Formulary 2009

2
2009 AHCCCS Formulary
Introduction
Health Choice Arizona (HCA) is pleased to provide the Health Choice Formulary to
be used when prescribing for patients covered by the pharmacy plan offered by
Health Choice.
This is a closed formulary; therefore, the drugs listed in this formulary are
the preferred medications which are covered by Health Choice. In the
absence of substantial documented clinical support, HCA requires that
formulary choices be utilized.
The drugs listed in the Health Choice Formulary have been reviewed and
approved by the Health Choice Pharmacy and Therapeutics (P&T) Committee.
The formulary has been developed to provide medications which are both clinically
appropriate and cost-effective for patients who have their drug benefit
administered through Health Choice. There may be occasions when an unlisted
drug is desired for medical management of a specific patient. In those instances,
the unlisted medication may be requested through the Prior Authorization process.
The information contained in the Health Choice Formulary and its appendices is
provided by Health Choice, solely for the convenience of medical providers. Health
Choice does not warrant or assure accuracy of such information, nor is it intended
to be comprehensive in nature. The Health Choice Formulary is not intended to be
a substitute for the knowledge, expertise, skill, and judgment of the medical
provider in their choice of prescription drugs. Health Choice does not assume
responsibility for the actions or omissions of any medical provider based upon
reliance, in whole or in part, on the information contained herein. The medical
provider should consult the drug manufacturer's product literature or
standard references for more detailed information.
Preface
The Health Choice Formulary is organized by sections. Each section includes
therapeutic groups identified by either a drug class or disease state. Products are
listed by generic name. Brand name products are included as a reference to assist
in product recognition. Unless exceptions are noted, generally all dosage forms
and strengths of the drug cited are covered.
This formulary covers selected, cost-effective over-the-counter (OTC) products.

You are encouraged to prescribe them when clinically appropriate.
3
Pharmacy and Therapeutics Committee
The actions of the Health Choice P&T Committee are communicated on the Health
Choice web site and in the Health Choice Provider Newsletter, which is distributed
to all network providers.
Product Selection Criteria

The Health Choice P&T Committee will consider all new-to-market drugs for
inclusion to the formulary. The evaluation includes a literature review and expert
external opinion may also be sought. Formal reviews are prepared that typically
address the following information:
Safety
Efficacy
Comparison studies
Approved indications
Adverse effects
Contraindications/Warnings/Precautions
Pharmacokinetics
Patient administration/compliance considerations
Cost effectiveness
When a new drug is considered for formulary inclusion, an attempt will be made to
examine the drug relative to similar drugs currently on formulary. In addition, entire
therapeutic classes are periodically reviewed. The class review process may result
in deletion of one or more drugs in a particular therapeutic class in an effort to
continually promote the most clinically useful and cost-effective agents.
All the information in the Health Choice formulary is provided as a reference for
drug therapy selection. Specific drug selection for an individual patient rests solely
with the prescriber.
Formulary Product Descriptions

To assist in understanding which specific strengths and dosage forms are on the
formulary, examples are noted below. The general principles shown in the
examples can then usually be extended to other entries in the book. Any
exceptions are noted in the drug list. There may also be a statement associated
with a drug list that gives additional information about which specific products or
dosage forms are on formulary.
The brand name products shown are for reference only; a different brand or a
generic version may be dispensed.
4 – Boldface indicates generic availability

Products on formulary include all strengths and dosage forms of the cited
brand name product.
ondansetron Zofran
In addition to the tablets, the oral solution and orally disintegrating tablets are on
formulary.
When a strength or dosage form is specified, only the specified strength and
dosage form is on formulary. Other strengths/dosage forms of the reference
product are not.
metronidazole tabs Flagyl
Only tablets are on formulary, not the capsules.
Extended-release and delayed-release products require their own entry.
bupropion ext-rel Wellbutrin XL
The long-acting product Wellbutrin SR is not on formulary based upon the

Wellbutrin XL entry.
Similarly, the brand name product Wellbutrin immediate-release is not on

formulary.
Dosage forms on formulary will be consistent with the category and use
where listed.
neomycin/polymyxin B/hydrocortisone Cortisporin
As listed in the OTIC section, limited to the otic solution and suspension. From this
entry the ophthalmic solution and ophthalmic ointment, and the topical cream
cannot be assumed to be on formulary unless there are entries for these products
in the OPHTHALMIC and DERMATOLOGY sections of the formulary.
Generic Availability
Boldface type of a generic drug name in this book indicates generic availability of
that product. However, not all strengths or dosage forms of the generic name in
boldface type may be generically available. In some cases, the brand name listed
is a generic drug. Examples of the latter include Levoxyl and Trivora.
Generic Substitution
Generic substitution is a pharmacy action whereby a generic version is dispensed
rather than a prescribed brand name product. An important consideration for
Boldface indicates generic availability - 5
generic substitution is the knowledge that all approvals of generic drugs by the
FDA since 1984, and many generic approvals prior to 1984, have a showing of
bioequivalence between the generic versions and the reference brand name
product. To gain FDA approval:
1. The generic drug must contain the same active ingredient(s), be the same
strength and the same dosage form as the brand name product.
2. The FDA has given the generic an "A" rating compared to the brand name
product indicating bioequivalence, and has determined the generic is
therapeutically equivalent to the reference brand name product. The
ratings of generic drugs are available by referring to the FDA reference,
Approved Drug Products with Therapeutic Equivalence Evaluations
(Orange Book).
When the above two criteria are met, a generic can be substituted with the full
expectation that the substituted product will produce the same clinical effect and
safety profile as the prescribed product. Drug products that have a narrow
therapeutic index (NTI) can also be guided by these principles. It is not necessary
for the healthcare practitioner to approach any one therapeutic class of drug
products (e.g., NTI drugs) differently from any other class, when there has been a
determination of therapeutic equivalence by the FDA for the drug products under
consideration. Also, additional clinical tests or examinations by the practitioner are
not needed when a therapeutically equivalent generic drug product is substituted
for the brand name product.
It is recommended that generic substitution not be exercised by the pharmacist

with multisource products that appear in the Orange Book and carry a "B" rating,
indicating that these products cannot be considered therapeutically equivalent to
other products in the group. It is also recommended that generic substitution not
be undertaken for any unrated multisource products that might be considered
narrow therapeutic index, or maintenance drugs where it is known that unrated
products from different labelers are not bioequivalent. State law or regulations may
dictate the ability to practice generic substitution for selected products or
categories of drugs.
Drug Efficacy Study Implementation Drugs

Drugs first marketed between 1938 and 1962 were approved as safe but required
no showing of effectiveness for FDA approval. Beginning in 1962, all new drugs
were required to be both safe and effective before they could be marketed. This
legislation also applied retroactively to all drugs approved as safe from 1938-1962.
The Drug Efficacy Study Implementation (DESI) program was established by the
FDA to review the effectiveness of these pre-1962 drugs for their labeled
indications, and a determination of fully effective was made for most of these
products and they remain in the marketplace. A few DESI products remain
classified as "less than fully effective" while awaiting final administrative
disposition. Also, classified as DESI are many products listed as identical, similar,
or related to actual DESI products.
AHCCCS and Health Choice will not pay for DESI "less than fully effective" drug
products.
Request for Formulary Consideration

Health Choice providers may formally request the HCA P&T Committee consider a
medication be considered for addition to the formulary. The instructions and
required submission form(s) which indicate how to submit a formulary medication
consideration request are detailed in the Health Choice Provider Manual as well as
on the Health Choice website.
Prior Authorization
Prior Authorization (PA) is required for two groups of medications and for two
clinical formulary override conditions:
Medication Groups
1. Medications noted with a PA in the drug list.
2. All unlisted medications.
Clinical Override Conditions

1. To override a Step Therapy (ST) edit.
2. To override a Quantity Level Limit (QLL) edit.
It is anticipated that a request for an unlisted medication will be infrequent, and that
physicians will be able to prescribe a formulary medication for the vast majority of
therapeutic needs. Physicians are encouraged to use this formulary when
prescribing medications for patients to avoid unnecessary delays in therapy.
A physician may request a formulary exception or clinical override by utilizing the

pharmacy override/exception form available from Health Choice. The completed
form and supportive documentation should be faxed to Health Choice Prior
Authorization at 1-888-291-4542. The request will be reviewed and a response will
be received within two to three business days. Urgent or emergent requests will be
responded to within 24 hours. In those extenuating circumstances where the
patient's medical condition may be in jeopardy by waiting 24 hours, certain
medications may be authorized by telephone at 480-968-6866, ext. 1800 or toll
free 1-800-322-8670, ext. 1800.
For your reference, we have included key factors that will be considered in
reviewing a prior authorization request. These precede the drug list in the
formulary.

Off-label Prescribing Guidelines
Health Choice Medical Services does not and can not promote off-label use of
currently available medications by granting approval for such use. Providers who
wish to utilize medications for off-label diagnoses and conditions do so outside the
realm of plan approval criteria.
In cases where off-label use of a medication has become the accepted community
standard of care as definitively reported in the medical literature, HCA will review
such requests on a case-by-case basis.
Editor
Your comments and suggestions regarding the Health Choice Formulary are
encouraged. Your input is vital to this clinical formulary's continued success. All
responses will be reviewed and considered. Please send your comments to:
Medical Services Department

Health Choice Arizona
th
410 North 44 Street, Suite 405
Phoenix, AZ 85008
Notice
The information contained in this document is proprietary information. The
information may not be copied in whole or in part without the written permission of
Health Choice. © All rights Reserved.
The drug names listed here are the registered and/or unregistered trademarks of
third-party pharmaceutical companies unrelated to and unaffiliated with Health
Choice. These trademarked brand names are included for informational purposes
only and are not intended to imply or suggest any affiliation between Health Choice
and such third-party pharmaceutical companies.
LEGEND
boldface Indicates generic availability
OTC Over-the-Counter
PA Prior Authorization Required
QLL Quantity Level Limit
SPBM Specialty Drug, Fill at CuraScript
ST Step Therapy through prerequisite drug required

OTC (Over-the-Counter) Formulary
The OTC products included on this list are covered for Health Choice AHCCCS
patients. A written prescription from a Health Choice provider is required.
Generic availability is indicated by boldface type

The brand name products noted are for reference only; generics should be
dispensed whenever possible
The list suggests dosage forms for some products. Generally, the commonly
available products associated with each line item are covered
ANTIINFECTIVES
TOPICAL ANTIBACTERIAL DRUGS

bacitracin
bacitracin/polymymyxin POLYSPORIN
bacitracin zinc
neomycin/bacitracin/polymyxin NEOSPORIN
VAGINAL ANTIFUNGALS
clotrimazole MYCELEX
miconazole nitrate MONISTAT
OTHER TOPICAL ANTIFUNGALS

clotrimazole LOTRIMIN
miconazole nitrate MICRO-GUARD
tolnaftate TINACTIN
AUTONOMIC AND CNS MEDICATIONS
ANALGESICS
acetaminophen TYLENOL
aspirin/buffers BAYER
ANTIVERTIGO AND ANTIEMETIC DRUGS

dimenhydrinate DRAMAMINE
DERMATOLOGICAL MEDICATIONS
TOPICAL CORTICOSTEROID DRUGS

hydrocortisone CORTAID
ANTIACNE DRUGS
OTC benzoyl peroxide BREVOXYL

KERATOLYTIC DRUGS
acetic acid/salicylic acid COMPOUND W
salicylic acid COMPOUND W
ANTIPSORIASIS AND ANTIECZEMA DRUGS

coal tar NEUTROGENA T/GEL
selenium sulfide SELSUN BLUE
TOPICAL DERMATOLOGICAL DRUGS

calamine
hydrogen peroxide
mineral oil/petrolatum AQUAPHOR
piperonyl butoxide/pyrethrins RID
urea 20% Carmol
EAR-NOSE-THROAT MEDICATIONS
DRUGS AFFECTING THE EAR

antipyrine/benzocaine BENZOTIC
carbamide peroxide DEBROX
DRUGS AFFECTING THE NOSE

cromolyn NASALCROM
GASTROINTESTINAL MEDICATIONS
ANTACIDS
aluminum hydroxide AMPHOJEL
calcium carbonate MYLANTA
dihydroxyaluminum sodium carbonate ROLAIDS
magnesium hydroxide/al hydrox MAALOX
mag hydrox/al hydrox/simeth MYLANTA
sodium bicarbonate GENATON
ANTIDIARRHEAL DRUGS
attapulgite KA-PEC
bismuth subsalicylate KAOPECTATE
loperamide IMODIUM
ANTIULCER DRUGS
cimetidine TAGAMET
ranitidine ZANTAC
PROTON PUMP INHIBITORS

QLL omeprazole magnesium PRILOSEC OTC
omeprazole magnesium/PRILOSEC maximum quantity 60 tablets every 30 days

LAXATIVES AND CATHARTICS
bisacodyl DULCOLAX
docusate sodium COLACE
magnesium hydroxide MILK OF MAGNESIA
magnesium sulfate EPSOM SALT
phenolphthalein
polyethylene glycol GLYCOLAX
psyllium METAMUCIL
senna/docusate sodium SENOKOT
sennosides a&b, calcium EX-LAX
sodium phosphate/NA biphos ENEMA
OTHER GI DRUGS
simethicone GAS-X
MUSCULOSKELETAL MEDICATIONS
SALICYLATES AND RELATED DRUGS

aspirin BAYER
aspirin/acetaminophen/caffeine EXCEDRIN
NUTRITION,BLOOD
VITAMINS & MINERALS & RELATED PRODUCTS

calcium carbonate tablet TUMS
ferrous gluconate FERGON
ferrous sulfate FERATAB
folic acid/vit b complex with c DAILYVITE
multivitamins
pyridoxine NESTREX
vitamin b complex
vitamin e
THERAPEUTIC VITAMINS & MINERALS

folic acid
zinc acetate
BLOOD DETOXICANTS
lactulose ENULOSE
ELECTROLYTES, IRRIGATING SOLUTIONS, ETC.

electrolyte solution PEDIALYTE

OBSTETRICAL & GYNECOLOGICAL MEDICATIONS
PRENATAL VITAMINS
iron
OTC, RX prenatal vitamins
Prenatal vitamins generics only covered for women age 14 to 45.
OPHTHALMIC MEDICATIONS
OTHER OPHTHALMIC DRUGS

carboxymethylcellulose, sodium THERA TEARS
dextran 70/he-cell TEARS NATURALE
hydroxypropyl methylcellulose GENTEAL
lanolin/mineral oil/petrolatum PURALUBE
naphazoline/pheniramine NAPHCON-A
petrolatum, white PURALUBE
polyvinyl alcohol HYPOTEARS
RESPIRATORY MEDICATIONS
ANTIHISTAMINES
QLL,OTC cetirizine tabs ZYRTEC
ST,QLL,OTC cetirizine syrup ZYRTEC
chlorpheniramine CHLOR-TRIMETON
QLL, OTC loratadine tabs, syrup CLARITIN
clemastine tabs TAVIST-1
diphenhyramine caps, tabs, elixir BENADRYL
cetirizine/ZYRTEC requires trial of OTC loratadine for prior authorization, maximum quantity 150mL
every 30 days. Limited to children under the age of 2
loratadine/CLARITIN maximum quantity 34 units per fill
DECONGESTANTS
pseudoephedrine SUDAFED
ANTIHISTAMINE/DECONGESTANT COMBINATIONS
pseudoephedrine/brompheniramine DIMETAPP
pseudoephedrine/loratidine CLARITIN-D
pseudoephedrine/tripolidine ACTIFED
ANTITUSSIVE AND EXPECTORANT DRUGS

guaifenesin/dextromethorphan GUAICON
guaifenesin/pseudoephedrine SINUTAB LiquiCaps
guaifenesin syrup ROBITUSSIN
SMOKING CESSATION PRODUCTS
QLL,OTC nicotine polacrilex gum NICORETTE

QLL,OTC nicotine patch NICODERM CQ
nicotine gum/NICORETTE maximum quantity 108 per fill, 324 in 6 months

nicotine patch/NICODERM maximum quantity 30 per fill, 90 in 6 months

UROLOGICAL MEDICATIONS
URINARY ANESTHETICS
phenazopyridine URISTAT
DIAGNOSTIC & MISCELLANEOUS MEDICATIONS
DIAGNOSTIC PRODUCTS
ketone testing products KETOCARE
ketone testing products CHEMSTRIP
MEDICAL (MISCELLANEOUS) SUPPLIES
DIABETIC SUPPLIES
glucose monitors, supplies ACCU-CHEK AVIVA,
COMPACT PLUS
HCA Formulary
ANTIINFECTIVES
CEPHALOSPORINS
cefaclor CECLOR
cefdinir OMNICEF
QLL cefixime 400mg SUPRAX
cefprozil CEFZIL
cephalexin KEFLEX
cefixime 400mg/SUPRAX maximum quantity 1 per month
CLINDAMYCINS
clindamycin hcl CLEOCIN HCL
QLL clindamycin palmitate CLEOCIN GRANULES
clindamycin palmitate/CLEOCIN GRANULES covered up to age 10 without prior authorization,
maximum of 300ml per rx. PA needed for either exception.
ERYTHROMYCINS
erythromycin ERY-TAB
erythromycin ethylsuccinate E.E.S
OTHER MACROLIDES
QLL azithromycin ZITHROMAX
azithromycin/ZITHROMAX maximum quantity 4 units per fill
PENICILLINS
amoxicillin AMOXIL
amoxicillin clavulanate AUGMENTIN
ampicillin PRINCIPEN
dicloxacillin DYNAPEN
penicillin VEETIDS
* amox/clavulanate AUGMENTIN ES-600
*Limited to children under age of 6.

SULFONAMIDES
erythromycin/sulfisoxazole PEDIAZOLE
sulfamethoxazole/trimethoprim SEPTRA
TETRACYCLINES
doxycycline hyclate DORYX
tetracycline SUMYCIN
URINARY ANTIINFECTIVES
nitrofurantoin macrocrystal MACROBID
trimethoprim PRIMSOL
QUINOLONES
ciprofloxacin CIPRO
levofloxacin LEVAQUIN
moxifloxacin AVELOX / ABC PACK
TOPICAL ANTIBACTERIAL DRUGS

OTC bacitracin
OTC bacitracin zinc
* clindamycin hcl topical solution 1% CLEOCIN HCL
erythromycin top solution 2% A/T/S
gentamicin sulfate GARAMYCIN
PA mupirocin oint BACTROBAN
OTC neomycin/bacitracin/polymyxin NEOSPORIN
silver sulfadiazine SILVADENE
mupirocin/BACROBAN requires prior authorization

*clindamycin is 2nd line after erythromycin
ORAL ANTIFUNGAL DRUGS

clotrimazole MYCELEX
PA, QLL fluconazole DIFLUCAN
griseofulvin ultramicrosize GRIS-PEG
PA, QLL itraconazole SPORANOX
ketoconazole NIZORAL
nystatin MYCOSTATIN
PA, QLL terbinafine LAMISIL
fluconazole/DIFLUCAN requires prior authorization, maximum quantity 2 units per fill, without PA for
150mg only
itraconazole/SPORANOX maximum quantity 34 units per fill
itraconazole/SPORANOX capsules requires prior authorization
terbinafine/LAMISIL tablets require prior authorization, maximum quantity 84 units per lifetime
VAGINAL ANTIFUNGALS
OTC butoconazole FEMSTAT 3
OTC clotrimazole MYCELEX
OTC miconazole nitrate MONISTAT
nystatin MYCOSTATIN
OTHER TOPICAL ANTIFUNGALS

OTC clotrimazole LOTRIMIN
ketoconazole NIZORAL
OTC miconazole nitrate MICRO-GUARD
nystatin MYCOSTATIN
OTC tolnaftate TINACTIN
TOPICAL CORTICOSTEROIDS
nystatin/triamcinolone MYCOLOG
ANTIRETROVIRALS & PROTEASE INHIBITORS

abacavir sulfate ZIAGEN
abacavir sulfate/lamivudine EPZICOM
amprenavir AGENERASE
atazanavir sulfate REYATAZ
darunavir ethanolate PREZISTA
delavirdine mesylate RESCRIPTOR
didanosine VIDEX
efavirenz SUSTIVA
emtricitabine EMTRIVA
emtricitabine/tenofovir TRUVADA
emtricitabine/tenofovir/efavir ATRIPLA
PA, SPBM enfuvirtide FUZEON
etravirine INTELENCE
fosamprenavir calcium LEXIVA
indinavir CRIXIVAN
lamivudine EPIVIR
lamivudine/zidovudine COMBIVIR
maraviroc SELZENTRY
nelfinavir mesylate VIRACEPT
nevirapine VIRAMUNE
raltegavir INSENTRESS
ritonavir NORVIR
ritonavir/lopinavir KALETRA
saquinavir FORTOVASE
saquinavir mesylate INVIRASE
stavudine ZERIT
tenofovir disproxil fumarate VIREAD
tipranavir APTIVUS
zalcitabine HIVID
zidovudine RETROVIR
zidovudine/lamivudine/abacavir TRIZIVIR
enfuvirtide/FUZEON use specialty pharmacy
OTHER ANTIVIRAL DRUGS

acyclovir ZOVIRAX
amantadine SYMMETREL
ganciclovir CYTOVENE
lamivudine EPIVIR
PA, SPBM ribavirin COPEGUS
PA, SPBM ribavirin REBETOL
PA, QLL valacyclovir VALTREX
ribavirin/COPEGUS, REBETOL use specialty pharmacy

valacyclovir/VALTREX requires prior authorization, maximum quantity 30 units per fill
TOPICAL ANTIVIRAL DRUGS

acyclovir ZOVIRAX
acyclovir oint ZOVIRAX OINT
paromomycin HUMATIN
ANTITUBERCULOSIS DRUGS
ethambutol MYAMBUTOL
isoniazid NYDRAZID
pyrazinamide
rifampin RIFADIN
PLASMODICIDES
hydroxychloroquine PLAQUENIL
mefloquine LARIAM
primaquine
SULFONES
dapsone
TRICHOMONOCIDES
metronidazole FLAGYL
ANTHELMINTICS
mebendazole VERMOX
pyrantel PIN-X
OTHER ANTIINFECTIVE DRUGS

atovaquone MEPRON
PA vancomycin vancocin
ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
ANTINEOPLASTIC/IMMUNOSUPPRESSANT DRUGS
PA,SPBM abatacept/maltose ORENCIA
PA,SPBM, QLL adalimumab HUMIRA
altretamine HEXALEN
PA anagrelide AGRYLIN
anastrozole ARIMIDEX
azathioprine AZASAN
bexarotene TARGRETIN
busulfan MYLERAN
chlorambucil LEUKERAN
PA,SPBM cyclophosphamide CYTOXAN
cyclosporine NEORAL
PA,SPBM cyclosporine SANDIMMUNE
PA,SPBM, QLL etanercept ENBREL
PA, SPBM etoposide TOPOSAR
exemestane AROMASIN
flutamide EULEXIN
hydroxyurea HYDREA
PA, SPBM infliximab REMICADE
letrozole FEMARA
lomustine CEENU
megestrol MEGACE
PA, SPBM melphalan ALKERAN
mercaptopurine PURINETHOL
methotrexate RHEUMATREX
mitotane LYSODREN
PA, SPBM mycophenolate mofetil CELLCEPT
procarbazine MATULANE
sirolimus RAPAMUNE
PA, SPBM tacrolimus PROGRAF
tamoxifen NOLVADEX
thioguanine
toremifene FARESTON
abatacept/maltose/ORENCIA use specialty pharmacy

adalimumab/HUMIRA use specialty pharmacy, maximum quantity 3 units per fill
anagrelide/AGRYLIN requires prior authorization
cyclophosphamide/CYTOXAN use specialty pharmacy
cyclosporine/SANDIMMUNE use specialty pharmacy
etanercept/ENBREL use specialty pharmacy, maximum quantity 5 units per dispensing
etoposide/TOPOSAR use specialty pharmacy
infliximab/REMICADE use specialty pharmacy
melphalan/ALKERAN use specialty pharmacy
mycophenolate mofetil/CELLCEPT injectable use specialty pharmacy
tacrolimus/PROGRAF injectable use specialty pharmacy
CARDIOVASCULAR MEDICATIONS
CARDIAC GLYCOSIDES
digitek LANOXIN
digoxin LANOXIN
CALCIUM ANTAGONISTS
amlodipine NORVASC
diltiazem CARDIZEM CD
diltiazem TIAZAC
nifedipine ADALAT CC
nifedipine PROCARDIA XL
verapamil CALAN SR
verapamil COVERA-HS
verapamil VERELAN
LOOP DIURETICS
furosemide LASIX
THIAZIDE AND RELATED DRUGS

chlorthalidone HYDONE
hydrochlorothiazide MICROZIDE
indapamide LOZOL
metolazone ZAROXOLYN
POTASSIUM SPARING DIURETICS

spironolactone ALDACTONE
spironolactone/hctz ALDACTAZIDE
hctz/triamterene MAXZIDE-25MG
hctz/triamterene DYAZIDE
BETA-ADRENERGIC ANTAGONIST DRUGS

atenolol TENORMIN
carvedilol COREG
labetalol TRANDATE
metoprolol succinate TOPROL XL
metoprolol tartrate LOPRESSOR
pindolol VISKEN
propranolol INDERAL

VASODILATOR ANTIHYPERTENSIVES
doxazosin CARDURA
hydralazine APRESOLINE
prazosin MINIPRESS
terazosin HYTRIN
CENTRALLY ACTING ANTIHYPERTENSIVES

clonidine tabs CATAPRES
methyldopa ALDOMET
ANGIOTENSIN CONVERTING ENZYME INHIBITORS

benazepril LOTENSIN
captopril CAPOTEN
enalapril VASOTEC
lisinopril PRINIVIL
lisinopril ZESTRIL
quinapril ACCUPRIL
ANGIOTENSIN II RECEPTOR ANTAGONISTS

ST irbesartan AVAPRO
ST losartan COZAAR
irbesartan/AVAPRO requires trial of generic ACEI first.
losartan/COZAAR requires trial of generic ACEI first.
OTHER ANTIHYPERTENSIVES
benazepril/hctz LOTENSIN HCT
captopril/hctz CAPOZIDE
hctz/bisoprolol fumarate ZIAC
ST irbesartan/hctz AVALIDE
lisinopril/hctz PRINZIDE
ST losartan /hctz HYZAAR
trandolapril/verapamil TARKA
irbesartan/hctz/AVALIDE requires trial of generic ACEI/HCTZ first.
losartan/hctz/HYZAAR requires trial of generic ACEI/HCTZ first.
NITRATES
isosorbide dinitrate SORBITRATE
isosorbide mononitrate MONOKET
isosorbide mononitrate IMDUR
nitroglycerin capsule NITRO-TIME
nitroglycerin sublingual NITROSTAT
nitroglycerin transdermal ointment NITRO-BID
CLASS 1A
procainamide PRONESTYL
quinidine gluconate QUINAGLUTE
quinidine sulfate QUINIDEX
CLASS 1C
propafenone RYTHMOL
AMIODARONES
amiodarone PACERONE
OTHER ANTIARRHYTHMICS
sotalol BETAPACE
sotalol BETAPACE AF
HYPOLIPOPROTEINEMICS
cholestyramine/aspartame QUESTRAN
cholestyramine/sucrose QUESTRAN
fenofibrate TRICOR, TRIGLIDE
gemfibrozil LOPID
niacin NIASPAN
HMG-COA REDUCTASE INHIBITORS

QLL, ST atorvastatin calcium LIPITOR
QLL lovastatin ALTOCOR
QLL lovastatin ALTOPREV
QLL lovastatin MEVACOR
QLL pravastatin PRAVACHOL
QLL, ST rosuvastatin calcium CRESTOR
simvastatin ZOCOR
atorvastatin calcium/LIPITOR 10mg, 20mg requires trial of a generic HMG first.
atorvastatin calcium/LIPITOR maximum quantity 30 tablets every 30 days
lovastatin/MEVACOR maximum quantity 30 tablets every 30 days
pravastatin/PRAVACHOL maximum quantity 30 tablets every 30 days
rosuvastatin calcium/CRESTOR 5mg requires trial of a generic HMG first.
rosuvastatin calcium/CRESTOR maximum quantity 30 tablets every 30 days
HMG-COA COMBINATIONS
QLL, ST amlodipine/atorvastatin CADUET
QLL, ST ezetimibe/simvastatin VYTORIN
amlodipine/atorvastatin/CADUET requires generic and single brand HMG first, maximum quantity 30
tablets every 30 days
ezetimibe/simvastatin/VYTORIN requires trial of a generic HMG first, maximum quantity 30 tablets
every 30 days
OTHER CARDIOVASCULAR DRUGS

midodrine PROAMATINE
pentoxifylline TRENTAL
ANALGESICS
OTC acetaminophen TYLENOL
OTC aspirin/buffers BAYER
QLL tramadol tab 50mg ULTRAM
CLASS II NARCOTICS
PA, QLL fentanyl DURAGESIC
hydromorphone DILAUDID
meperidine DEMEROL
methadone METHADOSE
PA, QLL morphine ext release AVINZA
PA, QLL oxycodone OXYCONTIN, ROXICODONE
oxycodone/acetaminophen 5/325 PERCOCET
oxycodone/acetaminophen 5/325 ROXICET
oxycodone/aspirin PERCODAN
QLL morphine sulfate ir, er tabs, soln MS IR, MS CONTIN
Morphine sulfate IR and ER are 1st line opiate therapy; oxycodone IR and ER are 2nd line therapy;
fentanyl is 3rd line ER therapy. Prior authorization is required for multiple dose/strength orders.
morphine ext release/AVINZA requires prior authorization, maximum quantity 30 capsules every 30
days
morphine ir/MSIR maximum quantity 240 tablets every 30 days
morphine er/MS CONTIN maximum quantity 90 tablets every 30 days
oxycodone/OXYCONTIN/ROXICODONE maximum quantity 90 tablets or capsules every 30 days
CLASS III NARCOTICS

codeine phosphate/apap PHENAPHEN
QLL hydrocodone bitartrate/apap All Strengths LORCET, LORTAB,
VICODAN, ES
hydrocodone bitartrate/apap, maximum quantity #120 every 30 days
CLASS IV NARCOTICS
propoxyphene DARVON
propoxyphene napsylate/apap DARVOCET-N 100
DRUGS TO PREVENT AND TREAT HEADACHES

apap/butalbital/caffeine FIORICET
aspirin/butalbital/caffeine FIORINAL
codeine/apap/butalbital/caffeine FIORICET
codeine/asa/butalbital/caffeine FIORINAL
ergotamine tartrate/caffeine CARFERGOT
QLL rizatriptan MAXALT / MLT
QLL sumatriptan IMITREX
QLL zolmitriptan ZOMIG / ZMT
rizatriptan/MAXALT/MAXALT MLT maximum quantity 9 tablets every 30 days

sumatriptan/IMITREX maximum quantity 9 tablets every 30 days
zolmitriptan/ZOMIG/ZOMIG ZMT maximum quantity 6 tablets every 30 days
ANXIOLYTICS
alprazolam XANAX
buspirone BUSPAR
chlordiazepoxide hcl LIBRIUM
diazepam VALIUM
lorazepam ATIVAN
oxazepam SERAX
SEDATIVE/HYPNOTIC DRUGS
chloral hydrate SOMNOTE
QLL temazepam RESTORIL
PA, QLL zolpidem AMBIEN
temazepam/RESTORIL maximum quantity 14 capsules every 30 days

zolpidem/AMBIEN requires prior authorization (temazepam is 1st line therapy); maximum quantity 14
tablets every 30 days
CARBAMAZEPINES
carbamazepine CARBATROL
carbamazepine TEGRETOL
PA oxcarbazepine TRILEPTAL
oxcarbazepine/TRILEPTAL requires prior authorization

ANTICONVULSANT BENZODIAZEPINES
clonazepam KLONOPIN
PA diazepam DIASTAT
diazepam/DIASTAT requires prior authorization
HYDANTOINS
phenytoin DILANTIN
phenytoin sodium DILANTIN
VALPROIC ACID AND DERIVATIVES

divalproex DEPAKOTE
valproic acid DEPAKENE
SUCCINIMIDES
ethosuximide ZARONTIN
ANTICONVULSANT BARBITURATES
phenobarbital
primidone MYSOLINE
OTHER ANTICONVULSANTS
PA felbamate FELBATOL
QLL gabapentin NEURONTIN
PA lamotrigine LAMICTAL
PA levetiracetam KEPPRA
PA, QLL pregabalin LYRICA
PA, QLL topiramate TOPAMAX
felbamate/FELBATOL requires prior authorization

gabapentin/NEURONTIN requires maximum quantity 90 units per fill
lamotrigine/LAMICTAL requires prior authorization
pregabalin/LYRICA requires prior authorization, maximum quantity 90 capsules every 30 days
topiramate/TOPAMAX requires prior authorization, maximum quantity 60 tabs per 30 days
TERTIARY AMINES
amitriptyline ELAVIL
doxepin ADAPIN
imipramine hcl TOFRANIL
imipramine pamoate TOFRANIL PM
SECONDARY AMINES
desipramine NORPRAMIN
nortriptyline AVENTYL
SELECTIVE SEROTONIN REUPTAKE INHIBITORS

citalopram CELEXA
PA escitalopram oxalate LEXAPRO
fluoxetine PROZAC
paroxetine PAXIL
PA paroxetine PAXIL CR
sertraline ZOLOFT
escitalopram oxalate/LEXAPRO requires prior authorization, use RHBA program

paroxetine/PAXIL CR requires prior authorization, use RHBA program
All SSRI drugs require Prior Authorization for members under age 18 years.

OTHER ANTIDEPRESSANTS
PA, QLL bupropion WELLBUTRIN, SR
PA, QLL bupropion WELLBUTRIN XL
PA mirtazapine REMERON
trazodone DESYREL
mirtazapine/REMERON requires prior authorization

bupropion/WELLBUTRIN requires prior authorization
MAO INHIBITORS
tranylcypromine PARNATE
SMOKING CESSATION PRODUCTS

QLL bupropion 150mg SR, bupropion 100mg SR ZYBAN
QLL nicotine nasal spray NICOTROL NS
QLL nicotine inhalation system NICOTROL Inhaler
QLL,OTC nicotine polacrilex gum NICORETTE
QLL,OTC nicotine patch NICODERM CQ
QLL varenicline tartrate CHANTIX
bupropion/ZYBAN maximum quantity 60 per fill, 180 in 6 months

nicotine gum/NICORETTE maximum quantity 108 per fill, 324 in 6 months
nicotine inhalation system/Nicotrol Inhaler has a maximum quantity of 168 cartridges per 28 days and
504 cartridges in 6 months
nicotine nasal spray/Nicotrol NS has a maximum quantity of 20 ml per 28 days and 60 ml in 6 months
nicotine patch/NICODERM CQ maximum quantity 30 per fill, 90 in 6 months
varenicline tartrate/CHANTIX maximum quantity 1 kit per fill, 3 kits in 6 months
ANTIVERTIGO AND ANTIEMETIC DRUGS

OTC dimenhydrinate DRAMAMINE
PA, QLL granisetron KYTRIL
meclizine hcl MEDIVERT
PA, QLL ondansetron ZOFRAN / ODT
prochlorperazine maleate COMPAZINE
promethazine PHERGAN
trimethobenzamide TIGAN
granisetron/KYTRIL requires prior authorization, maximum quantity 2 units per fill for tabs, 30ml per fill
for liquid
ondansetron/ZOFRAN/ZOFRAN ODT requires prior authorization, maximum quantity 1 unit per fill for
24mgtab,12 units per fill for 4 and 8mg tabs, 50ml per fill for liquid
ANTIPARKINSON ANTICHOLINERGIC DRUGS

benztropine COGENTIN
trihexyphenidyl ARTANE
OTHER ANTIPARKINSON DRUGS

PA bromocriptine mesylate PARLODEL
carbidopa/levodopa SINEMET
PA entacapone COMTAN
PA pergolide mesylate PERMAX
PA ropinirole REQUIP
selegiline ELDEPRYL

bromocriptine mesylate/PARLODEL requires prior authorization
entacapone/COMTAN requires prior authorization
pergolide mesylate/PERMAX requires prior authorization
pramipexole/MIRAPEX requires prior authorization
ropinirole/REQUIP requires prior authorization
ANTIPSYCHOTIC DRUGS
fluphenazine hcl PERMITIL
haloperidol 0.5mg, 1mg, 2mg, 5mg HALDOL
CNS STIMULANTS
QLL amphetamine/dextroamphetamine ADDERALL
QLL dextroamphetamine DEXEDRINE
PA, QLL methylphenidate CONCERTA
PA, QLL methylphenidate METADATE
QLL methylphenidate RITALIN
PA atomoxetine STRATTERA
Amphetamine/dextroamphetamine/methylphenidate requires prior authorization for Brand

products.
Generic: immediate release maximum quantity 60 per month; extended release maximum quantity 30
per month.
DEXEDRINE requires prior authorization; immediate release maximum quantity 60 per month;
extended release maximum quantity 30 per month
CONCERTA requires prior authorization; maximum quantity 30 per month, maximum quantity 30 per
month
RITALIN requires prior authorization (unless generic); immediate release maximum quantity 60 per
month; extended release maximum quantity 30 per month
Age restriction for CNS stimulants: 5 to 20 years of age
OTHER CNS/AUTONOMIC DRUGS

pyridostigmine MESTINON
ANTIDEMENTIA DRUGS
PA donepezil ARICEPT/ODT
donepezil/ARICEPT requires prior authorization, with current MMSE
DRUGS TO TREAT MULTIPLE SCLEROSIS

SPBM, QLL, PA glatiramer acetate COPAXONE
glatiramer acetate/COPAXONE use specialty pharmacy, maximum quantity 1 unit per fill, requires prior
authorization
DERMATOLOGICAL MEDICATIONS
TOPICAL CORTICOSTEROID DRUGS

VHP betamethasone/propylene glycol DIPROLENE AF
HP betamethasone dipropionate ALPHATREX
MP betamethasone valerate BETATREX
VHP clobetasol propionate CLOBEX
HP fluocinonide LIDEX
LP, OTC hydrocortisone CORTAID
MP, MP, HP triamcinolone acetonide 0.025%, 0.1%, 0.5% KENALOG
VHP = Very High Potency; HP = High Potency; MP = Medium Potency; LP = Low Potency
ANTIPRURITIC DRUGS
hydroxyzine ATARAX
hydroxyzine pamoate VISTARIL
ANTIACNE DRUGS
OTC benzoyl peroxide gel, lotion, liquid (generics) BREVOXYL
QLL clindamycin phosphate 1% top soln CLEOCIN
erythromycin 2% top soln, gel A/T/S
PA tretinoin RETIN-A
tretinoin/RETIN-A requires prior authorization
KERATOLYTIC DRUGS
OTC acetic acid/salicylic acid liquid COMPOUND W
OTC salicylic acid liquid COMPOUND W
ANTIPSORIASIS AND ANTIECZEMA DRUGS

PA calcipotriene DOVONEX
OTC coal tar NEUTROGENA T/GEL
OTC selenium sulfide SELSUN BLUE
PA tazarotene TAZORAC
calcipotriene/DOVONEX requires prior authorization

tazarotene/TAZORAC requires prior authorization
TOPICAL DERMATOLOGICAL DRUGS

OTC calamine
fluorouracil 1% cream FLUOROPLEX
OTC hydrogen peroxide
OTC mineral oil/petrolatum AQUAPHOR
permethrin ACTICIN
OTC piperonyl butoxide/pyrethrins RID
EAR-NOSE-THROAT MEDICATIONS
DRUGS AFFECTING THE EAR

acetic acid VOSOL
acetic acid/hydrocortisone VOSOL HC
OTC antipyrine/benzocaine BENZOTIC
OTC carbamide peroxide DEBROX
PA ciprofloxacin/dexameth CIPRODEX
neomycin sulfate/polymyxin/hc CORTISPORIN
ofloxacin FLOXIN
ciprofloxacin/dexameth/CIPRODEX OTIC drops require prior authorization
DRUGS AFFECTING THE NOSE

QLL azelastine hcl ASTELIN
ST, QLL budesonide RHINOCORT AQUA
OTC, QLL cromolyn NASALCROM
QLL fluticasone propionate FLONASE
QLL ipratropium ATROVENT
ST, QLL mometasone NASONEX
azelastine hcl/ASTELIN maximum quantity 30 units per fill

budesonide/RHINOCORT AQUA requires fluticasone first , maximum quantity 8.6 units per month
cromolyn/NASALCROM maximum quantity 13 units per dispensing
fluticasone propionate/FLONASE maximum quantity 16 units per month
ipratropium/ATROVENT maximum quantity 15 units per dispensing
mometasone/NASONEX requires fluticasone first, maximum quantity 17 units per month
st nd
Fluticasone is the 1 line nasal steroid spray. Rhinocort Aqua & Nasonex are 2 line.
DRUGS AFFECTING THE THROAT AND MOUTH

OTC carbamide peroxide GLY-OXIDE
chlorhexedine PERIDEX
triamcinolone acetonide KENALOG
lidocaine viscous XYLOCAINE VISCOUS
ENDOCRINE MEDICATIONS
INSULIN
QLL insulin aspart NOVOLOG
insulin glargine LANTUS
insulin human regular HUMULIN
insulin human regular NOVOLIN
QLL insulin lispro HUMALOG
insulin NPH HUMULIN N
insulin NPH NOVOLIN N
insulin regular HUMULIN R
insulin regular NOVOLIN R
insulin aspart/NOVOLOG vials maximum quantity 30ml per month

insulin lispro/HUMALOG vials maximum quantity 30ml per month
ORAL HYPOGLYCEMIC DRUGS

QLL acarbose PRECOSE
glipizide GLUCOTROL
glyburide GLYNASE
glyburide MICRONASE
glyburide/metformin GLUCOVANCE
metformin GLUCOPHAGE
QLL repaglinide PRANDIN
Acarbose/PRECOSE maximum quantity 90 units per fill

Repaglinide/PRANDIN maximum quantity 90 units per fill
INSULIN SENSITIZERS
QLL pioglitazone ACTOS
QLL pioglitazone/metformin ACTOPLUS MET
QLL rosiglitazone AVANDIA
QLL rosiglitazone/metformin AVANDAMET
pioglitazone/ACTOS maximum quantity 30 units per fill

pioglitazone/metformin/ACTOPLUS MET maximum quantity 90 units per fill
rosiglitazone/AVANDIA maximum quantity 30 units per fill
rosiglitazone/metformin/AVANDAMET maximum quantity 60 units per fill
DIPEPTIDYL PEPTIDASE – IV INHIB

PA sitagliptin phosphate JANUVIA
sitagliptin phosphate/JANUVIA requires prior authorization

GLUCOSE ELEVATING DRUGS
glucagon, human recombinant GLUCAGON
GLUCOCORTICOID DRUGS
dexamethasone DECADRON
hydrocortisone CORTEF
methylprednisolone MEDROL
prednisolone PRELONE
prednisone DELTASONE
MINERALOCORTICOID DRUGS
fludrocortisone FLORINEF
THYROID SUPPLEMENTS
levothyroxine LEVOXYL
levothyroxine LEVOTHROID
levothyroxine LEVOTHYROXINE -MYLAN
thyroid
ANTITHYROID DRUGS
methimazole TAPAZOLE
propylthiouracil
OTHER ENDOCRINE DRUGS

QLL alendronate FOSAMAX
PA cinacalcet SENSIPAR
PA desmopressin acetate nasal DDAVP NASAL
PA, SPBM desmopressin acetate inj DDAVP INJ
ST, QLL risedronate ACTONEL
PA, SPBM teriparatide FORTEO
alendronate/FOSAMAX, 10mg, 40mg maximum quantity 30 units per month; 35mg, 70mg maximum
quantity 4 units per month. Alendronate is the formulary’s 1st line bisphosphonate.
cinacalcet/SENSIPAR requires prior authorization
desmopressin acetate/DDAVP injectable use specialty pharmacy
risedronate/ACTONEL requires generic alendronate first; 5mg, 30mg maximum quantity 30 units per
month; 35mg maximum quantity 4 units per month; 75mg maximum quantity 2 units per month; 150mg
maximum quantity 1 unit per month
teriparatide/FORTEO use specialty pharmacy
Prior authorization requires DEXA-SCAN every 2 years.
GASTROINTESTINAL MEDICATIONS
ANTACIDS
OTC aluminum hydroxide AMPHOJEL
OTC calcium carbonate MYLANTA
OTC dihydroxyaluminum sodium carbonate ROLAIDS
OTC magnesium hydroxide/al hydrox MAALOX
OTC mag hydrox/al hydrox/simeth MYLANTA
OTC sodium bicarbonate GENATON
ANTIDIARRHEAL DRUGS
OTC bismuth subsalicylate KAOPECTATE
diphenoxylate/atropine sulfate LOMOTIL
OTC loperamide IMODIUM

ANTISPASMODICS/DRUGS AFFECT GI MOTILITY
dicyclomine BENTYL
hyoscyamine CYSTOSPAZ
metoclopramide REGLAN
ANTIULCER DRUGS
OTC cimetidine TAGAMET
OTC ranitidine ZANTAC
OTHER ANTIULCER DRUGS

misoprostol CYTOTEC
sucralfate tabs CARAFATE
PROTON PUMP INHIBITORS

PA, QLL esomeprazole mag trihyd NEXIUM
PA, QLL lansoprazole PREVACID
QLL, OTC omeprazole magnesium PRILOSEC OTC
PA, QLL pantoprazole 40mg PROTONIX
esomeprazole mag trihyd/NEXIUM requires prior authorization, maximum quantity 30 units per fill, 90
capsules per year
lansoprazole/PREVACID requires prior authorization, maximum quantity 30 units per fill, 90 capsules
per year
omeprazole magnesium/PRILOSEC OTC maximum quantity 60 tablets every 30 days without PA.
PRILOSEC OTC is formulary 1st line therapy
pantoprazole/PROTONIX requires prior authorization, maximum quantity 30 tablets every 30 days
LAXATIVES AND CATHARTICS

OTC bisacodyl DULCOLAX
OTC docusate sodium COLACE
OTC magnesium hydroxide MILK OF MAGNESIA
OTC magnesium sulfate EPSOM SALT
OTC phenolphthalein
OTC polyethylene glycol 3350 GLYCOLAX, MIRALAX
OTC psyllium METAMUCIL
OTC senna/docusate sodium SENOKOT
OTC sennosides a&b, calcium EX-LAX
OTC sodium phosphate/NA biphos OSMOPREP
OTHER GI DRUGS
amylase/lipase/protease CREON
amylase/lipase/protease PANGESTYME
amylase/lipase/protease ULTRASE/MT
electrolyte solution/PEG’S GOLYTELY
hydrocortisone acetate CORTIFOAM
mesalamine ASACOL
mesalamine CANASA
simethicone MYLANTA
sulfasalazine AZULFIDINE
ursodiol URSO
IMMUNOLOGICALS AND VACCINES
IMMUNOLOGICALS AND VACCINES

PA, SPBM palivizumab SYNAGIS

palivizumab/SYNAGIS use specialty pharmacy
MYELOID STIMULANTS
PA, SPBM filgrastim NEUPOGEN
PA, SPBM sargramostim LEUKINE
filgrastim/NEUPOGEN use specialty pharmacy

sargramostim/LEUKINE use specialty pharmacy
ERYTHROID STIMULANTS
PA darbepoetin alfa ARANESP
PA epoetin alfa PROCRIT
darbepoetin alfa/ARANESP use specialty pharmacy

epoetin alfa/PROCRIT use specialty pharmacy
INTERFERONS
PA, SPBM interferon alfa-2B, recombinant INTRON A
PA, SPBM, QLL interferon beta-1A AVONEX / ADMIN PACK
PA, SPBM, QLL peginterferon alfa-2A PEGASYS
interferon alfa-2B recombinant/INTRON A use specialty pharmacy

interferon beta-1A/AVONEX/AVONEX ADMINISTRATION PACK use specialty pharmacy, maximum
quantity 4 units per fill
peginteferon alfa-2A/PEGASYS use specialty pharmacy, maximum quantity 1 unit per fill
GROWTH HORMONES AND RELATED DRUGS

PA, SPBM somatropin NUTROPIN / AQ / DEPOT
PA, SPBM somatropin GENOTROPIN
PA, SPBM somatropin SEROSTIM
somatropin/NUTROPIN/NEUTROPIN AQ/NUTROPIN DEPOT use specialty pharmacy

somatropin/GENOTROPIN use specialty pharmacy
somatropin/SEROSTIM use specialty pharmacy
MUSCULOSKELETAL MEDICATIONS
SALICYLATES AND RELATED DRUGS

OTC aspirin BAYER
OTC aspirin/acetaminophen/caffeine EXCEDRIN
salsalate DISALCID
NON-STEROIDAL ANTIINFLAMMATORY AGENTS

diclofenac potassium CATAFLAM
diclofenac sodium VOLTAREN
QLL etodolac LODINE
fenoprofen calcium NALFON
ibuprofen ADVIL
ibuprofen MOTRIN
indomethacin INDOCIN
QLL meloxicam MOBIC
naproxen NAPROSYN
piroxicam FELDENE
sulindac CLINORIL

etodolac/LODINE maximum quantity 90 units per month
meloxicam/MOBIC maximum quantity 30 units per month
OTHER DRUGS FOR ARTHRITIS

auranofin RIDAURA
penicillamine CUPRIMINE
DRUGS TO PREVENT AND TREAT GOUT

allopurinol ALOPRIM
colchicine
probenecid
DIRECT MUSCLE RELAXANTS

QLL baclofen LIORESAL
QLL dantrolene sodium DANTRIUM
baclofen/LIORESAL maximum quantity 90 per fill

dantrolene sodium/DANTRIUM maximum quantity 120 per fill
CNS MUSCLE RELAXANTS

cyclobenzaprine FLEXERIL
methocarbamol ROBAXIN
NUTRITION,BLOOD
VITAMINS & MINERALS & RELATED PRODUCTS

OTC calcium carbonate tablet TUMS
OTC ferrous gluconate FERGON
OTC ferrous sulfate FERATAB
OTC folic acid/vit b complex with c DAILYVITE
OTC multivitamins
OTC pyridoxine NESTREX
OTC vitamin b complex
OTC vitamin e
THERAPEUTIC VITAMINS & MINERALS

calcium acetate PHOSLO
QLL cyanocobalamin 1000mcg injectable
PA doxercalciferol HECTOROL
OTC folic acid
OTC zinc acetate
cyanocobalamin maximum quantity 10ml

doxercalciferol/HECTOROL requires prior authorization
FLUORIDE PRODUCTS
sodium fluoride ETHEDENT
POTASSIUM SUPPLEMENTS
potassium chloride
ORAL ANTICOAGULANTS, VITAMIN K

warfarin sodium COUMADIN

HEPARIN AND HEPARIN ANTAGONISTS
QLL/PA enoxaparin LOVENOX
SPBM
QLL/PA dalteparin FRAGMIN
enoxaparin/LOVENOX, No PA needed for up to a 10 day supply, PA needed for over a 10 day supply;
use specialty pharmacy for chronic treatment use only
dalteparin/Fragmin, No PA needed for up to a 10 day supply, PA needed for over a 10 day supply, use
specialty pharmacy for chronic treatment use only
ANTIPLATELET DRUGS
clopidogrel PLAVIX
dipyridamole PERSANTINE
ticlopidine TICLID
BLOOD DETOXICANTS
OTC lactulose ENULOSE
PA lanthanum carbonate FOSRENOL
lanthanum carbonate/FOSRENOL requires 30 day trial of PHOSLO for prior authorization
ELECTROLYTES, IRRIGATING SOLUTIONS, ETC.

OTC electrolyte solution PEDIALYTE
OBSTETRICAL & GYNECOLOGICAL MEDICATIONS
PRENATAL VITAMINS
OTC iron
OTC, RX prenatal vitamins
Prenatal vitamins generics only covered for women age 14 – 45.
OB/GYN TOPICAL ANTIINFECTIVES

QLL metronidazole 0.75% gel METROGEL
ANDROGEN DRUGS
PA testosterone ANDRODERM
PA testosterone ANDROGEL
PA testosterone inj
testosterone/ANDRODERM requires prior authorization; testosterone Injectable is 1st line

testosterone/ANDROGEL requires prior authorization; testosterone Injectable is 1st line
ESTROGEN DRUGS
QLL estradiol patch CLIMARA
estradiol tab ESTRACE
estrogen,conjugated,synethetic A CENESTIN
estrogens,conjugated PREMARIN
estropipate ORTHO-EST
estradiol/CLIMARA maximum quantity 4 units per fill
ESTROGEN/PROGESTIN COMBINATIONS
estrogen/medroxyprogesterone PREMPRO
estrogen/medroxyprogesterone PREMPHASE
norethindrone A-E estradiol FEMHRT
SELECTIVE ESTROGEN RECEPTOR MODULATORS

raloxifene EVISTA
PROGESTIN DRUGS
PA levonorgestril MIRENA IUD
QLL medroxyprogesterone PROVERA
QLL norethindrone ERRIN
QLL norethindrone CAMILA
QLL norethindrone JOLIVETTE
QLL norethindrone NORA-BE
norethindrone acetate AYGESTINE
levonorgestril/MIRENA requires prior authorization
medoxyprogesterone/PROVERA maximum quantity 1 unit per fill
norethindrone/ERRIN maximum quantity 3 units per fill
norethindrone/CAMILA maximum quantity 3 units per fill
norethindrone/JOLIVETTE maximum quantity 3 units per fill
norethindrone/NORA-BE maximum quantity 3 units per fill
CONTRACEPTIVES
QLL desogestrel-ethilyn estradiol APRI
QLL desogestrel-ethilyn estradiol / ethynodiol KARIVA
QLL ethinyl estradiol/drospirenone YASMIN / 28
QLL ethinyl estradiol/norelgest ORTHO EVRA
QLL ethynodiol diace-eth estradiol ZOVIA
QLL etonogestrel/ethin estradiol NUVARING
levonorgestrel PLAN B
QLL levonorgestrel-ethin estradiol TRIVORA
QLL levonorgestrel-ethin estradiol LEVORA
QLL levonorgestrel-ethin estradiol AVIANE
QLL levonorgestrel-ethin estradiol ENPRESSE
QLL levonorgestrel-ethin estradiol PORTIA
QLL levonorgestrel-ethin estradiol LESSINA
QLL levonorgestrel-ethin estradiol LEVORA
QLL noreth A-ET estra/fe fumarate MICROGESTIN
QLL noreth A-ET estra/fe fumarate ESTROSTEP FE
QLL noreth A-ET estra/fe fumarate JUNEL FE
QLL norethindrone-ethin estradiol NECON
QLL norethindrone-ethin estradiol NORTREL
QLL norethindrone-ethin estradiol BREVICON
QLL norethindrone-ethin estradiol NELOVA
QLL norethindrone-mestranol NECON
QLL norethindrone-mestranol NELOVA
QLL norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN LO
QLL norgestimate-ethinyl estradiol TRINESSA
QLL norgestimate-ethinyl estradiol SPRINTEC
QLL norgestimate-ethinyl estradiol TRI-SPRINTEC
QLL norgestimate-ethinyl estradiol MONONESSA
QLL norgestimate-ethinyl estradiol PREVIFEM
QLL norgestrel-ethinyl estradiol LOW-OGESTREL
QLL norgestrel-ethinyl estradiol CRYSELLE
QLL norgestrel-ethinyl estradiol OGESTREL
etonogestrel/ethin estradiol/NUVARING maximum quantity one (1) cycle per fill

All quantity level limits are maximum one (1) cycle per fill

OXYTOCICS
methylergonovine METHERGINE
OPHTHALMIC MEDICATIONS
OPHTHALMIC TOPICAL ANTIBACTERIAL DRUGS

bacitracin
erythromycin ILOTYCIN
gentamicin GENTAK
PA moxifloxacin VIGAMOX
neomycin/bacitracin/polymyxin NEOSPORIN
ofloxacin OCUFLOX
polymyxin B sulfate POLYTRIM
sulfacetamide CETAMIDE
tobramycin TOBREX
trifluridine VIROPTIC
moxifloxacin/VIGAMOX eye drops require prior authorization

ofloxacin/OCUFLOX eye drops require prior authorization
OPHTHALMIC CORTICOSTEROID DRUGS

dexamethasone sodium phosp DECADRON
loteprednol etabonate LOTEMAX
prednisolone acetate ECONOPRED
prednisolone sodium phosphate PREDNISOL
PA rimexolone VEXOL
rimexolone/VEXOL 1% eye drops require prior authorization
OPHTHALMIC ANTIINFECTIVE/CORTICOSTEROIDS
neomycin/polymyxin/dexameth DEXACINE
sulfacetamide/prednisolone SP VASOCIDIN
sulfacetamide/prednisolone AC BLEPHAMIDE
tobramycin sulfate/dexameth TOBRADEX
ANTIGLAUCOMA DRUGS
acetazolamide DIAMOX
bimatoprost LUMIGAN
brimonidine tartrate ALPHAGAN / P
brinzolamide AZOPT
dipivefrin PROPINE
latanoprost XALATAN
levobunolol BETAGAN
methazolamide NEPTAZANE
pilocarpine PILOPINE
timolol BETIMOL
OTHER OPHTHALMIC DRUGS

atropine sulfate ATROPISOL
OTC carboxymethylcellulose, sodium THERA TEARS
PA cromolyn OPTICROM
OTC dextran 70/he-cell TEARS NATURALE
OTC hydroxypropyl methylcellulose GENTEAL
cromolyn/OPTICROM requires trial use of OTC for prior authorization
ketorolac/ACULAR eye drops require prior authorization
PA ketorolac ACULAR
OTC lanolin/mineral oil/petrolatum
OTC naphazoline/pheniramine NAPHCON-A
OTC petrolatum, white PURALUBE
OTC polyvinyl alcohol HYPOTEARS
BETA-2 ADRENERGIC DRUGS

QLL albuterol HFA PROAIR HFA
QLL albuterol soln, tabs PROVENTIL
QLL formoterol fumarate FORADIL
QLL salmeterol SEREVENT DISKUS
terbutaline sulfate BRETHAIRE
albuterol/PROAIR HFA maximum quantity 2 inhalers every 30 days

formoterol fumarate/FORADIL maximum quantity 60 capsules every 30 days
salmeterol/SEREVENT DISKUS maximum quantity 1 inhaler every 30 days
METHYL XANTHINE DRUGS

theophylline AEROLATE
OTHER DRUGS FOR ASTHMA

QLL albuterol sulfate/ipratropium COMBIVENT
QLL budesonide PULMICORT
QLL cromolyn INTAL
QLL epinephrine EPIPEN / JR
QLL fluticasone propionate FLOVENT HFA / DISKUS
QLL ipratropium ATROVENT HFA
QLL mometasone ASMANEX
QLL formoterol / budesonide SYMBICORT
QLL salmeterol/fluticasone ADVAIR HFA / DISKUS
sodium chloride BRONCHO SALINE
albuterol sulfate/ipratropium/COMBIVENT maximum quantity 3 inhalers per fill

budesonide/PULMICORT maximum quantity 1 inhaler every 60 days
cromolyn/INTAL maximum quantity 2 inhalers per fill
epinephrine/EPIPEN/EPIPEN JR maximum quantity 2 units per year
fluticasone propionate/FLOVENT maximum quantity 1 inhaler every 30 days
ipratropium/ATROVENT HFA maximum quantity 1 inhaler every 30 days
mometasone/ASMANEX maximum quantity 1 in haler every 30 days
salmeterol/fluticasone/ADVAIR HFA/ADVAIR DISKUS maximum quantity 1 inhaler every 30 days
LEUKOTRIENE MODIFIERS
ST montelukast sodium SINGULAIR
ST zafirlukast ACCOLATE
montelukast sodium/SINGULAIR for non-asthma use requires trial of generic non-sedating

antihistamine plus nasal steroid; for asthma use requires trial of beta-agonist and steroid inhaler for at
least 30 days
zafirlukast/ACCOLATE for non-asthma use requires trial of generic non-sedating antihistamine plus
nasal steroid; for asthma use requires trial of beta-agonist and steroid inhaler for at least 30 days
ANTIHISTAMINES
QLL,OTC cetirizine tabs ZYRTEC
ST,QLL,OTC cetirizine syrup ZYRTEC
OTC chlorpheniramine CHLOR-TRIMETON

clemastine fumarate TAVIST
cyproheptadine PERIACTIN
diphenhydramine tablet, capsule BENADRYL
PA, QLL fexofenadine ALLEGRA
QLL, OTC loratadine CLARITIN
promethazine PHENERGAN
cetirizine/ZYRTEC syrup requires trial of OTC loratadine for prior authorization, maximum quantity
150mL every 30 days. Limited to children under the age of 2.
cetirizine/ZYRTEC tabs maximum quantity 30 units per fill
fexofenadine/ALLEGRA requires prior authorization, maximum quantity 30 units per fill
loratadine/CLARITIN maximum quantity 30 units per fill
DECONGESTANTS
OTC pseudoephedrine SUDAFED
ANTIHISTAMINE/DECONGESTANT COMBINATIONS
phenylephrine/brompheniramine BROMFED CAP
OTC pseudoephedrine/brompheniramine BROMFED CAP SA, DRIXORAL
SYR
OTC pseudoephedrine/chlorpheniramine CHLOR-TRIMETON D,
DECONAMINE SR CAP
OTC pseudoephedrine/loratadine CLARITIN-D
OTC pseudoephedrine/triprolidine HISTAFED SYR, HISTA-TABS
ANTITUSSIVE AND EXPECTORANT DRUGS

benzonatate TESSALON
codeine/promethazine PHENERGAN W/CODEINE
dextromethorphan/promethazine PROMETHAZINE
dextromethorphan/pseudoephedrine/ TRIAMINIC COLD/COUGH
chlorpheniramine
OTC guaifenesin/codeine GUIATUSS AC
OTC guaifenesin/dextromethorphan GUAICON
OTC guaifenesin/pseudoephedrine ROBITUSSIN PE
OTC guaifenesin syrup MUCINEX
hydrocodone/homatropine HYCODAN
phenylephrine/codeine/promethazine PHENERGAN
phenylephrine/hydrocodone/chlorpheniramine H-C TUSSIVE
OTHER RESPIRATORY DRUGS AND DEVICES

PA alpha-1-proteinase inhibitor ARALAST
PA alpha-1-proteinase inhibitor PROLASTIN
spacer RITE-FLO
alpha-1-proteinase inhibitor/ARALAST requires prior authorization
alpha-1-proteinase inhibitor/PROLASTIN requires prior authorization
SPECIALTY MEDICATIONS
Aralast* Nutropin*
Aranesp* Orencia*
Aredia* Orthovisc*
Avastin* Pamidronate Disodium*
Avonex* Pegasys*
Betaseron* Procrit*
Boniva Injection* Prograf Injection*
CellCept Injection* Provisc*
Copaxone* Pulmozyme*
Cyclosprine* Remodulin*
DDAVP Injection* Revatio*
Desferal* Ribavirin*
Eligard * Rituxin*
Enbrel * Sandimmune
Epogen* Sandostatin
Erbitux* Supartz*
Exjade* Synagis*
Flolan* - generic available Synvisc*
Forteo* Tarceva*
Fuzeon* Temodar*
GenoTropin* Thalomid*
Humira* Tobi*
Hyalgan* Tracleer*
Immune Globulin IM* Tykerb*
Immune Globulin IV* Tysabi*
Implanon* Vectibix
Kineret* Vivaglobin*
Letairus* Xeloda*
Lovenox – Extended use* Xolair*
Lupron, Lupron Depot* Zemaira*
Methotrexate Injection*
Neulasta*
Neupogen*
Norditropin*
*Note: All Specialty medications that are dispensed to the member require HCA prior authorization and
are distributed by Health Choice’s Desginated Specialty Pharmacy.
Specialty Drug Medication description J Code
17 ALPHA-HYDROXYPROGESTERONE CAPROATE J3490

ALPHA 1 - PROTEINASE INHIBITOR - HUMAN, 10 MG J0256
APREPITANT 5 MG J8501
BORTEZOMIB, 0.1 MG J9041
CETUXIMAB, 10 MG J9055
BEVACIZUMAB, 10 MG J9035
BORTEZOMIB, 0.1MG J9041
DAPTOMYCIN, 1 MG J0878
DARBEPOETIN ALFA, 1 MICROGRAM (NON-ESRD USE) J0881
DARBEPOETIN ALFA, 1 MICROGRAM (FOR ESRD ON DIALYSIS J0882
DEFEROXAMINE MESYLATE, 500 MG J0895
DOLASETRON MESYLATE, 10 MG J1260
ENOXAPARIN SODIUM, 10 MG J1650
EPOETIN ALFA, 1000 UNITS (FOR ESRD ON DIALYSIS) J0886
EPOETIN ALFA, (FOR NON-ESRD USE), 1000 UNITS J0885
EPOPROSTENOL, 0.5 MG J1325
ERTAPENEM SODIUM, 500 MG J1335
ETANERCEPT, 25 MG J1438
ETONOGESTREL IMPLANT, 68 MG J7307
FILGRASTIM (G-CSF), 300 MCG J1440
FILGRASTIM (G-CSF), 480 MCG J1441
GAMMA GLOBULIN, INTRAMUSCULAR, OVER 10 CC J1560

GEMCITABINE, 200 MG J9201
GANCICLOVIR SODIUM, 500 MG J1570
GRANISETRON HYDROCHLORIDE, 100 MCG J1626
HISTRELIN IMPL ANT, 50 MG J9225
J9226
HYALURONIAN (SODIUM HYALURONATE) FOR G F 20, HYALGAN, J7321
HYLAN, PROVISC, EUFLEXXA, SUPARTZ, & SYNVISC PRODUCTS J7322
J7323
J7324
IMIGLUCERASE, PER UNIT J1785
IMMUNE GLOBULIN, INTRAVENOUS, LYOPHILIZED (E.G. POWDER), J1566
500 MG
IMMUNE GLOBULIN, INTRAVENOUS, NON-LYOPHILIZED (E.G. J1567
LIQUID),500MG
INFLIXIMAB, 10 MG J1745
KETOROLAC TROMETHAMINE, 15 MG J1885
LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 3.75 MG J1950
LEUPROLIDE ACETATE (FOR DEPOT SUSPENSION), 7.5 MG J9217
LINEZOLID, 200MG J2020
MEROPENEM, 100 MG J2185
NATALIZUMAB, 1 MG J2323
OCTREOTIDE, NON-DEPOT FORM FOR INTRAMUSCULAR J2354
INJECTION, 25mcg
OCTREOTIDE, DEPOT FORM FOR INTRAMUSCULAR INJECTION, 1 J2353
MG
ONDANSETRON HYDROCHLORIDE, PER 1 MG J2405
PAMIDRONATE DISODIUM, PER 30 MG J2430
PALONOSETRON HCL, 25 MCG J2469
PANITUMUMAB 10 mg J9303
PEGFILGRASTIM, 6 MG J2505
PIPERACILLIN/TAZOBACTAM 1 GRAM/0.125 GRAMS J2543
RENIBIZUMAB, 0.5MG J2778
RITUXIMAB, 100 MG J9310
SARGRAMOSTIM (GM-CSF), 50 MCG J2820
TESTOSTERONE CYPIONATE, 1 CC, 200 MG J1080
TESTOSTERONE SUSPENSION, UP TO 50 MG J3140
TESTOSTERONE CYPIONATE, UP TO 100 MG J1070
TESTOSTERONE CYPIONATE AND ESTRADIOL CYPIONATE, UP TO J1060
1 ML
TESTOSTERONE ENANTHATE, UP TO 100 MG J3120
TESTOSTERONE ENANTHATE, UP TO 200 MG J3130
TOBRAMYCIN, INHALATION SOLUTION, 300MG J7682
TRASTUZUMAB, 10 MG J9355
TREPROSTINIL, 1 MG J3285
TRIAMCINOLONE, INHALATION SOLUTION, COMPOUNDED J7683
PRODUCT, ADMINISTERED THROUGH DME
ZOLEDRONIC ACID, 1 MG J3487
UNCLASSIFIED DRUGS J3490
UNCLASSIFIED BIOLOGICS J3590
UNCLASSIFIED ANTINEOPLASTIC DRUGS J9999
* HCA PA required if administered in provider office

UROLOGICAL MEDICATIONS
ANTICHOLINERGIC ANTISPASMODICS
oxybutynin, ER DITROPAN, XL
tolterodine tartrate DETROL
tolterodine tartrate DETROL LA
CHOLINERGIC STIMULANTS
QLL bethanechol MYOTONACHOL
bethanechol/MYOTONACHOL maximum quantity 120 per fill
URINARY ANESTHETICS
OTC phenazopyridine URISTAT
OTHER GENITOURINARY PRODUCTS

PA dutasteride AVODART
PA finasteride PROSCAR
PA tamsulosin FLOMAX
dutasteride/AVODART requires prior authorization after trial of doxazosin or terazosin

finasteride/PROSCAR 5mg tablets requires prior authorization after trial of doxazosin or terazosin
tamsulosin/FLOMAX requires prior authorization after trial of doxazosin or terazosin
DIAGNOSTIC & MISCELLANEOUS MEDICATIONS
DIAGNOSTIC PRODUCTS
OTC ketone testing products KETOCARE
OTC ketone testing products CHEMSTRIP
MEDICAL (MISCELLANEOUS) SUPPLIES
DIABETIC SUPPLIES
OTC glucose monitors, supplies ACCU-CHEK AVIVA, ADVANTAGE,
COMPACT PLUS
insulin syringes/needles NOVOFINE / 30
insulin syringes/needles PRECISION
Index
A/T/S, 13, 23 alpha-1-proteinase inhibitor, 33, 34
abacavir sulfate, 14 ALPHAGAN / P, 31
abacavir sulfate/lamivudine, 14 ALPHATREX, 22
abatacept/maltose, 15, 16 alprazolam, 19
acarbose, 24 ALTOCOR, 18
ACCOLATE, 32 ALTOPREV, 18
ACCU-CHEK ADVANTAGE, 36 altretamine, 15
ACCU-CHEK ADVANTAGE, AVIVA, 12 aluminum hydroxide, 9, 25
ACCU-CHEK AVIVA, 36 amantadine, 14
ACCUPRIL, 17 AMBIEN, 19
acetaminophen, 8, 18 amiodarone, 17
acetazolamide, 31 amitriptyline, 20
acetic acid, 9, 23 amlodipine, 16, 18
acetic acid/hydrocortisone, 23 amlodipine/atorvast cal, 18
acetic acid/salicylic acid, 9, 23 amox/clavulanate, 12
ACTICIN, 23 amoxicillin, 12
ACTIFED, 11 amoxicillin clavulanate, 12
ACTONEL, 25 AMOXIL, 12
ACTOPLUS MET, 24 amphetamine/dextroamphetamine, 22
ACTOS, 24 AMPHOJEL, 9
ACULAR, 32 ampicillin, 12
acyclovir, 14 amprenavir, 14
acyclovir oint, 14 amylase/lipase/protease, 26
ADALAT CC, 16 anagrelide, 15, 16
adalimumab, 15, 16 anastrozole, 15
ADAPIN, 20 ANDRODERM, 29
ADDERALL, 22 ANDROGEL, 29
ADVAIR HFA / DISKUS, 32 antipyrine/benzocaine, 9, 23
ADVIL, 27 apap/butalbital/caffeine, 19
AEROLATE, 32 APRESOLINE, 17
AGENERASE, 14 APRI, 30
AGRYLIN, 15, 16 APTIVUS, 14
albuterol, 32 AQUAPHOR, 9, 23
albuterol HFA, 32 ARALAST, 33, 34
albuterol MDI, soln, tabs, 32 ARANESP, 27
albuterol sulfate/ipratropium, 32 ARICEPT, 22
ALDACTAZIDE, 16 ARICEPT/ODT, 22
ALDACTONE, 16 ARIMIDEX, 15
ALDOMET, 17 AROMASIN, 15
alendronate, 25 ARTANE, 21
ALKERAN, 15, 16 ASACOL, 26
ALLEGRA, 33 ASMANEX, 32
allopurinol, 28 aspirin, 8, 10, 18, 19, 27
ALOPRIM, 28 aspirin/acetaminophen/caffeine, 10, 27

aspirin/buffers, 8, 18 BENTYL, 26
aspirin/butalbital/caffeine, 19 benzonatate, 33
ASTELIN, 23, 24 BENZOTIC, 9, 23
ATARAX, 23 benzoyl peroxide, 8, 23
atazanavir sulfate, 14 benztropine, 21
atenolol, 16 BETAGAN, 31
ATIVAN, 19 betamethasone dipropionate, 22
atorvastatin calcium, 18 betamethasone valerate, 22
atovaquone, 15 betamethasone/propylene glycol, 22
ATRIPLA, 14 BETAPACE, 18
atropine sulfate, 31 BETAPACE AF, 18
ATROPISOL, 31 BETATREX, 22
ATROVENT, 23, 24, 32 bethanechol, 36
ATROVENT HFA, 32 BETIMOL, 31
attapulgite, 9 bexarotene, 15
AUGMENTIN, 12 bimatoprost, 31
AUGMENTIN ES-600, 12 bisacodyl, 10, 26
auranofin, 28 bismuth subsalicylate, 9, 26
AVALIDE, 17 BLEPHAMIDE, 31
AVANDAMET, 24, 25 BRETHAIRE, 32
AVANDIA, 24 BREVICON, 30
AVAPRO, 17 BREVOXYL, 8, 23
AVELOX / ABC PACK, 13 brimonidine tartrate, 31
AVENTYL, 20 brinzolamide, 31
AVIANE, 30 BROMFED CAP, 33
AVINZA, 18, 19 BROMFED CAP SA, DRIXORAL SYR, 33
AVODART, 36 bromocriptine mesylate, 21, 22
AVONEX / ADMIN PACK, 27 BRONCHO SALINE, 32
AYGESTINE, 30 budesonide, 23, 24, 32
AZASAN, 15 bupropion, 4, 21
azathioprine, 15 BUSPAR, 19
azelastine hcl, 23, 24 buspirone, 19
azithromycin, 12 busulfan, 15
AZOPT, 31 butoconazole, 13
AZULFIDINE, 26 CADUET, 18
bacitracin, 8, 13, 31 calamine, 9, 23
bacitracin zinc, 8, 13 CALAN SR, 16
bacitracin/plymymyxin, 8 calcipotriene, 23
baclofen, 28 calcium acetate, 28
BACTROBAN, 13 calcium carbonate, 9, 10, 25, 28
BAYER, 8, 10, 18, 27 calcium carbonate tablet, 10, 28
BENADRYL, 11, 33 CAMILA, 30
benazepril, 17 CANASA, 26
benazepril/hctz, 17 CAPOTEN, 17

CAPOZIDE, 17 citalopram, 20
captopril, 17 CLARITIN, 11, 33
captopril/hctz, 17 CLARITIN-D, 11, 33
CARAFATE, 26 clemastine, 11
carbamazepine, 19 clemastine fumarate, 33
carbamide peroxide, 9, 23, 24 CLEOCIN, 12, 13, 23
CARBATROL, 19 CLEOCIN GRANULES, 12
carbidopa/levodopa, 21 CLEOCIN HCL, 12, 13
carboxymethylcellulose, sodium, 11, 31 CLIMARA, 29, 30
CARDIZEM CD, 16 clindamycin hcl, 12, 13
CARDURA, 17 clindamycin palmitate, 12
CARFERGOT, 19 clindamycin phosphate, 23
carvedilol, 16, 17 CLINORIL, 28
CATAFLAM, 27 clobetasol propionate, 22
CATAPRES, 17 CLOBEX, 22
CECLOR, 12 clonazepam, 20
CEENU, 15 clonidine, 17
cefaclor, 12 clopidogrel, 29
cefdinir, 12 clotrimazole, 8, 13
cefprozil, 12 coal tar, 9, 23
CEFZIL, 12 codeine phosphate/apap, 19
CELEXA, 20 codeine/apap/butalbital/caffeine, 19
CELLCEPT, 15, 16 codeine/asa/butalbital/caffeine, 19
CENESTIN, 29 codeine/promethazine, 33
cephalexin, 12 COGENTIN, 21
CETAMIDE, 31 COLACE, 10, 26
cetirizine, 11, 33 colchicine, 28
CHEMSTRIP, 12, 36 COMBIVENT, 32
chloral hydrate, 19 COMBIVIR, 14
chlorambucil, 15 COMPACT PLUS, 12, 36
chlordiazepoxide hcl, 19 COMPAZINE, 21
chlorhexedine, 24 COMPOUND W, 9, 23
chlorpheniramine, 11, 33 COMTAN, 22
chlorthalidone, 16 CONCERTA, 22
CHLOR-TRIMETON, 11, 33 COPAXONE, 22
CHLOR-TRIMETON D, 33 COPEGUS, 14
cholestyramine/aspartame, 18 COREG, 16, 17
cholestyramine/sucrose, 18 CORTAID, 8, 22
cimetidine, 9, 26 CORTEF, 25
cinacalcet, 25 CORTIFOAM, 26
CIPRO, 13 CORTISPORIN, 23
CIPRODEX, 23 COUMADIN, 29
ciprofloxacin, 13, 23 COVERA-HS, 16
ciprofloxacin/dexameth, 23 COZAAR, 17

CREON, 26 dexamethasone, 25, 31
CRESTOR, 18 DEXEDRINE, 22
CRIXIVAN, 14 dextran 70/he-cell, 11, 32
cromolyn, 9, 23, 31, 32 dextroamphetamine, 22
CRYSELLE, 31 dextromethorphan/promethazine, 33
CUPRIMINE, 28 dextromethorphan/pseudoephedrine/chlor
pheniramine, 33
cyanocobalamin, 28
DIAMOX, 31
cyclobenzaprine, 28
DIASTAT, 20
cyclophosphamide, 15, 16
diazepam, 19, 20
cyclosporine, 15, 16
diclofenac potassium, 27
cyproheptadine, 33
diclofenac sodium, 27
CYSTOSPAZ, 26
dicloxacillin, 12
CYTOTEC, 26
dicyclomine, 26
CYTOVENE, 14
didanosine, 14
CYTOXAN, 15, 16
DIFLUCAN, 13
DANTRIUM, 28
digitek, 16
dantrolene sodium, 28
digoxin, 16
dapsone, 15
dihydroxyaluminum sodium carbonate, 9,
darbepoetin alfa, 27 25
darunavir ethanolate, 14 DILANTIN, 20
DARVOCET-N 100, 19 DILAUDID, 18
DARVON, 19 diltiazem, 16
DDAVP, 25 dimenhydrinate, 8, 21
DDAVP INJ, 25 DIMETAPP, 11
DDAVP NASAL, 25 diphenhydramine tablet, capsule, 33
DEBROX, 9, 23 diphenoxylate/atropine sulfate, 26
DECADRON, 25, 31 dipivefrin, 31
DECONAMINE SR CAP, 33
DIPROLENE AF, 22
delavirdine mesylate, 14
dipyridamole, 29
DELTASONE, 25
DISALCID, 27
DEMEROL, 18
DITROPAN, 36
DEPAKENE, 20
divalproex, 20
DEPAKOTE, 20
docusate sodium, 10, 26
DEPO-PROVERA, 30
donepezil, 22
desipramine, 20
DORYX, 13
desmopressin acetate, 25
DOVONEX, 23
desmopressin acetate inj, 25
doxazosin, 17
desmopressin acetate nasal, 25
doxepin, 20
desogestrel-ethilyn estradiol, 30
doxercalciferol, 28
desogestrel-ethilyn estradiol / ethynodiol,
30 doxycycline hyclate, 13
DESYREL, 21 DRAMAMINE, 8, 21
DETROL, 36 DULCOLAX, 10, 26
DETROL LA, 36 DURAGESIC, 18
DEXACINE, 31 dutasteride, 36
DYAZIDE, 16 ETHEDENT, 28
DYNAPEN, 12 ethinyl estradiol/drospirenone, 30
E.E.S, 12 ethinyl estradiol/norelgest, 30
ECONOPRED, 31 ethosuximide, 20
efavirenz, 14 ethynodiol diace-eth estradiol, 30
ELAVIL, 20 etonogestrel/ethin estradiol, 30, 31
ELDEPRYL, 22 etoposide, 15, 16
electrolyte solution, 10, 26, 29 EULEXIN, 15
emtricitabine, 14 EVISTA, 30
emtricitabine/tenofovir, 14 EXCEDRIN, 10, 27
emtricitabine/tenofovir/efavir, 14 exemestane, 15
EMTRIVA, 14 EX-LAX, 10, 26
enalapril, 17 ezetimibe/simvastatin, 18
ENBREL, 15, 16 FARESTON, 16
ENEMA, 10 felbamate, 20
enfuvirtide, 14 FELBATOL, 20
enoxaparin, 29 FELDENE, 28
ENPRESSE, 30 FEMARA, 15
entacapone, 22 FEMHRT, 30
ENULOSE, 10, 29 FEMSTAT 3, 13
epinephrine, 32 fenofibrate, 18
EPIPEN / JR, 32 fenoprofen calcium, 27
EPIVIR, 14 fentanyl, 18
epoetin alfa, 27 FERATAB, 10, 28
EPSOM SALT, 10, 26 FERGON, 10, 28
EPZICOM, 14 ferrous gluconate, 10, 28
ergotamine tartrate/caffeine, 19 ferrous sulfate, 10, 28
ERRIN, 30 fexofenadine, 33
ERY-TAB, 12 filgrastim, 27
erythromycin, 12, 13, 23, 31 finasteride, 36
erythromycin ethylsuccinate, 12 FIORICET, 19
erythromycin/sulfisoxazole, 13 FIORINAL, 19
escitalopram oxalate, 20, 21 FLAGYL, 15
ESTRACE, 29 FLEXERIL, 28
estradiol, 30 FLOMAX, 36
estradiol patch, 29 FLONASE, 23, 24
estradiol tab, 29 FLORINEF, 25
estrogen,conjugated,synethetic A, 29 FLOVENT HFA/DISKUS, 32
estrogen/medroxyprogesterone, 30 FLOXIN, 23
estrogens,conjugated, 29 fluconazole, 13
estropipate, 30 fludrocortisone, 25
ESTROSTEP FE, 30 fluocinonide, 22
etanercept, 15, 16 FLUOROPLEX, 23
ethambutol, 15 fluorouracil, 23

fluoxetine, 20 guaifenesin/dextromethorphan, 11, 33
fluphenazine hcl, 22 guaifenesin/pseudoephedrine, 11, 33
flutamide, 15 guaifensein/codeine, 33
fluticasone propionate, 23, 24, 32 GUIATUSS AC, 33
folic acid, 10, 28 HALDOL, 22
FORADIL, 32 haloperidol 0.5mg, 1mg, 2mg, 5mg, 22
formoterol fumarate, 32 H-C TUSSIVE, 33
FORTEO, 25 hctz/bisoprolol fumarate, 17
FORTOVASE, 14 hctz/triamterene, 16
FOSAMAX, 25 HECTOROL, 28
fosamprenavir calcium, 14 HEXALEN, 15
FOSRENOL, 29 HISTAFED SYR, HISTA-TABS, 33
furosemide, 16 HIVID, 14
FUZEON, 14 HUMALOG, 24
gabapentin, 20 HUMATIN, 15
ganciclovir, 14 HUMIRA, 15, 16
GARAMYCIN, 13 HUMULIN, 24
GAS-X, 10 HUMULIN N, 24
gemfibrozil, 18 HUMULIN R, 24
GENATON, 9, 25 HYCODAN, 33
GENOTROPIN, 27 HYDONE, 16
GENTAK, 31 hydralazine, 17
gentamicin, 13, 31 HYDREA, 15
gentamicin sulfate, 13 hydrochlorothiazide, 16
GENTEAL, 11, 32 hydrocodone bitartrate/apap, 19
hydrocodone/homatropine, 33
glatiramer acetate, 22
hydrocortisone, 4, 8, 22, 25
glipizide, 24
hydrocortisone acetate, 26
GLUCAGON, 25
hydrogen peroxide, 9, 23
glucagon, human recombinant, 25
hydromorphone, 18
GLUCOPHAGE, 24
hydroxychloroquine, 15
glucose monitors, supplies, 12, 36
hydroxypropyl methylcellulose, 11, 32
GLUCOTROL, 24
hydroxyurea, 15
GLUCOVANCE, 24
hydroxyzine, 23
glyburide, 24
hydroxyzine pamoate, 23
glyburide/metformin, 24
hyoscyamine, 26
GLYCOLAX, 10, 26
HYPOTEARS, 11, 32
GLYNASE, 24
HYTRIN, 17
GLY-OXIDE, 24
HYZAAR, 17
GOLYTELY, 26
ibuprofen, 27
granisetron, 21
ILOTYCIN, 31
griseofulvin ultramicrosize, 13
IMDUR, 17
GRIS-PEG, 13
imipramine hcl, 20
GUAICON, 11, 33
imipramine pamoate, 20
guaifenesin syrup, 11, 33
IMITREX, 19
IMODIUM, 9, 26 labetalol, 16
indapamide, 16 lactulose, 10, 29
INDERAL, 16 LAMICTAL, 20
indinavir, 14 LAMISIL, 13
INDOCIN, 27 lamivudine, 14
indomethacin, 27 lamivudine/zidovudine, 14
infliximab, 15, 16 lamotrigine, 20
INSENTRESS, 14 lanolin/mineral oil/petrolatum, 11, 32
insulin aspart, 24 LANOXIN, 16
insulin glargine, 24 lansoprazole, 26
insulin human regular, 24 lanthanum carbonate, 29
insulin lispro, 24 LANTUS, 24
insulin NPH, 24 LARIAM, 15
insulin regular, 24 LASIX, 16
insulin syringes/needles, 36 latanoprost, 31
INTAL, 32 LESSINA, 30
interferon alfa-2B, recombinant, 27 letrozole, 15
interferon beta-1A, 27 LEUKERAN, 15
INTRON A, 27 LEUKINE, 27
INVIRASE, 14 LEVAQUIN, 13
ipratropium, 23, 24, 32 levobunolol, 31
irbesartan, 17 levofloxacin, 13
irbesartan/hctz, 17 levonorgestrel, 30
iron, 11, 29 levonorgestrel-ethin estradiol, 30
isoniazid, 15 levonorgestril, 30
isosorbide dinitrate, 17 LEVORA, 30
isosorbide mononitrate, 17 LEVOTHROID, 25
itraconazole, 13 levothyroxine, 25
JANUVIA, 25 LEVOXYL, 25
JOLIVETTE, 30 LEXAPRO, 20, 21
JUNEL FE, 30 LEXIVA, 14
KALETRA, 14 LIBRIUM, 19
KAOPECTATE, 9, 26 LIDEX, 22
KA-PEC, 9 lidocaine viscous, 24
KARIVA, 30 LIORESAL, 28
KEFLEX, 12 LIPITOR, 18
KELNOR, 30 lisinopril, 17
KENALOG, 23, 24 lisinopril/hctz, 17
KETOCARE, 12, 36 LOMOTIL, 26
ketoconazole, 13 lomustine, 15
ketone testing products, 12, 36 loperamide, 9, 26
ketorolac, 32 LOPID, 18
KLONOPIN, 20 LOPRESSOR, 16
KYTRIL, 21 loratadine, 11, 33

lorazepam, 19 methadone, 18
LORCET, 19 METHADOSE, 18
LORTAB, 19 methazolamide, 31
losartan, 17 METHERGINE, 31
losartan /hctz, 17 methimazole, 25
LOTEMAX, 31 methocarbamol, 28
LOTENSIN, 17 methotrexate, 15
LOTENSIN HCT, 17 methyldopa, 17
loteprednol etabonate, 31 methylergonovine, 31
LOTRIMIN, 8, 13 methylphenidate, 22
lovastatin, 18 methylprednisolone, 25
LOVENOX, 29 metoclopramide, 26
LOW-OGESTREL, 30 metolazone, 16
LOZOL, 16 metoprolol succinate, 16
LUMIGAN, 31 metoprolol tartrate, 16
LYRICA, 20 METROGEL, 29
LYSODREN, 15 metronidazole, 4, 15, 29
MAALOX, 9, 25 MEVACOR, 18
MACROBID, 13 miconazole nitrate, 8, 13
mag hydrox/al hydrox/simeth, 9, 25 MICROGESTIN, 30
magnesium hydroxide, 9, 10, 25, 26 MICRO-GUARD, 8, 13
magnesium hydroxide/al hydrox, 9, 25 MICRONASE, 24
magnesium sulfate, 10, 26 MICROZIDE, 16
maraviroc, 14 midodrine, 18
MATULANE, 15 MILK OF MAGNESIA, 10, 26
MAXALT / MLT, 19 mineral oil/petrolatum, 9, 23
MAXZIDE-25MG, 16 MINIPRESS, 17
mebendazole, 15 MIRAPEX, 22
meclizine hcl, 21 MIRENA, 30
MEDIVERT, 21 MIRENA IUD, 30
MEDROL, 25 mirtazapine, 21
medroxyprogesterone, 30 misoprostol, 26
mefloquine, 15 mitotane, 15
MEGACE, 15 mometasone, 24, 32
megestrol, 15 MONISTAT, 8, 13
melphalan, 15, 16 MONOKET, 17
meperidine, 18 MONONESSA, 30
MEPRON, 15 montelukast sodium, 32
mercaptopurine, 15 morphine ext release, 18
mesalamine, 26 morphine sulfate ir, er tabs, soln, 18
MESTINON, 22 MOTRIN, 27
METADATA, 22 moxifloxacin, 13, 31
METAMUCIL, 10, 26 MSCONTIN, 18
metformin, 24 MUCINEX, 33

multivitamins, 10, 28 norethindrone acetate, 30
mupirocin, 13 norethindrone A-E estradiol, 30
MYAMBUTOL, 15 norethindrone-ethin estradiol, 30
MYCELEX, 8, 13 norethindrone-mestranol, 30
MYCOLOG, 14 norgestimate-ethinyl estradiol, 30
mycophenolate mofetil, 15, 16 norgestrel-ethinyl estradiol, 30, 31
MYCOSTATIN, 13, 14 NORPRAMIN, 20
MYLANTA, 9, 25, 26 NORTREL, 30
MYLERAN, 15 nortriptyline, 20
MYOTONACHOL, 36 NORVASC, 16
MYSOLINE, 20 NORVIR, 14
NALFON, 27 NOVOFINE / 30, 36
naphazoline/pheniramine, 11, 32 NOVOLIN, 24
NAPHCON-A, 11, 32 NOVOLIN N, 24
NAPROSYN, 28 NOVOLIN R, 24
naproxen, 28 NOVOLOG, 24
NASALCROM, 9, 23 NUTROPIN / AQ / DEPOT, 27
NASONEX, 24 NUVARING, 30, 31
NECON, 30 NYDRAZID, 15
nelfinavir mesylate, 14 nystatin, 13, 14
NELOVA, 30 nystatin/triamcinolone, 14
neomycin sulfate/polymyxin/hc, 23 OCUFLOX, 31
neomycin/bacitracin/polymyxin, 8, 13, 31 ofloxacin, 23, 31
neomycin/polymyxin/dexameth, 31 OGESTREL, 31
NEORAL, 15 omeprazole magnesium, 9, 26
NEOSPORIN, 8, 13, 31 OMNICEF, 12
NEPTAZANE, 31 ondansetron, 4, 21
NESTREX, 10, 28 OPTICROM, 31, 32
NEUPOGEN, 27 ORENCIA, 15, 16
NEURONTIN, 20 ORTHO EVRA, 30
NEUTROGENA T/GEL, 9, 23 ORTHO TRI-CYCLEN LO, 30
nevirapine, 14 ORTHO-EST, 30
NEXIUM, 26 OSMOPREP, 26
niacin, 18 oxazepam, 19
NIASPAN, 18 oxcarbazepine, 19, 20
nifedipine, 16 oxybutynin, 36
nitrofurantoin macrocrystal, 13 oxycodone, 18, 19
nitroglycerin capsule, 17 oxycodone/acetaminophen, 18
NITRO-TIME, 17 oxycodone/aspirin, 18
NIZORAL, 13 OXYCONTIN, 18, 19
NOLVADEX, 16 PACERONE, 17
NORA-BE, 30 palivizumab, 27
noreth A-ET estra/fe fumarate, 30 PANGESTYME, 26
norethindrone, 30 PARLODEL, 21, 22

PARNATE, 21 PLAN B, 30
paromomycin, 15 PLAQUENIL, 15
paroxetine, 20 PLAVIX, 29
PAXIL, 20 polyethylene glycol, 10, 26
PAXIL / CR, 20 polymyxin B sulfate, 31
PEDIALYTE, 10, 29 POLYSPORIN, 8
PEDIAZOLE, 13 POLYTRIM, 31
PEGASYS, 27 polyvinyl alcohol, 11, 32
peginterferon alfa-2A, 27 PORTIA, 30
penicillamine, 28 potassium chloride, 28
penicillin, 12 pramipexole, 22
pentoxifylline, 18 PRANDIN, 24
PERCOCET, 18 PRAVACHOL, 18
PERCODAN, 18 pravastatin, 18
pergolide mesylate, 22 prazosin, 17
PERIACTIN, 33 PRECISION, 36
PERIDEX, 24 PRECOSE, 24
PERMAX, 22 PREDNISOL, 31
permethrin, 23 prednisolone, 25, 31
PERMITIL, 22 prednisolone acetate, 31
PERSANTINE, 29 prednisolone sodium phosphate, 31
petrolatum, white, 11, 32 prednisone, 25
PHENAPHEN, 19 pregabalin, 20
phenazopyridine, 12, 36 PRELONE, 25
PHENERGAN, 33 PREMARIN, 29
PHENERGAN W/CODEINE, 33 PREMPHASE, 30
phenobarbital, 20 PREMPRO, 30
phenolphthalein, 10, 26 prenatal vitamins, 11, 29
phenylephrine/brompheniramine, 33 PREVACID, 26
phenylephrine/codeine/promethazine, 33 PREVIFEM, 30
phenylephrine/hydrocodone/chlorphenira PREZISTA, 14
mine, 33 PRILOSEC OTC, 9, 26
phenytoin, 20 primaquine, 15
phenytoin sodium, 20 primidone, 20
PHERGAN, 21 PRIMSOL, 13
PHOSLO, 28, 29 PRINCIPEN, 12
pilocarpine, 31 PRINIVIL, 17
PILOPINE, 31 PRINZIDE, 17
pindolol, 16 PROAIR HFA, 32
PIN-X, 15 PROAMATINE, 18
pioglitazone, 24, 25 probenecid, 28
pioglitazone/metformin, 24 procainamide, 17
piperonyl butoxide/pyrethrins, 9, 23 procarbazine, 15
piroxicam, 28 PROCARDIA XL, 16

prochlorperazine maleate, 21 repaglinide, 24
PROCRIT, 27 REQUIP, 22
PROGRAF, 16 RESCRIPTOR, 14
PROLASTIN, 33 RESTORIL, 19
promethazine, 21, 33 RETIN-A, 23
PROMETHAZINE, 33 RETROVIR, 14
PRONESTYL, 17 REYATAZ, 14
propafenone, 17 RHEUMATREX, 15
PROPINE, 31 RHINOCORT AQUA, 23, 24
propoxyphene, 19 ribavirin, 14
propoxyphene napsylate/apap, 19 RID, 9, 23
propranolol, 16 RIDAURA, 28
propylthiouracil, 25 RIFADIN, 15
PROSCAR, 36 rifampin, 15
PROVERA, 30 rimexolone, 31
PROZAC, 20 risedronate, 25
pseudoephedirne/triprolidine, 33 RITALIN, 22
pseudoephedrine, 11, 33 ritonavir, 14
pseudoephedrine/brompheniramine, 11, 33 ritonavir/lopinavir, 14
pseudoephedrine/chlorpheniramine, 33 rizatriptan, 19
pseudoephedrine/loratadine, 33 ROBAXIN, 28
pseudoephedrine/loratidine, 11 ROBITUSSIN, 11
pseudoephedrine/tripolidine, 11 ROBITUSSIN PE, 33
psyllium, 10, 26 ROLAIDS, 9, 25
PULMICORT, 32 ropinirole, 22
PURALUBE, 11, 32 rosiglitazone, 24, 25
PURINETHOL, 15 rosiglitazone/metformin, 24, 25
pyrantel, 15 rosuvastatin calcium, 18
pyrazinamide, 15 ROXICET, 18
pyridostigmine, 22 ROXICODONE, 18
pyridoxine, 10, 28 RYTHMOL, 17
QUESTRAN, 18 salicylic acid, 9, 23
QUINAGLUTE, 17 salmeterol, 32
quinapril, 17 salmeterol/fluticasone, 32
QUINIDEX, 17 salsalate, 27
quinidine gluconate, 17 SANDIMMUNE, 15, 16
quinidine sulfate, 17 saquinavir, 14
raloxifene, 30 saquinavir mesylate, 14
ranitidine, 9, 26 sargramostim, 27
RAPAMUNE, 16 selegiline, 22
REBETOL, 14 selenium sulfide, 9, 23
REGLAN, 26 SELSUN BLUE, 9, 23
REMERON, 21 SELZENTRY, 14
REMICADE, 15, 16 senna/docusate sodium, 10, 26

sennosides a&b, calcium, 10, 26 tamoxifen, 16
SENOKOT, 10, 26 tamsulosin, 36
SENSIPAR, 25 TAPAZOLE, 25
SEPTRA, 13 TARGRETIN, 15
SERAX, 19 TARKA, 17
SEREVENT DISKUS, 32 TAVIST, 33
SEROSTIM, 27 TAVIST-1, 11
sertraline, 20, 21 tazarotene, 23
SILVADENE, 13 TAZORAC, 23
silver sulfadiazine, 13 TEARS NATURALE, 11, 32
simethicone, 10, 26 TEGRETOL, 19
simvastatin, 18 temazepam, 19
SINEMET, 21 tenofovir disproxil fumarate, 14
SINGULAIR, 32 TENORMIN, 16
SINUTAB LiquiCaps, 11 terazosin, 17
sirolimus, 16 terbinafine, 13
sodium bicarbonate, 9, 25 terbutaline sulfate, 32
sodium chloride, 32 teriparatide, 25
sodium fluoride, 28 TESSALON, 33
sodium phosphate/NA biphos, 10, 26 testosterone, 29
somatropin, 27 tetracycline, 13
SOMNOTE, 19 theophylline, 32
SORBITRATE, 17 THERA TEARS, 11, 31
sotalol, 18 thioguanine, 16
spironolactone, 16 thyroid, 25
spironolactone/hctz, 16 TIAZAC, 16
SPORANOX, 13 TICLID, 29
SPRINTEC, 30 ticlopidine, 29
stavudine, 14 TIGAN, 21
sucralfate, 26 timolol, 31
SUDAFED, 11, 33 TINACTIN, 8, 14
sulfacetamide, 31 tipranavir, 14
sulfacetamide/prednisolone AC, 31 TOBRADEX, 31
sulfacetamide/prednisolone SP, 31 tobramycin, 31
sulfamethoxazole/trimethoprim, 13 tobramycin sulfate/dexameth, 31
sulfasalazine, 26 TOBREX, 31
sulindac, 28 TOFRANIL, 20
sumatriptan, 19 TOFRANIL PM, 20
SUMYCIN, 13 tolnaftate, 8, 14
SUSTIVA, 14 tolterodine tartrate, 36
SYMMETREL, 14 TOPAMAX, 20
SYNAGIS, 27 topiramate, 20
tacrolimus, 16 TOPOSAR, 15, 16
TAGAMET, 9, 26 TOPROL XL, 16

toremifene, 16 VIGAMOX, 31
tramadol, 18 VIRACEPT, 14
TRANDATE, 16 VIRAMUNE, 14
trandolapril/verapamil, 17 VIREAD, 14
tranylcypromine, 11, 21 VIROPTIC, 31
trazodone, 21 VISKEN, 16
TRENTAL, 18 VISTARIL, 23
tretinoin, 23 vitamin b complex, 10, 28
triamcinolone acetonide, 23, 24 vitamin e, 10, 28
TRIAMINIC COLD/COUGH, 33 VOLTAREN, 27
TRICOR, 18 VOSOL, 23
trifluridine, 31 VOSOL HC, 23
trihexyphenidyl, 21 VYTORIN, 18
TRILEPTAL, 19, 20 warfarin sodium, 29
trimethobenzamide, 21 WELLBUTRIN, SR, XL, 21
trimethoprim, 13 XALATAN, 31
TRINESSA, 30 XANAX, 19
TRI-SPRINTEC, 30 XYLOCAINE VISCOUS, 24
TRIVORA, 30 YASMIN / 28, 30
TRIZIVIR, 14 zafirlukast, 32
TRUVADA, 14 zalcitabine, 14
TUMS, 10, 28 ZANTAC, 9, 26
TYLENOL, 8, 18 ZARONTIN, 20
ULTRAM, 18 ZAROXOLYN, 16
ULTRASE/MT, 26 ZERIT, 14
URISTAT, 12, 36 ZESTRIL, 17
URSO, 26 ZIAC, 17
ursodiol, 26 ZIAGEN, 14
valacyclovir, 14 zidovudine, 14
VALIUM, 19 zidovudine/lamivudine/abacavir, 14
valproic acid, 20 zinc acetate, 10, 28
VALTREX, 14 ZITHROMAX, 12
vancocin, 15 ZOFRAN / ODT, 21
vancomycin, 15 zolmitriptan, 19
VASOCIDIN, 31 ZOLOFT, 20, 21
VASOTEC, 17 zolpidem, 19
VEETIDS, 12 ZOMIG / ZMT, 19
verapamil, 16 ZOVIA, 30
VERELAN, 16 ZOVIRAX, 14
VERMOX, 15 ZOVIRAX OINT, 14
VEXOL, 31 ZYRTEC, 11, 33
VIDEX, 14


Formulary 2009

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Formulary 2009

Uploaded by

Copyright:

Available Formats

2

2009 AHCCCS Formulary

This formulary covers selected, cost-effective over-the-counter (OTC) products.

Product Selection Criteria

Formulary Product Descriptions

4 – Boldface indicates generic availability

metronidazole tabs Flagyl

Only tablets are on formulary, not the capsules.

Extended-release and delayed-release products require their own entry.

bupropion ext-rel Wellbutrin XL

The long-acting product Wellbutrin SR is not on formulary based upon the

Similarly, the brand name product Wellbutrin immediate-release is not on

neomycin/polymyxin B/hydrocortisone Cortisporin

It is recommended that generic substitution not be exercised by the pharmacist

Drug Efficacy Study Implementation Drugs

Request for Formulary Consideration

Clinical Override Conditions

A physician may request a formulary exception or clinical override by utilizing the

Boldface indicates generic availability - 7

Medical Services Department

8 – Boldface indicates generic availability

Generic availability is indicated by boldface type

TOPICAL ANTIBACTERIAL DRUGS

OTHER TOPICAL ANTIFUNGALS

AUTONOMIC AND CNS MEDICATIONS

AUTONOMIC AND CNS MEDICATIONS

ANTIVERTIGO AND ANTIEMETIC DRUGS

TOPICAL CORTICOSTEROID DRUGS

Boldface indicates generic availability - 9

ANTIPSORIASIS AND ANTIECZEMA DRUGS

TOPICAL DERMATOLOGICAL DRUGS

DRUGS AFFECTING THE EAR

DRUGS AFFECTING THE NOSE

PROTON PUMP INHIBITORS

omeprazole magnesium/PRILOSEC maximum quantity 60 tablets every 30 days

10 – Boldface indicates generic availability

SALICYLATES AND RELATED DRUGS

VITAMINS & MINERALS & RELATED PRODUCTS

THERAPEUTIC VITAMINS & MINERALS

ELECTROLYTES, IRRIGATING SOLUTIONS, ETC.

Boldface indicates generic availability - 11

OTHER OPHTHALMIC DRUGS

ANTITUSSIVE AND EXPECTORANT DRUGS

SMOKING CESSATION PRODUCTS

QLL,OTC nicotine polacrilex gum NICORETTE

nicotine gum/NICORETTE maximum quantity 108 per fill, 324 in 6 months

12 – Boldface indicates generic availability

DIAGNOSTIC & MISCELLANEOUS MEDICATIONS

MEDICAL (MISCELLANEOUS) SUPPLIES

cefixime 400mg/SUPRAX maximum quantity 1 per month

azithromycin/ZITHROMAX maximum quantity 4 units per fill

*Limited to children under age of 6.

Boldface indicates generic availability - 13

TOPICAL ANTIBACTERIAL DRUGS

mupirocin/BACROBAN requires prior authorization

ORAL ANTIFUNGAL DRUGS

OTHER TOPICAL ANTIFUNGALS

ANTIRETROVIRALS & PROTEASE INHIBITORS

enfuvirtide/FUZEON use specialty pharmacy

OTHER ANTIVIRAL DRUGS

ribavirin/COPEGUS, REBETOL use specialty pharmacy

TOPICAL ANTIVIRAL DRUGS