2011Comprehensive Formularycover Jan€¦ · CVS Caremark Plus (PDP)¹ 2011 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER

CVS Caremark Plus (PDP)¹

2011 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2012. SilverScript Insurance Company is a Medicare-approved Part D Sponsor. Contact Customer Care 24 hours a day, 7 days a week, at 1-866-235-5660 to request materials in an alternate format or language. TTY users should call 1-866-236-1069. Llame al Servicio al Cliente las 24 horas del día, los 7 días de la semana, al 1-866-235-5660 para solicitar materiales en un formato o idioma diferente. Los usuarios de teléfono de texto (TTY) pueden llamar al 1-866-236-1069. ¹Other Pharmacies are Available in Our Network. 11012_Jan S5601_11_40002_Plus File & Use 10/01/2010 Version 9

authorization, quantity limits and/or step therapy

members of the change at least 60 days before the

1-866-236-1069. We will notify beneficiaries in

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A formulary is a list of covered drugs selected by CVS Caremark Plus (PDP)¹ in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program.

CVS Caremark Plus (PDP)¹ will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Generally, if you are taking a drug on our 2011 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2011 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released.

Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year.

We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, add prior

restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected

change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug.

If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

The enclosed formulary is current as of 01/01/2011. To get updated information about the drugs covered by CVS Caremark Plus (PDP)¹, please visit our Web site at www.silverscript.com or call Customer Care at 1-866-235-5660, 24 hours a day, 7 days a week. TTY users should call 1-866-236-1069.

If we have a mid-year non-maintenance formulary change (i.e. remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier), we will update our print formulary by reprinting it with the new information. The updated version may be obtained from our Web site or by calling Customer Care at 1-866-235-5660, 24 hours a day, 7 days a week. TTY users should call

writing prior to making this type of change.

¹Other Pharmacies are Available in our Network.

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What is the CVS Caremark Plus (PDP)¹ Formulary?

Can the formulary change?

CVS Caremark Plus (PDP)¹ covers both

CVS Caremark Plus (PDP)¹ requires you or your

from CVS Caremark Plus (PDP)¹ before you fill

CVS Caremark Plus (PDP)¹ may not cover the

For certain drugs, CVS Caremark Plus (PDP)¹ limits the amount of the drug that CVS Caremark Plus (PDP)¹ will cover. For example, CVS Caremark Plus (PDP)¹ provides up to twelve units

In some cases, CVS Caremark Plus (PDP)¹

CVS Caremark Plus (PDP)¹ may not cover Drug

work for you, CVS Caremark Plus (PDP)¹ will

formulary that begins on page 7. You can also get

You can ask CVS Caremark Plus (PDP)¹ to make an exception to these restrictions or limits. See

CVS Caremark Plus (PDP)¹ formulary?” on page

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There are two ways to find your drug within the formulary:

The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular”. If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug.

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 31. The Index provides an alphabetical list of all of the drugs included in this document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

physician to get prior authorization for certain drugs.

This means that you will need to get approval

your prescriptions. If you don’t get approval,

drug.

per prescription for MAXALT. This may be in addition to a standard one month or three month supply.

requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition,

B unless you try Drug A first. If Drug A does not

then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the

more information about the restrictions applied to specific covered drugs by visiting our Web site at www.silverscript.com.

the section, “How do I request an exception to the

3 for information about how to request an exception.

If your drug is not included in this formulary, you should first contact Customer Care and confirm that your drug is not covered.

¹Other Pharmacies are Available in our Network.2||

|

How do I use the formulary?

What are generic drugs?

Are there any restrictions on my coverage?

What if my drug is not on the formulary?

Medical Condition

Alphabetical Listing

Prior Authorization (PA)

Quantity Limits (QL)

Step Therapy (ST)

If you learn that CVS Caremark Plus (PDP)¹ does not cover your drug, you have two options:

him or her to prescribe a similar drug that is covered by CVS Caremark Plus (PDP)¹.You can ask CVS Caremark Plus (PDP)¹

You can ask CVS Caremark Plus (PDP)¹ to make

Plus (PDP)¹ limits the amount of the drug

Brand Drugs) instead. This would lower the

Generally, CVS Caremark Plus (PDP)¹ will only

utilization restriction exception. When you are

statement from your physician supporting

expedited (fast) exception if you or your doctor

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You can ask Customer Care for a list of similar drugs that are covered by CVS Caremark Plus (PDP)¹. When you receive the list, show it to your doctor and ask

to make an exception and cover your drug. See below for information about how to request an exception.

an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

You can ask us to cover your drug even if it is not on our formulary.You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, CVS Caremark

that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.You can ask us to provide a higher level of coverage for your drug. If your drug is contained in Tier 4 (Non-Preferred Generic and Non-Preferred Brand Drugs), you can ask us to cover it at the cost-sharing amount that applies to drugs in Tier 3 (Preferred

amount you must pay for your drug.

Please note, if we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in Tier 5 (Specialty Tier Drugs).

approve your request for an exception if the alternative drug is included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or

Generally, we must make our decision within 72 hours of getting your prescribing physician’s supporting statement. You can request an

believe that your health could be seriously harmed by waiting up to 72 hours for a decision.

If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement.

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take.

While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.


·

·

·

·

·

requesting a formulary, tiering or utilization restriction exception you should submit a

your request.

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How do I request an exception to the CVS Caremark Plus (PDP)¹ formulary?

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

limited, we will cover a temporary 30-day supply

31-day emergency supply of that drug (unless you

Caremark Plus (PDP)¹ prescription drug

(PDP)¹, please call Customer Care at

covered by CVS Caremark Plus (PDP)¹. If you

SYNTHROID) and generic drugs are listed in lowercase italics (e.g., levothyroxine).

The information in the Notes column tells you if CVS Caremark Plus (PDP)¹ has any special requirements for coverage of your drug.

PA – Prior authorization.QL – Drug has quantity limit.ST – Step therapy required.NM - Not available at mail-order.LA – Limited Access. This prescription may be

B/D – This drug may be covered under Medicare

GC - We provide additional coverage of this

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For each of your drugs that is not on our formulary or if your ability to get your drugs is

(unless you have a prescription written for fewer days) when you go to a network pharmacy.

After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a

have a prescription for fewer days) while you pursue a formulary exception.

If you experience a change in your level of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, we will cover a one-time temporary supply for up to 30-days (or 31-days if you are a long-term care resident) when you use a network pharmacy. During this period, you should use the plan's exception process if you wish to have continued coverage of the drug after the temporary supply is finished.

For more detailed information about your CVS

coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about CVS Caremark Plus

1-866-235-5660, 24 hours a day, 7 days a week. TTY users should call 1-866-236-1069. Or visit www.silverscript.com.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov.

The formulary that begins on page 7 provides coverage information about some of the drugs

have trouble finding your drug in the list, turn to the index that begins on page 31.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g.,

available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Care at 1-866-235-5660, 24 hours a day, 7 days a week. TTY users should call 1-866-236-1069.

Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

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


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For more information

CVS Caremark Plus (PDP)¹ Formulary

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Cost-Sharing Tier 3

Preferred Retail Network

pharmacy

Non-Preferred Retail Network

pharmacy The plan’s mail- order pharmacy

Cost-Sharing Tier 1

Cost-Sharing Tier 2

Cost-Sharing Tier 4

Cost-Sharing Tier 5

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(Up to a 30-day supply)



(Preferred Generic Drugs) $2.00 $5.00 $3.00

(Non- Preferred Generic Drugs)

$5.00 $5.00 $8.00

(Preferred Brand Drugs) $35.00 $35.00 $79.00

(Non-Preferred Generic and Non-Preferred Brand Drugs)

$90.00 $90.00 $248.00

(Specialty Tier Drugs) 33% 33% N/A

The Tier column of the drug list that begins on page 7 tells you which tier your drug is in. The tables below tell you the copayment or co-insurance amount (i.e. the share of the drug's cost that you will pay during the initial coverage period) for drugs in each tier.

Initial Coverage Period Co-payment / Co-insurance Levels

5 |||

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PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access GC - We provide coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.

7

SSI_CY2011_5T_PLUS_11010_Jan

Drug Tier Notes ANALGESICS COX-2 INHIBITORS CELEBREX 3 PA GOUT allopurinol (generic of ZYLOPRIM) 1 GC allopurinol sodium (generic of ALOPRIM)

2 GC

colchicine w/ probenecid 2 GC COLCRYS

QL (60 tabs / 30 days) 4 QL

probenecid 2 GC ULORIC 3 ST NARCOTIC ANALGESICS acetaminophen w/ codeine 2 GC butalbital-acetaminophen-caffeine w/ codeine (generic of FIORICET/CODEINE)

2 GC

butalbital-aspirin-caffeine w/cod (generic of FIORINAL/CODEINE #3)

2 GC

butorphanol tartrate (generic of STADOL)

2 GC

hydrocodone-acetaminophen (generic of VICODIN ES)

2 GC

NARCOTIC ANALGESICS, CII AVINZA

QL (60 ea / 30 days) 4 QL

DILAUDID-5 3 fentanyl (generic of DURAGESIC)

QL (10 ea / 30 days) patch

2 GC QL PA

fentanyl citrate (generic of SUBLIMAZE)

injection

2 GC B/D

hydromorphone hcl (generic of DILAUDID-HP) 10mg/ml

2 GC B/D

hydromorphone hcl (generic of DILAUDID) 2mg, 4mg, 8mg

2 GC

KADIAN QL (60 ea / 30 days)

3 QL

methadone hcl (generic of DOLOPHINE) 10mg, 5mg

QL (240 tabs / 30 days)

2 GC QL

methadone hcl (generic of METHADONE HCL INTENSOL) 10mg/ml

2 GC

Drug Tier Notes METHADONE HCL 10mg/5ml, 5mg/5ml

3

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

2 GC B/D

morphine sulfate (generic of MS CONTIN) 100mg, 15mg, 30mg, 60mg

QL (90 ea / 30 days)

2 GC QL

morphine sulfate 15mg, 30mg 2 GC morphine sulfate (generic of MS CONTIN) 200mg


2 GC QL

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

3

OPANA ER QL (120 ea / 30 days)

4 QL

oxycodone hcl (generic of ROXICODONE)

2 GC

oxycodone w/ acetaminophen (generic of PERCOCET)

2 GC

oxycodone w/ aspirin (generic of PERCODAN)

2 GC

OXYCONTIN QL (120 ea / 30 days)

3 QL

ROXICET solution

3

NON-NARCOTIC ANALGESICS tramadol hcl (generic of ULTRAM)

QL (240 tabs / 30 days) 2 GC QL

tramadol-acetaminophen (generic of ULTRACET)


2 GC QL

NSAIDS diclofenac potassium (generic of CATAFLAM)

2 GC

diclofenac sodium (generic of VOLTAREN-XR)

2 GC

diflunisal 2 GC etodolac 2 GC flurbiprofen 1 GC ibuprofen 1 GC INDOCIN

suspension 3

indomethacin 2 GC ketoprofen 2 GC ketorolac tromethamine


meloxicam (generic of MOBIC) 2 GC nabumetone 2 GC


8

Drug Tier Notes naproxen (generic of NAPROSYN) 250mg, 375mg

1 GC

naproxen (generic of NAPROSYN) 125mg/5ml, 375mg, 500mg

2 GC

naproxen sodium (generic of ANAPROX)

2 GC

oxaprozin (generic of DAYPRO) 2 GC piroxicam (generic of FELDENE) 1 GC sulindac 2 GC tolmetin sodium 2 GC VOLTAREN

gel 3

ANESTHETICS LOCAL ANESTHETICS lidocaine hcl (local anesth.) (generic of XYLOCAINE)

2 GC B/D

ANTI-INFECTIVES ANTIBACTERIALS amikacin sulfate (generic of AMIKIN) 250mg/ml

2 GC B/D

amikacin sulfate (generic of AMIKIN) 50mg/ml

2 GC

amoxicillin 1 GC amoxicillin & pot clavulanate (generic of AUGMENTIN)

2 GC

ampicillin 250mg, 500mg 1 GC ampicillin 125mg/5ml, 250mg/5ml 2 GC ampicillin & sulbactam sodium (generic of UNASYN)

2 GC B/D

ampicillin sodium 2 GC B/DAVELOX 3 B/D AVELOX 400mg 3 AVELOX ABC PACK 3 azithromycin (generic of ZITHROMAX) 100mg/5ml

QL (8 bottles / 30 days)

2 GC QL

azithromycin (generic of ZITHROMAX) 200mg/5ml

QL (120 ml / 30 days)

2 GC QL

azithromycin (generic of ZITHROMAX) 250mg, 500mg, 600mg

2 GC

azithromycin (generic of ZITHROMAX) 500mg

QL (50 vials / 30 days)

2 GC B/D QL

BICILLIN C-R 3 BICILLIN L-A 3 CEDAX 4

Drug Tier Notes cefaclor 2 GC CEFACLOR ER 3 cefadroxil 2 GC cefazolin sodium 1gm, 20gm, 500mg

2 GC B/D

CEFAZOLIN SODIUM 3 B/D cefdinir 2 GC cefepime hcl 2 GC B/Dcefotaxime sodium (generic of CLAFORAN) 10gm, 1gm, 2gm

2 GC

cefotaxime sodium (generic of CLAFORAN) 500mg

2 GC B/D

cefoxitin sodium 2 GC B/Dcefpodoxime proxetil (generic of VANTIN)

2 GC

cefprozil 2 GC ceftriaxone sodium 2 GC B/Dcefuroxime axetil (generic of CEFTIN)

2 GC

cefuroxime sodium (generic of ZINACEF)

2 GC B/D

CEFUROXIME/DEXTROSE 3 cephalexin (generic of KEFLEX) 250mg, 500mg

1 GC

cephalexin 125mg/5ml, 250mg/5ml 2 GC CIPRO

suspension 3

ciprofloxacin (generic of CIPRO I.V.) injection

2 GC B/D

ciprofloxacin hcl (generic of CIPRO) 250mg, 500mg, 750mg

1 GC

ciprofloxacin hcl 100mg 2 GC ciprofloxacin-ciprofloxacin hcl

ext rel 2 GC

clarithromycin 125mg/5ml QL (8 bottles / 10 days)

2 GC QL

clarithromycin (generic of BIAXIN) 250mg, 250mg/5ml, 500mg

2 GC

clarithromycin (generic of BIAXIN XL) 500mg


2 GC QL

dicloxacillin sodium 2 GC doxycycline (monohydrate) (generic of ADOXA PAK 1/150)

2 GC

doxycycline hyclate (generic of VIBRAMYCIN) 100mg, 50mg

1 GC

doxycycline hyclate 100mg injection

2 GC B/D

doxycycline hyclate (generic of 2 GC


9

Drug Tier Notes PERIOSTAT) 20mg ERYPED 200 3 ERYTHROCIN LACTOBIONATE 3 B/D erythromycin base 1 GC erythromycin ethylsuccinate 1 GC erythromycin stearate 1 GC gentamicin in saline 2 GC B/Dgentamicin in saline 2 GC gentamicin sulfate 2 GC LEVAQUIN 25mg/ml 4 B/D LEVAQUIN 250mg, 25mg/ml, 500mg, 750mg

4

minocycline hcl (generic of MINOCIN)

2 GC

nafcillin sodium 2 GC B/Dneomycin sulfate 2 GC paromomycin sulfate 2 GC penicillin g potassium (generic of PFIZERPEN-G)

2 GC B/D

PENICILLIN G PROCAINE 3 penicillin v potassium 1 GC piperacillin sodium-tazobactam sodium (generic of ZOSYN)

2 GC B/D

streptomycin sulfate 2 GC B/DSULFADIAZINE 3 SUPRAX 100mg/5ml, 200mg/5ml 4 SUPRAX 400mg


tetracycline hcl 1 GC tobramycin sulfate 2 GC B/DANTIFUNGALS amphotericin b 2 GC B/DANCOBON 3 CANCIDAS 3 B/D clotrimazole (generic of MYCELEX) 2 GC fluconazole (generic of DIFLUCAN) 150mg

1 GC

fluconazole (generic of DIFLUCAN) 100mg, 10mg/ml, 200mg, 40mg/ml, 50mg

2 GC

fluconazole in dextrose (generic of DIFLUCAN IN ISO-OSMOTIC D)

2 GC B/D

GRIS-PEG 3 griseofulvin microsize 2 GC itraconazole (generic of SPORANOX)

2 GC PA

ketoconazole 2 GC NOXAFIL 5 NM

Drug Tier Notes nystatin 2 GC SPORANOX 4 terbinafine hcl (generic of LAMISIL) 2 GC PA VFEND 5 NM PA VFEND IV 5 NM PA ANTIMALARIALS chloroquine phosphate 2 GC COARTEM 4 DARAPRIM 3 MALARONE 3 mefloquine hcl 2 GC QUALAQUIN 4 ANTIRETROVIRAL AGENTS APTIVUS 3 ATRIPLA 5 NM COMBIVIR 3 CRIXIVAN 3 didanosine (generic of VIDEX EC) 2 GC EMTRIVA 3 EPIVIR 3 EPZICOM 3 FUZEON 5 NM INTELENCE 3 INVIRASE 3 ISENTRESS 5 NM KALETRA 3 LEXIVA 3 NORVIR 3 PREZISTA 75mg 3 PREZISTA 400mg, 600mg 5 NM RESCRIPTOR 3 RETROVIR IV INFUSION 3 REYATAZ 3 SELZENTRY 5 NM stavudine (generic of ZERIT) 2 GC SUSTIVA 3 TRIZIVIR 3 TRUVADA 3 VIDEX 3 VIRACEPT 3 VIRAMUNE 3 VIREAD 3 ZIAGEN 3 zidovudine (generic of RETROVIR) 2 GC ANTITUBERCULAR AGENTS CAPASTAT SULFATE 4 B/D


10

Drug Tier Notes ethambutol hcl (generic of MYAMBUTOL)

2 GC

isoniazid 100mg, 300mg 1 GC isoniazid 100mg/ml, 50mg/5ml 2 GC MYCOBUTIN 3 PASER 4 PRIFTIN 4 pyrazinamide 2 GC rifampin (generic of RIFADIN) 150mg, 300mg

2 GC

rifampin (generic of RIFADIN) 600mg

2 GC B/D

SEROMYCIN 4 TRECATOR 4 ANTIVIRALS acyclovir (generic of ZOVIRAX) 2 GC acyclovir sodium 2 GC B/DBARACLUDE 3 EPIVIR HBV 3 famciclovir (generic of FAMVIR) 2 GC ganciclovir 250mg 2 GC GANCICLOVIR 500mg 5 NM HEPSERA 5 NM PA REBETOL 5 NM PA RELENZA DISKHALER

QL (3 inhalers / 180 days) 3 QL

RIBAPAK 5 NM PA RIBASPHERE 5 NM PA RIBAVIRIN 5 NM PA ribavirin (hepatitis c) (generic of COPEGUS)

2 GC NM PA

rimantadine hydrochloride (generic of FLUMADINE)

2 GC

TAMIFLU 12mg/ml QL (10.5 bottles / 180 days)

3 QL

TAMIFLU 30mg QL (84 caps / 180 days)

3 QL

TAMIFLU 45mg, 75mg QL (42 caps / 180 days)

3 QL

TYZEKA 3 PA valacyclovir hcl (generic of VALTREX)

2 GC

VALCYTE 5 NM MISCELLANEOUS ALBENZA 3 ALINIA 100mg/5ml

QL (3 bottles / 30 days) 3 QL

ALINIA 500mg 3 QL

Drug Tier Notes QL (12 tabs / 30 days)

CLEOCIN 75mg 3 CLEOCIN PEDIATRIC GRANULE 3 clindamycin hcl (generic of CLEOCIN)

2 GC

clindamycin phosphate (generic of CLEOCIN PHOSPHATE)

2 GC B/D

colistimethate sodium (generic of COLY-MYCIN M)

2 GC B/D

CUBICIN 5 B/D NMdapsone 2 GC erythromycin-sulfisoxazole 2 GC FURADANTIN 4 INVANZ 3 B/D MACRODANTIN 3 mebendazole 2 GC MEPRON 5 NM metronidazole (generic of FLAGYL) 250mg, 500mg

1 GC

metronidazole (generic of FLAGYL) 375mg

2 GC

metronidazole in nacl 2 GC nitrofurantoin macrocrystal (generic of MACRODANTIN)

2 GC

nitrofurantoin monohyd macro (generic of MACROBID)

2 GC

PRIMAXIN I.M. 3 PRIMAXIN IV 3 B/D sulfamethoxazole-trimethoprim (generic of BACTRIM DS)

tablet

1 GC

sulfamethoxazole-trimethoprim 2 GC B/Dsulfamethoxazole-trimethoprim 2 GC TINDAMAX 3 trimethoprim 1 GC TYGACIL 5 B/D NMVANCOCIN HCL 5 NM vancomycin hcl 2 GC B/DVANCOMYCIN HCL ISO-OSMOTI 3 B/D ZYVOX 5 NM PA ANTINEOPLASTIC AGENTS ALKYLATING AGENTS BICNU 3 B/D BUSULFEX 3 B/D CEENU 3 cyclophosphamide 2 GC B/Ddacarbazine 2 GC B/DEMCYT 3


11

Drug Tier Notes HEXALEN 5 NM IFEX 3 B/D IFOSFAMIDE 5 B/D NMLEUKERAN 3 melphalan hcl (generic of ALKERAN) 2 GC B/DMUSTARGEN 3 B/D TREANDA 5 B/D NMANTHRACYCLINES daunorubicin hcl 2 GC B/DDOXIL 5 B/D NMdoxorubicin hcl 2 GC B/DEPIRUBICIN HCL 5 B/D NMidarubicin hcl (generic of IDAMYCIN PFS)

2 GC B/D

ANTIBIOTICS bleomycin sulfate 2 GC B/DCOSMEGEN 3 B/D mitomycin 2 GC B/DANTIMETABOLITES ALIMTA 5 B/D NMcytarabine 2 GC B/Dfluorouracil 2 GC B/DGEMZAR 3 B/D mercaptopurine (generic of PURINETHOL)

2 GC

methotrexate sodium 1gm, 25mg/ml 2 GC B/Dpentostatin (generic of NIPENT) 2 GC B/DTABLOID 3 VIDAZA 5 B/D NMANTIMITOTIC, TAXOIDS paclitaxel 2 GC B/DTAXOTERE 5 B/D NMANTIMITOTIC, VINCA ALKALOIDS VINBLASTINE SULFATE 3 B/D vincristine sulfate 2 GC B/Dvinorelbine tartrate (generic of NAVELBINE)

2 GC B/D

BIOLOGIC RESPONSE MODIFIERS AVASTIN 5 B/D NMCAMPATH 3 B/D HERCEPTIN 5 B/D NMISTODAX 5 B/D NMONTAK 3 B/D PROLEUKIN 5 B/D NMRITUXAN 5 NM PA VELCADE 5 B/D NMHORMONAL ANTINEOPLASTIC AGENTS

Drug Tier Notes ARIMIDEX 3 AROMASIN 3 bicalutamide (generic of CASODEX) 2 GC DEPO-PROVERA 3 B/D FARESTON 3 FASLODEX 5 B/D NMFEMARA 3 flutamide 2 GC leuprolide acetate 2 GC NM

PA LUPRON DEPOT 11.25mg, 3.75mg 3 NM PA LUPRON DEPOT 22.5mg, 30mg, 7.5mg

5 NM PA

LUPRON DEPOT-PED 5 NM PA MEGACE ES 3 megestrol acetate 2 GC NILANDRON 3 tamoxifen citrate 2 GC TRELSTAR DEPOT MIXJECT 3 B/D NMTRELSTAR LA MIXJECT 3 B/D NMKINASE INHIBITORS AFINITOR 5 NM PA GLEEVEC 5 NM PA NEXAVAR 5 NM SPRYCEL 5 NM SUTENT 5 NM PA TARCEVA 5 NM PA TASIGNA 5 NM TYKERB 5 NM VOTRIENT 5 NM PA MISCELLANEOUS DROXIA 3 ELSPAR 3 B/D hydroxyurea (generic of HYDREA) 2 GC IRINOTECAN 5 B/D NMLYSODREN 3 MATULANE 3 MITOXANTRONE HCL 5 B/D NMONCASPAR 3 B/D PHOTOFRIN 3 B/D TARGRETIN 75mg 5 NM PA TRETINOIN 10mg

capsule 5 NM

TRISENOX 3 B/D ZOLINZA 5 NM NUCLEOSIDE ANALOGS cladribine (generic of LEUSTATIN) 2 GC B/D


12

Drug Tier Notes FLUDARABINE PHOSPHATE 5 B/D NMPLATINUM COORDINATION COMPLEX carboplatin 2 GC B/Dcisplatin 2 GC B/DOXALIPLATIN 5 B/D NMPROTECTIVE AGENTS amifostine crystalline (generic of ETHYOL)

2 GC B/D

dexrazoxane (generic of ZINECARD) 2 GC B/DELITEK 5 B/D NMifosfamide & mesna 2 GC B/Dleucovorin calcium 100mg, 350mg 2 GC B/Dleucovorin calcium 25mg, 5mg 2 GC LEUCOVORIN CALCIUM 10mg, 15mg

3

mesna (generic of MESNEX) 2 GC B/DMESNEX 3 TOPOISOMERASE INHIBITORS etoposide 2 GC B/DHYCAMTIN

injection 3 B/D

CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl (generic of LOTREL)

2 GC

benazepril & hydrochlorothiazide 2 GC captopril & hydrochlorothiazide 2 GC enalapril maleate & hydrochlorothiazide

2 GC

fosinopril sodium & hydrochlorothiazide

2 GC

lisinopril & hydrochlorothiazide (generic of PRINZIDE)

2 GC

LOTREL 5-40mg, 10-40mg

3

moexipril-hydrochlorothiazide (generic of UNIRETIC)

2 GC

quinapril-hydrochlorothiazide (generic of ACCURETIC)

2 GC

TARKA 4 trandolapril-verapamil hcl (generic of TARKA)

2 GC

ACE INHIBITORS benazepril hcl (generic of LOTENSIN)

1 GC

captopril 1 GC enalapril maleate (generic of VASOTEC)

1 GC

Drug Tier Notes fosinopril sodium 2 GC lisinopril (generic of PRINIVIL) 2 GC moexipril hcl (generic of UNIVASC) 2 GC perindopril erbumine (generic of ACEON)

2 GC

quinapril hcl (generic of ACCUPRIL) 2 GC ramipril (generic of ALTACE) 2 GC trandolapril (generic of MAVIK) 2 GC ADRENOLYTICS, CENTRAL clonidine hcl (generic of CATAPRES) .1mg, .2mg, .3mg

1 GC

clonidine hcl (generic of CATAPRES-TTS-1) .1mg/24hr, .2mg/24hr, .3mg/24hr

2 GC

guanfacine hcl (generic of TENEX) 2 GC ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone (generic of INSPRA) 2 GC PA spironolactone (generic of ALDACTONE)

2 GC

ALPHA BLOCKERS doxazosin mesylate (generic of CARDURA)

1 GC

prazosin hcl (generic of MINIPRESS) 2 GC terazosin hcl 2 GC ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS ATACAND HCT 4 DIOVAN HCT 3 EXFORGE 3 EXFORGE HCT 3 losartan potassium & hydrochlorothiazide (generic of HYZAAR)

2 GC

MICARDIS HCT 4 TEVETEN HCT 4 VALTURNA 3 ANGIOTENSIN II RECEPTOR ANTAGONISTS ATACAND 4 BENICAR 3 BENICAR HCT 3 DIOVAN 3 losartan potassium (generic of COZAAR)

2 GC

MICARDIS 4 TEVETEN 4


13

Drug Tier Notes ANTIARRHYTHMICS amiodarone hcl (generic of CORDARONE) 200mg, 400mg

2 GC

amiodarone hcl 50mg/ml 2 GC B/Ddisopyramide phosphate (generic of NORPACE)

2 GC

flecainide acetate (generic of TAMBOCOR)

2 GC

mexiletine hcl 2 GC MULTAQ 3 NORPACE CR 3 PACERONE 3 propafenone hcl (generic of RYTHMOL)

2 GC

quinidine gluconate 2 GC quinidine sulfate 2 GC RYTHMOL SR 3 sotalol hcl (generic of BETAPACE) 2 GC TIKOSYN 3 NM ANTILIPEMICS ADVICOR 4 ALTOPREV 20mg


ALTOPREV 40mg, 60mg 4 ANTARA 3 cholestyramine light (generic of QUESTRAN LIGHT)

2 GC

colestipol hcl (generic of COLESTID) 2 GC CRESTOR 10mg, 20mg, 5mg


CRESTOR 40mg 3 fenofibrate (generic of LOFIBRA) 2 GC fenofibrate micronized (generic of LOFIBRA)

2 GC

gemfibrozil (generic of LOPID) 2 GC LESCOL 4 LESCOL XL 4 LIPITOR 10mg, 20mg, 40mg


LIPITOR 80mg 3 lovastatin (generic of MEVACOR) 2 GC NIASPAN 3 pravastatin sodium (generic of PRAVACHOL) 10mg, 20mg, 40mg


2 GC QL

pravastatin sodium (generic of PRAVACHOL) 80mg

2 GC

SIMCOR 4

Drug Tier Notes simvastatin (generic of ZOCOR) 10mg, 20mg, 40mg, 5mg


2 GC QL

simvastatin (generic of ZOCOR) 80mg

2 GC

TRICOR 3 TRILIPIX 3 VYTORIN 4 WELCHOL 3 ZETIA 3 ST BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone (generic of TENORETIC 100)

1 GC

bisoprolol & hydrochlorothiazide (generic of ZIAC)

1 GC

metoprolol & hydrochlorothiazide 2 GC BETA-BLOCKERS acebutolol hcl (generic of SECTRAL) 2 GC atenolol (generic of TENORMIN) 1 GC bisoprolol fumarate (generic of ZEBETA)

2 GC

BYSTOLIC 3 carvedilol (generic of COREG) 2 GC COREG CR 3 labetalol hcl (generic of TRANDATE) 100mg, 200mg, 300mg

2 GC

labetalol hcl (generic of TRANDATE) 5mg/ml

2 GC B/D

metoprolol succinate (generic of TOPROL XL)

2 GC

metoprolol tartrate (generic of LOPRESSOR) 100mg, 25mg, 50mg

1 GC

metoprolol tartrate (generic of LOPRESSOR) 1mg/ml

2 GC B/D

nadolol (generic of CORGARD) 2 GC pindolol 1 GC propranolol hcl 10mg, 20mg, 40mg, 80mg

1 GC

propranolol hcl (generic of INDERAL LA) 120mg, 160mg, 20mg/5ml, 40mg/5ml, 60mg

2 GC

propranolol hcl 1mg/ml 2 GC B/Dpropranolol hcl (generic of INDERAL LA) 80mg

ext rel

2 GC

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS


14

Drug Tier Notes CADUET 4 CALCIUM CHANNEL BLOCKERS amlodipine besylate (generic of NORVASC)

2 GC

CARDIZEM CD 360mg

3

diltiazem hcl (generic of CARDIZEM) 120mg, 30mg, 60mg, 90mg

1 GC

diltiazem hcl 120mg, 180mg, 240mg, 60mg, 90mg

ext rel

2 GC

diltiazem hcl 25mg/5ml 2 GC B/Ddiltiazem hcl coated beads (generic of CARDIZEM CD)

ext rel

2 GC

diltiazem hcl extended release beads (generic of TIAZAC)

ext rel

2 GC

felodipine 2 GC isradipine 2 GC nifedipine (generic of PROCARDIA) 2 GC NIMODIPINE 5 NM nisoldipine 2 GC verapamil hcl (generic of CALAN) 120mg, 40mg, 80mg

1 GC

verapamil hcl (generic of VERELAN PM) 100mg, 180mg, 200mg, 240mg, 300mg

2 GC

verapamil hcl (generic of CALAN SR) 120mg

ext rel

2 GC

verapamil hcl 2.5mg/ml 2 GC B/DDIGITALIS GLYCOSIDES digoxin (generic of LANOXIN) .125mg, .25mg

1 GC

digoxin .05mg/ml, .25mg/ml 2 GC LANOXIN 3 DIRECT RENIN INHIBITORS TEKTURNA 3 TEKTURNA HCT 3 DIURETICS acetazolamide 2 GC ALDACTAZIDE

50/50 3

amiloride & hydrochlorothiazide 1 GC amiloride hcl (generic of MIDAMOR) 2 GC bumetanide .25mg/ml 2 GC B/Dbumetanide .5mg, 1mg, 2mg 2 GC

Drug Tier Notes chlorothiazide 1 GC chlorthalidone 1 GC furosemide 10mg/ml, 20mg, 40mg, 80mg

1 GC

furosemide 10mg/ml 2 GC B/Dhydrochlorothiazide 1 GC indapamide 1 GC methazolamide (generic of NEPTAZANE)

2 GC

metolazone 2 GC spironolactone & hydrochlorothiazide(generic of ALDACTAZIDE)

1 GC

THALITONE 3 torsemide (generic of DEMADEX) 100mg, 10mg, 20mg, 5mg

2 GC

TORSEMIDE 20mg/2ml injection

3 B/D

triamterene & hydrochlorothiazide 1 GC MISCELLANEOUS BIDIL 3 hydralazine hcl 100mg, 10mg, 25mg, 50mg

2 GC

hydralazine hcl 20mg/ml 2 GC B/Dmethyldopa 2 GC midodrine hcl (generic of PROAMATINE)

2 GC

minoxidil 2 GC RANEXA 3 PA NITRATES ISORDIL TITRADOSE 3 isosorbide dinitrate 10mg, 2.5mg, 20mg, 30mg, 5mg

1 GC

isosorbide dinitrate 40mg 2 GC isosorbide mononitrate (generic of MONOKET)

2 GC

NITRO-DUR .3mg,.8mg

3

nitroglycerin (generic of NITRO-DUR)

2 GC

NITROLINGUAL PUMPSPRAY 3 NITROSTAT 3 PULMONARY ARTERIAL HYPERTENSION ADCIRCA 5 NM PA LETAIRIS 5 NM PA REVATIO 5 NM PA TRACLEER 5 NM LA

PA


15

Drug Tier Notes CENTRAL NERVOUS SYSTEM ANTIANXIETY buspirone hcl 2 GC fluvoxamine maleate 100mg 2 GC fluvoxamine maleate 25mg, 50mg


meprobamate 2 GC ANTICONVULSANTS BANZEL 4 PA carbamazepine (generic of TEGRETOL)

2 GC

CARBATROL 4 CELONTIN 3 DILANTIN 3 DILANTIN INFATABS 3 divalproex sodium (generic of DEPAKOTE SPRINKLES)

2 GC

ethosuximide (generic of ZARONTIN)

2 GC

FELBATOL 4 gabapentin (generic of NEURONTIN) 100mg

QL (1080 caps / 30 days) ext rel

2 GC QL

gabapentin (generic of NEURONTIN) 300mg


2 GC QL



2 GC QL


QL (180 tabs / 30 days) ext rel

2 GC QL


QL (120 tabs / 30 days) ext rel

2 GC QL

GABITRIL 4 KEPPRA

injection 3 B/D

lamotrigine (generic of LAMICTAL) 2 GC levetiracetam (generic of KEPPRA) 2 GC LYRICA 100mg, 150mg, 200mg, 225mg, 25mg, 50mg, 75mg

QL (120 caps / 30 days)

3 QL ST

LYRICA 300mg 3 QL ST

Drug Tier Notes QL (60 caps / 30 days)

NEURONTIN QL (5 bottles / 30 days)

solution

3 QL

oxcarbazepine (generic of TRILEPTAL)

2 GC

PEGANONE 3 phenytoin (generic of DILANTIN) 2 GC phenytoin sodium 2 GC B/Dphenytoin sodium extended (generic of DILANTIN)

2 GC

primidone (generic of MYSOLINE) 2 GC SABRIL 5 NM PA TEGRETOL-XR 3 topiramate (generic of TOPAMAX) 2 GC valproate sodium (generic of DEPACON)

2 GC

valproic acid (generic of DEPAKENE)

2 GC

VIMPAT 3 PA zonisamide (generic of ZONEGRAN) 2 GC ANTIDEMENTIA ARICEPT 10mg 3 ARICEPT 5mg


ARICEPT ODT 10mg 3 ARICEPT ODT 5mg


EXELON 1.5mg QL (240 caps / 30 days)

3 QL

EXELON 2mg/ml QL (2 bottles / 30 days)

3 QL

EXELON 3mg QL (120 caps / 30 days)

3 QL

EXELON 4.5mg, 6mg QL (60 caps / 30 days)

3 QL

EXELON 4.6mg/24hr, 9.5mg/24hr QL (30 ea / 30 days)

patch

3 QL

galantamine hydrobromide (generic of RAZADYNE) 12mg, 4mg


2 GC QL

galantamine hydrobromide (generic of RAZADYNE ER) 16mg, 24mg, 4mg/ml, 8mg

2 GC

galantamine hydrobromide (generic of RAZADYNE ER) 8mg

QL (30 cap / 30 days)

2 GC QL

NAMENDA 3


16

Drug Tier Notes NAMENDA TITRATION PAK 3 ANTIDEPRESSANTS amitriptyline hcl 1 GC AMOXAPINE 3 bupropion hcl (generic of WELLBUTRIN)

2 GC

citalopram hydrobromide (generic of CELEXA) 10mg, 20mg


1 GC QL

citalopram hydrobromide (generic of CELEXA) 40mg

1 GC

citalopram hydrobromide 10mg/5ml 2 GC clomipramine hcl (generic of ANAFRANIL)

2 GC

CYMBALTA QL (30 ea / 30 days)

3 QL

desipramine hcl (generic of NORPRAMIN)

2 GC

doxepin hcl 1 GC EFFEXOR XR 150mg 3 EFFEXOR XR 37.5mg, 75mg


EMSAM QL (30 ea / 30 days)

3 QL PA

fluoxetine hcl 10mg QL (45 tabs / 30 days)

2 GC QL

fluoxetine hcl (generic of PROZAC) 10mg, 20mg

QL (30 caps / 30 days)

2 GC QL

fluoxetine hcl (generic of RAPIFLUX) 20mg, 20mg/5ml, 40mg

2 GC

imipramine hcl (generic of TOFRANIL)

2 GC

LEXAPRO 10mg, 5mg QL (45 tabs / 30 days)

3 QL

LEXAPRO 20mg, 5mg/5ml 3 maprotiline hcl 2 GC MARPLAN 3 mirtazapine (generic of REMERON SOLTAB) 15mg, 7.5mg


2 GC QL

mirtazapine (generic of REMERON) 30mg, 45mg

2 GC

NARDIL 3 nefazodone hcl 2 GC nortriptyline hcl (generic of PAMELOR) 10mg, 25mg, 50mg, 75mg

1 GC

nortriptyline hcl 10mg/5ml 2 GC

Drug Tier Notes paroxetine hcl (generic of PAXIL) 10mg, 20mg


2 GC QL

paroxetine hcl (generic of PAXIL) 10mg/5ml, 25mg, 30mg, 40mg

2 GC

paroxetine hcl (generic of PAXIL CR) 12.5mg


2 GC QL

PRISTIQ 100mg 3 PRISTIQ 50mg


protriptyline hcl (generic of VIVACTIL)

2 GC

sertraline hcl (generic of ZOLOFT) 100mg, 20mg/ml

2 GC

sertraline hcl (generic of ZOLOFT) 25mg, 50mg


2 GC QL

SURMONTIL 3 tranylcypromine sulfate (generic of PARNATE)

2 GC

trazodone hcl 100mg, 150mg, 50mg 1 GC trazodone hcl 300mg 2 GC venlafaxine hcl 2 GC ANTIPARKINSONIAN AGENTS amantadine hcl 2 GC APOKYN 5 NM AZILECT 3 benztropine mesylate .5mg, 1mg, 2mg

1 GC

benztropine mesylate (generic of COGENTIN) 1mg/ml

2 GC

bromocriptine mesylate (generic of PARLODEL)

2 GC

carbidopa-levodopa (generic of SINEMET)

2 GC

COMTAN 3 pramipexole dihydrochloride (generic of MIRAPEX)

2 GC

REQUIP XL 4 ropinirole hydrochloride (generic of REQUIP)

2 GC

selegiline hcl (generic of ELDEPRYL)

2 GC

STALEVO 100 3 STALEVO 125 3 STALEVO 150 3 STALEVO 200 3


17

Drug Tier Notes STALEVO 50 3 STALEVO 75 3 trihexyphenidyl hcl 2 GC ANTIPSYCHOTICS ABILIFY 10mg, 15mg, 5mg

QL (30 tabs / 30 days) 4 QL ST

ABILIFY 1mg/ml, 20mg, 2mg, 30mg 4 ST ABILIFY 9.75mg/1.3ml 4 B/D ABILIFY DISCMELT 4 ST chlorpromazine hcl 100mg, 10mg, 200mg, 25mg, 50mg

2 GC

CHLORPROMAZINE HCL 25mg/ml 3 clozapine (generic of CLOZARIL) 100mg, 25mg, 50mg

2 GC

CLOZAPINE 200mg 2 GC FANAPT 4 ST FANAPT TITRATION PACK 4 ST FAZACLO 4 PA fluphenazine decanoate 2 GC fluphenazine hcl 2 GC GEODON 20mg

injection 3 B/D

GEODON 20mg QL (240 caps / 30 days)

3 QL

GEODON 40mg QL (120 caps / 30 days)

3 QL

GEODON 60mg, 80mg QL (60 caps / 30 days)

3 QL

haloperidol 2 GC haloperidol decanoate (generic of HALDOL DECANOATE 100)

2 GC B/D

haloperidol lactate 2 GC INVEGA 1.5mg, 3mg

QL (30 ea / 30 days) 4 QL ST

INVEGA 6mg, 9mg 4 ST INVEGA SUSTENNA 39mg/0.25ml, 78mg/0.5ml

4 PA

INVEGA SUSTENNA 117mg/0.75ml, 156mg/ml, 234mg/1.5ml

5 NM PA

loxapine succinate (generic of LOXITANE)

2 GC

NAVANE 3 ORAP 3 perphenazine 2 GC RISPERDAL CONSTA 12.5mg, 25mg


3 QL PA

RISPERDAL CONSTA 37.5mg, 5 QL NM

Drug Tier Notes 50mg

QL (2 vials / 30 days) PA

risperidone .25mg, .5mg QL (90 tabs / 30 days)

2 GC QL

risperidone (generic of RISPERDAL M-TAB) 1mg, 2mg, 3mg


2 GC QL

risperidone (generic of RISPERDAL) 1mg/ml, 4mg

2 GC

SAPHRIS 4 ST SEROQUEL 100mg


SEROQUEL 200mg QL (120 tabs / 30 days)

3 QL


3 QL

SEROQUEL 300mg, 400mg QL (60 tabs / 30 days)

3 QL


3 QL

SEROQUEL XR 150mg, 200mg QL (30 ea / 30 days)

3 QL

SEROQUEL XR 300mg, 400mg QL (60 ea / 30 days)

3 QL

SEROQUEL XR 50mg QL (120 ea / 30 days)

3 QL

thioridazine hcl 2 GC thiothixene (generic of NAVANE) 2 GC trifluoperazine hcl 2 GC ZYPREXA 10mg, 15mg, 20mg 3 ZYPREXA 10mg

injection 3 B/D

ZYPREXA 2.5mg, 5mg, 7.5mg QL (30 tabs / 30 days)

3 QL

ZYPREXA ZYDIS 10mg, 15mg, 20mg

3

ZYPREXA ZYDIS 5mg QL (30 ea / 30 days)

3 QL

ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine (generic of ADDERALL)

2 GC PA

CONCERTA 4 PA dexmethylphenidate hcl (generic of FOCALIN)

2 GC PA

dextroamphetamine sulfate (generic of DEXEDRINE) 10mg, 15mg, 5mg

ext rel

2 GC

dextroamphetamine sulfate 10mg, 2 GC PA


18

Drug Tier Notes 5mg METADATE CD 4 PA METHYLIN 4 PA methylphenidate hcl (generic of RITALIN) 10mg, 20mg, 5mg

2 GC PA

methylphenidate hcl 10mg, 20mg ext rel

2 GC

RITALIN LA 4 PA STRATTERA 3 PA HYPNOTICS LUNESTA

QL (180 tabs / year) 4 QL

zaleplon (generic of SONATA) QL (180 caps / year)

2 GC QL

zolpidem tartrate (generic of AMBIEN)

QL (180 tabs / year)

2 GC QL

MIGRAINE dihydroergotamine mesylate (generic of D.H.E. 45)

2 GC

ergotamine w/ caffeine (generic of CAFERGOT)

2 GC

FROVA QL (18 tabs / 30 days)

4 QL

MAXALT QL (12 tabs / 30 days)

3 QL

MAXALT-MLT QL (12 ea / 30 days)

3 QL

MIGERGOT 3 RELPAX


sumatriptan succinate (generic of IMITREX) 100mg, 25mg, 50mg


2 GC QL

sumatriptan succinate 4mg/0.5ml, 6mg/0.5ml


2 GC QL

ZOMIG 2.5mg, 5mg QL (12 tabs / 30 days)

4 QL

ZOMIG 5mg QL (2 bottles / 30 days)

4 QL

ZOMIG ZMT QL (12 ea / 30 days)

4 QL

MISCELLANEOUS GUANIDINE HCL 3 lithium carbonate (generic of LITHIUM CARBONATE)

2 GC

LITHIUM CITRATE 3 MESTINON 3

Drug Tier Notes MESTINON TIMESPAN 3 pyridostigmine bromide (generic of MESTINON)

2 GC

REGONOL 3 B/D RILUTEK 5 NM SAVELLA


SAVELLA TITRATION PACK QL (1 kit / 30 days)

3 QL

XENAZINE 5 NM PA MULTIPLE SCLEROSIS AGENTS AMPYRA 5 NM PA AVONEX 5 NM PA BETASERON 5 NM PA COPAXONE 5 NM PA EXTAVIA 5 NM PA REBIF 5 NM PA REBIF TITRATION PACK 5 NM PA MUSCULOSKELETAL THERAPY AGENTSbaclofen 2 GC carisoprodol (generic of SOMA) 1 GC chlorzoxazone (generic of PARAFON FORTE DSC)

1 GC

cyclobenzaprine hcl (generic of FLEXERIL)

2 GC

dantrolene sodium (generic of DANTRIUM)

2 GC

metaxalone (generic of SKELAXIN) 2 GC methocarbamol (generic of ROBAXIN)

1 GC

orphenadrine citrate 2 GC ORPHENADRINE COMPOUND DS 3 orphenadrine w/ aspirin & caff 2 GC ROBAXIN

injection 3 B/D

tizanidine hcl 2 GC NARCOLEPSY/CATAPLEXY PROVIGIL 100mg

QL (90 tabs / 30 days) 3 QL PA

PROVIGIL 200mg QL (60 tabs / 30 days)

3 QL PA

XYREM 5 NM LA PA

PSYCHOTHERAPEUTIC-MISCELLANEOUS ANTABUSE 3 buprenorphine hcl (generic of SUBUTEX)

2 GC PA


19

Drug Tier Notes bupropion hcl (smoking deterrent) (generic of ZYBAN)

2 GC

CAMPRAL 3 PA CHANTIX 4 PA naloxone hcl 2 GC B/Dnaltrexone hcl (generic of REVIA) 2 GC NICOTROL INHALER 4 PA NICOTROL NS 4 PA perphenazine-amitriptyline 2 GC SUBOXONE 3 PA ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM

QL (30 ea / 30 days) 3 QL PA

ANDROGEL 3 PA oxandrolone (generic of OXANDRIN) 2.5mg

2 GC PA

OXANDROLONE 10mg 5 NM PA TESTIM 4 PA testosterone cypionate (generic of DEPO-TESTOSTERONE)

2 GC

testosterone enanthate (generic of DELATESTRYL)

2 GC

ANTIDIABETICS acarbose (generic of PRECOSE) 2 GC ACTOPLUS MET


ACTOS 3 ALCOHOL PREPS

QL (100 pads / 30 days) 3 QL

APIDRA 3 APIDRA SOLOSTAR 3 AVANDAMET


AVANDAMET QL (120 tabs / 30 days)

3 QL

AVANDARYL QL (30 tabs / 30 days)

3 QL

AVANDARYL QL (60 tabs / 30 days)

3 QL

AVANDIA 3 BYETTA

QL (1 pen / 30 days) 3 QL PA

DUETACT QL (30 tabs / 30 days)

3 QL

GAUZE PADS AND DRESSINGS - PADS 2 X 2

QL (100 / 30 days)

3 QL

Drug Tier Notes glimepiride (generic of AMARYL) 2 GC glipizide (generic of GLUCOTROL) 10mg, 5mg

1 GC

glipizide (generic of GLUCOTROL XL) 10mg, 2.5mg, 5mg

2 GC

glipizide-metformin hcl (generic of METAGLIP)

2 GC

glyburide 2 GC glyburide micronized (generic of GLYNASE)

1 GC

glyburide-metformin (generic of GLUCOVANCE)

2 GC

HUMALOG 3 HUMALOG MIX 50/50 3 HUMALOG MIX 50/50 PEN 3 HUMALOG MIX 75/25 3 HUMALOG MIX 75/25 PEN 3 HUMALOG PEN 3 HUMULIN 70/30 3 HUMULIN 70/30 PEN 3 HUMULIN N 3 HUMULIN N U-100 PEN 3 HUMULIN R 3 HUMULIN R U-500 (CONCENTR 3 INSULIN PEN NEEDLE

QL (100 / 30 days) 3 QL

INSULIN SYRINGE (DISP) U-100 0.3 ML

QL (100 / 30 days)

3 QL

INSULIN SYRINGE (DISP) U-100 1 ML

QL (100 / 30 days)

3 QL

INSULIN SYRINGE (DISP) U-100 1/2 ML

QL (100 / 30 days)

3 QL

JANUMET 3 JANUVIA 3 LANTUS 4 LANTUS SOLOSTAR 4 LEVEMIR 3 LEVEMIR FLEXPEN 3 metformin hcl (generic of GLUCOPHAGE)

2 GC

nateglinide (generic of STARLIX) 2 GC NEEDLES, INSULIN DISP., SAFETY

QL (100 / 30 days)

3 QL


20

Drug Tier Notes NOVOLIN 70/30 3 NOVOLIN 70/30 INNOLET 3 NOVOLIN N 3 NOVOLIN N INNOLET 3 NOVOLIN R 3 NOVOLOG 3 NOVOLOG FLEXPEN 3 NOVOLOG MIX 70/30 3 NOVOLOG MIX 70/30 PREFILL 3 ONGLYZA 3 PRANDIN 3 RELION R 3 SYMLIN 3 PA SYMLINPEN 120 3 PA SYMLINPEN 60 3 PA BISPHOSPHONATES ACTONEL 4 alendronate sodium (generic of FOSAMAX) 10mg, 40mg, 5mg

2 GC

alendronate sodium (generic of FOSAMAX) 35mg, 70mg


2 GC QL

BONIVA 3 ZOMETA 5 NM CALCITONINS calcitonin (salmon) (generic of MIACALCIN)

2 GC

MIACALCIN injection

3

CALCIUM RECEPTOR ANTAGONISTS SENSIPAR 30mg 3 NM SENSIPAR 60mg, 90mg 5 NM CHELATING AGENTS EXJADE 5 NM PA sodium polystyrene sulfonate (generic of KAYEXALATE)

2 GC

SYPRINE 3 CONTRACEPTIVES desogestrel & ethinyl estradiol (generic of DESOGEN)

2 GC

desogestrel-ethinyl estradiol (triphasic) (generic of CYCLESSA)

2 GC

drospirenone-ethinyl estradiol 2 GC ethynodiol diacet & eth estrad 2 GC levonorgestrel & eth estradiol 2 GC levonorgestrel (emergency oc) (generic of PLAN B)

2 GC

Drug Tier Notes levonorgestrel-eth estradiol (triphasic)

2 GC

levonorgestrel-ethinyl estradiol (91-day) (generic of SEASONALE)

2 GC

medroxyprogesterone acetate (contraceptive) (generic of DEPO-PROVERA CONTRACEPTIV)

QL (1 vial / 90 days)

2 GC B/D QL

NECON 10/11-28 3 norethin acet & estrad-fe (generic of LOESTRIN FE 1.5/30)

2 GC

norethindrone & eth estradiol (generic of NORINYL 1+35)

2 GC

norethindrone (contraceptive) (generic of NOR-QD)

2 GC

norethindrone acet & eth estra (generic of LOESTRIN 1/20-21)

2 GC

norethindrone acetate-ethinyl estradiol-fe (generic of ESTROSTEP FE)

2 GC

norethindrone-eth estradiol (triphasic) (generic of ORTHO-NOVUM 7/7/7-28)

2 GC

norgestimate-ethinyl estradiol (generic of ORTHO-CYCLEN)

2 GC

norgestimate-ethinyl estradiol (triphasic) (generic of ORTHO TRI-CYCLEN)

2 GC

norgestrel & ethinyl estradiol (generic of LO/OVRAL)

2 GC

NUVARING 3 ORTHO EVRA 3 ORTHO TRI-CYCLEN LO 3 ENDOMETRIOSIS danazol 2 GC SYNAREL 3 ENZYME REPLACEMENTS ADAGEN 5 NM PA ALDURAZYME 5 NM PA BUPHENYL 5 NM CEREZYME 5 NM PA CYSTADANE 3 CYSTAGON 3 NM ELAPRASE 5 NM PA FABRAZYME 5 NM PA KUVAN 5 NM levocarnitine (metabolic modifiers) (generic of CARNITOR)

2 GC

MYOZYME 5 NM PA


21

Drug Tier Notes NAGLAZYME 5 NM PA ORFADIN 5 NM PA SUCRAID 5 NM PA VPRIV 5 NM PA ZAVESCA 5 NM PA ESTROGEN/PROGESTINS CLIMARA PRO 3 COMBIPATCH 3 FEMHRT 1/5 4 FEMHRT LOW DOSE 4 PREFEST 4 PREMPHASE 3 PREMPRO 3 ESTROGENS ALORA 3 CENESTIN 4 ESTRACE

cream 4

ESTRADERM 3 estradiol (generic of ESTRACE) .5mg, 1mg, 2mg

1 GC

estradiol (generic of CLIMARA) .025mg/24hr, .05mg/24hr, .06mg/24hr, .075mg/24hr, .1mg/24hr, 37.5mcg/24hr

2 GC

ESTRING 4 estropipate 1 GC FEMRING 4 GYNODIOL 3 PREMARIN .3mg, .45mg, .625mg, .9mg, 1.25mg

3

PREMARIN 25mg 3 B/D PREMARIN W/APPLICATOR 3 VAGIFEM 3 VIVELLE-DOT 3 GLUCOCORTICOIDS cortisone acetate 2 GC dexamethasone .5mg, .75mg, 1.5mg, 1mg, 2mg, 4mg, 6mg

1 GC

dexamethasone .5mg/5ml 2 GC DEXAMETHASONE INTENSOL 3 dexamethasone sodium phosphate 2 GC B/Dfludrocortisone acetate 2 GC hydrocortisone (generic of CORTEF) 2 GC hydrocortisone sod succinate (generic of SOLU-CORTEF)

2 GC B/D

methylprednisolone (generic of 1 GC

Drug Tier Notes MEDROL DOSEPAK) 4mg methylprednisolone (generic of MEDROL) 16mg, 32mg, 8mg

2 GC

methylprednisolone acetate (generic of DEPO-MEDROL)

2 GC B/D

methylprednisolone sod succ (generic of SOLU-MEDROL)

2 GC B/D

prednisolone 2 GC prednisolone sodium phosphate (generic of ORAPRED)

2 GC

prednisone 10mg, 1mg, 2.5mg, 20mg, 50mg, 5mg

1 GC

prednisone 5mg/5ml 2 GC PREDNISONE INTENSOL 3 SOLU-CORTEF 3 B/D GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 3 GLUCAGON EMERGENCY KIT 3 PROGLYCEM 3 HUMAN GROWTH HORMONES INCRELEX 5 NM PA NORDITROPIN CARTRIDGE 5 NM PA NORDITROPIN NORDIFLEX PEN 5 NM PA SAIZEN 5 NM PA SAIZEN CLICK.EASY 5 NM PA TEV-TROPIN 5 NM PA MISCELLANEOUS cabergoline 2 GC chorionic gonadotropin 2 GC NM

PA octreotide acetate (generic of SANDOSTATIN) 50mcg/ml

2 GC NM PA

OCTREOTIDE ACETATE 1000mcg/ml, 100mcg/ml, 200mcg/ml, 500mcg/ml

5 NM PA

SANDOSTATIN LAR DEPOT 5 NM PA SOMATULINE DEPOT 5 NM PA SOMAVERT 5 NM PA PARATHYROID HORMONES FORTEO 5 NM PA PHOSPHATE BINDER AGENTS calcium acetate (phosphate binder) (generic of PHOSLO)

2 GC

FOSRENOL 3 PHOSLO 3 RENAGEL 3 RENVELA 3 PROGESTINS


22

Drug Tier Notes medroxyprogesterone acetate (generic of PROVERA)

1 GC

norethindrone acetate (generic of AYGESTIN)

2 GC

PROMETRIUM 4 SELECTIVE ESTROGEN RECEPTOR MODULATORS EVISTA 3 THYROID AGENTS levothyroxine sodium (generic of SYNTHROID)

1 GC

liothyronine sodium (generic of CYTOMEL)

2 GC

methimazole (generic of TAPAZOLE)

2 GC

propylthiouracil 2 GC SYNTHROID 3 VASOPRESSINS desmopressin acetate (generic of DDAVP)

2 GC

desmopressin acetate refrigerated (generic of DDAVP)

2 GC

desmopressin acetate spray refrigerated

2 GC

GASTROINTESTINAL ANTIDIARRHEALS diphenoxylate w/ atropine (generic of LOMOTIL)

1 GC

diphenoxylate w/ atropine 2 GC loperamide hcl 1 GC ANTIEMETICS DRONABINOL 2.5mg

QL (60 caps / 30 days) 4 QL PA

DRONABINOL 10mg, 5mg QL (60 caps / 30 days)

5 QL NM PA

EMEND 80mg QL (4 caps / 30 days)

3 QL PA

EMEND 125mg QL (2 caps / 30 days)

3 QL PA

EMEND 40mg 3 granisetron hcl 2 GC B/Dmeclizine hcl (generic of ANTIVERT) 2 GC metoclopramide hcl (generic of REGLAN) 10mg, 5mg, 5mg/5ml

1 GC

metoclopramide hcl (generic of REGLAN) 5mg/ml

2 GC B/D

ondansetron (generic of ZOFRAN ODT)

2 GC PA

Drug Tier Notes ondansetron hcl 2 GC PA prochlorperazine 2 GC prochlorperazine edisylate 2 GC prochlorperazine maleate 1 GC promethazine hcl 6.25mg/5ml 1 GC promethazine hcl 12.5mg, 25mg, 50mg

2 GC

promethazine hcl (generic of PHENERGAN) 25mg/ml, 50mg/ml

2 GC B/D

SANCUSO QL (2 patch / 15 days)

3 QL PA

TRANSDERM-SCOP 3 trimethobenzamide hcl (generic of TIGAN)

2 GC

ANTISPASMODICS dicyclomine hcl (generic of BENTYL) 10mg, 20mg

1 GC

dicyclomine hcl (generic of BENTYL) 10mg/5ml

2 GC

dicyclomine hcl (generic of BENTYL) 10mg/ml

2 GC B/D

glycopyrrolate (generic of ROBINUL) .2mg/ml

2 GC B/D

glycopyrrolate (generic of ROBINUL) 1mg, 2mg

2 GC

H2-RECEPTOR ANTAGONISTS cimetidine 1 GC cimetidine hcl 150mg/ml 2 GC B/Dcimetidine hcl 300mg/5ml 2 GC famotidine (generic of PEPCID I.V.) 10mg/ml

2 GC B/D

famotidine (generic of PEPCID) 20mg, 40mg

2 GC

famotidine in nacl (generic of PEPCID PREMIXED)

2 GC B/D

PEPCID suspension

3

ranitidine hcl (generic of ZANTAC) 150mg, 15mg/ml, 300mg

2 GC

ranitidine hcl (generic of ZANTAC) 150mg/6ml

2 GC B/D

INFLAMMATORY BOWEL DISEASE APRISO 3 ASACOL 4 CANASA 3 CIMZIA 5 NM PA DIPENTUM 4 ENTOCORT EC 4


23

Drug Tier Notes hydrocortisone (intrarectal) (generic of CORTENEMA)

2 GC

LIALDA 3 mesalamine 2 GC PENTASA 3 sulfasalazine (generic of AZULFIDINE EN-TABS)

2 GC

LAXATIVES HALFLYTELY BOWEL PREP 3 KRISTALOSE 4 lactulose 2 GC lactulose (encephalopathy) 2 GC peg 3350-kcl-sod bicarb-sod chloride-sod sulfate (generic of COLYTE-FLAVOR PACKS)

2 GC

peg 3350-potassium chloride-sod bicarbonate-sod chloride (generic of NULYTELY/FLAVOR PACKS)

2 GC

polyethylene glycol 3350 2 GC RELISTOR 3 PA VISICOL 4 MISCELLANEOUS AMITIZA

QL (60 caps / 30 days) 3 QL ST

CARAFATE suspension

3

GASTROCROM 3 LOTRONEX 3 misoprostol (generic of CYTOTEC) 2 GC sucralfate (generic of CARAFATE) 2 GC ursodiol (generic of URSO 250) 2 GC PANCREATIC ENZYMES CREON 3 ZENPEP 3 PROTON PUMP INHIBITOR/ANTI-INFECTIVE COMBINATIONS PREVPAC

QL (1 box / year) 3 QL

PROTON PUMP INHIBITORS DEXILANT

QL (90 days per year) 3 QL

LANSOPRAZOLE QL (90 days per year)

4 QL

NEXIUM QL (90 days per year)

3 QL

NEXIUM I.V. 3 B/D omeprazole (generic of PRILOSEC)

QL (90 days per year) 2 GC QL

Drug Tier Notes PANTOPRAZOLE SODIUM

QL (90 days per year) 4 QL

ZEGERID QL (90 days per year)

4 QL

GENITOURINARY BENIGN PROSTATIC HYPERPLASIA AVODART 3 finasteride (generic of PROSCAR) 2 GC tamsulosin hcl (generic of FLOMAX) 2 GC UROXATRAL 3 ST MISCELLANEOUS bethanechol chloride (generic of URECHOLINE)

2 GC

ELMIRON 4 potassium citrate (alkalinizer) (generic of UROCIT-K 10)

2 GC

THIOLA 3 URINARY ANTISPASMODICS DETROL 4 DETROL LA 2mg


DETROL LA 4mg 3 ENABLEX 15mg 3 ENABLEX 7.5mg


GELNIQUE 3 oxybutynin chloride 5mg 1 GC oxybutynin chloride (generic of DITROPAN XL) 10mg, 15mg, 5mg

ext rel

2 GC

oxybutynin chloride 5mg/5ml 2 GC OXYTROL 4 SANCTURA XR 4 TOVIAZ 4 VESICARE 10mg 3 VESICARE 5mg


VAGINAL ANTI-INFECTIVES CLEOCIN 100mg

suppository 3

clindamycin phosphate vaginal (generic of CLEOCIN)

2 GC

metronidazole vaginal (generic of METROGEL-VAGINAL)

2 GC

terconazole vaginal (generic of TERAZOL 7)

2 GC

HEMATOLOGIC ANTICOAGULANTS


24

Drug Tier Notes ARIXTRA 2.5mg/0.5ml

QL (60 syringes / 180 days) 3 QL NM

ARIXTRA 10mg/0.8ml QL (38 syringes / 180 days)

5 QL NM

ARIXTRA 5mg/0.4ml QL (75 syringes / 180 days)

5 QL NM

ARIXTRA 7.5mg/0.6ml QL (50 syringes / 180 days)

5 QL NM

COUMADIN 3 FRAGMIN 2500unit/0.2ml, 5000unit/0.2ml

QL (150 syringes / 180 days)

3 QL NM

FRAGMIN 10000unit/ml QL (30 syringes / 180 days)

5 QL NM

FRAGMIN 25000unit/ml QL (30 ml / 180 days)

5 QL NM

FRAGMIN 7500unit/0.3ml QL (100 syringes / 180 days)

5 QL NM

heparin (porcine) in sodium chloride (generic of HEPARIN SODIUM/SODIUM CHL)

2 GC B/D

heparin sod (porcine) in d5w 2 GC B/DHEPARIN SODIUM 3 B/D heparin sodium (porcine) 2 GC B/DHEPARIN SODIUM/NACL 0.45% 3 B/D LOVENOX 100mg/ml, 150mg/ml

QL (60 syringes / 180 days) 3 QL

LOVENOX 120mg/0.8ml, 80mg/0.8ml

QL (75 syringes / 180 days)

3 QL

LOVENOX 300mg/3ml QL (20 vials / 180 days)

3 QL

LOVENOX 30mg/0.3ml QL (200 syringes / 180 days)

3 QL


3 QL


3 QL

warfarin sodium (generic of COUMADIN)

1 GC

HEMATOPOIETIC GROWTH FACTORS LEUKINE 5 NM PA MOZOBIL 5 NM PA NEUPOGEN 5 NM PA PROCRIT 10000unit/ml, 3000unit/ml, 4000unit/ml


3 QL NM PA

PROCRIT 2000unit/ml QL (12 vials / 30 days)

3 QL PA

Drug Tier Notes PROCRIT 20000unit/ml

QL (12 vials / 30 days) 5 QL NM

PA PROCRIT 40000unit/ml

QL (6 vials / 30 days) 5 QL NM

PA MISCELLANEOUS anagrelide hcl (generic of AGRYLIN) 2 GC PA cilostazol (generic of PLETAL) 2 GC CYKLOKAPRON 3 pentoxifylline (generic of TRENTAL) 1 GC PROMACTA 5 NM PA PLATELET AGGREGATION INHIBITORS AGGRENOX 3 dipyridamole (generic of PERSANTINE)

2 GC

EFFIENT 3 PLAVIX 300mg


PLAVIX 75mg 3 ticlopidine hcl 2 GC IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ACTEMRA 5 NM PA HUMIRA 5 NM PA HUMIRA PEN-CROHNS DISEASE 5 NM PA hydroxychloroquine sulfate (generic of PLAQUENIL)

2 GC

leflunomide (generic of ARAVA) 2 GC methotrexate sodium 2.5mg 2 GC REMICADE 5 NM PA RHEUMATREX 3 IMMUNOGLOBULINS GAMASTAN S/D 3 B/D NMGAMMAGARD LIQUID 5 NM PA GAMUNEX 5 NM PA IMMUNOMODULATORS ACTIMMUNE 5 NM PA ARCALYST 5 NM PA INFERGEN 5 NM PA INTRON-A 5 B/D NMINTRON-A W/DILUENT 3 B/D NMPEG-INTRON 5 NM PA PEG-INTRON REDIPEN 5 NM PA PEGASYS 5 NM PA REVLIMID 5 NM LA

PA THALOMID 5 NM PA IMMUNOSUPPRESSANTS


25

Drug Tier Notes AZASAN 3 B/D azathioprine (generic of IMURAN) 2 GC B/Dazathioprine sodium 2 GC B/DCELLCEPT 3 B/D cyclosporine (generic of SANDIMMUNE)

2 GC B/D

cyclosporine modified (for microemulsion) (generic of NEORAL)

2 GC B/D

mycophenolate mofetil (generic of CELLCEPT)

2 GC B/D

MYFORTIC 3 B/D NEORAL 3 B/D PROGRAF .5mg, 1mg 3 B/D PROGRAF 5mg 5 B/D NMRAPAMUNE 3 B/D SANDIMMUNE 3 B/D tacrolimus (generic of PROGRAF) .5mg, 1mg

2 GC B/D

TACROLIMUS 5mg 5 B/D NMVACCINES ACTHIB 3 ADACEL 3 ATTENUVAX 3 BOOSTRIX 3 CERVARIX 3 COMVAX 3 B/D DAPTACEL 3 DECAVAC 3 B/D DIPHTHERIA/TETANUS TOXOID 3 B/D ENGERIX-B 3 B/D GARDASIL 3 HAVRIX 3 IMOVAX RABIES (H.D.C.V.) 3 INFANRIX 3 IPOL INACTIVATED IPV 3 IXIARO 3 JE-VAX 3 M-M-R II W/DILUENT 10 DOS 3 MENACTRA 3 MENOMUNE-A/C/Y/W-135 3 MERUVAX II W/DILUENT 10 D 3 PEDIARIX 3 B/D PEDVAX HIB 3 PROQUAD 3 RABAVERT 3 RECOMBIVAX HB 3 B/D

Drug Tier Notes ROTATEQ 3 TETANUS TOXOID ADSORBED 3 B/D TETANUS/DIPHTHERIA TOXOID 3 B/D TRIHIBIT 3 TRIPEDIA 3 TWINRIX 3 B/D TYPHIM VI 3 VAQTA 3 VARIVAX 3 VIVOTIF BERNA 3 YF-VAX 3 ZOSTAVAX

QL (1 vial in lifetime) 3 QL

NUTRITIONAL/SUPPLEMENTS ELECTROLYTES KLOR-CON M15 3 parenteral electrolytes 2 GC B/Dpotassium chloride (generic of K-TABS) 10meq, 8meq

2 GC

potassium chloride 2meq/ml 2 GC B/Dpotassium chloride microencapsulated crystals cr

2 GC

sodium chloride 2.5meq/ml 2 GC B/Dsodium fluoride 2 GC IV NUTRITION amino acid electrolyte infusion 2 GC B/Damino acid infusion 2 GC B/DAMINOSYN 3 B/D AMINOSYN 7%/ELECTROLYTES 3 B/D AMINOSYN II 3 B/D AMINOSYN II 3.5%/DEXTROSE 3 B/D AMINOSYN II 3.5/DEXTROSE 3 B/D AMINOSYN II 4.25/DEXTROSE 3 B/D AMINOSYN II 5/DEXTROSE 25 3 B/D AMINOSYN II M 3.5%/DEXTRO 3 B/D AMINOSYN M 3 B/D AMINOSYN-HBC 3 B/D AMINOSYN-PF 3 B/D AMINOSYN-PF 7% 3 B/D CLINIMIX 2.75%/DEXTROSE 5 3 B/D CLINIMIX 4.25%/DEXTROSE 1 3 B/D CLINIMIX 4.25%/DEXTROSE 2 3 B/D CLINIMIX 4.25%/DEXTROSE 5 3 B/D CLINIMIX 5%/DEXTROSE 15% 3 B/D CLINIMIX 5%/DEXTROSE 20% 3 B/D CLINIMIX 5%/DEXTROSE 25% 3 B/D CLINIMIX E 2.75%/DEXTROSE 3 B/D


26

Drug Tier Notes CLINIMIX E 4.25%/DEXTROSE 3 B/D CLINIMIX E 5%/DEXTROSE 15 3 B/D CLINIMIX E 5%/DEXTROSE 20 3 B/D CLINIMIX E 5%/DEXTROSE 25 3 B/D fat emulsion (generic of INTRALIPID)

2 GC B/D

FREAMINE HBC 6.9% 3 B/D FREAMINE III 3% 3 B/D HEPATASOL 3 B/D LIPOSYN II 3 B/D LIPOSYN III 3 B/D NEPHRAMINE 3 B/D PREMASOL 3 B/D PROCALAMINE 3 B/D PROSOL 3 B/D RENAMIN 3 B/D TRAVASOL 3 B/D TROPHAMINE 3 B/D IV REPLACEMENT SOLUTIONS alcohol in d5w 2 GC B/Ddextrose 2 GC B/DDEXTROSE 5% 3 B/D DEXTROSE 5%/POTASSIUM CHL 3 B/D dextrose w/ sodium chloride 2 GC B/Delectrolyte-m in dextrose 2 GC B/Delectrolyte-r 2 GC B/Delectrolyte-r in dextrose 2 GC B/DIONOSOL-B/DEXTROSE 5% 3 B/D IONOSOL-MB/DEXTROSE 5% 3 B/D IONOSOL-T/DEXTROSE 5% 3 B/D ISOLYTE-H/DEXTROSE 5% 3 B/D ISOLYTE-P/DEXTROSE 5% 3 B/D ISOLYTE-S 3 B/D ISOLYTE-S/DEXTROSE 5% 3 B/D KCL 0.15%/D10W/NACL 0.2% 3 B/D KCL 0.15%/D5W/LR 3 B/D KCL 0.15%/D5W/NACL 0.225% 3 B/D KCL 0.3%/D5W/NACL 0.9% 3 B/D lactated ringer's 2 GC B/DMAGNESIUM SULFATE IN D5W 3 NORMOSOL-R 3 B/D PLASMA-LYTE 56 3 B/D PLASMA-LYTE A 3 B/D PLASMA-LYTE-148 3 B/D PLASMA-LYTE-148/D5W 3 B/D PLASMA-LYTE-56/D5W 3 B/D potassium chloride (generic of POTASSIUM CHLORIDE)

2 GC B/D

Drug Tier Notes .4meq/ml, 10meq/100ml, 10meq/50ml, 30meq/100ml POTASSIUM CHLORIDE 0.15% 3 B/D POTASSIUM CHLORIDE 0.3%/ 3 B/D potassium chloride in d5w lactated ringers

2 GC B/D

potassium chloride in dextrose 2 GC B/Dpotassium chloride in dextrose & sodium chloride (generic of KCL 0.15%/D5W/NACL 0.9%)

2 GC B/D

potassium chloride in nacl (generic of POTASSIUM CHLORIDE 0.15%/)

2 GC B/D

ringer's 2 GC B/Dsodium chloride .45%, .9%, 3%, 5% 2 GC B/DVITAMINS calcitriol (generic of ROCALTROL) .25mcg, .5mcg

capsule

2 GC

calcitriol (generic of ROCALTROL) 1mcg/ml

2 GC

calcitriol (generic of CALCIJEX) 1mcg/ml

injection

2 GC B/D

CALCITRIOL 2mcg/ml injection

3 B/D

HECTOROL .5mcg, 1mcg, 2.5mcg 4 HECTOROL 4mcg/2ml 4 B/D prenatal without a vit w/ iron carbonyl-folic acid

2 GC

ZEMPLAR 1mcg, 2mcg, 4mcg 3 ZEMPLAR 2mcg/ml, 5mcg/ml 3 B/D OPHTHALMIC ANTI-GLAUCOMA BETIMOL 4 XALATAN

QL (2.5ml / 30 days) 4 QL

ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc 1 GC BLEPHAMIDE S.O.P. 3 neomycin-polymy-dexameth (generic of MAXITROL)

1 GC

neomycin-polymyxin-hc (ophth) 2 GC sulfacetamide sod-prednisolone 2 GC TOBRADEX

ointment 4

tobramycin-dexamethasone (generic of TOBRADEX)

2 GC

ANTI-INFECTIVES


27

Drug Tier Notes AZASITE 3 bacitracin (ophthalmic) 2 GC bacitracin-polymyxin b (ophth) 2 GC CILOXAN

ointment 3

ciprofloxacin hcl (ophth) (generic of CILOXAN)

2 GC

erythromycin (ophth) 1 GC gentamicin sulfate (ophth) .3% 1 GC gentamicin sulfate (ophth) .3%

ointment 2 GC

NATACYN 3 neomycin-bacitracin zn-polymyxin 1 GC neomycin-polymy-gramicid (generic of NEOSPORIN)

2 GC

ofloxacin (ophth) (generic of OCUFLOX)

2 GC

polymyxin b-trimethoprim (generic of POLYTRIM)

1 GC

QUIXIN 4 sulfacetamide sodium (ophth) (generic of BLEPH-10)

1 GC

tobramycin sulfate (ophth) (generic of TOBREX)

1 GC

TOBREX ointment

3

trifluridine (generic of VIROPTIC) 2 GC VIGAMOX 3 ZYMAR 3 ANTI-INFLAMMATORIES dexamethasone sodium phosphate (ophth)

2 GC

diclofenac sodium (ophth) (generic of VOLTAREN)

2 GC

fluorometholone (ophth) (generic of FML LIQUIFILM)

1 GC

flurbiprofen sodium (generic of OCUFEN)

1 GC

FML 3 ketorolac tromethamine (ophth) (generic of ACULAR LS)

2 GC

LOTEMAX 4 PRED MILD 4 prednisolone acetate (ophth) (generic of OMNIPRED)

1 GC

PREDNISOLONE SODIUM PHOSP 3 XIBROM 4 ANTIALLERGICS

Drug Tier Notes ALOCRIL 4 ALOMIDE 4 ALREX 3 azelastine hcl (ophth) (generic of OPTIVAR)

2 GC

cromolyn sodium (ophth) 2 GC PATADAY 3 PATANOL 3 ANTIGLAUCOMA AZOPT 3 BETOPTIC-S 3 brimonidine tartrate 2 GC carteolol hcl (ophth) 2 GC COMBIGAN 3 dorzolamide hcl (generic of TRUSOPT)

2 GC

dorzolamide-timolol (generic of COSOPT)

2 GC

levobunolol hcl 1 GC LUMIGAN

QL (2.5ml / 30 days) 3 QL

metipranolol (generic of OPTIPRANOLOL)

2 GC

PILOPINE HS 3 timolol maleate (ophth) (generic of TIMOPTIC) .25%, .5%

1 GC

timolol maleate (ophth) (generic of TIMOPTIC-XE) .25%, .5%

gel

2 GC

TRAVATAN Z QL (2.5ml / 30 days)

3 QL

MISCELLANEOUS LACRISERT 3 naphazoline hcl 1 GC proparacaine hcl (generic of ALCAINE)

2 GC

RESTASIS 3 RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS COMBIVENT


ipratropium-albuterol (generic of DUONEB)


2 GC B/D QL

ANTICHOLINERGICS ATROVENT HFA



28

Drug Tier Notes ipratropium bromide

QL (126 bags / 30 days) 2 GC B/D

QL ipratropium bromide (nasal) (generic of ATROVENT)

2 GC

SPIRIVA HANDIHALER QL (30 caps / 30 days)

3 QL

ANTIHISTAMINES, LOW/NONSEDATING ASTEPRO

QL (2 spray-bottles / 30 days) 3 QL

azelastine hcl (generic of ASTELIN) QL (2 inhalers per 25 days)

2 GC QL

cetirizine hcl 2 GC fexofenadine hcl (generic of ALLEGRA)

2 GC

XYZAL 3 ANTIHISTAMINES, SEDATING clemastine fumarate 2 GC cyproheptadine hcl 2 GC diphenhydramine hcl 12.5mg/5ml, 50mg

1 GC

diphenhydramine hcl (generic of BENADRYL) 50mg/ml

2 GC

hydroxyzine hcl 2 GC hydroxyzine pamoate 1 GC BETA AGONISTS albuterol sulfate 2mg, 2mg/5ml, 4mg 1 GC albuterol sulfate .083%, .63mg/3ml, 1.25mg/3ml

QL (100 bags / 30 days)

2 GC B/D QL

albuterol sulfate .5% QL (3 bottles / 30 days)

2 GC B/D QL

albuterol sulfate (generic of VOSPIRE ER) 4mg, 8mg

2 GC

FORADIL AEROLIZER QL (60 caps / 30 days)

4 QL

levalbuterol hcl (generic of XOPENEX CONCENTRATE)

QL (90 bags / 30 days)

2 GC B/D QL

PROAIR HFA QL (2 inhalers per 30 days)

3 QL

PROVENTIL HFA QL (2 inhalers / 30 days)

4 QL

SEREVENT DISKUS QL (1 inhaler / 30 days)

3 QL

terbutaline sulfate (generic of BRETHINE) 1mg/ml

2 GC B/D

terbutaline sulfate (generic of BRETHINE) 2.5mg, 5mg

2 GC

XOPENEX 4 B/D QL

Drug Tier Notes QL (96 bags / 30 days)

XOPENEX HFA QL (2 inhalers / 30 days)

4 QL

LEUKOTRIENE RECEPTOR ANTAGONISTS ACCOLATE 4 SINGULAIR 3 ST MAST CELL STABILIZERS cromolyn sodium

QL (120 bags / 30 days) 2 GC B/D

QL MISCELLANEOUS acetylcysteine 2 GC B/DARALAST NP 5 NM PA epinephrine hcl 2 GC EPIPEN 2-PAK 3 EPIPEN-JR 2-PAK 3 PULMOZYME 5 NM PA TOBI 5 B/D NMTYZINE 3 TYZINE PEDIATRIC NASAL DR 3 XOLAIR 5 NM PA NASAL STEROIDS flunisolide (nasal)

QL (2 bottles / 30 days) 2 GC QL

fluticasone propionate (nasal) (generic of FLONASE)

QL (1 bottle / 30 days)

2 GC QL

NASACORT AQ QL (1 inhaler / 30 days)

3 QL

NASONEX QL (2 inhalers / 30 days)

4 QL ST

RHINOCORT AQUA QL (2 bottles / 30 days)

4 QL ST

STEROID INHALANTS ASMANEX 120 METERED DOSES


ASMANEX 14 METERED DOSES QL (2 inhalers / 25 days)

3 QL

ASMANEX 30 METERED DOSES 110mcg/inh

QL (2 inhalers per 25 days)

3 QL

ASMANEX 30 METERED DOSES 220mcg/inh

QL (2 inhalers / 25 days)

3 QL

ASMANEX 60 METERED DOSES QL (2 inhalers / 25 days)

3 QL

FLOVENT DISKUS QL (2 inhalers / 30 days)

3 QL


29

Drug Tier Notes FLOVENT HFA


QVAR QL (3 inhalers / 30 days)

4 QL

STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS

QL (1 kit / 30 days) 3 QL

ADVAIR HFA QL (1 inhaler / 30 days)

3 QL

PULMICORT FLEXHALER 180mcg/act


4 QL

PULMICORT FLEXHALER 90mcg/act


4 QL

SYMBICORT QL (1 inhaler / 30 days)

3 QL

XANTHINES aminophylline 100mg, 200mg 1 GC aminophylline 25mg/ml 2 GC B/DELIXOPHYLLIN 3 THEO-24 3 theophylline 2 GC TOPICAL DERMATOLOGY, ACNE AZELEX 4 benzoyl peroxide-erythromycin (generic of BENZAMYCIN)

2 GC

clindamycin phosphate (topical) (generic of CLEOCIN-T)

2 GC

clindamycin phosphate-benzoyl peroxide (generic of BENZACLIN)

2 GC

erythromycin (acne aid) 2 GC isotretinoin 2 GC RETIN-A MICRO 4 PA sulfacetamide sodium (acne) (generic of KLARON)

2 GC

tretinoin (generic of RETIN-A) .01%, .025%, .05%, .1%

2 GC PA

DERMATOLOGY, ACTINIC KERATOSIS CARAC 3 FLUOROPLEX 4 fluorouracil (topical) 2 GC SOLARAZE 3 DERMATOLOGY, ANTIBIOTICS ALTABAX 3 BACTROBAN 3

Drug Tier Notes cream

gentamicin sulfate (topical) 1 GC mupirocin (generic of BACTROBAN) 2 GC silver sulfadiazine (generic of SILVADENE)

1 GC

DERMATOLOGY, ANTIFUNGALS ciclopirox (generic of LOPROX) 2 GC ciclopirox olamine 2 GC clotrimazole (topical) 2 GC econazole nitrate 2 GC ketoconazole (topical) 2% 2 GC MENTAX 4 nystatin (topical) 100000unit/gm

cream,ointment 1 GC

nystatin (topical) 100000unit/gm 2 GC OXISTAT 4 DERMATOLOGY, ANTIPRURITIC hydrocortisone (rectal) (generic of ANUSOL-HC)

1 GC

ZONALON 3 DERMATOLOGY, ANTIPSORIATICS calcipotriene (generic of DOVONEX) 2 GC DOVONEX

cream 3

OXSORALEN ULTRA 5 NM PA SORIATANE 4 STELARA 5 NM PA DERMATOLOGY, ANTISEBORRHEICS ketoconazole (topical) (generic of NIZORAL) 2%

2 GC

selenium sulfide (generic of SELSUN SHAMPOO)

2 GC

DERMATOLOGY, ANTIVIRALS DENAVIR 3 ZOVIRAX

cream,oint 3

DERMATOLOGY, CORTICOSTEROIDS alclometasone dipropionate (generic of ACLOVATE)

2 GC

betamethasone dipropionate (topical)

1 GC

betamethasone dipropionate augmented (generic of DIPROLENE)

2 GC

betamethasone valerate 1 GC clobetasol propionate (generic of TEMOVATE)

2 GC

clobetasol propionate emollient base(generic of TEMOVATE E)

2 GC


30

Drug Tier Notes CORDRAN 4 CORDRAN TAPE 4 DERMA-SMOOTHE/FS BODY OIL 3 desonide 2 GC DESOWEN OINTMENT/CETAPHIL 3 desoximetasone (generic of TOPICORT)

2 GC

diflorasone diacetate 2 GC fluocinolone acetonide 2 GC fluocinonide 2 GC fluocinonide emulsified base 2 GC fluticasone propionate (generic of CUTIVATE)

2 GC

halobetasol propionate (generic of ULTRAVATE)

2 GC

hydrocortisone (topical) (generic of PROCTOCORT)

1 GC

hydrocortisone butyrate (generic of LOCOID)

2 GC

hydrocortisone valerate (generic of WESTCORT)

2 GC

KENALOG 3 LOCOID LIPOCREAM 4 LUXIQ 4 mometasone furoate (generic of ELOCON)

2 GC

triamcinolone acetonide (topical) .025%, .1%, .5%

cream,ointment

1 GC

triamcinolone acetonide (topical) .025%, .1%

2 GC

DERMATOLOGY, IMMUNOMODULATORSELIDEL 3 PA PROTOPIC 3 PA DERMATOLOGY, LOCAL ANESTHETICS lidocaine 2 GC lidocaine hcl (generic of XYLOCAINE JELLY)

2 GC

lidocaine-prilocaine (generic of EMLA)

2 GC

LIDODERM QL (90 patches / 30 days)

3 QL PA

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE CONDYLOX

gel 4

imiquimod (generic of ALDARA) 2 GC lactic acid (ammonium lactate) 2 GC

Drug Tier Notes (generic of LAC-HYDRIN) PANRETIN 5 NM podofilox (generic of CONDYLOX) 2 GC TARGRETIN 1% 5 NM PA DERMATOLOGY, ROSACEA FINACEA 4 METROGEL 3 metronidazole (topical) (generic of METROLOTION)

2 GC

ORACEA 3 DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 3 malathion (generic of OVIDE) 2 GC permethrin 1 GC DERMATOLOGY, WOUND CARE AGENTSREGRANEX 5 NM PA SANTYL 3 sodium chloride (gu irrigant) 2 GC MOUTH/THROAT/DENTAL AGENTS chlorhexidine gluconate (mouth-throat) (generic of PERIDEX)

1 GC

EVOXAC 3 lidocaine hcl (mouth-throat) 1 GC nystatin (mouth-throat) 2 GC pilocarpine hcl (oral) (generic of SALAGEN)

2 GC

triamcinolone acetonide (mouth) 2 GC OTIC acetic acid (otic) (generic of VOSOL) 2 GC acetic acid-aluminum acetate 2 GC CIPRO HC 4 CIPRODEX 4 DERMOTIC 3 hydrocortisone w/acetic acid (generic of VOSOL HC)

2 GC

neomycin-polymyxin-hc (otic) 2 GC ofloxacin (otic) 2 GC

31

Index

A ABILIFY.............................. 17 ABILIFY DISCMELT........... 17 acarbose ............................ 19 ACCOLATE........................ 28 ACCUPRIL

see quinapril hcl ............. 12 ACCURETIC

see quinapril-hydrochlorothiazide .... 12

acebutolol hcl ..................... 13 ACEON

see perindopril erbumine 12 acetaminophen w/ codeine .. 7 acetazolamide .................... 14 acetic acid (otic) ................. 30 acetic acid-aluminum acetate........................................... 30 acetylcysteine..................... 28 ACLOVATE

see alclometasone dipropionate................ 29

ACTEMRA.......................... 24 ACTHIB .............................. 25 ACTIMMUNE ..................... 24 ACTONEL .......................... 20 ACTOPLUS MET ............... 19 ACTOS............................... 19 ACULAR LS

see ketorolac tromethamine (ophth) ........................ 27

acyclovir ............................. 10 acyclovir sodium................. 10 ADACEL............................. 25 ADAGEN............................ 20 ADCIRCA........................... 14 ADDERALL

see amphetamine-dextroamphetamine.... 17

ADOXA PAK 1/150 see doxycycline

(monohydrate) .............. 8 ADVAIR DISKUS ............... 29 ADVAIR HFA...................... 29 ADVICOR........................... 13 AFINITOR .......................... 11 AGGRENOX ...................... 24 AGRYLIN

see anagrelide hcl .......... 24 ALBENZA........................... 10 albuterol sulfate.................. 28 ALCAINE

see proparacaine hcl ...... 27

alclometasone dipropionate29 alcohol in d5w .....................26 ALCOHOL PREPS .............19 ALDACTAZIDE ...................14

see spironolactone & hydrochlorothiazide.....14

ALDACTONE see spironolactone..........12

ALDARA see imiquimod.................30

ALDURAZYME ...................20 alendronate sodium ............20 ALIMTA...............................11 ALINIA ................................10 ALKERAN

see melphalan hcl ...........11 ALLEGRA

see fexofenadine hcl .......28 allopurinol .............................7 allopurinol sodium .................7 ALOCRIL ............................27 ALOMIDE............................27 ALOPRIM

see allopurinol sodium ......7 ALORA................................21 ALREX................................27 ALTABAX............................29 ALTACE

see ramipril .....................12 ALTOPREV.........................13 amantadine hcl ...................16 AMARYL

see glimepiride................19 AMBIEN

see zolpidem tartrate ......18 amifostine crystalline ..........12 amikacin sulfate ....................8 AMIKIN

see amikacin sulfate .........8 amiloride & hydrochlorothiazide.............14 amiloride hcl........................14 amino acid electrolyte infusion............................................25 amino acid infusion .............25 aminophylline ......................29 AMINOSYN.........................25 AMINOSYN 7%/ELECTROLYTES .........25 AMINOSYN II......................25 AMINOSYN II 3.5%/DEXTROSE...............25 AMINOSYN II

3.5/DEXTROSE.................. 25 AMINOSYN II 4.25/DEXTROSE................ 25 AMINOSYN II 5/DEXTROSE 25 ....................................... 25 AMINOSYN II M 3.5%/DEXTRO ................... 25 AMINOSYN M .................... 25 AMINOSYN-HBC ............... 25 AMINOSYN-PF .................. 25 AMINOSYN-PF 7% ............ 25 amiodarone hcl ................... 13 AMITIZA ............................. 23 amitriptyline hcl................... 16 amlodipine besylate............ 14 amlodipine besylate-benazepril hcl ..................... 12 AMOXAPINE ...................... 16 amoxicillin ............................. 8 amoxicillin & pot clavulanate 8 amphetamine-dextroamphetamine............ 17 amphotericin b ...................... 9 ampicillin............................... 8 ampicillin & sulbactam sodium............................................. 8 ampicillin sodium .................. 8 AMPYRA ............................ 18 ANAFRANIL

see clomipramine hcl...... 16 anagrelide hcl ..................... 24 ANAPROX

see naproxen sodium ....... 8 ANCOBON ........................... 9 ANDRODERM.................... 19 ANDROGEL ....................... 19 ANTABUSE ........................ 18 ANTARA............................. 13 ANTIVERT

see meclizine hcl ............ 22 ANUSOL-HC

see hydrocortisone (rectal).................................... 29

APIDRA .............................. 19 APIDRA SOLOSTAR ......... 19 APOKYN ............................ 16 APRISO.............................. 22 APTIVUS .............................. 9 ARALAST NP ..................... 28 ARAVA

see leflunomide .............. 24 ARCALYST ........................ 24 ARICEPT............................ 15

32

ARICEPT ODT ................... 15 ARIMIDEX.......................... 11 ARIXTRA............................ 24 AROMASIN ........................ 11 ASACOL............................. 22 ASMANEX 120 METERED DOSES............................... 28 ASMANEX 14 METERED DOSES............................... 28 ASMANEX 30 METERED DOSES............................... 28 ASMANEX 60 METERED DOSES............................... 28 ASTELIN

see azelastine hcl........... 28 ASTEPRO.......................... 28 ATACAND.......................... 12 ATACAND HCT.................. 12 atenolol............................... 13 atenolol & chlorthalidone.... 13 ATRIPLA .............................. 9 ATROVENT

see ipratropium bromide (nasal) ........................ 28

ATROVENT HFA ............... 27 ATTENUVAX...................... 25 AUGMENTIN

see amoxicillin & pot clavulanate ................... 8

AVANDAMET..................... 19 AVANDARYL ..................... 19 AVANDIA ........................... 19 AVASTIN............................ 11 AVELOX............................... 8 AVELOX ABC PACK............ 8 AVINZA ................................ 7 AVODART.......................... 23 AVONEX ............................ 18 AYGESTIN

see norethindrone acetate................................... 22

AZASAN............................. 25 AZASITE ............................ 27 azathioprine........................ 25 azathioprine sodium ........... 25 azelastine hcl ..................... 28 azelastine hcl (ophth) ......... 27 AZELEX ............................. 29 AZILECT ............................ 16 azithromycin ......................... 8 AZOPT ............................... 27 AZULFIDINE EN-TABS

see sulfasalazine............ 23

B bacitracin (ophthalmic)........27 bacitracin-polymyxin b (ophth)............................................27 bacitracin-poly-neomycin-hc............................................26 baclofen ..............................18 BACTRIM DS

see sulfamethoxazole-trimethoprim ................10

BACTROBAN .....................29 see mupirocin .................29

BANZEL..............................15 BARACLUDE......................10 BENADRYL

see diphenhydramine hcl 28 benazepril & hydrochlorothiazide.............12 benazepril hcl......................12 BENICAR............................12 BENICAR HCT ...................12 BENTYL

see dicyclomine hcl.........22 BENZACLIN

see clindamycin phosphate-benzoyl peroxide.........29

BENZAMYCIN see benzoyl peroxide-

erythromycin ...............29 benzoyl peroxide-erythromycin .......................29 benztropine mesylate..........16 betamethasone dipropionate (topical) ...............................29 betamethasone dipropionate augmented ..........................29 betamethasone valerate .....29 BETAPACE

see sotalol hcl .................13 BETASERON......................18 bethanechol chloride...........23 BETIMOL ............................26 BETOPTIC-S ......................27 BIAXIN

see clarithromycin .............8 BIAXIN XL

see clarithromycin .............8 bicalutamide........................11 BICILLIN C-R........................8 BICILLIN L-A.........................8 BICNU.................................10 BIDIL...................................14 bisoprolol & hydrochlorothiazide.............13 bisoprolol fumarate .............13

bleomycin sulfate................ 11 BLEPH-10

see sulfacetamide sodium (ophth) ........................ 27

BLEPHAMIDE S.O.P.......... 26 BONIVA.............................. 20 BOOSTRIX......................... 25 BRETHINE

see terbutaline sulfate .... 28 brimonidine tartrate ............ 27 bromocriptine mesylate ...... 16 bumetanide......................... 14 BUPHENYL ........................ 20 buprenorphine hcl............... 18 bupropion hcl ...................... 16 bupropion hcl (smoking deterrent) ............................ 19 buspirone hcl ...................... 15 BUSULFEX ........................ 10 butalbital-acetaminophen-caffeine w/ codeine............... 7 butalbital-aspirin-caffeine w/cod .................................... 7 butorphanol tartrate .............. 7 BYETTA ............................. 19 BYSTOLIC.......................... 13

C cabergoline ......................... 21 CADUET............................. 14 CAFERGOT

see ergotamine w/ caffeine.................................... 18

CALAN see verapamil hcl............ 14

CALAN SR see verapamil hcl............ 14

CALCIJEX see calcitriol.................... 26

calcipotriene ....................... 29 calcitonin (salmon) ............. 20 calcitriol .............................. 26 CALCITRIOL ...................... 26 calcium acetate (phosphate binder) ................................ 21 CAMPATH.......................... 11 CAMPRAL .......................... 19 CANASA............................. 22 CANCIDAS........................... 9 CAPASTAT SULFATE ......... 9 captopril .............................. 12 captopril & hydrochlorothiazide ............ 12 CARAC............................... 29 CARAFATE ........................ 23

33

see sucralfate ................. 23 carbamazepine................... 15 CARBATROL ..................... 15 carbidopa-levodopa............ 16 carboplatin.......................... 12 CARDIZEM

see diltiazem hcl............. 14 CARDIZEM CD .................. 14

see diltiazem hcl coated beads.......................... 14

CARDURA see doxazosin mesylate . 12

carisoprodol........................ 18 CARNITOR

see levocarnitine (metabolic modifiers).................... 20

carteolol hcl (ophth)............ 27 carvedilol ............................ 13 CASODEX

see bicalutamide ............ 11 CATAFLAM

see diclofenac potassium . 7 CATAPRES

see clonidine hcl............. 12 CATAPRES-TTS-1

see clonidine hcl............. 12 CEDAX................................. 8 CEENU............................... 10 cefaclor................................. 8 CEFACLOR ER.................... 8 cefadroxil.............................. 8 cefazolin sodium .................. 8 CEFAZOLIN SODIUM.......... 8 cefdinir.................................. 8 cefepime hcl ......................... 8 cefotaxime sodium ............... 8 cefoxitin sodium ................... 8 cefpodoxime proxetil ............ 8 cefprozil................................ 8 CEFTIN

see cefuroxime axetil ....... 8 ceftriaxone sodium ............... 8 cefuroxime axetil .................. 8 cefuroxime sodium ............... 8 CEFUROXIME/DEXTROSE 8 CELEBREX.......................... 7 CELEXA

see citalopram hydrobromide ............. 16

CELLCEPT......................... 25 see mycophenolate mofetil

................................... 25 CELONTIN ......................... 15 CENESTIN ......................... 21 cephalexin ............................ 8

CEREZYME........................20 CERVARIX .........................25 cetirizine hcl ........................28 CHANTIX ............................19 chlorhexidine gluconate (mouth-throat) .....................30 chloroquine phosphate .........9 chlorothiazide......................14 chlorpromazine hcl..............17 CHLORPROMAZINE HCL..17 chlorthalidone .....................14 chlorzoxazone.....................18 cholestyramine light ............13 chorionic gonadotropin .......21 ciclopirox.............................29 ciclopirox olamine ...............29 cilostazol .............................24 CILOXAN ............................27

see ciprofloxacin hcl (ophth).........................27

cimetidine............................22 cimetidine hcl ......................22 CIMZIA................................22 CIPRO ..................................8

see ciprofloxacin hcl..........8 CIPRO HC ..........................30 CIPRO I.V.

see ciprofloxacin ...............8 CIPRODEX .........................30 ciprofloxacin..........................8 ciprofloxacin hcl ....................8 ciprofloxacin hcl (ophth)......27 ciprofloxacin-ciprofloxacin hcl..............................................8 cisplatin...............................12 citalopram hydrobromide ....16 cladribine ............................11 CLAFORAN

see cefotaxime sodium .....8 clarithromycin........................8 clemastine fumarate ...........28 CLEOCIN......................10, 23

see clindamycin hcl.........10 see clindamycin phosphate

vaginal.........................23 CLEOCIN PEDIATRIC GRANULE ..........................10 CLEOCIN PHOSPHATE

see clindamycin phosphate....................................10

CLEOCIN-T see clindamycin phosphate

(topical) .......................29 CLIMARA

see estradiol ...................21

CLIMARA PRO................... 21 clindamycin hcl ................... 10 clindamycin phosphate ....... 10 clindamycin phosphate (topical)............................... 29 clindamycin phosphate vaginal ................................ 23 clindamycin phosphate-benzoyl peroxide ................ 29 CLINIMIX 2.75%/DEXTROSE 5 ......................................... 25 CLINIMIX 4.25%/DEXTROSE 1 ......................................... 25 CLINIMIX 4.25%/DEXTROSE 2 ......................................... 25 CLINIMIX 4.25%/DEXTROSE 5 ......................................... 25 CLINIMIX 5%/DEXTROSE 15% .................................... 25 CLINIMIX 5%/DEXTROSE 20% .................................... 25 CLINIMIX 5%/DEXTROSE 25% .................................... 25 CLINIMIX E 2.75%/DEXTROSE ............ 25 CLINIMIX E 4.25%/DEXTROSE ............ 26 CLINIMIX E 5%/DEXTROSE 15 ....................................... 26 CLINIMIX E 5%/DEXTROSE 20 ....................................... 26 CLINIMIX E 5%/DEXTROSE 25 ....................................... 26 clobetasol propionate ......... 29 clobetasol propionate emollient base .................... 29 clomipramine hcl ................ 16 clonidine hcl........................ 12 clotrimazole .......................... 9 clotrimazole (topical) .......... 29 clozapine ............................ 17 CLOZAPINE ....................... 17 CLOZARIL

see clozapine.................. 17 COARTEM ........................... 9 COGENTIN

see benztropine mesylate.................................... 16

colchicine w/ probenecid ...... 7 COLCRYS ............................ 7 COLESTID

see colestipol hcl ............ 13 colestipol hcl ....................... 13 colistimethate sodium ......... 10 COLY-MYCIN M

34

see colistimethate sodium................................... 10

COLYTE-FLAVOR PACKS see peg 3350-kcl-sod

bicarb-sod chloride-sod sulfate......................... 23

COMBIGAN........................ 27 COMBIPATCH ................... 21 COMBIVENT...................... 27 COMBIVIR ........................... 9 COMTAN............................ 16 COMVAX............................ 25 CONCERTA....................... 17 CONDYLOX....................... 30

see podofilox .................. 30 COPAXONE....................... 18 COPEGUS

see ribavirin (hepatitis c) 10 CORDARONE

see amiodarone hcl ........ 13 CORDRAN......................... 30 CORDRAN TAPE............... 30 COREG

see carvedilol ................. 13 COREG CR........................ 13 CORGARD

see nadolol ..................... 13 CORTEF

see hydrocortisone ......... 21 CORTENEMA

see hydrocortisone (intrarectal) ................. 23

cortisone acetate................ 21 COSMEGEN ...................... 11 COSOPT

see dorzolamide-timolol . 27 COUMADIN........................ 24

see warfarin sodium ....... 24 COZAAR

see losartan potassium .. 12 CREON .............................. 23 CRESTOR.......................... 13 CRIXIVAN ............................ 9 cromolyn sodium ................ 28 cromolyn sodium (ophth).... 27 CUBICIN ............................ 10 CUTIVATE

see fluticasone propionate................................... 30

CYCLESSA see desogestrel-ethinyl

estradiol (triphasic) ..... 20 cyclobenzaprine hcl............ 18 cyclophosphamide ............. 10 cyclosporine ....................... 25

cyclosporine modified (for microemulsion) ...................25 CYKLOKAPRON ................24 CYMBALTA ........................16 cyproheptadine hcl..............28 CYSTADANE......................20 CYSTAGON........................20 cytarabine ...........................11 CYTOMEL

see liothyronine sodium ..22 CYTOTEC

see misoprostol...............23

D D.H.E. 45

see dihydroergotamine mesylate......................18

dacarbazine ........................10 danazol ...............................20 DANTRIUM

see dantrolene sodium ...18 dantrolene sodium ..............18 dapsone ..............................10 DAPTACEL.........................25 DARAPRIM...........................9 daunorubicin hcl..................11 DAYPRO

see oxaprozin ...................8 DDAVP

see desmopressin acetate....................................22

see desmopressin acetate refrigerated..................22

DECAVAC ..........................25 DELATESTRYL

see testosterone enanthate....................................19

DEMADEX see torsemide .................14

DENAVIR............................29 DEPACON

see valproate sodium......15 DEPAKENE

see valproic acid .............15 DEPAKOTE SPRINKLES

see divalproex sodium ....15 DEPO-MEDROL

see methylprednisolone acetate ........................21

DEPO-PROVERA...............11 DEPO-PROVERA CONTRACEPTIV

see medroxyprogesterone acetate (contraceptive)20

DEPO-TESTOSTERONE

see testosterone cypionate.................................... 19

DERMA-SMOOTHE/FS BODY OIL .......................... 30 DERMOTIC ........................ 30 desipramine hcl .................. 16 desmopressin acetate ........ 22 desmopressin acetate refrigerated ......................... 22 desmopressin acetate spray refrigerated ......................... 22 DESOGEN

see desogestrel & ethinyl estradiol ...................... 20

desogestrel & ethinyl estradiol........................................... 20 desogestrel-ethinyl estradiol (triphasic)............................ 20 desonide ............................. 30 DESOWEN OINTMENT/CETAPHIL ...... 30 desoximetasone ................. 30 DETROL............................. 23 DETROL LA ....................... 23 dexamethasone .................. 21 DEXAMETHASONE INTENSOL ......................... 21 dexamethasone sodium phosphate........................... 21 dexamethasone sodium phosphate (ophth) .............. 27 DEXEDRINE

see dextroamphetamine sulfate ......................... 17

DEXILANT.......................... 23 dexmethylphenidate hcl...... 17 dexrazoxane ....................... 12 dextroamphetamine sulfate 17 dextrose.............................. 26 DEXTROSE 5% ................. 26 DEXTROSE 5%/POTASSIUM CHL .................................... 26 dextrose w/ sodium chloride26 diclofenac potassium ............ 7 diclofenac sodium................. 7 diclofenac sodium (ophth) .. 27 dicloxacillin sodium............... 8 dicyclomine hcl ................... 22 didanosine ............................ 9 diflorasone diacetate .......... 30 DIFLUCAN

see fluconazole................. 9 DIFLUCAN IN ISO-OSMOTIC D

see fluconazole in dextrose

35

..................................... 9 diflunisal ............................... 7 digoxin................................ 14 dihydroergotamine mesylate........................................... 18 DILANTIN........................... 15

see phenytoin ................. 15 see phenytoin sodium

extended..................... 15 DILANTIN INFATABS ........ 15 DILAUDID

see hydromorphone hcl.... 7 DILAUDID-5 ......................... 7 DILAUDID-HP

see hydromorphone hcl.... 7 diltiazem hcl ....................... 14 diltiazem hcl coated beads. 14 diltiazem hcl extended release beads ................................. 14 DIOVAN ............................. 12 DIOVAN HCT..................... 12 DIPENTUM ........................ 22 diphenhydramine hcl .......... 28 diphenoxylate w/ atropine .. 22 DIPHTHERIA/TETANUS TOXOID ............................. 25 DIPROLENE

see betamethasone dipropionate augmented................................... 29

dipyridamole....................... 24 disopyramide phosphate .... 13 DITROPAN XL

see oxybutynin chloride.. 23 divalproex sodium .............. 15 DOLOPHINE

see methadone hcl ........... 7 dorzolamide hcl .................. 27 dorzolamide-timolol ............ 27 DOVONEX ......................... 29

see calcipotriene ............ 29 doxazosin mesylate............ 12 doxepin hcl ......................... 16 DOXIL ................................ 11 doxorubicin hcl ................... 11 doxycycline (monohydrate) .. 8 doxycycline hyclate .............. 8 DRONABINOL ................... 22 drospirenone-ethinyl estradiol........................................... 20 DROXIA ............................. 11 DUETACT .......................... 19 DUONEB

see ipratropium-albuterol 27 DURAGESIC

see fentanyl ......................7

E econazole nitrate ................29 EFFEXOR XR.....................16 EFFIENT.............................24 ELAPRASE.........................20 ELDEPRYL

see selegiline hcl ............16 electrolyte-m in dextrose.....26 electrolyte-r .........................26 electrolyte-r in dextrose ......26 ELIDEL ...............................30 ELITEK ...............................12 ELIXOPHYLLIN ..................29 ELMIRON ...........................23 ELOCON

see mometasone furoate 30 ELSPAR..............................11 EMCYT ...............................10 EMEND...............................22 EMLA

see lidocaine-prilocaine ..30 EMSAM...............................16 EMTRIVA..............................9 ENABLEX ...........................23 enalapril maleate ................12 enalapril maleate & hydrochlorothiazide.............12 ENGERIX-B ........................25 ENTOCORT EC..................22 epinephrine hcl ...................28 EPIPEN 2-PAK ...................28 EPIPEN-JR 2-PAK..............28 EPIRUBICIN HCL ...............11 EPIVIR ..................................9 EPIVIR HBV........................10 eplerenone..........................12 EPZICOM .............................9 ergotamine w/ caffeine........18 ERYPED 200 ........................9 ERYTHROCIN LACTOBIONATE ..................9 erythromycin (acne aid) ......29 erythromycin (ophth) ...........27 erythromycin base ................9 erythromycin ethylsuccinate .9 erythromycin stearate ...........9 erythromycin-sulfisoxazole .10 ESTRACE...........................21

see estradiol ...................21 ESTRADERM .....................21 estradiol ..............................21 ESTRING............................21 estropipate ..........................21

ESTROSTEP FE see norethindrone acetate-

ethinyl estradiol-fe ...... 20 ethambutol hcl .................... 10 ethosuximide ...................... 15 ethynodiol diacet & eth estrad........................................... 20 ETHYOL

see amifostine crystalline12 etodolac ................................ 7 etoposide ............................ 12 EURAX ............................... 30 EVISTA............................... 22 EVOXAC ............................ 30 EXELON............................. 15 EXFORGE.......................... 12 EXFORGE HCT ................. 12 EXJADE ............................. 20 EXTAVIA ............................ 18

F FABRAZYME ..................... 20 famciclovir .......................... 10 famotidine ........................... 22 famotidine in nacl ............... 22 FAMVIR

see famciclovir................ 10 FANAPT ............................. 17 FANAPT TITRATION PACK........................................... 17 FARESTON........................ 11 FASLODEX ........................ 11 fat emulsion ........................ 26 FAZACLO........................... 17 FELBATOL ......................... 15 FELDENE

see piroxicam ................... 8 felodipine ............................ 14 FEMARA ............................ 11 FEMHRT 1/5 ...................... 21 FEMHRT LOW DOSE ........ 21 FEMRING........................... 21 fenofibrate .......................... 13 fenofibrate micronized ........ 13 fentanyl ................................. 7 fentanyl citrate ...................... 7 fexofenadine hcl ................. 28 FINACEA............................ 30 finasteride ........................... 23 FIORICET/CODEINE

see butalbital-acetaminophen-caffeine w/ codeine .................... 7

FIORINAL/CODEINE #3 see butalbital-aspirin-

36

caffeine w/cod .............. 7 FLAGYL

see metronidazole .......... 10 flecainide acetate ............... 13 FLEXERIL

see cyclobenzaprine hcl . 18 FLOMAX

see tamsulosin hcl.......... 23 FLONASE

see fluticasone propionate (nasal) ........................ 28

FLOVENT DISKUS ............ 28 FLOVENT HFA .................. 29 fluconazole ........................... 9 fluconazole in dextrose ........ 9 FLUDARABINE PHOSPHATE........................................... 12 fludrocortisone acetate....... 21 FLUMADINE

see rimantadine hydrochloride.............. 10

flunisolide (nasal) ............... 28 fluocinolone acetonide ....... 30 fluocinonide ........................ 30 fluocinonide emulsified base........................................... 30 fluorometholone (ophth) ..... 27 FLUOROPLEX................... 29 fluorouracil.......................... 11 fluorouracil (topical)............ 29 fluoxetine hcl ...................... 16 fluphenazine decanoate ..... 17 fluphenazine hcl ................. 17 flurbiprofen ........................... 7 flurbiprofen sodium............. 27 flutamide............................. 11 fluticasone propionate ........ 30 fluticasone propionate (nasal)........................................... 28 fluvoxamine maleate .......... 15 FML.................................... 27 FML LIQUIFILM

see fluorometholone (ophth) ........................ 27

FOCALIN see dexmethylphenidate hcl

................................... 17 FORADIL AEROLIZER ...... 28 FORTEO ............................ 21 FOSAMAX

see alendronate sodium . 20 fosinopril sodium ................ 12 fosinopril sodium & hydrochlorothiazide ............ 12 FOSRENOL ....................... 21

FRAGMIN ...........................24 FREAMINE HBC 6.9% .......26 FREAMINE III 3% ...............26 FROVA ...............................18 FURADANTIN.....................10 furosemide ..........................14 FUZEON ...............................9

G gabapentin ..........................15 GABITRIL ...........................15 galantamine hydrobromide .15 GAMASTAN S/D.................24 GAMMAGARD LIQUID.......24 GAMUNEX..........................24 ganciclovir...........................10 GANCICLOVIR ...................10 GARDASIL..........................25 GASTROCROM..................23 GAUZE PADS AND DRESSINGS - PADS 2 X 2 19 GELNIQUE .........................23 gemfibrozil ..........................13 GEMZAR ............................11 gentamicin in saline ..............9 gentamicin sulfate .................9 gentamicin sulfate (ophth) ..27 gentamicin sulfate (topical) .29 GEODON............................17 GLEEVEC...........................11 glimepiride ..........................19 glipizide...............................19 glipizide-metformin hcl ........19 GLUCAGEN HYPOKIT.......21 GLUCAGON EMERGENCY KIT ......................................21 GLUCOPHAGE

see metformin hcl ...........19 GLUCOTROL

see glipizide ....................19 GLUCOTROL XL

see glipizide ....................19 GLUCOVANCE

see glyburide-metformin .19 glyburide .............................19 glyburide micronized ...........19 glyburide-metformin ............19 glycopyrrolate .....................22 GLYNASE

see glyburide micronized 19 granisetron hcl ....................22 griseofulvin microsize ...........9 GRIS-PEG ............................9 guanfacine hcl.....................12 GUANIDINE HCL................18

GYNODIOL ........................ 21

H HALDOL DECANOATE 100

see haloperidol decanoate.................................... 17

HALFLYTELY BOWEL PREP........................................... 23 halobetasol propionate ....... 30 haloperidol .......................... 17 haloperidol decanoate ........ 17 haloperidol lactate .............. 17 HAVRIX .............................. 25 HECTOROL ....................... 26 heparin (porcine) in sodium chloride ............................... 24 heparin sod (porcine) in d5w........................................... 24 HEPARIN SODIUM ............ 24 heparin sodium (porcine).... 24 HEPARIN SODIUM/NACL 0.45% ................................. 24 HEPARIN SODIUM/SODIUM CHL

see heparin (porcine) in sodium chloride .......... 24

HEPATASOL...................... 26 HEPSERA .......................... 10 HERCEPTIN....................... 11 HEXALEN........................... 11 HUMALOG ......................... 19 HUMALOG MIX 50/50........ 19 HUMALOG MIX 50/50 PEN19 HUMALOG MIX 75/25........ 19 HUMALOG MIX 75/25 PEN19 HUMALOG PEN................. 19 HUMIRA ............................. 24 HUMIRA PEN-CROHNS DISEASE............................ 24 HUMULIN 70/30 ................. 19 HUMULIN 70/30 PEN......... 19 HUMULIN N ....................... 19 HUMULIN N U-100 PEN .... 19 HUMULIN R ....................... 19 HUMULIN R U-500 (CONCENTR...................... 19 HYCAMTIN......................... 12 hydralazine hcl ................... 14 HYDREA

see hydroxyurea ............. 11 hydrochlorothiazide ............ 14 hydrocodone-acetaminophen7 hydrocortisone .................... 21 hydrocortisone (intrarectal). 23 hydrocortisone (rectal)........ 29

37

hydrocortisone (topical)...... 30 hydrocortisone butyrate...... 30 hydrocortisone sod succinate........................................... 21 hydrocortisone valerate...... 30 hydrocortisone w/acetic acid........................................... 30 hydromorphone hcl .............. 7 hydroxychloroquine sulfate 24 hydroxyurea ....................... 11 hydroxyzine hcl .................. 28 hydroxyzine pamoate ......... 28 HYZAAR

see losartan potassium & hydrochlorothiazide .... 12

I ibuprofen .............................. 7 IDAMYCIN PFS

see idarubicin hcl ........... 11 idarubicin hcl ...................... 11 IFEX ................................... 11 IFOSFAMIDE ..................... 11 ifosfamide & mesna............ 12 imipramine hcl .................... 16 imiquimod ........................... 30 IMITREX

see sumatriptan succinate................................... 18

IMOVAX RABIES (H.D.C.V.)........................................... 25 IMURAN

see azathioprine ............. 25 INCRELEX ......................... 21 indapamide......................... 14 INDERAL LA

see propranolol hcl ......... 13 INDOCIN .............................. 7 indomethacin........................ 7 INFANRIX .......................... 25 INFERGEN......................... 24 INSPRA

see eplerenone .............. 12 INSULIN PEN NEEDLE ..... 19 INSULIN SYRINGE (DISP) U-100 0.3 ML ......................... 19 INSULIN SYRINGE (DISP) U-100 1 ML ............................ 19 INSULIN SYRINGE (DISP) U-100 1/2 ML ......................... 19 INTELENCE......................... 9 INTRALIPID

see fat emulsion ............. 26 INTRON-A.......................... 24 INTRON-A W/DILUENT ..... 24

INVANZ...............................10 INVEGA ..............................17 INVEGA SUSTENNA..........17 INVIRASE .............................9 IONOSOL-B/DEXTROSE 5%............................................26 IONOSOL-MB/DEXTROSE 5%.......................................26 IONOSOL-T/DEXTROSE 5%............................................26 IPOL INACTIVATED IPV ....25 ipratropium bromide ............28 ipratropium bromide (nasal)28 ipratropium-albuterol ...........27 IRINOTECAN......................11 ISENTRESS .........................9 ISOLYTE-H/DEXTROSE 5%............................................26 ISOLYTE-P/DEXTROSE 5%............................................26 ISOLYTE-S .........................26 ISOLYTE-S/DEXTROSE 5%............................................26 isoniazid..............................10 ISORDIL TITRADOSE........14 isosorbide dinitrate..............14 isosorbide mononitrate .......14 isotretinoin ..........................29 isradipine ............................14 ISTODAX ............................11 itraconazole ..........................9 IXIARO................................25

J JANUMET...........................19 JANUVIA.............................19 JE-VAX ...............................25

K KADIAN ................................7 KALETRA .............................9 KAYEXALATE

see sodium polystyrene sulfonate .....................20

KCL 0.15%/D10W/NACL 0.2%....................................26 KCL 0.15%/D5W/LR ...........26 KCL 0.15%/D5W/NACL 0.225%................................26 KCL 0.15%/D5W/NACL 0.9%

see potassium chloride in dextrose & sodium chloride .......................26

KCL 0.3%/D5W/NACL 0.9%............................................26

KEFLEX see cephalexin.................. 8

KENALOG .......................... 30 KEPPRA............................. 15

see levetiracetam ........... 15 ketoconazole ........................ 9 ketoconazole (topical) ........ 29 ketoprofen ............................ 7 ketorolac tromethamine ........ 7 ketorolac tromethamine (ophth) ................................ 27 KLARON

see sulfacetamide sodium (acne) ......................... 29

KLOR-CON M15 ................ 25 KRISTALOSE..................... 23 K-TABS

see potassium chloride... 25 KUVAN ............................... 20

L labetalol hcl ........................ 13 LAC-HYDRIN

see lactic acid (ammonium lactate)........................ 30

LACRISERT ....................... 27 lactated ringer's .................. 26 lactic acid (ammonium lactate)........................................... 30 lactulose ............................. 23 lactulose (encephalopathy) 23 LAMICTAL

see lamotrigine ............... 15 LAMISIL

see terbinafine hcl ............ 9 lamotrigine .......................... 15 LANOXIN............................ 14

see digoxin ..................... 14 LANSOPRAZOLE .............. 23 LANTUS ............................. 19 LANTUS SOLOSTAR......... 19 leflunomide ......................... 24 LESCOL ............................. 13 LESCOL XL........................ 13 LETAIRIS ........................... 14 leucovorin calcium .............. 12 LEUCOVORIN CALCIUM .. 12 LEUKERAN ........................ 11 LEUKINE ............................ 24 leuprolide acetate ............... 11 LEUSTATIN

see cladribine ................. 11 levalbuterol hcl ................... 28 LEVAQUIN ........................... 9 LEVEMIR............................ 19

38

LEVEMIR FLEXPEN .......... 19 levetiracetam...................... 15 levobunolol hcl ................... 27 levocarnitine (metabolic modifiers) ........................... 20 levonorgestrel & eth estradiol........................................... 20 levonorgestrel (emergency oc)........................................... 20 levonorgestrel-eth estradiol (triphasic) ........................... 20 levonorgestrel-ethinyl estradiol (91-day) ............... 20 levothyroxine sodium ......... 22 LEXAPRO .......................... 16 LEXIVA................................. 9 LIALDA............................... 23 lidocaine ............................. 30 lidocaine hcl ....................... 30 lidocaine hcl (local anesth.) .. 8 lidocaine hcl (mouth-throat) 30 lidocaine-prilocaine ............ 30 LIDODERM ........................ 30 liothyronine sodium ............ 22 LIPITOR ............................. 13 LIPOSYN II......................... 26 LIPOSYN III........................ 26 lisinopril .............................. 12 lisinopril & hydrochlorothiazide........................................... 12 lithium carbonate................ 18 LITHIUM CARBONATE

see lithium carbonate ..... 18 LITHIUM CITRATE ............ 18 LO/OVRAL

see norgestrel & ethinyl estradiol...................... 20

LOCOID see hydrocortisone butyrate

................................... 30 LOCOID LIPOCREAM ....... 30 LOESTRIN 1/20-21

see norethindrone acet & eth estra ..................... 20

LOESTRIN FE 1.5/30 see norethin acet & estrad-

fe ................................ 20 LOFIBRA

see fenofibrate ............... 13 see fenofibrate micronized

................................... 13 LOMOTIL

see diphenoxylate w/ atropine ...................... 22

loperamide hcl.................... 22

LOPID see gemfibrozil................13

LOPRESSOR see metoprolol tartrate ....13

LOPROX see ciclopirox ..................29

losartan potassium..............12 losartan potassium & hydrochlorothiazide.............12 LOTEMAX...........................27 LOTENSIN

see benazepril hcl ...........12 LOTREL..............................12

see amlodipine besylate-benazepril hcl..............12

LOTRONEX ........................23 lovastatin.............................13 LOVENOX ..........................24 loxapine succinate ..............17 LOXITANE

see loxapine succinate....17 LUMIGAN ...........................27 LUNESTA ...........................18 LUPRON DEPOT ...............11 LUPRON DEPOT-PED.......11 LUXIQ .................................30 LYRICA...............................15 LYSODREN ........................11

M MACROBID

see nitrofurantoin monohyd macro ..........................10

MACRODANTIN .................10 see nitrofurantoin

macrocrystal................10 MAGNESIUM SULFATE IN D5W....................................26 MALARONE..........................9 malathion ............................30 maprotiline hcl.....................16 MARPLAN ..........................16 MATULANE ........................11 MAVIK

see trandolapril ...............12 MAXALT .............................18 MAXALT-MLT .....................18 MAXITROL

see neomycin-polymy-dexameth ....................26

mebendazole ......................10 meclizine hcl .......................22 MEDROL

see methylprednisolone ..21 MEDROL DOSEPAK

see methylprednisolone.. 21 medroxyprogesterone acetate........................................... 22 medroxyprogesterone acetate (contraceptive).................... 20 mefloquine hcl ...................... 9 MEGACE ES ...................... 11 megestrol acetate ............... 11 meloxicam ............................ 7 melphalan hcl ..................... 11 MENACTRA ....................... 25 MENOMUNE-A/C/Y/W-135 25 MENTAX ............................ 29 meprobamate ..................... 15 MEPRON............................ 10 mercaptopurine .................. 11 MERUVAX II W/DILUENT 10 D......................................... 25 mesalamine ........................ 23 mesna................................. 12 MESNEX ............................ 12

see mesna ...................... 12 MESTINON ........................ 18

see pyridostigmine bromide.................................... 18

MESTINON TIMESPAN ..... 18 METADATE CD.................. 18 METAGLIP

see glipizide-metformin hcl.................................... 19

metaxalone ......................... 18 metformin hcl ...................... 19 methadone hcl ...................... 7 METHADONE HCL .............. 7 METHADONE HCL INTENSOL

see methadone hcl ........... 7 methazolamide ................... 14 methimazole ....................... 22 methocarbamol................... 18 methotrexate sodium .... 11, 24 methyldopa ......................... 14 METHYLIN ......................... 18 methylphenidate hcl ........... 18 methylprednisolone ............ 21 methylprednisolone acetate21 methylprednisolone sod succ........................................... 21 metipranolol ........................ 27 metoclopramide hcl ............ 22 metolazone ......................... 14 metoprolol & hydrochlorothiazide ............ 13 metoprolol succinate .......... 13 metoprolol tartrate .............. 13

39

METROGEL....................... 30 METROGEL-VAGINAL

see metronidazole vaginal................................... 23

METROLOTION see metronidazole (topical)

................................... 30 metronidazole..................... 10 metronidazole (topical)....... 30 metronidazole in nacl ......... 10 metronidazole vaginal ........ 23 MEVACOR

see lovastatin ................. 13 mexiletine hcl ..................... 13 MIACALCIN........................ 20

see calcitonin (salmon) .. 20 MICARDIS.......................... 12 MICARDIS HCT ................. 12 MIDAMOR

see amiloride hcl ............ 14 midodrine hcl...................... 14 MIGERGOT........................ 18 MINIPRESS

see prazosin hcl ............. 12 MINOCIN

see minocycline hcl .......... 9 minocycline hcl..................... 9 minoxidil ............................. 14 MIRAPEX

see pramipexole dihydrochloride ........... 16

mirtazapine......................... 16 misoprostol......................... 23 mitomycin ........................... 11 MITOXANTRONE HCL ...... 11 M-M-R II W/DILUENT 10 DOS........................................... 25 MOBIC

see meloxicam ................. 7 moexipril hcl ....................... 12 moexipril-hydrochlorothiazide........................................... 12 mometasone furoate .......... 30 MONOKET

see isosorbide mononitrate................................... 14

morphine sulfate................... 7 MORPHINE SULFATE......... 7 MOZOBIL ........................... 24 MS CONTIN

see morphine sulfate ........ 7 MULTAQ ............................ 13 mupirocin............................ 29 MUSTARGEN .................... 11 MYAMBUTOL

see ethambutol hcl..........10 MYCELEX

see clotrimazole ................9 MYCOBUTIN ......................10 mycophenolate mofetil ........25 MYFORTIC .........................25 MYOZYME..........................20 MYSOLINE

see primidone .................15

N nabumetone ..........................7 nadolol ................................13 nafcillin sodium .....................9 NAGLAZYME......................21 naloxone hcl........................19 naltrexone hcl .....................19 NAMENDA..........................15 NAMENDA TITRATION PAK............................................16 naphazoline hcl...................27 NAPROSYN

see naproxen ....................8 naproxen...............................8 naproxen sodium ..................8 NARDIL...............................16 NASACORT AQ..................28 NASONEX ..........................28 NATACYN...........................27 nateglinide ..........................19 NAVANE .............................17

see thiothixene................17 NAVELBINE

see vinorelbine tartrate ...11 NECON 10/11-28................20 NEEDLES, INSULIN DISP., SAFETY..............................19 nefazodone hcl ...................16 neomycin sulfate ...................9 neomycin-bacitracin zn-polymyxin............................27 neomycin-polymy-dexameth............................................26 neomycin-polymy-gramicid .27 neomycin-polymyxin-hc (ophth) ................................26 neomycin-polymyxin-hc (otic)............................................30 NEORAL .............................25

see cyclosporine modified (for microemulsion) .....25

NEOSPORIN see neomycin-polymy-

gramicid ......................27 NEPHRAMINE....................26

NEPTAZANE see methazolamide ........ 14

NEUPOGEN....................... 24 NEURONTIN ...................... 15

see gabapentin ............... 15 NEXAVAR .......................... 11 NEXIUM ............................. 23 NEXIUM I.V. ....................... 23 NIASPAN............................ 13 NICOTROL INHALER ........ 19 NICOTROL NS................... 19 nifedipine ............................ 14 NILANDRON ...................... 11 NIMODIPINE ...................... 14 NIPENT

see pentostatin ............... 11 nisoldipine .......................... 14 NITRO-DUR ....................... 14

see nitroglycerin ............. 14 nitrofurantoin macrocrystal . 10 nitrofurantoin monohyd macro........................................... 10 nitroglycerin ........................ 14 NITROLINGUAL PUMPSPRAY..................... 14 NITROSTAT ....................... 14 NIZORAL

see ketoconazole (topical).................................... 29

NORDITROPIN CARTRIDGE........................................... 21 NORDITROPIN NORDIFLEX PEN .................................... 21 norethin acet & estrad-fe .... 20 norethindrone & eth estradiol........................................... 20 norethindrone (contraceptive)........................................... 20 norethindrone acet & eth estra........................................... 20 norethindrone acetate ........ 22 norethindrone acetate-ethinyl estradiol-fe.......................... 20 norethindrone-eth estradiol (triphasic)............................ 20 norgestimate-ethinyl estradiol........................................... 20 norgestimate-ethinyl estradiol (triphasic)............................ 20 norgestrel & ethinyl estradiol........................................... 20 NORINYL 1+35

see norethindrone & eth estradiol ...................... 20

NORMOSOL-R................... 26

40

NORPACE see disopyramide

phosphate................... 13 NORPACE CR ................... 13 NORPRAMIN

see desipramine hcl ....... 16 NOR-QD

see norethindrone (contraceptive)............ 20

nortriptyline hcl ................... 16 NORVASC

see amlodipine besylate. 14 NORVIR ............................... 9 NOVOLIN 70/30 ................. 20 NOVOLIN 70/30 INNOLET 20 NOVOLIN N ....................... 20 NOVOLIN N INNOLET....... 20 NOVOLIN R ....................... 20 NOVOLOG......................... 20 NOVOLOG FLEXPEN........ 20 NOVOLOG MIX 70/30........ 20 NOVOLOG MIX 70/30 PREFILL............................. 20 NOXAFIL.............................. 9 NULYTELY/FLAVOR PACKS

see peg 3350-potassium chloride-sod bicarbonate-sod chloride ................ 23

NUVARING ........................ 20 nystatin................................. 9 nystatin (mouth-throat) ....... 30 nystatin (topical) ................. 29

O octreotide acetate............... 21 OCTREOTIDE ACETATE .. 21 OCUFEN

see flurbiprofen sodium .. 27 OCUFLOX

see ofloxacin (ophth) ...... 27 ofloxacin (ophth)................. 27 ofloxacin (otic) .................... 30 omeprazole ........................ 23 OMNIPRED

see prednisolone acetate (ophth) ........................ 27

ONCASPAR....................... 11 ondansetron ....................... 22 ondansetron hcl.................. 22 ONGLYZA.......................... 20 ONTAK............................... 11 OPANA ER........................... 7 OPTIPRANOLOL

see metipranolol ............. 27 OPTIVAR

see azelastine hcl (ophth)....................................27

ORACEA.............................30 ORAP..................................17 ORAPRED

see prednisolone sodium phosphate ...................21

ORFADIN............................21 orphenadrine citrate ............18 ORPHENADRINE COMPOUND DS ................18 orphenadrine w/ aspirin & caff............................................18 ORTHO EVRA ....................20 ORTHO TRI-CYCLEN

see norgestimate-ethinyl estradiol (triphasic)......20

ORTHO TRI-CYCLEN LO ..20 ORTHO-CYCLEN

see norgestimate-ethinyl estradiol ......................20

ORTHO-NOVUM 7/7/7-28 see norethindrone-eth

estradiol (triphasic)......20 OVIDE

see malathion .................30 OXALIPLATIN.....................12 OXANDRIN

see oxandrolone .............19 oxandrolone ........................19 OXANDROLONE................19 oxaprozin ..............................8 oxcarbazepine ....................15 OXISTAT ............................29 OXSORALEN ULTRA.........29 oxybutynin chloride .............23 oxycodone hcl.......................7 oxycodone w/ acetaminophen..............................................7 oxycodone w/ aspirin ............7 OXYCONTIN ........................7 OXYTROL...........................23

P PACERONE........................13 paclitaxel.............................11 PAMELOR

see nortriptyline hcl .........16 PANRETIN..........................30 PANTOPRAZOLE SODIUM23 PARAFON FORTE DSC

see chlorzoxazone ..........18 parenteral electrolytes ........25 PARLODEL

see bromocriptine mesylate

.................................... 16 PARNATE

see tranylcypromine sulfate.................................... 16

paromomycin sulfate ............ 9 paroxetine hcl ..................... 16 PASER ............................... 10 PATADAY........................... 27 PATANOL........................... 27 PAXIL

see paroxetine hcl .......... 16 PAXIL CR

see paroxetine hcl .......... 16 PEDIARIX........................... 25 PEDVAX HIB...................... 25 peg 3350-kcl-sod bicarb-sod chloride-sod sulfate ............ 23 peg 3350-potassium chloride-sod bicarbonate-sod chloride........................................... 23 PEGANONE ....................... 15 PEGASYS .......................... 24 PEG-INTRON..................... 24 PEG-INTRON REDIPEN.... 24 penicillin g potassium ........... 9 PENICILLIN G PROCAINE .. 9 penicillin v potassium ........... 9 PENTASA........................... 23 pentostatin .......................... 11 pentoxifylline....................... 24 PEPCID .............................. 22

see famotidine ................ 22 PEPCID I.V.

see famotidine ................ 22 PEPCID PREMIXED

see famotidine in nacl..... 22 PERCOCET

see oxycodone w/ acetaminophen ............. 7

PERCODAN see oxycodone w/ aspirin . 7

PERIDEX see chlorhexidine gluconate

(mouth-throat)............. 30 perindopril erbumine........... 12 PERIOSTAT

see doxycycline hyclate.... 8 permethrin .......................... 30 perphenazine...................... 17 perphenazine-amitriptyline . 19 PERSANTINE

see dipyridamole ............ 24 PFIZERPEN-G

see penicillin g potassium. 9 PHENERGAN

41

see promethazine hcl ..... 22 phenytoin............................ 15 phenytoin sodium ............... 15 phenytoin sodium extended15 PHOSLO ............................ 21

see calcium acetate (phosphate binder) ..... 21

PHOTOFRIN ...................... 11 pilocarpine hcl (oral)........... 30 PILOPINE HS..................... 27 pindolol............................... 13 piperacillin sodium-tazobactam sodium .............. 9 piroxicam.............................. 8 PLAN B

see levonorgestrel (emergency oc) .......... 20

PLAQUENIL see hydroxychloroquine

sulfate......................... 24 PLASMA-LYTE 56 ............. 26 PLASMA-LYTE A ............... 26 PLASMA-LYTE-148 ........... 26 PLASMA-LYTE-148/D5W .. 26 PLASMA-LYTE-56/D5W .... 26 PLAVIX............................... 24 PLETAL

see cilostazol.................. 24 podofilox............................. 30 polyethylene glycol 3350 .... 23 polymyxin b-trimethoprim ... 27 POLYTRIM

see polymyxin b-trimethoprim ............... 27

potassium chloride ....... 25, 26 POTASSIUM CHLORIDE

see potassium chloride .. 26 POTASSIUM CHLORIDE 0.15%................................. 26 POTASSIUM CHLORIDE 0.15%/

see potassium chloride in nacl............................. 26

POTASSIUM CHLORIDE 0.3%/ .................................. 26 potassium chloride in d5w lactated ringers................... 26 potassium chloride in dextrose........................................... 26 potassium chloride in dextrose & sodium chloride............... 26 potassium chloride in nacl.. 26 potassium chloride microencapsulated crystals cr........................................... 25

potassium citrate (alkalinizer)............................................23 pramipexole dihydrochloride............................................16 PRANDIN............................20 PRAVACHOL

see pravastatin sodium ...13 pravastatin sodium..............13 prazosin hcl.........................12 PRECOSE

see acarbose ..................19 PRED MILD ........................27 prednisolone .......................21 prednisolone acetate (ophth)............................................27 PREDNISOLONE SODIUM PHOSP ...............................27 prednisolone sodium phosphate ...........................21 prednisone ..........................21 PREDNISONE INTENSOL .21 PREFEST ...........................21 PREMARIN.........................21 PREMARIN W/APPLICATOR............................................21 PREMASOL........................26 PREMPHASE .....................21 PREMPRO..........................21 prenatal without a vit w/ iron carbonyl-folic acid ...............26 PREVPAC...........................23 PREZISTA ............................9 PRIFTIN..............................10 PRILOSEC

see omeprazole ..............23 PRIMAXIN I.M. ...................10 PRIMAXIN IV ......................10 primidone ............................15 PRINIVIL

see lisinopril ....................12 PRINZIDE

see lisinopril & hydrochlorothiazide.....12

PRISTIQ .............................16 PROAIR HFA......................28 PROAMATINE

see midodrine hcl............14 probenecid ............................7 PROCALAMINE..................26 PROCARDIA

see nifedipine..................14 prochlorperazine .................22 prochlorperazine edisylate ..22 prochlorperazine maleate ...22 PROCRIT............................24

PROCTOCORT see hydrocortisone (topical)

.................................... 30 PROGLYCEM .................... 21 PROGRAF.......................... 25

see tacrolimus ................ 25 PROLEUKIN....................... 11 PROMACTA ....................... 24 promethazine hcl ................ 22 PROMETRIUM................... 22 propafenone hcl.................. 13 proparacaine hcl ................. 27 propranolol hcl .................... 13 propylthiouracil ................... 22 PROQUAD ......................... 25 PROSCAR

see finasteride ................ 23 PROSOL ............................ 26 PROTOPIC......................... 30 protriptyline hcl ................... 16 PROVENTIL HFA............... 28 PROVERA

see medroxyprogesterone acetate........................ 22

PROVIGIL .......................... 18 PROZAC

see fluoxetine hcl............ 16 PULMICORT FLEXHALER 29 PULMOZYME..................... 28 PURINETHOL

see mercaptopurine........ 11 pyrazinamide ...................... 10 pyridostigmine bromide ...... 18

Q QUALAQUIN ........................ 9 QUESTRAN LIGHT

see cholestyramine light . 13 quinapril hcl ........................ 12 quinapril-hydrochlorothiazide........................................... 12 quinidine gluconate ............ 13 quinidine sulfate ................. 13 QUIXIN ............................... 27 QVAR ................................. 29

R RABAVERT ........................ 25 ramipril................................ 12 RANEXA............................. 14 ranitidine hcl ....................... 22 RAPAMUNE ....................... 25 RAPIFLUX

see fluoxetine hcl............ 16 RAZADYNE

42

see galantamine hydrobromide ............. 15

RAZADYNE ER see galantamine

hydrobromide ............. 15 REBETOL .......................... 10 REBIF................................. 18 REBIF TITRATION PACK.. 18 RECOMBIVAX HB ............. 25 REGLAN

see metoclopramide hcl . 22 REGONOL ......................... 18 REGRANEX....................... 30 RELENZA DISKHALER ..... 10 RELION R .......................... 20 RELISTOR ......................... 23 RELPAX............................. 18 REMERON

see mirtazapine .............. 16 REMERON SOLTAB

see mirtazapine .............. 16 REMICADE ........................ 24 RENAGEL .......................... 21 RENAMIN........................... 26 RENVELA .......................... 21 REQUIP

see ropinirole hydrochloride................................... 16

REQUIP XL ........................ 16 RESCRIPTOR...................... 9 RESTASIS ......................... 27 RETIN-A

see tretinoin.................... 29 RETIN-A MICRO................ 29 RETROVIR

see zidovudine ................. 9 RETROVIR IV INFUSION .... 9 REVATIO ........................... 14 REVIA

see naltrexone hcl .......... 19 REVLIMID .......................... 24 REYATAZ............................. 9 RHEUMATREX.................. 24 RHINOCORT AQUA .......... 28 RIBAPAK............................ 10 RIBASPHERE.................... 10 RIBAVIRIN ......................... 10 ribavirin (hepatitis c) ........... 10 RIFADIN

see rifampin.................... 10 rifampin .............................. 10 RILUTEK............................ 18 rimantadine hydrochloride.. 10 ringer's ............................... 26 RISPERDAL

see risperidone ...............17 RISPERDAL CONSTA .......17 RISPERDAL M-TAB

see risperidone ...............17 risperidone ..........................17 RITALIN

see methylphenidate hcl .18 RITALIN LA.........................18 RITUXAN ............................11 ROBAXIN............................18

see methocarbamol ........18 ROBINUL

see glycopyrrolate...........22 ROCALTROL

see calcitriol ....................26 ropinirole hydrochloride ......16 ROTATEQ ..........................25 ROXICET..............................7 ROXICODONE

see oxycodone hcl ............7 RYTHMOL

see propafenone hcl .......13 RYTHMOL SR ....................13

S SABRIL ...............................15 SAIZEN...............................21 SAIZEN CLICK.EASY.........21 SALAGEN

see pilocarpine hcl (oral).30 SANCTURA XR ..................23 SANCUSO ..........................22 SANDIMMUNE ...................25

see cyclosporine .............25 SANDOSTATIN

see octreotide acetate ....21 SANDOSTATIN LAR DEPOT............................................21 SANTYL..............................30 SAPHRIS ............................17 SAVELLA............................18 SAVELLA TITRATION PACK............................................18 SEASONALE

see levonorgestrel-ethinyl estradiol (91-day) ........20

SECTRAL see acebutolol hcl ...........13

selegiline hcl .......................16 selenium sulfide ..................29 SELSUN SHAMPOO

see selenium sulfide .......29 SELZENTRY.........................9 SENSIPAR..........................20 SEREVENT DISKUS ..........28

SEROMYCIN...................... 10 SEROQUEL ....................... 17 SEROQUEL XR ................. 17 sertraline hcl ....................... 16 SILVADENE

see silver sulfadiazine .... 29 silver sulfadiazine ............... 29 SIMCOR ............................. 13 simvastatin ......................... 13 SINEMET

see carbidopa-levodopa . 16 SINGULAIR ........................ 28 SKELAXIN

see metaxalone .............. 18 sodium chloride ............ 25, 26 sodium chloride (gu irrigant)30 sodium fluoride ................... 25 sodium polystyrene sulfonate........................................... 20 SOLARAZE ........................ 29 SOLU-CORTEF.................. 21

see hydrocortisone sod succinate .................... 21

SOLU-MEDROL see methylprednisolone

sod succ ..................... 21 SOMA

see carisoprodol ............. 18 SOMATULINE DEPOT....... 21 SOMAVERT ....................... 21 SONATA

see zaleplon ................... 18 SORIATANE....................... 29 sotalol hcl ........................... 13 SPIRIVA HANDIHALER ..... 28 spironolactone .................... 12 spironolactone & hydrochlorothiazide ............ 14 SPORANOX ......................... 9

see itraconazole ............... 9 SPRYCEL........................... 11 STADOL

see butorphanol tartrate ... 7 STALEVO 100.................... 16 STALEVO 125.................... 16 STALEVO 150.................... 16 STALEVO 200.................... 16 STALEVO 50...................... 17 STALEVO 75...................... 17 STARLIX

see nateglinide ............... 19 stavudine .............................. 9 STELARA ........................... 29 STRATTERA ...................... 18 streptomycin sulfate ............. 9

43

SUBLIMAZE see fentanyl citrate ........... 7

SUBOXONE....................... 19 SUBUTEX

see buprenorphine hcl.... 18 SUCRAID ........................... 21 sucralfate............................ 23 sulfacetamide sodium (acne)........................................... 29 sulfacetamide sodium (ophth)........................................... 27 sulfacetamide sod-prednisolone....................... 26 SULFADIAZINE ................... 9 sulfamethoxazole-trimethoprim ....................... 10 sulfasalazine ...................... 23 sulindac ................................ 8 sumatriptan succinate ........ 18 SUPRAX .............................. 9 SURMONTIL ...................... 16 SUSTIVA.............................. 9 SUTENT............................. 11 SYMBICORT...................... 29 SYMLIN.............................. 20 SYMLINPEN 120 ............... 20 SYMLINPEN 60 ................. 20 SYNAREL .......................... 20 SYNTHROID ...................... 22

see levothyroxine sodium22 SYPRINE ........................... 20

T TABLOID............................ 11 tacrolimus........................... 25 TACROLIMUS.................... 25 TAMBOCOR

see flecainide acetate .... 13 TAMIFLU............................ 10 tamoxifen citrate................. 11 tamsulosin hcl .................... 23 TAPAZOLE

see methimazole ............ 22 TARCEVA .......................... 11 TARGRETIN ................ 11, 30 TARKA ............................... 12

see trandolapril-verapamil hcl............................... 12

TASIGNA ........................... 11 TAXOTERE........................ 11 TEGRETOL

see carbamazepine ........ 15 TEGRETOL-XR.................. 15 TEKTURNA........................ 14 TEKTURNA HCT ............... 14

TEMOVATE see clobetasol propionate

....................................29 TEMOVATE E

see clobetasol propionate emollient base.............29

TENEX see guanfacine hcl ..........12

TENORETIC 100 see atenolol &

chlorthalidone..............13 TENORMIN

see atenolol ....................13 TERAZOL 7

see terconazole vaginal ..23 terazosin hcl........................12 terbinafine hcl .......................9 terbutaline sulfate ...............28 terconazole vaginal.............23 TESTIM...............................19 testosterone cypionate........19 testosterone enanthate .......19 TETANUS TOXOID ADSORBED........................25 TETANUS/DIPHTHERIA TOXOID ..............................25 tetracycline hcl ......................9 TEVETEN ...........................12 TEVETEN HCT...................12 TEV-TROPIN ......................21 THALITONE........................14 THALOMID .........................24 THEO-24.............................29 theophylline.........................29 THIOLA...............................23 thioridazine hcl....................17 thiothixene ..........................17 TIAZAC

see diltiazem hcl extended release beads .............14

ticlopidine hcl ......................24 TIGAN

see trimethobenzamide hcl....................................22

TIKOSYN ............................13 timolol maleate (ophth) .......27 TIMOPTIC

see timolol maleate (ophth)....................................27

TIMOPTIC-XE see timolol maleate (ophth)

....................................27 TINDAMAX .........................10 tizanidine hcl .......................18 TOBI ...................................28

TOBRADEX........................ 26 see tobramycin-

dexamethasone .......... 26 tobramycin sulfate ................ 9 tobramycin sulfate (ophth) .. 27 tobramycin-dexamethasone26 TOBREX............................. 27

see tobramycin sulfate (ophth) ........................ 27

TOFRANIL see imipramine hcl.......... 16

tolmetin sodium .................... 8 TOPAMAX

see topiramate................ 15 TOPICORT

see desoximetasone....... 30 topiramate .......................... 15 TOPROL XL

see metoprolol succinate 13 torsemide............................ 14 TORSEMIDE ...................... 14 TOVIAZ .............................. 23 TRACLEER ........................ 14 tramadol hcl .......................... 7 tramadol-acetaminophen...... 7 TRANDATE

see labetalol hcl.............. 13 trandolapril.......................... 12 trandolapril-verapamil hcl ... 12 TRANSDERM-SCOP ......... 22 tranylcypromine sulfate ...... 16 TRAVASOL ........................ 26 TRAVATAN Z ..................... 27 trazodone hcl ...................... 16 TREANDA .......................... 11 TRECATOR........................ 10 TRELSTAR DEPOT MIXJECT........................................... 11 TRELSTAR LA MIXJECT... 11 TRENTAL

see pentoxifylline ............ 24 tretinoin............................... 29 TRETINOIN ........................ 11 triamcinolone acetonide (mouth) ............................... 30 triamcinolone acetonide (topical)............................... 30 triamterene & hydrochlorothiazide ............ 14 TRICOR.............................. 13 trifluoperazine hcl ............... 17 trifluridine ............................ 27 trihexyphenidyl hcl .............. 17 TRIHIBIT ............................ 25 TRILEPTAL

44

see oxcarbazepine ......... 15 TRILIPIX............................. 13 trimethobenzamide hcl ....... 22 trimethoprim ....................... 10 TRIPEDIA........................... 25 TRISENOX......................... 11 TRIZIVIR .............................. 9 TROPHAMINE ................... 26 TRUSOPT

see dorzolamide hcl ....... 27 TRUVADA............................ 9 TWINRIX ............................ 25 TYGACIL............................ 10 TYKERB............................. 11 TYPHIM VI ......................... 25 TYZEKA ............................. 10 TYZINE .............................. 28 TYZINE PEDIATRIC NASAL DR...................................... 28

U ULORIC................................ 7 ULTRACET

see tramadol-acetaminophen............. 7

ULTRAM see tramadol hcl ............... 7

ULTRAVATE see halobetasol propionate

................................... 30 UNASYN

see ampicillin & sulbactam sodium.......................... 8

UNIRETIC see moexipril-

hydrochlorothiazide .... 12 UNIVASC

see moexipril hcl ............ 12 URECHOLINE

see bethanechol chloride 23 UROCIT-K 10

see potassium citrate (alkalinizer) ................. 23

UROXATRAL ..................... 23 URSO 250

see ursodiol .................... 23 ursodiol............................... 23

V VAGIFEM........................... 21 valacyclovir hcl ................... 10 VALCYTE........................... 10 valproate sodium................ 15 valproic acid ....................... 15 VALTREX

see valacyclovir hcl .........10 VALTURNA.........................12 VANCOCIN HCL.................10 vancomycin hcl ...................10 VANCOMYCIN HCL ISO-OSMOTI..............................10 VANTIN

see cefpodoxime proxetil ..8 VAQTA................................25 VARIVAX ............................25 VASOTEC

see enalapril maleate......12 VELCADE ...........................11 venlafaxine hcl ....................16 verapamil hcl.......................14 VERELAN PM

see verapamil hcl ............14 VESICARE..........................23 VFEND..................................9 VFEND IV .............................9 VIBRAMYCIN

see doxycycline hyclate ....8 VICODIN ES

see hydrocodone-acetaminophen .............7

VIDAZA...............................11 VIDEX...................................9 VIDEX EC

see didanosine..................9 VIGAMOX ...........................27 VIMPAT ..............................15 VINBLASTINE SULFATE ...11 vincristine sulfate ................11 vinorelbine tartrate ..............11 VIRACEPT............................9 VIRAMUNE...........................9 VIREAD ................................9 VIROPTIC

see trifluridine .................27 VISICOL..............................23 VIVACTIL

see protriptyline hcl .........16 VIVELLE-DOT ....................21 VIVOTIF BERNA ................25 VOLTAREN ..........................8

see diclofenac sodium (ophth).........................27

VOLTAREN-XR see diclofenac sodium ......7

VOSOL see acetic acid (otic) .......30

VOSOL HC see hydrocortisone w/acetic

acid .............................30 VOSPIRE ER

see albuterol sulfate ....... 28 VOTRIENT ......................... 11 VPRIV................................. 21 VYTORIN ........................... 13

W warfarin sodium .................. 24 WELCHOL.......................... 13 WELLBUTRIN

see bupropion hcl ........... 16 WESTCORT

see hydrocortisone valerate.................................... 30

X XALATAN ........................... 26 XENAZINE ......................... 18 XIBROM ............................. 27 XOLAIR .............................. 28 XOPENEX .......................... 28 XOPENEX CONCENTRATE

see levalbuterol hcl......... 28 XOPENEX HFA.................. 28 XYLOCAINE

see lidocaine hcl (local anesth.)......................... 8

XYLOCAINE JELLY see lidocaine hcl ............. 30

XYREM............................... 18 XYZAL ................................ 28

Y YF-VAX .............................. 25

Z zaleplon .............................. 18 ZANTAC

see ranitidine hcl............. 22 ZARONTIN

see ethosuximide............ 15 ZAVESCA........................... 21 ZEBETA

see bisoprolol fumarate .. 13 ZEGERID ........................... 23 ZEMPLAR .......................... 26 ZENPEP ............................. 23 ZERIT

see stavudine ................... 9 ZETIA ................................. 13 ZIAC

see bisoprolol & hydrochlorothiazide .... 13

ZIAGEN ................................ 9 zidovudine ............................ 9 ZINACEF

45

see cefuroxime sodium .... 8 ZINECARD

see dexrazoxane ............ 12 ZITHROMAX

see azithromycin .............. 8 ZOCOR

see simvastatin .............. 13 ZOFRAN ODT

see ondansetron ............ 22 ZOLINZA............................ 11 ZOLOFT

see sertraline hcl ............ 16

zolpidem tartrate .................18 ZOMETA.............................20 ZOMIG ................................18 ZOMIG ZMT........................18 ZONALON ..........................29 ZONEGRAN

see zonisamide ...............15 zonisamide..........................15 ZOSTAVAX.........................25 ZOSYN

see piperacillin sodium-tazobactam sodium.......9

ZOVIRAX............................ 29 see acyclovir................... 10

ZYBAN see bupropion hcl (smoking

deterrent) .................... 19 ZYLOPRIM

see allopurinol .................. 7 ZYMAR............................... 27 ZYPREXA........................... 17 ZYPREXA ZYDIS ............... 17 ZYVOX ............................... 10

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

S5601_11_40002_Plus File & Use 10/01/2010

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

{Begin_Tag}+

000001

SCOTTSDALE, AZ 852609501 E SHEA BLVDJOHN Q SAMPLE

P.O. Box 280200, Nashville, TN 37288

/001/000001_DFORM_9100_

!852606719015!

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

Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2012.

SilverScript Insurance Company is a Medicare-approved Part D Sponsor.

Contact Customer Care 24 hours a day, 7 days a week, at 1-866-235-5660 to request materials in an alternate format or language. TTY users should call 1-866-236-1069. Llame al Servicio al Cliente las 24 horas del día, los 7 días de la semana, al 1-866-235-5660 para solicitar materiales en un formato o idioma diferente. Los usuarios de teléfono de texto (TTY) pueden llamar al 1-866-236-1069.

¹Other Pharmacies are Available in our Network.11010_Jan

NOTE: Please contact us if you have questions or concerns about our plans. Medicare representatives cannot answer questions about specific plan benefits. To change your phone number or address, call Customer Care at the numbers below.

Call Customer Care from 8:00 a.m. to 2:00 a.m. ET, 7 days a week at: 1-866-552-6106TTY: 1-866-552-6288

Call Customer Care 24 hours a day, 7 days a week at: 1-866-235-5660TTY: 1-866-236-1069

Or visit our Web site at www.silverscript.comSilverScript, P.O. Box 280200, Nashville, TN 37228

NOTE: Medicare representatives can only answer general questions about Medicare Part D prescription drug coverage. For questions about specific Plan benefits, please call our Customer Care representatives at the numbers above.

Call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week. Or visit www.medicare.gov.

S5601_11_40002_Plus File & Use 10/01/2010

Contact SilverScript Insurance Company for more information about our plans

For more information about Medicare

Prospective members

Current members

CVS Caremark Plus (PDP)¹

2011 FormularyList of Covered Drugs

Documents

2011Comprehensive Formularycover Jan€¦ · CVS Caremark Plus (PDP)¹ 2011 Formulary List of Covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER