list of covered drugs member - geisinger health plan formulary... · general formulary information...

LIST OF COVERED DRUGS

Member

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General Formulary Information

This formulary is applicable to the Triple Choice and Traditional Prescription Medication Benefit plans offered by Geisinger Health Plan, Geisinger Choice PPO and Geisinger Health Options.

We offer two main prescription medication benefits: the “Triple Choice benefit” and the “Traditional benefit.” Depending on the specific plan chosen by you or your employer, additional Tiers may also apply. You are enrolled in only one plan. We encourage you to contact our Pharmacy Customer Service Team if you have any questions about this information or the type of benefit in which you are enrolled. Also, please refer to your benefit documents, as formulary exclusions may differ based on the specific benefit. This formulary represents both the Triple Choice benefit and Traditional Prescription Medication benefit. This formulary was designed to be a useful tool if you have prescription medication coverage. It lists the medications covered by your benefit. Medications are listed in this formulary by medication category; individual medications can be looked up by using the index at the back. Please note that you can also view the formulary online at www.thehealthplan.com. Pharmacy Customer Service Team Contact Information

Telephone: (800) 988-4861 or (570)-271-5673; TDD/TTY 711 Fax: 570-271-5610 Mailing address: Geisinger Health Plan Pharmacy Department Internal Mail Code 32-46 100 North Academy Avenue Danville, PA 17822 Triple Choice Benefit

The Triple Choice benefit assigns each prescription medication to one of three different tiers, each representing a set copay amount. The copay amount will depend on your prescription medication rider. Additional medications, other than those included in this formulary, may be covered under the Triple Choice benefit. T he definitions of the copay levels are listed below: Tier 1–Includes most generic medications and has the lowest copayment. Prior authorization

is usually not necessary for medications in this tier. Tier 2–Includes certain formulary brand name medications with no generic equivalent. Prior

authorization may be necessary for medications in this tier. Tier 3–Includes certain formulary brand name medications, brand name medications with a

generic equivalent and non-formulary brand name medications. Prior authorization may be necessary for medications in this tier.

The Plan maintains sole discretion of assigning medications to tiers and moving medications from one tier to another. Several factors are considered when assigning medications to tiers. These factors include but are not limited to:

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Availability of a generic equivalent Absolute cost of a medication Cost of the medication relative to other medications in the same therapeutic class Availability of over-the-counter alternatives Clinical and economic factors

Please note: A medication may change in tier status without notice due to immediate generic availability or changes in medication availability in the marketplace. Traditional Benefit

The Traditional benefit has either a flat copayment/coinsurance, one copayment for generic and one copayment for brand, or assigns each prescription medication to one of two different tiers, each representing a set copayment amount. The copay amount will depend on your prescription medication rider. Additional medications, other than those included in this formulary, may be covered under t he Traditional benefit. The definitions of the copay levels are listed below: Tier 1–Includes most generic medications and has the lowest copayment. Prior authorization

is usually not necessary for medications in this tier. Tier 2–Includes certain formulary brand name medications with no generic equivalent. Prior

authorization may be necessary for medications in this tier.

*** For the Traditional Benefit any drug (without a generic) listed at Tier 3 in this formulary will be covered at Tier 2 ***

The Plan maintains sole discretion of assigning medications to tiers and moving medications from one tier to another. Several factors are considered when assigning medications to tiers. These factors include but are not limited to: Availability of a generic equivalent Absolute cost of a medication Cost of the medication relative to other medications in the same therapeutic class Availability of over-the-counter alternatives Clinical and economic factors Please note: A medication may change in tier status without notice due to immediate generic availability or changes in medication availability in the marketplace. Specialty Vendor Medication Program

Certain medications require the use of a contracted specialty pharmacy vendor for purchase. Please contact the Pharmacy Service Team for additional information on the program and a complete list of the medications included. A few things you should remember when using this formulary and your prescription benefit: All prescriptions must be filled at a participating pharmacy.

You will pay the applicable copay, coinsurance, or deductible when you receive the prescription.

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Under the Triple Choice benefit, a brand name medication with a generic equivalent will be covered at the highest applicable copay. Under the Traditional benefit a brand name medication with a generic equivalent requires prior authorization.

Some medications on the formulary require prior authorization or step therapy which your provider may request through our Pharmacy Customer Service Team.

If you require medications not listed on this formulary, your provider may request an exception through our Pharmacy Customer Service Team, except for those items listed as specific exclusions. Non-formulary medications not requiring prior authorization will be available at the highest copay level.

Some medications and diabetic supplies may be restricted to a specific manufacturer, vendor or supplier and may be subject to quantity limits.

Quantity limits may apply to certain medications.

Insulin syringes and lancets are covered at Tier 2.

Non-prescription (over-the-counter) medications are not covered unless required by healthcare reform legislation.

Note that if certain conditions are met some medications may be covered with no copay/coinsurance due to healthcare reform legislation. Please contact the pharmacy customer service team for more information.

Using this formulary

Please note: a percentage (%) copay applies for human growth hormone and is dependent upon your prescription medication rider.

Medication names with QL in the Requirements/Limits column have quantity limits Medication names followed by PA in the Requirements/Limits column require prior

authorization. Medication names followed by ST in the Requirements/Limits column have step therapy

requirements. (Please see Step Therapy List below). This formulary is accurate as of November 1, 2012, and is subject to change. Any additions

or deletions to the formulary throughout the year may be found in the following quarterly publications: “Member Update” for members and “Briefly” for providers. The most up-to-date source for formulary information is the online formulary search available at www.thehealthplan.com.

Restrictions in medication availability may result from use of a formulary. Certain prescription medications listed in this formulary may not be covered for everyone. Your prescription medication benefits are dependent upon the coverage selected by you or your employer. Please be aware that if you choose to obtain a non-formulary medication, you may be required to pay the full price of that medication. For information about your specific prescription medication benefits, please contact the Pharmacy Customer Service Team. Quantity Limits

Quantity limits are listed in the Requirements/Limits Column

Note that non-formulary medications in the same class/category as formulary drugs with quantity limits will have the same quantity limits applied.

http://www.thehealthplan.com/

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If not listed above the maximum days supply for specialty vendor medications is 34 days or as otherwise defined in the prescription medication benefit documents.

Step Therapy List

Medication Name Step Therapy Requirement

Byetta Formulary oral antidiabetic agent or insulin

Januvia Metformin, Actos, or Avandia

What is a Medication Formulary?

A medication formulary is a continually updated list of prescription medications. It represents the medications currently covered based upon the clinical judgment of the Pharmacy and Therapeutics Committee, which is made up of pharmacists and physicians. (The formulary is continually updated due to the high number of medications currently on the market, as well as the continuous introduction of new medications.) This committee thoroughly reviews medical literature to first determine which medications are likely to produce the best results for patients. Then, if two or more medications produce the same clinical results, elements like cost and ease of use are considered. A well-developed formulary enhances quality of patient care by encouraging physicians to prescribe medications that are safe, effective, and likely to achieve the best possible outcome for the patient. When you use a formulary medication, it is considered a “covered” medication and you pay your particular co-pay or coinsurance for that medication. The Plan recognizes that, in some situations, you may not respond well to a given formulary medication, or may have an allergy or other condition that warrants the use of a non-formulary medication. An exception process exists for these special instances. Your physician may initiate a request for a formulary exception by contacting our Pharmacy Service Team. Your request will be reviewed, including review of pertinent medical records, treatment and laboratory data. We respond to such requests within 48 hours of receiving all necessary information. If an exception is approved under the Triple Choice benefit, you will be charged at the highest applicable copay level. If your request is denied, the medication will be excluded from coverage under your prescription medication benefits. Formulary Exclusions

There are certain medications that your plan will not cover under any circumstance. These are called exclusions. Examples of exclusions include, but are not limited to, over-the-counter medications, medications used for experimental, investigational or unproven medication therapies, medications used for weight loss and weight management, life-style medications, medications used for cosmetic purposes, and medications for erectile dysfunction. Exclusions are subject to change so you should contact the Pharmacy Service Team when you are unsure whether a medication is covered.

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Formulary Development

When deciding whether or not a medication should be included in the formulary, the Pharmacy and Therapeutics Committee carefully considers each medication for coverage or non-coverage in order to ensure safety and effectiveness in the medications being prescribed. This information is then shared with participating providers for review and feedback. Based upon the gathered information and provider feedback, the Pharmacy and Therapeutics Committee will determine a medication’s inclusion or exclusion in the formulary. For the specific criteria used to determine a medication’s inclusion or exclusion in this formulary, please contact the Pharmacy Customer Service Team. What are Generics?

When a company develops a new medication, it receives a patent that protects the medication company’s right to be the only manufacturer of that medication for a certain period of time, which means that no generic can be manufactured. After that patent expires, other companies can then make the same medication and sell it in its generic form. The generic form of a medication has the same active ingredients, the same strength, and the same dosage as the brand name medication. The inactive ingredients (which provide texture, shape and color) may be different, which is why a generic typically looks different than its brand name counterpart. Generic medications are usually less expensive than brand name medications, but are just as safe and effective. This is because generic manufacturers have lower advertising costs and greater competition from other generic manufacturers. Additionally, the U.S. Food and Drug Administration regulates all pharmaceuticals, including generics, to assure quality, strength, purity and potency. Your prescription medication coverage is a generic-based plan and, whenever possible, you should use a cost-effective generic medication. Notes for Providers

Formulary review process: Medications selected for inclusion in the formulary are chosen in consideration of effectiveness, safety and overall value. Evaluation for formulary inclusion is based on formalized selection criteria to determine the most optimal benefit to members. These criteria include but are not limited to: Medication name/dosage form

Medication class/pharmacology

FDA-approved indications

Adverse reactions

Clinical evidence of safety and efficacy

Recommendations of national agencies and organizations

Therapeutic equivalence

Cost analysis

The criteria are reviewed by the Health Plan Pharmacy and Therapeutics Committee, which is comprised of pharmacists and participating physicians in active clinical practice from various specialties. The medication is then reviewed and evaluated by clinicians in particular specialties

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for additional feedback. The feedback is discussed by the Pharmacy and Therapeutics Committee prior to finalizing a decision on formulary status. To be included, the medication must offer a distinct advantage over existing formulary medications in the same therapeutic class. Specifically, the medication must demonstrate such attributes as: A distinct or unique therapeutic feature Greater efficacy, proven in clinical trials, over other medications in the same therapeutic

category An improved dosing schedule, safety profile or cost-effectiveness over existing formulary

medications If there are comparable therapeutic agents, additional analysis may be considered. These factors include: Member satisfaction Cost analysis Contract terms and conditions Market share analysis Patent life assessment Utilization management Consumer advertising Per member per month costs Generic substitution policy: The Health Plan prescription benefits are generically based. Generic substitution will occur for those medications included in the “Approved Medication Products with Therapeutic Equivalence Evaluations,” also known as “The Orange Book,” published by the U.S. Department of Health and Human Services. Generic medications, which have an equivalent rating by these standards, are generally provided under the member’s prescription medication benefit. The Health Plan may also elect to include only one brand-name medication in the formulary even if the medication is marketed by more than one company, or if the brand name medication does not significantly differ from the generic medication. Prior Authorization: To promote the most appropriate utilization, select medications may require prior authorization by the Health Plan to be eligible for coverage under the member’s prescription benefit. The Pharmacy and Therapeutics Committee determines prior authorization criteria. In order for a member to receive coverage for a medication requiring prior authorization, the prescribing physician must obtain prior authorization by contacting the Health Plan Pharmacy Department at the address, telephone, or fax number above. Submission of medical documentation is required. Step Therapy: Some medications may require that other medications be tried prior to or concomitantly with the requested medication. The pharmacy claims system looks for a record of the required medications and if they are not found, medical documentation must be submitted showing use of these medications or rationale for skipping the step therapy medications. Non-Formulary Medications: The formulary is designed to meet most therapeutic needs of the population served by the Health Plan. Occasionally, because of allergy, therapeutic failure, or a specific diagnostic-related need, formulary medications may not meet the special needs of an individual member. In these special instances, the prescribing physician may make requests to the Health Plan Pharmacy Department for non-formulary or restricted medications. The

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prescribing physician will receive written documentation and/or a verbal response from the Health Plan Pharmacy Department regarding the request. Formulary Addition Requests: Requests for changes or additions, comments, and suggestions for the formulary are welcome and can be made by written request to the Health Plan Pharmacy Department.

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Sources:

Academy of Managed Care Pharmacy (AMCP), “Formulary Management,” “Formularies,” www.amcp.org., November 2001.

Health Insurance Association of America (HIAA), “Guide to Managed Care: Choosing and Using a Health Plan.” www.hiaa.org., November 2001.

National Consumers League (NCL), “Consumer Guide to Generic Medications,” www.nclnet.org., November 2001.

“From the Pharmacist,” www.cvs.com., November 2001.

Drug Name Drug Tier

Requirements/Limits

Acidifying and Alkalinizing Agents Acidifying and Alkalinizing Agents citric acid/sodium citrate (Bicitra) 1 phosphorus #1 (K-phos Neutral) 1 potassium citrate (Urocit-K) 1 potassium citrate/citric acid

(Polycitra-k) 1

sod/pot/k cit/sod cit/cit acid

(Polycitra-lc) 1

K-PHOS ORIGINAL 2 ORACIT 2 Adrenals Adrenals budesonide (Pulmicort) 1 cortisone acetate (Cortisone Acetate) 1 dexamethasone (Dexamethasone) 1 fludrocortisone acetate (Florinef Acetate) 1 hydrocortisone (Cortef) 1 methylprednisolone (Medrol) 1 prednisolone sod phosphate

(Orapred) 1

prednisolone (Prednisolone) 1 prednisone (Prednisone) 1 VERIPRED 20 1 ADVAIR DISKUS 2 ADVAIR HFA 2 DULERA 2 FLOVENT DISKUS 2 FLOVENT HFA 2 PULMICORT FLEXHALER

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QVAR 2 SYMBICORT 2 ASMANEX 3 PULMICORT 3 ampul-neb: 1mg/

2ml Alpha-Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents doxazosin mesylate (Cardura) 1 prazosin hcl (Minipress) 1

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Geisinger 2012 Commercial Formulary Effective: November 01, 2012Formulary ID: 80102.000, Version: 2012-11

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Geisinger 2012 Commercial Formulary Effective: November 01, 2012

Drug Name Drug Tier

Requirements/Limits

terazosin hcl (Hytrin) 1 Ammonia Detoxicants Ammonia Detoxicants lactulose (Lactulose) 1 KRISTALOSE 2 LITHOSTAT 2 Analgesics and Antipyretics Analgesics And Antipyretics, Miscellaneous acetaminophen/caffeine/butalb

(Acetaminophen/caffeine/butalb) 1

acetaminophen/phenyltolx cit

(Staflex) 1

butalb/acetaminophen/caffeine

(Esgic) 1

butalbital/acetaminophen (Tencon) 1 isomethept/acetaminop/dichlphn

(Midrin) 1

mg sal/acetaminophn/p-tlox/caf

(Durabac Forte) 1

sal-amide/acetamin/p-tlox/caff

(Durabac) 1

sal-amide/acetaminophn/p-tlox

(Asp) 1

PHRENILIN FORTE 2 Nonsteroidal Anti-inflammatory Agents butalbital/aspirin/caffeine (Farbital) 1 choline sal/mag salicylate (Choline Sal/mag Salicylate) 1 diclofenac potassium (Cataflam) 1 diclofenac sodium (Voltaren) 1 diflunisal (Diflunisal) 1 etodolac (Etodolac) 1 fenoprofen calcium (Fenoprofen Calcium) 1 flurbiprofen (Ansaid) 1 ibuprofen (Motrin) 1 indomethacin (Indomethacin) 1 ketoprofen (Ketoprofen) 1 ketorolac tromethamine (Toradol) 1 QL: 20

per fill tablet

magnesium salicylate (Novasal) 1 meclofenamate sodium (Meclofenamate Sodium) 1

Formulary ID: 80102.000, Version: 2012-11

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Drug Name Drug Tier

Requirements/Limits

mefenamic acid (Ponstel) 1 meloxicam (Mobic) 1 methyl salicylate (Methyl Salicylate) 1 nabumetone (Relafen) 1 naproxen sodium (Anaprox) 1 naproxen (Naprosyn) 1 oxaprozin (Daypro) 1 phenylbutazone (Phenylbutazone) 1 piroxicam (Feldene) 1 salsalate (Salflex) 1 sulindac (Clinoril) 1 tolmetin sodium (Tolmetin Sodium) 1 INDOCIN 2 oral susp NALFON 2 ARTHROTEC 50 3 ARTHROTEC 75 3 CELEBREX 3 FLECTOR 3 PA VIMOVO 3 PA VOLTAREN 3 PA Opiate Agonists acetaminophen with codeine

(Tylenol-codeine No.3) 1

butalbit/acetamin/caff/codeine

(Fioricet with Codeine) 1

codeine phos/acetaminophen

(Codeine Phos/acetaminophen) 1

codeine sulfate (Codeine Sulfate) 1 CODEINE SULFATE 1 codeine/butalbital/asa/caffein

(Fiorinal with Codeine #3) 1

dhcodeine bt/acetaminophn/caff

(Panlor SS) 1

fentanyl citrate (Actiq) 1 PA, QL: 136 in 34 days

fentanyl (Duragesic) 1 hydrocodone bit/acetaminophen

(Vicodin) 1

hydrocodone/ibuprofen (Vicoprofen) 1


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Drug Name Drug Tier

Requirements/Limits

hydromorphone hcl (Dilaudid) 1 tablet ibuprofen/oxycodone hcl (Combunox) 1 levorphanol tartrate (Levo-dromoran) 1 meperidine hcl (Demerol) 1 solution, tablet methadone hcl (Methadose) 1 oral conc, solution,

tablet, tablet sol morphine sulfate (MS Contin) 1 cap er pel, solution,

supp.rect, tablet, tablet er

opium/belladonna alkaloids

(B & O Supprettes No.15-a) 1

OXECTA 1 oxycodone hcl (Roxicodone) 1 oxycodone hcl/acetaminophen

(Percocet) 1

oxycodone hcl/aspirin (Percodan) 1 oxycodone hcl/oxycodon ter/asa

(Oxycodone HCl/oxycodon Ter/asa)

1

oxymorphone hcl (Opana) 1 tablet ROXICODONE 1 tablet: 5mg tramadol hcl (Ultram) 1 tramadol hcl/acetaminophen

(Ultracet) 1

ABSTRAL 3 PA, QL: 136 in 34 days

AVINZA 3 FENTORA 3 PA NUCYNTA ER 3 PA NUCYNTA 3 PA ONSOLIS 3 PA, QL:

136 in 34 days

ORAMORPH SR 3 OXYCONTIN 3 PA SUBSYS 3 PA, QL:

136 in 34 days

Opiate Partial Agonists butorphanol tartrate (Butorphanol Tartrate) 1 spray


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Drug Name Drug Tier

Requirements/Limits

pentazocine hcl/acetaminophen

(Talacen) 1

pentazocine hcl/naloxone hcl

(Talwin NX) 1

BUTRANS 3 PA, QL: 4 in 28 days

Androgens Androgens danazol (Danocrine) 1 estrogen,ester/me-testosterone

(Estratest) 1

fluoxymesterone (Fluoxymesterone) 1 oxandrolone (Oxandrin) 1 testosterone cypionate (Depo-testosterone) 1 testosterone enanthate (Delatestryl) 1 ANDRODERM 2 ANDROGEL 3 DELATESTRYL 3 FORTESTA 3 PA STRIANT 3 PA Anorexigenics, Respiratory, Cerebral Stimulants Amphetamines amphet asp/amphet/d-amphet

(Adderall) 1

benzphetamine hcl (Didrex) 1 dextroamphetamine sulfate

(Dextrostat) 1

methamphetamine hcl (Desoxyn) 1 VYVANSE 3 PA Anorexigenics, Respiratory, Cerebral Stimulants, Miscellaneous caffeine citrated (Cafcit) 1 solution dexmethylphenidate hcl (Focalin) 1 methylphenidate hcl (Ritalin) 1 modafinil (Provigil) 1 PA METADATE CD 2 DAYTRANA 3 PA FOCALIN XR 3 PA cpmp 50-50: 5mg,

10mg, 15mg, 20mg, 30mg, 35mg, 40mg


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Drug Name Drug Tier

Requirements/Limits

NUVIGIL 3 PA RITALIN LA 3 PA cpmp 50-50: 10mg Anthelmintics Anthelmintics mebendazole (Mebendazole) 1 STROMECTOL 3 Antiallergic Agents Antiallergic Agents azelastine hcl (Astelin) 1 epinastine hcl (Elestat) 1 PATADAY 2 ALOMIDE 3 PA ASTEPRO 3 PA EMADINE 3 PA LASTACAFT 3 PA PATANASE 3 PA PATANOL 3 PA Antibacterials Aminoglycosides neomycin sulfate (Neomycin Sulfate) 1 TOBI 3 PA (QL: 34 days supply

per fill) Antibacterials, Miscellaneous clindamycin hcl (Cleocin HCl) 1 clindamycin palmitate hcl (Cleocin Palmitate) 1 vancomycin hcl (Vancocin HCl) 1 capsule ZYVOX 2 PA XIFAXAN 3 PA Cephalosporins cefaclor (Ceclor) 1 cefadroxil hydrate (Cefadroxil Hydrate) 1 cefdinir (Omnicef) 1 cefditoren pivoxil (Spectracef) 1 cefpodoxime proxetil (Vantin) 1 cefprozil (Cefzil) 1 cefuroxime axetil (Ceftin) 1 cephalexin (Keflex) 1 CEFTIN 2 susp recon SUPRAX 2


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Drug Name Drug Tier

Requirements/Limits

Macrolides azithromycin (Zithromax) 1 clarithromycin (Biaxin) 1 ery e-succ/sulfisoxazole (Pediazole) 1 ERY-TAB 1 erythromycin base (Erythromycin Base) 1 erythromycin ethylsuccinate

(Erythromycin Ethylsuccinate) 1

erythromycin stearate (Erythromycin Stearate) 1 E.E.S. 200 2 ERYPED 200 2 ERYPED 400 2 DIFICID 3 PA, QL:

20 per fill

Penicillins amoxicillin (Amoxil) 1 amoxicillin/potassium clav (Augmentin) 1 ampicillin trihydrate (Ampicillin Trihydrate) 1 dicloxacillin sodium (Dicloxacillin Sodium) 1 penicillin v potassium (Veetids 500) 1 AUGMENTIN 2 susp recon: 125-

31.25/ BACTOCILL 2 Quinolones ciprofloxacin hcl (Cipro) 1 ciprofloxacin/ciprofloxa hcl

(Cipro XR) 1

levofloxacin (Levaquin) 1 solution, tablet nalidixic acid (Nalidixic Acid) 1 ofloxacin (Floxin) 1 AVELOX 2 CIPRO 2 sus mc rec Sulfonamides (Systemic) sulfadiazine (Sulfadiazine) 1 sulfamethoxazole/trimethoprim

(Bactrim DS) 1 oral susp, tablet

sulfasalazine (Azulfidine) 1 Tetracyclines demeclocycline hcl (Declomycin) 1


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Drug Name Drug Tier

Requirements/Limits

doxycycline hyclate (Morgidox) 1 capsule, capsule dr, tablet, tablet dr

doxycycline monohydrate (Adoxa) 1 minocycline hcl (Dynacin) 1 tetracycline hcl (Ala-tet) 1 Anticholinergic Agents Antimuscarinics/Antispasmodics atropine sulfate (Atropine Sulfate) 1 tablet chlordiazepoxide/clidinium br

(Librax) 1

dicyclomine hcl (Bentyl) 1 glycopyrrolate (Robinul) 1 tablet hyoscyamine sulfate (Levsin-sl) 1 ipratropium bromide (Ipratropium Bromide) 1 isopropamide/prochlorperazine

(Isopropamide/prochlorperazine) 1

methscopolamine bromide (Pamine) 1 phenobarb/hyoscy/atropine/scop

(Donnatal) 1

propantheline bromide (Propantheline Bromide) 1 propantheline/phenobarbital

(Propantheline/phenobarbital) 1

ATROVENT HFA 2 SPIRIVA 2 Anticonvulsants Anticonvulsants, Miscellaneous carbamazepine (Tegretol) 1 divalproex sodium (Depakote ER) 1 felbamate (Felbatol) 1 gabapentin (Neurontin) 1 lamotrigine (Lamictal) 1 levetiracetam (Keppra) 1 solution, tab er 24h,

tablet oxcarbazepine (Trileptal) 1 primidone (Mysoline) 1 topiramate (Topamax) 1 valproate sodium (Depakene) 1 solution valproic acid (Depakene) 1 zonisamide (Zonegran) 1 GABITRIL 2


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Drug Name Drug Tier

Requirements/Limits

LYRICA 2 BANZEL 3 PA POTIGA 3 SABRIL 3 PA VIMPAT 3 PA solution, tablet Benzodiazepines (anticonvulsants) clonazepam (Klonopin) 1 Hydantoins phenytoin sodium extended

(Dilantin) 1

phenytoin (Dilantin-125) 1 DILANTIN 2 capsule: 30mg DILANTIN 2 tab chew PHENYTEK 2 Succinimides ethosuximide (Zarontin) 1 Antidiabetic Agents Antidiabetic Agents, Miscellaneous acarbose (Precose) 1 metformin hcl (Glucophage) 1 nateglinide (Starlix) 1 BYDUREON 2 ST BYETTA 2 ST GLYSET 2 JANUMET XR 2 JANUMET 2 JANUVIA 2 ST PRANDIN 2 JENTADUETO 3 PA JUVISYNC 3 PA KOMBIGLYZE XR 3 PA KORLYM 3 PA, QL:

136 in 34 days

ONGLYZA 3 PA SYMLIN 3 PA SYMLINPEN 120 3 PA SYMLINPEN 60 3 PA TRADJENTA 3 PA VICTOZA 3-PAK 3 PA


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Drug Name Drug Tier

Requirements/Limits

Insulins LANTUS SOLOSTAR 2 LANTUS 2 LEVEMIR 2 NOVOLIN 70-30 INNOLET

2

NOVOLIN 70-30 2 NOVOLIN N INNOLET 2 NOVOLIN N 2 NOVOLIN R 2 NOVOLOG MIX 70-30 2 NOVOLOG 2 APIDRA SOLOSTAR 3 PA APIDRA 3 PA HUMALOG MIX 50-50 3 PA HUMALOG MIX 75-25 3 PA HUMALOG 3 PA HUMULIN 70-30 3 PA HUMULIN N 3 PA HUMULIN R 3 PA Sulfonylureas chlorpropamide (Diabinese) 1 glimepiride (Amaryl) 1 glipizide (Glucotrol) 1 glipizide/metformin hcl (Metaglip) 1 glyburide (Micronase) 1 glyburide,micronized (Glynase) 1 glyburide/metformin hcl (Glucovance) 1 tolazamide (Tolazamide) 1 tolbutamide (Tolbutamide) 1 Thiazolidinediones pioglitazone hcl (Actos) 1 pioglitazone hcl/metformin hcl

(Actoplus Met) 1

Antidiarrhea Agents Antidiarrhea Agents diphenoxylate hcl/atropine (Lomotil) 1 loperamide hcl (Loperamide HCl) 1 opium tincture (Opium Tincture) 1 paregoric (Paregoric) 1


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Drug Name Drug Tier

Requirements/Limits

Antiemetics 5-ht3 Receptor Antagonists granisetron hcl (Kytril) 1 tablet, (QL: 2

tablets per 1 fill) granisetron hcl (Kytril) 1 QL: 30

per fill solution

ondansetron hcl (Zofran) 1 solution, tablet ondansetron (Zofran Odt) 1 SANCUSO 3 PA Antiemetics, Miscellaneous dronabinol (Marinol) 1 scopolamine hydrobromide

(Scopolamine Hydrobromide) 1

TRANSDERM-SCOP 2 EMEND 3 cap ds pk, capsule Antihistamines (GI Drugs) meclizine hcl (Antivert) 1 prochlorperazine maleate (Compazine) 1 trimethobenzamide hcl (Tigan) 1 capsule COMPAZINE 2 syrup Antifungal (Systemic) Antifungals, Miscellaneous flucytosine (Ancobon) 1 griseofulvin,microsize (Grifulvin V) 1 nystatin (Mycostatin) 1 FULVICIN U/F 2 GRIFULVIN V 2 GRIS-PEG 2 ANCOBON 3 (QL: 34 days supply

per fill) Azoles fluconazole (Diflucan) 1 itraconazole (Sporanox) 1 PA ketoconazole (Nizoral) 1 voriconazole (Vfend) 1 PA tablet, (QL: 34 days

supply per fill) NOXAFIL 3 PA (QL: 34 days supply

per fill) SPORANOX 3 PA solution


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Drug Name Drug Tier

Requirements/Limits

VFEND 3 PA (QL: 34 days supply per fill)

Antiglaucoma Agents Antiglaucoma Agents acetazolamide (Acetazolamide) 1 betaxolol hcl (Betaxolol HCl) 1 brimonidine tartrate (Alphagan P) 1 dorzolamide hcl (Trusopt) 1 dorzolamide hcl/timolol maleat

(Cosopt) 1

latanoprost (Xalatan) 1 levobunolol hcl (Betagan) 1 methazolamide (Neptazane) 1 metipranolol (Optipranolol) 1 pilocarpine hcl (Isopto Carpine) 1 timolol maleate (Timoptic) 1 ALPHAGAN P 2 drops: 0.1% AZOPT 2 BETOPTIC S 2 PHOSPHOLINE IODIDE 2 PILOPINE HS 2 TRAVATAN Z 2 ISOPTO CARPINE 3 drops: 8% LUMIGAN 3 PA ZIOPTAN 3 PA Anti-infectives (EENT) Anti-infectives (EENT) acetic acid (Vosol) 1 acetic acid/aluminum acetate

(Domeboro) 1

acetic acid/hydrocortisone (Vosol HC) 1 bacitracin (Bacitracin) 1 bacitracin/polymyxin b sulfate

(Polycin-b) 1

chlorhexidine gluconate (Peridex) 1 ciprofloxacin hcl (Ciloxan) 1 cresyl ace/ben alc/butanol/ipa

(Cresyl Ace/ben Alc/butanol/ipa) 1

doxycycline hyclate (Periostat) 1 erythromycin base (Ilotycin) 1


Drug Name Drug Tier

Requirements/Limits

gentamicin sulfate (Garamycin) 1 levofloxacin (Quixin) 1 neo/polymyx b sulf/dexameth

(Maxitrol) 1

neomy sulf/bacitra/polymyxin b

(Neo-polycin) 1

neomy sulf/bacitrac zn/poly/hc

(Triple Antibiotic HC) 1

neomycin sulfate/dex na ph

(Neomycin Sulfate/dex Na Ph) 1

neomycin/polymyxin b sulf/hc

(Oticin HC) 1

neomycin/polymyxn b/gramicidin

(Neosporin) 1

ofloxacin (Ocuflox) 1 polymyxin b sulfate/tmp (Polytrim) 1 sulfacetamide sodium (Sulfac) 1 sulfacetamide/prednisolone sp

(Sulfacetamide/prednisolone Sp) 1

tobramycin sulfate (Tobrex) 1 tobramycin/dexamethasone

(Tobradex) 1

trifluridine (Viroptic) 1 BACTROBAN NASAL 2 BLEPHAMIDE S.O.P. 2 BLEPHAMIDE 2 CILOXAN 2 oint. (g) CIPRO HC 2 CIPRODEX 2 NATACYN 2 PRED-G 2 drops susp TOBRADEX 2 oint. (g) AZASITE 3 BESIVANCE 3 VIGAMOX 3 Anti-infectives (Skin and Mucous Membrane) Antibacterials (Skin and Mucous Membrane) clindamycin phos/benzoyl perox

(Benzaclin) 1

clindamycin phosphate (Cleocin T) 1

21


Drug Name Drug Tier

Requirements/Limits

erythromycin base/ethanol (Emgel) 1 erythromycin/benzoyl peroxide

(Benzamycin) 1

gentamicin sulfate (Gentamicin Sulfate) 1 metronidazole (Metrocream) 1 mupirocin (Bactroban) 1 BACTROBAN 2 cream (g) CLEOCIN 2 supp.vag CLINDESSE 2 METROGEL 2 ALTABAX 3 PA DUAC CS 3 PA Antifungals (Skin and Mucous Membrane) ciclopirox olamine (Loprox) 1 ciclopirox (Loprox) 1 gel (gram),

shampoo clotrimazole (Mycelex) 1 clotrimazole/betamethasone dip

(Lotrisone) 1

econazole nitrate (Spectazole) 1 ketoconazole (Kuric) 1 miconazole nitrate (Monistat 3) 1 nystatin (Mycostatin) 1 nystatin/triamcin (Mycogen II) 1 sodium thiosulfate/sal acid (Sodium Thiosulfate/sal Acid) 1 terconazole (Terazol 7) 1 NAFTIN 2 FIRST-BXN 3 Antivirals (Skin and Mucous Membrane) DENAVIR 3 PA (QL: 1 copay/

coinsurance per tube)

VEREGEN 3 PA ZOVIRAX 3 PA (QL: 1 copay/

coinsurance per tube)

Local Anti-infectives, Miscellaneous hydrocortisone/iodoquinol (Vytone) 1 iodine/potassium iodide (Iodine/potassium Iodide) 1 selenium sulfide (Selenium Sulfide) 1

22


Drug Name Drug Tier

Requirements/Limits

silver nitrate (Silver Nitrate) 1 silver sulfadiazine (Thermazene) 1 sulfacetamd/sulfr/sknclnsr10

(Sulfacetamd/sulfr/sknclnsr10) 1

sulfacetamide sod/sulfur/urea

(Claris) 1

sulfacetamide sodium (Klaron) 1 sulfacetm na/avobenzone/sulfur

(Rosac) 1

THERMAZENE 1 alcohol antiseptic pads (Alcohol Antiseptic Pads) 2 AVC 2 Scabicides and Pediculicides lindane (Lindane) 1 malathion (Ovide) 1 permethrin (Elimite) 1 spinosad (Natroba) 1 Anti-inflammatory Agents (EENT) Anti-inflammatory Agents (EENT) bromfenac sodium (Bromfenac Sodium) 1 dexamethasone sod phosphate

(Ak-dex) 1

diclofenac sodium (Voltaren) 1 flunisolide (Nasarel) 1 fluocinolone acetonide oil (Dermotic) 1 fluorometholone (Fluorometholone) 1 flurbiprofen sodium (Ocufen) 1 fluticasone propionate (Flonase) 1 hc/pramox hcl/cl-xylenol/water

(HC/pramox HCl/cl-xylenol/water)

1

hc/pramoxine hcl/chloroxylenol

(Otozone) 1

ketorolac tromethamine (Acular LS) 1 prednisolone acetate (Pred Forte) 1 prednisolone sod phosphate

(Prednisol) 1

triamcinolone acetonide (Nasacort Aq) 1 DECADRON 2 FML S.O.P. 2 MAXIDEX 2

23


Drug Name Drug Tier

Requirements/Limits

NASONEX 2 BECONASE AQ 3 PA BROMDAY 3 PA FML 3 OMNARIS 3 PA QNASL 3 RESTASIS 3 RHINOCORT AQUA 3 VERAMYST 3 PA ZETONNA 3 PA Anti-inflammatory Agents (GI Drugs) Anti-inflammatory Agents (GI Drugs) balsalazide disodium (Colazal) 1 mesalamine w/cleansing wipes

(Rowasa) 1

CANASA 2 DIPENTUM 2 LIALDA 2 PENTASA 2 APRISO 3 PA ASACOL 3 Anti-inflammatory Agents (Respiratory) Anti-inflammatory Agents (Respiratory) cromolyn sodium (Cromolyn Sodium) 1 montelukast sodium (Singulair) 1 zafirlukast (Accolate) 1 SINGULAIR 2 gran pack Anti-inflammatory Agents (Skin and Mucous) Anti-inflammatory Agents (Skin and Mucous) alclometasone dipropionate

(Aclovate) 1

amcinonide (Amcinonide) 1 betamet diprop/prop gly (Diprolene AF) 1 betamethasone dipropionate

(Del-beta) 1

betamethasone valerate (Betamethasone Valerate) 1 clobetasol propionate (Temovate) 1 desonide (Desowen) 1 desoximetasone (Topicort) 1 diflorasone diacetate (Psorcon) 1

24


Drug Name Drug Tier

Requirements/Limits

fluocinolone acetonide (Synalar) 1 fluocinolone/shower cap (Derma-smoothe-fs) 1 fluocinonide (Lidex) 1 fluticasone propionate (Cutivate) 1 halobetasol propionate (Ultravate) 1 halobetasol/ammonium lactate

(Halonate Pac) 1

hydrocort/pramoxin/emol/pram#1

(Analpram E) 1

hydrocort/pramoxn/skn clnsr#16

(Zypram) 1

hydrocortisone ac/lidocaine

(Lidamantle HC) 1

hydrocortisone acetate (Hydrocortisone Acetate) 1 hydrocortisone acetate/aloe v

(Nucort) 1

hydrocortisone acetate/urea

(Carmol HC) 1

hydrocortisone butyrate (Locoid) 1 hydrocortisone valerate (Westcort) 1 hydrocortisone (Anusol-HC) 1 hydrocortisone/pramoxine (Pramcort) 1 mometasone furoate (Elocon) 1 prednicarbate (Dermatop) 1 triamcinolone acetonide (Triamcinolone Acetonide) 1 KENALOG 2 aerosol CORDRAN SP 3 CORDRAN 3 PROCTOFOAM-HC 3 VERDESO 3 PA Antilipemic Agents Antilipemic Agents, Miscellaneous NIASPAN 2 ZETIA 2 LOVAZA 3 VYTORIN 3 PA Bile Acid Sequestrants cholestyramine (with sugar)

(Questran) 1

cholestyramine/aspartame (Questran Light) 1

25


Drug Name Drug Tier

Requirements/Limits

colestipol hcl (Colestid) 1 colestipol hcl,micronized (Colestid) 1 WELCHOL 3 Fibric Acid Derivatives fenofibrate (Lofibra) 1 fenofibrate,micronized (Lofibra) 1 fenofibric acid (Fibricor) 1 gemfibrozil (Lopid) 1 TRICOR 2 TRILIPIX 2 ANTARA 3 PA HMG-CoA Reductase Inhibitors amlodipine/atorvastatin (Caduet) 1 atorvastatin calcium (Lipitor) 1 fluvastatin sodium (Lescol) 1 lovastatin (Mevacor) 1 pravastatin sodium (Pravachol) 1 simvastatin (Zocor) 1 CRESTOR 2 LESCOL XL 3 PA LIVALO 3 PA Antimigraine Agents Selective Serotonin Agonists naratriptan hcl (Amerge) 1 naratriptan hcl (Amerge) 1 (QL: 1 copay/

coinsurance per 9 tablets)

sumatriptan succinate (Imitrex) 1 sumatriptan succinate (Imitrex) 1 (QL: 1 copay/

coinsurance per 2 units)

sumatriptan succinate (Imitrex) 1 (QL: 1 copay/coinsurance per 4 units)

sumatriptan succinate (Imitrex) 1 (QL: 1 copay/coinsurance per 9 tablets)

sumatriptan (Imitrex) 1 (QL: 1 copay/coinsurance per 6 units)

26


Drug Name Drug Tier

Requirements/Limits

AXERT 2 (QL: 1 copay/coinsurance per 6 tablets)

MAXALT MLT 2 (QL: 1 copay/coinsurance per 12 tablets)

MAXALT 2 (QL: 1 copay/coinsurance per 12 tablets)

FROVA 3 (QL: 1 copay/coinsurance per 9 tablets)

RELPAX 3 (QL: 1 copay/coinsurance per 6 tablets)

TREXIMET 3 PA (QL: 1 copay/coinsurance per 9 tablets)

ZOMIG ZMT 3 (QL: 1 copay/coinsurance per 6 tablets)

ZOMIG 3 (QL: 1 copay/coinsurance per 6 tablets)

ZOMIG 3 (QL: 1 copay/coinsurance per 6 units)

Antimycobacterials Antimycobacterials dapsone (Dapsone) 1 ethambutol hcl (Myambutol) 1 isoniazid (Isoniazid) 1 syrup, tablet pyrazinamide (Pyrazinamide) 1 rifampin (Rifadin) 1 capsule rifampin/isoniazid (Rifamate) 1 MYCOBUTIN 2 RIFATER 2 Antineoplastic Agents Antineoplastic Agents anastrozole (Arimidex) 1

27


Drug Name Drug Tier

Requirements/Limits

bicalutamide (Casodex) 1 cyclophosphamide (Cytoxan) 1 tablet etoposide (Vepesid) 1 capsule exemestane (Aromasin) 1 flutamide (Flutamide) 1 hydroxyurea (Hydrea) 1 letrozole (Femara) 1 Age must

be > 45

megestrol acetate (Megace) 1 mercaptopurine (Purinethol) 1 methotrexate sodium (Methotrexate Sodium) 1 tamoxifen citrate (Nolvadex) 1 tretinoin (Tretinoin) 1 ALKERAN 2 tablet CEENU 2 EMCYT 2 HEXALEN 2 LEUKERAN 2 LYSODREN 2 MATULANE 2 MYLERAN 2 NILANDRON 2 XELODA 2 AFINITOR 3 PA (1 copay/

coinsurance per 15 days supply)

AFINITOR 3 PA (QL: 1 copay/coinsurance per 15 days supply

AFINITOR 3 PA (QL: 1 copay/coinsurance per 15 days supply)

CAPRELSA 3 PA (QL: 34 days supply per fill)

ERIVEDGE 3 PA, QL: 30 in 30 days

GLEEVEC 3 HYCAMTIN 3 capsule INLYTA 3 PA

28


Drug Name Drug Tier

Requirements/Limits

IRESSA 3 PA JAKAFI 3 PA, QL:

60 in 30 days

NEXAVAR 3 PA (QL: 1 copay/coinsurance per 15 days supply)

REVLIMID 3 PA SPRYCEL 3 PA (QL: 1 copay/

coinsurance per 15 days supply

SPRYCEL 3 PA (QL: 1 copay/coinsurance per 15 days supply)

SUTENT 3 PA (QL: 1 copay/coinsurance per 15 days supply)

TARCEVA 3 TARGRETIN 3 PA TASIGNA 3 PA (QL: 1 copay/


TEMODAR 3 capsule TYKERB 3 PA (QL: 34 days supply

per fill) VANDETANIB 3 PA (QL: 34 days supply

per fill) VOTRIENT 3 PA (QL: 1 copay/


XALKORI 3 PA, QL: 60 in 30 days

ZELBORAF 3 PA, QL: 240 in 30 days

ZOLINZA 3 PA (QL: 34 days supply per fill)

ZYTIGA 3 PA, QL: 120 in 30 days

29


Drug Name Drug Tier

Requirements/Limits

Antiparkinsonian Agents Antiparkinsonian Agents amantadine hcl (Amantadine HCl) 1 benztropine mesylate (Benztropine Mesylate) 1 tablet bromocriptine mesylate (Parlodel) 1 cabergoline (Cabergoline) 1 carbidopa/levodopa (Sinemet 25-100) 1 carbidopa/levodopa/entacapone

(Stalevo 50) 1

entacapone (Entacapone) 1 pramipexole di-hcl (Mirapex) 1 ropinirole hcl (Requip) 1 selegiline hcl (Eldepryl) 1 trihexyphenidyl hcl (Trihexyphenidyl HCl) 1 AZILECT 2 TASMAR 2 APOKYN 3 Antiprotozoal Agents Antiprotozoal Agents atovaquone/proguanil hcl (Malarone) 1 chloroquine phosphate (Aralen Phosphate) 1 hydroxychloroquine sulfate

(Plaquenil) 1

mefloquine hcl (Lariam) 1 metronidazole (Flagyl) 1 paromomycin sulfate (Humatin) 1 quinine sulfate (Qualaquin) 1 PA tinidazole (Tindamax) 1 ALINIA 2 DARAPRIM 2 MEPRON 2 NEBUPENT 2 YODOXIN 2 QUALAQUIN 3 PA Antipruritics and Local Anesthetics Antipruritics and Local Anesthetics hydrocortisone ac/lidocaine

(Anamantle Hc Forte) 1

hydrocortisone/lidocaine/aloe

(Peranex HC) 1

30


Drug Name Drug Tier

Requirements/Limits

lidocaine hcl (Lidamantle) 1 lidocaine/prilocaine (EMLA) 1 phenazopyridine hcl (Urodol) 1 pramoxine hcl (Pramoxine HCl) 1 foam LIDODERM 3 PA Antitussives Antitussives benzonatate (Tessalon) 1 bromphen mal/pe/carbetapen cit

(Trexbrom) 1

bromphenira/pseudoephed/codein

(Bromphenira/pseudoephed/codein)

1

brompheniram/pe/dihydrocodeine

(Brompheniram/pe/dihydrocodeine)

1

brompheniramin/pe/codeine phos

(Brompheniramin/pe/codeine Phos)

1

brompheniramin/pe/dextromethor

(Lortuss Dm) 1

bromphenrm/pseudoeph/dihydrocd

(Bromphenrm/pseudoeph/dihydrocd)

1

car-b-pen ta/chlor-tan (Trionate) 1 car-b-pen ta/phenylephrine/pyr

(Tussi-12d) 1

chlorpheniramine/codeine phos

(Notuss Ac) 1

codeine/promethazine hcl (Codeine/promethazine HCl) 1 dihydrocodeine/guaifenesin

(Dihydrocodeine/guaifenesin) 1

diphenhydramin/pe/codeine phos

(Endal Cd) 1

dm/phenyleph/chlorpheniramine

(Zotex-12d) 1

d-methorp tan/p-epd tan/d-cp

(Tandur Dm) 1

d-methorp tan/p-ephed tan/cp

(Allres Ds) 1

d-methorphan hb/pe/chlorphenir

(D-methorphan Hb/pe/chlorphenir)

1

d-methorphan hb/p-epd hcl/bpm

(Dallergy Dm) 1 Age must be > 60

liquid: 30-50-3mg

31


Drug Name Drug Tier

Requirements/Limits

d-methorphan hb/p-epd hcl/bpm

(Rondec-dm) 1 drops, liquid: 15-30-3/5, 20-20-4/5, 30-50-3mg; syrup

d-methorphan hb/p-ephed hcl/cp

(D-methorphan Hb/p-ephed HCl/cp)

1

d-methorphan hb/prometh hcl

(D-methorphan Hb/prometh HCl)

1

guaifenesin/codeine phosphate

(Myci-gc) 1

guaifenesin/dextromethorphan

(Trispec Dmx) 1

guaifenesin/dm/pseudoephedrine

(Maxifed Dm) 1

guaifenesin/p-ephed hcl/cod

(Guaifenesin/p-ephed HCl/cod) 1

hydrocodone bit/homatrop me-br

(Hycodan) 1

hydrocodone/chlorphen polis

(Tussionex) 1

p-ephed hcl/codeine/guaifen

(Suttar-2) 1

p-ephed hcl/dhcodeine bt/cp

(P-ephed HCl/dhcodeine Bt/cp) 1

p-ephed hcl/hydrocodone bit

(P-ephed HCl/hydrocodone Bit) 1

phenylephrine hcl/cod/prometh

(Phenylephrine HCl/cod/prometh)

1

phenylephrine/dhcodeine bt/cp

(Despec-pd) 1

pseudoephedrine hcl/codeine

(Notuss Dc) 1

pyrilamine/pe/dextromethorphan

(Poly Hist Dm) 1

Antiulcer Agents Antiulcer Agents cimetidine hcl (Cimetidine HCl) 1 solution cimetidine (Tagamet) 1 famotidine (Pepcid) 1 oral susp, tablet lansoprazole (Prevacid) 1 misoprostol (Cytotec) 1

32


Drug Name Drug Tier

Requirements/Limits

nizatidine (Axid) 1 omeprazole (Prilosec) 1 omeprazole/sodium bicarbonate

(Zegerid) 1 PA

pantoprazole sodium (Protonix) 1 ranitidine hcl (Zantac) 1 capsule, syrup,

tablet sucralfate (Carafate) 1 ACIPHEX 3 PA DEXILANT 3 PA, QL:

34 in 34 days

NEXIUM 3 PA ZEGERID 3 PA packet Antivirals (Systemic) Antiretrovirals abacavir sulfate (Ziagen) 1 didanosine (Videx EC) 1 lamivudine (Epivir) 1 lamivudine/zidovudine (Combivir) 1 nevirapine (Viramune) 1 stavudine (Zerit) 1 zidovudine (Retrovir) 1 ATRIPLA 2 CRIXIVAN 2 EMTRIVA 2 EPIVIR HBV 2 EPIVIR 2 solution EPZICOM 2 INTELENCE 2 INVIRASE 2 ISENTRESS 2 KALETRA 2 LEXIVA 2 NORVIR 2 PREZISTA 2 RESCRIPTOR 2 REYATAZ 2 SELZENTRY 2 SUSTIVA 2

33


Drug Name Drug Tier

Requirements/Limits

TRIZIVIR 2 TRUVADA 2 VIRACEPT 2 VIRAMUNE XR 2 VIREAD 2 tablet ZIAGEN 2 solution FUZEON 3 VIDEX 3 Antivirals, Miscellaneous rimantadine hcl (Flumadine) 1 INCIVEK 2 PA, QL:

180 in 30 days

RELENZA 2 (QL: 1 fill of Tamiflu or Relenza per season)

TAMIFLU 2 (QL: 1 fill of Tamiflu or Relenza per season)

Interferons INTRON A 2 INTRON A 2 (QL: 34 days supply

per fill) PEGASYS PROCLICK 2 (QL: 34 days supply

per fill) PEGASYS 2 (QL: 34 days supply

per fill) PEGINTRON REDIPEN 2 (QL: 34 days supply

per fill) PEGINTRON 2 (QL: 34 days supply

per fill) INFERGEN 3 (QL: 34 days supply

per fill) SYLATRON 4-PACK 3 PA, QL:

4 in 28 days

Nucleosides and Nucleotides acyclovir (Zovirax) 1 famciclovir (Famvir) 1 ganciclovir (Cytovene) 1

34


Drug Name Drug Tier

Requirements/Limits

RIBATAB 1 tab ds pk: 600-600mg

ribavirin (Rebetol) 1 valacyclovir hcl (Valtrex) 1 BARACLUDE 2 HEPSERA 2 VALCYTE 2 (QL: 34 days supply

per fill) VIRAZOLE 2 TYZEKA 3 Anxiolytics, Sedatives and Hypnotics Anxiolytics, Sedatives and Hypnotics, Miscellaneous buspirone hcl (Buspar) 1 chloral hydrate (Chloral Hydrate) 1 glutethimide (Glutethimide) 1 hydroxyzine hcl (Hydroxyzine HCl) 1 syrup, tablet hydroxyzine pamoate (Vistaril) 1 meprobamate (Miltown) 1 zaleplon (Sonata) 1 (QL: 1 copay/

coinsurance per 15 capsules)

zolpidem tartrate (Ambien) 1 (QL: 1 copay/coinsurance per 15 tablets)

INTERMEZZO 3 PA, QL: 15 per fill

(QL: 1 copay/coinsurance per 15 tablets)

LUNESTA 3 PA (QL: 1 copay/coinsurance per 15 capsules)

ROZEREM 3 PA (QL: 1 copay/coinsurance per 15 tablets)

Barbiturates (anxiolytic, Sedative/hypnotic) phenobarbital (Phenobarbital) 1 Benzodiazepines (anxiolytic, Sedative/hypnotic) alprazolam (Xanax) 1 chlordiazepoxide hcl (Librium) 1 clorazepate dipotassium (Tranxene T-tab) 1

35


Drug Name Drug Tier

Requirements/Limits

diazepam (Valium) 1 kit, oral conc, solution, tablet

estazolam (Prosom) 1 flurazepam hcl (Dalmane) 1 LORAZEPAM INTENSOL

1

lorazepam (Ativan) 1 tablet midazolam hcl (Midazolam HCl) 1 syrup oxazepam (Oxazepam) 1 temazepam (Restoril) 1 triazolam (Halcion) 1 ALPRAZOLAM INTENSOL

2

DIASTAT ACUDIAL 2 Astringents Astringents aluminum chloride (Drysol) 1 Beta-Adrenergic Blocking Agents Beta-Adrenergic Blocking Agents acebutolol hcl (Sectral) 1 atenolol (Tenormin) 1 atenolol/chlorthalidone (Tenoretic 100) 1 betaxolol hcl (Kerlone) 1 bisoprolol fumarate (Zebeta) 1 bisoprolol fumarate/hctz (Ziac) 1 carvedilol (Coreg) 1 labetalol hcl (Trandate) 1 tablet metoprolol succinate (Toprol XL) 1 metoprolol tartrate (Lopressor) 1 tablet metoprolol/hydrochlorothiazide

(Lopressor HCT) 1

nadolol (Corgard) 1 nadolol/bendroflumethiazide

(Corzide) 1

pindolol (Pindolol) 1 propranolol hcl (Inderal) 1 cap sa 24h, solution,

tablet propranolol/hydrochlorothiazid

(Inderide-40/25) 1

sotalol hcl (Betapace) 1

36


Drug Name Drug Tier

Requirements/Limits

timolol maleate (Timolol Maleate) 1 tablet: 5mg, 10mg INNOPRAN XL 2 BYSTOLIC 3 PA COREG CR 3 PA Calcium-Channel Blocking Agents Calcium-Channel Blocking Agents, Miscellaneous diltiazem hcl (Cardizem CD) 1 cap er 12h, cap er

24h, cap er deg, capsule er, tab er 24h, tablet

verapamil hcl (Calan) 1 cap24h pct, cap24h pel, tablet, tablet er

Dihydropyridines amlodipine besylate (Norvasc) 1 amlodipine besylate/benazepril

(Lotrel) 1

felodipine (Plendil) 1 isradipine (Dynacirc) 1 nicardipine hcl (Nicardipine HCl) 1 capsule nifedipine (Procardia XL) 1 nimodipine (Nimotop) 1 nisoldipine (Sular) 1 AZOR 3 PA DYNACIRC CR 3 EXFORGE HCT 3 PA EXFORGE 3 PA Cardiac Drugs Antiarrhythmic Agents amiodarone hcl (Cordarone) 1 tablet disopyramide phosphate (Norpace) 1 flecainide acetate (Tambocor) 1 mexiletine hcl (Mexitil) 1 procainamide hcl (Procainamide HCl) 1 capsule, tablet er,

tablet sa propafenone hcl (Rythmol) 1 quinidine gluconate (Quinidine Gluconate) 1 tablet er quinidine sulfate (Quinidine Sulfate) 1 MULTAQ 2 NORPACE CR 2 PRONESTYL 2

37


Drug Name Drug Tier

Requirements/Limits

TIKOSYN 2 Cardiac Drugs, Miscellaneous digoxin (Lanoxin) 1 tablet DIGOXIN 1 RANEXA 3 PA Cathartics and Laxatives Cathartics and Laxatives OCL 1 peg 3350/na sulf,bicarb,cl/kcl

(Colyte with Flavor Packets) 1

polyethylene glycol 3350 (Miralax) 1 sodium chloride/nahco3/kcl/peg

(Nulytely) 1

GOLYTELY 2 powd pack HALFLYTELY-BISACODYL

2

VISICOL 2 AMITIZA 3 QL: 68 in

34 days

MOVIPREP 3 PA Cell Stimulants and Proliferants Cell Stimulants and Proliferants tretinoin (Retin-A) 1 Age must

be < 30

tretinoin/emollient (Tretinoin/emollient) 1 Age must be < 30

RETIN-A MICRO 3 Age must be < 30

Central Nervous System Agents, Miscellaneous Central Nervous System Agents, Miscellaneous lithium carbonate (Eskalith) 1 lithium citrate (Lithium Citrate) 1 NAMENDA 2 solution, tablet SAVELLA 2 INTUNIV 3 PA RILUTEK 3 PA STRATTERA 3 XENAZINE 3 PA XYREM 3 PA (QL: 34 days supply

per fill)

38


Drug Name Drug Tier

Requirements/Limits

Contraceptives Contraceptives desogestrel-ethinyl estradiol

(Desogen) 1

desog-et estra/ethin estra (Mircette) 1 ethinyl estradiol/drospirenone

(Yaz) 1

ethynodiol d-ethinyl estradiol

(Demulen 1/50-28) 1

levonorgestrel (Plan B) 1 tablet: 0.75mg levonorgestrel-eth estradiol

(Lybrel) 1

l-norgest-eth estr/ethin estra

(Seasonique) 1

noreth a-et estra/fe fumarate

(Loestrin Fe) 1

noreth-ethinyl estradiol/iron

(Femcon Fe) 1

norethindrone a-e estradiol

(Loestrin) 1

norethindrone (Nor-Q-D) 1 norethindrone-ethinyl estrad

(Ortho-novum) 1

norethindrone-mestranol (Ortho-novum) 1 norgestimate-ethinyl estradiol

(Ortho-cyclen) 1

norgestrel-ethinyl estradiol

(Lo-ovral-28) 1

LOESTRIN 24 FE 3 NUVARING 3 ORTHO EVRA 3 ORTHO TRI-CYCLEN LO

3

OVCON-50 3 Devices Devices emollient combination no.10

(Biafine) 1

hyaluronate sodium (Hyaluronate Sodium) 1 1ST CHOICE LANCETS 2

39


Drug Name Drug Tier

Requirements/Limits

1ST TIER UNILET COMFORTOUCH

2

ACCU-CHEK SAFE-T-PRO

2

ACCU-CHEK 2 ADVANCED TRAVEL LANCETS

2

ADVOCATE LANCET 2 ADVOCATE LANCETS 2 ALTERNATE SITE LANCET

2

ASSURE LANCE 2 AT-LAST LANCETS 2 AURORA HEALTHCARE LANCETS

2

BD GENIE LANCET 2 CAREONE 2 CLEVER CHEK LANCETS

2

CLEVER CHEK ULTRA THIN LANCETS

2

COAGUCHEK 2 COLOR LANCETS 2 COMFORT LANCETS 2 DROPLET LANCETS 2 EASY COMFORT 2 E-Z JECT LANCETS 2 EZ SMART 2 E-ZJECT LANCETS 2 EZ-LETS 2 FINGERSTIX 2 FORA LANCETS 2 FREESTYLE LANCETS 2 FREESTYLE UNISTIK 2 2 GLUCOCOM LANCETS 2 GLUCOSOURCE 2 HAEMOLANCE PLUS 2 HAEMOLANCE, RETRACTABLE

2

40


Drug Name Drug Tier

Requirements/Limits

HAEMOLANCE 2 LADY LITE 2 LANCETS MICROTAINER

2

LANCETS 2 LIFESCAN 2 LITE TOUCH 2 MEDI-LANCE 2 MEDLANCE PLUS 2 MICRO THIN LANCET 2 MICRO THIN LANCETS 2 MICROLET 2 MINILET 2 MONOLET LANCETS 2 MONOLET THIN LANCETS

2

MYGLUCOHEALTH LANCETS

2

needles, insulin disposable (Needles, Insulin Disposable) 2 NOVA SUREFLEX 2 ONE TOUCH DELICA 2 ONE TOUCH LANCETS 2 ONE TOUCH SURESOFT

2

OPTICHAMBER 2 each OPTICHAMBER 2 spacer PRODIGY LANCETS 2 PRODIGY TWIST TOP LANCET

2

PUBLIX LANCET 2 RENEW ADVANCED MICRO-LANCETS

2

RIGHTEST GL300 LANCETS

2

SAFETY LANCETS 2 SAFETY-LET 2 SINGLE-LET 2 SMARTDIABETES VANTAGE

2

SMARTEST LANCET 2

41


Drug Name Drug Tier

Requirements/Limits

SOFT TOUCH 2 SOFTCLIX 2 SOLO V2 LANCETS 2 STAT-LET 2 SUPER THIN LANCET 2 SUPER THIN LANCETS 2 SURE COMFORT LANCETS

2

SURE-LANCE 2 SURGILANCE LANCETS

2

syring w-ndl,disp,insul,0.3ml

(Syring W-ndl,disp,insul,0.3ml) 2

syring w-ndl,disp,insul,0.5ml

(Syring W-ndl,disp,insul,0.5ml) 2

syringe & needle,insulin,1 ml

(Syringe & Needle,insulin,1 Ml) 2

TECHLITE BLOOD LANCET

2

TECHLITE 2 THIN LANCETS 2 TOPCARE UNIVERSAL1 THIN LANCET

2

ULTICARE 2 ULTILET BASIC 2 ULTILET CLASSIC 2 ULTILET LANCETS 2 ULTILET 2 ULTRA THIN II LANCETS

2

ULTRA THIN LANCETS 2 ULTRA THIN PLUS LANCETS

2

ULTRA THIN PLUS 2 ULTRALANCE 2 ULTRA-THIN II LANCETS

2

ULTRATLC LANCETS 2

42


Drug Name Drug Tier

Requirements/Limits

UNILET COMFORTOUCH

2

UNILET EXCELITE II 2 UNILET EXCELITE 2 UNILET GP LANCET 2 UNILET LANCET 2 UNISTIK 3 EXTRA 2 UNISTIK 3 2 UNISTIK CZT 2 VITALET PRO PLUS 2 VITALET PRO 2 VITALET 2 WAVESENSE LANCETS 2 Diabetes Mellitus Diabetes Mellitus FAST TAKE 2 (QL: 1 copay per

100 strips) ONE TOUCH TEST STRIPS

2 (QL: 1 copay per 100 strips)

ONE TOUCH ULTRA TEST STRIPS

2 (QL: 1 copay per 100 strips)

ONE TOUCH VERIO 2 SURESTEP PRO 2 (QL: 1 copay per

100 strips) SURESTEP 2 (QL: 1 copay per

100 strips) Diuretics Diuretics, Miscellaneous chlorthalidone (Chlorthalidone) 1 indapamide (Lozol) 1 metolazone (Zaroxolyn) 1 Loop Diuretics bumetanide (Bumex) 1 tablet furosemide (Lasix) 1 solution, tablet torsemide (Demadex) 1 tablet Potassium-sparing Diuretics amiloride hcl (Midamor) 1 amiloride/hydrochlorothiazide

(Amiloride/hydrochlorothiazide) 1

43


Drug Name Drug Tier

Requirements/Limits

triamterene/hydrochlorothiazid

(Maxzide-25mg) 1

Thiazide Diuretics chlorothiazide (Chlorothiazide) 1 hydrochlorothiazide (Hydrochlorothiazide) 1 methyclothiazide (Methyclothiazide) 1 DIURIL 2 EENT Drugs, Miscellaneous EENT Drugs, Miscellaneous apraclonidine hcl (Iopidine) 1 balanced salt irrig soln comb2

(Bss) 1

carteolol hcl (Carteolol HCl) 1 ipratropium bromide (Atrovent) 1 naphazoline hcl (Albalon) 1 naphazoline hcl/antazoline (Naphazoline HCl/antazoline) 1 phenylephrine hcl (Mydfrin) 1 Enzymes Enzymes PULMOZYME 3 PA (QL: 34 days supply

per fill) SUCRAID 3 PA Estrogens and Antiestrogens Estrogens and Antiestrogens clomiphene citrate (Clomid) 1 estradiol (Estrace) 1 estradiol/noreth ac (Activella) 1 estropipate (Ogen) 1 norethind ac/ethinyl estradiol

(Femhrt) 1

COMBIPATCH 2 ESTRADERM 2 ESTRING 2 PREMARIN 2 cream/appl, tablet PREMPHASE 2 PREMPRO 2 VIVELLE-DOT 2 DIVIGEL 3 ELESTRIN 3 ESTRACE 3 cream/appl

44


Drug Name Drug Tier

Requirements/Limits

EVISTA 3 FEMHRT 3 tablet: 0.5mg-2.5 VAGIFEM 3 Expectorants Expectorants guaifen/dm hb/p-ephedrine/bpm

(Guaifen/dm Hb/p-ephedrine/bpm)

1

guaifen/d-methorphan hb/pe/cp

(Guaifen/d-methorphan Hb/pe/cp)

1

guaifen/p-ephed hcl/dihy-cod

(Despec-exp) 1

guaifen/phenylephr/chlorphenir

(Guaifen/phenylephr/chlorphenir)

1

guaifenesin (Organidin Nr) 1 guaifenesin/carbetapentane cit

(Betavent) 1

guaifenesin/d-methorphan hb/pe

(Guaifenesin/d-methorphan Hb/pe)

1

guaifenesin/phenylephrine hcl

(Entex) 1

guaifenesin/pseudoephedrne hcl

(Maxifed-g) 1

phenylephrine/carbetapentan/gg

(Albatussin-nn) 1

pot guaiaco/car-b-pentane/pe

(Pot Guaiaco/car-b-pentane/pe) 1

First Generation Antihistamines First Generation Antihistamines brompheniramine maleate (Brompheniramine Maleate) 1 carbinoxamine maleate (Palgic) 1 chlor-mal/methscopolamine nit

(Allerx Df) 1

chlor-mal/phenyleph/methscop

(Dallergy) 1

chlorpheniramine maleate (Chlorpheniramine Maleate) 1 clemastine fumarate (Clemastine Fumarate) 1 cyproheptadine hcl (Cyproheptadine HCl) 1 dexchlorpheniramine maleate

(Dexchlorpheniramine Maleate) 1

45


Drug Name Drug Tier

Requirements/Limits

diphenhydramine hcl (Diphenhydramine HCl) 1 capsule: 50mg; elixir

doxylamine succinate (Doxylamine Succinate) 1 p-epd tan/chlor-tan (P-epd Tan/chlor-tan) 1 p-ephed hcl/chlor-mal/bell alk

(P-ephed HCl/chlor-mal/bell Alk)

1

p-ephed hcl/triprolidine hcl

(Zymine-d) 1

phenylephrine hcl/prometh hcl

(Phenylephrine HCl/prometh HCl)

1

phenylephrine/brompheniramin

(Vazobid) 1

phenylephrine/brompheniramine

(Vazol-d) 1

phenylephrine/chlorpheniramine

(Rondec) 1

phenylephrine/chlor-tan (Rynatan) 1 phenylephrine/diphenhydramine

(Phenylephrine/diphenhydramine)

1

phenylephrine/p-tlox ci/cp (Phenylephrine/p-tlox Ci/cp) 1 phenylephrine/pyril tan/cp (Allertan) 1 phenylephrine/pyrilamine ma/cp

(Poly Hist Pd) 1

phenylephrine/pyrilamine tan

(Phenylephrine/pyrilamine Tan) 1

promethazine hcl (Promethazine HCl) 1 supp.rect, syrup, tablet

pseudoephed/chlorpheniramine

(Accuhist) 1

pseudoephedrine hcl/chlor-mal

(Pseudoephedrine HCl/chlor-mal)

1

pseudoephedrine/brompheniramin

(Pseudoephedrine/brompheniramin)

1

pseudoephedrine/cpm/methscopol

(Durahist) 1

tripelennamine hcl (Tripelennamine HCl) 1 Genitourinary Smooth Muscle Relaxants Genitourinary Smooth Muscle Relaxants flavoxate hcl (Urispas) 1 oxybutynin chloride (Ditropan) 1

46


Drug Name Drug Tier

Requirements/Limits

tolterodine tartrate (Detrol) 1 trospium chloride (Sanctura) 1 GELNIQUE 2 PA gel md pmp VESICARE 2 DETROL LA 3 PA ENABLEX 3 PA OXYTROL 3 PA SANCTURA XR 3 PA TOVIAZ 3 PA GI Drugs, Miscellaneous GI Drugs, Miscellaneous lipase/protease/amylase (Zenpep) 1 metoclopramide hcl (Reglan) 1 solution, tablet ursodiol (Actigall) 1 CREON 2 ZENPEP 2 capsule dr: 3k-10k-

16k, 10-34-55k, 15-51-82k, 20-68-109k, 25-85-136k

CIMZIA 3 PA syringekit, (QL: 34 days supply per fill)

LOTRONEX 3 PERTZYE 3 PA RELISTOR 3 PA VIOKACE 3 PA Heavy Metal Antagonists Heavy Metal Antagonists DEPEN 2 EXJADE 3 (QL: 1 copay/

coinsurance per 15 days supply; 34 days per fill)

FERRIPROX 3 PA Hematologic Agents Anticoagulants enoxaparin sodium (Lovenox) 1 enoxaparin sodium (Lovenox) 1 (QL: 14 days supply

per fill) fondaparinux sodium (Arixtra) 1 (QL: 14 days supply

per fill)

47


Drug Name Drug Tier

Requirements/Limits

heparin sodium,porcine (Hep-lock) 1 heparin sodium,porcine/pf (Monoject Prefill Advanced) 1 disp syrin warfarin sodium (Coumadin) 1 XARELTO 2 tablet: 15mg, 20mg XARELTO 2 QL: 34

per fill tablet: 10mg

ARIXTRA 3 PA (QL: 14 days supply per fill)

LOVENOX 3 (QL: 14 days supply per fill)

PRADAXA 3 Hematologic Agents, Miscellaneous aminocaproic acid (Amicar) 1 solution, tablet anagrelide hcl (Agrylin) 1 pentoxifylline (Trental) 1 AMICAR 2 tablet: 1000mg ADVATE H 3 PA ADVATE L 3 PA ADVATE M 3 PA ADVATE SH 3 PA ADVATE 3 PA ADVATE 3 PA (QL: 34 days supply

per fill) ALPHANATE 3 PA (QL: 34 days supply

per fill) BIOCLATE 3 PA (QL: 34 days supply

per fill) FEIBA NF 3 PA (QL: 34 days supply

per fill) FEIBA VH IMMUNO 3 PA (QL: 34 days supply

per fill) HELIXATE FS 3 PA (QL: 34 days supply

per fill) HEMOFIL M 3 PA HEMOFIL M 3 PA (QL: 34 days supply

per fill) HUMATE-P 3 PA HUMATE-P 3 PA (QL: 34 days supply

per fill)

48


Drug Name Drug Tier

Requirements/Limits

KOATE-DVI 3 PA (QL: 34 days supply per fill)

KOGENATE FS 3 PA (QL: 34 days supply per fill)

MONOCLATE-P 3 PA (QL: 34 days supply per fill)

RECOMBINATE 3 PA RECOMBINATE 3 PA (QL: 34 days supply

per fill) REFACTO 3 PA (QL: 34 days supply

per fill) WILATE 3 PA (QL: 34 days supply

per fill) XYNTHA SOLOFUSE 3 PA (QL: 34 days supply

per fill) XYNTHA 3 PA (QL: 34 days supply

per fill) Platelet-aggregation Inhibitors cilostazol (Pletal) 1 clopidogrel bisulfate (Plavix) 1 ticlopidine hcl (Ticlid) 1 BRILINTA 3 EFFIENT 3 PA Hematopoietic Agents Hematopoietic Agents ARANESP 2 PA (QL: 34 days supply

per fill) EPOGEN 2 PA (QL: 34 days supply

per fill) LEUKINE 2 PA (QL: 7 days supply

per fill) NEULASTA 2 PA (QL: 7 days supply

per fill) NEUMEGA 2 PA (QL: 34 days supply

per fill) NEUPOGEN 2 PA (QL: 7 days supply

per fill) PROCRIT 2 PA (QL: 34 days supply

per fill)

49


Drug Name Drug Tier

Requirements/Limits

PROMACTA 3 PA (QL: 34 days supply per fill)

Hypotensive Agents Hypotensive Agents, Miscellaneous clonidine hcl (Catapres) 1 clonidine hcl/chlorthalidone

(Clonidine HCl/chlorthalidone) 1

clonidine (Catapres-TTS 3) 1 guanabenz acetate (Guanabenz Acetate) 1 guanfacine hcl (Tenex) 1 hydralazine hcl (Apresoline) 1 tablet hydralazine/hydrochlorothiazid

(Hydralazine/hydrochlorothiazid)

1

hydralazine/reserpin/hctz (Hydralazine/reserpin/hctz) 1 methyldopa (Aldomet) 1 methyldopa/hydrochlorothiazide

(Methyldopa/hydrochlorothiazide)

1

minoxidil (Minoxidil) 1 reserpine (Reserpine) 1 reserpine/hydrochlorothiazide

(Reserpine/hydrochlorothiazide) 1

NEXICLON XR 3 PA Ion-Removing Agents Ion-Removing Agents calcium acetate (Phoslo) 1 sodium polystyrene sulfonate

(Sodium Polystyrene Sulfonate) 1

FOSRENOL 2 RENAGEL 3 RENVELA 3 PA Keratolytic Agents Keratolytic Agents benzoyl peroxide microspheres

(Benzoyl Peroxide Microspheres)

1

benzoyl peroxide (Delos) 1 cleanser, gel (gram): 2.5%, 4%, 8%; gel alcohl, kit, lotion, med. pad, towelette

benzoyl peroxide/aloe vera

(Benziq) 1

50


Drug Name Drug Tier

Requirements/Limits

benzoyl peroxide/skin clnsr7

(Benzoyl Peroxide/skin Clnsr7) 1

potassium hydroxide (Potassium Hydroxide) 1 salicylic acid (Salex) 1 salicylic acid/ammon lact/aloe

(Salkera) 1

salicylic acid/ceramide cmb #1

(Salex) 1

silver nitrate applicator (Silver Nitrate Applicator) 1 sulfacet sod/sulfur/witch haz

(Plexion Sct) 1

sulfacetamide sodium/sulfur

(Avar) 1

urea (Uramaxin) 1 urea/hyaluronate sodium (Umecta) 1 urea/lactic ac/zn undecylenate

(Kerol) 1

urea/lactic acid/salicyl acid

(Kerol) 1

BENZASHAVE 2 Keratoplastic Agents Keratoplastic Agents sulfacetamide sodium/urea (Rosula Ns) 1 DRITHOCREME HP 2 DRITHO-SCALP 2 Local Anesthetics Local Anesthetics aa/antipyrn/bcaine/polico#1/al

(Auralgan) 1

antipyrine/benzocaine/glycerin

(Otra Nr) 1

chloroxylenol/pramoxine hcl

(Oticin) 1

lidocaine hcl (Xylocaine) 1 jel (ml), jel/pf app, solution

Miscellaneous Therapeutic Agents Miscellaneous Therapeutic Agents alendronate sodium (Fosamax) 1 allopurinol (Zyloprim) 1 azathioprine (Imuran) 1

51


Drug Tier

Drug Name Requirements/Limits

colchicine/probenecid (Colchicine/probenecid) 1 cyclosporine (Sandimmune) 1 capsule, solution cyclosporine, modified (Neoral) 1 disulfiram (Antabuse) 1 ergoloid mesylates (Ergoloid Mesylates) 1 etidronate disodium (Didronel) 1 finasteride (Proscar) 1 FLUORITAB 1 ibandronate sodium (Boniva) 1 leflunomide (Arava) 1 leucovorin calcium (Leucovorin Calcium) 1 tablet methylergonovine maleate (Methergine) 1 tablet mycophenolate mofetil (Cellcept) 1 octreotide acetate (Sandostatin) 1 probenecid (Probenecid) 1 sodium fluoride (Prevident 5000 Plus) 1 stannous fluoride (Gel-kam) 1 tacrolimus (Prograf) 1 ACTONEL 2 AVODART 2 BETASERON 2 (QL: 34 days supply

per fill) COLCRYS 2 COPAXONE 2 (QL: 34 days supply

per fill) CYSTAGON 2 FLUOR-A-DAY 2 drops FLUOR-A-DAY 2 tab chew FLURA-DROPS 2 FOSAMAX PLUS D 2 FOSAMAX 2 solution GANIRELIX ACETATE 2 GLUCAGEN 2 (QL: 2 kits per 1

fill) GLUCAGON EMERGENCY KIT

2 (QL: 2 kits per 1 fill)

MYFORTIC 2 RIDAURA 2 SYNAREL 2 THALOMID 2

52


Drug Tier


ACTIMMUNE 3 PA (QL: 34 days supply per fill))

AMPYRA 3 PA (QL: 34 days supply per fill)

ARAVA 3 tablet: 10mg ARCALYST 3 PA (QL: 34 days supply

per fill) AVONEX ADMINISTRATION PACK

3 PA (QL: 34 days supply per fill)

AVONEX 3 PA (QL: 34 days supply per fill)

CELLCEPT 3 susp recon CETROTIDE 3 PA ELMIRON 3 PA ENBREL 3 PA (QL: 34 days supply

per fill) EXTAVIA 3 PA GILENYA 3 PA (QL: 34 days supply

per fill) HUMIRA 3 PA (QL: 1 copay/

coinsurance per injection)

JALYN 3 PA KINERET 3 PA (QL: 34 days supply

per fill) KUVAN 3 PA (QL: 34 days supply

per fill) MESNEX 3 tablet ORENCIA 3 PA, QL:

4 in 28 days

disp syrin

RAPAMUNE 3 PA REBIF 3 PA (QL: 34 days supply

per fill) REVLIMID 3 PA (QL: 34 days supply

per fill) SANDOSTATIN 3 SENSIPAR 3 SIMPONI 3 PA (QL: 34 days supply

per fill)

53 Geisinger 2012 Commercial Formulary Effective: November 01, 2012Formulary ID: 80102.000, Version: 2012-11

Drug Tier


SOMATULINE DEPOT 3 PA ULORIC 3 PA ZAVESCA 3 PA (QL: 34 days supply

per fill) Mydriatics Mydriatics atropine sulfate (Isopto Atropine) 1 cyclopentolate hcl (Cyclogyl) 1 homatropine hbr (Isopto Homatropine) 1 PENTOLAIR 1 tropicamide (Mydriacyl) 1 ISOPTO HOMATROPINE

2 drops: 2%

ISOPTO HYOSCINE 2 Ocular Disorders Ocular Disorders fluorescein sodium (Fluorescein Sodium) 1 drops Opiate Antagonists Opiate Antagonists naltrexone hcl (Revia) 1 Parasympathomimetics (Cholinergic Agents) Parasympathomimetics (Cholinergic Agents) bethanechol chloride (Urecholine) 1 donepezil hcl (Aricept) 1 galantamine hbr (Razadyne ER) 1 guanidine hcl (Guanidine HCl) 1 pilocarpine hcl (Salagen) 1 pyridostigmine bromide (Mestinon) 1 rivastigmine tartrate (Exelon) 1 EXELON 2 solution MESTINON 2 syrup, tablet er PROSTIGMIN 2 CHANTIX 3 (QL: 6 months per

member per lifetime)

Parathyroid Parathyroid calcitonin,salmon,synthetic

(Miacalcin) 1

54


Drug Tier


FORTICAL 2 MIACALCIN 2 vial FORTEO 3 PA (QL: 34 days supply

per fill) Pituitary Pituitary desmopressin acetate (DDAVP) 1 solution, spray/

pump, tablet CHORIONIC GONADOTROPIN

2

STIMATE 2 BRAVELLE 3 PA FOLLISTIM AQ 3 (QL: 34 days supply

per fill) GONAL-F RFF 3 PA (QL: 34 days supply

per fill) GONAL-F 3 PA (QL: 34 days supply

per fill) LUVERIS 3 PA (QL: 34 days supply

per fill) MENOPUR 3 (QL: 34 days supply

per fill) NOVAREL 3 (QL: 34 days supply

per fill) OVIDREL 3 PA (QL: 34 days supply

per fill) PREGNYL 3 (QL: 34 days supply

per fill) REPRONEX 3 (QL: 34 days supply

per fill) GENOTROPIN % PA (QL: 34 days supply

per fill) NORDITROPIN NORDIFLEX

% PA (QL: 34 days supply per fill)

NORDITROPIN % PA (QL: 34 days supply per fill)

Progestins Progestins medroxyprogesterone acet (Provera) 1

55


Drug Tier


medroxyprogesterone acetate

(Provera) 1

norethindrone acetate (Aygestin) 1 progesterone (Progesterone In Oil) 1 progesterone,micronized (Prometrium) 1 CRINONE 3 DEPO-PROVERA 3 vial: 400mg/ml DEPO-SUBQ PROVERA 104

3

Psychotherapeutic Agents Antidepressants amitrip hcl/chlordiazepoxide

(Limbitrol) 1

amitriptyline hcl (Amitriptyline HCl) 1 amoxapine (Amoxapine) 1 bupropion hcl (Wellbutrin XL) 1 citalopram hydrobromide (Celexa) 1 clomipramine hcl (Anafranil) 1 desipramine hcl (Norpramin) 1 doxepin hcl (Doxepin HCl) 1 escitalopram oxalate (Lexapro) 1 fluoxetine hcl (Prozac) 1 fluvoxamine maleate (Fluvoxamine Maleate) 1 imipramine hcl (Tofranil) 1 imipramine pamoate (Tofranil-PM) 1 maprotiline hcl (Maprotiline HCl) 1 mirtazapine (Remeron) 1 nefazodone hcl (Serzone) 1 nortriptyline hcl (Pamelor) 1 olanzapine/fluoxetine hcl (Symbyax) 1 paroxetine hcl (Paxil) 1 perphenazine/amitriptyline hcl

(Perphenazine/amitriptyline HCl)

1

phenelzine sulfate (Nardil) 1 protriptyline hcl (Vivactil) 1 sertraline hcl (Zoloft) 1 tranylcypromine sulfate (Parnate) 1 trazodone hcl (Desyrel) 1 trimipramine maleate (Surmontil) 1

56


Drug Tier


VENLAFAXINE HCL ER

1

venlafaxine hcl (Effexor XR) 1 PAXIL 2 oral susp APLENZIN 3 PA CYMBALTA 3 FORFIVO XL 3 PA, QL:

1 in 1 day

OLEPTRO ER 3 PA PRISTIQ ER 3 PA SYMBYAX 3 PA capsule: 3mg-25mgVIIBRYD 3 PA Antipsychotic Agents chlorpromazine hcl (Chlorpromazine HCl) 1 oral conc., tablet clozapine (Clozaril) 1 fluphenazine decanoate (Fluphenazine Decanoate) 1 fluphenazine hcl (Fluphenazine HCl) 1 elixir, oral conc,

tablet haloperidol decanoate (Haloperidol Decanoate) 1 haloperidol lactate (Haloperidol Lactate) 1 haloperidol (Haloperidol) 1 loxapine succinate (Loxitane) 1 olanzapine (Zyprexa Zydis) 1 perphenazine (Perphenazine) 1 quetiapine fumarate (Seroquel) 1 risperidone (Risperdal) 1 thioridazine hcl (Thioridazine HCl) 1 thiothixene (Navane) 1 trifluoperazine hcl (Trifluoperazine HCl) 1 ziprasidone hcl (Geodon) 1 ABILIFY DISCMELT 2 ABILIFY 2 solution, tablet ORAP 2 RISPERDAL CONSTA 2 SEROQUEL XR 2 FANAPT 3 PA INVEGA 3 PA SAPHRIS 3 PA

57


Drug Tier


Renin-Angiotensin-Aldosterone System Inhibitors Angiotensin II Receptor Antagonists eprosartan mesylate (Teveten) 1 irbesartan (Avapro) 1 irbesartan/hydrochlorothiazide

(Avalide) 1

losartan potassium (Cozaar) 1 losartan/hydrochlorothiazide

(Hyzaar) 1

valsartan/hydrochlorothiazide

(Diovan HCT) 1 tablet: 160-25mg, 320-12.5mg, 320mg-25mg

valsartan/hydrochlorothiazide

(Diovan HCT) 1 PA tablet: 80-12.5mg, 160-12.5mg

ATACAND HCT 3 PA ATACAND 3 PA AVALIDE 3 PA tablet: 300mg-25mgBENICAR HCT 3 PA BENICAR 3 PA DIOVAN HCT 3 PA DIOVAN 3 PA EDARBI 3 PA EDARBYCLOR 3 PA MICARDIS HCT 3 PA MICARDIS 3 PA TEVETEN HCT 3 PA TEVETEN 3 PA tablet: 400mg Angiotensin-Converting Enzyme Inhibitors benazepril hcl (Lotensin) 1 benazepril/hydrochlorothiazide

(Lotensin HCT) 1

captopril (Capoten) 1 captopril/hydrochlorothiazide

(Capozide) 1

enalapril maleate (Vasotec) 1 enalapril/hydrochlorothiazide

(Vaseretic) 1

fosinopril sodium (Monopril) 1 fosinopril/hydrochlorothiazide

(Monopril HCT) 1

58


Drug Tier


lisinopril (Zestril) 1 lisinopril/hydrochlorothiazide

(Prinzide) 1

moexipril hcl (Univasc) 1 moexipril/hydrochlorothiazide

(Uniretic) 1

perindopril erbumine (Aceon) 1 quinapril hcl (Accupril) 1 quinapril/hydrochlorothiazide

(Accuretic) 1

ramipril (Altace) 1 trandolapril (Mavik) 1 trandolapril/verapamil hcl (Trandolapril/verapamil HCl) 1 Renin-Angiotensin-Aldosterone System Inhibitors eplerenone (Inspra) 1 spironolact/hydrochlorothiazid

(Aldactazide) 1

spironolactone (Aldactone) 1 AMTURNIDE 3 PA TEKTURNA HCT 3 PA TEKTURNA 3 PA VALTURNA 3 PA Replacement Preparations Replacement Preparations cal carb/mgox/d3/b12/fa/b6/bor

(Cal Carb/mgox/d3/b12/fa/b6/bor)

1 wafer: 500-300-1

pot chloride/pot bicarb/cit ac

(K-lyte-cl) 1

potassium bicarbonate/cit ac

(K-lyte) 1

potassium chloride (K-dur) 1 capsule er, liquid, packet, tab er prt, tablet er, tablet sa

potassium gluconate (Potassium Gluconate) 1 zinc sulfate (Zinc Sulfate) 1 capsule Respiratory Tract Agents, Miscellaneous Respiratory Tract Agents, Miscellaneous acetylcysteine (Acetylcysteine) 1 aminophylline (Aminophylline) 1 liquid, tablet

59


Drug Tier


guaifen/theop anhyd/p-ephed

(Guaifen/theop Anhyd/p-ephed) 1

guaifenesin/dyphylline (Difil-g) 1 theophylline anhydrous (Theochron) 1 DALIRESP 3 PA KALYDECO 3 PA, QL:

68 in 34 days

THEO-24 3 Second Generation Antihistamines Second Generation Antihistamines desloratadine (Clarinex) 1 CLARINEX 3 syrup, tab rapdis CLARINEX-D 12 HOUR 3 CLARINEX-D 24 HOUR 3 Skeletal Muscle Relaxants Skeletal Muscle Relaxants baclofen (Baclofen) 1 carisoprodol (Soma) 1 carisoprodol/aspirin (Soma Compound) 1 chlorzoxazone (Parafon Forte DSC) 1 chlorzoxazone/acetaminophen

(Chlorzoxazone/acetaminophen) 1

codeine phos/carisoprodol/asa

(Soma Compound with Codeine) 1

cyclobenzaprine hcl (Flexeril) 1 dantrolene sodium (Dantrium) 1 capsule metaxalone (Skelaxin) 1 methocarbamol (Robaxin-750) 1 orphenadrine citrate (Norflex) 1 tablet er orphenadrine/aspirin/caffeine

(Norgesic Forte) 1

tizanidine hcl (Zanaflex) 1 Skin and Mucous Membrane Agents, Miscellaneous Skin and Mucous Membrane Agents, Miscellaneous adapalene (Differin) 1 ammonium lactate (Lac-hydrin) 1 calcipotriene (Dovonex) 1 calcitriol (Vectical) 1 fluorouracil (Efudex) 1

60


Drug Tier


imiquimod (Aldara) 1 isotretinoin (Accutane) 1 isotretinoin (Accutane) 1 (QL: 34 days supply

per fill) lactic acid (Lactinol) 1 papain/urea (Gladase) 1 podofilox (Condylox) 1 trypsin/balsam peru/castor oil

(Xenaderm) 1

CONDYLOX 2 gel (gram) ELIDEL 2 PA PROTOPIC 2 PA SANTYL 2 DIFFERIN 3 gel (gram): 0.3%;

lotion, med. swab FINACEA 3 PA OXSORALEN 3 PA (QL: 34 days supply

per fill) OXSORALEN-ULTRA 3 PA (QL: 34 days supply

per fill) PICATO 3 PA, QL:

2 per fill gel (ea): 0.05%

PICATO 3 PA, QL: 3 per fill

gel (ea): 0.015%

SORIATANE 3 PA TARGRETIN 3 PA TAZORAC 3 Somatotropin Agonists and Antagonists Somatotropin Agonists and Antagonists SOMAVERT 3 PA Sympatholytic Adrenergic Blocking Agents Alpha-Adrenergic Blocking Agents alfuzosin hcl (Uroxatral) 1 dihydroergotamine mesylate

(D.H.E. 45) 1

ergotamine tartrate/caffeine

(Ergotamine Tartrate/caffeine) 1

tamsulosin hcl (Flomax) 1 CAFERGOT 2 DIBENZYLINE 2

61


Drug Tier


MIGRANAL 2 RAPAFLO 3 PA Sympathomimetic (Adrenergic) Agents Sympathomimetic (Adrenergic) Agents albuterol sulfate (Accuneb) 1 albuterol (Albuterol) 1 epinephrine (Adrenaclick) 1 disp syrin: 0.3mg/

0.3; pen injctr, (QL: 2 kits per 1 fill)

epinephrine (Epinephrine) 1 disp syrin: 0.3mg/0.3; pen injctr

ipratropium/albuterol sulfate

(Duoneb) 1

levalbuterol hcl (Xopenex) 1 metaproterenol sulfate (Metaproterenol Sulfate) 1 midodrine hcl (Proamatine) 1 p-ephed hcl/methscopolamn

(P-ephed HCl/methscopolamn) 1

terbutaline sulfate (Brethine) 1 tablet VENTOLIN HFA 1 EPIPEN JR 2 EPIPEN 2 (QL: 2 kits per 1

fill) FORADIL 2 SEREVENT DISKUS 2 BROVANA 3 PA COMBIVENT RESPIMAT

3

COMBIVENT 3 MAXAIR AUTOHALER 3 PERFOROMIST 3 PA TWINJECT 3 (QL: 1 package [2

injections] per fill) XOPENEX HFA 3 PA XOPENEX 3 PA vial-neb: 1.25mg/

3ml Thyroid and Antithyroid Agents Thyroid and Antithyroid Agents levothyroxine sodium (Synthroid) 1 tablet liothyronine sodium (Cytomel) 1 tablet

62


Drug Tier


methimazole (Tapazole) 1 potassium iodide (Potassium Iodide) 1 potassium iodide/iodine (Potassium Iodide/iodine) 1 propylthiouracil (Propylthiouracil) 1 thyroid,pork (Armour Thyroid) 1 ARMOUR THYROID 3 tablet: 15mg,

120mg, 180mg, 240mg, 300mg

Urinary Anti-infectives Urinary Anti-infectives methen/m-blue/sal/na phos/hyos

(Uro Blue) 1

methenam/me blue/ba/salicy/hyo

(Methenam/me Blue/ba/salicy/hyo)

1

methenamine mandelate (Mandelamine) 1 mth/me blue/sod phos/phen/hyos

(Mth/me Blue/sod Phos/phen/hyos)

1

nitrofurantoin macrocrystal

(Macrodantin) 1

nitrofurantoin (Furadantin) 1 trimethoprim (Trimethoprim) 1 PHOSPHASAL 2 URETRON D-S 2 URIN D.S. 2 Urine And Feces Contents Ketones KETOSTIX REAGENT 3 Vasodilating Agents Vasodilating Agents dipyridamole (Persantine) 1 tablet isosorbide dinitrate (Isordil) 1 isosorbide mononitrate (Imdur) 1 isoxsuprine hcl (Isoxsuprine HCl) 1 nitroglycerin (Nitro-dur) 1 capsule er, patch

td24, spray, tab sublnylidrin hcl (Nylidrin HCl) 1 papaverine hcl (Papaverine HCl) 1 capsule er, tablet AGGRENOX 2 NITRO-BID 2

63


Drug Tier


NITRO-DUR 2 patch td24: 0.3mg/hr, 0.8mg/hr

NITROSTAT 2 ADCIRCA 3 PA (QL: 1 copay/


LETAIRIS 3 PA (QL: 1 copay/coinsurance per 17 days supply; 34 days per fill)

REVATIO 3 PA tablet, (QL: 1 copay/coinsurance per 17 days supply; 34 days per fill)

TRACLEER 3 (QL: 1 copay/coinsurance per 17 days supply; 34 days per fill)

TYVASO 3 PA (QL: 34 days supply per fill)

VENTAVIS 3 PA (QL: 34 days supply per fill)

Vitamins and Minerals Vitamins and Minerals calcitriol (Rocaltrol) 1 capsule, solution COMPLETE-RF PRENATAL

1

ergocalciferol (vitamin d2)

(Drisdol) 1

FLUORABON 1 fluoride/iron/vit a,c&d (Fluoride/iron/vit A,c&d) 1 FLURA 1 folic acid (Folic Acid) 1 tablet GESTICARE DHA 1 iron,carbonyl/vit c/vit b12/fa

(Iron,carbonyl/vit C/vit B12/fa) 1

LOZI-FLUR 1 multivitamins with fluoride

(Multivitamins with Fluoride) 1

NATAFORT 1

64


65


Drug Name Drug Tier

Requirements/Limits

NEXA SELECT 1 ped mv a,c,d3 #21 w-fluoride

(Ped Mv A,c,d3 #21 W-fluoride) 1

pedi m.vit no.17 with fluoride

(Pedi M.vit No.17 with Fluoride) 1

pnv with ca,no.72/iron/fa (Pnv with Ca,no.72/iron/fa) 1 pnv39/iron fumarate/fa/dss/dha

(Prenexa) 1

pnv66/iron fumarate/fa/dss/dha

(Prenexa) 1

sodium fluoride (Luride) 1 DHT 2 FLUOR-A-DAY 2 HECTOROL 2 capsule MEPHYTON 2 ZEMPLAR 2 capsule

INDEX

1ST CHOICE LANCETS.. 39 1ST TIER UNILET

COMFORTOUCH......... 40 aa/antipyrn/bcaine/polico#1/

al .................................... 51 abacavir sulfate.................. 33 ABILIFY............................ 57 ABILIFY DISCMELT....... 57 ABSTRAL ......................... 12 acarbose ............................. 17 ACCU-CHEK .................... 40 ACCU-CHEK SAFE-T-PRO

........................................ 40 acebutolol hcl..................... 36 acetaminophen with codeine

........................................ 11 acetaminophen/caffeine/

butalb ............................. 10 acetaminophen/phenyltolx cit

........................................ 10 acetazolamide .................... 20 acetic acid .......................... 20 acetic acid/aluminum acetate

........................................ 20 acetic acid/hydrocortisone. 20 acetylcysteine ..................... 59 ACIPHEX .......................... 33 ACTIMMUNE................... 53 ACTONEL......................... 52 acyclovir............................. 34 adapalene ........................... 60 ADCIRCA.......................... 64 ADVAIR DISKUS............... 9 ADVAIR HFA..................... 9 ADVANCED TRAVEL

LANCETS...................... 40 ADVATE ........................... 48 ADVATE H ....................... 48 ADVATE L........................ 48 ADVATE M....................... 48 ADVATE SH..................... 48

ADVOCATE LANCET .....40 ADVOCATE LANCETS...40 AFINITOR .........................28 AGGRENOX .....................63 albuterol .............................62 albuterol sulfate..................62 alclometasone dipropionate

........................................24 alcohol antiseptic pads.......23 alendronate sodium ............51 alfuzosin hcl........................61 ALINIA ..............................30 ALKERAN.........................28 allopurinol ..........................51 ALOMIDE .........................14 ALPHAGAN P...................20 ALPHANATE....................48 alprazolam..........................35 ALPRAZOLAM INTENSOL

........................................36 ALTABAX.........................22 ALTERNATE SITE

LANCET ........................40 aluminum chloride..............36 amantadine hcl ...................30 amcinonide .........................24 AMICAR............................48 amiloride hcl ......................43 amiloride/

hydrochlorothiazide .......43 aminocaproic acid..............48 aminophylline .....................59 amiodarone hcl...................37 AMITIZA...........................38 amitrip hcl/chlordiazepoxide

........................................56 amitriptyline hcl .................56 amlodipine besylate............37 amlodipine besylate/

benazepril .......................37 amlodipine/atorvastatin .....26

ammonium lactate.............. 60 amoxapine.......................... 56 amoxicillin ......................... 15 amoxicillin/potassium clav 15 amphet asp/amphet/d-amphet

....................................... 13 ampicillin trihydrate .......... 15 AMPYRA .......................... 53 AMTURNIDE ................... 59 anagrelide hcl .................... 48 anastrozole......................... 27 ANCOBON ....................... 19 ANDRODERM ................. 13 ANDROGEL ..................... 13 ANTARA........................... 26 antipyrine/benzocaine/

glycerin .......................... 51 APIDRA ............................ 18 APIDRA SOLOSTAR....... 18 APLENZIN........................ 57 APOKYN........................... 30 apraclonidine hcl ............... 44 APRISO............................. 24 ARANESP......................... 49 ARAVA............................. 53 ARCALYST ...................... 53 ARIXTRA ......................... 48 ARMOUR THYROID....... 63 ARTHROTEC 50 .............. 11 ARTHROTEC 75 .............. 11 ASACOL ........................... 24 ASMANEX ......................... 9 ASSURE LANCE.............. 40 ASTEPRO ......................... 14 ATACAND........................ 58 ATACAND HCT............... 58 atenolol .............................. 36 atenolol/chlorthalidone ..... 36 AT-LAST LANCETS........ 40 atorvastatin calcium .......... 26 atovaquone/proguanil hcl.. 30

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ATRIPLA........................... 33 atropine sulfate ............ 16, 54 ATROVENT HFA............. 16 AUGMENTIN ................... 15 AURORA HEALTHCARE

LANCETS...................... 40 AVALIDE.......................... 58 AVC ................................... 23 AVELOX ........................... 15 AVINZA ............................ 12 AVODART........................ 52 AVONEX........................... 53 AVONEX

ADMINISTRATION PACK............................. 53

AXERT .............................. 27 AZASITE........................... 21 azathioprine ....................... 51 azelastine hcl...................... 14 AZILECT........................... 30 azithromycin....................... 15 AZOPT............................... 20 AZOR................................. 37 bacitracin ........................... 20 bacitracin/polymyxin b sulfate

........................................ 20 baclofen.............................. 60 BACTOCILL ..................... 15 BACTROBAN................... 22 BACTROBAN NASAL .... 21 balanced salt irrig soln

comb2 ............................. 44 balsalazide disodium.......... 24 BANZEL............................ 17 BARACLUDE ................... 35 BD GENIE LANCET ........ 40 BECONASE AQ................ 24 benazepril hcl..................... 58 benazepril/

hydrochlorothiazide ....... 58 BENICAR.......................... 58 BENICAR HCT................. 58 BENZASHAVE................. 51 benzonatate ........................ 31

benzoyl peroxide.................50 benzoyl peroxide

microspheres ..................50 benzoyl peroxide/aloe vera.50 benzoyl peroxide/skin clnsr7

........................................51 benzphetamine hcl ..............13 benztropine mesylate ..........30 BESIVANCE .....................21 betamet diprop/prop gly .....24 betamethasone dipropionate

........................................24 betamethasone valerate......24 BETASERON ....................52 betaxolol hcl .................20, 36 bethanechol chloride ..........54 BETOPTIC S......................20 bicalutamide .......................28 BIOCLATE ........................48 bisoprolol fumarate ............36 bisoprolol fumarate/hctz ....36 BLEPHAMIDE ..................21 BLEPHAMIDE S.O.P........21 BRAVELLE.......................55 BRILINTA .........................49 brimonidine tartrate ...........20 BROMDAY .......................24 bromfenac sodium ..............23 bromocriptine mesylate ......30 bromphen mal/pe/carbetapen

cit ....................................31 bromphenira/pseudoephed/

codein .............................31 brompheniram/pe/

dihydrocodeine ...............31 brompheniramin/pe/codeine

phos ................................31 brompheniramin/pe/

dextromethor ..................31 brompheniramine maleate..45 bromphenrm/pseudoeph/

dihydrocd........................31 BROVANA ........................62 budesonide............................9

bumetanide......................... 43 bupropion hcl..................... 56 buspirone hcl ..................... 35 butalb/acetaminophen/

caffeine........................... 10 butalbit/acetamin/caff/

codeine........................... 11 butalbital/acetaminophen .. 10 butalbital/aspirin/caffeine . 10 butorphanol tartrate .......... 12 BUTRANS......................... 13 BYDUREON..................... 17 BYETTA ........................... 17 BYSTOLIC........................ 37 cabergoline ........................ 30 CAFERGOT ...................... 61 caffeine citrated ................. 13 cal carb/mgox/d3/b12/fa/b6/

bor.................................. 59 calcipotriene ...................... 60 calcitonin,salmon,synthetic 54 calcitriol....................... 60, 64 calcium acetate .................. 50 CANASA........................... 24 CAPRELSA....................... 28 captopril............................. 58 captopril/hydrochlorothiazide

....................................... 58 carbamazepine................... 16 carbidopa/levodopa ........... 30 carbidopa/levodopa/

entacapone..................... 30 carbinoxamine maleate...... 45 car-b-pen ta/chlor-tan ....... 31 car-b-pen ta/phenylephrine/

pyr .................................. 31 CAREONE ........................ 40 carisoprodol ...................... 60 carisoprodol/aspirin .......... 60 carteolol hcl ....................... 44 carvedilol ........................... 36 CEENU.............................. 28 cefaclor .............................. 14 cefadroxil hydrate.............. 14

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cefdinir ............................... 14 cefditoren pivoxil ............... 14 cefpodoxime proxetil .......... 14 cefprozil.............................. 14 CEFTIN.............................. 14 cefuroxime axetil ................ 14 CELEBREX....................... 11 CELLCEPT........................ 53 cephalexin .......................... 14 CETROTIDE ..................... 53 CHANTIX.......................... 54 chloral hydrate................... 35 chlordiazepoxide hcl .......... 35 chlordiazepoxide/clidinium br

........................................ 16 chlorhexidine gluconate..... 20 chlor-mal/methscopolamine

nit ................................... 45 chlor-mal/phenyleph/

methscop ........................ 45 chloroquine phosphate....... 30 chlorothiazide .................... 44 chloroxylenol/pramoxine hcl

........................................ 51 chlorpheniramine maleate . 45 chlorpheniramine/codeine

phos ................................ 31 chlorpromazine hcl ............ 57 chlorpropamide.................. 18 chlorthalidone .................... 43 chlorzoxazone .................... 60 chlorzoxazone/acetaminophen

........................................ 60 cholestyramine (with sugar)

........................................ 25 cholestyramine/aspartame . 25 choline sal/mag salicylate.. 10 CHORIONIC

GONADOTROPIN........ 55 ciclopirox ........................... 22 ciclopirox olamine ............. 22 cilostazol ............................ 49 CILOXAN.......................... 21 cimetidine ........................... 32

cimetidine hcl .....................32 CIMZIA..............................47 CIPRO ................................15 CIPRO HC..........................21 CIPRODEX........................21 ciprofloxacin hcl...........15, 20 ciprofloxacin/ciprofloxa hcl

........................................15 citalopram hydrobromide...56 citric acid/sodium citrate .....9 CLARINEX........................60 CLARINEX-D 12 HOUR ..60 CLARINEX-D 24 HOUR ..60 clarithromycin ....................15 clemastine fumarate ...........45 CLEOCIN...........................22 CLEVER CHEK LANCETS

........................................40 CLEVER CHEK ULTRA

THIN LANCETS ...........40 clindamycin hcl ..................14 clindamycin palmitate hcl ..14 clindamycin phos/benzoyl

perox...............................21 clindamycin phosphate .......21 CLINDESSE ......................22 clobetasol propionate .........24 clomiphene citrate ..............44 clomipramine hcl................56 clonazepam.........................17 clonidine .............................50 clonidine hcl .......................50 clonidine hcl/chlorthalidone

........................................50 clopidogrel bisulfate...........49 clorazepate dipotassium .....35 clotrimazole ........................22 clotrimazole/betamethasone

dip...................................22 clozapine.............................57 COAGUCHEK...................40 codeine phos/acetaminophen

........................................11

codeine phos/carisoprodol/asa.................................. 60

codeine sulfate ................... 11 CODEINE SULFATE ....... 11 codeine/butalbital/asa/caffein

....................................... 11 codeine/promethazine hcl .. 31 colchicine/probenecid........ 52 COLCRYS......................... 52 colestipol hcl...................... 26 colestipol hcl,micronized ... 26 COLOR LANCETS........... 40 COMBIPATCH................. 44 COMBIVENT ................... 62 COMBIVENT RESPIMAT62 COMFORT LANCETS..... 40 COMPAZINE.................... 19 COMPLETE-RF

PRENATAL .................. 64 CONDYLOX..................... 61 COPAXONE ..................... 52 CORDRAN........................ 25 CORDRAN SP .................. 25 COREG CR ....................... 37 cortisone acetate.................. 9 CREON.............................. 47 CRESTOR ......................... 26 cresyl ace/ben alc/butanol/ipa

....................................... 20 CRINONE ......................... 56 CRIXIVAN........................ 33 cromolyn sodium................ 24 cyclobenzaprine hcl ........... 60 cyclopentolate hcl .............. 54 cyclophosphamide ............. 28 cyclosporine....................... 52 cyclosporine, modified....... 52 CYMBALTA..................... 57 cyproheptadine hcl ............ 45 CYSTAGON ..................... 52 DALIRESP ........................ 60 danazol............................... 13 dantrolene sodium ............. 60 dapsone .............................. 27

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DARAPRIM ...................... 30 DAYTRANA ..................... 13 DECADRON ..................... 23 DELATESTRYL ............... 13 demeclocycline hcl ............. 15 DENAVIR.......................... 22 DEPEN............................... 47 DEPO-PROVERA ............. 56 DEPO-SUBQ PROVERA

104.................................. 56 desipramine hcl .................. 56 desloratadine...................... 60 desmopressin acetate ......... 55 desogestrel-ethinyl estradiol

........................................ 39 desog-et estra/ethin estra ... 39 desonide ............................. 24 desoximetasone .................. 24 DETROL LA ..................... 47 dexamethasone ..................... 9 dexamethasone sod phosphate

........................................ 23 dexchlorpheniramine maleate

........................................ 45 DEXILANT ....................... 33 dexmethylphenidate hcl...... 13 dextroamphetamine sulfate 13 dhcodeine bt/acetaminophn/

caff.................................. 11 DHT ................................... 65 DIASTAT ACUDIAL ....... 36 diazepam ............................ 36 DIBENZYLINE................. 61 diclofenac potassium.......... 10 diclofenac sodium ........ 10, 23 dicloxacillin sodium ........... 15 dicyclomine hcl .................. 16 didanosine .......................... 33 DIFFERIN.......................... 61 DIFICID............................. 15 diflorasone diacetate.......... 24 diflunisal ............................ 10 digoxin................................ 38 DIGOXIN .......................... 38

dihydrocodeine/guaifenesin31 dihydroergotamine mesylate

........................................61 DILANTIN.........................17 diltiazem hcl .......................37 DIOVAN ............................58 DIOVAN HCT ...................58 DIPENTUM .......................24 diphenhydramin/pe/codeine

phos ................................31 diphenhydramine hcl ..........46 diphenoxylate hcl/atropine .18 dipyridamole.......................63 disopyramide phosphate.....37 disulfiram ...........................52 DIURIL ..............................44 divalproex sodium ..............16 DIVIGEL............................44 dm/phenyleph/

chlorpheniramine ...........31 d-methorp tan/p-epd tan/d-cp

........................................31 d-methorp tan/p-ephed tan/cp

........................................31 d-methorphan hb/pe/

chlorphenir .....................31 d-methorphan hb/p-epd hcl/

bpm ...........................31, 32 d-methorphan hb/p-ephed hcl/

cp ....................................32 d-methorphan hb/prometh hcl

........................................32 donepezil hcl.......................54 dorzolamide hcl ..................20 dorzolamide hcl/timolol

maleat .............................20 doxazosin mesylate ...............9 doxepin hcl .........................56 doxycycline hyclate ......16, 20 doxycycline monohydrate ...16 doxylamine succinate .........46 DRITHOCREME HP.........51 DRITHO-SCALP...............51 dronabinol ..........................19

DROPLET LANCETS ...... 40 DUAC CS.......................... 22 DULERA............................. 9 DYNACIRC CR................ 37 E.E.S. 200 .......................... 15 EASY COMFORT ............ 40 econazole nitrate................ 22 EDARBI ............................ 58 EDARBYCLOR ................ 58 EFFIENT ........................... 49 ELESTRIN ........................ 44 ELIDEL ............................. 61 ELMIRON......................... 53 EMADINE......................... 14 EMCYT ............................. 28 EMEND............................. 19 emollient combination no.10

....................................... 39 EMTRIVA......................... 33 ENABLEX......................... 47 enalapril maleate ............... 58 enalapril/hydrochlorothiazide

....................................... 58 ENBREL............................ 53 enoxaparin sodium ............ 47 entacapone......................... 30 epinastine hcl ..................... 14 epinephrine ........................ 62 EPIPEN.............................. 62 EPIPEN JR ........................ 62 EPIVIR .............................. 33 EPIVIR HBV..................... 33 eplerenone ......................... 59 EPOGEN ........................... 49 eprosartan mesylate........... 58 EPZICOM.......................... 33 ergocalciferol (vitamin d2) 64 ergoloid mesylates ............. 52 ergotamine tartrate/caffeine

....................................... 61 ERIVEDGE ....................... 28 ery e-succ/sulfisoxazole ..... 15 ERYPED 200..................... 15 ERYPED 400..................... 15

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ERY-TAB .......................... 15 erythromycin base ........ 15, 20 erythromycin base/ethanol. 22 erythromycin ethylsuccinate

........................................ 15 erythromycin stearate ........ 15 erythromycin/benzoyl

peroxide.......................... 22 escitalopram oxalate .......... 56 estazolam............................ 36 ESTRACE.......................... 44 ESTRADERM ................... 44 estradiol ............................. 44 estradiol/noreth ac ............. 44 ESTRING........................... 44 estrogen,ester/me-

testosterone .................... 13 estropipate.......................... 44 ethambutol hcl.................... 27 ethinyl estradiol/drospirenone

........................................ 39 ethosuximide ...................... 17 ethynodiol d-ethinyl estradiol

........................................ 39 etidronate disodium ........... 52 etodolac.............................. 10 etoposide ............................ 28 EVISTA ............................. 45 EXELON............................ 54 exemestane ......................... 28 EXFORGE ......................... 37 EXFORGE HCT ................ 37 EXJADE ............................ 47 EXTAVIA.......................... 53 E-Z JECT LANCETS ........ 40 EZ SMART........................ 40 E-ZJECT LANCETS ......... 40 EZ-LETS............................ 40 famciclovir ......................... 34 famotidine .......................... 32 FANAPT............................ 57 FAST TAKE ...................... 43 FEIBA NF.......................... 48 FEIBA VH IMMUNO ....... 48

felbamate ............................16 felodipine ............................37 FEMHRT............................45 fenofibrate ..........................26 fenofibrate,micronized........26 fenofibric acid ....................26 fenoprofen calcium .............10 fentanyl ...............................11 fentanyl citrate....................11 FENTORA .........................12 FERRIPROX......................47 FINACEA...........................61 finasteride...........................52 FINGERSTIX.....................40 FIRST-BXN .......................22 flavoxate hcl .......................46 flecainide acetate................37 FLECTOR ..........................11 FLOVENT DISKUS ............9 FLOVENT HFA...................9 fluconazole .........................19 flucytosine...........................19 fludrocortisone acetate.........9 flunisolide ...........................23 fluocinolone acetonide .......25 fluocinolone acetonide oil ..23 fluocinolone/shower cap ....25 fluocinonide ........................25 FLUORABON ...................64 FLUOR-A-DAY...........52, 65 fluorescein sodium..............54 fluoride/iron/vit a,c&d .......64 FLUORITAB .....................52 fluorometholone .................23 fluorouracil.........................60 fluoxetine hcl ......................56 fluoxymesterone..................13 fluphenazine decanoate ......57 fluphenazine hcl..................57 FLURA...............................64 FLURA-DROPS.................52 flurazepam hcl ....................36 flurbiprofen.........................10 flurbiprofen sodium ............23

flutamide ............................ 28 fluticasone propionate . 23, 25 fluvastatin sodium.............. 26 fluvoxamine maleate .......... 56 FML................................... 24 FML S.O.P......................... 23 FOCALIN XR ................... 13 folic acid ............................ 64 FOLLISTIM AQ ............... 55 fondaparinux sodium ......... 47 FORA LANCETS.............. 40 FORADIL.......................... 62 FORFIVO XL.................... 57 FORTEO............................ 55 FORTESTA....................... 13 FORTICAL........................ 55 FOSAMAX........................ 52 FOSAMAX PLUS D......... 52 fosinopril sodium ............... 58 fosinopril/

hydrochlorothiazide....... 58 FOSRENOL....................... 50 FREESTYLE LANCETS.. 40 FREESTYLE UNISTIK 2 . 40 FROVA.............................. 27 FULVICIN U/F ................. 19 furosemide ......................... 43 FUZEON ........................... 34 gabapentin ......................... 16 GABITRIL......................... 16 galantamine hbr................. 54 ganciclovir ......................... 34 GANIRELIX ACETATE .. 52 GELNIQUE....................... 47 gemfibrozil ......................... 26 GENOTROPIN.................. 55 gentamicin sulfate........ 21, 22 GESTICARE DHA............ 64 GILENYA ......................... 53 GLEEVEC......................... 28 glimepiride......................... 18 glipizide ............................. 18 glipizide/metformin hcl ...... 18 GLUCAGEN ..................... 52

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GLUCAGON EMERGENCY KIT................................. 52

GLUCOCOM LANCETS.. 40 GLUCOSOURCE.............. 40 glutethimide........................ 35 glyburide ............................ 18 glyburide,micronized ......... 18 glyburide/metformin hcl..... 18 glycopyrrolate .................... 16 GLYSET ............................ 17 GOLYTELY ...................... 38 GONAL-F.......................... 55 GONAL-F RFF.................. 55 granisetron hcl ................... 19 GRIFULVIN V .................. 19 griseofulvin,microsize ........ 19 GRIS-PEG.......................... 19 guaifen/dm hb/p-ephedrine/

bpm................................. 45 guaifen/d-methorphan hb/pe/

cp.................................... 45 guaifen/p-ephed hcl/dihy-cod

........................................ 45 guaifen/phenylephr/

chlorphenir..................... 45 guaifen/theop anhyd/p-ephed

........................................ 60 guaifenesin ......................... 45 guaifenesin/carbetapentane

cit.................................... 45 guaifenesin/codeine

phosphate ....................... 32 guaifenesin/

dextromethorphan .......... 32 guaifenesin/dm/

pseudoephedrine ............ 32 guaifenesin/d-methorphan hb/

pe.................................... 45 guaifenesin/dyphylline ....... 60 guaifenesin/p-ephed hcl/cod

........................................ 32 guaifenesin/phenylephrine hcl

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

guaifenesin/pseudoephedrne hcl ...................................45

guanabenz acetate ..............50 guanfacine hcl ....................50 guanidine hcl ......................54 HAEMOLANCE................41 HAEMOLANCE PLUS .....40 HAEMOLANCE,

RETRACTABLE ...........40 HALFLYTELY-

BISACODYL.................38 halobetasol propionate.......25 halobetasol/ammonium

lactate .............................25 haloperidol .........................57 haloperidol decanoate........57 haloperidol lactate .............57 hc/pramox hcl/cl-xylenol/

water...............................23 hc/pramoxine hcl/

chloroxylenol ..................23 HECTOROL.......................65 HELIXATE FS...................48 HEMOFIL M......................48 heparin sodium,porcine......48 heparin sodium,porcine/pf .48 HEPSERA ..........................35 HEXALEN.........................28 homatropine hbr .................54 HUMALOG .......................18 HUMALOG MIX 50-50 ....18 HUMALOG MIX 75-25 ....18 HUMATE-P .......................48 HUMIRA............................53 HUMULIN 70-30...............18 HUMULIN N .....................18 HUMULIN R .....................18 hyaluronate sodium ............39 HYCAMTIN ......................28 hydralazine hcl ...................50 hydralazine/

hydrochlorothiazid .........50 hydralazine/reserpin/hctz ...50 hydrochlorothiazide ...........44

hydrocodone bit/acetaminophen............... 11

hydrocodone bit/homatrop me-br.............................. 32

hydrocodone/chlorphen polis....................................... 32

hydrocodone/ibuprofen...... 11 hydrocort/pramoxin/emol/

pram#1........................... 25 hydrocort/pramoxn/skn

clnsr#16 ......................... 25 hydrocortisone ............... 9, 25 hydrocortisone ac/lidocaine

................................. 25, 30 hydrocortisone acetate ...... 25 hydrocortisone acetate/aloe v

....................................... 25 hydrocortisone acetate/urea

....................................... 25 hydrocortisone butyrate..... 25 hydrocortisone valerate ..... 25 hydrocortisone/iodoquinol. 22 hydrocortisone/lidocaine/aloe

....................................... 30 hydrocortisone/pramoxine. 25 hydromorphone hcl............ 12 hydroxychloroquine sulfate 30 hydroxyurea ....................... 28 hydroxyzine hcl .................. 35 hydroxyzine pamoate ......... 35 hyoscyamine sulfate ........... 16 ibandronate sodium ........... 52 ibuprofen............................ 10 ibuprofen/oxycodone hcl.... 12 imipramine hcl ................... 56 imipramine pamoate .......... 56 imiquimod .......................... 61 INCIVEK........................... 34 indapamide ........................ 43 INDOCIN .......................... 11 indomethacin ..................... 10 INFERGEN ....................... 34 INLYTA ............................ 28 INNOPRAN XL ................ 37

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INTELENCE...................... 33 INTERMEZZO.................. 35 INTRON A......................... 34 INTUNIV........................... 38 INVEGA ............................ 57 INVIRASE......................... 33 iodine/potassium iodide ..... 22 ipratropium bromide .... 16, 44 ipratropium/albuterol sulfate

........................................ 62 irbesartan ........................... 58 irbesartan/

hydrochlorothiazide ....... 58 IRESSA.............................. 29 iron,carbonyl/vit c/vit b12/fa

........................................ 64 ISENTRESS....................... 33 isomethept/acetaminop/

dichlphn.......................... 10 isoniazid ............................. 27 isopropamide/

prochlorperazine............ 16 ISOPTO CARPINE ........... 20 ISOPTO HOMATROPINE54 ISOPTO HYOSCINE ........ 54 isosorbide dinitrate ............ 63 isosorbide mononitrate ...... 63 isotretinoin ......................... 61 isoxsuprine hcl ................... 63 isradipine ........................... 37 itraconazole........................ 19 JAKAFI.............................. 29 JALYN............................... 53 JANUMET......................... 17 JANUMET XR .................. 17 JANUVIA .......................... 17 JENTADUETO.................. 17 JUVISYNC ........................ 17 KALETRA......................... 33 KALYDECO...................... 60 KENALOG ........................ 25 ketoconazole................. 19, 22 ketoprofen .......................... 10 ketorolac tromethamine10, 23

KETOSTIX REAGENT.....63 KINERET...........................53 KOATE-DVI......................49 KOGENATE FS.................49 KOMBIGLYZE XR...........17 KORLYM...........................17 K-PHOS ORIGINAL ...........9 KRISTALOSE ...................10 KUVAN .............................53 labetalol hcl........................36 lactic acid ...........................61 lactulose .............................10 LADY LITE .......................41 lamivudine ..........................33 lamivudine/zidovudine........33 lamotrigine .........................16 LANCETS..........................41 LANCETS MICROTAINER

........................................41 lansoprazole .......................32 LANTUS ............................18 LANTUS SOLOSTAR ......18 LASTACAFT.....................14 latanoprost .........................20 leflunomide .........................52 LESCOL XL ......................26 LETAIRIS ..........................64 letrozole ..............................28 leucovorin calcium .............52 LEUKERAN ......................28 LEUKINE...........................49 levalbuterol hcl...................62 LEVEMIR ..........................18 levetiracetam ......................16 levobunolol hcl ...................20 levofloxacin ..................15, 21 levonorgestrel.....................39 levonorgestrel-eth estradiol39 levorphanol tartrate ...........12 levothyroxine sodium..........62 LEXIVA.............................33 LIALDA.............................24 lidocaine hcl .................31, 51 lidocaine/prilocaine ...........31

LIDODERM ...................... 31 LIFESCAN ........................ 41 lindane ............................... 23 liothyronine sodium ........... 62 lipase/protease/amylase..... 47 lisinopril............................. 59 lisinopril/hydrochlorothiazide

....................................... 59 LITE TOUCH.................... 41 lithium carbonate............... 38 lithium citrate .................... 38 LITHOSTAT ..................... 10 LIVALO ............................ 26 l-norgest-eth estr/ethin estra

....................................... 39 LOESTRIN 24 FE ............. 39 loperamide hcl ................... 18 lorazepam .......................... 36 LORAZEPAM INTENSOL

....................................... 36 losartan potassium............. 58 losartan/hydrochlorothiazide

....................................... 58 LOTRONEX...................... 47 lovastatin ........................... 26 LOVAZA........................... 25 LOVENOX........................ 48 loxapine succinate ............. 57 LOZI-FLUR....................... 64 LUMIGAN ........................ 20 LUNESTA......................... 35 LUVERIS .......................... 55 LYRICA ............................ 17 LYSODREN...................... 28 magnesium salicylate......... 10 malathion ........................... 23 maprotiline hcl................... 56 MATULANE..................... 28 MAXAIR AUTOHALER.. 62 MAXALT .......................... 27 MAXALT MLT................. 27 MAXIDEX ........................ 23 mebendazole ...................... 14 meclizine hcl ...................... 19

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meclofenamate sodium....... 10 MEDI-LANCE................... 41 MEDLANCE PLUS........... 41 medroxyprogesterone acet . 55 medroxyprogesterone acetate

........................................ 56 mefenamic acid .................. 11 mefloquine hcl .................... 30 megestrol acetate ............... 28 meloxicam .......................... 11 MENOPUR........................ 55 meperidine hcl.................... 12 MEPHYTON ..................... 65 meprobamate...................... 35 MEPRON........................... 30 mercaptopurine .................. 28 mesalamine w/cleansing

wipes .............................. 24 MESNEX ........................... 53 MESTINON....................... 54 METADATE CD............... 13 metaproterenol sulfate ....... 62 metaxalone ......................... 60 metformin hcl ..................... 17 methadone hcl .................... 12 methamphetamine hcl ........ 13 methazolamide ................... 20 methen/m-blue/sal/na phos/

hyos ................................ 63 methenam/me blue/ba/salicy/

hyo.................................. 63 methenamine mandelate..... 63 methimazole ....................... 63 methocarbamol .................. 60 methotrexate sodium .......... 28 methscopolamine bromide . 16 methyclothiazide ................ 44 methyl salicylate................. 11 methyldopa ......................... 50 methyldopa/

hydrochlorothiazide ....... 50 methylergonovine maleate . 52 methylphenidate hcl ........... 13 methylprednisolone .............. 9

metipranolol .......................20 metoclopramide hcl ............47 metolazone..........................43 metoprolol succinate ..........36 metoprolol tartrate .............36 metoprolol/

hydrochlorothiazide .......36 METROGEL ......................22 metronidazole ...............22, 30 mexiletine hcl......................37 mg sal/acetaminophn/p-tlox/

caf ...................................10 MIACALCIN .....................55 MICARDIS ........................58 MICARDIS HCT ...............58 miconazole nitrate ..............22 MICRO THIN LANCET ...41 MICRO THIN LANCETS .41 MICROLET .......................41 midazolam hcl ....................36 midodrine hcl......................62 MIGRANAL ......................62 MINILET ...........................41 minocycline hcl...................16 minoxidil.............................50 mirtazapine.........................56 misoprostol .........................32 modafinil.............................13 moexipril hcl.......................59 moexipril/

hydrochlorothiazide .......59 mometasone furoate ...........25 MONOCLATE-P ...............49 MONOLET LANCETS .....41 MONOLET THIN

LANCETS......................41 montelukast sodium ............24 morphine sulfate .................12 MOVIPREP........................38 mth/me blue/sod phos/phen/

hyos.................................63 MULTAQ...........................37 multivitamins with fluoride.64 mupirocin ...........................22

MYCOBUTIN................... 27 mycophenolate mofetil ....... 52 MYFORTIC....................... 52 MYGLUCOHEALTH

LANCETS ..................... 41 MYLERAN ....................... 28 nabumetone........................ 11 nadolol ............................... 36 nadolol/bendroflumethiazide

....................................... 36 NAFTIN............................. 22 NALFON........................... 11 nalidixic acid ..................... 15 naltrexone hcl .................... 54 NAMENDA....................... 38 naphazoline hcl.................. 44 naphazoline hcl/antazoline 44 naproxen ............................ 11 naproxen sodium................ 11 naratriptan hcl ................... 26 NASONEX ........................ 24 NATACYN........................ 21 NATAFORT...................... 64 nateglinide ......................... 17 NEBUPENT ...................... 30 needles, insulin disposable 41 nefazodone hcl ................... 56 neo/polymyx b sulf/dexameth

....................................... 21 neomy sulf/bacitra/polymyxin

b ..................................... 21 neomy sulf/bacitrac zn/poly/

hc ................................... 21 neomycin sulfate ................ 14 neomycin sulfate/dex na ph 21 neomycin/polymyxin b sulf/hc

....................................... 21 neomycin/polymyxn b/

gramicidin...................... 21 NEULASTA ...................... 49 NEUMEGA ....................... 49 NEUPOGEN...................... 49 nevirapine .......................... 33 NEXA SELECT ................ 65

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NEXAVAR........................ 29 NEXICLON XR................. 50 NEXIUM............................ 33 NIASPAN .......................... 25 nicardipine hcl ................... 37 nifedipine............................ 37 NILANDRON.................... 28 nimodipine.......................... 37 nisoldipine.......................... 37 NITRO-BID ....................... 63 NITRO-DUR...................... 64 nitrofurantoin ..................... 63 nitrofurantoin macrocrystal

........................................ 63 nitroglycerin....................... 63 NITROSTAT ..................... 64 nizatidine............................ 33 NORDITROPIN ................ 55 NORDITROPIN

NORDIFLEX................. 55 noreth a-et estra/fe fumarate

........................................ 39 noreth-ethinyl estradiol/iron

........................................ 39 norethind ac/ethinyl estradiol

........................................ 44 norethindrone..................... 39 norethindrone acetate ........ 56 norethindrone a-e estradiol39 norethindrone-ethinyl estrad

........................................ 39 norethindrone-mestranol ... 39 norgestimate-ethinyl estradiol

........................................ 39 norgestrel-ethinyl estradiol 39 NORPACE CR................... 37 nortriptyline hcl ................. 56 NORVIR ............................ 33 NOVA SUREFLEX........... 41 NOVAREL ........................ 55 NOVOLIN 70-30 ............... 18 NOVOLIN 70-30 INNOLET

........................................ 18 NOVOLIN N ..................... 18

NOVOLIN N INNOLET ...18 NOVOLIN R......................18 NOVOLOG ........................18 NOVOLOG MIX 70-30 .....18 NOXAFIL ..........................19 NUCYNTA ........................12 NUCYNTA ER ..................12 NUVARING.......................39 NUVIGIL ...........................14 nylidrin hcl .........................63 nystatin .........................19, 22 nystatin/triamcin.................22 OCL....................................38 octreotide acetate ...............52 ofloxacin .......................15, 21 olanzapine ..........................57 olanzapine/fluoxetine hcl....56 OLEPTRO ER....................57 omeprazole .........................33 omeprazole/sodium

bicarbonate.....................33 OMNARIS .........................24 ondansetron ........................19 ondansetron hcl ..................19 ONE TOUCH DELICA .....41 ONE TOUCH LANCETS..41 ONE TOUCH SURESOFT 41 ONE TOUCH TEST STRIPS

........................................43 ONE TOUCH ULTRA TEST

STRIPS...........................43 ONE TOUCH VERIO........43 ONGLYZA.........................17 ONSOLIS...........................12 opium tincture ....................18 opium/belladonna alkaloids

........................................12 OPTICHAMBER ...............41 ORACIT...............................9 ORAMORPH SR ...............12 ORAP .................................57 ORENCIA ..........................53 orphenadrine citrate...........60

orphenadrine/aspirin/caffeine....................................... 60

ORTHO EVRA.................. 39 ORTHO TRI-CYCLEN LO

....................................... 39 OVCON-50........................ 39 OVIDREL.......................... 55 oxandrolone ....................... 13 oxaprozin ........................... 11 oxazepam ........................... 36 oxcarbazepine .................... 16 OXECTA........................... 12 OXSORALEN................... 61 OXSORALEN-ULTRA .... 61 oxybutynin chloride ........... 46 oxycodone hcl .................... 12 oxycodone hcl/acetaminophen

....................................... 12 oxycodone hcl/aspirin........ 12 oxycodone hcl/oxycodon ter/

asa.................................. 12 OXYCONTIN ................... 12 oxymorphone hcl................ 12 OXYTROL ........................ 47 pantoprazole sodium ......... 33 papain/urea........................ 61 papaverine hcl ................... 63 paregoric ........................... 18 paromomycin sulfate.......... 30 paroxetine hcl .................... 56 PATADAY ........................ 14 PATANASE ...................... 14 PATANOL......................... 14 PAXIL ............................... 57 ped mv a,c,d3 #21 w-fluoride

....................................... 65 pedi m.vit no.17 with fluoride

....................................... 65 peg 3350/na sulf,bicarb,cl/kcl

....................................... 38 PEGASYS ......................... 34 PEGASYS PROCLICK..... 34 PEGINTRON..................... 34 PEGINTRON REDIPEN... 34

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penicillin v potassium ........ 15 PENTASA.......................... 24 pentazocine hcl/

acetaminophen ............... 13 pentazocine hcl/naloxone hcl

........................................ 13 PENTOLAIR ..................... 54 pentoxifylline...................... 48 p-epd tan/chlor-tan ............ 46 p-ephed hcl/chlor-mal/bell alk

........................................ 46 p-ephed hcl/codeine/guaifen

........................................ 32 p-ephed hcl/dhcodeine bt/cp

........................................ 32 p-ephed hcl/hydrocodone bit

........................................ 32 p-ephed hcl/methscopolamn

........................................ 62 p-ephed hcl/triprolidine hcl46 PERFOROMIST................ 62 perindopril erbumine ......... 59 permethrin.......................... 23 perphenazine ...................... 57 perphenazine/amitriptyline

hcl................................... 56 PERTZYE.......................... 47 phenazopyridine hcl ........... 31 phenelzine sulfate............... 56 phenobarb/hyoscy/atropine/

scop ................................ 16 phenobarbital ..................... 35 phenylbutazone .................. 11 phenylephrine hcl............... 44 phenylephrine hcl/cod/

prometh .......................... 32 phenylephrine hcl/prometh

hcl................................... 46 phenylephrine/

brompheniramin............. 46 phenylephrine/

brompheniramine ........... 46 phenylephrine/carbetapentan/

gg.................................... 45

phenylephrine/chlorpheniramine ...........46

phenylephrine/chlor-tan .....46 phenylephrine/dhcodeine bt/

cp ....................................32 phenylephrine/

diphenhydramine ............46 phenylephrine/p-tlox ci/cp..46 phenylephrine/pyril tan/cp .46 phenylephrine/pyrilamine ma/

cp ....................................46 phenylephrine/pyrilamine tan

........................................46 PHENYTEK.......................17 phenytoin ............................17 phenytoin sodium extended 17 PHOSPHASAL ..................63 PHOSPHOLINE IODIDE..20 phosphorus #1 ......................9 PHRENILIN FORTE .........10 PICATO .............................61 pilocarpine hcl..............20, 54 PILOPINE HS....................20 pindolol...............................36 pioglitazone hcl ..................18 pioglitazone hcl/metformin

hcl ...................................18 piroxicam............................11 pnv with ca,no.72/iron/fa ...65 pnv39/iron fumarate/fa/dss/

dha ..................................65 pnv66/iron fumarate/fa/dss/

dha ..................................65 podofilox.............................61 polyethylene glycol 3350 ....38 polymyxin b sulfate/tmp......21 pot chloride/pot bicarb/cit ac

........................................59 pot guaiaco/car-b-pentane/pe

........................................45 potassium bicarbonate/cit ac

........................................59 potassium chloride .............59 potassium citrate ..................9

potassium citrate/citric acid 9 potassium gluconate .......... 59 potassium hydroxide .......... 51 potassium iodide ................ 63 potassium iodide/iodine..... 63 POTIGA............................. 17 PRADAXA........................ 48 pramipexole di-hcl ............. 30 pramoxine hcl .................... 31 PRANDIN ......................... 17 pravastatin sodium ............ 26 prazosin hcl.......................... 9 PRED-G............................. 21 prednicarbate..................... 25 prednisolone ........................ 9 prednisolone acetate.......... 23 prednisolone sod phosphate 9,

23 prednisone ........................... 9 PREGNYL......................... 55 PREMARIN....................... 44 PREMPHASE.................... 44 PREMPRO ........................ 44 PREZISTA......................... 33 primidone........................... 16 PRISTIQ ER...................... 57 probenecid ......................... 52 procainamide hcl ............... 37 prochlorperazine maleate.. 19 PROCRIT .......................... 49 PROCTOFOAM-HC......... 25 PRODIGY LANCETS ...... 41 PRODIGY TWIST TOP

LANCET ....................... 41 progesterone ...................... 56 progesterone,micronized ... 56 PROMACTA..................... 50 promethazine hcl................ 46 PRONESTYL .................... 37 propafenone hcl ................. 37 propantheline bromide ...... 16 propantheline/phenobarbital

....................................... 16 propranolol hcl .................. 36

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propranolol/hydrochlorothiazid......... 36

propylthiouracil ................. 63 PROSTIGMIN ................... 54 PROTOPIC ........................ 61 protriptyline hcl ................. 56 pseudoephed/

chlorpheniramine ........... 46 pseudoephedrine hcl/chlor-

mal.................................. 46 pseudoephedrine hcl/codeine

........................................ 32 pseudoephedrine/

brompheniramin............. 46 pseudoephedrine/cpm/

methscopol ..................... 46 PUBLIX LANCET ............ 41 PULMICORT ...................... 9 PULMICORT FLEXHALER

.......................................... 9 PULMOZYME .................. 44 pyrazinamide...................... 27 pyridostigmine bromide ..... 54 pyrilamine/pe/

dextromethorphan .......... 32 QNASL .............................. 24 QUALAQUIN.................... 30 quetiapine fumarate ........... 57 quinapril hcl....................... 59 quinapril/hydrochlorothiazide

........................................ 59 quinidine gluconate............ 37 quinidine sulfate................. 37 quinine sulfate .................... 30 QVAR .................................. 9 ramipril .............................. 59 RANEXA........................... 38 ranitidine hcl ...................... 33 RAPAFLO ......................... 62 RAPAMUNE ..................... 53 REBIF ................................ 53 RECOMBINATE............... 49 REFACTO ......................... 49 RELENZA ......................... 34

RELISTOR.........................47 RELPAX ............................27 RENAGEL .........................50 RENEW ADVANCED

MICRO-LANCETS .......41 RENVELA .........................50 REPRONEX.......................55 RESCRIPTOR....................33 reserpine.............................50 reserpine/hydrochlorothiazide

........................................50 RESTASIS .........................24 RETIN-A MICRO..............38 REVATIO ..........................64 REVLIMID ..................29, 53 REYATAZ .........................33 RHINOCORT AQUA........24 RIBATAB ..........................35 ribavirin..............................35 RIDAURA..........................52 rifampin ..............................27 rifampin/isoniazid...............27 RIFATER ...........................27 RIGHTEST GL300

LANCETS......................41 RILUTEK...........................38 rimantadine hcl ..................34 RISPERDAL CONSTA .....57 risperidone .........................57 RITALIN LA......................14 rivastigmine tartrate...........54 ropinirole hcl......................30 ROXICODONE .................12 ROZEREM.........................35 SABRIL..............................17 SAFETY LANCETS..........41 SAFETY-LET ....................41 sal-amide/acetamin/p-tlox/

caff ..................................10 sal-amide/acetaminophn/p-

tlox ..................................10 salicylic acid.......................51 salicylic acid/ammon lact/

aloe .................................51

salicylic acid/ceramide cmb #1 ................................... 51

salsalate ............................. 11 SANCTURA XR ............... 47 SANCUSO ........................ 19 SANDOSTATIN ............... 53 SANTYL ........................... 61 SAPHRIS........................... 57 SAVELLA......................... 38 scopolamine hydrobromide 19 selegiline hcl ...................... 30 selenium sulfide ................. 22 SELZENTRY .................... 33 SENSIPAR ........................ 53 SEREVENT DISKUS ....... 62 SEROQUEL XR................ 57 sertraline hcl...................... 56 silver nitrate....................... 23 silver nitrate applicator ..... 51 silver sulfadiazine .............. 23 SIMPONI........................... 53 simvastatin ......................... 26 SINGLE-LET .................... 41 SINGULAIR...................... 24 SMARTDIABETES

VANTAGE.................... 41 SMARTEST LANCET...... 41 sod/pot/k cit/sod cit/cit acid. 9 sodium chloride/nahco3/kcl/

peg ................................. 38 sodium fluoride ............ 52, 65 sodium polystyrene sulfonate

....................................... 50 sodium thiosulfate/sal acid 22 SOFT TOUCH................... 42 SOFTCLIX ........................ 42 SOLO V2 LANCETS........ 42 SOMATULINE DEPOT ... 54 SOMAVERT ..................... 61 SORIATANE..................... 61 sotalol hcl .......................... 36 spinosad ............................. 23 SPIRIVA............................ 16

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spironolact/hydrochlorothiazid......... 59

spironolactone.................... 59 SPORANOX...................... 19 SPRYCEL.......................... 29 stannous fluoride................ 52 STAT-LET......................... 42 stavudine ............................ 33 STIMATE .......................... 55 STRATTERA .................... 38 STRIANT........................... 13 STROMECTOL................. 14 SUBSYS ............................ 12 SUCRAID.......................... 44 sucralfate............................ 33 sulfacet sod/sulfur/witch haz

........................................ 51 sulfacetamd/sulfr/sknclnsr10

........................................ 23 sulfacetamide sod/sulfur/urea

........................................ 23 sulfacetamide sodium... 21, 23 sulfacetamide sodium/sulfur

........................................ 51 sulfacetamide sodium/urea 51 sulfacetamide/prednisolone

sp .................................... 21 sulfacetm na/avobenzone/

sulfur .............................. 23 sulfadiazine ........................ 15 sulfamethoxazole/

trimethoprim .................. 15 sulfasalazine....................... 15 sulindac .............................. 11 sumatriptan ........................ 26 sumatriptan succinate ........ 26 SUPER THIN LANCET.... 42 SUPER THIN LANCETS.. 42 SUPRAX............................ 14 SURE COMFORT

LANCETS...................... 42 SURE-LANCE................... 42 SURESTEP........................ 43 SURESTEP PRO ............... 43

SURGILANCE LANCETS42 SUSTIVA...........................33 SUTENT.............................29 SYLATRON 4-PACK........34 SYMBICORT.......................9 SYMBYAX........................57 SYMLIN.............................17 SYMLINPEN 120 ..............17 SYMLINPEN 60 ................17 SYNAREL .........................52 syring w-ndl,disp,insul,0.3ml

........................................42 syring w-ndl,disp,insul,0.5ml

........................................42 syringe & needle,insulin,1 ml

........................................42 tacrolimus...........................52 TAMIFLU ..........................34 tamoxifen citrate.................28 tamsulosin hcl.....................61 TARCEVA.........................29 TARGRETIN ...............29, 61 TASIGNA ..........................29 TASMAR ...........................30 TAZORAC.........................61 TECHLITE.........................42 TECHLITE BLOOD

LANCET ........................42 TEKTURNA ......................59 TEKTURNA HCT .............59 temazepam ..........................36 TEMODAR ........................29 terazosin hcl .......................10 terbutaline sulfate...............62 terconazole .........................22 testosterone cypionate ........13 testosterone enanthate........13 tetracycline hcl ...................16 TEVETEN..........................58 TEVETEN HCT.................58 THALOMID.......................52 THEO-24............................60 theophylline anhydrous ......60 THERMAZENE.................23

THIN LANCETS............... 42 thioridazine hcl .................. 57 thiothixene ......................... 57 thyroid,pork ....................... 63 ticlopidine hcl .................... 49 TIKOSYN.......................... 38 timolol maleate ............ 20, 37 tinidazole ........................... 30 tizanidine hcl...................... 60 TOBI.................................. 14 TOBRADEX ..................... 21 tobramycin sulfate ............. 21 tobramycin/dexamethasone 21 tolazamide.......................... 18 tolbutamide ........................ 18 tolmetin sodium.................. 11 tolterodine tartrate ............ 47 TOPCARE UNIVERSAL1

THIN LANCET............. 42 topiramate.......................... 16 torsemide ........................... 43 TOVIAZ ............................ 47 TRACLEER....................... 64 TRADJENTA .................... 17 tramadol hcl....................... 12 tramadol hcl/acetaminophen

....................................... 12 trandolapril........................ 59 trandolapril/verapamil hcl 59 TRANSDERM-SCOP ....... 19 tranylcypromine sulfate ..... 56 TRAVATAN Z.................. 20 trazodone hcl ..................... 56 tretinoin ....................... 28, 38 tretinoin/emollient ............. 38 TREXIMET....................... 27 triamcinolone acetonide ... 23,

25 triamterene/

hydrochlorothiazid ........ 44 triazolam ............................ 36 TRICOR............................. 26 trifluoperazine hcl.............. 57 trifluridine.......................... 21

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trihexyphenidyl hcl............. 30 TRILIPIX........................... 26 trimethobenzamide hcl ....... 19 trimethoprim ...................... 63 trimipramine maleate......... 56 tripelennamine hcl ............. 46 TRIZIVIR .......................... 34 tropicamide ........................ 54 trospium chloride ............... 47 TRUVADA........................ 34 trypsin/balsam peru/castor oil

........................................ 61 TWINJECT........................ 62 TYKERB............................ 29 TYVASO ........................... 64 TYZEKA............................ 35 ULORIC............................. 54 ULTICARE........................ 42 ULTILET ........................... 42 ULTILET BASIC .............. 42 ULTILET CLASSIC.......... 42 ULTILET LANCETS ........ 42 ULTRA THIN II LANCETS

........................................ 42 ULTRA THIN LANCETS.42 ULTRA THIN PLUS......... 42 ULTRA THIN PLUS

LANCETS...................... 42 ULTRALANCE................. 42 ULTRA-THIN II LANCETS

........................................ 42 ULTRATLC LANCETS.... 42 UNILET COMFORTOUCH

........................................ 43 UNILET EXCELITE......... 43 UNILET EXCELITE II ..... 43 UNILET GP LANCET ...... 43 UNILET LANCET ............ 43 UNISTIK 3......................... 43 UNISTIK 3 EXTRA .......... 43 UNISTIK CZT................... 43 urea .................................... 51 urea/hyaluronate sodium ... 51

urea/lactic ac/zn undecylenate...................51

urea/lactic acid/salicyl acid51 URETRON D-S..................63 URIN D.S. ..........................63 ursodiol...............................47 VAGIFEM..........................45 valacyclovir hcl ..................35 VALCYTE .........................35 valproate sodium ................16 valproic acid.......................16 valsartan/hydrochlorothiazide

........................................58 VALTURNA......................59 vancomycin hcl ...................14 VANDETANIB..................29 venlafaxine hcl....................57 VENLAFAXINE HCL ER.57 VENTAVIS........................64 VENTOLIN HFA...............62 VERAMYST......................24 verapamil hcl......................37 VERDESO .........................25 VEREGEN .........................22 VERIPRED 20 .....................9 VESICARE ........................47 VFEND...............................20 VICTOZA 3-PAK..............17 VIDEX ...............................34 VIGAMOX.........................21 VIIBRYD ...........................57 VIMOVO ...........................11 VIMPAT.............................17 VIOKACE..........................47 VIRACEPT ........................34 VIRAMUNE XR................34 VIRAZOLE........................35 VIREAD.............................34 VISICOL ............................38 VITALET...........................43 VITALET PRO ..................43 VITALET PRO PLUS .......43 VIVELLE-DOT .................44

VOLTAREN...................... 11 voriconazole....................... 19 VOTRIENT ....................... 29 VYTORIN ......................... 25 VYVANSE ........................ 13 warfarin sodium................. 48 WAVESENSE LANCETS 43 WELCHOL........................ 26 WILATE............................ 49 XALKORI ......................... 29 XARELTO......................... 48 XELODA........................... 28 XENAZINE....................... 38 XIFAXAN ......................... 14 XOPENEX......................... 62 XOPENEX HFA................ 62 XYNTHA .......................... 49 XYNTHA SOLOFUSE ..... 49 XYREM............................. 38 YODOXIN......................... 30 zafirlukast .......................... 24 zaleplon.............................. 35 ZAVESCA......................... 54 ZEGERID .......................... 33 ZELBORAF....................... 29 ZEMPLAR......................... 65 ZENPEP............................. 47 ZETIA................................ 25 ZETONNA ........................ 24 ZIAGEN ............................ 34 zidovudine .......................... 33 zinc sulfate ......................... 59 ZIOPTAN .......................... 20 ziprasidone hcl................... 57 ZOLINZA.......................... 29 zolpidem tartrate ............... 35 ZOMIG .............................. 27 ZOMIG ZMT..................... 27 zonisamide ......................... 16 ZOVIRAX ......................... 22 ZYTIGA ............................ 29 ZYVOX ............................. 14

GHP/Choice Member Formulary 11/1/12

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list of covered drugs member - geisinger health plan formulary... · general formulary information...

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