Comprehensive Care Management Corporation Summary of Benefits 2011 CCM Direct Complete Plan (HMO) Formulario CCM Direct 2011 Lista de medicamentos cubiertos January 1, 2011 – December 31, 2011 Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk and Westchester Counties, State of New York H5989_2011_SB_001 CMS Approved MMYYYY Del 1 de enero de 2011 al 31 de diciembre de 2011 Condados de Bronx, Kings, Nassau, Nueva York, Queens, Richmond, Suffolk y Westchester; Estado de Nueva York H5989_2011_FORM_001_S CMS Approved 09272010 Comprehensive Care Management Formulario 2011 (Lista de medicamentos cubiertos) TENGA EN CUENTA: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS MEDICAMENTOS CUBIERTOS POR ESTE PLAN. Nota para miembros actuales: este formulario ha cambiado desde el año pasado. Revise este documento para asegurarse de que aún contenga los medicamentos que usted toma. Comprehensive Care Management es un plan de salud con un contrato de Medicare. Esta información está disponible en diferentes formatos, por ejemplo, en otros idiomas, en letra grande y en cintas de audio. Si necesita información sobre el plan en otro formato o idioma, comuníquese con el servicio de atención para miembros al número indicado arriba. H5989_2011_FORM_001_S CMS Approved 09272010 i ¿Qué es el formulario Comprehensive Care Management? Un formulario es una lista de los medicamentos cubiertos seleccionados por Comprehensive Care Management y un equipo de proveedores de atención médica, y constituye los tratamientos recetados que se consideran una parte necesaria de un programa de tratamiento de calidad. Comprehensive Care Management generalmente cubrirá los medicamentos de la lista de nuestro formulario siempre que el medicamento sea necesario, que la receta se llena en una farmacia de la red de Comprehensive Care Management y que se sigan otras normas del plan. Para obtener más información sobre cómo llenar su receta, relea su Evidencia de cobertura. ¿El formulario puede cambiar? Generalmente, si está tomando un medicamento del formulario 2011 que se cubría a principios de año, no suspenderemos ni reduciremos la cobertura de éste durante la cobertura del 2011, a menos que se lance un nuevo medicamento genérico a un precio más reducido, o que se revele información que ponga en duda la seguridad o efectividad del medicamento. Otros cambios en los formularios, como la eliminación de un medicamento del formulario, no afectarán a los miembros que estén actualmente tomando el medicamento. Se mantendrá al mismo costo compartido para los miembros que lo tomen durante lo que quede de cobertura en el año. Sentimos que es importante que tenga acceso permanente a los medicamentos del formulario que estaban disponibles cuando eligió el plan durante el tiempo que queda de cobertura en el año, con excepción de los casos en los que pueda ahorrar dinero adicional o en los que nosotros podamos garantizar su seguridad. Si eliminamos medicamentos del formulario, agregamos el requisito de autorización previa, límites de cantidad o restricciones a tratamientos escalonados de un medicamento, o ubicamos un medicamento a un nivel superior de costo compartido, debemos notificar a los miembros afectados por el cambio al menos 60 días antes de que se haga efectivo ese cambio,o en el momento en el que el miembro solicite una nueva receta del medicamento y se le entregue un suministro del medicamento para 60 días. Si la Administración de Drogas y Alimentos (Food and Drug Administration, FDA) considera que algún medicamento del formulario no es seguro o si el fabricante del medicamento lo retira del mercado, nosotros lo retiraremos del formulario inmediatamente y lo comunicaremos a aquellos miembros que toman el medicamento. El formulario adjunto rige a partir del 1 de enero de 2011. Para obtener información sobre los medicamentos que cubre Comprehensive Care Management, visite nuestro sitio web en www.ccmny.org o llame al servicio de atención para miembros al 1-877-226-8500, los 7 días de la semana, de 8:00 a. m. a 8:00 p. m. Los usuarios de TTY deben llamar al: 1-800-650-2774. Si surge un cambio en el formulario a mitad de año que no afecte a medicamentos de mantenimiento, agregaremos una hoja de fe de erratas al formulario para explicar el cambio. ¿Cómo uso el formulario? Hay dos formas de encontrar su medicamento en el formulario: ii Afección médica El formulario comienza en la página 1. Los medicamentos de este formulario están agrupados en categorías de acuerdo con el tipo de afecciones médicas para las que se usan. Por ejemplo, los medicamentos que se usan para tratar una afección cardíaca se detallan en la categoría, "Afecciones cardiovasculares, hipertensión y lípidos". Si sabe para qué se usa su medicamento, busque el nombre de la categoría en la lista que comienza en la página 1. Luego busque su medicamento bajo el nombre de la categoría Lista alfabética Si no está seguro bajo qué categoría buscar, deberá buscar su medicamento en el índice de la página 32. El índice proporciona una lista alfabética de todos los medicamentos que están incluidos en este documento. En el índice aparecen tanto los medicamentos de marca como los genéricos. Busque en el índice y encuentre su medicamento. Al lado del nombre de su medicamento, encontrará el número de página en la que hay información sobre la cobertura. Diríjase a la página que indica el índice y encuentre el nombre del medicamento en la primera columna de la lista. ¿Qué son los medicamentos genéricos? Comprehensive Care Management cubre tanto los medicamentos de marca como los genéricos. La FDA aprueba un medicamento genérico que tenga el mismo ingrediente activo que un medicamento de marca. Generalmente, el costo de los medicamentos genéricos es menor al de los medicamentos de marca. ¿Hay alguna restricción en mi cobertura? Algunos medicamentos cubiertos pueden tener requisitos especiales o límites de cobertura. Estos requisitos y límites pueden incluir: Autorización previa: Comprehensive Care Management exige que usted o su médico obtengan autorización previa para ciertos medicamentos. Esto significa que necesitará obtener aprobación de Comprehensive Care Management antes de llenar sus recetas. Si no obtiene la aprobación, Comprehensive Care Management no cubrirá el medicamento. Límites de cantidad: para algunos medicamentos, Comprehensive Care Management limita la cantidad del medicamento a cubrir. Por ejemplo, Comprehensive Care Management proporciona 31 unidades por receta para CRESTOR. Esto puede sumarse al suministro estándar de uno o tres meses. Tratamiento escalonado: en algunos casos, Comprehensive Care Management exige que pruebe algunos medicamentos para tratar su afección médica antes de cubrir otro medicamento para ésa afección. Por ejemplo, si ambos medicamentos, A y B, sirven para tratar su afección médica, Comprehensive Care Management no cubrirá el medicamento B a menos que usted pruebe el medicamento A primero. Si el medicamento A no le da resultado, entonces Comprehensive Care Management cubrirá el medicamento B. iii Puede averiguar si su medicamento tiene requisitos adicionales o límites consultando el formulario que comienza en la página 1. También puede obtener más información sobre las restricciones que se aplican a medicamentos específicos cubiertos visitando nuestro sitio web en www.ccmny.org. Puede solicitar que Comprehensive Care Management haga una excepción a estos límites y restricciones. Consulte la sección, "¿Cómo solicito a Comprehensive Care Management que haga una excepción al formulario?" en la página IV para obtener información sobre cómo solicitar una excepción. ¿Qué sucede en caso de que mi medicamento no esté en el formulario? Si su medicamento no está incluido en este formulario, debe ponerse en contacto con servicios de atención al miembro para que le confirmen si su medicamento no está cubierto. Si le confirman que Comprehensive Care Management no cubre su medicamento, tiene dos opciones: Puede solicitar a servicios de atención al miembro una lista de medicamentos similares cubiertos por Comprehensive Care Management. Cuando reciba la lista, muéstresela a su médico y pídale que le recete un medicamento similar cubierto por Comprehensive Care Management. Puede solicitar a Comprehensive Care Management que haga una excepción y cubra su medicamento. Más abajo, encontrará información sobre cómo solicitar una excepción. ¿Cómo solicito una excepción al formulario de Comprehensive Care Management? Puede solicitar que Comprehensive Care Management haga una excepción a las normas de cobertura. Existen varios tipos de excepciones que puede solicitarnos. Puede solicitarnos la cobertura de su medicamento incluso si no está en el formulario. Puede solicitarnos que no apliquemos una restricción a la cobertura o limitaciones a su medicamento. Por ejemplo, para algunos medicamentos, Comprehensive Care Management limita la cantidad de medicamentos que cubre. Si su medicamento tiene un límite de cantidad, puede solicitarnos que anulemos ese límite y cubramos una mayor cantidad. Para nuestro plan CCM Direct Value, puede solicitarnos que le brindemos un nivel mayor de cobertura para su medicamento. Si su medicamento está incluido en el nivel de medicamentos no preferidos, puede solicitarnos la cobertura al monto del costo compartido que se aplica a iv medicamentos del nivel de medicamentos preferidos. Esto reducirá el monto que debe pagar por su medicamento.. Tenga en cuenta que si accedemos a su solicitud de cobertura de un medicamento que no está en el formulario, no podrá solicitar un nivel mayor de cobertura para el medicamento. Tampoco podrá solicitar un nivel mayor de cobertura para medicamentos que están en el nivel de medicamentos especiales. Generalmente, Comprehensive Care Management sólo aprobará su solicitud de excepción si los medicamentos alternativos que están incluidos en el formulario del plan u otras restricciones adicionales de utilización no serán tan efectivas para tratar su afección o pueden causarle efectos médicos adversos. Debe comunicarse con nosotros para solicitar una decisión de cobertura inicial para un formulario, o una excepción de restricción de utilización. Al solicitar una excepción de restricción de utilización, de nivel o de formulario, debe presentar una declaración de su médico que apoye su solicitud. Generalmente, debemos decidirnos dentro de las 72 horas de haber recibido la declaración de su médico autorizado. Puede solicitar una excepción acelerada (rápida) si usted o su médico consideran que su salud puede verse seriamente afectada por una espera de hasta 72 horas. Si se concede la solicitud de excepción acelerada, debemos comunicarle nuestra decisión 24 horas después de recibir la declaración de su médico autorizado. ¿Qué hago antes de hablar con mi médico sobre cambiar mis medicamentos o solicitar una excepción? Como miembro nuevo o permanente de nuestro plan, puede estar tomando medicamentos que no están en el formulario. O, puede estar tomando un medicamento que está en el formulario pero tiene capacidad limitada para obtenerlo. Por ejemplo, puede necesitar nuestra autorización previa antes de que pueda llenar su receta. Debe hablar con su médico para decidir si debe cambiar a un medicamento determinado que esté cubierto o solicitar una excepción al formulario para que cubramos el medicamento que está tomando. Mientras habla con su médico para determinar la medida correcta para usted, cubriremos su medicamento en ciertos casos durante los primeros 90 días que es miembro del plan. Para cada medicamento que no esté en nuestro formulario o si su capacidad para obtenerlo es limitada, cubriremos un suministro temporal de 31 días (a menos que tenga una receta para menos días) cuando vaya a una farmacia de la red. Después de su suministro de 31 días, no cubriremos esos medicamentos, aunque haya sido miembro del plan durante menos de 90 días. Si usted es residente en una institución de cuidado a largo plazo, cubriremos un suministro de transición temporal por 31 días (a menos que tenga una receta por menos días) Cubriremos más de una renovación de estos medicamentos durante los primeros 90 días que usted sea miembro de nuestro plan. Si necesita un medicamento que no está en nuestro formulario o si su capacidad para obtenerlo es limitada, pero han pasado los primeros 90 días de afiliación a nuestro plan, cubriremos un suministro de emergencia por 31 días (a menos que tenga una prescripción para menos días) mientras solicita una excepción de formulario. v Para obtener más información Para obtener más información detallada sobre su cobertura de medicamentos recetados Comprehensive Care Management revise su Evidencia de cobertura y otros materiales del plan. Si quiere hacer preguntas sobre Comprehensive Care Management, llame al servicio de atención para miembros al 1-877-226-8500, los 7 días de la semana, de 8:00 a. m. a 8:00 p m. Los usuarios de TTY deben llamar al 1800-650-2774, o visitar www.ccmny.org. Si tiene preguntas generales sobre la cobertura de medicamentos recetados de Medicare, llame a Medicare al 1-800-MEDICARE (1-800-633-4227), los 7 días de la semana, las 24 horas del día. Los usuarios de TTY/TDD deben llamar al: 1-877-486-2048. O, visitar www.medicare.gov. Formulario de Comprehensive Care Management El formulario comienza en la página siguiente y proporciona información sobre la cobertura de algunos de los medicamentos cubiertos por Comprehensive Care Management. Si tiene dificultades para encontrar su medicamento en la lista, diríjase al índice de la página 32. En la primera columna de la tabla encontrará la lista con los nombres de los medicamentos. Los medicamentos de marca se escriben con mayúscula (p. ej., ZOSYN) y los genéricos se detallan en minúscula itálica (p. ej., amoxicilina). Bajo la columna Notas podrá informarse si Comprehensive Care Management tiene algún requisito especial para cubrir su medicamento. Abajo figura una lista de abreviaturas que pueden aparecer en las páginas siguientes, en la columna Requisitos/Límites y que indican si existen requisitos especiales para la cobertura del medicamento. Lista de abreviaturas LC: límite de cantidad Para algunos medicamentos, el Plan limita la cantidad de medicamento que cubre. Por ejemplo, el plan proporciona 34 comprimidos por receta de CRESTOR®. TE: tratamiento escalonado. En algunos casos, el plan exige que pruebe ciertos medicamentos para tratar su afección médica antes de cubrir otro medicamento para esa afección. Por ejemplo, si ambos medicamentos, A y B, sirven para tratar su afección médica, no cubriremos el medicamento B a menos que pruebe el medicamento A primero. Si el medicamento A no funciona en su vi caso, entonces cubriremos el B. AP: autorización previa. El plan exige que usted o su médico obtengan autorización previa para ciertos medicamentos. Lo que significa que necesitará obtener la aprobación antes de completar sus recetas. Si no obtiene la aprobación, no cubriremos el medicamento. ID: infusión a domicilio A este medicamento recetado lo puede cubrir nuestro beneficio médico. Para obtener más información, llame al servicio de atención al cliente. IC: intervalo en la cobertura Brindamos cobertura de este medicamento recetado en el período de intervalo en la cobertura. Consulte nuestra información de evidencia de cobertura para conocer más detalles. El intervalo de cobertura se aplica sólo a los miembros del plan CCM Direct Value (HMO). DL: disponibilidad limitada. Esta receta puede estar disponible sólo en ciertas farmacias. Para obtener más información, llame al servicio de atención al cliente. PR: primera receta gratuita. La receta de este medicamento se la proporcionamos a un monto menor al costo compartido la primera vez que la llene. CS: cobertura superior La receta de este medicamento generalmente no se cubre en un plan de medicamentos recetados de Medicare. El monto que paga cuando llena una receta para este medicamento no cuenta como el costo total de medicamentos (esto quiere decir que el monto que paga no lo ayuda a reunir los requisitos para pasar a la cobertura catastrófica). Además, si está recibiendo ayuda adicional para pagar sus recetas, no obtendrá ayuda adicional para pagar el medicamento. BC: beneficio cubierto La receta de este medicamento tiene un límite al beneficio cubierto. PM: pedido de medicamentos. Esta receta de medicamentos está disponible mediante nuestro servicio de envío por correo y en las farmacias minoristas de nuestra red. Considere usar el sistema de pedidos para los medicamentos a largo plazo (mantenimiento) (por ejemplo, los medicamentos para la presión arterial alta). Las farmacias minoristas de la red pueden ser más apropiadas para las recetas de medicamentos a corto plazo (por ejemplo, los antibióticos). vii Commonly Prescribed Therapeutic Drug Categories ANTI - INFECTIVES ANTIFUNGAL AGENTS Drug Name amphotericin b ANCOBON clotrimazole troc DIFLUCAN IN NACL INJ 200MG/100ML; 0.9% ERAXIS INJ 100MG fluconazole in dextrose inj 0; 400mg/200ml fluconazole susr fluconazole tabs GRIS-PEG griseofulvin microsize itraconazole ketoconazole NOXAFIL nystatin susp nystatin tabs SPORANOX ORAL SOLN terbinafine tabs VFEND VFEND IV Drug Tier Notes 1 GC PA MO 2 MO 1 GC MO 2 MO 2 1 GC 1 1 3 1 1 1 2 1 1 2 1 2 2 GC MO GC MO MO GC MO GC MO GC MO MO GC MO GC MO MO GC MO MO MO acyclovir caps acyclovir inj 500mg acyclovir susp acyclovir tabs amantadine APTIVUS CAPS APTIVUS ORAL SOLN ATRIPLA BARACLUDE ORAL SOLN 1 1 1 1 1 4 4 4 2 GC MO GC MO GC MO GC MO GC MO MO BARACLUDE TABS 2 COMBIVIR CRIXIVAN CAPS 100MG 4 2 ANTIVIRALS MO QL(1890 per 90 days) MO QL(90 per 90 days) MO MO 1 Drug Name CRIXIVAN CAPS 200MG, 333MG, 400MG didanosine EMTRIVA CAPS EMTRIVA ORAL SOLN EPIVIR EPIVIR HBV EPZICOM famciclovir foscarnet sodium FUZEON ganciclovir caps HEPSERA Drug Tier 2 INTELENCE INVIRASE ISENTRESS KALETRA ORAL SOLN KALETRA TABS 200MG; 50MG KALETRA TABS 100MG; 25MG LEXIVA SUSP LEXIVA TABS NORVIR PREZISTA TABS 75MG PREZISTA TABS 400MG, 600MG REBETOL ORAL SOLN RELENZA DISKHALER 4 4 4 4 4 MO MO MO GC MO GC PA MO MO GC MO QL(90 per 90 days) MO MO MO MO MO MO 2 MO 2 4 2 2 4 MO MO MO MO MO 2 2 RESCRIPTOR RETROVIR IV INFUSION REYATAZ ribapak ribasphere caps ribasphere tabs 400mg ribasphere tabs 600mg ribasphere tabs 200mg ribavirin caps ribavirin tabs 200mg rimantadine hcl 3 2 4 4 4 4 4 1 4 1 1 PA MO QL(300 per 365 days) MO MO MO MO PA MO PA MO PA PA MO GC PA MO PA GC PA GC MO 1 2 2 2 2 4 1 1 4 1 4 Notes MO GC MO MO Drug Drug Name Tier Notes SELZENTRY 4 MO stavudine 1 GC MO SUSTIVA 2 MO TAMIFLU CAPS 45MG, 75MG 2 QL(56 per 365 days) MO TAMIFLU CAPS 30MG 2 QL(112 per 365 days) MO TAMIFLU SUSR 2 MO TRIZIVIR 4 MO TRUVADA 4 MO TYZEKA 4 MO valacyclovir hcl 1 GC MO VALCYTE ORAL SOLN 4 VALCYTE TABS 4 MO VIDEX PEDIATRIC ORAL 2 MO SOLN 2GM VIRACEPT POWD 2 MO VIRACEPT TABS 4 MO VIRAMUNE 2 MO VIREAD 2 MO ZIAGEN 2 MO zidovudine 1 GC MO Drug Drug Name Tier Notes cefuroxime sodium inj 7.5gm 1 GC cefuroxime sodium inj 1.5gm, 1 GC MO 750mg CEFUROXIME/DEXTROSE 2 cephalexin 1 GC MO FORTAZ INJ 1GM, 1GM/50ML; 2 5%, 2GM/50ML; 5%, 6GM FORTAZ INJ 2GM 2 MO MAXIPIME 3 MO SUPRAX 3 MO TAZICEF INJ 1GM, 2GM, 6GM 2 ZINACEF IN ISO-OSMOTIC 2 DEXTROSE ZINACEF IN ISO-OSMOTIC 2 DILUENT ZINACEF INJ 1.5GM, 750MG 2 ERYTHROMYCINS / OTHER MACROLIDES azithromycin inj 500mg azithromycin susr azithromycin tabs clarithromycin clarithromycin er e.e.s. 400 E.E.S. GRANULES ERY-TAB ERYTHROCIN LACTOBIONATE INJ 500MG erythrocin stearate erythromycin / sulfisoxazole ERYTHROMYCIN BASE ZMAX CEPHALOSPORINS cefaclor cefadroxil cefazolin inj 1gm; 5%, 20gm, 500mg cefazolin inj 1gm cefdinir cefepime inj 2gm cefepime inj 1gm cefotaxime sodium inj 10gm, 1gm, 500mg cefotaxime sodium inj 2gm cefoxitin sodium inj 10gm, 2gm cefoxitin sodium inj 1gm cefpodoxime proxetil ceftriaxone sodium inj 10gm ceftriaxone sodium inj 250mg, 500mg CEFTRIAXONE/DEXTROSE cefuroxime axetil 1 1 1 GC MO GC MO GC 1 1 1 1 1 GC MO GC MO GC GC MO GC 1 1 1 1 1 1 GC MO GC GC MO GC MO GC GC MO 2 1 GC MO 1 1 1 1 1 1 2 2 2 GC MO GC MO GC MO GC MO GC MO GC MO MO MO 1 1 2 2 GC MO GC MO MO MO MISCELLANEOUS ANTIINFECTIVES ALBENZA ALINIA amikacin sulfate inj 250mg/ml amikacin sulfate inj 50mg/ml AZACTAM IN DEXTROSE AZACTAM IN ISO-OSMOTIC DEXTROSE INJ 1GM; 0 AZACTAM INJ 2GM BILTRICIDE CAPASTAT SULFATE chloroquine 2 2 2 1 1 2 2 MO MO GC GC MO 2 2 3 1 MO MO GC MO Drug Drug Name Tier Notes CLEOCIN GALAXY 2 CLEOCIN PEDIATRIC 2 MO GRANULES clindamycin hcl 1 GC MO clindamycin phosphate add1 GC vantage COARTEM 2 MO colistimethate sodium 1 GC MO CUBICIN 2 MO DAPSONE 2 MO DARAPRIM 2 MO ethambutol tabs 400mg 1 GC ethambutol tabs 100mg 1 GC MO gentamicin sulfate inj 10mg/ml 1 GC gentamicin sulfate inj 40mg/ml 1 GC MO gentamicin sulfate/0.9% sodium 1 GC chloride gentamicin sulfate/sodium 1 GC chloride inj 1.2mg/ml; 0.9% hydroxychloroquine 1 GC MO isonarif 1 GC MO ISONIAZID SYRP 2 MO isoniazid tabs 1 GC MO isotonic gentamicin inj 0.6mg/ml; 1 GC 0.9%, 0.8mg/ml; 0.9% KETEK 2 QL(20 per 30 days) MO MALARONE 2 MO mebendazole 1 GC MO mefloquine hcl 1 GC MO MEPRON 4 MO metronidazole 1 GC MO metronidazole in nacl 0.79% 1 GC MO MYCOBUTIN 2 MO NEBUPENT 2 PA MO neomycin sulfate 1 GC MO paromomycin 1 GC MO PASER 2 MO PRIMAQUINE 2 MO PRIMAXIN I.M. 2 MO PRIMAXIN IV 2 MO pyrazinamide 1 GC MO QUALAQUIN 2 MO Drug Name rifampin SEROMYCIN STREPTOMYCIN SULFATE STROMECTOL TOBI tobramycin inj 10mg/ml tobramycin inj 80mg/2ml TOBRAMYCIN SULFATE / SODIUM CHLORIDE TRECATOR TYGACIL XIFAXAN TABS 200MG Drug Tier Notes 1 GC MO 2 MO 2 MO 2 MO 4 PA MO 1 GC 1 GC MO 2 2 2 3 ZYVOX INJ ZYVOX SUSR 2 2 ZYVOX TABS 2 MO MO QL(9 per 30 days) MO MO QL(1800 per 30 days) MO QL(56 per 30 days) MO PENICILLINS amoxicillin amoxicillin/clavulanate potassium amoxicillin/clavulanate potassium er amoxicillin/potassium clavulanate tabs ampicillin caps ampicillin inj 10gm, 1gm AMPICILLIN INJ 125MG ampicillin susr ampicillin-sulbactam inj 10gm; 5gm ampicillin-sulbactam inj 2gm; 1gm BICILLIN C-R BICILLIN L-A dicloxacillin sodium nafcillin sodium inj 10gm nafcillin sodium inj 1gm NALLPEN/DEXTROSE INJ 0; 1GM/50ML penicillin g potassium PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE 3 1 1 1 GC MO GC MO GC MO 1 GC MO 1 1 2 1 1 GC MO GC 1 GC MO 2 2 1 1 1 2 MO MO GC MO GC GC MO 1 2 GC GC MO GC Drug Drug Name Tier Notes PENICILLIN G PROCAINE 2 MO PENICILLIN G SODIUM 2 penicillin v potassium 1 GC MO pfizerpen-g inj 20mu 1 GC piperacillin sodium/ tazobactam 1 GC MO sodium inj 3gm; 0.375gm UNASYN INJ 2GM; 1GM 2 MO ZOSYN INJ 5%; 2GM/50ML; 2 0.25GM/50ML, 5%; 3GM/50ML; 0.375GM/50ML ZOSYN INJ 3GM; 0.375GM 2 MO Drug Drug Name Tier Notes MACRODANTIN CAPS 25MG 2 MO methenamine hippurate 1 GC MO nitrofurantoin macrocrystalline 1 GC MO caps 50mg nitrofurantoin monohydrate 1 GC MO PRIMSOL 3 MO trimethoprim 1 GC MO VANCOMYCIN VANCOCIN ORAL VANCOMYCIN HCL ISOOSMOTIC DEXTROSE vancomycin inj 10gm vancomycin inj 1000mg VIBATIV INJ 250MG QUINOLONES AVELOX ABC PACK AVELOX INJ AVELOX TABS CIPRO I.V.-IN D5W ciprofloxacin inj ciprofloxacin tabs LEVAQUIN INJ 5%; 750MG/150ML LEVAQUIN INJ 25MG/ML LEVAQUIN ORAL SOLN LEVAQUIN TABS NOROXIN ofloxacin 2 2 2 2 1 1 2 3 3 3 3 1 MO MO MO GC GC MO GC MO GC MO GC MO GC MO amifostine dexrazoxane inj 500mg ELITEK INJ 1.5MG leucovorin calcium inj 100mg, 350mg leucovorin calcium tabs 25mg, 5mg LEUCOVORIN CALCIUM TABS 10MG, 15MG mesna MESNEX TABS ZINECARD INJ 250MG 1 1 1 1 1 GC MO GC MO GC MO GC MO GC MO 1 1 1 2 GC MO GC MO GC MO MO 2 MO URINARY TRACT AGENTS FURADANTIN GC GC MO 4 1 4 1 MO GC MO 1 GC MO 2 MO 1 2 2 GC MO MO MO GC MO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS TETRACYCLINES demeclocycline hcl doxycycline hyclate caps doxycycline hyclate inj doxycycline hyclate tabs doxycycline monohydrate tabs 150mg, 50mg, 75mg minocycline hcl minocycline hcl er tetracycline hcl VIBRAMYCIN SYRP 1 1 2 ADJUNCTIVE AGENTS MO MO MO MO GC MO 1 1 1 1 MO ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS SULFA'S / RELATED AGENTS sulfadiazine sulfamethoxazole / trimethoprim sulfamethoxazole/trimethoprim ds sulfatrim 2 2 4 ABRAXANE adriamycin inj 2mg/ml AFINITOR TABS 5MG 3 1 4 AFINITOR TABS 10MG 4 ALIMTA INJ 500MG ALKERAN INJ ARIMIDEX AROMASIN ARRANON 3 3 2 2 3 MO GC PA QL(90 per 90 days) MO PA QL(180 per 90 days) MO MO MO MO Drug Drug Name Tier Notes ARZERRA 2 MO AVASTIN 3 MO azathioprine 1 GC PA MO azathioprine sodium 1 GC PA MO bicalutamide 1 GC MO BICNU 3 MO bleomycin sulfate inj 30unit 1 GC BUSULFEX 2 CAMPATH 3 MO carboplatin inj 150mg/15ml 1 GC MO CEENU 2 MO CELLCEPT 2 PA MO CELLCEPT INTRAVENOUS 2 cisplatin 1 GC MO cladribine 1 GC MO CLOLAR 3 COSMEGEN 3 MO cyclophosphamide tabs 1 GC PA MO cyclosporine caps 100mg, 25mg 1 GC PA MO CYCLOSPORINE CAPS 50MG 2 PA cyclosporine inj 1 GC PA cyclosporine oral soln 1 GC PA MO CYTARABINE AQUEOUS INJ 2 MO 100MG/ML cytarabine aqueous inj 20mg/ml 1 GC MO cytarabine inj 500mg 1 GC MO dacarbazine inj 200mg 1 GC MO DAUNORUBICIN HCL INJ 3 5MG/ML DOXIL 2 MO doxorubicin hcl 1 GC DROXIA 2 MO ELLENCE 3 MO ELOXATIN 3 MO ELSPAR 3 MO EMCYT 2 MO epirubicin hcl inj 50mg/25ml 1 GC ERBITUX 3 MO ETOPOPHOS 3 MO etoposide inj 1 GC MO FARESTON 3 MO FASLODEX 4 MO FEMARA 2 MO Drug Drug Name Tier Notes FIRMAGON INJ 80MG 2 MO FIRMAGON INJ 120MG 4 MO fludarabine phosphate inj 50mg 1 GC MO fluorouracil 1 GC MO flutamide 1 GC MO GEMZAR INJ 1GM 3 MO gengraf 1 GC PA MO GLEEVEC 4 MO HERCEPTIN 3 MO HEXALEN 4 MO HYCAMTIN INJ 3 MO hydroxyurea 1 GC MO idarubicin hcl 1 GC IFEX INJ 3GM 3 MO ifosfamide inj 1gm 1 GC ifosfamide/mesna 4 irinotecan 1 GC MO ISTODAX 2 MO IXEMPRA KIT INJ 45MG 4 MO LEUKERAN 2 MO leuprolide acetate 1 GC MO LEUSTATIN 2 MO LUPRON DEPOT INJ 3.75MG 2 MO LUPRON DEPOT INJ 11.25MG, 4 MO 22.5MG, 30MG, 7.5MG LUPRON DEPOT-PED INJ 4 MO 11.25MG, 15MG LYSODREN 2 MO MATULANE 4 MO MEGACE ES 3 MO megestrol acetate 1 GC MO melphalan hydrochloride 1 GC mercaptopurine 1 GC MO methotrexate 1 GC PA MO methotrexate sodium inj 25mg/ml 1 GC MO METHOTREXATE SODIUM 3 INJ 1GM mitomycin inj 20mg 1 GC MO mitoxantrone hcl 1 GC MO MUSTARGEN 3 MO mycophenolate mofetil 1 GC PA MO MYFORTIC 2 PA MO NEORAL 2 PA MO 5 Drug Name NEXAVAR Drug Tier 4 NILANDRON NIPENT octreotide ONCASPAR ONTAK ORTHOCLONE OKT3 oxaliplatin inj 100mg/20ml paclitaxel pentostatin PHOTOFRIN PROGRAF INJ RAPAMUNE ORAL SOLN RAPAMUNE TABS 1MG, 2MG REVLIMID RHEUMATREX RITUXAN SANDIMMUNE CAPS SANDIMMUNE INJ SANDIMMUNE ORAL SOLN SANDOSTATIN INJ 100MCG/ML, 500MCG/ML, 50MCG/ML SANDOSTATIN LAR DEPOT SIMULECT INJ 20MG SOMATULINE DEPOT SPRYCEL TABS 100MG, 50MG, 70MG 3 3 1 3 3 2 1 1 1 3 2 2 2 4 3 2 2 2 2 4 SPRYCEL TABS 20MG 4 3 2 4 4 SUTENT 4 TABLOID tacrolimus tamoxifen citrate TARCEVA TABS 100MG, 150MG 2 1 1 4 Drug Name TARCEVA TABS 25MG Notes LA PA QL(360 per 90 days) MO MO MO GC MO MO TARGRETIN TASIGNA CAPS 200MG TAXOTERE INJ 80MG/2ML THALOMID thiotepa toposar TORISEL TREANDA INJ 100MG TRELSTAR DEPOT MIXJECT TRELSTAR LA MIXJECT tretinoin TRISENOX TYKERB GC MO GC MO GC PA PA MO PA MO LA MO PA MO PA MO PA MO PA PA MO MO VECTIBIX VELCADE VIDAZA vinblastine sulfate inj 10mg vincasar pfs vincristine sulfate vinorelbine tartrate VOTRIENT ZANOSAR ZOLINZA MO MO MO QL(180 per 90 days) MO QL(360 per 90 days) MO PA QL(90 per 90 days) MO MO GC PA MO GC MO PA QL(90 per 90 days) MO Drug Tier Notes 4 PA QL(180 per 90 days) MO 2 MO 4 MO 4 MO 4 PA MO 1 GC MO 1 GC MO 4 PA MO 4 MO 3 MO 3 MO 1 GC MO 2 MO 4 LA QL(540 per 90 days) MO 4 MO 3 MO 4 QL(4200 per 90 days) MO 1 GC 1 GC 1 GC 1 GC MO 4 MO 3 MO 4 MO AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ANTICONVULSANTS BANZEL carbamazepine chew carbamazepine er carbamazepine susp carbamazepine tabs CARBATROL CELONTIN DILANTIN INFATABS divalproex sodium cpsp divalproex sodium er 6 2 1 1 1 1 2 2 2 1 1 MO GC MO GC MO GC GC MO MO MO MO GC MO GC MO Drug Drug Name Tier Notes divalproex sodium tbec 1 GC MO epitol 1 GC MO EQUETRO 2 MO ethosuximide 1 GC MO FELBATOL 2 MO gabapentin 1 GC MO GABITRIL 2 MO KEPPRA INJ 2 LAMICTAL ODT TBDP 2 MO LAMICTAL XR 2 MO lamotrigine 1 GC MO levetiracetam oral soln 1 GC MO levetiracetam tabs 1 GC MO LYRICA CAPS 225MG, 300MG 2 QL(180 per 90 days) MO LYRICA CAPS 100MG, 150MG, 2 QL(270 per 200MG, 25MG, 50MG, 75MG 90 days) MO NEURONTIN ORAL SOLN 2 MO oxcarbazepine 1 GC MO PEGANONE 2 MO phenytoin 1 GC MO PHENYTOIN SODIUM 2 phenytoin sodium extended 1 GC MO primidone 1 GC MO SABRIL 2 MO TEGRETOL-XR TB12 100MG 2 MO topiramate 1 GC MO valproate sodium 1 GC MO valproic acid 1 GC MO VIMPAT INJ 2 VIMPAT ORAL SOLN 2 MO VIMPAT TABS 2 MO zonisamide 1 GC MO Drug Drug Name Tier Notes carbidopa/levodopa odt 1 GC MO carbidopa/levodopa sr tbcr 50mg; 1 GC MO 200mg COMTAN 2 MO LODOSYN 2 MO MIRAPEX ER 2 MO pramipexole dihydrochloride tabs 1 GC 0.125mg, 0.25mg, 0.5mg, 1.5mg, 1mg REQUIP XL 2 MO ropinirole 1 GC MO selegiline 1 GC MO STALEVO 100 2 MO STALEVO 125 2 MO STALEVO 150 2 MO STALEVO 200 2 MO STALEVO 50 2 MO STALEVO 75 2 MO trihexyphenidyl 1 GC MO ZELAPAR 2 MO MIGRAINE / CLUSTER HEADACHE THERAPY ANTIPARKINSONISM AGENTS APOKYN AZILECT benztropine mesylate inj benztropine mesylate tabs bromocriptine mesylate carbidopa / levodopa carbidopa/levodopa cr 2 2 1 1 1 1 1 LA MO MO GC GC MO GC MO GC MO GC MO dihydroergotamine mesylate ergotamine tartrate / caffeine MAXALT 1 1 2 MAXALT-MLT 2 migergot MIGRANAL 1 3 sumatriptan succinate inj 6mg/0.5ml 1 sumatriptan succinate tabs 100mg 1 sumatriptan succinate tabs 25mg, 50mg 1 GC MO GC MO QL(36 per 90 days) MO QL(36 per 90 days) MO GC MO QL(24 per 90 days) MO GC QL(12 per 90 days) MO GC QL(27 per 90 days) MO GC QL(54 per 90 days) MO MISCELLANEOUS NEUROLOGICAL THERAPY 7 Drug Name ARICEPT ODT Drug Tier Notes 2 QL(90 per 90 days) MO ARICEPT TABS 10MG, 5MG 2 QL(90 per 90 days) MO COPAXONE 4 PA QL(90 per 90 days) MO EXELON CAPS 2 QL(180 per 90 days) MO EXELON ORAL SOLN 2 MO EXELON PT24 2 QL(90 per 90 days) MO galantamine hydrobromide cp24 1 GC QL(90 per 90 days) MO galantamine hydrobromide oral 1 GC MO soln galantamine hydrobromide tabs 1 GC QL(180 per 90 days) MO MYTELASE 2 MO NAMENDA ORAL SOLN 2 MO NAMENDA TABS 10MG 2 QL(180 per 90 days) MO NAMENDA TABS 5MG 2 QL(270 per 90 days) MO NAMENDA TITRATION PAK 2 MO XENAZINE 4 LA MO Drug Name orphenadrine /asa /caffeine orphenadrine citrate orphenadrine citrate er orphenadrine compound ds pyridostigmine bromide regonol tizanidine hcl 1 1 1 1 1 1 2 2 1 1 Notes GC MO GC MO GC MO GC MO GC MO GC GC MO acetaminophen / codeine oral soln acetaminophen / codeine tabs 300mg; 15mg acetaminophen/codeine #3 acetaminophen/codeine #4 ascomp/codeine BUPRENEX buprenorphine hcl inj buprenorphine hcl subl codeine sulfate tabs 30mg, 60mg DILAUDID INJ DILAUDID-5 DILAUDID-HP INJ 10MG/ML duramorph EMBEDA CPCR 20MG; 0.8MG, 30MG; 1.2MG, 50MG; 2MG endocet fentanyl citrate fentanyl citrate oral transmucosal 1 GC MO 1 GC MO 1 1 1 2 1 1 1 2 2 2 1 3 GC MO GC MO GC MO GC GC MO GC MO MO MO 1 1 1 fentanyl patches hydrocodone / acetaminophen hydrocodone / ibuprofen hydrocodone /acetaminophen-hs hydrocodone bitartrate/acetaminophen hydromorphone hcl inj 10mg/ml hydromorphone hcl tabs INFUMORPH 200 INFUMORPH 500 KADIAN levorphanol tartrate margesic-h 1 1 1 1 1 GC MO GC GC PA QL(360 per 90 days) MO GC MO GC MO GC MO GC MO GC MO 1 1 2 2 2 1 1 GC MO GC MO MO MO MO GC MO GC MO NARCOTIC ANALGESICS MUSCLE RELAXANTS / ANTISPASMODIC THERAPY baclofen carisoprodol /aspirin carisoprodol tabs 350mg chlorzoxazone cyclobenzaprine hcl dantrolene sodium MESTINON SYRP MESTINON TIMESPAN metaxalone methocarbamol Drug Tier 1 1 1 1 1 1 1 GC MO GC MO GC MO GC MO GC MO GC MO MO MO GC GC MO 8 GC MO MO Drug Drug Name Tier Notes meperidine hcl inj 10mg/ml, 1 GC 50mg/ml meperidine hcl inj 25mg/ml, 1 GC MO 75mg/ml meperidine hcl oral soln 1 GC MO methadone hcl conc 1 GC MO methadone hcl inj 1 GC METHADONE HCL ORAL 2 MO SOLN methadone hcl tabs 1 GC MO methadose tabs 10mg 1 GC methadose tabs 5mg 1 GC MO morphine sulfate er 1 GC MO morphine sulfate inj 0.5mg/ml, 1 GC 5mg/ml morphine sulfate inj 1mg/ml 1 GC MO morphine sulfate oral soln 1 GC MO morphine sulfate tabs 1 GC MO ONSOLIS 2 OPANA ER 2 MO oxycodone /acetaminophen caps 1 GC MO oxycodone /acetaminophen tabs 1 GC 325mg; 5mg oxycodone /acetaminophen tabs 1 GC MO 325mg; 2.5mg, 650mg; 10mg oxycodone /apap tabs 500mg; 1 GC MO 7.5mg oxycodone /aspirin 1 GC MO oxycodone hcl tabs 15mg, 30mg, 1 GC MO 5mg oxycodone-apap 1 GC MO OXYCONTIN 2 MO reprexain tabs 10mg; 200mg 1 GC MO ROXICET ORAL SOLN 2 MO roxicet tabs 325mg; 5mg 1 GC MO stagesic 1 GC MO zerlor 1 GC MO Drug Name CELEBREX depade diclofenac potassium diclofenac sodium diclofenac sodium ec diclofenac sodium xr diflunisal etodolac fenoprofen calcium FLECTOR flurbiprofen ibuprofen susp ibuprofen tabs 400mg, 600mg, 800mg indomethacin caps indomethacin er ketoprofen ketoprofen er meclofenamate sodium meloxicam nabumetone naloxone naltrexone naproxen sodium tabs 275mg, 550mg naproxen susp naproxen tabs 250mg, 375mg naproxen tbec oxaprozin piroxicam SUBOXONE SUBL sulindac tolmetin sodium tramadol tramadol hcl er VOLTAREN GEL NON-NARCOTIC ANALGESICS ARTHROTEC 50 ARTHROTEC 75 butorphanol tartrate nasal soln 3 3 1 MO MO GC PA QL(30 per 90 days) MO Drug Tier Notes 2 QL(180 per 90 days) MO 1 GC MO 1 GC MO 1 GC MO 1 GC MO 1 GC MO 1 GC MO 1 GC MO 1 GC MO 3 MO 1 GC MO 1 GC MO 1 GC MO 1 1 1 1 1 1 1 1 1 1 GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC GC MO GC MO 1 1 1 1 1 2 1 1 1 1 2 GC MO GC MO GC MO GC MO GC MO MO GC MO GC MO GC MO GC MO MO 1 1 1 1 GC MO GC MO GC MO GC MO PROPOXYPHENE balacet 325 propoxyphene /acetaminophen propoxyphene hcl propoxyphene-n /acetaminophen 9 Drug Name Drug Tier Drug Name citalopram tabs 10mg Notes PSYCHOTHERAPEUTIC DRUGS ABILIFY DISCMELT TBDP 15MG 3 ABILIFY DISCMELT TBDP 10MG 3 ABILIFY INJ ABILIFY ORAL SOLN ABILIFY TABS 20MG, 2MG, 30MG, 5MG 3 3 3 ABILIFY TABS 15MG 3 ABILIFY TABS 10MG 3 amitriptyline amoxapine amphetamine /dextroamphetamine tabs budeprion sr 1 1 1 budeprion xl tb24 300mg 1 budeprion xl tb24 150mg 1 1 bupropion hcl bupropion hcl sr tb12 100mg, 200mg 1 1 bupropion hcl sr tb12 150mg 1 buspirone hcl chlordiazepoxide /amitriptyline chlorpromazine citalopram oral soln citalopram tabs 40mg 1 1 1 1 1 QL(180 per 90 days) ST MO QL(270 per 90 days) ST MO ST ST MO QL(90 per 90 days) ST MO QL(180 per 90 days) ST MO QL(270 per 90 days) ST MO GC MO GC MO GC PA MO citalopram tabs 20mg clomipramine clozapine tabs 100mg, 25mg, 50mg CLOZAPINE TABS 200MG CYMBALTA CPEP 60MG GC QL(180 per 90 days) MO GC QL(90 per 90 days) MO GC QL(270 per 90 days) MO GC MO GC QL(180 per 90 days) MO GC PA QL(180 per 90 days) MO GC MO GC MO GC MO GC MO GC QL(90 per 90 days) MO 10 Drug Tier Notes 1 GC QL(180 per 90 days) MO 1 GC QL(270 per 90 days) MO 1 GC MO 1 GC 2 2 CYMBALTA CPEP 20MG, 30MG 2 desipramine dexmethylphenidate dextroamphetamine sulfate dextroamphetamine sulfate er doxepin caps 100mg, 10mg, 25mg, 50mg, 75mg doxepin conc EMSAM 1 1 1 1 1 FANAPT TABS 1MG, 2MG, 4MG 3 FANAPT TABS 10MG, 12MG, 6MG, 8MG 3 FANAPT TITRATION PACK FAZACLO TBDP 100MG, 12.5MG, 25MG fluoxetine caps 40mg 3 3 fluoxetine caps 20mg 1 fluoxetine caps 10mg 1 fluoxetine dr 1 1 3 1 QL(90 per 90 days) MO QL(180 per 90 days) MO GC MO GC PA MO GC PA MO GC PA MO GC MO GC MO QL(90 per 90 days) MO QL(90 per 90 days) MO QL(180 per 90 days) MO MO GC QL(180 per 90 days) MO GC QL(360 per 90 days) MO GC QL(720 per 90 days) MO GC QL(12 per 90 days) MO Drug Name fluoxetine oral soln fluoxetine tabs 20mg fluoxetine tabs 10mg fluphenazine conc fluphenazine decanoate inj fluphenazine elix fluphenazine inj fluphenazine tabs fluvoxamine FOCALIN XR CP24 10MG, 15MG, 20MG, 5MG GEODON CAPS Drug Tier Notes 1 GC MO 1 GC QL(360 per 90 days) MO 1 GC QL(720 per 90 days) MO 1 GC 1 GC MO 1 GC MO 1 GC MO 1 GC MO 1 GC QL(270 per 90 days) MO 2 PA MO 2 GEODON INJ HALDOL HALDOL DECANOATE 100 HALDOL DECANOATE 50 haloperidol haloperidol decanoate inj haloperidol lactate inj imipramine imipramine pamoate INVEGA SUSTENNA INVEGA TB24 1.5MG, 3MG, 9MG 2 2 2 2 1 1 1 1 1 2 2 INVEGA TB24 6MG 2 LEXAPRO ORAL SOLN LEXAPRO TABS 2 2 lithium carbonate lithium carbonate er lithium citrate loxapine maprotiline 1 1 1 1 1 QL(180 per 90 days) MO MO MO MO MO GC MO GC MO GC MO GC MO GC MO MO QL(90 per 90 days) MO QL(180 per 90 days) MO MO QL(90 per 90 days) MO GC MO GC MO GC MO GC MO GC MO 11 Drug Name MARPLAN METADATE CD metadate er methamphetamine hcl METHYLIN CHEW methylin er METHYLIN ORAL SOLN methylin tabs methylphenidate hcl methylphenidate hcl sr mirtazapine Drug Tier Notes 2 MO 3 PA MO 1 GC PA MO 1 GC PA MO 3 PA MO 1 GC PA MO 3 PA MO 1 GC PA MO 1 GC PA 1 GC PA 1 GC QL(90 per 90 days) MO mirtazapine odt tbdp 30mg, 45mg 1 GC QL(90 per 90 days) MO NARDIL 2 MO NAVANE CAPS 20MG 2 MO nefazodone 1 GC QL(180 per 90 days) MO nortriptyline 1 GC MO ORAP 2 MO paroxetine er tb24 12.5mg 1 GC QL(180 per 90 days) MO paroxetine er tb24 25mg 1 GC QL(270 per 90 days) MO paroxetine susp 1 GC MO paroxetine tabs 20mg, 40mg 1 GC QL(90 per 90 days) MO paroxetine tabs 10mg, 30mg 1 GC QL(180 per 90 days) MO PAXIL SUSP 2 MO perphenazine 1 GC MO PRISTIQ 2 QL(90 per 90 days) MO protriptyline hcl 1 GC MO PROVIGIL 2 PA QL(90 per 90 days) MO RISPERDAL CONSTA 2 MO Drug Name risperidone odt risperidone oral soln risperidone tabs RITALIN LA ROZEREM SAPHRIS SEROQUEL TABS 25MG, 300MG, 400MG SEROQUEL TABS 100MG, 200MG, 50MG SEROQUEL XR TB24 150MG, 300MG, 400MG SEROQUEL XR TB24 200MG, 50MG sertraline conc sertraline tabs 100mg, 25mg sertraline tabs 50mg STRATTERA SURMONTIL SYMBYAX thioridazine thiothixene tranylcypromine trazodone trifluoperazine venlafaxine hcl XYREM zaleplon Drug Tier Notes 1 GC QL(180 per 90 days) MO 1 GC MO 1 GC QL(180 per 90 days) MO 3 PA MO 3 MO 3 QL(180 per 90 days) MO 2 QL(180 per 90 days) MO 2 QL(270 per 90 days) MO 2 QL(180 per 90 days) MO 2 QL(270 per 90 days) MO 1 GC MO 1 GC QL(180 per 90 days) MO 1 GC QL(270 per 90 days) MO 2 MO 3 MO 3 QL(90 per 90 days) MO 1 GC MO 1 GC MO 1 GC MO 1 GC MO 1 GC MO 1 GC QL(270 per 90 days) MO 4 PA 1 GC MO 12 Drug Name zolpidem ZYPREXA INJ ZYPREXA TABS ZYPREXA ZYDIS Drug Tier Notes 1 GC MO 2 MO 2 QL(90 per 90 days) MO 2 QL(90 per 90 days) MO CARDIOVASCULAR, HYPERTENSION / LIPIDS ANTIARRHYTHMIC AGENTS amiodarone inj amiodarone tabs disopyramide phosphate flecainide acetate mexiletine MULTAQ NORPACE CR CP12 100MG PACERONE TABS 100MG, 400MG pacerone tabs 200mg procainamide propafenone hcl quinidine gluconate cr quinidine sulfate quinidine sulfate er sorine sotalol TIKOSYN 1 1 1 1 1 2 2 2 GC GC MO GC MO GC MO GC MO MO MO MO 1 1 1 1 1 1 1 1 3 GC MO GC GC MO GC MO GC MO GC MO GC MO GC MO MO ANTIHYPERTENSIVE THERAPY acebutolol afeditab cr amiloride amiloride / hydrochlorothiazide amlodipine / benazepril 1 1 1 1 1 amlodipine besylate atenolol atenolol / chlorthalidone benazepril benazepril / hydrochlorothiazide tabs 20mg; 12.5mg, 20mg; 25mg 1 1 1 1 1 GC MO GC MO GC MO GC MO GC QL(90 per 90 days) MO GC MO GC MO GC MO GC MO GC QL(360 per 90 days) MO Drug Drug Name Tier Notes benazepril / hydrochlorothiazide 1 GC QL(720 tabs 10mg; 12.5mg per 90 days) MO benazepril / hydrochlorothiazide 1 GC tabs 5mg; 6.25mg QL(1440 per 90 days) MO betaxolol hcl tabs 1 GC BIDIL 2 QL(540 per 90 days) MO bisoprolol fumarate 1 GC MO bisoprolol fumarate / 1 GC MO hydrochlorothiazide bumetanide 1 GC MO BYSTOLIC 2 MO captopril 1 GC MO captopril / hydrochlorothiazide 1 GC QL(90 tabs 25mg; 15mg, 25mg; 25mg, per 90 days) 50mg; 15mg MO captopril / hydrochlorothiazide 1 GC QL(270 tabs 50mg; 25mg per 90 days) MO cartia xt 1 GC MO carvedilol 1 GC MO chlorothiazide 1 GC MO chlorothiazide sodium 1 GC MO chlorthalidone tabs 25mg, 50mg 1 GC MO clonidine ptwk 1 GC clonidine tabs 1 GC MO COREG CR 2 MO DEMSER 2 MO DIBENZYLINE 3 MO dilt-cd cp24 120mg, 300mg 1 GC MO dilt-xr cp24 180mg, 240mg 1 GC diltiazem cd cp24 120mg, 240mg, 1 GC MO 300mg diltiazem hcl cp24 360mg 1 GC MO diltiazem hcl er cp12 1 GC MO diltiazem hcl er cp24 420mg 1 GC MO diltiazem hcl er tb24 1 GC diltiazem hcl inj 25mg/5ml 1 GC DILTIAZEM HCL INJ 100MG 2 diltiazem hcl tabs 1 GC MO diltzac 1 GC MO 13 Drug Name DIOVAN HCT Drug Tier Notes 2 QL(90 per 90 days) MO DIOVAN TABS 320MG 2 QL(90 per 90 days) MO DIOVAN TABS 160MG, 40MG, 2 QL(180 per 80MG 90 days) MO doxazosin 1 GC QL(180 per 90 days) MO EDECRIN 2 MO enalapril 1 GC MO enalapril / hydrochlorothiazide 1 GC QL(90 tabs 5mg; 12.5mg per 90 days) MO enalapril / hydrochlorothiazide 1 GC QL(180 tabs 10mg; 25mg per 90 days) MO eplerenone 1 GC MO EXFORGE 2 QL(90 per 90 days) MO EXFORGE HCT 2 QL(90 per 90 days) MO felodipine er 1 GC MO fosinopril 1 GC MO fosinopril / hydrochlorothiazide 1 GC QL(90 tabs 10mg; 12.5mg per 90 days) MO fosinopril / hydrochlorothiazide 1 GC QL(360 tabs 20mg; 12.5mg per 90 days) MO furosemide inj 1 GC MO furosemide oral soln 10mg/ml 1 GC MO FUROSEMIDE ORAL SOLN 2 MO 8MG/ML furosemide tabs 1 GC MO guanfacine hcl 1 GC MO hydralazine 1 GC MO hydrochlorothiazide 1 GC MO indapamide 1 GC MO isradipine 1 GC MO labetalol inj 1 GC Drug Name labetalol tabs lisinopril / hydrochlorothiazide tabs 12.5mg; 10mg, 12.5mg; 20mg lisinopril / hydrochlorothiazide tabs 25mg; 20mg lisinopril tabs 5mg lisinopril tabs 10mg, 2.5mg, 20mg, 30mg, 40mg losartan potassium tabs 100mg Drug Tier Notes 1 GC MO 1 GC QL(90 per 90 days) MO 1 GC QL(360 per 90 days) MO 1 GC 1 GC MO 1 losartan potassium tabs 25mg, 50mg 1 losartan potassium/hydrochlorothiazide 1 LOTREL CAPS 10MG; 40MG, 5MG; 40MG 2 methyclothiazide metolazone metoprolol / hydrochlorothiazide metoprolol succinate er metoprolol tartrate inj metoprolol tartrate tabs MICARDIS 1 1 1 1 1 1 2 MICARDIS HCT 2 minoxidil tabs moexipril moexipril / hydrochlorothiazide tabs 12.5mg; 15mg, 12.5mg; 7.5mg moexipril / hydrochlorothiazide tabs 25mg; 15mg 1 1 1 nadolol / bendroflumethiazide nadolol tabs 20mg, 40mg, 80mg nicardipine caps nifediac cc 1 1 1 1 1 GC QL(90 per 90 days) MO GC QL(180 per 90 days) MO GC QL(90 per 90 days) MO QL(90 per 90 days) MO GC MO GC MO GC MO GC GC GC MO QL(90 per 90 days) MO QL(90 per 90 days) MO GC MO GC MO GC QL(90 per 90 days) MO GC QL(180 per 90 days) MO GC MO GC MO GC MO GC MO 14 Drug Name nifedical xl nifedipine nifedipine er tb24 30mg, 60mg nifedipine er tb24 90mg nimodipine nisoldipine tb24 20mg, 30mg, 40mg perindopril erbumine pindolol prazosin Drug Tier 1 1 1 1 4 1 1 1 1 propranolol /hydrochlorothiazide propranolol hcl er propranolol hcl inj propranolol hcl oral soln propranolol hcl tabs quinapril quinapril / hydrochlorothiazide 1 1 1 1 1 1 1 ramipril reserpine SODIUM EDECRIN spironolactone spironolactone / hydrochlorothiazide SULAR taztia xt TEKTURNA 1 1 2 1 1 TEKTURNA HCT 2 terazosin hcl 1 timolol maleate torsemide tabs trandolapril trandolapril/verapamil hcl tbcr 2mg; 180mg, 2mg; 240mg trandolapril/verapamil hcl tbcr 4mg; 240mg 1 1 1 1 2 1 2 1 Notes GC MO GC MO GC GC MO MO GC MO GC MO GC MO GC QL(360 per 90 days) MO GC MO GC MO GC GC MO GC MO GC MO GC QL(90 per 90 days) MO GC MO GC MO GC MO GC MO MO GC MO QL(90 per 90 days) MO QL(90 per 90 days) MO GC QL(180 per 90 days) MO GC MO GC MO GC MO GC QL(90 per 90 days) GC QL(180 per 90 days) Drug Drug Name Tier Notes triamterene / hydrochlorothiazide 1 GC MO TWYNSTA 2 QL(90 per 90 days) MO VALTURNA 2 QL(90 per 90 days) MO verapamil er 1 GC MO verapamil inj 1 GC verapamil tabs 1 GC MO Drug Name LOVENOX INJ 100MG/ML, 120MG/0.8ML, 150MG/ML, 300MG/3ML, 60MG/0.6ML, 80MG/0.8ML pentopak pentoxifylline er PLAVIX PROMACTA TABS 50MG CARDIAC GLYCOSIDES digoxin inj digoxin oral soln digoxin tabs LANOXIN INJ LANOXIN TABS 1 1 1 2 2 GC GC MO GC MO MO COAGULATION THERAPY AGGRENOX ARIXTRA INJ 2.5MG/0.5ML ARIXTRA INJ 10MG/0.8ML, 5MG/0.4ML, 7.5MG/0.6ML cilostazol CYKLOKAPRON dipyridamole tabs EFFIENT FRAGMIN heparin sodium dcu HEPARIN SODIUM INJ 2500UNIT/ML HEPARIN SODIUM INJ 2000UNIT/ML heparin sodium inj 10000unit/ml, 1000unit/ml, 5000unit/ml heparin sodium/d5w inj 5%; 40unit/ml HEPARIN SODIUM/NACL 0.45% heparin sodium/sodium chloride 0.9% premix jantoven LOVENOX INJ 30MG/0.3ML, 40MG/0.4ML 2 2 4 MO MO MO 1 2 1 2 2 1 2 GC MO MO GC MO MO MO GC MO 2 MO 1 GC MO 1 GC Drug Tier 4 1 1 2 4 PROMACTA TABS 25MG 4 ticlopidine hcl warfarin 1 1 GC 1 2 GC MO MO GC MO GC MO MO LA PA QL(90 per 90 days) MO LA PA QL(270 per 90 days) MO GC MO GC MO LIPID/CHOLESTEROL LOWERING AGENTS CADUET 2 cholestyramine light pack COLESTID GRAN colestipol CRESTOR 1 2 1 2 fenofibrate fenofibrate micronized gemfibrozil LIPITOR 1 1 1 2 lovastatin tabs 10mg 1 lovastatin tabs 20mg, 40mg 1 LOVAZA NIASPAN pravastatin tabs 10mg, 20mg, 80mg 2 2 1 2 1 Notes MO 15 QL(90 per 90 days) MO GC MO MO GC MO QL(90 per 90 days) MO GC MO GC MO GC MO QL(90 per 90 days) MO GC QL(90 per 90 days) MO GC QL(180 per 90 days) MO MO MO GC QL(90 per 90 days) MO Drug Name pravastatin tabs 40mg Drug Tier Notes 1 GC QL(180 per 90 days) MO prevalite powd 1 GC MO SIMCOR TB24 1000MG; 20MG, 2 QL(180 per 500MG; 20MG, 750MG; 20MG 90 days) MO simvastatin 1 GC QL(90 per 90 days) MO TRICOR 2 MO TRILIPIX 2 MO ZETIA 2 QL(90 per 90 days) MO MISCELLANEOUS CARDIOVASCULAR AGENTS RANEXA 2 MO 1 1 1 1 1 1 1 GC MO GC MO GC MO GC MO GC MO GC PA GC 1 1 GC MO GC MO 2 2 MO MO NITRATES isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate isosorbide mononitrate er nitro-bid nitroglycerin inj nitroglycerin pt24 0.2mg/hr, 0.6mg/hr nitroglycerin pt24 0.4mg/hr nitroglycerin transdermal pt24 0.1mg/hr NITROLINGUAL PUMPSPRAY NITROSTAT amnesteem avita crea AZELEX claravis clindamycin phosphate external soln clindamycin phosphate foam clindamycin phosphate gel clindamycin phosphate lotn clindamycin phosphate swab clindamycin/benzoyl peroxide ery erythromycin / benzoyl peroxide erythromycin external soln erythromycin gel FINACEA METROGEL metronidazole sotret tretinoin ANTIPSORIATIC / ANTISEBORRHEIC 1 1 2 GC MO GC MO MO 1 1 1 GC MO GC MO GC MO BURN THERAPY silver sulfadiazine ssd thermazene Drug Tier 2 1 2 2 2 3 2 1 1 1 4 2 1 3 2 2 3 2 Notes MO GC MO MO MO MO MO MO GC MO GC MO GC MO MO GC MO MO PA MO MO MO MO 1 1 2 1 1 GC GC MO MO GC GC MO 1 1 1 1 1 1 1 1 1 2 2 1 1 1 GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO MO MO GC MO GC GC MO 1 1 GC MO GC MO THERAPY FOR ACNE DERMATOLOGICALS/TOPICAL THERAPY calcipotriene external soln selenium sulfide lotn 2.5% SORIATANE CAPS 17.5MG, 22.5MG Drug Name 8-MOP ammonium lactate CARAC CARMOL-HC CONDYLOX GEL ELIDEL FLUOROPLEX fluorouracil imiquimod laclotion OXSORALEN ULTRA PANRETIN podofilox PROTOPIC REGRANEX SOLARAZE VEREGEN ZONALON TOPICAL ANESTHETICS lidocaine / prilocaine crea lidocaine external soln MISCELLANEOUS DERMATOLOGICALS 16 Drug Name lidocaine gel lidocaine inj 0.5%, 1% lidocaine oint lidocaine viscous LIDODERM Drug Tier 1 1 1 1 3 Drug Drug Name Tier Notes amcinonide oint 1 GC augmented betamethasone 1 GC MO dipropionate beta-val crea 1 GC MO betamethasone dipropionate crea 1 GC MO betamethasone dipropionate oint 1 GC MO betamethasone valerate crea 1 GC MO betamethasone valerate lotn 1 GC betamethasone valerate oint 1 GC MO CAPEX 2 MO clobetasol propionate e 1 GC MO clobetasol propionate external 1 GC soln clobetasol propionate foam 1 GC MO clobetasol propionate gel 1 GC MO clobetasol propionate oint 1 GC MO CLOBEX LOTN 2 MO CLOBEX SHAM 2 MO CORDRAN TAPE 2 MO DERMA-SMOOTHE / FS BODY 2 MO OIL desonide 1 GC MO desoximetasone 1 GC MO diflorasone diacetate 1 GC MO fluocinolone acetonide 1 GC MO fluocinonide emollient base 1 GC fluocinonide external soln 1 GC MO fluocinonide gel 1 GC MO fluocinonide oint 1 GC MO fluticasone propionate 1 GC MO halobetasol propionate 1 GC MO hydrocortisone butyrate 1 GC MO hydrocortisone crea 1%, 2.5% 1 GC MO hydrocortisone lotn 1 GC MO hydrocortisone oint 1%, 2.5% 1 GC MO hydrocortisone valerate 1 GC MO LOCOID LOTN 2 MO LUXIQ 2 MO mometasone furoate 1 GC MO PANDEL 2 MO prednicarbate 1 GC MO triamcinolone acetonide crea 1 GC MO triamcinolone acetonide lotn 1 GC MO Notes GC MO GC GC MO GC MO PA MO TOPICAL ANTIBACTERIALS ALTABAX BACTROBAN CREA gentamicin sulfate crea gentamicin sulfate oint mupirocin PHISOHEX sodium sulfacetamide SULFAMYLON 2 2 1 1 1 2 1 2 MO MO GC MO GC MO GC MO MO GC MO MO 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 2 GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO MO 2 3 3 MO MO MO TOPICAL ANTIFUNGALS ciclopirox ciclopirox nail lacquer ciclopirox olamine clotrimazole / betamethasone clotrimazole external crea clotrimazole external soln econazole nitrate ketoconazole kuric NAFTIN nyamyc nystatin / triamcinolone nystatin crea nystatin external powd nystatin oint nystop pedi-dri XOLEGEL TOPICAL ANTIVIRALS DENAVIR ZOVIRAX CREA ZOVIRAX OINT TOPICAL CORTICOSTEROIDS ala cort alclometasone dipropionate amcinonide crea amcinonide lotn 1 1 1 1 GC MO GC MO GC MO GC MO 17 Drug Name triamcinolone acetonide oint triderm crea Drug Tier Notes 1 GC MO 1 GC MO TOPICAL ENZYMES SANTYL 2 MO TOPICAL SCABICIDES / PEDICULICIDES acticin EURAX LINDANE malathion OVIDE permethrin crea ULESFIA 1 2 2 1 2 1 3 GC MO MO MO GC MO MO GC MO DIAGNOSTICS / MISCELLANEOUS AGENTS sodium chloride 0.9% sodium chloride inj 0.9% sodium polystyrene sulfonate powd SYPRINE MISCELLANEOUS AGENTS ACTONEL TABS 30MG ADAGEN alcohol 5%/dextrose 5% alendronate sodium tabs 40mg anagrelide hydrochloride ANTABUSE TABS 250MG BUPHENYL CAMPRAL 3 4 1 1 1 2 2 2 CHEMET CLINIMIX / DEXTROSE DEXTROSE 10%/NACL 0.45% dextrose 10% flex container DEXTROSE 10%/NACL 0.2% dextrose 2.5%/sodium chloride 0.45% dextrose 5% dextrose 5%/nacl 0.2% dextrose 5%/nacl 0.225% DEXTROSE 5%/NACL 0.33% dextrose 5%/nacl 0.45% dextrose 5%/nacl 0.9% etidronate disodium EVOXAC EXJADE FOSRENOL 2 2 2 1 2 1 1 1 1 2 1 1 1 3 4 2 Drug Name INCRELEX kionex powd levocarnitine oral soln levocarnitine tabs midodrine ORFADIN pilocarpine hcl tabs PROLASTIN INJ 500MG RENAGEL RENVELA RILUTEK SKELID PA MO LA MO GC GC PA MO GC MO MO MO QL(540 per 90 days) MO MO Drug Tier Notes 4 LA PA MO 1 GC MO 1 GC MO 1 GC MO 1 GC MO 4 LA MO 1 GC MO 4 LA 2 MO 2 MO 4 MO 3 PA QL(180 per 90 days) MO 1 GC MO 1 GC MO 1 GC MO 2 MO buproban 1 CHANTIX TABS 2 CHANTIX TABS 0.5MG, 1MG 2 NICOTROL INHALER 3 NICOTROL NASAL 3 GC PA QL(180 per 90 days) MO PA QL(1 per 3 days) MO PA QL(168 per 90 days) MO PA QL(504 per 90 days) MO PA QL(90 per 90 days) MO SMOKING DETERRENTS GC GC GC MO GC GC EAR, NOSE / THROAT MEDICATIONS MISCELLANEOUS AGENTS GC MO GC MO GC MO MO LA MO MO ASTELIN ASTEPRO azelastine hcl nasal soln BACTROBAN NASAL chlorhexidine gluconate oral rinse 18 2 2 1 2 1 MO MO GC MO MO GC MO Drug Name ipratropium bromide nasal soln periogard triamcinolone in orabase TYZINE TYZINE PEDIATRIC NASAL DROPS Drug Tier Notes 1 GC MO 1 GC MO 1 GC MO 2 MO 2 Drug Name METHYLPREDNISOLONE SODIUMSUCCINATE INJ 1000MG methylprednisolone tabs 32mg methylprednisolone tabs 16mg, 4mg, 8mg prednisolone sodium phosphate oral soln 15mg/5ml prednisolone syrp prednisone PREDNISONE INTENSOL SOLU-CORTEF INJ 100MG SOLU-CORTEF INJ 250MG SOLU-MEDROL INJ 2GM, 40MG SOLU-MEDROL INJ 125MG solu-medrol inj 500mg MISCELLANEOUS OTIC PREPARATIONS acetasol hc acetic acid acetic acid / hydrocortisone borofair DERMOTIC ofloxacin 1 1 1 1 2 1 GC MO GC MO GC MO GC MO MO GC MO OTIC STEROID / ANTIBIOTIC CIPRO HC CIPRODEX COLY-MYCIN S CORTISPORIN-TC cortomycin neomycin /polymyxin /hc neomycin /polymyxin /hydrocortisone otic susp 3 2 2 2 1 1 1 MO MO MO MO GC MO GC MO GC MO Drug Tier Notes 2 PA MO 1 1 GC PA GC PA MO 1 GC PA MO 1 1 2 2 2 2 GC PA GC PA MO PA MO 2 1 PA MO GC PA 1 1 GC MO GC MO acarbose 1 ACTOPLUS MET 2 ACTOS 2 GC QL(270 per 90 days) MO QL(270 per 90 days) MO QL(90 per 90 days) MO ALCOHOL PREPS AVANDAMET 2 2 AVANDARYL TABS 2MG; 8MG, 4MG; 4MG, 4MG; 8MG 2 AVANDARYL TABS 1MG; 4MG, 2MG; 4MG 2 AVANDIA TABS 8MG 2 AVANDIA TABS 2MG, 4MG 2 ANTITHYROID AGENTS methimazole propylthiouracil DIABETES THERAPY ENDOCRINE/DIABETES ADRENAL HORMONES a-hydrocort a-methapred cortisone acetate DEPO-MEDROL dexamethasone elix dexamethasone inj 4mg/ml DEXAMETHASONE INTENSOL dexamethasone tabs 0.5mg, 0.75mg, 1.5mg, 4mg, 6mg DEXAMETHASONE TABS 1MG, 2MG fludrocortisone acetate hydrocortisone tabs methylprednisolone acetate methylprednisolone sodiumsuccinate inj 125mg, 40mg 1 1 1 2 1 1 2 GC MO GC PA MO GC MO PA MO GC MO GC MO MO 1 GC MO 2 MO 1 1 1 1 GC MO GC MO GC PA MO GC PA MO PA 19 QL(180 per 90 days) MO QL(90 per 90 days) MO QL(180 per 90 days) MO QL(90 per 90 days) MO QL(180 per 90 days) MO Drug Drug Name Tier Notes BD INSULIN SYRINGE 2 MO SAFETYGLIDE/1ML/29G X 1/2" BD INSULIN SYRINGE 2 MO ULTRAFINE/0.3ML/31G X 5/16" BD INSULIN SYRINGE 2 MO ULTRAFINE/0.5ML/30G X 1/2" BD INSULIN SYRINGE 2 MO ULTRAFINE/1ML/31G X 5/16" BD PEN 2 MO NEEDLE/ULTRAFINE/29G X 12.7MM BYETTA 3 QL(7.2 per 90 days) ST MO CURITY GAUZE PADS 2"X2" 2 MO DUETACT 2 QL(90 per 90 days) MO glimepiride tabs 1mg, 2mg 1 GC QL(90 per 90 days) MO glimepiride tabs 4mg 1 GC QL(180 per 90 days) MO glipizide / metformin 1 GC QL(360 per 90 days) MO glipizide er tb24 2.5mg 1 GC QL(90 per 90 days) glipizide tabs 10mg 1 GC QL(360 per 90 days) MO glipizide tabs 5mg 1 GC QL(720 per 90 days) MO glipizide xl tb24 5mg 1 GC QL(90 per 90 days) MO glipizide xl tb24 10mg 1 GC QL(180 per 90 days) MO GLUCAGEN HYPOKIT 2 MO GLUCAGON EMERGENCY 2 MO KIT 20 Drug Name glyburide / metformin tabs 1.25mg; 250mg, 2.5mg; 500mg Drug Tier Notes 1 GC QL(180 per 90 days) MO glyburide / metformin tabs 5mg; 1 GC QL(360 500mg per 90 days) MO glyburide micronized tabs 1.5mg, 1 GC QL(90 3mg per 90 days) MO glyburide micronized tabs 6mg 1 GC QL(180 per 90 days) MO glyburide tabs 1.25mg, 2.5mg 1 GC QL(180 per 90 days) MO glyburide tabs 5mg 1 GC QL(360 per 90 days) MO glycron tabs 1.5mg, 3mg 1 GC QL(180 per 90 days) MO GLYCRON TABS 4.5MG 2 QL(360 per 90 days) HUMALOG 2 MO HUMALOG MIX 50/50 2 MO HUMALOG MIX 50/50 PEN 2 MO HUMALOG MIX 75/25 2 MO HUMALOG MIX 75/25 PEN 2 MO HUMALOG PEN 2 MO HUMULIN 70/30 2 MO HUMULIN 70/30 PEN 2 MO HUMULIN N 2 MO HUMULIN N U-100 PEN 2 MO HUMULIN R 2 MO HUMULIN R U-500 2 MO (CONCENTRATED) JANUMET 2 QL(180 per 90 days) MO JANUVIA 2 QL(90 per 90 days) MO LANTUS 2 MO LANTUS SOLOSTAR 2 MO metformin hcl er tb24 750mg 1 GC QL(270 per 90 days) MO Drug Name metformin hcl er tb24 500mg metformin hcl tabs 1000mg metformin hcl tabs 850mg metformin hcl tabs 500mg nateglinide NOVOLIN 70/30 NOVOLIN 70/30 INNOLET NOVOLIN N NOVOLIN N INNOLET NOVOLIN R NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/30 NOVOLOG MIX 70/30 PREFILLED FLEXPEN ONGLYZA PRANDIN TABS 0.5MG, 1MG Drug Tier Notes 1 GC QL(450 per 90 days) MO 1 GC QL(180 per 90 days) MO 1 GC QL(270 per 90 days) MO 1 GC QL(360 per 90 days) MO 1 GC QL(270 per 90 days) MO 2 MO 2 MO 2 MO 2 MO 2 MO 2 MO 2 MO 2 MO 2 MO 2 2 PRANDIN TABS 2MG 2 PROGLYCEM RELION R SYMLIN 2 2 3 SYMLINPEN 120 3 SYMLINPEN 60 3 tolazamide tolbutamide 1 1 QL(90 per 90 days) MO QL(360 per 90 days) MO QL(720 per 90 days) MO MO MO QL(60 per 90 days) MO QL(33 per 90 days) MO QL(33 per 90 days) MO GC MO GC MO Drug Name Drug Tier Notes MISCELLANEOUS HORMONES ALDURAZYME ANADROL-50 ANDROGEL cabergoline calcitonin-salmon 4 3 2 1 1 calcitriol caps calcitriol inj 1mcg/ml calcitriol oral soln CEREZYME INJ 200UNIT danazol desmopressin acetate FABRAZYME INJ 35MG fortical 1 1 1 4 1 1 4 1 HECTOROL KUVAN NAGLAZYME oxandrolone SAMSCA TABS 30MG 2 4 4 1 4 SAMSCA TABS 15MG 4 SENSIPAR TABS 60MG, 90MG SENSIPAR TABS 30MG SOMAVERT 4 2 2 STIMATE SYNAREL testosterone cypionate inj 100mg/ml testosterone enanthate ZAVESCA ZEMPLAR ZOMETA 2 3 1 LA PA MO PA MO PA MO GC MO GC QL(12 per 90 days) MO GC MO GC MO GC MO LA PA MO GC MO GC MO LA PA MO GC QL(12 per 90 days) MO MO LA MO LA MO GC PA MO QL(730 per 365 days) MO QL(1460 per 365 days) MO MO MO PA QL(90 per 90 days) MO MO MO GC PA MO 1 2 2 4 GC PA MO LA MO MO 1 1 GC GC MO THYROID HORMONES levothyroxine tabs levoxyl 21 Drug Name liothyronine sodium tabs SYNTHROID unithroid Drug Tier Notes 1 GC MO 2 MO 1 GC MO Drug Name gavilyte-n/flavor pack generlac granisetron inj GASTROENTEROLOGY ANTIDIARRHEALS / ANTISPASMODICS atropine sulfate inj 0.1mg/ml ATROPINE SULFATE INJ 0.05MG/ML dicyclomine hcl caps dicyclomine hcl oral soln dicyclomine hcl tabs diphenoxylate / atropine glycopyrrolate loperamide hcl caps 1 2 GC 1 1 1 1 1 1 GC MO GC MO GC MO GC MO GC MO GC MO granisetron tabs hydrocortisone enem lactulose LOTRONEX MISCELLANEOUS GASTROINTESTINAL AGENTS AMITIZA ASACOL ASACOL HD balsalazide CANASA compro constulose CREON CYSTADANE DIPENTUM dronabinol EMEND CAPS 40MG 2 2 2 1 2 1 1 3 2 3 1 2 EMEND CAPS 125MG 2 EMEND CAPS 2 EMEND CAPS 80MG 2 ENTOCORT EC enulose GASTROCROM gavilyte-c gavilyte-g 2 1 2 1 1 MO MO MO GC MO GC MO GC MO MO MO MO GC PA MO PA QL(3 per 90 days) MO PA QL(6 per 90 days) MO PA QL(18 per 90 days) MO PA QL(24 per 90 days) MO MO GC MO MO GC MO GC MO 22 meclizine hcl mesalamine enem metoclopramide ondansetron hcl inj 4mg/2ml ondansetron hcl oral soln ondansetron hcl tabs 24mg ondansetron hcl tabs 4mg, 8mg ondansetron odt PENTASA polyethylene glycol 3350 powd prochlorperazine prochlorperazine edisylate prochlorperazine maleate procto-pak proctosol hc proctozone-hc RELISTOR REMICADE sulfasalazine tabs sulfazine ec TRANSDERM-SCOP trilyte URSO 250 URSO FORTE Drug Tier Notes 1 GC MO 1 GC MO 1 GC QL(42 per 90 days) MO 1 GC PA QL(180 per 90 days) 1 GC MO 1 GC MO 2 QL(180 per 90 days) MO 1 GC MO 1 GC MO 1 GC MO 1 GC MO 1 GC PA MO 1 GC PA QL(21 per 90 days) 1 GC PA QL(135 per 90 days) MO 1 GC PA QL(135 per 90 days) MO 2 MO 1 GC MO 1 GC 1 GC MO 1 GC MO 1 GC 1 GC MO 1 GC MO 2 MO 4 PA MO 1 GC MO 1 GC 3 MO 1 GC MO 2 MO 2 MO Drug Name ursodiol caps ursodiol tabs ZENPEP Drug Tier Notes 1 GC MO 1 GC 2 MO ULCER THERAPY CARAFATE SUSP famotidine inj famotidine premixed famotidine tabs 20mg, 40mg lansoprazole 2 1 1 1 1 misoprostol NEXIUM 1 2 NEXIUM I.V. INJ 20MG NEXIUM I.V. INJ 40MG nizatidine omeprazole cpdr 40mg 2 2 1 1 omeprazole cpdr 10mg, 20mg 1 PEPCID SUSR PREVPAC PYLERA ranitidine hcl caps ranitidine hcl syrp ranitidine hcl tabs sucralfate ZANTAC INJ 50MG/50ML; 0.45% 2 3 2 1 1 1 1 2 MO GC MO GC GC MO GC QL(180 per 90 days) MO GC MO QL(90 per 90 days) MO MO GC MO GC QL(90 per 90 days) MO GC QL(180 per 90 days) MO MO MO MO GC MO GC MO GC MO GC MO MO IMMUNOLOGY, VACCINES / BIOTECHNOLOGY BIOTECHNOLOGY DRUGS ACTIMMUNE ARANESP INJ 500MCG/ML 4 2 ARANESP INJ 150MCG/0.3ML 2 LA PA MO PA QL(3 per 90 days) MO PA QL(3.6 per 90 days) MO 23 Drug Drug Name Tier Notes ARANESP INJ 200MCG/0.4ML 2 PA QL(4.8 per 90 days) MO ARANESP INJ 100MCG/0.5ML 2 PA QL(6 per 90 days) MO ARANESP INJ 300MCG/0.6ML, 2 PA QL(7.2 60MCG/0.3ML per 90 days) MO ARANESP INJ 40MCG/0.4ML 2 PA QL(9.6 per 90 days) MO ARANESP INJ 25MCG/0.42ML 2 PA QL(10.08 per 90 days) MO ARANESP INJ 100MCG/ML, 2 PA QL(12 200MCG/ML, 300MCG/ML per 90 days) MO ARANESP INJ 25MCG/ML, 2 PA QL(24 40MCG/ML, 60MCG/ML per 90 days) MO ARCALYST 4 LA MO AVONEX 4 PA QL(12 per 90 days) MO BETASERON 4 PA QL(45 per 90 days) MO EPOGEN INJ 20000UNIT/ML 4 PA QL(36 per 90 days) MO EPOGEN INJ 40000UNIT/ML 3 PA QL(12 per 90 days) EPOGEN INJ 2000UNIT/ML, 3 PA QL(36 3000UNIT/ML, 4000UNIT/ML per 90 days) MO EPOGEN INJ 10000UNIT/ML 3 PA QL(72 per 90 days) MO INTRON-A INJ 3MU/0.2ML 2 PA MO INTRON-A INJ 10MU/0.2ML, 4 PA MO 5MU/0.2ML, 6000000UNIT/ML INTRON-A WITH DILUENT 4 PA MO INJ 10MU LEUKINE 4 PA MO Drug Name MOZOBIL NEULASTA NEUMEGA NEUPOGEN INJ 300MCG/0.5ML NEUPOGEN INJ 480MCG/0.8ML NEUPOGEN INJ 480MCG/1.6ML NORDITROPIN CARTRIDGE NORDITROPIN NORDIFLEX PEN omnitrope inj 5mg/1.5ml PEG-INTRON INJ 50MCG/0.5ML Drug Tier Notes 4 QL(4.8 per 90 days) MO 3 PA QL(3.6 per 90 days) MO 4 PA QL(63 per 90 days) MO 4 PA QL(21 per 90 days) MO 4 PA QL(33.6 per 90 days) MO 4 PA QL(67.2 per 90 days) MO 4 PA MO 4 PA MO 1 4 PEG-INTRON REDIPEN 4 PEGASYS INJ 180MCG/0.5ML 4 PROCRIT INJ 40000UNIT/ML 2 PROCRIT INJ 10000UNIT/ML, 20000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML PROLEUKIN REBIF 2 REBIF TITRATION PACK TEV-TROPIN 4 4 4 4 GC PA MO PA QL(12 per 90 days) MO PA QL(12 per 90 days) MO PA QL(6 per 90 days) MO PA QL(18 per 90 days) MO PA QL(36 per 90 days) MO MO PA QL(18 per 90 days) MO PA MO PA MO VACCINES / MISCELLANEOUS IMMUNOLOGICALS ACTHIB ADACEL 2 2 MO 24 Drug Drug Name Tier Notes ATTENUVAX 2 MO BOOSTRIX 2 MO CERVARIX 2 PA COMVAX 2 PA MO DAPTACEL 2 MO DECAVAC 2 MO DIPHTHERIA/TETANUS 2 TOXOID PEDIATRIC ENGERIX-B 2 PA GARDASIL 2 PA MO HAVRIX INJ 720ELU/0.5ML 2 HAVRIX INJ 1440ELU/ML 2 MO IMOVAX RABIES (H.D.C.V.) 2 INFANRIX 2 MO IPOL INACTIVATED IPV 2 MO IXIARO 2 JE-VAX 2 MO M-M-R II W/DILUENT 10 2 MO DOSE MENACTRA 2 MENOMUNE-A/C/Y/W-135 2 MO MERUVAX II W/DILUENT 10 2 MO DOSE PEDIARIX 2 PA PEDVAX HIB 2 MO PRIVIGEN 4 PA MO PROQUAD 2 RABAVERT 2 MO RECOMBIVAX HB 2 PA ROTATEQ 2 TETANUS / DIPHTHERIA 2 MO TOXOIDS-ADSORBED ADULT TETANUS TOXOID 2 ADSORBED THYMOGLOBULIN 2 PA TRIHIBIT 2 TRIPEDIA 2 TWINRIX 2 PA MO TYPHIM VI 2 VAQTA 2 MO VARIVAX 2 VIVAGLOBIN 4 PA MO YF-VAX 2 Drug Name ZOSTAVAX Drug Tier 2 Notes PA 1 2 1 1 2 GC MO MO GC MO GC MO MO ACTONEL TABS 150MG, 35MG, 5MG alendronate sodium tabs 10mg, 35mg, 5mg, 70mg BONIVA TABS EVISTA 3 ST MO 1 GC MO 2 2 FORTEO 4 MO QL(90 per 90 days) MO QL(7.2 per 90 days) MO MUSCULOSKELETAL / RHEUMATOLOGY GOUT THERAPY allopurinol COLCRYS probenecid probenecid /colchicine ULORIC OSTEOPOROSIS THERAPY OTHER RHEUMATOLOGICALS CUPRIMINE DEPEN TITRATABS ENBREL 2 2 4 HUMIRA INJ 20MG/0.4ML 4 HUMIRA INJ 40MG/0.8ML 4 HUMIRA PEN-CROHNS DISEASE STARTER leflunomide 4 1 RIDAURA SAVELLA 3 2 SAVELLA TITRATION PACK 2 MO MO PA QL(600 per 90 days) MO PA QL(2.4 per 90 days) MO PA QL(4.8 per 90 days) MO PA MO GC QL(90 per 90 days) MO MO QL(180 per 90 days) MO MO OBSTETRICS / GYNECOLOGY ESTROGENS / PROGESTINS 25 Drug Drug Name Tier Notes ALORA 2 MO camila 1 GC MO CLIMARA PRO 2 MO COMBIPATCH 2 MO CRINONE 2 PA MO DEPO-PROVERA 2 MO DEPO-SUBQ PROVERA 104 3 MO DIVIGEL 2 MO errin 1 GC MO ESTRADERM 2 MO estradiol / norethindrone acetate 1 GC MO estradiol ptwk 1 GC estradiol tabs 1 GC MO ESTRING 3 MO estropipate 1 GC MO FEMHRT 1/5 3 MO FEMHRT LOW DOSE 3 MO GYNODIOL 3 jolivette 1 GC MO medroxyprogesterone acetate 1 GC MO MENEST 3 MO MENOSTAR 3 MO nora-be 1 GC MO norethindrone tabs 5mg 1 GC MO ortho-est 1 GC PREFEST 3 MO PREMARIN TABS 2 MO PREMARIN W/APPLICATOR 2 MO PREMPHASE 2 MO PREMPRO 2 MO PROMETRIUM 2 MO VAGIFEM 2 MO VIVELLE-DOT 2 MO MISCELLANEOUS OB/GYN CLEOCIN SUPP clindamycin phosphate crea GYNAZOLE-1 metronidazole vaginal miconazole 3 NUVARING ORTHO EVRA terconazole 2 1 2 1 1 3 3 1 MO GC MO GC MO GC MO MO MO GC MO Drug Name vandazole zazole crea 0.4% zazole supp Drug Tier Notes 1 GC MO 1 GC MO 1 GC Drug Name sprintec 28 sronyx tri-legest fe tri-previfem tri-sprintec trinessa trivora-28 velivet zovia 1/35e zovia 1/50e ORAL CONTRACEPTIVES / RELATED AGENTS apri aranelle aviane balziva cesia cryselle-28 enpresse-28 junel junel fe 1.5/30 junel fe 1/20 kariva kelnor 1/35 leena lessina-28 levora low-ogestrel lutera microgestin 1.5/30 microgestin 1/20 microgestin fe microgestin fe 1.5/30 mononessa necon 0.5/35-28 necon 1/35-28 necon 10/11-28 necon 7/7/7 next choice nortrel 0.5/35 (28) nortrel 1/35 (21) nortrel 1/35 (28) nortrel 7/7/7 ogestrel portia-28 previfem quasense reclipsen solia 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 GC MO GC GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO Drug Tier 1 1 1 1 1 1 1 1 1 1 Notes GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO GC MO OXYTOCICS METHERGINE TABS 2 OPHTHALMOLOGY ANTIBIOTICS ak-tob AZASITE bacitracin / polymyxin b bacitracin ophthalmic oint CILOXAN OINT ciprofloxacin ophthalmic soln erythromycin oint gentak gentamicin sulfate ophthalmic soln gentasol NATACYN neomycin /bacitracin /polymyxin neomycin /polymyxin /gramicidin ofloxacin polycin b romycin tobramycin ophthalmic soln tobrasol TOBREX OINT trimethoprim sulfate/polymyxin b sulfate VIGAMOX ZYMAR 1 2 1 1 2 1 1 1 1 GC MO GC MO GC MO MO GC MO GC MO GC MO GC MO 1 2 1 1 1 1 1 1 1 2 1 GC MO MO GC MO GC MO GC MO GC GC MO GC MO GC MO GC MO 2 2 MO MO 1 3 GC MO MO ANTIVIRALS trifluridine ZIRGAN BETA-BLOCKERS 26 Drug Name betaxolol hcl ophthalmic soln carteolol hcl ISTALOL levobunolol hcl metipranolol timolol maleate timolol maleate ophthalmic gel forming TIMOPTIC OCUDOSE Drug Tier 1 1 2 1 1 1 1 Notes GC MO GC MO MO GC MO GC MO GC MO GC MO 2 MO Drug Name dorzolamide hcl/timolol maleate TRAVATAN Z XALATAN STEROID-ANTIBIOTIC COMBINATIONS neomycin /polymyxin /bacitracin /hydrocortisone neomycin /polymyxin /dexamethasone neomycin /polymyxin /hydrocortisone ophthalmic susp poly-dex oint poly-dex susp tobramycin /dexamethasone ZYLET CYCLOPLEGIC MYDRIATICS mydral ophthalmic soln 1% mydral ophthalmic soln 0.5% tropicamide 1 1 1 GC GC MO GC MO 2 MO DIRECT ACTING MIOTICS PILOPINE HS MISCELLANEOUS OPHTHALMOLOGICS ALOCRIL azelastine hcl ophthalmic soln cromolyn sodium ophthalmic soln LACRISERT parcaine PATADAY PATANOL proparacaine hcl RESTASIS 3 1 1 2 1 2 2 1 2 MO GC GC MO MO GC MO MO MO GC MO MO 2 1 1 1 MO GC MO GC MO GC MO 2 2 MO MO 1 1 1 2 2 1 1 GC MO 1 GC MO 1 1 1 2 GC MO GC GC MO MO sulfacetamide sodium / prednisolone sodium phospha 1 GC MO 2 1 1 2 2 2 1 1 MO GC MO GC MO MO MO MO GC MO GC MO 2 1 MO GC MO 2 1 1 MO GC MO GC MO 3 MO SULFONAMIDES BLEPH-10 sodium sulfacetamide SYMPATHOMIMETICS ALPHAGAN P apraclonidine brimonidine tartrate ophthalmic soln 0.2% IOPIDINE GC MO GC GC MO VASOCONSTRICTOR DECONGESTANTS ak-con naphazoline hcl OTHER GLAUCOMA DRUGS AZOPT COMBIGAN dorzolamide hcl GC MO STEROID-SULFONAMIDE COMBINATIONS ALREX dexamethasone ophthalmic soln fluorometholone FML FML FORTE LOTEMAX prednisolone acetate prednisolone sodium phosphate ophthalmic soln ORAL DRUGS FOR GLAUCOMA acetazolamide acetazolamide sodium methazolamide 1 STEROIDS NON-STEROIDAL ANTIINFLAMMATORY AGENTS ACUVAIL diclofenac sodium flurbiprofen sodium ketorolac tromethamine ophthalmic soln NEVANAC XIBROM Drug Tier Notes 1 GC MO 2 MO 2 MO MO MO GC MO 1 1 GC MO GC RESPIRATORY AND ALLERGY ANTIHISTAMINE / ANTIALLERGENIC AGENTS 27 Drug Name carbinoxamine maleate cetirizine hcl syrp CLARINEX REDITABS Drug Tier Notes 1 GC MO 1 GC MO 2 QL(90 per 90 days) MO CLARINEX SYRP 2 MO CLARINEX TABS 2 QL(90 per 90 days) MO CLARINEX-D 12 HOUR 2 QL(180 per 90 days) MO CLARINEX-D 24 HOUR 2 QL(90 per 90 days) MO clemastine fumarate syrp 1 GC MO clemastine fumarate tabs 2.68mg 1 GC MO diphenhydramine hcl caps 50mg 1 GC MO diphenhydramine hcl inj 1 GC MO epinephrine hcl inj 0.1mg/ml 1 GC EPIPEN 2 MO EPIPEN-JR 2 MO fexofenadine hcl tabs 180mg 1 GC QL(90 per 90 days) MO fexofenadine hcl tabs 30mg, 60mg 1 GC QL(180 per 90 days) MO hydroxyzine hcl inj 25mg/ml 1 GC hydroxyzine hcl inj 50mg/ml 1 GC MO hydroxyzine hcl syrp 1 GC PA MO hydroxyzine hcl tabs 1 GC PA MO palgic liqd 1 GC MO phenadoz 1 GC promethazine hcl inj 25mg/ml 1 GC promethazine hcl inj 50mg/ml 1 GC MO promethazine hcl supp 1 GC MO promethazine hcl syrp 1 GC PA MO promethazine hcl tabs 1 GC PA MO promethegan supp 25mg 1 GC promethegan supp 50mg 1 GC MO TWINJECT 2 MO Drug Name ACCOLATE PULMONARY AGENTS ipratropium bromide inhalation soln 28 acetylcysteine ADVAIR DISKUS ADVAIR HFA albuterol sulfate er albuterol sulfate nebu albuterol sulfate syrp albuterol sulfate tabs aminophylline inj aminophylline tabs ASMANEX 120 METERED DOSES ASMANEX 14 METERED DOSES ASMANEX 30 METERED DOSES ASMANEX 60 METERED DOSES ATROVENT HFA budesonide COMBIVENT cromolyn sodium nebu ELIXOPHYLLIN FLOVENT DISKUS FLOVENT HFA flunisolide nasal soln 0.025% fluticasone propionate FORADIL AEROLIZER Drug Tier Notes 3 QL(180 per 90 days) MO 1 GC PA MO 2 QL(180 per 90 days) MO 2 QL(36 per 90 days) MO 1 GC MO 1 GC PA MO 1 GC MO 1 GC MO 1 GC 1 GC MO 2 QL(3 per 90 days) MO 2 QL(3 per 90 days) 2 QL(3 per 90 days) MO 2 QL(3 per 90 days) MO 2 QL(77.4 per 90 days) MO 1 GC PA MO 2 QL(88.2 per 90 days) MO 1 GC PA MO 3 MO 2 QL(180 per 90 days) MO 2 QL(72 per 90 days) MO 1 GC MO 1 GC MO 2 QL(180 per 90 days) MO 1 GC PA MO Drug Name ipratropium bromide/albuterol sulfate LETAIRIS metaproterenol sulfate NASONEX PERFOROMIST PROAIR HFA PULMICORT SUSP 1MG/2ML PULMOZYME REVATIO TABS SEREVENT DISKUS Drug Tier Notes 1 GC PA MO 4 1 2 2 2 2 4 4 2 SINGULAIR 2 SPIRIVA HANDIHALER 2 SYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT SYMBICORT AERO 160MCG/ACT; 4.5MCG/ACT 2 terbutaline sulfate THEO-24 theochron theophylline er TRACLEER 1 3 1 1 4 2 VENTOLIN HFA 2 VERAMYST ZYFLO CR 2 3 Drug Name LA PA QL(90 per 90 days) MO GC MO MO PA MO QL(51 per 90 days) MO PA MO PA MO PA QL(270 per 90 days) MO QL(180 per 90 days) MO QL(90 per 90 days) MO QL(90 per 90 days) MO QL(30.6 per 90 days) QL(30.6 per 90 days) MO GC MO MO GC MO GC MO LA PA QL(180 per 90 days) MO QL(108 per 90 days) MO MO QL(360 per 90 days) MO 29 Notes ANTICHOLINERGICS / ANTISPASMODICS DETROL 2 DETROL LA 2 ENABLEX 2 flavoxate hcl oxybutynin oxybutynin er tb24 5mg 1 1 1 oxybutynin er tb24 10mg, 15mg 1 OXYTROL 2 QL(180 per 90 days) MO QL(90 per 90 days) MO QL(90 per 90 days) MO GC MO GC MO GC QL(90 per 90 days) MO GC QL(180 per 90 days) MO QL(32 per 90 days) MO BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY AVODART 2 finasteride 1 tamsulosin hcl 1 UROXATRAL 2 QL(90 per 90 days) MO GC QL(90 per 90 days) MO GC QL(180 per 90 days) MO QL(90 per 90 days) MO CHOLINERGIC STIMULANTS bethanechol chloride 1 GC MO MISCELLANEOUS UROLOGICALS CYSTAGON ELMIRON potassium citrate extendedrelease 2 2 1 VITAMINS, HEMATINICS / ELECTROLYTES ELECTROLYTES UROLOGICALS Drug Tier LA MO GC MO Drug Drug Name Tier calcium acetate 1 eliphos 1 K-TABS 3 KAON-CL-10 3 kcl 0.075%/d5w/nacl 0.45% 1 kcl 0.15%/d5w/lr 1 KCL 0.15%/D5W/NACL 0.2% 2 KCL 0.15%/D5W/NACL 0.225% 2 kcl 0.15%/d5w/nacl 0.9% 1 kcl 0.3%/d5w/lr iv lac ring 1 KCL 0.3%/D5W/NACL 0.2% 2 kcl 0.3%/d5w/nacl 0.45% 1 kcl 0.3%/d5w/nacl 0.9% 1 klor-con 10 1 klor-con 8 1 KLOR-CON M15 3 klor-con m20 1 LACTATED RINGERS 2 MAGNESIUM SULFATE IN 2 D5W INJ 5%; 10MG/ML MAGNESIUM SULFATE INJ 2 NORMOSOL 2 POTASSIUM CHLORIDE 2 0.075%/D5W/NACL 0.225% POTASSIUM CHLORIDE 0.15% 2 /NACL 0.45% VIAFLEX potassium chloride 0.15% 1 d5w/nacl 0.33% potassium chloride 0.15% 1 d5w/nacl 0.45% viaflex potassium chloride 0.15% nacl 1 0.9% POTASSIUM CHLORIDE 2 0.15%/D5W POTASSIUM CHLORIDE 0.22% 2 D5W/NACL 0.45% potassium chloride 0.224%/d5w 1 POTASSIUM CHLORIDE 0.3%/ 2 NACL 0.9% potassium chloride 0.3%/d5w 1 potassium chloride cr 1 potassium chloride er cpcr 1 potassium chloride er tbcr 20meq 1 Drug Name potassium chloride inj 10meq/100ml, 10meq/50ml, 2meq/ml POTASSIUM CHLORIDE INJ 0.4MEQ/ML, 30MEQ/100ML potassium chloride sr ringers injection sodium bicarbonate inj 7.5%, 8.4% sodium chloride 0.45% viaflex sodium chloride inj 3%, 5% sodium chloride inj 2.5meq/ml Notes GC GC MO MO MO GC GC GC GC GC GC GC MO GC MO MO GC MO MO Drug Tier 1 Notes GC 2 1 1 1 GC GC GC 1 1 1 GC MO GC GC MO MISCELLANEOUS NUTRITION PRODUCTS AMINOSYN AMINOSYN II AMINOSYN II M AMINOSYN-HBC AMINOSYN-HF AMINOSYN-PF AMINOSYN-PF 7% CLINIMIX / DEXTROSE CLINISOL SF DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX FREAMINE HBC FREAMINE III HEPATAMINE HEPATASOL INTRALIPID INJ 1.7%; 30% intralipid inj 2.25%; 20% IONOSOL ISOLYTE KCL 0.15%/D10W/NACL 0.2% LIPOSYN III INJ 1.8%; 2.5%; 30% NEPHRAMINE NORMOSOL novamine PLASMA-LYTE PREMASOL INJ premasol inj RENAMIN TRAVASOL GC GC MO GC GC GC GC GC MO GC MO 30 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2 2 1 2 2 1 2 2 MO GC GC GC Drug Name TROPHAMINE Drug Tier 2 Notes 1 1 GC GC VITAMINS / HEMATINICS prenatabs obn sodium fluoride tabs 31 Index of Drugs alclometasone dipropionate.................................17 alcohol 5%/dextrose 5% ......................................18 ALCOHOL PREPS..............................................19 ALDURAZYME..................................................21 alendronate sodium........................................18, 25 ALIMTA ................................................................4 ALINIA..................................................................2 ALKERAN ............................................................4 allopurinol............................................................25 ALOCRIL ............................................................27 ALORA................................................................25 ALPHAGAN P ....................................................27 ALREX ................................................................27 ALTABAX ..........................................................17 amantadine.............................................................1 amcinonide...........................................................17 a-methapred .........................................................19 amifostine...............................................................4 amikacin sulfate .....................................................2 amiloride ..............................................................12 amiloride / hydrochlorothiazide ..........................12 aminophylline.......................................................28 AMINOSYN ........................................................30 AMINOSYN II ....................................................30 AMINOSYN II M................................................30 AMINOSYN-HBC ..............................................30 AMINOSYN-HF..................................................30 AMINOSYN-PF ..................................................30 AMINOSYN-PF 7%............................................30 amiodarone ..........................................................12 AMITIZA.............................................................22 amitriptyline.........................................................10 amlodipine / benazepril........................................12 amlodipine besylate .............................................12 ammonium lactate................................................16 amnesteem............................................................16 amoxapine ............................................................10 amoxicillin..............................................................3 amoxicillin/clavulanate potassium.........................3 amoxicillin/clavulanate potassium er ....................3 amoxicillin/potassium clavulanate.........................3 amphetamine /dextroamphetamine ......................10 8 8-MOP................................................................. 16 A ABILIFY ............................................................. 10 ABILIFY DISCMELT ........................................ 10 ABRAXANE......................................................... 4 acarbose .............................................................. 19 ACCOLATE........................................................ 28 acebutolol ............................................................ 12 acetaminophen / codeine....................................... 8 acetaminophen/codeine #3.................................... 8 acetaminophen/codeine #4.................................... 8 acetasol hc........................................................... 19 acetazolamide...................................................... 27 acetazolamide sodium ......................................... 27 acetic acid ........................................................... 19 acetic acid / hydrocortisone ................................ 19 acetylcysteine ...................................................... 28 ACTHIB .............................................................. 24 acticin .................................................................. 18 ACTIMMUNE .................................................... 23 ACTONEL .................................................... 18, 25 ACTOPLUS MET............................................... 19 ACTOS................................................................ 19 ACUVAIL........................................................... 27 acyclovir ................................................................ 1 ADACEL............................................................. 24 ADAGEN ............................................................ 18 adriamycin............................................................. 4 ADVAIR DISKUS.............................................. 28 ADVAIR HFA .................................................... 28 afeditab cr ........................................................... 12 AFINITOR ............................................................ 4 AGGRENOX ...................................................... 15 a-hydrocort.......................................................... 19 ak-con .................................................................. 27 ak-tob................................................................... 26 ala cort ................................................................ 17 ALBENZA ............................................................ 2 albuterol sulfate................................................... 28 albuterol sulfate er .............................................. 28 32 amphotericin b....................................................... 1 ampicillin............................................................... 3 ampicillin-sulbactam............................................. 3 ANADROL-50 .................................................... 21 anagrelide hydrochloride.................................... 18 ANCOBON ........................................................... 1 ANDROGEL....................................................... 21 ANTABUSE........................................................ 18 APOKYN .............................................................. 7 apraclonidine ...................................................... 27 apri ...................................................................... 26 APTIVUS .............................................................. 1 aranelle................................................................ 26 ARANESP........................................................... 23 ARCALYST........................................................ 23 ARICEPT .............................................................. 8 ARICEPT ODT ..................................................... 8 ARIMIDEX........................................................... 4 ARIXTRA ........................................................... 15 AROMASIN.......................................................... 4 ARRANON ........................................................... 4 ARTHROTEC 50.................................................. 9 ARTHROTEC 75.................................................. 9 ARZERRA ............................................................ 5 ASACOL............................................................. 22 ASACOL HD ...................................................... 22 ascomp/codeine ..................................................... 8 ASMANEX 120 METERED DOSES ................ 28 ASMANEX 14 METERED DOSES................... 28 ASMANEX 30 METERED DOSES................... 28 ASMANEX 60 METERED DOSES................... 28 ASTELIN ............................................................ 18 ASTEPRO ........................................................... 18 atenolol................................................................ 12 atenolol / chlorthalidone ..................................... 12 ATRIPLA .............................................................. 1 atropine sulfate.................................................... 22 ATROVENT HFA .............................................. 28 ATTENUVAX .................................................... 24 augmented betamethasone dipropionate............. 17 AVANDAMET ................................................... 19 AVANDARYL.................................................... 19 AVANDIA .......................................................... 19 AVASTIN ..............................................................5 AVELOX ...............................................................4 AVELOX ABC PACK ..........................................4 aviane...................................................................26 avita......................................................................16 AVODART ..........................................................29 AVONEX.............................................................23 AZACTAM............................................................2 AZACTAM IN DEXTROSE.................................2 AZACTAM IN ISO-OSMOTIC DEXTROSE......2 AZASITE.............................................................26 azathioprine ...........................................................5 azathioprine sodium...............................................5 azelastine hcl..................................................18, 27 AZELEX ..............................................................16 AZILECT...............................................................7 azithromycin...........................................................2 AZOPT.................................................................27 B bacitracin .............................................................26 bacitracin / polymyxin b.......................................26 baclofen..................................................................8 BACTROBAN.....................................................17 BACTROBAN NASAL.......................................18 balacet 325.............................................................9 balsalazide ...........................................................22 balziva ..................................................................26 BANZEL................................................................6 BARACLUDE .......................................................1 BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2 ...................20 BD INSULIN SYRINGE ULTRAFINE/0.3ML/31G X 5/16 ...................20 BD INSULIN SYRINGE ULTRAFINE/0.5ML/30G X 1/2 .....................20 BD INSULIN SYRINGE ULTRAFINE/1ML/31G X 5/16...............................................................20 BD PEN NEEDLE/ULTRAFINE/29G X 12.7MM ..........................................................................20 benazepril.............................................................12 benazepril / hydrochlorothiazide ...................12, 13 benztropine mesylate..............................................7 33 betamethasone dipropionate ............................... 17 betamethasone valerate....................................... 17 BETASERON ..................................................... 23 beta-val................................................................ 17 betaxolol hcl .................................................. 13, 27 bethanechol chloride ........................................... 29 bicalutamide .......................................................... 5 BICILLIN C-R ...................................................... 3 BICILLIN L-A ...................................................... 3 BICNU .................................................................. 5 BIDIL .................................................................. 13 BILTRICIDE......................................................... 2 bisoprolol fumarate............................................. 13 bisoprolol fumarate / hydrochlorothiazide ......... 13 bleomycin sulfate................................................... 5 BLEPH-10........................................................... 27 BONIVA ............................................................. 25 BOOSTRIX......................................................... 24 borofair................................................................ 19 brimonidine tartrate ............................................ 27 bromocriptine mesylate ......................................... 7 budeprion sr ........................................................ 10 budeprion xl......................................................... 10 budesonide........................................................... 28 bumetanide .......................................................... 13 BUPHENYL........................................................ 18 BUPRENEX.......................................................... 8 buprenorphine hcl ................................................. 8 buproban ............................................................. 18 bupropion hcl ...................................................... 10 bupropion hcl sr .................................................. 10 buspirone hcl ....................................................... 10 BUSULFEX .......................................................... 5 butorphanol tartrate.............................................. 9 BYETTA ............................................................. 20 BYSTOLIC ......................................................... 13 calcium acetate ....................................................30 camila...................................................................25 CAMPATH ............................................................5 CAMPRAL ..........................................................18 CANASA .............................................................22 CAPASTAT SULFATE ........................................2 CAPEX ................................................................17 captopril...............................................................13 captopril / hydrochlorothiazide ...........................13 CARAC................................................................16 CARAFATE ........................................................23 carbamazepine .......................................................6 carbamazepine er...................................................6 CARBATROL .......................................................6 carbidopa / levodopa .............................................7 carbidopa/levodopa cr ...........................................7 carbidopa/levodopa odt .........................................7 carbidopa/levodopa sr ...........................................7 carbinoxamine maleate........................................28 carboplatin.............................................................5 carisoprodol...........................................................8 carisoprodol /aspirin .............................................8 CARMOL-HC......................................................16 carteolol hcl .........................................................27 cartia xt ................................................................13 carvedilol .............................................................13 CEENU ..................................................................5 cefaclor ..................................................................2 cefadroxil ...............................................................2 cefazolin .................................................................2 cefdinir ...................................................................2 cefepime .................................................................2 cefotaxime sodium..................................................2 cefoxitin sodium .....................................................2 cefpodoxime proxetil..............................................2 ceftriaxone sodium .................................................2 CEFTRIAXONE/DEXTROSE..............................2 cefuroxime axetil....................................................2 cefuroxime sodium .................................................2 CEFUROXIME/DEXTROSE................................2 CELEBREX...........................................................9 CELLCEPT............................................................5 CELLCEPT INTRAVENOUS ..............................5 C cabergoline.......................................................... 21 CADUET............................................................. 15 calcipotriene........................................................ 16 calcitonin-salmon ................................................ 21 calcitriol .............................................................. 21 34 CELONTIN........................................................... 6 cephalexin.............................................................. 2 CEREZYME ....................................................... 21 CERVARIX ........................................................ 24 cesia..................................................................... 26 cetirizine hcl ........................................................ 28 CHANTIX........................................................... 18 CHEMET ............................................................ 18 chlordiazepoxide /amitriptyline........................... 10 chlorhexidine gluconate oral rinse ..................... 18 chloroquine............................................................ 2 chlorothiazide...................................................... 13 chlorothiazide sodium ......................................... 13 chlorpromazine.................................................... 10 chlorthalidone ..................................................... 13 chlorzoxazone........................................................ 8 cholestyramine light ............................................ 15 ciclopirox............................................................. 17 ciclopirox nail lacquer ........................................ 17 ciclopirox olamine............................................... 17 cilostazol.............................................................. 15 CILOXAN........................................................... 26 CIPRO HC........................................................... 19 CIPRO I.V.-IN D5W............................................. 4 CIPRODEX......................................................... 19 ciprofloxacin.................................................... 4, 26 cisplatin ................................................................. 5 citalopram ........................................................... 10 cladribine .............................................................. 5 claravis ................................................................ 16 CLARINEX......................................................... 28 CLARINEX REDITABS .................................... 28 CLARINEX-D 12 HOUR ................................... 28 CLARINEX-D 24 HOUR ................................... 28 clarithromycin ....................................................... 2 clarithromycin er................................................... 2 clemastine fumarate ............................................ 28 CLEOCIN............................................................ 25 CLEOCIN GALAXY............................................ 3 CLEOCIN PEDIATRIC GRANULES ................. 3 CLIMARA PRO.................................................. 25 clindamycin hcl ..................................................... 3 clindamycin phosphate.................................. 16, 25 clindamycin phosphate add-vantage......................3 clindamycin/benzoyl peroxide..............................16 CLINIMIX / DEXTROSE .............................18, 30 CLINISOL SF......................................................30 clobetasol propionate...........................................17 clobetasol propionate e........................................17 CLOBEX..............................................................17 CLOLAR................................................................5 clomipramine .......................................................10 clonidine...............................................................13 clotrimazole......................................................1, 17 clotrimazole / betamethasone ..............................17 clozapine ..............................................................10 COARTEM ............................................................3 codeine sulfate .......................................................8 COLCRYS ...........................................................25 COLESTID ..........................................................15 colestipol ..............................................................15 colistimethate sodium.............................................3 COLY-MYCIN S.................................................19 COMBIGAN........................................................27 COMBIPATCH ...................................................25 COMBIVENT......................................................28 COMBIVIR............................................................1 compro .................................................................22 COMTAN ..............................................................7 COMVAX............................................................24 CONDYLOX .......................................................16 constulose.............................................................22 COPAXONE..........................................................8 CORDRAN TAPE ...............................................17 COREG CR..........................................................13 cortisone acetate ..................................................19 CORTISPORIN-TC.............................................19 cortomycin............................................................19 COSMEGEN..........................................................5 CREON ................................................................22 CRESTOR............................................................15 CRINONE............................................................25 CRIXIVAN ............................................................1 cromolyn sodium............................................27, 28 cryselle-28............................................................26 CUBICIN ...............................................................3 35 CUPRIMINE....................................................... 25 CURITY GAUZE PADS 2 ................................. 20 cyclobenzaprine hcl............................................... 8 cyclophosphamide ................................................. 5 cyclosporine .......................................................... 5 CYKLOKAPRON............................................... 15 CYMBALTA ...................................................... 10 CYSTADANE..................................................... 22 CYSTAGON ....................................................... 29 cytarabine.............................................................. 5 CYTARABINE AQUEOUS ................................. 5 DEXTROSE 10%/NACL 0.45% ........................18 DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX ........................................................30 dextrose 10% flex container.................................18 DEXTROSE 10%/NACL 0.2% ...........................18 dextrose 2.5%/sodium chloride 0.45% ................18 dextrose 5%..........................................................18 dextrose 5%/nacl 0.2% ........................................18 dextrose 5%/nacl 0.225% ....................................18 DEXTROSE 5%/NACL 0.33% ...........................18 dextrose 5%/nacl 0.45% ......................................18 dextrose 5%/nacl 0.9% ........................................18 DIBENZYLINE...................................................13 diclofenac potassium..............................................9 diclofenac sodium ............................................9, 27 diclofenac sodium ec..............................................9 diclofenac sodium xr ..............................................9 dicloxacillin sodium ...............................................3 dicyclomine hcl ....................................................22 didanosine ..............................................................1 diflorasone diacetate............................................17 DIFLUCAN IN NACL ..........................................1 diflunisal ................................................................9 digoxin..................................................................15 dihydroergotamine mesylate..................................7 DILANTIN INFATABS........................................6 DILAUDID ............................................................8 DILAUDID-5.........................................................8 DILAUDID-HP......................................................8 dilt-cd ...................................................................13 diltiazem cd ..........................................................13 diltiazem hcl .........................................................13 diltiazem hcl er.....................................................13 dilt-xr....................................................................13 diltzac...................................................................13 DIOVAN..............................................................13 DIOVAN HCT.....................................................13 DIPENTUM.........................................................22 diphenhydramine hcl............................................28 diphenoxylate / atropine ......................................22 DIPHTHERIA/TETANUS TOXOID PEDIATRIC ..........................................................................24 dipyridamole ........................................................15 D dacarbazine ........................................................... 5 danazol ................................................................ 21 dantrolene sodium ................................................. 8 DAPSONE ............................................................ 3 DAPTACEL........................................................ 24 DARAPRIM.......................................................... 3 DAUNORUBICIN HCL....................................... 5 DECAVAC.......................................................... 24 demeclocycline hcl ................................................ 4 DEMSER............................................................. 13 DENAVIR........................................................... 17 depade ................................................................... 9 DEPEN TITRATABS ......................................... 25 DEPO-MEDROL ................................................ 19 DEPO-PROVERA .............................................. 25 DEPO-SUBQ PROVERA 104............................ 25 DERMA-SMOOTHE / FS BODY OIL .............. 17 DERMOTIC ........................................................ 19 desipramine ......................................................... 10 desmopressin acetate........................................... 21 desonide............................................................... 17 desoximetasone.................................................... 17 DETROL ............................................................. 29 DETROL LA....................................................... 29 dexamethasone .............................................. 19, 27 DEXAMETHASONE INTENSOL .................... 19 dexmethylphenidate............................................. 10 dexrazoxane........................................................... 4 dextroamphetamine sulfate ................................. 10 dextroamphetamine sulfate er ............................. 10 36 disopyramide phosphate...................................... 12 divalproex sodium ............................................. 6, 7 divalproex sodium er............................................. 6 DIVIGEL............................................................. 25 dorzolamide hcl ................................................... 27 dorzolamide hcl/timolol maleate......................... 27 doxazosin............................................................. 13 doxepin ................................................................ 10 DOXIL .................................................................. 5 doxorubicin hcl...................................................... 5 doxycycline hyclate ............................................... 4 doxycycline monohydrate...................................... 4 dronabinol ........................................................... 22 DROXIA ............................................................... 5 DUETACT .......................................................... 20 duramorph............................................................. 8 ENTOCORT EC ..................................................22 enulose .................................................................22 epinephrine hcl.....................................................28 EPIPEN ................................................................28 EPIPEN-JR ..........................................................28 epirubicin hcl .........................................................5 epitol ......................................................................7 EPIVIR...................................................................1 EPIVIR HBV .........................................................1 eplerenone............................................................13 EPOGEN..............................................................23 EPZICOM ..............................................................1 EQUETRO.............................................................7 ERAXIS .................................................................1 ERBITUX ..............................................................5 ergotamine tartrate / caffeine ................................7 errin......................................................................25 ery ........................................................................16 ERY-TAB ..............................................................2 ERYTHROCIN LACTOBIONATE......................2 erythrocin stearate .................................................2 erythromycin ..................................................16, 26 erythromycin / benzoyl peroxide..........................16 erythromycin / sulfisoxazole ..................................2 ERYTHROMYCIN BASE ....................................2 ESTRADERM .....................................................25 estradiol ...............................................................25 estradiol / norethindrone acetate.........................25 ESTRING.............................................................25 estropipate............................................................25 ethambutol..............................................................3 ethosuximide ..........................................................7 etidronate disodium .............................................18 etodolac..................................................................9 ETOPOPHOS ........................................................5 etoposide ................................................................5 EURAX................................................................18 EVISTA ...............................................................25 EVOXAC.............................................................18 EXELON................................................................8 EXFORGE ...........................................................13 EXFORGE HCT ..................................................13 EXJADE ..............................................................18 E e.e.s. 400................................................................ 2 E.E.S. GRANULES .............................................. 2 econazole nitrate ................................................. 17 EDECRIN............................................................ 13 EFFIENT............................................................. 15 ELIDEL............................................................... 16 eliphos ................................................................. 30 ELITEK................................................................. 4 ELIXOPHYLLIN................................................ 28 ELLENCE ............................................................. 5 ELMIRON........................................................... 29 ELOXATIN........................................................... 5 ELSPAR ................................................................ 5 EMBEDA .............................................................. 8 EMCYT................................................................. 5 EMEND............................................................... 22 EMSAM .............................................................. 10 EMTRIVA............................................................. 1 ENABLEX .......................................................... 29 enalapril .............................................................. 13 enalapril / hydrochlorothiazide........................... 13 ENBREL ............................................................. 25 endocet .................................................................. 8 ENGERIX-B ....................................................... 24 enpresse-28.......................................................... 26 37 fluphenazine .........................................................11 fluphenazine decanoate inj ..................................11 flurbiprofen ............................................................9 flurbiprofen sodium..............................................27 flutamide ................................................................5 fluticasone propionate ...................................17, 28 fluvoxamine ..........................................................11 FML .....................................................................27 FML FORTE........................................................27 FOCALIN XR......................................................11 FORADIL AEROLIZER .....................................28 FORTAZ ................................................................2 FORTEO ..............................................................25 fortical..................................................................21 foscarnet sodium ....................................................1 fosinopril ..............................................................13 fosinopril / hydrochlorothiazide ..........................13 FOSRENOL.........................................................18 FRAGMIN ...........................................................15 FREAMINE HBC................................................30 FREAMINE III ....................................................30 FURADANTIN......................................................4 furosemide............................................................13 FUZEON................................................................1 F FABRAZYME .................................................... 21 famciclovir............................................................. 1 famotidine............................................................ 23 famotidine premixed............................................ 23 FANAPT ............................................................. 10 FANAPT TITRATION PACK ........................... 10 FARESTON .......................................................... 5 FASLODEX .......................................................... 5 FAZACLO .......................................................... 10 FELBATOL .......................................................... 7 felodipine er......................................................... 13 FEMARA .............................................................. 5 FEMHRT 1/5....................................................... 25 FEMHRT LOW DOSE ....................................... 25 fenofibrate ........................................................... 15 fenofibrate micronized......................................... 15 fenoprofen calcium................................................ 9 fentanyl citrate....................................................... 8 fentanyl citrate oral transmucosal ........................ 8 fentanyl patches..................................................... 8 fexofenadine hcl................................................... 28 FINACEA............................................................ 16 finasteride............................................................ 29 FIRMAGON.......................................................... 5 flavoxate hcl ........................................................ 29 flecainide acetate................................................. 12 FLECTOR ............................................................. 9 FLOVENT DISKUS ........................................... 28 FLOVENT HFA.................................................. 28 fluconazole ............................................................ 1 fluconazole in dextrose.......................................... 1 fludarabine phosphate........................................... 5 fludrocortisone acetate........................................ 19 flunisolide............................................................ 28 fluocinolone acetonide ........................................ 17 fluocinonide......................................................... 17 fluocinonide emollient base................................. 17 fluorometholone .................................................. 27 FLUOROPLEX................................................... 16 fluorouracil...................................................... 5, 16 fluoxetine ....................................................... 10, 11 fluoxetine dr......................................................... 10 G gabapentin..............................................................7 GABITRIL.............................................................7 galantamine hydrobromide....................................8 ganciclovir .............................................................1 GARDASIL .........................................................24 GASTROCROM..................................................22 gavilyte-c..............................................................22 gavilyte-g..............................................................22 gavilyte-n/flavor pack ..........................................22 gemfibrozil ...........................................................15 GEMZAR...............................................................5 generlac................................................................22 gengraf ...................................................................5 gentak...................................................................26 gentamicin sulfate ......................................3, 17, 26 gentamicin sulfate/0.9% sodium chloride..............3 gentamicin sulfate/sodium chloride .......................3 38 gentasol ............................................................... 26 GEODON ............................................................ 11 GLEEVEC............................................................. 5 glimepiride .......................................................... 20 glipizide ............................................................... 20 glipizide / metformin............................................ 20 glipizide er........................................................... 20 glipizide xl ........................................................... 20 GLUCAGEN HYPOKIT .................................... 20 GLUCAGON EMERGENCY KIT..................... 20 glyburide.............................................................. 20 glyburide / metformin .......................................... 20 glyburide micronized........................................... 20 glycopyrrolate ..................................................... 22 glycron................................................................. 20 granisetron .......................................................... 22 griseofulvin microsize ........................................... 1 GRIS-PEG............................................................. 1 guanfacine hcl ..................................................... 13 GYNAZOLE-1.................................................... 25 GYNODIOL........................................................ 25 HUMALOG MIX 50/50 ......................................20 HUMALOG MIX 50/50 PEN..............................20 HUMALOG MIX 75/25 ......................................20 HUMALOG MIX 75/25 PEN..............................20 HUMALOG PEN.................................................20 HUMIRA .............................................................25 HUMIRA PEN-CROHNS DISEASE STARTER ..........................................................................25 HUMULIN 70/30.................................................20 HUMULIN 70/30 PEN ........................................20 HUMULIN N.......................................................20 HUMULIN N U-100 PEN ...................................20 HUMULIN R .......................................................20 HUMULIN R U-500 (CONCENTRATED)........20 HYCAMTIN ..........................................................5 hydralazine...........................................................13 hydrochlorothiazide .............................................13 hydrocodone / acetaminophen ...............................8 hydrocodone / ibuprofen ........................................8 hydrocodone /acetaminophen-hs ...........................8 hydrocodone bitartrate/acetaminophen.................8 hydrocortisone .........................................17, 19, 22 hydrocortisone butyrate .......................................17 hydrocortisone valerate .......................................17 hydromorphone hcl ................................................8 hydroxychloroquine ...............................................3 hydroxyurea ...........................................................5 hydroxyzine hcl ....................................................28 H HALDOL ............................................................ 11 HALDOL DECANOATE 100 ............................ 11 HALDOL DECANOATE 50 .............................. 11 halobetasol propionate........................................ 17 haloperidol .......................................................... 11 haloperidol decanoate inj.................................... 11 haloperidol lactate inj ......................................... 11 HAVRIX ............................................................. 24 HECTOROL........................................................ 21 HEPARIN SODIUM........................................... 15 heparin sodium dcu ............................................. 15 heparin sodium/d5w ............................................ 15 HEPARIN SODIUM/NACL 0.45% ................... 15 heparin sodium/sodium chloride 0.9% premix ... 15 HEPATAMINE................................................... 30 HEPATASOL...................................................... 30 HEPSERA ............................................................. 1 HERCEPTIN......................................................... 5 HEXALEN ............................................................ 5 HUMALOG ........................................................ 20 I ibuprofen ................................................................9 idarubicin hcl .........................................................5 IFEX.......................................................................5 ifosfamide...............................................................5 ifosfamide/mesna....................................................5 imipramine ...........................................................11 imipramine pamoate ............................................11 imiquimod ............................................................16 IMOVAX RABIES (H.D.C.V.)...........................24 INCRELEX..........................................................18 indapamide...........................................................13 indomethacin..........................................................9 indomethacin er .....................................................9 39 INFANRIX.......................................................... 24 INFUMORPH 200 ................................................ 8 INFUMORPH 500 ................................................ 8 INTELENCE......................................................... 1 INTRALIPID ...................................................... 30 INTRON-A.......................................................... 23 INTRON-A WITH DILUENT............................ 23 INVEGA.............................................................. 11 INVEGA SUSTENNA........................................ 11 INVIRASE ............................................................ 1 IONOSOL ........................................................... 30 IOPIDINE............................................................ 27 IPOL INACTIVATED IPV ................................ 24 ipratropium bromide ..................................... 19, 28 ipratropium bromide/albuterol sulfate................ 29 irinotecan .............................................................. 5 ISENTRESS .......................................................... 1 ISOLYTE ............................................................ 30 isonarif .................................................................. 3 ISONIAZID........................................................... 3 isosorbide dinitrate ............................................. 16 isosorbide dinitrate er ......................................... 16 isosorbide mononitrate........................................ 16 isosorbide mononitrate er ................................... 16 isotonic gentamicin ............................................... 3 isradipine............................................................. 13 ISTALOL ............................................................ 27 ISTODAX ............................................................. 5 itraconazole........................................................... 1 IXEMPRA KIT ..................................................... 5 IXIARO............................................................... 24 KALETRA.............................................................1 KAON-CL-10 ......................................................30 kariva ...................................................................26 kcl 0.075%/d5w/nacl 0.45% ................................30 KCL 0.15%/D10W/NACL 0.2% .........................30 kcl 0.15%/d5w/lr ..................................................30 KCL 0.15%/D5W/NACL 0.2% ...........................30 KCL 0.15%/D5W/NACL 0.225% .......................30 kcl 0.15%/d5w/nacl 0.9% ....................................30 kcl 0.3%/d5w/lr iv lac ring...................................30 KCL 0.3%/D5W/NACL 0.2% .............................30 kcl 0.3%/d5w/nacl 0.45% ....................................30 kcl 0.3%/d5w/nacl 0.9% ......................................30 kelnor 1/35 ...........................................................26 KEPPRA ................................................................7 KETEK ..................................................................3 ketoconazole.....................................................1, 17 ketoprofen ..............................................................9 ketoprofen er ..........................................................9 ketorolac tromethamine .......................................27 kionex ...................................................................18 klor-con 10 ...........................................................30 klor-con 8 .............................................................30 KLOR-CON M15 ................................................30 klor-con m20 ........................................................30 K-TABS ...............................................................30 kuric .....................................................................17 KUVAN ...............................................................21 L labetalol .........................................................13, 14 laclotion ...............................................................16 LACRISERT........................................................27 LACTATED RINGERS ......................................30 lactulose ...............................................................22 LAMICTAL ODT..................................................7 LAMICTAL XR ....................................................7 lamotrigine.............................................................7 LANOXIN ...........................................................15 lansoprazole.........................................................23 LANTUS..............................................................20 LANTUS SOLOSTAR ........................................20 leena.....................................................................26 J jantoven ............................................................... 15 JANUMET .......................................................... 20 JANUVIA............................................................ 20 JE-VAX............................................................... 24 jolivette ................................................................ 25 junel..................................................................... 26 junel fe 1.5/30...................................................... 26 junel fe 1/20......................................................... 26 K KADIAN ............................................................... 8 40 leflunomide .......................................................... 25 lessina-28 ............................................................ 26 LETAIRIS ........................................................... 29 leucovorin calcium ................................................ 4 LEUKERAN ......................................................... 5 LEUKINE............................................................ 23 leuprolide acetate.................................................. 5 LEUSTATIN......................................................... 5 LEVAQUIN .......................................................... 4 levetiracetam ......................................................... 7 levobunolol hcl .................................................... 27 levocarnitine........................................................ 18 levora................................................................... 26 levorphanol tartrate .............................................. 8 levothyroxine ....................................................... 21 levoxyl.................................................................. 21 LEXAPRO .......................................................... 11 LEXIVA ................................................................ 1 lidocaine ........................................................ 16, 17 lidocaine / prilocaine .......................................... 16 lidocaine viscous ................................................. 17 LIDODERM........................................................ 17 LINDANE ........................................................... 18 liothyronine sodium............................................. 22 LIPITOR.............................................................. 15 LIPOSYN III ....................................................... 30 lisinopril .............................................................. 14 lisinopril / hydrochlorothiazide........................... 14 lithium carbonate ................................................ 11 lithium carbonate er ............................................ 11 lithium citrate ...................................................... 11 LOCOID.............................................................. 17 LODOSYN............................................................ 7 loperamide hcl..................................................... 22 losartan potassium .............................................. 14 losartan potassium/hydrochlorothiazide............. 14 LOTEMAX ......................................................... 27 LOTREL.............................................................. 14 LOTRONEX ....................................................... 22 lovastatin ............................................................. 15 LOVAZA ............................................................ 15 LOVENOX.......................................................... 15 low-ogestrel......................................................... 26 loxapine................................................................11 LUPRON DEPOT..................................................5 LUPRON DEPOT-PED.........................................5 lutera ....................................................................26 LUXIQ .................................................................17 LYRICA.................................................................7 LYSODREN ..........................................................5 M MACRODANTIN..................................................4 MAGNESIUM SULFATE ..................................30 MAGNESIUM SULFATE IN D5W ...................30 MALARONE.........................................................3 malathion .............................................................18 maprotiline...........................................................11 margesic-h..............................................................8 MARPLAN ..........................................................11 MATULANE .........................................................5 MAXALT ..............................................................7 MAXALT-MLT.....................................................7 MAXIPIME ...........................................................2 mebendazole...........................................................3 meclizine hcl.........................................................22 meclofenamate sodium...........................................9 medroxyprogesterone acetate ..............................25 mefloquine hcl........................................................3 MEGACE ES .........................................................5 megestrol acetate ...................................................5 meloxicam ..............................................................9 melphalan hydrochloride .......................................5 MENACTRA .......................................................24 MENEST..............................................................25 MENOMUNE-A/C/Y/W-135..............................24 MENOSTAR........................................................25 meperidine hcl........................................................9 MEPRON...............................................................3 mercaptopurine ......................................................5 MERUVAX II W/DILUENT 10 DOSE ..............24 mesalamine ..........................................................22 mesna .....................................................................4 MESNEX ...............................................................4 MESTINON...........................................................8 MESTINON TIMESPAN......................................8 41 METADATE CD ................................................ 11 metadate er.......................................................... 11 metaproterenol sulfate......................................... 29 metaxalone ............................................................ 8 metformin hcl....................................................... 21 metformin hcl er ............................................ 20, 21 methadone hcl ....................................................... 9 methadose.............................................................. 9 methamphetamine hcl.......................................... 11 methazolamide..................................................... 27 methenamine hippurate ......................................... 4 METHERGINE................................................... 26 methimazole......................................................... 19 methocarbamol...................................................... 8 methotrexate .......................................................... 5 methotrexate sodium ............................................. 5 methyclothiazide.................................................. 14 METHYLIN ........................................................ 11 methylin er........................................................... 11 methylphenidate hcl............................................. 11 methylphenidate hcl sr ........................................ 11 methylprednisolone ............................................. 19 methylprednisolone acetate................................. 19 methylprednisolone sodiumsuccinate.................. 19 metipranolol ........................................................ 27 metoclopramide................................................... 22 metolazone........................................................... 14 metoprolol / hydrochlorothiazide........................ 14 metoprolol succinate er....................................... 14 metoprolol tartrate .............................................. 14 METROGEL ....................................................... 16 metronidazole .................................................. 3, 16 metronidazole in nacl 0.79%................................. 3 metronidazole vaginal ......................................... 25 mexiletine ............................................................ 12 MICARDIS ......................................................... 14 MICARDIS HCT ................................................ 14 miconazole 3........................................................ 25 microgestin 1.5/30............................................... 26 microgestin 1/20.................................................. 26 microgestin fe ...................................................... 26 microgestin fe 1.5/30 ........................................... 26 midodrine ............................................................ 18 migergot .................................................................7 MIGRANAL ..........................................................7 minocycline hcl ......................................................4 minocycline hcl er ..................................................4 minoxidil ..............................................................14 MIRAPEX ER .......................................................7 mirtazapine ..........................................................11 mirtazapine odt ....................................................11 misoprostol...........................................................23 mitomycin...............................................................5 mitoxantrone hcl ....................................................5 M-M-R II W/DILUENT 10 DOSE......................24 moexipril ..............................................................14 moexipril / hydrochlorothiazide...........................14 mometasone furoate .............................................17 mononessa............................................................26 morphine sulfate.....................................................9 morphine sulfate er ................................................9 MOZOBIL ...........................................................24 MULTAQ ............................................................12 mupirocin .............................................................17 MUSTARGEN.......................................................5 MYCOBUTIN .......................................................3 mycophenolate mofetil ...........................................5 mydral ..................................................................27 MYFORTIC...........................................................5 MYTELASE ..........................................................8 N nabumetone ............................................................9 nadolol .................................................................14 nadolol / bendroflumethiazide .............................14 nafcillin sodium......................................................3 NAFTIN...............................................................17 NAGLAZYME ....................................................21 NALLPEN/DEXTROSE .......................................3 naloxone.................................................................9 naltrexone ..............................................................9 NAMENDA ...........................................................8 NAMENDA TITRATION PAK............................8 naphazoline hcl ....................................................27 naproxen ................................................................9 naproxen sodium....................................................9 42 NARDIL.............................................................. 11 NASONEX.......................................................... 29 NATACYN ......................................................... 26 nateglinide........................................................... 21 NAVANE ............................................................ 11 NEBUPENT .......................................................... 3 necon 0.5/35-28................................................... 26 necon 1/35-28...................................................... 26 necon 10/11-28.................................................... 26 necon 7/7/7 .......................................................... 26 nefazodone........................................................... 11 neomycin /bacitracin /polymyxin ........................ 26 neomycin /polymyxin /bacitracin /hydrocortisone ......................................................................... 27 neomycin /polymyxin /dexamethasone ................ 27 neomycin /polymyxin /gramicidin ....................... 26 neomycin /polymyxin /hc ..................................... 19 neomycin /polymyxin /hydrocortisone........... 19, 27 neomycin sulfate.................................................... 3 NEORAL............................................................... 5 NEPHRAMINE................................................... 30 NEULASTA........................................................ 24 NEUMEGA......................................................... 24 NEUPOGEN ....................................................... 24 NEURONTIN........................................................ 7 NEVANAC ......................................................... 27 NEXAVAR ........................................................... 6 NEXIUM............................................................. 23 NEXIUM I.V....................................................... 23 next choice........................................................... 26 NIASPAN............................................................ 15 nicardipine .......................................................... 14 NICOTROL INHALER ...................................... 18 NICOTROL NASAL .......................................... 18 nifediac cc ........................................................... 14 nifedical xl ........................................................... 14 nifedipine............................................................. 14 nifedipine er......................................................... 14 NILANDRON ....................................................... 6 nimodipine........................................................... 14 NIPENT................................................................. 6 nisoldipine ........................................................... 14 nitro-bid............................................................... 16 nitrofurantoin macrocrystalline.............................4 nitrofurantoin monohydrate...................................4 nitroglycerin.........................................................16 nitroglycerin transdermal ....................................16 NITROLINGUAL PUMPSPRAY.......................16 NITROSTAT .......................................................16 nizatidine..............................................................23 nora-be.................................................................25 NORDITROPIN CARTRIDGE ..........................24 NORDITROPIN NORDIFLEX PEN ..................24 norethindrone.......................................................25 NORMOSOL .......................................................30 NOROXIN .............................................................4 NORPACE CR.....................................................12 nortrel 0.5/35 (28)................................................26 nortrel 1/35 (21)...................................................26 nortrel 1/35 (28)...................................................26 nortrel 7/7/7 .........................................................26 nortriptyline .........................................................11 NORVIR ................................................................1 novamine ..............................................................30 NOVOLIN 70/30 .................................................21 NOVOLIN 70/30 INNOLET...............................21 NOVOLIN N .......................................................21 NOVOLIN N INNOLET .....................................21 NOVOLIN R........................................................21 NOVOLOG..........................................................21 NOVOLOG FLEXPEN .......................................21 NOVOLOG MIX 70/30.......................................21 NOVOLOG MIX 70/30 PREFILLED FLEXPEN ..........................................................................21 NOXAFIL ..............................................................1 NUVARING ........................................................25 nyamyc .................................................................17 nystatin.............................................................1, 17 nystatin / triamcinolone .......................................17 nystop ...................................................................17 O octreotide ...............................................................6 ofloxacin.....................................................4, 19, 26 ogestrel.................................................................26 omeprazole...........................................................23 43 omnitrope ............................................................ 24 ONCASPAR ......................................................... 6 ondansetron hcl ................................................... 22 ondansetron odt................................................... 22 ONGLYZA.......................................................... 21 ONSOLIS .............................................................. 9 ONTAK................................................................. 6 OPANA ER ........................................................... 9 ORAP .................................................................. 11 ORFADIN ........................................................... 18 orphenadrine /asa /caffeine................................... 8 orphenadrine citrate.............................................. 8 orphenadrine citrate er ......................................... 8 orphenadrine compound ds................................... 8 ORTHO EVRA ................................................... 25 ORTHOCLONE OKT3......................................... 6 ortho-est .............................................................. 25 OVIDE ................................................................ 18 oxaliplatin.............................................................. 6 oxandrolone......................................................... 21 oxaprozin............................................................... 9 oxcarbazepine........................................................ 7 OXSORALEN ULTRA ...................................... 16 oxybutynin ........................................................... 29 oxybutynin er ....................................................... 29 oxycodone /acetaminophen ................................... 9 oxycodone /apap.................................................... 9 oxycodone /aspirin ................................................ 9 oxycodone hcl........................................................ 9 oxycodone-apap .................................................... 9 OXYCONTIN ....................................................... 9 OXYTROL.......................................................... 29 PASER ...................................................................3 PATADAY ..........................................................27 PATANOL...........................................................27 PAXIL..................................................................11 PEDIARIX...........................................................24 pedi-dri.................................................................17 PEDVAX HIB .....................................................24 PEGANONE ..........................................................7 PEGASYS............................................................24 PEG-INTRON......................................................24 PEG-INTRON REDIPEN....................................24 penicillin g potassium ............................................3 PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE.......................................................3 PENICILLIN G PROCAINE.................................4 PENICILLIN G SODIUM.....................................4 penicillin v potassium ............................................4 PENTASA............................................................22 pentopak...............................................................15 pentostatin..............................................................6 pentoxifylline er ...................................................15 PEPCID................................................................23 PERFOROMIST ..................................................29 perindopril erbumine ...........................................14 periogard..............................................................19 permethrin............................................................18 perphenazine ........................................................11 pfizerpen-g .............................................................4 phenadoz ..............................................................28 phenytoin................................................................7 PHENYTOIN SODIUM........................................7 phenytoin sodium extended ....................................7 PHISOHEX..........................................................17 PHOTOFRIN .........................................................6 pilocarpine hcl .....................................................18 PILOPINE HS......................................................27 pindolol ................................................................14 piperacillin sodium/ tazobactam sodium ...............4 piroxicam ...............................................................9 PLASMA-LYTE..................................................30 PLAVIX...............................................................15 podofilox ..............................................................16 polycin b...............................................................26 P PACERONE........................................................ 12 paclitaxel ............................................................... 6 palgic................................................................... 28 PANDEL ............................................................. 17 PANRETIN ......................................................... 16 parcaine............................................................... 27 paromomycin......................................................... 3 paroxetine............................................................ 11 paroxetine er ....................................................... 11 44 poly-dex ............................................................... 27 polyethylene glycol 3350..................................... 22 portia-28.............................................................. 26 potassium chloride .............................................. 30 POTASSIUM CHLORIDE 0.075%/D5W/NACL 0.225%............................................................. 30 POTASSIUM CHLORIDE 0.15% /NACL 0.45% VIAFLEX........................................................ 30 potassium chloride 0.15% d5w/nacl 0.33% ........ 30 potassium chloride 0.15% d5w/nacl 0.45% viaflex ......................................................................... 30 potassium chloride 0.15% nacl 0.9%.................. 30 POTASSIUM CHLORIDE 0.15%/D5W............ 30 POTASSIUM CHLORIDE 0.22% D5W/NACL 0.45%............................................................... 30 potassium chloride 0.224%/d5w ......................... 30 POTASSIUM CHLORIDE 0.3%/ NACL 0.9% . 30 potassium chloride 0.3%/d5w ............................. 30 potassium chloride cr .......................................... 30 potassium chloride er .......................................... 30 potassium chloride sr .......................................... 30 potassium citrate extended-release ..................... 29 pramipexole dihydrochloride ................................ 7 PRANDIN ........................................................... 21 pravastatin..................................................... 15, 16 prazosin ............................................................... 14 prednicarbate ...................................................... 17 prednisolone ........................................................ 19 prednisolone acetate ........................................... 27 prednisolone sodium phosphate .................... 19, 27 prednisone ........................................................... 19 PREDNISONE INTENSOL ............................... 19 PREFEST ............................................................ 25 PREMARIN ........................................................ 25 PREMARIN W/APPLICATOR.......................... 25 PREMASOL........................................................ 30 PREMPHASE ..................................................... 25 PREMPRO .......................................................... 25 prenatabs obn...................................................... 31 prevalite............................................................... 16 previfem............................................................... 26 PREVPAC........................................................... 23 PREZISTA ............................................................ 1 PRIMAQUINE ......................................................3 PRIMAXIN I.M.....................................................3 PRIMAXIN IV.......................................................3 primidone ...............................................................7 PRIMSOL ..............................................................4 PRISTIQ ..............................................................11 PRIVIGEN...........................................................24 PROAIR HFA......................................................29 probenecid............................................................25 probenecid /colchicine .........................................25 procainamide .......................................................12 prochlorperazine..................................................22 prochlorperazine edisylate...................................22 prochlorperazine maleate ....................................22 PROCRIT.............................................................24 procto-pak ............................................................22 proctosol hc..........................................................22 proctozone-hc.......................................................22 PROGLYCEM.....................................................21 PROGRAF .............................................................6 PROLASTIN........................................................18 PROLEUKIN.......................................................24 PROMACTA .......................................................15 promethazine hcl..................................................28 promethegan ........................................................28 PROMETRIUM...................................................25 propafenone hcl ...................................................12 proparacaine hcl..................................................27 propoxyphene /acetaminophen ..............................9 propoxyphene hcl ...................................................9 propoxyphene-n /acetaminophen ...........................9 propranolol /hydrochlorothiazide........................14 propranolol hcl ....................................................14 propranolol hcl er ................................................14 propylthiouracil ...................................................19 PROQUAD ..........................................................24 PROTOPIC ..........................................................16 protriptyline hcl ...................................................11 PROVIGIL...........................................................11 PULMICORT ......................................................29 PULMOZYME ....................................................29 PYLERA ..............................................................23 pyrazinamide..........................................................3 45 pyridostigmine bromide......................................... 8 RIDAURA ...........................................................25 rifampin..................................................................3 RILUTEK ............................................................18 rimantadine hcl ......................................................1 ringers injection ...................................................30 RISPERDAL CONSTA.......................................11 risperidone ...........................................................12 risperidone odt .....................................................12 RITALIN LA .......................................................12 RITUXAN..............................................................6 romycin ................................................................26 ropinirole ...............................................................7 ROTATEQ...........................................................24 ROXICET ..............................................................9 ROZEREM ..........................................................12 Q QUALAQUIN....................................................... 3 quasense .............................................................. 26 quinapril .............................................................. 14 quinapril / hydrochlorothiazide .......................... 14 quinidine gluconate cr......................................... 12 quinidine sulfate .................................................. 12 quinidine sulfate er.............................................. 12 R RABAVERT ....................................................... 24 ramipril................................................................ 14 RANEXA ............................................................ 16 ranitidine hcl ....................................................... 23 RAPAMUNE ........................................................ 6 REBETOL............................................................. 1 REBIF.................................................................. 24 REBIF TITRATION PACK ............................... 24 reclipsen .............................................................. 26 RECOMBIVAX HB ........................................... 24 regonol .................................................................. 8 REGRANEX ....................................................... 16 RELENZA DISKHALER ..................................... 1 RELION R........................................................... 21 RELISTOR.......................................................... 22 REMICADE ........................................................ 22 RENAGEL .......................................................... 18 RENAMIN .......................................................... 30 RENVELA .......................................................... 18 reprexain ............................................................... 9 REQUIP XL .......................................................... 7 RESCRIPTOR....................................................... 1 reserpine.............................................................. 14 RESTASIS .......................................................... 27 RETROVIR IV INFUSION .................................. 1 REVATIO ........................................................... 29 REVLIMID ........................................................... 6 REYATAZ ............................................................ 1 RHEUMATREX ................................................... 6 ribapak .................................................................. 1 ribasphere.............................................................. 1 ribavirin................................................................. 1 S SABRIL .................................................................7 SAMSCA .............................................................21 SANDIMMUNE ....................................................6 SANDOSTATIN....................................................6 SANDOSTATIN LAR DEPOT.............................6 SANTYL..............................................................18 SAPHRIS .............................................................12 SAVELLA ...........................................................25 SAVELLA TITRATION PACK .........................25 selegiline ................................................................7 selenium sulfide....................................................16 SELZENTRY.........................................................2 SENSIPAR...........................................................21 SEREVENT DISKUS..........................................29 SEROMYCIN ........................................................3 SEROQUEL.........................................................12 SEROQUEL XR ..................................................12 sertraline ..............................................................12 silver sulfadiazine ................................................16 SIMCOR ..............................................................16 SIMULECT............................................................6 simvastatin ...........................................................16 SINGULAIR ........................................................29 SKELID ...............................................................18 sodium bicarbonate..............................................30 sodium chloride..............................................18, 30 46 sodium chloride 0.9%......................................... 18 sodium chloride 0.45% viaflex ............................ 30 SODIUM EDECRIN........................................... 14 sodium fluoride.................................................... 31 sodium polystyrene sulfonate .............................. 18 sodium sulfacetamide .................................... 17, 27 SOLARAZE ........................................................ 16 solia ..................................................................... 26 SOLU-CORTEF.................................................. 19 SOLU-MEDROL ................................................ 19 SOMATULINE DEPOT ....................................... 6 SOMAVERT....................................................... 21 SORIATANE ...................................................... 16 sorine................................................................... 12 sotalol .................................................................. 12 sotret.................................................................... 16 SPIRIVA HANDIHALER .................................. 29 spironolactone..................................................... 14 spironolactone / hydrochlorothiazide ................. 14 SPORANOX ......................................................... 1 sprintec 28 ........................................................... 26 SPRYCEL ............................................................. 6 sronyx .................................................................. 26 ssd........................................................................ 16 stagesic .................................................................. 9 STALEVO 100...................................................... 7 STALEVO 125...................................................... 7 STALEVO 150...................................................... 7 STALEVO 200...................................................... 7 STALEVO 50........................................................ 7 STALEVO 75........................................................ 7 stavudine................................................................ 2 STIMATE............................................................ 21 STRATTERA...................................................... 12 STREPTOMYCIN SULFATE.............................. 3 STROMECTOL .................................................... 3 SUBOXONE ......................................................... 9 sucralfate............................................................. 23 SULAR................................................................ 14 sulfacetamide sodium / prednisolone sodium phospha ........................................................... 27 sulfadiazine............................................................ 4 sulfamethoxazole / trimethoprim........................... 4 sulfamethoxazole/trimethoprim ds .........................4 SULFAMYLON ..................................................17 sulfasalazine.........................................................22 sulfatrim .................................................................4 sulfazine ec...........................................................22 sulindac ..................................................................9 sumatriptan succinate ............................................7 SUPRAX................................................................2 SURMONTIL ......................................................12 SUSTIVA...............................................................2 SUTENT ................................................................6 SYMBICORT ......................................................29 SYMBYAX..........................................................12 SYMLIN ..............................................................21 SYMLINPEN 120................................................21 SYMLINPEN 60..................................................21 SYNAREL ...........................................................21 SYNTHROID ......................................................22 SYPRINE.............................................................18 T TABLOID ..............................................................6 tacrolimus ..............................................................6 TAMIFLU..............................................................2 tamoxifen citrate ....................................................6 tamsulosin hcl ......................................................29 TARCEVA.............................................................6 TARGRETIN.........................................................6 TASIGNA ..............................................................6 TAXOTERE ..........................................................6 TAZICEF ...............................................................2 taztia xt.................................................................14 TEGRETOL-XR ....................................................7 TEKTURNA ........................................................14 TEKTURNA HCT ...............................................14 terazosin hcl .........................................................14 terbinafine ..............................................................1 terbutaline sulfate ................................................29 terconazole...........................................................25 testosterone cypionate..........................................21 testosterone enanthate .........................................21 TETANUS / DIPHTHERIA TOXOIDSADSORBED ADULT .....................................24 47 TETANUS TOXOID ADSORBED.................... 24 tetracycline hcl ...................................................... 4 TEV-TROPIN ..................................................... 24 THALOMID.......................................................... 6 THEO-24............................................................. 29 theochron............................................................. 29 theophylline er..................................................... 29 thermazene .......................................................... 16 thioridazine.......................................................... 12 thiotepa.................................................................. 6 thiothixene ........................................................... 12 THYMOGLOBULIN.......................................... 24 ticlopidine hcl...................................................... 15 TIKOSYN ........................................................... 12 timolol maleate.............................................. 14, 27 timolol maleate ophthalmic gel forming ............. 27 TIMOPTIC OCUDOSE ...................................... 27 tizanidine hcl ......................................................... 8 TOBI...................................................................... 3 tobramycin....................................................... 3, 26 tobramycin /dexamethasone................................ 27 TOBRAMYCIN SULFATE / SODIUM CHLORIDE....................................................... 3 tobrasol................................................................ 26 TOBREX............................................................. 26 tolazamide ........................................................... 21 tolbutamide.......................................................... 21 tolmetin sodium ..................................................... 9 topiramate ............................................................. 7 toposar................................................................... 6 TORISEL .............................................................. 6 torsemide ............................................................. 14 TRACLEER ........................................................ 29 tramadol ................................................................ 9 tramadol hcl er ...................................................... 9 trandolapril ......................................................... 14 trandolapril/verapamil hcl .................................. 14 TRANSDERM-SCOP......................................... 22 tranylcypromine .................................................. 12 TRAVASOL........................................................ 30 TRAVATAN Z ................................................... 27 trazodone............................................................. 12 TREANDA............................................................ 6 TRECATOR ..........................................................3 TRELSTAR DEPOT MIXJECT............................6 TRELSTAR LA MIXJECT ...................................6 tretinoin............................................................6, 16 triamcinolone acetonide.................................17, 18 triamcinolone in orabase .....................................19 triamterene / hydrochlorothiazide .......................15 TRICOR...............................................................16 triderm..................................................................18 trifluoperazine......................................................12 trifluridine............................................................26 trihexyphenidyl.......................................................7 TRIHIBIT ............................................................24 tri-legest fe ...........................................................26 TRILIPIX.............................................................16 trilyte ....................................................................22 trimethoprim ..........................................................4 trimethoprim sulfate/polymyxin b sulfate.............26 trinessa.................................................................26 TRIPEDIA ...........................................................24 tri-previfem ..........................................................26 TRISENOX............................................................6 tri-sprintec............................................................26 trivora-28 .............................................................26 TRIZIVIR ..............................................................2 TROPHAMINE ...................................................31 tropicamide ..........................................................27 TRUVADA ............................................................2 TWINJECT ..........................................................28 TWINRIX ............................................................24 TWYNSTA ..........................................................15 TYGACIL ..............................................................3 TYKERB................................................................6 TYPHIM VI .........................................................24 TYZEKA................................................................2 TYZINE ...............................................................19 TYZINE PEDIATRIC NASAL DROPS .............19 U ULESFIA .............................................................18 ULORIC...............................................................25 UNASYN...............................................................4 unithroid...............................................................22 48 UROXATRAL .................................................... 29 URSO 250 ........................................................... 22 URSO FORTE..................................................... 22 ursodiol................................................................ 23 VIVAGLOBIN ....................................................24 VIVELLE-DOT ...................................................25 VOLTAREN ..........................................................9 VOTRIENT............................................................6 V W VAGIFEM........................................................... 25 valacyclovir hcl ..................................................... 2 VALCYTE ............................................................ 2 valproate sodium ................................................... 7 valproic acid.......................................................... 7 VALTURNA....................................................... 15 VANCOCIN ORAL.............................................. 4 vancomycin............................................................ 4 VANCOMYCIN HCL ISO-OSMOTIC DEXTROSE ...................................................... 4 vandazole............................................................. 26 VAQTA............................................................... 24 VARIVAX .......................................................... 24 VECTIBIX ............................................................ 6 VELCADE ............................................................ 6 velivet .................................................................. 26 venlafaxine hcl..................................................... 12 VENTOLIN HFA................................................ 29 VERAMYST....................................................... 29 verapamil............................................................. 15 verapamil er ........................................................ 15 VEREGEN .......................................................... 16 VFEND.................................................................. 1 VFEND IV ............................................................ 1 VIBATIV .............................................................. 4 VIBRAMYCIN ..................................................... 4 VIDAZA................................................................ 6 VIDEX PEDIATRIC............................................. 2 VIGAMOX.......................................................... 26 VIMPAT................................................................ 7 vinblastine sulfate.................................................. 6 vincasar pfs ........................................................... 6 vincristine sulfate .................................................. 6 vinorelbine tartrate ............................................... 6 VIRACEPT ........................................................... 2 VIRAMUNE ......................................................... 2 VIREAD................................................................ 2 warfarin................................................................15 X XALATAN ..........................................................27 XENAZINE ...........................................................8 XIBROM..............................................................27 XIFAXAN..............................................................3 XOLEGEL ...........................................................17 XYREM ...............................................................12 Y YF-VAX ..............................................................24 Z zaleplon ................................................................12 ZANOSAR.............................................................6 ZANTAC .............................................................23 ZAVESCA ...........................................................21 zazole....................................................................26 ZELAPAR..............................................................7 ZEMPLAR...........................................................21 ZENPEP...............................................................23 zerlor ......................................................................9 ZETIA ..................................................................16 ZIAGEN.................................................................2 zidovudine ..............................................................2 ZINACEF...............................................................2 ZINACEF IN ISO-OSMOTIC DEXTROSE.........2 ZINACEF IN ISO-OSMOTIC DILUENT ............2 ZINECARD ...........................................................4 ZIRGAN ..............................................................26 ZMAX....................................................................2 ZOLINZA ..............................................................6 zolpidem ...............................................................12 ZOMETA.............................................................21 ZONALON ..........................................................16 zonisamide..............................................................7 ZOSTAVAX ........................................................25 49 ZOSYN.................................................................. 4 zovia 1/35e........................................................... 26 zovia 1/50e........................................................... 26 ZOVIRAX........................................................... 17 ZYFLO CR.......................................................... 29 ZYLET.................................................................27 ZYMAR ...............................................................26 ZYPREXA ...........................................................12 ZYPREXA ZYDIS ..............................................12 ZYVOX..................................................................3 50