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Antihistamine Drugs - Molina Healthcare

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<strong>Antihistamine</strong> <strong>Drugs</strong><br />

First Generation <strong>Antihistamine</strong>s<br />

Ethanolamine Derivatives<br />

ACETAMINOPHEN-PHENYLTOLOXAMINE-CAFFEINE CAP 425-45-35 MG<br />

ALAHIST LQ LIQ 25-7.5<br />

ALDEX-CT CHW 12.5-5MG<br />

alergy/sinus tab headache OTC<br />

all/sinus tab head OTC<br />

allergy mult tab nighttim OTC<br />

allergy relf tab 1.34mg OTC<br />

allergy sinu tab headache OTC<br />

allergy/sinu tab 25-60mg OTC<br />

allergy/sinu tab headache OTC<br />

allergy/sinu tab headache OTC<br />

allergy/sinu tab headache OTC<br />

allergy/sinu tab headache OTC<br />

allerhist-1 tab 1.34mg OTC<br />

allgy/sinus tab headache OTC<br />

allrgy sinus tab headache OTC<br />

allrgy/sinus tab strength OTC<br />

andehist nr dro 1-15/ml<br />

ARIDEX-D DRO PED<br />

as non asa tab sinus OTC<br />

BENADRYL ALL LIQ SINUS OTC<br />

BENADRYL ALL TAB COLD OTC<br />

BENADRYL ALL TAB SINUS OTC<br />

benadryl all tab sinus ha OTC<br />

benadryl sev tab all/sinu OTC<br />

BENADRYL-D LIQ ALLRGY/S OTC<br />

BENADRYL-D SOL CHILD OTC<br />

BENAPHEN CAP PLUS OTC<br />

BIODEC DRO 2-25/ML<br />

bromdec dro 1-15mg/m<br />

carbaxefed dro 1-15/ml<br />

carbic ds syp 2-25/5ml<br />

carbino-pse syp 2-25mg<br />

carbino-pse syp 2-25mg<br />

carbinox tan-pseudoephed tan susp 3.2-45.2 mg/5ml<br />

CARBINOX TAN-PSEUDOEPHED TAN SUSP 3.6-45.2 MG/5ML<br />

CARBINOXAMINE & PHENYLEPHRINE LIQUID 1-2 MG/ML<br />

CARBINOXAMINE & PHENYLEPHRINE LIQUID 1.5-1.5 MG/ML<br />

carbinoxamine & phenylephrine liquid 2-2 mg/ml<br />

CARBINOXAMINE & PHENYLEPHRINE TAB SR 12HR 8-40 MG<br />

carbinoxamine & pseudoephedrine liquid 1-15 mg/ml<br />

carbinoxamine & pseudoephedrine liquid 1.67-12.5 mg/5ml<br />

carbinoxamine & pseudoephedrine liquid 2-12.5 mg/5ml<br />

CARBINOXAMINE & PSEUDOEPHEDRINE LIQUID 2-17.5 MG/5ML<br />

CARBINOXAMINE & PSEUDOEPHEDRINE LIQUID 2-20 MG/5ML<br />

CARBINOXAMINE & PSEUDOEPHEDRINE SOLN 2-25 MG/ML<br />

carbinoxamine & pseudoephedrine syrup 2-25 mg/5ml<br />

carbinoxamine & pseudoephedrine tab 4-60 mg<br />

CARBINOXAMINE & PSEUDOEPHEDRINE TAB SR 12HR 8-120 MG<br />

carbinoxamine & pseudoephedrine tab sr 12hr 8-120 mg<br />

carbinoxamine & pseudoephedrine tab sr 12hr 8-80 mg<br />

carbinoxamine-pseudoeph-methscop syrup 2-15-1.25 mg/5ml<br />

carbinoxamine-pseudoeph-methscop tab sr 12hr 8-90-2.5 mg<br />

carbo-pseudo syp 2-25mg/5<br />

carboxine 12 sus d<br />

CARBOXINE- LIQ PSE<br />

carboxine-d liq<br />

cld cntrl pe tab cld/flu OTC<br />

clemastine syp 0.5/5ml<br />

clemastine tab 1.34mg OTC<br />

clemastine tab 2.68mg<br />

clemastine fumarate syrup 0.67 mg/5ml (0.5 mg/5ml base eq)<br />

clemastine fumarate tab 1.34 mg (1 mg base equiv) OTC<br />

clemastine fumarate tab 2.68 mg<br />

clemastine-1 tab 1.34mg OTC<br />

cold control tab OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 1


cold/allery sus child OTC<br />

cold/flu tab intense OTC<br />

coldec tab 4-60mg<br />

coldec d tab 8-80mg<br />

coldec-tr tab 8-120mg<br />

CONTAC DAY/N PAK AL/SINUS OTC<br />

CORDRON-12 D SUS<br />

CORDRON-D LIQ<br />

cordron-d nr liq<br />

CORICIDIN NT LIQ COLD/CGH OTC<br />

cvs dayhist tab 1.34mg OTC<br />

cvs flu/cold liq nightime OTC<br />

d-tann chw 25-10mg<br />

d-tann sus 25-7.5mg<br />

dailyhist-1 tab 1.34mg OTC<br />

dayhist alrg tab 12 hour OTC<br />

dayhist-1 tab 1.34mg OTC<br />

decongestant tab allergy OTC<br />

dimetapp liq nighttim OTC<br />

DIPHENHYD-PHENYLEPH TAB 25-10 MG & PHENYLEPH TAB 10 MG PAK OTC<br />

diphenhydram cap 50mg<br />

diphenhydram cap 50mg OTC<br />

DIPHENHYDRAMINE & PSEUDOEPHEDRINE CAP CR 25-60 MG OTC<br />

DIPHENHYDRAMINE & PSEUDOEPHEDRINE LIQUID 12.5-30 MG/5ML OTC<br />

diphenhydramine & pseudoephedrine tab 25-60 mg OTC<br />

DIPHENHYDRAMINE & PSEUDOEPHEDRINE TAB SR 12HR 100-120 MG<br />

DIPHENHYDRAMINE & PSEUDOEPHEDRINE TAB SR 12HR 37.5-58 MG<br />

DIPHENHYDRAMINE CITRATE-PSEUDOEPHEDRINE TAB DISP 19-30 MG OTC<br />

diphenhydramine hcl cap 50 mg<br />

diphenhydramine hcl cap 50 mg OTC<br />

diphenhydramine hcl inj 50 mg/ml PA<br />

DIPHENHYDRAMINE HCL-PHENYLEPH HCL TANNATE CHEW TAB 12.5-5 MG<br />

DIPHENHYDRAMINE TAN-PHENYLEPHRINE TAN CHEW TAB 25-10 MG<br />

diphenhydramine tan-phenylephrine tan chew tab 25-10 mg<br />

diphenhydramine tan-phenylephrine tan susp 25-7.5 mg/5ml<br />

DIPHENHYDRAMINE W/ APAP LIQUID 12.5-325 MG/15ML OTC<br />

DIPHENHYDRAMINE W/ APAP LIQUID 25-500 MG/15ML OTC<br />

diphenhydramine w/ apap tab 12.5-500 mg OTC<br />

diphenhydramine w/ apap tab 25-500 mg OTC<br />

DIPHENHYDRAMINE-PHENYLEPHRINE LIQ 25-7.5 MG/5ML<br />

diphenhydramine-phenylephrine liq 6.25-2.5 mg/5ml OTC<br />

DIPHENHYDRAMINE-PHENYLEPHRINE ORAL STRIP 12.5-5 MG OTC<br />

DIPHENHYDRAMINE-PHENYLEPHRINE ORAL STRIP 25-10 MG OTC<br />

DIPHENHYDRAMINE-PHENYLEPHRINE SOLN 12.5-5 MG/5ML OTC<br />

diphenhydramine-phenylephrine tab 25-10 mg OTC<br />

diphenhydramine-phenylephrine-apap liq 12.5-5-325 mg/15ml OTC<br />

diphenhydramine-phenylephrine-apap packet 25-10-650 mg OTC<br />

diphenhydramine-phenylephrine-apap susp 12.5-2.5-160 mg/5ml OTC<br />

diphenhydramine-phenylephrine-apap tab 12.5-5-325 mg OTC<br />

diphenhydramine-phenylephrine-apap tab 25-10-650 mg OTC<br />

diphenhydramine-phenylephrine-apap tab 25-5-325 mg OTC<br />

DIPHENHYDRAMINE-PSE W/ APAP SUSP 12.5-15-160 MG/5ML OTC<br />

diphenhydramine-pse w/ apap tab 12.5-30-500 mg OTC<br />

diphenhydramine-pse w/ apap tab 25-30-500 mg OTC<br />

diphenhydramine-pse w/ apap tab 25-60-500 mg OTC<br />

DIPHENMAX D CHW 25/10MG<br />

diphentann-d sus<br />

doxylamine-phenylephrine-apap cap 6.25-5-325 mg OTC<br />

doxylamine-pseudoephedrine w/ apap tab 6.25-30-500 mg OTC<br />

eq dayhist tab 1.34mg OTC<br />

eql dayhist tab 1.34mg OTC<br />

ex-dec-tr tab 8-120mg<br />

FLEXTRA CAP<br />

flu relief liq nightime OTC<br />

gnp dayhist tab 1.34mg OTC<br />

hca cold cap tab OTC<br />

HISTAMAX D DRO<br />

hydro-tussin syp cbx<br />

intense cold tab /flu med OTC<br />

intense cold tab medicine OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 2


mintex pse liq<br />

nacon tab<br />

night time cap sinus OTC<br />

night-time cap sinus OTC<br />

nite-time cap cold/flu OTC<br />

non-asa seve tab allergy OTC<br />

NOREL LA TAB 8-40MG<br />

pain relief tab severe OTC<br />

pain relieve tab pm OTC<br />

PEDIACARE LIQ ALRG/CLD OTC<br />

PEDIACARE LIQ NITEREST OTC<br />

PEDIATANN-CT CHW 12.5-5MG<br />

percogesic tab xs OTC<br />

pharbedryl cap 50mg OTC<br />

pse allergy liq<br />

PSE-APAP & PSE-APAP-DIPHENHYD TAB 60-650/60-650-50 MG OTC<br />

PSE-APAP TAB 30-500MG &DOXYL-PSE-APAP TAB 6.25-30-500MG PACK OTC<br />

pseudo carb liq<br />

pseudox m syp<br />

px dayhist tab 1.34mg OTC<br />

qc allergy tab multi-sy OTC<br />

qc allergy/ tab sinus OTC<br />

qc allergy/ tab sinus-d OTC<br />

qc cold tab relief OTC<br />

qc cold/cgh pow nighttim OTC<br />

qc flu relf liq nightime OTC<br />

qc intense tab cold OTC<br />

qc nighttime cap sinus OTC<br />

qc severe tab allergy OTC<br />

ra allergy tab multi-sy OTC<br />

ra apap flu tab pm max OTC<br />

re tann d chw 25-10mg<br />

RESPA SA TAB<br />

robitussin liq nighttim OTC<br />

RONDEC TR TAB 8-120<br />

RONDEC-TR TAB 8-120<br />

sb allergy tab sinus/ha OTC<br />

sb allergy/ tab cold pe OTC<br />

sb flu relf liq nightime OTC<br />

sb nighttime cap sinus OTC<br />

sb severe tab cold pe OTC<br />

severe alrgy tab OTC<br />

sildec dro 1-15/ml<br />

sine-off nit tab time OTC<br />

soba dayhist tab 1.34mg OTC<br />

SUDAFED PE PAK DAY&NGHT OTC<br />

sudafed pe tab nght/cld OTC<br />

TEKRAL TAB<br />

theraflu liq warm rlf OTC<br />

THERAFLU CLD MIS CGH NT OTC<br />

theraflu nt liq warm rlf OTC<br />

triacting nt liq cold/cgh OTC<br />

triacting nt liq cold/cgh OTC<br />

TRIAMINIC NT MIS COLD/CGH OTC<br />

TYLENOL CHLD SUS PLUS OTC<br />

TYLENOL COLD LIQ RELIEF OTC<br />

TYLENOL SINU MIS DAY/NITE OTC<br />

TYLENOL SORE LIQ THROAT OTC<br />

uni-tann d chw 25-10mg<br />

uni-tann d sus<br />

wal-dryl tab sinus OTC<br />

wal-dryl-d tab 25-60mg OTC<br />

wal-dryl-d tab alrg/sin OTC<br />

wal-flu liq nightime OTC<br />

wal-hist tab 1.34mg OTC<br />

wal-phed pe tab severe OTC<br />

x-hist dro 2-2mg/ml<br />

Ethylenediamine Derivatives<br />

allanvan-s sus 30-12.5<br />

k-tan tab 60-25mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 3


k-tan 4 sus<br />

pyrilafen ta sus 30-5mg/5<br />

PYRILAMINE MAL-PSEUDOEPHEDRINE HCL TANN SUSP 15-15 MG/5ML<br />

PYRILAMINE TAN-PHENYLEPH TAN CHEW TAB 30-25 MG<br />

PYRILAMINE TAN-PHENYLEPH TAN SUSP 12-9 MG/5ML<br />

pyrilamine tan-phenyleph tan susp 30-12.5 mg/5ml<br />

PYRILAMINE TAN-PHENYLEPH TAN SUSP 30-5 MG/5ML<br />

pyrilamine tan-phenyleph tan susp 30-5 mg/5ml<br />

pyrilamine tan-phenyleph tan tab 60-25 mg<br />

PYRILAMINE-PHENYLEPHRINE TAB 30-10 MG OTC<br />

PYRLEX PD SUS 12-9MG<br />

RU-HIST-D TAB 30-10MG OTC<br />

ry-t-12 sus 30-5/5ml<br />

RYNA-12 S SUS<br />

rynesa 12s sus<br />

tana r-12 sus 30-5/5ml<br />

tanavan sus 30-12.5<br />

V-TANN CHW 30-25MG<br />

v-tann b.i.d sus 30-12.5<br />

VIRAVAN-P SUS 15-15MG<br />

VIRAVAN-T CHW 30-25MG<br />

Phenothiazine Derivatives<br />

phenadoz sup 12.5mg<br />

phenadoz sup 25mg<br />

prometh vc syp 6.25-5/5<br />

prometh vc syp plain<br />

prometh/pe syp 6.25-5/5<br />

promethazine & phenylephrine syrup 6.25-5 mg/5ml<br />

promethazine hcl inj 25 mg/ml<br />

promethazine hcl inj 50 mg/ml<br />

promethazine hcl suppos 12.5 mg<br />

promethazine hcl suppos 25 mg<br />

PROMETHAZINE HCL SUPPOS 25 MG<br />

promethazine hcl suppos 50 mg<br />

promethazine hcl syrup 6.25 mg/5ml<br />

promethazine hcl tab 12.5 mg<br />

promethazine hcl tab 25 mg<br />

promethazine hcl tab 50 mg<br />

promethazine inj 25mg/ml<br />

promethazine inj 50mg/ml<br />

promethazine sol 6.25/5ml<br />

promethazine sup 12.5mg<br />

PROMETHAZINE SUP 25MG<br />

promethazine sup 25mg<br />

promethazine sup 50mg<br />

promethazine syp 6.25/5ml<br />

promethazine tab 12.5mg<br />

promethazine tab 25mg<br />

promethazine tab 50mg<br />

promethegan sup 12.5mg<br />

promethegan sup 25mg<br />

promethegan sup 50mg<br />

Proplamine Derivatives<br />

*CHLORPHEN-PSE CAP SR 12HR 8-120 MG & HOMEOPATH LOZ KIT***<br />

*CPM-PE-METHSCOP SOLN 2-10-1.25 MG/5ML & HOMEOPATH LOZ KIT**<br />

12 hr ah/dec tab 6-120 cr OTC<br />

12 hr nasal tab 6-120 cr OTC<br />

40pse/4brm tab 40-4mg OTC<br />

A-PHEDRIN CAP 2.5-60MG OTC<br />

a.r.m. tab caplet OTC<br />

ACCUHIST DRO 1-2.5MG<br />

actanol tab 2.5-60mg OTC<br />

actifed cold tab /sinus OTC<br />

ACTIFED PLUS TAB OTC<br />

actified cld tab /allergy OTC<br />

active syp 1.25-30 OTC<br />

ADVIL ALLERG TAB SINUS OTC<br />

ADVIL COLD TAB MULTI-SY OTC<br />

aerohist plu tab 8-20-2.5<br />

AEROKID SYP<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 4


af-aphedrid tab 2.5-60mg OTC<br />

af-dibromm elx 1-15/5ml OTC<br />

af-effer tab cold OTC<br />

ah-chew chw<br />

AH-CHEW CHW ULTRA<br />

AH-CHEW SUS<br />

AH-CHEW SUS ULTRA<br />

AH-CHEW II CHW<br />

ALA-HIST D TAB 6-25-20<br />

ALA-HIST PE TAB 2-10MG OTC<br />

ALACOL DRO 0.4-1MG<br />

ALACOL SYP 2-5MG<br />

ALENAZE-D LIQ<br />

alenaze-d nr liq<br />

ALKA-SELTZER TAB PLS COLD OTC<br />

allantan sus pedi<br />

allepak tab dose pac<br />

aller-time tab 2.5-60mg OTC<br />

allerfed tab 2.5-60mg OTC<br />

allerfrim syp 1.25-30 OTC<br />

allerfrim tab 2.5-60mg OTC<br />

allergy tab am/pm<br />

allergy tab multi-sy OTC<br />

allergy tab sinus-d OTC<br />

allergy dn mis<br />

allergy dn tab<br />

allergy mult pak day/nght OTC<br />

allergy mult tab daytime OTC<br />

allergy/sinu tab max str OTC<br />

allergy/sinu tab non-asa OTC<br />

allergy/sinu tab non-asa OTC<br />

ALLERSCRIPT MIS TABLETS<br />

ALLERTAN SUS<br />

ALLERX MIS<br />

ALLERX SUS<br />

ALLERX PE MIS<br />

altafed syp 1.25-30 OTC<br />

ambi 10peh/ tab 4cpm OTC<br />

ambi 60pse/ tab 4cpm OTC<br />

amdry-c tab<br />

AMERIFED LIQ 4-80MG/5<br />

andehist nr syp 4-45mg/m<br />

antihis/dec tab 2.5-60mg OTC<br />

antihist nas tab deconges OTC<br />

antihistabs tab 2.5-60mg OTC<br />

ANTIHISTAMIN TAB 2.5-30MG OTC<br />

apap allergy tab sinus OTC<br />

aphedrid tab 2.5-60mg OTC<br />

aprodine syp 1.25-30 OTC<br />

aprodine tab 2.5-60mg OTC<br />

b-vex d sus<br />

b-vex pd sus<br />

bellahist-d tab la<br />

bidhist-d tab 6-45mg<br />

biofed-pe syp 1.25-30 OTC<br />

bl triacting syp cold/all OTC<br />

blanex-a tab 4-40-20<br />

bpm pe liq<br />

bpm pseudo tab 6-45mg<br />

BPM-PSE TBCR 6-45 MG & CPM-PE-METHSCOP TBCR 8-25-2.5 MG PACK<br />

bpm/pse cap 6-60mgcr<br />

BROFED ELX 4-30/5<br />

brom/pe tann sus 4-5mg<br />

bromaline sol 1-15/5ml OTC<br />

bromaphedrin sus d<br />

bromax d tab<br />

bromaxefed syp rf<br />

bromdec syp 4-45/5ml<br />

BROMFED SYP 2-30/5 OTC<br />

BROMFED TAB 4-60MG<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 5


omfenex cap 12-120cr<br />

bromfenex pd cap 6-60mgcr<br />

bromfenex pe cap 12-15mg<br />

bromfenex pe cap pedi<br />

bromhist dro ped<br />

bromhist-nr dro<br />

bromphen tan-phenyleph tan chew tab 2.2-1.58 mg (base equiv)<br />

BROMPHEN TAN-PHENYLEPH TAN SUSP 2.2-1.58 MG/5ML (BASE EQUIV)<br />

BROMPHEN-DIPHENHYDRAMINE-PHENYLEPH TAB SR 12HR 6-25-20 MG<br />

bromphen-pse dro 1-7.5mg<br />

bromphen/pe sus tann<br />

bromphen/pse cap 9-90mg<br />

brompheniram sus phenyl<br />

brompheniram syp pse<br />

brompheniramine & phenylephrine cap sr 12hr 12-15 mg<br />

brompheniramine & phenylephrine cap sr 12hr 6-7.5 mg<br />

BROMPHENIRAMINE & PHENYLEPHRINE CHEW TAB 1-2.5 MG OTC<br />

BROMPHENIRAMINE & PHENYLEPHRINE CHEW TAB 6-15 MG<br />

BROMPHENIRAMINE & PHENYLEPHRINE DROPS 0.4-1 MG/ML<br />

brompheniramine & phenylephrine elixir 1-2.5 mg/5ml OTC<br />

BROMPHENIRAMINE & PHENYLEPHRINE ELIXIR 2-5 MG/5ML<br />

BROMPHENIRAMINE & PHENYLEPHRINE LIQD 2-5 MG/ML OTC<br />

BROMPHENIRAMINE & PHENYLEPHRINE LIQD 2-7.5 MG/5ML<br />

BROMPHENIRAMINE & PHENYLEPHRINE LIQD 4-10 MG/5ML<br />

brompheniramine & phenylephrine liqd 4-7.5 mg/5ml<br />

brompheniramine & phenylephrine susp 6-10 mg/5ml<br />

BROMPHENIRAMINE & PHENYLEPHRINE SYRUP 2-5 MG/5ML<br />

BROMPHENIRAMINE & PHENYLEPHRINE TAB 4-10 MG OTC<br />

brompheniramine & phenylephrine tab sr 12hr 6-19 mg<br />

brompheniramine & phenylephrine tab sr 12hr 6-30 mg<br />

brompheniramine & pseudoephedrine cap cr 12-120 mg<br />

BROMPHENIRAMINE & PSEUDOEPHEDRINE CAP CR 5.75-60 MG<br />

brompheniramine & pseudoephedrine cap cr 6-60 mg<br />

BROMPHENIRAMINE & PSEUDOEPHEDRINE CAP SR 12HR 10-120 MG<br />

brompheniramine & pseudoephedrine cap sr 12hr 10-120 mg<br />

brompheniramine & pseudoephedrine cap sr 12hr 9-90 mg<br />

BROMPHENIRAMINE & PSEUDOEPHEDRINE CAP SR 24HR 12-90 MG<br />

brompheniramine & pseudoephedrine elixir 1-15 mg/5ml OTC<br />

BROMPHENIRAMINE & PSEUDOEPHEDRINE ELIXIR 4-30 MG/5ML<br />

brompheniramine & pseudoephedrine liquid 1-12.5 mg/ml<br />

brompheniramine & pseudoephedrine liquid 1-15 mg/ml OTC<br />

brompheniramine & pseudoephedrine liquid 1-15 mg/ml<br />

BROMPHENIRAMINE & PSEUDOEPHEDRINE LIQUID 1-7.5 MG/ML<br />

brompheniramine & pseudoephedrine liquid 1-7.5 mg/ml<br />

BROMPHENIRAMINE & PSEUDOEPHEDRINE LIQUID 4-20 MG/5ML<br />

brompheniramine & pseudoephedrine liquid 4-60 mg/5ml<br />

BROMPHENIRAMINE & PSEUDOEPHEDRINE SYRUP 2-30 MG/5ML OTC<br />

brompheniramine & pseudoephedrine syrup 4-45 mg/5ml<br />

brompheniramine & pseudoephedrine syrup 4-45 mg/5ml<br />

brompheniramine & pseudoephedrine tab 4-40 mg OTC<br />

BROMPHENIRAMINE & PSEUDOEPHEDRINE TAB 4-60 MG<br />

BROMPHENIRAMINE & PSEUDOEPHEDRINE TAB SR 12HR 10-120 MG<br />

brompheniramine & pseudoephedrine tab sr 12hr 6-45 mg<br />

BROMPHENIRAMINE MAL-PHENYLEPHRINE HCL TANN CHEW TAB 6-15 MG<br />

BROMPHENIRAMINE TAN-PHENYLEPHRINE TAN SUSP 12-10 MG/5ML<br />

brompheniramine tan-phenylephrine tan susp 12-20 mg/5ml<br />

brompheniramine tan-phenylephrine tan susp 4-5 mg/5ml<br />

BROMPHENIRAMINE TAN-PHENYLEPHRINE TAN SUSP 5-5 MG/5ML<br />

BROMPHENIRAMINE TAN-PSEUDOEPHEDRINE TAN SUSP 6-30 MG/5ML<br />

brompheniramine tan-pseudoephedrine tan susp 6-30 mg/5ml<br />

BROMPHENIRAMINE TAN-PSEUDOEPHEDRINE TAN SUSP 8-90 MG/5ML<br />

BROMPHENIRAMINE-PSE W/ APAP LIQUID 4-60-1000 MG/30ML OTC<br />

BROMPHENIRAMINE-PSE W/ APAP SUSP 1-15-160 MG/5ML OTC<br />

BROMPHENIRAMINE-PSE W/ APAP TAB 2-30-500 MG OTC<br />

bromtapp col elx 1-15/5ml OTC<br />

brotapp liq OTC<br />

BROVEX ADT SUS 12-10<br />

BROVEX PB TAB 4-10MG OTC<br />

BROVEX PD SUS<br />

BROVEX PEB LIQ<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 6


BROVEX PSB LIQ<br />

C-HIST SR CAP<br />

c-phed tanna sus 4.5-75/5<br />

c-phen dro<br />

c-phen syp<br />

c-tan d sus 4-5mg<br />

C-TAN D PLUS SUS<br />

cardec dro<br />

cardec syp 4-12.5mg<br />

cardec syp 4-45mg/5<br />

CENHIST CHW 6-15MG<br />

centergy dro 1-2mg/ml<br />

ceron dro<br />

ceron syp<br />

child pain liq rel cold OTC<br />

child pain liq rel cold OTC<br />

CHILDRENS CHW CLD/PAIN OTC<br />

chlor-mes tab<br />

chlor-mes d syp liquid<br />

chlor-mes jr cap 4-20mg<br />

chlor-tan sus a 12<br />

chlor-trimet tab 4-60mg OTC<br />

chlorex-a tab 4-40-20<br />

chlorex-a 12 sus<br />

CHLORPHEN MAL-PE HCL-METHSCOP NIT TAN SUSP 2-10-1.5 MG/5ML<br />

CHLORPHEN POLACRILEX-PSEUDOEPH POLISTIREX CHEW TAB 4-30 MG<br />

CHLORPHEN TAB 4 MG & PSEUDOEPHED TAB 60 MG THERAPY PACK<br />

CHLORPHEN TAN & PHENYLEPH TAN CHEW TAB 4.5-5 MG<br />

CHLORPHEN TAN & PHENYLEPH TAN TAB 8-25 MG<br />

chlorphen tan & phenyleph tan tab 9-25 mg<br />

chlorphen tan & pseudoeph tan susp 4.5-75 mg/5ml<br />

CHLORPHEN TAN & PSEUDOEPH TAN SUSP 5-75 MG/5ML<br />

CHLORPHEN TAN-PE TAN-METHSCOPOLAMINE CHEW TAB 2-10-1.5 MG<br />

chlorphen tan-pe tan-methscopolamine susp 2-10-1.5 mg/5ml<br />

CHLORPHEN TAN-PE TAN-METHSCOPOLAMINE SUSP 2-10-1.5 MG/5ML<br />

chlorphen tan-pyrilamine tan-pe tan susp 2-12.5-5 mg/5ml<br />

CHLORPHEN TAN-PYRILAMINE TAN-PE TAN SUSP 8-12.5-15 MG/5ML<br />

chlorphen tan-pyrilamine tan-pe tan susp 8-12.5-15 mg/5ml<br />

chlorphen-pe-apap tab & diphenhyd-pe-apap tab day/night pack OTC<br />

chlorphen-pe-apap tab 2-5-325 mg & pe-apap tab 5-325 mg pack OTC<br />

CHLORPHEN-PE-APAP TAB 2-5-500 MG & PE-APAP TAB 5-500 MG PACK OTC<br />

chlorphen-pe-atropine-hyos-scopol tab sr 12hr 8-20 mg<br />

CHLORPHEN-PE-METHSCOPOLAMINE CAP SR 12HR 8-20-2.5 MG<br />

chlorphen-pe-methscopolamine syrup 2-10-0.625 mg/5ml<br />

CHLORPHEN-PE-METHSCOPOLAMINE TAB 4-10-1.25 MG<br />

CHLORPHEN-PE-METHSCOPOLAMINE TAB CR 8-20-2.5 MG<br />

chlorphen-pe-methscopolamine tab cr 8-20-2.5 mg<br />

CHLORPHEN-PE-METHSCOPOLAMINE TAB SR 12HR 12-20-2.5 MG<br />

chlorphen-pe-methscopolamine tab sr 12hr 12-20-2.5 mg<br />

CHLORPHEN-PE-METHSCOPOLAMINE TAB SR 12HR 12-40-1.25 MG<br />

CHLORPHEN-PE-METHSCOPOLAMINE TAB SR 12HR 12-40-2 MG<br />

chlorphen-pe-methscopolamine tab sr 12hr 4-10-1.25 mg<br />

chlorphen-pe-methscopolamine tab sr 12hr 8-20-1.25 mg<br />

chlorphen-pe-methscopolamine tab sr 12hr 8-20-2.5 mg<br />

CHLORPHEN-PE-METHSCOPOLAMINE TAB SR 12HR 8-25-2.5 MG<br />

CHLORPHEN-PE-METHSCOPOLAMINE TAB SR 12HR 8-40-2.5 MG<br />

chlorphen-pe-methscopolamine tab sr 12hr 8-40-2.5 mg<br />

chlorphen-phenylephrine w/ apap effer tab 2-5-250 mg OTC<br />

CHLORPHEN-PHENYLEPHRINE W/ APAP PACKET 4-10-650 MG OTC<br />

CHLORPHEN-PHENYLEPHRINE W/ APAP SUSP 1-2.5-160 MG/5ML OTC<br />

CHLORPHEN-PHENYLEPHRINE W/ APAP TAB 2-5-162 MG OTC<br />

chlorphen-phenylephrine w/ apap tab 2-5-325 mg OTC<br />

CHLORPHEN-PHENYLEPHRINE W/ APAP TAB 2-5-500 MG OTC<br />

chlorphen-phenylephrine w/ apap tab 2-5-500 mg OTC<br />

chlorphen-phenylephrine w/ apap tab 4-10-650 mg OTC<br />

CHLORPHEN-PHENYLEPHRINE W/ APAP TAB CR 8-40-500 MG<br />

CHLORPHEN-PSE & BELLADONNA ALK TAB SR 12HR 8-90-0.24 MG<br />

CHLORPHEN-PSE & METHSCOPOLAMINE SYRUP 4-30-1.25 MG/5ML<br />

CHLORPHEN-PSE & METHSCOPOLAMINE TAB SR 12HR 4-60-1.25 MG<br />

chlorphen-pse & methscopolamine tab sr 12hr 8-120-2.5 mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 7


chlorphen-pse & methscopolamine tab sr 12hr 8-60-1.25 mg<br />

chlorphen-pse & methscopolamine tab sr 12hr 8-90-2.5 mg<br />

CHLORPHEN-PSE & METHSCOPOLAMINE TAB SR 24HR 6-120-2.5 MG<br />

chlorphen-pse-atropine-hyos-scopol tab sr 12hr 8-90 mg<br />

CHLORPHEN-PSEUDOEPHED-ASPIRIN EFFER TAB 2-30-325 MG OTC<br />

chlorphen-pseudoephedrine w/ apap cap 2-30-325 mg OTC<br />

CHLORPHEN-PSEUDOEPHEDRINE W/ APAP CHEW TAB 0.5-7.5-80 MG OTC<br />

chlorphen-pseudoephedrine w/ apap chew tab 0.5-7.5-80 mg OTC<br />

chlorphen-pseudoephedrine w/ apap liquid 1-15-160 mg/5ml OTC<br />

CHLORPHEN-PSEUDOEPHEDRINE W/ APAP LIQUID 4-60-1000 MG/30ML OTC<br />

CHLORPHEN-PSEUDOEPHEDRINE W/ APAP PACK 4-60-1000 MG OTC<br />

CHLORPHEN-PSEUDOEPHEDRINE W/ APAP PACK 4-60-500 MG OTC<br />

chlorphen-pseudoephedrine w/ apap pack 4-60-650 mg OTC<br />

chlorphen-pseudoephedrine w/ apap tab 2-30-325 mg OTC<br />

chlorphen-pseudoephedrine w/ apap tab 2-30-500 mg OTC<br />

CHLORPHEN-PSEUDOEPHEDRINE W/ APAP TAB 4-60-650 MG OTC<br />

chlorphen-pseudoephedrine w/ apap tab 4-60-650 mg OTC<br />

CHLORPHEN-PTOLOX-PHENYLEPH CAP SR 12HR 4-50-20 MG<br />

chlorphen-ptolox-phenyleph liquid 2.5-7.5-5 mg/5ml<br />

CHLORPHEN-PTOLOX-PHENYLEPH TAB 2-25-10 MG<br />

chlorphen-ptolox-phenyleph tab cr 4-40-20 mg<br />

chlorphen-pyrilamine & pe liqd 2-10-10 mg/5ml<br />

chlorphen-pyrilamine & pe liqd 2-12.5-7.5 mg/5ml<br />

CHLORPHEN-PYRILAMINE & PE TAB 2-10-10 MG<br />

chlorphen-pyrilamine & pe tab cr 4-25-10 mg<br />

CHLORPHENIR MAL-PSEUDOEPHEDRINE HCL TANNATE CHEW TAB 4-30 MG<br />

chlorpheniramine & phenylephrine cap sr 12hr 4-20 mg<br />

chlorpheniramine & phenylephrine liquid 1-2 mg/ml<br />

CHLORPHENIRAMINE & PHENYLEPHRINE LIQUID 1-2.5 MG/5ML OTC<br />

CHLORPHENIRAMINE & PHENYLEPHRINE LIQUID 1-2.5 MG/ML<br />

chlorpheniramine & phenylephrine liquid 1-3.5 mg/ml<br />

CHLORPHENIRAMINE & PHENYLEPHRINE LIQUID 4-10 MG/5ML<br />

CHLORPHENIRAMINE & PHENYLEPHRINE SOLN 4-12.5 MG/5ML OTC<br />

CHLORPHENIRAMINE & PHENYLEPHRINE SYRUP 1-2.5 MG/5ML OTC<br />

chlorpheniramine & phenylephrine syrup 4-12.5 mg/5ml<br />

chlorpheniramine & phenylephrine tab 4-10 mg OTC<br />

chlorpheniramine & phenylephrine tab cr 8-20 mg<br />

chlorpheniramine & phenylephrine tab sr 12hr 4-20 mg<br />

CHLORPHENIRAMINE & PHENYLEPHRINE TAB SR 12HR 4-20 MG<br />

chlorpheniramine & pseudoephedrine cap cr 8-120 mg<br />

CHLORPHENIRAMINE & PSEUDOEPHEDRINE CAP SR 12HR 12-120 MG<br />

chlorpheniramine & pseudoephedrine cap sr 12hr 12-120 mg<br />

CHLORPHENIRAMINE & PSEUDOEPHEDRINE CAP SR 12HR 4-60 MG<br />

chlorpheniramine & pseudoephedrine cap sr 12hr 4-60 mg<br />

chlorpheniramine & pseudoephedrine cap sr 24hr 12-100 mg<br />

CHLORPHENIRAMINE & PSEUDOEPHEDRINE CAP SR 24HR 12-100 MG<br />

CHLORPHENIRAMINE & PSEUDOEPHEDRINE CHEW TAB 1-15 MG OTC<br />

chlorpheniramine & pseudoephedrine chew tab 2-15 mg<br />

chlorpheniramine & pseudoephedrine drops 0.8-9 mg/ml OTC<br />

chlorpheniramine & pseudoephedrine drops 0.8-9 mg/ml<br />

chlorpheniramine & pseudoephedrine liquid 2-30 mg/5ml<br />

CHLORPHENIRAMINE & PSEUDOEPHEDRINE LIQUID 4-80 MG/5ML<br />

chlorpheniramine & pseudoephedrine soln 2-30 mg/5ml OTC<br />

chlorpheniramine & pseudoephedrine syrup 1-15 mg/5ml OTC<br />

CHLORPHENIRAMINE & PSEUDOEPHEDRINE SYRUP 2-30 MG/5ML<br />

chlorpheniramine & pseudoephedrine syrup 2-30 mg/5ml<br />

chlorpheniramine & pseudoephedrine tab 4-60 mg OTC<br />

CHLORPHENIRAMINE & PSEUDOEPHEDRINE TAB SR 12HR 12-120 MG<br />

chlorpheniramine & pseudoephedrine tab sr 12hr 12-120 mg<br />

CHLORPHENIRAMINE TAN-PHENYLEPHRINE TAN SUSP 2-6 MG/ML<br />

chlorpheniramine tan-phenylephrine tan susp 2-6 mg/ml<br />

CHLORPHENIRAMINE TAN-PHENYLEPHRINE TAN SUSP 3-7.5 MG/5ML<br />

CHLORPHENIRAMINE TAN-PHENYLEPHRINE TAN SUSP 4-20 MG/5ML<br />

chlorpheniramine tan-phenylephrine tan susp 4-20 mg/5ml<br />

CHLORPHENIRAMINE TAN-PHENYLEPHRINE TAN SUSP 4-5 MG/5ML<br />

chlorpheniramine tan-phenylephrine tan susp 4.5-5 mg/5ml<br />

chlorpheniramine tan-phenylephrine tan susp 8-10 mg/5ml<br />

chlorpheniramine w/ apap tab 2-325 mg OTC<br />

chlorpheniramine-pe-methscopolamine chew tab 2-10-1.25 mg<br />

CHLORPHENIRAMINE-PE-METHSCOPOLAMINE CHEW TAB 2-15-1.25 MG<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 8


CHLORPHENIRAMINE-PE-METHSCOPOLAMINE SOLN 2-10-1.25 MG/5ML<br />

CHLORPHENIRAMINE-PE-METHSCOPOLAMINE SYRUP 2-10-0.75 MG/5ML<br />

chlorpheniramine-pe-methscopolamine syrup 2-10-0.75 mg/5ml<br />

chlorpheniramine-pe-methscopolamine syrup 2-10-1.25 mg/5ml<br />

chlorpheniramine-pe-methscopolamine syrup 2-10-1.25 mg/5ml<br />

chlorpheniramine-pe-methscopolamine syrup 2-8-0.75 mg/5ml<br />

CHLORPHENIRAMINE-PE-METHSCOPOLAMINE SYRUP 4-10-1.25 MG/5ML<br />

chlorpheniramine-pe-methscopolamine syrup 4-10-1.25 mg/5ml<br />

CHLORPHENIRAMINE-PHENYLEPHRINE-ASA EFFER TAB 2-7.8-325 MG OTC<br />

CHLORPHENIRAMINE-PSEUDOEPHEDRINE-IBUPROFEN TAB 2-30-200 MG OTC<br />

chlorphn mal dro pse hcl<br />

chlortan d sus<br />

CNTC CLD/FLU PAK DAY/NGHT OTC<br />

CNTC CLD/FLU TAB MAX ST OTC<br />

cold medicin cap plus OTC<br />

cold multi- tab symptom OTC<br />

cold relief tab eff OTC<br />

cold relief tab plus OTC<br />

cold relief tab plus OTC<br />

cold relieve tab original OTC<br />

cold&allergy tab relief OTC<br />

cold/allergy elx OTC<br />

cold/allergy elx OTC<br />

cold/allergy elx OTC<br />

cold/allergy elx 1-15/5ml OTC<br />

cold/allergy elx children OTC<br />

cold/allergy elx children OTC<br />

cold/allergy elx children OTC<br />

cold/allergy elx children OTC<br />

cold/allergy elx children OTC<br />

cold/allergy elx childs OTC<br />

cold/allergy elx dibromm OTC<br />

cold/allergy elx relief OTC<br />

cold/allergy tab OTC<br />

cold/allergy tab 2.5-60mg OTC<br />

cold/allergy tab 2.5-60mg OTC<br />

cold/allergy tab 2.5-60mg OTC<br />

cold/allergy tab 4-10mg OTC<br />

cold/allergy tab 4-10mg OTC<br />

cold/allergy tab max str OTC<br />

cold/allergy tab pe OTC<br />

cold/allergy tab relief OTC<br />

coldamine tab 8-90-2.5<br />

coldex-a sr tab 4-40-20<br />

colfed-a cap 8-120 cr<br />

COMHIST TAB<br />

COMPLETE SIN TAB RELIEF OTC<br />

comtrex pak cld/sinu OTC<br />

COMTREX TAB HEAD CLD OTC<br />

COMTREX D/NT MIS FLU THER OTC<br />

comtrex flu pak therapy OTC<br />

COMTREX NT LIQ FLU THER OTC<br />

COMTREX NT LIQ HEAD CLD OTC<br />

comtrex sev pak cld/sinu OTC<br />

comtrex sinu tab & nasal OTC<br />

conal sus<br />

CONEX SOL CLD/ALRG OTC<br />

CONEX TAB 2-60MG OTC<br />

congestant tab OTC<br />

COPHENE #2 CAP CR<br />

coricidin d tab OTC<br />

coricidin d tab OTC<br />

coryza-d tab<br />

cough/cold liq sf OTC<br />

cp dec dro<br />

cp dec syp 4-12.5mg<br />

cpm 8/pe 20/ tab msc 1.25<br />

CPM TAN-PE TAN-METHSCOP CHEW & CPM TAN- METHSCOP CHEW PACK<br />

cpm-meth-pse tab<br />

cpm-pe-msc syp<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 9


cpm/pe cap 4-20mg<br />

cpm/pe tab 4-20mg<br />

cpm/pe tab 8-20 cr<br />

cpm/pse cap 8-120 cr<br />

cpm/pse cap 8-120 sr<br />

cpm/pse dro 0.8-9mg OTC<br />

CPM/PSE SYP<br />

cpm/pse tab 12-120mg<br />

cpm/pse/msc tab<br />

cpm/pse/msc tab 12hr<br />

cpm/ptolox/ liq pe<br />

cvs children liq cold OTC<br />

cvs cld/alle elx children OTC<br />

d-amine-sr cap 8-120 cr<br />

d-hist d tab<br />

DALLERGY TAB<br />

DALLERGY TAB ER<br />

DALLERGY PE SYP<br />

DALLERGY PSE TAB<br />

DALLERGY-JR SUS<br />

dec-chlorphn liq<br />

dec-chlorphn syp<br />

DECON-A ELX 2-5MG/5M<br />

DECON-A LIQ DROPS OTC<br />

decon/antihi tab 60-2.5mg OTC<br />

decongestant tab OTC<br />

decongestant tab 4-60mg OTC<br />

decongestant tab cold OTC<br />

decongestant tab plus OTC<br />

decongestant tab plus OTC<br />

decongestine cap 8-120 tr<br />

DECONSAL CT CHW 16-10MG<br />

dehistine syp<br />

denaze syp<br />

dexaphen sa tab 6-120<br />

DEXBROMPHEN TAN-PYRILAMINE MAL-PE TAN SUSP 4-3.5-25 MG/5ML<br />

dexbromphen-pse w/ apap tab 2-60-500 mg OTC<br />

DEXBROMPHEN-PSE W/ APAP TAB CR 3-60-500 MG OTC<br />

DEXBROMPHENIRAMINE & PSEUDOEPHEDRINE SOLN 1-30 MG/5ML OTC<br />

DEXBROMPHENIRAMINE & PSEUDOEPHEDRINE TAB 2-60 MG OTC<br />

dexbrompheniramine & pseudoephedrine tab sr 12hr 6-120 mg<br />

dexbrompheniramine & pseudoephedrine tab sr 12hr 6-120 mg OTC<br />

DEXBROMPHENIRAMINE-PHENYLEPHRINE TAB 2-10 MG OTC<br />

DEXBROMPHENIRAMINE-PHENYLEPHRINE-APAP TAB 2-10-500 MG OTC<br />

DEXBROMPHENIRAMINE-PHENYLEPHRINE-APAP TAB 2-10-650 MG OTC<br />

DEXCHLORPHEN TAN & PSEUDOEPHED TAN SUSP 2.5-75 MG/5ML<br />

DEXCHLORPHEN TAN & PSEUDOEPHED TAN SUSP 3-50 MG/5ML<br />

DEXCHLORPHEN TAN-PYRIL TAN-PSE TAN SUSP 2.5-12.5-75 MG/5ML<br />

dexchlorphen-phenyleph-methscop soln 1-10-1.25 mg/5ml<br />

DEXCHLORPHEN-PHENYLEPH-METHSCOP SOLN 1-10-1.25 MG/5ML<br />

dexchlorphen-pseudoephed-methscop tab sr 12hr 3.5-45-1 mg<br />

DEXCHLORPHENIRAMINE & PSEUDOEPHEDRINE TAB CR 4-60 MG<br />

DEXCHLORPHENIRAMINE-PHENYLEPHRINE TAB 2-10 MG OTC<br />

DEXCHLORPHENIRAMINE-PHENYLEPHRINE TAB SR 12HR 3-20 MG<br />

DEXCHLORPHENIRAMINE-PHENYLEPHRINE TAB SR 12HR 3.5-18.5 MG<br />

DEXCHLORPHENIRAMINE-PHENYLEPHRINE TAB SR 12HR 6-40 MG<br />

DEXCHLORPHENIRAMINE-PSEUDOEPHED-APAP TAB 2-45-650 MG<br />

dexphen m sol<br />

di brom c/a elx cld/alle OTC<br />

DICEL SUS<br />

dimaphen elx OTC<br />

dimaphen elx children OTC<br />

DIMETAPP SUS COLD/FVR OTC<br />

DIMETAPP CLD CHW /ALLERGY OTC<br />

disophrol tab 6-120 cr OTC<br />

dixaphedrine tab 6-120 cr OTC<br />

drihist tab sr<br />

DRINEX TAB OTC<br />

drinex tab OTC<br />

dristan cold tab OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 10


drixomed tab 6-120 cr<br />

DRIXORAL TAB ALLERGY OTC<br />

DRIXORAL TAB COLD/FLU OTC<br />

DRYMAX SYP<br />

dryphen tab OTC<br />

drysec tab cr<br />

DUOTAN PD SUS<br />

duradryl chw<br />

duradryl syp<br />

duradryl sr tab<br />

duratan pe sus<br />

duratuss da cap 12-100mg<br />

duravent chw<br />

duravent-da tab<br />

DYNAHIST ER CAP 4-60MG<br />

eck non-asa tab allergy OTC<br />

eck sinus tab OTC<br />

ED A-HIST LIQ 4-10/5ML<br />

ed a-hist tab 8-20 cr<br />

ED CHLORPED SUS D<br />

effer antaci tab pain OTC<br />

EFFERVESCENT TAB COLD REL OTC<br />

effervescent tab plus cld OTC<br />

entre-b sus 6-10mg/5<br />

eq allergy tab sinus OTC<br />

eq childrens liq cold OTC<br />

eq cold plus cap OTC<br />

eq effervesc tab cld plus OTC<br />

eq triacting syp cold/all OTC<br />

eql allergy tab multi-sy OTC<br />

eql efferves tab plus cld OTC<br />

eql sinus tab allergy OTC<br />

eql triactin syp cold/all OTC<br />

EXTENDRYL SYP<br />

EXTENDRYL SR CAP<br />

extendryl sr tab<br />

FLU/COLD POW MEDICINE OTC<br />

flu/cold med pow OTC<br />

genac tab 2.5-60mg OTC<br />

genaphed tab plus OTC<br />

gnp allergy tab multi-sy OTC<br />

gnp allergy tab sinus pe OTC<br />

gnp cld/alle elx children OTC<br />

gnp di bromm elx childs OTC<br />

GNP FLU/COLD PAK NIGHT OTC<br />

gnp histafed syp 1.25-30 OTC<br />

gnp histafed tab 2.5-60mg OTC<br />

gnp sinus pak cng/pain OTC<br />

gnp sinus tab cng/pain OTC<br />

gnp triactin syp cold/all OTC<br />

hayfebrol sol sf OTC<br />

hca cold/flu tab medicine OTC<br />

hca complete tab sinus OTC<br />

hca sinus tab OTC<br />

hca suphedri tab plus OTC<br />

hca tri-afed tab 2.5-60mg OTC<br />

hca triactin syp cold/all OTC<br />

HEXAFED TAB 4-60MG<br />

HEXAFLU TAB 2-45-650<br />

hist-pse dro OTC<br />

hista-tabs tab 2.5-60mg OTC<br />

hista-vent tab 12hr<br />

hista-vent tab da<br />

histacol la tab<br />

histade mx tab<br />

histade sr cap 12-120mg<br />

HISTADEC SOL 4-12.5MG OTC<br />

histafed tab 2.5/60mg OTC<br />

histatab tab<br />

histatab d tab<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 11


histatab ph tab<br />

HISTEX SR CAP<br />

HISTEX SR TAB 10-120MG<br />

iso-chlor sol OTC<br />

J-TAN D SUS<br />

J-TAN D PD DRO 1-7.5MG<br />

kolephrin tab OTC<br />

kronofed-a cap 8-120 cr<br />

kronofed-a cap jr<br />

LODRANE 24D CAP 12-90MG<br />

LODRANE D SUS<br />

lodrane ld cap 6-60mgcr<br />

lohist-12d tab 6-45mg<br />

lohist-d liq<br />

lohist-lq liq<br />

lohist-pd dro ped<br />

maxichlor tab peh OTC<br />

maxichlor tab pse OTC<br />

medi-brom elx 1-15/5ml OTC<br />

medi-phedrin tab plus OTC<br />

medi-tabs tab alrg/sin OTC<br />

medicidin-d tab OTC<br />

mintex liq 2-30mg/5<br />

multi symptm tab allergy OTC<br />

myhist-pd liq<br />

NALDEX TAB<br />

nalex-a 12 sus<br />

NALFRX SUS<br />

nasal decon liq 1-15/5ml OTC<br />

nasal decon tab antihist OTC<br />

nasal decon/ liq antihist OTC<br />

nasal decong tab 2.5-60mg OTC<br />

nasal decong tab 60-2.5mg OTC<br />

nasal decong tab antihist OTC<br />

nasohist dro 1-2mg/ml<br />

neutrahist dro 0.8-9mg<br />

night time tab OTC<br />

nohist tab 8-20mg<br />

nohist-a liq<br />

nohist-pe syp<br />

nohist-plus chw<br />

nohist-plus tab jr<br />

non-asa algy tab sinus OTC<br />

non-asa cold chw child OTC<br />

non-asa sinu tab allergy OTC<br />

norel sd syp<br />

nuhist sus pedi<br />

ny-tannic tab 9-25mg<br />

omnihist tab l.a.<br />

OMNIHIST II TAB LA<br />

ONSET FORTE TAB OTC<br />

p-tann d sus<br />

pain relief tab alrg/sin OTC<br />

pain relief tab alrg/sin OTC<br />

pain relieve tab alrg/sin OTC<br />

pain relieve tab alrg/sin OTC<br />

pain relievr tab algy-sin OTC<br />

pcm chw<br />

pcm allergy tab<br />

pcm la tab<br />

pd-hist d dro<br />

pd-hist d syp 4-12.5mg<br />

PE-CPM-METHSCOP 20-8-2.5MG & CPM-METHSCOP 8-2.5MG TAB CR PK<br />

pe-cpm-scop tab 12hr<br />

PE-GG TAB 15-600 MG & CPM-PE-METHSCOP TBCR 8-25-2.5 MG PACK<br />

pe-methscop tab 40-2.5 mg & cpm-pe-methscop tab 8-10-2.5 mg<br />

PE-METHSCOP TAB 40-2.5 MG & CPM-PE-METHSCOP TAB 8-10-2.5 MG<br />

pe/bpm cap 15-12mg<br />

pe/bpm cap 7.5-6mg<br />

pe/cp tann sus 20-4/5ml<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 12


pe/cpm sus<br />

pe/cpm sus tannate<br />

pe/phenyltol tab cpm<br />

ped tan/chlo sus<br />

pediaphyl d sus<br />

PHENA-PLUS TAB<br />

phenabid tab 12hr<br />

phenclor tan sus pedi<br />

phenir-pe w/ sod salicyl & caff cit liq 13-4-83-25 mg/5ml OTC<br />

PHENIRAMINE-PHENYLEPHRINE W/ APAP POWD PACK 20-10-325 MG OTC<br />

PHENIRAMINE-PHENYLEPHRINE W/ APAP POWD PACK 20-10-650 MG OTC<br />

phenydryl syp<br />

phenyl chlor sus tan<br />

phenyleph cm tab<br />

POLY TAN D SUS<br />

pre-hist-d tab er<br />

pro-tannate sus pedi<br />

PROTID TAB CR<br />

pse 15/cpm 2 chw<br />

pse bpm liq<br />

pse cpm chw 15-2mg<br />

PSE-APAP & CPM-PSE-APAP TAB THERAPY PK 30-500 & 2-30-500 MG OTC<br />

PSE-CPM-METHSCOP 120-8-2.5MG & CPM-METHSCOP 8-2.5MG TBCR PAK<br />

PSE-METHSCOP TAB CR & CPM-PE-METHSCOP TAB CR THERAPY PACK<br />

pse-methscopol & cpm-methscopol tab cr 120-2.5 & 8-2.5 mg<br />

pse/bpm cap 60-6mgcr<br />

pse/cpm cap 100-12mg<br />

pse/cpm cap 120-8 sa<br />

pse/cpm cap 120-8mg<br />

pse/cpm tab 12hr<br />

pse/cpm/meth tab sr<br />

pse/cpm/scop tab 12hr<br />

pse/tripol tab 60-2.5mg OTC<br />

pse/tripol tab 60-2.5mg OTC<br />

pseubrom cap 12-120cr<br />

pseubrom tr cap 12-120cr<br />

pseubrom-pd cap 6-60mgcr<br />

pseudo cm tab<br />

pseudo-plus tab 4-60mg OTC<br />

pseudo/bpm tab 45-6mg<br />

pseudoephed tab cld/alrg OTC<br />

pseudoephed tab plus OTC<br />

px allergy tab sinus pe OTC<br />

px dibromm elx cld/alrg OTC<br />

pyrichlor pe liq<br />

pyril d sus 16-5mg/5<br />

pyril mal/pe sus 16-5mg/5<br />

pyrilamine mal-phenylephrine hcl tann susp 16-5 mg/5ml<br />

PYRILAMINE MAL-PHENYLEPHRINE HCL TANNATE CHEW TAB 16-10 MG<br />

q-tapp elx 1-15/5ml OTC<br />

qc allergy tab relief OTC<br />

qc suphedrin tab cld/alrg OTC<br />

qc suphedrin tab sinus OTC<br />

QDALL CAP 12-100MG<br />

qv-allergy syp<br />

r-tanna sus pedi<br />

r-tanna tab 9-25mg<br />

r-tannamine sus ped<br />

ra acta-tabs tab 2.5-60mg OTC<br />

ra acta-tabs tab pe OTC<br />

ra allergy tab multi-sy OTC<br />

ra cld/alrgy elx 1-2.5mg OTC<br />

ra cold/flu tab OTC<br />

ra nas decon tab antihist OTC<br />

ra sinus pak cng/pain OTC<br />

ra sinus tab OTC<br />

ra sinus tab ex str OTC<br />

ra suphedrin tab 4-60mg OTC<br />

ra suphedrin tab 4-60mg OTC<br />

ralix tab<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 13


RE-DRYLEX SYP<br />

re-drylex jr tab<br />

re2+30 syp<br />

redur-pcm sus<br />

RELCOF DN MIS PSE<br />

RELCOF DN PE MIS<br />

RELCOF PE TAB<br />

relcof pse tab<br />

relera tab<br />

RESCON TAB<br />

RESCON-JR TAB<br />

RESCON-MX TAB<br />

RESPA-A.R. TAB<br />

respahist cap 6-60mgcr<br />

rhinabid cap 12-15mg<br />

rhinabid pd cap 6-7.5mg<br />

rhinaclear tab dose pac<br />

rhinacon a liq<br />

rhinacon a tab<br />

RHINAHIST TAB<br />

RICOBID SUS<br />

RICOBID TAB 8-25MG<br />

rinate sus pedi<br />

ritifed syp 1.25-30 OTC<br />

robitussin tab cold/cng OTC<br />

rondex dro<br />

rondex syp<br />

ru-hist tab forte<br />

ru-tuss tab<br />

ry-tann tab 9-25mg<br />

RYMED TAB 2-10MG OTC<br />

RYNATAN PEDI CHW 4.5-5MG<br />

sb allergy tab multi-sy OTC<br />

sb antihist tab 2.5-60mg OTC<br />

sb cld/alrgy elx children OTC<br />

sb cold/flu tab hbp OTC<br />

sb pseudoeph tab plus OTC<br />

sb sinus cng pak /pain OTC<br />

sb sinus cng tab /pain OTC<br />

scopohist syp<br />

scopohist tab<br />

scopohist-pe tab<br />

seradex-la tab 6-19mg<br />

sg nas decon tab antihist OTC<br />

sg su-phedri tab plus OTC<br />

silafed syp 1.25-30 OTC<br />

sildec syp 4-45/5ml<br />

sildec-pe dro<br />

sildec-pe syp<br />

SINADRIN PE TAB 2-10-650 OTC<br />

sine-off tab OTC<br />

sinuhist tab<br />

sinus tab OTC<br />

sinus tab OTC<br />

sinus tab ex st OTC<br />

sinus tab max str OTC<br />

sinus tab max-st OTC<br />

sinus congst pak /pain OTC<br />

sinus congst pak day/nght OTC<br />

sinus congst tab night OTC<br />

sinus congst tab night OTC<br />

sinus congst tab nighttim OTC<br />

sinus max tab 2-30-500 OTC<br />

sinus relief tab OTC<br />

sinus/alergy tab max st OTC<br />

sinus/alergy tab max st OTC<br />

sinus/alergy tab pe max OTC<br />

sinus/alergy tab pe max OTC<br />

sinus/allerg tab 4-10mg OTC<br />

sinus/allerg tab max st OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 14


sinus/allerg tab max st OTC<br />

sinus/allerg tab pe OTC<br />

sinus/allrgy tab max st OTC<br />

sinutab m-s tab sin/alrg OTC<br />

sm allergy tab multi-sy OTC<br />

sm cld/alrgy elx children OTC<br />

sm cold tab alrgy pe OTC<br />

sm non-asa tab sin/alrg OTC<br />

soba sinus tab OTC<br />

sonahist dro 1-2mg/ml<br />

ss sinadrin tab 4-10-650 OTC<br />

suclor cap 8-120 cr<br />

sudafed pe tab 4-10mg OTC<br />

sudafed plus tab 4-60mg OTC<br />

sudafed sinu tab 2.5-60mg OTC<br />

SUDAHIST TAB 12-120MG<br />

SUDAL 12 CHW 4-30MG<br />

SUDAL 12 TAN CHW 4-30MG<br />

sudogest tab cld/alrg OTC<br />

super cold tab 4-10-650 OTC<br />

suphedrin tab plus OTC<br />

suphedrine tab cld/alrg OTC<br />

suphedrine tab cld/alrg OTC<br />

suphedrine tab pe OTC<br />

SUTAN SUS<br />

SYMPAK MIS<br />

SYMPAK II MIS<br />

SYMPAK PDX MIS<br />

tana pse sus<br />

tanabid chw 2.2-1.58<br />

tanabid da sus 4-5mg<br />

tanabid sr tab 6-30mg<br />

tanatan rf sus<br />

tanhst-d ped sus 2-6mg/ml<br />

tannate ped sus<br />

theraflu pak OTC<br />

theraflu pow flu/cold OTC<br />

THERAFLU CLD PAK /SORE TH OTC<br />

THERAFLU FLU PAK SORE THR OTC<br />

THERAFLU FLU POW /CLD/S-T OTC<br />

THERAFLU SEV PAK COLD NT OTC<br />

tibamine la tab 12-120mg<br />

TIME-HIST QD TAB<br />

TOURO ALLERG CAP CR<br />

touro allerg tab 6-45mg<br />

tri acting syp cold/all OTC<br />

tri-afed tab 2.5-60mg OTC<br />

tri-fed cold tab 2.5-60mg OTC<br />

tri-gestan s sus<br />

tri-hist ped sus<br />

tri-pseudaph tab 2.5-60mg OTC<br />

tri-tannate sus ped<br />

triacing ora syp 1-15mg/5 OTC<br />

triactin cld syp /allergy OTC<br />

triactin cld syp 1-15mg/5 OTC<br />

triacting syp cold/all OTC<br />

triall syp<br />

TRIAMINIC CHW OTC<br />

TRIAMINIC LIQ CLD/ALLR OTC<br />

TRIAMINIC SYP COLD/ALL OTC<br />

trifed tab 2.5-60mg OTC<br />

trifedrine tab 2.5-60mg OTC<br />

triotann sus ped<br />

triotann-s sus ped<br />

trip-pse liq OTC<br />

triplex ad liq<br />

TRIPOHIST D LIQ 1.25-45<br />

triprol/pse syp 1.25-30 OTC<br />

triprol/pse tab 2.5-60mg OTC<br />

TRIPROLIDINE & PSEUDOEPHEDRINE CAP 2.5-60 MG OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 15


triprolidine & pseudoephedrine liquid 0.938-10 mg/ml OTC<br />

TRIPROLIDINE & PSEUDOEPHEDRINE LIQUID 1.25-45 MG/5ML<br />

triprolidine & pseudoephedrine syrup 1.25-30 mg/5ml OTC<br />

TRIPROLIDINE & PSEUDOEPHEDRINE TAB 2.5-30 MG OTC<br />

triprolidine & pseudoephedrine tab 2.5-60 mg OTC<br />

TRIPROLIDINE TAN-PSEUDOEPHEDRINE TAN SUSP 2.5-45 MG/5ML<br />

TRIPROLIDINE-PSEUDOEPHEDRINE W/ APAP TAB 1.25-30-500 MG OTC<br />

trisofed tab 2.5-60mg OTC<br />

tylenol alle tab multi rr OTC<br />

tylenol alle tab multi-sy OTC<br />

TYLENOL CHLD SUS PLUS CLD OTC<br />

tylenol sinu tab cng/pain OTC<br />

ultrabrom cap 12-120cr<br />

ultrabrom pd cap 6-60mgcr<br />

uni-hist dro<br />

uni-tex er cap 120/10<br />

v-hist sus 6-10mg/5<br />

vaso dose tab pack 10<br />

vaso dose tab pack 30<br />

VAZOTAB CHW<br />

visrx tab dose pac<br />

wal-act tab 2.5-60mg OTC<br />

wal-finate d tab OTC<br />

WAL-FLU SVR PAK COLD NT OTC<br />

wal-phed tab 4-60mg OTC<br />

wal-phed pe tab 4-10mg OTC<br />

wal-tap elx children OTC<br />

wal-tap elx cld/alle OTC<br />

we allergy syp<br />

west-decon m tab 4-40-20<br />

xiral sr tab<br />

ZINX ALLERGY KIT<br />

ZINX KIDS KIT SNEEZE<br />

zotex-pe tab 6-30mg<br />

ZYMINE DXR SUS 2.5-45MG<br />

Derivatives, Miscellaneous<br />

CHLORPHEN-PHENYLTOLOX-PE- APAP TAB SR 12HR 8-50-40-325 MG<br />

chlorphen-phenyltolox-pe- apap tab sr 12hr 8-50-40-325 mg<br />

CHLORPHEN-PYRIL TAN-PE HCL-PE TAN SUSP 2-10-2.5-7.5 MG/5ML<br />

cyproheptad syp 2mg/5ml<br />

cyproheptad tab 4mg<br />

cyproheptadine hcl syrup 2 mg/5ml<br />

cyproheptadine hcl tab 4 mg<br />

NOREL SR TAB<br />

PHENA-S 12 SUS<br />

trital sr tab<br />

Second Generation <strong>Antihistamine</strong>s<br />

ACRIVASTINE & PSEUDOEPHEDRINE CAP 8-60 MG<br />

alavert syp OTC<br />

alavert tab 10mg OTC<br />

all day allg tab 10mg OTC<br />

ALLEGRA-D TAB 24 HOUR<br />

allerclear tab 10mg OTC<br />

allergy tab 10mg OTC<br />

allergy relf syp 5mg/5ml OTC<br />

allergy relf syp child OTC<br />

allergy relf tab 10mg OTC<br />

cetirizine tab 10mg OTC<br />

cetirizine tab 5mg OTC<br />

cetirizine hcl tab 10 mg OTC<br />

cetirizine hcl tab 5 mg OTC<br />

CLARINEX TAB 5MG PA<br />

CLARINEX-D TAB 2.5-120<br />

CLARINEX-D TAB 5-240MG<br />

CLARITIN CHW 5MG OTC<br />

claritin syp 5mg/5ml OTC<br />

claritin tab 10mg OTC<br />

claritin rdt tab 10mg OTC<br />

CLARITIN RDT TAB 5MG PA OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 16


clear-atadin syp 5mg/5ml OTC<br />

cvs allergy syp children OTC<br />

cvs allergy tab 10mg OTC<br />

DESLORATADINE & PSEUDOEPHEDRINE TAB SR 12HR 2.5-120 MG<br />

DESLORATADINE & PSEUDOEPHEDRINE TAB SR 24HR 5-240 MG<br />

dimetapp nd tab 10mg OTC<br />

eql all day tab allergy OTC<br />

fexofen/pse tab 60-120mg<br />

fexofenadine hcl tab 180 mg<br />

fexofenadine hcl tab 30 mg<br />

fexofenadine hcl tab 60 mg<br />

fexofenadine tab 180mg<br />

fexofenadine tab 30mg<br />

fexofenadine tab 60mg<br />

fexofenadine-pseudoephedrine tab sr 12hr 60-120 mg<br />

FEXOFENADINE-PSEUDOEPHEDRINE TAB SR 24HR 180-240 MG<br />

gnp all day tab allergy OTC<br />

loradamed tab 10mg OTC<br />

loratadine sol 5mg/5ml OTC<br />

loratadine syp 10/10ml OTC<br />

loratadine syp 5mg/5ml OTC<br />

loratadine syp allg rel OTC<br />

loratadine tab 10mg OTC<br />

loratadine tab allg rel OTC<br />

loratadine tab disinteg OTC<br />

loratadine & pseudoephedrine tab sr 12hr 5-120 mg PA OTC<br />

loratadine & pseudoephedrine tab sr 24hr 10-240 mg PA OTC<br />

LORATADINE CHEW TAB 5 MG OTC<br />

loratadine rapidly-disintegrating tab 10 mg PA OTC<br />

loratadine rapidly-disintegrating tab 10 mg OTC<br />

loratadine syrup 5 mg/5ml PA OTC<br />

loratadine syrup 5 mg/5ml OTC<br />

loratadine tab 10 mg PA OTC<br />

loratadine tab 10 mg OTC<br />

ra cetirizin tab 10mg OTC<br />

SEMPREX-D CAP 8-60MG<br />

sm loratadin syp 5mg/5ml OTC<br />

sm loratadin tab 10mg OTC<br />

tavist nd tab 10mg OTC<br />

triaminic tab OTC<br />

wal-itin syp 5mg/5ml OTC<br />

wal-itin tab 10mg OTC<br />

wal-itin tab aller-ml OTC<br />

wal-vert tab 10mg OTC<br />

wal-zyr tab 10mg OTC<br />

Anti-infective Agents<br />

Anthelmintics<br />

MEBENDAZOLE CHW 100MG<br />

mebendazole chw 100mg<br />

MEBENDAZOLE CHEW TAB 100 MG<br />

mebendazole chew tab 100 mg<br />

Antibacterials<br />

Aminoglycosides<br />

amikacin sulfate inj 250 mg/ml PA<br />

amikacin sulfate inj 50 mg/ml PA<br />

GENTAM/NACL INJ 0.9MG/ML PA<br />

GENTAM/NACL INJ 1.4MG/ML PA<br />

GENTAM/NACL INJ 100MG PB PA<br />

gentamicin in saline inj 0.6 mg/ml PA<br />

gentamicin in saline inj 0.8 mg/ml PA<br />

gentamicin in saline inj 1 mg/ml PA<br />

gentamicin in saline inj 1.2 mg/ml PA<br />

gentamicin in saline inj 1.6 mg/ml PA<br />

gentamicin sulfate inj 10 mg/ml PA<br />

gentamicin sulfate inj 40 mg/ml PA<br />

gentamicin sulfate iv soln 10 mg/ml PA<br />

KANAMYCIN INJ 333MG/ML PA<br />

neomycin tab 500mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 17


neomycin sulfate tab 500 mg<br />

STREPTOMYCIN INJ 1GM PA<br />

TOBRA/NACL INJ 60/0.9 PA<br />

TOBRA/NACL INJ 80/0.9 PA<br />

TOBRAMYCIN INJ 10MG/ML PA<br />

tobramycin sulfate for inj 1.2 gm PA<br />

tobramycin sulfate inj 10 mg/ml PA<br />

tobramycin sulfate inj 40 mg/ml PA<br />

First Generation Cephalosporins<br />

cefadroxil cap 500mg<br />

cefadroxil sus 250/5ml<br />

cefadroxil sus 500/5ml<br />

cefadroxil tab 1000mg<br />

cefadroxil tab 1gm<br />

cefadroxil cap 500 mg<br />

cefadroxil for susp 250 mg/5ml<br />

cefadroxil for susp 500 mg/5ml<br />

cefadroxil tab 1 gm<br />

CEFAZOL/DEX SOL 1GM PA<br />

CEFAZOLIN INJ 100GM PA<br />

CEFAZOLIN INJ 1GM/50ML PA<br />

CEFAZOLIN INJ 300GM PA<br />

CEFAZOLIN INJ 500MG PA<br />

cefazolin sodium for inj 1 gm PA<br />

cefazolin sodium for inj 10 gm PA<br />

cefazolin sodium for inj 20 gm PA<br />

cefazolin sodium for inj 500 mg PA<br />

cefazolin sodium for iv soln 1 gm PA<br />

cephalexin cap 250mg<br />

cephalexin cap 500mg<br />

cephalexin sus 125/5ml<br />

cephalexin sus 250/5ml<br />

cephalexin cap 250 mg<br />

cephalexin cap 500 mg<br />

cephalexin for susp 125 mg/5ml<br />

cephalexin for susp 250 mg/5ml<br />

KEFLEX CAP 750MG PA<br />

Second Generation Cephalosporins<br />

cefaclor cap 250mg<br />

cefaclor cap 500mg<br />

CEFACLOR SUS 125/5ML<br />

cefaclor sus 125/5ml<br />

cefaclor sus 125/5ml<br />

cefaclor sus 250/5ml<br />

cefaclor sus 250/5ml<br />

CEFACLOR SUS 250/5ML<br />

CEFACLOR SUS 375/5ML<br />

cefaclor cap 250 mg<br />

cefaclor cap 500 mg<br />

CEFACLOR ER TAB 500MG<br />

cefaclor er tab 500mg<br />

CEFACLOR FOR SUSP 125 MG/5ML<br />

cefaclor for susp 125 mg/5ml<br />

cefaclor for susp 125 mg/5ml<br />

CEFACLOR FOR SUSP 250 MG/5ML<br />

cefaclor for susp 250 mg/5ml<br />

cefaclor for susp 250 mg/5ml<br />

CEFACLOR FOR SUSP 375 MG/5ML<br />

cefaclor monohydrate tab sr 12hr 500 mg<br />

CEFACLOR MONOHYDRATE TAB SR 12HR 500 MG<br />

cefprozil sus 125/5ml<br />

cefprozil sus 250/5ml<br />

cefprozil tab 250mg<br />

cefprozil tab 500mg<br />

cefprozil for susp 125 mg/5ml<br />

cefprozil for susp 250 mg/5ml<br />

cefprozil tab 250 mg<br />

cefprozil tab 500 mg<br />

CEFUROX/DEXT INJ 1.5GM PA<br />

CEFUROX/DEXT INJ 750MG PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 18


CEFUROXIME INJ 225GM PA<br />

CEFUROXIME INJ 7.5GM PA<br />

CEFUROXIME INJ 75GM PA<br />

cefuroxime sodium for inj 1.5 gm PA<br />

cefuroxime sodium for inj 7.5 gm PA<br />

cefuroxime sodium for inj 750 mg PA<br />

cefuroxime sodium for iv soln 1.5 gm PA<br />

ZINACEF INJ 1.5GM PA<br />

ZINACEF INJ 750MG PA<br />

ZINACEF/D5W INJ 750MG PB PA<br />

ZINACEF/H20 INJ 1.5GM PB PA<br />

Third Generation Cephalosporins<br />

cefdinir cap 300mg<br />

cefdinir sus 125/5ml<br />

cefdinir sus 250/5ml<br />

cefdinir cap 300 mg<br />

cefdinir for susp 125 mg/5ml<br />

cefdinir for susp 250 mg/5ml<br />

CEFIXIME FOR SUSP 100 MG/5ML<br />

CEFIXIME FOR SUSP 200 MG/5ML<br />

CEFIXIME TAB 400 MG<br />

CEFIZOX INJ 10GM PA<br />

CEFIZOX INJ 1GM PA<br />

CEFIZOX INJ 2GM PA<br />

CEFIZOX/D5W INJ 1GM PA<br />

CEFIZOX/D5W INJ 2GM PA<br />

CEFOTAXIME INJ 20GM PA<br />

cefotaxime sodium for inj 1 gm PA<br />

cefotaxime sodium for inj 10 gm PA<br />

cefotaxime sodium for inj 2 gm PA<br />

cefotaxime sodium for inj 500 mg PA<br />

cefpodo prox sus 100/5ml NF<br />

cefpodo prox sus 50mg/5ml NF<br />

cefpodoxime tab 100mg NF<br />

cefpodoxime tab 200mg NF<br />

cefpodoxime proxetil for susp 100 mg/5ml NF<br />

cefpodoxime proxetil for susp 50 mg/5ml NF<br />

cefpodoxime proxetil tab 100 mg NF<br />

cefpodoxime proxetil tab 200 mg NF<br />

CEFTAZIDIME INJ 100GM PA<br />

ceftazidime for inj 1 gm PA<br />

ceftazidime for inj 2 gm PA<br />

ceftazidime for inj 6 gm PA<br />

ceftazidime for iv soln 1 gm PA<br />

ceftazidime for iv soln 2 gm PA<br />

CEFTRIAX/DEX INJ 1GM PA<br />

CEFTRIAX/DEX INJ 2GM PA<br />

CEFTRIAXONE INJ 100GM PA<br />

ceftriaxone sodium for inj 1 gm PA<br />

ceftriaxone sodium for inj 10 gm PA<br />

ceftriaxone sodium for inj 2 gm PA<br />

ceftriaxone sodium for inj 250 mg PA<br />

ceftriaxone sodium for inj 500 mg PA<br />

ceftriaxone sodium for iv soln 1 gm PA<br />

ceftriaxone sodium for iv soln 2 gm PA<br />

ceftriaxone sodium in dextrose inj 20 mg/ml PA<br />

ceftriaxone sodium in dextrose inj 40 mg/ml PA<br />

CLAFORAN INJ 1GM PA<br />

CLAFORAN INJ 2GM PA<br />

CLAFORAN/D5W INJ 1GM PA<br />

CLAFORAN/D5W INJ 2GM PA<br />

FORTAZ INJ 1GM PA<br />

FORTAZ INJ 2GM PA<br />

FORTAZ INJ 500MG PA<br />

ROCEPHIN INJ 1GM PA<br />

ROCEPHIN INJ 2GM PA<br />

SUPRAX SUS 100/5ML<br />

SUPRAX SUS 200/5ML<br />

SUPRAX TAB 400MG<br />

TAZICEF INJ 1GM/50ML PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 19


Fourth Generation Cephalosporins<br />

CEFEPIME INJ 1GM PA<br />

CEFEPIME INJ 2GM PA<br />

cefepime hcl for inj 1 gm PA<br />

cefepime hcl for inj 2 gm PA<br />

MAXIPIME INJ 1GM PA<br />

MAXIPIME INJ 2GM PA<br />

MAXIPIME INJ 500MG PA<br />

Miscellaneous B-Lactam Antibiotics<br />

INVANZ INJ 1GM PA<br />

Carbacepnems<br />

LORABID CAP 200MG NF<br />

LORABID CAP 400MG NF<br />

LORABID SUS 100/5ML NF<br />

LORABID SUS 200/5ML NF<br />

LORACARBEF CAP 200 MG NF<br />

LORACARBEF CAP 400 MG NF<br />

LORACARBEF FOR SUSP 100 MG/5ML NF<br />

LORACARBEF FOR SUSP 200 MG/5ML NF<br />

Carbapenems<br />

DORIBAX INJ 500MG PA<br />

INVANZ INJ 1GM PA<br />

MERREM INJ 1GM PA<br />

MERREM INJ 500MG PA<br />

PRIMAXIN IM INJ 500MG PA<br />

PRIMAXIN IV INJ 250MG PA<br />

PRIMAXIN IV INJ 500MG PA<br />

Cephamycins<br />

CEFOTAN INJ 1GM/50ML PA<br />

CEFOTAN INJ 2GM/50ML PA<br />

CEFOTET/DEX INJ 1-3.58% PA<br />

CEFOTET/DEX INJ 2-2.08% PA<br />

CEFOTETAN INJ 10G PA<br />

CEFOTETAN INJ 1GM/10ML PA<br />

CEFOTETAN INJ 2GM/20ML PA<br />

CEFOXITIN INJ 100GM PA<br />

CEFOXITIN INJ 1GM PA<br />

CEFOXITIN INJ 2GM PA<br />

cefoxitin sodium for inj 1 gm PA<br />

cefoxitin sodium for inj 10 gm PA<br />

cefoxitin sodium for inj 2 gm PA<br />

MEFOXIN/DEX INJ 1GM PA<br />

MEFOXIN/DEX INJ 2GM PA<br />

Monobactams<br />

AZACTAM INJ 1GM PA<br />

AZACTAM INJ 2GM PA<br />

AZACTAM INJ 500MG PA<br />

AZACTAM/DEX INJ 1GM PA<br />

AZACTAM/DEX INJ 2GM PA<br />

Chloramphenicol<br />

CHLORAMPHEN INJ 1GM PA<br />

Macrolides<br />

clarithromyc tab 500mg<br />

clarithromycin tab 500 mg<br />

Erythromycins<br />

e.e.s. 200 sus 200/5ml<br />

e.e.s. 400 sus 400/5ml<br />

e.e.s. 400 tab 400mg<br />

E.E.S. GRAN SUS 200/5ML<br />

e.s.p. sus 200-600<br />

ees/sulfisox sus 200-600<br />

ery-tab tab 250mg ec<br />

ERY-TAB TAB 250MG EC<br />

ery-tab tab 333mg ec<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 20


ERY-TAB TAB 500MG EC<br />

ery-tab tab 500mg ec<br />

ERYPED DRO 100/2.5<br />

ERYPED 200 SUS 200/5ML<br />

ERYPED 400 SUS 400/5ML<br />

ERYTHROCIN INJ 1000MG PA<br />

ERYTHROCIN INJ 500MG PA<br />

ERYTHROCIN TAB 250MG<br />

erythrocin tab 500mg<br />

ERYTHROCIN TAB 500MG<br />

erythrom eth sus 200/5ml<br />

erythrom eth sus 400/5ml<br />

erythrom eth tab 400mg<br />

erythrom st tab 250mg<br />

ERYTHROM ST TAB 250MG<br />

ERYTHROM ST TAB 500MG<br />

erythrom st tab 500mg<br />

ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 100 MG/2.5ML<br />

ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 200 MG/5ML<br />

ERYTHROMYCIN ETHYLSUCCINATE FOR SUSP 400 MG/5ML<br />

erythromycin ethylsuccinate susp 200 mg/5ml<br />

erythromycin ethylsuccinate susp 400 mg/5ml<br />

erythromycin ethylsuccinate tab 400 mg<br />

ERYTHROMYCIN STEARATE TAB 250 MG<br />

erythromycin stearate tab 250 mg<br />

erythromycin stearate tab 500 mg<br />

erythromycin stearate tab 500 mg<br />

ERYTHROMYCIN STEARATE TAB 500 MG<br />

erythromycin tab 250 mg<br />

ERYTHROMYCIN TAB 250 MG<br />

ERYTHROMYCIN TAB 250MG BS<br />

ERYTHROMYCIN TAB 250MG BS<br />

erythromycin tab 250mg bs<br />

erythromycin tab 333mg ec<br />

ERYTHROMYCIN TAB 500 MG<br />

erythromycin tab 500 mg<br />

erythromycin tab 500mg bs<br />

ERYTHROMYCIN TAB 500MG BS<br />

ERYTHROMYCIN TAB DELAYED RELEASE 250 MG<br />

erythromycin tab delayed release 250 mg<br />

erythromycin tab delayed release 333 mg<br />

erythromycin tab delayed release 500 mg<br />

ERYTHROMYCIN TAB DELAYED RELEASE 500 MG<br />

erythromycin-sulfisoxazole for susp 200-600 mg/5ml<br />

Other Macrolides<br />

AZITHROMYCIN EXTENDED RELEASE FOR ORAL SUSP 2 GM<br />

azithromycin for susp 100 mg/5ml<br />

azithromycin for susp 200 mg/5ml<br />

AZITHROMYCIN INJ 2.5GM PA<br />

AZITHROMYCIN INJ 500MG PA<br />

azithromycin iv for soln 500 mg PA<br />

AZITHROMYCIN POW 1GM PAK<br />

AZITHROMYCIN POWD PACK FOR SUSP 1 GM<br />

azithromycin sus 100/5ml<br />

azithromycin sus 200/5ml<br />

azithromycin tab 250 mg<br />

azithromycin tab 250mg<br />

azithromycin tab 500 mg<br />

azithromycin tab 500mg<br />

azithromycin tab 600 mg<br />

azithromycin tab 600mg<br />

clarithromyc sus 125/5ml<br />

clarithromyc sus 250/5ml<br />

clarithromyc tab 250mg<br />

clarithromyc tab 500mg<br />

clarithromycin for susp 125 mg/5ml<br />

clarithromycin for susp 250 mg/5ml<br />

clarithromycin tab 250 mg<br />

clarithromycin tab 500 mg<br />

ZITHROMAX POW 1GM PAK<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 21


ZMAX SUS 2GM<br />

ZMAX PEDIATR SUS 2GM<br />

Penicillins<br />

amox/k clav chw 400mg<br />

amox/k clav tab 500mg<br />

amox/k clav tab 875mg<br />

amoxicillin cap 250mg<br />

amoxicillin cap 500mg<br />

amoxicillin chw 125mg<br />

amoxicillin chw 250mg<br />

amoxicillin & k clavulanate chew tab 400-57 mg<br />

amoxicillin & k clavulanate tab 500-125 mg<br />

amoxicillin & k clavulanate tab 875-125 mg<br />

amoxicillin (trihydrate) cap 250 mg<br />

amoxicillin (trihydrate) cap 500 mg<br />

amoxicillin (trihydrate) chew tab 125 mg<br />

amoxicillin (trihydrate) chew tab 250 mg<br />

Natural Penicillins<br />

BICILLIN C-R INJ 1200000 PA<br />

BICILLIN C-R INJ 2400000 PA<br />

BICILLIN C-R INJ 600000 PA<br />

BICILLIN C-R INJ 900/300 PA<br />

BICILLIN L-A INJ 1200000 PA<br />

BICILLIN L-A INJ 2400000 PA<br />

BICILLIN L-A INJ 600000 PA<br />

PEN G PROC INJ 600000 PA<br />

PEN G PROC INJ 600000 PA<br />

PEN G SOD INJ 5000000 PA<br />

PENICILL GK/ INJ DEX 1MU PA<br />

PENICILL GK/ INJ DEX 2MU PA<br />

PENICILL GK/ INJ DEX 3MU PA<br />

penicillin g potassium for inj 20000000 unit PA<br />

penicillin g potassium for inj 5000000 unit PA<br />

penicillin v potassium for soln 125 mg/5ml<br />

penicillin v potassium for soln 250 mg/5ml<br />

penicillin v potassium tab 250 mg<br />

penicillin v potassium tab 500 mg<br />

penicilln vk sol 125/5ml<br />

penicilln vk sol 250/5ml<br />

penicilln vk tab 250mg<br />

penicilln vk tab 500mg<br />

veetids sol 125/5ml<br />

veetids sol 250/5ml<br />

veetids tab 250mg<br />

veetids tab 500mg<br />

Aminopenicillins<br />

amoclan sus 200/5ml<br />

amoclan sus 400/5ml<br />

amoclan sus 600-42.9<br />

amox/k clav chw 200mg<br />

amox/k clav chw 200mg<br />

amox/k clav chw 400mg<br />

amox/k clav chw 400mg<br />

amox/k clav sus 200/5ml<br />

amox/k clav sus 200/5ml<br />

amox/k clav sus 250/5ml<br />

amox/k clav sus 400/5ml<br />

amox/k clav sus 400/5ml<br />

amox/k clav sus 600/5ml<br />

amox/k clav tab 250mg<br />

amox/k clav tab 500mg<br />

amox/k clav tab 500mg<br />

amox/k clav tab 875mg<br />

amox/k clav tab 875mg<br />

amoxicillin cap 250mg<br />

amoxicillin cap 500mg<br />

amoxicillin chw 125mg<br />

amoxicillin chw 200mg<br />

AMOXICILLIN CHW 200MG<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 22


amoxicillin chw 250mg<br />

AMOXICILLIN CHW 400MG<br />

amoxicillin chw 400mg<br />

amoxicillin chw 400mg<br />

amoxicillin sus 125/5ml<br />

amoxicillin sus 200/5ml<br />

amoxicillin sus 250/5ml<br />

amoxicillin sus 400/5ml<br />

amoxicillin tab 500mg<br />

amoxicillin tab 875mg QL<br />

AMOXICILLIN & K CLAVULANATE CHEW TAB 125-31.25 MG<br />

amoxicillin & k clavulanate chew tab 200-28.5 mg<br />

AMOXICILLIN & K CLAVULANATE CHEW TAB 250-62.5 MG<br />

amoxicillin & k clavulanate chew tab 400-57 mg<br />

AMOXICILLIN & K CLAVULANATE FOR SUSP 125-31.25 MG/5ML<br />

amoxicillin & k clavulanate for susp 200-28.5 mg/5ml<br />

AMOXICILLIN & K CLAVULANATE FOR SUSP 250-62.5 MG/5ML<br />

amoxicillin & k clavulanate for susp 250-62.5 mg/5ml<br />

amoxicillin & k clavulanate for susp 400-57 mg/5ml<br />

amoxicillin & k clavulanate for susp 600-42.9 mg/5ml<br />

amoxicillin & k clavulanate tab 250-125 mg<br />

amoxicillin & k clavulanate tab 500-125 mg<br />

amoxicillin & k clavulanate tab 875-125 mg<br />

amoxicillin (trihydrate) cap 250 mg<br />

amoxicillin (trihydrate) cap 500 mg<br />

amoxicillin (trihydrate) chew tab 125 mg<br />

AMOXICILLIN (TRIHYDRATE) CHEW TAB 200 MG<br />

amoxicillin (trihydrate) chew tab 200 mg<br />

amoxicillin (trihydrate) chew tab 250 mg<br />

AMOXICILLIN (TRIHYDRATE) CHEW TAB 400 MG<br />

amoxicillin (trihydrate) chew tab 400 mg<br />

amoxicillin (trihydrate) chew tab 400 mg<br />

amoxicillin (trihydrate) for susp 125 mg/5ml<br />

amoxicillin (trihydrate) for susp 200 mg/5ml<br />

amoxicillin (trihydrate) for susp 250 mg/5ml<br />

amoxicillin (trihydrate) for susp 400 mg/5ml<br />

AMOXICILLIN (TRIHYDRATE) FOR SUSP 50 MG/ML<br />

amoxicillin (trihydrate) tab 500 mg<br />

amoxicillin (trihydrate) tab 875 mg QL<br />

amoxil cap 500mg<br />

AMOXIL DRO 50MG/ML<br />

amoxil sus 250/5ml<br />

ampicillin cap 250mg<br />

ampicillin cap 500mg<br />

AMPICILLIN INJ 125MG PA<br />

AMPICILLIN SUS 125/5ML<br />

AMPICILLIN SUS 250/5ML<br />

ampicillin sus 250/5ml<br />

ampicillin & sulbactam sodium for inj 1-0.5 gm PA<br />

ampicillin & sulbactam sodium for inj 10-5 gm PA<br />

ampicillin & sulbactam sodium for inj 2-1 gm PA<br />

ampicillin & sulbactam sodium for iv soln 1-0.5 gm PA<br />

ampicillin & sulbactam sodium for iv soln 2-1 gm PA<br />

ampicillin cap 250 mg<br />

ampicillin cap 500 mg<br />

AMPICILLIN FOR SUSP 125 MG/5ML<br />

AMPICILLIN FOR SUSP 250 MG/5ML<br />

ampicillin for susp 250 mg/5ml<br />

ampicillin sodium for inj 1 gm PA<br />

ampicillin sodium for inj 10 gm PA<br />

ampicillin sodium for inj 2 gm PA<br />

ampicillin sodium for inj 250 mg PA<br />

ampicillin sodium for inj 500 mg PA<br />

ampicillin sodium for iv soln 1 gm PA<br />

ampicillin sodium for iv soln 1 gm PA<br />

ampicillin sodium for iv soln 2 gm PA<br />

ampicillin sodium for iv soln 2 gm PA<br />

AUGMENTIN CHW 125MG<br />

AUGMENTIN CHW 250MG<br />

AUGMENTIN SUS 125/5ML<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 23


AUGMENTIN SUS 250/5ML<br />

MOXATAG TAB 775MG PA<br />

trimox cap 500mg<br />

trimox sus 250/5ml<br />

Penicillinase-resistant Penicillins<br />

BACTOCILL INJ DEX 1GM PA<br />

BACTOCILL INJ DEX 2GM PA<br />

dicloxacill cap 250mg<br />

dicloxacill cap 500mg<br />

dicloxacillin sodium cap 250 mg<br />

dicloxacillin sodium cap 500 mg<br />

NAFCILLIN INJ 10GM PA<br />

NAFCILLIN INJ 1GM PA<br />

NAFCILLIN INJ 200GM PA<br />

NAFCILLIN INJ 2GM PA<br />

nafcillin sodium for inj 1 gm PA<br />

nafcillin sodium for inj 10 gm PA<br />

nafcillin sodium for iv soln 1 gm PA<br />

nafcillin sodium for iv soln 2 gm PA<br />

NALLPEN/DEX INJ 1GM/50ML PA<br />

NALLPEN/DEX INJ 2GM PA<br />

NALLPEN/DEX INJ 2GM/100 PA<br />

OXACILLIN INJ 10GM PA<br />

OXACILLIN INJ 1GM PA<br />

OXACILLIN INJ 2GM PA<br />

oxacillin sodium for inj 10 gm PA<br />

Extended-spectrum Penicillins<br />

PIPERACILLIN INJ 2GM PA<br />

PIPERACILLIN INJ 3GM PA<br />

PIPERACILLIN INJ 40GM PA<br />

PIPERACILLIN INJ 4GM PA<br />

piperacillin sodium-tazobactam sodium for inj 2-0.25 gm PA<br />

piperacillin sodium-tazobactam sodium for inj 3-0.375 gm PA<br />

piperacillin sodium-tazobactam sodium for inj 36-4.5 gm PA<br />

piperacillin sodium-tazobactam sodium for inj 4-0.5 gm PA<br />

TIMENTIN INJ 3.1GM PA<br />

TIMENTIN INJ 31GM PA<br />

ZOSYN INJ 2G-0.25G PA<br />

ZOSYN INJ 36-4.5GM PA<br />

ZOSYN SOL 2-0.25GM PA<br />

ZOSYN SOL 3-0.375G PA<br />

ZOSYN SOL 4-0.50GM PA<br />

Quinolones<br />

AVELOX INJ PA<br />

ciprofloxacin 0.2% in d5w PA<br />

ciprofloxacin hcl tab 100 mg (base equiv)<br />

ciprofloxacin hcl tab 250 mg (base equiv)<br />

ciprofloxacin hcl tab 500 mg (base equiv)<br />

ciprofloxacin hcl tab 750 mg (base equiv)<br />

ciprofloxacin iv soln 1% PA<br />

ciprofloxacn tab 100mg<br />

ciprofloxacn tab 250mg<br />

ciprofloxacn tab 500mg<br />

ciprofloxacn tab 750mg<br />

LEVAQUIN INJ 25MG/ML PA<br />

LEVAQUIN SOL 25MG/ML<br />

LEVAQUIN TAB 250MG<br />

LEVAQUIN TAB 500MG<br />

LEVAQUIN TAB 750MG<br />

LEVAQUIN TAB LEVA-PAK<br />

LEVAQUIN/D5W INJ 250/50ML PA<br />

LEVAQUIN/D5W INJ 500/100 PA<br />

LEVAQUIN/D5W INJ 750/150 PA<br />

LEVOFLOXACIN ORAL SOLN 25 MG/ML<br />

LEVOFLOXACIN TAB 250 MG<br />

LEVOFLOXACIN TAB 500 MG<br />

LEVOFLOXACIN TAB 750 MG<br />

ofloxacin tab 200mg<br />

ofloxacin tab 300mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 24


ofloxacin tab 400mg<br />

ofloxacin tab 200 mg<br />

ofloxacin tab 300 mg<br />

ofloxacin tab 400 mg<br />

TEQUIN INJ 2MG/ML PA<br />

Sulfonamides<br />

SMZ-TMP INJ 400-80/5 PA<br />

smz-tmp sus<br />

smz-tmp sus 200-40/5<br />

smz-tmp tab 400-80mg<br />

smz-tmp ds tab 800-160<br />

smz/tmp ds tab 800-160<br />

sulfamethoxazole-trimethoprim susp 200-40 mg/5ml<br />

sulfamethoxazole-trimethoprim tab 400-80 mg<br />

sulfamethoxazole-trimethoprim tab 800-160 mg<br />

sulfasalazin tab 500mg<br />

sulfasalazin tab 500mg dr<br />

sulfasalazin tab 500mg ec<br />

sulfasalazine tab 500 mg<br />

sulfasalazine tab delayed release 500 mg<br />

sulfatrim sus 200-40/5<br />

sulfazine tab 500mg<br />

sulfazine ec tab 500mg<br />

SULFISOXAZOL TAB 0.5GM<br />

SULFISOXAZOLE TAB 500 MG<br />

tmp/smz ds tab 160-800<br />

Tetracyclines<br />

avidoxy tab 100mg<br />

DORYX TAB 100MG<br />

DORYX TAB 150MG<br />

DORYX TAB 75MG<br />

doxy-caps cap 100mg<br />

doxycyc mono cap 100mg<br />

doxycyc mono cap 50mg<br />

doxycyc mono tab 100mg<br />

doxycyc mono tab 150mg<br />

doxycyc mono tab 50mg<br />

doxycyc mono tab 75mg<br />

doxycycl hyc cap 100mg<br />

DOXYCYCL HYC CAP 100MG<br />

doxycycl hyc cap 50mg<br />

DOXYCYCL HYC CAP 75MG<br />

doxycycl hyc tab 100mg<br />

doxycycline sus 25mg/5ml<br />

doxycycline tab 20mg<br />

DOXYCYCLINE CALCIUM SYRUP 50 MG/5ML<br />

doxycycline hyclate cap 100 mg<br />

DOXYCYCLINE HYCLATE CAP 20 MG<br />

doxycycline hyclate cap 50 mg<br />

DOXYCYCLINE HYCLATE CAP DR PARTICLES 100 MG<br />

DOXYCYCLINE HYCLATE CAP DR PARTICLES 75 MG<br />

doxycycline hyclate for inj 100 mg PA<br />

doxycycline hyclate tab 100 mg<br />

doxycycline hyclate tab 20 mg<br />

DOXYCYCLINE HYCLATE TAB DELAYED RELEASE 100 MG<br />

DOXYCYCLINE HYCLATE TAB DELAYED RELEASE 150 MG<br />

DOXYCYCLINE HYCLATE TAB DELAYED RELEASE 75 MG<br />

doxycycline monohydrate cap 100 mg<br />

doxycycline monohydrate cap 50 mg<br />

doxycycline monohydrate for susp 25 mg/5ml<br />

DOXYCYCLINE MONOHYDRATE FOR SUSP 25 MG/5ML<br />

doxycycline monohydrate tab 100 mg<br />

doxycycline monohydrate tab 150 mg<br />

doxycycline monohydrate tab 50 mg<br />

doxycycline monohydrate tab 75 mg<br />

MINOCIN INJ 100MG PA<br />

minocycline hcl cap 100 mg PA<br />

minocycline hcl cap 50 mg PA<br />

ORAXYL CAP 20MG<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 25


SUMYCIN SYP 125/5ML<br />

SUMYCIN TAB 250MG<br />

SUMYCIN TAB 500MG<br />

tetracycline cap 250mg<br />

tetracycline cap 500mg<br />

tetracycline hcl cap 250 mg<br />

tetracycline hcl cap 500 mg<br />

TETRACYCLINE HCL SYRUP 125 MG/5ML<br />

TETRACYCLINE HCL TAB 250 MG<br />

TETRACYCLINE HCL TAB 500 MG<br />

VIBRAMYCIN SUS 25MG/5ML<br />

VIBRAMYCIN SYP 50MG/5ML<br />

Glycylcyclines<br />

TYGACIL INJ 50MG PA<br />

Bacitracins<br />

bacitracin intramuscular for soln 50000 unit PA<br />

Cyclic Lipopeptides<br />

CUBICIN SOL 500MG PA<br />

Glycopeptides<br />

VANCOMYC/DEX INJ 1GM PA<br />

VANCOMYC/DEX INJ 500MG PA<br />

VANCOMYCIN INJ 750MG PA<br />

vancomycin hcl for inj 10 gm PA<br />

vancomycin hcl for inj 1000 mg PA<br />

vancomycin hcl for inj 500 mg PA<br />

vancomycin hcl for inj 5000 mg PA<br />

VIBATIV INJ 250MG PA<br />

VIBATIV INJ 750MG PA<br />

Lincomycins<br />

CLEOCIN INJ 300MG PA<br />

CLEOCIN INJ 600MG PA<br />

CLEOCIN INJ 900MG PA<br />

clindamycin cap 150mg<br />

clindamycin hcl cap 150 mg<br />

clindamycin hcl cap 300 mg PA<br />

clindamycin phosphate inj 150 mg/ml PA<br />

clindamycin phosphate iv soln 150 mg/ml PA<br />

LINCOCIN INJ 300MG/ML PA<br />

Oxazolidinones<br />

ZYVOX SOL 2MG/ML PA<br />

Polymyxins<br />

colistimethate sodium for inj 150 mg PA<br />

polymyxin b sulfate for inj 500000 unit PA<br />

Streptogramins<br />

SYNERCID INJ 500MG PA<br />

Antifungals<br />

Allylamines<br />

terbinafine tab 250mg NF<br />

terbinafine hcl tab 250 mg NF<br />

Azoles<br />

fluconazole sus 10mg/ml NF<br />

fluconazole sus 40mg/ml NF<br />

fluconazole tab 150mg QL<br />

fluconazole for susp 10 mg/ml NF<br />

fluconazole for susp 40 mg/ml NF<br />

fluconazole in dextrose inj 200 mg/100ml PA<br />

fluconazole in dextrose inj 400 mg/200ml PA<br />

fluconazole in nacl 0.9% inj 200 mg/100ml PA<br />

fluconazole in nacl 0.9% inj 400 mg/200ml PA<br />

fluconazole tab 100 mg PA<br />

fluconazole tab 150 mg QL<br />

fluconazole tab 200 mg PA<br />

fluconazole tab 50 mg PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 26


FLUCONAZOLE/ INJ NACL 100 PA<br />

itraconazole cap 100 mg PA<br />

ketoconazole tab 200 mg<br />

ketoconazole tab 200mg<br />

SPORANOX KIT 250MG PA<br />

VFEND SUS 40MG/ML PA<br />

VFEND TAB 200MG PA<br />

VFEND TAB 50MG PA<br />

VFEND IV INJ 200MG PA<br />

Echinocandins<br />

CANCIDAS INJ 50MG PA<br />

CANCIDAS INJ 70MG PA<br />

ERAXIS INJ 100MG PA<br />

ERAXIS INJ 50MG PA<br />

MYCAMINE INJ 100MG PA<br />

MYCAMINE INJ 50MG PA<br />

Polyenes<br />

ABELCET INJ 5MG/ML PA<br />

AMBISOME INJ 50MG PA<br />

AMPHOTEC INJ 100MG PA<br />

AMPHOTEC INJ 50MG PA<br />

amphotericin b for inj 50 mg PA<br />

nystatin sus 100000<br />

nystatin susp 100000 unit/ml<br />

Antifungals, Miscellaneous<br />

GRIFULVIN V TAB 500MG<br />

GRIS-PEG TAB 125MG<br />

GRIS-PEG TAB 250MG<br />

griseofulvin microsize susp 125 mg/5ml<br />

GRISEOFULVIN MICROSIZE TAB 500 MG<br />

griseofulvin sus 125/5ml<br />

GRISEOFULVIN TAB 250 ULTR<br />

GRISEOFULVIN ULTRAMICROSIZE TAB 125 MG<br />

GRISEOFULVIN ULTRAMICROSIZE TAB 250 MG<br />

Antimycobacterials<br />

Antituberculosis Agents<br />

CAPASTAT SUL INJ 1GM PA<br />

ethambutol tab 100mg<br />

ethambutol tab 400mg<br />

ethambutol hcl tab 100 mg<br />

ethambutol hcl tab 400 mg<br />

ISONIAZID INJ 100MG/ML PA<br />

ISONIAZID SYP 50MG/5ML<br />

isoniazid tab 100mg<br />

isoniazid tab 300mg<br />

ISONIAZID SYRUP 50 MG/5ML<br />

isoniazid tab 100 mg<br />

isoniazid tab 300 mg<br />

pyrazinamide tab 500 mg<br />

pyrazinamide tab 500mg<br />

rifampin cap 150mg<br />

rifampin cap 300mg<br />

rifampin cap 150 mg<br />

rifampin cap 300 mg<br />

rifampin for inj 600 mg PA<br />

Antivirals<br />

HIV Fusion Inhibitors<br />

FUZEON KIT PA<br />

HIV Protease Inhibitors<br />

AGENERASE CAP 50MG PA<br />

AGENERASE SOL 15MG/ML PA<br />

CRIXIVAN CAP 100MG PA<br />

CRIXIVAN CAP 200MG PA<br />

CRIXIVAN CAP 333MG PA<br />

CRIXIVAN CAP 400MG PA<br />

INVIRASE CAP 200MG PA<br />

NORVIR CAP 100MG PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 27


NORVIR SOL 80MG/ML PA<br />

VIRACEPT POW 50MG/GM PA<br />

VIRACEPT TAB 250MG PA<br />

VIRACEPT TAB 625MG PA<br />

Nonnucleoside Reverse Transcriptase Inhibitors<br />

INTELENCE TAB 100MG PA QL<br />

RESCRIPTOR TAB 100 MG PA<br />

RESCRIPTOR TAB 200MG PA<br />

SUSTIVA CAP 100MG PA<br />

SUSTIVA CAP 200MG PA<br />

SUSTIVA CAP 50MG PA<br />

VIRAMUNE TAB 200MG PA<br />

Nucleoside & Nucleotide Rev Transcriptase Inhib<br />

COMBIVIR TAB PA<br />

EPIVIR SOL 10MG/ML PA<br />

EPIVIR TAB 150MG PA<br />

EPIVIR TAB 300MG PA<br />

EPIVIR HBV SOL 5MG/ML PA<br />

EPIVIR HBV TAB 100MG PA<br />

HIVID TAB 0.375MG PA<br />

HIVID TAB 0.75MG PA<br />

RETROVIR INJ 10MG/ML PA<br />

stavudine cap 15 mg PA<br />

stavudine cap 20 mg PA<br />

stavudine cap 30 mg PA<br />

stavudine cap 40 mg PA<br />

stavudine for oral soln 1 mg/ml PA<br />

VIDEX SOL 2GM PA<br />

VIDEX SOL 4GM PA<br />

ZIAGEN SOL 20MG/ML PA<br />

ZIAGEN TAB 300MG PA<br />

zidovudine cap 100 mg PA<br />

zidovudine syrup 10 mg/ml PA<br />

zidovudine tab 300 mg PA<br />

Interferons<br />

INFERGEN INJ 15MCG PA<br />

INFERGEN INJ 9MCG PA<br />

PEG-INTRON KIT 120 RP PA<br />

PEG-INTRON KIT 120MCG PA<br />

PEG-INTRON KIT 150 RP PA<br />

PEG-INTRON KIT 150MCG PA<br />

PEG-INTRON KIT 50MCG PA<br />

PEG-INTRON KIT 50MCG RP PA<br />

PEG-INTRON KIT 80MCG PA<br />

PEG-INTRON KIT 80MCG RP PA<br />

PEGASYS INJ 180MCG/M PA<br />

PEGASYS KIT PA<br />

Monoclonal Antibodies<br />

SYNAGIS INJ 100MG/ML PA<br />

SYNAGIS INJ 50MG PA<br />

Neuraminidase Inhibitors<br />

OSELTAMIVIR PHOSPHATE CAP 30 MG (BASE EQUIV)<br />

OSELTAMIVIR PHOSPHATE CAP 45 MG (BASE EQUIV)<br />

OSELTAMIVIR PHOSPHATE CAP 75 MG (BASE EQUIV)<br />

OSELTAMIVIR PHOSPHATE FOR SUSP 12 MG/ML (BASE EQUIV)<br />

RELENZA AER DISKHALE QL<br />

RELENZA MIS DISKHALE QL<br />

TAMIFLU CAP 30MG<br />

TAMIFLU CAP 45MG<br />

TAMIFLU CAP 75MG<br />

TAMIFLU SUS 12MG/ML<br />

ZANAMIVIR AERO POWDER BREATH ACTIVATED 5 MG/BLISTER QL<br />

Nucleosides and Nucleotides<br />

acyclovir cap 200mg<br />

acyclovir sus 200/5ml<br />

acyclovir tab 400mg<br />

acyclovir tab 800mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 28


acyclovir cap 200 mg<br />

ACYCLOVIR NA INJ 1000MG PA<br />

ACYCLOVIR NA INJ 50MG/ML PA<br />

acyclovir sodium for inj 500 mg PA<br />

acyclovir susp 200 mg/5ml<br />

acyclovir tab 400 mg<br />

acyclovir tab 800 mg<br />

CYTOVENE INJ 500MG PA<br />

GANCICLOVIR CAP 500MG PA<br />

ganciclovir cap 250 mg PA<br />

ganciclovir cap 500 mg PA<br />

HEPSERA TAB 10MG PA<br />

ribavirin cap 200 mg PA<br />

VALCYTE TAB 450MG<br />

VALGANCICLOVIR HCL TAB 450 MG<br />

VISTIDE INJ 75MG/ML PA<br />

Antivirals, Miscellaneous<br />

FOSCARNET INJ 24MG/ML PA<br />

Antiprotozoals<br />

Antimalarials<br />

DARAPRIM TAB 25MG<br />

hydroxychlor tab 200mg<br />

hydroxychloroquine sulfate tab 200 mg<br />

PRIMAQUINE TAB 26.3MG<br />

PRIMAQUINE PHOSPHATE TAB 26.3 MG<br />

PYRIMETHAMINE TAB 25 MG<br />

Antiprotozoals, Miscellaneous<br />

ALINIA SUS 100MG/5M PA QL<br />

ALINIA TAB 500MG PA QL<br />

METRO IV INJ 5MG/ML PA<br />

metronidazol tab 250mg<br />

metronidazol tab 500mg<br />

metronidazole in nacl 0.79% iv soln 500 mg/100ml PA<br />

metronidazole tab 250 mg<br />

metronidazole tab 500 mg<br />

NEBUPENT INH 300MG PA<br />

NEUTREXIN INJ 200MG PA<br />

NEUTREXIN INJ 25MG PA<br />

PENTAM 300 INJ 300MG PA<br />

pentamidine isethionate for soln 300 mg PA<br />

Urinary Anti-infectives<br />

FURADANTIN SUS 25MG/5ML<br />

MACRODANTIN CAP 25MG<br />

nitrofur mac cap 100mg<br />

nitrofur mac cap 50mg<br />

nitrofurantn cap 100mg<br />

nitrofuranto cap 100mg<br />

nitrofurantoin macrocrystalline cap 100 mg<br />

NITROFURANTOIN MACROCRYSTALLINE CAP 25 MG<br />

nitrofurantoin macrocrystalline cap 50 mg<br />

nitrofurantoin monohydrate macrocrystalline cap 100 mg<br />

NITROFURANTOIN SUSP 25 MG/5ML<br />

trimethoprim tab 100 mg<br />

trimethoprim tab 100mg<br />

Anti-infectives, Miscellaneous<br />

HELIDAC MIS<br />

METRONIDAZ TAB-TETRACYC CAP-BIS SUBSAL CHEW TAB THERAPY PACK<br />

Antineoplastic Agents<br />

ABRAXANE INJ 100MG PA<br />

ADRIAMYCIN INJ 20MG PA<br />

ALFERON N INJ 5MU/ML PA<br />

ALIMTA INJ 100MG PA<br />

ALIMTA INJ 500MG PA<br />

ALKERAN INJ 50MG PA<br />

ALKERAN TAB 2MG<br />

ALTRETAMINE CAP 50 MG<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 29


ARRANON INJ 5MG/ML PA<br />

ARZERRA CON 100/5ML PA<br />

AVASTIN INJ PA<br />

BEXAROTENE CAP 75 MG<br />

BEXXAR CON 14MG/ML PA<br />

BEXXAR 131 I INJ 0.61/ML PA<br />

BEXXAR 131 I INJ 5.6MCI/M PA<br />

BICNU INJ 100MG PA<br />

bleomycin sulfate for inj 15 unit PA<br />

bleomycin sulfate for inj 30 unit PA<br />

BUSULFAN TAB 2 MG<br />

BUSULFEX INJ 6MG/ML PA<br />

CAMPATH INJ 10MG/ML PA<br />

CAMPATH INJ 30MG/ML PA<br />

carboplatin iv for inj 150 mg PA<br />

carboplatin iv for inj 450 mg PA<br />

carboplatin iv for inj 450 mg PA<br />

carboplatin iv for inj 50 mg PA<br />

carboplatin iv for inj 50 mg PA<br />

carboplatin iv soln 10 mg/ml PA<br />

CEENU CAP 100MG<br />

CEENU CAP 10MG<br />

CEENU CAP 40MG<br />

CEENU PAK DOSEPACK<br />

CHLORAMBUCIL TAB 2 MG<br />

cisplatin inj 1 mg/ml PA<br />

cladribine inj 1 mg/ml PA<br />

CLOLAR INJ 1MG/ML PA<br />

COSMEGEN INJ 0.5MG PA<br />

CYCLOPHOSPH INJ 1GM PA<br />

CYCLOPHOSPH INJ 2GM PA<br />

CYCLOPHOSPH INJ 500MG PA<br />

CYCLOPHOSPH TAB 25MG<br />

cyclophosph tab 25mg<br />

cyclophosph tab 25mg<br />

CYCLOPHOSPH TAB 50MG<br />

cyclophosph tab 50mg<br />

cyclophosph tab 50mg<br />

cyclophosphamide tab 25 mg<br />

CYCLOPHOSPHAMIDE TAB 25 MG<br />

cyclophosphamide tab 25 mg<br />

CYCLOPHOSPHAMIDE TAB 50 MG<br />

cyclophosphamide tab 50 mg<br />

cyclophosphamide tab 50 mg<br />

CYTARABINE INJ 100MG PA<br />

CYTARABINE INJ 20MG/ML PA<br />

cytarabine for inj 1 gm PA<br />

cytarabine for inj 2 gm PA<br />

cytarabine for inj 500 mg PA<br />

cytarabine inj 100 mg/ml PA<br />

DACARBAZINE INJ 100MG PA<br />

dacarbazine for inj 200 mg PA<br />

DACOGEN INJ 50MG PA<br />

daunorubicin hcl for inj 20 mg PA<br />

daunorubicin hcl inj 5 mg/ml (base equiv) PA<br />

DAUNOXOME INJ 2MG/ML PA<br />

DEPOCYT INJ 50MG/5ML PA<br />

DOXIL INJ 2MG/ML PA<br />

doxorubicin hcl for inj 10 mg PA<br />

doxorubicin hcl for inj 50 mg PA<br />

doxorubicin hcl inj 2 mg/ml PA<br />

ELIGARD INJ 22.5MG PA<br />

ELIGARD INJ 30MG PA<br />

ELIGARD INJ 45MG PA<br />

ELIGARD INJ 7.5MG PA<br />

ELOXATIN INJ 100MG PA<br />

ELOXATIN INJ 50MG PA<br />

ELSPAR INJ 10000UNT PA<br />

EPIRUBICIN INJ 200MG PA<br />

EPIRUBICIN INJ 50MG PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 30


epirubicin hcl inj 2 mg/ml PA<br />

ERBITUX INJ 100MG PA<br />

ERBITUX INJ 200MG PA<br />

ETOPOPHOS INJ 100MG PA<br />

ETOPOSIDE CAP 50MG<br />

etoposide cap 50mg<br />

etoposide cap 50 mg<br />

ETOPOSIDE CAP 50 MG<br />

etoposide inj 20 mg/ml PA<br />

FASLODEX INJ 125MG PA<br />

FASLODEX INJ 250MG PA<br />

FIRMAGON INJ 120MG PA<br />

FIRMAGON INJ 80MG PA<br />

floxuridine for inj 0.5 gm PA<br />

fludarabine phosphate for inj 50 mg PA<br />

fludarabine phosphate inj 25 mg/ml PA<br />

fluorouracil inj 50 mg/ml PA<br />

FOLOTYN INJ 20MG/ML PA<br />

FOLOTYN INJ 40MG/2ML PA<br />

GEMZAR INJ 1 GM PA<br />

GEMZAR INJ 200MG PA<br />

HERCEPTIN INJ 440MG PA<br />

HEXALEN CAP 50MG<br />

HYCAMTIN INJ 4MG PA<br />

hydroxyurea cap 500mg<br />

hydroxyurea cap 500 mg<br />

idarubicin hcl iv inj 1 mg/ml PA<br />

IFEX INJ 3GM PA<br />

IFOSFAMIDE INJ 3GM PA<br />

IFOSFAMIDE KIT MESNA PA<br />

ifosfamide & mesna inj kit 1000-1000 mg PA<br />

ifosfamide & mesna inj kit 3000-1000 mg PA<br />

ifosfamide for inj 1 gm PA<br />

ifosfamide iv inj 50 mg/ml PA<br />

INTRON-A INJ 10MU PA<br />

INTRON-A INJ 10MU PEN PA<br />

INTRON-A INJ 18MU PA<br />

INTRON-A INJ 25MU PA<br />

INTRON-A INJ 3MU PEN PA<br />

INTRON-A INJ 50MU PA<br />

INTRON-A INJ 5MU PEN PA<br />

INTRON-A KIT 10MU/ML PA<br />

IRESSA TAB 250MG PA<br />

irinotecan hcl inj 20 mg/ml PA<br />

ISTODAX INJ 10MG PA<br />

IXEMPRA KIT INJ 15MG PA<br />

IXEMPRA KIT INJ 45MG PA<br />

LEUKERAN TAB 2MG<br />

LEUPROLIDE INJ 1MG/0.2 PA<br />

leuprolide acetate inj kit 5 mg/ml PA<br />

LOMUSTINE CAP 10 MG<br />

LOMUSTINE CAP 100 MG<br />

LOMUSTINE CAP 40 MG<br />

LOMUSTINE CAP DOSE PACK<br />

LUPR DEP-PED INJ 11.25MG PA<br />

LUPR DEP-PED INJ 15MG PA<br />

LUPR DEP-PED INJ 7.5MG PA<br />

LUPRON DEPOT INJ 11.25MG PA<br />

LUPRON DEPOT INJ 22.5MG PA<br />

LUPRON DEPOT INJ 3.75MG PA<br />

LUPRON DEPOT INJ 30MG PA<br />

LUPRON DEPOT INJ 7.5MG PA<br />

LYSODREN TAB 500MG<br />

MATULANE CAP 50MG<br />

megestrol ac sus 400mg/10<br />

megestrol ac sus 40mg/ml<br />

megestrol ac sus 800mg/20<br />

megestrol ac tab 20mg<br />

megestrol ac tab 40mg<br />

megestrol acetate susp 40 mg/ml<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 31


megestrol acetate tab 20 mg<br />

megestrol acetate tab 40 mg<br />

melphalan hcl for inj 50 mg (base equiv) PA<br />

MELPHALAN TAB 2 MG<br />

mercaptopur tab 50mg<br />

mercaptopurine tab 50 mg<br />

methotrexate sodium for inj 1 gm PA<br />

methotrexate sodium inj 25 mg/ml PA<br />

methotrexate sodium inj pf 25 mg/ml PA<br />

METHOTREXATE SODIUM TAB 2.5 MG (ANTIRHEUMATIC)<br />

methotrexate sodium tab 2.5 mg (antirheumatic)<br />

methotrexate sodium tab 2.5 mg (base equiv) NF<br />

methotrexate tab 2.5mg<br />

methotrexate tab 2.5mg NF<br />

mitomycin for inj 20 mg PA<br />

mitomycin for inj 40 mg PA<br />

mitomycin for inj 5 mg PA<br />

MITOTANE TAB 500 MG<br />

mitoxantrone hcl inj conc 2 mg/ml PA<br />

MUSTARGEN INJ 10MG PA<br />

MYLERAN TAB 2MG<br />

MYLOTARG INJ 5MG PA<br />

ONCASPAR INJ 750/ML PA<br />

ONTAK INJ 150/ML PA<br />

oxaliplatin iv soln 5 mg/ml PA<br />

oxaliplatin for iv inj 100 mg PA<br />

oxaliplatin for iv inj 50 mg PA<br />

paclitaxel iv conc 6 mg/ml PA<br />

pentostatin for inj 10 mg PA<br />

PHOTOFRIN INJ 75MG PA<br />

PLENAXIS INJ 100MG PA<br />

PROCARBAZINE HCL CAP 50 MG<br />

PROLEUKIN INJ 22MU PA<br />

PROVENGE INJ PA<br />

RHEUMATREX TAB 2.5MG<br />

RITUXAN INJ 100MG PA<br />

RITUXAN INJ 500MG PA<br />

ROFERON-A KIT 3MU/0.5 PA<br />

ROFERON-A KIT 6MU/0.5 PA<br />

ROFERON-A KIT 9MU/0.5 PA<br />

SUPPRELIN LA KIT 50MG PA<br />

TABLOID TAB 40MG<br />

TARGRETIN CAP 75MG<br />

TAXOTERE INJ 20/0.5ML PA<br />

TAXOTERE INJ 80MG/2ML PA<br />

TEMODAR INJ 100MG PA<br />

THIOGUANINE TAB 40 MG<br />

THIOTEPA INJ 15MG PA<br />

thiotepa for inj 15 mg PA<br />

TORISEL SOL 25MG/ML PA<br />

TREANDA INJ 100MG PA<br />

TREANDA INJ 25MG PA<br />

TRELSTAR DEP INJ 3.75MG PA<br />

TRELSTAR LA INJ 11.25MG PA<br />

TRELSTAR MIX INJ 22.5MG PA<br />

tretinoin cap 10mg<br />

tretinoin cap 10 mg<br />

TRISENOX SOL 10MG/10M PA<br />

VANTAS KIT 50MG PA<br />

VECTIBIX INJ 100MG PA<br />

VECTIBIX INJ 200MG PA<br />

VECTIBIX INJ 400MG PA<br />

VELCADE INJ 3.5MG PA<br />

VIADUR KIT PA<br />

VIDAZA INJ 100MG PA<br />

VINBLASTINE INJ 10MG PA<br />

VINBLASTINE INJ 1MG/ML PA<br />

vincristine sulfate iv soln 1 mg/ml PA<br />

vinorelbine tartrate inj 10 mg/ml PA<br />

VUMON INJ 50MG/5ML PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 32


ZANOSAR INJ 1GM PA<br />

ZEVALIN KIT IN-111 PA<br />

ZEVALIN KIT Y-90 PA<br />

ZOLADEX IMP 10.8MG PA<br />

ZOLADEX IMP 3.6MG PA<br />

Autonomic <strong>Drugs</strong><br />

Parasympathomimetic (Cholinergic) Agents<br />

bethanechol tab 10mg<br />

bethanechol tab 25mg<br />

bethanechol tab 50mg<br />

bethanechol tab 5mg<br />

bethanechol chloride tab 10 mg<br />

bethanechol chloride tab 25 mg<br />

bethanechol chloride tab 5 mg<br />

bethanechol chloride tab 50 mg<br />

ENLON-PLUS INJ PA<br />

ENLON-PLUS INJ 10-0.14 PA<br />

MESTINON SYP 60MG/5ML<br />

MESTINON TAB TIMESPAN<br />

neostigmine methylsulfate inj 0.5 mg/ml (1:2000) PA<br />

neostigmine methylsulfate inj 1 mg/ml PA<br />

PHYSOS SALIC INJ 1MG/ML PA<br />

physostigmine salicylate inj 1 mg/ml PA<br />

pyridostigm tab 60mg<br />

PYRIDOSTIGMINE BROMIDE SYRUP 60 MG/5ML<br />

pyridostigmine bromide tab 60 mg<br />

PYRIDOSTIGMINE BROMIDE TAB CR 180 MG<br />

REGONOL INJ 5MG/ML PA<br />

Anticholinergic Agents<br />

Antimuscarinics/Antispasmodics<br />

alkabel-sr tab<br />

antispasmod elx<br />

ATROPINE SUL INJ 0.05MG/1 PA<br />

ATROPINE SUL INJ 0.4/0.5 PA<br />

atropine sulfate inj 0.1 mg/ml PA<br />

atropine sulfate inj 0.4 mg/ml PA<br />

atropine sulfate inj 1 mg/ml PA<br />

ATROVENT HFA AER 17MCG QL<br />

bella alk/pb elx<br />

bella alk/pb elx<br />

bella alk/pb tab 16.2mg<br />

belladonna alkaloids-phenobarbital elixir 16 mg/5ml<br />

belladonna alkaloids-phenobarbital tab 16.2 mg<br />

belladonna alkaloids-phenobarbital tab cr 48 mg<br />

chlord/clidi cap 5-2.5mg<br />

chlord/clidi cap 5-2.5mg<br />

chlord/clidi cap 5-2.5mg<br />

clidi/chlord cap 2.5-5mg<br />

clidinium & chlordiazepoxide cap 2.5-5 mg<br />

colidrops dro 0.125/ml<br />

COLYTROL DRO PEDS PA<br />

dicyclomine cap 10mg<br />

dicyclomine tab 20mg<br />

dicyclomine hcl cap 10 mg<br />

dicyclomine hcl inj 10 mg/ml PA<br />

dicyclomine hcl oral soln 10 mg/5ml PA<br />

dicyclomine hcl tab 20 mg<br />

donnaphen tab<br />

glycopyrrolate inj 0.2 mg/ml PA<br />

haponal tab<br />

hyomax tab 0.125mg<br />

hyomax-sl sub 0.125mg<br />

hyoscyamine cap 0.375 cr<br />

hyoscyamine cap 0.375 er<br />

hyoscyamine cap 0.375 sr<br />

hyoscyamine cap 0.375 tr<br />

hyoscyamine dro 0.125/ml<br />

hyoscyamine elx 0.125/5<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 33


hyoscyamine sub 0.125mg<br />

hyoscyamine tab 0.125mg<br />

hyoscyamine sulfate cap sr 12hr 0.375 mg<br />

hyoscyamine sulfate elixir 0.125 mg/5ml<br />

hyoscyamine sulfate soln 0.125 mg/ml<br />

hyoscyamine sulfate tab 0.125 mg<br />

hyoscyamine sulfate tab sl 0.125 mg<br />

hyosyne dro 0.125/ml<br />

hyosyne elx 0.125/5<br />

ipratropium sol inhal<br />

ipratropium spr 0.03% QL<br />

IPRATROPIUM BROMIDE HFA INHAL AEROSOL 17 MCG/ACT QL<br />

ipratropium bromide inhal soln 0.02%<br />

ipratropium bromide nasal soln 0.03% (21 mcg/spray) QL<br />

lahey mixtur elx #3<br />

LEVSIN INJ 0.5MG/ML PA<br />

PROPANTHELIN TAB 15MG<br />

propanthelin tab 15mg<br />

propantheline bromide tab 15 mg<br />

PROPANTHELINE BROMIDE TAB 15 MG<br />

re-pb hyos elx 16mg/5ml<br />

SCOPOLAMINE INJ 0.4MG/ML PA<br />

servira tab 48mg<br />

spasdel dro 0.125/ml<br />

spasdel elx 0.125/5<br />

spasdel tab 0.125mg<br />

symax-sl sub 0.125mg<br />

Sympathomimetic (Adrenergic) Agents<br />

alpha-Adrenergic Agonists<br />

666 cold tab 5-325mg OTC<br />

contac tab cold+flu OTC<br />

cvs daytime cap sinus OTC<br />

day-time cap sinus OTC<br />

eql sinus tab cng/pain OTC<br />

EXTENDRYL TAB PEM<br />

flu/cold pak daytime OTC<br />

gnp day time cap sinus OTC<br />

gnp flu/cold pak daytime OTC<br />

gnp sinus tab 5-325mg OTC<br />

gnp sinus tab cng/pain OTC<br />

mapap sinus tab max st OTC<br />

non-pseudo tab sinus OTC<br />

pain relief tab sinus pe OTC<br />

pain relievr tab sinus pe OTC<br />

pain rlf sin tab pe day OTC<br />

phenylephrine hcl inj 10 mg/ml PA<br />

phenylephrine w/ acetaminophen cap 5-325 mg OTC<br />

PHENYLEPHRINE W/ ACETAMINOPHEN DROPS 1.25-80 MG/0.8ML OTC<br />

phenylephrine w/ acetaminophen powd pack 10-650 mg OTC<br />

phenylephrine w/ acetaminophen tab 5-325 mg OTC<br />

phenylephrine w/ acetaminophen tab 5-500 mg OTC<br />

PHENYLEPHRINE-METHSCOPOLAMINE TAB CR 30-1.25 MG<br />

pyrroxate tab 5-325mg OTC<br />

qc daytime cap sinus OTC<br />

qc sinus pai tab relief OTC<br />

ra sinus cng tab /pain dt OTC<br />

sb daytime cap sinus OTC<br />

sb sinus cng tab /pain dt OTC<br />

sinus congst tab /pain dt OTC<br />

sinus congst tab /pain dt OTC<br />

sinus congst tab daytime OTC<br />

sinus congst tab expr gel OTC<br />

sinus formul tab daytime OTC<br />

sinus pain tab day/rr OTC<br />

sinus pain tab daytime OTC<br />

sinus relief tab 5-325mg OTC<br />

sinutab sinu tab max st OTC<br />

sudafed pe tab sinus OTC<br />

suphedrine tab pe OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 34


suphedrn pe tab 5-325mg OTC<br />

TYLENOL INF DRO PLUS CLD OTC<br />

tylenol sinu tab cng/pain OTC<br />

tylenol sinu tab cng/rr OTC<br />

wal-flu cold pak daytime OTC<br />

wal-phed pe tab sinus ha OTC<br />

beta-Adrenergic Agonists<br />

ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV)<br />

PROAIR HFA AER<br />

Non-selective beta-Adrenergic Agonists<br />

ISUPREL INJ 0.2MG/ML PA<br />

Selective beta-1-Adrenergic Agonists<br />

dobutamine hcl inj 12.5 mg/ml PA<br />

dobutamine inj 1 mg/ml in d5w PA<br />

dobutamine inj 2 mg/ml in d5w PA<br />

dobutamine inj 4 mg/ml in d5w PA<br />

DOPAMINE INJ 160MG/ML PA<br />

dopamine hcl inj 40 mg/ml PA<br />

dopamine hcl inj 80 mg/ml PA<br />

dopamine inj 0.8 mg/ml in d5w PA<br />

dopamine inj 1.6 mg/ml in d5w PA<br />

dopamine inj 3.2 mg/ml in d5w PA<br />

Selective beta-2-Adrenergic Agonists<br />

ADVAIR DISKU AER 100/50 QL<br />

ADVAIR DISKU AER 250/50 QL<br />

ADVAIR DISKU AER 500/50 QL<br />

ADVAIR HFA AER 115/21 PA<br />

ADVAIR HFA AER 230/21 PA<br />

ADVAIR HFA AER 45/21 PA<br />

albuterol neb 0.083%<br />

albuterol neb 0.5%<br />

albuterol neb 0.63mg/3<br />

albuterol neb 1.25mg/3<br />

albuterol syp 2mg/5ml<br />

albuterol tab 2mg<br />

albuterol tab 4mg<br />

albuterol tab 4mg er<br />

albuterol tab 8mg er<br />

ALBUTEROL SULFATE INHAL AERO 108 MCG/ACT (90MCG BASE EQUIV)<br />

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)<br />

albuterol sulfate soln nebu 0.5% (5 mg/ml)<br />

albuterol sulfate soln nebu 0.63 mg/3ml (base equiv)<br />

albuterol sulfate soln nebu 1.25 mg/3ml (base equiv)<br />

albuterol sulfate syrup 2 mg/5ml<br />

albuterol sulfate tab 2 mg<br />

albuterol sulfate tab 4 mg<br />

albuterol sulfate tab sr 12hr 4 mg<br />

albuterol sulfate tab sr 12hr 8 mg<br />

ALUPENT INH AER 0.65/ACT QL<br />

FLUTICASONE-SALMETEROL AER POWDER BA 100-50 MCG/DOSE QL<br />

FLUTICASONE-SALMETEROL AER POWDER BA 250-50 MCG/DOSE QL<br />

FLUTICASONE-SALMETEROL AER POWDER BA 500-50 MCG/DOSE QL<br />

FORADIL CAP AEROLIZE QL<br />

FORMOTEROL FUMARATE INHAL CAP 12 MCG QL<br />

MAXAIR AUTOH AER 200MCG<br />

metaproteren neb 0.4%<br />

metaproteren neb 0.6%<br />

metaproteren syp 10mg/5ml<br />

metaproteren tab 10mg<br />

METAPROTEREN TAB 10MG<br />

METAPROTEREN TAB 20MG<br />

metaproteren tab 20mg<br />

METAPROTERENOL SULFATE INHAL AEROSOL POW 0.65 MG/ACT QL<br />

metaproterenol sulfate soln nebu 0.4%<br />

metaproterenol sulfate soln nebu 0.6%<br />

metaproterenol sulfate syrup 10 mg/5ml<br />

METAPROTERENOL SULFATE TAB 10 MG<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 35


metaproterenol sulfate tab 10 mg<br />

METAPROTERENOL SULFATE TAB 20 MG<br />

metaproterenol sulfate tab 20 mg<br />

PIRBUTEROL ACETATE BREATH ACTIVATED INHAL AEROSOL 200MCG/INH<br />

PROAIR HFA AER<br />

PROVENTIL AER HFA<br />

SALMETEROL XINAFOATE AER POW BA 50 MCG/DOSE (BASE EQUIV) QL<br />

SEREVENT DIS AER 50MCG QL<br />

terbutaline tab 2.5mg<br />

terbutaline tab 5mg<br />

terbutaline sulfate inj 1 mg/ml PA<br />

terbutaline sulfate tab 2.5 mg<br />

terbutaline sulfate tab 5 mg<br />

VENTOLIN HFA AER<br />

alpha- and beta-Adrenergic Agonists<br />

666 cold tab 30-500mg OTC<br />

ADRENACLICK INJ 0.15MG PA<br />

ADRENACLICK INJ 0.3MG QL<br />

ADVIL COLD/ CAP SINUS OTC<br />

af-ibup sinu tab 30-200mg OTC<br />

amdry-d tab 120-2.5<br />

apap sinus tab 30-500mg OTC<br />

bl ibu-profe tab cold/sin OTC<br />

child advil sus cold OTC<br />

child ibupro sus cold OTC<br />

cold tab 30-325mg OTC<br />

cvs ibuprofn tab cold/sin OTC<br />

cvs si/ha/de tab 30-500mg OTC<br />

cvs sinus tab max-str OTC<br />

dilotab tab OTC<br />

dimetapp sus cold/fvr OTC<br />

dristan tab sinus OTC<br />

dristan cold tab no-drows OTC<br />

eck ibuprofn tab cold/sin OTC<br />

eck infant dro cold OTC<br />

eck sinus tab headache OTC<br />

ephedrine sulfate inj 50 mg/ml PA<br />

EPHEDRINE W/ ASPIRIN-CAFF-ACETANILID CAP 30-180-15-60 MG OTC<br />

EPINEPHRINE INJ PA<br />

EPINEPHRINE INJ 0.15MG PA<br />

EPINEPHRINE INJ 0.3MG QL<br />

epinephrine hcl inj 0.1 mg/ml PA<br />

epinephrine hcl inj 1 mg/ml PA<br />

EPINEPHRINE INJ DEVICE 0.15 MG/0.3ML (1:2000) QL<br />

EPINEPHRINE INJ DEVICE 0.3 MG/0.3ML (1:1000) QL<br />

EPINEPHRINE INJ DEVICE 0.3 MG/0.3ML (1:1000) QL<br />

EPIPEN INJ 0.3MG QL<br />

EPIPEN 2-PAK INJ 0.3MG QL<br />

EPIPEN-JR INJ 0.15MG QL<br />

EPIPEN-JR INJ 2-PAK QL<br />

eq ibuprofen sus cold OTC<br />

eq ibuprofen tab cold/sin OTC<br />

eq sinus rel tab max st OTC<br />

eql ibuprofn tab cold/sin OTC<br />

eql sinus tab headache OTC<br />

extendryl tab pse<br />

genapap sinu tab max-str OTC<br />

gnp chld ibu sus cold OTC<br />

gnp ibuprofn tab cold/sin OTC<br />

HAYSMA CAP OTC<br />

ibu-profen tab cold/sin OTC<br />

ibu/pse tab cold/sin OTC<br />

ibuprofen sus cold OTC<br />

ibuprofen sus cold OTC<br />

ibuprofen tab cold/sin OTC<br />

ibuprofen tab cold/sin OTC<br />

ibuprofn/pse tab 200/30mg OTC<br />

infant pain dro rel/cold OTC<br />

infant pain dro rel/cold OTC<br />

iprin cold/ tab sinus OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 36


mapap sinus tab max-str OTC<br />

medi-profen tab cold/sin OTC<br />

medi-synal tab 30-325mg OTC<br />

medi-tabs tab sinus OTC<br />

motrin cold tab & sinus OTC<br />

nasal decon tab sinus OTC<br />

non aspirin sol OTC<br />

non-asa tab sinus OTC<br />

non-asa sinu tab 30-500mg OTC<br />

non-asa sinu tab 30-500mg OTC<br />

non-asa sinu tab max str OTC<br />

non-drowsy tab sinus OTC<br />

norepinephrine bitartrate inj 1 mg/ml PA<br />

ornex tab max st OTC<br />

ornex tab max str OTC<br />

pain relief tab sinus OTC<br />

pain relief tab sinus OTC<br />

pain relief tab sinus OTC<br />

pain relieve tab 30-500mg OTC<br />

pain relieve tab sinus OTC<br />

pain relievr tab sinus OTC<br />

profen ib tab cold/sin OTC<br />

pse/methscop tab 120/2.5<br />

pseudoephedrine w/ acetaminophen cap 30-325 mg OTC<br />

PSEUDOEPHEDRINE W/ ACETAMINOPHEN CAP 30-500 MG OTC<br />

PSEUDOEPHEDRINE W/ ACETAMINOPHEN LIQUID 15-160 MG/5ML OTC<br />

pseudoephedrine w/ acetaminophen soln 7.5-80 mg/0.8ml OTC<br />

pseudoephedrine w/ acetaminophen tab 30-325 mg OTC<br />

pseudoephedrine w/ acetaminophen tab 30-500 mg OTC<br />

PSEUDOEPHEDRINE-IBUPROFEN CAP 30-200 MG OTC<br />

pseudoephedrine-ibuprofen susp 15-100 mg/5ml OTC<br />

pseudoephedrine-ibuprofen tab 30-200 mg OTC<br />

pseudoephedrine-methscopolamine tab sr 12hr 120-2.5 mg<br />

px ibuprofen tab cold/sin OTC<br />

qc daytime cap sinus OTC<br />

qc ibuprofen tab cold/sin OTC<br />

ra ibu-profe tab cold/sin OTC<br />

ra ibuprofen sus cold OTC<br />

ra sinus tab formula OTC<br />

respivent-d tab<br />

sb ibuprofen tab cold/sin OTC<br />

SB NON ASA CAP SINUS OTC<br />

sb pseudoeph tab sinus OTC<br />

sg su-phedri tab max st OTC<br />

sinus tab OTC<br />

sinus tab 30-325mg OTC<br />

sinus headac tab no drows OTC<br />

sinus max tab 30-500mg OTC<br />

sinus max st tab 30-500mg OTC<br />

sinus max st tab 30-500mg OTC<br />

sinus no drw tab max str OTC<br />

sinus non- tab drowsy OTC<br />

sinus non-dr tab max str OTC<br />

sinus pain tab max str OTC<br />

sinus pain/ tab pressure OTC<br />

sinus relief tab 30-325mg OTC<br />

sinus w/o tab drows OTC<br />

sinus w/o tab drowsy OTC<br />

sinutab m/s tab non-drow OTC<br />

sinutab sinu tab no drows OTC<br />

sm ibuprofen sus cold OTC<br />

sm non asa tab sinus OTC<br />

sm sinus tab headache OTC<br />

sm sinus tab max st OTC<br />

su-phedrin tab sinus ms OTC<br />

sudafed tab sinus OTC<br />

sudafed sinu tab ext str OTC<br />

sudatrate tab<br />

suphedrin tab sinus ms OTC<br />

suphedrine tab sinus OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 37


suphedrine tab sinus OTC<br />

sw cold/sinu tab pain rel OTC<br />

tavist sinus tab nd/ms OTC<br />

TWINJECT INJ 0.15MG PA<br />

TWINJECT INJ 0.15MG PA<br />

TWINJECT INJ 0.3MG QL<br />

TWINJECT INJ 0.3MG QL<br />

TYLENOL CHLD LIQ SINUS OTC<br />

tylenol inf dro plus cld OTC<br />

wal-profen tab cold/sin OTC<br />

Sympatholytic (Adrenergic Block) Agents<br />

Skeletal Muscle Relaxants<br />

CENTRALLY ACTING SKELETAL MUSCLE RELAXANTS<br />

AMRIX CAP 15MG<br />

AMRIX CAP 30MG<br />

carisopr/asa tab 200-325 QL<br />

CARISOPRODOL TAB 250 MG QL<br />

carisoprodol tab 350 mg QL<br />

carisoprodol tab 350mg QL<br />

carisoprodol w/ aspirin tab 200-325 mg QL<br />

cyclobenzapr tab 10mg<br />

cyclobenzapr tab 5mg<br />

CYCLOBENZAPRINE HCL CAP SR 24HR 15 MG<br />

CYCLOBENZAPRINE HCL CAP SR 24HR 30 MG<br />

cyclobenzaprine hcl tab 10 mg<br />

cyclobenzaprine hcl tab 5 mg<br />

CYCLOBENZAPRINE HCL TAB 7.5 MG<br />

FEXMID TAB 7.5MG<br />

FEXMID TAB 7.5MG PA<br />

ROBAXIN INJ 100MG/ML PA<br />

SOMA TAB 250MG QL<br />

SOMA TAB 250MG PA<br />

DIRECT ACTING SKELETAL MUSCLE RELAXANTS<br />

DANTRIUM IV INJ 20MG PA<br />

dantrolene sodium for iv soln 20 mg PA<br />

GABA DERIVATIVE SKELETAL MUSCLE RELAXANTS<br />

baclofen tab 10mg<br />

baclofen tab 20mg<br />

baclofen tab 10 mg<br />

baclofen tab 20 mg<br />

LIORESAL INT INJ 0.05MG/1 PA<br />

LIORESAL INT INJ 10MG/20 PA<br />

LIORESAL INT INJ 10MG/5ML PA<br />

LIORESAL INT INJ 40MG/20 PA<br />

NEUROMUSCULAR BLOCKING AGENTS<br />

atracurium besylate iv soln 10 mg/ml PA<br />

NIMBEX INJ 10MG/ML PA<br />

NIMBEX INJ 2MG/ML PA<br />

pancuronium bromide inj 1 mg/ml PA<br />

pancuronium bromide inj 2 mg/ml PA<br />

QUELICIN INJ -1000 PA<br />

rocuronium bromide iv soln 10 mg/ml PA<br />

tizanidine tab 2mg NF<br />

tizanidine hcl tab 2 mg NF<br />

vecuronium bromide for inj 10 mg PA<br />

vecuronium bromide for inj 20 mg PA<br />

SKELETAL MUSCLE RELAXANTS<br />

orphenadrine citrate inj 30 mg/ml PA<br />

orphenadrine citrate tab sr 12hr 100 mg<br />

orphenadrine tab 100mg cr<br />

orphenadrine tab 100mg er<br />

Autonomic <strong>Drugs</strong>, Miscellaneous<br />

CHANTIX PAK 0.5& 1MG PA<br />

CHANTIX PAK 1MG PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 38


CHANTIX TAB 0.5MG PA<br />

CHANTIX TAB 1MG PA<br />

nicotine polacrilex gum 2 mg PA OTC<br />

nicotine polacrilex gum 4 mg PA OTC<br />

nicotine polacrilex lozenge 2 mg PA OTC<br />

nicotine polacrilex lozenge 4 mg PA OTC<br />

NICOTINE SYS KIT TRANSDER PA OTC<br />

nicotine td patch 24hr 11 mg/24hr PA OTC<br />

nicotine td patch 24hr 14 mg/24hr PA OTC<br />

nicotine td patch 24hr 14 mg/24hr PA<br />

nicotine td patch 24hr 21 mg/24hr PA OTC<br />

nicotine td patch 24hr 21 mg/24hr PA<br />

nicotine td patch 24hr 22 mg/24hr PA OTC<br />

nicotine td patch 24hr 7 mg/24hr PA OTC<br />

nicotine td patch 24hr 7 mg/24hr PA<br />

NICOTROL INH PA<br />

NICOTROL NS SPR 10MG/ML PA<br />

Blood Derivatives<br />

albumin, human inj 25% PA<br />

albumin, human inj 5% PA<br />

PANHEMATIN INJ 313MG PA<br />

PLAS/SD SOL GROUP B PA<br />

PLASBUMIN-20 INJ PA<br />

PLASMANATE INJ 5% PA<br />

Blood Formation, Coagulation & Thrombosis<br />

Antianemia <strong>Drugs</strong><br />

Iron Preparations<br />

*IRON COMBINATION CAP CR*** NF<br />

*iron combination cap***<br />

conison cap<br />

fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg<br />

feogen cap<br />

FERAHEME INJ 510/17ML PA<br />

ferocon cap<br />

ferotrin cap<br />

ferotrinsic cap<br />

ferragen cap<br />

ferrex 150 cap forte<br />

FERRLECIT INJ 12.5MG/M PA<br />

FETRIN CAP NF<br />

foltrin cap<br />

hematogen cap<br />

ICAR PEDS SUS OTC<br />

ICAR PEDS SUS GRAPE OTC<br />

iferex 150 cap forte<br />

IROFOL LIQ<br />

iron dextran inj 50 mg/ml PA<br />

iron polysacch complex-vit b12-fa cap 150-0.025-1 mg<br />

IRON SUSP 15 MG/1.25ML OTC<br />

IRON SUSP 15 MG/1.5ML OTC<br />

IRON-FOLIC ACID LIQUID 100-1 MG/5ML<br />

martinic cap<br />

myferon 150 cap forte<br />

MYKIDZ IRON SUS 15/1.5ML OTC<br />

NEOTRON-S INJ PA<br />

poly/iron cap 150 fort<br />

polysacchari cap iron<br />

tl icon cap<br />

tricon cap<br />

VENOFER INJ 20MG/ML PA<br />

Antithrombotic Agents<br />

Coumarin Derivatives<br />

COUMADIN INJ 5 MG PA<br />

COUMADIN TAB 10MG<br />

COUMADIN TAB 1MG<br />

COUMADIN TAB 2.5MG<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 39


COUMADIN TAB 2MG<br />

COUMADIN TAB 3MG<br />

COUMADIN TAB 4MG<br />

COUMADIN TAB 5MG<br />

COUMADIN TAB 6MG<br />

COUMADIN TAB 7.5MG<br />

jantoven tab 10mg<br />

jantoven tab 1mg<br />

jantoven tab 2.5mg<br />

jantoven tab 2mg<br />

jantoven tab 3mg<br />

jantoven tab 4mg<br />

jantoven tab 5mg<br />

jantoven tab 6mg<br />

jantoven tab 7.5mg<br />

warfarin tab 10mg<br />

warfarin tab 1mg<br />

warfarin tab 2.5mg<br />

warfarin tab 2mg<br />

warfarin tab 3mg<br />

warfarin tab 4mg<br />

warfarin tab 5mg<br />

warfarin tab 6mg<br />

warfarin tab 7.5mg<br />

warfarin sodium tab 1 mg<br />

WARFARIN SODIUM TAB 1 MG<br />

WARFARIN SODIUM TAB 10 MG<br />

warfarin sodium tab 10 mg<br />

WARFARIN SODIUM TAB 2 MG<br />

warfarin sodium tab 2 mg<br />

WARFARIN SODIUM TAB 2.5 MG<br />

warfarin sodium tab 2.5 mg<br />

WARFARIN SODIUM TAB 3 MG<br />

warfarin sodium tab 3 mg<br />

warfarin sodium tab 4 mg<br />

WARFARIN SODIUM TAB 4 MG<br />

WARFARIN SODIUM TAB 5 MG<br />

warfarin sodium tab 5 mg<br />

warfarin sodium tab 6 mg<br />

WARFARIN SODIUM TAB 6 MG<br />

warfarin sodium tab 7.5 mg<br />

WARFARIN SODIUM TAB 7.5 MG<br />

Direct Thrombin Inhibitors<br />

ANGIOMAX INJ 250MG PA<br />

ARGATROBAN INJ 100MG/ML PA<br />

REFLUDAN INJ 50MG PA<br />

Heparins<br />

FRAGMIN INJ 10000/ML PA<br />

FRAGMIN INJ 12500UNT PA<br />

FRAGMIN INJ 15000UNT PA<br />

FRAGMIN INJ 18000UNT PA<br />

FRAGMIN INJ 2500/0.2 PA<br />

FRAGMIN INJ 25000/ML PA<br />

FRAGMIN INJ 5000/0.2 PA<br />

FRAGMIN INJ 7500/0.3 PA<br />

HEP SOD/NACL INJ 12500UNT PA<br />

HEP SOD/NACL INJ 25000UNT PA<br />

HEPARIN LOCK INJ 2UNIT/ML PA<br />

HEPARIN SOD INJ 2000/ML PA<br />

HEPARIN SOD INJ 20000/ML PA<br />

HEPARIN SOD INJ 2500/ML PA<br />

heparin sodium (porcine) 100 unit/ml in d5w PA<br />

heparin sodium (porcine) 100 unit/ml in sodium chloride 0.9% PA<br />

heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9% PA<br />

heparin sodium (porcine) 40 unit/ml in d5w PA<br />

heparin sodium (porcine) 50 unit/ml in d5w PA<br />

heparin sodium (porcine) inj 1000 unit/ml PA<br />

heparin sodium (porcine) inj 10000 unit/ml PA<br />

heparin sodium (porcine) inj 5000 unit/ml PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 40


heparin sodium (porcine) lock flush iv soln 1 unit/ml PA<br />

heparin sodium (porcine) lock flush iv soln 10 unit/ml PA<br />

heparin sodium (porcine) lock flush iv soln 100 unit/ml PA<br />

heparin sodium (porcine) lock flush soln 10 unit/ml PA<br />

heparin sodium (porcine) lock flush soln 100 unit/ml PA<br />

heparin sodium (porcine) w/ nacl lock flush kit 10 unit/ml PA<br />

heparin sodium (porcine) w/ nacl lock flush kit 100 unit/ml PA<br />

INNOHEP INJ 20000/ML PA<br />

LOVENOX INJ 100/1ML PA<br />

LOVENOX INJ 120/0.8 PA<br />

LOVENOX INJ 150/1ML PA<br />

LOVENOX INJ 30/0.3ML PA<br />

LOVENOX INJ 300/3ML PA<br />

LOVENOX INJ 40/0.4ML PA<br />

LOVENOX INJ 60/0.6ML PA<br />

LOVENOX INJ 80/0.8ML PA<br />

Miscellaneous Anticoagulants<br />

ARIXTRA SOL 10/0.8 PA<br />

ARIXTRA SOL 2.5/0.5 PA<br />

ARIXTRA SOL 5.0/0.4 PA<br />

ARIXTRA SOL 7.5/0.6 PA<br />

ATRYN INJ 1750 PA<br />

CEPROTIN INJ 1000UNIT PA<br />

CEPROTIN INJ 500 UNIT PA<br />

THROMBAT III INJ 1000UNIT PA<br />

THROMBAT III INJ 500UNIT PA<br />

Platelet-Aggregation Inhibitors<br />

AGGRASTAT INJ 12.5/50 PA<br />

AGGRASTAT INJ 25MG/500 PA<br />

clopidogrel tab 75mg<br />

CLOPIDOGREL BISULFATE TAB 300 MG (BASE EQUIV)<br />

clopidogrel bisulfate tab 75 mg (base equiv)<br />

CLOPIDOGREL BISULFATE TAB 75 MG (BASE EQUIV)<br />

INTEGRILIN INJ 0.75MG/1 PA<br />

INTEGRILIN INJ 2MG/ML PA<br />

PLAVIX TAB 300MG<br />

PLAVIX TAB 75MG<br />

REOPRO INJ 2MG/ML PA<br />

Thrombolytic Agents<br />

ABBOKINASE INJ 250000 PA<br />

ACTIVASE INJ 100MG PA<br />

ACTIVASE INJ 50MG PA<br />

CATHFLO ACTI INJ VASE PA<br />

KINLYTIC INJ 250000 PA<br />

RETAVASE INJ PA<br />

RETAVASE INJ HALF-KIT PA<br />

TNKASE KIT 50MG PA<br />

Hematopoietic Agents<br />

ARANESP INJ 100MCG PA<br />

ARANESP INJ 100MCG PA<br />

ARANESP INJ 100MCG PA<br />

ARANESP INJ 150MCG PA<br />

ARANESP INJ 150MCG PA<br />

ARANESP INJ 150MCG PA<br />

ARANESP INJ 200MCG PA<br />

ARANESP INJ 200MCG PA<br />

ARANESP INJ 200MCG PA<br />

ARANESP INJ 25MCG PA<br />

ARANESP INJ 25MCG PA<br />

ARANESP INJ 25MCG PA<br />

ARANESP INJ 25MCG/ML PA<br />

ARANESP INJ 300MCG PA<br />

ARANESP INJ 300MCG PA<br />

ARANESP INJ 300MCG PA<br />

ARANESP INJ 40MCG PA<br />

ARANESP INJ 40MCG PA<br />

ARANESP INJ 40MCG PA<br />

ARANESP INJ 40MCG/ML PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 41


ARANESP INJ 500MCG PA<br />

ARANESP INJ 60MCG PA<br />

ARANESP INJ 60MCG PA<br />

ARANESP INJ 60MCG PA<br />

ARANESP INJ 60MCG/ML PA<br />

EPOGEN INJ 10000/ML PA<br />

EPOGEN INJ 2000/ML PA<br />

EPOGEN INJ 20000/ML PA<br />

EPOGEN INJ 3000/ML PA<br />

EPOGEN INJ 4000/ML PA<br />

EPOGEN INJ 40000/ML PA<br />

LEUKINE INJ 250MCG PA<br />

LEUKINE INJ 500 MCG PA<br />

NEULASTA INJ 6MG/0.6M PA<br />

NEUMEGA INJ 5MG PA<br />

NEUPOGEN INJ 300/0.5 PA<br />

NEUPOGEN INJ 300MCG PA<br />

NEUPOGEN INJ 480/0.8 PA<br />

NEUPOGEN INJ 480MCG PA<br />

NPLATE INJ 250MCG PA<br />

NPLATE INJ 500MCG PA<br />

PROCRIT INJ 10000/ML PA<br />

PROCRIT INJ 2000/ML PA<br />

PROCRIT INJ 20000/ML PA<br />

PROCRIT INJ 3000/ML PA<br />

PROCRIT INJ 4000/ML PA<br />

PROCRIT INJ 40000/ML PA<br />

Antihemorrhagic Agents<br />

Antiheparin Agents<br />

PROTAMINE SU SOL 10MG/ML PA<br />

Hemostatics<br />

ADVATE INJ 1000UNIT PA<br />

ADVATE INJ 1500UNIT PA<br />

ADVATE INJ 2000UNIT PA<br />

ADVATE INJ 250UNIT PA<br />

ADVATE INJ 3000UNIT PA<br />

ADVATE INJ 500UNIT PA<br />

ALPHANATE INJ PA<br />

ALPHANATE INJ 250-500 PA<br />

ALPHANATE INJ VWF/HUM PA<br />

ALPHANINE SD INJ 1000UNIT PA<br />

ALPHANINE SD INJ 1500UNIT PA<br />

ALPHANINE SD INJ 250-1500 PA<br />

ALPHANINE SD INJ 500UNIT PA<br />

aminocaproic acid inj 250 mg/ml PA<br />

BEBULIN VH INJ 200-1200 PA<br />

BENEFIX INJ 1000UNIT PA<br />

BENEFIX INJ 2000UNIT PA<br />

BENEFIX INJ 250UNIT PA<br />

BENEFIX INJ 500UNIT PA<br />

CYKLOKAPRON INJ 100MG/ML PA<br />

FEIBA NF INJ PA<br />

FEIBA VH INJ IMMUNO PA<br />

GENARC INJ 1000UNIT PA<br />

GENARC INJ 250 UNIT PA<br />

GENARC INJ 500 UNIT PA<br />

HELIXATE INJ 2000UNIT PA<br />

HELIXATE FS INJ 1000UNIT PA<br />

HELIXATE FS INJ 250UNIT PA<br />

HELIXATE FS INJ 3000UNIT PA<br />

HELIXATE FS INJ 500UNIT PA<br />

HELIXATE FS SOL 1000UNIT PA<br />

HELIXATE FS SOL 250UNIT PA<br />

HELIXATE FS SOL 500UNIT PA<br />

HEMOFIL M INJ 1701+ PA<br />

HEMOFIL M INJ 220-400 PA<br />

HEMOFIL M INJ 401-800 PA<br />

HEMOFIL M INJ 801-1700 PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 42


HUMATE-P INJ 1000UNIT PA<br />

HUMATE-P INJ 2000UNIT PA<br />

HUMATE-P INJ 500UNIT PA<br />

HUMATE-P SOL 1200UNIT PA<br />

HUMATE-P SOL 2400UNIT PA<br />

HUMATE-P SOL 600UNIT PA<br />

KOATE-DVI INJ 1000UNIT PA<br />

KOATE-DVI INJ 250UNIT PA<br />

KOATE-DVI INJ 500UNIT PA<br />

KOGENATE FS INJ 1000/BS PA<br />

KOGENATE FS INJ 1000UNIT PA<br />

KOGENATE FS INJ 2000/BS PA<br />

KOGENATE FS INJ 2000UNIT PA<br />

KOGENATE FS INJ 250/BS PA<br />

KOGENATE FS INJ 250UNIT PA<br />

KOGENATE FS INJ 3000/BS PA<br />

KOGENATE FS INJ 3000UNIT PA<br />

KOGENATE FS INJ 500/BS PA<br />

KOGENATE FS INJ 500UNIT PA<br />

MONARC-M INJ 1701+ PA<br />

MONARC-M INJ 220-400 PA<br />

MONARC-M INJ 250-1100 PA<br />

MONARC-M INJ 401-800 PA<br />

MONARC-M INJ 801-1700 PA<br />

MONOCLATE-P INJ 1000UNIT PA<br />

MONOCLATE-P INJ 1500UNIT PA<br />

MONOCLATE-P INJ 250UNIT PA<br />

MONOCLATE-P INJ 500UNIT PA<br />

MONONINE INJ 1000UNIT PA<br />

MONONINE INJ 250UNIT PA<br />

MONONINE INJ 500UNIT PA<br />

NOVOSEVEN INJ 1200MCG PA<br />

NOVOSEVEN INJ 2400MCG PA<br />

NOVOSEVEN INJ 4800MCG PA<br />

NOVOSEVEN RT INJ 1MG PA<br />

NOVOSEVEN RT INJ 2MG PA<br />

NOVOSEVEN RT INJ 5MG PA<br />

PROFILNINE INJ PA<br />

PROFILNINE INJ 1000UNIT PA<br />

PROFILNINE INJ 1500UNIT PA<br />

PROFILNINE INJ 500UNIT PA<br />

PROPLEX T INJ FACT IX PA<br />

RECOMBINATE INJ 220-400 PA<br />

RECOMBINATE INJ 401-800 PA<br />

RECOMBINATE INJ 801-1240 PA<br />

REFACTO INJ 1000UNIT PA<br />

REFACTO INJ 2000UNIT PA<br />

REFACTO INJ 250UNIT PA<br />

REFACTO INJ 500UNIT PA<br />

RIASTAP SOL 1GM PA<br />

TRASYLOL INJ 10000/ML PA<br />

WILATE INJ PA<br />

XYNTHA INJ 1000UNIT PA<br />

XYNTHA INJ 2000UNIT PA<br />

XYNTHA INJ 250UNIT PA<br />

XYNTHA INJ 500UNIT PA<br />

Cardiovascular <strong>Drugs</strong><br />

Cardiac <strong>Drugs</strong><br />

Antiarrhythmic Agents<br />

procainamide hcl tab cr 750 mg NF<br />

procainamide tab 750mg er NF<br />

Class Ia Antiarrhythmics<br />

procainamide cap 250mg<br />

procainamide cap 500mg<br />

procainamide hcl cap 250 mg<br />

PROCAINAMIDE HCL CAP 375 MG<br />

procainamide hcl cap 500 mg<br />

PROCAINAMIDE HCL TAB 375 MG<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 43


PROCAINAMIDE HCL TAB 500 MG<br />

PROCAINAMIDE HCL TAB SR 12HR 1000 MG<br />

PROCAINAMIDE HCL TAB SR 12HR 500 MG<br />

PROCAINAMIDE INJ 100MG/ML PA<br />

PROCAINAMIDE INJ 500MG/ML PA<br />

PROCANBID TAB 1000 MG<br />

PROCANBID TAB 500MG CR<br />

PRONESTYL CAP 375MG<br />

PRONESTYL TAB 375MG<br />

PRONESTYL TAB 500MG<br />

QUINIDINE GL INJ 80MG/ML PA<br />

quinidine gl tab 324mg cr<br />

quinidine gl tab 324mg er<br />

quinidine gl tab 324mg sa<br />

quinidine gluconate tab cr 324 mg<br />

quinidine su tab 200mg<br />

quinidine su tab 300mg<br />

quinidine sulfate tab 200 mg<br />

quinidine sulfate tab 300 mg<br />

Class Ib Antiarrhythmics<br />

LIDOCAINE INJ 10MG/ML PA<br />

lidocaine hcl iv inj 10 mg/ml PA<br />

lidocaine hcl iv inj 10 mg/ml PA<br />

lidocaine hcl iv inj 20 mg/ml PA<br />

lidocaine iv infusion in d5w inj 2 mg/ml PA<br />

lidocaine iv infusion in d5w inj 4 mg/ml PA<br />

lidocaine iv infusion in d5w inj 8 mg/ml PA<br />

Class Ic Antiarrhythmics<br />

FLECAINIDE TAB 100MG<br />

FLECAINIDE ACETATE TAB 100 MG<br />

Class III Antiarrhythmics<br />

amiodarone tab 200mg<br />

amiodarone hcl inj 50 mg/ml PA<br />

amiodarone hcl tab 200 mg<br />

ibutilide fumarate inj 0.1 mg/ml PA<br />

pacerone tab 200mg<br />

Class IV Antiarrhythmics<br />

adenosine iv soln 3 mg/ml PA<br />

Cardiotonic Agents<br />

DIGOXIN SOL 50MCG/ML PA<br />

digoxin tab 0.125mg<br />

digoxin tab 0.25mg<br />

digoxin inj 0.25 mg/ml PA<br />

DIGOXIN TAB 0.125 MG<br />

digoxin tab 0.125 mg<br />

digoxin tab 0.25 mg<br />

DIGOXIN TAB 0.25 MG<br />

INAMRINONE INJ 5MG/ML PA<br />

LANOXIN INJ 0.1MG/ML PA<br />

LANOXIN TAB 0.125MG<br />

LANOXIN TAB 0.25MG<br />

milrinone in dextrose iv soln 200 mcg/ml PA<br />

milrinone lactate iv soln 1 mg/ml (base equivalent) PA<br />

Hypotensive Agents<br />

Central Alpha-Agonists<br />

clonidine tab 0.1mg<br />

clonidine tab 0.2mg<br />

clonidine tab 0.3mg<br />

clonidine hcl inj (for epidural infusion) 100 mcg/ml PA<br />

clonidine hcl inj (for epidural infusion) 500 mcg/ml PA<br />

clonidine hcl tab 0.1 mg<br />

clonidine hcl tab 0.2 mg<br />

clonidine hcl tab 0.3 mg<br />

DURACLON INJ PA<br />

methyldopa tab 250mg<br />

methyldopa tab 500mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 44


methyldopa tab 125mg<br />

methyldopa tab 125mg<br />

methyldopa tab 250 mg<br />

methyldopa tab 500 mg<br />

METHYLDOPATE INJ 250/5ML PA<br />

Direct Vasodilators<br />

fenoldopam mesylate iv inj 10 mg/ml (base equiv) PA<br />

hydralazine tab 100mg<br />

hydralazine tab 10mg<br />

hydralazine tab 25mg<br />

hydralazine tab 50mg<br />

hydralazine hcl inj 20 mg/ml PA<br />

hydralazine hcl tab 10 mg<br />

hydralazine hcl tab 100 mg<br />

hydralazine hcl tab 25 mg<br />

hydralazine hcl tab 50 mg<br />

HYPERSTAT IV INJ 15MG/ML PA<br />

NITROPRESS INJ 25MG/ML PA<br />

Vasodilating Agents<br />

Nitrates and Nitrites<br />

DILATRATE SR CAP 40MG<br />

ISOSORBIDE DINITRATE CAP CR 40 MG<br />

NITROGLYCER INJ 5MG/ML PA<br />

nitroglycerin iv soln 100 mcg/ml in d5w PA<br />

nitroglycerin iv soln 200 mcg/ml in d5w PA<br />

nitroglycerin iv soln 400 mcg/ml in d5w PA<br />

NITROGLYCERIN SL TAB 0.3 MG<br />

NITROGLYCERIN SL TAB 0.4 MG<br />

NITROGLYCERIN SL TAB 0.6 MG<br />

NITROLINGUAL SPR DUO PACK PA<br />

NITROLINGUAL SPR PUMPSPRA PA<br />

NITROSTAT SUB 0.3MG<br />

NITROSTAT SUB 0.4MG<br />

NITROSTAT SUB 0.6MG<br />

Phosphodiesterase Inhibitors<br />

REVATIO INJ PA<br />

SILDENAFIL CITRATE TAB 50 MG NF<br />

VIAGRA TAB 50MG NF<br />

Vasodilating Agents, Miscellaneous<br />

alprostadil inj 500 mcg/ml PA<br />

CAVERJECT INJ 20MCG PA<br />

CAVERJECT INJ 40MCG PA<br />

CAVERJECT KIT 10MCG PA<br />

CAVERJECT KIT 20MCG PA<br />

dipyridamole iv soln 5 mg/ml PA<br />

EDEX KIT 10MCG PA<br />

EDEX KIT 20MCG PA<br />

EDEX KIT 40MCG PA<br />

epoprostenol sodium for inj 0.5 mg PA<br />

epoprostenol sodium for inj 1.5 mg PA<br />

NATRECOR INJ 1.5MG PA<br />

papaverine hcl inj 30 mg/ml PA<br />

REMODULIN INJ 10MG/ML PA<br />

REMODULIN INJ 1MG/ML PA<br />

REMODULIN INJ 2.5MG/ML PA<br />

REMODULIN INJ 5MG/ML PA<br />

Sclerosing Agents<br />

ETHAMOLIN INJ 5% PA<br />

morrhuate sodium inj 5% PA<br />

SOTRADECOL INJ 1% PA<br />

SOTRADECOL INJ 3% PA<br />

Alpha-Adrenergic Blocking Agents<br />

doxazosin tab 1mg<br />

doxazosin tab 2mg<br />

doxazosin tab 4mg<br />

doxazosin tab 8mg<br />

doxazosin mesylate tab 1 mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 45


doxazosin mesylate tab 2 mg<br />

doxazosin mesylate tab 4 mg<br />

doxazosin mesylate tab 8 mg<br />

prazosin hcl cap 1 mg<br />

prazosin hcl cap 1mg<br />

prazosin hcl cap 2 mg<br />

prazosin hcl cap 2mg<br />

prazosin hcl cap 5 mg<br />

prazosin hcl cap 5mg<br />

terazosin hcl cap 1 mg PA<br />

terazosin hcl cap 10 mg PA<br />

terazosin hcl cap 2 mg PA<br />

terazosin hcl cap 5 mg PA<br />

Beta-Adrenergic Blocking Agents<br />

atenolol tab 100mg<br />

atenolol tab 25mg<br />

atenolol tab 50mg<br />

atenolol tab 100 mg<br />

atenolol tab 25 mg<br />

atenolol tab 50 mg<br />

bisoprl/hctz tab 10/6.25<br />

bisoprl/hctz tab 2.5/6.25<br />

bisoprl/hctz tab 5/6.25mg<br />

bisoprol fum tab 10mg<br />

bisoprol fum tab 5mg<br />

bisoprolol & hydrochlorothiazide tab 10-6.25 mg<br />

bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg<br />

bisoprolol & hydrochlorothiazide tab 5-6.25 mg<br />

bisoprolol fumarate tab 10 mg<br />

bisoprolol fumarate tab 5 mg<br />

BREVIBLOC INJ 20MG/ML PA<br />

BREVIBLOC INJ 250MG/ML PA<br />

BREVIBLOC SOL PA<br />

BREVIBLOC SOL 10MG/ML PA<br />

COREG CR CAP 10MG PA<br />

COREG CR CAP 20MG PA<br />

COREG CR CAP 40MG PA<br />

COREG CR CAP 80MG PA<br />

esmolol hcl inj 10 mg/ml PA<br />

INNOPRAN XL CAP 120MG PA<br />

INNOPRAN XL CAP 80MG PA<br />

labetalol tab 100mg<br />

labetalol tab 200mg<br />

labetalol tab 300mg<br />

labetalol hcl iv soln 5 mg/ml PA<br />

labetalol hcl tab 100 mg<br />

labetalol hcl tab 200 mg<br />

labetalol hcl tab 300 mg<br />

LEVATOL TAB 20MG<br />

metoprol tar tab 100mg<br />

metoprol tar tab 25mg<br />

metoprol tar tab 50mg<br />

metoprolol tab 100mg er<br />

metoprolol tab 200mg er<br />

metoprolol tab 25mg er<br />

metoprolol tab 50mg er<br />

metoprolol succinate tab sr 24hr 100 mg<br />

metoprolol succinate tab sr 24hr 200 mg<br />

metoprolol succinate tab sr 24hr 25 mg<br />

metoprolol succinate tab sr 24hr 50 mg<br />

metoprolol tartrate inj 1 mg/ml PA<br />

metoprolol tartrate tab 100 mg<br />

metoprolol tartrate tab 25 mg<br />

metoprolol tartrate tab 50 mg<br />

NADOLOL TAB 160MG<br />

nadolol tab 20mg<br />

nadolol tab 40mg<br />

nadolol tab 80mg<br />

NADOLOL TAB 160 MG<br />

nadolol tab 20 mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 46


nadolol tab 40 mg<br />

nadolol tab 80 mg<br />

PENBUTOLOL SULFATE TAB 20 MG<br />

PROPRANOLOL SOL 20MG/5ML PA<br />

PROPRANOLOL SOL 40MG/5ML PA<br />

propranolol tab 10mg<br />

propranolol tab 20mg<br />

propranolol tab 40mg<br />

propranolol tab 60mg<br />

propranolol tab 80mg<br />

propranolol hcl inj 1 mg/ml PA<br />

propranolol hcl tab 10 mg<br />

propranolol hcl tab 20 mg<br />

propranolol hcl tab 40 mg<br />

propranolol hcl tab 60 mg<br />

propranolol hcl tab 80 mg<br />

SOTALOL HCL INJ 150/10ML PA<br />

TENORMIN INJ 5MG/10ML PA<br />

Calcium-Channel Blocking Agents<br />

Dihydropyridines<br />

afeditab tab 30mg cr<br />

afeditab tab 60mg cr<br />

amlod/benazp cap 10-20mg<br />

amlod/benazp cap 2.5-10mg<br />

amlod/benazp cap 5-10mg<br />

amlod/benazp cap 5-20mg<br />

amlodipine besylate-benazepril hcl cap 10-20 mg<br />

AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 10-40 MG<br />

amlodipine besylate-benazepril hcl cap 2.5-10 mg<br />

amlodipine besylate-benazepril hcl cap 5-10 mg<br />

amlodipine besylate-benazepril hcl cap 5-20 mg<br />

AMLODIPINE BESYLATE-BENAZEPRIL HCL CAP 5-40 MG<br />

CARDENE IV INJ 40/200ML PA<br />

CARDENE IV SOL 20/200ML PA<br />

CLEVIPREX EMU 0.5MG/ML PA<br />

DYNACIRC CR TAB 10MG<br />

DYNACIRC CR TAB 5MG<br />

felodipine tab 10mg er<br />

felodipine tab 2.5mg er<br />

felodipine tab 5mg er<br />

felodipine tab sr 24hr 10 mg<br />

felodipine tab sr 24hr 2.5 mg<br />

felodipine tab sr 24hr 5 mg<br />

ISRADIPINE CAP 2.5MG<br />

isradipine cap 2.5mg<br />

isradipine cap 5mg<br />

ISRADIPINE CAP 2.5 MG<br />

isradipine cap 2.5 mg<br />

isradipine cap 5 mg<br />

ISRADIPINE TAB SR 24HR 10 MG<br />

ISRADIPINE TAB SR 24HR 5 MG<br />

LOTREL CAP 10-40MG<br />

LOTREL CAP 5-40MG<br />

nicardipine hcl iv soln 2.5 mg/ml PA<br />

nifediac cc tab 30mg er<br />

nifediac cc tab 60mg er<br />

nifediac cc tab 90mg er<br />

nifedical xl tab 30mg<br />

nifedical xl tab 60mg<br />

nifedipine tab 30mg er<br />

nifedipine tab 60mg er<br />

nifedipine tab 90mg cr<br />

nifedipine tab 90mg er<br />

nifedipine tab sr 24hr 30 mg<br />

nifedipine tab sr 24hr 60 mg<br />

nifedipine tab sr 24hr 90 mg<br />

nifedipine tab sr 24hr osmotic 30 mg<br />

nifedipine tab sr 24hr osmotic 60 mg<br />

nifedipine tab sr 24hr osmotic 90 mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 47


Calcium-Channel Blocking Agents, Misc<br />

CARDIZEM CD CAP 360MG/24<br />

cartia xt cap 120/24hr<br />

cartia xt cap 180/24hr<br />

cartia xt cap 240/24hr<br />

cartia xt cap 300/24hr<br />

COVERA-HS TAB 180MG NF<br />

COVERA-HS TAB 240MG NF<br />

dilt-cd cap 120mg<br />

dilt-cd cap 180mg<br />

dilt-cd cap 240mg<br />

dilt-cd cap 300mg<br />

dilt-xr cap 120mg<br />

dilt-xr cap 180mg<br />

dilt-xr cap 240mg<br />

diltiazem cap 120mg cd<br />

diltiazem cap 120mg er<br />

diltiazem cap 120mg sr<br />

diltiazem cap 120mg/24<br />

diltiazem cap 180mg cd<br />

diltiazem cap 180mg er<br />

diltiazem cap 180mg/24<br />

diltiazem cap 240mg cd<br />

diltiazem cap 240mg er<br />

diltiazem cap 240mg xr<br />

diltiazem cap 240mg/24<br />

diltiazem cap 300mg cd<br />

diltiazem cap 300mg er<br />

diltiazem cap 300mg/24<br />

diltiazem cap 360mg/24<br />

diltiazem cap 420mg/24<br />

diltiazem cap 60mg er<br />

diltiazem cap 90mg er<br />

DILTIAZEM INJ 100MG PA<br />

diltiazem tab 120mg<br />

diltiazem tab 30mg<br />

diltiazem tab 60mg<br />

diltiazem tab 90mg<br />

diltiazem hcl cap sr 12hr 120 mg<br />

diltiazem hcl cap sr 12hr 60 mg<br />

diltiazem hcl cap sr 12hr 90 mg<br />

diltiazem hcl cap sr 24hr 120 mg<br />

diltiazem hcl cap sr 24hr 180 mg<br />

diltiazem hcl cap sr 24hr 240 mg<br />

diltiazem hcl coated beads cap sr 24hr 120 mg<br />

diltiazem hcl coated beads cap sr 24hr 180 mg<br />

diltiazem hcl coated beads cap sr 24hr 240 mg<br />

diltiazem hcl coated beads cap sr 24hr 300 mg<br />

DILTIAZEM HCL COATED BEADS CAP SR 24HR 360 MG<br />

diltiazem hcl extended release beads cap sr 24hr 120 mg<br />

diltiazem hcl extended release beads cap sr 24hr 180 mg<br />

diltiazem hcl extended release beads cap sr 24hr 240 mg<br />

diltiazem hcl extended release beads cap sr 24hr 300 mg<br />

diltiazem hcl extended release beads cap sr 24hr 360 mg<br />

diltiazem hcl extended release beads cap sr 24hr 420 mg<br />

diltiazem hcl iv soln 5 mg/ml PA<br />

diltiazem hcl tab 120 mg<br />

diltiazem hcl tab 30 mg<br />

diltiazem hcl tab 60 mg<br />

diltiazem hcl tab 90 mg<br />

diltzac cap 120mg/24<br />

diltzac cap 180mg/24<br />

diltzac cap 240mg/24<br />

diltzac cap 300mg/24<br />

diltzac cap 360mg/24<br />

taztia xt cap 120mg/24<br />

taztia xt cap 180mg/24<br />

taztia xt cap 240mg/24<br />

taztia xt cap 300mg/24<br />

taztia xt cap 360mg/24<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 48


verapamil tab 120mg<br />

verapamil tab 120mg er<br />

verapamil tab 120mg sr<br />

verapamil tab 180mg cr<br />

verapamil tab 180mg er<br />

verapamil tab 180mg sa<br />

verapamil tab 180mg sr<br />

verapamil tab 240mg cr<br />

verapamil tab 240mg er<br />

verapamil tab 240mg sa<br />

verapamil tab 240mg sr<br />

verapamil tab 40mg<br />

verapamil tab 80mg<br />

verapamil hcl iv soln 2.5 mg/ml PA<br />

verapamil hcl tab 120 mg<br />

verapamil hcl tab 40 mg<br />

verapamil hcl tab 80 mg<br />

verapamil hcl tab cr 120 mg<br />

verapamil hcl tab cr 180 mg<br />

verapamil hcl tab cr 240 mg<br />

VERAPAMIL HCL TAB SR 24HR (CONTROLLED ONSET) 180 MG NF<br />

VERAPAMIL HCL TAB SR 24HR (CONTROLLED ONSET) 240 MG NF<br />

Rennin-Angiotensin-Aldosterone Sys Inhib<br />

Angiotensin-Converting Enzyme Inhibitors<br />

benazep/hctz tab 10-12.5<br />

benazep/hctz tab 20-12.5<br />

benazep/hctz tab 20-25mg<br />

benazep/hctz tab 5-6.25<br />

benazepril tab 10mg<br />

benazepril tab 20mg<br />

benazepril tab 40mg<br />

benazepril tab 5mg<br />

benazepril & hydrochlorothiazide tab 10-12.5 mg<br />

benazepril & hydrochlorothiazide tab 20-12.5 mg<br />

benazepril & hydrochlorothiazide tab 20-25 mg<br />

benazepril & hydrochlorothiazide tab 5-6.25 mg<br />

benazepril hcl tab 10 mg<br />

benazepril hcl tab 20 mg<br />

benazepril hcl tab 40 mg<br />

benazepril hcl tab 5 mg<br />

captopr/hctz tab 25-15mg<br />

captopr/hctz tab 25-25mg<br />

captopr/hctz tab 50-15mg<br />

captopr/hctz tab 50-25mg<br />

captopril tab 100mg<br />

captopril tab 12.5mg<br />

captopril tab 25mg<br />

captopril tab 50mg<br />

captopril & hydrochlorothiazide tab 25-15 mg<br />

captopril & hydrochlorothiazide tab 25-25 mg<br />

captopril & hydrochlorothiazide tab 50-15 mg<br />

captopril & hydrochlorothiazide tab 50-25 mg<br />

captopril tab 100 mg<br />

captopril tab 12.5 mg<br />

captopril tab 25 mg<br />

captopril tab 50 mg<br />

enalapril maleate tab 10 mg PA<br />

enalapril maleate tab 2.5 mg PA<br />

enalapril maleate tab 20 mg PA<br />

enalapril maleate tab 5 mg PA<br />

enalaprilat iv inj 1.25 mg/ml PA<br />

fosinopril sodium tab 10 mg PA<br />

fosinopril sodium tab 20 mg PA<br />

fosinopril sodium tab 40 mg PA<br />

lisinop/hctz tab 10-12.5<br />

lisinop/hctz tab 20-12.5<br />

lisinop/hctz tab 20-25mg<br />

lisinopril tab 10mg<br />

lisinopril tab 2.5mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 49


lisinopril tab 20mg<br />

lisinopril tab 30mg<br />

lisinopril tab 40mg<br />

lisinopril tab 5mg<br />

lisinopril & hydrochlorothiazide tab 10-12.5 mg<br />

lisinopril & hydrochlorothiazide tab 20-12.5 mg<br />

lisinopril & hydrochlorothiazide tab 20-25 mg<br />

lisinopril tab 10 mg<br />

lisinopril tab 2.5 mg<br />

lisinopril tab 20 mg<br />

lisinopril tab 30 mg<br />

lisinopril tab 40 mg<br />

lisinopril tab 5 mg<br />

quinapril tab 10mg<br />

quinapril tab 20mg<br />

quinapril tab 40mg<br />

quinapril tab 5mg<br />

quinapril hcl tab 10 mg<br />

quinapril hcl tab 20 mg<br />

quinapril hcl tab 40 mg<br />

quinapril hcl tab 5 mg<br />

ramipril cap 1.25 mg PA<br />

ramipril cap 10 mg PA<br />

ramipril cap 2.5 mg PA<br />

ramipril cap 5 mg PA<br />

Angiotensin II Receptor Antagonists<br />

AVAPRO TAB 150MG PA<br />

AVAPRO TAB 300MG PA<br />

AVAPRO TAB 75MG PA<br />

BENICAR TAB 20MG<br />

BENICAR TAB 40MG<br />

BENICAR TAB 5MG<br />

BENICAR HCT TAB 20-12.5<br />

BENICAR HCT TAB 40-12.5<br />

BENICAR HCT TAB 40-25MG<br />

DIOVAN TAB 160MG<br />

DIOVAN TAB 320MG<br />

DIOVAN TAB 40MG<br />

DIOVAN TAB 80MG<br />

DIOVAN HCT TAB 160/12.5<br />

DIOVAN HCT TAB 160/25MG<br />

DIOVAN HCT TAB 320/12.5<br />

DIOVAN HCT TAB 320/25MG<br />

DIOVAN HCT TAB 80/12.5<br />

losartan potassium tab 100 mg PA<br />

losartan potassium tab 25 mg PA<br />

losartan potassium tab 50 mg PA<br />

OLMESARTAN MEDOXOMIL TAB 20 MG<br />

OLMESARTAN MEDOXOMIL TAB 40 MG<br />

OLMESARTAN MEDOXOMIL TAB 5 MG<br />

OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 20-12.5 MG<br />

OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-12.5 MG<br />

OLMESARTAN MEDOXOMIL-HYDROCHLOROTHIAZIDE TAB 40-25 MG<br />

VALSARTAN TAB 160 MG<br />

VALSARTAN TAB 320 MG<br />

VALSARTAN TAB 40 MG<br />

VALSARTAN TAB 80 MG<br />

VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-12.5 MG<br />

VALSARTAN-HYDROCHLOROTHIAZIDE TAB 160-25 MG<br />

VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-12.5 MG<br />

VALSARTAN-HYDROCHLOROTHIAZIDE TAB 320-25 MG<br />

VALSARTAN-HYDROCHLOROTHIAZIDE TAB 80-12.5 MG<br />

Central Nervous System Agents<br />

General Anesthetics<br />

BARBITURATES<br />

BREVITAL SOD INJ 2.5GM PA<br />

BREVITAL SOD INJ 500MG PA<br />

PENTOTHAL INJ 1GM PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 50


PENTOTHAL INJ 250MG PA<br />

PENTOTHAL INJ 400MG PA<br />

PENTOTHAL INJ 500MG PA<br />

GENERAL ANESTHETICS<br />

etomidate iv soln 2 mg/ml PA<br />

KETALAR INJ 10MG/ML PA<br />

ketamine hcl inj 10 mg/ml PA<br />

ketamine hcl inj 100 mg/ml PA<br />

ketamine hcl inj 50 mg/ml PA<br />

LUSEDRA INJ PA<br />

propofol iv emul 10 mg/ml PA<br />

Analgesics and Antipyretics<br />

Nonsteroidal Anti-inflammatory Agents<br />

butalbital-aspirin-caffeine tab 50-325-40 mg<br />

etodolac tab 500mg<br />

etodolac tab 500 mg<br />

farbital tab<br />

ibuprofen tab 400mg<br />

ibuprofen tab 600mg<br />

ibuprofen tab 800mg<br />

ibuprofen tab 400 mg<br />

ibuprofen tab 600 mg<br />

ibuprofen tab 800 mg<br />

INDOCIN SUP 50MG<br />

INDOCIN SUS 25MG/5ML<br />

indomethacin cap 25 mg<br />

indomethacin cap 25mg<br />

indomethacin cap 50 mg<br />

indomethacin cap 50mg<br />

INDOMETHACIN SUPPOS 50 MG<br />

INDOMETHACIN SUSP 25 MG/5ML<br />

nabumetone tab 750mg NF<br />

nabumetone tab 750 mg NF<br />

naproxen tab 250mg<br />

naproxen tab 375mg<br />

naproxen tab 500mg<br />

naproxen tab 250 mg<br />

naproxen tab 375 mg<br />

naproxen tab 500 mg<br />

Cyclooxygenase-2 (COX-2) Inhibitors<br />

CELEBREX CAP 100MG PA<br />

CELEBREX CAP 200MG PA<br />

CELEBREX CAP 400MG PA<br />

CELEBREX CAP 50MG PA<br />

Salicylates<br />

amigesic tab 500mg<br />

amigesic tab 750mg<br />

asa/caff/but cap 325-40-5<br />

ASPIRIN-ACETAMINOPHEN-CAFFEINE TAB 250-250-65 MG OTC<br />

but/asa/caff cap<br />

but/asa/caff cap<br />

but/asa/caff tab<br />

but/asa/caff tab<br />

butalbital cap cpd<br />

butalbital tab cpd<br />

butalbital-aspirin-caffeine cap 50-325-40 mg<br />

butalbital-aspirin-caffeine tab 50-325-40 mg<br />

EXCEDRIN TAB MIGRAINE OTC<br />

fortabs tab<br />

ORPH/ASA/CAF TAB<br />

orph/asa/caf tab<br />

orphen cpd tab ds<br />

ORPHEN CPD TAB DS<br />

orphenadrine w/ aspirin & caffeine tab 25-385-30 mg<br />

ORPHENADRINE W/ ASPIRIN & CAFFEINE TAB 50-770-60 MG<br />

orphenadrine w/ aspirin & caffeine tab 50-770-60 mg<br />

salflex tab 500mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 51


salflex tab 750mg<br />

salsalate tab 500mg<br />

salsalate tab 750mg<br />

salsalate tab 500 mg<br />

salsalate tab 750 mg<br />

Other Nonsteroidal Anti-inflammtory Agents<br />

advil jr st tab 100mg OTC<br />

ARTHROTEC 50 TAB PA<br />

ARTHROTEC 75 TAB PA<br />

CALDOLOR INJ 400/4ML PA<br />

CALDOLOR INJ 800/8ML PA<br />

DICLOFENAC TAB 25MG EC<br />

diclofenac tab 50mg dr<br />

diclofenac tab 50mg ec<br />

diclofenac tab 75mg dr<br />

diclofenac tab 75mg ec<br />

DICLOFENAC SODIUM TAB DELAYED RELEASE 25 MG<br />

diclofenac sodium tab delayed release 50 mg<br />

diclofenac sodium tab delayed release 75 mg<br />

eck ibuprofe tab 100mg OTC<br />

etodolac cap 200mg<br />

etodolac cap 300mg<br />

etodolac tab 400mg<br />

etodolac tab 500mg<br />

etodolac cap 200 mg<br />

etodolac cap 300 mg<br />

etodolac er tab 400mg NF<br />

etodolac er tab 500mg NF<br />

etodolac er tab 600mg<br />

etodolac tab 400 mg<br />

etodolac tab 500 mg<br />

etodolac tab sr 24hr 400 mg NF<br />

etodolac tab sr 24hr 500 mg NF<br />

etodolac tab sr 24hr 600 mg<br />

ibu tab 400mg<br />

ibu tab 600mg<br />

ibu tab 800mg<br />

ibuprofen sus 100/5ml<br />

ibuprofen tab 400mg<br />

ibuprofen tab 600mg<br />

ibuprofen tab 800mg<br />

ibuprofen jr tab 100mg OTC<br />

ibuprofen susp 100 mg/5ml<br />

ibuprofen tab 100 mg OTC<br />

ibuprofen tab 400 mg<br />

ibuprofen tab 600 mg<br />

ibuprofen tab 800 mg<br />

INDOCIN SUS 25MG/5ML<br />

indomethacin cap 25 mg<br />

indomethacin cap 25mg<br />

indomethacin cap 50 mg<br />

indomethacin cap 50mg<br />

indomethacin cap 75mg cr<br />

indomethacin cap 75mg er<br />

indomethacin cap 75mg sa<br />

indomethacin cap 75mg sr<br />

indomethacin cap cr 75 mg<br />

indomethacin sodium iv for soln 1 mg PA<br />

INDOMETHACIN SUP 50MG<br />

INDOMETHACIN SUPPOS 50 MG<br />

INDOMETHACIN SUSP 25 MG/5ML<br />

ketoprofen cap 200mg er NF<br />

KETOPROFEN CAP 200MG ER NF<br />

ketoprofen cap 200mg er NF<br />

ketoprofen cap sr 24hr 200 mg NF<br />

KETOPROFEN CAP SR 24HR 200 MG NF<br />

ketoprofen cap sr 24hr 200 mg NF<br />

ketorolac tab 10mg QL<br />

ketorolac tromethamine im inj 30 mg/ml PA<br />

ketorolac tromethamine inj 15 mg/ml PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 52


ketorolac tromethamine inj 30 mg/ml PA<br />

ketorolac tromethamine tab 10 mg QL<br />

nabumetone tab 500mg NF<br />

nabumetone tab 750mg NF<br />

nabumetone tab 500 mg NF<br />

nabumetone tab 750 mg NF<br />

naproxen sus 125/5ml<br />

naproxen tab 250mg<br />

naproxen tab 375mg<br />

naproxen tab 500mg<br />

naproxen dr tab 375mg<br />

naproxen dr tab 500mg<br />

naproxen ec tab 375mg<br />

naproxen ec tab 500mg<br />

naproxen sod tab 275mg<br />

naproxen sod tab 550mg<br />

naproxen sodium tab 275 mg<br />

naproxen sodium tab 550 mg<br />

naproxen susp 125 mg/5ml<br />

naproxen tab 250 mg<br />

naproxen tab 375 mg<br />

naproxen tab 500 mg<br />

naproxen tab ec 375 mg<br />

naproxen tab ec 500 mg<br />

NEOPROFEN SOL 10MG/ML PA<br />

oxaprozin tab 600mg NF<br />

oxaprozin tab 600 mg NF<br />

piroxicam cap 10mg<br />

piroxicam cap 20mg<br />

piroxicam cap 10 mg<br />

piroxicam cap 20 mg<br />

PREVACID NAP KIT 500MG PA<br />

profen ib tab jun str OTC<br />

pseudoephedrine-naproxen sodium tab sr 12hr 120-220 mg OTC<br />

sm ibuprofen tab 100mg jr OTC<br />

sudafed sinu tab /pain OTC<br />

sulindac tab 150mg<br />

sulindac tab 200mg<br />

sulindac tab 150 mg<br />

sulindac tab 200 mg<br />

Opiate Agonists<br />

acetaminophen w/ codeine soln 120-12 mg/5ml<br />

ACETAMINOPHEN W/ CODEINE SUSP 120-12 MG/5ML<br />

acetaminophen w/ codeine tab 300-15 mg<br />

acetaminophen w/ codeine tab 300-30 mg<br />

acetaminophen w/ codeine tab 300-60 mg<br />

ACETAMINOPHEN W/ CODEINE TAB 650-30 MG<br />

acetaminophen-caffeine-dihydrocodeine cap 356.4-30-16 mg<br />

acetaminophen-caffeine-dihydrocodeine cap 356.4-30-16 mg<br />

acetaminophen-caffeine-dihydrocodeine tab 712.8-60-32 mg<br />

alfentanil inj 500 mcg/ml PA<br />

anexsia tab 5-325mg<br />

anexsia tab 7.5-325<br />

apap/caff/di tab hydrocod<br />

apap/codeine sol 120-12/5<br />

apap/codeine tab 300-15mg<br />

apap/codeine tab 300-15mg<br />

apap/codeine tab 300-30mg<br />

apap/codeine tab 300-30mg<br />

apap/codeine tab 300-30mg<br />

apap/codeine tab 300-60mg<br />

apap/codeine tab 300-60mg<br />

apap/codeine tab 300-60mg<br />

apap/codeine tab 300-60mg<br />

apap/hydroco tab 500-5mg<br />

apap/oxycod tab 325-10mg<br />

apap/oxycod tab 325-5mg<br />

balacet 325 tab<br />

CAPITAL/COD SUS 120-12/5<br />

co-gesic tab 500-5mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 53


COCET TAB 650-30MG<br />

CODEINE PHOS INJ 30MG/2ML PA<br />

CODEINE PHOS INJ 60MG/2ML PA<br />

CODEINE PHOS TAB SOL 30MG PA<br />

CODEINE PHOS TAB SOL 60MG PA<br />

codeine/apap tab 15-300mg<br />

codeine/apap tab 30-300mg<br />

codeine/apap tab 30-300mg<br />

codeine/apap tab 30-300mg<br />

codeine/apap tab 60-300mg<br />

DEMEROL INJ 75MG/ML<br />

DILAUDID-HP INJ 250MG PA<br />

dolacet cap 5-500mg<br />

dolagesic cap 500-5mg<br />

dolorex fort cap 5-500mg<br />

endocet tab 10-325mg<br />

endocet tab 10-650mg<br />

endocet tab 5-325mg<br />

endocet tab 7.5-325m<br />

endocet tab 7.5-500m<br />

endodan tab<br />

FENT/BUPI/NS SOL 2MCG/ML PA<br />

FENT/BUPI/NS SOL 4MCG/ML PA<br />

FENT/BUPI/NS SOL 5MCG/ML PA<br />

FENT/ROPIV/ INJ NACL PA<br />

FENT/ROPIV/ INJ NACL PA<br />

fentanyl citrate inj 0.05 mg/ml PA<br />

FENTANYL/NS SOL 10MCG/ML PA<br />

FENTANYL/NS SOL 5MCG/ML PA<br />

HYCET SOL 7.5-325<br />

HYDR/BUPI/NS SOL 20MCG PA<br />

HYDR/BUPI/NS SOL 20MCG/ML PA<br />

hydrocet cap 500-5mg<br />

hydroco/apap tab 10-325mg<br />

hydroco/apap tab 10-500mg<br />

hydroco/apap tab 10-650mg<br />

hydroco/apap tab 10-660mg<br />

hydroco/apap tab 10-750mg<br />

hydroco/apap tab 2.5-500<br />

hydroco/apap tab 5-325mg<br />

hydroco/apap tab 5-500mg<br />

hydroco/apap tab 5-500mg<br />

hydroco/apap tab 5-500mg<br />

hydroco/apap tab 7.5-325<br />

hydroco/apap tab 7.5-500<br />

hydroco/apap tab 7.5-500<br />

hydroco/apap tab 7.5-650<br />

hydroco/apap tab 7.5-750<br />

hydrocod/ibu tab 7.5-200<br />

hydrocodone-acetaminophen cap 5-500 mg<br />

HYDROCODONE-ACETAMINOPHEN SOLN 10-500 MG/15ML<br />

HYDROCODONE-ACETAMINOPHEN SOLN 7.5-325 MG/15ML<br />

hydrocodone-acetaminophen soln 7.5-500 mg/15ml<br />

HYDROCODONE-ACETAMINOPHEN TAB 10-300 MG<br />

hydrocodone-acetaminophen tab 10-325 mg<br />

HYDROCODONE-ACETAMINOPHEN TAB 10-400 MG<br />

hydrocodone-acetaminophen tab 10-500 mg<br />

hydrocodone-acetaminophen tab 10-650 mg<br />

hydrocodone-acetaminophen tab 10-660 mg<br />

hydrocodone-acetaminophen tab 10-750 mg<br />

hydrocodone-acetaminophen tab 2.5-500 mg<br />

HYDROCODONE-ACETAMINOPHEN TAB 5-300 MG<br />

hydrocodone-acetaminophen tab 5-325 mg<br />

HYDROCODONE-ACETAMINOPHEN TAB 5-400 MG<br />

hydrocodone-acetaminophen tab 5-500 mg<br />

HYDROCODONE-ACETAMINOPHEN TAB 7.5-300 MG<br />

hydrocodone-acetaminophen tab 7.5-325 mg<br />

HYDROCODONE-ACETAMINOPHEN TAB 7.5-400 MG<br />

hydrocodone-acetaminophen tab 7.5-500 mg<br />

hydrocodone-acetaminophen tab 7.5-650 mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 54


hydrocodone-acetaminophen tab 7.5-750 mg<br />

hydrocodone-ibuprofen tab 10-200 mg<br />

HYDROCODONE-IBUPROFEN TAB 2.5-200 MG<br />

HYDROCODONE-IBUPROFEN TAB 5-200 MG<br />

hydrocodone-ibuprofen tab 5-200 mg<br />

hydrocodone-ibuprofen tab 7.5-200 mg<br />

hydrocodone/ sol apap<br />

hydrogesic cap 5-500mg<br />

HYDROMOR/NS INJ 1MG/ML PA<br />

HYDROMOR/NS SOL 1MG/ML PA<br />

HYDROMORPHON INJ /NACL PA<br />

HYDROMORPHON INJ /NS PA<br />

hydromorphone hcl inj 1 mg/ml PA<br />

hydromorphone hcl inj 10 mg/ml PA<br />

hydromorphone hcl inj 2 mg/ml PA<br />

hydromorphone hcl inj 4 mg/ml PA<br />

ibudone tab 10-200mg<br />

ibudone tab 5-200mg<br />

INFUMORPH INJ 10MG/ML PA<br />

INFUMORPH INJ 25MG/ML PA<br />

KADIAN CAP 100MG CR<br />

KADIAN CAP 10MG CR<br />

KADIAN CAP 200MG CR<br />

KADIAN CAP 20MG CR<br />

KADIAN CAP 20MG SR<br />

KADIAN CAP 30MG CR<br />

KADIAN CAP 50MG CR<br />

KADIAN CAP 60MG CR<br />

KADIAN CAP 80MG CR<br />

LEVO DROMORA INJ 2MG/ML PA<br />

LIQUICET SOL 10-500MG<br />

LYNOX TAB 10-300MG<br />

LYNOX TAB 2.5-300<br />

LYNOX TAB 5-300MG<br />

LYNOX TAB 7.5-300<br />

MAGNACET TAB 10-400MG<br />

MAGNACET TAB 2.5-400<br />

MAGNACET TAB 5-400MG<br />

MAGNACET TAB 7.5-400<br />

margesic-h cap 500-5mg<br />

MEPERIDI/NS SOL 10MG/ML<br />

meperidine inj 100mg/ml<br />

meperidine inj 10mg/ml<br />

meperidine inj 25mg/ml<br />

meperidine inj 300mg<br />

meperidine inj 50mg/ml<br />

meperidine inj 75mg/ml<br />

MEPERIDINE SOL 50MG/5ML<br />

meperidine tab 100mg<br />

meperidine tab 50mg<br />

meperidine hcl inj 10 mg/ml<br />

meperidine hcl inj 100 mg/ml<br />

meperidine hcl inj 25 mg/ml<br />

meperidine hcl inj 50 mg/ml<br />

meperidine hcl inj 75 mg/ml<br />

MEPERIDINE HCL INJ 75 MG/ML<br />

MEPERIDINE HCL ORAL SOLN 50 MG/5ML<br />

meperidine hcl tab 100 mg<br />

meperidine hcl tab 50 mg<br />

MEPERIDINE HCL-SODIUM CHLORIDE 0.9% INJ 10 MG/ML<br />

MEPERIDINE HCL-SODIUM CHLORIDE 0.9% IV SOLN 1000 MG/0.1L<br />

meperidine w/ promethazine cap 50-25 mg<br />

MEPERIDINE W/ PROMETHAZINE CAP 50-25 MG<br />

meperidine/ cap prometh<br />

MEPERIDNE/NS SOL 10MG/ML<br />

meperitab tab 100mg<br />

meperitab tab 50mg<br />

MEPROZINE CAP 50-25MG<br />

METHADONE INJ 10MG/ML PA<br />

methadone tab 10mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 55


methadone tab 40mg<br />

methadone tab 40mg<br />

methadone tab 5mg<br />

methadone hcl soln 10 mg/5ml PA<br />

methadone hcl soln 5 mg/5ml PA<br />

methadone hcl tab 10 mg<br />

methadone hcl tab 5 mg<br />

methadone hcl tab for oral susp 40 mg<br />

methadose tab 10mg<br />

methadose tab 40mg<br />

methadose tab 5mg<br />

MORPHINE SUL INJ 150/30ML PA<br />

MORPHINE SUL INJ 1MG/ML PA<br />

MORPHINE SUL INJ 2MG/ML PA<br />

MORPHINE SUL INJ 4MG/ML PA<br />

MORPHINE SUL INJ 5MG/ML PA<br />

MORPHINE SUL SOL 10MG/5ML PA<br />

MORPHINE SUL SOL 20MG/5ML PA<br />

morphine sul tab 100mg cr<br />

morphine sul tab 100mg er<br />

MORPHINE SUL TAB 10MG PA<br />

morphine sul tab 15mg cr<br />

morphine sul tab 15mg er<br />

morphine sul tab 200mg cr<br />

morphine sul tab 200mg er<br />

morphine sul tab 30mg cr<br />

morphine sul tab 30mg er<br />

morphine sul tab 60mg cr<br />

morphine sul tab 60mg er<br />

MORPHINE SULFATE CAP SR 24HR 10 MG<br />

MORPHINE SULFATE CAP SR 24HR 100 MG<br />

MORPHINE SULFATE CAP SR 24HR 20 MG<br />

MORPHINE SULFATE CAP SR 24HR 200 MG<br />

MORPHINE SULFATE CAP SR 24HR 30 MG<br />

MORPHINE SULFATE CAP SR 24HR 50 MG<br />

MORPHINE SULFATE CAP SR 24HR 60 MG<br />

MORPHINE SULFATE CAP SR 24HR 80 MG<br />

morphine sulfate inj 10 mg/ml PA<br />

morphine sulfate inj 15 mg/ml PA<br />

morphine sulfate inj 4 mg/ml PA<br />

morphine sulfate inj 8 mg/ml PA<br />

morphine sulfate inj pf 0.5 mg/ml PA<br />

morphine sulfate inj pf 1 mg/ml PA<br />

morphine sulfate iv soln 1 mg/ml PA<br />

morphine sulfate iv soln 25 mg/ml PA<br />

morphine sulfate iv soln 5 mg/ml PA<br />

morphine sulfate iv soln 50 mg/ml PA<br />

morphine sulfate oral soln 10 mg/5ml PA<br />

morphine sulfate oral soln 20 mg/5ml PA<br />

morphine sulfate oral soln 20 mg/ml PA<br />

morphine sulfate tab sol 10 mg (for parenteral use) PA<br />

morphine sulfate tab sol 15 mg (for parenteral use) PA<br />

morphine sulfate tab sol 30 mg (for parenteral use) PA<br />

MORPHINE SULFATE TAB SR 12HR 100 MG<br />

morphine sulfate tab sr 12hr 100 mg<br />

MORPHINE SULFATE TAB SR 12HR 15 MG<br />

morphine sulfate tab sr 12hr 15 mg<br />

morphine sulfate tab sr 12hr 200 mg<br />

MORPHINE SULFATE TAB SR 12HR 30 MG<br />

morphine sulfate tab sr 12hr 30 mg<br />

MORPHINE SULFATE TAB SR 12HR 60 MG<br />

morphine sulfate tab sr 12hr 60 mg<br />

MORPHINE/D5W INJ 1MG/ML PA<br />

MORPHINE/D5W INJ 2MG/ML PA<br />

MORPHINE/D5W SOL 1MG/ML PA<br />

MORPHINE/DW5 INJ 2MG/ML PA<br />

MORPHINE/NS INJ 1MG/ML PA<br />

MORPHINE/NS SOL 0.1MG/ML PA<br />

MORPHINE/NS SOL 1MG/ML PA<br />

narvox tab 10-500mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 56


NUMORPHAN INJ 1MG/ML PA<br />

OPANA INJ 1MG/ML PA<br />

ORAMORPH SR TAB 100MG<br />

ORAMORPH SR TAB 15MG<br />

ORAMORPH SR TAB 30MG<br />

ORAMORPH SR TAB 60MG<br />

oxycod/apap tab 10-325mg<br />

oxycod/apap tab 10-325mg<br />

oxycod/apap tab 10-325mg<br />

oxycod/apap tab 10-650mg<br />

oxycod/apap tab 2.5-325<br />

oxycod/apap tab 5-325mg<br />

oxycod/apap tab 5-325mg<br />

oxycod/apap tab 5-325mg<br />

oxycod/apap tab 7.5-325<br />

oxycod/apap tab 7.5-325<br />

oxycod/apap tab 7.5-500<br />

oxycod/apap tab 7.5-500<br />

oxycod/asa tab<br />

oxycodone tab 15mg NF<br />

oxycodone hcl tab 15 mg NF<br />

oxycodone hcl tab sr 12hr 10 mg PA<br />

oxycodone hcl tab sr 12hr 20 mg PA<br />

oxycodone hcl tab sr 12hr 40 mg PA<br />

oxycodone hcl tab sr 12hr 80 mg PA<br />

OXYCODONE W/ ACETAMINOPHEN TAB 10-300 MG<br />

OXYCODONE W/ ACETAMINOPHEN TAB 10-300 MG<br />

oxycodone w/ acetaminophen tab 10-325 mg<br />

OXYCODONE W/ ACETAMINOPHEN TAB 10-400 MG<br />

oxycodone w/ acetaminophen tab 10-500 mg<br />

OXYCODONE W/ ACETAMINOPHEN TAB 10-500 MG<br />

oxycodone w/ acetaminophen tab 10-650 mg<br />

OXYCODONE W/ ACETAMINOPHEN TAB 2.5-300 MG<br />

OXYCODONE W/ ACETAMINOPHEN TAB 2.5-300 MG<br />

oxycodone w/ acetaminophen tab 2.5-325 mg<br />

OXYCODONE W/ ACETAMINOPHEN TAB 2.5-400 MG<br />

OXYCODONE W/ ACETAMINOPHEN TAB 5-300 MG<br />

OXYCODONE W/ ACETAMINOPHEN TAB 5-300 MG<br />

oxycodone w/ acetaminophen tab 5-325 mg<br />

OXYCODONE W/ ACETAMINOPHEN TAB 5-400 MG<br />

OXYCODONE W/ ACETAMINOPHEN TAB 5-500 MG<br />

OXYCODONE W/ ACETAMINOPHEN TAB 7.5-300 MG<br />

OXYCODONE W/ ACETAMINOPHEN TAB 7.5-300 MG<br />

oxycodone w/ acetaminophen tab 7.5-325 mg<br />

OXYCODONE W/ ACETAMINOPHEN TAB 7.5-400 MG<br />

oxycodone w/ acetaminophen tab 7.5-500 mg<br />

oxycodone w/ aspirin tab full strength<br />

OXYCONTIN TAB 10MG CR PA<br />

OXYCONTIN TAB 15MG CR PA<br />

OXYCONTIN TAB 20MG CR PA<br />

OXYCONTIN TAB 30MG CR PA<br />

OXYCONTIN TAB 40MG CR PA<br />

OXYCONTIN TAB 60MG CR PA<br />

OXYCONTIN TAB 80MG CR PA<br />

PERLOXX TAB 10-300MG<br />

PERLOXX TAB 2.5-300<br />

PERLOXX TAB 5-300MG<br />

PERLOXX TAB 7.5-300<br />

polygesic cap 500-5mg<br />

PRIMALEV TAB 2.5-300<br />

PRIMLEV TAB 10-300MG<br />

PRIMLEV TAB 5-300MG<br />

PRIMLEV TAB 7.5-300<br />

propo-n/apap tab 100-650<br />

propo-n/apap tab 50/325<br />

propoxacet-n tab 100-650<br />

propoxyphene tab 100-325<br />

propoxyphene-n w/ apap tab 100-325 mg<br />

propoxyphene-n w/ apap tab 100-500 mg PA<br />

propoxyphene-n w/ apap tab 100-650 mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 57


propoxyphene-n w/ apap tab 50-325 mg<br />

reprexain tab 10-200mg<br />

REPREXAIN TAB 2.5-200<br />

REPREXAIN TAB 5-200MG<br />

reprexain tab 7.5-200<br />

roxicet tab 5-325mg<br />

ROXICET TAB 5-500MG<br />

RYBIX ODT TAB 50MG NF<br />

stagesic cap 500-5mg<br />

sufentanil citrate inj 50 mcg/ml PA<br />

TRAMADOL HCL SOLUBLE TAB 50 MG NF<br />

tramadol hcl tab 50 mg<br />

tramadol hcl tab 50mg<br />

trezix cap<br />

trezix cap<br />

ULTIVA INJ 1MG PA<br />

ULTIVA INJ 2MG PA<br />

ULTIVA INJ 5MG PA<br />

vanacet tab 5-500mg<br />

vicodin hp tab 10-660mg<br />

VOPAC TAB 650-30MG<br />

XODOL TAB 10-300MG<br />

XODOL TAB 5-300MG<br />

XODOL TAB 7.5-300<br />

XOLOX TAB 10-500MG<br />

zerlor tab<br />

ZYDONE TAB 10-400MG<br />

ZYDONE TAB 5-400MG<br />

ZYDONE TAB 7.5-400<br />

Opiate Partial Agonists<br />

buprenorphine hcl inj 0.3 mg/ml (base equiv) PA<br />

butorphanol tartrate inj 1 mg/ml PA<br />

butorphanol tartrate inj 2 mg/ml PA<br />

butorphanol tartrate nasal soln 10 mg/ml PA<br />

nalbuphine hcl inj 10 mg/ml PA<br />

nalbuphine hcl inj 20 mg/ml PA<br />

SUBOXONE SUB 2-0.5MG PA<br />

SUBOXONE SUB 8-2MG PA<br />

TALWIN INJ 30MG/ML PA<br />

Analgesics and Antipyretics, Misc<br />

8 hour pain tab 650mg OTC<br />

acephen sup 120mg OTC<br />

acephen sup 325mg OTC<br />

acephen sup 650mg OTC<br />

acetamin cap 500mg OTC<br />

acetamin chw 160mg OTC<br />

acetamin chw 80mg OTC<br />

acetamin chw 80mg frt OTC<br />

acetamin chw 80mg frt OTC<br />

acetamin chw 80mg grp OTC<br />

acetamin dro 100mg/ml OTC<br />

acetamin dro 80/0.8ml OTC<br />

acetamin dro 80/0.8ml OTC<br />

acetamin elx 160/5ml OTC<br />

acetamin liq 160/5ml OTC<br />

acetamin liq 500/15ml OTC<br />

acetamin sol 160/5ml OTC<br />

acetamin sup 120mg OTC<br />

acetamin sup 325mg OTC<br />

acetamin sup 650mg OTC<br />

acetamin tab 325mg OTC<br />

acetamin tab 500mg OTC<br />

acetamin tab 500mg es OTC<br />

acetamin tab 650mg cr OTC<br />

acetamin jr chw 160mg fr OTC<br />

acetamin jr tab 160mg rt OTC<br />

acetaminophen cap 500 mg OTC<br />

ACETAMINOPHEN CAP SPRINKLE 160 MG OTC<br />

ACETAMINOPHEN CAP SPRINKLE 80 MG OTC<br />

acetaminophen chew tab 160 mg OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 58


ACETAMINOPHEN CHEW TAB 500 MG OTC<br />

acetaminophen chew tab 80 mg OTC<br />

acetaminophen dispersible tab 160 mg OTC<br />

ACETAMINOPHEN DISPERSIBLE TAB 325 MG OTC<br />

ACETAMINOPHEN DISPERSIBLE TAB 500 MG OTC<br />

acetaminophen dispersible tab 80 mg OTC<br />

acetaminophen elixir 160 mg/5ml OTC<br />

ACETAMINOPHEN GEL SYRUP 160 MG/5ML OTC<br />

acetaminophen liquid 160 mg/5ml OTC<br />

acetaminophen liquid 167 mg/5ml OTC<br />

ACETAMINOPHEN LIQUID 500 MG/5ML OTC<br />

acetaminophen soln 100 mg/ml OTC<br />

acetaminophen soln 160 mg/5ml OTC<br />

ACETAMINOPHEN SOLN 325 MG/5ML OTC<br />

ACETAMINOPHEN SOLN 80 MG/ML OTC<br />

acetaminophen suppos 120 mg OTC<br />

acetaminophen suppos 325 mg OTC<br />

acetaminophen suppos 650 mg OTC<br />

ACETAMINOPHEN SUPPOS 80 MG OTC<br />

acetaminophen susp 160 mg/5ml OTC<br />

acetaminophen susp 80 mg/0.8ml OTC<br />

acetaminophen tab 160 mg OTC<br />

acetaminophen tab 325 mg OTC<br />

acetaminophen tab 500 mg OTC<br />

acetaminophen tab cr 650 mg OTC<br />

ACETAMINOPHEN W/ CALCIUM CARBONATE TAB 500-250 MG OTC<br />

acetaminophen w/ calcium carbonate tab 500-250 mg OTC<br />

ACETAMINOPHEN W/ PAMABROM TAB 325-25 MG OTC<br />

acetaminophen w/ pamabrom tab 500-25 mg OTC<br />

ACETAMINOPHEN-BROMELAINS TAB 500 MG-100000 UNIT OTC<br />

acetaminophen-caffeine tab 500-65 mg OTC<br />

acetaminophen-caffeine-pyrilamine tab 500-60-15 mg OTC<br />

ACETAMINOPHEN-MAGNESIUM SALICYLATE-CAFF TAB 250-290-50 MG OTC<br />

acetaminophen-pamabrom-pyrilamine cap 500-25-15 mg OTC<br />

acetaminophen-pamabrom-pyrilamine tab 500-25-15 mg OTC<br />

ACETAMINOPHEN-SALICYLAMIDE TAB 250-600 MG<br />

ACETAMINOPHEN-SALICYLAMIDE-CAFFEINE CAP 227-97-32 MG OTC<br />

ACETAMINOPHEN-SALICYLAMIDE-CAFFEINE TAB 226.8-97.2-32.4 MG OTC<br />

acetaminophen-salicylamide-phenyltoloxamine cap 300-200-20mg<br />

ACETAMINOPHEN-SALICYLAMIDE-PHENYLTOLOXAMINE CAP 325-200-25MG<br />

ACETAMINOPHEN-SALICYLAMIDE-PHENYLTOLOXAMINE TAB 300-200-20MG<br />

acetaminophn sus 160/5ml OTC<br />

acetaminophn sus 325mg OTC<br />

acetaminophn sus 650mg OTC<br />

af-apap infa dro 80/0.8ml OTC<br />

aminofen tab 325mg OTC<br />

aminofen tab 500mg OTC<br />

ANABAR TAB<br />

anacin af tab 500mg OTC<br />

apap cap 500mg OTC<br />

apap chw 80mg OTC<br />

apap dro 80/0.8ml OTC<br />

apap elx 80mg/2.5 OTC<br />

apap sol 80mg/2.5 OTC<br />

apap tab 325mg OTC<br />

apap tab 500mg OTC<br />

APAP 500 LIQ 500/5ML OTC<br />

apap child chw 80mg OTC<br />

apap child elx 160/5ml OTC<br />

apap child sus 160/5ml OTC<br />

apap ex str tab 500mg OTC<br />

apap-plus tab 500-65 OTC<br />

apara sol 160/5ml OTC<br />

apra elx 160/5ml OTC<br />

arthritis tab pain rel OTC<br />

arthrts pain tab 650mg OTC<br />

asa free chw 160mg jr OTC<br />

asp 300/200/ cap 20<br />

aspirin free tab 325mg OTC<br />

aspirin free tab 500mg OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 59


BACK PAINOFF TAB OTC<br />

be-flex plus cap<br />

bl pain reli chw 80mg OTC<br />

bl womens tab 500-25mg OTC<br />

but/apap/caf tab<br />

BUTALBITAL-ACETAMINOPHEN CAP 50-650 MG<br />

butalbital-acetaminophen-caffeine tab 50-325-40 mg<br />

by-ache cap<br />

chd pain rel chw 80mg OTC<br />

child apap chw 80mg OTC<br />

child apap chw 80mg grp OTC<br />

child apap chw 80mg gum OTC<br />

child apap elx 160/5ml OTC<br />

child apap tab 80mg OTC<br />

child nonasa chw 80mg OTC<br />

child nonasa chw pain/rel OTC<br />

child pain liq reliever OTC<br />

child pn rel chw 80mg OTC<br />

child pn rel elx 160/5ml OTC<br />

child pn/fev dro 80/0.8ml OTC<br />

child pn/fev dro 80/0.8ml OTC<br />

childrens chw 80mg OTC<br />

childs apap sus 160/5ml OTC<br />

childs apap sus 320/10ml OTC<br />

childs apap sus 325mg OTC<br />

childs apap sus 640/20ml OTC<br />

childs apap sus 650mg OTC<br />

childs pain sus relief OTC<br />

chld asafree elx 80/2.5ml OTC<br />

chld asafree sus 80/2.5ml OTC<br />

chld meditab chw 80mg OTC<br />

chld meditab sus 80/2.5ml OTC<br />

chld non-asa chw 80mg OTC<br />

chld non-asa chw 80mg grp OTC<br />

chld non-asa elx 160/5ml OTC<br />

chld non-asa tab 80mg OTC<br />

chld non-asa tab 80mg qm OTC<br />

chld non-asa tab 80mg qm OTC<br />

chld non-asa tab 80mg qm OTC<br />

chld pain rl tab 80mg OTC<br />

chld pn rel chw 80mg frt OTC<br />

chld pn rel chw 80mg grp OTC<br />

chld pn rel chw 80mg grp OTC<br />

chld pn rel elx 160/5ml OTC<br />

chld silapap liq 160/5ml OTC<br />

chlds mapap tab 80mg rt OTC<br />

chloraseptic liq sore thr OTC<br />

comtrex sore liq throat OTC<br />

CRAMP TAB OTC<br />

cvs 8 hour tab 650mg OTC<br />

cvs childs chw 80mg OTC<br />

cvs infants dro 80/0.8ml OTC<br />

cvs non-asa dro 80/0.8ml OTC<br />

cvs pain rel tab 500mg/rr OTC<br />

DAYTON ANASE TAB CAPLET OTC<br />

dolorex cap<br />

duraxin cap<br />

DURAXIN CAP<br />

eck acetamin tab 325mg OTC<br />

eck child sus non-asa OTC<br />

eck non-asa chw 80mg OTC<br />

eck pms tab relief OTC<br />

ed-apap liq 80mg/2.5 OTC<br />

ed-flex cap<br />

ELIXSURE GEL F/P BGUM OTC<br />

ELIXSURE GEL F/P CHRY OTC<br />

ELIXSURE GEL F/P GRPE OTC<br />

eq arthritis tab 650mg OTC<br />

eql acetamin tab 160mg OTC<br />

eql acetamin tab 650mg OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 60


eql acetamin tab 80mg OTC<br />

eql arthrits tab 650mg OTC<br />

eql infant dro 80/0.8ml OTC<br />

ex str pain tab reliever OTC<br />

FEBROL SOL 325/5ML OTC<br />

feverall sup 120mg OTC<br />

feverall sup 325mg OTC<br />

feverall sup 650mg OTC<br />

FEVERALL INF SUP 80MG OTC<br />

FEVERALL SPR CAP 160MG JR OTC<br />

FEVERALL SPR CAP 80MG CH OTC<br />

fp multi-sym tab pms OTC<br />

FRENADOL TAB<br />

genapap chw 80mg OTC<br />

genapap chw 80mg grp OTC<br />

genapap dro 80/0.8ml OTC<br />

genapap elx 160/5ml OTC<br />

genapap tab 325mg OTC<br />

genapap tab 500mg OTC<br />

genapap tab 500mg es OTC<br />

genebs tab 325mg OTC<br />

genebs tab 500mg OTC<br />

gnp acetamin sup 120mg OTC<br />

gnp headache tab relief OTC<br />

gnp pain rel chw 80mg OTC<br />

gnp pain rel tab ex st OTC<br />

gnp womens tab 500-25mg OTC<br />

hca child chw non-asa OTC<br />

hca child elx non-asa OTC<br />

hca child sus non-asa OTC<br />

hca infants dro non-asa OTC<br />

hca non-asa cap 500mg OTC<br />

ILARIS INJ 180MG PA<br />

inf asa free dro 80/0.8ml OTC<br />

inf mapap dro 80/0.8ml OTC<br />

inf non-asa dro 80/0.8ml OTC<br />

inf silapap dro 80/0.8ml OTC<br />

infant apap dro 80/0.8ml OTC<br />

infant apap sus 200/2ml OTC<br />

infantaire dro 80/0.8ml OTC<br />

infants apap dro 80/0.8ml OTC<br />

jr non-asa chw 160mg OTC<br />

jr non-asa tab 160mg qm OTC<br />

jr non-asa tab 160mg qm OTC<br />

jr non-asa tab 160mg qm OTC<br />

jr str pain chw reliever OTC<br />

jr. acetamin chw 80mg OTC<br />

junior mapap tab 160mg rt OTC<br />

LITTLE FEVER DRO FEV/PAIN OTC<br />

mapap cap 500mg OTC<br />

mapap chw 80mg OTC<br />

mapap dro 80/0.8ml OTC<br />

mapap liq 160/5ml OTC<br />

mapap tab 325mg OTC<br />

mapap tab 500mg OTC<br />

mapap tab 500mg/rr OTC<br />

mapap apap liq 500/15ml OTC<br />

mapap arthri tab 650mg OTC<br />

mapap child sus 160/5ml OTC<br />

mapap child tab 80mg rt OTC<br />

mapap jr str tab 160mg OTC<br />

MAPAP PLUS TAB HEADACHE OTC<br />

masophen tab 500mg OTC<br />

maxapap ms tab 500mg OTC<br />

maxapap rs tab 325mg OTC<br />

MEDI-GRAINE TAB OTC<br />

medi-tabs dro 80/0.8ml OTC<br />

medi-tabs elx 80/2.5ml OTC<br />

medi-tabs tab 325mg OTC<br />

medi-tabs tab 500mg OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 61


medi-tabs jr chw 160mg OTC<br />

menstrual tab 500-25mg OTC<br />

menstrual tab complete OTC<br />

menstrual tab max st OTC<br />

menstrual tab pms OTC<br />

midol tab 500/65mg OTC<br />

mp acetamin chw 80mg OTC<br />

ms.-aid tab 500-25mg OTC<br />

mult-sym pms tab menstrua OTC<br />

non aspirin elx 160/5ml OTC<br />

non aspirin sus 160/5ml OTC<br />

non aspirin tab 650mg er OTC<br />

non-asa chld dro 80/0.8ml OTC<br />

non-asa chld elx 160/5ml OTC<br />

non-asa chld liq 160/5ml OTC<br />

non-asa chld sus 160/5ml OTC<br />

non-asa infa dro 80/0.8ml OTC<br />

non-asa jr tab 160mg OTC<br />

non-asa jr tab 160mg qm OTC<br />

non-asa pain sus 160/5ml OTC<br />

non-aspirin cap 500mg OTC<br />

non-aspirin chw 160mg jr OTC<br />

non-aspirin chw 160mg jr OTC<br />

non-aspirin chw 160mg jr OTC<br />

non-aspirin chw 160mg jr OTC<br />

non-aspirin chw 80mg OTC<br />

non-aspirin elx 160/5ml OTC<br />

non-aspirin sol ex str OTC<br />

non-aspirin sus 160/5ml OTC<br />

non-aspirin sus child OTC<br />

non-aspirin tab 325mg OTC<br />

NON-ASPIRIN TAB 325MG QM OTC<br />

non-aspirin tab 500mg OTC<br />

NON-ASPIRIN TAB 500MG QM OTC<br />

non-aspirin tab 650mg OTC<br />

nortemp sol 160/5ml OTC<br />

nortemp sus 160/5ml OTC<br />

pain ex str tab 500mg OTC<br />

pain rel 8hr tab 650mg OTC<br />

pain rel cld chw 160mg OTC<br />

pain relief cap 500mg OTC<br />

pain relief chw 160mg jr OTC<br />

pain relief chw 160mg jr OTC<br />

pain relief chw 80mg OTC<br />

pain relief dro 100mg/ml OTC<br />

pain relief dro 80/0.8ml OTC<br />

pain relief dro 80/0.8ml OTC<br />

pain relief dro infants OTC<br />

pain relief liq 160/5ml OTC<br />

pain relief sus 160/5ml OTC<br />

pain relief sus child OTC<br />

pain relief tab 325mg OTC<br />

pain relief tab 500mg OTC<br />

pain relief tab 500mg/rr OTC<br />

pain relief tab 650mg OTC<br />

pain relief tab 650mg cr OTC<br />

pain relieve cap 500mg OTC<br />

pain relieve chw 160mg OTC<br />

pain relieve chw 160mg jr OTC<br />

pain relieve chw 160mg jr OTC<br />

pain relieve chw 160mg jr OTC<br />

pain relieve chw 160mg jr OTC<br />

pain relieve dro 80/0.8ml OTC<br />

pain relieve sup 120mg OTC<br />

pain relieve sus 160/5ml OTC<br />

pain relieve tab 160mg OTC<br />

pain relieve tab 325mg OTC<br />

pain relieve tab 500mg OTC<br />

pain relieve tab 500mg es OTC<br />

pain relieve tab 500mg es OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 62


pain relieve tab 500mg/rr OTC<br />

pain relievr chw 80mg OTC<br />

pain relievr tab 160mg OTC<br />

painaid pmf tab 500-25mg OTC<br />

pamprin ms cap mult-sym OTC<br />

pharbetol tab 325mg OTC<br />

pharbetol tab 500mg OTC<br />

PHENYLEPHRINE-APAP-CAFFEINE TAB 5-500-75 MG OTC<br />

PHRENILIN CAP FORTE<br />

pms tab mult-sym OTC<br />

pms formula tab 500-25-1 OTC<br />

premsyn pms cap max st OTC<br />

premsyn pms tab OTC<br />

PRIALT INJ 100MCG PA<br />

PRIALT INJ 25MCG/ML PA<br />

PRIALT INJ 500MCG PA<br />

q-pap liq 160/5ml OTC<br />

q-pap tab 325mg OTC<br />

q-pap child sus 160/5ml OTC<br />

q-pap child sus cherry OTC<br />

q-pap ex st tab 500mg OTC<br />

q-pap infant dro 80/0.8ml OTC<br />

qc arthritis tab 650mg cr OTC<br />

qc infants dro 80/0.8ml OTC<br />

qc non-asa sus children OTC<br />

qc pms multi tab symptom OTC<br />

ra acetamin chw 80mg OTC<br />

ra acetamin dro 100mg/ml OTC<br />

ra acetamin elx 160/5ml OTC<br />

ra acetamin tab 325mg OTC<br />

ra acetamin tab 500mg OTC<br />

ra acetamin tab 500mg/rr OTC<br />

ra acetamin tab 650mg er OTC<br />

ra acetamin tab plus ex OTC<br />

ra athenol tab 500mg OTC<br />

ra chld apap elx 160/5ml OTC<br />

ra menstrual tab relief OTC<br />

ra non-asa dro 80/0.8ml OTC<br />

ra non-asa sus 160/5ml OTC<br />

ra premnstrl tab relief OTC<br />

repan tab<br />

RID-A-PAIN CAP CPD OTC<br />

RID-A-PAIN TAB CPD OTC<br />

sb infants dro cherry OTC<br />

sb infants dro grape OTC<br />

sb non-asa chw 160mg OTC<br />

sb non-asa chw 80mg frt OTC<br />

sb non-asa chw 80mg grp OTC<br />

sb non-asa tab 500mg es OTC<br />

sb pain rel sus children OTC<br />

sg ex-prin chw 160mg jr OTC<br />

sg ex-prin chw 80mg frt OTC<br />

sg ex-prin chw 80mg grp OTC<br />

sg ex-prin chw 80mg gum OTC<br />

sg ex-prin dro infant OTC<br />

sg ex-prin elx 160/5ml OTC<br />

sg ex-prin sus 160/5ml OTC<br />

sg ex-prin tab 325mg OTC<br />

sg ex-prin tab 500mg OTC<br />

sm arthritis tab 650mg OTC<br />

sm non-asa chw 80mg OTC<br />

sm non-asa chw 80mg grp OTC<br />

sm non-asa elx 160/5ml OTC<br />

sm pain rel cap 500mg OTC<br />

sm pain rel tab 500mg/rr OTC<br />

sm pain rel tab 8 hour OTC<br />

sm tension tab headache OTC<br />

soba child p chw 80mg frt OTC<br />

soba childrn chw 80mg OTC<br />

soba pain re chw 160mg jr OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 63


sodium thiosalicylate inj 50 mg/ml PA<br />

tactinal chw children OTC<br />

tactinal tab 325mg OTC<br />

tactinal tab 500mg OTC<br />

tgt acetamin sus child OTC<br />

tgt acetamin tab 500mg OTC<br />

tgt acetamin tab 500mg/rr OTC<br />

tgt apap dro infants OTC<br />

tycolene tab 325mg OTC<br />

tycolene tab 500mg OTC<br />

tylenol chld tab 80mg OTC<br />

TYLENOL GO CHW EXTRA ST OTC<br />

tylophen cap 500mg OTC<br />

tylophen tab 325mg OTC<br />

un-aspirin tab 500mg OTC<br />

v-r non-asa dro 100mg/ml OTC<br />

v-r non-asa dro 80/0.8ml OTC<br />

v-r non-asa elx 160/5ml OTC<br />

womens menst tab relief OTC<br />

womns tylenl tab 500-25mg OTC<br />

Opiate Antagonists<br />

naloxone hcl inj 0.4 mg/ml PA<br />

naloxone hcl inj 1 mg/ml PA<br />

REVEX INJ 100MCG PA<br />

REVEX INJ 1MG/ML PA<br />

VIVITROL INJ 380MG PA<br />

Anticonvulsants<br />

Anticonvulsant Barbiturates<br />

primidone tab 250mg<br />

primidone tab 50mg<br />

primidone tab 250 mg<br />

primidone tab 50 mg<br />

Anticonvulsant Benzodiazepines<br />

clonazepam tab 0.5mg<br />

clonazepam tab 1mg<br />

clonazepam tab 2mg<br />

clonazepam tab 0.5 mg<br />

clonazepam tab 1 mg<br />

clonazepam tab 2 mg<br />

Hydantoins<br />

DILANTIN CAP 100MG<br />

DILANTIN CAP 30MG<br />

DILANTIN CHW 50MG<br />

DILANTIN-125 SUS 125/5ML<br />

DILANTIN-125 SUS 125/5ML<br />

fosphenytoin sodium inj 75 mg/ml (phenytoin equiv 50 mg/ml) PA<br />

PHENYTEK CAP 200MG<br />

PHENYTEK CAP 300MG<br />

phenytoin sus 100/4ml<br />

phenytoin sus 125/5ml<br />

PHENYTOIN CHEW TAB 50 MG<br />

phenytoin ex cap 100mg<br />

phenytoin ex cap 200mg<br />

phenytoin ex cap 300mg<br />

PHENYTOIN SODIUM EXTENDED CAP 100 MG<br />

phenytoin sodium extended cap 100 mg<br />

phenytoin sodium extended cap 200 mg<br />

PHENYTOIN SODIUM EXTENDED CAP 200 MG<br />

PHENYTOIN SODIUM EXTENDED CAP 30 MG<br />

phenytoin sodium extended cap 300 mg<br />

PHENYTOIN SODIUM EXTENDED CAP 300 MG<br />

phenytoin sodium inj 50 mg/ml PA<br />

PHENYTOIN SUSP 125 MG/5ML<br />

phenytoin susp 125 mg/5ml<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 64


Succinimides<br />

ethosuximide cap 250 mg<br />

ethosuximide cap 250mg<br />

ethosuximide sol 250/5ml<br />

ethosuximide soln 250 mg/5ml<br />

Anticonvulsants, Miscellaneous<br />

BANZEL TAB 200MG PA QL<br />

BANZEL TAB 400MG PA QL<br />

carbamazepin chw 100mg<br />

carbamazepin sus 100/5ml<br />

carbamazepin tab 200mg<br />

carbamazepin tab 200mg er<br />

carbamazepin tab 400mg er<br />

CARBAMAZEPINE CHEW TAB 100 MG<br />

carbamazepine chew tab 100 mg<br />

CARBAMAZEPINE SUSP 100 MG/5ML<br />

carbamazepine susp 100 mg/5ml<br />

carbamazepine tab 200 mg<br />

CARBAMAZEPINE TAB 200 MG<br />

CARBAMAZEPINE TAB SR 12HR 100 MG<br />

carbamazepine tab sr 12hr 200 mg<br />

CARBAMAZEPINE TAB SR 12HR 200 MG<br />

CARBAMAZEPINE TAB SR 12HR 400 MG<br />

CARBAMAZEPINE TAB SR 12HR 400 MG<br />

carbamazepine tab sr 12hr 400 mg<br />

divalproex cap 125mg<br />

divalproex tab 125mg dr<br />

divalproex tab 250mg dr<br />

divalproex tab 250mg ec<br />

divalproex tab 250mg er QL<br />

divalproex tab 500mg dr<br />

divalproex tab 500mg er QL<br />

divalproex sodium cap sprinkle 125 mg<br />

divalproex sodium tab delayed release 125 mg<br />

divalproex sodium tab delayed release 250 mg<br />

divalproex sodium tab delayed release 500 mg<br />

divalproex sodium tab sr 24 hr 250 mg QL<br />

divalproex sodium tab sr 24 hr 500 mg QL<br />

epitol tab 200mg<br />

KEPPRA INJ 500/5ML PA<br />

LAMICTAL CHW 2MG PA<br />

LAMICTAL ODT KIT PA<br />

LAMICTAL ODT TAB 100MG PA<br />

LAMICTAL ODT TAB 200MG PA<br />

LAMICTAL ODT TAB 25MG PA<br />

LAMICTAL ODT TAB 50MG PA<br />

LAMICTAL XR KIT PA<br />

LAMICTAL XR TAB 100MG PA<br />

LAMICTAL XR TAB 200MG PA<br />

LAMICTAL XR TAB 25MG PA<br />

LAMICTAL XR TAB 50MG PA<br />

lamotrigine tab 100 mg PA<br />

lamotrigine tab 150 mg PA<br />

lamotrigine tab 200 mg PA<br />

lamotrigine tab 25 mg PA<br />

lamotrigine tab 25 mg (35) starter kit PA<br />

lamotrigine tab 25 mg (42) & 100 mg (7) starter kit PA<br />

lamotrigine tab 25 mg (84) & 100 mg (14) starter kit PA<br />

lamotrigine tab chewable dispersible 25 mg PA<br />

lamotrigine tab chewable dispersible 5 mg PA<br />

levetiracetam oral soln 100 mg/ml PA<br />

levetiracetam tab 1000 mg PA<br />

levetiracetam tab 250 mg PA<br />

levetiracetam tab 500 mg PA<br />

levetiracetam tab 750 mg PA<br />

LYRICA CAP 300MG<br />

MAGNESIUM SU INJ 40MG/ML PA<br />

MAGNESIUM SU INJ 80MG/ML PA<br />

magnesium sulfate inj 50% PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 65


oxcarbazepine susp 300 mg/5ml (60 mg/ml) PA<br />

oxcarbazepine tab 150 mg PA<br />

oxcarbazepine tab 300 mg PA<br />

oxcarbazepine tab 600 mg PA<br />

PREGABALIN CAP 300 MG<br />

TEGRETOL CHW 100MG<br />

TEGRETOL SUS 100/5ML<br />

TEGRETOL TAB 200MG<br />

TEGRETOL XR TAB 100MG<br />

TEGRETOL XR TAB 200MG<br />

TEGRETOL XR TAB 400MG<br />

TEGRETOL XR TAB 400MG<br />

topiramate sprinkle cap 15 mg PA<br />

topiramate sprinkle cap 25 mg PA<br />

topiramate tab 100 mg PA<br />

topiramate tab 200 mg PA<br />

topiramate tab 25 mg PA<br />

topiramate tab 50 mg PA<br />

valproate sodium inj 100 mg/ml PA<br />

valproate sodium syrup 250 mg/5ml (base equiv)<br />

valproic acd cap 250mg<br />

valproic acd syp 250/5ml<br />

valproic acid cap 250 mg<br />

VIMPAT INJ 200MG/20 PA<br />

Psychotherapeutic Agents<br />

Antidepressants<br />

citalopram tab 10mg<br />

citalopram tab 20mg<br />

citalopram tab 40mg<br />

citalopram hydrobromide tab 10 mg (base equiv)<br />

citalopram hydrobromide tab 20 mg (base equiv)<br />

citalopram hydrobromide tab 40 mg (base equiv)<br />

fluoxetine cap 10mg<br />

fluoxetine cap 20mg<br />

fluoxetine sol 20mg/5ml<br />

fluoxetine hcl cap 10 mg<br />

fluoxetine hcl cap 20 mg<br />

fluoxetine hcl solution 20 mg/5ml<br />

nortriptylin cap 25mg<br />

nortriptyline hcl cap 25 mg<br />

paroxetine tab 20mg<br />

paroxetine hcl tab 20 mg<br />

trazodone tab 100mg<br />

trazodone tab 150mg<br />

trazodone tab 300mg<br />

trazodone tab 50mg<br />

trazodone hcl tab 100 mg<br />

trazodone hcl tab 150 mg<br />

trazodone hcl tab 300 mg<br />

trazodone hcl tab 50 mg<br />

Monomine Oxidase Inhibitors<br />

ISOCARBOXAZID TAB 10 MG<br />

MARPLAN TAB 10MG<br />

NARDIL TAB 15MG<br />

PHENELZINE SULFATE TAB 15 MG<br />

tranylcyprom tab 10mg<br />

tranylcypromine sulfate tab 10 mg<br />

Selective Serotonin- and Norepinephrine-reuptake<br />

CYMBALTA CAP 20MG PA<br />

CYMBALTA CAP 30MG PA<br />

CYMBALTA CAP 60MG PA<br />

EFFEXOR XR CAP 150MG<br />

EFFEXOR XR CAP 37.5MG<br />

EFFEXOR XR CAP 75MG<br />

venlafaxine tab 100mg<br />

venlafaxine tab 25mg<br />

venlafaxine tab 37.5mg<br />

venlafaxine tab 50mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 66


venlafaxine tab 75mg<br />

VENLAFAXINE HCL CAP SR 24HR 150 MG (BASE EQUIVALENT)<br />

VENLAFAXINE HCL CAP SR 24HR 37.5 MG (BASE EQUIVALENT)<br />

VENLAFAXINE HCL CAP SR 24HR 75 MG (BASE EQUIVALENT)<br />

venlafaxine hcl tab 100 mg<br />

venlafaxine hcl tab 25 mg<br />

venlafaxine hcl tab 37.5 mg<br />

venlafaxine hcl tab 50 mg<br />

venlafaxine hcl tab 75 mg<br />

Selective-serotonin Reuptake Inhibitors<br />

citalopram tab 10mg<br />

citalopram tab 20mg<br />

citalopram tab 40mg<br />

citalopram hydrobromide tab 10 mg (base equiv)<br />

citalopram hydrobromide tab 20 mg (base equiv)<br />

citalopram hydrobromide tab 40 mg (base equiv)<br />

ESCITALOPRAM OXALATE TAB 10 MG (BASE EQUIV) NF<br />

fluoxetine cap 10mg<br />

fluoxetine cap 20mg<br />

fluoxetine cap 40mg<br />

fluoxetine cap 90mg dr<br />

fluoxetine sol 20mg/5ml<br />

fluoxetine tab 10mg<br />

fluoxetine tab 20mg<br />

FLUOXETINE HCL (PMDD) CAP 10 MG<br />

fluoxetine hcl (pmdd) cap 10 mg<br />

fluoxetine hcl (pmdd) cap 20 mg<br />

fluoxetine hcl cap 10 mg<br />

fluoxetine hcl cap 20 mg<br />

fluoxetine hcl cap 40 mg<br />

fluoxetine hcl cap delayed release 90 mg<br />

FLUOXETINE HCL CAP DELAYED RELEASE 90 MG<br />

fluoxetine hcl solution 20 mg/5ml<br />

fluoxetine hcl tab 10 mg<br />

fluoxetine hcl tab 20 mg<br />

LEXAPRO TAB 10MG NF<br />

paroxetine tab 10mg<br />

paroxetine tab 20mg<br />

paroxetine tab 30mg<br />

paroxetine tab 40mg<br />

paroxetine hcl tab 10 mg<br />

paroxetine hcl tab 20 mg<br />

paroxetine hcl tab 30 mg<br />

paroxetine hcl tab 40 mg<br />

paroxetine hcl tab sr 24hr 12.5 mg PA<br />

paroxetine hcl tab sr 24hr 25 mg PA<br />

paroxetine hcl tab sr 24hr 37.5 mg PA<br />

PAXIL CR TAB 37.5MG PA<br />

PROZAC WEEKL CAP 90MG<br />

SARAFEM CAP 10MG<br />

selfemra cap 10mg<br />

selfemra cap 20mg<br />

sertraline tab 100mg<br />

sertraline tab 25mg<br />

sertraline tab 50mg<br />

sertraline hcl tab 100 mg<br />

sertraline hcl tab 25 mg<br />

sertraline hcl tab 50 mg<br />

Serotonin Modulators<br />

nefazodone tab 100mg<br />

nefazodone tab 100mg<br />

nefazodone tab 150mg<br />

nefazodone tab 150mg<br />

nefazodone tab 200mg<br />

nefazodone tab 200mg<br />

nefazodone tab 250mg<br />

nefazodone tab 250mg<br />

nefazodone tab 50mg<br />

nefazodone tab 50mg<br />

nefazodone hcl tab 100 mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 67


nefazodone hcl tab 100 mg<br />

nefazodone hcl tab 150 mg<br />

nefazodone hcl tab 150 mg<br />

nefazodone hcl tab 200 mg<br />

nefazodone hcl tab 200 mg<br />

nefazodone hcl tab 250 mg<br />

nefazodone hcl tab 250 mg<br />

nefazodone hcl tab 50 mg<br />

nefazodone hcl tab 50 mg<br />

trazodone tab 100mg<br />

trazodone tab 150mg<br />

trazodone tab 300mg<br />

trazodone tab 50mg<br />

trazodone hcl tab 100 mg<br />

trazodone hcl tab 150 mg<br />

trazodone hcl tab 300 mg<br />

trazodone hcl tab 50 mg<br />

Tricyclics and Other Norepinephrine-reuptake Inhib<br />

amitriptylin tab 100mg<br />

amitriptylin tab 10mg<br />

amitriptylin tab 150mg<br />

amitriptylin tab 25mg<br />

amitriptylin tab 50mg<br />

amitriptylin tab 75mg<br />

amitriptyline hcl tab 10 mg<br />

amitriptyline hcl tab 100 mg<br />

amitriptyline hcl tab 150 mg<br />

amitriptyline hcl tab 25 mg<br />

amitriptyline hcl tab 50 mg<br />

amitriptyline hcl tab 75 mg<br />

clomipramine cap 25mg<br />

clomipramine cap 50mg<br />

clomipramine cap 75mg<br />

clomipramine hcl cap 25 mg<br />

clomipramine hcl cap 50 mg<br />

clomipramine hcl cap 75 mg<br />

desipramine tab 100mg<br />

desipramine tab 10mg<br />

desipramine tab 150mg<br />

desipramine tab 25mg<br />

desipramine tab 50mg<br />

desipramine tab 75mg<br />

desipramine hcl tab 10 mg<br />

desipramine hcl tab 100 mg<br />

desipramine hcl tab 150 mg<br />

desipramine hcl tab 25 mg<br />

desipramine hcl tab 50 mg<br />

desipramine hcl tab 75 mg<br />

doxepin hcl cap 100mg<br />

doxepin hcl cap 10mg<br />

doxepin hcl cap 150mg<br />

DOXEPIN HCL CAP 150MG<br />

doxepin hcl cap 150mg<br />

doxepin hcl cap 25mg<br />

doxepin hcl cap 50mg<br />

doxepin hcl cap 75mg<br />

doxepin hcl con 10mg/ml<br />

doxepin hcl cap 10 mg<br />

doxepin hcl cap 100 mg<br />

doxepin hcl cap 150 mg<br />

doxepin hcl cap 150 mg<br />

DOXEPIN HCL CAP 150 MG<br />

doxepin hcl cap 25 mg<br />

doxepin hcl cap 50 mg<br />

doxepin hcl cap 75 mg<br />

doxepin hcl conc 10 mg/ml<br />

imipram hcl tab 10mg<br />

imipram hcl tab 25mg<br />

imipram hcl tab 50mg<br />

imipram pam cap 100mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 68


imipram pam cap 125mg<br />

imipram pam cap 150mg<br />

imipram pam cap 75mg<br />

imipramine hcl tab 10 mg<br />

imipramine hcl tab 25 mg<br />

imipramine hcl tab 50 mg<br />

imipramine pamoate cap 100 mg<br />

imipramine pamoate cap 125 mg<br />

imipramine pamoate cap 150 mg<br />

IMIPRAMINE PAMOATE CAP 75 MG<br />

imipramine pamoate cap 75 mg<br />

nortriptylin cap 10mg<br />

nortriptylin cap 25mg<br />

nortriptylin cap 50mg<br />

nortriptylin cap 75mg<br />

nortriptylin sol 10mg/5ml<br />

nortriptyline hcl cap 10 mg<br />

nortriptyline hcl cap 25 mg<br />

nortriptyline hcl cap 50 mg<br />

nortriptyline hcl cap 75 mg<br />

nortriptyline hcl soln 10 mg/5ml<br />

TOFRANIL-PM CAP 75MG<br />

Miscellaneous Antidepressants<br />

budeprion tab 100mg sr<br />

budeprion tab 150mg sr<br />

bupropion tab 100mg<br />

bupropion tab 100mg er<br />

bupropion tab 100mg sr<br />

bupropion tab 150mg er<br />

bupropion tab 150mg sr<br />

bupropion tab 200mg sr<br />

bupropion tab 75mg<br />

bupropion hcl (smoking deterrent) tab sr 12hr 150 mg PA<br />

bupropion hcl tab 100 mg<br />

bupropion hcl tab 75 mg<br />

bupropion hcl tab sr 12hr 100 mg<br />

bupropion hcl tab sr 12hr 150 mg<br />

bupropion hcl tab sr 12hr 200 mg<br />

mirtazapine tab 15mg<br />

mirtazapine tab 30mg<br />

mirtazapine tab 45mg<br />

mirtazapine tab 7.5mg<br />

mirtazapine tab 15 mg<br />

mirtazapine tab 30 mg<br />

mirtazapine tab 45 mg<br />

mirtazapine tab 7.5 mg<br />

Antipsychotics<br />

risperidone sol 1mg/ml PA<br />

risperidone soln 1 mg/ml PA<br />

SEROQUEL XR TAB 150MG PA<br />

SEROQUEL XR TAB 50MG PA<br />

Atypical Antipsychotics<br />

ABILIFY INJ 9.75MG PA<br />

ABILIFY SOL 1MG/ML PA<br />

ABILIFY TAB 10MG PA<br />

ABILIFY TAB 15MG PA<br />

ABILIFY TAB 20MG PA<br />

ABILIFY TAB 2MG PA<br />

ABILIFY TAB 30MG PA<br />

ABILIFY TAB 5MG PA<br />

ABILIFY DISC TAB 10MG PA<br />

ABILIFY DISC TAB 15MG PA<br />

CLOZAPINE TAB 12.5 PA<br />

CLOZAPINE TAB 200MG PA<br />

clozapine tab 100 mg PA<br />

clozapine tab 200 mg PA<br />

clozapine tab 25 mg PA<br />

clozapine tab 50 mg PA<br />

FAZACLO TAB 100MG PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 69


FAZACLO TAB 12.5MG PA<br />

FAZACLO TAB 25MG PA<br />

GEODON CAP 20MG PA<br />

GEODON CAP 40MG PA<br />

GEODON CAP 60MG PA<br />

GEODON CAP 80MG PA<br />

GEODON INJ 20MG PA<br />

INVEGA SUST INJ 117/0.75 PA<br />

INVEGA SUST INJ 156MG/ML PA<br />

INVEGA SUST INJ 234/1.5 PA<br />

INVEGA SUST INJ 39/0.25 PA<br />

INVEGA SUST INJ 78/0.5ML PA<br />

RISPERDAL INJ 12.5MG PA<br />

RISPERDAL INJ 25MG PA<br />

RISPERDAL INJ 37.5MG PA<br />

RISPERDAL INJ 50MG PA<br />

RISPERIDONE TAB 0.25 ODT PA QL<br />

risperidone orally disintegrating tab 0.5 mg PA QL<br />

risperidone orally disintegrating tab 1 mg PA QL<br />

risperidone orally disintegrating tab 2 mg PA QL<br />

risperidone orally disintegrating tab 3 mg PA QL<br />

risperidone orally disintegrating tab 4 mg PA QL<br />

risperidone soln 1 mg/ml PA<br />

risperidone tab 0.25 mg PA<br />

risperidone tab 0.5 mg PA<br />

risperidone tab 1 mg PA QL<br />

risperidone tab 2 mg PA QL<br />

risperidone tab 3 mg PA QL<br />

risperidone tab 4 mg PA QL<br />

SAPHRIS SUB 10MG PA<br />

SAPHRIS SUB 5MG PA<br />

SEROQUEL TAB 100MG PA<br />

SEROQUEL TAB 200MG PA<br />

SEROQUEL TAB 25MG PA<br />

SEROQUEL TAB 300MG PA<br />

SEROQUEL TAB 400MG PA<br />

SEROQUEL TAB 50MG PA<br />

SEROQUEL XR TAB 150MG PA<br />

SEROQUEL XR TAB 200MG PA<br />

SEROQUEL XR TAB 300MG PA<br />

SEROQUEL XR TAB 400MG PA<br />

SEROQUEL XR TAB 50MG PA<br />

ZYPREXA INJ 10MG PA<br />

ZYPREXA TAB 10MG PA<br />

ZYPREXA TAB 15MG PA<br />

ZYPREXA TAB 2.5MG PA<br />

ZYPREXA TAB 20MG PA<br />

ZYPREXA TAB 5MG PA<br />

ZYPREXA TAB 7.5MG PA<br />

ZYPREXA RELP INJ 210MG PA<br />

ZYPREXA RELP INJ 300MG PA<br />

ZYPREXA RELP INJ 405MG PA<br />

ZYPREXA ZYDI TAB 10MG PA<br />

ZYPREXA ZYDI TAB 15MG PA<br />

ZYPREXA ZYDI TAB 20MG PA<br />

ZYPREXA ZYDI TAB 5MG PA<br />

Butyrophenones<br />

haloperidol con 2mg/ml<br />

haloperidol tab 0.5mg<br />

haloperidol tab 10mg<br />

haloperidol tab 1mg<br />

haloperidol tab 20mg<br />

haloperidol tab 2mg<br />

haloperidol tab 5mg<br />

haloperidol decanoate im soln 100 mg/ml PA<br />

haloperidol decanoate im soln 50 mg/ml PA<br />

haloperidol lactate inj 5 mg/ml PA<br />

haloperidol lactate oral conc 2 mg/ml<br />

haloperidol tab 0.5 mg<br />

haloperidol tab 1 mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 70


haloperidol tab 10 mg<br />

haloperidol tab 2 mg<br />

haloperidol tab 20 mg<br />

haloperidol tab 5 mg<br />

Phenothiazines<br />

CHLORPROMAZ INJ 25MG/ML PA<br />

chlorpromaz tab 100mg<br />

chlorpromaz tab 10mg<br />

chlorpromaz tab 200mg<br />

chlorpromaz tab 25mg<br />

chlorpromaz tab 50mg<br />

chlorpromazine hcl tab 10 mg<br />

chlorpromazine hcl tab 100 mg<br />

chlorpromazine hcl tab 200 mg<br />

chlorpromazine hcl tab 25 mg<br />

chlorpromazine hcl tab 50 mg<br />

CHLORPROMAZINE SUPPOS 100 MG<br />

compro sup 25mg<br />

fluphenazine con 5mg/ml<br />

fluphenazine decanoate inj 25 mg/ml PA<br />

FLUPHENAZINE ELX 2.5/5ML<br />

fluphenazine elx 2.5/5ml<br />

fluphenazine hcl elixir 2.5 mg/5ml<br />

FLUPHENAZINE HCL ELIXIR 2.5 MG/5ML<br />

fluphenazine hcl oral conc 5 mg/ml<br />

fluphenazine hcl tab 1 mg<br />

fluphenazine hcl tab 10 mg<br />

fluphenazine hcl tab 2.5 mg<br />

fluphenazine hcl tab 5 mg<br />

FLUPHENAZINE INJ 2.5MG/ML PA<br />

fluphenazine tab 10mg<br />

fluphenazine tab 1mg<br />

fluphenazine tab 2.5mg<br />

fluphenazine tab 5mg<br />

perphenazine tab 16 mg<br />

perphenazine tab 16mg<br />

perphenazine tab 2 mg<br />

perphenazine tab 2mg<br />

perphenazine tab 4 mg<br />

perphenazine tab 4mg<br />

perphenazine tab 8 mg<br />

perphenazine tab 8mg<br />

prochlorper sup 25mg<br />

prochlorper tab 10mg<br />

prochlorper tab 5mg<br />

prochlorperazine edisylate inj 5 mg/ml PA<br />

prochlorperazine maleate tab 10 mg<br />

prochlorperazine maleate tab 5 mg<br />

prochlorperazine suppos 25 mg<br />

thioridazine hcl tab 10 mg<br />

thioridazine hcl tab 100 mg<br />

thioridazine hcl tab 25 mg<br />

thioridazine hcl tab 50 mg<br />

thioridazine tab 100mg<br />

thioridazine tab 10mg<br />

thioridazine tab 25mg<br />

thioridazine tab 50mg<br />

THORAZINE SUP 100MG<br />

trifluoperaz tab 10mg<br />

trifluoperaz tab 1mg<br />

trifluoperaz tab 2mg<br />

trifluoperaz tab 5mg<br />

trifluoperazine hcl tab 1 mg<br />

trifluoperazine hcl tab 10 mg<br />

trifluoperazine hcl tab 2 mg<br />

trifluoperazine hcl tab 5 mg<br />

Thioxanthenes<br />

NAVANE CAP 20MG<br />

thiothixene cap 10mg<br />

thiothixene cap 1mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 71


thiothixene cap 2mg<br />

thiothixene cap 5mg<br />

thiothixene cap 1 mg<br />

thiothixene cap 10 mg<br />

thiothixene cap 2 mg<br />

THIOTHIXENE CAP 20 MG<br />

thiothixene cap 5 mg<br />

Miscellaneous Antipsychotics<br />

loxapine cap 10mg<br />

loxapine cap 25mg<br />

loxapine cap 50mg<br />

loxapine cap 5mg<br />

loxapine succinate cap 10 mg<br />

loxapine succinate cap 25 mg<br />

loxapine succinate cap 5 mg<br />

loxapine succinate cap 50 mg<br />

Anorexigenics & Resp & Cereb Stimulants<br />

Amphetamines<br />

amphetamine cap 10mg er QL<br />

amphetamine cap 15mg er QL<br />

amphetamine cap 20mg er QL<br />

amphetamine cap 25mg er QL<br />

amphetamine cap 30mg er QL<br />

amphetamine cap 5mg er QL<br />

amphetamine tab 10mg QL<br />

amphetamine tab 12.5mg QL<br />

amphetamine tab 15mg QL<br />

amphetamine tab 20mg QL<br />

amphetamine tab 30mg QL<br />

amphetamine tab 5mg QL<br />

amphetamine tab 5mg NF<br />

amphetamine tab 7.5mg QL<br />

amphetamine-dextroamphetamine cap sr 24hr 10 mg QL<br />

amphetamine-dextroamphetamine cap sr 24hr 15 mg QL<br />

amphetamine-dextroamphetamine cap sr 24hr 20 mg QL<br />

amphetamine-dextroamphetamine cap sr 24hr 25 mg QL<br />

amphetamine-dextroamphetamine cap sr 24hr 30 mg QL<br />

amphetamine-dextroamphetamine cap sr 24hr 5 mg QL<br />

amphetamine-dextroamphetamine tab 10 mg QL<br />

amphetamine-dextroamphetamine tab 12.5 mg QL<br />

amphetamine-dextroamphetamine tab 15 mg QL<br />

amphetamine-dextroamphetamine tab 20 mg QL<br />

amphetamine-dextroamphetamine tab 30 mg QL<br />

amphetamine-dextroamphetamine tab 5 mg QL<br />

amphetamine-dextroamphetamine tab 5 mg NF<br />

amphetamine-dextroamphetamine tab 7.5 mg QL<br />

dextroamphet cap 10mg cr<br />

dextroamphet cap 10mg er<br />

dextroamphet cap 15mg cr<br />

dextroamphet cap 15mg er<br />

dextroamphet cap 5mg cr<br />

dextroamphet cap 5mg er<br />

dextroamphet tab 10mg<br />

dextroamphet tab 10mg<br />

dextroamphet tab 5mg<br />

dextroamphetamine sulfate cap sr 24hr 10 mg<br />

dextroamphetamine sulfate cap sr 24hr 15 mg<br />

dextroamphetamine sulfate cap sr 24hr 5 mg<br />

dextroamphetamine sulfate tab 10 mg<br />

dextroamphetamine sulfate tab 10 mg<br />

dextroamphetamine sulfate tab 5 mg<br />

dextrostat tab 10mg<br />

dextrostat tab 5mg<br />

LIQUADD SOL 5MG/5ML PA<br />

PROCENTRA SOL 5MG/5ML PA<br />

VYVANSE CAP 20MG PA<br />

VYVANSE CAP 30MG PA<br />

VYVANSE CAP 40MG PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 72


VYVANSE CAP 50MG PA<br />

VYVANSE CAP 60MG PA<br />

VYVANSE CAP 70MG PA<br />

Anorexigenics & Resp & Cereb Stim, Misc<br />

caffeine citrate inj 20 mg/ml (10 mg/ml base equiv) PA<br />

CAFFEINE/SOD INJ BENZOATE PA<br />

CONCERTA TAB 18MG PA ST<br />

CONCERTA TAB 18MG ST QL<br />

CONCERTA TAB 27MG PA ST<br />

CONCERTA TAB 27MG ST QL<br />

CONCERTA TAB 36MG PA ST<br />

CONCERTA TAB 36MG ST QL<br />

CONCERTA TAB 54MG PA ST<br />

CONCERTA TAB 54MG ST QL<br />

DAYTRANA DIS 10MG/9HR PA<br />

DAYTRANA DIS 15MG/9HR PA<br />

DAYTRANA DIS 20MG/9HR PA<br />

DAYTRANA DIS 30MG/9HR PA<br />

doxapram hcl inj 20 mg/ml PA<br />

FOCALIN XR CAP 10MG PA<br />

FOCALIN XR CAP 15MG PA<br />

FOCALIN XR CAP 20MG PA<br />

FOCALIN XR CAP 30MG PA<br />

FOCALIN XR CAP 5MG PA<br />

metadate tab 20mg er ST QL<br />

METADATE CD CAP 10MG QL<br />

METADATE CD CAP 20MG QL<br />

METADATE CD CAP 30MG QL<br />

METADATE CD CAP 40MG QL<br />

METADATE CD CAP 50MG QL<br />

METADATE CD CAP 60MG QL<br />

METHYLIN CHW 10MG QL<br />

METHYLIN CHW 2.5MG QL<br />

METHYLIN CHW 5MG QL<br />

METHYLIN SOL 10MG/5ML<br />

METHYLIN SOL 5MG/5ML<br />

methylin tab 10mg QL<br />

methylin tab 20mg QL<br />

methylin tab 5mg QL<br />

methylin er tab 10mg ST QL<br />

methylin er tab 20mg ST QL<br />

methylphenid tab 10mg QL<br />

methylphenid tab 10mg ST QL<br />

methylphenid tab 20mg QL<br />

methylphenid tab 20mg cr ST QL<br />

methylphenid tab 20mg er ST QL<br />

methylphenid tab 20mg sr ST QL<br />

methylphenid tab 5mg QL<br />

METHYLPHENIDATE HCL CAP CR 10 MG QL<br />

METHYLPHENIDATE HCL CAP CR 20 MG QL<br />

METHYLPHENIDATE HCL CAP CR 30 MG QL<br />

METHYLPHENIDATE HCL CAP CR 40 MG QL<br />

METHYLPHENIDATE HCL CAP CR 50 MG QL<br />

METHYLPHENIDATE HCL CAP CR 60 MG QL<br />

METHYLPHENIDATE HCL CAP SR 24HR 10 MG QL<br />

METHYLPHENIDATE HCL CAP SR 24HR 20 MG QL<br />

METHYLPHENIDATE HCL CAP SR 24HR 30 MG QL<br />

METHYLPHENIDATE HCL CAP SR 24HR 40 MG QL<br />

METHYLPHENIDATE HCL CHEW TAB 10 MG QL<br />

METHYLPHENIDATE HCL CHEW TAB 2.5 MG QL<br />

METHYLPHENIDATE HCL CHEW TAB 5 MG QL<br />

METHYLPHENIDATE HCL SOLN 10 MG/5ML<br />

METHYLPHENIDATE HCL SOLN 5 MG/5ML<br />

methylphenidate hcl tab 10 mg QL<br />

methylphenidate hcl tab 20 mg QL<br />

methylphenidate hcl tab 5 mg QL<br />

methylphenidate hcl tab cr 10 mg ST QL<br />

methylphenidate hcl tab cr 20 mg ST QL<br />

METHYLPHENIDATE HCL TAB SA OSM 18 MG ST QL<br />

METHYLPHENIDATE HCL TAB SA OSM 27 MG ST QL<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 73


METHYLPHENIDATE HCL TAB SA OSM 36 MG ST QL<br />

METHYLPHENIDATE HCL TAB SA OSM 54 MG ST QL<br />

MODAFINIL TAB 200 MG NF<br />

PROVIGIL TAB 200MG NF<br />

RITALIN LA CAP 10MG QL<br />

RITALIN LA CAP 20MG QL<br />

RITALIN LA CAP 30MG QL<br />

RITALIN LA CAP 40MG QL<br />

Anxiolytics, Sedatives and Hypnotics<br />

Barbiturates<br />

AMYTAL SOD INJ 500MG PA<br />

LUMINAL INJ 60MG/ML PA<br />

NEMBUTAL INJ 50MG/ML PA<br />

phenobarb elx 20mg/5ml<br />

PHENOBARB INJ 65MG/ML PA<br />

phenobarb tab 100mg<br />

phenobarb tab 15mg<br />

phenobarb tab 16.2mg<br />

phenobarb tab 30mg<br />

phenobarb tab 32.4mg<br />

phenobarb tab 60mg<br />

PHENOBARB TAB 64.8MG<br />

PHENOBARB TAB 97.2MG<br />

phenobarb tab 97.2mg<br />

phenobarbital elixir 20 mg/5ml<br />

phenobarbital sodium inj 130 mg/ml PA<br />

phenobarbital tab 100 mg<br />

phenobarbital tab 15 mg<br />

phenobarbital tab 16.2 mg<br />

phenobarbital tab 30 mg<br />

phenobarbital tab 32.4 mg<br />

phenobarbital tab 60 mg<br />

PHENOBARBITAL TAB 64.8 MG<br />

phenobarbital tab 97.2 mg<br />

PHENOBARBITAL TAB 97.2 MG<br />

Benzodiazepines<br />

alprazolam tab 0.25mg<br />

alprazolam tab 0.5mg<br />

alprazolam tab 1mg<br />

alprazolam tab 2mg<br />

alprazolam orally disintegrating tab 0.25 mg PA<br />

alprazolam orally disintegrating tab 0.5 mg PA<br />

alprazolam orally disintegrating tab 1 mg PA<br />

alprazolam orally disintegrating tab 2 mg PA<br />

alprazolam tab 0.25 mg<br />

alprazolam tab 0.5 mg<br />

alprazolam tab 1 mg<br />

alprazolam tab 2 mg<br />

chlordiazep cap 10mg<br />

chlordiazep cap 25mg<br />

chlordiazep cap 5mg<br />

chlordiazepoxide hcl cap 10 mg<br />

chlordiazepoxide hcl cap 25 mg<br />

chlordiazepoxide hcl cap 5 mg<br />

DIAZEPAM INJ 5MG/ML PA<br />

DIAZEPAM SOL 1MG/ML PA<br />

diazepam tab 10mg<br />

diazepam tab 2mg<br />

diazepam tab 5mg<br />

diazepam inj 5 mg/ml PA<br />

diazepam tab 10 mg<br />

diazepam tab 2 mg<br />

diazepam tab 5 mg<br />

estazolam tab 1mg<br />

estazolam tab 2mg<br />

estazolam tab 1 mg<br />

estazolam tab 2 mg<br />

flurazepam cap 15mg<br />

flurazepam cap 30mg<br />

flurazepam hcl cap 15 mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 74


flurazepam hcl cap 30 mg<br />

LIBRIUM INJ 100MG PA<br />

lorazepam tab 0.5mg<br />

lorazepam tab 1mg<br />

lorazepam tab 2mg<br />

lorazepam inj 2 mg/ml PA<br />

lorazepam inj 4 mg/ml PA<br />

lorazepam tab 0.5 mg<br />

lorazepam tab 1 mg<br />

lorazepam tab 2 mg<br />

midazolam hcl inj 1 mg/ml (base equivalent) PA<br />

midazolam hcl inj 5 mg/ml (base equivalent) PA<br />

MIDAZOLAM/ INJ NACL PA<br />

oxazepam cap 10mg<br />

oxazepam cap 15mg<br />

oxazepam cap 30mg<br />

oxazepam cap 10 mg<br />

oxazepam cap 15 mg<br />

oxazepam cap 30 mg<br />

RESTORIL CAP 7.5MG<br />

temazepam cap 15mg<br />

temazepam cap 30mg<br />

temazepam cap 7.5mg<br />

temazepam cap 15 mg<br />

temazepam cap 22.5 mg PA<br />

temazepam cap 30 mg<br />

TEMAZEPAM CAP 7.5 MG<br />

temazepam cap 7.5 mg<br />

triazolam tab 0.125mg<br />

triazolam tab 0.25mg<br />

triazolam tab 0.125 mg<br />

triazolam tab 0.25 mg<br />

Anxiolytics, Sedatives, & Hypnotics Misc<br />

acetamin pm tab 25-500mg OTC<br />

acetamin pm tab 25-500mg OTC<br />

acetamin pm tab 25-500mg OTC<br />

acetamin pm tab ex str OTC<br />

apap sleep tab x-str pm OTC<br />

apap/diphen tab 500-25mg OTC<br />

buspirone tab 10mg<br />

buspirone tab 15mg<br />

buspirone tab 30mg<br />

buspirone tab 5mg<br />

buspirone tab 7.5mg<br />

BUSPIRONE TAB 7.5MG<br />

buspirone hcl tab 10 mg<br />

buspirone hcl tab 15 mg<br />

buspirone hcl tab 30 mg<br />

buspirone hcl tab 5 mg<br />

BUSPIRONE HCL TAB 7.5 MG<br />

buspirone hcl tab 7.5 mg<br />

chloral hydr syp 500/5ml<br />

CHLORAL HYDR SYP 500/5ML<br />

CHLORAL HYDRATE CAP 500 MG<br />

CHLORAL HYDRATE SYRUP 500 MG/5ML<br />

chloral hydrate syrup 500 mg/5ml<br />

diphenhydramine w/ apap tab 25-500 mg (sleep) OTC<br />

droperidol inj 2.5 mg/ml PA<br />

eql headache tab pm OTC<br />

ex str apap tab 25-500mg OTC<br />

hca non-asa tab pm OTC<br />

hca non-asp tab pm ex st OTC<br />

headache tab pm OTC<br />

hydroxyz hcl inj 25mg/ml<br />

hydroxyz hcl inj 50mg/ml<br />

hydroxyz hcl syp 10mg/5ml<br />

hydroxyz hcl tab 10mg<br />

hydroxyz hcl tab 25mg<br />

hydroxyz hcl tab 50mg<br />

hydroxyz pam cap 100mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 75


hydroxyz pam cap 25mg<br />

hydroxyz pam cap 50mg<br />

hydroxyzine hcl im soln 25 mg/ml<br />

hydroxyzine hcl im soln 50 mg/ml<br />

hydroxyzine hcl syrup 10 mg/5ml<br />

hydroxyzine hcl tab 10 mg<br />

hydroxyzine hcl tab 25 mg<br />

hydroxyzine hcl tab 50 mg<br />

hydroxyzine pamoate cap 100 mg<br />

hydroxyzine pamoate cap 25 mg<br />

hydroxyzine pamoate cap 50 mg<br />

HYDROXYZINE PAMOATE SUSP 25 MG/5ML<br />

mapap pm tab 25-500mg OTC<br />

medi-tabs pm tab 25-500mg OTC<br />

night time tab 25-500mg OTC<br />

non-asa pm tab 25-500mg OTC<br />

non-asa pm tab 25-500mg OTC<br />

non-asa pm tab 25-500mg OTC<br />

non-asa pm tab ex st OTC<br />

non-aspirin tab pm OTC<br />

non-aspirin tab pm OTC<br />

non-aspirin tab pm OTC<br />

pain pm e/s tab 25-500mg OTC<br />

pain relf pm tab ex st/rr OTC<br />

pain relief tab pm OTC<br />

pain relief tab pm OTC<br />

pain relief tab pm OTC<br />

pain relief tab pm ex st OTC<br />

pain relief tab pm ex st OTC<br />

pain relieve tab 25-500mg OTC<br />

pain relieve tab 25-500mg OTC<br />

pain relieve tab 500-25mg OTC<br />

pain relieve tab expr gel OTC<br />

pain relieve tab pm OTC<br />

pain relieve tab pm ex st OTC<br />

pain relieve tab pm ex st OTC<br />

pain relieve tab pm qr OTC<br />

pain reliver tab 25-500mg OTC<br />

PRECEDEX INJ 100MCG PA<br />

ra acetam pm tab ex st/rr OTC<br />

ra acetamin tab pm ex st OTC<br />

sb non-asa tab 25-500mg OTC<br />

sb non-asa tab night OTC<br />

sg ex-prin tab pm xs OTC<br />

SOMNOTE CAP 500MG<br />

VISTARIL SUS 25MG/5ML<br />

zaleplon cap 10mg<br />

zaleplon cap 5mg<br />

zaleplon cap 10 mg<br />

zaleplon cap 5 mg<br />

zolpidem tartrate tab 10 mg PA<br />

zolpidem tartrate tab 5 mg PA<br />

Antimanic Agents<br />

lithium carb cap 150mg<br />

lithium carb cap 300mg<br />

lithium carb cap 600mg<br />

lithium carb tab 300mg<br />

lithium carb tab 300mg er<br />

lithium carb tab 450mg er<br />

lithium carbonate cap 150 mg<br />

lithium carbonate cap 300 mg<br />

lithium carbonate cap 600 mg<br />

lithium carbonate tab 300 mg<br />

lithium carbonate tab cr 300 mg<br />

lithium carbonate tab cr 450 mg<br />

Antimigraine Agents<br />

Selective Serotonin Agonists<br />

ELETRIPTAN HYDROBROMIDE TAB 20 MG (BASE EQUIVALENT) QL<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 76


ELETRIPTAN HYDROBROMIDE TAB 40 MG (BASE EQUIVALENT) QL<br />

IMITREX KIT 4MG/0.5 PA<br />

IMITREX KIT 4MG/0.5 PA<br />

IMITREX SPR 20MG/ACT PA<br />

IMITREX SPR 5MG/ACT PA<br />

IMITREX TAB 100MG QL<br />

MAXALT TAB 10MG QL<br />

MAXALT TAB 5MG QL<br />

MAXALT-MLT TAB 10MG QL<br />

MAXALT-MLT TAB 5MG QL<br />

RELPAX TAB 20MG QL<br />

RELPAX TAB 40MG QL<br />

RIZATRIPTAN BENZOATE ORALLY DISINTEGRATING TAB 10 MG QL<br />

RIZATRIPTAN BENZOATE ORALLY DISINTEGRATING TAB 5 MG QL<br />

RIZATRIPTAN BENZOATE TAB 10 MG QL<br />

RIZATRIPTAN BENZOATE TAB 5 MG QL<br />

SUMATRIPTAN KIT 4MG/0.5 PA<br />

SUMATRIPTAN KIT 4MG/0.5 PA<br />

SUMATRIPTAN SPR 20MG/ACT PA<br />

SUMATRIPTAN SPR 5MG/ACT PA<br />

sumatriptan tab 100mg QL<br />

sumatriptan tab 25mg QL<br />

sumatriptan tab 50mg QL<br />

sumatriptan succinate inj 12 mg/ml PA<br />

sumatriptan succinate inj 4 mg/0.5ml PA<br />

sumatriptan succinate inj kit 6 mg/0.5ml PA<br />

SUMATRIPTAN SUCCINATE TAB 100 MG QL<br />

sumatriptan succinate tab 100 mg QL<br />

sumatriptan succinate tab 25 mg QL<br />

sumatriptan succinate tab 50 mg QL<br />

SUMAVEL DOSE INJ 6MG/0.5 PA<br />

ZOLMITRIPTAN ORALLY DISINTEGRATING TAB 2.5 MG QL<br />

ZOLMITRIPTAN ORALLY DISINTEGRATING TAB 5 MG QL<br />

ZOLMITRIPTAN TAB 2.5 MG QL<br />

ZOLMITRIPTAN TAB 5 MG QL<br />

ZOMIG TAB 2.5MG QL<br />

ZOMIG TAB 5MG QL<br />

ZOMIG ZMT TAB 2.5 MG QL<br />

ZOMIG ZMT TAB 5MG QL<br />

Antimigraine Agents, Miscellaneous<br />

amidrine cap<br />

apap-isometheptene-dichloral cap 325-65-100 mg<br />

diacetazone cap<br />

duradrin cap<br />

epidrin cap<br />

ergotam/caff tab 1/100<br />

ERGOTAMINE W/ CAFFEINE SUPPOS 2-100 MG<br />

ergotamine w/ caffeine tab 1-100 mg<br />

isometh/apap cap dichlor<br />

isometh/apap cap dichlor<br />

MIGERGOT SUP 2/100<br />

migquin cap<br />

migratine cap<br />

migrazone cap<br />

migrin-a cap<br />

va-zone cap<br />

Antidepressants, Miscellaneous<br />

selegiline hcl tab 5 mg PA<br />

Central Nervous System Agents, Misc<br />

ATOMOXETINE HCL CAP 10 MG (BASE EQUIV)<br />

ATOMOXETINE HCL CAP 100 MG (BASE EQUIV)<br />

ATOMOXETINE HCL CAP 18 MG (BASE EQUIV)<br />

ATOMOXETINE HCL CAP 25 MG (BASE EQUIV)<br />

ATOMOXETINE HCL CAP 40 MG (BASE EQUIV)<br />

ATOMOXETINE HCL CAP 60 MG (BASE EQUIV)<br />

ATOMOXETINE HCL CAP 80 MG (BASE EQUIV)<br />

flumazenil iv soln 0.1 mg/ml PA<br />

STRATTERA CAP 100MG<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 77


STRATTERA CAP 10MG<br />

STRATTERA CAP 18MG<br />

STRATTERA CAP 25MG<br />

STRATTERA CAP 40MG<br />

STRATTERA CAP 60MG<br />

STRATTERA CAP 80MG<br />

Contraceptives<br />

*CERVICAL CAPS***<br />

*DIAPHRAGMS*** NF<br />

CERVICAL CAP 22 MM<br />

CERVICAL CAP 25 MM<br />

CERVICAL CAP 26 MM<br />

CERVICAL CAP 28 MM<br />

CERVICAL CAP 30 MM<br />

CERVICAL CAP 31 MM<br />

DIAPHRAGM ARC-SPRING 65 MM NF<br />

DIAPHRAGM ARC-SPRING 70 MM NF<br />

DIAPHRAGM ARC-SPRING 75 MM NF<br />

DIAPHRAGM ARC-SPRING 80 MM NF<br />

DIAPHRAGM ARC-SPRING KIT 55 MM NF<br />

DIAPHRAGM ARC-SPRING KIT 60 MM NF<br />

DIAPHRAGM ARC-SPRING KIT 65 MM NF<br />

DIAPHRAGM ARC-SPRING KIT 70 MM NF<br />

DIAPHRAGM ARC-SPRING KIT 75 MM NF<br />

DIAPHRAGM ARC-SPRING KIT 80 MM NF<br />

DIAPHRAGM ARC-SPRING KIT 85 MM NF<br />

DIAPHRAGM ARC-SPRING KIT 90 MM NF<br />

DIAPHRAGM ARC-SPRING KIT 95 MM NF<br />

DIAPHRAGM COIL SPRING KIT 100 MM NF<br />

DIAPHRAGM COIL SPRING KIT 105 MM NF<br />

DIAPHRAGM COIL SPRING KIT 50 MM NF<br />

DIAPHRAGM COIL SPRING KIT 55 MM NF<br />

DIAPHRAGM COIL SPRING KIT 60 MM NF<br />

DIAPHRAGM COIL SPRING KIT 65 MM NF<br />

DIAPHRAGM COIL SPRING KIT 70 MM NF<br />

DIAPHRAGM COIL SPRING KIT 75 MM NF<br />

DIAPHRAGM COIL SPRING KIT 80 MM NF<br />

DIAPHRAGM COIL SPRING KIT 85 MM NF<br />

DIAPHRAGM COIL SPRING KIT 90 MM NF<br />

DIAPHRAGM COIL SPRING KIT 95 MM NF<br />

DIAPHRAGM FLAT SPRING KIT 55 MM NF<br />

DIAPHRAGM FLAT SPRING KIT 60 MM NF<br />

DIAPHRAGM FLAT SPRING KIT 65 MM NF<br />

DIAPHRAGM FLAT SPRING KIT 70 MM NF<br />

DIAPHRAGM FLAT SPRING KIT 75 MM NF<br />

DIAPHRAGM FLAT SPRING KIT 80 MM NF<br />

DIAPHRAGM FLAT SPRING KIT 85 MM NF<br />

DIAPHRAGM FLAT SPRING KIT 90 MM NF<br />

DIAPHRAGM FLAT SPRING KIT 95 MM NF<br />

FEMCAP MIS 22MM<br />

FEMCAP MIS 26MM<br />

FEMCAP MIS 30MM<br />

NONOXYNOL-9 FOAM 12.5% OTC<br />

OMNIFLEX DPR NF<br />

ORTHO COIL DPR KIT 100 NF<br />

ORTHO COIL DPR KIT 105 NF<br />

ORTHO COIL DPR KIT 50 NF<br />

ORTHO COIL DPR KIT 55 NF<br />

ORTHO COIL DPR KIT 60 NF<br />

ORTHO COIL DPR KIT 65 NF<br />

ORTHO COIL DPR KIT 70 NF<br />

ORTHO COIL DPR KIT 75 NF<br />

ORTHO COIL DPR KIT 80 NF<br />

ORTHO COIL DPR KIT 85 NF<br />

ORTHO COIL DPR KIT 90 NF<br />

ORTHO COIL DPR KIT 95 NF<br />

ORTHO FLAT DPR KIT 55 NF<br />

ORTHO FLAT DPR KIT 60 NF<br />

ORTHO FLAT DPR KIT 65 NF<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 78


ORTHO FLAT DPR KIT 70 NF<br />

ORTHO FLAT DPR KIT 75 NF<br />

ORTHO FLAT DPR KIT 80 NF<br />

ORTHO FLAT DPR KIT 85 NF<br />

ORTHO FLAT DPR KIT 90 NF<br />

ORTHO FLAT DPR KIT 95 NF<br />

ORTHO FLEX DPR 55MM NF<br />

ORTHO FLEX DPR 60MM NF<br />

ORTHO FLEX DPR 65MM NF<br />

ORTHO FLEX DPR 65MM NF<br />

ORTHO FLEX DPR 70MM NF<br />

ORTHO FLEX DPR 70MM NF<br />

ORTHO FLEX DPR 75MM NF<br />

ORTHO FLEX DPR 75MM NF<br />

ORTHO FLEX DPR 80MM NF<br />

ORTHO FLEX DPR 85MM NF<br />

ORTHO FLEX DPR 90MM NF<br />

ORTHO FLEX DPR 95MM NF<br />

ORTHO INTROD DPR UNIVRSL NF<br />

PRENTIF MIS 22MM<br />

PRENTIF MIS 25MM<br />

PRENTIF MIS 28MM<br />

PRENTIF MIS 31MM<br />

PRENTIF MIS FITTING<br />

VCF VAGINAL AER CONTRACP OTC<br />

Diagnostic Agents<br />

ASPERGILLUS INJ 1:500 PA<br />

DIAGNOSTIC KIT PA<br />

LYMPHAZURIN INJ 1% PA<br />

MAGNEVIST INJ 46.9% PA<br />

OMNISCAN INJ 287MG/ML PA<br />

OMNISCAN KIT SAFEPAK PA<br />

PROHANCE INJ 279.3/ML PA<br />

TESLASCAN INJ PA<br />

THYREL TRH INJ 0.5MG/ML PA<br />

Adrenocortical Insufficiency<br />

cosyntropin for inj 0.25 mg PA<br />

Cardiac Function<br />

ADENOSCAN INJ 3MG/ML PA<br />

indocyanine green for inj 25 mg PA<br />

Diabetes Mellitus<br />

ACCU-CHEK TES ACTIVE PA OTC<br />

ACCU-CHEK TES ADVANTAG PA OTC<br />

ACCU-CHEK TES AVIVA PA OTC<br />

ACCU-CHEK TES COMFORT PA OTC<br />

ACCU-CHEK TES COMPACT PA OTC<br />

ACCU-CHEK TES DRUM PA OTC<br />

ACCU-CHEK TES INST GLC PA OTC<br />

ACCU-CHEK TES INST PLS PA OTC<br />

ACCUTREND TES GLUCOSE PA OTC<br />

ACURA TES STRIPS PA OTC<br />

ADVANCE TES INTUITIO PA OTC<br />

ADVANCE TES MICRO-DW PA OTC<br />

ADVOCATE TES PA OTC<br />

ADVOCATE TES REDICODE PA OTC<br />

ALBERTSONS TES PA OTC<br />

ASCENSIA TES ELITE PA OTC<br />

ASSURE 3 TES PA OTC<br />

ASSURE 4 TES PA OTC<br />

ASSURE II TES PA OTC<br />

ASSURE II TES PA OTC<br />

ASSURE II TES CHECK PA OTC<br />

ASSURE PRO TES PA OTC<br />

AT LAST TES PA OTC<br />

AUTOCODE GLUC TEST STRIPS PA OTC<br />

BAYER CONTOR TES BLD GLUC PA OTC<br />

BD TEST MIS PA OTC<br />

BIOSCANNER TES GLUCOSE PA OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 79


BL TEST MIS PA OTC<br />

BL TEST MIS PACK PA OTC<br />

BLOOD GLUCOS TES PA OTC<br />

BLOOD GLUCOS TES PA OTC<br />

CLEVER CHEK TES PA OTC<br />

CLEVER CHEK TES AUTO CD PA OTC<br />

CLEVER CHEK TES VOICE PA OTC<br />

CLEVR CHOICE TES AUTO-CD PA OTC<br />

COMPACT TES PA OTC<br />

CONTROL TES PA OTC<br />

CONTROL AST TES PA OTC<br />

CVS BLOOD TES GLUCOSE PA OTC<br />

CVS BLOOD TES GLUCOSE PA OTC<br />

DIABETIC.COM TES PA OTC<br />

DISCOUNT DRG TES BLD GLUC PA OTC<br />

DRG EMPORIUM TES PA OTC<br />

DUANE READE TES PA OTC<br />

DUO-CARE TES PA OTC<br />

EASY CHECK TES GLUCOSE PA OTC<br />

EASY STEP TES PA OTC<br />

EASYGLUCO TES PA OTC<br />

EASYMAX TES PA OTC<br />

EASYPRO TES BLD GLUC PA OTC<br />

EASYPRO PLUS TES PA OTC<br />

ECLIPSE TES PA OTC<br />

ELEMENT TES PA OTC<br />

EMBRACE TES STRIPS PA OTC<br />

ENVISION TES AUTOCODE PA OTC<br />

EVENCARE TES BLD GLUC PA OTC<br />

EVENCARE + TES BLD GLUC PA OTC<br />

EVOLUTION TES AUTOCODE PA OTC<br />

EXACTECH TES PA OTC<br />

EXACTECH TES R-S-G PA OTC<br />

EXCEL G TES PA OTC<br />

EXP MED TES STP PACK PA OTC<br />

EZ SMART TES BLD GLUC PA OTC<br />

EZ SMART PLS TES BLD GLUC PA OTC<br />

FASTTAKE TES PA OTC<br />

FIFTY50 GLUC TES 2.0 PA OTC<br />

FORA D10 TES BLD GLUC PA OTC<br />

FORA D15C TES BLD GLUC PA OTC<br />

FORA D15G TES BLD GLUC PA OTC<br />

FORA D15Z TES BLD GLUC PA OTC<br />

FORA G20 TES BLD GLUC PA OTC<br />

FORA V10 TES BLD GLUC PA OTC<br />

FORA V12 TES BLD GLUC PA OTC<br />

FORA V20 TES BLD GLUC PA OTC<br />

FORA V22 TES BLD GLUC PA OTC<br />

FREESTYLE TES PA OTC<br />

FREESTYLE TES LITE PA OTC<br />

GIANT EAGLE TES PHARMACY PA OTC<br />

GLUCO DEX TES SENSORS PA OTC<br />

GLUCO ELITE TES PA OTC<br />

GLUCOCARD TES VITAL PA OTC<br />

GLUCOCARD TES X-SENSOR PA OTC<br />

GLUCOCARD 01 TES PA OTC<br />

GLUCOCARD 01 TES SENSOR PA OTC<br />

GLUCOCOM TES PA OTC<br />

GLUCOFILM TES PA OTC<br />

GLUCOLAB TES PA OTC<br />

GLUCOMETER TES ENCORE PA OTC<br />

GLUCOSE BLOOD TEST STRIP OTC QL<br />

GLUCOSTIX TES PA OTC<br />

GNP TEST MIS PA OTC<br />

GNP TRUEREAD TES PA OTC<br />

GNP TRUETRAC TES SMRT SYS PA OTC<br />

HCA TEST TES PA OTC<br />

HLTH ALLIANC TES PA OTC<br />

INFINITY TES BLD GLUC PA OTC<br />

INFINITY TES GLUCOSE PA OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 80


KERR DRUG TES STP PACK PA OTC<br />

KINRAY TES PA OTC<br />

KROGER TES PA OTC<br />

KROGER BLOOD TES GLUCOSE PA OTC<br />

LIBERTY TES PA OTC<br />

LIFE MEDICAL TES PA OTC<br />

LONG TES PA OTC<br />

MAXIMA BLOOD TES GLUCOSE PA OTC<br />

MEIJER TES PA OTC<br />

MICRODOT TES STRIPS PA OTC<br />

NAVARRO TES BLD GLUC PA OTC<br />

NEXGEN TES PA OTC<br />

NOVA MAX TES GLUCOSE PA OTC<br />

ONETOUCH TES PA OTC<br />

ONETOUCH TES PA OTC<br />

ONETOUCH TES PA OTC<br />

ONETOUCH TES PA OTC<br />

ONETOUCH TES ULTRA PA OTC<br />

OPTIUM TES PA OTC<br />

POCKETCHEM TES EZ PA OTC<br />

PRECISION TES PCX PA OTC<br />

PRECISION TES PCX PLUS PA OTC<br />

PRECISION TES QID PA OTC<br />

PRECISION TES SOF-TACT PA OTC<br />

PRECISION TES XTRA PA OTC<br />

PRECISION PT TES OF CARE PA OTC<br />

PRESTIGE TES PA OTC<br />

PRESTIGE TES SMRT SYS PA OTC<br />

PRESTIGE VAL MIS PACK PA OTC<br />

PRODIGY TES BLD GLUC PA OTC<br />

PRODIGY AUTO TES BLD GLUC PA OTC<br />

PRODIGY EJCT TES BLD GLUC PA OTC<br />

PRODIGY NO TES CODING PA OTC<br />

PRODIGY VOIC TES BLD GLUC PA OTC<br />

PTS PANELS TES GLUCOSE PA OTC<br />

QUICKTEK TES PA OTC<br />

RA BLOOD TES GLUCOSE PA OTC<br />

RA TRUETEST TES PA OTC<br />

REFUAH PLUS TES GLUCOSE PA OTC<br />

RELION TES ULTIMA PA OTC<br />

RELION BLOOD TES GLUCOSE PA OTC<br />

RELION MICRO TES GLUCOSE PA OTC<br />

RIGHTEST TES GS100 PA OTC<br />

RIGHTEST TES GS300 PA OTC<br />

SENTRY TES PA OTC<br />

SHOPRITE TES PA OTC<br />

SM GLUCOSE TES PA OTC<br />

SMARTEST TES BLD GLUC PA OTC<br />

SOLO V2 TES PA OTC<br />

SUPREME TES PA OTC<br />

SURE EDGE TES PA OTC<br />

SURE-TEST TES EASYPLUS PA OTC<br />

SURECHEK TES BLD GLUC PA OTC<br />

SURESTEP TES PA OTC<br />

SURESTEP PRO TES PA OTC<br />

TRUE CARE TES STP PACK PA OTC<br />

TRUETEST TES OTC QL<br />

TRUETRACK TES OTC QL<br />

ULTIMA TES PA OTC<br />

ULTRATRK PRO TES PA OTC<br />

VICTORY TES AGM-4000 PA OTC<br />

WAVESENSE TES AMP PA OTC<br />

WAVESENSE TES JAZZ PA OTC<br />

WAVESENSE TES KEYNOTE PA OTC<br />

WAVESENSE TES PRESTO PA OTC<br />

WINN DIXIE TES MEDIC PA OTC<br />

Drug Hypersensitivity<br />

CANDIN INJ PA<br />

PRE-PEN INJ PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 81


Fungi<br />

HYSTOLYN-CYL INJ 1:100 PA<br />

SPHERULIN INJ 1:10 PA<br />

SPHERULIN INJ 1:100 PA<br />

Gallbladder Function<br />

KINEVAC INJ 5MCG PA<br />

Kidney Function<br />

AMINOHIPPURA INJ 20% PA<br />

indigotindisulfonate sodium inj 8 mg/ml PA<br />

INULIN INJ 100MG/ML PA<br />

Myasthenia Gravis<br />

edrophonium chloride inj 10 mg/ml PA<br />

ENLON INJ 150/15ML PA<br />

TENSILON INJ 10MG/ML PA<br />

Ocular Disorders<br />

fluorescein sodium inj 10% PA<br />

fluorescein sodium inj 25% PA<br />

Thyroid Function<br />

IODOPEN INJ 100MCG PA<br />

THYROGEN INJ 1.1MG PA<br />

Pheochromocytoma<br />

HISTATROL INJ 0.275/ML PA<br />

Pituitary Function<br />

ACTHREL INJ 100MCG PA<br />

FACTREL INJ 100MCG PA<br />

GEREF DIAG INJ 50MCG PA<br />

R-GENE 10 INJ 10% PA<br />

Roentgenography<br />

CHOLOGRAFIN INJ 52% PA<br />

CONRAY INJ 60% PA<br />

CONRAY 30 INJ 30% PA<br />

CONRAY 400 INJ 66.8% PA<br />

CONRAY 43 INJ 43% PA<br />

CYSTO-CONRAY INJ II 17.2% PA<br />

CYSTOGRAFIN INJ 30% PA<br />

CYSTOGRAFIN- INJ DILUTE PA<br />

diatrizoate meglumine & sodium oral soln 66-10% PA<br />

ETHIODOL INJ 37% PA<br />

FERIDEX I.V. INJ 11.2MF F PA<br />

GLOFIL-125 INJ 0.1% PA<br />

HEXABRIX INJ PA<br />

HYPAQUE MEGL INJ 30% PA<br />

HYPAQUE MEGL INJ 60% PA<br />

HYPAQUE SOD INJ 20% PA<br />

HYPAQUE SOD INJ 25% PA<br />

HYPAQUE SOD INJ 50% PA<br />

HYPAQUE-76 INJ PA<br />

HYPAQUE-CYST INJ 30% PA<br />

HYPAQUE-CYST INJ 30% PED PA<br />

ISOVUE-200 INJ 41% PA<br />

ISOVUE-250 INJ 51% PA<br />

ISOVUE-250 INJ 51%MLTPK PA<br />

ISOVUE-300 INJ 61% PA<br />

ISOVUE-300 INJ 61%MLTPK PA<br />

ISOVUE-370 INJ 76% PA<br />

ISOVUE-370 INJ 76%MLTPK PA<br />

ISOVUE-M 200 INJ 41% PA<br />

ISOVUE-M 300 INJ 61% PA<br />

MD-76 R INJ PA<br />

MD-GASTROVIE SOL 66-10% PA<br />

MYELO-KIT INJ 180MG/ML PA<br />

MYELO-KIT INJ 240MG/ML PA<br />

OMNIPAQUE INJ 140MG/ML PA<br />

OMNIPAQUE INJ 180MG/ML PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 82


OMNIPAQUE INJ 210MG/ML PA<br />

OMNIPAQUE INJ 240MG/ML PA<br />

OMNIPAQUE INJ 300MG/ML PA<br />

OMNIPAQUE INJ 350MG/ML PA<br />

OPTIRAY 160 INJ 34% PA<br />

OPTIRAY 240 INJ 51% PA<br />

OPTIRAY 300 INJ 64% PA<br />

OPTIRAY 320 INJ 68% PA<br />

OPTIRAY 350 INJ 74% PA<br />

RENO-30 INJ 30% PA<br />

RENO-60 INJ 60% PA<br />

RENO-CAL-76 INJ PA<br />

RENO-DIP INJ 30% PA<br />

RENOGRAFIN INJ -60 PA<br />

SINOGRAFIN INJ PA<br />

ULTRAVIST INJ 150MG/ML PA<br />

ULTRAVIST INJ 240MG/ML PA<br />

ULTRAVIST INJ 300MG/ML PA<br />

ULTRAVIST INJ 370MG/ML PA<br />

VISIPAQUE INJ 270MG/ML PA<br />

VISIPAQUE INJ 320MG/ML PA<br />

Trichinosis<br />

TRICHOPHYTON INJ 1:200 PA<br />

TRICHOPHYTON INJ 1:500 PA<br />

Tuberculosis<br />

APLISOL INJ 5/0.1ML PA<br />

TUBERSOL INJ 5/0.1ML PA<br />

TUBERSOL INJ 5/0.1ML PA<br />

TUBERSOL INJ 5/0.1ML PA<br />

Urine and Feces Contents<br />

Ketones<br />

ACETEST TAB TABLETS OTC<br />

ACETONE (URINE) TEST STRIP OTC<br />

ACETONE (URINE) TEST TAB OTC<br />

CHEK-STIX TES CONTROL OTC<br />

CHEK-STIX TES CONTROL OTC<br />

CHEMSTRIP K TES OTC<br />

KETOCARE TES OTC<br />

KETOSTIX TES OTC<br />

KETOSTIX TES STRIP OTC<br />

RELION KETON TES OTC<br />

Electrolytic, Caloric and Water Balance<br />

Acidifying Agents<br />

AMMONIUM CHL INJ 5MEQ/ML PA<br />

Alkalinizing Agents<br />

NEUT INJ 4% PA<br />

SOD LACTATE INJ 1/6M PA<br />

sodium acetate inj 2 meq/ml PA<br />

sodium acetate inj 4 meq/ml PA<br />

sodium bicarbonate inj 4.2% PA<br />

sodium bicarbonate inj 5% PA<br />

sodium bicarbonate inj 7.5% PA<br />

sodium bicarbonate inj 8.4% PA<br />

sodium lactate inj 5 meq/ml PA<br />

sodium lactate iv soln 167 meq/l (1/6m) PA<br />

THAM INJ 30MEQ PA<br />

Ammonia Detoxicants<br />

AMMONUL INJ 10% PA<br />

constulose sol 10gm/15<br />

enulose sol 10gm/15<br />

generlac sol 10gm/15<br />

lactulose sol 10gm/15<br />

lactulose sol 20gm/30<br />

lactulose (encephalopathy) solution 10 gm/15ml<br />

lactulose solution 10 gm/15ml<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 83


Replacement Preparations<br />

*electrolyte-75 in d5w soln*** PA<br />

*electrolyte-m in d5w soln*** PA<br />

*electrolyte-r in d5w soln*** PA<br />

*electrolyte-r solution*** PA<br />

*ORAL ELECTROLYTE SOLUTION*** OTC NF<br />

*parenteral electrolyte conc*** PA<br />

*parenteral electrolyte soln*** PA<br />

AMMON MOLYBD INJ 25MCG/ML PA<br />

ammonium molybdate inj 25 mcg/ml PA<br />

calc acetate cap 667mg<br />

calcium acetate (phosphate binder) cap 667 mg (169 mg ca)<br />

CALCIUM ACETATE (PHOSPHATE BINDER) CAP 667 MG (169 MG CA)<br />

CALCIUM ACETATE (PHOSPHATE BINDER) TAB 667 MG<br />

calcium chloride inj 10% PA<br />

calcium gluconate inj 10% PA<br />

CALPHOSAN INJ PA<br />

chromium chloride inj 4 mcg/ml PA<br />

COPPER SULF INJ 0.4MG/ML PA<br />

CUPRIC CHLOR INJ 0.4MG/ML PA<br />

D10W/NACL INJ 0.225% PA<br />

D10W/NACL INJ 0.45% PA<br />

D5W/LYTES INJ #48 PA<br />

D5W/NACL INJ 0.225% PA<br />

D5W/NACL INJ 0.3% PA<br />

dextran 40 inj 10% in d5w PA<br />

dextran 40 inj 10% in saline PA<br />

DEXTRAN 70 INJ 6% PA<br />

dextran 70 6% in saline iv soln PA<br />

DEXTRAN HM INJ 32% PA<br />

dextrose 10% w/ sodium chloride 0.2% PA<br />

dextrose 10% w/ sodium chloride 0.9% PA<br />

dextrose 2.5% in lactated ringers 1/2 strength PA<br />

dextrose 2.5% w/ sodium chloride 0.45% PA<br />

dextrose 5% in lactated ringers PA<br />

dextrose 5% in ringers PA<br />

dextrose 5% w/ sodium chloride 0.2% PA<br />

dextrose 5% w/ sodium chloride 0.33% PA<br />

dextrose 5% w/ sodium chloride 0.45% PA<br />

dextrose 5% w/ sodium chloride 0.9% PA<br />

ed k+10 tab 10meq cr<br />

ELECTROLYTE SOL -48/DEX PA<br />

ELIPHOS TAB 667MG<br />

ELLIOTTS B INJ PA<br />

ENFALYTE SOL OTC NF<br />

hetastarch in sodium chloride inj 6-0.9% PA<br />

HEXTEND SOL 6% PA<br />

IONOSOL-B/ INJ D5W PA<br />

IONOSOL-MB INJ /D5W PA<br />

IONOSOL-T INJ /D5W PA<br />

ISOLYTE-H INJ /D5W PA<br />

ISOLYTE-P INJ /D5W PA<br />

ISOLYTE-S INJ PA<br />

ISOLYTE-S INJ /D5W PA<br />

ISOLYTE-S INJ PH 7.4 PA<br />

kaon-cl-10 tab 10meq cr<br />

kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.2% inj PA<br />

kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj PA<br />

kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj PA<br />

kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj PA<br />

kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj PA<br />

kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.9% inj PA<br />

kcl 20 meq/l (0.15%) in nacl 0.45% inj PA<br />

kcl 20 meq/l (0.15%) in nacl 0.9% inj PA<br />

kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.2% inj PA<br />

kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj PA<br />

kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.2% inj PA<br />

kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj PA<br />

kcl 40 meq/l (0.3%) in nacl 0.9% inj PA<br />

KCL/D10/NACL INJ 0.15/0.2 PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 84


KCL/D5W INJ 0.075% PA<br />

KCL/D5W/LR INJ 0.15% PA<br />

KCL/D5W/LR INJ 0.3% PA<br />

KCL/D5W/LR INJ 0.3% PA<br />

KCL/D5W/NACL INJ .224/.33 PA<br />

KCL/D5W/NACL INJ 0.15/0.2 PA<br />

KCL/D5W/NACL INJ 0.3/0.9% PA<br />

klor-con 10 tab 10meq er<br />

klor-con m10 tab 10meq er<br />

klor-con m20 tab 20meq er<br />

klotrix tab 10meq cr<br />

lactated ringer's solution PA<br />

magnesium chloride inj 20% PA<br />

MANGANESE CL INJ 0.1MG/ML PA<br />

MANGANESE SU INJ 0.1MG/ML PA<br />

MG SO4/D5W INJ 10MG/ML PA<br />

MG SO4/D5W INJ 20MG/ML PA<br />

MULTITRACE-4 INJ PA<br />

MULTITRACE-4 INJ NEONATAL PA<br />

MULTITRACE-4 INJ PED PA<br />

MULTITRACE-5 INJ REGULAR PA<br />

NACL/BACT INJ 0.9%BENZ PA<br />

NORMOSOL-R INJ PH 7.4 PA<br />

PENTASPAN INJ PA<br />

PHOSLO CAP 667MG<br />

PLASMA-LYTE INJ -148 PA<br />

PLASMA-LYTE INJ -A PA<br />

PLASMA-LYTE INJ /D5W PA<br />

PLASMA-LYTE INJ 56 PA<br />

PLASMA-LYTE INJ 56/D5W PA<br />

pot bicarbonate & chloride effer tab 25 meq<br />

POT CHLORIDE INJ 10MEQ PA<br />

pot chloride liq 10%<br />

pot chloride liq 10% sf<br />

pot chloride liq 20%<br />

pot chloride liq 20% sf<br />

pot chloride sol 10% sf<br />

pot chloride tab 10meq cr<br />

pot chloride tab 10meq er<br />

pot chloride tab 10meq sr<br />

pot chloride tab 25meq ef<br />

pot cl micro tab 10meq cr<br />

pot cl micro tab 10meq er<br />

pot cl micro tab 20meq cr<br />

pot cl micro tab 20meq er<br />

pot/chloride tab 25meq ef<br />

potassium acetate inj 2 meq/ml PA<br />

potassium acetate inj 4 meq/ml PA<br />

potassium chloride 20 meq/l (0.15%) in dextrose 5% inj PA<br />

potassium chloride 30 meq/l (0.224%) in dextrose 5% inj PA<br />

potassium chloride 40 meq/l (0.3%) in dextrose 5% inj PA<br />

potassium chloride inj 10 meq/100 ml PA<br />

potassium chloride inj 2 meq/ml PA<br />

potassium chloride inj 20 meq/100 ml PA<br />

potassium chloride inj 20 meq/50 ml PA<br />

potassium chloride inj 30 meq/100 ml PA<br />

potassium chloride inj 40 meq/100 ml PA<br />

potassium chloride microencapsulated crys cr tab 10 meq<br />

potassium chloride microencapsulated crys cr tab 20 meq<br />

potassium chloride oral liq 10% (20 meq/15ml)<br />

potassium chloride oral liq 20% (40 meq/15ml)<br />

potassium chloride tab cr 10 meq<br />

potassium phosphate dibasic inj 3 mmole/ml PA<br />

PRISMASOL SOL 0/0/1.2 PA<br />

PRISMASOL SOL 0/2.5 PA<br />

PRISMASOL SOL 2/0 PA<br />

PRISMASOL SOL 2/3.5 PA<br />

PRISMASOL SOL 4/0/1.2 PA<br />

PRISMASOL SOL 4/2.5 PA<br />

PRISMASOL SOL B22GK2/0 PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 85


PROMIT INJ 150MG/ML PA<br />

ringer's solution PA<br />

saline injection bacteriostatic PA<br />

SALINE/PHENO SOL PA<br />

SELENIUM INJ 40MCG/ML PA<br />

sodium chloride inj 0.45% PA<br />

sodium chloride inj 0.9% PA<br />

sodium chloride inj 2.5 meq/ml (14.6%) PA<br />

sodium chloride inj 3% PA<br />

sodium chloride inj 4 meq/ml (23.4%) PA<br />

sodium chloride inj 5% PA<br />

sodium chloride iv soln 0.9% PA<br />

sodium phosphate inj 3 mmole/ml PA<br />

TRACE ELEM 4 INJ PED PA<br />

TRACE METALS INJ PA<br />

trace min (cr-cu-mn-se-zn) inj 10-1000-500-60-5000 mcg/ml PA<br />

trace min (cr-cu-mn-zn) inj 0.01-1-0.5-5 mg/ml PA<br />

VOLUVEN INJ 6%/NACL PA<br />

ZINC SULFATE INJ 1MG/ML PA<br />

ZINC SULFATE INJ 5MG/ML PA<br />

ZINC TRACE INJ 1MG/ML PA<br />

Caloric Agents<br />

*amino acid electrolyte infusion 8.5%*** PA<br />

*amino acid infusion 15%*** PA<br />

*amino acid infusion 6%*** PA<br />

*amino acid infusion 8%*** PA<br />

*amino acid infusion 8.5%*** PA<br />

*INFANT FOODS LIQUID** OTC NF<br />

*NUTRITIONAL SUPPLEMENT LIQUID** OTC NF<br />

ALCOHOL INJ 95% PA<br />

alcohol absolute inj 98% PA<br />

ALCOHOL/D5W INJ 10% PA<br />

ALCOHOL/D5W INJ 5% PA<br />

AMINESS INJ 5.2% PA<br />

AMINOSYN INJ 10% PA<br />

AMINOSYN INJ 3.5% PA<br />

AMINOSYN INJ 5% PA<br />

AMINOSYN INJ 7% PA<br />

AMINOSYN INJ 8.5% PA<br />

AMINOSYN 2-M INJ 4.25/D10 PA<br />

AMINOSYN 7% INJ /LYTES PA<br />

AMINOSYN II INJ 10% PA<br />

AMINOSYN II INJ 3.5/D25 PA<br />

AMINOSYN II INJ 3.5/D5 PA<br />

AMINOSYN II INJ 4.25/D10 PA<br />

AMINOSYN II INJ 4.25/D20 PA<br />

AMINOSYN II INJ 4.25/D25 PA<br />

AMINOSYN II INJ 5/D25 PA<br />

AMINOSYN II INJ 7% PA<br />

AMINOSYN II INJ 8.5% PA<br />

AMINOSYN IIM INJ 3.5%/D5W PA<br />

AMINOSYN M INJ 3.5% PA<br />

AMINOSYN-HBC INJ 7% PA<br />

AMINOSYN-PF INJ 10% PA<br />

AMINOSYN-PF INJ 7% PA<br />

AMINOSYN-RF INJ 5.2% PA<br />

AMINOSYN-RF INJ 5.2% PA<br />

AMINOSYN/D20 INJ II 4.25% PA<br />

AMINOSYN/D25 INJ II 3.5% PA<br />

AMINOSYN/D25 INJ II 4.25% PA<br />

BRANCHAMIN INJ 4% PA<br />

CLINIMIX INJ 2.75/D5W PA<br />

CLINIMIX INJ 4.25/D10 PA<br />

CLINIMIX INJ 4.25/D20 PA<br />

CLINIMIX INJ 4.25/D25 PA<br />

CLINIMIX INJ 4.25/D5W PA<br />

CLINIMIX INJ 5%/D15W PA<br />

CLINIMIX INJ 5%/D20W PA<br />

CLINIMIX INJ 5%/D25W PA<br />

CLINIMIX E INJ 2.75/D10 PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 86


CLINIMIX E INJ 2.75/D5W PA<br />

CLINIMIX E INJ 4.25/D10 PA<br />

CLINIMIX E INJ 4.25/D25 PA<br />

CLINIMIX E INJ 4.25/D5W PA<br />

CLINIMIX E INJ 5%/D15W PA<br />

CLINIMIX E INJ 5%/D20W PA<br />

CLINIMIX E INJ 5%/D25W PA<br />

CLINIMIX E INJ 5%/D35W PA<br />

cysteine hcl inj 50 mg/ml PA<br />

DEXTROSE INJ 2.5% PA<br />

dextrose inj 10% PA<br />

dextrose inj 20% PA<br />

dextrose inj 25% PA<br />

dextrose inj 30% PA<br />

dextrose inj 40% PA<br />

dextrose inj 5% PA<br />

dextrose inj 50% PA<br />

dextrose inj 60% PA<br />

dextrose inj 70% PA<br />

fat emulsion iv soln 10% PA<br />

fat emulsion iv soln 20% PA<br />

fat emulsion iv soln 30% PA<br />

FREAMINE HBC INJ 6.9% PA<br />

FREAMINE III INJ 10% PA<br />

FREAMINE III INJ 3% PA<br />

FREAMINE III INJ 8.5%/D50 PA<br />

HEPATASOL INJ 8% PA<br />

MICROLIPID EMU 50% PA<br />

NEPHRAMINE INJ 5.4% PA<br />

PREMASOL SOL 10% PA<br />

PROCALAMINE INJ 3% PA<br />

PROMOTE LIQ R-T-HANG OTC NF<br />

PROSOL INJ 20% PA<br />

RENAMIN INJ 6.5% PA<br />

SIMILAC RTF LIQ LOW-IRON OTC NF<br />

SIMILAC/IRON LIQ RTF OTC NF<br />

TRAVASOL INJ 10% PA<br />

TRAVASOL INJ 5.5% PA<br />

TRAVASOL INJ 8.5% PA<br />

TRAVASOL 3.5 INJ /LYTES PA<br />

TRAVASOL 5.5 INJ /LYTES PA<br />

TRAVASOL/D10 INJ 2.75% PA<br />

TRAVASOL/D10 INJ 4.25% PA<br />

TRAVASOL/D10 INJ 5.5% PA<br />

TRAVASOL/D10 INJ 8.5% PA<br />

TRAVASOL/D20 INJ 5.5% PA<br />

TRAVASOL/D20 INJ 8.5% PA<br />

TRAVASOL/D25 INJ 4.25% PA<br />

TRAVASOL/D5 INJ 2.75% PA<br />

TRAVASOL/D50 INJ 8.5% PA<br />

TROPHAMINE INJ 10% PA<br />

Diuretics<br />

Loop Diuretics<br />

bumetanide inj 0.25 mg/ml PA<br />

DEMADEX INJ 20MG/2ML PA<br />

DEMADEX INJ 50MG/5ML PA<br />

furosemide sol 10mg/ml<br />

furosemide sol 40mg/4ml<br />

furosemide tab 20mg<br />

furosemide tab 40mg<br />

furosemide tab 80mg<br />

furosemide inj 10 mg/ml PA<br />

furosemide oral soln 10 mg/ml<br />

furosemide oral soln 8 mg/ml PA<br />

furosemide tab 20 mg<br />

furosemide tab 40 mg<br />

furosemide tab 80 mg<br />

SOD EDECRIN INJ 50MG PA<br />

TORSEMIDE INJ 20MG/2ML PA<br />

TORSEMIDE INJ 50MG/5ML PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 87


Osmotic Diuretics<br />

mannitol iv soln 10% PA<br />

mannitol iv soln 15% PA<br />

mannitol iv soln 20% PA<br />

mannitol iv soln 25% PA<br />

mannitol iv soln 5% PA<br />

Potassium-sparing Diuretics<br />

hctz/triamt cap 25-50mg<br />

hctz/triamt tab 25-37.5<br />

hctz/triamt tab 50-75mg<br />

triam/hctz cap 37.5-25<br />

triamt/hctz cap 50-25mg<br />

triamt/hctz tab 37.5-25<br />

triamt/hctz tab 75-50mg<br />

triamterene & hydrochlorothiazide cap 37.5-25 mg<br />

triamterene & hydrochlorothiazide cap 50-25 mg<br />

triamterene & hydrochlorothiazide tab 37.5-25 mg<br />

triamterene & hydrochlorothiazide tab 75-50 mg<br />

Thiazide Diuretics<br />

chlorothiazide sodium for inj 500 mg PA<br />

hydrochlorot tab 12.5mg<br />

hydrochlorot tab 25mg<br />

hydrochlorot tab 50mg<br />

hydrochlorothiazide tab 12.5 mg<br />

hydrochlorothiazide tab 25 mg<br />

hydrochlorothiazide tab 50 mg<br />

Thiazide-like Diuretics<br />

metolazone tab 10mg<br />

metolazone tab 2.5mg<br />

metolazone tab 5mg<br />

metolazone tab 10 mg<br />

metolazone tab 2.5 mg<br />

metolazone tab 5 mg<br />

Diuretics, Miscellaneous<br />

VAPRISOL INJ PA<br />

VAPRISOL INJ 20MG/4ML PA<br />

Enzymes<br />

ADAGEN INJ 250/ML PA<br />

ALDURAZYME INJ 2.9MG/5M PA<br />

AMPHADASE INJ 150/ML PA<br />

CEREDASE INJ 80UNT/ML PA<br />

CEREZYME INJ 200UNIT PA<br />

CEREZYME INJ 400UNIT PA<br />

ELAPRASE INJ 6MG/3ML PA<br />

ELITEK INJ 1.5MG PA<br />

ELITEK INJ 7.5MG PA<br />

FABRAZYME INJ 35MG PA<br />

FABRAZYME INJ 5MG PA<br />

HYDASE INJ 150/ML PA<br />

HYLENEX INJ 150 UNIT PA<br />

MYOZYME SOL 50MG PA<br />

NAGLAZYME INJ 1MG/ML PA<br />

VITRASE INJ 200/ML PA<br />

VITRASE INJ 6200UNIT PA<br />

VPRIV INJ 400UNIT PA<br />

XIAFLEX INJ 0.9MG PA<br />

Respiratory Tract Agents<br />

Antitussives<br />

*PE TAN-CARBETA TAN SUSP 25-30 MG/5ML & HOMEOPATH LOZ KIT***<br />

*PE-CARBETA-GG SOLN 5-15-100 MG/5ML & HOMEOPATH LOZ KIT***<br />

*PE-PHENIRAMINE-COD-SOD SALICYLATE-SOD CIT-CAFF LIQUID***<br />

*PE-PHENIRAMINE-COD-SOD SALICYLATE-SOD CIT-CAFF SYRUP***<br />

*PHENYLEPH-DM-PYRIL-POT GUAI-SOD CIT-CIT ACID LIQUID***<br />

*phenyleph-dm-pyril-pot guai-sod cit-cit acid liquid***<br />

10peh/380gfn tab /15dm OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 88


10peh/400gfn tab /20dm OTC<br />

10peh/4cpm/ tab 20dm OTC<br />

40pse/400gfn tab /20dm<br />

45pse/400gfn tab /15dm OTC<br />

60pse/400gfn tab /20dm<br />

60pse/4cpm/ tab 20dm OTC<br />

666 cold liq prep OTC<br />

666 cold liq prepartn OTC<br />

a-cof dh syp<br />

aber-tuss dr syp 6-2-15<br />

aber-tuss hc syp 10-2-2.5<br />

ACCUHIST DRO PDX<br />

ACETAMINOPHEN W/ DM CAP 325-15 MG OTC<br />

ACETAMINOPHEN W/ DM CHEW TAB 160-5 MG OTC<br />

acetaminophen w/ dm drops 80-2.5 mg/0.8ml OTC<br />

acetaminophen w/ dm liq 1000-30 mg/30ml OTC<br />

acetaminophen w/ dm liq 160-5 mg/5ml OTC<br />

ACETAMINOPHEN W/ DM LIQ 160-7.5 MG/5ML OTC<br />

ACETAMINOPHEN W/ DM LIQ 325-15 MG/15ML OTC<br />

ACETAMINOPHEN W/ DM SYRUP 160-5 MG/5ML OTC<br />

AEROTUSS 12 SUS 30MG/5ML<br />

af-cough fm liq decong OTC<br />

af-dibromm elx dm OTC<br />

af-flu cough tab /cold ms OTC<br />

af-nitetime liq OTC<br />

af-nitetime liq cough OTC<br />

af-triacting liq nitetime OTC<br />

af-triacting liq sore thr OTC<br />

af-tussin cf syp OTC<br />

af-tussin dm liq 100-10/5 OTC<br />

af-tussin dm syp 100-10/5 OTC<br />

AIRACOF LIQ<br />

ALACOL DM DRO<br />

ALAHIST AC LIQ 7.5-10<br />

ALAHIST DHC LIQ 7.5-3<br />

ALBATUSSIN CAP<br />

ALBATUSSIN CAP SR<br />

ALBATUSSIN DRO DM PED<br />

ALBATUSSIN DRO PED<br />

ALBATUSSIN DRO PEDI NR OTC<br />

ALBATUSSIN LIQ OTC<br />

ALBATUSSIN LIQ NN<br />

albatussin liq nn<br />

albatussin liq ped<br />

ALBATUSSIN SYP PEDI<br />

albatussin tab sr<br />

ALBATUSSIN TAB SR<br />

ALBATUSSN CF DRO PED<br />

ALKA-SELT PL CAP COLD/CGH OTC<br />

all-nite liq cold/flu OTC<br />

all-nite cld liq formula OTC<br />

allanhist dro pdx<br />

allanhist syp pdx<br />

allanvan-dm sus<br />

ALLFEN C TAB 5-1000MG<br />

ALLFEN CD TAB 400-10MG<br />

ALLFEN CDX LIQ<br />

ALLFEN CDX TAB 400-20MG<br />

ALLFEN CX TAB<br />

ALLFEN DM TAB<br />

allfen dm tab 400-20mg<br />

ALLFEN DMA TAB 4-20-400<br />

ALLRES D SUS<br />

ALLRES G SUS<br />

ALLRES PD SUS<br />

altarussin liq 100-10/5 OTC<br />

altarussn dm syp 100-10/5 OTC<br />

ambi 1000/5 tab<br />

ambi 1000/55 tab<br />

ambi 20dm/ tab 4cpm OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 89


ambi 40/1000 tab /60<br />

ambi 45/800/ tab 30<br />

AMBI 5/15/ LIQ 100<br />

ambi 60/1000 tab /30<br />

ambi 60/580/ tab 30<br />

ambi 80/700/ tab 40<br />

ambi 80/780/ tab 40<br />

AMBIFED CD TAB<br />

AMBIFED CDX TAB<br />

AMBIFED DM TAB OTC<br />

AMBIFED-G TAB CDX<br />

AMBIFED-G CD TAB<br />

AMBIFED-G DM TAB OTC<br />

AMERIFED DM SYP<br />

AMERITUSS AD LIQ 10-3-15<br />

amibid dm tab 30-600cr<br />

ANAPLEX DMX SUS<br />

andehist dm dro nr<br />

andehist dm syp nr<br />

anextuss tab<br />

aquabid-dm tab 30-600cr<br />

AQUATAB C TAB<br />

AQUATAB DM TAB<br />

ARIDEX DRO PED<br />

ATUSS HD CAP 30-2-5MG<br />

ATUSS HS SUS<br />

ATUSS HX CAP 5-300MG<br />

balacall dm syp 5-2-10mg<br />

benzonatate cap 100mg<br />

benzonatate cap 200mg<br />

benzonatate cap 100 mg<br />

BENZONATATE CAP 150 MG<br />

benzonatate cap 200 mg<br />

BETATAN SUS<br />

betavent liq 20-100mg<br />

BIDEX-A TAB 25-600MG<br />

bidex-dmi tab 20-400mg OTC<br />

BIO-TUSSI LIQ OTC<br />

BIO-TUSSI LIQ PEDIATRC OTC<br />

BIOBRON SF SYP OTC<br />

biocotron liq 100-10/5 OTC<br />

biodec-dm dro<br />

biodec-dm syp<br />

BIODESP DM SYP OTC<br />

biogil liq OTC<br />

BIONEL LIQ OTC<br />

BIONEL LIQ PEDIATRC OTC<br />

BIOSPEC DMX LIQ OTC<br />

biotuss liq<br />

biotuss liq pediatrc<br />

biotuss dm liq 100-10/5 OTC<br />

biotussin sol dac<br />

biotussin syp ac<br />

bl pain reli dro OTC<br />

bl severe tab cold/flu OTC<br />

bl tussin cf syp OTC<br />

bp 8 cough sus<br />

bpm pe dm syp 5-2-10mg<br />

bpm pe hc liq<br />

bpm-pe-dm liq 4-10-20<br />

bpm-pe-dmhbr liq 4-10-20<br />

bpm-pse-dm liq 4-20-20<br />

bpm-pse-dmhb liq 4-20-20<br />

bpm/dm/pse syp<br />

bpm/hydrocod liq /pse<br />

brom mal/pe liq dex hbr<br />

brom t/dm t/ sus pse t<br />

brom/pe/dm syp 5-2-10mg<br />

brom/pseud/ elx dm OTC<br />

brom/pseud/ syp dm<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 90


omaline dm elx 15-1-5/5 OTC<br />

BROMATAN SUS PLUS<br />

bromatan-dm sus<br />

bromatane dx syp<br />

bromaxefed syp dm rf<br />

bromcomp hc liq<br />

bromdec dm dro<br />

bromdec dm syp<br />

bromdex d syp<br />

brometane dx syp<br />

bromfed dm syp<br />

bromhist pdx dro<br />

bromhist-dm dro<br />

bromhist-dm syp ped<br />

BROMHIST-PDX SYP<br />

bromophed dx syp<br />

bromphen/dm/ syp pse<br />

bromphenex syp dm OTC<br />

bromphenex syp dm<br />

BROMPHENEX SYP HD<br />

BROMPHENIRAMINE W/ HYDROCODONE-GG LIQD 2-5-200 MG/5ML<br />

bromplex dm syp<br />

bromplex hd sol 30-2-1.7<br />

bromtuss dm liq<br />

BRONCOPECTOL SYP<br />

broncotron liq 10-100/5 OTC<br />

BRONCOTRON-D SUS<br />

BRONKIDS DRO<br />

bronkids syp 10-2-15<br />

BRONTEX LIQ<br />

brontuss la tab<br />

BRONTUSS SF SYP<br />

brotapp dm liq 15-1-5/5 OTC<br />

BROVEX CB TAB 10-4MG<br />

BROVEX CBX TAB 20-4MG<br />

BROVEX PB C TAB 10-4-10<br />

BROVEX PB CX TAB 10-4-20<br />

BROVEX PB DM TAB 10-4-20 OTC<br />

BROVEX PSE TAB DM<br />

BUCKLEYS LIQ COUGH OTC<br />

c-phed dpd sus tannate<br />

c-phen dm dro<br />

c-phen dm syp<br />

c-tanna 12 sus 4-30mg/5<br />

c-tanna 12d sus<br />

CANGES-HC LIQ<br />

canges-hc nr liq<br />

canges-xp liq 5-150mg<br />

CAPMIST DM TAB OTC<br />

car-b-pen tab chlor-ta<br />

carb pse 12 sus dm<br />

carb pseudo- sus tan<br />

carb/pe/gg liq<br />

carb/pe/gg syp<br />

carb/phenyl sus 12<br />

CARBAPHEN 12 LIQ<br />

CARBAPHEN 12 SUS<br />

CARBAPHEN 12 SUS PED<br />

carbatab-12 tab<br />

CARBATUSS-12 SUS<br />

CARBATUSS-CL LIQ<br />

carbaxefed d dro rf<br />

CARBET CIT-CARBET TAN-PE HCL-PE TAN SUS 10-20-2.5-7.5 MG/5ML<br />

carbetapen/ tab chlorphn<br />

CARBETAPENTANE CIT-GUAIFENESIN TANNATE SUSP 7.5-200 MG/5ML<br />

CARBETAPENTANE CIT-GUAIFENESIN TANNATE SUSP 7.5-200 MG/5ML<br />

CARBETAPENTANE CIT-PSEUDOEPH HCL TANNATE SUSP 7.5-30 MG/5ML<br />

CARBETAPENTANE CIT-PSEUDOEPH HCL TANNATE SUSP 7.5-30 MG/5ML<br />

CARBETAPENTANE CIT-PSEUDOEPHED HCL TANNATE CHEW TAB 20-30 MG<br />

CARBETAPENTANE CIT-PSEUDOEPHED HCL TANNATE SUSP 20-30 MG/5ML<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 91


CARBETAPENTANE CIT-PSEUDOEPHED HCL TANNATE SUSP 20-30 MG/5ML<br />

CARBETAPENTANE TAN-PYRILAMINE TAN SUSP 22.5-12 MG/5ML<br />

CARBETAPENTANE TANNATE SUSP 30 MG/5ML<br />

CARBETAPENTANE-GUAIFENESIN CAP 8-200 MG<br />

CARBETAPENTANE-GUAIFENESIN CAP SR 12 HR 30-400 MG<br />

CARBETAPENTANE-GUAIFENESIN LIQUID 10-100 MG/5ML<br />

carbetapentane-guaifenesin liquid 20-100 mg/5ml<br />

CARBETAPENTANE-GUAIFENESIN LIQUID 20-75 MG/5ML<br />

CARBETAPENTANE-GUAIFENESIN SYRUP 7.5-150 MG/5ML<br />

CARBETAPENTANE-GUAIFENESIN TAB SR 12 HR 5-1000 MG<br />

carbetapentane-guaifenesin tab sr 12 hr 5-1000 mg<br />

CARBETAPENTANE-GUAIFENESIN TAB SR 12 HR 60-1000 MG<br />

CARBETAPENTANE-GUAIFENESIN TAB SR 12 HR 60-1200 MG<br />

carbetapentane-guaifenesin tab sr 12 hr 60-600 mg<br />

CARBETAPENTANE-GUAIFENESIN TAB SR 12 HR 60-600 MG<br />

CARBETAPENTANE-GUAIFENESIN TAB SR 12 HR 60-900 MG<br />

CARBETAPENTANE-PSEUDOEPHEDRINE LIQUID 20-30 MG/5ML<br />

carbetaplex sus ts<br />

carbetaplex syp<br />

carbinoxamin syp cpd<br />

carbodex dm dro<br />

carbodex dm syp<br />

carbofed dm dro<br />

carbofed dm syp<br />

carboxine 12 sus dm<br />

carboxine dm liq<br />

cardec dm dro<br />

cardec dm syp<br />

centergy dm dro<br />

ceron-dm dro 3.5-1-3<br />

ceron-dm syp<br />

CERTUSS TAB<br />

cgh reliever liq doubl st OTC<br />

cgh suppress syp 15mg/5ml OTC<br />

cgh/cold plu liq childs OTC<br />

cgh/cold/flu liq relief OTC<br />

cgh/cold/flu liq relief m OTC<br />

cheratussin sol dac<br />

cheratussin syp ac OTC<br />

cheratussin syp ac<br />

chest conges tab 20-400mg OTC<br />

chest conges tab 20-400mg OTC<br />

chest conges tab 20-400mg OTC<br />

chest conges tab 20-400mg OTC<br />

child cold syp OTC<br />

child cold/ chw cough OTC<br />

child pain liq cold/cgh OTC<br />

child plus sus cold OTC<br />

childrens liq 5-100mg OTC<br />

childrens liq nitetime OTC<br />

childs aller liq cold/cgh OTC<br />

chld cough/ sus runny ns OTC<br />

chld tylenol liq plus OTC<br />

CHLO TUSS LIQ OTC<br />

CHLOPHEDIANOL-PSEUDOEPHEDRINE LIQD 12.5-30 MG/5ML OTC<br />

chlor/phen dro dm<br />

chlor/pse/dm sus<br />

chlordex gp syp<br />

chlorphen dm dro pse hcl<br />

chlorphen hd syp 5-2-1.67<br />

chlorphen tannate-carbetapentane tannate susp 4-30 mg/5ml<br />

chlorphen tannate-carbetapentane tannate tab 5-60 mg<br />

CHLORPHEN TANNATE-CARBETAPENTANE TANNATE TAB 5-60 MG<br />

CHLORPHENIRAMINE TANNATE-HYDROCODONE TANNATE SUSP 4-5 MG/5ML<br />

chlorpheniramine w/ codeine liquid 2-10 mg/5ml<br />

CHLORPHENIRAMINE W/ CODEINE LIQUID 2-9 MG/5ML<br />

CHLORPHENIRAMINE W/ CODEINE SUSP 0.2-1 MG/ML<br />

CHLORPHENIRAMINE W/ CODEINE SUSP 0.222-1 MG/ML OTC<br />

CHLORPHENIRAMINE W/ CODEINE SUSP 0.25-1 MG/ML OTC<br />

CHLORPHENIRAMINE W/ CODEINE SUSP 0.267-1 MG/ML<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 92


CHLORPHENIRAMINE W/ CODEINE SUSP 0.286-1 MG/ML OTC<br />

CHLORPHENIRAMINE W/ CODEINE SUSP 0.333-1 MG/ML OTC<br />

CHLORPHENIRAMINE W/ CODEINE SUSP 0.4-1 MG/ML<br />

CHLORPHENIRAMINE W/ CODEINE TAB 4-10 MG<br />

CHLORPHENIRAMINE W/ CODEINE TAB 4-20 MG<br />

CHLORPHENIRAMINE W/ DM-GG TAB 4-20-400 MG<br />

CHLORPHENIRAMINE W/ HYDROCODONE CR SUSP 8-10 MG/5ML<br />

CHLORPHENIRAMINE W/ HYDROCODONE LIQUID 2-2.5 MG/5ML<br />

CHLORPHENIRAMINE-DM CHEW TAB 1-5 MG OTC<br />

chlorpheniramine-dm liquid 1-5 mg/5ml OTC<br />

chlorpheniramine-dm liquid 1-7.5 mg/5ml OTC<br />

CHLORPHENIRAMINE-DM LIQUID 2-15 MG/15ML OTC<br />

chlorpheniramine-dm liquid 2-15 mg/5ml OTC<br />

CHLORPHENIRAMINE-DM SYRUP 1-7.5 MG/5ML OTC<br />

CHLORPHENIRAMINE-DM SYRUP 2-10 MG/5ML OTC<br />

chlorpheniramine-dm tab 4-20 mg OTC<br />

chlorpheniramine-dm tab 4-30 mg OTC<br />

cld head cng tab nighttim OTC<br />

cld head cng tab nighttim OTC<br />

cld head cng tab nighttim OTC<br />

clear cough syp dm OTC<br />

CLOFERA LIQ OTC<br />

codafed syp expect<br />

codafed exp sol ped<br />

codal-dh syp<br />

codal-dm syp OTC<br />

codeine-brompheniramine syrup 10-2 mg/5ml<br />

CODEINE-BROMPHENIRAMINE TAB 10-4 MG<br />

CODEINE-BROMPHENIRAMINE TAB 20-4 MG<br />

CODEINE-CHLORPHENIRAMINE-ACETAMINOPHEN TAB 20-4-500 MG<br />

CODEINE-PYRILAMINE SYRUP 9-8.33 MG/5ML<br />

codeine/gg tab 10-300<br />

codeine/guai liq 10-300mg<br />

codiclear dh syp 5-100/5<br />

CODIMAL DH SYP<br />

CODIMAL PH SYP OTC<br />

CODIMAL PH SYP<br />

codituss dh syp<br />

codituss dm syp OTC<br />

cofex-dm tab 55-1000<br />

cold & cough elx dm OTC<br />

cold caplets tab OTC<br />

cold head pak day/nght OTC<br />

cold head pak day/nght OTC<br />

cold head tab cong dt OTC<br />

cold head tab congest OTC<br />

cold head tab congesti OTC<br />

cold mult-sy tab daytime OTC<br />

cold mult-sy tab daytime OTC<br />

cold mult-sy tab daytime OTC<br />

cold mult-sy tab expr gel OTC<br />

cold mult-sy tab sevr day OTC<br />

cold mult-sy tab sevr day OTC<br />

cold multi pak day/nght OTC<br />

cold multi pak day/nght OTC<br />

cold multi- tab symptom OTC<br />

cold multi-s tab night OTC<br />

cold multi-s tab night OTC<br />

cold multi-s tab nighttim OTC<br />

cold relief pak day/nght OTC<br />

COLD RELIEF TAB OTC<br />

cold relief tab complete OTC<br />

cold relief tab max str OTC<br />

cold relief tab multi-s OTC<br />

cold relieve tab OTC<br />

cold symptom tab relief OTC<br />

cold-allergy elx dm relie OTC<br />

cold/allergy elx dm OTC<br />

cold/allergy elx dm OTC<br />

cold/allergy elx dm OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 93


cold/cough cap 30-10-20 OTC<br />

cold/cough cap multisym OTC<br />

cold/cough elx child OTC<br />

cold/cough elx children OTC<br />

cold/cough elx dm OTC<br />

cold/cough elx dm OTC<br />

cold/cough elx dm child OTC<br />

cold/flu liq daytime OTC<br />

cold/flu liq daytime OTC<br />

cold/flu rel cap daytime OTC<br />

cold/flu rel cap night OTC<br />

cold/flu rel pak day/nght OTC<br />

cold/flu rel pak day/nght OTC<br />

cold/flu rel pak day/nght OTC<br />

cold/flu rlf liq cherry OTC<br />

cold/flu rlf liq orig flv OTC<br />

coldcough syp<br />

COLDCOUGH SYP HCM<br />

coldcough hc syp<br />

coldcough pd syp<br />

coldec dm syp<br />

coldmist dm tab 12hr<br />

coldtuss-dr syp 6-2-15<br />

complete tab max str OTC<br />

complete tab relief OTC<br />

comtrex tab cold/cgh OTC<br />

comtrex tab n-d OTC<br />

comtrex cold tab & cough OTC<br />

COMTREX D/NT KIT COLD/CGH OTC<br />

COMTREX DAY KIT DAY&NGHT OTC<br />

comtrex deep cap chst/cld OTC<br />

COMTREX NT LIQ COLD/CGH OTC<br />

comtrex nt tab cold/cgh OTC<br />

condasin syp<br />

congesta dm tab 20-400mg OTC<br />

CONTAC DAY/N PAK COLD/FLU OTC<br />

contac sever tab no-drows OTC<br />

CORDRON-12 SUS DM<br />

CORDRON-DM LIQ<br />

cordron-dm liq nr<br />

CORDRON-HC LIQ<br />

cordron-hc liq nr<br />

corfen-dm liq<br />

CORICIDIN CAP CONG/CGH OTC<br />

coricidin liq hbp OTC<br />

coryza-dm syp<br />

CORZALL LIQ 20-30MG<br />

CORZALL PLUS LIQ<br />

COTAB A TAB 4-10MG<br />

COTAB AX TAB 4-20MG<br />

COTABFLU TAB 20-4-500<br />

cotuss ex syp 2.5-120m<br />

cotuss hd syp<br />

cotuss ms syp<br />

cotuss-v syp 5-100/5<br />

cough & cold liq OTC<br />

cough & cold tab OTC<br />

cough & sore liq day time OTC<br />

cough & sore liq ngt time OTC<br />

cough & sore liq thrt day OTC<br />

cough cold liq flu rel OTC<br />

COUGH D SYP OTC<br />

cough dm syp 100-10/5 OTC<br />

COUGH FORM M SYP OTC<br />

cough formul elx relief d OTC<br />

cough m syp OTC<br />

cough relief liq 15mg/5ml OTC<br />

COUGH/COLD CAP PLUS OTC<br />

cough/head elx relief d OTC<br />

coughtuss liq 5-2-5<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 94


cp dec-dm dro 3.5-1-3<br />

cp dec-dm syp<br />

cpm/codeine liq 2-10mg/5<br />

cpm/pe/dm syp<br />

cpm/pse dm dro OTC<br />

CRANTEX HC SYP<br />

CREO-TERPIN SYP 10/15ML OTC<br />

CREOMULSION SYP 20/15ML OTC<br />

cvs children liq cold/cou OTC<br />

cvs cold rlf pak day/nght OTC<br />

cvs cold/cgh cap OTC<br />

cvs cold/cgh elx dm child OTC<br />

cvs daytime cap cold/flu OTC<br />

cvs infants dro cold OTC<br />

cvs infants dro dcon/cgh OTC<br />

cvs night ti liq formula OTC<br />

cvs non-aspi tab cold OTC<br />

cvs triactin liq cgh/run OTC<br />

cvs triactin liq cgh/runn OTC<br />

cvs tussin liq cf OTC<br />

cvs tussin liq cgh/cld OTC<br />

cvs tussin syp cgh/cold OTC<br />

cytuss hc syp<br />

cytuss-hc nr syp<br />

D-TANN AT SUS<br />

D-TANN CD SUS 15-25-30<br />

d-tann ct sus<br />

d-tann ct tab<br />

d-tann dm sus<br />

d-tann hc sus<br />

dacex-a liq<br />

dacex-dm syp<br />

dacex-pe tab<br />

day time cap OTC<br />

day time cap cold/flu OTC<br />

day time liq OTC<br />

day time d cap cold/flu OTC<br />

day-time cap cold/flu OTC<br />

day-time liq OTC<br />

day-time liq cold/flu OTC<br />

day-time liq cold/flu OTC<br />

day-time liq cold/flu OTC<br />

day-time pe cap OTC<br />

day-time pe cap cold/flu OTC<br />

daytime cap OTC<br />

daytime cap cold/flu OTC<br />

daytime cap cold/flu OTC<br />

daytime cap cold/flu OTC<br />

DAYTIME LIQ COLD MED OTC<br />

daytime liq cold/flu OTC<br />

daytime liq cold/flu OTC<br />

daytime liq cold/flu OTC<br />

daytime liq cold/flu OTC<br />

daytime cld/ sol cgh chld OTC<br />

daytime pe cap 10-5-325 OTC<br />

daytime pe cap cold/flu OTC<br />

de-chlor dm syp liquid<br />

de-chlor dr syp liquid<br />

de-chlor g syp<br />

de-chlor hc syp liquid<br />

de-chlor hd syp liquid<br />

de-chlor mr syp<br />

de-chlor nx sol liquid<br />

dec-chlorphn dro dm<br />

dec-chlorphn syp dm<br />

DECAHIST-DM SOL LIQUID<br />

decon dm syp 30-2-10<br />

DECONEX DM CAP OTC<br />

DECONEX DM TAB<br />

DECONGEST D SYP COUGH OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 95


decongestant elx d OTC<br />

decongestant syp formula OTC<br />

DECONSAL DM CHW<br />

decorel tab forte pl OTC<br />

DEKA LIQ<br />

DEKA PED DRO<br />

DELSYM LIQ 30MG/5ML OTC<br />

DELTUSS DMX LIQ<br />

DESPEC DRO<br />

DESPEC DRO<br />

DESPEC DM SYP OTC<br />

DESPEC DM SYP<br />

DESPEC DM TAB<br />

DESPEC NR DRO<br />

DESPEC-DM TAB OTC<br />

DESPEC-EXP SYP<br />

despec-pd syp<br />

detuss liq<br />

dex pc syp<br />

dex-tuss liq<br />

dex-tuss dm liq<br />

DEXALL SYP 10-2-20<br />

DEXALONE CAP 30MG OTC<br />

dexatrex d elx cf-nasal OTC<br />

dexcon-dm syp<br />

dexcon-pe tab<br />

dextromethorphan hbr cap 15 mg OTC<br />

DEXTROMETHORPHAN HBR CAP 30 MG OTC<br />

DEXTROMETHORPHAN HBR DROPS 3.75 MG/0.8ML OTC<br />

DEXTROMETHORPHAN HBR FREEZER POP 7.5 MG (7.5 MG/25ML) OTC<br />

DEXTROMETHORPHAN HBR GEL SYRUP 7.5 MG/5ML OTC<br />

DEXTROMETHORPHAN HBR LIQUID 10 MG/5ML OTC<br />

DEXTROMETHORPHAN HBR LIQUID 12.5 MG/5ML OTC<br />

DEXTROMETHORPHAN HBR LIQUID 15 MG/15ML OTC<br />

dextromethorphan hbr liquid 15 mg/5ml OTC<br />

dextromethorphan hbr liquid 7.5 mg/5ml OTC<br />

DEXTROMETHORPHAN HBR LIQUID 7.5 MG/ML OTC<br />

DEXTROMETHORPHAN HBR LOZENGE 10 MG OTC<br />

DEXTROMETHORPHAN HBR LOZENGE 2.5 MG OTC<br />

DEXTROMETHORPHAN HBR LOZENGE 7.5 MG OTC<br />

DEXTROMETHORPHAN HBR ORAL STRIP 15 MG (11 MG BASE EQUIV) OTC<br />

DEXTROMETHORPHAN HBR ORAL STRIP 7.5 MG (5.5 MG BASE EQUIV) OTC<br />

DEXTROMETHORPHAN HBR SYRUP 10 MG/15ML OTC<br />

dextromethorphan hbr syrup 10 mg/5ml OTC<br />

dextromethorphan hbr syrup 15 mg/5ml OTC<br />

DEXTROMETHORPHAN HBR SYRUP 20 MG/15ML OTC<br />

dextromethorphan hbr syrup 5 mg/5ml OTC<br />

dextromethorphan hbr syrup 7.5 mg/5ml OTC<br />

DEXTROMETHORPHAN HBR TAB 30 MG OTC<br />

DEXTROMETHORPHAN HBR-GUAIFENESIN TANNATE SUSP 15-225 MG/5ML<br />

DEXTROMETHORPHAN POLISTIREX LIQUID CR 30 MG/5ML OTC<br />

DEXTROMETHORPHAN TANNATE SUSP 30 MG/5ML<br />

DEXTROMETHORPHAN-APAP-CHLORPHEN LIQUID 30-650-4 MG/15ML OTC<br />

DEXTROMETHORPHAN-APAP-CHLORPHEN LIQUID 7.5-160-1 MG/5ML OTC<br />

DEXTROMETHORPHAN-APAP-CHLORPHEN LIQUID 7.5-162.5-1 MG/5ML OTC<br />

DEXTROMETHORPHAN-APAP-CHLORPHEN SYRUP 7.5-160-1 MG/5ML OTC<br />

DEXTROMETHORPHAN-APAP-CHLORPHENIRAMINE CAP 15-325-4 MG OTC<br />

dextromethorphan-apap-chlorpheniramine susp 5-160-1 mg/5ml OTC<br />

dextromethorphan-apap-chlorpheniramine tab 15-500-2 mg OTC<br />

DEXTROMETHORPHAN-CHLORPHEN-METHSCOP TAB SR 12HR 30-8-2.5 MG<br />

DEXTROMETHORPHAN-DIPHENHYD-APAP LIQUID 10-12.5-325 MG/5ML OTC<br />

DEXTROMETHORPHAN-DOXYLAMINE-APAP CAP 15-6.25-325 MG OTC<br />

dextromethorphan-doxylamine-apap cap 15-6.25-325 mg OTC<br />

dextromethorphan-doxylamine-apap liquid 30-12.5-1000 mg/30ml OTC<br />

DEXTROMETHORPHAN-GG-POT CITRATE LIQD 10-100-85 MG/5ML<br />

DEXTROMETHORPHAN-GG-POT CITRATE LIQD 10-100-85 MG/5ML OTC<br />

DEXTROMETHORPHAN-GUAIFENESIN CAP 10-200 MG OTC<br />

dextromethorphan-guaifenesin elixir 20-200 mg/5ml<br />

dextromethorphan-guaifenesin elixir 20-200 mg/5ml<br />

DEXTROMETHORPHAN-GUAIFENESIN GRANULES PACKET 5-100 MG OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 96


dextromethorphan-guaifenesin liquid 10-100 mg/5ml<br />

dextromethorphan-guaifenesin liquid 10-100 mg/5ml OTC<br />

DEXTROMETHORPHAN-GUAIFENESIN LIQUID 10-150 MG/5ML OTC<br />

dextromethorphan-guaifenesin liquid 10-200 mg/5ml OTC<br />

dextromethorphan-guaifenesin liquid 10-300 mg/5ml<br />

DEXTROMETHORPHAN-GUAIFENESIN LIQUID 15-200 MG/5ML OTC<br />

DEXTROMETHORPHAN-GUAIFENESIN LIQUID 15-25 MG/5ML OTC<br />

DEXTROMETHORPHAN-GUAIFENESIN LIQUID 15-25 MG/5ML<br />

dextromethorphan-guaifenesin liquid 20-200 mg/5ml<br />

DEXTROMETHORPHAN-GUAIFENESIN LIQUID 20-300 MG/5ML OTC<br />

dextromethorphan-guaifenesin liquid 20-300 mg/5ml OTC<br />

dextromethorphan-guaifenesin liquid 3.5-25 mg/5ml OTC<br />

dextromethorphan-guaifenesin liquid 30-200 mg/5ml OTC<br />

dextromethorphan-guaifenesin liquid 5-100 mg/5ml OTC<br />

DEXTROMETHORPHAN-GUAIFENESIN SOLN 15-250 MG/5ML (3-50 MG/ML)<br />

dextromethorphan-guaifenesin solution 25-225 mg/5ml<br />

dextromethorphan-guaifenesin syrup 10-100 mg/5ml<br />

dextromethorphan-guaifenesin syrup 10-100 mg/5ml OTC<br />

dextromethorphan-guaifenesin syrup 15-100 mg/5ml OTC<br />

DEXTROMETHORPHAN-GUAIFENESIN SYRUP 20-200 MG/15ML OTC<br />

DEXTROMETHORPHAN-GUAIFENESIN SYRUP 3.33-33.3 MG/5ML OTC<br />

dextromethorphan-guaifenesin tab 15-200 mg OTC<br />

DEXTROMETHORPHAN-GUAIFENESIN TAB 15-400 MG OTC<br />

dextromethorphan-guaifenesin tab 20-400 mg<br />

dextromethorphan-guaifenesin tab 20-400 mg OTC<br />

DEXTROMETHORPHAN-GUAIFENESIN TAB CR 25-600 MG<br />

dextromethorphan-guaifenesin tab sr 12hr 20-1200 mg<br />

DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 28-600 MG<br />

DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 28-835 MG<br />

dextromethorphan-guaifenesin tab sr 12hr 30-500 mg<br />

DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-575 MG<br />

dextromethorphan-guaifenesin tab sr 12hr 30-600 mg<br />

DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-600 MG OTC<br />

DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-600 MG<br />

dextromethorphan-guaifenesin tab sr 12hr 30-650 mg<br />

DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-675 MG<br />

dextromethorphan-guaifenesin tab sr 12hr 30-800 mg<br />

DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 30-835 MG<br />

DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 45-1200 MG<br />

DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 50-1000 MG<br />

dextromethorphan-guaifenesin tab sr 12hr 55-1000 mg<br />

DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 57.5-775 MG<br />

DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 58-1000 MG<br />

dextromethorphan-guaifenesin tab sr 12hr 60-1000 mg<br />

dextromethorphan-guaifenesin tab sr 12hr 60-1200 mg OTC<br />

dextromethorphan-guaifenesin tab sr 12hr 60-1200 mg<br />

DEXTROMETHORPHAN-GUAIFENESIN TAB SR 12HR 60-800 MG<br />

dextromethorphan-phenylephrine-apap cap 10-5-325 mg OTC<br />

DEXTROMETHORPHAN-PHENYLEPHRINE-APAP LIQ 2.5-1.25-80 MG/0.8ML OTC<br />

dextromethorphan-phenylephrine-apap liqd 10-5-325 mg/15ml OTC<br />

DEXTROMETHORPHAN-PHENYLEPHRINE-APAP LIQD 2.5-1.25-80 MG/ML OTC<br />

dextromethorphan-phenylephrine-apap powd pack 20-10-650 mg OTC<br />

dextromethorphan-phenylephrine-apap tab 10-5-325 mg OTC<br />

dextromethorphan-phenylephrine-apap tab 15-5-325 mg OTC<br />

DEXTROMETHORPHAN-POT GUAIACOLSULFONATE LIQD 15-100 MG/5ML<br />

dextromethorphan-pot guaiacolsulfonate liqd 15-300 mg/5ml<br />

DIABETIC CAP COLD/FLU OTC<br />

DIABETIC LIQ TUSSIN C<br />

diabetic tus liq children OTC<br />

DIABETIC TUS LIQ COLD/FLU OTC<br />

DIABETIC TUS LIQ COLD/FLU OTC<br />

diabetic tus liq dm OTC<br />

diabetic tus liq max str OTC<br />

diabetic tus liq max str OTC<br />

dibromm dm elx cold/cgh OTC<br />

DICEL DM SUS<br />

dihistine dh liq OTC<br />

dihistine dh liq<br />

DIHYDRO-CP SYP<br />

dihydro-gp syp<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 97


dihydrocode liq bpm/pe<br />

DIHYDROCODEINE-GUAIFENESIN LIQUID 7.5-100 MG/5ML<br />

dihyrdo-pe syp<br />

dimaphen dm elx OTC<br />

dimaphen dm elx cold/cgh OTC<br />

DIMETAPP DRO DCON/CGH OTC<br />

DIMETAPP SYP CGH/COLD OTC<br />

DIMETAPP CLD TAB CONGESTI OTC<br />

dimetapp flu sus nighttme OTC<br />

DIPHEN/PE/CT CHW 25-10-30<br />

DIPHENHYDRAMINE TAN-CARBETAPENTANE TAN SUSP 25-30 MG/5ML<br />

ditussin hc syp<br />

dm hb/pe/cpm syp strawber<br />

DM-DOXYLAMINE-APAP LIQ & DM-APAP LIQ DAY/NIGHT THERAPY PACK OTC<br />

dm-gg-pot cit-citric acid liqd 10-100-85-35 mg/5ml OTC<br />

DM-GG-SOD CITRATE LIQUID 20-30-100 MG/10ML (10-15-50MG/5ML)<br />

dm-pe-chlor dro<br />

DM-POT GUAIACOLSULFONATE LIQD 10-75 MG/5ML (2-15 MG/ML)<br />

dm/cpm/pe dro<br />

dm/cpm/pe liq<br />

dm/gg syp 10-100/5 OTC<br />

dm/guai liq 10-300mg<br />

dm/pe/bpm sus tannate<br />

dm/pe/cpm dro<br />

dm/pe/cpm liq<br />

dm/pe/dexchl sus tannate<br />

dm/pe/pyrila sus tannate<br />

dm/pot guaia liq 15-300mg<br />

DM/PSE/CPM SUS 30-30-4 OTC<br />

dm/pse/gg tab<br />

dm/pse/gg tab<br />

DMAX SYP 8-4-15/5<br />

DMAX PEDI LIQ 2-2-4/5<br />

DMT/PET/ SUS BROM T<br />

dometuss cap cough/cl<br />

dometuss dm liq 200-20/5<br />

DONATUSS DC SYP<br />

DONATUSS XP SUS<br />

DONATUSSIN LIQ MAX<br />

DONATUSSIN SUS DM<br />

donatussin syp dc<br />

doxylamine-dm liquid 6.25-15 mg/15ml OTC<br />

drituss dm elx 200-20/5<br />

drituss hd elx<br />

DRIXORAL CAP CGH & ST OTC<br />

DROCON-CS SYP<br />

drotuss liq<br />

drotuss-cp liq<br />

DUOHIST DH LIQ 5-2-7.25<br />

dur-tann sus forte<br />

dur-tann dm sus<br />

DURADEX TAB FORTE<br />

DURAMAX TAB<br />

DURATUSS SUS AC 12<br />

DURATUSS SUS DM 12<br />

DURATUSS CS TAB 60-900MG<br />

duravent-dpb syp 5-2-10mg<br />

dynatuss syp<br />

dynatuss ex syp<br />

dynatuss hc syp<br />

DYNEX 12 SUS<br />

DYNEX VR CAP<br />

DYTAN-CS SUS SUSP<br />

DYTAN-CS TAB<br />

DYTAN-HC SUS<br />

eck bromtapp elx dm OTC<br />

eck child na liq flu OTC<br />

eck max n-d pak cold/flu OTC<br />

eck non-asa tab congestn OTC<br />

eck tussin cap cold/cgh OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 98


eck tussin syp cf OTC<br />

ED DM CHW<br />

ed-a-hist dm liq<br />

ed-tlc syp 5-2-1.67<br />

ed-tuss hc syp<br />

ELIXSURE GEL COUGH OTC<br />

endacof-ac syp 10-2mg<br />

endacof-c liq 2-10mg/5<br />

endacof-dc liq<br />

endacof-dh liq<br />

endacof-dm syp<br />

endacof-hc sol 30-2-1.7<br />

endacof-pd dro<br />

endacof-plus liq<br />

endacof-tab tab<br />

endacof-xp syp<br />

ENDACON LIQ OTC<br />

endacon-dm tab<br />

ENDAL CD SYP<br />

ENTEX HC LIQ<br />

entre-s sus<br />

eq cold tab relief OTC<br />

eq cold plus chw cough OTC<br />

EQ COLD PLUS LIQ COUGH OTC<br />

eq cold relf mis day/nite OTC<br />

eq daytime cap cold/flu OTC<br />

eq daytime liq cold/flu OTC<br />

eq flu/cold pak congesti OTC<br />

eq infants dro cold/cgh OTC<br />

eq nite time cap cold/flu OTC<br />

eq nite time liq cold/flu OTC<br />

eq triacting liq cold/cgh OTC<br />

eq triacting liq night tm OTC<br />

eq triacting liq sore thr OTC<br />

eq tussin cap cld/cong OTC<br />

eq tussin syp dm OTC<br />

eq tussin cf liq OTC<br />

eql cold/cgh cap OTC<br />

eql daytime cap cold/flu OTC<br />

eql daytime cap cold/flu OTC<br />

eql daytime liq cold/flu OTC<br />

EQL FLU/COLD PAK /CONGEST OTC<br />

eql flu/cold pak /cough OTC<br />

eql flu/cold pak congesti OTC<br />

EQL INFANT DRO DCON/CGH OTC<br />

eql nighttim cap cold/flu OTC<br />

eql pain rel dro cold/cgh OTC<br />

eql pain rel liq plus flu OTC<br />

eql severe tab cold/flu OTC<br />

eql triactin elx cld/cgh OTC<br />

eql triactin liq cold/cgh OTC<br />

eql tussin liq cf OTC<br />

eql tussin liq cgh/cold OTC<br />

eql tussin syp 15mg/5ml OTC<br />

eql tussin syp cgh/cold OTC<br />

eql tussin syp dm OTC<br />

EXALL LIQ 10-100MG<br />

EXALL-D LIQ<br />

excof liq<br />

excof-sf liq<br />

execlear syp 3.5-100<br />

execlear-c liq 200-10mg<br />

execlear-dm syp<br />

execof tab<br />

execof-xp syp<br />

exefen dmx tab OTC<br />

exefen-dm tab 55-1000<br />

exefen-dmx tab<br />

exetuss-dm tab<br />

exetuss-hc liq<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 99


EXPECTUSS LIQ 20-75MG/<br />

exratuss sus<br />

extendryl sol gcp<br />

EXTENDRYL HC TAB<br />

extuss la tab 30-650mg<br />

extussive liq 100-10/5 OTC<br />

FATHER JOHNS SOL PLUS OTC<br />

father johns syp 10mg/5ml OTC<br />

FENESIN DM TAB 15-400MG OTC<br />

flu bp tab max st OTC<br />

FLU FORMULA CAP OTC<br />

flu formula liq childs OTC<br />

flu non-drow tab OTC<br />

flu relief liq daytime OTC<br />

flu relief tab OTC<br />

flu/cgh/cold pow max st OTC<br />

flu/cgh/cold pow nite OTC<br />

flu/cold/cg pow medicine OTC<br />

flu/cold/cgh pak max st OTC<br />

flu/cold/cgh pak ms n/d OTC<br />

flu/cold/cgh pow OTC<br />

flu/cold/cgh pow OTC<br />

flu/cold/cgh pow hot med OTC<br />

flu/cold/cgh pow max nite OTC<br />

flu/cold/cgh pow medicine OTC<br />

flu/cold/cgh pow medicine OTC<br />

flu/cold/cgh pow medicine OTC<br />

flu/cold/cgh pow medicine OTC<br />

flu/cold/cgh pow ms n/d OTC<br />

flu/cough/ pow /cold ms OTC<br />

flutabs tab<br />

FORMULA 44 LIQ CGH/CLD OTC<br />

formula d liq OTC<br />

g phen dm tab<br />

g-bid dm tab<br />

g-fen dm tab 20-400mg OTC<br />

gani-tuss dm liq 100-10/5<br />

gani-tuss nr liq 100-10/5<br />

gdp-ex liq<br />

genacol ms tab cold/flu OTC<br />

genantuss liq<br />

genantusside liq<br />

genatuss dm syp 100-10/5 OTC<br />

gene-t-press liq<br />

genebrom dm syp<br />

GENEBRONCO-D LIQ<br />

genecof-hc liq<br />

GENECOF-HC LIQ<br />

genecof-xp liq<br />

GENECOF-XP LIQ<br />

GENEDEL LIQ<br />

genedotuss liq -dm<br />

GENEPATUSS SYP<br />

genetuss sol<br />

genetuss sol OTC<br />

genetuss-2 liq OTC<br />

genetuss-2 liq<br />

GENEXPECT DM LIQ<br />

GENEXPECT-PE LIQ<br />

GENEXPECT-SF LIQ<br />

GENTEX HC LIQ<br />

gentex-lq syp<br />

geri-tussin syp dm OTC<br />

gestuss-hc syp<br />

GFN/DM/PSE TAB<br />

gfn/pse/dm tab<br />

GFN1000/DM50 TAB<br />

gfn1000/dm60 tab<br />

gfn1200/dm20 tab /pe40<br />

gfn1200/dm60 tab<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 100


gfn1200/dm60 tab /pse 120<br />

gfn500/dm30 tab<br />

GFN550/PSE60 TAB /DM 30<br />

gfn595/pse48 tab /dm32<br />

gfn600/pse60 tab /dm30 sa<br />

gfn800/dm30 tab<br />

gfn800/pse60 tab /dm 30<br />

gg/carbeta tab<br />

gg/codeine liq 200-10mg<br />

gg/codeine sol 100-10/5<br />

gg/codeine sol 100-10/5<br />

gg/codeine syp 100-10/5 OTC<br />

gg/codeine syp 100-10/5<br />

gg/codeine tab 300-10<br />

gg/codeine tab 300-10<br />

gg/dm syp 100-10/5 OTC<br />

gg/dm tab<br />

gg/dm tab 1200-20<br />

gg/dm cr tab 600-30mg<br />

gg/dm la tab<br />

gg/dm nr liq 100-10/5 OTC<br />

gg/dm sr tab 600-30mg<br />

gg/pse/ syp hydrocod<br />

gg/pse/cod sol<br />

GILTUSS LIQ<br />

GILTUSS LIQ PED-C<br />

GILTUSS HC LIQ<br />

GILTUSS PED LIQ<br />

GILTUSS TR CAP 7-14-288<br />

GILTUSS TR TAB<br />

gnp cgh relf liq 15mg/5ml OTC<br />

gnp children liq plus cgh OTC<br />

gnp cold tab daytime OTC<br />

gnp cold tab head con OTC<br />

gnp cold/cgh elx child OTC<br />

gnp complete tab relief OTC<br />

gnp cough liq sore thr OTC<br />

gnp cough liq sore thr OTC<br />

gnp day time cap 30-250-1 OTC<br />

gnp day time cap cold/flu OTC<br />

gnp day time liq cold/flu OTC<br />

gnp di bromm elx dm OTC<br />

gnp pain rel dro cold OTC<br />

gnp severe tab cold/flu OTC<br />

gnp triactin liq nitetime OTC<br />

gnp tussin liq dm OTC<br />

gnp tussin liq dm cough OTC<br />

gnp tussin syp cf OTC<br />

gnp tussin syp cf OTC<br />

GUACOL DM DRO PED<br />

guai 800/pse tab 60/dm 30<br />

guai/dm tab 800-30mg<br />

guaiasorb dm liq 100-10/5 OTC<br />

guaiatussin syp ac OTC<br />

guaiatussin syp ac<br />

guaiatussin syp dm OTC<br />

guaicon dm syp 100-10/5 OTC<br />

guaicon dms syp 100-10/5 OTC<br />

guaidex-tr tab<br />

guaif/dm/pse liq OTC<br />

guaifen dm tab<br />

guaifen dm tab 600-30mg<br />

guaifen dm tab 600-30mg<br />

guaifen-c liq<br />

guaifenesin liq ac OTC<br />

guaifenesin liq ac<br />

guaifenesin liq ac expct<br />

guaifenesin liq dm OTC<br />

guaifenesin liq dm<br />

guaifenesin liq dm nr<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 101


guaifenesin liq nr<br />

guaifenesin sol dac<br />

guaifenesin syp ac<br />

guaifenesin syp dm OTC<br />

guaifenesin syp dm OTC<br />

guaifenesin syp pse/dm OTC<br />

guaifenesin tab /dm er<br />

guaifenesin tab /dm sr<br />

guaifenesin tab dm<br />

guaifenesin-codeine cap 200-9 mg<br />

GUAIFENESIN-CODEINE LIQUID 200-10 MG/5ML<br />

guaifenesin-codeine liquid 200-10 mg/5ml<br />

GUAIFENESIN-CODEINE LIQUID 200-20 MG/5ML<br />

GUAIFENESIN-CODEINE LIQUID 225-7.5 MG/5ML<br />

GUAIFENESIN-CODEINE LIQUID 300-10 MG/20ML<br />

guaifenesin-codeine liquid 300-10 mg/20ml<br />

guaifenesin-codeine liquid 300-10 mg/5ml<br />

guaifenesin-codeine soln 100-10 mg/5ml OTC<br />

guaifenesin-codeine soln 100-10 mg/5ml<br />

guaifenesin-codeine soln 100-6.3 mg/5ml<br />

guaifenesin-codeine tab 300-10 mg<br />

GUAIFENESIN-CODEINE TAB 400-10 MG<br />

GUAIFENESIN-CODEINE TAB 400-20 MG<br />

guaifenesin/ liq codeine<br />

guaifenex dm tab 30-600cr<br />

guaimist dm syp<br />

guaitussin liq dac<br />

guaitussin syp ac<br />

guapetex hc syp<br />

guaphen tab forte<br />

guaphen ii tab dm<br />

guia-d tab<br />

guiadex dm liq<br />

guiadrine dx liq<br />

guiafen ii tab dm<br />

GUIAPLEX HC LIQ<br />

guiat clr dm syp 100-10/5 OTC<br />

guiatuss ac syp 100-10/5 OTC<br />

guiatuss ac syp 100-10/5<br />

guiatuss dac sol OTC<br />

guiatuss dac sol<br />

guiatuss dm syp 100-10/5 OTC<br />

hc tuss-nr syp<br />

hc tussive syp<br />

hc tussive-d sol 60-5/5ml<br />

hc/guai syp 3.5-300<br />

hc/pe/dbrom syp 2.5-5-1<br />

hca cough liq formula OTC<br />

hca cough-ex tab OTC<br />

hca day-time cap OTC<br />

hca day-time liq OTC<br />

HCA INTENSE LIQ COUGH OTC<br />

hca nite-tim liq cold/flu OTC<br />

hca nte-time cap OTC<br />

HCA SEVERE TAB COUGH OTC<br />

hca triactin liq cold/cgh OTC<br />

hca tussin cap cold/cgh OTC<br />

hca tussin liq 100-10/5 OTC<br />

hca tussin liq cf OTC<br />

hca tussin syp dm OTC<br />

hcod/pe/cpm liq<br />

hcod/pe/cpm liq 5-5-2mg<br />

hcod/pe/gg syp 2-10-100<br />

hdc dm syp<br />

healtussin syp dm OTC<br />

histacol bd dro<br />

histacol dm syp<br />

HISTADEC DM SOL OTC<br />

HISTENOL FOR TAB OTC<br />

HISTENOL-FOR TAB OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 102


histinex hc syp<br />

histinex pv syp<br />

histuss hc liq<br />

histussin d sol 60-5/5ml<br />

histussin hc syp<br />

honey tussin syp 10mg/5ml OTC<br />

hpb max liq<br />

hpr end liq<br />

ht-tuss dm elx 200-20/5<br />

hy-kxp syp<br />

hycomal dh syp<br />

hydex pd liq<br />

hydro gp syp<br />

hydro-dp syp<br />

hydro-pc ii syp<br />

hydro-pc ii syp plus<br />

hydro-tussin elx dm<br />

HYDRO-TUSSIN SOL HD<br />

hydro-tussin syp 15-2-3mg<br />

hydro-tussin syp dhc<br />

hydro-tussin syp exp<br />

hydro-tussin syp hg<br />

hydro-tussin syp xp<br />

hydro/pe/ctm syp<br />

hydro/pseudo sol /brom<br />

HYDROCOD POLST-CHLORPHEN POLST CAP SR 12HR 10-8 MG<br />

HYDROCOD POLST-CHLORPHEN POLST CAP SR 12HR 5-4 MG<br />

hydrocod/cp/ syp pseud<br />

hydrocod/gg syp 3.5-100<br />

hydrocod/gg syp 5-100/5<br />

hydrocod/gg syp 5-100/5<br />

hydrocod/gg tab 2.5-300<br />

hydrocod/hom syp 5-1.5/5<br />

hydrocod/hom syp 5-1.5/5<br />

hydrocodone syp pe/cpm<br />

hydrocodone syp pot guai<br />

hydrocodone w/ homatropine syrup 5-1.5 mg/5ml<br />

HYDROCODONE W/ HOMATROPINE TAB 5-1.5 MG<br />

hydrocodone w/ homatropine tab 5-1.5 mg<br />

HYDROCODONE-GUAIFENESIN CAP CR 5-300 MG<br />

HYDROCODONE-GUAIFENESIN LIQUID 4-100 MG/5ML<br />

HYDROCODONE-GUAIFENESIN LIQUID 5-100 MG/5ML<br />

hydrocodone-guaifenesin liquid 5-150 mg/5ml<br />

HYDROCODONE-GUAIFENESIN LIQUID 6-200 MG/5ML<br />

hydrocodone-guaifenesin liquid 7.5-200 mg/5ml<br />

HYDROCODONE-GUAIFENESIN SYRUP 2.5-100 MG/5ML<br />

hydrocodone-guaifenesin syrup 2.5-200 mg/5ml<br />

hydrocodone-guaifenesin syrup 3-90 mg/5ml<br />

hydrocodone-guaifenesin syrup 3.5-100 mg/5ml<br />

hydrocodone-guaifenesin syrup 3.5-300 mg/5ml<br />

hydrocodone-guaifenesin syrup 5-100 mg/5ml<br />

hydrocodone-guaifenesin tab 2.5-300 mg<br />

HYDROCODONE-GUAIFENESIN TAB SR 12HR 10-1000 MG<br />

HYDROCODONE-GUAIFENESIN TAB SR 12HR 10-1200 MG<br />

HYDROCODONE-GUAIFENESIN TAB SR 12HR 5-575 MG<br />

HYDROCODONE-GUAIFENESIN TAB SR 12HR 5-600 MG<br />

hydrocodone-pot guaiaco soln 5-300 mg/5ml<br />

hydrocodone-pot guaiaco syrup 2.5-120 mg/5ml<br />

hydrocodone-pot guaiaco syrup 2.5-175 mg/5ml<br />

hydrocodone-pot guaiaco syrup 3-150 mg/5ml<br />

HYDROCODONE-POT GUAIACO SYRUP 3-350 MG/5ML<br />

hydrocodone-pot guaiaco syrup 4.5-300 mg/5ml<br />

HYDROCODONE-POT GUAIACO SYRUP 5-300 MG/5ML<br />

hydrocodone-pot guaiaco syrup 5-350 mg/5ml<br />

hydrocodone-pot guaiaco syrup 5-400 mg/5ml<br />

hydrocodone/ tab homatrop<br />

hydrocof-hc syp<br />

hydrofed syp<br />

hydromet syp 5-1.5/5<br />

hydron cp syp liquid<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 103


hydron ex syp liquid<br />

HYDRON KGS SYP<br />

hydron psc liq<br />

hyphed syp<br />

hyphen-hd syp 5-2-1.67<br />

indamix dm sus<br />

inf pain rlf dro 15/160/5 OTC<br />

infants pain dro rlvr cld OTC<br />

infants pain dro rlvr cld OTC<br />

intense coug liq reliever OTC<br />

intense coug liq reliever OTC<br />

intense coug liq reliever OTC<br />

intense coug liq reliever OTC<br />

iobid dm tab 30-600cr<br />

iophen c-nr liq 100-10/5<br />

iophen dm liq 100-10/5 OTC<br />

iophen dm-nr liq 100-10/5 OTC<br />

iophen dm-nr liq 100-10/5<br />

J-COF DHC LIQ<br />

J-MAX DHC LIQ<br />

J-TAN D HC LIQ<br />

jaycof syp 5-350/5<br />

jaycof-hc liq<br />

jaycof-xp liq<br />

ken-tuss sf syp 10-100/5 OTC<br />

kgs-hc syp<br />

kidkare liq cgh/cold OTC<br />

KOLEPHRIN LIQ -GG/DM OTC<br />

kolephrin/dm tab OTC<br />

kwelcof syp 5-100/5<br />

l-all 12 sus<br />

l-all 12 nf sus 25-30mg<br />

lanzatuss liq n.f.<br />

LARTUS LIQ<br />

LEVALL 5.0 SOL<br />

lexuss 210 liq<br />

liquicough liq dm<br />

liquicough liq hc<br />

LITTLE COLDS DRO 7.5MG/ML OTC<br />

LITTLE COLDS DRO DECONGES OTC<br />

LITTLE COLDS DRO MULTI-S OTC<br />

livetan dm sus<br />

lohist-dm syp 5-2-10mg<br />

m-clear cap 200-9mg<br />

m-clear syp<br />

m-clear jr syp<br />

m-clear wc liq<br />

m-end liq (reform)<br />

m-end dm syp<br />

m-end max liq<br />

M-END PE LIQ<br />

m-end wc liq<br />

mapap child sus cgh/sinu OTC<br />

mapap cold tab OTC<br />

mapap cold tab formula OTC<br />

mapap cold tab formula OTC<br />

MAR-COF BP LIQ<br />

MAR-COF CG LIQ EXPECT<br />

marcof syp expctrnt<br />

MARDROPS-DX LIQ OTC<br />

MAXI-TUSS LIQ HCG<br />

MAXIFED CD TAB<br />

MAXIFED CDX TAB<br />

MAXIFED DM LIQ OTC<br />

MAXIFED DM TAB<br />

maxifed dmx tab OTC<br />

MAXIFED-G TAB CDX<br />

MAXIFED-G CD TAB<br />

MAXIFLU CD TAB<br />

MAXIFLU CDX TAB<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 104


MAXIFLU DM TAB<br />

MAXIFLU-G TAB<br />

MAXIPHEN ADT TAB<br />

MAXIPHEN CD TAB<br />

MAXIPHEN CDX TAB<br />

MAXIPHEN-G TAB DM<br />

mc jr cough syp<br />

medent-dmi tab OTC<br />

medi-brom elx cld/allg OTC<br />

medi-phedrin tab sev cold OTC<br />

medi-tabs tab cold OTC<br />

medi-tabs tab flu OTC<br />

medi-tuss dm liq dbl str OTC<br />

medi-tuss dm liq diabetic OTC<br />

medi-tussin cap cgh/cold OTC<br />

medi-tussin cap cgh/cold OTC<br />

medi-tussin liq OTC<br />

medi-tussin syp dm OTC<br />

medi-tussin syp max st OTC<br />

medi-tussin syp max str OTC<br />

METHSCOPOLAM TAB DM/CPM<br />

miltuss syp 15mg/5ml OTC<br />

mintex dm liq<br />

mintex hc liq 30-2-5/5<br />

mintuss dr syp<br />

mintuss g syp<br />

mintuss hc syp<br />

mintuss hd syp 10-4-2.5<br />

mintuss mr liq<br />

mintuss ms syp 10-2-5<br />

mintuss nx syp 3-150mg/<br />

MONTE-G HC LIQ<br />

MONTEFLU HC LIQ<br />

mp tussin cf liq OTC<br />

mp tussin dm syp 100-10/5 OTC<br />

MUCINEX CGH GRA 5-100MG OTC<br />

MUCINEX CGH GRA 5-100MG OTC<br />

mucinex cgh liq 5-100mg OTC<br />

mucinex cgh liq 5-100mg OTC<br />

MUCINEX DM TAB 30-600ER<br />

MUCINEX DM TAB 30-600ER OTC<br />

mucinex dm tab 60-1200 OTC<br />

mucosa dm tab 20-400mg OTC<br />

mucus relief liq 5-100mg OTC<br />

mucus relief liq 5-100mg OTC<br />

mucus relief liq 5-100mg OTC<br />

mucus relief liq 5-100mg OTC<br />

mucus relief liq 5-100mg OTC<br />

mucus relief tab dm OTC<br />

mucus relief tab dm OTC<br />

mucus relief tab dm cough OTC<br />

mucusrelief tab dm OTC<br />

mult symptom tab cold rlf OTC<br />

multi sympt tab cold OTC<br />

multi sympto tab cold OTC<br />

multi-sympt liq cold OTC<br />

multi-sympt tab cold rel OTC<br />

multi-symptm tab daytime OTC<br />

multi-symptm tab nighttim OTC<br />

multi-sympto cap cold/cgh OTC<br />

multi-sympto tab cold/cgh OTC<br />

MULTIDEXOL M SYP OTC<br />

myci-gc sol 100-10/5 OTC<br />

myci-gc sol 100-10/5<br />

myhist-dm liq<br />

myphetane dx syp<br />

mytussin ac syp 100-10/5 OTC<br />

mytussin ac syp 100-10/5<br />

mytussin dac sol OTC<br />

mytussin dac sol<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 105


nalex sol expect<br />

NALEX DH LIQ<br />

narcof syp 3.5-100<br />

NARIZ-HC LIQ<br />

nazarin hc liq<br />

NEO AC SYP<br />

NEO DM SUS<br />

NEO HC SYP<br />

neotuss liq OTC<br />

NEOTUSS PLUS LIQ<br />

NEOTUSS-D LIQ<br />

neutrahist dro<br />

night flu/ pow cold/cgh OTC<br />

night time cap OTC<br />

night time cap OTC<br />

night time cap cold/flu OTC<br />

night time cap cold/flu OTC<br />

night time cap cold/flu OTC<br />

NIGHT TIME CAP COLD/FLU OTC<br />

night time liq cold OTC<br />

night time liq cold OTC<br />

night time liq cold/flu OTC<br />

night time liq cold/flu OTC<br />

night time liq cold/flu OTC<br />

night time liq cold/flu OTC<br />

night time liq cold/flu OTC<br />

night time liq cough OTC<br />

night time liq cough OTC<br />

night time liq cough OTC<br />

night time liq cough OTC<br />

night time liq formula OTC<br />

night time d cap cold/flu OTC<br />

night-time cap cold/flu OTC<br />

night-time liq cold OTC<br />

night-time liq cold/flu OTC<br />

night-time liq cough OTC<br />

nighttime cap cold/flu OTC<br />

nighttime cap cold/flu OTC<br />

nighttime cap cold/flu OTC<br />

nighttime liq cold OTC<br />

nighttime liq cold OTC<br />

nighttime liq cold med OTC<br />

nighttime liq cold/flu OTC<br />

nighttime liq cold/flu OTC<br />

nighttime liq cough OTC<br />

nighttime tab cold/cgh OTC<br />

nighttime tab cold/cgh OTC<br />

NITE TIME CAP LIQUID OTC<br />

nite time liq OTC<br />

nite time liq OTC<br />

nite time liq cherry OTC<br />

nite time liq child OTC<br />

nite time liq child OTC<br />

nite time liq cold med OTC<br />

nite time liq cold/flu OTC<br />

nite time liq regular OTC<br />

nite-time cap OTC<br />

nite-time cap cold/flu OTC<br />

nite-time liq OTC<br />

nite-time liq cgh chry OTC<br />

NITE-TIME LIQ COLD/FLU OTC<br />

nite-time liq cold/flu OTC<br />

nite-time liq cough OTC<br />

nite-time ms liq cold/flu OTC<br />

nitetime cap cold/flu OTC<br />

nitetime liq cold/flu OTC<br />

nohist dmx tab<br />

nohist-pdx dro<br />

non aspirin dro OTC<br />

non-asa cold chw cough OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 106


non-asa cold syp child OTC<br />

non-asa cold syp cough OTC<br />

non-asa cold tab OTC<br />

non-asa flu tab max st OTC<br />

non-aspirin tab cold OTC<br />

non-aspirin tab congest OTC<br />

non-aspirin tab max str OTC<br />

non-pseudo tab cld rel OTC<br />

nortuss-de dro<br />

nortuss-de liq drops OTC<br />

nortuss-ex liq 200-20/5<br />

NOTUSS-FORTE SYP<br />

NOTUSS-PE LIQ<br />

novadyne sol expect OTC<br />

novadyne dh liq OTC<br />

novagest/cod sol expect<br />

NOVAHISTINE LIQ DH<br />

NOVASUS SUS<br />

NUCOFED CAP<br />

NUMOBID DX TAB<br />

NUMONYL DX DRO PED<br />

NUMONYL DX SOL<br />

nycair liq cherry OTC<br />

nycair liq original OTC<br />

nyquil d liq cold/flu OTC<br />

p-hist syp<br />

p-hist dm dro<br />

p-tuss dm tab<br />

P-V TUSSIN TAB<br />

pain rel cld tab pe day OTC<br />

PAIN RELIEF CAP FLU OTC<br />

pain relief chw cld-coug OTC<br />

pain relief chw cold+cgh OTC<br />

pain relief dro plus cgh OTC<br />

pain relief dro plus cgh OTC<br />

pain relief sus pls cold OTC<br />

pain relief syp cold/cgh OTC<br />

pain relief tab cold OTC<br />

pain relief tab cold OTC<br />

pain relief tab cold OTC<br />

pain relief tab cold OTC<br />

pain relief tab cold pe OTC<br />

pain relief tab cold pe OTC<br />

pain relief/ liq flu chld OTC<br />

pain relieve tab /cold OTC<br />

pain relieve tab cold OTC<br />

pain relieve tab flu OTC<br />

PANATUSS DXP LIQ<br />

PANATUSS DXP LIQ PEDIATRI<br />

pbm allergy syp<br />

pd-cof dro<br />

pd-cof syp<br />

pdm gg syp 10-30-20<br />

PE HCL-BROMPHEN MAL-HYDROCOD BITART TAN SUSP 10-6-5 MG/5ML<br />

PE HCL-DM HBR-GUAIFENESIN TANNATE SUSP 20-40-200 MG/10ML<br />

PE TAN -DIPHENHYD TAN-HYDROCOD TAN SUSP 7.5-25-3.5 MG/5ML<br />

pe tan -diphenhyd tan-hydrocod tan susp 7.5-25-3.5 mg/5ml<br />

PE TAN-DEXBROMPHEN TAN-PYRIL-DM TAN SUSP 25-4-3.5-30 MG/5ML<br />

PE TAN-DEXCHLORPHEN TAN-HYDROCOD TAN SUSP 10-2-6 MG/5ML<br />

PE TAN-DEXCHLORPHENIRAMINE TAN-DM TAN SUSP 20-2-30 MG/5ML<br />

pe tan-dexchlorpheniramine tan-dm tan susp 20-2-30 mg/5ml<br />

pe-dm-apap & pe-cpm-dm-apap tab day/night therapy pack OTC<br />

pe-dm-apap cap & doxylamine-dm-apap cap day/night ther pack OTC<br />

PE-DM-GG LIQ 5-10-100MG/5ML & DPH-PE LIQ 6.25-2.5MG/5ML PAK OTC<br />

PE-DM-GG TAB 15-30-600 & CPM-PE-METHSCOP TBCR 8-25-2.5 PACK<br />

PE-DM-GG-APAP TAB & PE-DIPHENHYD-APAP TAB THERAPY PACK OTC<br />

pe-hist dm syp 5-2-15mg<br />

PE-PSE-CPM-PYRIL W/ HYDROCOD LIQD 5-3.3-2-3.3-2.5 MG/5ML<br />

pe/guai/dm tab<br />

pe/hcod/cpm liq<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 107


pe/hcod/cpm syp<br />

pe/pyril/hyd syp<br />

ped formula liq 100-10/5 OTC<br />

ped sup tuss liq cgh/cold OTC<br />

pedi cgh/cld liq 15-1-5mg OTC<br />

pedi cou/cld liq 15-1-5mg OTC<br />

pedi-atric liq cgh/cold OTC<br />

pedi-atric liq niterest OTC<br />

pedia relief dro infant OTC<br />

pedia relief dro infant OTC<br />

pedia relief dro infant OTC<br />

pedia relief dro infant OTC<br />

pedia relief liq cgh/cold OTC<br />

pedia relief liq cgh/cold OTC<br />

pedia relief liq cgh/cold OTC<br />

pedia relief liq for chld OTC<br />

PEDIACARE CHW OTC<br />

pediacare dro infant OTC<br />

PEDIACARE DRO LONG-ACT OTC<br />

pediacare liq children OTC<br />

pediacare liq long-act OTC<br />

pediacare liq long-act OTC<br />

PEDIACARE MIS LA COUGH OTC<br />

pediahist dm dro 15-1-4mg<br />

pediahist dm syp<br />

PEDIATEX-JR SUS DM<br />

pediatric dro dcon/cgh OTC<br />

pediatric liq cgh/cold OTC<br />

pentuss sus<br />

pertussin liq 3.5-25/5 OTC<br />

pertussin 8h syp 15mg/5ml OTC<br />

phanatuss dm syp 100-10/5 OTC<br />

PHANATUSS HC LIQ 5-100/5M<br />

pharmatuss syp 100-10/5 OTC<br />

phen/chlor syp hc<br />

PHENA-HC LIQ<br />

phencarb gg syp<br />

phendacof hc syp<br />

PHENDACOF PL LIQ<br />

PHENFLU CD TAB<br />

PHENFLU CDX TAB<br />

PHENFLU DM TAB<br />

PHENFLU G TAB<br />

phenhist sol expect<br />

PHENYDEX LIQ<br />

PHENYLEPH HCL-DIPHENHYD HCL-DM HBR TAN SUS 15-12.5-15 MG/5ML<br />

PHENYLEPH HCL-PYRIL MAL-DM HBR TANNATE CHEW TAB 10-16-15 MG<br />

PHENYLEPH TAN-BROMPHEN TAN-CARBETA TAN SUSP 7.5-4-30 MG/5ML<br />

phenyleph tan-bromphen tan-carbeta tan susp 7.5-4-30 mg/5ml<br />

phenyleph tan-bromphen tan-dm tan susp 20-8-20 mg/5ml<br />

PHENYLEPH TAN-BROMPHEN TAN-DM TAN SUSP 25-10-30 MG/5ML<br />

phenyleph tan-bromphen tan-dm tan susp 25-10-30 mg/5ml<br />

phenyleph tan-chlorphen tan-carbet tan susp 12.5-4-30 mg/5ml<br />

PHENYLEPH TAN-CHLORPHEN TAN-CARBET TAN SUSP 2.5-2-15 MG/ML<br />

PHENYLEPH TAN-CHLORPHEN TAN-CARBET TAN SUSP 20-8-60 MG/5ML<br />

PHENYLEPH TAN-CHLORPHEN TAN-CARBETA TAN SUSP 10-8-60 MG/5ML<br />

phenyleph tan-chlorphen tan-carbeta tan susp 5-4-30 mg/5ml<br />

PHENYLEPH TAN-CHLORPHEN TAN-CARBETAPENT TAN TAB 10-5-60 MG<br />

phenyleph tan-chlorphen tan-carbetapent tan tab 10-5-60 mg<br />

PHENYLEPH TAN-CHLORPHEN TAN-DM TAN TAB 20-2-30 MG<br />

PHENYLEPH TAN-DIPHENHYD TAN-CARBETA TAN CHEW TAB 10-25-30 MG<br />

PHENYLEPH TAN-DIPHENHYD TAN-CARBETA TAN SUS 15-25-30 MG/5ML<br />

phenyleph tan-diphenhyd tan-carbeta tan sus 7.5-25-30 mg/5ml<br />

PHENYLEPH TAN-DIPHENHYD TAN-CARBETA TAN SUS 7.5-25-30 MG/5ML<br />

phenyleph tan-diphenhyd tan-carbeta tan tab 10-25-30 mg<br />

PHENYLEPH TAN-DIPHENHYD TAN-CARBETA TAN TAB 10-25-30 MG<br />

phenyleph tan-diphenhyd tan-dm tan susp 7.5-25-75 mg/5ml<br />

PHENYLEPH TAN-PYRILAMINE TAN-CARBETA TAN SUSP 5-30-30 MG/5ML<br />

phenyleph tan-pyrilamine tan-carbeta tan susp 5-30-30 mg/5ml<br />

PHENYLEPH TAN-PYRILAMINE TAN-CARBETA TAN TAB 10-40-60 MG<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 108


PHENYLEPH TAN-PYRILAMINE TAN-DM TAN CHEW TAB 25-30-25 MG<br />

phenyleph tan-pyrilamine tan-dm tan susp 12.5-30-25 mg/5ml<br />

phenyleph tan-pyrilamine tan-dm tan susp 15.5-15.5-25 mg/5ml<br />

phenyleph tan-pyrilamine tan-dm tan susp 15.5-15.5-25 mg/5ml<br />

PHENYLEPH-BROMPHEN-DM-GUAIFENESIN SYRUP 5-2-5-50 MG/5ML<br />

phenyleph-bromphen-dm-guaifenesin syrup 5-2-5-50 mg/5ml<br />

PHENYLEPH-BROMPHEN-HYDROCODONE LIQD 7.5-2-2.5 MG/5ML<br />

phenyleph-bromphen-hydrocodone liqd 7.5-2-5 mg/5ml<br />

phenyleph-bromphen-hydrocodone liqd 7.5-4-2.5 mg/5ml<br />

PHENYLEPH-CARBETAPENTANE-POT GUAIACO LIQD 10-20-100 MG/5ML<br />

phenyleph-chlorphen w/ dm-gg liquid 10-2-15-100 mg/5ml<br />

PHENYLEPH-CHLORPHEN W/ DM-GG LIQUID 5-2-15-150 MG/5ML<br />

phenyleph-chlorphen w/ dm-gg syrup 10-2-15-100 mg/5ml<br />

phenyleph-chlorphen w/ dm-gg syrup 10-2-7.5-100 mg/5ml<br />

PHENYLEPH-CHLORPHEN W/ DM-GG SYRUP 5-2-15-100 MG/5ML<br />

PHENYLEPH-CHLORPHEN W/ DM-GG SYRUP 5-2-5-75 MG/5ML<br />

PHENYLEPH-CHLORPHEN W/ DM-GG SYRUP 8.5-2.5-22.5-125 MG/5ML<br />

phenyleph-chlorphen w/ hydrocodone liqd 12-2-6 mg/5ml<br />

phenyleph-chlorphen w/ hydrocodone liqd 5-2-1.67 mg/5ml<br />

phenyleph-chlorphen w/ hydrocodone liqd 5-2-5 mg/5ml<br />

phenyleph-chlorphen w/ hydrocodone liqd 8-2.5-3.25 mg/5ml<br />

phenyleph-chlorphen w/ hydrocodone liqd 8-2.5-3.5 mg/5ml<br />

phenyleph-chlorphen w/ hydrocodone syrup 10-2-2.5 mg/5ml<br />

phenyleph-chlorphen w/ hydrocodone syrup 10-2-5 mg/5ml<br />

PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 10-2.5-3.5 MG/5ML<br />

phenyleph-chlorphen w/ hydrocodone syrup 10-4-2.5 mg/5ml<br />

phenyleph-chlorphen w/ hydrocodone syrup 5-2-1.67 mg/5ml<br />

phenyleph-chlorphen w/ hydrocodone syrup 5-2-2.5 mg/5ml<br />

PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 5-2-6 MG/5ML<br />

phenyleph-chlorphen w/ hydrocodone syrup 7.5-2-2 mg/5ml<br />

phenyleph-chlorphen w/ hydrocodone syrup 7.5-2-3.5 mg/5ml<br />

PHENYLEPH-CHLORPHEN W/ HYDROCODONE SYRUP 7.5-3-5 MG/5ML<br />

PHENYLEPH-CHLORPHEN-CARBETAPENTANE LIQD 10-4-27.5 MG/5ML<br />

PHENYLEPH-CHLORPHEN-CARBETAPENTANE SUSP 2.5-1.25-7.5 MG/ML<br />

phenyleph-chlorphen-dm w/apap susp 2.5-1-5-160 mg/5ml OTC<br />

phenyleph-chlorphen-dm w/apap tab 5-2-10-325 mg OTC<br />

phenyleph-chlorphen-dm w/apap tab 5-2-15-325 mg OTC<br />

PHENYLEPH-CHLORPHEN-PYRIL-HYDROCODONE LIQD 5-2-6-2.5 MG/5ML<br />

phenyleph-dexchlorphen-pyril-dm syrup 5-1.25-5-5 mg/5ml<br />

phenyleph-dexchlorpheniramine-hydrocodone liqd 5-2-4 mg/5ml<br />

PHENYLEPH-DEXCHLORPHENIRAMINE-HYDROCODONE SYRUP 5-1-2 MG/5ML<br />

PHENYLEPH-DEXCHLORPHENIRAMINE-HYDROCODONE SYRUP 5-2-4 MG/5ML<br />

PHENYLEPH-DIPHENHYD-CODEINE LIQUID 7.5-12.5-7.5 MG/5ML<br />

PHENYLEPH-DIPHENHYD-CODEINE SYRUP 7.5-10-7.5 MG/5ML<br />

PHENYLEPH-DIPHENHYD-CODEINE SYRUP 7.5-12.5-7.5 MG/5ML<br />

PHENYLEPH-DIPHENHYD-DM-APAP TAB SR 12HR 18-37.5-30-575 MG<br />

phenyleph-diphenhyd-hydrocodone syrup 5-12.5-3.5 mg/5ml<br />

phenyleph-diphenhyd-hydrocodone syrup 7.5-12.5-2 mg/5ml<br />

PHENYLEPH-DM-APAP & PHENYLEPH-DIPHENHYD-APAP CAP THERAPY PK OTC<br />

phenyleph-dm-sod cit-citric acid liq 2.5-7.5-150-40 mg/5ml<br />

phenyleph-ephed-cpm w/ carbetapentane susp 5-5-4-30 mg/5ml<br />

PHENYLEPH-EPHED-CPM W/ CARBETAPENTANE TAB 10-10-5-60 MG<br />

phenyleph-ephed-cpm w/ carbetapentane tab 10-10-5-60 mg<br />

PHENYLEPH-HYDROCODONE LIQ 5-1.67 MG/5ML<br />

phenyleph-hydrocodone liq 5-2.5 mg/5ml<br />

PHENYLEPH-HYDROCODONE LIQ 7.5-3.75 MG/5ML<br />

PHENYLEPH-PYRIL-DM W/APAP SYRUP 1.67-8.3-5-108.3 MG/5ML OTC<br />

PHENYLEPH-PYRILAMINE W/ DM-POT GUAIACOL CAP 20-25-40-600 MG<br />

PHENYLEPH-PYRILAMINE W/ HYDROCODONE LIQ 7.5-12.5-3.5 MG/5ML<br />

PHENYLEPH-PYRILAMINE W/ HYDROCODONE LIQUID 5-12-6 MG/5ML<br />

PHENYLEPH-PYRILAMINE W/ HYDROCODONE SYRUP 5-12-6 MG/5ML<br />

phenyleph-pyrilamine w/ hydrocodone syrup 5-12-6 mg/5ml<br />

phenyleph-pyrilamine w/ hydrocodone syrup 5-5-5 mg/5ml<br />

phenyleph-pyrilamine w/ hydrocodone syrup 5-8.33-1.66 mg/5ml<br />

PHENYLEPH-PYRILAMINE W/ HYDROCODONE SYRUP 5-8.33-2 MG/5ML<br />

phenylephrin liq complex<br />

phenylephrin liq hd<br />

phenylephrine tan-carbetapentane tan susp 25-30 mg/5ml<br />

phenylephrine tan-carbetapentane tan susp 30-30 mg/5ml<br />

PHENYLEPHRINE TAN-CARBETAPENTANE TAN SUSP 9-22.5 MG/5ML<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 109


PHENYLEPHRINE W/ CODEINE LIQD 10-10 MG/5ML<br />

PHENYLEPHRINE W/ CODEINE LIQD 7.5-10 MG/5ML<br />

PHENYLEPHRINE W/ CODEINE-GG LIQUID 2.5-3-50 MG/ML<br />

PHENYLEPHRINE W/ CODEINE-GG SYRUP 4-12.5-125 MG/5ML<br />

PHENYLEPHRINE W/ CODEINE-GG TAB 10-10-400 MG<br />

PHENYLEPHRINE W/ CODEINE-GG TAB 10-20-400 MG<br />

PHENYLEPHRINE W/ DM-GG CAP 10-15-390 MG OTC<br />

PHENYLEPHRINE W/ DM-GG CAP 7-14-288 MG<br />

PHENYLEPHRINE W/ DM-GG LIQD 1.5-4-20 MG/ML<br />

PHENYLEPHRINE W/ DM-GG LIQD 10-15-225 MG/5ML (2-3-45 MG/ML)<br />

phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml OTC<br />

phenylephrine w/ dm-gg liqd 10-15-300 mg/5ml<br />

PHENYLEPHRINE W/ DM-GG LIQD 10-28-388 MG/5ML<br />

phenylephrine w/ dm-gg liqd 10-30-200 mg/5ml<br />

phenylephrine w/ dm-gg liqd 2.5-3-35 mg/ml<br />

PHENYLEPHRINE W/ DM-GG LIQD 2.5-5-100 MG/2.5ML OTC<br />

phenylephrine w/ dm-gg liqd 2.5-5-50 mg/5ml OTC<br />

phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml OTC<br />

phenylephrine w/ dm-gg liqd 2.5-5-50 mg/ml<br />

PHENYLEPHRINE W/ DM-GG LIQD 2.5-5-75 MG/5ML<br />

PHENYLEPHRINE W/ DM-GG LIQD 2.5-5-75 MG/5ML OTC<br />

PHENYLEPHRINE W/ DM-GG LIQD 2.5-7.5-88 MG/ML<br />

phenylephrine w/ dm-gg liqd 5-10-100 mg/5ml OTC<br />

phenylephrine w/ dm-gg liqd 5-15-200 mg/5ml<br />

PHENYLEPHRINE W/ DM-GG LIQUID 10-20-100 MG/5ML OTC<br />

phenylephrine w/ dm-gg soln 10-10-100 mg/5ml<br />

phenylephrine w/ dm-gg soln 10-10-100 mg/5ml OTC<br />

PHENYLEPHRINE W/ DM-GG SOLN 10-15-225 MG/5ML<br />

PHENYLEPHRINE W/ DM-GG SUSP 10-40-400 MG/10ML<br />

PHENYLEPHRINE W/ DM-GG SYRUP 10-15-133 MG/5ML<br />

PHENYLEPHRINE W/ DM-GG SYRUP 10-15-350 MG/5ML<br />

PHENYLEPHRINE W/ DM-GG SYRUP 10-15-350 MG/5ML OTC<br />

phenylephrine w/ dm-gg syrup 10-20-100 mg/5ml<br />

phenylephrine w/ dm-gg syrup 10-30-200 mg/5ml<br />

phenylephrine w/ dm-gg syrup 12.5-25-175 mg/5ml<br />

phenylephrine w/ dm-gg syrup 5-10-100 mg/5ml OTC<br />

PHENYLEPHRINE W/ DM-GG SYRUP 5-15-100 MG/5ML OTC<br />

PHENYLEPHRINE W/ DM-GG SYRUP 5-15-100 MG/5ML<br />

phenylephrine w/ dm-gg tab 10-15-380 mg OTC<br />

phenylephrine w/ dm-gg tab 10-20-400 mg OTC<br />

PHENYLEPHRINE W/ DM-GG TAB 10-28-388 MG<br />

PHENYLEPHRINE W/ DM-GG TAB 12-15-350 MG<br />

PHENYLEPHRINE W/ DM-GG TAB 15-30-600 MG<br />

PHENYLEPHRINE W/ DM-GG TAB CR 15-30-600 MG<br />

phenylephrine w/ dm-gg tab cr 15-30-600 mg<br />

PHENYLEPHRINE W/ DM-GG TAB CR 30-50-825 MG<br />

phenylephrine w/ dm-gg tab sr 12hr 10-30-600 mg<br />

phenylephrine w/ dm-gg tab sr 12hr 20-20-800 mg<br />

PHENYLEPHRINE W/ DM-GG TAB SR 12HR 20-25-550 MG<br />

phenylephrine w/ dm-gg tab sr 12hr 20-25-550 mg<br />

phenylephrine w/ dm-gg tab sr 12hr 20-25-600 mg<br />

PHENYLEPHRINE W/ DM-GG TAB SR 12HR 20-30-1000 MG<br />

phenylephrine w/ dm-gg tab sr 12hr 20-30-600 mg<br />

PHENYLEPHRINE W/ DM-GG TAB SR 12HR 20-30-600 MG<br />

PHENYLEPHRINE W/ DM-GG TAB SR 12HR 25-45-1200 MG<br />

phenylephrine w/ dm-gg tab sr 12hr 30-30-1200 mg<br />

PHENYLEPHRINE W/ DM-GG TAB SR 12HR 30-30-900 MG<br />

phenylephrine w/ dm-gg tab sr 12hr 40-20-1200 mg<br />

phenylephrine w/ dm-gg tab sr 12hr 40-60-1000 mg<br />

phenylephrine w/ dm-gg tab sr 12hr 40-60-600 mg<br />

PHENYLEPHRINE W/ DM-GG TAB SR 12HR 9-23-600 MG<br />

PHENYLEPHRINE W/ HYDROCODONE-GG LIQUID 10-4-100 MG/5ML<br />

PHENYLEPHRINE W/ HYDROCODONE-GG LIQUID 10-5-200 MG/5ML<br />

PHENYLEPHRINE W/ HYDROCODONE-GG LIQUID 10-5-300 MG/5ML<br />

PHENYLEPHRINE W/ HYDROCODONE-GG LIQUID 15-5-100 MG/5ML<br />

PHENYLEPHRINE W/ HYDROCODONE-GG LIQUID 7.5-2.5-100 MG/5ML<br />

PHENYLEPHRINE W/ HYDROCODONE-GG LIQUID 7.5-2.5-200 MG/5ML<br />

phenylephrine w/ hydrocodone-gg liquid 7.5-2.5-200 mg/5ml<br />

phenylephrine w/ hydrocodone-gg solution 10-2.5-225 mg/5ml<br />

PHENYLEPHRINE W/ HYDROCODONE-GG SOLUTION 5-2.5-100 MG/5ML<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 110


phenylephrine w/ hydrocodone-gg syrup 10-2-100 mg/5ml<br />

PHENYLEPHRINE W/ HYDROCODONE-GG SYRUP 15-5-100 MG/5ML<br />

phenylephrine w/ hydrocodone-gg syrup 6-2.5-120 mg/5ml<br />

phenylephrine w/ hydrocodone-gg syrup 6-2.5-150 mg/5ml<br />

phenylephrine w/ hydrocodone-gg syrup 7.5-2.5-50 mg/5ml<br />

PHENYLEPHRINE W/ HYDROCODONE-GG SYRUP 7.5-5-100 MG/5ML<br />

phenylephrine w/ hydrocodone-gg syrup 7.5-5-100 mg/5ml<br />

PHENYLEPHRINE-BROMPHEN W/ CODEINE LIQD 3.33-1.33-6.33 MG/5ML<br />

phenylephrine-bromphen w/ codeine liqd 7.5-4-10 mg/5ml<br />

PHENYLEPHRINE-BROMPHEN W/ CODEINE TAB 10-4-10 MG<br />

PHENYLEPHRINE-BROMPHEN W/ CODEINE TAB 10-4-20 MG<br />

phenylephrine-bromphen-carbetapentane liq 10-6-30 mg/5ml<br />

phenylephrine-bromphen-carbetapentane susp 10-6-25 mg/5ml<br />

phenylephrine-bromphen-dihydrocodeine liqd 7.5-4-3 mg/5ml<br />

PHENYLEPHRINE-BROMPHENIRAMINE-DM DROPS 1-0.4-2 MG/ML<br />

phenylephrine-brompheniramine-dm elixir 2.5-1-5 mg/5ml OTC<br />

phenylephrine-brompheniramine-dm liquid 10-4-20 mg/5ml<br />

PHENYLEPHRINE-BROMPHENIRAMINE-DM LIQUID 10-4-30 MG/5ML OTC<br />

PHENYLEPHRINE-BROMPHENIRAMINE-DM LIQUID 7.5-2-15 MG/5ML<br />

phenylephrine-brompheniramine-dm liquid 7.5-2-15 mg/5ml<br />

phenylephrine-brompheniramine-dm liquid 7.5-4-15 mg/5ml<br />

phenylephrine-brompheniramine-dm syrup 5-2-10 mg/5ml<br />

PHENYLEPHRINE-BROMPHENIRAMINE-DM TAB 10-4-20 MG OTC<br />

PHENYLEPHRINE-CARBETAPENTANE-GG CAP 10-25-400 MG<br />

phenylephrine-carbetapentane-gg liqd 8-30-200 mg/5ml<br />

phenylephrine-carbetapentane-gg soln 5-15-100 mg/5ml<br />

phenylephrine-carbetapentane-gg syrup 10-20-100 mg/5ml<br />

phenylephrine-carbetapentane-gg syrup 15-20-100 mg/5ml<br />

PHENYLEPHRINE-CARBETAPENTANE-GG TAB 10-30-400 MG<br />

phenylephrine-carbetapentane-gg tab sr 12hr 15-60-600 mg<br />

PHENYLEPHRINE-CARBINOXAMINE W/ HYDROCODONE LIQD 6-2-5 MG/5ML<br />

phenylephrine-carbinoxamine w/ hydrocodone liqd 8-4-5 mg/5ml<br />

PHENYLEPHRINE-CARBINOXAMINE-CARBETAPENTANE LIQ 2-1-4 MG/ML<br />

phenylephrine-carbinoxamine-dm liquid 2-1-2 mg/ml<br />

phenylephrine-carbinoxamine-dm liquid 2-2-3 mg/ml<br />

PHENYLEPHRINE-CARBINOXAMINE-DM LIQUID 2-2-4 MG/ML<br />

PHENYLEPHRINE-CARBINOXAMINE-DM SYRUP 8-4-15 MG/5ML<br />

PHENYLEPHRINE-CHLORPHEN-DIHYDROCODEINE LIQD 4-2-6.5 MG/5ML<br />

PHENYLEPHRINE-CHLORPHEN-DIHYDROCODEINE LIQD 5-2-7.25 MG/5ML<br />

phenylephrine-chlorphen-dihydrocodeine syrup 20-5-3 mg/5ml<br />

phenylephrine-chlorphen-dihydrocodeine syrup 7.5-2-3 mg/5ml<br />

PHENYLEPHRINE-CHLORPHEN-DM CHEW TAB SR 12HR 30-4-30 MG<br />

PHENYLEPHRINE-CHLORPHEN-DM LIQUID 1.5-0.6-2.75 MG/ML<br />

phenylephrine-chlorphen-dm liquid 1.5-1-3 mg/ml<br />

phenylephrine-chlorphen-dm liquid 1.75-0.75-2.75 mg/ml<br />

PHENYLEPHRINE-CHLORPHEN-DM LIQUID 10-3-15 MG/5ML<br />

phenylephrine-chlorphen-dm liquid 10-4-15 mg/5ml<br />

phenylephrine-chlorphen-dm liquid 2-1-3 mg/ml<br />

PHENYLEPHRINE-CHLORPHEN-DM LIQUID 2.5-1-2.5 MG/ML<br />

phenylephrine-chlorphen-dm liquid 3.5-1-3 mg/ml<br />

PHENYLEPHRINE-CHLORPHEN-DM LIQUID 5-2-10 MG/5ML OTC<br />

PHENYLEPHRINE-CHLORPHEN-DM LIQUID 7.5-4-30 MG/5ML<br />

PHENYLEPHRINE-CHLORPHEN-DM SOLN 10-4-10 MG/30ML OTC<br />

phenylephrine-chlorphen-dm soln 10-4-15 mg/5ml<br />

PHENYLEPHRINE-CHLORPHEN-DM SOLN 12.5-4-15 MG/5ML OTC<br />

PHENYLEPHRINE-CHLORPHEN-DM SUSP 7.5-2-15 MG/5ML<br />

phenylephrine-chlorphen-dm syrup 10-2-15 mg/5ml<br />

phenylephrine-chlorphen-dm syrup 12.5-4-15 mg/5ml<br />

phenylephrine-chlorphen-dm syrup 5-2-15 mg/5ml<br />

phenylephrine-chlorphen-dm syrup 6-2-15 mg/5ml<br />

phenylephrine-chlorphen-dm tab 10-4-20 mg OTC<br />

phenylephrine-chlorphen-dm tab sr 12hr 20-8-30 mg<br />

PHENYLEPHRINE-CODEINE-GUAIFENESIN-APAP TAB 10-10-400-500 MG<br />

PHENYLEPHRINE-CODEINE-GUAIFENESIN-APAP TAB 10-20-400-500 MG<br />

PHENYLEPHRINE-DEXBROMPHEN-CHLOPHEDIANOL LIQD 5-1-12.5 MG/5ML OTC<br />

PHENYLEPHRINE-DEXBROMPHEN-DM-GG LIQUID 2-0.5-5-50 MG/ML<br />

PHENYLEPHRINE-DEXBROMPHEN-DM-GG LIQUID 5-1-15-100 MG/5ML<br />

phenylephrine-dexbromphen-hydrocodone syrup 5-1-2.5 mg/5ml<br />

PHENYLEPHRINE-DEXBROMPHENIRAMINE-DM SYRUP 10-2-20 MG/5ML<br />

PHENYLEPHRINE-DEXBROMPHENIRAMINE-DM TAB SR 12HR 20-6-30 MG<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 111


PHENYLEPHRINE-DEXCHLORPHENIR-CODEINE LIQUID 5-1-10 MG/5ML<br />

PHENYLEPHRINE-DIHYDROCODEINE LIQD 7.5-3 MG/5ML<br />

PHENYLEPHRINE-DIHYDROCODEINE-GG SYRUP 7.5-7.5-50 MG/5ML<br />

PHENYLEPHRINE-DIPHENHYDRAMINE-DM-APAP TAB 10-37.5-20-575 MG<br />

PHENYLEPHRINE-DM DROPS 1.25-2.5 MG/0.8ML OTC<br />

phenylephrine-dm drops 1.25-2.5 mg/0.8ml OTC<br />

PHENYLEPHRINE-DM LIQUID 10-20 MG/15ML OTC<br />

PHENYLEPHRINE-DM LIQUID 2.5-5 MG/ML OTC<br />

PHENYLEPHRINE-DM LIQUID 5-30 MG/10ML OTC<br />

PHENYLEPHRINE-DM ORAL STRIP 1.25-2.5 MG OTC<br />

PHENYLEPHRINE-DM ORAL STRIP 10-20 MG OTC<br />

PHENYLEPHRINE-DM ORAL STRIP 2.5-5 MG OTC<br />

phenylephrine-dm soln 2.5-5 mg/5ml OTC<br />

PHENYLEPHRINE-DM SOLN 2.5-5 MG/ML<br />

PHENYLEPHRINE-DM SYRUP 2.5-5 MG/5ML OTC<br />

PHENYLEPHRINE-DM SYRUP 2.5-7.5 MG/ML<br />

PHENYLEPHRINE-DM-GG W/ APAP LIQ 5-10-100-325 MG/5ML OTC<br />

PHENYLEPHRINE-DM-GG W/ APAP LIQ 5-10-200-325 MG/15ML OTC<br />

PHENYLEPHRINE-DM-GG W/ APAP TAB 10-20-400-500 MG<br />

PHENYLEPHRINE-DM-GG W/ APAP TAB 15-30-600-500 MG<br />

PHENYLEPHRINE-DM-GG W/ APAP TAB 5-10-100-325 MG OTC<br />

phenylephrine-dm-gg w/ apap tab 5-10-200-325 mg OTC<br />

phenylephrine-dm-gg w/ apap tab 5-15-200-325 mg OTC<br />

PHENYLEPHRINE-DM-SODIUM CITRATE LIQD 2.5-5-14.7 MG/ML<br />

PHENYLEPHRINE-DOXYLAMINE-DM-APAP LIQ 5-6.25-10-325 MG/15ML OTC<br />

PHENYLEPHRINE-DOXYLAMINE-DM-APAP LIQ 5-6.25-15-500 MG/15ML OTC<br />

PHENYLEPHRINE-PHENIRAMINE-DM POWD PACK 10-20-20 MG OTC<br />

phenylephrine-promethazine w/ codeine syrup 5-6.25-10 mg/5ml<br />

PHENYLEPHRINE-PYRILAMINE W/ CODEINE SYRUP 5-5-10 MG/5ML<br />

PHENYLEPHRINE-PYRILAMINE W/ CODEINE SYRUP 5-8.33-10 MG/5ML<br />

PHENYLEPHRINE-PYRILAMINE W/ CODEINE SYRUP 5-8.33-10 MG/5ML OTC<br />

PHENYLEPHRINE-PYRILAMINE W/ CODEINE SYRUP 5-8.33-9 MG/5ML<br />

PHENYLEPHRINE-PYRILAMINE W/ DM-GG LIQUID 10-25-20-200 MG/5ML<br />

PHENYLEPHRINE-PYRILAMINE-DM LIQUID 1-1.77-2 MG/ML OTC<br />

PHENYLEPHRINE-PYRILAMINE-DM LIQUID 5-12.5-15 MG/5ML OTC<br />

phenylephrine-pyrilamine-dm liquid 7.5-12.5-15 mg/5ml<br />

phenylephrine-pyrilamine-dm susp 5-16-15 mg/5ml<br />

phenylephrine-pyrilamine-dm syrup 5-8.33-10 mg/5ml OTC<br />

PHENYLHIST LIQ DH OTC<br />

PHENYLHIST LIQ DH<br />

phenylhist liq dh OTC<br />

phenylhistin sol expect OTC<br />

phenylhistin sol expect<br />

phlemex tab<br />

phlemex tab forte<br />

phlemex-pe tab<br />

pluratuss liq<br />

POLY HIST HC LIQ<br />

POLY TAN DM SUS<br />

POLY-TUSSIN LIQ XP<br />

POLY-TUSSIN SYP<br />

POLY-TUSSIN SYP HD<br />

pot guaiaco/ syp hydrocod<br />

PRO-CLEAR SYP<br />

PRO-CLEAR AC SYP<br />

PRO-RED SYP<br />

PRO-RED AC SYP<br />

prodec-dm dro<br />

prolex dh sol expect<br />

PROLEX DMX LIQ<br />

prometh vc/ syp codeine<br />

prometh/cod syp 6.25-10<br />

promethazine syp dm<br />

promethazine syp dm<br />

promethazine w/ codeine syrup 6.25-10 mg/5ml<br />

promethazine-dm syrup 6.25-15 mg/5ml<br />

protex liq 5-300mg<br />

protex d liq<br />

pse allergy liq dm<br />

pse bpm hd liq<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 112


pse brom dm syp<br />

pse carb dm dro<br />

pse carbinox syp dm<br />

PSE HCL-CARBINOXAMINE MAL-DM HBR TANNATE SUSP 15-2-3 MG/5ML<br />

PSE HCL-CHLORPHEN MAL-HYDROCOD BITART TAN SUSP 30-4-5 MG/5ML<br />

PSE HCL-DM HBR-GUAIFENESIN TANNATE SUSP 30-15-175 MG/5ML<br />

pse w/ hydrocodone-pot guaiacol liquid 30-5-300 mg/5ml<br />

PSE-APAP-DM & PSE-APAP-DIPHENHYD TAB 60-650-30-50 MG OTC<br />

PSE-DM-APAP & PSE-DIPHENHYD-APAP TAB 30-25-15-500 MG OTC<br />

PSE-DM-APAP &PSE-DM-APAP-CPM TAB KIT 30-15-500/30-15-500-2MG OTC<br />

pse-dm-apap &pse-dm-apap-cpm tab pak 30-15-325/30-15-325-2mg OTC<br />

pse-dm-gg tab<br />

pse/carb/dm liq drops<br />

pse/codeine liq<br />

pse/dm/gg syp 40-15-10<br />

PSE/DM/GG SYP 40-15-10<br />

pse/gg/dm tab<br />

pse/gg/dm tab<br />

pse/gg/dm tab<br />

pse/hydrocod liq /carbinx<br />

PSEUDACARB CHW 75-25MG<br />

pseudatex hc liq 45-6-200<br />

pseudo carb liq dm<br />

pseudo cough liq<br />

pseudo max tab dmx<br />

pseudo-chlor liq codeine OTC<br />

PSEUDOEPH HCL-PYRIL MAL-DM HBR TANNATE SUSP 15-15-15 MG/5ML<br />

pseudoeph tan-carbinox tan-dm tan susp 45.2-3.2-27.5 mg/5ml<br />

PSEUDOEPH TAN-CARBINOX TAN-DM TAN SUSP 45.2-3.6-27.5 MG/5ML<br />

pseudoeph-bromphen w/ hydrocodone liquid 15-2-2.5 mg/5ml<br />

PSEUDOEPH-BROMPHEN W/ HYDROCODONE LIQUID 15-3-2.5 MG/5ML<br />

pseudoeph-bromphen w/ hydrocodone liquid 30-3-2.5 mg/5ml<br />

pseudoeph-bromphen w/ hydrocodone soln 30-2-1.7 mg/5ml<br />

PSEUDOEPH-BROMPHEN W/ HYDROCODONE SYRUP 30-2-1.7 MG/5ML<br />

PSEUDOEPH-BROMPHEN W/ HYDROCODONE SYRUP 30-2-2.5 MG/5ML<br />

pseudoeph-carbinoxamine w/ hydrocodone liqd 30-2-5 mg/5ml<br />

PSEUDOEPH-CHLORPHEN W/ HYDROCODONE CAP CR 30-2-5 MG<br />

PSEUDOEPH-CHLORPHEN W/ HYDROCODONE LIQ 15-2-2.5 MG/5ML<br />

pseudoeph-chlorphen w/ hydrocodone liq 15-2-3 mg/5ml<br />

pseudoeph-chlorphen w/ hydrocodone liq 17.5-2.5-1.67 mg/5ml<br />

PSEUDOEPH-CHLORPHEN W/ HYDROCODONE LIQ 20-2.5-1.67 MG/5ML<br />

pseudoeph-chlorphen w/ hydrocodone liquid 30-2-5 mg/5ml<br />

pseudoeph-chlorphen w/ hydrocodone syr 30-2-2.5 mg/5ml<br />

pseudoeph-chlorphen w/ hydrocodone syrup 15-2-3 mg/5ml<br />

PSEUDOEPH-CHLORPHEN W/ HYDROCODONE SYRUP 40-4-5 MG/5ML<br />

PSEUDOEPH-CHLORPHEN-DM W/ APAP CAP 30-2-10-250 MG OTC<br />

PSEUDOEPH-CHLORPHEN-DM W/ APAP CAP 30-2-10-325 MG OTC<br />

pseudoeph-chlorphen-dm w/ apap chew tab 7.5-0.5-2.5-80 mg OTC<br />

pseudoeph-chlorphen-dm w/ apap liqd 15-1-5-160 mg/5ml OTC<br />

PSEUDOEPH-CHLORPHEN-DM W/ APAP LIQD 15-1-5-160 MG/5ML OTC<br />

pseudoeph-chlorphen-dm w/ apap liqd 15-1-7.5-160 mg/5ml OTC<br />

pseudoeph-chlorphen-dm w/ apap liqd 15-1-7.5-162.5 mg/5ml OTC<br />

PSEUDOEPH-CHLORPHEN-DM W/ APAP LIQD 60-4-30-1000 MG/30ML OTC<br />

pseudoeph-chlorphen-dm w/ apap pack 60-4-20-500 mg OTC<br />

pseudoeph-chlorphen-dm w/ apap pack 60-4-20-650 mg OTC<br />

pseudoeph-chlorphen-dm w/ apap pack 60-4-30-1000 mg OTC<br />

pseudoeph-chlorphen-dm w/ apap syrup 15-1-5-160 mg/5ml OTC<br />

PSEUDOEPH-CHLORPHEN-DM W/ APAP SYRUP 60-4-30-500 MG/20ML OTC<br />

pseudoeph-chlorphen-dm w/ apap tab 30-2-10-325 mg OTC<br />

pseudoeph-chlorphen-dm w/ apap tab 30-2-15-325 mg OTC<br />

pseudoeph-chlorphen-dm w/ apap tab 30-2-15-500 mg OTC<br />

PSEUDOEPH-DIPHENHYDR-DM W/ APAP CAP 30-25-15-250 MG OTC<br />

pseudoeph-doxylamine-dm w/ apap cap 30-6.25-10-250 mg OTC<br />

pseudoeph-doxylamine-dm w/ apap cap 30-6.25-15-325 mg OTC<br />

pseudoeph-doxylamine-dm w/ apap liq 60-7.5-30-1000 mg/30ml OTC<br />

pseudoeph-doxylamine-dm w/apap liq 60-12.5-30-1000 mg/30ml OTC<br />

pseudoephed hcl-chlorphen mal-dm hbr tan susp 30-4-30 mg/5ml<br />

pseudoephed tan-bromphen tan-dm tan susp 90-8-60 mg/5ml<br />

PSEUDOEPHED TAN-BROMPHEN TAN-DM TAN SUSP 90-8-60 MG/5ML<br />

PSEUDOEPHED TAN-BROMPHEN TAN-HYDROCOD TAN SUSP 45-6-6 MG/5ML<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 113


PSEUDOEPHED TAN-CHLORPHEN TAN-DM TAN SUSP 75-4.5-25 MG/5ML<br />

pseudoephed tan-chlorphen tan-dm tan susp 75-4.5-25 mg/5ml<br />

PSEUDOEPHED TAN-CHLORPHEN TAN-DM TAN SUSP 75-5-25 MG/5ML<br />

PSEUDOEPHED TAN-DEXCHLORPHEN TAN-DM TAN SUS 45-3.5-30 MG/5ML<br />

pseudoephed tan-dexchlorphen tan-dm tan sus 45-3.5-30 mg/5ml<br />

pseudoephed tan-dexchlorphen tan-dm tan sus 50-3-27.5 mg/5ml<br />

pseudoephed tan-dexchlorphen tan-dm tan sus 75-2.5-25 mg/5ml<br />

PSEUDOEPHED TAN-DEXCHLORPHEN TAN-DM TAN SUS 75-2.5-25 MG/5ML<br />

PSEUDOEPHED-BROMPHEN-DIHYDROCODEINE LIQD 15-3-7.5 MG/5ML<br />

pseudoephed-bromphen-dm elixir 15-1-5 mg/5ml OTC<br />

pseudoephed-bromphen-dm liquid 12-1-5 mg/ml<br />

PSEUDOEPHED-BROMPHEN-DM LIQUID 12-1-5 MG/ML<br />

pseudoephed-bromphen-dm liquid 12.5-1-3 mg/ml<br />

pseudoephed-bromphen-dm liquid 15-1-4 mg/ml<br />

pseudoephed-bromphen-dm liquid 20-4-20 mg/5ml<br />

PSEUDOEPHED-BROMPHEN-DM LIQUID 30-1-20 MG/5ML<br />

pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml<br />

pseudoephed-bromphen-dm syrup 30-2-10 mg/5ml OTC<br />

pseudoephed-bromphen-dm syrup 30-3-15 mg/5ml<br />

pseudoephed-bromphen-dm syrup 45-4-15 mg/5ml<br />

pseudoephed-bromphen-dm syrup 50-3-30 mg/5ml<br />

pseudoephed-bromphen-dm syrup 60-4-30 mg/5ml<br />

pseudoephed-bromphen-dm syrup 60-4-30 mg/5ml OTC<br />

PSEUDOEPHED-BROMPHEN-DM TAB 40-4-20 MG<br />

pseudoephed-bromphen-dm-gg syrup 30-2-5-50 mg/5ml<br />

PSEUDOEPHED-CARBETAPENTANE-GUAIFENESIN LIQD 30-10-100 MG/5ML<br />

pseudoephed-carbinoxamine-dm liquid 12.5-2.67-15 mg/5ml<br />

pseudoephed-carbinoxamine-dm liquid 12.5-3-15 mg/5ml<br />

pseudoephed-carbinoxamine-dm liquid 15-1-4 mg/ml<br />

PSEUDOEPHED-CARBINOXAMINE-DM LIQUID 15-3-15 MG/5ML<br />

pseudoephed-carbinoxamine-dm liquid 25-2-3.5 mg/ml<br />

pseudoephed-carbinoxamine-dm soln 25-2-4 mg/ml<br />

PSEUDOEPHED-CARBINOXAMINE-DM SYRUP 15-2-15 MG/5ML<br />

pseudoephed-carbinoxamine-dm syrup 60-4-12.5 mg/5ml<br />

pseudoephed-carbinoxamine-dm syrup 60-4-15 mg/5ml<br />

PSEUDOEPHED-CHLORPHEN W/ DM-GG LIQD 30-2-30-200 MG/5ML<br />

PSEUDOEPHED-CHLORPHEN-DIHYDROCODEINE SYRUP 15-2-7.5 MG/5ML<br />

pseudoephed-chlorphen-dihydrocodeine syrup 15-2-7.5 mg/5ml<br />

PSEUDOEPHED-CHLORPHEN-DM CHEW TAB 15-1-5 MG OTC<br />

pseudoephed-chlorphen-dm drops 9-0.8-3 mg/ml OTC<br />

pseudoephed-chlorphen-dm drops 9-0.8-3 mg/ml<br />

pseudoephed-chlorphen-dm liq 10-0.6-5 mg/5ml OTC<br />

pseudoephed-chlorphen-dm liq 15-1-5 mg/5ml OTC<br />

pseudoephed-chlorphen-dm liq 15-1-7.5 mg/5ml OTC<br />

PSEUDOEPHED-CHLORPHEN-DM LIQ 30-2-15 MG/5ML<br />

PSEUDOEPHED-CHLORPHEN-DM LIQ 30-2-20 MG/5ML<br />

PSEUDOEPHED-CHLORPHEN-DM SUSP 30-4-30 MG/5ML OTC<br />

PSEUDOEPHED-CHLORPHEN-DM SYRUP 15-1-7.5 MG/5ML OTC<br />

pseudoephed-chlorphen-dm syrup 15-2-15 mg/5ml<br />

PSEUDOEPHED-CHLORPHEN-DM SYRUP 30-2-10 MG/5ML OTC<br />

PSEUDOEPHED-CHLORPHEN-DM SYRUP 30-2-15 MG/15ML OTC<br />

pseudoephed-chlorphen-dm syrup 30-2-15 mg/5ml<br />

pseudoephed-chlorphen-dm syrup 30-2-15 mg/5ml OTC<br />

PSEUDOEPHED-CHLORPHEN-DM SYRUP 80-4-30 MG/5ML<br />

pseudoephed-chlorphen-dm tab 60-4-20 mg OTC<br />

PSEUDOEPHED-CODEINE-GUAIFENESIN-APAP TAB 40-10-400-500 MG<br />

PSEUDOEPHED-CODEINE-GUAIFENESIN-APAP TAB 60-20-400-500 MG<br />

PSEUDOEPHED-DEXCHLORPHEN-CHLOPHEDIANOL LIQD 30-1-12.5 MG/5ML OTC<br />

PSEUDOEPHED-PYRILAMINE-CARBETAPENTANE LIQD 30-7.5-20 MG/5ML<br />

PSEUDOEPHED-PYRILAMINE-CARBETAPENTANE SYRUP 8-7.5-20 MG/5ML<br />

PSEUDOEPHED-TRIPROLIDINE-HYDROCODONE LIQD 30-1.25-2.5 MG/5ML<br />

pseudoephedr tab /gg/dm<br />

PSEUDOEPHEDRINE TAN-CARBETAPENTANE TAN CHEW TAB 75-25 MG<br />

pseudoephedrine tan-carbetapentane tan susp 75-25 mg/5ml<br />

PSEUDOEPHEDRINE TAN-HYDROCODONE TAN SUSP 45-10 MG/5ML<br />

pseudoephedrine w/ apap-dm cap 30-325-15 mg OTC<br />

PSEUDOEPHEDRINE W/ APAP-DM CAP 30-500-15 MG OTC<br />

pseudoephedrine w/ apap-dm caps 30-250-10 mg OTC<br />

pseudoephedrine w/ apap-dm caps 30-250-10 mg<br />

PSEUDOEPHEDRINE W/ APAP-DM CHEW TAB 15-160-5 MG OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 114


pseudoephedrine w/ apap-dm liq 15-160-5 mg/1.6ml OTC<br />

pseudoephedrine w/ apap-dm liq 15-160-7.5 mg/5ml OTC<br />

pseudoephedrine w/ apap-dm liq 30-325-15 mg/15ml OTC<br />

PSEUDOEPHEDRINE W/ APAP-DM LIQ 60-1000-30 MG/30ML OTC<br />

pseudoephedrine w/ apap-dm liq 60-650-20 mg/30ml OTC<br />

PSEUDOEPHEDRINE W/ APAP-DM PACK 60-1000-30 MG OTC<br />

pseudoephedrine w/ apap-dm pack 60-1000-30 mg OTC<br />

PSEUDOEPHEDRINE W/ APAP-DM TAB 30-325-10 MG OTC<br />

pseudoephedrine w/ apap-dm tab 30-325-15 mg OTC<br />

pseudoephedrine w/ apap-dm tab 30-500-15 mg OTC<br />

pseudoephedrine w/ cod-gg soln 30-10-100 mg/5ml OTC<br />

pseudoephedrine w/ cod-gg soln 30-10-100 mg/5ml<br />

PSEUDOEPHEDRINE W/ COD-GG SUSP 3-1-20 MG/ML<br />

PSEUDOEPHEDRINE W/ COD-GG SUSP 3.333-1-20 MG/ML OTC<br />

PSEUDOEPHEDRINE W/ COD-GG SUSP 3.75-1-20 MG/ML OTC<br />

PSEUDOEPHEDRINE W/ COD-GG SUSP 4-1-20 MG/ML<br />

PSEUDOEPHEDRINE W/ COD-GG SUSP 4.286-1-20 MG/ML OTC<br />

PSEUDOEPHEDRINE W/ COD-GG SUSP 5-1-20 MG/ML OTC<br />

PSEUDOEPHEDRINE W/ COD-GG SUSP 6-1-20 MG/ML<br />

PSEUDOEPHEDRINE W/ COD-GG SYRUP 15-5-50 MG/5ML<br />

pseudoephedrine w/ cod-gg syrup 30-10-100 mg/5ml<br />

pseudoephedrine w/ cod-gg syrup 60-20-200 mg/5ml<br />

PSEUDOEPHEDRINE W/ COD-GG TAB 20-10-400 MG<br />

PSEUDOEPHEDRINE W/ COD-GG TAB 20-20-400 MG<br />

PSEUDOEPHEDRINE W/ COD-GG TAB 30-10-400 MG<br />

PSEUDOEPHEDRINE W/ COD-GG TAB 30-20-400 MG<br />

PSEUDOEPHEDRINE W/ COD-GG TAB 40-10-400 MG<br />

PSEUDOEPHEDRINE W/ COD-GG TAB 40-20-400 MG<br />

PSEUDOEPHEDRINE W/ COD-GG TAB 60-10-400 MG<br />

PSEUDOEPHEDRINE W/ COD-GG TAB 60-20-400 MG<br />

PSEUDOEPHEDRINE W/ CODEINE CAP 60-20 MG<br />

pseudoephedrine w/ codeine liquid 30-10 mg/5ml<br />

pseudoephedrine w/ dm-gg cap 30-10-200 mg OTC<br />

PSEUDOEPHEDRINE W/ DM-GG LIQUID 10-4-20 MG/ML<br />

PSEUDOEPHEDRINE W/ DM-GG LIQUID 15-5-100 MG/2.5ML OTC<br />

PSEUDOEPHEDRINE W/ DM-GG LIQUID 15-5-50 MG/5ML OTC<br />

PSEUDOEPHEDRINE W/ DM-GG LIQUID 15-5-50 MG/5ML<br />

PSEUDOEPHEDRINE W/ DM-GG LIQUID 15-5-50 MG/ML OTC<br />

PSEUDOEPHEDRINE W/ DM-GG LIQUID 20-10-200 MG/5ML OTC<br />

PSEUDOEPHEDRINE W/ DM-GG LIQUID 20-4-20 MG/ML<br />

pseudoephedrine w/ dm-gg liquid 30-10-100 mg/5ml OTC<br />

PSEUDOEPHEDRINE W/ DM-GG LIQUID 30-15-200 MG/5ML OTC<br />

PSEUDOEPHEDRINE W/ DM-GG LIQUID 30-15-200 MG/5ML<br />

PSEUDOEPHEDRINE W/ DM-GG LIQUID 30-15-25 MG/5ML<br />

pseudoephedrine w/ dm-gg liquid 32-15-175 mg/5ml<br />

pseudoephedrine w/ dm-gg liquid 32-15-200 mg/5ml<br />

PSEUDOEPHEDRINE W/ DM-GG LIQUID 36-15-200 MG/5ML<br />

PSEUDOEPHEDRINE W/ DM-GG LIQUID 45-15-100 MG/5ML<br />

PSEUDOEPHEDRINE W/ DM-GG LIQUID 5-5-25 MG/ML<br />

PSEUDOEPHEDRINE W/ DM-GG LIQUID 60-40-400 MG/10ML<br />

pseudoephedrine w/ dm-gg susp 30-15-175 mg/5ml<br />

PSEUDOEPHEDRINE W/ DM-GG SUSP 30-15-180 MG/5ML<br />

PSEUDOEPHEDRINE W/ DM-GG SYRUP 20-10-66.7 MG/5ML OTC<br />

pseudoephedrine w/ dm-gg syrup 20-10-66.7 mg/5ml OTC<br />

pseudoephedrine w/ dm-gg syrup 30-10-100 mg/5ml OTC<br />

pseudoephedrine w/ dm-gg syrup 30-15-150 mg/5ml<br />

PSEUDOEPHEDRINE W/ DM-GG SYRUP 40-15-100 MG/5ML<br />

pseudoephedrine w/ dm-gg syrup 40-15-100 mg/5ml<br />

PSEUDOEPHEDRINE W/ DM-GG SYRUP 40-15-200 MG/5ML<br />

PSEUDOEPHEDRINE W/ DM-GG SYRUP 45-15-100 MG/5ML<br />

PSEUDOEPHEDRINE W/ DM-GG TAB 20-20-400 MG OTC<br />

PSEUDOEPHEDRINE W/ DM-GG TAB 30-10-100 MG OTC<br />

PSEUDOEPHEDRINE W/ DM-GG TAB 30-10-200 MG OTC<br />

PSEUDOEPHEDRINE W/ DM-GG TAB 30-20-400 MG OTC<br />

PSEUDOEPHEDRINE W/ DM-GG TAB 30-30-400 MG OTC<br />

pseudoephedrine w/ dm-gg tab 40-20-400 mg<br />

PSEUDOEPHEDRINE W/ DM-GG TAB 40-30-400 MG OTC<br />

pseudoephedrine w/ dm-gg tab 45-15-400 mg OTC<br />

pseudoephedrine w/ dm-gg tab 60-20-400 mg OTC<br />

pseudoephedrine w/ dm-gg tab 60-20-400 mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 115


pseudoephedrine w/ dm-gg tab sr 12hr 120-60-1200 mg<br />

PSEUDOEPHEDRINE W/ DM-GG TAB SR 12HR 120-60-800 MG<br />

PSEUDOEPHEDRINE W/ DM-GG TAB SR 12HR 25-30-575 MG<br />

pseudoephedrine w/ dm-gg tab sr 12hr 45-30-800 mg<br />

pseudoephedrine w/ dm-gg tab sr 12hr 48-32-595 mg<br />

PSEUDOEPHEDRINE W/ DM-GG TAB SR 12HR 58-28-600 MG<br />

pseudoephedrine w/ dm-gg tab sr 12hr 60-30-1000 mg<br />

PSEUDOEPHEDRINE W/ DM-GG TAB SR 12HR 60-30-550 MG<br />

PSEUDOEPHEDRINE W/ DM-GG TAB SR 12HR 60-30-575 MG<br />

PSEUDOEPHEDRINE W/ DM-GG TAB SR 12HR 60-30-580 MG<br />

pseudoephedrine w/ dm-gg tab sr 12hr 60-30-580 mg<br />

pseudoephedrine w/ dm-gg tab sr 12hr 60-30-600 mg<br />

pseudoephedrine w/ dm-gg tab sr 12hr 60-30-800 mg<br />

PSEUDOEPHEDRINE W/ DM-GG TAB SR 12HR 60-60-1200 MG<br />

pseudoephedrine w/ dm-gg tab sr 12hr 80-40-700 mg<br />

pseudoephedrine w/ dm-gg tab sr 12hr 80-40-780 mg<br />

pseudoephedrine w/ dm-gg tab sr 12hr 90-60-800 mg<br />

pseudoephedrine w/ hydrocodone soln 60-5 mg/5ml<br />

pseudoephedrine w/ hydrocodone soln 60-5 mg/5ml<br />

PSEUDOEPHEDRINE W/ HYDROCODONE SYRUP 15-3 MG/5ML<br />

PSEUDOEPHEDRINE W/ HYDROCODONE TAB 60-5 MG<br />

pseudoephedrine w/ hydrocodone-gg elixir 30-2.5-100 mg/5ml<br />

PSEUDOEPHEDRINE W/ HYDROCODONE-GG LIQD 15-2.5-100 MG/5ML<br />

pseudoephedrine w/ hydrocodone-gg liqd 15-3-100 mg/5ml<br />

PSEUDOEPHEDRINE W/ HYDROCODONE-GG LIQD 22.5-3.75-50 MG/5ML<br />

pseudoephedrine w/ hydrocodone-gg liqd 45-6-200 mg/5ml<br />

PSEUDOEPHEDRINE W/ HYDROCODONE-GG SOLN 30-2.5-100 MG/5ML<br />

pseudoephedrine w/ hydrocodone-gg soln 30-2.5-100 mg/5ml<br />

pseudoephedrine w/ hydrocodone-gg soln 60-5-200 mg/5ml<br />

pseudoephedrine w/ hydrocodone-gg syrup 15-3-100 mg/5ml<br />

pseudoephedrine-bromphen-codeine liq 10-1.3-6.3 mg/5ml<br />

PSEUDOEPHEDRINE-BROMPHEN-CODEINE LIQ 10-1.33-6.33 MG/5ML<br />

PSEUDOEPHEDRINE-BROMPHEN-CODEINE LIQD 30-2-7.5 MG/5ML<br />

PSEUDOEPHEDRINE-CHLOPHEDIANOL-GG LIQD 30-12.5-100 MG/5ML OTC<br />

PSEUDOEPHEDRINE-CHLOPHEDIANOL-GG TAB 30-12.5-200 MG OTC<br />

PSEUDOEPHEDRINE-CHLORPHEN W/ CODEINE LIQ 30-2-10 MG/5ML OTC<br />

PSEUDOEPHEDRINE-CHLORPHEN W/ CODEINE LIQ 30-2-10 MG/5ML<br />

pseudoephedrine-chlorphen w/ codeine liq 30-2-10 mg/5ml<br />

pseudoephedrine-chlorphen w/ codeine liq 30-2-10 mg/5ml OTC<br />

PSEUDOEPHEDRINE-CHLORPHEN W/CODEINE SUSP 3-0.2-1 MG/ML<br />

PSEUDOEPHEDRINE-CHLORPHEN W/CODEINE SUSP 3.333-0.222-1 MG/ML OTC<br />

PSEUDOEPHEDRINE-CHLORPHEN W/CODEINE SUSP 3.75-0.25-1 MG/ML OTC<br />

PSEUDOEPHEDRINE-CHLORPHEN W/CODEINE SUSP 4-0.266-1 MG/ML<br />

PSEUDOEPHEDRINE-CHLORPHEN W/CODEINE SUSP 4.286-0.286-1 MG/ML OTC<br />

PSEUDOEPHEDRINE-CHLORPHEN W/CODEINE SUSP 5-0.333-1 MG/ML OTC<br />

PSEUDOEPHEDRINE-CHLORPHEN W/CODEINE SUSP 6-0.4-1 MG/ML<br />

pseudoephedrine-cpm-hydrocodone-gg liqd 15-2-2.5-100 mg/5ml<br />

PSEUDOEPHEDRINE-CPM-HYDROCODONE-GG LIQD 30-2-2.5-100 MG/5ML<br />

PSEUDOEPHEDRINE-DEXBROMPHEN W/DM-GG LIQ 30-1-30-200 MG/10ML<br />

PSEUDOEPHEDRINE-DEXBROMPHEN-DM-GG LIQD 12.5-0.5-4-40 MG/ML<br />

PSEUDOEPHEDRINE-DIHYDROCODEINE-GG SYRUP 15-7.5-100 MG/5ML<br />

pseudoephedrine-dihydrocodeine-gg syrup 15-7.5-100 mg/5ml<br />

pseudoephedrine-dm elixir 20-10 mg/5ml OTC<br />

PSEUDOEPHEDRINE-DM LIQD 15-5 MG/5ML OTC<br />

pseudoephedrine-dm liqd 15-7.5 mg/5ml OTC<br />

PSEUDOEPHEDRINE-DM LIQD 20-10 MG/5ML OTC<br />

pseudoephedrine-dm liqd 20-10 mg/5ml OTC<br />

PSEUDOEPHEDRINE-DM LIQD 30-15 MG/5ML OTC<br />

PSEUDOEPHEDRINE-DM SOLN 7.5-2.5 MG/0.8ML OTC<br />

pseudoephedrine-dm soln 7.5-2.5 mg/0.8ml OTC<br />

PSEUDOEPHEDRINE-DM SYRUP 15-5 MG/5ML OTC<br />

PSEUDOEPHEDRINE-DM SYRUP 15-7.5 MG/5ML OTC<br />

pseudoephedrine-dm syrup 30-15 mg/5ml OTC<br />

pseudoephedrine-dm-gg w/ apap cap 30-10-100-250 mg OTC<br />

pseudoephedrine-dm-gg w/ apap liq 30-10-100-325 mg/15ml OTC<br />

PSEUDOEPHEDRINE-DM-GG W/ APAP PACKET 60-30-400-1000 MG OTC<br />

PSEUDOEPHEDRINE-DM-GG W/ APAP SYRUP 15-7.5-50-125 MG/5ML OTC<br />

pseudoephedrine-dm-gg w/ apap tab 30-15-200-325 mg OTC<br />

pseudoephedrine-dm-gg w/ apap tab 60-20-200-500 mg<br />

PSEUDOEPHEDRINE-DM-GG W/ APAP TAB 60-20-400-500 MG<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 116


PSEUDOEPHEDRINE-DM-GG W/ APAP TAB 60-30-600-500 MG<br />

PSEUDOEPHEDRINE-DM-GG-SOD CITRATE LIQD 30-10-25-200 MG/5ML<br />

PSEUDOEPHEDRINE-PYRILAMINE-CODEINE SYRUP 30-15-10 MG/5ML<br />

pseudovent tab dm<br />

pulexn dm syp 100-10/5<br />

pulmari sus<br />

pulmari-gp liq 20-100mg<br />

px daytime cap mult-sym OTC<br />

px daytime liq cold/flu OTC<br />

px daytime tab cold OTC<br />

px nighttime tab cold OTC<br />

px nitetime cap cold/flu OTC<br />

px nitetime cap mult-sym OTC<br />

px nitetime liq cold/flu OTC<br />

px nitetime liq cough OTC<br />

px severe tab cold OTC<br />

px tussin cf liq OTC<br />

px tussin dm liq 100-10/5 OTC<br />

pyril dm sus<br />

pyril mal/pe sus dm hbr<br />

PYRILAMINE-DM-GG-SODIUM CITRATE LIQD 10-10-25-200 MG/5ML<br />

PYRLEX CB SUS<br />

q-tapp dm elx OTC<br />

q-tussin cf syp cgh/cold OTC<br />

q-tussin dm syp 100-10/5 OTC<br />

q-v tussin syp<br />

qc cgh relf liq 15mg/5ml OTC<br />

qc cgh/cold tab OTC<br />

qc cold relf sus plus ms OTC<br />

qc cold/cgh pow daytime OTC<br />

qc cold/head tab daytime OTC<br />

qc cold/head tab nighttim OTC<br />

qc cough liq sore thr OTC<br />

qc cough liq sore thr OTC<br />

qc daytime cap cold/flu OTC<br />

qc daytime liq cold med OTC<br />

qc flu relf liq daytime OTC<br />

qc medifin tab dm OTC<br />

qc nighttime cap cold/flu OTC<br />

qc nighttime liq cold/flu OTC<br />

qc nighttime liq cough OTC<br />

qc tussin cf syp OTC<br />

quad tann sus<br />

quad tann tab<br />

quad-tuss sus tann/ped<br />

quadratuss sus ped<br />

quadratuss tab<br />

qual-tussin syp<br />

qual-tussin syp dc<br />

quala-hc syp<br />

quartuss syp<br />

quartuss dm dro<br />

quindal-hd syp<br />

quintex hc liq<br />

ra apap flu tab sev cold OTC<br />

ra childrens sus pls cold OTC<br />

ra chld cgh/ sus runny ns OTC<br />

ra cold/cgh elx dm OTC<br />

ra complete tab cold rel OTC<br />

ra cough/cld elx dm OTC<br />

ra day time liq cold/flu OTC<br />

ra daytime cap cold/flu OTC<br />

ra daytime liq cold/flu OTC<br />

ra flu tab max st OTC<br />

ra flu formu liq child OTC<br />

ra inf cold/ liq cough OTC<br />

ra night flu pow c/c ms OTC<br />

ra nite time cap cold/flu OTC<br />

ra nite time liq child OTC<br />

ra nite time liq cold OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 117


a nite time liq cold/flu OTC<br />

ra nite time liq cough OTC<br />

ra nitetime liq cold/flu OTC<br />

ra triacting liq night tm OTC<br />

ra tussin syp max st OTC<br />

ra tussin cf liq OTC<br />

ra tussin dm liq 100-10/5 OTC<br />

re all 12 sus<br />

re dcp dro<br />

recofen caps tab 15-200 OTC<br />

refenesen dm tab 400-20mg OTC<br />

RELACON LAX TAB 30-835MG<br />

relacon-dm liq nr<br />

RELACON-DM SYP<br />

relacon-hc liq nr<br />

RELACON-HC SYP<br />

relahist-dm dro<br />

relasin dm liq<br />

relasin-hc liq<br />

relasin-hcx liq<br />

relatuss hc syp<br />

relcof c sol<br />

reme hist dm liq<br />

reme tussin syp dm<br />

rentamine sus ped<br />

RESCON-DM SYP OTC<br />

RESPA C&C TAB<br />

RESPA C&C IR TAB<br />

RESPA DM TAB 28-600MG<br />

resperal syp<br />

RESPERAL-DM DRO 12-1-5MG<br />

RESPI-TANN CHW<br />

RESPI-TANN SUS<br />

RESPI-TANN SUS PD<br />

RESPI-TANN G SUS<br />

rest easy nt liq cough OTC<br />

ri-tussin dm syp 100-10/5 OTC<br />

RICOTUSS SUS<br />

ricotuss sus<br />

RICOTUSS SUS 10-8-60<br />

RICOTUSS TAB<br />

rindal hd liq 5-2-1.67<br />

rindal hd syp plus<br />

rindal hpd syp<br />

robafen ac syp 100-10/5 OTC<br />

robafen ac syp 100-10/5<br />

robafen cf syp OTC<br />

robafen cf syp cgh/cold OTC<br />

robafen cgh cap 15mg OTC<br />

robafen dm syp 100-10/5 OTC<br />

robafen dm syp 100-10/5 OTC<br />

robituss ped syp 7.5/5ml OTC<br />

robitussin cap cold/flu OTC<br />

ROBITUSSIN DRO PEDIATRC OTC<br />

robitussin liq cf OTC<br />

robitussin liq cf OTC<br />

ROBITUSSIN LIQ CGH/ALRG OTC<br />

robitussin liq cgh/cld OTC<br />

ROBITUSSIN LIQ CGH/CLD OTC<br />

robitussin liq cgh/cold OTC<br />

robitussin liq to go dm OTC<br />

ROBITUSSIN MIS DAY/NGHT OTC<br />

robitussin sus cold/flu OTC<br />

robitussin syp 10mg/5ml OTC<br />

robitussin syp 15mg/5ml OTC<br />

robitussin syp 7.5/5ml OTC<br />

robitussin syp alrg/cgh OTC<br />

robitussin syp flu OTC<br />

robitussin syp max st OTC<br />

ROBITUSSIN SYP NGHT REL OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 118


ROBITUSSIN D LIQ CGH/COLD OTC<br />

romilar ac sol 100-10/5<br />

rondex-dm dro<br />

rondex-dm syp<br />

RU-TUSS DM SYP<br />

RU-TUSS DM TAB 60-800MG<br />

RYDEX LIQ<br />

RYNATUSS TAB<br />

S-T FORTE 2 LIQ SF<br />

safe tussin liq 30 OTC<br />

SAFETUSSIN LIQ CD OTC<br />

sb cgh contr cap 15mg OTC<br />

sb cgh contr liq cf OTC<br />

sb cgh relf liq 15mg/5ml OTC<br />

sb childrens liq nite tim OTC<br />

sb childrens sus pls cold OTC<br />

sb chld cgh/ sus runny ns OTC<br />

sb cold head tab congest OTC<br />

sb cold med tab OTC<br />

sb cold med tab no drows OTC<br />

sb cold mult pak day/nght OTC<br />

sb cold mult tab symp sev OTC<br />

sb cold/cgh elx dm child OTC<br />

sb cold/cgh tab hbp OTC<br />

sb day time cap cold/flu OTC<br />

sb daytime liq OTC<br />

sb flu hbp tab max st OTC<br />

sb flu relf liq daytime OTC<br />

sb flu/cold/ pak cough OTC<br />

sb nightime liq OTC<br />

sb nightime liq cherry OTC<br />

sb nighttme liq cough OTC<br />

SCOT-TUSSIN LIQ DIBTS/CF OTC<br />

scot-tussin liq dm sf OTC<br />

SCOT-TUSSIN LIQ SENIOR OTC<br />

SCOT-TUSSIN LOZ DM OTC<br />

severe cold tab OTC<br />

severe cold tab OTC<br />

severe cold tab OTC<br />

severe cold tab /congest OTC<br />

severe cold tab caplets OTC<br />

severe cold tab cold/flu OTC<br />

severe cold tab cold/flu OTC<br />

severe cold tab congesti OTC<br />

severe cold tab max str OTC<br />

severe cold tab non-asa OTC<br />

sg ex-prin chw chld/cld OTC<br />

sg exprin syp cold/cgh OTC<br />

sg flu/cold/ pow cough OTC<br />

sg night flu pow c/c ms OTC<br />

sg nighttime liq children OTC<br />

sg nighttime liq cold/flu OTC<br />

sg pedia rel liq cgh/cold OTC<br />

sg tussin dm syp 100-10/5 OTC<br />

sg tussin dm syp clear OTC<br />

sildec dm dro<br />

sildec dm syp<br />

sildec pe-dm dro<br />

sildec pe-dm syp<br />

silphen dm syp 10mg/5ml OTC<br />

siltussin dm liq das OTC<br />

siltussin-dm liq diabetic OTC<br />

siltussin-dm liq max st OTC<br />

siltussin-dm syp alc free OTC<br />

simply cough syp 5mg/5ml OTC<br />

simuc-dm sol<br />

simuc-hd sol<br />

SINUTUSS DM TAB<br />

sm cgh/cold cap multisym OTC<br />

sm childrens sus ms cold OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 119


sm cold head tab cong dt OTC<br />

sm cold head tab congest OTC<br />

sm cold/cgh elx dm child OTC<br />

sm cough liq sore thr OTC<br />

sm cough liq sore thr OTC<br />

sm cough/run liq nose chl OTC<br />

sm day time cap cold/flu OTC<br />

sm day time cap pe OTC<br />

sm day time liq cold/flu OTC<br />

sm flu/cold/ pow cough OTC<br />

sm nite time cap cold/flu OTC<br />

sm nite time cap cold/flu OTC<br />

sm nite time liq cold/flu OTC<br />

sm nite time liq cough OTC<br />

sm non asa tab cold OTC<br />

sm non-asa tab flu OTC<br />

sm tussin cap cgh/cold OTC<br />

sm tussin syp cgh/cold OTC<br />

sm tussin syp dm clear OTC<br />

sm tussin cf liq OTC<br />

sm tussin dm syp 100-10/5 OTC<br />

soba night t cap cold/fl OTC<br />

soba pain re chw cold/cgh OTC<br />

soba pedia liq relief OTC<br />

soba tussin liq cgh-cold OTC<br />

SOLOTUSS SUS 30MG/5ML<br />

sonahist dm dro<br />

SORBUTUSS LIQ<br />

sorbutuss liq 100-10/5 OTC<br />

SORBUTUSS NR LIQ OTC<br />

st joseph co syp 7.5/5ml OTC<br />

STATUSS LIQ GREEN<br />

statuss dm syp<br />

su-phedrin cap cgh/cold OTC<br />

su-tuss dm elx 200-20/5<br />

su-tuss hd elx<br />

SUCRETS DM LOZ 10MG OTC<br />

SUDAFED CHLD LIQ CLD&CGH OTC<br />

SUDAFED PE PAK COLD OTC<br />

sudafed pe sol cold/cgh OTC<br />

SUDAFED PE TAB CLD/CGH OTC<br />

sudatex-dm tab<br />

sudatuss dm syp OTC<br />

sudatuss dm syp<br />

sudatuss-2 sol<br />

sudatuss-2 sol df<br />

sudatuss-sf sol<br />

super tussin liq 100-10/5 OTC<br />

super tussin liq pediatri OTC<br />

supertussin syp dm OTC<br />

suphedrin cap cold/cgh OTC<br />

suphedrin tab sev cold OTC<br />

suphedrine tab cold/flu OTC<br />

supress-dx dro pediatrc<br />

sutan-dm sus<br />

SYMPAK DM MIS<br />

SYMTAN SUS<br />

SYMTAN A SUS<br />

T-TANNA DM SUS<br />

tana dm sus<br />

tana t-12 sus 4-30mg/5<br />

tanacof-dm sus<br />

TANAFED DMX SUS<br />

tanatuss sus<br />

tannate sus pd-dm<br />

tannate 12 s sus<br />

tannate dmp- sus dex<br />

tannate-12 sus<br />

tannate-12d sus s<br />

tannate-v-dm sus<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 120


tannic-12 sus<br />

tannic-12 tab 5-60mg<br />

tannic-12 s sus 4-30mg/5<br />

tannihist-12 sus 4-30mg/5<br />

tannihist-12 sus d<br />

tenar dm liq<br />

tetra tann sus ped<br />

tgt cold tab head con OTC<br />

tgt cold rel tab multi-sy OTC<br />

tgt cold/flu liq day time OTC<br />

tgt cold/flu liq day-time OTC<br />

tgt cold/flu liq night OTC<br />

tgt cold/flu liq night OTC<br />

tgt cough liq form dm OTC<br />

tgt ms cold sus child OTC<br />

theracaps tab OTC<br />

THERACOF PLS LIQ CGH/COLD OTC<br />

THERAFLU MIS COUGH OTC<br />

THERAFLU PAK COLD/CGH OTC<br />

THERAFLU POW OTC<br />

theraflu pow fl/cd/co OTC<br />

THERAFLU CLD MIS CGH DAY OTC<br />

theraflu dt liq warm rlf OTC<br />

theraflu flu pow /congest OTC<br />

theraflu ms tab non-drow OTC<br />

THERAFLU NIT POW MAX STR OTC<br />

theraflu nit tab max str OTC<br />

theraflu sev tab cold dt OTC<br />

theraflu sev tab cold nt OTC<br />

theraflu sev tab cold/cgh OTC<br />

thor syp cou/col OTC<br />

tidafen dm tab<br />

tl-dex dm liq<br />

tl-hist cd liq<br />

tl-hist cm liq<br />

tl-hist dm liq<br />

tolu-sed dm liq 100-10/5 OTC<br />

TOURO CC TAB<br />

TOURO CC-LD TAB<br />

TOURO DM TAB 30-575MG<br />

TOURO HC TAB<br />

trexbrom liq<br />

tri-fed x sus<br />

tri-vent dm syp<br />

tri-vent dpc syp 6-2-15/5<br />

tri-vent hc liq<br />

triacing cld liq cgh/chld OTC<br />

triactin cld liq /cough OTC<br />

triacting liq cgh/cold OTC<br />

triacting liq cgh/run OTC<br />

triacting liq cgh/run OTC<br />

TRIACTING LIQ CGH/SORE OTC<br />

triacting liq children OTC<br />

triacting liq children OTC<br />

triacting liq children OTC<br />

triacting liq cold/cgh OTC<br />

triacting liq cold/cgh OTC<br />

triacting liq cold/cgh OTC<br />

triacting liq night OTC<br />

triacting liq nite tim OTC<br />

triacting liq sore thr OTC<br />

triacting liq sore thr OTC<br />

triacting liq sore thr OTC<br />

triacting liq sore thr OTC<br />

triacting liq sore thr OTC<br />

triacting liq sore thr OTC<br />

triacting co liq 15-1-5mg OTC<br />

triacting dt liq cold/cgh OTC<br />

triacting dt liq cold/cgh OTC<br />

TRIAMIN FLU/ SYP CGH/FVR OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 121


TRIAMINIC CHW OTC<br />

TRIAMINIC CHW OTC<br />

triaminic liq OTC<br />

TRIAMINIC LIQ OTC<br />

triaminic liq OTC<br />

triaminic liq OTC<br />

triaminic liq cgh/nasl OTC<br />

triaminic liq night tm OTC<br />

TRIAMINIC MIS COLD/CGH OTC<br />

TRIAMINIC MIS COUGH OTC<br />

TRIAMINIC MIS INFANT OTC<br />

TRIAMINIC SOL COLD/CGH OTC<br />

TRIAMINIC SYP CGH/SORE OTC<br />

triaminic syp cough OTC<br />

TRIAMINIC SYP FEVER OTC<br />

triaminic am liq cgh/dec OTC<br />

TRIAMINIC CO SYP 15-5MG/5 OTC<br />

triaminic dt liq cold/cgh OTC<br />

TRIAMINIC-D SYP OTC<br />

TRICODENE SF SYP OTC<br />

tricof syp<br />

tricof exp syp<br />

tricof pd syp<br />

tricold pedi dro<br />

TRIDAL SYP<br />

tridal hd syp<br />

tridal hd syp plus<br />

TRIKOF-D TAB 12HR SR<br />

trionate sus 4-30mg/5<br />

trionate nf tab 5-60mg<br />

triplex dm liq<br />

TRISPEC DMX DRO PEDIATRC<br />

TRISPEC DMX LIQ<br />

TRISPEC PSE DRO PEDIATRC<br />

TRISPEC PSE LIQ<br />

trital dm liq<br />

TROCAL COUGH LOZ 7.5MG OTC<br />

tusana-d liq<br />

TUSDEC-DM LIQ<br />

TUSDEC-HC LIQ<br />

TUSNEL LIQ OTC<br />

TUSNEL LIQ<br />

tusnel c syp<br />

tusnel diabt liq 10-100/5 OTC<br />

TUSNEL PED-C SYP<br />

TUSNEL PEDI LIQ<br />

tusnel-a liq OTC<br />

TUSNEL-DM LIQ PEDI DRO<br />

TUSNEL-HC LIQ<br />

tusnel-hc liq<br />

TUSS-DA NR LIQ<br />

tuss-pv syp<br />

tussadur-hd sol<br />

TUSSAFED LIQ<br />

tussafed syp<br />

tussafed ex liq<br />

tussafed hc syp<br />

tussafed-la tab<br />

tusscough syp dhc<br />

tusscough hc syp<br />

TUSSI PRES-B LIQ OTC<br />

TUSSI-12 TAB 5-60MG<br />

TUSSI-12D TAB 10-40-60<br />

TUSSI-12D S SUS<br />

tussi-bid tab<br />

tussi-organi liq nr dm<br />

TUSSI-PRES LIQ PEDIATRC<br />

TUSSICAPS CAP 10-8MG<br />

TUSSICAPS CAP 5-4MG<br />

tussiclr dh syp 3.5-100<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 122


tussiden c liq 300-10mg<br />

tussiden dm liq 10-300mg<br />

TUSSIGON TAB 5MG<br />

tussin cap cgh/cold OTC<br />

tussin cap cold/cgh OTC<br />

tussin cf liq OTC<br />

tussin cf liq OTC<br />

tussin cf liq cgh/cld OTC<br />

tussin cf liq cgh/cold OTC<br />

tussin cf liq super OTC<br />

tussin cf syp OTC<br />

tussin cg/cd syp max st OTC<br />

TUSSIN CHILD SYP CGH/COLD OTC<br />

tussin cold cap cough OTC<br />

tussin cold/ cap congesti OTC<br />

tussin cold/ cap cough OTC<br />

tussin cough cap 15mg OTC<br />

tussin cough liq 10-100/5 OTC<br />

TUSSIN COUGH LIQ COLD OTC<br />

tussin cough liq congesti OTC<br />

tussin cough syp 15mg/5ml OTC<br />

tussin dm liq OTC<br />

tussin dm liq 100-10/5 OTC<br />

tussin dm liq 100-10/5 OTC<br />

tussin dm liq 100-10/5 OTC<br />

tussin dm liq clear OTC<br />

tussin dm liq max OTC<br />

tussin dm syp 100-10/5 OTC<br />

tussin dm syp 100-10/5 OTC<br />

tussin dm syp 100-10/5 OTC<br />

tussin dm syp 100-10/5 OTC<br />

tussin dm syp 100-10/5 OTC<br />

tussin dm syp clear OTC<br />

tussin max syp 15mg/5ml OTC<br />

tussin ped liq cgh/cold OTC<br />

tussin ped liq cgh/cold OTC<br />

tussin ped liq cgh/cold OTC<br />

tussin-dm syp 100-15/5 OTC<br />

tussin-v syp<br />

TUSSINAL 12 SUS<br />

TUSSIONEX SUS EXT-REL<br />

TUSSIREX SYP W/COD<br />

TUSSIREX-SF LIQ W/COD<br />

tussitab tab 1200-60m<br />

tussizone-12 sus 4-30mg/5<br />

tussizone-12 tab 5-60mg<br />

TUSSO-DF SYP 2.5-100<br />

TUSSO-DM TAB<br />

TUSSO-DMR CAP 7-14-288<br />

TUSSO-HC TAB<br />

TUSSO-XR SUS<br />

TUSSO-ZMR CAP 8-200MG<br />

TUSSO-ZR SYP 7.5-150<br />

tussplex syp<br />

tussplex dm syp<br />

tustan 12s sus<br />

tylenol cgh liq sore thr OTC<br />

TYLENOL CGH PAK SORE THR OTC<br />

TYLENOL COLD LIQ & FLU OTC<br />

TYLENOL COLD LIQ MULTI-S OTC<br />

TYLENOL COLD LIQ MULTI-SY OTC<br />

tylenol cold pak head con OTC<br />

tylenol cold pak multi-s OTC<br />

tylenol cold tab head con OTC<br />

tylenol cold tab multi rr OTC<br />

tylenol cold tab multi-s OTC<br />

TYLENOL FLU PAK DAY/NIGH OTC<br />

tylenol flu tab no-drow OTC<br />

TYLENOL INF DRO COLD/CGH OTC<br />

tylenol inf dro cold/cgh OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 123


tylenol nite liq cold/flu OTC<br />

ultratuss 12 sus s<br />

uni all 12 sus<br />

uni-cof syp<br />

uni-cof exp syp<br />

uni-hist pdx dro<br />

uni-hist pdx syp<br />

uni-tann cs sus<br />

v-cof sus<br />

VANACOF LIQ OTC<br />

VANACOF CD LIQ<br />

VANACOF DX LIQ OTC<br />

vanacon sol<br />

VANATAB DX TAB OTC<br />

VAZOTUSS HC SUS<br />

vi-q-tuss syp 5-100/5<br />

vick dayquil cap cold/flu OTC<br />

vick dayquil liq cold/flu OTC<br />

vicks liq dayquil OTC<br />

VICKS 44 LIQ CGH RELF OTC<br />

VICKS 44D LIQ COUGH OTC<br />

VICKS 44E SYP COUGH OTC<br />

VICKS 44E SYP PEDIATRI OTC<br />

VICKS 44M LIQ MULTI-SY OTC<br />

VICKS 44M LIQ PEDIATRI OTC<br />

VICKS DAYQUI LIQ COUGH OTC<br />

VICKS FORM SYP 44M PED OTC<br />

vicks nyquil cap cold/flu OTC<br />

VICKS NYQUIL LIQ CHILDREN OTC<br />

vicks nyquil liq cold/flu OTC<br />

vicoclear syp 5-100/5<br />

VIRATAN-DM CHW 25-30-25<br />

viratan-dm sus<br />

VIRAVAN-PDM SUS 15-15-15<br />

visvex hc liq<br />

vita-numonyl liq ad<br />

vita-numonyl liq nr<br />

vita-numonyl liq ped<br />

VITA-NUMONYL SOL DM<br />

vitussin syp 5-100/5<br />

wal-tap dm elx cold/cgh OTC<br />

wal-tap dm elx cold/cgh OTC<br />

wal-tussin cap cold OTC<br />

wal-tussin cap cough OTC<br />

wal-tussin liq cf OTC<br />

wal-tussin liq cgh/cld OTC<br />

wal-tussin liq cgh/cold OTC<br />

wal-tussin liq dm OTC<br />

wal-tussin syp 15mg/5ml OTC<br />

wal-tussin syp cgh/cold OTC<br />

wal-tussin syp dm clear OTC<br />

welltuss exp syp<br />

welltuss hc liq<br />

x-hist dm dro<br />

XIRATUSS TAB<br />

xiratuss tab<br />

XPECT-AT TAB<br />

XPECT-HC TAB 5-600MG<br />

Y-COF DM TAB<br />

Z-COF 12DM SUS<br />

Z-COF DMX LIQ<br />

z-dex dro<br />

z-dex syp<br />

z-dex 12d tab<br />

Z-TUSS 2 LIQ EXPECT<br />

Z-TUSS AC LIQ 2-9/5ML<br />

z-tuss dm liq<br />

zhist liq expect<br />

ZINX COLD KIT<br />

ZINX COUGH KIT<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 124


ZODRYL AC 25 SUS OTC<br />

ZODRYL AC 30 SUS OTC<br />

ZODRYL AC 35 SUS OTC<br />

ZODRYL AC 40 SUS OTC<br />

ZODRYL AC 50 SUS<br />

ZODRYL AC 60 SUS<br />

ZODRYL AC 80 SUS<br />

ZODRYL DAC SUS 25 OTC<br />

ZODRYL DAC SUS 30 OTC<br />

ZODRYL DAC SUS 35 OTC<br />

ZODRYL DAC SUS 40 OTC<br />

ZODRYL DAC SUS 50<br />

ZODRYL DAC SUS 60<br />

ZODRYL DAC SUS 80<br />

ZODRYL DEC25 SUS OTC<br />

ZODRYL DEC30 SUS OTC<br />

ZODRYL DEC35 SUS OTC<br />

ZODRYL DEC40 SUS OTC<br />

ZODRYL DEC50 SUS<br />

ZODRYL DEC60 SUS<br />

ZODRYL DEC80 SUS<br />

ZONATUSS CAP 150MG<br />

ZOTEX HC SYP<br />

zotex-12 sus<br />

zotex-12d tab<br />

ZOTEX-C SYP<br />

ZOTEX-D SYP<br />

ZOTEX-DM SYP<br />

ZOTEX-DMX TAB<br />

ZOTEX-EX TAB<br />

ZOTEX-G SYP<br />

ZOTEX-LA TAB<br />

ZYMINE HC LIQ<br />

zyrphen-hc liq<br />

Anti-inflammatory Agents<br />

Leukotriene Modifiers<br />

ACCOLATE TAB 10MG NF<br />

ACCOLATE TAB 20MG NF<br />

MONTELUKAST SODIUM CHEW TAB 4 MG (BASE EQUIV)<br />

MONTELUKAST SODIUM CHEW TAB 5 MG (BASE EQUIV)<br />

MONTELUKAST SODIUM ORAL GRANULES PACKET 4 MG (BASE EQUIV)<br />

MONTELUKAST SODIUM TAB 10 MG (BASE EQUIV)<br />

SINGULAIR CHW 4MG<br />

SINGULAIR CHW 5MG<br />

SINGULAIR GRA 4MG<br />

SINGULAIR TAB 10MG<br />

ZAFIRLUKAST TAB 10 MG NF<br />

ZAFIRLUKAST TAB 20 MG NF<br />

Mast-cell Stabilizers<br />

cromolyn sod neb 20mg/2ml<br />

CROMOLYN SODIUM INHAL AEROSOL SOLN 800 MCG/ACT (1 MG/VALVE)<br />

cromolyn sodium soln nebu 20 mg/2ml<br />

INTAL 112 AER 800MCG<br />

INTAL 200 AER 800MCG<br />

INTAL INH AER 800MCG<br />

NEDOCROMIL SODIUM INHAL AEROSOL 1.75 MG/ACT<br />

TILADE AER 1.75/ACT<br />

Expectorants<br />

*PE-GUAIFENESIN TAB SR 12H 30-1000 MG & HOMEOPATH LOZ KIT***<br />

10peh/380gfn tab OTC<br />

45pse/400gfn tab OTC<br />

a-tan 12x sus<br />

aber-fed tab 60-500mg<br />

ACETAMINOPHEN-GUAIFENESIN LIQUID 500-200 MG/15ML OTC<br />

ACETAMINOPHEN-GUAIFENESIN POWDER PACK 1000-400 MG OTC<br />

acetaminophen-guaifenesin tab 325-200 mg OTC<br />

acetaminophen-guaifenesin tab 650-400 mg OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 125


af-pseudoeph cap non-drsy OTC<br />

ALBATUSSIN DRO EX PED<br />

ALBATUSSIN INJ NN<br />

ALBATUSSIN TAB SR F<br />

ALBATUSSIN S TAB<br />

ALBATUSSN CF DRO PED<br />

ALBATUSSN CF LIQ<br />

ALLFEN A TAB 400-4MG<br />

altarussin syp -pe OTC<br />

altarussin syp 100/5ml OTC<br />

altex-pse tab 120-600<br />

ambi 10peh/ tab 400gfn OTC<br />

ambi 40/1000 tab<br />

ambi 40pse/ tab 400gfn<br />

ambi 45/800 tab<br />

ambi 60/1000 tab<br />

ambi 60/580 tab<br />

ambi 60pse/ tab 400gfn<br />

ambi 80/700 tab<br />

ambi 80/780 tab<br />

AMBIFED TAB OTC<br />

AMBIFED-G TAB 20-400MG OTC<br />

ami-tex la tab 30-600mg<br />

amidal tab<br />

amitex pse tab 120-600<br />

AQUATAB D TAB<br />

asthma tab relief OTC<br />

BABEE COF SYP OTC<br />

bidex tab 400mg OTC<br />

biotuss pe syp 30-100/5 OTC<br />

bl triacting syp chst con OTC<br />

BROMPHENIRAMINE W/ DM-GG CAP 2-15-200 MG<br />

BROMPHENIRAMINE W/ DM-GG LIQUID 1-15-25 MG/5ML<br />

BROMPHENIRAMINE W/ DM-GG LIQUID 2-15-200 MG/5ML<br />

BRONCHOLATE SYP 6.25-100<br />

BRONKAID TAB 25-400MG OTC<br />

buckleys liq chest OTC<br />

CCP CAFFEINE TAB FREE OTC<br />

centex-pse tab 600-120<br />

cgh control syp pe OTC<br />

chest conges liq child OTC<br />

chest conges tab 400mg OTC<br />

chest conges tab daytime OTC<br />

chest conges tab relief OTC<br />

chest conges tab relief d OTC<br />

chest congst tab rlf pe OTC<br />

chest congst tab rlf pe OTC<br />

chest/nasal syp congest OTC<br />

chest/sinus tab relief OTC<br />

chest/sinus tab relief OTC<br />

chst congest tab pain rel OTC<br />

chst congest tab pain/sns OTC<br />

COCILLANA-TERPIN HYDRATE SYRUP OTC<br />

cold & cough liq formula OTC<br />

coldmist jr tab 12hr<br />

coldmist la tab 12hr<br />

comtrex deep tab chst cld OTC<br />

CONPEC SOL<br />

conpec la nr tab 15-600mg<br />

cough syp 100/5ml OTC<br />

coughtab tab 200mg OTC<br />

crantex syp 7.5/100<br />

crantex la tab 30-600mg<br />

cvs non-dryi cap 30-200mg OTC<br />

cvs tussin syp 100/5ml OTC<br />

cvs tussin syp pe OTC<br />

d-feda ii tab 60-600cr<br />

d-phen 1000 tab<br />

d-tab tab 40-1200<br />

DECON-G DRO 2-1-40MG<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 126


DECONEX CAP 10-390MG OTC<br />

decongest ii tab 60-600cr<br />

deconsal ii tab 25-275mg<br />

DECOREL FORT TAB OTC<br />

despec liq OTC<br />

DESPEC SR TAB<br />

despec-tab tab 40-400mg OTC<br />

diabetic tus liq 100/5ml OTC<br />

DIABETIC TUS LIQ 200MG/5 OTC<br />

diabtc tussn syp 100/5ml OTC<br />

donatussin dro<br />

duomax tab 40-1200<br />

DURATUSS A TAB<br />

DURATUSS PE TAB 30-1050<br />

DYNEX TAB 90-1200<br />

eck tussin cap sev cong OTC<br />

eck tussin syp pe OTC<br />

ENTEX ER CAP 10-300MG<br />

entex la tab<br />

entex pse tab 50-525mg<br />

EPHEDRINE-GUAIFENESIN SYRUP 6.25-100 MG/5ML<br />

ephedrine-guaifenesin tab 12.5-200 mg OTC<br />

EPHEDRINE-GUAIFENESIN TAB 25-400 MG OTC<br />

eq non-dry cap sinus OTC<br />

eq tussin liq 100/5ml OTC<br />

eql chest tab congest OTC<br />

eql non-dryi cap 30-200mg OTC<br />

eql tussin syp 100/5ml OTC<br />

EUCALYPTOL INJ 75 MG/ML<br />

exefen tab 80-780mg<br />

exefen-ir tab 60-400mg<br />

exefen-pd tab 10-600mg<br />

exetuss tab 25-900mg<br />

exetuss-gp tab 25-1200<br />

exp cough ct syp 100/5ml OTC<br />

extendryl g tab<br />

fenesin ir tab 400mg OTC<br />

fenesin pe tab 10-400mg OTC<br />

g p tex tab<br />

g-fen ex tab 400mg OTC<br />

g-phed cap sr<br />

g-phed-pd cap 60-300sr<br />

G/P TAB 1200-75<br />

g/p 1200/60 tab<br />

ganidin nr liq 100/5ml<br />

gen entex la cap 30-400mg<br />

GENEXA LA CAP 30-400MG<br />

GENTEX LA TAB<br />

geri-tussin syp 100/5ml OTC<br />

gfn 1200/ tab pse 50<br />

gfn/pse tab 1200/120<br />

gfn1200/pe40 tab<br />

GFN550/PSE60 TAB<br />

gfn595/pse48 tab<br />

gfn600/pe20 tab<br />

gfn600/pe40 tab<br />

gfn795/pse85 tab<br />

gfn800/pe25 tab<br />

GFN800/PSE60 TAB<br />

gg 200 nr tab 200mg OTC<br />

gg-pe tab 900-30mg<br />

gg-psed sr tab 12hr<br />

gg/pe syp<br />

gg/pe tab 1200-25<br />

gg/pe tab 400-10mg OTC<br />

gg/pe tab 600-20mg<br />

gg/pe tab 900-25mg<br />

gg/phenylep liq<br />

gg/phenylep syp<br />

gg/phenylep tab 1200-40<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 127


gg/phenylep tab 40-1200<br />

gg/phenylep tab 600-30mg<br />

gg/pse syp 30-100/5 OTC<br />

gg/pse tab 1200/120<br />

gg/pse tab 80/800mg<br />

gg/pse cr cap 300-60mg<br />

gg/pse cr tab 600-120<br />

gg/pse cr tab 600-60mg<br />

gg/pse er tab 600-120<br />

gg/pse sr tab 12hr<br />

GILPHEX TR TAB 10-388MG<br />

GILPHEX TR TAB 12HR<br />

gnp triactin syp chst con OTC<br />

gnp tussin syp 100/5ml OTC<br />

gp-1200 tab 40-1200<br />

gripex pe dro ped<br />

guaiasorb syp 100/5ml OTC<br />

guaif/phenyl tab 600-40mg<br />

guaife/pseud tab<br />

GUAIFED SYP OTC<br />

guaifen pe tab<br />

guaifen pse tab 600-120<br />

guaifen/pse syp 30-100/5 OTC<br />

guaifen/pse tab 600-120<br />

guaifenesin liq nr<br />

guaifenesin sol 100/5ml OTC<br />

guaifenesin syp 100/5ml OTC<br />

guaifenesin tab 200mg<br />

guaifenesin tab 200mg OTC<br />

guaifenesin tab 400mg OTC<br />

guaifenesin tab 600mg cr<br />

GUAIFENESIN GRANULES PACKET 100 MG OTC<br />

GUAIFENESIN GRANULES PACKET 50 MG OTC<br />

guaifenesin liquid 100 mg/5ml OTC<br />

guaifenesin liquid 100 mg/5ml<br />

GUAIFENESIN LIQUID 100 MG/6.25ML OTC<br />

GUAIFENESIN LIQUID 200 MG/5ML OTC<br />

GUAIFENESIN LIQUID 250 MG/5ML (50 MG/ML)<br />

GUAIFENESIN SOLN 250 MG/5ML (50 MG/ML)<br />

GUAIFENESIN SOLN 50 MG/5ML OTC<br />

guaifenesin syrup 100 mg/5ml OTC<br />

guaifenesin tab 200 mg<br />

guaifenesin tab 200 mg OTC<br />

guaifenesin tab 400 mg OTC<br />

GUAIFENESIN TAB SR 12HR 1200 MG OTC<br />

guaifenesin tab sr 12hr 1200 mg OTC<br />

guaifenesin tab sr 12hr 600 mg<br />

GUAIFENESIN TAB SR 12HR 600 MG OTC<br />

GUAIFENESIN TAB SR 12HR 675 MG<br />

GUAIFENESIN-CHLORPHENIRAMINE MALEATE TAB 400-4 MG<br />

guaifenesin/ tab pse sa<br />

guaifenex tab pse 120<br />

guaifenex tab pse 60<br />

guaifenex tab pse 85<br />

guaifenex gp tab 120/1200<br />

guaifenex ps tab 80-800mg<br />

GUAIMAX-D TAB 120-600<br />

guaimist s syp 40-200/5<br />

guaiphen-d tab<br />

guaiphen-d tab 1200<br />

guaiphen-pd tab<br />

guapetex syp 7.5/100<br />

GUAPHENYL II CAP 20-375MG<br />

guaphenyl la cap 30-400mg<br />

guiadex pd tab 10-600mg<br />

guiatex pe syp<br />

guiatuss syp 100/5ml OTC<br />

guiatuss pe syp 30-100/5 OTC<br />

H 9600 SR TAB 90-600MG<br />

hca expector tab 200mg OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 128


hca non-dry cap sinus OTC<br />

hca tussin syp expect OTC<br />

hca tussin syp pe OTC<br />

HUMIBID TAB 1200MG OTC<br />

humibid tab 1200mg OTC<br />

iophen-nr liq 100/5ml<br />

iosal ii tab 60-600cr<br />

iotex pse tab 120-600<br />

J-MAX TAB<br />

KGS-PE LIQ 5MG-75MG<br />

LEMOHIST CAP PLUS<br />

LEV/PSE/GG CAP 90-400MG<br />

liquibid tab 400mg OTC<br />

liquibid d-r tab 10-400mg OTC<br />

LIQUIBID-D TAB 40-1200<br />

LIQUIBID-D TAB 40-650MG<br />

LIQUIBID-PD TAB<br />

lusair liq<br />

LUSONEX PLUS TAB<br />

MARDROPS-EX LIQ OTC<br />

maxifed tab 60-400mg<br />

maxiphen tab 10-400mg<br />

MAXIPHEN-G TAB<br />

medent-ldi tab 60-400mg OTC<br />

MEDENT-PE TAB 12.5-600<br />

medent-pei tab 10-400mg OTC<br />

medi-tussin cap sev cong OTC<br />

medi-tussin syp 100/5ml OTC<br />

medi-tussin syp pe OTC<br />

miraphen pse tab 120-600<br />

montephen tab 25-600mg<br />

mp tussin pe syp 30-100/5 OTC<br />

MUCINEX TAB 1200MG OTC<br />

MUCINEX TAB 600MG ER OTC<br />

MUCINEX CHLD GRA 50MG OTC<br />

mucinex chld liq 100/5ml OTC<br />

MUCINEX D TAB 120-1200 OTC<br />

MUCINEX D TAB 60-600MG<br />

MUCINEX D TAB 60-600MG OTC<br />

MUCINEX JR GRA 100MG OTC<br />

MUCINEX/KIDS GRA 100MG OTC<br />

MUCINEX/KIDS GRA 50MG OTC<br />

mucinex/kids liq 100/5ml OTC<br />

mucosa tab 400mg OTC<br />

mucus relief liq 100/5ml OTC<br />

mucus relief liq 400/20ml OTC<br />

mucus relief liq 400/20ml OTC<br />

mucus relief tab 400mg OTC<br />

mucus relief tab d OTC<br />

mucus relief tab multi OTC<br />

mucus relief tab pe OTC<br />

mucus relief tab pe OTC<br />

mucusrelief tab sinus OTC<br />

mydex tab 30-900mg<br />

mydocs tab 20-600mg<br />

NALDECON SYP SENIOR PA OTC<br />

nasal decon cap 30-200mg OTC<br />

NASATAB LA TAB<br />

nasex tab 25-650mg<br />

nasex-g tab 25-835mg<br />

nazarin liq<br />

nescon-pd tab 25-275mg<br />

nexphen pd cap 7.5-200<br />

nomuc-pe cap<br />

non-drying cap sinus OTC<br />

NOREL EX TAB 40-800MG<br />

NUMOBID TAB 675MG<br />

numonyl liq<br />

numonyl ped dro<br />

numonyl sr tab 15-600mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 129


organ-i nr tab 200mg<br />

organidin nr tab 200mg<br />

p chlor gg sol drops<br />

pe-guai dro 1.5-20mg<br />

pe/gg tab 15-600mg<br />

pe/gg tab 20-600mg<br />

pe/gg tab 25-900<br />

pe/gg tab 30-1200<br />

pe/gg la tab 20-600mg<br />

pe/guai tab 30-1200<br />

pe/guai tab 30-900mg<br />

pe/guaifenes dro 1.5-20mg<br />

pendex tab 10-600mg<br />

PHANASIN LIQ 50MG/ML<br />

phanasin syp 100/5ml OTC<br />

pharmasin syp 100/5ml OTC<br />

phenavent cap 15-400mg<br />

phenavent d tab 40-1200<br />

phenavent la cap 30-400mg<br />

phenavent pe cap 7.5-200<br />

phenydex dro pediatri<br />

phenyleph tan-pyrilamine tan-guaifenesin sus 5-30-100 mg/5ml<br />

PHENYLEPH TAN-PYRILAMINE TAN-GUAIFENESIN SUS 5-30-100 MG/5ML<br />

PHENYLEPH TAN-PYRILAMINE TAN-GUAIFENESIN TAB 25-60-200 MG<br />

phenyleph-diphenhyd-gg w/ apap liqd 5-25-200-325 mg/10ml OTC<br />

PHENYLEPHRINE TANNATE-GUAIFENESIN SUSP 5-100 MG/5ML<br />

PHENYLEPHRINE TANNATE-GUAIFENESIN TAB 25-200 MG<br />

PHENYLEPHRINE W/ DM-POT GUAIACOLSULF LIQD 5-10-75 MG/5ML<br />

PHENYLEPHRINE W/ DM-POT GUAIACOLSULF SOLN 1-2-15 MG/ML<br />

PHENYLEPHRINE W/ DM-POT GUAIACOLSULF TAB SR 12H 15-30-600 MG<br />

PHENYLEPHRINE W/ DM-POT GUAIACOLSULF TAB SR 12H 30-50-600 MG<br />

PHENYLEPHRINE-APAP-GG LIQD 5-325-200 MG/15ML OTC<br />

PHENYLEPHRINE-APAP-GG TAB 10-325-200 MG OTC<br />

phenylephrine-apap-gg tab 10-650-400 mg OTC<br />

phenylephrine-apap-gg tab 5-325-200 mg OTC<br />

PHENYLEPHRINE-APAP-GG TAB CR 20-650-600 MG<br />

PHENYLEPHRINE-APAP-GG TAB SR 12HR 30-250-1100 MG<br />

PHENYLEPHRINE-APAP-GG-CAFF TAB 10-325-200-32.5 MG OTC<br />

PHENYLEPHRINE-BROMPHENIRAMINE-GUAIFENESIN LIQD 2-1-40 MG/ML<br />

phenylephrine-chlorphen-gg soln 2-1-20 mg/ml<br />

PHENYLEPHRINE-GG-POTASSIUM CITRATE SOLN 5-110-80 MG/5ML<br />

PHENYLEPHRINE-GUAIFENESIN CAP 10-390 MG OTC<br />

PHENYLEPHRINE-GUAIFENESIN CAP SR 12HR 10-300 MG<br />

phenylephrine-guaifenesin cap sr 12hr 15-400 mg<br />

PHENYLEPHRINE-GUAIFENESIN CAP SR 12HR 20-375 MG<br />

phenylephrine-guaifenesin cap sr 12hr 30-400 mg<br />

PHENYLEPHRINE-GUAIFENESIN CAP SR 12HR 30-400 MG<br />

phenylephrine-guaifenesin cap sr 12hr 7.5-200 mg<br />

PHENYLEPHRINE-GUAIFENESIN DROPS 2.5-50 MG/ML OTC<br />

phenylephrine-guaifenesin liqd 10-225 mg/5ml (2-45 mg/ml)<br />

phenylephrine-guaifenesin liqd 2.5-100 mg/5ml OTC<br />

PHENYLEPHRINE-GUAIFENESIN LIQD 2.5-50 MG/5ML OTC<br />

phenylephrine-guaifenesin liqd 5-100 mg/5ml OTC<br />

phenylephrine-guaifenesin liqd 7.5-100 mg/5ml (1.5-20 mg/ml)<br />

phenylephrine-guaifenesin liqd 7.5-200 mg/5ml<br />

PHENYLEPHRINE-GUAIFENESIN LIQD 7.5-75 MG/5ML<br />

PHENYLEPHRINE-GUAIFENESIN SOLN 5-110 MG/5ML<br />

PHENYLEPHRINE-GUAIFENESIN SYRUP 2.5-50 MG/5ML OTC<br />

phenylephrine-guaifenesin syrup 5-200 mg/5ml<br />

phenylephrine-guaifenesin syrup 7.5-100 mg/5ml<br />

phenylephrine-guaifenesin tab 10-380 mg OTC<br />

PHENYLEPHRINE-GUAIFENESIN TAB 10-388 MG<br />

phenylephrine-guaifenesin tab 10-400 mg OTC<br />

phenylephrine-guaifenesin tab 10-400 mg<br />

PHENYLEPHRINE-GUAIFENESIN TAB 15-600 MG<br />

phenylephrine-guaifenesin tab 5-200 mg OTC<br />

PHENYLEPHRINE-GUAIFENESIN TAB 8.5-550 MG<br />

PHENYLEPHRINE-GUAIFENESIN TAB CR 12.5-600 MG<br />

phenylephrine-guaifenesin tab cr 15-600 mg<br />

phenylephrine-guaifenesin tab cr 20-300 mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 130


PHENYLEPHRINE-GUAIFENESIN TAB CR 20-800 MG<br />

phenylephrine-guaifenesin tab sr 12hr 10-600 mg<br />

PHENYLEPHRINE-GUAIFENESIN TAB SR 12HR 18-600 MG<br />

PHENYLEPHRINE-GUAIFENESIN TAB SR 12HR 20-1000 MG<br />

PHENYLEPHRINE-GUAIFENESIN TAB SR 12HR 20-1200 MG<br />

PHENYLEPHRINE-GUAIFENESIN TAB SR 12HR 20-315 MG<br />

phenylephrine-guaifenesin tab sr 12hr 20-600 mg<br />

PHENYLEPHRINE-GUAIFENESIN TAB SR 12HR 23.75-650 MG<br />

phenylephrine-guaifenesin tab sr 12hr 25-1200 mg<br />

phenylephrine-guaifenesin tab sr 12hr 25-275 mg<br />

PHENYLEPHRINE-GUAIFENESIN TAB SR 12HR 25-600 MG<br />

phenylephrine-guaifenesin tab sr 12hr 25-600 mg<br />

phenylephrine-guaifenesin tab sr 12hr 25-650 mg<br />

phenylephrine-guaifenesin tab sr 12hr 25-800 mg<br />

phenylephrine-guaifenesin tab sr 12hr 25-835 mg<br />

phenylephrine-guaifenesin tab sr 12hr 25-900 mg<br />

phenylephrine-guaifenesin tab sr 12hr 30-1000 mg<br />

PHENYLEPHRINE-GUAIFENESIN TAB SR 12HR 30-1050 MG<br />

phenylephrine-guaifenesin tab sr 12hr 30-1100 mg<br />

phenylephrine-guaifenesin tab sr 12hr 30-1200 mg<br />

phenylephrine-guaifenesin tab sr 12hr 30-600 mg<br />

phenylephrine-guaifenesin tab sr 12hr 30-800 mg<br />

PHENYLEPHRINE-GUAIFENESIN TAB SR 12HR 30-835 MG<br />

phenylephrine-guaifenesin tab sr 12hr 30-900 mg<br />

PHENYLEPHRINE-GUAIFENESIN TAB SR 12HR 35-1200 MG<br />

phenylephrine-guaifenesin tab sr 12hr 40-1000 mg<br />

PHENYLEPHRINE-GUAIFENESIN TAB SR 12HR 40-1200 MG<br />

phenylephrine-guaifenesin tab sr 12hr 40-1200 mg<br />

phenylephrine-guaifenesin tab sr 12hr 40-600 mg<br />

PHENYLEPHRINE-GUAIFENESIN TAB SR 12HR 40-650 MG<br />

PHENYLEPHRINE-GUAIFENESIN TAB SR 12HR 40-800 MG<br />

PHENYLEPHRINE-GUAIFENESIN TAB SR 12HR 8.5-550 MG<br />

PHENYLEPHRINE-POTASSIUM GUAIACOLSULFONATE LIQD 5-75 MG/5ML<br />

POLY-VENT TAB 90/650MG<br />

POLY-VENT TAB PLUS OTC<br />

POLY-VENT JR TAB 45/650<br />

POTASSIUM GUAIACOLSULFONATE LIQUID 300 MG/5ML<br />

POTASSIUM GUAIACOLSULFONATE SOLN 75 MG/5ML (15 MG/ML)<br />

POTASSIUM IODIDE LIQUID 600 MG/15ML<br />

proset d tab 20-600mg<br />

PSE-GG TAB 90-800MG<br />

pse/gg cap 120-400<br />

PSE/GG SYP 40-200MG<br />

pse/gg tab 120-600<br />

pse/gg tab 120-600<br />

pse/gg tab 120/1200<br />

pse/gg tab 85-795mg<br />

pse/gg cr tab 120-600<br />

pse/gg cr tab 60-600mg<br />

pse/gg la tab 120-600<br />

pse/gg la tab 45-800mg<br />

pse/gg sr tab 50-1200<br />

pse/gg sr tab 60-500mg<br />

pse/gg sr tab 60-600mg<br />

pseudo gg tr tab 48-595mg<br />

pseudo max tab<br />

pseudo/gg la tab 12hr<br />

pseudoeph/gg tab 45-800mg<br />

pseudoeph/gg tab 80/800mg<br />

PSEUDOEPHED-CHLORPHEN-GG CAP 32.4-2-100 MG<br />

PSEUDOEPHEDRINE-ACETAMINOPHEN-GUAIFENESIN TAB 30-325-200 MG OTC<br />

PSEUDOEPHEDRINE-ACETAMINOPHEN-GUAIFENESIN TAB 45-500-200 MG OTC<br />

PSEUDOEPHEDRINE-GUAIFENESIN CAP 30-150 MG<br />

pseudoephedrine-guaifenesin cap 30-200 mg OTC<br />

pseudoephedrine-guaifenesin cap cr 120-250 mg<br />

pseudoephedrine-guaifenesin cap cr 120-250 mg<br />

pseudoephedrine-guaifenesin cap cr 60-200 mg<br />

pseudoephedrine-guaifenesin cap cr 60-300 mg<br />

PSEUDOEPHEDRINE-GUAIFENESIN CAP SR 12HR 120-400 MG<br />

pseudoephedrine-guaifenesin cap sr 12hr 120-400 mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 131


pseudoephedrine-guaifenesin cap sr 12hr 120-400 mg<br />

PSEUDOEPHEDRINE-GUAIFENESIN CAP SR 12HR 90-400 MG<br />

PSEUDOEPHEDRINE-GUAIFENESIN LIQD 15-50 MG/ML OTC<br />

PSEUDOEPHEDRINE-GUAIFENESIN LIQD 30-25 MG/5ML OTC<br />

PSEUDOEPHEDRINE-GUAIFENESIN LIQD 40-200 MG/5ML<br />

pseudoephedrine-guaifenesin liqd 5-50 mg/ml<br />

pseudoephedrine-guaifenesin syrup 15-50 mg/5ml OTC<br />

pseudoephedrine-guaifenesin syrup 30-100 mg/5ml OTC<br />

PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 30-200 MG/5ML OTC<br />

PSEUDOEPHEDRINE-GUAIFENESIN SYRUP 40-200 MG/5ML<br />

pseudoephedrine-guaifenesin syrup 40-200 mg/5ml<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB 20-400 MG OTC<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB 30-400 MG OTC<br />

pseudoephedrine-guaifenesin tab 40-400 mg OTC<br />

pseudoephedrine-guaifenesin tab 40-400 mg<br />

pseudoephedrine-guaifenesin tab 45-400 mg OTC<br />

pseudoephedrine-guaifenesin tab 60-400 mg OTC<br />

pseudoephedrine-guaifenesin tab 60-400 mg<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-1200 MG OTC<br />

pseudoephedrine-guaifenesin tab sr 12hr 120-1200 mg<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-500 MG<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-525 MG<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-600 MG<br />

pseudoephedrine-guaifenesin tab sr 12hr 120-600 mg<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 120-800 MG<br />

pseudoephedrine-guaifenesin tab sr 12hr 45-600 mg<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 45-650 MG<br />

pseudoephedrine-guaifenesin tab sr 12hr 45-800 mg<br />

pseudoephedrine-guaifenesin tab sr 12hr 48-595 mg<br />

pseudoephedrine-guaifenesin tab sr 12hr 50-1200 mg<br />

pseudoephedrine-guaifenesin tab sr 12hr 50-525 mg<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 58-600 MG<br />

pseudoephedrine-guaifenesin tab sr 12hr 60-1000 mg<br />

pseudoephedrine-guaifenesin tab sr 12hr 60-1200 mg<br />

pseudoephedrine-guaifenesin tab sr 12hr 60-500 mg<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 60-550 MG<br />

pseudoephedrine-guaifenesin tab sr 12hr 60-580 mg<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 60-600 MG OTC<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 60-600 MG<br />

pseudoephedrine-guaifenesin tab sr 12hr 60-600 mg<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 60-800 MG<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 75-1200 MG<br />

pseudoephedrine-guaifenesin tab sr 12hr 80-700 mg<br />

pseudoephedrine-guaifenesin tab sr 12hr 80-780 mg<br />

pseudoephedrine-guaifenesin tab sr 12hr 80-800 mg<br />

pseudoephedrine-guaifenesin tab sr 12hr 85-795 mg<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 90-1200 MG<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 90-600 MG<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 90-650 MG<br />

PSEUDOEPHEDRINE-GUAIFENESIN TAB SR 12HR 90-800 MG<br />

pseudoephedrine-guaifenesin tab sr 12hr 90-800 mg<br />

PSEUDOVENT CAP 400<br />

pseudovent cap 400<br />

pseudovent cap cr<br />

pseudovent cap ped cr<br />

px tussin sol 100/5ml OTC<br />

q-tussin syp 100/5ml OTC<br />

q-tussin pe syp pe -af OTC<br />

qc medifin tab 200mg OTC<br />

qc medifin tab cp OTC<br />

qc triactin syp chst con OTC<br />

qual-tussin dro ped<br />

quintex syp 7.5-100<br />

ra decongest syp pe cough OTC<br />

ra suphedrin cap non-dry OTC<br />

ra tussin syp 100/5ml OTC<br />

ra tussin pe syp 30-100/5 OTC<br />

refenesen tab 200mg OTC<br />

refenesen tab 400mg OTC<br />

refenesen tab chst cng OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 132


efenesen tab chst pe OTC<br />

refenesen tab plus OTC<br />

refenesen pe tab 10-400mg OTC<br />

reluri tab 30-1200<br />

RESPA-1ST TAB CR<br />

RESPA-PE TAB 18-600<br />

respaire-120 cap cr<br />

RESPAIRE-30 CAP<br />

ri-tussin syp 100/5ml OTC<br />

robafen syp 100/5ml OTC<br />

robitussin liq hd/chst OTC<br />

ru-tuss jr tab 45-600mg<br />

RYNA-12X SUS 5-30-100<br />

RYNA-12X TAB<br />

sb bronchial tab 12.5-200 OTC<br />

sb cgh contr syp 100/5ml OTC<br />

sb coughtab tab 200mg OTC<br />

sb sev/conge cap OTC<br />

sb sinus cng tab /pain OTC<br />

scot-tussin liq expct sf OTC<br />

severe conge tab cough ai OTC<br />

severe conge tab cough ai OTC<br />

sg tussin syp 100/5ml OTC<br />

sil-tex syp 7.5-100<br />

siltuss das liq 100/5ml OTC<br />

siltussin sa syp 100/5ml OTC<br />

simuc tab 25-900mg<br />

simuc-gp tab 25-1200<br />

SINA-12X SUS<br />

SINA-12X TAB 25-200MG<br />

sinus conges tab pain/svr OTC<br />

sinus congst tab /pain OTC<br />

sinus congst tab severe OTC<br />

sinutab cap non-dry OTC<br />

SINUVENT PE TAB 15-600MG<br />

SITREX TAB<br />

SITREX PD LIQ 7.5-75MG<br />

sm pediatric syp 100/5ml OTC<br />

sm tussin syp 100/5ml OTC<br />

stamoist e tab 45-600mg<br />

sudafed pe tab sinus OTC<br />

SUDAFED TRPL TAB ACTION OTC<br />

sudatex syp 40-200mg<br />

sudatex g tab 40-400mg OTC<br />

sudatex-g tab 60-580mg<br />

sudex tab 20-600mg<br />

super tussin syp pe OTC<br />

supertussin syp 100/5ml OTC<br />

supherine cap non-dry OTC<br />

SUPRESS-PE DRO PEDIATRI OTC<br />

TENAR PSE LIQ<br />

THERAFLU LIQ WARM RLF OTC<br />

THERAFLU FLU PAK CHST CON OTC<br />

tidafen la tab 45-800mg<br />

TOURO LA TAB<br />

tri acting syp chst con OTC<br />

triac expect syp 15/50 OTC<br />

TRIACTIN SOL CHST CON OTC<br />

triactin syp 15-50mg OTC<br />

triactin syp chst con OTC<br />

triacting syp chst con OTC<br />

triacting ci syp 15-50mg/ OTC<br />

TRIAMINIC LIQ CHST/NAS OTC<br />

triaminic syp OTC<br />

TRIAMINIC SYP CHST/NSL OTC<br />

TRISPEC DEX LIQ OTC<br />

TRISPEC SFX LIQ<br />

TUSNEL CAP<br />

TUSSI PRES-B LIQ<br />

tussi-pres liq pe ped OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 133


tussin cap severe OTC<br />

tussin syp 100/5ml OTC<br />

tussin chest syp 100/5ml OTC<br />

tussin cold cap sev cong OTC<br />

tussin cough syp 100/5ml OTC<br />

tussin exp syp 100/5ml OTC<br />

tussin pe liq OTC<br />

tussin pe syp 30-100/5 OTC<br />

tussin pe syp 30-100/5 OTC<br />

tussin sever cap congest OTC<br />

TYLENOL CHES LIQ CONGEST OTC<br />

TYLENOL SINU TAB SEV CONG OTC<br />

v-r tussin syp 100/5ml OTC<br />

VICKS CASERO LIQ OTC<br />

visonex tab 30-900mg<br />

VITA-NUMONYL SOL<br />

VITA-NUMONYL SOL EX<br />

wal-tussin cap cold OTC<br />

wal-tussin syp 100/5ml OTC<br />

we mist ii tab la<br />

wellbid-d tab 1200<br />

wellbid-d tab 40-600mg<br />

XEDEC TAB 20-800MG<br />

xedec ii tab<br />

xpect tab 400mg OTC<br />

xpect-pe tab 25-1200<br />

YODEFAN LIQ 600MG/15<br />

YODEFAN-NF LIQ 300MG/5<br />

ZINX CONGEST KIT<br />

ZOTEX GPX TAB<br />

ZOTEX-GP TAB<br />

zyrphen liq 7.5-200<br />

Mucolytic Agents<br />

broncho sal aer 0.9% OTC<br />

HYPER-SAL NEB 7%<br />

saline spray aer 0.9% OTC<br />

simply salin aer baby OTC<br />

sod chloride neb 0.9% OTC<br />

sod chloride neb 0.9%<br />

sodium chlor neb 0.45% OTC<br />

SODIUM CHLOR NEB 0.45% OTC<br />

sodium chlor neb 10%<br />

sodium chlor neb 3%<br />

sodium chloride aero soln 0.9% OTC<br />

SODIUM CHLORIDE SOLN NEBU 0.45% OTC<br />

sodium chloride soln nebu 0.45% OTC<br />

sodium chloride soln nebu 0.9% OTC<br />

sodium chloride soln nebu 0.9%<br />

sodium chloride soln nebu 10%<br />

sodium chloride soln nebu 3%<br />

SODIUM CHLORIDE SOLN NEBU 7%<br />

Respiratory Tract Agents, Miscellaneous<br />

ARALAST INJ 400MG PA<br />

ARALAST INJ 800MG PA<br />

ARALAST NP INJ 400MG PA<br />

ARALAST NP INJ 800MG PA<br />

PROLASTIN INJ 1000MG PA<br />

PROLASTIN INJ 500MG PA<br />

PROLASTIN-C INJ 1000MG PA<br />

XOLAIR SOL 150MG PA<br />

ZEMAIRA INJ 1000MG PA<br />

Eye, Ear, Nose & Throat Preparations<br />

Antiallergic Agents<br />

ASTELIN NASA SPR 137MCG QL NF<br />

ASTEPRO SPR 0.15% QL NF<br />

ASTEPRO SPR 137MCG PA QL<br />

AZELASTINE HCL NASAL SPRAY 0.15% (205.5 MCG/SPRAY) QL NF<br />

AZELASTINE HCL NASAL SPRAY 137 MCG/SPRAY (1 MG/ML) QL NF<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 134


cromolyn sod sol 4% op<br />

cromolyn sodium ophth soln 4%<br />

ketotifen fumarate ophth soln 0.025% (base equiv) PA OTC<br />

ketotifen fumarate ophth soln 0.025% (base equiv) PA<br />

OLOPATADINE HCL OPHTH SOLN 0.1%<br />

PATADAY SOL 0.2% PA<br />

PATANOL SOL 0.1% OP<br />

ZADITOR DRO 0.025%OP PA OTC<br />

Anti-infectives<br />

Antibacterials<br />

ak-tob sol 0.3% op<br />

bac/neo/poly oin op<br />

bacitracin oin op NF<br />

bacitracin oin op NF<br />

bacitracin ophth oint 500 unit/gm NF<br />

bacitracin ophth oint 500 unit/gm NF<br />

CILOXAN OIN 0.3% OP PA<br />

ciprofloxacin hcl ophth soln 0.3%<br />

ciprofloxacn sol 0.3% op<br />

erythromycin oin op<br />

erythromycin ophth oint 5 mg/gm<br />

genoptic sol 0.3% op<br />

gentacidin sol 0.3% op<br />

gentak oin 0.3% op<br />

gentak sol 0.3% op<br />

gentamicin oin 0.3% op<br />

gentamicin sol 0.3% op<br />

gentamicin sulfate ophth oint 0.3%<br />

gentamicin sulfate ophth soln 0.3%<br />

gentasol sol 0.3% op<br />

gra/neo/poly sol op<br />

neo/bac/poly oin op<br />

neo/bac/poly oin op<br />

neo/poly/bac oin op<br />

neo/poly/gra sol op<br />

neocin oin op<br />

neocin-pg sol op<br />

neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin<br />

neomycin-polymyxin b-gramicidin ophth soln<br />

ocusulf-10 sol 10% op<br />

ocutricin sol op<br />

ofloxacin dro 0.3% op<br />

ofloxacin dro 0.3%otic NF<br />

ofloxacin ophth soln 0.3%<br />

ofloxacin otic soln 0.3% NF<br />

polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%<br />

polymyxin b/ sol trimethp<br />

romycin oin op<br />

sod sulfacet sol 10% op<br />

sulf-10 sol 10% op<br />

sulfac sol 10% op<br />

SULFACET SOD OIN 10% OP<br />

sulfacet sod sol 10% op<br />

SULFACETAMIDE SODIUM OPHTH OINT 10%<br />

sulfacetamide sodium ophth soln 10%<br />

tobramycin sol 0.3% op<br />

TOBRAMYCIN SULFATE OPHTH OINT 0.3%<br />

tobramycin sulfate ophth soln 0.3%<br />

tobrasol sol 0.3% op<br />

TOBREX OIN 0.3% OP<br />

trimethoprim sol polymyxn<br />

trimethoprim sol polymyxn<br />

triple antib oin op<br />

triple antib sol op<br />

ZYMAR DRO 0.3% PA<br />

Antifungals<br />

NATACYN SUS 5% OP<br />

NATAMYCIN OPHTH SUSP 5%<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 135


Antivirals<br />

trifluridine ophth soln 1%<br />

trifluridine sol 1% op<br />

Anti-inflammatory Agents<br />

Corticosteroids<br />

acetasol hc sol otic<br />

acetic acid dro /hc otic<br />

acetic acid sol /hc ear<br />

acetic acid sol /hc otic<br />

antibiot ear sol 1% otic<br />

antibiot ear sus 1% otic<br />

bac/poly/neo oin /hc 1%op<br />

bacitracin-polymyxin-neomycin-hc ophth oint 1%<br />

BECLOMETHASONE DIPROPIONATE MONOHYD NASAL SUSP 42 MCG/SPRAY QL<br />

BECONASE AQ SUS 0.042% QL<br />

BLEPHAMIDE OIN S.O.P. NF<br />

BLEPHAMIDE SUS LIQUIFLM NF<br />

BLEPHAMIDE SUS OP<br />

CIPRODEX SUS 0.3-0.1% PA<br />

cortomycin sol 1% otic<br />

cortomycin sus 1% otic<br />

dexameth pho sol 0.1% op<br />

dexamethasone sodium phosphate ophth soln 0.1%<br />

dexasol sol 0.1% op<br />

dexasporin sus 0.1% op<br />

DUREZOL EMU 0.05% PA<br />

flunisolide spr 0.025% QL NF<br />

FLUNISOLIDE SPR 29MCG QL NF<br />

flunisolide nasal soln 0.025% QL NF<br />

FLUNISOLIDE NASAL SOLN 29 MCG/ACT QL NF<br />

fluor-op sus 0.1% op<br />

fluoromethol sus 0.1% op<br />

FLUOROMETHOLONE OPHTH OINT 0.1%<br />

fluorometholone ophth susp 0.1%<br />

FLUOROMETHOLONE OPHTH SUSP 0.25%<br />

fluticasone spr 50mcg<br />

fluticasone propionate nasal susp 50 mcg/act<br />

FML OIN 0.1% OP<br />

FML FORTE SUS 0.25% OP<br />

GENTAMICIN-PREDNISOLONE ACE OPHTH OINT 0.3-0.6%<br />

GENTAMICIN-PREDNISOLONE ACE OPHTH SUSP 0.3-1%<br />

hc/acet acid sol otic<br />

hydrocortisone w/ acetic acid otic soln 1-2%<br />

methadex sus 0.1% op<br />

MOMETASONE FUROATE NASAL SUSP 50 MCG/ACT QL<br />

NASACORT AQ AER 55MCG/AC QL<br />

NASONEX SPR 50MCG/AC QL<br />

neo/bac/poly oin /hc 1%op<br />

neo/poly/bac oin /hc 1%op<br />

neo/poly/dex oin 0.1% op<br />

neo/poly/dex sus 0.1% op<br />

neo/poly/hc sol 1% otic<br />

neo/poly/hc sol 1% otic<br />

neo/poly/hc sus 1% otic<br />

neo/poly/hc sus 1% otic<br />

neo/poly/hc sus op<br />

neo/poly/hc sus op<br />

neomycin-polymyxin-dexamethasone ophth oint 0.1%<br />

neomycin-polymyxin-dexamethasone ophth susp 0.1%<br />

neomycin-polymyxin-hc ophth susp<br />

neomycin-polymyxin-hc ophth susp<br />

neomycin-polymyxin-hc otic soln 1%<br />

neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%<br />

oticin hc sus 1% otic<br />

poly-dex oin 0.1% op<br />

poly-dex sus 0.1% op<br />

PRED-G SUS OP<br />

PRED-G S.O.P OIN OP<br />

prednis/sulf sol op NF<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 136


prednis/sulf sus op<br />

prednisolone acetate ophth susp 1%<br />

prednisolone sus 1% op<br />

RHINOCORT SUS AQUA PA<br />

sulf/pred na sol op NF<br />

sulf/prednis sus op<br />

SULFACETAMIDE SODIUM-PREDNISOLONE OPHTH OINT 10-0.2% NF<br />

sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% NF<br />

SULFACETAMIDE SODIUM-PREDNISOLONE OPHTH SUSP 10-0.2%<br />

SULFACETAMIDE SODIUM-PREDNISOLONE OPHTH SUSP 10-0.2% NF<br />

sulfacetamide sodium-prednisolone ophth susp 10-0.2%<br />

TOBRADEX OIN OP<br />

TOBRAMYCIN-DEXAMETHASONE OPHTH OINT 0.3-0.1%<br />

tobramycin-dexamethasone ophth susp 0.3-0.1%<br />

tobramycin/ sus dexameth<br />

TRIAMCINOLONE ACETONIDE NASAL INHAL 55 MCG/ACT QL<br />

triple antib oin 0.1% op<br />

Nonsteroidal Anti-inflammatory Agents<br />

ACULAR SOL 0.5% OP<br />

ACULAR PF SOL 0.5% OP<br />

ACUVAIL SOL 0.45%<br />

diclofenac sol 0.1% op<br />

diclofenac sodium ophth soln 0.1%<br />

flurbiprofen sodium ophth soln 0.03%<br />

flurbiprofen sol 0.03% op<br />

ketorolac sol 0.4%<br />

ketorolac sol 0.5%<br />

ketorolac tromethamine ophth soln 0.4%<br />

KETOROLAC TROMETHAMINE OPHTH SOLN 0.45%<br />

KETOROLAC TROMETHAMINE OPHTH SOLN 0.5%<br />

ketorolac tromethamine ophth soln 0.5%<br />

Local Anesthetics<br />

a/b otic sol<br />

allergen sol otic<br />

antiben sol otic<br />

antipy/benzo dro otic<br />

antipy/benzo sol otic<br />

aurodex sol otic<br />

auroguard sol<br />

auroto sol otic<br />

balagan sol 1.4-5.4%<br />

BENZOCAINE-ANTIPYRINE OTIC SOLN 1.4-5.4%<br />

benzocaine-antipyrine otic soln 1.4-5.4%<br />

benzotic dro otic<br />

dolotic sol otic<br />

ear drops sol otic<br />

lidocaine sol 2% visc<br />

lidocaine sol 2% visc<br />

lidocaine hcl viscous soln 2%<br />

lidomar sol 2% visc<br />

OTILAM NR SOL 1.4-5.4%<br />

otogesic sol otic<br />

ototgesic dro<br />

otra nr sol otic<br />

pro-otic sol 1.4-5.4%<br />

Mydriatics<br />

ak-pentolate sol 1% op<br />

atropin-care sol 1% op<br />

atropine sul oin 1% op<br />

atropine sul sol 1% op<br />

atropine sulfate ophth oint 1%<br />

atropine sulfate ophth soln 1%<br />

CYCLOGYL SOL 0.5% OP<br />

CYCLOGYL SOL 2% OP<br />

cyclopentol sol 1% op<br />

CYCLOPENTOLATE HCL OPHTH SOLN 0.5%<br />

cyclopentolate hcl ophth soln 1%<br />

CYCLOPENTOLATE HCL OPHTH SOLN 2%<br />

cylate sol 1% op<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 137


dipivefrin sol 0.1% op<br />

dipivefrin hcl ophth soln 0.1%<br />

DIPIVEFRIN HCL OPHTH SOLN 0.1%<br />

homatropaire sol 5% op<br />

homatropine sol 5% op<br />

HOMATROPINE HBR OPHTH SOLN 2%<br />

homatropine hbr ophth soln 5%<br />

ISO HOMATROP SOL 2% OP<br />

ISO HYOSCINE SOL 0.25% OP<br />

mydral sol 0.5% op<br />

mydral sol 1% op<br />

PROPINE SOL 0.1% OP<br />

SCOPOLAMINE HBR OPHTH SOLN 0.25%<br />

tropicacyl sol 0.5% op<br />

tropicacyl sol 1% op<br />

tropicamide sol 0.5% op<br />

tropicamide sol 1% op<br />

tropicamide ophth soln 0.5%<br />

tropicamide ophth soln 1%<br />

Vasoconstrictors<br />

4-way fast spr act 1% OTC<br />

4-way menthl spr 1% OTC<br />

4-way no drp sol 1% OTC<br />

afrin allerg spr 0.5% OTC<br />

afrin child spr 0.25% OTC<br />

ak-dilate sol 10% op<br />

ak-dilate sol 2.5% op<br />

altafrin sol 0.12% OTC<br />

altafrin sol 10% op<br />

altafrin sol 2.5% op<br />

cvs nasal spr 1% OTC<br />

cvs nose dro 1% OTC<br />

decongestant dro 1% OTC<br />

decongestant sol 1% OTC<br />

ephrine nose dro 1% OTC<br />

eq nose dro 1% ex st OTC<br />

gnp nose dro 1% ex st OTC<br />

industrial sol OTC<br />

LITTLE NOSES DRO 0.125% OTC<br />

nasal four sol 1% OTC<br />

neofrin sol 10% op<br />

neofrin sol 2.5% op<br />

nose dro 1% OTC<br />

nu-way sol 1% OTC<br />

phenoptic sol 2.5% op<br />

phenylephrin sol 0.12% OTC<br />

phenylephrin sol 10% op<br />

phenylephrin sol 2.5% op<br />

PHENYLEPHRINE HCL NASAL SOLN 0.125% OTC<br />

PHENYLEPHRINE HCL NASAL SOLN 0.16% OTC<br />

phenylephrine hcl nasal soln 0.25% OTC<br />

phenylephrine hcl nasal soln 0.5% OTC<br />

phenylephrine hcl nasal soln 1% OTC<br />

phenylephrine hcl ophth soln 0.12% OTC<br />

phenylephrine hcl ophth soln 10%<br />

phenylephrine hcl ophth soln 2.5%<br />

qc multi way spr 1% OTC<br />

ra nose dro 1% ex st OTC<br />

rhinall sol 0.25% OTC<br />

rhinall spr 0.25% OTC<br />

sm nasal spr 1% OTC<br />

sm nose nasl dro 1% ex st OTC<br />

TUR-BI-KAL DRO 0.16% OTC<br />

wal-four sol 1% OTC<br />

Antiglaucoma Agents<br />

ALPHA ADRENERGIC AGONISTS<br />

ALPHAGAN P SOL 0.1%<br />

ALPHAGAN P SOL 0.15% NF<br />

brimonidine sol 0.15% NF<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 138


imonidine sol 0.2% op<br />

BRIMONIDINE TARTRATE OPHTH SOLN 0.1%<br />

brimonidine tartrate ophth soln 0.15% NF<br />

BRIMONIDINE TARTRATE OPHTH SOLN 0.15% NF<br />

brimonidine tartrate ophth soln 0.2%<br />

BETA ADRENERGIC BLOCKING AGENTS<br />

BETAXOLOL SOL 0.5% OP<br />

BETAXOLOL HCL OPHTH SOLN 0.5%<br />

BETAXOLOL HCL OPHTH SUSP 0.25%<br />

BETIMOL SOL 0.25% PA<br />

BETIMOL SOL 0.5% PA<br />

BETOPTIC-S SUS 0.25% OP<br />

ISTALOL SOL 0.5% OP<br />

levobunolol sol 0.25% op<br />

levobunolol sol 0.25% op<br />

levobunolol sol 0.5% op<br />

levobunolol hcl ophth soln 0.25%<br />

levobunolol hcl ophth soln 0.25%<br />

levobunolol hcl ophth soln 0.5%<br />

timolol gel sol 0.25% op<br />

timolol gel sol 0.5% op<br />

timolol mal sol 0.25% op<br />

timolol mal sol 0.5% op<br />

timolol maleate ophth gel forming soln 0.25%<br />

timolol maleate ophth gel forming soln 0.5%<br />

timolol maleate ophth soln 0.25%<br />

timolol maleate ophth soln 0.5%<br />

TIMOLOL MALEATE OPHTH SOLN 0.5% (ONCE-DAILY)<br />

CARBONIC ANYDRASE INHIBITORS<br />

acetazolamid cap 500mg<br />

acetazolamid tab 125mg<br />

acetazolamid tab 250mg<br />

acetazolamide cap sr 12hr 500 mg<br />

acetazolamide sodium for inj 500 mg PA<br />

acetazolamide tab 125 mg<br />

acetazolamide tab 250 mg<br />

dorzolamide sol 2% op<br />

dorzolamide hcl ophth soln 2%<br />

methazolamid tab 25mg<br />

methazolamid tab 50mg<br />

methazolamide tab 25 mg<br />

methazolamide tab 50 mg<br />

MIOTICS<br />

carbachol ophth soln 3% PA<br />

ISO CARBACHO SOL 1.5% OP PA<br />

ISO CARBACHO SOL 3% OP PA<br />

MIOSTAT INJ 0.01% OP PA<br />

pilocar sol 0.5% op<br />

pilocar sol 1% op<br />

pilocar sol 2% op<br />

pilocar sol 4% op<br />

pilocar sol 6% op<br />

PILOCARPINE SOL 0.5% OP<br />

pilocarpine sol 0.5% op<br />

pilocarpine sol 1% op<br />

pilocarpine sol 2% op<br />

PILOCARPINE SOL 3% OP<br />

pilocarpine sol 3% op<br />

pilocarpine sol 4% op<br />

pilocarpine sol 6% op<br />

PILOCARPINE HCL OPHTH SOLN 0.5%<br />

pilocarpine hcl ophth soln 0.5%<br />

pilocarpine hcl ophth soln 1%<br />

pilocarpine hcl ophth soln 2%<br />

pilocarpine hcl ophth soln 3%<br />

PILOCARPINE HCL OPHTH SOLN 3%<br />

pilocarpine hcl ophth soln 4%<br />

pilocarpine hcl ophth soln 6%<br />

piloptic-1 sol 1% op<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 139


PILOPTIC-1/2 SOL 0.5% OP<br />

piloptic-2 sol 2% op<br />

PILOPTIC-3 SOL 3% OP<br />

piloptic-4 sol 4% op<br />

piloptic-6 sol 6% op<br />

PROSTAGLANDIN ANALOGS<br />

BIMATOPROST OPHTH SOLN 0.03%<br />

LATANOPROST OPHTH SOLN 0.005%<br />

LUMIGAN SOL 0.03%<br />

XALATAN SOL 0.005%<br />

EENT <strong>Drugs</strong>, Miscellaneous<br />

acetic acid sol 2% otic<br />

acetic acid otic soln 2%<br />

AMVISC INJ 12MG/ML PA<br />

AMVISC PLUS INJ 16MG/ML PA<br />

DISCOVISC SOL PA<br />

DUOVISC KIT 0.35/0.4 PA<br />

DUOVISC KIT 0.5/0.55 PA<br />

HEALON INJ 10MG/ML PA<br />

HEALON GV INJ 14MG/ML PA<br />

HEALON5 INJ 23MG/ML PA<br />

PROVISC INJ 1% PA<br />

SHELLGEL SOL PA<br />

VISCOAT SOL PA<br />

VISUDYNE INJ 15MG PA<br />

VITRAX INJ 30MG/ML PA<br />

Gastrointestinal <strong>Drugs</strong><br />

Antidiarrhea Agents<br />

diphen/atrop liq 2.5/5<br />

diphen/atrop tab 2.5mg<br />

diphenatol tab 2.5mg<br />

diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml<br />

diphenoxylate w/ atropine tab 2.5-0.025 mg<br />

lofene tab 2.5mg<br />

lonox tab 2.5mg<br />

Cathartics and Laxatives<br />

GOLYTELY SOL NF<br />

PEG 3350-KCL-NA BICARB-NACL-NA SULFATE PACKET 227.1 GM NF<br />

Digestants<br />

AMY-LIP-PROT DR PARTICLES CAP 12000-4000-12000 UNIT<br />

AMY-LIP-PROT DR PARTICLES CAP 16600-5000-18750 UNIT<br />

AMY-LIP-PROT DR PARTICLES CAP 20000-4500-25000 UNIT<br />

amy-lip-prot dr particles cap 20000-4500-25000 unit<br />

AMY-LIP-PROT DR PARTICLES CAP 25000-4000-25000 UNIT<br />

AMY-LIP-PROT DR PARTICLES CAP 30000-10000-30000 UNIT<br />

amy-lip-prot dr particles cap 30000-10000-30000 unit<br />

AMY-LIP-PROT DR PARTICLES CAP 33200-10000-37500 UNIT<br />

amy-lip-prot dr particles cap 33200-10000-37500 unit<br />

AMY-LIP-PROT DR PARTICLES CAP 39000-12000-39000 UNIT<br />

amy-lip-prot dr particles cap 39000-12000-39000 unit<br />

AMY-LIP-PROT DR PARTICLES CAP 40000-8000-45000 UNIT<br />

AMY-LIP-PROT DR PARTICLES CAP 48000-16000-48000 UNIT<br />

amy-lip-prot dr particles cap 48000-16000-48000 unit<br />

AMY-LIP-PROT DR PARTICLES CAP 52000-16000-52000 UNIT<br />

AMY-LIP-PROT DR PARTICLES CAP 56000-20000-44000 UNIT<br />

AMY-LIP-PROT DR PARTICLES CAP 58500-18000-58500 UNIT<br />

amy-lip-prot dr particles cap 58500-18000-58500 unit<br />

AMY-LIP-PROT DR PARTICLES CAP 65000-20000-65000 UNIT<br />

amy-lip-prot dr particles cap 65000-20000-65000 unit<br />

AMY-LIP-PROT DR PARTICLES CAP 66400-20000-75000 UNIT<br />

amy-lip-prot dr particles cap 66400-20000-75000 unit<br />

AMYLASE-LIPASE-PROTEASE CAP 15000-1200-15000 UNIT<br />

AMYLASE-LIPASE-PROTEASE CAP 20000-4000-25000 UNIT<br />

AMYLASE-LIPASE-PROTEASE CAP 30000-2400-30000 UNIT<br />

AMYLASE-LIPASE-PROTEASE CAP 30000-8000-30000 UNIT<br />

AMYLASE-LIPASE-PROTEASE POWD 70000-16800-70000 UNIT<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 140


AMYLASE-LIPASE-PROTEASE TAB 12500-1000-12500 UNIT<br />

AMYLASE-LIPASE-PROTEASE TAB 30000-8000-30000 UNIT<br />

amylase-lipase-protease tab 30000-8000-30000 unit<br />

AMYLASE-LIPASE-PROTEASE TAB 60000-16000-60000 UNIT<br />

amylase-lipase-protease tab 60000-16000-60000 unit<br />

CREON 10 CAP EC<br />

CREON 20 CAP<br />

CREON 5 CAP<br />

DYGASE CAP<br />

ENZYCAP CAP<br />

ENZYMAX TAB<br />

hydrochloric acid inj 1:500 PA<br />

KU-ZYME CAP<br />

KU-ZYME-HP CAP<br />

KUTRASE CAP<br />

LAPASE CAP<br />

LIPRAM 4500 CAP<br />

LIPRAM-CR10 CAP<br />

LIPRAM-CR20 CAP<br />

lipram-pn10 cap<br />

LIPRAM-PN16 CAP<br />

LIPRAM-PN20 CAP<br />

LIPRAM-UL12 CAP<br />

LIPRAM-UL18 CAP<br />

lipram-ul20 cap<br />

PALCAPS 10 CAP<br />

PALCAPS 20 CAP<br />

PANCREASE MT CAP 10<br />

PANCREASE MT CAP 16<br />

PANCREASE MT CAP 20<br />

PANCREASE MT CAP 4<br />

PANCRECARB CAP MS-16<br />

PANCRECARB CAP MS-4<br />

PANCRECARB CAP MS-8<br />

PANCRELIPASE CAP<br />

PANCRELIPASE CAP 10000<br />

PANCRELIPASE CAP 16000<br />

PANCRELIPASE CAP 20000<br />

PANCRELIPASE CAP 4500<br />

PANCRELIPASE CAP 4500UNIT<br />

PANCRELIPASE CAP MST-16<br />

PANCRELIPASE TAB<br />

PANCRON 10 CAP EC<br />

PANCRON 20 CAP<br />

panges cn 10 cap<br />

PANGES CN 10 CAP<br />

panges cn 20 cap<br />

panges mt 16 cap<br />

panges ul 12 cap<br />

panges ul 18 cap<br />

panges ul 20 cap<br />

PANGESTYM EC CAP<br />

pangestym ec cap<br />

PANOCAPS CAP<br />

PANOCAPS CAP MT 16<br />

PANOCAPS CAP MT 20<br />

PANOKASE TAB<br />

panokase-16 tab<br />

PLARETASE TAB 8000<br />

plaretase tab 8000<br />

ULTRACAPS CAP MT 20<br />

ULTRASE CAP<br />

ULTRASE MT12 CAP<br />

ULTRASE MT18 CAP<br />

ULTRASE MT20 CAP<br />

VIOKASE POW<br />

VIOKASE 16 TAB<br />

VIOKASE 8 TAB<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 141


Antiemetics<br />

<strong>Antihistamine</strong>s<br />

DIMENHYDRIN INJ 50MG/ML PA<br />

tebamide sup 100mg<br />

tebamide sup 200mg<br />

trimethobenz cap 250mg<br />

trimethobenz cap 300mg<br />

trimethobenz sup 100mg<br />

trimethobenz sup 100mg<br />

trimethobenz sup 200mg<br />

trimethobenzamide hcl cap 250 mg<br />

trimethobenzamide hcl cap 300 mg<br />

trimethobenzamide hcl inj 100 mg/ml PA<br />

trimethobenzamide hcl suppos 100 mg<br />

trimethobenzamide-benzocaine suppos 100 mg-2%<br />

trimethobenzamide-benzocaine suppos 200 mg-2%<br />

5-HT3 Receptor Antagonists<br />

ALOXI INJ PA<br />

ALOXI INJ 0.25MG/5 PA<br />

ANZEMET INJ 20MG/ML PA<br />

granisetron hcl inj 0.1 mg/ml PA<br />

granisetron hcl inj 1 mg/ml PA<br />

granisetron hcl tab 1 mg PA<br />

GRANISOL SOL 2MG/10ML PA<br />

ONDANSETRON SOL 32MG/50M PA<br />

ondansetron hcl and dextrose inj 32 mg/50ml PA<br />

ondansetron hcl inj 2 mg/ml PA<br />

ondansetron hcl oral soln 4 mg/5ml PA<br />

ondansetron hcl tab 24 mg PA<br />

ondansetron hcl tab 4 mg PA<br />

ondansetron hcl tab 8 mg PA<br />

ondansetron orally disintegrating tab 4 mg PA<br />

ondansetron orally disintegrating tab 8 mg PA<br />

Antiemetics, Miscellaneous<br />

EMEND SOL 115MG PA<br />

Antiulcer Agents and Acid Suppressants<br />

Histamine H2-Antagonists<br />

acid reducer tab 200mg OTC<br />

acid relief tab 200mg OTC<br />

CIMETID/NACL INJ 300/50ML PA<br />

cimetidine sol 300/5ml<br />

cimetidine tab 200mg<br />

cimetidine tab 200mg OTC<br />

cimetidine tab 300mg<br />

cimetidine tab 400mg<br />

cimetidine tab 800mg<br />

cimetidine hcl inj 150 mg/ml PA<br />

cimetidine hcl soln 300 mg/5ml<br />

cimetidine tab 200 mg<br />

cimetidine tab 200 mg OTC<br />

cimetidine tab 300 mg<br />

cimetidine tab 400 mg<br />

cimetidine tab 800 mg<br />

eq heartburn tab relief OTC<br />

famotidine tab 20mg NF<br />

famotidine tab 40mg NF<br />

famotidine in nacl 0.9% iv soln 20 mg/50ml PA<br />

famotidine inj 10 mg/ml PA<br />

famotidine tab 20 mg NF<br />

famotidine tab 40 mg NF<br />

heartburn tab 200mg OTC<br />

heartburn tab relief OTC<br />

heartburn tab relief OTC<br />

heartburn tab relief OTC<br />

mp heartburn tab 200mg OTC<br />

PEPCID SUS 40MG/5ML PA<br />

qc heartburn tab 200mg OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 142


anitidine cap 150mg<br />

ranitidine cap 300mg<br />

ranitidine syp 150/10ml<br />

ranitidine syp 15mg/ml<br />

ranitidine syp 75mg/5ml<br />

ranitidine syp 75mg/5ml<br />

ranitidine hcl cap 150 mg<br />

ranitidine hcl cap 300 mg<br />

RANITIDINE HCL EFFER GRANULES PACKET 150 MG<br />

ranitidine hcl inj 25 mg/ml PA<br />

ranitidine hcl syrup 15 mg/ml (75 mg/5ml)<br />

sm acid redu tab 200mg OTC<br />

ZANTAC GRA 150MG<br />

ZANTAC INJ 50/50ML PA<br />

ZANTAC TAB 150MG EF PA<br />

ZANTAC TAB 25MG EF PA<br />

Prostaglandins<br />

misoprostol tab 100mcg<br />

misoprostol tab 200mcg<br />

misoprostol tab 100 mcg<br />

misoprostol tab 200 mcg<br />

Protectants<br />

CARAFATE SUS 1GM/10ML<br />

SUCRALFATE SUS 1GM/10ML<br />

sucralfate tab 1gm<br />

SUCRALFATE SUSP 1 GM/10ML<br />

sucralfate tab 1 gm<br />

Proton-pump Inhibitors<br />

AMOXICILLIN CAP-CLARITHRO TAB-LANSOPRAZ CAP DR THERAPY PACK<br />

lansoprazole cap delayed release 15 mg PA<br />

lansoprazole cap delayed release 30 mg PA<br />

LANSOPRAZOLE TAB DELAYED RELEASE ORALLY DISINTEGRATING 15 MG QL<br />

LANSOPRAZOLE TAB DELAYED RELEASE ORALLY DISINTEGRATING 30 MG QL<br />

NEXIUM CAP 20MG PA<br />

NEXIUM CAP 40MG PA<br />

NEXIUM I.V. INJ 20MG PA<br />

NEXIUM I.V. INJ 40MG PA<br />

omeprazole cap 20mg QL<br />

omeprazole cap delayed release 10 mg PA<br />

omeprazole cap delayed release 20 mg QL<br />

omeprazole cap delayed release 40 mg PA<br />

pantoprazole sodium ec tab 20 mg (base equiv) PA<br />

pantoprazole sodium ec tab 40 mg (base equiv) PA<br />

PREVACID CAP 15MG DR PA<br />

PREVACID CAP 30MG DR PA<br />

PREVACID GRA 15MG PA<br />

PREVACID GRA 30MG PA<br />

PREVACID TAB 15MG STB QL<br />

PREVACID TAB 30MG STB QL<br />

PREVACID 24H CAP 15MG DR PA OTC<br />

PREVACID I.V INJ 30MG PA<br />

PREVPAC MIS<br />

PROTONIX INJ 40MG PA<br />

PROTONIX TAB 40MG PA<br />

ZEGERID CAP 20-1100 PA<br />

ZEGERID CAP 40-1100 PA<br />

ZEGERID POW 20-1680 PA<br />

ZEGERID POW 40-1680 PA<br />

ZEGERID OTC CAP 20-1100 PA OTC<br />

Prokinetic Agents<br />

metoclopram syp 5mg/5ml<br />

metoclopram tab 10mg<br />

metoclopram tab 5mg<br />

metoclopramide hcl inj 5 mg/ml PA<br />

metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) PA<br />

metoclopramide hcl syrup 5 mg/5ml<br />

metoclopramide hcl tab 10 mg<br />

metoclopramide hcl tab 5 mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 143


Anti-inflammatory Agents<br />

ASACOL TAB 400MG DR PA<br />

LIALDA TAB 1.2GM PA<br />

MESALAMINE CAP CR 250 MG<br />

MESALAMINE CAP CR 500 MG<br />

PENTASA CAP 250MG CR<br />

PENTASA CAP 500MG CR<br />

GI <strong>Drugs</strong>, Miscellaneous<br />

CIMZIA KIT PA<br />

CIMZIA KIT 200MG/ML PA<br />

RELISTOR INJ 12/0.6ML PA QL<br />

RELISTOR KIT 12/0.6ML PA QL<br />

XENICAL CAP 120MG PA<br />

Gold Compounds<br />

gold sodium thiomalate inj 50 mg/ml PA<br />

Heavy Metal Antagonists<br />

BAL IN OIL INJ 100MG/ML PA<br />

CALCIUM DISO INJ 200MG/ML PA<br />

CALCIUM DISO INJ 500/2.5M PA<br />

deferoxamine mesylate for inj 2 gm PA<br />

deferoxamine mesylate for inj 500 mg PA<br />

edetate disodium inj 150 mg/ml PA<br />

ENDRATE INJ 150MG/ML PA<br />

SOD NITRITE INJ 30MG/ML PA<br />

SOD THIOSULF INJ 10% PA<br />

SOD THIOSULF INJ 25% PA<br />

sodium thiosulfate inj 10% PA<br />

sodium thiosulfate inj 25% PA<br />

Hormones and Synthetic Substitutes<br />

Adrenals<br />

AEROBID AER 250MCG QL<br />

AEROBID-M AER 250MCG QL<br />

ALVESCO AER 160MCG PA<br />

ALVESCO AER 80MCG PA<br />

ARISTOSPAN INJ 20MG/ML PA<br />

ARISTOSPAN INJ 5MG/ML PA<br />

AZMACORT AER 75MCG QL<br />

baycadron elx 0.5/5ml<br />

BECLOMETHASONE DIPROPIONATE INHAL AERO SOLN 40 MCG/ACT QL<br />

BECLOMETHASONE DIPROPIONATE INHAL AERO SOLN 80 MCG/ACT QL<br />

betamethasone acetate & sod phosphate inj susp 3-3 mg/ml PA<br />

budesonide sus 0.25mg/2 QL<br />

budesonide sus 0.5mg/2 QL<br />

BUDESONIDE INHAL AERO POWD 200 MCG/INH (BREATH ACTIVATED) QL<br />

budesonide inhalation susp 0.25 mg/2ml QL<br />

budesonide inhalation susp 0.5 mg/2ml QL<br />

BUDESONIDE INHALATION SUSP 1 MG/2ML QL<br />

DEPO-MEDROL INJ 20MG/ML PA<br />

dexamethason elx 0.5/5ml<br />

dexamethason tab 0.5mg<br />

dexamethason tab 0.75mg<br />

dexamethason tab 1.5mg<br />

dexamethason tab 1mg<br />

dexamethason tab 2mg<br />

dexamethason tab 4mg<br />

dexamethason tab 6mg<br />

dexamethasone elixir 0.5 mg/5ml<br />

dexamethasone sodium phosphate inj 10 mg/ml PA<br />

dexamethasone sodium phosphate inj 4 mg/ml PA<br />

dexamethasone tab 0.5 mg<br />

dexamethasone tab 0.75 mg<br />

dexamethasone tab 1 mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 144


dexamethasone tab 1.5 mg<br />

dexamethasone tab 1.5 mg taper pack<br />

DEXAMETHASONE TAB 1.5 MG TAPER PACK<br />

dexamethasone tab 2 mg<br />

dexamethasone tab 4 mg<br />

dexamethasone tab 6 mg<br />

DEXPAK PAK 10 DAY<br />

DEXPAK PAK 13 DAY<br />

FLOVENT HFA AER 110MCG QL<br />

FLOVENT HFA AER 220MCG QL<br />

FLOVENT HFA AER 44MCG QL<br />

fludrocort tab 0.1mg NF<br />

fludrocortisone acetate tab 0.1 mg NF<br />

FLUNISOLIDE INHAL AEROSOL 250 MCG/ACT QL<br />

FLUTICASONE PROPIONATE HFA INHAL AEROSOL 110 MCG/ACT QL<br />

FLUTICASONE PROPIONATE HFA INHAL AEROSOL 220 MCG/ACT QL<br />

FLUTICASONE PROPIONATE HFA INHAL AEROSOL 44 MCG/ACT QL<br />

hydrocort tab 10mg<br />

hydrocort tab 20mg<br />

hydrocort tab 5mg<br />

hydrocortisone sodium succinate for inj 100 mg PA<br />

hydrocortisone tab 10 mg<br />

hydrocortisone tab 20 mg<br />

hydrocortisone tab 5 mg<br />

MEDROL TAB 16MG<br />

MEDROL TAB 2MG<br />

methylpred pak 4mg<br />

methylpred tab 16mg<br />

methylpred tab 32mg<br />

methylpred tab 4mg<br />

methylpred tab 8mg<br />

methylprednisolone acetate inj susp 40 mg/ml PA<br />

methylprednisolone acetate inj susp 80 mg/ml PA<br />

methylprednisolone sodium succinate for inj 1000 mg PA<br />

methylprednisolone sodium succinate for inj 125 mg PA<br />

methylprednisolone sodium succinate for inj 40 mg PA<br />

methylprednisolone sodium succinate for inj 500 mg PA<br />

METHYLPREDNISOLONE TAB 16 MG<br />

methylprednisolone tab 16 mg<br />

METHYLPREDNISOLONE TAB 2 MG<br />

methylprednisolone tab 32 mg<br />

methylprednisolone tab 4 mg<br />

methylprednisolone tab 4 mg dose pack<br />

methylprednisolone tab 8 mg<br />

MILLIPRED SOL 10MG/5ML<br />

MILLIPRED TAB 5MG<br />

pred sod pho sol 5mg/5ml<br />

pred sod pho sol 6.7/5ml<br />

PREDNISOLONE SOD PHOSPHATE ORAL SOLN 10 MG/5ML (BASE EQUIV)<br />

prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)<br />

PREDNISOLONE SOD PHOSPHATE ORAL SOLN 20 MG/5ML (BASE EQUIV)<br />

prednisolone sod phosphate oral soln 5 mg/5ml (base equiv)<br />

prednisolone sol 15mg/5ml<br />

prednisolone sol 15mg/5ml<br />

prednisolone sol 15mg/5ml<br />

prednisolone syp 15mg/5ml<br />

prednisolone syp 5mg/5ml<br />

prednisolone syrup 15 mg/5ml (usp solution equivalent)<br />

prednisolone syrup 5 mg/5ml<br />

PREDNISOLONE TAB 5 MG<br />

prednisolone tab 5 mg<br />

PREDNISOLONE TAB 5MG<br />

prednisolone tab 5mg<br />

prednisone tab 10mg<br />

prednisone tab 1mg<br />

prednisone tab 2.5mg<br />

prednisone tab 20mg<br />

PREDNISONE TAB 50MG<br />

prednisone tab 50mg<br />

prednisone tab 5mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 145


prednisone tab 1 mg<br />

prednisone tab 10 mg<br />

prednisone tab 2.5 mg<br />

prednisone tab 20 mg<br />

prednisone tab 5 mg<br />

PREDNISONE TAB 50 MG<br />

prednisone tab 50 mg<br />

PULMICORT AER 200MCG QL<br />

PULMICORT INH 180MCG PA QL<br />

PULMICORT INH 200MCG QL<br />

PULMICORT INH 90MCG PA QL<br />

PULMICORT SUS 1MG/2ML QL<br />

QVAR AER 40MCG QL<br />

QVAR AER 80MCG QL<br />

SOLU-CORTEF INJ 1000MG PA<br />

SOLU-CORTEF INJ 250MG PA<br />

SOLU-CORTEF INJ 500MG PA<br />

SOLU-MEDROL INJ 2GM PA<br />

TRIAMCINOLONE ACETONIDE INHAL AEROSOL 75 MCG/ACT (200/VALVE) QL<br />

triamcinolone acetonide inj susp 10 mg/ml PA<br />

triamcinolone acetonide inj susp 40 mg/ml PA<br />

VERIPRED 20 SOL 20MG/5ML<br />

zema-pak pak 10 day<br />

zema-pak pak 13 day<br />

zema-pak pak 6 day<br />

Androgens<br />

danazol cap 100mg<br />

danazol cap 200mg<br />

danazol cap 50mg<br />

danazol cap 100 mg<br />

danazol cap 200 mg<br />

danazol cap 50 mg<br />

NANDROL DEC INJ 100MG/ML PA<br />

NANDROL DEC INJ 200MG/ML PA<br />

TESTOPEL MIS PELLETS PA<br />

testosterone cypionate im in oil 100 mg/ml PA<br />

testosterone cypionate im in oil 200 mg/ml PA<br />

testosterone enanthate im in oil 200 mg/ml PA<br />

Contraceptives<br />

apri tab<br />

aranelle tab<br />

azurette tab 28 day<br />

camila tab 0.35mg<br />

cryselle-28 tab 28 tabs<br />

desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)<br />

desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg<br />

DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.02 MG NF<br />

drospirenone-ethinyl estradiol tab 3-0.03 mg<br />

DROSPIRENONE-ETHINYL ESTRADIOL TAB 3-0.03 MG<br />

enpresse-28 tab<br />

errin tab 0.35mg<br />

ETONOGESTREL-ETHINYL ESTRADIOL VA RING 0.120-0.015 MG/24HR QL<br />

IMPLANON IMP 68MG PA<br />

jolivette tab 0.35mg<br />

kariva tab 28 day<br />

leena tab<br />

levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg<br />

levonorgestrel tab 0.75 mg QL<br />

LEVONORGESTREL TAB 1.5 MG QL<br />

levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg<br />

LEVONORGESTREL-ETH ESTRA TAB 0.05-30/0.075-40/0.125-30MG-MCG<br />

levora-28 tab 0.15/30<br />

low-ogestrel tab<br />

mononessa tab<br />

necon tab 0.5/35<br />

necon tab 1/35-28<br />

necon tab 1/50-28<br />

NECON TAB 10/11-28<br />

necon 7/7/7 tab 28 day<br />

next choice tab 0.75mg QL<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 146


nora-be tab 0.35mg<br />

NORELGESTROMIN-ETHINYL ESTRADIOL TD PTWK 150-20 MCG/24HR QL<br />

norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg<br />

norethindrone & ethinyl estradiol tab 1 mg-35 mcg<br />

norethindrone & mestranol tab 1 mg-50 mcg<br />

norethindrone tab 0.35 mg<br />

norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg<br />

NORETHINDRONE-ETH ESTRADIOL TAB 0.5-35/1-35 MG-MCG (10/11)<br />

norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg<br />

norgest/eth tab estrad<br />

norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg<br />

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg<br />

norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg<br />

nortrel (21) tab 1/35<br />

nortrel (28) tab 1/35<br />

nortrel 28 tab 0.5/35<br />

nortrel7/7/7 tab 28 days<br />

NUVARING MIS QL<br />

OCELLA TAB 3-0.03MG<br />

ocella tab 3-0.03mg<br />

ogestrel tab<br />

ORTHO EVRA DIS WEEK QL<br />

ORTHO TRI- TAB CYCLN LO PA<br />

PLAN B TAB 1.5MG QL<br />

portia-28 tab<br />

previfem tab<br />

reclipsen tab<br />

solia tab<br />

sprintec 28 tab 28 day<br />

TRIPHASIL 28 TAB<br />

trivora-28 tab<br />

YAZ TAB 3-0.02MG NF<br />

Estrogens and Antiestrogens<br />

Estrogens<br />

DEPO-ESTRADI INJ 5MG/ML PA<br />

ESTRADIOL TD PATCH BIWEEKLY 0.0375 MG/24HR NF<br />

ESTRADIOL TD PATCH BIWEEKLY 0.05 MG/24HR NF<br />

ESTRADIOL TD PATCH BIWEEKLY 0.075 MG/24HR NF<br />

ESTRADIOL TD PATCH BIWEEKLY 0.1 MG/24HR NF<br />

estradiol valerate im in oil 10 mg/ml PA<br />

estradiol valerate im in oil 20 mg/ml PA<br />

estradiol valerate im in oil 40 mg/ml PA<br />

PREMARIN INJ 25MG PA<br />

VIVELLE-DOT DIS 0.0375MG NF<br />

VIVELLE-DOT DIS 0.05MG NF<br />

VIVELLE-DOT DIS 0.075MG NF<br />

VIVELLE-DOT DIS 0.1MG NF<br />

Gonadotropins<br />

BRAVELLE INJ 75UNIT PA<br />

chorionic gonadotropin for inj 10000 unit PA<br />

FOLLISTIM AQ INJ 150UNIT PA<br />

FOLLISTIM AQ INJ 300UNIT PA<br />

FOLLISTIM AQ INJ 600UNIT PA<br />

FOLLISTIM AQ INJ 75UNIT PA<br />

FOLLISTIM AQ INJ 900UNIT PA<br />

GONAL-F INJ 1050UNIT PA<br />

GONAL-F INJ 450UNIT PA<br />

GONAL-F RFF INJ 300 PA<br />

GONAL-F RFF INJ 450 PA<br />

GONAL-F RFF INJ 75UNIT PA<br />

GONAL-F RFF INJ 900 PA<br />

LUVERIS INJ 75UNIT PA<br />

MENOPUR INJ 75UNIT PA<br />

NAFARELIN ACETATE NASAL SOLN 2 MG/ML<br />

OVIDREL INJ PA<br />

PROFASI HP INJ 5000UNIT PA<br />

REPRONEX INJ 75UNIT PA<br />

SYNAREL SOL 2MG/ML<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 147


Antidiabetic Agents<br />

Alpha-Glucosidase Inhibitors<br />

acarbose tab 100 mg PA<br />

acarbose tab 25 mg PA<br />

acarbose tab 50 mg PA<br />

Amylinomimetics<br />

SYMLIN INJ 600MCG PA<br />

SYMLINPEN 60 INJ 1000MCG PA<br />

SYMLNPEN 120 INJ 1000MCG PA<br />

Biguanides<br />

METFORMIN TAB 850MG<br />

metformin hcl tab 1000 mg PA QL<br />

metformin hcl tab 500 mg PA<br />

METFORMIN HCL TAB 850 MG<br />

metformin hcl tab 850 mg PA<br />

Incretin Mimetics<br />

BYETTA INJ 10MCG PA<br />

BYETTA INJ 5MCG PA<br />

VICTOZA INJ 18MG/3ML PA<br />

Insulins<br />

APIDRA INJ NF<br />

APIDRA INJ SOLOSTAR NF<br />

APIDRA INJ U-100 NF<br />

EXUBERA POW KIT NF<br />

EXUBERA COMB POW PACK 12 NF<br />

EXUBERA COMB POW PACK 15 NF<br />

EXUBERA PTPK POW 1MG NF<br />

EXUBERA PTPK POW 3MG NF<br />

HUMALOG INJ 100/ML PA<br />

HUMALOG INJ 100/ML QL<br />

HUMALOG KWIK INJ 100/ML QL<br />

HUMALOG MIX INJ 50/50 QL<br />

HUMALOG MIX INJ 50/50KWP QL<br />

HUMALOG MIX INJ 75/25KWP QL<br />

HUMALOG MIX SUS 75/25 QL<br />

HUMALOG PEN INJ 100/ML QL<br />

HUMALOG PEN INJ 100/ML PA<br />

HUMALOG PEN INJ 100/ML QL<br />

HUMALOG PEN INJ 50/50 QL<br />

HUMALOG PEN INJ 75/25 QL<br />

HUMULIN INJ 50/50 OTC<br />

HUMULIN INJ 70/30 OTC<br />

HUMULIN N INJ U-100 OTC<br />

HUMULIN N PN INJ U-100 OTC<br />

HUMULIN N PN INJ U-100 OTC QL<br />

HUMULIN N PN INJ U-100 OTC<br />

HUMULIN PEN INJ 70/30 OTC QL<br />

HUMULIN PEN INJ 70/30 OTC<br />

HUMULIN R INJ U-100 OTC<br />

HUMULIN R INJ U-100 OTC<br />

HUMULIN R INJ U-500<br />

INSULIN ASPART INJ 100 UNIT/ML NF<br />

INSULIN ASPART INJ 100 UNIT/ML QL<br />

INSULIN ASPART PROT & ASPART (HUMAN) INJ 100 UNIT/ML (70-30) QL<br />

INSULIN ASPART PROT & ASPART (HUMAN) INJ 100 UNIT/ML (70-30) NF<br />

INSULIN DETEMIR INJ 100 UNIT/ML NF<br />

INSULIN GLARGINE INJ 100 UNIT/ML QL<br />

INSULIN GLARGINE INJ 100 UNIT/ML QL<br />

INSULIN GLULISINE INJ 100 UNIT/ML NF<br />

INSULIN GLULISINE SUBCUTANEOUS INJ 100 UNIT/ML NF<br />

INSULIN ISOPHANE & REGULAR (HUMAN) INJ 100 UNIT/ML (50-50) OTC<br />

INSULIN ISOPHANE & REGULAR (HUMAN) INJ 100 UNIT/ML (70-30) OTC<br />

INSULIN ISOPHANE & REGULAR (HUMAN) INJ 100 UNIT/ML (70-30) OTC QL<br />

INSULIN ISOPHANE & REGULAR (HUMAN) INJ 100 UNIT/ML (70-30) OTC NF<br />

INSULIN ISOPHANE & REGULAR (HUMAN) INJ 100 UNIT/ML (70-30) OTC<br />

INSULIN ISOPHANE (HUMAN) INJ 100 UNIT/ML OTC QL<br />

INSULIN ISOPHANE (HUMAN) INJ 100 UNIT/ML OTC NF<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 148


INSULIN ISOPHANE (HUMAN) INJ 100 UNIT/ML OTC<br />

INSULIN ISOPHANE (HUMAN) INJ 100 UNIT/ML OTC<br />

INSULIN LISPRO (HUMAN) INJ 100 UNIT/ML QL<br />

INSULIN LISPRO (HUMAN) INJ 100 UNIT/ML QL<br />

INSULIN LISPRO PROT & LISPRO (HUMAN) INJ 100 UNIT/ML (50-50) QL<br />

INSULIN LISPRO PROT & LISPRO (HUMAN) INJ 100 UNIT/ML (50-50) QL<br />

INSULIN LISPRO PROT & LISPRO (HUMAN) INJ 100 UNIT/ML (75-25) QL<br />

INSULIN LISPRO PROT & LISPRO (HUMAN) INJ 100 UNIT/ML (75-25) QL<br />

INSULIN REGULAR (HUMAN) INHALATION POWDER 1 & 3 MG/BLISTER NF<br />

INSULIN REGULAR (HUMAN) INHALATION POWDER 1 MG/BLISTER NF<br />

INSULIN REGULAR (HUMAN) INHALATION POWDER 3 MG/BLISTER NF<br />

INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML OTC<br />

INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML OTC NF<br />

INSULIN REGULAR (HUMAN) INJ 100 UNIT/ML OTC<br />

INSULIN REGULAR (HUMAN) INJ 500 UNIT/ML<br />

LANTUS INJ 100/ML QL<br />

LANTUS INJ SOLOSTAR QL<br />

LANTUS FOR INJ OPTICLIK QL<br />

LEVEMIR INJ NF<br />

LEVEMIR INJ FLEXPEN NF<br />

NOVOLIN INJ 70/30 OTC<br />

NOVOLIN INJ 70/30 OTC NF<br />

NOVOLIN 70/ INJ 30 INNLT OTC<br />

NOVOLIN 70/ INJ 30 PNFIL OTC NF<br />

NOVOLIN N INJ INNOLET OTC<br />

NOVOLIN N INJ PENFILL OTC NF<br />

NOVOLIN N INJ U-100 OTC NF<br />

NOVOLIN N INJ U-100 OTC<br />

NOVOLIN N INJ U-100 OTC NF<br />

NOVOLIN R INJ INNOLET OTC<br />

NOVOLIN R INJ PENFILL OTC<br />

NOVOLIN R INJ PENFILL OTC NF<br />

NOVOLIN R INJ U-100 OTC NF<br />

NOVOLIN R INJ U-100 OTC NF<br />

NOVOLIN R INJ U-100 OTC<br />

NOVOLOG INJ 100/ML NF<br />

NOVOLOG INJ FLEXPEN QL<br />

NOVOLOG INJ FLEXPEN NF<br />

NOVOLOG INJ PENFILL NF<br />

NOVOLOG MIX INJ 70/30 NF<br />

NOVOLOG MIX INJ FLEXPEN QL<br />

NOVOLOG MIX INJ FLEXPEN NF<br />

NOVOLOG MIX INJ PENFILL NF<br />

RELION 70/30 INJ 100/ML PA OTC<br />

RELION 70/30 INJ INNOLET PA OTC<br />

RELION N INJ 100/ML PA OTC<br />

RELION N INJ INNOLET PA OTC<br />

RELION R INJ 100/ML PA OTC<br />

Meglitinides<br />

PRANDIN TAB 0.5MG PA<br />

PRANDIN TAB 1MG PA<br />

PRANDIN TAB 2MG PA<br />

Sulfonylureas<br />

chlorpropam tab 100mg<br />

chlorpropam tab 250mg<br />

chlorpropamide tab 100 mg<br />

chlorpropamide tab 250 mg<br />

DIABETA TAB 2.5MG NF<br />

DIABETA TAB 5MG NF<br />

glimepiride tab 1mg<br />

glimepiride tab 2mg<br />

glimepiride tab 4mg<br />

glimepiride tab 1 mg<br />

glimepiride tab 2 mg<br />

glimepiride tab 4 mg<br />

glipizide tab 10mg<br />

glipizide tab 5mg<br />

glipizide er tab 10mg<br />

glipizide er tab 2.5mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 149


glipizide er tab 5mg<br />

glipizide tab 10 mg<br />

glipizide tab 5 mg<br />

glipizide tab sr 24hr 10 mg<br />

glipizide tab sr 24hr 2.5 mg<br />

GLIPIZIDE TAB SR 24HR 2.5 MG<br />

glipizide tab sr 24hr 5 mg<br />

glipizide xl tab 10mg<br />

glipizide xl tab 2.5mg<br />

glipizide xl tab 5mg<br />

GLUCOTROL XL TAB 2.5MG<br />

glyburid mcr tab 1.5mg<br />

glyburid mcr tab 3mg<br />

glyburide micronized tab 1.5 mg<br />

glyburide micronized tab 3 mg<br />

glyburide micronized tab 6 mg PA<br />

GLYBURIDE TAB 2.5 MG NF<br />

GLYBURIDE TAB 5 MG NF<br />

glycron tab 1.5mg<br />

glycron tab 3mg<br />

tolazamide tab 100mg<br />

TOLAZAMIDE TAB 250MG<br />

tolazamide tab 250mg<br />

tolazamide tab 500mg<br />

TOLAZAMIDE TAB 500MG<br />

tolazamide tab 100 mg<br />

TOLAZAMIDE TAB 250 MG<br />

tolazamide tab 250 mg<br />

TOLAZAMIDE TAB 500 MG<br />

tolazamide tab 500 mg<br />

tolbutamide tab 500 mg PA<br />

Thiazolidinediones<br />

ACTOS TAB 15MG PA<br />

ACTOS TAB 30MG PA<br />

ACTOS TAB 45MG PA<br />

AVANDAMET TAB 1-500MG PA<br />

AVANDAMET TAB 2-1000MG PA<br />

AVANDAMET TAB 2-500MG PA<br />

AVANDAMET TAB 4-1000MG PA<br />

AVANDAMET TAB 4-500MG PA<br />

AVANDIA TAB 2MG PA<br />

AVANDIA TAB 4MG PA<br />

AVANDIA TAB 8MG PA<br />

Antihypoglycemic Agents<br />

Glycogenolytic Agents<br />

GLUCAGEN INJ 1MG PA<br />

GLUCAGEN INJ HYPOKIT PA<br />

GLUCAGON KIT 1MG<br />

glucagon kit 1mg<br />

GLUCAGON (RDNA) FOR INJ KIT 1 MG<br />

glucagon (rdna) for inj kit 1 mg<br />

Parathyroid<br />

calcitonin (salmon) nasal soln 200 unit/act PA<br />

FORTEO SOL 600/2.4 PA<br />

FORTEO SOL 750/3ML PA<br />

MIACALCIN INJ 200/ML PA<br />

Pituitary<br />

ACTHAR HP INJ 80UNIT PA<br />

desmopressin acetate inj 4 mcg/ml PA<br />

desmopressin acetate nasal soln 0.01% (refrigerated)<br />

desmopressin acetate nasal spray soln 0.01%<br />

desmopressin acetate nasal spray soln 0.01% (refrigerated)<br />

desmopressin acetate tab 0.1 mg PA<br />

desmopressin acetate tab 0.2 mg PA<br />

desmopressin sol 0.01%<br />

desmopressin spr 0.01%<br />

minirin spr nasal<br />

STIMATE SOL 1.5MG/ML PA<br />

vasopressin inj 20 unit/ml PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 150


Somatotropin Agonists and Antagonists<br />

Somatotropin Agonists<br />

GENOTROPIN INJ 0.2MG PA<br />

GENOTROPIN INJ 0.4MG PA<br />

GENOTROPIN INJ 0.6MG PA<br />

GENOTROPIN INJ 0.8MG PA<br />

GENOTROPIN INJ 1.2MG PA<br />

GENOTROPIN INJ 1.4MG PA<br />

GENOTROPIN INJ 1.6MG PA<br />

GENOTROPIN INJ 1.8MG PA<br />

GENOTROPIN INJ 12MG PA<br />

GENOTROPIN INJ 1MG PA<br />

GENOTROPIN INJ 2MG PA<br />

GENOTROPIN INJ 5MG PA<br />

HUMATROPE INJ 12MG PA<br />

HUMATROPE INJ 24MG PA<br />

HUMATROPE INJ 5MG PA<br />

HUMATROPE INJ 6MG PA<br />

INCRELEX INJ 40MG/4ML PA<br />

IPLEX INJ 36/0.6ML PA<br />

NORDITROPIN INJ 10/1.5ML PA<br />

NORDITROPIN INJ 10/1.5ML PA<br />

NORDITROPIN INJ 15/1.5ML PA<br />

NORDITROPIN INJ 15/1.5ML PA<br />

NORDITROPIN INJ 15/1.5ML PA<br />

NORDITROPIN INJ 30/3ML PA<br />

NORDITROPIN INJ 5/1.5ML PA<br />

NORDITROPIN INJ 5/1.5ML PA<br />

NORDITROPIN INJ 5/1.5ML PA<br />

NUTROPIN INJ 10MG PA<br />

NUTROPIN INJ 5MG PA<br />

NUTROPIN AQ INJ 10MG/2ML PA<br />

NUTROPIN AQ INJ 20MG/2ML PA<br />

NUTROPIN AQ INJ NUSPIN 5 PA<br />

OMNITROPE INJ 10/1.5ML PA<br />

OMNITROPE INJ 5.8MG PA<br />

OMNITROPE INJ 5/1.5ML PA<br />

TEV-TROPIN INJ 5MG PA<br />

Somatotropin Antagonists<br />

SOMAVERT INJ 10MG PA<br />

SOMAVERT INJ 15MG PA<br />

SOMAVERT INJ 20MG PA<br />

Progestins<br />

DEPO-PROVERA INJ 400/ML PA<br />

DEPO-SQ PROV INJ 104 PA<br />

medroxypr ac tab 10mg<br />

medroxypr ac tab 2.5mg<br />

medroxypr ac tab 5mg<br />

medroxyprogesterone acetate im susp 150 mg/ml PA<br />

medroxyprogesterone acetate tab 10 mg<br />

medroxyprogesterone acetate tab 2.5 mg<br />

medroxyprogesterone acetate tab 5 mg<br />

norethin ace tab 5mg<br />

norethindrone acetate tab 5 mg<br />

progesterone im in oil 50 mg/ml PA<br />

Thyroid and Antithyroid Agents<br />

Thyroid Agents<br />

ARMOUR THYRO TAB 120MG<br />

ARMOUR THYRO TAB 15MG<br />

ARMOUR THYRO TAB 180MG<br />

ARMOUR THYRO TAB 240MG<br />

ARMOUR THYRO TAB 300MG<br />

ARMOUR THYRO TAB 30MG<br />

ARMOUR THYRO TAB 60MG<br />

ARMOUR THYRO TAB 90MG<br />

levothroid tab 100mcg<br />

levothroid tab 112mcg<br />

levothroid tab 125mcg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 151


levothroid tab 137mcg<br />

levothroid tab 150mcg<br />

levothroid tab 175mcg<br />

levothroid tab 200mcg<br />

levothroid tab 25mcg<br />

levothroid tab 300mcg<br />

levothroid tab 50mcg<br />

levothroid tab 75mcg<br />

levothroid tab 88mcg<br />

levothyroxin tab 100mcg<br />

levothyroxin tab 112mcg<br />

levothyroxin tab 125mcg<br />

levothyroxin tab 137mcg<br />

levothyroxin tab 150mcg<br />

levothyroxin tab 175mcg<br />

levothyroxin tab 200mcg<br />

levothyroxin tab 25mcg<br />

levothyroxin tab 300mcg<br />

levothyroxin tab 50mcg<br />

levothyroxin tab 75mcg<br />

levothyroxin tab 88mcg<br />

levothyroxine sodium for inj 200 mcg PA<br />

levothyroxine sodium for inj 500 mcg PA<br />

LEVOTHYROXINE SODIUM TAB 100 MCG<br />

levothyroxine sodium tab 100 mcg<br />

LEVOTHYROXINE SODIUM TAB 112 MCG<br />

levothyroxine sodium tab 112 mcg<br />

LEVOTHYROXINE SODIUM TAB 125 MCG<br />

levothyroxine sodium tab 125 mcg<br />

LEVOTHYROXINE SODIUM TAB 137 MCG<br />

levothyroxine sodium tab 137 mcg<br />

LEVOTHYROXINE SODIUM TAB 150 MCG<br />

levothyroxine sodium tab 150 mcg<br />

LEVOTHYROXINE SODIUM TAB 175 MCG<br />

levothyroxine sodium tab 175 mcg<br />

LEVOTHYROXINE SODIUM TAB 200 MCG<br />

levothyroxine sodium tab 200 mcg<br />

LEVOTHYROXINE SODIUM TAB 25 MCG<br />

levothyroxine sodium tab 25 mcg<br />

LEVOTHYROXINE SODIUM TAB 300 MCG<br />

levothyroxine sodium tab 300 mcg<br />

LEVOTHYROXINE SODIUM TAB 50 MCG<br />

levothyroxine sodium tab 50 mcg<br />

levothyroxine sodium tab 75 mcg<br />

LEVOTHYROXINE SODIUM TAB 75 MCG<br />

LEVOTHYROXINE SODIUM TAB 88 MCG<br />

levothyroxine sodium tab 88 mcg<br />

levoxyl tab 100mcg<br />

LEVOXYL TAB 100MCG<br />

levoxyl tab 112mcg<br />

LEVOXYL TAB 112MCG<br />

LEVOXYL TAB 125MCG<br />

levoxyl tab 125mcg<br />

levoxyl tab 137mcg<br />

LEVOXYL TAB 137MCG<br />

levoxyl tab 150mcg<br />

LEVOXYL TAB 150MCG<br />

levoxyl tab 175mcg<br />

LEVOXYL TAB 175MCG<br />

LEVOXYL TAB 200MCG<br />

levoxyl tab 200mcg<br />

LEVOXYL TAB 25MCG<br />

levoxyl tab 25mcg<br />

LEVOXYL TAB 300MCG<br />

levoxyl tab 300mcg<br />

levoxyl tab 50mcg<br />

LEVOXYL TAB 50MCG<br />

LEVOXYL TAB 75MCG<br />

levoxyl tab 75mcg<br />

LEVOXYL TAB 88MCG<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 152


levoxyl tab 88mcg<br />

liothyronine sodium iv soln 10 mcg/ml PA<br />

NATURE-THROI TAB 130MG<br />

NATURE-THROI TAB 16.25MG<br />

NATURE-THROI TAB 195MG<br />

NATURE-THROI TAB 32.5MG<br />

NATURE-THROI TAB 65MG<br />

SYNTHROID TAB 100MCG<br />

SYNTHROID TAB 112MCG<br />

SYNTHROID TAB 125MCG<br />

SYNTHROID TAB 137MCG<br />

SYNTHROID TAB 150MCG<br />

SYNTHROID TAB 175MCG<br />

SYNTHROID TAB 200MCG<br />

SYNTHROID TAB 25MCG<br />

SYNTHROID TAB 300MCG<br />

SYNTHROID TAB 50MCG<br />

SYNTHROID TAB 75MCG<br />

SYNTHROID TAB 88MCG<br />

thyroid tab 120mg<br />

thyroid tab 130mg<br />

thyroid tab 15mg<br />

thyroid tab 180mg<br />

thyroid tab 195mg<br />

thyroid tab 1gr<br />

thyroid tab 2gr<br />

thyroid tab 30mg<br />

thyroid tab 32.4mg<br />

thyroid tab 32.5mg<br />

thyroid tab 60mg<br />

thyroid tab 65mg<br />

thyroid tab 90mg<br />

THYROID TAB 120 MG (2 GRAIN)<br />

thyroid tab 120 mg (2 grain)<br />

THYROID TAB 130 MG<br />

thyroid tab 130 mg<br />

THYROID TAB 15 MG (1/4 GRAIN)<br />

thyroid tab 15 mg (1/4 grain)<br />

THYROID TAB 16.25 MG<br />

THYROID TAB 180 MG (3 GRAIN)<br />

thyroid tab 180 mg (3 grain)<br />

THYROID TAB 195 MG<br />

thyroid tab 195 mg<br />

THYROID TAB 240 MG (4 GRAIN)<br />

THYROID TAB 30 MG (1/2 GRAIN)<br />

thyroid tab 30 mg (1/2 grain)<br />

THYROID TAB 300 MG (5 GRAIN)<br />

thyroid tab 32.4 mg<br />

THYROID TAB 32.5 MG<br />

thyroid tab 32.5 mg<br />

THYROID TAB 60 MG (1 GRAIN)<br />

thyroid tab 60 mg (1 grain)<br />

THYROID TAB 65 MG<br />

thyroid tab 65 mg<br />

THYROID TAB 90 MG (1 1/2 GRAIN)<br />

thyroid tab 90 mg (1 1/2 grain)<br />

unith direct tab 100mcg<br />

unith direct tab 112mcg<br />

unith direct tab 125mcg<br />

unith direct tab 150mcg<br />

unith direct tab 175mcg<br />

unith direct tab 200mcg<br />

unith direct tab 25mcg<br />

unith direct tab 300mcg<br />

unith direct tab 50mcg<br />

unith direct tab 75mcg<br />

unith direct tab 88mcg<br />

unithroid tab 100mcg<br />

unithroid tab 112mcg<br />

unithroid tab 125mcg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 153


unithroid tab 137mcg<br />

unithroid tab 150mcg<br />

unithroid tab 175mcg<br />

unithroid tab 200mcg<br />

unithroid tab 25mcg<br />

unithroid tab 300mcg<br />

unithroid tab 50mcg<br />

unithroid tab 75mcg<br />

unithroid tab 88mcg<br />

WESTHROID TAB 130MG<br />

WESTHROID TAB 32.5MG<br />

WESTHROID TAB 65MG<br />

Antithyroid Agents<br />

methimazole tab 10mg<br />

methimazole tab 5mg<br />

methimazole tab 10 mg<br />

METHIMAZOLE TAB 15 MG<br />

methimazole tab 20 mg<br />

methimazole tab 5 mg<br />

northyx tab 10mg<br />

NORTHYX TAB 15MG<br />

northyx tab 20mg<br />

northyx tab 5mg<br />

propylthiour tab 50mg<br />

propylthiouracil tab 50 mg<br />

Local Anesthetics<br />

BASIC BIOPSY KIT 20GX1.5" PA<br />

BONE MARROW KIT 16G PA<br />

BONE MARROW KIT 16GX2" PA<br />

BONE MARROW KIT 16GX2" PA<br />

BONE MARROW KIT BIOPSY PA<br />

BUPIVA/NS SOL PA<br />

BUPIVA/NS SOL 0.0625% PA<br />

BUPIVA/NS SOL 0.125% PA<br />

BUPIVACA/NS SOL 0.25% PA<br />

bupivacaine 0.75% in dextrose inj 8.25% PA<br />

bupivacaine hcl inj 0.25% PA<br />

bupivacaine hcl inj 0.5% PA<br />

bupivacaine hcl inj 0.75% PA<br />

bupivacaine inj 0.25% w/ epinephrine PA<br />

bupivacaine inj 0.5% w/ epinephrine PA<br />

chloroprocaine hcl inj 2% PA<br />

chloroprocaine hcl inj 3% PA<br />

DUOCAINE INJ PA<br />

LIDO/DEXTROS INJ 5-7.5% PA<br />

lidocaine hcl local inj 0.5% PA<br />

lidocaine hcl local inj 1% PA<br />

lidocaine hcl local inj 1.5% PA<br />

lidocaine hcl local inj 2% PA<br />

lidocaine hcl local inj 4% PA<br />

lidocaine hcl local preservative free (pf) inj 1% PA<br />

lidocaine hcl local preservative free (pf) inj 2% PA<br />

lidocaine inj 0.5% w/ epinephrine-1:200000 PA<br />

lidocaine inj 1% w/ epinephrine-1:100000 PA<br />

lidocaine inj 1% w/ epinephrine-1:200000 PA<br />

lidocaine inj 1.5% w/ epinephrine-1:200000 PA<br />

lidocaine inj 2% w/ epinephrine-1:100000 PA<br />

lidocaine inj 2% w/ epinephrine-1:200000 PA<br />

lidocaine inj 2% w/ epinephrine-1:50000 PA<br />

LUMBAR PUNCT KIT 20GX3.5" PA<br />

LUMBAR PUNCT KIT 22GX2.5" PA<br />

MEPIVACAINE INJ 3% PA<br />

mepivacaine hcl inj 1% PA<br />

mepivacaine hcl inj 1.5% PA<br />

mepivacaine hcl inj 2% PA<br />

NAROPIN INJ 10MG/ML PA<br />

NAROPIN INJ 2MG/ML PA<br />

NAROPIN INJ 5MG/ML PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 154


NAROPIN INJ 7.5MG/ML PA<br />

NESACAINE INJ 1% PA<br />

NOVOCAIN INJ 1% PA<br />

NOVOCAIN INJ 10% PA<br />

PARACENTESIS KIT TRAY 8FR PA<br />

PNEUMOTHORX KIT TRAY 8FR PA<br />

PONTOCAINE INJ 20MG PA<br />

PUDEND/LOCAL KIT 1% LIDO PA<br />

SENSORCAINE INJ -MPF/EPI PA<br />

SPINAL/EPIDU KIT CL CATH PA<br />

SPINAL/EPIDU KIT OPN CATH PA<br />

tetracaine hcl inj 1% PA<br />

Oxytocics<br />

ERGOTRATE INJ 0.2MG/ML PA<br />

HEMABATE INJ 250MCG PA<br />

methylergonovine maleate inj 0.2 mg/ml PA<br />

oxytocin inj 10 unit/ml PA<br />

Radioactive Agents<br />

QUADRAMET INJ PA<br />

QUADRAMET INJ VIAL PA<br />

Serums, Toxoids and Vaccines<br />

Serums<br />

ANTIVENIN KIT LAT MACT PA<br />

ANTIVENIN CR KIT POLYVAL PA<br />

ANTIVENIN MI KIT PA<br />

CARIMUNE NF INJ 12GM PA<br />

CARIMUNE NF INJ 1GM PA<br />

CARIMUNE NF INJ 3GM PA<br />

CARIMUNE NF INJ 6GM PA<br />

CROFAB INJ PA<br />

CYTOGAM INJ PA<br />

DIGIBIND SOL PA<br />

DIGIFAB INJ PA<br />

FLEBOGAMMA INJ 5% PA<br />

FLEBOGAMMA INJ DIF 5% PA<br />

GAMASTAN S/D INJ PA<br />

GAMMAGARD INJ 10GM/100 PA<br />

GAMMAGARD INJ 1G/10ML PA<br />

GAMMAGARD INJ 2.5GM/25 PA<br />

GAMMAGARD INJ 20GM/200 PA<br />

GAMMAGARD INJ 5GM/50ML PA<br />

GAMMAGARD SD INJ 0.5GM HU PA<br />

GAMMAGARD SD INJ 10GM HU PA<br />

GAMMAGARD SD INJ 10GM HU PA<br />

GAMMAGARD SD INJ 2.5GM HU PA<br />

GAMMAGARD SD INJ 5GM HU PA<br />

GAMMAGARD SD INJ 5GM HU PA<br />

GAMMAPLEX INJ 10GM PA<br />

GAMMAPLEX INJ 2.5GM PA<br />

GAMMAPLEX INJ 5GM PA<br />

GAMUNEX INJ 10% PA<br />

HEPAGAM B INJ PA<br />

HIZENTRA INJ 1GM/5ML PA<br />

HIZENTRA INJ 2GM/10ML PA<br />

HIZENTRA INJ 4GM/20ML PA<br />

HYPERHEP B INJ S/D PA<br />

HYPERRAB S/D INJ 150/ML PA<br />

HYPERRHO S/D INJ 300MCG PA<br />

HYPERRHO S/D INJ 50MCG PA<br />

HYPERTET S/D INJ 250/ML PA<br />

IMMUNE GLOBU INJ HUMAN PA<br />

IMOGAM RABIE INJ 150/ML PA<br />

IVEEGAM EN INJ 5GM HU PA<br />

MICRHOGAM PL INJ 50MCG PA<br />

NABI-HB INJ PA<br />

NP NABI-HB INJ PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 155


OCTAGAM INJ 10GM PA<br />

OCTAGAM INJ 1GM PA<br />

OCTAGAM INJ 2.5GM PA<br />

OCTAGAM INJ 25GM PA<br />

OCTAGAM INJ 5GM PA<br />

PANGLOBULIN INJ 12GM PA<br />

PANGLOBULIN INJ 1GM PA<br />

PANGLOBULIN INJ 3GM PA<br />

PANGLOBULIN INJ 6GM PA<br />

PANGLOBULIN SOL 12GM PA<br />

PANGLOBULIN SOL 6GM PA<br />

POLYGAM S/D SOL 0.5GM PA<br />

POLYGAM S/D SOL 10GM PA<br />

POLYGAM S/D SOL 2.5GM PA<br />

POLYGAM S/D SOL 5GM PA<br />

PRIVIGEN INJ 10GRAMS PA QL<br />

PRIVIGEN INJ 20GRAMS PA QL<br />

PRIVIGEN INJ 5 GRAMS PA QL<br />

RESPIGAM SOL 50MG/ML PA<br />

RHOGAM HUMAN INJ 300MCG PA<br />

RHOGAM PLUS INJ 300MCG PA<br />

RHOPHYLAC INJ 1500/2ML PA<br />

VARICELLA-ZO INJ 125UNIT PA<br />

VARICELLA-ZO INJ 625UNIT PA<br />

VENOGLOBUL-S INJ 10% PA<br />

VIVAGLOBIN SOL 160MG/ML PA<br />

WINRHO SDF INJ 15000UNT PA<br />

WINRHO SDF INJ 1500UNIT PA<br />

WINRHO SDF INJ 1500UNIT PA<br />

WINRHO SDF INJ 2500UNIT PA<br />

WINRHO SDF INJ 5000UNIT PA<br />

WINRHO SDF INJ 5000UNIT PA<br />

WINRHO SDF INJ 600UNIT PA<br />

WINRHO SDF INJ 600UNIT PA<br />

Toxoids<br />

ADACEL INJ PA<br />

BOOSTRIX INJ PA<br />

DAPTACEL INJ PA<br />

DECAVAC INJ 5-2LF PA<br />

DIP/TET PED INJ 6.7-5LF PA<br />

DTP ADSORBED INJ 6.7-5-4 PA<br />

INFANRIX INJ PA<br />

KINRIX INJ PA<br />

TE ANATOXAL INJ BERNA PA<br />

TET/DIP TOX INJ 2-2 LF PA<br />

TETANUS TOX INJ 4LF PA<br />

TETANUS TOX INJ 5LF ADS PA<br />

TRIHIBIT KIT P/F PA<br />

TRIPEDIA SUS P/F PA<br />

Vaccines<br />

ACTHIB INJ PA<br />

AFLURIA INJ 2007-08<br />

AFLURIA INJ 2008-09<br />

AFLURIA INJ 2009-10<br />

AFLURIA INJ PF 07-08<br />

AFLURIA INJ PF 08-09<br />

AGRIFLU INJ 09/10 PA<br />

ALFURIA INJ PF 09-10<br />

ATTENUVAX INJ LIVE PA<br />

CERVARIX INJ PA<br />

COMVAX INJ PA<br />

ENGERIX-B INJ 10/0.5ML PA<br />

ENGERIX-B INJ 20MCG/ML PA<br />

FLUARIX INJ PF 05-06<br />

FLUARIX INJ PF 06-07<br />

FLUARIX INJ PF 07-08<br />

FLUARIX INJ PF 08-09<br />

FLUARIX INJ PF 09-10<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 156


FLULAVAL INJ 2008-09<br />

FLULAVAL INJ 2009-10<br />

FLULAVAL INJ SPLIT<br />

FLUVIRIN INJ 2005-06<br />

FLUVIRIN INJ 2006-07<br />

FLUVIRIN INJ 2007-08<br />

FLUVIRIN INJ 2008-09<br />

FLUVIRIN INJ 2009-10<br />

FLUZONE INJ PF 05-06<br />

FLUZONE INJ PF 06-07<br />

FLUZONE INJ PF 07-08<br />

FLUZONE INJ PF 08-09<br />

FLUZONE INJ PF 09-10<br />

FLUZONE INJ PF 09-10<br />

FLUZONE PED/ INJ PF 05-06<br />

FLUZONE PED/ INJ PF 06-07<br />

FLUZONE PED/ INJ PF 07-08<br />

FLUZONE PED/ INJ PF 08-09<br />

FLUZONE PED/ INJ PF 09-10<br />

FLUZONE SPLT INJ 2005-06<br />

FLUZONE SPLT INJ 2006-07<br />

FLUZONE SPLT INJ 2007-08<br />

FLUZONE SPLT INJ 2008-09<br />

FLUZONE SPLT INJ 2009-10<br />

GARDASIL INJ PA<br />

HAVRIX INJ 1440UNIT PA<br />

HAVRIX INJ 720UNIT PA<br />

HIBERIX SOL 10-25MCG PA<br />

HIBTITER INJ PA<br />

IMOVAX RABIE INJ 2.5/ML PA<br />

INFLUENZA A INJ 09 H1N1<br />

INFLUENZA A INJ PF09H1N1 PA<br />

INFLUENZA A SPR 09 H1N1<br />

INFLUENZA A (H1N1) MONOVALENT VACCINE LIVE INTRANASAL LIQUID<br />

INFLUENZA A (H1N1) MONOVALENT VACCINE SPLIT INJ<br />

INFLUENZA VIRUS VACCINE SPLIT INJ<br />

INFLUENZA VIRUS VACCINE SPLIT PRESERVATIVE FREE INJ<br />

INFLUENZA VIRUS VACCINE TYPES A & B SURFACE ANTIGEN INJ<br />

IPOL INJ INACTIVE PA<br />

IXIARO INJ PA<br />

JE-VAX INJ PA<br />

M-M-R II INJ LIVE PA<br />

M-M-R II INJ LIVE PA<br />

M-M-R II INJ LIVE PA<br />

M-R-VAX II INJ PA<br />

MENACTRA INJ PA<br />

MENOMUNE INJ A/C/Y/W PA<br />

MENVEO INJ PA<br />

MERUVAX II INJ LIVE PA<br />

MUMPSVAX INJ LIVE PA<br />

PEDIARIX INJ 0.5ML PA<br />

PEDVAX HIB INJ PA<br />

PENTACEL INJ PA<br />

PNEUMOVAX 23 INJ 25/0.5 PA<br />

PNEUMOVAX 23 INJ 25/0.5 PA<br />

PREVNAR INJ PA<br />

PREVNAR 13 INJ PA<br />

PROQUAD INJ PA<br />

RABAVERT INJ PA<br />

RECOMBIVA HB INJ 10MCG/ML PA<br />

RECOMBIVA HB INJ 5MCG/0.5 PA<br />

RECOMBIVA-HB INJ 10MCG/ML PA<br />

RECOMBIVA-HB INJ 40MCG/ML PA<br />

TWINRIX INJ PA<br />

TYPHIM VI INJ PA<br />

TYPHOID VI SOL PA<br />

VAQTA INJ 25/0.5ML PA<br />

VAQTA INJ 50UNT/ML PA<br />

VARIVAX INJ PA<br />

YF-VAX INJ PA<br />

ZOSTAVAX INJ PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 157


Skin and Mucous Membrane Preparations<br />

Anti-infectives<br />

Antibacterials<br />

ACANYA GEL 1.2-2.5% PA<br />

ACZONE GEL 5% QL<br />

BENZAMYCIN GEL PAK<br />

benzoyl peroxide-erythromycin gel 5-3%<br />

BENZOYL PEROXIDE-ERYTHROMYCIN GEL PACK 5-3%<br />

CLINDAGEL GEL 1%<br />

clindamax cre 2% vag<br />

clindamax gel 1%<br />

clindamax lot 10mg/ml<br />

clindamycin cre 2% vag<br />

clindamycin gel 1%<br />

clindamycin lot 1%<br />

clindamycin lot 10mg/ml<br />

clindamycin pad 1%<br />

clindamycin sol 1%<br />

CLINDAMYCIN PHOSPHATE GEL 1%<br />

clindamycin phosphate gel 1%<br />

clindamycin phosphate lotion 1%<br />

clindamycin phosphate soln 1%<br />

clindamycin phosphate swab 1%<br />

CLINDAMYCIN PHOSPHATE SWAB KIT 1%<br />

clindamycin phosphate vaginal cream 2%<br />

clindamycin phosphate-benzoyl peroxide gel 1-5% PA<br />

CLINDAREACH KIT 1%<br />

DAPSONE GEL 5% QL<br />

emcin clear pad 2%<br />

ery pad 2%<br />

eryderm sol 2%<br />

erythromycin gel /benzoyl<br />

erythromycin pad 2%<br />

erythromycin pads 2%<br />

erythromycin sol 2%<br />

erythromycin soln 2%<br />

gentamicin cre 0.1%<br />

gentamicin oin 0.1%<br />

gentamicin sulfate cream 0.1%<br />

gentamicin sulfate oint 0.1%<br />

METROGEL-VAG GEL 0.75% QL<br />

metronidazol gel 0.75%vag QL<br />

metronidazole vaginal gel 0.75% QL<br />

METRONIDAZOLE VAGINAL GEL 0.75% QL<br />

pledgaclin pad 1%<br />

vandazole gel 0.75% QL<br />

Antifungals<br />

ciclopirox cre 0.77% NF<br />

ciclopirox sus 0.77% NF<br />

ciclopirox olamine cream 0.77% (base equiv) NF<br />

ciclopirox olamine susp 0.77% (base equiv) NF<br />

clotrim/beta cre diprop NF<br />

clotrimazole w/ betamethasone cream 1-0.05% NF<br />

nystatin cre 100000<br />

nystatin oin 100000<br />

nystatin cream 100000 unit/gm<br />

nystatin oint 100000 unit/gm<br />

Azoles<br />

clotrim/beta cre diprop NF<br />

clotrimazole loz 10mg QL<br />

clotrimazole tro 10mg QL<br />

clotrimazole troche 10 mg QL<br />

CLOTRIMAZOLE VAGINAL TAB 100 MG & 1% CREAM KIT OTC NF<br />

clotrimazole w/ betamethasone cream 1-0.05% NF<br />

ketoconazole cre 2%<br />

ketoconazole cream 2%<br />

KETOCONAZOLE GEL 2%<br />

KETOCONAZOLE GEL 2% & PYRITHIONE ZINC SHAMPOO 1% KIT<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 158


ketoconazole sha 2%<br />

KETOCONAZOLE SHAMPOO 1% OTC<br />

ketoconazole shampoo 2%<br />

kuric cre 2%<br />

MYCELEX-7 KIT COMBO PK OTC NF<br />

NIZORAL A-D SHA 1% OTC<br />

XOLEGEL GEL 2%<br />

XOLEGEL DUO/ KIT HEAD&SHD<br />

XOLEGEL DUO/ KIT XOLEX<br />

Hydroxypyridones<br />

ciclopirox cre 0.77% NF<br />

ciclopirox sus 0.77% NF<br />

ciclopirox olamine cream 0.77% (base equiv) NF<br />

ciclopirox olamine susp 0.77% (base equiv) NF<br />

Polyenes<br />

nystatin cre 100000<br />

nystatin oin 100000<br />

NYSTATIN TAB 100000<br />

nystatin cream 100000 unit/gm<br />

nystatin oint 100000 unit/gm<br />

NYSTATIN VAG TAB 100000<br />

NYSTATIN VAGINAL TAB 100000 UNIT<br />

Scabicides and Pediculicides<br />

acticin cre 5%<br />

lindane lot 1%<br />

LINDANE SHA 1%<br />

lindane sha 1%<br />

lindane lotion 1%<br />

LINDANE SHAMPOO 1%<br />

lindane shampoo 1%<br />

permethrin cre 5%<br />

permethrin cream 5%<br />

Local Anti-infectives, Miscellaneous<br />

acne 10 gel 10% OTC<br />

acne 10 lot 10% OTC<br />

acne medicat gel -5<br />

acne medicat lot 10% OTC<br />

acne treat cre 10% OTC<br />

acne treat cre 10% vf OTC<br />

acne-clear gel 10% OTC<br />

anti-dandruf sha 1% OTC<br />

benprox gel 2.75%<br />

benprox gel 5.25%<br />

benprox liq 5.25%<br />

benzashave cre 10%<br />

BENZASHAVE 5 CRE 5%<br />

BENZIQ GEL 5.25%<br />

benzl perox cre 6.5-10%<br />

benzl perox cre 8.5-10%<br />

benzl perox gel 4.5-10%<br />

benzl perox gel 6.5-10%<br />

benzl perox gel 8.5-10%<br />

benzl perox liq 4.5-10%<br />

benzl perox liq 6.5-10%<br />

benzl perox liq 8.5-10%<br />

benzl perox pad 4.5-10%<br />

benzl perox pad 6.5-10%<br />

benzl perox pad 8.5-10%<br />

benzoyl per gel 10% OTC<br />

benzoyl per gel 10%<br />

benzoyl per gel 2.5%<br />

benzoyl per gel 4%<br />

benzoyl per gel 5%<br />

benzoyl per gel 5% OTC<br />

benzoyl per gel 8%<br />

benzoyl per kit 4% wash<br />

benzoyl per kit 8% wash<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 159


enzoyl per liq 10%<br />

benzoyl per liq 10% wash<br />

benzoyl per liq 2.5%wash<br />

BENZOYL PER LIQ 2.5%WASH<br />

benzoyl per liq 4% crem<br />

benzoyl per liq 5%<br />

benzoyl per liq 5% wash<br />

benzoyl per liq 5.75-10%<br />

benzoyl per liq 7% wash<br />

benzoyl per liq 8% crem<br />

benzoyl per lot 10% OTC<br />

benzoyl per lot 3%<br />

benzoyl per lot 4%<br />

benzoyl per lot 5% OTC<br />

BENZOYL PER LOT 5% OTC<br />

benzoyl per lot 6%<br />

benzoyl per lot 8%<br />

benzoyl per lot 9%<br />

benzoyl per pad 3%<br />

benzoyl per pad 6%<br />

benzoyl per pad 9%<br />

benzoyl pero cre 3.5%<br />

benzoyl pero cre 5.5%<br />

benzoyl pero cre 8.5%<br />

benzoyl pero lot 10% OTC<br />

BENZOYL PEROXIDE BAR 10% OTC<br />

BENZOYL PEROXIDE BAR 10%<br />

BENZOYL PEROXIDE BAR 10% OTC<br />

BENZOYL PEROXIDE BAR 5% OTC<br />

BENZOYL PEROXIDE CLEANSER 4.25%<br />

benzoyl peroxide cream 10% OTC<br />

benzoyl peroxide cream 10%<br />

benzoyl peroxide cream 3.5%<br />

BENZOYL PEROXIDE CREAM 5%<br />

benzoyl peroxide cream 5.5%<br />

benzoyl peroxide cream 8.5%<br />

benzoyl peroxide creamy wash 4% & cleanser lotion kit<br />

benzoyl peroxide creamy wash 8% & cleanser lotion kit<br />

benzoyl peroxide gel 10% OTC<br />

benzoyl peroxide gel 10%<br />

benzoyl peroxide gel 2.5% OTC<br />

benzoyl peroxide gel 2.5%<br />

benzoyl peroxide gel 2.75%<br />

benzoyl peroxide gel 4%<br />

benzoyl peroxide gel 5%<br />

benzoyl peroxide gel 5% OTC<br />

benzoyl peroxide gel 5.25 %<br />

BENZOYL PEROXIDE GEL 5.25 %<br />

BENZOYL PEROXIDE GEL 6%<br />

BENZOYL PEROXIDE GEL 7%<br />

benzoyl peroxide gel 8%<br />

benzoyl peroxide liq 10% OTC<br />

benzoyl peroxide liq 10%<br />

benzoyl peroxide liq 2.5%<br />

BENZOYL PEROXIDE LIQ 2.5%<br />

BENZOYL PEROXIDE LIQ 4%<br />

benzoyl peroxide liq 4%<br />

benzoyl peroxide liq 5%<br />

benzoyl peroxide liq 5.25%<br />

benzoyl peroxide liq 7%<br />

BENZOYL PEROXIDE LIQ 8%<br />

benzoyl peroxide liq 8%<br />

benzoyl peroxide lotion 10% OTC<br />

benzoyl peroxide lotion 3%<br />

benzoyl peroxide lotion 4%<br />

BENZOYL PEROXIDE LOTION 5% OTC<br />

benzoyl peroxide lotion 5% OTC<br />

BENZOYL PEROXIDE LOTION 5.5% OTC<br />

benzoyl peroxide lotion 6%<br />

benzoyl peroxide lotion 8%<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 160


enzoyl peroxide lotion 9%<br />

BENZOYL PEROXIDE MASK 5% OTC<br />

benzoyl peroxide pad 3%<br />

benzoyl peroxide pad 6%<br />

benzoyl peroxide pad 9%<br />

benzoyl peroxide-urea cleanser 4.5-10%<br />

benzoyl peroxide-urea cleanser 5.75-10%<br />

benzoyl peroxide-urea cleanser 6.5-10%<br />

benzoyl peroxide-urea cleanser 8.5-10%<br />

BENZOYL PEROXIDE-UREA CREAM 4.5-10%<br />

BENZOYL PEROXIDE-UREA CREAM 6.5-10%<br />

benzoyl peroxide-urea cream 6.5-10%<br />

BENZOYL PEROXIDE-UREA CREAM 8.5-10%<br />

benzoyl peroxide-urea cream 8.5-10%<br />

benzoyl peroxide-urea gel 4.5-10%<br />

benzoyl peroxide-urea gel 6.5-10%<br />

benzoyl peroxide-urea gel 8.5-10%<br />

benzoyl peroxide-urea pad 4.5-10%<br />

benzoyl peroxide-urea pad 6.5-10%<br />

benzoyl peroxide-urea pad 8.5-10%<br />

bl acne 10 gel 10% OTC<br />

bp wash liq 7%<br />

bpo gel 4%<br />

bpo gel 8%<br />

BREVOXYL-4 LIQ CREM WSH<br />

BREVOXYL-8 LIQ CREM WSH<br />

clean&clear cre 10% OTC<br />

clearplex v gel 5% OTC<br />

clearplex x gel 10%<br />

clearskin cre 10% OTC<br />

CLINAC BPO GEL 7%<br />

cvs acne cre 10% OTC<br />

dandrex sha 1% OTC<br />

dandruff sha 1% OTC<br />

del-aqua cre 10% OTC<br />

del-aqua gel 5%<br />

desquam-e gel 2.5%<br />

DESQUAM-X BAR 10%<br />

ethexderm liq bpw-10<br />

ethexderm liq bpw-5<br />

gnp acne 10 gel 10% OTC<br />

invisible cre acne 10% OTC<br />

lavoclen-4 kit acne wsh<br />

lavoclen-4 liq crem wsh<br />

lavoclen-8 kit acne wsh<br />

lavoclen-8 liq crem wsh<br />

LOROXIDE LOT 5.5% OTC<br />

neutrogena gel 2.5% OTC<br />

NEUTROGENA MIS MASK 5% OTC<br />

oscion pad 3%<br />

oscion pad 6%<br />

oscion pad 9%<br />

oscion clnsr lot 3%<br />

oscion clnsr lot 6%<br />

oscion clnsr lot 9%<br />

oxy 10 balan gel 10% OTC<br />

oxy 10 balan liq 10% wash OTC<br />

oxy balance gel 5% OTC<br />

PACNEX MX LIQ 4.25%<br />

pacnex wash liq 7%<br />

PANOXYL BAR 10% OTC<br />

PANOXYL BAR 10% OTC<br />

PANOXYL BAR 5% OTC<br />

panoxyl aqua gel 10% OTC<br />

panoxyl wash liq 10% OTC<br />

peroderm gel 4.5-10%<br />

peroderm gel 6.5-10%<br />

peroderm gel 8.5-10%<br />

peroderm liq 4.5-10%<br />

peroderm liq 6.5-10%<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 161


peroderm liq 8.5-10%<br />

persa-gel gel 10% max OTC<br />

persa-gel gel 5% x-s OTC<br />

pr benzoyl liq 7% wash<br />

ra acne cre 10% OTC<br />

ra benzoyl lot 10% OTC<br />

ra dandruff sha 1% OTC<br />

se bpo wash liq 7%<br />

selenium sul lot 2.5%<br />

selenium sul sha 1% OTC<br />

selenium sul sha 2.5%<br />

selenium sulfide lotion 1% OTC<br />

selenium sulfide lotion 2.5%<br />

silver sulfa cre 1%<br />

silver sulfadiazine cream 1%<br />

soluclenz rx gel 5%<br />

ssd cre 1%<br />

ssd af cre 1%<br />

thermazene cre 1%<br />

TRIAZ GEL 6%<br />

zaclir lot 4%<br />

zaclir lot 8%<br />

ZODERM CRE 4.5%-10%<br />

ZODERM CRE 6.5-10%<br />

ZODERM CRE 8.5-10%<br />

Anti-inflammatory Agents<br />

ala cort cre 1%<br />

ala-cort lot 1%<br />

alphatrex gel 0.05% NF<br />

anti-itch cre /aloe/e OTC<br />

anti-itch cre /oatmeal OTC<br />

anti-itch cre 1%max st OTC<br />

anti-itch cre 1%max st OTC<br />

anti-itch oin max st OTC<br />

anti-itch/ cre aloe OTC<br />

anucort-hc sup 25mg<br />

anumed-hc sup 25mg<br />

apexicon oin 0.05% NF<br />

aquanil hc lot 1% OTC<br />

aristocort a cre 0.5%<br />

aug betamet cre 0.05% NF<br />

aug betamet gel 0.05% NF<br />

aug betamet lot 0.05% NF<br />

aug betamet oin 0.05% NF<br />

aveeno cre 1%max st OTC<br />

BALNEOL LOT 0.25% OTC<br />

beta diprop gel 0.05% NF<br />

beta hc lot 1% OTC<br />

beta-val cre 0.1% NF<br />

beta-val lot 0.1% NF<br />

betameth dip cre 0.05% NF<br />

betameth dip lot 0.05% NF<br />

betameth dip oin 0.05% NF<br />

betameth val cre 0.1% NF<br />

betameth val lot 0.1% NF<br />

betameth val oin 0.1% NF<br />

betamethasone dipropionate augmented cream 0.05% NF<br />

betamethasone dipropionate augmented gel 0.05% NF<br />

betamethasone dipropionate augmented lotion 0.05% NF<br />

betamethasone dipropionate augmented oint 0.05% NF<br />

betamethasone dipropionate cream 0.05% NF<br />

betamethasone dipropionate lotion 0.05% NF<br />

betamethasone dipropionate oint 0.05% NF<br />

betamethasone valerate cream 0.1% NF<br />

betamethasone valerate lotion 0.1% NF<br />

betamethasone valerate oint 0.1% NF<br />

caldecort cre 1% OTC<br />

cetacort lot 1%<br />

cortaid cre 1% OTC<br />

cortaid cre 1%max st OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 162


cortaid adv cre 1% 12 hr OTC<br />

CORTIFOAM AER 90MG<br />

cortisone cre 1%max st OTC<br />

cortisone + cre 1%max st OTC<br />

cortizone-10 cre /aloe 1% OTC<br />

cortizone-10 cre 1% OTC<br />

cortizone-10 cre anal itc OTC<br />

cortizone-10 cre healing OTC<br />

cortizone-10 cre plus OTC<br />

cortizone-10 oin 1% OTC<br />

cortizone-5 oin 0.5% OTC<br />

del-beta lot 0.05% NF<br />

DERMTEX HC LOT 0.5% OTC<br />

desonide cre 0.05%<br />

desonide oin 0.05% NF<br />

desonide cream 0.05%<br />

desonide oint 0.05% NF<br />

desoximetas cre 0.05% NF<br />

desoximetas cre 0.25% NF<br />

desoximetas gel 0.05% NF<br />

desoximetas oin 0.25%<br />

desoximetasone cream 0.05% NF<br />

desoximetasone cream 0.25% NF<br />

desoximetasone gel 0.05% NF<br />

desoximetasone oint 0.25%<br />

diflorasone cre 0.05% NF<br />

diflorasone oin 0.05% NF<br />

diflorasone diacetate cream 0.05% NF<br />

diflorasone diacetate oint 0.05% NF<br />

EPIFOAM AER 1%<br />

FLUOCIN ACET CRE 0.01%<br />

fluocin acet cre 0.025%<br />

FLUOCIN ACET OIN 0.025%<br />

FLUOCIN ACET SOL 0.01%<br />

FLUOCINOLONE ACETONIDE CREAM 0.01%<br />

fluocinolone acetonide cream 0.025%<br />

FLUOCINOLONE ACETONIDE OINT 0.025%<br />

FLUOCINOLONE ACETONIDE SOLN 0.01%<br />

fluocinonide cre 0.05% NF<br />

fluocinonide cream 0.05% NF<br />

FLUOCINONIDE CREAM 0.1% NF<br />

fluocinonide gel 0.05% NF<br />

fluocinonide gel 0.05% NF<br />

fluocinonide oin 0.05% NF<br />

fluocinonide oint 0.05% NF<br />

fluocinonide sol 0.05% NF<br />

fluocinonide soln 0.05% NF<br />

gnp hydrocor cre 1% OTC<br />

gnp hydrocor cre 1% plus OTC<br />

HALCINONIDE CREAM 0.1% NF<br />

HALCINONIDE OINT 0.1% NF<br />

HALCINONIDE SOLN 0.1% NF<br />

halobetasol cre 0.05% NF<br />

halobetasol oin 0.05% NF<br />

halobetasol propionate cream 0.05% NF<br />

halobetasol propionate oint 0.05% NF<br />

HALOG CRE 0.1% NF<br />

HALOG OIN 0.1% NF<br />

HALOG SOL 0.1% NF<br />

hc ac/aloe cre 0.5% OTC<br />

HC/ALOE CRE 0.5% OTC<br />

hca hydrocor oin 1% OTC<br />

hca max st cre hydrocor OTC<br />

hemorrhoidal cre -hc 2.5%<br />

hemorrhoidal sup -hc 25mg<br />

hemril-30 sup 30mg<br />

hydro-lotion lot 1% OTC<br />

hydrocort cre 0.5% OTC<br />

hydrocort cre 1% OTC<br />

hydrocort cre 1%<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 163


hydrocort cre 1% plus OTC<br />

hydrocort cre 1%max st OTC<br />

hydrocort cre 1%max st OTC<br />

hydrocort cre 1%max st OTC<br />

hydrocort cre 1%pls 12 OTC<br />

hydrocort cre 2.5%<br />

hydrocort lot 1%<br />

hydrocort lot 1% OTC<br />

hydrocort lot 2.5%<br />

hydrocort oin 0.5% OTC<br />

hydrocort oin 1% OTC<br />

hydrocort oin 1%<br />

hydrocort oin 2.5%<br />

hydrocort ac cre 0.5% OTC<br />

hydrocort ac sup 25mg<br />

hydrocort ac sup 30mg<br />

hydrocort/ cre aloe 1% OTC<br />

hydrocort/ cre aloe 1% OTC<br />

hydrocort/ cre aloe 1% OTC<br />

hydrocort/ oin aloe 1% OTC<br />

HYDROCORT/ OIN ALOE 1% OTC<br />

hydrocort/ab oin 1%<br />

hydrocortiso cre 2.5%<br />

HYDROCORTISONE ACETATE RECTAL FOAM 90 MG/DOSE<br />

hydrocortisone acetate suppos 25 mg<br />

hydrocortisone acetate suppos 30 mg<br />

hydrocortisone acetate-aloe vera cream 0.5% OTC<br />

hydrocortisone cream 0.5% OTC<br />

hydrocortisone cream 1%<br />

hydrocortisone cream 1% OTC<br />

hydrocortisone cream 2.5%<br />

HYDROCORTISONE LOTION 0.25% OTC<br />

HYDROCORTISONE LOTION 0.5% OTC<br />

hydrocortisone lotion 1% OTC<br />

hydrocortisone lotion 1%<br />

hydrocortisone lotion 2%<br />

hydrocortisone lotion 2.5%<br />

hydrocortisone oint 0.5% OTC<br />

hydrocortisone oint 1% OTC<br />

hydrocortisone oint 1%<br />

hydrocortisone oint 2.5%<br />

hydrocortisone rectal cream 2.5%<br />

hydrocortisone valerate cream 0.2% PA<br />

hydrocortisone valerate oint 0.2% PA<br />

HYDROCORTISONE-ALOE VERA CREAM 0.5% OTC<br />

hydrocortisone-aloe vera cream 1% OTC<br />

HYDROCORTISONE-ALOE VERA OINT 1% OTC<br />

hydrocortisone-aloe vera oint 1% OTC<br />

hytone cre 1% OTC<br />

instacort 5 cre 0.5% OTC<br />

itch-x lot 1% OTC<br />

kericort 10 cre 1% OTC<br />

med-derm hc cre 0.5% OTC<br />

med-derm hc cre 1% OTC<br />

mometasone cre 0.1% NF<br />

mometasone oin 0.1% NF<br />

mometasone sol 0.1% NF<br />

mometasone furoate cream 0.1% NF<br />

mometasone furoate oint 0.1% NF<br />

mometasone furoate solution 0.1% (lotion) NF<br />

monistat cre 1% OTC<br />

mp hydrocort cre 0.5% OTC<br />

mp hydrocort cre 1% OTC<br />

mp hydrocort cre 1%max st OTC<br />

mp hydrocort oin 1% OTC<br />

nupercainal cre 1% OTC<br />

nupercainal cre hc 1% OTC<br />

nystat/triam cre<br />

nystat/triam oin<br />

nystatin-triamcinolone cream 100000-0.1 unit/gm-%<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 164


nystatin-triamcinolone oint 100000-0.1 unit/gm-%<br />

PRAMOXINE-HC AEROSOL FOAM 1-1%<br />

prednicarbat cre 0.1% NF<br />

prednicarbate cream 0.1% NF<br />

prep h hc cre 1% OTC<br />

procto-kit cre 1%<br />

procto-kit cre 2.5%<br />

procto-pak cre 1%<br />

proctocare cre -hc 2.5%<br />

proctocream cre -hc 2.5%<br />

proctosert h sup 30 mg<br />

proctosol hc cre 2.5%<br />

proctozone cre -hc 2.5%<br />

qc hydrocort cre 1% OTC<br />

qc hydrocort cre 1%max st OTC<br />

ra hydrocort cre 0.5% OTC<br />

ra hydrocort cre 1% OTC<br />

ra hydrocort cre 1%max st OTC<br />

ra hydrocort cre 1%pls 12 OTC<br />

ra hydrocort oin 1% OTC<br />

recort plus cre 1% OTC<br />

recort plus lot 1% OTC<br />

rectasol-hc sup 25mg<br />

rederm lot 1% OTC<br />

sarnol-hc lot 1% OTC<br />

sb hydrocort cre 1% OTC<br />

sb hydrocort oin 1% OTC<br />

scalacort lot 2%<br />

sg hc/aloe cre 0.5% OTC<br />

sg hydrocort cre 1% OTC<br />

sm hydrocort cre 1% OTC<br />

sm hydrocort cre 1% OTC<br />

sm hydrocort oin 1% OTC<br />

theracort lot 1% OTC<br />

triam/nystat cre<br />

triam/nystat oin<br />

triamcinolon cre 0.025%<br />

triamcinolon cre 0.1%<br />

triamcinolon cre 0.5%<br />

triamcinolon lot 0.025%<br />

triamcinolon lot 0.1%<br />

triamcinolon oin 0.025%<br />

TRIAMCINOLON OIN 0.05%<br />

triamcinolon oin 0.1%<br />

triamcinolon oin 0.5%<br />

triamcinolon oin 0.5%<br />

triamcinolone acetonide cream 0.025%<br />

triamcinolone acetonide cream 0.1%<br />

triamcinolone acetonide cream 0.5%<br />

triamcinolone acetonide lotion 0.025%<br />

triamcinolone acetonide lotion 0.1%<br />

triamcinolone acetonide oint 0.025%<br />

TRIAMCINOLONE ACETONIDE OINT 0.05%<br />

triamcinolone acetonide oint 0.1%<br />

triamcinolone acetonide oint 0.5%<br />

triamcinolone acetonide oint 0.5%<br />

triderm cre 0.1%<br />

triderm oin 0.1%<br />

VANOS CRE 0.1% NF<br />

Antipruritics and Local Anesthetics<br />

azo dine tab 95mg OTC<br />

azo dine tab max st OTC<br />

azo tabs tab 95mg OTC<br />

azo-dine tab 97.2mg OTC<br />

azo-gesic tab 95mg OTC<br />

azo-septic tab 95mg OTC<br />

azo-standard tab 95mg OTC<br />

hca azo tab OTC<br />

HYDROCORTISONE ACETATE W/ PRAMOXINE RECTAL FOAM 1-1%<br />

mp azodine tab uranary OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 165


phenazo tab 200mg<br />

phenazo tab 95mg OTC<br />

phenazopyrid tab 100mg<br />

phenazopyrid tab 200mg<br />

phenazopyridine hcl tab 100 mg<br />

phenazopyridine hcl tab 200 mg<br />

phenazopyridine hcl tab 95 mg OTC<br />

phenazopyridine hcl tab 97 mg OTC<br />

phenazopyridine hcl tab 97.5 mg OTC<br />

phenazoyrid tab 95mg OTC<br />

PROCTOFOAM AER HC 1%<br />

qc azo tab 95mg OTC<br />

ra urinary tab 95mg OTC<br />

re-azo tab 97 mg OTC<br />

urinary anal tab 95mg OTC<br />

urinary pain tab 95mg OTC<br />

Astringents<br />

ALUMINUM CHLORIDE SOLN 12% OTC<br />

aluminum chloride soln 20%<br />

aluminum cl sol 20%<br />

ANTI-PERSPIR SOL 12% OTC<br />

CERTAIN DRI SOL OTC<br />

CERTAIN DRI SOL UNSCENT OTC<br />

hypercare sol 20%<br />

Cell Stimulants and Proliferants<br />

avita cre 0.025%<br />

avita gel 0.025%<br />

KEPIVANCE INJ 6.25MG PA<br />

REFISSA CRE 0.05%<br />

RENOVA CRE 0.02%<br />

RENOVA PUMP CRE 0.02%<br />

RETIN-A MICR GEL 0.04%<br />

RETIN-A MICR GEL 0.04%PMP<br />

RETIN-A MICR GEL 0.1%<br />

RETIN-A MICR GEL 0.1%PUMP<br />

TRETIN-X CRE KIT 0.025%<br />

TRETIN-X CRE KIT 0.05%<br />

TRETIN-X CRE KIT 0.1%<br />

TRETIN-X GEL KIT 0.01%<br />

TRETIN-X GEL KIT 0.025%<br />

tretinoin cre 0.025%<br />

tretinoin cre 0.05%<br />

tretinoin cre 0.1%<br />

tretinoin gel 0.01%<br />

tretinoin gel 0.025%<br />

TRETINOIN (FACIAL WRINKLES) CREAM 0.02%<br />

TRETINOIN (FACIAL WRINKLES) CREAM 0.05%<br />

tretinoin cream 0.025%<br />

TRETINOIN CREAM 0.025% W/ CLEANSER & MOISTURIZER KIT<br />

tretinoin cream 0.05%<br />

TRETINOIN CREAM 0.05% W/ CLEANSER & MOISTURIZER KIT<br />

tretinoin cream 0.1%<br />

TRETINOIN CREAM 0.1% W/ CLEANSER & MOISTURIZER KIT<br />

TRETINOIN EM CRE 0.05%<br />

tretinoin gel 0.01%<br />

TRETINOIN GEL 0.01% W/ CLEANSER & MOISTURIZER KIT<br />

tretinoin gel 0.025%<br />

TRETINOIN GEL 0.025% W/ CLEANSER & MOISTURIZER KIT<br />

TRETINOIN MICROSPHERE GEL 0.04%<br />

TRETINOIN MICROSPHERE GEL 0.1%<br />

Depigmenting and Pigmenting Agents<br />

Pigmenting Agents<br />

UVADEX INJ 20MCG/ML PA<br />

Skin and Mucous Membrane Agents, Misc<br />

AMEVIVE INJ 15MG PA<br />

ANTHRALIN CREAM 0.5%<br />

anthralin cream 1%<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 166


ANTHRALIN CREAM 1%<br />

ANTHRALIN CREAM 1.2%<br />

benzoyl peroxide-sulfur gel 6-3%<br />

BENZOYL PEROXIDE-SULFUR LOTION 10-5%<br />

BENZOYL PEROXIDE-SULFUR LOTION 5-2%<br />

BEXAROTENE GEL 1%<br />

bps gel 6-3%<br />

CALCIPOTRIENE CREAM 0.005% NF<br />

CALCIPOTRIENE OINT 0.005% NF<br />

CARAC CRE 0.5% NF<br />

DOVONEX CRE 0.005% NF<br />

DOVONEX OIN 0.005% NF<br />

DRITHO-CREME CRE HP 1%<br />

DRITHO-SCALP CRE 0.5%<br />

ELIDEL CRE 1% PA<br />

FLUOROPLEX CRE 1% NF<br />

fluorouracil cre 5% NF<br />

FLUOROURACIL CREAM 0.5% NF<br />

FLUOROURACIL CREAM 1% NF<br />

fluorouracil cream 5% NF<br />

PROTOPIC OIN 0.03% PA<br />

PROTOPIC OIN 0.1% PA<br />

psoriatec cre 1%<br />

RAPTIVA KIT 125MG PA<br />

SULFOXYL LOT<br />

SULFOXYL LOT STRONG<br />

TARGRETIN GEL 1%<br />

TAZAROTENE GEL 0.05% NF<br />

TAZAROTENE GEL 0.1% NF<br />

TAZORAC GEL 0.05% NF<br />

TAZORAC GEL 0.1% NF<br />

ZITHRANOL-RR CRE 1.2%<br />

Smooth Muscle Relaxants<br />

Genitourinary Smooth Muscle Relaxants<br />

oxybutynin syp 5mg/5ml<br />

oxybutynin tab 5mg<br />

oxybutynin chloride syrup 5 mg/5ml<br />

oxybutynin chloride tab 5 mg<br />

Respiratory Smooth Muscle Relaxants<br />

aminophylline inj 25 mg/ml PA<br />

ELIXOPHYLLIN ELX 80/15ML NF<br />

THEO-24 CAP 100MG CR NF<br />

THEO-24 CAP 200MG CR NF<br />

THEO-24 CAP 300MG CR NF<br />

THEO-24 CAP 300MG CR<br />

THEO-24 CAP 400MG ER NF<br />

THEOCAP CAP 125MG CR<br />

THEOCAP CAP 200MG CR<br />

theocap cap 300mg cr<br />

theochron tab 100mg cr<br />

theochron tab 200mg cr<br />

theochron tab 300mg cr<br />

theochron tab 450mg<br />

theophylline cap 125mg er<br />

theophylline cap 200mg er<br />

theophylline cap 300mg er<br />

THEOPHYLLINE CAP SR 12HR 125 MG<br />

theophylline cap sr 12hr 125 mg<br />

THEOPHYLLINE CAP SR 12HR 200 MG<br />

theophylline cap sr 12hr 200 mg<br />

theophylline cap sr 12hr 300 mg<br />

THEOPHYLLINE CAP SR 24HR 100 MG NF<br />

THEOPHYLLINE CAP SR 24HR 200 MG NF<br />

THEOPHYLLINE CAP SR 24HR 300 MG NF<br />

THEOPHYLLINE CAP SR 24HR 300 MG<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 167


THEOPHYLLINE CAP SR 24HR 400 MG NF<br />

THEOPHYLLINE ELIXIR 80 MG/15ML NF<br />

theophylline in d5w inj 0.8 mg/ml PA<br />

theophylline in d5w inj 1.6 mg/ml PA<br />

theophylline in d5w inj 2 mg/ml PA<br />

theophylline in d5w inj 3.2 mg/ml PA<br />

theophylline in d5w inj 4 mg/ml PA<br />

theophylline tab 100mg cr<br />

theophylline tab 100mg er<br />

theophylline tab 100mg td<br />

theophylline tab 200mg cr<br />

theophylline tab 200mg er<br />

theophylline tab 200mg sr<br />

theophylline tab 200mg td<br />

theophylline tab 300mg cr<br />

theophylline tab 300mg er<br />

theophylline tab 300mg sr<br />

theophylline tab 300mg td<br />

theophylline tab 300mgsr<br />

theophylline tab 400mg er<br />

theophylline tab 450mg cr<br />

theophylline tab 450mg er<br />

theophylline tab 600mg er<br />

theophylline tab sr 12hr 100 mg<br />

theophylline tab sr 12hr 200 mg<br />

theophylline tab sr 12hr 300 mg<br />

theophylline tab sr 12hr 450 mg<br />

theophylline tab sr 24hr 400 mg<br />

THEOPHYLLINE TAB SR 24HR 400 MG<br />

theophylline tab sr 24hr 600 mg<br />

THEOPHYLLINE TAB SR 24HR 600 MG<br />

UNIPHYL TAB 400MG CR<br />

UNIPHYL TAB 600MG CR<br />

Vitamins<br />

Vitamin A<br />

AQUASOL A INJ 50000/ML PA<br />

Vitamin B Complex<br />

*b-complex vitamin inj** PA<br />

b-6 tab 100mg OTC<br />

b-6 tab 250mg OTC<br />

b-6 tab 50mg OTC<br />

bl vit b-6 tab 100mg OTC<br />

bl vit b-6 tab 50mg OTC<br />

CALOMIST SPR 25MCG PA<br />

cvs vit b-6 tab 100mg OTC<br />

cvs vit b-6 tab 200mg OTC<br />

cvs vit b-6 tab 50mg OTC<br />

cyanocobalamin inj 1000 mcg/ml PA<br />

dexpanthenol inj 250 mg/ml PA<br />

DEXPANTHENOL INJ 250MG/ML PA<br />

FOLIC ACID INJ 5MG/ML PA<br />

gnp vit b-6 tab 100mg OTC<br />

gnp vit b-6 tab 50mg OTC<br />

hca vit b6 tab 100mg OTC<br />

HYDROXOCOBAL INJ 1000MCG PA<br />

MAGNESIUM W/ POTASSIUM-PYRIDOXINE CAP 100-99-200 MG OTC<br />

NASCOBAL SPR 500MCG PA<br />

NERVIDOX-6 INJ NR PA<br />

nestrex tab 25mg OTC<br />

NEURO-B12 INJ FORTE PA<br />

NEURO-B12 INJ FORTE NR PA<br />

neuro-k-250 tab 250mg OTC<br />

neuro-k-50 tab OTC<br />

neuro-k-500 tab OTC<br />

pyri 500 tab 500mg OTC<br />

pyridoxine tab 100mg OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 168


pyridoxine tab 25mg OTC<br />

pyridoxine tab 50mg OTC<br />

pyridoxine hcl inj 100 mg/ml PA<br />

pyridoxine hcl tab 100 mg OTC<br />

pyridoxine hcl tab 200 mg OTC<br />

pyridoxine hcl tab 25 mg OTC<br />

pyridoxine hcl tab 250 mg OTC<br />

pyridoxine hcl tab 50 mg OTC<br />

pyridoxine hcl tab 500 mg OTC<br />

PYRIDOXINE/ CAP MINERALS OTC<br />

ra vit b-6 tab 50mg OTC<br />

SHERI-B-12 LIQ PA OTC<br />

sm vit b-6 tab 100mg OTC<br />

sm vit b-6 tab 50mg OTC<br />

thiamine hcl inj 100 mg/ml PA<br />

v-r vit b-6 tab 100mg OTC<br />

v-r vit b-6 tab 50mg OTC<br />

vitamin b-6 tab 100mg OTC<br />

vitamin b-6 tab 200mg OTC<br />

vitamin b-6 tab 250mg OTC<br />

vitamin b-6 tab 25mg OTC<br />

vitamin b-6 tab 500mg OTC<br />

vitamin b-6 tab 50mg OTC<br />

vitamin b1 & b12 inj 100-1 mg/ml PA<br />

yl vit b-6 tab 100mg OTC<br />

Vitamin C<br />

ascorbic acid inj 500 mg/ml PA<br />

CECON SOL 90MG/ML PA OTC<br />

sodium ascorbate inj 250 mg/ml PA<br />

sodium ascorbate inj 500 mg/ml PA<br />

Vitamin D<br />

calcitriol cap 0.25mcg<br />

calcitriol cap 0.5mcg<br />

CALCITRIOL INJ 2MCG/ML PA<br />

calcitriol cap 0.25 mcg<br />

calcitriol cap 0.5 mcg<br />

calcitriol inj 1 mcg/ml PA<br />

calcitriol oral soln 1 mcg/ml PA<br />

ergocalciferol soln 8000 unit/ml PA OTC<br />

HECTOROL INJ 4MCG/2ML PA<br />

ZEMPLAR INJ 2MCG/ML PA<br />

ZEMPLAR INJ 5MCG/ML PA<br />

Vitamin K Activity<br />

MEPHYTON TAB 5MG<br />

phytonadione inj 2 mg/ml PA<br />

PHYTONADIONE TAB 5 MG<br />

VITAMIN K1 INJ 10MG/ML PA<br />

Multivitamin Preparations<br />

*multiple vitamin inj** PA<br />

*pediatric multiple vitamins w/ fl-fe chew tab 0.5-12 mg**<br />

*pediatric multiple vitamins w/ fl-fe chew tab 1-12 mg**<br />

*pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml**<br />

*pediatric multiple vitamins w/ fl-fe drops 0.5-10 mg/ml**<br />

*pediatric multiple vitamins w/ fl-fe drops 0.5-10 mg/ml**<br />

*pediatric multiple vitamins w/ fluoride chew tab 0.25 mg***<br />

*pediatric multiple vitamins w/ fluoride chew tab 0.5 mg***<br />

*pediatric multiple vitamins w/ fluoride chew tab 1 mg***<br />

*pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml***<br />

*pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml***<br />

*pediatric vitamins acd fluoride & fe drops 0.25-10 mg/ml***<br />

*pediatric vitamins acd w/ fluoride chew tab 1 mg***<br />

*pediatric vitamins acd w/ fluoride soln 0.25 mg/ml***<br />

*pediatric vitamins acd w/ fluoride soln 0.5 mg/ml***<br />

*prenatal multivitamins & minerals w/ iron & fa tab 1 mg***<br />

*prenatal multivitamins & minerals w/iron & fa tab 0.8 mg*** OTC<br />

*prenatal multivitamins & minerals w/iron & fa tab 0.8 mg***<br />

*prenatal vit w/ dss-fe fumarate-fa tab cr 90-1 mg***<br />

*prenatal vit w/ fe fumarate-fa tab 27-0.5 mg***<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 169


*prenatal vit w/ fe fumarate-fa tab 27-0.8 mg*** OTC<br />

*prenatal vit w/ fe fumarate-fa tab 27-0.8 mg***<br />

*prenatal vit w/ fe fumarate-fa tab 27-1 mg***<br />

*prenatal vit w/ fe fumarate-fa tab 28-0.8 mg*** OTC<br />

*prenatal vit w/ fe fumarate-fa tab 28-1 mg***<br />

*prenatal vit w/ fe fumarate-fa tab 29-1 mg***<br />

*prenatal vit w/ fe fumarate-fa tab 60-0.8 mg*** OTC<br />

*prenatal vit w/ fe fumarate-fa tab 60-1 mg***<br />

*prenatal vit w/ fe fumarate-fa tab 65-1 mg***<br />

*prenatal vit w/ fe fumarate-fa tab 65-1 mg***<br />

*PRENATAL VIT W/ FE FUMARATE-FA TAB 65-1 MG*** NF<br />

*PRENATAL VIT W/ FE GLUCONATE-FA TAB 30-0.4 MG*** OTC<br />

*prenatal vit w/ fe gluconate-fa tab 30-0.8 mg*** OTC<br />

*prenatal vit w/ fe polysac cmplx-fa tab 60-1 mg***<br />

*prenatal vit w/ iron carbonyl-fe sulf-fa tab 60-1 mg***<br />

*PRENATAL VIT W/ IRON CARBONYL-FE SULF-FA TAB 60-1 MG***<br />

*PRENATAL VIT W/ SEL-FE FUMARATE-FA TAB 27-1 MG***<br />

*prenatal vit w/ sel-fe fumarate-fa tab 27-1 mg***<br />

*prenatal w/o a vit w/ fe fumarate-fa tab 30-1 mg***<br />

*PRENATAL W/O A VIT W/ FE FUMARATE-FA TAB 40-1 MG***<br />

*prenatal w/o a vit w/ fe fumarate-fa tab dr 30-1 mg***<br />

adc/fluoride dro 0.25mg<br />

ALBAFORT INJ PA<br />

ALBAFORT S INJ PA<br />

aminate fe tab 90mg<br />

bl prenatal tab OTC<br />

bp multinatl tab plus<br />

cavan tab prenatal<br />

CERNEVIT INJ PA<br />

co-natal fa tab 29-1mg<br />

cvs prenatal tab OTC<br />

eck prenatal tab OTC<br />

eql prenatal tab formula OTC<br />

gnp prenatal tab 28-0.8mg OTC<br />

m-vit tab 27-1mg<br />

M.V.I PEDIAT INJ PA<br />

M.V.I-12 W/O INJ VIT K PA<br />

M.V.I. ADULT INJ PA<br />

maternity tab<br />

maternity-90 tab<br />

MISSION PREN TAB OTC<br />

mission pren tab /fa OTC<br />

mission pren tab hp OTC<br />

mult vit-bet chw /fl 1mg<br />

mult vit-bet chw fe/fl0.5<br />

mult vit-bet chw fe/fl1mg<br />

mult vit-bet chw fl 0.5mg<br />

mult vit-bet chw fl0.25mg<br />

mult-vit/fl chw 0.5mg<br />

mult-vit/fl chw 0.5mg<br />

multi prenat tab OTC<br />

multi vit/fl chw 0.25mg<br />

multi vit/fl chw 1mg<br />

multi vit/fl dro 0.25mg<br />

multi-vit/fe dro /fl 0.25<br />

multi-vit/fe dro /fl 0.5<br />

multi-vit/fe dro fl 0.25<br />

multi-vit/fl chw 0.25mg<br />

multi-vit/fl chw 0.25mg<br />

multi-vit/fl chw 0.5mg<br />

multi-vit/fl chw 0.5mg<br />

multi-vit/fl chw 0.5mg<br />

multi-vit/fl chw 1mg<br />

multi-vit/fl chw 1mg<br />

multi-vit/fl dro 0.25mg<br />

multi-vit/fl dro 0.25mg<br />

multi-vit/fl dro 0.25mg<br />

multi-vit/fl dro 0.5mg/ml<br />

multi-vit/fl dro 0.5mg/ml<br />

multifol plu tab 65-1mg<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 170


multivit/fl chw 0.25mg<br />

multivit/fl chw 0.25mg<br />

multivit/fl chw 0.25mg<br />

multivit/fl chw 0.5/fe12<br />

multivit/fl chw 0.5mg<br />

multivit/fl chw 0.5mg<br />

multivit/fl chw 0.5mg<br />

multivit/fl chw 1mg<br />

multivit/fl chw 1mg<br />

multivit/fl chw 1mg<br />

multivitamin chw fl1/fe12<br />

multivitamin chw w/fl/fe<br />

multivitamin dro /fluorid<br />

multivitamin dro fluor/fe<br />

multivite/fl chw 0.5mg<br />

mvc-fluoride chw 0.25mg<br />

mvc-fluoride chw 0.5mg<br />

mvc-fluoride chw 1mg<br />

mynatal plus tab<br />

mynatal-z tab<br />

mynate 90 tab plus<br />

NATAFORT TAB<br />

natalcare tab pic<br />

natalcare tab picforte<br />

natalcare tab plus<br />

natalcare tab three<br />

natalcare rx tab<br />

natamar rx tab<br />

natatab fa tab<br />

NEURODEP SOL PA<br />

niferex-pn tab forte<br />

OCTRON INJ PA<br />

p d natal/fa tab OTC<br />

p-d natal tab plus OTC<br />

poly iron pn tab<br />

poly iron pn tab forte<br />

poly-vit w/f dro 0.25mg<br />

poly-vit/fe chw /fl 1mg<br />

poly-vit/fe dro /fl 0.25<br />

poly-vit/fe dro /fl 0.5<br />

poly-vit/fl chw 0.5mg<br />

poly-vit/fl dro 0.25mg<br />

poly-vit/fl dro 0.5mg<br />

polyvit/fl dro 0.5mg/ml<br />

polyvites/fl chw 0.25mg<br />

polyvits/fe dro 0.25/fl<br />

pre-natal tab OTC<br />

pre-natal tab formula OTC<br />

PRECARE TAB PRENATAL<br />

prenaplus tab<br />

prenatabs fa tab<br />

prenatal tab<br />

prenatal tab<br />

prenatal tab OTC<br />

prenatal tab 27-0.8mg<br />

prenatal tab formula OTC<br />

prenatal tab formula<br />

prenatal tab forte OTC<br />

prenatal tab low iron OTC<br />

prenatal tab low iron<br />

prenatal tab plus<br />

prenatal tab plus/fe<br />

prenatal tab vitamins OTC<br />

prenatal 1 tab plus 1<br />

prenatal fa tab<br />

prenatal for tab 28-1mg<br />

prenatal mr tab 90 fe<br />

prenatal mtr tab selenium<br />

prenatal nf tab plus<br />

prenatal pls tab /betacar<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 171


prenatal pls tab /iron<br />

prenatal rx tab<br />

prenatal rx tab beta-car<br />

prenatal rx1 tab<br />

prenatal s tab OTC<br />

prenatal s tab<br />

prenatal vit tab OTC<br />

prenatal z tab<br />

prenatal z tab adv form<br />

prenatal/fa tab<br />

prenatal/fe tab OTC<br />

prenavite tab mult vit OTC<br />

prenavite pr tab coated OTC<br />

px prenatal tab multivit OTC<br />

qc prenatal tab 27-0.8mg OTC<br />

ra prenatal tab /fa OTC<br />

ra prenatal tab 27-0.8mg OTC<br />

ra prenatal tab 28-0.8mg OTC<br />

se-care tab conceive<br />

se-natal 90 tab<br />

se-natal one tab<br />

sm prenatal tab vitamins OTC<br />

taron-ec cal tab 28-1mg<br />

ternamar tab<br />

tri-a-vite chw w/fl 1mg<br />

tri-vit/fe dro /fl 0.25<br />

tri-vit/fe dro /fl 0.25<br />

tri-vit/fl chw<br />

tri-vit/fl dro 0.25mg<br />

tri-vit/fl dro 0.5mg<br />

tri-vit/fluo dro 0.25mg<br />

tri-vit/fluo dro 0.5mg<br />

tri-vita bet chw /fluorid<br />

tricare tab prenatal<br />

trinatal rx tab 1<br />

verotin-by tab<br />

verotin-gr tab<br />

vinatal tab forte<br />

vinate c tab<br />

VINATE M TAB<br />

vinate one tab<br />

VITA-NUMONYL INJ PA<br />

vitafol-ob tab 65-1mg<br />

VITAFOL-PN TAB NF<br />

VITAJECT INJ PA<br />

vitl nestabs tab OTC<br />

vynatal fa tab<br />

Miscellaneous Therapeutic Agents<br />

sod fluoride chw 0.5mg<br />

sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)<br />

Biologic Response Modifiers<br />

ACTIMMUNE INJ 2MU/0.5 PA<br />

AVONEX KIT 30MCG PA<br />

AVONEX PREFL KIT 30MCG PA<br />

BETASERON INJ 0.3MG PA<br />

COPAXONE KIT 20MG/ML PA<br />

EXTAVIA INJ 0.3MG PA<br />

REBIF INJ 22/0.5 PA<br />

REBIF INJ 44/0.5 PA<br />

REBIF TITRTN SOL PACK PA<br />

TYSABRI INJ PA<br />

Bone Resorption Inhibitors<br />

BONIVA KIT 3MG/3ML PA<br />

GANITE INJ 25MG/ML PA<br />

PAMIDRONATE INJ 6MG/ML PA<br />

pamidronate disodium for inj 30 mg PA<br />

pamidronate disodium for inj 90 mg PA<br />

pamidronate disodium iv soln 3 mg/ml PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 172


pamidronate disodium iv soln 9 mg/ml PA<br />

RECLAST INJ 5/100ML PA<br />

ZOMETA INJ 4MG/5ML PA<br />

Disease-Modifying Antirheumatic Agents<br />

ACTEMRA INJ 200/10ML PA<br />

ACTEMRA INJ 400/20ML PA<br />

ACTEMRA INJ 80MG/4ML PA<br />

ENBREL INJ 25/0.5ML PA<br />

ENBREL INJ 25MG PA<br />

ENBREL INJ 50MG/ML PA<br />

ENBREL SRCLK INJ 50MG/ML PA<br />

HUMIRA KIT 20MG/0.4 PA<br />

HUMIRA KIT 40MG/0.8 PA<br />

HUMIRA PEN KIT 40MG/0.8 PA<br />

HUMIRA PEN KIT CROHNS PA<br />

HUMIRA PEN KIT PSORIASI PA<br />

KINERET INJ PA<br />

ORENCIA INJ 250MG PA<br />

REMICADE INJ 100MG PA<br />

SIMPONI INJ 50MG PA<br />

Immunosuppressive Agents<br />

ATGAM INJ 250MG PA<br />

AZATHIOPRINE INJ 100MG PA<br />

CELLCEPT IV INJ 500MG PA<br />

cyclosporine cap 100 mg<br />

cyclosporine cap 100mg<br />

cyclosporine cap 100mg md<br />

cyclosporine cap 25 mg<br />

cyclosporine cap 25mg<br />

cyclosporine cap 25mg mod<br />

cyclosporine cap 50mg mod<br />

cyclosporine inj 50mg/ml<br />

cyclosporine iv soln 50 mg/ml<br />

cyclosporine modified cap 100 mg<br />

cyclosporine modified cap 25 mg<br />

cyclosporine modified cap 50 mg<br />

cyclosporine modified oral soln 100 mg/ml<br />

cyclosporine oral soln 100 mg/ml<br />

cyclosporine sol 100mg/ml<br />

cyclosporine sol modified<br />

gengraf cap 100mg<br />

gengraf cap 25mg<br />

gengraf sol 100mg/ml<br />

ORTHOCLONE INJ OKT3 PA<br />

PROGRAF INJ 5MG/ML PA<br />

RAPAMUNE SOL 1MG/ML<br />

SIMULECT INJ 10MG PA<br />

SIMULECT INJ 20MG PA<br />

SIROLIMUS ORAL SOLN 1 MG/ML<br />

STELARA INJ 45MG/0.5 PA<br />

STELARA INJ 90MG/ML PA<br />

tacrolimus cap 0.5mg<br />

tacrolimus cap 1mg<br />

tacrolimus cap 5mg<br />

tacrolimus cap 0.5 mg<br />

tacrolimus cap 1 mg<br />

tacrolimus cap 5 mg<br />

THYMOGLOBULN INJ 25MG PA<br />

ZENAPAX INJ 25MG/5ML PA<br />

Other Misc Therapeutic Agents<br />

*aromatic inhalants - inhalant*** OTC<br />

*camphor-eucalyptus-menthol - cream*** OTC<br />

*CAMPHOR-EUCALYPTUS-MENTHOL - LIQUID*** OTC<br />

*camphor-eucalyptus-menthol - liquid*** OTC<br />

*CAMPHOR-EUCALYPTUS-MENTHOL - OINT*** OTC<br />

*CAMPHOR-EUCALYPTUS-MENTHOL - SOLUBLE TAB FOR INHALATION*** OTC<br />

*CAMPHOR-EUCALYPTUS-MENTHOL - TOPICAL PATCH*** OTC<br />

*CAMPHOR-EUCALYPTUS-MENTHOL-BENZOIN - LIQUID*** OTC<br />

*camphor-eucalyptus-menthol-turp oil-white pet -oint*** OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 173


*CAMPHOR-MENTHOL - OINTMENT*** OTC<br />

ARCALYST INJ 220MG PA QL<br />

ARGENTUM MET INJ 8X PA<br />

ARGENTUM-D20 INJ PA<br />

ayr inh OTC<br />

BEE VENOM INJ 1300MCG PA<br />

BEE VENOM INJ 550MCG PA<br />

BL HOT STEAM LIQ OTC<br />

BOTOX INJ 100UNIT PA<br />

BOTOX INJ 200UNIT PA<br />

BOTOX COSMET INJ 100UNIT PA<br />

BOTOX COSMET INJ 50UNIT PA<br />

camphor inhalant liquid 6.2% OTC<br />

CAMPHOR-MENTHOL PATCH 4.7-2.6% OTC<br />

CAT HAIR INJ EXTRACT PA<br />

CERECOMP INJ PA<br />

chest rub oin medicate OTC<br />

COENZYME INJ COMPOSIT PA<br />

deconges rub mis OTC<br />

decongestant inh OTC<br />

decongestant inh nasal OTC<br />

decongestant inh vapor OTC<br />

DISCUS INJ COMPOSIT PA<br />

DYSPORT INJ 500UNIT PA<br />

ENGYSTOL INJ PA<br />

eq medicated oin chst rub OTC<br />

EUFLEXXA INJ 10MG/ML PA<br />

GALIUM-HEEL INJ PA<br />

GLYOXAL INJ COMPOSIT PA<br />

gnp hot liq steam OTC<br />

GRIPP-HEEL INJ PA<br />

HEPAR INJ COMPOSIT PA<br />

HONEY BEE INJ 1000MCG PA<br />

HONEY BEE KIT 100MCG PA<br />

HORNET VENOM INJ 1300MCG PA<br />

HORNET VENOM INJ 550MCG PA<br />

hot steam liq OTC<br />

hot steam liq 6.2% OTC<br />

hot steam liq medicati OTC<br />

HYALGAN INJ 20MG/2ML PA<br />

inhaler inh deconges OTC<br />

ISCAR MALI INJ PA<br />

ISCAR MALI INJ 100MG/ML PA<br />

ISCAR MALI INJ 50MG/ML PA<br />

ISCAR MALI INJ 5MG/ML PA<br />

ISCAR MALI INJ SERIES I PA<br />

ISCAR MALI INJ SERIES O PA<br />

ISCAR MALI INJ SERIESII PA<br />

ISCAR MALI INJ SPECIAL PA<br />

ISCAR PINI INJ 0.005MG/ PA<br />

ISCAR PINI INJ 0.05MG/M PA<br />

ISCAR PINI INJ 0.5MG/ML PA<br />

ISCAR PINI INJ 100MG/ML PA<br />

ISCAR PINI INJ 50MG/ML PA<br />

ISCAR PINI INJ 5MG/ML PA<br />

ISCAR PINI INJ SERIES I PA<br />

ISCAR PINI INJ SERIES I PA<br />

ISCAR PINI INJ SERIES O PA<br />

ISCAR QUERCU INJ PA<br />

ISCAR QUERCU INJ 100MG/ML PA<br />

ISCAR QUERCU INJ 25MG/ML PA<br />

ISCAR QUERCU INJ 50MG/ML PA<br />

ISCAR QUERCU INJ 5MG/ML PA<br />

ISCAR QUERCU INJ SERIES I PA<br />

ISCAR QUERCU INJ SERIES O PA<br />

ISCAR QUERCU INJ SERIESII PA<br />

KALBITOR INJ 10MG/ML PA<br />

levocarnitin tab 330mg<br />

levocarnitine inj 200 mg/ml PA<br />

levocarnitine oral soln 1 gm/10ml (10%) PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 174


levocarnitine tab 330 mg<br />

LYMPHOMYOSOT INJ PA<br />

MEDICATED OIN RUB OTC<br />

medicated oin rub OTC<br />

METASTRON INJ PA<br />

MIXED VESPID INJ 1650MCG PA<br />

MIXED VESPID INJ 3900MCG PA<br />

MIXED VESPID KIT 3000MCG PA<br />

MIXED VESPID KIT 300MCG PA<br />

MUCOSA INJ COMPOSIT PA<br />

MYOBLOC INJ 10000/2 PA<br />

MYOBLOC INJ 2500/0.5 PA<br />

MYOBLOC INJ 5000/ML PA<br />

NEXAVIR INJ PA<br />

OCTREOSCAN KIT PA<br />

octreotide acetate inj 100 mcg/ml (0.1 mg/ml) PA<br />

octreotide acetate inj 1000 mcg/ml (1 mg/ml) PA<br />

octreotide acetate inj 200 mcg/ml (0.2 mg/ml) PA<br />

octreotide acetate inj 50 mcg/ml (0.05 mg/ml) PA<br />

octreotide acetate inj 500 mcg/ml (0.5 mg/ml) PA<br />

PROSTASCINT KIT PA<br />

PX MEDICATED OIN CHESTRUB OTC<br />

QC HOT STEAM LIQ OTC<br />

ra decongest inh nasal OTC<br />

RA MEDICATED OIN RUB OTC<br />

ra vaporizin liq steam OTC<br />

SANDOSTATIN KIT LAR 10MG PA<br />

SANDOSTATIN KIT LAR 20MG PA<br />

SANDOSTATIN KIT LAR 30MG PA<br />

SARAPIN INJ PA<br />

SHOWER TAB OTC<br />

SHOWER TAB SOOTHERS OTC<br />

sm medicated mis chst rub OTC<br />

SOMATULINE INJ 120/.5ML PA<br />

SOMATULINE INJ 60/0.2ML PA<br />

SOMATULINE INJ 90/0.3ML PA<br />

SPASCUPREEL INJ PA<br />

STAPHAGE LYS INJ PA<br />

SUPARTZ INJ 25/2.5ML PA<br />

SYNVISC INJ 8MG/ML PA<br />

SYNVISC ONE INJ 8MG/ML PA<br />

TIGER BALM OIN 11%-10% OTC<br />

TIGER BALM OIN 11%-11% OTC<br />

TIGER BALM OIN 11%-8% OTC<br />

TRAUMEEL INJ PA<br />

TRAUMEEL INJ PA<br />

TRIAMINIC DIS CHERRY OTC<br />

TRIAMINIC DIS MENTHOL OTC<br />

UBICHINON INJ COMPOSIT PA<br />

vapor inhale inh OTC<br />

VAPOR PATCH DIS OTC<br />

vaporizing cre OTC<br />

vaporizing liq steam OTC<br />

VAPORIZING OIN RUB OTC<br />

VAPORX BALM OIN OTC<br />

VENOMIL KIT HONEYBEE PA<br />

VENOMIL KIT WASP PA<br />

VENOMIL KIT WHT HORN PA<br />

VENOMIL KIT YEL HORN PA<br />

VENOMIL KIT YEL JACK PA<br />

VENOMIL MIX INJ VESPID PA<br />

VICK VAPORUB OIN OTC<br />

VICKS CASERO OIN LEMON OTC<br />

WASP VENOM INJ 1000MCG PA<br />

WASP VENOM INJ 1300MCG PA<br />

WASP VENOM INJ 550MCG PA<br />

WASP VENOM KIT 100MCG PA<br />

WHITE HORNET KIT 100MCG PA<br />

WHITE HORNET SOL 1000MCG PA<br />

XIGRIS INJ 20MG PA<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 175


XIGRIS INJ 5MG PA<br />

YELLOW HORN INJ 550MCG PA<br />

YELLOW HORNT KIT 100MCG PA<br />

YELLOW HORNT SOL 1000MCG PA<br />

YELLOW JACK INJ 1300MCG PA<br />

YELLOW JACK INJ 550MCG PA<br />

YELLOW JACKT KIT 100MCG PA<br />

YELLOW JACKT SOL 1000MCG PA<br />

ZEEL INJ PA<br />

Devices<br />

*BLOOD GLUCOSE MONITORING DEVICES*** OTC QL<br />

*BLOOD GLUCOSE MONITORING KIT W/ DEVICE*** OTC QL<br />

*FEEDING TUBES - SETS*** OTC NF<br />

*FEEDING TUBES - TUBING*** OTC NF<br />

*INJECTION DEVICE - MISC*** OTC<br />

*INSULIN PEN NEEDLE*** OTC QL<br />

*lancets*** OTC<br />

*RESPIRATORY THERAPY SUPPLIES - MISC** QL<br />

*SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - BAGS*** QL<br />

*SPACER/AEROSOL-HOLDING CHAMBER SUPPLIES - MOUTHPIECES*** QL<br />

*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** OTC QL<br />

*SPACER/AEROSOL-HOLDING CHAMBERS - DEVICE*** QL<br />

1/2ML ALLERG KIT 27GX3/8" OTC<br />

1ML ALLERGIS KIT TRAY SYR OTC<br />

1ML ALLERGIS KIT TRAY SYR OTC<br />

1ML ALLR SYR MIS 27GX1/2" OTC<br />

1ML SYRINGE MIS 28GX1/2" OTC<br />

1st choice mis lancets OTC<br />

1st choice mis lancets OTC<br />

1st choice mis lancets OTC<br />

1ST TIER UNI MIS 29GX12MM OTC QL<br />

1ST TIER UNI MIS 31GX6MM OTC QL<br />

1ST TIER UNI MIS 31GX8MM OTC QL<br />

A1C NOW KIT PA OTC<br />

A1C NOW KIT SELFCHEC PA OTC<br />

ACCU-CHEK KIT ACTIVE PA OTC<br />

ACCU-CHEK KIT ADVANTAG PA OTC<br />

ACCU-CHEK KIT AVIVA PA OTC<br />

ACCU-CHEK KIT COMPACT PA OTC<br />

ACCU-CHEK KIT COMPACT PA OTC<br />

ACCU-CHEK KIT COMPACT PA OTC<br />

ACCU-CHEK KIT VOICEMAT PA OTC<br />

ACCU-CHEK MIS ACTIVE PA OTC<br />

ACCU-CHEK MIS AVIVA PA OTC<br />

accu-chek mis mlticlix OTC<br />

ACCU-CHEK MIS TRANSFER PA OTC<br />

ACCU-CHEK AD MIS METER PA OTC<br />

ACURA BLOOD KIT METER PA OTC<br />

ACURA BLOOD KIT STARTER PA OTC<br />

ADULT MASK MIS LARGE QL<br />

ADVANCE KIT INTUITIO PA OTC<br />

ADVANCE MIS INTUITIO PA OTC<br />

ADVANCE MIS MICRO-DW PA OTC<br />

ADVOCATE KIT PA OTC<br />

ADVOCATE KIT REDICODE PA OTC<br />

ADVOCATE MIS PA OTC<br />

advocate mis lancets OTC<br />

advocate mis lancets OTC<br />

ADVOCATE MIS REDICODE PA OTC<br />

ADVOCATE RED MIS PA OTC<br />

AERCHMBR PLS MIS LRG MASK QL<br />

AERCHMBR PLS MIS MASK QL<br />

AERCHMBR PLS MIS SM MASK QL<br />

AERCHMBR Z- MIS STAT PLS QL<br />

AERCHMBR Z- MIS STAT PLS QL<br />

AERCHMBR Z- MIS STAT PLS QL<br />

AERCHMBR Z- MIS STAT PLS QL<br />

AEROCHAMBER KIT ACTION QL<br />

AEROCHAMBER MIS FLOSIGNA QL<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 176


AEROCHAMBER MIS MV QL<br />

AEROCHAMBER MIS PLUS QL<br />

af lancets mis thin OTC<br />

ALBERTSONS KIT STARTER PA OTC<br />

ALLERGIST KIT 27GX1/2" OTC<br />

ALLERGIST KIT PACK OTC<br />

ALLERGIST KIT PACKAGE OTC<br />

ALLERGY TRAY KIT 1 ML 26 X 1/2" OTC<br />

ALLERGY TRAY KIT 1 ML 26 X 3/8" OTC<br />

ALLERGY TRAY KIT 1 ML 27 X 1/2" OTC<br />

ALLERGY TRAY KIT 1 ML 27 X 3/8" OTC<br />

ALLERGY TRAY KIT 1/2 ML 27 X 3/8" OTC<br />

ames glu sys mis OTC<br />

ASCENSIA KIT BREEZE PA OTC<br />

ASCENSIA KIT BRIO PA OTC<br />

ASCENSIA KIT DIAB XL PA OTC<br />

ASSURE 3 KIT METER PA OTC<br />

ASSURE 4 MIS PA OTC<br />

assure lance mis low flow OTC<br />

assure lance mis micro OTC<br />

ASSURE PRO MIS METER PA OTC<br />

AT LAST KIT GLUCOSE PA OTC<br />

at last mis lancets OTC<br />

aurora mis lancets OTC<br />

aurora lance mis 30g OTC<br />

aurora lance mis thin 23g OTC<br />

auto lancet mis OTC<br />

AUTOCODE SYS KIT GLUCOSE PA OTC<br />

AUTOSHIELD MIS 29GX1/2" OTC QL<br />

AUTOSHIELD MIS 29X3/16" OTC QL<br />

AUTOSHIELD MIS 29X5/16" OTC QL<br />

BAYER BREEZE KIT 2 SYSTEM PA OTC<br />

BAYER CONTOR KIT MONITOR PA OTC<br />

bayer micrlt mis lancets OTC<br />

bd genie mis lancet OTC<br />

bd genie mis lancets OTC<br />

bd lancet uf mis 30g OTC<br />

bd lancet uf mis 33g OTC<br />

BD LATITUDE KIT PA OTC<br />

BD LATITUDE KIT SYSTEM PA OTC<br />

BD LOGIC KIT MONITOR PA OTC<br />

bd microtain mis lancets OTC<br />

BD PEN NEEDL MIS 29GX1/2" OTC QL<br />

BD PEN NEEDL MIS 31GX3/16 OTC QL<br />

BD PEN NEEDL MIS 31GX3/16 OTC QL<br />

BD PEN NEEDL MIS 31GX5/16 OTC QL<br />

BD PEN NEEDL MIS 31GX5/16 OTC QL<br />

BD PEN NEEDL MIS 32GX4MM OTC QL<br />

bd ult fine mis lancets OTC<br />

bl lancets mis OTC<br />

bl lancets mis color OTC<br />

bl lancets mis thin OTC<br />

bl lancets mis thin OTC<br />

BLOOD GLUC KIT SYSTEM PA OTC<br />

BLOOD GLUC MIS METER PA OTC<br />

BLOOD GLUC MIS MONITOR PA OTC<br />

BLOOD GLUCOS KIT METER PA OTC<br />

BLOOD GLUCOS KIT MONITOR PA OTC<br />

BLOOD GLUCOS KIT MONITOR PA OTC<br />

BLOOD GLUCOS KIT MONITOR PA OTC<br />

BLOOD GLUCOS KIT MONITOR PA OTC<br />

BLOOD GLUCOS KIT SYSTEM PA OTC<br />

BLOOD GLUCOS KIT SYSTEM PA OTC<br />

BLOOD GLUCOS MIS METER PA OTC<br />

BREEZE 2 MIS SYSTEM PA OTC<br />

bullseye mis lancets OTC<br />

careone lanc mis 26g OTC<br />

careone lanc mis 28g OTC<br />

careone lanc mis 30g OTC<br />

careone lanc mis thin OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 177


careone lanc mis thin 23g OTC<br />

CHOICE DM KIT RISK TST PA OTC<br />

cleanlet 28g mis lancets OTC<br />

clever check mis OTC<br />

clever check mis 30g OTC<br />

CLEVER CHEK KIT SYSTEM PA OTC<br />

CLEVER CHEK MIS AUTO-CD PA OTC<br />

CLEVER CHEK MIS VOICE PA OTC<br />

CLEVER CHEK MIS VOICE PA OTC<br />

CLEVR CHOICE MIS AUTO-CD PA OTC<br />

CLEVR CHOICE MIS MINI PA OTC<br />

CLICKFINE MIS 31GX1/4" OTC QL<br />

CLICKFINE MIS 31GX1/4" OTC QL<br />

CLICKFINE MIS 31GX1/4" OTC QL<br />

CLICKFINE MIS 31GX5/16 OTC QL<br />

CLICKFINE MIS 31GX5/16 OTC QL<br />

CLICKFINE MIS 31GX5/16 OTC QL<br />

coaguchek mis lancets OTC<br />

color lancet mis OTC<br />

comfort mis lancets OTC<br />

comfortouch mis lancet OTC<br />

CONTOUR KIT BLUE PA OTC<br />

CONTOUR KIT ORANGE PA OTC<br />

CONTOUR MIS SYSTEM PA OTC<br />

CONTOUR USB KIT SYSTEM PA OTC<br />

CONTROL KIT MONITOR PA OTC<br />

CVS BLOOD GL MIS MONITOR PA OTC<br />

CVS BLOOD GL MIS MONITOR PA OTC<br />

cvs lancets mis 21g OTC<br />

cvs lancets mis original OTC<br />

cvs lancets mis thin OTC<br />

cvs lancets mis thin 26g OTC<br />

cvs lancets mis thin 30g OTC<br />

cvs lancets mis thin 33g OTC<br />

DAILY KIT DIABETIC PA OTC<br />

dd lancets mis OTC<br />

dd lancets mis thin OTC<br />

de lancets mis OTC<br />

de lancets mis thin OTC<br />

diabetic mis lancets OTC<br />

DIABETIC.COM KIT STARTER PA OTC<br />

DIDGET KIT PA OTC<br />

dr lancets mis colored OTC<br />

dr lancets mis thin OTC<br />

DRUG EMP KIT STARTER PA OTC<br />

DUANE READE KIT STARTER PA OTC<br />

e-z ject mis OTC<br />

e-z ject mis 21g colr OTC<br />

e-z ject mis 32g colr OTC<br />

e-z ject mis lanc 21g OTC<br />

e-z ject mis lancets OTC<br />

e-z ject mis lancets OTC<br />

e-z ject mis lancets OTC<br />

e-z ject mis thin OTC<br />

e-z ject mis thin 26g OTC<br />

e-z ject xl mis OTC<br />

E-Z SPACER MIS QL<br />

E-Z SPACER MIS MASK QL<br />

E-Z SPACER/ MIS MASK QL<br />

EASIVENT MIS QL<br />

EASIVENT MIS MASK LG QL<br />

EASIVENT MIS MASK SM QL<br />

EASIVENT MIS MASK MED QL<br />

EASY CHECK KIT PA OTC<br />

EASY CHECK MIS PA OTC<br />

EASY STEP KIT MONITOR PA OTC<br />

EASY STEP MIS MONITOR PA OTC<br />

easy touch mis 28g OTC<br />

EASY TOUCH MIS 29GX1/2" OTC QL<br />

easy touch mis 30g OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 178


EASY TOUCH MIS 31GX1/4" OTC QL<br />

EASY TOUCH MIS 31GX3/16 OTC QL<br />

EASY TOUCH MIS 31GX5/16 OTC QL<br />

EASYGLUCO KIT PA OTC<br />

EASYGLUCO KIT VALUE PK PA OTC<br />

EASYMAX N KIT SYSTEM PA OTC<br />

EASYMAX V MIS SYSTEM PA OTC<br />

EASYPRO KIT MONITOR PA OTC<br />

EASYPRO PLUS KIT PA OTC<br />

easytest mis lancets OTC<br />

easytest ii mis lancets OTC<br />

eck lancets mis thin OTC<br />

ECLIPSE KIT MONITOR PA OTC<br />

ELEMENT AUTO KIT SYSTEM PA OTC<br />

EMBRACE MIS PA OTC<br />

ENVISION KIT AUTOCODE PA OTC<br />

eql lancets mis 21g colr OTC<br />

eql lancets mis thin 26g OTC<br />

eql lancets mis thin 30g OTC<br />

equate reg mis lancets OTC<br />

equate thin mis lancets OTC<br />

EVENCARE SYS KIT BG MONIT PA OTC<br />

EVOLUTION MIS AUTOCODE PA OTC<br />

EXP MED STAR KIT PA OTC<br />

EZ SMART MIS PA OTC<br />

ez smart mis lancets OTC<br />

EZ SMART PLS MIS PA OTC<br />

ez-lets mis lancets OTC<br />

ez-lets 21g mis lancets OTC<br />

ez-lets 23g mis lancets OTC<br />

ez-lets 26g mis lancets OTC<br />

ez-lets 28g mis lancets OTC<br />

FASTTAKE KIT COMPACT PA OTC<br />

fc lancets mis colored OTC<br />

fc lancets mis thin OTC<br />

FIFTY50 GLUC KIT METR 2.0 PA OTC<br />

fifty50 safe mis lancets OTC<br />

fingerstix mis lancets OTC<br />

FLEXIFLO MIS 10FRENCH OTC NF<br />

FLEXIFLO MIS 8 FRENCH OTC NF<br />

FORA G20 KIT PA OTC<br />

FORA V10 MIS PA OTC<br />

FORA V12 MIS PA OTC<br />

FORA V20 MIS PA OTC<br />

FORA V22 KIT PA OTC<br />

fp lancets mis OTC<br />

fp lancets mis thin OTC<br />

FREESTYLE KIT FREEDOM PA OTC<br />

FREESTYLE KIT FREEDOM PA OTC<br />

FREESTYLE KIT SIDEKICK PA OTC<br />

FREESTYLE KIT SYSTEM PA OTC<br />

FREESTYLE KIT SYSTEM PA OTC<br />

freestyle mis lancets OTC<br />

freestyle mis lancets OTC<br />

FREESTYLE MIS LITE PA OTC<br />

freestyle mis unistick OTC<br />

gentle-let mis 26g OTC<br />

gentle-let mis 28g OTC<br />

gentle-let mis lancets OTC<br />

gentle-let mis lancets OTC<br />

GIANT EAGLE KIT VALU PK PA OTC<br />

GLUCOCARD KIT VITAL PA OTC<br />

GLUCOCARD KIT X-METER PA OTC<br />

GLUCOCARD 01 KIT MINI PA OTC<br />

GLUCOCARD 01 KIT SYSTEM PA OTC<br />

GLUCOCARD 01 MIS METER PA OTC<br />

GLUCOCOM KIT MONITOR PA OTC<br />

glucocom mis 28g OTC<br />

glucocom mis 30g OTC<br />

glucocom mis 33g OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 179


GLUCOCOM MIS MONITOR PA OTC<br />

GLUCOLAB KIT MONITOR PA OTC<br />

GLUCOMETER KIT CLASSIC PA OTC<br />

GLUCOMETER KIT ENCORE PA OTC<br />

glucosource mis lancets OTC<br />

gnp lancets mis OTC<br />

gnp lancets mis color OTC<br />

gnp lancets mis thin OTC<br />

gnp lancets mis thin OTC<br />

GNP TRUEREAD KIT PA OTC<br />

GNP TRUETRAC MIS SYSTEM PA OTC<br />

haemolance mis high flo OTC<br />

haemolance mis low flow OTC<br />

haemolance mis plus OTC<br />

haemolance mis plus low OTC<br />

haemolance mis plus max OTC<br />

haemolance mis plus ped OTC<br />

haemolance mis retract OTC<br />

hca lancets mis thin OTC<br />

IN CONTROL MIS 31GX6MM OTC QL<br />

IN CONTROL MIS 31GX8MM OTC QL<br />

INCONTROL MIS 29GX12MM OTC QL<br />

INFINITY KIT SYSTEM PA OTC<br />

INJECTION DEVICE 1 ML OTC<br />

INSPIREASE MIS BAGS QL<br />

INSPIREASE MIS DD SYST QL<br />

INSPIREASE MIS MOUTHPCE QL<br />

INSPIREASE MIS REP MOUT QL<br />

INSPIREASE MIS RES BAG QL<br />

INSULIN PEN MIS 29GX1/2" OTC QL<br />

INSULIN PEN MIS 31GX1/3" OTC QL<br />

INSULIN PEN NEEDLE 29 G X 12 MM (1/2") OTC QL<br />

INSULIN PEN NEEDLE 29 G X 12.7 MM OTC QL<br />

INSULIN PEN NEEDLE 29 G X 5 MM (3/16") OTC QL<br />

INSULIN PEN NEEDLE 29 G X 8 MM (5/16") OTC QL<br />

INSULIN PEN NEEDLE 30 G X 8 MM (1/3" OR 5/16") OTC QL<br />

INSULIN PEN NEEDLE 31 G X 5 MM (3/16") OTC QL<br />

INSULIN PEN NEEDLE 31 G X 6 MM (1/4") OTC QL<br />

INSULIN PEN NEEDLE 31 G X 8 MM (1/3" OR 5/16") OTC QL<br />

INSULIN PEN NEEDLE 32 G X 4 MM (5/32") OTC QL<br />

INSULIN PEN NEEDLE 32 G X 6 MM (1/4") OTC QL<br />

INSULIN PEN NEEDLE 32 G X 8 MM OTC QL<br />

insulin syrg mis 0.3/28g OTC<br />

insulin syrg mis 0.3/28g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 180


insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/29g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 181


insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/30g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

INSULIN SYRG MIS 0.3/31G OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.3/31g OTC<br />

insulin syrg mis 0.5/27g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

INSULIN SYRG MIS 0.5/28G OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 182


insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/28g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 183


insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/29g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

INSULIN SYRG MIS 0.5/30G OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/30g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 184


insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

INSULIN SYRG MIS 0.5/31G OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

insulin syrg mis 0.5/31g OTC<br />

INSULIN SYRG MIS 1ML<br />

INSULIN SYRG MIS 1ML<br />

INSULIN SYRG MIS 1ML OTC<br />

INSULIN SYRG MIS 1ML OTC<br />

INSULIN SYRG MIS 1ML OTC<br />

INSULIN SYRG MIS 1ML/25G OTC<br />

insulin syrg mis 1ml/25g OTC<br />

insulin syrg mis 1ml/25g OTC<br />

insulin syrg mis 1ml/25g<br />

insulin syrg mis 1ml/25g OTC<br />

insulin syrg mis 1ml/26g OTC<br />

insulin syrg mis 1ml/27g OTC<br />

insulin syrg mis 1ml/27g OTC<br />

insulin syrg mis 1ml/27g OTC<br />

insulin syrg mis 1ml/27g<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g<br />

insulin syrg mis 1ml/28g OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 185


insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/28g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

INSULIN SYRG MIS 1ML/29G OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

INSULIN SYRG MIS 1ML/29G OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 186


insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/29g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g<br />

insulin syrg mis 1ml/30g<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

INSULIN SYRG MIS 1ML/30G OTC<br />

INSULIN SYRG MIS 1ML/30G OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/30g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 187


insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

INSULIN SYRG MIS 1ML/31G OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 1ml/31g OTC<br />

insulin syrg mis 2/27.5g OTC<br />

insulin syrg mis 2ml/29g OTC<br />

insulin syringe (disp) u-100 0.3 ml OTC<br />

INSULIN SYRINGE (DISP) U-100 1 ML OTC<br />

INSULIN SYRINGE (DISP) U-100 1 ML<br />

insulin syringe (disp) u-100 1 ml OTC<br />

INSULIN SYRINGE (DISP) U-100 1/2 ML OTC<br />

insulin syringe (disp) u-100 1/2 ml OTC<br />

insulin syringe/needle u-100 0.3 ml 28 g x 1" OTC<br />

insulin syringe/needle u-100 0.3 ml 28 x 1/2" OTC<br />

insulin syringe/needle u-100 0.3 ml 29 g OTC<br />

insulin syringe/needle u-100 0.3 ml 29 x 1" OTC<br />

insulin syringe/needle u-100 0.3 ml 29 x 1/2" OTC<br />

insulin syringe/needle u-100 0.3 ml 29 x 1/2"<br />

insulin syringe/needle u-100 0.3 ml 29 x 5/16" OTC<br />

insulin syringe/needle u-100 0.3 ml 29 x 7/16" OTC<br />

insulin syringe/needle u-100 0.3 ml 30 g OTC<br />

insulin syringe/needle u-100 0.3 ml 30 x 1" OTC<br />

insulin syringe/needle u-100 0.3 ml 30 x 1/2" OTC<br />

insulin syringe/needle u-100 0.3 ml 30 x 3/8" OTC<br />

insulin syringe/needle u-100 0.3 ml 30 x 5/16" OTC<br />

insulin syringe/needle u-100 0.3 ml 30 x 5/16"<br />

insulin syringe/needle u-100 0.3 ml 30 x 7/16" OTC<br />

INSULIN SYRINGE/NEEDLE U-100 0.3 ML 31 X 3/8" OTC<br />

insulin syringe/needle u-100 0.3 ml 31 x 5/16" OTC<br />

insulin syringe/needle u-100 1 ml 25 x 1" OTC<br />

insulin syringe/needle u-100 1 ml 25 x 5/8" OTC<br />

insulin syringe/needle u-100 1 ml 25 x 5/8"<br />

insulin syringe/needle u-100 1 ml 26 x 1/2" OTC<br />

insulin syringe/needle u-100 1 ml 27 x 1/2" OTC<br />

insulin syringe/needle u-100 1 ml 27 x 1/2"<br />

insulin syringe/needle u-100 1 ml 27 x 5/8" OTC<br />

insulin syringe/needle u-100 1 ml 28 x 1/2" OTC<br />

insulin syringe/needle u-100 1 ml 28 x 1/2"<br />

insulin syringe/needle u-100 1 ml 28 x 5/16" OTC<br />

INSULIN SYRINGE/NEEDLE U-100 1 ML 29 G OTC<br />

insulin syringe/needle u-100 1 ml 29 x 1" OTC<br />

insulin syringe/needle u-100 1 ml 29 x 1/2" OTC<br />

insulin syringe/needle u-100 1 ml 29 x 1/2"<br />

insulin syringe/needle u-100 1 ml 29 x 5/16" OTC<br />

insulin syringe/needle u-100 1 ml 29 x 7/16" OTC<br />

insulin syringe/needle u-100 1 ml 30 g OTC<br />

insulin syringe/needle u-100 1 ml 30 g x 1" OTC<br />

insulin syringe/needle u-100 1 ml 30 x 1/2" OTC<br />

INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 3/8" OTC<br />

insulin syringe/needle u-100 1 ml 30 x 5/16"<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 188


insulin syringe/needle u-100 1 ml 30 x 5/16" OTC<br />

insulin syringe/needle u-100 1 ml 30 x 7/16" OTC<br />

INSULIN SYRINGE/NEEDLE U-100 1 ML 31 X 3/8" OTC<br />

insulin syringe/needle u-100 1 ml 31 x 5/16" OTC<br />

insulin syringe/needle u-100 1/2 ml 27 x 1/2" OTC<br />

insulin syringe/needle u-100 1/2 ml 28 x 1" OTC<br />

insulin syringe/needle u-100 1/2 ml 28 x 1/2" OTC<br />

insulin syringe/needle u-100 1/2 ml 28 x 1/2"<br />

INSULIN SYRINGE/NEEDLE U-100 1/2 ML 28 X 5/16" OTC<br />

insulin syringe/needle u-100 1/2 ml 29 g OTC<br />

insulin syringe/needle u-100 1/2 ml 29 x 1" OTC<br />

insulin syringe/needle u-100 1/2 ml 29 x 1/2" OTC<br />

insulin syringe/needle u-100 1/2 ml 29 x 1/2"<br />

insulin syringe/needle u-100 1/2 ml 29 x 5/16" OTC<br />

insulin syringe/needle u-100 1/2 ml 29 x 7/16" OTC<br />

insulin syringe/needle u-100 1/2 ml 30 g OTC<br />

insulin syringe/needle u-100 1/2 ml 30 g x 1" OTC<br />

insulin syringe/needle u-100 1/2 ml 30 x 1/2" OTC<br />

insulin syringe/needle u-100 1/2 ml 30 x 3/8" OTC<br />

insulin syringe/needle u-100 1/2 ml 30 x 5/16" OTC<br />

insulin syringe/needle u-100 1/2 ml 30 x 5/16"<br />

insulin syringe/needle u-100 1/2 ml 30 x 7/16" OTC<br />

INSULIN SYRINGE/NEEDLE U-100 1/2 ML 31 X 3/8" OTC<br />

insulin syringe/needle u-100 1/2 ml 31 x 5/16" OTC<br />

insulin syringe/needle u-100 2 ml 27.5 x 5/8" OTC<br />

insulin syringe/needle u-100 2 ml 29 x 1/2" OTC<br />

INSULIN SYRINGE/NEEDLE U-40 1 ML 25 X 5/8" OTC<br />

insulin syringe/needle u-40 1 ml 26 x 1/2" OTC<br />

INSUPEN SENS MIS 32GX6MM OTC QL<br />

INSUPEN SENS MIS 32GX8MM OTC QL<br />

INSUPEN ULTR MIS 29GX12MM OTC QL<br />

INSUPEN ULTR MIS 30GX8MM OTC QL<br />

INSUPEN ULTR MIS 31GX6MM OTC QL<br />

INSUPEN ULTR MIS 31GX8MM OTC QL<br />

INVERTA-PEG KIT 20FRENCH OTC NF<br />

KERR STARTER KIT PA OTC<br />

kinney mis lancets OTC<br />

kinney thin mis lancets OTC<br />

KINRAY KIT VALU PK PA OTC<br />

KROGER BGM KIT PA OTC<br />

kroger lance mis OTC<br />

kroger lance mis thin OTC<br />

kroger lance mis thin 30g OTC<br />

lady lite mis lancets OTC<br />

lancet mis 28g OTC<br />

lancet mis 2mm OTC<br />

lancet mis 30g OTC<br />

lancet alter mis site 26g OTC<br />

lancet micro mis thin 33g OTC<br />

lancet stand mis 21g OTC<br />

lancet super mis thin OTC<br />

lancet super mis thin 30g OTC<br />

lancet super mis thin 30g OTC<br />

lancet super mis thin 30g OTC<br />

lancet super mis thin 30g OTC<br />

lancet ultra mis 28g OTC<br />

lancet ultra mis thin 28g OTC<br />

lancet ultra mis thin 30g OTC<br />

lancets mis OTC<br />

lancets mis OTC<br />

lancets mis OTC<br />

lancets mis OTC<br />

lancets mis OTC<br />

lancets mis OTC<br />

lancets mis 21g OTC<br />

lancets mis 21g OTC<br />

lancets mis 21g OTC<br />

lancets mis 21g colr OTC<br />

lancets mis 23g OTC<br />

lancets mis 26g OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 189


lancets mis 26g OTC<br />

lancets mis 26g OTC<br />

lancets mis 28g OTC<br />

lancets mis 28g OTC<br />

lancets mis 28g OTC<br />

lancets mis 28g OTC<br />

lancets mis 28g OTC<br />

lancets mis 30g OTC<br />

lancets mis 30g OTC<br />

lancets mis 30g OTC<br />

lancets mis 30g OTC<br />

lancets mis 31g OTC<br />

lancets mis colored OTC<br />

lancets mis colored OTC<br />

lancets mis fine 28g OTC<br />

lancets mis funcolor OTC<br />

lancets mis orange OTC<br />

lancets mis original OTC<br />

lancets mis original OTC<br />

lancets mis thin OTC<br />

lancets mis thin OTC<br />

lancets mis thin OTC<br />

lancets mis thin 26g OTC<br />

lancets mis thin 30g OTC<br />

lancets mis thin 30g OTC<br />

lancets thin mis OTC<br />

lancets thin mis 26g OTC<br />

lancets thin mis 26g OTC<br />

lancets thin mis 26g OTC<br />

lancets thin mis 28g OTC<br />

lancets thin mis 30g OTC<br />

lancets ultr mis thin OTC<br />

lancets ultr mis thin OTC<br />

lancets ultr mis thin OTC<br />

lancets ultr mis thin 28g OTC<br />

lancets ultr mis thin 30g OTC<br />

lancets ultr mis thin 30g OTC<br />

lb lancet mis 28g OTC<br />

lifescan mis unistik2 OTC<br />

lite touch mis lancets OTC<br />

lite touch mis lancets OTC<br />

LONG STARTER KIT KIT PA OTC<br />

longs lancet mis adult OTC<br />

longs lancet mis standard OTC<br />

longs lancet mis thin OTC<br />

longs lancet mis ultra th OTC<br />

magellan ins mis 1ml/29g<br />

major comfor mis lancets OTC<br />

MAXIMA KIT SYSTEM PA OTC<br />

MAXIMA METER KIT PA OTC<br />

MAXIMA START KIT PA OTC<br />

medi-lance mis lancets OTC<br />

medichoice mis lancet OTC<br />

medichoice mis lancet OTC<br />

medlance mis extr 21g OTC<br />

medlance mis lite 25g OTC<br />

medlance mis plus OTC<br />

medlance mis unv 21g OTC<br />

MEIJER KIT STARTER PA OTC<br />

meijer mis lancets OTC<br />

meijer mis lancets OTC<br />

MICROCHAMBER MIS QL<br />

MICRODOT KIT SYSTEM PA OTC<br />

microlet mis lancets OTC<br />

microtainer mis lancet OTC<br />

monolet mis lancets OTC<br />

monolet neo mis lancets OTC<br />

monolet opd mis lancets OTC<br />

monolet thin mis lancets OTC<br />

monolettor mis lancets OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 190


navarro mis lancets OTC<br />

NEXGEN KIT METER PA OTC<br />

NOVA MAX KIT SYSTEM PA OTC<br />

NOVA MAX MIS SYSTEM PA OTC<br />

nova sure mis lancets OTC<br />

NOVOFINE MIS 30GX8MM OTC QL<br />

NOVOFINE MIS 32GX6MM OTC QL<br />

NOVOFINE 31 MIS DISPOS OTC QL<br />

NOVOFINE AUT MIS 30GX8MM OTC QL<br />

ONETOUCH KIT BASIC PA OTC<br />

ONETOUCH KIT PROFILE PA OTC<br />

ONETOUCH KIT ULT MINI PA OTC<br />

ONETOUCH KIT ULT SMRT PA OTC<br />

ONETOUCH KIT ULTRA PA OTC<br />

ONETOUCH KIT ULTRA 2 PA OTC<br />

ONETOUCH KIT ULTRALNK PA OTC<br />

onetouch mis combo OTC<br />

onetouch mis lancets OTC<br />

onetouch mis lancets OTC<br />

onetouch mis lancets OTC<br />

ONETOUCH MIS ULT SMRT PA OTC<br />

ONETOUCH MIS ULTRA PA OTC<br />

onetouch fp mis lancets OTC<br />

onetouch us mis lancets OTC<br />

OPTICHAMBER MIS ADV LRG QL<br />

OPTICHAMBER MIS ADV MED QL<br />

OPTICHAMBER MIS ADV SM QL<br />

OPTICHAMBER MIS ADVANTAG QL<br />

OPTICHAMBER MIS FACE MAS OTC QL<br />

OPTICHAMBER MIS FACE MAS OTC QL<br />

OPTICHAMBER MIS FACE MAS OTC QL<br />

OPTIUM KIT BL GLUC PA OTC<br />

OPTIUM MIS SYSTEM PA OTC<br />

PARADIGM KIT LINK PA<br />

PEAK FLOW METER W/INHALER ASSIST DEVICE KIT QL<br />

PEN NEEDLE MIS 29GX1/2" OTC QL<br />

PEN NEEDLE MIS 31GX5/16 OTC QL<br />

PEN NEEDLES MIS 29GX1/2" OTC QL<br />

PEN NEEDLES MIS 29GX12MM OTC QL<br />

PEN NEEDLES MIS 29GX12MM OTC QL<br />

PEN NEEDLES MIS 29GX12MM OTC QL<br />

PEN NEEDLES MIS 29GX12MM OTC QL<br />

PEN NEEDLES MIS 29GX12MM OTC QL<br />

PEN NEEDLES MIS 29GX12MM OTC QL<br />

PEN NEEDLES MIS 29GX12MM OTC QL<br />

PEN NEEDLES MIS 29GX12MM OTC QL<br />

PEN NEEDLES MIS 29GX12MM OTC QL<br />

PEN NEEDLES MIS 29GX12MM OTC QL<br />

PEN NEEDLES MIS 29GX12MM OTC QL<br />

PEN NEEDLES MIS 29GX12MM OTC QL<br />

PEN NEEDLES MIS 31GX1/4" OTC QL<br />

PEN NEEDLES MIS 31GX1/4" OTC QL<br />

PEN NEEDLES MIS 31GX3/16 OTC QL<br />

PEN NEEDLES MIS 31GX5/16 OTC QL<br />

PEN NEEDLES MIS 31GX6MM OTC QL<br />

PEN NEEDLES MIS 31GX6MM OTC QL<br />

PEN NEEDLES MIS 31GX6MM OTC QL<br />

PEN NEEDLES MIS 31GX6MM OTC QL<br />

PEN NEEDLES MIS 31GX6MM OTC QL<br />

PEN NEEDLES MIS 31GX6MM OTC QL<br />

PEN NEEDLES MIS 31GX6MM OTC QL<br />

PEN NEEDLES MIS 31GX6MM OTC QL<br />

PEN NEEDLES MIS 31GX6MM OTC QL<br />

PEN NEEDLES MIS 31GX6MM OTC QL<br />

PEN NEEDLES MIS 31GX6MM OTC QL<br />

PEN NEEDLES MIS 31GX6MM OTC QL<br />

PEN NEEDLES MIS 31GX6MM OTC QL<br />

PEN NEEDLES MIS 31GX6MM OTC QL<br />

PEN NEEDLES MIS 31GX8MM OTC QL<br />

PEN NEEDLES MIS 31GX8MM OTC QL<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 191


PEN NEEDLES MIS 31GX8MM OTC QL<br />

PEN NEEDLES MIS 31GX8MM OTC QL<br />

PEN NEEDLES MIS 31GX8MM OTC QL<br />

PEN NEEDLES MIS 31GX8MM OTC QL<br />

PEN NEEDLES MIS 31GX8MM OTC QL<br />

PEN NEEDLES MIS 31GX8MM OTC QL<br />

PEN NEEDLES MIS 31GX8MM OTC QL<br />

PEN NEEDLES MIS 31GX8MM OTC QL<br />

PEN NEEDLES MIS 31GX8MM OTC QL<br />

PEN NEEDLES MIS 31GX8MM OTC QL<br />

PEN NEEDLES MIS 31GX8MM OTC QL<br />

PEN NEEDLES MIS 31GX8MM OTC QL<br />

PEN NEEDLES MIS 31GX8MM OTC QL<br />

PEN NEEDLES MIS 31GX8MM OTC QL<br />

pharmacy cou mis lancets OTC<br />

PLAS ADAPT MIS 1ML OTC<br />

PLAS ADAPT MIS B-D PLAS OTC<br />

POCKETCHEM KIT EZ PA OTC<br />

PRECISION KIT LINK PA OTC<br />

PRECISION KIT XTRA PA OTC<br />

precision mis 28g OTC<br />

precision mis 28g(t) OTC<br />

PRECISION MIS QID PA OTC<br />

PRECISION MIS SOF-TACT PA OTC<br />

PRECISION MIS XTRA PA OTC<br />

PRECISION MIS XTRA PA OTC<br />

pres smart mis lancets OTC<br />

PRESTIG SMRT KIT VALU PK PA OTC<br />

PRESTIG SMRT MIS METER PA OTC<br />

PRESTIGE LX KIT STARTER PA OTC<br />

PRESTIGE LX KIT STARTER PA OTC<br />

PRESTIGE LX MIS METER PA OTC<br />

PRESTIGE SMT KIT SYS/METR PA OTC<br />

PRODIGY KIT PA OTC<br />

PRODIGY MIS PA OTC<br />

prodigy mis 21g OTC<br />

prodigy mis 26g OTC<br />

prodigy mis 26g OTC<br />

prodigy mis 28g OTC<br />

prodigy mis 28g OTC<br />

PRODIGY AUTO KIT METER PA OTC<br />

PRODIGY AUTO KIT MONITOR PA OTC<br />

PRODIGY AUTO MIS METER PA OTC<br />

PRODIGY EJCT MIS METER PA OTC<br />

PRODIGY PCKT KIT METER PA OTC<br />

PRODIGY PCKT MIS METER PA OTC<br />

PRODIGY PREF KIT METER PA OTC<br />

PRODIGY PREF MIS METER PA OTC<br />

PRODIGY VOIC KIT METER PA OTC<br />

PSS IQ METER MIS PA OTC<br />

PSS IQ START KIT KIT PA OTC<br />

pss safe lan mis OTC<br />

pss sel lanc mis OTC<br />

px lancets mis 28g OTC<br />

px lancets mis ult thin OTC<br />

qc lancets mis OTC<br />

qc lancets mis 28g OTC<br />

qc lancets mis 30g OTC<br />

qc lancets mis thin OTC<br />

QUICKTEK KIT PA OTC<br />

ra e-zject mis 28g OTC<br />

ra e-zject mis thin 26g OTC<br />

ra e-zject mis thin 28g OTC<br />

ra e-zject mis ult thin OTC<br />

RA GLUCOSE MIS MONITOR PA OTC<br />

ra lancets mis OTC<br />

ra lancets mis alternat OTC<br />

ra lancets mis colored OTC<br />

ra lancets mis thin OTC<br />

ra lancets mis thin OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 192


RA PEN NEEDL MIS 31GX5MM OTC QL<br />

reality mis lancets OTC<br />

reality trig mis lancets OTC<br />

REFUAH PLUS KIT SYSTEM PA OTC<br />

RELION KIT MONITOR PA OTC<br />

relion mis lancets OTC<br />

RELION MICRO KIT PA OTC<br />

relion stand mis lancets OTC<br />

relion thin mis lancets OTC<br />

relion ultra mis thin OTC<br />

relion ultra mis thin pls OTC<br />

renew adv mis refills OTC<br />

RIGHTEST SYS KIT GM100 PA OTC<br />

RIGHTEST SYS KIT GM300 PA OTC<br />

safe lancets mis 21g OTC<br />

safe lancets mis 26g OTC<br />

safe-t-lance mis 21g OTC<br />

safe-t-lance mis 25g OTC<br />

safe-t-lance mis hi flow OTC<br />

safe-t-lance mis low flow OTC<br />

safe-t-lance mis nor flow OTC<br />

safe-t-pro mis lancets OTC<br />

safe-t-pro mis plus OTC<br />

safety let mis lancets OTC<br />

sb lancets mis thin OTC<br />

sb lancets mis ultr thn OTC<br />

SENTRY KIT STARTER PA OTC<br />

SENTRY BLOOD MIS GLUC MET PA OTC<br />

SHOPRITE KIT VALU PK PA OTC<br />

single-let mis 23g OTC<br />

sm lancets mis OTC<br />

sm lancets mis 21g OTC<br />

sm lancets mis thin OTC<br />

sm lancets mis thin OTC<br />

sm lancets mis thin 26g OTC<br />

sm lancets mis thin 30g OTC<br />

SMARTEST KIT EJECT PA OTC<br />

SMARTEST KIT PROTEGE PA OTC<br />

SMARTEST MIS EJECT PA OTC<br />

smartest mis lancets OTC<br />

SMARTEST MIS PROTEGE PA OTC<br />

soba lancets mis colored OTC<br />

soba lancets mis thin OTC<br />

soft touch mis lancets OTC<br />

softclix mis lancets OTC<br />

SOLO V2 KIT SYSTEM PA OTC<br />

solo v2 twst mis lancets OTC<br />

super thin mis lancet OTC<br />

super thin mis lancets OTC<br />

super thin mis lancets OTC<br />

SURE COMFORT MIS 29GX1/2" OTC QL<br />

SURE COMFORT MIS 31GX3/16 OTC QL<br />

SURE COMFORT MIS 31GX5/16 OTC QL<br />

sure comfort mis lancets OTC<br />

sure comfort mis lancets OTC<br />

SURE EDGE MIS PA OTC<br />

SURE-FINE MIS 29GX1/2" OTC QL<br />

SURE-FINE MIS 31GX3/16 OTC QL<br />

SURE-FINE MIS 31GX5/16 OTC QL<br />

sure-lance mis 26g OTC<br />

sure-lance mis lancets OTC<br />

sure-lance mis lancets OTC<br />

sure-lance mis lancets OTC<br />

SURE-TEST MIS EASYPLUS PA OTC<br />

SURECHEK KIT PA OTC<br />

SURECHEK MIS PA OTC<br />

surelite mis lancets OTC<br />

SURESTEP KIT W/METER PA OTC<br />

techlite mis lancets OTC<br />

techlite ast mis lancets OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 193


tgt lancet mis 23g OTC<br />

tgt lancet mis 28g OTC<br />

tgt lancet mis 30g OTC<br />

tgt lancet mis alternat OTC<br />

thin lancets mis OTC<br />

thin lancets mis OTC<br />

thin lancets mis OTC<br />

thin lancets mis OTC<br />

thin lancets mis 26g OTC<br />

thin lancets mis 30g OTC<br />

thin lancets mis ultra OTC<br />

thinlets mis 28g(t) OTC<br />

thinlets gp mis 26g OTC<br />

TRUE CARE KIT STARTER PA OTC<br />

TRUE2GO KIT PA OTC<br />

TRUERESULT KIT OTC QL<br />

TRUERESULT KIT SYSTEM PA OTC<br />

TRUETEST LIQ LEVEL 1 PA OTC<br />

TRUETEST LIQ LEVEL 2 PA OTC<br />

TRUETEST LIQ LEVEL 3 PA OTC<br />

TRUETRACK KIT SYSTEM OTC QL<br />

TRUETRACK KIT SYSTEM OTC QL<br />

TRUETRACK MIS BLD GLC OTC QL<br />

TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 27 X 1/2" OTC<br />

TUBERCULIN/ALLERGY SYRINGE/NEEDLE (DISP) 1 ML 28 X 1/2" OTC<br />

ultilet mis 26g OTC<br />

ultilet mis 28g OTC<br />

ultilet mis 28g OTC<br />

ultilet mis 30g OTC<br />

ultilet mis lancets OTC<br />

ULTILET PEN MIS NEEDLE OTC QL<br />

ULTIMA KIT MONITOR PA OTC<br />

ultra thin mis 28g OTC<br />

ultra thin mis 30g OTC<br />

ultra thin mis lancets OTC<br />

ultra thin mis lancets OTC<br />

ultra thin mis lancets OTC<br />

ULTRATRAK MIS PRO PA OTC<br />

UNIFINE PNTP MIS 29GX1/2" OTC QL<br />

UNIFINE PNTP MIS 29GX12MM OTC QL<br />

UNIFINE PNTP MIS 29GX12MM OTC QL<br />

UNIFINE PNTP MIS 29GX12MM OTC QL<br />

UNIFINE PNTP MIS 29GX12MM OTC QL<br />

UNIFINE PNTP MIS 31GX6MM OTC QL<br />

UNIFINE PNTP MIS 31GX6MM OTC QL<br />

UNIFINE PNTP MIS 31GX6MM OTC QL<br />

UNIFINE PNTP MIS 31GX6MM OTC QL<br />

UNIFINE PNTP MIS 31GX6MM OTC QL<br />

UNIFINE PNTP MIS 31GX8MM OTC QL<br />

UNIFINE PNTP MIS 31GX8MM OTC QL<br />

UNIFINE PNTP MIS 31GX8MM OTC QL<br />

UNIFINE PNTP MIS 31GX8MM OTC QL<br />

UNIFINE PNTP MIS 31GX8MM OTC QL<br />

UNIFINE PNTP MIS 6MM OTC QL<br />

UNIFINE PNTP MIS 8MM OTC QL<br />

unilet mis 21g OTC<br />

unilet ex ii mis 28g OTC<br />

unilet excel mis 23g OTC<br />

unilet g.p mis supr 23g OTC<br />

unilet g.p. mis 21g OTC<br />

unilet gp 28 mis ult thin OTC<br />

unilet lance mis 21g OTC<br />

unilet super mis 23g OTC<br />

unilet super mis g.p. 23g OTC<br />

unistik 2 mis neonatal OTC<br />

unistik ii mis lancets OTC<br />

universal 1 mis lanc 26g OTC<br />

universal 1 mis lanc 30g OTC<br />

value health mis lancets OTC<br />

value plus mis lancets OTC<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 194


value plus mis lancets OTC<br />

VICTORY MIS SYSTEM PA OTC<br />

vitalet pro mis OTC<br />

vitalet pro mis plus OTC<br />

w&f lancets mis 21g OTC<br />

w&f lancets mis 26g OTC<br />

w&f lancets mis 26g OTC<br />

w&f lancets mis 30g OTC<br />

WAVESENSE KIT AMP PA OTC<br />

WAVESENSE KIT JAZZ PA OTC<br />

WAVESENSE KIT KEYNOTE PA OTC<br />

WAVESENSE KIT PRESTO PA OTC<br />

wavesense mis 33g OTC<br />

wd lancets mis OTC<br />

wd lancets mis thin OTC<br />

wd lancets mis thin OTC<br />

WIN DIX MEDI KIT VALU PK PA OTC<br />

Pharmaceutical Aids<br />

ACETYLCYST POW<br />

ACETYLCYST POW OTC<br />

ACETYLCYSTEINE POWDER OTC<br />

ACETYLCYSTEINE POWDER<br />

BACTER WATER INJ BENZ ALC PA<br />

BACTER WATER INJ PARABENS PA<br />

BENZOYL PER POW 70%<br />

BENZOYL PER POW HYDROUS OTC<br />

BENZOYL PER POW HYDROUS<br />

BENZOYL PEROXIDE POWDER<br />

BENZOYL PEROXIDE POWDER OTC<br />

BROMHEXINE POW HCL<br />

BROMHEXINE HCL POWDER<br />

CYCLOBENZAPR POW HCL<br />

CYCLOBENZAPRINE HCL POWDER<br />

DEXTROMETHOR CRY MONOHYDR OTC<br />

DEXTROMETHOR POW HBR<br />

DEXTROMETHOR POW HBR MONO<br />

DEXTROMETHORPHAN HBR CRYSTALS OTC<br />

DEXTROMETHORPHAN HBR POWDER<br />

glycine diluent for injection PA<br />

GRISEOFULVIN MICRONIZED (BULK) POWDER<br />

GRISEOFULVIN POW MICRONIZ<br />

GUAIFENESIN POW<br />

GUAIFENESIN POWDER<br />

HSA DILUENT SOL STERILE PA<br />

HYDROCODONE CRY BITARTRA<br />

HYDROCODONE POW BITARTRA<br />

HYDROCODONE BITARTRATE CRYSTALS<br />

HYDROCODONE BITARTRATE POWDER<br />

HYDROXYZINE POW HCL<br />

HYDROXYZINE HCL (BULK) POWDER<br />

IBUPROFEN POW<br />

IBUPROFEN POWDER<br />

INDOMETHACIN POW<br />

INDOMETHACIN POWDER<br />

ISONIAZID POW<br />

ISONIAZID POWDER<br />

KETOPROFEN POW<br />

KETOPROFEN POWDER<br />

METHOTREXATE POW<br />

METHOTREXATE POWDER<br />

N-ACETYL-L- POW CYSTEINE OTC<br />

NAPROXEN POW<br />

NAPROXEN POW SODIUM<br />

NAPROXEN POW USP<br />

NAPROXEN POWDER<br />

NAPROXEN SODIUM POWDER<br />

PHENOBARB POW<br />

PHENOBARB POW USP<br />

PHENOBARB POW USP NF<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 195


PHENOBARBITAL POWDER<br />

PIROXICAM POW<br />

PIROXICAM POWDER<br />

POT CHLORIDE CRY OTC<br />

POT CHLORIDE GRA OTC<br />

POT CHLORIDE GRA<br />

POT CHLORIDE POW<br />

POTASSIUM CHLORIDE CRYSTALS OTC<br />

POTASSIUM CHLORIDE GRANULES OTC<br />

POTASSIUM CHLORIDE GRANULES<br />

POTASSIUM CHLORIDE POWDER (FOR COMPOUNDING)<br />

PREDNISOLONE POW<br />

PREDNISOLONE POW ANHYDROU<br />

PREDNISOLONE POW HYDROUS<br />

PREDNISOLONE POW USP NF<br />

PREDNISOLONE POWDER<br />

PRIMAQUINE POW PHOSPHAT<br />

PRIMAQUINE PHOSPHATE POWDER<br />

PROMETHAZINE HCL POWDER<br />

PROMETHAZINE POW HCL<br />

STERIL WATER SOL<br />

SULINDAC POW<br />

SULINDAC POWDER<br />

TERPIN POW HYDRATE<br />

TERPIN HYD CRY<br />

TERPIN HYDR POW MONOHYDR<br />

TERPIN HYDRATE CRYSTALS<br />

TERPIN HYDRATE POWDER<br />

water for inject, bacteriostatic PA<br />

water for injection PA<br />

water for iv injection PA<br />

WATER, STERILE INHAL SOLN<br />

QL:Quantity Limitation PA:Prior Authorization Required ST:Step Therapy OTC:Over-the-Counter SP:Specialty Program<br />

Brand Name:UPPER CASE Generic Name:italic lower case NF:Approved: Non-Formulary<br />

created on 20100520 196


INDEX<br />

1<br />

1/2 ALLERGIST TRAY SYRING 176<br />

12 hour antihistamine/dec 4<br />

12 hour nasal decongestan 4<br />

1ML ALLERGIST SYRINGE DET 176<br />

1ML ALLERGIST TRAY REGULA 176<br />

1ML ALLERGIST TRAY SYRING 176<br />

1st choice lancets super 176<br />

1st choice lancets thin 176<br />

1st choice lancets ultra 176<br />

1ST CHOICE PEN NEEDLES 31 191<br />

1ST TIER UNIFINE PENTIPS 176<br />

4<br />

4-way fast acting 138<br />

4-way menthl 138<br />

4-way no drp 138<br />

6<br />

666 cold preparation 89<br />

666 cold 34<br />

666 cold 36<br />

8<br />

8 hour pain 58<br />

A<br />

a-cof dh 89<br />

a-tan 12x 125<br />

a.r.m. 4<br />

a/b otic 137<br />

A1C NOW SELFCHECK 176<br />

A1C NOW 176<br />

ABBOKINASE 41<br />

ABELCET 27<br />

aber-fed 125<br />

aber-tuss dr 89<br />

aber-tuss hc 89<br />

ABILIFY DISC 69<br />

ABILIFY 69<br />

ABRAXANE 29<br />

ACANYA 158<br />

acarbose 148<br />

ACCOLATE 125<br />

ACCU-CHEK ACTIVE CARE KIT 176<br />

ACCU-CHEK ACTIVE STRIPS 79<br />

ACCU-CHEK ACTIVE 176<br />

ACCU-CHEK ADVANTAGE DIABE 176<br />

ACCU-CHEK ADVANTAGE METER 176<br />

ACCU-CHEK ADVANTAGE TEST 79<br />

ACCU-CHEK AVIVA 176<br />

ACCU-CHEK AVIVA 79<br />

ACCU-CHEK COMFORT CURVE T 79<br />

ACCU-CHEK COMPACT CARE KI 176<br />

ACCU-CHEK COMPACT PLUS CA 176<br />

ACCU-CHEK COMPACT PLUS 176<br />

ACCU-CHEK COMPACT STRIPS 79<br />

ACCU-CHEK COMPACT TEST DR 79<br />

ACCU-CHEK INSTANT GLUCOSE 79<br />

ACCU-CHEK INSTANT PLUS 79<br />

accu-chek multiclix lance 176<br />

accu-chek safe-t-pro lanc 193<br />

accu-chek safe-t-pro plus 193<br />

accu-chek soft touch lanc 193<br />

accu-chek softclix lancet 193<br />

ACCU-CHEK TRANSFER PIPETT 176<br />

ACCU-CHEK VOICEMATE 176<br />

ACCUHIST PDX 89<br />

ACCUHIST 4<br />

accusure insulin syringe/ 183<br />

accusure insulin syringe/ 184<br />

accusure insulin syringe/ 186<br />

accusure insulin syringe/ 187<br />

accusure insulin syringe/ 188<br />

ACCUTREND GLUCOSE 79<br />

acephen 58<br />

acetamin 58<br />

acetaminophen childrens 58<br />

acetaminophen jr 58<br />

acetaminophen junior stre 58<br />

acetaminophen pm ex-str 75<br />

acetaminophen pm extra st 75<br />

acetaminophen pm 75<br />

ACETAMINOPHEN W/ CALCIUM<br />

CARBONATE 59<br />

acetaminophen w/ calcium carbonate<br />

59<br />

ACETAMINOPHEN W/ CODEINE 53<br />

acetaminophen w/ codeine 53<br />

ACETAMINOPHEN W/ DM 89<br />

acetaminophen w/ dm 89<br />

ACETAMINOPHEN W/ PAMABROM 59<br />

acetaminophen w/ pamabrom 59<br />

ACETAMINOPHEN-BROMELAINS 59<br />

acetaminophen-caff-dihydrocod 53<br />

acetaminophen-caffeine-pyrilamine 59<br />

acetaminophen-caffeine 59<br />

acetaminophen-codeine #4 53<br />

ACETAMINOPHEN-GUAIFENESIN 125<br />

acetaminophen-guaifenesin 125<br />

ACETAMINOPHEN-MAGNESIUM<br />

SALICYLATE-CAFFEINE 59<br />

acetaminophen-pamabrom-pyrilamine<br />

59<br />

ACETAMINOPHEN-<br />

PHENYLTOLOXAMINE-CAFFEINE 1<br />

ACETAMINOPHEN-SALICYL-CAFF 59<br />

ACETAMINOPHEN-SALICYLAMIDE-<br />

PHENYLTOLOXAMINE 59<br />

acetaminophen-salicylamidephenyltoloxamine<br />

59<br />

ACETAMINOPHEN-SALICYLAMIDE 59<br />

acetaminophen/caffeine/di 53<br />

acetaminophen/codeine #2 53<br />

acetaminophen/codeine #3 53<br />

acetaminophen/codeine #4 53<br />

acetaminophen/codeine pho 53<br />

acetaminophen/codeine 53<br />

acetaminophen/hydrocodone 53<br />

ACETAMINOPHEN 58<br />

acetaminophen 58<br />

ACETAMINOPHEN 59<br />

acetaminophen 59<br />

acetaminophn 59<br />

acetasol hc 136<br />

acetazolamid 139<br />

acetazolamide sodium 139<br />

acetazolamide 139<br />

ACETEST 83<br />

acetic acid (otic) 140<br />

acetic acid w/hc ear drop 136<br />

acetic acid/hydrocortison 136<br />

acetic acid 140<br />

ACETONE (URINE) TEST 83<br />

ACETYLCYSTEINE 195<br />

acid reducer 142<br />

acid relief 142<br />

acne medicat 159<br />

acne medication-5 159<br />

acne treat 159<br />

acne treatment vanishing 159<br />

acne-clear 159<br />

acne 159<br />

created on 20100520 197


ACRIVASTINE & PSEUDOEPHEDRINE<br />

16<br />

actanol 4<br />

ACTEMRA 173<br />

ACTHAR HP 150<br />

ACTHIB 156<br />

ACTHREL 82<br />

acticin 159<br />

actifed cold & allergy 4<br />

actifed cold/sinus 4<br />

ACTIFED PLUS 4<br />

ACTIMMUNE 172<br />

ACTIVASE 41<br />

active syrup 4<br />

ACTOS 150<br />

ACULAR PF 137<br />

ACULAR 137<br />

ACURA BLOOD GLUCOSE MONIT 176<br />

ACURA BLOOD GLUCOSE TEST 79<br />

ACUVAIL 137<br />

ACYCLOVIR NA 29<br />

acyclovir sodium 29<br />

acyclovir 28<br />

acyclovir 29<br />

ACZONE 158<br />

ADACEL 156<br />

ADAGEN 88<br />

ADENOSCAN 79<br />

adenosine 44<br />

ADRENACLICK 36<br />

ADRIAMYCIN 29<br />

ADULT MASK LARGE 176<br />

ADVAIR DISKUS 35<br />

ADVAIR HFA 35<br />

ADVANCE INTUITION BLOOD G 176<br />

ADVANCE INTUITION TEST ST 79<br />

ADVANCE MICRO-DRAW METER 176<br />

ADVANCE MICRO-DRAW TEST S 79<br />

ADVATE 42<br />

ADVIL ALLERGY SINUS 4<br />

ADVIL COLD & SINUS 36<br />

advil jr st 52<br />

ADVIL MULTI-SYMPTOM COLD 4<br />

ADVOCATE BLOOD GLUCOSE MO 176<br />

advocate lancets 176<br />

ADVOCATE REDI-CODE/TALKIN 176<br />

ADVOCATE REDI-CODE 176<br />

ADVOCATE REDI-CODE 79<br />

advocate safety lancets 176<br />

ADVOCATE TEST STRIPS 79<br />

AEROBID-M 144<br />

AEROBID 144<br />

AEROCHAMBER MV 177<br />

AEROCHAMBER PLUS/LARGE MA 176<br />

AEROCHAMBER PLUS/MASK 176<br />

AEROCHAMBER PLUS/SMALL MA 176<br />

AEROCHAMBER PLUS 177<br />

AEROCHAMBER Z-STAT PLUS/F 176<br />

AEROCHAMBER Z-STAT PLUS/L 176<br />

AEROCHAMBER Z-STAT PLUS/S 176<br />

AEROCHAMBER Z-STAT PLUS 176<br />

AEROCHAMBER/FLOWSIGNAL 176<br />

AEROGEAR ASTHMA ACTION 176<br />

aerohist plus 4<br />

AEROKID 4<br />

AEROTUSS 12 89<br />

af lancets super thin 177<br />

af-apap allergy sinus 5<br />

af-apap infa 59<br />

af-apap sinus 36<br />

af-aphedrid 5<br />

af-cough fm decong 89<br />

af-dibromm dm 89<br />

af-dibromm 5<br />

af-effer antacid pain 11<br />

af-effer cold 5<br />

af-flu cough/cold maximum 89<br />

af-ibup sinus 36<br />

af-nitetime cough 89<br />

af-nitetime 89<br />

af-pseudoephedrine sinus 126<br />

af-triacting nitetime 89<br />

af-triacting sore throat 89<br />

af-tussin cf 89<br />

af-tussin dm 89<br />

afedi 47<br />

AFLURIA 2007-2008 156<br />

AFLURIA 2008-2009 156<br />

AFLURIA 2009-2010 156<br />

AFLURIA PF 2007-2008 156<br />

AFLURIA PF 2008-2009 156<br />

AFLURIA PF 2009-2010 156<br />

afrin allerg 138<br />

afrin child 138<br />

AGENERASE 27<br />

AGGRASTAT 41<br />

AGRIFLU 2009/2010 156<br />

AH-CHEW II 5<br />

AH-CHEW ULTRA 5<br />

AH-CHEW 5<br />

ah-chew 5<br />

aimsco insulin syringe ma 183<br />

aimsco insulin syringe ma 185<br />

aimsco insulin syringe ul 180<br />

aimsco insulin syringe ul 182<br />

aimsco insulin syringe ul 183<br />

aimsco insulin syringe ul 184<br />

aimsco insulin syringe ul 185<br />

aimsco insulin syringe ul 186<br />

aimsco insulin syringe ul 187<br />

aimsco insulin syringe/0. 183<br />

aimsco insulin syringe/1m 186<br />

aimsco insulin syringe/ul 181<br />

AIRACOF 89<br />

ak-dilate 138<br />

ak-pentolate 137<br />

ak-tob 135<br />

ala cort 162<br />

ala-cort 162<br />

ALA-HIST D 5<br />

ALA-HIST PE 5<br />

ALACOL DM 89<br />

ALACOL 5<br />

ALAHIST AC 89<br />

ALAHIST DHC 89<br />

ALAHIST LQ 1<br />

alavert 16<br />

ALBAFORT S 170<br />

ALBAFORT 170<br />

ALBATUSSIN CF PEDIATRIC 126<br />

ALBATUSSIN CF PEDIATRIC 89<br />

ALBATUSSIN CF 126<br />

ALBATUSSIN DM PEDIATRIC 89<br />

ALBATUSSIN EX PEDIATRIC 126<br />

ALBATUSSIN NN 126<br />

ALBATUSSIN NN 89<br />

ALBATUSSIN PEDIATRIC DROP 89<br />

ALBATUSSIN PEDIATRIC NR 89<br />

ALBATUSSIN PEDIATRIC 89<br />

albatussin pediatric 89<br />

ALBATUSSIN SR F 126<br />

ALBATUSSIN SR 126<br />

ALBATUSSIN SR 89<br />

albatussin sr 89<br />

created on 20100520 198


albatussin-nn 89<br />

ALBATUSSIN 89<br />

albertsons childrens non- 12<br />

albertsons cold & allergy 9<br />

albertsons decongestant c 10<br />

albertsons extra strength 76<br />

albertsons flu and cold m 11<br />

albertsons flu/cold & cou 100<br />

albertsons flu/cough & co 100<br />

albertsons multi-symptom 63<br />

albertsons night time col 106<br />

albertsons sinus 37<br />

ALBERTSONS STARTER KIT 177<br />

albertsons suphedrine sin 37<br />

ALBERTSONS TEST STRIP 79<br />

albertsons tussin dm 123<br />

albertsons ultra thin lan 194<br />

albumin, human 39<br />

ALBUTEROL SULFATE 35<br />

albuterol sulfate 35<br />

albuterol 35<br />

ALCOHOL 10%/DEXTROSE 5% 86<br />

ALCOHOL 5%/DEXTROSE 5% 86<br />

ALCOHOL 86<br />

alcohol 86<br />

ALDEX-CT 1<br />

ALDURAZYME 88<br />

alenaze-d nr 5<br />

ALENAZE-D 5<br />

alfentanil 53<br />

ALFERON N 29<br />

ALIMTA 29<br />

ALINIA 29<br />

ALKA-SELTZER PLUS COLD & 89<br />

ALKA-SELTZER PLUS COLD 5<br />

alkabel-sr 33<br />

ALKERAN 29<br />

all day allg 16<br />

all-nite cold formula 89<br />

all-nite multi-symptom co 89<br />

all/sinus/head 1<br />

allanhist pdx 89<br />

allantan pediatric 5<br />

allanvan-dm 89<br />

allanvan-s 3<br />

ALLEGRA-D 16<br />

allepak 5<br />

aller-time 5<br />

allerclear 16<br />

allerfed 5<br />

allerfrim 5<br />

allergen 137<br />

ALLERGIST PACKAGE 177<br />

allergy & sinus intense 1<br />

allergy am/pm 5<br />

allergy decongestant 2<br />

allergy dn pe 5<br />

allergy dn 5<br />

allergy multi-symptom day 5<br />

allergy multi-symptom nig 1<br />

allergy multi-symptom 5<br />

allergy relf 16<br />

allergy relf 1<br />

allergy relief child 16<br />

allergy sinus headache re 1<br />

allergy sinus-d maximum s 5<br />

allergy/sinus headache 1<br />

allergy/sinus non-aspirin 5<br />

allergy/sinus pain reliev 5<br />

allergy 16<br />

allerhist-1 1<br />

ALLERSCRIPT 5<br />

ALLERTAN 5<br />

ALLERX DOSE PACK 5<br />

ALLERX PE 5<br />

ALLERX 5<br />

ALLFEN A 126<br />

ALLFEN C 89<br />

ALLFEN CD 89<br />

ALLFEN CDX 89<br />

ALLFEN CX 89<br />

ALLFEN DM 89<br />

allfen dm 89<br />

ALLFEN DMA 89<br />

ALLRES D 89<br />

ALLRES G 89<br />

ALLRES PD 89<br />

ALOXI 142<br />

ALPHAGAN P 138<br />

ALPHANATE/VON WILLEBRAND 42<br />

ALPHANATE 42<br />

ALPHANINE SD 42<br />

alphatrex 162<br />

alprazolam 74<br />

alprostadil 45<br />

altafed 5<br />

altafrin 138<br />

altarussin dm 89<br />

altarussin-pe 126<br />

altarussin 126<br />

altex-pse 126<br />

ALTRETAMINE 29<br />

ALUMINUM CHLORIDE 166<br />

aluminum chloride 166<br />

aluminum cl 166<br />

ALUPENT INH 35<br />

ALVESCO 144<br />

ambi 1000/55 89<br />

ambi 1000/5 89<br />

ambi 10peh/400gfn/20dm 89<br />

ambi 10peh/400gfn 126<br />

ambi 10peh/4cpm/20dm 89<br />

ambi 10peh/4cpm 5<br />

ambi 20dm/4cpm 89<br />

ambi 40/1000/60 90<br />

ambi 40/1000 126<br />

ambi 40pse/400gfn/20dm 89<br />

ambi 40pse/400gfn 126<br />

ambi 45/800/30 90<br />

ambi 45/800 126<br />

AMBI 5/15/100 90<br />

ambi 60/1000/30 90<br />

ambi 60/1000 126<br />

ambi 60/580/30 90<br />

ambi 60/580 126<br />

ambi 60pse/400gfn/20dm 89<br />

ambi 60pse/400gfn 126<br />

ambi 60pse/4cpm/20dm 89<br />

ambi 60pse/4cpm 5<br />

ambi 80/700/40 90<br />

ambi 80/700 126<br />

ambi 80/780/40 90<br />

ambi 80/780 126<br />

AMBIFED CD 90<br />

AMBIFED CDX 90<br />

AMBIFED DM 90<br />

AMBIFED-G CD 90<br />

AMBIFED-G CDX 90<br />

AMBIFED-G DM 90<br />

AMBIFED-G 126<br />

AMBIFED 126<br />

AMBISOME 27<br />

amdry-c 5<br />

amdry-d 36<br />

created on 20100520 199


AMERIFED DM 90<br />

AMERIFED 5<br />

AMERITUSS AD 90<br />

ames gluco system lancets 177<br />

AMEVIVE 166<br />

ami-tex la 126<br />

amibid dm 90<br />

amidal 126<br />

amidrine 77<br />

amigesic 51<br />

amikacin sulfate 17<br />

aminate fe-90 170<br />

AMINESS 86<br />

amino acid electrolyte infusion 86<br />

amino acid infusion 86<br />

aminocaproic acid 42<br />

aminofen 59<br />

AMINOHIPPURA 82<br />

aminophylline 167<br />

AMINOSYN 7%/ELECTROLYTES 86<br />

AMINOSYN II 3.5% 86<br />

AMINOSYN II 3.5 86<br />

AMINOSYN II 4.25 86<br />

AMINOSYN II 5/DEXTROSE 25 86<br />

AMINOSYN II M 3.5%/DEXTRO 86<br />

AMINOSYN II M 4.25/DEXTRO 86<br />

AMINOSYN II 86<br />

AMINOSYN M 86<br />

AMINOSYN-HBC 86<br />

AMINOSYN-PF 7% 86<br />

AMINOSYN-PF 86<br />

AMINOSYN-RF 86<br />

AMINOSYN 86<br />

amiodarone hcl 44<br />

amiodarone 44<br />

amitex pse 126<br />

amitriptylin 68<br />

amitriptyline hcl 68<br />

AMLODIPINE BESYLATE-BENAZEPRIL<br />

HCL 47<br />

amlodipine besylate-benazepril hcl 47<br />

amlodipine besylate/benaz 47<br />

AMMON MOLYBD 84<br />

AMMONIUM CHL 83<br />

ammonium molybdate 84<br />

AMMONUL 83<br />

amoclan 22<br />

amoxicillin & pot clavulanate 22<br />

AMOXICILLIN & POT CLAVULANATE<br />

23<br />

amoxicillin & pot clavulanate 23<br />

AMOXICILLIN-CLARITHROMYCIN W/<br />

LANSOPRAZOLE 143<br />

amoxicillin/clavulanate p 22<br />

amoxicillin/potassium cla 22<br />

AMOXICILLIN 22<br />

amoxicillin 22<br />

AMOXICILLIN 23<br />

amoxicillin 23<br />

AMOXIL 23<br />

amoxil 23<br />

AMPHADASE 88<br />

amphetamine-dextroamphetamine 72<br />

amphetamine/dextroampheta 72<br />

AMPHOTEC 27<br />

amphotericin b 27<br />

ampicillin & sulbactam sodium 23<br />

ampicillin sodium 23<br />

AMPICILLIN 23<br />

ampicillin 23<br />

AMRIX 38<br />

AMVISC PLUS 140<br />

AMVISC 140<br />

AMYLASE-LIPASE-PROTEASE 140<br />

amylase-lipase-protease 140<br />

AMYLASE-LIPASE-PROTEASE 141<br />

amylase-lipase-protease 141<br />

AMYTAL SOD 74<br />

ANABAR 59<br />

anacin af 59<br />

ANAPLEX DMX 90<br />

andehist dm nr 90<br />

andehist nr 1<br />

andehist nr 5<br />

anexsia 53<br />

anextuss 90<br />

ANGIOMAX 40<br />

ANTHRALIN 166<br />

anthralin 166<br />

ANTHRALIN 167<br />

anti-dandruf sha 159<br />

anti-itch maximum strengt 162<br />

anti-itch 162<br />

ANTI-PERSPIR 166<br />

anti-stick insulin syring 182<br />

anti-stick insulin syring 183<br />

anti-stick insulin syring 186<br />

antiben 137<br />

antibiotic ear 136<br />

antihistamine nasal decon 5<br />

antihistamine/decongestan 5<br />

ANTIHISTAMINE 5<br />

antipyrine/benzocaine 137<br />

antispasmodic 33<br />

ANTIVENIN CROTALIDAE POLY 155<br />

ANTIVENIN LATRODECTUS MAC 155<br />

ANTIVENIN MICRURUS FULVIU 155<br />

anucort-hc 162<br />

anumed-hc 162<br />

ANZEMET 142<br />

apap child 59<br />

apap drops 59<br />

apap ex str 59<br />

apap x-str sleep aid pm 75<br />

apap-isometheptene-dichloral 77<br />

apap-plus 59<br />

apap/diphenhydramine 75<br />

apap/oxycodone 53<br />

apap/oxycodone 57<br />

APAP 59<br />

apap 59<br />

apara 59<br />

apexicon 162<br />

aphedrid 5<br />

APIDRA SOLOSTAR 148<br />

APIDRA 148<br />

APLISOL 83<br />

apra 59<br />

apri 146<br />

aprodine 5<br />

aquabid-dm 90<br />

aquanil hc 162<br />

AQUASOL A PARENTERAL 168<br />

AQUATAB C 90<br />

AQUATAB D 126<br />

AQUATAB DM 90<br />

ARALAST NP 134<br />

ARALAST 134<br />

aranelle 146<br />

ARANESP ALBUMIN FREE SURE 41<br />

ARANESP ALBUMIN FREE SURE 42<br />

ARANESP ALBUMIN FREE 41<br />

ARANESP ALBUMIN FREE 42<br />

ARANESP 41<br />

created on 20100520 200


ARANESP 42<br />

ARCALYST 174<br />

ARGATROBAN 40<br />

ARGENTUM METALLICUM 8X 174<br />

ARGENTUM-D20 174<br />

ARGYLE LUMBAR PUNCTURE TR 154<br />

ARGYLE PARACENTESIS PROCE 155<br />

ARGYLE PNEUMOTHORAX PROCE 155<br />

ARIDEX PEDIATRIC 90<br />

ARIDEX-D PEDIATRIC 1<br />

aristocort a 162<br />

ARISTOSPAN 144<br />

ARIXTRA 41<br />

ARMOUR THYRO 151<br />

aromatic inhalants 173<br />

ARRANON 30<br />

ARTHROTEC 50 52<br />

ARTHROTEC 75 52<br />

arthrts pain 59<br />

ARZERRA 30<br />

ASACOL 144<br />

ASCENSIA BREEZE MONITOR 177<br />

ASCENSIA BRIO 177<br />

ASCENSIA ELITE TEST STRIP 79<br />

ASCENSIA ELITE XL DIABETE 177<br />

ascorbic acid 169<br />

asp 300/200/20 59<br />

ASPERGILLUS 79<br />

aspirin free 59<br />

ASPIRIN-ACETAMINOPHEN-CAFFEINE<br />

51<br />

aspirin-caffeine-butalbit 51<br />

ASSURE 3 METER 177<br />

ASSURE 3 TEST STRIPS 79<br />

ASSURE 4 BLOOD GLUCOSE ME 177<br />

ASSURE 4 TEST STRIPS 79<br />

ASSURE II CHECK STRIP 79<br />

ASSURE II TEST STRIPS 79<br />

ASSURE II 79<br />

assure lance lancets 177<br />

ASSURE PRO BLOOD GLUCOSE 177<br />

ASSURE PRO TEST STRIPS 79<br />

ASTELIN 134<br />

ASTEPRO 134<br />

AT LAST BLOOD GLUCOSE SYS 177<br />

at last lancets 177<br />

AT LAST TEST STRIPS 79<br />

atenolol 46<br />

ATGAM 173<br />

ATOMOXETINE HCL 77<br />

atracurium besylate 38<br />

atropin-care 137<br />

atropine sul 137<br />

atropine sulfate (ophthalmic) 137<br />

ATROPINE SULFATE 33<br />

atropine sulfate 33<br />

ATROVENT HFA 33<br />

ATRYN 41<br />

ATTENUVAX 156<br />

ATUSS HD 90<br />

ATUSS HS 90<br />

ATUSS HX 90<br />

aug betamet 162<br />

AUGMENTIN 23<br />

AUGMENTIN 24<br />

aurodex 137<br />

auroguard 137<br />

aurora healthcare lancets 177<br />

aurora lancet super thin 177<br />

aurora lancet thin 23g 177<br />

AURORA PEN NEEDLES 29GX12 191<br />

AURORA PEN NEEDLES 31G X 191<br />

auroto 137<br />

AUTOCODE GLUC TEST STRIPS 79<br />

AVANDAMET 150<br />

AVANDIA 150<br />

AVAPRO 50<br />

AVASTIN 30<br />

aveeno anti-itch maximum 162<br />

AVELOX 24<br />

avidoxy 25<br />

avita 166<br />

AVONEX 172<br />

ayr 174<br />

AZACTAM 20<br />

AZATHIOPRINE 173<br />

AZELASTINE HCL 134<br />

AZITHROMYCIN 21<br />

azithromycin 21<br />

AZMACORT 144<br />

azo dine 165<br />

azo tabs 165<br />

azo-dine 165<br />

azo-gesic 165<br />

azo-septic 165<br />

azo-standard 165<br />

azurette 146<br />

created on 20100520 201<br />

B<br />

b-6 168<br />

b-complex vitamins 168<br />

b-vex d 5<br />

b-vex pd 5<br />

BABEE COF 126<br />

bac/poly/neomy/hc 136<br />

bacitracin (ophthalmic) 135<br />

bacitracin-poly-neomycin-hc 136<br />

bacitracin/neomycin/polym 135<br />

bacitracin 135<br />

bacitracin 26<br />

BACK PAIN-OFF 60<br />

baclofen 38<br />

BACTERIOSTATIC WATER FOR 195<br />

BACTERIOSTATIC WATER PARA 195<br />

BACTOCILL 24<br />

BAL IN OIL 144<br />

balacall dm 90<br />

balacet 325 53<br />

balagan 137<br />

BALNEOL 162<br />

BANZEL 65<br />

baycadron 144<br />

BAYER BREEZE 2 BLOOD GLUC 177<br />

BAYER CONTOUR BLOOD GLUCO 177<br />

BAYER CONTOUR BLOOD GLUCO 79<br />

bayer microlet lancets 177<br />

bd lo-dose insulin syrin 182<br />

BD ALLERGIST TRAY SYRINGE 177<br />

BD AUTOSHIELD 29G X 1/2" 177<br />

BD AUTOSHIELD 29G X 3/16" 177<br />

BD AUTOSHIELD 29G X 5/16" 177<br />

bd genie lancets 177<br />

bd genie 177<br />

BD INSULIN SYRINGE LUER-L 185<br />

bd insulin syringe microf 180<br />

bd insulin syringe microf 182<br />

bd insulin syringe microf 185<br />

bd insulin syringe safety 182<br />

bd insulin syringe safety 183<br />

bd insulin syringe safety 186<br />

BD INSULIN SYRINGE SLIP T 185<br />

BD INSULIN SYRINGE U-40/1 185<br />

bd insulin syringe ultraf 180<br />

bd insulin syringe ultraf 181<br />

bd insulin syringe ultraf 182


d insulin syringe ultraf 183<br />

bd insulin syringe ultraf 184<br />

bd insulin syringe ultraf 186<br />

bd insulin syringe ultraf 187<br />

bd insulin syringe ultraf 188<br />

bd insulin syringe/detach 185<br />

bd insulin syringe/u-100/ 184<br />

bd insulin syringe/u-100/ 185<br />

bd insulin syringe/u-100/ 188<br />

bd integra insulin syring 186<br />

bd integra syringe/retrac 185<br />

bd lancet ultrafine 30g 177<br />

bd lancet ultrafine 33g 177<br />

BD LATITUDE DIABETES MANA 177<br />

BD LOGIC BLOOD GLUCOSE MO 177<br />

bd microtainer lancets 177<br />

BD PEN NEEDLE/MINI/ULTRAF 177<br />

BD PEN NEEDLE/NANO/ULTRA 177<br />

BD PEN NEEDLE/SHORT/ULTRA 177<br />

BD PEN NEEDLE/ULTRAFINE/2 177<br />

BD PEN NEEDLES SHORT/ULTR 177<br />

BD PLASTIPAK SYRINGES ALL 176<br />

BD PUDENDAL/LOCAL BLOCK 155<br />

bd safety-glide insulin s 183<br />

bd safety-lok insulin syr 186<br />

bd safetyglide insulin sy 184<br />

BD TEST STRIPS 79<br />

bd ultra fine lancets 177<br />

BD ULTRAFINE MINI PEN NEE 177<br />

be-flex plus 60<br />

BEBULIN VH 42<br />

BECLOMETHASONE DIPROP<br />

MONOHYD 136<br />

BECLOMETHASONE DIPROPIONATE<br />

144<br />

BECONASE AQ 136<br />

BEE VENOM 174<br />

belladonna alka/pb 33<br />

belladonna alkaloids-phenobarbital 33<br />

belladonna alkaloids/phen 33<br />

bellahist-d la 5<br />

BENADRYL ALLERGY & SINUS 1<br />

BENADRYL ALLERGY/COLD FAS 1<br />

BENADRYL ALLERGY/SINUS FA 1<br />

benadryl severe allergy & 1<br />

benadryl severe allergy/s 1<br />

BENADRYL-D ALLERGY & SINU 1<br />

BENAPHEN PLUS 1<br />

benazepril & hydrochlorothiazide 49<br />

benazepril hcl/hydrochlor 49<br />

benazepril hcl 49<br />

benazepril 49<br />

BENEFIX 42<br />

BENICAR HCT 50<br />

BENICAR 50<br />

benprox 159<br />

BENZAMYCINPAK 158<br />

BENZASHAVE 159<br />

benzashave 159<br />

BENZIQ 159<br />

BENZOCAINE & ANTIPYRINE 137<br />

benzocaine & antipyrine 137<br />

BENZONATATE 90<br />

benzonatate 90<br />

benzotic 137<br />

benzoyl per 159<br />

BENZOYL PER 160<br />

benzoyl per 160<br />

BENZOYL PER 195<br />

benzoyl pero 160<br />

benzoyl peroxide cleanser 159<br />

benzoyl peroxide creamy w 159<br />

benzoyl peroxide creamy w 160<br />

BENZOYL PEROXIDE HYDROUS 195<br />

benzoyl peroxide w/ cleanser 160<br />

BENZOYL PEROXIDE WASH 160<br />

benzoyl peroxide wash 160<br />

BENZOYL PEROXIDE-ERYTHROMYCIN<br />

158<br />

benzoyl peroxide-erythromycin 158<br />

BENZOYL PEROXIDE-SULFUR 167<br />

benzoyl peroxide-sulfur 167<br />

BENZOYL PEROXIDE-UREA 161<br />

benzoyl peroxide-urea 161<br />

benzoyl peroxide 159<br />

BENZOYL PEROXIDE 160<br />

benzoyl peroxide 160<br />

BENZOYL PEROXIDE 161<br />

benzoyl peroxide 161<br />

BENZOYL PEROXIDE 195<br />

beta diprop 162<br />

beta hc 162<br />

beta-val 162<br />

betameth dip 162<br />

betameth val 162<br />

betamethasone acetate & sod<br />

phosphate 144<br />

betamethasone dipropionate (topical)<br />

162<br />

betamethasone dipropionate<br />

augmented 162<br />

betamethasone valerate 162<br />

BETASERON 172<br />

BETATAN 90<br />

betavent 90<br />

BETAXOLOL HCL (OPHTH) 139<br />

BETAXOLOL 139<br />

bethanechol chloride 33<br />

bethanechol 33<br />

BETIMOL 139<br />

BETOPTIC-S 139<br />

BEXAROTENE (TOPICAL) 167<br />

BEXAROTENE 30<br />

BEXXAR 131 IODINE 30<br />

BEXXAR 30<br />

BICILLIN C-R 22<br />

BICILLIN L-A 22<br />

BICNU 30<br />

BIDEX-A 90<br />

bidex-dmi 90<br />

bidex 126<br />

bidhist-d 5<br />

BIMATOPROST 140<br />

BIO-TUSSI PEDIATRIC 90<br />

BIO-TUSSI 90<br />

BIOBRON SF 90<br />

biocotron 90<br />

biodec-dm 90<br />

BIODEC 1<br />

BIODESP DM 90<br />

biofed-pe 5<br />

biogil 90<br />

BIONEL PEDIATRIC 90<br />

BIONEL 90<br />

BIOSCANNER GLUCOSE TEST S 79<br />

BIOSPEC DMX 90<br />

biotuss dm 90<br />

biotuss pe 126<br />

biotuss pediatric 90<br />

biotuss 90<br />

biotussin ac 90<br />

biotussin dac 90<br />

bisoprol fum 46<br />

bisoprolol & hydrochlorothiazide 46<br />

created on 20100520 202


isoprolol fumarate/hydro 46<br />

bisoprolol fumarate 46<br />

bl acne 161<br />

bl color lancets 177<br />

bl flu/cold/cough 100<br />

BL HOT STEAM LIQUID 174<br />

bl ibu-profen cold & sinu 36<br />

bl infants pain reliever 90<br />

bl insulin syringe/0.3ml/ 181<br />

bl lancets super thin 177<br />

bl lancets thin 177<br />

bl lancets 177<br />

bl pain reli 60<br />

bl prenatal vitamins 170<br />

bl severe cold/flu maximu 90<br />

BL TEST STRIP 80<br />

BL TEST STRIPS 80<br />

bl triacting chest conges 126<br />

bl triacting cold/allergy 5<br />

bl tussin cf 90<br />

bl vit b-6 168<br />

bl womens menstrual relie 60<br />

blanex-a 5<br />

bleomycin sulfate 30<br />

BLEPHAMIDE LIQUIFILM 136<br />

BLEPHAMIDE S.O.P. 136<br />

BLEPHAMIDE 136<br />

BLOOD GLUCOSE METER 177<br />

BLOOD GLUCOSE MONITOR KIT 177<br />

BLOOD GLUCOSE MONITORING<br />

SUPPLIES 176<br />

BLOOD GLUCOSE MONITORING 177<br />

BLOOD GLUCOSE SYSTEM 177<br />

BLOOD GLUCOSE TEST STRIPS 80<br />

BONE MARROW ASPIRATION TR 154<br />

BONIVA 172<br />

BOOSTRIX 156<br />

BOTOX COSMET 174<br />

BOTOX 174<br />

bp 8 cough 90<br />

bp multinatal plus 170<br />

bp wash 161<br />

bpm mal/phenyleph hcl/dm 90<br />

bpm mal/pse hcl/dm hbr 90<br />

bpm pe dm 90<br />

bpm pe hc 90<br />

bpm pe 5<br />

bpm pseudo 5<br />

bpo 161<br />

bps 167<br />

BRANCHAMIN 4% 86<br />

BRAVELLE 147<br />

BREEZE 2 BLOOD GLUCOSE MO 177<br />

BREVIBLOC 46<br />

BREVITAL SOD 50<br />

BREVOXYL-4 CREAMY WASH 161<br />

BREVOXYL-8 CREAMY WASH 161<br />

BRIMONIDINE TARTRATE 139<br />

brimonidine tartrate 139<br />

brimonidine 138<br />

brimonidine 139<br />

BRITE LIFE BLOOD GLUCOSE 177<br />

BROFED 5<br />

brom mal/phenyl hcl/dex h 90<br />

brom tann/dm tann/pse tan 90<br />

brom/pseud/dm 90<br />

bromaline dm 91<br />

bromaline 5<br />

bromaphedrine d 5<br />

BROMATAN PLUS 91<br />

bromatan-dm 91<br />

bromatane dx 91<br />

bromax d 5<br />

bromaxefed dm rf 91<br />

bromaxefed rf 5<br />

bromcomp hc 91<br />

bromdec dm 91<br />

bromdec 1<br />

bromdec 5<br />

bromdex d 91<br />

brometane dx 91<br />

bromfed dm 91<br />

BROMFED 5<br />

bromfenex pd 6<br />

bromfenex pe pediatric 6<br />

bromfenex pe 6<br />

bromfenex 6<br />

BROMHEXINE HCL 195<br />

bromhist pdx 91<br />

bromhist pediatric 6<br />

bromhist-dm pediatric 91<br />

bromhist-dm 91<br />

bromhist-nr 6<br />

BROMHIST-PDX 91<br />

bromophed dx 91<br />

BROMPHEN-PSEUDOEPHED-<br />

CHLORPHEN-PHENYLEPH-<br />

METHSCOPOLAMINE 5<br />

bromphenex dm 91<br />

BROMPHENEX HD 91<br />

BROMPHENIRAMINE & PHENYLEPH 6<br />

brompheniramine & phenyleph 6<br />

BROMPHENIRAMINE & PSEUDOEPH 6<br />

brompheniramine & pseudoeph 6<br />

BROMPHENIRAMINE MALEATE-<br />

PHENYLEPHRINE HCL TANNATE 6<br />

brompheniramine maleate/p 6<br />

brompheniramine tann/phen 5<br />

BROMPHENIRAMINE TANNATE-<br />

PHENYLEPHRINE TANNATE 6<br />

brompheniramine tannatephenylephrine<br />

tannate 6<br />

BROMPHENIRAMINE TANNATE-<br />

PSEUDOEPHEDRINE TANNATE 6<br />

brompheniramine tannatepseudoephedrine<br />

tannate 6<br />

BROMPHENIRAMINE W/ DM-GG 126<br />

BROMPHENIRAMINE W/<br />

HYDROCODONE-GG 91<br />

BROMPHENIRAMINE-<br />

DIPHENHYDRAMINE-PHENYLEPHRINE<br />

6<br />

BROMPHENIRAMINE-PSE W/ APAP 6<br />

brompheniramine/dextromet 90<br />

brompheniramine/dextromet 91<br />

brompheniramine/hydrocodo 90<br />

brompheniramine/phenyleph 6<br />

brompheniramine/phenyleph 90<br />

brompheniramine/pse 6<br />

brompheniramine/pseudoeph 5<br />

brompheniramine/pseudoeph 6<br />

brompheniramine/pseudoeph 90<br />

bromplex dm 91<br />

bromplex hd 91<br />

bromtuss dm 91<br />

bronchial asthma relief 126<br />

broncho sal 134<br />

BRONCHOLATE 126<br />

BRONCOPECTOL 91<br />

BRONCOTRON-D 91<br />

broncotron 91<br />

BRONKAID 126<br />

BRONKIDS 91<br />

bronkids 91<br />

created on 20100520 203


BRONTEX 91<br />

brontuss la 91<br />

BRONTUSS SF 91<br />

brotapp dm 91<br />

brotapp 6<br />

BROVEX ADT 6<br />

BROVEX CB 91<br />

BROVEX CBX 91<br />

BROVEX PB C 91<br />

BROVEX PB CX 91<br />

BROVEX PB DM 91<br />

BROVEX PB 6<br />

BROVEX PD 6<br />

BROVEX PEB 6<br />

BROVEX PSB 7<br />

BROVEX PSE DM 91<br />

buckleys chest congestion 126<br />

BUCKLEYS COUGH 91<br />

budeprion 69<br />

BUDESONIDE (INHALATION) 144<br />

budesonide (inhalation) 144<br />

budesonide 144<br />

bullseye safety lancets 177<br />

bumetanide 87<br />

bupivacaine hcl 154<br />

bupivacaine in dextrose 154<br />

bupivacaine w/ epinephrine 154<br />

BUPIVACAINE/NS 154<br />

buprenorphine hcl 58<br />

bupropion hcl (smoking deterrent) 69<br />

bupropion hcl 69<br />

bupropion 69<br />

BUSPIRONE HCL 75<br />

buspirone hcl 75<br />

BUSPIRONE 75<br />

buspirone 75<br />

BUSULFAN 30<br />

BUSULFEX 30<br />

butal/asa/caff 51<br />

butalbital compound 51<br />

butalbital-acetaminophen-caffeine 60<br />

BUTALBITAL-ACETAMINOPHEN 60<br />

butalbital-aspirin-caffeine 51<br />

butalbital/apap/caffeine 60<br />

butalbital/asa/caffeine 51<br />

butalbital/aspirin/caffei 51<br />

butorphanol tartrate 58<br />

by-ache 60<br />

BYETTA 148<br />

C<br />

C-HIST SR 7<br />

c-phed dpd tannate 91<br />

c-phed tannate 7<br />

c-phen dm 91<br />

c-phen 7<br />

C-TAN D PLUS 7<br />

c-tan d 7<br />

c-tanna 12 91<br />

c-tanna 12d 91<br />

caffeine citrate 73<br />

CAFFEINE/SODIUM BENZOATE 73<br />

calc acetate 84<br />

CALCIPOTRIENE 167<br />

calcitonin (salmon) 150<br />

CALCITRIOL 169<br />

calcitriol 169<br />

CALCIUM ACETATE (PHOSPHATE<br />

BINDER) 84<br />

calcium acetate (phosphate binder) 84<br />

calcium chloride (dihydrate) 84<br />

CALCIUM DISO 144<br />

CALCIUM DISODIUM VERSENAT 144<br />

calcium gluconate 84<br />

caldecort 162<br />

CALDOLOR 52<br />

CALOMIST 168<br />

CALPHOSAN 84<br />

camila 146<br />

CAMPATH 30<br />

camphor (inhalant) 174<br />

CAMPHOR-EUCALYPTUS-MENTHOL-<br />

BENZOIN 173<br />

camphor-eucalyptus-mentholturpentine<br />

oil-white petrolatum 173<br />

CAMPHOR-EUCALYPTUS-MENTHOL<br />

173<br />

camphor-eucalyptus-menthol 173<br />

CAMPHOR-MENTHOL (INHALANT) 174<br />

CANCIDAS 27<br />

CANDIN 81<br />

canges-hc nr 91<br />

CANGES-HC 91<br />

canges-xp 91<br />

CAPASTAT SUL 27<br />

CAPITAL/CODEINE 53<br />

CAPMIST DM 91<br />

captopril & hydrochlorothiazide 49<br />

captopril/hydrochlorothia 49<br />

captopril 49<br />

car-b-pen ta/chlor-tan 91<br />

CARAC 167<br />

CARAFATE 143<br />

carb pse 12 dm 91<br />

carb pseudo-tan 91<br />

carb/phenyl-12 91<br />

carbachol (ophth) 139<br />

carbamazepin 65<br />

CARBAMAZEPINE 65<br />

carbamazepine 65<br />

CARBAPHEN 12 PED 91<br />

CARBAPHEN 12 91<br />

carbatab-12 91<br />

CARBATUSS-12 91<br />

CARBATUSS-CL 91<br />

carbaxefed dm rf 91<br />

carbaxefed rf 1<br />

CARBETAPENTANE CITRATE-<br />

CARBETAPENTANE TANNATE-PE HCL-<br />

PE TAN 91<br />

CARBETAPENTANE CITRATE-<br />

GUAIFENESIN TANNATE 91<br />

CARBETAPENTANE CITRATE-<br />

PSEUDOEPHEDRINE HCL TANNATE 91<br />

CARBETAPENTANE CITRATE-<br />

PSEUDOEPHEDRINE HCL TANNATE 92<br />

CARBETAPENTANE TANNATE-<br />

PYRILAMINE TANNATE 92<br />

carbetapentane tannate/ch 91<br />

CARBETAPENTANE TANNATE 92<br />

CARBETAPENTANE-GUAIFENESIN 92<br />

carbetapentane-guaifenesin 92<br />

CARBETAPENTANE-<br />

PSEUDOEPHEDRINE 92<br />

carbetapentane/phenylephr 91<br />

carbetaplex ts 92<br />

carbetaplex 92<br />

carbic ds 1<br />

CARBINOXAMINE & PHENYLEPHRINE<br />

1<br />

carbinoxamine & phenylephrine 1<br />

CARBINOXAMINE & PSEUDOEPH 1<br />

carbinoxamine & pseudoeph 1<br />

carbinoxamine compound 92<br />

carbinoxamine pse 1<br />

created on 20100520 204


CARBINOXAMINE TANNATE-<br />

PSEUDOEPHEDRINE TANNATE 1<br />

carbinoxamine tannatepseudoephedrine<br />

tannate 1<br />

carbinoxamine-pseudoephedrinemethscopolamine<br />

1<br />

carbinoxamine/pseudoephed 1<br />

carbodex dm 92<br />

carbofed dm 92<br />

carboplatin 30<br />

carboxine 12 d 1<br />

carboxine 12 dm 92<br />

carboxine dm 92<br />

carboxine-d 1<br />

CARBOXINE-PSE 1<br />

cardec dm 92<br />

cardec 7<br />

CARDENE IV 47<br />

CARDIZEM CD 48<br />

careone lancet thin 178<br />

careone lancet ultra thin 177<br />

careone lancet 177<br />

careone ultiguard insulin 180<br />

careone ultiguard insulin 181<br />

careone ultiguard insulin 183<br />

careone ultiguard insulin 184<br />

careone ultiguard insulin 186<br />

careone ultiguard insulin 187<br />

CARIMUNE NF 155<br />

carisoprodol w/ aspirin 38<br />

carisoprodol/aspirin 38<br />

CARISOPRODOL 38<br />

carisoprodol 38<br />

cartia xt 48<br />

CAT HAIR EXTRACT 174<br />

CATHFLO ACTIVASE 41<br />

cavan prenatal/ec calcium 170<br />

CAVERJECT 45<br />

CCP CAFFEINE FREE 126<br />

CECON 169<br />

CEENU 30<br />

CEFACLOR ER 18<br />

cefaclor er 18<br />

CEFACLOR MONOHYDRATE 18<br />

cefaclor monohydrate 18<br />

CEFACLOR 18<br />

cefaclor 18<br />

cefadroxil 18<br />

CEFAZOLIN SODIUM 18<br />

cefazolin sodium 18<br />

CEFAZOLIN 18<br />

cefdinir 19<br />

cefepime hcl 20<br />

CEFEPIME 20<br />

CEFIXIME 19<br />

CEFIZOX 19<br />

CEFOTAN-GALAXY 20<br />

cefotaxime sodium 19<br />

CEFOTAXIME 19<br />

CEFOTETAN 20<br />

CEFOXITIN SODIUM 20<br />

cefoxitin sodium 20<br />

CEFOXITIN 20<br />

cefpodo prox 19<br />

cefpodoxime proxetil 19<br />

cefpodoxime 19<br />

cefprozil 18<br />

CEFTAZIDIME 19<br />

ceftazidime 19<br />

ceftriaxone sodium in dextrose 19<br />

ceftriaxone sodium 19<br />

CEFTRIAXONE 19<br />

cefuroxime sodium 19<br />

CEFUROXIME 18<br />

CEFUROXIME 19<br />

CELEBREX 51<br />

CELLCEPT IV 173<br />

CENHIST 7<br />

centergy dm 92<br />

centergy 7<br />

centex-pse er 126<br />

cephalexin 18<br />

CEPROTIN 41<br />

CERECOMP 174<br />

CEREDASE 88<br />

CEREZYME 88<br />

CERNEVIT 170<br />

ceron-dm 92<br />

ceron 7<br />

CERTAIN DRI 166<br />

CERTUSS 92<br />

CERVARIX 156<br />

CERVICAL CAPS 78<br />

cetacort 162<br />

cetirizine hcl 16<br />

cetirizine 16<br />

cgh suppress 92<br />

CHANTIX 38<br />

CHANTIX 39<br />

chd pain rel 60<br />

CHEK-STIX COMBO PAK URINA 83<br />

CHEK-STIX CONTROL 83<br />

CHEMSTRIP-K 83<br />

cheratussin ac 92<br />

cheratussin dac 92<br />

chest conges 126<br />

chest congestion & pain r 126<br />

chest congestion and sinu 126<br />

chest congestion daytime 126<br />

chest congestion relief p 126<br />

chest congestion relief p 92<br />

chest congestion relief 126<br />

chest congestion/cough re 92<br />

chest congestion/pain & s 126<br />

chest/sinus congestion re 126<br />

chewable multivitamins/fl 171<br />

chewable multivite w/fl 171<br />

child apap 60<br />

child nite time 106<br />

child nonasa 60<br />

child pn rel 60<br />

child pn/fev 60<br />

childrens acetaminophen 60<br />

childrens advil cold 36<br />

childrens apap 60<br />

childrens aspirin free 60<br />

childrens cold & allergy 9<br />

childrens cold plus cough 92<br />

CHILDRENS COLD/PAIN 7<br />

childrens cough 92<br />

childrens ibuprofen cold 36<br />

childrens mapap rapid tab 60<br />

childrens medi-tabs 60<br />

childrens mucus relief co 105<br />

childrens nite time cold/ 92<br />

childrens non-aspirin col 107<br />

childrens non-aspirin pai 60<br />

childrens non-aspirin plu 106<br />

childrens non-aspirin plu 107<br />

childrens non-aspirin 60<br />

childrens pain relief col 7<br />

childrens pain relief 60<br />

childrens pain relief 62<br />

childrens pain reliever c 92<br />

created on 20100520 205


childrens pain reliever 60<br />

childrens pain/fever 60<br />

childrens plus cold & all 2<br />

childrens plus cough/runn 92<br />

childrens plus multi-symp 92<br />

childrens tactinal 64<br />

CHILDRENS TRIACTING COUGH 121<br />

childrens triacting cough 121<br />

childrens triacting night 121<br />

childrens tylenol plus co 92<br />

CHILDRENS TYLENOL SINUS 38<br />

childrens 60<br />

childs allergy cold/cough 92<br />

childs apap 60<br />

childs cold/allergy 9<br />

childs pain reliever with 60<br />

chld meditab 60<br />

chld non-asa 60<br />

chld pain rl 60<br />

chld pn rel 60<br />

chld silapap 60<br />

CHLO TUSS 92<br />

CHLOPHEDIANOL-PSEUDOEPHEDRINE<br />

92<br />

chlor-mes d 7<br />

chlor-mes jr 7<br />

chlor-mes 7<br />

chlor-tan a 12 7<br />

chlor-trimeton 7<br />

CHLORAL HYDR 75<br />

chloral hydr 75<br />

CHLORAL HYDRATE 75<br />

chloral hydrate 75<br />

CHLORAMBUCIL 30<br />

CHLORAMPHEN 20<br />

chloraseptic sore throat 60<br />

chlordex gp 92<br />

chlordiazep 74<br />

chlordiazepoxide hcl/clid 33<br />

chlordiazepoxide hcl 74<br />

chlordiazepoxide/clidiniu 33<br />

chlorex-a 12 7<br />

chlorex-a 7<br />

chloroprocaine hcl 154<br />

chlorothiazide sodium 88<br />

chlorphen hd 92<br />

chlorphen mal/dex hbr/pse 92<br />

chlorphen mal/pseudoeph h 9<br />

CHLORPHEN TAN & PSEUDOEPH TAN<br />

7<br />

chlorphen tan & pseudoeph tan 7<br />

chlorphen-pe-atropine-hyoscyaminescopolamine<br />

7<br />

CHLORPHEN-PHENYLEPH W/APAP 7<br />

chlorphen-phenyleph w/apap 7<br />

CHLORPHEN-PHENYLTOLOX-PE 8<br />

chlorphen-phenyltolox-pe 8<br />

chlorphen-pse-atropine-hyoscyaminescopolamine<br />

8<br />

CHLORPHEN-PSEUDOEPHED W/ APAP<br />

13<br />

CHLORPHEN-PSEUDOEPHED W/ APAP<br />

8<br />

chlorphen-pseudoephed w/ apap 8<br />

CHLORPHENIRAMINE &<br />

PHENYLEPHRINE 8<br />

chlorpheniramine & phenylephrine 8<br />

CHLORPHENIRAMINE & PSEUDOEPH 7<br />

CHLORPHENIRAMINE & PSEUDOEPH 8<br />

chlorpheniramine & pseudoeph 8<br />

CHLORPHENIRAMINE MAL-<br />

PHENYLEPHRINE HCL-METHSCOP NIT<br />

TANNATE 7<br />

CHLORPHENIRAMINE MALEATE-<br />

PSEUDOEPHEDRINE HCL TANNATE 8<br />

chlorpheniramine maleate/ 10<br />

CHLORPHENIRAMINE POLACRILEX-<br />

PSEUDOEPHEDRINE POLISTIREX 7<br />

CHLORPHENIRAMINE TAN-<br />

PYRILAMINE TAN-PHENYLEPHRINE<br />

TAN 7<br />

chlorpheniramine tan-pyrilamine tanphenylephrine<br />

tan 7<br />

CHLORPHENIRAMINE TANNATE-<br />

CARBETAPENTANE TANNATE 92<br />

chlorpheniramine tannatecarbetapentane<br />

tannate 92<br />

CHLORPHENIRAMINE TANNATE-<br />

HYDROCODONE TANNATE 92<br />

CHLORPHENIRAMINE TANNATE-<br />

PHENYLEPHRINE TAN-<br />

METHSCOPOLAMINE 7<br />

chlorpheniramine tannatephenylephrine<br />

tan-methscopolamine 7<br />

CHLORPHENIRAMINE TANNATE-<br />

PHENYLEPHRINE TAN-<br />

METHSCOPOLAMINE 9<br />

CHLORPHENIRAMINE TANNATE-<br />

PHENYLEPHRINE TANNATE 7<br />

chlorpheniramine tannatephenylephrine<br />

tannate 7<br />

CHLORPHENIRAMINE TANNATE-<br />

PHENYLEPHRINE TANNATE 8<br />

chlorpheniramine tannatephenylephrine<br />

tannate 8<br />

chlorpheniramine w/ apap 8<br />

CHLORPHENIRAMINE W/ CODEINE 92<br />

chlorpheniramine w/ codeine 92<br />

CHLORPHENIRAMINE W/ CODEINE 93<br />

CHLORPHENIRAMINE W/ DM-GG 93<br />

CHLORPHENIRAMINE<br />

W/HYDROCODONE 93<br />

chlorpheniramine-diphenhydraminephenylephrine-apap<br />

7<br />

CHLORPHENIRAMINE-DM 93<br />

chlorpheniramine-dm 93<br />

CHLORPHENIRAMINE-<br />

PHENYLEPHRINE-ASA 9<br />

CHLORPHENIRAMINE-<br />

PHENYLEPHRINE-<br />

METHSCOPOLAMINE &<br />

HOMEOPATHIC 4<br />

CHLORPHENIRAMINE-<br />

PHENYLEPHRINE-<br />

METHSCOPOLAMINE 12<br />

chlorpheniramine-phenylephrinemethscopolamine<br />

12<br />

CHLORPHENIRAMINE-<br />

PHENYLEPHRINE-<br />

METHSCOPOLAMINE 7<br />

chlorpheniramine-phenylephrinemethscopolamine<br />

7<br />

CHLORPHENIRAMINE-<br />

PHENYLEPHRINE-<br />

METHSCOPOLAMINE 8<br />

chlorpheniramine-phenylephrinemethscopolamine<br />

8<br />

CHLORPHENIRAMINE-<br />

PHENYLEPHRINE-<br />

METHSCOPOLAMINE 9<br />

chlorpheniramine-phenylephrinemethscopolamine<br />

9<br />

CHLORPHENIRAMINE-<br />

PHENYLTOLOXAMINE-<br />

created on 20100520 206


PHENYLEPHRINE-APAP 16<br />

chlorpheniramine-phenyltoloxaminephenylephrine-apap<br />

16<br />

CHLORPHENIRAMINE-<br />

PSEUDOEPHEDRINE & BELLADONNA<br />

ALKALOIDS 7<br />

CHLORPHENIRAMINE-<br />

PSEUDOEPHEDRINE & HOMEOPATHIC<br />

PRODUCT 4<br />

CHLORPHENIRAMINE-<br />

PSEUDOEPHEDRINE &<br />

METHSCOPOLAMINE 13<br />

chlorpheniramine-pseudoephedrine &<br />

methscopolamine 13<br />

CHLORPHENIRAMINE-<br />

PSEUDOEPHEDRINE &<br />

METHSCOPOLAMINE 7<br />

chlorpheniramine-pseudoephedrine &<br />

methscopolamine 7<br />

CHLORPHENIRAMINE-<br />

PSEUDOEPHEDRINE &<br />

METHSCOPOLAMINE 8<br />

chlorpheniramine-pseudoephedrine &<br />

methscopolamine 8<br />

CHLORPHENIRAMINE-<br />

PSEUDOEPHEDRINE-ASPIRIN 8<br />

CHLORPHENIRAMINE-<br />

PSEUDOEPHEDRINE-IBUPROFEN 9<br />

CHLORPHENIRAMINE-PYRILAMINE &<br />

PHENYLEPHRINE 8<br />

chlorpheniramine-pyrilamine &<br />

phenylephrine 8<br />

CHLORPHENIRAMINE-PYRILAMINE<br />

TAN-PHENYLEPH HCL-PHENYLEPH<br />

TAN 16<br />

chlorpheniramine/codeine 95<br />

chlorpheniramine/methscop 9<br />

chlorpheniramine/phenylep 10<br />

chlorpheniramine/phenylep 92<br />

chlorpheniramine/phenylep 95<br />

chlorpheniramine/phenylto 10<br />

chlorpheniramine/pseudo/d 92<br />

CHLORPHENIRAMINE/PSEUDOEP 10<br />

chlorpheniramine/pseudoep 10<br />

CHLORPROMAZ 71<br />

chlorpromaz 71<br />

chlorpromazine hcl 71<br />

CHLORPROMAZINE 71<br />

chlorpropam 149<br />

chlorpropamide 149<br />

chlortan d 9<br />

CHOICE DM DIABETES RISK I 178<br />

CHOLOGRAFIN 82<br />

chorionic gonadotropin 147<br />

chromium chloride 84<br />

ciclopirox olamine 158<br />

ciclopirox olamine 159<br />

ciclopirox 158<br />

ciclopirox 159<br />

CILOXAN 135<br />

CIMETIDINE HCL/NACL 142<br />

cimetidine hcl 142<br />

cimetidine 142<br />

CIMZIA 144<br />

CIPRODEX 136<br />

ciprofloxacin hcl (ophth) 135<br />

ciprofloxacin hcl 24<br />

ciprofloxacin in d5w 24<br />

ciprofloxacin 24<br />

ciprofloxacn 135<br />

ciprofloxacn 24<br />

cisplatin 30<br />

citalopram hydrobromide 66<br />

citalopram hydrobromide 67<br />

citalopram 66<br />

citalopram 67<br />

cladribine 30<br />

CLAFORAN/D5W 19<br />

CLAFORAN 19<br />

CLARINEX-D 16<br />

CLARINEX 16<br />

clarithromyc 20<br />

clarithromyc 21<br />

clarithromycin 20<br />

clarithromycin 21<br />

CLARITIN 16<br />

claritin 16<br />

clean & clear persa-gel e 162<br />

clean & clear persa-gel m 162<br />

clean&clear 161<br />

cleanlet lancets 28g 178<br />

clear cough dm 93<br />

clear-atadin 17<br />

clearplex x 161<br />

clearplex 161<br />

clearskin 161<br />

clemastine fumarate 1<br />

clemastine-1 1<br />

clemastine 1<br />

CLEOCIN 26<br />

CLEVER CHEK AUTO CODE VOI 178<br />

CLEVER CHEK AUTO-CODE BLO 178<br />

CLEVER CHEK AUTO-CODE TES 80<br />

CLEVER CHEK AUTO-CODE VOI 178<br />

CLEVER CHEK AUTO-CODE VOI 80<br />

CLEVER CHEK BLOOD GLUCOSE 178<br />

clever chek lancets ultra 178<br />

CLEVER CHEK TEST STRIPS 80<br />

CLEVER CHOICE AUTO-CODE P 178<br />

CLEVER CHOICE AUTO-CODE P 80<br />

CLEVER CHOICE MINI BLOOD 178<br />

CLEVIPREX 47<br />

CLICKFINE PEN NEEDLE UNIV 178<br />

CLICKFINE UNIVERSAL PEN N 178<br />

clidinium & chlordiazepoxide 33<br />

clidinium/chlordiazepoxid 33<br />

CLINAC BPO 161<br />

CLINDA 158<br />

clindamax 158<br />

clindamycin hcl 26<br />

CLINDAMYCIN PHOSPHATE (TOPICAL)<br />

158<br />

clindamycin phosphate (topical) 158<br />

clindamycin phosphate vaginal 158<br />

clindamycin phosphate-benzoyl<br />

peroxide 158<br />

clindamycin phosphate 158<br />

clindamycin phosphate 26<br />

clindamycin 158<br />

clindamycin 26<br />

CLINDAREACH 158<br />

CLINIMIX 2.75%/DEXTROSE 5 86<br />

CLINIMIX 4.25%/DEXTROSE 1 86<br />

CLINIMIX 4.25%/DEXTROSE 2 86<br />

CLINIMIX 4.25%/DEXTROSE 5 86<br />

CLINIMIX 5%/DEXTROSE 15% 86<br />

CLINIMIX 5%/DEXTROSE 20% 86<br />

CLINIMIX 5%/DEXTROSE 25% 86<br />

CLINIMIX E 2.75% 86<br />

CLINIMIX E 2.75% 87<br />

CLINIMIX E 4.25% 87<br />

CLINIMIX E 5%/DEXTROSE 15 87<br />

CLINIMIX E 5%/DEXTROSE 20 87<br />

CLINIMIX E 5%/DEXTROSE 25 87<br />

created on 20100520 207


CLINIMIX E 5%/DEXTROSE 35 87<br />

CLOFERA 93<br />

CLOLAR 30<br />

clomipramine hcl 68<br />

clomipramine 68<br />

clonazepam 64<br />

clonidine hcl (analgesia) 44<br />

clonidine hcl 44<br />

clonidine 44<br />

CLOPIDOGREL BISULFATE 41<br />

clopidogrel bisulfate 41<br />

clopidogrel 41<br />

clotrimazole tro 158<br />

CLOTRIMAZOLE VAGINAL 158<br />

clotrimazole w/ betamethasone 158<br />

clotrimazole/betamethason 158<br />

clotrimazole 158<br />

CLOZAPINE 69<br />

clozapine 69<br />

co-gesic 53<br />

co-natal fa 170<br />

coaguchek lancets 178<br />

COCET 54<br />

COCILLANA-TERPIN HYDRATE 126<br />

codafed expectorant 93<br />

codafed pediatric expecto 93<br />

codal-dh 93<br />

codal-dm 93<br />

CODEINE PHOS TAB SOL 54<br />

codeine phosphate/acetami 54<br />

codeine phosphate/apap 54<br />

codeine phosphate/guaifen 93<br />

CODEINE PHOSPHATE 54<br />

CODEINE-BROMPHENIRAMINE 93<br />

codeine-brompheniramine 93<br />

CODEINE-CHLORPHENIRAMINE-<br />

ACETAMINOPHEN 93<br />

CODEINE-PYRILAMINE 93<br />

codeine/acetaminophen 54<br />

codeine/guaifenesin 93<br />

codiclear dh 93<br />

CODIMAL DH 93<br />

CODIMAL PH 93<br />

codituss dh 93<br />

codituss dm 93<br />

COENZYME COMPOSITUM 174<br />

cofex-dm 93<br />

cold & allergy 9<br />

cold & cough dm 93<br />

cold & flu intense streng 2<br />

cold caplets 93<br />

cold control + 1<br />

cold control pe intense c 1<br />

cold head congestion day/ 93<br />

cold head congestion dayt 93<br />

cold head congestion nigh 93<br />

cold head congestion seve 93<br />

cold medicine plus 9<br />

cold multi-symptom day/ni 93<br />

cold multi-symptom daytim 93<br />

cold multi-symptom nightt 93<br />

cold multi-symptom severe 93<br />

cold multi-symptom 93<br />

cold multi-symptom 9<br />

cold relief effervescent 9<br />

cold relief plus 9<br />

cold symptoms relief maxi 93<br />

cold tablets 36<br />

cold/allergy childrens 9<br />

cold/allergy pe 9<br />

cold/allergy/sinus 9<br />

cold/allergy 9<br />

cold/cough childrens 94<br />

cold/cough dm childrens 94<br />

cold/cough multi-symptom 94<br />

cold/flu relief day/night 94<br />

cold/flu relief daytime m 94<br />

coldamine 9<br />

coldcough hc 94<br />

COLDCOUGH HCM 94<br />

coldcough pd 94<br />

coldcough 94<br />

coldec d 2<br />

coldec dm 94<br />

coldec-tr 2<br />

coldec 2<br />

coldex-a sr 9<br />

coldmist dm 94<br />

coldmist jr 126<br />

coldmist la 126<br />

coldtuss-dr 94<br />

colfed-a 9<br />

colidrops 33<br />

colistimethate sodium 26<br />

color lancets 178<br />

COLYTROL PEDIATRIC 33<br />

COMBIVIR 28<br />

comfort lancets 178<br />

COMHIST 9<br />

COMPACT TEST STRIPS 80<br />

complete sinus relief 14<br />

COMPLETE SINUS RELIEF 9<br />

complete 94<br />

compro 71<br />

COMTREX ACUTE HEAD COLD 9<br />

comtrex cold & cough 94<br />

comtrex cold/cough relief 94<br />

COMTREX DAY/NIGHT COLD & 94<br />

COMTREX DAY/NIGHT FLU THE 9<br />

comtrex deep chest cold m 126<br />

comtrex deep chest cold 94<br />

comtrex flu therapy maxim 9<br />

comtrex maximum-strength 94<br />

COMTREX NIGHTTIME ACUTE H 9<br />

COMTREX NIGHTTIME COLD & 94<br />

comtrex nighttime cold & 94<br />

COMTREX NIGHTTIME FLU THE 9<br />

comtrex severe cold & sin 9<br />

comtrex sinus & nasal dec 9<br />

comtrex sore throat 60<br />

COMTREX/DAY & NIGHT/COLD 94<br />

COMVAX 156<br />

conal 9<br />

CONCERTA 73<br />

condasin 94<br />

CONEX COLD/ALLERGY 9<br />

congesta dm 94<br />

congestant 9<br />

conison 39<br />

conpec la nr 126<br />

CONPEC 126<br />

CONRAY 400 82<br />

CONRAY 82<br />

constulose 83<br />

contac cold+flu maximum s 34<br />

CONTAC COLD/FLU DAY & NIG 9<br />

CONTAC COLD/FLU MAXIMUM S 9<br />

CONTAC DAY/NIGHT ALLERGY/ 2<br />

CONTAC DAY/NIGHT COLD/FLU 94<br />

contac severe cold/flu no 94<br />

CONTOUR BLOOD GLUCOSE MON 178<br />

CONTOUR USB BLOOD GLUCOSE 178<br />

CONTROL AST 80<br />

created on 20100520 208


CONTROL BLOOD GLUCOSE MON 178<br />

CONTROL TEST STRIPS 80<br />

COPAXONE 172<br />

COPHENE #2 9<br />

COPPER SULF 84<br />

CORDRON-12 D 2<br />

CORDRON-12 DM 94<br />

cordron-d nr 2<br />

CORDRON-D 2<br />

cordron-dm nr 94<br />

CORDRON-DM 94<br />

cordron-hc nr 94<br />

CORDRON-HC 94<br />

COREG CR 46<br />

corfen-dm 94<br />

coricidin d cold/flu/sinu 9<br />

coricidin d 9<br />

CORICIDIN HBP CHEST CONGE 94<br />

coricidin hbp nighttime m 94<br />

CORICIDIN NIGHTTIME COLD/ 2<br />

cortaid advanced 163<br />

cortaid maximum strength 162<br />

cortaid 162<br />

CORTIFOAM 163<br />

cortizone-10 external ana 163<br />

cortizone-10 intensive he 163<br />

cortizone-10 plus 163<br />

cortizone-10/aloe 163<br />

cortizone-10 163<br />

cortizone-5 163<br />

cortomycin 136<br />

coryza-d 9<br />

coryza-dm 94<br />

CORZALL PLUS 94<br />

CORZALL 94<br />

COSMEGEN 30<br />

cosyntropin 79<br />

COTAB A 94<br />

COTAB AX 94<br />

COTABFLU 94<br />

cotuss ex 94<br />

cotuss hd 94<br />

cotuss ms 94<br />

cotuss 94<br />

cough & cold 94<br />

cough & sore throat day t 94<br />

cough & sore throat day 94<br />

cough & sore throat night 94<br />

cough cold & flu relief m 94<br />

cough formula d 94<br />

COUGH FORMULA M 94<br />

cough relief 94<br />

cough reliever double str 92<br />

COUGH SYRUP D 94<br />

cough syrup m 94<br />

cough/cold medicine 9<br />

cough/cold/flu relief m 92<br />

cough/head congestion rel 94<br />

cough 126<br />

coughtuss 94<br />

COUMADIN 39<br />

COUMADIN 40<br />

COVERA-HS 48<br />

cp dec-dm 95<br />

cp dec 9<br />

cpm 8/pe 20/msc 1.25 9<br />

cpm 8/pse 90/msc 2.5 10<br />

cpm-pe-msc 9<br />

cpm/pse dm 95<br />

cpm/pse 10<br />

CRAMP TABS 60<br />

CRANTEX HC 95<br />

crantex la 126<br />

crantex 126<br />

CREO-TERPIN 95<br />

CREOMULSION 95<br />

CREON 10 141<br />

CREON 20 141<br />

CREON 5 141<br />

CRIXIVAN 27<br />

CROFAB 155<br />

cromolyn sod 125<br />

cromolyn sod 135<br />

cromolyn sodium (ophth) 135<br />

CROMOLYN SODIUM 125<br />

cromolyn sodium 125<br />

cryselle-28 146<br />

CUBICIN 26<br />

CUPRIC CHLOR 84<br />

cvs 8 hour 60<br />

cvs acne 161<br />

cvs allergy sinus headach 1<br />

cvs allergy 17<br />

cvs anti-itch maximum str 162<br />

CVS BLOOD GLUCOSE STRIPS 80<br />

CVS BLOOD GLUCOSE TEST 80<br />

CVS BLOOD GLUCOSE 178<br />

cvs chest congestion expe 126<br />

cvs chest congestion reli 92<br />

cvs chest rub medicated 174<br />

cvs childrens allergy rel 17<br />

cvs childrens cold plus c 95<br />

cvs childrens cold 10<br />

cvs childrens multi-sympt 105<br />

cvs childrens triacting c 95<br />

cvs childs 60<br />

cvs cold & allergy dm 93<br />

cvs cold & allergy relief 9<br />

cvs cold & cough 95<br />

cvs cold reliever 9<br />

cvs cold/allergy children 10<br />

cvs cold/allergy 9<br />

cvs cold/cough dm childre 95<br />

CVS COMPLETE MONITORING 178<br />

cvs congestion & pain nig 14<br />

cvs cortisone + maximum s 163<br />

cvs cortisone maximum str 163<br />

cvs dayhist 2<br />

cvs daytime cold/flu 95<br />

cvs daytime multi-symptom 95<br />

cvs daytime sinus relief 34<br />

cvs decongestant plus 10<br />

cvs flu & severe cold nig 2<br />

cvs flu/cold/cough medici 100<br />

cvs flu/cold/cough/maximu 100<br />

cvs head congestion cold 95<br />

cvs hot steam 174<br />

cvs hydrocortisone maximu 164<br />

cvs hydrocortisone plus m 164<br />

cvs ibu-profen cold & sin 36<br />

cvs ibuprofen cold childr 36<br />

cvs infants cold 95<br />

cvs infants decongestant 95<br />

cvs infants 60<br />

cvs insulin syringe/0.3ml 180<br />

cvs insulin syringe/0.3ml 181<br />

cvs insulin syringe/0.5ml 183<br />

cvs insulin syringe/0.5ml 184<br />

cvs insulin syringe/1ml/2 186<br />

cvs lancets 21g 178<br />

cvs lancets micro thin 33 178<br />

cvs lancets original 178<br />

cvs lancets thin 26g 178<br />

cvs lancets thin 178<br />

created on 20100520 209


cvs lancets ultra thin 30 178<br />

cvs nasal decongestant an 12<br />

cvs nasal decongestant 12<br />

cvs nasal 138<br />

cvs night time cold & flu 94<br />

cvs night time cold/flu r 106<br />

cvs night time cold/flu 106<br />

cvs night time cough 106<br />

cvs night time formula 106<br />

cvs night time formula 95<br />

cvs night time multi-symp 106<br />

cvs nighttime multi-sympt 106<br />

cvs non-asa 60<br />

cvs non-aspirin allergy 12<br />

cvs non-aspirin child 62<br />

cvs non-aspirin cold mult 107<br />

cvs non-aspirin cold 95<br />

cvs non-aspirin flu medic 107<br />

cvs non-aspirin jr 62<br />

cvs non-aspirin pm extra 76<br />

cvs non-aspirin pm 76<br />

cvs non-aspirin severe co 119<br />

cvs non-drying sinus 126<br />

cvs nose 138<br />

cvs pain relief extra str 60<br />

cvs pain relief pm extra 76<br />

cvs prenatal 170<br />

cvs saline spray 134<br />

cvs severe cold formula 119<br />

cvs sinus & allergy maxim 14<br />

cvs sinus headache decong 36<br />

cvs sinus maximum strengt 36<br />

cvs sinus pain & congesti 14<br />

cvs sinus pain & congesti 34<br />

cvs triacting cough & col 121<br />

cvs triacting cough & sor 121<br />

cvs triacting night time 121<br />

cvs tussin cf 95<br />

CVS TUSSIN CHILD COUGH/CO 123<br />

cvs tussin cold severe co 134<br />

cvs tussin cough/cold cf 95<br />

cvs tussin cough/cold max 95<br />

cvs tussin dm clear 123<br />

cvs tussin dm 123<br />

cvs tussin pe 126<br />

cvs tussin-dm 123<br />

cvs tussin 126<br />

cvs ultra thin lancets 194<br />

cvs vaporizing 175<br />

cvs vit b-6 168<br />

cyanocobalamin 168<br />

cyclobenzapr 38<br />

CYCLOBENZAPRINE HCL 195<br />

CYCLOBENZAPRINE HCL 38<br />

cyclobenzaprine hcl 38<br />

CYCLOGYL 137<br />

cyclopentol 137<br />

CYCLOPENTOLATE HCL 137<br />

cyclopentolate hcl 137<br />

CYCLOPHOSPH 30<br />

cyclophosph 30<br />

CYCLOPHOSPHAMIDE 30<br />

cyclophosphamide 30<br />

cyclosporine modified (for<br />

microemulsion) 173<br />

cyclosporine modified 173<br />

cyclosporine 173<br />

CYKLOKAPRON 42<br />

cylate 137<br />

CYMBALTA 66<br />

cyproheptad 16<br />

cyproheptadine hcl 16<br />

cysteine hcl 87<br />

CYSTO-CONRAY II 82<br />

CYSTOGRAFIN-DILUTE 82<br />

CYSTOGRAFIN 82<br />

CYTARABINE 30<br />

cytarabine 30<br />

CYTOGAM 155<br />

CYTOVENE 29<br />

cytuss hc 95<br />

cytuss-hc nr 95<br />

created on 20100520 210<br />

D<br />

d&k insulin syringe/u-100 180<br />

d&k insulin syringe/u-100 181<br />

d&k insulin syringe/u-100 183<br />

d&k insulin syringe/u-100 184<br />

d&k insulin syringe/u-100 186<br />

d&k insulin syringe/u-100 187<br />

d-amine-sr 10<br />

d-feda ii 126<br />

d-hist d 10<br />

d-methorphan hb/pe/cpm 98<br />

d-phen 1000 126<br />

d-tab 126<br />

D-TANN AT 95<br />

D-TANN CD 95<br />

d-tann ct 95<br />

d-tann dm 95<br />

d-tann hc 95<br />

d-tann 2<br />

DACARBAZINE 30<br />

dacarbazine 30<br />

dacex-a 95<br />

dacex-dm 95<br />

dacex-pe 95<br />

DACOGEN 30<br />

DAILY DIABETIC 178<br />

dailyhist-1 2<br />

DALLERGY PE 10<br />

DALLERGY PSE 10<br />

DALLERGY-JR 10<br />

DALLERGY 10<br />

danazol 146<br />

dandrex 161<br />

dandruff shampoo 161<br />

DANTRIUM IV 38<br />

dantrolene sodium 38<br />

DAPSONE (TOPICAL) 158<br />

DAPTACEL 156<br />

DARAPRIM 29<br />

daunorubicin hcl 30<br />

DAUNOXOME 30<br />

day time multi-symptom co 95<br />

day time 95<br />

day-time cold/flu relief 95<br />

day-time multi-symptom co 95<br />

day-time pe cold/flu reli 95<br />

day-time pe 95<br />

day-time sinus 34<br />

day-time 95<br />

dayhist allergy 12 hour r 2<br />

dayhist-1 2<br />

DAYTIME COLD MEDICINE 95<br />

daytime cold/flu relief 95<br />

daytime cold/flu 95<br />

daytime multi-symptom col 95<br />

daytime non-drowsy cold/f 95<br />

daytime pe multi-symptom 95<br />

daytime 95<br />

DAYTO ANASE 60<br />

DAYTRANA 73<br />

dd lancets 178<br />

dd thin lancets 178


de lancets 178<br />

de thin lancets 178<br />

de-chlor dm 95<br />

de-chlor dr 95<br />

de-chlor g 95<br />

de-chlor hc 95<br />

de-chlor hd 95<br />

de-chlor mr 95<br />

de-chlor nx 95<br />

dec-chlorphen dm 95<br />

dec-chlorphen 10<br />

DECAHIST-DM 95<br />

DECAVAC 156<br />

decon dm 95<br />

DECON-A 10<br />

DECON-G 126<br />

DECONEX DM 95<br />

DECONEX 127<br />

decongest ii 127<br />

decongestant + 10<br />

DECONGESTANT D COUGH 95<br />

decongestant d 96<br />

decongestant inh nasal 174<br />

decongestant inh 174<br />

decongestant plus 10<br />

decongestant rub 174<br />

decongestant vapor inhale 174<br />

decongestant/antihistamin 10<br />

decongestant 10<br />

decongestant 138<br />

decongestine tr 10<br />

DECONSAL CT 10<br />

DECONSAL DM 96<br />

deconsal ii 127<br />

decorel forte plus severe 96<br />

DECOREL FORTE 127<br />

deferoxamine mesylate 144<br />

dehistine 10<br />

DEKA PEDIATRIC 96<br />

DEKA 96<br />

del-aqua 161<br />

del-beta 163<br />

DELSYM 96<br />

DELTUSS DMX 96<br />

DEMADEX 87<br />

DEMEROL 54<br />

denaze 10<br />

DEPO-ESTRADI 147<br />

DEPO-MEDROL 144<br />

DEPO-PROVERA 151<br />

DEPO-SQ PROV 151<br />

DEPOCYT 30<br />

DERMTEX HC 163<br />

desipramine hcl 68<br />

desipramine 68<br />

DESLORATADINE-PSEUDOEPHEDRINE<br />

17<br />

desmopressin acetate refrigerated 150<br />

desmopressin acetate spray<br />

refrigerated 150<br />

desmopressin acetate spray 150<br />

desmopressin acetate 150<br />

desmopressin 150<br />

desogestrel & ethinyl estradiol 146<br />

desonide 163<br />

desoximetas 163<br />

desoximetasone 163<br />

DESPEC DM 96<br />

DESPEC DROPS 96<br />

DESPEC NR 96<br />

DESPEC SR 127<br />

DESPEC-DM 96<br />

DESPEC-EXP 96<br />

despec-pd 96<br />

despec-tab 127<br />

despec 127<br />

DESPEC 96<br />

desquam-e 161<br />

DESQUAM-X 161<br />

detuss 96<br />

dex pc 96<br />

dex-tuss dm 96<br />

dex-tuss 96<br />

dexa 136<br />

DEXALL 96<br />

DEXALONE 96<br />

dexameth pho 136<br />

dexamethason 144<br />

dexamethasone sodium phosphate<br />

(ophth) 136<br />

dexamethasone sodium phosphate 144<br />

dexamethasone 144<br />

DEXAMETHASONE 145<br />

dexamethasone 145<br />

dexaphen sa 10<br />

dexasporin 136<br />

dexatrex d nasal 96<br />

DEXBROMPHEN-PSEUDOEPHED<br />

W/APAP 10<br />

dexbromphen-pseudoephed w/apap 10<br />

DEXBROMPHENIRAMINE &<br />

PSEUDOEPHEDRINE 10<br />

dexbrompheniramine &<br />

pseudoephedrine 10<br />

DEXBROMPHENIRAMINE TAN-<br />

PYRILAMINE MAL-PHENYLEPHRINE<br />

TAN 10<br />

DEXBROMPHENIRAMINE-<br />

PHENYLEPHRINE-ACETAMINOPHEN 10<br />

DEXBROMPHENIRAMINE-<br />

PHENYLEPHRINE 10<br />

DEXCHLORPHENIRAMINE &<br />

PSEUDOEPHEDRINE 10<br />

DEXCHLORPHENIRAMINE TAN-<br />

PYRILAMINE TAN-PSEUDOEPHEDRINE<br />

TAN 10<br />

DEXCHLORPHENIRAMINE TANNATE &<br />

PSEUDOEPHEDRINE TANNATE 10<br />

DEXCHLORPHENIRAMINE-<br />

PHENYLEPHRINE-<br />

METHSCOPOLAMINE 10<br />

dexchlorpheniramine-phenylephrinemethscopolamine<br />

10<br />

DEXCHLORPHENIRAMINE-<br />

PHENYLEPHRINE 10<br />

DEXCHLORPHENIRAMINE-<br />

PSEUDOEPHEDRINE-ACETAMINOPHEN<br />

10<br />

dexchlorpheniraminepseudoephedrine-methscopolamine<br />

10<br />

dexcon-dm 96<br />

dexcon-pe 96<br />

DEXPAK 10 DAY 145<br />

DEXPAK 13 DAY 145<br />

DEXPANTHENOL 168<br />

dexpanthenol 168<br />

dexphen m 10<br />

dextran 40 in d5w 84<br />

dextran 40 in saline 84<br />

dextran 70 in saline 84<br />

DEXTRAN 70 84<br />

DEXTRAN HM 84<br />

dextroamphet 72<br />

created on 20100520 211


dextroamphetamine sulfate 72<br />

DEXTROMETHORPHAN HBR MONO 195<br />

DEXTROMETHORPHAN HBR-<br />

GUAIFENESIN TANNATE 96<br />

dextromethorphan hbr/chlo 98<br />

dextromethorphan hbr/phen 98<br />

dextromethorphan hbr/pseu 98<br />

DEXTROMETHORPHAN HBR 195<br />

DEXTROMETHORPHAN HBR 96<br />

dextromethorphan hbr 96<br />

DEXTROMETHORPHAN POLISTIREX 96<br />

dextromethorphan tan/phen 98<br />

DEXTROMETHORPHAN TANNATE 96<br />

DEXTROMETHORPHAN-<br />

ACETAMINOPHEN-<br />

CHLORPHENIRAMINE 96<br />

dextromethorphan-acetaminophenchlorpheniramine<br />

96<br />

DEXTROMETHORPHAN-<br />

CHLORPHENIRAMINE-<br />

METHSCOPOLAMINE 96<br />

DEXTROMETHORPHAN-<br />

DIPHENHYDRAMINE-<br />

ACETAMINOPHEN 96<br />

DEXTROMETHORPHAN-DOXYLAMINE<br />

-ACETAMINOPHEN 96<br />

dextromethorphan-doxylamineacetaminophen<br />

96<br />

DEXTROMETHORPHAN-DOXYLAMINE<br />

-ACETAMINOPHEN 98<br />

dextromethorphan-gg-pot citratecitric<br />

acid 98<br />

DEXTROMETHORPHAN-GG-<br />

POTASSIUM CITRATE 96<br />

DEXTROMETHORPHAN-GG-SODIUM<br />

CITRATE 98<br />

DEXTROMETHORPHAN-GUAIFENESIN<br />

96<br />

dextromethorphan-guaifenesin 96<br />

DEXTROMETHORPHAN-GUAIFENESIN<br />

97<br />

dextromethorphan-guaifenesin 97<br />

DEXTROMETHORPHAN-<br />

PHENYLEPHRINE-ACETAMINOPHEN 97<br />

dextromethorphan-phenylephrineacetaminophen<br />

97<br />

DEXTROMETHORPHAN-POTASSIUM<br />

GUAIACOLSULFONATE 97<br />

dextromethorphan-potassium<br />

guaiacolsulfonate 97<br />

DEXTROMETHORPHAN-POTASSIUM<br />

GUAIACOLSULFONATE 98<br />

DEXTROMETHORPHAN/CHLORPHE 105<br />

dextromethorphan/chlorphe 98<br />

dextromethorphan/guaifene 98<br />

dextromethorphan/phenylep 98<br />

DEXTROMETHORPHAN/PSEUDOEP 98<br />

dextromethorphan/pseudoep 98<br />

DEXTROSE 10%/NACL 0.45% 84<br />

DEXTROSE 5% 84<br />

DEXTROSE 10%/NACL 0.225% 84<br />

DEXTROSE 5%/NACL 0.225% 84<br />

DEXTROSE 5%/NACL 0.3% 84<br />

DEXTROSE 5%/POTASSIUM CHL 85<br />

dextrose in lactated ringers 84<br />

dextrose in ringers 84<br />

dextrose w/ sodium chloride 84<br />

DEXTROSE 87<br />

dextrose 87<br />

dextrostat 72<br />

di bromm cold/allergy 10<br />

DIABETA 149<br />

diabetic siltussin-dm max 119<br />

diabetic siltussin-dm 119<br />

diabetic sterile lancets 178<br />

DIABETIC TUS 127<br />

diabetic tus 127<br />

DIABETIC TUSSIN C 97<br />

DIABETIC TUSSIN COLD & FL 97<br />

DIABETIC TUSSIN COLD/FLU 97<br />

diabetic tussin dm 97<br />

diabetic tussin for child 97<br />

diabetic tussin maximum s 97<br />

diabetic tussin maximum 97<br />

DIABETIC TUSSIN NIGHT TIM 97<br />

DIABETIC.COM STARTER KIT 178<br />

DIABETIC.COM TEST STRIPS 80<br />

diabtc tussn 127<br />

diacetazone 77<br />

DIAGNOSTIC KIT 79<br />

DIAPHRAGM ARC-SPRING 78<br />

DIAPHRAGM COIL SPRING 78<br />

DIAPHRAGM FLAT SPRING 78<br />

DIAPHRAGMS 78<br />

diatrizoate meglumine & sodium 82<br />

DIAZEPAM 74<br />

diazepam 74<br />

DICEL DM 97<br />

DICEL 10<br />

diclofenac sodium (ophth) 137<br />

DICLOFENAC SODIUM 52<br />

diclofenac sodium 52<br />

diclofenac 137<br />

DICLOFENAC 52<br />

diclofenac 52<br />

dicloxacill 24<br />

dicloxacillin sodium 24<br />

dicyclomine hcl 33<br />

dicyclomine 33<br />

DIDGET 178<br />

diflorasone diacetate 163<br />

diflorasone 163<br />

DIGIBIND 155<br />

DIGIFAB 155<br />

DIGOXIN 44<br />

digoxin 44<br />

dihistine dh 97<br />

DIHYDRO-CP 97<br />

dihydro-gp 97<br />

dihydro-pe 98<br />

DIHYDROCODEINE-GUAIFENESIN 98<br />

dihydrocodeine/bpm/phenyl 98<br />

DILANTIN-125 64<br />

DILANTIN 64<br />

DILATRATE SR 45<br />

DILAUDID-HP 54<br />

dilotab 36<br />

dilt-cd 48<br />

dilt-xr 48<br />

diltiazem cd 48<br />

DILTIAZEM HCL COATED BEADS 48<br />

diltiazem hcl coated beads 48<br />

diltiazem hcl extended release beads<br />

48<br />

diltiazem hcl 48<br />

DILTIAZEM 48<br />

diltiazem 48<br />

diltzac 48<br />

dimaphen childrens 10<br />

dimaphen dm cold/cough ch 98<br />

dimaphen dm 98<br />

dimaphen 10<br />

DIMENHYDRIN 142<br />

DIMETAPP COLD & CONGESTI 98<br />

created on 20100520 212


DIMETAPP COLD & ALLERGY 10<br />

DIMETAPP COLD & FEVER 10<br />

dimetapp cold & fever 36<br />

DIMETAPP DECONGESTANT PLU 98<br />

DIMETAPP LONG ACTING COUG 98<br />

dimetapp nd 17<br />

dimetapp nighttime cold & 2<br />

dimetapp nighttime flu 98<br />

DIOVAN HCT 50<br />

DIOVAN 50<br />

DIPHEN TANN 25/PE TANN 10 98<br />

diphenatol 140<br />

diphenhydram 2<br />

DIPHENHYDRAMINE & PSEUDOEPHED<br />

2<br />

diphenhydramine & pseudoephed 2<br />

DIPHENHYDRAMINE CITRATE-<br />

PSEUDOEPHEDRINE 2<br />

DIPHENHYDRAMINE HCL-<br />

PHENYLEPHRINE HCL TANNATE 2<br />

diphenhydramine hcl 2<br />

DIPHENHYDRAMINE TANNATE-<br />

CARBETAPENTANE TANNATE 98<br />

DIPHENHYDRAMINE TANNATE-<br />

PHENYLEPHRINE TANNATE 2<br />

diphenhydramine tannatephenylephrine<br />

tannate 2<br />

diphenhydramine w/ apap (sleep) 75<br />

DIPHENHYDRAMINE W/ APAP 2<br />

diphenhydramine w/ apap 2<br />

diphenhydramine-phenylephrineacetaminophen<br />

2<br />

DIPHENHYDRAMINE-PHENYLEPHRINE<br />

2<br />

diphenhydramine-phenylephrine 2<br />

DIPHENHYDRAMINE-PSE W/ APAP 2<br />

diphenhydramine-pse w/ apap 2<br />

DIPHENHYDRAMINE-PSE W/ APAP 3<br />

DIPHENMAX D 2<br />

diphenoxylate w/ atropine 140<br />

diphenoxylate/atropine 140<br />

diphentann-d 2<br />

DIPHTHERIA/TETANUS TOXOID 156<br />

DIPIVEFRIN HCL 138<br />

dipivefrin hcl 138<br />

dipivefrin 138<br />

dipyridamole (diagnostic) 45<br />

DISCOUNT DRUG MART TEST S 80<br />

DISCOUNT DRUG MART VALUE 177<br />

DISCOVISC 140<br />

DISCUS COMPOSITUM 174<br />

disophrol 10<br />

ditussin hc 98<br />

divalproex sodium 65<br />

divalproex 65<br />

dixaphedrine 10<br />

DM TANN/PE TANN/BROM TANN 98<br />

dm-pe-chlor 98<br />

dm-pot guaiacolsulfonate 98<br />

dm/guai 98<br />

DMAX PEDIATRIC 98<br />

DMAX 98<br />

dobutamine hcl 35<br />

dobutamine in d5w 35<br />

dolacet 54<br />

dolagesic 54<br />

dolorex forte 54<br />

dolorex 60<br />

dolotic 137<br />

dometuss cough/cold 98<br />

dometuss dm 98<br />

DONATUSS DC 98<br />

DONATUSS XP 98<br />

donatussin dc 98<br />

DONATUSSIN DM 98<br />

DONATUSSIN MAX 98<br />

donatussin 127<br />

donnaphen 33<br />

dopamine hcl 35<br />

dopamine in d5w 35<br />

DOPAMINE 35<br />

DORIBAX 20<br />

DORYX 25<br />

dorzolamide hcl 139<br />

dorzolamide 139<br />

DOVONEX 167<br />

doxapram hcl 73<br />

doxazosin mesylate 45<br />

doxazosin mesylate 46<br />

doxazosin 45<br />

DOXEPIN HCL 68<br />

doxepin hcl 68<br />

DOXIL 30<br />

doxorubicin hcl 30<br />

doxy-caps 25<br />

doxycyc mono 25<br />

DOXYCYCL HYC CAP 25<br />

doxycycl hyc 25<br />

DOXYCYCLINE (MONOHYDRATE) 25<br />

doxycycline (monohydrate) 25<br />

DOXYCYCLINE CALCIUM 25<br />

DOXYCYCLINE HYCLATE 25<br />

doxycycline hyclate 25<br />

doxycycline 25<br />

doxylamine-dm 98<br />

doxylamine-phenylephrineacetaminophen<br />

2<br />

doxylamine-pseudoephedrine-apap 2<br />

DOXYLAMINE-PSEUDOEPHEDRINE-<br />

APAP 3<br />

dr lancets 178<br />

dr thin lancets 178<br />

drihist sr 10<br />

DRINEX 10<br />

drinex 10<br />

dristan cold non-drowsy 36<br />

dristan cold 10<br />

dristan sinus 36<br />

DRITHO-CREME HP 167<br />

DRITHO-SCALP 167<br />

drituss dm 98<br />

drituss hd 98<br />

drixomed 11<br />

DRIXORAL ALLERGY SINUS 11<br />

DRIXORAL COLD/FLU 11<br />

DRIXORAL COUGH & SORE THR 98<br />

DROCON-CS 98<br />

droperidol 75<br />

DROSPIRENONE-ETHINYL ESTRADIOL<br />

146<br />

drospirenone-ethinyl estradiol 146<br />

drotuss-cp 98<br />

drotuss 98<br />

DRUG EMP STARTER KIT 178<br />

DRUG EMPORIUM TEST STRIPS 80<br />

drug mart lancets thin 190<br />

drug mart lancets ultra t 190<br />

drug mart ultra comfort i 180<br />

drug mart ultra comfort i 181<br />

drug mart ultra comfort i 182<br />

drug mart ultra comfort i 184<br />

drug mart ultra comfort i 186<br />

drug mart ultra comfort i 187<br />

DRYMAX 11<br />

created on 20100520 213


dryphen 11<br />

drysec 11<br />

DTP ADSORBED 156<br />

duane reade lancet altern 189<br />

duane reade lancet super 189<br />

duane reade lancet ultra 189<br />

DUANE READE STARTER KIT 178<br />

DUANE READE TEST STRIPS 80<br />

DUANE READE UNIFINE PENTI 194<br />

DUO-CARE TEST STRIPS 80<br />

DUOCAINE 154<br />

DUOHIST DH 98<br />

duomax 127<br />

DUOTAN PD 11<br />

DUOVISC 140<br />

dur-tann dm 98<br />

dur-tann forte 98<br />

DURACLON 44<br />

DURADEX FORTE 98<br />

duradrin 77<br />

duradryl sr 11<br />

duradryl 11<br />

DURAMAX 98<br />

DURASAFE SPINAL/EPIDURAL 155<br />

duratan pe 11<br />

DURATUSS A 127<br />

DURATUSS AC 12 98<br />

DURATUSS CS 98<br />

duratuss da 11<br />

DURATUSS DM 12 98<br />

DURATUSS PE 127<br />

duravent-da 11<br />

duravent-dpb 98<br />

duravent 11<br />

DURAXIN 60<br />

duraxin 60<br />

DUREZOL 136<br />

DYGASE 141<br />

DYNACIRC CR 47<br />

DYNAHIST ER 11<br />

dynatuss ex 98<br />

dynatuss hc 98<br />

dynatuss 98<br />

DYNEX 12 98<br />

DYNEX VR 98<br />

DYNEX 127<br />

DYSPORT 174<br />

DYTAN-CS 98<br />

DYTAN-HC 98<br />

E<br />

e-z ject blood lancets 178<br />

e-z ject lancets color 178<br />

e-z ject lancets super th 178<br />

e-z ject lancets thin 178<br />

e-z ject lancets 178<br />

e-z ject thin 178<br />

e-z ject xl blood lancets 178<br />

E-Z SPACER MASK 178<br />

E-Z SPACER/MASK 178<br />

E-Z SPACER 178<br />

E.E.S. GRAN 20<br />

e.e.s. 20<br />

e.s.p. 20<br />

ear drops 137<br />

EASIVENT/MASK-LARGE 178<br />

EASIVENT/MASK-MEDIUM 178<br />

EASIVENT/MASK-SMALL 178<br />

EASIVENT 178<br />

EASY CHECK BLOOD GLUCOSE 178<br />

EASY CHECK GLUCOSE TEST S 80<br />

easy comfort insulin syri 181<br />

easy comfort insulin syri 184<br />

easy comfort insulin syri 187<br />

EASY STEP BLOOD GLUCOSE M 178<br />

EASY STEP TEST STRIPS 80<br />

easy touch insulin syring 181<br />

easy touch insulin syring 182<br />

easy touch insulin syring 183<br />

easy touch insulin syring 184<br />

easy touch insulin syring 185<br />

easy touch insulin syring 186<br />

easy touch insulin syring 187<br />

easy touch insulin syring 188<br />

easy touch lancets 178<br />

EASY TOUCH PEN NEEDLES 29 178<br />

EASY TOUCH PEN NEEDLES 31 179<br />

EASY TOUCH PEN NEEDLES/31 179<br />

easy twist & cap lancets 190<br />

EASYGLUCO VALUE PACK 179<br />

EASYGLUCO 179<br />

EASYGLUCO 80<br />

EASYMAX N BLOOD GLUCOSE S 179<br />

EASYMAX TEST STRIPS 80<br />

EASYMAX V BLOOD GLUCOSE S 179<br />

EASYPRO BLOOD GLUCOSE MON 179<br />

EASYPRO BLOOD GLUCOSE TES 80<br />

EASYPRO PLUS 179<br />

EASYPRO PLUS 80<br />

easytest ii lancets 179<br />

easytest lancets 179<br />

ECK A-PHEDRIN 4<br />

eck acetamin 60<br />

ECK BLOOD GLUCOSE MONITOR 177<br />

ECK BLOOD GLUCOSE TEST ST 80<br />

eck bromtapp cold/allergy 6<br />

eck bromtapp dm 98<br />

eck child cold 92<br />

eck child na flu 98<br />

eck childrens non-aspirin 60<br />

eck flu non-drowsy 100<br />

eck ibuprofe 52<br />

eck ibuprofen cold/sinus 36<br />

eck infant cold 36<br />

eck insulin syringe/0.3ml 181<br />

eck insulin syringe/0.5ml 183<br />

eck insulin syringe/0.5ml 184<br />

eck insulin syringe/1ml/2 186<br />

eck insulin syringe/1ml/3 187<br />

eck loratadine disintegra 17<br />

eck loratadine 17<br />

eck max n-d cold/flu 98<br />

eck night time 106<br />

eck nighttime cold & coug 106<br />

eck nighttime cold formul 106<br />

eck non-asa 60<br />

eck non-aspirin allergy s 11<br />

eck non-aspirin allergy s 5<br />

eck non-aspirin pain reli 76<br />

eck non-aspirin severe co 98<br />

eck non-aspirin sinus max 37<br />

eck non-aspirin sinus rel 37<br />

eck pediatric cough/cold 108<br />

eck pms pain relief multi 60<br />

eck prenatal 170<br />

eck severe cold 119<br />

eck sinus headache maximu 36<br />

eck sinus 11<br />

eck su-phedrin maximum st 37<br />

eck su-phedrin multi-symp 120<br />

eck suphedrine cold/aller 15<br />

eck supherine non-dry 133<br />

eck thin lancets 179<br />

eck tri acting chest cong 133<br />

eck tri acting cold & all 15<br />

created on 20100520 214


eck tri acting sore throa 121<br />

eck tussin cf 99<br />

eck tussin cold/cough 98<br />

eck tussin dm 123<br />

eck tussin pe 127<br />

eck tussin pediatric coug 123<br />

eck tussin severe congest 127<br />

ECLIPSE BLOOD GLUCOSE MON 179<br />

ECLIPSE TEST STRIPS 80<br />

ED A-HIST 11<br />

ed a-hist 11<br />

ED CHLORPED D 11<br />

ED DM 99<br />

ed k+ 84<br />

ed-a-hist dm 99<br />

ed-apap 60<br />

ed-flex 60<br />

ed-tlc 99<br />

ed-tuss hc 99<br />

edetate disodium 144<br />

EDEX 45<br />

edrophonium chloride 82<br />

effervescent plus cold 11<br />

effervescent pot chloride 85<br />

effervescent potassium/ch 85<br />

EFFEXOR XR 66<br />

ELAPRASE 88<br />

ELECTROLYTE-48 84<br />

electrolyte-75 in dextrose 84<br />

electrolyte-m in dextrose 84<br />

electrolyte-r in dextrose 84<br />

electrolyte-r 84<br />

ELEMENT AUTOCODE SYSTEM 179<br />

ELEMENT TEST STRIPS 80<br />

ELETRIPTAN HYDROBROMIDE 76<br />

ELETRIPTAN HYDROBROMIDE 77<br />

ELIDEL 167<br />

ELIGARD 30<br />

ELIPHOS 84<br />

ELITE-THIN INSULIN SYRING 182<br />

elite-thin insulin syring 182<br />

elite-thin insulin syring 183<br />

elite-thin insulin syring 184<br />

elite-thin insulin syring 185<br />

elite-thin insulin syring 186<br />

elite-thin insulin syring 187<br />

elite-thin insulin syring 188<br />

ELITEK 88<br />

ELIXOPHYLLIN 167<br />

ELIXSURE COUGH 99<br />

ELIXSURE FEVER/PAIN 60<br />

ELLIOTTS B 84<br />

ELOXATIN 30<br />

ELSPAR 30<br />

EMBRACE BLOOD GLUCOSE MON 179<br />

EMBRACE BLOOD GLUCOSE TES 80<br />

emcin clear 158<br />

EMEND 142<br />

enalapril maleate 49<br />

enalaprilat 49<br />

ENBREL SRCLK 173<br />

ENBREL 173<br />

endacof-ac 99<br />

endacof-c 99<br />

endacof-dc 99<br />

endacof-dh 99<br />

endacof-dm 99<br />

endacof-hc 99<br />

endacof-pd 99<br />

endacof-plus 99<br />

endacof-tab 99<br />

endacof-xp 99<br />

endacon-dm 99<br />

ENDACON 99<br />

ENDAL CD 99<br />

endocet 54<br />

endodan 54<br />

ENDRATE 144<br />

ENFALYTE 84<br />

ENGERIX-B 156<br />

ENGYSTOL 174<br />

ENLON-PLUS 33<br />

ENLON 82<br />

enpresse-28 146<br />

ENTEX ER 127<br />

ENTEX HC 99<br />

entex la 127<br />

entex pse 127<br />

entre-b 11<br />

entre-s 99<br />

enulose 83<br />

ENVISION AUTOCODE TEST ST 80<br />

ENVISION AUTOCODE 179<br />

ENZYCAP 141<br />

ENZYMAX 141<br />

ephedrine sulfate (pressors) 36<br />

EPHEDRINE W/ ASPIRIN-CAFFEINE-<br />

ACETANILID 36<br />

EPHEDRINE-GUAIFENESIN 127<br />

ephedrine-guaifenesin 127<br />

ephrine nose 138<br />

epidrin 77<br />

EPIFOAM 163<br />

epinephrine hcl 36<br />

EPINEPHRINE 36<br />

EPIPEN 2-PAK 36<br />

EPIPEN-JR 2-PAK 36<br />

EPIPEN-JR 36<br />

EPIPEN 36<br />

epirubicin hcl 31<br />

EPIRUBICIN 30<br />

epitol 65<br />

EPIVIR HBV 28<br />

EPIVIR 28<br />

EPOGEN 42<br />

epoprostenol sodium 45<br />

eq allergy sinus maximum 11<br />

eq allergy/sinus headache 1<br />

eq allergy/sinus 1<br />

eq antihistabs 5<br />

eq arthritis 60<br />

eq childrens cold 11<br />

EQ COLD PLUS COUGH CHILDR 99<br />

eq cold plus cough childr 99<br />

eq cold plus 11<br />

eq cold relief complete 93<br />

eq cold relief convenienc 99<br />

eq cold relief 99<br />

eq cold/allergy childrens 9<br />

eq cold/cough dm 94<br />

EQ COLD/COUGH PLUS 94<br />

eq dayhist 2<br />

eq daytime cold/flu relie 99<br />

eq effervescent cold plus 11<br />

eq flu relief 100<br />

eq flu/severe cold/conges 99<br />

eq heartburn relief 142<br />

eq ibuprofen cold childre 36<br />

eq ibuprofen cold/sinus 36<br />

eq infants cold plus coug 99<br />

eq medicated chest rub 174<br />

eq night time cough 106<br />

eq nite time cold/flu rel 99<br />

eq non-drying sinus 127<br />

created on 20100520 215


eq nose drops extra stren 138<br />

eq pain reliever junior 62<br />

eq pain reliever pm 76<br />

eq sinus maximum strength 37<br />

eq sinus relief maximum s 36<br />

eq triacting cold/allergy 11<br />

eq triacting cold/cough 99<br />

eq triacting cough/sore t 99<br />

eq triacting night time 99<br />

eq tussin cf 99<br />

eq tussin cold/congestion 99<br />

eq tussin dm 99<br />

eq tussin 127<br />

eql acetamin 60<br />

eql acetamin 61<br />

eql all day allergy 17<br />

eql allergy/sinus headach 1<br />

eql arthrits 61<br />

eql childrens pain relief 7<br />

eql cold & allergy 9<br />

eql cold & cough 99<br />

eql cold/allergy children 9<br />

eql color lancets 21g 179<br />

eql cough/cold/flu relief 92<br />

eql dayhist 2<br />

eql daytime cold/flu reli 99<br />

eql daytime multi-symptom 99<br />

eql effervescent plus col 11<br />

eql flu/cold/cough night 99<br />

EQL FLU/SEVERE COLD/CONGE 99<br />

eql flu/severe cold/conge 99<br />

eql headache pm 75<br />

eql ibuprofen cold childr 36<br />

eql ibuprofen cold/sinus 36<br />

eql infant 61<br />

EQL INFANTS DECONGESTANT/ 99<br />

eql infants pain relief p 99<br />

eql insulin syringe/0.3ml 181<br />

eql insulin syringe/0.3ml 182<br />

eql insulin syringe/0.5ml 183<br />

eql insulin syringe/0.5ml 184<br />

eql insulin syringe/0.5ml 185<br />

eql insulin syringe/1ml/2 186<br />

eql insulin syringe/1ml/3 187<br />

eql insulin syringe/1ml/3 188<br />

eql insulin syringe/u-100 181<br />

eql insulin syringe/u-100 183<br />

eql insulin syringe/u-100 184<br />

eql insulin syringe/u-100 186<br />

eql insulin syringe/u-100 187<br />

eql multi-symptom nightti 99<br />

eql night time cold/flu r 106<br />

eql night time cough 106<br />

eql nighttime cold/flu re 106<br />

eql non-drying sinus 127<br />

eql pain relief allergy m 11<br />

eql pain relief chest con 127<br />

eql pain relief plus cold 107<br />

eql pain relief plus flu 99<br />

eql pain relief pm 76<br />

eql pain relief/allergy s 12<br />

eql pain relief/cold 107<br />

eql pain relief/sinus 37<br />

eql prenatal formula 170<br />

eql severe cold/flu 99<br />

eql severe cold 119<br />

EQL SHORT PEN NEEDLES 31G 192<br />

eql sinus congestion & pa 34<br />

eql sinus headache maximu 36<br />

eql sinus/allergy 11<br />

eql super thin lancets 30 179<br />

eql thin lancets 26g 179<br />

eql triacting chest/nasal 126<br />

eql triacting cold/allerg 11<br />

eql triacting cold/cough/ 121<br />

eql triacting cold/cough 99<br />

eql triacting cold/night 121<br />

eql tussin cf cough/cold/ 99<br />

eql tussin cough/chest co 123<br />

eql tussin cough/cold max 99<br />

eql tussin dm cough/chest 99<br />

eql tussin ped cough/cold 99<br />

eql tussin 127<br />

eql tussin 99<br />

EQL ULTRA SHORT PEN NEEDL 191<br />

equate regular lancets 179<br />

equate thin lancets 179<br />

ERAXIS 27<br />

ERBITUX 31<br />

ergocalciferol 169<br />

ergotamine tartrate/caffe 77<br />

ERGOTAMINE W/ CAFFEINE 77<br />

ergotamine w/ caffeine 77<br />

ERGOTRATE 155<br />

errin 146<br />

ERY-TAB 20<br />

ery-tab 20<br />

ERY-TAB 21<br />

ery-tab 21<br />

ery 158<br />

eryderm 158<br />

ERYPED 21<br />

ERYTHROCIN 21<br />

erythrocin 21<br />

erythrom eth 21<br />

ERYTHROM ST 21<br />

erythrom st 21<br />

erythromycin (acne aid) 158<br />

erythromycin (ophth) 135<br />

ERYTHROMYCIN BASE 21<br />

erythromycin base 21<br />

ERYTHROMYCIN ETHYLSUCCINATE<br />

21<br />

erythromycin ethylsuccinate 21<br />

ERYTHROMYCIN STEARATE 21<br />

erythromycin stearate 21<br />

erythromycin-sulfisoxazole 21<br />

erythromycin/benzoyl pero 158<br />

erythromycin/sulfisoxazol 20<br />

erythromycin 135<br />

erythromycin 158<br />

ERYTHROMYCIN 21<br />

erythromycin 21<br />

ESCITALOPRAM OXALATE 67<br />

esmolol hcl 46<br />

estazolam 74<br />

estradiol valerate 147<br />

ESTRADIOL 147<br />

ethambutol hcl 27<br />

ethambutol 27<br />

ETHAMOLIN 45<br />

ethexderm bpw-10 161<br />

ethexderm bpw-5 161<br />

ETHIODOL 82<br />

ethosuximide 65<br />

etodolac er 52<br />

etodolac 51<br />

etodolac 52<br />

etomidate 51<br />

ETONOGESTREL-ETHINYL ESTRADIOL<br />

146<br />

ETOPOPHOS 31<br />

ETOPOSIDE 31<br />

etoposide 31<br />

created on 20100520 216


EUCALYPTOL 127<br />

EUFLEXXA 174<br />

EVENCARE + BLOOD GLUCOSE 80<br />

EVENCARE BLOOD GLUCOSE MO 179<br />

EVENCARE BLOOD GLUCOSE TE 80<br />

EVOLUTION AUTOCODE 179<br />

EVOLUTION AUTOCODE 80<br />

ex str apap 75<br />

ex-dec-tr 2<br />

EXACTECH R-S-G TEST STRIP 80<br />

EXACTECH TEST STRIPS 80<br />

EXALL-D 99<br />

EXALL 99<br />

EXCEDRIN MIGRAINE 51<br />

EXCEL G TEST STRIPS 80<br />

excof-sf 99<br />

excof 99<br />

execlear-c 99<br />

execlear-dm 99<br />

execlear 99<br />

execof-xp 99<br />

execof 99<br />

exefen dmx 99<br />

exefen-dm 99<br />

exefen-dmx 99<br />

exefen-ir 127<br />

exefen-pd 127<br />

exefen 127<br />

EXEL INSULIN PEN NEEDLES 180<br />

EXEL INSULIN PEN NEEDLES 191<br />

exel insulin syringe/0.3m 181<br />

exel insulin syringe/0.5m 182<br />

exel insulin syringe/0.5m 183<br />

exel insulin syringe/0.5m 184<br />

exel insulin syringe/1ml/ 186<br />

exel insulin syringe/1ml/ 187<br />

exetuss-dm 99<br />

exetuss-gp 127<br />

exetuss-hc 99<br />

exetuss 127<br />

exp cough ct 127<br />

EXPECTUSS 100<br />

EXPRESS MED STARTER KIT 179<br />

EXPRESS MED TEST STRIP PA 80<br />

exratuss 100<br />

EXTAVIA 172<br />

extendryl g 127<br />

extendryl gcp 100<br />

EXTENDRYL HC 100<br />

EXTENDRYL PEM 34<br />

extendryl pse 36<br />

EXTENDRYL SR 11<br />

extendryl sr 11<br />

EXTENDRYL 11<br />

extra strength pain relie 61<br />

extuss la 100<br />

extussive 100<br />

EXUBERA COMBINATION PACK 148<br />

EXUBERA KIT 148<br />

EXUBERA PATIENT PACK 148<br />

ez smart blood glucose la 179<br />

EZ SMART BLOOD GLUCOSE TE 80<br />

EZ SMART DIABETES MONITOR 179<br />

EZ SMART PLUS BLOOD GLUCO 80<br />

EZ SMART PLUS DIABETES MO 179<br />

ez-lets lancets 21g 179<br />

ez-lets lancets 23g 179<br />

ez-lets lancets 26g 179<br />

ez-lets lancets 28g 179<br />

ez-lets lancets 179<br />

F<br />

FABRAZYME 88<br />

FACTREL 82<br />

famotidine in nacl 142<br />

famotidine 142<br />

farbital 51<br />

FASLODEX 31<br />

FASTTAKE COMPACT MONITORI 179<br />

FASTTAKE TEST STRIPS 80<br />

fat emulsion 87<br />

FATHER JOHNS MEDICINE PLU 100<br />

father johns 100<br />

FAZACLO 69<br />

FAZACLO 70<br />

FEBROL 61<br />

FEEDING TUBES - SETS 176<br />

FEEDING TUBES - TUBING 176<br />

FEIBA NF 42<br />

FEIBA VH IMMUNO 42<br />

felodipine 47<br />

FEMCAP 78<br />

FENESIN DM IR 100<br />

fenesin ir 127<br />

fenesin pe ir 127<br />

fenoldopam mesylate 45<br />

FENTANYL CITRATE/ROPIVAC 54<br />

FENTANYL CITRATE/ROPIVACA 54<br />

fentanyl citrate 54<br />

FENTANYL/BUPIVACAINE/NS 54<br />

FENTANYL/NS 54<br />

feogen 39<br />

FERAHEME 39<br />

FERIDEX I.V. 82<br />

ferocon 39<br />

ferotrin 39<br />

ferotrinsic 39<br />

ferragen 39<br />

ferrex 150 forte 39<br />

FERRLECIT 39<br />

ferrous fumarate w/ b12-vit c-fa-ifc 39<br />

FETRIN 39<br />

FEVERALL INF 61<br />

FEVERALL SPRINKLE CAPS CH 61<br />

FEVERALL SPRINKLE CAPS JU 61<br />

feverall 61<br />

FEXMID 38<br />

fexofenadine hcl 17<br />

FEXOFENADINE-PSEUDOEPHEDRINE<br />

17<br />

fexofenadine-pseudoephedrine 17<br />

fexofenadine/pseudoephedr 17<br />

fexofenadine 17<br />

FIFTY50 GLUCOSE METER 2.0 179<br />

FIFTY50 GLUCOSE TEST STRI 80<br />

fifty50 safety seal lance 179<br />

fingerstix lancets 179<br />

FIRMAGON 31<br />

first choice ins syringe/ 182<br />

first choice insulin syri 180<br />

first choice insulin syri 183<br />

first choice insulin syri 184<br />

first choice insulin syri 186<br />

first choice insulin syri 187<br />

first choice lancets colo 179<br />

first choice lancets thin 179<br />

FLEBOGAMMA DIF 155<br />

FLEBOGAMMA 155<br />

FLECAINIDE ACETATE 44<br />

FLECAINIDE 44<br />

FLEXIFLO LAP J LAPAROSCOP 179<br />

FLEXIFLO OVER-THE-GUIDEWI 179<br />

FLEXTRA 2<br />

FLOVENT HFA 145<br />

floxuridine 31<br />

created on 20100520 217


flu bp maximum strength 100<br />

flu cold & cough medicine 100<br />

FLU FORMULA 100<br />

flu relief therapy daytim 100<br />

flu relief therapy nightt 2<br />

flu,cold & cough 100<br />

FLU/COLD MEDICINE 11<br />

flu/cold/cough medicine m 100<br />

flu/cold/cough medicine 100<br />

flu/cough/cold maximum st 100<br />

flu/cough/cold nite 100<br />

flu/severe cold daytime 34<br />

FLUARIX 2005-2006 156<br />

FLUARIX 2006-2007 156<br />

FLUARIX 2007-2008 156<br />

FLUARIX 2008-2009 156<br />

FLUARIX 2009-2010 156<br />

fluconazole in dextrose 26<br />

fluconazole in nacl 26<br />

FLUCONAZOLE IN NACL 27<br />

fluconazole 26<br />

fludarabine phosphate 31<br />

fludrocort 145<br />

fludrocortisone acetate 145<br />

FLULAVAL 2008-2009 157<br />

FLULAVAL 2009-2010 157<br />

FLULAVAL 157<br />

flumazenil 77<br />

FLUNISOLIDE (NASAL) 136<br />

flunisolide (nasal) 136<br />

FLUNISOLIDE 136<br />

flunisolide 136<br />

FLUNISOLIDE 145<br />

FLUOCIN ACET 163<br />

fluocin acet 163<br />

FLUOCINOLONE ACETONIDE 163<br />

fluocinolone acetonide 163<br />

FLUOCINONIDE 163<br />

fluocinonide 163<br />

fluor-op 136<br />

fluorescein sodium injection 82<br />

fluoromethol 136<br />

FLUOROMETHOLONE (OPHTH) 136<br />

fluorometholone (ophth) 136<br />

FLUOROPLEX 167<br />

FLUOROURACIL (TOPICAL) 167<br />

fluorouracil (topical) 167<br />

fluorouracil 167<br />

fluorouracil 31<br />

FLUOXETINE HCL (PMDD) 67<br />

fluoxetine hcl (pmdd) 67<br />

fluoxetine hcl 66<br />

FLUOXETINE HCL 67<br />

fluoxetine hcl 67<br />

fluoxetine 66<br />

fluoxetine 67<br />

fluphenazine decanoate 71<br />

FLUPHENAZINE HCL 71<br />

fluphenazine hcl 71<br />

FLUPHENAZINE 71<br />

fluphenazine 71<br />

flurazepam hcl 74<br />

flurazepam hcl 75<br />

flurazepam 74<br />

flurbiprofen sodium 137<br />

flurbiprofen 137<br />

flutabs 100<br />

FLUTICASONE PROPIONATE HFA 145<br />

fluticasone propionate (nasal) 136<br />

fluticasone propionate 136<br />

FLUTICASONE-SALMETEROL 35<br />

FLUVIRIN 2005-2006 157<br />

FLUVIRIN 2006-2007 157<br />

FLUVIRIN 2007-2008 157<br />

FLUVIRIN 2008-2009 157<br />

FLUVIRIN 2009-2010 157<br />

FLUZONE HIGH-DOSE PF 2009 157<br />

FLUZONE PEDIATRIC PF 2005 157<br />

FLUZONE PEDIATRIC PF 2006 157<br />

FLUZONE PEDIATRIC PF 2007 157<br />

FLUZONE PEDIATRIC PF 2008 157<br />

FLUZONE PEDIATRIC PF 2009 157<br />

FLUZONE PF 2005-2006 157<br />

FLUZONE PF 2006-2007 157<br />

FLUZONE PF 2007-2008 157<br />

FLUZONE PF 2008-2009 157<br />

FLUZONE PF 2009-2010 157<br />

FLUZONE SPLIT 2005-2006 157<br />

FLUZONE SPLIT 2006-2007 157<br />

FLUZONE SPLIT 2007-2008 157<br />

FLUZONE SPLIT 2008-2009 157<br />

FLUZONE SPLIT 2009-2010 157<br />

FML FORTE 136<br />

FML 136<br />

FOCALIN XR 73<br />

FOLIC ACID 168<br />

FOLLISTIM AQ 147<br />

FOLOTYN 31<br />

foltrin 39<br />

FORA D10 BLOOD GLUCOSE TE 80<br />

FORA D15C BLOOD GLUCOSE T 80<br />

FORA D15G BLOOD GLUCOSE T 80<br />

FORA D15Z BLOOD GLUCOSE T 80<br />

FORA G20 BLOOD GLUCOSE MO 179<br />

FORA G20 BLOOD GLUCOSE TE 80<br />

FORA V10 BLOOD GLUCOSE MO 179<br />

FORA V10 BLOOD GLUCOSE TE 80<br />

FORA V12 BLOOD GLUCOSE MO 179<br />

FORA V12 BLOOD GLUCOSE TE 80<br />

FORA V20 BLOOD GLUCOSE MO 179<br />

FORA V20 BLOOD GLUCOSE TE 80<br />

FORA V22 BLOOD GLUCOSE MO 179<br />

FORA V22 BLOOD GLUCOSE TE 80<br />

FORADIL AEROLIZER 35<br />

FORMOTEROL FUMARATE 35<br />

formula d 100<br />

fortabs 51<br />

FORTAZ 19<br />

FORTEO 150<br />

FOSCARNET 29<br />

fosinopril sodium 49<br />

fosphenytoin sodium 64<br />

fp insulin syringe/0.3ml/ 180<br />

fp insulin syringe/0.3ml/ 181<br />

fp insulin syringe/0.3ml/ 182<br />

fp insulin syringe/0.5ml/ 182<br />

fp insulin syringe/0.5ml/ 183<br />

fp insulin syringe/0.5ml/ 184<br />

fp insulin syringe/0.5ml/ 185<br />

fp insulin syringe/1ml/30 187<br />

fp insulin syringe/1ml/31 188<br />

fp insulin syringe/u-100/ 180<br />

fp insulin syringe/u-100/ 181<br />

fp insulin syringe/u-100/ 182<br />

fp insulin syringe/u-100/ 183<br />

fp insulin syringe/u-100/ 184<br />

fp insulin syringe/u-100/ 186<br />

fp insulin syringe/u-100/ 187<br />

fp lancets super thin 189<br />

fp lancets thin 179<br />

fp lancets 179<br />

fp multi-symptom pms 61<br />

FRAGMIN 40<br />

FREAMINE HBC 6.9% 87<br />

created on 20100520 218


FREAMINE III 3% 87<br />

FREAMINE III 8.5%/DEXTROS 87<br />

FREAMINE III 87<br />

FREESTYLE FLASH SYSTEM 179<br />

FREESTYLE FREEDOM LITE 179<br />

FREESTYLE FREEDOM 179<br />

freestyle lancets 179<br />

FREESTYLE LITE BLOOD GLUC 179<br />

FREESTYLE LITE TEST STRIP 80<br />

FREESTYLE SIDEKICK II VAL 179<br />

FREESTYLE SYSTEM KIT 179<br />

FREESTYLE TEST STRIPS 80<br />

freestyle unistick ii lan 179<br />

FRENADOL 61<br />

FURADANTIN 29<br />

furosemide 87<br />

FUZEON 27<br />

G<br />

g p tex 127<br />

g phen dm 100<br />

g-bid dm 100<br />

g-fen dm 100<br />

g-fen ex 127<br />

g-phed-pd 127<br />

g-phed 127<br />

g/p 1200/60 127<br />

G/P 127<br />

GALIUM-HEEL 174<br />

GAMASTAN S/D 155<br />

GAMMAGARD LIQUID 155<br />

GAMMAGARD S/D IGA LESS TH 155<br />

GAMMAGARD S/D 155<br />

GAMMAGARD 155<br />

GAMMAPLEX 155<br />

GAMUNEX 155<br />

GANCICLOVIR 29<br />

ganciclovir 29<br />

gani-tuss dm nr 100<br />

gani-tuss nr 100<br />

ganidin nr 127<br />

GANITE 172<br />

GARDASIL 157<br />

gauifenesin/pseudoephedri 101<br />

gdp-ex 100<br />

GEMZAR 31<br />

genac 11<br />

genacol maximum strength 100<br />

genantuss 100<br />

genantussidex 100<br />

genapap extra strength 61<br />

genapap sinus maximum str 36<br />

genapap 61<br />

genaphed plus 11<br />

GENARC 42<br />

genatuss dm 100<br />

gene-t-press 100<br />

genebrom dm 100<br />

GENEBRONCO-D 100<br />

genebs 61<br />

GENECOF-HC 100<br />

genecof-hc 100<br />

GENECOF-XP 100<br />

genecof-xp 100<br />

GENEDEL 100<br />

genedotuss-dm 100<br />

GENEPATUSS 100<br />

generic entex la 127<br />

generlac 83<br />

genetuss-2 100<br />

genetuss 100<br />

GENEXA LA 127<br />

GENEXPECT DM 100<br />

GENEXPECT-PE 100<br />

GENEXPECT-SF 100<br />

gengraf 173<br />

genoptic 135<br />

GENOTROPIN 151<br />

genta 135<br />

gentacidin 135<br />

gentak 135<br />

gentamicin in saline 17<br />

gentamicin sulfate (ophth) 135<br />

gentamicin sulfate (topical) 158<br />

GENTAMICIN SULFATE/0.9% S 17<br />

gentamicin sulfate 17<br />

GENTAMICIN-PREDNISOLONE<br />

ACETATE 136<br />

gentamicin 135<br />

gentamicin 158<br />

GENTEX HC 100<br />

GENTEX LA 127<br />

gentex-lq 100<br />

gentle touch insulin syri 182<br />

gentle touch insulin syri 183<br />

gentle touch insulin syri 186<br />

gentle-let gp lancets 179<br />

gentle-let lancets genera 179<br />

gentle-let lancets safety 179<br />

GEODON 70<br />

GEREF DIAG 82<br />

geri-tussin dm 100<br />

geri-tussin 127<br />

gestuss-hc 100<br />

GFN 1000/DM 50 100<br />

gfn 1000/dm 60 100<br />

gfn 1200/dm 20/pe 40 100<br />

gfn 1200/dm 60/pse 120 101<br />

gfn 1200/dm 60 100<br />

gfn 1200/phenylephrine 40 127<br />

gfn 1200/pse 50 127<br />

gfn 500/dm 30 101<br />

GFN 550/PSE 60/DM 30 101<br />

GFN 550/PSE 60 127<br />

gfn 595/pse 48/dm 32 101<br />

gfn 595/pse 48 127<br />

gfn 600/phenylephrine 20 127<br />

gfn 600/phenylephrine 40 127<br />

gfn 795/pse 85 127<br />

gfn 800/dm 30 101<br />

gfn 800/pe 25 127<br />

gfn 800/pse 60/dm 30 101<br />

GFN 800/PSE 60 127<br />

GFN/DM/PSE 100<br />

gfn/pse 127<br />

gfn600/pse60/dm30 sa 101<br />

gg 200 nr 127<br />

gg/pse/cod 101<br />

giant eagle lancets color 190<br />

giant eagle lancets 189<br />

GIANT EAGLE PHARMACY TEST 80<br />

GIANT EAGLE PHARMACY VALU 179<br />

GILPHEX TR 128<br />

GILTUSS HC 101<br />

GILTUSS PED-C 101<br />

GILTUSS PEDIATRIC 101<br />

GILTUSS TR 101<br />

GILTUSS 101<br />

glimepiride 149<br />

glipizide er 149<br />

glipizide er 150<br />

glipizide xl 150<br />

glipizide 149<br />

GLIPIZIDE 150<br />

glipizide 150<br />

created on 20100520 219


GLOFIL-125 82<br />

GLUCAGEN HYPOKIT 150<br />

GLUCAGEN 150<br />

GLUCAGON (RDNA) 150<br />

glucagon (rdna) 150<br />

GLUCAGON 150<br />

glucagon 150<br />

GLUCOCARD 01 BLOOD GLUCOS 179<br />

GLUCOCARD 01 SENSOR 80<br />

GLUCOCARD 01 TEST STRIPS 80<br />

GLUCOCARD 01-MINI BLOOD G 179<br />

GLUCOCARD VITAL BLOOD GLU 179<br />

GLUCOCARD VITAL TEST STRI 80<br />

GLUCOCARD X-METER 179<br />

GLUCOCARD X-SENSOR 80<br />

GLUCOCOM BLOOD GLUCOSE MO 179<br />

GLUCOCOM BLOOD GLUCOSE MO 180<br />

glucocom lancets 28g 179<br />

glucocom lancets 30g 179<br />

glucocom lancets 33g 179<br />

GLUCOCOM TEST STRIPS 80<br />

GLUCOFILM TEST STRIPS 80<br />

GLUCOLAB BLOOD GLUCOSE MO 180<br />

GLUCOLAB TEST STRIPS 80<br />

GLUCOMETER DEX TEST SENSO 80<br />

GLUCOMETER ELITE CLASSIC 180<br />

GLUCOMETER ELITE 80<br />

GLUCOMETER ENCORE QA+ SYS 180<br />

GLUCOMETER ENCORE TEST ST 80<br />

glucopro insulin syringe/ 181<br />

glucopro insulin syringe/ 182<br />

glucopro insulin syringe/ 184<br />

glucopro insulin syringe/ 185<br />

glucopro insulin syringe/ 187<br />

glucopro insulin syringe/ 188<br />

GLUCOSE BLOOD 80<br />

glucosource lancets 180<br />

GLUCOSTIX 80<br />

GLUCOTROL XL 150<br />

glyburid mcr 150<br />

glyburide micronized 150<br />

GLYBURIDE 150<br />

glycine diluent 195<br />

glycopyrrolate 33<br />

glycron 150<br />

GLYOXAL COMPOSITUM 174<br />

gnp acetamin 61<br />

gnp acne 161<br />

gnp all day allergy 17<br />

gnp allergy & sinus heada 1<br />

gnp allergy multi-symptom 11<br />

gnp allergy sinus pe day 11<br />

gnp cgh relf 101<br />

gnp childrens di bromm co 11<br />

gnp childrens di bromm dm 101<br />

gnp childrens ibuprofen c 36<br />

gnp childrens pain relief 107<br />

gnp childrens plus cough 101<br />

GNP CLICKFINE UNIVERSAL P 178<br />

gnp cold & allergy childr 11<br />

gnp cold & allergy pe 9<br />

gnp cold & cough children 101<br />

gnp cold head congestion 101<br />

gnp cold head congestion 93<br />

gnp cold multi-symptom da 93<br />

gnp cold multi-symptom ni 93<br />

gnp cold severe congestio 101<br />

gnp color lancets 180<br />

gnp complete cold & flu r 101<br />

gnp cough & sore throat d 101<br />

gnp cough & sore throat n 101<br />

gnp day time cold/flu rel 101<br />

gnp day time cold/flu 101<br />

gnp day time d cold/flu 95<br />

gnp day time liquid caps 101<br />

gnp day time sinus/multi- 34<br />

gnp dayhist 2<br />

GNP FLU & SEVERE COLD/NIG 11<br />

gnp flu cold & cough medi 100<br />

gnp flu/severe cold dayti 34<br />

gnp headache relief 61<br />

gnp histafed 11<br />

gnp hot steam 174<br />

gnp hydro-lotion 163<br />

gnp hydrocor 163<br />

gnp hydrocortisone plus 163<br />

gnp hydrocortisone/aloe 164<br />

gnp ibuprofen cold/sinus 36<br />

gnp infants pain relief 62<br />

gnp infants pain reliever 101<br />

gnp insulin syringe/0.3ml 180<br />

gnp insulin syringe/0.3ml 181<br />

gnp insulin syringe/0.3ml 182<br />

gnp insulin syringe/0.5ml 182<br />

gnp insulin syringe/0.5ml 183<br />

gnp insulin syringe/0.5ml 184<br />

gnp insulin syringe/0.5ml 185<br />

gnp insulin syringe/1ml/2 186<br />

gnp insulin syringe/1ml/3 187<br />

gnp insulin syringe/1ml/3 188<br />

gnp jr strength non-aspir 61<br />

gnp lancets super thin 180<br />

gnp lancets thin 180<br />

gnp lancets 180<br />

gnp mucus relief cough ch 105<br />

gnp mucus relief dm 105<br />

gnp mucus relief multi 129<br />

gnp mucus relief pe 129<br />

gnp night time cold/flu r 106<br />

gnp night time cough 106<br />

gnp night time d cold/flu 106<br />

gnp night time sinus/mult 3<br />

gnp nose drops extra stre 138<br />

gnp pain rel 61<br />

gnp pain relief plus coug 107<br />

gnp pain relief pm extra 76<br />

gnp pain relief sinus pe 34<br />

gnp pain reliever extra s 61<br />

gnp pain reliever junior 62<br />

gnp prenatal vitamins 170<br />

gnp severe cold/flu maxim 101<br />

gnp sinus & allergy pe 14<br />

gnp sinus congestion & pa 11<br />

gnp sinus congestion & pa 34<br />

gnp sinus congestion/pain 11<br />

gnp sinus congestion/pain 133<br />

gnp sinus maximum strengt 34<br />

gnp suphedrin cold/cough 120<br />

GNP TEST STRIPS 80<br />

gnp triacting chest conge 128<br />

gnp triacting cold/allerg 11<br />

gnp triacting cough & sor 121<br />

gnp triacting day time co 121<br />

gnp triacting night time 121<br />

gnp triacting night time 3<br />

gnp triacting nite time 101<br />

GNP TRUEREAD 180<br />

GNP TRUEREAD 80<br />

GNP TRUETRACK SMART SYSTE 180<br />

GNP TRUETRACK SMART SYSTE 80<br />

gnp tussin cf cough & col 101<br />

gnp tussin cf 101<br />

gnp tussin dm cough 101<br />

gnp tussin dm 101<br />

created on 20100520 220


gnp tussin 128<br />

gnp vit b-6 168<br />

gnp womens menstrual reli 61<br />

gold sodium thiomalate 144<br />

GOLYTELY 140<br />

GONAL-F RFF 147<br />

GONAL-F 147<br />

gp-1200 128<br />

gramicidin/neomycin/polym 135<br />

GRANI 142<br />

granisetron hcl 142<br />

GRIFULVIN 27<br />

gripex pe pediatric 128<br />

GRIPP-HEEL 174<br />

GRIS-PEG 27<br />

GRISEOFULVIN MICRONIZED 195<br />

GRISEOFULVIN MICROSIZE 27<br />

griseofulvin microsize 27<br />

GRISEOFULVIN ULTRAMICROSI 27<br />

GRISEOFULVIN ULTRAMICROSIZE 27<br />

GRISEOFULVIN 195<br />

griseofulvin 27<br />

GUACOL DM PEDIATRIC 101<br />

guai 800mg/dm 30mg 101<br />

guai 800mg/pse 60mg/dm30m 101<br />

guaiasorb dm 101<br />

guaiasorb 128<br />

guaiatussin ac 101<br />

guaiatussin dm 101<br />

guaicon dm 101<br />

guaicon dms 101<br />

guaidex-tr 101<br />

guaif/dm/pse 101<br />

GUAIFED 128<br />

guaifen dm 101<br />

guaifen pe 128<br />

guaifen pse 128<br />

guaifen-c 101<br />

guaifen/pse 128<br />

guaifenesin 600/pse 120 128<br />

guaifenesin ac expectoran 101<br />

guaifenesin ac 101<br />

guaifenesin ac 102<br />

guaifenesin dac 102<br />

guaifenesin dm nr 101<br />

guaifenesin dm 101<br />

guaifenesin dm 102<br />

guaifenesin nr 102<br />

guaifenesin nr 128<br />

guaifenesin pse 128<br />

GUAIFENESIN-CHLORPHENIRAMINE<br />

MALEATE 128<br />

guaifenesin-codeine 101<br />

GUAIFENESIN-CODEINE 102<br />

guaifenesin-codeine 102<br />

guaifenesin-dm nr 101<br />

guaifenesin-dm 102<br />

guaifenesin-pseudoephedri 127<br />

guaifenesin/carbetapentan 101<br />

guaifenesin/codeine phosp 101<br />

guaifenesin/codeine 101<br />

guaifenesin/codeine 102<br />

guaifenesin/dex 101<br />

guaifenesin/dextromethorp 101<br />

guaifenesin/dextromethorp 102<br />

guaifenesin/dm sr 102<br />

guaifenesin/phenylephrine 127<br />

guaifenesin/phenylephrine 128<br />

guaifenesin/pse sa 128<br />

guaifenesin/pse/dm 100<br />

guaifenesin/pseudoephedri 102<br />

guaifenesin/pseudoephedri 128<br />

GUAIFENESIN 128<br />

guaifenesin 128<br />

GUAIFENESIN 195<br />

guaifenex dm 102<br />

guaifenex gp 128<br />

guaifenex pse 120 128<br />

guaifenex pse 60 128<br />

guaifenex pse 80 128<br />

guaifenex pse 85 128<br />

GUAIMAX-D 128<br />

guaimist dm 102<br />

guaimist s 128<br />

guaiphen-d 1200 128<br />

guaiphen-d 128<br />

guaiphen-pd 128<br />

guaitussin ac 102<br />

guaitussin dac 102<br />

guapetex hc 102<br />

guapetex 128<br />

guaphen forte 102<br />

guaphen ii dm 102<br />

GUAPHENYL II 128<br />

guaphenyl la 128<br />

guia-d 102<br />

guiadex dm 102<br />

guiadex pd 128<br />

guiadrine dx 102<br />

guiafen ii dm 102<br />

GUIAPLEX HC 102<br />

guiatex pe 128<br />

guiatuss ac 102<br />

guiatuss clear dm 102<br />

guiatuss dac 102<br />

guiatuss dm 102<br />

guiatuss pe 128<br />

guiatuss 128<br />

created on 20100520 221<br />

H<br />

H 9600 SR 128<br />

h&h thinlet lancets 26g 190<br />

h&h thinlet super thin la 190<br />

H-E-B IN CONTROL PEN NEED 180<br />

H-E-B INCONTROL PEN NEEDL 180<br />

haemolance low flow lance 180<br />

haemolance plus high flow 180<br />

haemolance plus low flow 180<br />

haemolance plus max flow 180<br />

haemolance plus pediatric 180<br />

haemolance plus 180<br />

haemolance 180<br />

HALCINONIDE 163<br />

halobetasol propionate 163<br />

halobetasol 163<br />

HALOG 163<br />

haloperidol decanoate 70<br />

haloperidol lactate 70<br />

haloperidol 70<br />

haloperidol 71<br />

haponal 33<br />

HAVRIX 157<br />

hayfebrol 11<br />

HAYSMA 36<br />

hc tussive-d 102<br />

hc tussive-nr 102<br />

hc tussive 102<br />

hca azo 165<br />

hca childrens non-aspirin 61<br />

hca cold & allergy dm 93<br />

hca cold & cough formula 126<br />

hca cold caps 2<br />

hca cold/allergy 9<br />

hca cold/flu medicine 11<br />

hca complete sinus relief 11


hca cough formula 102<br />

hca cough-ex 102<br />

hca day-time 102<br />

hca expector 128<br />

hca heartburn relief 142<br />

hca hydrocor 163<br />

hca infants non-aspirin 61<br />

hca insulin syringe/u-100 180<br />

hca insulin syringe/u-100 181<br />

hca insulin syringe/u-100 184<br />

hca insulin syringe/u-100 187<br />

HCA INTENSE COUGH FORMULA 102<br />

hca lancets thin 180<br />

hca lancets ultra thin 190<br />

hca maximum strength hydr 163<br />

hca nite-time multi sympt 102<br />

hca nite-time 102<br />

hca non-asa 61<br />

hca non-asp pm extra stre 75<br />

hca non-aspirin pm 75<br />

hca non-drying sinus 129<br />

hca severe congestion/cou 133<br />

HCA SEVERE COUGH STOPPER 102<br />

hca sinus 11<br />

hca suphedrine plus 11<br />

HCA TEST STRIPS 80<br />

hca tri-afed 11<br />

hca triactin cold & aller 11<br />

hca triactin cold & cough 102<br />

hca tussin cf 102<br />

hca tussin cold/cough 102<br />

hca tussin dm clear 102<br />

hca tussin dm 102<br />

hca tussin expectorant 129<br />

hca tussin pe 129<br />

hca ultra comfort insulin 182<br />

hca ultra comfort insulin 185<br />

hca ultra comfort insulin 188<br />

hca vit b6 168<br />

hctz/triamterene 88<br />

hdc dm 102<br />

headache pm 75<br />

HEALON GV 140<br />

HEALON5 140<br />

HEALON 140<br />

HEALTH ALLIANCE STRIP 80<br />

HEALTHWISE MINI PEN NEEDL 191<br />

HEALTHWISE PEN NEEDLES 29 191<br />

HEALTHWISE SHORT PEN NEED 192<br />

healtussin dm 102<br />

heartburn relief 142<br />

heartburn 142<br />

HECTOROL 169<br />

HELIDAC 29<br />

HELIXATE FS 42<br />

HEMABATE 155<br />

hematogen 39<br />

HEMOFIL M 42<br />

hemorrhoidal-hc 163<br />

hemril-30 163<br />

HEPAGAM B 155<br />

HEPAR COMPOSITUM 174<br />

heparin (porcine) in sodium chloride<br />

40<br />

HEPARIN LOCK 40<br />

heparin sod (porcine) in d5w 40<br />

heparin sodium (porcine) 40<br />

heparin sodium (porcine) 41<br />

HEPARIN SODIUM DCU 40<br />

HEPARIN SODIUM/NACL 0.45% 40<br />

HEPARIN SODIUM 40<br />

HEPATASOL 87<br />

HEPSERA 29<br />

HERCEPTIN 31<br />

hetastarch in sodium chloride 84<br />

HEXABRIX 82<br />

HEXAFED 11<br />

HEXAFLU 11<br />

HEXALEN 31<br />

HEXTEND 84<br />

HIBERIX 157<br />

HIBTITER 157<br />

hist-pse 11<br />

hista-tabs 11<br />

hista-vent da 11<br />

hista-vent pse 11<br />

histacol bd 102<br />

histacol dm 102<br />

histacol la 11<br />

histade mx 11<br />

histade sr 11<br />

HISTADEC DM 102<br />

HISTADEC 11<br />

histafed 11<br />

HISTAMAX D 2<br />

histatab d 11<br />

histatab ph 12<br />

histatab 11<br />

HISTATROL 82<br />

HISTENOL-FORTE 102<br />

HISTEX SR 12<br />

histinex hc 103<br />

histinex pv 103<br />

histuss hc 103<br />

histussin d 103<br />

histussin hc 103<br />

HIVID 28<br />

HIZENTRA 155<br />

hm monoject insulin syrin 180<br />

hm monoject insulin syrin 182<br />

hm monoject insulin syrin 183<br />

hm monoject insulin syrin 186<br />

homatropaire 138<br />

HOMATROPINE HBR 138<br />

homatropine hbr 138<br />

homatropine 138<br />

HONEY BEE 174<br />

honey tussin 103<br />

HORNET VENOM 174<br />

hot steam medication 174<br />

hot steam 174<br />

hpb max 103<br />

hpr end 103<br />

HSA STERILE DILUENT 195<br />

ht-tuss dm 103<br />

HUMALOG KWIKPEN 148<br />

HUMALOG MIX 50/50 KWIKPEN 148<br />

HUMALOG MIX 50/50 PEN 148<br />

HUMALOG MIX 50/50 148<br />

HUMALOG MIX 75/25 KWIKPEN 148<br />

HUMALOG MIX 75/25 PEN 148<br />

HUMALOG MIX 75/25 148<br />

HUMALOG PEN 148<br />

HUMALOG 148<br />

HUMATE-P 43<br />

HUMATROPE 151<br />

HUMIBID 129<br />

humibid 129<br />

HUMIRA PEN-CROHNS DISEASE 173<br />

HUMIRA PEN-PSORIASIS STAR 173<br />

HUMIRA PEN 173<br />

HUMIRA 173<br />

HUMULIN 50/50 148<br />

HUMULIN 70/30 PEN 148<br />

created on 20100520 222


HUMULIN 70/30 148<br />

HUMULIN N U-100 PEN 148<br />

HUMULIN N 148<br />

HUMULIN R U-500 (CONCENTR 148<br />

HUMULIN R 148<br />

hy-kxp 103<br />

hy-vee insulin syringe/u- 180<br />

hy-vee insulin syringe/u- 181<br />

hy-vee insulin syringe/u- 183<br />

hy-vee insulin syringe/u- 184<br />

hy-vee insulin syringe/u- 186<br />

hy-vee insulin syringe/u- 187<br />

hy-vee lancets 190<br />

hy-vee thin lancets 190<br />

HYALGAN 174<br />

HYCAMTIN 31<br />

HYCET 54<br />

hycomal dh 103<br />

HYDASE 88<br />

hydex pd 103<br />

hydralazine hcl 45<br />

hydralazine 45<br />

hydro gp 103<br />

hydro-dp 103<br />

hydro-pc ii plus 103<br />

hydro-pc ii 103<br />

hydro-tussin cbx 2<br />

hydro-tussin dhc 103<br />

hydro-tussin dm 103<br />

hydro-tussin exp 103<br />

hydro-tussin hc 103<br />

HYDRO-TUSSIN HD 103<br />

hydro-tussin hg 103<br />

hydro-tussin xp 103<br />

hydro/pseudo/brom 103<br />

hydrocet 54<br />

hydrochloric acid 141<br />

hydrochlorot 88<br />

hydrochlorothiazide 88<br />

hydrocod/cp/pseud 103<br />

HYDROCODONE BITARTRATE<br />

(ANTITUSSIVE) 195<br />

hydrocodone bitartrate/ac 54<br />

hydrocodone bitartrate/ap 54<br />

hydrocodone bitartrate/gu 103<br />

hydrocodone bitartrate/ho 103<br />

HYDROCODONE BITARTRATE 195<br />

hydrocodone bitrate/pheny 103<br />

HYDROCODONE POLISTIREX-<br />

CHLORPHENIRAMINE POLISTIREX 103<br />

HYDROCODONE W/ HOMATROPINE<br />

103<br />

hydrocodone w/ homatropine 103<br />

HYDROCODONE-ACETAMINOPHEN 54<br />

hydrocodone-acetaminophen 54<br />

hydrocodone-acetaminophen 55<br />

HYDROCODONE-GUAIFENESIN 103<br />

hydrocodone-guaifenesin 103<br />

HYDROCODONE-IBUPROFEN 55<br />

hydrocodone-ibuprofen 55<br />

HYDROCODONE-POTASSIUM<br />

GUAIACOLSULFONATE 103<br />

hydrocodone-potassium<br />

guaiacolsulfonate 103<br />

hydrocodone/acetaminophen 54<br />

hydrocodone/acetaminophen 55<br />

hydrocodone/apap 54<br />

hydrocodone/guaifenesin e 103<br />

hydrocodone/guaifenesin 102<br />

hydrocodone/guaifenesin 103<br />

hydrocodone/homatropine 103<br />

hydrocodone/ibuprofen 54<br />

hydrocodone/phenylephrine 102<br />

hydrocodone/potassium gua 103<br />

hydrocof-hc 103<br />

hydrocort ac 164<br />

hydrocort/ab 164<br />

hydrocort 145<br />

hydrocort 163<br />

hydrocort 164<br />

hydrocortiso 164<br />

hydrocortisone (rectal) 164<br />

HYDROCORTISONE (TOPICAL) 164<br />

hydrocortisone (topical) 164<br />

HYDROCORTISONE ACETATE<br />

(INTRARECTAL) 164<br />

hydrocortisone acetate (rectal) 164<br />

HYDROCORTISONE ACETATE W/<br />

PRAMOXINE 165<br />

hydrocortisone acetate-aloe vera 164<br />

hydrocortisone acetate/al 163<br />

hydrocortisone acetate/al 164<br />

hydrocortisone maximum st 164<br />

hydrocortisone plus 12 164<br />

hydrocortisone plus 164<br />

hydrocortisone sod succinate 145<br />

hydrocortisone valerate 164<br />

hydrocortisone w/acetic acid 136<br />

HYDROCORTISONE-ALOE VERA 164<br />

hydrocortisone-aloe vera 164<br />

hydrocortisone/acetic aci 136<br />

HYDROCORTISONE/ALOE 163<br />

HYDROCORTISONE/ALOE 164<br />

hydrocortisone/aloe 164<br />

hydrocortisone 145<br />

hydrofed 103<br />

hydrogesic 55<br />

hydromet 103<br />

hydromorphone hcl 55<br />

HYDROMORPHONE/BUPIVACAINE 54<br />

HYDROMORPHONE/NS 55<br />

HYDROMORPHONE/SODIUM CHLO 55<br />

hydron cp 103<br />

hydron ex 104<br />

HYDRON KGS 104<br />

hydron psc 104<br />

HYDROXOCOBAL 168<br />

hydroxychlor 29<br />

hydroxychloroquine sulfate 29<br />

hydroxyurea 31<br />

hydroxyz hcl 75<br />

hydroxyz pam 75<br />

hydroxyz pam 76<br />

HYDROXYZINE HCL (BULK) 195<br />

HYDROXYZINE HCL 195<br />

hydroxyzine hcl 76<br />

HYDROXYZINE PAMOATE 76<br />

hydroxyzine pamoate 76<br />

HYLENEX 88<br />

hyomax-sl 33<br />

hyomax 33<br />

hyoscyamine sulfate 34<br />

hyoscyamine 33<br />

hyoscyamine 34<br />

hyosyne 34<br />

HYPAQUE MEGL 82<br />

HYPAQUE SOD 82<br />

HYPAQUE-76 82<br />

HYPAQUE-CYST 82<br />

HYPAQUE-CYSTO PEDIATRIC 82<br />

HYPER-SAL 134<br />

hypercare 166<br />

HYPERHEP B S/D 155<br />

HYPERRAB S/D 155<br />

created on 20100520 223


HYPERRHO S/D 155<br />

HYPERSTAT IV 45<br />

HYPERTET S/D 155<br />

hyphed 104<br />

hyphen-hd 104<br />

HYSTOLYN-CYL 82<br />

hytone 164<br />

I<br />

ibu-profen cold/sinus 36<br />

ibu 52<br />

ibudone 55<br />

ibuprofen cold & sinus 36<br />

ibuprofen cold/sinus 36<br />

ibuprofen jr 52<br />

ibuprofen/pseudoephedrine 36<br />

IBUPROFEN 195<br />

ibuprofen 51<br />

ibuprofen 52<br />

ibutilide fumarate 44<br />

ICAR PEDIATRIC 39<br />

ICAR PEDS 39<br />

idarubicin hcl 31<br />

iferex 150 forte 39<br />

IFEX 31<br />

ifosfamide & mesna 31<br />

IFOSFAMIDE/MESNA 31<br />

IFOSFAMIDE 31<br />

ifosfamide 31<br />

ILARIS 61<br />

imipram hcl 68<br />

imipram pam 68<br />

imipram pam 69<br />

imipramine hcl 69<br />

IMIPRAMINE PAMOATE 69<br />

imipramine pamoate 69<br />

IMITREX STATDOSE REFILL 77<br />

IMITREX STATDOSE SYSTEM 77<br />

IMITREX 77<br />

IMMUNE GLOBULIN 155<br />

IMOGAM RABIES-HT 155<br />

IMOVAX RABIES (H.D.C.V.) 157<br />

IMPLANON 146<br />

INAMRINONE 44<br />

INCRELEX 151<br />

indamix dm 104<br />

indigotindisulfonate sodium 82<br />

INDOCIN 51<br />

INDOCIN 52<br />

indocyanine green 79<br />

indomethacin sodium 52<br />

INDOMETHACIN 195<br />

INDOMETHACIN 51<br />

indomethacin 51<br />

INDOMETHACIN 52<br />

indomethacin 52<br />

industrial 138<br />

inf asa free 61<br />

inf mapap 61<br />

inf non-asa 61<br />

INFANRIX 156<br />

infant apap 61<br />

INFANT FOODS 86<br />

infantaire 61<br />

infants acetaminophen 61<br />

infants apap 61<br />

infants pain relief cold/ 104<br />

infants pain relief 62<br />

infants pain reliever col 104<br />

infants pain reliever col 36<br />

infants silapap 61<br />

INFERGEN 28<br />

INFINITY BLOOD GLUCOSE MO 180<br />

INFINITY BLOOD GLUCOSE TE 80<br />

INFLUENZA A (H1N1) MONOVA 157<br />

INFLUENZA A (H1N1) MONOVALENT<br />

VACCINE LIVE 157<br />

INFLUENZA A (H1N1) MONOVALENT<br />

VACCINE SPLIT 157<br />

INFLUENZA VIRUS VACCINE SPLIT<br />

PRESERVATIVE FREE 157<br />

INFLUENZA VIRUS VACCINE SPLIT 157<br />

INFLUENZA VIRUS VACCINE TYPES A<br />

& B SURFACE ANTIGEN 157<br />

INFUMORPH 55<br />

inhaler decongestant 174<br />

INJECTION DEVICE 176<br />

INJECTION DEVICE 180<br />

INNOHEP 41<br />

INNOPRAN XL 46<br />

INSPIREASE BAGS 180<br />

INSPIREASE DRUG DELIVERY 180<br />

INSPIREASE MOUTHPIECE 180<br />

INSPIREASE REPLACEMENT MO 180<br />

INSPIREASE RESERVOIR BAGS 180<br />

instacort 5 164<br />

INSULIN ASPART PROTAMINE &<br />

ASPART (HUMAN) 148<br />

INSULIN ASPART 148<br />

INSULIN DETEMIR 148<br />

INSULIN GLARGINE 148<br />

INSULIN GLULISINE 148<br />

INSULIN ISOPHANE & REG (HUMAN)<br />

148<br />

INSULIN ISOPHANE (HUMAN) 148<br />

INSULIN ISOPHANE (HUMAN) 149<br />

INSULIN LISPRO (HUMAN) 149<br />

INSULIN LISPRO PROTAMINE &<br />

LISPRO (HUMAN) 149<br />

INSULIN PEN NEEDLE 176<br />

INSULIN PEN NEEDLE 180<br />

INSULIN REGULAR (HUMAN) 149<br />

INSULIN SYRINGE LUER-LOK/ 185<br />

insulin syringe/0.3ml/28g 180<br />

insulin syringe/0.3ml/29g 180<br />

insulin syringe/0.3ml/30g 181<br />

insulin syringe/0.3ml/31g 182<br />

insulin syringe/0.5ml/27g 182<br />

insulin syringe/0.5ml/28g 182<br />

insulin syringe/0.5ml/29g 183<br />

insulin syringe/0.5ml/30g 184<br />

insulin syringe/0.5ml/31g 185<br />

insulin syringe/1ml/28g x 186<br />

insulin syringe/1ml/29g x 186<br />

insulin syringe/1ml/30g x 187<br />

insulin syringe/1ml/31g x 187<br />

INSULIN SYRINGE/NEEDLE U-100 188<br />

insulin syringe/needle u-100 188<br />

INSULIN SYRINGE/NEEDLE U-100 189<br />

insulin syringe/needle u-100 189<br />

INSULIN SYRINGE/NEEDLE U-40 189<br />

insulin syringe/needle u-40 189<br />

insulin syringe/u-100/0.3 180<br />

insulin syringe/u-100/0.3 182<br />

insulin syringe/u-100/0.5 182<br />

insulin syringe/u-100/0.5 183<br />

insulin syringe/u-100/0.5 185<br />

insulin syringe/u-100/1ml 186<br />

insulin syringe/u-100/1ml 187<br />

INSULIN SYRINGES (DISPOSABLE) 188<br />

insulin syringes (disposable) 188<br />

INSUPEN SENSITIVE 32GX6MM 189<br />

INSUPEN SENSITIVE 32GX8MM 189<br />

INSUPEN ULTRAFIN 29GX12MM 189<br />

INSUPEN ULTRAFIN 30GX8MM 189<br />

created on 20100520 224


INSUPEN ULTRAFIN 31GX6MM 189<br />

INSUPEN ULTRAFIN 31GX8MM 189<br />

INTAL 112 125<br />

INTAL 200 125<br />

INTAL INH 125<br />

INTEGRILIN 41<br />

INTELENCE 28<br />

intense cold medicine 2<br />

intense cold/flu medicine 2<br />

intense cough reliever do 104<br />

intense cough reliever ex 104<br />

intense cough reliever 104<br />

INTRON-A 31<br />

INULIN 82<br />

INVANZ 20<br />

INVEGA SUST 70<br />

INVEGA SUSTENNA 70<br />

INVERTA-PEG BASIC GAST KI 189<br />

INVIRASE 27<br />

invisible acne maximum st 161<br />

iobid dm 104<br />

IODOPEN 82<br />

IONOSOL-B/DEXTROSE 5% 84<br />

IONOSOL-MB/DEXTROSE 5% 84<br />

IONOSOL-T/DEXTROSE 5% 84<br />

iophen c-nr 104<br />

iophen dm-nr 104<br />

iophen dm 104<br />

iophen-nr 129<br />

iosal ii 129<br />

iotex pse 129<br />

IPLEX 151<br />

IPOL INACTIVATED IPV 157<br />

ipratropium bromide (nasal) 34<br />

IPRATROPIUM BROMIDE HFA 34<br />

ipratropium bromide 34<br />

ipratropium 34<br />

iprin cold/sinus 36<br />

IRESSA 31<br />

irinotecan hcl 31<br />

IROFOL 39<br />

IRON & FOLIC ACID 39<br />

IRON COMBINATIONS 39<br />

iron combinations 39<br />

iron dextran 39<br />

iron polysaccharide complex-vit b12folic<br />

acid 39<br />

IRON 39<br />

ISCAR MALI SERIES I 174<br />

ISCAR MALI SERIES II 174<br />

ISCAR MALI SERIES O 174<br />

ISCAR MALI SPECIAL 174<br />

ISCAR MALI 174<br />

ISCAR PINI SERIES I 174<br />

ISCAR PINI SERIES II 174<br />

ISCAR PINI SERIES O 174<br />

ISCAR PINI 174<br />

ISCAR QUERCU 174<br />

ISCAR QUERCUS SERIES I 174<br />

ISCAR QUERCUS SERIES II 174<br />

ISCAR QUERCUS SERIES O 174<br />

ISO CARBACHO 139<br />

ISO HOMATROP 138<br />

ISO HYOSCINE 138<br />

iso-chlor 12<br />

ISOCARBOXAZID 66<br />

ISOLYTE-H/DEXTROSE 5% 84<br />

ISOLYTE-P/DEXTROSE 5% 84<br />

ISOLYTE-S PH 7.4 84<br />

ISOLYTE-S/DEXTROSE 5% 84<br />

ISOLYTE-S 84<br />

isometheptene/apap/dichlo 77<br />

isometheptene/dichloralph 77<br />

ISONIAZID 195<br />

ISONIAZID 27<br />

isoniazid 27<br />

ISOSORBIDE DINITRATE 45<br />

ISOTONIC GENTAMICIN 17<br />

ISOVUE-200 82<br />

ISOVUE-250 MULTIPACK 82<br />

ISOVUE-250 82<br />

ISOVUE-300 MULTIPACK 82<br />

ISOVUE-300 82<br />

ISOVUE-370 MULTIPACK 82<br />

ISOVUE-370 82<br />

ISOVUE-M 200 82<br />

ISOVUE-M 300 82<br />

ISRADIPINE 47<br />

isradipine 47<br />

ISTALOL 139<br />

ISTODAX 31<br />

ISUPREL 35<br />

itch-x 164<br />

itraconazole 27<br />

IVEEGAM EN 155<br />

IXEMPRA KIT 31<br />

IXIARO 157<br />

created on 20100520 225<br />

J<br />

J-COF DHC 104<br />

J-MAX DHC 104<br />

J-MAX 129<br />

J-TAN D HC 104<br />

J-TAN D PD 12<br />

J-TAN D 12<br />

jantoven 40<br />

jaycof-hc 104<br />

jaycof-xp 104<br />

jaycof 104<br />

JE-VAX 157<br />

jolivette 146<br />

jr non-asa 61<br />

jr strength non-aspirin 61<br />

jr strength pain reliever 61<br />

jr. acetamin 61<br />

junior mapap rapid tabs 61<br />

K<br />

k-tan 4 4<br />

k-tan 3<br />

KADIAN 55<br />

KALBITOR 174<br />

KANAMYCIN 17<br />

kaon-cl-10 84<br />

kariva 146<br />

KCL 0.15%/D10W/NACL 0.2% 84<br />

KCL 0.15%/D5W/LR 85<br />

KCL 0.15%/D5W/NACL 0.225% 85<br />

KCL 0.3%/D5W/LR IV LAC RI 85<br />

KCL 0.3%/D5W/LR 85<br />

KCL 0.3%/D5W/NACL 0.9% 85<br />

KEFLEX 18<br />

ken-tuss sf 104<br />

KEPIVANCE 166<br />

KEPPRA 65<br />

kericort 10 164<br />

KERR DRUG STARTER KIT 189<br />

KERR DRUG TEST STRIP PACK 81<br />

KETALAR 51<br />

ketamine hcl 51<br />

KETOCARE 83<br />

KETOCONAZOLE & PYRITHIONE ZINC<br />

158<br />

KETOCONAZOLE (TOPICAL) 158<br />

ketoconazole (topical) 158<br />

KETOCONAZOLE (TOPICAL) 159


ketoconazole (topical) 159<br />

ketoconazole 158<br />

ketoconazole 159<br />

ketoconazole 27<br />

KETOPROFEN 195<br />

KETOPROFEN 52<br />

ketoprofen 52<br />

KETOROLAC TROMETHAMINE<br />

(OPHTH) 137<br />

ketorolac tromethamine (ophth) 137<br />

ketorolac tromethamine 52<br />

ketorolac tromethamine 53<br />

ketorolac 137<br />

ketorolac 52<br />

KETOSTIX 83<br />

ketotifen fumarate (ophth) 135<br />

kgs-hc 104<br />

KGS-PE 129<br />

kidkare cough/cold 104<br />

kin-ray insulin syringe/0 183<br />

KINERET 173<br />

KINEVAC 82<br />

KINLYTIC 41<br />

kinney lancets 189<br />

kinney thin lancets 189<br />

kinray insulin syringe pr 182<br />

kinray insulin syringe pr 185<br />

kinray insulin syringe pr 187<br />

KINRAY TEST STRIPS 81<br />

KINRAY VALUE PACK 189<br />

KINRIX 156<br />

klor-con m 85<br />

klor-con 85<br />

klotrix 85<br />

kmart valu plus insulin s 181<br />

kmart valu plus insulin s 183<br />

KMART VALU PLUS INSULIN S 184<br />

KMART VALU PLUS INSULIN S 186<br />

kmart valu plus insulin s 186<br />

KOATE-DVI 43<br />

KOGENATE FS BIO-SET 43<br />

KOGENATE FS 43<br />

KOLEPHRIN-GG/DM 104<br />

kolephrin/dm 104<br />

kolephrin 12<br />

KROGER BLOOD GLUCOSE MONI 189<br />

KROGER BLOOD GLUCOSE TEST 81<br />

kroger insulin syringe/0. 180<br />

kroger insulin syringe/0. 181<br />

kroger insulin syringe/0. 182<br />

kroger insulin syringe/0. 183<br />

kroger insulin syringe/0. 184<br />

kroger insulin syringe/0. 185<br />

kroger insulin syringe/1m 186<br />

kroger insulin syringe/1m 187<br />

kroger insulin syringe/u- 180<br />

kroger insulin syringe/u- 181<br />

kroger insulin syringe/u- 184<br />

kroger insulin syringe/u- 186<br />

kroger insulin syringe/u- 187<br />

kroger lancets 21g 189<br />

kroger lancets micro thin 189<br />

kroger lancets super thin 189<br />

kroger lancets thin 26g 190<br />

kroger lancets thin 189<br />

kroger lancets ultrathin 189<br />

kroger lancets 189<br />

KROGER PEN NEEDLES 29G X 191<br />

KROGER PEN NEEDLES 31G X 192<br />

KROGER PEN NEEDLES 31GX1/ 191<br />

KROGER TEST STRIPS 81<br />

kronofed-a-jr 12<br />

kronofed-a 12<br />

KU-ZYME HP 141<br />

KU-ZYME 141<br />

kuric 159<br />

KUTRASE 141<br />

kwelcof 104<br />

created on 20100520 226<br />

L<br />

l-all 12 nf 104<br />

l-all 12 104<br />

labetalol hcl 46<br />

labetalol 46<br />

lactated ringer's 85<br />

lactulose (encephalopathy) 83<br />

lactulose 83<br />

lady lite lancets 189<br />

lahey mixture #3 34<br />

LAMICTAL ODT 65<br />

LAMICTAL XR 65<br />

LAMICTAL 65<br />

lamotrigine 65<br />

lancets 26g twist top 189<br />

lancets 28g 190<br />

lancets 30g twist top 190<br />

lancets 30g 190<br />

lancets 31g twist top 190<br />

lancets fun color 190<br />

lancets safety seal 21g 189<br />

lancets safety seal 26g 190<br />

lancets safety seal 28g 190<br />

lancets safety seal 30g 190<br />

lancets super thin 190<br />

lancets thin 190<br />

lancets twist top 189<br />

lancets ultra thin 190<br />

lancets 176<br />

lancets 189<br />

lancets 190<br />

LANOXIN 44<br />

LANSOPRAZOLE 143<br />

lansoprazole 143<br />

LANTUS FOR OPTICLIK 149<br />

LANTUS SOLOSTAR 149<br />

LANTUS 149<br />

lanzatuss-n.f. 104<br />

LAPASE 141<br />

LARTUS 104<br />

LATANOPROST 140<br />

lavoclen-4 acne wash kit 161<br />

lavoclen-4 creamy wash 161<br />

lavoclen-8 acne wash kit 161<br />

lavoclen-8 creamy wash 161<br />

leader insulin syringe/0. 180<br />

leader insulin syringe/0. 181<br />

leader insulin syringe/0. 182<br />

leader insulin syringe/0. 183<br />

leader insulin syringe/0. 184<br />

leader insulin syringe/0. 185<br />

leader insulin syringe/1m 186<br />

leader insulin syringe/1m 187<br />

leader lancets colored 190<br />

leader super thin lancet 193<br />

leader thin lancets 194<br />

leena 146<br />

LEMOHIST PLUS 129<br />

LEUKERAN 31<br />

LEUKINE 42<br />

LEUPROLIDE ACETATE 31<br />

leuprolide acetate 31<br />

LEV/PSE/GG 129<br />

LEVALL 5.0 104<br />

LEVAQUIN 24<br />

LEVATOL 46


LEVEMIR FLEXPEN 149<br />

LEVEMIR 149<br />

levetiracetam 65<br />

LEVO DROMORA 55<br />

levobunolol hcl 139<br />

levobunolol 139<br />

levocarnitin 174<br />

levocarnitine (metabolic modifiers)<br />

174<br />

levocarnitine (metabolic modifiers)<br />

175<br />

LEVOFLOXACIN 24<br />

levonorgestrel & eth estradiol 146<br />

LEVONORGESTREL (EMERGENCY OC)<br />

146<br />

levonorgestrel (emergency oc) 146<br />

LEVONORGESTREL-ETH ESTRADIOL<br />

(TRIPHASIC) 146<br />

levonorgestrel-eth estradiol (triphasic)<br />

146<br />

levora 0.15/30-28 146<br />

levothroid 151<br />

levothroid 152<br />

levothyroxin 152<br />

LEVOTHYROXINE SODIUM 152<br />

levothyroxine sodium 152<br />

LEVOXYL 152<br />

levoxyl 152<br />

levoxyl 153<br />

LEVSIN 34<br />

LEXAPRO 67<br />

lexuss 210 104<br />

LIALDA 144<br />

LIBERTY BLOOD GLUCOSE MET 177<br />

LIBERTY BLOOD GLUCOSE MON 177<br />

LIBERTY TEST STRIPS 81<br />

LIBRIUM 75<br />

lidocaine hcl (cardiac) 44<br />

lidocaine hcl (local anesth.) 154<br />

lidocaine hcl (mouth-throat) 137<br />

lidocaine hcl 137<br />

LIDOCAINE HCL 154<br />

lidocaine in d5w 44<br />

lidocaine viscous 137<br />

lidocaine w/ epinephrine 154<br />

LIDOCAINE 44<br />

lidomar viscous 137<br />

LIFE MED BLOOD GLUCOSE MO 177<br />

LIFE MEDICAL TEST STRIPS 81<br />

lifescan unistik 2 deep p 190<br />

lifescan unistik ii lance 194<br />

lifescan unistik ii neona 194<br />

LINCOCIN 26<br />

LINDANE 159<br />

lindane 159<br />

LIORESAL INT INJ 38<br />

LIORESAL INTRATHECAL 38<br />

liothyronine sodium 153<br />

LIPRAM 4500 141<br />

LIPRAM-CR10 141<br />

LIPRAM-CR20 141<br />

lipram-pn10 141<br />

LIPRAM-PN16 141<br />

LIPRAM-PN20 141<br />

LIPRAM-UL12 141<br />

LIPRAM-UL18 141<br />

lipram-ul20 141<br />

LIQUADD 72<br />

liquibid d-r 129<br />

LIQUIBID-D 1200 129<br />

LIQUIBID-D 129<br />

LIQUIBID-PD 129<br />

liquibid 129<br />

LIQUICET 55<br />

liquicough dm 104<br />

liquicough hc 104<br />

lisinopril & hydrochlorothiazide 50<br />

lisinopril/hydrochlorothi 49<br />

lisinopril 49<br />

lisinopril 50<br />

lite touch insulin syring 180<br />

lite touch insulin syring 181<br />

lite touch insulin syring 182<br />

lite touch insulin syring 183<br />

lite touch insulin syring 184<br />

lite touch insulin syring 185<br />

lite touch insulin syring 186<br />

lite touch insulin syring 187<br />

lite touch lancets 190<br />

LITE TOUCH PEN NEEDLES/31 191<br />

lithium carb 76<br />

lithium carbonate 76<br />

LITTLE COLDS DECONGESTANT 104<br />

LITTLE COLDS DRO 104<br />

LITTLE COLDS MULTI-SYMPTO 104<br />

LITTLE FEVERS FEVER/PAIN 61<br />

LITTLE NOSES 138<br />

live better lancet super 189<br />

live better lancet ultra 190<br />

LIVE BETTER PEN NEEDLES 2 191<br />

LIVE BETTER PEN NEEDLES 3 191<br />

LIVE BETTER PEN NEEDLES 3 192<br />

livetan dm 104<br />

LODRANE 24D 12<br />

LODRANE D 12<br />

lodrane ld 12<br />

lofene 140<br />

lohist-12d 12<br />

lohist-d 12<br />

lohist-dm 104<br />

lohist-lq 12<br />

lohist-pd 12<br />

LOMUSTINE 31<br />

LONG STARTER KIT 190<br />

LONG TEST STRIP 81<br />

longs childrens cgh/cold 92<br />

longs childrens flu formu 100<br />

longs cold/cough dm 94<br />

longs insulin syringe/0.5 185<br />

longs insulin syringe/u-1 180<br />

longs insulin syringe/u-1 181<br />

longs insulin syringe/u-1 183<br />

longs insulin syringe/u-1 184<br />

longs insulin syringe/u-1 186<br />

longs insulin syringe/u-1 187<br />

longs lancets adult 190<br />

longs lancets standard 190<br />

longs lancets thin 190<br />

longs lancets ultra thin 190<br />

longs nasal decon/antihis 12<br />

longs nasal decongestant 12<br />

longs original lancets 190<br />

longs pedia relief cough 108<br />

longs pedia relief infant 108<br />

longs super tussin cf 123<br />

longs super tussin dm cle 120<br />

longs super tussin pedia 120<br />

longs ultra thin lancets 194<br />

lonox 140<br />

LORABID 20<br />

LORACARBEF 20<br />

loradamed 17<br />

loratadine & pseudoephedrine 17<br />

loratadine allergy relief 17<br />

created on 20100520 227


LORATADINE 17<br />

loratadine 17<br />

lorazepam 75<br />

LOROXIDE 161<br />

losartan potassium 50<br />

LOTREL 47<br />

LOVENOX 41<br />

low-ogestrel 146<br />

loxapine succinate 72<br />

loxapine 72<br />

LUMIGAN 140<br />

LUMINAL 74<br />

LUPR DEP-PED INJ 31<br />

LUPRON DEPOT INJ 31<br />

lusair 129<br />

LUSEDRA 51<br />

LUSONEX PLUS 129<br />

LUVERIS 147<br />

LYMPHAZURIN 79<br />

LYMPHOMYOSOT 175<br />

LYNOX 55<br />

LYRICA 65<br />

LYSODREN 31<br />

M<br />

m-clear jr 104<br />

m-clear wc 104<br />

m-clear 104<br />

m-end (reformulated) 104<br />

m-end dm 104<br />

m-end max 104<br />

M-END PE 104<br />

m-end wc 104<br />

M-M-R II W/DILUENT 1 DOSE 157<br />

M-M-R II W/DILUENT 10 DOS 157<br />

M-M-R II 157<br />

M-R-VAX II 157<br />

m-vit 170<br />

M.V.I. ADULT 170<br />

M.V.I. PEDIATRIC 170<br />

M.V.I.-12 WITHOUT VITAMIN 170<br />

MACRODANTIN 29<br />

magellan insulin safety s 190<br />

MAGNACET 55<br />

magnesium chloride 85<br />

MAGNESIUM SU 65<br />

magnesium sulfate 65<br />

MAGNESIUM SULFATE 85<br />

MAGNESIUM W/ POTASSIUM-<br />

PYRIDOXINE 168<br />

MAGNEVIST 79<br />

major comfort lancets 190<br />

MANGANESE CL 85<br />

MANGANESE SU 85<br />

mannitol 88<br />

mapap apap 61<br />

mapap arthri 61<br />

mapap child 61<br />

mapap childrens cough/sin 104<br />

mapap childrens 61<br />

mapap cold formula multi- 104<br />

mapap cold formula 104<br />

mapap cold 104<br />

MAPAP HEADACHE PLUS 61<br />

mapap jr str 61<br />

mapap pm 76<br />

mapap sinus maximum stren 34<br />

mapap sinus maximum stren 37<br />

mapap 61<br />

MAR-COF BP 104<br />

MAR-COF CG EXPECTORANT 104<br />

marcof expectorant 104<br />

MARDROPS-DX 104<br />

MARDROPS-EX 129<br />

margesic-h 55<br />

MARPLAN 66<br />

martinic 39<br />

masophen 61<br />

maternity-90 170<br />

maternity 170<br />

MATULANE 31<br />

max strength complete 94<br />

MAXAIR AUTOH AER 35<br />

MAXALT-MLT 77<br />

MAXALT 77<br />

maxapap ms 61<br />

maxapap rs 61<br />

maxi-comfort insulin syri 182<br />

maxi-comfort insulin syri 186<br />

MAXI-TUSS HCG 104<br />

maxichlor peh 12<br />

maxichlor pse 12<br />

MAXIFED CD 104<br />

MAXIFED CDX 104<br />

MAXIFED DM 104<br />

maxifed dmx 104<br />

MAXIFED-G CD 104<br />

MAXIFED-G CDX 104<br />

maxifed 129<br />

MAXIFLU CD 104<br />

MAXIFLU CDX 104<br />

MAXIFLU DM 105<br />

MAXIFLU-G 105<br />

MAXIMA BLOOD GLUCOSE MONI 190<br />

MAXIMA BLOOD GLUCOSE TEST 81<br />

MAXIMA METER KIT 190<br />

MAXIMA STARTER KIT 190<br />

MAXIPHEN ADT 105<br />

MAXIPHEN CD 105<br />

MAXIPHEN CDX 105<br />

MAXIPHEN-G DM 105<br />

MAXIPHEN-G 129<br />

maxiphen 129<br />

MAXIPIME 20<br />

mc jr cough 105<br />

MD-76 R 82<br />

MD-GASTROVIEW 82<br />

MEBENDAZOLE 17<br />

mebendazole 17<br />

med-derm hc 164<br />

med-fast monoject insulin 183<br />

med-fast monoject insulin 186<br />

medent-dmi 105<br />

medent-ldi 129<br />

MEDENT-PE 129<br />

medent-pei 129<br />

medi-brom cold allergy dm 105<br />

medi-brom 12<br />

MEDI-GRAINE 61<br />

medi-lance lancets 190<br />

medi-phedrine plus 12<br />

medi-phedrine severe cold 105<br />

medi-profen cold/sinus 37<br />

medi-synal 37<br />

medi-tabs allergy sinus m 12<br />

medi-tabs childrens 61<br />

medi-tabs cold 105<br />

medi-tabs extra strength 61<br />

medi-tabs flu 105<br />

medi-tabs jr 62<br />

medi-tabs pm extra streng 76<br />

medi-tabs sinus maximum s 37<br />

medi-tabs 61<br />

medi-tussin cough/cold 105<br />

medi-tussin dm diabetic 105<br />

created on 20100520 228


medi-tussin dm double str 105<br />

medi-tussin dm 105<br />

medi-tussin max strength 105<br />

medi-tussin pe 129<br />

medi-tussin severe conges 129<br />

medi-tussin 105<br />

medi-tussin 129<br />

medic insulin syringe/0.3 181<br />

medic insulin syringe/0.5 184<br />

MEDICATED CHEST RUB 175<br />

medicated chest rub 175<br />

medichoice pre-set safety 190<br />

medichoice safety lancet 190<br />

medicidin-d 12<br />

medicine shoppe lancets t 190<br />

medicine shoppe lancets 189<br />

MEDICINE SHOPPE PEN NEEDL 191<br />

MEDICINE SHOPPE PEN NEEDL 192<br />

MEDIFIRST COLD RELIEF 93<br />

medisense thin lancets 194<br />

medlance plus lancets 190<br />

medlance/extra 190<br />

medlance/lite 190<br />

medlance/universal 190<br />

MEDROL 145<br />

medroxypr ac 151<br />

medroxyprogesterone acetate<br />

(contraceptive) 151<br />

medroxyprogesterone acetate 151<br />

MEFOXIN 20<br />

megestrol ac 31<br />

megestrol acetate 31<br />

megestrol acetate 32<br />

meijer cough syrup dm 94<br />

meijer jr strength aspiri 59<br />

meijer lancets thin 190<br />

meijer lancets 190<br />

MEIJER PEN NEEDLES 29G X 191<br />

MEIJER PEN NEEDLES 31G X 191<br />

MEIJER PEN NEEDLES 31G X 192<br />

MEIJER STARTER KIT 190<br />

meijer super thin lancets 193<br />

MEIJER TEST STRIPS 81<br />

melphalan hcl 32<br />

MELPHALAN 32<br />

MENACTRA 157<br />

MENOMUNE-A/C/Y/W-135 157<br />

MENOPUR 147<br />

menstrual complete maximu 62<br />

menstrual pms 62<br />

menstrual relief maximum 62<br />

MENVEO 157<br />

meperi 55<br />

MEPERIDINE HCL-SODIUM CHLORIDE<br />

55<br />

MEPERIDINE HCL/NS 55<br />

MEPERIDINE HCL 55<br />

meperidine hcl 55<br />

MEPERIDINE W/ PROMETHAZINE 55<br />

meperidine w/ promethazine 55<br />

MEPERIDINE/NS 55<br />

meperidine/promethazine 55<br />

MEPERIDINE 55<br />

meperidine 55<br />

MEPHYTON 169<br />

mepivacaine hcl 154<br />

MEPIVACAINE 154<br />

MEPROZINE 55<br />

mercaptopur 32<br />

mercaptopurine 32<br />

MERREM 20<br />

MERUVAX II W/DILUENT 10 D 157<br />

MESALAMINE 144<br />

MESTINON TIMESPAN 33<br />

MESTINON 33<br />

METADATE CD 73<br />

metadate 73<br />

METAPROTEREN 35<br />

metaproteren 35<br />

METAPROTERENOL SULFATE 35<br />

metaproterenol sulfate 35<br />

METAPROTERENOL SULFATE 36<br />

metaproterenol sulfate 36<br />

METASTRON 175<br />

METFORMIN HCL 148<br />

metformin hcl 148<br />

METFORMIN 148<br />

methadex 136<br />

methadone hcl diskets 56<br />

methadone hcl 56<br />

METHADONE 55<br />

methadone 55<br />

methadone 56<br />

methadose 56<br />

methazolamid 139<br />

methazolamide 139<br />

METHIMAZOLE 154<br />

methimazole 154<br />

METHOTREXATE SODIUM<br />

(ANTIRHEUMATIC) 32<br />

methotrexate sodium (antirheumatic)<br />

32<br />

methotrexate sodium 32<br />

METHOTREXATE 195<br />

methotrexate 32<br />

methyldopa 44<br />

methyldopa 45<br />

METHYLDOPATE 45<br />

methylergonovine maleate 155<br />

methylin er 73<br />

METHYLIN 73<br />

methylin 73<br />

methylphenid 73<br />

METHYLPHENIDATE HCL 73<br />

methylphenidate hcl 73<br />

METHYLPHENIDATE HCL 74<br />

methylpred 145<br />

methylprednisolone acetate 145<br />

methylprednisolone sod succ 145<br />

METHYLPREDNISOLONE 145<br />

methylprednisolone 145<br />

metoclopram 143<br />

metoclopramide hcl 143<br />

metolazone 88<br />

metoprol tar 46<br />

metoprolol succinate 46<br />

metoprolol tartrate 46<br />

metoprolol 46<br />

METRO IV 29<br />

METROGEL-VAGINAL 158<br />

metronidazol 29<br />

metronidazole in nacl 29<br />

METRONIDAZOLE VAGINAL 158<br />

metronidazole vaginal 158<br />

METRONIDAZOLE-TETRACYCLINE W/<br />

BISMUTH SUBSALICYLATE 29<br />

metronidazole 29<br />

MIACALCIN 150<br />

MICRHOGAM PL 155<br />

MICROCHAMBER 190<br />

MICRODOT BLOOD GLUCOSE MO 190<br />

MICRODOT TEST STRIPS 81<br />

microlet lancets 190<br />

MICROLIPID 87<br />

created on 20100520 229


microtainer safety flow l 190<br />

MIDAZOLAM HCL/NACL 75<br />

midazolam hcl 75<br />

midol menstrual headache 62<br />

MIGERGOT 77<br />

migquin 77<br />

migratine 77<br />

migrazone 77<br />

migrin-a 77<br />

MILLIPRED 145<br />

milrinone in dextrose 44<br />

milrinone lactate 44<br />

miltuss 105<br />

minirin 150<br />

MINOCIN 25<br />

minocycline hcl 25<br />

mintex dm 105<br />

mintex hc 105<br />

mintex pse 3<br />

mintex 12<br />

mintuss dr 105<br />

mintuss g 105<br />

mintuss hc 105<br />

mintuss hd 105<br />

mintuss mr 105<br />

mintuss ms 105<br />

mintuss nx 105<br />

MIOSTAT 139<br />

miraphen pse 129<br />

mirtazapine 69<br />

misoprostol 143<br />

mission prenatal hp 170<br />

mission prenatal/folic ac 170<br />

MISSION PRENATAL 170<br />

mitomycin 32<br />

MITOTANE 32<br />

mitoxantrone hcl 32<br />

MIXED VESPID VENOM PROTEI 175<br />

MODAFINIL 74<br />

MOMETASONE FUROATE (NASAL) 136<br />

mometasone furoate 164<br />

mometasone 164<br />

MONARC-M 43<br />

monistat 164<br />

MONOCLATE-P 43<br />

MONOJECT BASIC BIOPSY TRA 154<br />

MONOJECT BONE MARROW ASPI 154<br />

MONOJECT BONE MARROW BIOP 154<br />

monoject insulin syringe/ 180<br />

monoject insulin syringe/ 181<br />

monoject insulin syringe/ 182<br />

monoject insulin syringe/ 183<br />

monoject insulin syringe/ 184<br />

MONOJECT INSULIN SYRINGE/ 185<br />

monoject insulin syringe/ 185<br />

monoject insulin syringe/ 186<br />

monoject insulin syringe/ 187<br />

MONOJECT INSULIN SYRINGE 185<br />

monoject ultra comfort in 180<br />

monoject ultra comfort in 181<br />

monoject ultra comfort in 182<br />

monoject ultra comfort in 183<br />

monoject ultra comfort in 184<br />

monoject ultra comfort in 185<br />

monoject ultra comfort in 186<br />

monoject ultra comfort in 187<br />

monolet lancets 190<br />

monolet neolet lancets 190<br />

monolet opd lancets 190<br />

monolet thin lancets 190<br />

monolettor safety lancets 190<br />

mononessa 146<br />

MONONINE 43<br />

MONTE-G HC 105<br />

MONTEFLU HC 105<br />

MONTELUKAST SODIUM 125<br />

montephen 129<br />

moore med monoject insuli 182<br />

moore med monoject insuli 183<br />

moore med monoject insuli 185<br />

moore med monoject insuli 186<br />

MORPHINE SUL TAB 56<br />

MORPHINE SUL 56<br />

morphine sul 56<br />

MORPHINE SULFATE IN DEXTR 56<br />

MORPHINE SULFATE/D5W 56<br />

MORPHINE SULFATE/NS 56<br />

MORPHINE SULFATE 56<br />

morphine sulfate 56<br />

MORPHINE/D5W 56<br />

morrhuate sodium 45<br />

motrin cold & sinus 37<br />

MOXATAG 24<br />

mp acetamin 62<br />

mp acetaminophen es 58<br />

mp acetaminophen pm 75<br />

mp azodine uranary 165<br />

mp cold-allergy dm relief 93<br />

mp cold/allergy relief 9<br />

mp heartburn 142<br />

mp hydrocort 164<br />

mp hydrocortisone maximum 164<br />

mp multi symptom cold 105<br />

mp nite time 106<br />

mp non aspirin 106<br />

mp non aspirin 37<br />

mp pain reliever pm 76<br />

mp tri-fed cold 15<br />

mp triactin chest congest 133<br />

mp triactin cold-allergy 15<br />

mp tussin cf 105<br />

mp tussin dm 105<br />

mp tussin pe 129<br />

ms insulin syringe/0.3ml/ 180<br />

ms insulin syringe/0.3ml/ 181<br />

ms insulin syringe/0.3ml/ 182<br />

ms insulin syringe/0.5ml/ 183<br />

ms insulin syringe/0.5ml/ 184<br />

ms insulin syringe/0.5ml/ 185<br />

ms insulin syringe/1ml/29 186<br />

ms insulin syringe/1ml/30 187<br />

ms insulin syringe/1ml/31 188<br />

ms.-aid 62<br />

MUCINEX CHLD GRA 129<br />

mucinex chld 129<br />

mucinex cough childrens 105<br />

MUCINEX COUGH FOR KIDS 105<br />

mucinex cough for kids 105<br />

MUCINEX COUGH/KIDS 105<br />

MUCINEX D 129<br />

mucinex dm maximum streng 105<br />

MUCINEX DM 105<br />

MUCINEX JUNIOR STRENGTH 129<br />

MUCINEX/KIDS GRA 129<br />

mucinex/kids 129<br />

MUCINEX 129<br />

MUCOSA COMPOSITUM 175<br />

mucosa dm 105<br />

mucosa 129<br />

mucus relief adult 129<br />

mucus relief chest conges 129<br />

mucus relief cough childr 105<br />

mucus relief d 129<br />

mucus relief dm cough 105<br />

created on 20100520 230


mucus relief dm 105<br />

mucus relief pe 129<br />

mucus relief 129<br />

mucusrelief dm 105<br />

mucusrelief sinus 129<br />

mult-vitamin/fluoride 170<br />

multi prenatal 170<br />

multi symptom cold severe 105<br />

multi vit/fl 170<br />

multi vita-bets/fluoride/ 170<br />

multi vita-bets/fluoride 170<br />

multi-symptom allergy rel 12<br />

multi-symptom cold & coug 105<br />

multi-symptom cold relief 105<br />

multi-symptom cold/cough 105<br />

multi-symptom pms menstru 62<br />

multi-vit/fluoride 1/2 st 170<br />

multi-vit/fluoride/iron 170<br />

multi-vit/fluoride 170<br />

multi-vit/iron/fluoride 170<br />

multi-vitamin drops 170<br />

multi-vitamin/fluoride 170<br />

multi-vits/fluoride 170<br />

MULTIDEXOL M 105<br />

multifol plus 170<br />

multiple symptom cold 105<br />

multiple vitamin 169<br />

multiple vitamins/fluorid 170<br />

MULTITRACE-4 NEONATAL 85<br />

MULTITRACE-4 PEDIATRIC 85<br />

MULTITRACE-4 85<br />

MULTITRACE-5 85<br />

multivitamin drops/fluori 171<br />

multivitamin/fluoride 171<br />

multivitamins/fluoride/ir 171<br />

multivitamins/fluoride 171<br />

MUMPSVAX W/DILUENT 10 DOS 157<br />

MUSTARGEN 32<br />

mvc-fluoride 171<br />

MYCAMINE 27<br />

MYCELEX-7 COMBO PACK 159<br />

myci-gc 105<br />

mydex 129<br />

mydocs 129<br />

mydral 138<br />

MYELO-KIT 82<br />

myferon 150 forte 39<br />

myhist-dm 105<br />

myhist-pd 12<br />

MYKIDZ IRON 10 39<br />

MYLERAN 32<br />

MYLOTARG 32<br />

mynatal plus 171<br />

mynatal-z 171<br />

mynate 90 plus 171<br />

MYOBLOC 175<br />

MYOZYME 88<br />

myphetane dx 105<br />

mytussin ac 105<br />

mytussin dac 105<br />

N<br />

N-ACETYL-L-CYSTEINE 195<br />

NABI-HB 155<br />

nabumetone 51<br />

nabumetone 53<br />

nacon 3<br />

NADOLOL 46<br />

nadolol 46<br />

nadolol 47<br />

NAFARELIN ACETATE 147<br />

nafcillin sodium 24<br />

NAFCILLIN 24<br />

NAGLAZYME 88<br />

nalbuphine hcl 58<br />

NALDECON SENIOR 129<br />

NALDEX 12<br />

NALEX DH 106<br />

nalex expectorant 106<br />

nalex-a 12 12<br />

NALFRX 12<br />

NALLPEN ISO-OSMOTIC IN DE 24<br />

NALLPEN 24<br />

naloxone hcl 64<br />

NANDROL DEC 146<br />

naproxen dr 53<br />

naproxen ec 53<br />

naproxen sod 53<br />

NAPROXEN SODIUM 195<br />

naproxen sodium 53<br />

NAPROXEN 195<br />

naproxen 51<br />

naproxen 53<br />

narcof 106<br />

NARDIL 66<br />

NARIZ-HC 106<br />

NAROPIN 154<br />

NAROPIN 155<br />

narvox 56<br />

NASACORT AQ 136<br />

nasal decongestant non-dr 129<br />

nasal decongestant sinus 37<br />

nasal four 138<br />

NASATAB LA 129<br />

NASCOBAL 168<br />

nasex-g 129<br />

nasex 129<br />

nasohist 12<br />

NASONEX 136<br />

NATACYN 135<br />

NATAFORT 171<br />

natalcare pic forte 171<br />

natalcare pic 171<br />

natalcare plus 171<br />

natalcare rx 171<br />

natalcare three 171<br />

natamar rx 171<br />

NATAMYCIN 135<br />

natatab fa 171<br />

NATRECOR 45<br />

NATURE-THROI 153<br />

NAVANE 71<br />

NAVARRO BLOOD GLUCOSE MET 177<br />

NAVARRO BLOOD GLUCOSE TES 81<br />

navarro lancets 191<br />

nazarin hc 106<br />

nazarin 129<br />

NEBUPENT 29<br />

necon 0.5/35-28 146<br />

necon 1/35-28 146<br />

necon 1/50-28 146<br />

NECON 10/11-28 146<br />

necon 7/7/7 146<br />

NEDOCROMIL SODIUM 125<br />

nefazodone hcl 67<br />

nefazodone hcl 68<br />

nefazodone 67<br />

NEMBUTAL 74<br />

NEO AC 106<br />

NEO DM 106<br />

NEO HC 106<br />

neo/poly/bac/hc 136<br />

neo/polymyxin/hc 5-10000- 136<br />

neocin-pg 135<br />

neocin 135<br />

created on 20100520 231


neofrin 138<br />

neomycin sulfate 18<br />

neomycin-bacitracin zn-polymyxin<br />

135<br />

neomycin-polymy-dexameth 136<br />

neomycin-polymy-gramicid 135<br />

neomycin-polymyxin-hc (ophth) 136<br />

neomycin-polymyxin-hc (otic) 136<br />

neomycin/bacitracin zn/po 135<br />

neomycin/bacitracin/polym 135<br />

neomycin/bacitracin/polym 136<br />

neomycin/polymyxin/bacitr 135<br />

neomycin/polymyxin/dexame 136<br />

neomycin/polymyxin/gramic 135<br />

neomycin/polymyxin/hc 136<br />

neomycin/polymyxin/hydroc 136<br />

neomycin 17<br />

NEOPROFEN 53<br />

neostigmine methylsulfate 33<br />

NEOTRON-S 39<br />

NEOTUSS PLUS 106<br />

NEOTUSS-D 106<br />

neotuss 106<br />

NEPHRAMINE 87<br />

NERVIDOX-6 NR 168<br />

NESACAINE 155<br />

nescon-pd 129<br />

nestrex 168<br />

netgroup lancets 189<br />

NEULASTA 42<br />

NEUMEGA 42<br />

NEUPOGEN 42<br />

NEURO-B12 FORTE NR 168<br />

NEURO-B12 FORTE 168<br />

neuro-k-250 vitamin b6 168<br />

neuro-k-500 168<br />

neuro-k-50 168<br />

NEURODEP 171<br />

NEUT 83<br />

neutrahist pdx 106<br />

neutrahist 12<br />

NEUTREXIN 29<br />

NEUTROGENA ACNE MASK 161<br />

neutrogena 161<br />

NEXAVIR 175<br />

NEXGEN METER KIT 191<br />

NEXGEN TEST STRIPS 81<br />

NEXIUM I.V. 143<br />

NEXIUM 143<br />

nexphen pd 129<br />

next choice 146<br />

nicardipine hcl 47<br />

nicotine polacrilex 39<br />

NICOTINE TRANSDERMAL SYST 39<br />

nicotine 39<br />

NICOTROL INHALER 39<br />

NICOTROL NS 39<br />

nifediac cc 47<br />

nifedical xl 47<br />

nifedipine 47<br />

niferex-pn forte 171<br />

night time cold medicine 106<br />

NIGHT TIME MULTI-SYMPTOM 106<br />

night time pain medicine 76<br />

night time 106<br />

night-time cold medicine 106<br />

night-time cold/flu relie 106<br />

night-time cough 106<br />

night-time multi-symptom 106<br />

night-time sinus 3<br />

nighttime cold & cough 106<br />

nighttime cold medicine 106<br />

nighttime cold/flu relief 106<br />

nighttime cold 106<br />

nighttime cough 106<br />

nighttime flu/cold/cough 106<br />

nighttime multi-symptom c 106<br />

nighttime sinus congestio 12<br />

NIMBEX 38<br />

nite time childrens cold 106<br />

nite time cold medicine 106<br />

NITE TIME LIQUID CAPS 106<br />

nite time multi-symptom c 106<br />

nite time 106<br />

NITE-TIME COLD/FLU RELIEF 106<br />

nite-time cold/flu relief 106<br />

nite-time cold/flu relief 3<br />

nite-time cough medicine 106<br />

nite-time liquid caps 106<br />

nite-time multi-symptom c 106<br />

nite-time multi-symptom 106<br />

nite-time 106<br />

nitetime multi-symptom co 106<br />

nitrofur mac 29<br />

nitrofurantn 29<br />

nitrofuranto 29<br />

NITROFURANTOIN MACROCRYSTAL<br />

29<br />

nitrofurantoin macrocrystal 29<br />

nitrofurantoin monohyd macro 29<br />

NITROFURANTOIN 29<br />

NITROGLYCER 45<br />

nitroglycerin in d5w 45<br />

NITROGLYCERIN 45<br />

NITROLINGUAL PUMPSPRAY DU 45<br />

NITROLINGUAL PUMPSPRAY 45<br />

NITROPRESS 45<br />

NITROSTAT 45<br />

NIZORAL A-D 159<br />

nohist dmx 106<br />

nohist-a 12<br />

nohist-pdx 106<br />

nohist-pe 12<br />

nohist-plus jr 12<br />

nohist-plus 12<br />

nohist 12<br />

nomuc-pe 129<br />

non aspirin 62<br />

non-asa chld 62<br />

non-asa infa 62<br />

non-asa jr 62<br />

non-asa pain 62<br />

non-asa severe allergy 3<br />

non-aspirin childrens 62<br />

non-aspirin cold 107<br />

NON-ASPIRIN EXTRA STRENGT 62<br />

non-aspirin extra strengt 62<br />

non-aspirin flu maximum s 107<br />

non-aspirin jr strength 62<br />

non-aspirin junior streng 61<br />

non-aspirin junior streng 62<br />

non-aspirin pain relief p 76<br />

non-aspirin pm extra stre 76<br />

NON-ASPIRIN REGULAR STREN 62<br />

non-aspirin severe conges 107<br />

non-aspirin sinus maximum 37<br />

non-aspirin sinus/allergy 12<br />

non-aspirin sinus 37<br />

non-aspirin 62<br />

non-drowsy sinus 37<br />

non-drying sinus 129<br />

non-pseudo cold relief 107<br />

non-pseudo sinus pain/pre 34<br />

NONOXYNOL-9 78<br />

created on 20100520 232


nora-be 147<br />

NORDITROPIN CARTRIDGE 151<br />

NORDITROPIN FLEXPRO 151<br />

NORDITROPIN NORDIFLEX PEN 151<br />

NOREL EX 129<br />

NOREL LA 3<br />

norel sd 12<br />

NOREL SR 16<br />

NORELGESTROMIN-ETHINYL<br />

ESTRADIOL 147<br />

norepinephrine bitartrate 37<br />

norethin ace 151<br />

norethindrone & eth estradiol 147<br />

norethindrone & mestranol 147<br />

norethindrone (contraceptive) 147<br />

norethindrone acetate 151<br />

NORETHINDRONE-ETH ESTRADIOL<br />

(BIPHASIC) 147<br />

norethindrone-eth estradiol (triphasic)<br />

147<br />

norgestimate-ethinyl estradiol 147<br />

norgestrel & ethinyl estradiol 147<br />

norgestrel/ethinyl estrad 147<br />

NORMOSOL-R 85<br />

nortemp 62<br />

NORTHYX 154<br />

northyx 154<br />

nortrel 0.5/35 (28) 147<br />

nortrel 1/35 (21) 147<br />

nortrel 1/35 (28) 147<br />

nortrel 7/7/7 147<br />

nortriptylin 66<br />

nortriptylin 69<br />

nortriptyline hcl 66<br />

nortriptyline hcl 69<br />

nortuss-de 107<br />

nortuss-ex 107<br />

NORVIR 27<br />

NORVIR 28<br />

nose 138<br />

NOTUSS-FORTE 107<br />

NOTUSS-PE 107<br />

NOVA MAX BLOOD GLUCOSE MO 191<br />

NOVA MAX GLUCOSE TEST STR 81<br />

nova sureflex lancets 191<br />

novadyne dh 107<br />

novadyne expectorant 107<br />

novagest expectorant/code 107<br />

NOVAHISTINE DH 107<br />

NOVAPLUS NABI-HB 155<br />

NOVASUS 107<br />

NOVOCAIN 155<br />

NOVOFINE 30GX8MM 191<br />

NOVOFINE 31 191<br />

NOVOFINE 32GX6MM 191<br />

NOVOFINE AUTOCOVER 30GX8M 191<br />

NOVOLIN 70/30 INNOLET 149<br />

NOVOLIN 70/30 PENFILL 149<br />

NOVOLIN 70/30 149<br />

NOVOLIN N INNOLET 149<br />

NOVOLIN N U-100 PENFILL 149<br />

NOVOLIN N U-100 149<br />

NOVOLIN N 149<br />

NOVOLIN R INNOLET 149<br />

NOVOLIN R U-100 PENFILL 149<br />

NOVOLIN R U-100 149<br />

NOVOLIN R 149<br />

NOVOLOG FLEXPEN 149<br />

NOVOLOG MIX 70/30 PENFILL 149<br />

NOVOLOG MIX 70/30 PREFILL 149<br />

NOVOLOG MIX 70/30 149<br />

NOVOLOG PENFILL 149<br />

NOVOLOG 149<br />

NOVOSEVEN RT 43<br />

NOVOSEVEN 43<br />

NPLATE 42<br />

nu-way 138<br />

NUCOFED 107<br />

nuhist pediatric 12<br />

NUMOBID DX 107<br />

NUMOBID 129<br />

NUMONYL DX PEDIATRIC 107<br />

NUMONYL DX 107<br />

numonyl pediatric 129<br />

numonyl sr 129<br />

numonyl 129<br />

NUMORPHAN 57<br />

nupercainal hc 164<br />

nupercainal 164<br />

NUTRITIONAL SUPPLEMENTS 86<br />

NUTROPIN AQ NUSPIN 5 151<br />

NUTROPIN AQ 151<br />

NUTROPIN 151<br />

NUVARING 147<br />

ny-tannic 12<br />

nycair 107<br />

nyquil d cold/flu 107<br />

nystatin (mouth-throat) 27<br />

nystatin (topical) 158<br />

nystatin (topical) 159<br />

NYSTATIN VAG 159<br />

NYSTATIN VAGINAL 159<br />

nystatin-triamcinolone 164<br />

nystatin-triamcinolone 165<br />

nystatin/triamcinolone 164<br />

nystatin 158<br />

NYSTATIN 159<br />

nystatin 159<br />

nystatin 27<br />

created on 20100520 233<br />

O<br />

OCELLA 147<br />

ocella 147<br />

OCTAGAM 156<br />

OCTREOSCAN 175<br />

octreotide acetate 175<br />

OCTRON 171<br />

ocusulf- 135<br />

ocutricin 135<br />

ofloxacin (ophth) 135<br />

ofloxacin (otic) 135<br />

ofloxacin 135<br />

ofloxacin 24<br />

ofloxacin 25<br />

ogestrel 147<br />

OLMESARTAN MEDOXOMIL-<br />

HYDROCHLOROTHIAZIDE 50<br />

OLMESARTAN MEDOXOMIL 50<br />

OLOPATADINE HCL 135<br />

omeprazole 143<br />

OMNIFLEX DIAPHRAGM 78<br />

OMNIHIST II LA 12<br />

omnihist l.a. 12<br />

OMNIPAQUE 82<br />

OMNIPAQUE 83<br />

OMNISCAN SAFEPAK 79<br />

OMNISCAN 79<br />

OMNITROPE 151<br />

ONCASPAR 32<br />

ondansetron hcl and dextrose 142<br />

ONDANSETRON HCL 142<br />

ondansetron hcl 142<br />

ondansetron 142<br />

ONETOUCH BASIC SYSTEM 191<br />

ONETOUCH BASIC/PROFILE TE 81


ONETOUCH BASIC/PROFILE/ON 81<br />

onetouch club lancets fin 191<br />

onetouch combo pack 191<br />

onetouch delica lancets 191<br />

onetouch finepoint lancet 191<br />

onetouch lancets 191<br />

ONETOUCH PROFILE SYSTEM 191<br />

ONETOUCH TEST STRIPS VIAL 81<br />

ONETOUCH TEST STRIPS 81<br />

ONETOUCH ULTRA 2 191<br />

ONETOUCH ULTRA MINI 191<br />

ONETOUCH ULTRA SYSTEM KIT 191<br />

ONETOUCH ULTRA TEST STRIP 81<br />

ONETOUCH ULTRA 191<br />

ONETOUCH ULTRALINK SYSTEM 191<br />

ONETOUCH ULTRASMART 191<br />

onetouch ultrasoft lancet 191<br />

ONSET FORTE 12<br />

ONTAK 32<br />

OPANA 57<br />

OPTICHAMBER ADVANTAGE/LAR 191<br />

OPTICHAMBER ADVANTAGE/MED 191<br />

OPTICHAMBER ADVANTAGE/SMA 191<br />

OPTICHAMBER ADVANTAGE 191<br />

OPTICHAMBER FACE MASK/LAR 191<br />

OPTICHAMBER FACE MASK/MED 191<br />

OPTICHAMBER FACE MASK/SMA 191<br />

OPTIRAY 160 83<br />

OPTIRAY 240 83<br />

OPTIRAY 300 83<br />

OPTIRAY 320 83<br />

OPTIRAY 350 83<br />

OPTIUM BLOOD GLUCOSE MONI 191<br />

OPTIUM TEST STRIPS 81<br />

ORAL ELECTROLYTES 84<br />

ORAMORPH SR 57<br />

ORAXYL 25<br />

ORENCIA 173<br />

organ-i nr 130<br />

organidin nr 130<br />

ornex maximum strength 37<br />

orphenadrine citrate 38<br />

ORPHENADRINE COMPOUND DS 51<br />

orphenadrine compound ds 51<br />

ORPHENADRINE W/ ASPIRIN & CAFF<br />

51<br />

orphenadrine w/ aspirin & caff 51<br />

ORPHENADRINE/ASA/CAFFEINE 51<br />

orphenadrine/asa/caffeine 51<br />

orphenadrine 38<br />

orsini insulin syringe/u- 183<br />

orsini insulin syringe/u- 184<br />

orsini insulin syringe/u- 187<br />

ORTHO DIAPHRAGM ALL-FLEX/ 79<br />

ORTHO DIAPHRAGM ALL-FLEX 79<br />

ORTHO DIAPHRAGM COIL SPRI 78<br />

ORTHO DIAPHRAGM FLAT SPRI 78<br />

ORTHO DIAPHRAGM FLAT SPRI 79<br />

ORTHO EVRA 147<br />

ORTHO TRI-CYCLEN LO 147<br />

ORTHO UNIVERSAL INTRODUCE 79<br />

ORTHOCLONE OKT3 173<br />

oscion clnsr 161<br />

oscion 161<br />

OSELTAMIVIR PHOSPHATE 28<br />

oticin hc 136<br />

OTILAM NR 137<br />

otogesic otic 137<br />

otogesic 137<br />

otra nr 137<br />

OVIDREL 147<br />

oxacillin sodium 24<br />

OXACILLIN 24<br />

oxaliplatin 32<br />

oxaprozin 53<br />

oxazepam 75<br />

oxcarbazepine 66<br />

oxy 10 balance emergency 161<br />

oxy 10 balance maximum me 161<br />

oxy balance 161<br />

oxybutynin chloride 167<br />

oxybutynin 167<br />

oxycodone hcl 57<br />

OXYCODONE W/ ACETAMINOPHEN 57<br />

oxycodone w/ acetaminophen 57<br />

oxycodone w/ aspirin 57<br />

oxycodone-apap 57<br />

oxycodone/acetaminophen 57<br />

oxycodone/apap 57<br />

oxycodone/aspirin 57<br />

oxycodone 57<br />

OXYCONTIN 57<br />

oxytocin 155<br />

created on 20100520 234<br />

P<br />

p chlor gg 130<br />

p d natal vitamins/folic 171<br />

p-d natal plus w/folic 171<br />

p-epd tan/chlor-tan 13<br />

p-hist dm 107<br />

p-hist 107<br />

p-tann d 12<br />

p-tuss dm 107<br />

P-V TUSSIN 107<br />

pacerone 44<br />

paclitaxel 32<br />

PACNEX MX 161<br />

pacnex wash 161<br />

pain ex str 62<br />

pain pm extra strength 76<br />

pain rel 8hr 62<br />

pain rel cld 62<br />

pain relief allergy sinus 12<br />

pain relief cold pe sever 107<br />

pain relief cold pe/day 107<br />

pain relief cold pe/night 107<br />

pain relief cold severe c 107<br />

pain relief cold-cough ch 107<br />

pain relief cold 107<br />

pain relief extra strengt 62<br />

PAIN RELIEF FLU 107<br />

pain relief junior streng 62<br />

pain relief plus cough 107<br />

pain relief pm extra stre 76<br />

pain relief pm 76<br />

pain relief severe allerg 3<br />

pain relief sinus maximum 37<br />

pain relief sinus pe dayt 34<br />

pain relief sinus 37<br />

pain relief 62<br />

pain relieve 62<br />

pain reliever & sleep aid 76<br />

pain reliever allergy sin 12<br />

pain reliever cold multi- 107<br />

pain reliever cold plus c 107<br />

pain reliever extra stren 63<br />

pain reliever flu childre 107<br />

pain reliever junior stre 62<br />

pain reliever junior 62<br />

pain reliever pm extra st 76<br />

pain reliever pm 76<br />

pain reliever sinus 37<br />

pain relievr 63<br />

painaid pmf 63<br />

PALCAPS 10 141


PALCAPS 20 141<br />

pamidronate disodium 172<br />

pamidronate disodium 173<br />

PAMIDRONATE 172<br />

pamprim multi-sympton max 63<br />

PANATUSS DXP PEDIATRIC 107<br />

PANATUSS DXP 107<br />

PANCREASE MT 10 141<br />

PANCREASE MT 16 141<br />

PANCREASE MT 20 141<br />

PANCREASE MT 4 141<br />

PANCRECARB MS-16 141<br />

PANCRECARB MS-4 141<br />

PANCRECARB MS-8 141<br />

PANCRELIPASE 10000 141<br />

PANCRELIPASE 16000 141<br />

PANCRELIPASE 20000 141<br />

PANCRELIPASE 4500 141<br />

PANCRELIPASE MST-16 141<br />

PANCRELIPASE 141<br />

PANCRON 10 141<br />

PANCRON 20 141<br />

pancuronium bromide 38<br />

PANGESTYME CN 10 141<br />

pangestyme cn 10 141<br />

pangestyme cn 20 141<br />

PANGESTYME EC 141<br />

pangestyme ec 141<br />

pangestyme mt 16 141<br />

pangestyme ul 12 141<br />

pangestyme ul 18 141<br />

pangestyme ul 20 141<br />

PANGLOBULIN 156<br />

PANHEMATIN 39<br />

PANOCAPS MT 16 141<br />

PANOCAPS MT 20 141<br />

PANOCAPS 141<br />

panokase-16 141<br />

PANOKASE 141<br />

panoxyl aqua 161<br />

panoxyl wash 161<br />

PANOXYL 161<br />

pantoprazole sodium 143<br />

papaverine hcl 45<br />

PARADIGM LINK BLOOD GLUCO 191<br />

parenteral electrolytes 84<br />

paroxetine hcl 66<br />

paroxetine hcl 67<br />

paroxetine 66<br />

paroxetine 67<br />

PATADAY 135<br />

PATANOL 135<br />

PAXIL CR 67<br />

pbm allergy 107<br />

PC UNIFINE PENTIPS 29G X 194<br />

PC UNIFINE PENTIPS 31G X 194<br />

pcm allergy 12<br />

pcm la 12<br />

pcm 12<br />

pd-cof 107<br />

pd-hist d 12<br />

pdm gg 107<br />

pe 15mg/guai 600mg/dm 30 107<br />

pe 30mg/guai 1200mg 130<br />

pe 30mg/guai 900mg 130<br />

pe tann/cp tann 12<br />

pe-guai 130<br />

pe-hist dm 107<br />

PE-PSE-CPM-PYRIL W/ HYDROCODONE<br />

107<br />

PEAK FLOW METER W/INHALER<br />

ASSIST DEVICE 191<br />

ped multivitamins w/fl & iron 169<br />

pedi-atric cough-cold 108<br />

pedi-atric nightrest 108<br />

pedia relief cough-cold 108<br />

pedia relief cough/cold 108<br />

pedia relief infant 108<br />

pedia relief infants 108<br />

PEDIACARE CHILDRENS ALLER 3<br />

pediacare childrens long- 108<br />

pediacare childrens multi 108<br />

PEDIACARE CHILDRENS NIGHT 3<br />

pediacare infant deconges 108<br />

PEDIACARE INFANT LONG-ACT 108<br />

PEDIACARE LONG ACTING COU 108<br />

pediacare long-acting cou 108<br />

PEDIACARE MULTI-SYMPTOM 108<br />

pediahist dm 108<br />

pediaphyl d 13<br />

PEDIARIX 157<br />

PEDIATANN-CT 3<br />

PEDIATEX-JR DM 108<br />

pediatric cough/cold 108<br />

pediatric decongestant/co 108<br />

pediatric formula cough a 108<br />

pediatric multivitamins w/fl 169<br />

pediatric super tussin co 108<br />

pediatric vitamins acd fluoride & iron<br />

169<br />

pediatric vitamins acd w/ fluoride 169<br />

PEDVAX HIB 157<br />

PEG 3350-KCL-SOD BICARB-SOD<br />

CHLORIDE-SOD SULFATE 140<br />

PEG-INTRON 28<br />

PEGASYS 28<br />

PEN G PROC 22<br />

PEN G SOD 22<br />

PEN NEEDLES 29G X 12MM 191<br />

PEN NEEDLES 29GX1/2" 191<br />

PEN NEEDLES 31G X 1/4" SH 191<br />

PEN NEEDLES 31G X 6MM 191<br />

PEN NEEDLES 31G X 8MM 192<br />

PEN NEEDLES 31GX5/16" 191<br />

PENBUTOLOL SULFATE 47<br />

pendex 130<br />

PENICILLIN G POTASSIUM IN 22<br />

penicillin g potassium 22<br />

penicillin v potassium 22<br />

penicilln vk 22<br />

PENTACEL 157<br />

PENTAM 29<br />

pentamidine isethionate 29<br />

PENTASA 144<br />

PENTASPAN 85<br />

pentostatin 32<br />

PENTOTHAL 50<br />

PENTOTHAL 51<br />

pentuss 108<br />

PEPCID 142<br />

percogesic extra strength 3<br />

PERLOXX 57<br />

permethrin 159<br />

peroderm cleanser 161<br />

peroderm cleanser 162<br />

peroderm 161<br />

perphenazine 71<br />

pertussin 8h 108<br />

pertussin 108<br />

PHANASIN 130<br />

phanasin 130<br />

phanatuss dm 108<br />

PHANATUSS HC 108<br />

pharbedryl 3<br />

created on 20100520 235


pharbetol 63<br />

pharm monoject insulin sy 183<br />

pharm monoject insulin sy 186<br />

PHARMACIST CHOICE AUTOCOD 177<br />

pharmacist choice ultra t 190<br />

pharmacist choice ultra t 194<br />

pharmacy counter lancets 192<br />

pharmasin 130<br />

pharmatuss dm 108<br />

phen/chlor hc 108<br />

PHENA-HC 108<br />

PHENA-PLUS 13<br />

PHENA-S 12 16<br />

phenabid 13<br />

phenadoz 4<br />

phenavent d 130<br />

phenavent la 130<br />

phenavent ped 130<br />

phenavent 130<br />

phenazo 166<br />

phenazopyrid 166<br />

phenazopyridine hcl 166<br />

phenazoyrid 166<br />

phencarb gg 108<br />

phenclor tannate pediatri 13<br />

phendacof hc 108<br />

PHENDACOF PLUS 108<br />

PHENELZINE SULFATE 66<br />

PHENFLU CD 108<br />

PHENFLU CDX 108<br />

PHENFLU DM 108<br />

PHENFLU G 108<br />

phenhist expectorant 108<br />

pheniramine-pe w/ sod salicylate &<br />

caffeine citrate 13<br />

PHENIRAMINE-PHENYLEPHRINE W/<br />

APAP 13<br />

PHENOBARB 74<br />

phenobarb 74<br />

phenobarbital sodium 74<br />

PHENOBARBITAL 195<br />

PHENOBARBITAL 196<br />

PHENOBARBITAL 74<br />

phenobarbital 74<br />

phenoptic 138<br />

phenydex pediatric 130<br />

PHENYDEX 108<br />

phenydryl 13<br />

phenyl chlor-tan 13<br />

PHENYLEPH HCL-DIPHENHYD HCL-<br />

DEXTROMETHORPHAN HBR TANNATE<br />

108<br />

PHENYLEPH HCL-PYRILAMINE MAL-<br />

DEXTROMETHORPHAN HBR TANNATE<br />

108<br />

PHENYLEPH TAN-DEXBROMPHEN TAN<br />

-PYRILAMINE MALEATE-DM TAN 107<br />

PHENYLEPH TANNATE-BROMPHEN<br />

TANNATE-CARBETAPENTANE<br />

TANNATE 108<br />

phenyleph tannate-bromphen tannatecarbetapentane<br />

tannate 108<br />

PHENYLEPH TANNATE-BROMPHEN<br />

TANNATE-DEXTROMETHORPHAN<br />

TANNATE 108<br />

phenyleph tannate-bromphen tannatedextromethorphan<br />

tannate 108<br />

PHENYLEPH TANNATE-CHLORPHEN<br />

TANNATE-CARBETAPENTANE<br />

TANNATE 108<br />

phenyleph tannate-chlorphen tannatecarbetapentane<br />

tannate 108<br />

PHENYLEPH TANNATE-CHLORPHEN<br />

TANNATE-DEXTROMETHORPHAN<br />

TANNATE 108<br />

PHENYLEPH TANNATE-DIPHENHYD<br />

TANNATE-CARBETAPENTANE<br />

TANNATE 108<br />

phenyleph tannate-diphenhyd tannatecarbetapentane<br />

tannate 108<br />

phenyleph tannate-diphenhyd tannatedextromethorphan<br />

tannate 108<br />

PHENYLEPH TANNATE-PYRILAMINE<br />

TANNATE-CARBETAPENTANE<br />

TANNATE 108<br />

phenyleph tannate-pyrilamine tannate<br />

-carbetapentane tannate 108<br />

PHENYLEPH TANNATE-PYRILAMINE<br />

TANNATE-DEXTROMETHORPHAN TAN<br />

109<br />

phenyleph tannate-pyrilamine tannate<br />

-dextromethorphan tan 109<br />

PHENYLEPH-CPM W/ HYDROCOD 109<br />

phenyleph-cpm w/ hydrocod 109<br />

PHENYLEPH-DM-PYRIL-POT GUAI-SOD<br />

CIT-CITRIC ACID 88<br />

phenyleph-dm-pyril-pot guai-sod citcitric<br />

acid 88<br />

phenyleph-dm-sod citrate-citric acid<br />

109<br />

PHENYLEPH-HYDROCODONE 109<br />

phenyleph-hydrocodone 109<br />

phenyleph-promethazine w/ cod 112<br />

PHENYLEPH-PYRIL W/ HYDROCOD 109<br />

phenyleph-pyril w/ hydrocod 109<br />

PHENYLEPH-PYRIL-DM W/APAP 109<br />

phenyleph/chlorphen/hydro 103<br />

phenylephrin 138<br />

phenylephrine cm 13<br />

phenylephrine complex 109<br />

phenylephrine hcl (ophth) 138<br />

phenylephrine hcl (pressors) 34<br />

PHENYLEPHRINE HCL-BROMPHEN<br />

MAL-HYDROCODONE BITART<br />

TANNATE 107<br />

PHENYLEPHRINE HCL-<br />

DEXTROMETHORPHAN HBR-<br />

GUAIFENESIN TANNATE 107<br />

phenylephrine hcl/guaifen 130<br />

PHENYLEPHRINE HCL 138<br />

phenylephrine hcl 138<br />

phenylephrine hd 109<br />

phenylephrine hydrochlori 12<br />

phenylephrine hydrochlori 130<br />

PHENYLEPHRINE TAN-<br />

CARBETAPENTANE TAN &<br />

HOMEOPATHIC PRODUCT 88<br />

PHENYLEPHRINE TAN-<br />

DEXCHLORPHENIR TAN-<br />

DEXTROMETHORPHAN TAN 107<br />

phenylephrine tan-dexchlorphenir tan<br />

-dextromethorphan tan 107<br />

PHENYLEPHRINE TAN-<br />

DEXCHLORPHENIRAMINE TAN-<br />

HYDROCODONE TAN 107<br />

PHENYLEPHRINE TAN-<br />

DIPHENHYDRAMINE TAN-<br />

HYDROCODONE TAN 107<br />

phenylephrine tan-diphenhydramine<br />

tan-hydrocodone tan 107<br />

PHENYLEPHRINE TANNATE-<br />

CARBETAPENTANE TANNATE 109<br />

created on 20100520 236


phenylephrine tannate-carbetapentane<br />

tannate 109<br />

PHENYLEPHRINE TANNATE-<br />

GUAIFENESIN 130<br />

PHENYLEPHRINE TANNATE-<br />

PYRILAMINE TANNATE-GUAIFENESIN<br />

130<br />

phenylephrine tannate-pyrilamine<br />

tannate-guaifenesin 130<br />

phenylephrine tannate/chl 13<br />

PHENYLEPHRINE W/<br />

ACETAMINOPHEN 34<br />

phenylephrine w/ acetaminophen 34<br />

PHENYLEPHRINE W/ CODEINE-GG 110<br />

PHENYLEPHRINE W/ CODEINE 110<br />

PHENYLEPHRINE W/ DM-GG 110<br />

phenylephrine w/ dm-gg 110<br />

PHENYLEPHRINE W/ DM-POTASSIUM<br />

GUAIACOLSULFONATE 130<br />

PHENYLEPHRINE W/HYDROCODONE-<br />

GG 110<br />

phenylephrine w/hydrocodone-gg 110<br />

PHENYLEPHRINE W/HYDROCODONE-<br />

GG 111<br />

phenylephrine w/hydrocodone-gg 111<br />

PHENYLEPHRINE-ACETAMINOPHEN-<br />

GUAIFENESIN-CAFFEINE 130<br />

PHENYLEPHRINE-ACETAMINOPHEN-<br />

GUAIFENESIN 130<br />

phenylephrine-acetaminophenguaifenesin<br />

130<br />

PHENYLEPHRINE-APAP-CAFFEINE 63<br />

PHENYLEPHRINE-BROMPHENIRAMINE<br />

W/ CODEINE 111<br />

phenylephrine-brompheniramine w/<br />

codeine 111<br />

phenylephrine-brompheniraminecarbetapentane<br />

111<br />

PHENYLEPHRINE-BROMPHENIRAMINE<br />

-DEXTROMETHORPHAN-GUAIFENESIN<br />

109<br />

phenylephrine-brompheniraminedextromethorphan-guaifenesin<br />

109<br />

phenylephrine-brompheniraminedihydrocodeine<br />

111<br />

PHENYLEPHRINE-BROMPHENIRAMINE<br />

-DM 111<br />

phenylephrine-brompheniramine-dm<br />

111<br />

PHENYLEPHRINE-BROMPHENIRAMINE<br />

-GUAIFENESIN 130<br />

PHENYLEPHRINE-BROMPHENIRAMINE<br />

-HYDROCODONE 109<br />

phenylephrine-brompheniraminehydrocodone<br />

109<br />

PHENYLEPHRINE-CARBETAPENTANE-<br />

GUAIFENESIN & HOMEOPATHIC PROD<br />

88<br />

PHENYLEPHRINE-CARBETAPENTANE-<br />

GUAIFENESIN 111<br />

phenylephrine-carbetapentaneguaifenesin<br />

111<br />

PHENYLEPHRINE-CARBETAPENTANE-<br />

POTASSIUM GUAIACOLSULFONATE<br />

109<br />

PHENYLEPHRINE-CARBINOXAMINE<br />

W/ HYDROCODONE 111<br />

phenylephrine-carbinoxamine w/<br />

hydrocodone 111<br />

PHENYLEPHRINE-CARBINOXAMINE-<br />

CARBETAPENTANE 111<br />

PHENYLEPHRINE-CARBINOXAMINE-<br />

DM 111<br />

phenylephrine-carbinoxamine-dm 111<br />

PHENYLEPHRINE-CHLORPHEN-DM 111<br />

phenylephrine-chlorphen-dm 111<br />

phenylephrine-chlorphen-gg 130<br />

PHENYLEPHRINE-<br />

CHLORPHENIRAMINE W/ DM-GG 109<br />

phenylephrine-chlorpheniramine w/<br />

dm-gg 109<br />

PHENYLEPHRINE-<br />

CHLORPHENIRAMINE-<br />

CARBETAPENTANE 109<br />

PHENYLEPHRINE-<br />

CHLORPHENIRAMINE-<br />

DIHYDROCODEINE 111<br />

phenylephrine-chlorpheniraminedihydrocodeine<br />

111<br />

phenylephrine-chlorpheniramine-dm<br />

w/ apap 107<br />

phenylephrine-chlorpheniramine-dm<br />

w/ apap 109<br />

PHENYLEPHRINE-<br />

CHLORPHENIRAMINE-DM-GG-<br />

METHSCOPOLAMINE 107<br />

PHENYLEPHRINE-<br />

CHLORPHENIRAMINE-PYRILAMINE-<br />

HYDROCODONE 109<br />

PHENYLEPHRINE-CODEINE-<br />

GUAIFENESIN-ACETAMINOPHEN 111<br />

PHENYLEPHRINE-<br />

DEXBROMPHENIRAMINE-<br />

CHLOPHEDIANOL 111<br />

PHENYLEPHRINE-<br />

DEXBROMPHENIRAMINE-<br />

DEXTROMETHORPHAN 111<br />

PHENYLEPHRINE-<br />

DEXBROMPHENIRAMINE-DM-<br />

GUAIFENESIN 111<br />

phenylephrine-dexbrompheniraminehydrocodone<br />

111<br />

PHENYLEPHRINE-<br />

DEXCHLORPHENIRAMINE-CODEINE<br />

112<br />

PHENYLEPHRINE-<br />

DEXCHLORPHENIRAMINE-<br />

HYDROCODONE 109<br />

phenylephrine-dexchlorpheniraminehydrocodone<br />

109<br />

phenylephrine-dexchlorpheniraminepyrilamine-dm<br />

109<br />

PHENYLEPHRINE-<br />

DEXTROMETHORPHAN-SODIUM<br />

CITRATE 112<br />

PHENYLEPHRINE-DIHYDROCODEINE-<br />

GUAIFENESIN 112<br />

PHENYLEPHRINE-DIHYDROCODEINE<br />

112<br />

PHENYLEPHRINE-DIPHENHYDRAMINE<br />

-CODEINE 109<br />

PHENYLEPHRINE-DIPHENHYDRAMINE<br />

-DM W/ APAP 109<br />

PHENYLEPHRINE-DIPHENHYDRAMINE<br />

-DM W/ APAP 112<br />

PHENYLEPHRINE-DIPHENHYDRAMINE<br />

-DM-GG 107<br />

PHENYLEPHRINE-DIPHENHYDRAMINE<br />

-DM-GUAIFENESIN-APAP 107<br />

phenylephrine-diphenhydramine-gg<br />

w/ apap 130<br />

phenylephrine-diphenhydraminehydrocodone<br />

109<br />

created on 20100520 237


PHENYLEPHRINE-DM-GG W/ APAP 112<br />

phenylephrine-dm-gg w/ apap 112<br />

PHENYLEPHRINE-DM 112<br />

phenylephrine-dm 112<br />

phenylephrine-doxylaminedextromethorphan-acetaminophen<br />

107<br />

PHENYLEPHRINE-DOXYLAMINE-<br />

DEXTROMETHORPHAN-<br />

ACETAMINOPHEN 112<br />

PHENYLEPHRINE-EPHEDRINE-<br />

CHLORPHENIRAMINE W/<br />

CARBETAPENTANE 109<br />

phenylephrine-ephedrinechlorpheniramine<br />

w/ carbetapentane<br />

109<br />

PHENYLEPHRINE-GUAIFENESIN &<br />

HOMEOPATHIC PRODUCT 125<br />

PHENYLEPHRINE-GUAIFENESIN-<br />

CHLORPHENIRAMINE-<br />

METHSCOPOLAMINE 12<br />

PHENYLEPHRINE-GUAIFENESIN-<br />

POTASSIUM CITRATE 130<br />

PHENYLEPHRINE-GUAIFENESIN 130<br />

phenylephrine-guaifenesin 130<br />

PHENYLEPHRINE-GUAIFENESIN 131<br />

phenylephrine-guaifenesin 131<br />

PHENYLEPHRINE-<br />

METHSCOPOLAMINE 34<br />

PHENYLEPHRINE-PHENIRAMINE-COD-<br />

SOD SALICYLATE-SOD CIT-CAFF 88<br />

PHENYLEPHRINE-PHENIRAMINE-DM<br />

112<br />

PHENYLEPHRINE-POTASSIUM<br />

GUAIACOLSULFONATE 131<br />

PHENYLEPHRINE-PYRILAMINE W/ DM-<br />

GG 112<br />

PHENYLEPHRINE-PYRILAMINE W/ DM-<br />

POT GUAIACOLSULFONATE 109<br />

PHENYLEPHRINE-PYRILAMINE W/COD<br />

112<br />

PHENYLEPHRINE-PYRILAMINE-DM 112<br />

phenylephrine-pyrilamine-dm 112<br />

phenylephrine/chlorphenir 13<br />

phenylephrine/cpmm/methsc 12<br />

phenylephrine/gg la 130<br />

phenylephrine/guaifenesin 130<br />

phenylephrine/hydrocodone 107<br />

phenylephrine/hydrocodone 108<br />

phenylephrine/phenyltolox 13<br />

phenylephrine/pyrilamine/ 108<br />

phenylhistine dh modified 112<br />

PHENYLHISTINE DH 112<br />

phenylhistine expectorant 112<br />

PHENYTEK 64<br />

phenytoin ex 64<br />

PHENYTOIN SODIUM EXTENDED 64<br />

phenytoin sodium extended 64<br />

phenytoin sodium 64<br />

PHENYTOIN 64<br />

phenytoin 64<br />

phlemex forte 112<br />

phlemex-pe 112<br />

phlemex 112<br />

PHOSLO 85<br />

PHOTOFRIN 32<br />

PHRENILIN FORTE 63<br />

PHYSOS SALIC 33<br />

physostigmine salicylate 33<br />

PHYTONADIONE 169<br />

phytonadione 169<br />

pilocar 139<br />

PILOCARPINE HCL 139<br />

pilocarpine hcl 139<br />

PILOCARPINE 139<br />

pilocarpine 139<br />

PILOPTIC-1/2 140<br />

piloptic- 139<br />

PILOPTIC- 140<br />

piloptic- 140<br />

piperacillin sodium-tazobactam<br />

sodium 24<br />

PIPERACILLIN 24<br />

PIRBUTEROL ACETATE 36<br />

PIROXICAM 196<br />

piroxicam 53<br />

PLAN B 147<br />

PLARETASE 8000 141<br />

plaretase 8000 141<br />

PLAS/SD GROUP B 39<br />

PLASBUMIN-20 39<br />

PLASMA-LYTE 56 85<br />

PLASMA-LYTE A 85<br />

PLASMA-LYTE-148/D5W 85<br />

PLASMA-LYTE-148 85<br />

PLASMA-LYTE-56/D5W 85<br />

PLASMANATE 39<br />

PLASTIC ADAPTER FOR BUSH 192<br />

PLAVIX 41<br />

pledgaclin 158<br />

PLENAXIS 32<br />

pluratuss 112<br />

pms formula 63<br />

PNEUMOVAX 23/1 DOSE 157<br />

PNEUMOVAX 23/5 DOSE 157<br />

POCKETCHEM EZ BLOOD GLUCO 192<br />

POCKETCHEM EZ BLOOD GLUCO 81<br />

POLY HIST HC 112<br />

poly iron pn forte 171<br />

poly iron pn 171<br />

POLY TAN D 13<br />

POLY TAN DM 112<br />

poly-dex 136<br />

poly-iron 150 forte 39<br />

POLY-TUSSIN HD 112<br />

POLY-TUSSIN XP 112<br />

POLY-TUSSIN 112<br />

POLY-VENT JR. 131<br />

POLY-VENT PLUS 131<br />

POLY-VENT 131<br />

poly-vit drops w/fluoride 171<br />

poly-vitamin/fluoride 171<br />

poly-vitamin/iron/fluorid 171<br />

POLYGAM S/D 156<br />

polygesic 57<br />

polymyxin b sulfate/trime 135<br />

polymyxin b sulfate 26<br />

polymyxin b-trimethoprim 135<br />

polysaccharide iron forte 39<br />

polyvitamin/fluoride 171<br />

polyvites/fluoride 171<br />

polyvits/fluoride/iron 171<br />

PONTOCAINE 155<br />

portia-28 147<br />

pot chloride 85<br />

pot cl micro 85<br />

potassium acetate 85<br />

potassium bicarb & chloride 85<br />

POTASSIUM CHLORIDE 0.224% 85<br />

potassium chloride in dextrose &<br />

sodium chloride 84<br />

potassium chloride in dextrose 85<br />

potassium chloride in nacl 84<br />

potassium chloride microencapsulated<br />

crystals cr 85<br />

created on 20100520 238


POTASSIUM CHLORIDE 196<br />

POTASSIUM CHLORIDE 85<br />

potassium chloride 85<br />

potassium guaiaco/hydroco 112<br />

POTASSIUM GUAIACOLSULFONATE<br />

131<br />

POTASSIUM IODIDE (EXPECTORANT)<br />

131<br />

potassium phosphate dibasic 85<br />

pr benzoyl peroxide wash 162<br />

PRAMOXINE-HC 165<br />

PRANDIN 149<br />

prazosin hcl 46<br />

pre-hist d 13<br />

pre-natal formula 171<br />

pre-natal 171<br />

PRE-PEN 81<br />

PRECARE PRENATAL 171<br />

PRECEDEX 76<br />

PRECISION LINK 192<br />

PRECISION PCX PLUS TEST S 81<br />

PRECISION PCX 81<br />

PRECISION POINT OF CARE T 81<br />

PRECISION QID MONITOR 192<br />

PRECISION QID TEST STRIPS 81<br />

PRECISION SOF-TACT MONITO 192<br />

PRECISION SOF-TACT TEST S 81<br />

precision sure-dose insul 181<br />

precision sure-dose insul 182<br />

precision sure-dose insul 183<br />

precision sure-dose insul 184<br />

precision sure-dose insul 185<br />

precision sure-dose plus 180<br />

precision sure-dose plus 186<br />

precision thin lancets 192<br />

precision thins gp lancet 190<br />

precision ultra lancet 192<br />

PRECISION XTRA BLOOD GLUC 81<br />

PRECISION XTRA MONITOR 192<br />

PRECISION XTRA 192<br />

pred sod pho 145<br />

PRED-G S.O.P. 136<br />

PRED-G 136<br />

prednicarbat 165<br />

prednicarbate 165<br />

prednisolone acetate (ophth) 137<br />

PREDNISOLONE ANHYDROUS 196<br />

PREDNISOLONE HYDROUS 196<br />

prednisolone sodium phosp 145<br />

PREDNISOLONE SODIUM PHOSPHATE<br />

145<br />

prednisolone sodium phosphate 145<br />

prednisolone sol 145<br />

prednisolone/sulfacetamid 136<br />

prednisolone/sulfacetamid 137<br />

prednisolone 137<br />

PREDNISOLONE 145<br />

prednisolone 145<br />

PREDNISOLONE 196<br />

PREDNISONE 145<br />

prednisone 145<br />

PREDNISONE 146<br />

prednisone 146<br />

preferred plus insulin sy 180<br />

preferred plus insulin sy 181<br />

preferred plus insulin sy 182<br />

preferred plus insulin sy 183<br />

preferred plus insulin sy 184<br />

preferred plus insulin sy 185<br />

preferred plus insulin sy 186<br />

preferred plus insulin sy 187<br />

preferred plus lancets co 189<br />

preferred plus lancets su 190<br />

preferred plus lancets th 190<br />

PREFERRED PLUS UNIFINE PE 194<br />

PREGABALIN 66<br />

PREMARIN 147<br />

PREMASOL 87<br />

premsyn pms maximum stren 63<br />

premsyn pms 63<br />

prenaplus 171<br />

prenatabs fa 171<br />

prenatal 1 plus 1 171<br />

prenatal and iron 172<br />

prenatal fa 171<br />

prenatal formula 3 171<br />

prenatal formula 171<br />

prenatal forte 171<br />

prenatal low iron 171<br />

prenatal mr 90 fe 171<br />

prenatal mtr/selenium 171<br />

prenatal multivit-min w/fe-fa 169<br />

prenatal multivitamin & 171<br />

prenatal plus nf 171<br />

prenatal plus/27mg iron 172<br />

prenatal plus/betacaroten 171<br />

prenatal plus/iron 171<br />

prenatal plus 171<br />

prenatal rx 1 172<br />

prenatal rx/beta-carotene 172<br />

prenatal rx 172<br />

prenatal s 172<br />

prenatal vit w/ docusate-fe fumaratefolic<br />

acid 169<br />

prenatal vit w/ ferrous fumarate-folic<br />

acid 169<br />

PRENATAL VIT W/ FERROUS<br />

FUMARATE-FOLIC ACID 170<br />

prenatal vit w/ ferrous fumarate-folic<br />

acid 170<br />

PRENATAL VIT W/ FERROUS<br />

GLUCONATE-FOLIC ACID 170<br />

prenatal vit w/ ferrous gluconate-folic<br />

acid 170<br />

PRENATAL VIT W/ IRON CARBONYL-<br />

FE SULFATE-FOLIC ACID 170<br />

prenatal vit w/ iron carbonyl-fe<br />

sulfate-folic acid 170<br />

prenatal vit w/ iron polysaccharide<br />

complex-folic acid 170<br />

PRENATAL VIT W/ SELENIUM-FE<br />

FUMARATE-FOLIC ACID 170<br />

prenatal vit w/ selenium-fe fumaratefolic<br />

acid 170<br />

prenatal vitamins 171<br />

prenatal vitamins 172<br />

PRENATAL WITHOUT A VIT W/ FE<br />

FUMARATE-FOLIC ACID 170<br />

prenatal without a vit w/ fe fumaratefolic<br />

acid 170<br />

prenatal z advanced formu 172<br />

prenatal z 172<br />

prenatal/folic acid 172<br />

prenatal 171<br />

prenavite multiple vitami 172<br />

prenavite protein coated 172<br />

PRENTIF CAVITY-RIM CERVIC 79<br />

PRENTIF FITTING SET 79<br />

prep h hc 165<br />

prestige lite touch lance 190<br />

PRESTIGE LX BLOOD GLUCOSE 192<br />

PRESTIGE LX STARTER KIT 192<br />

PRESTIGE SMART SYSTEM CO- 192<br />

PRESTIGE SMART SYSTEM CO- 81<br />

created on 20100520 239


PRESTIGE SMART SYSTEM IQ 192<br />

prestige smart system lan 192<br />

PRESTIGE SMART SYSTEM VAL 192<br />

PRESTIGE SMART SYSTEM/MET 192<br />

PRESTIGE TEST STRIPS 81<br />

PRESTIGE VALUE PACK 81<br />

PREVACID 24H 143<br />

PREVACID I.V 143<br />

PREVACID NAPRAPAC 53<br />

PREVACID SOLUTAB 143<br />

PREVACID 143<br />

previfem 147<br />

PREVNAR 13 157<br />

PREVNAR 157<br />

PREVPAC 143<br />

PRIALT 63<br />

PRIMALEV 57<br />

PRIMAQUINE PHOSPHATE 196<br />

PRIMAQUINE PHOSPHATE 29<br />

PRIMAQUINE 29<br />

PRIMAXIN I.M. 20<br />

PRIMAXIN IV 20<br />

primidone 64<br />

PRIMLEV 57<br />

PRISMASOL B22GK 2/0 85<br />

PRISMASOL BGK 0/2.5 85<br />

PRISMASOL BGK 2/0 85<br />

PRISMASOL BGK 2/3.5 85<br />

PRISMASOL BGK 4/0/1.2 85<br />

PRISMASOL BGK 4/2.5 85<br />

PRISMASOL BK 0/0/1.2 85<br />

PRIVIGEN 156<br />

PRO-CLEAR AC 112<br />

PRO-CLEAR 112<br />

pro-otic 137<br />

PRO-RED AC 112<br />

PRO-RED 112<br />

pro-tannate pediatric 13<br />

PROAIR HFA 35<br />

PROAIR HFA 36<br />

PROCAINAMIDE HCL 43<br />

procainamide hcl 43<br />

PROCAINAMIDE HCL 44<br />

procainamide 43<br />

PROCAINAMIDE 44<br />

PROCALAMINE 87<br />

PROCANBID 44<br />

PROCARBAZINE HCL 32<br />

PROCENTRA 72<br />

prochlorper 71<br />

prochlorperazine edisylate 71<br />

prochlorperazine maleate 71<br />

prochlorperazine 71<br />

PROCRIT 42<br />

procto-kit 165<br />

procto-pak 165<br />

proctocare-hc 165<br />

proctocream-hc 165<br />

PROCTOFOAM HC 166<br />

proctosert h 165<br />

proctosol hc 165<br />

proctozone-hc 165<br />

prodec-dm 112<br />

PRODIGY AUTOCODE BLOOD GL 192<br />

PRODIGY AUTOCODE BLOOD GL 81<br />

PRODIGY BLOOD GLUCOSE MON 192<br />

PRODIGY BLOOD GLUCOSE TES 81<br />

PRODIGY EJECT BLOOD GLUCO 192<br />

PRODIGY EJECT BLOOD GLUCO 81<br />

prodigy insulin syring/u- 182<br />

prodigy insulin syringe/1 185<br />

PRODIGY NO CODING BLOOD G 81<br />

PRODIGY POCKET BLOOD GLUC 192<br />

PRODIGY PREFERRED BLOOD G 192<br />

prodigy pressure activate 192<br />

prodigy safety lancets 192<br />

prodigy twist top lancets 192<br />

PRODIGY VOICE BLOOD GLUCO 192<br />

PRODIGY VOICE BLOOD GLUCO 81<br />

PROFASI HP 147<br />

PROFILNINE 43<br />

progesterone 151<br />

PROGRAF 173<br />

PROHANCE 79<br />

PROLASTIN-C 134<br />

PROLASTIN 134<br />

PROLEUKIN 32<br />

prolex dh expectorant 112<br />

PROLEX DMX 112<br />

promethazine & phenylephrine 4<br />

PROMETHAZINE HCL 196<br />

PROMETHAZINE HCL 4<br />

promethazine hcl 4<br />

promethazine vc plain 4<br />

promethazine vc/codeine 112<br />

promethazine vc 4<br />

promethazine w/codeine 112<br />

promethazine-dm 112<br />

promethazine/codeine 112<br />

promethazine/dextromethor 112<br />

promethazine/phenylephrin 4<br />

PROMETHAZINE 4<br />

promethazine 4<br />

promethegan 4<br />

PROMIT 86<br />

PROMOTE 87<br />

PRONESTYL 44<br />

PROPANTHELIN 34<br />

propanthelin 34<br />

PROPANTHELINE BROMIDE 34<br />

propantheline bromide 34<br />

PROPINE 138<br />

PROPLEX T FACTOR IX COMP 43<br />

propofol 51<br />

propoxacet-n 57<br />

propoxyphene napsylate/ac 57<br />

propoxyphene-n w/ apap 57<br />

propoxyphene-n w/ apap 58<br />

propoxyphene-n/acetaminop 57<br />

propranolol hcl 47<br />

PROPRANOLOL 47<br />

propranolol 47<br />

propylthiour 154<br />

propylthiouracil 154<br />

PROQUAD 157<br />

proset d 131<br />

PROSOL 87<br />

PROSTASCINT 175<br />

PROTAMINE SU 42<br />

protex d 112<br />

protex 112<br />

PROTID 13<br />

PROTONIX 143<br />

PROTOPIC 167<br />

PROVENGE 32<br />

PROVENTIL HFA 36<br />

PROVIGIL 74<br />

PROVISC 140<br />

PROZAC WEEKL 67<br />

pse 120/msc 2.5 37<br />

pse 15/cpm 2 13<br />

pse 90/cpm 8/msc 2.5 10<br />

pse allergy dm 112<br />

pse allergy 3<br />

created on 20100520 240


pse bpm hd 112<br />

pse bpm 13<br />

pse brom dm 113<br />

pse carb dm 113<br />

pse carbinoxamine dm 113<br />

pse cpm 13<br />

pse/cpm 13<br />

pseubrom-pd 13<br />

pseubrom 13<br />

PSEUDACARB 113<br />

pseudatex hc 113<br />

pseudo carb dm 113<br />

pseudo carb 3<br />

pseudo cm 13<br />

pseudo cough 113<br />

pseudo gg tr 131<br />

pseudo max dmx 113<br />

pseudo max 131<br />

pseudo-chlor/codeine 113<br />

pseudo-plus 13<br />

pseudo/bromphen maleate 13<br />

pseudo/guaifen/dex 113<br />

pseudo/trip 13<br />

PSEUDOEPH HCL-PYRILAMINE MAL-<br />

DEXTROMETHORPHAN HBR TANNATE<br />

113<br />

PSEUDOEPH W/HYDROCODONE-GG<br />

116<br />

pseudoeph w/hydrocodone-gg 116<br />

PSEUDOEPH-CHLORPHEN W/ COD 116<br />

pseudoeph-chlorphen w/ cod 116<br />

PSEUDOEPH-CPM-DM W/APAP 113<br />

pseudoeph-cpm-dm w/apap 113<br />

PSEUDOEPH-CPM-GG 131<br />

PSEUDOEPH-DIPHENHYD-DM W/APAP<br />

113<br />

pseudoeph/carbinox/dm 113<br />

pseudoeph/guaifenesin 131<br />

PSEUDOEPHED HCL-CARBINOX MAL-<br />

DM HBR TANNATE 113<br />

pseudoephed hcl-chlorphen mal-dm<br />

hbr tannate 113<br />

PSEUDOEPHED-BROMPHEN-DM 114<br />

pseudoephed-bromphen-dm 114<br />

PSEUDOEPHED-CARBINOX-DM 114<br />

pseudoephed-carbinox-dm 114<br />

PSEUDOEPHED-CPM W/ HYDROCOD<br />

113<br />

pseudoephed-cpm w/ hydrocod 113<br />

pseudoephed-doxyl-dm w/apap 113<br />

PSEUDOEPHED-METHSCOP &<br />

CHLORPHEN-PHENYLEPH-METHSCOP<br />

13<br />

pseudoephedrine cold/alle 13<br />

PSEUDOEPHEDRINE HCL-CHLORPHEN<br />

MAL-HYDROCODONE BITART<br />

TANNATE 113<br />

PSEUDOEPHEDRINE HCL-<br />

DEXTROMETHORPHAN HBR-<br />

GUAIFENESIN TANNATE 113<br />

pseudoephedrine hcl/chlor 13<br />

pseudoephedrine hcl/guaif 113<br />

PSEUDOEPHEDRINE HCL/GUAIF 131<br />

pseudoephedrine hcl/guaif 131<br />

pseudoephedrine hcl/tripr 13<br />

pseudoephedrine plus 13<br />

PSEUDOEPHEDRINE TAN-BROMPHEN<br />

TAN-DEXTROMETHORPHAN TAN 113<br />

pseudoephedrine tan-bromphen tandextromethorphan<br />

tan 113<br />

PSEUDOEPHEDRINE TAN-<br />

BROMPHENIRAMINE TAN-<br />

HYDROCODONE TAN 113<br />

PSEUDOEPHEDRINE TAN-<br />

CARBINOXAMINE TAN-<br />

DEXTROMETHORPHAN TAN 113<br />

pseudoephedrine tan-carbinoxamine<br />

tan-dextromethorphan tan 113<br />

PSEUDOEPHEDRINE TAN-CHLORPHEN<br />

TAN-DEXTROMETHORPHAN TAN 114<br />

pseudoephedrine tan-chlorphen tandextromethorphan<br />

tan 114<br />

PSEUDOEPHEDRINE TAN-<br />

DEXCHLORPHEN TAN-<br />

DEXTROMETHORPHAN TAN 114<br />

pseudoephedrine tan-dexchlorphen<br />

tan-dextromethorphan tan 114<br />

PSEUDOEPHEDRINE TANNATE-<br />

CARBETAPENTANE TANNATE 114<br />

pseudoephedrine tannatecarbetapentane<br />

tannate 114<br />

PSEUDOEPHEDRINE TANNATE-<br />

HYDROCODONE TANNATE 114<br />

PSEUDOEPHEDRINE W/ APAP-DM 114<br />

pseudoephedrine w/ apap-dm 114<br />

PSEUDOEPHEDRINE W/ APAP-DM 115<br />

pseudoephedrine w/ apap-dm 115<br />

PSEUDOEPHEDRINE W/ APAP 37<br />

pseudoephedrine w/ apap 37<br />

PSEUDOEPHEDRINE W/ CODEINE-GG<br />

115<br />

pseudoephedrine w/ codeine-gg 115<br />

PSEUDOEPHEDRINE W/ CODEINE 115<br />

pseudoephedrine w/ codeine 115<br />

PSEUDOEPHEDRINE W/ DM-GG 115<br />

pseudoephedrine w/ dm-gg 115<br />

PSEUDOEPHEDRINE W/ DM-GG 116<br />

pseudoephedrine w/ dm-gg 116<br />

pseudoephedrine w/ hydrocodonepotassium<br />

guaiacolsulfonate 113<br />

PSEUDOEPHEDRINE W/<br />

HYDROCODONE 116<br />

pseudoephedrine w/ hydrocodone 116<br />

PSEUDOEPHEDRINE-ACETAMINOPHEN<br />

-GUAIFENESIN 131<br />

PSEUDOEPHEDRINE-<br />

BROMPHENIRAMINE-CODEINE 116<br />

pseudoephedrine-brompheniraminecodeine<br />

116<br />

PSEUDOEPHEDRINE-<br />

BROMPHENIRAMINE-<br />

DIHYDROCODEINE 114<br />

pseudoephedrine-brompheniraminedm-gg<br />

114<br />

PSEUDOEPHEDRINE-<br />

BROMPHENIRAMINE-HYDROCODONE<br />

113<br />

pseudoephedrine-brompheniraminehydrocodone<br />

113<br />

PSEUDOEPHEDRINE-<br />

CARBETAPENTANE-GUAIFENESIN 114<br />

pseudoephedrine-carbinoxamine w/<br />

hydrocodone 113<br />

PSEUDOEPHEDRINE-CHLOPHEDIANOL<br />

-GUAIFENESIN 116<br />

PSEUDOEPHEDRINE-CHLORPHEN-DM<br />

114<br />

pseudoephedrine-chlorphen-dm 114<br />

PSEUDOEPHEDRINE-<br />

CHLORPHENIRAMINE W/ DM-GG 114<br />

PSEUDOEPHEDRINE-<br />

CHLORPHENIRAMINE W/<br />

HYDROCODONE-GG 116<br />

created on 20100520 241


pseudoephedrine-chlorpheniramine<br />

w/ hydrocodone-gg 116<br />

PSEUDOEPHEDRINE-<br />

CHLORPHENIRAMINE-<br />

DIHYDROCODEINE 114<br />

pseudoephedrine-chlorpheniraminedihydrocodeine<br />

114<br />

PSEUDOEPHEDRINE-CODEINE-<br />

GUAIFENESIN-ACETAMINOPHEN 114<br />

PSEUDOEPHEDRINE-<br />

DEXBROMPHENIRAMINE W/ DM-GG<br />

116<br />

PSEUDOEPHEDRINE-<br />

DEXCHLORPHENIRAMINE-<br />

CHLOPHEDIANOL 114<br />

PSEUDOEPHEDRINE-<br />

DIHYDROCODEINE-GUAIFENESIN 116<br />

pseudoephedrine-dihydrocodeineguaifenesin<br />

116<br />

PSEUDOEPHEDRINE-DM-GG W/ APAP<br />

116<br />

pseudoephedrine-dm-gg w/ apap 116<br />

PSEUDOEPHEDRINE-DM-GG W/ APAP<br />

117<br />

PSEUDOEPHEDRINE-DM-GG-SODIUM<br />

CITRATE 117<br />

PSEUDOEPHEDRINE-DM 116<br />

pseudoephedrine-dm 116<br />

PSEUDOEPHEDRINE-GUAIFENESIN 131<br />

pseudoephedrine-guaifenesin 131<br />

PSEUDOEPHEDRINE-GUAIFENESIN 132<br />

pseudoephedrine-guaifenesin 132<br />

PSEUDOEPHEDRINE-IBUPROFEN 37<br />

pseudoephedrine-ibuprofen 37<br />

pseudoephedrine-methscopolamine 37<br />

pseudoephedrine-naproxen sodium 53<br />

PSEUDOEPHEDRINE-PYRILAMINE-<br />

CARBETAPENTANE 114<br />

PSEUDOEPHEDRINE-PYRILAMINE-<br />

CODEINE 117<br />

PSEUDOEPHEDRINE-TRIPROLIDINE-<br />

HYDROCODONE 114<br />

pseudoephedrine/brompheni 13<br />

pseudoephedrine/chlorphen 13<br />

pseudoephedrine/codeine 113<br />

PSEUDOEPHEDRINE/DEXTROMET 113<br />

pseudoephedrine/dextromet 113<br />

pseudoephedrine/guaifenes 113<br />

pseudoephedrine/guaifenes 114<br />

PSEUDOEPHEDRINE/GUAIFENES 131<br />

pseudoephedrine/guaifenes 131<br />

pseudoephedrine/hydrocodo 113<br />

pseudopehedrine-dextromet 113<br />

PSEUDOVENT 400 132<br />

pseudovent 400 132<br />

pseudovent dm 117<br />

pseudovent ped 132<br />

pseudovent 132<br />

pseudox m 3<br />

psoriatec 167<br />

pss select gp lancets 192<br />

pss select safety lancets 192<br />

PTS PANELS GLUCOSE TEST 81<br />

pulexn dm 117<br />

pulmari-gp 117<br />

pulmari 117<br />

PULMICORT FLEXHALER 146<br />

PULMICORT TURBUHALER 146<br />

PULMICORT 146<br />

px allergy sinus pe 13<br />

px childrens pain relief 60<br />

px cold relief multi-symp 93<br />

px cold/flu relief day/ni 94<br />

px dayhist 3<br />

px daytime cold/flu relie 117<br />

px daytime cold 117<br />

px daytime multi-symptom 117<br />

px daytime pe 95<br />

px dibromm cold/allergy c 13<br />

px dibromm dm cold/cough 97<br />

PX EXTRA SHORT PEN NEEDLE 191<br />

px ibuprofen cold & sinus 37<br />

px insulin syringe/u-100/ 181<br />

px insulin syringe/u-100/ 182<br />

px insulin syringe/u-100/ 184<br />

px insulin syringe/u-100/ 185<br />

px insulin syringe/u-100/ 187<br />

px insulin syringe/u-100/ 188<br />

px lancets ultra thin 192<br />

px lancets 192<br />

PX MEDICATED CHESTRUB 175<br />

px nighttime cold 117<br />

px nitetime cold/flu reli 117<br />

px nitetime cough 117<br />

px nitetime multi-symptom 117<br />

px pain relief pm extra s 76<br />

PX PEN NEEDLE 29GX12MM 191<br />

PX PEN NEEDLE 31GX8MM 192<br />

px prenatal multivitamins 172<br />

px severe cold 117<br />

px sinus relief 34<br />

px tussin cf 117<br />

px tussin dm 117<br />

px tussin 132<br />

pyrazinamide 27<br />

pyri 168<br />

pyrichlor pe 13<br />

pyridostigm 33<br />

PYRIDOSTIGMINE BROMIDE 33<br />

pyridostigmine bromide 33<br />

pyridoxine hcl 169<br />

PYRIDOXINE/MINERALS 169<br />

pyridoxine 168<br />

pyridoxine 169<br />

pyril d 13<br />

pyril dm 117<br />

pyril mal/phenyleph hcl/d 117<br />

pyril mal/phenyleph hcl 13<br />

pyrilafen tannate-12 4<br />

PYRILAMINE MALEATE-<br />

PHENYLEPHRINE HCL TANNATE 13<br />

pyrilamine maleate-phenylephrine hcl<br />

tannate 13<br />

PYRILAMINE MALEATE-<br />

PSEUDOEPHEDRINE HCL TANNATE 4<br />

PYRILAMINE TANNATE-<br />

PHENYLEPHRINE TANNATE 4<br />

pyrilamine tannate-phenylephrine<br />

tannate 4<br />

PYRILAMINE-DM-GG-SODIUM<br />

CITRATE 117<br />

PYRILAMINE-PHENYLEPHRINE 4<br />

PYRIMETHAMINE 29<br />

PYRLEX CB 117<br />

PYRLEX PD 4<br />

pyrroxate 34<br />

created on 20100520 242<br />

Q<br />

q-pap child 63<br />

q-pap childrens 63<br />

q-pap ex st 63<br />

q-pap infant 63<br />

q-pap 63<br />

q-tapp dm 117<br />

q-tapp 13


q-tussin cf cough & cold 117<br />

q-tussin dm 117<br />

q-tussin pe -af 132<br />

q-tussin 132<br />

q-v tussin 117<br />

qc allergy relief multi-s 13<br />

qc allergy relief multi-s 3<br />

qc allergy/sinus headache 3<br />

qc allergy/sinus-d 3<br />

qc arthritis 63<br />

qc azo 166<br />

qc cgh relf 117<br />

qc childrens non-aspirin 60<br />

qc cold & allergy dm 93<br />

qc cold & allergy 9<br />

qc cold head congestion n 117<br />

qc cold head congestion s 117<br />

qc cold multi-symptom nig 105<br />

qc cold multi-symptom sev 105<br />

qc cold relief plus multi 117<br />

qc cold relief plus 9<br />

qc cold relief 3<br />

qc cold/allergy 9<br />

qc cough/cold 117<br />

qc cough/sore throat dayt 117<br />

qc cough/sore throat nigh 117<br />

qc daytime cold medicine 117<br />

qc daytime multi-symptom 117<br />

qc daytime sinus 34<br />

qc daytime sinus 37<br />

qc flu relief therapy sev 117<br />

qc flu relief therapy sev 3<br />

qc heartburn 142<br />

QC HOT STEAM 175<br />

qc hydrocort 165<br />

qc hydrocortisone maximum 165<br />

qc ibuprofen cold/sinus 37<br />

qc ibuprofen/pseudoephedr 36<br />

qc infants 63<br />

qc insulin syringe 0.5ml/ 183<br />

qc insulin syringe 0.5ml/ 184<br />

QC INSULIN SYRINGE 1ML/29 186<br />

qc insulin syringe/0.3ml/ 181<br />

qc insulin syringe/0.5ml/ 183<br />

qc insulin syringe/0.5ml/ 185<br />

qc insulin syringe/1ml/29 186<br />

qc insulin syringe/1ml/30 187<br />

qc insulin syringe/1ml/31 188<br />

qc intense cold medicine 3<br />

qc intense cough reliever 104<br />

qc lancets super thin 192<br />

qc lancets thin 192<br />

qc lancets ultra thin 192<br />

qc lancets 192<br />

qc medifin cp 132<br />

qc medifin dm 117<br />

qc medifin 132<br />

qc multi way 138<br />

qc nighttime cold/flu rel 117<br />

qc nighttime cough 117<br />

qc nighttime multi-sympto 117<br />

qc nighttime sinus 3<br />

qc non-aspirin childrens 63<br />

qc non-aspirin pm 76<br />

QC PEN NEEDLES 29G X 12MM 191<br />

QC PEN NEEDLES 31G X 6MM 191<br />

QC PEN NEEDLES 31G X 8MM 192<br />

qc pms multi-symptom 63<br />

qc prenatal 172<br />

qc severe allergy 3<br />

qc severe cold & cough da 117<br />

qc severe cold & cough ni 3<br />

qc severe cold congestion 119<br />

qc sinus congestion & pai 133<br />

qc sinus pain relief 34<br />

qc suphedrine cold/allerg 13<br />

qc suphedrine sinus night 13<br />

qc triactin chest congest 132<br />

qc triactin cold/allergy 15<br />

qc triactin cold/cough 121<br />

qc tussin cf 117<br />

qc tussin cf 123<br />

qc tussin cold/cough 123<br />

QDALL 13<br />

quad tann pediatric 117<br />

quad tann 117<br />

quad-tuss tannate pediatr 117<br />

QUADRAMET 155<br />

quadratuss pediatric 117<br />

quadratuss 117<br />

qual-tussin dc 117<br />

qual-tussin pediatric 132<br />

qual-tussin 117<br />

quala-hc 117<br />

quartuss dm 117<br />

quartuss 117<br />

QUELICIN 1000 38<br />

QUICKTEK TEST STRIPS 81<br />

QUICKTEK 192<br />

quinapril hcl 50<br />

quinapril 50<br />

quindal-hd 117<br />

QUINIDINE GL 44<br />

quinidine gl 44<br />

quinidine gluconate 44<br />

quinidine su 44<br />

quinidine sulfate 44<br />

quintex hc 117<br />

quintex 132<br />

qv-allergy 13<br />

QVAR 146<br />

created on 20100520 243<br />

R<br />

R-GENE 82<br />

r-tanna pediatric 13<br />

r-tanna 13<br />

r-tannamine pediatric 13<br />

ra acetamin 63<br />

ra acetaminophen extra st 63<br />

ra acetaminophen flu nigh 3<br />

ra acetaminophen flu seve 117<br />

ra acetaminophen plus ext 63<br />

ra acetaminophen pm extra 76<br />

ra acne 162<br />

ra acta-tabs pe 13<br />

ra acta-tabs 13<br />

ra allergy multi-symptom 13<br />

ra allergy multi-symptom 3<br />

ra athenol 63<br />

ra benzoyl 162<br />

RA BLOOD GLUCOSE MONITOR 192<br />

RA BLOOD GLUCOSE TEST STR 81<br />

ra cetirizin 17<br />

ra childrens flu formula 117<br />

ra childrens nite time 117<br />

ra childrens plus cough/r 117<br />

ra childrens plus multisy 117<br />

ra chld apap 63<br />

ra cold & allergy 13<br />

ra cold & cough dm 117<br />

ra cold & flu 13<br />

ra cold multi-symptom day 93<br />

ra cold multi-symptom nig 93<br />

ra cold multi-symptom sev 93<br />

ra cold relief maximum st 93


a cold/allergy dibromm 9<br />

ra complete symptomatic c 117<br />

ra cough/cold dm 117<br />

ra dandruff shampoo 162<br />

ra day time cold/flu form 117<br />

ra daytime cold/flu 117<br />

ra daytime multi-symptom 117<br />

ra decongestant inhaler 175<br />

ra decongestant pe cough 132<br />

ra e-zject lancets 28g 192<br />

ra e-zject lancets thin 2 192<br />

ra e-zject lancets ultra 192<br />

RA EFFERVESCENT PLUS COLD 11<br />

ra flu maximum strength 117<br />

ra flu/cold/cough medicin 100<br />

ra hydrocort 165<br />

ra hydrocortisone maximum 165<br />

ra hydrocortisone plus 12 165<br />

ra hydrocortisone plus 165<br />

ra ibu-profen cold/sinus 37<br />

ra ibuprofen cold childre 37<br />

ra infants cold/cough 117<br />

ra insulin syringe/0.5ml/ 183<br />

ra insulin syringe/1ml/29 186<br />

ra insulin syringe/u-100/ 184<br />

ra insulin syringe/u-100/ 187<br />

ra lancets alternate site 192<br />

ra lancets colored 192<br />

ra lancets thin 192<br />

ra lancets ultra thin 192<br />

ra lancets 192<br />

RA MEDICATED CHEST RUB 175<br />

ra menstrual relief 63<br />

ra nasal decongestant/ant 13<br />

ra nighttime flu/cold/cou 117<br />

ra nite time cold formula 117<br />

ra nite time cold/flu for 117<br />

ra nite time cold/flu for 118<br />

ra nite time cough 118<br />

ra nitetime cold/flu 118<br />

ra non-asa 63<br />

ra non-aspirin junior str 62<br />

ra nose drops extra stren 138<br />

ra pedia relief cough/col 108<br />

RA PEN NEEDLES 31G X 5MM 193<br />

RA PEN NEEDLES 31G X 8MM 192<br />

ra premenstrual symptom r 63<br />

ra prenatal/folic acid 172<br />

ra prenatal 172<br />

ra sinus congestion & pai 13<br />

ra sinus congestion & pai 34<br />

ra sinus formula daytime 34<br />

ra sinus formula 37<br />

ra sinus tablets extra st 13<br />

ra sinus 13<br />

ra suphedrine cold/allerg 13<br />

ra suphedrine non-drying 132<br />

ra suphedrine pe sinus he 35<br />

ra suphedrine pe 15<br />

ra suphedrine pe 34<br />

ra suphedrine 13<br />

ra triacting cold/cough n 118<br />

ra triacting sore throat 121<br />

RA TRUETEST STRIPS 81<br />

ra tussin cf 118<br />

ra tussin cough 123<br />

ra tussin dm 118<br />

ra tussin pe 132<br />

ra tussin 118<br />

ra tussin 132<br />

ra urinary 166<br />

ra vaporizing steam 175<br />

ra vit b-6 169<br />

RABAVERT 157<br />

ralix 13<br />

ramipril 50<br />

RANITIDINE HCL 143<br />

ranitidine hcl 143<br />

ranitidine 143<br />

RAPAMUNE 173<br />

RAPTIVA 167<br />

re all 12 118<br />

re chlordiazepoxide/clidi 33<br />

re dcp 118<br />

re multivit with fluoride 171<br />

re tann d 3<br />

re-azo 166<br />

re-drylex jr 14<br />

RE-DRYLEX 14<br />

re-pb hyos 34<br />

re2+30 14<br />

reality insulin syringe/u 182<br />

reality insulin syringe/u 183<br />

reality insulin syringe/u 185<br />

reality insulin syringe/u 186<br />

reality lancets 193<br />

reality trigger lancets 193<br />

REBIF TITRATION PACK 172<br />

REBIF 172<br />

RECLAST 173<br />

reclipsen 147<br />

recofen caps 118<br />

RECOMBINATE 43<br />

RECOMBIVA HB 157<br />

RECOMBIVA-HB 157<br />

RECOMBIVAX HB 157<br />

recort plus 165<br />

rectasol-hc 165<br />

rederm 165<br />

redur-pcm 14<br />

REFACTO 43<br />

refenesen chest congestio 132<br />

refenesen chest congestio 133<br />

refenesen dm 118<br />

refenesen pe 133<br />

refenesen plus 133<br />

refenesen 132<br />

REFISSA 166<br />

REFLUDAN 40<br />

REFUAH PLUS BLOOD GLUCOSE 193<br />

REFUAH PLUS BLOOD GLUCOSE 81<br />

REGONOL 33<br />

RELACON LAX 118<br />

relacon-dm nr 118<br />

RELACON-DM 118<br />

relacon-hc nr 118<br />

RELACON-HC 118<br />

relahist-dm 118<br />

relasin dm 118<br />

relasin-hc 118<br />

relasin-hcx 118<br />

relatuss hc 118<br />

relcof c 118<br />

RELCOF DN PE 14<br />

RELCOF DN PSE 14<br />

RELCOF PE 14<br />

relcof pse 14<br />

RELENZA DISKHALER 28<br />

relera 14<br />

RELION 70/30 INNOLET 149<br />

RELION 70/30 149<br />

RELION BLOOD GLUCOSE TEST 81<br />

RELION CONFIRM BLOOD GLUC 193<br />

relion insulin syringe/u- 181<br />

created on 20100520 244


elion insulin syringe/u- 182<br />

relion insulin syringe/u- 183<br />

relion insulin syringe/u- 184<br />

relion insulin syringe/u- 185<br />

relion insulin syringe/u- 187<br />

relion insulin syringe/u- 188<br />

relion insulin syringe/u 183<br />

RELION KETONE 83<br />

relion lancets 193<br />

RELION MICRO BLOOD GLUCOS 193<br />

RELION MICRO BLOOD GLUCOS 81<br />

RELION MINI PEN NEEDLES 3 191<br />

RELION N INNOLET 149<br />

RELION N 149<br />

RELION PEN NEEDLES 29GX12 191<br />

RELION PEN NEEDLES 31GX8M 192<br />

RELION R 149<br />

RELION SHORT PEN NEEDLES 192<br />

relion standard lancets 193<br />

relion thin lancets 193<br />

RELION ULTIMA BLOOD GLUCO 81<br />

relion ultra thin lancets 193<br />

relion ultra thin plus la 193<br />

RELISTOR 144<br />

RELPAX 77<br />

reluri 133<br />

reme hist dm 118<br />

reme tussin dm 118<br />

REMICADE 173<br />

REMODULIN 45<br />

RENAMIN 87<br />

renew advanced lancing ca 193<br />

RENO-30 83<br />

RENO-60 83<br />

RENO-CAL-76 83<br />

RENO-DIP 83<br />

RENOGRAFIN-60 83<br />

RENOVA PUMP 166<br />

RENOVA 166<br />

rentamine pediatric 118<br />

REOPRO 41<br />

repan 63<br />

REPREXAIN 58<br />

reprexain 58<br />

REPRONEX 147<br />

RESCON DM 118<br />

RESCON-JR 14<br />

RESCON-MX 14<br />

RESCON 14<br />

RESCRIPTOR 28<br />

RESPA C&C IR 118<br />

RESPA C&C 118<br />

RESPA DM 118<br />

RESPA SA 3<br />

RESPA-1ST 133<br />

RESPA-A.R. 14<br />

RESPA-PE 133<br />

respahist 14<br />

respaire-120 133<br />

RESPAIRE-30 133<br />

RESPERAL-DM 118<br />

resperal 118<br />

RESPI-TANN G 118<br />

RESPI-TANN PD 118<br />

RESPI-TANN 118<br />

RESPIGAM 156<br />

RESPIRATORY THERAPY SUPPLIES 176<br />

respivent-d 37<br />

rest easy nighttime cough 118<br />

RESTORIL 75<br />

RETAVASE HALF-KIT 41<br />

RETAVASE 41<br />

RETIN-A MICR 166<br />

RETIN-A MICRO PUMP 166<br />

RETROVIR 28<br />

REVATIO 45<br />

REVEX 64<br />

RHEUMATREX 32<br />

rhinabid pd 14<br />

rhinabid 14<br />

rhinaclear 14<br />

rhinacon a 14<br />

RHINAHIST 14<br />

rhinall 138<br />

RHINOCORT AQUA 137<br />

RHOGAM HUMAN 156<br />

RHOGAM PLUS 156<br />

RHOPHYLAC 156<br />

ri-tussin dm 118<br />

ri-tussin 133<br />

RIASTAP 43<br />

ribavirin (hepatitis c) 29<br />

RICOBID 14<br />

RICOTUSS 118<br />

ricotuss 118<br />

RID-A-PAIN COMPOUND 63<br />

rifampin 27<br />

RIGHTEST GM100 BLOOD GLUC 193<br />

RIGHTEST GM300 BLOOD GLUC 193<br />

RIGHTEST GS100 BLOOD GLUC 81<br />

RIGHTEST GS300 BLOOD GLUC 81<br />

rinate pediatric 14<br />

rindal hd plus 118<br />

rindal hd 118<br />

rindal hpd 118<br />

ringer's 86<br />

RISPERDAL 70<br />

RISPERIDONE ODT 70<br />

risperidone 69<br />

risperidone 70<br />

RITALIN LA 74<br />

ritifed 14<br />

RITUXAN 32<br />

RIZATRIPTAN BENZOATE 77<br />

robafen ac 118<br />

robafen cf cough & cold 118<br />

robafen cf 118<br />

robafen cgh 118<br />

robafen dm clear 118<br />

robafen dm 118<br />

robafen 133<br />

ROBAXIN 38<br />

robituss ped 118<br />

robitussin allergy/cough 118<br />

robitussin cf 118<br />

robitussin childrens coug 118<br />

robitussin cold/congestio 14<br />

robitussin cold/cough/flu 118<br />

ROBITUSSIN COUGH & ALLERG 118<br />

ROBITUSSIN COUGH & COLD D 118<br />

ROBITUSSIN COUGH & COLD D 119<br />

robitussin cough & cold l 118<br />

robitussin cough/cold cf 118<br />

robitussin flu 118<br />

robitussin head/chest con 133<br />

ROBITUSSIN NIGHT RELIEF 118<br />

robitussin night time cou 118<br />

robitussin night time cou 3<br />

ROBITUSSIN PEDIATRIC COUG 118<br />

ROBITUSSIN PEDIATRIC 118<br />

robitussin to go cough & 118<br />

robitussin 118<br />

ROCEPHIN 19<br />

rocuronium bromide 38<br />

created on 20100520 245


ROFERON-A 32<br />

romilar ac 119<br />

romycin 135<br />

RONDEC TR 3<br />

RONDEC-TR 3<br />

rondex -dm 119<br />

rondex-dm 119<br />

rondex 14<br />

ROXICET 58<br />

roxicet 58<br />

ru-hist forte 14<br />

RU-HIST-D 4<br />

RU-TUSS 800 DM 119<br />

RU-TUSS DM 119<br />

ru-tuss jr. 133<br />

ru-tuss 14<br />

ry-t-12 4<br />

ry-tann 14<br />

RYBIX ODT 58<br />

RYDEX 119<br />

RYMED 14<br />

RYNA-12 S 4<br />

RYNA-12X 133<br />

RYNATAN PEDIATRIC 14<br />

RYNATUSS 119<br />

rynesa 12s 4<br />

S<br />

S-T FORTE 2 119<br />

safe tussin 30 119<br />

safe-t-lance low flow 25g 193<br />

safe-t-lance normal flow 193<br />

safe-t-lance plus safety 193<br />

safesnap insulin syringe/ 181<br />

safesnap insulin syringe/ 183<br />

safesnap insulin syringe/ 184<br />

safesnap insulin syringe/ 185<br />

safesnap insulin syringe/ 187<br />

SAFETUSSIN CD 119<br />

safety lancet 2mm 189<br />

safety lancets 193<br />

safety let lancets 193<br />

safety-glide insulin syri 181<br />

salflex 51<br />

salflex 52<br />

saline, bacteriostatic 86<br />

SALINE/PHENOL 86<br />

SALMETEROL XINAFOATE 36<br />

salsalate 52<br />

SANDOSTATIN LAR DEPOT 175<br />

SAPHRIS 70<br />

SARAFEM 67<br />

SARAPIN 175<br />

sarnol-hc 165<br />

sb allergy & cold pe 3<br />

sb allergy multi-symptom 14<br />

sb allergy/sinus/headache 3<br />

sb antihistamine 14<br />

sb bronchial 133<br />

sb cgh contr 119<br />

sb cgh contr 133<br />

sb cgh relf 119<br />

sb childrens nite time 119<br />

sb childrens non-aspirin 60<br />

sb childrens plus cough/r 119<br />

sb childrens plus multisy 119<br />

sb cold & allergy childre 14<br />

sb cold & cough dm childr 119<br />

sb cold & cough hbp 119<br />

sb cold & flu hbp 14<br />

sb cold head congestion s 119<br />

sb cold med non drowsy 119<br />

sb cold medicine 119<br />

sb cold multi-symptom day 119<br />

sb cold multi-symptom sev 119<br />

sb cough control cf 119<br />

sb cough control pe 126<br />

sb cough 133<br />

sb day time cold/flu reli 119<br />

sb daytime sinus 34<br />

sb daytime 119<br />

sb flu maximum strength h 119<br />

sb flu relief therapy sev 119<br />

sb flu relief therapy sev 3<br />

sb flu/cold/cough 119<br />

sb hydrocort 165<br />

sb infants concentrated d 63<br />

sb insulin syringe/u-100/ 183<br />

sb insulin syringe/u-100/ 184<br />

sb insulin syringe/u-100/ 187<br />

sb insulin syringe/u-100/ 188<br />

sb lancets thin 193<br />

sb lancets ultra thin 193<br />

sb night time cold/flu re 106<br />

sb nightime 119<br />

sb nighttime cough 119<br />

sb nighttime sinus multi- 3<br />

sb non aspirin sinus 1<br />

SB NON ASPIRIN SINUS 37<br />

sb non-asa night time 76<br />

sb non-asa 63<br />

sb non-aspirin extra stre 63<br />

sb non-aspirin jr strengt 62<br />

sb non-aspirin nighttime 76<br />

sb non-aspirin 63<br />

sb pain reliever children 63<br />

sb pain reliever extra st 62<br />

sb pseudoephedrin sinus 37<br />

sb pseudoephedrine plus 14<br />

sb sev/congest 133<br />

sb severe cold congestion 119<br />

sb severe cold pe 3<br />

sb sinus & allergy maximu 14<br />

sb sinus congestion & pai 133<br />

sb sinus congestion & pai 14<br />

sb sinus congestion & pai 34<br />

sb sinus/allergy max stre 14<br />

scalacort 165<br />

schnucks insulin syringe 184<br />

scopohist-pe 14<br />

scopohist 14<br />

SCOPOLAMINE HBR (OPHTH) 138<br />

SCOPOLAMINE 34<br />

SCOT-TUSSIN DIABETES CF 119<br />

SCOT-TUSSIN DM COUGH CHAS 119<br />

scot-tussin dm 119<br />

scot-tussin expectorant 133<br />

SCOT-TUSSIN SENIOR 119<br />

se bpo wash 162<br />

se-care conceive 172<br />

se-natal 90 172<br />

se-natal one 172<br />

selegiline hcl 77<br />

selenium sul sha 162<br />

selenium sul 162<br />

selenium sulfide 162<br />

SELENIUM 86<br />

selfemra 67<br />

SEMPREX-D 17<br />

SENSORCAINE-MPF/EPINEPHRI 155<br />

SENTRY BLOOD GLUCOSE METE 193<br />

SENTRY STARTER KIT 193<br />

SENTRY TEST STRIPS 81<br />

seradex-la 14<br />

SEREVENT DISKUS 36<br />

created on 20100520 246


SEROQUEL XR 69<br />

SEROQUEL XR 70<br />

SEROQUEL 70<br />

sertraline hcl 67<br />

sertraline 67<br />

servira 34<br />

severe allergy 3<br />

severe cold & flu 119<br />

severe cold/flu maximum s 119<br />

severe cold 119<br />

severe congestion/cough a 133<br />

sg ex-prin child 63<br />

sg ex-prin for children c 119<br />

sg ex-prin infant 63<br />

sg ex-prin jr strength 63<br />

sg ex-prin multi-symptom 119<br />

sg ex-prin pm extra stren 76<br />

sg ex-prin 63<br />

sg flu/cold/cough medicin 119<br />

sg hydrocort 165<br />

sg hydrocortisone/aloe 165<br />

sg nasal decongestant/ant 14<br />

sg nighttime cold/flu 119<br />

sg nighttime flu/cold/cou 119<br />

sg nighttime for children 119<br />

sg pedia relief cough/col 119<br />

sg su-phedrin maximum str 37<br />

sg su-phedrin plus 14<br />

sg tussin dm clear cough 119<br />

sg tussin dm cough 119<br />

sg tussin 133<br />

SHELLGEL 140<br />

SHERI-B-12 169<br />

SHOPRITE TEST STRIPS 81<br />

SHOPRITE VALUE PACK 193<br />

SHOWER TABLETS 175<br />

sil-tex 133<br />

silafed 14<br />

sildec dm 119<br />

sildec pe-dm 119<br />

sildec-pe 14<br />

sildec 14<br />

sildec 3<br />

SILDENAFIL CITRATE 45<br />

silphen dm 119<br />

siltuss das 133<br />

siltussin dm das 119<br />

siltussin sa 133<br />

siltussin-dm 119<br />

silver sulfa 162<br />

silver sulfadiazine 162<br />

SIMILAC LOW-IRON 87<br />

SIMILAC/IRON 87<br />

simply cough 119<br />

simply saline baby 134<br />

SIMPONI 173<br />

simuc-dm 119<br />

simuc-gp 133<br />

simuc-hd 119<br />

simuc 133<br />

SIMULECT 173<br />

SINA-12X 133<br />

SINADRIN PE COMPLETE SINU 14<br />

sine-off night time formu 3<br />

sine-off 14<br />

single-let 193<br />

SINGULAIR 125<br />

SINOGRAFIN 83<br />

sinuhist 14<br />

sinus & allergy pe maximu 14<br />

sinus congestion & pain 34<br />

sinus congestion/pain day 14<br />

sinus congestion/pain day 34<br />

sinus congestion/pain nig 14<br />

sinus congestion/pain sev 133<br />

sinus extra strength 14<br />

sinus headache max streng 37<br />

sinus max 14<br />

sinus maximum relief 37<br />

sinus maximum strength 14<br />

sinus maximum strength 37<br />

sinus non-drowsiness 37<br />

sinus non-drowsy maximum 37<br />

sinus non-drowsy/maximum 37<br />

sinus pain & pressure 37<br />

sinus pain reliever maxim 37<br />

sinus relief 37<br />

sinus tablets 14<br />

sinus w/o drowsiness 37<br />

sinus/allergy maximum str 15<br />

sinus/allergy pe 15<br />

sinus 14<br />

sinus 37<br />

sinutab maximum strength 15<br />

sinutab non-drowsy maximu 37<br />

sinutab non-drying 133<br />

sinutab sinus maximum str 34<br />

sinutab sinus/no drowsine 37<br />

SINUTUSS DM 119<br />

SINUVENT PE 133<br />

SIROLIMUS 173<br />

SITREX PD 133<br />

SITREX 133<br />

sm acid redu 143<br />

sm allergy multi-symptom 15<br />

sm allergy/sinus headache 1<br />

sm arthritis 63<br />

sm chest congestion relie 126<br />

sm chest congestion relie 92<br />

sm childrens non-aspirin 63<br />

sm childrens pain relief 119<br />

sm cold & allergy childre 15<br />

sm cold & allergy childre 9<br />

sm cold & allergy pe 15<br />

sm cold & cough childrens 94<br />

sm cold & cough dm childr 120<br />

sm cold head congestion d 120<br />

sm cold head congestion n 93<br />

sm cold head congestion s 120<br />

sm cough & cold multi-sym 119<br />

sm cough & runny nose chi 120<br />

sm cough & sore throat da 120<br />

sm cough & sore throat ni 120<br />

sm day time cold & flu re 120<br />

sm day time pe cold & flu 120<br />

sm daytime cold & cough c 95<br />

sm decongestant cough for 96<br />

sm flu/cold/cough medicin 120<br />

SM GLUCOSE TEST STRIPS 81<br />

sm hydrocort 165<br />

sm hydrocortisone plus 165<br />

sm hydrocortisone/aloe ma 164<br />

sm ibuprofen cold & sinus 37<br />

sm ibuprofen cold childre 37<br />

sm ibuprofen jr 53<br />

sm infants pain reliever 104<br />

sm insulin syringe/0.3ml/ 182<br />

sm insulin syringe/0.5ml/ 185<br />

sm insulin syringe/1ml/31 188<br />

sm insulin syringe/u-100/ 181<br />

sm insulin syringe/u-100/ 182<br />

sm insulin syringe/u-100/ 184<br />

sm insulin syringe/u-100/ 185<br />

sm insulin syringe/u-100/ 187<br />

created on 20100520 247


sm lancets 21g 193<br />

sm lancets 193<br />

sm loratadin 17<br />

sm medicated chest rub 175<br />

sm mucus relief cough chi 105<br />

sm nasal decongestant/ant 12<br />

sm nasal 138<br />

sm nite time cold & flu r 120<br />

sm nite time cold/flu rel 120<br />

sm nite time cough 120<br />

sm non aspirin allergy si 15<br />

sm non aspirin cold 120<br />

sm non aspirin sinus 37<br />

sm non-asa 63<br />

sm non-aspirin flu 120<br />

sm nose drops nasal decon 138<br />

sm pain rel 63<br />

sm pain relief extra stre 63<br />

sm pain reliever 8 hour e 63<br />

sm pain reliever allergy 12<br />

sm pain reliever cold 107<br />

sm pain reliever extra st 62<br />

sm pain reliever junior s 62<br />

sm pain reliever pm extra 76<br />

sm pain reliever sinus ma 37<br />

sm pain reliever sinus pe 34<br />

sm pedia relief for child 108<br />

sm pedia relief infants 108<br />

sm pediatric 133<br />

sm prenatal vitamins 172<br />

sm severe cold 119<br />

sm sinus & allergy maximu 15<br />

sm sinus & allergy pe max 14<br />

sm sinus headache 37<br />

sm sinus maximum strength 37<br />

sm super thin lancets 30g 193<br />

sm super thin lancets 193<br />

sm tension headache 63<br />

sm thin lancets 26g 193<br />

sm thin lancets 193<br />

sm triacting citrus 133<br />

sm triacting cold & cough 121<br />

sm triacting orange 15<br />

sm tussin cf 120<br />

sm tussin cough & cold ma 120<br />

sm tussin cough & cold 120<br />

sm tussin dm clear 120<br />

sm tussin dm 120<br />

sm tussin 133<br />

sm ultra comfort insulin 181<br />

sm ultra comfort insulin 184<br />

sm ultra comfort insulin 187<br />

sm vit b-6 169<br />

SMARTEST BLOOD GLUCOSE TE 81<br />

SMARTEST EJECT BLOOD GLUC 193<br />

SMARTEST EJECT STARTER KI 193<br />

smartest lancets 28g 193<br />

SMARTEST PROTEGE BLOOD GL 193<br />

SMARTEST PROTEGE STARTER 193<br />

smz-tmp ds 25<br />

soba child pain reliever 63<br />

soba childrens pain relie 120<br />

soba childrn 63<br />

soba cold reliever 93<br />

soba cold/flu daytime 94<br />

soba dayhist 3<br />

soba infant pain reliever 36<br />

soba lancets colored 193<br />

soba night time cold/flu 120<br />

soba pain reliever allerg 12<br />

soba pain reliever cold 107<br />

soba pain reliever flu 107<br />

soba pain reliever junior 63<br />

soba pain reliever pm 76<br />

soba pain reliever/sinus 37<br />

soba pedia relief 120<br />

soba profen ib cold/sinus 37<br />

soba profen ib junior str 53<br />

soba sinus 15<br />

soba thin lancets 193<br />

soba tussin cough/cold 120<br />

soba tussin pe cough 134<br />

sod chloride 134<br />

SOD EDECRIN 87<br />

sod fluoride 172<br />

SOD NITRITE 144<br />

sod sulfacet 135<br />

SOD THIOSULF 144<br />

sodium acetate 83<br />

sodium ascorbate 169<br />

sodium bicarbonate 83<br />

SODIUM CHLOR 134<br />

sodium chlor 134<br />

SODIUM CHLORIDE (INHALANT) 134<br />

sodium chloride (inhalant) 134<br />

SODIUM CHLORIDE BACTERIOS 85<br />

sodium chloride 86<br />

sodium fluoride 172<br />

SODIUM LACTATE 83<br />

sodium lactate 83<br />

sodium phosphate 86<br />

sodium thiosalicylate 64<br />

sodium thiosulfate 144<br />

solia 147<br />

SOLO V2 BLOOD GLUCOSE MAN 193<br />

SOLO V2 TEST STRIP 81<br />

solo v2 twist lancets 193<br />

SOLOTUSS 120<br />

SOLU-CORTEF 146<br />

SOLU-MEDROL 146<br />

soluclenz rx 162<br />

SOMA 38<br />

SOMATULINE DEPOT 175<br />

SOMAVERT 151<br />

SOMNOTE 76<br />

sonahist dm 120<br />

sonahist 15<br />

SORBUTUSS NR 120<br />

SORBUTUSS 120<br />

sorbutuss 120<br />

SOTALOL HCL 47<br />

SOTRADECOL 45<br />

SPACER/AEROSOL-HOLDING<br />

CHAMBER SUPPLIES - BAGS 176<br />

SPACER/AEROSOL-HOLDING<br />

CHAMBER SUPPLIES - MOUTHPIECES<br />

176<br />

SPACER/AEROSOL-HOLDING<br />

CHAMBERS 176<br />

SPASCUPREEL 175<br />

spasdel 34<br />

SPHERULIN 82<br />

SPORANOX 27<br />

sprintec 28 147<br />

ssd af 162<br />

ssd 162<br />

st joseph co 120<br />

stagesic 58<br />

stamoist e 133<br />

STAPHAGE LYSATE I & III 175<br />

statuss dm 120<br />

STATUSS GREEN 120<br />

stavudine 28<br />

STELARA 173<br />

created on 20100520 248


STERILE WATER 196<br />

STIMATE 150<br />

STRATTERA 77<br />

STRATTERA 78<br />

STREPTOMYCIN 18<br />

su-tuss dm 120<br />

su-tuss hd 120<br />

SUBOXONE 58<br />

suclor 15<br />

SUCRALFATE 143<br />

sucralfate 143<br />

SUCRETS DM 120<br />

SUDACARE SHOWER SOOTHERS 175<br />

SUDAFED CHILDRENS COLD & 120<br />

sudafed pe cold & cough c 120<br />

SUDAFED PE COLD/COUGH MUL 120<br />

SUDAFED PE DAY & NIGHT CO 120<br />

SUDAFED PE DAY & NIGHT 3<br />

sudafed pe nighttime cold 3<br />

sudafed pe non-drying sin 133<br />

sudafed pe sinus headache 34<br />

sudafed pe sinus/allergy 15<br />

sudafed plus 15<br />

sudafed sinus & pain 12 h 53<br />

sudafed sinus extra stren 37<br />

sudafed sinus nighttime 15<br />

sudafed sinus 37<br />

SUDAFED TRIPLE ACTION 133<br />

SUDAHIST 15<br />

SUDAL 12 TANNATE 15<br />

SUDAL 12 15<br />

sudatex g 133<br />

sudatex-dm 120<br />

sudatex-g 133<br />

sudatex 133<br />

sudatrate 37<br />

sudatuss dm 120<br />

sudatuss-2 df 120<br />

sudatuss-2 120<br />

sudatuss-sf 120<br />

sudex 133<br />

sudogest cold & allergy 15<br />

sufentanil citrate 58<br />

sulf- 135<br />

sulfac 135<br />

SULFACET SOD 135<br />

sulfacet sod 135<br />

SULFACETAMIDE SOD-<br />

PREDNISOLONE 137<br />

sulfacetamide sod-prednisolone 137<br />

SULFACETAMIDE SODIUM (OPHTH)<br />

135<br />

sulfacetamide sodium (ophth) 135<br />

sulfacetamide sodium/pred 137<br />

sulfacetamide/prednisolon 137<br />

sulfamethoxazole-trimethoprim 25<br />

SULFAMETHOXAZOLE/TRIMETHO 25<br />

sulfamethoxazole/trimetho 25<br />

sulfasalazin 25<br />

sulfasalazine 25<br />

sulfatrim 25<br />

sulfazine ec 25<br />

sulfazine 25<br />

SULFISOXAZOLE 25<br />

SULFOXYL REGULAR 167<br />

SULFOXYL STRONG 167<br />

SULINDAC 196<br />

sulindac 53<br />

SUMATRIPTAN SUCCINATE REF 77<br />

SUMATRIPTAN SUCCINATE 77<br />

sumatriptan succinate 77<br />

SUMATRIPTAN 77<br />

sumatriptan 77<br />

SUMAVEL DOSEPRO 77<br />

SUMYCIN 26<br />

SUPARTZ 175<br />

super cold tabs 15<br />

super strength sinadrin 15<br />

super thin lancets 193<br />

super tussin pe 133<br />

supertussin dm 120<br />

supertussin 133<br />

suphedrin plus 15<br />

suphedrin severe cold 120<br />

suphedrin sinus/maximum s 37<br />

suphedrine cold/allergy 15<br />

suphedrine severe cold/fl 120<br />

suphedrine sinus 38<br />

SUPPRELIN LA 32<br />

SUPRAX 19<br />

SUPREME TEST STRIPS 81<br />

supress-dx pediatric 120<br />

SUPRESS-PE PEDIATRIC 133<br />

sure comfort insulin syri 181<br />

sure comfort insulin syri 182<br />

sure comfort insulin syri 183<br />

sure comfort insulin syri 184<br />

sure comfort insulin syri 185<br />

sure comfort insulin syri 187<br />

sure comfort insulin syri 188<br />

sure comfort lancets 28g 193<br />

sure comfort lancets 30g 193<br />

SURE COMFORT PEN NEEDLES 193<br />

SURE EDGE BLOOD GLUCOSE M 193<br />

SURE EDGE BLOOD GLUCOSE T 81<br />

sure one insulin syringe/ 182<br />

sure one insulin syringe/ 183<br />

sure one insulin syringe/ 184<br />

sure one insulin syringe/ 185<br />

sure one insulin syringe/ 187<br />

sure one insulin syringe/ 188<br />

SURE-FINE PEN NEEDLES 29G 193<br />

SURE-FINE PEN NEEDLES 31G 193<br />

sure-ject insulin syringe 181<br />

sure-ject insulin syringe 182<br />

sure-ject insulin syringe 183<br />

sure-ject insulin syringe 184<br />

sure-ject insulin syringe 185<br />

sure-ject insulin syringe 187<br />

sure-ject insulin syringe 188<br />

sure-lance flat lancets 193<br />

sure-lance lancets 26g 193<br />

sure-lance thin lancets 2 193<br />

sure-lance ultra thin lan 193<br />

SURE-TEST EASYPLUS MINI B 81<br />

SURE-TEST EASYPLUS MINI S 193<br />

SURECHEK BLOOD GLUCOSE MO 193<br />

SURECHEK BLOOD GLUCOSE TE 81<br />

surelite lancets 193<br />

SURESTEP COMPLETE BLOOD G 193<br />

SURESTEP PRO TEST STRIPS 81<br />

SURESTEP TEST STRIPS 81<br />

SUSTIVA 28<br />

sutan-dm 120<br />

SUTAN 15<br />

sw cold & sinus pain reli 38<br />

symax-sl 34<br />

SYMLIN 148<br />

SYMLINPEN 60 148<br />

SYMLNPEN 120 148<br />

SYMPAK DM 120<br />

SYMPAK II 15<br />

SYMPAK PDX 15<br />

SYMPAK 15<br />

created on 20100520 249


SYMTAN A 120<br />

SYMTAN 120<br />

SYNAGIS 28<br />

SYNAREL 147<br />

SYNERCID 26<br />

SYNTHROID 153<br />

SYNVISC ONE 175<br />

SYNVISC 175<br />

T<br />

T-TANNA DM 120<br />

TABLOID 32<br />

tacrolimus 173<br />

tactinal 64<br />

TALWIN 58<br />

TAMIFLU 28<br />

tana dm 120<br />

tana pse 15<br />

tana r-12 4<br />

tana t-12 120<br />

tanabid da 15<br />

tanabid sr 15<br />

tanabid 15<br />

tanacof-dm 120<br />

TANAFED DMX 120<br />

tanahist-d pediatric 15<br />

tanatan rf 15<br />

tanatuss pediatric 120<br />

tanavan 4<br />

tannate 12 s 120<br />

tannate dmp-dex 120<br />

tannate pd-dm 120<br />

tannate pediatric 15<br />

tannate-12 120<br />

tannate-12d s 120<br />

tannate-v-dm 120<br />

tannic-12 s 121<br />

tannic-12 121<br />

tannihist-12 d 121<br />

tannihist-12 rf 121<br />

TARGRETIN 167<br />

TARGRETIN 32<br />

taron-ec cal 172<br />

tavist nd 17<br />

tavist sinus non drowsy m 38<br />

TAXOTERE 32<br />

TAZAROTENE 167<br />

TAZICEF 19<br />

TAZORAC 167<br />

taztia xt 48<br />

TE ANATOXAL BERNA 156<br />

tebamide pediatric 142<br />

tebamide 142<br />

techlite ast lancets 193<br />

techlite lancets 193<br />

TEGRETOL XR 66<br />

TEGRETOL 66<br />

TEKRAL 3<br />

TEMAZEPAM 75<br />

temazepam 75<br />

TEMODAR 32<br />

tenar dm 121<br />

TENAR PSE 133<br />

TENORMIN 47<br />

TENSILON 82<br />

TEQUIN 25<br />

terazosin hcl 46<br />

terbinafine hcl 26<br />

terbinafine 26<br />

terbutaline sulfate 36<br />

terbutaline 36<br />

ternamar 172<br />

TERPIN HYDRATE MONOHYDRAT 196<br />

TERPIN HYDRATE 196<br />

terumo insulin syringe/0. 181<br />

terumo insulin syringe/0. 184<br />

TERUMO INSULIN SYRINGE/1M 187<br />

terumo insulin syringe/u- 181<br />

terumo surguard insulin s 181<br />

terumo surguard insulin s 182<br />

terumo surguard insulin s 183<br />

terumo surguard insulin s 185<br />

terumo surguard insulin s 187<br />

TESLASCAN 79<br />

TESTOPEL 146<br />

testosterone cypionate 146<br />

testosterone enanthate 146<br />

TETANUS TOXOID ADSORBED 156<br />

TETANUS TOXOID 156<br />

TETANUS/DIPHTHERIA TOXOID 156<br />

tetra tannate pediatric 121<br />

tetracaine hcl 155<br />

TETRACYCLINE HCL 26<br />

tetracycline hcl 26<br />

tetracycline 26<br />

TEV-TROPIN 151<br />

tg 10peh/380gfn/15dm 88<br />

tg 10peh/380gfn 125<br />

tg 40pse/4brm 4<br />

tg 45pse/400gfn/15dm 89<br />

tg 45pse/400gfn 125<br />

tgt acetamin 64<br />

tgt acetaminophen extra s 64<br />

tgt acetaminophen infants 64<br />

tgt anti-itch plus oatmea 162<br />

tgt anti-itch/aloe maximu 162<br />

tgt anti-itch/aloe/vitami 162<br />

tgt arthritis pain relief 59<br />

tgt childrens acetaminoph 64<br />

tgt cold head congestion 121<br />

tgt cold relief multi-sym 121<br />

tgt cold relief multi-sym 93<br />

tgt cold/flu relief day t 121<br />

tgt cold/flu relief day/n 94<br />

tgt cold/flu relief multi 121<br />

tgt cold/flu relief multi 94<br />

tgt cold/flu relief night 121<br />

tgt cough & cold 94<br />

tgt cough formula dm 121<br />

tgt lancet alternate site 194<br />

tgt lancet super thin 30g 194<br />

tgt lancet thin 23g 194<br />

tgt lancet ultra thin 28g 194<br />

tgt mucus relief cough ch 105<br />

tgt multi-symptom cold pl 121<br />

tgt pain reliever pm extr 3<br />

tgt pain reliever pm extr 76<br />

tgt sinus congestion/pain 14<br />

tgt sinus congestion/pain 34<br />

tgt tussin dm cough 123<br />

THAM 83<br />

THEO-24 167<br />

THEO 167<br />

theo 167<br />

theochron 167<br />

theophylline in dextrose 168<br />

theophylline sr 168<br />

THEOPHYLLINE 167<br />

theophylline 167<br />

THEOPHYLLINE 168<br />

theophylline 168<br />

theracaps cough & cold re 121<br />

THERACOF PLUS COUGH AND C 121<br />

theracort 165<br />

THERAFLU COLD & COUGH 121<br />

created on 20100520 250


THERAFLU COLD & SORE THRO 15<br />

theraflu cold & sore thro 15<br />

THERAFLU COLD/COUGH DAYTI 121<br />

THERAFLU COLD/COUGH NIGHT 3<br />

THERAFLU FLU & CHEST CONG 121<br />

THERAFLU FLU & CHEST CONG 133<br />

THERAFLU FLU & SORE THROA 15<br />

theraflu flu/cold/cough 121<br />

THERAFLU FLU/COLD/SORE TH 15<br />

theraflu flu/cold 15<br />

theraflu flu/congestion m 121<br />

THERAFLU LONG ACTING COUG 121<br />

theraflu nighttime maximu 121<br />

THERAFLU NIGHTTIME MEDICI 121<br />

theraflu non drowsy formu 121<br />

theraflu severe cold & co 121<br />

theraflu severe cold dayt 121<br />

theraflu severe cold nigh 121<br />

THERAFLU SEVERE COLD NIGH 15<br />

THERAFLU WARMING RELIEF C 133<br />

theraflu warming relief f 3<br />

theraflu warming relief s 121<br />

theraflu warming relief s 3<br />

thermazene 162<br />

thiamine hcl 169<br />

thin lancets 194<br />

thinlets gp lancets 194<br />

thinlets lancet 194<br />

thinpro insulin syringe/0 181<br />

THINPRO INSULIN SYRINGE/0 182<br />

thinpro insulin syringe/0 183<br />

thinpro insulin syringe/0 184<br />

THINPRO INSULIN SYRINGE/0 185<br />

thinpro insulin syringe/1 185<br />

THINPRO INSULIN SYRINGE/1 187<br />

thinpro insulin syringe/1 187<br />

THINPRO INSULIN SYRINGE/1 188<br />

THIOGUANINE 32<br />

thioridazine hcl 71<br />

thioridazine 71<br />

THIOTEPA 32<br />

thiotepa 32<br />

thiothixene 71<br />

THIOTHIXENE 72<br />

thiothixene 72<br />

thor cough & cold 121<br />

THORAZINE 71<br />

THROMBAT III 41<br />

THYMOGLOBULN 173<br />

THYREL TRH 79<br />

THYROGEN 82<br />

THYROID 153<br />

thyroid 153<br />

tibamine la 15<br />

tidafen dm 121<br />

tidafen la 133<br />

TIGER BALM EXTRA STRENGTH 175<br />

TIGER BALM REGULAR STRENG 175<br />

TIGER BALM ULTRA STRENGTH 175<br />

TILADE 125<br />

TIME-HIST QD 15<br />

TIMENTIN 24<br />

timolol gel 139<br />

timolol mal 139<br />

TIMOLOL MALEATE (OPHTH) 139<br />

timolol maleate (ophth) 139<br />

tizanidine hcl 38<br />

tizanidine 38<br />

tl icon 39<br />

tl-dex dm 121<br />

tl-hist cd 121<br />

tl-hist cm 121<br />

tl-hist dm 121<br />

TNKASE 41<br />

tobra 135<br />

TOBRADEX 137<br />

TOBRAMYCIN SULFATE (OPHTH) 135<br />

tobramycin sulfate (ophth) 135<br />

TOBRAMYCIN SULFATE/SODIUM 18<br />

tobramycin sulfate 18<br />

TOBRAMYCIN-DEXAMETHASONE 137<br />

tobramycin-dexamethasone 137<br />

tobramycin/dexamethasone 137<br />

tobramycin 135<br />

TOBRAMYCIN 18<br />

TOBREX 135<br />

TOFRANIL-PM 69<br />

TOLAZAMIDE 150<br />

tolazamide 150<br />

tolbutamide 150<br />

tolu-sed dm 121<br />

topcare ultra comfort ins 181<br />

topcare ultra comfort ins 182<br />

topcare ultra comfort ins 183<br />

topcare ultra comfort ins 184<br />

topcare ultra comfort ins 185<br />

topcare ultra comfort ins 186<br />

topcare ultra comfort ins 187<br />

topcare ultra comfort ins 188<br />

topco insulin syringe/u-1 181<br />

topco insulin syringe/u-1 183<br />

topco insulin syringe/u-1 185<br />

topco insulin syringe/u-1 186<br />

topiramate 66<br />

TORISEL 32<br />

TORSEMIDE 87<br />

TOURO ALLERGY 15<br />

touro allergy 15<br />

TOURO CC-LD 121<br />

TOURO CC 121<br />

TOURO DM 121<br />

TOURO HC 121<br />

TOURO LA 133<br />

TRACE ELEMENTS 4/PEDIATRI 86<br />

TRACE METALS ADDITIVE FTV 86<br />

trace minerals (cr-cu-mn-se-zn) 86<br />

trace minerals (cr-cu-mn-zn) 86<br />

TRAMADOL HCL 58<br />

tramadol hcl 58<br />

tranylcyprom 66<br />

tranylcypromine sulfate 66<br />

TRASYLOL 43<br />

TRAUMEEL 175<br />

TRAVASOL 2.75%/DEXTROSE 1 87<br />

TRAVASOL 2.75%/DEXTROSE 5 87<br />

TRAVASOL 3.5%/ELECTROLYTE 87<br />

TRAVASOL 4.25%/DEXTROSE 1 87<br />

TRAVASOL 4.25%/DEXTROSE 2 87<br />

TRAVASOL 5.5%/DEXTROSE 10 87<br />

TRAVASOL 5.5%/DEXTROSE 20 87<br />

TRAVASOL 5.5%/ELECTROLYTE 87<br />

TRAVASOL 8.5%/DEXTROSE 10 87<br />

TRAVASOL 8.5%/DEXTROSE 20 87<br />

TRAVASOL 8.5%/DEXTROSE 50 87<br />

TRAVASOL 87<br />

trazodone hcl 66<br />

trazodone hcl 68<br />

trazodone 66<br />

trazodone 68<br />

TREANDA 32<br />

TRELSTAR DEP 32<br />

TRELSTAR LA 32<br />

TRELSTAR MIX 32<br />

TRETIN-X 166<br />

created on 20100520 251


tretinoin (chemotherapy) 32<br />

TRETINOIN (FACIAL WRINKLES) 166<br />

TRETINOIN EM 166<br />

TRETINOIN MICROSPHERE 166<br />

TRETINOIN W/ CLEANSER &<br />

MOISTURIZER 166<br />

tretinoin 166<br />

tretinoin 32<br />

trexbrom 121<br />

trezix 58<br />

tri-a-vite w/fluoride 172<br />

tri-afed allergy/head col 15<br />

tri-fed x 121<br />

tri-gestan s 15<br />

tri-hist pediatric 15<br />

tri-pseudaphed 15<br />

tri-vent dm 121<br />

tri-vent dpc 121<br />

tri-vent hc 121<br />

tri-vit/fl chewable 172<br />

tri-vit/fluoride/iron 172<br />

tri-vit/fluoride 172<br />

tri-vita bets w/fluoride 172<br />

tri-vitamin/fluoride 172<br />

tri-vitamin/iron/fluoride 172<br />

TRIACTIN CHEST CONGESTION 133<br />

triactin chest congestion 133<br />

triacting chest congestio 133<br />

triacting cold & cough 121<br />

triacting cold/allergy 15<br />

triacting cold/cough 121<br />

triacting day time cold/c 121<br />

triacting expectorant 133<br />

triacting nighttime cold& 3<br />

triacting nite time 121<br />

triacting sore throat for 121<br />

triacting sore throat 121<br />

triacting 121<br />

triall 15<br />

TRIAMCINOLON 165<br />

triamcinolon 165<br />

TRIAMCINOLONE ACETONIDE<br />

(INHALANT) 146<br />

TRIAMCINOLONE ACETONIDE<br />

(NASAL) 137<br />

TRIAMCINOLONE ACETONIDE<br />

(TOPICAL) 165<br />

triamcinolone acetonide (topical) 165<br />

triamcinolone acetonide 146<br />

triamcinolone/nystatin 165<br />

triaminic am cough/decong 122<br />

TRIAMINIC CHEST & NASAL C 133<br />

TRIAMINIC CHEST/NASAL CON 133<br />

triaminic chest/nasal con 133<br />

TRIAMINIC COLD & ALLERGY 15<br />

TRIAMINIC COLD & COUGH DA 122<br />

triaminic cold & cough da 122<br />

TRIAMINIC COLD/ALLERGY 15<br />

TRIAMINIC COLD/COUGH DAYT 122<br />

TRIAMINIC COLD/COUGH NIGH 3<br />

triaminic cold/cough/feve 122<br />

triaminic cough & nasal c 122<br />

TRIAMINIC COUGH & RUNNY N 122<br />

TRIAMINIC COUGH & SORE TH 122<br />

triaminic cough & sore th 122<br />

TRIAMINIC COUGH 122<br />

TRIAMINIC DECONGESTANT PL 122<br />

TRIAMINIC FLU COUGH & FEV 121<br />

TRIAMINIC FLU/COUGH/FEVER 122<br />

triaminic flu/cough/fever 122<br />

TRIAMINIC LONG ACTING COU 122<br />

triaminic long acting cou 122<br />

TRIAMINIC MULTI-SYMPTOM F 122<br />

triaminic night time coug 122<br />

TRIAMINIC RUNNY NOSE & CO 15<br />

TRIAMINIC VAPOR PATCH 175<br />

TRIAMINIC-D 122<br />

triaminic 17<br />

triamterene & hydrochlorothiazide 88<br />

triamterene/hydrochloroth 88<br />

TRIAZ 162<br />

triazolam 75<br />

tricare 172<br />

TRICHOPHYTON 83<br />

TRICODENE SF 122<br />

tricof exp 122<br />

tricof pd 122<br />

tricof 122<br />

tricold pediatric 122<br />

tricon 39<br />

tridal hd plus 122<br />

tridal hd 122<br />

TRIDAL 122<br />

triderm 165<br />

trifed 15<br />

trifedrine 15<br />

trifluoperaz 71<br />

trifluoperazine hcl 71<br />

trifluridine 136<br />

TRIHIBIT 156<br />

TRIKOF-D 122<br />

trimethobenz 142<br />

trimethobenzamide hcl 142<br />

trimethobenzamide-benzocaine 142<br />

trimethoprim sulfate/poly 135<br />

trimethoprim/polymyxin b 135<br />

trimethoprim/sulfamethoxa 25<br />

trimethoprim 29<br />

trimox 24<br />

trinatal rx 1 172<br />

trionate nf 122<br />

trionate 122<br />

triotann pediatric 15<br />

triotann-s pediatric 15<br />

trip-pse 15<br />

TRIPEDIA 156<br />

TRIPHASIL 28 147<br />

triple antibiotic 135<br />

triple antibiotic 137<br />

triple tannate pediatric 15<br />

triplex ad 15<br />

triplex dm 122<br />

TRIPOHIST D 15<br />

TRIPROLIDINE & PSEUDOEPHEDRINE<br />

15<br />

TRIPROLIDINE & PSEUDOEPHEDRINE<br />

16<br />

triprolidine & pseudoephedrine 16<br />

TRIPROLIDINE TANNATE-<br />

PSEUDOEPHEDRINE TANNATE 16<br />

TRIPROLIDINE-PSEUDOEPH W/APAP 16<br />

triprolidine/pseudoephedr 15<br />

TRISENOX 32<br />

trisofed 16<br />

TRISPEC DEX 133<br />

TRISPEC DMX PEDIATRIC 122<br />

TRISPEC DMX 122<br />

TRISPEC PSE PEDIATRIC 122<br />

TRISPEC PSE 122<br />

TRISPEC SFX 133<br />

trital dm 122<br />

trital sr 16<br />

trivora-28 147<br />

TROCAL COUGH 122<br />

created on 20100520 252


TROPHAMINE 87<br />

tropicacyl 138<br />

tropicamide 138<br />

TRUE CARE STARTER KIT 194<br />

TRUE CARE TEST STRIP PACK 81<br />

TRUE2GO BLOOD GLUCOSE MON 194<br />

TRUERESULT BLOOD GLUCOSE 194<br />

TRUETEST GLUCOSE CONTROL 194<br />

TRUETEST STRIPS 81<br />

TRUETRACK BLOOD GLUCOSE M 194<br />

TRUETRACK SMART SYSTEM 194<br />

TRUETRACK TEST 81<br />

TUBERCULIN/ALLERGY SYRINGES 177<br />

TUBERCULIN/ALLERGY SYRINGES 194<br />

TUBERSOL 10 TEST 83<br />

TUBERSOL 50 TEST 83<br />

TUBERSOL 83<br />

TUR-BI-KAL 138<br />

tusana-d 122<br />

TUSDEC-DM 122<br />

TUSDEC-HC 122<br />

tusnel c 122<br />

tusnel diabetic 122<br />

TUSNEL PED-C 122<br />

TUSNEL PEDIATRIC 122<br />

tusnel-a 122<br />

TUSNEL-DM PEDIATRIC 122<br />

TUSNEL-HC 122<br />

tusnel-hc 122<br />

TUSNEL 122<br />

TUSNEL 133<br />

TUSS-DA NR 122<br />

tuss-pv 122<br />

tussadur-hd 122<br />

tussafed ex 122<br />

tussafed hc 122<br />

tussafed-la 122<br />

TUSSAFED 122<br />

tussafed 122<br />

tusscough dhc 122<br />

tusscough hc 122<br />

TUSSI PRES-B 122<br />

TUSSI PRES-B 133<br />

TUSSI-12 122<br />

TUSSI-12D S 122<br />

TUSSI-12D 122<br />

tussi-bid 122<br />

tussi-organidin nr dm 122<br />

tussi-pres pe pediatric 133<br />

TUSSI-PRES PEDIATRIC 122<br />

TUSSICAPS 122<br />

tussiclear dh 122<br />

tussiden c 123<br />

tussiden dm 123<br />

TUSSIGON 123<br />

tussin cf cough & cold 123<br />

tussin cf 123<br />

tussin chest 134<br />

tussin cold-cough 123<br />

tussin cold/congestion 123<br />

tussin cold/cough 123<br />

tussin cold/cough 94<br />

TUSSIN COUGH-COLD 123<br />

tussin cough/cold maximum 123<br />

tussin cough/cold 123<br />

tussin cough 123<br />

tussin cough 134<br />

tussin dm clear 123<br />

tussin dm max 123<br />

tussin dm 123<br />

tussin exp 134<br />

tussin max 123<br />

tussin pe 134<br />

tussin pediatric cough & 123<br />

tussin pediatric cough/co 123<br />

tussin severe congestion 134<br />

tussin severe 134<br />

tussin 123<br />

tussin 134<br />

TUSSINAL 12 123<br />

TUSSIONEX PENNKINETIC EXT 123<br />

TUSSIREX 123<br />

tussitab 123<br />

tussizone-12 rf 123<br />

TUSSO-DF 123<br />

TUSSO-DM 123<br />

TUSSO-DMR 123<br />

TUSSO-HC 123<br />

TUSSO-XR 123<br />

TUSSO-ZMR 123<br />

TUSSO-ZR 123<br />

tussplex dm 123<br />

tussplex 123<br />

tustan 12s 123<br />

TWINJECT 38<br />

TWINRIX 157<br />

tycolene 64<br />

TYGACIL 26<br />

tylenol allergy multi-sym 16<br />

TYLENOL CHEST CONGESTION 134<br />

TYLENOL CHILDRENS PLUS CO 16<br />

TYLENOL CHILDRENS PLUS CO 3<br />

tylenol chld 64<br />

TYLENOL COLD & FLU SEVERE 123<br />

tylenol cold head congest 123<br />

TYLENOL COLD MULTI-SYMPTO 123<br />

tylenol cold multi-sympto 123<br />

TYLENOL COLD RELIEF NIGHT 3<br />

TYLENOL COUGH & SORE THRO 123<br />

tylenol cough & sore thro 123<br />

TYLENOL FLU CONVENIENCE P 123<br />

tylenol flu no drowsiness 123<br />

TYLENOL GO TABS EXTRA STR 64<br />

TYLENOL INFANTS PLUS COLD 123<br />

tylenol infants plus cold 123<br />

TYLENOL INFANTS PLUS COLD 35<br />

tylenol infants plus cold 38<br />

tylenol maximum strength 124<br />

tylenol sinus congestion 16<br />

tylenol sinus congestion 35<br />

TYLENOL SINUS CONVENIENCE 3<br />

TYLENOL SINUS SEVERE CONG 134<br />

TYLENOL SORE THROAT NIGHT 3<br />

tylophen 64<br />

TYPHIM VI 157<br />

TYPHOID VI 157<br />

TYSABRI 172<br />

created on 20100520 253<br />

U<br />

UBICHINON COMPOSITUM 175<br />

ulticare insulin syringe/ 181<br />

ulticare insulin syringe/ 183<br />

ulticare insulin syringe/ 184<br />

ulticare insulin syringe/ 185<br />

ulticare insulin syringe/ 186<br />

ulticare insulin syringe/ 187<br />

ulticare insulin syringe 182<br />

ulticare insulin syringe 185<br />

ulticare insulin syringe 188<br />

ULTICARE MINI PEN NEEDLES 191<br />

ULTICARE ORIGINAL PEN NEE 191<br />

ULTICARE SHORT PEN NEEDLE 192<br />

ulticare thin lancets 30g 190<br />

ulticare thin lancets ult 190<br />

ultiguard insulin syringe 181


ultiguard insulin syringe 182<br />

ultiguard insulin syringe 183<br />

ultiguard insulin syringe 184<br />

ultiguard insulin syringe 185<br />

ultiguard insulin syringe 186<br />

ultiguard insulin syringe 187<br />

ultiguard insulin syringe 188<br />

ultilet classic lancets 194<br />

ultilet insulin syringe/0 181<br />

ultilet insulin syringe/0 183<br />

ultilet insulin syringe/0 184<br />

ultilet insulin syringe/1 186<br />

ultilet insulin syringe/1 187<br />

ultilet insulin syringe/s 182<br />

ultilet insulin syringe/s 184<br />

ultilet insulin syringe/s 187<br />

ultilet lancets 194<br />

ULTILET PEN NEEDLE 194<br />

ULTIMA TEST STRIPS 81<br />

ULTIMA 194<br />

ULTIVA 58<br />

ultra comfort insulin syr 181<br />

ultra comfort insulin syr 182<br />

ultra comfort insulin syr 183<br />

ultra comfort insulin syr 184<br />

ultra comfort insulin syr 185<br />

ultra comfort insulin syr 186<br />

ultra comfort insulin syr 187<br />

ultra comfort insulin syr 188<br />

ultra insulin syringe/u-1 183<br />

ultra thin lancets 28g 190<br />

ultra thin lancets 30g 190<br />

ultra-comfort insulin syr 181<br />

ultra-comfort insulin syr 182<br />

ultra-comfort insulin syr 183<br />

ultra-comfort insulin syr 184<br />

ultra-comfort insulin syr 185<br />

ultra-comfort insulin syr 186<br />

ultra-comfort insulin syr 187<br />

ultra-comfort insulin syr 188<br />

ultra-thin ii auto lancet 177<br />

ultra-thin ii insulin syr 181<br />

ultra-thin ii insulin syr 182<br />

ultra-thin ii insulin syr 183<br />

ultra-thin ii insulin syr 184<br />

ultra-thin ii insulin syr 186<br />

ultra-thin ii insulin syr 187<br />

ultra-thin ii lancet/28g 189<br />

ultra-thin ii lancet/30g 189<br />

ULTRA-THIN II PEN NEEDLE/ 191<br />

ultrabrom pd 16<br />

ultrabrom 16<br />

ULTRACAPS MT 20 141<br />

ULTRASE MT 12 141<br />

ULTRASE MT 18 141<br />

ULTRASE MT 20 141<br />

ULTRASE 141<br />

ULTRATRAK PRO TEST STRIPS 81<br />

ULTRATRAK PRO 194<br />

ultratuss 12 s 124<br />

ULTRAVIST 83<br />

un-aspirin 64<br />

uni all 12 124<br />

uni-cof exp 124<br />

uni-cof 124<br />

uni-hist pdx 124<br />

uni-hist 16<br />

uni-tann cs 124<br />

uni-tann d 3<br />

uni-tex 120/10 er 16<br />

UNIFINE PENTIPS 29G X 12M 194<br />

UNIFINE PENTIPS 29GX12MM 194<br />

UNIFINE PENTIPS 31G X 6MM 194<br />

UNIFINE PENTIPS 31G X 8MM 194<br />

UNIFINE PENTIPS 31GX6MM 194<br />

UNIFINE PENTIPS 31GX8MM 194<br />

UNIFINE PENTIPS 194<br />

unilet comfortouch lancet 178<br />

unilet excelite ii 194<br />

unilet excelite 194<br />

unilet g.p. lancet 194<br />

unilet g.p. superlite lan 194<br />

unilet gp 28 ultra thin 194<br />

unilet lancet 194<br />

unilet superlite lancet 194<br />

UNIPHYL 168<br />

unith direct 153<br />

unithroid 153<br />

unithroid 154<br />

universal 1 lancets thin 194<br />

universal 1 lancets ultra 194<br />

urinary anal 166<br />

urinary pain 166<br />

UVADEX 166<br />

created on 20100520 254<br />

V<br />

v-cof 124<br />

v-hist 16<br />

v-r heartburn relief 142<br />

v-r monoject insulin syri 181<br />

v-r monoject insulin syri 182<br />

v-r monoject insulin syri 183<br />

v-r monoject insulin syri 185<br />

v-r monoject insulin syri 186<br />

v-r non-asa 64<br />

v-r tussin 134<br />

v-r vit b-6 169<br />

v-r womens menstrual reli 64<br />

v-tann b.i.d 4<br />

V-TANN 4<br />

va-zone 77<br />

VALCYTE 29<br />

VALGANCICLOVIR HCL 29<br />

valproate sodium 66<br />

valproic acd 66<br />

valproic acid 66<br />

VALSARTAN-<br />

HYDROCHLOROTHIAZIDE 50<br />

VALSARTAN 50<br />

value health insulin syri 183<br />

value health insulin syri 186<br />

value health lancets 194<br />

value plus lancets standa 189<br />

value plus lancets super 189<br />

value plus lancets thin 2 190<br />

value plus lancets 194<br />

value plus thin lancets 195<br />

valumark lancet super thi 189<br />

valumark lancet ultra thi 189<br />

VALUMARK PEN NEEDLES 29GX 191<br />

VALUMARK PEN NEEDLES 31G 191<br />

VALUMARK PEN NEEDLES 31G 192<br />

vanacet 58<br />

VANACOF CD 124<br />

VANACOF DX 124<br />

VANACOF 124<br />

vanacon 124<br />

VANATAB DX 124<br />

VANCOMYCIN HCL ISO-OSMOTI 26<br />

vancomycin hcl 26<br />

VANCOMYCIN 26<br />

vandazole 158<br />

vanishpoint insulin syrin 184<br />

vanishpoint insulin syrin 186<br />

VANOS 165


VANTAS 32<br />

vapor inhaler 175<br />

VAPOR PATCH 175<br />

VAPORIZING CHEST RUB 175<br />

vaporizing steam 175<br />

VAPORX BALM 175<br />

VAPRISOL 88<br />

VAQTA 157<br />

VARICELLA-ZOSTER IMMUNE G 156<br />

VARIVAX 157<br />

vaso dose pack 10 16<br />

vaso dose pack 30 16<br />

vasopressin 150<br />

VAZOTAB 16<br />

VAZOTUSS HC 124<br />

VCF VAGINAL CONTRACEPTIVE 79<br />

VECTIBIX 32<br />

vecuronium bromide 38<br />

veetids 22<br />

VELCADE 32<br />

VENLAFAXINE HCL 67<br />

venlafaxine hcl 67<br />

venlafaxine 66<br />

venlafaxine 67<br />

VENOFER 39<br />

VENOGLOBUL-S 156<br />

VENOMIL HONEY BEE VENOM 175<br />

VENOMIL MIXED VESPID VENO 175<br />

VENOMIL WASP VENOM PROTEI 175<br />

VENOMIL WHITE FACED HORNE 175<br />

VENOMIL YELLOW HORNET VEN 175<br />

VENOMIL YELLOW JACKET VEN 175<br />

VENTOLIN HFA 36<br />

VERAPAMIL HCL 49<br />

verapamil hcl 49<br />

verapamil 49<br />

VERIPRED 146<br />

verotin-by 172<br />

verotin-gr 172<br />

VFEND IV 27<br />

VFEND 27<br />

vi-q-tuss 124<br />

VIADUR 32<br />

VIAGRA 45<br />

VIBATIV 26<br />

VIBRAMYCIN 26<br />

VICKS 44M PEDIATRIC COUGH 124<br />

VICKS CASERO 134<br />

VICKS CASERO 175<br />

VICKS DAYQUIL COUGH 124<br />

vicks dayquil multi-sympt 124<br />

VICKS FORMULA 44 COUGH RE 124<br />

VICKS FORMULA 44 CUSTOM C 100<br />

VICKS FORMULA 44D COUGH/N 124<br />

VICKS FORMULA 44E COUGH/C 124<br />

VICKS FORMULA 44E PEDIATR 124<br />

VICKS FORMULA 44M MULTI-S 124<br />

VICKS FORMULA 44M PEDIATR 124<br />

VICKS NYQUIL CHILDRENS CO 124<br />

vicks nyquil multi-sympto 124<br />

VICKS VAPORUB 175<br />

vicoclear 124<br />

vicodin hp 58<br />

VICTORY AGM-4000 TEST STR 81<br />

VICTORY BLOOD GLUCOSE MON 195<br />

VICTOZA 148<br />

VIDAZA 32<br />

VIDEX 28<br />

VIMPAT 66<br />

vinatal forte 172<br />

vinate c 172<br />

VINATE M 172<br />

vinate one 172<br />

VINBLASTINE 32<br />

vincristine sulfate 32<br />

vinorelbine tartrate 32<br />

VIOKASE 16 141<br />

VIOKASE 8 141<br />

VIOKASE 141<br />

VIRACEPT 28<br />

VIRAMUNE 28<br />

VIRATAN-DM 124<br />

viratan-dm 124<br />

VIRAVAN-P 4<br />

VIRAVAN-PDM 124<br />

VIRAVAN-T 4<br />

VISCOAT 140<br />

VISIPAQUE 83<br />

visonex 134<br />

visrx dose pack 16<br />

VISTARIL 76<br />

VISTIDE 29<br />

VISUDYNE 140<br />

visvex hc 124<br />

vita-numonyl ad 124<br />

VITA-NUMONYL DM 124<br />

vita-numonyl nr 124<br />

vita-numonyl pediatric 124<br />

VITA-NUMONYL 134<br />

VITA-NUMONYL 172<br />

vitafol-ob 172<br />

VITAFOL-PN 172<br />

VITAJECT 172<br />

vitalet pro lancets 195<br />

vitalet pro plus lancets 195<br />

vitamin b-6 169<br />

vitamin b1 & b12 169<br />

VITAMIN K1 169<br />

vitamins a/d/c/fluoride 170<br />

vitelle nestabs 172<br />

VITRASE 88<br />

VITRAX 140<br />

vitussin 124<br />

VIVAGLOBIN 156<br />

VIVELLE-DOT 147<br />

VIVITROL 64<br />

VOLUVEN 86<br />

VOPAC 58<br />

vp insulin syringe/u-100/ 181<br />

VPRIV 88<br />

VUMON 32<br />

vynatal fa 172<br />

VYVANSE 72<br />

VYVANSE 73<br />

created on 20100520 255<br />

W<br />

w&f color lancets 195<br />

w&f lancets 26g 195<br />

w&f lancets colored 21g 195<br />

w&f lancets ultra thin 195<br />

wal-act 16<br />

wal-dryl allergy/sinus he 3<br />

wal-dryl-d allergy/sinus 3<br />

wal-dryl-d 3<br />

wal-finate-d 16<br />

wal-flu severe cold dayti 35<br />

WAL-FLU SEVERE COLD NIGHT 16<br />

wal-flu warming comfort s 3<br />

wal-four 138<br />

wal-hist 3<br />

wal-itin aller-melts 17<br />

wal-itin 17<br />

wal-phed pe severe cold 3<br />

wal-phed pe sinus headach 35<br />

wal-phed pe sinus/allergy 16


wal-phed sinus/allergy 16<br />

wal-profen cold/sinus 38<br />

wal-tap childrens 16<br />

wal-tap cold & allergy 16<br />

wal-tap dm cold & cough 124<br />

wal-tap dm cold/cough 124<br />

wal-tussin cf 124<br />

wal-tussin cold 124<br />

wal-tussin cold 134<br />

wal-tussin cough & cold 124<br />

wal-tussin cough/cold cf 124<br />

wal-tussin cough 124<br />

wal-tussin dm clear 124<br />

wal-tussin dm 124<br />

wal-tussin pediatric coug 124<br />

wal-tussin 124<br />

wal-tussin 134<br />

wal-vert 17<br />

wal-zyr 17<br />

walgreens lancets 189<br />

walgreens thin lancets 194<br />

walgreens ultra thin lanc 194<br />

WARFARIN SODIUM 40<br />

warfarin sodium 40<br />

warfarin 40<br />

WASP VENOM 175<br />

water for inject, bacteriostatic 196<br />

water for injection, sterile 196<br />

WATER, STERILE 196<br />

WAVESENSE AMP TEST STRIPS 81<br />

WAVESENSE AMP 195<br />

WAVESENSE JAZZ TEST STRIP 81<br />

WAVESENSE JAZZ 195<br />

WAVESENSE KEYNOTE TEST ST 81<br />

WAVESENSE KEYNOTE 195<br />

WAVESENSE PRESTO TEST STR 81<br />

WAVESENSE PRESTO 195<br />

wavesense ultra-thin lanc 195<br />

wd lancets thin 195<br />

wd lancets 195<br />

wd medic insulin syringe/ 181<br />

wd medic insulin syringe/ 182<br />

wd medic insulin syringe/ 183<br />

wd medic insulin syringe/ 184<br />

wd medic insulin syringe/ 186<br />

wd medic insulin syringe/ 187<br />

wd thin lancets 195<br />

we allergy 16<br />

we mist ii la 134<br />

wellbid-d 1200 134<br />

wellbid-d 134<br />

welltuss exp 124<br />

welltuss hc 124<br />

west-decon m 16<br />

WESTHROID 154<br />

WHITE HORNET 175<br />

WILATE 43<br />

WINN DIXIE MEDIC TEST STR 81<br />

WINN DIXIE MEDIC VALUE 195<br />

WINRHO SDF 156<br />

womens menstrual relief 62<br />

womens tylenol 64<br />

X<br />

x-hist dm 124<br />

x-hist 3<br />

XALATAN 140<br />

xedec ii 134<br />

XEDEC 134<br />

XENICAL 144<br />

XIAFLEX 88<br />

XIGRIS 175<br />

XIGRIS 176<br />

xiral sr 16<br />

XIRATUSS 124<br />

xiratuss 124<br />

XODOL 58<br />

XOLAIR 134<br />

XOLE 159<br />

XOLEGEL DUO/HEAD & SHOULD 159<br />

XOLEGEL DUO/XOLEX 159<br />

XOLOX 58<br />

XPECT-AT 124<br />

XPECT-HC 124<br />

xpect-pe 134<br />

xpect 134<br />

XYNTHA 43<br />

created on 20100520 256<br />

Y<br />

Y-COF DM 124<br />

YAZ 147<br />

YELLOW HORN 176<br />

YELLOW HORNT 176<br />

YELLOW JACK 176<br />

YELLOW JACKT 176<br />

YF-VAX 157<br />

yl vit b-6 169<br />

YODEFAN-NF 134<br />

YODEFAN 134<br />

Z<br />

Z-COF 12DM 124<br />

Z-COF DMX 124<br />

z-dex 12d 124<br />

z-dex 124<br />

Z-TUSS 2 EXPECTORANT 124<br />

Z-TUSS AC 124<br />

z-tuss dm 124<br />

zaclir 162<br />

ZADITOR 135<br />

ZAFIRLUKAST 125<br />

zaleplon 76<br />

ZANAMIVIR 28<br />

ZANOSAR 33<br />

ZANTAC 143<br />

ZEEL 176<br />

ZEGERID OTC 143<br />

ZEGERID 143<br />

zema-pak 10 day 146<br />

zema-pak 13 day 146<br />

zema-pak 6 day 146<br />

ZEMAIRA 134<br />

ZEMPLAR 169<br />

ZENAPAX 173<br />

zerlor 58<br />

ZEVALIN IN-111 33<br />

ZEVALIN Y-90 33<br />

zhist expectorant 124<br />

ZIAGEN 28<br />

zidovudine 28<br />

ZINACEF 19<br />

ZINC SULFATE 86<br />

ZINC TRACE 86<br />

ZINX ALLERGY 16<br />

ZINX COLD 124<br />

ZINX CONGESTION 134<br />

ZINX COUGH 124<br />

ZINX KIDS SNEEZE 16<br />

ZITHRANOL-RR 167<br />

ZITHROMAX 21<br />

ZMAX PEDIATR 22<br />

ZMAX 22<br />

ZODERM 162<br />

ZODRYL AC 25 125<br />

ZODRYL AC 30 125<br />

ZODRYL AC 35 125


ZODRYL AC 40 125<br />

ZODRYL AC 50 125<br />

ZODRYL AC 60 125<br />

ZODRYL AC 80 125<br />

ZODRYL DAC 25 125<br />

ZODRYL DAC 30 125<br />

ZODRYL DAC 35 125<br />

ZODRYL DAC 40 125<br />

ZODRYL DAC 50 125<br />

ZODRYL DAC 60 125<br />

ZODRYL DAC 80 125<br />

ZODRYL DEC 25 125<br />

ZODRYL DEC 30 125<br />

ZODRYL DEC 35 125<br />

ZODRYL DEC 40 125<br />

ZODRYL DEC 50 125<br />

ZODRYL DEC 60 125<br />

ZODRYL DEC 80 125<br />

ZOLADEX 33<br />

ZOLMITRIPTAN 77<br />

zolpidem tartrate 76<br />

ZOMETA 173<br />

ZOMIG ZMT 77<br />

ZOMIG 77<br />

ZONATUSS 125<br />

ZOSTAVAX 157<br />

ZOSYN 24<br />

ZOTEX -GP 134<br />

ZOTEX GPX 134<br />

ZOTEX HC 125<br />

zotex-12 125<br />

zotex-12d 125<br />

ZOTEX-C 125<br />

ZOTEX-D 125<br />

ZOTEX-DM 125<br />

ZOTEX-DMX 125<br />

ZOTEX-EX 125<br />

ZOTEX-G 125<br />

ZOTEX-LA 125<br />

zotex-pe 16<br />

ZYDONE 58<br />

ZYMAR 135<br />

ZYMINE DXR 16<br />

ZYMINE HC 125<br />

ZYPREXA RELP 70<br />

ZYPREXA ZYDI 70<br />

ZYPREXA 70<br />

zyrphen-hc 125<br />

zyrphen 134<br />

ZYVOX 26<br />

created on 20100520 257

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