2015 Hrinj Drugs

PREFERRED DRUG LIST
MEMBER FORMULARY GUIDE
EFFECTIVE JANUARY 1, 2015
Comprehensive
PREFERRED DRUG LIST

HEALTH REPUBLIC New Jersey 2015
PAGE 1
LAST UPDATED 11/2014
LEGEND
TIER
DESCRIPTION
Preventative
Preferred Generics
Preferred Brands
Non-Preferred Brands
Specialty
TYPE
DESCRIPTION
QL
Quantity Limit
There is a limit on the amount of drug covered per prescription, or

within a specific time frame.
PA
Prior Authorization
Prior Authorization required before prescription can be filled.
ST
Step Therapy
Requires trial and failure of one or more preferred products prior to

coverage.
GL
Gender Limit
Drug is limited to specific gender.
AL
Age Limit
Drug is limited to specific age.
MDD
Max Daily Dose
A limit on the number of times the drug can be taken per day
MPL
Max Package Limit
A limit on the amount of drug covered per prescription.
MFL
Max Fill Limit
There is a limit on the number of times this drug can be refilled.
PAGE 2
LIST OF COVERED PRESCRIPTION MEDICATIONS

PRODUCT DESCRIPTION
BRAND/GEN
TIER
LIMITS & RESTRICTIONS
*ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS*
*Amphetamines**
amphetamine-dextroamphet er cap er 24h 10
mg
generic
QL
30 / 30 days

mg
generic
QL
30 / 30 days

mg
generic
QL
30 / 30 days

mg
generic
QL
30 / 30 days

mg
generic
QL
30 / 30 days

mg
generic
QL
30 / 30 days
amphetamine-dextroamphetamine tab 10 mg
generic
QL
90 / 30 days
amphetamine-dextroamphetamine tab 12.5 mg
generic
QL
90 / 30 days
generic
QL
90 / 30 days
generic
QL
90 / 30 days
generic
QL
90 / 30 days
generic
QL
90 / 30 days
amphetamine-dextroamphetamine tab 7.5 mg
generic
QL
90 / 30 days
dextroamphetamine sulfate er cap er 24h 10

mg
generic
QL
30 / 30 days
dextroamphetamine sulfate er cap er 24h 15

mg
generic
QL
30 / 30 days
dextroamphetamine sulfate er cap er 24h 5 mg
generic
QL
30 / 30 days
dextroamphetamine sulfate tab 10 mg
generic
QL
90 / 30 days
dextroamphetamine sulfate tab 5 mg
generic
QL
90 / 30 days
methamphetamine hcl tab 5 mg
generic
QL
120 / 30 days
VYVANSE CAP 20 MG
lisdexamfetamine dimesylate
BRAND
QL
30 / 30 days
VYVANSE CAP 30 MG
BRAND
QL
30 / 30 days
PAGE 3
PRODUCT DESCRIPTION
BRAND/GEN
TIER
VYVANSE CAP 40 MG
BRAND
QL
30 / 30 days
VYVANSE CAP 50 MG
BRAND
QL
30 / 30 days
VYVANSE CAP 60 MG
BRAND
QL
30 / 30 days
VYVANSE CAP 70 MG
BRAND
QL
30 / 30 days
zenzedi tab 10 mg
generic
zenzedi tab 5 mg
generic
phentermine hcl cap 15 mg
generic
PA
phentermine hcl cap 30 mg
generic
PA
phentermine hcl cap 37.5 mg
generic
PA
phentermine hcl tab 37.5 mg
generic
PA
QSYMIA CAP ER 24H 11.25-69 MG

phentermine hcl-topiramate
BRAND
PA
QSYMIA CAP ER 24H 15-92 MG

BRAND
PA

BRAND
PA

BRAND
PA
BRAND
PA
*Anorexiants Non-Amphetamine**
*Anti-Obesity Agents**
XENICAL CAP 120 MG
orlistat
*Attention-Deficit/Hyperactivity Disorder (ADHD) Agents**

clonidine hcl er tab er 12h 0.1 mg
generic
QL
30 / 30 days
INTUNIV TAB ER 24H 1 MG

guanfacine hcl (adhd)
BRAND
QL
30 / 30 days

BRAND
QL
30 / 30 days

BRAND
QL
30 / 30 days
BRAND
QL
30 / 30 days
PAGE 4
PRODUCT DESCRIPTION
BRAND/GEN
TIER

STRATTERA CAP 10 MG
atomoxetine hcl
BRAND
QL
30 / 30 days
STRATTERA CAP 100 MG

atomoxetine hcl
BRAND
QL
30 / 30 days
STRATTERA CAP 18 MG
atomoxetine hcl
BRAND
QL
30 / 30 days
STRATTERA CAP 25 MG
atomoxetine hcl
BRAND
QL
30 / 30 days
STRATTERA CAP 40 MG
atomoxetine hcl
BRAND
QL
30 / 30 days
STRATTERA CAP 60 MG
atomoxetine hcl
BRAND
QL
30 / 30 days
STRATTERA CAP 80 MG
atomoxetine hcl
BRAND
QL
30 / 30 days
dexmethylphenidate hcl er cap er 24h 15 mg
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
dexmethylphenidate hcl tab 10 mg
generic
QL
60 / 30 days
dexmethylphenidate hcl tab 2.5 mg
generic
QL
60 / 30 days
dexmethylphenidate hcl tab 5 mg
generic
QL
60 / 30 days
metadate er tab er 20 mg
generic
QL
90 / 30 days
METHYLIN CHEW TAB 10 MG

methylphenidate hcl
BRAND
QL
120 / 30 days
METHYLIN CHEW TAB 2.5 MG

methylphenidate hcl
BRAND
QL
120 / 30 days
METHYLIN CHEW TAB 5 MG

methylphenidate hcl
BRAND
QL
120 / 30 days
methylin er tab er 10 mg
generic
QL
90 / 30 days
methylin er tab er 20 mg
generic
QL
90 / 30 days
methylin tab 10 mg
generic
QL
120 / 30 days
methylin tab 20 mg
generic
QL
120 / 30 days
methylin tab 5 mg
generic
QL
120 / 30 days
*Stimulants - Misc.**
PAGE 5
PRODUCT DESCRIPTION
BRAND/GEN
TIER
methylphenidate hcl er (cd) cap er 10 mg
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
methylphenidate hcl er (la) cap er 24h 20 mg
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
methylphenidate hcl er tab er 10 mg
generic
QL
90 / 30 days
METHYLPHENIDATE HCL ER TAB ER 10 MG

methylphenidate hcl
BRAND
QL
90 / 30 days
generic
QL
30 / 30 days
generic
QL
90 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
methylphenidate hcl tab 10 mg
generic
QL
120 / 30 days
generic
QL
120 / 30 days
generic
QL
120 / 30 days
QL
modafinil tab 100 mg
generic
60 / 30 days
1
PA
QL
modafinil tab 200 mg
generic
60 / 30 days
1
PA
QL
NUVIGIL TAB 150 MG

armodafinil
BRAND
NUVIGIL TAB 250 MG

armodafinil
BRAND
NUVIGIL TAB 50 MG
BRAND
PAGE 6
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
3
QL
60 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
TIER
armodafinil

PA
*AMINOGLYCOSIDES*
*Aminoglycosides**
amikacin sulfate solution 1 gm/4ml
generic
PA
amikacin sulfate solution 50 mg/ml
generic
PA
AMIKACIN SULFATE SOLUTION 50 MG/ML

amikacin sulfate
BRAND
PA
amikacin sulfate solution 500 mg/2ml
generic
PA
BETHKIS NEBU SOLN 300 MG/4ML

tobramycin
BRAND
PA
gentamicin in saline solution 0.6-0.9 mg/ml-%
generic
PA
generic
PA
GENTAMICIN IN SALINE SOLUTION 0.9-0.9

MG/ML-%
gentamicin in saline
BRAND
PA
gentamicin in saline solution 1-0.9 mg/ml-%
generic
PA
generic
PA
GENTAMICIN IN SALINE SOLUTION 1.4-0.9

MG/ML-%
gentamicin in saline
BRAND
PA
generic
PA
gentamicin in saline solution 2-0.9 mg/ml-%
generic
PA
gentamicin sulfate solution 10 mg/ml
generic
PA
gentamicin sulfate solution 40 mg/ml
generic
PA
kanamycin sulfate solution 333 mg/ml
generic
PA
NEO-FRADIN SOLUTION 25 MG/ML

neomycin sulfate
BRAND
PA
neomycin sulfate tab 500 mg
generic
paromomycin sulfate cap 250 mg
generic
streptomycin sulfate recon soln 1 gm
generic
PA
TOBI PODHALER CAP 28 MG

tobramycin
BRAND
PA
tobramycin nebu soln 300 mg/5ml
generic
PA
PAGE 7
PRODUCT DESCRIPTION
BRAND/GEN
TIER
TOBRAMYCIN SULFATE IN SALINE

SOLUTION 0.8-0.9 MG/ML-%
tobramycin sulfate in saline
BRAND
PA
TOBRAMYCIN SULFATE IN SALINE

SOLUTION 1.2-0.9 MG/ML-%
tobramycin sulfate in saline
BRAND
PA
tobramycin sulfate recon soln 1.2 gm
generic
PA
tobramycin sulfate solution 1.2 gm/30ml
generic
PA
tobramycin sulfate solution 10 mg/ml
generic
PA
tobramycin sulfate solution 2 gm/50ml
generic
PA
tobramycin sulfate solution 80 mg/2ml
generic
PA
HUMIRA KIT 20 MG/0.4ML

adalimumab
BRAND
PA
HUMIRA KIT 40 MG/0.8ML

adalimumab
BRAND
PA
HUMIRA PEN KIT 40 MG/0.8ML

adalimumab
BRAND
PA
HUMIRA PEN-CROHNS STARTER KIT 40

MG/0.8ML
adalimumab
BRAND
PA
HUMIRA PEN-PSORIASIS STARTER KIT 40

MG/0.8ML
adalimumab
BRAND
PA
SIMPONI ARIA SOLUTION 50 MG/4ML

golimumab
BRAND
PA
SIMPONI SOLN A-INJ 100 MG/ML

golimumab
BRAND
PA
SIMPONI SOLN A-INJ 50 MG/0.5ML

golimumab
BRAND
PA
SIMPONI SOLN PRSYR 100 MG/ML

golimumab
BRAND
PA
SIMPONI SOLN PRSYR 50 MG/0.5ML

golimumab
BRAND
PA
*ANALGESICS - ANTI-INFLAMMATORY*
*Anti-TNF-alpha - Monoclonal Antibodies**
*Antirheumatic - Enzyme Inhibitors**
PAGE 8
PRODUCT DESCRIPTION
BRAND/GEN
TIER
XELJANZ TAB 5 MG
tofacitinib citrate
BRAND
OTREXUP SOLN A-INJ 10 MG/0.4ML

methotrexate (antirheumatic)
BRAND

BRAND

BRAND

BRAND
RHEUMATREX TAB 2.5 MG

methotrexate sodium (antirheumatic)
BRAND
BRAND
PA
BRAND
PA
BRAND
BRAND
PA
ACTEMRA SOLN PRSYR 162 MG/0.9ML

tocilizumab
BRAND
PA
ACTEMRA SOLUTION 200 MG/10ML

tocilizumab
BRAND
PA

tocilizumab
BRAND
PA

tocilizumab
BRAND
PA
CELEBREX CAP 100 MG

celecoxib
BRAND
ST
CELEBREX CAP 200 MG
BRAND
ST
PA
*Antirheumatic Antimetabolites**
*Gold Compounds**
RIDAURA CAP 3 MG
auranofin
*Interleukin-1 Blockers**
ARCALYST RECON SOLN 220 MG
rilonacept
*Interleukin-1 Receptor Antagonist (IL-1Ra)**
KINERET SOLN PRSYR 100 MG/0.67ML
anakinra
*Interleukin-1beta Blockers**
ILARIS RECON SOLN 180 MG
canakinumab
*Interleukin-6 Receptor Inhibitors**
*Nonsteroidal Anti-inflammatory Agents (NSAIDs)**
PAGE 9
PRODUCT DESCRIPTION
BRAND/GEN
TIER
celecoxib
CELEBREX CAP 400 MG
celecoxib
BRAND
ST
CELEBREX CAP 50 MG
celecoxib
BRAND
ST
diclofenac potassium tab 50 mg
generic
diclofenac sodium er tab er 24h 100 mg
generic
diclofenac sodium tab dr 25 mg
generic
generic
generic
diclofenac-misoprostol tab dr 50-0.2 mg
generic
diclofenac-misoprostol tab dr 75-0.2 mg
generic
etodolac cap 200 mg
generic
etodolac cap 300 mg
generic
etodolac tab 400 mg
generic
etodolac tab 500 mg
generic
fenoprofen calcium tab 600 mg
generic
flurbiprofen tab 100 mg
generic
flurbiprofen tab 50 mg
generic
ibuprofen tab 400 mg
generic
generic
generic
INDOCIN SUSPENSION 25 MG/5ML

indomethacin
BRAND
indomethacin cap 25 mg
generic
indomethacin cap 50 mg
generic
ketoprofen cap 50 mg
generic
ketoprofen cap 75 mg
generic
ketorolac tromethamine solution 15 mg/ml
generic
ketorolac tromethamine solution 300 mg/10ml
generic
ketorolac tromethamine solution 60 mg/2ml
generic
ketorolac tromethamine tab 10 mg
generic
meclofenamate sodium cap 100 mg
generic
PAGE 10
QL
20 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
TIER
meclofenamate sodium cap 50 mg
generic
mefenamic acid cap 250 mg
generic
meloxicam 15 mg
generic
meloxicam 7.5 mg
generic
meloxicam suspension 7.5 mg/5ml
generic
meloxicam tab 15 mg
generic
meloxicam tab 7.5 mg
generic
nabumetone tab 500 mg
generic
nabumetone tab 750 mg
generic
naproxen dr tab dr 375 mg
generic
naproxen dr tab dr 500 mg
generic
naproxen sodium tab 550 mg
generic
naproxen tab 250 mg
generic
naproxen tab 375 mg
generic
naproxen tab 500 mg
generic
oxaprozin tab 600 mg
generic
piroxicam cap 10 mg
generic
piroxicam cap 20 mg
generic
sulindac tab 150 mg
generic
sulindac tab 200 mg
generic
tolmetin sodium cap 400 mg
generic
tolmetin sodium tab 200 mg
generic
tolmetin sodium tab 600 mg
generic
OTEZLA TAB 30 MG
apremilast
BRAND
OTEZLA TAB THPK 10 & 20 & 30 MG

apremilast
BRAND
leflunomide tab 10 mg
generic
leflunomide tab 20 mg
generic
*Phosphodiesterase 4 (PDE4) Inhibitors**
*Pyrimidine Synthesis Inhibitors**
*Selective Costimulation Modulators**
PAGE 11
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ORENCIA RECON SOLN 250 MG

abatacept
BRAND
PA
ORENCIA SOLN PRSYR 125 MG/ML

abatacept
BRAND
PA
ENBREL KIT 25 MG
etanercept
BRAND
PA
ENBREL SOLN PRSYR 25 MG/0.5ML

etanercept
BRAND
PA
ENBREL SOLN PRSYR 50 MG/ML

etanercept
BRAND
PA
ENBREL SURECLICK SOLN A-INJ 50 MG/ML

etanercept
BRAND
PA
alagesic cap 50-325-40 mg
generic
MDD
12 per day
butalbital compound/asa tab 50-325-40 mg
generic
butalbital-acetaminophen tab 50-325 mg
generic
MDD
12 per day
butalbital-apap-caffeine cap 50-325-40 mg
generic
MDD
12 per day
butalbital-apap-caffeine tab 50-325-40 mg
generic
MDD
12 per day
butalbital-asa-caffeine cap 50-325-40 mg
generic
butalbital-aspirin-caffeine cap 50-325-40 mg
generic
butalbital-aspirin-caffeine tab 50-325-40 mg
generic
capacet cap 50-325-40 mg
generic
MDD
12 per day
margesic cap 50-325-40 mg
generic
MDD
12 per day
marten-tab tab 50-325 mg
generic
repan tab 50-325-40 mg
generic
MDD
12 per day
zebutal cap 50-325-40 mg
generic
MDD
12 per day
PRIALT SOLUTION 500 MCG/20ML

ziconotide acetate
BRAND
PRIALT SOLUTION 500 MCG/5ML

ziconotide acetate
BRAND
*Soluble Tumor Necrosis Factor Receptor Agents**
*ANALGESICS - NonNarcotic*
*Analgesic Combinations**
*Analgesics-Peptide Channel Blockers**
PAGE 12
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Salicylates**
acetyl salicylic acid powder
generic
AL
Up to 79 yrs old
aspirin powder
generic
AL
Up to 79 yrs old
diflunisal tab 500 mg
generic
CODEINE SULFATE SOLUTION 15 MG/2.5ML

codeine sulfate
BRAND
MDD
2 per day
CODEINE SULFATE SOLUTION 30 MG/5ML

codeine sulfate
BRAND
MDD
2 per day
codeine sulfate tab 15 mg
generic
MDD
2 per day
generic
MDD
2 per day
generic
MDD
2 per day
EXALGO TB24 DETER 32 MG

hydromorphone hcl
BRAND
EXALGO TB24 DETER 8 MG

hydromorphone hcl
BRAND
fentanyl citrate loz handle 1200 mcg
generic
QL
90 / 30 days
generic
QL
90 / 30 days
generic
QL
90 / 30 days
generic
QL
90 / 30 days
generic
QL
90 / 30 days
generic
QL
90 / 30 days
fentanyl patch 72hr 100 mcg/hr
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
hydromorphone hcl er tb24 deter 12 mg
generic
PA
generic
PA
*ANALGESICS - OPIOID*
*Opioid Agonists**
QL
60 / 30 days
PA
QL
60 / 30 days
3
PA
PAGE 13
PRODUCT DESCRIPTION
BRAND/GEN
TIER
HYDROMORPHONE HCL ER TB24 DETER

32 MG
hydromorphone hcl
BRAND
generic
PA
hydromorphone hcl pf solution 1 mg/ml
generic
PA
generic
PA
generic
PA
generic
PA
hydromorphone hcl pf solution 50 mg/5ml
generic
PA
hydromorphone hcl pf solution 500 mg/50ml
generic
PA
hydromorphone hcl tab 2 mg
generic
QL
180 / 30 days
generic
QL
180 / 30 days
generic
QL
180 / 30 days
levorphanol tartrate tab 2 mg
generic
meperidine hcl tab 100 mg
generic
QL
180 / 30 days
meperidine hcl tab 50 mg
generic
QL
180 / 30 days
meperitab tab 100 mg
generic
QL
180 / 30 days
meperitab tab 50 mg
generic
QL
180 / 30 days
methadone hcl tab 10 mg
generic
QL
180 / 30 days
methadone hcl tab 5 mg
generic
QL
180 / 30 days
methadose tab 10 mg
generic
QL
180 / 30 days
morphine sulfate er beads cap er 24h 120 mg
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
morphine sulfate er cap er 24h 10 mg
generic
QL
30 / 30 days
PA
PAGE 14
PRODUCT DESCRIPTION
BRAND/GEN
generic
generic
TIER

QL
30 / 30 days
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
morphine sulfate er tab er 100 mg
generic
QL
90 / 30 days
generic
QL
90 / 30 days
generic
QL
90 / 30 days
generic
QL
90 / 30 days
generic
QL
90 / 30 days
morphine sulfate suppos 30 mg
generic
QL
120 / 30 days
morphine sulfate tab 15 mg
generic
QL
120 / 30 days
morphine sulfate tab 30 mg
generic
QL
120 / 30 days
NUCYNTA ER TAB ER 12H 100 MG

tapentadol hcl
QL
BRAND
60 / 30 days

tapentadol hcl
BRAND

tapentadol hcl
BRAND

tapentadol hcl
BRAND

tapentadol hcl
BRAND
NUCYNTA TAB 100 MG

tapentadol hcl
BRAND
NUCYNTA TAB 50 MG
tapentadol hcl
BRAND
NUCYNTA TAB 75 MG
BRAND
PAGE 15
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
90 / 30 days
3
PA
QL
90 / 30 days
3
PA
3
QL
90 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
TIER
tapentadol hcl
PA
QL
OPANA ER TAB ER 12H 10 MG

oxymorphone hcl
BRAND

oxymorphone hcl
BRAND

oxymorphone hcl
BRAND

oxymorphone hcl
BRAND

oxymorphone hcl
BRAND

oxymorphone hcl
BRAND
OPANA ER TAB ER 12H 7.5 MG

oxymorphone hcl
BRAND
OPANA ER TB12 DETER 10 MG

oxymorphone hcl
BRAND

oxymorphone hcl
BRAND

oxymorphone hcl
BRAND

oxymorphone hcl
BRAND

oxymorphone hcl
BRAND

oxymorphone hcl
BRAND
OPANA ER TB12 DETER 7.5 MG

oxymorphone hcl
BRAND
ORAMORPH SR TAB ER 100 MG

morphine sulfate
BRAND
PAGE 16
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
3
PA
QL
60 / 30 days
2
PA
QL
60 / 30 days
2
PA
QL
60 / 30 days
2
PA
QL
60 / 30 days
2
PA
QL
60 / 30 days
2
PA
QL
60 / 30 days
2
PA
QL
60 / 30 days
2
PA
QL
90 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
TIER
morphine sulfate
BRAND
QL
90 / 30 days
morphine sulfate
BRAND
QL
90 / 30 days
morphine sulfate
BRAND
QL
90 / 30 days
oxycodone hcl cap 5 mg
generic
QL
180 / 30 days
OXYCODONE HCL CAP 5 MG

oxycodone hcl
BRAND
QL
180 / 30 days
oxycodone hcl tab 10 mg
generic
QL
180 / 30 days
generic
QL
180 / 30 days
generic
QL
180 / 30 days
generic
QL
180 / 30 days
generic
QL
180 / 30 days
OXYCONTIN TB12 DETER 10 MG

oxycodone hcl
BRAND

oxycodone hcl
BRAND

oxycodone hcl
BRAND

oxycodone hcl
BRAND

oxycodone hcl
BRAND

oxycodone hcl
BRAND

oxycodone hcl
BRAND
oxymorphone hcl er tab er 12h 10 mg
generic
PA
MDD
2 per day
PA
3
MDD
2 per day
PA
3
MDD
2 per day
PA
3
MDD
2 per day
PA
3
MDD
2 per day
PA
3
MDD
2 per day
PA
3
MDD
QL
2 per day
60 / 30 days
3
PA
QL
generic
60 / 30 days
3
PA
PAGE 17
PRODUCT DESCRIPTION
BRAND/GEN
generic
TIER

QL
60 / 30 days
3
PA
QL
generic
60 / 30 days
3
PA
QL
generic
60 / 30 days
3
PA
QL
generic
60 / 30 days
3
PA
QL
oxymorphone hcl er tab er 12h 7.5 mg
generic
60 / 30 days
3
PA
QL
oxymorphone hcl tab 10 mg
generic
120 / 30 days
3
PA
QL
oxymorphone hcl tab 5 mg
generic
120 / 30 days
3
PA
tramadol hcl 50 mg
generic
QL
240 / 30 days
tramadol hcl er (biphasic) tab er 24h 100 mg
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
tramadol hcl er tab er 24h 100 mg
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
tramadol hcl tab 50 mg
generic
QL
240 / 30 days
QL
generic
4 / day
*Opioid Combinations**
acetaminophen-codeine #2 tab 300-15 mg
generic
generic
MDD
6 per day
MDD
6 per day
QL
acetaminophen-codeine solution 120-12

mg/5ml
PAGE 18
generic
4 / day
MDD
6 per day
MDD
30 per day
PRODUCT DESCRIPTION
BRAND/GEN
acetaminophen-codeine tab 300-15 mg
generic
generic
generic
ascomp-codeine cap 50-325-40-30 mg
generic
butalbital compound/codeine cap 50-325-40-30

mg
generic
butalbital-apap-caff-cod cap 50-300-40-30 mg
generic
MDD
12 per day
butalbital-apap-caff-cod cap 50-325-40-30 mg
generic
MDD
12 per day
butalbital-asa-caff-codeine cap 50-325-40-30

mg
generic
co-gesic tab 5-500 mg
generic
MDD
8 per day
endocet tab 10-325 mg
generic
MDD
6 per day
generic
generic
MDD
6 per day
endocet tab 7.5-325 mg
generic
endocet tab 7.5-500 mg
generic
hydrocodone-acetaminophen 5-325 mg
generic
MDD
12 per day
hydrocodone-acetaminophen solution 10-325

mg/15ml
generic
MDD
180 per day
hydrocodone-acetaminophen solution 2.5-108

mg/5ml
generic
MDD
180 per day
hydrocodone-acetaminophen solution 5-217

mg/10ml
generic
MDD
180 per day

mg/15ml
generic
MDD
180 per day

mg/15ml
generic
MDD
120 per day
hydrocodone-acetaminophen tab 10-300 mg
generic
MDD
12 per day
generic
MDD
12 per day
generic
MDD
8 per day
generic
MDD
6 per day
generic
MDD
6 per day
generic
MDD
5 per day
PAGE 19
TIER
PRODUCT DESCRIPTION
BRAND/GEN
HYDROCODONE-ACETAMINOPHEN TAB 10750 MG

hydrocodone-acetaminophen
BRAND
MDD
5 per day
hydrocodone-acetaminophen tab 2.5-325 mg
generic
MDD
12 per day
HYDROCODONE-ACETAMINOPHEN TAB
2.5-325 MG
BRAND
MDD
12 per day
generic
MDD
8 per day
generic
MDD
12 per day
generic
MDD
12 per day
generic
MDD
8 per day
generic
MDD
12 per day
generic
MDD
12 per day
HYDROCODONE-ACETAMINOPHEN TAB
7.5-500 MG
BRAND
MDD
8 per day
generic
MDD
6 per day
generic
MDD
5 per day
hydrocodone-ibuprofen tab 7.5-200 mg
generic
oxycodone-acetaminophen cap 5-500 mg
generic
MDD
6 per day
oxycodone-acetaminophen tab 10-325 mg
generic
MDD
6 per day
generic
MDD
6 per day
oxycodone-acetaminophen tab 2.5-325 mg
generic
MDD
6 per day
generic
MDD
6 per day
generic
MDD
6 per day
generic
MDD
6 per day
oxycodone-ibuprofen tab 5-400 mg
generic
ROXICET SOLUTION 5-325 MG/5ML

oxycodone w/ acetaminophen
BRAND
MDD
30 per day
roxicet tab 5-325 mg
generic
MDD
6 per day
ROXICET TAB 5-500 MG

oxycodone w/ acetaminophen
BRAND
MDD
6 per day
PAGE 20
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
tramadol-acetaminophen tab 37.5-325 mg
generic
generic

QL
4 / day
QL
90 / 30 days
*Opioid Partial Agonists**

buprenorphine hcl sl tab 2 mg
PA
QL
buprenorphine hcl sl tab 8 mg
generic
90 / 30 days
1
PA
QL
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg
generic
90 / 30 days
1
PA
QL
buprenorphine hcl-naloxone hcl sl tab 8-2 mg
generic
90 / 30 days
1
PA
butorphanol tartrate solution 10 mg/ml
generic
BUTRANS PATCH WK 10 MCG/HR

buprenorphine
BRAND
QL
4 / 30 days

buprenorphine
BRAND
QL
4 / 30 days

buprenorphine
BRAND
QL
4 / 30 days

buprenorphine
BRAND
QL
4 / 30 days
nalbuphine hcl solution 10 mg/ml
generic
PA
nalbuphine hcl solution 20 mg/ml
generic
PA
pentazocine-naloxone hcl tab 50-0.5 mg
generic
SUBOXONE FILM 12-3 MG

buprenorphine hcl-naloxone hcl dihydrate
BRAND
PA
SUBOXONE FILM 2-0.5 MG

BRAND
PA

BRAND
PA

BRAND
PA
ANADROL-50 TAB 50 MG
oxymetholone
BRAND
oxandrolone tab 10 mg
generic
*ANDROGENS-ANABOLIC*
*Anabolic Steroids**
PAGE 21
PRODUCT DESCRIPTION
BRAND/GEN
TIER
oxandrolone tab 2.5 mg
generic
ANDRODERM PATCH 24HR 2 MG/24HR

testosterone
BRAND
ANDRODERM PATCH 24HR 2.5 MG/24HR

testosterone
BRAND

testosterone
BRAND

testosterone
BRAND
ANDROGEL GEL 20.25 MG/1.25GM (1.62%)

testosterone
BRAND
ANDROGEL GEL 25 MG/2.5GM

testosterone
BRAND
ANDROGEL GEL 40.5 MG/2.5GM (1.62%)

testosterone
BRAND
ANDROGEL GEL 50 MG/5GM

testosterone
BRAND
ANDROGEL PUMP GEL 12.5 MG/ACT (1%)

testosterone
BRAND
ANDROGEL PUMP GEL 20.25 MG/ACT

(1.62%)
testosterone
BRAND
ANDROID CAP 10 MG
methyltestosterone
BRAND
ANDROXY TAB 10 MG
fluoxymesterone
BRAND
danazol cap 100 mg
generic
danazol cap 200 mg
generic
danazol cap 50 mg
generic
METHITEST TAB 10 MG
methyltestosterone
BRAND
TESTIM GEL 50 MG/5GM

testosterone
BRAND
testosterone cypionate solution 100 mg/ml
generic
testosterone cypionate solution 200 mg/ml
generic
testosterone enanthate solution 200 mg/ml
generic
TESTRED CAP 10 MG
methyltestosterone
BRAND
*Androgens**
PAGE 22
PRODUCT DESCRIPTION
BRAND/GEN
TIER
VOGELXO GEL 50 MG/5GM

testosterone
BRAND
VOGELXO PUMP GEL 12.5 MG/ACT (1%)

testosterone
BRAND
colocort enema 100 mg/60ml
generic
hydrocortisone enema 100 mg/60ml
generic
hc pram cream 1-1 %
generic
hc pram cream 2.5-1 %
generic
hydrocortisone ace-pramoxine cream 1-1 %
generic
hydrocortisone ace-pramoxine cream 2.5-1 %
generic
pramcort cream 1-1 %
generic
anucort-hc suppos 25 mg
generic
grx hicort 25 suppos 25 mg
generic
hemorrhoidal-hc suppos 25 mg
generic
hemril-30 suppos 30 mg
generic
hydrocortisone acetate suppos 25 mg
generic
hydrocortisone acetate suppos 30 mg
generic
hydrocortisone cream 2.5 %
generic
proctocare-hc cream 2.5 %
generic
proctocream hc cream 2.5 %
generic
proctosol hc cream 2.5 %
generic
proctozone-hc cream 2.5 %
generic
rectacort-hc suppos 25 mg
generic
BRAND
*ANORECTAL AGENTS*
*Intrarectal Steroids**
*Rectal Combinations**
*Rectal Steroids**
*Vasodilating Agents**
RECTIV OINTMENT 0.4 %
nitroglycerin (intra-anal)
*ANTHELMINTICS*
*Anthelmintics**
PAGE 23
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ALBENZA TAB 200 MG

albendazole
BRAND
BILTRICIDE TAB 600 MG

praziquantel
BRAND
mebendazole chew tab 100 mg
generic
MEBENDAZOLE CHEW TAB 100 MG

mebendazole
BRAND
STROMECTOL TAB 3 MG
ivermectin
BRAND
PA
AZACTAM IN DEXTROSE SOLUTION 1 GM

aztreonam in dextrose
BRAND
PA
AZACTAM IN DEXTROSE SOLUTION 2 GM

aztreonam in dextrose
BRAND
PA
aztreonam recon soln 1 gm
generic
PA
aztreonam recon soln 2 gm
generic
PA
CAYSTON RECON SOLN 75 MG

aztreonam lysine
BRAND
PA
colistimethate sodium recon soln 150 mg
generic
PA
COLY-MYCIN M RECON SOLN 150 MG

colistimethate sodium
BRAND
PA
FIRST-VANCOMYCIN 25 SOLUTION 25
MG/ML
vancomycin hcl
BRAND
FIRST-VANCOMYCIN 50 SOLUTION 50
MG/ML
vancomycin hcl
BRAND
FLAGYL ER TAB ER 24H 750 MG

metronidazole
BRAND
metronidazole cap 375 mg
generic
metronidazole in nacl solution 5-0.79 mg/ml-%
generic
PA
metronidazole in nacl solution 500-0.79

mg/100ml-%
generic
PA
metronidazole tab 250 mg
generic
metronidazole tab 500 mg
generic
NEBUPENT RECON SOLN 300 MG
BRAND
PA
*ANTI-INFECTIVE AGENTS - MISC.*

*Anti-infective Agents - Misc.**
PAGE 24
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
pentamidine isethionate
PENTAM RECON SOLN 300 MG
pentamidine isethionate
BRAND
trimethoprim tab 100 mg
generic
VANCOCIN HCL CAP 125 MG

vancomycin hcl
BRAND
QL
40 / 30 days
VANCOCIN HCL CAP 250 MG

vancomycin hcl
BRAND
QL
40 / 30 days
vancomycin hcl cap 125 mg
generic
QL
40 / 30 days
vancomycin hcl cap 250 mg
generic
QL
40 / 30 days
VANCOMYCIN HCL IN DEXTROSE

SOLUTION 1 GM/200ML
vancomycin hcl in dextrose
BRAND
PA

SOLUTION 500 MG/100ML
BRAND
PA

SOLUTION 750 MG/150ML
BRAND
PA
vancomycin hcl recon soln 10 gm
generic
PA
vancomycin hcl recon soln 1000 mg
generic
PA
generic
PA
generic
PA
VANCOMYCIN HCL RECON SOLN 750 MG

vancomycin hcl
BRAND
PA
VIBATIV RECON SOLN 250 MG

telavancin hcl
BRAND
PA
VIBATIV RECON SOLN 750 MG

telavancin hcl
BRAND
PA
XIFAXAN TAB 200 MG

rifaximin
BRAND
PA
XIFAXAN TAB 550 MG

rifaximin
BRAND
PA
e.s.p. recon susp 200-600 mg/5ml
generic
erythromycin-sulfisoxazole recon susp 200-600

mg/5ml
generic
PA
*Anti-infective Misc. - Combinations**
PAGE 25
PRODUCT DESCRIPTION
BRAND/GEN
TIER
smz-tmp ds tab 800-160 mg
generic
sulfamethoxazole-tmp ds tab 800-160 mg
generic
sulfamethoxazole-trimethoprim solution 400-80

mg/5ml
generic
sulfamethoxazole-trimethoprim suspension
200-40 mg/5ml
generic
sulfamethoxazole-trimethoprim suspension
800-160 mg/20ml
generic
sulfamethoxazole-trimethoprim tab 400-80 mg
generic
sulfatrim pediatric suspension 200-40 mg/5ml
generic
ALINIA RECON SUSP 100 MG/5ML

nitazoxanide
BRAND
ALINIA TAB 500 MG

nitazoxanide
BRAND
atovaquone suspension 750 mg/5ml
generic
DORIBAX RECON SOLN 250 MG

doripenem
BRAND
PA
DORIBAX RECON SOLN 500 MG

doripenem
BRAND
PA
INVANZ RECON SOLN 1 GM

ertapenem sodium
BRAND
BRAND
PA
BRAND
PA
KETEK TAB 300 MG

telithromycin
BRAND
KETEK TAB 400 MG

telithromycin
BRAND
dapsone tab 100 mg
generic
dapsone tab 25 mg
generic
PA
*Antiprotozoal Agents**
*Carbapenems**
*Cyclic Lipopeptides**
CUBICIN RECON SOLN 500 MG
daptomycin
*Glycylcyclines**
TYGACIL RECON SOLN 50 MG
tigecycline
*Ketolides**
*Leprostatics**
PAGE 26
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Lincosamides**
clindamycin hcl cap 150 mg
generic
generic
generic
clindamycin palmitate hcl recon soln 75 mg/5ml
generic
clindamycin phosphate in d5w solution 300

mg/50ml
generic
PA

mg/50ml
generic
PA

mg/50ml
generic
PA
clindamycin phosphate solution 300 mg/2ml
generic
PA
CLINDAMYCIN PHOSPHATE SOLUTION 300

MG/2ML
clindamycin phosphate
BRAND
PA
generic
PA
clindamycin phosphate solution 9 gm/60ml
generic
PA
generic
PA
generic
PA
LINCOCIN SOLUTION 300 MG/ML

lincomycin hcl
BRAND
PA
ZYVOX RECON SUSP 100 MG/5ML

linezolid
BRAND
PA
ZYVOX SOLUTION 2 MG/ML

linezolid
BRAND
PA
ZYVOX TAB 600 MG

linezolid
BRAND
PA
generic
PA
RANEXA TAB ER 12H 1000 MG

ranolazine
BRAND
PA
RANEXA TAB ER 12H 500 MG
BRAND
PA
*Oxazolidinones**
*Polymyxins**
polymyxin b sulfate recon soln 500000 unit
*ANTIANGINAL AGENTS*
*Antianginals-Other**
PAGE 27
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ranolazine
*Nitrates**
isochron tab er 40 mg
generic
isoditrate er tab er 40 mg
generic
isosorbide dinitrate er tab er 40 mg
generic
isosorbide dinitrate sl tab 2.5 mg
generic
isosorbide dinitrate sl tab 5 mg
generic
isosorbide dinitrate tab 10 mg
generic
generic
generic
generic
isosorbide mononitrate er tab er 24h 120 mg
generic
generic
generic
isosorbide mononitrate tab 10 mg
generic
isosorbide mononitrate tab 20 mg
generic
meloxicam tab 15 mg
generic
minitran patch 24hr 0.1 mg/hr
generic
generic
generic
generic
NITRO-BID OINTMENT 2 %
nitroglycerin
BRAND
nitro-time cap er 2.5 mg
generic
nitro-time cap er 6.5 mg
generic
nitro-time cap er 9 mg
generic
nitroglycerin aero soln 400 mcg/spray
generic
nitroglycerin er cap er 2.5 mg
generic
nitroglycerin er cap er 6.5 mg
generic
nitroglycerin er cap er 9 mg
generic
nitroglycerin patch 24hr 0.1 mg/hr
generic
generic
1
1
PAGE 28
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
generic
NITROSTAT SL TAB 0.3 MG

nitroglycerin
BRAND

nitroglycerin
BRAND

nitroglycerin
BRAND
buspirone hcl tab 10 mg
generic
generic
generic
generic
buspirone hcl tab 7.5 mg
generic
hydroxyzine hcl solution 10 mg/5ml
generic
hydroxyzine hcl syrup 10 mg/5ml
generic
hydroxyzine hcl tab 10 mg
generic
generic
generic
hydroxyzine pamoate 25 mg
generic
hydroxyzine pamoate cap 100 mg
generic
generic
generic
meprobamate tab 200 mg
generic
meprobamate tab 400 mg
generic
alprazolam er tab er 24h 0.5 mg
generic
QL
30 / 30 days
alprazolam er tab er 24h 1 mg
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
alprazolam tab 0.25 mg
generic
QL
120 / 30 days
*ANTIANXIETY AGENTS*
*Antianxiety Agents - Misc.**
*Benzodiazepines**
PAGE 29
PRODUCT DESCRIPTION
BRAND/GEN
alprazolam tab 0.5 mg
generic
alprazolam tab 1 mg
generic
alprazolam tab 2 mg
TIER

QL
120 / 30 days
QL
120 / 30 days
generic
QL
120 / 30 days
alprazolam tab disp 0.25 mg
generic
QL
120 / 30 days
alprazolam tab disp 0.5 mg
generic
QL
120 / 30 days
alprazolam tab disp 1 mg
generic
QL
120 / 30 days
alprazolam tab disp 2 mg
generic
QL
120 / 30 days
alprazolam xr tab er 24h 0.5 mg
generic
QL
30 / 30 days
alprazolam xr tab er 24h 1 mg
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
diazepam tab 10 mg
generic
QL
2 / 30 days
diazepam tab 2 mg
generic
QL
120 / 30 days
diazepam tab 5 mg
generic
QL
120 / 30 days
lorazepam solution 4 mg/ml
generic
QL
8 / 30 days
lorazepam tab 0.5 mg
generic
QL
120 / 30 days
lorazepam tab 1 mg
generic
QL
120 / 30 days
lorazepam tab 2 mg
generic
QL
120 / 30 days
disopyramide phosphate cap 100 mg
generic
disopyramide phosphate cap 150 mg
generic
procainamide hcl solution 100 mg/ml
generic
PA
PROCAINAMIDE HCL SOLUTION 100 MG/ML

procainamide hcl
BRAND
PA
PROCAINAMIDE HCL SOLUTION 500 MG/ML

procainamide hcl
BRAND
PA
*ANTIARRHYTHMICS*
*Antiarrhythmics Type I-A**
*Antiarrhythmics Type I-B**
PAGE 30
PRODUCT DESCRIPTION
BRAND/GEN
TIER
LIDOCAINE HCL (CARDIAC) SOLUTION 10

MG/ML
lidocaine hcl (cardiac)
BRAND
PA
lidocaine hcl (cardiac) solution 20 mg/ml
generic
PA
lidocaine in d5w solution 4-5 mg/ml-%
generic
PA
lidocaine in d5w solution 8-5 mg/ml-%
generic
PA
mexiletine hcl cap 150 mg
generic
generic
generic
flecainide acetate tab 100 mg
generic
generic
generic
propafenone hcl er cap er 12h 225 mg
generic
generic
generic
propafenone hcl tab 150 mg
generic
generic
generic
amiodarone hcl tab 100 mg
generic
generic
generic
MULTAQ TAB 400 MG

dronedarone hcl
BRAND
TIKOSYN CAP 125 MCG

dofetilide
BRAND
PA
TIKOSYN CAP 250 MCG

dofetilide
BRAND
PA
TIKOSYN CAP 500 MCG

dofetilide
BRAND
PA
*Antiarrhythmics Type I-C**
*Antiarrhythmics Type III**
*ANTIASTHMATIC AND BRONCHODILATOR AGENTS*

*Anti-Inflammatory Agents**
cromolyn sodium nebu soln 20 mg/2ml
PAGE 31
generic
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Antiasthmatic - Monoclonal Antibodies**

XOLAIR RECON SOLN 150 MG
omalizumab
BRAND
ATROVENT HFA AERO SOLN 17 MCG/ACT

ipratropium bromide hfa
BRAND
ipratropium bromide solution 0.02 %
generic
SPIRIVA HANDIHALER CAP 18 MCG

tiotropium bromide monohydrate
BRAND
montelukast sodium chew tab 4 mg
generic
QL
30 / 30 days
montelukast sodium chew tab 5 mg
generic
QL
30 / 30 days
montelukast sodium packet 4 mg
generic
QL
30 / 30 days
montelukast sodium tab 10 mg
generic
QL
30 / 30 days
zafirlukast tab 10 mg
generic
QL
60 / 30 days
zafirlukast tab 20 mg
generic
QL
60 / 30 days
ZYFLO CR TAB ER 12H 600 MG

zileuton
BRAND
PA
ZYFLO TAB 600 MG

zileuton
BRAND
PA
ASMANEX 120 METERED DOSES AER POW

BA 220 MCG/INH
mometasone furoate (inhalation)
BRAND

BA 220 MCG/INH
BRAND

BA 110 MCG/INH
BRAND

BA 220 MCG/INH
BRAND

BA 220 MCG/INH
BRAND
BRAND
PA
*Bronchodilators - Anticholinergics**
*Leukotriene Modulators**
*Steroid Inhalants**
PAGE 32
PRODUCT DESCRIPTION
BRAND/GEN
TIER
BA 110 MCG/INH
budesonide suspension 0.25 mg/2ml
generic
budesonide suspension 0.5 mg/2ml
generic
FLOVENT DISKUS AER POW BA 250

MCG/BLIST
fluticasone propionate (inhalation)
BRAND
FLOVENT HFA AEROSOL 110 MCG/ACT

fluticasone propionate hfa
BRAND

BRAND

BRAND
PULMICORT FLEXHALER AER POW BA 180

MCG/ACT
budesonide (inhalation)
BRAND
PULMICORT FLEXHALER AER POW BA 90

MCG/ACT
BRAND
PULMICORT SUSPENSION 1 MG/2ML

BRAND
QVAR AERO SOLN 40 MCG/ACT

beclomethasone dipropionate
BRAND
QVAR AERO SOLN 80 MCG/ACT

beclomethasone dipropionate
BRAND
ADVAIR DISKUS AER POW BA 100-50

MCG/DOSE
fluticasone-salmeterol
BRAND

MCG/DOSE
BRAND

MCG/DOSE
BRAND
ADVAIR HFA AEROSOL 115-21 MCG/ACT

BRAND

BRAND

BRAND
*Sympathomimetics**
PAGE 33
PRODUCT DESCRIPTION
BRAND/GEN
TIER
albuterol sulfate nebu soln (5 mg/ml) 0.5%
generic
albuterol sulfate nebu soln 0.63 mg/3ml
generic
albuterol sulfate nebu soln 1.25 mg/3ml
generic
albuterol sulfate syrup 2 mg/5ml
generic
albuterol sulfate tab 2 mg
generic
albuterol sulfate tab 4 mg
generic
ARCAPTA NEOHALER CAP 75 MCG

indacaterol maleate
BRAND
BROVANA NEBU SOLN 15 MCG/2ML

arformoterol tartrate
BRAND
COMBIVENT RESPIMAT AERO SOLN 20-100

MCG/ACT
ipratropium-albuterol
BRAND
DULERA AEROSOL 100-5 MCG/ACT

mometasone furoate-formoterol fumarate
dihydrate
BRAND
DULERA AEROSOL 200-5 MCG/ACT

mometasone furoate-formoterol fumarate
dihydrate
BRAND
epinephrine hcl soln prsyr 0.1 mg/ml
generic
QL
1 / 30 days
PA
epinephrine hcl solution 1 mg/ml
generic
FORADIL AEROLIZER CAP 12 MCG

formoterol fumarate
BRAND
ipratropium-albuterol solution 0.5-2.5 (3)

mg/3ml
generic
levalbuterol hcl nebu soln 0.31 mg/3ml
generic
generic
levalbuterol hcl nebu soln 1.25 mg/0.5ml
generic
generic
MAXAIR AUTOHALER AERO BA 200

MCG/INH
pirbuterol acetate
BRAND
metaproterenol sulfate syrup 10 mg/5ml
generic
metaproterenol sulfate tab 10 mg
generic
metaproterenol sulfate tab 20 mg
generic
PERFOROMIST NEBU SOLN 20 MCG/2ML
BRAND
PAGE 34
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
formoterol fumarate
PROAIR HFA AERO SOLN 108 (90 BASE)
MCG/ACT
albuterol sulfate
BRAND
PROVENTIL HFA AERO SOLN 108 (90 BASE)

MCG/ACT
albuterol sulfate
BRAND
SEREVENT DISKUS AER POW BA 50

MCG/DOSE
salmeterol xinafoate
BRAND
SYMBICORT AEROSOL 160-4.5 MCG/ACT

budesonide-formoterol fumarate dihydrate
BRAND
SYMBICORT AEROSOL 80-4.5 MCG/ACT

budesonide-formoterol fumarate dihydrate
BRAND
terbutaline sulfate tab 2.5 mg
generic
terbutaline sulfate tab 5 mg
generic
VENTOLIN HFA AERO SOLN 108 (90 BASE)

MCG/ACT
albuterol sulfate
BRAND
XOPENEX HFA AEROSOL 45 MCG/ACT

levalbuterol tartrate
BRAND
elixophyllin elixir 80 mg/15ml
generic
lufyllin tab 200 mg
generic
PA
LUFYLLIN TAB 400 MG

dyphylline
BRAND
PA
THEO-24 CAP ER 24H 100 MG

theophylline
BRAND

theophylline
BRAND

theophylline
BRAND

theophylline
BRAND
theochron tab er 12h 100 mg
generic
generic
generic
theophylline elixir 80 mg/15ml
generic
*Xanthines**
PAGE 35
PRODUCT DESCRIPTION
BRAND/GEN
TIER
theophylline er tab er 12h 100 mg
generic
generic
generic
generic
generic
generic
theophylline solution 80 mg/15ml
generic
COUMADIN RECON SOLN 5 MG

warfarin sodium
BRAND
jantoven tab 1 mg
generic
jantoven tab 10 mg
generic
jantoven tab 2 mg
generic
jantoven tab 2.5 mg
generic
jantoven tab 3 mg
generic
jantoven tab 4 mg
generic
jantoven tab 5 mg
generic
jantoven tab 6 mg
generic
jantoven tab 7.5 mg
generic
warfarin sodium tab 1 mg
generic
generic
generic
warfarin sodium tab 2.5 mg
generic
generic
generic
generic
generic
warfarin sodium tab 7.5 mg
generic
ELIQUIS TAB 2.5 MG

apixaban
BRAND
PA
ELIQUIS TAB 5 MG
BRAND
PA
*ANTICOAGULANTS*
*Coumarin Anticoagulants**
PA
*Direct Factor Xa Inhibitors**
PAGE 36
PRODUCT DESCRIPTION
BRAND/GEN
TIER
apixaban
XARELTO TAB 10 MG
rivaroxaban
BRAND
PA
XARELTO TAB 15 MG
rivaroxaban
BRAND
PA
XARELTO TAB 20 MG
rivaroxaban
BRAND
PA
generic
*Heparins And Heparinoid-Like Agents**

QL
enoxaparin sodium solution 100 mg/ml
60 / 30 days
PA
QL
enoxaparin sodium solution 120 mg/0.8ml
generic
60 / 30 days
4
PA
QL
enoxaparin sodium solution 150 mg/ml
generic
60 / 30 days
4
PA
QL
generic
60 / 30 days
4
PA
QL
enoxaparin sodium solution 300 mg/3ml
generic
60 / 30 days
4
PA
QL
generic
60 / 30 days
4
PA
QL
generic
60 / 30 days
4
PA
QL
generic
60 / 30 days
4
PA
QL
fondaparinux sodium solution 10 mg/0.8ml
generic
30 / 30 days
4
PA
QL
fondaparinux sodium solution 2.5 mg/0.5ml
generic
30 / 30 days
4
PA
QL
fondaparinux sodium solution 5 mg/0.4ml
generic
30 / 30 days
4
PA
QL
fondaparinux sodium solution 7.5 mg/0.6ml
generic
30 / 30 days
4
PA
4
PAGE 37
PRODUCT DESCRIPTION
BRAND/GEN
TIER
FRAGMIN SOLUTION 10000 UNIT/ML

dalteparin sodium
BRAND
FRAGMIN SOLUTION 12500 UNIT/0.5ML

dalteparin sodium
BRAND

dalteparin sodium
BRAND
FRAGMIN SOLUTION 18000 UNT/0.72ML

dalteparin sodium
BRAND

dalteparin sodium
BRAND
FRAGMIN SOLUTION 25000 UNIT/ML

dalteparin sodium
BRAND

dalteparin sodium
BRAND

dalteparin sodium
BRAND
HEPARIN (PORCINE) IN NACL SOLUTION

100-0.45 UNIT/ML-%
heparin (porcine) in sodium chloride
BRAND
HEPARIN (PORCINE) IN NACL SOLUTION

50-0.45 UNIT/ML-%
heparin (porcine) in sodium chloride
BRAND
heparin sodium (porcine) pf solution 5000

unit/0.5ml
generic
INNOHEP SOLUTION 20000 UNIT/ML

tinzaparin sodium
BRAND
PRADAXA CAP 150 MG

dabigatran etexilate mesylate
BRAND
PA
PRADAXA CAP 75 MG
dabigatran etexilate mesylate
BRAND
PA
generic
QL
QL
30 / 30 days
PA
QL
30 / 30 days
4
PA
QL
30 / 30 days
4
PA
QL
30 / 30 days
4
PA
QL
30 / 30 days
4
PA
QL
30 / 30 days
4
PA
QL
30 / 30 days
4
PA
QL
30 / 30 days
4
PA
*Thrombin Inhibitors**
*ANTICONVULSANTS*
*Anticonvulsants - Benzodiazepines**
clonazepam tab 0.5 mg
120 / 30 days
PAGE 38
PRODUCT DESCRIPTION
BRAND/GEN
clonazepam tab 1 mg
generic
clonazepam tab 2 mg
generic
clonazepam tab disp 0.125 mg
TIER

QL
120 / 30 days
QL
120 / 30 days
generic
QL
120 / 30 days
generic
QL
120 / 30 days
generic
QL
120 / 30 days
clonazepam tab disp 1 mg
generic
QL
120 / 30 days
clonazepam tab disp 2 mg
generic
QL
120 / 30 days
diazepam gel 10 mg
generic
QL
2 / 30 days
diazepam gel 2.5 mg
generic
QL
2 / 30 days
diazepam gel 20 mg
generic
QL
2 / 30 days
BANZEL SUSPENSION 40 MG/ML

rufinamide
BRAND
BANZEL TAB 200 MG

rufinamide
BRAND
BANZEL TAB 400 MG

rufinamide
BRAND
carbamazepine chew tab 100 mg
generic
carbamazepine er cap er 12h 100 mg
generic
generic
generic
carbamazepine er tab er 12h 200 mg
generic
carbamazepine er tab er 12h 400 mg
generic
carbamazepine suspension 100 mg/5ml
generic
carbamazepine tab 200 mg
generic
epitol tab 200 mg
generic
gabapentin 300 mg
generic
gabapentin 400 mg
generic
gabapentin cap 100 mg
generic
generic
generic
*Anticonvulsants - Misc.**
PAGE 39
PRODUCT DESCRIPTION
BRAND/GEN
gabapentin solution 250 mg/5ml
generic
gabapentin tab 600 mg
generic
gabapentin tab 800 mg
generic
lamotrigine chew tab 25 mg
generic
lamotrigine chew tab 5 mg
generic
lamotrigine er tab er 24h 100 mg
generic
generic
generic
generic
generic
generic
lamotrigine tab 100 mg
generic
generic
generic
generic
levetiracetam er tab er 24h 500 mg
generic
levetiracetam er tab er 24h 750 mg
generic
levetiracetam tab 1000 mg
generic
generic
generic
generic
LYRICA CAP 100 MG

pregabalin
BRAND
LYRICA CAP 150 MG

pregabalin
BRAND
LYRICA CAP 200 MG

pregabalin
BRAND
LYRICA CAP 225 MG

pregabalin
BRAND
LYRICA CAP 25 MG
pregabalin
BRAND
LYRICA CAP 300 MG
BRAND
PAGE 40
TIER
QL
90 / 30 days
PA
QL
90 / 30 days
3
PA
QL
90 / 30 days
3
PA
QL
90 / 30 days
3
PA
QL
90 / 30 days
3
PA
3
QL
90 / 30 days
PRODUCT DESCRIPTION
BRAND/GEN
TIER
pregabalin

PA
QL
LYRICA CAP 50 MG
pregabalin
BRAND
LYRICA CAP 75 MG
pregabalin
BRAND
LYRICA SOLUTION 20 MG/ML

pregabalin
BRAND
oxcarbazepine suspension 300 mg/5ml
generic
oxcarbazepine tab 150 mg
generic
generic
generic
POTIGA TAB 200 MG

ezogabine
BRAND
PA
POTIGA TAB 300 MG

ezogabine
BRAND
PA
POTIGA TAB 400 MG

ezogabine
BRAND
PA
POTIGA TAB 50 MG
ezogabine
BRAND
PA
primidone tab 250 mg
generic
primidone tab 50 mg
generic
TEGRETOL-XR TAB ER 12H 100 MG

carbamazepine
BRAND
topiragen tab 100 mg
generic
topiragen tab 200 mg
generic
topiragen tab 25 mg
generic
topiragen tab 50 mg
generic
topiramate cap sprink 15 mg
generic
topiramate cap sprink 25 mg
generic
topiramate tab 100 mg
generic
generic
generic
generic
VIMPAT SOLUTION 10 MG/ML

lacosamide
BRAND
PAGE 41
90 / 30 days
3
PA
QL
90 / 30 days
3
PA
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
VIMPAT SOLUTION 200 MG/20ML

lacosamide
BRAND
VIMPAT TAB 100 MG

lacosamide
BRAND
PA
VIMPAT TAB 150 MG

lacosamide
BRAND
PA
VIMPAT TAB 200 MG

lacosamide
BRAND
PA
VIMPAT TAB 50 MG
lacosamide
BRAND
PA
zonisamide cap 100 mg
generic
generic
generic
felbamate suspension 600 mg/5ml
generic
felbamate tab 400 mg
generic
felbamate tab 600 mg
generic
GABITRIL TAB 12 MG
tiagabine hcl
BRAND
GABITRIL TAB 16 MG
tiagabine hcl
BRAND
SABRIL PACKET 500 MG

vigabatrin
BRAND
PA
SABRIL TAB 500 MG

vigabatrin
BRAND
PA
tiagabine hcl tab 2 mg
generic
tiagabine hcl tab 4 mg
generic
DILANTIN CAP 30 MG
phenytoin sodium extended
BRAND
DILANTIN INFATABS CHEW TAB 50 MG

phenytoin
BRAND
PEGANONE TAB 250 MG

ethotoin
BRAND
phenytoin chew tab 50 mg
generic
phenytoin infatabs chew tab 50 mg
generic
*Carbamates**
*GABA Modulators**
*Hydantoins**
PAGE 42
PRODUCT DESCRIPTION
BRAND/GEN
TIER
phenytoin sodium extended cap 100 mg
generic
generic
generic
phenytoin suspension 100 mg/4ml
generic
phenytoin suspension 125 mg/5ml
generic
CELONTIN CAP 300 MG

methsuximide
BRAND
ethosuximide cap 250 mg
generic
ethosuximide solution 250 mg/5ml
generic
divalproex sodium cap sprink 125 mg
generic
divalproex sodium er tab er 24h 250 mg
generic
divalproex sodium er tab er 24h 500 mg
generic
divalproex sodium tab dr 125 mg
generic
generic
generic
valproate sodium solution 100 mg/ml
generic
PA
valproate sodium solution 500 mg/5ml
generic
PA
valproic acid cap 250 mg
generic
mirtazapine tab 15 mg
generic
generic
generic
mirtazapine tab 7.5 mg
generic
mirtazapine tab disp 15 mg
generic
generic
generic
budeprion sr tab er 12h 100 mg
generic
QL
60 / 30 days
budeprion sr tab er 12h 150 mg
generic
QL
60 / 30 days
*Succinimides**
*Valproic Acid**
*ANTIDEPRESSANTS*
*Alpha-2 Receptor Antagonists (Tetracyclics)**
*Antidepressants - Misc.**
PAGE 43
PRODUCT DESCRIPTION
BRAND/GEN
TIER
budeprion xl tab er 24h 150 mg
generic
QL
60 / 30 days
budeprion xl tab er 24h 300 mg
generic
QL
60 / 30 days
bupropion hcl er (sr) tab er 12h 100 mg
generic
QL
60 / 30 days
generic
QL
60 / 30 days
generic
QL
60 / 30 days
bupropion hcl er (xl) tab er 24h 150 mg
generic
QL
60 / 30 days
bupropion hcl er (xl) tab er 24h 300 mg
generic
QL
60 / 30 days
bupropion hcl tab 100 mg
generic
bupropion hcl tab 75 mg
generic
maprotiline hcl tab 25 mg
generic
generic
generic
EMSAM PATCH 24HR 12 MG/24HR

selegiline
BRAND

selegiline
BRAND

selegiline
BRAND
MARPLAN TAB 10 MG
isocarboxazid
BRAND
phenelzine sulfate tab 15 mg
generic
tranylcypromine sulfate tab 10 mg
generic
citalopram hydrobromide tab 10 mg
generic
QL
45 / 30 days
generic
QL
45 / 30 days
generic
QL
45 / 30 days
escitalopram oxalate tab 10 mg
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
*Monoamine Oxidase Inhibitors (MAOIs)**
*Selective Serotonin Reuptake Inhibitors (SSRIs)**
PAGE 44
PRODUCT DESCRIPTION
BRAND/GEN
TIER
fluoxetine hcl cap 10 mg
generic
generic
generic
fluoxetine hcl cap dr 90 mg
generic
fluoxetine hcl tab 10 mg
generic
generic
generic
fluvoxamine maleate er cap er 24h 100 mg
generic
fluvoxamine maleate er cap er 24h 150 mg
generic
fluvoxamine maleate tab 100 mg
generic
generic
generic
paroxetine hcl 30 mg
generic
QL
45 / 30 days
paroxetine hcl 40 mg
generic
QL
45 / 30 days
paroxetine hcl er tab er 24h 12.5 mg
generic
QL
30 / 30 days
paroxetine hcl er tab er 24h 25 mg
generic
QL
30 / 30 days
paroxetine hcl er tab er 24h 37.5 mg
generic
QL
30 / 30 days
paroxetine hcl tab 10 mg
generic
QL
45 / 30 days
generic
QL
45 / 30 days
generic
QL
45 / 30 days
generic
QL
45 / 30 days
PAXIL SUSPENSION 10 MG/5ML

paroxetine hcl
BRAND
sertraline hcl tab 100 mg
generic
QL
60 / 30 days
generic
QL
60 / 30 days
generic
QL
60 / 30 days
nefazodone hcl tab 100 mg
generic
generic
generic
*Serotonin Modulators**
PAGE 45
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
generic
OLEPTRO TAB ER 24H 150 MG

trazodone hcl
BRAND
OLEPTRO TAB ER 24H 300 MG

trazodone hcl
BRAND
trazodone hcl tab 100 mg
generic
generic
generic
generic
VIIBRYD KIT 10 & 20 & 40 MG

vilazodone hcl
BRAND
VIIBRYD TAB 10 MG
vilazodone hcl
BRAND
VIIBRYD TAB 20 MG
vilazodone hcl
BRAND
VIIBRYD TAB 40 MG
vilazodone hcl
BRAND
QL
30 / 30 days
ST
QL
30 / 30 days
2
ST
QL
30 / 30 days
2
ST
*Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)**

QL
desvenlafaxine er tab er 24h 100 mg
generic
30 / 30 days
1
ST
QL
desvenlafaxine er tab er 24h 50 mg
generic
30 / 30 days
1
ST
QL
duloxetine hcl cp dr part 20 mg
generic
60 / 30 days
1
PA
QL
generic
60 / 30 days
1
PA
QL
generic
60 / 30 days
1
PA
QL
PRISTIQ TAB ER 24H 100 MG

desvenlafaxine succinate
BRAND
PRISTIQ TAB ER 24H 50 MG

desvenlafaxine succinate
BRAND
PAGE 46
30 / 30 days
3
ST
QL
30 / 30 days
3
ST
PRODUCT DESCRIPTION
BRAND/GEN
TIER
venlafaxine hcl er cap er 24h 150 mg
generic
QL
30 / 30 days
venlafaxine hcl er cap er 24h 37.5 mg
generic
QL
30 / 30 days
venlafaxine hcl er cap er 24h 75 mg
generic
QL
30 / 30 days
venlafaxine hcl er tab er 24h 150 mg
generic
QL
30 / 30 days
VENLAFAXINE HCL ER TAB ER 24H 225 MG

venlafaxine hcl
BRAND
QL
30 / 30 days
venlafaxine hcl er tab er 24h 37.5 mg
generic
QL
30 / 30 days
venlafaxine hcl er tab er 24h 75 mg
generic
QL
30 / 30 days
venlafaxine hcl tab 100 mg
generic
QL
90 / 30 days
generic
QL
90 / 30 days
venlafaxine hcl tab 37.5 mg
generic
QL
90 / 30 days
generic
QL
90 / 30 days
generic
QL
90 / 30 days
amitriptyline hcl tab 10 mg
generic
generic
generic
generic
generic
generic
amoxapine tab 100 mg
generic
amoxapine tab 150 mg
generic
amoxapine tab 25 mg
generic
amoxapine tab 50 mg
generic
clomipramine hcl cap 25 mg
generic
generic
generic
desipramine hcl tab 10 mg
generic
generic
*Tricyclic Agents**
PAGE 47
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
generic
generic
generic
doxepin hcl cap 10 mg
generic
generic
generic
generic
generic
generic
imipramine hcl tab 10 mg
generic
generic
generic
imipramine pamoate cap 100 mg
generic
generic
generic
generic
nortriptyline hcl cap 10 mg
generic
generic
generic
generic
protriptyline hcl tab 10 mg
generic
protriptyline hcl tab 5 mg
generic
trimipramine maleate cap 100 mg
generic
generic
generic
acarbose tab 100 mg
generic
acarbose tab 25 mg
generic
acarbose tab 50 mg
generic
GLYSET TAB 100 MG

miglitol
BRAND
*ANTIDIABETICS*
*Alpha-Glucosidase Inhibitors**
PAGE 48
PRODUCT DESCRIPTION
BRAND/GEN
TIER
GLYSET TAB 25 MG
miglitol
BRAND
GLYSET TAB 50 MG
miglitol
BRAND
SYMLIN SOLUTION 600 MCG/ML

pramlintide acetate
BRAND
PA
SYMLINPEN 120 SOLN PEN 2700

MCG/2.7ML
pramlintide acetate
BRAND
PA
SYMLINPEN 60 SOLN PEN 1500 MCG/1.5ML

pramlintide acetate
BRAND
PA
ACTOPLUS MET XR TAB ER 24H 15-1000

MG
pioglitazone hcl-metformin hcl
BRAND
ACTOPLUS MET XR TAB ER 24H 30-1000

MG
pioglitazone hcl-metformin hcl
BRAND
glipizide-metformin hcl tab 2.5-250 mg
generic
glipizide-metformin hcl tab 2.5-500 mg
generic
glipizide-metformin hcl tab 5-500 mg
generic
glyburide-metformin tab 1.25-250 mg
generic
glyburide-metformin tab 2.5-500 mg
generic
glyburide-metformin tab 5-500 mg
generic
JANUMET TAB 50-1000 MG

sitagliptin-metformin hcl
BRAND
ST
JANUMET TAB 50-500 MG

BRAND
ST
JANUMET XR TAB ER 24H 100-1000 MG

BRAND
ST

BRAND
ST

BRAND
ST
JENTADUETO TAB 2.5-1000 MG

linagliptin-metformin hcl
BRAND
ST
pioglitazone hcl-metformin hcl tab 15-500 mg
generic
pioglitazone hcl-metformin hcl tab 15-850 mg
generic
*Antidiabetic - Amylin Analogs**
*Antidiabetic Combinations**
PAGE 49
PRODUCT DESCRIPTION
BRAND/GEN
TIER
PRANDIMET TAB 1-500 MG

repaglinide-metformin hcl
BRAND
PRANDIMET TAB 2-500 MG

repaglinide-metformin hcl
BRAND
metformin hcl er (osm) tab er 24h 1000 mg
generic
metformin hcl er (osm) tab er 24h 500 mg
generic
metformin hcl er tab er 24h 500 mg
generic
metformin hcl er tab er 24h 750 mg
generic
metformin hcl tab 1000 mg
generic
generic
generic
RIOMET SOLUTION 500 MG/5ML

metformin hcl
BRAND
GLUCAGEN HYPOKIT RECON SOLN 1 MG

glucagon hcl (rdna)
BRAND
GLUCAGEN RECON SOLN 1 MG

glucagon hcl (rdna)
BRAND
GLUCAGON EMERGENCY KIT 1 MG

glucagon (rdna)
BRAND
KORLYM TAB 300 MG

mifepristone (hyperglycemia)
BRAND
PROGLYCEM SUSPENSION 50 MG/ML

diazoxide
BRAND
JANUVIA TAB 100 MG

sitagliptin phosphate
BRAND
ST
JANUVIA TAB 25 MG
BRAND
ST
JANUVIA TAB 50 MG
BRAND
ST
ONGLYZA TAB 2.5 MG

saxagliptin hcl
BRAND
ST
ONGLYZA TAB 5 MG
saxagliptin hcl
BRAND
ST
TRADJENTA TAB 5 MG
linagliptin
BRAND
ST
*Biguanides**
*Diabetic Other**
*Dipeptidyl Peptidase-4 (DPP-4) Inhibitors**
PAGE 50
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Dopamine Receptor Agonists - Antidiabetic**

CYCLOSET TAB 0.8 MG
bromocriptine mesylate (diabetes)
BRAND
*Incretin Mimetic Agents (GLP-1 Receptor Agonists)**

BYDUREON PEN 2 MG
exenatide
BRAND
ST
BYDUREON RECON SUSP 2 MG

exenatide
BRAND
ST
BYETTA 10 MCG PEN SOLN PEN 10

MCG/0.04ML
exenatide
BRAND
ST
BYETTA 5 MCG PEN SOLN PEN 5

MCG/0.02ML
exenatide
BRAND
ST
VICTOZA SOLN PEN 18 MG/3ML

liraglutide
BRAND
ST
AVANDIA TAB 2 MG
rosiglitazone maleate
BRAND
AVANDIA TAB 4 MG
BRAND
AVANDIA TAB 8 MG
BRAND
pioglitazone hcl tab 15 mg
generic
generic
generic
APIDRA SOLOSTAR SOLN PEN 100 UNIT/ML

insulin glulisine
BRAND
APIDRA SOLUTION 100 UNIT/ML

insulin glulisine
BRAND
HUMALOG KWIKPEN SOLN PEN 100

UNIT/ML
insulin lispro (human)
BRAND
HUMALOG MIX 50/50 KWIKPEN SUSP PEN

(50-50) 100 UNIT/ML
insulin lispro protamine & lispro (human)
BRAND
HUMALOG MIX 50/50 PEN SUSP PEN (50-50)

100 UNIT/ML
BRAND
*Insulin Sensitizing Agents**
*Insulin**
PAGE 51
PRODUCT DESCRIPTION
BRAND/GEN
HUMALOG MIX 50/50 SUSPENSION (50-50)

100 UNIT/ML
BRAND
HUMALOG MIX 75/25 KWIKPEN SUSP PEN

(75-25) 100 UNIT/ML
BRAND
HUMALOG MIX 75/25 PEN SUSP PEN (75-25)

100 UNIT/ML
BRAND
HUMALOG MIX 75/25 SUSPENSION (75-25)

100 UNIT/ML
BRAND
HUMALOG PEN SOLN PEN 100 UNIT/ML

BRAND
HUMALOG SOLN CART 100 UNIT/ML

BRAND
HUMALOG SOLUTION 100 UNIT/ML

BRAND
HUMULIN 70/30 KWIKPEN SUSP PEN (70-30)

100 UNIT/ML
insulin isophane & reg (human)
BRAND
HUMULIN 70/30 SUSPENSION (70-30) 100

UNIT/ML
BRAND
HUMULIN N KWIKPEN SUSP PEN 100

UNIT/ML
insulin isophane (human)
BRAND
HUMULIN N SUSPENSION 100 UNIT/ML

BRAND
HUMULIN R SOLUTION 100 UNIT/ML

insulin regular (human)
BRAND
HUMULIN R U-500 (CONCENTRATED)

SOLUTION 500 UNIT/ML
BRAND
LANTUS FOR OPTICLIK SOLN CART 100

UNIT/ML
insulin glargine
BRAND
LANTUS SOLOSTAR SOLN PEN 100

UNIT/ML
insulin glargine
BRAND
LANTUS SOLUTION 100 UNIT/ML

insulin glargine
BRAND
LEVEMIR FLEXPEN SOLN PEN 100 UNIT/ML
BRAND
PAGE 52
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
insulin detemir
LEVEMIR SOLUTION 100 UNIT/ML
insulin detemir
BRAND
NOVOLIN 70/30 RELION SUSPENSION (7030) 100 UNIT/ML

BRAND
NOVOLIN 70/30 SUSPENSION (70-30) 100

UNIT/ML
BRAND
NOVOLIN N RELION SUSPENSION 100

UNIT/ML
BRAND
NOVOLIN N SUSPENSION 100 UNIT/ML

BRAND
NOVOLIN R RELION SOLUTION 100 UNIT/ML

BRAND
NOVOLIN R SOLUTION 100 UNIT/ML

BRAND
NOVOLOG FLEXPEN SOLN PEN 100

UNIT/ML
insulin aspart
BRAND
NOVOLOG MIX 70/30 FLEXPEN SUSP PEN

(70-30) 100 UNIT/ML
insulin aspart protamine & aspart (human)
BRAND
NOVOLOG MIX 70/30 SUSPENSION (70-30)

100 UNIT/ML
insulin aspart protamine & aspart (human)
BRAND
NOVOLOG PENFILL SOLN CART 100

UNIT/ML
insulin aspart
BRAND
NOVOLOG SOLUTION 100 UNIT/ML

insulin aspart
BRAND
RELION 70/30 SUSPENSION (70-30) 100

UNIT/ML
BRAND
RELION N SUSPENSION 100 UNIT/ML

BRAND
RELION R SOLUTION 100 UNIT/ML

BRAND
generic
*Meglitinide Analogues**
nateglinide tab 120 mg
PAGE 53
PRODUCT DESCRIPTION
BRAND/GEN
TIER
nateglinide tab 60 mg
generic
repaglinide tab 0.5 mg
generic
repaglinide tab 1 mg
generic
repaglinide tab 2 mg
generic
*Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors**

INVOKANA TAB 100 MG
canagliflozin
BRAND
PA
INVOKANA TAB 300 MG

canagliflozin
BRAND
PA
chlorpropamide tab 100 mg
generic
chlorpropamide tab 250 mg
generic
glimepiride tab 1 mg
generic
generic
generic
glipizide er tab er 24h 10 mg
generic
glipizide er tab er 24h 2.5 mg
generic
glipizide er tab er 24h 5 mg
generic
glipizide tab 10 mg
generic
glipizide tab 5 mg
generic
glipizide xl tab er 24h 10 mg
generic
glipizide xl tab er 24h 2.5 mg
generic
glipizide xl tab er 24h 5 mg
generic
glyburide tab 1.25 mg
generic
glyburide tab 2.5 mg
generic
glyburide tab 5 mg
generic
tolazamide tab 250 mg
generic
tolazamide tab 500 mg
generic
tolbutamide tab 500 mg
generic
diphenatol tab 2.5-0.025 mg
generic
diphenoxylate-atropine liquid 2.5-0.025 mg/5ml
generic
*Sulfonylureas**
*ANTIDIARRHEALS*
*Antiperistaltic Agents**
PAGE 54
PRODUCT DESCRIPTION
BRAND/GEN
TIER
diphenoxylate-atropine tab 2.5-0.025 mg
generic
loperamide hcl cap 2 mg
generic
loperamide hcl tab 2 mg
generic
MOTOFEN TAB 1-0.025 MG

difenoxin w/ atropine
BRAND
CHEMET CAP 100 MG

succimer
BRAND
EXJADE TAB SOL 125 MG

deferasirox
BRAND
PA

deferasirox
BRAND
PA

deferasirox
BRAND
PA
FERRIPROX TAB 500 MG

deferiprone
BRAND
deferoxamine mesylate recon soln 2 gm
generic
PA
deferoxamine mesylate recon soln 500 mg
generic
PA
depade tab 50 mg
generic
naloxone hcl solution 0.4 mg/ml
generic
naltrexone hcl tab 50 mg
generic
VIVITROL RECON SUSP 380 MG

naltrexone
BRAND
PA
ALOXI SOLUTION 0.25 MG/5ML

palonosetron hcl
BRAND
PA
ANZEMET SOLUTION 20 MG/ML

dolasetron mesylate
BRAND
PA
ANZEMET TAB 100 MG

dolasetron mesylate
BRAND
PA
ANZEMET TAB 50 MG
dolasetron mesylate
BRAND
PA
PA
*ANTIDOTES*
*Antidotes - Chelating Agents**
*Antidotes**
*Opioid Antagonists**
PA
*ANTIEMETICS*
*5-HT3 Receptor Antagonists**
PAGE 55
PRODUCT DESCRIPTION
BRAND/GEN
TIER
granisetron hcl tab 1 mg
generic
ondansetron hcl solution 4 mg/2ml
generic
generic
generic
PA
ondansetron hcl tab 24 mg
generic
QL
30 / 30 days
generic
QL
90 / 30 days
generic
QL
90 / 30 days
ondansetron hcl-dextrose solution 32 mg/50ml
generic
PA
ONDANSETRON HCL-DEXTROSE
SOLUTION 32 MG/50ML
ondansetron hcl and dextrose
BRAND
PA
ONDANSETRON HCL-NACL SOLUTION 32

MG/50ML
ondansetron hcl and sodium chloride
BRAND
PA
ondansetron tab disp 4 mg
generic
QL
90 / 30 days
ondansetron tab disp 8 mg
generic
QL
90 / 30 days
meclizine hcl tab 12.5 mg
generic
meclizine hcl tab 25 mg
generic
TRANSDERM-SCOP PATCH 72HR 1.5 MG

scopolamine
BRAND
trimethobenzamide hcl cap 300 mg
generic
trimethobenzamide hcl solution 100 mg/ml
generic
PA
CESAMET CAP 1 MG
nabilone
BRAND
PA
dronabinol cap 10 mg
generic
dronabinol cap 2.5 mg
generic
dronabinol cap 5 mg
generic
PA
*Antiemetics - Anticholinergic**
*Antiemetics - Miscellaneous**
*Substance P/Neurokinin 1 (NK1) Receptor Antagonists**

EMEND CAP 125 MG
aprepitant
BRAND
MFL
1 / 30 days
EMEND CAP 40 MG
BRAND
MFL
1 / 30 days
PAGE 56
PRODUCT DESCRIPTION
BRAND/GEN
TIER
aprepitant
EMEND CAP 80 & 125 MG
aprepitant
BRAND
MFL
1 / 30 days
EMEND CAP 80 MG
aprepitant
BRAND
MFL
1 / 30 days
EMEND RECON SOLN 115 MG

fosaprepitant dimeglumine
BRAND
PA
EMEND RECON SOLN 150 MG

fosaprepitant dimeglumine
BRAND
PA
*ANTIFUNGALS*
*Antifungal - Glucan Synthesis Inhibitors (Echinocandins)**
CANCIDAS RECON SOLN 50 MG
caspofungin acetate
BRAND
PA
CANCIDAS RECON SOLN 70 MG

caspofungin acetate
BRAND
PA
MYCAMINE RECON SOLN 100 MG

micafungin sodium
BRAND
PA
MYCAMINE RECON SOLN 50 MG

micafungin sodium
BRAND
PA
ABELCET SUSPENSION 5 MG/ML

amphotericin b lipid
BRAND
PA
AMBISOME RECON SUSP 50 MG

amphotericin b liposome
BRAND
PA
AMPHOTEC RECON SUSP 100 MG

amphotericin b cholesteryl sulfate complex
BRAND
PA
AMPHOTEC RECON SUSP 50 MG

amphotericin b cholesteryl sulfate complex
BRAND
PA
amphotericin b recon soln 50 mg
generic
PA
AMPHOTERICIN B RECON SOLN 50 MG

amphotericin b
BRAND
PA
ANCOBON CAP 250 MG

flucytosine
BRAND
ANCOBON CAP 500 MG

flucytosine
BRAND
flucytosine cap 250 mg
generic
flucytosine cap 500 mg
generic
GRIFULVIN V TAB 500 MG
BRAND
*Antifungals**
PAGE 57
PRODUCT DESCRIPTION
BRAND/GEN
TIER
griseofulvin microsize
griseofulvin microsize suspension 125 mg/5ml
generic
griseofulvin microsize tab 500 mg
generic
griseofulvin ultramicrosize tab 125 mg
generic
griseofulvin ultramicrosize tab 250 mg
generic
nystatin tab 500000 unit
generic
terbinafine hcl tab 250 mg
generic
fluconazole in dextrose 200 mg/100ml
generic
PA
fluconazole in dextrose 400 mg/200ml
generic
PA
fluconazole in dextrose solution 200 mg/100ml
generic
PA
fluconazole in dextrose solution 400 mg/200ml
generic
PA
fluconazole in sodium chloride solution 100-0.9

mg/50ml-%
generic
PA

mg/100ml-%
generic
PA

mg/200ml-%
generic
PA
fluconazole recon susp 10 mg/ml
generic
fluconazole recon susp 40 mg/ml
generic
fluconazole tab 100 mg
generic
generic
generic
generic
itraconazole cap 100 mg
generic
ketoconazole tab 200 mg
generic
NOXAFIL SOLUTION 300 MG/16.7ML

posaconazole
BRAND
NOXAFIL SUSPENSION 40 MG/ML

posaconazole
BRAND
NOXAFIL TAB DR 100 MG

posaconazole
BRAND
SPORANOX SOLUTION 10 MG/ML

itraconazole
BRAND
*Imidazole-Related Antifungals**
PAGE 58
PA
PA
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
voriconazole recon soln 200 mg
generic
voriconazole recon susp 40 mg/ml
generic
voriconazole tab 200 mg
generic
voriconazole tab 50 mg
generic
arbinoxa solution 4 mg/5ml
generic
arbinoxa tab 4 mg
generic
clemastine fumarate tab 2.68 mg
generic
diphenhydramine hcl cap 50 mg
generic
diphenhydramine hcl solution 50 mg/ml
generic
desloratadine tab 5 mg
generic
desloratadine tab disp 2.5 mg
generic
desloratadine tab disp 5 mg
generic
levocetirizine dihydrochloride solution 2.5

mg/5ml
generic
levocetirizine dihydrochloride tab 5 mg
generic
phenadoz suppos 12.5 mg
generic
phenadoz suppos 25 mg
generic
promethazine hcl 12.5 mg
generic
promethazine hcl 50 mg
generic
promethazine hcl solution 25 mg/ml
generic
PA
promethazine hcl solution 50 mg/ml
generic
PA
promethazine hcl solution 6.25 mg/5ml
generic
promethazine hcl suppos 12.5 mg
generic
promethazine hcl suppos 25 mg
generic
promethazine hcl syrup 6.25 mg/5ml
generic
promethazine hcl tab 12.5 mg
generic
promethazine hcl tab 25 mg
generic
PA
*ANTIHISTAMINES*
*Antihistamines - Ethanolamines**
PA
*Antihistamines - Non-Sedating**
QL
30 / 30 days
*Antihistamines - Phenothiazines**
PAGE 59
PRODUCT DESCRIPTION
BRAND/GEN
TIER
promethazine hcl tab 50 mg
generic
promethegan suppos 12.5 mg
generic
promethegan suppos 25 mg
generic
promethegan suppos 50 mg
generic
cyproheptadine hcl syrup 2 mg/5ml
generic
cyproheptadine hcl tab 4 mg
generic
VYTORIN TAB 10-10 MG

ezetimibe-simvastatin
BRAND
ST

BRAND
ST

BRAND
ST

BRAND
ST
BRAND
PA
cholestyramine light packet 4 gm
generic
cholestyramine light powder 4 gm/dose
generic
cholestyramine packet 4 gm
generic
colestipol hcl granules 5 gm
generic
colestipol hcl packet 5 gm
generic
colestipol hcl tab 1 gm
generic
micronized colestipol hcl tab 1 gm
generic
prevalite packet 4 gm
generic
prevalite powder 4 gm/dose
generic
WELCHOL PACKET 3.75 GM

colesevelam hcl
BRAND
WELCHOL TAB 625 MG

colesevelam hcl
BRAND
*Antihistamines - Piperidines**
*ANTIHYPERLIPIDEMICS*
*Antihyperlipidemics - Combinations**
*Antihyperlipidemics - Misc.**
KYNAMRO SOLN PRSYR 200 MG/ML
mipomersen sodium
*Bile Acid Sequestrants**
*Fibric Acid Derivatives**
PAGE 60
PRODUCT DESCRIPTION
BRAND/GEN
TIER
fenofibrate micronized cap 130 mg
generic
generic
generic
generic
generic
fenofibrate tab 145 mg
generic
generic
generic
generic
fenofibric acid cap dr 135 mg
generic
fenofibric acid cap dr 45 mg
generic
fenofibric acid tab 105 mg
generic
fenofibric acid tab 35 mg
generic
gemfibrozil tab 600 mg
generic
ADVICOR TAB ER 24H 1000-20 MG

niacin-lovastatin
BRAND

niacin-lovastatin
BRAND

niacin-lovastatin
BRAND

niacin-lovastatin
BRAND
atorvastatin calcium tab 10 mg
generic
generic
generic
generic
CRESTOR TAB 10 MG
rosuvastatin calcium
BRAND
ST
CRESTOR TAB 20 MG
BRAND
ST
CRESTOR TAB 40 MG
BRAND
ST
CRESTOR TAB 5 MG
BRAND
ST
*HMG CoA Reductase Inhibitors**
PAGE 61
PRODUCT DESCRIPTION
BRAND/GEN
fluvastatin sodium cap 20 mg
generic
fluvastatin sodium cap 40 mg
generic
LESCOL XL TAB ER 24H 80 MG

fluvastatin sodium
BRAND
LIPITOR TAB 10 MG
atorvastatin calcium
BRAND
PA
LIPITOR TAB 20 MG
BRAND
PA
LIPITOR TAB 40 MG
BRAND
PA
LIPITOR TAB 80 MG
BRAND
PA
LIVALO TAB 1 MG
pitavastatin calcium
BRAND
ST
LIVALO TAB 2 MG
BRAND
ST
LIVALO TAB 4 MG
BRAND
ST
lovastatin tab 10 mg
generic
generic
generic
pravastatin sodium tab 10 mg
generic
generic
generic
generic
SIMCOR TAB ER 24H 1000-20 MG

niacin-simvastatin
BRAND

niacin-simvastatin
BRAND

niacin-simvastatin
BRAND

niacin-simvastatin
BRAND

niacin-simvastatin
BRAND
simvastatin 10 mg
generic
simvastatin 20 mg
generic
simvastatin 40 mg
generic
PAGE 62
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
simvastatin 5 mg
generic
simvastatin 80 mg
generic
simvastatin tab 10 mg
generic
generic
generic
generic
generic
BRAND
*Intestinal Cholesterol Absorption Inhibitors**

ZETIA TAB 10 MG
ezetimibe
ST
*Microsomal Triglyceride Transfer Protein (MTP) Inhibitors**

JUXTAPID CAP 10 MG
lomitapide mesylate
BRAND
JUXTAPID CAP 20 MG
lomitapide mesylate
BRAND
JUXTAPID CAP 5 MG
lomitapide mesylate
BRAND
niacin er (antihyperlipidemic) tab er 1000 mg
generic
generic
generic
benazepril hcl tab 10 mg
generic
generic
generic
generic
captopril tab 100 mg
generic
captopril tab 12.5 mg
generic
captopril tab 25 mg
generic
captopril tab 50 mg
generic
enalapril maleate 10 mg
generic
enalapril maleate 5 mg
generic
*Nicotinic Acid Derivatives**
*ANTIHYPERTENSIVES*
*ACE Inhibitors**
PAGE 63
PRODUCT DESCRIPTION
BRAND/GEN
TIER
enalapril maleate tab 10 mg
generic
enalapril maleate tab 2.5 mg
generic
generic
generic
fosinopril sodium 10 mg
generic
generic
generic
fosinopril sodium tab 10 mg
generic
generic
generic
lisinopril 2.5 mg
generic
lisinopril 20 mg
generic
lisinopril 40 mg
generic
lisinopril 5 mg
generic
lisinopril tab 10 mg
generic
lisinopril tab 2.5 mg
generic
generic
generic
generic
lisinopril tab 5 mg
generic
moexipril hcl tab 15 mg
generic
moexipril hcl tab 7.5 mg
generic
perindopril erbumine tab 2 mg
generic
generic
generic
quinapril hcl tab 10 mg
generic
generic
generic
generic
ramipril cap 1.25 mg
generic
ramipril cap 10 mg
generic
ramipril cap 2.5 mg
generic
PAGE 64
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ramipril cap 5 mg
generic
trandolapril tab 1 mg
generic
generic
generic
BRAND
BENICAR TAB 20 MG
olmesartan medoxomil
BRAND
ST
BENICAR TAB 40 MG
BRAND
ST
BENICAR TAB 5 MG
BRAND
ST
candesartan cilexetil tab 16 mg
generic
generic
generic
generic
EDARBI TAB 40 MG
azilsartan medoxomil
BRAND
ST
EDARBI TAB 80 MG
azilsartan medoxomil
BRAND
ST
irbesartan tab 150 mg
generic
generic
generic
losartan potassium tab 100 mg
generic
generic
generic
telmisartan tab 20 mg
generic
generic
generic
TEVETEN TAB 400 MG

eprosartan mesylate
BRAND
generic
*Agents for Pheochromocytoma**

DIBENZYLINE CAP 10 MG
phenoxybenzamine hcl
*Angiotensin II Receptor Antagonists**
*Antiadrenergic Antihypertensives**
clonidine hcl patch wk 0.1 mg/24hr
PAGE 65
ST
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
ST
generic
ST
clonidine hcl tab 0.1 mg
generic
generic
generic
doxazosin mesylate tab 1 mg
generic
generic
generic
generic
guanfacine hcl tab 1 mg
generic
guanfacine hcl tab 2 mg
generic
methyldopa tab 250 mg
generic
methyldopa tab 500 mg
generic
prazosin hcl cap 1 mg
generic
generic
generic
terazosin hcl cap 1 mg
generic
generic
generic
generic
amlodipine besy-benazepril hcl cap 10-20 mg
generic
generic
amlodipine besy-benazepril hcl cap 2.5-10 mg
generic
generic
generic
generic
atenolol-chlorthalidone tab 100-25 mg
generic
atenolol-chlorthalidone tab 50-25 mg
generic
benazepril-hydrochlorothiazide tab 10-12.5 mg
generic
generic
benazepril-hydrochlorothiazide tab 20-25 mg
generic
*Antihypertensive Combinations**
PAGE 66
PRODUCT DESCRIPTION
BRAND/GEN
generic
BENICAR HCT TAB 20-12.5 MG

olmesartan medoxomil-hydrochlorothiazide
BRAND
ST
BENICAR HCT TAB 40-12.5 MG

BRAND
ST
BENICAR HCT TAB 40-25 MG

BRAND
ST
bisoprolol-hydrochlorothiazide tab 10-6.25 mg
generic
bisoprolol-hydrochlorothiazide tab 2.5-6.25 mg
generic
bisoprolol-hydrochlorothiazide tab 5-6.25 mg
generic
candesartan cilexetil-hctz tab 16-12.5 mg
generic
candesartan cilexetil-hctz tab 32-12.5 mg
generic
candesartan cilexetil-hctz tab 32-25 mg
generic
captopril-hydrochlorothiazide tab 25-15 mg
generic
generic
generic
generic
DUTOPROL TAB ER 24H 100-12.5 MG

metoprolol & hydrochlorothiazide
BRAND

BRAND

BRAND
enalapril-hydrochlorothiazide tab 10-25 mg
generic
enalapril-hydrochlorothiazide tab 5-12.5 mg
generic
fosinopril sodium-hctz tab 10-12.5 mg
generic
fosinopril sodium-hctz tab 20-12.5 mg
generic
irbesartan-hydrochlorothiazide tab 150-12.5 mg
generic
irbesartan-hydrochlorothiazide tab 300-12.5 mg
generic
lisinopril-hydrochlorothiazide 10-12.5 mg
generic
lisinopril-hydrochlorothiazide 20-12.5 mg
generic
lisinopril-hydrochlorothiazide 20-25 mg
generic
lisinopril-hydrochlorothiazide tab 10-12.5 mg
generic
lisinopril-hydrochlorothiazide tab 20-12.5 mg
generic
lisinopril-hydrochlorothiazide tab 20-25 mg
generic
PAGE 67
TIER
PRODUCT DESCRIPTION
BRAND/GEN
losartan potassium-hctz tab 100-12.5 mg
generic
losartan potassium-hctz tab 100-25 mg
generic
losartan potassium-hctz tab 50-12.5 mg
generic
methyldopa-hydrochlorothiazide tab 250-15 mg
generic
methyldopa-hydrochlorothiazide tab 250-25 mg
generic
metoprolol-hydrochlorothiazide tab 100-25 mg
generic
generic
generic
moexipril-hydrochlorothiazide tab 15-12.5 mg
generic
moexipril-hydrochlorothiazide tab 15-25 mg
generic
moexipril-hydrochlorothiazide tab 7.5-12.5 mg
generic
propranolol-hctz tab 40-25 mg
generic
propranolol-hctz tab 80-25 mg
generic
quinapril-hydrochlorothiazide tab 10-12.5 mg
generic
quinapril-hydrochlorothiazide tab 20-12.5 mg
generic
quinapril-hydrochlorothiazide tab 20-25 mg
generic
TEKTURNA HCT TAB 150-12.5 MG

aliskiren-hydrochlorothiazide
BRAND
ST
TEKTURNA HCT TAB 150-25 MG

BRAND
ST
TEKTURNA HCT TAB 300-12.5 MG

BRAND
ST
TEKTURNA HCT TAB 300-25 MG

BRAND
ST
telmisartan-amlodipine tab 40-10 mg
generic
generic
generic
generic
telmisartan-hctz tab 40-12.5 mg
generic
telmisartan-hctz tab 80-12.5 mg
generic
telmisartan-hctz tab 80-25 mg
generic
valsartan-hydrochlorothiazide tab 160-12.5 mg
generic
valsartan-hydrochlorothiazide tab 160-25 mg
generic
generic
PAGE 68
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
valsartan-hydrochlorothiazide tab 320-25 mg
generic
generic
TEKTURNA TAB 150 MG

aliskiren fumarate
BRAND
ST
TEKTURNA TAB 300 MG

aliskiren fumarate
BRAND
ST
*Direct Renin Inhibitors**
*Selective Aldosterone Receptor Antagonists (SARAs)**

eplerenone tab 25 mg
generic
eplerenone tab 50 mg
generic
hydralazine hcl tab 10 mg
generic
generic
generic
generic
minoxidil tab 10 mg
generic
minoxidil tab 2.5 mg
generic
atovaquone-proguanil hcl tab 250-100 mg
generic
atovaquone-proguanil hcl tab 62.5-25 mg
generic
COARTEM TAB 20-120 MG

artemether-lumefantrine
BRAND
chloroquine phosphate tab 250 mg
generic
chloroquine phosphate tab 500 mg
generic
DARAPRIM TAB 25 MG
pyrimethamine
BRAND
hydroxychloroquine sulfate tab 200 mg
generic
mefloquine hcl tab 250 mg
generic
primaquine phosphate tab 26.3 mg
generic
quinine sulfate cap 324 mg
generic
*Vasodilators**
*ANTIMALARIALS*
*Antimalarial Combinations**
*Antimalarials**
*ANTIMYASTHENIC/CHOLINERGIC AGENTS*
PAGE 69
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Antimyasthenic/Cholinergic Agents**
GUANIDINE HCL TAB 125 MG
guanidine hcl
BRAND
MESTINON SYRUP 60 MG/5ML

pyridostigmine bromide
BRAND
MESTINON TAB ER 180 MG

BRAND
MYTELASE TAB 10 MG
ambenonium chloride
BRAND
pyridostigmine bromide tab 60 mg
generic
REGONOL SOLUTION 5 MG/ML

BRAND
isonarif cap 150-300 mg
generic
RIFAMATE CAP 150-300 MG

isoniazid & rifampin
BRAND
RIFATER TAB 50-120-300 MG

isoniazid-rifampin w/ pyrazinamide
BRAND
CAPASTAT SULFATE RECON SOLN 1 GM

capreomycin sulfate
BRAND
CYCLOSERINE CAP 250 MG

cycloserine
BRAND
ethambutol hcl tab 100 mg
generic
ethambutol hcl tab 400 mg
generic
isoniazid solution 100 mg/ml
generic
ISONIAZID SYRUP 50 MG/5ML

isoniazid
BRAND
isoniazid tab 100 mg
generic
isoniazid tab 300 mg
generic
MYCOBUTIN CAP 150 MG

rifabutin
BRAND
PASER PACKET 4 GM
aminosalicylic acid
BRAND
PRIFTIN TAB 150 MG

rifapentine
BRAND
PA
*ANTIMYCOBACTERIAL AGENTS*
*Anti TB Combinations**
*Antimycobacterial Agents**
PAGE 70
PA
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
pyrazinamide tab 500 mg
generic
rifabutin cap 150 mg
generic
rifampin cap 150 mg
generic
rifampin cap 300 mg
generic
rifampin recon soln 600 mg
generic
PA
SEROMYCIN CAP 250 MG

cycloserine
BRAND
PA
TRECATOR TAB 250 MG

ethionamide
BRAND
*ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES*

*Alkylating Agents**
ALKERAN TAB 2 MG
melphalan
BRAND
BICNU RECON SOLN 100 MG

carmustine
BRAND
PA
BUSULFEX SOLUTION 6 MG/ML

busulfan
BRAND
PA
carboplatin recon soln 150 mg
generic
PA
generic
PA
generic
PA
carboplatin solution 150 mg/15ml
generic
PA
generic
PA
generic
PA
generic
PA
CEENU CAP 10 MG
lomustine
BRAND
CEENU CAP 100 MG

lomustine
BRAND
CEENU CAP 40 MG
lomustine
BRAND
cisplatin solution 100 mg/100ml
generic
PA
generic
PA
generic
PA
PAGE 71
PRODUCT DESCRIPTION
BRAND/GEN
cyclophosphamide cap 25 mg
generic
PA
cyclophosphamide cap 50 mg
generic
PA
CYCLOPHOSPHAMIDE RECON SOLN 1 GM

cyclophosphamide
BRAND
PA
CYCLOPHOSPHAMIDE RECON SOLN 2 GM

cyclophosphamide
BRAND
PA
CYCLOPHOSPHAMIDE RECON SOLN 500

MG
cyclophosphamide
BRAND
PA
cyclophosphamide tab 25 mg
generic
PA
cyclophosphamide tab 50 mg
generic
PA
ELOXATIN SOLUTION 100 MG/20ML

oxaliplatin
BRAND

oxaliplatin
BRAND

oxaliplatin
BRAND
GLIADEL WAFER WAFER 7.7 MG

carmustine in polifeprosan
BRAND
PA
HEXALEN CAP 50 MG
altretamine
BRAND
PA
IFEX RECON SOLN 1 GM

ifosfamide
BRAND
IFEX RECON SOLN 3 GM

ifosfamide
BRAND
PA
ifosfamide recon soln 1 gm
generic
PA
IFOSFAMIDE RECON SOLN 3 GM

ifosfamide
BRAND
PA
ifosfamide solution 1 gm/20ml
generic
PA
ifosfamide solution 3 gm/60ml
generic
PA
LEUKERAN TAB 2 MG
chlorambucil
BRAND
PA
lomustine cap 10 mg
generic
PA
lomustine cap 100 mg
generic
PA
lomustine cap 40 mg
generic
PA
melphalan hcl recon soln 50 mg
generic
PA
PAGE 72
TIER
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
MUSTARGEN RECON SOLN 10 MG

mechlorethamine hcl
BRAND
PA
MYLERAN TAB 2 MG
busulfan
BRAND
PA
oxaliplatin recon soln 100 mg
generic
PA
oxaliplatin recon soln 50 mg
generic
PA
oxaliplatin solution 100 mg/20ml
generic
PA
oxaliplatin solution 50 mg/10ml
generic
PA
temozolomide cap 100 mg
generic
PA
generic
PA
generic
PA
generic
PA
generic
PA
generic
PA
thiotepa recon soln 15 mg
generic
PA
TREANDA RECON SOLN 100 MG

bendamustine hcl
BRAND
PA
TREANDA RECON SOLN 25 MG

bendamustine hcl
BRAND
PA
ZANOSAR RECON SOLN 1 GM

streptozocin
BRAND
PA
adrucil solution 2.5 gm/50ml
generic
PA
adrucil solution 5 gm/100ml
generic
PA
adrucil solution 500 mg/10ml
generic
PA
ALIMTA RECON SOLN 100 MG

pemetrexed disodium
BRAND
PA
ALIMTA RECON SOLN 500 MG

pemetrexed disodium
BRAND
PA
ARRANON SOLUTION 5 MG/ML

nelarabine
BRAND
PA
PA
*Antimetabolites**
PAGE 73
PRODUCT DESCRIPTION
BRAND/GEN
TIER
azacitidine recon susp 100 mg
generic
capecitabine tab 150 mg
generic
PA
capecitabine tab 500 mg
generic
PA
cladribine solution 1 mg/ml
generic
PA
CLOLAR SOLUTION 1 MG/ML

clofarabine
BRAND
PA
cytarabine (pf) solution 20 mg/ml
generic
PA
cytarabine recon soln 1 gm
generic
PA
cytarabine recon soln 100 mg
generic
PA
cytarabine recon soln 2 gm
generic
PA
cytarabine recon soln 500 mg
generic
PA
cytarabine solution 20 mg/ml
generic
PA
DACOGEN RECON SOLN 50 MG

decitabine
BRAND
decitabine recon soln 50 mg
generic
PA
DEPOCYT SUSPENSION 50 MG/5ML

cytarabine liposome
BRAND
PA
floxuridine recon soln 0.5 gm
generic
PA
fludarabine phosphate solution 50 mg/2ml
generic
PA
fluorouracil solution 1 gm/20ml
generic
PA
fluorouracil solution 2.5 gm/50ml
generic
PA
fluorouracil solution 5 gm/100ml
generic
PA
fluorouracil solution 500 mg/10ml
generic
PA
FOLOTYN SOLUTION 20 MG/ML

pralatrexate
BRAND
PA
FOLOTYN SOLUTION 40 MG/2ML

pralatrexate
BRAND
PA
gemcitabine hcl recon soln 1 gm
generic
PA
gemcitabine hcl recon soln 2 gm
generic
PA
gemcitabine hcl recon soln 200 mg
generic
PA
PAGE 74
PRODUCT DESCRIPTION
BRAND/GEN
GEMCITABINE HCL SOLUTION 1 GM/26.3ML

gemcitabine hcl
BRAND
GEMCITABINE HCL SOLUTION 2 GM/52.6ML

gemcitabine hcl
BRAND
PA
GEMCITABINE HCL SOLUTION 200

MG/5.26ML
gemcitabine hcl
BRAND
PA
LEUSTATIN SOLUTION 1 MG/ML

cladribine
BRAND
mercaptopurine tab 50 mg
generic
methotrexate sodium (pf) solution 1 gm/40ml
generic
PA
methotrexate sodium (pf) solution 100 mg/4ml
generic
PA
generic
PA
methotrexate sodium (pf) solution 25 mg/ml
generic
PA
generic
PA
generic
PA
methotrexate sodium recon soln 1 gm
generic
PA
methotrexate sodium solution 25 mg/ml
generic
PA
methotrexate tab 2.5 mg
generic
OFORTA TAB 10 MG
fludarabine phosphate
BRAND
PA
TABLOID TAB 40 MG
thioguanine
BRAND
PA
TREXALL TAB 10 MG
methotrexate sodium
BRAND
TREXALL TAB 15 MG
methotrexate sodium
BRAND
TREXALL TAB 5 MG
methotrexate sodium
BRAND
TREXALL TAB 7.5 MG

methotrexate sodium
BRAND
VIDAZA RECON SUSP 100 MG

azacitidine
BRAND
PA
XELODA TAB 150 MG

capecitabine
BRAND
PA
XELODA TAB 500 MG
BRAND
PA
PAGE 75
TIER

PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
capecitabine
*Antineoplastic - Angiogenesis Inhibitors**
AVASTIN SOLUTION 100 MG/4ML
bevacizumab
BRAND
PA
AVASTIN SOLUTION 400 MG/16ML

bevacizumab
BRAND
PA
CYRAMZA SOLUTION 100 MG/10ML

ramucirumab
BRAND
CYRAMZA SOLUTION 500 MG/50ML

ramucirumab
BRAND
ZALTRAP SOLUTION 100 MG/4ML

ziv-aflibercept
BRAND
PA
ZALTRAP SOLUTION 200 MG/8ML

ziv-aflibercept
BRAND
PA
ADCETRIS RECON SOLN 50 MG

brentuximab vedotin
BRAND
PA
ARZERRA CONC 100 MG/5ML

ofatumumab
BRAND
PA
ARZERRA CONC 1000 MG/50ML

ofatumumab
BRAND
PA
BEXXAR CONC 14 MG/ML

tositumomab
BRAND
PA
CAMPATH SOLUTION 30 MG/ML

alemtuzumab
BRAND
PA
ERBITUX SOLUTION 100 MG/50ML

cetuximab
BRAND
PA
ERBITUX SOLUTION 200 MG/100ML

cetuximab
BRAND
PA
HERCEPTIN RECON SOLN 440 MG

trastuzumab
BRAND
PA
PERJETA SOLUTION 420 MG/14ML

pertuzumab
BRAND
PA
RITUXAN CONC 10 MG/ML

rituximab
BRAND
PA
VECTIBIX SOLUTION 100 MG/5ML

panitumumab
BRAND
PA
VECTIBIX SOLUTION 400 MG/20ML

panitumumab
BRAND
PA
*Antineoplastic - Antibodies**
PAGE 76
PRODUCT DESCRIPTION
BRAND/GEN
TIER
YERVOY SOLUTION 200 MG/40ML

ipilimumab
BRAND
YERVOY SOLUTION 50 MG/10ML

ipilimumab
BRAND
PA
BRAND
PA
anastrozole tab 1 mg
generic
bicalutamide tab 50 mg
generic
ELIGARD KIT 22.5 MG

leuprolide acetate (3 month)
BRAND
PA
ELIGARD KIT 30 MG
BRAND
PA
ELIGARD KIT 45 MG
BRAND
PA
ELIGARD KIT 7.5 MG

leuprolide acetate
BRAND
PA
EMCYT CAP 140 MG

estramustine phosphate sodium
BRAND
PA
exemestane tab 25 mg
generic
FARESTON TAB 60 MG
toremifene citrate
BRAND
PA
FASLODEX SOLUTION 250 MG/5ML

fulvestrant
BRAND
PA
FIRMAGON RECON SOLN 120 MG

degarelix acetate
BRAND
FIRMAGON RECON SOLN 80 MG

degarelix acetate
BRAND
flutamide cap 125 mg
generic
letrozole tab 2.5 mg
generic
leuprolide acetate kit 1 mg/0.2ml
generic
PA
LUPRON DEPOT KIT 11.25 MG

BRAND
PA

BRAND
PA

leuprolide acetate
BRAND
PA
PA
*Antineoplastic - Hedgehog Pathway Inhibitors**

ERIVEDGE CAP 150 MG
vismodegib
*Antineoplastic - Hormonal and Related Agents**
PAGE 77
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
LUPRON DEPOT KIT 30 MG

BRAND
PA
LUPRON DEPOT KIT 45 MG

BRAND
PA

leuprolide acetate
BRAND
PA
LYSODREN TAB 500 MG

mitotane
BRAND
PA
megestrol acetate suspension 40 mg/ml
generic
megestrol acetate suspension 400 mg/10ml
generic
megestrol acetate suspension 800 mg/20ml
generic
megestrol acetate tab 20 mg
generic
megestrol acetate tab 40 mg
generic
NILANDRON TAB 150 MG

nilutamide
BRAND
QL
60 / 30 days
PA
SOLTAMOX SOLUTION 10 MG/5ML

tamoxifen citrate
BRAND
GL
Female
AL
40 to 999 yrs old
tamoxifen citrate tab 10 mg
generic
tamoxifen citrate tab 20 mg
generic
TRELSTAR DEPOT MIXJECT RECON SUSP

3.75 MG
triptorelin pamoate
BRAND
PA
TRELSTAR DEPOT RECON SUSP 3.75 MG

triptorelin pamoate
BRAND
PA
TRELSTAR LA MIXJECT RECON SUSP 11.25

MG
triptorelin pamoate
BRAND
PA
TRELSTAR LA RECON SUSP 11.25 MG

triptorelin pamoate
BRAND
PA
TRELSTAR MIXJECT RECON SUSP 22.5 MG

triptorelin pamoate
BRAND
PA
VANTAS KIT 50 MG
histrelin acetate
BRAND
PA
XTANDI CAP 40 MG
enzalutamide
BRAND
PA
ZOLADEX IMPLANT 10.8 MG

goserelin acetate
BRAND
PA
PAGE 78
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ZOLADEX IMPLANT 3.6 MG

goserelin acetate
BRAND
ZYTIGA TAB 250 MG

abiraterone acetate
BRAND
PA
POMALYST CAP 1 MG
pomalidomide
BRAND
PA
POMALYST CAP 2 MG
pomalidomide
BRAND
PA
POMALYST CAP 3 MG
pomalidomide
BRAND
PA
POMALYST CAP 4 MG
pomalidomide
BRAND
PA
adriamycin recon soln 10 mg
generic
PA
ADRIAMYCIN RECON SOLN 20 MG

doxorubicin hcl
BRAND
PA
adriamycin recon soln 50 mg
generic
PA
adriamycin solution 2 mg/ml
generic
PA
CERUBIDINE RECON SOLN 20 MG

daunorubicin hcl
BRAND
COSMEGEN RECON SOLN 0.5 MG

dactinomycin
BRAND
PA
dactinomycin recon soln 0.5 mg
generic
PA
daunorubicin hcl injectable 5 mg/ml
generic
PA
daunorubicin hcl recon soln 20 mg
generic
PA
DAUNOXOME INJECTABLE 2 MG/ML

daunorubicin citrate liposome
BRAND
PA
DOXIL INJECTABLE 2 MG/ML

doxorubicin hcl liposomal
BRAND
PA
doxorubicin hcl liposomal injectable 2 mg/ml
generic
PA
doxorubicin hcl recon soln 10 mg
generic
PA
doxorubicin hcl recon soln 50 mg
generic
PA
doxorubicin hcl solution 2 mg/ml
generic
PA
ELLENCE SOLUTION 200 MG/100ML
BRAND
PA
*Antineoplastic - Immunomodulators**
*Antineoplastic Antibiotics**
PAGE 79
PRODUCT DESCRIPTION
BRAND/GEN
TIER
epirubicin hcl
ELLENCE SOLUTION 50 MG/25ML
epirubicin hcl
BRAND
EPIRUBICIN HCL RECON SOLN 200 MG

epirubicin hcl
BRAND
PA
EPIRUBICIN HCL RECON SOLN 50 MG

epirubicin hcl
BRAND
PA
epirubicin hcl solution 200 mg/100ml
generic
PA
epirubicin hcl solution 50 mg/25ml
generic
PA
IDAMYCIN PFS SOLUTION 10 MG/10ML

idarubicin hcl
BRAND

idarubicin hcl
BRAND

idarubicin hcl
BRAND
idarubicin hcl solution 10 mg/10ml
generic
PA
generic
PA
generic
PA
lipodox 50 injectable 2 mg/ml
generic
PA
lipodox injectable 2 mg/ml
generic
PA
mitoxantrone hcl conc 20 mg/10ml
generic
PA
mitoxantrone hcl conc 25 mg/12.5ml
generic
PA
mitoxantrone hcl conc 30 mg/15ml
generic
PA
NOVANTRONE CONC 20 MG/10ML

mitoxantrone hcl
BRAND
PA
VALSTAR SOLUTION 40 MG/ML

valrubicin
BRAND
PA
AFINITOR DISPERZ TAB SOL 2 MG

everolimus
BRAND
PA

everolimus
BRAND
PA

everolimus
BRAND
PA
AFINITOR TAB 10 MG
BRAND
PA
*Antineoplastic Enzyme Inhibitors**
PAGE 80
PRODUCT DESCRIPTION
BRAND/GEN
TIER
everolimus
AFINITOR TAB 2.5 MG
everolimus
BRAND
PA
AFINITOR TAB 5 MG
everolimus
BRAND
PA
AFINITOR TAB 7.5 MG

everolimus
BRAND
PA
BOSULIF TAB 100 MG

bosutinib
BRAND
PA
BOSULIF TAB 500 MG

bosutinib
BRAND
PA
CAPRELSA TAB 100 MG

vandetanib
BRAND
PA
CAPRELSA TAB 300 MG

vandetanib
BRAND
PA
COMETRIQ (100 MG DAILY DOSE) KIT 1 X

80 & 1 X 20 MG
cabozantinib s-malate
BRAND
PA
COMETRIQ (140 MG DAILY DOSE) KIT 1 X

80 & 3 X 20 MG
BRAND
PA
COMETRIQ (60 MG DAILY DOSE) KIT 20 MG

BRAND
PA
GILOTRIF TAB 20 MG
afatinib dimaleate
BRAND
GILOTRIF TAB 30 MG
afatinib dimaleate
BRAND
GILOTRIF TAB 40 MG
afatinib dimaleate
BRAND
GLEEVEC TAB 100 MG

imatinib mesylate
BRAND
PA
GLEEVEC TAB 400 MG

imatinib mesylate
BRAND
PA
ICLUSIG TAB 15 MG
ponatinib hcl
BRAND
ICLUSIG TAB 45 MG
ponatinib hcl
BRAND
IMBRUVICA CAP 140 MG

ibrutinib
BRAND
INLYTA TAB 1 MG
axitinib
BRAND
PAGE 81
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
INLYTA TAB 5 MG
axitinib
BRAND
IRESSA TAB 250 MG

gefitinib
BRAND
ISTODAX RECON SOLN 10 MG

romidepsin
BRAND
PA
JAKAFI TAB 10 MG
ruxolitinib phosphate
BRAND
PA
JAKAFI TAB 15 MG
BRAND
PA
JAKAFI TAB 20 MG
BRAND
PA
JAKAFI TAB 25 MG
BRAND
PA
JAKAFI TAB 5 MG
BRAND
PA
KYPROLIS RECON SOLN 60 MG

carfilzomib
BRAND
PA
MEKINIST TAB 0.5 MG

trametinib dimethyl sulfoxide
BRAND
MEKINIST TAB 2 MG
trametinib dimethyl sulfoxide
BRAND
NEXAVAR TAB 200 MG

sorafenib tosylate
BRAND
PA
SPRYCEL TAB 100 MG

dasatinib
BRAND
PA
SPRYCEL TAB 140 MG

dasatinib
BRAND
PA
SPRYCEL TAB 20 MG
dasatinib
BRAND
PA
SPRYCEL TAB 50 MG
dasatinib
BRAND
PA
SPRYCEL TAB 70 MG
dasatinib
BRAND
PA
SPRYCEL TAB 80 MG
dasatinib
BRAND
PA
STIVARGA TAB 40 MG
regorafenib
BRAND
PA
SUTENT CAP 12.5 MG

sunitinib malate
BRAND
PA
PA
PAGE 82
PRODUCT DESCRIPTION
BRAND/GEN
SUTENT CAP 25 MG
sunitinib malate
BRAND
SUTENT CAP 50 MG
sunitinib malate
BRAND
PA
TAFINLAR CAP 50 MG
dabrafenib mesylate
BRAND
PA
TAFINLAR CAP 75 MG
dabrafenib mesylate
BRAND
PA
TARCEVA TAB 100 MG

erlotinib hcl
BRAND
PA
TARCEVA TAB 150 MG

erlotinib hcl
BRAND
PA
TARCEVA TAB 25 MG
erlotinib hcl
BRAND
PA
TASIGNA CAP 150 MG

nilotinib hcl
BRAND
PA
TASIGNA CAP 200 MG

nilotinib hcl
BRAND
PA
TORISEL SOLUTION 25 MG/ML

temsirolimus
BRAND
PA
TYKERB TAB 250 MG

lapatinib ditosylate
BRAND
PA
VANDETANIB TAB 100 MG

vandetanib
BRAND
PA
VANDETANIB TAB 300 MG

vandetanib
BRAND
PA
VELCADE RECON SOLN 3.5 MG

bortezomib
BRAND
PA
VOTRIENT TAB 200 MG

pazopanib hcl
BRAND
PA
XALKORI CAP 200 MG

crizotinib
BRAND
PA
XALKORI CAP 250 MG

crizotinib
BRAND
PA
ZELBORAF TAB 240 MG

vemurafenib
BRAND
PA
ZOLINZA CAP 100 MG

vorinostat
BRAND
PA
ZYKADIA CAP 150 MG

ceritinib
BRAND
PAGE 83
TIER

PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Antineoplastic Enzymes**
ELSPAR RECON SOLN 10000 UNIT
asparaginase
BRAND
ERWINAZE RECON SOLN 10000 UNIT

asparaginase erwinia chrysanthemi
BRAND
ONCASPAR SOLUTION 750 UNIT/ML

pegaspargase
BRAND
ACTIMMUNE SOLUTION 2000000

UNIT/0.5ML
interferon gamma-1b
BRAND
PA
ALFERON N SOLUTION 5000000 UNIT/ML

interferon alfa-n3
BRAND
PA
dacarbazine powder
generic
PA
dacarbazine recon soln 100 mg
generic
PA
dacarbazine recon soln 200 mg
generic
PA
hydroxyurea cap 500 mg
generic
INTRON-A RECON SOLN 10000000 UNIT

interferon alfa-2b
BRAND
PA

interferon alfa-2b
BRAND
PA

interferon alfa-2b
BRAND
PA
INTRON-A SOLUTION 10000000 UNIT/ML

interferon alfa-2b
BRAND
PA
INTRON-A SOLUTION 6000000 UNIT/ML

interferon alfa-2b
BRAND
PA
MATULANE CAP 50 MG
procarbazine hcl
BRAND
PA
NIPENT RECON SOLN 10 MG

pentostatin
BRAND
ONTAK SOLUTION 150 MCG/ML

denileukin diftitox
BRAND
PA
pentostatin recon soln 10 mg
generic
PA
PHOTOFRIN RECON SOLN 75 MG

porfimer sodium
BRAND
PA
PROLEUKIN RECON SOLN 22000000 UNIT

aldesleukin
BRAND
*Antineoplastics Misc.**
PAGE 84
PRODUCT DESCRIPTION
BRAND/GEN
TIER
SYLATRON KIT 296 MCG

peginterferon alfa-2b (antineoplastic)
BRAND
PA
SYLATRON KIT 4 X 296 MCG

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA
SYNRIBO RECON SOLN 3.5 MG

omacetaxine mepesuccinate
BRAND
PA
TARGRETIN CAP 75 MG
bexarotene
BRAND
PA
THERACYS RECON SUSP 81 MG/VIAL

bcg live intravesical
BRAND
PA
tretinoin cap 10 mg
generic
TRISENOX SOLUTION 10 MG/10ML

arsenic trioxide
BRAND
UVADEX SOLUTION 20 MCG/ML

methoxsalen (photopheresis)
BRAND
BRAND
PA
amifostine recon soln 500 mg
generic
PA
calcium folinate solution 100 mg/10ml
generic
PA
calcium folinate solution 300 mg/30ml
generic
PA
dexrazoxane recon soln 250 mg
generic
PA
dexrazoxane recon soln 500 mg
generic
PA
FUSILEV RECON SOLN 50 MG

levoleucovorin calcium
BRAND
leucovorin calcium recon soln 100 mg
generic
PA
generic
PA
PA
*Chemotherapy Adjuncts**
KEPIVANCE RECON SOLN 6.25 MG
palifermin
*Chemotherapy Rescue/Antidote Agents**
PAGE 85
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
PA
generic
PA
generic
PA
leucovorin calcium solution 10 mg/ml
generic
PA
leucovorin calcium tab 10 mg
generic
generic
generic
generic
mesna solution 100 mg/ml
generic
MESNEX SOLUTION 100 MG/ML

mesna
BRAND
MESNEX TAB 400 MG

mesna
BRAND
TOTECT RECON SOLN 500 MG

dexrazoxane
BRAND
VORAXAZE RECON SOLN 1000 UNIT

glucarpidase
BRAND
ABRAXANE RECON SUSP 100 MG

paclitaxel protein-bound particles
BRAND
PA
DOCEFREZ RECON SOLN 20 MG

docetaxel
BRAND
PA
DOCEFREZ RECON SOLN 80 MG

docetaxel
BRAND
PA
DOCETAXEL CONC 140 MG/7ML

docetaxel
BRAND
PA

docetaxel
BRAND
PA
DOCETAXEL CONC 20 MG/0.5ML

docetaxel
BRAND
docetaxel conc 20 mg/ml
generic
PA
DOCETAXEL CONC 20 MG/ML

docetaxel
BRAND
PA
docetaxel conc 80 mg/4ml
generic
PA

docetaxel
BRAND
PA
PA
*Mitotic Inhibitors**
PAGE 86
PRODUCT DESCRIPTION
BRAND/GEN
docetaxel solution 160 mg/16ml
generic
PA
DOCETAXEL SOLUTION 160 MG/16ML

docetaxel
BRAND
PA
generic
PA

docetaxel
BRAND
PA
generic
PA

docetaxel
BRAND
PA
ETOPOPHOS RECON SOLN 100 MG

etoposide phosphate
BRAND
PA
etoposide cap 50 mg
generic
PA
ETOPOSIDE CAP 50 MG
etoposide
BRAND
PA
etoposide solution 1 gm/50ml
generic
PA
etoposide solution 100 mg/5ml
generic
PA
etoposide solution 500 mg/25ml
generic
PA
HALAVEN SOLUTION 1 MG/2ML

eribulin mesylate
BRAND
PA
IXEMPRA KIT RECON SOLN 15 MG

ixabepilone
BRAND
PA
IXEMPRA KIT RECON SOLN 45 MG

ixabepilone
BRAND
PA
JEVTANA SOLUTION 60 MG/1.5ML

cabazitaxel
BRAND
PA
MARQIBO SUSPENSION 5 MG/31ML

vincristine sulfate liposome
BRAND
PA
NAVELBINE SOLUTION 10 MG/ML

vinorelbine tartrate
BRAND
NAVELBINE SOLUTION 50 MG/5ML

vinorelbine tartrate
BRAND
paclitaxel conc 100 mg/16.7ml
generic
PA
paclitaxel conc 150 mg/25ml
generic
PA
generic
PA
generic
PA
PAGE 87
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
TAXOTERE CONC 20 MG/0.5ML

docetaxel
BRAND
TAXOTERE CONC 20 MG/ML

docetaxel
BRAND
PA
TAXOTERE CONC 80 MG/4ML

docetaxel
BRAND
PA
TENIPOSIDE SOLUTION 10 MG/ML

teniposide
BRAND
PA
toposar solution 1 gm/50ml
generic
PA
toposar solution 100 mg/5ml
generic
toposar solution 500 mg/25ml
generic
PA
vinblastine sulfate recon soln 10 mg
generic
PA
vinblastine sulfate solution 1 mg/ml
generic
PA
vincasar pfs solution 1 mg/ml
generic
PA
vincristine sulfate solution 1 mg/ml
generic
PA
vinorelbine tartrate solution 10 mg/ml
generic
PA
vinorelbine tartrate solution 50 mg/5ml
generic
PA
VUMON SOLUTION 10 MG/ML

teniposide
BRAND
PA
CAMPTOSAR SOLUTION 100 MG/5ML

irinotecan hcl
BRAND

irinotecan hcl
BRAND

irinotecan hcl
BRAND
HYCAMTIN CAP 0.25 MG

topotecan hcl
BRAND
PA
HYCAMTIN CAP 1 MG
topotecan hcl
BRAND
PA
HYCAMTIN RECON SOLN 4 MG

topotecan hcl
BRAND
irinotecan hcl solution 100 mg/5ml
generic
PA
irinotecan hcl solution 40 mg/2ml
generic
PA
IRINOTECAN HCL SOLUTION 500 MG/25ML
BRAND
PA
*Topoisomerase I Inhibitors**
PAGE 88
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
irinotecan hcl
topotecan hcl recon soln 4 mg
generic
PA
topotecan hcl solution 4 mg/4ml
generic
PA
TOPOTECAN HCL SOLUTION 4 MG/4ML

topotecan hcl
BRAND
PA
generic
benztropine mesylate solution 1 mg/ml
generic
benztropine mesylate tab 0.5 mg
generic
benztropine mesylate tab 1 mg
generic
benztropine mesylate tab 2 mg
generic
trihexyphenidyl hcl elixir 0.4 mg/ml
generic
trihexyphenidyl hcl tab 2 mg
generic
trihexyphenidyl hcl tab 5 mg
generic
entacapone tab 200 mg
generic
TASMAR TAB 100 MG

tolcapone
BRAND
amantadine hcl cap 100 mg
generic
amantadine hcl syrup 50 mg/5ml
generic
amantadine hcl tab 100 mg
generic
APOKYN SOLUTION 10 MG/ML

apomorphine hydrochloride
BRAND
bromocriptine mesylate cap 5 mg
generic
bromocriptine mesylate tab 2.5 mg
generic
carbidopa-levodopa er tab er 25-100 mg
generic
carbidopa-levodopa er tab er 50-200 mg
generic
carbidopa-levodopa tab 10-100 mg
generic
generic
*ANTIPARKINSON AGENTS*
*Antiparkinson Adjuvants**
carbidopa tab 25 mg
*Antiparkinson Anticholinergics**
*Antiparkinson COMT Inhibitors**
*Antiparkinson Dopaminergics**
PA
PAGE 89
PRODUCT DESCRIPTION
BRAND/GEN
generic
carbidopa-levodopa tab disp 10-100 mg
generic
generic
generic
carbidopa-levodopa-entacapone tab 12.5-50200 mg
generic
generic
carbidopa-levodopa-entacapone tab 25-100200 mg
generic
generic
generic
carbidopa-levodopa-entacapone tab 50-200200 mg
generic
NEUPRO PATCH 24HR 1 MG/24HR

rotigotine
BRAND

rotigotine
BRAND

rotigotine
BRAND

rotigotine
BRAND

rotigotine
BRAND

rotigotine
BRAND
pramipexole dihydrochloride tab 0.125 mg
generic
generic
generic
generic
pramipexole dihydrochloride tab 1 mg
generic
generic
ropinirole hcl tab 0.25 mg
generic
ropinirole hcl tab 0.5 mg
generic
ropinirole hcl tab 1 mg
generic
PAGE 90
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
generic
generic
generic
AZILECT TAB 0.5 MG

rasagiline mesylate
BRAND
AZILECT TAB 1 MG
rasagiline mesylate
BRAND
selegiline hcl cap 5 mg
generic
selegiline hcl tab 5 mg
generic
lithium carbonate cap 150 mg
generic
generic
generic
lithium carbonate er tab er 300 mg
generic
lithium carbonate er tab er 450 mg
generic
lithium carbonate powder
generic
lithium carbonate tab 300 mg
generic
lithium solution 8 meq/5ml
generic
EQUETRO CAP ER 12H 100 MG

carbamazepine (antipsychotic)
BRAND

BRAND

BRAND
GEODON RECON SOLN 20 MG

ziprasidone mesylate
BRAND
LATUDA TAB 120 MG

lurasidone hcl
BRAND
LATUDA TAB 20 MG
lurasidone hcl
BRAND
*Antiparkinson Monoamine Oxidase Inhibitors**

QL
30 / 30 days
PA
QL
30 / 30 days
3
PA
*ANTIPSYCHOTICS/ANTIMANIC AGENTS*
*Antimanic Agents**
*Antipsychotics - Misc.**
PAGE 91
ST
PRODUCT DESCRIPTION
BRAND/GEN
TIER
LATUDA TAB 40 MG
lurasidone hcl
BRAND
LATUDA TAB 60 MG
lurasidone hcl
BRAND
LATUDA TAB 80 MG
lurasidone hcl
BRAND
ziprasidone hcl cap 20 mg
generic
generic
generic
generic
FANAPT TAB 1 MG
iloperidone
BRAND
QL
60 / 30 days
FANAPT TAB 10 MG
iloperidone
BRAND
QL
60 / 30 days
FANAPT TAB 12 MG
iloperidone
BRAND
QL
60 / 30 days
FANAPT TAB 2 MG
iloperidone
BRAND
QL
60 / 30 days
FANAPT TAB 4 MG
iloperidone
BRAND
QL
60 / 30 days
FANAPT TAB 6 MG
iloperidone
BRAND
QL
60 / 30 days
FANAPT TAB 8 MG
iloperidone
BRAND
QL
60 / 30 days
FANAPT TITRATION PACK TAB 1 & 2 & 4 & 6

MG
iloperidone
BRAND
INVEGA SUSTENNA SUSPENSION 117

MG/0.75ML
paliperidone palmitate
BRAND
ST

MG/ML
BRAND
ST

MG/1.5ML
BRAND
ST

MG/0.25ML
BRAND
ST
*Benzisoxazoles**
PAGE 92
PRODUCT DESCRIPTION
BRAND/GEN
TIER

MG/0.5ML
BRAND
INVEGA TAB ER 24H 1.5 MG

paliperidone
BRAND
QL
60 / 30 days
INVEGA TAB ER 24H 3 MG

paliperidone
BRAND
QL
60 / 30 days

paliperidone
BRAND
QL
60 / 30 days

paliperidone
BRAND
QL
60 / 30 days
RISPERDAL CONSTA RECON SUSP 12.5 MG

risperidone microspheres
BRAND
ST
RISPERDAL CONSTA RECON SUSP 25 MG

BRAND
ST
RISPERDAL CONSTA RECON SUSP 37.5 MG

BRAND
ST
RISPERDAL CONSTA RECON SUSP 50 MG

BRAND
ST
risperidone m-tab tab disp 0.5 mg
generic
risperidone m-tab tab disp 1 mg
generic
generic
generic
generic
risperidone solution 1 mg/ml
generic
risperidone tab 0.25 mg
generic
risperidone tab 0.5 mg
generic
risperidone tab 1 mg
generic
generic
generic
generic
risperidone tab disp 0.25 mg
generic
risperidone tab disp 0.5 mg
generic
risperidone tab disp 1 mg
generic
generic
generic
ST
PAGE 93
PRODUCT DESCRIPTION
BRAND/GEN
generic
TIER
*Butyrophenones**
haloperidol 10 mg
generic
haloperidol decanoate solution 100 mg/ml
generic
haloperidol decanoate solution 50 mg/ml
generic
haloperidol lactate solution 5 mg/ml
generic
haloperidol tab 0.5 mg
generic
haloperidol tab 1 mg
generic
generic
generic
generic
generic
clozapine tab 100 mg
generic
clozapine tab 200 mg
generic
clozapine tab 25 mg
generic
clozapine tab 50 mg
generic
clozapine tab disp 100 mg
generic
clozapine tab disp 12.5 mg
generic
clozapine tab disp 25 mg
generic
FAZACLO TAB DISP 100 MG

clozapine
BRAND
FAZACLO TAB DISP 12.5 MG

clozapine
BRAND

clozapine
BRAND

clozapine
BRAND

clozapine
BRAND
loxapine succinate cap 10 mg
generic
generic
generic
generic
*Dibenzapines**
PAGE 94
PRODUCT DESCRIPTION
BRAND/GEN
olanzapine recon soln 10 mg
generic
olanzapine tab 10 mg
generic
generic
olanzapine tab 2.5 mg
generic
generic
olanzapine tab 5 mg
generic
olanzapine tab 7.5 mg
generic
olanzapine tab disp 10 mg
generic
generic
generic
generic
quetiapine fumarate tab 100 mg
generic
generic
generic
generic
generic
generic
SAPHRIS SL TAB 10 MG
asenapine maleate
BRAND
SAPHRIS SL TAB 5 MG
asenapine maleate
BRAND
SEROQUEL XR TAB ER 24H 150 MG

quetiapine fumarate
BRAND
ST

quetiapine fumarate
BRAND
ST

quetiapine fumarate
BRAND
ST

quetiapine fumarate
BRAND
ST

quetiapine fumarate
BRAND
ST
ZYPREXA RELPREVV RECON SUSP 210 MG

olanzapine pamoate
BRAND
ST

olanzapine pamoate
BRAND
ST
BRAND
ST
PAGE 95
TIER

ST
PRODUCT DESCRIPTION
BRAND/GEN
TIER
olanzapine pamoate
*Phenothiazines**
chlorpromazine hcl solution 25 mg/ml
generic
chlorpromazine hcl tab 10 mg
generic
generic
generic
generic
generic
compazine suppos 25 mg
generic
compro suppos 25 mg
generic
fluphenazine decanoate solution 25 mg/ml
generic
fluphenazine hcl solution 2.5 mg/ml
generic
fluphenazine hcl tab 1 mg
generic
generic
fluphenazine hcl tab 2.5 mg
generic
generic
perphenazine tab 16 mg
generic
generic
generic
generic
prochlorperazine edisylate solution 5 mg/ml
generic
prochlorperazine maleate tab 10 mg
generic
prochlorperazine maleate tab 5 mg
generic
prochlorperazine suppos 25 mg
generic
thioridazine hcl tab 10 mg
generic
generic
generic
generic
trifluoperazine hcl tab 1 mg
generic
generic
generic
generic
PAGE 96
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Quinolinone Derivatives**
QL
ABILIFY DISCMELT TAB DISP 10 MG

aripiprazole
BRAND
ABILIFY DISCMELT TAB DISP 15 MG

aripiprazole
BRAND
ABILIFY MAINTENA RECON SUSP 300 MG

aripiprazole
BRAND
ST
ABILIFY MAINTENA RECON SUSP 400 MG

aripiprazole
BRAND
ST
ABILIFY SOLUTION 1 MG/ML

aripiprazole
BRAND
PA
ABILIFY SOLUTION 9.75 MG/1.3ML

aripiprazole
BRAND
PA
ABILIFY TAB 10 MG
aripiprazole
BRAND
ABILIFY TAB 15 MG
aripiprazole
BRAND
ABILIFY TAB 2 MG
aripiprazole
BRAND
ABILIFY TAB 20 MG
aripiprazole
BRAND
ABILIFY TAB 30 MG
aripiprazole
BRAND
ABILIFY TAB 5 MG
aripiprazole
BRAND
30 / 30 days
3
PA
QL
30 / 30 days
3
PA
QL
30 / 30 days
PA
QL
30 / 30 days
2
PA
QL
30 / 30 days
2
PA
QL
30 / 30 days
2
PA
QL
30 / 30 days
2
PA
QL
30 / 30 days
2
PA
*Thioxanthenes**
NAVANE CAP 20 MG
thiothixene
BRAND
thiothixene cap 1 mg
generic
generic
generic
generic
*ANTISEPTICS & DISINFECTANTS*
PAGE 97
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Chlorine Antiseptics**
PHISOHEX LIQUID 3 %
hexachlorophene
BRAND
abacavir sulfate tab 300 mg
generic
abacavir-lamivudine-zidovudine tab 300-150300 mg
generic
APTIVUS CAP 250 MG

tipranavir
BRAND
APTIVUS SOLUTION 100 MG/ML

tipranavir
BRAND
ATRIPLA TAB 600-200-300 MG

efavirenz-emtricitabine-tenofovir disoproxil
fumarate
BRAND
COMBIVIR TAB 150-300 MG

lamivudine-zidovudine
BRAND
COMPLERA TAB 200-25-300 MG

emtricitabine-rilpivirine-tenofovir disoproxil
fumarate
BRAND
CRIXIVAN CAP 200 MG

indinavir sulfate
BRAND
CRIXIVAN CAP 400 MG

indinavir sulfate
BRAND
didanosine cap dr 125 mg
generic
generic
generic
generic
EDURANT TAB 25 MG
rilpivirine hcl
BRAND
EMTRIVA CAP 200 MG

emtricitabine
BRAND
EMTRIVA SOLUTION 10 MG/ML

emtricitabine
BRAND
EPIVIR HBV SOLUTION 5 MG/ML

lamivudine
BRAND
PA
EPIVIR HBV TAB 100 MG

lamivudine
BRAND
PA
*ANTIVIRALS*
*Antiretrovirals**
PAGE 98
PRODUCT DESCRIPTION
BRAND/GEN
EPIVIR SOLUTION 10 MG/ML

lamivudine
BRAND
EPIVIR TAB 150 MG

lamivudine
BRAND
EPIVIR TAB 300 MG

lamivudine
BRAND
EPZICOM TAB 600-300 MG

abacavir sulfate-lamivudine
BRAND
FUZEON KIT 90 MG
enfuvirtide
BRAND
PA
FUZEON RECON SOLN 90 MG

enfuvirtide
BRAND
PA
INTELENCE TAB 100 MG

etravirine
BRAND
INTELENCE TAB 200 MG

etravirine
BRAND
INTELENCE TAB 25 MG
etravirine
BRAND
INVIRASE CAP 200 MG

saquinavir mesylate
BRAND
INVIRASE TAB 500 MG

saquinavir mesylate
BRAND
ISENTRESS CHEW TAB 100 MG

raltegravir potassium
BRAND
ISENTRESS CHEW TAB 25 MG

BRAND
ISENTRESS PACKET 100 MG

BRAND
ISENTRESS TAB 400 MG

BRAND
KALETRA SOLUTION 400-100 MG/5ML

lopinavir-ritonavir
BRAND
KALETRA TAB 100-25 MG

lopinavir-ritonavir
BRAND
KALETRA TAB 200-50 MG

lopinavir-ritonavir
BRAND
lamivudine tab 100 mg
generic
generic
generic
lamivudine-zidovudine tab 150-300 mg
generic
PAGE 99
TIER
PRODUCT DESCRIPTION
BRAND/GEN
LEXIVA SUSPENSION 50 MG/ML

fosamprenavir calcium
BRAND
LEXIVA TAB 700 MG

fosamprenavir calcium
BRAND
nevirapine er tab er 24h 400 mg
generic
nevirapine suspension 50 mg/5ml
generic
nevirapine tab 200 mg
generic
NORVIR CAP 100 MG

ritonavir
BRAND
NORVIR SOLUTION 80 MG/ML

ritonavir
BRAND
NORVIR TAB 100 MG

ritonavir
BRAND
PREZISTA SUSPENSION 100 MG/ML

darunavir ethanolate
BRAND
PREZISTA TAB 150 MG

BRAND
PREZISTA TAB 400 MG

BRAND
PREZISTA TAB 600 MG

BRAND
PREZISTA TAB 75 MG
BRAND
PREZISTA TAB 800 MG

BRAND
RESCRIPTOR TAB 100 MG

delavirdine mesylate
BRAND
RESCRIPTOR TAB 200 MG

delavirdine mesylate
BRAND
RETROVIR SOLUTION 10 MG/ML

zidovudine
BRAND
REYATAZ CAP 100 MG

atazanavir sulfate
BRAND
REYATAZ CAP 150 MG

atazanavir sulfate
BRAND
REYATAZ CAP 200 MG

atazanavir sulfate
BRAND
REYATAZ CAP 300 MG

atazanavir sulfate
BRAND
SELZENTRY TAB 150 MG
BRAND
PAGE 100
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
maraviroc
SELZENTRY TAB 300 MG
maraviroc
BRAND
stavudine cap 15 mg
generic
stavudine cap 20 mg
generic
stavudine cap 30 mg
generic
stavudine cap 40 mg
generic
stavudine recon soln 1 mg/ml
generic
STRIBILD TAB 150-150-200-300 MG

elvitegravir-cobicistat-emtricitabine-tenofovir
BRAND
SUSTIVA CAP 200 MG

efavirenz
BRAND
SUSTIVA CAP 50 MG
efavirenz
BRAND
SUSTIVA TAB 600 MG

efavirenz
BRAND
TIVICAY TAB 50 MG
dolutegravir sodium
BRAND
TRUVADA TAB 200-300 MG

emtricitabine-tenofovir disoproxil fumarate
BRAND
VIDEX RECON SOLN 2 GM

didanosine
BRAND
VIDEX RECON SOLN 4 GM

didanosine
BRAND
VIRACEPT POWDER 50 MG/GM

nelfinavir mesylate
BRAND
VIRACEPT TAB 250 MG

nelfinavir mesylate
BRAND
VIRACEPT TAB 625 MG

nelfinavir mesylate
BRAND
viramune suspension 50 mg/5ml
generic
VIREAD POWDER 40 MG/GM

tenofovir disoproxil fumarate
BRAND
VIREAD TAB 150 MG

BRAND
VIREAD TAB 200 MG

BRAND
VIREAD TAB 250 MG

BRAND
PAGE 101
PRODUCT DESCRIPTION
BRAND/GEN
TIER
VIREAD TAB 300 MG

BRAND
zidovudine cap 100 mg
generic
zidovudine syrup 50 mg/5ml
generic
zidovudine tab 300 mg
generic
cidofovir solution 75 mg/ml
generic
PA
CYTOVENE RECON SOLN 500 MG

ganciclovir sodium
BRAND
PA
FOSCARNET SODIUM SOLUTION 24 MG/ML

foscarnet sodium
BRAND
PA
FOSCAVIR SOLUTION 24 MG/ML

foscarnet sodium
BRAND
PA
ganciclovir sodium recon soln 500 mg
generic
PA
VALCYTE RECON SOLN 50 MG/ML

valganciclovir hcl
BRAND
PA
VALCYTE TAB 450 MG

valganciclovir hcl
BRAND
PA
VISTIDE SOLUTION 75 MG/ML

cidofovir
BRAND
PA
adefovir dipivoxil tab 10 mg
generic
PA
BARACLUDE SOLUTION 0.05 MG/ML

entecavir
BRAND
PA
BARACLUDE TAB 0.5 MG

entecavir
BRAND
PA
BARACLUDE TAB 1 MG
entecavir
BRAND
PA
HEPSERA TAB 10 MG
adefovir dipivoxil
BRAND
INCIVEK TAB 375 MG

telaprevir
BRAND
PA
INFERGEN INJECTABLE 15 MCG/0.5ML

interferon alfacon-1
BRAND
PA
INFERGEN INJECTABLE 9 MCG/0.3ML

interferon alfacon-1
BRAND
PA
MODERIBA 1200 DOSE PACK TAB 600 MG

ribavirin (hepatitis c)
BRAND
*CMV Agents**
*Hepatitis Agents**
PAGE 102
PRODUCT DESCRIPTION
BRAND/GEN
MODERIBA 800 DOSE PACK TAB 400 MG

BRAND
MODERIBA MISC 200 & 400 MG

BRAND
MODERIBA MISC 400 & 600 MG

BRAND
moderiba tab 200 mg
generic
OLYSIO CAP 150 MG

simeprevir sodium
BRAND
PA
PEG-INTRON KIT 120 MCG/0.5ML

peginterferon alfa-2b
BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA
PEG-INTRON REDIPEN KIT 120 MCG/0.5ML

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA
PEG-INTRON REDIPEN PAK 4 KIT 120

MCG/0.5ML
BRAND
PA

MCG/0.5ML
BRAND
PA

MCG/0.5ML
BRAND
PA

MCG/0.5ML
BRAND
PA
PEGASYS KIT 180 MCG/0.5ML

peginterferon alfa-2a
BRAND
PA
PEGASYS PROCLICK SOLUTION 135

MCG/0.5ML
BRAND
PA
PAGE 103
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
PEGASYS PROCLICK SOLUTION 180

MCG/0.5ML
BRAND
PA
PEGASYS SOLUTION 180 MCG/0.5ML

BRAND
PA
PEGASYS SOLUTION 180 MCG/ML

BRAND
PA
REBETOL SOLUTION 40 MG/ML

BRAND
ribasphere cap 200 mg
generic
RIBASPHERE RIBAPAK TAB 200 & 400 MG

BRAND
RIBASPHERE RIBAPAK TAB 400 & 600 MG

BRAND
RIBASPHERE RIBAPAK TAB 400 MG

BRAND
RIBASPHERE RIBAPAK TAB 600 MG

BRAND
ribasphere tab 200 mg
generic
RIBASPHERE TAB 400 MG

BRAND
RIBASPHERE TAB 600 MG

BRAND
RIBATAB MISC 400 & 600 MG

BRAND
RIBATAB TAB 400 MG

BRAND
RIBATAB TAB 600 MG

BRAND
ribavirin 200 mg
generic
ribavirin cap 200 mg
generic
ribavirin tab 200 mg
generic
SOVALDI TAB 400 MG

sofosbuvir
BRAND
PA
TYZEKA TAB 600 MG

telbivudine
BRAND
PA
VICTRELIS CAP 200 MG

boceprevir
BRAND
PA
*Herpes Agents**
PAGE 104
PRODUCT DESCRIPTION
BRAND/GEN
TIER
acyclovir cap 200 mg
generic
acyclovir sodium recon soln 1000 mg
generic
PA
acyclovir sodium recon soln 500 mg
generic
PA
acyclovir sodium solution 50 mg/ml
generic
PA
acyclovir suspension 200 mg/5ml
generic
acyclovir tab 400 mg
generic
acyclovir tab 800 mg
generic
famciclovir tab 125 mg
generic
generic
generic
valacyclovir hcl tab 1 gm
generic
valacyclovir hcl tab 500 mg
generic
RELENZA DISKHALER AER POW BA 5

MG/BLISTER
zanamivir
BRAND
rimantadine hcl tab 100 mg
generic
TAMIFLU CAP 30 MG
oseltamivir phosphate
BRAND
MFL
1 / 30 days
TAMIFLU CAP 45 MG
BRAND
MFL
1 / 30 days
TAMIFLU CAP 75 MG
BRAND
MFL
1 / 30 days
TAMIFLU RECON SUSP 12 MG/ML

BRAND
MFL
1 / 30 days
TAMIFLU RECON SUSP 6 MG/ML

BRAND
MFL
1 / 30 days
CUPRIMINE CAP 250 MG

penicillamine
BRAND
DEPEN TITRATABS TAB 250 MG

penicillamine
BRAND
SYPRINE CAP 250 MG

trientine hcl
BRAND
QL
30 / 30 days
QL
20 / 30 days
*Influenza Agents**
*ASSORTED CLASSES*
*Chelating Agents**
PAGE 105
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Enzymes**
XIAFLEX RECON SOLN 0.9 MG
collagenase clostridium histolyticum
BRAND
PA
BRAND
PA
REVLIMID CAP 10 MG
lenalidomide
BRAND
PA
REVLIMID CAP 15 MG
lenalidomide
BRAND
PA
REVLIMID CAP 2.5 MG

lenalidomide
BRAND
PA
REVLIMID CAP 20 MG
lenalidomide
BRAND
PA
REVLIMID CAP 25 MG
lenalidomide
BRAND
PA
REVLIMID CAP 5 MG
lenalidomide
BRAND
PA
THALOMID CAP 100 MG

thalidomide
BRAND
PA
THALOMID CAP 150 MG

thalidomide
BRAND
PA
THALOMID CAP 200 MG

thalidomide
BRAND
PA
THALOMID CAP 50 MG
thalidomide
BRAND
PA
ASTAGRAF XL CAP ER 24H 0.5 MG

tacrolimus
BRAND
PA
ASTAGRAF XL CAP ER 24H 1 MG

tacrolimus
BRAND
PA
ASTAGRAF XL CAP ER 24H 5 MG

tacrolimus
BRAND
PA
ATGAM INJECTABLE 50 MG/ML

lymphocyte immune globulin,anti-thymocyte
globulin (equine)
BRAND
PA
AZASAN TAB 100 MG

azathioprine
BRAND
*Fecal Incontinence Bulking Agents**

SOLESTA GEL 50-15 MG/ML
dextranomer-sodium hyaluronate
*Immunomodulators**
*Immunosuppressive Agents**
PAGE 106
PRODUCT DESCRIPTION
BRAND/GEN
AZASAN TAB 75 MG
azathioprine
BRAND
azathioprine tab 50 mg
generic
CELLCEPT RECON SUSP 200 MG/ML

mycophenolate mofetil
BRAND
cyclosporine cap 100 mg
generic
cyclosporine cap 25 mg
generic
cyclosporine modified cap 100 mg
generic
generic
generic
cyclosporine modified solution 100 mg/ml
generic
cyclosporine solution 100 mg/ml
generic
cyclosporine solution 50 mg/ml
generic
gengraf cap 100 mg
generic
gengraf cap 25 mg
generic
gengraf solution 100 mg/ml
generic
mycophenolate mofetil cap 250 mg
generic
mycophenolate mofetil tab 500 mg
generic
mycophenolic acid tab dr 180 mg
generic
mycophenolic acid tab dr 360 mg
generic
NULOJIX RECON SOLN 250 MG

belatacept
BRAND
PA
ORTHOCLONE OKT3 INJECTABLE 1 MG/ML

muromonab cd3
BRAND
PA
PROGRAF SOLUTION 5 MG/ML

tacrolimus
BRAND
RAPAMUNE SOLUTION 1 MG/ML

sirolimus
BRAND
RAPAMUNE TAB 1 MG
sirolimus
BRAND
RAPAMUNE TAB 2 MG
sirolimus
BRAND
SANDIMMUNE SOLUTION 100 MG/ML

cyclosporine
BRAND
SIMULECT RECON SOLN 10 MG

basiliximab
BRAND
PAGE 107
TIER
PA
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
SIMULECT RECON SOLN 20 MG

basiliximab
BRAND
sirolimus tab 0.5 mg
generic
tacrolimus cap 0.5 mg
generic
tacrolimus cap 1 mg
generic
tacrolimus cap 5 mg
generic
THYMOGLOBULIN RECON SOLN 25 MG

anti-thymocyte globulin (rabbit), lymphocyte
immune globulin
BRAND
PA
ZORTRESS TAB 0.25 MG

everolimus (immunosuppressant)
BRAND
PA
ZORTRESS TAB 0.5 MG

BRAND
PA
ZORTRESS TAB 0.75 MG

BRAND
PA
lactated ringers solution
generic
PHYSIOSOL IRRIGATION SOLUTION

irrigation solutions, physiological
BRAND
DELFLEX-LC/2.5% DEXTROSE SOLUTION

peritoneal dialysis solutions
BRAND
DIANEAL LOW CALCIUM/1.5% DEX

SOLUTION 344 MOSM/L
BRAND
DIANEAL PD-2/1.5% DEXTROSE SOLUTION

346 MOSM/L
BRAND

396 MOSM/L
BRAND

485 MOSM/L
BRAND
EXTRANEAL SOLUTION
BRAND
ULTRABAG/DIANEAL PD-2/1.5% DEX

SOLUTION 346 MOSM/L
BRAND
ULTRABAG/DIANEAL PD-2/2.5% DEX
BRAND
PA
*Irrigation Solutions**
*Peritoneal Dialysis Solutions**
PAGE 108
PRODUCT DESCRIPTION
BRAND/GEN
TIER
SOLUTION 396 MOSM/L

ULTRABAG/DIANEAL PD-2/4.25%DEX
SOLUTION 485 MOSM/L
BRAND
ULTRABAG/DIANEAL/1.5% DEXTROSE
SOLUTION
BRAND
ULTRABAG/DIANEAL/4.25% DEX SOLUTION

BRAND
kionex suspension 15 gm/60ml
generic
sodium polystyrene sulfonate suspension 15

gm/60ml
generic

gm/120ml
generic

gm/200ml
generic
alprostadil solution 500 mcg/ml
generic
PA
PROSTIN VR SOLUTION 500 MCG/ML

alprostadil
BRAND
PA
BENLYSTA RECON SOLN 120 MG

belimumab
BRAND
PA
BENLYSTA RECON SOLN 400 MG

belimumab
BRAND
PA
carvedilol 12.5 mg
generic
carvedilol 25 mg
generic
carvedilol 6.25 mg
generic
carvedilol tab 12.5 mg
generic
carvedilol tab 25 mg
generic
generic
generic
*Potassium Removing Resins**
*Prostaglandins**
*Systemic Lupus Erythematosus Agents**
*BETA BLOCKERS*
*Alpha-Beta Blockers**
PAGE 109
PRODUCT DESCRIPTION
BRAND/GEN
TIER
labetalol hcl tab 100 mg
generic
generic
generic
acebutolol hcl cap 200 mg
generic
acebutolol hcl cap 400 mg
generic
atenolol tab 100 mg
generic
atenolol tab 25 mg
generic
atenolol tab 50 mg
generic
betaxolol hcl tab 10 mg
generic
betaxolol hcl tab 20 mg
generic
bisoprolol fumarate tab 10 mg
generic
bisoprolol fumarate tab 5 mg
generic
BYSTOLIC TAB 10 MG
nebivolol hcl
BRAND
ST
BYSTOLIC TAB 2.5 MG

nebivolol hcl
BRAND
ST
BYSTOLIC TAB 20 MG
nebivolol hcl
BRAND
ST
BYSTOLIC TAB 5 MG
nebivolol hcl
BRAND
ST
metoprolol succinate er tab er 24h 100 mg
generic
generic
generic
generic
metoprolol tartrate tab 100 mg
generic
generic
generic
INNOPRAN XL CAP ER 24H 120 MG

propranolol hcl sustained-release beads
BRAND
INNOPRAN XL CAP ER 24H 80 MG

propranolol hcl sustained-release beads
BRAND
LEVATOL TAB 20 MG
penbutolol sulfate
BRAND
*Beta Blockers Cardio-Selective**
*Beta Blockers Non-Selective**
PAGE 110
ST
PRODUCT DESCRIPTION
BRAND/GEN
TIER
nadolol tab 20 mg
generic
nadolol tab 40 mg
generic
nadolol tab 80 mg
generic
pindolol tab 10 mg
generic
pindolol tab 5 mg
generic
propranolol hcl er cap er 24h 120 mg
generic
generic
generic
generic
propranolol hcl solution 20 mg/5ml
generic
propranolol hcl solution 40 mg/5ml
generic
propranolol hcl tab 10 mg
generic
generic
generic
generic
generic
sotalol hcl (af) tab 120 mg
generic
generic
generic
sotalol hcl tab 120 mg
generic
generic
generic
generic
timolol maleate tab 10 mg
generic
generic
generic
BRAND
*BIOLOGICALS MISC*
*Biologicals Misc**
ADAGEN SOLUTION 250 UNIT/ML
pegademase bovine
PA
*CALCIUM CHANNEL BLOCKERS*

*Calcium Channel Blockers**
PAGE 111
PRODUCT DESCRIPTION
BRAND/GEN
afeditab cr tab er 24h 30 mg
generic
afeditab cr tab er 24h 60 mg
generic
amlodipine besylate 10 mg
generic
amlodipine besylate 2.5 mg
generic
amlodipine besylate 5 mg
generic
amlodipine besylate tab 10 mg
generic
amlodipine besylate tab 2.5 mg
generic
amlodipine besylate tab 5 mg
generic
CARDENE SR CAP ER 12H 30 MG

nicardipine hcl
BRAND

nicardipine hcl
BRAND

nicardipine hcl
BRAND
dilt-cd cap er 24h 120 mg
generic
generic
generic
generic
dilt-xr cap er 24h 120 mg
generic
generic
generic
diltiazem hcl cd cap er 24h 360 mg
generic
diltiazem hcl er beads cap er 24h 120 mg
generic
generic
generic
generic
generic
generic
diltiazem hcl er cap er 12h 120 mg
generic
generic
generic
generic
generic
generic
PAGE 112
TIER
PRODUCT DESCRIPTION
BRAND/GEN
diltiazem hcl er coated beads cap er 24h 120

mg
generic

mg
generic

mg
generic

mg
generic

mg
generic
diltiazem hcl er coated beads tab er 24h 180

mg
generic

mg
generic

mg
generic

mg
generic

mg
generic
DILTIAZEM HCL RECON SOLN 100 MG

diltiazem hcl
BRAND
PA
diltiazem hcl solution 125 mg/25ml
generic
PA
generic
PA
generic
PA
diltiazem hcl tab 120 mg
generic
generic
generic
generic
DYNACIRC CR TAB ER 24H 10 MG

isradipine
BRAND
DYNACIRC CR TAB ER 24H 5 MG

isradipine
BRAND
felodipine er tab er 24h 10 mg
generic
felodipine er tab er 24h 2.5 mg
generic
felodipine er tab er 24h 5 mg
generic
isradipine cap 2.5 mg
generic
PAGE 113
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
isradipine cap 5 mg
generic
nicardipine hcl cap 20 mg
generic
nicardipine hcl cap 30 mg
generic
nifediac cc tab er 24h 30 mg
generic
generic
generic
nifedical xl tab er 24h 30 mg
generic
nifedical xl tab er 24h 60 mg
generic
nifedipine cap 10 mg
generic
nifedipine cap 20 mg
generic
nifedipine er osmotic tab er 24h 30 mg
generic
generic
generic
nifedipine er tab er 24h 30 mg
generic
generic
generic
nimodipine cap 30 mg
generic
nisoldipine er tab er 24h 17 mg
generic
generic
nisoldipine er tab er 24h 25.5 mg
generic
generic
generic
generic
nisoldipine er tab er 24h 8.5 mg
generic
verapamil hcl er cap er 24h 100 mg
generic
generic
generic
generic
generic
generic
generic
verapamil hcl er tab er 120 mg
generic
PAGE 114
PRODUCT DESCRIPTION
BRAND/GEN
TIER
generic
generic
verapamil hcl solution 2.5 mg/ml
generic
verapamil hcl tab 120 mg
generic
generic
generic
digox tab 125 mcg
generic
digox tab 250 mcg
generic
digoxin solution 0.05 mg/ml
generic
digoxin tab 125 mcg
generic
digoxin tab 250 mcg
generic
BRAND
CIALIS TAB 10 MG
tadalafil
BRAND
QL
CIALIS TAB 2.5 MG

tadalafil
BRAND
PA
CIALIS TAB 20 MG
tadalafil
BRAND
QL
CIALIS TAB 5 MG
tadalafil
BRAND
PA
MUSE PELLET 1000 MCG

alprostadil (vasodilator)
BRAND
MUSE PELLET 125 MCG

BRAND
MUSE PELLET 250 MCG

BRAND
MUSE PELLET 500 MCG

BRAND
PA
*CARDIOTONICS*
*Cardiac Glycosides**
*CARDIOVASCULAR AGENTS - MISC.*

*Cardiovascular Agents Misc. - Combinations**
BIDIL TAB 20-37.5 MG
isosorbide dinitrate-hydralazine hcl
*Impotence Agents**
PAGE 115
QL
8 / 30 days
8 / 30 days
8 / 30 days
PA
QL
8 / 30 days
3
PA
QL
8 / 30 days
3
PA
QL
8 / 30 days
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
VIAGRA TAB 100 MG

sildenafil citrate
BRAND
VIAGRA TAB 25 MG
sildenafil citrate
BRAND
VIAGRA TAB 50 MG
sildenafil citrate
BRAND
epoprostenol sodium recon soln 0.5 mg
QL
8 / 30 days
QL
8 / 30 days
generic
PA
epoprostenol sodium recon soln 1.5 mg
generic
PA
REMODULIN SOLUTION 1 MG/ML

treprostinil sodium
BRAND
PA

treprostinil sodium
BRAND
PA
REMODULIN SOLUTION 2.5 MG/ML

treprostinil sodium
BRAND
PA

treprostinil sodium
BRAND
PA
TYVASO REFILL SOLUTION 0.6 MG/ML

treprostinil
BRAND
PA
TYVASO SOLUTION 0.6 MG/ML

treprostinil
BRAND
PA
TYVASO STARTER SOLUTION 0.6 MG/ML

treprostinil
BRAND
PA
VELETRI RECON SOLN 0.5 MG

epoprostenol sodium
BRAND
PA
VELETRI RECON SOLN 1.5 MG

epoprostenol sodium
BRAND
PA
VENTAVIS SOLUTION 10 MCG/ML

iloprost
BRAND
PA
VENTAVIS SOLUTION 20 MCG/ML

iloprost
BRAND
PA
*Prostaglandin Vasodilators**
*Pulmonary Hypertension - Endothelin Receptor Antagonists**

LETAIRIS TAB 10 MG
ambrisentan
BRAND
PA
LETAIRIS TAB 5 MG
ambrisentan
BRAND
PA
OPSUMIT TAB 10 MG
BRAND
PA
PAGE 116
PRODUCT DESCRIPTION
BRAND/GEN
TIER
macitentan
TRACLEER TAB 125 MG
bosentan
BRAND
PA
TRACLEER TAB 62.5 MG

bosentan
BRAND
PA
*Pulmonary Hypertension - Phosphodiesterase Inhibitors**

ADCIRCA TAB 20 MG
tadalafil (pulmonary hypertension)
BRAND
PA
sildenafil citrate tab 20 mg
generic
PA
*Pulmonary Hypertension - Sol Guanylate Cyclase Stimulator**

ADEMPAS TAB 0.5 MG
riociguat
BRAND
PA
ADEMPAS TAB 1 MG
riociguat
BRAND
PA
ADEMPAS TAB 1.5 MG

riociguat
BRAND
PA
ADEMPAS TAB 2 MG
riociguat
BRAND
PA
ADEMPAS TAB 2.5 MG

riociguat
BRAND
PA
cefadroxil cap 500 mg
generic
cefadroxil recon susp 250 mg/5ml
generic
cefadroxil recon susp 500 mg/5ml
generic
cefadroxil tab 1 gm
generic
cefazolin sodium 500 mg
generic
PA
cefazolin sodium recon soln 1 gm
generic
PA
CEFAZOLIN SODIUM RECON SOLN 1 GM

cefazolin sodium
BRAND
PA
generic
PA
generic
PA
cefazolin sodium recon soln 500 mg
generic
PA
CEFAZOLIN SODIUM SOLUTION 1-5 GM-%

cefazolin in d5w
BRAND
PA
*CEPHALOSPORINS*
*Cephalosporins - 1st Generation**
PAGE 117
PRODUCT DESCRIPTION
BRAND/GEN
TIER
CEFAZOLIN SODIUM-DEXTROSE RECON

SOLN 1-4 GM-%
cefazolin sodium and dextrose
BRAND
PA
CEFAZOLIN SODIUM-DEXTROSE RECON

SOLN 2-3 GM-%
cefazolin sodium and dextrose
BRAND
PA
cephalexin cap 250 mg
generic
cephalexin cap 500 mg
generic
cephalexin recon susp 125 mg/5ml
generic
cephalexin recon susp 250 mg/5ml
generic
cephalexin tab 250 mg
generic
cephalexin tab 500 mg
generic
cefaclor cap 250 mg
generic
cefaclor cap 500 mg
generic
cefaclor er tab er 12h 500 mg
generic
cefaclor recon susp 125 mg/5ml
generic
generic
generic
cefoxitin sodium recon soln 1 gm
generic
PA
generic
PA
generic
PA
CEFOXITIN SODIUM-DEXTROSE RECON

SOLN 1-4 GM-%
cefoxitin sodium and dextrose
BRAND
PA
CEFOXITIN SODIUM-DEXTROSE RECON

SOLN 2-2.2 GM-%
cefoxitin sodium and dextrose
BRAND
PA
cefprozil recon susp 125 mg/5ml
generic
cefprozil recon susp 250 mg/5ml
generic
cefprozil tab 250 mg
generic
cefprozil tab 500 mg
generic
CEFTIN RECON SUSP 250 MG/5ML

cefuroxime axetil
BRAND
cefuroxime axetil recon susp 125 mg/5ml
generic
*Cephalosporins - 2nd Generation**
PAGE 118
PRODUCT DESCRIPTION
BRAND/GEN
TIER
cefuroxime axetil tab 250 mg
generic
cefuroxime axetil tab 500 mg
generic
cefuroxime sodium recon soln 1.5 gm
generic
PA
cefuroxime sodium recon soln 7.5 gm
generic
PA
CEFUROXIME SODIUM RECON SOLN 7.5

GM
cefuroxime sodium
BRAND
PA
cefuroxime sodium recon soln 750 mg
generic
PA
CEFUROXIME SODIUM-DEXTROSE RECON

SOLN 750-4.1 MG-%
cefuroxime sodium and dextrose
BRAND
PA
CEFUROXIME-DEXTROSE RECON SOLN

1.5-2.9 GM-%
cefuroxime sodium and dextrose
BRAND
PA
MEFOXIN SOLUTION 1-2 GM/50ML

cefoxitin sodium in dextrose
BRAND
PA
MEFOXIN SOLUTION 2-1.1 GM/50ML

cefoxitin sodium in dextrose
BRAND
PA
ZINACEF RECON SOLN 750 MG

cefuroxime sodium
BRAND
PA
cefdinir cap 300 mg
generic
cefdinir recon susp 125 mg/5ml
generic
cefdinir recon susp 250 mg/5ml
generic
cefotaxime sodium recon soln 1 gm
generic
PA
generic
PA
generic
PA
cefotaxime sodium recon soln 500 mg
generic
PA
cefpodoxime proxetil recon susp 100 mg/5ml
generic
cefpodoxime proxetil recon susp 50 mg/5ml
generic
cefpodoxime proxetil tab 100 mg
generic
cefpodoxime proxetil tab 200 mg
generic
CEFTIBUTEN CAP 400 MG

ceftibuten
BRAND
CEFTIBUTEN RECON SUSP 180 MG/5ML
BRAND
*Cephalosporins - 3rd Generation**
PAGE 119
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ceftibuten
CLAFORAN RECON SOLN 2 GM
cefotaxime sodium
BRAND
PA
SUPRAX CAP 400 MG

cefixime
BRAND
ST
SUPRAX CHEW TAB 100 MG

cefixime
BRAND
ST
SUPRAX CHEW TAB 200 MG

cefixime
BRAND
ST
SUPRAX RECON SUSP 100 MG/5ML

cefixime
BRAND
ST

cefixime
BRAND
ST

cefixime
BRAND
ST
SUPRAX TAB 400 MG

cefixime
BRAND
ST
cefepime hcl recon soln 1 gm
generic
PA
cefepime hcl recon soln 2 gm
generic
PA
CEFEPIME HCL SOLUTION 1 GM/50ML

cefepime hcl
BRAND
PA
CEFEPIME HCL SOLUTION 2 GM/100ML

cefepime hcl
BRAND
PA
CEFEPIME-DEXTROSE RECON SOLN 1

GM/50ML
cefepime hcl and dextrose
BRAND
PA
CEFEPIME-DEXTROSE RECON SOLN 2

GM/50ML
cefepime hcl and dextrose
BRAND
PA
generic
generic
*Cephalosporins - 4th Generation**
*CHEMICALS*
*Bulk Chemicals - K's**
ketorolac tromethamine powder
*Liquids**
ammonium lactate solution 70 %
*CONTRACEPTIVES*
*Combination Contraceptives - Oral**
PAGE 120
PRODUCT DESCRIPTION
BRAND/GEN
altavera tab 0.15-30 mg-mcg
generic
GL
Female
alyacen 1/35 tab 1-35 mg-mcg
generic
GL
Female
alyacen 7/7/7 tab 0.5/0.75/1-35 mg-mcg
generic
GL
Female
amethia lo tab 0.1-0.02 & 0.01 mg
generic
GL
Female
amethia tab 0.15-0.03 &0.01 mg
generic
GL
Female
AMETHYST TAB 90-20 MCG

levonorgestrel-ethinyl estradiol (continuous)
BRAND
GL
Female
apri tab 0.15-30 mg-mcg
generic
GL
Female
aranelle tab 0.5/1/0.5-35 mg-mcg
generic
GL
Female
aubra tab 0.1-20 mg-mcg
generic
GL
Female
aviane tab 0.1-20 mg-mcg
generic
GL
Female
azurette tab 0.15-0.02/0.01 mg (21/5)
generic
GL
Female
balziva tab 0.4-35 mg-mcg
generic
GL
Female
BEYAZ TAB 3-0.02-0.451 MG

drospirenone-ethinyl estradiol-levomefolate
calcium
BRAND
GL
Female
briellyn tab 0.4-35 mg-mcg
generic
GL
Female
camrese lo tab 0.1-0.02 & 0.01 mg
generic
GL
Female
camrese tab 0.15-0.03 &0.01 mg
generic
GL
Female
caziant tab 0.1/0.125/0.15 -0.025 mg
generic
GL
Female
chateal tab 0.15-30 mg-mcg
generic
GL
Female
cryselle-28 tab 0.3-30 mg-mcg
generic
GL
Female
cyclafem 1/35 tab 1-35 mg-mcg
generic
GL
Female
cyclafem 7/7/7 tab 0.5/0.75/1-35 mg-mcg
generic
GL
Female
dasetta 1/35 tab 1-35 mg-mcg
generic
GL
Female
dasetta 7/7/7 tab 0.5/0.75/1-35 mg-mcg
generic
GL
Female
daysee tab 0.15-0.03 &0.01 mg
generic
GL
Female
delyla tab 0.1-20 mg-mcg
generic
desogestrel-ethinyl estradiol tab 0.15-0.02/0.01

mg (21/5)
generic
PAGE 121
TIER
PRODUCT DESCRIPTION
BRAND/GEN
desogestrel-ethinyl estradiol tab 0.15-30 mgmcg
generic
GL
Female
drospirenone-ethinyl estradiol tab 3-0.03 mg
generic
GL
Female
elinest tab 0.3-30 mg-mcg
generic
GL
Female
emoquette tab 0.15-30 mg-mcg
generic
GL
Female
enpresse-28 tab
generic
GL
Female
enskyce tab 0.15-30 mg-mcg
generic
GL
Female
estarylla tab 0.25-35 mg-mcg
generic
GL
Female
FALESSA KIT 20-1-0.1 MCG-MG

levonorgestrel-ethinyl estradiol & folic acid
BRAND
GL
Female
falmina tab 0.1-20 mg-mcg
generic
GL
Female
GENERESS FE CHEW TAB 0.8-25 MG-MCG

norethindrone & ethinyl estradiol-fe
BRAND
GL
Female
gianvi tab 3-0.02 mg
generic
GL
Female
gildagia tab 0.4-35 mg-mcg
generic
GL
Female
gildess 1.5/30 tab 1.5-30 mg-mcg
generic
GL
Female
gildess 1/20 tab 1-20 mg-mcg
generic
GL
Female
gildess fe 1.5/30 tab 1.5-30 mg-mcg
generic
GL
Female
gildess fe 1/20 tab 1-20 mg-mcg
generic
GL
Female
introvale tab 0.15-0.03 mg
generic
GL
Female
jolessa tab 0.15-0.03 mg
generic
GL
Female
junel 1.5/30 tab 1.5-30 mg-mcg
generic
GL
Female
junel 1/20 tab 1-20 mg-mcg
generic
GL
Female
junel fe 1.5/30 tab 1.5-30 mg-mcg
generic
GL
Female
junel fe 1/20 tab 1-20 mg-mcg
generic
GL
Female
kariva tab 0.15-0.02/0.01 mg (21/5)
generic
GL
Female
kelnor 1/35 tab 1-35 mg-mcg
generic
GL
Female
kurvelo tab 0.15-30 mg-mcg
generic
GL
Female
larin 1.5/30 tab 1.5-30 mg-mcg
generic
PAGE 122
TIER
PRODUCT DESCRIPTION
BRAND/GEN
larin 1/20 tab 1-20 mg-mcg
generic
GL
Female
larin fe 1.5/30 tab 1.5-30 mg-mcg
generic
GL
Female
larin fe 1/20 tab 1-20 mg-mcg
generic
GL
Female
leena tab 0.5/1/0.5-35 mg-mcg
generic
GL
Female
lessina tab 0.1-20 mg-mcg
generic
GL
Female
levonest tab
generic
GL
Female
levonorgest-eth estrad 91-day tab 0.1-0.02 &

0.01 mg
generic
GL
Female
levonorgest-eth estrad 91-day tab 0.15-0.03 mg
generic
GL
Female
levonorgestrel-ethinyl estrad tab 0.1-20 mgmcg
generic
GL
Female
levonorgestrel-ethinyl estrad tab 0.15-30 mgmcg
generic
GL
Female
levora 0.15/30 (28) tab 0.15-30 mg-mcg
generic
GL
Female
LO LOESTRIN FE TAB 1 MG-10 MCG / 10

MCG
norethindrone acetate-ethinyl estradiol-fe fum
(biphasic)
BRAND
GL
Female
LO MINASTRIN FE THER PACK 1 MG-10

MCG / 10 MCG
norethindrone acetate-ethinyl estradiol-fe fum
(biphasic)
BRAND
GL
Female
LOESTRIN 24 FE TAB 1-20 MG-MCG

norethin acet & estrad-fe
BRAND
GL
Female
loryna tab 3-0.02 mg
generic
GL
Female
low-ogestrel tab 0.3-30 mg-mcg
generic
GL
Female
lutera tab 0.1-20 mg-mcg
generic
GL
Female
marlissa tab 0.15-30 mg-mcg
generic
GL
Female
microgestin 1.5/30 tab 1.5-30 mg-mcg
generic
GL
Female
microgestin 1/20 tab 1-20 mg-mcg
generic
GL
Female
microgestin fe 1.5/30 tab 1.5-30 mg-mcg
generic
GL
Female
microgestin fe 1/20 tab 1-20 mg-mcg
generic
GL
Female
MINASTRIN 24 FE CHEW TAB 1-20 MGMCG(24)
BRAND
GL
Female
PAGE 123
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
norethin acet & estrad-fe

mono-linyah tab 0.25-35 mg-mcg
generic
GL
Female
mononessa tab 0.25-35 mg-mcg
generic
GL
Female
myzilra tab
generic
GL
Female
NATAZIA TAB 3/2-2/2-3/1 MG

estradiol valerate-dienogest
BRAND
GL
Female
necon 0.5/35 (28) tab 0.5-35 mg-mcg
generic
GL
Female
necon 1/35 (28) tab 1-35 mg-mcg
generic
GL
Female
NECON 1/50 (28) TAB 1-50 MG-MCG

norethindrone & mestranol
BRAND
GL
Female
NECON 10/11 (28) TAB 35 MCG

norethindrone-eth estradiol (biphasic)
BRAND
GL
Female
necon 7/7/7 tab 0.5/0.75/1-35 mg-mcg
generic
GL
Female
nikki tab 3-0.02 mg
generic
norethin ace-eth estrad-fe tab 1-20 mg-mcg
generic
norethindrone acet-ethinyl est tab 1-20 mg-mcg
generic
norgestim-eth estrad triphasic tab

0.18/0.215/0.25 mg-35 mcg
generic
GL
Female
norgestimate-eth estradiol tab 0.25-35 mg-mcg
generic
GL
Female
norgestrel-ethinyl estradiol tab 0.3-30 mg-mcg
generic
GL
Female
NORINYL 1+50 (28) TAB 1-50 MG-MCG

norethindrone & mestranol
BRAND
GL
Female
nortrel 0.5/35 (28) tab 0.5-35 mg-mcg
generic
GL
Female
nortrel 1/35 (21) tab 1-35 mg-mcg
generic
GL
Female
nortrel 1/35 (28) tab 1-35 mg-mcg
generic
GL
Female
nortrel 7/7/7 tab 0.5/0.75/1-35 mg-mcg
generic
GL
Female
ocella tab 3-0.03 mg
generic
GL
Female
OGESTREL TAB 0.5-50 MG-MCG

norgestrel & ethinyl estradiol
BRAND
GL
Female
orsythia tab 0.1-20 mg-mcg
generic
GL
Female
OVCON-50 TAB 50-1 MCG-MG

norethindrone & eth estradiol
BRAND
GL
Female
PAGE 124
PRODUCT DESCRIPTION
BRAND/GEN
philith tab 0.4-35 mg-mcg
generic
pimtrea tab 0.15-0.02/0.01 mg (21/5)
generic
pirmella 1/35 tab 1-35 mg-mcg
TIER

GL
Female
GL
Female
generic
GL
Female
pirmella 7/7/7 tab 0.5/0.75/1-35 mg-mcg
generic
GL
Female
portia-28 tab 0.15-30 mg-mcg
generic
GL
Female
previfem tab 0.25-35 mg-mcg
generic
GL
Female
QUARTETTE TAB 42-21-21-7 DAYS

levonorgestrel-ethinyl estradiol (91-day)
BRAND
GL
Female
quasense tab 0.15-0.03 mg
generic
GL
Female
reclipsen tab 0.15-30 mg-mcg
generic
GL
Female
SAFYRAL TAB 3-0.03-0.451 MG

drospirenone-ethinyl estradiol-levomefolate
calcium
BRAND
GL
Female
solia tab 0.15-30 mg-mcg
generic
GL
Female
sprintec 28 tab 0.25-35 mg-mcg
generic
GL
Female
sronyx tab 0.1-20 mg-mcg
generic
GL
Female
syeda tab 3-0.03 mg
generic
GL
Female
tilia fe tab 1-20/1-30/1-35 mg-mcg
generic
GL
Female
tri-estarylla tab 0.18/0.215/0.25 mg-35 mcg
generic
GL
Female
tri-legest fe tab 1-20/1-30/1-35 mg-mcg
generic
GL
Female
tri-linyah tab 0.18/0.215/0.25 mg-35 mcg
generic
GL
Female
tri-previfem tab 0.18/0.215/0.25 mg-35 mcg
generic
GL
Female
tri-sprintec tab 0.18/0.215/0.25 mg-35 mcg
generic
GL
Female
trinessa (28) tab 0.18/0.215/0.25 mg-35 mcg
generic
GL
Female
trivora (28) tab
generic
GL
Female
velivet tab 0.1/0.125/0.15 -0.025 mg
generic
GL
Female
vestura tab 3-0.02 mg
generic
GL
Female
viorele tab 0.15-0.02/0.01 mg (21/5)
generic
GL
Female
vyfemla tab 0.4-35 mg-mcg
generic
GL
Female
PAGE 125
PRODUCT DESCRIPTION
BRAND/GEN
TIER
wera tab 0.5-35 mg-mcg
generic
GL
Female
wymzya fe chew tab 0.4-35 mg-mcg
generic
GL
Female
zarah tab 3-0.03 mg
generic
GL
Female
zenchent fe chew tab 0.4-35 mg-mcg
generic
GL
Female
zenchent tab 0.4-35 mg-mcg
generic
GL
Female
zeosa chew tab 0.4-35 mg-mcg
generic
GL
Female
zovia 1/35e (28) tab 1-35 mg-mcg
generic
GL
Female
ZOVIA 1/50E (28) TAB 1-50 MG-MCG

ethynodiol diacet & eth estrad
BRAND
GL
Female
generic
GL
Female
BRAND
GL
Female
BRAND
GL
Female
ELLA TAB 30 MG
ulipristal acetate
BRAND
GL
Female
levonorgestrel tab 0.75 mg
generic
GL
Female
levonorgestrel tab 1.5 mg
generic
GL
Female
my way tab 1.5 mg
generic
GL
Female
next choice one dose tab 1.5 mg
generic
GL
Female
next choice tab 0.75 mg
generic
GL
Female
IMPLANON IMPLANT 68 MG
etonogestrel
BRAND
NEXPLANON IMPLANT 68 MG
etonogestrel
BRAND
*Combination Contraceptives - Transdermal**

xulane patch wk 150-35 mcg/24hr
*Combination Contraceptives - Vaginal**
NUVARING RING 0.12-0.015 MG/24HR
etonogestrel-ethinyl estradiol
*Copper Contraceptives - IUD**
PARAGARD INTRAUTERINE COPPER IUD
copper (iud)
*Emergency Contraceptives**
*Progestin Contraceptives - Implants**

PA
GL
Female
PA
0
GL
Female
*Progestin Contraceptives - Injectable**
PAGE 126
PRODUCT DESCRIPTION
BRAND/GEN
TIER
DEPO-SUBQ PROVERA 104 SUSPENSION

104 MG/0.65ML
medroxyprogesterone acetate (contraceptive)
BRAND
GL
Female
medroxyprogesterone acetate suspension 150

mg/ml
generic
GL
Female
MIRENA IUD 20 MCG/24HR

levonorgestrel (iud)
BRAND
GL
Female
SKYLA IUD 13.5 MG

levonorgestrel (iud)
BRAND
GL
Female
camila tab 0.35 mg
generic
GL
Female
errin tab 0.35 mg
generic
GL
Female
heather tab 0.35 mg
generic
GL
Female
jencycla tab 0.35 mg
generic
GL
Female
jolivette tab 0.35 mg
generic
GL
Female
lyza tab 0.35 mg
generic
GL
Female
nora-be tab 0.35 mg
generic
GL
Female
norethindrone tab 0.35 mg
generic
GL
Female
norlyroc tab 0.35 mg
generic
A-HYDROCORT RECON SOLN 100 MG

hydrocortisone sod succinate
BRAND
PA
a-methapred 125 mg
generic
PA
a-methapred recon soln 125 mg
generic
PA
a-methapred recon soln 40 mg
generic
PA
asmalpred plus solution 15 mg/5ml
generic
asmalpred solution 15 mg/5ml
generic
baycadron elixir 0.5 mg/5ml
generic
betamethasone sod phos & acet suspension 6

(3-3) mg/ml
generic
budesonide er cap er 24h 3 mg
generic
*Progestin Contraceptives - IUD**
*Progestin Contraceptives - Oral**
*CORTICOSTEROIDS*
*Glucocorticosteroids**
PAGE 127
PA
PRODUCT DESCRIPTION
BRAND/GEN
cortisone acetate tab 25 mg
generic
DEPO-MEDROL SUSPENSION 20 MG/ML

methylprednisolone acetate
BRAND
dexamethasone elixir 0.5 mg/5ml
generic
DEXAMETHASONE INTENSOL CONC 1

MG/ML
dexamethasone
BRAND
dexamethasone sodium phosphate solution 10

mg/ml
generic
PA
dexamethasone sodium phosphate solution

100 mg/10ml
generic
PA
dexamethasone sodium phosphate solution

120 mg/30ml
generic
PA

mg/5ml
generic
PA

mg/ml
generic
PA
dexamethasone solution 0.5 mg/5ml
generic
dexamethasone tab 0.5 mg
generic
generic
dexamethasone tab 1 mg
generic
generic
generic
generic
generic
DEXPAK 13 DAY TAB 1.5 MG

dexamethasone
BRAND
DEXPAK 6 DAY TAB 1.5 MG

dexamethasone
BRAND
hydrocortisone tab 10 mg
generic
generic
generic
KENALOG SUSPENSION 10 MG/ML

triamcinolone acetonide
BRAND
PA
KENALOG SUSPENSION 40 MG/ML

triamcinolone acetonide
BRAND
PA
MEDROL TAB 2 MG
methylprednisolone
BRAND
PAGE 128
TIER
PRODUCT DESCRIPTION
BRAND/GEN
methylprednisolone (pak) tab 4 mg
generic
methylprednisolone acetate suspension 40

mg/ml
generic
PA
methylprednisolone acetate suspension 80

mg/ml
generic
PA
methylprednisolone sodium succ recon soln

1000 mg
generic
PA

125 mg
generic
PA
methylprednisolone sodium succ recon soln 40

mg
generic
PA

500 mg
generic
PA
methylprednisolone tab 16 mg
generic
generic
generic
generic
MILLIPRED DP 12-DAY TAB 5 MG

prednisolone
BRAND
MILLIPRED DP TAB 5 MG
prednisolone
BRAND
MILLIPRED SOLUTION 10 MG/5ML

prednisolone sodium phosphate
BRAND
MILLIPRED TAB 5 MG
prednisolone
BRAND
ORAPRED ODT TAB DISP 10 MG

BRAND

BRAND

BRAND
prednisolone sodium phosphate solution 15

mg/5ml
generic
PREDNISOLONE SODIUM PHOSPHATE

SOLUTION 25 MG/5ML
BRAND
prednisolone sodium phosphate solution 6.7 (5

base) mg/5ml
generic
prednisolone solution 15 mg/5ml
generic
PAGE 129
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
prednisolone syrup 15 mg/5ml
generic
prednisone (pak) tab 10 mg
generic
prednisone (pak) tab 5 mg
generic
PREDNISONE INTENSOL CONC 5 MG/ML

prednisone
BRAND
prednisone solution 5 mg/5ml
generic
prednisone tab 1 mg
generic
prednisone tab 10 mg
generic
prednisone tab 2.5 mg
generic
generic
prednisone tab 5 mg
generic
generic
SOLU-CORTEF RECON SOLN 250 MG

hydrocortisone sod succinate
BRAND
SOLU-MEDROL RECON SOLN 2 GM

methylprednisolone sod succ
BRAND
UCERIS TAB ER 24H 9 MG

budesonide
BRAND
VERIPRED 20 SOLUTION 20 MG/5ML

BRAND
generic
benzonatate cap 100 mg
generic
benzonatate cap 200 mg
generic
hydrocodone-homatropine syrup 5-1.5 mg/5ml
generic
gani-tuss nr liquid 100-10 mg/5ml
generic
guaifenesin-codeine solution 100-10 mg/5ml
generic
guaifenesin-codeine syrup 100-10 mg/5ml
generic
hydrocod polst-cpm polst er liquid er 10-8

mg/5ml
generic
myci-gc solution 100-10 mg/5ml
generic
*Mineralocorticoids**
fludrocortisone acetate tab 0.1 mg
*COUGH/COLD/ALLERGY*
*Antitussives**
*Cough/Cold/Allergy Combinations**
PAGE 130
PRODUCT DESCRIPTION
BRAND/GEN
TIER
promethazine vc plain syrup 6.25-5 mg/5ml
generic
promethazine vc syrup 6.25-5 mg/5ml
generic
promethazine vc/codeine syrup 6.25-5-10

mg/5ml
generic
promethazine-codeine syrup 6.25-10 mg/5ml
generic
promethazine-dm syrup 6.25-15 mg/5ml
generic
PROMETHAZINE-PHENYLEPHRINE SYRUP
6.25-5 MG/5ML
promethazine & phenylephrine
BRAND
robafen ac syrup 100-10 mg/5ml
generic
HYPERSAL NEBU SOLN 3.5 %

sodium chloride (inhalant)
BRAND
HYPERSAL NEBU SOLN 7 %

BRAND
nebusal nebu soln 3 %
generic
NEBUSAL NEBU SOLN 6 %

BRAND
pulmosal nebu soln 7 %
generic
sodium chloride nebu soln 0.9 %
generic
sodium chloride nebu soln 10 %
generic
generic
generic
acetylcysteine solution 10 %
generic
acetylcysteine solution 20 %
generic
ABSORICA CAP 10 MG
isotretinoin
BRAND
QL
30 / 30 days
ABSORICA CAP 20 MG
isotretinoin
BRAND
QL
30 / 30 days
ABSORICA CAP 30 MG
isotretinoin
BRAND
QL
30 / 30 days
ABSORICA CAP 40 MG
isotretinoin
BRAND
QL
30 / 30 days
*Misc. Respiratory Inhalants**
*Mucolytics**
*DERMATOLOGICALS*
*Acne Products**
PAGE 131
PRODUCT DESCRIPTION
BRAND/GEN
acne medication 5 gel 5 %
generic
adapalene cream 0.1 %
generic
adapalene gel 0.1 %
generic
amnesteem cap 10 mg
generic
QL
30 / 30 days
amnesteem cap 20 mg
generic
QL
30 / 30 days
amnesteem cap 40 mg
generic
QL
30 / 30 days
avar-e green cream 10-5 %
generic
avita cream 0.025 %
generic
avita gel 0.025 %
generic
AZELEX CREAM 20 %
azelaic acid (acne)
BRAND
benprox liquid 5.25 %
generic
benzepro foam 5.3 %
generic
benzepro short contact foam 9.8 %
generic
benzoyl peroxide cleanser lotion 3 %
generic
generic
generic
benzoyl peroxide cleansing lotion 4 %
generic
benzoyl peroxide cream 3.5 %
generic
generic
generic
benzoyl peroxide creamy wash kit 4 %
generic
benzoyl peroxide creamy wash kit 8 %
generic
benzoyl peroxide creamy wash liquid 4 %
generic
benzoyl peroxide creamy wash liquid 8 %
generic
benzoyl peroxide foam 5.3 %
generic
benzoyl peroxide foam 9.8 %
generic
benzoyl peroxide gel 10 %
generic
benzoyl peroxide gel 2.5 %
generic
benzoyl peroxide gel 5 %
generic
benzoyl peroxide liquid 4.25 %
generic
benzoyl peroxide pad 3 %
generic
PAGE 132
TIER
PRODUCT DESCRIPTION
BRAND/GEN
generic
generic
benzoyl peroxide short contact foam 9.8 %
generic
benzoyl peroxide wash liquid 10 %
generic
benzoyl peroxide wash liquid 2.5 %
generic
generic
generic
benzoyl peroxide-erythromycin gel 5-3 %
generic
bp 10-1 emulsion 10-1 %
generic
bp cleanser liquid 4.25 %
generic
bp foam foam 9.8 %
generic
bp wash liquid 2.5 %
generic
bp wash liquid 5.25 %
generic
bp wash liquid 7 %
generic
cerisa wash emulsion 10-1 %
generic
claravis cap 10 mg
generic
QL
30 / 30 days
claravis cap 20 mg
generic
QL
30 / 30 days
CLARAVIS CAP 30 MG
isotretinoin
BRAND
QL
30 / 30 days
claravis cap 40 mg
generic
QL
30 / 30 days
clenia cream 10-5 %
generic
clenia foaming wash emulsion 10-5 %
generic
CLINDAGEL GEL 1 %
clindamycin phosphate (topical)
BRAND
clindamax gel 1 %
generic
clindamax lotion 1 %
generic
clindamycin phos-benzoyl perox gel 1-5 %
generic
clindamycin phos-benzoyl perox gel 1.2-5 %
generic
clindamycin phosphate foam 1 %
generic
clindamycin phosphate gel 1 %
generic
clindamycin phosphate lotion 1 %
generic
clindamycin phosphate solution 1 %
generic
clindamycin phosphate swab 1 %
generic
PAGE 133
TIER
PRODUCT DESCRIPTION
BRAND/GEN
DIFFERIN LOTION 0.1 %

adapalene
BRAND
EPIDUO GEL 0.1-2.5 %

adapalene-benzoyl peroxide
BRAND
ery pad 2 %
generic
ERYTHROMYCIN GEL 2 %
erythromycin (acne aid)
BRAND
erythromycin gel 2 %
generic
erythromycin pad 2 %
generic
erythromycin solution 2 %
generic
myorisan cap 10 mg
generic
QL
30 / 30 days
myorisan cap 20 mg
generic
QL
30 / 30 days
myorisan cap 40 mg
generic
QL
30 / 30 days
NEOBENZ MICRO PLUS PACK CREAM 5.5 %

benzoyl peroxide
BRAND
NEOBENZ MICRO SD CREAM 5.5 %

benzoyl peroxide
BRAND
oscion cleanser lotion 6 %
generic
oscion cleanser lotion 9 %
generic
pr benzoyl peroxide wash liquid 7 %
generic
prascion emulsion 10-5 %
generic
rosaderm emulsion 10-5 %
generic
rosaderm kit 10-5 %
generic
rosanil cleanser emulsion 10-5 %
generic
se 10-5 ss cream 10-5 %
generic
se bpo foaming cloths misc 3 %
generic
generic
generic
se bpo wash liquid 7 %
generic
sotret cap 10 mg
generic
QL
30 / 30 days
sotret cap 20 mg
generic
QL
30 / 30 days
sotret cap 30 mg
generic
QL
30 / 30 days
sulfacetamide sod-sulfur wash emulsion 10-5

%
generic
PAGE 134
TIER

PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
sulfacetamide sodium (acne) lotion 10 %
generic
sulfacetamide sodium suspension 10 %
generic
sulfacetamide sodium-sulfur cream 10-2 %
generic
sulfacetamide sodium-sulfur cream 10-5 %
generic
sulfacetamide sodium-sulfur emulsion 10-5 %
generic
sulfacetamide sodium-sulfur foam 10-5 %
generic
sulfacetamide sodium-sulfur liquid 10-2 %
generic
sulfacetamide sodium-sulfur liquid 9-4 %
generic
sulfacetamide sodium-sulfur liquid 9-4.5 %
generic
sulfacetamide sodium-sulfur lotion 10-5 %
generic
sulfacetamide sodium-sulfur pad 10-5 %
generic
sulfacetamide sodium-sulfur suspension 10-5

%
generic
sulfacetamide sodium-sulfur suspension 8-4 %
generic
sulfacleanse 8/4 suspension 8-4 %
generic
tl bpo mx cleanser liquid 4.25 %
generic
topisulf cream 10-5 %
generic
tretinoin cream 0.025 %
generic
generic
generic
tretinoin gel 0.01 %
generic
tretinoin gel 0.025 %
generic
tretinoin microsphere gel 0.04 %
generic
tretinoin microsphere gel 0.1 %
generic
tretinoin microsphere pump gel 0.04 %
generic
tretinoin microsphere pump gel 0.1 %
generic
virti-sulf cream 10-5 %
generic
zenatane cap 10 mg
generic
QL
30 / 30 days
zenatane cap 20 mg
generic
QL
30 / 30 days
zenatane cap 40 mg
generic
QL
30 / 30 days
zencia liquid 9-4 %
generic
*Agents for External Genital and Perianal Warts**
PAGE 135
PRODUCT DESCRIPTION
BRAND/GEN
TIER
VEREGEN OINTMENT 15 %
sinecatechins
BRAND
BRAND
QL
ALTABAX OINTMENT 1 %
retapamulin
BRAND
PA
CORTISPORIN CREAM 0.5-0.5-10000

neomycin-polymyxin-hc
BRAND
CORTISPORIN OINTMENT 1 %
bacitracin-polymyxin-neomycin hc
BRAND
gentamicin sulfate cream 0.1 %
generic
gentamicin sulfate ointment 0.1 %
generic
mupirocin calcium cream 2 %
generic
mupirocin ointment 2 %
generic
ciclodan cream 0.77 %
generic
ciclodan solution 8 %
generic
ciclopirox gel 0.77 %
generic
ciclopirox olamine cream 0.77 %
generic
ciclopirox olamine suspension 0.77 %
generic
ciclopirox shampoo 1 %
generic
ciclopirox solution 8 %
generic
ciclopirox treatment kit 8 %
generic
clotrimazole cream 1 %
generic
clotrimazole solution 1 %
generic
clotrimazole-betamethasone cream 1-0.05 %
generic
clotrimazole-betamethasone lotion 1-0.05 %
generic
econazole nitrate cream 1 %
generic
ERTACZO CREAM 2 %
sertaconazole nitrate
BRAND
PA
EXELDERM CREAM 1 %
sulconazole nitrate
BRAND
PA
EXELDERM SOLUTION 1 %
BRAND
PA
*Anti-inflammatory Agents - Topical**

VOLTAREN GEL 1 %
diclofenac sodium (topical)
300 / 30 days
*Antibiotics - Topical**
*Antifungals - Topical**
PAGE 136
PRODUCT DESCRIPTION
BRAND/GEN
TIER
sulconazole nitrate
ketoconazole cream 2 %
generic
ketoconazole foam 2 %
generic
ketoconazole shampoo 2 %
generic
MENTAX CREAM 1 %
butenafine hcl
BRAND
NAFTIN CREAM 1 %
naftifine hcl
BRAND
NAFTIN CREAM 2 %
naftifine hcl
BRAND
NAFTIN GEL 1 %
naftifine hcl
BRAND
NAFTIN GEL 2 %
naftifine hcl
BRAND
nyamyc powder 100000 unit/gm
generic
nystatin cream 100000 unit/gm
generic
nystatin ointment 100000 unit/gm
generic
nystatin powder 100000 unit/gm
generic
nystatin-triamcinolone cream 100000-0.1

unit/gm-%
generic
NYSTATIN-TRIAMCINOLONE CREAM
100000-0.1 UNIT/GM-%
nystatin-triamcinolone
BRAND
nystatin-triamcinolone ointment 100000-0.1

unit/gm-%
generic
nystop powder 100000 unit/gm
generic
OXISTAT CREAM 1 %
oxiconazole nitrate
BRAND
OXISTAT LOTION 1 %
oxiconazole nitrate
BRAND
pedi-dri powder 100000 unit/gm
generic
PEDIPIROX-4 NAIL KIT 8 %

ciclopirox
BRAND
*Antineoplastic or Premalignant Lesion Agents - Topical**

fluorouracil cream 5 %
generic
fluorouracil solution 2 %
generic
fluorouracil solution 5 %
generic
PAGE 137
PRODUCT DESCRIPTION
BRAND/GEN
TIER
PANRETIN GEL 0.1 %

alitretinoin
BRAND
PICATO GEL 0.015 %

ingenol mebutate
BRAND
PICATO GEL 0.05 %

ingenol mebutate
BRAND
TARGRETIN GEL 1 %
bexarotene (topical)
BRAND
PA
VALCHLOR GEL 0.016 %

mechlorethamine hcl (topical)
BRAND
PA
PRUDOXIN CREAM 5 %
doxepin hcl (antipruritic)
BRAND
ZONALON CREAM 5 %
doxepin hcl (antipruritic)
BRAND
8-MOP CAP 10 MG
methoxsalen
BRAND
PA
acitretin cap 10 mg
generic
PA
acitretin cap 17.5 mg
generic
PA
acitretin cap 25 mg
generic
PA
AMEVIVE RECON SOLN 15 MG

alefacept
BRAND
PA
calcipotriene cream 0.005 %
generic
calcipotriene ointment 0.005 %
generic
calcipotriene solution 0.005 %
generic
calcitrene ointment 0.005 %
generic
calcitriol ointment 3 mcg/gm
generic
SORIATANE CAP 10 MG
acitretin
BRAND
SORIATANE CAP 17.5 MG

acitretin
BRAND
SORIATANE CAP 22.5 MG

acitretin
BRAND
SORIATANE CAP 25 MG
acitretin
BRAND
STELARA 45 MG/0.5ML
BRAND
PA
*Antipruritics - Topical**
*Antipsoriatics**
PAGE 138
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ustekinumab
STELARA SOLN PRSYR 45 MG/0.5ML
ustekinumab
BRAND
STELARA SOLN PRSYR 90 MG/ML

ustekinumab
BRAND
TAZORAC CREAM 0.05 %

tazarotene
BRAND
PA
TAZORAC CREAM 0.1 %

tazarotene
BRAND
PA
TAZORAC GEL 0.05 %

tazarotene
BRAND
PA
TAZORAC GEL 0.1 %

tazarotene
BRAND
PA
VECTICAL OINTMENT 3 MCG/GM

calcitriol (topical)
BRAND
re 10 wash liquid 10 %
generic
seb-prev wash liquid 10 %
generic
selenium sulfide lotion 2.5 %
generic
sodium sulfacetamide shampoo 10 %
generic
sulfacetamide sodium gel 10 % (cleans)
generic
sulfacetamide sodium liquid 10 %
generic
sulfacetamide sodium powder
generic
acyclovir ointment 5 %
generic
DENAVIR CREAM 1 %
penciclovir
BRAND
mafenide acetate packet 5 %
generic
silver sulfadiazine cream 1 %
generic
ssd af cream 1 %
generic
ssd cream 1 %
generic
thermazene cream 1 %
generic
generic
*Antiseborrheic Products**
*Antivirals - Topical**
*Burn Products**
*Corticosteroids - Topical**
ala cort cream 1 %
PAGE 139
PRODUCT DESCRIPTION
BRAND/GEN
alclometasone dipropionate cream 0.05 %
generic
alclometasone dipropionate ointment 0.05 %
generic
amcinonide cream 0.1 %
generic
amcinonide lotion 0.1 %
generic
amcinonide ointment 0.1 %
generic
beta-val cream 0.1 %
generic
beta-val lotion 0.1 %
generic
betamethasone dipropionate aug cream 0.05 %
generic
betamethasone dipropionate aug gel 0.05 %
generic
betamethasone dipropionate aug lotion 0.05 %
generic
betamethasone dipropionate aug ointment 0.05

%
generic
betamethasone dipropionate cream 0.05 %
generic
betamethasone dipropionate lotion 0.05 %
generic
betamethasone dipropionate ointment 0.05 %
generic
betamethasone valerate cream 0.1 %
generic
betamethasone valerate foam 0.12 %
generic
betamethasone valerate lotion 0.1 %
generic
betamethasone valerate ointment 0.1 %
generic
BETAMETHASONE VALERATE OINTMENT

0.1 %
betamethasone valerate
BRAND
calcipotriene-betameth diprop ointment 0.0050.064 %
generic
clobetasol propionate cream 0.05 %
generic
clobetasol propionate foam 0.05 %
generic
clobetasol propionate gel 0.05 %
generic
clobetasol propionate lotion 0.05 %
generic
clobetasol propionate ointment 0.05 %
generic
clobetasol propionate shampoo 0.05 %
generic
clobetasol propionate solution 0.05 %
generic
clocortolone pivalate cream 0.1 %
generic
clocortolone pivalate pump cream 0.1 %
generic
CORDRAN CREAM 0.05 %
BRAND
PAGE 140
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
flurandrenolide
CORDRAN LOTION 0.05 %
flurandrenolide
BRAND
CORDRAN TAPE 4 MCG/SQCM

flurandrenolide
BRAND
cormax ointment 0.05 %
generic
cormax scalp application solution 0.05 %
generic
cormax solution 0.05 %
generic
desonide cream 0.05 %
generic
desonide lotion 0.05 %
generic
desonide ointment 0.05 %
generic
DESOXIMETASONE CREAM 0.05 %

desoximetasone
BRAND
desoximetasone cream 0.25 %
generic
desoximetasone gel 0.05 %
generic
DESOXIMETASONE OINTMENT 0.05 %

desoximetasone
BRAND
desoximetasone ointment 0.25 %
generic
DIFLORASONE DIACETATE CREAM 0.05 %

diflorasone diacetate
BRAND
diflorasone diacetate ointment 0.05 %
generic
FIRST-HYDROCORTISONE GEL 10 %
hydrocortisone (topical)
BRAND
fluocinolone acetonide body oil 0.01 %
generic
fluocinolone acetonide cream 0.01 %
generic
fluocinolone acetonide cream 0.025 %
generic
fluocinolone acetonide ointment 0.025 %
generic
fluocinolone acetonide scalp oil 0.01 %
generic
fluocinolone acetonide solution 0.01 %
generic
fluocinonide cream 0.05 %
generic
fluocinonide cream 0.1 %
generic
fluocinonide gel 0.05 %
generic
fluocinonide ointment 0.05 %
generic
fluocinonide solution 0.05 %
generic
fluticasone propionate cream 0.05 %
generic
PAGE 141
PRODUCT DESCRIPTION
BRAND/GEN
fluticasone propionate lotion 0.05 %
generic
fluticasone propionate ointment 0.005 %
generic
halobetasol propionate cream 0.05 %
generic
halobetasol propionate ointment 0.05 %
generic
HALOG CREAM 0.1 %

halcinonide
BRAND
HALOG OINTMENT 0.1 %

halcinonide
BRAND
hydrocortisone ace-pramoxine cream 2.5-1 %
generic
hydrocortisone acetate lotion 2 %
generic
hydrocortisone butyr lipo base cream 0.1 %
generic
hydrocortisone butyrate cream 0.1 %
generic
hydrocortisone butyrate ointment 0.1 %
generic
hydrocortisone butyrate solution 0.1 %
generic
hydrocortisone cream 1 %
generic
hydrocortisone cream 2.5 %
generic
hydrocortisone lotion 2.5 %
generic
hydrocortisone ointment 1 %
generic
hydrocortisone ointment 2.5 %
generic
hydrocortisone powder
generic
hydrocortisone valerate cream 0.2 %
generic
hydrocortisone valerate ointment 0.2 %
generic
lokara lotion 0.05 %
generic
LUXIQ FOAM 0.12 %

betamethasone valerate
BRAND
mometasone furoate cream 0.1 %
generic
mometasone furoate ointment 0.1 %
generic
mometasone furoate solution 0.1 %
generic
PRAMOSONE CREAM 1-2.5 %

pramoxine-hc
BRAND
prednicarbate cream 0.1 %
generic
prednicarbate ointment 0.1 %
generic
scalacort lotion 2 %
generic
TACLONEX SUSPENSION 0.005-0.064 %
BRAND
PAGE 142
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
calcipotriene-betamethasone dipropionate
TOPICORT CREAM 0.05 %
desoximetasone
BRAND
TOPICORT OINTMENT 0.05 %

desoximetasone
BRAND
triamcinolone acetonide cream 0.025 %
generic
generic
generic
triamcinolone acetonide lotion 0.025 %
generic
triamcinolone acetonide lotion 0.1 %
generic
triamcinolone acetonide ointment 0.025 %
generic
generic
TRIAMCINOLONE ACETONIDE OINTMENT

0.5 %
triamcinolone acetonide (topical)
BRAND
generic
TRIAMCINOLONE IN ABSORBASE
OINTMENT 0.05 %
BRAND
TRIANEX OINTMENT 0.05 %

BRAND
triderm cream 0.1 %
generic
VERDESO FOAM 0.05 %

desonide
BRAND
BRAND
BOTOX COSMETIC RECON SOLN 100 UNIT

onabotulinumtoxina (cosmetic)
BRAND
BOTOX COSMETIC RECON SOLN 50 UNIT

onabotulinumtoxina (cosmetic)
BRAND
DYSPORT (GLABELLAR LINES) RECON

SOLN 300 UNIT
abobotulinumtoxina (glabellar lines)
BRAND
generic
*Enzymes - Topical**
SANTYL OINTMENT 250 UNIT/GM
collagenase
*Glabellar Lines (Frown Lines) Agents**
*Immunomodulating Agents - Topical**

imiquimod cream 5 %
PAGE 143
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Immunosuppressive Agents - Topical**

QL
ELIDEL CREAM 1 %
pimecrolimus
BRAND
PROTOPIC OINTMENT 0.03 %

tacrolimus (topical)
BRAND
PROTOPIC OINTMENT 0.1 %

tacrolimus (topical)
BRAND
30 / 30 days
3
ST
QL
30 / 30 days
3
ST
QL
30 / 30 days
3
ST
*Keratolytic/Antimitotic Agents**
aliclen shampoo 6 %
generic
podofilox solution 0.5 %
generic
re sa cream 6 %
generic
re sa lotion 6 %
generic
salacyn cream 6 %
generic
salacyn lotion 6 %
generic
salicylic acid cream 6 %
generic
salicylic acid foam 6 %
generic
salicylic acid gel 6 %
generic
salicylic acid lotion 6 %
generic
salicylic acid shampoo 6 %
generic
lidocaine hcl cream 3 %
generic
lidocaine hcl gel 2 %
generic
lidocaine hcl lotion 3 %
generic
lidocaine hcl solution 4 %
generic
lidocaine ointment 5 %
generic
lidocaine patch 5 %
generic
lidocaine-prilocaine cream 2.5-2.5 %
generic
lidocaine-prilocaine kit 2.5-2.5 %
generic
QUTENZA (2 PATCH) KIT 8 %

capsaicin & cleansing gel
BRAND
PA
QUTENZA KIT 8 %
capsaicin & cleansing gel
BRAND
PA
*Local Anesthetics - Topical**
PA
PAGE 144
PRODUCT DESCRIPTION
BRAND/GEN
SYNERA PATCH 70-70 MG

lidocaine-tetracaine
BRAND
TIER

PA
*Pigmenting-Depigmenting Agents**
OXSORALEN LOTION 1 %
methoxsalen (topical)
BRAND
BRAND
acticin cream 5 %
generic
EURAX CREAM 10 %
crotamiton
BRAND
EURAX LOTION 10 %
crotamiton
BRAND
lindane lotion 1 %
generic
lindane shampoo 1 %
generic
malathion lotion 0.5 %
generic
permethrin cream 5 %
generic
SKLICE LOTION 0.5 %

ivermectin (pediculicide)
BRAND
SPINOSAD SUSPENSION 0.9 %

spinosad
BRAND
ULESFIA LOTION 5 %
benzyl alcohol (pediculicide)
BRAND
APLIGRAF DISK
cultured skin substitute
BRAND
REGRANEX GEL 0.01 %

becaplermin
BRAND
cosyntropin recon soln 0.25 mg
generic
THYROGEN RECON SOLN 1.1 MG

thyrotropin alfa
BRAND
PA
*Rosacea Agents**
FINACEA GEL 15 %
azelaic acid
*Scabicides & Pediculicides**
*Wound Care Products**
*DIAGNOSTIC PRODUCTS*
*Diagnostic Drugs**
PA
*Diagnostic Tests**
PAGE 145
PRODUCT DESCRIPTION
BRAND/GEN
TIER
CVS ADVANCED GLUCOSE TEST STRIP

glucose blood
BRAND
FREESTYLE INSULINX TEST STRIP

glucose blood
BRAND
GHT TEST STRIP

glucose blood
BRAND
ONETOUCH ULTRA BLUE STRIP

glucose blood
BRAND
TRUETEST TEST STRIP

glucose blood
BRAND
TRUETRACK TEST STRIP

glucose blood
BRAND
CREON CP DR PART 12000 UNIT

pancrelipase (lipase-protease-amylase)
BRAND

BRAND
CREON CP DR PART 3000-9500 UNIT

BRAND

BRAND

BRAND
PANCREAZE CP DR PART 10500 UNIT

BRAND

BRAND

BRAND

BRAND
pancrelipase (lip-prot-amyl) cp dr part 5000 unit
generic
PERTZYE CP DR PART 16000 UNIT

BRAND
PERTZYE CP DR PART 8000 UNIT

BRAND
SUCRAID SOLUTION 8500 UNIT/ML

sacrosidase
BRAND
*DIGESTIVE AIDS*
*Digestive Enzymes**
PA
PAGE 146
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ULTRESA CP DR PART 13800 UNIT

BRAND

BRAND

BRAND
VIOKACE TAB 10440 UNIT

BRAND
VIOKACE TAB 20880 UNIT

BRAND
ZENPEP CP DR PART 10000 UNIT

BRAND

BRAND

BRAND

BRAND
ZENPEP CP DR PART 3000-10000 UNIT

BRAND
zenpep cp dr part 5000 unit
generic
acetazolamide er cap er 12h 500 mg
generic
acetazolamide tab 125 mg
generic
acetazolamide tab 250 mg
generic
methazolamide tab 25 mg
generic
methazolamide tab 50 mg
generic
ALDACTAZIDE TAB 50-50 MG

spironolactone & hydrochlorothiazide
BRAND
amiloride-hydrochlorothiazide tab 5-50 mg
generic
spironolactone-hctz tab 25-25 mg
generic
triamterene-hctz cap 37.5-25 mg
generic
triamterene-hctz cap 50-25 mg
generic
triamterene-hctz tab 37.5-25 mg
generic
*DIURETICS*
*Carbonic Anhydrase Inhibitors**
*Diuretic Combinations**
PAGE 147
PRODUCT DESCRIPTION
BRAND/GEN
triamterene-hctz tab 75-50 mg
generic
TIER
*Loop Diuretics**
bumetanide tab 0.5 mg
generic
bumetanide tab 1 mg
generic
bumetanide tab 2 mg
generic
EDECRIN TAB 25 MG
ethacrynic acid
BRAND
furosemide solution 10 mg/ml
generic
furosemide solution 40 mg/4ml
generic
furosemide solution 8 mg/ml
generic
furosemide tab 20 mg
generic
generic
generic
torsemide tab 10 mg
generic
torsemide tab 100 mg
generic
torsemide tab 20 mg
generic
torsemide tab 5 mg
generic
amiloride hcl tab 5 mg
generic
DYRENIUM CAP 100 MG

triamterene
BRAND
PA
DYRENIUM CAP 50 MG
triamterene
BRAND
PA
spironolactone tab 100 mg
generic
generic
generic
chlorothiazide tab 250 mg
generic
chlorothiazide tab 500 mg
generic
chlorthalidone tab 25 mg
generic
CHLORTHALIDONE TAB 25 MG
chlorthalidone
BRAND
chlorthalidone tab 50 mg
generic
DIURIL SUSPENSION 250 MG/5ML
BRAND
*Potassium Sparing Diuretics**
*Thiazides and Thiazide-Like Diuretics**
PAGE 148
PRODUCT DESCRIPTION
BRAND/GEN
TIER
chlorothiazide
hydrochlorothiazide cap 12.5 mg
generic
hydrochlorothiazide tab 12.5 mg
generic
hydrochlorothiazide tab 25 mg
generic
hydrochlorothiazide tab 50 mg
generic
indapamide tab 1.25 mg
generic
indapamide tab 2.5 mg
generic
methyclothiazide tab 5 mg
generic
metolazone tab 10 mg
generic
metolazone tab 2.5 mg
generic
metolazone tab 5 mg
generic
*ENDOCRINE AND METABOLIC AGENTS - MISC.*

*Bone Density Regulators**
alendronate sodium tab 10 mg
generic
QL
30 / 30 days
generic
QL
4 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
4 / 30 days
AREDIA RECON SOLN 30 MG

pamidronate disodium
BRAND
AREDIA RECON SOLN 90 MG

BRAND
calcitonin (salmon) solution 200 unit/act
generic
etidronate disodium tab 200 mg
generic
etidronate disodium tab 400 mg
generic
FORTEO SOLUTION 600 MCG/2.4ML

teriparatide (recombinant)
BRAND
FORTICAL SOLUTION 200 UNIT/ACT

calcitonin (salmon)
BRAND
ibandronate sodium solution 3 mg/3ml
generic
ibandronate sodium tab 150 mg
generic
pamidronate disodium recon soln 30 mg
generic
PA
PA
PA
PAGE 149
PRODUCT DESCRIPTION
BRAND/GEN
TIER
pamidronate disodium recon soln 90 mg
generic
pamidronate disodium solution 30 mg/10ml
generic
PA
PAMIDRONATE DISODIUM SOLUTION 6

MG/ML
BRAND
PA
pamidronate disodium solution 90 mg/10ml
generic
PA
PROLIA SOLUTION 60 MG/ML

denosumab
BRAND
PA
RECLAST SOLUTION 5 MG/100ML

zoledronic acid
BRAND
PA
SKELID TAB 200 MG

tiludronate disodium
BRAND
XGEVA SOLUTION 120 MG/1.7ML

denosumab
BRAND
PA
zoledronic acid conc 4 mg/5ml
generic
PA
ZOLEDRONIC ACID RECON SOLN 4 MG

zoledronic acid
BRAND
PA
ZOLEDRONIC ACID SOLUTION 4 MG/100ML

zoledronic acid
BRAND
PA
zoledronic acid solution 5 mg/100ml
generic
PA
ACTHAR HP GEL 80 UNIT/ML

corticotropin
BRAND
PA
HP ACTHAR GEL 80 UNIT/ML

corticotropin
BRAND
PA
BRAVELLE RECON SOLN 75 UNIT

urofollitropin purified
BRAND
PA
chorionic gonadotropin recon soln 10000 unit
generic
PA
clomiphene citrate tab 50 mg
generic
PA
FOLLISTIM AQ SOLUTION 150 UNT/0.5ML

follitropin beta
BRAND
PA

follitropin beta
BRAND
PA

follitropin beta
BRAND
PA
PA
*Corticotropin**
*Fertility Regulators**
PAGE 150
PRODUCT DESCRIPTION
BRAND/GEN
TIER

follitropin beta
BRAND

follitropin beta
BRAND
PA
GONAL-F RECON SOLN 1050 UNIT

follitropin alfa
BRAND
PA
GONAL-F RECON SOLN 450 UNIT

follitropin alfa
BRAND
PA
GONAL-F RFF PEN SOLUTION 300

UNIT/0.5ML
follitropin alfa
BRAND
PA

UNT/0.75ML
follitropin alfa
BRAND
PA

UNIT/1.5ML
follitropin alfa
BRAND
PA
GONAL-F RFF RECON SOLN 75 UNIT

follitropin alfa
BRAND
PA
LUVERIS RECON SOLN 75 UNIT

lutropin alfa
BRAND
PA
novarel recon soln 10000 unit
generic
PA
OVIDREL INJECTABLE 250 MCG/0.5ML

choriogonadotropin alfa
BRAND
PA
pregnyl recon soln 10000 unit
generic
PA
REPRONEX RECON SOLN 75 UNIT

menotropins
BRAND
PA
serophene tab 50 mg
generic
PA
CETROTIDE KIT 0.25 MG

cetrorelix acetate
BRAND
PA
CETROTIDE KIT 3 MG
cetrorelix acetate
BRAND
PA
GANIRELIX ACETATE SOLUTION 250

MCG/0.5ML
ganirelix acetate
BRAND
PA
BRAND
PA
PA
*GnRH/LHRH Antagonists**
*Growth Hormone Receptor Antagonists**

SOMAVERT RECON SOLN 10 MG
pegvisomant
PAGE 151
PRODUCT DESCRIPTION
BRAND/GEN
TIER

pegvisomant
BRAND
PA

pegvisomant
BRAND
PA
EGRIFTA RECON SOLN 1 MG

tesamorelin acetate
BRAND
PA
EGRIFTA RECON SOLN 2 MG

tesamorelin acetate
BRAND
PA
GENOTROPIN MINIQUICK RECON SOLN 0.2

MG
somatropin
BRAND
PA

MG
somatropin
BRAND
PA

MG
somatropin
BRAND
PA

MG
somatropin
BRAND
PA
GENOTROPIN MINIQUICK RECON SOLN 1

MG
somatropin
BRAND
PA

MG
somatropin
BRAND
PA

MG
somatropin
BRAND
PA

MG
somatropin
BRAND
PA

MG
somatropin
BRAND
PA
GENOTROPIN MINIQUICK RECON SOLN 2

MG
somatropin
BRAND
PA
GENOTROPIN RECON SOLN 12 MG

somatropin
BRAND
PA
*Growth Hormone Releasing Hormones (GHRH)**
*Growth Hormones**
PAGE 152
PRODUCT DESCRIPTION
BRAND/GEN
GENOTROPIN RECON SOLN 5 MG

somatropin
BRAND
PA
HUMATROPE RECON SOLN 12 MG

somatropin
BRAND
PA

somatropin
BRAND
PA

somatropin
BRAND
PA

somatropin
BRAND
PA
NORDITROPIN FLEXPRO SOLUTION 10

MG/1.5ML
somatropin
BRAND
PA

MG/1.5ML
somatropin
BRAND
PA

MG/1.5ML
somatropin
BRAND
PA
NORDITROPIN NORDIFLEX PEN SOLUTION

10 MG/1.5ML
somatropin
BRAND
PA

15 MG/1.5ML
somatropin
BRAND
PA

30 MG/3ML
somatropin
BRAND
PA

5 MG/1.5ML
somatropin
BRAND
PA
NORDITROPIN SOLUTION 15 MG/1.5ML

somatropin
BRAND
PA
NORDITROPIN SOLUTION 5 MG/1.5ML

somatropin
BRAND
PA
NUTROPIN AQ NUSPIN 10 SOLUTION 10

MG/2ML
somatropin
BRAND
PA

MG/2ML
somatropin
BRAND
PA

MG/2ML
BRAND
PA
PAGE 153
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
somatropin
NUTROPIN AQ PEN SOLUTION 10 MG/2ML
somatropin
BRAND
PA
NUTROPIN AQ PEN SOLUTION 20 MG/2ML

somatropin
BRAND
PA
NUTROPIN AQ SOLUTION 10 MG/2ML

somatropin
BRAND
PA
NUTROPIN RECON SOLN 10 MG

somatropin
BRAND
PA
OMNITROPE RECON SOLN 5.8 MG

somatropin
BRAND
PA
OMNITROPE SOLUTION 10 MG/1.5ML

somatropin
BRAND
PA
OMNITROPE SOLUTION 5 MG/1.5ML

somatropin
BRAND
PA
SAIZEN CLICK.EASY RECON SOLN 8.8 MG

somatropin (non-refrigerated)
BRAND
PA
SAIZEN RECON SOLN 5 MG

BRAND
PA
SAIZEN RECON SOLN 8.8 MG

BRAND
PA
SEROSTIM RECON SOLN 4 MG

BRAND
PA

BRAND
PA

BRAND
PA
TEV-TROPIN RECON SOLN 5 MG

somatropin
BRAND
PA
ZORBTIVE RECON SOLN 8.8 MG

BRAND
PA
generic
BRAND
PA
PA
*Hormone Receptor Modulators**

raloxifene hcl tab 60 mg
*Insulin-Like Growth Factors (Somatomedins)**
INCRELEX SOLUTION 40 MG/4ML
mecasermin
*LHRH/GnRH Agonist Analog Pituitary Suppressants**

LUPRON DEPOT-PED KIT 11.25 MG
leuprolide acetate (cpp)
PAGE 154
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
TIER
LUPRON DEPOT-PED KIT 11.25 MG (PED)

leuprolide acetate (cpp) (3 month)
BRAND
PA
LUPRON DEPOT-PED KIT 15 MG

BRAND
PA
LUPRON DEPOT-PED KIT 30 MG (PED)

leuprolide acetate (cpp) (3 month)
BRAND
PA
LUPRON DEPOT-PED KIT 7.5 MG

BRAND
PA
SUPPRELIN LA KIT 50 MG
histrelin acetate (cpp)
BRAND
PA
SYNAREL SOLUTION 2 MG/ML

nafarelin acetate
BRAND
PA
ALDURAZYME SOLUTION 2.9 MG/5ML

laronidase
BRAND
PA
BUPHENYL POWDER 3 GM/TSP

sodium phenylbutyrate
BRAND
BUPHENYL TAB 500 MG

sodium phenylbutyrate
BRAND
calcitriol cap 0.25 mcg
generic
calcitriol cap 0.5 mcg
generic
CARBAGLU TAB 200 MG

carglumic acid
BRAND
CYSTADANE POWDER
betaine
BRAND
doxercalciferol cap 0.5 mcg
generic
doxercalciferol cap 1 mcg
generic
doxercalciferol cap 2.5 mcg
generic
ELAPRASE SOLUTION 6 MG/3ML

idursulfase
BRAND
FABRAZYME RECON SOLN 35 MG

agalsidase beta
BRAND
PA
FABRAZYME RECON SOLN 5 MG

agalsidase beta
BRAND
PA
KUVAN PACKET 100 MG

sapropterin dihydrochloride
BRAND
PA
KUVAN TAB SOL 100 MG

sapropterin dihydrochloride
BRAND
PA
LUMIZYME RECON SOLN 50 MG
BRAND
PA
*Metabolic Modifiers**
PAGE 155
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
alglucosidase alfa
MYALEPT RECON SOLN 11.3 MG
metreleptin
BRAND
MYOZYME RECON SOLN 50 MG

alglucosidase alfa
BRAND
PA
NAGLAZYME SOLUTION 1 MG/ML

galsulfase
BRAND
PA
ORFADIN CAP 10 MG
nitisinone
BRAND
PA
ORFADIN CAP 2 MG
nitisinone
BRAND
PA
ORFADIN CAP 5 MG
nitisinone
BRAND
PA
paricalcitol cap 1 mcg
generic
generic
generic
RAVICTI LIQUID 1.1 GM/ML

glycerol phenylbutyrate
BRAND
SENSIPAR TAB 30 MG
cinacalcet hcl
BRAND
SENSIPAR TAB 60 MG
cinacalcet hcl
BRAND
SENSIPAR TAB 90 MG
cinacalcet hcl
BRAND
sodium phenylbutyrate powder 3 gm/tsp
generic
VIMIZIM SOLUTION 5 MG/5ML

elosulfase alfa
BRAND
desmopressin ace rhinal tube solution 0.01 %
generic
MPL
3 / 30 days
desmopressin ace spray refrig solution 0.01 %
generic
MPL
3 / 30 days
desmopressin acetate spray solution 0.01 %
generic
MPL
3 / 30 days
desmopressin acetate tab 0.1 mg
generic
QL
90 / 30 days
desmopressin acetate tab 0.2 mg
generic
QL
90 / 30 days
minirin 0.1 mg/ml
generic
STIMATE SOLUTION 1.5 MG/ML

desmopressin acetate
BRAND
PA
*Posterior Pituitary Hormones**
PAGE 156
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Prolactin Inhibitors**
cabergoline tab 0.5 mg
generic
octreotide acetate solution 100 mcg/ml
generic
PA
octreotide acetate solution 1000 mcg/5ml
generic
PA
generic
PA
generic
PA
generic
PA
generic
PA
SANDOSTATIN LAR DEPOT KIT 10 MG

octreotide acetate
BRAND
PA

octreotide acetate
BRAND
PA

octreotide acetate
BRAND
PA
SANDOSTATIN SOLUTION 100 MCG/ML

octreotide acetate
BRAND

octreotide acetate
BRAND

octreotide acetate
BRAND

octreotide acetate
BRAND

octreotide acetate
BRAND
SIGNIFOR SOLUTION 0.3 MG/ML

pasireotide diaspartate
BRAND
PA

BRAND
PA

BRAND
PA
SOMATULINE DEPOT SOLUTION 120

MG/0.5ML
lanreotide acetate
BRAND
PA

MG/0.2ML
lanreotide acetate
BRAND
PA
*Somatostatic Agents**
PAGE 157
PRODUCT DESCRIPTION
BRAND/GEN
TIER

MG/0.3ML
lanreotide acetate
BRAND
PA
SAMSCA TAB 15 MG
tolvaptan
BRAND
PA
SAMSCA TAB 30 MG
tolvaptan
BRAND
PA
CLIMARA PRO PATCH WK 0.045-0.015

MG/DAY
estradiol-levonorgestrel
BRAND
covaryx hs tab 0.625-1.25 mg
generic
covaryx tab 1.25-2.5 mg
generic
eemt hs tab 0.625-1.25 mg
generic
eemt tab 1.25-2.5 mg
generic
essian h.s. tab 0.625-1.25 mg
generic
essian tab 1.25-2.5 mg
generic
est estrogens-methyltest ds tab 1.25-2.5 mg
generic
est estrogens-methyltest hs tab 0.625-1.25 mg
generic
est estrogens-methyltest tab 1.25-2.5 mg
generic
PREMPHASE TAB 0.625-5 MG

conjugated estrogens-medroxyprogesterone
acetate
BRAND
PREMPRO TAB 0.3-1.5 MG

acetate
BRAND

acetate
BRAND

acetate
BRAND
PREMPRO TAB 0.625-5 MG

acetate
BRAND
*Vasopressin Receptor Antagonists**
*ESTROGENS*
*Estrogen Combinations**
*Estrogens**
PAGE 158
PRODUCT DESCRIPTION
BRAND/GEN
CENESTIN TAB 0.3 MG

estrogens, conjugated synthetic a
BRAND
CENESTIN TAB 0.45 MG

BRAND

BRAND
CENESTIN TAB 0.9 MG

BRAND

BRAND
DELESTROGEN OIL 10 MG/ML

estradiol valerate
BRAND
DEPO-ESTRADIOL OIL 5 MG/ML

estradiol cypionate
BRAND
DIVIGEL GEL 0.25 MG/0.25GM

estradiol
BRAND
DIVIGEL GEL 0.5 MG/0.5GM

estradiol
BRAND
DIVIGEL GEL 1 MG/GM

estradiol
BRAND
ELESTRIN GEL 0.52 MG/0.87 GM (0.06%)

estradiol
BRAND
ENJUVIA TAB 0.3 MG

estrogens, conjugated synthetic b
BRAND
ENJUVIA TAB 0.45 MG

BRAND
ENJUVIA TAB 0.625 MG

BRAND
ENJUVIA TAB 0.9 MG

BRAND
ENJUVIA TAB 1.25 MG

BRAND
estradiol patch wk 0.025 mg/24hr
generic
generic
generic
generic
generic
generic
estradiol tab 0.5 mg
generic
PAGE 159
TIER
PA
PRODUCT DESCRIPTION
BRAND/GEN
estradiol tab 1 mg
generic
estradiol tab 2 mg
generic
ESTRASORB EMULSION 4.35 MG/1.74GM

estradiol
BRAND
ESTROGEL GEL 0.75 MG/1.25 GM (0.06%)

estradiol
BRAND
estropipate tab 0.75 mg
generic
estropipate tab 1.5 mg
generic
estropipate tab 3 mg
generic
ESTROPIPATE TAB 3 MG
estropipate
BRAND
EVAMIST SOLUTION 1.53 MG/SPRAY

estradiol
BRAND
MENEST TAB 0.3 MG

esterified estrogens
BRAND
MENEST TAB 0.625 MG

BRAND
MENEST TAB 1.25 MG

BRAND
MENEST TAB 2.5 MG

BRAND
MENOSTAR PATCH WK 14 MCG/24HR

estradiol
BRAND
PREMARIN RECON SOLN 25 MG

estrogens, conjugated
BRAND
PREMARIN TAB 0.3 MG

BRAND
PREMARIN TAB 0.45 MG

BRAND

BRAND
PREMARIN TAB 0.9 MG

BRAND

BRAND
VIVELLE-DOT PATCH TW 0.025 MG/24HR

estradiol
BRAND

estradiol
BRAND
PAGE 160
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER

estradiol
BRAND

estradiol
BRAND

estradiol
BRAND
AVELOX SOLUTION 400 MG/250ML

moxifloxacin hcl in sodium chloride
BRAND
ciprofloxacin hcl tab 100 mg
generic
generic
generic
generic
ciprofloxacin in d5w solution 200 mg/100ml
generic
PA
ciprofloxacin in d5w solution 400 mg/200ml
generic
PA
ciprofloxacin solution 1200 mg/120ml
generic
PA
generic
PA
generic
PA
ciprofloxacin-ciproflox hcl er tab er 24h 1000

mg
generic
ciprofloxacin-ciproflox hcl er tab er 24h 500 mg
generic
FACTIVE TAB 320 MG

gemifloxacin mesylate
BRAND
levofloxacin in d5w solution 250 mg/50ml
generic
PA
generic
PA
generic
PA
levofloxacin solution 25 mg/ml
generic
PA
levofloxacin tab 250 mg
generic
generic
generic
moxifloxacin hcl tab 400 mg
generic
NOROXIN TAB 400 MG
BRAND
*FLUOROQUINOLONES*
*Fluoroquinolones**
PAGE 161
PRODUCT DESCRIPTION
BRAND/GEN
TIER
norfloxacin
ofloxacin tab 200 mg
generic
generic
generic
OFLOXACIN TAB 400 MG

ofloxacin
BRAND
ursodiol cap 300 mg
generic
ursodiol tab 250 mg
generic
ursodiol tab 500 mg
generic
AMITIZA CAP 24 MCG

lubiprostone
BRAND
AMITIZA CAP 8 MCG

lubiprostone
BRAND
metoclopramide hcl solution 1 mg/ml
generic
metoclopramide hcl solution 10 mg/10ml
generic
metoclopramide hcl solution 5 mg/5ml
generic
metoclopramide hcl solution 5 mg/ml
generic
metoclopramide hcl tab 10 mg
generic
metoclopramide hcl tab 5 mg
generic
APRISO CAP ER 24H 0.375 GM

mesalamine
BRAND
ASACOL HD TAB DR 800 MG

mesalamine
BRAND
ASACOL TAB DR 400 MG

mesalamine
BRAND
balsalazide disodium cap 750 mg
generic
CANASA SUPPOS 1000 MG

mesalamine
BRAND
CIMZIA KIT 2 X 200 MG

certolizumab pegol
BRAND
*GASTROINTESTINAL AGENTS - MISC.*

*Gallstone Solubilizing Agents**
*Gastrointestinal Chloride Channel Activators**
*Gastrointestinal Stimulants**
PA
*Inflammatory Bowel Agents**
PAGE 162
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
CIMZIA PREFILLED KIT 2 X 200 MG/ML

certolizumab pegol
BRAND
PA
CIMZIA STARTER KIT KIT 6 X 200 MG/ML

certolizumab pegol
BRAND
PA
DELZICOL CAP DR 400 MG

mesalamine
BRAND
DIPENTUM CAP 250 MG

olsalazine sodium
BRAND
LIALDA TAB DR 1.2 GM

mesalamine
BRAND
mesalamine enema 4 gm
generic
PENTASA CAP ER 250 MG

mesalamine
BRAND
PENTASA CAP ER 500 MG

mesalamine
BRAND
REMICADE RECON SOLN 100 MG

infliximab
BRAND
SFROWASA ENEMA 4 GM/60ML

mesalamine
BRAND
sulfasalazine tab 500 mg
generic
sulfasalazine tab dr 500 mg
generic
sulfazine ec tab dr 500 mg
generic
sulfazine tab 500 mg
generic
enulose solution 10 gm/15ml
generic
generlac solution 10 gm/15ml
generic
lactulose encephalopathy solution 10 gm/15ml
generic
LOTRONEX TAB 0.5 MG

alosetron hcl
BRAND
PA
LOTRONEX TAB 1 MG
alosetron hcl
BRAND
PA
ENTEREG CAP 12 MG
alvimopan
BRAND
PA
RELISTOR KIT 12 MG/0.6ML

methylnaltrexone bromide
BRAND
PA
PA
*Intestinal Acidifiers**
*Irritable Bowel Syndrome (IBS) Agents**
*Peripheral Opioid Receptor Antagonists**
PAGE 163
PRODUCT DESCRIPTION
BRAND/GEN
TIER
RELISTOR SOLUTION 12 MG/0.6ML

BRAND
RELISTOR SOLUTION 8 MG/0.4ML

BRAND
calcium acetate (phos binder) tab 667 mg
generic
FOSRENOL CHEW TAB 1000 MG

lanthanum carbonate
BRAND
ST

lanthanum carbonate
BRAND
ST

lanthanum carbonate
BRAND
ST
PHOSLYRA SOLUTION 667 MG/5ML

calcium acetate (phosphate binder)
BRAND
RENAGEL TAB 400 MG

sevelamer hcl
BRAND
RENAGEL TAB 800 MG

sevelamer hcl
BRAND
RENVELA PACKET 0.8 GM

sevelamer carbonate
BRAND
RENVELA PACKET 2.4 GM

sevelamer carbonate
BRAND
RENVELA TAB 800 MG

sevelamer carbonate
BRAND
SEVELAMER CARBONATE TAB 800 MG

sevelamer carbonate
BRAND
BRAND
cytra k crystals packet 3300-1002 mg
generic
potassium citrate er tab er 10 meq (1080 mg)
generic
POTASSIUM CITRATE ER TAB ER 10 MEQ

(1080 MG)
potassium citrate (alkalinizer)
BRAND
generic
generic
PA
PA
*Phosphate Binder Agents**
*Short Bowel Syndrome (SBS) Agents**

GATTEX KIT 5 MG
teduglutide (rdna)
PA
*GENITOURINARY AGENTS - MISCELLANEOUS*

*Alkalinizers**
PAGE 164
PRODUCT DESCRIPTION
BRAND/GEN
TIER
taron-crystals packet 3300-1002 mg
generic
CYSTAGON CAP 150 MG

cysteamine bitartrate
BRAND
CYSTAGON CAP 50 MG
BRAND
PROCYSBI CAP DR 25 MG
BRAND
PROCYSBI CAP DR 75 MG
BRAND
acetic acid solution 0.25 %
generic
aminoacetic acid solution 1.5 %
generic
glycine solution 1.5 %
generic
glycine urologic solution 1.5 %
generic
sodium chloride solution 0.9 %
generic
BRAND
alfuzosin hcl er tab er 24h 10 mg
generic
AVODART CAP 0.5 MG

dutasteride
BRAND
finasteride tab 5 mg
generic
RAPAFLO CAP 4 MG
silodosin
BRAND
ST
RAPAFLO CAP 8 MG
silodosin
BRAND
ST
tamsulosin hcl cap 0.4 mg
generic
phenazo tab 200 mg
generic
phenazopyridine hcl tab 100 mg
generic
phenazopyridine hcl tab 200 mg
generic
*Cystinosis Agents**
*Genitourinary Irrigants**
*Interstitial Cystitis Agents**

ELMIRON CAP 100 MG
pentosan polysulfate sodium
*Prostatic Hypertrophy Agents**
QL
30 / 30 days
QL
30 / 30 days
ST
*Urinary Analgesics**
*GOUT AGENTS*
PAGE 165
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Gout Agent Combinations**

colchicine-probenecid tab 0.5-500 mg
generic
allopurinol tab 100 mg
generic
allopurinol tab 300 mg
generic
colchicine tab 0.6 mg
generic
QL
120 / 30 days
COLCRYS TAB 0.6 MG

colchicine
BRAND
QL
120 / 30 days
KRYSTEXXA SOLUTION 8 MG/ML

pegloticase
BRAND
PA
ULORIC TAB 40 MG
febuxostat
BRAND
ST
ULORIC TAB 80 MG
febuxostat
BRAND
ST
generic
ADVATE RECON SOLN 1000 UNIT

antihemophilic factor rahf-pfm
BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA
ALPHANATE/VWF COMPLEX/HUMAN
RECON SOLN 1000 UNIT
antihemophilic factor/von willebrand factor
complex (human)
BRAND
PA
RECON SOLN 1500 UNIT
BRAND
PA
*Gout Agents**
*Uricosurics**
probenecid tab 500 mg
*HEMATOLOGICAL AGENTS - MISC.*
*Antihemophilic Products**
PAGE 166
PRODUCT DESCRIPTION
BRAND/GEN
TIER

complex (human)
RECON SOLN 250 UNIT
complex (human)
BRAND
PA
RECON SOLN 500 UNIT
complex (human)
BRAND
PA
ALPHANINE SD RECON SOLN 1000 UNIT

coagulation factor ix
BRAND
PA

BRAND
PA

BRAND
PA
ALPROLIX RECON SOLN 1000 UNIT

coagulation factor ix (recomb) fc fusion protein
(rfixfc)
BRAND

(rfixfc)
BRAND

(rfixfc)
BRAND

(rfixfc)
BRAND
BEBULIN RECON SOLN 200-1200 UNIT

factor ix complex
BRAND
PA
BEBULIN VH RECON SOLN 200-1200 UNIT

factor ix complex
BRAND
PA
BENEFIX RECON SOLN 1000 UNIT

coagulation factor ix (recombinant)
BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA
PAGE 167
PRODUCT DESCRIPTION
BRAND/GEN
CORIFACT KIT 1000-1600 UNIT

factor xiii concentrate (human)
BRAND
FEIBA NF RECON SOLN

antiinhibitor coagulant complex
BRAND
PA
FEIBA VH IMMUNO RECON SOLN

antiinhibitor coagulant complex
BRAND
PA
HELIXATE FS KIT 1000 UNIT

antihemophilic factor (recombinant)
BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA
HEMOFIL M RECON SOLN 1000 UNIT

antihemophilic factor (human)
BRAND
PA
HEMOFIL M RECON SOLN 1501-2000 UNIT

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA
HUMATE-P RECON SOLN 1000-2400 UNIT

complex (human)
BRAND
PA

complex (human)
BRAND
PA
BRAND
PA
PAGE 168
TIER

PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER

complex (human)
KOATE-DVI RECON SOLN 1000 UNIT
BRAND
PA

BRAND
PA

BRAND
PA
KOGENATE FS BIO-SET KIT 1000 UNIT

BRAND

BRAND

BRAND

BRAND

BRAND
KOGENATE FS KIT 1000 UNIT

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA
MONOCLATE-P KIT 1000 UNIT

BRAND
MONOCLATE-P KIT 1500 UNIT

BRAND
MONONINE RECON SOLN 1000 UNIT

BRAND
PA
NOVOSEVEN RT RECON SOLN 1 MG

coagulation factor viia (recombinant)
BRAND
PA

BRAND
PA

BRAND
PA
PAGE 169
PRODUCT DESCRIPTION
BRAND/GEN

BRAND
PROFILNINE SD RECON SOLN 1000 UNIT

factor ix complex
BRAND
PA

factor ix complex
BRAND
PA

factor ix complex
BRAND
PA
RECOMBINATE RECON SOLN 1241-1800

UNIT
BRAND
PA

UNIT
BRAND
PA
RECOMBINATE RECON SOLN 220-400 UNIT

BRAND
PA
RECOMBINATE RECON SOLN 401-800 UNIT

BRAND
PA

UNIT
BRAND
PA
RIASTAP RECON SOLN

fibrinogen concentrate (human)
BRAND
RIXUBIS RECON SOLN 1000 UNIT

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA
TRETTEN RECON SOLN 2000-3125 UNIT

coagulation factor xiii a-subunit (recombinant)
BRAND
WILATE RECON SOLN 1000-1000 UNIT

complex (human)
BRAND
PA

complex (human)
BRAND
PA
BRAND
PA
PAGE 170
TIER

PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER

complex (human)
complex (human)
BRAND
PA
XYNTHA KIT 1000 UNIT

plasma/alblumin free
BRAND
PA
XYNTHA KIT 2000 UNIT

BRAND
PA
XYNTHA KIT 250 UNIT

BRAND
PA
XYNTHA KIT 500 UNIT

BRAND
PA
XYNTHA SOLOFUSE KIT 1000 UNIT

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA
BRAND
PA
BERINERT KIT 500 UNIT

c1 esterase inhibitor (human)
BRAND
CINRYZE RECON SOLN 500 UNIT

c1 esterase inhibitor (human)
BRAND
PA
SOLIRIS SOLUTION 10 MG/ML

eculizumab
BRAND
PA
*Bradykinin B2 Receptor Antagonists**

FIRAZYR SOLUTION 30 MG/3ML
icatibant acetate
*Complement Inhibitors**
PAGE 171
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Hematorheologic Agents**
pentoxifylline er tab er 400 mg
generic
CEPROTIN RECON SOLN 1000 UNIT

protein c concentrate (human)
BRAND
PA
CEPROTIN RECON SOLN 500 UNIT

protein c concentrate (human)
BRAND
PA
BRAND
PA
ATRYN RECON SOLN 1750 UNIT

antithrombin (human) (recombinant)
BRAND
PA
THROMBATE III RECON SOLN 1000 UNIT

antithrombin iii (human)
BRAND
PA
THROMBATE III RECON SOLN 500 UNIT

antithrombin iii (human)
BRAND
PA
AGGRENOX CAP ER 12H 25-200 MG

aspirin-dipyridamole
BRAND
anagrelide hcl cap 0.5 mg
generic
anagrelide hcl cap 1 mg
generic
cilostazol tab 100 mg
generic
cilostazol tab 50 mg
generic
clopidogrel bisulfate tab 75 mg
generic
dipyridamole tab 25 mg
generic
generic
generic
EFFIENT TAB 10 MG
prasugrel hcl
BRAND
EFFIENT TAB 5 MG
prasugrel hcl
BRAND
REOPRO SOLUTION 2 MG/ML

abciximab
BRAND
ticlopidine hcl tab 250 mg
generic
*Human Protein C**
*Plasma Kallikrein Inhibitors**

KALBITOR SOLUTION 10 MG/ML
ecallantide
*Plasma Proteins**
*Platelet Aggregation Inhibitors**
PA
*HEMATOPOIETIC AGENTS*
PAGE 172
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Agents for Gaucher Disease**

CEREDASE SOLUTION 80 UNIT/ML
alglucerase
BRAND
PA
CEREZYME RECON SOLN 200 UNIT

imiglucerase
BRAND
PA
CEREZYME RECON SOLN 400 UNIT

imiglucerase
BRAND
PA
ELELYSO RECON SOLN 200 UNIT

taliglucerase alfa
BRAND
VPRIV RECON SOLN 400 UNIT

velaglucerase alfa
BRAND
PA
ZAVESCA CAP 100 MG

miglustat
BRAND
PA
DROXIA CAP 200 MG

hydroxyurea (sickle cell anemia)
BRAND
PA
DROXIA CAP 300 MG

BRAND
PA
DROXIA CAP 400 MG

BRAND
PA
generic
folic acid 1 mg
generic
folic acid powder
generic
*Agents for Sickle Cell Anemia**
*Cobalamins**
cyanocobalamin solution 1000 mcg/ml
*Folic Acid/Folates**
folic acid solution 5 mg/ml

folic acid tab 1 mg
generic
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
generic
ARANESP (ALBUMIN FREE) SOLUTION 100

MCG/0.5ML
darbepoetin alfa-polysorbate 80
BRAND
PA

MCG/ML
BRAND
PA
BRAND
PA
*Hematopoietic Growth Factors**
PAGE 173
PRODUCT DESCRIPTION
BRAND/GEN
TIER
MCG/0.3ML
MCG/0.75ML
BRAND
PA

MCG/0.4ML
BRAND
PA

MCG/ML
BRAND
PA

MCG/0.42ML
BRAND
PA

MCG/ML
BRAND
PA

MCG/0.6ML
BRAND
PA

MCG/ML
BRAND
PA

MCG/0.4ML
BRAND
PA

MCG/ML
BRAND
PA

MCG/ML
BRAND
PA

MCG/0.3ML
BRAND
PA

MCG/ML
BRAND
PA
EPOGEN SOLUTION 10000 UNIT/ML

epoetin alfa
BRAND
PA

epoetin alfa
BRAND
PA

epoetin alfa
BRAND
PA
PAGE 174
PRODUCT DESCRIPTION
BRAND/GEN
TIER

epoetin alfa
BRAND
PA

epoetin alfa
BRAND
PA
GRANIX SOLN PRSYR 300 MCG/0.5ML

tbo-filgrastim
BRAND
PA
GRANIX SOLN PRSYR 480 MCG/0.8ML

tbo-filgrastim
BRAND
PA
LEUKINE RECON SOLN 250 MCG

sargramostim
BRAND
PA
LEUKINE SOLUTION 500 MCG/ML

sargramostim
BRAND
PA
NEULASTA SOLUTION 6 MG/0.6ML

pegfilgrastim
BRAND
PA
NEUMEGA RECON SOLN 5 MG

oprelvekin
BRAND
PA
NEUPOGEN SOLUTION 300 MCG/0.5ML

filgrastim
BRAND
PA
NEUPOGEN SOLUTION 300 MCG/ML

filgrastim
BRAND
PA

filgrastim
BRAND
PA

filgrastim
BRAND
PA
NPLATE RECON SOLN 250 MCG

romiplostim
BRAND
PA
NPLATE RECON SOLN 500 MCG

romiplostim
BRAND
PA
OMONTYS SOLUTION 10 MG/ML

peginesatide acetate
BRAND
OMONTYS SOLUTION 20 MG/2ML

peginesatide acetate
BRAND
PROCRIT SOLUTION 10000 UNIT/ML

epoetin alfa
BRAND
PA

epoetin alfa
BRAND
PA

epoetin alfa
BRAND
PA

epoetin alfa
BRAND
PA
PAGE 175
PRODUCT DESCRIPTION
BRAND/GEN
TIER

epoetin alfa
BRAND

epoetin alfa
BRAND
PA
PROMACTA TAB 12.5 MG

eltrombopag olamine
BRAND
PA
PROMACTA TAB 25 MG
eltrombopag olamine
BRAND
PA
PROMACTA TAB 50 MG
eltrombopag olamine
BRAND
PA
PROMACTA TAB 75 MG
eltrombopag olamine
BRAND
PA
iferex 150 forte cap 150-25-1 mg-mcg-mg
generic
myferon 150 forte cap 150-25-1 mg-mcg-mg
generic
poly-iron 150 forte cap 150-25-1 mg-mcg-mg
generic
polysaccharide iron forte cap 150-25-1 mgmcg-mg
generic
dexferrum solution 50 mg/ml
generic
AL
Up to 1 yrs old
FERAHEME SOLUTION 510 MG/17ML

ferumoxytol
BRAND
AL
Up to 1 yrs old
FERRLECIT SOLUTION 12.5 MG/ML

sodium ferric gluconate complex in sucrose
BRAND
AL
Up to 1 yrs old
ferrous sulfate granules
generic
AL
Up to 1 yrs old
ferrous sulfate powder
generic
AL
Up to 1 yrs old
infed solution 50 mg/ml
generic
AL
Up to 1 yrs old
INJECTAFER SOLUTION 750 MG/15ML

ferric carboxymaltose
BRAND
AL
Up to 1 yrs old
na ferric gluc cplx in sucrose solution 12.5

mg/ml
generic
AL
Up to 1 yrs old
nulecit solution 12.5 mg/ml
generic
AL
Up to 1 yrs old
VENOFER SOLUTION 20 MG/ML

iron sucrose
BRAND
AL
Up to 1 yrs old
PA
*Hematopoietic Mixtures**
*Iron**
*Stem Cell Mobilizers**
PAGE 176
PRODUCT DESCRIPTION
BRAND/GEN
TIER
MOZOBIL SOLUTION 24 MG/1.2ML

plerixafor
BRAND
PA
tranexamic acid solution 100 mg/ml
generic
PA
tranexamic acid tab 650 mg
generic
phenobarbital elixir 20 mg/5ml
generic
phenobarbital solution 20 mg/5ml
generic
phenobarbital tab 100 mg
generic
PHENOBARBITAL TAB 100 MG

phenobarbital
BRAND
generic
phenobarbital
BRAND
phenobarbital tab 16.2 mg
generic
generic
phenobarbital
BRAND
generic
generic
phenobarbital
BRAND
generic
generic
generic
*HEMOSTATICS*
*Hemostatics - Systemic**
*HYPNOTICS*
*Barbiturate Hypnotics**
*Non-Barbiturate Hypnotics**
QL
eszopiclone tab 1 mg
30 / 30 days
ST
QL
generic
30 / 30 days
3
ST
QL
generic
30 / 30 days
3
ST
1
PAGE 177
PRODUCT DESCRIPTION
BRAND/GEN
zaleplon cap 10 mg
generic
zaleplon cap 5 mg
generic
zolpidem tartrate er tab er 12.5 mg
TIER

QL
30 / 30 days
QL
30 / 30 days
generic
QL
30 / 30 days
zolpidem tartrate er tab er 6.25 mg
generic
QL
30 / 30 days
zolpidem tartrate tab 10 mg
generic
QL
30 / 30 days
zolpidem tartrate tab 5 mg
generic
QL
30 / 30 days
QL
BRAND
30 / 30 days
*Selective Melatonin Receptor Agonists**

ROZEREM TAB 8 MG
ramelteon
ST
*LAXATIVES*
*Laxative Combinations**
COLYTE WITH FLAVOR PACKS RECON
SOLN 227.1 GM
peg 3350-kcl-sod bicarb-sod chloride-sod
sulfate
BRAND
COLYTE WITH FLAVOR PACKS RECON

SOLN 240 GM
sulfate
BRAND
gavilyte-c recon soln 240 gm
generic
gavilyte-g recon soln 236 gm
generic
gavilyte-n with flavor pack recon soln 420 gm
generic
GOLYTELY RECON SOLN 227.1 GM

sulfate
BRAND
GOLYTELY RECON SOLN 236 GM

sulfate
BRAND
HALFLYTELY WITH FLAVOR PACKS KIT 5210 MG-GM

bisacodyl-peg 3350-pot chloride-sod bicarb-sod
chloride
BRAND
MOVIPREP RECON SOLN 100 GM

peg 3350-kcl-nacl-na sulfate-na ascorbateascorbic acid
NULYTELY WITH FLAVOR PACKS RECON
SOLN 420 GM
peg 3350-potassium chloride-sod bicarbonate-
PAGE 178
AL
55 to 75 yrs old
AL
55 to 75 yrs old
AL
55 to 75 yrs old
BRAND
AL
55 to 75 yrs old
BRAND
PRODUCT DESCRIPTION
BRAND/GEN
TIER
sod chloride
peg 3350-kcl-na bicarb-nacl recon soln 420 gm
generic
peg 3350/electrolytes recon soln 240 gm
generic
peg-3350/electrolytes recon soln 236 gm
generic
PREPOPIK PACKET 10-3.5-12 MG-GM-GM

sodium picosulfate-magnesium oxideanhydrous citric acid
BRAND
AL
55 to 75 yrs old
SUCLEAR KIT
na sulfate-k sulfate-mg sulfate & peg3350-naclna bicarb-kcl
BRAND
AL
55 to 75 yrs old
SUPREP BOWEL PREP SOLUTION

sodium sulfate-potassium sulfate-magnesium
sulfate
BRAND
AL
55 to 75 yrs old
trilyte recon soln 420 gm
generic
constulose solution 10 gm/15ml
generic
lactulose solution 10 gm/15ml
generic
lactulose solution 20 gm/30ml
generic
pegylax powder
generic
polyethylene glycol 3350 packet
generic
polyethylene glycol 3350 powder
generic
BRAND
lidocaine-epinephrine solution 0.5 %-1:200000
generic
PA
lidocaine-epinephrine solution 1 %-1:100000
generic
PA
lidocaine-epinephrine solution 1.5 %-1:200000
generic
PA
generic
PA
generic
PA
XYLOCAINE-MPF/EPINEPHRINE SOLUTION
1 %-1:200000
lidocaine w/ epinephrine
BRAND
PA
*Laxatives - Miscellaneous**
*Saline Laxatives**
OSMOPREP TAB 1.102-0.398 GM
sodium phosphate monobasic-sodium
phosphate dibasic
*LOCAL ANESTHETICS-Parenteral*
*Local Anesthetic Combinations**
PAGE 179
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Local Anesthetics - Amides**

lidocaine hcl (cardiac) solution 20 mg/ml
generic
PA
lidocaine hcl (pf) solution 0.5 %
generic
PA
lidocaine hcl (pf) solution 1 %
generic
PA
lidocaine hcl (pf) solution 2 %
generic
PA
lidocaine hcl solution 0.5 %
generic
PA
generic
PA
lidocaine hcl solution 1.5 %
generic
PA
generic
PA
generic
PA
azithromycin hydrogencitrate recon soln 2.5 gm
generic
PA
azithromycin packet 1 gm
generic
azithromycin recon soln 500 mg
generic
azithromycin recon susp 100 mg/5ml
generic
azithromycin recon susp 200 mg/5ml
generic
azithromycin tab 250 mg
generic
generic
generic
zithromax packet 1 gm
generic
clarithromycin er tab er 24h 500 mg
generic
clarithromycin recon susp 125 mg/5ml
generic
clarithromycin recon susp 250 mg/5ml
generic
clarithromycin tab 250 mg
generic
clarithromycin tab 500 mg
generic
BRAND
*MACROLIDES*
*Azithromycin**
*Clarithromycin**
*Erythromycins**
E.E.S. 400 TAB 400 MG
erythromycin ethylsuccinate
PAGE 180
PRODUCT DESCRIPTION
BRAND/GEN
TIER
e.e.s. 400 tab 400 mg
generic
e.e.s. granules recon susp 200 mg/5ml
generic
ERY-TAB TAB DR 250 MG

erythromycin base
BRAND

erythromycin base
BRAND

erythromycin base
BRAND
eryped 200 recon susp 200 mg/5ml
generic
ERYPED 400 RECON SUSP 400 MG/5ML

BRAND
ERYTHROCIN LACTOBIONATE RECON

SOLN 1000 MG
erythromycin lactobionate
BRAND
PA
ERYTHROCIN LACTOBIONATE RECON

SOLN 500 MG
erythromycin lactobionate
BRAND
PA
ERYTHROCIN STEARATE TAB 250 MG

erythromycin stearate
BRAND
ERYTHROMYCIN BASE CP DR PART 250

MG
erythromycin base
BRAND
erythromycin base tab 250 mg
generic
ERYTHROMYCIN BASE TAB 250 MG

erythromycin base
BRAND
erythromycin base tab 500 mg
generic
ERYTHROMYCIN BASE TAB 500 MG

erythromycin base
BRAND
erythromycin ethylsuccinate tab 400 mg
generic
ERYTHROMYCIN ETHYLSUCCINATE TAB

400 MG
BRAND
ERYTHROMYCIN STEARATE TAB 250 MG

erythromycin stearate
BRAND
PCE TAB DR 333 MG

erythromycin base (coated)
BRAND
PCE TAB DR 500 MG

erythromycin base (coated)
BRAND
*Fidaxomicin**
PAGE 181
PRODUCT DESCRIPTION
BRAND/GEN
TIER
DIFICID TAB 200 MG

fidaxomicin
BRAND
PA
FEMCAP DEVICE 22 MM
cervical caps
BRAND
GL
Female
FEMCAP DEVICE 26 MM
cervical caps
BRAND
GL
Female
FEMCAP DEVICE 30 MM
cervical caps
BRAND
GL
Female
OMNIFLEX DIAPHRAGM DIAPHRAGM

diaphragms
BRAND
GL
Female
ORTHO DIAPHRAGM ALL-FLEX

DIAPHRAGM 65 MM
diaphragm arc-spring
BRAND
GL
Female

DIAPHRAGM 70 MM
BRAND
GL
Female

DIAPHRAGM 75 MM
BRAND
GL
Female

DIAPHRAGM 80 MM
BRAND
GL
Female
PRENTIF FITTING SET MISC

cervical caps
BRAND
GL
Female
WIDE-SEAL DIAPHRAGM 60 DIAPHRAGM 2

%
diaphragm wide seal
BRAND
GL
Female

%
diaphragm wide seal
BRAND
GL
Female

%
diaphragm wide seal
BRAND
GL
Female

%
diaphragm wide seal
BRAND
GL
Female

%
diaphragm wide seal
BRAND
GL
Female
BRAND
GL
Female
*MEDICAL DEVICES*
*Contraceptives**
PAGE 182
PRODUCT DESCRIPTION
BRAND/GEN
TIER
%
diaphragm wide seal
%
diaphragm wide seal
BRAND
GL
Female

%
diaphragm wide seal
BRAND
GL
Female
CAFERGOT TAB 1-100 MG

ergotamine w/ caffeine
BRAND
epidrin cap 325-65-100 mg
generic
QL
4 / day
ergotamine-caffeine tab 1-100 mg
generic
isometheptene-apap-dichloral cap 65-325-100

mg
generic
QL
4 / day
ISOMETHEPTENE-CAFFEINE-APAP TAB
130-20-500 MG
isometheptene-caffeine-acetaminophen
BRAND
MIGERGOT SUPPOS 2-100 MG

ergotamine w/ caffeine
BRAND
migragesic ida cap 325-65-100 mg
generic
QL
4 / day
nodolor cap 325-65-100 mg
generic
QL
4 / day
PRODRIN TAB 130-20-500 MG

isometheptene-caffeine-acetaminophen
BRAND
D.H.E. 45 SOLUTION 1 MG/ML

dihydroergotamine mesylate
BRAND
PA
dihydroergotamine mesylate solution 1 mg/ml
generic
PA
dihydroergotamine mesylate solution 4 mg/ml
generic
QL
8 / 30 days
ERGOMAR SL TAB 2 MG
ergotamine tartrate
BRAND
migranal solution 4 mg/ml
generic
QL
8 / 30 days
BRAND
QL
4 / 30 days
*MIGRAINE PRODUCTS*
*Migraine Combinations**
*Migraine Products**
*Serotonin Agonists**
ALSUMA SOLN A-INJ 6 MG/0.5ML
sumatriptan succinate
PAGE 183
PRODUCT DESCRIPTION
BRAND/GEN
AXERT TAB 12.5 MG

almotriptan malate
BRAND
AXERT TAB 6.25 MG

almotriptan malate
BRAND
FROVA TAB 2.5 MG

frovatriptan succinate
TIER

QL
6 / 30 days
QL
6 / 30 days
BRAND
QL
6 / 30 days
naratriptan hcl tab 1 mg
generic
QL
9 / 30 days
naratriptan hcl tab 2.5 mg
generic
QL
9 / 30 days
RELPAX TAB 20 MG
eletriptan hydrobromide
BRAND
QL
6 / 30 days
RELPAX TAB 40 MG
eletriptan hydrobromide
BRAND
QL
6 / 30 days
rizatriptan benzoate tab 10 mg
generic
QL
9 / 30 days
rizatriptan benzoate tab 5 mg
generic
QL
9 / 30 days
rizatriptan benzoate tab disp 10 mg
generic
QL
9 / 30 days
rizatriptan benzoate tab disp 5 mg
generic
QL
9 / 30 days
sumatriptan solution 20 mg/act
generic
QL
6 / 30 days
sumatriptan solution 5 mg/act
generic
QL
6 / 30 days
sumatriptan succinate refill soln cart 4 mg/0.5ml
generic
QL
4 / 30 days
sumatriptan succinate refill soln cart 6 mg/0.5ml
generic
QL
4 / 30 days
sumatriptan succinate soln a-inj 4 mg/0.5ml
generic
QL
4 / 30 days
sumatriptan succinate soln a-inj 6 mg/0.5ml
generic
QL
4 / 30 days
sumatriptan succinate soln prsyr 4 mg/0.5ml
generic
QL
4 / 30 days
sumatriptan succinate soln prsyr 6 mg/0.5ml
generic
QL
4 / 30 days
SUMATRIPTAN SUCCINATE SOLN PRSYR 6

MG/0.5ML
sumatriptan succinate
BRAND
QL
4 / 30 days
sumatriptan succinate solution 4 mg/0.5ml
generic
QL
4 / 30 days
sumatriptan succinate solution 6 mg/0.5ml
generic
QL
4 / 30 days
sumatriptan succinate tab 100 mg
generic
QL
9 / 30 days
generic
QL
9 / 30 days
generic
QL
9 / 30 days
PAGE 184
PRODUCT DESCRIPTION
BRAND/GEN
TIER
zolmitriptan tab 2.5 mg
generic
QL
9 / 30 days
zolmitriptan tab 5 mg
generic
QL
9 / 30 days
zolmitriptan tab disp 2.5 mg
generic
QL
9 / 30 days
zolmitriptan tab disp 5 mg
generic
QL
9 / 30 days
calcium chloride solution 10 %
generic
calcium gluconate solution 10 %
generic
BRAND
dextrose in lactated ringers solution 5 %
generic
dextrose in ringers solution 5 %
generic
DEXTROSE-NACL SOLUTION 10-0.2 %

dextrose w/ sodium chloride
BRAND

BRAND

BRAND
dextrose-nacl solution 10-0.9 %
generic
dextrose-nacl solution 2.5-0.45 %
generic
generic

BRAND

BRAND
generic
generic
generic
IONOSOL-B IN D5W SOLUTION

electrolyte-b in dextrose
BRAND
*MINERALS & ELECTROLYTES*

*Calcium**
*Chloride**
AMMONIUM CHLORIDE SOLUTION 5
MEQ/ML
ammonium chloride
*Electrolyte Mixtures**
PAGE 185
PRODUCT DESCRIPTION
BRAND/GEN
IONOSOL-MB IN D5W SOLUTION

electrolyte-mb in dextrose
BRAND
ISOLYTE-H IN D5W SOLUTION

electrolyte-h in dextrose
BRAND
ISOLYTE-P IN D5W SOLUTION

electrolyte-p in dextrose
BRAND
ISOLYTE-S SOLUTION
electrolyte-s
BRAND
KCL IN D5W LACTATED RINGERS

SOLUTION 40 MEQ/L
potassium chloride in d5w lactated ringers
BRAND
kcl in dextrose-nacl solution 10-5-0.2 meq/l-%%
generic
generic
generic
KCL IN DEXTROSE-NACL SOLUTION 20-50.225 MEQ/L-%-%

potassium chloride in dextrose & sodium
chloride
BRAND
generic
generic
generic
generic
generic
generic
KCL IN DEXTROSE-NACL SOLUTION 40-50.9 MEQ/L-%-%

potassium chloride in dextrose & sodium
chloride
BRAND
generic
KCL-LACTATED RINGERS-D5W SOLUTION

20 MEQ/L
potassium chloride in d5w lactated ringers
BRAND
PAGE 186
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
kcl-lactated ringers-d5w solution 20 meq/l
generic
lactated ringers solution
generic
NORMOSOL-R IN D5W SOLUTION

electrolyte-r in dextrose
BRAND
NORMOSOL-R PH 7.4 SOLUTION

electrolyte-r (ph 7.4)
BRAND
PLASMA-LYTE 148 SOLUTION

electrolyte-148
BRAND
PLASMA-LYTE A SOLUTION
electrolyte-a
BRAND
PLASMA-LYTE-56 IN D5W SOLUTION

electrolyte-56 in dextrose
BRAND
potassium chloride in dextrose solution 20-5

meq/l-%
generic

meq/l-%
generic

meq/l-%
generic
potassium chloride in nacl solution 20-0.45

meq/l-%
generic

meq/l-%
generic

meq/l-%
generic
epiflur chew tab 0.55 (0.25 f) mg
generic
AL
Up to 5 yrs old
epiflur chew tab 1.1 (0.5 f) mg
generic
AL
Up to 5 yrs old
epiflur chew tab 2.2 (1 f) mg
generic
AL
Up to 5 yrs old
FLUOR-A-DAY CHEW TAB 0.25 (F)-236.79

MG
sodium fluoride-xylitol
BRAND
AL
Up to 5 yrs old
FLUOR-A-DAY CHEW TAB 0.5 (F)-236.79 MG

BRAND
AL
Up to 5 yrs old
FLUOR-A-DAY CHEW TAB 1 (F)-236.79 MG

BRAND
AL
Up to 5 yrs old
fluor-a-day solution 0.275 (0.125 f) mg/drop
generic
AL
Up to 5 yrs old
FLUORABON SOLUTION 0.55 (0.25 F)

MG/0.6ML
BRAND
AL
Up to 5 yrs old
*Fluoride**
PAGE 187
PRODUCT DESCRIPTION
BRAND/GEN
TIER
sodium fluoride
fluoritab chew tab 1.1 (0.5 f) mg
generic
AL
Up to 5 yrs old
fluoritab chew tab 2.2 (1 f) mg
generic
AL
Up to 5 yrs old
fluoritab solution 0.275 (0.125 f) mg/drop
generic
AL
Up to 5 yrs old
FLURA-DROPS SOLUTION 0.55 (0.25 F)

MG/DROP
sodium fluoride
BRAND
AL
Up to 5 yrs old
LOZI-FLUR LOZENGE 2.2 (1 F) MG

sodium fluoride
BRAND
AL
Up to 5 yrs old
ludent chew tab 0.55 (0.25 f) mg
generic
AL
Up to 5 yrs old
ludent chew tab 1.1 (0.5 f) mg
generic
AL
Up to 5 yrs old
ludent chew tab 2.2 (1 f) mg
generic
AL
Up to 5 yrs old
renaf chew tab 0.55 (0.25 f) mg
generic
AL
Up to 5 yrs old
renaf chew tab 1.1 (0.5 f) mg
generic
AL
Up to 5 yrs old
renaf chew tab 2.2 (1 f) mg
generic
AL
Up to 5 yrs old
sodiphluor solution 1.1 (0.5 f) mg/ml
generic
AL
Up to 5 yrs old
sodium fluoride 1.1 (0.5 f) mg
generic
AL
Up to 5 yrs old
sodium fluoride chew tab 0.55 (0.25 f) mg
generic
AL
Up to 5 yrs old
sodium fluoride chew tab 1.1 (0.5 f) mg
generic
AL
Up to 5 yrs old
sodium fluoride chew tab 2.2 (1 f) mg
generic
AL
Up to 5 yrs old
sodium fluoride solution 1.1 (0.5 f) mg/ml
generic
AL
Up to 5 yrs old
sodium fluoride tab 1.1 (0.5 f) mg
generic
AL
Up to 5 yrs old
sodium fluoride tab 2.2 (1 f) mg
generic
AL
Up to 5 yrs old
SODIUM FLUORIDE TAB 2.2 (1 F) MG

sodium fluoride
BRAND
AL
Up to 5 yrs old
MAGNESIUM SULFATE IN D5W SOLUTION

10-5 MG/ML-%
magnesium sulfate in d5w
BRAND
MAGNESIUM SULFATE SOLUTION 40

MG/ML
magnesium sulfate
BRAND
*Magnesium**
PAGE 188
PRODUCT DESCRIPTION
BRAND/GEN
TIER
magnesium sulfate solution 50 %
generic
MAGNESIUM SULFATE SOLUTION 80

MG/ML
magnesium sulfate
BRAND
potassium phosphate dibasic solution 3

mmole/ml
generic
potassium phosphates dibasic solution 3

mmole/ml
generic
effer-k effer tab 25 meq
generic
epiklor packet 20 meq
generic
epiklor/25 packet 25 meq
generic
k-effervescent effer tab 25 meq
generic
K-TAB TAB ER 20 MEQ

potassium chloride
BRAND
k-vescent effer tab 25 meq
generic
k-vescent packet 20 meq
generic
klor-con 10 tab er 10 meq
generic
KLOR-CON M15 TAB ER 15 MEQ

potassium chloride microencapsulated crystals
cr
BRAND
klor-con packet 20 meq
generic
KLOR-CON PACKET 25 MEQ

potassium chloride
BRAND
klor-con/ef effer tab 25 meq
generic
potassium acetate solution 2 meq/ml
generic
potassium acetate solution 4 meq/ml
generic
potassium bicarbonate effer tab 25 meq
generic
potassium chloride crys er tab er 10 meq
generic
potassium chloride er cap er 10 meq
generic
potassium chloride er tab er 10 meq
generic
POTASSIUM CHLORIDE ER TAB ER 20 MEQ

potassium chloride
BRAND
potassium chloride packet 20 meq
generic
potassium chloride solution 0.4 meq/ml
generic
*Phosphate**
*Potassium**
PAGE 189
PRODUCT DESCRIPTION
BRAND/GEN
TIER
potassium chloride solution 10 meq/100ml
generic
generic
POTASSIUM CHLORIDE SOLUTION 10

MEQ/50ML
potassium chloride
BRAND
potassium chloride solution 2 meq/ml
generic
generic
POTASSIUM CHLORIDE SOLUTION 30

MEQ/100ML
potassium chloride
BRAND
generic
bd posiflush solution 0.9 %
generic
kendall sodium chloride flush solution 0.9 %
generic
monoject flush syringe solution 0.9 %
generic
monoject sodium chloride flush solution 0.9 %
generic
normal saline flush solution 0.9 %
generic
saline flush solution 0.9 %
generic
saline flush zr solution 0.9 %
generic
sodium chloride flush solution 0.9 %
generic
generic
generic
sodium chloride solution 2.5 meq/ml
generic
sodium chloride solution 3 %
generic
sodium chloride solution 4 meq/ml
generic
sodium chloride solution 5 %
generic
swabflush saline flush solution 0.9 %
generic
FIRST-MOUTHWASH BLM SUSPENSION

diphenhydramine-lidocaine-alum hydroxide-mg
hydroxide-simeth
BRAND
generic
lidocaine viscous solution 2 %
generic
*Sodium**
*MOUTH/THROAT/DENTAL AGENTS*
*Anesthetics Topical Oral**
PAGE 190
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Anti-infectives - Throat**
FIRST-MARYS MOUTHWASH SUSPENSION
diphenhydramine-hydrocortisone-nystatintetracycline
BRAND
nystatin suspension 100000 unit/ml
generic
chlorhexidine gluconate solution 0.12 %
generic
paroex solution 0.12 %
generic
periogard solution 0.12 %
generic
cavarest gel 1.1 %
generic
controlrx cream 1.1 %
generic
controlrx paste 1.1 %
generic
denta 5000 plus cream 1.1 %
generic
dentagel gel 1.1 %
generic
fluoridex daily defense gel 1.1 %
generic
phos-flur gel 1.1 %
generic
sf 5000 plus cream 1.1 %
generic
sf gel 1.1 %
generic
BRAND
oralone paste 0.1 %
generic
triamcinolone acetonide paste 0.1 %
generic
cevimeline hcl cap 30 mg
generic
pilocarpine hcl tab 5 mg
generic
pilocarpine hcl tab 7.5 mg
generic
generic
*Antiseptics - Mouth/Throat**
*Dental Products**
*Periodontal Products**
ARESTIN MISC 1 MG
minocycline hcl (subgingival)
PA
*Steroids - Mouth/Throat**
*Throat Products - Misc.**
*MULTIVITAMINS*
*B-Complex w/ Folic Acid**
b-plex tab
PAGE 191
GL
Female
AL
11 to 50 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
DIALYVITE 3000 TAB 3 MG

b-complex w/ c-biotin-e-minerals & folic acid
BRAND
DIALYVITE 5000 TAB 5 MG

b-complex w/ c-biotin-e-minerals & folic acid
BRAND
dialyvite tab
generic
DIALYVITE/ZINC TAB
b-complex w/ c-zn & folic acid
BRAND
DIATX ZN TAB 5 MG
b-complex w/ c-biotin-minerals & folic acid
BRAND
folbee plus cz tab 5 mg
generic
folbee plus tab
mynephrocaps cap 1 mg
generic
generic
NEPHPLEX RX TAB
b-complex w/ c-zn & folic acid
BRAND
NEPHRO-VITE RX TAB 1 MG
b-complex w/ c & folic acid
BRAND
NEPHROCAPS CAP 1 MG
BRAND
NEPHROCAPS QT TAB DISP 1 MG

b-complex w/ c-biotin-d & folic acid
BRAND
nephronex tab
generic
NUTRIVIT LIQUID
b-complex w/ lysine-min-fe & folic acid
BRAND
rena-vite rx tab 1 mg
generic
renal cap 1 mg
PAGE 192
generic
TIER

GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
Up to 1 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
PRODUCT DESCRIPTION
renalpren cap 1 mg
reno caps cap 1 mg
BRAND/GEN
generic
generic
SM B-COMPLEX/VITAMIN C TAB
BRAND
STROVITE TAB
BRAND
SUPERVITE LIQUID
b-complex w/ lysine-zn & folic acid
BRAND
therobec tab
generic
triphrocaps cap 1 mg
virt-caps cap 1 mg
virt-vite plus tab 5 mg
generic
generic
generic
VITAL-D RX TAB 1 MG
b-complex w/ c-biotin-d-zinc & folic acid
BRAND
vol-care rx tab 1 mg
generic
TIER

AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
*Iron & B12 w/ Vitamins**

PROMAR CAP
iron & b-12 w/ vitamins
BRAND
AL
Up to 1 yrs old
VITAFOL SYRUP
iron w/ vitamins
BRAND
AL
Up to 1 yrs old
VITAFOL TAB
iron w/ vitamins
BRAND
AL
Up to 1 yrs old
*Iron w/ Vitamins**
*Multiple Vitamins w/ Minerals & Calcium-Folic Acid**
PAGE 193
PRODUCT DESCRIPTION
BRAND/GEN
FOLGARD OS TAB 500-1.1 MG

multiple vitamins w/ minerals & calcium-folic
acid
BRAND
PROTECTBONE WAFER 500-1 MG

acid
BRAND
TL G-FOL OS TAB 500-1.1 MG

acid
BRAND
TIER

GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
*Multiple Vitamins w/ Minerals**

corvita tab 1.25 mg
generic
CORVITE TAB 1.25 MG

multiple vitamins w/ minerals & folic acid
BRAND
DIALYVITE SUPREME D TAB 3 MG

BRAND
GLUTOFAC-ZX TAB 2.8 MG

BRAND
MULTICHEW CHEW TAB 1 MG

BRAND
re fac-x tab 2.8 mg
generic
RENAX TAB 2.5 MG

BRAND
RENAX TAB 5.5 MG

BRAND
SUPERVITE EC TAB DR 1 MG
BRAND
SYNAGEX CAP 1.25 MG

BRAND
SYNATEK CAP 1.25 MG

BRAND
UDAMIN SP TAB 1 MG
BRAND
PAGE 194
PRODUCT DESCRIPTION
BRAND/GEN
UDAMIN TAB 2 MG
BRAND
TIER
GL
Female
AL
11 to 50 yrs old
AL
Up to 5 yrs old
*Ped Multi Vitamins w/Fl & FE**

ESCAVITE CHEW TAB 0.25-7.5 MG
ped multivitamins w/fl & iron
BRAND
ESCAVITE D CHEW TAB 0.25-6 MG

BRAND
escavite lq solution 0.25-10 mg/ml
generic
AL
Up to 5 yrs old
multi-vit/fluoride/iron solution 0.25-10 mg/ml
generic
AL
Up to 5 yrs old
multi-vitamin/fluoride/iron solution 0.25-10

mg/ml
generic
AL
Up to 5 yrs old
MYKIDZ IRON FL SUSPENSION 0.25-10

MG/2ML
pediatric vitamins acd fluoride & iron
BRAND
AL
Up to 5 yrs old
phluorivit + fe solution 0.25-10 mg/ml
generic
AL
Up to 5 yrs old
POLY-VI-FLOR/IRON CHEW TAB 0.5-10 MG

BRAND
AL
Up to 5 yrs old
POLY-VI-FLOR/IRON SUSPENSION 0.25-7

MG/ML
BRAND
AL
Up to 5 yrs old
poly-vitamin/fluoride/iron solution 0.25-10

mg/ml
generic
AL
Up to 5 yrs old
POLY-VITAMIN/FLUORIDE/IRON SOLUTION
0.5-10 MG/ML
BRAND
AL
Up to 5 yrs old
polyvits/fluoride/iron solution 0.25-10 mg/ml
generic
AL
Up to 5 yrs old
TL-FLUORIVITE CHEW TAB 0.25-7.5 MG

BRAND
AL
Up to 5 yrs old
TRI-VIT/FLUORIDE/IRON SOLUTION 0.25-10

MG/ML
pediatric vitamins acd fluoride & iron
BRAND
AL
Up to 5 yrs old
tri-vitamin/iron/fluoride solution 0.25-10 mg/ml
generic
AL
Up to 5 yrs old
multi vitamin/fluoride chew tab 0.25 mg
generic
AL
Up to 5 yrs old
multi vitamin/fluoride chew tab 1 mg
generic
AL
Up to 5 yrs old
*Ped MV w/ Fluoride**
PAGE 195
PRODUCT DESCRIPTION
BRAND/GEN
multi-vit/fluoride solution 0.25 mg/ml
generic
AL
Up to 5 yrs old
multi-vit/fluoride solution 0.5 mg/ml
generic
AL
Up to 5 yrs old
multi-vitamin/fluoride chew tab 0.25 mg
generic
AL
Up to 5 yrs old
multi-vitamin/fluoride chew tab 0.5 mg
generic
AL
Up to 5 yrs old
multi-vitamin/fluoride chew tab 1 mg
generic
AL
Up to 5 yrs old
multi-vitamin/fluoride solution 0.25 mg/ml
generic
AL
Up to 5 yrs old
multi-vitamins/fluoride solution 0.5 mg/ml
generic
AL
Up to 5 yrs old
multivitamin/fluoride chew tab 0.25 mg
generic
AL
Up to 5 yrs old
multivitamin/fluoride chew tab 0.5 mg
generic
AL
Up to 5 yrs old
multivitamin/fluoride chew tab 1 mg
generic
AL
Up to 5 yrs old
multivitamins/fluoride chew tab 0.25 mg
generic
AL
Up to 5 yrs old
multivitamins/fluoride chew tab 0.5 mg
generic
AL
Up to 5 yrs old
multivitamins/fluoride chew tab 1 mg
generic
AL
Up to 5 yrs old
mvc-fluoride chew tab 0.25 mg
generic
AL
Up to 5 yrs old
mvc-fluoride chew tab 0.5 mg
generic
AL
Up to 5 yrs old
mvc-fluoride chew tab 1 mg
generic
AL
Up to 5 yrs old
phluorivit solution 0.25 mg/ml
generic
AL
Up to 5 yrs old
phluorivit solution 0.5 mg/ml
generic
AL
Up to 5 yrs old
POLY-VI-FLOR CHEW TAB 0.25 MG

pediatric multivitamins w/fl
BRAND
AL
Up to 5 yrs old
POLY-VI-FLOR CHEW TAB 0.5 MG

BRAND
AL
Up to 5 yrs old
POLY-VI-FLOR CHEW TAB 1 MG

BRAND
AL
Up to 5 yrs old
POLY-VI-FLOR SUSPENSION 0.25 MG/ML

BRAND
AL
Up to 5 yrs old
poly-vitamin/fluoride solution 0.25 mg/ml
generic
AL
Up to 5 yrs old
poly-vitamin/fluoride solution 0.5 mg/ml
generic
AL
Up to 5 yrs old
polyvitamin/fluoride solution 0.25 mg/ml
generic
AL
Up to 5 yrs old
polyvitamin/fluoride solution 0.5 mg/ml
generic
AL
Up to 5 yrs old
PAGE 196
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
QUFLORA PEDIATRIC CHEW TAB 0.25 MG

BRAND
AL
Up to 5 yrs old
QUFLORA PEDIATRIC CHEW TAB 0.5 MG

BRAND
AL
Up to 5 yrs old
QUFLORA PEDIATRIC CHEW TAB 1 MG

BRAND
AL
Up to 5 yrs old
QUFLORA PEDIATRIC SOLUTION 0.25

MG/ML
BRAND
QUFLORA PEDIATRIC SOLUTION 0.5 MG/ML

BRAND
re multivit with fluoride chew tab 0.25 mg
generic
AL
Up to 5 yrs old
re multivit with fluoride chew tab 0.5 mg
generic
AL
Up to 5 yrs old
re multivit with fluoride chew tab 1 mg
generic
AL
Up to 5 yrs old
TRI-VI-FLOR SUSPENSION 0.25 MG/ML

pediatric vitamins acd & l-methylfolate w/
fluoride
BRAND
AL
Up to 5 yrs old
TRI-VI-FLOR SUSPENSION 0.5 MG/ML

fluoride
BRAND
AL
Up to 5 yrs old
TRI-VI-FLORO SUSPENSION 0.25 MG/ML

fluoride
BRAND
AL
Up to 5 yrs old
TRI-VI-FLORO SUSPENSION 0.5 MG/ML

fluoride
BRAND
AL
Up to 5 yrs old
tri-vit/fluoride solution 0.25 mg/ml
generic
AL
Up to 5 yrs old
tri-vit/fluoride solution 0.5 mg/ml
generic
AL
Up to 5 yrs old
tri-vitamin/fluoride solution 0.25 mg/ml
generic
AL
Up to 5 yrs old
tri-vitamin/fluoride solution 0.5 mg/ml
generic
AL
Up to 5 yrs old
TRIPHLUORIVIT SOLUTION 0.25 MG/ML

pediatric vitamins acd w/ fluoride
BRAND
AL
Up to 5 yrs old
triple-vitamin/fluoride solution 0.25 mg/ml
generic
AL
Up to 5 yrs old
vitamins acd-fluoride solution 0.25 mg/ml
generic
AL
Up to 5 yrs old
*Prenatal Vitamins**
PAGE 197
PRODUCT DESCRIPTION
BRAND/GEN
ACTIVE OB CAP 20-1-320 MG

prenatal w/o vit a w/ fe carbonyl-folic acid-dha
BRAND
ATABEX EC TAB DR 29-1 MG

prenatal vit w/ docusate-iron carbonyl-folic acid
BRAND
B-NEXA TAB 1.2 MG

prenatal w/ calcium-vit b6-folic acid-ginger
BRAND
B-NEXA TAB 1.22 MG

BRAND
BAL-CARE DHA ESSENTIAL MISC 27-1 & 374

MG
prenatal w/fe polysacch cmplx-sod feredetatefa-omega 3
BRAND
BAL-CARE DHA MISC 27-1 & 430 MG

BRAND
BP FOLINATAL PLUS B TAB 1 MG

prenatal w/ calcium carbonate-vit b6-vit b12folic acid
BRAND
BP MULTINATAL PLUS CHEW TAB 40-1 MG

prenatal without a vit w/ fe fumarate-folic acid
BRAND
BP MULTINATAL PLUS TAB 30-1 MG

BRAND
C-NATE DHA CAP 28-1-200 MG

prenatal vit w/ ferrous fumarate-fa-omega 3
fatty acids
BRAND
CALCIUM PNV CAP 28-1-250 MG

prenatal without vit a w/ fe fum-fa-omega fatty
acids
BRAND
CAVAN ONE OMEGA CAP 27-1 MG

prenatal vit w/ iron carbonyl-fe aspart glyc-faomega 3
BRAND
CAVAN PRENATAL/EC CALCIUM TAB DR 281 MG

BRAND
CAVAN-ALPHA KIT 27-1 & 300 MG

BRAND
CAVAN-EC SOD DHA MISC 30-1 & 440 MG

prenatal vit w/ sodium feredetate-folic acid-
BRAND
PAGE 198
TIER

GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
TIER
omega 3
CAVAN-FOLATE DHA MISC 65-1 & 250 MG
prenatal mv & min w/ ferrous fumarate-l
methylfolate-dha
BRAND
cavan-folate ob tab 65-1 mg
generic
CAVAN-HEME OMEGA MISC 28-1 & 200 MG

prenatal w/o vit a w/ iron-fa-dha
BRAND
CHOICE-OB+DHA MISC 29-1 & 250 MG

prenatal mv & min w/fe polysaccharide
complex-fa-dha
BRAND
CITRANATAL 90 DHA MISC 90-1 & 300 MG

prenatal w/o vit a w/ fe carbonyl-fe gluconatedss-fa-dha
BRAND
CITRANATAL ASSURE MISC 300 MG

BRAND
CITRANATAL B-CALM MISC 20-1 & 25 (2) MG

prenatal w/o vit a w/ fe carbonyl-fe gluconate-fa
& vit b6
BRAND
CITRANATAL DHA MISC 27-1 & 250 MG

BRAND
CITRANATAL HARMONY CAP 27-1-250 MG

prenatal w/o vit a w/ fe carbonyl-dss-fa-dha
BRAND

prenatal w/o vit a w/ fe fumarate-fe carbonyldss-fa-dha
BRAND

BRAND

BRAND

BRAND
CITRANATAL RX TAB 27-1 MG

prenatal without vit a w/ fe carbonyl-fe glucdocusate-fa
BRAND
COMPLETE NATAL DHA MISC 29-1-200 &
BRAND
PAGE 199
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
PRODUCT DESCRIPTION
BRAND/GEN
TIER
250 MG
prenatal mv & min w/fe bisglyc-fe prot succ-faca-omega 3
COMPLETE-RF PRENATAL TAB 90-1 MG
prenatal without a w/ fe carbonyl-docusate-folic
acid
BRAND
COMPLETENATE CHEW TAB 29-1 MG

prenatal vit w/ ferrous fumarate-folic acid
BRAND
CONCEPT DHA CAP 53.5-38-1 MG

prenatal vit w/ fe fum-iron polysacch complex fa-omega 3
BRAND
CONCEPT OB CAP 130-92.4-1 MG

prenatal without a vit w/ fe fum-iron polysacch
complex -fa
BRAND
CORENATE-DHA MISC 35-1 & 300 MG

BRAND
DOCOSAVIT CAP 15-15-1 MG

BRAND
DUET DHA 400 MISC 25-1 & 400 MG

BRAND
DUET DHA 400EC MISC 25-1 & 400 MG (DR)

BRAND
DUET DHA 430 MISC 25-1 & 430 MG

BRAND
DUET DHA 430EC MISC 25-1 & 430 MG (DR)

BRAND
DUET DHA BALANCED MISC 24-1 & 272 MG

BRAND

BRAND

BRAND

prenatal w/fe polysacch cmplx-sod feredetate-
BRAND
PAGE 200

AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
TIER
fa-omega 3
BRAND
DUET DHA COMPLETE MISC 27-1 & 430 MG

BRAND
DUET DHA EC MISC 25-1 & 400 MG (DR)

BRAND
DUET DHA EC MISC 25-1 & 430 MG (DR)

BRAND
DUET DHA MISC 25-1 & 400 MG

BRAND
DUET DHA MISC 25-1 & 430 MG

BRAND
EDGE OB CHEW TAB 29-1 MG

prenatal vit w/ iron polysaccharide complexfolic acid
BRAND
ELITE OB WITH DHA CAP 28-1.25-200 MG

fatty acids
BRAND
ELITE-OB 400 CAP 35-5-1.2 MG

prenatal vit w/ fe carbonyl-fe bisglycinate-fa-fish
oil
BRAND
ELITE-OB TAB 50-1.25 MG

prenatal vit w/ iron carbonyl-folic acid
BRAND
EXTRA-VIRT PLUS DHA CAP 29-1.25-350 MG

prenatal w/o vit a w/fe fumarate-docusate cafolic acid-dha
BRAND
FEMECAL OB TAB 22-6-1 MG

prenatal vit w/ fe polysacch complex-fe asp-fe
glyc-fa
BRAND
FOCALGIN-B TAB 1.22 MG

BRAND
FOLBECAL TAB 1 MG
BRAND
FOLCAL DHA CAP 27-1.25-300 MG
BRAND
PAGE 201
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
PRODUCT DESCRIPTION
BRAND/GEN
TIER
prenatal w/o vit a w/ fe fumarate-dss-fa-dha

FOLCAPS CARE ONE CAP 20-7-1 MG
prenatal w/fe cbnyl-fe asparto glyc-fa-dssomega 3
BRAND
FOLCAPS OMEGA 3 CAP 20-7-1 MG

prenatal w/ fe carbonyl-fe asp-fe glyc-fa-omega
fatty acids
BRAND
FOLCAPS OMEGA 3 CAP 27-1 MG

BRAND
FOLIVANE-OB CAP 130-92.4-1 MG

complex -fa
BRAND
FOLIVANE-PRX DHA NF CAP 30-1.24-265

MG
BRAND
GESTICARE DHA MISC 27-1 & 250 MG

prenatal mv & min w/fe fumarate-fa-dha
BRAND
GESTICARE TAB DR 28-1 MG

BRAND
HEMENATAL OB + DHA MISC 28-6-1 & 203

MG
prenatal vit w/ fe poly cmplx-fe heme polypeptfa & omega 3
BRAND
HEMENATAL OB TAB 28-6-1 MG

prenatal vit w/ fe polysacch complex-fe heme
polypeptide-fa
BRAND
INATAL ADVANCE TAB

BRAND
INATAL GT TAB
BRAND
INATAL ULTRA TAB

BRAND
INATAL ULTRA TAB 90-1 MG

BRAND
INFANATE BALANCE CAP 29-1-265 MG

BRAND
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
PAGE 202
GL
PRODUCT DESCRIPTION
BRAND/GEN
INFANATE DHA CAP 28-1-250 MG

acids
BRAND
KOLNATAL DHA MISC 27-1 & 250 MG

BRAND
L-METHYLFOLATE PNV DHA CAP 27-1.130.4 MG

prenatal vit w/ ferrous fumarate-l methylfolatefa-dha
BRAND
lactocal-f tab
generic
LEVOMEFOLATE DHA CAP 27-1.13-0.4 MG

prenatal vit w/ ferrous fumarate-l methylfolatefa-dha
BRAND
LEVOMEFOLATE PNV MISC 29-1.4-0.5 MG

prenatal vit w/ iron polysaccharide cmplx-l
methylfolate-fa
BRAND
M-VIT TAB
BRAND
MACNATAL CN DHA CAP 28-1-250 MG

BRAND
MARNATAL-F CAP 60-1 MG

prenatal without vit a w/ iron polysaccharide
complex-fa
BRAND
MAXINATE TAB 20-0.8 MG

prenatal vit w/ fe gluconate-fe fumarate-folic
acid
BRAND
MOMS CHOICE RX MISC 26-1 & 278 MG

BRAND
MULTI-NATE 30 DHA MISC 29-1-200 & 400

MG
BRAND
MULTI-NATE 30 DHA MISC 29-1-200 & 430

MG
BRAND
MULTI-NATE 30 TAB 29-1 MG

prenatal vit w/ fe bisglycinate-fe protein succfolic acid
BRAND
PAGE 203
TIER

Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
MULTI-NATE DHA EXTRA MISC 29-1-200 &

400 MG (DR)
BRAND
MULTI-NATE DHA EXTRA MISC 29-1-200 &

430 MG (DR)
BRAND
MYNATAL ADVANCE TAB

BRAND
MYNATAL CAP
prenatal multivit-min w/fe-fa
BRAND
mynatal plus tab
generic
MYNATAL TAB 90-1 MG

BRAND
mynatal-z tab
generic
MYNATE 90 PLUS TAB ER

prenatal vit w/ docusate-fe fumarate-folic acid
BRAND
NATA KOMPLETE TAB 25-1 MG

prenatal vit w/ fe fum-fe bisglycinate chelatefolic acid
BRAND
NATACHEW CHEW TAB 28-1 MG

prenatal vit w/ fe fum-fe bisglycinate chelatefolic acid
BRAND
NATACHEW CHEW TAB 29-1 MG

BRAND
NATAFORT TAB 60-1 MG

prenatal without a vit w/ fe carbonyl-fe
fumarate-folic acid
BRAND
NATAL-V RX TAB 29-1 MG

BRAND
NATALVIRT 90 DHA MISC 90-1 & 300 MG

BRAND
NATALVIRT CA MISC 35-1 & 300 MG

prenatal w/o vit a w/ fe carbonyl-fe gluconate-
BRAND
PAGE 204
TIER

GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
PRODUCT DESCRIPTION
BRAND/GEN
TIER
dss-fa-dha
NATALVIT TAB
BRAND
NATELLE EZ TAB 25-1 MG

prenatal vit w/ fe bisglycinate chelate-folic acid
BRAND
NATELLE ONE CAP 28-1-250 MG

acids
BRAND
NATELLE-EZ TAB 25-0.8 MG

BRAND
NAVATAB + DHA MISC 26-1 & 200 MG

prenatal mv & min w/fe bisglycinate-fa-dha
BRAND
NEEVO DHA CAP 27-1.13 MG

prenatal without vit a w/ fe fumarate-l
methylfolate-omegas
BRAND
NEEVO DHA CAP 27-1.53 MG

prenatal without a w/ fe fumarate-l methylfolatefa-omegas
BRAND
NEEVO MISC 29-1.4-0.5 MG

methylfolate-fa
BRAND
NESTABS ABC MISC 32-1-200 MG

prenatal mv & min w/o vit a w/fe polysac cmplxfa-ca-omega 3
BRAND
NESTABS DHA MISC 32-1 MG

prenatal vit without vit a w/ fe bisglycinate-faomeg 3
BRAND
NESTABS TAB 32-1 MG

prenatal vit without vit a w/ fe bisglycinate-folic
acid
BRAND
NEWGEN TAB 32-1 MG

acid
BRAND
NEXA PLUS CAP 29-1.25-350 MG

BRAND
NEXA SELECT CAP 29-1.25-325 MG

BRAND
NEXA SELECT CAP 29-1.25-337.5 MG
BRAND
PAGE 205

AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
PRODUCT DESCRIPTION
BRAND/GEN
TIER

NUTRI-TAB OB + DHA MISC 32-1 MG
BRAND
NUTRI-TAB OB TAB 32-1 MG

acid
BRAND
O-CAL FA TAB 27-1 MG

BRAND
O-CAL PRENATAL TAB

BRAND
OB COMPLETE 400 CAP 35-5-1.2 MG

oil
BRAND
OB COMPLETE 400 CAP 40-10-1-400 MG

prenatal w/o vit a w/ fe carbonyl-fe aspart glycfa-fish oil
BRAND
OB COMPLETE CHEW TAB 15-5-1-100 MG

prenatal w/o vit a w/ fe carbonyl-fe aspart glycfa-dha
BRAND
OB COMPLETE ONE CAP 50-1-476 MG

prenatal w/o vit a w/ fe carbonyl-fe aspart glycfa-fish oil
BRAND
OB COMPLETE PETITE CAP 35-5-1-200 MG

prenatal w/o vit a w/ fe carbonyl-fe aspart glycfa-omega 3
BRAND
OB COMPLETE PREMIER TAB 30-20-1 MG

prenatal vit w/ iron carbonyl-fe aspart glycinatefa
BRAND
OB COMPLETE TAB 50-1.25 MG

BRAND
OB COMPLETE WITH DHA CAP 28-1.25-200

MG
fatty acids
BRAND
OB COMPLETE/DHA CAP 30-10-1-200 MG

prenat vit w/ iron carbonyl-fe asp glyc-fa-omega
fatty acid
BRAND
OB-NATAL ONE CAP 27-1 MG

BRAND
PAGE 206

AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
OBSTETRIX DHA MISC 29-1 & 387 MG

prenatal w/fe carbonyl-fa-dss-omega 3 fatty
acids
BRAND
OBSTETRIX EC TAB 29-1 MG

BRAND
PAIRE OB MISC 22-6-1 & 200 MG

prenatal vit w/ fe polysacch cmplx-fe asp-fe
glyc-fa & dha
BRAND
pnv fe fum/docusate/folic acid tab 29-1 mg
generic
TIER
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
PNV FOLIC ACID + IRON TAB 27-1 MG

BRAND
PNV OB+DHA MISC 27-1 & 250 MG

BRAND
PNV PRENATAL PLUS MULTIVITAMIN TAB

27-1 MG
BRAND
PNV TABS 29-1 TAB 29-1 MG

BRAND
PNV-DHA CAP 27-0.6-0.4-300 MG

prenatal without a w/ fe fumarate-l methylfolatefa-dha
BRAND
PNV-DHA+DOCUSATE CAP 27-1.25-300 MG

BRAND
PNV-FIRST CAP 29-1-200 MG

complex-fa-dha
BRAND
PNV-OB/DHA MISC 65-1 & 250 MG

BRAND
PNV-OMEGA CAP 28-0.6-0.4-340 MG

prenatal without a w/ fe fumarate-l methylfolatefa-omega 3
BRAND
PNV-SELECT TAB 27-0.6-0.4 MG

prenatal vit w/ ferrous fumarate-l methylfolatefolic acid
BRAND
PNV-TOTAL CAP 35-5-1.2 MG

oil
BRAND
PAGE 207
GL
PRODUCT DESCRIPTION
BRAND/GEN
PR NATAL 400 EC MISC 29-1-200 & 400 MG

(DR)
BRAND
PR NATAL 400 MISC 29-1-200 & 400 MG

BRAND
PR NATAL 430 EC MISC 29-1-200 & 430 MG

(DR)
BRAND
PR NATAL 430 MISC 29-1-200 & 430 MG

BRAND
PR NATAL 440 EC MISC 30-1 & 440 MG

prenatal vit w/ sodium feredetate-folic acidomega 3
BRAND
PREFERA OB + DHA MISC 28-6-1 & 203 MG

BRAND
PREFERA OB TAB 28-6-1 MG

polypeptide-fa
BRAND
PREFERAOB ONE CAP 22-6-1-200 MG

prenatal vit w/ fe polysacch cmplx-fe heme
polypept-fa & dha
BRAND
PREFOL-DHA CAP 26-1.2-300 MG

BRAND
PRENA1 CHEW TAB 1.4 MG

prenatal w/ vit b2-b6-b12-cholecalciferol-folic
acid
BRAND
PRENA1 PEARL CAP ER 30-1.4-200 MG

prenatal without a w/ fe fumarate-sod
feredetate-fa-dha
BRAND
PRENA1 PLUS/QUATREFOLIC MISC 30-0.60.4 &300 MG

prenatal without a w/ fe chelate-l methylfolatefa-dha
BRAND
PRENA1/QUATREFOLIC CAP 30-0.6-0.4-200

MG
BRAND
PRENA1/QUATREFOLIC CHEW TAB 0.6-0.4

MG
BRAND
PAGE 208
TIER

Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
TIER
prenatal w/ vit b2-b6-b12-cholecalciferol-l

methylfolate-fa
PRENACARE TAB 90-1 MG
BRAND
PRENAFIRST TAB 17-1 MG

BRAND
PRENAISSANCE 90 DHA MISC 90-1 & 300

MG
BRAND
PRENAISSANCE BALANCE CAP 30-1-260

MG
BRAND
PRENAISSANCE CAP 29-1.25-325 MG

BRAND
PRENAISSANCE DHA MISC 27-1 & 250 MG

BRAND
PRENAISSANCE HARMONY DHA MISC 27-1

& 380 MG
BRAND
PRENAISSANCE NEXT TAB 1.2 MG

BRAND
PRENAISSANCE NEXT-B TAB 1.22 MG

BRAND
PRENAISSANCE PLUS CAP 28-1-250 MG

BRAND
PRENAISSANCE PROMISE MISC 35-1 & 300

MG
BRAND
PRENAPLUS TAB 27-1 MG

BRAND
PRENATA CHEW TAB 29-1 MG

BRAND
PRENATABS FA TAB
BRAND
PAGE 209
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
PRODUCT DESCRIPTION
BRAND/GEN
PRENATABS RX TAB 29-1 MG

BRAND
PRENATAL 19 CHEW TAB

BRAND
PRENATAL 19 CHEW TAB 29-1 MG

BRAND
prenatal 19 tab
generic
TIER
generic
PRENATAL LOW IRON TAB 27-1 MG

BRAND
PRENATAL MV & MIN-FE-FA-DHA CAP 11-30.5-100 MG

polypept-fa & dha
BRAND
PRENATAL PLUS IRON TAB 29-1 MG

BRAND
PRENATAL PLUS TAB 27-1 MG

BRAND
PRENATAL PLUS/IRON TAB 27-1 MG

BRAND
PRENATAL TAB 27-0.8 MG

BRAND
PRENATAL TAB 27-1 MG

BRAND
PAGE 210
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
prenatal 19 tab 29-1 mg
BRAND
GL
PRENATAL FORMULA TAB 27-1 MG

11 to 50 yrs old
BRAND
BRAND
AL
PRENATAL 19 TAB 29-1 MG

PRENATAL AD TAB
PRODUCT DESCRIPTION
BRAND/GEN
PRENATAL VITAMINS PLUS TAB 27-1 MG

BRAND
PRENATAL+DHA MISC 27-1 & 250 MG

BRAND
PRENATAL-U CAP 106.5-1 MG

BRAND
PRENATE AM TAB 1 MG
prenatal w/ calcium-vit b6-vit b12-folic acidginger
BRAND
PRENATE CHEW TAB 0.6-0.4 MG

prenatal multivitamins & minerals w/ lmethylfolate-fa
BRAND
PRENATE DHA CAP 28-0.6-0.4-300 MG

BRAND
PRENATE ELITE TAB 26-0.6-0.4 MG

BRAND
PRENATE ELITE TAB 27-0.6-0.4 MG

BRAND
PRENATE ENHANCE CAP 28-0.6-0.4-400 MG

BRAND
PRENATE ESSENTIAL CAP 18-0.6-0.4-300

MG
prenatal w/o a w/ fe asparto glyc-l methylfolatefa-dha
BRAND

MG
BRAND

MG
prenatal without a w/ fe asp glyc-l methylfolatefa-omega 3
BRAND
PRENATE MINI CAP 29-0.6-0.4-350 MG

prenatal without a w/ fe carbonyl-l methylfolatefa-dha
BRAND
PRENATE RESTORE CAP 27-0.6-0.4-400 MG
BRAND
PAGE 211
TIER
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
PRODUCT DESCRIPTION
BRAND/GEN
TIER

PRENEXA CAP 27-1.25-300 MG
BRAND
PRENEXA PREMIER CAP 27-1.25-310 MG

BRAND
PREPLUS TAB 27-1 MG

BRAND
PREQUE 10 TAB 15-0.5-50 MG

prenatal mv & min w/fe carbonyl-fa-dha
BRAND
PREQUE 10 TAB 15-25-0.5-50 MG

prenatal mv & min w/fe carbonyl-docusate-folic
acid-dha
BRAND
PRETAB TAB 29-1 MG

BRAND
PREVITE RX TAB 1 MG
BRAND
PROTECTNATAL TAB DR 13.5-0.5-700 MG

prenatal vit w/polysaccharide fe-fa-fish oil
BRAND
PROVIDA OB CAP 20-20-1.25 MG

complex -fa
BRAND
PUREFE OB PLUS CAP 162-115.2-1 MG

complex -fa
BRAND
R-NATAL OB CAP 20-1-320 MG

prenatal w/o vit a w/ fe carbonyl-folic acid-dha
BRAND
RE DUALVIT OB CAP 162-115.2-1 MG

complex -fa
BRAND
RE OB + 90 DHA MISC 90-1 & 250 MG

BRAND
RE OB + DHA MISC 27-1 & 250 MG

BRAND
RE PRENATAL MULTIVITAMIN/IRON CHEW

TAB 29-1 MG
BRAND
PAGE 212

AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
PRODUCT DESCRIPTION
BRAND/GEN
TIER

RE-NATA 29 OB TAB 29-1 MG
BRAND
REAPHIRM CAP 29-1-200 MG

complex-fa-dha
BRAND
RELNATE DHA CAP 28-1-200 MG

fatty acids
BRAND
SE-CARE CHEW TAB 40-1 MG

BRAND
SE-CARE CONCEIVE TAB 30-1 MG

BRAND
SE-NATAL 19 CHEW TAB 29-1 MG

BRAND
se-natal 19 tab 29-1 mg
generic
SE-NATAL 90 TAB ER 90-1 MG

BRAND
se-natal one tab 60-1 mg
generic
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
SE-PLETE DHA CAP 28-1.25-200 MG

fatty acids
BRAND
SE-TAN DHA CAP 15-15-1 MG

BRAND
SELECT-OB CHEW TAB 29-0.6-0.4 MG

methylfolate-fa
BRAND
SELECT-OB CHEW TAB 29-1 MG

prenatal vit w/ iron polysaccharide complexfolic acid
BRAND
SELECT-OB+DHA MISC 29-1 & 250 MG

complex-fa-dha
BRAND
SETONET MISC 29-1-200 & 430 MG
BRAND
PAGE 213
PRODUCT DESCRIPTION
BRAND/GEN
TIER

SETONET-EC MISC 29-1-200 & 430 MG (DR)
BRAND
TANDEM DHA CAP 15-15-1 MG

BRAND
TANDEM OB CAP 162-115.2-1 MG

complex -fa
BRAND
TARON-BC MISC 20-1 & 25 (2) MG

prenatal without vit a w/ iron carbonyl-folic acid
& vit b6
BRAND
TARON-C DHA CAP 53.5-38-1 MG

BRAND
TARON-DUO EC MISC 29-1-200 & 400 MG

(DR)
BRAND
TARON-PREX CAP 30-1.2-265 MG

BRAND
TL-ASSURE ONE CAP 29-1-200 MG

complex-fa-dha
BRAND
TL-ASSURE+DHA MISC 29-1 & 250 MG

complex-fa-dha
BRAND
TL-CARE DHA CAP 27-1-500 MG

prenatal w/fe fumarate-fa-dss-fish oil
BRAND
TL-SELECT CAP 29-1.25-325 MG

BRAND
TL-SELECT DHA CAP 29-1.25-350 MG

BRAND
TRI RX TAB 27-1 MG

BRAND
TRI-TABS DHA MISC 32-1 MG

BRAND
PAGE 214

AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
TRIADVANCE TAB 90-1 MG

BRAND
TRICARE DHA 301 CAP 27-1-710 MG

BRAND
TRICARE PRENATAL COMPLEAT MISC 27-1

MG
prenatal without vit a w/ fe fumarate-fa-fish oil
BRAND
TRICARE PRENATAL DHA ONE CAP 27-1500 MG

BRAND
TRICARE TAB
BRAND
TRIMESIS RX TAB 1 MG
BRAND
TRINATAL GT TAB 90-1 MG

BRAND
trinatal rx 1 tab 60-1 mg
generic
TRINATAL ULTRA TAB 90-1 MG

BRAND
TRINATE TAB
BRAND
TRIVEEN-DUO DHA MISC 29-1-200 & 400 MG

BRAND
TRIVEEN-ONE CAP 27-1-250 MG

acids
BRAND
TRIVEEN-PRX RNF CAP 26-1.2-300 MG

BRAND
TRIVEEN-TEN TAB 15-0.5-50 MG

prenatal mv & min w/fe carbonyl-fa-dha
BRAND
TRIVEEN-U CAP 106.5-1 MG

BRAND
TIER

GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
PAGE 215
PRODUCT DESCRIPTION
BRAND/GEN
TRUST NATAL DHA MISC 29-1-200 & 250 MG

BRAND
ULTIMATE OB DHA MISC 22-6-1 & 200 MG

prenatal vit w/ fe polysacch cmplx-fe asp-fe
glyc-fa & dha
BRAND
ULTIMATECARE ONE CAP 27-1 MG

BRAND
ULTIMATECARE ONE NF CAP 20-7-1 MG

prenatal w/fe cbnyl-fe asparto glyc-fa-dssomega 3
BRAND
ULTRA NATALCARE TAB 90-1 MG

BRAND
V-NATAL DHA MISC 32-1 MG

BRAND
V-NATAL TAB 32-1 MG

acid
BRAND
VEMAVITE-PRX 2 CAP 27-1.25-300 MG

BRAND
VENA-BAL DHA MISC 27-1 & 430 MG

BRAND
VENATAL COMPLETE DHA MISC 27-1 & 430

MG
BRAND
VENATAL-FA TAB 29-1 MG

BRAND
VINACAL B MISC 20-1 & 25 (2) MG

prenatal w/o vit a w/ fe carbonyl-fe gluconate-fa
& vit b6
BRAND
VINACAL TAB 27-1 MG

BRAND
VINATE AZ EXTRA TAB 29-1 MG

BRAND
VINATE AZ TAB 27-1 MG

BRAND
PAGE 216
TIER

GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
PRODUCT DESCRIPTION
BRAND/GEN
TIER

11 to 50 yrs old
VINATE C TAB 30-1 MG

BRAND
VINATE CALCIUM TAB 27-1 MG

prenatal vit w/ iron carbonyl-fe gluconate-folic
acid
BRAND
VINATE CARE CHEW TAB 40-1 MG

BRAND
VINATE DHA CAP 27-1.53 MG

prenatal without a w/ fe fumarate-l methylfolatefa-omegas
BRAND
VINATE DHA RF CAP 27-1.13 MG

prenatal without vit a w/ fe fumarate-l
methylfolate-omegas
BRAND
VINATE GT TAB 90-1 MG

BRAND
VINATE IC CAP 162-115.2-1 MG

complex -fa
BRAND
VINATE II TAB 29-1 MG

BRAND
VINATE M TAB 27-1 MG

prenatal vit w/ selenium-fe fumarate-folic acid
BRAND
vinate one tab 60-1 mg
generic
VINATE PN CARE TAB 30-1 MG

prenatal without a w/ fe asparto glyc-docusatefolic acid
BRAND
VINATE ULTRA TAB

BRAND
VIRT-BAL DHA MISC 13-13-1 & 374 MG

BRAND
VIRT-BAL DHA PLUS MISC 27-1 & 380 MG

BRAND
VIRT-PN DHA CAP 27-0.6-0.4-300 MG
BRAND
PAGE 217
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
PRODUCT DESCRIPTION
BRAND/GEN
TIER

VIRT-PN PLUS CAP 28-0.6-0.4-340 MG
BRAND
VIRT-PN TAB 27-0.6-0.4 MG

BRAND
VIRT-SELECT CAP 29-1.25-325 MG

BRAND
VITAFOL ULTRA CAP 29-0.6-0.4-200 MG

prenatal vit w/ fe polysacch complex-l
methylfolate-fa-dha
BRAND
VITAFOL-NANO TAB 18-0.6-0.4 MG

prenatal w/o a vit w/ fe fumarate-l methylfolatefolic acid
BRAND
vitafol-ob tab
generic
VITAFOL-OB+DHA MISC 65-1 & 250 MG

BRAND
VITAFOL-ONE CAP 29-1-200 MG

complex-fa-dha
BRAND
VITAFOL-PLUS CAP 27-1-200 MG

complex-fa-dha
BRAND
vitafol-pn tab
generic
VITAMEDMD ONE RX/QUATREFOLIC CAP

30-0.6-0.4-200 MG
BRAND
VITAMEDMD PLUS RX/QUATREFOLIC MISC

30-0.6-0.4 &300 MG
prenatal without a w/ fe chelate-l methylfolatefa-dha
BRAND
VITAMEDMD REDICHEW RX CHEW TAB 0.60.4 MG

prenatal w/ vit b2-b6-b12-cholecalciferol-l
methylfolate-fa
BRAND
VITAMEDMD REDICHEW RX CHEW TAB 1.4
BRAND
PAGE 218

AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
TIER
MG
prenatal w/ vit b2-b6-b12-cholecalciferol-folic
acid
VITAPEARL CAP ER 30-1.4-200 MG
prenatal without a w/ fe fumarate-sod
feredetate-fa-dha
BRAND
VITAPHIL + DHA MISC 26-1 & 200 MG

prenatal mv & min w/fe bisglycinate-fa-dha
BRAND
VITAPHIL TAB 25-1 MG

BRAND
VITASPIRE TAB 29-1 MG

prenatal without a vit w/ iron carbonyl-folic acid
BRAND
VIVA CT PRENATAL CHEW TAB 28-1 MG

BRAND
VIVA DHA CAP 28-1-200 MG

fatty acids
BRAND
VOL-NATE TAB 28-1 MG

BRAND
VOL-PLUS TAB 27-1 MG

BRAND
VOL-TAB RX TAB 29-1 MG

BRAND
VP CH ULTRA CAP 27-1-260 MG

prenatal w/o vit a w/ fe fumarate-fe carbonyldss-fa-dha
BRAND
VP-CH PLUS CAP 29-1-265 MG

BRAND
VP-CH-PNV CAP 30-1-260 MG

BRAND
VP-ERA OB PLUS TAB 22-6-1 MG

polypeptide-fa
BRAND
VP-GGR-B6 PRENATAL TAB 1.2 MG

BRAND
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
PAGE 219
PRODUCT DESCRIPTION
BRAND/GEN
VP-HEME OB + DHA MISC 28-6-1 & 203 MG

BRAND
VP-HEME OB TAB 28-6-1 MG

polypeptide-fa
BRAND
VP-HEME ONE CAP 22-6-1-200 MG

polypept-fa & dha
BRAND
VP-PNV-DHA CAP 28-1-215.8 MG

fatty acids
BRAND
ZATEAN-CH CAP 27-1-250 MG

BRAND
ZATEAN-PN DHA CAP 27-0.6-0.4-300 MG

BRAND
ZATEAN-PN PLUS CAP 28-0.6-0.4-340 MG

BRAND
ZATEAN-PN TAB 27-0.6-0.4 MG

BRAND
ZINGIBER TAB 1.2 MG

BRAND
TIER

GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
GL
Female
AL
11 to 50 yrs old
QL
120 / 30 days
*MUSCULOSKELETAL THERAPY AGENTS*

*Central Muscle Relaxants**
baclofen tab 10 mg
generic
baclofen tab 20 mg
generic
CARISOPRODOL TAB 250 MG

carisoprodol
BRAND
carisoprodol tab 350 mg
generic
chlorzoxazone tab 500 mg
generic
cyclobenzaprine hcl tab 10 mg
generic
QL
120 / 30 days
cyclobenzaprine hcl tab 5 mg
generic
QL
120 / 30 days
ed baclofen tab 10 mg
generic
FEXMID TAB 7.5 MG

cyclobenzaprine hcl
BRAND
PAGE 220
PRODUCT DESCRIPTION
BRAND/GEN
TIER
LORZONE TAB 375 MG

chlorzoxazone
BRAND
LORZONE TAB 750 MG

chlorzoxazone
BRAND
metaxalone tab 800 mg
generic
methocarbamol tab 500 mg
generic
methocarbamol tab 750 mg
generic
orphenadrine citrate er tab er 12h 100 mg
generic
tizanidine hcl 2 mg
generic
tizanidine hcl 4 mg
generic
tizanidine hcl cap 2 mg
generic
generic
generic
tizanidine hcl tab 2 mg
generic
tizanidine hcl tab 4 mg
generic
EUFLEXXA SOLN PRSYR 20 MG/2ML

sodium hyaluronate (viscosupplement)
BRAND
PA
GEL-ONE PRSYR 30 MG/3ML

cross-linked hyaluronate
BRAND
PA
HYALGAN SOLN PRSYR 20 MG/2ML

BRAND
PA
HYALGAN SOLUTION 20 MG/2ML

BRAND
PA
ORTHOVISC SOLN PRSYR 30 MG/2ML

hyaluronan
BRAND
PA
SUPARTZ SOLN PRSYR 25 MG/2.5ML

BRAND
PA
SYNVISC ONE SOLN PRSYR 48 MG/6ML

hylan
BRAND
PA
SYNVISC SOLN PRSYR 16 MG/2ML

hylan
BRAND
PA
BRAND
*Viscosupplements**
*NASAL AGENTS - SYSTEMIC AND TOPICAL*

*Nasal Anti-infectives**
BACTROBAN NASAL OINTMENT 2 %
mupirocin calcium
PAGE 221
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Nasal Antiallergy**
azelastine hcl solution 0.15 %
generic
azelastine hcl solution 137 mcg/spray
generic
PATANASE SOLUTION 0.6 %

olopatadine hcl (nasal)
BRAND
generic
generic
budesonide suspension 32 mcg/act
generic
FLUNISOLIDE SOLUTION 25 MCG/ACT

(0.025%)
flunisolide (nasal)
BRAND
flunisolide solution 25 mcg/act (0.025%)
generic
flunisolide solution 29 mcg/act (0.025%)
generic
fluticasone propionate suspension 50 mcg/act
generic
NASONEX SUSPENSION 50 MCG/ACT

mometasone furoate (nasal)
BRAND
triamcinolone acetonide aerosol 55 mcg/act
generic
TYZINE SOLUTION 0.05 %

tetrahydrozoline hcl
BRAND
TYZINE SOLUTION 0.1 %

tetrahydrozoline hcl
BRAND
RILUTEK TAB 50 MG
riluzole
BRAND
riluzole tab 50 mg
generic
BOTOX RECON SOLN 100 UNIT

onabotulinumtoxina
BRAND
PA
BOTOX RECON SOLN 200 UNIT

onabotulinumtoxina
BRAND
PA
DYSPORT RECON SOLN 300 UNIT

abobotulinumtoxina
BRAND
PA
*Nasal Anticholinergics**
*Nasal Steroids**
*Sympathomimetic Decongestants**
*NEUROMUSCULAR AGENTS*
*ALS Agents**
*Neuromuscular Blocking Agent - Neurotoxins**
PAGE 222
PRODUCT DESCRIPTION
BRAND/GEN
TIER
DYSPORT RECON SOLN 500 UNIT

abobotulinumtoxina
BRAND
PA
MYOBLOC SOLUTION 10000 UNIT/2ML

rimabotulinumtoxinb
BRAND
PA
MYOBLOC SOLUTION 2500 UNIT/0.5ML

rimabotulinumtoxinb
BRAND
PA
MYOBLOC SOLUTION 5000 UNIT/ML

rimabotulinumtoxinb
BRAND
PA
XEOMIN RECON SOLN 100 UNIT

incobotulinumtoxina
BRAND
PA
XEOMIN RECON SOLN 50 UNIT

incobotulinumtoxina
BRAND
PA
CLINIMIX E/DEXTROSE (5/20) SOLUTION 5

%
amino acid electrolyte w/ calcium infusion in
d20w
BRAND
CLINIMIX/DEXTROSE (2.75/5) SOLUTION

2.75 %
amino acid infusion in d5w
BRAND

4.25 %
BRAND

4.25 %
BRAND

4.25 %
BRAND
CLINIMIX/DEXTROSE (5/25) SOLUTION 5 %

BRAND
betaxolol hcl solution 0.5 %
generic
BETIMOL SOLUTION 0.25 %

timolol
BRAND
BETIMOL SOLUTION 0.5 %

timolol
BRAND
BETOPTIC-S SUSPENSION 0.25 %
BRAND
*NUTRIENTS*
*Proteins**
*OPHTHALMIC AGENTS*
*Beta-blockers - Ophthalmic**
PAGE 223
PRODUCT DESCRIPTION
BRAND/GEN
TIER
betaxolol hcl (ophth)

carteolol hcl solution 1 %
generic
COMBIGAN SOLUTION 0.2-0.5 %

brimonidine tartrate-timolol maleate
BRAND
COSOPT PF SOLUTION 22.3-6.8 MG/ML

dorzolamide hcl-timolol maleate
BRAND
dorzolamide hcl-timolol mal solution 22.3-6.8

mg/ml
generic
ISTALOL SOLUTION 0.5 %

timolol maleate (ophth)
BRAND
levobunolol hcl solution 0.25 %
generic
levobunolol hcl solution 0.5 %
generic
metipranolol solution 0.3 %
generic
timolol maleate gel f soln 0.25 %
generic
timolol maleate gel f soln 0.5 %
generic
timolol maleate solution 0.25 %
generic
timolol maleate solution 0.5 %
generic
TIMOPTIC OCUDOSE SOLUTION 0.25 %

BRAND
TIMOPTIC OCUDOSE SOLUTION 0.5 %

BRAND
atropine sulfate solution 1 %
generic
atropine-care solution 1 %
generic
mydral solution 0.5 %
generic
mydral solution 1 %
generic
tropicamide solution 0.5 %
generic
tropicamide solution 1 %
generic
PHOSPHOLINE IODIDE RECON SOLN 0.125

%
echothiophate iodide
BRAND
pilocarpine hcl solution 1 %
generic
generic
generic
*Cycloplegic Mydriatics**
*Miotics**
PAGE 224
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Ophthalmic - Angiogenesis Inhibitors**

EYLEA SOLUTION 2 MG/0.05ML
aflibercept
BRAND
PA
LUCENTIS SOLUTION 0.3 MG/0.05ML

ranibizumab
BRAND
PA
LUCENTIS SOLUTION 0.5 MG/0.05ML

ranibizumab
BRAND
PA
MACUGEN SOLUTION 0.3 MG

pegaptanib sodium
BRAND
PA
ALPHAGAN P SOLUTION 0.1 %

brimonidine tartrate
BRAND
apraclonidine hcl solution 0.5 %
generic
brimonidine tartrate solution 0.15 %
generic
brimonidine tartrate solution 0.2 %
generic
IOPIDINE SOLUTION 1 %
apraclonidine hcl
BRAND
AZASITE SOLUTION 1 %
azithromycin (ophth)
BRAND
BESIVANCE SUSPENSION 0.6 %

besifloxacin hcl
BRAND
ciprofloxacin hcl solution 0.3 %
generic
erythromycin ointment 5 mg/gm
generic
gatifloxacin solution 0.5 %
generic
gentak ointment 0.3 %
generic
gentamicin sulfate ointment 0.3 %
generic
gentamicin sulfate solution 0.3 %
generic
gentasol solution 0.3 %
generic
ilotycin ointment 5 mg/gm
generic
levofloxacin solution 0.5 %
generic
MITOSOL KIT 0.2 MG

mitomycin (ophthalmic)
BRAND
NATACYN SUSPENSION 5 %
natamycin
BRAND
neo-polycin ointment 3.5-400-10000
generic
*Ophthalmic Adrenergic Agents**
*Ophthalmic Anti-infectives**
PAGE 225
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
neomycin-bacitracin zn-polymyx ointment 5400-10000
generic
neomycin-polymyxin-gramicidin solution 1.7510000-.025
generic
ofloxacin solution 0.3 %
generic
romycin ointment 5 mg/gm
generic
sulfacetamide sodium ointment 10 %
generic
sulfacetamide sodium solution 10 %
generic
tobramycin solution 0.3 %
generic
tobrasol solution 0.3 %
generic
trifluridine solution 1 %
generic
triple antibiotic ointment 5-400-10000
generic
VIGAMOX SOLUTION 0.5 %

moxifloxacin hcl (ophth)
BRAND
ZYMAXID SOLUTION 0.5 %

gatifloxacin (ophth)
BRAND
naphazoline hcl solution 0.1 %
generic
NAPHAZOLINE HCL SOLUTION 0.1 %

naphazoline hcl
BRAND
BRAND
parcaine solution 0.5 %
generic
proparacaine hcl solution 0.5 %
generic
BRAND
ALREX SUSPENSION 0.2 %

loteprednol etabonate
BRAND
bacitra-neomycin-polymyxin-hc ointment 1 %
generic
BLEPHAMIDE SUSPENSION 10-0.2 %

sulfacetamide sod-prednisolone
BRAND
PA
*Ophthalmic Decongestants**
*Ophthalmic Immunomodulators**
RESTASIS EMULSION 0.05 %
cyclosporine (ophth)
*Ophthalmic Local Anesthetics**
*Ophthalmic Photodynamic Therapy Agents**

VISUDYNE RECON SOLN 15 MG
verteporfin
PA
*Ophthalmic Steroids**
PAGE 226
PRODUCT DESCRIPTION
BRAND/GEN
dexamethasone sodium phosphate solution 0.1

%
generic
DUREZOL EMULSION 0.05 %

difluprednate
BRAND
FLAREX SUSPENSION 0.1 %

fluorometholone acetate
BRAND
fluorometholone suspension 0.1 %
generic
FML FORTE SUSPENSION 0.25 %

fluorometholone (ophth)
BRAND
FML OINTMENT 0.1 %

fluorometholone (ophth)
BRAND
LOTEMAX GEL 0.5 %

BRAND
LOTEMAX OINTMENT 0.5 %

BRAND
LOTEMAX SUSPENSION 0.5 %

BRAND
MAXIDEX SUSPENSION 0.1 %

dexamethasone (ophth)
BRAND
neo-polycin hc ointment 1 %
generic
neomycin-polymyxin-dexameth ointment 3.510000-0.1
generic
neomycin-polymyxin-dexameth suspension 3.510000-0.1
generic
neomycin-polymyxin-hc suspension 3.5-100001
generic
OZURDEX IMPLANT 0.7 MG

dexamethasone (ophth)
BRAND
poly-dex ointment 3.5-10000-0.1
generic
PRED MILD SUSPENSION 0.12 %

prednisolone acetate (ophth)
BRAND
prednisolone acetate suspension 1 %
generic
prednisolone sodium phosphate solution 1 %
generic
RETISERT IMPLANT 0.59 MG

fluocinolone acetonide (ophth)
BRAND
sulfacetamide-prednisolone solution 10-0.23 %
generic
SULFACETAMIDE-PREDNISOLONE
SUSPENSION 10-0.2 %
sulfacetamide sod-prednisolone
BRAND
PAGE 227
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
TOBRADEX OINTMENT 0.3-0.1 %

tobramycin-dexamethasone
BRAND
tobramycin-dexamethasone suspension 0.3-0.1

%
generic
VEXOL SUSPENSION 1 %
rimexolone
BRAND
ALOCRIL SOLUTION 2 %
nedocromil sodium (ophth)
BRAND
PA
ALOMIDE SOLUTION 0.1 %

lodoxamide tromethamine
BRAND
PA
azelastine hcl solution 0.05 %
generic
AZOPT SUSPENSION 1 %
brinzolamide
BRAND
BEPREVE SOLUTION 1.5 %

bepotastine besilate
BRAND
BROMDAY SOLUTION 0.09 %

bromfenac sodium (ophth)
BRAND
bromfenac sodium (once-daily) solution 0.09 %
generic
bromfenac sodium solution 0.09 %
generic
cromolyn sodium solution 4 %
generic
CYSTARAN SOLUTION 0.44 %

cysteamine hcl
BRAND
diclofenac sodium solution 0.1 %
generic
dorzolamide hcl solution 2 %
generic
EMADINE SOLUTION 0.05 %

emedastine difumarate
BRAND
epinastine hcl solution 0.05 %
generic
flurbiprofen sodium solution 0.03 %
generic
ILEVRO SUSPENSION 0.3 %

nepafenac
BRAND
ketorolac tromethamine solution 0.4 %
generic
ketorolac tromethamine solution 0.5 %
generic
LASTACAFT SOLUTION 0.25 %

alcaftadine
BRAND
NEVANAC SUSPENSION 0.1 %

nepafenac
BRAND
*Ophthalmics - Misc.**
PA
PA
PA
PA
PAGE 228
PRODUCT DESCRIPTION
BRAND/GEN
TIER
PATADAY SOLUTION 0.2 %

olopatadine hcl
BRAND
PATANOL SOLUTION 0.1 %

olopatadine hcl
BRAND
latanoprost solution 0.005 %
generic
LUMIGAN SOLUTION 0.01 %

bimatoprost
BRAND
ST
LUMIGAN SOLUTION 0.03 %

bimatoprost
BRAND
ST
TRAVATAN Z SOLUTION 0.004 %

travoprost
BRAND
ST
ZIOPTAN SOLUTION 0.0015 %

tafluprost
BRAND
ST
generic
CETRAXAL SOLUTION 0.2 %

ciprofloxacin hcl (otic)
BRAND
ciprofloxacin hcl solution 0.2 %
generic
ofloxacin solution 0.3 %
generic
a/b otic solution 5.4-1.4 %
generic
antibiotic ear solution 3.5-10000-1
generic
antipyrine-benzocaine solution 5.4-1.4 %
generic
antipyrine-benzocaine solution 5.5-1.4 %
generic
antipyrine-benzocaine solution 54-14 mg/ml
generic
aurax solution 5.5-1.4 %
generic
aurodex solution 5.4-1.4 %
generic
auroguard solution 54-14 mg/ml
generic
auroto solution 5.4-1.4 %
generic
CIPRO HC SUSPENSION 0.2-1 %

ciprofloxacin-hydrocortisone
BRAND
CIPRODEX SUSPENSION 0.3-0.1 %
BRAND
PA
*Prostaglandins - Ophthalmic**
*OTIC AGENTS*
*Otic Agents - Miscellaneous**
acetic acid solution 2 %
*Otic Anti-infectives**
*Otic Combinations**
PAGE 229
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ciprofloxacin-dexamethasone
COLY-MYCIN S SUSPENSION 3.3-3-10-0.5
MG/ML
neomycin-colistin-hc-thonzonium
BRAND
CORTISPORIN-TC SUSPENSION 3.3-3-100.5 MG/ML

neomycin-colistin-hc-thonzonium
BRAND
cortomycin solution 3.5-10000-1
generic
cortomycin suspension 3.5-10000-1
generic
neomycin-polymyxin-hc solution 1 %
generic
neomycin-polymyxin-hc solution 3.5-10000-1
generic
neomycin-polymyxin-hc suspension 3.5-100001
generic
acetasol hc solution 2-1 %
generic
DERMOTIC OIL 0.01 %

fluocinolone acetonide (otic)
BRAND
fluocinolone acetonide oil 0.01 %
generic
hydrocortisone-acetic acid solution 1-2 %
generic
BIVIGAM SOLUTION 10 GM/100ML

immune globulin (human) iv
BRAND
PA
BIVIGAM SOLUTION 5 GM/50ML

BRAND
PA
CARIMUNE NF RECON SOLN 12 GM

BRAND
PA

BRAND
PA

BRAND
PA
CYTOGAM INJECTABLE 50 MG/ML

cytomegalovirus immune globulin (human)
BRAND
FLEBOGAMMA DIF SOLUTION 0.5 GM/10ML

BRAND
PA
FLEBOGAMMA DIF SOLUTION 10 GM/100ML

BRAND
PA
BRAND
PA
*Otic Steroids**
*PASSIVE IMMUNIZING AGENTS*

*Immune Serums**
PAGE 230
PRODUCT DESCRIPTION
BRAND/GEN
TIER

FLEBOGAMMA DIF SOLUTION 2.5 GM/50ML
BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA
GAMASTAN S/D INJECTABLE

immune globulin (human)
BRAND
PA
GAMMAGARD S/D LESS IGA RECON SOLN

10 GM
BRAND
PA
GAMMAGARD S/D LESS IGA RECON SOLN

5 GM
BRAND
PA
GAMMAGARD S/D RECON SOLN 0.5 GM

BRAND
PA
GAMMAGARD S/D RECON SOLN 10 GM

BRAND
PA
GAMMAGARD S/D RECON SOLN 2.5 GM

BRAND
PA
GAMMAGARD S/D RECON SOLN 5 GM

BRAND
PA
GAMMAGARD SOLUTION 1 GM/10ML

immune globulin (human) iv or subcutaneous
BRAND
PA

BRAND
PA
GAMMAGARD SOLUTION 2.5 GM/25ML

BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA
GAMMAKED SOLUTION 1 GM/10ML

BRAND
PA
PAGE 231
PRODUCT DESCRIPTION
BRAND/GEN
TIER

BRAND
PA
GAMMAKED SOLUTION 2.5 GM/25ML

BRAND
PA

BRAND
PA

BRAND
PA
GAMMAPLEX SOLUTION 10 GM/200ML

BRAND
PA
GAMMAPLEX SOLUTION 2.5 GM/50ML

BRAND
PA

BRAND

BRAND
PA
GAMUNEX SOLUTION 1 GM/10ML

BRAND
PA

BRAND
PA
GAMUNEX SOLUTION 2.5 GM/25ML

BRAND
PA

BRAND
PA

BRAND
PA
GAMUNEX-C SOLUTION 1 GM/10ML

BRAND
PA

BRAND
PA
GAMUNEX-C SOLUTION 2.5 GM/25ML

BRAND
PA

BRAND
PA

BRAND
PA
HEPAGAM B SOLUTION
hepatitis b immune globulin (human)
BRAND
PA
HIZENTRA 20% SOLUTION 1 GM/5ML

immune globulin (human) subcutaneous
BRAND
PA
PAGE 232
PRODUCT DESCRIPTION
BRAND/GEN

BRAND

BRAND
PA
HIZENTRA SOLUTION 10 GM/50ML

BRAND
PA
HYPERHEP B S/D SOLUTION

BRAND
PA
HYPERRAB S/D INJECTABLE 150 UNIT/ML

rabies immune globulin (human)
BRAND
PA
HYPERRHO S/D INJECTABLE 300 MCG

rho d immune globulin (human)
BRAND
PA
HYPERRHO S/D INJECTABLE 50 MCG

BRAND
PA
HYPERTET S/D INJECTABLE 250 UNIT/ML

tetanus immune globulin (human)
BRAND
PA
IMOGAM RABIES-HT INJECTABLE 150

UNIT/ML
rabies immune globulin (human)
BRAND
PA
MICRHOGAM ULTRA-FILTERED PLUS

INJECTABLE 50 MCG
BRAND
PA
NABI-HB SOLUTION
BRAND
PA
OCTAGAM SOLUTION 1 GM/20ML

BRAND
PA

BRAND
PA
OCTAGAM SOLUTION 2.5 GM/50ML

BRAND
PA

BRAND
PA

BRAND
PA
PRIVIGEN SOLUTION 10 GM/100ML

BRAND
PA

BRAND
PA

BRAND
PA
BRAND
PA
PAGE 233
TIER

PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER

RHOGAM ULTRA-FILTERED PLUS
INJECTABLE 300 MCG
BRAND
PA
RHOPHYLAC SOLUTION 1500 UNIT/2ML

BRAND
PA
VIVAGLOBIN SOLUTION 160 MG/ML

BRAND
PA
WINRHO SDF SOLUTION 1500 UNIT/1.3ML

BRAND
PA
WINRHO SDF SOLUTION 15000 UNIT/13ML

BRAND
PA

BRAND
PA

BRAND
PA
SYNAGIS SOLUTION 100 MG/ML

palivizumab
BRAND
PA
SYNAGIS SOLUTION 50 MG/0.5ML

palivizumab
BRAND
PA
amoxicillin 250 mg
generic
amoxicillin cap 250 mg
generic
amoxicillin cap 500 mg
generic
amoxicillin chew tab 125 mg
generic
amoxicillin chew tab 250 mg
generic
AMOXICILLIN CHEW TAB 250 MG

amoxicillin
BRAND
amoxicillin recon susp 125 mg/5ml
generic
generic
generic
generic
amoxicillin tab 500 mg
generic
amoxicillin tab 875 mg
generic
*Monoclonal Antibodies**
*PENICILLINS*
*Aminopenicillins**
PAGE 234
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ampicillin cap 250 mg
generic
ampicillin cap 500 mg
generic
ampicillin recon susp 125 mg/5ml
generic
ampicillin recon susp 250 mg/5ml
generic
ampicillin sodium recon soln 1 gm
generic
PA
generic
PA
AMPICILLIN SODIUM RECON SOLN 10 GM

ampicillin sodium
BRAND
PA
ampicillin sodium recon soln 125 mg
generic
PA
generic
PA
generic
PA
generic
PA
BICILLIN L-A SUSPENSION 1200000

UNIT/2ML
penicillin g benzathine
BRAND
PA
BICILLIN L-A SUSPENSION 2400000

UNIT/4ML
BRAND
PA
BICILLIN L-A SUSPENSION 600000 UNIT/ML

BRAND
PA
penicillin g pot in dextrose solution 20000

unit/ml
generic
PA

unit/ml
generic
PA

unit/ml
generic
PA
penicillin g potassium recon soln 20000000 unit
generic
PA
penicillin g potassium recon soln 5000000 unit
generic
PA
PENICILLIN G PROCAINE SUSPENSION

600000 UNIT/ML
penicillin g procaine
BRAND
PA
penicillin g sodium recon soln 5000000 unit
generic
PA
penicillin v potassium recon soln 125 mg/5ml
generic
penicillin v potassium recon soln 250 mg/5ml
generic
*Natural Penicillins**
PAGE 235
PRODUCT DESCRIPTION
BRAND/GEN
TIER
penicillin v potassium tab 250 mg
generic
penicillin v potassium tab 500 mg
generic
pfizerpen-g recon soln 5000000 unit
generic
amoxicillin-pot clavulanate chew tab 200-28.5

mg
generic
amoxicillin-pot clavulanate chew tab 400-57 mg
generic
amoxicillin-pot clavulanate er tab er 12h 100062.5 mg
generic
amoxicillin-pot clavulanate recon susp 200-28.5

mg/5ml
generic

mg/5ml
generic
amoxicillin-pot clavulanate recon susp 400-57

mg/5ml
generic

mg/5ml
generic
amoxicillin-pot clavulanate tab 250-125 mg
generic
generic
generic
ampicillin-sulbactam recon soln 3 (2-1) gm
generic
PA
ampicillin-sulbactam sodium recon soln 1.5 (10.5) gm
generic
PA
ampicillin-sulbactam sodium recon soln 15 (105) gm
generic
PA
ampicillin-sulbactam sodium recon soln 3 (2-1)

gm
generic
PA
AMPICILLIN-SULBACTAM SODIUM RECON

SOLN 3 (2-1) GM
ampicillin & sulbactam sodium
BRAND
PA
BICILLIN C-R 900/300 SUSPENSION 900000300000 UNIT/2ML

penicillin g benzathine & procaine
BRAND
PA
BICILLIN C-R SUSPENSION 1200000

UNIT/2ML
penicillin g benzathine & procaine
BRAND
PA
TIMENTIN RECON SOLN 3.1 GM

ticarcillin & pot clavulanate
BRAND
PA
PA
*Penicillin Combinations**
PAGE 236
PRODUCT DESCRIPTION
BRAND/GEN
TIER
TIMENTIN RECON SOLN 31 GM

BRAND
TIMENTIN SOLUTION 3.1 GM/100ML

BRAND
PA
nafcillin sodium recon soln 1 gm
generic
PA
generic
PA
generic
PA
oxacillin sodium recon soln 1 gm
generic
PA
generic
PA
generic
PA
STERILE DILUENT FOR FLOLAN SOLUTION

glycine diluent
BRAND
sterile diluent/epoprostenol solution
generic
MAKENA OIL 250 MG/ML

hydroxyprogesterone caproate
BRAND
medroxyprogesterone acetate tab 10 mg
generic
medroxyprogesterone acetate tab 2.5 mg
generic
medroxyprogesterone acetate tab 5 mg
generic
MEGACE ES SUSPENSION 625 MG/5ML

megestrol acetate (appetite)
BRAND
norethindrone acetate tab 5 mg
generic
progesterone micronized cap 100 mg
generic
progesterone micronized cap 200 mg
generic
PA
*Penicillinase-Resistant Penicillins**
*PHARMACEUTICAL ADJUVANTS*
*Liquid Vehicles**
*PROGESTINS*
*Progestins**
PA
*PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.*

*Agents for Chemical Dependency**
acamprosate calcium tab dr 333 mg
generic
disulfiram tab 250 mg
generic
1
1
PAGE 237
PRODUCT DESCRIPTION
BRAND/GEN
disulfiram tab 500 mg
generic
TIER
*Anti-Cataplectic Agents**
XYREM SOLUTION 500 MG/ML
sodium oxybate
PA
BRAND
4
MPL
3 / 30 days
*Antidementia Agents**
donepezil hcl tab 10 mg
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
donepezil hcl tab disp 10 mg
generic
QL
30 / 30 days
donepezil hcl tab disp 5 mg
generic
QL
30 / 30 days
EXELON PATCH 24HR 13.3 MG/24HR

rivastigmine
BRAND
PA

rivastigmine
BRAND
PA

rivastigmine
BRAND
PA
EXELON SOLUTION 2 MG/ML

rivastigmine tartrate
BRAND
galantamine hydrobromide er cap er 24h 16 mg
generic
QL
30 / 30 days
generic
QL
30 / 30 days
generic
QL
30 / 30 days
galantamine hydrobromide solution 4 mg/ml
generic
galantamine hydrobromide tab 12 mg
generic
QL
60 / 30 days
generic
QL
60 / 30 days
generic
QL
60 / 30 days
NAMENDA SOLUTION 10 MG/5ML

memantine hcl
BRAND
PA
NAMENDA TAB 10 MG
memantine hcl
BRAND
QL
60 / 30 days
NAMENDA TAB 5 MG
memantine hcl
BRAND
QL
60 / 30 days
NAMENDA TITRATION PAK TAB 5 (28)-10

(21) MG
BRAND
PAGE 238
PRODUCT DESCRIPTION
BRAND/GEN
TIER
memantine hcl
NAMENDA XR CAP ER 24H 14 MG
memantine hcl
BRAND
PA

memantine hcl
BRAND
PA

memantine hcl
BRAND
PA

memantine hcl
BRAND
PA
rivastigmine tartrate cap 1.5 mg
generic
QL
60 / 30 days
rivastigmine tartrate cap 3 mg
generic
QL
60 / 30 days
rivastigmine tartrate cap 4.5 mg
generic
QL
60 / 30 days
rivastigmine tartrate cap 6 mg
generic
QL
60 / 30 days
duo-vil 2-10 tab 2-10 mg
generic
duo-vil 2-25 tab 2-25 mg
generic
perphenazine-amitriptyline tab 2-10 mg
generic
generic
generic
generic
generic
SAVELLA TAB 100 MG

milnacipran hcl
BRAND
PA
SAVELLA TAB 12.5 MG

milnacipran hcl
BRAND
PA
SAVELLA TAB 25 MG
milnacipran hcl
BRAND
PA
SAVELLA TAB 50 MG
milnacipran hcl
BRAND
PA
SAVELLA TITRATION PACK MISC 12.5 & 25

& 50 MG
milnacipran hcl
BRAND
BRAND
*Combination Psychotherapeutics**
*Fibromyalgia Agents**
*Movement Disorder Drug Therapy**

XENAZINE TAB 12.5 MG
tetrabenazine
PAGE 239
PA
PRODUCT DESCRIPTION
BRAND/GEN
TIER
XENAZINE TAB 25 MG
tetrabenazine
BRAND
PA
AMPYRA TAB ER 12H 10 MG

dalfampridine
BRAND
PA
AUBAGIO TAB 14 MG
teriflunomide
BRAND
PA
AUBAGIO TAB 7 MG
teriflunomide
BRAND
PA
AVONEX KIT 30 MCG

interferon beta-1a
BRAND
PA
AVONEX PEN KIT 30 MCG/0.5ML

interferon beta-1a
BRAND
AVONEX PREFILLED KIT 30 MCG/0.5ML

interferon beta-1a
BRAND
BETASERON KIT 0.3 MG

interferon beta-1b
BRAND
PA
COPAXONE KIT 20 MG/ML

glatiramer acetate
BRAND
PA
COPAXONE SOLN PRSYR 40 MG/ML

glatiramer acetate
BRAND
EXTAVIA KIT 0.3 MG

interferon beta-1b
BRAND
PA
GILENYA CAP 0.5 MG

fingolimod hcl
BRAND
PA
REBIF REBIDOSE SOLUTION 22 MCG/0.5ML

interferon beta-1a
BRAND
REBIF REBIDOSE SOLUTION 44 MCG/0.5ML

interferon beta-1a
BRAND
REBIF REBIDOSE TITRATION PACK

SOLUTION 6X8.8 & 6X22 MCG
interferon beta-1a
BRAND
PA
REBIF SOLUTION 22 MCG/0.5ML

interferon beta-1a
BRAND
PA
REBIF SOLUTION 44 MCG/0.5ML

interferon beta-1a
BRAND
PA
REBIF TITRATION PACK SOLUTION 6X8.8 &

6X22 MCG
interferon beta-1a
BRAND
PA
TECFIDERA CAP DR 120 MG

dimethyl fumarate
BRAND
PA
*Multiple Sclerosis Agents**
PAGE 240
PRODUCT DESCRIPTION
BRAND/GEN
TIER
TECFIDERA CAP DR 240 MG

dimethyl fumarate
BRAND
PA
TECFIDERA MISC 120 & 240 MG

dimethyl fumarate
BRAND
PA
TYSABRI CONC 300 MG/15ML

natalizumab
BRAND
PA
GRALISE TAB 300 MG

gabapentin (phn)
BRAND
GRALISE TAB 600 MG

gabapentin (phn)
BRAND
BRAND
*Postherpetic Neuralgia (PHN) Agents**
*Pseudobulbar Affect (PBA) Agents**

NUEDEXTA CAP 20-10 MG
dextromethorphan hbr-quinidine sulfate
*Psychotherapeutic and Neurological Agents - Misc.**

ergoloid mesylates tab 1 mg
generic
ORAP TAB 1 MG
pimozide
BRAND
ORAP TAB 2 MG
pimozide
BRAND
HORIZANT TAB ER 300 MG

gabapentin enacarbil
BRAND
HORIZANT TAB ER 600 MG

gabapentin enacarbil
BRAND
buproban tab er 12h 150 mg
generic
QL
90 / 365 days
bupropion hcl er (smoking det) tab er 12h 150

mg
generic
QL
90 / 365 days
CHANTIX CONTINUING MONTH PAK TAB 1

MG
varenicline tartrate
BRAND
QL
90 / 365 days
CHANTIX STARTING MONTH PAK TAB 0.5

MG X 11 & 1 MG X 42
BRAND
CHANTIX TAB 0.5 MG

BRAND
QL
90 / 365 days
CHANTIX TAB 1 MG
BRAND
QL
90 / 365 days
*Restless Leg Syndrome (RLS) Agents**
*Smoking Deterrents**
PAGE 241
PRODUCT DESCRIPTION
BRAND/GEN
TIER
nicotine patch 24hr 14 mg/24hr
generic
QL
90 / 365 days
generic
QL
90 / 365 days
generic
QL
90 / 365 days
NICOTROL INHALER 10 MG
nicotine
BRAND
QL
90 / 365 days
NICOTROL NS SOLUTION 10 MG/ML

nicotine
BRAND
QL
90 / 365 days
ARALAST NP RECON SOLN 1000 MG

alpha1-proteinase inhibitor (human)
BRAND
PA

BRAND
PA

BRAND
PA

BRAND
PA
ARALAST RECON SOLN 800 MG

BRAND
PA
GLASSIA SOLUTION 1000 MG/50ML

BRAND
PA
PROLASTIN RECON SOLN 500 MG

BRAND
PROLASTIN RECON SUSP 1000 MG

BRAND
PROLASTIN-C RECON SOLN 1000 MG

BRAND
ZEMAIRA RECON SOLN 1000 MG

BRAND
KALYDECO TAB 150 MG

ivacaftor
BRAND
PA
PULMOZYME SOLUTION 1 MG/ML

dornase alfa
BRAND
PA
*RESPIRATORY AGENTS - MISC.*

*Alpha-Proteinase Inhibitor (Human)**
*Cystic Fibrosis Agents**
*SULFONAMIDES*
*Sulfonamides**
PAGE 242
PRODUCT DESCRIPTION
BRAND/GEN
TIER
sulfadiazine tab 500 mg
generic
avidoxy tab 100 mg
generic
demeclocycline hcl tab 150 mg
generic
demeclocycline hcl tab 300 mg
generic
doxy 100 recon soln 100 mg
generic
PA
doxycycline hyclate cap 100 mg
generic
PA
doxycycline hyclate cap 50 mg
generic
doxycycline hyclate recon soln 100 mg
generic
PA
doxycycline hyclate tab 100 mg
generic
PA
doxycycline hyclate tab 20 mg
generic
doxycycline hyclate tab dr 100 mg
generic
generic
generic
doxycycline monohydrate cap 100 mg
generic
generic
generic
generic
doxycycline monohydrate tab 100 mg
generic
generic
generic
generic
minocycline hcl cap 100 mg
generic
generic
generic
minocycline hcl tab 100 mg
generic
generic
generic
morgidox cap 100 mg
generic
TETRACYCLINE HCL CAP 250 MG

tetracycline hcl
BRAND
*TETRACYCLINES*
*Tetracyclines**
PAGE 243
PRODUCT DESCRIPTION
BRAND/GEN
TIER
TETRACYCLINE HCL CAP 500 MG

tetracycline hcl
BRAND
VIBRAMYCIN SYRUP 50 MG/5ML

doxycycline calcium
BRAND
methimazole tab 10 mg
generic
methimazole tab 5 mg
generic
propylthiouracil tab 50 mg
generic
armour thyroid tab 120 mg
generic
ARMOUR THYROID TAB 15 MG

thyroid
BRAND

thyroid
BRAND

thyroid
BRAND

thyroid
BRAND
levothroid tab 100 mcg
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
levothyroxine sodium recon soln 100 mcg
generic
generic
generic
*THYROID AGENTS*
*Antithyroid Agents**
*Thyroid Hormones**
PA
PAGE 244
PRODUCT DESCRIPTION
BRAND/GEN
levothyroxine sodium tab 100 mcg
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
levoxyl tab 100 mcg
generic
levoxyl tab 112 mcg
generic
levoxyl tab 125 mcg
generic
levoxyl tab 137 mcg
generic
levoxyl tab 150 mcg
generic
levoxyl tab 175 mcg
generic
levoxyl tab 200 mcg
generic
levoxyl tab 25 mcg
generic
levoxyl tab 50 mcg
generic
levoxyl tab 75 mcg
generic
levoxyl tab 88 mcg
generic
liothyronine sodium tab 25 mcg
generic
generic
generic
NATURE-THROID TAB 162.5 MG

thyroid
BRAND
NATURE-THROID TAB 325 MG

thyroid
BRAND
NATURE-THROID TAB 48.75 MG

thyroid
BRAND
NATURE-THROID TAB 65 MG
thyroid
BRAND
PAGE 245
TIER
PRODUCT DESCRIPTION
BRAND/GEN
np thyroid tab 30 mg
generic
generic
generic
THYROLAR-1 TAB 60 (12.5-50) MG (MCG)

liotrix (t3-t4)
BRAND
THYROLAR-1/2 TAB 30 (6.25-25) MG (MCG)

liotrix (t3-t4)
BRAND
THYROLAR-1/4 TAB 15 (3.1-12.5) MG (MCG)

liotrix (t3-t4)
BRAND
THYROLAR-2 TAB 120 (25-100) MG (MCG)

liotrix (t3-t4)
BRAND
THYROLAR-3 TAB 180 (37.5-150) MG (MCG)

liotrix (t3-t4)
BRAND
unithroid tab 100 mcg
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
generic
WESTHROID TAB 162.5 MG

thyroid
BRAND
WESTHROID TAB 325 MG

thyroid
BRAND
WESTHROID TAB 48.75 MG

thyroid
BRAND
WESTHROID TAB 65 MG
thyroid
BRAND
WESTHROID-P TAB 48.75 MG

thyroid
BRAND
WESTHROID-P TAB 65 MG
thyroid
BRAND
PAGE 246
TIER
PRODUCT DESCRIPTION
BRAND/GEN
TIER
WP THYROID TAB 48.75 MG

thyroid
BRAND
WP THYROID TAB 65 MG
thyroid
BRAND
ADACEL SUSPENSION 5-2-15.5 LF-MCG/0.5

tetanus toxoid-diphtheria-acellular pertussis
adsorb (tdap)
BRAND
BOOSTRIX SUSPENSION 5-2.5-18.5

tetanus toxoid-diphtheria-acellular pertussis
adsorb (tdap)
BRAND
DAPTACEL SUSPENSION 10-15-5

diphtheria, acellular pertussis & tetanus toxoids
BRAND
DECAVAC INJECTABLE 5-2 LFU

tetanus-diphtheria toxoids (td)
BRAND
DIPHTHERIA-TETANUS TOXOIDS DT
SUSPENSION 25-5 LFU/0.5ML
diphtheria-tetanus toxoids (dt)
BRAND
DIPHTHERIA-TETANUS TOXOIDS
INJECTABLE 6.7-5 LFU/0.5ML
diphtheria-tetanus toxoids (dt)
BRAND
INFANRIX SUSPENSION 25-58-10

BRAND
KINRIX SUSPENSION
diph-tetanus tox ad-acell pertussis & polio
virus, ipv vac
BRAND
AL
Up to 18 yrs old
PEDIARIX SUSPENSION
diph-tetanus tox-acell pert-hepatitis b recombpolio ipv vac
BRAND
AL
Up to 18 yrs old
PENTACEL RECON SUSP

diph-ac pert-tet tox ad-polio ipv-haemophil b
poly vac
BRAND
AL
Up to 18 yrs old
TENIVAC INJECTABLE 5-2 LFU

BRAND
tetanus-diphtheria toxoids td suspension 2-2

lf/0.5ml
generic
TETANUS-DIPHTHERIA TOXOIDS TD
SUSPENSION 2-2 LF/0.5ML
BRAND
TRIHIBIT PRESERVATIVE FREE KIT 46.8-6.7

MCG-LFU
BRAND
AL
Up to 18 yrs old
*TOXOIDS*
*Toxoid Combinations**
PAGE 247
PRODUCT DESCRIPTION
BRAND/GEN
TIER
diph, acellular pertussis, tetanus tox &

haemophilus b poly
TRIPEDIA PRESERVATIVE FREE
SUSPENSION 46.8-6.7-5
BRAND
BRAND
CUVPOSA SOLUTION 1 MG/5ML

glycopyrrolate
BRAND
dicyclomine hcl cap 10 mg
generic
dicyclomine hcl solution 10 mg/5ml
generic
dicyclomine hcl tab 20 mg
generic
GLYCATE TAB 1.5 MG

glycopyrrolate
BRAND
glycopyrrolate tab 1 mg
generic
glycopyrrolate tab 2 mg
generic
hyomax tab 0.125 mg
generic
hyomax-sl sl tab 0.125 mg
generic
hyomax-sr tab er 12h 0.375 mg
generic
hyoscyamine sulfate elixir 0.125 mg/5ml
generic
hyoscyamine sulfate er tab er 12h 0.375 mg
generic
hyoscyamine sulfate sl tab 0.125 mg
generic
hyoscyamine sulfate tab 0.125 mg
generic
hyoscyamine sulfate tab disp 0.125 mg
generic
hyosyne elixir 0.125 mg/5ml
generic
methscopolamine bromide tab 2.5 mg
generic
methscopolamine bromide tab 5 mg
generic
oscimin sl tab 0.125 mg
generic
oscimin sr tab er 12h 0.375 mg
generic
oscimin tab 0.125 mg
generic
oscimin tab disp 0.125 mg
generic
*Toxoids**
TETANUS TOXOID ADSORBED SOLUTION 5
LFU
tetanus toxoid adsorbed
*ULCER DRUGS*
*Antispasmodics**
PAGE 248
PRODUCT DESCRIPTION
BRAND/GEN
TIER
SAL-TROPINE TAB 0.4 MG

atropine sulfate
BRAND
scopolamine hbr solution 0.4 mg/ml
generic
symax-sl sl tab 0.125 mg
generic
symax-sr tab er 12h 0.375 mg
generic
cimetidine tab 200 mg
generic
generic
generic
generic
famotidine recon susp 40 mg/5ml
generic
famotidine tab 20 mg
generic
famotidine tab 40 mg
generic
nizatidine cap 150 mg
generic
nizatidine cap 300 mg
generic
nizatidine solution 15 mg/ml
generic
ranitidine hcl 150 mg
generic
ranitidine hcl cap 150 mg
generic
ranitidine hcl cap 300 mg
generic
ranitidine hcl tab 150 mg
generic
ranitidine hcl tab 300 mg
generic
carafate suspension 1 gm/10ml
generic
sucralfate suspension 1 gm/10ml
generic
sucralfate tab 1 gm
generic
DEXILANT CAP DR 30 MG
dexlansoprazole
BRAND
DEXILANT CAP DR 60 MG
dexlansoprazole
BRAND
FIRST-LANSOPRAZOLE SUSPENSION 3
MG/ML
lansoprazole
BRAND
PA
*H-2 Antagonists**
*Misc. Anti-Ulcer**
*Proton Pump Inhibitors**
PAGE 249
QL
30 / 30 days
ST
QL
30 / 30 days
3
ST
PRODUCT DESCRIPTION
BRAND/GEN
TIER
FIRST-OMEPRAZOLE SUSPENSION 2
MG/ML
omeprazole
BRAND
lansoprazole cap dr 15 mg
generic
QL
30 / 30 days
lansoprazole cap dr 30 mg
generic
QL
30 / 30 days
lansoprazole tab disp 15 mg
generic
QL
30 / 30 days
lansoprazole tab disp 30 mg
generic
QL
30 / 30 days
NEXIUM CAP DR 20 MG
esomeprazole magnesium
QL
BRAND
30 / 30 days
NEXIUM CAP DR 40 MG
BRAND
NEXIUM PACKET 10 MG
BRAND
NEXIUM PACKET 2.5 MG

BRAND
NEXIUM PACKET 20 MG
BRAND
NEXIUM PACKET 40 MG
BRAND
NEXIUM PACKET 5 MG
BRAND
omeprazole cap dr 10 mg
generic
QL
60 / 30 days
generic
QL
60 / 30 days
generic
QL
60 / 30 days
OMEPRAZOLE+SYRSPEND SF ALKA
SUSPENSION 2 MG/ML
omeprazole
BRAND
pantoprazole sodium recon soln 40 mg
generic
QL
30 / 30 days
pantoprazole sodium tab dr 20 mg
generic
QL
30 / 30 days
pantoprazole sodium tab dr 40 mg
generic
QL
30 / 30 days
QL
rabeprazole sodium tab dr 20 mg
generic
30 / 30 days
ST
QL
30 / 30 days
3
ST
QL
30 / 30 days
ST
QL
30 / 30 days
3
ST
ST
*Ulcer Drugs - Prostaglandins**
PAGE 250
PRODUCT DESCRIPTION
BRAND/GEN
TIER
misoprostol tab 100 mcg
generic
misoprostol tab 200 mcg
generic
methenamine hippurate tab 1 gm
generic
methenamine mandelate tab 0.5 gm
generic
methenamine mandelate tab 1 gm
generic
MONUROL PACKET 3 GM
fosfomycin tromethamine
BRAND
nitrofurantoin macrocrystal cap 100 mg
generic
nitrofurantoin macrocrystal cap 50 mg
generic
nitrofurantoin monohyd macro cap 100 mg
generic
*URINARY ANTI-INFECTIVES*
*Urinary Anti-infectives**
*URINARY ANTISPASMODICS*
*Urinary Antispasmodic - Antimuscarinics (Anticholinergic)**
ENABLEX TAB ER 24H 15 MG
darifenacin hydrobromide
BRAND
ST
ENABLEX TAB ER 24H 7.5 MG

darifenacin hydrobromide
BRAND
ST
oxybutynin chloride er tab er 24h 10 mg
generic
generic
generic
oxybutynin chloride syrup 5 mg/5ml
generic
oxybutynin chloride tab 5 mg
generic
tolterodine tartrate er cap er 24h 2 mg
generic
ST
tolterodine tartrate er cap er 24h 4 mg
generic
ST
tolterodine tartrate tab 1 mg
generic
tolterodine tartrate tab 2 mg
generic
TOVIAZ TAB ER 24H 4 MG

fesoterodine fumarate
BRAND
ST
TOVIAZ TAB ER 24H 8 MG

fesoterodine fumarate
BRAND
ST
trospium chloride er cap er 24h 60 mg
generic
trospium chloride tab 20 mg
generic
VESICARE TAB 10 MG
BRAND
PAGE 251
ST
PRODUCT DESCRIPTION
BRAND/GEN
TIER
solifenacin succinate
VESICARE TAB 5 MG
solifenacin succinate
BRAND
bethanechol chloride tab 10 mg
generic
generic
generic
generic
ST
*Urinary Antispasmodics - Cholinergic Agonists**
*Urinary Antispasmodics - Direct Muscle Relaxants**

flavoxate hcl tab 100 mg
generic
ACTHIB RECON SOLN

haemophilus b polysac conj vac
BRAND
AL
Up to 18 yrs old
HIBERIX RECON SOLN 10 MCG

BRAND
AL
Up to 18 yrs old
MENACTRA INJECTABLE
meningococcal (a,c,y&w-135) polysaccharide
conjugate vaccine
BRAND
MENHIBRIX RECON SOLN 5-5-2.5 MCG

meningococcal (c & y)-haemophilus b tetanus
tox conj vaccine
BRAND
AL
Up to 18 yrs old
MENOMUNE INJECTABLE
meningococcal vac a,c,y&w-135
BRAND
MENVEO RECON SOLN

meningococcal (a,c,y&w-135) oligosaccharide
conjugate vac
BRAND
PEDVAX HIB SUSPENSION 7.5 MCG/0.5ML

BRAND
AL
Up to 18 yrs old
PNEUMOVAX 23 INJECTABLE 25
MCG/0.5ML
pneumococcal vac polyvalent
BRAND
AL
19 to 999 yrs old
PREVNAR 13 SUSPENSION
pneumococcal 13-valent conjugate vaccine
BRAND
AL
19 to 999 yrs old
BRAND
AL
Up to 18 yrs old
*VACCINES*
*Bacterial Vaccines**
*Mixed Vaccine Combinations**

COMVAX SUSPENSION 7.5-5 MCG/0.5ML
haemophilus b polysac conj-hepatitis b
(recomb) vaccines
PAGE 252
PRODUCT DESCRIPTION
BRAND/GEN
TIER
*Viral Vaccines**
AFLURIA PRESERVATIVE FREE
SUSPENSION
influenza virus vaccine split preservative free
BRAND
AFLURIA SUSPENSION
influenza virus vaccine split
BRAND
AGRIFLU SUSPENSION
influenza virus vaccine types a & b preservative
free
BRAND
ENGERIX-B INJECTABLE 20 MCG/ML

hepatitis b vaccine (recomb)
BRAND
ENGERIX-B SUSPENSION 10 MCG/0.5ML

BRAND
ENGERIX-B SUSPENSION 20 MCG/ML

BRAND
FLUARIX QUADRIVALENT SUSPENSION 0.5

ML
influenza virus vaccine split quadrivalent
BRAND
FLUARIX SUSPENSION
BRAND
FLUBLOK SOLUTION
influenza virus vaccine recombinant
hemagglutinin (ha)
BRAND
FLUCELVAX SUSPENSION
influenza virus vaccine tissue-cultured subunit
BRAND
FLULAVAL INJECTABLE
BRAND
FLULAVAL QUADRIVALENT SUSPENSION

BRAND
FLULAVAL QUADRIVALENT SUSPENSION

0.5 ML
BRAND
FLUMIST LIQUID
influenza virus vaccine live
BRAND
FLUMIST QUADRIVALENT SUSPENSION

influenza virus vaccine live quadrivalent
BRAND
FLUVIRIN INJECTABLE
influenza virus vaccine types a & b surface
antigen
BRAND
FLUVIRIN PRESERVATIVE FREE

SUSPENSION
BRAND
PAGE 253
PRODUCT DESCRIPTION
BRAND/GEN
TIER
free
FLUZONE DEVICE 9 MCG/STRAIN
BRAND
FLUZONE HIGH-DOSE SUSPENSION

influenza virus vaccine split high-dose
preservative free
BRAND
FLUZONE INJECTABLE
BRAND
FLUZONE PEDIATRIC PF SUSPENSION

BRAND
FLUZONE PRESERVATIVE FREE

SUSPENSION
BRAND
FLUZONE QUADRIVALENT SUSPENSION

BRAND

0.25 ML
BRAND

0.5 ML
BRAND
GARDASIL SUSPENSION
human papillomavirus (hpv) quadrivalent
recombinant vaccine
BRAND
HAVRIX SUSPENSION 1440 EL U/ML

hepatitis a vaccine
BRAND
HAVRIX SUSPENSION 720 EL U/0.5ML

hepatitis a vaccine
BRAND
IPOL INJECTABLE
poliovirus vaccine, ipv
BRAND
M-M-R II INJECTABLE
measles, mumps & rubella virus vaccines
BRAND
MEDICAL PROVIDER EZ FLU PF KIT

free
BRAND
MEDICAL PROVIDER EZ FLU SHOT KIT 0.5

ML
BRAND
PHYSICIANS EZ USE FLU KIT

influenza virus vaccine types a & b surface
antigen
BRAND
PROQUAD INJECTABLE
BRAND
PAGE 254
GL
Female
AL
Up to 18 yrs old
PRODUCT DESCRIPTION
BRAND/GEN
TIER
measles-mumps-rubella-varicella virus
vaccines
RECOMBIVAX HB SUSPENSION 10 MCG/ML
BRAND
RECOMBIVAX HB SUSPENSION 40 MCG/ML

BRAND
RECOMBIVAX HB SUSPENSION 5
MCG/0.5ML
BRAND
ROTARIX RECON SUSP

rotavirus vaccine, live oral
BRAND
AL
Up to 18 yrs old
ROTATEQ SOLUTION
rotavirus vaccine, live oral pentavalent
BRAND
AL
Up to 18 yrs old
TWINRIX SUSPENSION 720-20

hepatitis a (inactivated)-hepatitis b
(recombinant) vaccines
BRAND
VAQTA SUSPENSION 25 UNIT/0.5ML

hepatitis a vaccine
BRAND
VAQTA SUSPENSION 50 UNIT/ML

hepatitis a vaccine
BRAND
VARIVAX INJECTABLE 1350 PFU/0.5ML

varicella virus vaccine live
BRAND
ZOSTAVAX RECON SOLN 19400

UNT/0.65ML
zoster vaccine live
BRAND
AL
19 to 999 yrs old
clindamycin phosphate cream 2 %
generic
GYNAZOLE-1 CREAM 2 %
butoconazole nitrate (one dose)
BRAND
miconazole 3 kit 200-2 mg-% (9gm)
generic
MICONAZOLE 3 SUPPOS 200 MG

miconazole nitrate vaginal
BRAND
NYSTATIN TAB 100000 UNIT

nystatin vaginal
BRAND
terconazole cream 0.4 %
generic
terconazole cream 0.8 %
generic
terconazole suppos 80 mg
generic
zazole cream 0.4 %
generic
*VAGINAL PRODUCTS*
*Vaginal Anti-infectives**
PAGE 255
PRODUCT DESCRIPTION
BRAND/GEN
TIER
zazole cream 0.8 %
generic
ESTRACE CREAM 0.1 MG/GM

estradiol vaginal
BRAND
ESTRING RING 2 MG
estradiol vaginal
BRAND
FEMRING RING 0.05 MG/24HR

estradiol acetate vaginal
BRAND
FEMRING RING 0.1 MG/24HR

estradiol acetate vaginal
BRAND
PREMARIN CREAM 0.625 MG/GM

estrogens, conjugated vaginal
BRAND
CRINONE GEL 4 %
progesterone (vaginal)
BRAND
CRINONE GEL 8 %
BRAND
ENDOMETRIN INSERT 100 MG

BRAND
FIRST-PROGESTERONE VGS 100 SUPPOS

100 MG
BRAND

200 MG
BRAND

25 MG
BRAND

400 MG
BRAND

50 MG
BRAND
PROCHIEVE GEL 4 %
BRAND
PROCHIEVE GEL 8 %
BRAND
*Vaginal Estrogens**
*Vaginal Progestins**
*VASOPRESSORS*
*Anaphylaxis Therapy Agents**
PAGE 256
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ADRENACLICK SOLN A-INJ 0.15 MG/0.15ML

epinephrine
BRAND
QL
1 / 30 days
adrenaclick soln a-inj 0.3 mg/0.3ml
generic
QL
1 / 30 days
AUVI-Q SOLN A-INJ 0.15 MG/0.15ML

epinephrine
BRAND
QL
1 / 30 days
auvi-q soln a-inj 0.3 mg/0.3ml
generic
QL
1 / 30 days
QL
epinephrine soln a-inj 0.15 mg/0.15ml
generic
1 / 30 days
1
PA
QL
EPINEPHRINE SOLN A-INJ 0.15 MG/0.15ML

epinephrine
BRAND
epinephrine soln a-inj 0.3 mg/0.3ml
generic
1 / 30 days
2
PA
QL
1 / 30 days
1
PA
epipen 2-pak soln a-inj 0.3 mg/0.3ml
generic
QL
1 / 30 days
EPIPEN JR 2-PAK SOLN A-INJ 0.15

MG/0.3ML
epinephrine
BRAND
QL
1 / 30 days
EPIPEN JR SOLN A-INJ 0.15 MG/0.3ML

epinephrine
BRAND
QL
1 / 30 days
epipen soln a-inj 0.3 mg/0.3ml
generic
QL
1 / 30 days
TWINJECT SOLN A-INJ 0.15 MG/0.15ML

epinephrine
BRAND
QL
1 / 30 days
twinject soln a-inj 0.3 mg/0.3ml
generic
QL
1 / 30 days
midodrine hcl tab 10 mg
generic
midodrine hcl tab 2.5 mg
generic
midodrine hcl tab 5 mg
generic
DECARA CAP 25000 UNIT

cholecalciferol
BRAND
AL
65 to 999 yrs old
decara cap 50000 unit
generic
AL
65 to 999 yrs old
DRISDOL CAP 50000 UNIT

ergocalciferol
BRAND
AL
65 to 999 yrs old
ergocalciferol cap 50000 unit
generic
AL
65 to 999 yrs old
*Vasopressors**
*VITAMINS*
*Oil Soluble Vitamins**
PAGE 257
PRODUCT DESCRIPTION
BRAND/GEN
TIER
ergocalciferol powder
generic
MEPHYTON TAB 5 MG
phytonadione
BRAND
phytonadione solution 1 mg/0.5ml
generic
PA
vitamin d (ergocalciferol) cap 50000 unit
generic
AL
vitamin k1 solution 1 mg/0.5ml
generic
PA
vitamin k1 solution 2 mg/ml
generic
PA
generic
AL
65 to 999 yrs old
65 to 999 yrs old
*Water Soluble Vitamins**

PAGE 258
Index of covered drugs
Adagen
8-Mop
Adalimumab
138
Adapalene
132,133
Adapalene-Benzoyl Peroxide
A
A-Hydrocort
111
127
134
Adcetris
76
Adcirca
117
Abacavir Sulfate
98
Adefovir Dipivoxil
102
Abacavir Sulfate-Lamivudine
99
Adempas
117
Abacavir Sulfate-Lamivudine-Zidovudine
98
Adrenaclick
256
Abatacept
11,12
Adriamycin
79
Abciximab
172
Advair Diskus
33
33
Abelcet
57
Advair HFA
Abilify
97
Advate
166
Abilify Discmelt
96,97
Advicor
61
Abilify Maintena
97
Afatinib Dimaleate
81
Abiraterone Acetate
79
Afinitor
AbobotulinumtoxinA
222
Afinitor Disperz
AbobotulinumtoxinA (Glabellar Lines)
143
Aflibercept
224
Afluria
253
80,81
80
Abraxane
86
Absorica
131
Afluria Preservative Free
252
Acamprosate Calcium
237
Agalsidase beta
155
Aggrenox
172
Agriflu
253
Acarbose
Acebutolol HCl
Acetaminophen w/ Codeine
48
110
18,19
Acetaminophen-Isometheptene-
Albendazole
23
Albenza
23
Dichloralphenazone
183
Albuterol Sulfate
Acetazolamide
147
Alcaftadine
Acetic Acid
165
Alclometasone Dipropionate
Acetic Acid (Otic)
229
Aldactazide
147
Acetylcysteine
131
Aldesleukin
84
Acitretin
138
Aldurazyme
155
Actemra
Alefacept
138
Acthar HP
150
Alemtuzumab
ActHIB
252
Alendronate Sodium
Actimmune
84
Active OB
197
Actoplus met XR
Acyclovir
49
104,105
Alferon N
33,34,35
228
139,140
76
149
84
Alfuzosin HCl
165
Alglucerase
172
Alglucosidase Alfa
155,156
Acyclovir Sodium
105
Alimta
73
Acyclovir Topical
139
Alinia
26
Adacel
247
Aliskiren Fumarate
69
PAGE 259
Aliskiren-Hydrochlorothiazide
Alitretinoin
Alkeran
Allopurinol
Almotriptan Malate
68
137
71
166
183,184
Amitriptyline HCl
47
Amlodipine Besylate
112
Amlodipine Besylate-Benazepril HCl
66
Ammonium Chloride
185
Ammonium Lactate
120
Alocril
228
Amoxapine
47
Alomide
228
Amoxicillin
234
Alosetron HCl
163
Amoxicillin & Pot Clavulanate
236
Aloxi
55
Amphetamine-Dextroamphetamine
Alpha1-Proteinase Inhibitor (Human)
242
Amphotec
57
Alphagan P
225
Amphotericin B
57
Amphotericin B Cholesteryl Sulfate Complex
57
Amphotericin B Lipid
57
Amphotericin B Liposome
57
Alphanate/VWF Complex/Human
AlphaNine SD
Alprazolam
166,167
167
29,30
Alprolix
167
Ampicillin
Alprostadil
109
Ampicillin & Sulbactam Sodium
236
Alprostadil (Vasodilator)
115
Ampicillin Sodium
235
Alrex
226
Ampicillin-Sulbactam Sodium
236
Alsuma
183
Ampyra
240
Altabax
136
Anadrol-50
Altretamine
72
Alvimopan
163
234,235
21
Anagrelide HCl
172
Anakinra
Amantadine HCl
89
Anastrozole
77
Ambenonium Chloride
70
Ancobon
57
AmBisome
57
Androderm
22
Ambrisentan
116
AndroGel
22
Amcinonide
140
AndroGel Pump
22
Amethyst
121
Android
22
Amevive
138
Androxy
22
Amifostine Crystalline
Amikacin Sulfate
85
7
Anti-Thymocyte Globulin (Rabbit), Lymphocyte

Immune Globulin
108
Amiloride & Hydrochlorothiazide
147
Antihemophilic Factor (Human)
Amiloride HCl
148
Antihemophilic Factor (Recombinant)
Amino Acid Electrolyte w/ Calcium Infusion in
168,169
168,169,170
Antihemophilic Factor (Recombinant) Plasma/Alblumin
D20W
223
Free
171
Amino Acid Infusion in D10W
223
Antihemophilic Factor rAHF-PFM
166
223
Antihemophilic Factor/von Willebrand Factor Complex
223
(Human)
166,167,168,170,171
Aminosalicylic Acid
70
Antiinhibitor Coagulant Complex
168
Amiodarone HCl
31
Antipyrine-Benzocaine
229
Antithrombin (Human) (Recombinant)
172
Amitiza
PAGE 260
162
Antithrombin III (Human)
172
Atabex EC
198
Anzemet
55
Atazanavir Sulfate
100
Apidra
51
Atenolol
110
Apidra SoloStar
51
Atenolol & Chlorthalidone
Apixaban
36
Atgam
66
106
Apligraf
145
Apokyn
89
Atorvastatin Calcium
Apomorphine Hydrochloride
89
Atovaquone
26
Atovaquone-Proguanil HCl
69
Atripla
98
Apraclonidine HCl
225
Apremilast
11
Aprepitant
56,57
Atomoxetine HCl
5
61,62
Atropine Sulfate
248
Atropine Sulfate (Ophthalmic)
224
Apriso
162
Aptivus
98
Aralast
242
Atryn
172
Aralast NP
242
Aubagio
240
Aranesp (Albumin Free)

Arcalyst
173,174
Atrovent HFA
32
Auranofin
Auvi-Q
257
34
Avandia
51
Aredia
149
Avastin
76
Arestin
191
Avelox
161
34
Avodart
165
Aripiprazole
96,97
Avonex
240
Armodafinil
Avonex Pen
240
Avonex Prefilled
240
Arcapta Neohaler
Arformoterol Tartrate
Armour Thyroid
244
Arranon
73
Axert
183,184
Arsenic Trioxide
85
Axitinib
Artemether-Lumefantrine
69
Azacitidine
Arzerra
76
Azactam in Dextrose
Asacol
162
Azasan
106
Asacol HD
162
AzaSite
225
81
73,75
24
Asenapine Maleate
95
Azathioprine
106,107
Asmanex 120 Metered Doses
32
Azelaic Acid
145
32
Azelaic Acid (Acne)
132
32
Azelastine HCl
32
Azelastine HCl (Ophth)
228
32
Azelex
132
Asparaginase
83
Azilect
91
Asparaginase Erwinia Chrysanthemi
84
Azilsartan Medoxomil
65
Aspirin
12,13
221,222
Azithromycin
180
Aspirin-Dipyridamole
172
Azithromycin (Ophth)
225
Astagraf XL
106
Azithromycin Hydrogencitrate
180
PAGE 261
Azopt
228
Benzoyl Peroxide w/ Cleanser
132
133
Aztreonam
24
Benzoyl Peroxide-Erythromycin
Aztreonam in Dextrose
24
Benztropine Mesylate
Aztreonam Lysine
24
Benzyl Alcohol (Pediculicide)
145
Bepotastine Besilate
228
Bepreve
228
Berinert
171
B
B-Complex w/ C & Folic Acid
191,192,193
89
B-Complex w/ C-Biotin-D & Folic Acid
192
Besifloxacin HCl
225
B-Complex w/ C-Biotin-D-Zinc & Folic Acid
193
Besivance
225
B-Complex w/ C-Biotin-E-Minerals & Folic Acid 191,192
Betaine
155
B-Complex w/ C-Biotin-Minerals & Folic Acid
192
Betamethasone Dipropionate (Topical)
140
B-Complex w/ C-Zn & Folic Acid
192
Betamethasone Dipropionate Augmented
140
B-Complex w/ Lysine-Min-Fe & Folic Acid
192
Betamethasone Sod Phosphate & Acetate
127
B-Complex w/ Lysine-Zn & Folic Acid
193
Betamethasone Valerate
B-Nexa
198
Betaseron
240
Betaxolol HCl
110
Bacitracin-Poly-Neomycin-HC
226,227
140,142
Bacitracin-Polymyxin-Neomycin HC
136
Betaxolol HCl (Ophth)
223
Baclofen
220
Bethanechol Chloride
252
Bactroban Nasal
221
Bethkis
Bal-Care DHA
198
Betimol
223
Bal-Care DHA Essential
198
Betoptic-S
223
Balsalazide Disodium
162
Bevacizumab
76
Bexarotene
85
Banzel
39
Baraclude
102
Bexarotene (Topical)
Basiliximab
107
Bexxar
76
85
Beyaz
121
BCG Live Intravesical
138
Bebulin
167
Bicalutamide
Bebulin VH
167
Bicillin C-R
236
Becaplermin
145
Bicillin C-R 900/300
236
Bicillin L-A
235
Beclomethasone Dipropionate
33
Belatacept
107
BiCNU
Belimumab
109
BiDil
77
71
115
Benazepril & Hydrochlorothiazide
66
Biltricide
24
Benazepril HCl
63
Bimatoprost
Bendamustine HCl
73
Bisacodyl-PEG 3350-Pot Chloride-Sod Bicarb-Sod
229
BeneFIX
167
Chloride
178
Benicar
65
Bisoprolol & Hydrochlorothiazide
Benicar HCT
67
Bisoprolol Fumarate
110
67
Benlysta
109
Bivigam
230
Benzonatate
130
Blephamide
226
Boceprevir
104
Benzoyl Peroxide
PAGE 262
131,132,133,134,135
Boostrix
Butrans
21
Bydureon
51
117
Byetta 10 MCG Pen
51
Bosulif
81
Byetta 5 MCG Pen
51
Bosutinib
81
Bystolic
Bortezomib
Bosentan
247
83
110
Botox
222
Botox Cosmetic
143
BP FoliNatal Plus B
198
C-Nate DHA
198
BP MultiNatal Plus
198
C1 Esterase Inhibitor (Human)
171
Bravelle
150
Cabazitaxel
87
Brentuximab Vedotin
76
Cabergoline
156
Brimonidine Tartrate
225
Cabozantinib S-Malate
Brimonidine Tartrate-Timolol Maleate
224
Cafergot
183
Brinzolamide
228
Calcipotriene
138
Bromday
228
Calcipotriene-Betamethasone Dipropionate
Bromfenac Sodium (Ophth)
228
Calcitonin (Salmon)
149
155
81
140,142
Bromocriptine Mesylate
89
Calcitriol
Bromocriptine Mesylate (Diabetes)
50
Calcitriol (Topical)
Brovana
34
Calcium Acetate (Phosphate Binder)
164
Calcium Chloride (Dihydrate)
185
Calcium Gluconate
185
Calcium PNV
198
Budesonide
Budesonide (Inhalation)
Budesonide (Nasal)
Budesonide-Formoterol Fumarate Dihydrate
127,130
33
222
35
138,139
Campath
76
Bumetanide
148
Camptosar
88
Buphenyl
155
Canagliflozin
54
Buprenorphine
21
Canakinumab
Buprenorphine HCl
21
Canasa
Buprenorphine HCl-Naloxone HCl Dihydrate
21
Cancidas
57
Candesartan Cilexetil
65
Candesartan Cilexetil-Hydrochlorothiazide
67
Capastat Sulfate
70
Bupropion HCl
Bupropion HCl (Smoking Deterrent)
Buspirone HCl
43,44
241
29
162
Busulfan
71,73
Capecitabine
74,75
Busulfex
71
Caprelsa
81
Butalbital-Acetaminophen
12
Capreomycin Sulfate
70
Butalbital-Acetaminophen-Caffeine
12
Capsaicin & Cleansing Gel
Butalbital-Acetaminophen-Caffeine w/ Codeine
19
Captopril
63
Butalbital-Aspirin-Caffeine
12
Captopril & Hydrochlorothiazide
67
Butalbital-Aspirin-Caffeine w/Cod
19
Carbaglu
144
155
Butenafine HCl
137
Carbamazepine
Butoconazole Nitrate (One Dose)
255
Carbamazepine (Antipsychotic)
91
Carbidopa
89
Butorphanol Tartrate
PAGE 263
21
39,41
Carbidopa-Levodopa
89,90
Cefprozil
118
Carbidopa-Levodopa-Entacapone
90
Ceftibuten
119
Carbinoxamine Maleate
59
Ceftin
118
Carboplatin
71
Cefuroxime Axetil
Cardene SR
112
Carfilzomib
82
118,119
Cefuroxime Sodium
119
Cefuroxime Sodium and Dextrose
119
Carglumic Acid
155
Cefuroxime Sodium-Dextrose
119
Carimune NF
230
Cefuroxime-Dextrose
119
Carisoprodol
220
CeleBREX
9,10
Carmustine
71
Celecoxib
9,10
Carmustine in Polifeprosan
72
CellCept
107
Carteolol HCl (Ophth)
224
Celontin
43
Carvedilol
109
Cenestin
158,159
Caspofungin Acetate
57
Cephalexin
118
Cavan One Omega
198
Ceprotin
172
Cavan Prenatal/EC Calcium
198
Ceredase
172
Cavan-Alpha
198
Cerezyme
173
Cavan-EC SOD DHA
198
Ceritinib
Cavan-Folate DHA
199
Certolizumab Pegol
Cavan-Heme Omega
199
Cerubidine
83
162,163
79
Cayston
24
Cervical Caps
182
CeeNU
71
Cesamet
56
Cefaclor
118
Cetraxal
229
Cefaclor Monohydrate
118
Cetrorelix Acetate
151
Cefadroxil
117
Cetrotide
151
Cefazolin in D5W
117
Cetuximab
Cefazolin Sodium
117
Cevimeline HCl
191
CeFAZolin Sodium
117
Chantix
241
76
Cefazolin Sodium and Dextrose
117,118
Chantix Continuing Month Pak
241
CeFAZolin Sodium-Dextrose
117,118
Chantix Starting Month Pak
241
Cefdinir
119
Chemet
55
Cefepime HCl
120
Chlorambucil
72
Cefepime HCl and Dextrose
120
Chlorhexidine Gluconate (Mouth-Throat)
Cefepime-Dextrose
120
Chloroquine Phosphate
Cefixime
120
Chlorothiazide
Cefotaxime Sodium
119,120
191
69
148
Chlorpromazine HCl
96
54
Cefoxitin Sodium
118
Chlorpropamide
Cefoxitin Sodium and Dextrose
118
Chlorthalidone
148
Cefoxitin Sodium in Dextrose
119
Chlorzoxazone
220,221
CefOXitin Sodium-Dextrose
118
Choice-OB+DHA
199
Cefpodoxime Proxetil
119
Cholecalciferol
257
PAGE 264
Cholestyramine
60
Clindamycin HCl
26,27
Cholestyramine Light
60
Clindamycin Palmitate Hydrochloride
27
Choline Fenofibrate
61
Clindamycin Phosphate
27
Choriogonadotropin Alfa
151
Chorionic Gonadotropin
150,151
Clindamycin Phosphate in D5W
27
115
Clindamycin Phosphate Vaginal
255
136,137
Clindamycin Phosphate-Benzoyl Peroxide
133
Ciclopirox Olamine
136
Clindamycin Phosphate-Benzoyl Peroxide
Cidofovir
102
(Refrigerate)
133
Cilostazol
172
Clinimix E/Dextrose (5/20)
223
Cimetidine
249
Clinimix/Dextrose (2.75/5)
223
Cimzia
162
223
Cimzia Prefilled
162
223
Cimzia Starter Kit
163
223
Cinacalcet HCl
156
Clinimix/Dextrose (5/25)
223
Cinryze
171
Clobetasol Propionate
Cipro HC
229
Clocortolone Pivalate
Ciprodex
229
Clofarabine
74
Ciprofloxacin
161
Clolar
74
Ciprofloxacin HCl
161
Clomiphene Citrate
Ciprofloxacin HCl (Ophth)
225
Clomipramine HCl
Ciprofloxacin HCl (Otic)
229
Clonazepam
38,39
Ciprofloxacin in D5W
161
Clonidine HCl
65,66
Ciprofloxacin-Ciprofloxacin HCl
161
Clonidine HCl (ADHD)
Ciprofloxacin-Dexamethasone
229
Clopidogrel Bisulfate
172
Ciprofloxacin-Hydrocortisone
229
Clotrimazole (Topical)
136
136
Cialis
Ciclopirox
Clindamycin Phosphate (Topical)
133
140,141
140
150,151
47
Cisplatin
71
Clotrimazole w/ Betamethasone
Citalopram Hydrobromide
44
Clozapine
94
CitraNatal 90 DHA
199
Coagulation Factor IX
CitraNatal Assure
199
Coagulation Factor IX (Recomb) Fc Fusion Protein
CitraNatal B-Calm
199
(rFIXFc)
CitraNatal DHA
199
Coagulation Factor IX (Recombinant)
CitraNatal Harmony
199
Coagulation Factor VIIa (Recombinant)
169
CitraNatal Rx
199
Coagulation Factor XIII A-Subunit (Recombinant)
170
Cladribine
74,75
167,169
167
167,170
Coartem
69
13
Claforan
120
Codeine Sulfate
Claravis
133
Colchicine
166
Clarithromycin
180
Colchicine w/ Probenecid
165
Colcrys
166
Clemastine Fumarate
59
Climara Pro
158
Colesevelam HCl
60
Clindagel
133
Colestipol HCl
60
PAGE 265
Colistimethate Sodium
24
Cromolyn Sodium (Ophth)
228
Collagenase
143
Cross-Linked Hyaluronate
221
Collagenase Clostridium Histolyticum
105
Crotamiton
145
Coly-Mycin M
24
Cubicin
26
Coly-Mycin S
230
Cultured Skin Substitute
145
Colyte with Flavor Packs
178
Cuprimine
105
Combigan
224
Cuvposa
248
Combivent Respimat
34
CVS Advanced Glucose Test
145
Combivir
98
Cyanocobalamin
173
Cometriq (100 mg Daily Dose)
81
Cyclobenzaprine HCl
220
81
Cyclophosphamide
71,72
81
Cycloserine
70,71
Complera
98
CycloSERINE
70
50
Complete Natal DHA
199
Cycloset
Complete-RF Prenatal
200
Cyclosporine
107
CompleteNate
200
Cyclosporine (Ophth)
226
Comvax
252
Cyclosporine Modified (For Microemulsion)
107
Concept DHA
200
Cyproheptadine HCl
60
Concept OB
200
Cyramza
76
Conjugated Estrogens-Medroxyprogesterone
Cystadane
155
Acetate
158
Cystagon
165
Copaxone
240
Cystaran
228
Copper (IUD)
126
Cysteamine Bitartrate
165
Cysteamine HCl
228
Cordran
140,141
CoreNate-DHA
200
Cytarabine
74
Corifact
167
Cytarabine Liposome
74
Corticotropin
150
Cytogam
230
Cortisone Acetate
127
Cytomegalovirus Immune Globulin (Human)
230
Cortisporin
136
Cytovene
102
Cortisporin-TC
230
Corvite
194
Cosmegen
79
Cosopt PF
224
Dabigatran Etexilate Mesylate
38
Cosyntropin
145
Dabrafenib Mesylate
83
Dacarbazine
84
Dacogen
74
Coumadin
36
D.H.E. 45
183
Creon
146
Crestor
61
Dactinomycin
79
Crinone
256
Dalfampridine
240
Crixivan
98
Dalteparin Sodium
Crizotinib
83
Danazol
22
Cromolyn Sodium
31
Dapsone
26
PAGE 266
37,38
Daptacel
247
Desoximetasone
141,143
Daptomycin
26
Desvenlafaxine
46
Daraprim
69
Desvenlafaxine Succinate
46
Darbepoetin Alfa-Polysorbate 80
173,174
Dexamethasone
127,128
Darifenacin Hydrobromide
251
Dexamethasone (Ophth)
227
Darunavir Ethanolate
100
Dexamethasone Intensol
128
Dasatinib
82
Dexamethasone Sodium Phosphate
128
Daunorubicin Citrate Liposome
79
Dexamethasone Sodium Phosphate (Ophth)
226
Daunorubicin HCl
79
Dexilant
249
DaunoXome
79
Dexlansoprazole
249
Decara
257
Dexmethylphenidate HCl
Decavac
247
DexPak 13 Day
128
Decitabine
74
DexPak 6 Day
128
Deferasirox
55
Dexrazoxane
Deferiprone
55
Dextranomer-Sodium Hyaluronate
106
Deferoxamine Mesylate
55
Dextroamphetamine Sulfate
3,4
Degarelix Acetate
77
Dextromethorphan HBr-Quinidine Sulfate
241
85,86
Delavirdine Mesylate
100
Dextrose in Lactated Ringers
185
Delestrogen
159
Dextrose in Ringers
185
Delflex-LC/2.5% Dextrose
108
Dextrose w/ Sodium Chloride
185
Delzicol
163
Dextrose-NaCl
185
Demeclocycline HCl
243
Dialyvite 3000
191
Denavir
139
Dialyvite 5000
192
Dialyvite Supreme D
194
Denileukin Diftitox
84
Denosumab
150
Dialyvite/Zinc
192
Depen Titratabs
105
Dianeal Low Calcium/1.5% Dex
108
Depo-Estradiol
159
Dianeal PD-2/1.5% Dextrose
108
Depo-Medrol
128
108
Depo-SubQ Provera 104
126
108
DepoCyt
74
Diaphragm Arc-Spring
182
DermOtic
230
Diaphragm Wide Seal
182,183
Desipramine HCl
Desloratadine
47,48
59
Diaphragms
182
Diatx Zn
192
Desmopressin Acetate
156
Diazepam
30
Desmopressin Acetate Refrigerated
156
Diazepam (Anticonvulsant)
39
Desmopressin Acetate Spray
156
Diazoxide
50
Desmopressin Acetate Spray Refrigerated
156
Dibenzyline
65
Desogestrel & Ethinyl Estradiol
121,122,125
Diclofenac Potassium
10
Desogestrel-Ethinyl Estradiol (Biphasic)
121,122,125
Diclofenac Sodium
10
Desogestrel-Ethinyl Estradiol (Triphasic)
121,125
Desonide
PAGE 267
141,142,143
Diclofenac Sodium (Ophth)
228
Diclofenac Sodium (Topical)
136
Diclofenac w/ Misoprostol
10
Dicyclomine HCl
Didanosine
248
98,101
Difenoxin w/ Atropine
Divalproex Sodium
43
Divigel
159
Docefrez
86
55
Docetaxel
Differin
133
DOCEtaxel
Dificid
181
Docosavit
200
Diflorasone Diacetate
141
Dofetilide
31
13
Dolasetron Mesylate
55
Difluprednate
227
Dolutegravir Sodium
101
Digoxin
115
Donepezil Hydrochloride
238
Dihydroergotamine Mesylate
183
Doribax
26
26
Diflunisal
86,87,88
86,87
Dilantin
42
Doripenem
Dilantin Infatabs
42
Dornase Alfa
242
Diltiazem HCl
112,113
Dorzolamide HCl
228
Diltiazem HCl Coated Beads
112,113
Dorzolamide HCl-Timolol Maleate
224
Diltiazem HCl Extended Release Beads

Dimethyl Fumarate
112
240,241
Dipentum
163
Doxazosin Mesylate
66
Doxepin HCl
48
Doxepin HCl (Antipruritic)
138
Diph, Acellular Pertussis, Tetanus Tox & Haemophilus
Doxercalciferol
155
B Poly
Doxil
79
Diph-Ac Pert-Tet Tox Ad-Polio IPV-Haemophil B Poly
Doxorubicin HCl
79
Vac
Doxorubicin HCl Liposomal
79,80
Doxycycline (Monohydrate)
243
247
Doxycycline Calcium
244
Diph-Tetanus Tox-Acell Pert-Hepatitis B Recomb-Polio
Doxycycline Hyclate
243
IPV Vac
Drisdol
257
247
247
Diph-Tetanus Tox Ad-Acell Pertussis & Polio Virus,

IPV Vac
247
Diphenhydramine HCl
59
Diphenhydramine-Hydrocortisone-NystatinTetracycline
190
Diphenhydramine-Lidocaine-Alum Hydroxide-Mg
Hydroxide-Simeth
Diphenoxylate w/ Atropine
56
Dronedarone HCl
31
Drospirenone-Ethinyl Estradiol
122,123,124,125,126
Drospirenone-Ethinyl Estradiol-Levomefolate
190
54
Diphtheria, Acellular Pertussis & Tetanus

Toxoids
Dronabinol
247,248
Calcium
121,125
Droxia
173
Duet DHA
201
Duet DHA 400
200
Diphtheria-Tetanus Toxoids
247
Duet DHA 400EC
200
Diphtheria-Tetanus Toxoids (DT)
247
Duet DHA 430
200
Diphtheria-Tetanus Toxoids DT
247
Duet DHA 430EC
200
Dipyridamole
172
Duet DHA Balanced
200,201
30
Duet DHA Complete
201
201
Disopyramide Phosphate
Disulfiram
237
Duet DHA EC
Diuril
148
Dulera
PAGE 268
34
Duloxetine HCl
46
Eliquis
36
Durezol
227
Elite OB with DHA
201
Dutasteride
165
Elite-OB
201
Elite-OB 400
201
Ella
126
Dutoprol
DynaCirc CR
67
113
Dyphylline
35
Ellence
79,80
Dyrenium
148
Elmiron
165
Dysport
222
Elosulfase Alfa
156
Dysport (Glabellar Lines)
143
Eloxatin
72
Elspar
83
Eltrombopag Olamine
176
E.E.S. 400
180
Elvitegravir-Cobicistat-Emtricitabine-Tenofovir
101
Ecallantide
172
Emadine
228
Echothiophate Iodide
224
Emcyt
Econazole Nitrate
136
Emedastine Difumarate
Eculizumab
171
Emend
56,57
Edarbi
65
Emsam
44
Edecrin
148
Emtricitabine
98
Edge OB
201
Emtricitabine-Rilpivirine-Tenofovir Disoproxil
Edurant
98
Efavirenz
101
Efavirenz-Emtricitabine-Tenofovir Disoproxil
Fumarate
98
77
228
Fumarate
98
Emtricitabine-Tenofovir Disoproxil Fumarate
101
Emtriva
98
Enablex
251
Effient
172
Enalapril Maleate
Egrifta
152
Enalapril Maleate & Hydrochlorothiazide
67
Elaprase
155
Enbrel
12
Electrolyte-148
187
Enbrel SureClick
12
Electrolyte-56 in Dextrose
187
Endometrin
256
Electrolyte-A
187
Enfuvirtide
99
Electrolyte-B in Dextrose
185
Engerix-B
253
Electrolyte-H in Dextrose
186
Enjuvia
159
Electrolyte-MB in Dextrose
185
Enoxaparin Sodium
37
Electrolyte-P in Dextrose
186
Entacapone
89
Electrolyte-R (PH 7.4)
187
Entecavir
102
Electrolyte-R in Dextrose
187
Entereg
163
Electrolyte-S
186
Enzalutamide
Elelyso
173
Epiduo
134
Elestrin
159
Epinastine HCl (Ophth)
228
Eletriptan Hydrobromide
184
Epinephrine
Elidel
143
EPINEPHrine
Eligard
PAGE 269
77
Epinephrine HCl
63,64
78
256,257
257
34
EpiPen Jr
257
Esterified Estrogens
160
EpiPen Jr 2-Pak
257
Esterified Estrogens & Methyltestosterone
158
256
Epirubicin HCl
79,80
Estrace
Epivir
98,99
Estradiol
159,160,161
Epivir HBV
98
Estradiol Acetate Vaginal
256
Eplerenone
69
Estradiol Cypionate
159
Epoetin Alfa
174,175,176
Estradiol Vaginal
256
Estradiol Valerate
159
Estradiol Valerate-Dienogest
124
158
Epogen
174,175
Epoprostenol Sodium
116
Eprosartan Mesylate
65
Estradiol-Levonorgestrel
Epzicom
99
Estramustine Phosphate Sodium
Equetro
91
Estrasorb
160
Erbitux
76
Estring
256
Estrogel
160
160
Ergocalciferol
257,258
77
Ergoloid Mesylates
241
Estrogens, Conjugated
Ergomar
183
Estrogens, Conjugated Synthetic A
158,159
Ergotamine Tartrate
183
Estrogens, Conjugated Synthetic B
159
Ergotamine w/ Caffeine
183
Estrogens, Conjugated Vaginal
256
Eribulin Mesylate
87
Estropipate
160
Erivedge
77
Eszopiclone
177
Erlotinib HCl
83
Etanercept
12
Ertaczo
136
Ethacrynic Acid
148
Ertapenem Sodium
26
Ethambutol HCl
70
Erwinaze
84
Ethionamide
71
Ery-Tab
181
Ethosuximide
43
EryPed 400
181
Ethotoin
42
Erythrocin Lactobionate
181
Ethynodiol Diacet & Eth Estrad
Erythrocin Stearate
181
Etidronate Disodium
Erythromycin
134
Etodolac
Erythromycin (Acne Aid)
134
Etonogestrel
126
Etonogestrel-Ethinyl Estradiol
126
Erythromycin (Ophth)
225,226
Erythromycin Base
181
Etopophos
Erythromycin Base (Coated)
181
Etoposide
Erythromycin Ethylsuccinate
180,181
122,126
149
10
87
87,88
Etoposide Phosphate
87
Erythromycin Lactobionate
181
Etravirine
99
Erythromycin Stearate
181
Euflexxa
221
Eurax
145
160
Erythromycin-Sulfisoxazole
25
Escavite
195
Evamist
Escavite D
195
Everolimus
Escitalopram Oxalate
Esomeprazole Magnesium
PAGE 270
44
250
80,81
Everolimus (Immunosuppressant)
Exalgo
108
13
Exelderm
136
Ferric Carboxymaltose
176
Exelon
238
Ferriprox
55
Exemestane
77
Ferrlecit
176
Exenatide
51
Ferrous Sulfate
176
Exjade
55
Ferumoxytol
176
Extavia
240
Fesoterodine Fumarate
251
Extra-Virt Plus DHA
201
Fexmid
220
Extraneal
108
Fibrinogen Concentrate (Human)
170
Eylea
224
Fidaxomicin
181
Ezetimibe
63
Filgrastim
175
Ezetimibe-Simvastatin
60
Finacea
145
Ezogabine
41
Finasteride
165
Fingolimod HCl
240
Firazyr
171
F
Fabrazyme
155
Firmagon
Factive
161
First-Hydrocortisone
141
First-Lansoprazole
249
Factor IX Complex
167,170
77
Factor XIII Concentrate (Human)
167
First-Marys Mouthwash
190
FaLessa
122
First-Mouthwash BLM
190
Famciclovir
105
First-Omeprazole
249
Famotidine
249
First-Progesterone VGS 100
256
Fanapt
92
256
Fanapt Titration Pack
92
256
Fareston
77
256
Faslodex
77
256
FazaClo
94
First-Vancomycin 25
24
Febuxostat
166
First-Vancomycin 50
24
Feiba NF
168
Flagyl ER
24
Feiba VH Immuno
168
Flarex
227
Flavoxate HCl
252
Felbamate
42
Felodipine
113
Flebogamma DIF
FemCap
182
Flecainide Acetate
31
Femecal OB
201
Flovent Diskus
33
Femring
256
Flovent HFA
33
Floxuridine
74
Fenofibrate
Fenofibrate Micronized
61
60,61
230,231
Fluarix
253
Fenofibric Acid
61
Fluarix Quadrivalent
253
Fenoprofen Calcium
10
Flublok
253
Fentanyl
13
Flucelvax
253
Fentanyl Citrate
13
Fluconazole
58
Fluconazole in Dextrose
58
Feraheme
PAGE 271
176
Fluconazole in NaCl
58
Fluzone Preservative Free
254
Flucytosine
57
Fluzone Quadrivalent
254
FML
227
Fludarabine Phosphate
74,75
Fludrocortisone Acetate
130
FML Forte
227
Flulaval
253
Focalgin-B
201
Flulaval Quadrivalent
253
Folbecal
201
FluMist
253
Folcal DHA
201
FluMist Quadrivalent
253
Folcaps Care One
202
Flunisolide
222
Folcaps Omega 3
202
Flunisolide (Nasal)
222
Folgard OS
193
Fluocinolone Acetonide
141
Folic Acid
173
Fluocinolone Acetonide (Ophth)
227
Folivane-OB
202
Fluocinolone Acetonide (Otic)
230
Folivane-PRx DHA NF
202
Fluocinonide
141
Follistim AQ
Fluor-a-day
187
Follitropin Alfa
Fluorabon
187
Follitropin Beta
Fluorometholone (Ophth)
227
Folotyn
74
Fluorometholone Acetate
227
Fondaparinux Sodium
37
Foradil Aerolizer
34
Formoterol Fumarate
34
Fluorouracil
Fluorouracil (Topical)
Fluoxetine HCl
73,74
137
44,45
150,151
151
150,151
Forteo
149
149
Fluoxymesterone
22
Fortical
Fluphenazine Decanoate
96
Fosamprenavir Calcium
Fluphenazine HCl
96
Fosaprepitant Dimeglumine
Flura-Drops
Flurandrenolide
Flurbiprofen
Flurbiprofen Sodium
Flutamide
Fluticasone Propionate
188
140,141
10
228
77
99,100
57
Foscarnet Sodium
102
Foscavir
102
Fosfomycin Tromethamine
251
Fosinopril Sodium
64
Fosinopril Sodium & Hydrochlorothiazide
67
141,142
Fosrenol
164
Fluticasone Propionate HFA
33
Fragmin
37,38
Fluticasone Propionate (Inhalation)
33
FreeStyle InsuLinx Test
146
Frova
184
Frovatriptan Succinate
184
Fluticasone Propionate (Nasal)

Fluticasone-Salmeterol
Fluvastatin Sodium
222
33
61,62
Fulvestrant
77
148
Fluvirin
253
Furosemide
Fluvirin Preservative Free
253
Fusilev
85
45
Fuzeon
99
Fluvoxamine Maleate
Fluzone
254
Fluzone High-Dose
254
Fluzone Pediatric PF
254
Gabapentin
PAGE 272
39,40
Gabapentin (PHN)
241
Glipizide
54
Gabapentin Enacarbil
241
Glipizide-Metformin HCl
49
GlucaGen
50
Gabitril
42
Galantamine Hydrobromide
238
GlucaGen HypoKit
50
Galsulfase
156
Glucagon (rDNA)
50
GamaSTAN S/D
231
Glucagon Emergency
50
Gammagard
231
Glucagon HCl (rDNA)
50
Gammagard S/D
231
Glucarpidase
86
Gammagard S/D Less IgA
231
Glucose Blood
145,146
Gammaked
231,232
Gammaplex
232
Glyburide
54
Gamunex
232
Glyburide-Metformin
49
Gamunex-C
232
Glycate
248
Ganciclovir Sodium
102
Glycerol Phenylbutyrate
156
Ganirelix Acetate
151
Glycine (GU Irrigant)
165
Gardasil
254
Glycine Diluent
237
225,226
Glycopyrrolate
248
Gatifloxacin (Ophth)
Gattex
164
Gefitinib
82
Gel-One
221
Gemcitabine HCl
Gemfibrozil
74,75
61
Glutofac-ZX
194
Glyset
48,49
Golimumab
Golytely
178
Gonal-f
151
Gonal-f RFF
151
Gemifloxacin Mesylate
161
Gonal-f RFF Pen
151
Generess FE
122
Goserelin Acetate
78
Genotropin
152
Gralise
Genotropin MiniQuick
152
Granisetron HCl
Gentamicin in Saline
Granix
Gentamicin Sulfate
Grifulvin V
241
55
175
57
Gentamicin Sulfate (Ophth)
225
Griseofulvin Microsize
Gentamicin Sulfate (Topical)
136
Griseofulvin Ultramicrosize
Geodon
91
57,58
Guaifenesin-Codeine
58
130,131
Gesticare
202
Guanfacine HCl
66
Gesticare DHA
202
Guanfacine HCl (ADHD)
GHT Test
146
Guanidine HCl
Gilenya
240
Gynazole-1
Gilotrif
81
Glassia
242
Glatiramer Acetate
240
Haemophilus B Polysac Conj Vac
4
69
255
252
Gleevec
81
Haemophilus B Polysac Conj-Hepatitis B (Recomb)
Gliadel Wafer
72
Vaccines
252
Glimepiride
54
Halaven
87
PAGE 273
Halcinonide
142
Human Papillomavirus (HPV) Quadrivalent
HalfLytely with Flavor Packs
178
Recombinant Vaccine
254
Halobetasol Propionate
142
Humate-P
168
Halog
142
Humatrope
153
Haloperidol
94
Humira
Haloperidol Decanoate
94
Humira Pen
Haloperidol Lactate
94
Humira Pen-Crohns Starter
8
8
Havrix
254
Humira Pen-Psoriasis Starter
Helixate FS
168
HumuLIN 70/30
52
HemeNatal OB
202
HumuLIN 70/30 KwikPen
52
HemeNatal OB + DHA
202
HumuLIN N
52
Hemofil M
168
HumuLIN N KwikPen
52
HepaGam B
232
HumuLIN R
52
52
Heparin (Porcine) in NaCl
38
HumuLIN R U-500 (CONCENTRATED)
Heparin (Porcine) in Sodium Chloride
38
Hyalgan
221
Heparin Sodium (Porcine)
38
Hyaluronan
221
Hepatitis A (Inactivated)-Hepatitis B (Recombinant)

Vaccines
255
Hycamtin
88
Hydralazine HCl
69
Hepatitis A Vaccine
254,255
Hydrochlorothiazide
149
Hepatitis B Immune Globulin (Human)
232,233
Hydrocodone Polistirex-Chlorpheniramine
Hepatitis B Vaccine (Recomb)
253,255
Polistirex
130
Hepsera
102
Hydrocodone w/ Homatropine
130
Herceptin
76
Hydrocodone-Acetaminophen
19,20
Hexachlorophene
97
Hydrocodone-Ibuprofen
Hexalen
72
Hydrocortisone
Hiberix
252
20
128
Hydrocortisone (Intrarectal)
23
78
Hydrocortisone (Rectal)
23
Histrelin Acetate (CPP)
155
Hydrocortisone (Topical)
Hizentra
233
Hydrocortisone Acetate (Rectal)
23
Hydrocortisone Acetate (Topical)
142
Histrelin Acetate
Hizentra 20%
232,233
139,141,142
Horizant
241
Hydrocortisone Acetate w/ Pramoxine
HP Acthar
150
Hydrocortisone Butyrate
142
HumaLOG
52
Hydrocortisone Butyrate Hydrophilic Lipo Base
142
HumaLOG KwikPen
51
Hydrocortisone Sod Succinate
HumaLOG Mix 50/50
51
Hydrocortisone Valerate
142
HumaLOG Mix 50/50 KwikPen
51
Hydrocortisone w/Acetic Acid
230
HumaLOG Mix 50/50 Pen
51
Hydromorphone HCl
HumaLOG Mix 75/25
52
HYDROmorphone HCl ER
13
HumaLOG Mix 75/25 KwikPen
52
Hydroxychloroquine Sulfate
69
HumaLOG Mix 75/25 Pen
52
Hydroxyprogesterone Caproate
HumaLOG Pen
52
Hydroxyurea
PAGE 274
23
127,130
13,14
237
84
Hydroxyurea (Sickle Cell Anemia)
173
Incivek
102
Hydroxyzine HCl
29
IncobotulinumtoxinA
223
Hydroxyzine Pamoate
29
Increlex
154
Hylan
Hyoscyamine Sulfate
221
248,249
Indacaterol Maleate
34
Indapamide
149
HyperHEP B S/D
233
Indinavir Sulfate
98
HyperRAB S/D
233
Indocin
10
HyperRHO S/D
233
Indomethacin
10
HyperSal
131
Infanate Balance
202
HyperTET S/D
233
Infanate DHA
202
Infanrix
247
Infergen
102
Infliximab
163
I
Ibandronate Sodium
149
Ibrutinib
81
Influenza Virus Vaccine Live
253
Ibuprofen
10
Influenza Virus Vaccine Live Quadrivalent
253
Icatibant Acetate
171
Influenza Virus Vaccine Recombinant Hemagglutinin
Iclusig
81
(HA)
Idamycin PFS
80
Influenza Virus Vaccine Split
Idarubicin HCl
80
Influenza Virus Vaccine Split High-Dose Preservative
Idursulfase
155
253
Free
254
Ifex
72
Influenza Virus Vaccine Split Preservative
Ifosfamide
72
Free
Ilaris
Ilevro
Iloperidone
Iloprost
9
228
92
116
253,254
252,253,254
Influenza Virus Vaccine Split Quadrivalent
Influenza Virus Vaccine Tissue-Cultured Subunit

Free
253,254
81
Influenza Virus Vaccine Types A & B Surface
Imbruvica
81
Antigen
173
253
Influenza Virus Vaccine Types A & B Preservative
Imatinib Mesylate
Imiglucerase
253,254
253,254
Ingenol Mebutate
138
176
Imipramine HCl
48
Injectafer
Imipramine Pamoate
48
Inlyta
81
38
Imiquimod
143
Innohep
Immune Globulin (Human)
231
InnoPran XL
110
Insulin Aspart
53
Immune Globulin (Human) IV or Subcutaneous231,232
Insulin Aspart Protamine & Aspart (Human)
53
Immune Globulin (Human) Subcutaneous 232,233,234
Insulin Detemir
52,53
Imogam Rabies-HT
233
Insulin Glargine
52
Implanon
126
Insulin Glulisine
51
iNatal Advance
202
Insulin Isophane & Reg (Human)
52,53
Inatal GT
202
Insulin Isophane (Human)
52,53
iNatal Ultra
202
Insulin Lispro (Human)
51,52
Immune Globulin (Human) IV
PAGE 275
230,231,232,233
Insulin Lispro Protamine & Lispro (Human)
51,52
Isometheptene-Caffeine-APAP
183
Insulin Regular (Human)
52,53
Isoniazid
70
Intelence
99
Isoniazid & Rifampin
70
Interferon Alfa-2B
84
Isoniazid-Rifampin w/ Pyrazinamide
70
Interferon Alfa-n3
84
Isosorbide Dinitrate
28
Interferon alfacon-1
102
Isosorbide Dinitrate-Hydralazine HCl
Interferon Beta-1a
240
Isosorbide Mononitrate
Interferon Beta-1b
240
Isotretinoin
Interferon Gamma-1B
84
Isradipine
113
Intron-A
84
Istalol
224
Intuniv
INVanz
115
28
131,132,133,134,135
Istodax
82
26
Itraconazole
58
Invega
93
Ivacaftor
Invega Sustenna
92
Ivermectin
Invirase
99
Ivermectin (Pediculicide)
Invokana
54
Ixabepilone
87
Ionosol-B in D5W
185
Ixempra Kit
87
Ionosol-MB in D5W
185
Iopidine
225
Ipilimumab
Ipol
Ipratropium Bromide
Ipratropium Bromide (Nasal)
76,77
254
32
222
242
24
145
J
Jakafi
82
Janumet
49
Janumet XR
49
Januvia
50
Ipratropium Bromide HFA
32
Jentadueto
49
Ipratropium-Albuterol
34
Jevtana
87
Irbesartan
65
Juxtapid
63
Irbesartan-Hydrochlorothiazide
67
Iressa
82
Irinotecan HCl
88
K-Tab
189
Iron & B-12 w/ Vitamins
193
Kalbitor
172
Iron Dextran
176
Kaletra
99
Iron Polysaccharide Complex-Vit B12-Folic Acid
176
Kalydeco
Iron Sucrose
176
Kanamycin Sulfate
Iron w/ Vitamins
193
KCl in D5W Lactated Ringers
186
Irrigation Solutions, Physiological
108
KCl in Dextrose-NaCl
186
242
7
Isentress
99
KCl-Lactated Ringers-D5W
186
Isocarboxazid
44
Kenalog
128
Isolyte-H in D5W
186
Kepivance
85
Isolyte-P in D5W
186
Ketek
26
Isolyte-S
186
Ketoconazole
58
Isometheptene-Caffeine-Acetaminophen
183
Ketoconazole (Topical)
PAGE 276
137
Ketoprofen
10
Lenalidomide
Ketorolac Tromethamine
10
Lescol XL
Ketorolac Tromethamine (Bulk)
120
Letairis
Ketorolac Tromethamine (Ophth)
228
Letrozole
Kineret
106
62
116
77
Leucovorin Calcium
85,86
Kinrix
247
Leukeran
Klor-Con
189
Leukine
Klor-Con M15
189
Leuprolide Acetate
Koate-DVI
169
Leuprolide Acetate (3 Month)
77
Kogenate FS
169
77
Kogenate FS Bio-Set
169
77,78
Kolnatal DHA
203
Leuprolide Acetate (CPP)
154,155
Leuprolide Acetate (CPP) (3 Month)
154,155
Korlym
50
72
175
77,78
Krystexxa
166
Leustatin
75
Kuvan
155
Levalbuterol HCl
34
35
Kynamro
60
Levalbuterol Tartrate
Kyprolis
82
Levatol
110
Levemir
53
Levemir FlexPen
52
Levetiracetam
40
L
L-Methylfolate PNV DHA
Labetalol HCl
Lacosamide
203
109,110
41,42
Levobunolol HCl
224
Levocetirizine Dihydrochloride
59
Lactated Ringer's
187
Levofloxacin
161
Lactated Ringer's (Irrigation)
108
Levofloxacin (Ophth)
225
Lactulose
179
Levofloxacin in D5W
161
Lactulose (Encephalopathy)
163
Levoleucovorin Calcium
85
Lamivudine
98,99
Levomefolate DHA
203
Lamivudine-Zidovudine
98,99
Levomefolate PNV
203
Lamotrigine
Lanreotide Acetate
Lansoprazole
Lanthanum Carbonate
40
157
249,250
164
Levonorgestrel & Eth

Estradiol
120,121,122,123,124,125
Levonorgestrel (Emergency OC)
126
Levonorgestrel (IUD)
127
Lantus
52
Levonorgestrel-Eth Estradiol
Lantus for OptiClik
52
(Triphasic)
Lantus SoloStar
52
Levonorgestrel-Ethinyl Estradiol & Folic Acid
Lapatinib Ditosylate
83
Levonorgestrel-Ethinyl Estradiol (91-
122,123,124,125
Laronidase
155
Day)
Lastacaft
228
Levonorgestrel-Ethinyl Estradiol (Continuous)
Latanoprost
229
Levorphanol Tartrate
Latuda
Leflunomide
PAGE 277
91,92
11
Levothyroxine Sodium
Lexiva
122
121,122,123,125
121
14
244,245,246
99,100
Lialda
163
Lovastatin
62
Lidocaine
144
Loxapine Succinate
94
Lidocaine HCl
144
Lozi-Flur
188
Lubiprostone
162
225
Lidocaine HCl (Cardiac)
30,31,179
Lidocaine HCl (Local Anesth.)
180
Lucentis
Lidocaine HCl (Mouth-Throat)
190
Lufyllin
Lidocaine in D5W
31
35
Lumigan
229
155
Lidocaine w/ Epinephrine
179
Lumizyme
Lidocaine-Prilocaine
144
Lupron Depot
Lidocaine-Tetracaine
144
Lupron Depot-Ped
77,78
154,155
Linagliptin
50
Lurasidone HCl
Linagliptin-Metformin HCl
49
Lutropin Alfa
151
Lincocin
27
Luveris
151
Lincomycin HCl
27
Luxiq
142
Lindane
145
Linezolid
27
91,92
Lymphocyte Immune Globulin,Anti-Thymocyte Globulin

(Equine)
Liothyronine Sodium
245
Lyrica
Liotrix (T3-T4)
246
Lysodren
106
40,41
78
Lipitor
62
Liraglutide
51
Lisdexamfetamine Dimesylate
3,4
M-M-R II
254
Lisinopril
64
M-Vit
203
Lisinopril & Hydrochlorothiazide
67
Macitentan
116
Lithium
91
Macnatal CN DHA
203
Lithium Carbonate
91
Macugen
225
Livalo
62
Mafenide Acetate
139
Lo Loestrin Fe
123
Magnesium Sulfate
Lo Minastrin Fe
123
Magnesium Sulfate in D5W
188
Lodoxamide Tromethamine
228
Makena
237
Loestrin 24 Fe
123
Malathion
145
Lomitapide Mesylate
Lomustine
63
71,72
188,189
Maprotiline HCl
44
Maraviroc
100,101
Loperamide HCl
55
Marnatal-F
Lopinavir-Ritonavir
99
Marplan
44
Lorazepam
30
Marqibo
87
Matulane
84
Maxair Autohaler
34
Lorzone
Losartan Potassium
Losartan Potassium & Hydrochlorothiazide
Lotemax
Loteprednol Etabonate
Lotronex
PAGE 278
220,221
65
67,68
227
226,227
163
203
Maxidex
227
Maxinate
203
Measles, Mumps & Rubella Virus Vaccines
254
Measles-Mumps-Rubella-Varicella Virus Vaccines 254
Mebendazole
24
Mecasermin
154
Mesna
86
73
Mesnex
86
138
Mestinon
70
34
Mechlorethamine HCl
Mechlorethamine HCl (Topical)
Mesalamine
Meclizine HCl
56
Metaproterenol Sulfate
Meclofenamate Sodium
10
Metaxalone
162,163
221
Medical Provider EZ Flu PF
254
Metformin HCl
50
Medical Provider EZ Flu Shot
254
Methadone HCl
14
Medrol
128
Methamphetamine HCl
Medroxyprogesterone Acetate
237
Methazolamide
147
Medroxyprogesterone Acetate (Contraceptive) 126,127
Methenamine Hippurate
251
Mefenamic Acid
11
Methenamine Mandelate
251
Mefloquine HCl
69
Methimazole
244
Mefoxin
119
Methitest
Megace ES
237
Methocarbamol
Megestrol Acetate
78
Megestrol Acetate (Appetite)
237
Mekinist
82
22
221
Methotrexate (Antirheumatic)
Methotrexate Sodium
9
75
Methotrexate Sodium (Antirheumatic)
Meloxicam
11,28
Melphalan
71
Methoxsalen (Photopheresis)
Melphalan HCl
72
Methoxsalen (Topical)
145
Methscopolamine Bromide
248
Memantine HCl
238,239
Methoxsalen
9
138
85
Menactra
252
Methsuximide
Menest
160
Methyclothiazide
Menhibrix
252
Methyldopa
66
Methyldopa & Hydrochlorothiazide
68
Meningococcal (A,C,Y&W-135) Oligosaccharide

Conjugate Vac
252
Meningococcal (A,C,Y&W-135) Polysaccharide

Conjugate Vaccine
43
149
Methylin
Methylnaltrexone Bromide
252
Methylphenidate HCl
163,164
5,6
Meningococcal (C & Y)-Haemophilus B Tetanus Tox
Methylphenidate HCl ER
Conj Vaccine
252
Methylprednisolone
128,129
Meningococcal Vac A,C,Y&W-135
252
Methylprednisolone Acetate
128,129
Menomune
252
Methylprednisolone Sod Succ
Menostar
160
Methyltestosterone
Menotropins
151
Metipranolol
224
Mentax
137
Metoclopramide HCl
162
Menveo
252
Metolazone
149
Meperidine HCl
Mephyton
14
258
127,129,130
22
Metoprolol & Hydrochlorothiazide
67,68
Metoprolol Succinate
110
Meprobamate
29
Metoprolol Tartrate
110
Mercaptopurine
75
Metreleptin
156
PAGE 279
Metronidazole
24
Mononine
Metronidazole in NaCl
24
Montelukast Sodium
Mexiletine HCl
31
Monurol
Micafungin Sodium
57
Morphine Sulfate
169
32
251
14,15,16,17
Miconazole 3
255
Morphine Sulfate Beads
14
Miconazole Nitrate Vaginal
255
Motofen
55
MICRhoGAM Ultra-Filtered Plus
233
MoviPrep
178
Midodrine HCl
257
Moxifloxacin HCl
161
Moxifloxacin HCl (Ophth)
226
Moxifloxacin HCl in Sodium Chloride
161
Mozobil
176
31
Mifepristone (Hyperglycemia)
Migergot
Miglitol
50
183
48,49
Miglustat
173
Multaq
Millipred
129
Multi-Nate 30
203
Millipred DP
129
Multi-Nate 30 DHA
203
Millipred DP 12-Day
129
Multi-Nate DHA Extra
Milnacipran HCl
239
Multichew
Minastrin 24 Fe
123
Multiple Vitamins w/ Minerals & Calcium-Folic
Minocycline HCl
243
Acid
193,194
Minocycline HCl (Subgingival)
191
Multiple Vitamins w/ Minerals & Folic Acid
194,195
203,204
194
Minoxidil
69
Mupirocin
136
Mipomersen Sodium
60
Mupirocin Calcium
221
Mupirocin Calcium (Topical)
136
Muromonab CD3
107
Muse
115
Mirena
127
Mirtazapine
43
Misoprostol
250,251
Mitomycin (Ophthalmic)
225
Mustargen
Mitosol
225
Myalept
73
156
Mitotane
78
Mycamine
57
Mitoxantrone HCl
80
Mycobutin
70
Modafinil
Mycophenolate Mofetil
107
Moderiba
103
Mycophenolate Sodium
107
Moderiba 1200 Dose Pack
102
MyKidz Iron FL
195
Moderiba 800 Dose Pack
102
Myleran
73
Moexipril HCl
64
Mynatal
204
Moexipril-Hydrochlorothiazide
68
Mynatal Advance
204
Mynate 90 Plus
204
32
Myobloc
223
222
Myozyme
156
Mytelase
70
Mometasone Furoate
Mometasone Furoate (Inhalation)
Mometasone Furoate (Nasal)
142
Mometasone Furoate-Formoterol Fumarate

Dihydrate
34
Moms Choice Rx
203
Monoclate-P
169
PAGE 280
Navane
97
Navatab + DHA
205
Na Sulfate-K Sulfate-Mg Sulfate & PEG3350-NaCl-Na
Navelbine
Bicarb-KCl
179
Nebivolol HCl
Nabi-HB
233
Nebupent
Nabilone
56
Nebusal
131
Nabumetone
11
Necon 1/50 (28)
124
Necon 10/11 (28)
124
Nadolol
110,111
87
110
24
Nafarelin Acetate
155
Nedocromil Sodium (Ophth)
228
Nafcillin Sodium
237
Neevo
205
Naftifine HCl
137
Neevo DHA
205
Naftin
137
Nefazodone HCl
Naglazyme
156
Nelarabine
45,46
73
Nalbuphine HCl
21
Nelfinavir Mesylate
101
Naloxone HCl
55
Neo-Fradin
Naltrexone
55
NeoBenz Micro Plus Pack
134
Naltrexone HCl
55
NeoBenz Micro SD
134
Namenda
238
Neomycin Sulfate
Namenda Titration Pak
238
Neomycin-Bacitracin Zn-Polymyxin
225,226
Namenda XR
239
Neomycin-Colistin-HC-Thonzonium
230
Naphazoline HCl
226
Neomycin-Polymy-Dexameth
227
Naproxen
11
Neomycin-Polymyxin-Gramicidin
226
Naproxen Sodium
11
Neomycin-Polymyxin-HC
136
227
Naratriptan HCl
184
Neomycin-Polymyxin-HC (Ophth)
Nasonex
222
Neomycin-Polymyxin-HC (Otic)
Nata Komplete
204
Nepafenac
228
NataChew
204
Nephplex Rx
192
Natacyn
225
Nephro-Vite Rx
192
NataFort
204
Nephrocaps
192
Natal-V RX
204
Nephrocaps QT
192
Natalizumab
241
Nestabs
205
NatalVirt 90 DHA
204
Nestabs ABC
205
NatalVirt CA
204
Nestabs DHA
205
Natalvit
205
Neulasta
175
Natamycin
225
Neumega
175
Natazia
124
Neupogen
175
Nateglinide
53
Natelle EZ
205
Nevanac
Natelle ONE
205
Nevirapine
Natelle-ez
205
Newgen
205
Nature-Throid
245
Nexa Plus
205
PAGE 281
Neupro
229,230
90
228
100,101
Nexa Select
205
NexAVAR
82
Norethindrone-Eth Estradiol (Biphasic)
124
Norethindrone-Eth Estradiol
NexIUM
250
(Triphasic)
121,123,124,125
Nexplanon
126
Norfloxacin
161
Niacin (Antihyperlipidemic)
63,258
Norgestimate-Ethinyl Estradiol
122,124,125
Niacin-Lovastatin
61
Norgestimate-Ethinyl Estradiol (Triphasic)
Niacin-Simvastatin
62
Norgestrel & Ethinyl Estradiol
Nicardipine HCl
112,114
124,125
121,122,123,124
Norinyl 1+50 (28)
124
Nicotine
242
Normosol-R in D5W
187
Nicotrol
242
Normosol-R pH 7.4
187
Nicotrol NS
242
Noroxin
161
Nifedipine
111,112,114
Nilandron
78
Norvir
Nilotinib HCl
83
Novantrone
80
Nilutamide
78
NovoLIN 70/30
53
Nimodipine
114
NovoLIN 70/30 ReliOn
53
NovoLIN N
53
NovoLIN N ReliOn
53
NovoLIN R
53
NovoLIN R ReliOn
53
NovoLOG
53
Nipent
84
Nisoldipine
114
Nitazoxanide
26
Nitisinone
156
Nitro-Bid
28
Nortriptyline HCl
48
100
Nitrofurantoin Macrocrystal
251
NovoLOG FlexPen
53
Nitrofurantoin Monohyd Macro
251
NovoLOG Mix 70/30
53
NovoLOG Mix 70/30 FlexPen
53
53
Nitroglycerin
28,29
Nitroglycerin (Intra-Anal)
23
NovoLOG PenFill
Nitrostat
29
NovoSeven RT
169
Nizatidine
249
Noxafil
58
Norditropin
153
Nplate
175
Norditropin FlexPro
153
Nucynta
15
Norditropin NordiFlex Pen
153
Nucynta ER
15
Norelgestromin-Ethinyl Estradiol
126
Nuedexta
241
Nulojix
107
Nulytely with Flavor Packs
178
Nutri-Tab OB
206
Norethin Acet & Estrad-Fe

Norethindrone & Eth Estradiol
122,123,124
121,122,124,125,126
Norethindrone & Ethinyl Estradiol-Fe
122,126
Norethindrone & Mestranol
124
Nutri-Tab OB + DHA
206
Norethindrone (Contraceptive)
127
Nutrivit
192
Nutropin
154
Norethindrone Acet & Eth Estra
122,123,124
Norethindrone Acetate
237
Nutropin AQ
154
Norethindrone Acetate-Ethinyl Estradiol-Fe
125
Nutropin AQ NuSpin 10
153
153
153
Norethindrone Acetate-Ethinyl Estradiol-Fe Fum

(Biphasic)
PAGE 282
123
Nutropin AQ Pen
154
Omeprazole
NuvaRing
126
Omeprazole+Syrspend SF Alka
250
Omniflex Diaphragm
182
Omnitrope
154
Nuvigil
Nystatin
6
58,255
249,250
Nystatin (Mouth-Throat)
191
Omontys
175
Nystatin (Topical)
137
OnabotulinumtoxinA
222
Nystatin Vaginal
255
OnabotulinumtoxinA (Cosmetic)
143
Nystatin-Triamcinolone
137
Oncaspar
84
Ondansetron
56
Ondansetron HCl
56
O
O-Cal FA
206
Ondansetron HCl and Dextrose
56
O-Cal Prenatal
206
Ondansetron HCl and Sodium Chloride
56
OB Complete
206
Ondansetron HCl-Dextrose
56
OB Complete 400
206
Ondansetron HCl-NaCl
56
OB Complete One
206
OneTouch Ultra Blue
OB Complete Petite
206
Onglyza
50
OB Complete Premier
206
Ontak
84
OB Complete with DHA
206
Opana ER
16
OB Complete/DHA
206
Oprelvekin
175
OB-Natal One
206
Opsumit
116
Obstetrix DHA
206
Oramorph SR
Obstetrix EC
207
Orap
241
Octagam
233
Orapred ODT
129
Octreotide Acetate
157
Orencia
11,12
76
Orfadin
156
Ofloxacin
162
Orlistat
Ofloxacin (Ophth)
226
Orphenadrine Citrate
221
Ofloxacin (Otic)
229
Ortho Diaphragm All-Flex
182
Orthoclone OKT3
107
OrthoVisc
221
Oseltamivir Phosphate
105
179
Ofatumumab
Oforta
Ogestrel
Olanzapine
75
124
94,95
146
16,17
Olanzapine Pamoate
95
OsmoPrep
Oleptro
46
Otezla
Olmesartan Medoxomil
65
Otrexup
Olmesartan Medoxomil-Hydrochlorothiazide
67
Ovcon-50
124
Ovidrel
151
237
Olopatadine HCl
228,229
11
9
Olopatadine HCl (Nasal)
222
Oxacillin Sodium
Olsalazine Sodium
163
Oxaliplatin
Olysio
103
Oxandrolone
21
72,73
Omacetaxine Mepesuccinate
85
Oxaprozin
11
Omalizumab
31
Oxcarbazepine
41
PAGE 283
Oxiconazole Nitrate
137
Pediarix
247
Oxistat
137
Pediatric Multivitamins w/Fl
Oxsoralen
145
Pediatric Vitamins ACD & L-Methylfolate w/
Oxybutynin Chloride
251
Fluoride
197
195,196,197
Oxycodone HCl
17
Pediatric Vitamins ACD Fluoride & Iron
195
OxyCODONE HCl
17
Pediatric Vitamins ACD w/ Fluoride
197
Pedipirox-4 Nail
137
252
Oxycodone w/ Acetaminophen
19,20
Oxycodone-Ibuprofen
20
Pedvax HIB
OxyCONTIN
17
PEG 3350-KCl-NaCl-Na Sulfate-Na Ascorbate-
Oxymetholone
21
Ascorbic Acid
Oxymorphone HCl
Ozurdex
16,17,18
227
178
PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod

Sulfate
178,179
PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod
Chloride
178,179
Paclitaxel
87
Peg-Intron
103
Paclitaxel Protein-Bound Particles
86
Peg-Intron Redipen
103
Peg-Intron Redipen Pak 4
103
111
Paire OB
207
Palifermin
85
Pegademase Bovine
Paliperidone
93
Peganone
Paliperidone Palmitate
92
Pegaptanib Sodium
Palivizumab
Palonosetron HCl
Pamidronate Disodium
234
55
225
Pegaspargase
84
Pegasys
103,104
Pegasys ProClick
103
Pegfilgrastim
175
146,147
Peginesatide Acetate
175
76
Peginterferon alfa-2a
103,104
Panretin
137
Peginterferon alfa-2b
103
Pantoprazole Sodium
250
Peginterferon alfa-2b (Antineoplastic)
Paragard Intrauterine Copper
126
Pegloticase
Paricalcitol
156
Pegvisomant
Pancreaze
Pancrelipase (Lipase-Protease-Amylase)
Panitumumab
Paromomycin Sulfate
149,150
42
146
84,85
166
151,152
Pemetrexed Disodium
73
Paroxetine HCl
45
Penbutolol Sulfate
110
Paser
70
Penciclovir
139
Pasireotide Diaspartate
157
Penicillamine
105
Pataday
228
Penicillin G Benzathine
235
Patanase
222
Penicillin G Benzathine & Procaine
236
Patanol
229
Penicillin G Pot in Dextrose
235
Paxil
45
Penicillin G Potassium
Pazopanib HCl
83
Penicillin G Procaine
235
PCE
181
Penicillin G Sodium
235
Ped Multivitamins w/Fl & Iron
195
Penicillin V Potassium
PAGE 284
235,236
235,236
Pentacel
247
Pentam
25
Pentamidine Isethionate
Pentasa
Pentazocine w/ Naloxone
Pentosan Polysulfate Sodium
Pentostatin
Pentoxifylline
24,25
163
21
165
84
171
Pioglitazone HCl-Metformin HCl
49
Pirbuterol Acetate
34
Piroxicam
11
Pitavastatin Calcium
62
Plasma-Lyte 148
187
Plasma-Lyte A
187
Plasma-Lyte-56 in D5W
187
Plerixafor
176
Perforomist
34
Pneumococcal 13-Valent Conjugate Vaccine
252
Perindopril Erbumine
64
Pneumococcal Vac Polyvalent
252
Pneumovax 23
252
PNV Folic Acid + Iron
207
PNV OB+DHA
207
PNV Prenatal Plus Multivitamin
207
PNV Tabs 29-1
207
PNV-DHA
207
Peritoneal Dialysis Solutions

Perjeta
Permethrin
Perphenazine
Perphenazine-Amitriptyline
Pertuzumab
108,109
76
145
96
239
76
Pertzye
146
PNV-DHA+Docusate
207
Phenazopyridine HCl
165
PNV-First
207
44
PNV-OB/DHA
207
Phenobarbital
177
PNV-Omega
207
PHENobarbital
177
PNV-Select
207
65
PNV-Total
207
Phentermine HCl
Podofilox
144
Phentermine HCl-Topiramate
Poliovirus Vaccine, IPV
254
Poly-Vi-Flor
196
Phenelzine Sulfate
Phenoxybenzamine HCl
Phenyleph-Promethazine w/ Cod
131
Phenytoin
42,43
Poly-Vi-Flor/Iron
195
Phenytoin Sodium Extended
42,43
Poly-Vitamin/Fluoride/Iron
195
Phisohex
97
Polyethylene Glycol 3350
179
Phoslyra
164
Polymyxin B Sulfate
27
Phospholine Iodide
224
Pomalidomide
79
Pomalyst
79
Photofrin
84
Physicians EZ Use Flu
254
Ponatinib HCl
81
Physiosol Irrigation
108
Porfimer Sodium
84
Phytonadione
258
Posaconazole
58
Picato
138
Potassium Acetate
189
Pilocarpine HCl
224
Potassium Bicarbonate
189
Pilocarpine HCl (Oral)
191
Potassium Chloride
Pimecrolimus
143
Potassium Chloride ER
189
Pimozide
241
Potassium Chloride in D5W Lactated Ringers
186
Pindolol
111
Potassium Chloride in Dextrose
187
Pioglitazone HCl
PAGE 285
51
189,190
Potassium Chloride in Dextrose & Sodium Chloride 186
Potassium Chloride in NaCl
187
Potassium Chloride Microencapsulated Crystals
Prena1
208
Prena1 Pearl
208
CR
189
Prena1 Plus/Quatrefolic
208
Potassium Citrate (Alkalinizer)
164
Prena1/Quatrefolic
208
Potassium Citrate ER
164
PrenaCare
209
Potassium Citrate-Citric Acid
164
PrenaFirst
209
Potassium Phosphate Dibasic
189
Prenaissance
209
41
Prenaissance 90 DHA
209
PR Natal 400
208
Prenaissance Balance
209
PR Natal 400 ec
207
Prenaissance DHA
209
PR Natal 430
208
Prenaissance Harmony DHA
209
PR Natal 430 ec
208
Prenaissance Next
209
PR Natal 440 ec
208
Prenaissance Next-B
209
Potiga
Pradaxa
38
Prenaissance Plus
209
Pralatrexate
74
Prenaissance Promise
209
Pramipexole Dihydrochloride
90
PrenaPlus
209
Pramlintide Acetate
49
Prenat Vit w/ Iron Carbonyl-Fe Asp Glyc-FA-Omega
Pramosone
142
Fatty Acid
206
Pramoxine-HC
142
PreNata
209
49,50
Prenatabs FA
209
172
Prenatabs Rx
210
PrandiMet
Prasugrel HCl
Pravastatin Sodium
62
Prenatal
210
Praziquantel
24
Prenatal 19
210
Prazosin HCl
66
Prenatal AD
210
Pred Mild
227
Prenatal Formula
210
Prednicarbate
142
Prenatal Low Iron
210
Prednisolone
129
Prenatal Multivit-Min w/Fe-FA
204
Prednisolone Acetate (Ophth)
227
Prenatal Multivitamins & Minerals w/ L-Methylfolate-
Prednisolone Sodium Phosphate
127,129,130
FA
211
PrednisoLONE Sodium Phosphate
129
Prenatal MV & Min w/ Ferrous Fumarate-L
Prednisolone Sodium Phosphate (Ophth)
227
Methylfolate-DHA
Prednisone
130
Prenatal MV & Min w/Fe Bisglyc-Fe Prot Succ-FA-CA-
PredniSONE Intensol
130
Omega 3
Prefera OB
208
Prenatal MV & Min w/Fe Bisglycinate-FA-DHA 205,219
Prefera OB + DHA
208
Prenatal MV & Min w/Fe Carbonyl-Docusate-Folic
PreferaOB One
208
Acid-DHA
PreFol-DHA
208
Prenatal MV & Min w/Fe Carbonyl-FA-DHA
Pregabalin
Premarin
40,41
160,256
199
199,203,204,207,208,213,214,215
212
212,215
Prenatal MV & Min w/Fe Fumarate-FADHA
202,203,207,218
Premphase
158
Prenatal MV & Min w/Fe Polysaccharide Complex-FA-
Prempro
158
DHA
PAGE 286
199,207,213,214,218
Prenatal MV & Min w/o Vit A w/FE Polysac Cmplx-FA-
Prenatal Vit w/ Ferrous Fumarate-L Methylfolate-Folic
CA-Omega 3
205
Acid
Prenatal MV & MIN-FE-FA-DHA
210
Prenatal Vit w/ Iron Carbonyl-Fe Aspart Glyc-FA-
Prenatal Plus
210
Omega 3
Prenatal Plus Iron
210
Prenatal Vit w/ Iron Carbonyl-Fe Aspart Glycinate-
Prenatal Plus/Iron
210
FA
207,211,218,220
198,202,206,216
206
Prenatal Vit w/ Docusate-Fe Fumarate-Folic
Prenatal Vit w/ Iron Carbonyl-Fe Gluconate-Folic
Acid
Acid
204,207,210,213
217
Prenatal Vit w/ Docusate-Iron Carbonyl-Folic
Prenatal Vit w/ Iron Carbonyl-Folic
Acid
Acid
198,202,204,207,209,210,214,215,216,217
201,204,206,207,210,213,219
Prenatal Vit w/ Fe Bisglycinate Chelate-Folic
Prenatal Vit w/ Iron Polysaccharide Cmplx-L
Acid
Methylfolate-FA
205,216,217,219
203,205,213
Prenatal Vit w/ Fe Bisglycinate-Fe Protein Succ-Folic
Prenatal Vit w/ Iron Polysaccharide Complex-Folic
Acid
Acid
203
201,213
Prenatal Vit w/ Fe Carbonyl-Fe Bisglycinate-FA-Fish
Prenatal Vit w/ Selenium-Fe Fumarate-Folic Acid
Oil
Prenatal Vit w/ Sodium Feredetate-Folic Acid-Omega
201,206,207
Prenatal Vit w/ Fe Fum-Fe Bisglycinate Chelate-Folic
Acid
Prenatal Vit w/Polysaccharide Fe-FA-Fish Oil
204
217
198,208
212
Prenatal Vit w/ Fe Fum-Iron Polysacch Complex -FA-
Prenatal Vit without Vit A w/ Fe Bisglycinate-FA-Omeg
Omega 3
200,213,214
Prenatal Vit w/ Fe Gluconate-Fe Fumarate-Folic

Acid
205,206,214,216
Prenatal Vit without Vit A w/ Fe Bisglycinate-Folic

203
Acid
205,206,216
Prenatal Vit w/ Fe Poly Cmplx-Fe Heme Polypept-FA &
PreNatal Vitamins Plus
Omega 3
Prenatal w/ Calcium Carbonate-Vit B6-Vit B12-Folic
202,208,219
211
Prenatal Vit w/ Fe Polysacch Cmplx-Fe Asp-Fe Glyc-
Acid
FA & DHA
Prenatal w/ Calcium-Vit B6-Folic Acid-
207,216
198,201,212,215
Prenatal Vit w/ Fe Polysacch Cmplx-Fe Heme
Ginger
Polypept-FA & DHA
Prenatal w/ Calcium-Vit B6-Vit B12-Folic Acid-
208,210,220
Prenatal Vit w/ Fe Polysacch Complex-Fe Asp-Fe

Glyc-FA
198,201,209,219,220
Ginger
201
211
Prenatal w/ Fe Carbonyl-Fe Asp-Fe Glyc-FA-Omega
Prenatal Vit w/ Fe Polysacch Complex-Fe Heme
Fatty Acids
Polypeptide-FA
Prenatal w/ Vit B2-B6-B12-Cholecalciferol-Folic
202,208,219,220
202
Prenatal Vit w/ Fe Polysacch Complex-L Methylfolate-
Acid
FA-DHA
Prenatal w/ Vit B2-B6-B12-Cholecalciferol-L
218
208,218
Prenatal Vit w/ Ferrous Fumarate-FA-Omega 3 Fatty
Methylfolate-FA
Acids
Prenatal w/Fe Carbonyl-FA-DSS-Omega 3 Fatty
198,201,206,213,219,220
208,218
Prenatal Vit w/ Ferrous Fumarate-Folic
Acids
Acid199,200,203,204,205,206,207,209,210,211,212,21
Prenatal w/Fe Cbnyl-Fe Asparto Glyc-FA-DSS-Omega
3,215,216,217,218,219
202,216
Prenatal Vit w/ Ferrous Fumarate-L Methylfolate-FA-
Prenatal w/Fe Fumarate-FA-DSS-Fish Oil
214,215
DHA
PAGE 287
206
203
Prenatal w/Fe Polysacch Cmplx-Sod Feredetate-FA-
Prenatal without A w/ Fe Carbonyl-L Methylfolate-FA-
Omega 3
DHA
198,200,201,203,209,216,217
211
Prenatal w/o A Vit w/ Fe Fumarate-L Methylfolate-Folic
Prenatal without A w/ Fe Chelate-L Methylfolate-FA-
Acid
DHA
218
208,218
Prenatal w/o A w/ Fe Asparto Glyc-L Methylfolate-FA-
Prenatal without A w/ Fe Fumarate-L Methylfolate-FA-
DHA
DHA
211
207,208,211,217,218,220
Prenatal w/o Vit A w/ Fe Carbonyl-DSS-FA-
DHA
Omega 3
199,202,203,209,212,219,220
207,211,218,220
Prenatal w/o Vit A w/ Fe Carbonyl-Fe Aspart Glyc-FA-
DHA
Omegas
206
205,217
Prenatal without A w/ Fe Fumarate-Sod Feredetate-
Fish Oil
FA-DHA
206
208,219
Prenatal without Vit A w/ Fe Carbonyl-Fe Gluc-
Omega 3
Docusate-FA
206
199,214,216
Prenatal w/o Vit A w/ Fe Carbonyl-Fe Gluconate-DSS-
Prenatal without Vit A w/ Fe Fum-FA-Omega Fatty
FA-DHA
Acids
199,200,204,207,209,211,212
198,202,205,215
Prenatal w/o Vit A w/ Fe Carbonyl-Fe Gluconate-FA &
Prenatal without Vit A w/ Fe Fumarate-FA-Fish Oil 215
Vit B6
Prenatal without Vit A w/ Fe Fumarate-L Methylfolate-
199,216
Prenatal w/o Vit A w/ Fe Carbonyl-Folic AcidDHA
Omegas
197,212
205,217
Prenatal without Vit A w/ Iron Carbonyl-Folic Acid & Vit
Prenatal w/o Vit A w/ Fe Fumarate-DSS-FA-
B6
DHA
Prenatal without Vit A w/ Iron Polysaccharide Complex-
201,202,205,207,208,209,212,214,215,216,218
214
Prenatal w/o Vit A w/ Fe Fumarate-Fe Carbonyl-DSS-
FA
203
FA-DHA
Prenatal+DHA
211
Prenatal-U
211
Prenatal w/o Vit A w/Fe Fumarate-Docusate Ca-Folic
Prenate
211
Acid-DHA
Prenate AM
211
Prenatal without A Vit w/ Fe Carbonyl-Fe Fumarate-
Prenate DHA
211
Folic Acid
Prenate Elite
211
Prenatal without A Vit w/ Fe Fum-Iron Polysacch
Prenate Enhance
211
Complex -FA
Prenate Essential
211
Prenatal without A Vit w/ Fe Fumarate-Folic
Prenate Mini
211
Acid
Prenate Restore
211
PreNexa
212
Prenatal without A w/ Fe Asp Glyc-L Methylfolate-FA-
PreNexa Premier
212
Omega 3
Prentif Fitting Set
182
Prenatal without A w/ Fe Asparto Glyc-Docusate-Folic
PrePLUS
212
Acid
Prepopik
179
PreQue 10
212
PreTAB
212
Previte Rx
212
199,219
Prenatal w/o Vit A w/ Iron-FA-DHA
199
201,205,214
204
200,202,212,214,217
198,202,209,211,213,215,217,219
Prenatal without A Vit w/ Iron Carbonyl-Folic Acid
219
211
217
Prenatal without A w/ Fe Carbonyl-Docusate-Folic

Acid
PAGE 288
200
Prevnar 13
252
ProQuad
254
Prezista
100
Prostin VR
109
Prialt
12
ProtectBone
194
Priftin
70
ProtectNatal
212
Primaquine Phosphate
69
Protein C Concentrate (Human)
172
Primidone
41
Protopic
144
Pristiq
46
Protriptyline HCl
48
Proventil HFA
35
Privigen
233
ProAir HFA
35
Provida OB
212
Probenecid
166
Prudoxin
138
Procainamide HCl
30
Pulmicort
33
Procarbazine HCl
84
Pulmicort Flexhaler
33
Prochieve
256
Pulmozyme
242
212
Prochlorperazine
96
PureFe OB Plus
Prochlorperazine Edisylate
96
Pyrazinamide
70
Prochlorperazine Maleate
96
Pyridostigmine Bromide
70
Pyrimethamine
69
Procrit
175,176
Procysbi
165
Prodrin
183
Profilnine SD
170
Qsymia
Progesterone (Vaginal)
256
Quartette
Progesterone Micronized
237
Quetiapine Fumarate
Proglycem
50
4
125
95
Quflora Pediatric
196,197
Prograf
107
Quinapril HCl
64
Prolastin
242
Quinapril-Hydrochlorothiazide
68
Prolastin-C
242
Quinine Sulfate
69
Proleukin
84
Qutenza
144
144
Prolia
150
Qutenza (2 Patch)
Promacta
176
Qvar
Promar
193
Promethazine & Phenylephrine

Promethazine HCl
130,131
59,60
33
R
R-Natal OB
212
Promethazine w/Codeine
131
Rabeprazole Sodium
250
Promethazine-DM
131
Rabies Immune Globulin (Human)
233
Promethazine-Phenylephrine
131
Raloxifene HCl
154
Propafenone HCl
31
Proparacaine HCl
226
Propranolol & Hydrochlorothiazide
68
Raltegravir Potassium
Ramelteon
99
178
Ramipril
64
Propranolol HCl
111
Ramucirumab
76
Propranolol HCl Sustained-Release Beads
110
Ranexa
27
Propylthiouracil
244
Ranibizumab
PAGE 289
225
Ranitidine HCl
Ranolazine
249
27
Restasis
226
Retapamulin
136
Rapaflo
165
Retisert
227
Rapamune
107
Retrovir
100
91
Revlimid
106
Ravicti
156
Reyataz
100
RE DualVit OB
212
Rheumatrex
RE OB + 90 DHA
212
Rho D Immune Globulin (Human)
RE OB + DHA
212
RhoGAM Ultra-Filtered Plus
234
RE Prenatal Multivitamin/Iron
212
Rhophylac
234
RE-Nata 29 OB
213
RiaSTAP
170
Reaphirm
213
Ribasphere
104
Rebetol
104
Ribasphere RibaPak
104
Rebif
240
RibaTab
104
Rebif Rebidose
240
Ribavirin (Hepatitis C)
Rebif Rebidose Titration Pack
240
Ridaura
Rebif Titration Pack
240
Rifabutin
70,71
Reclast
150
Rifamate
70
Recombinate
170
Rifampin
71
Recombivax HB
255
Rifapentine
70
Rasagiline Mesylate
9
233,234
102,103,104
9
Rectiv
23
Rifater
70
Regonol
70
Rifaximin
25
Regorafenib
82
Rilonacept
Regranex
145
Rilpivirine HCl
Relenza Diskhaler
105
Rilutek
222
ReliOn 70/30
53
Riluzole
222
ReliOn N
53
RimabotulinumtoxinB
223
ReliOn R
53
Rimantadine Hydrochloride
105
Rimexolone
228
117
Relistor
163,164
98
Relnate DHA
213
Riociguat
Relpax
184
Riomet
50
Remicade
163
RisperDAL Consta
93
Remodulin
116
Risperidone
93
Renagel
164
Risperidone Microspheres
93
Renax
194
Ritonavir
100
Renvela
164
Rituxan
76
ReoPro
172
Rituximab
76
54
Rivaroxaban
37
49,50
Rivastigmine
238
Repaglinide
Repaglinide-Metformin HCl
Repronex
151
Rivastigmine Tartrate
Rescriptor
100
Rixubis
PAGE 290
238,239
170
Rizatriptan Benzoate
184
Se-Natal 19
213
Romidepsin
82
Se-Natal 90
213
Romiplostim
175
Se-Plete DHA
213
Se-Tan DHA
213
Ropinirole Hydrochloride
90,91
Rosiglitazone Maleate
51
Select-OB
213
Rosuvastatin Calcium
61
Select-OB+DHA
213
Rotarix
255
Selegiline
44
RotaTeq
255
Selegiline HCl
91
Rotavirus Vaccine, Live Oral
255
Selenium Sulfide
Rotavirus Vaccine, Live Oral Pentavalent
255
Selzentry
100,101
Rotigotine
90
Sensipar
156
Roxicet
20
Serevent Diskus
35
Seromycin
71
95
Rozerem
178
139
Rufinamide
39
SEROquel XR
Ruxolitinib Phosphate
82
Serostim
154
Sertaconazole Nitrate
136
S
Sabril
Sertraline HCl
42
45
SetonET
213
Sacrosidase
146
SetonET-EC
214
Safyral
125
Sevelamer Carbonate
164
Saizen
154
Sevelamer HCl
164
Saizen Click.Easy
154
SfRowasa
163
Sal-Tropine
248
Signifor
157
Salicylic Acid
144
Sildenafil Citrate
116
Sildenafil Citrate (Pulmonary Hypertension)
117
Salmeterol Xinafoate
35
Samsca
158
Silodosin
165
SandIMMUNE
107
Silver Sulfadiazine
139
SandoSTATIN
157
Simcor
SandoSTATIN LAR Depot
157
Simeprevir Sodium
Santyl
143
Simponi
Simponi Aria
Saphris
Sapropterin Dihydrochloride
Saquinavir Mesylate
95
155
99
62
103
Simulect
107
Simvastatin
62,63
Sargramostim
175
Sinecatechins
135
Savella
239
Sirolimus
Savella Titration Pack
239
Sitagliptin Phosphate
50
49
107,108
Saxagliptin HCl
50
Sitagliptin-Metformin HCl
Scopolamine
56
Skelid
150
Scopolamine HBr
249
Sklice
145
Se-Care
213
Skyla
127
Se-Care Conceive
213
SM B-Complex/Vitamin C
193
PAGE 291
Sodium Chloride
190
Stelara
Sodium Chloride (GU Irrigant)
165
Sterile Diluent for Flolan
237
Sodium Chloride (Inhalant)
131
Stimate
156
Sodium Chloride Flush
190
Stivarga
82
Sodium Ferric Gluconate Complex in Sucrose
176
Strattera
Streptomycin Sulfate
Sodium Fluoride
187,188
Sodium Fluoride (Dental)
191
Streptozocin
Sodium Fluoride-Xylitol
187
Stribild
Sodium Hyaluronate (Viscosupplement)
221
Stromectol
Sodium Oxybate
238
Strovite
Sodium Phenylbutyrate
155,156
Sodium Phosphate Monobasic-Sodium Phosphate

Dibasic
179
Sodium Picosulfate-Magnesium Oxide-Anhydrous
138,139
73
101
24
193
Suboxone
21
Succimer
55
Suclear
179
Sucraid
146
Citric Acid
179
Sucralfate
249
Sodium Polystyrene Sulfonate
109
Sulconazole Nitrate
136
Sodium Sulfate-Potassium Sulfate-Magnesium
Sulfacetamide Sod-Prednisolone
Sulfate
179
Sulfacetamide Sodium
Sofosbuvir
104
Sulfacetamide Sodium (Acne)
Solesta
106
Sulfacetamide Sodium (Ophth)
Solifenacin Succinate
Soliris
Soltamox
251,252
171
78
139
Sulfacetamide Sodium w/ Sulfur
227
242
Solu-MEDROL
130
Sulfamethoxazole-Trimethoprim
Sulfasalazine
Somatropin (Non-Refrigerated)
154
Sulindac
Somatuline Depot
157
Sumatriptan
Sorafenib Tosylate
132,133,134,135
Sulfacetamide-Prednisolone
Sulfadiazine
Somavert
226
134
130
152,153,154
134,135
Sulfacetamide Sodium-Sulfur w/ Skin Cleanser
Solu-CORTEF
Somatropin
226,227
25,26
163
11
184
151,152
Sumatriptan Succinate
183,184
82
SUMAtriptan Succinate
184
Soriatane
138
Sunitinib Malate
Sotalol HCl
111
Supartz
221
Sotalol HCl (AFIB/AFL)
111
Supervite
193
Sovaldi
104
Supervite EC
194
Spinosad
145
Supprelin LA
155
Suprax
120
Spiriva HandiHaler
32
82,83
Spironolactone
148
Suprep Bowel Prep
179
Spironolactone & Hydrochlorothiazide
147
Sustiva
101
Sporanox
58
Sutent
82,83
Sprycel
82
Sylatron
84,85
Stavudine
PAGE 292
101
Symbicort
35
Symlin
49
Tecfidera
240,241
SymlinPen 120
49
Teduglutide (rDNA)
SymlinPen 60
49
TEGretol-XR
41
164
Synagex
194
Tekturna
69
Synagis
234
Tekturna HCT
68
Synarel
155
Telaprevir
SynaTek
194
Telavancin HCl
Synera
144
Telbivudine
Synribo
85
Synvisc
102
25
104
Telithromycin
26
221
Telmisartan
65
Synvisc One
221
Telmisartan-Amlodipine
68
Syprine
105
Telmisartan-Hydrochlorothiazide
68
Temozolomide
73
Temsirolimus
83
Teniposide
88
T
Tabloid
Taclonex
Tacrolimus
75
142
106,107,108
Tenivac
247
Tenofovir Disoproxil Fumarate
101
Tacrolimus (Topical)
144
Terazosin HCl
66
Tadalafil
115
Terbinafine HCl
58
Tadalafil (Pulmonary Hypertension)
117
Terbutaline Sulfate
35
Tafinlar
83
Terconazole Vaginal
255
Tafluprost
229
Teriflunomide
240
Taliglucerase Alfa
173
Teriparatide (Recombinant)
149
Tamiflu
105
Tesamorelin Acetate
152
Tamoxifen Citrate
78
Testim
22
Tamsulosin HCl
165
Testosterone
22,23
Tandem DHA
214
Testosterone Cypionate
22
Tandem OB
214
Testosterone Enanthate
22
22
Tapentadol HCl
15
Testred
Tarceva
83
Tetanus Immune Globulin (Human)
233
Tetanus Toxoid Adsorbed
248
Targretin
85,138
Taron-Bc
214
Tetanus Toxoid-Diphtheria-Acellular Pertussis Adsorb
Taron-C DHA
214
(Tdap)
247
Taron-Duo EC
214
Tetanus-Diphtheria Toxoids (Td)
247
Taron-Prex
214
Tetanus-Diphtheria Toxoids Td
247
Tasigna
83
Tetrabenazine
239
Tasmar
89
Tetracycline HCl
243
Tetrahydrozoline HCl
222
154
Taxotere
87,88
Tazarotene
139
Tev-Tropin
Tazorac
139
Teveten
Tbo-Filgrastim
175
Thalidomide
PAGE 293
65
106
Thalomid
106
Theo-24
35
Theophylline
35,36
Tobi Podhaler
TobraDex
227
Tobramycin
TheraCys
85
Tobramycin (Ophth)
226
Thioguanine
75
Tobramycin Sulfate
Thioridazine HCl
96
Tobramycin Sulfate in Saline
Thiotepa
73
Tobramycin-Dexamethasone
227,228
Thiothixene
97
Tocilizumab
9
8
Thrombate III
172
Tofacitinib Citrate
Thymoglobulin
108
Tolazamide
54
Thyrogen
145
Tolbutamide
54
Tolcapone
89
11
Thyroid
244,245,246,247
Thyrolar-1
246
Tolmetin Sodium
Thyrolar-1/2
246
Tolterodine Tartrate
251
Thyrolar-1/4
246
Tolvaptan
158
Thyrolar-2
246
Topicort
143
Thyrolar-3
246
Topiramate
Thyrotropin Alfa
145
Topotecan HCl
Tiagabine HCl
Ticarcillin & Pot Clavulanate
Ticlopidine HCl
42
236,237
172
41
88,89
Toremifene Citrate
77
Torisel
83
Torsemide
148
Tigecycline
26
Tositumomab
76
Tikosyn
31
Totect
86
150
Toviaz
251
Tracleer
117
Tiludronate Disodium
Timentin
236,237
Timolol
223
Tradjenta
50
Timolol Maleate
111
Tramadol HCl
18
Timolol Maleate (Ophth)
224
Tramadol-Acetaminophen
20
Timoptic Ocudose
224
Trametinib Dimethyl Sulfoxide
82
Tinzaparin Sodium
38
Trandolapril
65
Tiotropium Bromide Monohydrate
32
Tranexamic Acid
177
Tipranavir
98
Transderm-Scop
56
Tivicay
101
Tranylcypromine Sulfate
44
Tizanidine HCl
221
Trastuzumab
76
TL G-Fol OS
194
Travatan Z
229
TL-Assure ONE
214
Travoprost
229
TL-Assure+DHA
214
Trazodone HCl
46
TL-Care DHA
214
Treanda
73
TL-Fluorivite
195
Trecator
71
TL-Select
214
Trelstar Depot
78
TL-Select DHA
214
Trelstar Depot Mixject
78
PAGE 294
Trelstar LA
78
TriPhluoriVit
197
Trelstar LA Mixject
78
Triptorelin Pamoate
78
Trelstar Mixject
78
Trisenox
85
Treprostinil
116
Triveen-Duo DHA
215
Treprostinil Sodium
116
Triveen-One
215
Triveen-PRx RNF
215
Triveen-Ten
215
Tretinoin
Tretinoin (Chemotherapy)
132,135
85
Tretinoin Microsphere
135
Triveen-U
215
Tretten
170
Tropicamide
224
Trexall
75
Trospium Chloride
251
Tri Rx
214
TRUEtest Test
146
Tri-Tabs DHA
214
TrueTrack Test
146
Tri-Vi-Flor
197
Trust Natal DHA
215
Tri-Vi-Floro
197
Truvada
101
Tri-Vit/Fluoride/Iron
195
Twinject
257
TriAdvance
214
Twinrix
255
128,143
Tygacil
26
Triamcinolone Acetonide (Mouth)
191
Tykerb
83
Triamcinolone Acetonide (Nasal)
222
Tysabri
241
Triamcinolone Acetonide (Topical)
143
Tyvaso
116
Triamcinolone in Absorbase
143
Tyvaso Refill
116
Triamterene
148
Tyvaso Starter
116
Triamterene & Hydrochlorothiazide
147
Tyzeka
104
Trianex
143
Tyzine
222
TriCare
215
TriCare DHA 301
215
TriCare Prenatal Compleat
215
Uceris
130
TriCare Prenatal DHA ONE
215
Udamin
195
Trientine HCl
105
Udamin SP
194
Ulesfia
145
Ulipristal Acetate
126
Uloric
166
Triamcinolone Acetonide
Trifluoperazine HCl
Trifluridine
Trihexyphenidyl HCl
96
226
89
TriHIBit Preservative Free
247
Ultimate OB DHA
216
Trimesis Rx
215
UltimateCare ONE
216
Trimethobenzamide HCl
56
UltimateCare ONE NF
216
Trimethoprim
25
Ultra NatalCare
216
Trimipramine Maleate
48
UltraBag/Dianeal PD-2/1.5% Dex
108
Trinatal GT
215
UltraBag/Dianeal PD-2/2.5% Dex
108
Trinatal Ultra
215
UltraBag/Dianeal PD-2/4.25%Dex
109
Trinate
215
UltraBag/Dianeal/1.5% Dextrose
109
Tripedia Preservative Free
248
UltraBag/Dianeal/4.25% Dex
109
PAGE 295
Ultresa
146,147
Ventolin HFA
35
Urofollitropin Purified
150
Verapamil HCl
Ursodiol
162
Verdeso
143
138,139
Veregen
135
Veripred 20
130
Verteporfin
226
Ustekinumab
Uvadex
85
114,115
VESIcare
251,252
V-Natal
216
Vexol
228
V-Natal DHA
216
Viagra
116
Valacyclovir HCl
105
Vibativ
25
Valchlor
138
Vibramycin
Valcyte
102
Victoza
51
Valganciclovir HCl
102
Victrelis
104
Valproate Sodium
43
Vidaza
75
Valproic Acid
43
Videx
101
Valrubicin
80
Vigabatrin
Valsartan-Hydrochlorothiazide
68,69
244
42
Vigamox
226
Valstar
80
Viibryd
46
Vancocin HCl
25
Vilazodone HCl
46
Vancomycin HCl
Vancomycin HCl in Dextrose
Vandetanib
24,25
Vimizim
156
25
Vimpat
41,42
81,83
Vinacal
216
Vantas
78
Vinacal B
216
Vaqta
255
Vinate AZ
216
Varenicline Tartrate
241
Vinate AZ Extra
216
Varicella Virus Vaccine Live
255
Vinate C
217
Varivax
255
Vinate Calcium
217
Vectibix
76
Vinate Care
217
Vectical
139
Vinate DHA
217
Velaglucerase Alfa
173
Vinate DHA RF
217
83
Vinate GT
217
Veletri
116
Vinate IC
217
VemaVite-PRx 2
216
Vinate II
217
83
Vinate M
217
Velcade
Vemurafenib
Vena-Bal DHA
216
Vinate PN Care
217
Venatal Complete DHA
216
Vinate Ultra
217
Venatal-FA
216
Vinblastine Sulfate
88
Venlafaxine HCl
47
Vincristine Sulfate
88
Venlafaxine HCl ER
47
Vincristine Sulfate Liposome
87
Venofer
176
Vinorelbine Tartrate
Ventavis
116
Viokace
PAGE 296
87,88
147
Viracept
101
VP-CH Plus
219
Viread
101
VP-CH-PNV
219
Virt-Bal DHA
217
VP-ERA OB Plus
219
Virt-Bal DHA Plus
217
VP-GGR-B6 Prenatal
219
Virt-PN
218
VP-Heme OB
220
Virt-PN DHA
217
VP-Heme OB + DHA
219
Virt-PN Plus
218
VP-HEME One
220
Virt-Select
218
VP-PNV-DHA
220
Vpriv
173
Vismodegib
77
Vistide
102
Vumon
88
Visudyne
226
Vytorin
60
Vitafol
193
Vyvanse
3,4
Vitafol Ultra
218
Vitafol-Nano
218
Vitafol-OB+DHA
218
Warfarin Sodium
36
Vitafol-One
218
Welchol
60
Vitafol-Plus
218
Westhroid
246
Vital-D Rx
193
Westhroid-P
246
VitaMedMD One Rx/Quatrefolic
218
Wide-Seal Diaphragm 60
182
VitaMedMD Plus Rx/Quatrefolic
218
182
VitaMedMD RediChew Rx
218
182
VitaPearl
219
182
VitaPhil
219
182
VitaPhil + DHA
219
182
VitaSpire
219
183
Viva CT Prenatal
219
183
Viva DHA
219
Wilate
Vivaglobin
234
WinRho SDF
Vivelle-Dot
160,161
WP Thyroid
170,171
234
246,247
Vivitrol
55
Vogelxo
22
Vogelxo Pump
23
Xalkori
83
Vol-Nate
219
Xarelto
37
Vol-Plus
219
Xeljanz
Vol-Tab Rx
219
Xeloda
75
Voltaren
136
Xenazine
Voraxaze
86
Xenical
58,59
Xeomin
223
Voriconazole
239
Vorinostat
83
Xgeva
150
Votrient
83
Xiaflex
105
219
Xifaxan
25
VP CH Ultra
PAGE 297
Xolair
31
Zonisamide
Xopenex HFA
35
Zorbtive
154
Xtandi
78
Zortress
108
Xylocaine-MPF/Epinephrine
179
Zostavax
255
Xyntha
171
Zoster Vaccine Live
255
Xyntha Solofuse
171
Zovia 1/50E (28)
126
Xyrem
238
Zyflo
32
Zyflo CR
32
Zykadia
83
Zymaxid
226
Y
Yervoy
76,77
Z
Zafirlukast
Zaleplon
Zaltrap
Zanamivir
Zanosar
32
79
Zyvox
27
73
220
Zatean-Pn DHA
220
Zatean-Pn Plus
220
Zavesca
173
Zelboraf
83
Zemaira
242
Zenpep
147
Zetia
63
Ziconotide Acetate
12
100,102
Zileuton
32
Zinacef
119
Zingiber
220
Zioptan
229
Ziprasidone HCl
92
Ziprasidone Mesylate
91
Ziv-Aflibercept
76
Zoladex
78
150
83
Zolmitriptan
185
Zolpidem Tartrate
178
Zonalon
138
PAGE 298
Zytiga
105
Zatean-Pn
Zolinza
95
76
220
Zoledronic Acid
ZyPREXA Relprevv
177,178
Zatean-CH
Zidovudine
42

2015 Hrinj Drugs

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2015 Hrinj Drugs

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PREFERRED DRUG LIST

MEMBER FORMULARY GUIDE

EFFECTIVE JANUARY 1, 2015

PREFERRED DRUG LIST

LAST UPDATED 11/2014

There is a limit on the amount of drug covered per prescription, or

Prior Authorization required before prescription can be filled.

Requires trial and failure of one or more preferred products prior to

Drug is limited to specific gender.

Drug is limited to specific age.

Max Daily Dose

Max Package Limit

A limit on the amount of drug covered per prescription.

Max Fill Limit

There is a limit on the number of times this drug can be refilled.

LAST UPDATED 11/2014

LIST OF COVERED PRESCRIPTION MEDICATIONS

LIMITS & RESTRICTIONS

amphetamine-dextroamphet er cap er 24h 15

amphetamine-dextroamphet er cap er 24h 20

amphetamine-dextroamphet er cap er 24h 25

amphetamine-dextroamphet er cap er 24h 30

amphetamine-dextroamphet er cap er 24h 5

amphetamine-dextroamphetamine tab 12.5 mg

amphetamine-dextroamphetamine tab 7.5 mg

dextroamphetamine sulfate er cap er 24h 10

dextroamphetamine sulfate er cap er 24h 15

dextroamphetamine sulfate er cap er 24h 5 mg

dextroamphetamine sulfate tab 10 mg

dextroamphetamine sulfate tab 5 mg

methamphetamine hcl tab 5 mg

LAST UPDATED 11/2014

LIMITS & RESTRICTIONS

phentermine hcl cap 15 mg

phentermine hcl cap 30 mg

phentermine hcl cap 37.5 mg

phentermine hcl tab 37.5 mg

QSYMIA CAP ER 24H 11.25-69 MG

QSYMIA CAP ER 24H 15-92 MG

QSYMIA CAP ER 24H 3.75-23 MG

QSYMIA CAP ER 24H 7.5-46 MG

*Attention-Deficit/Hyperactivity Disorder (ADHD) Agents**

INTUNIV TAB ER 24H 1 MG

INTUNIV TAB ER 24H 2 MG

INTUNIV TAB ER 24H 3 MG

INTUNIV TAB ER 24H 4 MG

LAST UPDATED 11/2014

LIMITS & RESTRICTIONS

guanfacine hcl (adhd)

STRATTERA CAP 100 MG

dexmethylphenidate hcl er cap er 24h 15 mg

dexmethylphenidate hcl er cap er 24h 30 mg

dexmethylphenidate hcl er cap er 24h 40 mg

dexmethylphenidate hcl tab 10 mg

dexmethylphenidate hcl tab 2.5 mg

dexmethylphenidate hcl tab 5 mg

METHYLIN CHEW TAB 10 MG

METHYLIN CHEW TAB 2.5 MG

METHYLIN CHEW TAB 5 MG

LAST UPDATED 11/2014

LIMITS & RESTRICTIONS

methylphenidate hcl er (cd) cap er 10 mg

methylphenidate hcl er (cd) cap er 20 mg

methylphenidate hcl er (cd) cap er 30 mg