Kaiser Permanente Medicare Plus

Kaiser Permanente is a health plan with a Medicare contract.

This information is available for free in other languages. Please contact our customer service number listed on the back cover.

Se puede obtener esta información gratis en otros idiomas. Por favor llame a nuestro número de servicio al cliente que aparece en la contraportada.

此資訊免費以其他語言提供。請聯絡我們的會員服務中心,電話號碼見封底。

This document is available in a different format for the visually impaired by calling our plan at the number listed on the back cover for your Kaiser Permanente Region.

Kaiser Permanente

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.

Members must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium, and/or copayments/coinsurance may change on January 1 of each year.

Y0043_N007514_Final09 approved HPMS Approved Formulary File Submission 00013041, Version 15

Updated 11/2013

What is the Kaiser Permanente formulary?

A formulary is a list of covered drugs selected by our plan 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. Our plan will generally cover the drugs listed on our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed. Our formulary includes all drugs that can be covered under Medicare Part D according to Medicare requirements. 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, 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 (FDA) 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 November 1, 2013. To get updated information about the drugs covered by our plan, please visit our Web site at kp.org/seniormedrx or call our plan at the number listed on the back cover for your Kaiser Permanente Region.

In the event of a midyear nonmaintenance formulary change, we will provide details in the Provision of Notice and in the Kaiser Permanente 2013 Comprehensive Formulary posted at kp.org/seniormedrx.

How do I use the formulary?

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

Medical condition The formulary begins on page 6. The drugs on this formulary are grouped into categories depending on the type of medical conditions that they are used to

Kaiser Permanente 2013 Comprehensive Formulary • 1

http://www.kp.org/seniormedrx


treat. For example, drugs used to treat a heart condition are listed under the category “Cardiovascular Drugs.” If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug.

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 46. The index provides an alphabetical list of all of the drugs included in this document. Preferred generic and brand-name drugs, nonpreferred generic and brand-name drugs, specialty-tier drugs, and injectable vaccines 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?

Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name and specialty-tier drugs. Cost sharing for preferred generic drugs may be different than for nonpreferred generic drugs. Please see your Evidence of Coverage for more information.

What are brand-name drugs?

Brand-name drugs are manufactured and sold by the pharmaceutical company that originally researched and developed the

drug. When the patent on a brand-name drug expires, other pharmaceutical companies may manufacture and sell an FDA-approved generic version of the drug with the same active ingredient(s) at lower prices. Cost sharing for preferred brand-name drugs may be different than for nonpreferred brand-name drugs. Please see your Evidence of Coverage for more information.

What are specialty-tier drugs?

Specialty-tier drugs are very high-cost drugs approved by the FDA that are on our formulary.

What are injectable Part D vaccines?

Part D vaccines are certain injectable vaccines that are covered under Medicare Part D (for example, Zostavax for shingles, Adacel for Diphtheria, Tetanus, and Pertussis, which are approved by the FDA).

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: Our plan may require you or your network provider to get prior authorization for certain drugs. This means that you will need to get approval from our plan before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

2 • Kaiser Permanente 2013 Comprehensive Formulary

Note: If your prescription has more than one refill remaining, you can only get one refill at a time, unless authorized because you will be away from our service area for an extended period of time. For certain drugs, we may limit the amount of an extended day supply (amounts that exceed a 30-day supply) that you can receive. Also, if there is a shortage in the marketplace, we may charge one Part D cost sharing for a limited quantity.

You can find out if your drug has any additional requirements or limits by looking on the formulary that begins on page 6. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site at kp.org/seniormedrx.

You can ask us to make an exception to these restrictions or limits. See the section, “How do I request an exception to the Kaiser Permanente formulary?” on this page for information about how to request an exception.

What if my drug is not on the formulary?

If your drug is not included on this formulary, you should first check for updates to this document at kp.org/seniormedrx or call our plan at the number listed on the back cover for your Kaiser Permanente Region and confirm that your drug is not covered.

In the rare case that your Medicare Part D prescription drug is not on our Kaiser Permanente 2013 Comprehensive Formulary, you have two options:

• You can ask your network provider to prescribe a similar drug that is included on our formulary.

• You can ask us to make an exception and cover your drug. See the next section for information about how to request an exception.

How do I request an exception to the Kaiser Permanente formulary?

You can ask us 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 may not be on our Kaiser Permanente 2013 Comprehensive Formulary.

• You can ask us to waive a prior authorization requirement on your Part D drug.

• You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our nonpreferred brand-name tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred brand-name tier, subject to the tiering exception process. 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 specialty tier (Tier 5), preferred brand-name tier (Tier 3), or the nonpreferred generic tier (Tier 2).




Note: For employer-sponsored group plan members and certain members who get Extra Help from Medicare, tiering exceptions may not apply to your drug plan.

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

You should contact us to ask us for an initial coverage decision about your request for an exception. When you are requesting an exception, you or your network provider should submit a physician statement supporting your request.

Generally, we must make our decision within 72 hours of getting your prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your network provider 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 prescribing physician’s supporting statement.

Please note: You can only request an exception for drugs that are considered Medicare Part D prescription drugs by the Centers for Medicare & Medicaid Services (CMS). You cannot get an exception for drugs that are excluded under Medicare Part D or for obtaining a brand-name drug at the cost sharing that applies to generic drugs. Please refer to your Evidence of Coverage for more information about

requesting exceptions, including the appeals process.

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

In rare cases, you might be taking Medicare Part D 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 network provider to decide if you should switch to an appropriate drug that we cover or request an exception so that we will cover the drug you take. While you talk to your network provider 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 Part D drugs that may not be on our formulary or if your ability to get your drugs is limited, we will cover a temporary one-month supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first one-month supply, we may cover an additional refill, as medically necessary. After you have used these refills, we will not pay for these drugs.

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 up to a 98-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 written for fewer days) while you pursue an exception.

As a current member of our plan, if you have a covered inpatient stay in the hospital or in a skilled nursing facility, the drugs you obtain during your stay will be covered under your medical benefit rather than your Medicare Part D prescription drug coverage. When you are discharged home or to a custodial level of care at a long-term care facility, many outpatient prescription drugs you obtain at a pharmacy may be covered under your Medicare Part D coverage. Since your drug coverage is different depending on the setting where you obtain the drug, it is possible that a drug you were taking that was covered under your medical benefit might not be covered by Medicare Part D (for example, over-the-counter drugs, or cough medicine).

If this happens, you will have to pay full price for that drug unless you have other coverage (for example, employer-sponsored group coverage).

For more information

For more detailed information about our prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about our plan, please call us at the number listed on the back cover for your Kaiser Permanente Region. Or visit kp.org/seniormedrx.

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.



http://www.medicare.gov/

Kaiser Permanente’s Formulary

The formulary list that begins on the next page provides coverage information about some of the drugs covered by our plan. If you have trouble finding your drug in the list, turn to the index that begins on page 46.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., ALBENZA) and generic drugs are listed in lower-case italics (e.g., amoxicillin).

The second column, “Drug Tier,” will indicate what tier number the drug is in:

Tier 1 – Preferred generic drugs

Tier 2 – Nonpreferred generic drugs

Tier 3 – Preferred brand-name drugs

Tier 4 – Nonpreferred brand-name drugs

Tier 5 – Specialty-tier drugs

Tier 6 – Injectable Part D vaccines

Generally, the cost sharing you will pay for your drugs depends on your coverage stage, the type of network pharmacy where you purchase your drugs, and your drug’s cost-sharing tier on our formulary. Please refer to your Evidence of Coverage for the details about your Medicare Part D prescription drug coverage, including your cost-sharing amounts.

Note: If your coverage is through an employer-sponsored group plan (including a union or trust fund), you may have different drug benefits and cost sharing, and you may have coverage for other drugs that are not covered by Medicare Part D (non-Part D drugs). The amount you pay for non-Part D drugs does not count toward your total out-of-pocket expenditures, and if you are receiving Extra Help to pay for your Medicare Part D prescription drugs, you will not receive any Extra Help to pay for non-Part D

drugs. Please check with your group benefits administrator or see your Evidence of Coverage.

The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. Certain strengths or forms of the drug may be subject to the utilization management codes listed below.

HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies. For more information, please consult your pharmacy directory or call our plan at the number listed on the back cover for your Kaiser Permanente Region.

LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies. For more information, consult your pharmacy directory or call our plan at the number listed on the back cover for your Kaiser Permanente Region.

MO = Mail-order drugs. You may order prescription refills of certain medications through our mail-order service online at kp.org/rxrefill or by phone or mobile app, which may lower your costs for a three-month supply. Additional drugs may be available for mail order. Not all drugs can be mailed; restrictions and limitations apply. For more information, please contact your pharmacy or the phone number on the prescription label, visit kp.org/seniormedrx, or call our plan at the number listed on the back cover for your Kaiser Permanente Region.

PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (e.g., via infusion pump, nebulizer, or other Durable Medical Equipment device), where they are administered (at home or in a long-term care facility), and what medical condition they are administered for. Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered.


http://www.kp.org/rxrefill


Drug Name Drug Tier

Requirements /Limits

ANTI-INFECTIVE AGENTS ANTHELMINTICS ALBENZA 3 MO BILTRICIDE 3 MO SKLICE 4 STROMECTOL 4 MO ANTI-INFECTIVES, MISCELLANEOUS HELIDAC 4 MO PYLERA 4 MO ANTIBACTERIALS amikacin sulfate 2 HI amoxicillin 2 MO amoxicillin & pot clavulanate 2 MO

AMOXIL DRO 50MG/ML 3 ampicillin 2 MO ampicillin & sulbactam sodium 2 HI

ampicillin sodium 2 HI AUGMENTIN 3 MO AVELOX 3 HI,MO AVELOX ABC PACK 3 MO AZACTAM 3 HI AZACTAM IN ISO-OSMOTIC DEXTROSE 3 HI

azithromycin 2 HI,MO aztreonam 2 HI AZULFIDINE 4 MO AZULFIDINE EN-TABS 4 MO bacitracin 2 BACTOCILL IN DEXTROSE 3 HI

BACTRIM 4 MO BACTRIM DS 4 MO BIAXIN 4 MO BIAXIN XL 4 MO BIAXIN XL PAC 4 MO BICILLIN C-R 4 BICILLIN L-A 3 CAYSTON 5 LD CEDAX 4 MO cefaclor 2 MO cefaclor monohydrate 2 MO cefadroxil 2 MO cefazolin in d5w 2 HI cefazolin sodium 2 HI CEFAZOLIN SODIUM/DEXTROSE 3 HI

Drug Name Drug Tier


cefdinir 2 MO cefepime hcl 2 HI cefixime 2 MO cefotaxime sodium 2 HI cefotetan disodium 2 HI cefoxitin sodium 2 HI CEFOXITIN SODIUM 3 HI cefpodoxime proxetil 2 MO cefprozil 2 MO ceftazidime 2 HI CEFTAZIDIME/ DEXTROSE 3 HI

CEFTIN SUS 125/5ML 4 CEFTIN SUS 250/5ML 3 CEFTIN TAB 250MG 4 MO CEFTIN TAB 500MG 4 MO ceftriaxone sodium 2 HI CEFTRIAXONE/ DEXTROSE 3 HI

cefuroxime axetil 2 MO cefuroxime sodium 2 HI CEFUROXIME/ DEXTROSE 3 HI

cephalexin 2 MO chloramphenicol sodium succinate 2 HI

CIPRO SUSP 3 MO CIPRO 4 MO CIPRO I.V.-IN D5W 4 HI ciprofloxacin 2 HI ciprofloxacin hcl 2 MO ciprofloxacin in d5w 2 HI ciprofloxacin-ciprofloxacin hcl 2 MO

CLAFORAN 4 HI clarithromycin 2 MO CLEOCIN 4 MO CLEOCIN IN D5W 3 HI CLEOCIN PHOSPHATE 4 HI clindamycin hcl 2 MO clindamycin palmitate hydrochloride 2

clindamycin phosphate 2 HI clindamycin phosphate in d5w 2 HI

colistimethate sodium 2 HI COLY-MYCIN M 4 HI CUBICIN 5 HI


Drug Name Drug Tier


demeclocycline hcl 2 MO dicloxacillin sodium 2 MO DIFICID 5 DORIBAX 4 HI DORYX 4 MO doxycycline (monohydrate) 2 MO

doxycycline hyclate 2 HI,MO E.E.S. GRANULES 3 ERYPED 200 3 ERYPED 400 3 ERYTHROCIN LACTOBIONATE 3 HI

erythromycin base 2 MO erythromycin ethylsuccinate 2 MO

erythromycin lactobionate 2 HI

erythromycin stearate 2 MO FACTIVE 4 MO FORTAZ 3 HI FORTAZ 4 HI gentamicin in saline 2 HI gentamicin sulfate 2 HI imipenem-cilastatin 2 HI INVANZ 3 HI kanamycin sulfate 2 HI KEFLEX 4 MO KETEK 4 MO LEVAQUIN 4 HI,MO levofloxacin 2 HI,MO levofloxacin in d5w 2 HI LINCOCIN 4 HI MAXIPIME 3 HI meropenem 2 HI MERREM 4 HI MINOCIN 4 MO minocycline hcl 2 MO MONODOX CAP 100MG 4 MO MONODOX CAP 75MG 4 MO MOXATAG TAB 775MG 4 MO nafcillin sodium 2 HI NALLPEN ISO-OSMOTIC IN DEXTROSE

3 HI

NALLPEN/DEXTROSE 3 HI neomycin sulfate 2 MO NOROXIN 4 MO ofloxacin 2 MO

Drug Name Drug Tier


oxacillin sodium 2 HI PCE 4 MO penicillin g potassium 2 HI PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE

3 HI

penicillin g procaine 2 penicillin g sodium 2 HI penicillin v potassium 2 MO piperacillin sodium-tazobactam sodium 2 HI

polymyxin b sulfate 2 HI PRIMAXIN I.M. INJ 500MG 3

PRIMAXIN IV INJ 250MG 4 HI

PRIMAXIN IV INJ 500MG 4 HI

SEPTRA DS 4 MO SOLODYN 4 MO SPECTRACEF 4 MO streptomycin sulfate 2 sulfadiazine 2 MO sulfamethoxazole-trimethoprim 2 HI,MO

sulfasalazine 2 MO SUPRAX 4 MO SYNERCID 3 HI TEFLARO 4 HI tetracycline hcl 2 MO ticarcillin & pot clavulanate 2 HI

TOBI NEB 300/5ML 5 TOBI PODHALER CAP 28MG 4 MO

tobramycin sulfate 2 HI tobramycin sulfate in saline 2 HI

TYGACIL 4 HI UNASYN 4 HI UNASYN BULK PACK 4 HI VANCOCIN HCL 5 MO vancomycin hcl 2 HI,MO VANCOMYCIN HCL IN DEXTROSE 3 HI

VIBATIV 4 HI VIBRAMYCIN 4 MO VIBRAMYCIN SUS 25MG/5ML 3


Drug Name Drug Tier


XIFAXAN 4 ZINACEF IN ISO-OSMOTIC DEXTROSE 3 HI

ZINACEF IN ISO-OSMOTIC DILUENT 3 HI

ZINACEF INJ 1.5GM 4 HI ZINACEF INJ 7.5GM 4 HI ZINACEF INJ 750MG 3 HI ZINACEF INJ 750MG 4 HI ZITHROMAX INJ 500MG 4 HI ZITHROMAX POW 1GM PAK 3

ZITHROMAX SUS 100/5ML 4

ZITHROMAX SUS 200/5ML 4

ZITHROMAX TAB 250MG 4 MO



ZITHROMAX TRI-PAK TAB TRI-PAK 4 MO

ZITHROMAX Z-PAK TAB Z-PAK 4 MO

ZMAX SUS 2GM 4 ZOSYN 3 HI ZYVOX 5 HI ANTIFUNGALS ABELCET 4 HI AMBISOME 5 HI AMPHOTEC 4 HI amphotericin b 2 HI ANCOBON 5 CANCIDAS 5 HI DIFLUCAN 4 MO ERAXIS 4 HI fluconazole 2 MO fluconazole in dextrose 2 HI flucytosine 2 MO GRIS-PEG 3 MO griseofulvin microsize 2 MO griseofulvin ultramicrosize 2 MO

itraconazole 2 MO ketoconazole 2 MO LAMISIL 4 MO

Drug Name Drug Tier


MYCAMINE 4 HI NOXAFIL 5 nystatin 2 MO nystatin (mouth-throat) 2 ONMEL TAB 200MG 4 MO SPORANOX CAP 100MG 4 MO

SPORANOX PULSEPAK CAP PULSEPAK 4 MO

SPORANOX SOL 10MG/ML 3

terbinafine hcl 2 MO VFEND IV INJ 200MG 3 HI VFEND SUS 40MG/ML 5 VFEND TAB 200MG 5 VFEND TAB 50MG 5 voriconazole 2 HI,MO ANTIMYCOBACTERIALS aminosalicylic acid 2 MO CAPASTAT SULFATE 3 HI cycloserine 2 MO dapsone 2 MO ethambutol hcl 2 MO isoniazid 2 MO isoniazid & rifampin 2 MO MYAMBUTOL 4 MO MYCOBUTIN 3 MO PRIFTIN 4 MO pyrazinamide 2 RIFADIN 4 HI,MO rifampin 2 HI,MO RIFATER 4 MO SIRTURO 5 LD TRECATOR 4 MO ANTIPROTOZOALS ALINIA 3 MO ARALEN 4 MO atovaquone-proguanil hcl 2 MO chloroquine phosphate 2 MO COARTEM 3 MO DARAPRIM 3 MO FLAGYL 4 MO FLAGYL ER 4 MO hydroxychloroquine sulfate 2 MO

MALARONE TAB 250-100 4 MO


Drug Name Drug Tier


MALARONE TAB 62.5-25 3 MO

mefloquine hcl 2 MO MEPRON 5 METRO IV 3 HI metronidazole 2 MO metronidazole in nacl 2 HI NEBUPENT INH 300MG 3 paromomycin sulfate 2 MO PENTAM 300 INJ 300MG 4

PLAQUENIL 4 MO PRIMAQUINE PHOSPHATE 3 MO

QUALAQUIN 4 MO quinine sulfate 2 MO tinidazole 2 ANTIVIRALS abacavir sulfate 2 MO acyclovir 2 MO acyclovir sodium 2 HI APTIVUS 5 ATRIPLA 5 BARACLUDE SOL .05MG/ML 3

BARACLUDE TAB 0.5MG 5

BARACLUDE TAB 1MG 5 cidofovir 2 HI COMBIVIR 5 MO COMPLERA 5 COPEGUS 4 MO CRIXIVAN 3 MO CYTOVENE 4 HI didanosine 2 MO EDURANT 5 EMTRIVA 3 MO EPIVIR HBV SOL 5MG/ML 3

EPIVIR HBV TAB 100MG 3 MO

EPIVIR SOL 10MG/ML 3 EPIVIR TAB 150MG 4 MO EPIVIR TAB 300MG 3 MO EPIVIR TAB 300MG 4 MO EPZICOM 5 famciclovir 2 MO FAMVIR 4 MO foscarnet sodium 2 HI

Drug Name Drug Tier


FUZEON 5 ganciclovir 2 MO ganciclovir sodium 2 HI HEPSERA 5 INCIVEK 5 INFERGEN 5 INTELENCE TAB 100MG 5

INTELENCE TAB 200MG 5

INTELENCE TAB 25MG 3 INVIRASE CAP 200MG 3 MO INVIRASE TAB 500MG 5 ISENTRESS 5 KALETRA SOL 5 KALETRA TAB 100-25MG 3 MO

KALETRA TAB 200-50MG 5

lamivudine 2 MO lamivudine-zidovudine 2 MO LEXIVA SUS 50MG/ML 4 LEXIVA TAB 700MG 5 nevirapine 2 MO NORVIR 3 MO PEG-INTRON 5 PEG-INTRON REDIPEN 5 PEGASYS 5 PEGASYS PROCLICK 5 PREZISTA SUS 100MG/ML 4

PREZISTA TAB 150MG 5 PREZISTA TAB 400MG 5 PREZISTA TAB 600MG 5 PREZISTA TAB 75MG 3 MO PREZISTA TAB 800MG 5 REBETOL 4 MO RELENZA DISKHALER 3 MO RESCRIPTOR 3 MO RETROVIR CAP 100MG 4 MO RETROVIR IV INFUSION INJ 10MG/ML 3 HI

RETROVIR SYP 50MG/5ML 4

RETROVIR TAB 300MG 4 MO REYATAZ CAP 100MG 3 MO REYATAZ CAP 150MG 5 REYATAZ CAP 200MG 5 REYATAZ CAP 300MG 5


Drug Name Drug Tier


ribavirin (hepatitis c) 2 MO rimantadine hydrochloride 2 MO

SELZENTRY 5 stavudine 2 MO STRIBILD 5 SUSTIVA 3 MO SYNAGIS 5 TAMIFLU CAP 30MG 4 MO TAMIFLU CAP 45MG 4 MO TAMIFLU CAP 75MG 3 MO TAMIFLU SUS 12MG/ML 3

TAMIFLU SUS 6MG/ML 3 TIVICAY 5 TRIZIVIR 5 MO TRUVADA 5 TYZEKA 4 MO valacyclovir hcl 2 MO VALCYTE SOL 50MG/ML 3

VALCYTE TAB 450MG 5 VALTREX 4 MO VICTRELIS 5 VIDEX EC CAP 125MG 4 MO VIDEX EC CAP 200MG 4 MO VIDEX EC CAP 250MG 4 MO VIDEX EC CAP 400MG 4 MO VIDEX PEDIATRIC SOL 2GM 3

VIDEX PEDIATRIC SOL 4GM 3

VIRACEPT 5 VIRAMUNE SUS 50MG/5ML 3

VIRAMUNE TAB 200MG 3 MO VIRAMUNE XR TAB 100MG 4 MO

VIRAMUNE XR TAB 400MG 4 MO

VIRAZOLE 3 MO VIREAD 5 VISTIDE 5 HI ZERIT 4 MO ZIAGEN 3 MO zidovudine 2 HI,MO ZOVIRAX 4 MO

Drug Name Drug Tier


URINARY ANTI-INFECTIVES FURADANTIN 4 HIPREX 4 MO MACROBID 4 MO MACRODANTIN CAP 100MG 4 MO

MACRODANTIN CAP 25MG 3 MO

methenamine hippurate 2 MO MONUROL 4 MO nitrofurantoin 2 nitrofurantoin macrocrystal 2 MO

nitrofurantoin monohyd macro 2 MO

PRIMSOL 3 trimethoprim 2 MO ANTIHISTAMINE DRUGS ANTIHISTAMINE DRUGS carbinoxamine maleate 2 MO cetirizine hcl 2 CLARINEX 4 MO CLARINEX REDITABS 4 MO CLARINEX-D 12 HOUR 4 MO CLARINEX-D 24 HOUR 4 MO clemastine fumarate 2 MO cyproheptadine hcl 2 MO desloratadine 2 MO dexchlorpheniramine maleate 2

diphenhydramine hcl 2 MO levocetirizine dihydrochloride 2 MO

promethazine & phenylephrine 2

promethazine hcl 2 MO SEMPREX-D 4 MO XYZAL 4 MO ANTINEOPLASTIC AGENTS ANTINEOPLASTIC AGENTS ABRAXANE 3 AFINITOR 5 AFINITOR DISPERZ 5 ALIMTA 3 ALKERAN 4 anastrozole 2 ARIMIDEX 4 AROMASIN 4


Drug Name Drug Tier


ARRANON 3 ARZERRA 4 AVASTIN 3 BCG VACCINE 3 bicalutamide 2 BICNU 3 bleomycin sulfate 2 BOSULIF 5 BUSULFEX 4 CAMPATH 3 CAMPTOSAR 4 CAPRELSA 3 LD carboplatin 2 CASODEX 4 CEENU 3 cisplatin 2 cladribine 2 CLOLAR 4 COMETRIQ 5 COSMEGEN 4 cyclophosphamide 2 PA cytarabine 2 dacarbazine 2 DACOGEN 3 daunorubicin hcl 2 DAUNOXOME 3 decitabine 2 DOCEFREZ INJ 20MG 4 DOCEFREZ INJ 80MG 4 DOCETAXEL INJ 80MG/4ML 4

DOCETAXEL INJ 80MG/8ML 3

DOXIL 3 doxorubicin hcl 2 DROXIA 4 ELIGARD INJ 22.5MG 4 ELIGARD INJ 30MG 4 ELIGARD INJ 45MG 4 ELIGARD INJ 7.5MG 4 ELLENCE 4 ELOXATIN INJ 100MG 4 ELOXATIN INJ 200MG 3 ELSPAR 3 EMCYT 3 epirubicin hcl 2 ERBITUX 3 ERIVEDGE 5 ETOPOPHOS 4

Drug Name Drug Tier


etoposide 2 exemestane 2 FARESTON 4 FASLODEX 5 FEMARA 4 FIRMAGON 4 FLUDARA 4 fludarabine phosphate 2 fluorouracil 2 flutamide 2 FOLOTYN 4 gemcitabine hcl 2 GEMZAR 4 GILOTRIF 5 GLEEVEC 5 HALAVEN 4 HERCEPTIN 3 HEXALEN 5 HYCAMTIN 4 HYDREA 4 hydroxyurea 2 ICLUSIG 5 IDAMYCIN PFS 4 idarubicin hcl 2 IFEX 3 ifosfamide 2 INLYTA 5 INTRON-A INJ 10MU PEN 4

INTRON-A INJ 18MU 5 INTRON-A INJ 25MU 5 INTRON-A INJ 3MU PEN 5

INTRON-A INJ 5MU PEN 5

INTRON-A W/DILUENT INJ 10MU 5



irinotecan hcl 2 ISTODAX 3 IXEMPRA KIT 5 JAKAFI 5 JEVTANA 3 KADCYLA 5 KYPROLIS 5 letrozole 2


Drug Name Drug Tier


LEUKERAN 3 leuprolide acetate 2 LUPRON DEPOT INJ 11.25MG 3

LUPRON DEPOT INJ 22.5MG 3


LUPRON DEPOT INJ 30MG 3

LUPRON DEPOT INJ 45MG 3


LUPRON DEPOT-PED 3 LUPRON DEPOT-PED INJ 11.25MG 4

LUPRON DEPOT-PED INJ 30MG 3

LYSODREN 3 MATULANE 5 MEGACE ORAL 4 megestrol acetate 2 MEKINIST 5 melphalan hcl 2 mercaptopurine 2 methotrexate sodium 2 PA mitomycin 2 mitoxantrone hcl 2 MUSTARGEN 3 NEXAVAR 5 NILANDRON 3 NIPENT 4 ONCASPAR 3 ONTAK 3 oxaliplatin 2 paclitaxel 2 pentostatin 2 PERJETA 5 POMALYST 5 PROLEUKIN 5 PURINETHOL 4 REVLIMID 5 RHEUMATREX 4 PA RITUXAN 3 SOLTAMOX 4 MO SPRYCEL 5 STIVARGA 5

Drug Name Drug Tier


SUTENT 5 SYLATRON 3 SYNRIBO 5 TABLOID 3 TAFINLAR 5 tamoxifen citrate 2 MO TARCEVA 5 TARGRETIN 5 MO TASIGNA 5 TAXOTERE INJ 20/0.5ML 3

TAXOTERE INJ 80MG/2ML 3

TAXOTERE INJ 80MG/4ML 4

TEMODAR 3 thiotepa 2 TICE BCG 3 topotecan hcl 2 TORISEL 3 TREANDA 3 TRELSTAR DEPOT MIXJECT 4

TRELSTAR LA MIXJECT 4

TRELSTAR MIXJECT 4 tretinoin (chemotherapy) 2 TRISENOX 3 TYKERB 5 VALSTAR 3 VANDETANIB 3 MO VANTAS 3 VECTIBIX 4 VELCADE 3 VIDAZA 3 vinblastine sulfate 2 vincristine sulfate 2 vinorelbine tartrate 2 VOTRIENT 5 VUMON 3 XALKORI 5 XTANDI 5 YERVOY 3 ZALTRAP 5 ZANOSAR 3 ZELBORAF 5 ZOLINZA 5 ZYTIGA 5


Drug Name Drug Tier


AUTONOMIC DRUGS ANTICHOLINERGIC AGENTS atropine sulfate 2 ATROPINE SULFATE 3 ATROVENT 4 ATROVENT HFA 3 MO BENTYL 4 MO CANTIL 4 MO CUVPOSA SOL 1MG/5ML 3

dicyclomine hcl 2 MO glycopyrrolate 2 MO ipratropium bromide 1 ipratropium bromide (nasal) 2

methscopolamine bromide 2 MO

PAMINE 4 MO PAMINE FORTE 4 MO propantheline bromide 2 MO ROBINUL FORTE TAB 2MG 4 MO

ROBINUL TAB 1MG 4 MO SPIRIVA HANDIHALER 3 MO TUDORZA PRESSAIR 4 AUTONOMIC DRUGS, MISCELLANEOUS CHANTIX 4 CHANTIX STARTING MONTH PAK 4

NICOTROL INHALER INH 3

NICOTROL NS SPR 10MG/ML 4

PARASYMPATHOMIMETIC (CHOLINERGIC) AGENTS ARICEPT 4 MO ARICEPT ODT 4 MO bethanechol chloride 2 MO cevimeline hcl 2 MO donepezil hydrochloride 2 MO EVOXAC 4 MO EXELON 4 MO galantamine hydrobromide 2 MO

GUANIDINE HCL 4 MO MESTINON SYP 60MG/5ML 3

MESTINON TAB 60MG 4 MO

Drug Name Drug Tier


MESTINON TIMESPAN TAB TIMESPAN 3 MO

MYTELASE 3 MO pilocarpine hcl (oral) 2 MO pyridostigmine bromide 2 MO RAZADYNE 4 MO RAZADYNE ER 4 MO REGONOL INJ 5MG/ML 3 rivastigmine tartrate 2 MO SALAGEN 4 MO SKELETAL MUSCLE RELAXANTS AMRIX 4 MO baclofen 2 MO carisoprodol 2 MO carisoprodol w/ aspirin 2 MO carisoprodol w/ aspirin & codeine 2

chlorzoxazone 2 MO cyclobenzaprine hcl 2 MO DANTRIUM 4 MO dantrolene sodium 2 MO GABLOFEN 4 LIORESAL INTRATHECAL 4

methocarbamol 2 MO orphenadrine citrate 2 MO PARAFON FORTE DSC 4 MO SKELAXIN 4 MO SOMA 4 MO tizanidine hcl 2 MO ZANAFLEX 4 MO SYMPATHOLYTIC (ADRENERGIC BLOCKING) AGENTS alfuzosin hcl 2 MO DIBENZYLINE 3 MO dihydroergotamine mesylate 2

ergoloid mesylates 2 MO ergotamine tartrate 2 FLOMAX 4 MO MIGRANAL 3 RAPAFLO 4 MO tamsulosin hcl 2 MO UROXATRAL 4 MO SYMPATHOMIMETIC (ADRENERGIC) AGENTS ACCUNEB NEB 0.63MG/3 4

ACCUNEB NEB 1.25MG/3 4


Drug Name Drug Tier


ADRENALIN INJ 1MG/ML 4

ADVAIR DISKUS AER 100/50 3 MO



ADVAIR HFA AER 115/21 4 MO

ADVAIR HFA AER 230/21 4 MO

ADVAIR HFA AER 45/21 4 MO albuterol sulfate er tab 4mg er 2 MO

albuterol sulfate er tab 8mg er 2 MO

albuterol sulfate neb 0.083% 1

albuterol sulfate neb 0.5% 1

albuterol sulfate neb 0.63mg/3 2

albuterol sulfate neb 1.25mg/3 2

albuterol sulfate syp 2mg/5ml 2

albuterol sulfate tab 2mg 2 MO albuterol sulfate tab 4mg 2 MO ARCAPTA NEOHALER 4 MO AUVI-Q INJ 0.15MG 4 AUVI-Q INJ 0.3MG 4 BROVANA 4 COMBIVENT AER 3 MO COMBIVENT RESPIMAT AER RESPIMAT

3 MO

DUONEB SOL 4 epinephrine hcl 2 EPIPEN 2-PAK INJ 0.3MG 3

EPIPEN-JR 2-PAK INJ 2-PAK 3

FORADIL AEROLIZER 4 MO ipratropium-albuterol 2 MO levalbuterol hcl 2 MAXAIR AUTOHALER 3 MO metaproterenol sulfate 2 MO midodrine hcl 2 MO

Drug Name Drug Tier


PERFOROMIST 4 PROAIR HFA AER 3 MO PROVENTIL HFA AER HFA 4 MO

SEREVENT DISKUS 3 MO terbutaline sulfate 2 MO TWINJECT INJ 0.15MG 3 TWINJECT INJ 0.3MG 3 VENTOLIN HFA AER 4 MO vospire er tab 4mg 2 MO vospire er tab 8mg 2 MO XOPENEX 4 XOPENEX HFA 4 BLOOD FORMATION, COAGULATION, AND THROMBOSIS COAGULANTS AND ANTICOAGULANTS AGGRENOX 3 MO AGRYLIN 4 MO AMICAR 3 MO anagrelide hcl 2 MO argatroban 2 HI ARGATROBAN 4 HI ARIXTRA 4 BRILINTA 3 MO cilostazol 2 MO clopidogrel bisulfate 2 MO COUMADIN 4 HI,MO CYKLOKAPRON INJ 100MG/ML 3 HI

EFFIENT 3 MO ELIQUIS 4 MO enoxaparin sodium 2 fondaparinux sodium 2 FRAGMIN 4 heparin (porcine) in sodium chloride 2

heparin sod (porcine) in d5w 2 HI

heparin sodium (porcine) 2 HI HEPARIN SODIUM/NACL 0.45% 4

INTEGRILIN 3 HI LOVENOX 3 LYSTEDA TAB 650MG 4 MO pentoxifylline 2 MO PLAVIX 4 MO PLETAL 4 MO PRADAXA 4 MO


Drug Name Drug Tier


ticlopidine hcl 2 MO tranexamic acid 2 HI,MO TRENTAL 4 MO warfarin sodium 1 HI,MO XARELTO 4 MO HEMATOPOIETIC AGENTS ARANESP ALBUMIN FREE 4 PA

EPOGEN INJ 10000/ML 4 PA EPOGEN INJ 2000/ML 4 PA EPOGEN INJ 20000/ML 4 PA EPOGEN INJ 3000/ML 4 PA EPOGEN INJ 4000/ML 4 PA LEUKINE INJ 250MCG 3 HI LEUKINE INJ 500 MCG 4 MOZOBIL 4 NEULASTA 5 NEUMEGA 5 NEUPOGEN 5 PROCRIT INJ 10000/ML 3 PROCRIT INJ 10000/ML 3 PA PROCRIT INJ 2000/ML 3 PA PROCRIT INJ 20000/ML 3 PA PROCRIT INJ 3000/ML 3 PA PROCRIT INJ 4000/ML 3 PA PROCRIT INJ 40000/ML 3 PA PROMACTA 5 CARDIOVASCULAR DRUGS A-ADRENERGIC BLOCKING AGENTS CARDURA 4 MO CARDURA XL 4 MO doxazosin mesylate 1 MO MINIPRESS 4 MO prazosin hcl 1 MO terazosin hcl 1 MO ANTILIPEMIC AGENTS ADVICOR 4 MO ALTOPREV 4 MO ANTARA 4 MO atorvastatin calcium 2 MO cholestyramine 2 MO cholestyramine light 2 MO choline fenofibrate 2 MO COLESTID 4 MO colestipol hcl 2 MO CRESTOR 4 MO ESOMEPRAZOLE STRONTIUM 4 MO

fenofibrate 2 MO

Drug Name Drug Tier


fenofibrate micronized 2 MO FENOGLIDE 4 MO FIBRICOR 4 MO fluvastatin sodium 2 MO gemfibrozil 2 MO JUXTAPID 5 KYNAMRO 5 LESCOL 4 MO LESCOL XL 4 MO LIPITOR 4 MO LIPOFEN 4 MO LIPTRUZET 4 MO LIVALO 4 MO LOPID 4 MO lovastatin 1 MO LOVAZA 4 MO MEVACOR 4 MO NIASPAN 4 MO PRAVACHOL 4 MO pravastatin sodium 2 MO SIMCOR 4 MO simvastatin 1 MO TRICOR 4 MO TRILIPIX 4 MO VASCEPA 4 VYTORIN 4 MO WELCHOL 4 MO ZETIA 4 MO ZOCOR 4 MO CALCIUM-CHANNEL BLOCKING AGENTS ADALAT CC 4 MO amlodipine besylate 1 MO amlodipine besylate-benazepril hcl 2 MO

AZOR 4 MO CADUET 4 MO CALAN 4 MO CALAN SR 4 MO CARDIZEM 4 MO CARDIZEM CD 4 MO CARDIZEM LA 4 MO COVERA-HS 4 MO dilacor xr cap 240mg/24 2 MO dilt-xr cap 180mg 2 MO dilt-xr cap 240mg 2 MO diltiazem hcl coated beads 2 MO

diltiazem hcl er cap 120mg er 2 MO


Drug Name Drug Tier




diltiazem hcl extended release beads 2 MO

diltiazem hcl inj 100mg 2 HI diltiazem hcl inj 50/10ml 2 HI diltiazem hcl tab 120mg 1 MO diltiazem hcl tab 30mg 1 MO diltiazem hcl tab 60mg 1 MO diltiazem hcl tab 90mg 1 MO DYNACIRC CR 4 MO EXFORGE 4 MO EXFORGE HCT 4 MO felodipine 2 MO isradipine 2 MO LOTREL 4 MO nicardipine hcl 2 HI,MO nifedipine 2 MO nimodipine 2 MO nisoldipine 2 MO NORVASC 4 MO PROCARDIA 4 MO PROCARDIA XL 4 MO SULAR 4 MO TARKA 4 MO TIAZAC 4 MO TRIBENZOR 4 MO TWYNSTA 4 MO verapamil hcl er cap 100mg er 2 MO

verapamil hcl er cap 120mg er 2 MO





verapamil hcl er tab 120mg er 2 MO



Drug Name Drug Tier


verapamil hcl inj 2.5mg/ml 2 HI

verapamil hcl sr cap 360mg sr 2 MO

verapamil hcl tab 120mg 1 MO verapamil hcl tab 40mg 2 MO verapamil hcl tab 80mg 1 MO VERELAN 4 MO VERELAN PM 4 MO CARDIAC DRUGS amiodarone hcl 2 HI,MO CORDARONE 4 MO digoxin inj 0.25mg/1 2 DIGOXIN SOL 50MCG/ML 3

digoxin tab 0.125mg 1 MO digoxin tab 0.25mg 1 MO disopyramide phosphate 2 MO flecainide acetate 2 MO LANOXIN INJ 0.25MG/1 4 LANOXIN PEDIATRIC INJ 0.1MG/ML 3

LANOXIN TAB 0.125MG 4 MO LANOXIN TAB 0.25MG 4 MO mexiletine hcl 2 MO MULTAQ 4 MO NEXTERONE 4 HI NORPACE CAP 100MG 4 MO NORPACE CAP 150MG 4 MO NORPACE CR CAP 100MG CR 3 MO

NORPACE CR CAP 150MG CR 3 MO

procainamide hcl 2 propafenone hcl 2 MO quinidine gluconate 2 MO QUINIDINE GLUCONATE 3

quinidine sulfate 2 MO RANEXA 4 MO RYTHMOL 4 MO RYTHMOL SR 4 MO TIKOSYN 3 MO HYPOTENSIVE AGENTS CATAPRES 4 MO CATAPRES-TTS-1 4 MO CATAPRES-TTS-2 4 MO CATAPRES-TTS-3 4 MO


Drug Name Drug Tier


clonidine & chlorthalidone 2 MO

clonidine hcl dis 0.1/24hr 2 MO clonidine hcl dis 0.2/24hr 2 MO clonidine hcl dis 0.3/24hr 2 MO clonidine hcl tab 0.1mg 1 MO clonidine hcl tab 0.2mg 1 MO clonidine hcl tab 0.3mg 2 MO guanfacine hcl tab 1mg 1 MO guanfacine hcl tab 2mg 2 MO hydralazine hcl inj 20mg/ml 2

hydralazine hcl tab 100mg 2 MO

hydralazine hcl tab 10mg 1 MO hydralazine hcl tab 25mg 1 MO hydralazine hcl tab 50mg 2 MO KAPVAY 4 MO mecamylamine hcl 2 MO methyldopa 1 MO methyldopa & hydrochlorothiazide 2 MO

methyldopate hcl 2 HI minoxidil 2 MO PROGLYCEM 3 RESERPINE 3 MO TENEX 4 MO RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS ACCUPRIL 4 MO ACCURETIC 4 MO ACEON 4 MO ALDACTAZIDE 4 MO ALDACTONE 4 MO ALTACE 4 MO AMTURNIDE 4 MO ATACAND 4 MO ATACAND HCT 4 MO AVALIDE 4 MO AVAPRO 4 MO benazepril & hydrochlorothiazide 2 MO

benazepril hcl 1 MO BENICAR 4 MO BENICAR HCT 4 MO candesartan cilexetil 2 MO candesartan cilexetil-hydrochlorothiazide 2 MO

captopril 1 MO

Drug Name Drug Tier


captopril & hydrochlorothiazide 2 MO

COZAAR 4 MO DIOVAN 4 MO DIOVAN HCT 4 MO EDARBI 4 MO EDARBYCLOR 4 MO enalapril maleate 1 MO enalapril maleate & hydrochlorothiazide 2 MO

eplerenone 2 MO eprosartan mesylate 2 MO fosinopril sodium 2 MO fosinopril sodium & hydrochlorothiazide 2 MO

HYZAAR 4 MO INSPRA 4 MO irbesartan 2 MO irbesartan-hydrochlorothiazide 2 MO

lisinopril & hydrochlorothiazide 1 MO

lisinopril tab 10mg 1 MO lisinopril tab 2.5mg 1 MO lisinopril tab 20mg 1 MO lisinopril tab 30mg 2 MO lisinopril tab 40mg 1 MO lisinopril tab 5mg 1 MO losartan potassium 2 MO losartan potassium & hydrochlorothiazide 2 MO

LOTENSIN 4 MO LOTENSIN HCT 4 MO MAVIK 4 MO MICARDIS 4 MO MICARDIS HCT 4 MO moexipril hcl 2 MO moexipril-hydrochlorothiazide 2 MO

perindopril erbumine 2 MO PRINIVIL 4 MO PRINZIDE 4 MO quinapril hcl 2 MO quinapril-hydrochlorothiazide 2 MO

ramipril 2 MO spironolactone & hydrochlorothiazide 2 MO


Drug Name Drug Tier


spironolactone tab 100mg 2 MO

spironolactone tab 25mg 1 MO spironolactone tab 50mg 2 MO TEKAMLO 4 MO TEKTURNA 4 MO TEKTURNA HCT 4 MO TEVETEN 4 MO TEVETEN HCT 4 MO trandolapril 2 MO UNIRETIC 4 MO UNIVASC 4 MO valsartan-hydrochlorothiazide 2 MO

VALTURNA 4 MO VASERETIC 4 MO VASOTEC 4 MO ZESTORETIC 4 MO ZESTRIL 4 MO VASODILATING AGENTS ADCIRCA 5 BIDIL 4 MO CIALIS 4 PA DILATRATE SR CAP 40MG 3 MO

dipyridamole 2 MO ISORDIL TITRADOSE TAB 40MG 3 MO

ISORDIL TITRADOSE TAB 5MG 4 MO

isosorbide dinitrate 2 MO isosorbide mononitrate er tab 120mg er 2 MO

isosorbide mononitrate er tab 30mg er 1 MO

isosorbide mononitrate er tab 60mg er 1 MO

isosorbide mononitrate tab 10mg 2 MO

isosorbide mononitrate tab 20mg 2 MO

LETAIRIS 5 LD MONOKET 4 MO NITRO-DUR DIS 0.1MG/HR 4 MO

NITRO-DUR DIS 0.2MG/HR 4 MO

Drug Name Drug Tier






nitroglycerin 2 HI,MO NITROLINGUAL PUMPSPRAY SPR PUMPSPRA

3 MO

NITROMIST AER 400MCG 4 MO

NITROSTAT SUB 0.3MG 3 MO



PERSANTINE 4 MO REMODULIN 5 LD REVATIO 5 sildenafil citrate (pulmonary hypertension)

2 PA

TRACLEER 5 LD TYVASO 4 LD VENTAVIS SOL 10MCG/ML 5 LD

VENTAVIS SOL 20MCG/ML 4 LD

ß-ADRENERGIC BLOCKING AGENTS acebutolol hcl 2 MO atenolol 1 MO atenolol & chlorthalidone 1 MO BETAPACE 4 MO BETAPACE AF 4 MO betaxolol hcl 2 MO bisoprolol & hydrochlorothiazide 1 MO

bisoprolol fumarate 2 MO BYSTOLIC 4 MO carvedilol 1 MO COREG 4 MO COREG CR 4 MO CORGARD 4 MO CORZIDE 4 MO


Drug Name Drug Tier


DUTOPROL 4 MO INDERAL LA 4 MO INNOPRAN XL 4 MO labetalol hcl 2 HI,MO LEVATOL 4 MO LOPRESSOR 4 HI,MO LOPRESSOR HCT 4 MO metoprolol & hydrochlorothiazide 2 MO

metoprolol succinate 2 MO metoprolol tartrate inj 1mg/ml 2 HI

metoprolol tartrate tab 100mg 1 MO



nadolol & bendroflumethiazide 2 MO

nadolol tab 20mg 1 MO nadolol tab 40mg 1 MO nadolol tab 80mg 2 MO pindolol 2 MO propranolol & hydrochlorothiazide 2 MO

propranolol hcl er cap 120mg er 2 MO




propranolol hcl inj 1mg/ml 2 HI

propranolol hcl sol 20mg/5ml 2

propranolol hcl sol 40mg/5ml 2

propranolol hcl tab 10mg 1 MO propranolol hcl tab 20mg 1 MO propranolol hcl tab 40mg 1 MO propranolol hcl tab 60mg 2 MO propranolol hcl tab 80mg 1 MO SECTRAL 4 MO sorine tab 120mg 2 MO sorine tab 160mg 2 MO sorine tab 240mg 2 MO

Drug Name Drug Tier


sorine tab 80mg 1 MO sotalol hcl (afib/afl) 2 MO sotalol hcl tab 120mg 2 MO sotalol hcl tab 160mg 2 MO sotalol hcl tab 240mg 2 MO sotalol hcl tab 80mg 1 MO SOTALOL HYDROCHLORIDE 4 HI

TENORETIC 100 4 MO TENORETIC 50 4 MO TENORMIN 4 MO timolol maleate 2 MO TOPROL XL 4 MO TRANDATE 4 MO ZEBETA 4 MO ZIAC 4 MO CENTRAL NERVOUS SYSTEM AGENTS ANALGESICS AND ANTIPYRETICS ABSTRAL 4 acetaminophen w/ codeine 2

acetaminophen-caff-dihydrocod 2

ACTIQ 4 ANAPROX 4 MO ANAPROX DS 4 MO ARTHROTEC 50 4 MO ARTHROTEC 75 4 MO AVINZA 4 BUPRENEX 4 buprenorphine hcl 2 buprenorphine hcl-naloxone hcl dihydrate 2

butalbital-acetaminophen-caffeine w/ codeine

2

butalbital-aspirin-caffeine w/cod 2

butorphanol tartrate 2 BUTRANS 4 CAMBIA 4 CATAFLAM 4 CELEBREX 4 MO CLINORIL 4 MO CODEINE PHOSPHATE 3 CODEINE SULFATE TAB 15MG 3

CODEINE SULFATE TAB 30MG 3


Drug Name Drug Tier


CODEINE SULFATE TAB 60MG 4

CONZIP 4 DAYPRO 4 MO DEMEROL 4 diclofenac potassium 2 MO diclofenac sodium 2 MO diclofenac w/ misoprostol 2 MO diflunisal 2 MO DILAUDID INJ 1MG/ML 4 DILAUDID INJ 2MG/ML 4 DILAUDID INJ 4MG/ML 4 DILAUDID TAB 2MG 4 DILAUDID TAB 4MG 4 DILAUDID TAB 8MG 4 DILAUDID-5 LIQ 1MG/ML 3

DILAUDID-HP INJ 10MG/ML 4

DOLOPHINE HCL TAB 5MG 4

DOLOPHINE TAB 10MG 4 DUEXIS 4 MO DURAGESIC 4 EC-NAPROSYN 4 MO etodolac 2 MO EXALGO TAB 12MG 4 EXALGO TAB 16MG 4 EXALGO TAB 8MG 4 FELDENE 4 MO fenoprofen calcium 2 MO fentanyl 2 fentanyl citrate 2 FENTORA 4 FIORICET/CODEINE 4 FIORINAL/CODEINE #3 4 flurbiprofen 2 MO GRALISE 4 GRALISE STARTER 4 hydrocodone-acetaminophen 2

hydrocodone-ibuprofen 2 hydromorphone hcl 2 ibuprofen 2 MO ILARIS 5 INDOCIN 4 indomethacin 2 MO

Drug Name Drug Tier


KADIAN CAP 100MG CR 4

KADIAN CAP 10MG CR 4 KADIAN CAP 200MG CR 4

KADIAN CAP 20MG CR 4 KADIAN CAP 30MG CR 4 KADIAN CAP 50MG CR 4 KADIAN CAP 60MG CR 4 KADIAN CAP 80MG CR 4 ketoprofen 2 MO ketorolac tromethamine 2 MO levorphanol tartrate 2 meclofenamate sodium 2 MO mefenamic acid 2 MO meloxicam 2 MO MELOXICAM 4 MO meperidine hcl 2 methadone hcl 2 METHADONE HCL INJ 10MG/ML 3

MOBIC 4 MO morphine sulfate 2 MORPHINE SULFATE SOL 20MG/ML 3

MORPHINE SULFATE TAB 15MG 3

MORPHINE SULFATE TAB 30MG 3

MS CONTIN TAB 100MG CR 4





nabumetone 2 MO nalbuphine hcl 2 NALFON 4 MO NAPRELAN 4 MO NAPROSYN 4 MO naproxen 2 MO naproxen sodium 2 MO NUCYNTA 4 NUCYNTA ER 4 MO


Drug Name Drug Tier


ONSOLIS 4 OPANA 4 OPANA ER (CRUSH RESISTANT) 4

orphenadrine w/ aspirin & caff 2 MO

oxaprozin 2 MO OXECTA 4 oxycodone hcl 2 OXYCODONE HCL 4 oxycodone w/ acetaminophen 2

oxycodone-aspirin 2 oxycodone-ibuprofen 2 OXYCONTIN 4 oxymorphone hcl 2 pentazocine w/ naloxone 2 pentazocine-acetaminophen 2

PERCODAN 4 piroxicam 2 MO PONSTEL 4 MO ROXICODONE 4 RYZOLT 4 SPRIX 4 SUBOXONE MIS 12-3MG 4

SUBOXONE MIS 2-0.5MG 4

SUBOXONE MIS 4-1MG 4 SUBOXONE MIS 8-2MG 4 SUBOXONE SUB 2-0.5MG 3

SUBOXONE SUB 8-2MG 3

SUBSYS 4 sulindac 2 MO SYNALGOS-DC 4 TALWIN 4 tolmetin sodium 2 MO tramadol hcl 2 tramadol-acetaminophen 2 ULTRACET 4 ULTRAM 4 ULTRAM ER 4 VICOPROFEN 4 VIMOVO 4 VOLTAREN-XR 4 MO ZIPSOR 4

Drug Name Drug Tier


ZUBSOLV SUB 1.4-0.36 4 ZUBSOLV SUB 5.7-1.4 4 ANOREXIGENIC AGENTS AND RESPIRATORY AND CEREBRAL STIMULANTS ADDERALL XR 3 amphetamine-dextroamphetamine 2

CONCERTA TAB 18MG 3 CONCERTA TAB 27MG 3 CONCERTA TAB 36MG 3 CONCERTA TAB 54MG 3 DAYTRANA 4 DESOXYN 4 DEXEDRINE 4 dexmethylphenidate hcl 2 MO dextroamphetamine sulfate 2

FOCALIN 4 FOCALIN XR 4 MO METADATE CD CAP 10MG 3

METADATE CD CAP 20MG 3





methamphetamine hcl 2 METHYLIN CHW 10MG 4 METHYLIN CHW 2.5MG 3 METHYLIN CHW 5MG 4 METHYLIN SOL 10MG/5ML 4

METHYLIN SOL 5MG/5ML 4

methylphenidate hcl 2 modafinil 2 NUVIGIL 4 PROVIGIL 4 QUILLIVANT XR SUS XR 4

RITALIN LA CAP 10MG 4 RITALIN LA CAP 20MG 4 RITALIN LA CAP 30MG 4 RITALIN LA CAP 40MG 4


Drug Name Drug Tier


RITALIN SR TAB 20MG SR 4

RITALIN TAB 10MG 4 RITALIN TAB 20MG 4 RITALIN TAB 5MG 4 VYVANSE 3 ANTICONVULSANTS BANZEL 3 MO carbamazepine 2 MO CARBATROL CAP 100MG 4 MO

CARBATROL CAP 200MG 4 MO

CARBATROL CAP 300MG 4 MO

CELONTIN 3 MO clonazepam 2 MO DEPACON 4 HI DEPAKENE 4 MO DEPAKOTE 4 MO DEPAKOTE ER 4 MO DEPAKOTE SPRINKLES 4 MO

DILANTIN 4 MO divalproex sodium 2 MO EQUETRO 4 MO ethosuximide 2 MO felbamate 2 MO FELBATOL 5 fosphenytoin sodium 2 gabapentin 2 MO GABITRIL 4 MO HORIZANT 4 MO KEPPRA 4 MO KEPPRA XR 4 MO KLONOPIN 4 MO LAMICTAL CHEWABLE DISPERSIBLE CHW 25MG

4 MO

LAMICTAL CHEWABLE DISPERSIBLE CHW 5MG

4 MO

LAMICTAL ODT TAB 100MG 4 MO



Drug Name Drug Tier



LAMICTAL STARTER /NOT TAKING CARBAMAZEPINE KIT START 49

3 MO

LAMICTAL STARTER /TAKING CARBAMAZEPINE/NOT TAKING VALPROATE KIT START 98

3 MO

LAMICTAL STARTER /TAKING VALPROATE KIT START 35

3 MO

LAMICTAL TAB 100MG 4 MO LAMICTAL TAB 150MG 4 MO LAMICTAL TAB 200MG 4 MO LAMICTAL TAB 25MG 4 MO LAMICTAL XR KIT 4 MO LAMICTAL XR TAB 100MG 4 MO

LAMICTAL XR TAB 200MG 4 MO





lamotrigine 2 MO levetiracetam 2 HI,MO LEVETIRACETAM 3 HI,MO LYRICA 4 magnesium sulfate 2 HI MAGNESIUM SULFATE 3 HI MYSOLINE 4 MO NEURONTIN 4 MO ONFI 4 MO oxcarbazepine 2 MO PEGANONE 4 MO phenytoin 2 MO phenytoin sodium 2 phenytoin sodium extended 2 MO

POTIGA 4 MO primidone 2 MO SABRIL 5 LD


Drug Name Drug Tier


STAVZOR 4 MO TEGRETOL CHW 100MG 4 MO

TEGRETOL SUS 100/5ML 4

TEGRETOL TAB 200MG 4 MO TEGRETOL-XR TAB 100MG 3 MO

TEGRETOL-XR TAB 200MG 4 MO

TEGRETOL-XR TAB 400MG 4 MO

tiagabine hcl 2 MO TOPAMAX 4 MO TOPAMAX SPRINKLE 4 MO topiramate 2 MO TRILEPTAL SUS 300MG/5M 3

TRILEPTAL TAB 150MG 4 MO TRILEPTAL TAB 300MG 4 MO TRILEPTAL TAB 600MG 4 MO valproate sodium 2 HI valproic acid 2 MO VIMPAT 4 HI ZARONTIN 4 MO ZONEGRAN 4 MO zonisamide 2 MO ANTIMIGRAINE AGENTS ALSUMA 4 AMERGE 4 AXERT 4 ergotamine w/ caffeine 2 FROVA 4 IMITREX 4 IMITREX STATDOSE REFILL 4

MAXALT 4 MAXALT-MLT 4 naratriptan hcl 2 RELPAX 4 rizatriptan benzoate 2 sumatriptan succinate 2 SUMAVEL DOSEPRO 4 TREXIMET 4 ZOMIG 4 ZOMIG ZMT 4 ANTIPARKINSONIAN AGENTS amantadine hcl 2 MO APOKYN 5 LD

Drug Name Drug Tier


AZILECT 3 MO benztropine mesylate inj 1mg/ml 2

benztropine mesylate tab 0.5mg 2 MO

benztropine mesylate tab 1mg 2 MO

benztropine mesylate tab 2mg 1 MO

bromocriptine mesylate 2 MO cabergoline 2 MO carbidopa-levodopa 2 MO COGENTIN 4 COMTAN 3 MO ELDEPRYL 4 MO EMSAM 4 MO entacapone 2 MO LODOSYN 3 MO MIRAPEX 4 MO MIRAPEX ER 4 MO NEUPRO 4 PARLODEL 4 MO pramipexole dihydrochloride 2 MO

REQUIP 4 MO REQUIP XL 4 MO ropinirole hydrochloride 2 MO selegiline hcl 2 MO SINEMET 4 MO SINEMET CR 4 MO STALEVO 100 3 MO STALEVO 125 3 MO STALEVO 150 3 MO STALEVO 200 3 MO STALEVO 50 3 MO STALEVO 75 3 MO TASMAR 4 MO trihexyphenidyl hcl 2 MO ZELAPAR 4 MO ANXIOLYTICS, SEDATIVES, AND HYPNOTICS alprazolam 2 AMBIEN 4 AMBIEN CR 4 ATIVAN 4 buspirone hcl tab 10mg 1 buspirone hcl tab 15mg 2 buspirone hcl tab 30mg 2 buspirone hcl tab 5mg 1 buspirone hcl tab 7.5mg 2


Drug Name Drug Tier


butabarbital sodium 2 BUTISOL SODIUM 4 chlordiazepoxide hcl 2 clorazepate dipotassium 2 diazepam 2 DIAZEPAM 4 EDLUAR 4 estazolam 2 flurazepam hcl 2 HALCION 4 hydroxyzine hcl 2 hydroxyzine pamoate 2 INTERMEZZO 4 MO LAZANDA 4 lorazepam 2 LUNESTA 4 meprobamate 2 NIRAVAM 4 oxazepam 2 phenobarbital 2 RESTORIL 4 ROZEREM 4 SILENOR 4 SONATA 4 temazepam 2 TRANXENE T 4 triazolam 2 VALIUM 4 VISTARIL 4 XANAX 4 XANAX XR 4 zaleplon 2 zolpidem tartrate 2 MO ZOLPIMIST 4 CENTRAL NERVOUS SYSTEM AGENTS, MISCELLANEOUS acamprosate calcium 2 MO CAMPRAL 3 MO INTUNIV 4 MO NAMENDA SOL 10MG/5ML 3

NAMENDA TAB 10MG 3 MO NAMENDA TAB 5MG 3 MO NAMENDA TITRATION PAK TAB 5-10MG 3 MO

NAMENDA XR CAP 14MG 4 MO

Drug Name Drug Tier





NAMENDA XR TITRATION PACK CAP TITRATIO

4 MO

NUEDEXTA 3 MO RILUTEK 5 riluzole 2 SAVELLA 3 MO SAVELLA TITRATION PACK 3 MO

STRATTERA 4 MO XENAZINE 5 XYREM 5 LD OPIATE ANTAGONISTS naloxone hcl 2 naltrexone hcl 2 VIVITROL 4 PSYCHOTHERAPEUTIC AGENTS ABILIFY DISCMELT TAB 10MG 3 MO

ABILIFY DISCMELT TAB 15MG 3 MO

ABILIFY INJ 9.75MG 3 ABILIFY MAINTENA INJ 300MG 4

ABILIFY SOL 1MG/ML 3 ABILIFY TAB 10MG 3 MO ABILIFY TAB 15MG 3 MO ABILIFY TAB 20MG 3 MO ABILIFY TAB 2MG 3 MO ABILIFY TAB 30MG 3 MO ABILIFY TAB 5MG 3 MO amitriptyline hcl 2 MO amoxapine 2 MO ANAFRANIL 4 MO APLENZIN 4 MO BRISDELLE 4 MO bupropion hcl 2 MO bupropion hcl (smoking deterrent) 2 MO

CELEXA 4 MO chlordiazepoxide-amitriptyline 2


Drug Name Drug Tier


chlorpromazine hcl 2 MO citalopram hydrobromide sol 10mg/5ml 2

citalopram hydrobromide tab 10mg 2 MO



clomipramine hcl 2 MO clozapine 2 MO CLOZARIL TAB 100MG 4 MO CLOZARIL TAB 25MG 4 MO CYMBALTA 4 MO desipramine hcl 2 MO DESVENLAFAXINE ER 4 MO doxepin hcl cap 100mg 1 MO doxepin hcl cap 10mg 1 MO doxepin hcl cap 150mg 2 MO doxepin hcl cap 25mg 1 MO doxepin hcl cap 50mg 1 MO doxepin hcl cap 75mg 1 MO doxepin hcl con 10mg/ml 2 EFFEXOR XR CAP 150MG 4 MO

EFFEXOR XR CAP 37.5MG 4 MO

EFFEXOR XR CAP 75MG 4 MO

escitalopram oxalate 2 MO FANAPT 4 MO FANAPT TITRATION PACK 4 MO

FAZACLO TAB 100/ODT 3 MO FAZACLO TAB 12.5/ODT 4 MO

FAZACLO TAB 150MG 4 MO FAZACLO TAB 200MG 4 MO FAZACLO TAB 25MG ODT 3 MO

fluoxetine dr cap 90mg dr 2 MO

FLUOXETINE HCL 4 MO fluoxetine hcl cap 10mg 1 MO fluoxetine hcl cap 20mg 1 MO fluoxetine hcl cap 40mg 1 MO fluoxetine hcl sol 20mg/5ml 2

fluoxetine hcl tab 10mg 2 MO

Drug Name Drug Tier


fluoxetine hcl tab 20mg 2 MO fluphenazine decanoate 2 fluphenazine hcl 2 MO fluvoxamine maleate 2 MO FORFIVO XL 4 GEODON 3 MO GEODON 4 MO HALDOL 4 HALDOL DECANOATE 100 4

HALDOL DECANOATE 50 4

haloperidol 2 MO haloperidol decanoate 2 haloperidol lactate 2 imipramine hcl 2 MO imipramine pamoate 2 MO INTERMEZZO 4 MO INVEGA 4 MO INVEGA SUSTENNA 4 LATUDA 4 MO LEXAPRO 4 MO lithium carbonate 2 MO LITHIUM CARBONATE CAP 600MG 3 MO

LITHIUM CITRATE 3 LITHOBID TAB 300MG CR 4 MO

loxapine succinate 2 MO LUVOX CR 4 MO maprotiline hcl 2 MO MARPLAN 4 MO mirtazapine 2 MO NARDIL 4 MO NAVANE 3 MO nefazodone hcl 2 MO NORPRAMIN 4 MO nortriptyline hcl cap 10mg 1 MO

nortriptyline hcl cap 25mg 1 MO



nortriptyline hcl sol 10mg/5ml 2

olanzapine 2 MO olanzapine-fluoxetine hcl 2 MO


Drug Name Drug Tier


OLEPTRO 4 MO ORAP 3 MO PAMELOR 4 MO PARNATE 4 MO paroxetine hcl er tab 12.5mg 2 MO

paroxetine hcl er tab 25mg er 2 MO

paroxetine hcl er tab 37.5mg 2 MO

paroxetine hcl tab 10mg 1 MO paroxetine hcl tab 20mg 1 MO paroxetine hcl tab 30mg 2 MO paroxetine hcl tab 40mg 2 MO PAXIL 4 MO PAXIL CR 4 MO perphenazine 2 MO perphenazine-amitriptyline 2 MO

PEXEVA 4 MO phenelzine sulfate 2 MO PRISTIQ 4 MO prochlorperazine 2 MO prochlorperazine edisylate 2

prochlorperazine maleate 2 MO

protriptyline hcl 2 MO PROZAC 4 MO PROZAC WEEKLY 4 MO quetiapine fumarate 2 MO REMERON 4 MO REMERON SOLTAB 4 MO RISPERDAL 4 MO RISPERDAL CONSTA 4 RISPERDAL M-TAB 4 MO risperidone 2 MO SAPHRIS 4 MO SARAFEM 4 MO SEROQUEL 4 MO SEROQUEL XR 4 MO sertraline hcl 2 MO SURMONTIL 4 MO SYMBYAX 4 MO thioridazine hcl 2 MO thiothixene 2 MO TOFRANIL-PM 4 MO tranylcypromine sulfate 2 MO

Drug Name Drug Tier


trazodone hcl tab 100mg 1 MO trazodone hcl tab 150mg 1 MO trazodone hcl tab 300mg 2 MO trazodone hcl tab 50mg 1 MO trifluoperazine hcl 2 MO trimipramine maleate 2 MO venlafaxine hcl 2 MO VENLAFAXINE HCL ER TAB 150MG ER 3 MO

VENLAFAXINE HCL ER TAB 225MG ER 3 MO

VENLAFAXINE HCL ER TAB 37.5 ER 3 MO

VENLAFAXINE HCL ER TAB 75MG ER 3 MO

VIIBRYD 4 MO WELLBUTRIN 4 MO WELLBUTRIN SR 4 MO WELLBUTRIN XL 4 MO ziprasidone hcl 2 MO ZOLOFT 4 MO ZYBAN 4 MO ZYPREXA 4 MO ZYPREXA ZYDIS 4 MO DIABETIC SUPPLIES DIABETIC SUPPLIES alcohol swabs 2 gauze pads & dressings 2 insulin pen needle 2 insulin syringe/needle u-100 2

syringe/needle (disp) 1 ml 2

ELECTROLYTIC, CALORIC, AND WATER BALANCE ACIDIFYING AND ALKALINIZING AGENTS ammonium chloride 2 HI potassium citrate (alkalinizer) 2

SODIUM LACTATE INJ 1/6M 3 HI

SODIUM LACTATE INJ 5MEQ/ML 4 HI

UROCIT-K 10 4 UROCIT-K 15 4 UROCIT-K 5 4 AMMONIA DETOXICANTS BUPHENYL 5


Drug Name Drug Tier


CARBAGLU 4 MO lactulose 2 MO lactulose (encephalopathy) 2

RAVICTI 5 sodium phenylbutyrate 2 CALORIC AGENTS amino acid electrolyte infusion 2 HI

amino acid infusion 2 HI AMINOSYN II 4.25/DEXTROSE 10% 3 HI

AMINOSYN II 4.25/DEXTROSE 20% 3 HI

AMINOSYN II 4.25/DEXTROSE 25% 3 HI

AMINOSYN II INJ 10% 4 HI AMINOSYN II INJ 15% 4 HI AMINOSYN II INJ 7% 4 HI AMINOSYN II INJ 8.5% 4 HI AMINOSYN II M 4.25 /DEXTROSE 10% 3 HI

AMINOSYN M INJ 3.5% 4 HI AMINOSYN-HBC INJ 7% 4 HI

AMINOSYN-PF 7% INJ 7% 4 HI

AMINOSYN-PF INJ 10% 4 HI BRANCHAMIN 4% INJ 4% 3 HI

CLINIMIX 2.75% /DEXTROSE 5% INJ 2.75/D5W

3 HI

CLINIMIX 4.25% /DEXTROSE 10% 3 HI




CLINIMIX 5% /DEXTROSE 15% 3 HI



CLINIMIX E 2.75% /DEXTROSE 10% 3 HI

Drug Name Drug Tier






CLINIMIX E 5% /DEXTROSE 15% 3 HI



DEXTRAN HM 3 HI dextrose 2 HI fat emulsion 2 HI FREAMINE III 3% INJ 3% 3 HI

INTRALIPID INJ 30% 4 HI LIPOSYN III INJ 10% 3 HI LIPOSYN III INJ 20% 4 HI NEPHRAMINE INJ 5.4% 3 HI PROCALAMINE INJ 3% 3 HI RENAMIN INJ 6.5% 3 HI TROPHAMINE INJ 10% 3 HI TROPHAMINE INJ 6% 3 HI DIURETICS amiloride & hydrochlorothiazide 1 MO

amiloride hcl 2 MO bumetanide inj 0.25/ml 2 bumetanide tab 0.5mg 1 MO bumetanide tab 1mg 1 MO bumetanide tab 2mg 2 MO chlorothiazide 2 MO chlorothiazide sodium 2 HI chlorthalidone 1 MO DEMADEX 4 MO DIURIL 3 DYAZIDE 4 MO DYRENIUM 3 MO EDECRIN 3 MO furosemide inj 10mg/ml 2 HI furosemide sol 10mg/ml 2 furosemide sol 8mg/ml 2 furosemide tab 20mg 1 MO furosemide tab 40mg 1 MO furosemide tab 80mg 1 MO


Drug Name Drug Tier


hydrochlorothiazide cap 12.5mg 1 MO

hydrochlorothiazide tab 12.5mg 2 MO

hydrochlorothiazide tab 25mg 1 MO

hydrochlorothiazide tab 50mg 1 MO

indapamide 1 MO LASIX 4 MO MAXZIDE 4 MO MAXZIDE-25 4 MO methyclothiazide 2 MO metolazone 2 MO MICROZIDE 4 MO SAMSCA 4 SODIUM DIURIL 4 HI SODIUM EDECRIN 3 HI THALITONE 4 MO torsemide 2 HI,MO triamterene/hydrochloro-thiazide cap 37.5-25 2 MO

triamterene/hydrochloro-thiazide cap 50-25mg 2 MO

triamterene/hydrochloro-thiazide tab 37.5-25 1 MO

triamterene/hydrochloro-thiazide tab 75-50mg 1 MO

ION-REMOVING AGENTS FOSRENOL 4 MO KAYEXALATE 4 MO RENAGEL 4 MO RENVELA PAK 0.8GM 4 MO RENVELA PAK 2.4GM 3 MO RENVELA TAB 800MG 3 MO sodium polystyrene sulfonate 2 MO

IRRIGATING SOLUTIONS irrigation solutions, physiological 2

lactated ringer's (irrigation) 2

ringer's irrigation 2 sodium chloride (gu irrigant) 2

water for irrigation, sterile 2

Drug Name Drug Tier


REPLACEMENT PREPARATIONS calcium acetate (phosphate binder) 2 MO

DEXTROSE 10%/NACL 0.45% INJ 0.45% 3 HI

DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX

3 HI



dextrose in lactated ringers 2 HI

dextrose w/ sodium chloride 2 HI

electrolyte-h in dextrose 2 HI electrolyte-m in dextrose 2 HI electrolyte-p in dextrose 2 HI electrolyte-s 2 HI electrolyte-s in dextrose 2 HI IONOSOL-B /DEXTROSE 5% 4 HI

IONOSOL-MB /DEXTROSE 5% 4 HI

K-TABS 3 MO KCL 0.15%/D5W/LR 3 HI KCL 0.15%/D5W/NACL 0.225% INJ 0.15/0.2 4 HI

KCL 0.3%/D5W/NACL 0.9% INJ 0.3/0.9% 3 HI

lactated ringer's 2 HI MAGNESIUM SULFATE IN D5W 3 HI

NORMOSOL-R 4 HI NORMOSOL-R IN D5W 4 HI parenteral electrolytes 2 HI PHOSLO CAP 667MG 4 MO PHOSLYRA SOL 3 PLASMA-LYTE A 3 HI PLASMA-LYTE-148 3 HI PLASMA-LYTE-56/D5W 3 HI potassium chloride 2 HI,MO POTASSIUM CHLORIDE 0.15% /NACL 0.45% VIAFLEX INJ .15-0.45

3 HI


Drug Name Drug Tier


POTASSIUM CHLORIDE 0.3%/ NACL 0.9% INJ 0.3-0.9

4 HI

potassium chloride in dextrose 2 HI

potassium chloride in dextrose & sodium chloride

2 HI

potassium chloride in nacl 2 HI

potassium chloride microencapsulated crystals cr

2 MO

ringer's inj 2 HI sodium chloride 2 HI ZINC TRACE METAL 3 HI URICOSURIC AGENTS colchicine w/ probenecid 2 MO probenecid 2 MO ENZYMES ENZYMES ADAGEN 3 LD ALDURAZYME 3 HI CEREZYME 5 HI ELAPRASE 5 ELELYSO 5 ELITEK 3 HI FABRAZYME 5 HI LUMIZYME 5 MYOZYME 5 NAGLAZYME 5 PULMOZYME 5 SUCRAID 4 LD VPRIV 5 EYE, EAR, NOSE, AND THROAT (EENT) PREPARATIONS ANTI-INFECTIVES AZASITE 4 bacitracin (ophthalmic) 2 MO bacitracin-polymyxin b (ophth) 2 MO

BESIVANCE 4 BLEPH-10 4 chlorhexidine gluconate (mouth-throat) 2

CILOXAN OIN 0.3% OP 3 MO CILOXAN SOL 0.3% OP 4 ciprofloxacin hcl (ophth) 2 MO erythromycin (ophth) 2 MO

Drug Name Drug Tier


gentamicin sulfate (ophth) 2 MO

levofloxacin (ophth) 2 MOXEZA 4 NATACYN 3 neomycin-bacitracin zn-polymyxin 2 MO

neomycin-polymy-gramicid 2

OCUFLOX 4 ofloxacin (ophth) 2 ofloxacin (otic) 2 polymyxin b-trimethoprim 2 POLYTRIM 4 sulfacetamide sodium (ophth) 2 MO

tobramycin sulfate (ophth) 2 MO

TOBREX OIN 0.3% OP 3 MO TOBREX SOL 0.3% OP 4 trifluridine 2 VIGAMOX 4 VIROPTIC 4 ZIRGAN 4 MO ZYMAXID 3 ANTI-INFLAMMATORY AGENTS ACULAR 4 ACULAR LS 4 ACUVAIL 4 ALREX 4 bacitracin-poly-neomycin-hc 2 MO

BECONASE AQ 4 BLEPHAMIDE 3 BROMDAY 4 bromfenac sodium (ophth) 2

CIPRO HC 4 CIPRODEX 3 COLY-MYCIN S 3 CORTISPORIN 4 MO CORTISPORIN-TC 3 DERMOTIC 4 dexamethasone sodium phosphate (ophth) 2

diclofenac sodium (ophth) 2

DUREZOL 4 FLAREX 4


Drug Name Drug Tier


FLONASE 4 flunisolide (nasal) 2 fluocinolone acetonide (otic) 2

flurbiprofen sodium 2 fluticasone propionate (nasal) 2

FML FORTE SUS 0.25% OP 3

FML LIQUIFILM SUS 0.1% OP 4

FML OIN 0.1% OP 3 MO hydrocortisone w/acetic acid 2

ILEVRO 4 ketorolac tromethamine (ophth) 2

LOTEMAX 4 MO MAXIDEX 4 MAXITROL 4 MO NASACORT AQ 4 NASONEX 4 neomycin-polymy-dexameth 2 MO

neomycin-polymyxin-hc (ophth) 2

neomycin-polymyxin-hc (otic) 2

NEVANAC 4 OCUFEN 4 OMNARIS 4 OMNIPRED SUS 1% OP 4 PRED FORTE SUS 1% OP 4

PRED MILD SUS 0.12% OP 3

PRED-G 3 PRED-G S.O.P. 3 MO prednisolone acetate (ophth) 2

prednisolone sodium phosphate (ophth) 2

PROLENSA 4 QNASL 4 RESTASIS 3 RHINOCORT AQUA 4 sulfacetamide sod-prednisolone 2 MO

Drug Name Drug Tier


TOBRADEX OIN 0.3-0.1% 3 MO

TOBRADEX ST SUS 0.3-0.05 4

TOBRADEX SUS 0.3-0.1% 4

tobramycin-dexamethasone 2 MO

triamcinolone acetonide (nasal) 2

VERAMYST 4 VEXOL 4 VOLTAREN 4 MO ZETONNA 4 ZYLET 4 ANTIALLERGIC AGENTS ALOCRIL 3 ALOMIDE 4 ASTELIN 4 ASTEPRO 4 azelastine hcl 2 azelastine hcl (ophth) 2 BEPREVE 4 cromolyn sodium (ophth) 2 DYMISTA 4 ELESTAT 4 EMADINE 4 epinastine hcl (ophth) 2 LASTACAFT 4 OPTIVAR 4 PATADAY 4 PATANASE 4 PATANOL 4 ANTIGLAUCOMA AGENTS acetazolamide 2 MO acetazolamide sodium 2 HI ALPHAGAN P 4 AZOPT 4 BETAGAN 4 betaxolol hcl (ophth) 2 BETIMOL 4 BETOPTIC-S 4 brimonidine tartrate 2 carteolol hcl (ophth) 2 COMBIGAN 4 COSOPT 4 DIAMOX 4 MO dorzolamide hcl 2


Drug Name Drug Tier


dorzolamide hcl-timolol maleate 2

ISOPTO CARPINE SOL 1% OP 4



ISTALOL 4 latanoprost 2 levobunolol hcl 2 LUMIGAN 3 methazolamide 2 MO metipranolol 2 OPTIPRANOLOL 4 PHOSPHOLINE IODIDE 3 PILOPINE HS GEL 4% OP 3 MO

RESCULA 4 SIMBRINZA 4 timolol maleate (ophth) 2 MO TIMOPTIC OCUDOSE 4 TIMOPTIC-XE 4 TRAVATAN Z 4 travoprost 2 TRUSOPT 4 XALATAN 4 ZIOPTAN 4 EENT DRUGS, MISCELLANEOUS acetic acid (otic) 2 apraclonidine hcl 2 CYSTARAN 4 IOPIDINE SOL 0.5% OP 4 IOPIDINE SOL 1% OP 3 LACRISERT 3 MO LOCAL ANESTHETICS lidocaine hcl (mouth-throat) 2

proparacaine hcl 2 MYDRIATICS tropicamide 2 VASOCONSTRICTORS naphazoline hcl 2 tetrahydrozoline hcl 2 GASTROINTESTINAL DRUGS ANTI-INFLAMMATORY AGENTS APRISO CAP 0.375GM 4 MO ASACOL HD TAB 800MG 4 MO

Drug Name Drug Tier


ASACOL TAB 400MG DR 3 MO

balsalazide disodium 2 MO CANASA SUP 1000MG 3 MO COLAZAL 4 MO DELZICOL CAP 400MG 4 MO DIPENTUM 4 MO GIAZO 4 LIALDA TAB 1.2GM 3 MO LOTRONEX 4 MO mesalamine w/ cleanser 2 PENTASA CAP 250MG CR 3 MO

PENTASA CAP 500MG CR 3 MO

SFROWASA ENE 4GM 4 ANTIDIARRHEA AGENTS diphenoxylate w/ atropine 2

FULYZAQ 4 MO LOMOTIL 4 loperamide hcl 2 MO MOTOFEN 4 ANTIEMETICS ALOXI 4 HI ANTIVERT 4 MO ANZEMET 4 PA,HI,MO CESAMET 4 PA dronabinol 2 EMEND CAP 125MG 3 PA,MO EMEND CAP 40MG 4 PA,MO EMEND CAP 80MG 3 PA,MO EMEND PAK 80 & 125 4 PA,MO granisetron hcl 2 PA,HI,MO MARINOL 4 meclizine hcl 2 MO ondansetron 2 PA,MO ondansetron hcl 2 PA,MO SANCUSO 4 MO TIGAN 4 PA,MO TRANSDERM-SCOP 3 MO trimethobenzamide hcl 2 PA,MO ZOFRAN 4 PA,MO ZOFRAN ODT 4 PA,MO ZUPLENZ 4 PA,MO ANTIULCER AGENTS AND ACID SUPPRESSANTS ACIPHEX 4 MO AXID 4


Drug Name Drug Tier


CARAFATE SUS 1GM/10ML 3

CARAFATE TAB 1GM 4 MO cimetidine 2 MO cimetidine hcl 2 CYTOTEC 4 MO DEXILANT 4 MO ESOMEPRAZOLE STRONTIUM 4 MO

famotidine 2 HI,MO famotidine in nacl 2 HI lansoprazole 2 MO misoprostol 2 MO NEXIUM 4 MO NEXIUM I.V. 4 HI nizatidine 2 MO OMECLAMOX-PAK 4 MO omeprazole 2 MO omeprazole-sodium bicarbonate 2 MO

pantoprazole sodium 2 HI,MO PEPCID 4 MO PREVACID 4 MO PREVACID SOLUTAB 4 MO PREVPAC 4 MO PRILOSEC 4 MO PROTONIX INJ 40MG 3 HI PROTONIX PAK 3 MO PROTONIX TAB 20MG 4 MO PROTONIX TAB 40MG 4 MO ranitidine hcl 2 HI,MO sucralfate 2 MO ZANTAC INJ 3 HI,MO ZANTAC 4 HI,MO ZEGERID 4 MO CATHARTICS AND LAXATIVES COLYTE-FLAVOR PACKS 4 MO

GOLYTELY 4 HALFLYTELY BOWEL PREP/FLAVOR PACKS 4

MOVIPREP 4 NULYTELY/FLAVOR PACKS 4

OSMOPREP 4 MO peg 3350-kcl-sod bicarb-sod chloride-sod sulfate 2 MO

Drug Name Drug Tier


peg 3350-potassium chloride-sod bicarbonate-sod chloride

2

polyethylene glycol 3350 2 PREPOPIK 4 SUPREP BOWEL PREP 4 DIGESTANTS CREON CAP 12000UNT 3 MO CREON CAP 24000UNT 3 MO CREON CAP 3000UNIT 3 MO CREON CAP 36000UNT 3 MO CREON CAP 6000UNIT 3 MO PANCREAZE CAP 10500UNT 4 MO

PANCREAZE CAP 16800UNT 4 MO

PANCREAZE CAP 21000UNT 4 MO

PANCREAZE CAP 4200UNIT 4 MO

PERTZYE CAP 4 ULTRESA CAP 13800UNT 4 MO

ULTRESA CAP 20700UNT 4 MO

ULTRESA CAP 23000UNT 4 MO

VIOKACE TAB 4 ZENPEP CAP 10000UNT 3 MO

ZENPEP CAP 15000UNT 3 MO



ZENPEP CAP 3000UNIT 4 MO ZENPEP CAP 5000UNIT 3 MO GI DRUGS, MISCELLANEOUS ACTIGALL CAP 300MG 4 MO AMITIZA 3 MO chenodiol 2 GATTEX 5 LINZESS 4 metoclopramide hcl 2 HI,MO METOZOLV ODT 4 MO REGLAN 4 MO RELISTOR 4


Drug Name Drug Tier


URSO 250 TAB 250MG 3 MO URSO FORTE TAB 500MG 3 MO

ursodiol 2 MO GOLD COMPOUNDS GOLD COMPOUNDS RIDAURA 3 HEAVY METAL ANTAGONISTS HEAVY METAL ANTAGONISTS CHEMET 3 CUPRIMINE 3 DEPEN TITRATABS 3 EXJADE TAB 125MG 3 EXJADE TAB 250MG 5 EXJADE TAB 500MG 5 FERRIPROX 5 SYPRINE 4 HORMONES AND SYNTHETIC SUBSTITUTES ADRENALS ARISTOSPAN INTRA-ARTICULAR 3

ARISTOSPAN INTRALESIONAL 3

budesonide 2 MO CELESTONE 3 CORTEF 4 MO cortisone acetate 2 MO DEPO-MEDROL INJ 20MG/ML 3 PA

DEPO-MEDROL INJ 40MG/ML 4 PA

DEPO-MEDROL INJ 80MG/ML 4 PA

dexamethasone 2 PA,MO dexamethasone sodium phosphate 2

ENTOCORT EC 5 FLO-PRED 4 fludrocortisone acetate 2 MO hydrocortisone 2 MO hydrocortisone sod succinate 2

KENALOG-10 3 KENALOG-40 3 MEDROL DOSEPAK PAK 4MG 4 PA,MO

MEDROL TAB 16MG 4 PA,MO MEDROL TAB 2MG 3 MO MEDROL TAB 32MG 4 PA,MO

Drug Name Drug Tier


MEDROL TAB 4MG 4 PA,MO MEDROL TAB 8MG 4 PA,MO methylprednisolone 2 PA,MO methylprednisolone acetate 2 PA

methylprednisolone sod succ 2 PA

ORAPRED ODT 4 MO prednisolone 2 MO prednisolone sodium phosphate 2 PA,MO

prednisone 2 PA,MO RAYOS 4 PA SOLU-CORTEF 3 SOLU-MEDROL INJ 125MG 4 PA

SOLU-MEDROL INJ 1GM 3

SOLU-MEDROL INJ 2GM 3 PA

SOLU-MEDROL INJ 40MG 3 PA

SOLU-MEDROL INJ 500MG 3 PA

UCERIS 5 ANDROGENS ANDRODERM DIS 2MG/24HR 3

ANDRODERM DIS 4MG/24HR 3

ANDROGEL GEL 1%(50MG) 4

ANDROGEL PUMP GEL 1.62% 4

ANDROGEL PUMP GEL PUMP 1% 3

AXIRON SOL 30MG/ACT 4

danazol 2 MO DELATESTRYL 4 fluoxymesterone 2 FORTESTA GEL 10MG/ACT 4

methyltestosterone 2 oxandrolone 2 STRIANT MIS 30MG 4 TESTIM GEL 1%(50MG) 4 testosterone cypionate 2 testosterone enanthate 2


Drug Name Drug Tier


CONTRACEPTIVES BEYAZ 4 MO BREVICON-28 4 MO CYCLESSA 4 MO DESOGEN 4 MO desogestrel & ethinyl estradiol 2 MO

desogestrel-ethinyl estradiol (biphasic) 2 MO

desogestrel-ethinyl estradiol (triphasic) 2 MO

drospirenone-ethinyl estradiol 2 MO

ELLA 3 MO ESTROSTEP FE 4 MO ethynodiol diacet & eth estrad 2 MO

FEMCON FE 4 MO GENERESS FE 4 MO levonorgestrel & eth estradiol 2 MO

levonorgestrel (emergency oc) 2 MO

levonorgestrel-eth estradiol (triphasic) 2 MO

levonorgestrel-ethinyl estradiol (91-day) 2 MO

levonorgestrel-ethinyl estradiol (continuous) 2 MO

LO LOESTRIN FE 4 MO LO MINASTRIN FE 4 MO LO/OVRAL-28 4 MO LOESTRIN 24 FE 4 MO LOSEASONIQUE 4 MO LYBREL 4 MO MINASTRIN 24 FE 4 MO MODICON 4 MO NOR-QD 4 MO NORDETTE-28 4 MO norethin acet & estrad-fe 2 MO norethindrone & eth estradiol 2 MO

norethindrone & ethinyl estradiol-fe 2 MO

norethindrone (contraceptive) 2 MO

norethindrone acet & eth estra 2 MO

Drug Name Drug Tier


norethindrone acetate-ethinyl estradiol-fe 2 MO

norethindrone-eth estradiol (biphasic) 2 MO

norethindrone-eth estradiol (triphasic) 2 MO

norgestimate-ethinyl estradiol 2 MO

norgestimate-ethinyl estradiol (triphasic) 2 MO

norgestrel & ethinyl estradiol 2 MO

NORINYL 1+35 4 MO NUVARING 3 MO ORTHO EVRA 4 MO ORTHO MICRONOR 4 MO ORTHO TRI-CYCLEN 4 MO ORTHO TRI-CYCLEN LO 4 MO

ORTHO-CEPT 4 MO ORTHO-CYCLEN 4 MO ORTHO-NOVUM 7/7/7 4 MO OVCON-50 28 4 MO PLAN B ONE-STEP 3 MO QUARTETTE 4 MO SAFYRAL 4 MO SEASONALE 4 MO SEASONIQUE 4 MO TRI-NORINYL 28 4 MO YASMIN 28 4 MO YAZ 4 MO DIABETIC AGENTS acarbose 2 MO ACTOPLUS MET 4 MO ACTOPLUS MET XR 4 MO ACTOS TAB 15MG 3 MO ACTOS TAB 30MG 4 MO ACTOS TAB 45MG 4 MO AMARYL 4 MO APIDRA 4 APIDRA SOLOSTAR 4 AVANDAMET 4 LD,MO AVANDARYL 4 LD,MO AVANDIA 4 LD,MO BYDUREON 4 BYETTA 4 chlorpropamide 2 MO CYCLOSET 4 MO


Drug Name Drug Tier


DIABETA 4 MO DUETACT 4 MO FORTAMET 4 MO glimepiride 2 MO glipizide er tab 10mg 2 MO glipizide er tab 2.5mg 2 MO glipizide er tab 5mg 2 MO glipizide tab 10mg 1 MO glipizide tab 5mg 1 MO glipizide-metformin hcl 2 MO GLUCAGEN HYPOKIT 3 GLUCAGON EMERGENCY KIT 3

GLUCOPHAGE 4 MO GLUCOPHAGE XR 4 MO GLUCOTROL 4 MO GLUCOTROL XL 4 MO GLUCOVANCE 4 MO GLUMETZA 4 MO glyburide 2 MO glyburide micronized 2 MO glyburide-metformin 2 MO GLYNASE 4 MO GLYSET 4 MO HUMALOG INJ 100/ML 3 PA HUMALOG KWIKPEN INJ 100/ML 4

HUMALOG MIX 50/50 4 HUMALOG MIX 50/50 KWIKPEN 4

HUMALOG MIX 75/25 4 HUMALOG MIX 75/25 KWIKPEN 4

HUMULIN 70/30 INJ 70/30 3

HUMULIN 70/30 PEN INJ 70/30 4

HUMULIN N INJ U-100 3 HUMULIN N U-100 PEN INJ U-100 4

HUMULIN R INJ U-100 3 PA HUMULIN R U-500 (CONCENTRATED) INJ U-500

3

INVOKANA 4 MO JANUMET 4 MO JANUMET XR 4 MO JANUVIA 4 MO JENTADUETO 4 MO

Drug Name Drug Tier


JUVISYNC 4 MO KAZANO 4 MO KOMBIGLYZE XR 4 MO KORLYM 5 LANTUS INJ 100/ML 3 LANTUS SOLOSTAR INJ SOLOSTAR 4

LEVEMIR 4 LEVEMIR FLEXPEN 4 metformin hcl er tab 1000mg 2 MO

metformin hcl er tab 500mg er 1 MO

metformin hcl er tab 750mg er 2 MO

metformin hcl tab 1000mg 1 MO

metformin hcl tab 500mg 1 MO metformin hcl tab 850mg 1 MO nateglinide 2 MO NESINA 4 MO NOVOLIN 70/30 INJ 70/30 4

NOVOLIN N INJ U-100 4 NOVOLIN R INJ U-100 4 PA NOVOLOG 4 PA NOVOLOG FLEXPEN 4 NOVOLOG MIX 70/30 4 NOVOLOG MIX 70/30 PREFILLED FLEXPEN 4

ONGLYZA 4 MO OSENI 4 MO pioglitazone hcl 2 MO pioglitazone hcl-glimepiride 2 MO

pioglitazone hcl-metformin hcl 2 MO

PRANDIMET 4 MO PRANDIN 3 MO PRECOSE 4 MO repaglinide 2 MO RIOMET 4 STARLIX 4 MO SYMLINPEN 120 4 SYMLINPEN 60 4 tolazamide 2 MO tolbutamide 2 MO TRADJENTA 4 MO VICTOZA 4


Drug Name Drug Tier


ESTROGENS AND ANTIESTROGENS ACTIVELLA 4 MO ALORA DIS 0.025MG 4 MO ALORA DIS 0.05MG 4 MO ALORA DIS 0.075MG 4 MO ALORA DIS 0.1MG 4 MO ANGELIQ 4 MO CENESTIN 4 MO CLIMARA DIS 0.025MG 3 MO CLIMARA DIS 0.0375MG 3 MO

CLIMARA DIS 0.05MG 3 MO CLIMARA DIS 0.06MG 3 MO CLIMARA DIS 0.075MG 3 MO CLIMARA DIS 0.1MG 3 MO CLIMARA PRO 4 MO COMBIPATCH 4 MO DELESTROGEN 4 DIVIGEL GEL 1MG/GM 4 MO ELESTRIN GEL 0.06% 4 MO ENJUVIA 4 MO esterified estrogens 2 MO estradiol 2 MO estradiol & norethindrone acetate 2 MO

estradiol cypionate 2 estradiol vaginal 2 MO estradiol valerate 2 estradiol-norgestimate 2 MO ESTRASORB EMU 4 ESTRING 3 MO estropipate 2 MO EVAMIST SPR 1.53MG 4 EVISTA 3 MO FEMHRT 1/5 4 MO FEMHRT LOW DOSE 4 MO FEMRING 4 MO FEMTRACE 4 MO MENOSTAR DIS 14MCG 4 MO

MINIVELLE DIS 0.0375MG 4 MO

MINIVELLE DIS 0.05MG 4 MO MINIVELLE DIS 0.075MG 4 MO

MINIVELLE DIS 0.1MG 4 MO norethindrone acetate-ethinyl estradiol 2 MO

Drug Name Drug Tier


PREMARIN 3 MO PREMARIN INJ 25MG 3 PREMARIN TAB 0.3MG 4 MO PREMARIN TAB 0.45MG 4 MO

PREMARIN TAB 0.625MG 4 MO

PREMARIN TAB 0.9MG 4 MO PREMARIN TAB 1.25MG 4 MO

PREMPHASE 4 MO PREMPRO 4 MO VAGIFEM 3 MO VIVELLE-DOT DIS 0.025MG 4 MO

VIVELLE-DOT DIS 0.0375MG 4 MO




GONADOTROPINS chorionic gonadotropin 2 SYNAREL 3 PARATHYROID calcitonin (salmon) 2 FORTEO 5 PA FORTICAL SPR 200/ACT 3

MIACALCIN INJ 200/ML 3 MIACALCIN SPR 200/ACT 4

PITUITARY ACTHAR HP 5 DDAVP 4 MO DDAVP INJ 4MCG/ML 4 DDAVP TAB 0.1MG 4 MO DDAVP TAB 0.2MG 4 MO desmopressin acetate 2 MO desmopressin acetate spray refrigerated 2

STIMATE SOL 1.5MG/ML 3

PROGESTINS CRINONE 4 MO DEPO-PROVERA 3


Drug Name Drug Tier


DEPO-PROVERA CONTRACEPTIVE INJ 150MG/ML

4

DEPO-SUBQ PROVERA 104 INJ 104 3

ENDOMETRIN 4 MO medroxyprogesterone acetate 2 MO

medroxyprogesterone acetate (contraceptive) 2

MEGACE ES 4 norethindrone acetate 2 MO progesterone micronized 2 MO PROMETRIUM 4 MO PROVERA 4 MO SOMATOTROPIN AGONISTS AND ANTAGONISTS EGRIFTA 4 GENOTROPIN INJ 12MG 4

GENOTROPIN INJ 5MG 4 GENOTROPIN MINIQUICK INJ 0.2MG 4

GENOTROPIN MINIQUICK INJ 0.4MG 4







GENOTROPIN MINIQUICK INJ 1MG 4

GENOTROPIN MINIQUICK INJ 2MG 4

HUMATROPE COMBO PACK INJ 5MG 5

HUMATROPE INJ 12MG 5 HUMATROPE INJ 24MG 5 HUMATROPE INJ 6MG 5 INCRELEX 5 LD NORDITROPIN FLEXPRO INJ 10/1.5ML 5

Drug Name Drug Tier


NORDITROPIN FLEXPRO INJ 15/1.5ML 5

NORDITROPIN FLEXPRO INJ 5/1.5ML 5

NORDITROPIN NORDIFLEX PEN INJ 30/3ML

5

NUTROPIN AQ NUSPIN 5 INJ NUSPIN 5 5

NUTROPIN AQ PEN INJ 10MG/2ML 5

NUTROPIN AQ PEN INJ 20MG/2ML 5

NUTROPIN INJ 10MG 5 OMNITROPE INJ 10/1.5ML 3

OMNITROPE INJ 5.8MG 3 OMNITROPE INJ 5/1.5ML 3

SAIZEN 5 SAIZEN CLICK.EASY 5 SEROSTIM 5 SIGNIFOR 5 SOMAVERT 5 LD TEV-TROPIN INJ 5MG 5 ZORBTIVE 5 THYROID AND ANTITHYROID AGENTS ARMOUR THYROID 3 MO CYTOMEL 4 MO levothyroxine sodium 2 MO liothyronine sodium 2 HI,MO methimazole 2 MO propylthiouracil 2 MO SYNTHROID 4 MO THYROLAR-1 4 MO THYROLAR-1/2 4 MO THYROLAR-1/4 4 MO THYROLAR-2 4 MO THYROLAR-3 4 MO TIROSINT 4 MO MISCELLANEOUS THERAPEUTIC AGENTS MISCELLANEOUS THERAPEUTIC AGENTS acetylcysteine 2 PA ACTEMRA 4 HI ACTIMMUNE 5 LD ACTONEL 4 alendronate sodium sol 70/75ml 2


Drug Name Drug Tier


alendronate sodium tab 10mg 1





allopurinol 2 allopurinol sodium 2 HI amifostine crystalline 2 HI AMPYRA 5 ARAVA 4 ARCALYST 5 LD ASTAGRAF XL CAP 0.5MG 4 MO

ASTAGRAF XL CAP 1MG 4 MO

ASTAGRAF XL CAP 5MG 4 MO

ATELVIA 4 ATGAM 4 HI AUBAGIO 5 AVODART 4 AVONEX 5 AVONEX PEN 5 azathioprine 2 PA azathioprine sodium 2 HI BENLYSTA 5 BERINERT 5 BETASERON INJ 0.3MG 5 BINOSTO 4 MO BONIVA 4 PA,HI BOTOX 3 CARNITOR 4 PA,HI CELLCEPT CAP 250MG 4 PA CELLCEPT INTRAVENOUS 4 PA,HI

CELLCEPT SUS 200MG/ML 3 PA

CELLCEPT TAB 500MG 4 PA CIMZIA 5 CINRYZE 5 HI COLCRYS 3 COPAXONE 5 cyclosporine 2 PA,HI

Drug Name Drug Tier


cyclosporine modified (for microemulsion) 2 PA

CYSTADANE 4 LD CYSTAGON CAP 150MG 4 LD

CYSTAGON CAP 50MG 4 LD DEMSER 4 dexrazoxane 2 HI DIDRONEL 4 disulfiram 2 DYSPORT 4 ELMIRON 3 ENBREL 5 ENBREL SURECLICK 5 ETHYOL 4 HI etidronate disodium 2 EXTAVIA INJ 0.3MG 3 finasteride 2 FIRAZYR 5 fomepizole 2 HI FOSAMAX 4 FOSAMAX PLUS D 4 FUSILEV 4 HI GILENYA 5 HEMABATE 3 HUMIRA 5 HUMIRA PEN-CROHNS DISEASE STARTER 5

ibandronate sodium 2 PA,HI IMURAN 4 PA JALYN 4 KINERET 5 KUVAN 5 leflunomide 2 leucovorin calcium 2 HI levocarnitine (metabolic modifiers) 2 PA,HI

lidocaine hcl (local anesth.) 2

mesna 2 HI MESNEX INJ 1GM 4 HI MESNEX TAB 400MG 3 METHERGINE 4 methylergonovine maleate 2

MIFEPREX 3 mycophenolate mofetil 2 PA MYFORTIC 3 PA


Drug Name Drug Tier


NEORAL CAP 100MG 4 PA NEORAL CAP 25MG 4 PA NEORAL SOL 100MG/ML 3 PA

NULOJIX 5 PA,HI octreotide acetate 2 ORENCIA 5 ORFADIN 5 LD pamidronate disodium 2 HI PROCYSBI CAP 25MG 5 PROCYSBI CAP 75MG 5 PROGRAF CAP 0.5MG 4 PA PROGRAF CAP 1MG 4 PA PROGRAF CAP 5MG 4 PA PROGRAF INJ 5MG/ML 3 PA,HI PROLIA SOL 60MG/ML 4 PROSCAR 4 RAPAMUNE SOL 1MG/ML 5 PA

RAPAMUNE TAB 0.5MG 3 PA RAPAMUNE TAB 1MG 5 PA RAPAMUNE TAB 2MG 5 PA REBIF 5 REBIF TITRATION PACK 5

RECLAST 4 HI REMICADE 5 RIMSO-50 3 SANDIMMUNE 3 PA,HI SANDOSTATIN INJ 1000MCG 4

SANDOSTATIN INJ 100MCG 4



SANDOSTATIN INJ 50MCG/ML 4

SANDOSTATIN LAR DEPOT KIT LAR 10MG 5



SENSIPAR 3 SIMPONI 5 SIMPONI ARIA 5 SIMULECT 4 PA,HI

Drug Name Drug Tier


SKELID 4 SODIUM FLUORIDE 3 SODIUM FLUORIDE 3 SOMATULINE DEPOT 4 tacrolimus 2 PA,HI,MO TECFIDERA 5 TECFIDERA STARTER PACK 5

THALOMID 5 THYMOGLOBULIN 4 HI TYSABRI 5 ULORIC 4 VORAXAZE 5 XELJANZ 5 XEOMIN 4 XGEVA INJ 5 XYLOCAINE 4 ZAVESCA 5 LD ZINECARD 3 HI zoledronic acid 2 HI ZOMETA 4 HI ZORTRESS 4 PA ZYLOPRIM 4 RESPIRATORY TRACT AGENTS ANTI-INFLAMMATORY AGENTS ACCOLATE 4 MO cromolyn sodium 2 cromolyn sodium (mastocytosis) 2

GASTROCROM 4 montelukast sodium 2 MO SINGULAIR 3 MO zafirlukast 2 MO ZYFLO 4 MO ZYFLO CR 4 MO RESPIRATORY AGENTS, MISCELLANEOUS ALVESCO 4 MO ARALAST NP 5 ASMANEX 120 METERED DOSES AER 220MCG

3 MO

ASMANEX 14 METERED DOSES AER 220MCG

4 MO


3 MO


Drug Name Drug Tier



4 MO


3 MO

budesonide (inhalation) 2 MO DALIRESP 4 MO DULERA 3 MO FLOVENT DISKUS 4 MO FLOVENT HFA AER 110MCG 4 MO

FLOVENT HFA AER 220MCG 4 MO

FLOVENT HFA AER 44MCG 3 MO

GLASSIA 5 KALYDECO 5 PROLASTIN-C 5 PULMICORT FLEXHALER INH 180MCG

3 MO

PULMICORT FLEXHALER INH 90MCG

4 MO

PULMICORT SUS 0.25MG/2 4

PULMICORT SUS 0.5MG/2 4

PULMICORT SUS 1MG/2ML 4

QVAR 3 MO SYMBICORT 4 MO XOLAIR 5 LD ZEMAIRA 5 SERUMS, TOXOIDS, AND VACCINES SERUMS ANTIVENIN LATRODECTUS MAC TANS

3

CARIMUNE NANOFILTERED 3 PA,HI

CYTOGAM 3 HI FLEBOGAMMA DIF 3 HI GAMASTAN S/D 3 GAMMAGARD LIQUID 3 PA,HI GAMMAGARD S/D 3 HI GAMMAPLEX 3 PA,HI GAMUNEX 3 HI

Drug Name Drug Tier


GAMUNEX-C 3 HI HIZENTRA 4 PA HYPERRHO S/D 3 HYPERTET S/D 3 IMOGAM RABIES-HT 3 NABI-HB 3 OCTAGAM 3 HI PRIVIGEN 3 PA,HI RHOPHYLAC 3 TOXOIDS DECAVAC 6 DIPHTHERIA/TETANUS TOXOID PEDIATRIC 6

TETANUS TOXOID ADSORBED 3

TETANUS/DIPHTHERIA TOXOID S-ADSORBED ADULT

6

VACCINES ACTHIB 6 ADACEL 6 BOOSTRIX 6 CERVARIX 6 COMVAX 6 DAPTACEL 6 ENGERIX-B 6 PA GARDASIL 6 HAVRIX 6 IMOVAX RABIES (H.D.C.V.) 6

INFANRIX 6 IPOL INACTIVATED IPV 6 IXIARO 6 JE-VAX 6 M-M-R II W/DILUENT 10 DOSE 6

MENACTRA 6 MENOMUNE-A/C/Y/W-135 6

MENVEO 6 PEDVAX HIB 6 PROQUAD 6 RABAVERT 6 RECOMBIVAX HB 6 PA ROTATEQ 6 TRIPEDIA 6 TWINRIX 6 TYPHIM VI 6


Drug Name Drug Tier


VAQTA 6 VARIVAX 6 YF-VAX 6 ZOSTAVAX 6 SKIN AND MUCOUS MEMBRANE AGENTS ANTI-INFECTIVES (SKIN AND MUCOUS MEMBRANE) ACANYA 4 MO acyclovir topical 2 MO AKNE-MYCIN 3 MO ALTABAX 4 MO AVC 3 MO BACTROBAN 3 MO BACTROBAN 4 MO BACTROBAN NASAL 3 MO BENZACLIN WITH PUMP 4 MO

BENZAMYCIN 4 MO benzoyl peroxide-erythromycin 2 MO

butoconazole nitrate (one dose) 2

ciclopirox 2 MO ciclopirox olamine 2 MO CLEOCIN CRE 2% VAG 4 MO CLEOCIN SUP 100MG 3 MO CLEOCIN-T 4 MO CLINDAGEL 4 MO clindamycin phosphate & cleanser 2 MO

clindamycin phosphate (topical) 2 MO

clindamycin phosphate vaginal 2 MO

clindamycin phosphate-benzoyl peroxide 2 MO

clotrimazole 2 MO clotrimazole (topical) 2 MO clotrimazole w/ betamethasone 2 MO

DENAVIR 4 MO econazole nitrate 2 MO ERTACZO 4 MO erythromycin (acne aid) 2 MO EURAX 4 MO EVOCLIN 4 EXELDERM 4 MO EXTINA 4

Drug Name Drug Tier


gentamicin sulfate (topical) 2 MO

ketoconazole & cleanser 2 ketoconazole (topical) 2 MO KLARON 4 lindane 2 LOPROX 4 MO LOPROX SHAMPOO 4 LOTRISONE 4 MO mafenide acetate 2 MO malathion 2 MENTAX 4 MO METROCREAM 4 MO METROGEL 4 MO METROGEL-VAGINAL 4 MO METROLOTION 4 metronidazole (topical) 2 MO metronidazole vaginal 2 MO miconazole nitrate vaginal 2 MO

mupirocin 2 MO mupirocin calcium (topical) 2 MO

NAFTIN 4 MO neomycin/polymyxin b gu 2 NIZORAL 4 NORITATE 4 MO nystatin (topical) 2 MO OVIDE 4 OXISTAT 4 MO PENLAC NAIL LACQUER 4

permethrin 2 MO PHISOHEX 3 selenium sulfide 2 SILVADENE 4 MO silver sulfadiazine 2 MO SPINOSAD 4 sulfacetamide sodium (acne) 2

SULFAMYLON CRE 85MG/GM 3 MO

SULFAMYLON PAK 5% 4 TERAZOL 3 4 MO TERAZOL 7 4 MO terconazole vaginal 2 MO ULESFIA 4 XERESE 4 MO ZOVIRAX 4 MO


Drug Name Drug Tier


ANTI-INFLAMMATORY AGENTS (SKIN AND MUCOUS MEMBRANE) alclometasone dipropionate 2 MO

amcinonide 2 MO betamethasone dipropionate (topical) 2 MO

betamethasone dipropionate augmented 2 MO

betamethasone valerate 2 MO CAPEX SHA 0.01% 3 clobetasol propionate 2 MO clobetasol propionate emollient base 2 MO

CLOBEX 4 CLODERM PUMP 4 MO CORDRAN LOT 0.05% 4 CORDRAN TAPE TAP 4MCG/CM 3 MO

CORTENEMA 4 CORTIFOAM 4 MO CORTISPORIN 3 MO CUTIVATE 4 MO DERMA-SMOOTHE/FS BODY OIL OIL /FS BODY

4

DERMATOP 4 MO DESONATE 4 MO desonide 2 MO DESOWEN 4 MO desoximetasone 2 MO DESOXIMETASONE 4 MO diflorasone diacetate 2 MO DIPROLENE 4 MO DIPROLENE AF 4 MO ELOCON 4 MO fluocinolone acetonide 2 MO fluocinonide 2 MO fluocinonide emulsified base 2 MO

fluticasone propionate 2 MO halobetasol propionate 2 MO HALOG 4 MO hydrocortisone (intrarectal) 2

hydrocortisone (rectal) 2 MO hydrocortisone (topical) 2 MO hydrocortisone butyrate 2 MO

Drug Name Drug Tier


hydrocortisone valerate 2 MO KENALOG 3 LOCOID 4 MO LOCOID LIPOCREAM 4 MO LUXIQ 4 MO mometasone furoate 2 MO nystatin-triamcinolone 2 MO OLUX-E 4 PANDEL 4 MO prednicarbate 2 MO SYNALAR CREAM KIT 4 TACLONEX 4 MO TOPICORT 4 MO triamcinolone acetonide (mouth) 2 MO

triamcinolone acetonide (topical) 2 MO

ULTRAVATE 4 MO urea-hc acetate 2 MO VANOS 4 MO VERDESO 4 WESTCORT 4 MO ANTIPRURITICS AND LOCAL ANESTHETICS EMLA 4 PA,MO hydrocortisone acetate w/ pramoxine 2

lidocaine 2 MO lidocaine hcl 2 MO lidocaine-prilocaine 2 PA,MO LIDODERM 4 MO SYNERA 4 MO XYLOCAINE 4 ZONALON 4 MO CELL STIMULANTS AND PROLIFERANTS ATRALIN GEL 0.05% 4 PA,MO KEPIVANCE 5 HI RETIN-A CRE 0.025% 3 PA RETIN-A CRE 0.05% 3 PA RETIN-A CRE 0.1% 3 PA RETIN-A GEL 0.01% 3 PA RETIN-A GEL 0.025% 3 PA RETIN-A MICRO 3 PA tretinoin 2 PA,MO tretinoin w/ cleanser & moisturizer 2 PA

SKIN AND MUCOUS MEMBRANE AGENTS, MISCELLANEOUS 8-MOP 3 MO


Drug Name Drug Tier


ABSORICA 4 MO acitretin 2 ACZONE 4 MO adapalene 2 MO ALDARA 4 MO AMEVIVE 5 AZELEX 3 MO calcipotriene 2 MO CARAC CRE 0.5% 3 MO CONDYLOX 3 MO DIFFERIN CRE 0.1% 3 MO DIFFERIN GEL 0.1% 3 MO DIFFERIN GEL 0.3% 3 MO DIFFERIN LOT 0.1% 4 DOVONEX 4 MO DOVONEX SCALP 4 EFUDEX CRE 5% 4 MO ELIDEL 3 MO EPIDUO 3 MO FINACEA 3 MO FLECTOR 4 MO FLUOROPLEX CRE 1% 3 MO fluorouracil (topical) 2 MO imiquimod 2 MO isotretinoin 2 MO LAC-HYDRIN 4 MO lactic acid (ammonium lactate) 2 MO

ORACEA 4 MO OXSORALEN 3 OXSORALEN ULTRA 3 MO PANRETIN 5 PENNSAID 4 PICATO 4 MO podofilox 2 MO PROTOPIC 3 MO PRUDOXIN 3 MO RECTIV 4 MO REGRANEX 5 SANTYL 3 MO SOLARAZE 4 MO SORIATANE 5 SORILUX 4 STELARA 4 TARGRETIN 3 MO TAZORAC 3 MO UVADEX 4 VECTICAL 3 MO VELTIN 4 MO

Drug Name Drug Tier


VEREGEN 4 MO VOLTAREN 4 MO ZIANA 4 MO ZYCLARA 4 MO SMOOTH MUSCLE RELAXANTS SMOOTH MUSCLE RELAXANTS aminophylline 2 HI DETROL 4 MO DETROL LA 4 MO DITROPAN XL 4 MO ENABLEX 4 MO flavoxate hcl 2 MO GELNIQUE 4 MO GELNIQUE GEL 3% 4 MO LUFYLLIN 4 MO MYRBETRIQ 4 oxybutynin chloride 2 MO OXYTROL DIS 3.9MG/24 3 MO

SANCTURA 4 MO SANCTURA XR 4 MO theophylline 2 MO tolterodine tartrate 2 MO TOVIAZ 4 MO trospium chloride 2 MO VESICARE 4 MO VITAMINS VITAMINS CALCIJEX INJ 1MCG/ML 4 HI

calcitriol 2 PA,HI,MO HECTOROL 4 PA,HI,MO niacin (antihyperlipidemic) 2 MO

ROCALTROL CAP 0.25MCG 3 PA,MO

ROCALTROL CAP 0.5MCG 3 PA,MO

ROCALTROL SOL 1MCG/ML 4 PA

TRINATAL RX 1 3 MO VINATE CALCIUM 3 MO VITASPIRE 3 MO ZEMPLAR 4 PA,HI,MO


The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug. Certain strengths or forms of the drug may be subject to the utilization management codes listed below. HI = Home infusion drugs may be covered under our medical benefit and obtained at home infusion pharmacies. For more information, please consult your pharmacy directory or call our plan at the number listed on the back cover for your Kaiser Permanente Region. LD = Limited-distribution drugs can only be obtained at certain specialty pharmacies. For more information, consult your pharmacy directory or call our plan at the number listed on the back cover for your Kaiser Permanente Region. MO = Mail-order drugs. You may order prescription refills of certain medications through our mail-order service online at kp.org/rxrefill or

by phone or mobile app, which may lower your costs for a three-month supply. Additional drugs may be available for mail order. Not all drugs can be mailed; restrictions and limitations apply. For more information, please contact your pharmacy or the phone number on the prescription label, visit kp.org/seniormedrx, or call our plan at the number listed on the back cover for your Kaiser Permanente Region. PA = Prior authorization medications may be covered under Medicare Part D or Medicare Part B depending on how they are administered (e.g., via infusion pump, nebulizer, or other Durable Medical Equipment device), where they are administered (at home or in a long-term care facility), and what medical condition they are administered for. Prior authorization may also apply to drugs for which treatment for the medical condition will determine if the drug is non-Part D (excluded) or covered.


http://www.kp.org/rxrefill


Index of Drugs

8 8-MOP ........................................................ 43

A abacavir sulfate .......................................... 10 ABELCET ..................................................... 9 ABILIFY DISCMELT TAB 10MG ................ 25 ABILIFY DISCMELT TAB 15MG ................ 25 ABILIFY INJ 9.75MG .................................. 25 ABILIFY MAINTENA INJ 300MG ................ 25 ABILIFY SOL 1MG/ML ............................... 25 ABILIFY TAB 10MG ................................... 25 ABILIFY TAB 15MG ................................... 25 ABILIFY TAB 20MG ................................... 25 ABILIFY TAB 2MG ..................................... 25 ABILIFY TAB 30MG ................................... 25 ABILIFY TAB 5MG ..................................... 25 ABRAXANE ................................................ 11 ABSORICA ................................................. 44 ABSTRAL ................................................... 20 acamprosate calcium.................................. 25 ACANYA .................................................... 42 acarbose .................................................... 35 ACCOLATE ................................................ 40 ACCUNEB NEB 0.63MG/3 ......................... 14 ACCUNEB NEB 1.25MG/3 ......................... 14 ACCUPRIL ................................................. 18 ACCURETIC .............................................. 18 acebutolol hcl ............................................. 19 ACEON ...................................................... 18 acetaminophen w/ codeine ......................... 20 acetaminophen-caff-dihydrocod ................. 20 acetazolamide ............................................ 31 acetazolamide sodium ................................ 31 acetic acid (otic) ......................................... 32 acetylcysteine ............................................. 38 ACIPHEX ................................................... 32 acitretin ....................................................... 44 ACTEMRA .................................................. 38 ACTHAR HP ............................................... 37 ACTHIB ...................................................... 41 ACTIGALL CAP 300MG ............................. 33 ACTIMMUNE .............................................. 38 ACTIQ ........................................................ 20 ACTIVELLA ................................................ 37 ACTONEL .................................................. 38 ACTOPLUS MET ....................................... 35

ACTOPLUS MET XR .................................. 35 ACTOS TAB 15MG ..................................... 35 ACTOS TAB 30MG ..................................... 35 ACTOS TAB 45MG ..................................... 35 ACULAR ..................................................... 30 ACULAR LS ................................................ 30 ACUVAIL .................................................... 30 acyclovir ...................................................... 10 acyclovir sodium ......................................... 10 acyclovir topical .......................................... 42 ACZONE ..................................................... 44 ADACEL ..................................................... 41 ADAGEN .................................................... 30 ADALAT CC ................................................ 16 adapalene ................................................... 44 ADCIRCA.................................................... 19 ADDERALL XR ........................................... 22 ADRENALIN INJ 1MG/ML .......................... 15 ADVAIR DISKUS AER 100/50 .................... 15 ADVAIR DISKUS AER 250/50 .................... 15 ADVAIR DISKUS AER 500/50 .................... 15 ADVAIR HFA AER 115/21 .......................... 15 ADVAIR HFA AER 230/21 .......................... 15 ADVAIR HFA AER 45/21 ............................ 15 ADVICOR ................................................... 16 AFINITOR ................................................... 11 AFINITOR DISPERZ ................................... 11 AGGRENOX ............................................... 15 AGRYLIN .................................................... 15 AKNE-MYCIN ............................................. 42 ALBENZA ..................................................... 7 albuterol sulfate er tab 4mg er .................... 15 albuterol sulfate er tab 8mg er .................... 15 albuterol sulfate neb 0.083% ...................... 15 albuterol sulfate neb 0.5% .......................... 15 albuterol sulfate neb 0.63mg/3 .................... 15 albuterol sulfate neb 1.25mg/3 .................... 15 albuterol sulfate syp 2mg/5ml ..................... 15 albuterol sulfate tab 2mg ............................. 15 albuterol sulfate tab 4mg ............................. 15 alclometasone dipropionate ........................ 43 alcohol swabs ............................................. 27 ALDACTAZIDE ........................................... 18 ALDACTONE .............................................. 18 ALDARA ..................................................... 44 ALDURAZYME ........................................... 30 alendronate sodium sol 70/75ml ................. 38 alendronate sodium tab 10mg..................... 39 alendronate sodium tab 35mg..................... 39


alendronate sodium tab 40mg .................... 39 alendronate sodium tab 5mg ...................... 39 alendronate sodium tab 70mg .................... 39 alfuzosin hcl ................................................ 14 ALIMTA ...................................................... 11 ALINIA .......................................................... 9 ALKERAN................................................... 11 allopurinol ................................................... 39 allopurinol sodium ...................................... 39 ALOCRIL .................................................... 31 ALOMIDE ................................................... 31 ALORA DIS 0.025MG ................................. 37 ALORA DIS 0.05MG................................... 37 ALORA DIS 0.075MG ................................. 37 ALORA DIS 0.1MG .................................... 37 ALOXI ......................................................... 32 ALPHAGAN P ............................................ 31 alprazolam .................................................. 24 ALREX ....................................................... 30 ALSUMA .................................................... 24 ALTABAX ................................................... 42 ALTACE ..................................................... 18 ALTOPREV ................................................ 16 ALVESCO .................................................. 40 amantadine hcl ........................................... 24 AMARYL .................................................... 35 AMBIEN ..................................................... 24 AMBIEN CR ............................................... 24 AMBISOME .................................................. 9 amcinonide ................................................. 43 AMERGE .................................................... 24 AMEVIVE ................................................... 44 AMICAR ..................................................... 15 amifostine crystalline .................................. 39 amikacin sulfate ............................................ 7 amiloride & hydrochlorothiazide .................. 28 amiloride hcl ............................................... 28 amino acid electrolyte infusion.................... 28 amino acid infusion ..................................... 28 aminophylline ............................................. 44 aminosalicylic acid ........................................ 9 AMINOSYN II 4.25/DEXTROSE 10% ......... 28 AMINOSYN II 4.25/DEXTROSE 20% ......... 28 AMINOSYN II 4.25/DEXTROSE 25% ......... 28 AMINOSYN II INJ 10% ............................... 28 AMINOSYN II INJ 15% ............................... 28 AMINOSYN II INJ 7% ................................. 28 AMINOSYN II INJ 8.5% .............................. 28 AMINOSYN II M 4.25/DEXTROSE 10% ..... 28 AMINOSYN M INJ 3.5% ............................. 28 AMINOSYN-HBC INJ 7% ........................... 28

AMINOSYN-PF 7% INJ 7% ........................ 28 AMINOSYN-PF INJ 10% ............................ 28 amiodarone hcl ........................................... 17 AMITIZA ..................................................... 33 amitriptyline hcl ........................................... 25 amlodipine besylate .................................... 16 amlodipine besylate-benazepril hcl ............. 16 ammonium chloride..................................... 27 amoxapine .................................................. 25 amoxicillin ..................................................... 7 amoxicillin & pot clavulanate ......................... 7 AMOXIL DRO 50MG/ML ............................... 7 amphetamine-dextroamphetamine ............. 22 AMPHOTEC ................................................. 9 amphotericin b .............................................. 9 ampicillin ....................................................... 7 ampicillin & sulbactam sodium ...................... 7 ampicillin sodium .......................................... 7 AMPYRA .................................................... 39 AMRIX ........................................................ 14 AMTURNIDE .............................................. 18 ANAFRANIL ................................................ 25 anagrelide hcl ............................................. 15 ANAPROX .................................................. 20 ANAPROX DS ............................................ 20 anastrozole ................................................. 11 ANCOBON.................................................... 9 ANDRODERM DIS 2MG/24HR ................... 34 ANDRODERM DIS 4MG/24HR ................... 34 ANDROGEL GEL 1%(50MG) ..................... 34 ANDROGEL PUMP GEL 1.62% ................. 34 ANDROGEL PUMP GEL PUMP 1% ........... 34 ANGELIQ .................................................... 37 ANTARA ..................................................... 16 ANTIVENIN LATRODECTUS MAC TANS .. 41 ANTIVERT .................................................. 32 ANZEMET................................................... 32 APIDRA ...................................................... 35 APIDRA SOLOSTAR .................................. 35 APLENZIN .................................................. 25 APOKYN ..................................................... 24 apraclonidine hcl ......................................... 32 APRISO CAP 0.375GM .............................. 32 APTIVUS .................................................... 10 ARALAST NP ............................................. 40 ARALEN ....................................................... 9 ARANESP ALBUMIN FREE ....................... 16 ARAVA ....................................................... 39 ARCALYST ................................................. 39 ARCAPTA NEOHALER .............................. 15 argatroban .................................................. 15


ARGATROBAN .......................................... 15 ARICEPT .................................................... 14 ARICEPT ODT ........................................... 14 ARIMIDEX .................................................. 11 ARISTOSPAN INTRA-ARTICULAR ........... 34 ARISTOSPAN INTRALESIONAL ............... 34 ARIXTRA .................................................... 15 ARMOUR THYROID .................................. 38 AROMASIN ................................................ 11 ARRANON ................................................. 12 ARTHROTEC 50 ........................................ 20 ARTHROTEC 75 ........................................ 20 ARZERRA .................................................. 12 ASACOL HD TAB 800MG .......................... 32 ASACOL TAB 400MG DR .......................... 32 ASMANEX 120 METERED DOSES AER

220MCG ................................................. 40 ASMANEX 14 METERED DOSES AER




220MCG ................................................. 41 ASTAGRAF XL CAP 0.5MG ....................... 39 ASTAGRAF XL CAP 1MG .......................... 39 ASTAGRAF XL CAP 5MG .......................... 39 ASTELIN .................................................... 31 ASTEPRO .................................................. 31 ATACAND .................................................. 18 ATACAND HCT .......................................... 18 ATELVIA .................................................... 39 atenolol ....................................................... 19 atenolol & chlorthalidone ............................ 19 ATGAM ...................................................... 39 ATIVAN ...................................................... 24 atorvastatin calcium .................................... 16 atovaquone-proguanil hcl ............................. 9 ATRALIN GEL 0.05% ................................. 43 ATRIPLA .................................................... 10 atropine sulfate ........................................... 14 ATROPINE SULFATE ................................ 14 ATROVENT ................................................ 14 ATROVENT HFA ........................................ 14 AUBAGIO ................................................... 39 AUGMENTIN ................................................ 7 AUVI-Q INJ 0.15MG ................................... 15 AUVI-Q INJ 0.3MG ..................................... 15 AVALIDE .................................................... 18 AVANDAMET ............................................. 35 AVANDARYL .............................................. 35

AVANDIA .................................................... 35 AVAPRO ..................................................... 18 AVASTIN .................................................... 12 AVC ............................................................ 42 AVELOX ....................................................... 7 AVELOX ABC PACK .................................... 7 AVINZA ....................................................... 20 AVODART .................................................. 39 AVONEX ..................................................... 39 AVONEX PEN ............................................ 39 AXERT ........................................................ 24 AXID ........................................................... 32 AXIRON SOL 30MG/ACT ........................... 34 AZACTAM..................................................... 7 AZACTAM IN ISO-OSMOTIC DEXTROSE ... 7 AZASITE ..................................................... 30 azathioprine ................................................ 39 azathioprine sodium .................................... 39 azelastine hcl .............................................. 31 azelastine hcl (ophth) .................................. 31 AZELEX ...................................................... 44 AZILECT ..................................................... 24 azithromycin .................................................. 7 AZOPT ........................................................ 31 AZOR .......................................................... 16 aztreonam ..................................................... 7 AZULFIDINE ................................................. 7 AZULFIDINE EN-TABS ................................ 7

B bacitracin ...................................................... 7 bacitracin (ophthalmic) ................................ 30 bacitracin-polymyxin b (ophth) .................... 30 bacitracin-poly-neomycin-hc ....................... 30 baclofen ...................................................... 14 BACTOCILL IN DEXTROSE ......................... 7 BACTRIM...................................................... 7 BACTRIM DS ................................................ 7 BACTROBAN ............................................. 42 BACTROBAN NASAL ................................. 42 balsalazide disodium................................... 32 BANZEL ...................................................... 23 BARACLUDE SOL .05MG/ML .................... 10 BARACLUDE TAB 0.5MG .......................... 10 BARACLUDE TAB 1MG ............................. 10 BCG VACCINE ........................................... 12 BECONASE AQ .......................................... 30 benazepril & hydrochlorothiazide ................ 18 benazepril hcl .............................................. 18 BENICAR .................................................... 18 BENICAR HCT ........................................... 18 BENLYSTA ................................................. 39


BENTYL ..................................................... 14 BENZACLIN WITH PUMP .......................... 42 BENZAMYCIN ............................................ 42 benzoyl peroxide-erythromycin ................... 42 benztropine mesylate inj 1mg/ml ................ 24 benztropine mesylate tab 0.5mg ................. 24 benztropine mesylate tab 1mg.................... 24 benztropine mesylate tab 2mg.................... 24 BEPREVE .................................................. 31 BERINERT ................................................. 39 BESIVANCE ............................................... 30 BETAGAN .................................................. 31 betamethasone dipropionate (topical) ........ 43 betamethasone dipropionate augmented ... 43 betamethasone valerate ............................. 43 BETAPACE ................................................ 19 BETAPACE AF ........................................... 19 BETASERON INJ 0.3MG ........................... 39 betaxolol hcl ............................................... 19 betaxolol hcl (ophth) ................................... 31 bethanechol chloride .................................. 14 BETIMOL ................................................... 31 BETOPTIC-S .............................................. 31 BEYAZ ....................................................... 35 BIAXIN ......................................................... 7 BIAXIN XL .................................................... 7 BIAXIN XL PAC ............................................ 7 bicalutamide ............................................... 12 BICILLIN C-R ............................................... 7 BICILLIN L-A ................................................ 7 BICNU ........................................................ 12 BIDIL .......................................................... 19 BILTRICIDE .................................................. 7 BINOSTO ................................................... 39 bisoprolol & hydrochlorothiazide ................. 19 bisoprolol fumarate ..................................... 19 bleomycin sulfate ........................................ 12 BLEPH-10 .................................................. 30 BLEPHAMIDE ............................................ 30 BONIVA ...................................................... 39 BOOSTRIX ................................................. 41 BOSULIF .................................................... 12 BOTOX ....................................................... 39 BRANCHAMIN 4% INJ 4% ......................... 28 BREVICON-28 ........................................... 35 BRILINTA ................................................... 15 brimonidine tartrate .................................... 31 BRISDELLE ................................................ 25 BROMDAY ................................................. 30 bromfenac sodium (ophth) .......................... 30 bromocriptine mesylate .............................. 24

BROVANA .................................................. 15 budesonide ................................................. 34 budesonide (inhalation) ............................... 41 bumetanide inj 0.25/ml ................................ 28 bumetanide tab 0.5mg ................................ 28 bumetanide tab 1mg ................................... 28 bumetanide tab 2mg ................................... 28 BUPHENYL ................................................ 27 BUPRENEX ................................................ 20 buprenorphine hcl ....................................... 20 buprenorphine hcl-naloxone hcl dihydrate .. 20 bupropion hcl .............................................. 25 bupropion hcl (smoking deterrent) .............. 25 buspirone hcl tab 10mg ............................... 24 buspirone hcl tab 15mg ............................... 24 buspirone hcl tab 30mg ............................... 24 buspirone hcl tab 5mg ................................. 24 buspirone hcl tab 7.5mg .............................. 24 BUSULFEX ................................................. 12 butabarbital sodium..................................... 25 butalbital-acetaminophen-caffeine w/ codeine

................................................................ 20 butalbital-aspirin-caffeine w/cod .................. 20 BUTISOL SODIUM ..................................... 25 butoconazole nitrate (one dose) .................. 42 butorphanol tartrate .................................... 20 BUTRANS................................................... 20 BYDUREON ............................................... 35 BYETTA ...................................................... 35 BYSTOLIC .................................................. 19

C cabergoline ................................................. 24 CADUET ..................................................... 16 CALAN ........................................................ 16 CALAN SR .................................................. 16 CALCIJEX INJ 1MCG/ML ........................... 44 calcipotriene ................................................ 44 calcitonin (salmon) ...................................... 37 calcitriol ....................................................... 44 calcium acetate (phosphate binder) ............ 29 CAMBIA ...................................................... 20 CAMPATH .................................................. 12 CAMPRAL .................................................. 25 CAMPTOSAR ............................................. 12 CANASA SUP 1000MG .............................. 32 CANCIDAS ................................................... 9 candesartan cilexetil ................................... 18 candesartan cilexetil-hydrochlorothiazide ... 18 CANTIL ....................................................... 14 CAPASTAT SULFATE .................................. 9


CAPEX SHA 0.01% .................................... 43 CAPRELSA ................................................ 12 captopril ...................................................... 18 captopril & hydrochlorothiazide................... 18 CARAC CRE 0.5% ..................................... 44 CARAFATE SUS 1GM/10ML ..................... 33 CARAFATE TAB 1GM ................................ 33 CARBAGLU ................................................ 28 carbamazepine ........................................... 23 CARBATROL CAP 100MG ........................ 23 CARBATROL CAP 200MG ........................ 23 CARBATROL CAP 300MG ........................ 23 carbidopa-levodopa .................................... 24 carbinoxamine maleate .............................. 11 carboplatin .................................................. 12 CARDIZEM ................................................. 16 CARDIZEM CD .......................................... 16 CARDIZEM LA ........................................... 16 CARDURA.................................................. 16 CARDURA XL ............................................ 16 CARIMUNE NANOFILTERED .................... 41 carisoprodol ................................................ 14 carisoprodol w/ aspirin ................................ 14 carisoprodol w/ aspirin & codeine ............... 14 CARNITOR ................................................. 39 carteolol hcl (ophth) .................................... 31 carvedilol .................................................... 19 CASODEX .................................................. 12 CATAFLAM ................................................ 20 CATAPRES ................................................ 17 CATAPRES-TTS-1 ..................................... 17 CATAPRES-TTS-2 ..................................... 17 CATAPRES-TTS-3 ..................................... 17 CAYSTON .................................................... 7 CEDAX ......................................................... 7 CEENU ....................................................... 12 cefaclor ......................................................... 7 cefaclor monohydrate ................................... 7 cefadroxil ...................................................... 7 cefazolin in d5w ............................................ 7 cefazolin sodium ........................................... 7 CEFAZOLIN SODIUM/DEXTROSE ............. 7 cefdinir .......................................................... 7 cefepime hcl ................................................. 7 cefixime ........................................................ 7 cefotaxime sodium ....................................... 7 cefotetan disodium ....................................... 7 cefoxitin sodium ............................................ 7 CEFOXITIN SODIUM ................................... 7 cefpodoxime proxetil..................................... 7 cefprozil ........................................................ 7 ceftazidime ................................................... 7

CEFTAZIDIME/DEXTROSE ......................... 7 CEFTIN SUS 125/5ML .................................. 7 CEFTIN SUS 250/5ML .................................. 7 CEFTIN TAB 250MG .................................... 7 CEFTIN TAB 500MG .................................... 7 ceftriaxone sodium ........................................ 7 CEFTRIAXONE/DEXTROSE ........................ 7 cefuroxime axetil ........................................... 7 cefuroxime sodium ........................................ 7 CEFUROXIME/DEXTROSE ......................... 7 CELEBREX ................................................. 20 CELESTONE .............................................. 34 CELEXA ..................................................... 25 CELLCEPT CAP 250MG ............................ 39 CELLCEPT INTRAVENOUS ...................... 39 CELLCEPT SUS 200MG/ML ...................... 39 CELLCEPT TAB 500MG ............................. 39 CELONTIN.................................................. 23 CENESTIN.................................................. 37 cephalexin..................................................... 7 CEREZYME ................................................ 30 CERVARIX ................................................. 41 CESAMET .................................................. 32 cetirizine hcl ................................................ 11 cevimeline hcl ............................................. 14 CHANTIX .................................................... 14 CHANTIX STARTING MONTH PAK ........... 14 CHEMET .................................................... 34 chenodiol .................................................... 33 chloramphenicol sodium succinate ............... 7 chlordiazepoxide hcl ................................... 25 chlordiazepoxide-amitriptyline ..................... 25 chlorhexidine gluconate (mouth-throat) ....... 30 chloroquine phosphate .................................. 9 chlorothiazide .............................................. 28 chlorothiazide sodium ................................. 28 chlorpromazine hcl ...................................... 26 chlorpropamide ........................................... 35 chlorthalidone ............................................. 28 chlorzoxazone ............................................. 14 cholestyramine ............................................ 16 cholestyramine light .................................... 16 choline fenofibrate ...................................... 16 chorionic gonadotropin ................................ 37 CIALIS ........................................................ 19 ciclopirox ..................................................... 42 ciclopirox olamine ....................................... 42 cidofovir ...................................................... 10 cilostazol ..................................................... 15 CILOXAN OIN 0.3% OP ............................. 30 CILOXAN SOL 0.3% OP ............................. 30 cimetidine.................................................... 33


cimetidine hcl .............................................. 33 CIMZIA ....................................................... 39 CINRYZE ................................................... 39 CIPRO .......................................................... 7 CIPRO HC .................................................. 30 CIPRO I.V.-IN D5W ...................................... 7 CIPRO SUSP ............................................... 7 CIPRODEX................................................. 30 ciprofloxacin ................................................. 7 ciprofloxacin hcl ............................................ 7 ciprofloxacin hcl (ophth) .............................. 30 ciprofloxacin in d5w ...................................... 7 ciprofloxacin-ciprofloxacin hcl ....................... 7 cisplatin ...................................................... 12 citalopram hydrobromide sol 10mg/5ml ...... 26 citalopram hydrobromide tab 10mg ............ 26 citalopram hydrobromide tab 20mg ............ 26 citalopram hydrobromide tab 40mg ............ 26 cladribine .................................................... 12 CLAFORAN .................................................. 7 CLARINEX ................................................. 11 CLARINEX REDITABS ............................... 11 CLARINEX-D 12 HOUR ............................. 11 CLARINEX-D 24 HOUR ............................. 11 clarithromycin ............................................... 7 clemastine fumarate ................................... 11 CLEOCIN ..................................................... 7 CLEOCIN CRE 2% VAG ............................ 42 CLEOCIN IN D5W ........................................ 7 CLEOCIN PHOSPHATE .............................. 7 CLEOCIN SUP 100MG .............................. 42 CLEOCIN-T ................................................ 42 CLIMARA DIS 0.025MG ............................. 37 CLIMARA DIS 0.0375MG ........................... 37 CLIMARA DIS 0.05MG ............................... 37 CLIMARA DIS 0.06MG ............................... 37 CLIMARA DIS 0.075MG ............................. 37 CLIMARA DIS 0.1MG ................................. 37 CLIMARA PRO ........................................... 37 CLINDAGEL ............................................... 42 clindamycin hcl ............................................. 7 clindamycin palmitate hydrochloride ............. 7 clindamycin phosphate ................................. 7 clindamycin phosphate & cleanser ............. 42 clindamycin phosphate (topical) ................. 42 clindamycin phosphate in d5w ...................... 7 clindamycin phosphate vaginal ................... 42 clindamycin phosphate-benzoyl peroxide ... 42 CLINIMIX 2.75%/DEXTROSE 5% INJ

2.75/D5W ................................................ 28 CLINIMIX 4.25%/DEXTROSE 10% ............ 28

CLINIMIX 4.25%/DEXTROSE 20% ............ 28 CLINIMIX 4.25%/DEXTROSE 25% ............ 28 CLINIMIX 4.25%/DEXTROSE 5% .............. 28 CLINIMIX 5%/DEXTROSE 15% ................. 28 CLINIMIX 5%/DEXTROSE 20% ................. 28 CLINIMIX 5%/DEXTROSE 25% ................. 28 CLINIMIX E 2.75%/DEXTROSE 10% ......... 28 CLINIMIX E 2.75%/DEXTROSE 5% ........... 28 CLINIMIX E 4.25%/DEXTROSE 10% ......... 28 CLINIMIX E 4.25%/DEXTROSE 25% ......... 28 CLINIMIX E 4.25%/DEXTROSE 5% ........... 28 CLINIMIX E 5%/DEXTROSE 15% .............. 28 CLINIMIX E 5%/DEXTROSE 20% .............. 28 CLINIMIX E 5%/DEXTROSE 25% .............. 28 CLINORIL ................................................... 20 clobetasol propionate .................................. 43 clobetasol propionate emollient base .......... 43 CLOBEX ..................................................... 43 CLODERM PUMP ...................................... 43 CLOLAR ..................................................... 12 clomipramine hcl ......................................... 26 clonazepam ................................................ 23 clonidine & chlorthalidone ........................... 18 clonidine hcl dis 0.1/24hr ............................ 18 clonidine hcl dis 0.2/24hr ............................ 18 clonidine hcl dis 0.3/24hr ............................ 18 clonidine hcl tab 0.1mg ............................... 18 clonidine hcl tab 0.2mg ............................... 18 clonidine hcl tab 0.3mg ............................... 18 clopidogrel bisulfate .................................... 15 clorazepate dipotassium ............................. 25 clotrimazole ................................................. 42 clotrimazole (topical) ................................... 42 clotrimazole w/ betamethasone ................... 42 clozapine .................................................... 26 CLOZARIL TAB 100MG .............................. 26 CLOZARIL TAB 25MG ................................ 26 COARTEM .................................................... 9 CODEINE PHOSPHATE ............................ 20 CODEINE SULFATE TAB 15MG ................ 20 CODEINE SULFATE TAB 30MG ................ 20 CODEINE SULFATE TAB 60MG ................ 21 COGENTIN ................................................. 24 COLAZAL ................................................... 32 colchicine w/ probenecid ............................. 30 COLCRYS .................................................. 39 COLESTID .................................................. 16 colestipol hcl ............................................... 16 colistimethate sodium ................................... 7 COLY-MYCIN M ........................................... 7 COLY-MYCIN S .......................................... 30


COLYTE-FLAVOR PACKS ........................ 33 COMBIGAN ................................................ 31 COMBIPATCH ........................................... 37 COMBIVENT AER ...................................... 15 COMBIVENT RESPIMAT AER RESPIMAT 15 COMBIVIR.................................................. 10 COMETRIQ ................................................ 12 COMPLERA ............................................... 10 COMTAN .................................................... 24 COMVAX .................................................... 41 CONCERTA TAB 18MG ............................. 22 CONCERTA TAB 27MG ............................. 22 CONCERTA TAB 36MG ............................. 22 CONCERTA TAB 54MG ............................. 22 CONDYLOX ............................................... 44 CONZIP ...................................................... 21 COPAXONE ............................................... 39 COPEGUS ................................................. 10 CORDARONE ............................................ 17 CORDRAN LOT 0.05% .............................. 43 CORDRAN TAPE TAP 4MCG/CM ............. 43 COREG ...................................................... 19 COREG CR ................................................ 19 CORGARD ................................................. 19 CORTEF .................................................... 34 CORTENEMA ............................................ 43 CORTIFOAM .............................................. 43 cortisone acetate ........................................ 34 CORTISPORIN .................................... 30, 43 CORTISPORIN-TC..................................... 30 CORZIDE ................................................... 19 COSMEGEN .............................................. 12 COSOPT .................................................... 31 COUMADIN ................................................ 15 COVERA-HS .............................................. 16 COZAAR .................................................... 18 CREON CAP 12000UNT ............................ 33 CREON CAP 24000UNT ............................ 33 CREON CAP 3000UNIT ............................. 33 CREON CAP 36000UNT ............................ 33 CREON CAP 6000UNIT ............................. 33 CRESTOR .................................................. 16 CRINONE ................................................... 37 CRIXIVAN .................................................. 10 cromolyn sodium ........................................ 40 cromolyn sodium (mastocytosis) ................ 40 cromolyn sodium (ophth) ............................ 31 CUBICIN ...................................................... 7 CUPRIMINE ............................................... 34 CUTIVATE.................................................. 43 CUVPOSA SOL 1MG/5ML ......................... 14 CYCLESSA ................................................ 35

cyclobenzaprine hcl .................................... 14 cyclophosphamide ...................................... 12 cycloserine .................................................... 9 CYCLOSET ................................................ 35 cyclosporine ................................................ 39 cyclosporine modified (for microemulsion) .. 39 CYKLOKAPRON INJ 100MG/ML ................ 15 CYMBALTA ................................................ 26 cyproheptadine hcl ...................................... 11 CYSTADANE .............................................. 39 CYSTAGON CAP 150MG ........................... 39 CYSTAGON CAP 50MG ............................. 39 CYSTARAN ................................................ 32 cytarabine ................................................... 12 CYTOGAM.................................................. 41 CYTOMEL .................................................. 38 CYTOTEC................................................... 33 CYTOVENE ................................................ 10

D dacarbazine ................................................ 12 DACOGEN.................................................. 12 DALIRESP .................................................. 41 danazol ....................................................... 34 DANTRIUM ................................................. 14 dantrolene sodium ...................................... 14 dapsone ........................................................ 9 DAPTACEL ................................................. 41 DARAPRIM ................................................... 9 daunorubicin hcl .......................................... 12 DAUNOXOME ............................................ 12 DAYPRO .................................................... 21 DAYTRANA ................................................ 22 DDAVP ....................................................... 37 DDAVP INJ 4MCG/ML ................................ 37 DDAVP TAB 0.1MG .................................... 37 DDAVP TAB 0.2MG .................................... 37 DECAVAC .................................................. 41 decitabine ................................................... 12 DELATESTRYL .......................................... 34 DELESTROGEN ......................................... 37 DELZICOL CAP 400MG ............................. 32 DEMADEX .................................................. 28 demeclocycline hcl ........................................ 8 DEMEROL .................................................. 21 DEMSER .................................................... 39 DENAVIR .................................................... 42 DEPACON .................................................. 23 DEPAKENE ................................................ 23 DEPAKOTE ................................................ 23 DEPAKOTE ER .......................................... 23 DEPAKOTE SPRINKLES ........................... 23


DEPEN TITRATABS .................................. 34 DEPO-MEDROL INJ 20MG/ML .................. 34 DEPO-MEDROL INJ 40MG/ML .................. 34 DEPO-MEDROL INJ 80MG/ML .................. 34 DEPO-PROVERA ...................................... 37 DEPO-PROVERA CONTRACEPTIVE INJ

150MG/ML .............................................. 38 DEPO-SUBQ PROVERA 104 INJ 104 ....... 38 DERMA-SMOOTHE/FS BODY OIL OIL /FS

BODY ..................................................... 43 DERMATOP ............................................... 43 DERMOTIC ................................................ 30 desipramine hcl .......................................... 26 desloratadine .............................................. 11 desmopressin acetate ................................ 37 desmopressin acetate spray refrigerated .... 37 DESOGEN ................................................. 35 desogestrel & ethinyl estradiol .................... 35 desogestrel-ethinyl estradiol (biphasic) ...... 35 desogestrel-ethinyl estradiol (triphasic) ...... 35 DESONATE ................................................ 43 desonide ..................................................... 43 DESOWEN ................................................. 43 desoximetasone ......................................... 43 DESOXIMETASONE .................................. 43 DESOXYN .................................................. 22 DESVENLAFAXINE ER ............................. 26 DETROL ..................................................... 44 DETROL LA ............................................... 44 dexamethasone .......................................... 34 dexamethasone sodium phosphate ............ 34 dexamethasone sodium phosphate (ophth) 30 dexchlorpheniramine maleate..................... 11 DEXEDRINE .............................................. 22 DEXILANT .................................................. 33 dexmethylphenidate hcl .............................. 22 dexrazoxane ............................................... 39 DEXTRAN HM ............................................ 28 dextroamphetamine sulfate ........................ 22 dextrose ..................................................... 28 DEXTROSE 10%/NACL 0.2% INJ 0.2%..... 29 DEXTROSE 10%/NACL 0.45% INJ 0.45% . 29 DEXTROSE 5%/ELECTROLYTE #48

VIAFLEX ................................................. 29 DEXTROSE 5%/NACL 0.225% INJ 0.225%29 dextrose in lactated ringers ........................ 29 dextrose w/ sodium chloride ....................... 29 DIABETA .................................................... 36 DIAMOX ..................................................... 31 diazepam .................................................... 25 DIAZEPAM ................................................. 25

DIBENZYLINE ............................................ 14 diclofenac potassium .................................. 21 diclofenac sodium ....................................... 21 diclofenac sodium (ophth) ........................... 30 diclofenac w/ misoprostol ............................ 21 dicloxacillin sodium ....................................... 8 dicyclomine hcl ........................................... 14 didanosine .................................................. 10 DIDRONEL ................................................. 39 DIFFERIN CRE 0.1% .................................. 44 DIFFERIN GEL 0.1% .................................. 44 DIFFERIN GEL 0.3% .................................. 44 DIFFERIN LOT 0.1% .................................. 44 DIFICID ......................................................... 8 diflorasone diacetate ................................... 43 DIFLUCAN .................................................... 9 diflunisal ...................................................... 21 digoxin inj 0.25mg/1 .................................... 17 DIGOXIN SOL 50MCG/ML ......................... 17 digoxin tab 0.125mg.................................... 17 digoxin tab 0.25mg ..................................... 17 dihydroergotamine mesylate ....................... 14 dilacor xr cap 240mg/24 .............................. 16 DILANTIN ................................................... 23 DILATRATE SR CAP 40MG ....................... 19 DILAUDID INJ 1MG/ML .............................. 21 DILAUDID INJ 2MG/ML .............................. 21 DILAUDID INJ 4MG/ML .............................. 21 DILAUDID TAB 2MG .................................. 21 DILAUDID TAB 4MG .................................. 21 DILAUDID TAB 8MG .................................. 21 DILAUDID-5 LIQ 1MG/ML .......................... 21 DILAUDID-HP INJ 10MG/ML ...................... 21 diltiazem hcl coated beads .......................... 16 diltiazem hcl er cap 120mg er ..................... 16 diltiazem hcl er cap 60mg er ....................... 17 diltiazem hcl er cap 90mg er ....................... 17 diltiazem hcl extended release beads ......... 17 diltiazem hcl inj 100mg ................................ 17 diltiazem hcl inj 50/10ml .............................. 17 diltiazem hcl tab 120mg .............................. 17 diltiazem hcl tab 30mg ................................ 17 diltiazem hcl tab 60mg ................................ 17 diltiazem hcl tab 90mg ................................ 17 dilt-xr cap 180mg ........................................ 16 dilt-xr cap 240mg ........................................ 16 DIOVAN ...................................................... 18 DIOVAN HCT .............................................. 18 DIPENTUM ................................................. 32 diphenhydramine hcl ................................... 11 diphenoxylate w/ atropine ........................... 32


DIPHTHERIA/TETANUS TOXOID PEDIATRIC ............................................ 41

DIPROLENE ............................................... 43 DIPROLENE AF ......................................... 43 dipyridamole ............................................... 19 disopyramide phosphate ............................ 17 disulfiram .................................................... 39 DITROPAN XL ........................................... 44 DIURIL ....................................................... 28 divalproex sodium ...................................... 23 DIVIGEL GEL 1MG/GM .............................. 37 DOCEFREZ INJ 20MG ............................... 12 DOCEFREZ INJ 80MG ............................... 12 DOCETAXEL INJ 80MG/4ML ..................... 12 DOCETAXEL INJ 80MG/8ML ..................... 12 DOLOPHINE HCL TAB 5MG ..................... 21 DOLOPHINE TAB 10MG ............................ 21 donepezil hydrochloride .............................. 14 DORIBAX ..................................................... 8 DORYX ........................................................ 8 dorzolamide hcl .......................................... 31 dorzolamide hcl-timolol maleate ................. 32 DOVONEX ................................................. 44 DOVONEX SCALP ..................................... 44 doxazosin mesylate .................................... 16 doxepin hcl cap 100mg ............................... 26 doxepin hcl cap 10mg ................................. 26 doxepin hcl cap 150mg ............................... 26 doxepin hcl cap 25mg ................................. 26 doxepin hcl cap 50mg ................................. 26 doxepin hcl cap 75mg ................................. 26 doxepin hcl con 10mg/ml ............................ 26 DOXIL ........................................................ 12 doxorubicin hcl ........................................... 12 doxycycline (monohydrate) ........................... 8 doxycycline hyclate ...................................... 8 dronabinol .................................................. 32 drospirenone-ethinyl estradiol..................... 35 DROXIA ..................................................... 12 DUETACT .................................................. 36 DUEXIS ...................................................... 21 DULERA ..................................................... 41 DUONEB SOL ............................................ 15 DURAGESIC .............................................. 21 DUREZOL .................................................. 30 DUTOPROL ............................................... 20 DYAZIDE .................................................... 28 DYMISTA ................................................... 31 DYNACIRC CR .......................................... 17 DYRENIUM ................................................ 28 DYSPORT .................................................. 39

E E.E.S. GRANULES ....................................... 8 EC-NAPROSYN ......................................... 21 econazole nitrate ........................................ 42 EDARBI ...................................................... 18 EDARBYCLOR ........................................... 18 EDECRIN.................................................... 28 EDLUAR ..................................................... 25 EDURANT .................................................. 10 EFFEXOR XR CAP 150MG ........................ 26 EFFEXOR XR CAP 37.5MG ....................... 26 EFFEXOR XR CAP 75MG .......................... 26 EFFIENT ..................................................... 15 EFUDEX CRE 5% ...................................... 44 EGRIFTA .................................................... 38 ELAPRASE ................................................. 30 ELDEPRYL ................................................. 24 electrolyte-h in dextrose .............................. 29 electrolyte-m in dextrose ............................. 29 electrolyte-p in dextrose .............................. 29 electrolyte-s ................................................ 29 electrolyte-s in dextrose .............................. 29 ELELYSO ................................................... 30 ELESTAT .................................................... 31 ELESTRIN GEL 0.06% ............................... 37 ELIDEL ....................................................... 44 ELIGARD INJ 22.5MG ................................ 12 ELIGARD INJ 30MG ................................... 12 ELIGARD INJ 45MG ................................... 12 ELIGARD INJ 7.5MG .................................. 12 ELIQUIS ..................................................... 15 ELITEK ....................................................... 30 ELLA ........................................................... 35 ELLENCE ................................................... 12 ELMIRON ................................................... 39 ELOCON .................................................... 43 ELOXATIN INJ 100MG ............................... 12 ELOXATIN INJ 200MG ............................... 12 ELSPAR ..................................................... 12 EMADINE ................................................... 31 EMCYT ....................................................... 12 EMEND CAP 125MG .................................. 32 EMEND CAP 40MG .................................... 32 EMEND CAP 80MG .................................... 32 EMEND PAK 80 & 125 ............................... 32 EMLA .......................................................... 43 EMSAM ...................................................... 24 EMTRIVA .................................................... 10 ENABLEX ................................................... 44 enalapril maleate ........................................ 18 enalapril maleate & hydrochlorothiazide ..... 18 ENBREL ..................................................... 39


ENBREL SURECLICK ................................ 39 ENDOMETRIN ........................................... 38 ENGERIX-B ................................................ 41 ENJUVIA .................................................... 37 enoxaparin sodium ..................................... 15 entacapone................................................. 24 ENTOCORT EC ......................................... 34 EPIDUO ..................................................... 44 epinastine hcl (ophth) ................................. 31 epinephrine hcl ........................................... 15 EPIPEN 2-PAK INJ 0.3MG ......................... 15 EPIPEN-JR 2-PAK INJ 2-PAK .................... 15 epirubicin hcl .............................................. 12 EPIVIR HBV SOL 5MG/ML ........................ 10 EPIVIR HBV TAB 100MG ........................... 10 EPIVIR SOL 10MG/ML ............................... 10 EPIVIR TAB 150MG ................................... 10 EPIVIR TAB 300MG ................................... 10 eplerenone ................................................. 18 EPOGEN INJ 10000/ML ............................. 16 EPOGEN INJ 2000/ML ............................... 16 EPOGEN INJ 20000/ML ............................. 16 EPOGEN INJ 3000/ML ............................... 16 EPOGEN INJ 4000/ML ............................... 16 eprosartan mesylate ................................... 18 EPZICOM ................................................... 10 EQUETRO.................................................. 23 ERAXIS ........................................................ 9 ERBITUX .................................................... 12 ergoloid mesylates ..................................... 14 ergotamine tartrate ..................................... 14 ergotamine w/ caffeine ............................... 24 ERIVEDGE ................................................. 12 ERTACZO .................................................. 42 ERYPED 200 ................................................ 8 ERYPED 400 ................................................ 8 ERYTHROCIN LACTOBIONATE ................. 8 erythromycin (acne aid) .............................. 42 erythromycin (ophth)................................... 30 erythromycin base ........................................ 8 erythromycin ethylsuccinate ......................... 8 erythromycin lactobionate ............................. 8 erythromycin stearate ................................... 8 escitalopram oxalate................................... 26 ESOMEPRAZOLE STRONTIUM .......... 16, 33 estazolam ................................................... 25 esterified estrogens .................................... 37 estradiol ...................................................... 37 estradiol & norethindrone acetate ............... 37 estradiol cypionate ..................................... 37 estradiol vaginal ......................................... 37

estradiol valerate ........................................ 37 estradiol-norgestimate ................................ 37 ESTRASORB EMU ..................................... 37 ESTRING .................................................... 37 estropipate .................................................. 37 ESTROSTEP FE ........................................ 35 ethambutol hcl .............................................. 9 ethosuximide ............................................... 23 ethynodiol diacet & eth estrad ..................... 35 ETHYOL ..................................................... 39 etidronate disodium..................................... 39 etodolac ...................................................... 21 ETOPOPHOS ............................................. 12 etoposide .................................................... 12 EURAX ....................................................... 42 EVAMIST SPR 1.53MG .............................. 37 EVISTA ....................................................... 37 EVOCLIN .................................................... 42 EVOXAC ..................................................... 14 EXALGO TAB 12MG .................................. 21 EXALGO TAB 16MG .................................. 21 EXALGO TAB 8MG .................................... 21 EXELDERM ................................................ 42 EXELON ..................................................... 14 exemestane ................................................ 12 EXFORGE .................................................. 17 EXFORGE HCT .......................................... 17 EXJADE TAB 125MG ................................. 34 EXJADE TAB 250MG ................................. 34 EXJADE TAB 500MG ................................. 34 EXTAVIA INJ 0.3MG ................................... 39 EXTINA ....................................................... 42

F FABRAZYME .............................................. 30 FACTIVE ...................................................... 8 famciclovir ................................................... 10 famotidine ................................................... 33 famotidine in nacl ........................................ 33 FAMVIR ...................................................... 10 FANAPT ..................................................... 26 FANAPT TITRATION PACK ....................... 26 FARESTON ................................................ 12 FASLODEX ................................................. 12 fat emulsion ................................................ 28 FAZACLO TAB 100/ODT ............................ 26 FAZACLO TAB 12.5/ODT ........................... 26 FAZACLO TAB 150MG ............................... 26 FAZACLO TAB 200MG ............................... 26 FAZACLO TAB 25MG ODT ........................ 26 felbamate .................................................... 23


FELBATOL ................................................. 23 FELDENE ................................................... 21 felodipine .................................................... 17 FEMARA .................................................... 12 FEMCON FE .............................................. 35 FEMHRT 1/5 .............................................. 37 FEMHRT LOW DOSE ................................ 37 FEMRING ................................................... 37 FEMTRACE ................................................ 37 fenofibrate .................................................. 16 fenofibrate micronized ................................ 16 FENOGLIDE ............................................... 16 fenoprofen calcium ..................................... 21 fentanyl ....................................................... 21 fentanyl citrate ............................................ 21 FENTORA .................................................. 21 FERRIPROX .............................................. 34 FIBRICOR .................................................. 16 FINACEA .................................................... 44 finasteride ................................................... 39 FIORICET/CODEINE ................................. 21 FIORINAL/CODEINE #3 ............................. 21 FIRAZYR .................................................... 39 FIRMAGON ................................................ 12 FLAGYL ....................................................... 9 FLAGYL ER .................................................. 9 FLAREX ..................................................... 30 flavoxate hcl ............................................... 44 FLEBOGAMMA DIF ................................... 41 flecainide acetate ....................................... 17 FLECTOR................................................... 44 FLOMAX .................................................... 14 FLONASE................................................... 31 FLO-PRED ................................................. 34 FLOVENT DISKUS..................................... 41 FLOVENT HFA AER 110MCG ................... 41 FLOVENT HFA AER 220MCG ................... 41 FLOVENT HFA AER 44MCG ..................... 41 fluconazole ................................................... 9 fluconazole in dextrose ................................. 9 flucytosine .................................................... 9 FLUDARA................................................... 12 fludarabine phosphate ................................ 12 fludrocortisone acetate ............................... 34 flunisolide (nasal) ....................................... 31 fluocinolone acetonide ................................ 43 fluocinolone acetonide (otic) ....................... 31 fluocinonide ................................................ 43 fluocinonide emulsified base ...................... 43 FLUOROPLEX CRE 1% ............................. 44 fluorouracil .................................................. 12 fluorouracil (topical) .................................... 44

fluoxetine dr cap 90mg dr ........................... 26 FLUOXETINE HCL ..................................... 26 fluoxetine hcl cap 10mg .............................. 26 fluoxetine hcl cap 20mg .............................. 26 fluoxetine hcl cap 40mg .............................. 26 fluoxetine hcl sol 20mg/5ml ......................... 26 fluoxetine hcl tab 10mg ............................... 26 fluoxetine hcl tab 20mg ............................... 26 fluoxymesterone ......................................... 34 fluphenazine decanoate .............................. 26 fluphenazine hcl .......................................... 26 flurazepam hcl ............................................ 25 flurbiprofen .................................................. 21 flurbiprofen sodium ..................................... 31 flutamide ..................................................... 12 fluticasone propionate ................................. 43 fluticasone propionate (nasal) ..................... 31 fluvastatin sodium ....................................... 16 fluvoxamine maleate ................................... 26 FML FORTE SUS 0.25% OP ...................... 31 FML LIQUIFILM SUS 0.1% OP ................... 31 FML OIN 0.1% OP ...................................... 31 FOCALIN .................................................... 22 FOCALIN XR .............................................. 22 FOLOTYN ................................................... 12 fomepizole .................................................. 39 fondaparinux sodium................................... 15 FORADIL AEROLIZER ............................... 15 FORFIVO XL .............................................. 26 FORTAMET ................................................ 36 FORTAZ ....................................................... 8 FORTEO ..................................................... 37 FORTESTA GEL 10MG/ACT ...................... 34 FORTICAL SPR 200/ACT ........................... 37 FOSAMAX .................................................. 39 FOSAMAX PLUS D .................................... 39 foscarnet sodium ........................................ 10 fosinopril sodium ......................................... 18 fosinopril sodium & hydrochlorothiazide ...... 18 fosphenytoin sodium ................................... 23 FOSRENOL ................................................ 29 FRAGMIN ................................................... 15 FREAMINE III 3% INJ 3% ........................... 28 FROVA ....................................................... 24 FULYZAQ ................................................... 32 FURADANTIN ............................................. 11 furosemide inj 10mg/ml ............................... 28 furosemide sol 10mg/ml .............................. 28 furosemide sol 8mg/ml ................................ 28 furosemide tab 20mg .................................. 28 furosemide tab 40mg .................................. 28 furosemide tab 80mg .................................. 28


FUSILEV .................................................... 39 FUZEON .................................................... 10

G gabapentin.................................................. 23 GABITRIL ................................................... 23 GABLOFEN ................................................ 14 galantamine hydrobromide ......................... 14 GAMASTAN S/D ........................................ 41 GAMMAGARD LIQUID ............................... 41 GAMMAGARD S/D..................................... 41 GAMMAPLEX ............................................. 41 GAMUNEX ................................................. 41 GAMUNEX-C ............................................. 41 ganciclovir .................................................. 10 ganciclovir sodium ...................................... 10 GARDASIL ................................................. 41 GASTROCROM ......................................... 40 GATTEX ..................................................... 33 gauze pads & dressings ............................. 27 GELNIQUE ................................................. 44 GELNIQUE GEL 3%................................... 44 gemcitabine hcl .......................................... 12 gemfibrozil .................................................. 16 GEMZAR .................................................... 12 GENERESS FE .......................................... 35 GENOTROPIN INJ 12MG .......................... 38 GENOTROPIN INJ 5MG ............................ 38 GENOTROPIN MINIQUICK INJ 0.2MG ...... 38 GENOTROPIN MINIQUICK INJ 0.4MG ...... 38 GENOTROPIN MINIQUICK INJ 0.6MG ...... 38 GENOTROPIN MINIQUICK INJ 0.8MG ...... 38 GENOTROPIN MINIQUICK INJ 1.2MG ...... 38 GENOTROPIN MINIQUICK INJ 1.4MG ...... 38 GENOTROPIN MINIQUICK INJ 1.6MG ...... 38 GENOTROPIN MINIQUICK INJ 1.8MG ...... 38 GENOTROPIN MINIQUICK INJ 1MG......... 38 GENOTROPIN MINIQUICK INJ 2MG......... 38 gentamicin in saline ...................................... 8 gentamicin sulfate ........................................ 8 gentamicin sulfate (ophth) .......................... 30 gentamicin sulfate (topical) ......................... 42 GEODON ................................................... 26 GIAZO ........................................................ 32 GILENYA .................................................... 39 GILOTRIF ................................................... 12 GLASSIA .................................................... 41 GLEEVEC .................................................. 12 glimepiride .................................................. 36 glipizide er tab 10mg .................................. 36 glipizide er tab 2.5mg ................................. 36

glipizide er tab 5mg ..................................... 36 glipizide tab 10mg ....................................... 36 glipizide tab 5mg ......................................... 36 glipizide-metformin hcl ................................ 36 GLUCAGEN HYPOKIT ............................... 36 GLUCAGON EMERGENCY KIT ................. 36 GLUCOPHAGE .......................................... 36 GLUCOPHAGE XR..................................... 36 GLUCOTROL ............................................. 36 GLUCOTROL XL ........................................ 36 GLUCOVANCE ........................................... 36 GLUMETZA ................................................ 36 glyburide ..................................................... 36 glyburide micronized ................................... 36 glyburide-metformin .................................... 36 glycopyrrolate ............................................. 14 GLYNASE ................................................... 36 GLYSET ..................................................... 36 GOLYTELY ................................................. 33 GRALISE .................................................... 21 GRALISE STARTER ................................... 21 granisetron hcl ............................................ 32 griseofulvin microsize .................................... 9 griseofulvin ultramicrosize ............................. 9 GRIS-PEG .................................................... 9 guanfacine hcl tab 1mg ............................... 18 guanfacine hcl tab 2mg ............................... 18 GUANIDINE HCL ........................................ 14

H HALAVEN ................................................... 12 HALCION .................................................... 25 HALDOL ..................................................... 26 HALDOL DECANOATE 100 ....................... 26 HALDOL DECANOATE 50 ......................... 26 HALFLYTELY BOWEL PREP/FLAVOR

PACKS .................................................... 33 halobetasol propionate ................................ 43 HALOG ....................................................... 43 haloperidol .................................................. 26 haloperidol decanoate ................................. 26 haloperidol lactate ....................................... 26 HAVRIX ...................................................... 41 HECTOROL ................................................ 44 HELIDAC ...................................................... 7 HEMABATE ................................................ 39 heparin (porcine) in sodium chloride ........... 15 heparin sod (porcine) in d5w ....................... 15 heparin sodium (porcine) ............................ 15 HEPARIN SODIUM/NACL 0.45% ............... 15 HEPSERA................................................... 10


HERCEPTIN ............................................... 12 HEXALEN................................................... 12 HIPREX ...................................................... 11 HIZENTRA ................................................. 41 HORIZANT ................................................. 23 HUMALOG INJ 100/ML .............................. 36 HUMALOG KWIKPEN INJ 100/ML ............. 36 HUMALOG MIX 50/50 ................................ 36 HUMALOG MIX 50/50 KWIKPEN ............... 36 HUMALOG MIX 75/25 ................................ 36 HUMALOG MIX 75/25 KWIKPEN ............... 36 HUMATROPE COMBO PACK INJ 5MG .... 38 HUMATROPE INJ 12MG ........................... 38 HUMATROPE INJ 24MG ........................... 38 HUMATROPE INJ 6MG ............................. 38 HUMIRA ..................................................... 39 HUMIRA PEN-CROHNS DISEASE

STARTER ............................................... 39 HUMULIN 70/30 INJ 70/30 ......................... 36 HUMULIN 70/30 PEN INJ 70/30 ................. 36 HUMULIN N INJ U-100 .............................. 36 HUMULIN N U-100 PEN INJ U-100 ........... 36 HUMULIN R INJ U-100 .............................. 36 HUMULIN R U-500 (CONCENTRATED) INJ

U-500 ...................................................... 36 HYCAMTIN ................................................. 12 hydralazine hcl inj 20mg/ml ........................ 18 hydralazine hcl tab 100mg .......................... 18 hydralazine hcl tab 10mg ............................ 18 hydralazine hcl tab 25mg ............................ 18 hydralazine hcl tab 50mg ............................ 18 HYDREA .................................................... 12 hydrochlorothiazide cap 12.5mg ................. 29 hydrochlorothiazide tab 12.5mg.................. 29 hydrochlorothiazide tab 25mg .................... 29 hydrochlorothiazide tab 50mg .................... 29 hydrocodone-acetaminophen ..................... 21 hydrocodone-ibuprofen ............................... 21 hydrocortisone ............................................ 34 hydrocortisone (intrarectal) ......................... 43 hydrocortisone (rectal) ................................ 43 hydrocortisone (topical) .............................. 43 hydrocortisone acetate w/ pramoxine ......... 43 hydrocortisone butyrate .............................. 43 hydrocortisone sod succinate ..................... 34 hydrocortisone valerate .............................. 43 hydrocortisone w/acetic acid....................... 31 hydromorphone hcl ..................................... 21 hydroxychloroquine sulfate ........................... 9 hydroxyurea ................................................ 12 hydroxyzine hcl ........................................... 25 hydroxyzine pamoate ................................. 25

HYPERRHO S/D ........................................ 41 HYPERTET S/D .......................................... 41 HYZAAR ..................................................... 18

I ibandronate sodium .................................... 39 ibuprofen ..................................................... 21 ICLUSIG ..................................................... 12 IDAMYCIN PFS .......................................... 12 idarubicin hcl ............................................... 12 IFEX ............................................................ 12 ifosfamide ................................................... 12 ILARIS ........................................................ 21 ILEVRO ...................................................... 31 imipenem-cilastatin ....................................... 8 imipramine hcl ............................................. 26 imipramine pamoate ................................... 26 imiquimod ................................................... 44 IMITREX ..................................................... 24 IMITREX STATDOSE REFILL .................... 24 IMOGAM RABIES-HT ................................. 41 IMOVAX RABIES (H.D.C.V.) ...................... 41 IMURAN ..................................................... 39 INCIVEK ..................................................... 10 INCRELEX .................................................. 38 indapamide ................................................. 29 INDERAL LA ............................................... 20 INDOCIN .................................................... 21 indomethacin .............................................. 21 INFANRIX ................................................... 41 INFERGEN ................................................. 10 INLYTA ....................................................... 12 INNOPRAN XL ........................................... 20 INSPRA ...................................................... 18 insulin pen needle ....................................... 27 insulin syringe/needle u-100 ....................... 27 INTEGRILIN ................................................ 15 INTELENCE TAB 100MG ........................... 10 INTELENCE TAB 200MG ........................... 10 INTELENCE TAB 25MG ............................. 10 INTERMEZZO ...................................... 25, 26 INTRALIPID INJ 30% .................................. 28 INTRON-A INJ 10MU PEN ......................... 12 INTRON-A INJ 18MU .................................. 12 INTRON-A INJ 25MU .................................. 12 INTRON-A INJ 3MU PEN ........................... 12 INTRON-A INJ 5MU PEN ........................... 12 INTRON-A W/DILUENT INJ 10MU ............. 12 INTRON-A W/DILUENT INJ 18MU ............. 12 INTRON-A W/DILUENT INJ 50MU ............. 12 INTUNIV ..................................................... 25 INVANZ ........................................................ 8


INVEGA ...................................................... 26 INVEGA SUSTENNA ................................. 26 INVIRASE CAP 200MG .............................. 10 INVIRASE TAB 500MG .............................. 10 INVOKANA ................................................. 36 IONOSOL-B/DEXTROSE 5% ..................... 29 IONOSOL-MB/DEXTROSE 5% .................. 29 IOPIDINE SOL 0.5% OP ............................ 32 IOPIDINE SOL 1% OP ............................... 32 IPOL INACTIVATED IPV ............................ 41 ipratropium bromide.................................... 14 ipratropium bromide (nasal) ........................ 14 ipratropium-albuterol................................... 15 irbesartan ................................................... 18 irbesartan-hydrochlorothiazide ................... 18 irinotecan hcl .............................................. 12 irrigation solutions, physiological ................ 29 ISENTRESS ............................................... 10 isoniazid ....................................................... 9 isoniazid & rifampin ...................................... 9 ISOPTO CARPINE SOL 1% OP ................. 32 ISOPTO CARPINE SOL 2% OP ................. 32 ISOPTO CARPINE SOL 4% OP ................. 32 ISORDIL TITRADOSE TAB 40MG ............. 19 ISORDIL TITRADOSE TAB 5MG ............... 19 isosorbide dinitrate ..................................... 19 isosorbide mononitrate er tab 120mg er ..... 19 isosorbide mononitrate er tab 30mg er ....... 19 isosorbide mononitrate er tab 60mg er ....... 19 isosorbide mononitrate tab 10mg ............... 19 isosorbide mononitrate tab 20mg ............... 19 isotretinoin .................................................. 44 isradipine .................................................... 17 ISTALOL .................................................... 32 ISTODAX ................................................... 12 itraconazole .................................................. 9 IXEMPRA KIT ............................................. 12 IXIARO ....................................................... 41

J JAKAFI ....................................................... 12 JALYN ........................................................ 39 JANUMET .................................................. 36 JANUMET XR ............................................ 36 JANUVIA .................................................... 36 JENTADUETO ........................................... 36 JE-VAX ....................................................... 41 JEVTANA ................................................... 12 JUVISYNC.................................................. 36 JUXTAPID .................................................. 16

K KADCYLA ................................................... 12 KADIAN CAP 100MG CR ........................... 21 KADIAN CAP 10MG CR ............................. 21 KADIAN CAP 200MG CR ........................... 21 KADIAN CAP 20MG CR ............................. 21 KADIAN CAP 30MG CR ............................. 21 KADIAN CAP 50MG CR ............................. 21 KADIAN CAP 60MG CR ............................. 21 KADIAN CAP 80MG CR ............................. 21 KALETRA SOL ........................................... 10 KALETRA TAB 100-25MG .......................... 10 KALETRA TAB 200-50MG .......................... 10 KALYDECO ................................................ 41 kanamycin sulfate ......................................... 8 KAPVAY ..................................................... 18 KAYEXALATE ............................................ 29 KAZANO ..................................................... 36 KCL 0.15%/D5W/LR ................................... 29 KCL 0.15%/D5W/NACL 0.225% INJ 0.15/0.2

................................................................ 29 KCL 0.3%/D5W/NACL 0.9% INJ 0.3/0.9% .. 29 KEFLEX ........................................................ 8 KENALOG .................................................. 43 KENALOG-10 ............................................. 34 KENALOG-40 ............................................. 34 KEPIVANCE ............................................... 43 KEPPRA ..................................................... 23 KEPPRA XR ............................................... 23 KETEK .......................................................... 8 ketoconazole ................................................. 9 ketoconazole & cleanser ............................. 42 ketoconazole (topical) ................................. 42 ketoprofen ................................................... 21 ketorolac tromethamine .............................. 21 ketorolac tromethamine (ophth) .................. 31 KINERET .................................................... 39 KLARON ..................................................... 42 KLONOPIN ................................................. 23 KOMBIGLYZE XR ...................................... 36 KORLYM .................................................... 36 K-TABS ....................................................... 29 KUVAN ....................................................... 39 KYNAMRO.................................................. 16 KYPROLIS .................................................. 12

L labetalol hcl ................................................. 20 LAC-HYDRIN .............................................. 44 LACRISERT ................................................ 32


lactated ringer's .......................................... 29 lactated ringer's (irrigation) ......................... 29 lactic acid (ammonium lactate) ................... 44 lactulose ..................................................... 28 lactulose (encephalopathy) ......................... 28 LAMICTAL CHEWABLE DISPERSIBLE CHW

25MG ...................................................... 23 LAMICTAL CHEWABLE DISPERSIBLE CHW

5MG ........................................................ 23 LAMICTAL ODT TAB 100MG ..................... 23 LAMICTAL ODT TAB 200MG ..................... 23 LAMICTAL ODT TAB 25MG ....................... 23 LAMICTAL ODT TAB 50MG ....................... 23 LAMICTAL STARTER/NOT TAKING

CARBAMAZEPINE KIT START 49 ......... 23 LAMICTAL STARTER/TAKING

CARBAMAZEPINE/NOT TAKING VALPROATE KIT START 98 .................. 23

LAMICTAL STARTER/TAKING VALPROATE KIT START 35 ........................................ 23

LAMICTAL TAB 100MG ............................. 23 LAMICTAL TAB 150MG ............................. 23 LAMICTAL TAB 200MG ............................. 23 LAMICTAL TAB 25MG ............................... 23 LAMICTAL XR KIT ..................................... 23 LAMICTAL XR TAB 100MG ....................... 23 LAMICTAL XR TAB 200MG ....................... 23 LAMICTAL XR TAB 250MG ....................... 23 LAMICTAL XR TAB 25MG ......................... 23 LAMICTAL XR TAB 300MG ....................... 23 LAMICTAL XR TAB 50MG ......................... 23 LAMISIL ....................................................... 9 lamivudine .................................................. 10 lamivudine-zidovudine ................................ 10 lamotrigine .................................................. 23 LANOXIN INJ 0.25MG/1 ............................. 17 LANOXIN PEDIATRIC INJ 0.1MG/ML ........ 17 LANOXIN TAB 0.125MG ............................ 17 LANOXIN TAB 0.25MG .............................. 17 lansoprazole ............................................... 33 LANTUS INJ 100/ML .................................. 36 LANTUS SOLOSTAR INJ SOLOSTAR ...... 36 LASIX ......................................................... 29 LASTACAFT ............................................... 31 latanoprost.................................................. 32 LATUDA ..................................................... 26 LAZANDA ................................................... 25 leflunomide ................................................. 39 LESCOL ..................................................... 16 LESCOL XL ................................................ 16 LETAIRIS ................................................... 19 letrozole ...................................................... 12

leucovorin calcium ...................................... 39 LEUKERAN ................................................ 13 LEUKINE INJ 250MCG ............................... 16 LEUKINE INJ 500 MCG .............................. 16 leuprolide acetate ....................................... 13 levalbuterol hcl ............................................ 15 LEVAQUIN.................................................... 8 LEVATOL.................................................... 20 LEVEMIR .................................................... 36 LEVEMIR FLEXPEN ................................... 36 levetiracetam .............................................. 23 LEVETIRACETAM ...................................... 23 levobunolol hcl ............................................ 32 levocarnitine (metabolic modifiers) .............. 39 levocetirizine dihydrochloride ...................... 11 levofloxacin ................................................... 8 levofloxacin (ophth) ..................................... 30 levofloxacin in d5w ........................................ 8 levonorgestrel & eth estradiol...................... 35 levonorgestrel (emergency oc).................... 35 levonorgestrel-eth estradiol (triphasic) ........ 35 levonorgestrel-ethinyl estradiol (91-day) ..... 35 levonorgestrel-ethinyl estradiol (continuous)

................................................................ 35 levorphanol tartrate ..................................... 21 levothyroxine sodium .................................. 38 LEXAPRO ................................................... 26 LEXIVA SUS 50MG/ML .............................. 10 LEXIVA TAB 700MG................................... 10 LIALDA TAB 1.2GM .................................... 32 lidocaine ..................................................... 43 lidocaine hcl ................................................ 43 lidocaine hcl (local anesth.) ......................... 39 lidocaine hcl (mouth-throat) ........................ 32 lidocaine-prilocaine ..................................... 43 LIDODERM ................................................. 43 LINCOCIN..................................................... 8 lindane ........................................................ 42 LINZESS ..................................................... 33 LIORESAL INTRATHECAL ........................ 14 liothyronine sodium ..................................... 38 LIPITOR ...................................................... 16 LIPOFEN .................................................... 16 LIPOSYN III INJ 10% .................................. 28 LIPOSYN III INJ 20% .................................. 28 LIPTRUZET ................................................ 16 lisinopril & hydrochlorothiazide.................... 18 lisinopril tab 10mg ....................................... 18 lisinopril tab 2.5mg ...................................... 18 lisinopril tab 20mg ....................................... 18 lisinopril tab 30mg ....................................... 18 lisinopril tab 40mg ....................................... 18


lisinopril tab 5mg ........................................ 18 lithium carbonate ........................................ 26 LITHIUM CARBONATE CAP 600MG ......... 26 LITHIUM CITRATE ..................................... 26 LITHOBID TAB 300MG CR ........................ 26 LIVALO ....................................................... 16 LO LOESTRIN FE ...................................... 35 LO MINASTRIN FE .................................... 35 LO/OVRAL-28 ............................................ 35 LOCOID ..................................................... 43 LOCOID LIPOCREAM ................................ 43 LODOSYN .................................................. 24 LOESTRIN 24 FE ....................................... 35 LOMOTIL ................................................... 32 loperamide hcl ............................................ 32 LOPID ........................................................ 16 LOPRESSOR ............................................. 20 LOPRESSOR HCT ..................................... 20 LOPROX .................................................... 42 LOPROX SHAMPOO ................................. 42 lorazepam................................................... 25 losartan potassium ..................................... 18 losartan potassium & hydrochlorothiazide .. 18 LOSEASONIQUE ....................................... 35 LOTEMAX .................................................. 31 LOTENSIN ................................................. 18 LOTENSIN HCT ......................................... 18 LOTREL ..................................................... 17 LOTRISONE ............................................... 42 LOTRONEX ................................................ 32 lovastatin .................................................... 16 LOVAZA ..................................................... 16 LOVENOX .................................................. 15 loxapine succinate ...................................... 26 LUFYLLIN................................................... 44 LUMIGAN ................................................... 32 LUMIZYME ................................................. 30 LUNESTA ................................................... 25 LUPRON DEPOT INJ 11.25MG ................. 13 LUPRON DEPOT INJ 22.5MG ................... 13 LUPRON DEPOT INJ 3.75MG ................... 13 LUPRON DEPOT INJ 30MG ...................... 13 LUPRON DEPOT INJ 45MG ...................... 13 LUPRON DEPOT INJ 7.5MG ..................... 13 LUPRON DEPOT-PED ............................... 13 LUPRON DEPOT-PED INJ 11.25MG ......... 13 LUPRON DEPOT-PED INJ 30MG .............. 13 LUVOX CR ................................................. 26 LUXIQ ........................................................ 43 LYBREL ..................................................... 35 LYRICA ...................................................... 23

LYSODREN ................................................ 13 LYSTEDA TAB 650MG ............................... 15

M MACROBID ................................................ 11 MACRODANTIN CAP 100MG .................... 11 MACRODANTIN CAP 25MG ...................... 11 mafenide acetate ........................................ 42 magnesium sulfate ...................................... 23 MAGNESIUM SULFATE ............................. 23 MAGNESIUM SULFATE IN D5W ............... 29 MALARONE TAB 250-100 ............................ 9 MALARONE TAB 62.5-25 ........................... 10 malathion .................................................... 42 maprotiline hcl ............................................. 26 MARINOL ................................................... 32 MARPLAN .................................................. 26 MATULANE ................................................ 13 MAVIK ........................................................ 18 MAXAIR AUTOHALER ............................... 15 MAXALT ..................................................... 24 MAXALT-MLT ............................................. 24 MAXIDEX.................................................... 31 MAXIPIME .................................................... 8 MAXITROL ................................................. 31 MAXZIDE .................................................... 29 MAXZIDE-25 ............................................... 29 mecamylamine hcl ...................................... 18 meclizine hcl ............................................... 32 meclofenamate sodium ............................... 21 MEDROL DOSEPAK PAK 4MG ................. 34 MEDROL TAB 16MG .................................. 34 MEDROL TAB 2MG .................................... 34 MEDROL TAB 32MG .................................. 34 MEDROL TAB 4MG .................................... 34 MEDROL TAB 8MG .................................... 34 medroxyprogesterone acetate .................... 38 medroxyprogesterone acetate (contraceptive)

................................................................ 38 mefenamic acid ........................................... 21 mefloquine hcl ............................................. 10 MEGACE ES .............................................. 38 MEGACE ORAL ......................................... 13 megestrol acetate ....................................... 13 MEKINIST ................................................... 13 meloxicam................................................... 21 MELOXICAM .............................................. 21 melphalan hcl .............................................. 13 MENACTRA ................................................ 41 MENOMUNE-A/C/Y/W-135 ........................ 41 MENOSTAR DIS 14MCG ........................... 37


MENTAX .................................................... 42 MENVEO .................................................... 41 meperidine hcl ............................................ 21 meprobamate ............................................. 25 MEPRON ................................................... 10 mercaptopurine .......................................... 13 meropenem .................................................. 8 MERREM ..................................................... 8 mesalamine w/ cleanser ............................. 32 mesna ........................................................ 39 MESNEX INJ 1GM ..................................... 39 MESNEX TAB 400MG ................................ 39 MESTINON SYP 60MG/5ML ...................... 14 MESTINON TAB 60MG .............................. 14 MESTINON TIMESPAN TAB TIMESPAN .. 14 METADATE CD CAP 10MG ....................... 22 METADATE CD CAP 20MG ....................... 22 METADATE CD CAP 30MG ....................... 22 METADATE CD CAP 40MG ....................... 22 METADATE CD CAP 50MG ....................... 22 METADATE CD CAP 60MG ....................... 22 metaproterenol sulfate ................................ 15 metformin hcl er tab 1000mg ...................... 36 metformin hcl er tab 500mg er .................... 36 metformin hcl er tab 750mg er .................... 36 metformin hcl tab 1000mg .......................... 36 metformin hcl tab 500mg ............................ 36 metformin hcl tab 850mg ............................ 36 methadone hcl ............................................ 21 METHADONE HCL INJ 10MG/ML ............. 21 methamphetamine hcl ................................ 22 methazolamide ........................................... 32 methenamine hippurate .............................. 11 METHERGINE ........................................... 39 methimazole ............................................... 38 methocarbamol ........................................... 14 methotrexate sodium .................................. 13 methscopolamine bromide ......................... 14 methyclothiazide ......................................... 29 methyldopa ................................................. 18 methyldopa & hydrochlorothiazide .............. 18 methyldopate hcl ........................................ 18 methylergonovine maleate ......................... 39 METHYLIN CHW 10MG ............................. 22 METHYLIN CHW 2.5MG ............................ 22 METHYLIN CHW 5MG ............................... 22 METHYLIN SOL 10MG/5ML....................... 22 METHYLIN SOL 5MG/5ML ........................ 22 methylphenidate hcl.................................... 22 methylprednisolone .................................... 34 methylprednisolone acetate ........................ 34 methylprednisolone sod succ ..................... 34

methyltestosterone ..................................... 34 metipranolol ................................................ 32 metoclopramide hcl ..................................... 33 metolazone ................................................. 29 metoprolol & hydrochlorothiazide ................ 20 metoprolol succinate ................................... 20 metoprolol tartrate inj 1mg/ml...................... 20 metoprolol tartrate tab 100mg ..................... 20 metoprolol tartrate tab 25mg ....................... 20 metoprolol tartrate tab 50mg ....................... 20 METOZOLV ODT ....................................... 33 METRO IV .................................................. 10 METROCREAM .......................................... 42 METROGEL ................................................ 42 METROGEL-VAGINAL ............................... 42 METROLOTION ......................................... 42 metronidazole ............................................. 10 metronidazole (topical) ................................ 42 metronidazole in nacl .................................. 10 metronidazole vaginal ................................. 42 MEVACOR.................................................. 16 mexiletine hcl .............................................. 17 MIACALCIN INJ 200/ML ............................. 37 MIACALCIN SPR 200/ACT ......................... 37 MICARDIS .................................................. 18 MICARDIS HCT .......................................... 18 miconazole nitrate vaginal .......................... 42 MICROZIDE ................................................ 29 midodrine hcl .............................................. 15 MIFEPREX ................................................. 39 MIGRANAL ................................................. 14 MINASTRIN 24 FE...................................... 35 MINIPRESS ................................................ 16 MINIVELLE DIS 0.0375MG ........................ 37 MINIVELLE DIS 0.05MG ............................ 37 MINIVELLE DIS 0.075MG .......................... 37 MINIVELLE DIS 0.1MG .............................. 37 MINOCIN ...................................................... 8 minocycline hcl ............................................. 8 minoxidil ...................................................... 18 MIRAPEX.................................................... 24 MIRAPEX ER .............................................. 24 mirtazapine ................................................. 26 misoprostol ................................................. 33 mitomycin.................................................... 13 mitoxantrone hcl ......................................... 13 M-M-R II W/DILUENT 10 DOSE ................. 41 MOBIC ........................................................ 21 modafinil ..................................................... 22 MODICON .................................................. 35 moexipril hcl ................................................ 18 moexipril-hydrochlorothiazide ..................... 18


mometasone furoate................................... 43 MONODOX CAP 100MG ............................. 8 MONODOX CAP 75MG ............................... 8 MONOKET ................................................. 19 montelukast sodium.................................... 40 MONUROL ................................................. 11 morphine sulfate ......................................... 21 MORPHINE SULFATE SOL 20MG/ML ...... 21 MORPHINE SULFATE TAB 15MG ............ 21 MORPHINE SULFATE TAB 30MG ............ 21 MOTOFEN ................................................. 32 MOVIPREP ................................................ 33 MOXATAG TAB 775MG ............................... 8 MOXEZA .................................................... 30 MOZOBIL ................................................... 16 MS CONTIN TAB 100MG CR..................... 21 MS CONTIN TAB 15MG CR ...................... 21 MS CONTIN TAB 200MG CR..................... 21 MS CONTIN TAB 30MG CR ...................... 21 MS CONTIN TAB 60MG CR ...................... 21 MULTAQ .................................................... 17 mupirocin .................................................... 42 mupirocin calcium (topical) ......................... 42 MUSTARGEN ............................................ 13 MYAMBUTOL ............................................... 9 MYCAMINE .................................................. 9 MYCOBUTIN ................................................ 9 mycophenolate mofetil ................................ 39 MYFORTIC ................................................. 39 MYOZYME ................................................. 30 MYRBETRIQ .............................................. 44 MYSOLINE ................................................. 23 MYTELASE ................................................ 14

N NABI-HB ..................................................... 41 nabumetone ............................................... 21 nadolol & bendroflumethiazide ................... 20 nadolol tab 20mg ........................................ 20 nadolol tab 40mg ........................................ 20 nadolol tab 80mg ........................................ 20 nafcillin sodium ............................................. 8 NAFTIN ...................................................... 42 NAGLAZYME ............................................. 30 nalbuphine hcl ............................................ 21 NALFON ..................................................... 21 NALLPEN ISO-OSMOTIC IN DEXTROSE ... 8 NALLPEN/DEXTROSE ................................ 8 naloxone hcl ............................................... 25 naltrexone hcl ............................................. 25 NAMENDA SOL 10MG/5ML ....................... 25

NAMENDA TAB 10MG ............................... 25 NAMENDA TAB 5MG ................................. 25 NAMENDA TITRATION PAK TAB 5-10MG 25 NAMENDA XR CAP 14MG ......................... 25 NAMENDA XR CAP 21MG ......................... 25 NAMENDA XR CAP 28MG ......................... 25 NAMENDA XR CAP 7MG ........................... 25 NAMENDA XR TITRATION PACK CAP

TITRATIO ................................................ 25 naphazoline hcl ........................................... 32 NAPRELAN ................................................ 21 NAPROSYN ................................................ 21 naproxen ..................................................... 21 naproxen sodium ........................................ 21 naratriptan hcl ............................................. 24 NARDIL ...................................................... 26 NASACORT AQ .......................................... 31 NASONEX .................................................. 31 NATACYN................................................... 30 nateglinide .................................................. 36 NAVANE ..................................................... 26 NEBUPENT INH 300MG ............................ 10 nefazodone hcl ........................................... 26 neomycin sulfate ........................................... 8 neomycin/polymyxin b gu ............................ 42 neomycin-bacitracin zn-polymyxin .............. 30 neomycin-polymy-dexameth ....................... 31 neomycin-polymy-gramicid ......................... 30 neomycin-polymyxin-hc (ophth) .................. 31 neomycin-polymyxin-hc (otic)...................... 31 NEORAL CAP 100MG ................................ 40 NEORAL CAP 25MG .................................. 40 NEORAL SOL 100MG/ML .......................... 40 NEPHRAMINE INJ 5.4% ............................ 28 NESINA ...................................................... 36 NEULASTA ................................................. 16 NEUMEGA.................................................. 16 NEUPOGEN ............................................... 16 NEUPRO .................................................... 24 NEURONTIN .............................................. 23 NEVANAC .................................................. 31 nevirapine ................................................... 10 NEXAVAR................................................... 13 NEXIUM ...................................................... 33 NEXIUM I.V. ............................................... 33 NEXTERONE ............................................. 17 niacin (antihyperlipidemic) .......................... 44 NIASPAN .................................................... 16 nicardipine hcl ............................................. 17 NICOTROL INHALER INH .......................... 14 NICOTROL NS SPR 10MG/ML .................. 14


nifedipine .................................................... 17 NILANDRON .............................................. 13 nimodipine .................................................. 17 NIPENT ...................................................... 13 NIRAVAM ................................................... 25 nisoldipine .................................................. 17 NITRO-DUR DIS 0.1MG/HR ...................... 19 NITRO-DUR DIS 0.2MG/HR ...................... 19 NITRO-DUR DIS 0.3MG/HR ...................... 19 NITRO-DUR DIS 0.4MG/HR ...................... 19 NITRO-DUR DIS 0.6MG/HR ...................... 19 NITRO-DUR DIS 0.8MG/HR ...................... 19 nitrofurantoin .............................................. 11 nitrofurantoin macrocrystal ......................... 11 nitrofurantoin monohyd macro .................... 11 nitroglycerin ................................................ 19 NITROLINGUAL PUMPSPRAY SPR

PUMPSPRA ........................................... 19 NITROMIST AER 400MCG ........................ 19 NITROSTAT SUB 0.3MG ........................... 19 NITROSTAT SUB 0.4MG ........................... 19 NITROSTAT SUB 0.6MG ........................... 19 nizatidine .................................................... 33 NIZORAL .................................................... 42 NORDETTE-28 .......................................... 35 NORDITROPIN FLEXPRO INJ 10/1.5ML ... 38 NORDITROPIN FLEXPRO INJ 15/1.5ML ... 38 NORDITROPIN FLEXPRO INJ 5/1.5ML ..... 38 NORDITROPIN NORDIFLEX PEN INJ

30/3ML.................................................... 38 norethin acet & estrad-fe ............................ 35 norethindrone & eth estradiol...................... 35 norethindrone & ethinyl estradiol-fe ............ 35 norethindrone (contraceptive) ..................... 35 norethindrone acet & eth estra ................... 35 norethindrone acetate ................................. 38 norethindrone acetate-ethinyl estradiol ....... 37 norethindrone acetate-ethinyl estradiol-fe ... 35 norethindrone-eth estradiol (biphasic) ........ 35 norethindrone-eth estradiol (triphasic) ........ 35 norgestimate-ethinyl estradiol ..................... 35 norgestimate-ethinyl estradiol (triphasic) .... 35 norgestrel & ethinyl estradiol ...................... 35 NORINYL 1+35 .......................................... 35 NORITATE ................................................. 42 NORMOSOL-R ........................................... 29 NORMOSOL-R IN D5W ............................. 29 NOROXIN..................................................... 8 NORPACE CAP 100MG ............................. 17 NORPACE CAP 150MG ............................. 17 NORPACE CR CAP 100MG CR ................ 17 NORPACE CR CAP 150MG CR ................ 17

NORPRAMIN .............................................. 26 NOR-QD ..................................................... 35 nortriptyline hcl cap 10mg ........................... 26 nortriptyline hcl cap 25mg ........................... 26 nortriptyline hcl cap 50mg ........................... 26 nortriptyline hcl cap 75mg ........................... 26 nortriptyline hcl sol 10mg/5ml...................... 26 NORVASC .................................................. 17 NORVIR ...................................................... 10 NOVOLIN 70/30 INJ 70/30 ......................... 36 NOVOLIN N INJ U-100 ............................... 36 NOVOLIN R INJ U-100 ............................... 36 NOVOLOG.................................................. 36 NOVOLOG FLEXPEN ................................ 36 NOVOLOG MIX 70/30 ................................ 36 NOVOLOG MIX 70/30 PREFILLED

FLEXPEN ................................................ 36 NOXAFIL ...................................................... 9 NUCYNTA .................................................. 21 NUCYNTA ER ............................................ 21 NUEDEXTA ................................................ 25 NULOJIX .................................................... 40 NULYTELY/FLAVOR PACKS ..................... 33 NUTROPIN AQ NUSPIN 5 INJ NUSPIN 5 .. 38 NUTROPIN AQ PEN INJ 10MG/2ML .......... 38 NUTROPIN AQ PEN INJ 20MG/2ML .......... 38 NUTROPIN INJ 10MG ................................ 38 NUVARING ................................................. 35 NUVIGIL ..................................................... 22 nystatin ......................................................... 9 nystatin (mouth-throat) .................................. 9 nystatin (topical) .......................................... 42 nystatin-triamcinolone ................................. 43

O OCTAGAM.................................................. 41 octreotide acetate ....................................... 40 OCUFEN .................................................... 31 OCUFLOX .................................................. 30 ofloxacin ....................................................... 8 ofloxacin (ophth) ......................................... 30 ofloxacin (otic) ............................................. 30 olanzapine .................................................. 26 olanzapine-fluoxetine hcl ............................ 26 OLEPTRO................................................... 27 OLUX-E ...................................................... 43 OMECLAMOX-PAK .................................... 33 omeprazole ................................................. 33 omeprazole-sodium bicarbonate ................. 33 OMNARIS ................................................... 31 OMNIPRED SUS 1% OP ............................ 31 OMNITROPE INJ 10/1.5ML ........................ 38


OMNITROPE INJ 5.8MG ............................ 38 OMNITROPE INJ 5/1.5ML ......................... 38 ONCASPAR ............................................... 13 ondansetron ............................................... 32 ondansetron hcl .......................................... 32 ONFI ........................................................... 23 ONGLYZA .................................................. 36 ONMEL TAB 200MG .................................... 9 ONSOLIS ................................................... 22 ONTAK ....................................................... 13 OPANA ....................................................... 22 OPANA ER (CRUSH RESISTANT) ............ 22 OPTIPRANOLOL ....................................... 32 OPTIVAR ................................................... 31 ORACEA .................................................... 44 ORAP ......................................................... 27 ORAPRED ODT ......................................... 34 ORENCIA ................................................... 40 ORFADIN ................................................... 40 orphenadrine citrate.................................... 14 orphenadrine w/ aspirin & caff .................... 22 ORTHO EVRA ............................................ 35 ORTHO MICRONOR .................................. 35 ORTHO TRI-CYCLEN ................................ 35 ORTHO TRI-CYCLEN LO .......................... 35 ORTHO-CEPT ............................................ 35 ORTHO-CYCLEN ....................................... 35 ORTHO-NOVUM 7/7/7 ............................... 35 OSENI ........................................................ 36 OSMOPREP ............................................... 33 OVCON-50 28 ............................................ 35 OVIDE ........................................................ 42 oxacillin sodium ............................................ 8 oxaliplatin ................................................... 13 oxandrolone................................................ 34 oxaprozin .................................................... 22 oxazepam ................................................... 25 oxcarbazepine ............................................ 23 OXECTA .................................................... 22 OXISTAT .................................................... 42 OXSORALEN ............................................. 44 OXSORALEN ULTRA ................................ 44 oxybutynin chloride ..................................... 44 oxycodone hcl ............................................ 22 OXYCODONE HCL .................................... 22 oxycodone w/ acetaminophen .................... 22 oxycodone-aspirin ...................................... 22 oxycodone-ibuprofen .................................. 22 OXYCONTIN .............................................. 22 oxymorphone hcl ........................................ 22 OXYTROL DIS 3.9MG/24 ........................... 44

P paclitaxel ..................................................... 13 PAMELOR .................................................. 27 pamidronate disodium ................................. 40 PAMINE ...................................................... 14 PAMINE FORTE ......................................... 14 PANCREAZE CAP 10500UNT ................... 33 PANCREAZE CAP 16800UNT ................... 33 PANCREAZE CAP 21000UNT ................... 33 PANCREAZE CAP 4200UNIT .................... 33 PANDEL ..................................................... 43 PANRETIN.................................................. 44 pantoprazole sodium................................... 33 PARAFON FORTE DSC ............................. 14 parenteral electrolytes ................................. 29 PARLODEL ................................................. 24 PARNATE ................................................... 27 paromomycin sulfate ................................... 10 paroxetine hcl er tab 12.5mg ...................... 27 paroxetine hcl er tab 25mg er ..................... 27 paroxetine hcl er tab 37.5mg ...................... 27 paroxetine hcl tab 10mg .............................. 27 paroxetine hcl tab 20mg .............................. 27 paroxetine hcl tab 30mg .............................. 27 paroxetine hcl tab 40mg .............................. 27 PATADAY ................................................... 31 PATANASE ................................................. 31 PATANOL ................................................... 31 PAXIL ......................................................... 27 PAXIL CR ................................................... 27 PCE .............................................................. 8 PEDVAX HIB .............................................. 41 peg 3350-kcl-sod bicarb-sod chloride-sod

sulfate ..................................................... 33 peg 3350-potassium chloride-sod

bicarbonate-sod chloride ......................... 33 PEGANONE ............................................... 23 PEGASYS................................................... 10 PEGASYS PROCLICK ............................... 10 PEG-INTRON ............................................. 10 PEG-INTRON REDIPEN ............................ 10 penicillin g potassium .................................... 8 PENICILLIN G POTASSIUM IN ISO-

OSMOTIC DEXTROSE ............................. 8 penicillin g procaine ...................................... 8 penicillin g sodium ........................................ 8 penicillin v potassium .................................... 8 PENLAC NAIL LACQUER .......................... 42 PENNSAID ................................................. 44 PENTAM 300 INJ 300MG ........................... 10 PENTASA CAP 250MG CR ........................ 32


PENTASA CAP 500MG CR ....................... 32 pentazocine w/ naloxone ............................ 22 pentazocine-acetaminophen ...................... 22 pentostatin .................................................. 13 pentoxifylline ............................................... 15 PEPCID ...................................................... 33 PERCODAN ............................................... 22 PERFOROMIST ......................................... 15 perindopril erbumine ................................... 18 PERJETA ................................................... 13 permethrin .................................................. 42 perphenazine .............................................. 27 perphenazine-amitriptyline ......................... 27 PERSANTINE ............................................ 19 PERTZYE CAP .......................................... 33 PEXEVA ..................................................... 27 phenelzine sulfate ...................................... 27 phenobarbital .............................................. 25 phenytoin .................................................... 23 phenytoin sodium ....................................... 23 phenytoin sodium extended ........................ 23 PHISOHEX ................................................. 42 PHOSLO CAP 667MG ............................... 29 PHOSLYRA SOL ........................................ 29 PHOSPHOLINE IODIDE ............................ 32 PICATO ...................................................... 44 pilocarpine hcl (oral) ................................... 14 PILOPINE HS GEL 4% OP ........................ 32 pindolol ....................................................... 20 pioglitazone hcl ........................................... 36 pioglitazone hcl-glimepiride ........................ 36 pioglitazone hcl-metformin hcl .................... 36 piperacillin sodium-tazobactam sodium ........ 8 piroxicam .................................................... 22 PLAN B ONE-STEP ................................... 35 PLAQUENIL ............................................... 10 PLASMA-LYTE A ....................................... 29 PLASMA-LYTE-148.................................... 29 PLASMA-LYTE-56/D5W ............................. 29 PLAVIX ....................................................... 15 PLETAL ...................................................... 15 podofilox ..................................................... 44 polyethylene glycol 3350 ............................ 33 polymyxin b sulfate ....................................... 8 polymyxin b-trimethoprim ........................... 30 POLYTRIM ................................................. 30 POMALYST ................................................ 13 PONSTEL................................................... 22 potassium chloride ..................................... 29 POTASSIUM CHLORIDE 0.15% /NACL

0.45% VIAFLEX INJ .15-0.45 ................. 29

POTASSIUM CHLORIDE 0.3%/ NACL 0.9% INJ 0.3-0.9 .............................................. 30

potassium chloride in dextrose .................... 30 potassium chloride in dextrose & sodium

chloride ................................................... 30 potassium chloride in nacl ........................... 30 potassium chloride microencapsulated

crystals cr ................................................ 30 potassium citrate (alkalinizer)...................... 27 POTIGA ...................................................... 23 PRADAXA................................................... 15 pramipexole dihydrochloride ....................... 24 PRANDIMET ............................................... 36 PRANDIN.................................................... 36 PRAVACHOL .............................................. 16 pravastatin sodium ...................................... 16 prazosin hcl ................................................. 16 PRECOSE .................................................. 36 PRED FORTE SUS 1% OP ........................ 31 PRED MILD SUS 0.12% OP ....................... 31 PRED-G ...................................................... 31 PRED-G S.O.P. .......................................... 31 prednicarbate .............................................. 43 prednisolone ............................................... 34 prednisolone acetate (ophth) ...................... 31 prednisolone sodium phosphate ................. 34 prednisolone sodium phosphate (ophth) ..... 31 prednisone .................................................. 34 PREMARIN ................................................. 37 PREMARIN INJ 25MG ................................ 37 PREMARIN TAB 0.3MG ............................. 37 PREMARIN TAB 0.45MG ........................... 37 PREMARIN TAB 0.625MG ......................... 37 PREMARIN TAB 0.9MG ............................. 37 PREMARIN TAB 1.25MG ........................... 37 PREMPHASE ............................................. 37 PREMPRO.................................................. 37 PREPOPIK ................................................. 33 PREVACID ................................................. 33 PREVACID SOLUTAB ................................ 33 PREVPAC................................................... 33 PREZISTA SUS 100MG/ML ....................... 10 PREZISTA TAB 150MG .............................. 10 PREZISTA TAB 400MG .............................. 10 PREZISTA TAB 600MG .............................. 10 PREZISTA TAB 75MG ................................ 10 PREZISTA TAB 800MG .............................. 10 PRIFTIN ........................................................ 9 PRILOSEC.................................................. 33 PRIMAQUINE PHOSPHATE ...................... 10 PRIMAXIN I.M. INJ 500MG .......................... 8 PRIMAXIN IV INJ 250MG ............................. 8


PRIMAXIN IV INJ 500MG ............................. 8 primidone ................................................... 23 PRIMSOL ................................................... 11 PRINIVIL .................................................... 18 PRINZIDE................................................... 18 PRISTIQ ..................................................... 27 PRIVIGEN .................................................. 41 PROAIR HFA AER ..................................... 15 probenecid.................................................. 30 procainamide hcl ........................................ 17 PROCALAMINE INJ 3% ............................. 28 PROCARDIA .............................................. 17 PROCARDIA XL ......................................... 17 prochlorperazine ......................................... 27 prochlorperazine edisylate .......................... 27 prochlorperazine maleate ........................... 27 PROCRIT INJ 10000/ML ............................ 16 PROCRIT INJ 2000/ML .............................. 16 PROCRIT INJ 20000/ML ............................ 16 PROCRIT INJ 3000/ML .............................. 16 PROCRIT INJ 4000/ML .............................. 16 PROCRIT INJ 40000/ML ............................ 16 PROCYSBI CAP 25MG .............................. 40 PROCYSBI CAP 75MG .............................. 40 progesterone micronized ............................ 38 PROGLYCEM ............................................ 18 PROGRAF CAP 0.5MG .............................. 40 PROGRAF CAP 1MG ................................. 40 PROGRAF CAP 5MG ................................. 40 PROGRAF INJ 5MG/ML ............................. 40 PROLASTIN-C ........................................... 41 PROLENSA ................................................ 31 PROLEUKIN ............................................... 13 PROLIA SOL 60MG/ML ............................. 40 PROMACTA ............................................... 16 promethazine & phenylephrine ................... 11 promethazine hcl ........................................ 11 PROMETRIUM ........................................... 38 propafenone hcl .......................................... 17 propantheline bromide ................................ 14 proparacaine hcl ......................................... 32 propranolol & hydrochlorothiazide .............. 20 propranolol hcl er cap 120mg er ................. 20 propranolol hcl er cap 160mg er ................. 20 propranolol hcl er cap 60mg er ................... 20 propranolol hcl er cap 80mg er ................... 20 propranolol hcl inj 1mg/ml ........................... 20 propranolol hcl sol 20mg/5ml ...................... 20 propranolol hcl sol 40mg/5ml ...................... 20 propranolol hcl tab 10mg ............................ 20 propranolol hcl tab 20mg ............................ 20

propranolol hcl tab 40mg ............................ 20 propranolol hcl tab 60mg ............................ 20 propranolol hcl tab 80mg ............................ 20 propylthiouracil ............................................ 38 PROQUAD.................................................. 41 PROSCAR .................................................. 40 PROTONIX INJ 40MG ................................ 33 PROTONIX PAK ......................................... 33 PROTONIX TAB 20MG .............................. 33 PROTONIX TAB 40MG .............................. 33 PROTOPIC ................................................. 44 protriptyline hcl ............................................ 27 PROVENTIL HFA AER HFA ....................... 15 PROVERA .................................................. 38 PROVIGIL ................................................... 22 PROZAC ..................................................... 27 PROZAC WEEKLY ..................................... 27 PRUDOXIN ................................................. 44 PULMICORT FLEXHALER INH 180MCG ... 41 PULMICORT FLEXHALER INH 90MCG ..... 41 PULMICORT SUS 0.25MG/2 ...................... 41 PULMICORT SUS 0.5MG/2 ........................ 41 PULMICORT SUS 1MG/2ML ...................... 41 PULMOZYME ............................................. 30 PURINETHOL ............................................. 13 PYLERA ....................................................... 7 pyrazinamide ................................................ 9 pyridostigmine bromide ............................... 14

Q QNASL ....................................................... 31 QUALAQUIN ............................................... 10 QUARTETTE .............................................. 35 quetiapine fumarate .................................... 27 QUILLIVANT XR SUS XR ........................... 22 quinapril hcl ................................................. 18 quinapril-hydrochlorothiazide ...................... 18 quinidine gluconate ..................................... 17 QUINIDINE GLUCONATE .......................... 17 quinidine sulfate .......................................... 17 quinine sulfate ............................................. 10 QVAR ......................................................... 41

R RABAVERT ................................................ 41 ramipril ........................................................ 18 RANEXA ..................................................... 17 ranitidine hcl ................................................ 33 RAPAFLO ................................................... 14 RAPAMUNE SOL 1MG/ML ......................... 40


RAPAMUNE TAB 0.5MG ........................... 40 RAPAMUNE TAB 1MG .............................. 40 RAPAMUNE TAB 2MG .............................. 40 RAVICTI ..................................................... 28 RAYOS ....................................................... 34 RAZADYNE ................................................ 14 RAZADYNE ER .......................................... 14 REBETOL................................................... 10 REBIF ......................................................... 40 REBIF TITRATION PACK .......................... 40 RECLAST ................................................... 40 RECOMBIVAX HB ..................................... 41 RECTIV ...................................................... 44 REGLAN .................................................... 33 REGONOL INJ 5MG/ML ............................ 14 REGRANEX ............................................... 44 RELENZA DISKHALER .............................. 10 RELISTOR ................................................. 33 RELPAX ..................................................... 24 REMERON ................................................. 27 REMERON SOLTAB .................................. 27 REMICADE ................................................ 40 REMODULIN .............................................. 19 RENAGEL .................................................. 29 RENAMIN INJ 6.5% ................................... 28 RENVELA PAK 0.8GM ............................... 29 RENVELA PAK 2.4GM ............................... 29 RENVELA TAB 800MG .............................. 29 repaglinide .................................................. 36 REQUIP ..................................................... 24 REQUIP XL ................................................ 24 RESCRIPTOR ............................................ 10 RESCULA .................................................. 32 RESERPINE ............................................... 18 RESTASIS.................................................. 31 RESTORIL ................................................. 25 RETIN-A CRE 0.025% ............................... 43 RETIN-A CRE 0.05% ................................. 43 RETIN-A CRE 0.1% ................................... 43 RETIN-A GEL 0.01% .................................. 43 RETIN-A GEL 0.025% ................................ 43 RETIN-A MICRO ........................................ 43 RETROVIR CAP 100MG ............................ 10 RETROVIR IV INFUSION INJ 10MG/ML .... 10 RETROVIR SYP 50MG/5ML ...................... 10 RETROVIR TAB 300MG ............................ 10 REVATIO ................................................... 19 REVLIMID .................................................. 13 REYATAZ CAP 100MG .............................. 10 REYATAZ CAP 150MG .............................. 10 REYATAZ CAP 200MG .............................. 10 REYATAZ CAP 300MG .............................. 10

RHEUMATREX ........................................... 13 RHINOCORT AQUA ................................... 31 RHOPHYLAC ............................................. 41 ribavirin (hepatitis c) .................................... 11 RIDAURA.................................................... 34 RIFADIN ....................................................... 9 rifampin ......................................................... 9 RIFATER ...................................................... 9 RILUTEK .................................................... 25 riluzole ........................................................ 25 rimantadine hydrochloride ........................... 11 RIMSO-50 ................................................... 40 ringer's inj ................................................... 30 ringer's irrigation ......................................... 29 RIOMET ...................................................... 36 RISPERDAL ............................................... 27 RISPERDAL CONSTA ................................ 27 RISPERDAL M-TAB ................................... 27 risperidone .................................................. 27 RITALIN LA CAP 10MG .............................. 22 RITALIN LA CAP 20MG .............................. 22 RITALIN LA CAP 30MG .............................. 22 RITALIN LA CAP 40MG .............................. 22 RITALIN SR TAB 20MG SR........................ 23 RITALIN TAB 10MG ................................... 23 RITALIN TAB 20MG ................................... 23 RITALIN TAB 5MG ..................................... 23 RITUXAN .................................................... 13 rivastigmine tartrate .................................... 14 rizatriptan benzoate .................................... 24 ROBINUL FORTE TAB 2MG ...................... 14 ROBINUL TAB 1MG ................................... 14 ROCALTROL CAP 0.25MCG ..................... 44 ROCALTROL CAP 0.5MCG ....................... 44 ROCALTROL SOL 1MCG/ML..................... 44 ropinirole hydrochloride ............................... 24 ROTATEQ .................................................. 41 ROXICODONE ........................................... 22 ROZEREM .................................................. 25 RYTHMOL .................................................. 17 RYTHMOL SR ............................................ 17 RYZOLT ..................................................... 22

S SABRIL ....................................................... 23 SAFYRAL ................................................... 35 SAIZEN ....................................................... 38 SAIZEN CLICK.EASY ................................. 38 SALAGEN ................................................... 14 SAMSCA .................................................... 29 SANCTURA ................................................ 44 SANCTURA XR .......................................... 44


SANCUSO.................................................. 32 SANDIMMUNE ........................................... 40 SANDOSTATIN INJ 1000MCG .................. 40 SANDOSTATIN INJ 100MCG .................... 40 SANDOSTATIN INJ 200MCG .................... 40 SANDOSTATIN INJ 500MCG .................... 40 SANDOSTATIN INJ 50MCG/ML ................ 40 SANDOSTATIN LAR DEPOT KIT LAR 10MG

............................................................... 40 SANDOSTATIN LAR DEPOT KIT LAR 20MG

............................................................... 40 SANDOSTATIN LAR DEPOT KIT LAR 30MG

............................................................... 40 SANTYL ..................................................... 44 SAPHRIS ................................................... 27 SARAFEM .................................................. 27 SAVELLA ................................................... 25 SAVELLA TITRATION PACK ..................... 25 SEASONALE .............................................. 35 SEASONIQUE ............................................ 35 SECTRAL ................................................... 20 selegiline hcl ............................................... 24 selenium sulfide .......................................... 42 SELZENTRY .............................................. 11 SEMPREX-D .............................................. 11 SENSIPAR ................................................. 40 SEPTRA DS ................................................. 8 SEREVENT DISKUS .................................. 15 SEROQUEL ............................................... 27 SEROQUEL XR ......................................... 27 SEROSTIM................................................. 38 sertraline hcl ............................................... 27 SFROWASA ENE 4GM .............................. 32 SIGNIFOR .................................................. 38 sildenafil citrate (pulmonary hypertension) . 19 SILENOR ................................................... 25 SILVADENE ............................................... 42 silver sulfadiazine ....................................... 42 SIMBRINZA ................................................ 32 SIMCOR ..................................................... 16 SIMPONI .................................................... 40 SIMPONI ARIA ........................................... 40 SIMULECT ................................................. 40 simvastatin ................................................. 16 SINEMET ................................................... 24 SINEMET CR ............................................. 24 SINGULAIR ................................................ 40 SIRTURO ..................................................... 9 SKELAXIN .................................................. 14 SKELID ...................................................... 40 SKLICE ........................................................ 7

sodium chloride ........................................... 30 sodium chloride (gu irrigant) ....................... 29 SODIUM DIURIL ......................................... 29 SODIUM EDECRIN .................................... 29 SODIUM FLUORIDE .................................. 40 SODIUM LACTATE INJ 1/6M ..................... 27 SODIUM LACTATE INJ 5MEQ/ML ............. 27 sodium phenylbutyrate ................................ 28 sodium polystyrene sulfonate...................... 29 SOLARAZE ................................................. 44 SOLODYN .................................................... 8 SOLTAMOX ................................................ 13 SOLU-CORTEF .......................................... 34 SOLU-MEDROL INJ 125MG ...................... 34 SOLU-MEDROL INJ 1GM .......................... 34 SOLU-MEDROL INJ 2GM .......................... 34 SOLU-MEDROL INJ 40MG ........................ 34 SOLU-MEDROL INJ 500MG ...................... 34 SOMA ......................................................... 14 SOMATULINE DEPOT ............................... 40 SOMAVERT ................................................ 38 SONATA ..................................................... 25 SORIATANE ............................................... 44 SORILUX .................................................... 44 sorine tab 120mg ........................................ 20 sorine tab 160mg ........................................ 20 sorine tab 240mg ........................................ 20 sorine tab 80mg .......................................... 20 sotalol hcl (afib/afl) ...................................... 20 sotalol hcl tab 120mg .................................. 20 sotalol hcl tab 160mg .................................. 20 sotalol hcl tab 240mg .................................. 20 sotalol hcl tab 80mg .................................... 20 SOTALOL HYDROCHLORIDE ................... 20 SPECTRACEF .............................................. 8 SPINOSAD ................................................. 42 SPIRIVA HANDIHALER .............................. 14 spironolactone & hydrochlorothiazide ......... 18 spironolactone tab 100mg ........................... 19 spironolactone tab 25mg ............................. 19 spironolactone tab 50mg ............................. 19 SPORANOX CAP 100MG ............................ 9 SPORANOX PULSEPAK CAP PULSEPAK .. 9 SPORANOX SOL 10MG/ML ......................... 9 SPRIX ......................................................... 22 SPRYCEL ................................................... 13 STALEVO 100 ............................................ 24 STALEVO 125 ............................................ 24 STALEVO 150 ............................................ 24 STALEVO 200 ............................................ 24 STALEVO 50 .............................................. 24


STALEVO 75 .............................................. 24 STARLIX .................................................... 36 stavudine .................................................... 11 STAVZOR .................................................. 24 STELARA ................................................... 44 STIMATE SOL 1.5MG/ML .......................... 37 STIVARGA ................................................. 13 STRATTERA .............................................. 25 streptomycin sulfate...................................... 8 STRIANT MIS 30MG .................................. 34 STRIBILD ................................................... 11 STROMECTOL ............................................ 7 SUBOXONE MIS 12-3MG .......................... 22 SUBOXONE MIS 2-0.5MG ......................... 22 SUBOXONE MIS 4-1MG ............................ 22 SUBOXONE MIS 8-2MG ............................ 22 SUBOXONE SUB 2-0.5MG ........................ 22 SUBOXONE SUB 8-2MG ........................... 22 SUBSYS ..................................................... 22 SUCRAID ................................................... 30 sucralfate .................................................... 33 SULAR ....................................................... 17 sulfacetamide sodium (acne) ...................... 42 sulfacetamide sodium (ophth)..................... 30 sulfacetamide sod-prednisolone ................. 31 sulfadiazine .................................................. 8 sulfamethoxazole-trimethoprim ..................... 8 SULFAMYLON CRE 85MG/GM ................. 42 SULFAMYLON PAK 5% ............................. 42 sulfasalazine ................................................. 8 sulindac ...................................................... 22 sumatriptan succinate ................................. 24 SUMAVEL DOSEPRO ............................... 24 SUPRAX ...................................................... 8 SUPREP BOWEL PREP ............................ 33 SURMONTIL .............................................. 27 SUSTIVA .................................................... 11 SUTENT ..................................................... 13 SYLATRON ................................................ 13 SYMBICORT .............................................. 41 SYMBYAX .................................................. 27 SYMLINPEN 120 ........................................ 36 SYMLINPEN 60 .......................................... 36 SYNAGIS ................................................... 11 SYNALAR CREAM KIT .............................. 43 SYNALGOS-DC ......................................... 22 SYNAREL................................................... 37 SYNERA .................................................... 43 SYNERCID ................................................... 8 SYNRIBO ................................................... 13 SYNTHROID .............................................. 38 SYPRINE ................................................... 34

syringe/needle (disp) 1 ml ........................... 27

T TABLOID .................................................... 13 TACLONEX ................................................ 43 tacrolimus ................................................... 40 TAFINLAR .................................................. 13 TALWIN ...................................................... 22 TAMIFLU CAP 30MG ................................. 11 TAMIFLU CAP 45MG ................................. 11 TAMIFLU CAP 75MG ................................. 11 TAMIFLU SUS 12MG/ML ........................... 11 TAMIFLU SUS 6MG/ML ............................. 11 tamoxifen citrate ......................................... 13 tamsulosin hcl ............................................. 14 TARCEVA ................................................... 13 TARGRETIN ......................................... 13, 44 TARKA ........................................................ 17 TASIGNA .................................................... 13 TASMAR ..................................................... 24 TAXOTERE INJ 20/0.5ML .......................... 13 TAXOTERE INJ 80MG/2ML........................ 13 TAXOTERE INJ 80MG/4ML........................ 13 TAZORAC................................................... 44 TECFIDERA ............................................... 40 TECFIDERA STARTER PACK ................... 40 TEFLARO ..................................................... 8 TEGRETOL CHW 100MG .......................... 24 TEGRETOL SUS 100/5ML ......................... 24 TEGRETOL TAB 200MG ............................ 24 TEGRETOL-XR TAB 100MG ...................... 24 TEGRETOL-XR TAB 200MG ...................... 24 TEGRETOL-XR TAB 400MG ...................... 24 TEKAMLO................................................... 19 TEKTURNA ................................................ 19 TEKTURNA HCT ........................................ 19 temazepam ................................................. 25 TEMODAR .................................................. 13 TENEX ........................................................ 18 TENORETIC 100 ........................................ 20 TENORETIC 50 .......................................... 20 TENORMIN ................................................. 20 TERAZOL 3 ................................................ 42 TERAZOL 7 ................................................ 42 terazosin hcl ................................................ 16 terbinafine hcl ............................................... 9 terbutaline sulfate ....................................... 15 terconazole vaginal ..................................... 42 TESTIM GEL 1%(50MG) ............................ 34 testosterone cypionate ................................ 34 testosterone enanthate ............................... 34 TETANUS TOXOID ADSORBED ............... 41


TETANUS/DIPHTHERIA TOXOID S-ADSORBED ADULT ............................... 41

tetracycline hcl .............................................. 8 tetrahydrozoline hcl .................................... 32 TEVETEN ................................................... 19 TEVETEN HCT .......................................... 19 TEV-TROPIN INJ 5MG ............................... 38 THALITONE ............................................... 29 THALOMID ................................................. 40 theophylline ................................................ 44 thioridazine hcl ........................................... 27 thiotepa ...................................................... 13 thiothixene .................................................. 27 THYMOGLOBULIN .................................... 40 THYROLAR-1 ............................................. 38 THYROLAR-1/2 .......................................... 38 THYROLAR-1/4 .......................................... 38 THYROLAR-2 ............................................. 38 THYROLAR-3 ............................................. 38 tiagabine hcl ............................................... 24 TIAZAC ...................................................... 17 ticarcillin & pot clavulanate ........................... 8 TICE BCG .................................................. 13 ticlopidine hcl .............................................. 16 TIGAN ........................................................ 32 TIKOSYN ................................................... 17 timolol maleate ........................................... 20 timolol maleate (ophth) ............................... 32 TIMOPTIC OCUDOSE ............................... 32 TIMOPTIC-XE ............................................ 32 tinidazole .................................................... 10 TIROSINT................................................... 38 TIVICAY ..................................................... 11 tizanidine hcl ............................................... 14 TOBI NEB 300/5ML ...................................... 8 TOBI PODHALER CAP 28MG ..................... 8 TOBRADEX OIN 0.3-0.1% ......................... 31 TOBRADEX ST SUS 0.3-0.05 .................... 31 TOBRADEX SUS 0.3-0.1% ........................ 31 tobramycin sulfate ........................................ 8 tobramycin sulfate (ophth) .......................... 30 tobramycin sulfate in saline .......................... 8 tobramycin-dexamethasone ....................... 31 TOBREX OIN 0.3% OP .............................. 30 TOBREX SOL 0.3% OP ............................. 30 TOFRANIL-PM ........................................... 27 tolazamide .................................................. 36 tolbutamide ................................................. 36 tolmetin sodium .......................................... 22 tolterodine tartrate ...................................... 44 TOPAMAX .................................................. 24

TOPAMAX SPRINKLE ................................ 24 TOPICORT ................................................. 43 topiramate ................................................... 24 topotecan hcl .............................................. 13 TOPROL XL ................................................ 20 TORISEL .................................................... 13 torsemide .................................................... 29 TOVIAZ ....................................................... 44 TRACLEER ................................................. 19 TRADJENTA ............................................... 36 tramadol hcl ................................................ 22 tramadol-acetaminophen ............................ 22 TRANDATE ................................................ 20 trandolapril .................................................. 19 tranexamic acid ........................................... 16 TRANSDERM-SCOP .................................. 32 TRANXENE T ............................................. 25 tranylcypromine sulfate ............................... 27 TRAVATAN Z ............................................. 32 travoprost .................................................... 32 trazodone hcl tab 100mg ............................ 27 trazodone hcl tab 150mg ............................ 27 trazodone hcl tab 300mg ............................ 27 trazodone hcl tab 50mg .............................. 27 TREANDA................................................... 13 TRECATOR .................................................. 9 TRELSTAR DEPOT MIXJECT .................... 13 TRELSTAR LA MIXJECT ........................... 13 TRELSTAR MIXJECT ................................. 13 TRENTAL ................................................... 16 tretinoin ....................................................... 43 tretinoin (chemotherapy) ............................. 13 tretinoin w/ cleanser & moisturizer .............. 43 TREXIMET.................................................. 24 triamcinolone acetonide (mouth) ................. 43 triamcinolone acetonide (nasal) .................. 31 triamcinolone acetonide (topical) ................ 43 triamterene/hydrochlorothiazide cap 37.5-25

................................................................ 29 triamterene/hydrochlorothiazide cap 50-25mg

................................................................ 29 triamterene/hydrochlorothiazide tab 37.5-25

................................................................ 29 triamterene/hydrochlorothiazide tab 75-50mg

................................................................ 29 triazolam ..................................................... 25 TRIBENZOR ............................................... 17 TRICOR ...................................................... 16 trifluoperazine hcl ........................................ 27 trifluridine .................................................... 30 trihexyphenidyl hcl ...................................... 24


TRILEPTAL SUS 300MG/5M ..................... 24 TRILEPTAL TAB 150MG ............................ 24 TRILEPTAL TAB 300MG ............................ 24 TRILEPTAL TAB 600MG ............................ 24 TRILIPIX ..................................................... 16 trimethobenzamide hcl ............................... 32 trimethoprim ............................................... 11 trimipramine maleate .................................. 27 TRINATAL RX 1 ......................................... 44 TRI-NORINYL 28 ....................................... 35 TRIPEDIA ................................................... 41 TRISENOX ................................................. 13 TRIZIVIR .................................................... 11 TROPHAMINE INJ 10% ............................. 28 TROPHAMINE INJ 6% ............................... 28 tropicamide ................................................. 32 trospium chloride ........................................ 44 TRUSOPT .................................................. 32 TRUVADA .................................................. 11 TUDORZA PRESSAIR ............................... 14 TWINJECT INJ 0.15MG ............................. 15 TWINJECT INJ 0.3MG ............................... 15 TWINRIX .................................................... 41 TWYNSTA .................................................. 17 TYGACIL ...................................................... 8 TYKERB ..................................................... 13 TYPHIM VI ................................................. 41 TYSABRI .................................................... 40 TYVASO ..................................................... 19 TYZEKA ..................................................... 11

U UCERIS ...................................................... 34 ULESFIA .................................................... 42 ULORIC ...................................................... 40 ULTRACET ................................................ 22 ULTRAM .................................................... 22 ULTRAM ER ............................................... 22 ULTRAVATE .............................................. 43 ULTRESA CAP 13800UNT ........................ 33 ULTRESA CAP 20700UNT ........................ 33 ULTRESA CAP 23000UNT ........................ 33 UNASYN ...................................................... 8 UNASYN BULK PACK ................................. 8 UNIRETIC .................................................. 19 UNIVASC ................................................... 19 urea-hc acetate .......................................... 43 UROCIT-K 10 ............................................. 27 UROCIT-K 15 ............................................. 27 UROCIT-K 5 ............................................... 27 UROXATRAL ............................................. 14 URSO 250 TAB 250MG ............................. 34

URSO FORTE TAB 500MG ........................ 34 ursodiol ....................................................... 34 UVADEX ..................................................... 44

V VAGIFEM.................................................... 37 valacyclovir hcl ............................................ 11 VALCYTE SOL 50MG/ML ........................... 11 VALCYTE TAB 450MG ............................... 11 VALIUM ...................................................... 25 valproate sodium ........................................ 24 valproic acid ................................................ 24 valsartan-hydrochlorothiazide ..................... 19 VALSTAR ................................................... 13 VALTREX ................................................... 11 VALTURNA ................................................. 19 VANCOCIN HCL ........................................... 8 vancomycin hcl ............................................. 8 VANCOMYCIN HCL IN DEXTROSE ............ 8 VANDETANIB ............................................. 13 VANOS ....................................................... 43 VANTAS ..................................................... 13 VAQTA ....................................................... 42 VARIVAX .................................................... 42 VASCEPA ................................................... 16 VASERETIC ............................................... 19 VASOTEC................................................... 19 VECTIBIX ................................................... 13 VECTICAL .................................................. 44 VELCADE ................................................... 13 VELTIN ....................................................... 44 venlafaxine hcl ............................................ 27 VENLAFAXINE HCL ER TAB 150MG ER ... 27 VENLAFAXINE HCL ER TAB 225MG ER ... 27 VENLAFAXINE HCL ER TAB 37.5 ER ....... 27 VENLAFAXINE HCL ER TAB 75MG ER ..... 27 VENTAVIS SOL 10MCG/ML ....................... 19 VENTAVIS SOL 20MCG/ML ....................... 19 VENTOLIN HFA AER ................................. 15 VERAMYST ................................................ 31 verapamil hcl er cap 100mg er .................... 17 verapamil hcl er cap 120mg er .................... 17 verapamil hcl er cap 180mg er .................... 17 verapamil hcl er cap 200mg er .................... 17 verapamil hcl er cap 240mg er .................... 17 verapamil hcl er cap 300mg er .................... 17 verapamil hcl er tab 120mg er..................... 17 verapamil hcl er tab 180mg er..................... 17 verapamil hcl er tab 240mg er..................... 17 verapamil hcl inj 2.5mg/ml .......................... 17 verapamil hcl sr cap 360mg sr .................... 17 verapamil hcl tab 120mg ............................. 17


verapamil hcl tab 40mg .............................. 17 verapamil hcl tab 80mg .............................. 17 VERDESO .................................................. 43 VEREGEN .................................................. 44 VERELAN................................................... 17 VERELAN PM ............................................ 17 VESICARE ................................................. 44 VEXOL ....................................................... 31 VFEND IV INJ 200MG .................................. 9 VFEND SUS 40MG/ML ................................ 9 VFEND TAB 200MG..................................... 9 VFEND TAB 50MG....................................... 9 VIBATIV ....................................................... 8 VIBRAMYCIN ............................................... 8 VIBRAMYCIN SUS 25MG/5ML .................... 8 VICOPROFEN ............................................ 22 VICTOZA .................................................... 36 VICTRELIS ................................................. 11 VIDAZA ...................................................... 13 VIDEX EC CAP 125MG .............................. 11 VIDEX EC CAP 200MG .............................. 11 VIDEX EC CAP 250MG .............................. 11 VIDEX EC CAP 400MG .............................. 11 VIDEX PEDIATRIC SOL 2GM .................... 11 VIDEX PEDIATRIC SOL 4GM .................... 11 VIGAMOX................................................... 30 VIIBRYD ..................................................... 27 VIMOVO ..................................................... 22 VIMPAT ...................................................... 24 VINATE CALCIUM ..................................... 44 vinblastine sulfate ....................................... 13 vincristine sulfate ........................................ 13 vinorelbine tartrate ...................................... 13 VIOKACE TAB ........................................... 33 VIRACEPT ................................................. 11 VIRAMUNE SUS 50MG/5ML...................... 11 VIRAMUNE TAB 200MG ............................ 11 VIRAMUNE XR TAB 100MG ...................... 11 VIRAMUNE XR TAB 400MG ...................... 11 VIRAZOLE.................................................. 11 VIREAD ...................................................... 11 VIROPTIC .................................................. 30 VISTARIL ................................................... 25 VISTIDE ..................................................... 11 VITASPIRE................................................. 44 VIVELLE-DOT DIS 0.025MG ..................... 37 VIVELLE-DOT DIS 0.0375MG.................... 37 VIVELLE-DOT DIS 0.05MG ....................... 37 VIVELLE-DOT DIS 0.075MG ..................... 37 VIVELLE-DOT DIS 0.1MG ......................... 37 VIVITROL ................................................... 25

VOLTAREN .......................................... 31, 44 VOLTAREN-XR .......................................... 22 VORAXAZE ................................................ 40 voriconazole .................................................. 9 vospire er tab 4mg ...................................... 15 vospire er tab 8mg ...................................... 15 VOTRIENT.................................................. 13 VPRIV ......................................................... 30 VUMON ...................................................... 13 VYTORIN .................................................... 16 VYVANSE ................................................... 23

W warfarin sodium .......................................... 16 water for irrigation, sterile ............................ 29 WELCHOL .................................................. 16 WELLBUTRIN ............................................. 27 WELLBUTRIN SR ....................................... 27 WELLBUTRIN XL ....................................... 27 WESTCORT ............................................... 43

X XALATAN ................................................... 32 XALKORI .................................................... 13 XANAX ....................................................... 25 XANAX XR.................................................. 25 XARELTO ................................................... 16 XELJANZ .................................................... 40 XENAZINE .................................................. 25 XEOMIN ..................................................... 40 XERESE ..................................................... 42 XGEVA INJ ................................................. 40 XIFAXAN ...................................................... 9 XOLAIR ...................................................... 41 XOPENEX .................................................. 15 XOPENEX HFA .......................................... 15 XTANDI ...................................................... 13 XYLOCAINE ......................................... 40, 43 XYREM ....................................................... 25 XYZAL ........................................................ 11

Y YASMIN 28 ................................................. 35 YAZ ............................................................. 35 YERVOY ..................................................... 13 YF-VAX ....................................................... 42

Z zafirlukast.................................................... 40


zaleplon ...................................................... 25 ZALTRAP ................................................... 13 ZANAFLEX ................................................. 14 ZANOSAR .................................................. 13 ZANTAC ..................................................... 33 ZANTAC INJ ............................................... 33 ZARONTIN ................................................. 24 ZAVESCA................................................... 40 ZEBETA ..................................................... 20 ZEGERID ................................................... 33 ZELAPAR ................................................... 24 ZELBORAF ................................................ 13 ZEMAIRA ................................................... 41 ZEMPLAR .................................................. 44 ZENPEP CAP 10000UNT .......................... 33 ZENPEP CAP 15000UNT .......................... 33 ZENPEP CAP 20000UNT .......................... 33 ZENPEP CAP 25000UNT .......................... 33 ZENPEP CAP 3000UNIT ........................... 33 ZENPEP CAP 5000UNIT ........................... 33 ZERIT ......................................................... 11 ZESTORETIC ............................................. 19 ZESTRIL .................................................... 19 ZETIA ......................................................... 16 ZETONNA .................................................. 31 ZIAC ........................................................... 20 ZIAGEN ...................................................... 11 ZIANA ......................................................... 44 zidovudine .................................................. 11 ZINACEF IN ISO-OSMOTIC DEXTROSE .... 9 ZINACEF IN ISO-OSMOTIC DILUENT ........ 9 ZINACEF INJ 1.5GM .................................... 9 ZINACEF INJ 7.5GM .................................... 9 ZINACEF INJ 750MG ................................... 9 ZINC TRACE METAL ................................. 30 ZINECARD ................................................. 40 ZIOPTAN .................................................... 32 ziprasidone hcl ........................................... 27 ZIPSOR ...................................................... 22 ZIRGAN ...................................................... 30 ZITHROMAX INJ 500MG ............................. 9 ZITHROMAX POW 1GM PAK ...................... 9

ZITHROMAX SUS 100/5ML.......................... 9 ZITHROMAX SUS 200/5ML.......................... 9 ZITHROMAX TAB 250MG ............................ 9 ZITHROMAX TAB 500MG ............................ 9 ZITHROMAX TAB 600MG ............................ 9 ZITHROMAX TRI-PAK TAB TRI-PAK ........... 9 ZITHROMAX Z-PAK TAB Z-PAK .................. 9 ZMAX SUS 2GM ........................................... 9 ZOCOR ....................................................... 16 ZOFRAN ..................................................... 32 ZOFRAN ODT ............................................ 32 zoledronic acid ............................................ 40 ZOLINZA .................................................... 13 ZOLOFT ..................................................... 27 zolpidem tartrate ......................................... 25 ZOLPIMIST ................................................. 25 ZOMETA ..................................................... 40 ZOMIG ........................................................ 24 ZOMIG ZMT ................................................ 24 ZONALON .................................................. 43 ZONEGRAN ............................................... 24 zonisamide.................................................. 24 ZORBTIVE .................................................. 38 ZORTRESS ................................................ 40 ZOSTAVAX ................................................. 42 ZOSYN ......................................................... 9 ZOVIRAX .............................................. 11, 42 ZUBSOLV SUB 1.4-0.36 ............................. 22 ZUBSOLV SUB 5.7-1.4 ............................... 22 ZUPLENZ ................................................... 32 ZYBAN ........................................................ 27 ZYCLARA ................................................... 44 ZYFLO ........................................................ 40 ZYFLO CR .................................................. 40 ZYLET ........................................................ 31 ZYLOPRIM ................................................. 40 ZYMAXID .................................................... 30 ZYPREXA ................................................... 27 ZYPREXA ZYDIS ....................................... 27 ZYTIGA ....................................................... 13 ZYVOX ......................................................... 9


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