2013 COMpreHensive FOrMulAry - AlohaCare

H5969_ACA108501_1 CMS Accepted 07212012

AlohaCare Advantage (HMO) 2013 COMpreHensive 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.

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AlohaCare Advantage (HMO)

2013 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, 2014. AlohaCare Advantage is a health plan with a Medicare contract. Call 1-866-973-6395 to receive material in an alternate format or language. 00013470 Version 13 H5969_ACA108501_1 CMS Accepted 07212012

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What is the AlohaCare Advantage (HMO) Formulary? A formulary is a list of covered drugs selected by AlohaCare Advantage 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. AlohaCare Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an AlohaCare Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary change? Generally, if you are taking a drug on our 2013 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2013 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 authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the 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 August 15, 2012. To get updated information about the drugs covered by AlohaCare Advantage, please visit our Web site at www.AlohaCare.org or call Customer Service at 1-866-973-6395, 8 a.m. to 8 p.m., 7 days a week. TTY users should call 1-877-447-5990.

If we make any mid-year non-maintenance changes to the AlohaCare Advantage formulary, we will mail you a copy of the formulary changes via errata sheets to ensure that you have a complete and updated formulary. How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 1. 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, HYPERTENSION/ LIPIDS. If you know what your drug is used for, look for the category name in the list that begins page 1. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 78. 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.

What are generic drugs? AlohaCare Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active

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ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: AlohaCare Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from AlohaCare Advantage before you fill your prescriptions. If you don’t get approval, AlohaCare Advantage may not cover the drug.

• Quantity Limits: For certain drugs, AlohaCare Advantage limits the amount of the drug that AlohaCare Advantage will cover. For example, AlohaCare Advantage provides 18 tablets/30 days per prescription for sumatriptan 50mg. This may be in addition to a standard one month or three month supply.

• Step Therapy: In some cases, AlohaCare

Advantage 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, AlohaCare Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, AlohaCare Advantage will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site at www.AlohaCare.org. You can ask AlohaCare Advantage to make an exception to these restrictions or limits. See the section, “How do I request an exception to the

AlohaCare Advantage’s formulary?” on page iii for information about how to request an exception. What are over-the counter (OTC) drugs? OTC drugs are non-prescription drugs that are not normally covered by a Medicare Prescription Drug Plan. AlohaCare Advantage pays for certain OTC drugs, Prilosec OTC 20mg, omeprazole OTC 20mg, Prevacid 24 Hour 15mg, Claritin OTC 10mg, loratadine OTC 10mg, Allegra OTC 180mg, Zyrtec OTC 10mg and cetirizine OTC 10mg. AlohaCare Advantage will provide these OTC drugs at no cost to you. The cost to AlohaCare Advantage of these OTC drugs will not count toward your total drug costs. What if my drug is not on the Formulary? If your drug is not included in this formulary, you should first contact Customer Service and confirm that your drug is not covered. If you learn that AlohaCare Advantage does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by AlohaCare Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by AlohaCare Advantage.

• You can ask AlohaCare Advantage to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the AlohaCare Advantage’s Formulary? You can ask AlohaCare Advantage to make 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, AlohaCare Advantage limits the amount of the drug that we will cover. If your drug has a

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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 our non-preferred tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier instead. This would lower the 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 the tier designated as the high-cost tier.

Generally, AlohaCare Advantage will only approve your request for an exception if the alternative drugs 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 utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor 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. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? 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. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (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 allow you to refill your prescription until we have provided you with a 91-day transition supply, consistent with the dispensing increment, (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 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. Transition policy for level of care changes Upon notification, AlohaCare Advantage will cover up to a 60-day supply of a prescription drug (unless you have a prescription written for fewer days) for current members who have a level of care change. A level of care change includes the following situations: if you enter a long-term care facility from a hospital or other setting; if you leave a long-term care facility to return to a community/home setting; if you are discharged from a hospital to a community/home setting; if you end your skilled nursing facility stay covered under Medicare Part A and need to revert to coverage under AlohaCare Advantage; if your hospice status reverts to standard Medicare Part

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A and B benefits; or, if you are discharged from a psychiatric hospital with a drug regimen that is highly individualized. For more information For more detailed information about your AlohaCare Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have any questions about AlohaCare Advantage, please call Customer Service at 1-866-973-6395, 8 a.m. to 8 p.m., 7 days a week. TTY users should call 1-877-447-5990. Or visit www.AlohaCare.org. 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. AlohaCare Advantage’s Formulary The formulary that begins on the next page provides coverage information about some of the drugs covered by AlohaCare Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 78. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CIPRO) and generic drugs are listed in lower-case italics (e.g., ciprofloxacin).

The information in the Requirements/Limits column tells you if AlohaCare Advantage has any special requirements for coverage of your drug. The following abbreviations explain any restrictions on coverage, which are described in more detail on page iii. BvsD = Part B versus Part D: This drug may be covered under Medicare Part B or Part D, depending on the circumstances MO = Mail Order service available: This service helps you save money on your prescription drug costs and your drugs will be conveniently mailed to your home. PA = Prior Authorization QL = Quantity Limit ST = Step Therapy LA = Limited Access: This prescription may be available only at certain pharmacies. For more information consult your Provider & Pharmacy Directory or call Customer Service at 1-866-973-6395, 8 a.m. to 8 p.m., 7 days a week. TTY users should call 1-877-447-5990. All drugs on the AlohaCare Advantage formulary are listed with a tier designation. The tier designation of a drug and coverage level determines the amount of copayment or coinsurance that you will pay for that drug. Please refer to the following table for copayment and coinsurance amounts. For more information, please see the Evidence of Coverage.

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Effective January 1, 2013 Initial Coverage Coverage Gap

(Doughnut Hole) Catastrophic

Coverage

When your total drug cost for Part D drugs (paid by you and any Part D plan) for 2013 is less than $2,970, you pay:

Once the total cost of your Part D drugs paid by you and any Part D plan reaches $2,970, you pay:

Once your out-of-pocket expense (TrOOP) for covered Part D drugs reach $4,750 you pay:

Tier 1: Preferred Generic Drugs • 30-day retail • 90-day retail • 90-day mail order

• $4 copay • $12 copay • $8 copay

Member pays 79% of the costs of generic drugs for a 30 or 90-day supply

The greater of: $2.65 or 5% $2.65 or 5% $2.65 or 5%

Tier 2: Non-Preferred Generic Drugs • 30-day retail • 90-day retail • 90-day mail order


Member pays 79% of the costs of generic drugs for a 30 or 90-day supply


Tier 3: Preferred Brand Drugs • 30-day retail • 90-day retail • 90-day mail order


Member pays no more than 47.5% of the costs of brand drugs for a 30 or 90-day supply


Tier 4: Non-Preferred Brand Drugs • 30-day retail • 90-day retail • 90-day mail


Member pays no more than 47.5% of the costs of brand drugs for a 30 or 90-day supply


Tier 5: Specialty Drugs • 30-day retail • 90-day retail • 90-day mail order

• 33% coinsurance • 33% coinsurance • 33% coinsurance

Member pays for a 30 or 90-day supply


Page 1 of 89

Drug Tier Requirements/

Limits

Anti - Infectives

Antifungal Agents

ABELCET IV 5

mg/mL

4 BvsD; MO

AMBISOME IV

SUSP 50 mg

4 BvsD; MO

AMPHOTEC IV

SUSP 50 mg

4 BvsD; MO

amphotericin B

Solution for Injection

50 mg

2 BvsD; MO

ANCOBON

CAPSULE 250 mg,

500 mg

5 MO

CANCIDAS IV

SOLUTION 50 mg,

70 mg

4 BvsD; MO

clotrimazole Troche

10 mg

2 MO

ERAXIS(WATER

DILUENT) IV

SOLUTION 100 mg

3 BvsD; MO

fluconazole Oral Susp

10 mg/mL, 40 mg/mL

1 MO

fluconazole tablet 100

mg, 200 mg, 50 mg

1 MO

fluconazole tablet 150

mg

1 MO; QL (2 EA

per 30 day(s))

fluconazole in

dextrose (iso-osmotic)

IV Piggy Back 400

mg/200 mL

1 BvsD; MO

flucytosine capsule

250 mg, 500 mg

2 MO

griseofulvin microsize

Oral Susp 125 mg/5

mL

1 MO

GRIS-PEG TABLET

125 mg, 250 mg

3 MO


Limits

itraconazole capsule

100 mg

2 MO; QL (120 EA

per 30 day(s))

ketoconazole tablet

200 mg

1 MO

MYCAMINE IV

SOLUTION 100 mg,

50 mg

4 BvsD; MO

nystatin Oral Susp

100,000 unit/mL

1 MO

nystatin tablet 500,000

unit

1 MO

SPORANOX ORAL

SOLN 10 mg/mL

4 MO

terbinafine tablet 250

mg

1 MO

VFEND ORAL SUSP

200 mg/5 mL (40

mg/mL)

5 MO

VFEND TABLET 200

mg, 50 mg

5 MO

VFEND IV SOLN

200 mg

4 BvsD; MO

voriconazole tablet

200 mg, 50 mg

2 MO

Antivirals

acyclovir capsule 200

mg

1 MO

acyclovir Oral Susp

200 mg/5 mL

1 MO

acyclovir tablet 400

mg, 800 mg

1 MO

acyclovir sodium IV

powder for Solution

500 mg

2 MO

amantadine capsule

100 mg

1 MO

amantadine Syrup 50

mg/5 mL

1 MO

Page 2 of 89


Limits

amantadine tablet 100

mg

1 MO

APTIVUS CAPSULE

250 mg

5 MO

APTIVUS ORAL

SOLN 100 mg/mL

5 MO

ATRIPLA TABLET

600-200-300 mg

5 MO

BARACLUDE ORAL

SOLN 0.05 mg/mL

3 MO

BARACLUDE

TABLET 0.5 mg, 1

mg

5 MO

COMBIVIR TABLET

150-300 mg

5 MO

COMPLERA

TABLET 200-25-300

mg

5 MO

CRIXIVAN

CAPSULE 200 mg,

400 mg

4 MO

CYTOVENE IV

SOLUTION 500 mg

4 BvsD; MO

didanosine

capsule,delayed

release 125 mg, 200

mg, 250 mg, 400 mg

2 MO

EDURANT TABLET

25 mg

5 MO

EMTRIVA

CAPSULE 200 mg

4 MO

EMTRIVA ORAL

SOLN 10 mg/mL

4 MO

EPIVIR ORAL SOLN

10 mg/mL

4 MO

EPIVIR TABLET 150

mg, 300 mg

4 MO


Limits

EPIVIR HBV ORAL

SOLN 25 mg/5 mL (5

mg/mL)

4 MO

EPIVIR HBV

TABLET 100 mg

4 MO

EPZICOM TABLET

600-300 mg

5 MO

famciclovir tablet 125

mg, 250 mg, 500 mg

1 MO

foscarnet IV 24 mg/mL 1 MO

FUZEON SUB-Q KIT

90 mg

5 MO

ganciclovir capsule

250 mg, 500 mg

2 MO

ganciclovir IV

Solution 500 mg

2 BvsD; MO

HEPSERA TABLET

10 mg

5 MO; QL (30 EA

per 30 day(s))

INCIVEK TABLET

375 mg

5 MO

INTELENCE

TABLET 100 mg, 200

mg

5 MO

INVIRASE

CAPSULE 200 mg

4 MO

INVIRASE TABLET

500 mg

5 MO

ISENTRESS

TABLET 400 mg

5 MO

KALETRA TABLET

100-25 mg

4 MO

KALETRA ORAL

SOLN 400-100 mg/5

mL

5 MO

KALETRA TABLET

200-50 mg

5 MO

lamivudine tablet 150

mg, 300 mg

2 MO

Page 3 of 89


Limits

lamivudine-zidovudine

tablet 150-300 mg

2 MO

LEXIVA ORAL

SUSP 50 mg/mL

4 MO

LEXIVA TABLET

700 mg

5 MO

nevirapine tablet 200

mg

2 MO

NORVIR CAPSULE

100 mg

3 MO

NORVIR TABLET

100 mg

3 MO

NORVIR ORAL

SOLN 80 mg/mL

4 MO

PREZISTA TABLET

75 mg

4 MO

PREZISTA TABLET

150 mg, 400 mg, 600

mg

5 MO

REBETOL ORAL

SOLN 40 mg/mL

4 MO

RELENZA

DISKHALER FOR

INHALATION 5

mg/actuation

3 MO

RESCRIPTOR

DISPERSIBLE

TABLET 100 mg

3 MO

RESCRIPTOR

TABLET 200 mg

3 MO

RETROVIR IV 10

mg/mL

4 MO

REYATAZ

CAPSULE 100 mg

4 MO

REYATAZ

CAPSULE 150 mg,

200 mg, 300 mg

5 MO


Limits

RIBAPAK DOSE

PACK TABLETS

400-400 mg (28)-mg

(28), 600-400 mg

(28)-mg (28), 600-600

mg (28)-mg (28)

2 MO

RIBASPHERE

TABLET 400 mg, 600

mg

2 MO

RIBASPHERE

CAPSULE 200 mg

2 MO; QL (180 EA

per 30 day(s))

RIBASPHERE

TABLET 200 mg

2 MO; QL (180 EA

per 30 day(s))

ribavirin capsule 200

mg

2 MO

ribavirin tablet 200

mg

2 MO

rimantadine tablet 100

mg

1 MO

SELZENTRY

TABLET 150 mg, 300

mg

5 MO

stavudine capsule 15

mg, 20 mg, 30 mg, 40

mg

1 MO

SUSTIVA CAPSULE

200 mg, 50 mg

4 MO

SUSTIVA TABLET

600 mg

4 MO

SYNAGIS IM SOLN

50 mg/0.5 mL

4 MO

TAMIFLU CAPSULE

30 mg, 45 mg, 75 mg

3 MO

TAMIFLU ORAL

SUSP 6 mg/mL

3 MO

TRIZIVIR TABLET

300-150-300 mg

5 MO

TRUVADA TABLET

200-300 mg

5 MO

Page 4 of 89


Limits

TYZEKA TABLET

600 mg

5 MO

valacyclovir tablet 1

g, 500 mg

2 MO; QL (60 EA

per 30 day(s))

VALCYTE TABLET

450 mg

4 MO

VALTREX TABLET

1 g, 500 mg

4 MO; QL (60 EA

per 30 day(s))

VICTRELIS

CAPSULE 200 mg

5 MO

VIDEX 2 GRAM

PEDIATRIC ORAL

SOLUTION 10

mg/mL (Final)

4 MO

VIDEX EC

CAPSULE,DELAYE

D RELEASE 125 mg

4 MO

VIRACEPT TABLET

250 mg, 625 mg

3 MO

VIRAMUNE ORAL

SUSP 50 mg/5 mL

4 MO

VIRAMUNE

TABLET 200 mg

4 MO

VIRAMUNE XR

TABLET,EXTENDE

D RELEASE 400 mg

4 MO

VIREAD ORAL

POWDER 40

mg/scoop (40

mg/gram)

4 MO

VIREAD TABLET

150 mg, 200 mg, 250

mg, 300 mg

4 MO

VISTIDE IV 75

mg/mL

3 BvsD; MO

ZERIT CAPSULE 15

mg, 20 mg, 30 mg, 40

mg

4 MO


Limits

ZERIT ORAL

SOLUTION 1 mg/mL

4 MO

ZIAGEN ORAL

SOLN 20 mg/mL

4 MO

ZIAGEN TABLET

300 mg

4 MO

zidovudine capsule

100 mg

2 MO

zidovudine Syrup 10

mg/mL

2 MO

zidovudine tablet 300

mg

2 MO

Cephalosporins

CEDAX CAPSULE

400 mg

4 MO

cefaclor capsule 250

mg, 500 mg

1 MO

cefaclor ER

tablet,extended

release,12 hr 500 mg

1 MO

cefadroxil capsule 500

mg

1 MO

cefadroxil Oral Susp

250 mg/5 mL, 500

mg/5 mL

1 MO

cefadroxil tablet 1

gram

1 MO

cefazolin Solution for

Injection 1 gram, 10

gram, 500 mg

2 MO

cefazolin in dextrose

(iso-osmotic) IV Piggy

Back 1 gram/50 mL

1 MO

cefdinir capsule 300

mg

1 MO

cefdinir Oral Susp 125

mg/5 mL, 250 mg/5

mL

1 MO

Page 5 of 89


Limits

cefepime Solution for

Injection 1 gram, 2

gram

2 MO

cefotaxime Solution

for Injection 1 gram,

10 gram, 2 gram

2 MO

cefotetan IV Solution

10 gram

1 MO

cefotetan Solution for

Injection 1 gram, 2

gram

3 MO

cefoxitin IV Solution 1

gram, 10 gram, 2

gram

1 MO

cefpodoxime Oral

Susp 100 mg/5 mL, 50

mg/5 mL

2 MO

cefpodoxime tablet

100 mg, 200 mg

2 MO

cefprozil Oral Susp

125 mg/5 mL, 250

mg/5 mL

2 MO

cefprozil tablet 250

mg, 500 mg

2 MO

ceftazidime in

dextrose 5 % in water

IV Piggy Back 1

gram/50 mL, 2

gram/50 mL

2 MO

ceftriaxone IV

Solution 1 gram, 2

gram

1 MO

ceftriaxone Solution

for Injection 10 gram,

250 mg, 500 mg

2 MO

cefuroxime axetil

tablet 250 mg, 500 mg

2 MO

cefuroxime sodium


1.5 gram, 750 mg

2 BvsD; MO


Limits

cefuroxime sodium IV

Solution 7.5 gram

2 MO

cephalexin capsule

250 mg, 500 mg

1 MO

cephalexin Oral Susp

125 mg/5 mL, 250

mg/5 mL

1 MO

cephalexin tablet 250

mg, 500 mg

1 MO

CLAFORAN IV

SOLUTION 1 gram

3 BvsD; MO

FORTAZ SOLUTION

FOR INJECTION 6

gram

4 MO

FORTAZ IN D5W IV

PIGGY BACK 1

gram/50 mL, 2

gram/50 mL

4 MO

SUPRAX TABLET

400 mg

4 MO; QL (20 per

30 Day(s))

TEFLARO IV

SOLUTION 400 mg,

600 mg

4 BvsD; MO

ZINACEF IN

STERILE WATER IV

PIGGY BACK 1.5

gram/50 mL

4 BvsD; MO

Erythromycins / Other Macrolides

azithromycin IV

Solution 500 mg

2 MO

azithromycin Oral

Susp 100 mg/5 mL,

200 mg/5 mL

2 MO

azithromycin tablet

250 mg, 500 mg, 600

mg

2 MO

clarithromycin ER

tablet,extended

release 24 hr 500 mg

1 MO

Page 6 of 89


Limits

clarithromycin Oral

Susp 125 mg/5 mL,

250 mg/5 mL

1 MO

clarithromycin tablet

250 mg, 500 mg

1 MO

E.E.S. 400 TABLET

400 mg

1 MO

ERYPED 200 ORAL

SUSP 200 mg/5 mL

3 MO

ERY-TAB

TABLET,DELAYED

RELEASE 250 mg,

333 mg

1 MO

ERY-TAB

TABLET,DELAYED

RELEASE 500 mg

3 MO

ERYTHROCIN IV

SOLUTION 500 mg

3 BvsD; MO

ERYTHROCIN

STEARATE TABLET

250 mg

2 MO

erythromycin tablet

250 mg, 500 mg

3 MO

erythromycin

ethylsuccinate tablet

400 mg

1 MO

ZMAX ORAL

SUSPENSION,EXTE

NDED RELEASE 2

gram/60 mL

4 MO

Miscellaneous Antiinfectives

ALBENZA TABLET

200 mg

4 MO

ALINIA ORAL SUSP

100 mg/5 mL

4 MO

ALINIA TABLET

500 mg

4 MO; QL (6 EA

per 30 day(s))


Limits

amikacin Injection

100 mg/2 mL, 500

mg/2 mL

1 MO

atovaquone-proguanil

tablet 250-100 mg

2 MO

AZACTAM

SOLUTION FOR

INJECTION 2 gram

4 MO

AZACTAM IN ISO-

OSMOTIC

DEXTROSE IV

PIGGY BACK 1

gram/50 mL, 2

gram/50 mL

4 MO

aztreonam Solution

for Injection 1 gram

2 MO

BACIIM IM 50,000

unit

2 MO

bacitracin IM 50,000

unit

2 MO

BILTRICIDE

TABLET 600 mg

3 MO

CAPASTAT

SOLUTION FOR

INJECTION 1 gram

3 BvsD; MO

chloramphenicol sod

succinate IV Solution

1 gram

4 BvsD; MO

chloroquine tablet 250

mg, 500 mg

1 MO

CLEOCIN CAPSULE

75 mg

4 MO

CLEOCIN IN D5W

IV PIGGY BACK 300

mg/50 mL, 600 mg/50

mL, 900 mg/50 mL

4 BvsD; MO

clindamycin capsule

150 mg, 300 mg

1 MO

clindamycin IV 600

mg/4 mL

1 MO

Page 7 of 89


Limits

colistin (colistimethate

sodium) Solution for

Injection 150 mg

2 MO

CUBICIN IV

SOLUTION 500 mg

4 BvsD; MO

dapsone tablet 100

mg, 25 mg

3 MO

DARAPRIM

TABLET 25 mg

3 MO

DORIBAX IV SUSP

500 mg

4 BvsD; MO

ethambutol tablet 100

mg, 400 mg

1 MO

FLAGYL ER

TABLET,EXTENDE

D RELEASE 750 mg

4 MO

gentamicin Injection

40 mg/mL

1 MO

gentamicin in sodium

chloride(iso-osmotic)

IV Piggy Back 100

mg/100 mL, 60 mg/50

mL, 80 mg/100 mL

1 BvsD; MO



IV Piggy Back 80

mg/50 mL

1 MO



IV Piggy Back 70

mg/50 mL, 90 mg/100

mL

3 MO

gentamicin sulfate

(PF) IV 80 mg/8 mL

3 MO

hydroxychloroquine

tablet 200 mg

1 MO

imipenem-cilastatin IV

Solution 250 mg, 500

mg

2 BvsD; MO


Limits

INVANZ SOLUTION

FOR INJECTION 1

gram

3 BvsD; MO

isoniazid Injection 100

mg/mL

1 MO

isoniazid tablet 100

mg, 300 mg

1 MO

isoniazid Syrup 50

mg/5 mL

3 MO

kanamycin Injection 1

gram/3 mL

2 MO

KETEK TABLET 300

mg, 400 mg

4 MO

MALARONE

TABLET 250-100 mg,

62.5-25 mg

4 MO

mefloquine tablet 250

mg

1 MO

MEPRON ORAL

SUSP 750 mg/5 mL

4 MO

meropenem IV

Solution 500 mg

2 BvsD; MO

MERREM IV

SOLUTION 500 mg

4 BvsD; MO

metronidazole capsule

375 mg

1 MO

metronidazole tablet

250 mg, 500 mg

1 MO

metronidazole in

sodium chloride (iso-

osm) IV Piggy Back

500 mg/100 mL

1 MO

MYCOBUTIN

CAPSULE 150 mg

4 MO

NEBUPENT

SOLUTION FOR

INHALATION 300

mg

4 BvsD; MO

Page 8 of 89


Limits

neomycin tablet 500

mg

2 MO

paromomycin capsule

250 mg

2 MO

PASER ORAL

PACKET 4 gram

3 MO

PENTAM

SOLUTION FOR

INJECTION 300 mg

4 BvsD; MO

polymyxin B sulfate


500,000 unit

2 MO

PRIFTIN TABLET

150 mg

4 MO

primaquine tablet 26.3

mg

4 MO

PRIMAXIN IV IV

SOLUTION 250 mg,

500 mg

4 MO

QUALAQUIN

CAPSULE 324 mg

4 MO

rifampin capsule 150

mg, 300 mg

1 MO

rifampin IV Solution

600 mg

2 MO

RIFATER TABLET

50-120-300 mg

4 MO

SEROMYCIN

CAPSULE 250 mg

4 MO

streptomycin IM 1

gram

3 MO

STROMECTOL

TABLET 3 mg

3 MO

SYNERCID IV

SOLUTION 500 mg

5 BvsD; MO

TOBI NEB

SOLUTION 300 mg/5

mL

5 BvsD; MO


Limits

tobramycin in NS IV

Piggy Back 80 mg/100

mL

3 BvsD; MO

tobramycin in NS IV

Piggy Back 60 mg/50

mL

3 MO

tobramycin Injection

10 mg/mL, 40 mg/mL

1 MO

TRECATOR

TABLET 250 mg

4 MO

TYGACIL IV

SOLUTION 50 mg

4 BvsD; MO

XIFAXAN TABLET

200 mg, 550 mg

4 MO

ZYVOX IV 600

mg/300 mL

4 MO

ZYVOX ORAL SUSP

100 mg/5 mL

4 MO

ZYVOX TABLET

600 mg

4 MO

Penicillins

amoxicillin capsule

250 mg, 500 mg

1 MO

amoxicillin chewable


1 MO

amoxicillin Oral Susp

125 mg/5 mL, 200

mg/5 mL, 250 mg/5

mL, 400 mg/5 mL

1 MO

amoxicillin tablet 500

mg, 875 mg

1 MO

amoxicillin-potassium

clavulanate chewable

tablet 200-28.5 mg,

400-57 mg

1 MO

Page 9 of 89


Limits


clavulanate Oral Susp

200-28.5 mg/5 mL,

250-62.5 mg/5 mL,

400-57 mg/5 mL, 600-

42.9 mg/5 mL

1 MO


clavulanate tablet

250-125 mg, 500-125

mg, 875-125 mg

1 MO

ampicillin capsule 250

mg, 500 mg

1 MO

ampicillin Oral Susp

125 mg/5 mL, 250

mg/5 mL

1 MO

ampicillin Solution for


gram

2 MO

ampicillin Solution for

Injection 125 mg

4 MO

ampicillin-sulbactam


15 gram, 3 gram

2 MO

BICILLIN C-R IM

SYRINGE 1,200,000

unit/ 2

mL(600k/600k),

1,200,000 unit/ 2

mL(900k/300k)

4 MO

BICILLIN L-A IM

SYRINGE 1,200,000

unit/2 mL, 2,400,000

unit/4 mL, 600,000

unit/mL

4 MO

dicloxacillin capsule

250 mg, 500 mg

1 MO

MOXATAG

TABLET,EXTENDE

D RELEASE 775 mg

4 MO


Limits

nafcillin Solution for


gram

2 MO

nafcillin in D2.4W IV

Piggy Back 1 gram/50

mL

4 MO

oxacillin Solution for


gram

3 MO

oxacillin in dextrose,

iso-osmotic IV Piggy

Back 1 g/50 mL, 2

g/50 mL

4 MO

penicillin G pot in

dextrose IV Piggy

Back 2 million unit/50

mL, 3 million unit/50

mL

3 BvsD; MO

penicillin G potassium


5 million unit

2 MO

penicillin G procaine

IM Syringe 1.2 million

unit/2 mL

3 BvsD; MO

penicillin G sodium


5 million unit

3 BvsD; MO

penicillin V potassium


1 MO

penicillin V potassium

Oral Solution 125

mg/5 mL, 250 mg/5

mL

2 MO

PFIZERPEN-G

SOLUTION FOR

INJECTION 20

million unit

2 MO

piperacillin-

tazobactam IV

Solution 3.375 gram,

4.5 gram

2 BvsD; MO

Page 10 of 89


Limits

TIMENTIN IV

SOLUTION 3.1 g

4 BvsD; MO

ZOSYN IV

SOLUTION 3.375

gram

4 BvsD; MO

ZOSYN IN

DEXTROSE (ISO-

OSMOTIC) IV

PIGGY BACK 2.25

gram/50 mL, 3.375

gram/50 mL

4 BvsD; MO

Quinolones

AVELOX TABLET

400 mg

4 MO

AVELOX ABC

PACK TABLET 400

mg

4 MO

AVELOX IN

SODIUM

CHLORIDE (ISO-

OSMOTIC) IV

PIGGY BACK 400

mg/250 mL

4 BvsD; MO

CIPRO ORAL SUSP

250 mg/5 mL, 500

mg/5 mL

4 MO

ciprofloxacin tablet

100 mg, 250 mg, 500

mg, 750 mg

1 MO

ciprofloxacin IV 400

mg/40 mL

2 MO

ciprofloxacin ER

tablet,extended

release 24hr mphase

1,000 mg, 500 mg

2 MO

FACTIVE TABLET

320 mg

4 MO

LEVAQUIN ORAL

SOLN 250 mg/10 mL

4 MO


Limits

LEVAQUIN

TABLET 250 mg, 500

mg, 750 mg

4 MO

LEVAQUIN IN D5W

IV PIGGY BACK 750

mg/150 mL

4 BvsD; MO

levofloxacin IV 25

mg/mL

2 BvsD; MO

levofloxacin Oral Soln

250 mg/10 mL

2 MO

levofloxacin tablet 250

mg, 500 mg, 750 mg

2 MO

levofloxacin in D5W

IV Piggy Back 500

mg/100 mL

2 BvsD; MO

NOROXIN TABLET

400 mg

4 MO

ofloxacin tablet 200

mg, 300 mg, 400 mg

2 MO

Sulfa's / Related Agents

sulfadiazine tablet 500

mg

1 MO

sulfamethoxazole-

trimethoprim IV 400-

80 mg/5 mL

1 MO

sulfamethoxazole-

trimethoprim Oral

Susp 200-40 mg/5 mL

1 MO

sulfamethoxazole-

trimethoprim tablet

400-80 mg, 800-160

mg

1 MO

Tetracyclines

demeclocycline tablet

150 mg, 300 mg

2 MO

doxycycline hyclate

capsule 100 mg, 50

mg

1 MO

Page 11 of 89


Limits

doxycycline hyclate


1 MO

doxycycline hyclate IV

Solution 100 mg

2 MO

doxycycline

monohydrate capsule

75 mg

1 MO

doxycycline

monohydrate tablet

150 mg, 50 mg, 75 mg

1 MO

minocycline capsule

100 mg, 50 mg, 75 mg

1 MO

minocycline tablet 100

mg, 50 mg, 75 mg

1 MO

minocycline ER

tablet,extended

release 24 hr 135 mg,

45 mg, 90 mg

2 MO

ORACEA CAPSULE,

EXTENDED

RELEASE 40 mg

4 MO

tetracycline capsule

250 mg, 500 mg

1 MO

VIBRAMYCIN

SYRUP 50 mg/5 mL

4 MO

Urinary Tract Agents

FURADANTIN

ORAL SUSP 25 mg/5

mL

4 MO

MACRODANTIN

CAPSULE 25 mg

3 MO

methenamine

hippurate tablet 1

gram

1 MO

MONUROL ORAL

PACKET 3 gram

4 MO

nitrofurantoin Oral

Susp 25 mg/5 mL

2 MO


Limits

nitrofurantoin

macrocrystal capsule

50 mg

1 MO

nitrofurantoin

monohydrate/macrocr

ystals capsule 100 mg

2 MO

PRIMSOL ORAL

SOLN 50 mg/5 mL

3 MO

trimethoprim tablet

100 mg

1 MO

Vancomycin

VANCOCIN

CAPSULE 125 mg,

250 mg

4 MO

vancomycin capsule

125 mg, 250 mg

2 MO

vancomycin IV

Solution 1,000 mg

2 MO

vancomycin IV

Solution 10 gram, 500

mg

4 BvsD; MO

Antineoplastic / Immunosuppressant Drugs

Adjunctive Agents

amifostine crystalline

IV Solution 500 mg

2 MO

dexrazoxane IV

Solution 500 mg

2 BvsD; MO

ELITEK IV

SOLUTION 1.5 mg

4 BvsD; MO

FUSILEV IV

SOLUTION 50 mg

4 BvsD; MO

KEPIVANCE

SOLUTION 6.25 mg

5 BvsD; MO

leucovorin calcium

tablet 25 mg, 5 mg

1 MO

leucovorin calcium


100 mg, 350 mg

2 BvsD; MO

Page 12 of 89


Limits

leucovorin calcium

tablet 10 mg, 15 mg

3 MO

mesna IV 100 mg/mL 1 BvsD; MO

MESNEX TABLET

400 mg

4 MO

XGEVA SUB-Q 120

mg/1.7 mL (70

mg/mL)

5 BvsD; MO

ZINECARD IV

SOLUTION 250 mg

4 BvsD; MO

Antineoplastic / Immunosuppressant Drugs

ADRIAMYCIN PFS

IV 2 mg/mL

1 BvsD; MO

AFINITOR TABLET

10 mg, 2.5 mg, 5 mg,

7.5 mg

5 MO

ALIMTA IV

SOLUTION 500 mg

4 BvsD; MO

ALKERAN IV

SOLUTION 50 mg

4 BvsD; MO

anastrozole tablet 1

mg

2 MO

ARIMIDEX TABLET

1 mg

4 MO

AROMASIN

TABLET 25 mg

4 MO

ARRANON IV 250

mg/50 mL

4 BvsD; MO

ARZERRA IV 100

mg/5 mL

5 MO

AVASTIN IV 25

mg/mL

5 BvsD; MO

AZASAN TABLET

100 mg, 75 mg

4 BvsD; MO

azathioprine tablet 50

mg

1 BvsD; MO

azathioprine Solution

for Injection 100 mg

2 BvsD; MO


Limits

bicalutamide tablet 50

mg

1 MO

BICNU IV

SOLUTION 100 mg

4 BvsD; MO

bleomycin Solution for

Injection 30 unit

2 BvsD; MO

BUSULFEX IV 60

mg/10 mL

4 BvsD; MO

CAMPATH IV 30

mg/mL

5 BvsD; MO

CAPRELSA TABLET

100 mg, 300 mg

5 MO

carboplatin IV 10

mg/mL

2 BvsD; MO

CASODEX TABLET

50 mg

4 MO

CEENU CAPSULE

10 mg, 100 mg, 40 mg

4 MO

CELLCEPT

CAPSULE 250 mg

4 BvsD; MO

CELLCEPT ORAL

SUSP 200 mg/mL

4 BvsD; MO

CELLCEPT TABLET

500 mg

4 BvsD; MO

CELLCEPT

INTRAVENOUS IV

SOLUTION 500 mg

4 BvsD; MO

cisplatin IV 1 mg/mL 2 BvsD; MO

cladribine IV 10

mg/10 mL

2 BvsD; MO

CLOLAR IV 20

mg/20 mL

5 BvsD; MO

COSMEGEN IV

SOLUTION 0.5 mg

3 BvsD; MO

cyclophosphamide

tablet 25 mg, 50 mg

2 BvsD; MO

cyclosporine capsule

100 mg, 25 mg

2 BvsD; MO

Page 13 of 89


Limits

cyclosporine IV 250

mg/5 mL

2 BvsD; MO

cyclosporine modified

capsule 100 mg

2 BvsD; MO


Oral Soln 100 mg/mL

2 BvsD; MO


capsule 50 mg

4 BvsD; MO

cytarabine Injection

20 mg/mL

2 BvsD; MO

cytarabine (PF)

Injection 2 gram/20

mL (100 mg/mL)

1 BvsD; MO

cytarabine (PF)


500 mg

2 BvsD; MO

dacarbazine IV

Solution 200 mg

2 BvsD; MO

DACOGEN IV

SOLUTION 50 mg

4 BvsD; MO

daunorubicin IV Inj 5

mg/mL

4 BvsD; MO

DOCEFREZ IV

SOLUTION 20 mg,

80 mg

4 BvsD; MO

docetaxel IV 80 mg/4

mL (20 mg/mL)

2 BvsD; MO

docetaxel IV 80 mg/8

mL (10 mg/mL)

4 BvsD; MO

DOXIL IV 2 mg/mL 4 BvsD; MO

doxorubicin IV 50

mg/25 mL

2 BvsD; MO

DROXIA CAPSULE

200 mg, 300 mg, 400

mg

3 MO

ELIGARD SUB-Q

SYRINGE 22.5 mg,

30 mg, 45 mg, 7.5 mg

4 BvsD; MO


Limits

ELLENCE IV 200

mg/100 mL

5 BvsD; MO

ELOXATIN SOLN

100 mg/20 mL

4 BvsD; MO

ELSPAR SOLUTION

FOR INJECTION

10,000 unit

4 BvsD; MO

EMCYT CAPSULE

140 mg

4 MO

epirubicin IV 50

mg/25 mL

2 BvsD; MO

ERBITUX IV 100

mg/50 mL

4 BvsD; MO

ERIVEDGE

CAPSULE 150 mg

5 MO

ETOPOPHOS IV

SOLUTION 100 mg

4 BvsD; MO

etoposide IV 20

mg/mL

2 BvsD; MO

exemestane tablet 25

mg

2 MO

FARESTON

TABLET 60 mg

4 MO

FASLODEX IM

SYRINGE 250 mg/5

mL

5 BvsD; MO

FEMARA TABLET

2.5 mg

4 MO

fludarabine IV powder

for Solution 50 mg

2 BvsD; MO

fluorouracil IV 500

mg/10 mL

2 BvsD; MO

flutamide capsule 125

mg

2 MO

gemcitabine IV

Solution 1 gram

4 BvsD; MO

GEMZAR IV

SOLUTION 1 gram

4 BvsD; MO

Page 14 of 89


Limits

GENGRAF

CAPSULE 100 mg,

25 mg

2 BvsD; MO

GENGRAF ORAL

SOLN 100 mg/mL

2 BvsD; MO

GLEEVEC TABLET

100 mg, 400 mg

5 MO

HALAVEN IV 1 mg/2

mL (0.5 mg/mL)

4 BvsD; MO

HERCEPTIN IV

SOLUTION 440 mg

5 BvsD; MO

HEXALEN

CAPSULE 50 mg

5 MO

HYCAMTIN IV

SOLUTION 4 mg

4 BvsD; MO

hydroxyurea capsule

500 mg

2 MO

idarubicin IV 1 mg/mL 2 BvsD; MO

IFEX IV SOLUTION

3 gram

4 BvsD; MO

ifosfamide IV Solution

1 gram

4 BvsD; MO

INLYTA TABLET 1

mg, 5 mg

4 MO

irinotecan IV 100

mg/5 mL

2 MO

IXEMPRA IV

SOLUTION 45 mg

4 BvsD; MO

JAKAFI TABLET 10

mg, 15 mg, 20 mg, 25

mg, 5 mg

5 MO

JEVTANA IV 10

mg/mL (Final)

5 MO

letrozole tablet 2.5 mg 2 MO

LEUKERAN

TABLET 2 mg

4 MO

leuprolide Sub-Q Kit 1

mg/0.2 mL

2 MO


Limits

LUPRON DEPOT IM

SYRINGE KIT 3.75

mg, 7.5 mg

4 BvsD; MO

LUPRON DEPOT (3

MONTH) IM

SYRINGE KIT 22.5

mg

4 BvsD; MO

LUPRON DEPOT (4

MONTH) IM

SYRINGE KIT 30 mg

4 BvsD; MO

LUPRON DEPOT (6

MONTH) IM

SYRINGE KIT 45 mg

4 MO

LUPRON DEPOT-

PED IM KIT 11.25

mg, 15 mg

4 BvsD; MO

LUPRON DEPOT-

PED (3 MONTH) IM

SYRINGE KIT 11.25

mg

4 BvsD; MO

LYSODREN

TABLET 500 mg

3 MO

MATULANE

CAPSULE 50 mg

3 MO

megestrol Oral Susp

400 mg/10 mL (40

mg/mL)

1 MO

megestrol tablet 20

mg, 40 mg

1 MO

melphalan IV Solution

50 mg

2 BvsD; MO

mercaptopurine tablet

50 mg

2 MO

methotrexate sodium

tablet 2.5 mg

1 BvsD; MO

methotrexate sodium

(PF) Injection 25

mg/mL

1 BvsD; MO

Page 15 of 89


Limits

methotrexate sodium

(PF) Solution for

Injection 1 gram

3 BvsD; MO

mitomycin IV Solution

20 mg

2 BvsD; MO

mitoxantrone

Concentrate, IV 2

mg/mL

2 BvsD; MO

MUSTARGEN

SOLUTION FOR

INJECTION 10 mg

3 BvsD; MO

mycophenolate mofetil

capsule 250 mg

2 BvsD; MO

mycophenolate mofetil

tablet 500 mg

2 BvsD; MO

MYFORTIC

TABLET,DELAYED

RELEASE 180 mg,

360 mg

4 BvsD; MO

NEORAL CAPSULE

100 mg, 25 mg

4 BvsD; MO

NEORAL ORAL

SOLN 100 mg/mL

4 BvsD; MO

NEXAVAR TABLET

200 mg

4 MO

NILANDRON

TABLET 150 mg

4 MO

NULOJIX IV

SOLUTION 250 mg

5 MO

octreotide acetate

Injection 1,000

mcg/mL, 100 mcg/mL,

200 mcg/mL, 50

mcg/mL, 500 mcg/mL

2 BvsD; MO

ONTAK IV 150

mcg/mL

5 BvsD; MO

oxaliplatin IV Soln

100 mg/20 mL

2 BvsD; MO


Limits

paclitaxel

Concentrate, IV 6

mg/mL

2 BvsD; MO

pentostatin IV

Solution 10 mg

2 BvsD; MO

PROGRAF

CAPSULE 0.5 mg, 1

mg, 5 mg

4 BvsD; MO

PROGRAF IV 5

mg/mL

4 BvsD; MO

RAPAMUNE ORAL

SOLN 1 mg/mL

4 BvsD; MO

RAPAMUNE

TABLET 0.5 mg, 1

mg, 2 mg

4 BvsD; MO

REVLIMID

CAPSULE 10 mg, 15

mg, 25 mg, 5 mg

5 MO; LA

RHEUMATREX

TABLETS IN A

DOSE PACK 2.5 mg

4 BvsD; MO

RITUXAN

CONCENTRATE, IV

10 mg/mL

3 BvsD; MO

SANDIMMUNE

CAPSULE 100 mg,

25 mg

4 BvsD; MO

SANDIMMUNE IV

250 mg/5 mL

4 BvsD; MO

SANDIMMUNE

ORAL SOLN 100

mg/mL

4 BvsD; MO

SIMULECT IV

SOLUTION 20 mg

4 BvsD; MO

SOMATULINE

DEPOT SUB-Q

SYRINGE 120 mg/0.5

mL, 90 mg/0.3 mL

4 BvsD; MO

Page 16 of 89


Limits

SPRYCEL TABLET

100 mg, 140 mg, 20

mg, 50 mg, 70 mg, 80

mg

5 MO

SUTENT CAPSULE

12.5 mg, 25 mg, 50

mg

5 MO

TABLOID TABLET

40 mg

4 MO

tacrolimus capsule 0.5

mg, 1 mg, 5 mg

2 BvsD; MO

tamoxifen tablet 10

mg, 20 mg

1 MO

TARCEVA TABLET

100 mg, 150 mg, 25

mg

5 MO

TARGRETIN

CAPSULE 75 mg

4 MO

TARGRETIN

TOPICAL GEL 1 %

4 MO

TASIGNA CAPSULE

150 mg

3 MO

TASIGNA CAPSULE

200 mg

4 MO

THALOMID

CAPSULE 100 mg,

150 mg, 200 mg, 50

mg

5 MO

thiotepa Solution for

Injection 15 mg

2 BvsD; MO

topotecan IV Solution

4 mg

2 BvsD; MO

TORISEL IV

SOLUTION 30 mg/3

mL (10 mg/mL)

(Final)

4 BvsD; MO

TREANDA IV

SOLUTION 100 mg

4 BvsD; MO


Limits

TRELSTAR IM

SYRINGE 11.25 mg/2

mL, 3.75 mg/2 mL

4 BvsD; MO

tretinoin

(chemotherapy)

capsule 10 mg

2 MO

TREXALL TABLET

10 mg, 15 mg, 5 mg,

7.5 mg

4 BvsD; MO

TRISENOX IV 10

mg/10 mL

4 BvsD; MO

TYKERB TABLET

250 mg

4 MO

VECTIBIX IV 100

mg/5 mL (20 mg/mL)

4 BvsD; MO

VELCADE

SOLUTION FOR

INJECTION 3.5 mg

4 BvsD; MO

VIDAZA SUB-Q

SOLN 100 mg

5 BvsD; MO

vinblastine IV powder

for Solution 10 mg

2 BvsD; MO

vincristine IV 1 mg/mL 2 BvsD; MO

vinorelbine IV 50

mg/5 mL

2 BvsD; MO

VOTRIENT TABLET

200 mg

5 MO

XALKORI CAPSULE

200 mg, 250 mg

5 MO

YERVOY IV 50

mg/10 mL (5 mg/mL)

5 BvsD; MO

ZANOSAR IV

SOLUTION 1 gram

4 BvsD; MO

ZELBORAF

TABLET 240 mg

5 MO

ZOLINZA CAPSULE

100 mg

5 MO

Page 17 of 89


Limits

ZORTRESS TABLET

0.25 mg

4 BvsD; MO

ZORTRESS TABLET

0.5 mg, 0.75 mg

5 BvsD; MO

ZYTIGA TABLET

250 mg

5 MO

Autonomic / Cns Drugs, Neurology / Psych

Anticonvulsants

BANZEL ORAL

SUSP 40 mg/mL

4 MO

BANZEL TABLET

200 mg, 400 mg

4 MO

carbamazepine

chewable tablet 100

mg

1 MO

carbamazepine ER

capsule,extended

release mphase12hr

100 mg, 200 mg, 300

mg

1 MO

carbamazepine Oral

Susp 100 mg/5 mL

1 MO

carbamazepine tablet

200 mg

1 MO

CARBATROL

CAPSULE,

EXTENDED

RELEASE 100 mg,

200 mg, 300 mg

4 MO

CELONTIN

CAPSULE 300 mg

4 MO

DEPAKOTE

TABLET,DELAYED

RELEASE 125 mg,

250 mg, 500 mg

4 MO

DEPAKOTE ER

TABLET,EXTENDE

D RELEASE 250 mg,

500 mg

4 MO


Limits

DEPAKOTE

SPRINKLES

CAPSULE 125 mg

4 MO

DILANTIN

CAPSULE 30 mg

4 MO

DILANTIN

INFATABS

CHEWABLE

TABLET 50 mg

4 MO

divalproex ER

tablet,extended


500 mg

1 MO

divalproex sprinkle

capsule 125 mg

1 MO

divalproex

tablet,delayed release

125 mg, 250 mg, 500

mg

1 MO

EPITOL TABLET

200 mg

2 MO

EQUETRO

CAPSULE,

EXTENDED

RELEASE 100 mg,

200 mg, 300 mg

4 MO

ethosuximide capsule

250 mg

1 MO

ethosuximide Syrup

250 mg/5 mL

1 MO

felbamate Oral Susp

600 mg/5 mL

2 MO

felbamate tablet 400

mg, 600 mg

2 MO

FELBATOL ORAL

SUSP 600 mg/5 mL

4 MO

FELBATOL TABLET

400 mg, 600 mg

4 MO

fosphenytoin Injection

100 mg PE/2 mL

1 MO

Page 18 of 89


Limits

gabapentin capsule

100 mg, 300 mg, 400

mg

1 MO

gabapentin tablet 600

mg, 800 mg

1 MO

GABITRIL TABLET

12 mg, 16 mg, 2 mg, 4

mg

4 MO

GRALISE

TABLET,EXTENDE

D RELEASE 300 mg,

600 mg

3 MO

GRALISE 30-DAY

STARTER PACK

TABLET,EXT.

RELEASE 300 mg

(9)- 600 mg (69)

3 MO

KEPPRA ORAL

SOLN 100 mg/mL

4 MO

KEPPRA TABLET

1,000 mg, 250 mg,

500 mg, 750 mg

4 MO

KEPPRA XR

TABLET,EXTENDE

D RELEASE 500 mg,

750 mg

4 MO

LAMICTAL

TABLET 100 mg, 150

mg, 200 mg, 25 mg

4 MO

LAMICTAL

STARTER (BLUE)

KIT TABLETS IN A

DOSE PACK 25 mg

(35)

4 MO

LAMICTAL

STARTER (GREEN)

KIT TABLETS,

DOSE PACK 25 mg

(84) -100 mg (14)

4 MO


Limits

LAMICTAL

STARTER

(ORANGE) KIT

TABLETS, DOSE

PACK 25 mg (42) -

100 mg (7)

4 MO

LAMICTAL XR

TABLET,EXTENDE

D RELEASE 100 mg,

200 mg, 25 mg, 250

mg, 50 mg

4 MO

LAMICTAL XR

STARTER (BLUE)

TABLET,EXTEND

RELEASE 25 mg (21)

-50 mg (7)

4 MO

LAMICTAL XR

STARTER (GREEN)

TAB,EXT.REL 50

mg(14)-100mg (14)-

200 mg (7)

4 MO

LAMICTAL XR

STARTER

(ORANGE)

TAB,EXT.REL 25mg

(14)-50 mg (14)-

100mg (7)

4 MO

lamotrigine chewable

dispersible tablet 25

mg, 5 mg

2 MO

lamotrigine tablet 100

mg, 150 mg, 200 mg,

25 mg

2 MO

levetiracetam IV 500

mg/5 mL

2 BvsD; MO

levetiracetam ER

tablet,extended


750 mg

2 MO

levetiracetam Oral

Soln 100 mg/mL

2 MO

Page 19 of 89


Limits

levetiracetam tablet

1,000 mg, 250 mg, 500

mg, 750 mg

2 MO

LYRICA CAPSULE

100 mg, 150 mg, 200

mg, 225 mg, 25 mg,

300 mg, 50 mg, 75 mg

3

NEURONTIN ORAL

SOLN 250 mg/5 mL

4 MO

ONFI TABLET 10

mg, 20 mg, 5 mg

4 MO

oxcarbazepine tablet

150 mg, 300 mg, 600

mg

2 MO

PEGANONE

TABLET 250 mg

3 MO

phenobarbital Elixir

20 mg/5 mL

1 MO

phenobarbital tablet

16.2 mg, 30 mg, 32.4

mg, 64.8 mg, 97.2 mg

1 MO

PHENYTEK

CAPSULE 200 mg,

300 mg

4 MO

phenytoin Oral Susp

125 mg/5 mL

1 MO

phenytoin sodium IV

50 mg/mL

3 MO

phenytoin sodium

extended capsule 100

mg

1 MO

POTIGA TABLET

200 mg, 300 mg, 400

mg, 50 mg

5 MO

primidone tablet 250

mg, 50 mg

1 MO

SABRIL ORAL

POWDER IN

PACKET 500 mg

5 MO; LA


Limits

SABRIL TABLET

500 mg

5 MO; LA

STAVZOR

CAPSULE,DELAYE

D RELEASE 125 mg,

250 mg, 500 mg

3 MO

TEGRETOL XR

TABLET,EXTENDE

D RELEASE 100 mg,

200 mg, 400 mg

3 MO

TOPAMAX

SPRINKLE

CAPSULE 15 mg, 25

mg

4 MO

TOPAMAX TABLET

100 mg, 200 mg, 25

mg, 50 mg

4 MO

topiramate sprinkle

capsule 15 mg, 25 mg

2 MO

topiramate tablet 100

mg, 200 mg, 25 mg, 50

mg

2 MO

TRILEPTAL ORAL

SUSP 300 mg/5 mL

4 MO

TRILEPTAL

TABLET 150 mg, 300

mg, 600 mg

4 MO

valproate sodium IV

500 mg/5 mL (100

mg/mL)

1 MO

valproic acid capsule

250 mg

1 MO

valproic acid (as

sodium salt) Oral Soln

250 mg/5 mL

1 MO

VIMPAT IV 200

mg/20 mL

4 MO

VIMPAT ORAL

SOLN 10 mg/mL

4 MO

Page 20 of 89


Limits

VIMPAT TABLET

100 mg, 150 mg, 200

mg, 50 mg

4 MO

zonisamide capsule

100 mg, 25 mg, 50 mg

2 MO

Antiparkinsonism Agents

APOKYN SUBQ

CARTRIDGE 10

mg/mL

4 BvsD; MO

AZILECT TABLET

0.5 mg, 1 mg

4 MO

benztropine tablet 0.5

mg, 1 mg, 2 mg

1 MO

benztropine Injection

2 mg/2 mL

3 MO

bromocriptine capsule

5 mg

2 MO

bromocriptine tablet

2.5 mg

2 MO

carbidopa-levodopa

disintegrating tablet

10-100 mg, 25-100

mg, 25-250 mg

1 MO

carbidopa-levodopa

ER tablet,extended

release 25-100 mg,

50-200 mg

1 MO

carbidopa-levodopa

tablet 10-100 mg, 25-

100 mg, 25-250 mg

1 MO

COMTAN TABLET

200 mg

4 MO

LODOSYN TABLET

25 mg

4 MO

MIRAPEX TABLET

0.125 mg, 0.25 mg,

0.5 mg, 0.75 mg, 1

mg, 1.5 mg

4 MO


Limits

MIRAPEX ER

TABLET,EXTENDE

D RELEASE 0.375

mg, 0.75 mg, 1.5 mg,

2.25 mg, 3 mg, 3.75

mg, 4.5 mg

4 MO

pramipexole tablet

0.125 mg, 0.25 mg, 0.5

mg, 0.75 mg, 1 mg, 1.5

mg

1 MO

ropinirole ER

tablet,extended

release 24 hr 12 mg, 2

mg, 4 mg, 6 mg, 8 mg

2 MO

ropinirole tablet 0.25

mg, 0.5 mg, 1 mg, 2


2 MO

selegiline capsule 5

mg

1 MO

selegiline tablet 5 mg 1 MO

STALEVO 100

TABLET 25-100-200

mg

4 MO

STALEVO 125

TABLET 31.25-125-

200 mg

4 MO

STALEVO 150

TABLET 37.5-150-

200 mg

4 MO

STALEVO 200

TABLET 50-200-200

mg

4 MO

STALEVO 50

TABLET 12.5-50-200

mg

4 MO

STALEVO 75

TABLET 18.75-75-

200 mg

4 MO

TASMAR TABLET

100 mg

4 MO

Page 21 of 89


Limits

trihexyphenidyl Elixir

0.4 mg/mL

1 MO

trihexyphenidyl tablet

2 mg, 5 mg

1 MO

ZELAPAR

DISINTEGRATING

TABLET 1.25 mg

4 MO

Migraine / Cluster Headache Therapy

dihydroergotamine

Injection 1 mg/mL

1 MO

ergotamine-caffeine

tablet 1-100 mg

1 MO

MAXALT TABLET

10 mg, 5 mg

4 MO; QL (12 EA

per 30 day(s))

MAXALT-MLT

DISINTEGRATING

TABLET 10 mg, 5 mg

4 MO; QL (12 EA

per 30 day(s))

MIGERGOT

RECTAL

SUPPOSITORY 2-

100 mg

1 MO

MIGRANAL NASAL

SPRAY 0.5 mg/pump

act. (4 mg/mL)

4 MO

sumatriptan Sub-Q 6

mg/0.5 mL

2 MO

sumatriptan Sub-Q

Pen Injector 6 mg/0.5

mL

2 MO

sumatriptan tablet 25

mg

2 MO


mg

2 MO; QL (18 EA

per 30 day(s))


mg

2 MO; QL (9 EA

per 30 day(s))

Miscellaneous Neurological Therapy

ARICEPT TABLET

10 mg, 23 mg, 5 mg

4 MO; QL (30 EA

per 30 day(s))


Limits

ARICEPT ODT

DISINTEGRATING

TABLET 10 mg, 5 mg

4 MO; QL (30 EA

per 30 day(s))

COPAXONE SUB-Q

KIT 20 mg

4 MO

donepezil


10 mg, 5 mg

2 MO; QL (30 EA

per 30 day(s))

donepezil tablet 10

mg, 5 mg

2 MO; QL (30 EA

per 30 day(s))

EXELON ORAL

SOLN 2 mg/mL

4 MO

EXELON

TRANSDERM 24 HR

PATCH 4.6 mg/24

hour, 9.5 mg/24 hour

4 MO

EXELON CAPSULE

1.5 mg, 3 mg, 4.5 mg,

6 mg

4 MO; QL (60 EA

per 30 day(s))

galantamine Oral Soln

4 mg/mL

2 MO

galantamine tablet 12

mg, 4 mg, 8 mg

2 MO

galantamine ER 24 hr

capsule,extended

release 16 mg, 24 mg,

8 mg

2 MO; QL (30 EA

per 30 day(s))

MYTELASE

TABLET 10 mg

4 MO

NAMENDA ORAL

SOLN 10 mg/5 mL

3 MO

NAMENDA TABLET

10 mg

3 MO; QL (60 EA

per 30 day(s))

NAMENDA TABLET

5 mg

3 MO; QL (90 EA

per 30 day(s))

NAMENDA

TITRATION PAK

TABLETS IN A

DOSE PACK 5-10 mg

3 MO

Page 22 of 89


Limits

rivastigmine capsule

1.5 mg, 3 mg, 4.5 mg,

6 mg

2 MO; QL (60 EA

per 30 day(s))

TYSABRI IV 300

mg/15 mL

4 BvsD; MO; LA

XENAZINE TABLET

12.5 mg, 25 mg

5 MO; LA

Muscle Relaxants / Antispasmodic Therapy

AMRIX

CAPSULE,EXTEND

ED RELEASE 15 mg,

30 mg

4 MO

baclofen tablet 10 mg,

20 mg

1 MO

carisoprodol tablet

350 mg

1 MO

carisoprodol-ASA-

codeine tablet 200-

325-16 mg

1 MO

carisoprodol-aspirin

tablet 200-325 mg

1 MO

chlorzoxazone tablet

500 mg

1 MO

cyclobenzaprine ER

capsule,extended


30 mg

1 MO

cyclobenzaprine tablet

10 mg, 5 mg, 7.5 mg

1 MO

dantrolene capsule

100 mg, 25 mg, 50 mg

2 MO

meprobamate tablet

200 mg, 400 mg

2 MO

MESTINON SYRUP

60 mg/5 mL

4 MO

MESTINON

TIMESPAN

TABLET,EXTENDE

D RELEASE 180 mg

4 MO


Limits

methocarbamol tablet

500 mg, 750 mg

2 MO

orphenadrine citrate

ER tablet,extended

release 100 mg

2 MO

ORPHENADRINE

COMPOUND

TABLET 25-385-30

mg

2 MO

ORPHENADRINE

COMPOUND-DS

TABLET 50-770-60

mg

2 MO

pyridostigmine

bromide tablet 60 mg

1 MO

REGONOL

INJECTION 5 mg/mL

1 MO

SKELAXIN TABLET

800 mg

4 MO

SOMA TABLET 250

mg

4 MO

tizanidine capsule 2

mg, 4 mg, 6 mg

2 MO

tizanidine tablet 2 mg,

4 mg

2 MO

ZANAFLEX

CAPSULE 2 mg, 4

mg, 6 mg

4 MO

Narcotic Analgesics

acetaminophen-

codeine Elixir 120-12

mg/5 mL

1

acetaminophen-

codeine tablet 300-15

mg, 300-30 mg, 300-

60 mg

1

ASCOMP

W/CODEINE

CAPSULE 30-50-325-

40 mg

2

Page 23 of 89


Limits

buprenorphine

sublingual tablet 8 mg

2

buprenorphine

Syringe 0.3 mg/mL

2 BvsD

buprenorphine

sublingual tablet 2 mg

2 MO

codeine-butalbital-

acetaminophen-

caffeine cap 30-50-

325-40 mg

1

codeine tablet 15 mg,

30 mg, 60 mg

1

DILAUDID-5 ORAL

LIQUID 1 mg/mL

4

DURAMORPH (PF)

INJECTION 0.5

mg/mL, 1 mg/mL

2

ENDOCET TABLET

10-325 mg, 10-650

mg, 5-325 mg, 7.5-

325 mg, 7.5-500 mg

1

fentanyl Transderm

Patch 100 mcg/hr, 12

mcg/hr, 25 mcg/hr, 50

mcg/hr, 75 mcg/hr

2

fentanyl Lozenge on a

Handle 1,200 mcg,

1,600 mcg, 200 mcg,

400 mcg, 600 mcg,

800 mcg

2

hydrocodone-

acetaminophen Oral

Soln 7.5-500 mg/15

mL

1


Limits

hydrocodone-

acetaminophen tablet

10-325 mg, 10-500

mg, 10-650 mg, 10-

660 mg, 2.5-500 mg,

5-325 mg, 5-500 mg,

7.5-325 mg, 7.5-500

mg, 7.5-650 mg, 7.5-

750 mg

1

hydrocodone-


10-300 mg, 10-750

mg, 5-300 mg, 7.5-300

mg

2

hydrocodone-

acetaminophen Oral

Soln 7.5-325 mg/15

mL

2 MO

hydrocodone-

ibuprofen tablet 7.5-

200 mg

1

hydromorphone tablet

2 mg, 4 mg, 8 mg

1

hydromorphone (PF)

Injection 10 mg/mL

1

ibuprofen-oxycodone

tablet 400-5 mg

1

levorphanol tartrate

tablet 2 mg

2

MAGNACET

TABLET 10-400 mg,

5-400 mg, 7.5-400 mg

4

meperidine Oral Soln

50 mg/5 mL

1

meperidine tablet 100

mg, 50 mg

1

meperidine (PF)

Injection 25 mg/mL,

50 mg/mL

2

methadone Injection

10 mg/mL

1

Page 24 of 89


Limits

methadone Oral

Concentrate 10

mg/mL

1

methadone tablet 10

mg, 5 mg

1

methadone Oral Soln

10 mg/5 mL, 5 mg/5

mL

4

METHADOSE

TABLET 10 mg

1

morphine ER

tablet,extended

release 100 mg, 15

mg, 200 mg, 30 mg, 60

mg

1

morphine Oral Soln

10 mg/5 mL, 20 mg/5

mL

1

morphine tablet 15

mg, 30 mg

1

morphine ER

capsule,extended

release pellets 100

mg, 20 mg, 30 mg, 50

mg, 60 mg, 80 mg

2 MO

morphine concentrate

Oral 100 mg/5 mL (20

mg/mL)

1

OPANA TABLET 10

mg, 5 mg

4

OPANA ER

TABLET,EXTENDE

D RELEASE 10 mg,

20 mg, 30 mg, 40 mg,

5 mg

4

oxycodone capsule 5

mg

1

oxycodone Oral

Concentrate 20

mg/mL

1


Limits

oxycodone tablet 15

mg, 30 mg, 5 mg

1

oxycodone-

acetaminophen

capsule 5-500 mg

1

oxycodone-


10-325 mg, 2.5-325

mg, 5-325 mg, 7.5-325

mg, 7.5-500 mg

1

oxycodone-aspirin

tablet 4.8355-325 mg

2

oxymorphone tablet

10 mg, 5 mg

2

oxymorphone ER

tablet,extended

release,12 hr 15 mg,

7.5 mg

2 MO

REPREXAIN

TABLET 10-200 mg

2

REPREXAIN

TABLET 5-200 mg

3

REPREXAIN

TABLET 2.5-200 mg

3 MO

ROXICET ORAL

SOLN 5-325 mg/5 mL

3

ROXICET TABLET

5-500 mg

3

STAGESIC

CAPSULE 5-500 mg

2

Non-Narcotic Analgesics

ARTHROTEC 50

TABLET,DELAYED

RELEASE 50-200

mg-mcg

4 MO

ARTHROTEC 75

TABLET,DELAYED

RELEASE 75-200

mg-mcg

4 MO

Page 25 of 89


Limits

butorphanol tartrate

Injection 1 mg/mL, 2

mg/mL

2

butorphanol tartrate

Nasal Spray 10 mg/mL

2

CELEBREX

CAPSULE 100 mg,

200 mg, 400 mg, 50

mg

3 MO; QL (60 EA

per 30 day(s))

diclofenac potassium

tablet 50 mg

1 MO

diclofenac sodium


75 mg

1 MO

diclofenac ER

tablet,extended

release 24 hr 100 mg

2 MO

diclofenac sodium


25 mg, 50 mg

2 MO

diflunisal tablet 500

mg

2 MO

etodolac capsule 200

mg

2 MO

etodolac ER

tablet,extended


500 mg, 600 mg

2 MO

etodolac tablet 400

mg, 500 mg

2 MO

fenoprofen tablet 600

mg

2 MO

flurbiprofen tablet 100

mg, 50 mg

1 MO

ibuprofen Oral Susp

100 mg/5 mL

1 MO

ibuprofen tablet 400

mg, 600 mg, 800 mg

1 MO


Limits

INDOCIN ORAL

SUSP 25 mg/5 mL

4 MO

indomethacin capsule

25 mg, 50 mg

1 MO

indomethacin ER

capsule,extended

release 75 mg

2 MO

ketoprofen capsule 50

mg, 75 mg

1 MO

ketoprofen ER 24 hr

capsule,extended

release 200 mg

2 MO

ketorolac Injection 15

mg/mL, 30 mg/mL (1

mL)

1 MO

ketorolac tablet 10 mg 1 MO; QL (20 EA

per 30 day(s))

meclofenamate

capsule 100 mg, 50

mg

2 MO

mefenamic acid

capsule 250 mg

2 MO

meloxicam Oral Susp

7.5 mg/5 mL

1 MO

meloxicam tablet 15

mg, 7.5 mg

1 MO

nabumetone tablet 500

mg, 750 mg

1 MO

nalbuphine Injection

10 mg/mL, 20 mg/mL

2

NALFON CAPSULE

200 mg, 400 mg

4 MO

naloxone Syringe 1

mg/mL

2 MO

naltrexone tablet 50

mg

2 MO

naproxen Oral Susp

125 mg/5 mL

1 MO

Page 26 of 89


Limits

naproxen tablet 250

mg, 375 mg, 500 mg

1 MO

naproxen


375 mg, 500 mg

2 MO

naproxen sodium


1 MO

oxaprozin tablet 600

mg

1 MO

pentazocine-


25-650 mg

2

pentazocine-naloxone

tablet 50-0.5 mg

2

piroxicam capsule 10

mg, 20 mg

1 MO

SUBOXONE

SUBLINGUAL FILM

2-0.5 mg, 8-2 mg

4

SUBOXONE

SUBLINGUAL

TABLET 2-0.5 mg, 8-

2 mg

4

sulindac tablet 150

mg, 200 mg

1 MO

TALWIN

INJECTION 30

mg/mL

4 BvsD

tolmetin capsule 400

mg

2 MO

tolmetin tablet 200

mg, 600 mg

2 MO

tramadol tablet 50 mg 1 MO

tramadol ER

tablet,extended


200 mg

2 MO


Limits

tramadol ER

tablet,extended

release 24hr mphase

300 mg

2 MO

tramadol-


37.5-325 mg

2 MO

VIVITROL IM

SUSPENSION,EXTE

NDED RELEASE 380

mg

4 BvsD; MO

VOLTAREN

TOPICAL GEL 1 %

4 MO

Psychotherapeutic Drugs

ABILIFY IM 9.75

mg/1.3 mL

4 MO

ABILIFY ORAL

SOLN 1 mg/mL

4 MO

ABILIFY TABLET

10 mg, 15 mg, 2 mg,

20 mg, 30 mg, 5 mg

4 MO

ABILIFY DISCMELT

DISINTEGRATING

TABLET 10 mg, 15

mg

4 MO

ADDERALL XR

CAPSULE,EXTEND

ED RELEASE 10 mg,

15 mg, 20 mg, 25 mg,

30 mg, 5 mg

4

amitriptyline tablet 10

mg, 100 mg, 150 mg,

25 mg, 50 mg, 75 mg

1 MO

amitriptyline-

chlordiazepoxide

tablet 12.5-5 mg, 25-

10 mg

2 MO

amoxapine tablet 100

mg, 150 mg, 25 mg, 50

mg

2 MO

Page 27 of 89


Limits

AMPHETAMINE

SALT COMBO

TABLET 10 mg, 12.5

mg, 15 mg, 20 mg, 30

mg, 5 mg, 7.5 mg

1

APLENZIN

TABLET,EXTENDE

D RELEASE 174 mg,

348 mg, 522 mg

4 MO

BUDEPRION SR

TABLET,EXTENDE

D RELEASE 100 mg,

150 mg

2 MO

BUDEPRION XL 24

HR TABLET,

EXTENDED

RELEASE 150 mg,

300 mg

2 MO

bupropion HCl SR

tablet,extended

release 100 mg, 200

mg

1 MO

bupropion HCl tablet

100 mg, 75 mg

1 MO

bupropion HCl SR

tablet,extended

release 150 mg

2 MO

buspirone tablet 10

mg, 15 mg, 30 mg, 5

mg, 7.5 mg

1 MO

chlorpromazine

Injection 25 mg/mL

1 MO

chlorpromazine tablet

10 mg, 100 mg, 200

mg, 25 mg, 50 mg

1 MO

citalopram Oral Soln

10 mg/5 mL

2 MO

citalopram tablet 10

mg, 20 mg, 40 mg

2 MO

clomipramine capsule

25 mg, 50 mg, 75 mg

1 MO


Limits

clonazepam


0.125 mg, 0.25 mg, 0.5

mg, 1 mg, 2 mg

1 MO

clonazepam tablet 0.5

mg, 1 mg, 2 mg

1 MO

clorazepate

dipotassium tablet 15

mg, 3.75 mg, 7.5 mg

1 MO

clozapine tablet 100

mg, 25 mg, 50 mg

1 MO

clozapine tablet 200

mg

4 MO

CLOZARIL TABLET

100 mg, 25 mg

4 MO

CONCERTA

TABLET,EXTENDE

D RELEASE 18 mg,

27 mg, 36 mg, 54 mg

4

CYMBALTA

CAPSULE,DELAYE

D RELEASE 20 mg,

30 mg, 60 mg

4 MO

desipramine tablet 10

mg, 100 mg, 150 mg,

25 mg, 50 mg, 75 mg

1 MO

DESOXYN TABLET

5 mg

4

dexmethylphenidate

tablet 10 mg, 2.5 mg,

5 mg

1

dextroamphetamine

tablet 10 mg, 5 mg

1

dextroamphetamine

ER capsule,extended


5 mg

2

diazepam Oral Soln 5

mg/5 mL

1 MO

Page 28 of 89


Limits

diazepam Rectal Kit

12.5-15-17.5-20 mg,

2.5 mg, 5-7.5-10 mg

1 MO

diazepam tablet 10

mg, 2 mg, 5 mg

1 MO

DIAZEPAM

INTENSOL ORAL

CONCENTRATE 5

mg/mL

1 MO

doxepin capsule 10

mg, 100 mg, 150 mg,

25 mg, 50 mg, 75 mg

1 MO

doxepin Oral

Concentrate 10

mg/mL

1 MO

EFFEXOR XR

CAPSULE,EXTEND

ED RELEASE 150

mg, 37.5 mg, 75 mg

4 MO

EMSAM

TRANSDERM 24 HR

PATCH 12 mg/24 hr,

6 mg/24 hr, 9 mg/24

hr

4 MO

ergoloid tablet 1 mg 2 MO

escitalopram Oral

Soln 5 mg/5 mL

2 MO

escitalopram tablet 10

mg, 20 mg, 5 mg

2 MO

FANAPT TABLET 1

mg, 10 mg, 12 mg, 2


4 MO

FANAPT TABLETS

IN A DOSE PACK

1mg(2)-2mg(2)-

4mg(2)-6mg(2)

4 MO

FAZACLO

DISINTEGRATING

TABLET 100 mg,

12.5 mg, 150 mg, 200

mg, 25 mg

4 MO


Limits

fluoxetine capsule 10

mg, 20 mg, 40 mg

2 MO

fluoxetine

capsule,delayed

release 90 mg

2 MO

fluoxetine Oral Soln

20 mg/5 mL

2 MO

fluoxetine tablet 10

mg, 20 mg

2 MO

fluphenazine

decanoate Injection 25

mg/mL

2 MO

fluphenazine Elixir 2.5

mg/5 mL

1 MO

fluphenazine Injection

2.5 mg/mL

1 MO

fluphenazine Oral

Concentrate 5 mg/mL

1 MO

fluphenazine tablet 1

mg, 10 mg, 2.5 mg, 5

mg

1 MO

fluvoxamine tablet 100

mg, 25 mg, 50 mg

2 MO

FOCALIN TABLET

10 mg, 2.5 mg, 5 mg

3

FOCALIN XR

CAPSULE,EXTEND

ED RELEASE 10 mg,

15 mg, 20 mg, 30 mg,

40 mg, 5 mg

4

FOCALIN XR

CAPSULE,EXTEND

ED RELEASE 25 mg,

35 mg

4 MO

GEODON IM 20 mg 4 BvsD; MO

GEODON CAPSULE

20 mg, 40 mg, 60 mg,

80 mg

4 MO

Page 29 of 89


Limits

HALDOL

INJECTION 5 mg/mL

4 MO

HALDOL

DECANOATE IM

100 mg/mL, 50

mg/mL

4 MO

haloperidol tablet 0.5

mg, 1 mg, 10 mg, 2

mg, 20 mg, 5 mg

1 MO

haloperidol decanoate

IM 100 mg/mL, 50

mg/mL

2 MO

haloperidol Injection

5 mg/mL

1 MO

haloperidol Oral

Concentrate 2 mg/mL

1 MO

imipramine tablet 10

mg, 25 mg, 50 mg

1 MO

imipramine pamoate

capsule 100 mg, 125

mg, 150 mg, 75 mg

2 MO

INTUNIV ER

TABLET,EXTENDE

D RELEASE 1 mg, 2

mg, 3 mg, 4 mg

4 MO

INVEGA

TABLET,EXTENDE

D RELEASE 1.5 mg,

3 mg, 6 mg, 9 mg

4 MO

INVEGA

SUSTENNA IM

SYRINGE 39 mg/0.25

mL, 78 mg/0.5 mL

4 BvsD; MO

INVEGA

SUSTENNA IM

SYRINGE 117

mg/0.75 mL, 156

mg/mL (1 mL), 234

mg/1.5 mL

5 BvsD; MO

LATUDA TABLET

20 mg, 40 mg, 80 mg

4 MO


Limits

LEXAPRO ORAL

SOLN 5 mg/5 mL

4 MO

LEXAPRO TABLET

10 mg, 20 mg, 5 mg

4 MO

lithium carbonate

capsule 150 mg, 300

mg

1 MO

lithium carbonate ER

tablet,extended

release 300 mg, 450

mg

1 MO

lithium carbonate

tablet 300 mg

1 MO

lithium carbonate

capsule 600 mg

3 MO

lithium citrate Oral

Soln 8 mEq/5 mL

1 MO

loxapine capsule 10

mg, 25 mg, 5 mg, 50

mg

1 MO

LUNESTA TABLET

1 mg, 2 mg, 3 mg

4 PA

LUVOX CR

CAPSULE,EXTEND

ED RELEASE 100

mg, 150 mg

4 MO

maprotiline tablet 25

mg, 50 mg, 75 mg

1 MO

MARPLAN TABLET

10 mg

4 MO

METADATE CD

CAPSULE,EXTEND

ED RELEASE 10 mg,

20 mg, 30 mg, 40 mg,

50 mg, 60 mg

4

METADATE ER

TABLET,EXTENDE

D RELEASE 20 mg

2

methamphetamine

tablet 5 mg

2

Page 30 of 89


Limits

METHYLIN

CHEWABLE

TABLET 10 mg, 2.5

mg, 5 mg

3

METHYLIN ORAL

SOLN 10 mg/5 mL, 5

mg/5 mL

3

methylphenidate ER

tablet,extended

release 20 mg

1

methylphenidate Oral

Soln 5 mg/5 mL

1

methylphenidate tablet

10 mg, 20 mg, 5 mg

1

methylphenidate ER

capsule,extended

release multiphase 50-

50 20 mg, 30 mg, 40

mg

1 MO

mirtazapine


15 mg, 30 mg, 45 mg

2 MO

mirtazapine tablet 15

mg, 30 mg, 45 mg, 7.5

mg

2 MO

NARDIL TABLET 15

mg

4 MO

nefazodone tablet 100

mg, 150 mg, 200 mg,

250 mg, 50 mg

1 MO

nortriptyline capsule

10 mg, 25 mg, 50 mg,

75 mg

1 MO

olanzapine


10 mg, 15 mg, 20 mg,

5 mg

2 MO

olanzapine IM 10 mg 2 MO


Limits

olanzapine tablet 10

mg, 15 mg, 2.5 mg, 20

mg, 5 mg, 7.5 mg

2 MO

ORAP TABLET 1

mg, 2 mg

4 MO

paroxetine ER

tablet,extended

release 24 hr 12.5 mg

1 MO

paroxetine ER

tablet,extended


37.5 mg

2 MO

paroxetine tablet 10

mg, 20 mg, 30 mg, 40

mg

2 MO

PAXIL ORAL SUSP

10 mg/5 mL

3 MO

perphenazine tablet 16


1 MO

perphenazine-

amitriptyline tablet 2-

10 mg, 2-25 mg, 4-10

mg, 4-25 mg, 4-50 mg

1 MO

PEXEVA TABLET

10 mg, 20 mg, 30 mg,

40 mg

4 MO

phenelzine tablet 15

mg

2 MO

PRISTIQ

TABLET,EXTENDE

D RELEASE 100 mg,

50 mg

4 MO

protriptyline tablet 10

mg, 5 mg

2 MO

PROVIGIL TABLET

100 mg, 200 mg

3

PROZAC WEEKLY

CAPSULE,DELAYE

D RELEASE 90 mg

4 MO

Page 31 of 89


Limits

quetiapine tablet 100

mg, 200 mg, 25 mg,

300 mg, 400 mg, 50

mg

2 MO

RISPERDAL

CONSTA IM

SYRINGE 12.5 mg/2

mL, 25 mg/2 mL, 37.5

mg/2 mL, 50 mg/2 mL

4 BvsD; MO

RISPERDAL M-TAB

DISINTEGRATING

TABLET 0.5 mg, 1


4 MO

risperidone


0.5 mg, 1 mg, 2 mg, 3

mg, 4 mg

2 MO

risperidone Oral Soln

1 mg/mL

2 MO

risperidone tablet 0.25

mg, 0.5 mg, 1 mg, 2

mg, 3 mg, 4 mg

2 MO

risperidone


0.25 mg

3 MO

ROZEREM TABLET

8 mg

4 PA; MO

SAPHRIS

SUBLINGUAL

TABLET 10 mg, 5 mg

4 MO

SARAFEM TABLET

10 mg, 20 mg

4 MO

SEROQUEL

TABLET 100 mg, 200

mg, 25 mg, 300 mg,

400 mg, 50 mg

4 MO

SEROQUEL XR

TABLET,EXTENDE

D RELEASE 150 mg,

200 mg, 300 mg, 400

mg, 50 mg

4 MO


Limits

sertraline Oral

Concentrate 20

mg/mL

2 MO

sertraline tablet 100

mg, 25 mg, 50 mg

2 MO

STRATTERA

CAPSULE 10 mg,

100 mg, 18 mg, 25

mg, 40 mg, 60 mg, 80

mg

4 MO

SURMONTIL

CAPSULE 100 mg

4 MO

SYMBYAX

CAPSULE 12-25 mg,

12-50 mg, 3-25 mg, 6-

25 mg, 6-50 mg

4 MO

thioridazine tablet 10

mg, 100 mg, 25 mg, 50

mg

1 MO

thiothixene capsule 1

mg, 10 mg, 2 mg, 5 mg

1 MO

TOFRANIL-PM

CAPSULE 100 mg,

125 mg, 150 mg, 75

mg

4 MO

tranylcypromine tablet

10 mg

1 MO

trazodone tablet 100

mg, 150 mg, 300 mg,

50 mg

1 MO

trifluoperazine tablet

1 mg, 10 mg, 2 mg, 5

mg

1 MO

trimipramine capsule

100 mg, 25 mg, 50 mg

2 MO

venlafaxine tablet 100

mg, 25 mg, 37.5 mg,

50 mg, 75 mg

1 MO

Page 32 of 89


Limits

venlafaxine ER

capsule,extended


37.5 mg, 75 mg

2 MO

venlafaxine ER

tablet,24 hr extended

release 150 mg, 225

mg, 37.5 mg, 75 mg

4 MO

VIIBRYD TABLET

10 mg, 20 mg, 40 mg

4 MO

VIIBRYD TABLETS

IN A DOSE PACK 10

mg (7)-20 mg (7)-40

mg (16)

4 MO

VYVANSE

CAPSULE 20 mg, 30

mg, 40 mg, 50 mg, 60

mg, 70 mg

4

XYREM ORAL

SOLN 500 mg/mL

4 LA

zaleplon capsule 10

mg, 5 mg

2

ziprasidone capsule

20 mg, 40 mg, 60 mg,

80 mg

2 MO

zolpidem ER

tablet,extended

release,multiphase

12.5 mg, 6.25 mg

2

zolpidem tablet 10 mg,

5 mg

2

ZYPREXA IM 10 mg 4 MO

ZYPREXA TABLET

10 mg, 15 mg, 2.5 mg,

20 mg, 5 mg, 7.5 mg

4 MO

ZYPREXA ZYDIS

DISINTEGRATING

TABLET 10 mg, 15

mg, 20 mg, 5 mg

4 MO

Cardiovascular, Hypertension / Lipids


Limits

Antiarrhythmic Agents

amiodarone IV 50

mg/mL

1 MO

amiodarone tablet 200

mg, 400 mg

1 MO

disopyramide capsule

100 mg, 150 mg

1 MO

flecainide tablet 100

mg, 150 mg, 50 mg

2 MO

mexiletine capsule 150

mg, 200 mg, 250 mg

1 MO

MULTAQ TABLET

400 mg

4 MO; QL (60 EA

per 30 day(s))

PACERONE

TABLET 200 mg

2 MO

PACERONE

TABLET 100 mg

4 MO

procainamide

Injection 100 mg/mL,

500 mg/mL

1 MO

propafenone ER

capsule,extended


325 mg, 425 mg

2 MO

propafenone tablet

150 mg, 225 mg, 300

mg

2 MO

quinidine ER

tablet,extended

release 324 mg

1 MO

quinidine Injection 80

mg/mL

3 MO

quinidine sulfate ER

tablet,extended

release 300 mg

1 MO

quinidine tablet 200

mg, 300 mg

1 MO

Page 33 of 89


Limits

SORINE TABLET

120 mg, 160 mg, 240

mg, 80 mg

2 MO

sotalol tablet 120 mg,

160 mg, 240 mg, 80

mg

1 MO

TIKOSYN CAPSULE

125 mcg, 250 mcg,

500 mcg

4 MO

Antihypertensive Therapy

acebutolol capsule

200 mg, 400 mg

1 MO

ADCIRCA TABLET

20 mg

3 MO

AFEDITAB CR

TABLET,EXTENDE

D RELEASE 30 mg,

60 mg

1 MO

ALDACTAZIDE

TABLET 50-50 mg

4 MO

amiloride tablet 5 mg 1 MO

amiloride-

hydrochlorothiazide

tablet 5-50 mg

1 MO

amlodipine tablet 10

mg, 2.5 mg, 5 mg

1 MO

amlodipine-benazepril

capsule 10-20 mg, 10-

40 mg, 2.5-10 mg, 5-

10 mg, 5-20 mg, 5-40

mg

2 MO

atenolol tablet 100

mg, 25 mg, 50 mg

1 MO

atenolol-

chlorthalidone tablet

100-25 mg, 50-25 mg

1 MO

AZOR TABLET 10-

20 mg, 10-40 mg, 5-

20 mg, 5-40 mg

4 MO


Limits

benazepril tablet 10

mg, 20 mg, 40 mg, 5

mg

1 MO

benazepril-

hydrochlorothiazide

tablet 10-12.5 mg, 20-

12.5 mg, 20-25 mg, 5-

6.25 mg

1 MO

betaxolol tablet 20 mg 1 MO

bisoprolol fumarate

tablet 10 mg, 5 mg

1 MO

bisoprolol-

hydrochlorothiazide

tablet 10-6.25 mg, 2.5-

6.25 mg, 5-6.25 mg

1 MO

bumetanide Injection

0.25 mg/mL

1 MO

bumetanide tablet 0.5

mg, 1 mg, 2 mg

1 MO

BYSTOLIC TABLET

10 mg, 2.5 mg, 20 mg,

5 mg

4 MO

captopril tablet 100

mg, 12.5 mg, 25 mg,

50 mg

1 MO

captopril-

hydrochlorothiazide

tablet 25-15 mg, 25-25

mg, 50-15 mg, 50-25

mg

1 MO

CARDURA XL

TABLET,EXTENDE

D RELEASE 4 mg, 8

mg

4 MO; QL (60 EA

per 30 day(s))

CARTIA XT

CAPSULE,EXTEND

ED RELEASE 120

mg, 180 mg, 240 mg,

300 mg

1 MO

Page 34 of 89


Limits

carvedilol tablet 12.5

mg, 25 mg, 3.125 mg,

6.25 mg

1 MO

chlorothiazide tablet

250 mg, 500 mg

1 MO

chlorothiazide sodium

IV Solution 500 mg

1 BvsD; MO

chlorthalidone tablet

25 mg, 50 mg

1 MO

clonidine tablet 0.1

mg, 0.2 mg, 0.3 mg

1 MO

clonidine Weekly

Transderm Patch 0.1

mg/24 hr, 0.2 mg/24

hr, 0.3 mg/24 hr

1 MO

CLORPRES TABLET

0.1-15 mg, 0.2-15 mg,

0.3-15 mg

4 MO

COREG CR

CAPSULE,

EXTENDED

RELEASE 10 mg, 20

mg, 40 mg, 80 mg

4 MO

COZAAR TABLET

100 mg

4 ST; MO; QL (30

EA per 30 day(s))

COZAAR TABLET

25 mg, 50 mg

4 ST; MO; QL (60

EA per 30 day(s))

DEMSER CAPSULE

250 mg

4 MO

DIBENZYLINE

CAPSULE 10 mg

4 MO

DILT-CD

CAPSULE,EXTEND

ED RELEASE 120

mg, 300 mg

1 MO

diltiazem CD

capsule,extended


240 mg, 300 mg

1 MO


Limits

diltiazem ER

capsule,extended

release 180 mg, 360

mg

1 MO

diltiazem ER

capsule,extended


60 mg, 90 mg

1 MO

diltiazem IV 5 mg/mL 1 MO

diltiazem tablet 120

mg, 30 mg, 60 mg, 90

mg

1 MO

diltiazem IV powder

for Solution 100 mg

3 MO

DILT-XR CAPSULE,

EXTENDED

RELEASE 180 mg,

240 mg

1 MO

DIOVAN TABLET

320 mg

4 ST; MO; QL (30

EA per 30 day(s))

DIOVAN TABLET

160 mg, 40 mg, 80 mg

4 ST; MO; QL (60

EA per 30 day(s))

DIOVAN HCT

TABLET 160-12.5

mg, 160-25 mg, 320-

12.5 mg, 320-25 mg,

80-12.5 mg

4 ST; MO; QL (30

EA per 30 day(s))

DIURIL ORAL SUSP

250 mg/5 mL

4 MO

DIURIL IV

SOLUTION 500 mg

4 BvsD; MO

doxazosin tablet 1 mg,

2 mg, 4 mg, 8 mg

1 MO; QL (60 EA

per 30 day(s))

DYNACIRC CR

TABLET,EXTENDE

D RELEASE 10 mg, 5

mg

4 MO

DYRENIUM

CAPSULE 100 mg,

50 mg

4 MO

Page 35 of 89


Limits

EDARBI TABLET 40

mg, 80 mg

3 ST; MO

EDARBYCLOR

TABLET 40-12.5 mg,

40-25 mg

3 MO

EDECRIN TABLET

25 mg

4 MO

enalapril maleate


20 mg, 5 mg

1 MO

enalapril-

hydrochlorothiazide

tablet 10-25 mg, 5-

12.5 mg

1 MO

eplerenone tablet 25

mg, 50 mg

2 MO

eprosartan tablet 600

mg

2 MO

EXFORGE TABLET

10-160 mg, 10-320

mg, 5-160 mg, 5-320

mg

4 MO

EXFORGE HCT

TABLET 10-160-12.5

mg, 10-160-25 mg,

10-320-25 mg, 5-160-

12.5 mg, 5-160-25 mg

4 MO

felodipine ER

tablet,extended


2.5 mg, 5 mg

1 MO

fosinopril tablet 10

mg, 20 mg, 40 mg

1 MO

fosinopril-

hydrochlorothiazide

tablet 10-12.5 mg, 20-

12.5 mg

1 MO

furosemide Injection

10 mg/mL

1 MO


Limits

furosemide Oral Soln

10 mg/mL

1 MO

furosemide tablet 20

mg, 40 mg, 80 mg

1 MO

furosemide Oral Soln

40 mg/5 mL

3 MO

guanfacine tablet 1

mg, 2 mg

1 MO

hydralazine Injection

20 mg/mL

1 MO

hydralazine tablet 10

mg, 100 mg, 25 mg, 50

mg

1 MO

hydrochlorothiazide

capsule 12.5 mg

1 MO

hydrochlorothiazide

tablet 12.5 mg, 25 mg,

50 mg

1 MO

HYZAAR TABLET

100-12.5 mg, 100-25

mg, 50-12.5 mg

4 ST; MO; QL (30

EA per 30 day(s))

indapamide tablet

1.25 mg, 2.5 mg

1 MO

irbesartan tablet 150

mg, 300 mg, 75 mg

2 MO

irbesartan-

hydrochlorothiazide

tablet 150-12.5 mg,

300-12.5 mg

2 MO

isradipine capsule 2.5

mg, 5 mg

2 MO

labetalol IV 5 mg/mL 1 MO

labetalol tablet 100

mg, 200 mg, 300 mg

1 MO

LEVATOL TABLET

20 mg

4 MO

lisinopril tablet 10 mg,

2.5 mg, 20 mg, 30 mg,

40 mg, 5 mg

1 MO

Page 36 of 89


Limits

lisinopril-

hydrochlorothiazide

tablet 10-12.5 mg, 20-

12.5 mg, 20-25 mg

1 MO

losartan tablet 100

mg, 25 mg, 50 mg

1 MO

losartan-

hydrochlorothiazide

tablet 100-12.5 mg,

100-25 mg, 50-12.5

mg

1 MO

methyclothiazide

tablet 5 mg

1 MO

methyldopa tablet 250

mg, 500 mg

1 MO

methyldopa-

hydrochlorothiazide

tablet 250-15 mg, 250-

25 mg

1 MO

methyldopate IV 250

mg/5 mL

1 MO

metolazone tablet 10

mg, 2.5 mg, 5 mg

1 MO

metoprolol succinate

ER tablet,extended


200 mg, 25 mg, 50 mg

2 MO

metoprolol tartrate-

hydrochlorothiazide

tablet 100-25 mg, 100-

50 mg, 50-25 mg

1 MO

metoprolol IV 5 mg/5

mL

1 BvsD; MO

metoprolol tartrate

tablet 100 mg, 25 mg,

50 mg

1 MO

MICARDIS TABLET

20 mg, 40 mg, 80 mg

3 ST; MO


Limits

MICARDIS HCT

TABLET 40-12.5 mg,

80-12.5 mg, 80-25 mg

3 ST; MO

minoxidil tablet 10

mg, 2.5 mg

2 MO

moexipril tablet 15

mg, 7.5 mg

2 MO

moexipril-

hydrochlorothiazide

tablet 15-12.5 mg, 15-

25 mg, 7.5-12.5 mg

2 MO

nadolol tablet 20 mg,

40 mg, 80 mg

2 MO

nadolol-

bendroflumethiazide

tablet 40-5 mg, 80-5

mg

2 MO

nicardipine capsule 20

mg, 30 mg

1 MO

NIFEDIAC CC

TABLET,EXTENDE

D RELEASE 90 mg

1 MO

NIFEDICAL XL

TABLET,EXTENDE

D RELEASE 30 mg,

60 mg

1 MO

nifedipine capsule 10

mg, 20 mg

1 MO

nifedipine ER

tablet,24 hr extended


90 mg

1 MO

nimodipine capsule 30

mg

2 MO

nisoldipine ER

tablet,extended


30 mg, 40 mg

2 MO

pindolol tablet 10 mg,

5 mg

2 MO

Page 37 of 89


Limits

prazosin capsule 2

mg, 5 mg

1 MO; QL (120 EA

per 30 day(s))

prazosin capsule 1 mg 1 MO; QL (90 EA

per 30 day(s))

propranolol ER

capsule,24

hr,extended release

120 mg, 160 mg, 60

mg, 80 mg

1 MO

propranolol IV 1

mg/mL

1 MO

propranolol Oral Soln

20 mg/5 mL, 40 mg/5

mL

1 MO

propranolol tablet 10

mg, 20 mg, 40 mg, 60

mg, 80 mg

1 MO

propranolol-

hydrochlorothiazide

tablet 40-25 mg, 80-25

mg

1 MO

quinapril tablet 10

mg, 20 mg, 40 mg, 5

mg

1 MO

quinapril-

hydrochlorothiazide

tablet 10-12.5 mg, 20-

12.5 mg, 20-25 mg

1 MO

ramipril capsule 1.25

mg

1 MO

ramipril capsule 10

mg, 2.5 mg, 5 mg

2 MO

REMODULIN

INJECTION 1

mg/mL, 10 mg/mL,

2.5 mg/mL, 5 mg/mL

4 BvsD; MO

reserpine tablet 0.1

mg, 0.25 mg

1 MO

spironolactone tablet

100 mg, 25 mg, 50 mg

1 MO


Limits

spironolactone-

hydrochlorothiazide

tablet 25-25 mg

1 MO

SULAR

TABLET,EXTENDE

D RELEASE 34 mg,

8.5 mg

4 MO

TAZTIA XT

CAPSULE,EXTEND

ED RELEASE 120

mg, 180 mg, 240 mg,

300 mg, 360 mg

1 MO

TEKTURNA

TABLET 150 mg, 300

mg

4 MO

TEKTURNA HCT

TABLET 150-12.5

mg, 150-25 mg, 300-

12.5 mg, 300-25 mg

4 MO

terazosin capsule 1

mg, 10 mg, 2 mg, 5 mg

1 MO

THALITONE

TABLET 15 mg

4 MO

timolol tablet 10 mg,

20 mg, 5 mg

1 MO

torsemide tablet 10

mg, 100 mg, 20 mg, 5

mg

1 MO

torsemide IV 20 mg/2

mL (10 mg/mL)

4 MO

trandolapril tablet 1

mg, 2 mg, 4 mg

1 MO

triamterene-

hydrochlorothiazide

capsule 37.5-25 mg,

50-25 mg

1 MO

triamterene-

hydrochlorothiazide

tablet 37.5-25 mg, 75-

50 mg

1 MO

Page 38 of 89


Limits

verapamil ER (PM)

capsule 24hr pellet

CT,ext.release 100

mg, 200 mg, 300 mg

1 MO

verapamil ER (SR)

tablet,extended

release 120 mg, 180

mg, 240 mg

1 MO

verapamil ER 24 hr

capsule,extended

release 120 mg, 180

mg, 240 mg

1 MO

verapamil IV 2.5

mg/mL

1 MO

verapamil tablet 120

mg, 40 mg, 80 mg

1 MO

Cardiac Glycosides

digoxin Injection 250

mcg/mL

1 MO

digoxin Oral Soln 50

mcg/mL

1 MO

digoxin tablet 125

mcg, 250 mcg

1 MO

LANOXIN

PEDIATRIC

INJECTION 100

mcg/mL

4 BvsD; MO

Coagulation Therapy

AGGRENOX

CAPSULE,

EXTENDED

RELEASE 200-25 mg

4 MO; QL (60 EA

per 30 day(s))

ARIXTRA SUB-Q

SYRINGE 10 mg/0.8

mL, 2.5 mg/0.5 mL, 5

mg/0.4 mL, 7.5

mg/0.6 mL

4 BvsD; MO

cilostazol tablet 100

mg, 50 mg

2 MO


Limits

clopidogrel tablet 300

mg

2 MO

clopidogrel tablet 75

mg

2 MO; QL (30 per

30 Day(s))

CYKLOKAPRON IV

100 mg/mL

3 MO

dipyridamole tablet 25

mg, 50 mg, 75 mg

2 MO

enoxaparin Sub-Q

Syringe 100 mg/mL,

120 mg/0.8 mL, 150

mg/mL, 30 mg/0.3 mL,

40 mg/0.4 mL, 60

mg/0.6 mL, 80 mg/0.8

mL

2 BvsD; MO

fondaparinux Sub-Q

Syringe 10 mg/0.8 mL,

2.5 mg/0.5 mL, 5

mg/0.4 mL, 7.5 mg/0.6

mL

1 BvsD; MO

FRAGMIN SUB-Q

25,000 unit/mL

4 BvsD; MO

FRAGMIN SUB-Q

SYRINGE 10,000

unit/mL, 12,500

unit/0.5 mL, 15,000

unit/0.6 mL, 18,000

unit/0.72 mL, 2,500

unit/0.2 mL, 5,000

unit/0.2 mL, 7,500

unit/0.3 mL

4 BvsD; MO

heparin (porcine)

Injection 1,000

unit/mL, 10,000

unit/mL, 20,000

unit/mL, 5,000

unit/mL

2 MO

heparin (porcine) in

D5W IV 20,000

unit/500 mL

2 BvsD; MO

Page 39 of 89


Limits


0.9 % NaCl (PF) IV

2,000 unit/1,000 mL

2 MO


0.45 % NaCl IV

25,000 unit/250 mL,

25,000 unit/500 mL

3 MO

JANTOVEN

TABLET 1 mg, 10

mg, 2 mg, 2.5 mg, 3

mg, 4 mg, 5 mg, 6 mg,

7.5 mg

2 MO

LOVENOX SUB-Q

300 mg/3 mL

4 BvsD; MO

LOVENOX SUB-Q

SYRINGE 100

mg/mL, 120 mg/0.8

mL, 150 mg/mL, 30

mg/0.3 mL, 40 mg/0.4

mL, 60 mg/0.6 mL, 80

mg/0.8 mL

4 BvsD; MO

pentoxifylline ER

tablet,extended

release 400 mg

1 MO

PLAVIX TABLET

300 mg

3 MO

PLAVIX TABLET 75

mg

3 MO; QL (30 EA

per 30 day(s))

PRADAXA

CAPSULE 150 mg,

75 mg

4 MO

PROMACTA

TABLET 12.5 mg, 25

mg, 50 mg, 75 mg

5 MO

ticlopidine tablet 250

mg

1 MO

warfarin tablet 1 mg,

10 mg, 2 mg, 2.5 mg, 3

mg, 4 mg, 5 mg, 6 mg,

7.5 mg

1 MO

Direct Renin Inhibitors


Limits

AMTURNIDE

TABLET 150-5-12.5

mg, 300-10-12.5 mg,

300-10-25 mg, 300-5-

12.5 mg, 300-5-25 mg

4 MO; QL (30 EA

per 30 day(s))

Lipid/Cholesterol Lowering Agents

ADVICOR

TABLET,EXTENDE

D RELEASE 1,000-20

mg, 1,000-40 mg,

500-20 mg, 750-20

mg

4 MO

atorvastatin tablet 10

mg, 20 mg, 40 mg, 80

mg

2 ST; MO

CADUET TABLET

10-10 mg, 10-20 mg,

10-40 mg, 10-80 mg,

2.5-10 mg, 2.5-20 mg,

2.5-40 mg, 5-10 mg,

5-20 mg, 5-40 mg, 5-

80 mg

4 MO; QL (30 EA

per 30 day(s))

CHOLESTYRAMINE

LIGHT PACKET 4

gram

2 MO

colestipol Oral

Granules 5 gram

2 MO

colestipol tablet 1

gram

2 MO

CRESTOR TABLET

10 mg, 20 mg, 40 mg,

5 mg

4 ST; MO

fenofibrate tablet 160

mg, 54 mg

1 MO

fenofibrate micronized

capsule 134 mg, 200

mg, 67 mg

2 MO

FIBRICOR TABLET

105 mg, 35 mg

3 MO

fluvastatin capsule 20

mg, 40 mg

2 MO

Page 40 of 89


Limits

gemfibrozil tablet 600

mg

1 MO

lovastatin tablet 10

mg, 20 mg, 40 mg

1 MO

LOVAZA CAPSULE

1 gram

4 MO

NIACOR TABLET

500 mg

4 MO

NIASPAN

EXTENDED-

RELEASE

TABLET,EXTENDE

D RELEASE 1,000

mg, 500 mg, 750 mg

4 MO

pravastatin tablet 10

mg, 20 mg, 40 mg, 80

mg

1 MO

PREVALITE ORAL

POWDER 4 gram

2 MO

simvastatin tablet 10

mg, 20 mg, 40 mg, 5

mg, 80 mg

1 MO

VYTORIN 10-10

TABLET 10-10 mg

4 MO; QL (30 EA

per 30 day(s))

VYTORIN 10-20

TABLET 10-20 mg

4 MO; QL (30 EA

per 30 day(s))

VYTORIN 10-40

TABLET 10-40 mg

4 MO; QL (30 EA

per 30 day(s))

VYTORIN 10-80

TABLET 10-80 mg

4 MO; QL (30 EA

per 30 day(s))

WELCHOL ORAL

POWDER PACK 3.75

gram

4 MO

WELCHOL TABLET

625 mg

4 MO

ZETIA TABLET 10

mg

4 MO; QL (30 EA

per 30 day(s))

Miscellaneous Cardiovascular Agents


Limits

RANEXA

TABLET,EXTENDE

D RELEASE 1,000

mg, 500 mg

4 PA; MO

Nitrates

isosorbide dinitrate

ER tablet,extended

release 40 mg

1 MO


sublingual tablet 2.5

mg, 5 mg

1 MO


tablet 10 mg, 20 mg,

30 mg, 5 mg

1 MO

isosorbide

mononitrate ER

tablet,extended


30 mg, 60 mg

1 MO

isosorbide

mononitrate tablet 20

mg

1 MO

MINITRAN

TRANSDERM 24 HR

PATCH 0.1 mg/hr, 0.2

mg/hr, 0.4 mg/hr, 0.6

mg/hr

3 MO

NITRO-BID

TRANSDERMAL

OINTMENT 2 %

2 MO

nitroglycerin IV 50

mg/10 mL (5 mg/mL)

1 MO

nitroglycerin

Transderm 24 hr

Patch 0.1 mg/hr, 0.2

mg/hr, 0.4 mg/hr, 0.6

mg/hr

1 MO

NITROLINGUAL

SPRAY 0.4 mg/dose

4 MO

Page 41 of 89


Limits

NITROSTAT

SUBLINGUAL

TABLET 0.3 mg, 0.4

mg, 0.6 mg

3 MO

Dermatologicals/Topical Therapy

Antipsoriatic / Antiseborrheic

AMEVIVE IM 15 mg

(0.5 mL)

4 BvsD; MO

calcipotriene

Ointment 0.005 %

2 MO

calcipotriene Topical

Soln 0.005 %

2 MO

DOVONEX

TOPICAL CREAM

0.005 %

4 MO

selenium sulfide

Topical Susp 2.5 %

1 MO

SORIATANE

CAPSULE 10 mg,

17.5 mg, 25 mg

4 MO

TACLONEX SCALP

TOPICAL SUSP

0.005-0.064 %

4 MO

Burn Therapy

silver sulfadiazine

Topical Cream 1 %

1 MO

SSD TOPICAL

CREAM 1 %

1 MO

Miscellaneous Dermatologicals

8-MOP CAPSULE 10

mg

4 MO

ALDARA TOPICAL

CREAM PACKET 5

%

4 MO

ammonium lactate

Lotion 12 %

1 MO

ammonium lactate

Topical Cream 12 %

1 MO


Limits

CARAC TOPICAL

CREAM 0.5 %

4 MO

ELIDEL TOPICAL

CREAM 1 %

4 MO

FLUOROPLEX

TOPICAL CREAM 1

%

4 MO

fluorouracil Topical

Cream 5 %

2 MO

imiquimod Topical

Cream Packet 5 %

2 MO

LACLOTION 12 % 2 MO

OXSORALEN

LOTION 1 %

4 MO

OXSORALEN

ULTRA CAPSULE

10 mg

4 MO

PANRETIN

TOPICAL GEL 0.1 %

4 MO

podofilox Topical Soln

0.5 %

2 MO

PROTOPIC

OINTMENT 0.03 %,

0.1 %

4 MO

SOLARAZE

TOPICAL GEL 3 %

4 MO

U-CORT TOPICAL

CREAM 1-10 %

4 MO

UVADEX

INJECTION 20

mcg/mL

4 BvsD; MO

VEREGEN

OINTMENT 15 %

4 MO

Therapy For Acne

ACANYA TOPICAL

GEL 1.2-2.5 %

4 MO

adapalene Topical

Cream 0.1 %

2 MO

Page 42 of 89


Limits

adapalene Topical Gel

0.1 %

2 MO

AMNESTEEM

CAPSULE 10 mg, 20

mg, 40 mg

2 MO

AVITA TOPICAL

CREAM 0.025 %

2 MO

AZELEX TOPICAL

CREAM 20 %

4 MO

CLARAVIS

CAPSULE 10 mg, 20

mg, 30 mg, 40 mg

2 MO

clindamycin Lotion 1

%

2 MO

clindamycin

phosphate Topical

Swab 1 %

2 MO

clindamycin Topical

Gel 1 %

2 MO

clindamycin Topical

Soln 1 %

2 MO

clindamycin-benzoyl

peroxide Topical Gel

1-5 %

2 MO

ERY PADS

TOPICAL SWAB 2 %

2 MO

erythromycin with

ethanol Topical Gel 2

%

2 MO

erythromycin with

ethanol Topical Soln 2

%

2 MO

erythromycin-benzoyl

peroxide Topical Gel

3-5 %

2 MO

FINACEA TOPICAL

GEL 15 %

4 MO

METROGEL

TOPICAL 1 %

4 MO


Limits

metronidazole Lotion

0.75 %

2 MO

metronidazole Topical

Cream 0.75 %

2 MO

metronidazole Topical

Gel 0.75 %

2 MO

TAZORAC TOPICAL

CREAM 0.05 %, 0.1

%

4 MO

TAZORAC TOPICAL

GEL 0.05 %, 0.1 %

4 MO

tretinoin Topical

Cream 0.025 %, 0.05

%, 0.1 %

2 MO

tretinoin Topical Gel

0.01 %, 0.025 %

2 MO

Topical Anesthetics

lidocaine Ointment 5

%

1 MO

lidocaine (PF)

Injection 10 mg/mL (1

%)

1 MO

lidocaine Injection 5

mg/mL (0.5 %)

1 MO

lidocaine Mucosal Gel

2 %

1 MO

lidocaine Mucosal

Soln 4 %

1 MO

lidocaine Mucous

Membrane Jelly in

Applicator 2 %

1 MO

lidocaine-prilocaine

Topical Cream 2.5-2.5

%

1 MO

LIDODERM

ADHESIVE PATCH

5 %(700 mg/patch)

4 MO

SYNERA PATCH 70-

70 mg

4 MO

Page 43 of 89


Limits

Topical Antibacterials

ALTABAX

OINTMENT 1 %

4 MO

BACTROBAN

TOPICAL CREAM 2

%

3 MO

CORTISPORIN

TOPICAL CREAM

3.5-10,000-0.5 mg/g-

unit/g-%

3 MO

gentamicin Ointment

0.1 %

1 MO

gentamicin Topical

Cream 0.1 %

1 MO

mupirocin Ointment 2

%

1 MO

PHISOHEX

TOPICAL LIQUID 3

%

3 MO

sulfacetamide sodium

(acne) Topical Susp

10 %

2 MO

SULFAMYLON

TOPICAL CREAM

85 mg/g

3 MO

SULFAMYLON

TOPICAL PACKET

50 gram

3 MO

Topical Antifungals

ciclopirox Topical

Cream 0.77 %

2 MO

ciclopirox Topical Gel

0.77 %

2 MO

ciclopirox Topical

Soln 8 %

2 MO

ciclopirox Topical

Susp 0.77 %

2 MO

clotrimazole Topical

Cream 1 %

1 MO


Limits

clotrimazole Topical

Soln 1 %

1 MO

clotrimazole-

betamethasone Lotion

1-0.05 %

2 MO

clotrimazole-

betamethasone

Topical Cream 1-0.05

%

2 MO

econazole Topical

Cream 1 %

1 MO

EXELDERM

TOPICAL CREAM 1

%

3 MO

EXELDERM

TOPICAL SOLN 1 %

3 MO

EXTINA TOPICAL

FOAM 2 %

3 MO

ketoconazole Shampoo

2 %

1 MO

ketoconazole Topical

Cream 2 %

1 MO

ketoconazole Topical

Foam 2 %

1 MO

NYAMYC TOPICAL

POWDER 100,000

unit/g

2 MO

nystatin Ointment

100,000 unit/g

1 MO

nystatin Topical

Cream 100,000 unit/g

1 MO

nystatin Topical

Powder 100,000 unit/g

2 MO

nystatin-triamcinolone

Ointment 100,000-0.1

unit/gram-%

1 MO

nystatin-triamcinolone

Topical Cream

100,000-0.1 unit/g-%

1 MO

Page 44 of 89


Limits

NYSTOP TOPICAL

POWDER 100,000

unit/g

2 MO

PEDI-DRI TOPICAL

POWDER 100,000

unit/g

2 MO

Topical Antivirals

DENAVIR TOPICAL

CREAM 1 %

3 MO

ZOVIRAX

OINTMENT 5 %

4 MO

ZOVIRAX TOPICAL

CREAM 5 %

4 MO

Topical Corticosteroids

ALA-CORT

TOPICAL CREAM 1

%

2 MO

ALA-SCALP

LOTION 2 %

4 MO

alclometasone

Ointment 0.05 %

1 MO

alclometasone Topical

Cream 0.05 %

1 MO

amcinonide Lotion 0.1

%

1 MO

amcinonide Ointment

0.1 %

1 MO

amcinonide Topical

Cream 0.1 %

1 MO

betamethasone

dipropionate Lotion

0.05 %

1 MO

betamethasone

dipropionate Ointment

0.05 %

1 MO

betamethasone

dipropionate Topical

Cream 0.05 %

1 MO


Limits

betamethasone

valerate Lotion 0.1 %

1 MO

betamethasone

valerate Ointment 0.1

%

1 MO

betamethasone

valerate Topical

Cream 0.1 %

1 MO

betamethasone,

augmented Lotion

0.05 %

1 MO

betamethasone,

augmented Ointment

0.05 %

1 MO

betamethasone,

augmented Topical

Cream 0.05 %

1 MO

CAPEX SHAMPOO

0.01 %

4 MO

clobetasol Lotion 0.05

%

1 MO

clobetasol Ointment

0.05 %

1 MO

clobetasol Shampoo

0.05 %

1 MO

clobetasol Topical

Foam 0.05 %

1 MO

clobetasol Topical Gel

0.05 %

1 MO

clobetasol Topical

Soln 0.05 %

1 MO

clobetasol-emollient

Topical Cream 0.05 %

1 MO

CORDRAN LOTION

0.05 %

4 MO

CORDRAN TAPE 4

mcg/cm2

4 MO

Page 45 of 89


Limits

DERMA-

SMOOTHE/FS

BODY OIL

TOPICAL 0.01 %

4 MO

DESONATE

TOPICAL GEL 0.05

%

3 MO

desonide Lotion 0.05

%

1 MO

desonide Ointment

0.05 %

1 MO

desonide Topical

Cream 0.05 %

1 MO

desoximetasone

Ointment 0.25 %

2 MO

desoximetasone

Topical Cream 0.05

%, 0.25 %

2 MO

desoximetasone

Topical Gel 0.05 %

2 MO

diflorasone Ointment

0.05 %

2 MO

diflorasone Topical

Cream 0.05 %

2 MO

fluocinolone Ointment

0.025 %

1 MO

fluocinolone Topical

Body Oil 0.01 %

1 MO


Cream 0.01 %, 0.025

%

1 MO


Soln 0.01 %

1 MO

fluocinonide Ointment

0.05 %

1 MO

fluocinonide Topical

Gel 0.05 %

1 MO

fluocinonide Topical

Soln 0.05 %

1 MO


Limits

FLUOCINONIDE-E

TOPICAL CREAM

0.05 %

1 MO

fluticasone Lotion

0.05 %

1 MO

fluticasone Ointment

0.005 %

1 MO

fluticasone Topical

Cream 0.05 %

1 MO

halobetasol

propionate Ointment

0.05 %

2 MO

halobetasol

propionate Topical

Cream 0.05 %

2 MO

HALOG OINTMENT

0.1 %

4 MO

HALOG TOPICAL

CREAM 0.1 %

4 MO

hydrocortisone Lotion

2.5 %

1 MO

hydrocortisone

Ointment 1 %, 2.5 %

1 MO

hydrocortisone

Topical Cream 1 %,

2.5 %

1 MO

hydrocortisone

valerate Ointment 0.2

%

2 MO

hydrocortisone

valerate Topical

Cream 0.2 %

2 MO

KENALOG

TOPICAL AEROSOL

0.147 mg/gram

3 MO

LOCOID LOTION

0.1 %

4 MO

mometasone Lotion

0.1 %

2 MO

Page 46 of 89


Limits

mometasone Ointment

0.1 %

2 MO

mometasone Topical

Cream 0.1 %

2 MO

prednicarbate

Ointment 0.1 %

2 MO

prednicarbate Topical

Cream 0.1 %

2 MO

triamcinolone

acetonide Lotion

0.025 %, 0.1 %

1 MO

triamcinolone

acetonide Ointment

0.025 %, 0.1 %, 0.5 %

1 MO

triamcinolone

acetonide Topical

Cream 0.025 %, 0.1

%, 0.5 %

1 MO

TRIDERM TOPICAL

CREAM 0.1 %

2 MO

Topical Enzymes

SANTYL

OINTMENT 250

unit/g

3 MO

Topical Scabicides / Pediculicides

EURAX LOTION 10

%

3 MO

EURAX TOPICAL

CREAM 10 %

3 MO

lindane Lotion 1 % 3 MO

lindane Shampoo 1 % 3 MO

malathion Lotion 0.5

%

2 MO

permethrin Topical

Cream 5 %

1 MO

Diagnostics / Miscellaneous Agents

Irrigating Solutions


Limits

lactated ringers

Irrigation Soln

2 MO

neomycin-polymyxin B

GU Irrigation Soln

40-200,000 mg-

unit/mL

2 MO

ringers Irrigation Soln 2 MO

Miscellaneous Agents

ACTONEL TABLET

30 mg

4 ST; MO; QL (30

EA per 30 day(s))

ADAGEN IM 250

unit/mL

5 BvsD; MO

alendronate tablet 40

mg

2 MO

anagrelide capsule 0.5

mg, 1 mg

2 MO

ANTABUSE

TABLET 250 mg, 500

mg

4 MO

ARALAST NP IV

SUSP 500 mg

4 BvsD; MO

BUPHENYL ORAL

POWDER

4 MO

BUPHENYL

TABLET 500 mg

4 MO

CAMPRAL

TABLET,DELAYED

RELEASE 333 mg

4 MO; QL (180 EA

per 30 day(s))

CARNITOR IV 200

mg/mL

4 BvsD; MO

CHEMET CAPSULE

100 mg

4 MO

CLINIMIX 4.25%/D5

SULFITE FREE IV

4.25 %

4 BvsD; MO

CLINIMIX E

2.75%/D10 SULFITE

FREE IV 2.75 %

4 BvsD; MO

Page 47 of 89


Limits

CLINIMIX E

2.75%/D5 SULFITE

FREE IV 2.75 %

4 BvsD; MO

dextrose 10 % and

0.45 % sodium

chloride IV

3 BvsD; MO

dextrose 2.5 % and

0.45 % sodium

chloride IV

2 BvsD; MO

dextrose 5 % and 0.9

% sodium chloride IV

2 BvsD; MO

dextrose 5 % and 0.45


2 BvsD; MO

dextrose 10 % and

0.225 % sodium

chloride IV

3 BvsD; MO

dextrose 10% in water

(D10W) IV Soln

2 BvsD; MO

dextrose 5% in water

(D5W) IV

2 BvsD; MO

dextrose 5% and

0.225 % sodium

chloride IV

2 BvsD; MO

dextrose 5% and 0.33


3 BvsD; MO

disulfiram tablet 250

mg, 500 mg

1 MO

etidronate disodium


2 MO

EVOXAC CAPSULE

30 mg

4 MO

EXJADE

DISPERSIBLE

TABLET 125 mg

4 MO

EXJADE

DISPERSIBLE

TABLET 250 mg, 500

mg

5 MO


Limits

FOSRENOL

CHEWABLE

TABLET 1,000 mg,

500 mg, 750 mg

4 MO

INCRELEX SUB-Q

10 mg/mL

5 BvsD; MO

KIONEX ORAL

POWDER

2 MO

levocarnitine tablet

330 mg

2 MO

levocarnitine IV 200

mg/mL

4 BvsD; MO

levocarnitine (with

sugar) Oral Soln 100

mg/mL

2 MO

midodrine tablet 10

mg

1 MO

midodrine tablet 2.5

mg, 5 mg

2 MO

ORFADIN CAPSULE

10 mg, 2 mg, 5 mg

5 MO

pilocarpine tablet 5

mg, 7.5 mg

2 MO

PROLASTIN C IV

SUSP 1,000 mg

5 BvsD; MO

RENAGEL TABLET

400 mg, 800 mg

4 MO

RENVELA ORAL

POWDER PACKET

0.8 gram, 2.4 gram

4 MO

RENVELA TABLET

800 mg

4 MO

RILUTEK TABLET

50 mg

5 MO

SKELID TABLET

240 mg

4 MO; QL (60 EA

per 30 day(s))

sodium chloride

Irrigation Soln 0.9 %

2 MO

Page 48 of 89


Limits

sodium chloride 0.9 %

IV 0.9 %

2 BvsD; MO

SYPRINE CAPSULE

250 mg

4 MO

water for irrigation,

sterile Solution

2 MO

ZEMAIRA IV SUSP

1,000 mg

5 BvsD; MO

Smoking Deterrents

BUPROBAN

TABLET,EXTENDE

D RELEASE 150 mg

2 MO

CHANTIX TABLET

0.5 mg, 1 mg

4 PA; MO

CHANTIX

STARTING MONTH

BOX TABLETS IN

DOSE PACK 0.5

(11)-1 (42) mg

4 PA; MO

NICOTROL

INHALATION

CARTRIDGE 10 mg

3 MO

NICOTROL NS

NASAL SPRAY 10

mg/mL

3 MO

ZYBAN

TABLET,EXTENDE

D RELEASE 150 mg

4 MO

Ear, Nose / Throat Medications

Miscellaneous Agents

ASTELIN NASAL

SPRAY AEROSOL

137 mcg

3 MO

azelastine Nasal Spray

Aerosol 137 mcg

2 MO

BACTROBAN

NASAL OINTMENT

2 %

3 MO


Limits

chlorhexidine

gluconate Mouthwash

0.12 %

1 MO

ipratropium bromide

Nasal Spray 0.03 %,

0.06 %

1 MO

PATANASE NASAL

SPRAY 0.6 %

4 MO

PERIOGARD

MOUTHWASH 0.12

%

1 MO

triamcinolone

acetonide Dental

Paste 0.1 %

1 MO

TYZINE NASAL

DROPS 0.05 %, 0.1 %

3 MO

Miscellaneous Otic Preparations

ACETASOL HC EAR

DROPS 1-2 %

2 MO

acetic acid Ear Soln 2

%

1 MO

DERMOTIC OIL

EAR DROPS 0.01 %

3 MO

fluocinolone acetonide

oil Ear Drops 0.01 %

2 MO

hydrocortisone-acetic

acid Ear Drops 1-2 %

1 MO

ofloxacin Ear Drops

0.3 %

2 MO

Otic Steroid / Antibiotic

CIPRO HC EAR

DROPS, SUSP 0.2-1

%

4 MO

CIPRODEX EAR

DROPS, SUSP 0.3-0.1

%

4 MO

COLY-MYCIN S

EAR DROPS, SUSP

3.3-3-10-0.5 mg/mL

3 MO

Page 49 of 89


Limits

CORTISPORIN-TC

EAR DROPS, SUSP

3.3-3-10-0.5 mg/mL

3 MO

neomycin-polymyxin-

HC Ear Drops, Susp

3.5-10,000-1 mg-

unit/mL-%

1 MO

neomycin-polymyxin-

HC Ear Soln 3.5-

10,000-1 mg-unit/mL-

%

1 MO

Endocrine/Diabetes

Adrenal Hormones

A-HYDROCORT

SOLUTION FOR

INJECTION 100 mg

2 BvsD; MO

CELESTONE ORAL

SOLN 0.6 mg/5 mL

3 MO

cortisone tablet 25 mg 1 MO

dexamethasone Elixir

0.5 mg/5 mL

1 MO

dexamethasone tablet

0.5 mg, 0.75 mg, 1.5

mg, 4 mg, 6 mg

1 MO

dexamethasone tablet

1 mg, 2 mg

3 MO

DEXAMETHASONE

INTENSOL DROPS

(CONCENTRATE) 1

mg/mL

4 MO

dexamethasone

Injection 4 mg/mL

1 MO

DEXPAK TABLETS

IN A DOSE PACK

1.5 mg (51 tabs)

3 MO

fludrocortisone tablet

0.1 mg

1 MO

hydrocortisone tablet

10 mg, 20 mg, 5 mg

1 MO


Limits

methylprednisolone

tablet 16 mg, 32 mg, 8

mg

1 MO

methylprednisolone

tablets in a dose pack

4 mg

1 MO

methylprednisolone

acetate Susp for

Injection 40 mg/mL,

80 mg/mL

1 BvsD; MO

methylprednisolone

sodium succ IV

Solution 1,000 mg

3 BvsD; MO

MILLIPRED ORAL

SOLN 10 mg/5 mL

3 MO

ORAPRED ODT

DISINTEGRATING

TABLET 15 mg, 30

mg

4 MO

prednisolone sodium

phosphate Oral Soln

15 mg/5 mL, 5 mg

base/5 mL (6.7 mg/5

mL)

2 MO

prednisone Oral Soln

5 mg/5 mL

1 MO

prednisone tablet 1

mg, 10 mg, 2.5 mg, 20

mg, 5 mg, 50 mg

1 MO

PREDNISONE

INTENSOL ORAL

CONCENTRATE 5

mg/mL

3 BvsD; MO

SOLU-CORTEF (PF)

SOLUTION FOR

INJECTION 100 mg/2

mL, 250 mg/2 mL

3 BvsD; MO

SOLU-MEDROL IV

SOLUTION 2 gram

3 BvsD; MO

Page 50 of 89


Limits

SOLU-MEDROL (PF)

IV SOLUTION 500

mg/4 mL

2 BvsD; MO

SOLU-MEDROL (PF)

SOLUTION FOR

INJECTION 40

mg/mL

3 BvsD; MO

VERIPRED 20 ORAL

SOLN 20 mg/5 mL

3 MO

Antithyroid Agents

methimazole tablet 10

mg, 5 mg

1 MO

propylthiouracil tablet

50 mg

1 MO

Diabetes Therapy

acarbose tablet 100

mg, 25 mg, 50 mg

2 MO

ACTOPLUS MET

TABLET 15-500 mg,

15-850 mg

3 ST; MO

ACTOPLUS MET XR

TABLET,EXTENDE

D RELEASE 15-1,000

mg, 30-1,000 mg

3 ST; MO

ACTOS TABLET 15

mg, 30 mg, 45 mg

3 ST; MO; QL (30

EA per 30 day(s))

alcohol swabs 3 MO

BYETTA SUB-Q

PEN INJECTOR 10

mcg/0.04 mL, 5

mcg/0.02 mL

4 MO

chlorpropamide tablet

100 mg, 250 mg

1 MO

CURITY GAUZE

BANDAGE 2 X 2 "

3 MO

DUETACT TABLET

30-2 mg, 30-4 mg

3 ST; MO

glimepiride tablet 1

mg, 2 mg, 4 mg

1 MO


Limits

glipizide ER tablet,24

hr extended release 10

mg, 2.5 mg, 5 mg

1 MO

glipizide tablet 10 mg,

5 mg

1 MO

glipizide-metformin

tablet 2.5-250 mg, 2.5-

500 mg, 5-500 mg

1 MO

GLUCAGEN

HYPOKIT

INJECTION 1 mg

3 MO

GLUCAGON

EMERGENCY

INJECTION KIT 1

mg

3 MO

glyburide tablet 1.25

mg, 2.5 mg, 5 mg

1 MO

glyburide micronized

tablet 1.5 mg, 3 mg, 6

mg

1 MO

glyburide-metformin

tablet 1.25-250 mg,

2.5-500 mg, 5-500 mg

1 MO

huber safety needles

(disposable) 22 x 3/4 "

3 MO

HUMALOG SUB-Q

100 unit/mL

3 MO

HUMALOG

KWIKPEN SUB-Q

PEN 100 unit/mL

4 MO

HUMALOG MIX 50-

50 SUSP, SUB-Q INJ

100 unit/mL (50-50)

3 MO

HUMALOG MIX 50-

50 KWIKPEN SUB-Q

PEN 100 unit/mL (50-

50)

4 MO

HUMALOG MIX 75-

25 SUSP, SUB-Q INJ

100 unit/mL (75-25)

3 MO

Page 51 of 89


Limits

HUMALOG MIX 75-

25 KWIKPEN SUB-Q

PEN 100 unit/mL (75-

25)

4 MO

INSULIN PEN

NEEDLE 31

3 MO

insulin syringe-needle

U-100 0.3 mL 30, 1

mL 28, 1/2 mL

3 MO

JANUMET TABLET

50-1,000 mg, 50-500

mg

4 ST; MO

JANUMET XR

TABLET,EXTENDE

D RELEASE 100-

1000 mg, 50-1,000

mg, 50-500 mg

4 ST; MO

JANUVIA TABLET

100 mg, 25 mg, 50 mg

4 ST; MO

JENTADUETO

TABLET 2.5-1,000

mg, 2.5-500 mg, 2.5-

850 mg

4 ST; MO

KOMBIGLYZE XR

TABLET,EXTENDE

D RELEASE 2.5-

1,000 mg, 5-1,000 mg,

5-500 mg

4 ST; MO

LANTUS SUB-Q 100

unit/mL

3 MO

LANTUS

SOLOSTAR SUB-Q

INSULIN PEN 100

unit/mL (3 mL)

4 MO

LEVEMIR SUB-Q

100 unit/mL

3 MO

LEVEMIR FLEXPEN

SUB-Q INSULIN

PEN 100 unit/mL (3

mL)

4 MO


Limits

metformin ER

tablet,extended


750 mg

1 MO

metformin tablet 1,000

mg, 500 mg, 850 mg

1 MO

nateglinide tablet 120

mg, 60 mg

2 MO

NOVOLIN 70/30

SUSP, SUB-Q INJ

100 unit/mL (70-30)

3 MO

NOVOLIN N SUSP,

SUB-Q INJ 100

unit/mL

3 MO

NOVOLIN R

INJECTION 100

unit/mL

3 MO

NOVOLOG SUB-Q

100 unit/mL

3 MO

NOVOLOG

FLEXPEN SUB-Q

100 unit/mL

4 MO

NOVOLOG MIX 70-

30 SUB-Q 100

unit/mL (70-30)

3 MO

NOVOLOG MIX 70-

30 FLEXPEN SUB-Q

100 unit/mL (70-30)

4 MO

ONGLYZA TABLET

2.5 mg, 5 mg

4 ST; MO

PRANDIMET

TABLET 1-500 mg,

2-500 mg

4 MO

PRANDIN TABLET

0.5 mg, 1 mg

4 MO; QL (120 EA

per 30 day(s))

PRANDIN TABLET

2 mg

4 MO; QL (240 EA

per 30 day(s))

PROGLYCEM ORAL

SUSP 50 mg/mL

4 MO

Page 52 of 89


Limits

RIOMET ORAL

SOLN 500 mg/5 mL

3 MO

SYMLINPEN 120

SUB-Q PEN

INJECTOR 2,700

mcg/2.7 mL

4 PA; MO

SYMLINPEN 60

SUB-Q PEN

INJECTOR 1,500

mcg/1.5 mL

4 PA; MO

tolazamide tablet 250

mg, 500 mg

1 MO

tolbutamide tablet 500

mg

1 MO

TRADJENTA

TABLET 5 mg

4 ST; MO

VICTOZA SUB-Q

PEN INJECTOR 0.6

mg/0.1 mL (18 mg/3

mL)

4 MO

Miscellaneous Hormones

ALDURAZYME IV

2.9 mg/5 mL

5 BvsD; MO

ANDROGEL

TRANSDERMAL

GEL PUMP 20.25

mg/1.25 gram (1.62

%)

4

ANDROGEL

TRANSDERMAL

PACKET 1 %(50

mg/5 gram)

4

ANDROXY TABLET

10 mg

2

cabergoline tablet 0.5

mg

2 MO

calcitonin (salmon)

Nasal Spray 200

unit/actuation

2 MO


Limits

calcitriol capsule 0.25

mcg, 0.5 mcg

1 MO

calcitriol IV 1 mcg/mL 1 MO

calcitriol Oral Soln 1

mcg/mL

1 MO

CEREZYME IV

SOLUTION 200 unit

5 BvsD; MO

danazol capsule 100

mg, 200 mg, 50 mg

2 MO

desmopressin

Injection 4 mcg/mL

2 BvsD; MO

desmopressin tablet

0.1 mg, 0.2 mg

2 MO

ELAPRASE IV 6

mg/3 mL

5 BvsD; MO

FABRAZYME IV

SOLUTION 35 mg

5 BvsD; MO

FORTICAL NASAL

SPRAY 200

unit/actuation

2 MO

HECTOROL IV 4

mcg/2 mL

4 BvsD; MO

HECTOROL

CAPSULE 0.5 mcg, 1

mcg, 2.5 mcg

4 MO

KUVAN SOLUBLE

TABLET 100 mg

4 MO

METHITEST

TABLET 10 mg

4

MIACALCIN

INJECTION 200

unit/mL

3 MO

MYOZYME IV

SOLUTION 50 mg

5 BvsD; MO

NAGLAZYME IV 5

mg/5 mL

5 BvsD; MO

oxandrolone tablet 10

mg, 2.5 mg

2

Page 53 of 89


Limits

pamidronate IV 30

mg/10 mL (3 mg/mL),

90 mg/10 mL (9

mg/mL)

2 MO

pamidronate IV 60

mg/10 mL (6 mg/mL)

4 MO

SENSIPAR TABLET

30 mg

3 MO; QL (60 EA

per 30 day(s))

SENSIPAR TABLET

90 mg

5 MO; QL (120 EA

per 30 day(s))

SENSIPAR TABLET

60 mg

5 MO; QL (60 EA

per 30 day(s))

SOMAVERT SUB-Q

SOLN 10 mg, 15 mg,

20 mg

4 BvsD; MO

STIMATE NASAL

SPRAY 150

mcg/spray

4 MO

STRIANT BUCCAL

SYSTEM,SUSTAINE

D RELEASE 30 mg

4 QL (60 EA per 30

day(s))

SYNAREL NASAL

SPRAY 2 mg/mL

5 MO

TESTIM

TRANSDERMAL

GEL 50 mg/5 gram (1

%)

3

testosterone cypionate

IM Oil 100 mg/mL

2

testosterone cypionate

IM Oil 200 mg/mL

2 BvsD; MO

testosterone enanthate

IM Oil 200 mg/mL

2

TESTRED CAPSULE

10 mg

4

ZAVESCA

CAPSULE 100 mg

4 MO


Limits

ZEMPLAR IV

SOLUTION 2

mcg/mL, 5 mcg/mL

4 BvsD; MO

ZEMPLAR

CAPSULE 1 mcg, 2

mcg, 4 mcg

4 MO

ZOMETA IV 4

mg/100 mL, 4 mg/5

mL

5 BvsD; MO

Thyroid Hormones

levothyroxine tablet

100 mcg, 112 mcg,

125 mcg, 137 mcg,

150 mcg, 175 mcg,

200 mcg, 25 mcg, 300

mcg, 50 mcg, 75 mcg,

88 mcg

1 MO

LEVOXYL TABLET

100 mcg, 112 mcg,

125 mcg, 137 mcg,

150 mcg, 175 mcg,

200 mcg, 25 mcg, 50

mcg, 75 mcg, 88 mcg

1 MO

liothyronine IV 10

mcg/mL

1 MO

liothyronine tablet 25

mcg, 5 mcg, 50 mcg

1 MO

SYNTHROID

TABLET 100 mcg,

112 mcg, 125 mcg,

137 mcg, 150 mcg,

175 mcg, 200 mcg, 25

mcg, 300 mcg, 50

mcg, 75 mcg, 88 mcg

3 MO

Gastroenterology

Antidiarrheals / Antispasmodics

atropine Syringe 0.1

mg/mL

1 MO

atropine Syringe 0.05

mg/mL

3 MO

Page 54 of 89


Limits

BENTYL IM 10

mg/mL

3 BvsD; MO

CANTIL TABLET 25

mg

3 MO

dicyclomine capsule

10 mg

1 MO

dicyclomine Syrup 10

mg/5 mL

1 MO

dicyclomine tablet 20

mg

1 MO

diphenoxylate-

atropine Oral Liquid

2.5-0.025 mg/5 mL

1

diphenoxylate-

atropine tablet 2.5-

0.025 mg

1

glycopyrrolate

Injection 0.2 mg/mL

2 MO

glycopyrrolate tablet 1

mg, 2 mg

2 MO

loperamide capsule 2

mg

1 MO

methscopolamine

tablet 2.5 mg, 5 mg

2 MO

MOTOFEN TABLET

1-0.025 mg

3 MO

propantheline tablet

15 mg

2 MO

Miscellaneous Gastrointestinal Agents

ALOXI IV 0.25 mg/5

mL

4 BvsD; MO

AMITIZA CAPSULE

24 mcg, 8 mcg

4 PA; MO

ANTIVERT TABLET

50 mg

3 MO

ANZEMET IV 100

mg/5 mL

4 BvsD; MO


Limits

ANZEMET TABLET

100 mg, 50 mg

4 BvsD; MO; QL

(7 EA per 30

day(s))

APRISO

CAPSULE,EXTEND

ED RELEASE 0.375

gram

4 MO

ASACOL

TABLET,DELAYED

RELEASE 400 mg

4 MO

ASACOL HD

TABLET,DELAYED

RELEASE 800 mg

4 MO

balsalazide capsule

750 mg

2 MO

budesonide DR & ER

capsule,delayed &

extended release 3 mg

2 MO

CANASA RECTAL

SUPPOSITORY

1,000 mg

4 MO

CESAMET

CAPSULE 1 mg

4 BvsD; MO

COMPRO RECTAL

SUPPOSITORY 25

mg

2 MO

CREON

CAPSULE,DELAYE

D RELEASE 12,000-

38,000 -60,000 unit,

24,000-76,000 -

120,000 unit, 3,000-

9,500- 15,000 unit,

6,000-19,000 -30,000

unit

3 MO

cromolyn Oral Soln

100 mg/5 mL

2 MO

CYSTADANE ORAL

POWDER

4 MO

DIPENTUM

CAPSULE 250 mg

4 MO

Page 55 of 89


Limits

dronabinol capsule 10

mg, 2.5 mg, 5 mg

2 BvsD

EMEND CAPSULE

40 mg

4 BvsD; MO

EMEND CAPSULE

125 mg

4 BvsD; MO; QL

(2 EA per 30

day(s))

EMEND CAPSULE

80 mg

4 BvsD; MO; QL

(4 EA per 30

day(s))

EMEND CAPSULES

IN A DOSE PACK

125-80-80 mg

4 BvsD; MO; QL

(6 EA per 30

day(s))

ENTOCORT EC

CAPSULE,DELAYE

D & EXTENDED

RELEASE 3 mg

4 MO

ENULOSE ORAL

SOLN 10 gram/15 mL

1 MO

GASTROCROM

ORAL SOLN 100

mg/5 mL

4 MO

GAVILYTE-C ORAL

SOLUTION 240-

22.72-6.72 gram

2 MO

GAVILYTE-N ORAL

SOLUTION 420 g

2 MO

GOLYTELY ORAL

SOLUTION 236-

22.74-6.74 gram

3 MO

GOLYTELY

PACKET 227.1-21.5-

6.36 gram

3 MO

granisetron IV 1

mg/mL (1 mL)

2 BvsD; MO

granisetron tablet 1

mg

2 BvsD; MO

granisetron (PF) IV

100 mcg/mL

2 BvsD; MO


Limits

GRANISOL ORAL

SOLN 1 mg/5 mL

4 BvsD; MO

hydrocortisone Enema

100 mg/60 mL

1 MO

lactulose Oral Soln 10

gram/15 mL

1 MO

LIALDA

TABLET,DELAYED

RELEASE 1.2 g

4 MO

LOTRONEX

TABLET 0.5 mg, 1

mg

3 MO; QL (60 EA

per 30 day(s))

meclizine tablet 12.5

mg, 25 mg

1 MO

mesalamine with

cleansing wipes Rectal

Kit 4 gram/60 mL

1 MO

metoclopramide

Injection 5 mg/mL

1 BvsD; MO

metoclopramide Oral

Soln 5 mg/5 mL

1 MO

metoclopramide tablet

10 mg, 5 mg

1 MO

MOVIPREP ORAL

POWDER PACKET

100-7.5-2.691 gram

3 MO

NULYTELY WITH

FLAVOR PACKS

ORAL SOLUTION

420 g

3 MO

ondansetron

disintegrating tablet 4

mg, 8 mg

2 BvsD; MO

ondansetron HCl Oral

Soln 4 mg/5 mL

2 BvsD; MO

ondansetron HCl


mg

2 BvsD; MO

Page 56 of 89


Limits

ondansetron HCl (PF)

Injection 4 mg/2 mL

2 BvsD; MO

OSMOPREP

TABLET 1.5 gram

4 MO

PANCREAZE

CAPSULE,DELAYE

D RELEASE 10,500-

25,000 -43,750 unit,

16,800-40,000 -70,000

unit, 21,000-37,000 -

61,000 unit, 4,200-

10,000 -17,500 unit

3 MO

PENTASA

CAPSULE,EXTEND

ED RELEASE 250

mg, 500 mg

4 MO

polyethylene glycol

3350 Oral Powder 17

gram/dose

1 MO

prochlorperazine

Rectal Suppository 25

mg

1 MO

prochlorperazine

Edisylate Injection 10

mg/2 mL (5 mg/mL)

1 MO

prochlorperazine

maleate tablet 10 mg,

5 mg

1 MO

RECTIV OINTMENT

0.4 % (w/w)

4 MO

RELISTOR SUB-Q

KIT 12 mg/0.6 mL

4 MO

REMICADE IV

SOLUTION 100 mg

5 BvsD; MO

SUCRAID ORAL

SOLN 8,500 unit/mL

5 MO

sulfasalazine tablet

500 mg

1 MO


Limits

SULFAZINE EC

TABLET,DELAYED

RELEASE 500 mg

1 MO

TRILYTE WITH

FLAVOR PACKETS

ORAL SOLUTION

420 g

2 MO

trimethobenzamide

capsule 300 mg

2 MO

URSO 250 TABLET

250 mg

4 MO

URSO FORTE

TABLET 500 mg

4 MO

ursodiol capsule 300

mg

2 MO

ursodiol tablet 250

mg, 500 mg

2 MO

ZENPEP

CAPSULE,DELAYE

D RELEASE 10,000-

34,000 -55,000 unit,

15,000-51,000 -82,000

unit, 20,000-68,000 -

109,000 unit, 25,000-

85,000- 136,000 unit,

3,000-10,000- 16,000

unit, 5,000-17,000 -

27,000 unit

3 MO

Ulcer Therapy

CARAFATE ORAL

SUSP 100 mg/mL

3 MO

cimetidine Oral Soln

300 mg/5 mL

2 MO

cimetidine tablet 200

mg, 300 mg, 400 mg,

800 mg

2 MO

cimetidine Injection

150 mg/mL

2 MO

Page 57 of 89


Limits

DEXILANT

CAPSULE,

DELAYED

RELEASE 30 mg, 60

mg

3 ST; MO

famotidine Oral Susp

40 mg/5 mL

1 MO

famotidine tablet 20

mg, 40 mg

1 MO

famotidine (PF) IV 20

mg/2 mL

1 MO

famotidine (PF) in

NaCl (iso-osmotic) IV

Piggy Back 20 mg/50

mL

2 MO

HELIDAC ORAL

PACK 250-500-262.4

mg

4 MO

lansoprazole

capsule,delayed

release 15 mg, 30 mg

2 ST; MO

misoprostol tablet 200

mcg

2 MO

nizatidine Oral Soln

150 mg/10 mL

1 MO

nizatidine capsule 150

mg, 300 mg

2 MO

omeprazole

capsule,delayed


40 mg

2 MO

pantoprazole


20 mg, 40 mg

2 ST; MO

PEPCID ORAL SUSP

40 mg/5 mL

3 MO


Limits

PREVACID

SOLUTAB

DELAYED

RELEASE,DISINTE

GRATING TABLET

15 mg, 30 mg

4 MO

PREVPAC ORAL

PACK 500-500-30 mg

4 MO

PROTONIX IV

SOLUTION 40 mg

4 MO

PYLERA CAPSULE

140-125-125 mg

3 MO

ranitidine capsule 150

mg, 300 mg

1 MO

ranitidine Syrup 15

mg/mL

1 MO

ranitidine tablet 150

mg, 300 mg

1 MO

ranitidine Injection 25

mg/mL

2 MO

sucralfate tablet 1

gram

1 MO

Immunology, Vaccines / Biotechnology

Biotechnology Drugs

ACTIMMUNE SUB-

Q 2 million unit/0.5

mL

5 MO

ARANESP

(POLYSORBATE)

INJECTION 25

mcg/mL, 40 mcg/mL

3 BvsD; MO

ARANESP

(POLYSORBATE)

SYRINGE 25

mcg/0.42 mL

3 BvsD; MO

ARANESP

(POLYSORBATE)

INJECTION 100

mcg/mL, 60 mcg/mL

4 BvsD; MO

Page 58 of 89


Limits

ARANESP

(POLYSORBATE)

SYRINGE 100

mcg/0.5 mL, 40

mcg/0.4 mL, 60

mcg/0.3 mL

4 BvsD; MO

ARANESP

(POLYSORBATE)

INJECTION 200

mcg/mL, 300 mcg/mL

5 BvsD; MO

ARANESP

(POLYSORBATE)

SYRINGE 150

mcg/0.3 mL, 200

mcg/0.4 mL, 300

mcg/0.6 mL, 500

mcg/mL

5 BvsD; MO

ARCALYST SUB-Q

SOLN 220 mg

5 BvsD; MO; LA

AVONEX IM KIT 30

mcg

5 BvsD; MO

AVONEX

ADMINISTRATION

PACK IM KIT 30

mcg/0.5 mL

5 BvsD; MO

BETASERON SUB-Q

KIT 0.3 mg

5 BvsD; MO

EPOGEN

INJECTION 2,000

unit/mL, 20,000 unit/2

mL, 20,000 unit/mL,

3,000 unit/mL, 4,000

unit/mL

3 BvsD; MO

GENOTROPIN

SUBQ CARTRIDGE

12 mg/mL (36

unit/mL), 5 mg/mL

(15 unit/mL)

4 MO


Limits

GENOTROPIN

MINIQUICK SUB-Q

SYRINGE 0.2

mg/0.25 mL, 0.4

mg/0.25 mL, 0.6

mg/0.25 mL, 0.8

mg/0.25 mL, 1

mg/0.25 mL, 1.2

mg/0.25 mL, 1.4

mg/0.25 mL, 1.6

mg/0.25 mL, 1.8

mg/0.25 mL, 2

mg/0.25 mL

4 MO

HUMATROPE

INJECTION,

CARTRIDGE 12 (36

unit) mg, 24 (72 unit)

mg, 6 (18 unit) mg

4 MO

HUMATROPE

SOLUTION FOR

INJECTION 5 (15

unit) mg

4 MO

INFERGEN SUB-Q

15 mcg/0.5 mL

4 BvsD; MO

INTRON A

INJECTION 6 million

unit/mL

4 BvsD; MO

INTRON A

SOLUTION FOR

INJECTION 10

million unit (1 mL)

4 BvsD; MO

INTRON A SUBQ

PEN KIT 10 million

unit/0.2 mL, 3 million

unit /0.2 mL-6 doses

4 BvsD; MO

INTRON A SUBQ

PEN KIT 5 million

unit/0.2 mL

5 BvsD; MO

LEUKINE

INJECTION 500

mcg/mL

5 BvsD; MO

Page 59 of 89


Limits

LEUKINE

SOLUTION FOR

INJECTION 250 mcg

5 BvsD; MO

NEULASTA SUB-Q

SYRINGE 6

mg/0.6mL

5 BvsD; MO

NEUMEGA SUB-Q

SOLN 5 mg

5 BvsD; MO

NEUPOGEN

INJECTION 480

mcg/1.6 mL

5 BvsD; MO

NEUPOGEN

SYRINGE 300

mcg/0.5 mL, 480

mcg/0.8 mL

5 BvsD; MO

NORDITROPIN

FLEXPRO SUB-Q

PEN INJECTOR 10

mg/1.5 mL (6.7

mg/mL), 15 mg/1.5

mL (10 mg/mL), 5

mg/1.5 mL (3.3

mg/mL)

5 MO

NORDITROPIN

NORDIFLEX SUB-Q

PEN INJECTOR 30

mg/3 mL (10 mg/mL)

5 MO

NUTROPIN SUB-Q

SOLN 10 mg

4 MO

NUTROPIN AQ

SUBQ CARTRIDGE

10 mg/2 mL (5

mg/mL), 20 mg/2 mL

(10 mg/mL)

4 MO

NUTROPIN AQ

NUSPIN SUBQ

CARTRIDGE 5 mg/2

mL (2.5 mg/mL)

4 MO

OMNITROPE SUBQ

CARTRIDGE 5

mg/1.5 mL (3.3

mg/mL)

2 MO


Limits

OMNITROPE SUB-Q

SOLN 5.8 mg

4 MO

OMNITROPE SUBQ

CARTRIDGE 10

mg/1.5 mL

4 MO

PEGASYS SUB-Q

180 mcg/mL

5 MO

PEGASYS

CONVENIENCE

PACK SUB-Q KIT

180 mcg/0.5 mL

5 MO

PEGASYS

PROCLICK SUB-Q

PEN INJECTOR 135

mcg/0.5 mL

5 MO

PEGINTRON SUB-Q

KIT 50 mcg/0.5 mL

4 MO

PEGINTRON

REDIPEN SUBQ KIT

120 mcg/0.5 mL, 150

mcg/0.5 mL, 50

mcg/0.5 mL, 80

mcg/0.5 mL

4 MO

PROCRIT

INJECTION 10,000

unit/mL, 2,000

unit/mL, 3,000

unit/mL, 4,000

unit/mL

3 BvsD; MO

PROCRIT

INJECTION 20,000

unit/mL, 40,000

unit/mL

5 BvsD; MO

PROLEUKIN IV

SOLUTION 22

million unit

5 BvsD; MO

REBIF SUB-Q

SYRINGE 22 mcg/0.5

mL, 44 mcg/0.5 mL

5 MO

Page 60 of 89


Limits

REBIF TITRATION

PACK SUB-Q

SYRINGE

8.8mcg/0.2mL-22

mcg/0.5mL (6)

5 MO

SAIZEN SUB-Q

SOLN 5 mg

4 MO

SAIZEN

CLICK.EASY SUBQ

CARTRIDGE 8.8

mg/1.5 mL (Fnl)

4 MO

SEROSTIM SUB-Q

SOLN 4 mg, 5 mg, 6

mg

5 MO

SYLATRON SUB-Q

KIT 296 mcg, 444

mcg, 888 mcg

5 MO

TEV-TROPIN SUB-Q

SOLN 5 mg

4 MO

ZORBTIVE SUB-Q

SOLN 8.8 mg

5 MO

Vaccines / Miscellaneous Immunologicals

ACTHIB (PF) IM 10

mcg/0.5 mL

4 MO

ADACEL

(ADOLESCENT &

ADULT) (PF) IM

SUSP 2-5-3-5-5 Lf-

mcg-Lf/0.5mL

4 MO

ATGAM IV 50

mg/mL

5 BvsD; MO

BOOSTRIX (PF) IM

SUSP 2.5-8-5 Lf-mcg-

Lf/0.5mL

4 MO

BOOSTRIX (PF) IM

SYRINGE 2.5-8-5 Lf-

mcg-Lf/0.5mL

4 MO

CARIMUNE NF

NANOFILTERED IV

SOLUTION 3 gram

4 BvsD; MO


Limits

CERVARIX

VACCINE (PF) IM

SYRINGE 20-20

mcg/0.5 mL

4 MO

COMVAX (PF) IM 5-

7.5-125 mcg/0.5 mL

4 MO

DAPTACEL

(PEDIATRIC) (PF)

IM SUSP 15-10-5 Lf-

mcg-Lf/0.5mL

4 MO

DECAVAC (PF) IM

SYRINGE 5-2 Lf

unit/0.5 mL

4 BvsD; MO

ENGERIX-B (PF) IM

SUSP 10 mcg/0.5 mL

4 BvsD; MO

ENGERIX-B (PF) IM

SYRINGE 10 mcg/0.5

mL, 20 mcg/mL

4 BvsD; MO

fomepizole IV 1

gram/mL

2 MO

GAMMAGARD

LIQUID IV 10 %

2 BvsD; MO

GAMUNEX-C

INJECTION 1

gram/10 mL (10 %)

4 BvsD; MO

GARDASIL (PF) IM

SUSP 20-40-40-20

mcg/0.5 mL

4 MO

HAVRIX (PF) IM

SUSP 1,440 EL

unit/mL

4 BvsD; MO

HAVRIX (PF) IM

SYRINGE 720 EL

unit/0.5 mL

4 BvsD; MO

INFANRIX (PF) IM

SUSP 25-58-10 Lf-

mcg-Lf/0.5mL

4 MO

IPOL SUSP FOR

INJECTION 40-8-32

unit/0.5 mL

4 MO

Page 61 of 89


Limits

IXIARO (PF) IM

SYRINGE 6 mcg/0.5

mL

4 MO

MENOMUNE -

A/C/Y/W-135 (PF)

SUB-Q SOLN 50 mcg

4 MO

MENVEO A-C-Y-W-

135-DIP (PF) IM KIT

10-5 mcg/0.5 mL

4 MO

M-M-R II (PF) SUB-

Q SUSP 1,000-12,500

TCID50/0.5 mL

4 MO

PEDVAX HIB (PF)

IM 7.5 mcg/0.5 mL

4 MO

PROQUAD (PF)

SUB-Q 10exp3-4.3-3-

3.99 TCID50/0.5

4 MO

RABAVERT (PF) IM

KIT 2.5 unit

4 BvsD; MO

RECOMBIVAX HB

(PF) IM SUSP 10

mcg/mL, 40 mcg/mL

4 BvsD; MO

ROTATEQ

VACCINE ORAL

SUSP 2 mL

4 MO

tetanus-diphtheria

toxoids-Td IM Susp 2-

2 Lf unit/0.5 mL

4 BvsD; MO

THYMOGLOBULIN

IV SOLUTION 25 mg

4 BvsD; MO

TWINRIX (PF) IM

SUSP 720-20 EL unit-

mcg/mL

4 BvsD; MO

TYPHIM VI IM 25

mcg/0.5 mL

4 MO

VAQTA (PF) IM

SUSP 25 unit/0.5 mL

4 BvsD; MO

VARIVAX (PF) SUB-

Q SOLN 1,350

unit/0.5 mL

4 MO


Limits

YF-VAX (PF) SUB-Q

SUSP 10 exp4.74

unit/0.5 mL

4 MO

ZOSTAVAX (PF)

SUB-Q SOLN 19,400

unit

4 MO

Musculoskeletal / Rheumatology

Gout Therapy

allopurinol tablet 100

mg, 300 mg

1 MO

allopurinol IV

Solution 500 mg

3 BvsD; MO

ALOPRIM IV

SOLUTION 500 mg

4 BvsD; MO

colchicine-probenecid

tablet 0.5-500 mg

1 MO

COLCRYS TABLET

0.6 mg

4 MO

probenecid tablet 500

mg

1 MO

Osteoporosis Therapy

ACTONEL TABLET

150 mg

4 ST; MO; QL (1

EA per 30 day(s))

ACTONEL TABLET

35 mg

4 ST; MO; QL (4

EA per 30 day(s))

ACTONEL TABLET

5 mg

4 ST; MO; QL (90

EA per 30 day(s))


mg

2 MO; QL (17 EA

per 30 day(s))


mg

2 MO; QL (30 EA

per 30 day(s))


mg

2 MO; QL (4 EA

per 30 day(s))


mg

2 MO; QL (60 EA

per 30 day(s))

ATELVIA

TABLET,DELAYED

RELEASE 35 mg

4 ST; MO; QL (4

EA per 30 day(s))

Page 62 of 89


Limits

BONIVA TABLET

150 mg

3 MO; QL (1 EA

per 30 day(s))

BONIVA IV

SYRINGE 3 mg/3 mL

4 BvsD; MO

EVISTA TABLET 60

mg

3 MO; QL (30 EA

per 30 day(s))

FORTEO SUB-Q

PEN INJECTOR 20

mcg/dose - 600

mcg/2.4 mL

4 PA; MO; BvsD

FOSAMAX PLUS D

TABLET 70-2,800

mg-unit, 70-5,600 mg-

unit

4 ST; MO

ibandronate tablet 150

mg

2 MO; QL (1 per

30 Day(s))

Other Rheumatologicals

BENLYSTA IV

SOLUTION 120 mg

4 BvsD; MO

DEPEN TITRATABS

TABLET 250 mg

4 MO

ENBREL SUB-Q KIT

25 mg (1 mL)

5 BvsD; MO

ENBREL SUB-Q

SYRINGE 25

mg/0.5mL (0.51), 50

mg/mL (0.98 mL)

5 BvsD; MO

HUMIRA SUB-Q

KIT 20 mg/0.4 mL, 40

mg/0.8 mL

5 BvsD; MO

HUMIRA CROHN'S

DISEASE STARTER

PACK SUBQ PEN

KIT 40 mg/0.8 mL

5 MO

KINERET SUB-Q

SYRINGE 100

mg/0.67 mL

5 MO

leflunomide tablet 10

mg, 20 mg

2 MO


Limits

RIDAURA

CAPSULE 3 mg

4 MO

Obstetrics / Gynecology

Estrogens / Progestins

CAMILA TABLET

0.35 mg

1 MO

CENESTIN TABLET

0.3 mg, 0.45 mg,

0.625 mg, 0.9 mg,

1.25 mg

3 MO

CRINONE

VAGINAL GEL 8 %

4 MO

DEPO-ESTRADIOL

IM OIL 5 mg/mL

4 MO

DEPO-PROVERA IM

400 mg/mL

4 BvsD; MO

DEPO-SUBQ

PROVERA 104

SYRINGE 104

mg/0.65 mL

4 MO

DIVIGEL

TRANSDERMAL

GEL PACKET 1 (0.1)

mg (%)

3 MO

ENDOMETRIN

VAGINAL INSERTS

100 mg

4 MO

ENJUVIA TABLET

0.3 mg, 0.45 mg,

0.625 mg, 0.9 mg,

1.25 mg

4 MO

ERRIN TABLET 0.35

mg

1 MO

ESTRACE

VAGINAL CREAM

0.01 % (0.1 mg/g)

4 MO

estradiol tablet 0.5

mg, 1 mg, 2 mg

1 MO

Page 63 of 89


Limits

estradiol Weekly

Transderm Patch

0.025 mg/24 hr,

0.0375 mg/24 hr, 0.05

mg/24 hr, 0.06 mg/24

hr, 0.075 mg/24 hr,

0.1 mg/24 hr

1 MO

estradiol valerate IM

Oil 10 mg/mL, 20

mg/mL, 40 mg/mL

2 MO

estradiol-

norethindrone acet

tablet 1-0.5 mg

1 MO

ESTRING VAGINAL

2 mg

4 MO; QL (1 EA

per 90 day(s))

estropipate tablet 0.75

mg, 1.5 mg, 3 mg

1 MO

EVAMIST

TRANSDERMAL

SPRAY 1.53 mg/spray

(1.7%)

3 MO

FEMHRT 1/5

TABLET 1-5 mg-mcg

4 MO

FEMHRT LOW

DOSE TABLET 0.5-

2.5 mg-mcg

4 MO

FEMRING

VAGINAL 0.05

mg/24 hr, 0.1 mg/24

hr

4 MO; QL (1 EA

per 90 day(s))

JINTELI TABLET 1-

5 mg-mcg

2 MO

JOLIVETTE

TABLET 0.35 mg

1 MO

medroxyprogesterone

IM Susp 150 mg/mL

1 MO

medroxyprogesterone


5 mg

1 MO


Limits

MENEST TABLET

0.3 mg, 0.625 mg,

1.25 mg, 2.5 mg

3 MO

MENOSTAR

TRANSDERM

PATCH 14 mcg/24 hr

3 MO

NORA-BE TABLET

0.35 mg

1 MO

norethindrone acetate

tablet 5 mg

1 MO

PREMARIN

SOLUTION FOR

INJECTION 25 mg

4 BvsD; MO

PREMARIN

TABLET 0.3 mg, 0.45

mg, 0.625 mg, 0.9 mg,

1.25 mg

4 MO

PREMARIN

VAGINAL CREAM

0.625 mg/gram

4 MO

PREMPHASE

TABLET 0.625 mg

(14)/ 0.625mg-

5mg(14)

3 MO; QL (30 EA

per 30 day(s))

PREMPRO TABLET

0.3-1.5 mg, 0.45-1.5

mg, 0.625-2.5 mg,

0.625-5 mg

4 MO; QL (30 EA

per 30 day(s))

progesterone

micronized capsule

100 mg, 200 mg

2 MO

VIVELLE-DOT

TRANSDERM

PATCH 0.025 mg/24

hr, 0.0375 mg/24 hr,

0.05 mg/24 hr, 0.075

mg/24 hr, 0.1 mg/24

hr

4 MO

Miscellaneous Ob/Gyn

clindamycin Vaginal

Cream 2 %

1 MO

Page 64 of 89


Limits

metronidazole Vaginal

Gel 0.75 %

1 MO

MICONAZOLE-3

VAGINAL

SUPPOSITORY 200

mg

2 MO

terconazole Vaginal

Cream 0.4 %

1 MO

terconazole Vaginal

Suppository 80 mg

1 MO

VANDAZOLE

VAGINAL GEL 0.75

%

2 MO

ZAZOLE VAGINAL

CREAM 0.4 %

2 MO

Oral Contraceptives / Related Agents

AMETHIA

TABLETS,3 MONTH

DOSE PACK 0.15

mg-30 mcg (84)/10

mcg (7)

2 MO

AMETHYST

TABLET 90-20 mcg

2 MO

APRI TABLET 0.15-

30 mg-mcg

1 MO

ARANELLE (28)

TABLET 0.5/1/0.5-35

mg-mcg

1 MO

AVIANE TABLET

0.1-20 mg-mcg

1 MO

BALZIVA (28)

TABLET 0.4-35 mg-

mcg

1 MO

BRIELLYN TABLET

0.4-35 mg-mcg

2 MO

CRYSELLE (28)

TABLET 0.3-30 mg-

mcg

1 MO


Limits

CYCLAFEM 1/35

(28) TABLET 1-35

mg-mcg

2 MO

CYCLAFEM 7/7/7

(28) TABLET

0.5/0.75/1 mg- 35 mcg

2 MO

EMOQUETTE

TABLET 0.15-30 mg-

mcg

1 MO

ENPRESSE TABLET

50-30 (6)/75-40

(5)/125-30(10)

1 MO

FEMCON FE

CHEWABLE

TABLET 0.4mg-

35mcg(21) & 75 mg

(7)

4 MO

GIANVI TABLET 3-

20 mg-mcg

2 MO

INTROVALE

TABLETS,3 MONTH

DOSE PACK 0.15-30

mg-mcg

2 MO

JUNEL 1.5/30 (21)

TABLET 1.5-30 mg-

mcg

1 MO

JUNEL 1/20 (21)

TABLET 1-20 mg-

mcg

1 MO

JUNEL FE 1.5/30 (28)

TABLET 1.5-30 mg-

mcg

1 MO

JUNEL FE 1/20 (28)

TABLET 1-20 mg-

mcg

1 MO

KARIVA TABLET

0.15-0.02mg x21 /0.01

mg x 5

2 MO

KELNOR 1/35 (28)

TABLET 1-35 mg-

mcg

2 MO

Page 65 of 89


Limits

LEENA 28 TABLET

0.5/1/0.5-35 mg-mcg

1 MO

LESSINA TABLET

0.1-20 mg-mcg

1 MO

LEVORA-28

TABLET 0.15-30 mg-

mcg

1 MO

LOESTRIN 24 FE

TABLET 1-20 (24)-

75(4) mg-mcg-mg

4 MO

LOW-OGESTREL

(28) TABLET 0.3-30

mg-mcg

1 MO

LUTERA (28)

TABLET 0.1-20 mg-

mcg

1 MO

LYBREL TABLET

90-20 mcg

4 MO

MARLISSA TABLET

0.15-30 mg-mcg

2 MO

MICROGESTIN

1.5/30 (21) TABLET

1.5-30 mg-mcg

1 MO

MICROGESTIN 1/20

(21) TABLET 1-20

mg-mcg

1 MO

MICROGESTIN FE

1.5/30 (28) TABLET

1.5-30 mg-mcg

1 MO

MICROGESTIN FE

1/20 (28) TABLET 1-

20 mg-mcg

1 MO

MONONESSA (28)

TABLET 0.25-35 mg-

mcg

1 MO

NECON 0.5/35 (28)

TABLET 0.5-35 mg-

mcg

1 MO


Limits

NECON 1/35 (28)

TABLET 1-35 mg-

mcg

1 MO

NECON 10/11 (28)

TABLET 0.5-35/1-35

mg-mcg/mg-mcg

1 MO

NECON 7/7/7 (28)

TABLET 0.5/0.75/1

mg- 35 mcg

1 MO

NORTREL 0.5/35

(28) TABLET 0.5-35

mg-mcg

1 MO

NORTREL 1/35 (21)

TABLET 1-35 mg-

mcg

1 MO

NORTREL 1/35 (28)

TABLET 1-35 mg-

mcg

1 MO

NORTREL 7/7/7 (28)

TABLET 0.5/0.75/1

mg- 35 mcg

1 MO

OCELLA TABLET 3-

0.03 mg

2 MO

OGESTREL (28)

TABLET 0.5-50 mg-

mcg

1 MO

ORSYTHIA TABLET

0.1-20 mg-mcg

1 MO

ORTHO TRI-

CYCLEN LO

TABLET

0.18/0.215/0.25 mg-25

mcg

4 MO

OVCON-50 (28)

TABLET 1-50 mg-

mcg

4 MO

PORTIA TABLET

0.15-30 mg-mcg

1 MO

PREVIFEM TABLET

0.25-35 mg-mcg

1 MO

Page 66 of 89


Limits

QUASENSE

TABLETS,3 MONTH

DOSE PACK 0.15-30

mg-mcg

2 MO

RECLIPSEN (28)

TABLET 0.15-30 mg-

mcg

2 MO

SEASONIQUE

TABLETS,3 MONTH

DOSE PACK 0.15

mg-30 mcg (84)/10

mcg (7)

4 MO

SPRINTEC (28)

TABLET 0.25-35 mg-

mcg

1 MO

SRONYX TABLET

0.1-20 mg-mcg

1 MO

TRI-LEGEST FE

TABLET 1-20(5)/1-

30(7) /1mg-35mcg (9)

2 MO

TRINESSA (28)

TABLET

0.18/0.215/0.25 mg-35

mcg (28)

2 MO

TRI-PREVIFEM (28)

TABLET

0.18/0.215/0.25 mg-35

mcg (28)

2 MO

TRI-SPRINTEC (28)

TABLET

0.18/0.215/0.25 mg-35

mcg (28)

2 MO

TRIVORA (28)

TABLET 50-30

(6)/75-40 (5)/125-

30(10)

1 MO

VELIVET TABLET

0.1/.125/.15-25 mg-

mcg

1 MO

VESTURA TABLET

3-20 mg-mcg

2 MO


Limits

ZEOSA CHEWABLE

TABLET 0.4mg-

35mcg(21) & 75 mg

(7)

2 MO

ZOVIA 1/35E (28)

TABLET 1-35 mg-

mcg

1 MO

ZOVIA 1/50E (28)

TABLET 1-50 mg-

mcg

1 MO

Oxytocics

METHERGINE

TABLET 0.2 mg

4 MO

methylergonovine

tablet 0.2 mg

1 MO

Ophthalmology

Antibiotics

AZASITE EYE

DROPS 1 %

3 MO

bacitracin Eye

Ointment 500 unit/g

1 MO

bacitracin-polymyxin

B Eye Ointment 500-

10,000 unit/g

1 MO

CILOXAN EYE

OINTMENT 0.3 %

4 MO

ciprofloxacin Eye

Drops 0.3 %

1 MO

erythromycin Eye

Ointment 5 mg/gram

(0.5 %)

1 MO

GENTAK EYE

OINTMENT 0.3 % (3

mg/g)

1 MO

gentamicin Eye Drops

0.3 %

1 MO

levofloxacin Eye

Drops 0.5 %

2 MO

Page 67 of 89


Limits

MOXEZA EYE

DROPS 0.5 %

3 MO

NATACYN EYE

DROPS 5 %

4 MO

neomycin-bacitracin-

polymyxin Eye Oint

3.5-400-10,000 mg-

unit-unit/g

1 MO

neomycin-polymyxin-

gramicidin Eye Drops

1.75-10K-0.025 mg-

unit-mg/mL

1 MO

ofloxacin Eye Drops

0.3 %

2 MO

tobramycin Eye Drops

0.3 %

1 MO

TOBREX EYE

OINTMENT 0.3 %

3 MO

trimethoprim-

polymyxin B Eye

Drops 0.1-10,000 %-

unit/mL

1 MO

VIGAMOX EYE

DROPS 0.5 %

4 MO

Antivirals

trifluridine Eye Drops

1 %

2 MO

VIROPTIC EYE

DROPS 1 %

3 MO

ZIRGAN EYE GEL

0.15 %

4 MO

Beta-Blockers

betaxolol Eye Drops

0.5 %

1 MO

BETOPTIC S EYE

DROPS 0.25 %

4 MO

carteolol Eye Drops 1

%

1 MO


Limits

levobunolol Eye

Drops 0.5 %

1 MO

metipranolol Eye

Drops 0.3 %

1 MO

timolol Eye Gel

Forming Soln 0.25 %,

0.5 %

1 MO

timolol maleate Eye

Drops 0.25 %, 0.5 %

1 MO

Cholinesterase Inhibitor Miotics

PHOSPHOLINE

IODIDE EYE DROPS

0.125 %

4 MO

Cycloplegic Mydriatics

tropicamide Eye

Drops 0.5 %, 1 %

1 MO

Direct Acting Miotics

ISOPTO CARPINE

EYE DROPS 1 %, 2

%, 4 %

3 MO

PILOPINE HS EYE

GEL 4 %

3 MO

Miscellaneous Ophthalmologics

ALOCRIL EYE

DROPS 2 %

3 MO

ALOMIDE EYE

DROPS 0.1 %

3 MO

azelastine Eye Drops

0.05 %

2 MO

cromolyn Eye Drops 4

%

1 MO

ELESTAT EYE

DROPS 0.05 %

4 MO

EMADINE EYE

DROPS 0.05 %

3 MO

epinastine Eye Drops

0.05 %

2 MO

Page 68 of 89


Limits

PATADAY EYE

DROPS 0.2 %

3 MO

PATANOL EYE

DROPS 0.1 %

3 MO

proparacaine Eye

Drops 0.5 %

1 MO

RESTASIS EYE

DROPPERETTE 0.05

%

4 MO; QL (60 EA

per 30 day(s))

Non-Steroidal Anti-Inflammatory Agents

ACUVAIL (PF) EYE

DROPPERETTE 0.45

%

4 MO

bromfenac Eye Drops

0.09 %

2 MO

diclofenac Eye Drops

0.1 %

1 MO

flurbiprofen Eye

Drops 0.03 %

1 MO

ketorolac Eye Drops

0.4 %, 0.5 %

2 MO

NEVANAC EYE

DROPS 0.1 %

3 MO

Oral Drugs For Glaucoma

acetazolamide tablet

125 mg, 250 mg

1 MO

acetazolamide ER

capsule,extended

release 500 mg

2 MO

acetazolamide


500 mg

2 MO

methazolamide tablet

25 mg, 50 mg

1 MO

Other Glaucoma Drugs

AZOPT EYE DROPS

1 %

3 MO


Limits

COMBIGAN EYE

DROPS 0.2-0.5 %

3 MO

dorzolamide Eye

Drops 2 %

1 MO

dorzolamide-timolol

Eye Drops 2-0.5 %

2 MO

latanoprost Eye Drops

0.005 %

2 MO

LUMIGAN EYE

DROPS 0.01 %, 0.03

%

3 MO

TRAVATAN Z EYE

DROPS 0.004 %

4 MO

XALATAN EYE

DROPS 0.005 %

4 MO

Steroid-Antibiotic Combinations


poly-HC Eye Ointment

3.5-400-10,000 mg-

unit/g-1%

1 MO

neomycin-polymyxin-

dexameth Eye Drops

3.5-10,000-0.1

mg/mL-unit/mL-%

1 MO

neomycin-polymyxin-

dexameth Eye

Ointment 3.5-10,000-

0.1 mg-unit/g-%

1 MO

neomycin-polymyxin-

HC Eye Drops, Susp

3.5-10,000-10 mg-

unit-mg/mL

1 MO

PRED-G EYE

DROPS 0.3-1 %

3 MO

PRED-G S.O.P. EYE

OINTMENT 0.3-0.6

%

3 MO

TOBRADEX EYE

OINTMENT 0.3-0.1

%

3 MO

Page 69 of 89


Limits

tobramycin-

dexamethasone Eye

Drops, Susp 0.3-0.1 %

2 MO

ZYLET EYE DROPS

0.3-0.5 %

4 MO

Steroids

ALREX EYE DROPS

0.2 %

3 MO

dexamethasone Eye

Drops 0.1 %

1 MO

FLAREX EYE

DROPS 0.1 %

3 MO

FML FORTE EYE

DROPS 0.25 %

3 MO

FML S.O.P. EYE

OINTMENT 0.1 %

3 MO

LOTEMAX EYE

DROPS 0.5 %

4 MO

LOTEMAX EYE

OINTMENT 0.5 %

4 MO

MAXIDEX EYE

DROPS 0.1 %

3 MO

prednisolone acetate

Eye Drops, Susp 1 %

1 MO

prednisolone sodium

phosphate Eye Drops

1 %

1 MO

VEXOL EYE DROPS

1 %

3 MO

Steroid-Sulfonamide Combinations

BLEPHAMIDE EYE

DROPS 10-0.2 %

3 MO

BLEPHAMIDE

S.O.P. EYE

OINTMENT 10-0.2 %

3 MO


Limits

sulfacetamide-

prednisolone Eye

Drops 10 %-0.23 %

(0.25 %)

1 MO

Sulfonamides

BLEPH-10 EYE

DROPS 10 %

3 MO


Eye Drops 10 %

1 MO


Eye Ointment 10 %

1 MO

Sympathomimetics

ALPHAGAN P EYE

DROPS 0.1 %, 0.15 %

3 MO

apraclonidine Eye

Drops 0.5 %

2 MO

brimonidine Eye

Drops 0.15 %, 0.2 %

1 MO

IOPIDINE EYE

DROPPERETTE 1 %

4 MO

IOPIDINE EYE

DROPS 0.5 %

4 MO

Vasoconstrictor Decongestants

AK-CON EYE

DROPS 0.1 %

1 MO

Otc-Product

Otc-Product

OTC-PRODUCT 1 MO

Respiratory And Allergy

Antihistamine / Antiallergenic Agents

carbinoxamine Oral

Liquid 4 mg/5 mL

2 MO

carbinoxamine tablet

4 mg

2 MO

cetirizine Oral Soln 1

mg/mL

1 MO

Page 70 of 89


Limits

CLARINEX

DISINTEGRATING

TABLET 2.5 mg, 5

mg

4 ST; MO

CLARINEX SYRUP

2.5 mg/5 mL (0.5

mg/mL)

4 ST; MO

CLARINEX TABLET

5 mg

4 ST; MO

CLARINEX-D 12

HOUR

TABLET,EXTENDE

D RELEASE 2.5-120

mg

4 MO

CLARINEX-D 24

HOUR

TABLET,EXTENDE

D RELEASE 5-240

mg

4 MO

clemastine Syrup 0.67

mg/5 mL

1 MO

clemastine tablet 2.68

mg

1 MO

cyproheptadine Syrup

2 mg/5 mL

2 MO

cyproheptadine tablet

4 mg

2 MO

diphenhydramine

capsule 50 mg

1 MO

epinephrine HCl

Syringe 0.1 mg/mL

1 MO

EPIPEN IM

INJECTOR 0.3

mg/0.3 mL

4 MO

EPIPEN JR IM

INJECTOR 0.15

mg/0.3 mL

4 MO

hydroxyzine IM 25

mg/mL, 50 mg/mL

1 MO


Limits

hydroxyzine Syrup 10

mg/5 mL

1 MO

hydroxyzine tablet 10

mg, 25 mg, 50 mg

1 MO

hydroxyzine pamoate

capsule 100 mg, 25

mg, 50 mg

1 MO

levocetirizine Oral

Soln 2.5 mg/5 mL

2 MO

levocetirizine tablet 5

mg

2 MO

PALGIC ORAL

LIQUID 4 mg/5 mL

2 MO

PALGIC TABLET 4

mg

4 MO

PHENADOZ

RECTAL

SUPPOSITORY 12.5

mg, 25 mg

2 MO

promethazine

Injection 50 mg/mL

1 MO

promethazine Rectal

Suppository 12.5 mg,

25 mg

1 MO

promethazine Syringe

25 mg/mL

1 MO

promethazine Syrup

6.25 mg/5 mL

1 MO

promethazine tablet

12.5 mg, 25 mg, 50 mg

1 MO

PROMETHEGAN

RECTAL

SUPPOSITORY 25

mg, 50 mg

2 MO

TWINJECT

AUTOINJECTOR IM

PEN 0.15 mg/0.15

mL, 0.3 mg/0.3 mL

3 MO

Page 71 of 89


Limits

XYZAL ORAL

SOLN 2.5 mg/5 mL

4 ST; MO

XYZAL TABLET 5

mg

4 ST; MO

Pulmonary Agents

ACCOLATE

TABLET 10 mg, 20

mg

3 MO

acetylcysteine Soln

100 mg/mL (10 %),

200 mg/mL (20 %)

1 MO

ADVAIR DISKUS

FOR INHALATION

100-50 mcg/dose,

250-50 mcg/dose,

500-50 mcg/dose

4 MO

ADVAIR HFA

AEROSOL

INHALER 115-21

mcg/actuation, 230-21

mcg/actuation, 45-21

mcg/actuation

4 MO

albuterol sulfate Neb

Solution 0.63 mg/3

mL, 1.25 mg/3 mL, 2.5

mg /3 mL (0.083 %), 5

mg/mL

1 BvsD; MO

albuterol sulfate ER

tablet,extended

release,12 hr 4 mg, 8

mg

1 MO

albuterol sulfate Syrup

2 mg/5 mL

1 MO

albuterol sulfate tablet

2 mg, 4 mg

1 MO

aminophylline IV 250

mg/10 mL

1 MO


Limits

ASMANEX

TWISTHALER

BREATH

ACTIVATED 110

mcg (30 doses), 220

mcg (14 doses)

4 MO

ATROVENT HFA

AEROSOL

INHALER 17

mcg/actuation

3 MO

BECONASE AQ

NASAL SPRAY 42

mcg (0.042 %)

4 MO

BROVANA NEB

SOLUTION 15 mcg/2

mL

4 BvsD; MO

budesonide Neb

Suspension 0.25 mg/2

mL, 0.5 mg/2 mL

2 BvsD; MO

COMBIVENT

AEROSOL

INHALER 18-103

mcg/actuation

3 MO

cromolyn Neb

Solution 20 mg/2 mL

1 BvsD; MO

ELIXOPHYLLIN 80

mg/15 mL

3 MO

FLOVENT HFA

AEROSOL

INHALER 110

mcg/actuation, 220

mcg/actuation, 44

mcg/actuation

3 MO

flunisolide Nasal

Spray 25 mcg (0.025

%)

1 MO

fluticasone Nasal

Spray, Susp 50

mcg/actuation

2 MO

Page 72 of 89


Limits

ipratropium bromide

Soln for Inhalation

0.02 %

1 MO

ipratropium-albuterol

Neb Solution 0.5 mg-3

mg(2.5 mg base)/3 mL

1 MO

levalbuterol Neb

Solution 1.25 mg/0.5

mL

1 PA; MO; BvsD

LUFYLLIN TABLET

200 mg

3 MO

MAXAIR

AUTOHALER

BREATH

ACTIVATED 200

mcg/Inhalation

4 MO

metaproterenol Syrup

10 mg/5 mL

1 MO

metaproterenol tablet

10 mg, 20 mg

1 MO

NASACORT AQ

NASAL SPRAY

AEROSOL 55 mcg

3 MO

NASONEX SPRAY

50 mcg/actuation

3 MO

OMNARIS NASAL

SPRAY 50 mcg

3 MO

PERFOROMIST NEB

SOLUTION 20 mcg/2

mL

4 BvsD; MO

PROAIR HFA

AEROSOL

INHALER 90

mcg/actuation

1 MO

PROVENTIL HFA

AEROSOL

INHALER 90

mcg/actuation

3 MO


Limits

PULMICORT NEB

SUSPENSION 1 mg/2

mL

4 BvsD; MO

PULMICORT

FLEXHALER

BREATH

ACTIVATED 180

mcg/actuation, 90

mcg/actuation

4 MO

PULMOZYME SOLN

FOR INHALATION 1

mg/mL

4 BvsD; MO

QVAR AEROSOL

INHALER 40

mcg/actuation, 80

mcg/actuation

4 MO

REVATIO TABLET

20 mg

5 MO

SEREVENT DISKUS

FOR INHALATION

50 mcg/dose

4 MO

SINGULAIR

CHEWABLE

TABLET 4 mg, 5 mg

3 MO

SINGULAIR ORAL

GRANULES IN

PACKET 4 mg

3 MO

SINGULAIR

TABLET 10 mg

3 MO

SPIRIVA WITH

HANDIHALER &

INHALATION

CAPSULES 18 mcg

3 MO

SYMBICORT HFA

AEROSOL

INHALER 160-4.5

mcg/actuation, 80-4.5

mcg/actuation

3 MO; QL (10.2

GM per 30

day(s))

terbutaline tablet 2.5

mg, 5 mg

1 MO

Page 73 of 89


Limits

terbutaline Sub-Q 1

mg/mL

2 BvsD; MO

theophylline ER

tablet,extended

release 400 mg, 600

mg

1 MO

theophylline ER

tablet,extended

release,12 hr 100 mg,

200 mg, 300 mg, 450

mg

1 MO

TRACLEER

TABLET 125 mg,

62.5 mg

5 PA; MO; LA

triamcinolone

acetonide Nasal Spray

Aerosol 55 mcg

2 MO

VENTAVIS NEB

SOLUTION 10

mcg/mL

5 BvsD; MO

VENTOLIN HFA

AEROSOL

INHALER 90

mcg/actuation

3 MO

XOLAIR SUB-Q

SOLN 150 mg

4 BvsD; MO

XOPENEX NEB

SOLUTION 0.31

mg/3 mL, 0.63 mg/3

mL, 1.25 mg/3 mL

4 PA; MO; BvsD

XOPENEX HFA

AEROSOL

INHALER 45

mcg/actuation

4 MO

zafirlukast tablet 10

mg, 20 mg

2 MO

ZYFLO TABLET 600

mg

4 MO

ZYFLO CR

TABLET,EXTENDE

D RELEASE 600 mg

4 MO


Limits

Urologicals

Anticholinergics / Antispasmodics

DETROL TABLET 1

mg, 2 mg

3 MO

DETROL LA

CAPSULE,EXTEND

ED RELEASE 2 mg,

4 mg

3 MO

ENABLEX

TABLET,EXTENDE

D RELEASE 15 mg,

7.5 mg

4 MO; QL (30 EA

per 30 day(s))

flavoxate tablet 100

mg

2 MO

oxybutynin chloride

ER tablet,24 hr

extended release 10

mg, 15 mg, 5 mg

1 MO

oxybutynin chloride

Syrup 5 mg/5 mL

1 MO

oxybutynin chloride

tablet 5 mg

1 MO

SANCTURA

TABLET 20 mg

3 MO; QL (60 EA

per 30 day(s))

SANCTURA XR

CAPSULE,EXTEND

ED RELEASE 60 mg

3 MO; QL (30 EA

per 30 day(s))

trospium tablet 20 mg 2 MO; QL (60 EA

per 30 day(s))

VESICARE TABLET

10 mg, 5 mg

4 MO; QL (30 EA

per 30 day(s))

Benign Prostatic Hyperplasia(Bph) Therapy

alfuzosin ER

tablet,extended

release 24 hr 10 mg

1 MO

AVODART

CAPSULE 0.5 mg

4 MO; QL (30 EA

per 30 day(s))

finasteride tablet 5 mg 1 MO; QL (30 EA

per 30 day(s))

Page 74 of 89


Limits

JALYN CAPSULE,

EXTENDED

RELEASE 0.5-0.4 mg

3 MO

tamsulosin ER

capsule,extended

release 24 hr 0.4 mg

1 MO; QL (60 EA

per 30 day(s))

UROXATRAL

TABLET,EXTENDE

D RELEASE 10 mg

4 MO; QL (30 EA

per 30 day(s))

Cholinergic Stimulants

bethanechol chloride


mg, 50 mg

2 MO

Miscellaneous Urologicals

ammonium chloride

IV 5 mEq/mL

3 BvsD; MO

CYSTAGON

CAPSULE 150 mg,

50 mg

3 MO

ELMIRON

CAPSULE 100 mg

3 MO

Vitamins, Hematinics / Electrolytes

Electrolytes

0.45 % sodium

chloride with

potassium chloride IV

20 mEq/L

3 BvsD; MO

0.9 % sodium chloride

& potassium chloride

IV 20 mEq/L

1 BvsD; MO

0.9 % sodium chloride

& potassium chloride

IV 40 mEq/L

3 BvsD; MO

calcium acetate

capsule 667 mg

2 MO

D5-0.45 % sodium

chloride & potassium

chloride IV 10 mEq/L,

20 mEq/L, 40 mEq/L

1 BvsD; MO


Limits

D5-0.45 % sodium


chloride IV 30 mEq/L

3 BvsD; MO

D5-0.225 % sodium



3 BvsD; MO

D5-0.33 % in sodium



1 BvsD; MO

D5 & 0.9 % sodium

chloride with


20 mEq/L, 40 mEq/L

1 BvsD; MO

D5-LR with potassium


1 MO

D5W with potassium

chloride IV 30 mEq/L,

40 mEq/L

2 BvsD; MO

D5W with potassium


3 BvsD; MO

dextrose 5% and

lactated ringers IV

1 MO

ELIPHOS TABLET

667 mg

1 MO

KLOR-CON

TABLET,EXTENDE

D RELEASE 8 mEq

1 MO

KLOR-CON 10

TABLET,EXTENDE

D RELEASE 10 mEq

1 MO

KLOR-CON M15

TABLET,EXTENDE

D RELEASE 15 mEq

3 MO

KLOR-CON M20

TABLET,EXTENDE

D RELEASE 20 mEq

1 MO

lactated ringers IV 3 BvsD; MO

magnesium sulfate

Syringe 4 mEq/mL

3 BvsD; MO

Page 75 of 89


Limits

NORMOSOL-R IN

D5W IV 5 %

3 BvsD; MO


Piggy Back 10

mEq/100 mL, 10

mEq/50 mL

1 BvsD; MO


Soln 2 mEq/mL

1 BvsD; MO

potassium chloride ER

capsule,extended

release 10 mEq, 8

mEq

1 MO

potassium chloride ER

tablet,extended

release(part/cryst) 10

mEq, 20 mEq

1 MO


Piggy Back 20 mEq/50

mL, 30 mEq/100 mL

3 BvsD; MO

ringers IV 1 MO

sodium chloride IV 2.5

mEq/mL

1 BvsD; MO

sodium chloride 0.45

% IV 0.45 %

1 BvsD; MO

sodium chloride 3 %

IV 3 %

1 BvsD; MO

sodium chloride 5 %

IV 5 %

1 BvsD; MO

sodium lactate IV 5

mEq/mL

1 BvsD; MO

sodium lactate IV Soln

167 mEq/L

1 BvsD; MO

Miscellaneous Nutrition Products

AMINOSYN II 10 %

IV

3 BvsD; MO

AMINOSYN II 15%

IV 15 %

2 MO

AMINOSYN II 7 %

IV 7 %

3 BvsD; MO


Limits

AMINOSYN II 8.5 %

IV 8.5 %

3 BvsD; MO

AMINOSYN M 3.5 %

IV 3.5 %

3 BvsD; MO

AMINOSYN-HBC

7% IV 7 %

3 BvsD; MO

AMINOSYN-PF 10 %

IV 10 %

3 BvsD; MO

AMINOSYN-PF 7 %

(SULFITE-FREE) IV

7 %

3 BvsD; MO

CLINIMIX 2.75%/D5

SULFITE FREE IV

2.75 %

3 BvsD; MO

CLINIMIX

4.25%/D10 SULFITE

FREE IV 4.25 %

3 BvsD; MO

CLINIMIX

4.25%/D20 SULFITE

FREE IV 4.25 %

3 BvsD; MO

CLINIMIX 5%/D15

SULFITE FREE IV 5

%

3 BvsD; MO

CLINIMIX 5%/D20

SULFITE FREE IV 5

%

3 BvsD; MO

CLINIMIX 5%/D25

SULFITE FREE IV 5

%

3 BvsD; MO

CLINIMIX E

4.25%/D25 SULFITE

FREE IV 4.25 %

3 BvsD; MO

CLINIMIX E

4.25%/D5 SULFITE

FREE IV 4.25 %

3 BvsD; MO

CLINIMIX E 5%/D15

SULFITE FREE IV 5

%

3 BvsD; MO

Page 76 of 89


Limits

CLINIMIX E 5%/D20

SULFITE FREE IV 5

%

3 BvsD; MO

CLINIMIX E 5%/D25

SULFITE FREE IV 5

%

3 BvsD; MO

FREAMINE III 3 %

WITH

ELECTROLYTES IV

3 %

3 BvsD; MO

FREAMINE III 8.5 %

IV 8.5 %

3 BvsD; MO

HEPATAMINE 8%

IV 8 %

3 BvsD; MO

HEPATASOL 8 % IV

8 %

3 BvsD; MO

INTRALIPID IV 20

%

2 BvsD; MO

INTRALIPID IV 30

%

3 BvsD; MO

IONOSOL-B IN D5W

IV 5 %

3 BvsD; MO

IONOSOL-MB IN

D5W IV 5 %

3 BvsD; MO

ISOLYTE-H IN D5W

IV 5 %

3 BvsD; MO

ISOLYTE-P IN D5W

IV 5 %

3 BvsD; MO

ISOLYTE-S IV 3 BvsD; MO

ISOLYTE-S IN D5W

IV

3 BvsD; MO

NEPHRAMINE 5.4 %

IV 5.4 %

3 BvsD; MO

NORMOSOL-R PH

7.4 IV

3 BvsD; MO

PLASMA-LYTE 148

IV

3 BvsD; MO


Limits

PLASMA-LYTE A

IV

3 BvsD; MO

PLASMA-LYTE-56

IN D5W IV 5 %

3 BvsD; MO

PREMASOL 10 % IV 2 BvsD; MO

PREMASOL 6 % IV 3 BvsD; MO

PROCALAMINE 3%

IV 3 %

3 BvsD; MO

PROSOL 20% IV 3 BvsD; MO

TRAVASOL 10 % IV

10 %

2 MO

TROPHAMINE 10 %

IV 10 %

3 BvsD; MO

TROPHAMINE 6%

IV 6 %

3 BvsD; MO

Vitamins / Hematinics

PRENATAL PLUS

WITH IRON

(CALCIUM

CARBONATE)

TABLET 27-1 mg

1 MO

sodium fluoride tablet

1 mg fluoride (2.2 mg)

1 MO

Page 77 of 89

OTC Drugs


Limits

ALAVERT

DISINTEGRATING

TABLET 10 mg

1 MO

ALAVERT TABLET

10 mg

1 MO

ALL DAY

ALLERGY

(CETIRIZINE)

CHEWABLE

TABLET 10 mg, 5 mg

1 MO

ALL DAY

ALLERGY

(CETIRIZINE)

TABLET 10 mg

1 MO

ALLEGRA

ALLERGY TABLET

180 mg, 60 mg

1 MO

ALLER-EASE

TABLET 180 mg

1 MO

ALLERGY RELIEF

(FEXOFENADINE)

TABLET 180 mg

1 MO

ALLERGY RELIEF

(LORATADINE)

ORAL SOLN 5 mg/5

mL

1 MO

ALLERGY RELIEF

(LORATADINE)

TABLET 10 mg

1 MO

cetirizine tablet 5 mg 1 MO

CHILDREN'S

ALLERGY RELIEF

(CETIRIZINE)

CHEWABLE

TABLET 10 mg, 5 mg

1 MO

CHILDREN'S

ALLEGRA

ALLERGY

DISINTEGRATING

TABLET 30 mg

1 MO

CHILDREN'S

ALLEGRA

ALLERGY ORAL

SUSP 30 mg/5 mL

1 MO


Limits

CHILDREN'S

ALLEGRA

ALLERGY TABLET

30 mg

1 MO

CHILDREN'S

ALLERGY RELIEF

ORAL SOLN 5 mg/5

mL

1 MO

CHILDREN'S

CLEAR-ATADINE

DISINTEGRATING

TABLET 10 mg

1 MO

CHILDREN'S WAL-

ZYR CHEWABLE

TABLET 10 mg

1 MO

CLEAR-ATADINE

TABLET 10 mg

1 MO

loratadine Oral Soln 5

mg/5 mL

1 MO

loratadine tablet 10

mg

1 MO

NON-DROWSY

ALLERGY TABLET

10 mg

1 MO

omeprazole


20 mg

1 MO

omeprazole

magnesium

capsule,delayed

release 20 mg

1 MO

PREVACID 24HR

CAPSULE,DELAYE

D RELEASE 15 mg

1 MO

PRILOSEC OTC

TABLET,DELAYED

RELEASE 20 mg

1 MO

WAL-ITIN TABLET

10 mg

1 MO

WAL-ZYR TABLET

10 mg

1 MO

Page 78 of 89

Index

0.45 % NaCl-potassium

chloride.............................. 74

0.9% NaCl & potassium

chloride.............................. 74

8-Mop .................................... 41

Abelcet .................................... 1

Abilify ................................... 26

Abilify Discmelt .................... 26

Acanya .................................. 41

acarbose ................................. 50

Accolate ................................ 71

acebutolol .............................. 33

acetaminophen-codeine ......... 22

Acetasol HC .......................... 48

acetazolamide ........................ 68

acetazolamide sodium ........... 68

acetic acid .............................. 48

acetylcysteine ........................ 71

ActHIB (PF) .......................... 60

Actimmune ............................ 57

Actonel ............................ 46, 61

Actoplus MET ....................... 50

Actoplus Met XR .................. 50

Actos ..................................... 50

Acuvail (PF) .......................... 68

acyclovir .................................. 1

acyclovir sodium ..................... 1

Adacel (Adolescent

&Adult)(PF) ...................... 60

Adagen .................................. 46

adapalene ......................... 41, 42

Adcirca .................................. 33

Adderall XR .......................... 26

Adriamycin PFS .................... 12

Advair Diskus ....................... 71

Advair HFA........................... 71

Advicor.................................. 39

Afeditab CR .......................... 33

Afinitor .................................. 12

Aggrenox ............................... 38

A-Hydrocort .......................... 49

AK-Con ................................. 69

Ala-Cort ................................ 44

Ala-Scalp ............................... 44

Alavert ................................... 77

Albenza ................................... 6

albuterol sulfate ..................... 71

alclometasone ........................ 44

alcohol swabs ........................ 50

Aldactazide ........................... 33

Aldara ................................... 41

Aldurazyme .......................... 52

alendronate ..................... 46, 61

alfuzosin ............................... 73

Alimta ................................... 12

Alinia ...................................... 6

Alkeran ................................. 12

All Day Allergy (cetirizine) .. 77

Allegra Allergy ..................... 77

Aller-ease .............................. 77

Allergy Relief (fexofenadine)

.......................................... 77

Allergy Relief (loratadine) ... 77

allopurinol ............................. 61

allopurinol sodium ................ 61

Alocril ................................... 67

Alomide ................................ 67

Aloprim ................................. 61

Aloxi ..................................... 54

Alphagan P ........................... 69

Alrex ..................................... 69

Altabax ................................. 43

amantadine .......................... 1, 2

AmBisome .............................. 1

amcinonide ........................... 44

Amethia ................................ 64

Amethyst ............................... 64

Amevive ............................... 41

amifostine crystalline ............ 11

amikacin ................................. 6

amiloride ............................... 33

amiloride-hydrochlorothiazide

.......................................... 33

aminophylline ....................... 71

Aminosyn II 10 % ................ 75

Aminosyn II 15% ................. 75

Aminosyn II 7 % .................. 75

Aminosyn II 8.5 % ............... 75

Aminosyn M 3.5 % ............... 75

Aminosyn-HBC 7% .............. 75

Aminosyn-PF 10 % .............. 75

Aminosyn-PF 7 % (Sulfite-

Free) .................................. 75

amiodarone ........................... 32

Amitiza ................................. 54

amitriptyline ......................... 26

amitriptyline-chlordiazepoxide

........................................... 26

amlodipine ............................. 33

amlodipine-benazepril ........... 33

ammonium chloride .............. 74

ammonium lactate ................. 41

Amnesteem ........................... 42

amoxapine ............................. 26

amoxicillin .............................. 8

amoxicillin-pot clavulanate . 8, 9

Amphetamine Salt Combo .... 27

Amphotec ................................ 1

amphotericin B ........................ 1

ampicillin ................................ 9

ampicillin sodium .................... 9

ampicillin-sulbactam ............... 9

Amrix .................................... 22

Amturnide ............................. 39

anagrelide .............................. 46

anastrozole ............................ 12

Ancobon .................................. 1

AndroGel ............................... 52

Androxy ................................ 52

Antabuse ............................... 46

Antivert ................................. 54

Anzemet ................................ 54

Aplenzin ................................ 27

APOKYN .............................. 20

apraclonidine ......................... 69

Apri ....................................... 64

Apriso .................................... 54

Aptivus .................................... 2

Aralast NP ............................. 46

Aranelle (28) ......................... 64

Aranesp (polysorbate) ..... 57, 58

Arcalyst ................................. 58

Aricept ................................... 21

Aricept ODT ......................... 21

Arimidex ............................... 12

Arixtra ................................... 38

Aromasin ............................... 12

Arranon ................................. 12

Arthrotec 50 .......................... 24

Arthrotec 75 .......................... 24

Arzerra .................................. 12

Asacol ................................... 54

Asacol HD ............................. 54

Ascomp w/Codeine ............... 22

Page 79 of 89

Asmanex Twisthaler ............. 71

Astelin ................................... 48

Atelvia ................................... 61

atenolol .................................. 33

atenolol-chlorthalidone ......... 33

Atgam .................................... 60

atorvastatin ............................ 39

atovaquone-proguanil.............. 6

ATRIPLA ................................ 2

atropine.................................. 53

Atrovent HFA ....................... 71

AVASTIN ............................. 12

Avelox ................................... 10

Avelox ABC Pack ................. 10

Avelox in NaCl (iso-osmotic)

........................................... 10

Aviane ................................... 64

Avita ...................................... 42

Avodart.................................. 73

Avonex .................................. 58

Avonex Administration Pack 58

Azactam .................................. 6

Azactam-iso-osmotic dextrose 6

Azasan ................................... 12

Azasite ................................... 66

azathioprine ........................... 12

azathioprine sodium .............. 12

azelastine ......................... 48, 67

Azelex ................................... 42

AZILECT .............................. 20

azithromycin............................ 5

Azopt ..................................... 68

Azor ....................................... 33

aztreonam ................................ 6

BACiiM ................................... 6

bacitracin ........................... 6, 66

bacitracin-polymyxin B......... 66

baclofen ................................. 22

Bactroban .............................. 43

Bactroban Nasal .................... 48

balsalazide ............................. 54

Balziva (28) ........................... 64

Banzel.................................... 17

Baraclude ................................ 2

Beconase AQ......................... 71

benazepril .............................. 33

benazepril-hydrochlorothiazide

........................................... 33

Benlysta ................................. 62

Bentyl .................................... 54

benztropine ........................... 20

betamethasone dipropionate . 44

betamethasone valerate ......... 44

betamethasone, augmented ... 44

Betaseron .............................. 58

betaxolol ......................... 33, 67

bethanechol chloride ............. 74

Betoptic S ............................. 67

bicalutamide ......................... 12

Bicillin C-R ............................ 9

Bicillin L-A ............................ 9

BiCNU .................................. 12

Biltricide ................................. 6

bisoprolol fumarate ............... 33

bisoprolol-hydrochlorothiazide

.......................................... 33

bleomycin ............................. 12

Bleph-10 ............................... 69

Blephamide ........................... 69

Blephamide S.O.P. ............... 69

Boniva ................................... 62

Boostrix (PF) ........................ 60

Briellyn ................................. 64

brimonidine ........................... 69

bromfenac ............................. 68

bromocriptine ....................... 20

Brovana ................................. 71

Budeprion SR ....................... 27

Budeprion XL ....................... 27

budesonide ...................... 54, 71

bumetanide ........................... 33

Buphenyl ............................... 46

buprenorphine ....................... 23

Buproban .............................. 48

bupropion HCl ...................... 27

buspirone .............................. 27

Busulfex ................................ 12

butorphanol tartrate .............. 25

Byetta .................................... 50

Bystolic ................................. 33

cabergoline ........................... 52

Caduet ................................... 39

calcipotriene ......................... 41

calcitonin (salmon) ............... 52

calcitriol ................................ 52

calcium acetate ..................... 74

Camila ................................... 62

Campath ................................ 12

Campral ................................ 46

Canasa ................................... 54

Cancidas .................................. 1

Cantil ..................................... 54

Capastat ................................... 6

Capex .................................... 44

Caprelsa ................................. 12

captopril ................................ 33

captopril-hydrochlorothiazide

........................................... 33

Carac ..................................... 41

Carafate ................................. 56

carbamazepine ....................... 17

Carbatrol ............................... 17

carbidopa-levodopa ............... 20

carbinoxamine maleate ......... 69

carboplatin ............................. 12

Cardura XL ........................... 33

Carimune NF Nanofiltered.... 60

carisoprodol ........................... 22

carisoprodol-ASA-codeine.... 22

carisoprodol-aspirin .............. 22

Carnitor ................................. 46

carteolol ................................. 67

Cartia XT .............................. 33

carvedilol ............................... 34

Casodex ................................. 12

Cedax ...................................... 4

CeeNU ................................... 12

cefaclor .................................... 4

cefadroxil ................................ 4

cefazolin .................................. 4

cefazolin in dextrose (iso-os) .. 4

cefdinir .................................... 4

cefepime .................................. 5

cefotaxime ............................... 5

cefotetan .................................. 5

cefoxitin .................................. 5

cefpodoxime ............................ 5

cefprozil .................................. 5

ceftazidime in D5W ................ 5

ceftriaxone ............................... 5

cefuroxime axetil..................... 5

cefuroxime sodium .................. 5

Celebrex ................................ 25

Celestone ............................... 49

CellCept ................................ 12

CellCept Intravenous ............ 12

Celontin ................................. 17

Cenestin ................................. 62

cephalexin ............................... 5

Cerezyme .............................. 52

Page 80 of 89

Cervarix Vaccine (PF) .......... 60

Cesamet ................................. 54

cetirizine .......................... 69, 77

Chantix .................................. 48

Chantix Starting Month Box . 48

Chemet .................................. 46

Child Allergy Relf(cetirizine)

........................................... 77

Children's Allegra Allergy .... 77

Children's Allergy Relief ...... 77

Children's Clear-Atadine ....... 77

Children's Wal-Zyr ................ 77

chloramphenicol sod succinate 6

chlorhexidine gluconate ........ 48

chloroquine phosphate ............ 6

chlorothiazide ........................ 34

chlorothiazide sodium ........... 34

chlorpromazine...................... 27

chlorpropamide ..................... 50

chlorthalidone........................ 34

chlorzoxazone ....................... 22

Cholestyramine Light ............ 39

ciclopirox .............................. 43

cilostazol ............................... 38

Ciloxan .................................. 66

cimetidine .............................. 56

cimetidine HCl ...................... 56

Cipro...................................... 10

Cipro HC ............................... 48

CIPRODEX ........................... 48

ciprofloxacin ................... 10, 66

ciprofloxacin (mixture) ......... 10

cisplatin ................................. 12

citalopram.............................. 27

cladribine ............................... 12

Claforan ................................... 5

Claravis ................................. 42

Clarinex ................................. 70

Clarinex-D 12 HOUR ........... 70

Clarinex-D 24 HOUR ........... 70

clarithromycin ..................... 5, 6

Clear-Atadine ........................ 77

clemastine.............................. 70

Cleocin .................................... 6

Cleocin in D5W ...................... 6

clindamycin HCl ..................... 6

clindamycin phosphate 6, 42, 63

clindamycin-benzoyl peroxide

........................................... 42

Clinimix 2.75%/D5 Sulfite Free

.......................................... 75

Clinimix 4.25%/D5 Sulfite Free

.......................................... 46

Clinimix 4.25/D10 Sulfite Free

.......................................... 75

Clinimix 4.25/D20 Sulfite Free

.......................................... 75

Clinimix 5%/D15 Sulfite Free

.......................................... 75


.......................................... 75


.......................................... 75

Clinimix E 2.75/D10 SulfitFree

.......................................... 46

Clinimix E 2.75/D5 SulfiteFree

.......................................... 47

Clinimix E 4.25/D25 SulfitFree

.......................................... 75

Clinimix E 4.25/D5 SulfiteFree

.......................................... 75

Clinimix E 5%/D15 Sulfite

Free ................................... 75


Free ................................... 76


Free ................................... 76

clobetasol .............................. 44

clobetasol-emollient ............. 44

CLOLAR .............................. 12

clomipramine ........................ 27

clonazepam ........................... 27

clonidine ............................... 34

clopidogrel ............................ 38

clorazepate dipotassium ........ 27

Clorpres ................................ 34

clotrimazole ...................... 1, 43

clotrimazole-betamethasone . 43

clozapine ............................... 27

Clozaril ................................. 27

cod-butalbital-acetaminop-caf

.......................................... 23

codeine sulfate ...................... 23

colchicine-probenecid ........... 61

Colcrys .................................. 61

colestipol ............................... 39

colistin (colistimethate Na) ..... 7

Coly-Mycin S ....................... 48

Combigan ............................. 68

Combivent ............................. 71

Combivir ................................. 2

Complera ................................. 2

Compro ................................. 54

Comtan .................................. 20

Comvax (PF) ......................... 60

Concerta ................................ 27

Copaxone .............................. 21

Cordran ................................. 44

Coreg CR .............................. 34

cortisone ................................ 49

Cortisporin ............................ 43

Cortisporin-TC ...................... 49

Cosmegen .............................. 12

Cozaar ................................... 34

Creon ..................................... 54

Crestor ................................... 39

Crinone .................................. 62

Crixivan ................................... 2

cromolyn ................... 54, 67, 71

Cryselle (28) .......................... 64

CUBICIN ................................ 7

Curity Gauze ......................... 50

Cyclafem 1/35 (28) ............... 64

Cyclafem 7/7/7 (28) .............. 64

cyclobenzaprine .................... 22

cyclophosphamide ................. 12

cyclosporine .................... 12, 13

cyclosporine modified ........... 13

Cyklokapron .......................... 38

Cymbalta ............................... 27

cyproheptadine ...................... 70

Cystadane .............................. 54

Cystagon ............................... 74

cytarabine .............................. 13

cytarabine (PF) ...................... 13

Cytovene ................................. 2

D10 % & 0.45 % sodium

chloride ............................. 47

D2.5 %-0.45 % sodium

chloride ............................. 47

D5 % and 0.9 % sodium

chloride ............................. 47

D5 %-0.45 % sodium chloride

........................................... 47

D5 in 0.45%NaCl & potassium

Cl ....................................... 74

D5-0.225 % NaCl and KCl ... 74

D5-0.33 % NaCl & potassium

chl ...................................... 74

Page 81 of 89

D5-0.9%NaCl-potassium

chloride.............................. 74

D5-LR with potassium chloride

........................................... 74

D5W with potassium chloride

........................................... 74

dacarbazine ............................ 13

Dacogen ................................ 13

danazol .................................. 52

dantrolene .............................. 22

dapsone.................................... 7

Daptacel (Pediatric) (PF) ...... 60

Daraprim ................................. 7

daunorubicin.......................... 13

DECAVAC (PF) ................... 60

demeclocycline ...................... 10

Demser .................................. 34

Denavir .................................. 44

Depakote ............................... 17

Depakote ER ......................... 17

Depakote Sprinkles ............... 17

Depen Titratabs ..................... 62

Depo-Estradiol ...................... 62

Depo-Provera ........................ 62

Depo-SubQ provera 104 ....... 62

Derma-Smoothe/FS Body Oil

........................................... 45

DermOtic Oil......................... 48

desipramine ........................... 27

desmopressin ......................... 52

Desonate ................................ 45

desonide ................................ 45

desoximetasone ..................... 45

Desoxyn ................................ 27

Detrol .................................... 73

Detrol LA .............................. 73

dexamethasone ...................... 49

Dexamethasone Intensol ....... 49

dexamethasone sodium

phosphate .................... 49, 69

Dexilant ................................. 57

dexmethylphenidate .............. 27

DexPak .................................. 49

dexrazoxane .......................... 11

dextroamphetamine ............... 27

dextrose 10 % & 0.225 % NaCl

........................................... 47

dextrose 10% in water (D10W)

........................................... 47

dextrose 5% in water (D5W) 47

dextrose 5%-0.225 % NaCl .. 47

dextrose 5%-0.33%

sod.chloride ...................... 47

dextrose 5%-lactated ringers 74

diazepam ......................... 27, 28

Diazepam Intensol ................ 28

Dibenzyline ........................... 34

diclofenac potassium ............ 25

diclofenac sodium ........... 25, 68

dicloxacillin ............................ 9

dicyclomine .......................... 54

didanosine ............................... 2

diflorasone ............................ 45

diflunisal ............................... 25

digoxin .................................. 38

dihydroergotamine ................ 21

Dilantin ................................. 17

Dilantin Infatabs ................... 17

Dilaudid-5 ............................. 23

DILT-CD .............................. 34

diltiazem HCl ........................ 34

DILT-XR .............................. 34

Diovan .................................. 34

Diovan HCT ......................... 34

Dipentum .............................. 54

diphenhydramine HCl .......... 70

diphenoxylate-atropine ......... 54

dipyridamole ......................... 38

disopyramide ........................ 32

disulfiram .............................. 47

Diuril ..................................... 34

Diuril IV ............................... 34

divalproex ............................. 17

Divigel .................................. 62

Docefrez ............................... 13

docetaxel ............................... 13

donepezil ............................... 21

Doribax ................................... 7

dorzolamide .......................... 68

dorzolamide-timolol ............. 68

Dovonex ............................... 41

doxazosin .............................. 34

doxepin ................................. 28

Doxil ..................................... 13

doxorubicin ........................... 13

doxycycline hyclate ........ 10, 11

doxycycline monohydrate .... 11

dronabinol ............................. 55

Droxia ................................... 13

DUETACT ........................... 50

Duramorph (PF) .................... 23

DynaCirc CR ......................... 34

Dyrenium .............................. 34

E.E.S. 400 ............................... 6

econazole ............................... 43

Edarbi .................................... 35

Edarbyclor ............................. 35

Edecrin .................................. 35

Edurant .................................... 2

Effexor XR ............................ 28

ELAPRASE .......................... 52

ELESTAT ............................. 67

Elidel ..................................... 41

Eligard ................................... 13

Eliphos .................................. 74

Elitek ..................................... 11

Elixophyllin ........................... 71

Ellence ................................... 13

Elmiron ................................. 74

Eloxatin ................................. 13

Elspar .................................... 13

Emadine ................................ 67

Emcyt .................................... 13

Emend ................................... 55

Emoquette ............................. 64

Emsam ................................... 28

Emtriva .................................... 2

Enablex ................................. 73

enalapril maleate ................... 35

enalapril-hydrochlorothiazide

........................................... 35

Enbrel .................................... 62

Endocet ................................. 23

Endometrin ............................ 62

Engerix-B (PF) ...................... 60

Enjuvia .................................. 62

enoxaparin ............................. 38

Enpresse ................................ 64

Entocort EC ........................... 55

Enulose .................................. 55

epinastine .............................. 67

epinephrine HCl .................... 70

EpiPen ................................... 70

EpiPen Jr ............................... 70

epirubicin .............................. 13

Epitol ..................................... 17

Epivir ....................................... 2

Epivir HBV ............................. 2

eplerenone ............................. 35

Epogen .................................. 58

Page 82 of 89

eprosartan .............................. 35

Epzicom .................................. 2

Equetro .................................. 17

Eraxis(Water Diluent) ............. 1

Erbitux ................................... 13

ergoloid ................................. 28

ergotamine-caffeine .............. 21

Erivedge ................................ 13

Errin ...................................... 62

Ery Pads ................................ 42

EryPed 200 .............................. 6

Ery-Tab ................................... 6

Erythrocin................................ 6

Erythrocin Stearate .................. 6

erythromycin ..................... 6, 66

erythromycin ethylsuccinate ... 6

erythromycin with ethanol .... 42

erythromycin-benzoyl peroxide

........................................... 42

escitalopram .......................... 28

Estrace ................................... 62

estradiol ........................... 62, 63

estradiol valerate ................... 63

estradiol-norethindrone acet .. 63

Estring ................................... 63

estropipate ............................. 63

ethambutol ............................... 7

ethosuximide ......................... 17

etidronate disodium ............... 47

etodolac ................................. 25

Etopophos.............................. 13

etoposide ............................... 13

Eurax ..................................... 46

Evamist.................................. 63

Evista ..................................... 62

Evoxac ................................... 47

Exelderm ............................... 43

Exelon ................................... 21

exemestane ............................ 13

Exforge .................................. 35

Exforge HCT ......................... 35

Exjade.................................... 47

Extina .................................... 43

Fabrazyme ............................. 52

Factive ................................... 10

famciclovir .............................. 2

famotidine ............................. 57

famotidine (PF) ..................... 57

famotidine (PF)-NaCl (iso-os)

........................................... 57

Fanapt ................................... 28

Fareston ................................ 13

Faslodex ................................ 13

FazaClo ................................. 28

felbamate .............................. 17

Felbatol ................................. 17

felodipine .............................. 35

Femara .................................. 13

Femcon Fe ............................ 64

Femhrt 1/5 ............................ 63

Femhrt Low Dose ................. 63

Femring ................................. 63

fenofibrate ............................. 39

fenofibrate micronized .......... 39

fenoprofen ............................. 25

fentanyl ................................. 23

fentanyl citrate ...................... 23

Fibricor ................................. 39

Finacea .................................. 42

finasteride ............................. 73

Flagyl ER ................................ 7

Flarex .................................... 69

flavoxate ............................... 73

flecainide .............................. 32

Flovent HFA ......................... 71

fluconazole ............................. 1

fluconazole in dextrose(iso-o) 1

flucytosine .............................. 1

fludarabine ............................ 13

fludrocortisone ...................... 49

flunisolide ............................. 71

fluocinolone .......................... 45

fluocinolone acetonide oil .... 48

fluocinonide .......................... 45

Fluocinonide-E ..................... 45

Fluoroplex ............................. 41

fluorouracil ..................... 13, 41

fluoxetine .............................. 28

fluphenazine decanoate ........ 28

fluphenazine HCl .................. 28

flurbiprofen ........................... 25

flurbiprofen sodium .............. 68

flutamide ............................... 13

fluticasone ....................... 45, 71

fluvastatin ............................. 39

fluvoxamine .......................... 28

FML Forte ............................ 69

FML S.O.P. ........................... 69

Focalin .................................. 28

Focalin XR ............................ 28

fomepizole ............................. 60

fondaparinux ......................... 38

Fortaz ...................................... 5

Fortaz in D5W ......................... 5

Forteo .................................... 62

FORTICAL ........................... 52

Fosamax Plus D .................... 62

foscarnet .................................. 2

fosinopril ............................... 35

fosinopril-hydrochlorothiazide

........................................... 35

fosphenytoin .......................... 17

FOSRENOL .......................... 47

Fragmin ................................. 38

Freamine III 3 %-Electrolytes

........................................... 76

Freamine III 8.5 % ................ 76

Furadantin ............................. 11

furosemide ............................. 35

Fusilev ................................... 11

Fuzeon ..................................... 2

gabapentin ............................. 18

Gabitril .................................. 18

galantamine ........................... 21

Gammagard Liquid ............... 60

Gamunex-C ........................... 60

ganciclovir ............................... 2

ganciclovir sodium .................. 2

Gardasil (PF) ......................... 60

Gastrocrom ............................ 55

Gavilyte-C ............................. 55

GaviLyte-N ........................... 55

gemcitabine ........................... 13

gemfibrozil ............................ 40

Gemzar .................................. 13

Gengraf ................................. 14

Genotropin ............................ 58

Genotropin Miniquick ........... 58

Gentak ................................... 66

gentamicin ................... 7, 43, 66

gentamicin in NaCl (iso-osm) . 7

gentamicin sulfate (PF) ........... 7

Geodon .................................. 28

Gianvi .................................... 64

Gleevec ................................. 14

glimepiride ............................ 50

glipizide ................................. 50

glipizide-metformin .............. 50

GlucaGen HypoKit ............... 50

Glucagon Emergency ............ 50

Page 83 of 89

glyburide ............................... 50

glyburide micronized ............ 50

glyburide-metformin ............. 50

glycopyrrolate ....................... 54

Golytely ................................. 55

Gralise ................................... 18

Gralise 30-Day Starter Pack .. 18

granisetron ............................. 55

granisetron (PF)..................... 55

Granisol ................................. 55

griseofulvin microsize ............. 1

Gris-PEG ................................. 1

guanfacine ............................. 35

Halaven ................................. 14

Haldol .................................... 29

Haldol Decanoate .................. 29

halobetasol propionate .......... 45

Halog ..................................... 45

haloperidol ............................ 29

haloperidol decanoate ........... 29

haloperidol lactate ................. 29

Havrix (PF) ........................... 60

Hectorol ................................. 52

Helidac .................................. 57

heparin (porcine) ................... 38

heparin (porcine) in D5W ..... 38

heparin (porcine) in NaCl (PF)

........................................... 39

heparin(porcine) in 0.45%

NaCl .................................. 39

Hepatamine 8% ..................... 76

Hepatasol 8 % ....................... 76

Hepsera.................................... 2

Herceptin ............................... 14

Hexalen ................................. 14

huber safety needles (disp.) ... 50

Humalog ................................ 50

Humalog KwikPen ................ 50

Humalog Mix 50-50 .............. 50

Humalog Mix 50-50 KwikPen

........................................... 50

Humalog Mix 75-25 .............. 50

Humalog Mix 75-25 KwikPen

........................................... 51

Humatrope ............................. 58

Humira .................................. 62

Humira Crohn's Dis Start Pck

........................................... 62

Hycamtin ............................... 14

hydralazine ............................ 35

hydrochlorothiazide .............. 35

hydrocodone-acetaminophen 23

hydrocodone-ibuprofen ........ 23

hydrocortisone .......... 45, 49, 55

hydrocortisone valerate ........ 45

hydrocortisone-acetic acid .... 48

hydromorphone ..................... 23

hydromorphone (PF) ............ 23

hydroxychloroquine ................ 7

hydroxyurea .......................... 14

hydroxyzine HCl .................. 70

hydroxyzine pamoate ............ 70

Hyzaar ................................... 35

ibandronate ........................... 62

ibuprofen ............................... 25

ibuprofen-oxycodone ............ 23

idarubicin .............................. 14

Ifex ........................................ 14

ifosfamide ............................. 14

imipenem-cilastatin ................ 7

imipramine HCl .................... 29

imipramine pamoate ............. 29

imiquimod ............................. 41

Incivek .................................... 2

Increlex ................................. 47

indapamide ........................... 35

Indocin .................................. 25

indomethacin ........................ 25

Infanrix (PF) ......................... 60

Infergen ................................. 58

Inlyta ..................................... 14

Insulin Pen Needle ................ 51

insulin syringe-needle U-100 51

Intelence ................................. 2

Intralipid ............................... 76

Intron A ................................ 58

Introvale ................................ 64

Intuniv ER ............................ 29

Invanz ..................................... 7

Invega ................................... 29

Invega Sustenna .................... 29

Invirase ................................... 2

Ionosol-B in D5W ................ 76

Ionosol-MB in D5W ............. 76

Iopidine ................................. 69

IPOL ..................................... 60

ipratropium bromide ....... 48, 72

ipratropium-albuterol ............ 72

irbesartan .............................. 35

irbesartan-hydrochlorothiazide

........................................... 35

irinotecan ............................... 14

Isentress ................................... 2

Isolyte-H in D5W .................. 76

Isolyte-P in D5W .................. 76

Isolyte-S ................................ 76

Isolyte-S in D5W .................. 76

isoniazid .................................. 7

Isopto Carpine ....................... 67

isosorbide dinitrate ................ 40

isosorbide mononitrate .......... 40

isradipine ............................... 35

itraconazole ............................. 1

Ixempra ................................. 14

Ixiaro (PF) ............................. 61

Jakafi ..................................... 14

Jalyn ...................................... 74

Jantoven ................................ 39

Janumet ................................. 51

Janumet XR ........................... 51

Januvia .................................. 51

Jentadueto ............................. 51

Jevtana ................................... 14

Jinteli ..................................... 63

Jolivette ................................. 63

Junel 1.5/30 (21) ................... 64

Junel 1/20 (21) ...................... 64

Junel FE 1.5/30 (28) .............. 64

Junel FE 1/20 (28) ................. 64

Kaletra ..................................... 2

kanamycin ............................... 7

Kariva .................................... 64

Kelnor 1/35 (28) .................... 64

Kenalog ................................. 45

Kepivance ............................. 11

Keppra ................................... 18

Keppra XR ............................ 18

KETEK ................................... 7

ketoconazole ..................... 1, 43

ketoprofen ............................. 25

ketorolac .......................... 25, 68

Kineret ................................... 62

Kionex ................................... 47

Klor-Con ............................... 74

Klor-Con 10 .......................... 74

Klor-Con M15 ....................... 74

Klor-Con M20 ....................... 74

Kombiglyze XR .................... 51

Kuvan .................................... 52

Page 84 of 89

labetalol ................................. 35

LAClotion ............................. 41

lactated ringers ................ 46, 74

lactulose ................................ 55

Lamictal ................................ 18

Lamictal Starter (Blue) Kit ... 18

Lamictal Starter (Green) Kit . 18

Lamictal Starter (Orange) Kit18

Lamictal XR .......................... 18

Lamictal XR Starter (Blue) ... 18

Lamictal XR Starter (Green) . 18

Lamictal XR Starter (Orange)

........................................... 18

lamivudine ............................... 2

lamivudine-zidovudine............ 3

lamotrigine ............................ 18

Lanoxin Pediatric .................. 38

lansoprazole .......................... 57

Lantus .................................... 51

Lantus Solostar ...................... 51

latanoprost ............................. 68

Latuda.................................... 29

Leena 28 ................................ 65

leflunomide ........................... 62

Lessina .................................. 65

letrozole ................................. 14

leucovorin calcium .......... 11, 12

Leukeran................................ 14

Leukine............................ 58, 59

leuprolide .............................. 14

levalbuterol HCl .................... 72

Levaquin................................ 10

Levaquin in D5W .................. 10

Levatol .................................. 35

Levemir ................................. 51

Levemir Flexpen ................... 51

levetiracetam ................... 18, 19

levobunolol............................ 67

levocarnitine .......................... 47

levocarnitine (with sugar) ..... 47

levocetirizine ......................... 70

levofloxacin ..................... 10, 66

levofloxacin in D5W ............. 10

Levora-28 .............................. 65

levorphanol tartrate ............... 23

levothyroxine ........................ 53

Levoxyl ................................. 53

Lexapro ................................. 29

Lexiva...................................... 3

Lialda .................................... 55

lidocaine ............................... 42

lidocaine (PF) ....................... 42

lidocaine HCl ........................ 42

lidocaine-prilocaine .............. 42

Lidoderm .............................. 42

lindane .................................. 46

liothyronine ........................... 53

lisinopril ................................ 35

lisinopril-hydrochlorothiazide

.......................................... 36

lithium carbonate .................. 29

lithium citrate ........................ 29

Locoid ................................... 45

Lodosyn ................................ 20

Loestrin 24 Fe ....................... 65

loperamide ............................ 54

loratadine .............................. 77

losartan ................................. 36

losartan-hydrochlorothiazide 36

Lotemax ................................ 69

Lotronex ............................... 55

lovastatin ............................... 40

Lovaza .................................. 40

Lovenox ................................ 39

Low-Ogestrel (28) ................ 65

loxapine succinate ................ 29

Lufyllin ................................. 72

Lumigan ................................ 68

Lunesta ................................. 29

Lupron Depot ........................ 14

Lupron Depot (3 Month) ...... 14



Lupron Depot-Ped ................ 14

Lupron Depot-Ped (3 Month) 14

Lutera (28) ............................ 65

Luvox CR ............................. 29

Lybrel ................................... 65

Lyrica .................................... 19

Lysodren ............................... 14

Macrodantin .......................... 11

Magnacet .............................. 23

magnesium sulfate ................ 74

Malarone ................................. 7

malathion .............................. 46

maprotiline ............................ 29

Marlissa ................................ 65

Marplan ................................. 29

Matulane ............................... 14

Maxair Autohaler .................. 72

Maxalt ................................... 21

Maxalt-MLT ......................... 21

Maxidex ................................ 69

meclizine ............................... 55

meclofenamate ...................... 25

medroxyprogesterone ............ 63

mefenamic acid ..................... 25

mefloquine .............................. 7

megestrol ............................... 14

meloxicam ............................. 25

melphalan .............................. 14

Menest ................................... 63

Menomune - A/C/Y/W-135

(PF) ................................... 61

Menostar ............................... 63

Menveo A-C-Y-W-135-Dip

(PF) ................................... 61

meperidine ............................. 23

meperidine (PF) .................... 23

meprobamate ......................... 22

Mepron .................................... 7

mercaptopurine ..................... 14

meropenem .............................. 7

Merrem .................................... 7

mesalamine-cleansing wipes . 55

mesna .................................... 12

Mesnex .................................. 12

Mestinon ............................... 22

Mestinon Timespan ............... 22

Metadate CD ......................... 29

Metadate ER .......................... 29

metaproterenol ...................... 72

metformin .............................. 51

methadone ....................... 23, 24

Methadose ............................. 24

methamphetamine ................. 29

methazolamide ...................... 68

methenamine hippurate ......... 11

Methergine ............................ 66

methimazole .......................... 50

Methitest ............................... 52

methocarbamol ...................... 22

methotrexate sodium ............. 14

methotrexate sodium (PF) .... 14,

15

methscopolamine .................. 54

methyclothiazide ................... 36

methyldopa ............................ 36

methyldopa-

hydrochlorothiazide .......... 36

Page 85 of 89

methyldopate ......................... 36

methylergonovine.................. 66

Methylin ................................ 30

methylphenidate .................... 30

methylprednisolone ............... 49

methylprednisolone acetate ... 49

methylprednisolone sodium

succ.................................... 49

metipranolol .......................... 67

metoclopramide HCl ............. 55

metolazone ............................ 36

metoprolol succinate ............. 36

metoprolol ta-hydrochlorothiaz

........................................... 36

metoprolol tartrate ................. 36

Metrogel ................................ 42

metronidazole .............. 7, 42, 64

metronidazole in NaCl (iso-os)

............................................. 7

mexiletine .............................. 32

Miacalcin ............................... 52

Micardis ................................ 36

Micardis HCT ....................... 36

Miconazole-3 ........................ 64

Microgestin 1.5/30 (21)......... 65

Microgestin 1/20 (21)............ 65

Microgestin Fe 1.5/30 (28) .... 65

Microgestin FE 1/20 (28) ...... 65

midodrine .............................. 47

Migergot ................................ 21

Migranal ................................ 21

Millipred................................ 49

Minitran ................................. 40

minocycline ........................... 11

minoxidil ............................... 36

Mirapex ................................. 20

Mirapex ER ........................... 20

mirtazapine ............................ 30

misoprostol ............................ 57

mitomycin ............................. 15

mitoxantrone ......................... 15

M-M-R II (PF) ...................... 61

moexipril ............................... 36

moexipril-hydrochlorothiazide

........................................... 36

mometasone .................... 45, 46

Mononessa (28) ..................... 65

Monurol ................................. 11

morphine ............................... 24

morphine concentrate ............ 24

Motofen ................................ 54

MoviPrep .............................. 55

Moxatag .................................. 9

Moxeza ................................. 67

Multaq ................................... 32

mupirocin .............................. 43

Mustargen ............................. 15

Mycamine ............................... 1

Mycobutin ............................... 7

mycophenolate mofetil ......... 15

Myfortic ................................ 15

Myozyme .............................. 52

Mytelase ............................... 21

nabumetone ........................... 25

nadolol .................................. 36

nadolol-bendroflumethiazide 36

nafcillin ................................... 9

nafcillin in D2.4W .................. 9

Naglazyme ............................ 52

nalbuphine ............................ 25

Nalfon ................................... 25

naloxone ............................... 25

naltrexone ............................. 25

Namenda ............................... 21

Namenda Titration Pak ......... 21

naproxen ......................... 25, 26

naproxen sodium .................. 26

Nardil .................................... 30

Nasacort AQ ......................... 72

Nasonex ................................ 72

Natacyn ................................. 67

nateglinide ............................ 51

Nebupent ................................. 7

Necon 0.5/35 (28) ................. 65

Necon 1/35 (28) .................... 65

Necon 10/11 (28) .................. 65

Necon 7/7/7 (28) ................... 65

nefazodone ............................ 30

neomycin ................................ 8

neomycin-bacitracin-poly-HC

.......................................... 68


polymyxin ......................... 67

neomycin-polymyxin B GU . 46

neomycin-polymyxin-dexameth

.......................................... 68

neomycin-polymyxin-

gramicidin ......................... 67

neomycin-polymyxin-HC49, 68

Neoral ................................... 15

Nephramine 5.4 % ................ 76

Neulasta ................................. 59

Neumega ............................... 59

Neupogen .............................. 59

Neurontin .............................. 19

Nevanac ................................. 68

nevirapine ................................ 3

Nexavar ................................. 15

Niacor .................................... 40

Niaspan Extended-Release .... 40

nicardipine ............................. 36

Nicotrol ................................. 48

Nicotrol NS ........................... 48

Nifediac CC .......................... 36

Nifedical XL ......................... 36

nifedipine .............................. 36

Nilandron .............................. 15

nimodipine ............................ 36

nisoldipine ............................. 36

Nitro-Bid ............................... 40

nitrofurantoin ........................ 11

nitrofurantoin macrocrystal ... 11

nitrofurantoin monohyd/m-

cryst ................................... 11

nitroglycerin .......................... 40

Nitrolingual ........................... 40

Nitrostat ................................. 41

nizatidine ............................... 57

Non-Drowsy Allergy ............ 77

Nora-BE ................................ 63

Norditropin FlexPro .............. 59

Norditropin Nordiflex ........... 59

norethindrone acetate ............ 63

Normosol-R in D5W ............. 75

Normosol-R pH 7.4 ............... 76

Noroxin ................................. 10

Nortrel 0.5/35 (28) ................ 65

Nortrel 1/35 (21) ................... 65

Nortrel 1/35 (28) ................... 65

Nortrel 7/7/7 (28) .................. 65

nortriptyline ........................... 30

Norvir ...................................... 3

Novolin 70/30 ....................... 51

Novolin N .............................. 51

Novolin R .............................. 51

Novolog ................................. 51

Novolog Flexpen ................... 51

Novolog Mix 70-30 ............... 51

Novolog Mix 70-30 FlexPen 51

Nulojix .................................. 15

Page 86 of 89

NuLYTELY with Flavor Packs

........................................... 55

Nutropin ................................ 59

Nutropin AQ ......................... 59

Nutropin AQ Nuspin ............. 59

Nyamyc ................................. 43

nystatin .............................. 1, 43

nystatin-triamcinolone .......... 43

Nystop ................................... 44

Ocella .................................... 65

octreotide acetate ................... 15

ofloxacin.................... 10, 48, 67

Ogestrel (28) ......................... 65

olanzapine ............................. 30

omeprazole ...................... 57, 77

omeprazole magnesium......... 77

Omnaris ................................. 72

Omnitrope ............................. 59

ondansetron ........................... 55

ondansetron HCl ................... 55

ondansetron HCl (PF) ........... 56

Onfi ....................................... 19

Onglyza ................................. 51

Ontak ..................................... 15

Opana .................................... 24

Opana ER .............................. 24

Oracea ................................... 11

Orap ....................................... 30

Orapred ODT ........................ 49

Orfadin .................................. 47

orphenadrine citrate ............... 22

Orphenadrine Compound ...... 22

Orphenadrine Compound-DS 22

Orsythia ................................. 65

Ortho Tri-Cyclen Lo ............. 65

OsmoPrep .............................. 56

OTC-PRODUCT ................... 69

Ovcon-50 (28) ....................... 65

oxacillin ................................... 9

oxacillin in dextrose, iso-osm . 9

oxaliplatin.............................. 15

oxandrolone ........................... 52

oxaprozin ............................... 26

oxcarbazepine ........................ 19

Oxsoralen .............................. 41

Oxsoralen Ultra ..................... 41

oxybutynin chloride .............. 73

oxycodone ............................. 24

oxycodone-acetaminophen .... 24

oxycodone-aspirin ................. 24

oxymorphone ........................ 24

Pacerone ............................... 32

paclitaxel ............................... 15

PALGIC ................................ 70

pamidronate .......................... 53

Pancreaze .............................. 56

Panretin ................................. 41

pantoprazole ......................... 57

paromomycin .......................... 8

paroxetine HCl ...................... 30

Paser ....................................... 8

Pataday ................................. 68

Patanase ................................ 48

Patanol .................................. 68

Paxil ...................................... 30

Pedi-Dri ................................ 44

Pedvax HIB (PF) .................. 61

Peganone ............................... 19

Pegasys ................................. 59

Pegasys Convenience Pack ... 59

Pegasys ProClick .................. 59

PegIntron .............................. 59

PegIntron Redipen ................ 59

penicillin G pot in dextrose .... 9

penicillin G potassium ............ 9

penicillin G procaine .............. 9

penicillin G sodium ................ 9

penicillin V potassium ............ 9

Pentam .................................... 8

Pentasa .................................. 56

pentazocine-acetaminophen . 26

pentazocine-naloxone ........... 26

pentostatin ............................. 15

pentoxifylline ........................ 39

Pepcid ................................... 57

Perforomist ........................... 72

Periogard ............................... 48

permethrin ............................. 46

perphenazine ......................... 30

perphenazine-amitriptyline ... 30

PEXEVA .............................. 30

Pfizerpen-G ............................. 9

Phenadoz ............................... 70

phenelzine ............................. 30

phenobarbital ........................ 19

Phenytek ............................... 19

phenytoin .............................. 19

phenytoin sodium ................. 19

phenytoin sodium extended .. 19

Phisohex ............................... 43

Phospholine Iodide ................ 67

pilocarpine HCl ..................... 47

Pilopine HS ........................... 67

pindolol ................................. 36

piperacillin-tazobactam ........... 9

piroxicam .............................. 26

Plasma-Lyte 148 ................... 76

Plasma-Lyte A ...................... 76

Plasma-Lyte-56 in D5W ....... 76

Plavix .................................... 39

podofilox ............................... 41

polyethylene glycol 3350 ...... 56

polymyxin B sulfate ................ 8

Portia ..................................... 65

potassium chloride ................ 75

Potiga .................................... 19

Pradaxa .................................. 39

pramipexole ........................... 20

Prandimet .............................. 51

Prandin .................................. 51

pravastatin ............................. 40

prazosin ................................. 37

Pred-G ................................... 68

Pred-G S.O.P. ........................ 68

prednicarbate ......................... 46

prednisolone acetate .............. 69

prednisolone sodium phosphate

..................................... 49, 69

prednisone ............................. 49

Prednisone Intensol ............... 49

Premarin ................................ 63

Premasol 10 % ...................... 76

Premasol 6 % ........................ 76

Premphase ............................. 63

Prempro ................................. 63

Prenatal Plus with Iron (Ca) .. 76

Prevacid 24Hr ....................... 77

Prevacid SoluTab .................. 57

Prevalite ................................ 40

Previfem ................................ 65

Prevpac .................................. 57

Prezista .................................... 3

Priftin ...................................... 8

Prilosec OTC ......................... 77

primaquine .............................. 8

Primaxin IV ............................. 8

primidone .............................. 19

Primsol .................................. 11

Pristiq .................................... 30

ProAir HFA ........................... 72

Page 87 of 89

probenecid ............................. 61

procainamide ......................... 32

Procalamine 3% .................... 76

prochlorperazine .................... 56

prochlorperazine Edisylate .... 56

prochlorperazine maleate ...... 56

Procrit .................................... 59

progesterone micronized ....... 63

Proglycem ............................. 51

Prograf ................................... 15

Prolastin C ............................. 47

Proleukin ............................... 59

Promacta................................ 39

promethazine ......................... 70

Promethegan.......................... 70

propafenone ........................... 32

propantheline ......................... 54

proparacaine .......................... 68

propranolol ............................ 37

propranolol-hydrochlorothiazid

........................................... 37

propylthiouracil ..................... 50

ProQuad (PF) ........................ 61

Prosol 20% ............................ 76

Protonix ................................. 57

Protopic ................................. 41

protriptyline ........................... 30

Proventil HFA ....................... 72

Provigil .................................. 30

Prozac Weekly ...................... 30

Pulmicort ............................... 72

Pulmicort Flexhaler ............... 72

Pulmozyme............................ 72

Pylera .................................... 57

pyridostigmine bromide ........ 22

Qualaquin ................................ 8

Quasense ............................... 66

quetiapine .............................. 31

quinapril ................................ 37

quinapril-hydrochlorothiazide

........................................... 37

quinidine gluconate ............... 32

quinidine sulfate .................... 32

Qvar ....................................... 72

RabAvert (PF) ....................... 61

ramipril .................................. 37

Ranexa ................................... 40

ranitidine HCl ........................ 57

Rapamune.............................. 15

REBETOL ............................... 3

Rebif ..................................... 59

Rebif Titration Pack ............. 60

Reclipsen (28) ....................... 66

Recombivax HB (PF) ........... 61

Rectiv .................................... 56

Regonol ................................. 22

Relenza Diskhaler ................... 3

Relistor ................................. 56

Remicade .............................. 56

Remodulin ............................ 37

Renagel ................................. 47

Renvela ................................. 47

Reprexain .............................. 24

Rescriptor ............................... 3

reserpine ............................... 37

Restasis ................................. 68

Retrovir ................................... 3

Revatio .................................. 72

REVLIMID ........................... 15

Reyataz ................................... 3

Rheumatrex ........................... 15

RibaPak Dose Pack ................. 3

Ribasphere .............................. 3

ribavirin .................................. 3

Ridaura ................................. 62

rifampin .................................. 8

Rifater ..................................... 8

Rilutek .................................. 47

rimantadine ............................. 3

ringers ............................. 46, 75

RIOMET ............................... 52

Risperdal Consta ................... 31

Risperdal M-TAB ................. 31

risperidone ............................ 31

Rituxan ................................. 15

rivastigmine .......................... 22

ropinirole .............................. 20

RotaTeq Vaccine .................. 61

Roxicet .................................. 24

Rozerem ................................ 31

Sabril ..................................... 19

Saizen ................................... 60

Saizen click.easy ................... 60

Sanctura ................................ 73

Sanctura XR .......................... 73

Sandimmune ......................... 15

Santyl .................................... 46

Saphris .................................. 31

Sarafem ................................. 31

Seasonique ............................ 66

selegiline HCl ........................ 20

selenium sulfide .................... 41

Selzentry ................................. 3

Sensipar ................................. 53

Serevent Diskus .................... 72

Seromycin ............................... 8

Seroquel ................................ 31

Seroquel XR .......................... 31

Serostim ................................ 60

sertraline ................................ 31

silver sulfadiazine ................. 41

Simulect ................................ 15

simvastatin ............................ 40

Singulair ................................ 72

Skelaxin ................................. 22

Skelid .................................... 47

sodium chloride ............... 47, 75

sodium chloride 0.45 % ........ 75

sodium chloride 0.9 % .......... 48

sodium chloride 3 % ............. 75

sodium chloride 5 % ............. 75

sodium fluoride ..................... 76

sodium lactate ....................... 75

Solaraze ................................. 41

Solu-Cortef (PF) .................... 49

Solu-Medrol .......................... 49

Solu-Medrol (PF) .................. 50

Soma ..................................... 22

Somatuline Depot .................. 15

SOMAVERT ......................... 53

Soriatane ............................... 41

Sorine .................................... 33

sotalol .................................... 33

Spiriva with HandiHaler ....... 72

spironolactone ....................... 37

spironolacton-hydrochlorothiaz

........................................... 37

Sporanox ................................. 1

Sprintec (28) .......................... 66

Sprycel .................................. 16

Sronyx ................................... 66

SSD ....................................... 41

Stagesic ................................. 24

Stalevo 100 ............................ 20

Stalevo 125 ............................ 20

Stalevo 150 ............................ 20

Stalevo 200 ............................ 20

Stalevo 50 .............................. 20

Stalevo 75 .............................. 20

stavudine ................................. 3

Page 88 of 89

Stavzor .................................. 19

Stimate .................................. 53

Strattera ................................. 31

streptomycin ............................ 8

Striant .................................... 53

Stromectol ............................... 8

Suboxone ............................... 26

Sucraid .................................. 56

sucralfate ............................... 57

Sular ...................................... 37

sulfacetamide sodium ............ 69

sulfacetamide sodium (acne) . 43

sulfacetamide-prednisolone .. 69

sulfadiazine ........................... 10

sulfamethoxazole-trimethoprim

........................................... 10

Sulfamylon ............................ 43

sulfasalazine .......................... 56

Sulfazine EC ......................... 56

sulindac ................................. 26

sumatriptan succinate ............ 21

Suprax ..................................... 5

Surmontil ............................... 31

Sustiva ..................................... 3

Sutent .................................... 16

Sylatron ................................. 60

Symbicort .............................. 72

Symbyax................................ 31

SymlinPen 120 ...................... 52

SymlinPen 60 ........................ 52

Synagis .................................... 3

Synarel .................................. 53

Synera.................................... 42

Synercid .................................. 8

Synthroid ............................... 53

Syprine .................................. 48

Tabloid .................................. 16

Taclonex Scalp ...................... 41

tacrolimus .............................. 16

Talwin ................................... 26

Tamiflu .................................... 3

tamoxifen .............................. 16

tamsulosin ............................. 74

Tarceva .................................. 16

Targretin ................................ 16

Tasigna .................................. 16

Tasmar ................................... 20

Tazorac .................................. 42

Taztia XT .............................. 37

Teflaro ..................................... 5

Tegretol XR .......................... 19

Tekturna ................................ 37

Tekturna HCT ....................... 37

terazosin ................................ 37

terbinafine ............................... 1

terbutaline ....................... 72, 73

terconazole ............................ 64

Testim ................................... 53

testosterone cypionate .......... 53

testosterone enanthate ........... 53

Testred .................................. 53

tetanus-diphtheria toxoids-Td61

tetracycline ........................... 11

Tev-Tropin ............................ 60

Thalitone ............................... 37

Thalomid ............................... 16

theophylline .......................... 73

thioridazine ........................... 31

thiotepa ................................. 16

thiothixene ............................ 31

Thymoglobulin ..................... 61

ticlopidine ............................. 39

Tikosyn ................................. 33

Timentin ............................... 10

timolol maleate ............... 37, 67

tizanidine .............................. 22

Tobi ......................................... 8

TobraDex .............................. 68

tobramycin in NS .................... 8

tobramycin sulfate ............ 8, 67

tobramycin-dexamethasone .. 69

Tobrex ................................... 67

Tofranil-PM .......................... 31

tolazamide ............................. 52

tolbutamide ........................... 52

tolmetin ................................. 26

Topamax ............................... 19

topiramate ............................. 19

topotecan ............................... 16

Torisel ................................... 16

torsemide .............................. 37

Tracleer ................................. 73

Tradjenta ............................... 52

tramadol ................................ 26

tramadol-acetaminophen ...... 26

trandolapril ........................... 37

tranylcypromine .................... 31

Travasol 10 % ....................... 76

Travatan Z ............................ 68

trazodone .............................. 31

Treanda ................................. 16

Trecator ................................... 8

Trelstar .................................. 16

tretinoin ................................. 42

tretinoin (chemotherapy) ....... 16

Trexall ................................... 16

triamcinolone acetonide . 46, 48,

73

triamterene-hydrochlorothiazid

........................................... 37

Triderm ................................. 46

trifluoperazine ....................... 31

trifluridine ............................. 67

trihexyphenidyl ..................... 21

Tri-Legest Fe ......................... 66

Trileptal ................................. 19

TriLyte With Flavor Packets . 56

trimethobenzamide ................ 56

trimethoprim ......................... 11

trimethoprim-polymyxin B ... 67

trimipramine .......................... 31

TriNessa (28) ........................ 66

Tri-Previfem (28) .................. 66

Trisenox ................................ 16

Tri-Sprintec (28) ................... 66

Trivora (28) ........................... 66

Trizivir .................................... 3

TrophAmine 10 % ................. 76

Trophamine 6% ..................... 76

tropicamide ........................... 67

trospium ................................ 73

Truvada ................................... 3

Twinject Autoinjector ........... 70

Twinrix (PF) .......................... 61

Tygacil .................................... 8

Tykerb ................................... 16

Typhim VI ............................. 61

TYSABRI ............................. 22

Tyzeka ..................................... 4

Tyzine ................................... 48

U-Cort ................................... 41

Uroxatral ............................... 74

URSO 250 ............................. 56

URSO Forte .......................... 56

ursodiol ................................. 56

Uvadex .................................. 41

valacyclovir ............................. 4

Valcyte .................................... 4

valproate sodium ................... 19

valproic acid .......................... 19

Page 89 of 89

valproic acid (as sodium salt) 19

Valtrex ..................................... 4

Vancocin ............................... 11

vancomycin ........................... 11

Vandazole.............................. 64

Vaqta (PF) ............................. 61

Varivax (PF) .......................... 61

Vectibix ................................. 16

Velcade.................................. 16

Velivet ................................... 66

venlafaxine ...................... 31, 32

Ventavis ................................ 73

Ventolin HFA ........................ 73

verapamil ............................... 38

Veregen ................................. 41

Veripred 20 ........................... 50

Vesicare ................................. 73

Vestura .................................. 66

Vexol ..................................... 69

Vfend ....................................... 1

Vfend IV ................................. 1

Vibramycin............................ 11

Victoza .................................. 52

Victrelis ................................... 4

Vidaza ................................... 16

Videx 2 gram Pediatric ........... 4

Videx EC ................................. 4

Vigamox ................................ 67

Viibryd .................................. 32

Vimpat ............................. 19, 20

vinblastine ............................. 16

vincristine .............................. 16

vinorelbine ............................ 16

Viracept ................................... 4

Viramune ................................. 4

Viramune XR .......................... 4

Viread ..................................... 4

Viroptic ................................. 67

Vistide ..................................... 4

Vivelle-Dot ........................... 63

Vivitrol ................................. 26

Voltaren ................................ 26

voriconazole ........................... 1

Votrient ................................. 16

Vytorin 10-10 ....................... 40

Vytorin 10-20 ....................... 40

Vytorin 10-40 ....................... 40

Vytorin 10-80 ....................... 40

Vyvanse ................................ 32

Wal-itin ................................. 77

Wal-Zyr ................................ 77

warfarin ................................. 39

water for irrigation, sterile .... 48

WelChol ................................ 40

Xalatan .................................. 68

Xalkori .................................. 16

Xenazine ............................... 22

Xgeva .................................... 12

Xifaxan ................................... 8

Xolair .................................... 73

Xopenex ................................ 73

Xopenex HFA ....................... 73

Xyrem ................................... 32

Xyzal ..................................... 71

Yervoy .................................. 16

YF-Vax (PF) ......................... 61

zafirlukast ............................. 73

zaleplon ................................. 32

Zanaflex ................................ 22

Zanosar ................................. 16

ZAVESCA ............................ 53

ZAZOLE ............................... 64

Zelapar .................................. 21

Zelboraf ................................. 16

Zemaira ................................. 48

Zemplar ................................. 53

Zenpep ................................... 56

Zeosa ..................................... 66

Zerit ......................................... 4

Zetia ...................................... 40

Ziagen ..................................... 4

zidovudine ............................... 4

Zinacef in Sterile Water .......... 5

Zinecard ................................ 12

ziprasidone HCl .................... 32

Zirgan .................................... 67

Zmax ....................................... 6

Zolinza .................................. 16

zolpidem ................................ 32

Zometa .................................. 53

zonisamide ............................ 20

Zorbtive ................................. 60

Zortress ................................. 17

ZOSTAVAX (PF) ................. 61

Zosyn ..................................... 10

Zosyn in dextrose (iso-osm) .. 10

Zovia 1/35E (28) ................... 66

Zovia 1/50E (28) ................... 66

Zovirax .................................. 44

Zyban .................................... 48

Zyflo ...................................... 73

Zyflo CR ............................... 73

Zylet ...................................... 69

Zyprexa ................................. 32

Zyprexa Zydis ....................... 32

Zytiga .................................... 17

Zyvox ...................................... 8

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