health net cal mediconnect plan (medicare-medicaid plan ... · for san diego county, tty: 711. the...

Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)

2016 年承保藥品清單（處方一覽表）

HPMS Approved Formulary File Submission ID: 16213 Version Number: H3237_2016_0006_ CHI CMS Approved 07102015

本藥品清單已於年月日更新。如果您有疑問，請致電與 Health Net Cal MediConnect 聯絡，如果您在 Los Angeles County，請致電 1-855-464-3571；如果您在 San Diego County，請致電 1-855-464-3572；聽障專線：711。從週一至週五的上午 8:00 至晚上 8:00，我們皆有專人可與您洽談。在週六、週日及聯邦法定假日期間，您可於上午 8:00 至晚上 8:00 在語音信箱中留言。我們將會在下一個工作日回電給您。上述電話均為免費。

如需更多資訊，請瀏覽 www.healthnet.com/calmediconnect。

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? 如果您有疑問，請致電與 Health Net Cal MediConnect 聯絡，如果您在 Los Angeles County，請致電 1-855-464-3571；如果您在 San Diego County，請致電 1-855-464-3572；聽障專線：711。從週一至週五的上午 8:00 至晚上 8:00，我們皆有專人可與您洽談。在週六、週日及聯邦法定假日期間，您可於上午 8:00 至晚上 8:00 在語音信箱中留言。我們將會在下一個工作日回電給您。上述電話均為免費。如需更多資訊，請瀏覽 www.healthnet.com/calmediconnect。

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此為會員透過 Health Net Cal MediConnect 可取得的藥品清單。

• Health Net Cal MediConnect Plan （Medicare-Medicaid Plan）是一項與 Medicare 和 Medi-Cal 均簽有合約的健保計畫，為計畫參加者同時提供此兩

項方案的福利。

• 承保藥品清單及/或藥房和醫療服務提供者網絡可能會在一年當中變更。

在進行會對您產生影響的變更之前，

我們將會事先寄通知給您。

• 福利及/或共付額可能會在每年的 1 月 1 日變更。

• 您可隨時透過 www.healthnet.com/calmediconnect 網站查詢 Health Net Cal MediConnect 最新的承保藥品清單，或者如果您在 Los Angeles County，請致電 1-855-464-3571；如果您在 San Diego County，請致電 1-855-464-3572；聽障專線：711。

• 您可免費索取本資訊的其他格式，例如大字版、盲文版或語音版。如

果您在 Los Angeles County，請致電 1-855-464-3571；如果您在 San Diego County，請致電 1-855-464-3572；聽障專線：711。上述電話均為免費。

• 限制、共付額和約束規定可能適用。如需更多資訊，請致電 Health Net Cal MediConnect 會員服務部或參閱 Health Net Cal MediConnect 會員手冊。

• 處方藥共付額可能會根據您所獲得的額外協助程度多寡而不同。請與計畫

聯絡以瞭解詳情。

• You can get this information for free in other languages. Call 1-855-464-3571 for Los Angeles County or 1-855-464-3572 for San Diego County, TTY: 711. The call is free.

Usted puede obtener esta información de forma gratuita en otros idiomas. Llame al 1-855-464-3571 para el condado de Los Angeles o 1-855-464-3572 para el condado de San Diego, TTY: 711. La llamada es gratuita.

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常見問題 (FAQ)如果您對本承保藥品清單有疑問，您可在此尋找解答。您可閱讀所有的 FAQ 以瞭解更多資訊，或僅查詢某問題的解答。

1. 承保藥品清單中有哪些處方藥？（我們將承保藥品清單簡稱為「藥品

清單」。）

在藥品清單中的藥品均是 Health Net Cal MediConnect 的承保藥品。您可在本計畫網絡內的藥房取得這些藥品。本

計畫網絡內的藥房是與本計畫簽訂協

議，並與本計畫合作為您提供服務的藥

房。我們稱這些藥房為「網絡藥房」。

如果您符合以下條件，Health Net Cal MediConnect 將會承保藥品清單中所有醫療所必需的藥品：

• 您的醫師或其他開立處方者表示您需要該藥品才能改善病情或保持健康；

且

• 您在 Health Net Cal MediConnect 的網絡藥房領取處方藥。

在某些情況下，您必須在領取藥品之前採取一些行動（請參閱後面的問題 5）。

您也可在我們的網站 www.healthnet.com/calmediconnect 瀏覽本計畫最新的承保藥品清單，或致電與會員服務部

聯絡，如果您在 Los Angeles County，請致電 1-855-464-3571；如果您在 San Diego County，請致電 1-855-464-3572；聽障專線：711。


2. 藥品清單的內容會變更嗎？

會。Health Net Cal MediConnect 可能會在一年當中將藥品新增至藥品清單中或

將藥品自藥品清單中移除。一般而言，

藥品清單的內容僅有在下列情況下才會

變更：

• 有價格較低且功效與現在藥品清單中之藥品相當的藥品出現；或

• 我們得知某項藥品並不安全。

我們也可能會變更本計畫的藥品相關規

定。例如，我們可：

• 決定某藥品是否需要事先核准。（事先核准是指您必須先取得 Health Net Cal MediConnect 的許可才能領取藥品。）

• 增加或變更您可領取的藥量（稱為「藥量限制」）。

• 新增或變更某藥品的階段療法限制。（階段療法是指您必須先試用某種藥品，而後我們才會承保其他藥品。）

（如需更多有關這些藥品規定的資訊，

請參閱第 iv 頁。）

當我們將您正在服用的藥品自藥品清單

中移除時，我們將會告知您。當我們變

更本計畫的藥品承保規定時，我們亦會

告知您。以下的問題 3、4 和 7 將會提供更多有關藥品清單變更事宜的資訊。

• 您可隨時在 www.healthnet.com/calmediconnect 網站查詢 Health Net Cal MediConnect 最新的藥品清單。您也可致電會員服務部查詢最新的

藥品清單。如果您在 Los Angeles County，請致電 1-855-464-3571；如果您在 San Diego County，請致電 1-855-464-3572；聽障專線：711。

3. 當有價格較低且功效與現在藥品清單中之藥品相當的藥品出現時將會

怎樣？

如果您正在服用的藥品因有價格較低且

功效相當的藥品出現而遭移除，我們將

會告知您。我們會在將藥品自藥品清單中移除的至少 60 天前或在您要求補充處方時告知您。而後，您將可在該藥品自藥品清單中移除之前獲得該藥品 60 天份的藥量。如果我們針對藥品清單進行了任何其他對您不利的變更，我們將會寄信告知您這些變更。我們也

會將這些變更公布在我們的網站 www.healthnet.com/calmediconnect。

4. 如果我們發現某項藥品並不安全將會怎樣？

如果 Food and Drug Administration (FDA) 表示您正在服用的藥品並不安全，我們會立刻將該藥品自藥品清單中

移除。我們亦會寄信告知您此事宜。如

果您收到此類信函，請致電向您的醫師

洽詢其他藥品選項。

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5. 藥品承保是否有任何限制或上限？或者在領取某些藥品之前是否有任

何必須採取的行動？

是，部分藥品有承保規定或您可領取的

藥量限制。在某些情況下，您或您的醫

師或其他開立處方者必須在您領取藥品

之前採取一些行動。例如：

• 事先核准（或事先授權）：針對部分藥品，您或您的醫師或其他

開立處方者必須先獲得 Health Net Cal MediConnect 的核准，您才可以領取處方藥。如果您未獲得核

准，Health Net Cal MediConnect 可能無法承保該藥品。

• 藥量限制：Health Net Cal MediConnect 有時會限制您可領取的藥量。

• 階段療法：Health Net Cal MediConnect 有時會要求您接受階段療法。這表示

您將必須針對您的醫療狀況依序試用

一些藥品。您可能必須先試用某種藥

品，而後我們才會承保其他藥品。如

果您的醫師認為第一種藥品對您沒有

療效，那麼我們將會承保第二種藥品。

您可查看第 1 頁索引 1 的表格，以瞭解您的藥品是否有任何其他規定或限制。

您也可瀏覽我們的網站 www.healthnet.com/calmediconnect 以取得更多資訊。我們已在網站上發布了事

先授權及階段療法限制的說明文件。您

也可要求我們寄一份副本給您。

您可要求我們針對這些限制進行「例外

處理」。請參閱問題 11 以瞭解更多有關例外處理的資訊。

• 如果您住在療養院或其他長期照護機構且您需要不在藥品清單中的藥品，

或者您無法輕易取得您所需的藥品，

我們可協助您。不論您是否是 Health Net Cal MediConnect 的新會員，我們皆會為您所需的藥品承保 31 天份的緊急藥量（除非您的處方天數

較短）。這將讓您有時間可以和您的

醫師或其他開立處方者商量。其可協

助您決定藥品清單中是否有類似的藥

品可以取代您服用的藥品，或者協助

您決定是否應該申請例外處理。請參

閱問題 11 以瞭解更多有關例外處理的資訊。

6. 您該如何知道您需要的藥品是否有限制或您是否需要在領取藥品之前

採取任何行動？

第 1 頁的承保藥品清單中有「必要行動、限制或使用上限」一欄。

7. 如果我們變更本計畫部分藥品的承保規定將會怎樣？例如，我們新增了某藥品的事先授權（核准）、藥

量限制和/或階段療法限制。如果我們新增了某藥品的事先核准、藥

量限制和/或階段療法限制，我們將會告知您。我們將會在新增限制的至少 60 天前或在您下次要求藥房補充處方時告知您。而後，您將可在承保規定變

更之前獲得該藥品 60 天份的藥量。這將讓您有時間可以和您的醫師或其他開

立處方者商量接下來該怎麼做。


8. 您該如何在藥品清單中尋找藥品？尋找藥品的方式有兩種：

• 您可按英文字母的順序搜尋（如果您知道藥名的拼法）；或

• 您可按醫療狀況搜尋。

如欲按英文字母的順序搜尋，請至「按字母順序排列的清單」一節。您可

在從第 Index 1 頁開始的索引處找到該清單。

如欲按醫療狀況搜尋，請至第 1 頁的「按醫療病況排列的藥品清單」一節。

本節中的藥品是根據藥品用於治療醫療

病況的類型來分類。例如，如果您患有

心臟病況，您即應查詢「心血管藥品 - 各式藥品 – 用於治療心臟和循環系統病況的藥品」類別。您將可在該類別中找

到治療心臟病況的藥品。

9. 如果您欲服用的藥品不在藥品清單中該怎麼辦？

如果您在藥品清單中沒看到您所需的

藥品，請致電向會員服務部洽詢，如

果您在 Los Angeles County，請致電 1-855-464-3571；如果您在 San Diego County，請致電 1-855-464-3572；聽障專線：711。如果您得知 Health Net Cal MediConnect 將不會承保該藥品，您可採取下列任何一項行動：

• 向會員服務部索取與您欲服用之藥品類似的藥品清單。然後將該清單交給

您的醫師或其他開立處方者。其可開

立藥品清單中與您欲服用之藥品類似

的藥品。或者

• 您可要求健保計畫進行例外處理以承保您的藥品。請參閱問題 11 以瞭解更多有關例外處理的資訊。

10. 如果您是 Health Net Cal MediConnect 的新會員而您在藥品清單中找不到您的藥品或是您

在領取藥品時有問題該怎麼辦？

我們能夠提供協助。在您成為 Health Net Cal MediConnect 會員的前 90 天期間，我們可為您的藥品承保 30 天份的暫時藥量。這將讓您有時間可以

和您的醫師或其他開立處方者商量。其

可協助您決定藥品清單中是否有類似的

藥品可以取代您服用的藥品，或者協助

您決定是否應該申請例外處理。

如果您符合以下條件，我們將會為您的

藥品承保 30 天份的藥量：

• 您正在服用未列於本計畫藥品清單中的藥品；或

• 根據健保計畫的規定，您無法取得開立處方者所開立的藥量；或

• 您的藥品需要 Health Net Cal MediConnect 的事先核准；或

• 您正在服用的藥品是屬於階段療法限制中的藥品。

如果您住在療養院或其他長期照護機

構，您可能可補充處方藥長達 98 天的時間。您可在您加入計畫的前 90 天期

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間多次補充藥品。這將讓開立處方者有

時間可以將您的藥品更換為藥品清單中

的藥品或申請例外處理。

照護層級變更

如果您的照護層級有所變更，我們將會

為您承保您的過渡藥量。當您從醫院出

院時，您的照護層級即會發生變更。當

您入住或遷離長期照護機構時，您的照

護層級亦會發生變更。

• 如果您自長期照護機構或醫院返家並需要過渡藥量，我們將會為您承保一

次 30 天份的藥量。如果您處方開立的天數較短，則我們將會允許您補充

處方，直到我們為您提供的總藥量達

到 30 天份為止。• 如果您從自家或醫院遷入長期照護機構並需要過渡藥量，我們將會為您承

保一次 31 天份的藥量。如果您處方開立的天數較短，則我們將會允許您補

充處方，直到我們為您提供的總藥量

達到 31 天份為止。

11. 您可以申請例外處理以使您的藥品獲得承保嗎？

可以。您可以向 Health Net Cal MediConnect 申請例外處理，以承保不在藥品清單中的藥品。

您也可要求本計畫變更您藥品的相關規定。

• 例如，Health Net Cal MediConnect 可能會限制本計畫將承保的藥量。如果

您的藥品受到限制，您可要求本計畫

變更該限制並增加承保的藥量。

• 其他範例為：您可要求本計畫取消階段療法限制或事先核准規定。

12. 例外處理申請需要多久時間？首先，我們必須收到您開立處方者所提

供的聲明，以作為您例外處理申請的佐

證。在我們收到聲明後，我們將會在 72 小時內告知您我們針對您例外處理申請所作的決定。

如果您或您的開立處方者認為等待決定 72 小時將會危害您的健康，您可申請特急例外處理。這表示您將可更快得到

決定。如果您的開立處方者有為您的申

請提供佐證，我們將會在收到您開立處

方者所提供之佐證聲明後的 24 小時內告知您我們的決定。

13. 您該如何提出例外處理申請？如欲提出例外處理申請，請致電與會員

服務部聯絡。會員服務部將會與您及您

的醫療服務提供者合作，協助您提出例

外處理申請。

14. 什麼是普通牌藥品？普通牌藥品是由與品牌藥品相同的成份所製成。普通牌藥品的價格通常比品牌

藥品低，且普通牌藥品的名稱通常較不

廣為人知。普通牌藥品已獲得 Food and Drug Administration (FDA) 的核准。

Health Net Cal MediConnect 既承保品牌藥品也承保普通牌藥品。


15. 何謂非處方 (OTC) 藥品？ OTC 是指非處方藥品，其英文全名為「over-the-counter」。Health Net Cal MediConnect 承保部分 OTC 藥品，但條件是其必須是由您醫療服務提供者

開立處方。

您可參閱 Health Net Cal MediConnect 的藥品清單，查詢哪些 OTC 藥品屬於承保範圍。

16. Health Net Cal MediConnect 是否承保 OTC 非藥品產品？

Health Net Cal MediConnect 承保部分 OTC 非藥品產品，但條件是其必須是由您醫療服務提供者開立處方。

您可參閱 Health Net Cal MediConnect 的藥品清單，查詢哪些 OTC 非藥品產品屬於承保範圍。

17. 您需支付多少共付額？您可參閱 Health Net Cal MediConnect 的藥品清單，瞭解每種藥品的共付額。

住在療養院或其他長期照護機構的 Health Net Cal MediConnect 會員無需支付任何共付額。部分透過社區取得長期

照護的會員也無需支付任何共付額。

共付額按層級列出。層級是具有相同共

付額的藥品群組。

• 層級 1 藥品的共付額較低。這些藥品是屬於普通牌藥品。共付額介於 0.00 美元至 2.95 美元之間。共付額的多寡將視您 Medi-Cal 的承保層級而定。

• 層級 2 藥品的共付額較高。這些藥品是屬於品牌藥品。共付額介於 0.00 美元至 7.40 美元之間。共付額的多寡將視您 Medi-Cal 的承保層級而定。

• 層級 3 藥品的共付額為 0.00 美元。這些藥品為 Medi-Cal 承保的處方和 OTC 藥品。

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承保藥品清單從第 1 頁開始的承保藥品清單將為您提供有關 Health Net Cal MediConnect 的承保藥品資訊。如果您在清單中找不到

您的藥品，您可至從第 Index 1 頁開始的索引處尋找。

表格第一欄所列的是藥品名稱。品牌藥

品以大寫字母表示（如 LIPITOR），普通牌藥品則以斜體小寫字母表示（如 atorvastatin calcium）。

「必要行動、限制或使用上限」一欄的資訊將為您說明 Health Net Cal MediConnect 在承保您的藥品時是否有任何規定。

縮寫代表意義作用方式AL 年齡限制如果您的年齡不符合製藥公司、FDA 或臨床的

準則，該藥品可能需要事先授權。

B/D Medicare B 部分或 D 部分

此藥品可能需要事先授權才能決定該藥品應屬於 Medicare B 部分或 D 部分的承保範圍。這是 Medicare 的一項規定。您的醫師或其他開立處方者可能必須提供更多資訊以協助我們作此決定。

GL 性別限制此藥品可能僅能供男性或女性安全使用。

LA 取得來源有限此藥品可能僅可在某家或少數藥房取得，原因如下：

• FDA 限制該藥品僅能由特定設施、藥房或開立處方者提供；或

• 某些藥品需要特殊處理或病人需要經過訓練，因而無法在零售藥房提供。

您應向您的醫師、其他開立處方者或藥劑師洽詢有關領取取得來源有限之藥品的詳細資訊。

MO 郵購您可透過 Health Net Cal MediConnect 的郵購藥房領取此類藥品。


ix

縮寫代表意義作用方式NF 不屬於承保範圍此藥品不屬於藥品清單的承保範圍。您可申請

例外處理以使該藥品獲得承保。

NT 不屬於 D 部分此藥品不屬於「D 部分藥品」。您將無需為這些藥品支付共付額。

PA 事先授權此藥品需要事先授權。這表示您或您的醫師必須先取得 Health Net Cal MediConnect 的核准，您才可以領取處方藥。如果您未獲得核准，本計畫可能無法承保該藥品。

QL 藥量限制 Health Net Cal MediConnect 針對此藥品設有承保藥量限制。

RX/OTC 處方和非處方藥 (OTC) 藥品

此藥品有處方和 OTC 形式。

SL 安全限制基於獲得 FDA 證實的安全因素考量，本藥品有每日劑量上限限制。這代表 Health Net 將不會承保超過每日劑量上限的藥量。例如，FDA 規定 simvastatin 的每日劑量上限為 80 毫克。因此，我們將僅會承保每天兩錠 40 毫克的 simvastatin。

ST 階段療法此藥品需要遵守階段療法規定。這表示您將必須針對您的醫療狀況依序試用一些藥品。您可能必須先試用某種藥品，而後我們才會承保其他藥品。如果您的醫師認為第一種藥品對您沒有療效，那麼我們將會承保第二種藥品。

x

注意：藥品旁邊有 NT 標示代表該藥品不屬於「D 部分藥品」。您將無需為這些藥品支付共付額。這類藥品也有不同

的上訴規定。上訴是指透過正式方式要求我們審查我們所作的承保決定，且若

您認為我們的決定有誤，要求我們變更

我們的決定。例如，我們可能決定某項

您欲取得的藥品不屬於承保範圍或不

再屬於 Medicare 或 Medi-Cal 的承保範圍。如果您或您的醫師不同意我們的決

定，您可以提出上訴。如果您在任何時

候有疑問，請致電與會員服務部聯絡，

如果您在 Los Angeles County，請致電 1-855-464-3571；如果您在 San Diego County，請致電 1-855-464-3572；聽障專線：711。您也可參閱會員手冊以瞭解針對我們決定提出上訴的方式。

按醫療病況排列的藥品清單本節中的藥品是根據藥品用於治療醫療

病況的類型來分類。例如，如果您患有

心臟病況，您即應查詢「心血管藥品 - 各式藥品 – 用於治療心臟和循環系統病況的藥品」類別。您將可在該類別中找

到治療心臟病況的藥品。

Name of drug

Whatthe

drugwillcostyou(tier

level)

Necessaryactions,restrictions, orlimits on use

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating DisordersAmphetaminesADDERALL XR CP24(Amphetamine-Dextroamphetamine)

NFMO

amphetamine-dextroamphetamine cp24

$0-$2.95(Tier

1)

MO

amphetamine-dextroamphetamine tabs

$0-$2.95(Tier

1)

MO

DESOXYN TABS(Methamphetamine HCl) NF MO

DEXEDRINE CP24(DextroamphetamineSulfate)

NFMO

dextroamphetamine sulfatecp24 10 mg, 15 mg, 5 mg

$0-$2.95(Tier

1)

MO

dextroamphetamine sulfatetabs 10 mg, 5 mg

$0-$2.95(Tier

1)

MO

methamphetamine hcl tabs$0-

$2.95(Tier

1)

MO

Anorexiants Non-AmphetamineADIPEX-P CAPS(Phentermine HCl) NF PA; MO; NT

ADIPEX-P TABS(Phentermine HCl) NF PA; MO; NT

benzphetamine hcl tabs 25mg

$0(Tier

3)

PA; MO; NT

Name of drug

Whatthe


level)


diethylpropion hcl tabs 25mg

$0(Tier

3)

PA; MO; NT

DIETHYLPROPION HCLTABS 25 MG(Diethylpropion HCl)

NFPA; MO; NT

diethylpropion hcl tb24 75mg

$0(Tier

3)

PA; MO; NT

phentermine hcl caps$0

(Tier3)

PA; MO; NT

phentermine hcl tabs$0

(Tier3)

PA; MO; NT

QSYMIA CP24$0

(Tier3)

PA; NT

REGIMEX TABS$0

(Tier3)

PA; MO; NT

SUPRENZA TBDP 15 MG,30 MG

$0(Tier

3)

PA; MO; NT

Anti-Obesity Agents

ALLI CAPS$0

(Tier3)

PA; NT

BELVIQ TABS$0

(Tier3)

PA; MO; NT

BELVIQ XR TB24$0

(Tier3)

PA; MO; NT

CONTRAVE TB12$0

(Tier3)

PA; MO; NT

SAXENDA SOPN$0

(Tier3)

PA; MO; NT

You can find information on what the symbols and abbreviations in this table mean by going topage viii.

Health Net 2016 Cal MediConnect Drug List Updated 12/1/2016

1

Name of drug

Whatthe


level)


XENICAL CAPS$0

(Tier3)

PA; MO; NT

Attention-Deficit/Hyperactivity Disorder (ADHD)

clonidine hcl (adhd) tb12$0-

$2.95(Tier

1)

MO

guanfacine hcl (adhd) tb24$0-

$2.95(Tier

1)

AL; MO

INTUNIV TB24(Guanfacine HCl (ADHD)) NF AL; MO

KAPVAY TB12 (ClonidineHCl (ADHD)) NF MO

STRATTERA CAPS 10 MG$0-

$7.40(Tier

2)

SL(10 ea daily);MO

STRATTERA CAPS 100MG

$0-$7.40(Tier

2)

SL(1 ea daily);MO


$7.40(Tier

2)

SL(5.55 eadaily); MO


$7.40(Tier

2)

SL(4 ea daily);MO


$7.40(Tier

2)

SL(2.5 eadaily); MO


$7.40(Tier

2)


Name of drug

Whatthe


level)



$7.40(Tier

2)


Stimulants - Misc.CONCERTA TBCR 27 MG,36 MG (MethylphenidateHCl)

NFMO

dexmethylphenidate hclcp24 15 mg

$0-$2.95(Tier

1)

MO

dexmethylphenidate hcltabs 10 mg, 2.5 mg, 5 mg

$0-$2.95(Tier

1)

MO

FOCALIN TABS(Dexmethylphenidate HCl) NF MO

FOCALIN XR CP24 15 MG(Dexmethylphenidate HCl) NF MO

METADATE CD CPCR(Methylphenidate HCl) NF MO

methylphenidate hcl cp24or 20 mg, 30 mg, 40 mg

$0-$2.95(Tier

1)

MO

methylphenidate hcl cpcr or10 mg, 20 mg, 30 mg, 40mg, 50 mg, 60 mg

$0-$2.95(Tier

1)

MO

methylphenidate hcl tabs or10 mg, 20 mg, 5 mg

$0-$2.95(Tier

1)

MO

methylphenidate hcl tb24 or27 mg, 36 mg

$0-$2.95(Tier

1)

methylphenidate hcl tbcr or20 mg, 27 mg, 36 mg

$0-$2.95(Tier

1)

MO



2

Name of drug

Whatthe


level)


modafinil tabs$0-

$2.95(Tier

1)

PA; MO

PROVIGIL TABS(Modafinil) NF PA; MO

RITALIN LA CP24 20 MG,30 MG, 40 MG(Methylphenidate HCl)

NFMO

RITALIN LA CP24 60 MG$0-

$7.40(Tier

2)

MO

RITALIN TABS(Methylphenidate HCl) NF MO

ALTERNATIVE MEDICINES

Alternative Medicine - A's

ALPHA LIPOIC ACIDCAPS OR 50 MG

$0(Tier

3)

NT

alpha-lipoic acid (thiocticacid) caps 100 mg

$0(Tier

3)

MO; NT

ALPHA-LIPOIC ACIDCAPS

$0(Tier

3)

NT

Alternative Medicine - C's

CHEW Q CHEW 100 MG$0

(Tier3)

NT

coenzyme q10(ubidecarenone) caps 10mg, 150 mg, 60 mg

$0(Tier

3)

NT

coenzyme q10(ubidecarenone) caps 30mg

$0(Tier

3)

MO; NT

COENZYME Q10 CHEWOR 60 MG

$0(Tier

3)

NT

Name of drug

Whatthe


level)


COENZYME Q10 TABSOR 25 MG

$0(Tier

3)

MO; NT

Alternative Medicine - G's

glucosamine sulfate capsor 500 mg

$0(Tier

3)

MO; NT

glucosamine sulfate tabs or500 mg

$0(Tier

3)

NT

Alternative Medicine - L's

lutein caps or 6 mg$0

(Tier3)

NT

Alternative Medicine Combinations

glucosamine-chondroitincaps 200mg-250mg

$0(Tier

3)

NT

glucosamine-chondroitintabs 200mg-250mg

$0(Tier

3)

NT

LIQ-10 SYRP 50MG/5ML-15UNIT/5ML

$0(Tier

3)

NT

VITALINECOQ10/VITAMIN E WAFR100MG-300UNIT

$0(Tier

3)

NT

AMINOGLYCOSIDES - Drugs to Treat BacterialInfectionsAminoglycosides

amikacin sulfate soln ij 1gm/4ml, 500 mg/2ml

$0-$2.95(Tier

1)

MO

BETHKIS NEBU$0-

$7.40(Tier

2)

B/D



3

Name of drug

Whatthe


level)


gentamicin in saline soln0.9%-1mg/ml

$0-$2.95(Tier

1)

gentamicin sulfate soln ij40 mg/ml

$0-$2.95(Tier

1)

MO

KITABIS PAK NEBU$0-

$7.40(Tier

2)

B/D

neomycin sulfate tabs or$0-

$2.95(Tier

1)

MO

paromomycin sulfate caps$0-

$2.95(Tier

1)

MO

TOBI NEBU (Tobramycin) NF B/D

TOBI PODHALER CAPS$0-

$7.40(Tier

2)

tobramycin nebu in$0-

$2.95(Tier

1)

B/D

tobramycin sulfate soln ij1.2 gm/30ml, 40 mg/ml, 80mg/2ml

$0-$2.95(Tier

1)

MO

tobramycin sulfate solr ij1.2 gm

$0-$2.95(Tier

1)

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditionsAnti-TNF-alpha - Monoclonal Antibodies

Name of drug

Whatthe


level)


HUMIRA PEDIATRICCROHNS DISEASESTARTER PACK PSKT

$0-$7.40(Tier

2)

PA

HUMIRA PEN PNKT$0-

$7.40(Tier

2)

PA

HUMIRA PEN-CROHNSDISEASESTARTER PNKT

$0-$7.40(Tier

2)

PA

HUMIRA PEN-PSORIASISSTARTER PNKT

$0-$7.40(Tier

2)

PA

HUMIRA PSKT$0-

$7.40(Tier

2)

PA

SIMPONI ARIA SOLN$0-

$7.40(Tier

2)

PA

SIMPONI SOAJ$0-

$7.40(Tier

2)

PA

SIMPONI SOSY$0-

$7.40(Tier

2)

PA

Antirheumatic - Enzyme Inhibitors

XELJANZ TABS$0-

$7.40(Tier

2)

PA

Antirheumatic Antimetabolites

OTREXUP SOAJ$0-

$7.40(Tier

2)

PA



4

Name of drug

Whatthe


level)


RASUVO SOAJ$0-

$7.40(Tier

2)

PA

Gold Compounds

RIDAURA CAPS$0-

$7.40(Tier

2)

MO

Interleukin-1 Blockers

ARCALYST SOLR$0-

$7.40(Tier

2)

LA

Interleukin-1 Receptor Antagonist (IL-1Ra)

KINERET SOSY$0-

$7.40(Tier

2)

PA

Interleukin-1beta Blockers

ILARIS SOLR$0-

$7.40(Tier

2)

LA

Interleukin-6 Receptor Inhibitors

ACTEMRA SOLN$0-

$7.40(Tier

2)

PA

ACTEMRA SOSY$0-

$7.40(Tier

2)

PA

Nonsteroidal Anti-inflammatory Agents (NSAIDs)ADVIL CAPS (Ibuprofen) NF MO; NT

ADVIL MIGRAINE CAPS(Ibuprofen) NF MO; NT

ADVIL TABS (Ibuprofen) NF MO; NT

Name of drug

Whatthe


level)


ALEVE CAPS (NaproxenSodium) NF NT

ANAPROX DS TABS(Naproxen Sodium) NF MO

ARTHROTEC 50 TBEC(Diclofenac w/ Misoprostol) NF MO

ARTHROTEC 75 TBEC(Diclofenac w/ Misoprostol) NF MO

CATAFLAM TABS(Diclofenac Potassium) NF MO

CELEBREX CAPS(Celecoxib) NF MO

celecoxib caps$0-

$2.95(Tier

1)

MO

CHILDRENS MOTRINJUNIOR STRENGTHCHEW (Ibuprofen)

NFMO; NT

DAYPRO TABS(Oxaprozin) NF MO

diclofenac potassium tabs$0-

$2.95(Tier

1)

MO

diclofenac sodium tb24 or100 mg

$0-$2.95(Tier

1)

MO

diclofenac sodium tbec or25 mg, 50 mg, 75 mg

$0-$2.95(Tier

1)

MO

diclofenac w/ misoprostoltbec

$0-$2.95(Tier

1)

MO

EC-NAPROSYN TBEC(Naproxen) NF MO



5

Name of drug

Whatthe


level)


etodolac caps 200 mg, 300mg

$0-$2.95(Tier

1)

MO

etodolac tabs 400 mg, 500mg

$0-$2.95(Tier

1)

MO

etodolac tb24 400 mg, 500mg, 600 mg

$0-$2.95(Tier

1)

MO

FELDENE CAPS(Piroxicam) NF MO

flurbiprofen tabs or 100 mg,50 mg

$0-$2.95(Tier

1)

MO

ibuprofen caps or 200 mg$0

(Tier3)

MO; NT

ibuprofen chew or 100 mg$0

(Tier3)

MO; NT

ibuprofen susp or 100mg/5ml

$0-$2.95(Tier

1)

RX/OTC; MO

ibuprofen susp or 40mg/ml, 50 mg/1.25ml

$0(Tier

3)

NT

ibuprofen tabs or 100 mg$0

(Tier3)

NT

ibuprofen tabs or 200 mg$0

(Tier3)

MO; NT

ibuprofen tabs or 400 mg$0-

$2.95(Tier

1)

SL(8 ea daily);MO

Name of drug

Whatthe


level)



$2.95(Tier

1)



$2.95(Tier

1)

SL(4 ea daily);MO

indomethacin caps or 25mg, 50 mg

$0-$2.95(Tier

1)

AL; MO

indomethacin cpcr or 75mg

$0-$2.95(Tier

1)

AL; MO

INFANTS ADVIL SUSP(Ibuprofen) NF NT

ketoprofen caps or 50 mg,75 mg

$0-$2.95(Tier

1)

MO

ketorolac tromethaminesoln ij 15 mg/ml, 30 mg/ml

$0-$2.95(Tier

1)

AL; MO

ketorolac tromethaminesoln im 30 mg/ml, 60mg/2ml

$0-$2.95(Tier

1)

AL; MO

mefenamic acid caps or$0-

$2.95(Tier

1)

MO

meloxicam tabs or 15 mg,7.5 mg

$0-$2.95(Tier

1)

MO

MOBIC TABS 15 MG, 7.5MG (Meloxicam) NF MO

MOTRIN INFANTSDROPS SUSP (Ibuprofen) NF NT



6

Name of drug

Whatthe


level)


MOTRIN INFANTS SUSP(Ibuprofen) NF NT

MOTRIN JUNIORSTRENGTH TABS(Ibuprofen)

NFNT

nabumetone tabs$0-

$2.95(Tier

1)

MO

NAPROSYN TABS 250MG, 375 MG, 500 MG(Naproxen)

NFMO

naproxen sodium caps or220 mg

$0(Tier

3)

NT

naproxen sodium tabs or275 mg, 550 mg

$0-$2.95(Tier

1)

MO

naproxen tabs or 250 mg,375 mg, 500 mg

$0-$2.95(Tier

1)

MO

naproxen tbec or 375 mg,500 mg

$0-$2.95(Tier

1)

MO

oxaprozin tabs$0-

$2.95(Tier

1)

MO

piroxicam caps or 10 mg,20 mg

$0-$2.95(Tier

1)

MO

PONSTEL CAPS(Mefenamic Acid) NF MO

sulindac tabs or 150 mg,200 mg

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


tolmetin sodium caps 400mg

$0-$2.95(Tier

1)

MO

tolmetin sodium tabs 200mg

$0-$2.95(Tier

1)VOLTAREN-XR TB24(Diclofenac Sodium) NF MO

Phosphodiesterase 4 (PDE4) Inhibitors

OTEZLA TABS$0-

$7.40(Tier

2)

PA

OTEZLA TBPK$0-

$7.40(Tier

2)

PA

Pyrimidine Synthesis InhibitorsARAVA TABS(Leflunomide) NF MO

leflunomide tabs or 10 mg,20 mg

$0-$2.95(Tier

1)

MO

Selective Costimulation Modulators

ORENCIA CLICKJECTSOAJ

$0-$7.40(Tier

2)

PA

ORENCIA SOLR$0-

$7.40(Tier

2)

PA

ORENCIA SOSY$0-

$7.40(Tier

2)

PA

Soluble Tumor Necrosis Factor Receptor Agents



7

Name of drug

Whatthe


level)


ENBREL SOLR$0-

$7.40(Tier

2)

PA

ENBREL SOSY$0-

$7.40(Tier

2)

PA

ENBREL SURECLICKSOAJ

$0-$7.40(Tier

2)

PA

ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint ConditionsAnalgesic Combinations

acetaminophen-caffeine-pyrilamine tabs

$0(Tier

3)

NT

BIPHENOX TABS$0

(Tier3)

NT

MIDOL COMPLETE TABS500MG-15MG-60MG(Acetaminophen-Caffeine-Pyrilamine)

NF

NT

MIDOL MAXIMUMSTRENGTH MENSTRUALFORMULA TABS(Acetaminophen-Caffeine-Pyrilamine)

NF

NT

MIDOL MAXIMUMSTRENGTH MENSTRUALTABS (Acetaminophen-Caffeine-Pyrilamine)

NF

NT

Analgesics Other

acetaminophen chew or160 mg

$0(Tier

3)

NT

acetaminophen chew or 80mg

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


acetaminophen elix or 160mg/5ml, 80 mg/2.5ml

$0(Tier

3)

NT

acetaminophen liqd or 160mg/5ml

$0(Tier

3)

MO; NT

acetaminophen soln or 160mg/5ml, 80 mg/0.8ml

$0(Tier

3)

MO; NT

acetaminophen supp re120 mg

$0(Tier

3)

MO; NT

acetaminophen susp or160 mg/5ml, 80 mg/2.5ml

$0(Tier

3)

MO; NT

acetaminophen susp or 80mg/0.8ml

$0(Tier

3)

NT

acetaminophen tbdp or 160mg

$0(Tier

3)

MO; NT

acetaminophen tbdp or 80mg

$0(Tier

3)

NT

ELIXSURE FEVER/PAINGEL

$0(Tier

3)

NT

FEVERALL INFANTSSUPP

$0(Tier

3)

NT

INFANTS SILAPAP SOLN$0

(Tier3)

MO; NT

TYLENOL CHILDRENSSUSP (Acetaminophen) NF MO; NT

TYLENOL INFANTSPAIN+FEVER SUSP(Acetaminophen)

NFMO; NT

TYLENOL INFANTS SUSP(Acetaminophen) NF MO; NT

Salicylates



8

Name of drug

Whatthe


level)


ASCRIPTIN TABS$0

(Tier3)

NT

aspirin buffered (cal carb-mag carb-mag oxide) tabs

$0(Tier

3)

MO; NT

ASPIRIN LOW DOSETABS

$0(Tier

3)

NT

ASPIRIN SUPP RE 120MG, 200 MG

$0(Tier

3)

NT

aspirin supp re 300 mg,600 mg

$0(Tier

3)

NT

aspirin tabs or 325 mg$0

(Tier3)

MO; NT

aspirin tbec or 324 mg, 325mg, 500 mg, 81 mg

$0(Tier

3)

MO; NT

BUFFERIN TABS (AspirinBuffered (Cal Carb-MagCarb-Mag Oxide))

NFMO; NT

diflunisal tabs$0-

$2.95(Tier

1)

MO

ECOTRIN MAXIMUMSTRENGTH TBEC(Aspirin)

NFMO; NT

ECOTRIN REGULARSTRENGTH TBEC(Aspirin)

NFMO; NT

ST JOSEPH ADULTANALGESICLOW DOSEBITE SIZE CHEW

$0(Tier

3)

NT

ST JOSEPH ADULTCHEW

$0(Tier

3)

NT

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint Conditions

Name of drug

Whatthe


level)


Opioid AgonistsACTIQ LPOP 1200 MCG,1600 MCG, 400 MCG, 600MCG, 800 MCG (FentanylCitrate)

NF

PA; QL(4 eadaily); MO

ACTIQ LPOP 200 MCG(Fentanyl Citrate) NF PA; QL(6 ea

daily); MODEMEROL SOLN IJ 100MG/ML, 50 MG/ML(Meperidine HCl)

NFAL; MO

DEMEROL SOLN IJ 25MG/ML (Meperidine HCl) NF AL

DILAUDID LIQD OR 1MG/ML (HydromorphoneHCl)

NFQL(32 mldaily); MO

DILAUDID SOLN IJ 2MG/ML

$0-$7.40(Tier

2)DILAUDID TABS OR 2 MG(Hydromorphone HCl) NF QL(29 ea

daily); MODILAUDID TABS OR 4 MG(Hydromorphone HCl) NF QL(14 ea

daily); MODILAUDID TABS OR 8 MG(Hydromorphone HCl) NF QL(7 ea daily);

MODILAUDID-HP SOLN 10MG/ML (HydromorphoneHCl)

NF

DOLOPHINE TABS 10 MG(Methadone HCl) NF QL(19 ea

daily); MODOLOPHINE TABS 5 MG(Methadone HCl) NF QL(38 ea

daily); MODURAGESIC PT72 100MCG/HR (Fentanyl) NF QL(1 ea daily);

MO

DURAGESIC PT72 12MCG/HR (Fentanyl) NF

Limit 43patches permonth;QL(1.44ea daily); MO



9

Name of drug

Whatthe


level)








fentanyl citrate lpop bu1200 mcg, 1600 mcg, 400mcg, 600 mcg, 800 mcg

$0-$2.95(Tier

1)


fentanyl citrate lpop bu 200mcg

$0-$2.95(Tier

1)


fentanyl pt72 100 mcg/hr$0-

$2.95(Tier

1)

QL(1 ea daily);MO


$2.95(Tier

1)



$2.95(Tier

1)



$2.95(Tier

1)



$2.95(Tier

1)


Name of drug

Whatthe


level)


hydromorphone hcl liqd or1 mg/ml

$0-$2.95(Tier

1)

QL(32 mldaily); MO

hydromorphone hcl soln ij10 mg/ml, 50 mg/5ml, 500mg/50ml

$0-$2.95(Tier

1)

hydromorphone hcl soln ij 2mg/ml

$0-$2.95(Tier

1)

MO

hydromorphone hcl tabs or2 mg

$0-$2.95(Tier

1)

QL(29 eadaily); MO


$0-$2.95(Tier

1)

QL(14 eadaily); MO


$0-$2.95(Tier

1)

QL(7 ea daily);MO

KADIAN CP24 10 MG(Morphine Sulfate) NF QL(20 ea

daily); MOKADIAN CP24 100 MG(Morphine Sulfate) NF QL(6 ea daily);

MOKADIAN CP24 20 MG, 30MG, 50 MG, 60 MG, 80 MG(Morphine Sulfate)

NFQL(5 ea daily);MO

LAZANDA SOLN 100MCG/ACT

$0-$7.40(Tier

2)



$0-$7.40(Tier

2)

PA; QL(5 eadaily)


$0-$7.40(Tier

2)

PA; QL(4 eadaily)



10

Name of drug

Whatthe


level)


meperidine hcl soln ij 100mg/ml, 50 mg/ml

$0-$2.95(Tier

1)

AL; MO

meperidine hcl soln ij 25mg/ml

$0-$2.95(Tier

1)

AL

methadone hcl conc or 10mg/ml

$0-$2.95(Tier

1)

QL(4 ml daily);MO

methadone hcl soln or 10mg/5ml

$0-$2.95(Tier

1)

QL(20 mldaily); MO

methadone hcl soln or 5mg/5ml

$0-$2.95(Tier

1)

QL(40 mldaily); MO

methadone hcl tabs or 10mg

$0-$2.95(Tier

1)

QL(19 eadaily); MO

methadone hcl tabs or 5mg

$0-$2.95(Tier

1)

QL(38 eadaily); MO

METHADOSE CONC(Methadone HCl) NF QL(4 ml daily);

MOMETHADOSE SUGAR-FREE CONC (MethadoneHCl)

NFQL(4 ml daily);MO

morphine sulfate cp24 or10 mg

$0-$2.95(Tier

1)

QL(20 eadaily); MO

morphine sulfate cp24 or100 mg

$0-$2.95(Tier

1)

QL(6 ea daily);MO

Name of drug

Whatthe


level)


morphine sulfate cp24 or20 mg, 30 mg, 50 mg, 60mg, 80 mg

$0-$2.95(Tier

1)

QL(5 ea daily);MO

morphine sulfate soln ij 0.5mg/ml

$0-$2.95(Tier

1)

morphine sulfate soln ij 1mg/ml

$0-$2.95(Tier

1)

MO

morphine sulfate soln or 10mg/5ml

$0-$2.95(Tier

1)

QL(60 mldaily); MO

morphine sulfate soln or100 mg/5ml, 20 mg/ml

$0-$2.95(Tier

1)

QL(6 ml daily);MO

morphine sulfate soln or 20mg/5ml

$0-$2.95(Tier

1)

QL(30 mldaily); MO

MORPHINE SULFATETABS OR 15 MG

$0-$7.40(Tier

2)

QL(8 ea daily);MO

MORPHINE SULFATETABS OR 30 MG

$0-$7.40(Tier

2)

QL(14 eadaily); MO

morphine sulfate tbcr or100 mg

$0-$2.95(Tier

1)

QL(6 ea daily);MO

morphine sulfate tbcr or 15mg

$0-$2.95(Tier

1)

QL(8 ea daily);MO



11

Name of drug

Whatthe


level)


morphine sulfate tbcr or200 mg

$0-$2.95(Tier

1)

QL(3 ea daily);MO

morphine sulfate tbcr or 30mg, 60 mg

$0-$2.95(Tier

1)

QL(5 ea daily);MO

MS CONTIN TBCR 100MG (Morphine Sulfate) NF QL(6 ea daily);

MOMS CONTIN TBCR 15 MG(Morphine Sulfate) NF QL(8 ea daily);

MOMS CONTIN TBCR 200MG (Morphine Sulfate) NF QL(3 ea daily);

MOMS CONTIN TBCR 30 MG,60 MG (Morphine Sulfate) NF QL(5 ea daily);

MOOPANA TABS OR 10 MG(Oxymorphone HCl) NF QL(4 ea daily);

MOOPANA TABS OR 5 MG(Oxymorphone HCl) NF QL(8 ea daily);

MO

oxycodone hcl caps or 5mg

$0-$2.95(Tier

1)

QL(17 eadaily); MO

oxycodone hcl conc or 100mg/5ml

$0-$2.95(Tier

1)

QL(4 ml daily);MO

oxycodone hcl tabs or 15mg

$0-$2.95(Tier

1)

QL(11 eadaily); MO

oxycodone hcl tabs or 30mg

$0-$2.95(Tier

1)

QL(15 eadaily); MO

oxycodone hcl tabs or 5 mg$0-

$2.95(Tier

1)

QL(17 eadaily); MO

Name of drug

Whatthe


level)


oxymorphone hcl tabs 10mg

$0-$2.95(Tier

1)

QL(4 ea daily);MO

oxymorphone hcl tabs 5 mg$0-

$2.95(Tier

1)

QL(8 ea daily);MO

oxymorphone hcl tb12 15mg

$0-$2.95(Tier

1)

QL(2.67 eadaily); MO

oxymorphone hcl tb12 7.5mg

$0-$2.95(Tier

1)

QL(5 ea daily);MO

ROXICODONE TABS 15MG (Oxycodone HCl) NF QL(11 ea

daily); MOROXICODONE TABS 30MG (Oxycodone HCl) NF QL(15 ea

daily); MOROXICODONE TABS 5MG (Oxycodone HCl) NF QL(17 ea

daily); MO

SUBSYS LIQD 100 MCG,200 MCG

$0-$7.40(Tier

2)


SUBSYS LIQD 1200 MCG$0-

$7.40(Tier

2)

PA; QL(4 eadaily)

SUBSYS LIQD 1600 MCG,400 MCG, 600 MCG, 800MCG

$0-$7.40(Tier

2)


tramadol hcl tabs or 50 mg$0-

$2.95(Tier

1)

SL(8 ea daily);MO

tramadol hcl tb24 or 100mg

$0-$2.95(Tier

1)

SL(3 ea daily);MO



12

Name of drug

Whatthe


level)



$0-$2.95(Tier

1)

SL(1.5 eadaily); MO


$0-$2.95(Tier

1)

SL(1 ea daily);MO

ULTRAM ER TB24 100MG (Tramadol HCl) NF SL(3 ea daily);

MOULTRAM ER TB24 200MG (Tramadol HCl) NF SL(1.5 ea

daily); MOULTRAM ER TB24 300MG (Tramadol HCl) NF SL(1 ea daily);

MOULTRAM TABS (TramadolHCl) NF SL(8 ea daily);

MO

ZOHYDRO ER C12A 10MG, 15 MG, 20 MG, 30MG, 40 MG, 50 MG

$0-$7.40(Tier

2)


ZOHYDRO ER CP12 10MG, 15 MG, 20 MG, 30MG, 40 MG, 50 MG

$0-$7.40(Tier

2)

PA; QL(2 eadaily)

Opioid Combinations

acetaminophen w/ codeinesoln 120mg/5ml-12mg/5ml

$0-$2.95(Tier

1)

SL(166 mldaily); MO

acetaminophen w/ codeinetabs 300mg-15mg

$0-$2.95(Tier

1)


acetaminophen w/ codeinetabs 300mg-30mg, 300mg-60mg

$0-$2.95(Tier

1)

SL(13 ea daily);MO

butalbital-aspirin-caffeinew/cod caps

$0-$2.95(Tier

1)

AL; MO

Name of drug

Whatthe


level)


FIORINAL/CODEINE #3CAPS (Butalbital-Aspirin-Caffeine w/Cod)

NFAL; MO

hydrocodone-acetaminophen soln2.5mg/5ml-108mg/5ml,5mg/10ml-217mg/10ml,7.5mg/15ml-325mg/15ml

$0-$2.95(Tier

1)

Limit 5535mlspermonth;SL(184.5 ml daily); MO

hydrocodone-acetaminophen tabs 10mg-300mg, 5mg-300mg,7.5mg-300mg

$0-$2.95(Tier

1)


hydrocodone-acetaminophen tabs 10mg-325mg, 5mg-325mg,7.5mg-325mg

$0-$2.95(Tier

1)


hydrocodone-ibuprofentabs

$0-$2.95(Tier

1)

MO

oxycodone w/acetaminophen soln5mg/5ml-325mg/5ml

$0-$2.95(Tier

1)

Limit 1845mlspermonth;SL(61.5ml daily)

oxycodone w/acetaminophen tabs 10mg-325mg, 2.5mg-325mg,5mg-325mg, 7.5mg-325mg

$0-$2.95(Tier

1)


oxycodone-aspirin tabs$0-

$2.95(Tier

1)

MO

PERCODAN TABS(Oxycodone-Aspirin) NF MO

tramadol-acetaminophentabs

$0-$2.95(Tier

1)

SL(8 ea daily);MO

ULTRACET TABS(Tramadol-Acetaminophen) NF SL(8 ea daily);

MOVICOPROFEN TABS(Hydrocodone-Ibuprofen) NF MO



13

Name of drug

Whatthe


level)


Opioid Partial AgonistsBUPRENEX SOLN(Buprenorphine HCl) NF MO

buprenorphine hcl soln ij0.3 mg/ml

$0-$2.95(Tier

1)

MO

buprenorphine hcl subl sl 2mg

$0-$2.95(Tier

1)


buprenorphine hcl subl sl 8mg

$0-$2.95(Tier

1)


buprenorphine hcl-naloxone hcl dihydrate subl2mg-0.5mg

$0-$2.95(Tier

1)


buprenorphine hcl-naloxone hcl dihydrate subl8mg-2mg

$0-$2.95(Tier

1)


butorphanol tartrate soln ij2 mg/ml

$0-$2.95(Tier

1)

MO

butorphanol tartrate soln na10 mg/ml

$0-$2.95(Tier

1)

Limit 126mlspermonth;QL(4.2ml daily); MO

nalbuphine hcl soln ij 10mg/ml, 20 mg/ml

$0-$2.95(Tier

1)

MO

ANDROGENS-ANABOLIC - Drugs to RegulateHormonesAnabolic Steroids

ANADROL-50 TABS$0-

$7.40(Tier

2)

MO

Name of drug

Whatthe


level)


OXANDRIN TABS(Oxandrolone) NF MO

oxandrolone tabs or 10 mg,2.5 mg

$0-$2.95(Tier

1)

MO

Androgens

ANDRODERM PT24$0-

$7.40(Tier

2)

GL; MO

ANDROGEL GEL 20.25MG/1.25GM, 40.5MG/2.5GM

$0-$7.40(Tier

2)

GL; MO

ANDROGEL GEL 25MG/2.5GM, 50 MG/5GM(Testosterone)

$0-$7.40(Tier

2)

GL; MO

ANDROGEL PUMP GEL1.62 %

$0-$7.40(Tier

2)

GL; MO

AVEED SOLN$0-

$7.40(Tier

2)

LA

danazol caps or 100 mg,200 mg, 50 mg

$0-$2.95(Tier

1)

MO

fluoxymesterone tabs or$0-

$2.95(Tier

1)

MO

testosterone cypionate soln$0-

$2.95(Tier

1)

MO

testosterone enanthatesoln im

$0-$2.95(Tier

1)

MO



14

Name of drug

Whatthe


level)


testosterone gel td 1 %, 25mg/2.5gm, 50 mg/5gm

$0-$2.95(Tier

1)

GL; MO

TESTOSTERONE GEL TD1 %, 25 MG/2.5GM, 50MG/5GM

$0-$7.40(Tier

2)

GL; MO

TESTOSTERONE PUMPGEL

$0-$7.40(Tier

2)

GL; MO

VOGELXO GEL$0-

$7.40(Tier

2)

GL; MO

VOGELXO PUMP GEL$0-

$7.40(Tier

2)

GL; MO

ANORECTAL AGENTS - Rectal Drugs to TreatPain, Swelling and ItchingIntrarectal SteroidsCORTENEMA ENEM(Hydrocortisone(Intrarectal))

NFMO

hydrocortisone (intrarectal)enem

$0-$2.95(Tier

1)

MO

UCERIS FOAM RE 2MG/ACT

$0-$7.40(Tier

2)

MO

Rectal Combinations

phenylephrine-shark liveroil-glycerin-petrolatum crea

$0(Tier

3)

NT

Rectal Products - Misc.

Name of drug

Whatthe


level)


starch (topical) supp$0

(Tier3)

NT

Rectal Steroids

hydrocortisone (rectal) crea$0-

$2.95(Tier

1)

MO

PROCTOCORT CREA 1 %(Hydrocortisone (Rectal)) NF MO

Vasodilating Agents

RECTIV OINT$0-

$7.40(Tier

2)

MO

ANTACIDS - Ulcer and Stomach Acid Drugs

Antacid Combinationsalum & mag hydrox-simethicone chew 200mg-25mg-200mg

$0(Tier

3)

NT

alum & mag hydrox-simethicone liqd200mg/5ml-20mg/5ml-200mg/5ml, 400mg/5ml-40mg/5ml-400mg/5ml

$0(Tier

3)

MO; NT

alum & mag hydrox-simethicone susp200mg/5ml-200mg/5ml-20mg/5ml-20mg/5ml-200mg/5ml-200mg/5ml,200mg/5ml-20mg/5ml-200mg/5ml, 400mg/5ml-400mg/5ml-40mg/5ml-40mg/5ml-400mg/5ml-400mg/5ml, 400mg/5ml-40mg/5ml-400mg/5ml

$0(Tier

3)

MO; NT

aluminum hydroxide-magtrisil chew

$0(Tier

3)

NT



15

Name of drug

Whatthe


level)


GELUSIL CHEW 200MG-25MG-200MG (Alum &Mag Hydrox-Simethicone)

NFNT

HYVEE ADVANCEDANTACID MAXIMUMSTRENGTH SUSP (Alum& Mag Hydrox-Simethicone)

NF

MO; NT

MYLANTA DOUBLE-STRENGTH SUSP (Alum& Mag Hydrox-Simethicone)

NF

MO; NT

MYLANTA SUSP200MG/5ML-20MG/5ML-200MG/5ML (Alum & MagHydrox-Simethicone)

NF

MO; NT

Antacids - Aluminum Salts

ALUMINUM HYDROXIDESUSP OR

$0(Tier

3)

NT

Antacids - Calcium Saltscalcium carbonate(antacid) chew 500 mg,750 mg

$0(Tier

3)

MO; NT

calcium carbonate(antacid) chew 600 mg

$0(Tier

3)

NT

calcium carbonate(antacid) tabs 648 mg

$0(Tier

3)

MO; NT

MAALOX CHEW$0

(Tier3)

NT

TUMS CHEW (CalciumCarbonate (Antacid)) NF MO; NT

TUMS E-X 750 CHEW(Calcium Carbonate(Antacid))

NFMO; NT

TUMS KIDS CHEW(Calcium Carbonate(Antacid))

NFMO; NT

Name of drug

Whatthe


level)


TUMS LASTING EFFECTSCHEW (Calcium Carbonate(Antacid))

NFMO; NT

TUMS SMOOTHIESCHEW (Calcium Carbonate(Antacid))

NFMO; NT

ANTHELMINTICS - Drugs to Treat WormInfectionsAnthelmintics

ALBENZA TABS$0-

$7.40(Tier

2)

MO

ivermectin tabs or$0-

$2.95(Tier

1)

MO

STROMECTOL TABS(Ivermectin)

$0-$7.40(Tier

2)

MO

ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial InfectionsAnti-infective Agents - Misc.AZACTAM SOLR(Aztreonam) NF MO

aztreonam solr$0-

$2.95(Tier

1)

MO

CAYSTON SOLR$0-

$7.40(Tier

2)

LA

colistimethate sodium solr ij$0-

$2.95(Tier

1)

MO

COLY-MYCIN M SOLR(Colistimethate Sodium) NF MO



16

Name of drug

Whatthe


level)


FLAGYL CAPS 375 MG(Metronidazole) NF SL(10.6 ea

daily); MOFLAGYL TABS 250 MG(Metronidazole) NF SL(16 ea daily);

MOFLAGYL TABS 500 MG(Metronidazole) NF SL(8 ea daily);

MO

metronidazole caps or 375mg

$0-$2.95(Tier

1)


metronidazole in nacl soln$0-

$2.95(Tier

1)

metronidazole tabs or 250mg

$0-$2.95(Tier

1)

SL(16 ea daily);MO

metronidazole tabs or 500mg

$0-$2.95(Tier

1)

SL(8 ea daily);MO

NEBUPENT SOLR$0-

$7.40(Tier

2)

MO; B/D

ORBACTIV SOLR$0-

$7.40(Tier

2)

PENTAM 300 SOLR$0-

$7.40(Tier

2)

MO

TINDAMAX TABS(Tinidazole) NF MO

tinidazole tabs or 250 mg,500 mg

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


trimethoprim tabs or$0-

$2.95(Tier

1)

MO

VANCOCIN HCL CAPS(Vancomycin HCl) NF PA; MO

vancomycin hcl caps or125 mg, 250 mg

$0-$2.95(Tier

1)

PA; MO

VANCOMYCIN HCL INDEXTROSE SOLN

$0-$7.40(Tier

2)

vancomycin hcl solr iv 10gm, 1000 mg, 5000 mg

$0-$2.95(Tier

1)

vancomycin hcl solr iv 500mg

$0-$2.95(Tier

1)

MO

XIFAXAN TABS$0-

$7.40(Tier

2)

MO

Anti-infective Misc. - CombinationsBACTRIM DS TABS(Sulfamethoxazole-Trimethoprim)

NFMO

BACTRIM TABS(Sulfamethoxazole-Trimethoprim)

NFMO

sulfamethoxazole-trimethoprim soln

$0-$2.95(Tier

1)

MO

sulfamethoxazole-trimethoprim susp

$0-$2.95(Tier

1)

MO



17

Name of drug

Whatthe


level)


sulfamethoxazole-trimethoprim tabs

$0-$2.95(Tier

1)

MO

Antiprotozoal Agents

ALINIA TABS 500 MG$0-

$7.40(Tier

2)

MO

atovaquone susp$0-

$2.95(Tier

1)

MO

MEPRON SUSP(Atovaquone) NF MO

Carbapenems

imipenem-cilastatin solr$0-

$2.95(Tier

1)

MO

INVANZ SOLR IJ$0-

$7.40(Tier

2)

MO

meropenem solr$0-

$2.95(Tier

1)

MO

MERREM SOLR(Meropenem) NF MO

PRIMAXIN IV SOLR(Imipenem-Cilastatin) NF MO

Chloramphenicols

chloramphenicol sodiumsuccinate solr

$0-$2.95(Tier

1)

Cyclic Lipopeptides

Name of drug

Whatthe


level)


CUBICIN RF SOLR(Daptomycin)

$0-$7.40(Tier

2)

CUBICIN SOLR(Daptomycin)

$0-$7.40(Tier

2)

daptomycin solr$0-

$2.95(Tier

1)

Glycylcyclines

TIGECYCLINE SOLR$0-

$7.40(Tier

2)

TYGACIL SOLR$0-

$7.40(Tier

2)

Leprostatics

dapsone tabs or 100 mg,25 mg

$0-$2.95(Tier

1)

MO

LincosamidesCLEOCIN CAPS OR 150MG, 300 MG, 75 MG(Clindamycin HCl)

NFMO

CLEOCIN IN D5W SOLN(Clindamycin Phosphate inD5W)

NF

CLEOCIN PHOSPHATESOLN IJ 600 MG/4ML, 900MG/6ML (ClindamycinPhosphate)

NF

MO



18

Name of drug

Whatthe


level)


CLEOCIN PHOSPHATESOLN IV 300MG/50ML-5%, 600MG/50ML-5%,900MG/50ML-5%(Clindamycin Phosphate inD5W)

NF

clindamycin hcl caps or150 mg, 300 mg, 75 mg

$0-$2.95(Tier

1)

MO

clindamycin palmitatehydrochloride solr

$0-$2.95(Tier

1)

MO

clindamycin phosphate ind5w soln

$0-$2.95(Tier

1)

clindamycin phosphatesoln ij 150 mg/ml, 9000mg/60ml

$0-$2.95(Tier

1)

clindamycin phosphatesoln ij 600 mg/4ml, 900mg/6ml

$0-$2.95(Tier

1)

MO

clindamycin phosphatesoln iv 150 mg/ml, 600mg/4ml

$0-$2.95(Tier

1)

LINCOCIN SOLN(Lincomycin HCl)

$0-$7.40(Tier

2)

MO

lincomycin hcl soln ij$0-

$2.95(Tier

1)

MO

Oxazolidinones

linezolid in sodium chloridesoln

$0-$2.95(Tier

1)

Name of drug

Whatthe


level)


linezolid soln iv 600mg/300ml

$0-$2.95(Tier

1)

linezolid susr or 100mg/5ml

$0-$2.95(Tier

1)

MO

linezolid tabs or 600 mg$0-

$2.95(Tier

1)

MO

SIVEXTRO SOLR IV$0-

$7.40(Tier

2)

SIVEXTRO TABS OR$0-

$7.40(Tier

2)

MO

ZYVOX SOLN IV 200MG/100ML

$0-$7.40(Tier

2)

ZYVOX SOLN IV 600MG/300ML (Linezolid)

$0-$7.40(Tier

2)

ZYVOX SUSR OR 100MG/5ML (Linezolid)

$0-$7.40(Tier

2)

MO

ZYVOX TABS OR 600 MG(Linezolid)

$0-$7.40(Tier

2)

MO

Polymyxins

polymyxin b sulfate solr ij$0-

$2.95(Tier

1)

Streptogramins



19

Name of drug

Whatthe


level)


SYNERCID SOLR$0-

$7.40(Tier

2)

ANTIANGINAL AGENTS - Drugs to Treat ChestPainAntianginals-Other

RANEXA TB12$0-

$7.40(Tier

2)

PA; MO

NitratesISORDIL TITRADOSETABS 5 MG (IsosorbideDinitrate)

NFMO

isosorbide dinitrate tabs$0-

$2.95(Tier

1)

MO

isosorbide dinitrate tbcr$0-

$2.95(Tier

1)

MO

isosorbide mononitratetabs 10 mg, 20 mg

$0-$2.95(Tier

1)

MO

isosorbide mononitratetb24 120 mg, 30 mg, 60 mg

$0-$2.95(Tier

1)

MO

NITRO-DUR PT24 0.1MG/HR, 0.2 MG/HR, 0.4MG/HR, 0.6 MG/HR(Nitroglycerin)

NF

MO

NITROGLYCERINLINGUAL AERS

$0-$7.40(Tier

2)

MO

Name of drug

Whatthe


level)


nitroglycerin pt24 td 0.1mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hr

$0-$2.95(Tier

1)

MO

nitroglycerin soln tl 0.4mg/spray

$0-$2.95(Tier

1)

MO

nitroglycerin subl sl 0.3 mg,0.4 mg, 0.6 mg

$0-$2.95(Tier

1)

MO

NITROLINGUALPUMPSPRAY SOLN(Nitroglycerin)

NFMO

NITROMIST AERS$0-

$7.40(Tier

2)

MO

NITROSTAT SUBL(Nitroglycerin)

$0-$7.40(Tier

2)

MO

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc.

buspirone hcl tabs or 10mg, 15 mg, 30 mg, 5 mg,7.5 mg

$0-$2.95(Tier

1)

MO

hydroxyzine hcl soln im 50mg/ml

$0-$2.95(Tier

1)

AL; MO

hydroxyzine hcl soln or 10mg/5ml

$0-$2.95(Tier

1)

AL; MO

hydroxyzine hcl syrp or 10mg/5ml

$0-$2.95(Tier

1)

AL; MO



20

Name of drug

Whatthe


level)


hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg

$0-$2.95(Tier

1)

AL; MO

hydroxyzine pamoate capsor 25 mg, 50 mg

$0-$2.95(Tier

1)

AL; MO

VISTARIL CAPS(Hydroxyzine Pamoate) NF AL; MO

Benzodiazepines

alprazolam tabs or 0.25mg, 0.5 mg, 1 mg, 2 mg

$0-$2.95(Tier

1)

MO

alprazolam tb24 or 0.5 mg,1 mg, 2 mg, 3 mg

$0-$2.95(Tier

1)

MO

alprazolam tbdp or 0.25mg, 0.5 mg, 1 mg, 2 mg

$0-$2.95(Tier

1)

MO

ATIVAN SOLN IJ 2 MG/ML(Lorazepam) NF MO

ATIVAN SOLN IJ 4 MG/ML(Lorazepam) NF

ATIVAN TABS OR 0.5 MG,1 MG, 2 MG (Lorazepam) NF MO

clorazepate dipotassiumtabs

$0-$2.95(Tier

1)

MO

diazepam conc or 5 mg/ml$0-

$2.95(Tier

1)

MO

diazepam soln or 1 mg/ml$0-

$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


diazepam tabs or 10 mg, 2mg, 5 mg

$0-$2.95(Tier

1)

MO

lorazepam conc or 2 mg/ml$0-

$2.95(Tier

1)

MO

lorazepam soln ij 2 mg/ml,20 mg/10ml

$0-$2.95(Tier

1)

MO

lorazepam soln ij 4 mg/ml$0-

$2.95(Tier

1)

lorazepam tabs or 0.5 mg,1 mg, 2 mg

$0-$2.95(Tier

1)

MO

oxazepam caps$0-

$2.95(Tier

1)

MO

TRANXENE T TABS(Clorazepate Dipotassium) NF MO

VALIUM TABS (Diazepam) NF MO

XANAX TABS (Alprazolam) NF MO

XANAX XR TB24(Alprazolam) NF MO

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythmsAntiarrhythmics Type I-A

disopyramide phosphatecaps

$0-$2.95(Tier

1)

AL; MO

NORPACE CAPS(Disopyramide Phosphate) NF AL; MO



21

Name of drug

Whatthe


level)


quinidine gluconate tbcr or324 mg

$0-$2.95(Tier

1)

MO

quinidine sulfate tabs$0-

$2.95(Tier

1)

MO

Antiarrhythmics Type I-B

mexiletine hcl caps$0-

$2.95(Tier

1)

MO

Antiarrhythmics Type I-C

flecainide acetate tabs 100mg

$0-$2.95(Tier

1)

SL(4 ea daily);MO


$0-$2.95(Tier

1)



$0-$2.95(Tier

1)

SL(8 ea daily);MO

propafenone hcl cp12$0-

$2.95(Tier

1)

MO

propafenone hcl tabs$0-

$2.95(Tier

1)

MO

RYTHMOL SR CP12(Propafenone HCl) NF MO

RYTHMOL TABS(Propafenone HCl) NF MO

Antiarrhythmics Type III

Name of drug

Whatthe


level)


amiodarone hcl tabs or 100mg, 200 mg, 400 mg

$0-$2.95(Tier

1)

MO

CORDARONE TABS(Amiodarone HCl) NF MO

dofetilide caps$0-

$2.95(Tier

1)

MULTAQ TABS$0-

$7.40(Tier

2)

MO

TIKOSYN CAPS(Dofetilide)

$0-$7.40(Tier

2)

ANTIASTHMATIC AND BRONCHODILATORAGENTS - Drugs to Treat Lung ConditionsAnti-Inflammatory Agents

cromolyn sodium nebu in$0-

$2.95(Tier

1)

MO; B/D

Antiasthmatic - Monoclonal Antibodies

CINQAIR SOLN$0-

$7.40(Tier

2)

PA

NUCALA SOLR$0-

$7.40(Tier

2)

PA; LA

XOLAIR SOLR$0-

$7.40(Tier

2)

PA; LA

Asthma and Bronchodilator Agent Combinations



22

Name of drug

Whatthe


level)


dyphylline-guaifenesin liqd$0

(Tier3)

NT

Bronchodilators - Anticholinergics

ATROVENT HFA AERS$0-

$7.40(Tier

2)

Limit 2 inhalerspermonth;QL(0.86gm daily); MO

ipratropium bromide soln in$0-

$2.95(Tier

1)

MO; B/D

SPIRIVA HANDIHALERCAPS

$0-$7.40(Tier

2)

QL(1 ea daily);MO

SPIRIVA RESPIMATAERS 1.25 MCG/ACT, 2.5MCG/ACT

$0-$7.40(Tier

2)

Limit 1 inhalerper month (60actuations);SL(0.14 gm daily);MO

SPIRIVA RESPIMATAERS 2.5 MCG/ACT

$0-$7.40(Tier

2)

Limit 2 inhalersper month(InstitutionalPack) ;SL(0.29gm daily); MO

TUDORZA PRESSAIRAEPB

$0-$7.40(Tier

2)

Limit 1 inhalerpermonth;QL(0.04ea daily); MO

Leukotriene ModulatorsACCOLATE TABS(Zafirlukast) NF MO

montelukast sodium chew4 mg, 5 mg

$0-$2.95(Tier

1)

MO

montelukast sodium tabs10 mg

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


SINGULAIR CHEW 4 MG,5 MG (MontelukastSodium)

NFMO

SINGULAIR TABS 10 MG(Montelukast Sodium) NF MO

zafirlukast tabs$0-

$2.95(Tier

1)

MO

Selective Phosphodiesterase 4 (PDE4) Inhibitors

DALIRESP TABS$0-

$7.40(Tier

2)

QL(1 ea daily);MO

Steroid Inhalants

AEROSPAN AERS$0-

$7.40(Tier

2)

Limit 2 inhalersper month (120actuations);SL(0.6 gm daily);MO

AEROSPAN AERS$0-

$7.40(Tier

2)

Limit 3 inhalersper month(Institutionalpack);SL(0.6gm daily); MO

budesonide (inhalation)susp 0.25 mg/2ml, 0.5mg/2ml

$0-$2.95(Tier

1)

MO; B/D

FLOVENT DISKUS AEPB100 MCG/BLIST

$0-$7.40(Tier

2)

SL(20 ea daily);MO


$0-$7.40(Tier

2)

SL(8 ea daily);MO


$0-$7.40(Tier

2)

SL(40 ea daily);MO



23

Name of drug

Whatthe


level)


FLOVENT HFA AERO 110MCG/ACT, 220 MCG/ACT

$0-$7.40(Tier

2)


FLOVENT HFA AERO 44MCG/ACT

$0-$7.40(Tier

2)

Limit 1 inhalerpermonth;QL(0.36gm daily); MO

PULMICORT SUSP 0.25MG/2ML, 0.5 MG/2ML(Budesonide (Inhalation))

NFMO; B/D

QVAR AERS$0-

$7.40(Tier

2)


Sympathomimetics

ADVAIR DISKUS AEPB$0-

$7.40(Tier

2)

MO

ADVAIR HFA AERO$0-

$7.40(Tier

2)

QL(4 gm daily);MO

albuterol sulfate nebu in0.083 %, 0.5 %, 0.63mg/3ml, 1.25 mg/3ml

$0-$2.95(Tier

1)

MO; B/D

albuterol sulfate syrp or 2mg/5ml

$0-$2.95(Tier

1)

MO

albuterol sulfate tabs or 2mg, 4 mg

$0-$2.95(Tier

1)

MO

albuterol sulfate tb12 or 4mg, 8 mg

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


ANORO ELLIPTA AEPB$0-

$7.40(Tier

2)

QL(2 ea daily);MO

BREO ELLIPTA AEPB25MCG/INH-100MCG/INH,25MCG/INH-200MCG/INH

$0-$7.40(Tier

2)

Limit 2 inhalersper month(InstitutionalPack);SL(2 eadaily); MO

BREO ELLIPTA AEPB25MCG/INH-100MCG/INH,25MCG/INH-200MCG/INH

$0-$7.40(Tier

2)

Limit 1 inhalerper month;SL(2ea daily); MO

COMBIVENT RESPIMATAERS

$0-$7.40(Tier

2)

Limit 1 inhalerpermonth;SL(0.2gm daily); MO

DULERA AERO$0-

$7.40(Tier

2)

QL(4 gm daily);MO

EPHEDRINE HCL TABSOR

$0(Tier

3)

NT

FORADIL AEROLIZERCAPS

$0-$7.40(Tier

2)

QL(2 ea daily)

ipratropium-albuterol soln$0-

$2.95(Tier

1)

MO; B/D

levalbuterol hcl nebu in0.31 mg/3ml, 0.63 mg/3ml,1.25 mg/0.5ml, 1.25mg/3ml

$0-$2.95(Tier

1)

MO; B/D

PROAIR HFA AERS$0-

$7.40(Tier

2)

MO



24

Name of drug

Whatthe


level)


PROAIR RESPICLICKAEPB

$0-$7.40(Tier

2)

MO

PROVENTIL HFA AERS$0-

$7.40(Tier

2)

MO

SEREVENT DISKUSAEPB

$0-$7.40(Tier

2)

QL(2 ea daily);MO

STIOLTO RESPIMATAERS

$0-$7.40(Tier

2)

Limit 1 inhalerpermonth;QL(0.14gm daily); MO

STRIVERDI RESPIMATAERS

$0-$7.40(Tier

2)

Limit 1 inhalerper month (60actuations);SL(0.14 gm daily);MO

terbutaline sulfate tabs or2.5 mg, 5 mg

$0-$2.95(Tier

1)

MO

XOPENEXCONCENTRATE NEBU(Levalbuterol HCl)

NFMO; B/D

XOPENEX NEBU(Levalbuterol HCl) NF MO; B/D

Xanthines

aminophylline soln$0-

$2.95(Tier

1)

theophylline tb12 100 mg,200 mg, 300 mg, 450 mg

$0-$2.95(Tier

1)

MO

theophylline tb24 400 mg,600 mg

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


ANTICOAGULANTS - Blood Thinners

Coumarin AnticoagulantsCOUMADIN TABS(Warfarin Sodium) NF MO

warfarin sodium tabs$0-

$2.95(Tier

1)

MO

Direct Factor Xa Inhibitors

ELIQUIS TABS$0-

$7.40(Tier

2)

MO

XARELTO STARTERPACK TBPK

$0-$7.40(Tier

2)

MO

XARELTO TABS$0-

$7.40(Tier

2)

MO

Heparins And Heparinoid-Like AgentsARIXTRA SOLN(Fondaparinux Sodium) NF MO

enoxaparin sodium soln$0-

$2.95(Tier

1)

MO

fondaparinux sodium soln$0-

$2.95(Tier

1)

MO

FRAGMIN SOLN 10000UNIT/ML, 12500UNIT/0.5ML, 15000UNIT/0.6ML, 18000UNT/0.72ML, 2500UNIT/0.2ML, 5000UNIT/0.2ML, 7500UNIT/0.3ML, 95000UNIT/3.8ML

$0-$7.40(Tier

2)

MO



25

Name of drug

Whatthe


level)


FRAGMIN SOLN 25000UNIT/ML

$0-$7.40(Tier

2)

heparin sodium (porcine)soln

$0-$2.95(Tier

1)

MO

LOVENOX SOLN(Enoxaparin Sodium) NF MO

Thrombin Inhibitors

argatroban soln 250mg/2.5ml

$0-$2.95(Tier

1)

MO

IPRIVASK SOLR$0-

$7.40(Tier

2)

PRADAXA CAPS$0-

$7.40(Tier

2)

MO

ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor Antagonists

FYCOMPA SUSP 0.5MG/ML

$0-$7.40(Tier

2)

FYCOMPA TABS 10 MG,12 MG, 2 MG, 4 MG, 6 MG,8 MG

$0-$7.40(Tier

2)

MO

Anticonvulsants - Benzodiazepines

clonazepam tabs or 0.5 mg$0-

$2.95(Tier

1)

SL(40 ea daily);MO

Name of drug

Whatthe


level)


clonazepam tabs or 1 mg$0-

$2.95(Tier

1)

SL(20 ea daily);MO

clonazepam tabs or 2 mg$0-

$2.95(Tier

1)

SL(10 ea daily);MO

clonazepam tbdp or 0.125mg, 0.25 mg, 0.5 mg, 1 mg,2 mg

$0-$2.95(Tier

1)

MO

DIASTAT ACUDIAL GEL$0-

$7.40(Tier

2)

MO

DIASTAT PEDIATRIC GEL$0-

$7.40(Tier

2)

MO

DIAZEPAM GEL RE 10MG, 2.5 MG, 20 MG

$0-$7.40(Tier

2)

MO

KLONOPIN TABS 0.5 MG(Clonazepam) NF SL(40 ea daily);

MOKLONOPIN TABS 1 MG(Clonazepam) NF SL(20 ea daily);

MOKLONOPIN TABS 2 MG(Clonazepam) NF SL(10 ea daily);

MO

ONFI SUSP$0-

$7.40(Tier

2)

MO

ONFI TABS$0-

$7.40(Tier

2)

MO

Anticonvulsants - Misc.



26

Name of drug

Whatthe


level)


APTIOM TABS$0-

$7.40(Tier

2)

MO

BANZEL SUSP$0-

$7.40(Tier

2)

MO

BANZEL TABS$0-

$7.40(Tier

2)

MO

BRIVIACT SOLN IV 50MG/5ML

$0-$7.40(Tier

2)

SL(20 ml daily)

BRIVIACT SOLN OR 10MG/ML

$0-$7.40(Tier

2)

PA; SL(20 mldaily)

BRIVIACT TABS OR 10MG

$0-$7.40(Tier

2)

PA; SL(20 eadaily)


$0-$7.40(Tier

2)

PA; SL(2 eadaily); MO


$0-$7.40(Tier

2)



$0-$7.40(Tier

2)



$0-$7.40(Tier

2)

PA; SL(2.67 eadaily)

Name of drug

Whatthe


level)


carbamazepine chew or100 mg

$0-$2.95(Tier

1)

MO

carbamazepine cp12 or100 mg, 200 mg, 300 mg

$0-$2.95(Tier

1)

MO

carbamazepine susp or100 mg/5ml

$0-$2.95(Tier

1)

MO

carbamazepine tabs or 200mg

$0-$2.95(Tier

1)

MO

carbamazepine tb12 or 100mg, 200 mg, 400 mg

$0-$2.95(Tier

1)

MO

CARBATROL CP12(Carbamazepine) NF MO

gabapentin caps or 100mg, 300 mg, 400 mg

$0-$2.95(Tier

1)

MO

gabapentin soln or 250mg/5ml, 300 mg/6ml

$0-$2.95(Tier

1)

MO

gabapentin tabs or 600 mg,800 mg

$0-$2.95(Tier

1)

MO

KEPPRA SOLN(Levetiracetam) NF MO

KEPPRA TABS(Levetiracetam) NF MO

KEPPRA XR TB24(Levetiracetam) NF MO

LAMICTAL CHEWABLEDISPERSIBLE CHEW(Lamotrigine)

NFMO



27

Name of drug

Whatthe


level)


LAMICTAL TABS(Lamotrigine) NF MO

LAMICTAL XR KIT$0-

$7.40(Tier

2)

MO

LAMICTAL XR TB24 100MG, 200 MG, 25 MG, 250MG, 300 MG, 50 MG(Lamotrigine)

NF

MO

lamotrigine chew 25 mg, 5mg

$0-$2.95(Tier

1)

MO

lamotrigine tabs 100 mg,150 mg, 200 mg, 25 mg

$0-$2.95(Tier

1)

MO

lamotrigine tb24 100 mg,200 mg, 25 mg, 250 mg,300 mg, 50 mg

$0-$2.95(Tier

1)

MO

LEVETIRACETAM SOLNIV 1000MG/100ML-750MG/100ML,1500MG/100ML-540MG/100ML,500MG/100ML-820MG/100ML

$0-$7.40(Tier

2)

levetiracetam soln iv 500mg/5ml

$0-$2.95(Tier

1)

MO

levetiracetam soln or 100mg/ml, 500 mg/5ml

$0-$2.95(Tier

1)

MO

levetiracetam tabs or 1000mg, 250 mg, 500 mg, 750mg

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


levetiracetam tb24 or 500mg, 750 mg

$0-$2.95(Tier

1)

MO

LYRICA CAPS 100 MG$0-

$7.40(Tier

2)

SL(6 ea daily);MO


$7.40(Tier

2)

SL(4 ea daily);MO


$7.40(Tier

2)

SL(3 ea daily);MO


$7.40(Tier

2)



$7.40(Tier

2)

SL(24 ea daily);MO


$7.40(Tier

2)

SL(2 ea daily);MO


$7.40(Tier

2)

SL(12 ea daily);MO


$7.40(Tier

2)

SL(8 ea daily);MO

LYRICA SOLN 20 MG/ML$0-

$7.40(Tier

2)

SL(30 ml daily);MO

MYSOLINE TABS(Primidone) NF MO



28

Name of drug

Whatthe


level)


NEURONTIN CAPS(Gabapentin) NF MO

NEURONTIN SOLN(Gabapentin) NF MO

NEURONTIN TABS(Gabapentin) NF MO

oxcarbazepine susp$0-

$2.95(Tier

1)

MO

oxcarbazepine tabs$0-

$2.95(Tier

1)

MO

POTIGA TABS 200 MG$0-

$7.40(Tier

2)

SL(6 ea daily);MO


$7.40(Tier

2)

SL(4 ea daily);MO


$7.40(Tier

2)

SL(3 ea daily);MO


$7.40(Tier

2)

SL(24 ea daily);MO

primidone tabs or 250 mg,50 mg

$0-$2.95(Tier

1)

MO

SPRITAM TB3D 1000 MG$0-

$7.40(Tier

2)



$7.40(Tier

2)

PA; SL(12 eadaily)

Name of drug

Whatthe


level)



$7.40(Tier

2)



$7.40(Tier

2)


TEGRETOL SUSP(Carbamazepine) NF MO

TEGRETOL TABS(Carbamazepine) NF MO

TEGRETOL-XR TB12 100MG (Carbamazepine)

$0-$7.40(Tier

2)

MO

TEGRETOL-XR TB12 200MG, 400 MG(Carbamazepine)

NFMO

TOPAMAX SPRINKLECPSP (Topiramate) NF MO

TOPAMAX TABS(Topiramate) NF MO

topiramate cpsp or 15 mg,25 mg

$0-$2.95(Tier

1)

MO

topiramate tabs or 100 mg,200 mg, 25 mg, 50 mg

$0-$2.95(Tier

1)

MO

TRILEPTAL SUSP(Oxcarbazepine) NF MO

TRILEPTAL TABS(Oxcarbazepine) NF MO

VIMPAT SOLN IV 200MG/20ML

$0-$7.40(Tier

2)



29

Name of drug

Whatthe


level)


VIMPAT SOLN OR 10MG/ML

$0-$7.40(Tier

2)

MO

VIMPAT TABS OR 100MG, 150 MG, 200 MG, 50MG

$0-$7.40(Tier

2)

MO

ZONEGRAN CAPS(Zonisamide) NF MO

zonisamide caps$0-

$2.95(Tier

1)

MO

Carbamates

felbamate susp$0-

$2.95(Tier

1)

MO

felbamate tabs$0-

$2.95(Tier

1)

MO

FELBATOL SUSP(Felbamate) NF MO

FELBATOL TABS(Felbamate) NF MO

GABA Modulators

GABITRIL TABS 12 MG,16 MG

$0-$7.40(Tier

2)

MO

GABITRIL TABS 2 MG, 4MG (Tiagabine HCl) NF MO

SABRIL PACK$0-

$7.40(Tier

2)

LA

SABRIL TABS$0-

$7.40(Tier

2)

LA

Name of drug

Whatthe


level)


tiagabine hcl tabs$0-

$2.95(Tier

1)

MO

HydantoinsCEREBYX SOLN 100 MGPE/2ML (FosphenytoinSodium)

NF

CEREBYX SOLN 500 MGPE/10ML (FosphenytoinSodium)

NFMO

DILANTIN-125 SUSP(Phenytoin) NF MO

fosphenytoin sodium soln100 mg pe/2ml

$0-$2.95(Tier

1)

fosphenytoin sodium soln500 mg pe/10ml

$0-$2.95(Tier

1)

MO

PEGANONE TABS$0-

$7.40(Tier

2)

MO

phenytoin chew or 50 mg$0-

$2.95(Tier

1)

MO

phenytoin sodium extendedcaps

$0-$2.95(Tier

1)

MO

phenytoin sodium soln ij$0-

$2.95(Tier

1)

phenytoin susp or 125mg/5ml

$0-$2.95(Tier

1)

MO

Succinimides



30

Name of drug

Whatthe


level)


CELONTIN CAPS$0-

$7.40(Tier

2)

MO

ethosuximide caps or 250mg

$0-$2.95(Tier

1)

MO

ethosuximide soln or 250mg/5ml

$0-$2.95(Tier

1)

MO

ZARONTIN CAPS(Ethosuximide) NF MO

Valproic AcidDEPACON SOLN(Valproate Sodium) NF

DEPAKENE CAPS(Valproic Acid) NF MO

DEPAKENE SYRP(Valproate Sodium) NF MO

DEPAKOTE ER TB24(Divalproex Sodium) NF MO

DEPAKOTE SPRINKLESCSDR (Divalproex Sodium) NF MO

DEPAKOTE TBEC(Divalproex Sodium) NF MO

divalproex sodium csdr$0-

$2.95(Tier

1)

MO

divalproex sodium tb24$0-

$2.95(Tier

1)

MO

divalproex sodium tbec$0-

$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


valproate sodium soln iv100 mg/ml, 500 mg/5ml

$0-$2.95(Tier

1)

valproate sodium soln or250 mg/5ml

$0-$2.95(Tier

1)

MO

valproate sodium syrp or250 mg/5ml

$0-$2.95(Tier

1)

MO

valproic acid caps or$0-

$2.95(Tier

1)

MO

ANTIDEPRESSANTS - Drugs to Treat Depression

Alpha-2 Receptor Antagonists (Tetracyclics)

mirtazapine tabs$0-

$2.95(Tier

1)

MO

mirtazapine tbdp$0-

$2.95(Tier

1)

MO

REMERON SOLTAB TBDP(Mirtazapine) NF MO

REMERON TABS(Mirtazapine) NF MO

Antidepressants - Misc.

bupropion hcl tabs or 100mg

$0-$2.95(Tier

1)

SL(4.5 eadaily); MO

bupropion hcl tabs or 75mg

$0-$2.95(Tier

1)

SL(6 ea daily);MO



31

Name of drug

Whatthe


level)


bupropion hcl tb12 or 100mg

$0-$2.95(Tier

1)

SL(4 ea daily);MO


$0-$2.95(Tier

1)



$0-$2.95(Tier

1)

SL(2 ea daily);MO


$0-$2.95(Tier

1)

SL(3 ea daily);MO


$0-$2.95(Tier

1)

SL(1.5 eadaily); MO

FORFIVO XL TB24$0-

$7.40(Tier

2)

ST; MO

maprotiline hcl tabs$0-

$2.95(Tier

1)

MO

WELLBUTRIN SR TB12100 MG (Bupropion HCl) NF SL(4 ea daily);

MOWELLBUTRIN SR TB12150 MG (Bupropion HCl) NF SL(2.66 ea

daily); MOWELLBUTRIN SR TB12200 MG (Bupropion HCl) NF SL(2 ea daily);

MOWELLBUTRIN TABS 100MG (Bupropion HCl) NF SL(4.5 ea

daily); MOWELLBUTRIN TABS 75MG (Bupropion HCl) NF SL(6 ea daily);

MOWELLBUTRIN XL TB24150 MG (Bupropion HCl) NF SL(3 ea daily);

MOWELLBUTRIN XL TB24300 MG (Bupropion HCl) NF SL(1.5 ea

daily); MO

Name of drug

Whatthe


level)


Monoamine Oxidase Inhibitors (MAOIs)

EMSAM PT24$0-

$7.40(Tier

2)

MO

MARPLAN TABS$0-

$7.40(Tier

2)

MO

NARDIL TABS (PhenelzineSulfate) NF MO

PARNATE TABS(Tranylcypromine Sulfate) NF MO

phenelzine sulfate tabs or$0-

$2.95(Tier

1)

MO

tranylcypromine sulfatetabs

$0-$2.95(Tier

1)

MO

Selective Serotonin Reuptake Inhibitors (SSRIs)CELEXA TABS 10 MG(Citalopram Hydrobromide) NF SL(4 ea daily);

MOCELEXA TABS 20 MG(Citalopram Hydrobromide) NF SL(2 ea daily);

MOCELEXA TABS 40 MG(Citalopram Hydrobromide) NF SL(1 ea daily);

MO

citalopram hydrobromidesoln 10 mg/5ml

$0-$2.95(Tier

1)

SL(20 ml daily);MO

citalopram hydrobromidetabs 10 mg

$0-$2.95(Tier

1)

SL(4 ea daily);MO


$0-$2.95(Tier

1)

SL(2 ea daily);MO



32

Name of drug

Whatthe


level)



$0-$2.95(Tier

1)

SL(1 ea daily);MO

escitalopram oxalate soln$0-

$2.95(Tier

1)

MO

escitalopram oxalate tabs$0-

$2.95(Tier

1)

MO

fluoxetine hcl caps or 10mg, 20 mg, 40 mg

$0-$2.95(Tier

1)

MO

fluoxetine hcl cpdr or 90mg

$0-$2.95(Tier

1)

MO

fluoxetine hcl soln or 20mg/5ml

$0-$2.95(Tier

1)

MO

fluoxetine hcl tabs or 10mg, 20 mg

$0-$2.95(Tier

1)

MO

fluvoxamine maleate cp24$0-

$2.95(Tier

1)

MO

fluvoxamine maleate tabs$0-

$2.95(Tier

1)

MO

LEXAPRO SOLN(Escitalopram Oxalate) NF MO

LEXAPRO TABS(Escitalopram Oxalate) NF MO

Name of drug

Whatthe


level)


paroxetine hcl tabs$0-

$2.95(Tier

1)

MO

paroxetine hcl tb24$0-

$2.95(Tier

1)

MO

PAXIL CR TB24(Paroxetine HCl) NF MO

PAXIL SUSP 10 MG/5ML$0-

$7.40(Tier

2)

MO

PAXIL TABS 10 MG, 20MG, 30 MG, 40 MG(Paroxetine HCl)

NFMO

PROZAC CAPS(Fluoxetine HCl) NF MO

PROZAC WEEKLY CPDR(Fluoxetine HCl) NF MO

sertraline hcl conc or 20mg/ml

$0-$2.95(Tier

1)

MO

sertraline hcl tabs or 100mg, 25 mg, 50 mg

$0-$2.95(Tier

1)

MO

ZOLOFT CONC (SertralineHCl) NF MO

ZOLOFT TABS (SertralineHCl) NF MO

Serotonin Modulators

BRINTELLIX TABS 10 MG$0-

$7.40(Tier

2)

ST; QL(2 eadaily); MO


$7.40(Tier

2)




33

Name of drug

Whatthe


level)



$7.40(Tier

2)


nefazodone hcl tabs$0-

$2.95(Tier

1)

MO

trazodone hcl tabs or 100mg, 150 mg, 300 mg, 50mg

$0-$2.95(Tier

1)

MO

TRINTELLIX TABS 10 MG$0-

$7.40(Tier

2)



$7.40(Tier

2)



$7.40(Tier

2)


VIIBRYD KIT$0-

$7.40(Tier

2)

ST

VIIBRYD STARTER PACKKIT

$0-$7.40(Tier

2)

ST; MO

VIIBRYD TABS 10 MG, 20MG, 40 MG

$0-$7.40(Tier

2)

ST; MO

Serotonin-Norepinephrine Reuptake InhibitorsCYMBALTA CPEP(Duloxetine HCl) NF MO

DESVENLAFAXINE ERTB24 100 MG, 50 MG

$0-$7.40(Tier

2)

ST; MO

Name of drug

Whatthe


level)


DESVENLAFAXINE ERTB24 100 MG, 50 MG

$0-$7.40(Tier

2)

ST; Fumarate

duloxetine hcl cpep 20 mg,30 mg, 60 mg

$0-$2.95(Tier

1)

MO

EFFEXOR XR CP24 150MG (Venlafaxine HCl) NF SL(1.5 ea

daily); MOEFFEXOR XR CP24 37.5MG (Venlafaxine HCl) NF SL(6 ea daily);

MOEFFEXOR XR CP24 75MG (Venlafaxine HCl) NF SL(3 ea daily);

MO

FETZIMA CP24 120 MG,40 MG, 80 MG

$0-$7.40(Tier

2)


FETZIMA CP24 20 MG$0-

$7.40(Tier

2)


FETZIMA TITRATIONPACK C4PK

$0-$7.40(Tier

2)

ST; MO

KHEDEZLA TB24$0-

$7.40(Tier

2)

ST; MO

PRISTIQ TB24$0-

$7.40(Tier

2)

ST; MO

venlafaxine hcl cp24 150mg

$0-$2.95(Tier

1)

SL(1.5 eadaily); MO

venlafaxine hcl cp24 37.5mg

$0-$2.95(Tier

1)

SL(6 ea daily);MO



34

Name of drug

Whatthe


level)


venlafaxine hcl cp24 75 mg$0-

$2.95(Tier

1)

SL(3 ea daily);MO

VENLAFAXINE HCL ERTB24

$0-$7.40(Tier

2)

ST; SL(1 eadaily); MO

venlafaxine hcl tabs 100mg

$0-$2.95(Tier

1)


venlafaxine hcl tabs 25 mg$0-

$2.95(Tier

1)

SL(15 ea daily);MO

venlafaxine hcl tabs 37.5mg

$0-$2.95(Tier

1)

SL(10 ea daily);MO


$2.95(Tier

1)

SL(7.5 eadaily); MO


$2.95(Tier

1)

SL(5 ea daily);MO

venlafaxine hcl tb24 150mg

$0-$2.95(Tier

1)

SL(1.5 eadaily); MO

venlafaxine hcl tb24 37.5mg

$0-$2.95(Tier

1)

SL(6 ea daily);MO

venlafaxine hcl tb24 75 mg$0-

$2.95(Tier

1)

SL(3 ea daily);MO

Tricyclic Agents

Name of drug

Whatthe


level)


amitriptyline hcl tabs$0-

$2.95(Tier

1)

AL; MO

amoxapine tabs$0-

$2.95(Tier

1)

MO

ANAFRANIL CAPS(Clomipramine HCl) NF AL; MO

clomipramine hcl caps or25 mg, 50 mg, 75 mg

$0-$2.95(Tier

1)

AL; MO

desipramine hcl tabs or 10mg, 100 mg, 150 mg, 25mg, 50 mg, 75 mg

$0-$2.95(Tier

1)

MO

doxepin hcl caps or 10 mg,100 mg, 150 mg, 25 mg, 50mg, 75 mg

$0-$2.95(Tier

1)

AL; MO

doxepin hcl conc or 10mg/ml

$0-$2.95(Tier

1)

AL; MO

ELAVIL TABS(Amitriptyline HCl) NF AL; MO

imipramine hcl tabs or 10mg, 25 mg, 50 mg

$0-$2.95(Tier

1)

AL; MO

imipramine pamoate caps$0-

$2.95(Tier

1)

AL; MO

NORPRAMIN TABS(Desipramine HCl) NF MO

nortriptyline hcl caps or 10mg, 25 mg, 50 mg, 75 mg

$0-$2.95(Tier

1)

MO



35

Name of drug

Whatthe


level)


nortriptyline hcl soln or 10mg/5ml

$0-$2.95(Tier

1)

MO

PAMELOR CAPS(Nortriptyline HCl) NF MO

protriptyline hcl tabs$0-

$2.95(Tier

1)

MO

SURMONTIL CAPS$0-

$7.40(Tier

2)

AL; MO

TOFRANIL-PM CAPS(Imipramine Pamoate) NF AL; MO

trimipramine maleate capsor 100 mg, 25 mg, 50 mg

$0-$2.95(Tier

1)

AL; MO

ANTIDIABETICS - Drugs to Regulate Blood Sugar

Alpha-Glucosidase Inhibitors

acarbose tabs$0-

$2.95(Tier

1)

QL(3 ea daily);MO

GLYSET TABS (Miglitol)$0-

$7.40(Tier

2)

QL(3 ea daily);MO

miglitol tabs$0-

$2.95(Tier

1)

QL(3 ea daily);MO

PRECOSE TABS(Acarbose) NF QL(3 ea daily);

MOAntidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN$0-

$7.40(Tier

2)

Limit 12mls permonth;QL(0.4ml daily); MO

Name of drug

Whatthe


level)


SYMLINPEN 60 SOPN$0-

$7.40(Tier

2)


Antidiabetic CombinationsACTOPLUS MET TABS(Pioglitazone HCl-Metformin HCl)

NFSL(3 ea daily);MO

ALOGLIPTIN/METFORMINHCL TABS

$0-$7.40(Tier

2)


ALOGLIPTIN/PIOGLITAZONE TABS 12.5MG-15MG

$0-$7.40(Tier

2)


ALOGLIPTIN/PIOGLITAZONE TABS 12.5MG-30MG

$0-$7.40(Tier

2)

PA; SL(1.5 eadaily); MO

ALOGLIPTIN/PIOGLITAZONE TABS 12.5MG-45MG,25MG-15MG, 25MG-30MG, 25MG-45MG

$0-$7.40(Tier

2)


DUETACT TABS(Pioglitazone HCl-Glimepiride)

NFSL(1.5 eadaily); MO

glipizide-metformin hcl tabs2.5mg-250mg

$0-$2.95(Tier

1)

SL(8 ea daily);MO

glipizide-metformin hcl tabs2.5mg-500mg, 5mg-500mg

$0-$2.95(Tier

1)

SL(4 ea daily);MO

GLUCOVANCE TABS1.25MG-250MG(Glyburide-Metformin)

NFAL; SL(8 eadaily); MO

GLUCOVANCE TABS2.5MG-500MG, 5MG-500MG (Glyburide-Metformin)

NF

AL; SL(4 eadaily); MO



36

Name of drug

Whatthe


level)


glyburide-metformin tabs1.25mg-250mg

$0-$2.95(Tier

1)


glyburide-metformin tabs2.5mg-500mg, 5mg-500mg

$0-$2.95(Tier

1)


INVOKAMET TABS150MG-1000MG, 150MG-500MG, 50MG-1000MG

$0-$7.40(Tier

2)

SL(2 ea daily);MO

INVOKAMET TABS 50MG-500MG

$0-$7.40(Tier

2)

SL(4 ea daily);MO

JANUMET TABS$0-

$7.40(Tier

2)

SL(2 ea daily);MO

JANUMET XR TB24100MG-1000MG

$0-$7.40(Tier

2)

SL(1 ea daily);MO

JANUMET XR TB2450MG-1000MG, 50MG-500MG

$0-$7.40(Tier

2)

SL(2 ea daily);MO

JENTADUETO TABS$0-

$7.40(Tier

2)

SL(2 ea daily);MO

JENTADUETO XR TB242.5MG-1000MG

$0-$7.40(Tier

2)

SL(2 ea daily);MO

JENTADUETO XR TB245MG-1000MG

$0-$7.40(Tier

2)

SL(1 ea daily);MO

Name of drug

Whatthe


level)


KAZANO TABS$0-

$7.40(Tier

2)


KOMBIGLYZE XR TB242.5MG-1000MG

$0-$7.40(Tier

2)


KOMBIGLYZE XR TB245MG-1000MG, 5MG-500MG

$0-$7.40(Tier

2)


OSENI TABS 12.5MG-15MG

$0-$7.40(Tier

2)


OSENI TABS 12.5MG-30MG

$0-$7.40(Tier

2)


OSENI TABS 12.5MG-45MG, 25MG-15MG,25MG-30MG, 25MG-45MG

$0-$7.40(Tier

2)


pioglitazone hcl-glimepiridetabs

$0-$2.95(Tier

1)

SL(1.5 eadaily); MO

pioglitazone hcl-metforminhcl tabs

$0-$2.95(Tier

1)

SL(3 ea daily);MO

PRANDIMET TABS(Repaglinide-MetforminHCl)

$0-$7.40(Tier

2)

SL(5 ea daily);MO

repaglinide-metformin hcltabs

$0-$2.95(Tier

1)

SL(5 ea daily);MO



37

Name of drug

Whatthe


level)


SYNJARDY TABS12.5MG-1000MG, 5MG-1000MG

$0-$7.40(Tier

2)

SL(2 ea daily);MO

SYNJARDY TABS12.5MG-500MG, 5MG-500MG

$0-$7.40(Tier

2)

SL(4 ea daily);MO

BiguanidesFORTAMET TB24 1000MG (Metformin HCl) NF Osmotic;SL(2.5

ea daily); MOFORTAMET TB24 500 MG(Metformin HCl) NF Osmotic;SL(5

ea daily); MOGLUCOPHAGE TABS1000 MG (Metformin HCl) NF SL(2.55 ea

daily); MOGLUCOPHAGE TABS 500MG (Metformin HCl) NF SL(5.1 ea

daily); MOGLUCOPHAGE TABS 850MG (Metformin HCl) NF SL(3 ea daily);

MOGLUCOPHAGE XR TB24500 MG (Metformin HCl) NF SL(4 ea daily);

MOGLUCOPHAGE XR TB24750 MG (Metformin HCl) NF SL(2.66 ea

daily); MO

metformin hcl tabs or 1000mg

$0-$2.95(Tier

1)



$0-$2.95(Tier

1)

SL(5.1 eadaily); MO


$0-$2.95(Tier

1)

SL(3 ea daily);MO

metformin hcl tb24 or 1000mg

$0-$2.95(Tier

1)

(GLUMETZA);SL(2 ea daily);MO

Name of drug

Whatthe


level)



$0-$2.95(Tier

1)

Osmotic;SL(2.5ea daily); MO


$0-$2.95(Tier

1)

(GLUMETZA);SL(4 ea daily);MO


$0-$2.95(Tier

1)

Osmotic;SL(5ea daily); MO


$0-$2.95(Tier

1)

SL(4 ea daily);MO


$0-$2.95(Tier

1)


Diabetic Other

BD GLUCOSE CHEW$0

(Tier3)

NT

CVS GLUCOSE CHEW 4GM

$0(Tier

3)

MO; NT

DEX4 QUICK DISSOLVEGLUCOSE CHEW

$0(Tier

3)

MO; NT

dextrose (diabetic use) gel15 gm/38gm, 40 %

$0(Tier

3)

MO; NT

GLUCAGEN HYPOKITSOLR

$0-$7.40(Tier

2)

MO

glucagon (rdna) kit$0-

$2.95(Tier

1)

MO



38

Name of drug

Whatthe


level)


GLUCOSE CHEW 4 GM$0

(Tier3)

MO; NT

GNP GLUCOSE CHEW 4GM

$0(Tier

3)

MO; NT

GNP QUICK DISSOLVEGLUCOSE CHEW

$0(Tier

3)

MO; NT

KORLYM TABS$0-

$7.40(Tier

2)

SL(4 ea daily);LA

LEADER QUICKDISSOLVE GLUCOSECHEW

$0(Tier

3)

MO; NT

PROGLYCEM SUSP$0-

$7.40(Tier

2)

MO

SM GLUCOSE CHEW 4GM

$0(Tier

3)

MO; NT

WALGREENS GLUCOSECHEW 4 GM

$0(Tier

3)

MO; NT

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

ALOGLIPTIN TABS$0-

$7.40(Tier

2)

PA; MO

JANUVIA TABS$0-

$7.40(Tier

2)

MO

NESINA TABS$0-

$7.40(Tier

2)

PA; MO

Name of drug

Whatthe


level)


ONGLYZA TABS$0-

$7.40(Tier

2)

PA; MO

TRADJENTA TABS$0-

$7.40(Tier

2)

MO

Dopamine Receptor Agonists - Antidiabetic

CYCLOSET TABS$0-

$7.40(Tier

2)

QL(6 ea daily);MO

Incretin Mimetic Agents (GLP-1 Receptor

BYDUREON PEN PEN$0-

$7.40(Tier

2)

ST; MO

BYDUREON SRER$0-

$7.40(Tier

2)

ST; MO

BYETTA SOPN$0-

$7.40(Tier

2)

ST; MO

VICTOZA SOPN$0-

$7.40(Tier

2)

ST; Limit 9mlspermonth;QL(0.3ml daily); MO

Insulin Sensitizing AgentsACTOS TABS 15 MG(Pioglitazone HCl) NF SL(3 ea daily);

MOACTOS TABS 30 MG(Pioglitazone HCl) NF SL(1.5 ea

daily); MOACTOS TABS 45 MG(Pioglitazone HCl) NF SL(1 ea daily);

MO

AVANDIA TABS 2 MG$0-

$7.40(Tier

2)

SL(4 ea daily);MO



39

Name of drug

Whatthe


level)


AVANDIA TABS 4 MG$0-

$7.40(Tier

2)

SL(2 ea daily);MO

pioglitazone hcl tabs 15 mg$0-

$2.95(Tier

1)

SL(3 ea daily);MO


$2.95(Tier

1)

SL(1.5 eadaily); MO


$2.95(Tier

1)

SL(1 ea daily);MO

Insulin

HUMALOG KWIKPENSOPN

$0-$7.40(Tier

2)


HUMALOG MIX 50/50KWIKPEN SUPN

$0-$7.40(Tier

2)


HUMALOG MIX 50/50SUSP

$0-$7.40(Tier

2)


HUMALOG MIX 75/25KWIKPEN SUPN

$0-$7.40(Tier

2)


HUMALOG MIX 75/25SUSP

$0-$7.40(Tier

2)


HUMALOG SOCT$0-

$7.40(Tier

2)


Name of drug

Whatthe


level)


HUMALOG SOLN$0-

$7.40(Tier

2)


HUMULIN 70/30 KWIKPENSUPN

$0-$7.40(Tier

2)


HUMULIN 70/30 SUSP$0-

$7.40(Tier

2)


HUMULIN N KWIKPENSUPN

$0-$7.40(Tier

2)


HUMULIN N SUSP$0-

$7.40(Tier

2)


HUMULIN R SOLN$0-

$7.40(Tier

2)


HUMULIN R U-500(CONCENTRATED) SOLN

$0-$7.40(Tier

2)


HUMULIN R U-500KWIKPEN SOPN

$0-$7.40(Tier

2)


LANTUS SOLN$0-

$7.40(Tier

2)


LANTUS SOLOSTARSOPN

$0-$7.40(Tier

2)




40

Name of drug

Whatthe


level)


LEVEMIR FLEXTOUCHSOPN

$0-$7.40(Tier

2)


LEVEMIR SOLN$0-

$7.40(Tier

2)


TOUJEO SOLOSTARSOPN

$0-$7.40(Tier

2)


TRESIBA FLEXTOUCHSOPN 100 UNIT/ML

$0-$7.40(Tier

2)

QL(1.5 mldaily); MO

TRESIBA FLEXTOUCHSOPN 200 UNIT/ML

$0-$7.40(Tier

2)

QL(0.9 mldaily); MO

Meglitinide Analogues

nateglinide tabs$0-

$2.95(Tier

1)

QL(3 ea daily);MO

PRANDIN TABS 0.5 MG(Repaglinide) NF SL(32 ea daily);

MOPRANDIN TABS 1 MG(Repaglinide) NF SL(16 ea daily);

MOPRANDIN TABS 2 MG(Repaglinide) NF SL(8 ea daily);

MO

repaglinide tabs 0.5 mg$0-

$2.95(Tier

1)

SL(32 ea daily);MO

repaglinide tabs 1 mg$0-

$2.95(Tier

1)

SL(16 ea daily);MO

Name of drug

Whatthe


level)


repaglinide tabs 2 mg$0-

$2.95(Tier

1)

SL(8 ea daily);MO

STARLIX TABS(Nateglinide) NF QL(3 ea daily);

MOSodium-Glucose Co-Transporter 2 (SGLT2)

INVOKANA TABS$0-

$7.40(Tier

2)

MO

JARDIANCE TABS$0-

$7.40(Tier

2)

MO

SulfonylureasAMARYL TABS 1 MG(Glimepiride) NF SL(8 ea daily);

MOAMARYL TABS 2 MG(Glimepiride) NF SL(4 ea daily);

MOAMARYL TABS 4 MG(Glimepiride) NF SL(2 ea daily);

MO

DIABETA TABS 1.25 MG(Glyburide)

$0-$7.40(Tier

2)


DIABETA TABS 2.5 MG(Glyburide)

$0-$7.40(Tier

2)


DIABETA TABS 5 MG(Glyburide)

$0-$7.40(Tier

2)


glimepiride tabs 1 mg$0-

$2.95(Tier

1)

SL(8 ea daily);MO


$2.95(Tier

1)

SL(4 ea daily);MO



41

Name of drug

Whatthe


level)



$2.95(Tier

1)

SL(2 ea daily);MO

glipizide tabs or 10 mg$0-

$2.95(Tier

1)

SL(4 ea daily);MO

glipizide tabs or 5 mg$0-

$2.95(Tier

1)

SL(8 ea daily);MO

glipizide tb24 or 10 mg$0-

$2.95(Tier

1)

SL(2 ea daily);MO

glipizide tb24 or 2.5 mg$0-

$2.95(Tier

1)

SL(8 ea daily);MO

glipizide tb24 or 5 mg$0-

$2.95(Tier

1)

SL(4 ea daily);MO

GLUCOTROL TABS 10MG (Glipizide) NF SL(4 ea daily);

MOGLUCOTROL TABS 5 MG(Glipizide) NF SL(8 ea daily);

MOGLUCOTROL XL TB24 10MG (Glipizide) NF SL(2 ea daily);

MOGLUCOTROL XL TB24 2.5MG (Glipizide) NF SL(8 ea daily);

MOGLUCOTROL XL TB24 5MG (Glipizide) NF SL(4 ea daily);

MO

glyburide micronized tabs1.5 mg

$0-$2.95(Tier

1)


glyburide micronized tabs 3mg

$0-$2.95(Tier

1)


Name of drug

Whatthe


level)


glyburide micronized tabs 6mg

$0-$2.95(Tier

1)


glyburide tabs or 1.25 mg$0-

$2.95(Tier

1)


glyburide tabs or 2.5 mg$0-

$2.95(Tier

1)


glyburide tabs or 5 mg$0-

$2.95(Tier

1)


GLYNASE TABS 1.5 MG(Glyburide Micronized) NF AL; SL(8 ea

daily); MOGLYNASE TABS 3 MG(Glyburide Micronized) NF AL; SL(4 ea

daily); MOGLYNASE TABS 6 MG(Glyburide Micronized) NF AL; SL(2 ea

daily); MO

tolazamide tabs 250 mg$0-

$2.95(Tier

1)

SL(4 ea daily);MO

tolazamide tabs 500 mg$0-

$2.95(Tier

1)

SL(2 ea daily);MO

tolbutamide tabs$0-

$2.95(Tier

1)

SL(6 ea daily);MO

ANTIDIARRHEALS - Drugs to Treat Diarrhea

Antidiarrheal Agents - Misc.

bismuth subsalicylate chewor 262 mg

$0(Tier

3)

MO; NT



42

Name of drug

Whatthe


level)


bismuth subsalicylate suspor 262 mg/15ml, 525mg/30ml, 527 mg/30ml

$0(Tier

3)

MO; NT

bismuth subsalicylate suspor 525 mg/15ml

$0(Tier

3)

NT

bismuth subsalicylate tabsor 262 mg

$0(Tier

3)

NT

PEPTO BISMOL TABS(Bismuth Subsalicylate) NF NT

PEPTO-BISMOL CHEW262 MG (BismuthSubsalicylate)

NFMO; NT

PEPTO-BISMOLINSTACOOL CHEW(Bismuth Subsalicylate)

NFMO; NT

PEPTO-BISMOL MAXSTRENGTH SUSP(Bismuth Subsalicylate)

NFNT

PEPTO-BISMOL SUSP262 MG/15ML (BismuthSubsalicylate)

NFMO; NT

PEPTO-BISMOL TO-GOCHEW (BismuthSubsalicylate)

NFMO; NT

Antiperistaltic Agents

diphenoxylate w/ atropinetabs

$0-$2.95(Tier

1)

MO

LOMOTIL TABS(Diphenoxylate w/Atropine)

NFMO

loperamide hcl caps or 2mg

$0-$2.95(Tier

1)

RX/OTC; MO

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes - Chelating Agents

Name of drug

Whatthe


level)


EXJADE TBSO$0-

$7.40(Tier

2)

LA

FERRIPROX TABS 500MG

$0-$7.40(Tier

2)

PA; LA

JADENU TABS$0-

$7.40(Tier

2)

Antidotes and Specific Antagonists

SM IPECAC SYRUP SYRP$0

(Tier3)

NT

Opioid Antagonists

naloxone hcl sosy ij 2mg/2ml

$0-$2.95(Tier

1)

MO

naltrexone hcl tabs or$0-

$2.95(Tier

1)

MO

REVIA TABS (NaltrexoneHCl) NF MO

ANTIEMETICS - Drugs to Treat Nausea andVomiting5-HT3 Receptor Antagonists

granisetron hcl tabs or 1mg

$0-$2.95(Tier

1)

MO; B/D

ondansetron hcl soln ij 4mg/2ml, 40 mg/20ml

$0-$2.95(Tier

1)

MO



43

Name of drug

Whatthe


level)


ondansetron hcl soln or 4mg/5ml

$0-$2.95(Tier

1)

MO; B/D

ondansetron hcl tabs or 24mg, 4 mg, 8 mg

$0-$2.95(Tier

1)

MO; B/D

ondansetron tbdp$0-

$2.95(Tier

1)

MO; B/D

ZOFRAN ODT TBDP(Ondansetron) NF MO; B/D

ZOFRAN SOLN IJ 40MG/20ML (OndansetronHCl)

NFMO

ZOFRAN SOLN OR 4MG/5ML (OndansetronHCl)

NFMO; B/D

ZOFRAN TABS OR 4 MG,8 MG (Ondansetron HCl) NF MO; B/D

Antiemetics - Anticholinergic

meclizine hcl chew 25 mg$0

(Tier3)

MO; NT

meclizine hcl tabs 12.5 mg,25 mg

$0-$2.95(Tier

1)

RX/OTC; MO

TIGAN SOLN IM 100MG/ML

$0-$7.40(Tier

2)

AL; MO

TRANSDERM-SCOP PT72$0-

$7.40(Tier

2)

MO

Antiemetics - Miscellaneous

Name of drug

Whatthe


level)


CESAMET CAPS$0-

$7.40(Tier

2)

MO; B/D

dronabinol caps$0-

$2.95(Tier

1)

MO; B/D

MARINOL CAPS(Dronabinol) NF MO; B/D

Substance P/Neurokinin 1 (NK1) Receptor

EMEND CAPS OR 125MG, 80 MG

$0-$7.40(Tier

2)

MO; B/D

EMEND CAPS OR 40 MG$0-

$7.40(Tier

2)

PA; MO

VARUBI TABS$0-

$7.40(Tier

2)

B/D

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungal - Glucan Synthesis Inhibitors

CANCIDAS SOLR 50 MG$0-

$7.40(Tier

2)

CANCIDAS SOLR 70 MG$0-

$7.40(Tier

2)

MO

ERAXIS SOLR 100 MG$0-

$7.40(Tier

2)

MYCAMINE SOLR$0-

$7.40(Tier

2)

MO



44

Name of drug

Whatthe


level)


Antifungals

ABELCET SUSP$0-

$7.40(Tier

2)

AMBISOME SUSR$0-

$7.40(Tier

2)

amphotericin b solr ij 50 mg$0-

$2.95(Tier

1)

MO

ANCOBON CAPS 500 MG(Flucytosine) NF MO

flucytosine caps 500 mg$0-

$2.95(Tier

1)

MO

GRIS-PEG TABS(GriseofulvinUltramicrosize)

NFMO

griseofulvin microsize susp$0-

$2.95(Tier

1)

MO

griseofulvin microsize tabs$0-

$2.95(Tier

1)

MO

griseofulvin ultramicrosizetabs

$0-$2.95(Tier

1)

MO

LAMISIL TABS 250 MG(Terbinafine HCl) NF MO

nystatin tabs or$0-

$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


terbinafine hcl tabs or$0-

$2.95(Tier

1)

MO

Imidazole-Related Antifungals

CRESEMBA CAPS OR186 MG

$0-$7.40(Tier

2)

MO

CRESEMBA SOLR IV 372MG

$0-$7.40(Tier

2)DIFLUCAN SUSR(Fluconazole) NF MO

DIFLUCAN TABS(Fluconazole) NF MO

fluconazole in dextrosesoln

$0-$2.95(Tier

1)

fluconazole in nacl soln200mg/100ml-0.9%,400mg/200ml-0.9%

$0-$2.95(Tier

1)

fluconazole susr or 10mg/ml, 40 mg/ml

$0-$2.95(Tier

1)

MO

fluconazole tabs or 100 mg,150 mg, 200 mg, 50 mg

$0-$2.95(Tier

1)

MO

itraconazole caps or$0-

$2.95(Tier

1)

MO

ketoconazole tabs or$0-

$2.95(Tier

1)

MO



45

Name of drug

Whatthe


level)


NOXAFIL SOLN IV 300MG/16.7ML

$0-$7.40(Tier

2)

NOXAFIL SUSP OR 40MG/ML

$0-$7.40(Tier

2)

MO

NOXAFIL TBEC OR 100MG

$0-$7.40(Tier

2)

MO

SPORANOX CAPS 100MG (Itraconazole) NF MO

SPORANOX PULSEPAKCAPS (Itraconazole) NF MO

VFEND IV SOLR(Voriconazole) NF

VFEND SUSR(Voriconazole) NF MO

VFEND TABS(Voriconazole) NF MO

voriconazole solr iv 200 mg$0-

$2.95(Tier

1)

voriconazole susr or 40mg/ml

$0-$2.95(Tier

1)

MO

voriconazole tabs or 200mg, 50 mg

$0-$2.95(Tier

1)

MO

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - AlkylaminesCHLOR-TRIMETON SYRP2 MG/5ML(ChlorpheniramineMaleate)

NF

AL; NT

Name of drug

Whatthe


level)


CHLOR-TRIMETON TABS4 MG (ChlorpheniramineMaleate)

NFAL; MO; NT

chlorpheniramine maleatesyrp or 2 mg/5ml

$0(Tier

3)

AL; NT

chlorpheniramine maleatetabs or 4 mg

$0(Tier

3)

AL; MO; NT

ED CHLORPED LIQD$0

(Tier3)

AL; NT

Antihistamines - Ethanolamines

ALER-DRYL TABS$0

(Tier3)

AL; NT

BENADRYL ALLERGYCAPS (DiphenhydramineHCl)

NFAL; MO; NT

BENADRYL ALLERGYCHILDRENS CHEW 12.5MG (DiphenhydramineHCl)

NF

AL; NT

BENADRYL ALLERGYCHILDRENS LIQD 12.5MG/5ML (DiphenhydramineHCl)

NF

AL; MO; NT

BENADRYL ALLERGYTABS (DiphenhydramineHCl)

NFAL; MO; NT

BENADRYL DYE-FREEALLERGYLIQUID-GELSCAPS (DiphenhydramineHCl)

NF

AL; MO; NT

carbinoxamine maleatesoln

$0-$2.95(Tier

1)

AL; MO

carbinoxamine maleatetabs

$0-$2.95(Tier

1)

AL; MO



46

Name of drug

Whatthe


level)


clemastine fumarate tabsor 2.68 mg

$0-$2.95(Tier

1)

AL; MO

diphenhydramine hcl capsor 25 mg

$0(Tier

3)

AL; MO; NT

diphenhydramine hcl chewor 12.5 mg

$0(Tier

3)

AL; NT

diphenhydramine hcl elix or12.5 mg/5ml

$0-$2.95(Tier

1)

AL; RX/OTC

diphenhydramine hcl liqd or12.5 mg/5ml, 25 mg/10ml,50 mg/20ml

$0(Tier

3)

AL; MO; NT

diphenhydramine hcl soln ij50 mg/ml

$0-$2.95(Tier

1)

AL; MO

diphenhydramine hcl syrpor 12.5 mg/5ml

$0(Tier

3)

AL; NT

diphenhydramine hcl tabsor 25 mg

$0(Tier

3)

AL; MO; NT

TRIAMINIC COUGH &RUNNY NOSE STRP

$0(Tier

3)

AL; NT

Antihistamines - Non-Sedating

cetirizine hcl soln 1 mg/ml$0-

$2.95(Tier

1)

RX/OTC; MO

cetirizine hcl syrp 1 mg/ml$0-

$2.95(Tier

1)

RX/OTC; MO

CLARINEX TABS 5 MG(Desloratadine) NF MO

Name of drug

Whatthe


level)


CLARITIN TABS 10 MG(Loratadine) NF QL(1 ea daily);

MO; NT

desloratadine tabs$0-

$2.95(Tier

1)

MO

desloratadine tbdp$0-

$2.95(Tier

1)

MO

levocetirizinedihydrochloride soln

$0-$2.95(Tier

1)

MO

levocetirizinedihydrochloride tabs

$0-$2.95(Tier

1)

MO

loratadine tabs or 10 mg$0

(Tier3)

QL(1 ea daily);MO; NT

XYZAL SOLN(LevocetirizineDihydrochloride)

NFMO

XYZAL TABS(LevocetirizineDihydrochloride)

NFMO

Antihistamines - Phenothiazines

promethazine hcl soln ij 25mg/ml, 50 mg/ml

$0-$2.95(Tier

1)

AL; MO

promethazine hcl soln or6.25 mg/5ml

$0-$2.95(Tier

1)

AL; MO

promethazine hcl supp re12.5 mg, 25 mg

$0-$2.95(Tier

1)

AL; MO



47

Name of drug

Whatthe


level)


promethazine hcl syrp or6.25 mg/5ml

$0-$2.95(Tier

1)

AL; MO

promethazine hcl tabs or12.5 mg, 25 mg, 50 mg

$0-$2.95(Tier

1)

AL; MO

Antihistamines - Piperidines

cyproheptadine hcl syrp or2 mg/5ml

$0-$2.95(Tier

1)

AL; MO

cyproheptadine hcl tabs or4 mg

$0-$2.95(Tier

1)

AL; MO

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterolAntihyperlipidemics - Misc.

KYNAMRO SOSY$0-

$7.40(Tier

2)

PA; LA

LOVAZA CAPS (Omega-3-acid Ethyl Esters) NF MO

omega-3-acid ethyl esterscaps

$0-$2.95(Tier

1)

MO

VASCEPA CAPS 0.5 GM$0-

$7.40(Tier

2)

ST

VASCEPA CAPS 1 GM$0-

$7.40(Tier

2)

ST; MO

Bile Acid Sequestrants

Name of drug

Whatthe


level)


cholestyramine light pack$0-

$2.95(Tier

1)

MO

cholestyramine light powd$0-

$2.95(Tier

1)

MO

cholestyramine pack or 4gm

$0-$2.95(Tier

1)

MO

cholestyramine powd or 4gm/dose

$0-$2.95(Tier

1)

MO

COLESTID FLAVOREDGRAN 5 GM (ColestipolHCl)

NFMO

COLESTID GRAN(Colestipol HCl) NF MO

COLESTID PACK(Colestipol HCl) NF MO

COLESTID TABS(Colestipol HCl) NF MO

colestipol hcl gran$0-

$2.95(Tier

1)

MO

colestipol hcl pack$0-

$2.95(Tier

1)

MO

colestipol hcl tabs$0-

$2.95(Tier

1)

MO

WELCHOL PACK$0-

$7.40(Tier

2)

MO



48

Name of drug

Whatthe


level)


WELCHOL TABS$0-

$7.40(Tier

2)

MO

Fibric Acid Derivatives

ANTARA CAPS 30 MG$0-

$7.40(Tier

2)


ANTARA CAPS 90 MG$0-

$7.40(Tier

2)


choline fenofibrate cpdr$0-

$2.95(Tier

1)

MO

fenofibrate micronized caps130 mg

$0-$2.95(Tier

1)

SL(1 ea daily);MO

fenofibrate micronized caps134 mg, 200 mg, 67 mg

$0-$2.95(Tier

1)

MO

fenofibrate micronized caps43 mg

$0-$2.95(Tier

1)


fenofibrate tabs 145 mg,160 mg, 48 mg, 54 mg

$0-$2.95(Tier

1)

MO

gemfibrozil tabs or$0-

$2.95(Tier

1)

MO

LOPID TABS (Gemfibrozil) NF MO

TRICOR TABS(Fenofibrate) NF MO

Name of drug

Whatthe


level)


TRIGLIDE TABS$0-

$7.40(Tier

2)

MO

TRILIPIX CPDR (CholineFenofibrate) NF MO

HMG CoA Reductase Inhibitors

atorvastatin calcium tabs$0-

$2.95(Tier

1)

MO

CRESTOR TABS(Rosuvastatin Calcium)

$0-$7.40(Tier

2)

ST; MO

fluvastatin sodium caps 20mg, 40 mg

$0-$2.95(Tier

1)

MO

LESCOL CAPS(Fluvastatin Sodium) NF MO

LIPITOR TABS(Atorvastatin Calcium) NF MO

lovastatin tabs$0-

$2.95(Tier

1)

MO

MEVACOR TABS(Lovastatin) NF MO

PRAVACHOL TABS(Pravastatin Sodium) NF MO

pravastatin sodium tabs$0-

$2.95(Tier

1)

MO

rosuvastatin calcium tabs$0-

$2.95(Tier

1)

ST; MO



49

Name of drug

Whatthe


level)


simvastatin tabs or 10 mg$0-

$2.95(Tier

1)

SL(8 ea daily);MO


$2.95(Tier

1)

SL(4 ea daily);MO


$2.95(Tier

1)

SL(2 ea daily);MO


$2.95(Tier

1)

SL(16 ea daily);MO


$2.95(Tier

1)

SL(1 ea daily);MO

ZOCOR TABS 10 MG(Simvastatin) NF SL(8 ea daily);

MOZOCOR TABS 20 MG(Simvastatin) NF SL(4 ea daily);




MOIntestinal Cholesterol Absorption Inhibitors

ZETIA TABS$0-

$7.40(Tier

2)

MO

Microsomal Triglyceride Transfer Protein (MTP)

JUXTAPID CAPS 10 MG$0-

$7.40(Tier

2)

PA; SL(6 eadaily); LA

Name of drug

Whatthe


level)



$7.40(Tier

2)



$7.40(Tier

2)



$7.40(Tier

2)

PA; SL(1.5 eadaily); LA


$7.40(Tier

2)



$7.40(Tier

2)


Nicotinic Acid Derivatives

niacin (antihyperlipidemic)tbcr

$0-$2.95(Tier

1)

MO

NIASPAN TBCR (Niacin(Antihyperlipidemic)) NF MO

Proprotein Convertase Subtilisin/Kexin Type 9

PRALUENT SOPN 150MG/ML

$0-$7.40(Tier

2)

PA; Limit 2mlsper 28days;SL(0.08ml daily)

PRALUENT SOPN 75MG/ML

$0-$7.40(Tier

2)


PRALUENT SOSY 150MG/ML

$0-$7.40(Tier

2)




50

Name of drug

Whatthe


level)


PRALUENT SOSY 75MG/ML

$0-$7.40(Tier

2)


REPATHA PUSHTRONEXSYSTEM SOCT

$0-$7.40(Tier

2)

PA

REPATHA SOSY$0-

$7.40(Tier

2)

PA

REPATHA SURECLICKSOAJ

$0-$7.40(Tier

2)

PA

ANTIHYPERTENSIVES - Drugs to Treat HighBlood PressureACE InhibitorsACCUPRIL TABS(Quinapril HCl) NF MO

ACEON TABS 4 MG(Perindopril Erbumine) NF SL(4 ea daily);

MOACEON TABS 8 MG(Perindopril Erbumine) NF SL(2 ea daily);

MO

ALTACE CAPS (Ramipril) NF MO

benazepril hcl tabs or 10mg, 20 mg, 40 mg, 5 mg

$0-$2.95(Tier

1)

MO

captopril tabs or 100 mg,12.5 mg, 25 mg, 50 mg

$0-$2.95(Tier

1)

MO

enalapril maleate tabs or10 mg

$0-$2.95(Tier

1)

SL(4 ea daily);MO

Name of drug

Whatthe


level)


enalapril maleate tabs or2.5 mg

$0-$2.95(Tier

1)

SL(16 ea daily);MO

enalapril maleate tabs or20 mg

$0-$2.95(Tier

1)

SL(2 ea daily);MO

enalapril maleate tabs or 5mg

$0-$2.95(Tier

1)

SL(8 ea daily);MO

fosinopril sodium tabs$0-

$2.95(Tier

1)

MO

lisinopril tabs or 10 mg, 2.5mg, 20 mg, 30 mg, 40 mg,5 mg

$0-$2.95(Tier

1)

MO

LOTENSIN TABS(Benazepril HCl) NF MO

MAVIK TABS (Trandolapril) NF MO

moexipril hcl tabs$0-

$2.95(Tier

1)

MO

perindopril erbumine tabs 2mg

$0-$2.95(Tier

1)

SL(8 ea daily);MO


$0-$2.95(Tier

1)

SL(4 ea daily);MO


$0-$2.95(Tier

1)

SL(2 ea daily);MO

PRINIVIL TABS (Lisinopril) NF MO



51

Name of drug

Whatthe


level)


quinapril hcl tabs$0-

$2.95(Tier

1)

MO

ramipril caps$0-

$2.95(Tier

1)

MO

trandolapril tabs$0-

$2.95(Tier

1)

MO

VASOTEC TABS 10 MG(Enalapril Maleate) NF SL(4 ea daily);

MOVASOTEC TABS 2.5 MG(Enalapril Maleate) NF SL(16 ea daily);

MOVASOTEC TABS 20 MG(Enalapril Maleate) NF SL(2 ea daily);

MOVASOTEC TABS 5 MG(Enalapril Maleate) NF SL(8 ea daily);

MO

ZESTRIL TABS (Lisinopril) NF MO

Agents for Pheochromocytoma

DEMSER CAPS$0-

$7.40(Tier

2)

MO

DIBENZYLINE CAPS(Phenoxybenzamine HCl)

$0-$7.40(Tier

2)

MO

phenoxybenzamine hclcaps or

$0-$2.95(Tier

1)

MO

Angiotensin II Receptor AntagonistsATACAND TABS(Candesartan Cilexetil) NF MO

AVAPRO TABS(Irbesartan) NF MO

Name of drug

Whatthe


level)


candesartan cilexetil tabs$0-

$2.95(Tier

1)

MO

COZAAR TABS (LosartanPotassium) NF MO

DIOVAN TABS (Valsartan) NF MO

eprosartan mesylate tabs$0-

$2.95(Tier

1)

MO

irbesartan tabs$0-

$2.95(Tier

1)

MO

losartan potassium tabs$0-

$2.95(Tier

1)

MO

valsartan tabs$0-

$2.95(Tier

1)

MO

Antiadrenergic AntihypertensivesCARDURA TABS(Doxazosin Mesylate) NF MO

CATAPRES TABS(Clonidine HCl) NF MO

CATAPRES-TTS-1 PTWK(Clonidine HCl) NF MO



clonidine hcl ptwk td 0.1mg/24hr, 0.2 mg/24hr, 0.3mg/24hr

$0-$2.95(Tier

1)

MO



52

Name of drug

Whatthe


level)


clonidine hcl tabs or 0.1mg, 0.2 mg, 0.3 mg

$0-$2.95(Tier

1)

MO

doxazosin mesylate tabs$0-

$2.95(Tier

1)

MO

guanfacine hcl tabs$0-

$2.95(Tier

1)

AL; MO

MINIPRESS CAPS(Prazosin HCl) NF MO

prazosin hcl caps$0-

$2.95(Tier

1)

MO

RESERPINE TABS OR 0.1MG

$0-$7.40(Tier

2)

RESERPINE TABS OR0.25 MG

$0-$7.40(Tier

2)

AL

TENEX TABS (GuanfacineHCl) NF AL; MO

terazosin hcl caps$0-

$2.95(Tier

1)

MO

Antihypertensive CombinationsACCURETIC TABS(Quinapril-Hydrochlorothiazide)

NFMO

amlodipine besylate-benazepril hcl caps

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


ATACAND HCT TABS(Candesartan Cilexetil-Hydrochlorothiazide)

NFMO

atenolol & chlorthalidonetabs

$0-$2.95(Tier

1)

MO

AVALIDE TABS(Irbesartan-Hydrochlorothiazide)

NFMO

benazepril &hydrochlorothiazide tabs

$0-$2.95(Tier

1)

MO

bisoprolol &hydrochlorothiazide tabs

$0-$2.95(Tier

1)

MO

candesartan cilexetil-hydrochlorothiazide tabs

$0-$2.95(Tier

1)

MO

captopril &hydrochlorothiazide tabs

$0-$2.95(Tier

1)

MO

CORZIDE TABS (Nadolol& Bendroflumethiazide) NF MO

DIOVAN HCT TABS(Valsartan-Hydrochlorothiazide)

NFMO

enalapril maleate &hydrochlorothiazide tabs

$0-$2.95(Tier

1)

MO

fosinopril sodium &hydrochlorothiazide tabs

$0-$2.95(Tier

1)

MO

HYZAAR TABS (LosartanPotassium &Hydrochlorothiazide)

NFMO



53

Name of drug

Whatthe


level)


irbesartan-hydrochlorothiazide tabs

$0-$2.95(Tier

1)

MO

lisinopril &hydrochlorothiazide tabs

$0-$2.95(Tier

1)

MO

LOPRESSOR HCT TABS(Metoprolol &Hydrochlorothiazide)

NFMO

losartan potassium &hydrochlorothiazide tabs

$0-$2.95(Tier

1)

MO

LOTENSIN HCT TABS(Benazepril &Hydrochlorothiazide)

NFMO

LOTREL CAPS(Amlodipine Besylate-Benazepril HCl)

NFMO

metoprolol &hydrochlorothiazide tabs

$0-$2.95(Tier

1)

MO

moexipril-hydrochlorothiazide tabs

$0-$2.95(Tier

1)

MO

nadolol &bendroflumethiazide tabs

$0-$2.95(Tier

1)

MO

quinapril-hydrochlorothiazide tabs

$0-$2.95(Tier

1)

MO

TEKTURNA HCT TABS$0-

$7.40(Tier

2)

MO

TENORETIC 100 TABS(Atenolol & Chlorthalidone) NF MO

Name of drug

Whatthe


level)


TENORETIC 50 TABS(Atenolol & Chlorthalidone) NF MO

valsartan-hydrochlorothiazide tabs

$0-$2.95(Tier

1)

MO

VASERETIC TABS(Enalapril Maleate &Hydrochlorothiazide)

NFMO

ZESTORETIC TABS(Lisinopril &Hydrochlorothiazide)

NFMO

ZIAC TABS (Bisoprolol &Hydrochlorothiazide) NF MO

Direct Renin Inhibitors

TEKTURNA TABS$0-

$7.40(Tier

2)

MO

Selective Aldosterone Receptor Antagonists

eplerenone tabs$0-

$2.95(Tier

1)

MO

INSPRA TABS(Eplerenone) NF MO

Vasodilators

hydralazine hcl tabs or 10mg, 100 mg, 25 mg, 50 mg

$0-$2.95(Tier

1)

MO

minoxidil tabs or 10 mg, 2.5mg

$0-$2.95(Tier

1)

MO

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections)Antimalarial Combinations



54

Name of drug

Whatthe


level)


atovaquone-proguanil hcltabs 250mg-100mg

$0-$2.95(Tier

1)

MO

COARTEM TABS$0-

$7.40(Tier

2)

MO

MALARONE TABS250MG-100MG(Atovaquone-ProguanilHCl)

NF

MO

AntimalarialsARALEN TABS(Chloroquine Phosphate) NF MO

chloroquine phosphatetabs or 250 mg, 500 mg

$0-$2.95(Tier

1)

MO

DARAPRIM TABS$0-

$7.40(Tier

2)

hydroxychloroquine sulfatetabs or

$0-$2.95(Tier

1)

MO

mefloquine hcl tabs$0-

$2.95(Tier

1)

MO

PLAQUENIL TABS(HydroxychloroquineSulfate)

NFMO

primaquine phosphate tabs$0-

$2.95(Tier

1)

MO

PRIMAQUINEPHOSPHATE TABS

$0-$7.40(Tier

2)

MO

Name of drug

Whatthe


level)


QUALAQUIN CAPS(Quinine Sulfate) NF PA; MO

quinine sulfate caps or$0-

$2.95(Tier

1)

PA; MO

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic Agents

guanidine hcl tabs$0-

$2.95(Tier

1)MESTINON TABS 60 MG(Pyridostigmine Bromide) NF MO

MESTINON TIMESPANTBCR (PyridostigmineBromide)

$0-$7.40(Tier

2)

MO

pyridostigmine bromidetabs or 60 mg

$0-$2.95(Tier

1)

MO

pyridostigmine bromide tbcror 180 mg

$0-$2.95(Tier

1)

MO

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections)Anti TB Combinations

isoniazid & rifampin caps$0-

$2.95(Tier

1)

MO

RIFATER TABS$0-

$7.40(Tier

2)

MO

Antimycobacterial Agents



55

Name of drug

Whatthe


level)


aminosalicylic acid pack or$0-

$2.95(Tier

1)

MO

CAPASTAT SULFATESOLR

$0-$7.40(Tier

2)

ethambutol hcl tabs or 100mg, 400 mg

$0-$2.95(Tier

1)

MO

isoniazid tabs or 100 mg,300 mg

$0-$2.95(Tier

1)

MO

MYAMBUTOL TABS(Ethambutol HCl) NF MO

MYCOBUTIN CAPS(Rifabutin) NF MO

PRIFTIN TABS$0-

$7.40(Tier

2)

MO

pyrazinamide tabs or$0-

$2.95(Tier

1)

MO

rifabutin caps$0-

$2.95(Tier

1)

MO

RIFADIN CAPS (Rifampin) NF MO

RIFADIN SOLR (Rifampin) NF MO

rifampin caps or 150 mg,300 mg

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


rifampin solr iv 600 mg$0-

$2.95(Tier

1)

MO

SIRTURO TABS$0-

$7.40(Tier

2)

TRECATOR TABS$0-

$7.40(Tier

2)

MO

ANTINEOPLASTICS AND ADJUNCTIVETHERAPIES - Drugs to Treat CancerAlkylating AgentsALKERAN SOLR IV 50 MG(Melphalan HCl) NF

ALKERAN TABS OR 2 MG$0-

$7.40(Tier

2)

MO; B/D

BENDEKA SOLN$0-

$7.40(Tier

2)

BICNU SOLR$0-

$7.40(Tier

2)

BUSULFEX SOLN$0-

$7.40(Tier

2)

carboplatin soln$0-

$2.95(Tier

1)

cisplatin soln 100mg/100ml, 200 mg/200ml,50 mg/50ml

$0-$2.95(Tier

1)



56

Name of drug

Whatthe


level)


CYCLOPHOSPHAMIDECAPS OR 25 MG, 50 MG

$0-$7.40(Tier

2)

MO; B/D

ELOXATIN SOLN(Oxaliplatin) NF

EVOMELA SOLR$0-

$7.40(Tier

2)

GLEOSTINE CAPS$0-

$7.40(Tier

2)

HEXALEN CAPS$0-

$7.40(Tier

2)

MO

IFEX SOLR 1 GM(Ifosfamide) NF

IFEX SOLR 3 GM$0-

$7.40(Tier

2)

ifosfamide soln 1 gm/20ml,3 gm/60ml

$0-$2.95(Tier

1)

ifosfamide solr 1 gm$0-

$2.95(Tier

1)

IFOSFAMIDE SOLR 3 GM$0-

$7.40(Tier

2)

LEUKERAN TABS$0-

$7.40(Tier

2)

MO

Name of drug

Whatthe


level)


melphalan hcl solr$0-

$2.95(Tier

1)

MUSTARGEN SOLR$0-

$7.40(Tier

2)

oxaliplatin soln$0-

$2.95(Tier

1)

oxaliplatin solr$0-

$2.95(Tier

1)

TEMODAR SOLR$0-

$7.40(Tier

2)

THIOTEPA SOLR IJ$0-

$7.40(Tier

2)

TREANDA SOLN$0-

$7.40(Tier

2)

TREANDA SOLR$0-

$7.40(Tier

2)

YONDELIS SOLR$0-

$7.40(Tier

2)

LA

ZANOSAR SOLR$0-

$7.40(Tier

2)

MO

Antimetabolites



57

Name of drug

Whatthe


level)


ALIMTA SOLR 100 MG$0-

$7.40(Tier

2)

ALIMTA SOLR 500 MG$0-

$7.40(Tier

2)

MO

ARRANON SOLN$0-

$7.40(Tier

2)

azacitidine susr$0-

$2.95(Tier

1)

cladribine soln$0-

$2.95(Tier

1)

CLOLAR SOLN$0-

$7.40(Tier

2)

cytarabine soln$0-

$2.95(Tier

1)DACOGEN SOLR(Decitabine) NF

decitabine solr$0-

$2.95(Tier

1)FLUDARA SOLR(Fludarabine Phosphate) NF

fludarabine phosphate solr50 mg

$0-$2.95(Tier

1)

Name of drug

Whatthe


level)


fluorouracil soln iv 1gm/20ml, 2.5 gm/50ml, 500mg/10ml

$0-$2.95(Tier

1)

FOLOTYN SOLN$0-

$7.40(Tier

2)

gemcitabine hcl soln$0-

$2.95(Tier

1)

gemcitabine hcl solr$0-

$2.95(Tier

1)GEMZAR SOLR(Gemcitabine HCl) NF

mercaptopurine tabs or$0-

$2.95(Tier

1)

MO

methotrexate sodium soln ij1 gm/40ml, 100 mg/4ml,200 mg/8ml, 250 mg/10ml,50 mg/2ml

$0-$2.95(Tier

1)

methotrexate sodium solr ij1 gm

$0-$2.95(Tier

1)

methotrexate sodium tabsor 10 mg, 15 mg, 2.5 mg, 5mg, 7.5 mg

$0-$2.95(Tier

1)

MO

PURINETHOL TABS(Mercaptopurine) NF MO

PURIXAN SUSP$0-

$7.40(Tier

2)

PA



58

Name of drug

Whatthe


level)


TABLOID TABS$0-

$7.40(Tier

2)

MO

VIDAZA SUSR(Azacitidine) NF

Antineoplastic - Angiogenesis Inhibitors

AVASTIN SOLN$0-

$7.40(Tier

2)

CYRAMZA SOLN$0-

$7.40(Tier

2)

LA

ZALTRAP SOLN$0-

$7.40(Tier

2)

Antineoplastic - Antibodies

ARZERRA CONC$0-

$7.40(Tier

2)

BLINCYTO SOLR$0-

$7.40(Tier

2)

CAMPATH SOLN$0-

$7.40(Tier

2)

DARZALEX SOLN$0-

$7.40(Tier

2)

LA

EMPLICITI SOLR$0-

$7.40(Tier

2)

Name of drug

Whatthe


level)


ERBITUX SOLN$0-

$7.40(Tier

2)

GAZYVA SOLN$0-

$7.40(Tier

2)

LA

HERCEPTIN SOLR$0-

$7.40(Tier

2)

KADCYLA SOLR$0-

$7.40(Tier

2)

KEYTRUDA SOLN$0-

$7.40(Tier

2)

KEYTRUDA SOLR$0-

$7.40(Tier

2)

LARTRUVO SOLN$0-

$7.40(Tier

2)

OPDIVO SOLN$0-

$7.40(Tier

2)

PERJETA SOLN$0-

$7.40(Tier

2)

PORTRAZZA SOLN$0-

$7.40(Tier

2)



59

Name of drug

Whatthe


level)


RITUXAN SOLN$0-

$7.40(Tier

2)

TECENTRIQ SOLN$0-

$7.40(Tier

2)

VECTIBIX SOLN$0-

$7.40(Tier

2)

YERVOY SOLN$0-

$7.40(Tier

2)

Antineoplastic - BCL-2 Inhibitors

VENCLEXTA STARTINGPACK TBPK

$0-$7.40(Tier

2)

PA; LA

VENCLEXTA TABS$0-

$7.40(Tier

2)

PA; LA

Antineoplastic - Hedgehog Pathway Inhibitors

ERIVEDGE CAPS$0-

$7.40(Tier

2)

LA

ODOMZO CAPS$0-

$7.40(Tier

2)

LA

Antineoplastic - Hormonal and Related Agents

anastrozole tabs or$0-

$2.95(Tier

1)

MO

ARIMIDEX TABS(Anastrozole) NF MO

Name of drug

Whatthe


level)


AROMASIN TABS(Exemestane) NF MO

bicalutamide tabs$0-

$2.95(Tier

1)

MO

CASODEX TABS(Bicalutamide) NF MO

DEPO-PROVERA SUSP$0-

$7.40(Tier

2)

MO

ELIGARD KIT$0-

$7.40(Tier

2)

EMCYT CAPS$0-

$7.40(Tier

2)

MO

exemestane tabs$0-

$2.95(Tier

1)

MO

FARESTON TABS$0-

$7.40(Tier

2)

MO

FASLODEX SOLN$0-

$7.40(Tier

2)

FEMARA TABS (Letrozole) NF MO

FIRMAGON SOLR$0-

$7.40(Tier

2)

flutamide caps$0-

$2.95(Tier

1)

MO



60

Name of drug

Whatthe


level)


HYDROXYPROGESTERONE CAPROATE SOLN IM

$0-$7.40(Tier

2)

letrozole tabs$0-

$2.95(Tier

1)

MO

leuprolide acetate kit ij$0-

$2.95(Tier

1)

LUPRON DEPOT KIT$0-

$7.40(Tier

2)

LYSODREN TABS$0-

$7.40(Tier

2)

MO

MEGACE ORAL SUSP(Megestrol Acetate) NF AL; MO

megestrol acetate susp or40 mg/ml, 400 mg/10ml

$0-$2.95(Tier

1)

AL; MO

megestrol acetate tabs or20 mg, 40 mg

$0-$2.95(Tier

1)

AL; MO

NILANDRON TABS(Nilutamide)

$0-$7.40(Tier

2)

MO

nilutamide tabs$0-

$2.95(Tier

1)

MO

SOLTAMOX SOLN$0-

$7.40(Tier

2)

MO

Name of drug

Whatthe


level)


tamoxifen citrate tabs or 10mg, 20 mg

$0-$2.95(Tier

1)

MO

TRELSTAR MIXJECTSUSR

$0-$7.40(Tier

2)

TRELSTAR SUSR$0-

$7.40(Tier

2)

VANTAS KIT$0-

$7.40(Tier

2)

XTANDI CAPS$0-

$7.40(Tier

2)

PA; LA

ZOLADEX IMPL$0-

$7.40(Tier

2)

ZYTIGA TABS$0-

$7.40(Tier

2)

Antineoplastic - Immunomodulators

POMALYST CAPS$0-

$7.40(Tier

2)

LA

Antineoplastic Antibiotics

bleomycin sulfate solr$0-

$2.95(Tier

1)

COSMEGEN SOLR$0-

$7.40(Tier

2)



61

Name of drug

Whatthe


level)


daunorubicin hcl inj$0-

$2.95(Tier

1)DOXIL INJ (DoxorubicinHCl Liposomal) NF

doxorubicin hcl liposomalinj

$0-$2.95(Tier

1)

doxorubicin hcl soln 2mg/ml

$0-$2.95(Tier

1)

MO

doxorubicin hcl solr 10 mg,50 mg

$0-$2.95(Tier

1)ELLENCE SOLN(Epirubicin HCl) NF

epirubicin hcl soln$0-

$2.95(Tier

1)IDAMYCIN PFS SOLN(Idarubicin HCl) NF

idarubicin hcl soln$0-

$2.95(Tier

1)

mitomycin solr iv 20 mg, 40mg, 5 mg

$0-$2.95(Tier

1)

MO

mitoxantrone hcl conc$0-

$2.95(Tier

1)

VALSTAR SOLN$0-

$7.40(Tier

2)

Name of drug

Whatthe


level)


Antineoplastic Combinations

LONSURF TABS$0-

$7.40(Tier

2)

PA

Antineoplastic Enzyme Inhibitors

AFINITOR DISPERZ TBSO$0-

$7.40(Tier

2)

AFINITOR TABS$0-

$7.40(Tier

2)

ALECENSA CAPS$0-

$7.40(Tier

2)

PA; LA

BELEODAQ SOLR$0-

$7.40(Tier

2)

BOSULIF TABS$0-

$7.40(Tier

2)

PA

CABOMETYX TABS$0-

$7.40(Tier

2)

PA

CAPRELSA TABS$0-

$7.40(Tier

2)

LA

COMETRIQ KIT$0-

$7.40(Tier

2)

LA

COTELLIC TABS$0-

$7.40(Tier

2)

LA



62

Name of drug

Whatthe


level)


FARYDAK CAPS$0-

$7.40(Tier

2)

PA; LA

GILOTRIF TABS$0-

$7.40(Tier

2)

LA

GLEEVEC TABS 100 MG,400 MG (ImatinibMesylate)

$0-$7.40(Tier

2)

GLEEVEC TABS 400 MG$0-

$7.40(Tier

2)

IBRANCE CAPS$0-

$7.40(Tier

2)

LA

ICLUSIG TABS$0-

$7.40(Tier

2)

LA

imatinib mesylate tabs$0-

$2.95(Tier

1)

IMBRUVICA CAPS$0-

$7.40(Tier

2)

PA; LA

INLYTA TABS$0-

$7.40(Tier

2)

PA; LA

IRESSA TABS$0-

$7.40(Tier

2)

LA; MO

Name of drug

Whatthe


level)


ISTODAX (OVERFILL)SOLR

$0-$7.40(Tier

2)

ISTODAX SOLR$0-

$7.40(Tier

2)

JAKAFI TABS$0-

$7.40(Tier

2)

LA

LENVIMA 10 MG DAILYDOSE CPPK

$0-$7.40(Tier

2)

PA


$0-$7.40(Tier

2)

PA


$0-$7.40(Tier

2)

PA


$0-$7.40(Tier

2)

PA


$0-$7.40(Tier

2)

PA


$0-$7.40(Tier

2)

PA

LYNPARZA CAPS$0-

$7.40(Tier

2)

PA; LA



63

Name of drug

Whatthe


level)


MEKINIST TABS$0-

$7.40(Tier

2)

NEXAVAR TABS$0-

$7.40(Tier

2)

LA

NINLARO CAPS$0-

$7.40(Tier

2)

PA

SPRYCEL TABS$0-

$7.40(Tier

2)

STIVARGA TABS$0-

$7.40(Tier

2)

PA; LA

SUTENT CAPS$0-

$7.40(Tier

2)

TAFINLAR CAPS$0-

$7.40(Tier

2)

TAGRISSO TABS$0-

$7.40(Tier

2)

LA

TARCEVA TABS$0-

$7.40(Tier

2)

TASIGNA CAPS$0-

$7.40(Tier

2)

Name of drug

Whatthe


level)


TORISEL SOLN$0-

$7.40(Tier

2)

TYKERB TABS$0-

$7.40(Tier

2)

VELCADE SOLR$0-

$7.40(Tier

2)

VOTRIENT TABS$0-

$7.40(Tier

2)

XALKORI CAPS$0-

$7.40(Tier

2)

ZELBORAF TABS$0-

$7.40(Tier

2)

LA

ZOLINZA CAPS$0-

$7.40(Tier

2)

ZYDELIG TABS$0-

$7.40(Tier

2)

PA; LA

ZYKADIA CAPS$0-

$7.40(Tier

2)

PA; LA

Antineoplastic Enzymes

ERWINAZE SOLR$0-

$7.40(Tier

2)



64

Name of drug

Whatthe


level)


ONCASPAR SOLN$0-

$7.40(Tier

2)

Antineoplastics Misc.

ACTIMMUNE SOLN$0-

$7.40(Tier

2)

LA

bexarotene caps$0-

$2.95(Tier

1)

dacarbazine solr$0-

$2.95(Tier

1)HYDREA CAPS(Hydroxyurea) NF MO

hydroxyurea caps or$0-

$2.95(Tier

1)

MO

INTRON A SOLN$0-

$7.40(Tier

2)

INTRON A SOLR$0-

$7.40(Tier

2)

INTRON A W/DILUENTSOLR

$0-$7.40(Tier

2)

MATULANE CAPS$0-

$7.40(Tier

2)

LA

PROLEUKIN SOLR$0-

$7.40(Tier

2)

Name of drug

Whatthe


level)


SYLATRON KIT$0-

$7.40(Tier

2)

SYNRIBO SOLR$0-

$7.40(Tier

2)

TARGRETIN CAPS OR 75MG (Bexarotene)

$0-$7.40(Tier

2)

THERACYS SUSR$0-

$7.40(Tier

2)

TICE BCG SUSR$0-

$7.40(Tier

2)

tretinoin (chemotherapy)caps

$0-$2.95(Tier

1)

MO

TRISENOX SOLN$0-

$7.40(Tier

2)

UVADEX SOLN$0-

$7.40(Tier

2)

Chemotherapy Adjuncts

ELITEK SOLR$0-

$7.40(Tier

2)

KEPIVANCE SOLR$0-

$7.40(Tier

2)

Chemotherapy Rescue/Antidote Agents



65

Name of drug

Whatthe


level)


amifostine crystalline solr$0-

$2.95(Tier

1)

MO

dexrazoxane solr 250 mg,500 mg

$0-$2.95(Tier

1)ETHYOL SOLR (AmifostineCrystalline) NF MO

FUSILEV SOLR(Levoleucovorin Calcium)

$0-$7.40(Tier

2)

leucovorin calcium solr ij100 mg, 350 mg

$0-$2.95(Tier

1)

MO

leucovorin calcium solr ij200 mg, 50 mg, 500 mg

$0-$2.95(Tier

1)

leucovorin calcium tabs or10 mg, 15 mg, 25 mg, 5 mg

$0-$2.95(Tier

1)

MO

levoleucovorin calcium soln$0-

$2.95(Tier

1)

levoleucovorin calcium solr$0-

$2.95(Tier

1)

LEVOLEUCOVORIN SOLN$0-

$7.40(Tier

2)

mesna soln$0-

$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


MESNEX SOLN IV 100MG/ML (Mesna) NF MO

MESNEX TABS OR 400MG

$0-$7.40(Tier

2)

MO

ZINECARD SOLR(Dexrazoxane) NF

Mitotic Inhibitors

ABRAXANE SUSR$0-

$7.40(Tier

2)

MO

DOCEFREZ SOLR$0-

$7.40(Tier

2)

docetaxel conc 140mg/7ml, 20 mg/ml, 80mg/4ml

$0-$2.95(Tier

1)

DOCETAXEL CONC 20MG/ML, 80 MG/4ML

$0-$7.40(Tier

2)

DOCETAXEL SOLN 160MG/16ML, 20 MG/2ML,200 MG/20ML, 80 MG/8ML

$0-$7.40(Tier

2)

ETOPOPHOS SOLR$0-

$7.40(Tier

2)

etoposide soln iv 1gm/50ml, 100 mg/5ml, 500mg/25ml

$0-$2.95(Tier

1)

HALAVEN SOLN$0-

$7.40(Tier

2)



66

Name of drug

Whatthe


level)


IXEMPRA KIT SOLR$0-

$7.40(Tier

2)

JEVTANA SOLN$0-

$7.40(Tier

2)

MARQIBO SUSP$0-

$7.40(Tier

2)NAVELBINE SOLN(Vinorelbine Tartrate) NF MO

paclitaxel conc 100mg/16.7ml, 150 mg/25ml

$0-$2.95(Tier

1)

paclitaxel conc 30 mg/5ml,300 mg/50ml

$0-$2.95(Tier

1)

MO

TAXOL CONC (Paclitaxel) NF MO

TAXOTERE CONC(Docetaxel)

$0-$7.40(Tier

2)

vinblastine sulfate soln$0-

$2.95(Tier

1)

MO

vincristine sulfate soln$0-

$2.95(Tier

1)

MO

vinorelbine tartrate soln$0-

$2.95(Tier

1)

MO

Topoisomerase I Inhibitors

Name of drug

Whatthe


level)


CAMPTOSAR SOLN 100MG/5ML, 40 MG/2ML(Irinotecan HCl)

NF

CAMPTOSAR SOLN 300MG/15ML

$0-$7.40(Tier

2)HYCAMTIN SOLR(Topotecan HCl) NF MO

irinotecan hcl soln$0-

$2.95(Tier

1)

TOPOTECAN HCL SOLN4 MG/4ML

$0-$7.40(Tier

2)

topotecan hcl solr 4 mg$0-

$2.95(Tier

1)

MO

ANTIPARKINSON AGENTS - Drugs to TreatParkinson's DiseaseAntiparkinson Adjuvants

carbidopa tabs or$0-

$2.95(Tier

1)

MO

LODOSYN TABS(Carbidopa) NF MO

Antiparkinson Anticholinergics

benztropine mesylate solnij 1 mg/ml

$0-$2.95(Tier

1)

MO

benztropine mesylate tabsor 0.5 mg, 1 mg, 2 mg

$0-$2.95(Tier

1)

AL; MO

COGENTIN SOLN(Benztropine Mesylate) NF MO



67

Name of drug

Whatthe


level)


trihexyphenidyl hcl elix$0-

$2.95(Tier

1)

AL; MO

trihexyphenidyl hcl tabs$0-

$2.95(Tier

1)

AL; MO

Antiparkinson COMT InhibitorsCOMTAN TABS(Entacapone) NF SL(8 ea daily);

MO

entacapone tabs$0-

$2.95(Tier

1)

SL(8 ea daily);MO

TASMAR TABS(Tolcapone)

$0-$7.40(Tier

2)

MO

tolcapone tabs$0-

$2.95(Tier

1)

MO

Antiparkinson Dopaminergics

amantadine hcl caps or100 mg

$0-$2.95(Tier

1)

MO

amantadine hcl syrp or 50mg/5ml

$0-$2.95(Tier

1)

MO

amantadine hcl tabs or 100mg

$0-$2.95(Tier

1)

MO

APOKYN SOLN$0-

$7.40(Tier

2)

LA

Name of drug

Whatthe


level)


bromocriptine mesylatecaps or 5 mg

$0-$2.95(Tier

1)

MO

bromocriptine mesylatetabs or 2.5 mg

$0-$2.95(Tier

1)

MO

carbidopa-levodopa tabs$0-

$2.95(Tier

1)

MO

carbidopa-levodopa tbcr$0-

$2.95(Tier

1)

MO

carbidopa-levodopa tbdp$0-

$2.95(Tier

1)

MO

DUOPA SUSP$0-

$7.40(Tier

2)

B/D

MIRAPEX TABS(PramipexoleDihydrochloride)

NFMO

NEUPRO PT24$0-

$7.40(Tier

2)

MO

PARLODEL CAPS(Bromocriptine Mesylate) NF MO

PARLODEL TABS(Bromocriptine Mesylate) NF MO

pramipexoledihydrochloride tabs 0.125mg, 0.25 mg, 0.5 mg, 0.75mg, 1 mg, 1.5 mg

$0-$2.95(Tier

1)

MO

REQUIP TABS (RopiniroleHydrochloride) NF MO

REQUIP XL TB24(Ropinirole Hydrochloride) NF MO



68

Name of drug

Whatthe


level)


ropinirole hydrochloridetabs

$0-$2.95(Tier

1)

MO

ropinirole hydrochloridetb24

$0-$2.95(Tier

1)

MO

RYTARY CPCR$0-

$7.40(Tier

2)

MO

SINEMET CR TBCR(Carbidopa-Levodopa) NF MO

SINEMET TABS(Carbidopa-Levodopa) NF MO

Antiparkinson Monoamine Oxidase Inhibitors

AZILECT TABS$0-

$7.40(Tier

2)

MO

ELDEPRYL CAPS(Selegiline HCl) NF MO

selegiline hcl caps or$0-

$2.95(Tier

1)

MO

selegiline hcl tabs or$0-

$2.95(Tier

1)

MO

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood DisordersAntimanic Agents

lithium carbonate caps or150 mg, 300 mg, 600 mg

$0-$2.95(Tier

1)

MO

LITHIUM CARBONATECAPS OR 600 MG (LithiumCarbonate)

NFMO

Name of drug

Whatthe


level)


lithium carbonate tabs or300 mg

$0-$2.95(Tier

1)

MO

lithium carbonate tbcr or300 mg, 450 mg

$0-$2.95(Tier

1)

MO

lithium soln$0-

$2.95(Tier

1)

MO

LITHOBID TBCR (LithiumCarbonate) NF MO

Antipsychotics - Misc.

EQUETRO CP12$0-

$7.40(Tier

2)

MO

GEODON CAPS OR 20MG, 40 MG, 60 MG, 80 MG(Ziprasidone HCl)

NFMO

GEODON SOLR IM 20 MG$0-

$7.40(Tier

2)

MO

LATUDA TABS 120 MG$0-

$7.40(Tier

2)



$7.40(Tier

2)

SL(8 ea daily);MO


$7.40(Tier

2)

SL(4 ea daily);MO


$7.40(Tier

2)




69

Name of drug

Whatthe


level)



$7.40(Tier

2)

SL(2 ea daily);MO

NUPLAZID TABS$0-

$7.40(Tier

2)

PA; LA

VRAYLAR CAPS 1.5 MG$0-

$7.40(Tier

2)


VRAYLAR CAPS 3 MG$0-

$7.40(Tier

2)


VRAYLAR CAPS 4.5 MG$0-

$7.40(Tier

2)


VRAYLAR CAPS 6 MG$0-

$7.40(Tier

2)


VRAYLAR CPPK$0-

$7.40(Tier

2)

PA; MO

ziprasidone hcl caps$0-

$2.95(Tier

1)

MO

Benzisoxazoles

FANAPT TABS$0-

$7.40(Tier

2)

MO

INVEGA SUSTENNASUSP

$0-$7.40(Tier

2)

MO

Name of drug

Whatthe


level)


INVEGA TB24 1.5 MG(Paliperidone)

$0-$7.40(Tier

2)

SL(8 ea daily);MO

INVEGA TB24 3 MG(Paliperidone)

$0-$7.40(Tier

2)

SL(4 ea daily);MO


$0-$7.40(Tier

2)

SL(2 ea daily);MO


$0-$7.40(Tier

2)


INVEGA TRINZA SUSP$0-

$7.40(Tier

2)

paliperidone tb24 1.5 mg$0-

$2.95(Tier

1)

SL(8 ea daily);MO

paliperidone tb24 3 mg$0-

$2.95(Tier

1)

SL(4 ea daily);MO


$2.95(Tier

1)

SL(2 ea daily);MO


$2.95(Tier

1)


RISPERDAL CONSTASUSR 12.5 MG

$0-$7.40(Tier

2)

Limit 8 vials per28days;SL(0.29ea daily); MO



70

Name of drug

Whatthe


level)


RISPERDAL CONSTASUSR 25 MG

$0-$7.40(Tier

2)


RISPERDAL CONSTASUSR 37.5 MG

$0-$7.40(Tier

2)

Limit 4 vials per42 days;SL(0.1ea daily); MO

RISPERDAL CONSTASUSR 50 MG

$0-$7.40(Tier

2)


RISPERDAL M-TAB TBDP(Risperidone) NF MO

RISPERDAL SOLN(Risperidone) NF MO

RISPERDAL TABS(Risperidone) NF MO

risperidone soln$0-

$2.95(Tier

1)

MO

risperidone tabs$0-

$2.95(Tier

1)

MO

risperidone tbdp$0-

$2.95(Tier

1)

MO

ButyrophenonesHALDOL DECANOATE100 SOLN (HaloperidolDecanoate)

NFMO

HALDOL DECANOATE 50SOLN (HaloperidolDecanoate)

NFMO

HALDOL SOLN(Haloperidol Lactate) NF MO

Name of drug

Whatthe


level)


haloperidol decanoate solnim 100 mg/ml, 50 mg/ml

$0-$2.95(Tier

1)

MO

haloperidol lactate conc$0-

$2.95(Tier

1)

MO

haloperidol lactate soln$0-

$2.95(Tier

1)

MO

haloperidol tabs$0-

$2.95(Tier

1)

MO

Dibenzapines

CLOZAPINE ODT TBDP$0-

$7.40(Tier

2)

clozapine tabs$0-

$2.95(Tier

1)

clozapine tbdp$0-

$2.95(Tier

1)CLOZARIL TABS(Clozapine) NF

FAZACLO TBDP 100 MG,25 MG (Clozapine)

$0-$7.40(Tier

2)

FAZACLO TBDP 12.5 MG,150 MG, 200 MG

$0-$7.40(Tier

2)

loxapine succinate caps$0-

$2.95(Tier

1)

MO



71

Name of drug

Whatthe


level)


olanzapine solr$0-

$2.95(Tier

1)

MO

olanzapine tabs$0-

$2.95(Tier

1)

MO

olanzapine tbdp$0-

$2.95(Tier

1)

MO

quetiapine fumarate tabs100 mg, 200 mg, 25 mg,300 mg, 400 mg, 50 mg

$0-$2.95(Tier

1)

MO

SAPHRIS SUBL 10 MG$0-

$7.40(Tier

2)

SL(2 ea daily);MO

SAPHRIS SUBL 2.5 MG$0-

$7.40(Tier

2)

SL(8 ea daily);MO

SAPHRIS SUBL 5 MG$0-

$7.40(Tier

2)

SL(4 ea daily);MO

SEROQUEL TABS(Quetiapine Fumarate) NF MO

VERSACLOZ SUSP$0-

$7.40(Tier

2)

PA; SL(18 mldaily)

ZYPREXA RELPREVVSUSR 210 MG

$0-$7.40(Tier

2)ZYPREXA SOLR(Olanzapine) NF MO

ZYPREXA TABS(Olanzapine) NF MO

Name of drug

Whatthe


level)


ZYPREXA ZYDIS TBDP(Olanzapine) NF MO

Dihydroindolones

molindone hcl tabs$0-

$2.95(Tier

1)

MO

Phenothiazines

chlorpromazine hcl soln ij25 mg/ml

$0-$2.95(Tier

1)

MO

chlorpromazine hcl soln ij50 mg/2ml

$0-$2.95(Tier

1)

chlorpromazine hcl tabs or10 mg, 100 mg, 200 mg, 25mg, 50 mg

$0-$2.95(Tier

1)

MO

fluphenazine decanoatesoln ij

$0-$2.95(Tier

1)

MO

fluphenazine hcl conc or 5mg/ml

$0-$2.95(Tier

1)

MO

fluphenazine hcl soln ij 2.5mg/ml

$0-$2.95(Tier

1)

MO

fluphenazine hcl tabs or 1mg, 10 mg, 2.5 mg, 5 mg

$0-$2.95(Tier

1)

MO

perphenazine tabs or 16mg, 2 mg, 4 mg, 8 mg

$0-$2.95(Tier

1)

MO



72

Name of drug

Whatthe


level)


prochlorperazine edisylatesoln ij

$0-$2.95(Tier

1)

MO

prochlorperazine maleatetabs or 10 mg, 5 mg

$0-$2.95(Tier

1)

MO

prochlorperazine supp$0-

$2.95(Tier

1)

MO

thioridazine hcl tabs or 10mg, 100 mg, 25 mg, 50 mg

$0-$2.95(Tier

1)

AL; MO

trifluoperazine hcl tabs$0-

$2.95(Tier

1)

MO

Quinolinone Derivatives

ABILIFY DISCMELT TBDP10 MG

$0-$7.40(Tier

2)

SL(3 ea daily);MO

ABILIFY DISCMELT TBDP15 MG

$0-$7.40(Tier

2)

SL(2 ea daily);MO

ABILIFY MAINTENA SUSR$0-

$7.40(Tier

2)

MO

ABILIFY SOLN IM 9.75MG/1.3ML

$0-$7.40(Tier

2)

SL(4 ml daily);MO

ABILIFY SOLN OR 1MG/ML

$0-$7.40(Tier

2)

SL(30 ml daily);MO

Name of drug

Whatthe


level)


ABILIFY TABS OR 10 MG(Aripiprazole)

$0-$7.40(Tier

2)

SL(3 ea daily);MO


$0-$7.40(Tier

2)

SL(2 ea daily);MO


$0-$7.40(Tier

2)

SL(15 ea daily);MO


$0-$7.40(Tier

2)

SL(1.5 eadaily); MO


$0-$7.40(Tier

2)

SL(1 ea daily);MO


$0-$7.40(Tier

2)

SL(6 ea daily);MO

aripiprazole soln 1 mg/ml$0-

$2.95(Tier

1)

SL(30 ml daily);MO

aripiprazole tabs 10 mg$0-

$2.95(Tier

1)

SL(3 ea daily);MO


$2.95(Tier

1)

SL(2 ea daily);MO


$2.95(Tier

1)

SL(15 ea daily);MO



73

Name of drug

Whatthe


level)



$2.95(Tier

1)

SL(1.5 eadaily); MO


$2.95(Tier

1)

SL(1 ea daily);MO


$2.95(Tier

1)

SL(6 ea daily);MO

aripiprazole tbdp 10 mg$0-

$2.95(Tier

1)

SL(3 ea daily);MO

aripiprazole tbdp 15 mg$0-

$2.95(Tier

1)

SL(2 ea daily);MO

ARISTADA PRSY$0-

$7.40(Tier

2)

REXULTI TABS 0.25 MG$0-

$7.40(Tier

2)


REXULTI TABS 0.5 MG$0-

$7.40(Tier

2)


REXULTI TABS 1 MG$0-

$7.40(Tier

2)



$7.40(Tier

2)


Name of drug

Whatthe


level)



$7.40(Tier

2)



$7.40(Tier

2)


Thioxanthenes

thiothixene caps$0-

$2.95(Tier

1)

MO

ANTISEPTICS & DISINFECTANTS - Drugs toPrevent Bacterial Skin InfectionsChlorine Antiseptics

BENZALKONIUMCHLORIDE SOLN

$0(Tier

3)

NT

dakin's solution soln 0.25%, 0.5 %

$0(Tier

3)

MO; NT

triclosan bar ex 0.3 %$0

(Tier3)

NT

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals

abacavir sulfate tabs$0-

$2.95(Tier

1)

MO

abacavir sulfate-lamivudinetabs

$0-$2.95(Tier

1)

MO

abacavir sulfate-lamivudine-zidovudine tabs

$0-$2.95(Tier

1)

MO



74

Name of drug

Whatthe


level)


APTIVUS CAPS 250 MG$0-

$7.40(Tier

2)

MO

APTIVUS SOLN 100MG/ML

$0-$7.40(Tier

2)

ATRIPLA TABS$0-

$7.40(Tier

2)

MO

COMBIVIR TABS(Lamivudine-Zidovudine) NF MO

COMPLERA TABS$0-

$7.40(Tier

2)

MO

CRIXIVAN CAPS$0-

$7.40(Tier

2)

MO

DESCOVY TABS$0-

$7.40(Tier

2)

MO

didanosine cpdr$0-

$2.95(Tier

1)

MO

EDURANT TABS$0-

$7.40(Tier

2)

MO

EMTRIVA CAPS$0-

$7.40(Tier

2)

MO

EMTRIVA SOLN$0-

$7.40(Tier

2)

MO

Name of drug

Whatthe


level)


EPIVIR SOLN 10 MG/ML(Lamivudine)

$0-$7.40(Tier

2)

MO

EPIVIR TABS 150 MG, 300MG (Lamivudine) NF MO

EPZICOM TABS (AbacavirSulfate-Lamivudine)

$0-$7.40(Tier

2)

MO

EVOTAZ TABS$0-

$7.40(Tier

2)

MO

FUZEON SOLR$0-

$7.40(Tier

2)

GENVOYA TABS$0-

$7.40(Tier

2)

MO

INTELENCE TABS 100MG, 200 MG

$0-$7.40(Tier

2)

MO

INTELENCE TABS 25 MG$0-

$7.40(Tier

2)

INVIRASE CAPS$0-

$7.40(Tier

2)

MO

INVIRASE TABS$0-

$7.40(Tier

2)

MO

ISENTRESS CHEW 100MG

$0-$7.40(Tier

2)

SL(6 ea daily);MO



75

Name of drug

Whatthe


level)


ISENTRESS CHEW 25 MG$0-

$7.40(Tier

2)

SL(24 ea daily);MO

ISENTRESS PACK 100MG

$0-$7.40(Tier

2)

SL(2 ea daily)

ISENTRESS TABS 400MG

$0-$7.40(Tier

2)

MO

KALETRA SOLN$0-

$7.40(Tier

2)

MO

KALETRA TABS$0-

$7.40(Tier

2)

MO

lamivudine soln$0-

$2.95(Tier

1)

MO

lamivudine tabs$0-

$2.95(Tier

1)

MO

lamivudine-zidovudine tabs$0-

$2.95(Tier

1)

MO

LEXIVA SUSP$0-

$7.40(Tier

2)

MO

LEXIVA TABS$0-

$7.40(Tier

2)

MO

Name of drug

Whatthe


level)


NEVIRAPINE SUSP 50MG/5ML

$0-$7.40(Tier

2)

MO

nevirapine tabs 200 mg$0-

$2.95(Tier

1)

MO

nevirapine tb24 100 mg,400 mg

$0-$2.95(Tier

1)

MO

NORVIR CAPS$0-

$7.40(Tier

2)

MO

NORVIR SOLN$0-

$7.40(Tier

2)

MO

NORVIR TABS$0-

$7.40(Tier

2)

MO

ODEFSEY TABS$0-

$7.40(Tier

2)

MO

PREZCOBIX TABS$0-

$7.40(Tier

2)

MO

PREZISTA SUSP$0-

$7.40(Tier

2)

MO

PREZISTA TABS$0-

$7.40(Tier

2)

MO



76

Name of drug

Whatthe


level)


RESCRIPTOR TABS$0-

$7.40(Tier

2)

MO

RETROVIR CAPS(Zidovudine) NF MO

RETROVIR IV INFUSIONSOLN

$0-$7.40(Tier

2)RETROVIR SYRP(Zidovudine) NF MO

REYATAZ CAPS$0-

$7.40(Tier

2)

MO

REYATAZ PACK$0-

$7.40(Tier

2)

MO

SELZENTRY TABS$0-

$7.40(Tier

2)

MO

stavudine caps$0-

$2.95(Tier

1)

MO

stavudine solr$0-

$2.95(Tier

1)

MO

STRIBILD TABS$0-

$7.40(Tier

2)

MO

SUSTIVA CAPS$0-

$7.40(Tier

2)

MO

Name of drug

Whatthe


level)


SUSTIVA TABS$0-

$7.40(Tier

2)

MO

TIVICAY TABS$0-

$7.40(Tier

2)

MO

TRIUMEQ TABS$0-

$7.40(Tier

2)

MO

TRIZIVIR TABS (AbacavirSulfate-Lamivudine-Zidovudine)

NFMO

TRUVADA TABS$0-

$7.40(Tier

2)

MO

TYBOST TABS$0-

$7.40(Tier

2)

MO

VIDEX EC CPDR(Didanosine)

$0-$7.40(Tier

2)

MO

VIDEXPEDIATRIC SOLR$0-

$7.40(Tier

2)

MO

VIRACEPT TABS$0-

$7.40(Tier

2)

MO

VIRAMUNE SUSP 50MG/5ML

$0-$7.40(Tier

2)

MO

VIRAMUNE TABS 200 MG(Nevirapine) NF MO



77

Name of drug

Whatthe


level)


VIRAMUNE XR TB24 100MG (Nevirapine)

$0-$7.40(Tier

2)

MO

VIRAMUNE XR TB24 400MG (Nevirapine) NF MO

VIREAD POWD$0-

$7.40(Tier

2)

MO

VIREAD TABS$0-

$7.40(Tier

2)

MO

VITEKTA TABS$0-

$7.40(Tier

2)

ZERIT CAPS (Stavudine) NF MO

ZERIT SOLR (Stavudine) NF MO

ZIAGEN SOLN 20 MG/ML$0-

$7.40(Tier

2)

MO

ZIAGEN TABS 300 MG(Abacavir Sulfate) NF MO

zidovudine caps$0-

$2.95(Tier

1)

MO

zidovudine syrp$0-

$2.95(Tier

1)

MO

zidovudine tabs$0-

$2.95(Tier

1)

MO

CMV Agents

Name of drug

Whatthe


level)


cidofovir soln$0-

$2.95(Tier

1)CYTOVENE SOLR(Ganciclovir Sodium) NF MO

ganciclovir sodium solr$0-

$2.95(Tier

1)

MO

VALCYTE TABS 450 MG(Valganciclovir HCl)

$0-$7.40(Tier

2)

MO

valganciclovir hcl tabs 450mg

$0-$2.95(Tier

1)

MO

VISTIDE SOLN (Cidofovir) NF

Hepatitis Agents

adefovir dipivoxil tabs$0-

$2.95(Tier

1)

MO

BARACLUDE SOLN 0.05MG/ML

$0-$7.40(Tier

2)

MO

BARACLUDE TABS 0.5MG, 1 MG (Entecavir)

$0-$7.40(Tier

2)

MO

COPEGUS TABS(Ribavirin (Hepatitis C)) NF

DAKLINZA TABS$0-

$7.40(Tier

2)

PA

entecavir tabs$0-

$2.95(Tier

1)

MO



78

Name of drug

Whatthe


level)


EPIVIR HBV SOLN 5MG/ML

$0-$7.40(Tier

2)

MO

EPIVIR HBV TABS 100MG (Lamivudine (HBV)) NF MO

HARVONI TABS$0-

$7.40(Tier

2)

PA

HEPSERA TABS (AdefovirDipivoxil) NF MO

lamivudine (hbv) tabs$0-

$2.95(Tier

1)

MO

OLYSIO CAPS$0-

$7.40(Tier

2)

PA

PEG-INTRON KIT$0-

$7.40(Tier

2)

PEG-INTRON REDIPENKIT

$0-$7.40(Tier

2)

PEG-INTRON REDIPENPAK 4 KIT

$0-$7.40(Tier

2)

PEGASYS PROCLICKSOLN

$0-$7.40(Tier

2)

PEGASYS SOLN$0-

$7.40(Tier

2)

Name of drug

Whatthe


level)


PEGINTRON KIT$0-

$7.40(Tier

2)REBETOL CAPS 200 MG(Ribavirin (Hepatitis C)) NF

ribavirin (hepatitis c) caps$0-

$2.95(Tier

1)

ribavirin (hepatitis c) tabs$0-

$2.95(Tier

1)

SOVALDI TABS$0-

$7.40(Tier

2)

PA

TECHNIVIE TABS$0-

$7.40(Tier

2)

PA

TYZEKA TABS$0-

$7.40(Tier

2)

MO

VICTRELIS CAPS$0-

$7.40(Tier

2)

PA

VIEKIRA PAK TBPK$0-

$7.40(Tier

2)

PA

ZEPATIER TABS$0-

$7.40(Tier

2)

PA

Herpes Agents

acyclovir caps or 200 mg$0-

$2.95(Tier

1)

MO



79

Name of drug

Whatthe


level)


acyclovir sodium soln 50mg/ml

$0-$2.95(Tier

1)

acyclovir sodium solr 500mg

$0-$2.95(Tier

1)

MO

acyclovir susp or 200mg/5ml

$0-$2.95(Tier

1)

MO

acyclovir tabs or 400 mg,800 mg

$0-$2.95(Tier

1)

MO

famciclovir tabs$0-

$2.95(Tier

1)

MO

FAMVIR TABS(Famciclovir) NF MO

valacyclovir hcl tabs or 1gm, 1000 mg, 500 mg

$0-$2.95(Tier

1)

MO

VALTREX TABS(Valacyclovir HCl) NF MO

ZOVIRAX CAPS OR 200MG (Acyclovir) NF MO

ZOVIRAX SUSP OR 200MG/5ML (Acyclovir) NF MO

ZOVIRAX TABS OR 400MG, 800 MG (Acyclovir) NF MO

Influenza AgentsFLUMADINE TABS(RimantadineHydrochloride)

NFMO

RELENZA DISKHALERAEPB

$0-$7.40(Tier

2)

MO

Name of drug

Whatthe


level)


rimantadine hydrochloridetabs

$0-$2.95(Tier

1)

MO

TAMIFLU CAPS$0-

$7.40(Tier

2)

MO

TAMIFLU SUSR$0-

$7.40(Tier

2)

MO

Respiratory Syncytial Virus (RSV) Agents

VIRAZOLE SOLR$0-

$7.40(Tier

2)

ASSORTED CLASSES - Miscellaneous Drugs

Assorted Classes

gelatin caps or 650 mg$0

(Tier3)

NT

NULLO TABS$0

(Tier3)

NT

Chelating Agents

CUPRIMINE CAPS$0-

$7.40(Tier

2)

MO

DEPEN TITRATABS TABS$0-

$7.40(Tier

2)

MO

SYPRINE CAPS$0-

$7.40(Tier

2)

MO

Enzymes



80

Name of drug

Whatthe


level)


papaya chew 5mg-5mg-3mg-2mg-20mg

$0(Tier

3)

NT

Immunomodulators

REVLIMID CAPS$0-

$7.40(Tier

2)

LA

THALOMID CAPS$0-

$7.40(Tier

2)

Immunosuppressive Agents

ASTAGRAF XL CP24$0-

$7.40(Tier

2)

MO; B/D

AZATHIOPRINE SOLR IJ100 MG

$0-$7.40(Tier

2)

B/D

azathioprine tabs or 100mg, 50 mg, 75 mg

$0-$2.95(Tier

1)

MO; B/D

CELLCEPT CAPS 250 MG(Mycophenolate Mofetil) NF MO; B/D

CELLCEPTINTRAVENOUS SOLR(Mycophenolate MofetilHCl)

$0-$7.40(Tier

2)

B/D

CELLCEPT SUSR 200MG/ML (MycophenolateMofetil)

$0-$7.40(Tier

2)

MO; B/D

CELLCEPT TABS 500 MG(Mycophenolate Mofetil) NF MO; B/D

cyclosporine caps or 100mg, 25 mg

$0-$2.95(Tier

1)

MO; B/D

Name of drug

Whatthe


level)


cyclosporine modified (formicroemulsion) caps 100mg, 25 mg, 50 mg

$0-$2.95(Tier

1)

MO; B/D

cyclosporine soln iv 50mg/ml

$0-$2.95(Tier

1)

B/D

ENVARSUS XR TB24$0-

$7.40(Tier

2)

MO; B/D

IMURAN TABS(Azathioprine) NF MO; B/D

mycophenolate mofetilcaps

$0-$2.95(Tier

1)

MO; B/D

mycophenolate mofetil hclsolr

$0-$2.95(Tier

1)

B/D

mycophenolate mofetil susr$0-

$2.95(Tier

1)

MO; B/D

mycophenolate mofetil tabs$0-

$2.95(Tier

1)

MO; B/D

mycophenolate sodiumtbec

$0-$2.95(Tier

1)

MO; B/D

MYFORTIC TBEC(Mycophenolate Sodium) NF MO; B/D

NEORAL CAPS 100 MG,25 MG (CyclosporineModified (ForMicroemulsion))

NF

MO; B/D



81

Name of drug

Whatthe


level)


NULOJIX SOLR$0-

$7.40(Tier

2)

B/D

PROGRAF CAPS OR 0.5MG, 1 MG, 5 MG(Tacrolimus)

NFMO; B/D

PROGRAF SOLN IV 5MG/ML

$0-$7.40(Tier

2)

B/D

RAPAMUNE SOLN 1MG/ML

$0-$7.40(Tier

2)

MO; B/D

RAPAMUNE TABS 0.5 MG(Sirolimus) NF MO; B/D

RAPAMUNE TABS 1 MG,2 MG (Sirolimus)

$0-$7.40(Tier

2)

MO; B/D

SANDIMMUNE CAPS OR100 MG, 25 MG(Cyclosporine)

NFMO; B/D

SANDIMMUNE SOLN IV50 MG/ML (Cyclosporine) NF B/D

SANDIMMUNE SOLN OR100 MG/ML

$0-$7.40(Tier

2)

MO; B/D

SIMULECT SOLR$0-

$7.40(Tier

2)

B/D

sirolimus tabs$0-

$2.95(Tier

1)

MO; B/D

tacrolimus caps or 0.5 mg,1 mg, 5 mg

$0-$2.95(Tier

1)

MO; B/D

Name of drug

Whatthe


level)


THYMOGLOBULIN SOLR$0-

$7.40(Tier

2)

B/D

ZORTRESS TABS$0-

$7.40(Tier

2)

MO; B/D

Irrigation Solutions

irrigation solutions,physiological soln

$0-$2.95(Tier

1)

water for irrigation, sterilesoln

$0-$2.95(Tier

1)

MO

Potassium Removing AgentsKAYEXALATE POWD(Sodium PolystyreneSulfonate)

NFMO

sodium polystyrenesulfonate powd or

$0-$2.95(Tier

1)

MO

sodium polystyrenesulfonate susp or 15gm/60ml

$0-$2.95(Tier

1)

MO

VELTASSA PACK 16.8 GM$0-

$7.40(Tier

2)

ST; SL(1.5 eadaily); LA


$7.40(Tier

2)

ST; SL(1 eadaily); LA


$7.40(Tier

2)

ST; SL(3 eadaily); LA

Systemic Lupus Erythematosus Agents



82

Name of drug

Whatthe


level)


BENLYSTA SOLR 120 MG$0-

$7.40(Tier

2)

BETA BLOCKERS - Drugs to Treat High BloodPressureAlpha-Beta Blockers

carvedilol tabs 12.5 mg$0-

$2.95(Tier

1)

SL(8 ea daily);MO

carvedilol tabs 25 mg$0-

$2.95(Tier

1)

SL(4 ea daily);MO


$2.95(Tier

1)

SL(32 ea daily);MO


$2.95(Tier

1)

SL(16 ea daily);MO

COREG CR CP24$0-

$7.40(Tier

2)

MO

COREG TABS 12.5 MG(Carvedilol) NF SL(8 ea daily);

MOCOREG TABS 25 MG(Carvedilol) NF SL(4 ea daily);

MOCOREG TABS 3.125 MG(Carvedilol) NF SL(32 ea daily);

MOCOREG TABS 6.25 MG(Carvedilol) NF SL(16 ea daily);

MO

labetalol hcl tabs or 100mg, 200 mg, 300 mg

$0-$2.95(Tier

1)

MO

Beta Blockers Cardio-Selective

Name of drug

Whatthe


level)


acebutolol hcl caps or 200mg, 400 mg

$0-$2.95(Tier

1)

MO

atenolol tabs or 100 mg, 25mg, 50 mg

$0-$2.95(Tier

1)

MO

betaxolol hcl tabs$0-

$2.95(Tier

1)

MO

bisoprolol fumarate tabs$0-

$2.95(Tier

1)

MO

KERLONE TABS(Betaxolol HCl) NF MO

LOPRESSOR TABS OR100 MG, 50 MG(Metoprolol Tartrate)

NFMO

metoprolol succinate tb24$0-

$2.95(Tier

1)

MO

metoprolol tartrate tabs or100 mg, 25 mg, 50 mg

$0-$2.95(Tier

1)

MO

METOPROLOLTARTRATE TABS OR 37.5MG, 75 MG

$0-$7.40(Tier

2)

MO

SECTRAL CAPS(Acebutolol HCl) NF MO

TENORMIN TABS(Atenolol) NF MO

TOPROL XL TB24(Metoprolol Succinate) NF MO

ZEBETA TABS (BisoprololFumarate) NF MO

Beta Blockers Non-Selective



83

Name of drug

Whatthe


level)


BETAPACE AF TABS(Sotalol HCl (AFIB/AFL)) NF MO

BETAPACE TABS (SotalolHCl) NF tabs;MO

CORGARD TABS(Nadolol) NF MO

INDERAL LA CP24(Propranolol HCl) NF MO

nadolol tabs or 20 mg, 40mg, 80 mg

$0-$2.95(Tier

1)

MO

pindolol tabs$0-

$2.95(Tier

1)

MO

propranolol hcl cp24 or 120mg, 160 mg, 60 mg, 80 mg

$0-$2.95(Tier

1)

MO

propranolol hcl tabs or 10mg, 20 mg, 40 mg, 60 mg,80 mg

$0-$2.95(Tier

1)

MO

sotalol hcl (afib/afl) tabs$0-

$2.95(Tier

1)

MO

Sotalol Hcl IV Soln NF

sotalol hcl tabs$0-

$2.95(Tier

1)

tabs;MO

SOTYLIZE SOLN$0-

$7.40(Tier

2)

MO

BIOLOGICALS MISC - Drugs to Treat LowEnzymesBiologicals Misc

Name of drug

Whatthe


level)


ADAGEN SOLN$0-

$7.40(Tier

2)

LA

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood PressureCalcium Channel BlockersADALAT CC TB24(Nifedipine) NF MO

amlodipine besylate tabs or10 mg

$0-$2.95(Tier

1)

SL(1 ea daily);MO

amlodipine besylate tabs or2.5 mg

$0-$2.95(Tier

1)

SL(4 ea daily);MO

amlodipine besylate tabs or5 mg

$0-$2.95(Tier

1)

SL(2 ea daily);MO

CALAN SR TBCR(Verapamil HCl) NF MO

CALAN TABS (VerapamilHCl) NF MO

CARDIZEM CD CP24(Diltiazem HCl CoatedBeads)

NFMO

CARDIZEM LA TB24 180MG, 240 MG, 300 MG, 360MG, 420 MG (DiltiazemHCl Coated Beads)

NF

MO

CARDIZEM TABS(Diltiazem HCl) NF MO

diltiazem hcl coated beadscp24

$0-$2.95(Tier

1)

MO

diltiazem hcl coated beadstb24

$0-$2.95(Tier

1)

MO



84

Name of drug

Whatthe


level)


diltiazem hcl cp12 or 120mg, 60 mg, 90 mg

$0-$2.95(Tier

1)

MO

diltiazem hcl cp24 or 120mg, 180 mg, 240 mg

$0-$2.95(Tier

1)

MO

diltiazem hcl extendedrelease beads cp24

$0-$2.95(Tier

1)

MO

diltiazem hcl tabs or 120mg, 30 mg, 60 mg, 90 mg

$0-$2.95(Tier

1)

MO

felodipine tb24$0-

$2.95(Tier

1)

MO

nicardipine hcl caps or 20mg, 30 mg

$0-$2.95(Tier

1)

MO

nifedipine tb24 or 30 mg,60 mg, 90 mg

$0-$2.95(Tier

1)

MO

nimodipine caps or 30 mg,30mg

$0-$2.95(Tier

1)

MO

nisoldipine tb24 17 mg, 34mg, 8.5 mg

$0-$2.95(Tier

1)

MO

NORVASC TABS 10 MG(Amlodipine Besylate) NF SL(1 ea daily);

MONORVASC TABS 2.5 MG(Amlodipine Besylate) NF SL(4 ea daily);

MONORVASC TABS 5 MG(Amlodipine Besylate) NF SL(2 ea daily);

MO

Name of drug

Whatthe


level)


NYMALIZE SOLN$0-

$7.40(Tier

2)PROCARDIA XL TB24(Nifedipine) NF MO

SULAR TB24 (Nisoldipine) NF MO

TIAZAC CP24 (DiltiazemHCl Extended ReleaseBeads)

NFMO

verapamil hcl cp24 or 100mg, 120 mg, 180 mg, 200mg, 240 mg, 300 mg, 360mg

$0-$2.95(Tier

1)

MO

verapamil hcl tabs or 120mg, 40 mg, 80 mg

$0-$2.95(Tier

1)

MO

verapamil hcl tbcr or 120mg, 180 mg, 240 mg

$0-$2.95(Tier

1)

MO

VERELAN CP24(Verapamil HCl) NF MO

VERELAN PM CP24(Verapamil HCl) NF MO

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart RhythmCardiac Glycosides

DIGOXIN SOLN OR 0.05MG/ML

$0-$7.40(Tier

2)

MO

digoxin tabs or 0.125 mg,125 mcg

$0-$2.95(Tier

1)

MO

digoxin tabs or 0.25 mg,250 mcg

$0-$2.95(Tier

1)

AL; MO



85

Name of drug

Whatthe


level)


LANOXIN TABS OR 125MCG (Digoxin) NF MO

LANOXIN TABS OR 187.5MCG

$0-$7.40(Tier

2)

AL; MO

LANOXIN TABS OR 250MCG (Digoxin) NF AL; MO

LANOXIN TABS OR 62.5MCG

$0-$7.40(Tier

2)

MO

CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation ConditionsCardiovascular Agents Misc. - Combinations

ENTRESTO TABS$0-

$7.40(Tier

2)

PA; MO

Prostaglandin Vasodilators

REMODULIN SOLN$0-

$7.40(Tier

2)

LA; B/D

TYVASO REFILL SOLN$0-

$7.40(Tier

2)

LA; B/D

TYVASO SOLN$0-

$7.40(Tier

2)

LA; B/D

TYVASO STARTER SOLN$0-

$7.40(Tier

2)

LA; B/D

VENTAVIS SOLN$0-

$7.40(Tier

2)

LA; B/D

Pulmonary Hypertension - Endothelin Receptor

Name of drug

Whatthe


level)


LETAIRIS TABS$0-

$7.40(Tier

2)

LA

OPSUMIT TABS$0-

$7.40(Tier

2)

TRACLEER TABS$0-

$7.40(Tier

2)

LA

Pulmonary Hypertension - Phosphodiesterase

ADCIRCA TABS$0-

$7.40(Tier

2)

PA

REVATIO SOLN IV 10MG/12.5ML (SildenafilCitrate (PulmonaryHypertension))

$0-$7.40(Tier

2)

PA

REVATIO TABS OR 20MG (Sildenafil Citrate(Pulmonary Hypertension))

NFPA

sildenafil citrate (pulmonaryhypertension) soln

$0-$2.95(Tier

1)

PA

sildenafil citrate (pulmonaryhypertension) tabs

$0-$2.95(Tier

1)

PA

Pulmonary Hypertension - Prostacyclin Receptor

UPTRAVI TABS$0-

$7.40(Tier

2)

PA; LA

UPTRAVI TBPK$0-

$7.40(Tier

2)

PA; LA

Pulmonary Hypertension - Sol Guanylate Cyclase



86

Name of drug

Whatthe


level)


ADEMPAS TABS 0.5 MG$0-

$7.40(Tier

2)

PA; SL(15 eadaily)

ADEMPAS TABS 1 MG$0-

$7.40(Tier

2)

PA; SL(7.5 eadaily)


$7.40(Tier

2)

PA; SL(5 eadaily)

ADEMPAS TABS 2 MG$0-

$7.40(Tier

2)

PA; SL(3.75 eadaily)


$7.40(Tier

2)

PA; SL(3 eadaily)

Sinus Node Inhibitors

CORLANOR TABS 5 MG$0-

$7.40(Tier

2)

SL(3 ea daily);MO

CORLANOR TABS 7.5 MG$0-

$7.40(Tier

2)

SL(2 ea daily);MO

CEPHALOSPORINS - Drugs to Treat BacterialInfectionsCephalosporins - 1st Generation

cefadroxil caps 500 mg$0-

$2.95(Tier

1)

MO

cefadroxil susr 500 mg/5ml$0-

$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


cefadroxil tabs 1 gm$0-

$2.95(Tier

1)

MO

cefazolin sodium solr ij 1gm, 10 gm, 500 mg

$0-$2.95(Tier

1)

MO

cephalexin caps 250 mg,500 mg, 750 mg

$0-$2.95(Tier

1)

MO

cephalexin susr 125mg/5ml, 250 mg/5ml

$0-$2.95(Tier

1)

MO

KEFLEX CAPS(Cephalexin) NF MO

Cephalosporins - 2nd Generation

cefaclor caps 250 mg, 500mg

$0-$2.95(Tier

1)

MO

cefoxitin sodium solr ij 10gm

$0-$2.95(Tier

1)

cefoxitin sodium solr iv 1gm

$0-$2.95(Tier

1)

MO

cefoxitin sodium solr iv 2gm

$0-$2.95(Tier

1)

cefprozil susr 250 mg/5ml$0-

$2.95(Tier

1)

MO

cefprozil tabs 250 mg, 500mg

$0-$2.95(Tier

1)

MO



87

Name of drug

Whatthe


level)


CEFTIN TABS 250 MG,500 MG (CefuroximeAxetil)

NFMO

cefuroxime axetil tabs$0-

$2.95(Tier

1)

MO

cefuroxime sodium solr ij1.5 gm

$0-$2.95(Tier

1)ZINACEF SOLR IJ 1.5 GM(Cefuroxime Sodium) NF

Cephalosporins - 3rd Generation

cefdinir caps$0-

$2.95(Tier

1)

MO

cefdinir susr$0-

$2.95(Tier

1)

MO

cefixime chew$0-

$2.95(Tier

1)

MO

cefixime susr$0-

$2.95(Tier

1)

MO

cefpodoxime proxetil susr100 mg/5ml

$0-$2.95(Tier

1)

MO

cefpodoxime proxetil tabs100 mg, 200 mg

$0-$2.95(Tier

1)

MO

ceftazidime solr ij 1 gm, 2gm

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


ceftazidime solr ij 6 gm$0-

$2.95(Tier

1)

ceftriaxone sodium solr ij 1gm

$0-$2.95(Tier

1)

SL(4 ea daily)

ceftriaxone sodium solr ij 2gm

$0-$2.95(Tier

1)

SL(2 ea daily);MO

ceftriaxone sodium solr ij250 mg

$0-$2.95(Tier

1)

SL(16 ea daily);MO

ceftriaxone sodium solr ij500 mg

$0-$2.95(Tier

1)

SL(8 ea daily);MO

ceftriaxone sodium solr iv 1gm

$0-$2.95(Tier

1)

SL(4 ea daily)

ceftriaxone sodium solr iv10 gm

$0-$2.95(Tier

1)

MO

FORTAZ SOLR IJ 1 GM, 2GM (Ceftazidime) NF MO

FORTAZ SOLR IJ 6 GM(Ceftazidime) NF

ROCEPHIN SOLR(Ceftriaxone Sodium) NF SL(4 ea daily)

SUPRAX CAPS 400 MG$0-

$7.40(Tier

2)

MO

Cephalosporins - 4th Generation



88

Name of drug

Whatthe


level)


cefepime hcl solr$0-

$2.95(Tier

1)

MO

CEFEPIME SOLN 2GM/100ML

$0-$7.40(Tier

2)MAXIPIME SOLR IJ 1 GM,2 GM (Cefepime HCl) NF MO

Cephalosporins - 5th Generation

TEFLARO SOLR 600 MG$0-

$7.40(Tier

2)

CHEMICALS

Acids, Bases, & Buffers

LACTIC ACID RACEMICSOLN

$0(Tier

3)

RX/OTC; MO;NT

LACTIC ACID SOLN$0

(Tier3)

RX/OTC; MO;NT

Bulk Chemicals - S's

SODIUM CITRATEDIHYDRATE GRAN

$0(Tier

3)

NT

Liquids

GLYCERIN LIQD 99 %,99.5 %

$0(Tier

3)

RX/OTC; MO;NT

GLYCERINE LIQD$0

(Tier3)

RX/OTC; MO;NT

GLYCEROL FORMALLIQD

$0(Tier

3)

RX/OTC; MO;NT

Semi-Solids

Name of drug

Whatthe


level)


COAL TAR SOLN XX$0

(Tier3)

RX/OTC; MO;NT

SolidsSODIUMCHLORIDE/SODIUMBICARBONATE POWD

$0(Tier

3)

NT

THYMOL CRYS$0

(Tier3)

RX/OTC; MO;NT

CONTRACEPTIVES - Drugs to PreventPregnancyCombination Contraceptives - OralBREVICON-28 TABS(Norethindrone & EthEstradiol)

NFMO

DESOGEN TABS(Desogestrel & EthinylEstradiol)

NFMO

desogestrel & ethinylestradiol tabs

$0-$2.95(Tier

1)

MO

desogestrel-ethinylestradiol (biphasic) tabs

$0-$2.95(Tier

1)

MO

drospirenone-ethinylestradiol tabs

$0-$2.95(Tier

1)

MO

ethynodiol diacet & ethestrad tabs

$0-$2.95(Tier

1)

MO

FEMCON FE CHEW(Norethindrone & EthinylEstradiol-Fe)

NFMO

levonorgestrel & ethestradiol tabs

$0-$2.95(Tier

1)

MO



89

Name of drug

Whatthe


level)


levonorgestrel-eth estradiol(triphasic) tabs

$0-$2.95(Tier

1)

MO

levonorgestrel-ethinylestradiol (91-day) tabs

$0-$2.95(Tier

1)

MO

LOSEASONIQUE TABS(Levonorgestrel-EthinylEstradiol (91-Day))

NFMO

MODICON TABS(Norethindrone & EthEstradiol)

NFMO

norethin acet & estrad-fetabs 75mg-20mcg-1mg,75mg-30mcg-1.5mg

$0-$2.95(Tier

1)

MO

norethindrone & ethestradiol tabs

$0-$2.95(Tier

1)

MO

norethindrone & ethinylestradiol-fe chew 0.4mg-35mcg

$0-$2.95(Tier

1)

MO

norethindrone acet & ethestra tabs 20mcg-1mg,30mcg-1.5mg

$0-$2.95(Tier

1)

MO

norethindrone-eth estradiol(triphasic) tabs

$0-$2.95(Tier

1)

MO

norgestimate-ethinylestradiol (triphasic) tabs

$0-$2.95(Tier

1)

MO

norgestimate-ethinylestradiol tabs

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


norgestrel & ethinylestradiol tabs

$0-$2.95(Tier

1)

MO

NORINYL 1+35 TABS(Norethindrone & EthEstradiol)

NFMO

ORTHO TRI-CYCLENTABS (Norgestimate-Ethinyl Estradiol(Triphasic))

NF

MO

ORTHO-CEPT TABS(Desogestrel & EthinylEstradiol)

NFMO

ORTHO-CYCLEN TABS(Norgestimate-EthinylEstradiol)

NFMO

ORTHO-NOVUM 1/35TABS (Norethindrone & EthEstradiol)

NFMO

ORTHO-NOVUM 7/7/7TABS (Norethindrone-EthEstradiol (Triphasic))

NFMO

SEASONIQUE TABS(Levonorgestrel-EthinylEstradiol (91-Day))

NFMO

YASMIN 28 TABS(Drospirenone-EthinylEstradiol)

NFMO

YAZ TABS (Drospirenone-Ethinyl Estradiol) NF MO

Combination Contraceptives - Transdermal

norelgestromin-ethinylestradiol ptwk

$0-$2.95(Tier

1)

MO

ORTHO EVRA PTWK(Norelgestromin-EthinylEstradiol)

NFMO

Combination Contraceptives - Vaginal



90

Name of drug

Whatthe


level)


NUVARING RING$0-

$7.40(Tier

2)

MO

Emergency Contraceptives

ELLA TABS$0-

$7.40(Tier

2)

levonorgestrel (emergencyoc) tabs 0.75 mg

$0-$2.95(Tier

1)

levonorgestrel (emergencyoc) tabs 1.5 mg

$0(Tier

3)

RX/OTC; NT

PLAN B ONE-STEP TABS(Levonorgestrel(Emergency OC))

NFRX/OTC; NT

Progestin Contraceptives - InjectableDEPO-PROVERACONTRACEPTIVE SUSP(MedroxyprogesteroneAcetate (Contraceptive))

NF

MO

DEPO-PROVERACONTRACEPTIVE SUSY(MedroxyprogesteroneAcetate (Contraceptive))

NF

MO

medroxyprogesteroneacetate (contraceptive)susp

$0-$2.95(Tier

1)

MO

medroxyprogesteroneacetate (contraceptive)susy

$0-$2.95(Tier

1)

MO

Progestin Contraceptives - OralNOR-QD TABS(Norethindrone(Contraceptive))

NFMO

Name of drug

Whatthe


level)


norethindrone(contraceptive) tabs

$0-$2.95(Tier

1)

MO

ORTHO MICRONORTABS (Norethindrone(Contraceptive))

NFMO

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling ConditionsGlucocorticosteroids

ARISTOSPAN INTRA-ARTICULAR SUSP

$0-$7.40(Tier

2)

MO

betamethasone sodphosphate & acetate susp

$0-$2.95(Tier

1)

MO

budesonide cpep or$0-

$2.95(Tier

1)

MO

CELESTONE-SOLUSPANSUSP (BetamethasoneSod Phosphate & Acetate)

NFMO

CORTEF TABS(Hydrocortisone) NF MO

cortisone acetate tabs or$0-

$2.95(Tier

1)

MO

DEPO-MEDROL SUSP 20MG/ML

$0-$7.40(Tier

2)

MO

DEPO-MEDROL SUSP 40MG/ML, 80 MG/ML(MethylprednisoloneAcetate)

NF

MO



91

Name of drug

Whatthe


level)


dexamethasone elix or 0.5mg/5ml

$0-$2.95(Tier

1)

MO

dexamethasone sodiumphosphate soln ij 10 mg/ml

$0-$2.95(Tier

1)

dexamethasone sodiumphosphate soln ij 10 mg/ml

$0-$2.95(Tier

1)

PreservativeFree;MO

dexamethasone sodiumphosphate soln ij 100mg/10ml, 120 mg/30ml, 20mg/5ml, 4 mg/ml

$0-$2.95(Tier

1)

MO

dexamethasone soln or 0.5mg/5ml

$0-$2.95(Tier

1)

MO

dexamethasone tabs or 0.5mg, 0.75 mg, 1 mg, 1.5 mg,2 mg, 4 mg, 6 mg

$0-$2.95(Tier

1)

MO

dexamethasone tbpk or 1.5mg

$0-$2.95(Tier

1)

MO

ENTOCORT EC CPEP(Budesonide) NF MO

hydrocortisone tabs or 10mg, 20 mg, 5 mg

$0-$2.95(Tier

1)

MO

KENALOG-10 SUSP$0-

$7.40(Tier

2)

MO

KENALOG-40 SUSP$0-

$7.40(Tier

2)

MO

Name of drug

Whatthe


level)


MEDROL DOSEPAK TBPK(Methylprednisolone) NF MO

MEDROL TABS 16 MG, 32MG, 4 MG, 8 MG(Methylprednisolone)

NFMO

MEDROL TABS 2 MG$0-

$7.40(Tier

2)

MO

methylprednisolone acetatesusp ij 40 mg/ml, 80 mg/ml

$0-$2.95(Tier

1)

MO

methylprednisolone sodsucc solr

$0-$2.95(Tier

1)

MO

methylprednisolone tabs or16 mg, 32 mg, 4 mg, 8 mg

$0-$2.95(Tier

1)

MO

methylprednisolone tbpk or4 mg

$0-$2.95(Tier

1)

MO

ORAPRED ODT TBDP(Prednisolone SodiumPhosphate)

NFMO

prednisolone sodiumphosphate soln or 15mg/5ml, 5 mg/5ml, 6.7mg/5ml

$0-$2.95(Tier

1)

MO

prednisolone sodiumphosphate tbdp or 10 mg,15 mg, 30 mg

$0-$2.95(Tier

1)

MO

prednisolone soln or 15mg/5ml

$0-$2.95(Tier

1)

MO



92

Name of drug

Whatthe


level)


prednisolone syrp or 15mg/5ml

$0-$2.95(Tier

1)

MO

prednisolone tabs or 5 mg$0-

$2.95(Tier

1)

MO

prednisone conc or 5mg/ml

$0-$2.95(Tier

1)

MO

prednisone soln or 5mg/5ml

$0-$2.95(Tier

1)

MO

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

$0-$2.95(Tier

1)

MO

prednisone tbpk or 10 mg,5 mg

$0-$2.95(Tier

1)

MO

SOLU-CORTEF SOLR 100MG, 250 MG, 500 MG

$0-$7.40(Tier

2)

MO

SOLU-CORTEF SOLR1000 MG

$0-$7.40(Tier

2)SOLU-MEDROL SOLR1000 MG, 125 MG, 40 MG(Methylprednisolone SodSucc)

NF

MO

SOLU-MEDROL SOLR500 MG

$0-$7.40(Tier

2)

MO

Mineralocorticoids

Name of drug

Whatthe


level)


fludrocortisone acetate tabsor

$0-$2.95(Tier

1)

MO

COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy SymptomsAntitussives

benzonatate caps 100 mg,200 mg

$0(Tier

3)

MO; NT

hydrocodone w/homatropine syrp

$0(Tier

3)

MO; NT

hydrocodone w/homatropine tabs

$0(Tier

3)

MO; NT

TESSALON PERLESCAPS (Benzonatate) NF MO; NT

Cough/Cold/Allergy Combinations

ACTIDOM DMX LIQD$0

(Tier3)

NT

ADVIL ALLERGY &CONGESTION TABS

$0(Tier

3)

AL; NT

brompheniramine &phenyleph elix 1mg/5ml-1mg/5ml-2.5mg/5ml-2.5mg/5ml, 1mg/5ml-2.5mg/5ml

$0(Tier

3)

AL; NT

brompheniramine &pseudoeph elix

$0(Tier

3)

AL; NT

brompheniramine &pseudoeph liqd

$0(Tier

3)

AL; NT

cetirizine-pseudoephedrinetb12

$0(Tier

3)

MO; NT



93

Name of drug

Whatthe


level)


CHILDRENS PLUS COLDSUSP

$0(Tier

3)

AL; NT

chlorpheniramine &phenylephrine tabs 4mg-10mg

$0(Tier

3)

AL; NT

chlorpheniramine &pseudoeph syrp 15mg/5ml-1mg/5ml

$0(Tier

3)

AL; NT

chlorpheniramine w/codeine liqd

$0(Tier

3)

AL; RX/OTC;NT

CODITUSSIN AC LIQD$0

(Tier3)

NT

DECON-A ELIX 2MG/5ML-5MG/5ML

$0(Tier

3)

AL; NT

dexbrompheniramine &pseudoephedrine tb12

$0(Tier

3)

AL; MO; NT

DIMETAPP COLD &ALLERGY ELIX 1MG/5ML-2.5MG/5ML(Brompheniramine &Phenyleph)

NF

AL; NT

diphenhydramine-phenylephrine liqd12.5mg/5ml-5mg/5ml

$0(Tier

3)

AL; NT

diphenhydramine-phenylephrine soln12.5mg/5ml-5mg/5ml

$0(Tier

3)

AL; NT

diphenhydramine-phenylephrine tabs 25mg-10mg

$0(Tier

3)

AL; NT

diphenhydramine-phenylephrine-acetaminophen susp12.5mg/5ml-160mg/5ml-2.5mg/5ml

$0(Tier

3)

AL; NT

Name of drug

Whatthe


level)


diphenhydramine-phenylephrine-acetaminophen tabs12.5mg-12.5mg-325mg-325mg-5mg-5mg, 12.5mg-325mg-5mg

$0(Tier

3)

AL; NT

diphenhydramine-pseudoephedrine-acetaminophen tabs

$0(Tier

3)

AL; NT

DOMETUSS-DMX LIQD$0

(Tier3)

NT

DRIXORALCOLD/ALLERGY TB12

$0(Tier

3)

AL; MO; NT

ED CHLORPED D LIQD$0

(Tier3)

AL; NT

ENTRE-HIST PSE LIQD$0

(Tier3)

AL; NT

EQ TRIACTINGCOLD/ALLERGY SYRP

$0(Tier

3)

AL; NT

guaifenesin-codeine liqd100mg/5ml-10mg/5ml

$0(Tier

3)

MO; NT

guaifenesin-codeine soln100mg/5ml-10mg/5ml

$0(Tier

3)

MO; NT

guaifenesin-codeine syrp100mg/5ml-10mg/5ml

$0(Tier

3)

MO; NT

hydrocodone polistirex-chlorpheniramine polistirexsuer

$0(Tier

3)

AL; MO; NT

LEXUSS 210 LIQD$0

(Tier3)

AL; RX/OTC;NT

NEXAFED SINUSPRESSURE +PAIN TABS

$0(Tier

3)

NT



94

Name of drug

Whatthe


level)


phenyleph-promethazinew/ cod syrp

$0(Tier

3)

AL; MO; NT

phenylephrine w/ dm-ggliqd 30mg/5ml-200mg/5ml-10mg/5ml

$0(Tier

3)

NT

phenylephrine-chlorpheniramine-dm w/apap susp 5mg/5ml-1mg/5ml-160mg/5ml-2.5mg/5ml, 5mg/5ml-5mg/5ml-1mg/5ml-1mg/5ml-160mg/5ml-160mg/5ml-2.5mg/5ml-2.5mg/5ml

$0(Tier

3)

NT

promethazine w/codeinesyrp

$0(Tier

3)

AL; MO; NT

promethazine-dm syrp$0

(Tier3)

AL; MO; NT

pseudoephedrine-acetaminophen tabs

$0(Tier

3)

NT

pseudoephedrine-ibuprofensusp 100mg/5ml-15mg/5ml

$0(Tier

3)

NT

RYMED TABS$0

(Tier3)

AL; NT

SUDAFED PE SEVERECOLD MULTI-SYMPTOMTABS (Diphenhydramine-Phenylephrine-Acetaminophen)

NF

AL; NT

triprolidine &pseudoephedrine liqd0.938mg/ml-10mg/ml

$0(Tier

3)

AL; NT

triprolidine &pseudoephedrine tabs2.5mg-2.5mg-60mg-60mg,2.5mg-60mg

$0(Tier

3)

AL; MO; NT

Name of drug

Whatthe


level)


TUSSIONEXPENNKINETICEXTENDED RELEASESUER (HydrocodonePolistirex-ChlorpheniraminePolistirex)

NF

AL; MO; NT

TYLENOL CHILDRENSPLUS FLU SUSP(Phenylephrine-Chlorpheniramine-DM w/APAP)

NF

NT

TYLENOL CHILDRENSPLUS MULTI-SYMPTOMCOLD SUSP(Phenylephrine-Chlorpheniramine-DM w/APAP)

NF

NT

ZYRTEC-DALLERGY/CONGESTIONTB12 (Cetirizine-Pseudoephedrine)

NF

MO; NT

Misc. Respiratory Inhalants

sodium chloride (inhalant)aers

$0(Tier

3)

NT

Mucolytics

acetylcysteine soln in 10 %,20 %

$0-$2.95(Tier

1)

MO; B/D

DERMATOLOGICALS - Drugs to Treat SkinConditionsAcne Products

ABSORICA CAPS 10 MG,20 MG, 25 MG, 35 MG, 40MG

$0-$7.40(Tier

2)

ABSORICA CAPS 30 MG(Isotretinoin)

$0-$7.40(Tier

2)



95

Name of drug

Whatthe


level)


ACNE MEDICATION 10LOTN

$0(Tier

3)

MO; NT

ACNE MEDICATION LOTN$0

(Tier3)

MO; NT

adapalene crea 0.1 %$0-

$2.95(Tier

1)

MO

adapalene gel 0.1 %$0-

$2.95(Tier

1)

MO

ADULT ACNOMEL CREA$0

(Tier3)

NT

BENSULFOID CREA$0

(Tier3)

NT

BENZACLIN GEL(Clindamycin Phosphate-Benzoyl Peroxide)

NFMO

BENZACLIN WITH PUMPGEL (ClindamycinPhosphate-BenzoylPeroxide)

NF

MO

BENZAMYCIN GEL(Benzoyl Peroxide-Erythromycin)

NFMO

benzoyl peroxide gel ex 5%

$0(Tier

3)

MO; NT

benzoyl peroxide-erythromycin gel

$0-$2.95(Tier

1)

MO

CLEARASIL DAILY CLEARCREA

$0(Tier

3)

NT

CLEOCIN-T GEL(Clindamycin Phosphate(Topical))

NFMO

Name of drug

Whatthe


level)


CLEOCIN-T LOTN(Clindamycin Phosphate(Topical))

NFMO

CLEOCIN-T SOLN(Clindamycin Phosphate(Topical))

NFMO

CLEOCIN-T SWAB(Clindamycin Phosphate(Topical))

NFMO

CLINDAGEL GEL$0-

$7.40(Tier

2)

MO

clindamycin phosphate(topical) foam

$0-$2.95(Tier

1)

MO

clindamycin phosphate(topical) gel

$0-$2.95(Tier

1)

MO

clindamycin phosphate(topical) lotn

$0-$2.95(Tier

1)

MO

clindamycin phosphate(topical) soln

$0-$2.95(Tier

1)

MO

clindamycin phosphate(topical) swab

$0-$2.95(Tier

1)

MO

clindamycin phosphate-benzoyl peroxide(refrigerate) gel

$0-$2.95(Tier

1)

MO

clindamycin phosphate-benzoyl peroxide gel

$0-$2.95(Tier

1)

MO

DIFFERIN CREA 0.1 %(Adapalene) NF MO



96

Name of drug

Whatthe


level)


DIFFERIN GEL 0.1 %(Adapalene) NF MO

DUAC GEL (ClindamycinPhosphate-BenzoylPeroxide (Refrigerate))

NFMO

erythromycin (acne aid)soln

$0-$2.95(Tier

1)

MO

EVOCLIN FOAM(Clindamycin Phosphate(Topical))

NFMO

isotretinoin caps or 10 mg,20 mg, 30 mg, 40 mg

$0-$2.95(Tier

1)KLARON LOTN(Sulfacetamide Sodium(Acne))

NFMO

RETIN-A CREA (Tretinoin) NF MO

RETIN-A GEL (Tretinoin) NF MO

RETIN-A MICRO GEL(Tretinoin Microsphere) NF MO

RETIN-A MICRO PUMPGEL 0.04 %, 0.1 %(Tretinoin Microsphere)

NFMO

REZAMID LOTN$0

(Tier3)

MO; NT

sulfacetamide sodium(acne) lotn

$0-$2.95(Tier

1)

MO

sulfacetamide sodium(acne) susp

$0-$2.95(Tier

1)

MO

tretinoin crea ex 0.025 %,0.05 %, 0.1 %

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


tretinoin gel ex 0.01 %,0.025 %

$0-$2.95(Tier

1)

MO

tretinoin microsphere gel$0-

$2.95(Tier

1)

MO

Analgesics - Topical

menthol (topical analgesic)pads 5 %

$0(Tier

3)

MO; NT

Anti-inflammatory Agents - Topical

diclofenac sodium (topical)gel 1 %

$0-$2.95(Tier

1)

MO

FLECTOR PTCH$0-

$7.40(Tier

2)

PA; MO

VOLTAREN GEL(Diclofenac Sodium(Topical))

$0-$7.40(Tier

2)

MO

Antibiotics - TopicalBACIGUENT OINT(Bacitracin (Topical)) NF MO; NT

bacitracin (topical) oint$0

(Tier3)

MO; NT

bacitracin zinc oint ex$0

(Tier3)

MO; NT

bacitracin-polymyxin b oint$0

(Tier3)

MO; NT

BACTROBAN CREA(Mupirocin Calcium(Topical))

NFMO



97

Name of drug

Whatthe


level)


BACTROBAN OINT(Mupirocin) NF MO

CENTANY OINT$0-

$7.40(Tier

2)

MO

gentamicin sulfate (topical)crea

$0-$2.95(Tier

1)

MO

gentamicin sulfate (topical)oint

$0-$2.95(Tier

1)

MO

mupirocin calcium (topical)crea

$0-$2.95(Tier

1)

MO

mupirocin oint ex$0-

$2.95(Tier

1)

MO

neomycin-bacitracin-polymyxin w/ lidocaine oint

$0(Tier

3)

NT

POLYSPORIN OINT(Bacitracin-Polymyxin B) NF MO; NT

Antifungals - Topical

ALEVAZOL OINT$0

(Tier3)

NT

ciclopirox gel 0.77 %$0-

$2.95(Tier

1)

MO

ciclopirox olamine crea ex$0-

$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


ciclopirox olamine susp ex$0-

$2.95(Tier

1)

MO

ciclopirox sham 1 %$0-

$2.95(Tier

1)

MO

ciclopirox soln 8 %$0-

$2.95(Tier

1)

MO

clotrimazole (topical) crea$0-

$2.95(Tier

1)

RX/OTC; MO

clotrimazole (topical) soln$0-

$2.95(Tier

1)

RX/OTC; MO

clotrimazole w/betamethasone crea

$0-$2.95(Tier

1)

MO

clotrimazole w/betamethasone lotn

$0-$2.95(Tier

1)

MO

CLOVERINE SALVE OINT$0

(Tier3)

NT

econazole nitrate crea$0-

$2.95(Tier

1)

MO

EXTINA FOAM(Ketoconazole (Topical)) NF MO

ketoconazole (topical) crea$0-

$2.95(Tier

1)

MO



98

Name of drug

Whatthe


level)


ketoconazole (topical) foam$0-

$2.95(Tier

1)

MO

ketoconazole (topical)sham

$0-$2.95(Tier

1)

MO

LAMISIL AT CREA(Terbinafine HCl (Topical)) NF MO; NT

LAMISIL AT JOCK ITCHCREA (Terbinafine HCl(Topical))

NFMO; NT

LOPROX CREA 0.77 %(Ciclopirox Olamine) NF MO

LOPROX SHAMPOOSHAM (Ciclopirox) NF MO

LOTRISONE CREA(Clotrimazole w/Betamethasone)

NFMO

MICATIN CREA(Miconazole Nitrate(Topical))

NFMO; NT

miconazole nitrate (topical)crea

$0(Tier

3)

MO; NT

naftifine hcl crea 2 %$0-

$2.95(Tier

1)

MO

NAFTIN CREA 2 %(Naftifine HCl)

$0-$7.40(Tier

2)

MO

NAFTIN GEL 2 %$0-

$7.40(Tier

2)

MO

NIZORAL A-D SHAM$0

(Tier3)

MO; NT

Name of drug

Whatthe


level)


NIZORAL SHAM(Ketoconazole (Topical)) NF MO

nystatin (topical) crea$0-

$2.95(Tier

1)

MO

nystatin (topical) oint$0-

$2.95(Tier

1)

MO

nystatin (topical) powd$0-

$2.95(Tier

1)

MO

nystatin-triamcinolone crea$0-

$2.95(Tier

1)

MO

nystatin-triamcinolone oint$0-

$2.95(Tier

1)

MO

PENLAC NAIL LACQUERSOLN (Ciclopirox) NF MO

terbinafine hcl (topical) crea$0

(Tier3)

MO; NT

TINACTIN CREA(Tolnaftate) NF MO; NT

TINACTIN JOCK ITCHCREA (Tolnaftate) NF MO; NT

tolnaftate crea ex$0

(Tier3)

MO; NT

tolnaftate liqd ex$0

(Tier3)

MO; NT

tolnaftate soln ex$0

(Tier3)

MO; NT



99

Name of drug

Whatthe


level)


UNDELENIC TINCTURETINC

$0(Tier

3)

NT

Antihistamines-Topical

diphenhydramine hcl(topical) crea

$0(Tier

3)

NT

Antineoplastic or Premalignant Lesion Agents -

CARAC CREA$0-

$7.40(Tier

2)

MO

diclofenac sodium (actinickeratoses) gel

$0-$2.95(Tier

1)

MO

EFUDEX CREA(Fluorouracil (Topical)) NF MO

fluorouracil (topical) crea$0-

$2.95(Tier

1)

MO

fluorouracil (topical) soln$0-

$2.95(Tier

1)

MO

FLUOROURACIL CREAEX 0.5 %

$0-$7.40(Tier

2)

MO

PANRETIN GEL$0-

$7.40(Tier

2)

MO

PICATO GEL$0-

$7.40(Tier

2)

MO

SOLARAZE GEL(Diclofenac Sodium (ActinicKeratoses))

NFMO

Name of drug

Whatthe


level)


TARGRETIN GEL EX 1 %$0-

$7.40(Tier

2)

VALCHLOR GEL$0-

$7.40(Tier

2)

PA

Antipsoriatics

acitretin caps$0-

$2.95(Tier

1)

MO

calcipotriene crea$0-

$2.95(Tier

1)

MO

calcipotriene oint$0-

$2.95(Tier

1)

MO

calcipotriene soln$0-

$2.95(Tier

1)

MO

COSENTYXSENSOREADY PEN SOAJ

$0-$7.40(Tier

2)

PA; LA

COSENTYX SOSY$0-

$7.40(Tier

2)

PA; LA

DOVONEX CREA(Calcipotriene) NF MO

methoxsalen rapid caps$0-

$2.95(Tier

1)

MO

OXSORALEN ULTRACAPS (Methoxsalen Rapid)

$0-$7.40(Tier

2)

MO



100

Name of drug

Whatthe


level)


SORIATANE CAPS(Acitretin) NF MO

STELARA SOSY SC 45MG/0.5ML, 90 MG/ML

$0-$7.40(Tier

2)

PA

TALTZ SOAJ$0-

$7.40(Tier

2)

PA

TALTZ SOSY$0-

$7.40(Tier

2)

PA

TAZORAC CREA$0-

$7.40(Tier

2)

MO

TAZORAC GEL$0-

$7.40(Tier

2)

MO

Antiseborrheic Products

DERMAZINC BABY LIQD$0

(Tier3)

MO; NT

DERMAZINC SCALP LIQD$0

(Tier3)

MO; NT

DERMAZINC SPRAY LIQD(Pyrithione Zinc) NF MO; NT

DHS ZINC SHAM(Pyrithione Zinc) NF MO; NT

NOBLE FORMULA BAR 2%

$0(Tier

3)

NT

P & S LIQD$0

(Tier3)

MO; NT

pyrithione zinc liqd 0.25 %$0

(Tier3)

MO; NT

Name of drug

Whatthe


level)


pyrithione zinc sham 2 %$0

(Tier3)

MO; NT

selenium sulfide lotn ex 2.5%

$0-$2.95(Tier

1)

MO

Antivirals - Topical

acyclovir topical oint$0-

$2.95(Tier

1)

MO

DENAVIR CREA$0-

$7.40(Tier

2)

MO

ZOVIRAX CREA EX 5 %$0-

$7.40(Tier

2)

MO

ZOVIRAX OINT EX 5 %(Acyclovir Topical) NF MO

Bath Products

AVEENO SKIN RELIEFSHOWER& BATH OIL

$0(Tier

3)

MO; NT

bath products oil 40%-40%-40%-40%, 5%-5%-5%

$0(Tier

3)

MO; NT

BODI WHIRL OIL OIL$0

(Tier3)

MO; NT

GERISILK BATH OIL OIL$0

(Tier3)

MO; NT

ULTRA DERM BATH OILOIL

$0(Tier

3)

MO; NT

Burn Products



101

Name of drug

Whatthe


level)


mafenide acetate pack ex$0-

$2.95(Tier

1)

MO

SILVADENE CREA (SilverSulfadiazine) NF MO

silver sulfadiazine crea ex$0-

$2.95(Tier

1)

MO

SULFAMYLON CREA 85MG/GM

$0-$7.40(Tier

2)

MO

SULFAMYLON PACK 5 %(Mafenide Acetate) NF MO

Corticosteroids - Topical

alclometasone dipropionatecrea

$0-$2.95(Tier

1)

MO

alclometasone dipropionateoint

$0-$2.95(Tier

1)

MO

amcinonide crea$0-

$2.95(Tier

1)

MO

betamethasonedipropionate (topical) crea

$0-$2.95(Tier

1)

MO

betamethasonedipropionate (topical) lotn

$0-$2.95(Tier

1)

MO

betamethasonedipropionate (topical) oint

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


betamethasonedipropionate augmentedcrea

$0-$2.95(Tier

1)

MO

betamethasonedipropionate augmentedgel

$0-$2.95(Tier

1)

MO

betamethasonedipropionate augmentedlotn

$0-$2.95(Tier

1)

MO

betamethasonedipropionate augmentedoint

$0-$2.95(Tier

1)

MO

betamethasone valeratecrea ex 0.1 %

$0-$2.95(Tier

1)

MO

betamethasone valeratefoam ex 0.12 %

$0-$2.95(Tier

1)

MO

betamethasone valeratelotn ex 0.1 %

$0-$2.95(Tier

1)

MO

betamethasone valerateoint ex 0.1 %

$0-$2.95(Tier

1)

MO

clobetasol propionate creaex

$0-$2.95(Tier

1)

MO

clobetasol propionateemollient base crea

$0-$2.95(Tier

1)

MO



102

Name of drug

Whatthe


level)


clobetasol propionateemulsion foam

$0-$2.95(Tier

1)

MO

clobetasol propionate foamex

$0-$2.95(Tier

1)

MO

clobetasol propionate gelex

$0-$2.95(Tier

1)

MO

clobetasol propionate lotnex

$0-$2.95(Tier

1)

MO

clobetasol propionate ointex

$0-$2.95(Tier

1)

MO

clobetasol propionate shamex

$0-$2.95(Tier

1)

MO

clobetasol propionate solnex

$0-$2.95(Tier

1)

MO

CLOBEX LOTN(Clobetasol Propionate) NF MO

CLOBEX SHAM(Clobetasol Propionate) NF MO

CUTIVATE CREA(Fluticasone Propionate) NF MO

CUTIVATE LOTN(Fluticasone Propionate) NF MO

CVS HDYROCORTISONEACETATE CREA

$0(Tier

3)

NT

DERMA-SMOOTHE/FSBODY OIL (FluocinoloneAcetonide)

NFMO

Name of drug

Whatthe


level)


DERMA-SMOOTHE/FSSCALP OIL (FluocinoloneAcetonide)

NFMO

DERMATOP CREA(Prednicarbate) NF MO

desonide crea ex$0-

$2.95(Tier

1)

MO

desonide lotn ex$0-

$2.95(Tier

1)

MO

desonide oint ex$0-

$2.95(Tier

1)

MO

DESOWEN CREA(Desonide) NF MO

desoximetasone crea ex0.25 %

$0-$2.95(Tier

1)

MO

desoximetasone gel ex0.05 %

$0-$2.95(Tier

1)

MO

desoximetasone oint ex0.25 %

$0-$2.95(Tier

1)

MO

diflorasone diacetate oint$0-

$2.95(Tier

1)

MO

DIPROLENE AF CREA(BetamethasoneDipropionate Augmented)

NFMO

DIPROLENE LOTN(BetamethasoneDipropionate Augmented)

NFMO



103

Name of drug

Whatthe


level)


DIPROLENE OINT(BetamethasoneDipropionate Augmented)

NFMO

ELOCON CREA(Mometasone Furoate) NF MO

ELOCON OINT(Mometasone Furoate) NF MO

fluocinolone acetonide creaex 0.01 %, 0.025 %

$0-$2.95(Tier

1)

MO

fluocinolone acetonide oilex 0.01 %

$0-$2.95(Tier

1)

MO

fluocinolone acetonide ointex 0.025 %

$0-$2.95(Tier

1)

MO

fluocinolone acetonide solnex 0.01 %

$0-$2.95(Tier

1)

MO

fluocinonide crea ex 0.05%

$0-$2.95(Tier

1)

MO

fluocinonide emulsifiedbase crea

$0-$2.95(Tier

1)

MO

fluocinonide gel ex 0.05 %$0-

$2.95(Tier

1)

MO

fluocinonide oint ex 0.05 %$0-

$2.95(Tier

1)

MO

fluocinonide soln ex 0.05 %$0-

$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


fluticasone propionate creaex 0.05 %

$0-$2.95(Tier

1)

MO

fluticasone propionate lotnex 0.05 %

$0-$2.95(Tier

1)

MO

fluticasone propionate ointex 0.005 %

$0-$2.95(Tier

1)

MO

halobetasol propionatecrea

$0-$2.95(Tier

1)

MO

halobetasol propionate oint$0-

$2.95(Tier

1)

MO

hydrocortisone (topical)crea 0.5 %

$0(Tier

3)

MO; NT

hydrocortisone (topical)crea 1 %

$0-$2.95(Tier

1)

RX/OTC; MO

hydrocortisone (topical)crea 2.5 %

$0-$2.95(Tier

1)

MO

hydrocortisone (topical) lotn1 %

$0(Tier

3)

MO; NT

hydrocortisone (topical) lotn2.5 %

$0-$2.95(Tier

1)

MO

hydrocortisone (topical) oint0.5 %

$0(Tier

3)

MO; NT



104

Name of drug

Whatthe


level)


hydrocortisone (topical)oint 1 %

$0-$2.95(Tier

1)

RX/OTC; MO

hydrocortisone (topical)oint 2.5 %

$0-$2.95(Tier

1)

MO

hydrocortisone (topical)soln 1 %

$0(Tier

3)

NT

hydrocortisone acetate(topical) crea

$0(Tier

3)

NT

hydrocortisone butyratecrea

$0-$2.95(Tier

1)

MO

hydrocortisone butyratehydrophilic lipo base crea

$0-$2.95(Tier

1)

MO

hydrocortisone butyrateoint

$0-$2.95(Tier

1)

MO

hydrocortisone butyratesoln

$0-$2.95(Tier

1)

MO

hydrocortisone valeratecrea

$0-$2.95(Tier

1)

MO

hydrocortisone valerateoint

$0-$2.95(Tier

1)

MO

hydrocortisone-aloe veracrea

$0(Tier

3)

NT

LOCOID CREA(Hydrocortisone Butyrate) NF MO

Name of drug

Whatthe


level)


LOCOID LIPOCREAMCREA (HydrocortisoneButyrate Hydrophilic LipoBase)

NF

MO

LOCOID OINT(Hydrocortisone Butyrate) NF MO

LOCOID SOLN(Hydrocortisone Butyrate) NF MO

LUXIQ FOAM(Betamethasone Valerate)

$0-$7.40(Tier

2)

MO

mometasone furoate creaex

$0-$2.95(Tier

1)

MO

mometasone furoate ointex

$0-$2.95(Tier

1)

MO

mometasone furoate solnex

$0-$2.95(Tier

1)

MO

OLUX FOAM (ClobetasolPropionate) NF MO

OLUX-E FOAM (ClobetasolPropionate Emulsion) NF MO

prednicarbate crea$0-

$2.95(Tier

1)

MO

SYNALAR CREA(Fluocinolone Acetonide) NF MO

SYNALAR OINT(Fluocinolone Acetonide) NF MO

SYNALAR SOLN(Fluocinolone Acetonide) NF MO

TEMOVATE CREA(Clobetasol Propionate) NF MO



105

Name of drug

Whatthe


level)


TEMOVATE E CREA(Clobetasol PropionateEmollient Base)

NFMO

TEMOVATE GEL(Clobetasol Propionate) NF MO

TEMOVATE OINT(Clobetasol Propionate) NF MO

TEMOVATE SOLN(Clobetasol Propionate) NF MO

triamcinolone acetonide(topical) crea 0.025 %, 0.1%, 0.5 %

$0-$2.95(Tier

1)

MO

triamcinolone acetonide(topical) lotn 0.025 %, 0.1%

$0-$2.95(Tier

1)

MO

triamcinolone acetonide(topical) oint 0.025 %, 0.1%

$0-$2.95(Tier

1)

MO

TRIDESILON CREA(Desonide) NF MO

ULTRAVATE CREA(Halobetasol Propionate) NF MO

ULTRAVATE OINT(Halobetasol Propionate) NF MO

WESTCORT OINT(Hydrocortisone Valerate) NF MO

Emollient/Keratolytic AgentsCARMOL 20 CREA (Urea) NF MO; NT

CARMOL SHAM$0

(Tier3)

NT

ULTRA MIDE 25 LOTN(Urea) NF MO; NT

urea crea ex 20 %$0

(Tier3)

MO; NT

Name of drug

Whatthe


level)


urea lotn ex 25 %$0

(Tier3)

MO; NT

EmollientsLAC-HYDRIN CREA(Lactic Acid (AmmoniumLactate))

NFRX/OTC; MO

LAC-HYDRIN LOTN (LacticAcid (Ammonium Lactate)) NF RX/OTC; MO

lactic acid (ammoniumlactate) crea 12 %

$0-$2.95(Tier

1)

RX/OTC; MO

lactic acid (ammoniumlactate) lotn 12 %

$0-$2.95(Tier

1)

RX/OTC; MO

lactic acid (ammoniumlactate) lotn 5 %

$0(Tier

3)

MO; NT

PANTHODERM CREA$0

(Tier3)

NT

PETROLATUM OINT$0

(Tier3)

NT

SUPER E CREA$0

(Tier3)

NT

SUPER E DAY CREA$0

(Tier3)

NT

SUPER E EYE CREA$0

(Tier3)

NT

SUPER E NIGHT CREA$0

(Tier3)

NT

vitamin e (topical) crea1000 unit, 1500 unit/30gm,30000 unit/60gm, 6000 unit

$0(Tier

3)

NT



106

Name of drug

Whatthe


level)


vitamin e (topical) oil 100unit/5drop, 12000 unit,20000 unit, 28000 unit,28000 unit/29ml, 400unit/ml, 4000 unit, 49000unit/52ml, 933.333 unit/ml

$0(Tier

3)

NT

Enzymes - Topical

SANTYL OINT$0-

$7.40(Tier

2)

MO

Immunomodulating Agents - TopicalALDARA CREA(Imiquimod) NF MO

imiquimod crea ex$0-

$2.95(Tier

1)

MO

ZYCLARA CREA$0-

$7.40(Tier

2)

MO

ZYCLARA PUMP CREA$0-

$7.40(Tier

2)

MO

Immunosuppressive Agents - Topical

ELIDEL CREA$0-

$7.40(Tier

2)

MO

PROTOPIC OINT(Tacrolimus (Topical)) NF MO

tacrolimus (topical) oint$0-

$2.95(Tier

1)

MO

Keratolytic/Antimitotic AgentsCONDYLOX SOLN(Podofilox) NF MO

Name of drug

Whatthe


level)


KERALYT GEL 6 %(Salicylic Acid) NF MO; NT

MEDIPLAST MISC$0

(Tier3)

NT

MOSCO CALLUS/CORNREMOVER SOLN

$0(Tier

3)

NT

P & S SHAM$0

(Tier3)

NT

podofilox soln ex$0-

$2.95(Tier

1)

MO

salicylic acid gel ex 6 %$0

(Tier3)

MO; NT

LinimentsARTHRICARE DOUBLEICE PAIN RELIEVING RUBGEL

$0(Tier

3)

NT

ARTHRICARE PAINRELIEVINGRUB GEL

$0(Tier

3)

NT

ARTHRICARE TRIPLEMEDICATED PAINRELIEVING RUB GEL

$0(Tier

3)

NT

BIOFLEXOR GEL$0

(Tier3)

NT

BLUE-EMU SUPERSTRENGTH CREA

$0(Tier

3)

MO; NT

DEEP BLUE RELIEF GEL$0

(Tier3)

NT

liniments & rubs crea0.01%-5%-10%, 1.2%-2.6%-4.7%, 10%-0.025%-15%

$0(Tier

3)

MO; NT



107

Name of drug

Whatthe


level)


liniments & rubs oint0.25%, 8%-2%

$0(Tier

3)

NT

SM PAINRELIEF/MENTHOL GEL

$0(Tier

3)

NT

VICKS BABYRUB CREA$0

(Tier3)

MO; NT

Local Anesthetics - Topical

AMERICAINE AERO EX$0

(Tier3)

MO; NT

AXSAIN CREA$0

(Tier3)

NT

DERMOPLAST AERO$0

(Tier3)

NT

DERMOPLAST PAINRELIEVINGSPRAY AERO

$0(Tier

3)

NT

EMLA CREA (Lidocaine-Prilocaine) NF MO

ITCH-X GEL$0

(Tier3)

MO; NT

LANACANE CREA$0

(Tier3)

NT

lidocaine hcl gel ex 0.5 %$0

(Tier3)

NT

lidocaine hcl gel ex 2 %$0

(Tier3)

OTC;RX/OTC;MO; NT

lidocaine hcl gel ex 2 %$0-

$2.95(Tier

1)

RX/OTC; MO

Name of drug

Whatthe


level)


lidocaine hcl soln ex 4 %$0-

$2.95(Tier

1)

MO

lidocaine oint ex 5 %$0-

$2.95(Tier

1)

MO

lidocaine ptch ex 5 %$0-

$2.95(Tier

1)

PA; MO

lidocaine-prilocaine crea$0-

$2.95(Tier

1)

MO

LIDODERM PTCH(Lidocaine) NF PA; MO

pramoxine-camphor-zincacetate lotn

$0(Tier

3)

NT

REGENECARE HA LIQD$0

(Tier3)

NT

XYLOCAINE SOLN EX 4% (Lidocaine HCl) NF MO

Misc. Dermatological Products

ATOPICLAIR CREA$0

(Tier3)

RX/OTC; MO;NT

AURSTAT ANTI-ITCHHYDROGEL GEL

$0(Tier

3)

RX/OTC; MO;NT

BURN SPRAY AERO$0

(Tier3)

MO; NT

CALICYLIC CREA$0

(Tier3)

RX/OTC; MO;NT

CURE-ALL CREA$0

(Tier3)

RX/OTC; MO;NT



108

Name of drug

Whatthe


level)


DERMAGRAN AERO$0

(Tier3)

MO; NT

DERMAREST ROSACEACREA

$0(Tier

3)

RX/OTC; MO;NT

DEXERYL CREA$0

(Tier3)

RX/OTC; MO;NT

ELETONE CREA$0

(Tier3)

RX/OTC; MO;NT

ELETONE TWINPACKCREA

$0(Tier

3)

RX/OTC; MO;NT

FRESH'N FEMININEDEODORANT AERO

$0(Tier

3)

MO; NT

HEAL AID PLUS CREA$0

(Tier3)

RX/OTC; MO;NT

HPR PLUS CREA$0

(Tier3)

RX/OTC; MO;NT

HYLATOPIC PLUS CREA$0

(Tier3)

RX/OTC; MO;NT

MOISTURE CREAM CREA$0

(Tier3)

RX/OTC; MO;NT

NASALGUARD GEL$0

(Tier3)

RX/OTC; MO;NT

NEOSALUS CP CREA$0

(Tier3)

RX/OTC; MO;NT

NEOSALUS CREA$0

(Tier3)

RX/OTC; MO;NT

NEW SKIN AERO$0

(Tier3)

MO; NT

Name of drug

Whatthe


level)


NIVATOPIC PLUS CREA$0

(Tier3)

RX/OTC; MO;NT

NONYX GEL$0

(Tier3)

RX/OTC; MO;NT

OC8 GEL$0

(Tier3)

RX/OTC; MO;NT

PRUCLAIR CREA$0

(Tier3)

RX/OTC; MO;NT

PRUMYX CREA$0

(Tier3)

RX/OTC; MO;NT

SEBUDERM GEL$0

(Tier3)

RX/OTC; MO;NT

SUMMERS EVEDEODORANT SPRAYAERO

$0(Tier

3)

MO; NT

SUMMERS EVEDEODORANT SPRAYULTRA AERO

$0(Tier

3)

MO; NT

TETRIX CREA$0

(Tier3)

RX/OTC; MO;NT

XERALUX CREA$0

(Tier3)

RX/OTC; MO;NT

YODORA DEODORANTCREA

$0(Tier

3)

RX/OTC; MO;NT

Misc. TopicalA & D ZINC OXIDE CREA(Dimethicone-Zinc Oxide-Vitamin A-Vitamin D)

NFMO; NT

A-MANTLE CREA$0

(Tier3)

MO; NT



109

Name of drug

Whatthe


level)


ACNE-AID BAR$0

(Tier3)

MO; NT

ACUICYN DAILY EYELID& EYELASH CLEANSERLIQD

$0(Tier

3)

RX/OTC; MO;NT

ALOE VESTA MULTIPURPOSECLEANSINGFOAM

$0(Tier

3)

NT

ALUMINUM ACETATESOLN

$0(Tier

3)

MO; NT

aluminum hydroxide oint ex$0

(Tier3)

NT

aluminum sulfate & calciumacetate pack

$0(Tier

3)

NT

ANTI-BACTERIAL HANDLOTION LOTN

$0(Tier

3)

MO; NT

AQUANIL SKINCLEANSER LOTN

$0(Tier

3)

MO; NT

AVEENO MOISTURIZINGBAR

$0(Tier

3)

MO; NT

AVEENO POSITIVELYAGELESSDAILYEXFOLIATING CLEANSERLOTN

$0(Tier

3)

MO; NT

AVEENO POSITIVELYRADIANTCLEANSERLOTN

$0(Tier

3)

MO; NT

AVEENO ULTRA-CALMING CLEANSERFOAM

$0(Tier

3)

NT

AVENOVA SOLN$0

(Tier3)

RX/OTC; MO;NT

Name of drug

Whatthe


level)


AVENOVA/NEUTROXSOLN

$0(Tier

3)

RX/OTC; MO;NT

BASIS ALL CLEAR BAR$0

(Tier3)

MO; NT

BASIS COMBINATIONBAR

$0(Tier

3)

MO; NT

BASIS EXTRA DRY BAR$0

(Tier3)

MO; NT

BASIS NORMAL/DRY BAR$0

(Tier3)

MO; NT

BASIS SENSITIVE SKINBAR

$0(Tier

3)

MO; NT

BODY WASH &SHAMPOO FOAM

$0(Tier

3)

NT

CALAMINE LOTN EX$0

(Tier3)

Calamine-ZincOxideLotion;MO; NT

CALAMINE LOTN EX$0

(Tier3)

NT

CALAMINE PHENOLATEDLOTN

$0(Tier

3)

NT

CARRAFOAM FOAM$0

(Tier3)

NT

CAVILON NO STINGBARRIERFILM MISC

$0(Tier

3)

MO; NT

CETAPHIL GENTLECLEANSING BAR

$0(Tier

3)

MO; NT

CONTI CASTILE SOAPBAR

$0(Tier

3)

MO; NT



110

Name of drug

Whatthe


level)


CVS SALINE WOUNDWASH SOLN

$0(Tier

3)

NT

DERMAGRAN OINT(Aluminum Hydroxide) NF NT

DIABETIDERMCLEANSING LOTN

$0(Tier

3)

MO; NT

dimethicone-zinc oxide-vitamin a-vitamin d crea

$0(Tier

3)

MO; NT

DOMEBORO PACK(Aluminum Sulfate &Calcium Acetate)

NFNT

ELTA CLEANSE FOAMFOAM

$0(Tier

3)

NT

EQL DEODORANT BARSOAP BAR

$0(Tier

3)

MO; NT

EQL MOISTURIZINGBEAUTY BAR BAR

$0(Tier

3)

MO; NT

EQL MOISTURIZINGBEAUTY BAR/SENSITIVESKIN BAR

$0(Tier

3)

MO; NT

FORMULA 405 FACIAL &BODYCLEANSING LOTN

$0(Tier

3)

MO; NT

FORMULA 405MOISTURIZINGSOAPBAR

$0(Tier

3)

MO; NT

GENTLE SKIN CLEANSERLOTN

$0(Tier

3)

MO; NT

GNP CALAMINE LOTN$0

(Tier3)


GNP CALAMINEPHENOLATED LOTN

$0(Tier

3)

NT

Name of drug

Whatthe


level)


GNP SALINE WOUNDWASH SOLN

$0(Tier

3)

NT

GRANDPAS BAKINGSODA SOAP BAR

$0(Tier

3)

MO; NT

GRANDPAS INDIANCORN SOAP BAR

$0(Tier

3)

MO; NT

GRANDPAS LOVE MYLOOFAH SOAP BAR

$0(Tier

3)

MO; NT

GRANDPAS OATMEALSOAP BAR

$0(Tier

3)

MO; NT

GRANDPAS ORANGEESSENCE SOAP BAR

$0(Tier

3)

MO; NT

GRANDPAS PATCHOULISOAP BAR

$0(Tier

3)

MO; NT

GRANDPAS SHEABUTTER SOAP BAR

$0(Tier

3)

MO; NT

GRANDPAS WITCHHAZEL SOAP BAR

$0(Tier

3)

MO; NT

HM CALAMINE LOTN$0

(Tier3)


HYDROPEL OINT$0

(Tier3)

NT

JOHNSONS BABY BARBAR

$0(Tier

3)

MO; NT

JOHNSONS BUDDIESEASY-GRIP SUDZINGBAR

$0(Tier

3)

MO; NT

lanolin (topical) crea$0

(Tier3)

NT



111

Name of drug

Whatthe


level)


LOBOB CONTACT LENSWEARERS SOAP BAR

$0(Tier

3)

MO; NT

LOWILA BAR$0

(Tier3)

MO; NT

MEIJER CALAMINE LOTN$0

(Tier3)

NT

NATURE DE FRANCEALGOLI SOAP BAR

$0(Tier

3)

MO; NT

NATURE DE FRANCEARGILE BLANCHE SOAPBAR

$0(Tier

3)

MO; NT

NATURE DE FRANCEARGIMIEL SOAP BAR

$0(Tier

3)

MO; NT

NEUTROGENA ACNECLEANSING SOAP BAR

$0(Tier

3)

MO; NT

NEUTROGENA FACIALSOAP ORIGINALFORMULA BAR

$0(Tier

3)

MO; NT

NEUTROGENANATURALS FACE& BODYBAR

$0(Tier

3)

MO; NT

NIVEA MOISTURIZINGBODY WASH 2 IN 1 LOTN

$0(Tier

3)

MO; NT

NIVEA MOISTURIZINGBODY WASH LOTN

$0(Tier

3)

MO; NT

NIVEA TOUCH OFSMOOTHNESSMOISTURIZING BODYWASH LOTN

$0(Tier

3)

MO; NT

NIVEA VISAGE GENTLECLEANSING LOTN

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


NO-STING SKIN-PREPMISC

$0(Tier

3)

MO; NT

OCUSOFT HAND SOAPLOTN

$0(Tier

3)

MO; NT

OCUSOFT HYPOCHLORLIQD

$0(Tier

3)

RX/OTC; MO;NT

OCUSOFT LID SCRUBFOAMING SOLN

$0(Tier

3)

RX/OTC; MO;NT

OCUSOFT LID SCRUBORIGINAL LIQD

$0(Tier

3)

RX/OTC; MO;NT

OILATUM BAR$0

(Tier3)

MO; NT

PROSHIELD FOAM &SPRAY CLEANSER FOAM

$0(Tier

3)

NT

PX CALAMINE LOTN$0

(Tier3)


QC CALAMINE LOTN$0

(Tier3)

NT

RA BEAUTY BAR BAR$0

(Tier3)

MO; NT

RA CALAMINE LOTN6.971%-6.971%

$0(Tier

3)


RA SALINE WOUNDWASH SOLN

$0(Tier

3)

NT

SAFE WASH SOLN$0

(Tier3)

NT

SALINE WOUND WASHSOLN

$0(Tier

3)

NT



112

Name of drug

Whatthe


level)


SALJET RINSE SOLN$0

(Tier3)

NT

SALJET SOLN$0

(Tier3)

NT

SAYMAN LANOLIN BAR$0

(Tier3)

MO; NT

SAYMAN WITCH HAZELBAR

$0(Tier

3)

MO; NT

skin protectants, misc. liqd$0

(Tier3)

NT

SM CALAMINE LOTN$0

(Tier3)

NT

SM CALAMINEPHENOLATED LOTN

$0(Tier

3)

NT

SM SKIN CLEANSERGENTLE/SENSITIVE SKINLOTN

$0(Tier

3)

MO; NT

STYGIENE STERILEEYELID CLEANSER LIQD

$0(Tier

3)

RX/OTC; MO;NT

SUMMERS EVE NIGHT-TIMECLEANSING/SENSITIVESKIN BAR

$0(Tier

3)

MO; NT

TERSASEPTICGLYCERINE CLEANSINGBAR

$0(Tier

3)

MO; NT

TOPICLEAR LOTN$0

(Tier3)

MO; NT

UNIVERSAL REMOVERWIPES MISC

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


URO-PREP PROTECTIVESKINWIPES MISC

$0(Tier

3)

MO; NT

VANICREAM BAR$0

(Tier3)

MO; NT

witch hazel-glycerin pads$0

(Tier3)

NT

WOUND WASH SALINESOLN

$0(Tier

3)

NT

Rosacea Agents

FINACEA GEL$0-

$7.40(Tier

2)

MO

METROCREAM CREA(Metronidazole (Topical)) NF MO

METROGEL GEL(Metronidazole (Topical)) NF MO

METROLOTION LOTN(Metronidazole (Topical)) NF MO

metronidazole (topical)crea

$0-$2.95(Tier

1)

MO

metronidazole (topical) gel$0-

$2.95(Tier

1)

MO

metronidazole (topical) lotn$0-

$2.95(Tier

1)

MO

MIRVASO GEL$0-

$7.40(Tier

2)

PA; MO

Scabicides & Pediculicides



113

Name of drug

Whatthe


level)


lindane lotn$0-

$2.95(Tier

1)

LYCELLE GEL$0

(Tier3)

RX/OTC; NT

malathion lotn$0-

$2.95(Tier

1)

MO

nit remover gel$0

(Tier3)

RX/OTC; NT

NIX CREME RINSE LIQD(Permethrin) NF MO; NT

permethrin aero xx 0.5 %$0

(Tier3)

NT

permethrin crea ex 5 %$0-

$2.95(Tier

1)

MO

permethrin liqd ex 1 %$0

(Tier3)

MO; NT

permethrin lotn ex 1 %$0

(Tier3)

NT

PRONTO SHAM EX0.33%-4% (Pyrethrins-Piperonyl Butoxide)

NFMO; NT

pyrethrins-piperonylbutoxide liqd 0.33%-4%,1.2%-0.3%-0.3%-2.4%-3%

$0(Tier

3)

NT

pyrethrins-piperonylbutoxide sham 0.3%-0.33%-4%, 0.33%-4%

$0(Tier

3)

MO; NT

pyrethrins-piperonylbutoxide sham 0.33%-4%

$0(Tier

3)

NT

Name of drug

Whatthe


level)


RID AERO (Permethrin) NF NT

RID LIQD (Pyrethrins-Piperonyl Butoxide) NF NT

Sunscreens

BULL FROG QUIK GELSPF 36 GEL

$0(Tier

3)

MO; NT

BULL FROG QUIK GELSPF 50 GEL

$0(Tier

3)

MO; NT

BULL FROG QUIK GELSPORTSPF 36 GEL

$0(Tier

3)

MO; NT

BULL FROG QUIK GELSPORTSPRAY SPF 50GEL

$0(Tier

3)

MO; NT

BULL FROG SPF 36 GEL$0

(Tier3)

MO; NT

BULL FROG WATERARMOR SPORT QUIKGEL SPF 50 GEL

$0(Tier

3)

MO; NT

BULL FROG WATERARMOR SPORT QUIKSPRAY SPF 50 GEL

$0(Tier

3)

MO; NT

NIVEA VISAGE EYECONTOUR GEL

$0(Tier

3)

MO; NT

PRESUN ULTRA/PARSOLGEL 3%-5%-7.5%-6%

$0(Tier

3)

MO; NT

SHADE OIL FREE CLEARGELSPF 25 GEL

$0(Tier

3)

MO; NT

SOLBAR PF LIQUID/GELSPF30 GEL

$0(Tier

3)

MO; NT

Tar Products



114

Name of drug

Whatthe


level)


coal tar extract sham 1 %$0

(Tier3)

NT

COAL TAR SOLN EX$0

(Tier3)

NT

CUTAR OIL$0

(Tier3)

MO; NT

ELTA LITE TAR LOTN$0

(Tier3)

NT

ELTA TAR CREA$0

(Tier3)

NT

GRANDPAS PINE TARSOAP BAR

$0(Tier

3)

NT

MG217 MEDICATED TARLOTN

$0(Tier

3)

NT

MG217 MEDICATED TAROINT

$0(Tier

3)

NT

MG217 MEDICATED TARSHAMPOO SHAM

$0(Tier

3)

MO; NT

POLYTAR BAR$0

(Tier3)

NT

TARSUM SHAM$0

(Tier3)

MO; NT

THERAPLEX T SHAM(Coal Tar Extract) NF NT

Wound Care Products

REGRANEX GEL$0-

$7.40(Tier

2)

MO

DIAGNOSTIC PRODUCTS

Name of drug

Whatthe


level)


Diagnostic Drugs

GLUTOL LIQD$0

(Tier3)

NT

Diagnostic Tests

ALBUSTIX STRP$0

(Tier3)

MO; NT

CHEK-STIX COMBO PAKURINALYSIS CONTROLSTRP

$0(Tier

3)

MO; NT

CHEK-STIX CONTROLSTRP

$0(Tier

3)

MO; NT

CHEMSTRIP -10 WITH SGSTRP

$0(Tier

3)

MO; NT

CHEMSTRIP 10 MD STRP$0

(Tier3)

MO; NT

CHEMSTRIP 2 GPSTRIPS STRP

$0(Tier

3)

MO; NT

CHEMSTRIP 2 LN STRIPSSTRP

$0(Tier

3)

MO; NT

CHEMSTRIP 5 OB STRP$0

(Tier3)

MO; NT

CHEMSTRIP 7 STRP$0

(Tier3)

MO; NT

CHEMSTRIP 9 STRIPSSTRP

$0(Tier

3)

MO; NT

CHEMSTRIP UGK STRP$0

(Tier3)

MO; NT

CHEMSTRIP-K STRP$0

(Tier3)

MO; NT



115

Name of drug

Whatthe


level)


CHEMSTRIP-MICRALSTRP

$0(Tier

3)

MO; NT

CLINISTIX STRP$0

(Tier3)

MO; NT

CLINITEST REAGENTTABS

$0(Tier

3)

NT

CLINITEST TABS$0

(Tier3)

NT

COMBISTIX STRP$0

(Tier3)

MO; NT

CVS KETONE CARESTRP

$0(Tier

3)

MO; NT

DIASTIX STRP$0

(Tier3)

MO; NT

HEMA-COMBISTIX STRP$0

(Tier3)

MO; NT

KETO-DIASTIX STRP$0

(Tier3)

MO; NT

KETOCARE STRP$0

(Tier3)

MO; NT

KETONE TEST STRIPSSTRP

$0(Tier

3)

MO; NT

KETOSTIX STRP$0

(Tier3)

MO; NT

LABSTIX STRP$0

(Tier3)

MO; NT

MULTISTIX 10 SG STRP$0

(Tier3)

MO; NT

Name of drug

Whatthe


level)


MULTISTIX 5 STRP$0

(Tier3)

MO; NT

MULTISTIX 7 STRP$0

(Tier3)

MO; NT


(Tier3)

MO; NT


(Tier3)

MO; NT

MULTISTIX 9 STRP$0

(Tier3)

MO; NT

MULTISTIX STRP$0

(Tier3)

MO; NT

NITRATEST PAPER TEST$0

(Tier3)

MO; NT

NOVA MAX PLUSKETONE TESTSTRIPSSTRP

$0(Tier

3)

MO; NT

PRECISION XTRA STRP$0

(Tier3)

MO; NT

PTS PANELS KETONETEST STRP

$0(Tier

3)

MO; NT

RELION KETONE STRP$0

(Tier3)

MO; NT

RELION KETONE TESTSTRIPS STRP

$0(Tier

3)

MO; NT

UNIVERSAL PH STRIPSSTRP

$0(Tier

3)

MO; NT

URISTIX 4 STRP$0

(Tier3)

MO; NT



116

Name of drug

Whatthe


level)


URISTIX STRP$0

(Tier3)

MO; NT

WFHC PH PAPER TEST$0

(Tier3)

MO; NT

DIETARY PRODUCTS/DIETARY MANAGEMENTPRODUCTSDietary Management Products

CEREFOLIN TABS$0

(Tier3)

MO; NT

folic acid-pyridoxine-cyanocobalamin tabs

$0(Tier

3)

MO; NT

L-METHYL-MC TABS$0

(Tier3)

MO; NT

METAFOLBIC TABS$0

(Tier3)

MO; NT

NEOKE BCAA4 POWD$0

(Tier3)

RX/OTC; NT

SULFZIX POWD500MCG/0.25GM

$0(Tier

3)

RX/OTC; NT

XIZFLUS POWD500MCG/0.25GM

$0(Tier

3)

RX/OTC; NT

Nutritional SupplementsDEXATRIM MAX PACK1MG-5.5UNIT-34MCG-72MG-75MG-0.35MG-70MG-45MG-0.263MG-10MG-1.8MG-3.5MG-0.3MG-3MCG-70MCG-0.35MG-25MG-30MG

$0(Tier

3)

NT

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymesDigestive Enzymes

Name of drug

Whatthe


level)


CREON CPEP$0-

$7.40(Tier

2)

MO

PANCREAZE CPEP10000UNIT-4200UNIT-17500UNIT, 25000UNIT-10500UNIT-43750UNIT,37000UNIT-21000UNIT-61000UNIT, 40000UNIT-16800UNIT-70000UNIT

$0-$7.40(Tier

2)

MO

PANCREAZE CPEP6200UNIT-2600UNIT-10850UNIT

$0-$7.40(Tier

2)

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood PressureCarbonic Anhydrase Inhibitors

acetazolamide cp12 or 500mg

$0-$2.95(Tier

1)

MO

acetazolamide tabs or 250mg

$0-$2.95(Tier

1)

MO

DIAMOX CP12(Acetazolamide) NF MO

methazolamide tabs or 25mg, 50 mg

$0-$2.95(Tier

1)

MO

Diuretic CombinationsALDACTAZIDE TABS25MG-25MG(Spironolactone &Hydrochlorothiazide)

NF

MO

amiloride &hydrochlorothiazide tabs

$0-$2.95(Tier

1)

MO



117

Name of drug

Whatthe


level)


DYAZIDE CAPS(Triamterene &Hydrochlorothiazide)

NFMO

MAXZIDE TABS(Triamterene &Hydrochlorothiazide)

NFMO

MAXZIDE-25 TABS(Triamterene &Hydrochlorothiazide)

NFMO

spironolactone &hydrochlorothiazide tabs

$0-$2.95(Tier

1)

MO

triamterene &hydrochlorothiazide caps

$0-$2.95(Tier

1)

MO

triamterene &hydrochlorothiazide tabs

$0-$2.95(Tier

1)

MO

Loop Diuretics

bumetanide tabs or 0.5 mg,1 mg, 2 mg

$0-$2.95(Tier

1)

MO

BUMEX TABS(Bumetanide) NF MO

DEMADEX TABS(Torsemide) NF MO

furosemide soln ij 10 mg/ml$0-

$2.95(Tier

1)

MO

furosemide soln or 10mg/ml

$0-$2.95(Tier

1)

MO

furosemide tabs or 20 mg,40 mg, 80 mg

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


LASIX TABS (Furosemide) NF MO

torsemide tabs or 10 mg,100 mg, 20 mg, 5 mg

$0-$2.95(Tier

1)

MO

Potassium Sparing DiureticsALDACTONE TABS(Spironolactone) NF MO

amiloride hcl tabs or$0-

$2.95(Tier

1)

MO

spironolactone tabs or 100mg, 25 mg, 50 mg

$0-$2.95(Tier

1)

MO

Thiazides and Thiazide-Like Diuretics

chlorothiazide tabs 500 mg$0-

$2.95(Tier

1)

MO

chlorthalidone tabs 25 mg$0-

$2.95(Tier

1)

MO

hydrochlorothiazide caps or12.5 mg

$0-$2.95(Tier

1)

MO

hydrochlorothiazide tabs or12.5 mg, 25 mg, 50 mg

$0-$2.95(Tier

1)

MO

indapamide tabs$0-

$2.95(Tier

1)

MO

metolazone tabs$0-

$2.95(Tier

1)

MO



118

Name of drug

Whatthe


level)


MICROZIDE CAPS(Hydrochlorothiazide) NF MO

ZAROXOLYN TABS(Metolazone) NF MO

ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate HormonesBone Density Regulators

alendronate sodium tabs10 mg, 5 mg

$0-$2.95(Tier

1)

MO

alendronate sodium tabs35 mg, 70 mg

$0-$2.95(Tier

1)

QL(0.15 eadaily); MO

BONIVA SOLN IV 3MG/3ML (IbandronateSodium)

NF

Limit 3mls per3months;QL(0.04 ml daily); MO

BONIVA TABS OR 150 MG(Ibandronate Sodium) NF

Limit 1 tab per28 days (3 per84);QL(0.036ea daily); MO

calcitonin (salmon) soln$0-

$2.95(Tier

1)

MO

FORTEO SOLN$0-

$7.40(Tier

2)

Limit 2.4mlsper 28days;QL(0.09ml daily)

FORTICAL SOLN$0-

$7.40(Tier

2)

MO

FOSAMAX TABS(Alendronate Sodium) NF QL(0.15 ea

daily); MO

ibandronate sodium soln iv3 mg/3ml

$0-$2.95(Tier

1)

Limit 3mls per3months;QL(0.04 ml daily); MO

Name of drug

Whatthe


level)


ibandronate sodium tabs or150 mg

$0-$2.95(Tier

1)

Limit 1 tab per28 days (3 per84);QL(0.036ea daily); MO

MIACALCIN SOLN IJ 200UNIT/ML

$0-$7.40(Tier

2)

MO

MIACALCIN SOLN NA 200UNIT/ACT (Calcitonin(Salmon))

NFMO

NATPARA CART$0-

$7.40(Tier

2)

PA; LA

PROLIA SOLN$0-

$7.40(Tier

2)

Limit 1 ml per 6months;QL(0.01 ml daily)

RECLAST SOLN(Zoledronic Acid) NF

Limit 100mlsperyear;QL(0.28ml daily)

XGEVA SOLN$0-

$7.40(Tier

2)

Limit 6.8mlsper 28days;QL(0.243ml daily)

zoledronic acid conc 4mg/5ml

$0-$2.95(Tier

1)

zoledronic acid soln 5mg/100ml

$0-$2.95(Tier

1)

Limit 100mlsperyear;QL(0.28ml daily)

zoledronic acid solr 4 mg$0-

$2.95(Tier

1)ZOMETA CONC 4MG/5ML (Zoledronic Acid) NF

Corticotropin



119

Name of drug

Whatthe


level)


H.P. ACTHAR GEL$0-

$7.40(Tier

2)

PA; LA

Fertility Regulators

chorionic gonadotropin solrim

$0-$2.95(Tier

1)

Growth Hormone Receptor Antagonists

SOMAVERT SOLR$0-

$7.40(Tier

2)

LA

Growth Hormone Releasing Hormones (GHRH)

EGRIFTA SOLR 2 MG$0-

$7.40(Tier

2)

Growth Hormones

GENOTROPIN MINIQUICKSOLR 0.4 MG

$0-$7.40(Tier

2)

PA

GENOTROPIN SOLR 5MG

$0-$7.40(Tier

2)

PA

HUMATROPE COMBOPACK SOLR

$0-$7.40(Tier

2)

PA

HUMATROPE SOLR$0-

$7.40(Tier

2)

PA

NORDITROPIN FLEXPROSOLN 10 MG/1.5ML, 5MG/1.5ML

$0-$7.40(Tier

2)

PA

Name of drug

Whatthe


level)


NUTROPIN AQ NUSPIN20 SOLN

$0-$7.40(Tier

2)

PA

NUTROPIN AQ PEN SOLN20 MG/2ML

$0-$7.40(Tier

2)

PA

OMNITROPE SOLN 10MG/1.5ML, 5 MG/1.5ML

$0-$7.40(Tier

2)

PA

SEROSTIM SOLR 4 MG, 6MG

$0-$7.40(Tier

2)

PA

ZOMACTON SOLR 5 MG$0-

$7.40(Tier

2)

PA

Hormone Receptor ModulatorsEVISTA TABS (RaloxifeneHCl) NF QL(1 ea daily);

MO

raloxifene hcl tabs$0-

$2.95(Tier

1)

QL(1 ea daily);MO

Insulin-Like Growth Factors (Somatomedins)

INCRELEX SOLN$0-

$7.40(Tier

2)

LA

LHRH/GnRH Agonist Analog Pituitary

LUPRON DEPOT-PED KIT11.25 MG

$0-$7.40(Tier

2)

3 month kit

LUPRON DEPOT-PED KIT11.25 MG, 15 MG, 7.5 MG

$0-$7.40(Tier

2)



120

Name of drug

Whatthe


level)


LUPRON DEPOT-PED KIT30 MG

$0-$7.40(Tier

2)

SYNAREL SOLN$0-

$7.40(Tier

2)

MO

Metabolic Modifiers

calcitriol caps or 0.25 mcg,0.5 mcg

$0-$2.95(Tier

1)

MO

calcitriol soln or 1 mcg/ml$0-

$2.95(Tier

1)

MO

CARBAGLU TABS$0-

$7.40(Tier

2)

LA

FABRAZYME SOLR 35MG

$0-$7.40(Tier

2)

LA

KANUMA SOLN$0-

$7.40(Tier

2)

LA

KUVAN PACK$0-

$7.40(Tier

2)

LA

KUVAN TBSO$0-

$7.40(Tier

2)

LA

levocarnitine (metabolicmodifiers) tabs or 330 mg

$0-$2.95(Tier

1)

RX/OTC; MO

Name of drug

Whatthe


level)


LUMIZYME SOLR$0-

$7.40(Tier

2)

LA

MYALEPT SOLR$0-

$7.40(Tier

2)

LA

MYOZYME SOLR$0-

$7.40(Tier

2)

LA

NAGLAZYME SOLN$0-

$7.40(Tier

2)

LA

ORFADIN CAPS 10 MG, 2MG, 20 MG, 5 MG

$0-$7.40(Tier

2)

LA

paricalcitol caps or 1 mcg,2 mcg, 4 mcg

$0-$2.95(Tier

1)

MO

RAVICTI LIQD$0-

$7.40(Tier

2)

LA

ROCALTROL CAPS(Calcitriol) NF MO

ROCALTROL SOLN(Calcitriol) NF MO

SENSIPAR TABS$0-

$7.40(Tier

2)

STRENSIQ SOLN$0-

$7.40(Tier

2)

PA; LA



121

Name of drug

Whatthe


level)


VIMIZIM SOLN$0-

$7.40(Tier

2)ZEMPLAR CAPS OR 1MCG, 2 MCG (Paricalcitol) NF MO

Posterior Pituitary HormonesDDAVP SOLN(Desmopressin AcetateRefrigerated)

NFMO

DDAVP SOLN(Desmopressin AcetateSpray)

NFMO

DDAVP SOLN(Desmopressin Acetate) NF MO

DDAVP TABS(Desmopressin Acetate) NF MO

desmopressin acetaterefrigerated soln

$0-$2.95(Tier

1)

MO

desmopressin acetate solnij 4 mcg/ml

$0-$2.95(Tier

1)

MO

desmopressin acetatespray refrigerated soln

$0-$2.95(Tier

1)

MO

desmopressin acetatespray soln

$0-$2.95(Tier

1)

MO

desmopressin acetate tabsor 0.1 mg, 0.2 mg

$0-$2.95(Tier

1)

MO

Prolactin Inhibitors

cabergoline tabs$0-

$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


Somatostatic Agents

octreotide acetate soln 100mcg/ml, 200 mcg/ml, 50mcg/ml

$0-$2.95(Tier

1)

SANDOSTATIN LARDEPOT KIT 20 MG, 30 MG

$0-$7.40(Tier

2)SANDOSTATIN SOLN 100MCG/ML, 200 MCG/ML, 50MCG/ML (OctreotideAcetate)

NF

SIGNIFOR LAR SUSR 20MG

$0-$7.40(Tier

2)

Limit 3 vials per28days;SL(0.11ea daily); LA


$0-$7.40(Tier

2)

Limit 3 vials per56days;SL(0.054ea daily); LA


$0-$7.40(Tier

2)

Limit 1 vial per28days;SL(0.036ea daily); LA

SIGNIFOR SOLN$0-

$7.40(Tier

2)

LA

SOMATULINE DEPOTSOLN

$0-$7.40(Tier

2)

Vasopressin Receptor Antagonists

SAMSCA TABS$0-

$7.40(Tier

2)

ESTROGENS - Hormone Replacement/ModifyingDrugsEstrogen Combinations



122

Name of drug

Whatthe


level)


ACTIVELLA TABS(Estradiol & NorethindroneAcetate)

NFAL; MO

estradiol & norethindroneacetate tabs

$0-$2.95(Tier

1)

AL; MO

PREMPHASE TABS$0-

$7.40(Tier

2)

AL; MO

PREMPRO TABS$0-

$7.40(Tier

2)

AL; MO

EstrogensCLIMARA PTWK(Estradiol) NF AL; MO

DELESTROGEN OIL 10MG/ML

$0-$7.40(Tier

2)

MO

DELESTROGEN OIL 20MG/ML, 40 MG/ML(Estradiol Valerate)

NFMO

DIVIGEL GEL$0-

$7.40(Tier

2)

AL; MO

estradiol ptwk td 0.025mg/24hr, 0.05 mg/24hr,0.06 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr

$0-$2.95(Tier

1)

AL; MO

estradiol tabs or 0.5 mg, 1mg, 2 mg

$0-$2.95(Tier

1)

AL; MO

estradiol valerate oil im 20mg/ml, 40 mg/ml

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


estropipate tabs 0.75 mg,1.5 mg

$0-$2.95(Tier

1)

AL; MO

PREMARIN TABS OR 0.3MG, 0.45 MG, 0.625 MG,0.9 MG, 1.25 MG

$0-$7.40(Tier

2)

AL; MO

FLUOROQUINOLONES - Drugs to Treat BacterialInfectionsFluoroquinolonesCIPRO I.V.-IN D5W SOLN(Ciprofloxacin in D5W) NF MO

CIPRO TABS 250 MG, 500MG (Ciprofloxacin HCl) NF MO

CIPRO XR TB24(Ciprofloxacin-CiprofloxacinHCl)

NFMO

ciprofloxacin hcl tabs or100 mg, 250 mg, 500 mg,750 mg

$0-$2.95(Tier

1)

MO

ciprofloxacin in d5w soln200mg/100ml-5%

$0-$2.95(Tier

1)

ciprofloxacin in d5w soln400mg/200ml-5%

$0-$2.95(Tier

1)

MO

ciprofloxacin soln iv 400mg/40ml

$0-$2.95(Tier

1)

MO

ciprofloxacin-ciprofloxacinhcl tb24

$0-$2.95(Tier

1)

MO



123

Name of drug

Whatthe


level)


LEVAQUIN SOLN IV250MG/50ML-5%,500MG/100ML-5%,750MG/150ML-5%(Levofloxacin in D5W)

NF

LEVAQUIN SOLN OR 25MG/ML (Levofloxacin) NF MO

LEVAQUIN TABS OR 250MG, 500 MG, 750 MG(Levofloxacin)

NFMO

levofloxacin in d5w soln$0-

$2.95(Tier

1)

levofloxacin soln iv 25mg/ml

$0-$2.95(Tier

1)

levofloxacin soln or 25mg/ml

$0-$2.95(Tier

1)

MO

levofloxacin tabs or 250mg, 500 mg, 750 mg

$0-$2.95(Tier

1)

MO

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal DrugsAntiflatulentsGAS-X EXTRASTRENGTH CHEW 125MG (Simethicone)

NFMO; NT

MYLANTA GAS CHEW(Simethicone) NF MO; NT

MYLANTA GAS RELIEFMAXIMUM STRENGTHCAPS (Simethicone)

NFMO; NT

simethicone caps or 125mg, 125mg

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


simethicone chew or 125mg

$0(Tier

3)

MO; NT

Farnesoid X Receptor (FXR) Agonists

OCALIVA TABS 10 MG$0-

$7.40(Tier

2)

PA; SL(1 eadaily)

OCALIVA TABS 5 MG$0-

$7.40(Tier

2)

PA; SL(2 eadaily)

Gallstone Solubilizing AgentsACTIGALL CAPS(Ursodiol) NF MO

chenodiol tabs$0-

$2.95(Tier

1)

LA

URSO 250 TABS(Ursodiol) NF MO

URSO FORTE TABS(Ursodiol) NF MO

ursodiol caps or 300 mg$0-

$2.95(Tier

1)

MO

ursodiol tabs or 250 mg,500 mg

$0-$2.95(Tier

1)

MO

Gastrointestinal Antiallergy Agents

cromolyn sodium(mastocytosis) conc

$0-$2.95(Tier

1)

MO

GASTROCROM CONC(Cromolyn Sodium(Mastocytosis))

NFMO

Gastrointestinal Stimulants



124

Name of drug

Whatthe


level)


metoclopramide hcl soln ij5 mg/ml

$0-$2.95(Tier

1)

MO

metoclopramide hcl soln or10 mg/10ml, 5 mg/5ml

$0-$2.95(Tier

1)

MO

metoclopramide hcl tabs or10 mg, 5 mg

$0-$2.95(Tier

1)

MO

REGLAN TABS(Metoclopramide HCl) NF MO

Inflammatory Bowel Agents

APRISO CP24$0-

$7.40(Tier

2)

MO

ASACOL HD TBEC$0-

$7.40(Tier

2)

MO

AZULFIDINE EN-TABSTBEC (Sulfasalazine) NF MO

AZULFIDINE TABS(Sulfasalazine) NF MO

balsalazide disodium caps$0-

$2.95(Tier

1)

MO

CIMZIA KIT$0-

$7.40(Tier

2)

PA

CIMZIA STARTER KIT KIT$0-

$7.40(Tier

2)

PA

COLAZAL CAPS(Balsalazide Disodium) NF MO

Name of drug

Whatthe


level)


DELZICOL CPDR$0-

$7.40(Tier

2)

MO

DIPENTUM CAPS$0-

$7.40(Tier

2)

MO

ENTYVIO SOLR$0-

$7.40(Tier

2)

PA

MESALAMINE DR TBEC$0-

$7.40(Tier

2)

MO

mesalamine enem re$0-

$2.95(Tier

1)

MO

mesalamine w/ cleanser kit$0-

$2.95(Tier

1)

MO

REMICADE SOLR$0-

$7.40(Tier

2)

PA

ROWASA KIT (Mesalaminew/ Cleanser) NF MO

sulfasalazine tabs or$0-

$2.95(Tier

1)

MO

sulfasalazine tbec or$0-

$2.95(Tier

1)

MO

Intestinal Acidifiers

lactulose (encephalopathy)soln

$0-$2.95(Tier

1)

MO



125

Name of drug

Whatthe


level)


Irritable Bowel Syndrome (IBS) Agents

alosetron hcl tabs$0-

$2.95(Tier

1)

MO

LINZESS CAPS$0-

$7.40(Tier

2)

MO

LOTRONEX TABS(Alosetron HCl)

$0-$7.40(Tier

2)

MO

VIBERZI TABS$0-

$7.40(Tier

2)

PA; MO

Peripheral Opioid Receptor Antagonists

MOVANTIK TABS$0-

$7.40(Tier

2)

MO

RELISTOR SOLN SC 12MG/0.6ML, 8 MG/0.4ML

$0-$7.40(Tier

2)

MO

Phosphate Binder Agents

calcium acetate (phosphatebinder) caps

$0-$2.95(Tier

1)

MO

FOSRENOL CHEW 1000MG, 500 MG, 750 MG

$0-$7.40(Tier

2)

MO

PHOSLO CAPS (CalciumAcetate (PhosphateBinder))

NFMO

RENVELA PACK 2.4 GM$0-

$7.40(Tier

2)

MO

Name of drug

Whatthe


level)


RENVELA TABS 800 MG$0-

$7.40(Tier

2)

MO

Short Bowel Syndrome (SBS) Agents

GATTEX KIT$0-

$7.40(Tier

2)

PA; LA

GENITOURINARY AGENTS - MISCELLANEOUS- Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary SystemAlkalinizers

potassium citrate(alkalinizer) tbcr 1080 mg,540 mg

$0-$2.95(Tier

1)

MO

UROCIT-K 10 TBCR(Potassium Citrate(Alkalinizer))

$0-$7.40(Tier

2)

MO

UROCIT-K 5 TBCR(Potassium Citrate(Alkalinizer))

$0-$7.40(Tier

2)

MO

Genitourinary Irrigants

acetic acid soln$0-

$2.95(Tier

1)

MO

neomycin/polymyxin b gusoln

$0-$2.95(Tier

1)

MO

sodium chloride (guirrigant) soln

$0-$2.95(Tier

1)

MO

Prostatic Hypertrophy Agents



126

Name of drug

Whatthe


level)


alfuzosin hcl tb24$0-

$2.95(Tier

1)

MO

AVODART CAPS(Dutasteride)

$0-$7.40(Tier

2)

GL; MO

dutasteride caps$0-

$2.95(Tier

1)

GL; MO

dutasteride-tamsulosin hclcaps

$0-$2.95(Tier

1)

GL; MO

finasteride tabs or$0-

$2.95(Tier

1)

GL; MO

FLOMAX CAPS(Tamsulosin HCl) NF MO

JALYN CAPS (Dutasteride-Tamsulosin HCl)

$0-$7.40(Tier

2)

GL; MO

PROSCAR TABS(Finasteride) NF GL; MO

tamsulosin hcl caps$0-

$2.95(Tier

1)

MO

UROXATRAL TB24(Alfuzosin HCl) NF MO

Urinary Analgesics

phenazopyridine hcl tabs or100 mg, 200 mg

$0(Tier

3)

MO; NT

PYRIDIUM TABS(Phenazopyridine HCl) NF MO; NT

GOUT AGENTS - Drugs to Treat Gout

Name of drug

Whatthe


level)


Gout Agent Combinations

colchicine w/ probenecidtabs

$0-$2.95(Tier

1)

MO

Gout Agents

allopurinol tabs or 100 mg$0-

$2.95(Tier

1)

SL(8 ea daily);MO

allopurinol tabs or 300 mg$0-

$2.95(Tier

1)


COLCHICINE TABS OR$0-

$7.40(Tier

2)

MO

COLCRYS TABS$0-

$7.40(Tier

2)

MO

ZYLOPRIM TABS 100 MG(Allopurinol) NF SL(8 ea daily);

MOZYLOPRIM TABS 300 MG(Allopurinol) NF SL(2.66 ea

daily); MOUricosurics

probenecid tabs$0-

$2.95(Tier

1)

MO

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood DisordersBradykinin B2 Receptor Antagonists

FIRAZYR SOLN$0-

$7.40(Tier

2)

Complement Inhibitors



127

Name of drug

Whatthe


level)


BERINERT KIT$0-

$7.40(Tier

2)

LA

CINRYZE SOLR$0-

$7.40(Tier

2)

LA

RUCONEST SOLR$0-

$7.40(Tier

2)

Hematorheologic Agents

pentoxifylline tbcr or$0-

$2.95(Tier

1)

MO

Plasma Kallikrein Inhibitors

KALBITOR SOLN$0-

$7.40(Tier

2)

Platelet Aggregation Inhibitors

AGGRENOX CP12$0-

$7.40(Tier

2)

MO

AGRYLIN CAPS(Anagrelide HCl) NF MO

anagrelide hcl caps$0-

$2.95(Tier

1)

MO

ASPIRIN/DIPYRIDAMOLECP12

$0-$7.40(Tier

2)

MO

BRILINTA TABS$0-

$7.40(Tier

2)

MO

Name of drug

Whatthe


level)


cilostazol tabs$0-

$2.95(Tier

1)

MO

clopidogrel bisulfate tabs300 mg

$0-$2.95(Tier

1)

clopidogrel bisulfate tabs75 mg

$0-$2.95(Tier

1)

MO

dipyridamole tabs or 25mg, 50 mg, 75 mg

$0-$2.95(Tier

1)

AL; MO

EFFIENT TABS$0-

$7.40(Tier

2)

MO

PERSANTINE TABS(Dipyridamole) NF AL; MO

PLAVIX TABS 300 MG(Clopidogrel Bisulfate) NF

PLAVIX TABS 75 MG(Clopidogrel Bisulfate) NF MO

PLETAL TABS (Cilostazol) NF MO

ticlopidine hcl tabs$0-

$2.95(Tier

1)

AL

ZONTIVITY TABS$0-

$7.40(Tier

2)

MO

HEMATOPOIETIC AGENTS - Drugs to TreatBlood DisordersAgents for Gaucher Disease



128

Name of drug

Whatthe


level)


CERDELGA CAPS$0-

$7.40(Tier

2)

PA

CEREZYME SOLR$0-

$7.40(Tier

2)

LA

ELELYSO SOLR$0-

$7.40(Tier

2)

VPRIV SOLR$0-

$7.40(Tier

2)

ZAVESCA CAPS$0-

$7.40(Tier

2)

LA

Agents for Sickle Cell Anemia

DROXIA CAPS$0-

$7.40(Tier

2)

MO

Cobalamins

cyanocobalamin subl sl1000 mcg

$0(Tier

3)

MO; NT

cyanocobalamin tabs or250 mcg

$0(Tier

3)

MO; NT

Folic Acid/Folates

folic acid caps or 0.8 mg,800 mcg

$0(Tier

3)

NT

FOLIC ACID CAPS OR 20MG

$0(Tier

3)

NT

FOLIC ACID CAPS OR 5MG

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


folic acid tabs or 1 mg$0

(Tier3)

RX/OTC; MO;NT

folic acid tabs or 400 mcg,800 mcg

$0(Tier

3)

MO; NT

Hematopoietic Growth Factors

ARANESP ALBUMINFREE SOLN

$0-$7.40(Tier

2)

PA

ARANESP ALBUMINFREE SOSY

$0-$7.40(Tier

2)

PA

EPOGEN SOLN$0-

$7.40(Tier

2)

PA; B/D

GRANIX SOSY$0-

$7.40(Tier

2)

PA

LEUKINE SOLR$0-

$7.40(Tier

2)

PA

NEULASTA ONPRO KITPSKT

$0-$7.40(Tier

2)

PA

NEULASTA SOSY$0-

$7.40(Tier

2)

PA

NEUMEGA SOLR$0-

$7.40(Tier

2)

PA

NEUPOGEN SOLN$0-

$7.40(Tier

2)

PA



129

Name of drug

Whatthe


level)


NEUPOGEN SOSY$0-

$7.40(Tier

2)

PA

PROCRIT SOLN 10000UNIT/ML, 2000 UNIT/ML,20000 UNIT/ML, 3000UNIT/ML, 4000 UNIT/ML,40000 UNIT/ML

$0-$7.40(Tier

2)

PA; B/D

PROMACTA TABS 12.5MG

$0-$7.40(Tier

2)

SL(12 ea daily);LA

PROMACTA TABS 25 MG$0-

$7.40(Tier

2)

SL(6 ea daily);LA


$7.40(Tier

2)

SL(3 ea daily);LA


$7.40(Tier

2)

SL(2 ea daily);LA

ZARXIO SOSY$0-

$7.40(Tier

2)

PA

Hematopoietic Mixtures

B-6 FOLIC ACID CAPS$0

(Tier3)

NT

FOLGARD RX TABS (FolicAcid-Vitamin B6-VitaminB12)

NFMO; NT

FOLIC + B12 TABS$0

(Tier3)

RX/OTC; MO;NT

folic acid-vitamin b6-vitamin b12 tabs

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


FOLTRATE TABS$0

(Tier3)

RX/OTC; MO;NT

HEMOCYTE-F ELIX$0

(Tier3)

RX/OTC; NT

I.L.X. B-12 ELIX$0

(Tier3)

RX/OTC; NT

iron combinations caps$0

(Tier3)

RX/OTC; MO;NT

MTX SUPPORT TABS$0

(Tier3)

RX/OTC; MO;NT

OPURITY B12/FOLICACID TABS

$0(Tier

3)

RX/OTC; MO;NT

PRE-FOLIC TABS$0

(Tier3)

NT

VITAMIN B12/FOLIC ACIDTABS

$0(Tier

3)

RX/OTC; MO;NT

IronFER-IN-SOL SOLN(Ferrous Sulfate) NF MO; NT

FERGON TABS (FerrousGluconate) NF NT

FERRETTS TABS$0

(Tier3)

MO; NT

ferrous fumarate tabs or324 mg

$0(Tier

3)

MO; NT

FERROUS FUMARATETABS OR 90 MG

$0(Tier

3)

NT

FERROUS GLUCONATETABS OR 225 MG

$0(Tier

3)

NT



130

Name of drug

Whatthe


level)


ferrous gluconate tabs or240 mg, 27 mg

$0(Tier

3)

NT

ferrous sulfate dried tbcr160 mg

$0(Tier

3)

NT

ferrous sulfate elix or 220mg/5ml

$0(Tier

3)

MO; NT

FERROUS SULFATE LIQDOR 220 MG/5ML

$0(Tier

3)

NT

ferrous sulfate soln or 15mg/ml

$0(Tier

3)

MO; NT

FERROUS SULFATESYRP OR 300 MG/5ML

$0(Tier

3)

NT

ferrous sulfate tabs or 325mg, 65 mg

$0(Tier

3)

MO; NT

ferrous sulfate tbcr or 50mg

$0(Tier

3)

NT

FERROUS SULFATETBEC OR 324 MG

$0(Tier

3)

MO; NT

ferrous sulfate tbec or 325mg

$0(Tier

3)

NT

HEMOCYTE TABS(Ferrous Fumarate) NF MO; NT

IRON CHEWS PEDIATRICCHEW

$0(Tier

3)

MO; NT

IRON TABS 256 MG$0

(Tier3)

NT

IRON TABS 28 MG$0

(Tier3)

NT

Name of drug

Whatthe


level)


polysaccharide ironcomplex caps 150 mg

$0(Tier

3)

MO; NT

PROFERRIN ES TABS$0

(Tier3)

MO; NT

Stem Cell Mobilizers

MOZOBIL SOLN$0-

$7.40(Tier

2)

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood DisordersHemostatics - Systemic

AMICAR SOLN 0.25GM/ML

$0-$7.40(Tier

2)

MO

AMICAR TABS 500 MG$0-

$7.40(Tier

2)

MO

aminocaproic acid tabs or500 mg

$0-$2.95(Tier

1)

MO

CYKLOKAPRON SOLN(Tranexamic Acid) NF

LYSTEDA TABS(Tranexamic Acid) NF MO

tranexamic acid soln iv1000 mg/10ml

$0-$2.95(Tier

1)

tranexamic acid tabs or 650mg

$0-$2.95(Tier

1)

MO

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTSBarbiturate Hypnotics



131

Name of drug

Whatthe


level)


BUTISOL SODIUM TABS30 MG

$0-$7.40(Tier

2)

AL; MO

phenobarbital elix or 20mg/5ml

$0-$2.95(Tier

1)

AL; MO

phenobarbital soln or 20mg/5ml

$0-$2.95(Tier

1)

AL; MO

phenobarbital tabs or 100mg, 15 mg, 16.2 mg, 30mg, 32.4 mg, 60 mg, 64.8mg, 97.2 mg

$0-$2.95(Tier

1)

AL; MO

Hypnotics - Tricyclic Agents

SILENOR TABS$0-

$7.40(Tier

2)

MO

Non-Barbiturate HypnoticsAMBIEN CR TBCR 12.5MG (Zolpidem Tartrate) NF AL; SL(1 ea

daily); MOAMBIEN CR TBCR 6.25MG (Zolpidem Tartrate) NF AL; SL(2 ea

daily); MOAMBIEN TABS 10 MG(Zolpidem Tartrate) NF AL; SL(1 ea

daily); MOAMBIEN TABS 5 MG(Zolpidem Tartrate) NF AL; SL(2 ea

daily); MOHALCION TABS(Triazolam) NF MO

RESTORIL CAPS(Temazepam) NF MO

SONATA CAPS (Zaleplon) NF AL; MO

temazepam caps$0-

$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


triazolam tabs 0.125 mg,0.25 mg

$0-$2.95(Tier

1)

MO

zaleplon caps$0-

$2.95(Tier

1)

AL; MO

zolpidem tartrate tabs or 10mg

$0-$2.95(Tier

1)


zolpidem tartrate tabs or 5mg

$0-$2.95(Tier

1)


zolpidem tartrate tbcr or12.5 mg

$0-$2.95(Tier

1)


zolpidem tartrate tbcr or6.25 mg

$0-$2.95(Tier

1)


Orexin Receptor Antagonists

BELSOMRA TABS 10 MG$0-

$7.40(Tier

2)



$7.40(Tier

2)



$7.40(Tier

2)



$7.40(Tier

2)


Selective Melatonin Receptor Agonists



132

Name of drug

Whatthe


level)


HETLIOZ CAPS$0-

$7.40(Tier

2)

PA

ROZEREM TABS$0-

$7.40(Tier

2)

MO

LAXATIVES - Bowel Treatment Drugs

Bulk Laxatives

calcium polycarbophil tabs$0

(Tier3)

MO; NT

CITRUCEL FIBERLAXATIVE POWD(Methylcellulose (Laxative))

NFMO; NT

CVS NATURAL FIBERSUPPLEMENT PACK

$0(Tier

3)

NT

EQL NATURAL FIBERPOWD

$0(Tier

3)

NT

EQUALACTIN CHEW$0

(Tier3)

MO; NT

EVAC POWD (Psyllium) NF MO; NT

FIBERCON TABS (CalciumPolycarbophil) NF MO; NT

HYDROCIL INSTANTPACK

$0(Tier

3)

MO; NT

HYDROCIL INSTANTPOWD (Psyllium) NF MO; NT

KONSYL PACK 100 %$0

(Tier3)

MO; NT

KONSYL PACK 28.3 %,60.3 %

$0(Tier

3)

NT

Name of drug

Whatthe


level)


KONSYL POWD 100 %(Psyllium) NF MO; NT

KONSYL POWD 60.3 %,71.67 %

$0(Tier

3)

NT

KONSYL-D POWD$0

(Tier3)

NT

METAMUCIL CAPS 0.52GM (Psyllium) NF MO; NT

METAMUCILMULTIHEALTH FIBERPOWD 55.46 %

$0(Tier

3)

NT

METAMUCIL ORIGINALTEXTURE POWD(Psyllium)

NFMO; NT

METAMUCIL POWD 48.57% (Psyllium) NF MO; NT

METAMUCIL SMOOTHTEXTUREFIBER SINGLESPACK

$0(Tier

3)

MO; NT

methylcellulose (laxative)powd 2 gm/10.2gm, 2gm/19gm

$0(Tier

3)

MO; NT

psyllium caps 0.52 gm, 520mg

$0(Tier

3)

MO; NT

psyllium powd 100 %,48.57 %, 58.6 %, 95 %

$0(Tier

3)

MO; NT

psyllium powd 28.3 %, 30%, 30.9 %, 33 %, 49 %, 68%

$0(Tier

3)

NT

UNIFIBER POWD$0

(Tier3)

NT

Laxative Combinations

COLYTE-FLAVOR PACKSSOLR 227.1GM-21.5GM-5.53GM-2.82GM-6.36GM

$0-$7.40(Tier

2)



133

Name of drug

Whatthe


level)


COLYTE-FLAVOR PACKSSOLR 240GM-22.72GM-5.84GM-2.98GM-6.72GM(PEG 3350-KCl-SodBicarb-Sod Chloride-SodSulfate)

NF

MO

GOLYTELY SOLR 236GM-22.74GM-5.86GM-2.97GM-6.74GM (PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)

NF

MO

NULYTELY/FLAVORPACKS SOLR (PEG 3350-Potassium Chloride-SodBicarbonate-Sod Chloride)

NF

MO

peg 3350-kcl-sod bicarb-sod chloride-sod sulfatesolr

$0-$2.95(Tier

1)

MO

peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr

$0-$2.95(Tier

1)

MO

SUPREP BOWEL PREPSOLN

$0-$7.40(Tier

2)

MO

Laxatives - Miscellaneous

CEO-TWO SUPP$0

(Tier3)

MO; NT

FLEET LIQUID GLYCERINSUPPOSITORIES ENEM

$0(Tier

3)

MO; NT

lactulose soln$0-

$2.95(Tier

1)

MO

polyethylene glycol 3350pack or

$0-$2.95(Tier

1)

RX/OTC; MO

Name of drug

Whatthe


level)


polyethylene glycol 3350powd or

$0-$2.95(Tier

1)

RX/OTC; MO

Saline Laxatives

magnesium hydroxidechew or 311 mg

$0(Tier

3)

NT

MILK OF MAGNESIACONCENTRATE SUSP

$0(Tier

3)

MO; NT

PHILLIPS MILK OFMAGNESIA CHEWABLECHEW

$0(Tier

3)

NT

PHILLIPS MILK OFMAGNESIACONCENTRATED SUSP

$0(Tier

3)

NT

PHILLIPS MILK OFMAGNESIA SUSP

$0(Tier

3)

NT

Stimulant Laxatives

bisacodyl supp re 10 mg$0

(Tier3)

MO; NT

bisacodyl tbec or 5 mg$0

(Tier3)

MO; NT

DULCOLAX BOWEL PREPKIT KIT

$0(Tier

3)

NT

DULCOLAX SUPP(Bisacodyl) NF MO; NT

DULCOLAX TBEC(Bisacodyl) NF MO; NT

EX-LAX TABS(Sennosides) NF MO; NT

FLEET BISACODYL ENEM$0

(Tier3)

MO; NT



134

Name of drug

Whatthe


level)


sennosides tabs 15 mg$0

(Tier3)

MO; NT

Surfactant LaxativesCOLACE CAPS (DocusateSodium) NF MO; NT

COLACE CLEAR CAPS(Docusate Sodium) NF MO; NT

docusate calcium caps$0

(Tier3)

MO; NT

docusate sodium caps or100 mg, 250 mg, 50 mg

$0(Tier

3)

MO; NT

docusate sodium liqd or150 mg/15ml, 50 mg/5ml

$0(Tier

3)

MO; NT

docusate sodium syrp or60 mg/15ml

$0(Tier

3)

MO; NT

docusate sodium tabs or100 mg

$0(Tier

3)

NT

DOCUSOL KIDS ENEM$0

(Tier3)

NT

DOCUSOL MINI ENEM$0

(Tier3)

MO; NT

DOCUSOL PLUS MINI-ENEMA ENEM

$0(Tier

3)

MO; NT

ENEMEEZ MINI ENEM$0

(Tier3)

MO; NT

ENEMEEZ PLUS ENEM$0

(Tier3)

MO; NT

LOCAL ANESTHETICS-Parenteral - Drugs forNumbingLocal Anesthetics - Amides

Name of drug

Whatthe


level)


lidocaine hcl (local anesth.)soln 1 %, 2 %

$0-$2.95(Tier

1)XYLOCAINE SOLN IJ 1 %,2 % (Lidocaine HCl (LocalAnesth.))

NF

XYLOCAINE-MPF SOLN 1% (Lidocaine HCl (LocalAnesth.))

NF

MACROLIDES - Drugs to Treat BacterialInfectionsAzithromycin

azithromycin solr iv 500 mg$0-

$2.95(Tier

1)

MO

azithromycin susr or 100mg/5ml, 200 mg/5ml

$0-$2.95(Tier

1)

MO

azithromycin tabs or 250mg, 500 mg, 600 mg

$0-$2.95(Tier

1)

MO

ZITHROMAX SOLR IV 500MG (Azithromycin) NF MO

ZITHROMAX SUSR OR100 MG/5ML, 200 MG/5ML(Azithromycin)

NFMO

ZITHROMAX TABS OR250 MG, 500 MG, 600 MG(Azithromycin)

NFMO

ZITHROMAX TRI-PAKTABS (Azithromycin) NF MO

ZITHROMAX Z-PAK TABS(Azithromycin) NF MO

ClarithromycinBIAXIN SUSR(Clarithromycin) NF MO



135

Name of drug

Whatthe


level)


BIAXIN TABS(Clarithromycin) NF MO

clarithromycin susr or 250mg/5ml

$0-$2.95(Tier

1)

MO

clarithromycin tabs or 250mg, 500 mg

$0-$2.95(Tier

1)

MO

clarithromycin tb24 or 500mg

$0-$2.95(Tier

1)

MO

Erythromycins

erythromycin base tabs250 mg

$0-$2.95(Tier

1)

SL(16 ea daily);MO

erythromycin base tabs500 mg

$0-$2.95(Tier

1)

SL(8 ea daily);MO

erythromycinethylsuccinate tabs or 400mg

$0-$2.95(Tier

1)

SL(10 ea daily);MO

erythromycin lactobionatesolr

$0-$2.95(Tier

1)

SL(8 ea daily)

erythromycin stearate tabs$0-

$2.95(Tier

1)

SL(16 ea daily);MO

Fidaxomicin

DIFICID TABS$0-

$7.40(Tier

2)

MO

MEDICAL DEVICES

Name of drug

Whatthe


level)


Contraceptives

CONDOMS$0

(Tier3)

MEDICAL DEVICES AND SUPPLIES

Bandages-Dressings-Tape

gauze pads 2" x 2"$0-

$2.95(Tier

1)

RX/OTC;MO

Contraceptives

OMNIFLEX DIAPHRAGMDPRH

$0(Tier

3)

NT

Misc. Devices

ALCOHOL PADS$0-

$7.40(Tier

2)

RX/OTC; MO

Parenteral Therapy Supplies

INSULIN SYRINGES ANDPEN NEEDLES

$0-$7.40(Tier

2)

MO

Respiratory Therapy Supplies

AEROCHAMBER MINIAEROSOLCHAMBERDEVI

$0(Tier

3)

QL(1 ea per365 daysretail,1 ea per365 days mail);RX/OTC; MO;NT

AEROCHAMBER MVMISC

$0(Tier

3)




136

Name of drug

Whatthe


level)


AEROCHAMBER PLUSFLOW VU MISC

$0(Tier

3)


AEROCHAMBER PLUSFLOW-VU MISC

$0(Tier

3)


AEROCHAMBER PLUSFLOW-VU/LARGE MASKMISC

$0(Tier

3)


AEROCHAMBER PLUSFLOW-VU/MASK MISC

$0(Tier

3)


AEROCHAMBER PLUSFLOW-VU/MEDIUM MASKMISC

$0(Tier

3)


AEROCHAMBER PLUSFLOW-VU/SMALL MASKMISC

$0(Tier

3)


AEROCHAMBER Z-STATPLUS VALVED HOLDINGCHAMBER W/FLOW VUMISC

$0(Tier

3)


Name of drug

Whatthe


level)


AEROCHAMBER Z-STATPLUS/FLOWSIGNAL MISC

$0(Tier

3)


AEROCHAMBER Z-STATPLUS/LARGE MASK MISC

$0(Tier

3)


AEROCHAMBER Z-STATPLUS/MEDIUM MASKMISC

$0(Tier

3)


AEROCHAMBER Z-STATPLUS/SMALL MASK MISC

$0(Tier

3)


AEROCHAMBER/FLOWSIGNAL MISC

$0(Tier

3)


AEROVENT PLUSHOLDINGCHAMBER/COLLAPSIBLEDEVI

$0(Tier

3)


AIRZONE PEAK FLOWMETER DEVI

$0(Tier

3)

RX/OTC; MO;NT



137

Name of drug

Whatthe


level)


ARIAL CHAMBER DEVI$0

(Tier3)


ASSESS FULL RANGEPEAK FLOW METER DEVI

$0(Tier

3)

RX/OTC; MO;NT

ASSESS LOW RANGEPEAK FLOW METER DEVI

$0(Tier

3)

RX/OTC; MO;NT

ASSESS PEAK FLOWMETER FULL RANGEDEVI

$0(Tier

3)

RX/OTC; MO;NT

ASSESS PEAK FLOWMETER LOW RANGEDEVI

$0(Tier

3)

RX/OTC; MO;NT

ASTHMA CHECK METER-ZONE SYSTEM DEVI

$0(Tier

3)

RX/OTC; MO;NT

ASTHMAMENTOR DEVI$0

(Tier3)

RX/OTC; MO;NT

BREATHERITECOLLAPSIBLEADULTSPACER W/MASK MISC

$0(Tier

3)


BREATHERITECOLLAPSIBLECHILDSPACER W/MASK MISC

$0(Tier

3)


BREATHERITECOLLAPSIBLEINFANTSPACER W/MASK MISC

$0(Tier

3)


Name of drug

Whatthe


level)


BREATHERITECOLLAPSIBLESMALLCHILD SPACER W/MASKMISC

$0(Tier

3)


BREATHERITECOLLAPSIBLESPACERW/ NEONATE MASK MISC

$0(Tier

3)


BREATHERITE MISC$0

(Tier3)


BREATHERITE RIGIDSPACERW/MASK MISC

$0(Tier

3)


BREATHERITE W/LARGEMASK MISC

$0(Tier

3)


BREATHERITEW/MEDIUM MASK MISC

$0(Tier

3)


BREATHERITE W/SMALLMASK MISC

$0(Tier

3)




138

Name of drug

Whatthe


level)


CLEVER CHOICE ANTI-STATICVALVEDHOLDINGCHAMBER/ADULT LARGEDEVI

$0(Tier

3)


CLEVER CHOICE ANTI-STATICVALVEDHOLDINGCHAMBER/MEDIUM DEVI

$0(Tier

3)


CLEVER CHOICE ANTI-STATICVALVEDHOLDINGCHAMBER/SMALL DEVI

$0(Tier

3)


COMPACT SPACECHAMBER/ANTI-STATICDEVI

$0(Tier

3)


COMPACT SPACECHAMBER/ANTI-STATIC/LARGE MASKDEVI

$0(Tier

3)


COMPACT SPACECHAMBER/ANTI-STATIC/MEDIUM MASKDEVI

$0(Tier

3)


COMPACT SPACECHAMBER/ANTI-STATIC/SMALL MASKDEVI

$0(Tier

3)


Name of drug

Whatthe


level)


E-Z SPACER DEVI$0

(Tier3)


E-Z SPACER THE BODYGUARDS PACK DEVI

$0(Tier

3)


EASIVENT MISC$0

(Tier3)


EASIVENT/MASK-LARGEMISC

$0(Tier

3)


EASIVENT/MASK-MEDIUM MISC

$0(Tier

3)


EASIVENT/MASK-SMALLMISC

$0(Tier

3)


FLEXICHAMBER DEVI$0

(Tier3)




139

Name of drug

Whatthe


level)


INSPIRACHAMBER/ANTI-STATICVALVED/MOUTHPIECEDEVI

$0(Tier

3)


INSPIRACHAMBER/LARGE DEVI

$0(Tier

3)


INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/MEDIUM DEVI

$0(Tier

3)


INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/SMALL DEVI

$0(Tier

3)


INSPIREASE DRUGDELIVERYSYSTEM MISC

$0(Tier

3)


LITEAIRE DEVI$0

(Tier3)


MICROCHAMBER MISC$0

(Tier3)


Name of drug

Whatthe


level)


MICROLIFE DIGITALPEAK FLOW METER DEVI

$0(Tier

3)

RX/OTC; MO;NT

MICROSPACER MISC$0

(Tier3)


MINI WRIGHT AFS PEAKFLOWMETER LOWRANGE DEVI

$0(Tier

3)

RX/OTC; MO;NT

MINI WRIGHT PEAKFLOW METER DEVI

$0(Tier

3)

RX/OTC; MO;NT

NESSI SPACER/LARGEMASK DEVI

$0(Tier

3)


NESSISPACER/MOUTHPIECEDEVI

$0(Tier

3)


NESSISPACER/SMALL/MEDMASK DEVI

$0(Tier

3)


OPTICHAMBERADVANTAGE MISC

$0(Tier

3)




140

Name of drug

Whatthe


level)


OPTICHAMBERADVANTAGE/LARGEMASK MISC

$0(Tier

3)


OPTICHAMBERADVANTAGE/MEDIUMFACE MASK MISC

$0(Tier

3)


OPTICHAMBERADVANTAGE/SMALLFACE MASK MISC

$0(Tier

3)


OPTICHAMBERDIAMOND DEVI

$0(Tier

3)


OPTICHAMBERDIAMOND MISC

$0(Tier

3)


OPTICHAMBERDIAMOND/LARGEFACEMASK DEVI

$0(Tier

3)


OPTICHAMBERDIAMOND/MEDIUM FACEMASK MISC

$0(Tier

3)


Name of drug

Whatthe


level)


OPTICHAMBERDIAMOND/SMALLFACEMASK MISC

$0(Tier

3)


OPTICHAMBER FACEMASK/LARGE MISC

$0(Tier

3)


OPTICHAMBER FACEMASK/MEDIUM MISC

$0(Tier

3)


OPTICHAMBER FACEMASK/SMALL MISC

$0(Tier

3)


OPTIHALER MDI DRUGDELIVERY SYSTEM DEVI

$0(Tier

3)


OPTIHALER MISC$0

(Tier3)


PEAK AIR PEAK FLOWMETERADULT/PEDIATRIC DEVI

$0(Tier

3)

RX/OTC; MO;NT

PEAK FLOW METER DEVI$0

(Tier3)

RX/OTC; MO;NT



141

Name of drug

Whatthe


level)


PERSONAL BEST FULLRANGE DEVI

$0(Tier

3)

RX/OTC; MO;NT

PERSONAL BEST LOWRANGE DEVI

$0(Tier

3)

RX/OTC; MO;NT

PIKO 1 ELECTRONICDEVI

$0(Tier

3)

RX/OTC; MO;NT

POCKET CHAMBER DEVI$0

(Tier3)


POCKET PEAK FLOWMETER DEVI

$0(Tier

3)

RX/OTC; MO;NT

POCKET SPACER DEVI$0

(Tier3)


POCKETPEAK PEAKFLOW METER LOWRANGE DEVI

$0(Tier

3)

RX/OTC; MO;NT

POCKETPEAK PEAKFLOWMETER/UNIVERSALRANGE 50-720 LPM DEVI

$0(Tier

3)

RX/OTC; MO;NT

POCKETPEAK PEAKFLOWMETER/UNIVERSALRANGE DEVI

$0(Tier

3)

RX/OTC; MO;NT

RITEFLO DEVI$0

(Tier3)


Name of drug

Whatthe


level)


TRUZONE PEAK FLOWMETER DEVI

$0(Tier

3)

RX/OTC; MO;NT

VALVED HOLDINGCHAMBER DEVI

$0(Tier

3)


VORTEX VALVEDHOLDING CHAMBERDEVI

$0(Tier

3)


WATCHHALER DEVI$0

(Tier3)


MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadachesMigraine ProductsD.H.E. 45 SOLN(DihydroergotamineMesylate)

NFMO

dihydroergotaminemesylate soln ij 1 mg/ml

$0-$2.95(Tier

1)

MO

ergotamine tartrate subl sl$0-

$2.95(Tier

1)

Serotonin AgonistsAMERGE TABS(Naratriptan HCl) NF QL(0.3 ea

daily); MOIMITREX SOLN SC 6MG/0.5ML (SumatriptanSuccinate)

NFLimit 8mls permonth;QL(0.27ml daily); MO



142

Name of drug

Whatthe


level)


IMITREX STATDOSEREFILL SOCT 4 MG/0.5ML(Sumatriptan Succinate)


IMITREX STATDOSEREFILL SOCT 6 MG/0.5ML(Sumatriptan Succinate)


IMITREX STATDOSESYSTEM SOAJ 4MG/0.5ML (SumatriptanSuccinate)

NF


IMITREX TABS OR 100MG (SumatriptanSuccinate)

NFQL(0.3 eadaily); MO

IMITREX TABS OR 25 MG(Sumatriptan Succinate) NF QL(0.9 ea

daily); MOIMITREX TABS OR 50 MG(Sumatriptan Succinate) NF QL(0.6 ea

daily); MOMAXALT TABS 10 MG(Rizatriptan Benzoate) NF QL(0.4 ea

daily); MOMAXALT TABS 5 MG(Rizatriptan Benzoate) NF QL(0.8 ea

daily); MOMAXALT-MLT TBDP 10MG (Rizatriptan Benzoate) NF QL(0.4 ea

daily); MOMAXALT-MLT TBDP 5 MG(Rizatriptan Benzoate) NF QL(0.8 ea

daily); MO

naratriptan hcl tabs$0-

$2.95(Tier

1)

QL(0.3 eadaily); MO

rizatriptan benzoate tabs10 mg

$0-$2.95(Tier

1)

QL(0.4 eadaily); MO

rizatriptan benzoate tabs 5mg

$0-$2.95(Tier

1)

QL(0.8 eadaily); MO

rizatriptan benzoate tbdp10 mg

$0-$2.95(Tier

1)

QL(0.4 eadaily); MO

Name of drug

Whatthe


level)


rizatriptan benzoate tbdp 5mg

$0-$2.95(Tier

1)

QL(0.8 eadaily); MO

sumatriptan succinate soajsc 4 mg/0.5ml

$0-$2.95(Tier

1)


sumatriptan succinate soajsc 6 mg/0.5ml

$0-$2.95(Tier

1)


sumatriptan succinate soctsc 4 mg/0.5ml

$0-$2.95(Tier

1)


sumatriptan succinate soctsc 6 mg/0.5ml

$0-$2.95(Tier

1)


sumatriptan succinate solnsc 6 mg/0.5ml

$0-$2.95(Tier

1)


sumatriptan succinate tabsor 100 mg

$0-$2.95(Tier

1)

QL(0.3 eadaily); MO


$0-$2.95(Tier

1)

QL(0.9 eadaily); MO


$0-$2.95(Tier

1)

QL(0.6 eadaily); MO

zolmitriptan tabs 2.5 mg$0-

$2.95(Tier

1)

SL(4 ea daily);MO



143

Name of drug

Whatthe


level)


zolmitriptan tabs 5 mg$0-

$2.95(Tier

1)

SL(2 ea daily);MO

zolmitriptan tbdp 2.5 mg$0-

$2.95(Tier

1)

SL(4 ea daily);MO

zolmitriptan tbdp 5 mg$0-

$2.95(Tier

1)

SL(2 ea daily);MO

ZOMIG TABS OR 2.5 MG(Zolmitriptan) NF SL(4 ea daily);

MOZOMIG TABS OR 5 MG(Zolmitriptan) NF SL(2 ea daily);

MOZOMIG ZMT TBDP 2.5 MG(Zolmitriptan) NF SL(4 ea daily);

MOZOMIG ZMT TBDP 5 MG(Zolmitriptan) NF SL(2 ea daily);

MO

MINERALS & ELECTROLYTES

Bicarbonates

sodium bicarbonate soln iv8.4 %

$0-$2.95(Tier

1)

MO

Calcium

CALCI-CHEW CHEW$0

(Tier3)

NT

CALCI-MIX CAPS$0

(Tier3)

MO; NT

CALCIONATE SYRP$0

(Tier3)

MO; NT

CALCIUM & MAGNESIUMTABS

$0(Tier

3)

NT

Name of drug

Whatthe


level)


calcium & phosphorus w/vitamin d tabs

$0(Tier

3)

NT

calcium carbonate tabs or1250 mg, 1500 mg, 500mg, 600 mg, 600mg

$0(Tier

3)

MO; NT

calcium carbonate-cholecalciferol caps600mg-500unit

$0(Tier

3)

MO; NT

calcium carbonate-cholecalciferol chew500mg-100unit

$0(Tier

3)

MO; NT

calcium carbonate-cholecalciferol tabs 500mg-200unit

$0(Tier

3)

MO; NT

calcium carbonate-vitamind tabs 125unit-250mg,125unit-500mg, 250mg-125unit, 500mg-125unit

$0(Tier

3)

NT

calcium carbonate-vitamind tabs 200unit-500mg,500mg-200unit, 500mg-500mg-200unit-200unit

$0(Tier

3)

MO; NT

CALCIUM CITRATEMALATE/VITAMIN D TABS

$0(Tier

3)

NT

calcium citrate tabs or 200mg, 950 mg

$0(Tier

3)

MO; NT

CALCIUM CITRATE TABSOR 250 MG

$0(Tier

3)

MO; NT

calcium citrate-vitamin dtabs 250mg-200unit

$0(Tier

3)

NT

calcium citrate-vitamin dtabs 315mg-200unit

$0(Tier

3)

MO; NT

calcium gluconate soln iv10 %

$0(Tier

3)

MO; NT



144

Name of drug

Whatthe


level)


CALCIUM GLUCONATETABS OR 500 MG

$0(Tier

3)

NT

CALCIUM LACTATE TABS648 MG

$0(Tier

3)

MO; NT

CALCIUM LACTATE TABS750 MG

$0(Tier

3)

NT

calcium tabs 600 mg$0

(Tier3)

NT

calcium w/ magnesiumtabs 500mg-250mg

$0(Tier

3)

NT

CALCIUM/VITAMIN DCAPS

$0(Tier

3)

NT

CITRACAL/VITAMIN DTABS (Calcium Citrate-Vitamin D)

NFNT

CORAL CALCIUM TABSOR 500 MG

$0(Tier

3)

NT

EQL CALCIUM/VITAMIN DCAPS

$0(Tier

3)

NT

GNP VITAMIN D-400TABS

$0(Tier

3)

NT

MAGNEBIND 200 TABS$0

(Tier3)

NT

oyster shell tabs$0

(Tier3)

MO; NT

RA OYSTER SHELLCALCIUM/VITAMIN DTABS 250MG-125UNIT

$0(Tier

3)

NT

RISACAL-D TABS$0

(Tier3)

NT

Name of drug

Whatthe


level)


Chloride

ammonium chloride soln iv$0-

$2.95(Tier

1)

MO

Electrolyte MixturesCERALYTE 70 SOLN60MEQ/L-70MEQ/L-20MEQ/L-30MEQ/L

$0(Tier

3)

MO; NT

CERASPORT EX1 SOLN$0

(Tier3)

MO; NT

CERASPORT SOLN4MEQ/L-18MEQ/L-20MEQ/L-6MEQ/L

$0(Tier

3)

MO; NT

dextrose in lactated ringerssoln

$0-$2.95(Tier

1)

dextrose w/ sodiumchloride soln 0.45%-2.5%,0.45%-5%

$0-$2.95(Tier

1)

dextrose w/ sodiumchloride soln 0.9%-5%

$0-$2.95(Tier

1)

MO

ENFAMIL ENFALYTESOLN

$0(Tier

3)

MO; NT

lactated ringer's soln$0-

$2.95(Tier

1)

MEDI-LYTE TABS$0

(Tier3)

NT



145

Name of drug

Whatthe


level)


oral electrolytes soln18.8meq/l-42.4meq/l-33.2meq/l-4.8gm/l-18.8gm/l, 20meq/1000ml-45meq/1000ml-35meq/1000ml-25gm/1000ml, 20meq/l-20meq/l-45meq/l-45meq/l-35meq/l-25gm/l, 20meq/l-20meq/l-45meq/l-45meq/l-35meq/l-35meq/l-30meq/l-30meq/l-25gm/l-25gm/l,20meq/l-20meq/l-45meq/l-45meq/l-35meq/l-35meq/l-30meq/l-30meq/l-5gm/l-20gm/l, 20meq/l-45meq/l-35meq/l-25gm/l, 20meq/l-45meq/l-35meq/l-30meq/l-25gm/l, 20meq/l-45meq/l-35meq/l-30meq/l-5gm/l-20gm/l, 20meq/l-45meq/l-35meq/l-30meq/l-5gm/l-25gm/l, 20meq/l-45meq/l-35meq/l-5gm/l-20gm/l,20meq/l-45meq/l-35meq/l-7.8mg/l-25gm, 20meq/l-45meq/l-35meq/l-7.8mg/l-25gm/l, 20meq/l-45meq/l-35meq/l-7.8mg/l-25meq/l,20meq/l-45meq/l-45meq/l-35meq/l-5gm/l-20gm/l,35meq/l-45meq/l-20meq/l-25gm/l, 35meq/l-45meq/l-20meq/l-30meq/l-25gm/l,35meq/l-45meq/l-20meq/l-30meq/l-30gm/l, 35meq/l-45meq/l-20meq/l-30meq/l-5gm/l-20gm/l, 35meq/l-45meq/l-20meq/l-5gm/l-20gm/l, 35meq/l-45meq/l-20meq/l-7.5mg/l-25meq/l,35meq/l-45meq/l-20meq/l-7.8mg/l-25gm/l, 35meq/l-7.8mg/l-45meq/l-20meq/l-25gm/l, 65meq/l-75meq/l-20meq/l-30meq/l-2

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


oral electrolytes tabs287mg-180mg-15mg

$0(Tier

3)

NT

parenteral electrolytes conc$0-

$2.95(Tier

1)

B/D

parenteral electrolytes soln$0-

$2.95(Tier

1)

B/D

PEDIALYTE FREEZERPOPS SOLN (OralElectrolytes)

NFMO; NT

PEDIALYTE SOLN20MEQ/L-45MEQ/L-35MEQ/L-30MEQ/L-25GM/L, 20MEQ/L-45MEQ/L-35MEQ/L-5GM/L-20GM/L (OralElectrolytes)

NF

MO; NT

potassium chloride indextrose & sodium chloridesoln 0.45%-20meq/l-5%

$0-$2.95(Tier

1)

THERMOTABS TABS$0

(Tier3)

NT

Fluoride

FLORICAL CAPS$0

(Tier3)

MO; NT

MONOCAL TABS$0

(Tier3)

MO; NT

Iodine Products

IODINE STRONG SOLN$0

(Tier3)

MO; NT

POTASSIUM IODIDETABS OR

$0(Tier

3)

NT



146

Name of drug

Whatthe


level)


Magnesium

MAG-TAB SR TBCR$0

(Tier3)

MO; NT

MAGINEX DS PACK$0

(Tier3)

NT

MAGINEX TBEC$0

(Tier3)

NT

MAGNESIUM CHLORIDEHEXAHYDRATE CRYS

$0(Tier

3)

NT

magnesium chloride tbcr or535 mg, 64 mg

$0(Tier

3)

MO; NT

MAGNESIUMELEMENTAL TABS 30 MG

$0(Tier

3)

NT

MAGNESIUMGLUCONATE TABS OR250 MG, 500 MG, 550 MG

$0(Tier

3)

NT

magnesium sulfate soln ij50 %

$0-$2.95(Tier

1)

MO

magnesium tabs 250 mg,250mg

$0(Tier

3)

NT

Phosphate

PHOS-NAK POWDERCONCENTRATE PACK

$0(Tier

3)

MO; NT

PotassiumK-TAB TBCR 10 MEQ(Potassium Chloride) NF MO

K-TAB TBCR 8 MEQ$0-

$7.40(Tier

2)

MO

Name of drug

Whatthe


level)


MICRO-K CPCR(Potassium Chloride) NF MO

potassium chloride cpcr or10 meq, 8 meq

$0-$2.95(Tier

1)

MO

POTASSIUM CHLORIDEER TBCR

$0-$2.95(Tier

1)

MO

potassium chloridemicroencapsulated crystalscr tbcr

$0-$2.95(Tier

1)

MO

potassium chloride soln iv 2meq/ml

$0-$2.95(Tier

1)

MO

potassium chloride soln or10 %, 20 %

$0-$2.95(Tier

1)

MO

potassium chloride tbcr or10 meq, 20 meq, 8 meq

$0-$2.95(Tier

1)

MO

Sodium

sodium chloride soln iv0.45 %

$0-$2.95(Tier

1)

sodium chloride soln iv 0.9%

$0-$2.95(Tier

1)

MO

Trace Minerals

chromium picolinate capsor 200 mcg

$0(Tier

3)

NT

chromium picolinate tabs or200 mcg

$0(Tier

3)

MO; NT



147

Name of drug

Whatthe


level)


chromium tabs 200 mcg$0

(Tier3)

NT

MULTITRACE-4 SOLN$0

(Tier3)

MO; NT

SELENIUM SOLN IV 40MCG/ML

$0(Tier

3)

MO; NT

selenium tabs or 100 mcg$0

(Tier3)

NT

selenium tabs or 50 mcg$0

(Tier3)

MO; NT

trace minerals (cr-cu-mn-zn) soln

$0(Tier

3)

NT

Zinc

ORAZINC TABS$0

(Tier3)

MO; NT

ZINC 15 TABS$0

(Tier3)

NT

zinc gluconate tabs or 50mg

$0(Tier

3)

MO; NT

ZINC LOZG MT 10 MG$0

(Tier3)

NT

ZINC SULFATE SOLN IV 1MG/ML, 5 MG/ML

$0(Tier

3)

MO; NT

zinc tabs or 25 mg$0

(Tier3)

NT

zinc tabs or 50 mg$0

(Tier3)

MO; NT

MOUTH/THROAT/DENTAL AGENTS

Name of drug

Whatthe


level)


Anesthetics Topical OralBABY ANBESOL GEL(Benzocaine (Dental)) NF NT

BABY ORAJEL GEL(Benzocaine (Dental)) NF NT

BABY ORAJEL LIQD$0

(Tier3)

NT

benzocaine (dental) gel 7.5%

$0(Tier

3)

NT

benzocaine (dental) pste20 %

$0(Tier

3)

MO; NT

benzocaine (dental) soln 20%

$0(Tier

3)

RX/OTC; MO;NT

HURRICAINE ONE SOLN(Benzocaine (Dental)) NF RX/OTC; MO;

NTHURRICAINE SOLN(Benzocaine (Dental)) NF RX/OTC; MO;

NT

lidocaine hcl (mouth-throat)soln

$0-$2.95(Tier

1)

MO

ORABASE PSTE(Benzocaine (Dental)) NF MO; NT

ZILACTIN GEL$0

(Tier3)

MO; NT

Anti-infectives - Throat

carbamide peroxide soln mt$0

(Tier3)

MO; NT

clotrimazole lozg mt$0-

$2.95(Tier

1)

MO



148

Name of drug

Whatthe


level)


clotrimazole troc mt$0-

$2.95(Tier

1)

MO

hydrogen peroxide (mouth-throat) soln

$0(Tier

3)

NT

hydrogen peroxide-benzylalcohol soln

$0(Tier

3)

MO; NT

nystatin (mouth-throat)susp

$0-$2.95(Tier

1)

MO

PEROXYL SOLN EX 1.5%-6% (Hydrogen Peroxide-Benzyl Alcohol)

NFMO; NT

ULCEREASE SOLN 1.5%-1.5%-0.6%-1.5%

$0(Tier

3)

MO; NT

Antiseptics - Mouth/Throat

chlorhexidine gluconate(mouth-throat) soln

$0-$2.95(Tier

1)

MO

PERIDEX SOLN(Chlorhexidine Gluconate(Mouth-Throat))

NFMO

Steroids - Mouth/Throat

triamcinolone acetonide(mouth) pste

$0-$2.95(Tier

1)

MO

Throat Products - Misc.

AQUORAL AERS$0

(Tier3)

MO; NT

cevimeline hcl caps$0-

$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


EVOXAC CAPS(Cevimeline HCl) NF MO

pilocarpine hcl (oral) tabs$0-

$2.95(Tier

1)

MO

SALAGEN TABS(Pilocarpine HCl (Oral)) NF MO

MULTIVITAMINS

B-Complex Vitaminsb-complex vitamins caps or60mg-60mg-3mg-5mg-20mg-3mg-1mcg-0.5mg,60mg-60mg-5mg-20mg-3mg-1mcg-3mg-0.5mg,70mg-100mg-1mg-10mg-2mg-1.5mg-100mcg

$0(Tier

3)

MO; NT

b-complex vitamins inj ij2mg/ml-100mg/ml-2mg/ml-100mg/ml-2mg/ml

$0(Tier

3)

MO; NT

b-complex vitamins soln ij2mg/ml-2%-100mg/ml-2mg/ml-100mg/ml-2mg/ml

$0(Tier

3)

MO; NT

b-complex vitamins tabs or0.1mg-20mg-2mg-5mcg-3mg-1mg, 100mg-50mg-40mg-10mg-20mg-5mg-4.6mg-1mcg-5mg-1mg,10mg-10mg-2mg-1.5mg-0.2mg, 10mg-14mg-25mcg-7mg-4.5mg, 15mg-2mg-5mg-2mcg-2mg-2mg,30mg-50mg-50mg-50mg-50mg-50mg-50mcg-50mg-100mcg-50mcg-50mg,3mg-10mg-20mg-3mg-6mcg-2mg, 3mg-20mg-3mg-10mg-6mcg-2mg,3mg-3mg-20mg-20mg-3mg-3mg-10mg-10mg-6mcg-6mcg-2mg-2mg,83mg-3mg-20mg-2mg-5mcg-1mg

$0(Tier

3)

MO; NT



149

Name of drug

Whatthe


level)


B-Complex w/ Cb complex w/ c caps10.2mg-10mg-15mg-50mg-5mg-300mg, 10mg-50mg-10.2mg-15mg-5mg-300mg,10mg-50mg-10mg-15mg-5mg-300mg, 15mg-10mg-50mg-10mg-5mg-300mg

$0(Tier

3)

NT

b complex w/ c tabs10.2mg-10.2mg-10mg-10mg-50mg-50mg-15mg-15mg-5mg-5mg-300mg-300mg, 100mg-100mg-25mg-20mg-6mg-15mcg-100mg-5mcg-2mg-150mg,100mg-100mg-5.5mg-20mg-15mcg-25mg-400mcg-5mcg-2mg-150mg, 100mg-10mg-20mg-10mcg-15mg-5mg-500mg, 100mg-20mg-5.5mg-15mcg-2mg-25mg-150mg-400mcg-5mcg-150mg, 10mg-10mg-15mg-50mg-5mg-300mg, 15mg-10.2mg-10mg-50mg-5mg-300mg, 15mg-10mg-50mg-10.2mg-5mg-300mg,15mg-10mg-50mg-10.2mg-6mcg-400mcg-5mg-300mg, 15mg-10mg-50mg-10mg-5mg-300mg, 15mg-150mg-10mg-50mg-10.2mg-5mg-300mg,15mg-20mg-50mg-10mg-10mcg-5mg-300mg, 15mg-50mg-10.2mg-10mg-5mg-300mg, 50mg-10.2mg-10mg-15mg-5mg-300mg,50mg-10mg-10mg-15mg-5mg-300mg, 50mg-15mg-10mg-10.2mg-5mg-300mg

$0(Tier

3)

NT

B-Complex w/ Folic Acid

Name of drug

Whatthe


level)


B-100 COMPLEX TABS$0

(Tier3)

MO; NT

b-complex w/ c & folic acidtabs 10mg-20mg-1.5mg-1mg-1.5mg-5mg-300mcg-50mg-60mg, 20mg-1.5mg-10mg-1mg-1.5mg-5mg-300mcg-50mg-60mg

$0(Tier

3)

MO; NT

b-complex w/ folic acid tabs1.5mg-20mg-1.7mg-6mcg-400mcg-2mg, 1.7mg-10mg-6mcg-1.2mg-20mg-0.4mg-2mg, 100mg-100mg-100mg-100mcg-400mcg-100mg, 100mg-100mg-100mg-100mg-10mcg-400mcg-100mcg-100mg, 10mg-10mg-50mg-10mg-10mg-10mg-10mcg-10mg-400mcg-10mcg-10mg, 10mg-20mg-1.7mg-6mcg-1.5mg-400mcg-2mg,15mg-100mg-200mg-17mg-60mcg-400mcg-20mg, 30mg-20mg-50mg-30mg-10mg-10mcg-400mcg-8mg, 40mcg-1mg-6mg-5mcg-3mg-2mcg-19mcg, 50mg-50mg-50mg-50mcg-50mg-400mcg-50mcg-50mg

$0(Tier

3)

MO; NT

b-complex w/ folic acid tbcr100mg-100mg-100mg-100mg-100mcg-400mcg-100mcg-100mg, 125mg-125mg-125mg-125mg-125mcg-125mg-125mg-400mcg-125mcg-125mg,50mg-50mg-50mg-50mg-50mcg-0.4mg-50mcg-50mg, 50mg-50mg-50mg-50mg-50mcg-100mcg-50mcg-50mg

$0(Tier

3)

NT



150

Name of drug

Whatthe


level)


NERVO B-12 SL LOZG$0

(Tier3)

NT

Ped MV w/ Fluoride

Name of drug

Whatthe


level)


pediatric multivitamins w/flchew 0.25mg-15unit-1.2mg-2500unit-4.5mcg-400unit-1.05mg-13.5mg-1.05mg-0.3mg-60mg,0.25mg-15unit-400unit-2500unit-1.2mg-4.5mcg-13.5mg-1.05mg-0.3mg-1.05mg-60mg, 0.5mg-15unit-1.2mg-2500unit-4.5mcg-400unit-1.05mg-13.5mg-1.05mg-0.3mg-60mg, 0.5mg-15unit-400unit-2500unit-1.2mg-4.5mcg-13.5mg-1.05mg-0.3mg-1.05mg-60mg,0.5mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-15unit-1.05mg-60mg, 15unit-0.25mg-1.05mg-13.5mg-1.2mg-2500unit-4.5mcg-400unit-0.3mg-1.05mg-60mg, 15unit-0.25mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-1.05mg-60mg,15unit-0.5mg-1.05mg-13.5mg-1.2mg-2500unit-4.5mcg-400unit-0.3mg-1.05mg-60mg, 15unit-0.5mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-1.05mg-60mg, 15unit-1mg-1.05mg-13.5mg-1.2mg-2500unit-4.5mcg-400unit-0.3mg-1.05mg-60mg, 15unit-1mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-1.05mg-60mg, 1mg-15unit-1.2mg-2500unit-4.5mcg-400unit-1.05mg-13.5mg-1.05mg-0.3mg-60mg, 1mg-15unit-400unit-2500unit-1.2mg-4.5mcg-

$0(Tier

3)

MO; NT



151

Name of drug

Whatthe


level)


13.5mg-1.05mg-0.3mg-1.05mg-60mgpediatric multivitamins w/flsoln 0.5mg/ml-5unit/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml,0.5mg/ml-5unit/ml-8mg/ml-0.6mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml, 5unit/ml-0.5mg/ml-8mg/ml-0.6mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml

$0(Tier

3)

MO; NT

pediatric vitamins acd w/fluoride soln

$0(Tier

3)

MO; NT

POLY-VI-FLOR CHEW$0

(Tier3)

MO; NT

QUFLORA PEDIATRICCHEW 108MCG-1MG-15UNIT-0.25MG-15MG-1200UNIT-5MG-1.3MG-4MCG-400UNIT-1.2MG-100MCG-1.5MG-60MG,108MCG-1MG-15UNIT-0.5MG-15MG-1200UNIT-5MG-1.3MG-4MCG-400UNIT-1.2MG-100MCG-1.5MG-60MG, 108MCG-1MG-15UNIT-1MG-15MG-1200UNIT-5MG-1.3MG-4MCG-400UNIT-1.2MG-100MCG-1.5MG-60MG

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


QUFLORA PEDIATRICSOLN 150MCG/ML-1MG/ML-0.5MG/ML-12MG/ML-1100UNIT/ML-2MG/ML-1MG/ML-3MCG/ML-400UNIT/ML-1MG/ML-81MCG/ML-12UNIT/ML-1MG/ML-45MG/ML

$0(Tier

3)

MO; NT

Ped MV w/ Iron

MULTI-DELYN/IRON LIQD$0

(Tier3)

NT

pediatric multiple vitaminsw/ iron liqd 1500unit/ml-10mg/ml-5unit/ml-400unit/ml-8mg/ml-0.6mg/ml-0.5mg/ml-0.4mg/ml-35mg/ml

$0(Tier

3)

MO; NT

pediatric multiple vitaminsw/ iron soln 0.6mg/ml-10mg/ml-5unit/ml-8mg/ml-1500unit/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml

$0(Tier

3)

MO; NT

Ped Multi Vitamins w/Fl & FE

ped multivitamins w/fl &iron soln

$0(Tier

3)

MO; NT

TRI-VIT/FLUORIDE/IRONSOLN

$0(Tier

3)

MO; NT

Pediatric Multiple Vitamins

EQL CHILDRENSMULTIVITAMINS CHEW

$0(Tier

3)

NT

pediatric multiple vitamin w/c soln

$0(Tier

3)

MO; NT

pediatric multiple vitamin w/extra c & fa chew

$0(Tier

3)

NT



152

Name of drug

Whatthe


level)


Pediatric Vitamins

pediatric vitamins adc soln$0

(Tier3)

MO; NT

Prenatal Vitamins

MULTI PRENATAL TABS$0

(Tier3)

MO; NT

ONE A DAY WOMENSPRENATAL/DHA MISC

$0(Tier

3)

NT

PRENATAL FORMULACAPS 35MG-30UNIT-4000UNIT-200MG-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG

$0(Tier

3)

NT

PRENATAL LOW IRONTABS

$0(Tier

3)

MO; NT

PRENATAL ONE DAILYTABS

$0(Tier

3)

MO; NT

PRENATAL TABS 11UNIT-263MG-25MG-1.5MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-0.8MG-2.6MG-100MG

$0(Tier

3)

MO; NT

PRENATAL VITAMINTABS

$0(Tier

3)

MO; NT

RIGHT STEP PRENATALTABS

$0(Tier

3)

MO; NT

TRINATAL RX 1 TABS$0-

$7.40(Tier

2)

MO

Name of drug

Whatthe


level)


VINATE ONE TABS$0-

$7.40(Tier

2)

MO

Specialty Vitamins Products

ULTRA MAN TBCR$0

(Tier3)

NT

ULTRA WOMAN TBCR$0

(Tier3)

NT

Vitamin Mixturescod liver oil caps 10 minim,110mg-2664unit-1000mg-100mg-200unit, 1250unit-130unit, 1250unit-133.33unit, 1250unit-133unit, 1250unit-135unit,200unit-4000unit, 20mg-35mg-1250unit-45mg-133.333unit, 34mg-1250unit-415mg-32mg-135unit, 50mg-110mg-250unit-110mg-100unit-10unit, 52mg-2500unit-600mg-52mg-270unit,530mg-1250unit-130unit,90mg-37mg-415mg-36mg-1250unit-135unit

$0(Tier

3)

NT

COD LIVER OIL FOR KIDSOIL

$0(Tier

3)

RX/OTC; NT

COD LIVER OIL OIL4000UNIT/5ML-400UNIT/5ML,5000UNIT/5ML-500UNIT/5ML

$0(Tier

3)

RX/OTC; NT

CVS COD LIVER OIL OIL$0

(Tier3)

RX/OTC; NT

NORWEGIAN COD LIVEROIL OIL

$0(Tier

3)

RX/OTC; NT



153

Name of drug

Whatthe


level)


QC COD LIVER OIL OIL$0

(Tier3)

RX/OTC; NT

RA COD LIVER OIL OIL$0

(Tier3)

RX/OTC; NT

vitamins a & d caps10000unit-400unit,10000unit-5000unit,1250unit-133unit, 1250unit-135unit, 5000unit-400unit,700unit-400unit, 8000unit-400unit

$0(Tier

3)

MO; NT

Vitamins w/ Lipotropics

ACTIFLOVIT EARHEALTH TABS

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


vitamins w/ lipotropics tabs10000unit-10mg-18mg-100unit-225mcg-10mg-150mg-100mg-30mg-10mg-25mg-25mg-50mg-50mg-10mg-50mg-50mg-200mcg-400unit-50mg-400mcg-50mg-250mg,100mg-100mg-100mg-100mcg-100mg-100mcg-100mcg-100mg, 100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-100mcg-100mcg-100mg, 100mg-100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mcg-100mcg-100mg,100mg-100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-200mcg-100mcg-100mg,100mg-111.3mg-0.33mg-1.7mg-1.7mcg-0.33mg-111.3mg-3.3mg-0.33mg-100mg, 100mg-43.33mg-111.3mg-0.33mg-1.7mg-1.7mcg-0.33mg-111.3mg-3.3mg-0.33mg-100mg,200mg-29mg-0.333mg-1.666mg-3.33mg-111.333mg-111.333mg-1mg-1.666mcg-0.333mg-100mg, 200mg-29mg-0.33mg-1.67mg-3.33mg-111.33mg-111.33mg-1mg-1.67mcg-0.33mg-100mg,200mg-29mg-0.34mg-1.67mg-3.34mg-111mg-111mg-1mg-1.67mcg-0.34mg-100mg, 20mg-50mg-30mg-10mg-10mcg-30mg-8mg, 25mg-40mg-20mg-3.4mg-20mg-12mcg-3mg-20mg-400mcg-30mcg-4mg-150mg, 25mg-

$0(Tier

3)

MO; NT



154

Name of drug

Whatthe


level)


40mg-20mg-3.4mg-20mg-12mcg-3mg-20mg-400mg-30mcg-4mg, 266.667mg-29mg-0.333mg-1.667mg-3.333mg-111.333mg-111.333mg-1mg-1.667mcg-0.33MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat SpasmsCentral Muscle Relaxants

baclofen tabs or 10 mg$0-

$2.95(Tier

1)

SL(8 ea daily);MO

baclofen tabs or 20 mg$0-

$2.95(Tier

1)

SL(4 ea daily);MO

carisoprodol tabs or 350mg

$0-$2.95(Tier

1)

AL; MO

chlorzoxazone tabs$0-

$2.95(Tier

1)

AL; MO

cyclobenzaprine hcl tabs or10 mg, 5 mg

$0-$2.95(Tier

1)

AL; MO

metaxalone tabs$0-

$2.95(Tier

1)

AL; MO

methocarbamol tabs or 500mg, 750 mg

$0-$2.95(Tier

1)

AL; MO

PARAFON FORTE DSCTABS (Chlorzoxazone) NF AL; MO

ROBAXIN TABS OR 500MG (Methocarbamol) NF AL; MO

Name of drug

Whatthe


level)


ROBAXIN-750 TABS(Methocarbamol) NF AL; MO

SKELAXIN TABS(Metaxalone) NF AL; MO

SOMA TABS 350 MG(Carisoprodol) NF AL; MO

tizanidine hcl caps or 2 mg$0-

$2.95(Tier

1)

SL(18 ea daily);MO


$2.95(Tier

1)

SL(9 ea daily);MO


$2.95(Tier

1)

SL(6 ea daily);MO

tizanidine hcl tabs or 2 mg$0-

$2.95(Tier

1)

SL(18 ea daily);MO

tizanidine hcl tabs or 4 mg$0-

$2.95(Tier

1)

SL(9 ea daily);MO

ZANAFLEX CAPS 2 MG(Tizanidine HCl) NF SL(18 ea daily);

MOZANAFLEX CAPS 4 MG(Tizanidine HCl) NF SL(9 ea daily);

MOZANAFLEX CAPS 6 MG(Tizanidine HCl) NF SL(6 ea daily);

MOZANAFLEX TABS 4 MG(Tizanidine HCl) NF SL(9 ea daily);

MODirect Muscle RelaxantsDANTRIUM CAPS(Dantrolene Sodium) NF MO

dantrolene sodium caps or100 mg, 25 mg, 50 mg

$0-$2.95(Tier

1)

MO



155

Name of drug

Whatthe


level)


NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or SinusNasal Agents - Misc.

AYR NASAL DROPSSOLN

$0(Tier

3)

NT

ENTSOL HYPERTONICNASAL IRRIGATION MISTSOLN

$0(Tier

3)

NT

ENTSOL NASAL SPRAYSOLN

$0(Tier

3)

NT

ENTSOL NASAL WASHSOLN

$0(Tier

3)

NT

GELONASAL SOLN$0

(Tier3)

MO; NT

OCEAN NASAL SPRAYSOLN (Saline) NF MO; NT

PONARIS SOLN$0

(Tier3)

MO; NT

saline gel na$0

(Tier3)

MO; NT

saline soln na 0.65 %,0.65%, 0.65%-0.002%

$0(Tier

3)

MO; NT

SALTAIRE SOLN$0

(Tier3)

NT

Nasal Antiallergy

azelastine hcl soln 0.1 %$0-

$2.95(Tier

1)

MO

olopatadine hcl (nasal) soln$0-

$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


PATANASE SOLN(Olopatadine HCl (Nasal)) NF MO

Nasal AnticholinergicsATROVENT SOLN(Ipratropium Bromide(Nasal))

NFMO

ipratropium bromide (nasal)soln

$0-$2.95(Tier

1)

MO

Nasal Steroids

budesonide (nasal) susp$0-

$2.95(Tier

1)

RX/OTC; MO

flunisolide (nasal) soln$0-

$2.95(Tier

1)

MO

fluticasone propionate(nasal) susp

$0-$2.95(Tier

1)

RX/OTC; MO

RHINOCORT AQUA SUSP(Budesonide (Nasal)) NF RX/OTC; MO

triamcinolone acetonide(nasal) aero

$0-$2.95(Tier

1)

RX/OTC; MO

Sympathomimetic Decongestants

BENZEDREX INHALERINHA

$0(Tier

3)

NT

NASAL DECONGESTANTLIQD

$0(Tier

3)

MO; NT

NASAL DECONGESTANTSYRP

$0(Tier

3)

NT



156

Name of drug

Whatthe


level)


NEO-SYNEPHRINE COLD& SINUS MILD SOLN(Phenylephrine HCl)

NFMO; NT

NEO-SYNEPHRINE COLD& SINUS REGULAR SOLN

$0(Tier

3)

MO; NT

NEO-SYNEPHRINE SOLN0.25 % (PhenylephrineHCl)

NFMO; NT

NEO-SYNEPHRINE SOLN0.5 %

$0(Tier

3)

MO; NT

phenylephrine hcl soln na0.25 %

$0(Tier

3)

MO; NT

pseudoephedrine hcl liqdor 15 mg/5ml

$0(Tier

3)

MO; NT

pseudoephedrine hcl tabsor 30 mg, 60 mg

$0(Tier

3)

MO; NT

SUDAFED CHILDRENSLIQD (PseudoephedrineHCl)

NFMO; NT

SUDAFED CONGESTIONTABS (PseudoephedrineHCl)

NFMO; NT

SUDAFED NASALDECONGESTANTMAXIMUM STRENGTHTABS (PseudoephedrineHCl)

NF

MO; NT

SUDAFED PECHILDRENS NASALDECONGESTANT SOLN

$0(Tier

3)

NT

SUDAFED TABS(Pseudoephedrine HCl) NF MO; NT

NEUROMUSCULAR AGENTS - Drugs toRelax/Paralyze MusclesALS AgentsRILUTEK TABS (Riluzole) NF MO

Name of drug

Whatthe


level)


riluzole tabs$0-

$2.95(Tier

1)

MO

Neuromuscular Blocking Agent - Neurotoxins

BOTOX SOLR$0-

$7.40(Tier

2)

PA

XEOMIN SOLR$0-

$7.40(Tier

2)

PA

NUTRIENTS

Carbohydrates

dextrose soln iv 10 %$0-

$2.95(Tier

1)

B/D

dextrose soln iv 5 %$0-

$2.95(Tier

1)

MO; B/D

GLUCOSE NURSETTESOLN (Glucose) NF NT

glucose soln 5 %$0

(Tier3)

NT

POLYCOSE LIQD$0

(Tier3)

NT

Lipids

fat emulsion emul 20gm/100ml

$0-$2.95(Tier

1)

B/D

MCT OIL OIL$0

(Tier3)

NT



157

Name of drug

Whatthe


level)


MICROLIPID EMUL$0

(Tier3)

MO; NT

Lipotropics

INOSITOL TABS OR 500MG

$0(Tier

3)

MO; NT

lecithin caps or$0

(Tier3)

MO; NT

LECITHINCONCENTRATE CAPS

$0(Tier

3)

NT

Misc. Nutritional Substances

docosahexaenoic acidcaps 200 mg

$0(Tier

3)

NT

EXPECTA LIPIL CAPS(Docosahexaenoic Acid) NF NT

omega-3 fatty acids caps180mg-120mg, 300mg,300mg-160mg-1000mg-100mg-5unit, 300mg-772.5mg-90mg-180mg

$0(Tier

3)

NT

omega-3 fatty acids caps180mg-500mg-120mg,27mg-244mg-500mg-89mg, 300mg-1000mg-200mg, 300mg-200mg,500 mg, 500mg, 500mg-270mg-135mg, 500mg-300mg-1000mg-200mg-1unit, 500mg-320mg-130mg, 90mg-500mg-60mg

$0(Tier

3)

MO; NT

Proteins

ADD-INS COMPLETEPACK

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


amino acid infusion 15%$0-

$2.95(Tier

1)

B/D

amino acids caps 130mg-10mg-130mg-130mg

$0(Tier

3)

RX/OTC; NT



158

Name of drug

Whatthe


level)


amino acids tabs 100mg-6.15mg-2.1mg-0.85mg-1.95mg-0.55mg-2.3mg-1.95mg-0.75mg-1.15mg-0.6mg-3.65mg-0.65mg-3.25mg-3.8mg-1.95mg-1.7mg-0.7mg-1.05mg,115.333mg-54.667mg-21mg-33.333mg-33.333mg-46.667mg-14.167mg-46.667mg-40mg-53.333mg-18.167mg-41mg-66.667mg-40mg-30.667mg-17.333mg-14mg, 115.3mg-54.7mg-21mg-33.3mg-13.3mg-33.3mg-63.3mg-14.2mg-46.7mg-40mg-53.3mg-18.2mg-41mg-66.7mg-40mg-30.7mg-17.3mg-14mg, 1200mg-100mg,18.33mg-200mg-33.33mg-50mg-23.16mg-58.33mg-18.33mg-75mg-108.33mg,200mg-33.33mg-50mg-23.16mg-18.33mg-58.33mg-18.33mg-75mg-108.33mg, 35mg-29.5mg-24.667mg-4.833mg-17.667mg-24.667mg-12.5mg-24mg-19mg-36mg-17.5mg-4.667mg-75mg-15mg, 74mg-50mg-0.7mg-77mg-1.4mg-72mg-64mg-27mg-54mg-70mg-41mg-17mg-109mg-7mg-27mg-68mg-47mg-41mg-64mg,74mg-5mg-0.7mg-77mg-1.4mg-72mg-64mg-22mg-54mg-7mg-41mg-17mg-109mg-97mg-27mg-68mg-47mg-41mg-64mg

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


amino acids-proteinhydrolysate liqd

$0(Tier

3)

MO; NT

AMINOSYN II 15% (Useamino acid infusion) NF B/D

ARGIMENT AT PACK$0

(Tier3)

MO; NT

ARGIMENT PACK$0

(Tier3)

MO; NT

arginine tabs 500 mg$0

(Tier3)

MO; NT

COMPLEX MSUD AMINOACID BAR BAR

$0(Tier

3)

MO; NT

GLUTAMENT PACK$0

(Tier3)

NT

HEPAMENT PACK$0

(Tier3)

MO; NT

L-CARNITINE TABS OR250 MG

$0(Tier

3)

NT

L-CITRULLINE CAPS OR$0

(Tier3)

NT

levocarnitine caps or 250mg

$0(Tier

3)

MO; NT

PHENYLADE AMINO ACIDBAR

$0(Tier

3)

MO; NT

PHENYLADE AMINO ACIDBLEND PACK

$0(Tier

3)

MO; NT

PHENYLADE MTE AMINOACIDBLEND PACK

$0(Tier

3)

MO; NT



159

Name of drug

Whatthe


level)


PHENYLADE PHEBLOCTABS

$0(Tier

3)

MO; NT

PHENYLADE40 DRINKMIX PACK

$0(Tier

3)

MO; NT

PHLEXY-10 CAPS$0

(Tier3)

RX/OTC; NT

PROTEINEX LIQD$0

(Tier3)

MO; NT

SOLVIL PACK$0

(Tier3)

MO; NT

SUPER-AMINO 1600TABS

$0(Tier

3)

MO; NT

TRIAMINO TABS$0

(Tier3)

MO; NT

tyrosine tabs 500 mg$0

(Tier3)

NT

Name of drug

Whatthe


level)


XPHE MAXAMUM PACK153MG-280MG-41MCG-1114UNIT-29MCG-13MCG-0.9MG-410MCG-4.5MG-569MG-7.4MG-9.2UNIT-18.5MCG-65.5MCG-592MG-280MG-350MG-2.9MG-40MG-215MG-0.49MG-2.5MG-1.6MCG-166UNIT-0.46MG-246MCG-12.3MCG-0.8MG-31MG, 153MG-280MG-41MCG-29MCG-13MCG-0.9MG-410MCG-4.5MG-569MG-7.4MG-9.2UNIT-18.5MCG-65.5MCG-592MG-280MG-350MG-1114UNIT-2.9MG-40MG-215MG-0.49MG-2.5MG-1.6MCG-166UNIT-0.46MG-246MCG-12.3MCG-0.8MG-31MG

$0(Tier

3)

MO; NT

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and LubricantsGENTEAL MILD TOMODERATE SOLN(Hypromellose (Ophth))

NFMO; NT

hypromellose (ophth) soln0.3 %, 3 mg/ml

$0(Tier

3)

MO; NT

ISOPTO TEARS SOLN$0

(Tier3)

MO; NT

NUTRATEAR SOLN$0

(Tier3)

NT

polyvinyl alcohol soln op$0

(Tier3)

MO; NT

TEARS AGAIN NIGHT &DAY GEL

$0(Tier

3)

NT



160

Name of drug

Whatthe


level)


TGT LUBRICANT EYEDROPS SOLN

$0(Tier

3)

NT

Beta-blockers - OphthalmicBETAGAN SOLN(Levobunolol HCl) NF MO

betaxolol hcl (ophth) soln$0-

$2.95(Tier

1)

MO

carteolol hcl (ophth) soln$0-

$2.95(Tier

1)

MO

COSOPT SOLN(Dorzolamide HCl-TimololMaleate)

NFMO

dorzolamide hcl-timololmaleate soln

$0-$2.95(Tier

1)

MO

levobunolol hcl soln$0-

$2.95(Tier

1)

MO

timolol maleate (ophth)solg

$0-$2.95(Tier

1)

MO

timolol maleate (ophth)soln

$0-$2.95(Tier

1)

MO

TIMOPTIC SOLN (TimololMaleate (Ophth)) NF MO

TIMOPTIC-XE SOLG(Timolol Maleate (Ophth)) NF MO

Cycloplegic Mydriatics

cyclopentolate hcl soln op1 %

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


Miotics

ISOPTO CARPINE SOLN(Pilocarpine HCl)

$0-$7.40(Tier

2)

MO

PHOSPHOLINE IODIDESOLR

$0-$7.40(Tier

2)

pilocarpine hcl soln op 1 %,2 %, 4 %

$0-$2.95(Tier

1)

MO

Ophthalmic Adrenergic Agents

ALPHAGAN P SOLN 0.1 %$0-

$7.40(Tier

2)

MO

ALPHAGAN P SOLN 0.15% (Brimonidine Tartrate) NF MO

apraclonidine hcl soln$0-

$2.95(Tier

1)

MO

brimonidine tartrate soln$0-

$2.95(Tier

1)

MO

IOPIDINE SOLN 0.5 %(Apraclonidine HCl) NF MO

Ophthalmic Anti-infectives

bacitracin-polymyxin b(ophth) oint

$0-$2.95(Tier

1)

MO

BLEPH-10 SOLN(Sulfacetamide Sodium(Ophth))

NFMO

CILOXAN SOLN(Ciprofloxacin HCl (Ophth)) NF MO



161

Name of drug

Whatthe


level)


ciprofloxacin hcl (ophth)soln

$0-$2.95(Tier

1)

MO

erythromycin (ophth) oint$0-

$2.95(Tier

1)

MO

gatifloxacin (ophth) soln$0-

$2.95(Tier

1)

MO

gentamicin sulfate (ophth)oint

$0-$2.95(Tier

1)

MO

gentamicin sulfate (ophth)soln

$0-$2.95(Tier

1)

MO

levofloxacin (ophth) soln$0-

$2.95(Tier

1)

MO

neomycin-bacitracin zn-polymyxin oint

$0-$2.95(Tier

1)

MO

neomycin-polymyxin-gramicidin soln

$0-$2.95(Tier

1)

MO

OCUFLOX SOLN(Ofloxacin (Ophth)) NF MO

ofloxacin (ophth) soln$0-

$2.95(Tier

1)

MO

polymyxin b-trimethoprimsoln

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


POLYTRIM SOLN(Polymyxin B-Trimethoprim)

NFMO

sulfacetamide sodium(ophth) soln

$0-$2.95(Tier

1)

MO

tobramycin (ophth) soln$0-

$2.95(Tier

1)

MO

TOBREX SOLN(Tobramycin (Ophth)) NF MO

trifluridine soln op$0-

$2.95(Tier

1)

MO

VIGAMOX SOLN$0-

$7.40(Tier

2)

MO

VIROPTIC SOLN(Trifluridine) NF MO

ZIRGAN GEL$0-

$7.40(Tier

2)

MO

ZYMAXID SOLN(Gatifloxacin (Ophth)) NF MO

Ophthalmic Decongestantsnaphazoline w/pheniramine soln 0.025%-0.3%

$0(Tier

3)

MO; NT

NAPHCON-A SOLN(Naphazoline w/Pheniramine)

NFMO; NT

Ophthalmic Immunomodulators

RESTASIS EMUL$0-

$7.40(Tier

2)

MO



162

Name of drug

Whatthe


level)


RESTASIS MULTIDOSEEMUL

$0-$7.40(Tier

2)

MO

Ophthalmic Local Anesthetics

proparacaine hcl soln op$0-

$2.95(Tier

1)

MO

Ophthalmic Steroids

bacitracin-poly-neomycin-hc oint

$0-$2.95(Tier

1)

MO

dexamethasone sodiumphosphate (ophth) soln

$0-$2.95(Tier

1)

MO

DUREZOL EMUL$0-

$7.40(Tier

2)

MO

fluorometholone (ophth)susp

$0-$2.95(Tier

1)

MO

FML LIQUIFILM SUSP(Fluorometholone (Ophth)) NF MO

LOTEMAX OINT$0-

$7.40(Tier

2)

MO

MAXITROL OINT(Neomycin-Polymy-Dexameth)

NFMO

MAXITROL SUSP(Neomycin-Polymy-Dexameth)

NFMO

neomycin-polymy-dexameth oint

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


neomycin-polymy-dexameth susp

$0-$2.95(Tier

1)

MO

OMNIPRED SUSP(Prednisolone Acetate(Ophth))

NFMO

PRED FORTE SUSP(Prednisolone Acetate(Ophth))

NFMO

prednisolone acetate(ophth) susp

$0-$2.95(Tier

1)

MO

sulfacetamide sod-prednisolone soln

$0-$2.95(Tier

1)

MO

TOBRADEX SUSP(Tobramycin-Dexamethasone)

NFMO

tobramycin-dexamethasone susp

$0-$2.95(Tier

1)

MO

Ophthalmics - Misc.ACULAR LS SOLN(Ketorolac Tromethamine(Ophth))

NFMO

ACULAR SOLN (KetorolacTromethamine (Ophth)) NF MO

azelastine hcl (ophth) soln$0-

$2.95(Tier

1)

MO

AZOPT SUSP$0-

$7.40(Tier

2)

MO



163

Name of drug

Whatthe


level)


bromfenac sodium (ophth)soln

$0-$2.95(Tier

1)

Once dailydosing;MO

cromolyn sodium (ophth)soln

$0-$2.95(Tier

1)

MO

CYSTARAN SOLN$0-

$7.40(Tier

2)

Limit 60mls per28days;QL(2.15ml daily); LA

diclofenac sodium (ophth)soln

$0-$2.95(Tier

1)

MO

dorzolamide hcl soln$0-

$2.95(Tier

1)

MO

ELESTAT SOLN(Epinastine HCl (Ophth)) NF MO

ENUCLENE SOLN$0

(Tier3)

MO; NT

epinastine hcl (ophth) soln$0-

$2.95(Tier

1)

MO

EYE STREAM SOLN$0

(Tier3)

MO; NT

flurbiprofen sodium soln$0-

$2.95(Tier

1)

MO

ILEVRO SUSP$0-

$7.40(Tier

2)

MO

Name of drug

Whatthe


level)


ketorolac tromethamine(ophth) soln

$0-$2.95(Tier

1)

MO

ketotifen fumarate (ophth)soln

$0(Tier

3)

MO; NT

MURO 128 OINT 5 %(Sodium ChlorideHypertonic)

NFMO; NT

MURO 128 SOLN 2 %$0

(Tier3)

MO; NT

MURO 128 SOLN 5 %(Sodium ChlorideHypertonic)

NFMO; NT

NEVANAC SUSP$0-

$7.40(Tier

2)

MO

OCUFEN SOLN(Flurbiprofen Sodium) NF MO

OPTIVAR SOLN(Azelastine HCl (Ophth)) NF MO

PATADAY SOLN$0-

$7.40(Tier

2)

MO

sodium chloride hypertonicoint

$0(Tier

3)

MO; NT

sodium chloride hypertonicsoln

$0(Tier

3)

MO; NT

TRUSOPT SOLN(Dorzolamide HCl) NF MO

ZADITOR SOLN (KetotifenFumarate (Ophth)) NF MO; NT

Prostaglandins - Ophthalmic



164

Name of drug

Whatthe


level)


BIMATOPROST SOLN$0-

$7.40(Tier

2)

MO

latanoprost soln$0-

$2.95(Tier

1)

MO

LUMIGAN SOLN$0-

$7.40(Tier

2)

MO

TRAVATAN Z SOLN$0-

$7.40(Tier

2)

MO

XALATAN SOLN(Latanoprost) NF MO

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous

acetic acid (otic) soln$0-

$2.95(Tier

1)

MO

acetic acid-aluminumacetate soln

$0-$2.95(Tier

1)

MO

carbamide peroxide (otic)soln

$0(Tier

3)

MO; NT

DEBROX SOLN(Carbamide Peroxide(Otic))

NFMO; NT

Otic Anti-infectivesFLOXIN OTIC SOLN(Ofloxacin (Otic)) NF MO

ofloxacin (otic) soln$0-

$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


Otic Combinations

boric acid in isopropyl soln$0

(Tier3)

NT

CIPRODEX SUSP$0-

$7.40(Tier

2)

MO

neomycin-polymyxin-hc(otic) soln

$0-$2.95(Tier

1)

MO

neomycin-polymyxin-hc(otic) susp

$0-$2.95(Tier

1)

MO

Otic SteroidsDERMOTIC OIL(Fluocinolone Acetonide(Otic))

NFMO

fluocinolone acetonide(otic) oil

$0-$2.95(Tier

1)

MO

hydrocortisone w/aceticacid soln

$0-$2.95(Tier

1)

MO

OXYTOCICS - Drugs to Prevent/Control UterineBleedingOxytocics

methylergonovine maleatetabs or 0.2 mg

$0-$2.95(Tier

1)

MO

PASSIVE IMMUNIZING AGENTS - AntibodyDrugs to Treat Low Immune SystemImmune Serums



165

Name of drug

Whatthe


level)


BIVIGAM SOLN$0-

$7.40(Tier

2)

B/D

CUVITRU SOLN$0-

$7.40(Tier

2)

B/D

FLEBOGAMMA DIF SOLN10 %

$0-$7.40(Tier

2)

B/D

GAMASTAN S/D INJ$0-

$7.40(Tier

2)

B/D

GAMMAGARD LIQUIDSOLN

$0-$7.40(Tier

2)

B/D

GAMMAKED SOLN$0-

$7.40(Tier

2)

B/D

GAMUNEX-C SOLN$0-

$7.40(Tier

2)

B/D

HIZENTRA SOLN$0-

$7.40(Tier

2)

B/D

OCTAGAM SOLN 10GM/100ML, 2 GM/20ML,20 GM/200ML, 5 GM/50ML

$0-$7.40(Tier

2)

B/D

PRIVIGEN SOLN$0-

$7.40(Tier

2)

B/D

Name of drug

Whatthe


level)


VARIZIG SOLN 125UNIT/1.2ML

$0-$7.40(Tier

2)

Monoclonal Antibodies

SYNAGIS SOLN 50MG/0.5ML

$0-$7.40(Tier

2)

Passive Immunizing Agents - Combinations

HYQVIA KIT$0-

$7.40(Tier

2)

B/D

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins

amoxicillin caps 250 mg,500 mg

$0-$2.95(Tier

1)

MO

amoxicillin susr 125mg/5ml, 200 mg/5ml, 250mg/5ml, 400 mg/5ml

$0-$2.95(Tier

1)

MO

amoxicillin tabs 500 mg,875 mg

$0-$2.95(Tier

1)

MO

ampicillin caps 250 mg,500 mg

$0-$2.95(Tier

1)

MO

ampicillin sodium solr ij 1gm, 2 gm

$0-$2.95(Tier

1)

MO

ampicillin sodium solr iv 10gm

$0-$2.95(Tier

1)

Natural Penicillins



166

Name of drug

Whatthe


level)


BICILLIN L-A SUSP$0-

$7.40(Tier

2)

MO

penicillin g potassium solr20 mu, 20000000 unit,5000000 unit

$0-$2.95(Tier

1)

MO

penicillin v potassium solr250 mg/5ml

$0-$2.95(Tier

1)

MO

penicillin v potassium tabs250 mg, 500 mg

$0-$2.95(Tier

1)

MO

Penicillin Combinations

amoxicillin & potclavulanate chew 200mg-28.5mg, 400mg-57mg

$0-$2.95(Tier

1)

MO

amoxicillin & potclavulanate susr200mg/5ml-28.5mg/5ml,250mg/5ml-62.5mg/5ml,400mg/5ml-57mg/5ml,600mg/5ml-42.9mg/5ml

$0-$2.95(Tier

1)

MO

amoxicillin & potclavulanate tabs 250mg-125mg, 500mg-125mg,875mg-125mg

$0-$2.95(Tier

1)

MO

amoxicillin & potclavulanate tb12 1000mg-62.5mg

$0-$2.95(Tier

1)

ampicillin & sulbactamsodium solr ij 1gm-2gm

$0-$2.95(Tier

1)

MO

ampicillin & sulbactamsodium solr iv 5gm-10gm

$0-$2.95(Tier

1)

Name of drug

Whatthe


level)


AUGMENTIN ES-600SUSR (Amoxicillin & PotClavulanate)

NFMO

AUGMENTIN SUSR250MG/5ML-62.5MG/5ML(Amoxicillin & PotClavulanate)

NF

MO

AUGMENTIN TABS500MG-125MG, 875MG-125MG (Amoxicillin & PotClavulanate)

NF

MO

AUGMENTIN XR TB12(Amoxicillin & PotClavulanate)

NF

BICILLIN C-R SUSP300000UNIT/ML-300000UNIT/ML

$0-$7.40(Tier

2)

MO

BICILLIN C-R SUSP900000UNIT/2ML-300000UNIT/2ML

$0-$7.40(Tier

2)

piperacillin sodium-tazobactam sodium solr

$0-$2.95(Tier

1)UNASYN SOLR 1GM-2GM(Ampicillin & SulbactamSodium)

NFMO

ZOSYN SOLR 0.25GM-2GM, 0.375GM-3GM,0.5GM-4GM, 4.5GM-36GM(Piperacillin Sodium-Tazobactam Sodium)

NF

Penicillinase-Resistant Penicillins

dicloxacillin sodium caps$0-

$2.95(Tier

1)

MO

nafcillin sodium solr ij 10gm

$0-$2.95(Tier

1)



167

Name of drug

Whatthe


level)


nafcillin sodium solr ij 2 gm$0-

$2.95(Tier

1)

MO

oxacillin sodium solr 10 gm$0-

$2.95(Tier

1)

oxacillin sodium solr 2 gm$0-

$2.95(Tier

1)

MO

PHARMACEUTICAL ADJUVANTS

Liquid Vehicles

CHERRY CONCENTRATESYRP

$0(Tier

3)

RX/OTC; MO;NT

CHERRY SYRUP SYRP$0

(Tier3)

RX/OTC; MO;NT

PROPYLENE GLYCOLSOLN EX

$0(Tier

3)

RX/OTC; MO;NT

RASPBERRY SYRUPSYRP

$0(Tier

3)

RX/OTC; NT

Pharmaceutical Excipients

KARAYA GUM GUM$0

(Tier3)

RX/OTC; MO;NT

Semi Solid Vehicles

LANOLIN ANHYDROUSOINT

$0(Tier

3)

RX/OTC; NT

LANOLIN ANHYDROUS-GRX OINT

$0(Tier

3)

RX/OTC; NT

lanolin oint ex$0

(Tier3)

RX/OTC; NT

Name of drug

Whatthe


level)


PROGESTINS - Hormone Replacement/ModifyingDrugsProgestins

medroxyprogesteroneacetate tabs or 10 mg, 2.5mg, 5 mg

$0-$2.95(Tier

1)

MO

MEGACE ES SUSP(Megestrol Acetate(Appetite))

$0-$7.40(Tier

2)

AL; MO

megestrol acetate(appetite) susp

$0-$2.95(Tier

1)

AL; MO

norethindrone acetate tabsor

$0-$2.95(Tier

1)

MO

progesterone micronizedcaps or 100 mg, 200 mg

$0-$2.95(Tier

1)

MO

PROMETRIUM CAPS(Progesterone Micronized) NF MO

PROVERA TABS(MedroxyprogesteroneAcetate)

NFMO

PSYCHOTHERAPEUTIC AND NEUROLOGICALAGENTS - MISC. - Drugs to Treat Mental andEmotional ConditionsAgents for Chemical Dependency

acamprosate calcium tbec$0-

$2.95(Tier

1)

MO

CAMPRAL TBEC(Acamprosate Calcium) NF MO



168

Name of drug

Whatthe


level)


disulfiram tabs or 250 mg,500 mg

$0-$2.95(Tier

1)

MO

Anti-Cataplectic Agents

XYREM SOLN$0-

$7.40(Tier

2)

LA

Antidementia AgentsARICEPT ODT TBDP(Donepezil Hydrochloride) NF MO

ARICEPT TABS (DonepezilHydrochloride) NF MO

donepezil hydrochloridetabs

$0-$2.95(Tier

1)

MO

donepezil hydrochloridetbdp

$0-$2.95(Tier

1)

MO

EXELON CAPS OR 1.5MG, 3 MG, 4.5 MG, 6 MG(Rivastigmine Tartrate)

NFMO

EXELON PT24 TD 13.3MG/24HR, 4.6 MG/24HR,9.5 MG/24HR(Rivastigmine)

$0-$7.40(Tier

2)

MO

galantamine hydrobromidecp24

$0-$2.95(Tier

1)

MO

galantamine hydrobromidesoln

$0-$2.95(Tier

1)

MO

galantamine hydrobromidetabs

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


memantine hcl soln 2mg/ml

$0-$2.95(Tier

1)

AL; MO

memantine hcl tabs 10 mg,5 mg

$0-$2.95(Tier

1)

MO

NAMENDA SOLN 10MG/5ML (Memantine HCl)

$0-$7.40(Tier

2)

AL; MO

NAMENDA TABS 10 MG, 5MG (Memantine HCl)

$0-$7.40(Tier

2)

MO

NAMENDA TITRATIONPAK TABS (MemantineHCl)

$0-$7.40(Tier

2)

MO

NAMENDA XR CP24 14MG

$0-$7.40(Tier

2)

SL(2 ea daily);MO


$0-$7.40(Tier

2)



$0-$7.40(Tier

2)

SL(1 ea daily);MO

NAMENDA XR CP24 7 MG$0-

$7.40(Tier

2)

SL(4 ea daily);MO

NAMENDA XR TITRATIONPACK CP24

$0-$7.40(Tier

2)

MO

RAZADYNE ER CP24(GalantamineHydrobromide)

NFMO



169

Name of drug

Whatthe


level)


RAZADYNE SOLN(GalantamineHydrobromide)

NFMO

RAZADYNE TABS(GalantamineHydrobromide)

NFMO

rivastigmine pt24$0-

$2.95(Tier

1)

MO

rivastigmine tartrate caps$0-

$2.95(Tier

1)

MO

Combination Psychotherapeutics

chlordiazepoxide-amitriptyline tabs

$0-$2.95(Tier

1)

AL; MO

olanzapine-fluoxetine hclcaps

$0-$2.95(Tier

1)

MO

perphenazine-amitriptylinetabs

$0-$2.95(Tier

1)

AL; MO

SYMBYAX CAPS(Olanzapine-FluoxetineHCl)

NFMO

Movement Disorder Drug Therapy

tetrabenazine tabs$0-

$2.95(Tier

1)

XENAZINE TABS(Tetrabenazine)

$0-$7.40(Tier

2)

LA

Multiple Sclerosis Agents

Name of drug

Whatthe


level)


AMPYRA TB12$0-

$7.40(Tier

2)

AUBAGIO TABS$0-

$7.40(Tier

2)

PA

AVONEX KIT$0-

$7.40(Tier

2)

PA

AVONEX PEN AJKT$0-

$7.40(Tier

2)

PA

AVONEX PSKT$0-

$7.40(Tier

2)

PA

BETASERON KIT$0-

$7.40(Tier

2)

PA

COPAXONE SOSY 20MG/ML (GlatiramerAcetate)

$0-$7.40(Tier

2)

PA

COPAXONE SOSY 40MG/ML

$0-$7.40(Tier

2)

PA

EXTAVIA KIT$0-

$7.40(Tier

2)

PA

GILENYA CAPS$0-

$7.40(Tier

2)

PA



170

Name of drug

Whatthe


level)


glatiramer acetate sosy$0-

$2.95(Tier

1)

PA

LEMTRADA SOLN$0-

$7.40(Tier

2)

PA; LA

PLEGRIDY SOPN$0-

$7.40(Tier

2)

PA

PLEGRIDY SOSY$0-

$7.40(Tier

2)

PA

PLEGRIDY STARTERPACK SOPN

$0-$7.40(Tier

2)

PA

PLEGRIDY STARTERPACK SOSY

$0-$7.40(Tier

2)

PA

REBIF REBIDOSE SOAJ$0-

$7.40(Tier

2)

PA

REBIF REBIDOSETITRATIONPACK SOAJ

$0-$7.40(Tier

2)

PA

REBIF SOSY$0-

$7.40(Tier

2)

PA

REBIF TITRATION PACKSOSY

$0-$7.40(Tier

2)

PA

Name of drug

Whatthe


level)


TECFIDERA CPDR$0-

$7.40(Tier

2)

PA

TECFIDERA STARTERPACK MISC

$0-$7.40(Tier

2)

PA

TYSABRI CONC$0-

$7.40(Tier

2)

PA

Premenstrual Dysphoric Disorder (PMDD) Agentsfluoxetine hcl (pmdd) cap10 mg, 20 mg NF

Pseudobulbar Affect (PBA) Agents

NUEDEXTA CAPS$0-

$7.40(Tier

2)

MO

Psychotherapeutic and Neurological Agents -

ergoloid mesylates tabs or$0-

$2.95(Tier

1)

AL; MO

ORAP TABS (Pimozide)

$0-$7.40(Tier

2)

MO

pimozide tabs$0-

$2.95(Tier

1)

MO

Smoking Deterrents

bupropion hcl (smokingdeterrent) tb12

$0-$2.95(Tier

1)

SL(2 ea daily);MO



171

Name of drug

Whatthe


level)


CHANTIX CONTINUINGMONTHPAK TABS

$0-$7.40(Tier

2)

PA; MO

CHANTIX TABS$0-

$7.40(Tier

2)

PA; MO

NICODERM CQ PT24(Nicotine) NF MO; NT

NICORETTE GUM(Nicotine Polacrilex) NF PA; MO; NT

NICORETTE LOZG(Nicotine Polacrilex) NF PA; MO; NT

NICORETTE MINI LOZG(Nicotine Polacrilex) NF PA; MO; NT

NICORETTE STARTERKIT GUM (NicotinePolacrilex)

NFPA; MO; NT

nicotine polacrilex gum mt2 mg, 4 mg

$0(Tier

3)

PA; MO; NT

nicotine polacrilex lozg mt2 mg, 4 mg

$0(Tier

3)

PA; MO; NT

nicotine pt24$0

(Tier3)

MO; NT

NICOTINETRANSDERMAL SYSTEMKIT

$0(Tier

3)

NT

NICOTROL INHALERINHA

$0-$7.40(Tier

2)

SL(17 ea daily);MO

NICOTROL NS SOLN$0-

$7.40(Tier

2)

MO

ZYBAN TB12 (BupropionHCl (Smoking Deterrent)) NF SL(2 ea daily);

MOVasomotor Symptom Agents

Name of drug

Whatthe


level)


BRISDELLE CAPS$0-

$7.40(Tier

2)

MO

RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung ConditionsAlpha-Proteinase Inhibitor (Human)

ARALAST NP SOLR 1000MG

$0-$7.40(Tier

2)

LA

PROLASTIN-C SOLR$0-

$7.40(Tier

2)

LA

ZEMAIRA SOLR$0-

$7.40(Tier

2)

LA

Cystic Fibrosis Agents

KALYDECO PACK$0-

$7.40(Tier

2)

PA

KALYDECO TABS$0-

$7.40(Tier

2)

PA

ORKAMBI TABS$0-

$7.40(Tier

2)

PA; LA

PULMOZYME SOLN$0-

$7.40(Tier

2)

B/D

Pulmonary Fibrosis Agents

ESBRIET CAPS$0-

$7.40(Tier

2)

PA; LA



172

Name of drug

Whatthe


level)


OFEV CAPS$0-

$7.40(Tier

2)

PA; LA

SULFONAMIDES - Drugs to Treat BacterialInfectionsSulfonamides

sulfadiazine tabs or$0-

$2.95(Tier

1)

MO

TETRACYCLINES - Drugs to Treat BacterialInfectionsTetracyclinesADOXA PAK 1/100 TABS(Doxycycline(Monohydrate))

NFMO

ADOXA PAK 1/150 TABS(Doxycycline(Monohydrate))

NFMO

ADOXA PAK 2/100 TABS(Doxycycline(Monohydrate))

NFMO

ADOXA TABS 100 MG, 50MG, 75 MG (Doxycycline(Monohydrate))

NFMO

demeclocycline hcl tabs$0-

$2.95(Tier

1)

MO

doxycycline (monohydrate)caps 100 mg, 50 mg, 75mg

$0-$2.95(Tier

1)

MO

doxycycline (monohydrate)susr 25 mg/5ml

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


doxycycline (monohydrate)tabs 100 mg, 150 mg, 50mg, 75 mg

$0-$2.95(Tier

1)

MO

doxycycline hyclate caps or100 mg, 50 mg

$0-$2.95(Tier

1)

MO

doxycycline hyclate solr iv100 mg

$0-$2.95(Tier

1)

MO

doxycycline hyclate tabs or100 mg, 20 mg

$0-$2.95(Tier

1)

MO

doxycycline hyclate tbec or150 mg

$0-$2.95(Tier

1)

MO

MINOCIN CAPS OR 100MG, 50 MG, 75 MG(Minocycline HCl)

NFMO

minocycline hcl caps or 100mg, 50 mg, 75 mg

$0-$2.95(Tier

1)

MO

minocycline hcl tabs or 100mg, 50 mg

$0-$2.95(Tier

1)

MO

MONODOX CAPS(Doxycycline(Monohydrate))

NFMO

tetracycline hcl caps or 250mg, 500 mg

$0-$2.95(Tier

1)

MO

VIBRAMYCIN CAPS 100MG (Doxycycline Hyclate) NF MO

VIBRAMYCIN SUSR 25MG/5ML (Doxycycline(Monohydrate))

NFMO



173

Name of drug

Whatthe


level)


THYROID AGENTS - Drugs to Regulate ThyroidHormonesAntithyroid Agents

methimazole tabs or 10mg, 5 mg

$0-$2.95(Tier

1)

MO

propylthiouracil tabs or$0-

$2.95(Tier

1)

MO

Thyroid HormonesCYTOMEL TABS(Liothyronine Sodium) NF MO

levothyroxine sodium tabsor 100 mcg, 112 mcg, 125mcg, 137 mcg, 150 mcg,175 mcg, 200 mcg, 25mcg, 300 mcg, 50 mcg, 75mcg, 88 mcg

$0-$2.95(Tier

1)

MO

liothyronine sodium tabs or25 mcg, 5 mcg, 50 mcg

$0-$2.95(Tier

1)

MO

SYNTHROID TABS(Levothyroxine Sodium) NF MO

TOXOIDS

Toxoid Combinations

ADACEL SUSP$0-

$7.40(Tier

2)

BOOSTRIX SUSP$0-

$7.40(Tier

2)

DAPTACEL SUSP$0-

$7.40(Tier

2)

Name of drug

Whatthe


level)


DIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC SUSP

$0-$7.40(Tier

2)

INFANRIX SUSP$0-

$7.40(Tier

2)

TENIVAC INJ$0-

$7.40(Tier

2)

B/D

TETANUS/DIPHTHERIATOXOIDS-ADSORBEDADULT SUSP

$0-$7.40(Tier

2)

TETANUS/DIPHTHERIATOXOIDS-ADSORBEDSUSP

$0-$7.40(Tier

2)

ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach ConditionsAntispasmodicsBENTYL CAPS OR 10 MG(Dicyclomine HCl) NF MO

BENTYL TABS OR 20 MG(Dicyclomine HCl) NF MO

dicyclomine hcl caps or 10mg

$0-$2.95(Tier

1)

MO

dicyclomine hcl tabs or 20mg

$0-$2.95(Tier

1)

MO

glycopyrrolate soln ij 0.2mg/ml

$0-$2.95(Tier

1)

MO



174

Name of drug

Whatthe


level)


glycopyrrolate tabs or 1 mg$0-

$2.95(Tier

1)

SL(8 ea daily);MO

glycopyrrolate tabs or 2 mg$0-

$2.95(Tier

1)

SL(4 ea daily);MO

methscopolamine bromidetabs or 2.5 mg, 5 mg

$0-$2.95(Tier

1)

MO

PAMINE FORTE TABS(MethscopolamineBromide)

NFMO

PAMINE TABS(MethscopolamineBromide)

NFMO

ROBINUL FORTE TABS(Glycopyrrolate) NF SL(4 ea daily);

MOROBINUL SOLN IJ 0.2MG/ML (Glycopyrrolate) NF MO

ROBINUL TABS OR 1 MG(Glycopyrrolate) NF SL(8 ea daily);

MOH-2 Antagonists

cimetidine tabs or 200 mg$0-

$2.95(Tier

1)

RX/OTC; MO

cimetidine tabs or 300 mg,400 mg, 800 mg

$0-$2.95(Tier

1)

MO

famotidine soln iv 20mg/2ml, 200 mg/20ml, 40mg/4ml

$0-$2.95(Tier

1)

famotidine susr or 40mg/5ml

$0-$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


famotidine tabs or 10 mg$0

(Tier3)

MO; NT

famotidine tabs or 20 mg$0-

$2.95(Tier

1)

RX/OTC; MO

famotidine tabs or 40 mg$0-

$2.95(Tier

1)

MO

nizatidine caps 150 mg,300 mg

$0-$2.95(Tier

1)

MO

PEPCID AC CHEW$0

(Tier3)

NT

PEPCID AC TABS(Famotidine) NF MO; NT

PEPCID SUSR(Famotidine) NF MO

ranitidine hcl caps or 150mg, 300 mg

$0-$2.95(Tier

1)

MO

ranitidine hcl syrp or 15mg/ml, 150 mg/10ml, 75mg/5ml

$0-$2.95(Tier

1)

MO

ranitidine hcl tabs or 150mg

$0-$2.95(Tier

1)

RX/OTC; MO

ranitidine hcl tabs or 300mg

$0-$2.95(Tier

1)

MO

ranitidine hcl tabs or 75 mg$0

(Tier3)

MO; NT

ZANTAC 75 TABS(Ranitidine HCl) NF MO; NT



175

Name of drug

Whatthe


level)


ZANTAC TABS OR 150MG (Ranitidine HCl) NF RX/OTC; MO

ZANTAC TABS OR 300MG (Ranitidine HCl) NF MO

Misc. Anti-UlcerCARAFATE TABS 1 GM(Sucralfate) NF MO

sucralfate tabs or$0-

$2.95(Tier

1)

MO

Proton Pump Inhibitors

DEXILANT CPDR$0-

$7.40(Tier

2)

ST; MO

esomeprazole magnesiumcpdr 20 mg

$0-$2.95(Tier

1)

ST; RX/OTC;MO

esomeprazole magnesiumcpdr 40 mg

$0-$2.95(Tier

1)

ST; MO

esomeprazole sodium solr40 mg

$0-$2.95(Tier

1)

ESOMEPRAZOLESTRONTIUM CPDR 49.3MG

$0-$7.40(Tier

2)

ST

lansoprazole cpdr or 15 mg$0-

$2.95(Tier

1)

RX/OTC; MO

lansoprazole cpdr or 30 mg$0-

$2.95(Tier

1)

MO

Name of drug

Whatthe


level)


NEXIUM CPDR 20 MG(EsomeprazoleMagnesium)

$0-$7.40(Tier

2)

ST; RX/OTC;MO

NEXIUM CPDR 40 MG(EsomeprazoleMagnesium)

$0-$7.40(Tier

2)

ST; MO

NEXIUM I.V. SOLR(Esomeprazole Sodium) NF

NEXIUM PACK 10 MG, 2.5MG, 20 MG, 40 MG, 5 MG

$0-$7.40(Tier

2)

ST; MO

omeprazole cpdr or 10 mg,20 mg, 40 mg

$0-$2.95(Tier

1)

MO

pantoprazole sodium solr iv40 mg

$0-$2.95(Tier

1)

pantoprazole sodium tbecor 20 mg, 40 mg

$0-$2.95(Tier

1)

MO

PREVACID CPDR 15 MG(Lansoprazole) NF RX/OTC; MO

PREVACID CPDR 30 MG(Lansoprazole) NF MO

PRILOSEC CPDR 10 MG,20 MG, 40 MG(Omeprazole)

NFMO

PROTONIX SOLR IV 40MG

$0-$7.40(Tier

2)PROTONIX TBEC OR 20MG, 40 MG (PantoprazoleSodium)

NFMO

Ulcer Drugs - Prostaglandins



176

Name of drug

Whatthe


level)


CYTOTEC TABS(Misoprostol) NF MO

misoprostol tabs or 100mcg, 200 mcg

$0-$2.95(Tier

1)

MO

Ulcer Therapy Combinations

amoxicillin-clarithromycinw/ lansoprazole misc

$0-$2.95(Tier

1)

MO

OMECLAMOX-PAK MISC$0-

$7.40(Tier

2)

MO

omeprazole-sodiumbicarbonate caps 20mg-1100mg

$0-$2.95(Tier

1)

RX/OTC; MO

omeprazole-sodiumbicarbonate caps 40mg-1100mg

$0-$2.95(Tier

1)

MO

omeprazole-sodiumbicarbonate pack 20mg-1680mg

$0-$2.95(Tier

1)

ST; MO

PREVPAC MISC(Amoxicillin-Clarithromycinw/ Lansoprazole)

NFMO

ZEGERID CAPS 20MG-1100MG (Omeprazole-Sodium Bicarbonate)

NFRX/OTC; MO

ZEGERID CAPS 40MG-1100MG (Omeprazole-Sodium Bicarbonate)

NFMO

ZEGERID PACK 20MG-1680MG (Omeprazole-Sodium Bicarbonate)

$0-$7.40(Tier

2)

ST; MO

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney Infections

Name of drug

Whatthe


level)


Urinary Anti-infectivesHIPREX TABS(Methenamine Hippurate) NF MO

MACROBID CAPS(Nitrofurantoin MonohydMacro)

NFMO

MACRODANTIN CAPS100 MG, 50 MG(NitrofurantoinMacrocrystal)

NF

AL; MO

methenamine hippuratetabs

$0-$2.95(Tier

1)

MO

nitrofurantoin macrocrystalcaps or 100 mg, 50 mg

$0-$2.95(Tier

1)

AL; MO

nitrofurantoin monohydmacro caps

$0-$2.95(Tier

1)

MO

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder SpasmsUrinary Antispasmodic - AntimuscarinicsDETROL LA CP24(Tolterodine Tartrate) NF MO

DETROL TABS(Tolterodine Tartrate) NF MO

DITROPAN XL TB24(Oxybutynin Chloride) NF MO

oxybutynin chloride syrp$0-

$2.95(Tier

1)

MO

oxybutynin chloride tabs$0-

$2.95(Tier

1)

MO



177

Name of drug

Whatthe


level)


oxybutynin chloride tb24$0-

$2.95(Tier

1)

MO

tolterodine tartrate cp24$0-

$2.95(Tier

1)

MO

tolterodine tartrate tabs$0-

$2.95(Tier

1)

MO

trospium chloride cp24$0-

$2.95(Tier

1)

MO

trospium chloride tabs$0-

$2.95(Tier

1)

MO

Urinary Antispasmodics - Beta-3 Adrenergic

MYRBETRIQ TB24$0-

$7.40(Tier

2)

MO

Urinary Antispasmodics - Cholinergic Agonists

bethanechol chloride tabs10 mg, 25 mg, 5 mg, 50 mg

$0-$2.95(Tier

1)

MO

Urinary Antispasmodics - Direct Muscle Relaxants

flavoxate hcl tabs$0-

$2.95(Tier

1)

MO

VACCINES

Bacterial Vaccines

ACTHIB SOLR$0-

$7.40(Tier

2)

Name of drug

Whatthe


level)


MENACTRA INJ$0-

$7.40(Tier

2)

MENOMUNE-A/C/Y/W-135INJ

$0-$7.40(Tier

2)

MENVEO SOLR$0-

$7.40(Tier

2)

PEDVAX HIB SUSP$0-

$7.40(Tier

2)

TYPHIM VI SOLN$0-

$7.40(Tier

2)

Mixed Vaccine Combinations

COMVAX SUSP$0-

$7.40(Tier

2)

Viral Vaccines

CERVARIX SUSP$0-

$7.40(Tier

2)

ENGERIX-B SUSP IJ 10MCG/0.5ML, 20 MCG/ML

$0-$7.40(Tier

2)

B/D

GARDASIL 9 SUSP$0-

$7.40(Tier

2)

GARDASIL 9 SUSY$0-

$7.40(Tier

2)



178

Name of drug

Whatthe


level)


GARDASIL SUSP$0-

$7.40(Tier

2)

HAVRIX SUSP$0-

$7.40(Tier

2)

IMOVAX RABIES(H.D.C.V.) INJ

$0-$7.40(Tier

2)

B/D

IPOL INACTIVATED IPVINJ

$0-$7.40(Tier

2)

IXIARO SUSP$0-

$7.40(Tier

2)

M-M-R II INJ$0-

$7.40(Tier

2)

PROQUAD INJ$0-

$7.40(Tier

2)

RABAVERT SUSR$0-

$7.40(Tier

2)

B/D

RECOMBIVAX HB SUSP$0-

$7.40(Tier

2)

B/D

ROTARIX SUSR$0-

$7.40(Tier

2)

Name of drug

Whatthe


level)


ROTATEQ SOLN$0-

$7.40(Tier

2)

TWINRIX SUSP$0-

$7.40(Tier

2)

VAQTA SUSP$0-

$7.40(Tier

2)

VARIVAX INJ$0-

$7.40(Tier

2)

YF-VAX INJ$0-

$7.40(Tier

2)

ZOSTAVAX SOLR$0-

$7.40(Tier

2)

VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low HormonesMiscellaneous Vaginal Products

benzocaine-resorcinolvaginal crea 2%-5%

$0(Tier

3)

NT

FEMINEASE CREA$0

(Tier3)

NT

VAGISIL CREA(Benzocaine-ResorcinolVaginal)

NFNT

Spermicides

ENCARE SUPP$0

(Tier3)

NT



179

Name of drug

Whatthe


level)


nonoxynol-9 gel$0

(Tier3)

NT

OPTIONS CONCEPTROLVAGINALCONTRACEPTIVE GEL(Nonoxynol-9)

$0(Tier

3)

NT

OPTIONS GYNOL IIVAGINALCONTRACEPTIVE GEL

$0(Tier

3)

MO; NT

SHUR-SEAL GEL$0

(Tier3)

NT

VCF VAGINALCONTRACEPTIVE FILMFILM

$0(Tier

3)

NT

VCF VAGINALCONTRACEPTIVE FOAMFOAM

$0(Tier

3)

NT

Vaginal Anti-infectivesCLEOCIN CREA VA 2 %(Clindamycin PhosphateVaginal)

NFMO

clindamycin phosphatevaginal crea

$0-$2.95(Tier

1)

MO

clotrimazole vaginal crea 1%

$0(Tier

3)

MO; NT

GYNE-LOTRIMIN CREA(Clotrimazole Vaginal) NF MO; NT

METROGEL-VAGINALGEL (MetronidazoleVaginal)

NFMO

metronidazole vaginal gel$0-

$2.95(Tier

1)

MO

miconazole nitrate vaginalsupp 100 mg

$0(Tier

3)

MO; NT

Name of drug

Whatthe


level)


TERAZOL 3 CREA(Terconazole Vaginal) NF MO

TERAZOL 7 CREA(Terconazole Vaginal) NF MO

terconazole vaginal crea$0-

$2.95(Tier

1)

MO

terconazole vaginal supp$0-

$2.95(Tier

1)

MO

tioconazole vaginal oint$0

(Tier3)

NT

VAGISTAT-1 OINT(Tioconazole Vaginal) NF NT

Vaginal Estrogens

estradiol vaginal crea 0.1mg/gm

$0-$2.95(Tier

1)

MO

PREMARIN CREA VA0.625 MG/GM

$0-$7.40(Tier

2)

MO

VASOPRESSORS - Drugs to Treat Heart andCirculation ConditionsAnaphylaxis Therapy Agents

ADRENACLICK SOAJ$0-

$7.40(Tier

2)

MO

AUVI-Q SOAJ$0-

$7.40(Tier

2)

MO

EPINEPHRINE SOAJ IJ0.15 MG/0.15ML, 0.3MG/0.3ML

$0-$7.40(Tier

2)

MO



180

Name of drug

Whatthe


level)


EPIPEN 2-PAK SOAJ$0-

$7.40(Tier

2)

MO

EPIPEN-JR 2-PAK SOAJ$0-

$7.40(Tier

2)

MO

Neurogenic Orthostatic Hypotension (NOH) -

NORTHERA CAPS 100MG

$0-$7.40(Tier

2)

PA; SL(18 eadaily)

NORTHERA CAPS 200MG

$0-$7.40(Tier

2)

PA; SL(9 eadaily)

NORTHERA CAPS 300MG

$0-$7.40(Tier

2)

PA; SL(6 eadaily)

Vasopressors

dobutamine hcl soln$0-

$2.95(Tier

1)

midodrine hcl tabs$0-

$2.95(Tier

1)

MO

VITAMINS

Oil Soluble Vitamins

A-25 CAPS$0

(Tier3)

NT

BABY DDROPS LIQD(Cholecalciferol) NF NT

BETA CAROTENE CAPSOR 10000 UNIT

$0(Tier

3)

NT

Name of drug

Whatthe


level)


beta carotene caps or25000 unit

$0(Tier

3)

MO; NT

cholecalciferol caps or1000 unit, 2000 unit, 400unit, 5000 unit

$0(Tier

3)

MO; NT

cholecalciferol liqd or 400unit/ml

$0(Tier

3)

MO; NT

cholecalciferol liqd or 400unt/0.03ml

$0(Tier

3)

NT

cholecalciferol tabs or 1000unit, 2000 unit, 400 unit

$0(Tier

3)

MO; NT

cholecalciferol tabs or 5000unit, 50000 unit

$0(Tier

3)

NT

D-VI-SOL LIQD(Cholecalciferol) NF MO; NT

DRISDOL CAPS(Ergocalciferol) NF MO; NT

DRISDOL SOLN(Ergocalciferol) NF MO; NT

ergocalciferol caps or50000 unit

$0(Tier

3)

MO; NT

ergocalciferol soln or 8000unit/ml

$0(Tier

3)

MO; NT

MEPHYTON TABS$0

(Tier3)

MO; NT

phytonadione tabs or 100mcg

$0(Tier

3)

MO; NT

vitamin a caps 10000 unit$0

(Tier3)

MO; NT

VITAMIN A CAPS 25000UNIT

$0(Tier

3)

NT



181

Name of drug

Whatthe


level)


vitamin a caps 8000 unit$0

(Tier3)

NT

VITAMIN A TABS10000UNIT-1000UNIT

$0(Tier

3)

NT

vitamin e caps or 100 unit,1000 unit

$0(Tier

3)

MO; NT

vitamin e liqd or 400unit/15ml

$0(Tier

3)

NT

vitamin e soln or 15unit/0.3ml

$0(Tier

3)

MO; NT

WHEAT GERM OIL$0

(Tier3)

NT

Water Soluble Vitamins

ascorbic acid chew or 250mg, 250mg

$0(Tier

3)

MO; NT

ascorbic acid cpcr or 500mg

$0(Tier

3)

MO; NT

ASCORBIC ACID GRANOR

$0(Tier

3)

NT

ascorbic acid soln ij 500mg/ml

$0(Tier

3)

MO; NT

ascorbic acid tabs or 100mg

$0(Tier

3)

NT

ascorbic acid tabs or 250mg

$0(Tier

3)

MO; NT

ascorbic acid tbcr or 1000mg, 500 mg, 500mg

$0(Tier

3)

NT

Name of drug

Whatthe


level)


B-1 TABS$0

(Tier3)

NT

biotin tabs or 300 mcg$0

(Tier3)

MO; NT

biotin tabs or 5 mg, 5000mcg, 800 mcg

$0(Tier

3)

NT

BIOTIN TABS OR 800MCG

$0(Tier

3)

NT

calcium ascorbate tabs or$0

(Tier3)

NT

niacin cpcr or 250 mg, 500mg

$0(Tier

3)

MO; NT

niacin tabs or 100 mg, 250mg, 50 mg, 500 mg

$0(Tier

3)

MO; NT

niacin tbcr or 250 mg, 500mg, 750 mg

$0(Tier

3)

MO; NT

NIACIN TR TBCR$0

(Tier3)

MO; NT

niacinamide tabs or 100 mg$0

(Tier3)

NT

niacinamide tabs or 500 mg$0

(Tier3)

MO; NT

pyridoxine hcl tabs or 100mg, 25 mg, 50 mg

$0(Tier

3)

MO; NT

riboflavin tabs or 100 mg,25 mg

$0(Tier

3)

MO; NT

riboflavin tabs or 50 mg$0

(Tier3)

NT



182

Name of drug

Whatthe


level)


SLO-NIACIN TBCR(Niacin) NF MO; NT

thiamine hcl tabs or 100mg, 50 mg

$0(Tier

3)

MO; NT

thiamine hcl tabs or 250mg

$0(Tier

3)

NT

thiamine mononitrate tabs$0

(Tier3)

NT



183

IndexA & D ZINC OXIDE 109A-25 181A-MANTLE 109abacavir sulfate 74abacavir sulfate-lamivudine 74abacavir sulfate-lamivudine-zidovudine 74ABELCET 45ABILIFY 1 MG/ML 73ABILIFY 10 MG 73ABILIFY 15 MG 73ABILIFY 2 MG 73ABILIFY 20 MG 73ABILIFY 30 MG 73ABILIFY 5 MG 73ABILIFY 9.75 MG/1.3ML 73ABILIFY DISCMELT 10 MG 73ABILIFY DISCMELT 15 MG 73ABILIFY MAINTENA 73ABRAXANE 66ABSORICA 10 MG, 20 MG, 25MG, 35 MG, 40 MG 95ABSORICA 30 MG 95acamprosate calcium 168acarbose 36ACCOLATE 23ACCUPRIL 51ACCURETIC 53acebutolol hcl 200 mg, 400mg 83ACEON 4 MG 51ACEON 8 MG 51acetaminophen 120 mg 8acetaminophen 160 mg 8acetaminophen 160 mg/5ml 8acetaminophen 160 mg/5ml, 80mg/0.8ml 8acetaminophen 160 mg/5ml, 80mg/2.5ml 8acetaminophen 80 mg 8acetaminophen 80 mg/0.8ml 8acetaminophen w/ codeine120mg/5ml-12mg/5ml 13acetaminophen w/ codeine300mg-15mg 13acetaminophen w/ codeine300mg-30mg, 300mg-60mg 13acetaminophen-caffeine-pyrilamine 8acetazolamide 250 mg 117

acetazolamide 500 mg 117acetic acid 126acetic acid (otic) 165acetic acid-aluminumacetate 165acetylcysteine 10 %, 20 % 95acitretin 100ACNE MEDICATION 96ACNE MEDICATION 10 96ACNE-AID 110ACTEMRA 5ACTHIB 178ACTIDOM DMX 93ACTIFLOVIT EARHEALTH 154ACTIGALL 124ACTIMMUNE 65ACTIQ 1200 MCG, 1600 MCG,400 MCG, 600 MCG, 800MCG 9ACTIQ 200 MCG 9ACTIVELLA 123ACTOPLUS MET 36ACTOS 15 MG 39ACTOS 30 MG 39ACTOS 45 MG 39ACUICYN DAILY EYELID &EYELASH CLEANSER 110ACULAR 163ACULAR LS 163acyclovir 200 mg 79acyclovir 200 mg/5ml 80acyclovir 400 mg, 800 mg 80acyclovir sodium 50 mg/ml 80acyclovir sodium 500 mg 80acyclovir topical 101ADACEL 174ADAGEN 84ADALAT CC 84adapalene 0.1 % 96ADCIRCA 86ADD-INS COMPLETE 158ADDERALL XR 1adefovir dipivoxil 78ADEMPAS 0.5 MG 87ADEMPAS 1 MG 87ADEMPAS 1.5 MG 87ADEMPAS 2 MG 87

ADEMPAS 2.5 MG 87ADIPEX-P 1ADOXA 100 MG, 50 MG, 75MG 173ADOXA PAK 1/100 173ADOXA PAK 1/150 173ADOXA PAK 2/100 173ADRENACLICK 180ADULT ACNOMEL 96ADVAIR DISKUS 24ADVAIR HFA 24ADVIL 5ADVIL ALLERGY &CONGESTION 93ADVIL MIGRAINE 5AEROCHAMBER MINIAEROSOLCHAMBER 136AEROCHAMBER MV 136AEROCHAMBER PLUS FLOWVU 137AEROCHAMBER PLUS FLOW-VU 137AEROCHAMBER PLUS FLOW-VU/LARGE MASK 137AEROCHAMBER PLUS FLOW-VU/MASK 137AEROCHAMBER PLUS FLOW-VU/MEDIUM MASK 137AEROCHAMBER PLUS FLOW-VU/SMALL MASK 137AEROCHAMBER Z-STAT PLUSVALVED HOLDING CHAMBERW/FLOW VU 137AEROCHAMBER Z-STATPLUS/FLOWSIGNAL 137AEROCHAMBER Z-STATPLUS/LARGE MASK 137AEROCHAMBER Z-STATPLUS/MEDIUM MASK 137AEROCHAMBER Z-STATPLUS/SMALL MASK 137AEROCHAMBER/FLOWSIGNAL

137AEROSPAN 23AEROVENT PLUS HOLDINGCHAMBER/COLLAPSIBLE 137AFINITOR 62AFINITOR DISPERZ 62AGGRENOX 128AGRYLIN 128AIRZONE PEAK FLOWMETER 137ALBENZA 16ALBUSTIX 115

Index 1

albuterol sulfate 0.083 %, 0.5 %,0.63 mg/3ml, 1.25 mg/3ml 24albuterol sulfate 2 mg, 4 mg 24albuterol sulfate 2 mg/5ml 24albuterol sulfate 4 mg, 8 mg 24alclometasone dipropionate102ALCOHOL PADS 136ALDACTAZIDE 25MG-25MG 117ALDACTONE 118ALDARA 107ALECENSA 62alendronate sodium 10 mg, 5mg 119alendronate sodium 35 mg, 70mg 119ALER-DRYL 46ALEVAZOL 98ALEVE 5alfuzosin hcl 127ALIMTA 100 MG 58ALIMTA 500 MG 58ALINIA 500 MG 18ALKERAN 2 MG 56ALKERAN 50 MG 56ALLI 1allopurinol 100 mg 127allopurinol 300 mg 127ALOE VESTA MULTIPURPOSECLEANSING 110ALOGLIPTIN 39ALOGLIPTIN/METFORMINHCL 36ALOGLIPTIN/PIOGLITAZONE12.5MG-15MG 36ALOGLIPTIN/PIOGLITAZONE12.5MG-30MG 36ALOGLIPTIN/PIOGLITAZONE12.5MG-45MG, 25MG-15MG,25MG-30MG, 25MG-45MG 36alosetron hcl 126ALPHA LIPOIC ACID 50 MG 3ALPHA-LIPOIC ACID 3alpha-lipoic acid (thioctic acid)100 mg 3ALPHAGAN P 0.1 % 161ALPHAGAN P 0.15 % 161alprazolam 0.25 mg, 0.5 mg, 1mg, 2 mg 21alprazolam 0.5 mg, 1 mg, 2 mg, 3mg 21ALTACE 51

alum & mag hydrox-simethicone 200mg-25mg-200mg 15alum & mag hydrox-simethicone 200mg/5ml-200mg/5ml-20mg/5ml-20mg/5ml-200mg/5ml-200mg/5ml, 200mg/5ml-20mg/5ml-200mg/5ml,400mg/5ml-400mg/5ml-40mg/5ml-40mg/5ml-400mg/5ml-400mg/5ml,400mg/5ml-40mg/5ml-400mg/5ml 15alum & mag hydrox-simethicone 200mg/5ml-20mg/5ml-200mg/5ml,400mg/5ml-40mg/5ml-400mg/5ml 15ALUMINUM ACETATE 110ALUMINUM HYDROXIDE 16aluminum hydroxide 110aluminum hydroxide-magtrisil 15aluminum sulfate & calciumacetate 110amantadine hcl 100 mg 68amantadine hcl 50 mg/5ml 68AMARYL 1 MG 41AMARYL 2 MG 41AMARYL 4 MG 41AMBIEN 10 MG 132AMBIEN 5 MG 132AMBIEN CR 12.5 MG 132AMBIEN CR 6.25 MG 132AMBISOME 45amcinonide 102AMERGE 142AMERICAINE 108AMICAR 0.25 GM/ML 131AMICAR 500 MG 131amifostine crystalline 66amikacin sulfate 1 gm/4ml, 500mg/2ml 3amiloride &hydrochlorothiazide 117amiloride hcl 118amino acid infusion 15% 158

amino acids 100mg-6.15mg-2.1mg-0.85mg-1.95mg-0.55mg-2.3mg-1.95mg-0.75mg-1.15mg-0.6mg-3.65mg-0.65mg-3.25mg-3.8mg-1.95mg-1.7mg-0.7mg-1.05mg, 115.333mg-54.667mg-21mg-33.333mg-33.333mg-46.667mg-14.167mg-46.667mg-40mg-53.333mg-18.167mg-41mg-66.667mg-40mg-30.667mg-17.333mg-14mg,115.3mg-54.7mg-21mg-33.3mg-13.3mg-33.3mg-63.3mg-14.2mg-46.7mg-40mg-53.3mg-18.2mg-41mg-66.7mg-40mg-30.7mg-17.3mg-14mg, 1200mg-100mg,18.33mg-200mg-33.33mg-50mg-23.16mg-58.33mg-18.33mg-75mg-108.33mg, 200mg-33.33mg-50mg-23.16mg-18.33mg-58.33mg-18.33mg-75mg-108.33mg, 35mg-29.5mg-24.667mg-4.833mg-17.667mg-24.667mg-12.5mg-24mg-19mg-36mg-17.5mg-4.667mg-75mg-15mg, 74mg-50mg-0.7mg-77mg-1.4mg-72mg-64mg-27mg-54mg-70mg-41mg-17mg-109mg-7mg-27mg-68mg-47mg-41mg-64mg,74mg-5mg-0.7mg-77mg-1.4mg-72mg-64mg-22mg-54mg-7mg-41mg-17mg-109mg-97mg-27mg-68mg-47mg-41mg-64mg 159amino acids 130mg-10mg-130mg-130mg 158amino acids-proteinhydrolysate 159aminocaproic acid 500 mg 131aminophylline 25aminosalicylic acid 56AMINOSYN II 15% (Use aminoacid infusion) 159amiodarone hcl 100 mg, 200 mg,400 mg 22amitriptyline hcl 35amlodipine besylate 10 mg 84amlodipine besylate 2.5 mg 84amlodipine besylate 5 mg 84amlodipine besylate-benazeprilhcl 53ammonium chloride 145amoxapine 35amoxicillin & pot clavulanate1000mg-62.5mg 167

Index 2

amoxicillin & pot clavulanate200mg-28.5mg, 400mg-57mg 167amoxicillin & pot clavulanate200mg/5ml-28.5mg/5ml,250mg/5ml-62.5mg/5ml,400mg/5ml-57mg/5ml,600mg/5ml-42.9mg/5ml 167amoxicillin & pot clavulanate250mg-125mg, 500mg-125mg,875mg-125mg 167amoxicillin 125 mg/5ml, 200mg/5ml, 250 mg/5ml, 400mg/5ml 166amoxicillin 250 mg, 500 mg 166amoxicillin 500 mg, 875 mg 166amoxicillin-clarithromycin w/lansoprazole 177amphetamine-dextroamphetamine 1amphotericin b 50 mg 45ampicillin & sulbactam sodium1gm-2gm 167ampicillin & sulbactam sodium5gm-10gm 167ampicillin 250 mg, 500 mg 166ampicillin sodium 1 gm, 2gm 166ampicillin sodium 10 gm 166AMPYRA 170ANADROL-50 14ANAFRANIL 35anagrelide hcl 128ANAPROX DS 5anastrozole 60ANCOBON 500 MG 45ANDRODERM 14ANDROGEL 20.25 MG/1.25GM,40.5 MG/2.5GM 14ANDROGEL 25 MG/2.5GM, 50MG/5GM 14ANDROGEL PUMP 1.62 % 14ANORO ELLIPTA 24ANTARA 30 MG 49ANTARA 90 MG 49ANTI-BACTERIAL HANDLOTION 110APOKYN 68apraclonidine hcl 161APRISO 125APTIOM 27APTIVUS 100 MG/ML 75APTIVUS 250 MG 75

AQUANIL SKINCLEANSER 110AQUORAL 149ARALAST NP 1000 MG 172ARALEN 55ARANESP ALBUMINFREE 129ARAVA 7ARCALYST 5argatroban 250 mg/2.5ml 26ARGIMENT 159ARGIMENT AT 159arginine 500 mg 159ARIAL CHAMBER 138ARICEPT 169ARICEPT ODT 169ARIMIDEX 60aripiprazole 1 mg/ml 73aripiprazole 10 mg 73aripiprazole 15 mg 73aripiprazole 2 mg 73aripiprazole 20 mg 74aripiprazole 30 mg 74aripiprazole 5 mg 74ARISTADA 74ARISTOSPAN INTRA-ARTICULAR 91ARIXTRA 25AROMASIN 60ARRANON 58ARTHRICARE DOUBLE ICEPAIN RELIEVING RUB 107ARTHRICARE PAINRELIEVINGRUB 107ARTHRICARE TRIPLEMEDICATED PAIN RELIEVINGRUB 107ARTHROTEC 50 5ARTHROTEC 75 5ARZERRA 59ASACOL HD 125ASCORBIC ACID 182ascorbic acid 100 mg 182ascorbic acid 1000 mg, 500 mg,500mg 182ascorbic acid 250 mg 182ascorbic acid 250 mg,250mg 182ascorbic acid 500 mg 182ascorbic acid 500 mg/ml 182

ASCRIPTIN 9ASPIRIN 120 MG, 200 MG 9aspirin 300 mg, 600 mg 9aspirin 324 mg, 325 mg, 500 mg,81 mg 9aspirin 325 mg 9aspirin buffered (cal carb-magcarb-mag oxide) 9ASPIRIN LOW DOSE 9ASPIRIN/DIPYRIDAMOLE 128ASSESS FULL RANGE PEAKFLOW METER 138ASSESS LOW RANGE PEAKFLOW METER 138ASSESS PEAK FLOW METERFULL RANGE 138ASSESS PEAK FLOW METERLOW RANGE 138ASTAGRAF XL 81ASTHMA CHECK METER-ZONESYSTEM 138ASTHMAMENTOR 138ATACAND 52ATACAND HCT 53atenolol & chlorthalidone 53atenolol 100 mg, 25 mg, 50mg 83ATIVAN 0.5 MG, 1 MG, 2MG 21ATIVAN 2 MG/ML 21ATIVAN 4 MG/ML 21ATOPICLAIR 108atorvastatin calcium 49atovaquone 18atovaquone-proguanil hcl 250mg-100mg 55ATRIPLA 75ATROVENT 156ATROVENT HFA 23AUBAGIO 170AUGMENTIN 250MG/5ML-62.5MG/5ML 167AUGMENTIN 500MG-125MG,875MG-125MG 167AUGMENTIN ES-600 167AUGMENTIN XR 167AURSTAT ANTI-ITCHHYDROGEL 108AUVI-Q 180AVALIDE 53AVANDIA 2 MG 39AVANDIA 4 MG 40

Index 3

AVAPRO 52AVASTIN 59AVEED 14AVEENO MOISTURIZING 110AVEENO POSITIVELYAGELESSDAILY EXFOLIATINGCLEANSER 110AVEENO POSITIVELYRADIANTCLEANSER 110AVEENO SKIN RELIEFSHOWER& BATH 101AVEENO ULTRA-CALMINGCLEANSER 110AVENOVA 110AVENOVA/NEUTROX 110AVODART 127AVONEX 170AVONEX PEN 170AXSAIN 108AYR NASAL DROPS 156azacitidine 58AZACTAM 16AZATHIOPRINE 100 MG 81azathioprine 100 mg, 50 mg, 75mg 81azelastine hcl (ophth) 163azelastine hcl 0.1 % 156AZILECT 69azithromycin 100 mg/5ml, 200mg/5ml 135azithromycin 250 mg, 500 mg,600 mg 135azithromycin 500 mg 135AZOPT 163aztreonam 16AZULFIDINE 125AZULFIDINE EN-TABS 125

b complex w/ c 10.2mg-10.2mg-10mg-10mg-50mg-50mg-15mg-15mg-5mg-5mg-300mg-300mg, 100mg-100mg-25mg-20mg-6mg-15mcg-100mg-5mcg-2mg-150mg,100mg-100mg-5.5mg-20mg-15mcg-25mg-400mcg-5mcg-2mg-150mg, 100mg-10mg-20mg-10mcg-15mg-5mg-500mg, 100mg-20mg-5.5mg-15mcg-2mg-25mg-150mg-400mcg-5mcg-150mg, 10mg-10mg-15mg-50mg-5mg-300mg,15mg-10.2mg-10mg-50mg-5mg-300mg, 15mg-10mg-50mg-10.2mg-5mg-300mg,15mg-10mg-50mg-10.2mg-6mcg-400mcg-5mg-300mg,15mg-10mg-50mg-10mg-5mg-300mg, 15mg-150mg-10mg-50mg-10.2mg-5mg-300mg,15mg-20mg-50mg-10mg-10mcg-5mg-300mg, 15mg-50mg-10.2mg-10mg-5mg-300mg, 50mg-10.2mg-10mg-15mg-5mg-300mg, 50mg-10mg-10mg-15mg-5mg-300mg,50mg-15mg-10mg-10.2mg-5mg-300mg 150b complex w/ c 10.2mg-10mg-15mg-50mg-5mg-300mg,10mg-50mg-10.2mg-15mg-5mg-300mg, 10mg-50mg-10mg-15mg-5mg-300mg,15mg-10mg-50mg-10mg-5mg-300mg 150B-1 182B-100 COMPLEX 150B-6 FOLIC ACID 130b-complex vitamins 0.1mg-20mg-2mg-5mcg-3mg-1mg,100mg-50mg-40mg-10mg-20mg-5mg-4.6mg-1mcg-5mg-1mg, 10mg-10mg-2mg-1.5mg-0.2mg, 10mg-14mg-25mcg-7mg-4.5mg, 15mg-2mg-5mg-2mcg-2mg-2mg, 30mg-50mg-50mg-50mg-50mg-50mg-50mcg-50mg-100mcg-50mcg-50mg, 3mg-10mg-20mg-3mg-6mcg-2mg, 3mg-20mg-3mg-10mg-6mcg-2mg, 3mg-3mg-20mg-20mg-3mg-3mg-10mg-10mg-6mcg-6mcg-2mg-2mg,83mg-3mg-20mg-2mg-5mcg-1mg 149

b-complex vitamins 2mg/ml-100mg/ml-2mg/ml-100mg/ml-2mg/ml 149b-complex vitamins 2mg/ml-2%-100mg/ml-2mg/ml-100mg/ml-2mg/ml 149b-complex vitamins 60mg-60mg-3mg-5mg-20mg-3mg-1mcg-0.5mg, 60mg-60mg-5mg-20mg-3mg-1mcg-3mg-0.5mg, 70mg-100mg-1mg-10mg-2mg-1.5mg-100mcg 149b-complex w/ c & folic acid 10mg-20mg-1.5mg-1mg-1.5mg-5mg-300mcg-50mg-60mg, 20mg-1.5mg-10mg-1mg-1.5mg-5mg-300mcg-50mg-60mg 150b-complex w/ folic acid 1.5mg-20mg-1.7mg-6mcg-400mcg-2mg,1.7mg-10mg-6mcg-1.2mg-20mg-0.4mg-2mg, 100mg-100mg-100mg-100mcg-400mcg-100mg,100mg-100mg-100mg-100mg-10mcg-400mcg-100mcg-100mg,10mg-10mg-50mg-10mg-10mg-10mg-10mcg-10mg-400mcg-10mcg-10mg, 10mg-20mg-1.7mg-6mcg-1.5mg-400mcg-2mg, 15mg-100mg-200mg-17mg-60mcg-400mcg-20mg, 30mg-20mg-50mg-30mg-10mg-10mcg-400mcg-8mg, 40mcg-1mg-6mg-5mcg-3mg-2mcg-19mcg, 50mg-50mg-50mg-50mcg-50mg-400mcg-50mcg-50mg 150b-complex w/ folic acid 100mg-100mg-100mg-100mg-100mcg-400mcg-100mcg-100mg, 125mg-125mg-125mg-125mg-125mcg-125mg-125mg-400mcg-125mcg-125mg, 50mg-50mg-50mg-50mg-50mcg-0.4mg-50mcg-50mg,50mg-50mg-50mg-50mg-50mcg-100mcg-50mcg-50mg 150BABY ANBESOL 148BABY DDROPS 181BABY ORAJEL 148BACIGUENT 97bacitracin (topical) 97bacitracin zinc 97bacitracin-poly-neomycin-hc

163bacitracin-polymyxin b 97bacitracin-polymyxin b(ophth) 161baclofen 10 mg 155

Index 4

baclofen 20 mg 155BACTRIM 17BACTRIM DS 17BACTROBAN 97balsalazide disodium 125BANZEL 27BARACLUDE 0.05 MG/ML 78BARACLUDE 0.5 MG, 1 MG 78BASIS ALL CLEAR 110BASIS COMBINATION 110BASIS EXTRA DRY 110BASIS NORMAL/DRY 110BASIS SENSITIVE SKIN 110bath products 40%-40%-40%-40%, 5%-5%-5% 101BD GLUCOSE 38BELEODAQ 62BELSOMRA 10 MG 132BELSOMRA 15 MG 132BELSOMRA 20 MG 132BELSOMRA 5 MG 132BELVIQ 1BELVIQ XR 1BENADRYL ALLERGY 46BENADRYL ALLERGYCHILDRENS 12.5 MG 46BENADRYL ALLERGYCHILDRENS 12.5 MG/5ML 46BENADRYL DYE-FREEALLERGYLIQUID-GELS 46benazepril &hydrochlorothiazide 53benazepril hcl 10 mg, 20 mg, 40mg, 5 mg 51BENDEKA 56BENLYSTA 120 MG 83BENSULFOID 96BENTYL 10 MG 174BENTYL 20 MG 174BENZACLIN 96BENZACLIN WITH PUMP 96BENZALKONIUMCHLORIDE 74BENZAMYCIN 96BENZEDREX INHALER 156benzocaine (dental) 20 % 148benzocaine (dental) 7.5 % 148benzocaine-resorcinol vaginal2%-5% 179

benzonatate 100 mg, 200mg 93benzoyl peroxide 5 % 96benzoyl peroxide-erythromycin 96benzphetamine hcl 25 mg 1benztropine mesylate 0.5 mg, 1mg, 2 mg 67benztropine mesylate 1mg/ml 67BERINERT 128BETA CAROTENE 10000UNIT 181beta carotene 25000 unit 181BETAGAN 161betamethasone dipropionate(topical) 102betamethasone dipropionateaugmented 102betamethasone sod phosphate& acetate 91betamethasone valerate 0.1% 102betamethasone valerate 0.12% 102BETAPACE 84BETAPACE AF 84BETASERON 170betaxolol hcl 83betaxolol hcl (ophth) 161bethanechol chloride 10 mg, 25mg, 5 mg, 50 mg 178BETHKIS 3bexarotene 65BIAXIN 135bicalutamide 60BICILLIN C-R 300000UNIT/ML-300000UNIT/ML 167BICILLIN C-R900000UNIT/2ML-300000UNIT/2ML 167BICILLIN L-A 167BICNU 56BIMATOPROST 165BIOFLEXOR 107biotin 300 mcg 182biotin 5 mg, 5000 mcg, 800mcg 182BIOTIN 800 MCG 182BIPHENOX 8bisacodyl 10 mg 134bisacodyl 5 mg 134

bismuth subsalicylate 262mg 42bismuth subsalicylate 262mg/15ml, 525 mg/30ml, 527mg/30ml 43bismuth subsalicylate 525mg/15ml 43bisoprolol &hydrochlorothiazide 53bisoprolol fumarate 83BIVIGAM 166bleomycin sulfate 61BLEPH-10 161BLINCYTO 59BLUE-EMU SUPERSTRENGTH 107BODI WHIRL OIL 101BODY WASH &SHAMPOO 110BONIVA 150 MG 119BONIVA 3 MG/3ML 119BOOSTRIX 174boric acid in isopropyl 165BOSULIF 62BOTOX 157BREATHERITE 138BREATHERITECOLLAPSIBLEADULT SPACERW/MASK 138BREATHERITECOLLAPSIBLECHILD SPACERW/MASK 138BREATHERITECOLLAPSIBLEINFANT SPACERW/MASK 138BREATHERITECOLLAPSIBLESMALL CHILDSPACER W/MASK 138BREATHERITECOLLAPSIBLESPACER W/NEONATE MASK 138BREATHERITE RIGIDSPACERW/MASK 138BREATHERITE W/LARGEMASK 138BREATHERITE W/MEDIUMMASK 138BREATHERITE W/SMALLMASK 138BREO ELLIPTA 25MCG/INH-100MCG/INH, 25MCG/INH-200MCG/INH 24BREVICON-28 89BRILINTA 128brimonidine tartrate 161

Index 5

BRINTELLIX 10 MG 33BRINTELLIX 20 MG 33BRINTELLIX 5 MG 34BRISDELLE 172BRIVIACT 10 MG 27BRIVIACT 10 MG/ML 27BRIVIACT 100 MG 27BRIVIACT 25 MG 27BRIVIACT 50 MG 27BRIVIACT 50 MG/5ML 27BRIVIACT 75 MG 27bromfenac sodium (ophth) 164bromocriptine mesylate 2.5mg 68bromocriptine mesylate 5 mg68brompheniramine & phenyleph1mg/5ml-1mg/5ml-2.5mg/5ml-2.5mg/5ml, 1mg/5ml-2.5mg/5ml 93brompheniramine &pseudoeph 93budesonide 91budesonide (inhalation) 0.25mg/2ml, 0.5 mg/2ml 23budesonide (nasal) 156BUFFERIN 9BULL FROG QUIK GEL SPF36 114BULL FROG QUIK GEL SPF50 114BULL FROG QUIK GELSPORTSPF 36 114BULL FROG QUIK GELSPORTSPRAY SPF 50 114BULL FROG SPF 36 114BULL FROG WATER ARMORSPORT QUIK GEL SPF 50 114BULL FROG WATER ARMORSPORT QUIK SPRAY SPF50 114bumetanide 0.5 mg, 1 mg, 2mg 118BUMEX 118BUPRENEX 14buprenorphine hcl 0.3 mg/ml 14buprenorphine hcl 2 mg 14buprenorphine hcl 8 mg 14buprenorphine hcl-naloxone hcldihydrate 2mg-0.5mg 14buprenorphine hcl-naloxone hcldihydrate 8mg-2mg 14bupropion hcl (smokingdeterrent) 171

bupropion hcl 100 mg 31bupropion hcl 150 mg 32bupropion hcl 200 mg 32bupropion hcl 300 mg 32bupropion hcl 75 mg 31BURN SPRAY 108buspirone hcl 10 mg, 15 mg, 30mg, 5 mg, 7.5 mg 20BUSULFEX 56butalbital-aspirin-caffeinew/cod 13BUTISOL SODIUM 30MG 132butorphanol tartrate 10mg/ml 14butorphanol tartrate 2mg/ml 14BYDUREON 39BYDUREON PEN 39BYETTA 39cabergoline 122CABOMETYX 62CALAMINE 110CALAMINEPHENOLATED 110CALAN 84CALAN SR 84CALCI-CHEW 144CALCI-MIX 144CALCIONATE 144calcipotriene 100calcitonin (salmon) 119calcitriol 0.25 mcg, 0.5mcg 121calcitriol 1 mcg/ml 121CALCIUM &MAGNESIUM 144calcium & phosphorus w/vitamin d 144calcium 600 mg 145calcium acetate (phosphatebinder) 126calcium ascorbate 182calcium carbonate (antacid)500 mg, 750 mg 16calcium carbonate (antacid)600 mg 16calcium carbonate (antacid)648 mg 16calcium carbonate 1250 mg,1500 mg, 500 mg, 600 mg,600mg 144

calcium carbonate-cholecalciferol500mg-100unit 144calcium carbonate-cholecalciferol500mg-200unit 144calcium carbonate-cholecalciferol600mg-500unit 144calcium carbonate-vitamin d125unit-250mg, 125unit-500mg,250mg-125unit, 500mg-125unit 144calcium carbonate-vitamin d200unit-500mg, 500mg-200unit,500mg-500mg-200unit-200unit

144calcium citrate 200 mg, 950mg 144CALCIUM CITRATE 250MG 144CALCIUM CITRATEMALATE/VITAMIN D 144calcium citrate-vitamin d 250mg-200unit 144calcium citrate-vitamin d 315mg-200unit 144calcium gluconate 10 % 144CALCIUM GLUCONATE 500MG 145CALCIUM LACTATE 648MG 145CALCIUM LACTATE 750MG 145calcium polycarbophil 133calcium w/ magnesium 500mg-250mg 145CALCIUM/VITAMIN D 145CALICYLIC 108CAMPATH 59CAMPRAL 168CAMPTOSAR 100 MG/5ML, 40MG/2ML 67CAMPTOSAR 300MG/15ML 67CANCIDAS 50 MG 44CANCIDAS 70 MG 44candesartan cilexetil 52candesartan cilexetil-hydrochlorothiazide 53CAPASTAT SULFATE 56CAPRELSA 62captopril &hydrochlorothiazide 53captopril 100 mg, 12.5 mg, 25mg, 50 mg 51CARAC 100CARAFATE 1 GM 176

Index 6

CARBAGLU 121carbamazepine 100 mg 27carbamazepine 100 mg, 200 mg,300 mg 27carbamazepine 100 mg, 200 mg,400 mg 27carbamazepine 100 mg/5ml 27carbamazepine 200 mg 27carbamide peroxide 148carbamide peroxide (otic) 165CARBATROL 27carbidopa 67carbidopa-levodopa 68carbinoxamine maleate 46carboplatin 56CARDIZEM 84CARDIZEM CD 84CARDIZEM LA 180 MG, 240 MG,300 MG, 360 MG, 420 MG 84CARDURA 52carisoprodol 350 mg 155CARMOL 106CARMOL 20 106CARRAFOAM 110carteolol hcl (ophth) 161carvedilol 12.5 mg 83carvedilol 25 mg 83carvedilol 3.125 mg 83carvedilol 6.25 mg 83CASODEX 60CATAFLAM 5CATAPRES 52CATAPRES-TTS-1 52CATAPRES-TTS-2 52CATAPRES-TTS-3 52CAVILON NO STINGBARRIERFILM 110CAYSTON 16cefaclor 250 mg, 500 mg 87cefadroxil 1 gm 87cefadroxil 500 mg 87cefadroxil 500 mg/5ml 87cefazolin sodium 1 gm, 10 gm,500 mg 87cefdinir 88CEFEPIME 2 GM/100ML 89cefepime hcl 89cefixime 88

cefoxitin sodium 1 gm 87cefoxitin sodium 10 gm 87cefoxitin sodium 2 gm 87cefpodoxime proxetil 100 mg,200 mg 88cefpodoxime proxetil 100mg/5ml 88cefprozil 250 mg, 500 mg 87cefprozil 250 mg/5ml 87ceftazidime 1 gm, 2 gm 88ceftazidime 6 gm 88CEFTIN 250 MG, 500 MG 88ceftriaxone sodium 1 gm 88ceftriaxone sodium 10 gm 88ceftriaxone sodium 2 gm 88ceftriaxone sodium 250 mg88ceftriaxone sodium 500 mg88cefuroxime axetil 88cefuroxime sodium 1.5 gm 88CELEBREX 5celecoxib 5CELESTONE-SOLUSPAN 91CELEXA 10 MG 32CELEXA 20 MG 32CELEXA 40 MG 32CELLCEPT 200 MG/ML 81CELLCEPT 250 MG 81CELLCEPT 500 MG 81CELLCEPTINTRAVENOUS 81CELONTIN 31CENTANY 98CEO-TWO 134cephalexin 125 mg/5ml, 250mg/5ml 87cephalexin 250 mg, 500 mg,750 mg 87CERALYTE 70 60MEQ/L-70MEQ/L-20MEQ/L-30MEQ/L

145CERASPORT 4MEQ/L-18MEQ/L-20MEQ/L-6MEQ/L

145CERASPORT EX1 145CERDELGA 129CEREBYX 100 MGPE/2ML 30CEREBYX 500 MGPE/10ML 30CEREFOLIN 117

CEREZYME 129CERVARIX 178CESAMET 44CETAPHIL GENTLECLEANSING 110cetirizine hcl 1 mg/ml 47cetirizine-pseudoephedrine 93cevimeline hcl 149CHANTIX 172CHANTIX CONTINUINGMONTHPAK 172CHEK-STIX COMBO PAKURINALYSIS CONTROL 115CHEK-STIX CONTROL 115CHEMSTRIP -10 WITH SG 115CHEMSTRIP 10 MD 115CHEMSTRIP 2 GP STRIPS115CHEMSTRIP 2 LN STRIPS 115CHEMSTRIP 5 OB 115CHEMSTRIP 7 115CHEMSTRIP 9 STRIPS 115CHEMSTRIP UGK 115CHEMSTRIP-K 115CHEMSTRIP-MICRAL 116chenodiol 124CHERRY CONCENTRATE 168CHERRY SYRUP 168CHEW Q 100 MG 3CHILDRENS MOTRIN JUNIORSTRENGTH 5CHILDRENS PLUS COLD 94CHLOR-TRIMETON 2MG/5ML 46CHLOR-TRIMETON 4 MG 46chloramphenicol sodiumsuccinate 18chlordiazepoxide-amitriptyline

170chlorhexidine gluconate (mouth-throat) 149chloroquine phosphate 250 mg,500 mg 55chlorothiazide 500 mg 118chlorpheniramine &phenylephrine 4mg-10mg 94chlorpheniramine & pseudoeph15mg/5ml-1mg/5ml 94chlorpheniramine maleate 2mg/5ml 46chlorpheniramine maleate 4mg 46chlorpheniramine w/ codeine 94

Index 7

chlorpromazine hcl 10 mg, 100mg, 200 mg, 25 mg, 50 mg 72chlorpromazine hcl 25 mg/ml72chlorpromazine hcl 50mg/2ml 72chlorthalidone 25 mg 118chlorzoxazone 155cholecalciferol 1000 unit, 2000unit, 400 unit 181cholecalciferol 1000 unit, 2000unit, 400 unit, 5000 unit 181cholecalciferol 400 unit/ml 181cholecalciferol 400unt/0.03ml 181cholecalciferol 5000 unit, 50000unit 181cholestyramine 4 gm 48cholestyramine 4 gm/dose 48cholestyramine light 48choline fenofibrate 49chorionic gonadotropin 120chromium 200 mcg 148chromium picolinate 200mcg 147ciclopirox 0.77 % 98ciclopirox 1 % 98ciclopirox 8 % 98ciclopirox olamine 98cidofovir 78cilostazol 128CILOXAN 161cimetidine 200 mg 175cimetidine 300 mg, 400 mg, 800mg 175CIMZIA 125CIMZIA STARTER KIT 125CINQAIR 22CINRYZE 128CIPRO 250 MG, 500 MG 123CIPRO I.V.-IN D5W 123CIPRO XR 123CIPRODEX 165ciprofloxacin 400 mg/40ml 123ciprofloxacin hcl (ophth) 162ciprofloxacin hcl 100 mg, 250 mg,500 mg, 750 mg 123ciprofloxacin in d5w200mg/100ml-5% 123ciprofloxacin in d5w400mg/200ml-5% 123

ciprofloxacin-ciprofloxacinhcl 123cisplatin 100 mg/100ml, 200mg/200ml, 50 mg/50ml 56citalopram hydrobromide 10mg 32citalopram hydrobromide 10mg/5ml 32citalopram hydrobromide 20mg 32citalopram hydrobromide 40mg 33CITRACAL/VITAMIN D 145CITRUCEL FIBERLAXATIVE 133cladribine 58CLARINEX 5 MG 47clarithromycin 250 mg, 500mg 136clarithromycin 250mg/5ml 136clarithromycin 500 mg 136CLARITIN 10 MG 47CLEARASIL DAILYCLEAR 96clemastine fumarate 2.68mg 47CLEOCIN 150 MG, 300 MG, 75MG 18CLEOCIN 2 % 180CLEOCIN IN D5W 18CLEOCIN PHOSPHATE300MG/50ML-5%,600MG/50ML-5%,900MG/50ML-5% 19CLEOCIN PHOSPHATE 600MG/4ML, 900 MG/6ML 18CLEOCIN-T 96CLEVER CHOICE ANTI-STATICVALVED HOLDINGCHAMBER/ADULTLARGE 139CLEVER CHOICE ANTI-STATICVALVED HOLDINGCHAMBER/MEDIUM 139CLEVER CHOICE ANTI-STATICVALVED HOLDINGCHAMBER/SMALL 139CLIMARA 123CLINDAGEL 96clindamycin hcl 150 mg, 300mg, 75 mg 19clindamycin palmitatehydrochloride 19clindamycin phosphate(topical) 96

clindamycin phosphate 150mg/ml, 600 mg/4ml 19clindamycin phosphate 150mg/ml, 9000 mg/60ml 19clindamycin phosphate 600mg/4ml, 900 mg/6ml 19clindamycin phosphate ind5w 19clindamycin phosphatevaginal 180clindamycin phosphate-benzoylperoxide 96clindamycin phosphate-benzoylperoxide (refrigerate) 96CLINISTIX 116CLINITEST 116CLINITEST REAGENT 116clobetasol propionate 102clobetasol propionate emollientbase 102clobetasol propionateemulsion 103CLOBEX 103CLOLAR 58clomipramine hcl 25 mg, 50 mg,75 mg 35clonazepam 0.125 mg, 0.25 mg,0.5 mg, 1 mg, 2 mg 26clonazepam 0.5 mg 26clonazepam 1 mg 26clonazepam 2 mg 26clonidine hcl (adhd) 2clonidine hcl 0.1 mg, 0.2 mg, 0.3mg 53clonidine hcl 0.1 mg/24hr, 0.2mg/24hr, 0.3 mg/24hr 52clopidogrel bisulfate 300mg 128clopidogrel bisulfate 75 mg 128clorazepate dipotassium 21clotrimazole 148clotrimazole (topical) 98clotrimazole vaginal 1 % 180clotrimazole w/betamethasone 98CLOVERINE SALVE 98clozapine 71CLOZAPINE ODT 71CLOZARIL 71COAL TAR 89coal tar extract 1 % 115COARTEM 55

Index 8

cod liver oil 10 minim, 110mg-2664unit-1000mg-100mg-200unit, 1250unit-130unit,1250unit-133.33unit, 1250unit-133unit, 1250unit-135unit,200unit-4000unit, 20mg-35mg-1250unit-45mg-133.333unit,34mg-1250unit-415mg-32mg-135unit, 50mg-110mg-250unit-110mg-100unit-10unit, 52mg-2500unit-600mg-52mg-270unit,530mg-1250unit-130unit, 90mg-37mg-415mg-36mg-1250unit-135unit 153COD LIVER OIL 4000UNIT/5ML-400UNIT/5ML, 5000UNIT/5ML-500UNIT/5ML 153COD LIVER OIL FOR KIDS153CODITUSSIN AC 94coenzyme q10 (ubidecarenone)10 mg, 150 mg, 60 mg 3coenzyme q10 (ubidecarenone)30 mg 3COENZYME Q10 25 MG 3COENZYME Q10 60 MG 3COGENTIN 67COLACE 135COLACE CLEAR 135COLAZAL 125COLCHICINE 127colchicine w/ probenecid 127COLCRYS 127COLESTID 48COLESTID FLAVORED 5GM 48colestipol hcl 48colistimethate sodium 16COLY-MYCIN M 16COLYTE-FLAVOR PACKS227.1GM-21.5GM-5.53GM-2.82GM-6.36GM 133COLYTE-FLAVOR PACKS240GM-22.72GM-5.84GM-2.98GM-6.72GM 134COMBISTIX 116COMBIVENT RESPIMAT 24COMBIVIR 75COMETRIQ 62COMPACT SPACECHAMBER/ANTI-STATIC 139COMPACT SPACECHAMBER/ANTI-STATIC/LARGE MASK 139

COMPACT SPACECHAMBER/ANTI-STATIC/MEDIUM MASK 139COMPACT SPACECHAMBER/ANTI-STATIC/SMALL MASK 139COMPLERA 75COMPLEX MSUD AMINOACID BAR 159COMTAN 68COMVAX 178CONCERTA 27 MG, 36 MG 2CONDOMS 136CONDYLOX 107CONTI CASTILE SOAP 110CONTRAVE 1COPAXONE 20 MG/ML 170COPAXONE 40 MG/ML 170COPEGUS 78CORAL CALCIUM 500MG 145CORDARONE 22COREG 12.5 MG 83COREG 25 MG 83COREG 3.125 MG 83COREG 6.25 MG 83COREG CR 83CORGARD 84CORLANOR 5 MG 87CORLANOR 7.5 MG 87CORTEF 91CORTENEMA 15cortisone acetate 91CORZIDE 53COSENTYX 100COSENTYX SENSOREADYPEN 100COSMEGEN 61COSOPT 161COTELLIC 62COUMADIN 25COZAAR 52CREON 117CRESEMBA 186 MG 45CRESEMBA 372 MG 45CRESTOR 49CRIXIVAN 75cromolyn sodium 22

cromolyn sodium(mastocytosis) 124cromolyn sodium (ophth) 164CUBICIN 18CUBICIN RF 18CUPRIMINE 80CURE-ALL 108CUTAR 115CUTIVATE 103CUVITRU 166CVS COD LIVER OIL 153CVS GLUCOSE 4 GM 38CVS HDYROCORTISONEACETATE 103CVS KETONE CARE 116CVS NATURAL FIBERSUPPLEMENT 133CVS SALINE WOUNDWASH 111cyanocobalamin 1000 mcg 129cyanocobalamin 250 mcg 129cyclobenzaprine hcl 10 mg, 5mg 155cyclopentolate hcl 1 % 161CYCLOPHOSPHAMIDE 25 MG,50 MG 57CYCLOSET 39cyclosporine 100 mg, 25 mg 81cyclosporine 50 mg/ml 81cyclosporine modified (formicroemulsion) 100 mg, 25 mg,50 mg 81CYKLOKAPRON 131CYMBALTA 34cyproheptadine hcl 2 mg/5ml48cyproheptadine hcl 4 mg 48CYRAMZA 59CYSTARAN 164cytarabine 58CYTOMEL 174CYTOTEC 177CYTOVENE 78D-VI-SOL 181D.H.E. 45 142dacarbazine 65DACOGEN 58dakin's solution 0.25 %, 0.5% 74DAKLINZA 78DALIRESP 23

Index 9

danazol 100 mg, 200 mg, 50mg 14DANTRIUM 155dantrolene sodium 100 mg, 25mg, 50 mg 155dapsone 100 mg, 25 mg 18DAPTACEL 174daptomycin 18DARAPRIM 55DARZALEX 59daunorubicin hcl 62DAYPRO 5DDAVP 122DEBROX 165decitabine 58DECON-A 2MG/5ML-5MG/5ML 94DEEP BLUE RELIEF 107DELESTROGEN 10MG/ML 123DELESTROGEN 20 MG/ML, 40MG/ML 123DELZICOL 125DEMADEX 118demeclocycline hcl 173DEMEROL 100 MG/ML, 50MG/ML 9DEMEROL 25 MG/ML 9DEMSER 52DENAVIR 101DEPACON 31DEPAKENE 31DEPAKOTE 31DEPAKOTE ER 31DEPAKOTE SPRINKLES 31DEPEN TITRATABS 80DEPO-MEDROL 20 MG/ML 91DEPO-MEDROL 40 MG/ML, 80MG/ML 91DEPO-PROVERA 60DEPO-PROVERACONTRACEPTIVE 91DERMA-SMOOTHE/FSBODY 103DERMA-SMOOTHE/FSSCALP 103DERMAGRAN 109DERMAREST ROSACEA 109DERMATOP 103DERMAZINC BABY 101

DERMAZINC SCALP 101DERMAZINC SPRAY 101DERMOPLAST 108DERMOPLAST PAINRELIEVINGSPRAY 108DERMOTIC 165DESCOVY 75desipramine hcl 10 mg, 100mg, 150 mg, 25 mg, 50 mg, 75mg 35desloratadine 47desmopressin acetate 0.1 mg,0.2 mg 122desmopressin acetate 4mcg/ml 122desmopressin acetaterefrigerated 122desmopressin acetatespray 122desmopressin acetate sprayrefrigerated 122DESOGEN 89desogestrel & ethinylestradiol 89desogestrel-ethinyl estradiol(biphasic) 89desonide 103DESOWEN 103desoximetasone 0.05 % 103desoximetasone 0.25 % 103DESOXYN 1DESVENLAFAXINE ER 100MG, 50 MG 34DETROL 177DETROL LA 177DEX4 QUICK DISSOLVEGLUCOSE 38dexamethasone 0.5 mg, 0.75mg, 1 mg, 1.5 mg, 2 mg, 4 mg,6 mg 92dexamethasone 0.5mg/5ml 92dexamethasone 1.5 mg 92dexamethasone sodiumphosphate (ophth) 163dexamethasone sodiumphosphate 10 mg/ml 92dexamethasone sodiumphosphate 100 mg/10ml, 120mg/30ml, 20 mg/5ml, 4mg/ml 92

DEXATRIM MAX 1MG-5.5UNIT-34MCG-72MG-75MG-0.35MG-70MG-45MG-0.263MG-10MG-1.8MG-3.5MG-0.3MG-3MCG-70MCG-0.35MG-25MG-30MG

117dexbrompheniramine &pseudoephedrine 94DEXEDRINE 1DEXERYL 109DEXILANT 176dexmethylphenidate hcl 10 mg,2.5 mg, 5 mg 2dexmethylphenidate hcl 15mg 2dexrazoxane 250 mg, 500mg 66dextroamphetamine sulfate 10mg, 15 mg, 5 mg 1dextroamphetamine sulfate 10mg, 5 mg 1dextrose (diabetic use) 15gm/38gm, 40 % 38dextrose 10 % 157dextrose 5 % 157dextrose in lactated ringers 145dextrose w/ sodium chloride0.45%-2.5%, 0.45%-5% 145dextrose w/ sodium chloride0.9%-5% 145DHS ZINC 101DIABETA 1.25 MG 41DIABETA 2.5 MG 41DIABETA 5 MG 41DIABETIDERMCLEANSING 111DIAMOX 117DIASTAT ACUDIAL 26DIASTAT PEDIATRIC 26DIASTIX 116diazepam 1 mg/ml 21diazepam 10 mg, 2 mg, 5mg 21DIAZEPAM 10 MG, 2.5 MG, 20MG 26diazepam 5 mg/ml 21DIBENZYLINE 52diclofenac potassium 5diclofenac sodium (actinickeratoses) 100diclofenac sodium (ophth) 164diclofenac sodium (topical) 1% 97diclofenac sodium 100 mg 5

Index 10

diclofenac sodium 25 mg, 50 mg,75 mg 5diclofenac w/ misoprostol 5dicloxacillin sodium 167dicyclomine hcl 10 mg 174dicyclomine hcl 20 mg 174didanosine 75diethylpropion hcl 25 mg 1DIETHYLPROPION HCL 25MG 1diethylpropion hcl 75 mg 1DIFFERIN 0.1 % 96DIFICID 136diflorasone diacetate 103DIFLUCAN 45diflunisal 9DIGOXIN 0.05 MG/ML 85digoxin 0.125 mg, 125 mcg 85digoxin 0.25 mg, 250 mcg 85dihydroergotamine mesylate 1mg/ml 142DILANTIN-125 30DILAUDID 1 MG/ML 9DILAUDID 2 MG 9DILAUDID 2 MG/ML 9DILAUDID 4 MG 9DILAUDID 8 MG 9DILAUDID-HP 10 MG/ML 9diltiazem hcl 120 mg, 180 mg,240 mg 85diltiazem hcl 120 mg, 30 mg, 60mg, 90 mg 85diltiazem hcl 120 mg, 60 mg, 90mg 85diltiazem hcl coated beads 84diltiazem hcl extended releasebeads 85DIMETAPP COLD & ALLERGY1MG/5ML-2.5MG/5ML 94dimethicone-zinc oxide-vitamin a-vitamin d 111DIOVAN 52DIOVAN HCT 53DIPENTUM 125diphenhydramine hcl(topical) 100diphenhydramine hcl 12.5mg 47diphenhydramine hcl 12.5mg/5ml 47

diphenhydramine hcl 12.5mg/5ml, 25 mg/10ml, 50mg/20ml 47diphenhydramine hcl 25mg 47diphenhydramine hcl 50mg/ml 47diphenhydramine-phenylephrine 12.5mg/5ml-5mg/5ml 94diphenhydramine-phenylephrine 25mg-10mg 94diphenhydramine-phenylephrine-acetaminophen12.5mg-12.5mg-325mg-325mg-5mg-5mg, 12.5mg-325mg-5mg 94diphenhydramine-phenylephrine-acetaminophen12.5mg/5ml-160mg/5ml-2.5mg/5ml 94diphenhydramine-pseudoephedrine-acetaminophen 94diphenoxylate w/ atropine 43DIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC 174DIPROLENE 103DIPROLENE AF 103dipyridamole 25 mg, 50 mg, 75mg 128disopyramide phosphate 21disulfiram 250 mg, 500mg 169DITROPAN XL 177divalproex sodium 31DIVIGEL 123dobutamine hcl 181DOCEFREZ 66docetaxel 140 mg/7ml, 20mg/ml, 80 mg/4ml 66DOCETAXEL 160 MG/16ML,20 MG/2ML, 200 MG/20ML, 80MG/8ML 66DOCETAXEL 20 MG/ML, 80MG/4ML 66docosahexaenoic acid 200mg 158docusate calcium 135docusate sodium 100 mg 135docusate sodium 100 mg, 250mg, 50 mg 135docusate sodium 150 mg/15ml,50 mg/5ml 135

docusate sodium 60mg/15ml 135DOCUSOL KIDS 135DOCUSOL MINI 135DOCUSOL PLUS MINI-ENEMA 135dofetilide 22DOLOPHINE 10 MG 9DOLOPHINE 5 MG 9DOMEBORO 111DOMETUSS-DMX 94donepezil hydrochloride 169dorzolamide hcl 164dorzolamide hcl-timololmaleate 161DOVONEX 100doxazosin mesylate 53doxepin hcl 10 mg, 100 mg, 150mg, 25 mg, 50 mg, 75 mg 35doxepin hcl 10 mg/ml 35DOXIL 62doxorubicin hcl 10 mg, 50mg 62doxorubicin hcl 2 mg/ml 62doxorubicin hcl liposomal 62doxycycline (monohydrate) 100mg, 150 mg, 50 mg, 75 mg 173doxycycline (monohydrate) 100mg, 50 mg, 75 mg 173doxycycline (monohydrate) 25mg/5ml 173doxycycline hyclate 100 mg173doxycycline hyclate 100 mg, 20mg 173doxycycline hyclate 100 mg, 50mg 173doxycycline hyclate 150 mg173DRISDOL 181DRIXORALCOLD/ALLERGY 94dronabinol 44drospirenone-ethinylestradiol 89DROXIA 129DUAC 97DUETACT 36DULCOLAX 134DULCOLAX BOWEL PREPKIT 134DULERA 24duloxetine hcl 20 mg, 30 mg, 60mg 34

Index 11

DUOPA 68DURAGESIC 100 MCG/HR 9DURAGESIC 12 MCG/HR 9DURAGESIC 25 MCG/HR 10DURAGESIC 50 MCG/HR 10DURAGESIC 75 MCG/HR 10DUREZOL 163dutasteride 127dutasteride-tamsulosin hcl 127DYAZIDE 118dyphylline-guaifenesin 23E-Z SPACER 139E-Z SPACER THE BODYGUARDS PACK 139EASIVENT 139EASIVENT/MASK-LARGE 139EASIVENT/MASK-MEDIUM

139EASIVENT/MASK-SMALL 139EC-NAPROSYN 5econazole nitrate 98ECOTRIN MAXIMUMSTRENGTH 9ECOTRIN REGULARSTRENGTH 9ED CHLORPED 46ED CHLORPED D 94EDURANT 75EFFEXOR XR 150 MG 34EFFEXOR XR 37.5 MG 34EFFEXOR XR 75 MG 34EFFIENT 128EFUDEX 100EGRIFTA 2 MG 120ELAVIL 35ELDEPRYL 69ELELYSO 129ELESTAT 164ELETONE 109ELETONE TWINPACK 109ELIDEL 107ELIGARD 60ELIQUIS 25ELITEK 65ELIXSURE FEVER/PAIN 8ELLA 91ELLENCE 62ELOCON 104

ELOXATIN 57ELTA CLEANSE FOAM 111ELTA LITE TAR 115ELTA TAR 115EMCYT 60EMEND 125 MG, 80 MG 44EMEND 40 MG 44EMLA 108EMPLICITI 59EMSAM 32EMTRIVA 75enalapril maleate &hydrochlorothiazide 53enalapril maleate 10 mg 51enalapril maleate 2.5 mg 51enalapril maleate 20 mg 51enalapril maleate 5 mg 51ENBREL 8ENBREL SURECLICK 8ENCARE 179ENEMEEZ MINI 135ENEMEEZ PLUS 135ENFAMIL ENFALYTE 145ENGERIX-B 10 MCG/0.5ML,20 MCG/ML 178enoxaparin sodium 25entacapone 68entecavir 78ENTOCORT EC 92ENTRE-HIST PSE 94ENTRESTO 86ENTSOL HYPERTONICNASAL IRRIGATIONMIST 156ENTSOL NASAL SPRAY 156ENTSOL NASAL WASH 156ENTYVIO 125ENUCLENE 164ENVARSUS XR 81EPHEDRINE HCL 24epinastine hcl (ophth) 164EPINEPHRINE 0.15MG/0.15ML, 0.3MG/0.3ML 180EPIPEN 2-PAK 181EPIPEN-JR 2-PAK 181epirubicin hcl 62EPIVIR 10 MG/ML 75

EPIVIR 150 MG, 300 MG 75EPIVIR HBV 100 MG 79EPIVIR HBV 5 MG/ML 79eplerenone 54EPOGEN 129eprosartan mesylate 52EPZICOM 75EQ TRIACTINGCOLD/ALLERGY 94EQL CALCIUM/VITAMIN D 145EQL CHILDRENSMULTIVITAMINS 152EQL DEODORANT BARSOAP 111EQL MOISTURIZING BEAUTYBAR 111EQL MOISTURIZING BEAUTYBAR/SENSITIVE SKIN 111EQL NATURAL FIBER 133EQUALACTIN 133EQUETRO 69ERAXIS 100 MG 44ERBITUX 59ergocalciferol 50000 unit 181ergocalciferol 8000 unit/ml 181ergoloid mesylates 171ergotamine tartrate 142ERIVEDGE 60ERWINAZE 64erythromycin (acne aid) 97erythromycin (ophth) 162erythromycin base 250 mg 136erythromycin base 500 mg 136erythromycin ethylsuccinate 400mg 136erythromycin lactobionate 136erythromycin stearate 136ESBRIET 172escitalopram oxalate 33esomeprazole magnesium 20mg 176esomeprazole magnesium 40mg 176esomeprazole sodium 40mg 176ESOMEPRAZOLE STRONTIUM49.3 MG 176estradiol & norethindroneacetate 123

Index 12

estradiol 0.025 mg/24hr, 0.05mg/24hr, 0.06 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr 123estradiol 0.5 mg, 1 mg, 2mg 123estradiol vaginal 0.1 mg/gm180estradiol valerate 20 mg/ml, 40mg/ml 123estropipate 0.75 mg, 1.5mg 123ethambutol hcl 100 mg, 400mg 56ethosuximide 250 mg 31ethosuximide 250 mg/5ml 31ethynodiol diacet & ethestrad 89ETHYOL 66etodolac 200 mg, 300 mg 6etodolac 400 mg, 500 mg 6etodolac 400 mg, 500 mg, 600mg 6ETOPOPHOS 66etoposide 1 gm/50ml, 100mg/5ml, 500 mg/25ml 66EVAC 133EVISTA 120EVOCLIN 97EVOMELA 57EVOTAZ 75EVOXAC 149EX-LAX 134EXELON 1.5 MG, 3 MG, 4.5 MG,6 MG 169EXELON 13.3 MG/24HR, 4.6MG/24HR, 9.5 MG/24HR 169exemestane 60EXJADE 43EXPECTA LIPIL 158EXTAVIA 170EXTINA 98EYE STREAM 164FABRAZYME 35 MG 121famciclovir 80famotidine 10 mg 175famotidine 20 mg 175famotidine 20 mg/2ml, 200mg/20ml, 40 mg/4ml 175famotidine 40 mg 175famotidine 40 mg/5ml 175FAMVIR 80

FANAPT 70FARESTON 60FARYDAK 63FASLODEX 60fat emulsion 20 gm/100ml157FAZACLO 100 MG, 25 MG71FAZACLO 12.5 MG, 150 MG,200 MG 71felbamate 30FELBATOL 30FELDENE 6felodipine 85FEMARA 60FEMCON FE 89FEMINEASE 179fenofibrate 145 mg, 160 mg, 48mg, 54 mg 49fenofibrate micronized 130mg 49fenofibrate micronized 134 mg,200 mg, 67 mg 49fenofibrate micronized 43mg 49fentanyl 100 mcg/hr 10fentanyl 12 mcg/hr 10fentanyl 25 mcg/hr 10fentanyl 50 mcg/hr 10fentanyl 75 mcg/hr 10fentanyl citrate 1200 mcg, 1600mcg, 400 mcg, 600 mcg, 800mcg 10fentanyl citrate 200 mcg 10FER-IN-SOL 130FERGON 130FERRETTS 130FERRIPROX 500 MG 43ferrous fumarate 324 mg 130FERROUS FUMARATE 90MG 130FERROUS GLUCONATE 225MG 130ferrous gluconate 240 mg, 27mg 131ferrous sulfate 15 mg/ml 131ferrous sulfate 220mg/5ml 131FERROUS SULFATE 220MG/5ML 131FERROUS SULFATE 300MG/5ML 131FERROUS SULFATE 324MG 131

ferrous sulfate 325 mg 131ferrous sulfate 325 mg, 65mg 131ferrous sulfate 50 mg 131ferrous sulfate dried 160mg 131FETZIMA 120 MG, 40 MG, 80MG 34FETZIMA 20 MG 34FETZIMA TITRATION PACK34FEVERALL INFANTS 8FIBERCON 133FINACEA 113finasteride 127FIORINAL/CODEINE #3 13FIRAZYR 127FIRMAGON 60FLAGYL 250 MG 17FLAGYL 375 MG 17FLAGYL 500 MG 17flavoxate hcl 178FLEBOGAMMA DIF 10 % 166flecainide acetate 100 mg 22flecainide acetate 150 mg 22flecainide acetate 50 mg 22FLECTOR 97FLEET BISACODYL 134FLEET LIQUID GLYCERINSUPPOSITORIES 134FLEXICHAMBER 139FLOMAX 127FLORICAL 146FLOVENT DISKUS 100MCG/BLIST 23FLOVENT DISKUS 250MCG/BLIST 23FLOVENT DISKUS 50MCG/BLIST 23FLOVENT HFA 110 MCG/ACT,220 MCG/ACT 24FLOVENT HFA 44MCG/ACT 24FLOXIN OTIC 165fluconazole 10 mg/ml, 40mg/ml 45fluconazole 100 mg, 150 mg, 200mg, 50 mg 45fluconazole in dextrose 45fluconazole in nacl 200mg/100ml-0.9%, 400mg/200ml-0.9% 45flucytosine 500 mg 45

Index 13

FLUDARA 58fludarabine phosphate 50mg 58fludrocortisone acetate 93FLUMADINE 80flunisolide (nasal) 156fluocinolone acetonide(otic) 165fluocinolone acetonide 0.01% 104fluocinolone acetonide 0.01 %,0.025 % 104fluocinolone acetonide 0.025% 104fluocinonide 0.05 % 104fluocinonide emulsifiedbase 104fluorometholone (ophth) 163fluorouracil (topical) 100FLUOROURACIL 0.5 % 100fluorouracil 1 gm/20ml, 2.5gm/50ml, 500 mg/10ml 58fluoxetine hcl (PMDD) cap 10 mg,20 mg 171fluoxetine hcl 10 mg, 20 mg 33fluoxetine hcl 10 mg, 20 mg, 40mg 33fluoxetine hcl 20 mg/5ml 33fluoxetine hcl 90 mg 33fluoxymesterone 14fluphenazine decanoate 72fluphenazine hcl 1 mg, 10 mg, 2.5mg, 5 mg 72fluphenazine hcl 2.5 mg/ml 72fluphenazine hcl 5 mg/ml 72flurbiprofen 100 mg, 50 mg 6flurbiprofen sodium 164flutamide 60fluticasone propionate(nasal) 156fluticasone propionate 0.005% 104fluticasone propionate 0.05% 104fluvastatin sodium 20 mg, 40mg 49fluvoxamine maleate 33FML LIQUIFILM 163FOCALIN 2FOCALIN XR 15 MG 2FOLGARD RX 130FOLIC + B12 130

folic acid 0.8 mg, 800mcg 129folic acid 1 mg 129FOLIC ACID 20 MG 129folic acid 400 mcg, 800mcg 129FOLIC ACID 5 MG 129folic acid-pyridoxine-cyanocobalamin 117folic acid-vitamin b6-vitaminb12 130FOLOTYN 58FOLTRATE 130fondaparinux sodium 25FORADIL AEROLIZER 24FORFIVO XL 32FORMULA 405 FACIAL &BODYCLEANSING 111FORMULA 405MOISTURIZINGSOAP 111FORTAMET 1000 MG 38FORTAMET 500 MG 38FORTAZ 1 GM, 2 GM 88FORTAZ 6 GM 88FORTEO 119FORTICAL 119FOSAMAX 119fosinopril sodium 51fosinopril sodium &hydrochlorothiazide 53fosphenytoin sodium 100 mgpe/2ml 30fosphenytoin sodium 500 mgpe/10ml 30FOSRENOL 1000 MG, 500MG, 750 MG 126FRAGMIN 10000 UNIT/ML,12500 UNIT/0.5ML, 15000UNIT/0.6ML, 18000UNT/0.72ML, 2500UNIT/0.2ML, 5000 UNIT/0.2ML,7500 UNIT/0.3ML, 95000UNIT/3.8ML 25FRAGMIN 25000 UNIT/ML26FRESH'N FEMININEDEODORANT 109furosemide 10 mg/ml 118furosemide 20 mg, 40 mg, 80mg 118FUSILEV 66FUZEON 75FYCOMPA 0.5 MG/ML 26

FYCOMPA 10 MG, 12 MG, 2MG, 4 MG, 6 MG, 8 MG 26gabapentin 100 mg, 300 mg, 400mg 27gabapentin 250 mg/5ml, 300mg/6ml 27gabapentin 600 mg, 800 mg 27GABITRIL 12 MG, 16 MG 30GABITRIL 2 MG, 4 MG 30galantamine hydrobromide 169GAMASTAN S/D 166GAMMAGARD LIQUID 166GAMMAKED 166GAMUNEX-C 166ganciclovir sodium 78GARDASIL 179GARDASIL 9 178GAS-X EXTRA STRENGTH 125MG 124GASTROCROM 124gatifloxacin (ophth) 162GATTEX 126gauze pads 2" X 2" 136GAZYVA 59gelatin 650 mg 80GELONASAL 156GELUSIL 200MG-25MG-200MG 16gemcitabine hcl 58gemfibrozil 49GEMZAR 58GENOTROPIN 5 MG 120GENOTROPIN MINIQUICK 0.4MG 120gentamicin in saline 0.9%-1mg/ml 4gentamicin sulfate (ophth) 162gentamicin sulfate (topical) 98gentamicin sulfate 40 mg/ml 4GENTEAL MILD TOMODERATE 160GENTLE SKIN CLEANSER111GENVOYA 75GEODON 20 MG 69GEODON 20 MG, 40 MG, 60MG, 80 MG 69GERISILK BATH OIL 101GILENYA 170GILOTRIF 63glatiramer acetate 171

Index 14

GLEEVEC 100 MG, 400 MG 63GLEEVEC 400 MG 63GLEOSTINE 57glimepiride 1 mg 41glimepiride 2 mg 41glimepiride 4 mg 42glipizide 10 mg 42glipizide 2.5 mg 42glipizide 5 mg 42glipizide-metformin hcl 2.5mg-250mg 36glipizide-metformin hcl 2.5mg-500mg, 5mg-500mg 36GLUCAGEN HYPOKIT 38glucagon (rdna) 38GLUCOPHAGE 1000 MG 38GLUCOPHAGE 500 MG 38GLUCOPHAGE 850 MG 38GLUCOPHAGE XR 500 MG 38GLUCOPHAGE XR 750 MG 38glucosamine sulfate 500 mg 3glucosamine-chondroitin 200mg-250mg 3GLUCOSE 4 GM 39glucose 5 % 157GLUCOSE NURSETTE 157GLUCOTROL 10 MG 42GLUCOTROL 5 MG 42GLUCOTROL XL 10 MG 42GLUCOTROL XL 2.5 MG 42GLUCOTROL XL 5 MG 42GLUCOVANCE 1.25MG-250MG 36GLUCOVANCE 2.5MG-500MG,5MG-500MG 36GLUTAMENT 159GLUTOL 115glyburide 1.25 mg 42glyburide 2.5 mg 42glyburide 5 mg 42glyburide micronized 1.5 mg 42glyburide micronized 3 mg 42glyburide micronized 6 mg 42glyburide-metformin 1.25mg-250mg 37glyburide-metformin 2.5mg-500mg, 5mg-500mg 37GLYCERIN 99 %, 99.5 % 89GLYCERINE 89

GLYCEROL FORMAL 89glycopyrrolate 0.2 mg/ml 174glycopyrrolate 1 mg 175glycopyrrolate 2 mg 175GLYNASE 1.5 MG 42GLYNASE 3 MG 42GLYNASE 6 MG 42GLYSET 36GNP CALAMINE 111GNP CALAMINEPHENOLATED 111GNP GLUCOSE 4 GM 39GNP QUICK DISSOLVEGLUCOSE 39GNP SALINE WOUNDWASH 111GNP VITAMIN D-400 145GOLYTELY 236GM-22.74GM-5.86GM-2.97GM-6.74GM

134GRANDPAS BAKING SODASOAP 111GRANDPAS INDIAN CORNSOAP 111GRANDPAS LOVE MYLOOFAH SOAP 111GRANDPAS OATMEALSOAP 111GRANDPAS ORANGEESSENCE SOAP 111GRANDPAS PATCHOULISOAP 111GRANDPAS PINE TARSOAP 115GRANDPAS SHEA BUTTERSOAP 111GRANDPAS WITCH HAZELSOAP 111granisetron hcl 1 mg 43GRANIX 129GRIS-PEG 45griseofulvin microsize 45griseofulvin ultramicrosize 45guaifenesin-codeine100mg/5ml-10mg/5ml 94guanfacine hcl 53guanfacine hcl (adhd) 2guanidine hcl 55GYNE-LOTRIMIN 180H.P. ACTHAR 120HALAVEN 66HALCION 132

HALDOL 71HALDOL DECANOATE 100 71HALDOL DECANOATE 50 71halobetasol propionate 104haloperidol 71haloperidol decanoate 100mg/ml, 50 mg/ml 71haloperidol lactate 71HARVONI 79HAVRIX 179HEAL AID PLUS 109HEMA-COMBISTIX 116HEMOCYTE 131HEMOCYTE-F 130HEPAMENT 159heparin sodium (porcine) 26HEPSERA 79HERCEPTIN 59HETLIOZ 133HEXALEN 57HIPREX 177HIZENTRA 166HM CALAMINE 111HPR PLUS 109HUMALOG 40HUMALOG KWIKPEN 40HUMALOG MIX 50/50 40HUMALOG MIX 50/50KWIKPEN 40HUMALOG MIX 75/25 40HUMALOG MIX 75/25KWIKPEN 40HUMATROPE 120HUMATROPE COMBOPACK 120HUMIRA 4HUMIRA PEDIATRIC CROHNSDISEASE STARTER PACK 4HUMIRA PEN 4HUMIRA PEN-CROHNSDISEASESTARTER 4HUMIRA PEN-PSORIASISSTARTER 4HUMULIN 70/30 40HUMULIN 70/30 KWIKPEN 40HUMULIN N 40HUMULIN N KWIKPEN 40HUMULIN R 40HUMULIN R U-500(CONCENTRATED) 40

Index 15

HUMULIN R U-500KWIKPEN 40HURRICAINE 148HURRICAINE ONE 148HYCAMTIN 67hydralazine hcl 10 mg, 100 mg,25 mg, 50 mg 54HYDREA 65hydrochlorothiazide 12.5mg 118hydrochlorothiazide 12.5 mg, 25mg, 50 mg 118HYDROCIL INSTANT 133hydrocodone polistirex-chlorpheniramine polistirex 94hydrocodone w/homatropine 93hydrocodone-acetaminophen10mg-300mg, 5mg-300mg,7.5mg-300mg 13hydrocodone-acetaminophen10mg-325mg, 5mg-325mg,7.5mg-325mg 13hydrocodone-acetaminophen2.5mg/5ml-108mg/5ml,5mg/10ml-217mg/10ml,7.5mg/15ml-325mg/15ml 13hydrocodone-ibuprofen 13hydrocortisone (intrarectal) 15hydrocortisone (rectal) 15hydrocortisone (topical) 0.5% 104hydrocortisone (topical) 1% 104hydrocortisone (topical) 2.5% 104hydrocortisone 10 mg, 20 mg, 5mg 92hydrocortisone acetate(topical) 105hydrocortisone butyrate 105hydrocortisone butyratehydrophilic lipo base 105hydrocortisone valerate 105hydrocortisone w/aceticacid 165hydrocortisone-aloe vera 105hydrogen peroxide (mouth-throat) 149hydrogen peroxide-benzylalcohol 149hydromorphone hcl 1 mg/ml 10hydromorphone hcl 10 mg/ml, 50mg/5ml, 500 mg/50ml 10hydromorphone hcl 2 mg 10

hydromorphone hcl 2mg/ml 10hydromorphone hcl 4 mg 10hydromorphone hcl 8 mg 10HYDROPEL 111hydroxychloroquine sulfate 55HYDROXYPROGESTERONECAPROATE 61hydroxyurea 65hydroxyzine hcl 10 mg, 25 mg,50 mg 21hydroxyzine hcl 10 mg/5ml 20hydroxyzine hcl 50 mg/ml 20hydroxyzine pamoate 25 mg,50 mg 21HYLATOPIC PLUS 109hypromellose (ophth) 0.3 %, 3mg/ml 160HYQVIA 166HYVEE ADVANCED ANTACIDMAXIMUM STRENGTH 16HYZAAR 53I.L.X. B-12 130ibandronate sodium 150mg 119ibandronate sodium 3mg/3ml 119IBRANCE 63ibuprofen 100 mg 6ibuprofen 100 mg/5ml 6ibuprofen 200 mg 6ibuprofen 40 mg/ml, 50mg/1.25ml 6ibuprofen 400 mg 6ibuprofen 600 mg 6ibuprofen 800 mg 6ICLUSIG 63IDAMYCIN PFS 62idarubicin hcl 62IFEX 1 GM 57IFEX 3 GM 57ifosfamide 1 gm 57ifosfamide 1 gm/20ml, 3gm/60ml 57IFOSFAMIDE 3 GM 57ILARIS 5ILEVRO 164imatinib mesylate 63IMBRUVICA 63imipenem-cilastatin 18

imipramine hcl 10 mg, 25 mg, 50mg 35imipramine pamoate 35imiquimod 107IMITREX 100 MG 143IMITREX 25 MG 143IMITREX 50 MG 143IMITREX 6 MG/0.5ML 142IMITREX STATDOSE REFILL 4MG/0.5ML 143IMITREX STATDOSE REFILL 6MG/0.5ML 143IMITREX STATDOSE SYSTEM 4MG/0.5ML 143IMOVAX RABIES(H.D.C.V.) 179IMURAN 81INCRELEX 120indapamide 118INDERAL LA 84indomethacin 25 mg, 50 mg 6indomethacin 75 mg 6INFANRIX 174INFANTS ADVIL 6INFANTS SILAPAP 8INLYTA 63INOSITOL 500 MG 158INSPIRACHAMBER/ANTI-STATICVALVED/MOUTHPIECE 140INSPIRACHAMBER/LARGE

140INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/MEDIUM

140INSPIRACHAMBER/SOOTHERMASK/INSPIRAMASK/SMALL

140INSPIREASE DRUGDELIVERYSYSTEM 140INSPRA 54INSULIN SYRINGES AND PENNEEDLES 136INTELENCE 100 MG, 200MG 75INTELENCE 25 MG 75INTRON A 65INTRON A W/DILUENT 65INTUNIV 2INVANZ 18INVEGA 1.5 MG 70INVEGA 3 MG 70

Index 16

INVEGA 6 MG 70INVEGA 9 MG 70INVEGA SUSTENNA 70INVEGA TRINZA 70INVIRASE 75INVOKAMET 150MG-1000MG,150MG-500MG, 50MG-1000MG 37INVOKAMET 50MG-500MG 37INVOKANA 41IODINE STRONG 146IOPIDINE 0.5 % 161IPOL INACTIVATED IPV 179ipratropium bromide 23ipratropium bromide (nasal)156ipratropium-albuterol 24IPRIVASK 26irbesartan 52irbesartan-hydrochlorothiazide

54IRESSA 63irinotecan hcl 67IRON 256 MG 131IRON 28 MG 131IRON CHEWS PEDIATRIC 131iron combinations 130irrigation solutions,physiological 82ISENTRESS 100 MG 75ISENTRESS 25 MG 76ISENTRESS 400 MG 76isoniazid & rifampin 55isoniazid 100 mg, 300 mg 56ISOPTO CARPINE 161ISOPTO TEARS 160ISORDIL TITRADOSE 5 MG 20isosorbide dinitrate 20isosorbide mononitrate 10 mg, 20mg 20isosorbide mononitrate 120 mg,30 mg, 60 mg 20isotretinoin 10 mg, 20 mg, 30 mg,40 mg 97ISTODAX 63ISTODAX (OVERFILL) 63ITCH-X 108itraconazole 45ivermectin 16IXEMPRA KIT 67

IXIARO 179JADENU 43JAKAFI 63JALYN 127JANUMET 37JANUMET XR 100MG-1000MG 37JANUMET XR 50MG-1000MG,50MG-500MG 37JANUVIA 39JARDIANCE 41JENTADUETO 37JENTADUETO XR 2.5MG-1000MG 37JENTADUETO XR 5MG-1000MG 37JEVTANA 67JOHNSONS BABY BAR 111JOHNSONS BUDDIES EASY-GRIP SUDZING 111JUXTAPID 10 MG 50JUXTAPID 20 MG 50JUXTAPID 30 MG 50JUXTAPID 40 MG 50JUXTAPID 5 MG 50JUXTAPID 60 MG 50K-TAB 10 MEQ 147K-TAB 8 MEQ 147KADCYLA 59KADIAN 10 MG 10KADIAN 100 MG 10KADIAN 20 MG, 30 MG, 50MG, 60 MG, 80 MG 10KALBITOR 128KALETRA 76KALYDECO 172KANUMA 121KAPVAY 2KARAYA GUM 168KAYEXALATE 82KAZANO 37KEFLEX 87KENALOG-10 92KENALOG-40 92KEPIVANCE 65KEPPRA 27KEPPRA XR 27KERALYT 6 % 107KERLONE 83

KETO-DIASTIX 116KETOCARE 116ketoconazole 45ketoconazole (topical) 98KETONE TEST STRIPS 116ketoprofen 50 mg, 75 mg 6ketorolac tromethamine(ophth) 164ketorolac tromethamine 15mg/ml, 30 mg/ml 6ketorolac tromethamine 30mg/ml, 60 mg/2ml 6KETOSTIX 116ketotifen fumarate (ophth) 164KEYTRUDA 59KHEDEZLA 34KINERET 5KITABIS PAK 4KLARON 97KLONOPIN 0.5 MG 26KLONOPIN 1 MG 26KLONOPIN 2 MG 26KOMBIGLYZE XR 2.5MG-1000MG 37KOMBIGLYZE XR 5MG-1000MG, 5MG-500MG 37KONSYL 100 % 133KONSYL 28.3 %, 60.3 % 133KONSYL 60.3 %, 71.67 % 133KONSYL-D 133KORLYM 39KUVAN 121KYNAMRO 48L-CARNITINE 250 MG 159L-CITRULLINE 159L-METHYL-MC 117labetalol hcl 100 mg, 200 mg, 300mg 83LABSTIX 116LAC-HYDRIN 106lactated ringer's 145LACTIC ACID 89lactic acid (ammonium lactate) 12% 106lactic acid (ammonium lactate) 5% 106LACTIC ACID RACEMIC 89lactulose 134lactulose (encephalopathy) 125LAMICTAL 28

Index 17

LAMICTAL CHEWABLEDISPERSIBLE 27LAMICTAL XR 28LAMICTAL XR 100 MG, 200 MG,25 MG, 250 MG, 300 MG, 50MG 28LAMISIL 250 MG 45LAMISIL AT 99LAMISIL AT JOCK ITCH 99lamivudine 76lamivudine (hbv) 79lamivudine-zidovudine 76lamotrigine 100 mg, 150 mg, 200mg, 25 mg 28lamotrigine 100 mg, 200 mg, 25mg, 250 mg, 300 mg, 50 mg 28lamotrigine 25 mg, 5 mg 28LANACANE 108lanolin 168lanolin (topical) 111LANOLIN ANHYDROUS 168LANOLIN ANHYDROUS-GRX 168LANOXIN 125 MCG 86LANOXIN 187.5 MCG 86LANOXIN 250 MCG 86LANOXIN 62.5 MCG 86lansoprazole 15 mg 176lansoprazole 30 mg 176LANTUS 40LANTUS SOLOSTAR 40LARTRUVO 59LASIX 118latanoprost 165LATUDA 120 MG 69LATUDA 20 MG 69LATUDA 40 MG 69LATUDA 60 MG 69LATUDA 80 MG 70LAZANDA 100 MCG/ACT 10LAZANDA 300 MCG/ACT 10LAZANDA 400 MCG/ACT 10LEADER QUICK DISSOLVEGLUCOSE 39lecithin 158LECITHINCONCENTRATE 158leflunomide 10 mg, 20 mg 7LEMTRADA 171

LENVIMA 10 MG DAILYDOSE 63LENVIMA 14 MG DAILYDOSE 63LENVIMA 18 MG DAILYDOSE 63LENVIMA 20 MG DAILYDOSE 63LENVIMA 24 MG DAILYDOSE 63LENVIMA 8 MG DAILYDOSE 63LESCOL 49LETAIRIS 86letrozole 61leucovorin calcium 10 mg, 15mg, 25 mg, 5 mg 66leucovorin calcium 100 mg, 350mg 66leucovorin calcium 200 mg, 50mg, 500 mg 66LEUKERAN 57LEUKINE 129leuprolide acetate 61levalbuterol hcl 0.31 mg/3ml,0.63 mg/3ml, 1.25 mg/0.5ml,1.25 mg/3ml 24LEVAQUIN 25 MG/ML 124LEVAQUIN 250 MG, 500 MG,750 MG 124LEVAQUIN 250MG/50ML-5%,500MG/100ML-5%,750MG/150ML-5% 124LEVEMIR 41LEVEMIR FLEXTOUCH 41levetiracetam 100 mg/ml, 500mg/5ml 28levetiracetam 1000 mg, 250mg, 500 mg, 750 mg 28LEVETIRACETAM1000MG/100ML-750MG/100ML,1500MG/100ML-540MG/100ML, 500MG/100ML-820MG/100ML 28levetiracetam 500 mg, 750mg 28levetiracetam 500 mg/5ml 28levobunolol hcl 161levocarnitine (metabolicmodifiers) 330 mg 121levocarnitine 250 mg 159levocetirizinedihydrochloride 47levofloxacin (ophth) 162

levofloxacin 25 mg/ml 124levofloxacin 250 mg, 500 mg, 750mg 124levofloxacin in d5w 124LEVOLEUCOVORIN 66levoleucovorin calcium 66levonorgestrel & ethestradiol 89levonorgestrel (emergency oc)0.75 mg 91levonorgestrel (emergency oc)1.5 mg 91levonorgestrel-eth estradiol(triphasic) 90levonorgestrel-ethinyl estradiol(91-day) 90levothyroxine sodium 100 mcg,112 mcg, 125 mcg, 137 mcg, 150mcg, 175 mcg, 200 mcg, 25 mcg,300 mcg, 50 mcg, 75 mcg, 88mcg 174LEXAPRO 33LEXIVA 76LEXUSS 210 94lidocaine 5 % 108lidocaine hcl (local anesth.) 1 %,2 % 135lidocaine hcl (mouth-throat) 148lidocaine hcl 0.5 % 108lidocaine hcl 2 % 108lidocaine hcl 4 % 108lidocaine-prilocaine 108LIDODERM 108LINCOCIN 19lincomycin hcl 19lindane 114linezolid 100 mg/5ml 19linezolid 600 mg 19linezolid 600 mg/300ml 19linezolid in sodium chloride 19liniments & rubs 0.01%-5%-10%,1.2%-2.6%-4.7%, 10%-0.025%-15% 107liniments & rubs 0.25%, 8%-2% 108LINZESS 126liothyronine sodium 25 mcg, 5mcg, 50 mcg 174LIPITOR 49LIQ-10 50MG/5ML-15UNIT/5ML 3lisinopril &hydrochlorothiazide 54

Index 18

lisinopril 10 mg, 2.5 mg, 20 mg,30 mg, 40 mg, 5 mg 51LITEAIRE 140lithium 69lithium carbonate 150 mg, 300mg, 600 mg 69lithium carbonate 300 mg 69lithium carbonate 300 mg, 450mg 69LITHIUM CARBONATE 600MG 69LITHOBID 69LOBOB CONTACT LENSWEARERS SOAP 112LOCOID 105LOCOID LIPOCREAM 105LODOSYN 67LOMOTIL 43LONSURF 62loperamide hcl 2 mg 43LOPID 49LOPRESSOR 100 MG, 50MG 83LOPRESSOR HCT 54LOPROX 0.77 % 99LOPROX SHAMPOO 99loratadine 10 mg 47lorazepam 0.5 mg, 1 mg, 2mg 21lorazepam 2 mg/ml 21lorazepam 2 mg/ml, 20mg/10ml 21lorazepam 4 mg/ml 21losartan potassium 52losartan potassium &hydrochlorothiazide 54LOSEASONIQUE 90LOTEMAX 163LOTENSIN 51LOTENSIN HCT 54LOTREL 54LOTRISONE 99LOTRONEX 126lovastatin 49LOVAZA 48LOVENOX 26LOWILA 112loxapine succinate 71LUMIGAN 165LUMIZYME 121

LUPRON DEPOT 61LUPRON DEPOT-PED 11.25MG 120LUPRON DEPOT-PED 11.25MG, 15 MG, 7.5 MG 120LUPRON DEPOT-PED 30MG 121lutein 6 mg 3LUXIQ 105LYCELLE 114LYNPARZA 63LYRICA 100 MG 28LYRICA 150 MG 28LYRICA 20 MG/ML 28LYRICA 200 MG 28LYRICA 225 MG 28LYRICA 25 MG 28LYRICA 300 MG 28LYRICA 50 MG 28LYRICA 75 MG 28LYSODREN 61LYSTEDA 131M-M-R II 179MAALOX 16MACROBID 177MACRODANTIN 100 MG, 50MG 177mafenide acetate 102MAG-TAB SR 147MAGINEX 147MAGINEX DS 147MAGNEBIND 200 145magnesium 250 mg,250mg 147magnesium chloride 535 mg,64 mg 147MAGNESIUM CHLORIDEHEXAHYDRATE 147MAGNESIUM ELEMENTAL 30MG 147MAGNESIUM GLUCONATE250 MG, 500 MG, 550MG 147magnesium hydroxide 311mg 134magnesium sulfate 50 % 147MALARONE 250MG-100MG 55malathion 114maprotiline hcl 32MARINOL 44

MARPLAN 32MARQIBO 67MATULANE 65MAVIK 51MAXALT 10 MG 143MAXALT 5 MG 143MAXALT-MLT 10 MG 143MAXALT-MLT 5 MG 143MAXIPIME 1 GM, 2 GM 89MAXITROL 163MAXZIDE 118MAXZIDE-25 118MCT OIL 157meclizine hcl 12.5 mg, 25mg 44meclizine hcl 25 mg 44MEDI-LYTE 145MEDIPLAST 107MEDROL 16 MG, 32 MG, 4 MG,8 MG 92MEDROL 2 MG 92MEDROL DOSEPAK 92medroxyprogesterone acetate(contraceptive) 91medroxyprogesterone acetate 10mg, 2.5 mg, 5 mg 168mefenamic acid 6mefloquine hcl 55MEGACE ES 168MEGACE ORAL 61megestrol acetate(appetite) 168megestrol acetate 20 mg, 40mg 61megestrol acetate 40 mg/ml, 400mg/10ml 61MEIJER CALAMINE 112MEKINIST 64meloxicam 15 mg, 7.5 mg 6melphalan hcl 57memantine hcl 10 mg, 5 mg169memantine hcl 2 mg/ml 169MENACTRA 178MENOMUNE-A/C/Y/W-135

178menthol (topical analgesic) 5% 97MENVEO 178meperidine hcl 100 mg/ml, 50mg/ml 11

Index 19

meperidine hcl 25 mg/ml 11MEPHYTON 181MEPRON 18mercaptopurine 58meropenem 18MERREM 18mesalamine 125MESALAMINE DR 125mesalamine w/ cleanser 125mesna 66MESNEX 100 MG/ML 66MESNEX 400 MG 66MESTINON 60 MG 55MESTINON TIMESPAN 55METADATE CD 2METAFOLBIC 117METAMUCIL 0.52 GM 133METAMUCIL 48.57 % 133METAMUCIL MULTIHEALTHFIBER 55.46 % 133METAMUCIL ORIGINALTEXTURE 133METAMUCIL SMOOTHTEXTUREFIBER SINGLES133metaxalone 155metformin hcl 1000 mg 38metformin hcl 500 mg 38metformin hcl 750 mg 38metformin hcl 850 mg 38methadone hcl 10 mg 11methadone hcl 10 mg/5ml 11methadone hcl 10 mg/ml 11methadone hcl 5 mg 11methadone hcl 5 mg/5ml 11METHADOSE 11METHADOSE SUGAR-FREE 11methamphetamine hcl 1methazolamide 25 mg, 50mg 117methenamine hippurate 177methimazole 10 mg, 5 mg 174methocarbamol 500 mg, 750mg 155methotrexate sodium 1 gm 58methotrexate sodium 1 gm/40ml,100 mg/4ml, 200 mg/8ml, 250mg/10ml, 50 mg/2ml 58methotrexate sodium 10 mg, 15mg, 2.5 mg, 5 mg, 7.5 mg 58

methoxsalen rapid 100methscopolamine bromide 2.5mg, 5 mg 175methylcellulose (laxative) 2gm/10.2gm, 2 gm/19gm 133methylergonovine maleate 0.2mg 165methylphenidate hcl 10 mg, 20mg, 30 mg, 40 mg, 50 mg, 60mg 2methylphenidate hcl 10 mg, 20mg, 5 mg 2methylphenidate hcl 20 mg, 27mg, 36 mg 2methylphenidate hcl 20 mg, 30mg, 40 mg 2methylphenidate hcl 27 mg, 36mg 2methylprednisolone 16 mg, 32mg, 4 mg, 8 mg 92methylprednisolone 4 mg 92methylprednisolone acetate 40mg/ml, 80 mg/ml 92methylprednisolone sodsucc 92metoclopramide hcl 10 mg, 5mg 125metoclopramide hcl 10mg/10ml, 5 mg/5ml 125metoclopramide hcl 5mg/ml 125metolazone 118metoprolol &hydrochlorothiazide 54metoprolol succinate 83metoprolol tartrate 100 mg, 25mg, 50 mg 83METOPROLOL TARTRATE37.5 MG, 75 MG 83METROCREAM 113METROGEL 113METROGEL-VAGINAL 180METROLOTION 113metronidazole (topical) 113metronidazole 250 mg 17metronidazole 375 mg 17metronidazole 500 mg 17metronidazole in nacl 17metronidazole vaginal 180MEVACOR 49mexiletine hcl 22MG217 MEDICATEDTAR 115MG217 MEDICATED TARSHAMPOO 115

MIACALCIN 200 UNIT/ACT119MIACALCIN 200 UNIT/ML 119MICATIN 99miconazole nitrate (topical) 99miconazole nitrate vaginal 100mg 180MICRO-K 147MICROCHAMBER 140MICROLIFE DIGITAL PEAKFLOW METER 140MICROLIPID 158MICROSPACER 140MICROZIDE 119midodrine hcl 181MIDOL COMPLETE 500MG-15MG-60MG 8MIDOL MAXIMUM STRENGTHMENSTRUAL 8MIDOL MAXIMUM STRENGTHMENSTRUAL FORMULA 8miglitol 36MILK OF MAGNESIACONCENTRATE 134MINI WRIGHT AFS PEAKFLOWMETER LOWRANGE 140MINI WRIGHT PEAK FLOWMETER 140MINIPRESS 53MINOCIN 100 MG, 50 MG, 75MG 173minocycline hcl 100 mg, 50mg 173minocycline hcl 100 mg, 50 mg,75 mg 173minoxidil 10 mg, 2.5 mg 54MIRAPEX 68mirtazapine 31MIRVASO 113misoprostol 100 mcg, 200mcg 177mitomycin 20 mg, 40 mg, 5mg 62mitoxantrone hcl 62MOBIC 15 MG, 7.5 MG 6modafinil 3MODICON 90moexipril hcl 51moexipril-hydrochlorothiazide

54MOISTURE CREAM 109molindone hcl 72

Index 20

mometasone furoate 105MONOCAL 146MONODOX 173montelukast sodium 10 mg 23montelukast sodium 4 mg, 5mg 23morphine sulfate 0.5 mg/ml 11morphine sulfate 1 mg/ml 11morphine sulfate 10 mg 11morphine sulfate 10 mg/5ml 11morphine sulfate 100 mg 11morphine sulfate 100 mg/5ml, 20mg/ml 11MORPHINE SULFATE 15MG 11morphine sulfate 15 mg 11morphine sulfate 20 mg, 30 mg,50 mg, 60 mg, 80 mg 11morphine sulfate 20 mg/5ml 11morphine sulfate 200 mg 12MORPHINE SULFATE 30MG 11morphine sulfate 30 mg, 60mg 12MOSCO CALLUS/CORNREMOVER 107MOTRIN INFANTS 7MOTRIN INFANTS DROPS 6MOTRIN JUNIORSTRENGTH 7MOVANTIK 126MOZOBIL 131MS CONTIN 100 MG 12MS CONTIN 15 MG 12MS CONTIN 200 MG 12MS CONTIN 30 MG, 60 MG 12MTX SUPPORT 130MULTAQ 22MULTI PRENATAL 153MULTI-DELYN/IRON 152MULTISTIX 116MULTISTIX 10 SG 116MULTISTIX 5 116MULTISTIX 7 116MULTISTIX 8 SG 116MULTISTIX 9 116MULTISTIX 9 SG 116MULTITRACE-4 148mupirocin 98mupirocin calcium (topical) 98

MURO 128 2 % 164MURO 128 5 % 164MUSTARGEN 57MYALEPT 121MYAMBUTOL 56MYCAMINE 44MYCOBUTIN 56mycophenolate mofetil 81mycophenolate mofetil hcl 81mycophenolate sodium 81MYFORTIC 81MYLANTA 200MG/5ML-20MG/5ML-200MG/5ML 16MYLANTA DOUBLE-STRENGTH 16MYLANTA GAS 124MYLANTA GAS RELIEFMAXIMUM STRENGTH 124MYOZYME 121MYRBETRIQ 178MYSOLINE 28nabumetone 7nadolol &bendroflumethiazide 54nadolol 20 mg, 40 mg, 80mg 84nafcillin sodium 10 gm 167nafcillin sodium 2 gm 168naftifine hcl 2 % 99NAFTIN 2 % 99NAGLAZYME 121nalbuphine hcl 10 mg/ml, 20mg/ml 14naloxone hcl 2 mg/2ml 43naltrexone hcl 43NAMENDA 10 MG, 5 MG 169NAMENDA 10 MG/5ML 169NAMENDA TITRATIONPAK 169NAMENDA XR 14 MG 169NAMENDA XR 21 MG 169NAMENDA XR 28 MG 169NAMENDA XR 7 MG 169NAMENDA XR TITRATIONPACK 169naphazoline w/ pheniramine0.025%-0.3% 162NAPHCON-A 162NAPROSYN 250 MG, 375 MG,500 MG 7

naproxen 250 mg, 375 mg, 500mg 7naproxen 375 mg, 500 mg 7naproxen sodium 220 mg 7naproxen sodium 275 mg, 550mg 7naratriptan hcl 143NARDIL 32NASAL DECONGESTANT 156NASALGUARD 109nateglinide 41NATPARA 119NATURE DE FRANCE ALGOLISOAP 112NATURE DE FRANCE ARGILEBLANCHE SOAP 112NATURE DE FRANCEARGIMIEL SOAP 112NAVELBINE 67NEBUPENT 17nefazodone hcl 34NEO-SYNEPHRINE 0.25% 157NEO-SYNEPHRINE 0.5 % 157NEO-SYNEPHRINE COLD &SINUS MILD 157NEO-SYNEPHRINE COLD &SINUS REGULAR 157NEOKE BCAA4 117neomycin sulfate 4neomycin-bacitracin zn-polymyxin 162neomycin-bacitracin-polymyxin w/lidocaine 98neomycin-polymy-dexameth 163neomycin-polymyxin-gramicidin

162neomycin-polymyxin-hc(otic) 165neomycin/polymyxin b gu 126NEORAL 100 MG, 25 MG 81NEOSALUS 109NEOSALUS CP 109NERVO B-12 SL 151NESINA 39NESSI SPACER/LARGEMASK 140NESSISPACER/MOUTHPIECE 140NESSI SPACER/SMALL/MEDMASK 140NEULASTA 129

Index 21

NEULASTA ONPRO KIT 129NEUMEGA 129NEUPOGEN 129NEUPRO 68NEURONTIN 29NEUTROGENA ACNECLEANSING SOAP 112NEUTROGENA FACIAL SOAPORIGINAL FORMULA 112NEUTROGENA NATURALSFACE& BODY 112NEVANAC 164nevirapine 100 mg, 400 mg 76nevirapine 200 mg 76NEVIRAPINE 50 MG/5ML 76NEW SKIN 109NEXAFED SINUS PRESSURE+PAIN 94NEXAVAR 64NEXIUM 10 MG, 2.5 MG, 20 MG,40 MG, 5 MG 176NEXIUM 20 MG 176NEXIUM 40 MG 176NEXIUM I.V. 176niacin (antihyperlipidemic) 50niacin 100 mg, 250 mg, 50 mg,500 mg 182niacin 250 mg, 500 mg 182niacin 250 mg, 500 mg, 750mg 182NIACIN TR 182niacinamide 100 mg 182niacinamide 500 mg 182NIASPAN 50nicardipine hcl 20 mg, 30 mg85NICODERM CQ 172NICORETTE 172NICORETTE MINI 172NICORETTE STARTERKIT 172nicotine 172nicotine polacrilex 2 mg, 4mg 172NICOTINE TRANSDERMALSYSTEM 172NICOTROL INHALER 172NICOTROL NS 172nifedipine 30 mg, 60 mg, 90mg 85NILANDRON 61nilutamide 61

nimodipine 30 mg, 30mg 85NINLARO 64nisoldipine 17 mg, 34 mg, 8.5mg 85nit remover 114NITRATEST PAPER 116NITRO-DUR 0.1 MG/HR, 0.2MG/HR, 0.4 MG/HR, 0.6MG/HR 20nitrofurantoin macrocrystal 100mg, 50 mg 177nitrofurantoin monohydmacro 177nitroglycerin 0.1 mg/hr, 0.2mg/hr, 0.4 mg/hr, 0.6mg/hr 20nitroglycerin 0.3 mg, 0.4 mg,0.6 mg 20nitroglycerin 0.4 mg/spray 20NITROGLYCERINLINGUAL 20NITROLINGUALPUMPSPRAY 20NITROMIST 20NITROSTAT 20NIVATOPIC PLUS 109NIVEA MOISTURIZING BODYWASH 112NIVEA MOISTURIZING BODYWASH 2 IN 1 112NIVEA TOUCH OFSMOOTHNESSMOISTURIZING BODYWASH 112NIVEA VISAGE EYECONTOUR 114NIVEA VISAGE GENTLECLEANSING 112NIX CREME RINSE 114nizatidine 150 mg, 300mg 175NIZORAL 99NIZORAL A-D 99NO-STING SKIN-PREP 112NOBLE FORMULA 2 % 101nonoxynol-9 180NONYX 109NOR-QD 91NORDITROPIN FLEXPRO 10MG/1.5ML, 5 MG/1.5ML 120norelgestromin-ethinylestradiol 90norethin acet & estrad-fe 75mg-20mcg-1mg, 75mg-30mcg-1.5mg 90

norethindrone & eth estradiol90norethindrone & ethinyl estradiol-fe 0.4mg-35mcg 90norethindrone(contraceptive) 91norethindrone acet & eth estra20mcg-1mg, 30mcg-1.5mg 90norethindrone acetate 168norethindrone-eth estradiol(triphasic) 90norgestimate-ethinylestradiol 90norgestimate-ethinyl estradiol(triphasic) 90norgestrel & ethinyl estradiol 90NORINYL 1+35 90NORPACE 21NORPRAMIN 35NORTHERA 100 MG 181NORTHERA 200 MG 181NORTHERA 300 MG 181nortriptyline hcl 10 mg, 25 mg, 50mg, 75 mg 35nortriptyline hcl 10 mg/5ml 36NORVASC 10 MG 85NORVASC 2.5 MG 85NORVASC 5 MG 85NORVIR 76NORWEGIAN COD LIVEROIL 153NOVA MAX PLUS KETONETESTSTRIPS 116NOXAFIL 100 MG 46NOXAFIL 300 MG/16.7ML 46NOXAFIL 40 MG/ML 46NUCALA 22NUEDEXTA 171NULLO 80NULOJIX 82NULYTELY/FLAVORPACKS 134NUPLAZID 70NUTRATEAR 160NUTROPIN AQ NUSPIN20 120NUTROPIN AQ PEN 20MG/2ML 120NUVARING 91NYMALIZE 85nystatin 45nystatin (mouth-throat) 149

Index 22

nystatin (topical) 99nystatin-triamcinolone 99OC8 109OCALIVA 10 MG 124OCALIVA 5 MG 124OCEAN NASAL SPRAY 156OCTAGAM 10 GM/100ML, 2GM/20ML, 20 GM/200ML, 5GM/50ML 166octreotide acetate 100 mcg/ml,200 mcg/ml, 50 mcg/ml 122OCUFEN 164OCUFLOX 162OCUSOFT HAND SOAP 112OCUSOFT HYPOCHLOR 112OCUSOFT LID SCRUBFOAMING 112OCUSOFT LID SCRUBORIGINAL 112ODEFSEY 76ODOMZO 60OFEV 173ofloxacin (ophth) 162ofloxacin (otic) 165OILATUM 112olanzapine 72olanzapine-fluoxetine hcl 170olopatadine hcl (nasal) 156OLUX 105OLUX-E 105OLYSIO 79OMECLAMOX-PAK 177omega-3 fatty acids 180mg-120mg, 300mg, 300mg-160mg-1000mg-100mg-5unit, 300mg-772.5mg-90mg-180mg 158omega-3 fatty acids 180mg-500mg-120mg, 27mg-244mg-500mg-89mg, 300mg-1000mg-200mg, 300mg-200mg, 500 mg,500mg, 500mg-270mg-135mg,500mg-300mg-1000mg-200mg-1unit, 500mg-320mg-130mg,90mg-500mg-60mg 158omega-3-acid ethyl esters 48omeprazole 10 mg, 20 mg, 40mg 176omeprazole-sodium bicarbonate20mg-1100mg 177omeprazole-sodium bicarbonate20mg-1680mg 177

omeprazole-sodiumbicarbonate 40mg-1100mg 177OMNIFLEX DIAPHRAGM136OMNIPRED 163OMNITROPE 10 MG/1.5ML, 5MG/1.5ML 120ONCASPAR 65ondansetron 44ondansetron hcl 24 mg, 4 mg, 8mg 44ondansetron hcl 4 mg/2ml, 40mg/20ml 43ondansetron hcl 4 mg/5ml 44ONE A DAY WOMENSPRENATAL/DHA 153ONFI 26ONGLYZA 39OPANA 10 MG 12OPANA 5 MG 12OPDIVO 59OPSUMIT 86OPTICHAMBERADVANTAGE 140OPTICHAMBERADVANTAGE/LARGEMASK 141OPTICHAMBERADVANTAGE/MEDIUM FACEMASK 141OPTICHAMBERADVANTAGE/SMALL FACEMASK 141OPTICHAMBERDIAMOND 141OPTICHAMBERDIAMOND/LARGEFACEMASK 141OPTICHAMBERDIAMOND/MEDIUM FACEMASK 141OPTICHAMBERDIAMOND/SMALLFACEMASK 141OPTICHAMBER FACEMASK/LARGE 141OPTICHAMBER FACEMASK/MEDIUM 141OPTICHAMBER FACEMASK/SMALL 141OPTIHALER 141OPTIHALER MDI DRUGDELIVERY SYSTEM 141OPTIONS CONCEPTROLVAGINALCONTRACEPTIVE 180

OPTIONS GYNOL IIVAGINALCONTRACEPTIVE

180OPTIVAR 164OPURITY B12/FOLICACID 130ORABASE 148oral electrolytes 18.8meq/l-42.4meq/l-33.2meq/l-4.8gm/l-18.8gm/l, 20meq/1000ml-45meq/1000ml-35meq/1000ml-25gm/1000ml, 20meq/l-20meq/l-45meq/l-45meq/l-35meq/l-25gm/l,20meq/l-20meq/l-45meq/l-45meq/l-35meq/l-35meq/l-30meq/l-30meq/l-25gm/l-25gm/l,20meq/l-20meq/l-45meq/l-45meq/l-35meq/l-35meq/l-30meq/l-30meq/l-5gm/l-20gm/l,20meq/l-45meq/l-35meq/l-25gm/l,20meq/l-45meq/l-35meq/l-30meq/l-25gm/l, 20meq/l-45meq/l-35meq/l-30meq/l-5gm/l-20gm/l, 20meq/l-45meq/l-35meq/l-30meq/l-5gm/l-25gm/l,20meq/l-45meq/l-35meq/l-5gm/l-20gm/l, 20meq/l-45meq/l-35meq/l-7.8mg/l-25gm, 20meq/l-45meq/l-35meq/l-7.8mg/l-25gm/l,20meq/l-45meq/l-35meq/l-7.8mg/l-25meq/l, 20meq/l-45meq/l-45meq/l-35meq/l-5gm/l-20gm/l, 35meq/l-45meq/l-20meq/l-25gm/l, 35meq/l-45meq/l-20meq/l-30meq/l-25gm/l,35meq/l-45meq/l-20meq/l-30meq/l-30gm/l, 35meq/l-45meq/l-20meq/l-30meq/l-5gm/l-20gm/l, 35meq/l-45meq/l-20meq/l-5gm/l-20gm/l, 35meq/l-45meq/l-20meq/l-7.5mg/l-25meq/l, 35meq/l-45meq/l-20meq/l-7.8mg/l-25gm/l, 35meq/l-7.8mg/l-45meq/l-20meq/l-25gm/l,65meq/l-75meq/l-20meq/l-30meq/l-2 146oral electrolytes 287mg-180mg-15mg 146ORAP 171ORAPRED ODT 92ORAZINC 148ORBACTIV 17ORENCIA 7ORENCIA CLICKJECT 7ORFADIN 10 MG, 2 MG, 20 MG,5 MG 121

Index 23

ORKAMBI 172ORTHO EVRA 90ORTHO MICRONOR 91ORTHO TRI-CYCLEN 90ORTHO-CEPT 90ORTHO-CYCLEN 90ORTHO-NOVUM 1/35 90ORTHO-NOVUM 7/7/7 90OSENI 12.5MG-15MG 37OSENI 12.5MG-30MG 37OSENI 12.5MG-45MG, 25MG-15MG, 25MG-30MG, 25MG-45MG 37OTEZLA 7OTREXUP 4oxacillin sodium 10 gm 168oxacillin sodium 2 gm 168oxaliplatin 57OXANDRIN 14oxandrolone 10 mg, 2.5 mg 14oxaprozin 7oxazepam 21oxcarbazepine 29OXSORALEN ULTRA 100oxybutynin chloride 177oxycodone hcl 100 mg/5ml 12oxycodone hcl 15 mg 12oxycodone hcl 30 mg 12oxycodone hcl 5 mg 12oxycodone w/ acetaminophen10mg-325mg, 2.5mg-325mg,5mg-325mg, 7.5mg-325mg 13oxycodone w/ acetaminophen5mg/5ml-325mg/5ml 13oxycodone-aspirin 13oxymorphone hcl 10 mg 12oxymorphone hcl 15 mg 12oxymorphone hcl 5 mg 12oxymorphone hcl 7.5 mg 12oyster shell 145P & S 101paclitaxel 100 mg/16.7ml, 150mg/25ml 67paclitaxel 30 mg/5ml, 300mg/50ml 67paliperidone 1.5 mg 70paliperidone 3 mg 70paliperidone 6 mg 70paliperidone 9 mg 70

PAMELOR 36PAMINE 175PAMINE FORTE 175PANCREAZE 10000UNIT-4200UNIT-17500UNIT,25000UNIT-10500UNIT-43750UNIT, 37000UNIT-21000UNIT-61000UNIT,40000UNIT-16800UNIT-70000UNIT 117PANCREAZE 6200UNIT-2600UNIT-10850UNIT 117PANRETIN 100PANTHODERM 106pantoprazole sodium 20 mg, 40mg 176pantoprazole sodium 40mg 176papaya 5mg-5mg-3mg-2mg-20mg 81PARAFON FORTE DSC 155parenteral electrolytes 146paricalcitol 1 mcg, 2 mcg, 4mcg 121PARLODEL 68PARNATE 32paromomycin sulfate 4paroxetine hcl 33PATADAY 164PATANASE 156PAXIL 10 MG, 20 MG, 30 MG,40 MG 33PAXIL 10 MG/5ML 33PAXIL CR 33PEAK AIR PEAK FLOWMETERADULT/PEDIATRIC

141PEAK FLOW METER 141ped multivitamins w/fl &iron 152PEDIALYTE 20MEQ/L-45MEQ/L-35MEQ/L-30MEQ/L-25GM/L, 20MEQ/L-45MEQ/L-35MEQ/L-5GM/L-20GM/L

146PEDIALYTE FREEZERPOPS 146pediatric multiple vitamin w/c 152pediatric multiple vitamin w/extra c & fa 152

pediatric multiple vitamins w/ iron0.6mg/ml-10mg/ml-5unit/ml-8mg/ml-1500unit/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml

152pediatric multiple vitamins w/ iron1500unit/ml-10mg/ml-5unit/ml-400unit/ml-8mg/ml-0.6mg/ml-0.5mg/ml-0.4mg/ml-35mg/ml

152pediatric multivitamins w/fl0.25mg-15unit-1.2mg-2500unit-4.5mcg-400unit-1.05mg-13.5mg-1.05mg-0.3mg-60mg, 0.25mg-15unit-400unit-2500unit-1.2mg-4.5mcg-13.5mg-1.05mg-0.3mg-1.05mg-60mg, 0.5mg-15unit-1.2mg-2500unit-4.5mcg-400unit-1.05mg-13.5mg-1.05mg-0.3mg-60mg, 0.5mg-15unit-400unit-2500unit-1.2mg-4.5mcg-13.5mg-1.05mg-0.3mg-1.05mg-60mg,0.5mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-15unit-1.05mg-60mg, 15unit-0.25mg-1.05mg-13.5mg-1.2mg-2500unit-4.5mcg-400unit-0.3mg-1.05mg-60mg, 15unit-0.25mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-1.05mg-60mg, 15unit-0.5mg-1.05mg-13.5mg-1.2mg-2500unit-4.5mcg-400unit-0.3mg-1.05mg-60mg,15unit-0.5mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-1.05mg-60mg, 15unit-1mg-1.05mg-13.5mg-1.2mg-2500unit-4.5mcg-400unit-0.3mg-1.05mg-60mg, 15unit-1mg-2500unit-13.5mg-1.2mg-4.5mcg-400unit-1.05mg-0.3mg-1.05mg-60mg, 1mg-15unit-1.2mg-2500unit-4.5mcg-400unit-1.05mg-13.5mg-1.05mg-0.3mg-60mg, 1mg-15unit-400unit-2500unit-1.2mg-4.5mcg-13.5mg-1.05mg-0.3mg-1.05mg-60mg

151

Index 24

pediatric multivitamins w/fl0.5mg/ml-5unit/ml-0.6mg/ml-8mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml, 0.5mg/ml-5unit/ml-8mg/ml-0.6mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml, 5unit/ml-0.5mg/ml-8mg/ml-0.6mg/ml-1500unit/ml-2mcg/ml-400unit/ml-0.5mg/ml-0.4mg/ml-35mg/ml

152pediatric vitamins acd w/fluoride 152pediatric vitamins adc 153PEDVAX HIB 178peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 134peg 3350-potassium chloride-sodbicarbonate-sod chloride 134PEG-INTRON 79PEG-INTRON REDIPEN 79PEG-INTRON REDIPEN PAK4 79PEGANONE 30PEGASYS 79PEGASYS PROCLICK 79PEGINTRON 79penicillin g potassium 20 mu,20000000 unit, 5000000unit 167penicillin v potassium 250 mg,500 mg 167penicillin v potassium 250mg/5ml 167PENLAC NAIL LACQUER 99PENTAM 300 17pentoxifylline 128PEPCID 175PEPCID AC 175PEPTO BISMOL 43PEPTO-BISMOL 262 MG 43PEPTO-BISMOL 262MG/15ML 43PEPTO-BISMOLINSTACOOL 43PEPTO-BISMOL MAXSTRENGTH 43PEPTO-BISMOL TO-GO 43PERCODAN 13PERIDEX 149perindopril erbumine 2 mg 51perindopril erbumine 4 mg 51

perindopril erbumine 8 mg 51PERJETA 59permethrin 0.5 % 114permethrin 1 % 114permethrin 5 % 114PEROXYL 1.5%-6% 149perphenazine 16 mg, 2 mg, 4mg, 8 mg 72perphenazine-amitriptyline

170PERSANTINE 128PERSONAL BEST FULLRANGE 142PERSONAL BEST LOWRANGE 142PETROLATUM 106phenazopyridine hcl 100 mg,200 mg 127phenelzine sulfate 32phenobarbital 100 mg, 15 mg,16.2 mg, 30 mg, 32.4 mg, 60mg, 64.8 mg, 97.2 mg 132phenobarbital 20 mg/5ml 132phenoxybenzamine hcl 52phentermine hcl 1PHENYLADE AMINOACID 159PHENYLADE AMINO ACIDBLEND 159PHENYLADE MTE AMINOACIDBLEND 159PHENYLADE PHEBLOC 160PHENYLADE40 DRINKMIX 160phenyleph-promethazine w/cod 95phenylephrine hcl 0.25 % 157phenylephrine w/ dm-gg30mg/5ml-200mg/5ml-10mg/5ml 95phenylephrine-chlorpheniramine-dm w/ apap5mg/5ml-1mg/5ml-160mg/5ml-2.5mg/5ml, 5mg/5ml-5mg/5ml-1mg/5ml-1mg/5ml-160mg/5ml-160mg/5ml-2.5mg/5ml-2.5mg/5ml 95phenylephrine-shark liver oil-glycerin-petrolatum 15phenytoin 125 mg/5ml 30phenytoin 50 mg 30phenytoin sodium 30phenytoin sodiumextended 30

PHILLIPS MILK OFMAGNESIA 134PHILLIPS MILK OF MAGNESIACHEWABLE 134PHILLIPS MILK OF MAGNESIACONCENTRATED 134PHLEXY-10 160PHOS-NAK POWDERCONCENTRATE 147PHOSLO 126PHOSPHOLINE IODIDE 161phytonadione 100 mcg 181PICATO 100PIKO 1 ELECTRONIC 142pilocarpine hcl (oral) 149pilocarpine hcl 1 %, 2 %, 4% 161pimozide 171pindolol 84pioglitazone hcl 15 mg 40pioglitazone hcl 30 mg 40pioglitazone hcl 45 mg 40pioglitazone hcl-glimepiride 37pioglitazone hcl-metforminhcl 37piperacillin sodium-tazobactamsodium 167piroxicam 10 mg, 20 mg 7PLAN B ONE-STEP 91PLAQUENIL 55PLAVIX 300 MG 128PLAVIX 75 MG 128PLEGRIDY 171PLEGRIDY STARTERPACK 171PLETAL 128POCKET CHAMBER 142POCKET PEAK FLOWMETER 142POCKET SPACER 142POCKETPEAK PEAK FLOWMETER LOW RANGE 142POCKETPEAK PEAK FLOWMETER/UNIVERSALRANGE 142POCKETPEAK PEAK FLOWMETER/UNIVERSAL RANGE 50-720 LPM 142podofilox 107POLY-VI-FLOR 152POLYCOSE 157polyethylene glycol 3350 134

Index 25

polymyxin b sulfate 19polymyxin b-trimethoprim 162polysaccharide iron complex 150mg 131POLYSPORIN 98POLYTAR 115POLYTRIM 162polyvinyl alcohol 160POMALYST 61PONARIS 156PONSTEL 7PORTRAZZA 59potassium chloride 10 %, 20% 147potassium chloride 10 meq, 20meq, 8 meq 147potassium chloride 10 meq, 8meq 147potassium chloride 2meq/ml 147POTASSIUM CHLORIDEER 147potassium chloride in dextrose &sodium chloride 0.45%-20meq/l-5% 146potassium chloridemicroencapsulated crystalscr 147potassium citrate (alkalinizer)1080 mg, 540 mg 126POTASSIUM IODIDE 146POTIGA 200 MG 29POTIGA 300 MG 29POTIGA 400 MG 29POTIGA 50 MG 29PRADAXA 26PRALUENT 150 MG/ML 50PRALUENT 75 MG/ML 50pramipexole dihydrochloride0.125 mg, 0.25 mg, 0.5 mg, 0.75mg, 1 mg, 1.5 mg 68pramoxine-camphor-zincacetate 108PRANDIMET 37PRANDIN 0.5 MG 41PRANDIN 1 MG 41PRANDIN 2 MG 41PRAVACHOL 49pravastatin sodium 49prazosin hcl 53PRE-FOLIC 130PRECISION XTRA 116

PRECOSE 36PRED FORTE 163prednicarbate 105prednisolone 15 mg/5ml 92prednisolone 5 mg 93prednisolone acetate(ophth) 163prednisolone sodiumphosphate 10 mg, 15 mg, 30mg 92prednisolone sodiumphosphate 15 mg/5ml, 5mg/5ml, 6.7 mg/5ml 92prednisone 1 mg, 10 mg, 2.5mg, 20 mg, 5 mg, 50 mg 93prednisone 10 mg, 5 mg 93prednisone 5 mg/5ml 93prednisone 5 mg/ml 93PREMARIN 0.3 MG, 0.45 MG,0.625 MG, 0.9 MG, 1.25MG 123PREMARIN 0.625MG/GM 180PREMPHASE 123PREMPRO 123PRENATAL 11UNIT-263MG-25MG-1.5MG-27MG-4000UNIT-18MG-1.7MG-4MCG-400UNIT-0.8MG-2.6MG-100MG 153PRENATAL FORMULA 35MG-30UNIT-4000UNIT-200MG-25MG-1.8MG-200MG-28MG-20MG-1.7MG-8MCG-400UNIT-800MCG-2.6MG-120MG 153PRENATAL LOW IRON 153PRENATAL ONE DAILY 153PRENATAL VITAMIN 153PRESUN ULTRA/PARSOL 3%-5%-7.5%-6% 114PREVACID 15 MG 176PREVACID 30 MG 176PREVPAC 177PREZCOBIX 76PREZISTA 76PRIFTIN 56PRILOSEC 10 MG, 20 MG, 40MG 176primaquine phosphate 55PRIMAQUINEPHOSPHATE 55PRIMAXIN IV 18primidone 250 mg, 50 mg 29

PRINIVIL 51PRISTIQ 34PRIVIGEN 166PROAIR HFA 24PROAIR RESPICLICK 25probenecid 127PROCARDIA XL 85prochlorperazine 73prochlorperazine edisylate 73prochlorperazine maleate 10 mg,5 mg 73PROCRIT 10000 UNIT/ML, 2000UNIT/ML, 20000 UNIT/ML, 3000UNIT/ML, 4000 UNIT/ML, 40000UNIT/ML 130PROCTOCORT 1 % 15PROFERRIN ES 131progesterone micronized 100 mg,200 mg 168PROGLYCEM 39PROGRAF 0.5 MG, 1 MG, 5MG 82PROGRAF 5 MG/ML 82PROLASTIN-C 172PROLEUKIN 65PROLIA 119PROMACTA 12.5 MG 130PROMACTA 25 MG 130PROMACTA 50 MG 130PROMACTA 75 MG 130promethazine hcl 12.5 mg, 25mg 47promethazine hcl 12.5 mg, 25mg, 50 mg 48promethazine hcl 25 mg/ml, 50mg/ml 47promethazine hcl 6.25mg/5ml 47promethazine w/codeine 95promethazine-dm 95PROMETRIUM 168PRONTO 0.33%-4% 114propafenone hcl 22proparacaine hcl 163propranolol hcl 10 mg, 20 mg, 40mg, 60 mg, 80 mg 84propranolol hcl 120 mg, 160 mg,60 mg, 80 mg 84PROPYLENE GLYCOL 168propylthiouracil 174PROQUAD 179

Index 26

PROSCAR 127PROSHIELD FOAM & SPRAYCLEANSER 112PROTEINEX 160PROTONIX 20 MG, 40 MG 176PROTONIX 40 MG 176PROTOPIC 107protriptyline hcl 36PROVENTIL HFA 25PROVERA 168PROVIGIL 3PROZAC 33PROZAC WEEKLY 33PRUCLAIR 109PRUMYX 109pseudoephedrine hcl 15mg/5ml 157pseudoephedrine hcl 30 mg, 60mg 157pseudoephedrine-acetaminophen

95pseudoephedrine-ibuprofen100mg/5ml-15mg/5ml 95psyllium 0.52 gm, 520 mg 133psyllium 100 %, 48.57 %, 58.6 %,95 % 133psyllium 28.3 %, 30 %, 30.9 %,33 %, 49 %, 68 % 133PTS PANELS KETONETEST 116PULMICORT 0.25 MG/2ML, 0.5MG/2ML 24PULMOZYME 172PURINETHOL 58PURIXAN 58PX CALAMINE 112pyrazinamide 56pyrethrins-piperonyl butoxide0.3%-0.33%-4%, 0.33%-4% 114pyrethrins-piperonyl butoxide0.33%-4% 114pyrethrins-piperonyl butoxide0.33%-4%, 1.2%-0.3%-0.3%-2.4%-3% 114PYRIDIUM 127pyridostigmine bromide 180mg 55pyridostigmine bromide 60mg 55pyridoxine hcl 100 mg, 25 mg, 50mg 182pyrithione zinc 0.25 % 101

pyrithione zinc 2 % 101QC CALAMINE 112QC COD LIVER OIL 154QSYMIA 1QUALAQUIN 55quetiapine fumarate 100 mg,200 mg, 25 mg, 300 mg, 400mg, 50 mg 72QUFLORA PEDIATRIC108MCG-1MG-15UNIT-0.25MG-15MG-1200UNIT-5MG-1.3MG-4MCG-400UNIT-1.2MG-100MCG-1.5MG-60MG,108MCG-1MG-15UNIT-0.5MG-15MG-1200UNIT-5MG-1.3MG-4MCG-400UNIT-1.2MG-100MCG-1.5MG-60MG,108MCG-1MG-15UNIT-1MG-15MG-1200UNIT-5MG-1.3MG-4MCG-400UNIT-1.2MG-100MCG-1.5MG-60MG 152QUFLORA PEDIATRIC150MCG/ML-1MG/ML-0.5MG/ML-12MG/ML-1100UNIT/ML-2MG/ML-1MG/ML-3MCG/ML-400UNIT/ML-1MG/ML-81MCG/ML-12UNIT/ML-1MG/ML-45MG/ML 152quinapril hcl 52quinapril-hydrochlorothiazide

54quinidine gluconate 324mg 22quinidine sulfate 22quinine sulfate 55QVAR 24RA BEAUTY BAR 112RA CALAMINE 6.971%-6.971% 112RA COD LIVER OIL 154RA OYSTER SHELLCALCIUM/VITAMIN D 250MG-125UNIT 145RA SALINE WOUNDWASH 112RABAVERT 179raloxifene hcl 120ramipril 52RANEXA 20ranitidine hcl 15 mg/ml, 150mg/10ml, 75 mg/5ml 175ranitidine hcl 150 mg 175

ranitidine hcl 150 mg, 300mg 175ranitidine hcl 300 mg 175ranitidine hcl 75 mg 175RAPAMUNE 0.5 MG 82RAPAMUNE 1 MG, 2 MG 82RAPAMUNE 1 MG/ML 82RASPBERRY SYRUP 168RASUVO 5RAVICTI 121RAZADYNE 170RAZADYNE ER 169REBETOL 200 MG 79REBIF 171REBIF REBIDOSE 171REBIF REBIDOSETITRATIONPACK 171REBIF TITRATION PACK 171RECLAST 119RECOMBIVAX HB 179RECTIV 15REGENECARE HA 108REGIMEX 1REGLAN 125REGRANEX 115RELENZA DISKHALER 80RELION KETONE 116RELION KETONE TESTSTRIPS 116RELISTOR 12 MG/0.6ML, 8MG/0.4ML 126REMERON 31REMERON SOLTAB 31REMICADE 125REMODULIN 86RENVELA 2.4 GM 126RENVELA 800 MG 126repaglinide 0.5 mg 41repaglinide 1 mg 41repaglinide 2 mg 41repaglinide-metformin hcl 37REPATHA 51REPATHA PUSHTRONEXSYSTEM 51REPATHA SURECLICK 51REQUIP 68REQUIP XL 68RESCRIPTOR 77

Index 27

RESERPINE 0.1 MG 53RESERPINE 0.25 MG 53RESTASIS 162RESTASIS MULTIDOSE 163RESTORIL 132RETIN-A 97RETIN-A MICRO 97RETIN-A MICRO PUMP 0.04 %,0.1 % 97RETROVIR 77RETROVIR IV INFUSION 77REVATIO 10 MG/12.5ML 86REVATIO 20 MG 86REVIA 43REVLIMID 81REXULTI 0.25 MG 74REXULTI 0.5 MG 74REXULTI 1 MG 74REXULTI 2 MG 74REXULTI 3 MG 74REXULTI 4 MG 74REYATAZ 77REZAMID 97RHINOCORT AQUA 156ribavirin (hepatitis c) 79riboflavin 100 mg, 25 mg 182riboflavin 50 mg 182RID 114RIDAURA 5rifabutin 56RIFADIN 56rifampin 150 mg, 300 mg 56rifampin 600 mg 56RIFATER 55RIGHT STEP PRENATAL 153RILUTEK 157riluzole 157rimantadine hydrochloride 80RISACAL-D 145RISPERDAL 71RISPERDAL CONSTA 12.5MG 70RISPERDAL CONSTA 25MG 71RISPERDAL CONSTA 37.5MG 71RISPERDAL CONSTA 50MG 71

RISPERDAL M-TAB 71risperidone 71RITALIN 3RITALIN LA 20 MG, 30 MG, 40MG 3RITALIN LA 60 MG 3RITEFLO 142RITUXAN 60rivastigmine 170rivastigmine tartrate 170rizatriptan benzoate 10mg 143rizatriptan benzoate 5 mg 143ROBAXIN 500 MG 155ROBAXIN-750 155ROBINUL 0.2 MG/ML 175ROBINUL 1 MG 175ROBINUL FORTE 175ROCALTROL 121ROCEPHIN 88ropinirole hydrochloride 69rosuvastatin calcium 49ROTARIX 179ROTATEQ 179ROWASA 125ROXICODONE 15 MG 12ROXICODONE 30 MG 12ROXICODONE 5 MG 12ROZEREM 133RUCONEST 128RYMED 95RYTARY 69RYTHMOL 22RYTHMOL SR 22SABRIL 30SAFE WASH 112SALAGEN 149salicylic acid 6 % 107saline 156saline 0.65 %, 0.65%, 0.65%-0.002% 156SALINE WOUND WASH 112SALJET 113SALJET RINSE 113SALTAIRE 156SAMSCA 122SANDIMMUNE 100 MG, 25MG 82

SANDIMMUNE 100 MG/ML 82SANDIMMUNE 50 MG/ML 82SANDOSTATIN 100 MCG/ML,200 MCG/ML, 50 MCG/ML 122SANDOSTATIN LAR DEPOT 20MG, 30 MG 122SANTYL 107SAPHRIS 10 MG 72SAPHRIS 2.5 MG 72SAPHRIS 5 MG 72SAXENDA 1SAYMAN LANOLIN 113SAYMAN WITCH HAZEL 113SEASONIQUE 90SEBUDERM 109SECTRAL 83selegiline hcl 69selenium 100 mcg 148SELENIUM 40 MCG/ML 148selenium 50 mcg 148selenium sulfide 2.5 % 101SELZENTRY 77sennosides 15 mg 135SENSIPAR 121SEREVENT DISKUS 25SEROQUEL 72SEROSTIM 4 MG, 6 MG 120sertraline hcl 100 mg, 25 mg, 50mg 33sertraline hcl 20 mg/ml 33SHADE OIL FREE CLEARGELSPF 25 114SHUR-SEAL 180SIGNIFOR 122SIGNIFOR LAR 20 MG 122SIGNIFOR LAR 40 MG 122SIGNIFOR LAR 60 MG 122sildenafil citrate (pulmonaryhypertension) 86SILENOR 132SILVADENE 102silver sulfadiazine 102simethicone 125 mg 124simethicone 125 mg,125mg 124SIMPONI 4SIMPONI ARIA 4SIMULECT 82simvastatin 10 mg 50

Index 28

simvastatin 20 mg 50simvastatin 40 mg 50simvastatin 5 mg 50simvastatin 80 mg 50SINEMET 69SINEMET CR 69SINGULAIR 10 MG 23SINGULAIR 4 MG, 5 MG 23sirolimus 82SIRTURO 56SIVEXTRO 19SKELAXIN 155skin protectants, misc. 113SLO-NIACIN 183SM CALAMINE 113SM CALAMINEPHENOLATED 113SM GLUCOSE 4 GM 39SM IPECAC SYRUP 43SM PAINRELIEF/MENTHOL 108SM SKIN CLEANSERGENTLE/SENSITIVE SKIN 113sodium bicarbonate 8.4 % 144sodium chloride (guirrigant) 126sodium chloride (inhalant) 95sodium chloride 0.45 % 147sodium chloride 0.9 % 147sodium chloride hypertonic 164SODIUM CHLORIDE/SODIUMBICARBONATE 89SODIUM CITRATEDIHYDRATE 89sodium polystyrenesulfonate 82sodium polystyrene sulfonate 15gm/60ml 82SOLARAZE 100SOLBAR PF LIQUID/GELSPF30 114SOLTAMOX 61SOLU-CORTEF 100 MG, 250MG, 500 MG 93SOLU-CORTEF 1000 MG 93SOLU-MEDROL 1000 MG, 125MG, 40 MG 93SOLU-MEDROL 500 MG 93SOLVIL 160SOMA 350 MG 155SOMATULINE DEPOT 122

SOMAVERT 120SONATA 132SORIATANE 101sotalol hcl 84sotalol hcl (afib/afl) 84Sotalol Hcl IV Soln 84SOTYLIZE 84SOVALDI 79SPIRIVA HANDIHALER 23SPIRIVA RESPIMAT 1.25MCG/ACT, 2.5 MCG/ACT 23SPIRIVA RESPIMAT 2.5MCG/ACT 23spironolactone &hydrochlorothiazide 118spironolactone 100 mg, 25 mg,50 mg 118SPORANOX 100 MG 46SPORANOX PULSEPAK 46SPRITAM 1000 MG 29SPRITAM 250 MG 29SPRITAM 500 MG 29SPRITAM 750 MG 29SPRYCEL 64ST JOSEPH ADULT 9ST JOSEPH ADULTANALGESICLOW DOSE BITESIZE 9starch (topical) 15STARLIX 41stavudine 77STELARA 45 MG/0.5ML, 90MG/ML 101STIOLTO RESPIMAT 25STIVARGA 64STRATTERA 10 MG 2STRATTERA 100 MG 2STRATTERA 18 MG 2STRATTERA 25 MG 2STRATTERA 40 MG 2STRATTERA 60 MG 2STRATTERA 80 MG 2STRENSIQ 121STRIBILD 77STRIVERDI RESPIMAT 25STROMECTOL 16STYGIENE STERILE EYELIDCLEANSER 113SUBSYS 100 MCG, 200MCG 12

SUBSYS 1200 MCG 12SUBSYS 1600 MCG, 400 MCG,600 MCG, 800 MCG 12sucralfate 176SUDAFED 157SUDAFED CHILDRENS 157SUDAFED CONGESTION 157SUDAFED NASALDECONGESTANT MAXIMUMSTRENGTH 157SUDAFED PE CHILDRENSNASAL DECONGESTANT 157SUDAFED PE SEVERE COLDMULTI-SYMPTOM 95SULAR 85sulfacetamide sod-prednisolone 163sulfacetamide sodium (acne)97sulfacetamide sodium(ophth) 162sulfadiazine 173sulfamethoxazole-trimethoprim

17SULFAMYLON 5 % 102SULFAMYLON 85 MG/GM 102sulfasalazine 125SULFZIX 500MCG/0.25GM117sulindac 150 mg, 200 mg 7sumatriptan succinate 100mg 143sumatriptan succinate 25mg 143sumatriptan succinate 4mg/0.5ml 143sumatriptan succinate 50mg 143sumatriptan succinate 6mg/0.5ml 143SUMMERS EVE DEODORANTSPRAY 109SUMMERS EVE DEODORANTSPRAY ULTRA 109SUMMERS EVE NIGHT-TIMECLEANSING/SENSITIVESKIN 113SUPER E 106SUPER E DAY 106SUPER E EYE 106SUPER E NIGHT 106SUPER-AMINO 1600 160SUPRAX 400 MG 88SUPRENZA 15 MG, 30 MG 1SUPREP BOWEL PREP 134

Index 29

SURMONTIL 36SUSTIVA 77SUTENT 64SYLATRON 65SYMBYAX 170SYMLINPEN 120 36SYMLINPEN 60 36SYNAGIS 50 MG/0.5ML 166SYNALAR 105SYNAREL 121SYNERCID 20SYNJARDY 12.5MG-1000MG,5MG-1000MG 38SYNJARDY 12.5MG-500MG,5MG-500MG 38SYNRIBO 65SYNTHROID 174SYPRINE 80TABLOID 59tacrolimus (topical) 107tacrolimus 0.5 mg, 1 mg, 5mg 82TAFINLAR 64TAGRISSO 64TALTZ 101TAMIFLU 80tamoxifen citrate 10 mg, 20mg 61tamsulosin hcl 127TARCEVA 64TARGRETIN 1 % 100TARGRETIN 75 MG 65TARSUM 115TASIGNA 64TASMAR 68TAXOL 67TAXOTERE 67TAZORAC 101TEARS AGAIN NIGHT &DAY 160TECENTRIQ 60TECFIDERA 171TECFIDERA STARTERPACK 171TECHNIVIE 79TEFLARO 600 MG 89TEGRETOL 29TEGRETOL-XR 100 MG 29

TEGRETOL-XR 200 MG, 400MG 29TEKTURNA 54TEKTURNA HCT 54temazepam 132TEMODAR 57TEMOVATE 105TEMOVATE E 106TENEX 53TENIVAC 174TENORETIC 100 54TENORETIC 50 54TENORMIN 83TERAZOL 3 180TERAZOL 7 180terazosin hcl 53terbinafine hcl 45terbinafine hcl (topical) 99terbutaline sulfate 2.5 mg, 5mg 25terconazole vaginal 180TERSASEPTIC GLYCERINECLEANSING 113TESSALON PERLES 93testosterone 1 %, 25 mg/2.5gm,50 mg/5gm 15TESTOSTERONE 1 %, 25MG/2.5GM, 50 MG/5GM 15testosterone cypionate 14testosterone enanthate 14TESTOSTERONE PUMP 15TETANUS/DIPHTHERIATOXOIDS-ADSORBED 174TETANUS/DIPHTHERIATOXOIDS-ADSORBEDADULT 174tetrabenazine 170tetracycline hcl 250 mg, 500mg 173TETRIX 109TGT LUBRICANT EYEDROPS 161THALOMID 81theophylline 100 mg, 200 mg,300 mg, 450 mg 25theophylline 400 mg, 600mg 25THERACYS 65THERAPLEX T 115THERMOTABS 146thiamine hcl 100 mg, 50mg 183

thiamine hcl 250 mg 183thiamine mononitrate 183thioridazine hcl 10 mg, 100 mg,25 mg, 50 mg 73THIOTEPA 57thiothixene 74THYMOGLOBULIN 82THYMOL 89tiagabine hcl 30TIAZAC 85TICE BCG 65ticlopidine hcl 128TIGAN 100 MG/ML 44TIGECYCLINE 18TIKOSYN 22timolol maleate (ophth) 161TIMOPTIC 161TIMOPTIC-XE 161TINACTIN 99TINACTIN JOCK ITCH 99TINDAMAX 17tinidazole 250 mg, 500 mg 17tioconazole vaginal 180TIVICAY 77tizanidine hcl 2 mg 155tizanidine hcl 4 mg 155tizanidine hcl 6 mg 155TOBI 4TOBI PODHALER 4TOBRADEX 163tobramycin 4tobramycin (ophth) 162tobramycin sulfate 1.2 gm 4tobramycin sulfate 1.2 gm/30ml,40 mg/ml, 80 mg/2ml 4tobramycin-dexamethasone 163TOBREX 162TOFRANIL-PM 36tolazamide 250 mg 42tolazamide 500 mg 42tolbutamide 42tolcapone 68tolmetin sodium 200 mg 7tolmetin sodium 400 mg 7tolnaftate 99tolterodine tartrate 178

Index 30

TOPAMAX 29TOPAMAX SPRINKLE 29TOPICLEAR 113topiramate 100 mg, 200 mg, 25mg, 50 mg 29topiramate 15 mg, 25 mg 29topotecan hcl 4 mg 67TOPOTECAN HCL 4MG/4ML 67TOPROL XL 83TORISEL 64torsemide 10 mg, 100 mg, 20 mg,5 mg 118TOUJEO SOLOSTAR 41trace minerals (cr-cu-mn-zn) 148TRACLEER 86TRADJENTA 39tramadol hcl 100 mg 12tramadol hcl 200 mg 13tramadol hcl 300 mg 13tramadol hcl 50 mg 12tramadol-acetaminophen 13trandolapril 52tranexamic acid 1000mg/10ml 131tranexamic acid 650 mg 131TRANSDERM-SCOP 44TRANXENE T 21tranylcypromine sulfate 32TRAVATAN Z 165trazodone hcl 100 mg, 150 mg,300 mg, 50 mg 34TREANDA 57TRECATOR 56TRELSTAR 61TRELSTAR MIXJECT 61TRESIBA FLEXTOUCH 100UNIT/ML 41TRESIBA FLEXTOUCH 200UNIT/ML 41tretinoin (chemotherapy) 65tretinoin 0.01 %, 0.025 % 97tretinoin 0.025 %, 0.05 %, 0.1% 97tretinoin microsphere 97TRI-VIT/FLUORIDE/IRON 152triamcinolone acetonide(mouth) 149triamcinolone acetonide(nasal) 156

triamcinolone acetonide(topical) 0.025 %, 0.1 % 106triamcinolone acetonide(topical) 0.025 %, 0.1 %, 0.5% 106TRIAMINIC COUGH & RUNNYNOSE 47TRIAMINO 160triamterene &hydrochlorothiazide 118triazolam 0.125 mg, 0.25mg 132triclosan 0.3 % 74TRICOR 49TRIDESILON 106trifluoperazine hcl 73trifluridine 162TRIGLIDE 49trihexyphenidyl hcl 68TRILEPTAL 29TRILIPIX 49trimethoprim 17trimipramine maleate 100 mg,25 mg, 50 mg 36TRINATAL RX 1 153TRINTELLIX 10 MG 34TRINTELLIX 20 MG 34TRINTELLIX 5 MG 34triprolidine & pseudoephedrine0.938mg/ml-10mg/ml 95triprolidine & pseudoephedrine2.5mg-2.5mg-60mg-60mg,2.5mg-60mg 95TRISENOX 65TRIUMEQ 77TRIZIVIR 77trospium chloride 178TRUSOPT 164TRUVADA 77TRUZONE PEAK FLOWMETER 142TUDORZA PRESSAIR 23TUMS 16TUMS E-X 750 16TUMS KIDS 16TUMS LASTINGEFFECTS 16TUMS SMOOTHIES 16TUSSIONEX PENNKINETICEXTENDED RELEASE 95TWINRIX 179

TYBOST 77TYGACIL 18TYKERB 64TYLENOL CHILDRENS 8TYLENOL CHILDRENS PLUSFLU 95TYLENOL CHILDRENS PLUSMULTI-SYMPTOM COLD 95TYLENOL INFANTS 8TYLENOL INFANTSPAIN+FEVER 8TYPHIM VI 178tyrosine 500 mg 160TYSABRI 171TYVASO 86TYVASO REFILL 86TYVASO STARTER 86TYZEKA 79UCERIS 2 MG/ACT 15ULCEREASE 1.5%-1.5%-0.6%-1.5% 149ULTRA DERM BATH OIL 101ULTRA MAN 153ULTRA MIDE 25 106ULTRA WOMAN 153ULTRACET 13ULTRAM 13ULTRAM ER 100 MG 13ULTRAM ER 200 MG 13ULTRAM ER 300 MG 13ULTRAVATE 106UNASYN 1GM-2GM 167UNDELENIC TINCTURE 100UNIFIBER 133UNIVERSAL PH STRIPS 116UNIVERSAL REMOVERWIPES 113UPTRAVI 86urea 20 % 106urea 25 % 106URISTIX 117URISTIX 4 116URO-PREP PROTECTIVESKINWIPES 113UROCIT-K 10 126UROCIT-K 5 126UROXATRAL 127URSO 250 124URSO FORTE 124

Index 31

ursodiol 250 mg, 500 mg 124ursodiol 300 mg 124UVADEX 65VAGISIL 179VAGISTAT-1 180valacyclovir hcl 1 gm, 1000 mg,500 mg 80VALCHLOR 100VALCYTE 450 MG 78valganciclovir hcl 450 mg 78VALIUM 21valproate sodium 100 mg/ml, 500mg/5ml 31valproate sodium 250mg/5ml 31valproic acid 31valsartan 52valsartan-hydrochlorothiazide

54VALSTAR 62VALTREX 80VALVED HOLDINGCHAMBER 142VANCOCIN HCL 17vancomycin hcl 10 gm, 1000 mg,5000 mg 17vancomycin hcl 125 mg, 250mg 17vancomycin hcl 500 mg 17VANCOMYCIN HCL INDEXTROSE 17VANICREAM 113VANTAS 61VAQTA 179VARIVAX 179VARIZIG 125 UNIT/1.2ML 166VARUBI 44VASCEPA 0.5 GM 48VASCEPA 1 GM 48VASERETIC 54VASOTEC 10 MG 52VASOTEC 2.5 MG 52VASOTEC 20 MG 52VASOTEC 5 MG 52VCF VAGINALCONTRACEPTIVE FILM 180VCF VAGINALCONTRACEPTIVE FOAM 180VECTIBIX 60VELCADE 64

VELTASSA 16.8 GM 82VELTASSA 25.2 GM 82VELTASSA 8.4 GM 82VENCLEXTA 60VENCLEXTA STARTINGPACK 60venlafaxine hcl 100 mg 35venlafaxine hcl 150 mg 34venlafaxine hcl 25 mg 35venlafaxine hcl 37.5 mg 34venlafaxine hcl 50 mg 35venlafaxine hcl 75 mg 35VENLAFAXINE HCL ER 35VENTAVIS 86verapamil hcl 100 mg, 120 mg,180 mg, 200 mg, 240 mg, 300mg, 360 mg 85verapamil hcl 120 mg, 180 mg,240 mg 85verapamil hcl 120 mg, 40 mg,80 mg 85VERELAN 85VERELAN PM 85VERSACLOZ 72VFEND 46VFEND IV 46VIBERZI 126VIBRAMYCIN 100 MG 173VIBRAMYCIN 25MG/5ML 173VICKS BABYRUB 108VICOPROFEN 13VICTOZA 39VICTRELIS 79VIDAZA 59VIDEX EC 77VIDEXPEDIATRIC 77VIEKIRA PAK 79VIGAMOX 162VIIBRYD 34VIIBRYD 10 MG, 20 MG, 40MG 34VIIBRYD STARTER PACK34VIMIZIM 122VIMPAT 10 MG/ML 30VIMPAT 100 MG, 150 MG, 200MG, 50 MG 30VIMPAT 200 MG/20ML 29VINATE ONE 153

vinblastine sulfate 67vincristine sulfate 67vinorelbine tartrate 67VIRACEPT 77VIRAMUNE 200 MG 77VIRAMUNE 50 MG/5ML 77VIRAMUNE XR 100 MG 78VIRAMUNE XR 400 MG 78VIRAZOLE 80VIREAD 78VIROPTIC 162VISTARIL 21VISTIDE 78VITALINE COQ10/VITAMIN E100MG-300UNIT 3vitamin a 10000 unit 181VITAMIN A 10000UNIT-1000UNIT 182VITAMIN A 25000 UNIT 181vitamin a 8000 unit 182VITAMIN B12/FOLIC ACID 130vitamin e (topical) 100 unit/5drop,12000 unit, 20000 unit, 28000unit, 28000 unit/29ml, 400 unit/ml,4000 unit, 49000 unit/52ml,933.333 unit/ml 107vitamin e (topical) 1000 unit, 1500unit/30gm, 30000 unit/60gm,6000 unit 106vitamin e 100 unit, 1000unit 182vitamin e 15 unit/0.3ml 182vitamin e 400 unit/15ml 182vitamins a & d 10000unit-400unit,10000unit-5000unit, 1250unit-133unit, 1250unit-135unit,5000unit-400unit, 700unit-400unit, 8000unit-400unit 154

Index 32

vitamins w/ lipotropics 10000unit-10mg-18mg-100unit-225mcg-10mg-150mg-100mg-30mg-10mg-25mg-25mg-50mg-50mg-10mg-50mg-50mg-200mcg-400unit-50mg-400mcg-50mg-250mg, 100mg-100mg-100mg-100mcg-100mg-100mcg-100mcg-100mg, 100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-100mcg-100mcg-100mg, 100mg-100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mcg-100mcg-100mg, 100mg-100mg-100mg-100mg-100mg-100mg-100mg-100mcg-100mg-200mcg-100mcg-100mg, 100mg-111.3mg-0.33mg-1.7mg-1.7mcg-0.33mg-111.3mg-3.3mg-0.33mg-100mg, 100mg-43.33mg-111.3mg-0.33mg-1.7mg-1.7mcg-0.33mg-111.3mg-3.3mg-0.33mg-100mg, 200mg-29mg-0.333mg-1.666mg-3.33mg-111.333mg-111.333mg-1mg-1.666mcg-0.333mg-100mg, 200mg-29mg-0.33mg-1.67mg-3.33mg-111.33mg-111.33mg-1mg-1.67mcg-0.33mg-100mg, 200mg-29mg-0.34mg-1.67mg-3.34mg-111mg-111mg-1mg-1.67mcg-0.34mg-100mg, 20mg-50mg-30mg-10mg-10mcg-30mg-8mg,25mg-40mg-20mg-3.4mg-20mg-12mcg-3mg-20mg-400mcg-30mcg-4mg-150mg, 25mg-40mg-20mg-3.4mg-20mg-12mcg-3mg-20mg-400mg-30mcg-4mg,266.667mg-29mg-0.333mg-1.667mg-3.333mg-111.333mg-111.333mg-1mg-1.667mcg-0.33

154VITEKTA 78VOGELXO 15VOGELXO PUMP 15VOLTAREN 97VOLTAREN-XR 7voriconazole 200 mg 46voriconazole 200 mg, 50 mg 46voriconazole 40 mg/ml 46VORTEX VALVED HOLDINGCHAMBER 142VOTRIENT 64VPRIV 129

VRAYLAR 70VRAYLAR 1.5 MG 70VRAYLAR 3 MG 70VRAYLAR 4.5 MG 70VRAYLAR 6 MG 70WALGREENS GLUCOSE 4GM 39warfarin sodium 25WATCHHALER 142water for irrigation, sterile 82WELCHOL 48WELLBUTRIN 100 MG 32WELLBUTRIN 75 MG 32WELLBUTRIN SR 100 MG32WELLBUTRIN SR 150 MG32WELLBUTRIN SR 200 MG32WELLBUTRIN XL 150 MG 32WELLBUTRIN XL 300 MG 32WESTCORT 106WFHC PH PAPER 117WHEAT GERM 182witch hazel-glycerin 113WOUND WASH SALINE 113XALATAN 165XALKORI 64XANAX 21XANAX XR 21XARELTO 25XARELTO STARTERPACK 25XELJANZ 4XENAZINE 170XENICAL 2XEOMIN 157XERALUX 109XGEVA 119XIFAXAN 17XIZFLUS500MCG/0.25GM 117XOLAIR 22XOPENEX 25XOPENEXCONCENTRATE 25

XPHE MAXAMUM 153MG-280MG-41MCG-1114UNIT-29MCG-13MCG-0.9MG-410MCG-4.5MG-569MG-7.4MG-9.2UNIT-18.5MCG-65.5MCG-592MG-280MG-350MG-2.9MG-40MG-215MG-0.49MG-2.5MG-1.6MCG-166UNIT-0.46MG-246MCG-12.3MCG-0.8MG-31MG, 153MG-280MG-41MCG-29MCG-13MCG-0.9MG-410MCG-4.5MG-569MG-7.4MG-9.2UNIT-18.5MCG-65.5MCG-592MG-280MG-350MG-1114UNIT-2.9MG-40MG-215MG-0.49MG-2.5MG-1.6MCG-166UNIT-0.46MG-246MCG-12.3MCG-0.8MG-31MG 160XTANDI 61XYLOCAINE 1 %, 2 % 135XYLOCAINE 4 % 108XYLOCAINE-MPF 1 % 135XYREM 169XYZAL 47YASMIN 28 90YAZ 90YERVOY 60YF-VAX 179YODORA DEODORANT 109YONDELIS 57ZADITOR 164zafirlukast 23zaleplon 132ZALTRAP 59ZANAFLEX 2 MG 155ZANAFLEX 4 MG 155ZANAFLEX 6 MG 155ZANOSAR 57ZANTAC 150 MG 176ZANTAC 300 MG 176ZANTAC 75 175ZARONTIN 31ZAROXOLYN 119ZARXIO 130ZAVESCA 129ZEBETA 83ZEGERID 20MG-1100MG 177ZEGERID 20MG-1680MG 177ZEGERID 40MG-1100MG 177ZELBORAF 64

Index 33

ZEMAIRA 172ZEMPLAR 1 MCG, 2 MCG 122ZEPATIER 79ZERIT 78ZESTORETIC 54ZESTRIL 52ZETIA 50ZIAC 54ZIAGEN 20 MG/ML 78ZIAGEN 300 MG 78zidovudine 78ZILACTIN 148ZINACEF 1.5 GM 88ZINC 10 MG 148ZINC 15 148zinc 25 mg 148zinc 50 mg 148zinc gluconate 50 mg 148ZINC SULFATE 1 MG/ML, 5MG/ML 148ZINECARD 66ziprasidone hcl 70ZIRGAN 162ZITHROMAX 100 MG/5ML, 200MG/5ML 135ZITHROMAX 250 MG, 500 MG,600 MG 135ZITHROMAX 500 MG 135ZITHROMAX TRI-PAK 135ZITHROMAX Z-PAK 135ZOCOR 10 MG 50ZOCOR 20 MG 50ZOCOR 40 MG 50ZOCOR 5 MG 50ZOCOR 80 MG 50ZOFRAN 4 MG, 8 MG 44ZOFRAN 4 MG/5ML 44ZOFRAN 40 MG/20ML 44ZOFRAN ODT 44ZOHYDRO ER 10 MG, 15 MG,20 MG, 30 MG, 40 MG, 50MG 13ZOLADEX 61zoledronic acid 4 mg 119zoledronic acid 4 mg/5ml 119zoledronic acid 5 mg/100ml 119ZOLINZA 64zolmitriptan 2.5 mg 143

zolmitriptan 5 mg 144ZOLOFT 33zolpidem tartrate 10 mg 132zolpidem tartrate 12.5 mg 132zolpidem tartrate 5 mg 132zolpidem tartrate 6.25 mg 132ZOMACTON 5 MG 120ZOMETA 4 MG/5ML 119ZOMIG 2.5 MG 144ZOMIG 5 MG 144ZOMIG ZMT 2.5 MG 144ZOMIG ZMT 5 MG 144ZONEGRAN 30zonisamide 30ZONTIVITY 128ZORTRESS 82ZOSTAVAX 179ZOSYN 0.25GM-2GM,0.375GM-3GM, 0.5GM-4GM,4.5GM-36GM 167ZOVIRAX 200 MG 80ZOVIRAX 200 MG/5ML 80ZOVIRAX 400 MG, 800MG 80ZOVIRAX 5 % 101ZYBAN 172ZYCLARA 107ZYCLARA PUMP 107ZYDELIG 64ZYKADIA 64ZYLOPRIM 100 MG 127ZYLOPRIM 300 MG 127ZYMAXID 162ZYPREXA 72ZYPREXA RELPREVV 210MG 72ZYPREXA ZYDIS 72ZYRTEC-DALLERGY/CONGESTION 95ZYTIGA 61ZYVOX 100 MG/5ML 19ZYVOX 200 MG/100ML 19ZYVOX 600 MG 19ZYVOX 600 MG/300ML 19

Index 34

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