CD
51
VANACOF DX
51
VANCOCIN HCL
10
vancomycin hcl 125 mg, 250
mg
10
VANOS
60
VANOXIDE-HC
54
VARUBI
25
VASCEPA 0.5 GM
26
VASCEPA 1 GM
26
VASERETIC
30
VASOTEC
28
VECAMYL
30
VECTICAL
56
VELTASSA
41
VELTIN
54
VEMAVITE-PRX 2
90
VEMLIDY
39
VENA-BAL DHA
90
VENCLEXTA
32
VENCLEXTA STARTING
PACK
32
venlafaxine hcl 100 mg, 25 mg,
37.5 mg, 50 mg, 75 mg
20
venlafaxine hcl 150 mg
20
venlafaxine hcl 150 mg, 37.5 mg,
75 mg
20
venlafaxine hcl 37.5 mg, 75
mg
20
VENLAFAXINE HCL ER
20
VENTAVIS
44
VENTOLIN HFA
15
VERAMYST
93
verapamil hcl 100 mg, 120 mg,
180 mg, 200 mg, 240 mg, 300
mg, 360 mg
43
verapamil hcl 120 mg, 180 mg,
240 mg
43
verapamil hcl 120 mg, 40 mg, 80
mg
43
VERDESO
60
VEREGEN
54
VERELAN
43
VERELAN PM
43
VERIPRED 20
48
VERSACLOZ
36
VESICARE
105
VEXA
62
VEXOL
96
VFEND 200 MG, 50 MG
25
VFEND 40 MG/ML
25
VIAGRA
43
VIBERZI
77
VIBRAMYCIN 100 MG
102
VIBRAMYCIN 25 MG/5ML 102
VIBRAMYCIN 50 MG/5ML 102
VICOPROFEN
8
VICTORY AGM-4000 TEST
STRIPS
71
VICTRELIS
39
VIDEX EC
38
VIDEXPEDIATRIC
38
VIEKIRA PAK
39
VIEKIRA XR
39
VIGAMOX
95
VIIBRYD
20
VIIBRYD 10 MG, 20 MG, 40
MG
20
VIIBRYD STARTER PACK 20
VIMOVO
5
VIMPAT 10 MG/ML
17
VIMPAT 100 MG, 150 MG, 200
MG, 50 MG
17
VINACAL B
90
VINATE C
90
VINATE CALCIUM
90
VINATE DHA RF
90
VINATE ONE
90
VIOKACE
71
VIRACEPT
38
VIRAMUNE 200 MG
38
VIRAMUNE 50 MG/5ML
38
VIRAMUNE XR
38
VIRASAL
62
VIRAZOLE
40
VIREAD
38
VIROPTIC
95
VIRT-ADVANCE
90
VIRT-C DHA
91
VIRT-CARE ONE
91
VIRT-NATE DHA
91
VIRT-PN
91
VIRT-PN DHA
91
VIRT-PN PLUS
91
VIRT-SELECT
91
VIRT-VITE GT
91
VIRTPREX
91
VISTARIL
12
VISTOGARD
24
VITAFOL FE+
91
VITAFOL GUMMIES
91
VITAFOL-NANO
91
VITAFOL-ONE
91
VITAMEDMD ONE
RX/QUATREFOLIC
91
VITAMEDMD PLUS
RX/QUATREFOLIC
91
VITAMEDMD REDICHEW
RX
91
VITAPEARL
91
VITATRUE
91
VITEKTA
38
VITUZ
51
VIVA DHA
91
VIVELLE-DOT 0.025
MG/24HR
75
VIVELLE-DOT 0.0375
MG/24HR
75
VIVELLE-DOT 0.05 MG/24HR,
0.075 MG/24HR, 0.1
MG/24HR
75
VIVOTIF
106
VIVOTIF BERNA
106
VOCAL POINT BLOOD
VOGELXO
9
VOGELXO PUMP
9
VOL-TAB RX
91
VOLTAREN
54
VOLTAREN-XR
5
VORICONAZOLE
45
voriconazole 200 mg, 50
mg
25
voriconazole 40 mg/ml
25
VOSPIRE ER
15
VOTRIENT
34
VP CH ULTRA
91
VP-CH PLUS
91
VP-CH-PNV
91
VP-GGR-B6 PRENATAL
91
VP-HEME OB
91
VP-HEME OB + DHA
91
VP-PNV-DHA
91
VRAYLAR
35
VUSION
55
VYTONE
56
VYTORIN 10MG-10MG
26
VYTORIN 10MG-20MG, 40MG10MG
26
VYTORIN 80MG-10MG
26
VYVANSE 10 MG
1
VYVANSE 20 MG, 30 MG, 40
MG, 50 MG, 60 MG, 70 MG 1
warfarin sodium
15
WAVESENSE PRESTO TEST
STRIPS
71
WEGMANS COMPLETE
PRENATAL+DHA
91
WELCHOL
27
WELLBUTRIN
19
WELLBUTRIN SR
19
WELLBUTRIN XL
19
WESTCORT
60
WESTHROID 113.75 MG, 130
MG, 146.25 MG, 16.25 MG, 195
MG, 260 MG, 32.5 MG, 325 MG,
65 MG, 81.25 MG, 97.5 MG102
WESTHROID 162.5 MG, 48.75
MG
102
WIDE-SEAL SILICONE
DIAPHRAGM KIT 60
82
WIDE-SEAL SILICONE
DIAPHRAGM KIT 65
82
WIDE-SEAL SILICONE
DIAPHRAGM KIT 70
82
WIDE-SEAL SILICONE
DIAPHRAGM KIT 75
82
WIDE-SEAL SILICONE
DIAPHRAGM KIT 80
82
WIDE-SEAL SILICONE
DIAPHRAGM KIT 85
82
WIDE-SEAL SILICONE
DIAPHRAGM KIT 90
82
WIDE-SEAL SILICONE
DIAPHRAGM KIT 95
82
WP THYROID 113.75 MG, 130
MG, 16.25 MG, 32.5 MG, 65 MG,
81.25 MG, 97.5 MG
102
WP THYROID 48.75 MG 102
XALATAN
97
Index 29
XALKORI
34
XANAX
12
XANAX XR
12
XARELTO STARTER PACK 15
XARTEMIS XR
8
XELJANZ
3
XELJANZ XR
3
XELODA
32
XENAZINE
100
XENICAL
1
XERAC AC
63
XERESE
57
XIFAXAN 200 MG
10
XIFAXAN 550 MG
10
XIGDUO XR
21
XODOL
8
XOLEGEL
56
XOPENEX
15
XOPENEX CONCENTRATE 15
XOPENEX HFA
15
XTAMPZA ER
7
XTANDI
33
XULANE
47
XYLOCAINE 4 %
62
XYREM
99
XYZAL 2.5 MG/5ML
26
XYZAL 5 MG
26
YASMIN 28
47
YAZ
47
Z-TUSS AC
51
zaleplon
80
ZANAFLEX
92
ZANTAC 150 MAXIMUM
STRENGTH
104
ZANTAC 150 MG
104
ZANTAC 300 MG
104
ZARONTIN
18
ZAROXOLYN
72
ZATEAN-CH
91
ZATEAN-PN
91
ZATEAN-PN DHA
91
ZATEAN-PN PLUS
91
ZAVESCA
79
ZEBETA
41
ZECUITY
84
ZEGERID 20MG-1680MG,
40MG-1680MG
105
Index 30
ZELAPAR
35
ZELBORAF
34
ZEMPLAR 1 MCG, 2 MCG 74
ZENPEP 10000UNIT3000UNIT-16000UNIT,
85000UNIT-25000UNIT136000UNIT
71
ZENPEP 17000UNIT5000UNIT-27000UNIT
71
ZENZEDI
1
ZEPATIER
39
ZERIT
38
ZESTORETIC
30
ZESTRIL
28
ZETIA
27
ZETONNA
93
ZIAC
30
ZIAGEN 20 MG/ML
38
ZIAGEN 300 MG
38
ZIANA
54
zidovudine
38
zinc sulfate 220 mg
85
ZIOPTAN
97
ziprasidone hcl
36
ZIPSOR
5
ZIRGAN
95
ZITHRANOL-RR
56
ZITHROMAX 1 GM
81
ZITHROMAX 100 MG/5ML, 200
MG/5ML
81
ZITHROMAX 250 MG
81
ZITHROMAX 500 MG
81
ZITHROMAX 600 MG
81
ZITHROMAX TRI-PAK
81
ZITHROMAX Z-PAK
81
ZMAX
81
ZOCOR
27
ZOFRAN 4 MG, 8 MG
24
ZOFRAN 4 MG/5ML
24
ZOFRAN ODT
24
ZOHYDRO ER
7
ZOLINZA
34
zolmitriptan 2.5 mg, 5 mg 84
ZOLOFT
20
zolpidem tartrate 1.75 mg, 3.5
mg
80
zolpidem tartrate 10 mg, 5
mg
80
zolpidem tartrate 12.5 mg, 6.25
mg
80
ZOLPIMIST
80
ZOMACTON 10 MG
73
ZOMIG 2.5 MG
84
ZOMIG 2.5 MG, 5 MG
84
ZOMIG NASAL SPRAY
84
ZOMIG ZMT
84
ZONALON
56
ZONATUSS
48
ZONEGRAN
17
zonisamide
17
ZONTIVITY
79
ZORBTIVE
73
ZORTRESS
41
ZORVOLEX
5
ZOVIRAX 200 MG
40
ZOVIRAX 200 MG/5ML
40
ZOVIRAX 400 MG, 800 MG 40
ZOVIRAX 5 %
57
ZUBSOLV
9
ZUPLENZ
24
ZURAMPIC
78
ZUTRIPRO
51
ZYBAN
101
ZYCLARA
61
ZYCLARA PUMP 2.5 %
61
ZYCLARA PUMP 3.75 %
61
ZYDELIG
34
ZYFLO
13
ZYFLO CR
13
ZYKADIA
34
ZYLET
96
ZYLOPRIM
78
ZYMAXID
95
ZYPREXA
36
ZYPREXA ZYDIS
36
ZYTIGA
33
ZYVOX 100 MG/5ML
11
ZYVOX 600 MG
11

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REGIMEX TABS (Use

Attention-Deficit/Hyperactivity Disorder (ADHD)

guanfacine hcl (adhd) tb24

INTUNIV TB24 (Use

Updated: January 1, 2017

CONCERTA TBCR 18 MG,

methylphenidate hcl cpcr

methylphenidate hcl tbcr 10

methylphenidate hcl tbcr 18

methylphenidate hcl tbcr 54

NUVIGIL TABS (Use

Updated: January 1, 2017

AMINOGLYCOSIDES - Drugs to Treat Bacterial

Nonsteroidal Anti-inflammatory Agents (NSAIDs)

KITABIS PAK NEBU

neomycin sulfate tabs

paromomycin sulfate caps

TOBI NEBU (Use

TOBI PODHALER CAPS

ANALGESICS - ANTI-INFLAMMATORY - Drugs

DAYPRO TABS (Use

diclofenac potassium tabs

Updated: January 1, 2017

EC-NAPROSYN TBEC 500 GP

mefenamic acid caps

meloxicam susp 7.5

meloxicam tabs 7.5 mg

MOBIC SUSP 7.5 MG/5ML

MOBIC TABS 15 MG (Use

nabumetone tabs 750 mg

NAPRELAN TB24 750 MG

ibuprofen tabs 400 mg, 600

NAPROSYN SUSP (Use

flurbiprofen tabs 100 mg

nabumetone tabs 500 mg

NAPRELAN TB24 375 MG,

naproxen susp 125 mg/5ml

naproxen tabs 250 mg, 375

naproxen tbec 500 mg

Updated: January 1, 2017