Simply Healthcare Plans, Inc

Simply Healthcare Plans, Inc 

Simply Care (HMO SNP) H5471-008/Simply Comfort (HMO SNP) H5471-009 

Miami-Dade County 

2012 Formulary 

(List of Covered Drugs) 

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE 

COVER IN THIS PLAN 

Note to existing members: This formulary has changed since last year. Please review this document to 

make sure that it still contains the drugs you take. 

This document includes Simply Healthcare Plans, Inc. partial formulary as of January 1, 2012. For a 

complete, updated formulary, please visit our Web site at www.mysimplymedicare.com or call 1-877-577- 

0115, Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m.-8:00p.m. Eastern. 

TTY/TDD users should call 711 Telecommunications Relay Services. 

Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, 

pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2013. 

“A Coordinated Care plan with a Medicare Advantage contract” 

To get this material in other formats or ask for language translation services, call Simply Healthcare Plans, Inc. 

Member Services at 1-877-577-0115 (TTY/TDD users only: 711 Telecommunications Relay Services), if you 

need plan information in another format. 

This information is available for free in other languages. Please contact our Member Service’s department at 1- 

877-577-0115 or 711 for TTY, for additional information. 

Esta información esta disponible de gratis en otros idiomas. Por favor llame a nuestro departamento de 

Servicios al Afiliados al 1-877-577-0115. Si usted usa un dispositivo TTY, por favor llame al 711. 

Formulary ID: 12487 Ver 5/ Formulary ID: 12488 Ver 5 

H5471_2012AForm_Retail CMS File & Use 08/29/2011 

i

What is the Simply Healthcare Plans, Inc.’s Formulary 

A formulary is a list of covered drugs selected by Simply Healthcare Plans, Inc. in consultation with a team of 

health care providers, which represents the prescription therapies believed to be a necessary part of a quality 

treatment program. Simply Healthcare Plans, Inc. will generally cover the drugs listed in our formulary as long 

as the drug is medically necessary, the prescription is filled at a Simply Healthcare Plans, Inc. network 

pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please 

review your Evidence of Coverage. 

This document is a partial formulary and includes only some of the drugs covered by Simply Healthcare Plans, 

Inc. For a complete listing of all prescription drugs covered by Simply Healthcare Plans, Inc. , please visit our 

Web site at www.mysimplymedicare.com or call 1-877-577-0115, Sunday, Monday, Tuesday, Wednesday, 

Thursday, Friday, Saturday, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711 Telecommunications 

Relay Services. 

Can the Formulary change 

Generally, if you are taking a drug on our 2012 formulary that was covered at the beginning of the year, 

we will not discontinue or reduce coverage of the drug during the 2012 coverage year except when a new, 

less expensive generic drug becomes available or when new adverse information about the safety or 

effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our 

formulary, will not affect members who are currently taking the drug. It will remain available at the same 

cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important 

that you have continued access for the remainder of the coverage year to the formulary drugs that were 

available when you chose our plan, except for cases in which you can save additional money or we can 

ensure your safety. 

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy 

restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the 

change at least 60 days before the change becomes effective, or at the time the member requests a refill of 

the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug 

Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug 

from the market, we will immediately remove the drug from our formulary and provide notice to members 

who take the drug. The enclosed formulary is current as of January 1, 2012. To get updated information 

about the drugs covered by Simply Healthcare Plans, Inc., please visit our Web site at 

www.mysimplymedicare.com or call Member Services at 1-877-577-0115, Sunday, Monday, Tuesday, 

Wednesday, Thursday, Friday, Saturday, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711 

Telecommunications Relay Services. In the event of a mid-year non-maintenance formulary change such 

as changing a preferred or non-preferred formulary drug, adding an additional requirement or limit to a 

drug, remove a dosage form, or exchanging therapeutic alternatives by adding or deleting a drug or 

changing a tier as a result of a therapeutic alternative, we will notify you by providing you with a written 

notice of the non-maintenance formulary change. 

How do I use the Formulary 

There are two ways to find your drug within the formulary: 

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Medical Condition 

The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the 

type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are 

listed under the category, “Cardiovascular Agents”. If you know what your drug is used for, look for the 

category name in the list that begins on page 1. Then look under the category name for your drug. 

Alphabetical Listing 

If you are not sure what category to look under, you should look for your drug in the Index that begins on 

page 46. The Index provides an alphabetical list of all of the drugs included in this document. Both brand 

name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your 

drug, you will see the page number where you can find coverage information. Turn to the page listed in the 

Index and find the name of your drug in the first column of the list. 

What are generic drugs 

Simply Healthcare Plans, Inc. covers both brand name drugs and generic drugs. A generic drug is approved 

by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less 

than brand name drugs. 

Are there any restrictions on my coverage 

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits 

may include: 

 

Prior Authorization: Simply Healthcare Plans, Inc. requires you or your physician to get prior 

authorization for certain drugs. This means that you will need to get approval from Simply Healthcare 

Plans, Inc. before you fill your prescriptions. If you don’t get approval, Simply Healthcare Plans, Inc. 

may not cover the drug. 

 

Quantity Limits: For certain drugs, Simply Healthcare Plans, Inc. limits the amount of the drug that 

Simply Healthcare Plans, Inc. limits will cover. For example, Simply Healthcare Plans, Inc. provides 30 

tablets per prescription for LIPITOR 10 MG TABLETS. This may be in addition to a standard one 

month or three month supply. 

 

Step Therapy: In some cases, Simply Healthcare Plans, Inc. requires you to first try certain drugs to 

treat your medical condition before we will cover another drug for that condition. For example, if Drug 

A and Drug B both treat your medical condition, Simply Healthcare Plans, Inc. may not cover Drug B 

unless you try Drug A first. If Drug A does not work for you, Simply Healthcare Plans, Inc. will then 

cover Drug B. 

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins 

on page 1. You can also get more information about the restrictions applied to specific covered drugs by 

visiting our Web site at www.mysimplymedicare.com. 

iii

You can ask Simply Healthcare Plans, Inc. to make an exception to these restrictions or limits. See the section, 

“How do I request an exception to the Simply Healthcare Plans, Inc. formulary” on page iv for information 

about how to request an exception. 

What if my drug is not on the Formulary 

If your drug is not included in this list of covered drugs, you should first contact Member Services and ask if 

your drug is covered. This document includes only a partial list of covered drugs, so Simply Healthcare Plans, 

Inc. may cover your drug. You can contact Member Services at 1-877-577-0115, Sunday, Monday, Tuesday, 

Wednesday, Thursday, Friday, Saturday, 8:00 am – 8:00 pm Eastern. TTY/TDD users should call 711 

Telecommunications Relay Services. 

If you learn that Simply Healthcare Plans, Inc. does not cover your drug, you have two options: 

 

You can ask Member Services for a list of similar drugs that are covered by Simply Complete (HMO 

SNP). When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug 

that is covered by Simply Healthcare Plans, Inc. 

 

You can ask Simply Healthcare Plans, Inc. to make an exception and cover your drug. See below for 

information about how to request an exception. 

How do I request an exception to the Simply Healthcare Plans, Inc. Formulary 

You can ask Simply Healthcare Plans, Inc. to make an exception to our coverage rules. There are several types 

of exceptions that you can ask us to make. 

 

You can ask us to cover your drug even if it is not on our formulary. 

 

You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, 

Simply Healthcare Plans, Inc. limits the amount of the drug that we will cover. If your drug has a 

quantity limit, you can ask us to waive the limit and cover more. 

 

You can ask us to provide a higher level of coverage for your drug. If your drug is contained in our nonpreferred 

brand tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the 

preferred brand tier instead. This would lower the amount you must pay for your drug. Please note, if 

we grant your request to cover a drug that is not on our formulary, you may not ask us to provide a 

higher level of coverage for the drug. “Also, you may not ask us to provide a higher level of coverage 

for drugs that are in the Tier 5, Specialty tier.” 

Generally, Simply Healthcare Plans, Inc. will only approve your request for an exception if the alternative drugs 

included on the plan’s formulary, the lower-tiered drug or additional utilization restrictions would not be as 

effective in treating your condition and/or would cause you to have adverse medical effects. 

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction 

exception. When you are requesting a formulary, tiering or utilization restriction exception you should 

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submit a statement from your prescriber’s or physician supporting your request. Generally, we must 

make our decision within 72 hours of getting your prescribing physician’s supporting statement. You can 

request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by 

waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no 

later than 24 hours after we get your prescriber’s or prescribing physician’s supporting statement. 

What do I do before I can talk to my doctor about changing my drugs or requesting an 

exception 

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may 

be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior 

authorization from us before you can fill your prescription. You should talk to your doctor to decide if you 

should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the 

drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your 

drug in certain cases during the first 90 days you are a member of our plan. 

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a 

temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network 

pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of 

the plan less than 90 days. 

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have 

provided you with 93-day transition supply, consistent with dispensing increment, (unless you have a 

prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you 

are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is 

limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply 

of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. 

For current members who are changing from one treatment setting to another, for example entering a 

longterm care facility from a hospital or being discharged from a hospital to home, the member and provider 

will need to utilize our exception and appeals process should the drugs not be on our formulary. Members 

entering or being discharged from a long-term care facility will be allowed a one-time emergency supply of a 

31-day supply for medications which the member has not already received a transition supply. In addition, 

the dispensing pharmacist will need to call the Pharmacy Help Desk to receive appropriate directions to 

dispense a prescription required due to a level of care change. 

For more information 

For more detailed information about your Simply Healthcare Plans, Inc. prescription drug coverage, please 

review your Evidence of Coverage and other plan materials. 

If you have questions about Simply Healthcare Plans, Inc., please call Member Services at 1-877-577-0115, 

Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 am – 8:00 pm Eastern. TTY/TDD 

users should call 711 Telecommunications Relay Services. Or visit www.mysimplymedicare.com. 

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800- 

MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should call 1-877-486-2048. 

Or, visit www.medicare.gov. 

v

Simply’s (HMO SNP) Formulary 

The abridged formulary below provides coverage information about some of the drugs covered by Simply 

Healthcare Plans, Inc. If you have trouble finding your drug in the list, turn to the Index that begins on page 46. 

Remember: This is only a partial list of drugs covered by Simply Healthcare Plans, Inc. If your prescription is 

not in this partial formulary, please visit our Web site at www.mysimplymedicare.com or call Member Services 

at 1-877-577-0115, Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 am – 8:00 pm 

Eastern. TTY/TDD users should call 711 Telecommunications Relay Services, for additional help. 

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIPITOR 10 mg) and 

generic drugs are listed in lower-case italics (e.g., pravastatin sodium 10 mg). 

The information in the Requirements/Limits column tells you if Simply Healthcare Plans, Inc. has any special 

requirements for coverage of your drug. 

ST 

PA 

BD 

QL 

SP 

E 

GC 

Step Therapy 

Prior Authorization 

BvD Prior Authorization, may be covered under Medicare Part B or Part D depending upon the 

circumstances. Information may need to be submitted describing the use setting of the drug to make the 

determination. 

Quantity Limit per 30 day supply 

This prescription may be available only at certain pharmacies. For more information consult your 

Pharmacy Directory or call Member Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm 

Eastern. TTY/TDD users should call 711 Telecommunication Relay Services 

This prescription drug is not normally covered in a Medicare Prescription Drug Plan. The amount you 

pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the 

amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving 

extra help to pay for your prescriptions, you will not get any extra help to pay for this drug. 

We provide additional coverage of this prescription drug in the coverage gap. Please refer to our 

Evidence of Coverage for more information about this coverage. 

vi

Plan H5471-008 Simply Care (HMO SNP) 

Below is a chart showing your co-payment/co-insurance by drug tier. 

Formulary Drug Tier 

Copayment/Co-insurance at Retail 

Pharmacies 

Copayment/Co-insurance for 90 

day supply at retail pharmacies 

Tier 1 $0 $0 

Tier 2 $0 $0 

Tier 3 $10 $30 

Tier 4 $25 Limited to 30 day supply 

Tier 5 33% Limited to 30 day supply 

Plan H5471-009 Simply Comfort (HMO SNP) 

Below is a chart showing your co-payment/co-insurance by drug tier. 

Formulary Drug Tier 

Copayment/Co-insurance at Retail 

Pharmacies 

Copayment/Co-insurance for 90 

day supply at retail pharmacies 

Tier 1 $0 $0 

Tier 2 $0 $0 

Tier 3 $10 $30 

Tier 4 $25 Limited to 30 day supply 

Tier 5 33% Limited to 30 day supply 

vii

Simply Healthcare Plans, Inc 

Simply Care (HMO SNP) H5471-008/ Simply Comfort (HMO SNP) 

H5471-009 

Condado de Miami-Dade 

Formulario de 2012 

(Lista de medicamentos cubiertos) 

LEA POR FAVOR: ESTE DOCUMENTO CONTIENE INFORMACIÓN SOBRE LOS 

MEDICAMENTOS QUE CUBRE ESTE PLAN 

Nota a los afiliados existentes: Este formulario ha cambiado desde el año pasado. Revise este documento 

para asegurarse de que sigue incluyendo los medicamentos que toma. 

Este documento contiene el formulario parcial de Simply Healthcare Plans, Inc. actualizado al 1 de enero 

de 2012. Si desea el formulario completo y actualizado, visite nuestro sitio web en 

www.mysimplymedicare.com o llame al 1-877-577-0115. Se atiende domingos, lunes, martes, miércoles, 

jueves, viernes y sábados de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios con TTY/TDD deben 

marcar 711, el Centro de Enlace de Telecomunicaciones. 

Los beneficiarios deben usar las farmacias de la red para tener acceso a su beneficio de medicamentos recetados. 

El 1 de enero de 2013 podría haber cambios en los beneficios, el formulario, la red de farmacias, las primas, los 

copagos o el coaseguro. 

Una Organización Medicare Advantage con contrato con Medicare. 

Si desea este material o información del plan en otro formato, o si desea servicios de traducción de idiomas, 

comuníquese con el Departamento de Servicios para Afiliados de Simply Healthcare Plans, Inc. llamando al 1- 

877-577-0115 (los usuarios con TTY/TDD deben marcar 711, el Centro de Enlace de Telecomunicaciones). 

Id. del Formulario: 12487, Ver. 5 / Id. del Formulario: 12488, Ver.5 

H5471_2012AForm_RetailBIL CMS File & Use 08/29/2011 

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¿Qué es el Formulario de Simply Healthcare Plans, Inc. 

El formulario es una lista de medicamentos seleccionados cubiertos por Simply Healthcare Plans, Inc. en 

colaboración con un equipo de proveedores de atención médica, que representa las terapias farmacológicas 

consideradas como parte necesaria de un programa de tratamiento de calidad. Por lo general, Simply Healthcare 

Plans, Inc. cubrirá los medicamentos incluidos en nuestro formulario siempre y cuando se necesiten por razones 

médicas, el medicamento sea surtido en una farmacia de la red de Simply Healthcare Plans, Inc., y se hayan 

seguido otras reglas de cobertura. Si desea más información sobre cómo hacer para que le surtan sus 

medicamentos recetados, consulte su Evidencia de Cobertura. 

Este documento es un formulario parcial y solo incluye algunos de los medicamentos cubiertos por Simply 

Healthcare Plans, Inc. Si desea la lista completa de todos los medicamentos recetados cubiertos por Simply 

Healthcare Plans, Inc., visite nuestro sitio web en www.mysimplymedicare.com o llame al 1-877-577-0115. Se 

atiende domingos, lunes, martes, miércoles, jueves, viernes y sábados de 8:00 a.m. a 8:00 p.m., hora del Este. 

Los usuarios con TTY/TDD deben marcar 711, el Centro de Enlace de Telecomunicaciones. 

¿Es posible que cambie el formulario 

Por lo general, si está tomando un medicamento de nuestro formulario de 2012 que estaba cubierto al 

principio del año, no lo descontinuaremos ni reduciremos su cobertura durante el año de cobertura 2012, 

excepto cuando un medicamento genérico nuevo y menos costoso se ponga a disposición, o cuando se 

publique nueva información adversa sobre la seguridad o efectividad de un medicamento. Otros tipos de 

cambios en el formulario, como el retiro de un medicamento de nuestro formulario, no afectará a los 

afiliados que están tomando actualmente el medicamento. Seguirá estando disponible con la misma 

participación de costos para aquellos afiliados que lo están tomando durante el resto del año de cobertura. 

Creemos que es importante que usted tenga acceso continuo durante el resto del año de la cobertura a los 

medicamentos del formulario que estaban disponibles cuando eligió nuestro plan, excepto en los casos en 

los que pueda ahorrar dinero o podamos garantizar su seguridad. 

Si retiramos medicamentos de nuestro formulario o añadimos autorizaciones previas, límites en las 

cantidades o restricciones en la terapia por fases en un medicamento, o trasladamos un medicamento a un 

nivel con distribución de costos más alta, debemos notificar a los afiliados afectados sobre el cambio 

cuando menos con 60 días de anticipación a que entre en vigencia. Alternativamente, daremos notificación 

cuando el afiliado solicite la repetición de la receta del medicamento, momento en el cual el afiliado 

recibirá un surtido de 60 días del medicamento en cuestión. Si la Administración de Alimentos y 

Medicamentos considera que un medicamento en nuestro formulario no es seguro, o el fabricante del 

medicamento lo retira del mercado, nosotros eliminaremos inmediatamente dicho medicamento de nuestro 

formulario y daremos aviso a los afiliados que lo usan. El formulario adjunto está actualizado al 1 de enero 

de 2012. Si desea información actualizada de los medicamentos cubiertos por Simply Healthcare Plans, 

Inc., visite nuestro sitio web en www.mysimplymedicare.com o comuníquese con el Departamento de 

Servicios para Afiliados llamando al 1-877-577-0115. Se atiende domingos, lunes, martes, miércoles, 

jueves, viernes y sábados de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios con TTY/TDD deben 

marcar 711, el Centro de Enlace de Telecomunicaciones. En caso de que se haga un cambio en el 

formulario de un medicamento que no sea de mantenimiento a mitad de año, como el cambio de un 

medicamento preferido o no preferido del formulario, añadir un requisito adicional o poner un límite a un 

medicamento, retirar una forma de dosis, o intercambiar alternativas terapéuticas agregando o eliminando 

un medicamento o cambiando un nivel como resultado de una alternativa terapéutica, se lo notificaremos 

mediante aviso por escrito del cambio en el formulario del medicamento que no es de mantenimiento. 

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¿Cómo uso el formulario 

Hay dos maneras de encontrar su medicamento en el formulario. 

Afección 

El formulario comienza en la página 1. Los medicamentos en este formulario se agrupan en categorías en 

función del tipo de afecciones que tratan habitualmente. Por ejemplo, los medicamentos para tratar 

afecciones cardiacas se incluyen en la categoría “Agentes Cardiovasculares”. Si sabe para qué sirve su 

medicamento, busque el nombre de la categoría en la lista que comienza en la página 1. A continuación 

busque su medicamento en dicha categoría. 

Lista en orden alfabético 

Si no sabe a qué categoría corresponde su medicamento, deberá buscarlo en el Índice que comienza en la 

página 46.. El Índice ofrece una lista alfabética de todos los medicamentos incluidos en este documento. El 

Índice incluye tanto los medicamentos de marca como los genéricos. Busque en el Índice para encontrar su 

medicamento. Junto al medicamento, verá el número de la página que contiene la información sobre la 

cobertura. Vaya a la página indicada en el Índice y encuentre el nombre de su medicamento en la primera 

columna de la lista. 

¿Qué son los medicamentos genéricos 

Simply Healthcare Plans, Inc. cubre medicamentos genéricos y de marca. Un medicamento genérico recibirá 

la aprobación de la FDA si tiene el mismo ingrediente activo que el medicamento de marca. Por lo general, 

los medicamentos genéricos cuestan menos que los de marca. 

¿Hay restricciones en mi cobertura 

Algunos medicamentos cubiertos pueden tener requisitos adicionales o limitaciones en la cobertura. Estos 

requisitos y límites pueden incluir: 

 

Autorización Previa. Simply Healthcare Plans, Inc. requiere que usted o su médico obtengan 

autorización previa para ciertos medicamentos. Esto significa que necesitará obtener aprobación de 

Simply Healthcare Plans, Inc. antes de que pueda surtir sus recetas. Si no obtiene la aprobación, es 

posible que Simply Healthcare Plans, Inc. no cubra el medicamento. 

 

Límites en la Cantidad. Para ciertos medicamentos, Simply Healthcare Plans, Inc. limita la cantidad 

del medicamento que Simply Healthcare Plans, Inc. va a cubrir. Por ejemplo, Simply Healthcare Plans, 

Inc. proporciona 30 tabletas por receta del medicamento LIPITOR EN TABLETAS DE 10 MG. Esto 

puede ser adicional al suministro estándar de un mes o tres meses. 

 

Terapia por Fases. En algunos casos, Simply Healthcare Plans, Inc. requiere que usted pruebe primero 

ciertos medicamentos para tratar su condición médica antes de que demos cobertura a otro medicamento 

para dicha afección. Por ejemplo, si tanto el Medicamento A como el Medicamento B tratan su 

condición médica, es posible que Simply Healthcare Plans, Inc. no cubra el Medicamento B a menos 

3

que usted pruebe primero el Medicamento A. Si el Medicamento A no funciona en su caso, Simply 

Healthcare Plans, Inc. cubrirá el Medicamento B. 

Usted puede consultar el formulario que comienza en la página 1 para determinar si su medicamento tiene 

requisitos o límites adicionales. También puede obtener más información sobre las restricciones que se aplican a 

medicamentos cubiertos específicos si visita nuestro sitio web en www.mysimplymedicare.com. 

Puede solicitar a Simply Healthcare Plans, Inc. que haga una excepción a estas restricciones o límites. Consulte 

la sección “¿Cómo solicito una excepción en el formulario de Simply Healthcare Plans, Inc.” en la página 4 

para obtener información sobre cómo solicitar una excepción. 

¿Qué sucede si su medicamento no está en el formulario 

Si su medicamento no está incluido en esta lista de medicamentos cubiertos, debe comunicarse primero con el 

Departamento de Servicios para Afiliados para preguntar si está cubierto. Como este documento solo incluye 

una lista parcial de los medicamentos cubiertos, es posible que Simply Healthcare Plans, Inc. cubra su 

medicamento. Puede comunicarse con el Departamento de Servicios para Afiliados llamando al 1-877-577- 

0115. Se atiende domingos, lunes, martes, miércoles, jueves, viernes y sábados de 8:00 a.m. a 8:00 p.m., hora 

del Este. Los usuarios con TTY/TDD deben marcar 711, el Centro de Enlace de Telecomunicaciones. 

Si se entera de que Simply Healthcare Plans, Inc. no cubre su medicamento, usted tiene dos opciones: 

 

Puede solicitar al Departamento de Servicios para Afiliados que le dé una lista de medicamentos 

similares que estén cubiertos por Simply Care (HMO SNP). Cuando reciba la lista, muéstrela a su 

médico y pídale que le recete un medicamento similar que esté cubierto por Simply Healthcare Plans, 

Inc. 

 

Puede solicitar a Simply Healthcare Plans, Inc. que haga una excepción a estas restricciones o límites. 

Consulte la sección que sigue para obtener información sobre cómo solicitar una excepción. 

¿Cómo solicito una excepción en el formulario de Simply Healthcare Plans, Inc. 

Puede solicitar a Simply Healthcare Plans, Inc. que haga una excepción a nuestras reglas de cobertura. Hay 

varios tipos de excepciones que puede pedir. 

 

Puede solicitarnos que cubramos su medicamento aunque no esté incluido en nuestro formulario. 

 

Puede solicitarnos que cancelemos las restricciones o limitaciones en la cobertura para su medicamento. 

Por ejemplo, en algunos medicamentos, Simply Healthcare Plans, Inc. limita la cantidad que tendrá 

cobertura. Si su medicamento tiene un límite en la cantidad, puede solicitarnos que cancelemos dicha 

limitación y cubramos una mayor cantidad. 

 

Puede pedirnos que proporcionemos un nivel de cobertura más alto para su medicamento. Si su 

medicamento está incluido en nuestro nivel de medicamentos de marca no preferidos, puede solicitarnos 

que en su lugar lo cubramos en el nivel de participación de costos que se aplica a los medicamentos que 

4

están en el nivel de medicamentos de marca preferidos. Esto reduciría la cantidad que debe pagar por el 

medicamento. Tenga presente que si concedemos la solicitud de cubrir un medicamento que no se 

incluye en nuestro formulario, usted no puede pedirnos que demos un nivel de cobertura más alto para 

dicho medicamento. “Asimismo, no puede pedirnos que demos un nivel de cobertura más alto a los 

medicamentos que están en el Nivel 5, que corresponde a los medicamentos especiales.” 

Por lo general, Simply Healthcare Plans, Inc. solo aprobará su solicitud para una excepción si los medicamentos 

alternativos incluidos en el formulario del plan, o el medicamento de nivel más bajo o las restricciones de uso 

adicional no son tan eficaces para tratar su afección o pueden ocasionar efectos médicos adversos. 

Debe comunicarse con nosotros para solicitar una decisión de cobertura inicial para una excepción en el 

formulario, el nivel o la limitación en el uso. Cuando solicite una excepción en el formulario, el nivel o la 

limitación en el uso, debe presentar una declaración de su médico, o de quien le receta, que respalde su 

solicitud. Por lo general, debemos tomar una decisión en un plazo de 72 horas a partir del momento en el que 

hayamos recibido la declaración de respaldo de su médico tratante. Usted puede solicitar una excepción 

acelerada (rápida) si su médico considera que una espera de 72 horas para una decisión puede perjudicar 

gravemente su salud. Si se concede acelerar su solicitud, debemos otorgarle una decisión antes de 24 horas a 

partir del momento en que recibamos la declaración de respaldo de su médico tratante o de quien le receta. 

¿Qué debo hacer antes de hablar con mi médico sobre el cambio de mis medicamentos o la 

solicitud de una excepción 

Si usted es afiliado nuevo o continúa en nuestro plan, podría estar tomando medicamentos que no están en 

nuestro formulario. O podría estar tomando un medicamento que está en nuestro formulario pero su capacidad 

para adquirirlo es limitada. Por ejemplo, podría necesitar una autorización previa de nuestra parte para poder 

surtir su receta. Debe hablar con su médico para decidir si debe cambiar a un medicamento apropiado que 

nosotros cubramos o solicitar una excepción en el formulario para que podamos cubrir el medicamento que está 

tomando. Mientras habla con su médico para determinar el mejor modo de actuar para usted, podríamos cubrir 

su medicamento en ciertos casos durante los primeros 90 días de su afiliación a nuestro plan. 

Para cada uno de sus medicamentos que no esté en nuestro formulario, o si su capacidad para adquirir sus 

medicamentos es limitada, daremos cobertura a un suministro temporal de 30 días (a menos que tenga una 

receta para un número menor de días) cuando vaya a una farmacia de la red. Después de su primer suministro 

de 30 días, nosotros no pagaremos estos medicamentos, incluso si usted ha estado afiliado al plan menos de 90 

días. 

Si reside en un establecimiento de atención médica prolongada, le permitiremos que surta su receta hasta que 

hayamos proporcionado un suministro de transición de 93 días, consistente con el incremento en el suministro, 

(a menos que su receta indique un número menor de días). Daremos cobertura a más de un surtido de estos 

medicamentos durante los primeros 90 días de su afiliación a nuestro plan. Si necesita un medicamento que no 

está en nuestro formulario, o si su capacidad para adquirir sus medicamentos es limitada, pero han pasado los 

primeros 90 días de su afiliación a nuestro plan, daremos cobertura a un suministro de emergencia de 31 días de 

dicho medicamento (a menos que su receta indique un número menor de días) mientras busca una excepción en 

el formulario. 

Para los afiliados actuales que están cambiando de un lugar de tratamiento a otro, por ejemplo, si después de 

estar en un hospital ingresan a un establecimiento de atención médica prolongada, o que regresan a su hogar 

después de ser dados de alta de un hospital, el afiliado y el proveedor deberán utilizar nuestro proceso de 

excepciones y apelaciones en caso de que los medicamentos no estén en nuestro formulario. Los afiliados que 

ingresan a un establecimiento de atención médica prolongada, o que salen de él, tendrán permitido un 

5

suministro único de emergencia de 31 días de los medicamentos para los cuales no hayan recibido aún un 

suministro de transición. Adicionalmente, el farmacéutico que surte la receta deberá comunicarse con el Centro de 

Ayuda para Farmacias con el fin de recibir instrucciones apropiadas para surtir una receta requerida debido a un 

cambio en el nivel de la atención. 

Si desea más información 

Si desea información detallada sobre su cobertura de medicamentos recetados de Simply Healthcare Plans, Inc., 

consulte su Evidencia de Cobertura y demás documentos del plan. 

Si tiene preguntas sobre Simply Healthcare Plans, Inc., comuníquese con el Departamento de Servicios para 

Afiliados llamando al 1-877-577-0115. Se atiende domingos, lunes, martes, miércoles, jueves, viernes y 

sábados de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios con TTY/TDD deben marcar 711, el Centro de 

Enlace de Telecomunicaciones. O visite www.mysimplymedicare.com. 

Si tiene alguna pregunta general sobre la cobertura de medicamentos recetados de Medicare, comuníquese con 

Medicare llamando al 1-800-MEDICARE (1-800-633-4227). Se atiende las 24 horas del día, los 7 días de la 

semana. Las personas con impedimentos auditivos pueden llamar al 1-877-486-2048 o visitar la página 

www.medicare.gov. 

Formulario de Simply Healthcare Plans, Inc. 

El formulario abreviado que se ofrece a continuación proporciona información de cobertura de algunos de los 

medicamentos cubiertos por Simply Healthcare Plans, Inc. Si tiene problemas para encontrar su medicamento 

en la lista, diríjase al Índice que comienza en la página 46. Recuerde: Ésta es solo una lista parcial de los 

medicamentos recetados cubiertos por Simply Healthcare Plans, Inc. Si su medicamento recetado no está en 

este formulario parcial, visite nuestro sitio web en www.mysimplymedicare.com o comuníquese con el 

Departamento de Servicios para Afiliados llamando al 1-877-577-0115. Se atiende domingos, lunes, martes, 

miércoles, jueves, viernes y sábados de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios con TTY/TDD deben 

marcar 711, el Centro de Enlace de Telecomunicaciones, para recibir más ayuda. 

En la primera columna del diagrama se incluye el nombre del medicamento. Los medicamentos de marca están 

con letras mayúsculas (por ejemplo, LIPITOR 10 mg), y los medicamentos genéricos se incluyen con letras 

minúsculas en itálica (por ejemplo, pravastatin sodium 10 mg). 

La información en la columna de requisitos y límites indica si Simply Healthcare Plans, Inc. tiene algún 

requisito especial para dar cobertura a su medicamento. 

ST 

PA 

BD 

QL 

SP 

6 

Terapia por fases. 

Autorización previa. 

Autorización Previa BvD, podría tener cobertura con la Parte B o la Parte D de Medicare dependiendo 

de las circunstancias. Puede ser necesario enviar información sobre el uso del medicamento y la 

situación específica para tomar una determinación. 

Límite en la Cantidad por suministro de 30 días. 

Este medicamento recetado solo podría estar disponible en algunas farmacias. Si desea más 

información, consulte su Directorio de Farmacias o comuníquese con el Departamento de Servicios

E 

GC 

para Afiliados llamando al 1-877-577-0115. Se atiende los siete días de la semana de 8:00 a.m. a 8:00 

p.m., hora del Este. Los usuarios con TTY/TDD deben marcar 711, el Centro de Enlace de 

Telecomunicaciones. 

Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de 

Medicare. La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en 

cuenta en su costo total de medicamentos (es decir, la cantidad que paga no le ayuda a reunir los 

requisitos para la cobertura por catástrofe). Además, si está recibiendo ayuda adicional para pagar sus 

medicamentos, no obtendrá ningún otro tipo de ayuda adicional para pagar este medicamento. 

Proporcionamos cobertura adicional de este medicamento recetado durante la brecha en la cobertura. 

Consulte nuestra Evidencia de Cobertura para obtener más información sobre esta cobertura. 

7

Simply Care (HMO SNP) A continuación se ofrece una tabla con el copago o coaseguro por 

nivel de medicamento. 

Nivel del medicamento en el 

formulario 

Copago o coaseguro en farmacias 

minoristas 

Copago o coaseguro para 

pedido por correo y suministro 

de 90 días en farmacias 

minoristas 

Nivel 1 $0 $0 

Nivel 2 $0 $0 

Nivel 3 $10 $30 

Nivel 4 $25 Limitado a un suministro de 30 

días 

Nivel 5 33% Limitado a un suministro de 30 

días 

Simply Comfort (HMO SNP) A continuación se ofrece una tabla con el copago o coaseguro 

por nivel de medicamento. 

Nivel del medicamento en el 

formulario 

Copago o coaseguro en farmacias 

minoristas 

Copago o coaseguro para 

pedido por correo y suministro 

de 90 días en farmacias 

minoristas 

Nivel 1 $0 $0 

Nivel 2 $0 $0 

Nivel 3 $10 $30 

Nivel 4 $25 Limitado a un suministro de 30 

días 

Nivel 5 33% Limitado a un suministro de 30 

días 

8

Drug Name Tier Notes 

ANALGESICS 

Nonsteroidal Anti-inflammatory Drugs 

ARTHROTEC 4 

CELEBREX 100, 200 MG 3 QL 60 ST 

CELEBREX 50, 400 MG 3 QL 62/31 ST 

diclofenac potassium 2 

diclofenac sodium 2 

diflunisal 2 

etodolac 2 

FELDENE 4 

fenoprofen calcium 2 

FLECTOR 4 

flurbiprofen 2 

ibuprofen 1 GC 

INDOCIN 4 

indomethacin 1 GC 

ketoprofen 1 GC 

ketoprofen er 2 

ketorolac tromethamine inj 1 GC 

ketorolac tromethamine tab 1 QL 20/5 GC 

meclofenamate sodium 2 

meloxicam susp 1 QL 300 GC 

meloxicam tab 1 QL 30 GC 

MOBIC 4 PA 

nabumetone 2 

NALFON 4 

NAPRELAN 4 

NAPROSYN 4 

naproxen 1 GC 

oxaprozin 2 

oxycodone hcl/ibuprofen 2 

piroxicam 1 GC 

sulindac 2 

tolmetin sodium 2 

Opioid Analgesics 

apap/cod 300-15 mg tab 2 QL 403/31 

apap/cod 300-30 mg tab 2 QL 372/31 

apap/cod 300-60 mg tab 2 QL 180 

apap/cod sol 2 

ascomp/codeine 2 

astramorph 1 GC 

SP-Este medicamento recetado puede estar disponible solo en algunas farmacias. Si desea más información, consulte su 

Directorio de Farmacias o comuníquese con el Departamento de Servicios para Afiliados llamando al 1-877-577-0115. 

Se atiende los siete días de la semana de 8:00 a.m. a 8:00 p.m., hora del Este. Los usuarios con TTY/TDD deben marcar 

711; E-Este medicamento recetado por lo general no está cubierto en un Plan de Medicamentos Recetados de Medicare. 

La cantidad que usted paga cuando le surten una receta de este medicamento no se toma en cuenta en su costo total de 

medicamentos (es decir, la cantidad que paga no le ayuda a reunir los requisitos para la cobertura por catástrofe). 

Además, si está recibiendo ayuda adicional para pagar sus medicamentos, no obtendrá ningún otro tipo de ayuda 

adicional para pagar este medicamento.; GC-Proporcionamos cobertura adicional de este medicamento recetado durante 

la brecha en la cobertura. Consulte nuestra Evidencia de Cobertura para obtener más información sobre esta cobertura. 

1


butalbital/apap/caff 1 E GC 

co-gesic 2 QL 240 

duramorph 1 GC 

EMBEDA 3 QL 90 

endocet 2 QL 372 

endocet 10-650 mg 2 QL 186 

endocet 7.5-500 mg 2 QL 248 

fentanyl lozenge 5 PA 

fentanyl lozenge 0.2 mg 2 PA 

fentanyl transdermal patch 2 QL 10 

FENTORA 5 PA 

FIORICET/CODEINE 4 PA 

FIORINAL/CODEINE 3 

hydroco/apap 10-325 mg 1 QL 186/31 GC 




hydroco/apap 2.5-500 mg 1 QL 248/31 GC 







hydroco/apap sol 1 GC 

hydroco/ibuprofen 2 QL 155/31 

hydromorphone hcl 1 GC 

infumorph 4 

KADIAN CR 10, 50, 80 MG 3 QL 90 

KADIAN CR 100, 200 MG 3 QL 180 

KADIAN CR 20, 30, 60 MG 3 QL 120 

levorphanol 1 GC 

LORCET 4 PA 

LORTAB 4 PA 

MAGNACET 4 

margesic-h 2 

MAXIDONE 4 

methadone hcl 2 

methadose 2 

morphine sulfate 2 

morphine sulfate inj 1 GC 

SP-This prescription may be available only at certain pharmacies. For more information consult your Pharmacy 

Directory or call Member Services at 1-877-577-0115, 7 days a week, 8:00 am – 8:00 pm Eastern. TTY/TDD 

users should call 711 Telecommu-nication Relay Services; E-This prescription drug is not normally covered in a 

Medicare Prescription Drug Plan. The amount you pay when you fill a prescription for this drug does not count 

towards your to-tal drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In 

addi-tion, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for this 

drug.; GC-We provide additional coverage of this prescription drug in the coverage gap. Please refer to our 


2


MS CONTIN 4 PA 

nalbuphine hcl 1 GC 

NORCO 4 PA 

NUCYNTA 4 

ONSOLIS 4 PA 

OPANA 4 

OPANA ER 30 MG 3 QL 90 

OPANA ER 5, 10, 20, 40 MG 3 QL 120 

ORAMORPH 4 

orphenadrine/asa/caff 2 

oxycodone hcl 2 

OXYCODONE HCL SOL 4 

oxycodone/apap 2 QL 372/31 

oxycodone/apap 7.5-500mg 2 QL 248/31 

OXYCONTIN CR 4 PA QL 120 

OXYCONTIN CR 80 MG 4 PA QL 180 

oxymorphone 2 

PANLOR SS 4 

pentazocine/apap 2 QL 180 

PERCOCET 4 PA 

PERCODAN 4 PA 

repan 1 E GC 

roxicet 5-325 mg tab 2 QL 372/31 

roxicet 5-500 mg tab 2 QL 248/31 

roxicet sol 2 

ROXICODONE 15, 30 MG TAB 4 

roxicodone 5mg tab 2 PA 

RYZOLT 4 ST 

stagesic 2 

tramadol hcl 1 QL 240 GC 

tramadol hcl er 2 QL 240 ST 

tramadol hcl/apap 2 QL 240 

ANESTHETICS 

Local Anesthetics 

lidocaine 1 GC 

lidocaine/prilocaine 2 

LIDODERM 4 PA QL 90/30 

ANTIBACTERIALS 

Aminoglycosides 

ak-tob 1 GC 

gentak 2 










3


gentamicin 1 GC 

gentamicin/nacl 100 mg 1 GC 

gentamicin/nacl 60, 80 mg 2 

gentasol 1 GC 

kanamycin sulfate 1 GC 

neomycin sulfate 2 

paromomycin 2 

tobramycin inj 2 

tobramycin sulfate 1 GC 

tobrasol 1 GC 

Antibacterials, Other 

acetic acid 2 

baciim 2 

bacitracin 1 GC 

CHANTIX 0.5 MG 4 QL 11 

clindamycin hcl 2 

clindamycin phosphate 2 

colistimethate sodium 2 BD 

FLAGYL 4 

HIPREX 4 

LINCOCIN 4 

MACROBID 4 

MACRODANTIN 4 

methenamine hippurate 2 

METROCREAM 4 

METROGEL 4 

METROLOTION 4 

metronidazole cap, tab 1 GC 

metronidazole crm 2 

mupirocin 2 

nitrofurantoin 2 

nitrofurantoin macrocrystal 2 

nitrofurantoin monohydrate 2 

NORITATE 4 

trimethoprim 1 GC 

VANCOCIN HCL CAP 5 

VANCOCIN HCL INJ 3 BD 

vancomycin hcl 2 BD 

vandazole 2 

ZYVOX 5 

Beta-lactam, Cephalosporins 









4


cefaclor 2 

cefazolin sodium 1 GC 

cefdinir 2 

cefepime 1 GC 

cefoxitin sodium 1 GC 

cefpodoxime 2 

ceftriaxone sodium 1 GC 

cefuroxime axetil 1 GC 

cefuroxime sodium 1 GC 

cephalexin 1 GC 

FORTAZ 2 

KEFLEX 4 

ROCEPHIN 4 

SPECTRACEF 4 

SUPRAX 4 

ZINACEF 4 

Beta-lactam, Other 

AZACTAM IN DEXTROSE 3 

INVANZ 2 

MERREM 3 

PRIMAXIN 2 

Beta-lactam, Penicillins 

amoxicillin 200mg chw tab 3 

amoxicillin cap, susp, tab 1 GC 

amoxicillin/clavulanate p 2 

ampicillin 1 GC 

ampicillin/sulbactam 10-5 gm 2 BD 

dicloxacillin sodium 2 

MOXATAG 4 

nafcillin 1, 10 gm 1 GC 

nafcillin 20 mg/ml 2 

OXACILLIN INJ 1 GC 

OXACILLIN DEX INJ 2 

penicillin g potassium 1 GC 

penicillin g sodium 1 GC 

penicillin v potassium 1 GC 

PFIZERPEN 1 GC 

piperacillin sodium 1 GC 

Macrolides 

azithromycin 2 

erythrocin stearate 2 










5


erythromycin 1 GC 

erythromycin ethylsuccinate 2 

erythromycin/sulfisoxazole 1 GC 

KETEK 4 

PCE 4 

romycin 1 GC 

Quinolones 

ciprofloxacin 1 GC 

IQUIX 4 

LEVAQUIN INJ, TAB 4 

LEVAQUIN SOL, PREMIX 3 

NOROXIN 4 

OCUFLOX 4 

ofloxacin 2 

PROQUIN 4 

Sulfonamides 

KLARON 4 

SILVADENE 4 

silver sulfadiazine 1 GC 

ssd 1 GC 

sulfadiazine 2 

sulfamethoxazole/trimetho 1 GC 

thermazene 1 GC 

Tetracyclines 

doxycycline 10 mg/ml inj 1 GC BD 

doxycycline hyclate 1 GC 

doxycycline monohydrate 1 GC 

MINOCIN 4 PA 

minocycline 2 

MONODOX 4 

ORACEA 4 PA 

PERIOSTAT 4 

SOLODYN 105 MG 3 

SOLODYN 45, 90, 135 MG 4 PA 

SOLODYN 65, 115 MG 3 PA 

tetracycline hcl 1 GC 

ANTICONVULSANTS 

Anticonvulsants, Other 

KEPPRA 4 

KEPPRA XR 500 MG 4 PA 

levetiracetam 2 









6


phenobarbital 1 E GC 

primidone 2 

Calcium Channel Modifying Agents 

CELONTIN 4 

ethosuximide 2 

LYRICA 4 QL 90 

zonisamide 2 

Gamma-aminobutyric Acid (GABA) Augmenting Agents 

divalproex sodium 2 

gabapentin 2 

GABITRIL 12 MG 4 QL 120 

GABITRIL 2, 16 MG 4 QL 60 

GABITRIL 4 MG 4 

MYSOLINE 4 PA 

NEURONTIN 4 PA 

NEURONTIN SOL 4 

SABRIL 500 MG TAB 5 PA QL 186/31 

SABRIL SOL 5 PA 

valproate sodium 1 GC 

valproic acid 2 

Glutamate Reducing Agents 

FELBATOL 4 

LAMICTAL 4 

LAMICTAL KIT 3 

lamotrigine 2 

lamotrigine 150, 200 mg 2 QL 90 

topiramate cap 2 

Sodium Channel Agents 

BANZEL 200 MG TAB 4 PA QL 480 

BANZEL 400 MG TAB 4 PA QL 240 

carbamazepine 1 GC 

CARBATROL 100, 200 MG 4 QL 30 

CARBATROL 300 MG 4 QL 160 

DILANTIN INFATABS 4 

fosphenytoin sodium 1 GC 

oxcarbazepine 2 

PEGANONE 4 

PHENYTEK 3 

phenytoin 1 GC 

phenytoin er 200mg cap 2 

phenytoin susp 2 










7


TEGRETOL 4 

VIMPAT INJ, ORAL SOL 4 QL 1200 

VIMPAT TAB 4 QL 60 

Sodium Channel Inhibitors 

BANZEL SUSP 4 

ANTIDEMENTIA AGENTS 

Cholinesterase Inhibitors 

ARICEPT 4 

donepezil 2 

EXELON 3 QL 31/31 

galantamine 12 mg tab 2 QL 62/31 

galantamine 4 mg tab 2 

galantamine 8 mg tab 2 QL 30 

galantamine er cap 2 QL 31/31 

RAZADYNE 4 PA QL 180 

Glutamate Pathway Modifiers 

NAMENDA SOL 3 QL 360 

NAMENDA TAB 3 QL 60 

ANTIDEPRESSANTS 

Antidepressants, Other 

ABILIFY DISCMELT 4 PA 

ABILIFY INJ 4 PA QL 120 

ABILIFY SOL 4 PA 

ABILIFY TAB 4 PA QL 30 

APLENZIN 4 QL 30 ST 

budeprion 2 

bupropion 2 

bupropion sr 100 mg tab 2 

bupropion sr 150 mg tab 2 QL 62/31 

bupropion sr 200 mg tab 2 QL 60 

maprotiline hcl 2 

mirtazapine 2 

nefazodone hcl 1 GC 

OLEPTRO 4 

paroxetine er 12.5 mg tab 2 QL 180 

SEROQUEL XR 3 QL 60 

SYMBYAX 4 QL 30 

trazodone hcl 1 GC 

Monoamine Oxidase Inhibitors 

EMSAM 4 QL 31/31 

MARPLAN 4 









8


PARNATE 4 

phenelzine 2 

tranylcypromine sulfate 2 

Serotonin/Norepinephrine Reuptake Inhibitors 

citalopram 10 mg tab 1 QL 60 GC 



citalopram sol 1 GC 

CYMBALTA 20, 30 MG 3 QL 62/31 

CYMBALTA 60 MG 3 QL 31/31 

fluoxetine 10 mg cap 2 QL 240 



fluoxetine sol, tab 2 

fluvoxamine maleate 2 QL 90 

LEXAPRO SOL 3 QL 600 

LEXAPRO TAB 3 QL 30 

LUVOX 4 

paroxetine er 25 mg tab 2 QL 90 

paroxetine er 37.5 mg tab 2 

PAXIL 4 

PRISTIQ 4 QL 30 

PROZAC 4 PA 

PROZAC WEEKLY 4 

SARAFEM 4 

selfemra 4 

venlafaxine 2 

venlafaxine er 150 mg tab 2 QL 60 

venlafaxine er 225 mg tab 2 QL 30 

venlafaxine er 37.5,75 mg tab 2 QL 90 

VIIBRYD 4 

Tricyclics 

amitriptyline hcl 1 GC 

amoxapine 2 

chlordiazepoxide/amitript 2 

clomipramine hcl 2 

desipramine hcl 2 

doxepin hcl 1 GC 

imipramine hcl 1 GC 

imipramine pamoate 2 

NORPRAMIN 4 










9


nortriptyline hcl 1 GC 

PAMELOR 4 PA 

perphenazine/amitriptylin 2 

protriptyline hcl 2 

SURMONTIL 4 

ANTIDOTES, DETERRENTS, AND TOXICOLOGICAL AGENTS 

Antidotes 

EXJADE 125 MG TAB 4 PA 

EXJADE 250, 500 MG TAB 5 PA 

fomepizole 1 GC 

Deterrents 

ANTABUSE 4 

CHANTIX 1 MG 4 QL 180 

CHANTIX PAK 4 QL 53 

NICOTROL 4 

Toxicological Agents 

buprenorphine 2 

naloxone hcl 1 GC 

naltrexone hcl 2 

pentazocine/naloxone hcl 2 

SUBOXONE 4 

ANTIEMETICS 

Antiemetics 

CELLCEPT INJ 4 BD 

chlorpromazine 10, 25mg tab 2 BD 

chlorpromazine inj, tab 2 

diphenhydramine hcl 1 GC 

dronabinol 10 mg 2 QL 60 BD 

dronabinol 2.5, 5 mg 2 BD 

EMEND 125 MG 4 QL 2/31 

EMEND 40 MG 4 QL 1/31 

EMEND 80 MG 4 QL 2/21 

EMEND PAK 4 QL 6/31 

granisetron 0.1mg/ml inj, tab 1 QL 60 GC BD 

granisetron 1mg/ml inj 1 GC BD 

GRANISOL 2 BD 

hydroxyzine hcl 2 

hydroxyzine pamoate 1 GC 

MARINOL 4 PA 

meclizine hcl 2 

metoclopramide hcl 1 GC 









10


METOZOLV 4 ST 

ondansetron inj 2 QL 160 BD 

ondansetron 24 mg tab 2 QL 30 BD 

ondansetron 4 mg tab 2 BD 

ondansetron 8 mg tab 2 QL 60 BD 

ondansetron odt 2 QL 60 BD 

ondansetron sol 1 GC BD 

perphenazine 2 

phenadoz 2 

PHENERGAN 4 

prochlorperazine 1 GC 

prochlorperazine edisylate 1 GC 

prochlorperazine maleate 1 GC BD 

promethazine hcl 2 

promethegan 2 

SANCUSO 4 QL 2/21 BD 

ANTIFUNGALS 

Antifungals 

amphotericin b 2 BD 

ANCOBON 4 

ciclopirox 2 

clotrimazole 2 

econazole nitrate 2 

fluconazole 1 GC 

fluconazole 2 mg/ml inj 1 GC BD 

GRIFULVIN V 4 

GRIS-PEG 4 

griseofulvin microsize 2 

GYNAZOLE-1 4 

itraconazole 2 

ketoconazole 2 

LAMISIL 4 

LOPROX GEL 4 PA 

LOPROX SHAMPOO 4 

miconazole 2 

MYCAMINE 5 

NAFTIN 3 

NATACYN 4 

NIZORAL 4 

NOXAFIL 5 PA 

nyamyc 2 










11


nystatin 1 GC 

nystatin powder, tab 2 

nystop 2 

ORAVIG 3 

OXISTAT 4 

pedi-dri 2 

PENLAC NAIL LACQUER 4 

SPORANOX 4 PA 

terbinafine 2 PA 

terconazole 2 

zazole 2 

ZOLINZA 5 PA QL 120 

ANTIGOUT AGENTS 

Antigout Agents 

allopurinol 1 GC 

COLCRYS 3 

probenecid 2 

ULORIC 3 PA QL 30 

ANTIINFLAMMATORIES 

Glucocorticoids 

dexamethasone 1 GC 

dexamethasone sod phos 1 GC 

methylprednisolone 1 GC 

methylprednisolone ac 2 

MILLIPRED 4 

ORAPRED 4 

PEDIAPRED 4 

prednisolone sod phosp 1 GC 

prednisone 1 GC 

SOLU-CORTEF 4 

SOLU-MEDROL 4 

ANTIMIGRAINE AGENTS 

Abortive Agents 

dihydroergotamine mesylate 1 GC 

FROVA 4 

IMITREX 4 PA 

MAXALT 4 

migergot 2 

MIGRANAL 4 

RELPAX 4 QL 9 









12


sumatriptan succ inj 2 QL 10 

sumatriptan succ tab 2 QL 18 

Prophylactic Agents 

timolol maleate 1 GC 

topiramate 50 mg tab 2 QL 240 

topiramate tab 2 QL 60 

ANTIMYASTHENIC AGENTS 

Parasympathomimetics 

MESTINON 4 

MESTINON 60 MG TAB 4 PA 

MYTELASE 4 

pyridostigmine bromide 2 

ANTIMYCOBACTERIALS 

Antimycobacterials, Other 

dapsone 2 

MYCOBUTIN 4 

Antituberculars 

CAPASTAT SULFATE 4 

ethambutol hcl 2 

isonarif 2 

isoniazid 1 GC 

MYAMBUTOL 4 

PASER 3 

PRIFTIN 4 

pyrazinamide 2 

rifampin 2 

TRECATOR 4 

ANTINEOPLASTICS 

Alkylating Agents 

BUSULFEX 4 BD 

CEENU 4 

cyclophosphamide 2 BD 

HEXALEN 5 

LEUKERAN 3 

MATULANE 5 

melphalan 1 GC BD 

SEROMYCIN 4 

Antiangiogenic Agents 

REVLIMID 5 PA QL 30 SP 

THALOMID 5 PA QL 30 










13


THALOMID 200 MG 5 PA QL 60 

Antiestrogens/Modifiers 

EMCYT 4 

FARESTON 4 QL 30 

tamoxifen citrate 2 

Antimetabolites 

HYDREA 4 

hydroxyurea 2 

TABLOID 3 

Antineoplastics, Other 

ALIMTA 5 BD 

amifostine 5 BD 

AVASTIN 5 PA 

bleomycin sulfate 1 GC BD 

DOCETAXEL 5 

ELITEK 5 

GEMZAR 5 BD 

HALAVEN 5 

HERCEPTIN 5 

IDAMYCIN 5 BD 

idarubicin hcl 5 BD 

IFEX 4 BD 

IFOSFAMIDE 50 MG/ML 1 GC BD 

IFOSFAMIDE/MESNA 1 GM 2 

IFOSFAMIDE/MESNA 3 GM 3 BD 

irinotecan hcl inj 1 GC 

IXEMPRA 5 

leucovorin inj 1 GC BD 

leucovorin tab 2 

LEUSTATIN 2 BD 

mesna inj 2 BD 

MESNEX INJ 5 BD 

MESNEX TAB 4 

mitoxantrone hcl 2 BD 

MUSTARGEN 4 BD 

NIPENT 5 BD 

NOVANTRONE 5 BD 

ONTAK 5 

oxaliplatin inj 1 GC BD 

paclitaxel 1 GC BD 

pentostatin inj 2 BD 









14


PHOTOFRIN 5 

PREZISTA 4 

PROLEUKIN 5 

TAXOTERE 80 MG/2ML INJ 5 

TAXOTERE 80 MG/4ML INJ 4 

TRISENOX 4 BD 

VELCADE 5 PA 

VIDAZA 5 PA 

Aromatase Inhibitors, 3rd Generation 

anastrozole 5 

ARIMIDEX 3 QL 30 

exemestane 2 

letrozole 2 

Enzyme Inhibitors 

etoposide 1 GC BD 

HYCAMTIN 5 BD 

Molecular Target Inhibitors 

AFINITOR 2.5 MG 3 

AFINITOR 5 MG, 10 MG 5 PA QL 30 

GLEEVEC 100 MG 5 PA QL 120 

GLEEVEC 400 MG 5 PA QL 60 

IRESSA 5 QL 30 

ISTODAX 4 PA 

NEXAVAR 5 PA QL 120 SP 

SPRYCEL 100 MG 5 PA QL 30 

SPRYCEL 20, 50, 70 MG 5 PA QL 60 

SPRYCEL 80, 140 MG 5 PA 

SUTENT 5 PA QL 30 

TARCEVA 5 PA QL 30 

TASIGNA 5 PA QL 120 

TYKERB 5 PA QL 150 

VANDETANIB 5 

VOTRIENT 5 PA QL 120 

Monoclonal Antibodies 

ARZERRA 5 QL 400 BD 

CAMPATH 5 

RITUXAN 5 PA 

Retinoids 

PANRETIN 5 

TARGRETIN 5 PA 

TRETINOIN 3 PA 










15


ANTIPARASITICS 

Anthelmintics 

ALBENZA 3 

mebendazole 2 

STROMECTOL 4 

Antiprotozoals 

chloroquine phosphate 2 

DARAPRIM 4 

hydroxychloroquine sulfate 2 

LACRISERT 4 

MALARONE 4 

mefloquine hcl 2 

MEPRON 5 

NEBUPENT 4 QL 6/28 BD 

PENTAM 4 BD 

PLAQUENIL 4 

Pediculicides/ Scabicides 

acticin 1 GC 

EURAX 4 

lindane 2 

malathion 2 

OVIDE 4 

permethrin 2 

ANTIPARKINSON AGENTS 

Antiparkinson Agents 

amantadine 2 

APOKYN 5 QL 90 SP 

AZILECT 3 QL 30 

benztropine mesylate 1 GC 

bromocriptine mesylate 2 

carbidopa/levodopa 2 

COMTAN 3 QL 240 

MIRAPEX 4 

MIRAPEX ER 4 PA 

PARCOPA 4 

PARLODEL 4 PA 

pramipexole 2 

ropinirole hcl 2 

selegiline hcl 2 

SINEMET 4 

SINEMET CR 4 PA 









16


STALEVO 3 

trihexyphenidyl hcl 1 GC 

ANTIPSYCHOTICS 

Atypicals 

clozapine 2 

FANAPT 4 PA QL 62/31 

FAZACLO 4 ST 

GEODON 3 QL 60 

INVEGA 6 MG TAB 4 QL 60 ST 

INVEGA INJ 4 

INVEGA TAB 4 QL 30 ST 

LATUDA 4 

RISPERDAL 4 

RISPERDAL CONSTA 4 QL 2/28 

risperidone 2 QL 68/34 

risperidone sol 2 QL 522/34 

SEROQUEL 3 QL 90 

SEROQUEL 300, 400 MG 3 QL 60 

ZYPREXA 3 QL 30 

ZYPREXA ZYDIS 3 QL 30 

Conventional 

fluphenazine 2 

fluphenazine decanoate 2 

HALDOL 4 

haloperidol decanoate 2 

haloperidol lactate 1 GC 

haloperidol oral conc 1 GC 

haloperidol tab 2 

loxapine succinate 2 

LOXITANE 2 

NAVANE 4 

ORAP 4 

thioridazine hcl 1 GC 

thiothixene 2 

trifluoperazine hcl 2 

ANTISPASTICITY AGENTS 

Antispasticity Agents 

baclofen 1 GC 

tizanidine hcl 2 

ANTIVIRALS 










17


Anti-cytomegalovirus (CMV) Agents 

foscarnet sodium 2 BD 

ganciclovir 2 

VALCYTE SOL 4 QL 968 

VALCYTE TAB 5 QL 102 

ZIRGAN 4 QL 5 

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors 

ATRIPLA 5 

EDURANT 4 

INTELENCE 5 QL 120 

RESCRIPTOR 4 

SUSTIVA 3 

VIRAMUNE 4 

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors 

COMBIVIR TAB 5 

didanosine 2 

EMTRIVA 4 

EPIVIR 4 

EPZICOM TAB 5 

RETROVIR IV INFUSION 4 

stavudine 2 

TRIZIVIR 5 

TRUVADA 5 

VIDEX 4 

VIREAD 4 

ZIAGEN 3 

zidovudine 2 

Anti-HIV Agents, Other 

FUZEON 5 QL 60 

ISENTRESS 5 QL 60 

SELZENTRY 150 MG 5 QL 60 

SELZENTRY 300 MG 5 QL 120 

Anti-HIV Agents, Protease Inhibitors 

APTIVUS 5 

CRIXIVAN 3 

INVIRASE CAP 4 

INVIRASE TAB 5 

KALETRA 4 

LEXIVA 3 

NORVIR 4 

PREZISTA 4 









18


REYATAZ 3 

VIRACEPT 4 

VIRACEPT 625 MG TAB 5 

Anti-influenza Agents 

rimantadine hcl 2 

TAMIFLU 30 MG 4 QL 84/180 

TAMIFLU 45 MG 4 QL 42/180 

TAMIFLU 75 MG 4 QL 28 

Antihepatitis Agents 

BARACLUDE SOL 4 QL 600 

BARACLUDE TAB 5 QL 30 

EPIVIR HBV 4 

HEPSERA 4 

INFERGEN 5 PA 

PEGASYS 5 PA QL 4 

PEGINTRON 5 PA 

ribapak 400, 600 mg 5 PA QL 56/28 

RIBAPAK PAK 5 PA QL 56 

ribasphere 200 mg cap, tab 4 PA QL 180 

ribasphere 400, 600mg tab 5 PA QL 60 

ribavirin 2 PA 

TYZEKA 4 QL 30 

Antiherpetic Agents 

acyclovir 1 GC 

famciclovir 2 

trifluridine 2 

valacyclovir 1 gm tab 2 QL 30 

valacyclovir 500 mg tab 2 QL 60 

ANXIOLYTICS 

Antidepressants 

paroxetine 10 tab 1 QL 30 GC 

paroxetine susp 1 GC 

paroxetine tab 1 QL 60 GC 

PAXIL 4 

PEXEVA 4 QL 60 

PEXEVA 10 MG 4 QL 30 

sertraline hcl 1 QL 60 GC 

Anxiolytics, Other 

alprazolam 1 E GC 

buspirone 1 GC 

chlordiazepoxide hcl 1 E GC 










19


cloraepate dipotassium 1 E GC 

clozazepam 1 E GC 

diazepam 1 E GC 

lorazepam 1 E GC 

meprobamate 2 

oxazepam 1 E GC 

Serotonin/Norepinephrine Reuptake Inhibitors 

sertraline hcl conc 2 

BIPOLAR AGENTS 

Bipolar Agents 

lithium carbonate 1 GC 

LITHIUM CITRATE 3 

SAPHRIS 4 QL 60 ST 

BLOOD GLUCOSE REGULATORS 

Antidiabetic Agents 

acarbose 2 

ACTOPLUS MET 3 QL 93/31 ST 

ACTOS 3 QL 31/31 

ACTOS 15 MG 3 QL 93/31 

ALCOHOL SWABS 3 

AVANDAMET 4 QL 62/31 ST 

AVANDAMET 2/500 MG 4 QL 124/31 ST 

AVANDARYL 4 QL 30 ST 

AVANDARYL 4/2 MG 4 QL 31/31 ST 

AVANDIA 2 MG 4 QL 124/31 ST 



BYETTA 10 MCG 4 QL 1.2 ST 

BYETTA 5 MCG 4 QL 2.4 ST 

DUETACT 3 QL 30 ST 

FORTAMET 4 ST 

GAUZE PADS 3 

glimepiride 1 GC 

glipizide 1 GC 

glipizide/metformin hcl 2 

GLUCOPHAGE 4 

GLUCOTROL 4 

GLUCOVANCE 4 

GLUMETZA 4 

glyburide 1 GC 

glyburide micronized 1 GC 









20


glyburide/metformin hcl 1 GC 

GLYNASE 4 

GLYSET 4 

INSULIN PEN NEEDLES 3 

INSULIN SYRG/NEEDLES 3 

JANUMET 3 QL 60 

JANUVIA 3 QL 31/31 

METAGLIP 4 

metformin hcl 1 GC 

metformin hcl er 500 mg 1 QL 120 GC 

metformin hcl er 750 mg 1 QL 90 GC 

nateglinide 2 

ONGLYZA 4 QL 30 ST 

PRANDIN 4 

PRECOSE 4 

STARLIX 4 

SYMLIN 120 INJ 1000 MCG 4 PA QL 35 

SYMLIN 600 MCG INJ 4 PA QL 22 

SYMLINPEN 60 INJ 1000 MCG 4 PA QL 12 

WELCHOL 3 

Glycemic Agents 

GLUCAGEN HYPOKIT 4 

GLUCAGON EMERGENCY KIT 3 

PROGLYCEM 4 

Insulins 

APIDRA 4 

APIDRA SOLOSTAR 4 

HUMALOG 3 QL 30 

HUMALOG MIX 3 

HUMALOG PEN 3 

HUMULIN 70/30 3 

HUMULIN N 3 

HUMULIN R 3 

LANTUS 3 

LANTUS SOLOSTAR 3 

LEVEMIR 3 

NOVOLIN 70/30 3 

NOVOLIN N 3 

NOVOLIN R 3 

NOVOLOG 3 

NOVOLOG MIX 70/30 3 










21


BLOOD PRODUCTS/MODIFIERS/ VOLUME EXPANDERS 

Anticoagulants 

ARIXTRA 2.5 MG/0.5ML 3 QL 15.5/31 

ARIXTRA 5 MG/0.4ML 3 QL 12.4/31 



enoxaparin 2 

FRAGMIN 10000 U 2 

FRAGMIN 12500, 15000, 18000 U 5 

FRAGMIN 2500 U/0.2ML, 25000 U 3 QL 2/5D 

FRAGMIN 7500 U/0.3ML 3 QL 3.8/5D 

heparin sodium 1 GC BD 

heparin sodium/d5w 1 GC 

heparin sodium/nacl 1 GC 

INNOHEP 2 

jantoven 1 GC 

LOVENOX 100 MG/ML 4 QL 20/10 

LOVENOX 120 MG/0.8ML 4 QL 16/10 

LOVENOX 150 MG/ML 4 QL 20/10 


LOVENOX 300 MG/3ML 4 QL 3/1 




PRADAXA 4 

warfarin sodium 1 GC 

Blood Formation Modifiers 

NEUMEGA 5 QL 21/21 

Blood Formation Products 

anagrelide 2 

LEUKINE 250 MCG 5 PA 

LEUKINE 500 MCG 1 PA GC 

MOZOBIL 4 PA 

NEULASTA 5 PA 

NEUPOGEN 5 PA QL 16 

NEUPOGEN 480 MCG/1.6ML 5 PA QL 32 

PROCRIT 10000/ML 4 PA QL 12/28 

PROCRIT 2000/ML 4 PA QL 23 












22



PROMACTA 5 

Coagulants 

CYKLOKAPRON 3 

Platelet Aggregation Agents 

AGGRENOX 3 

cilostazol 2 

dipyridamole 2 

EFFIENT 4 QL 30 

PERSANTINE 4 

PLAVIX 3 

PLETAL 4 

ticlopidine hcl 2 

CARDIOVASCULAR AGENTS 

ACE Inhibitors 

benazepril hcl/hztc 1 GC 

captopril/hctz 1 GC 

enalapril maleate/hctz 1 GC 

fosinopril sodium/hctz 2 

lisinopril/hctz 1 GC 

LOTENSIN HCT 4 

moexipril/hctz 2 

quinapril/hctz 2 

Alpha-adrenergic Agonists 

clonidine hcl 1 GC 

guanabenz 2 

methyldopa 2 

methyldopa/hctz 2 

methyldopate hcl 1 GC 

midodrine hcl 2 

Alpha-adrenergic Blocking Agents 

doxazosin mesylate 1 GC 

MINIPRESS 4 

prazosin hcl 1 GC 

terazosin hcl 1 GC 

Antiarrhythmics 

amiodarone hcl 2 

disopyramide phosphate 2 

flecainide acetate 2 

mexiletine hcl 2 

MULTAQ 3 QL 60 










23


NORPACE 4 

pacerone 2 

procainamide hcl 1 GC 

propafenone hcl 2 

quinidine gluconate cr 2 

quinidine sulfate 2 

RYTHMOL CAP 3 

RYTHMOL TAB 4 

sorine 1 GC 

sotalol hcl 1 GC 

TIKOSYN 4 QL 60 

Beta-adrenergic Blocking Agents 

acebutolol hcl 1 GC 

atenolol 1 GC 

atenolol/chlorthalidone 1 GC 

betaxolol hcl 2 

bisoprolol fumarate 2 

bisoprolol fumarate/hctz 2 

BYSTOLIC 10 MG 3 QL 120 

BYSTOLIC 2.5, 5 MG 3 QL 30 

BYSTOLIC 20MG 3 QL 60 

carvedilol 1 GC 

INDERAL 4 

INNOPRAN 4 

KERLONE 4 

labetalol hcl 2 

LEVATOL 1 GC 

LOPRESSOR 4 

metoprolol succinate er 1 QL 60 GC 

metoprolol tartrate 1 GC 

metoprolol/hctz 2 

nadolol 1 GC 

nadolol/bend 2 

pindolol 1 GC 

propranolol 20 mg/5ml sol 1 GC 

propranolol 40 mg/5ml sol 2 

propranolol er 2 

propranolol inj, tab 1 GC 

propranolol/hctz 1 GC 

Calcium Channel Blocking Agents 

afeditab cr 2 QL 30 









24


amlodipine besylate 1 GC 

amlodipine besylate/benaz 2 QL 30 

cartia xt 2 QL 30 

dilt-xr 2 QL 60 

diltiazem cd 2 QL 30 

diltiazem er 360, 420 mg cap 2 QL 30 

diltiazem er cap 2 

diltiazem inj, tab 2 

felodipine er 2 QL 30 

ISOPTIN 4 

isradipine 2 

LOTREL 3 

nicardipine hcl 1 GC 

nifediac cc 2 QL 30 

nifedical xl 2 QL 30 

nifedipine 2 

nifedipine er 2 QL 30 

nimodipine 2 

nisoldipine 2 QL 30 

NORVASC 4 PA 

PROCARDIA 4 

PROCARDIA XL 4 PA 

taztia xt 2 QL 30 

verapamil hcl 1 GC 

Cardiovascular Agents, Other 

digoxin 1 GC 

LANOXIN 4 

pentoxifylline er 1 GC 

RANEXA 3 QL 60 ST 

Diuretics 

acetazolamide 2 

amiloride hcl 2 

amiloride/hctz 1 GC 

bumetanide 1 GC 

chlorothiazide 1 GC 

chlorthalidone 1 GC 

DYRENIUM 4 

EDECRIN SODIUM 4 

eplerenone 2 

furosemide 1 GC 

hctz 1 GC 










25


indapamide 1 GC 

INSPRA 4 

LASIX 20, 40 MG 4 

LASIX 80 MG 2 

MAXZIDE 4 

methazolamide 2 

methyclothiazide 1 GC 

metolazone 2 

MICROZIDE 4 

spironolactone 1 GC 

torsemide 2 

triamterene/hctz 1 GC 

Dyslipidemics 

CRESTOR 3 QL 31/31 

fenofibrate 2 QL 30 

gemfibrozil 2 QL 60 

LESCOL 2 

LIPITOR 3 QL 30 

LIPOFEN 4 PA 

LIVALO 4 QL 30 ST 

LOFIBRA 2 PA QL 30 

LOPID 4 

lovastatin 2 QL 60 

LOVAZA 3 QL 120 

MEVACOR 4 QL 60 

niacor 1 GC 

NIASPAN 3 

PRAVACHOL 4 PA QL 30 

pravastatin sodium 2 QL 30 

prevalite 2 

SIMCOR 1000/40 MG 4 

SIMCOR 500/20, 750/20 MG 4 QL 30 

simvastatin 1 QL 30 GC 

TRICOR 3 QL 30 

ZETIA 3 QL 30 ST 

Renin-Angiotensin-Aldosterone System Inhibitors 

benazepril hcl 1 GC 

BENICAR 4 QL 30 

BENICAR HCT 4 QL 30 

captopril 1 GC 

DIOVAN 3 QL 62/31 









26


DIOVAN 320 MG 3 QL 31/31 

DIOVAN HCT 3 QL 62/31 

DIOVAN HCT 320-12.5, 320-25MG 3 QL 31/31 

enalapril maleate 1 GC 

fosinopril sodium 2 

HYZAAR 4 

lisinopril 1 GC 

losartan 1 QL 30 GC 

losartan/hctz 1 QL 30 GC 

LOTENSIN 4 

MAVIK 4 

MICARDIS 4 QL 30 

MICARDIS HCT 4 QL 30 

moexipril hcl 2 

perindopril erbumine 2 

quinapril hcl 2 

ramipril 2 

TEKTURNA 3 QL 30 

TEKTURNA HCT 3 QL 30 

trandolapril 2 

Vasodilators 

hydralazine hcl 2 

isochron 2 

ISORDIL 4 

isosorbide dinitrate 1 GC 

isosorbide mononitrate 2 

minitran 2 QL 30 

minoxidil 2 

MONOKET 4 

NITRO-BID 4 

NITRO-DUR 4 

nitroglycerin 1 GC 

NITROLINGUAL PUMPSPRAY 4 

NITROSTAT 4 

CENTRAL NERVOUS SYSTEM AGENTS 

Amphetamines, ADHD 

amphetamine salts combo 2 

dextroamphetamine sulfate 2 

methamphetamine hcl 2 

Non-Amphetamines, ADHD 

FOCALIN 4 










27


METADATE CAP 3 

METADATE TAB 2 

methylin 2 

methylphenidate hcl 2 

RITALIN CAP 4 

RITALIN TAB 4 PA 

STRATTERA 10, 18, 25 MG 4 QL 60 

STRATTERA 40, 60, 80, 100 MG 4 QL 30 

Non-Amphetamines, Other 

AMPYRA 5 PA QL 60 

AVONEX KIT 30 MCG 5 PA QL 4/28 

AVONEX PREFL KIT 30 MCG 5 PA QL 2/28 

BETASERON 5 PA QL 15 

COPAXONE 5 QL 30 BD 

GILENYA 5 

INTUNIV 4 

REBIF 5 PA QL 12 

RILUTEK 3 

SAVELLA 3 QL 30 

SAVELLA 4-WEEK TITRATION 3 QL 60 

XENAZINE 12.5 MG 5 PA QL 240 

XENAZINE 25 MG 5 PA QL 120 

DENTAL AND ORAL AGENTS 

Dental and Oral Agents 

chlorhexadine gluconate 1 GC 

KEPIVANCE 5 

periogard 1 GC 

pilocarpine hcl 2 

triamcinolone in orabase 1 GC 

DERMATOLOGICAL AGENTS 

Dermatological Agents 

8-MOP 5 

ala-cort 1 GC 

alclometasone dipropionate 2 

ALDARA 4 QL 24 

amcinonide 2 

betamethasone dipropionate 1 GC 

betamethasone valerate 1 GC 

calcipotriene 2 QL 60 

claravis 2 

clobetasol propionate 2 









28


clotrimazole/beta crm 1 GC 

clotrimazole/beta lot 2 

CONDYLOX 4 

desonide 2 

desoximetasone 2 

diflorasone diacetate 2 

DOVONEX 4 QL 120 

erythromycin/benzoyl pero 2 

FINACEA 4 

fluocinolone acetonide 1 GC 

fluocinonide 1 GC 

fluocinonide emollient ba 1 GC 

fluorouracil 2 

fluticasone propionate 2 

halobetasol propionate 2 

HALOG 4 

hydrocortisone 1 GC 

hydrocortisone butyrate 2 

hydrocortisone valerate 2 

imiquimod 2 QL 24 

KENALOG 4 

LAC-HYDRIN 4 

laclotion 2 

LOCOID 4 

lokara 2 

LOTRISONE 4 

LUXIQ 4 

mometasone furoate 2 

nystatin/triamcinolone 1 GC 

OLUX 4 

OXSORALEN 4 

OXSORALEN ULTRA 5 

PANDEL 4 

podofilox 2 

prednicarbate 2 

PROTOPIC 4 

REGRANEX 5 

SANTYL 4 

selenium sulfide 1 GC 

SOLARAZE 3 

SORIATANE 5 










29


sotret 2 

TAZORAC 3 

triamcinolone acetonide 1 GC 

triderm 1 GC 

u-cort 2 

VOLTAREN 4 

ENZYME REPLACEMENT/ MODIFIERS 

Enzyme Replacement/ Modifiers 

ADAGEN 5 SP 

ALDURAZYME 5 SP 

BUPHENYL 5 

CEREDASE 5 

CEREZYME 5 SP BD 

FABRAZYME 5 SP BD 

KUVAN 5 PA 

MYOZYME 5 

NAGLAZYME 5 

ORFADIN 5 SP 

PANCREAZE 4 

ZAVESCA 5 QL 90 

ZENPEP 3 

GASTROINTESTINAL AGENTS 

Antispasmodics, Gastrointestinal 

atropine sulfate 1 GC 

dicyclomine hcl 1 GC 

glycopyrrolate 2 

methscopolamine 2 

PAMINE 4 

ROBINUL 4 

Gastrointestinal Agents, Other 

diphenoxylate/atropine 1 GC 

ELMIRON 4 

entocort ec 4 

gaviltye-g 1 GC 

gavilyte-c 1 GC 

gavilyte-n 1 GC 

GOLYTELY 3 

HELIDAC THERAPY 4 

KRISTALOSE 4 

lactulose 1 GC 

LOMOTIL 4 









30


loperamide hcl 1 GC 

MOTOFEN 4 

MOVIPREP 3 

NULYTELY 3 

polyethylene glycol 2 

PREVPAC 4 

PYLERA 4 

RELISTOR 4 

XIFAXAN 4 

Histamine2 (H2) Blocking Agents 

famotidine 1 GC 

nizatidine 150 mg 1 GC 

nizatidine 300 mg 2 

PEPCID 4 

ranitidine 1 GC 

ranitidine 150 mg cap 2 

ranitidine syr 2 

Irritable Bowel Syndrome Agents 

AMITIZA 3 

LOTRONEX 3 QL 60 

Protectants 

CARAFATE 4 

misoprostol 2 

sucralfate 2 

Proton Pump Inhibitors 

DEXILANT 4 QL 180/365 

lansoprazole 2 

NEXIUM 3 

NEXIUM INJ 4 

omeprazole 2 

pantoprazole sodium 2 QL 30 

PRILOSEC 4 PA 

PROTONIX 4 

GENITOURINARY AGENTS 

Antispasmodics, Urinary 

DETROL 3 QL 60 

DETROL LA 3 QL 30 

flavoxate 2 

GELNIQUE 4 

oxybutynin chloride 1 GC 

oxybutynin chloride er 2 










31


OXYTROL 4 

SANCTURA 4 

VESICARE 3 QL 30 

Benign Prostatic Hypertrophy Agents 

AVODART 3 QL 30 

finasteride 2 QL 30 

FLOMAX 4 QL 60 

JALYN 4 

PROSCAR 4 PA 

tamsulosin 2 QL 60 

Genitourinary Agents, Other 

CIALIS 1 QL 6 E GC 

CUPRIMINE 4 

METHERGINE 3 

VIAGRA 1 QL 6 E GC 

Phosphate Binders 

calcium acetate 2 

FOSRENOL 4 ST 

PHOSLO 3 

RENVELA 3 QL 270 

HORMONAL AGENTS, STIMULANT/REPLACEMENT/ MODIFYING (THYROID) 

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) 

levothroid 1 GC 

levothyroxine sodium 1 GC 

levoxyl 1 GC 

liothyronine sodium inj 1 GC 

liothyronine sodium tab 2 

SYNTHROID 3 

unithroid 1 GC 

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (ADRENAL) 

Glucocorticoids/Mineralocorticoids 

fludrocortisone 1 GC 

hydrocortisone 1 GC 

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (PITUITARY) 

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) 

chorionic gonadotropin 2 

desmopressin acetate 2 

HUMATROPE 12 MG 5 PA QL 2 

HUMATROPE 6, 24 MG 5 PA QL 1 

HUMATROPE COMBO PACK 5 PA QL 6 









32


INCRELEX 5 SP 

NORDITROPIN 4 

novarel 4 

NUTROPIN 5 PA QL 6 

NUTROPIN AQ 5 PA QL 12 

OMNITROPE 4 

OMNITROPE 5.8 MG 4 PA 

PREGNYL 4 

SAIZEN 5 MG 5 PA 

SAIZEN 8.8 MG 4 

SEROSTIM 5 PA 

HORMONAL AGENTS, STIMULANT/REPLACEMENT/MODIFYING (SEX 

HORMONES/MODIFIERS) 

Anabolic Steroids 

ANADROL-50 5 

OXANDRIN 4 PA 

oxandrolone 10mg tab 5 QL 60 

oxandrolone 2.5mg tab 2 QL 120 

Androgens 

ANDRODERM 4 PA QL 30 

ANDROXY 4 

danazol 2 

METHITEST 4 

testosterone cypionate 2 

testosterone enanthate 2 

Estrogens 

ESTRACE 4 

estradiol 0.0375, 0.06 mg dis 2 

estradiol dis 2 QL 4 

estradiol tab 1 GC 

FEMRING 4 

FEMTRACE 4 

MENEST 4 

MENOSTAR 4 

PREMARIN 3 

Progestins 

AYGESTIN 2 

jolivette 2 

medroxyprogesterone ac inj 1 QL 50 GC 

medroxyprogesterone ac tab 1 GC 

MEGACE 4 










33


megestrol acetate 2 

NOR-QD 4 

NORA-BE 2 

norethindrone acetate 2 

ORTHO MICRONOR 4 

PROMETRIUM 4 

PROVERA 4 

Selective Estrogen Receptor Modifying Agents 

EVISTA 3 QL 30 

HORMONAL AGENTS, SUPPRESSANT (ADRENAL) 

Hormonal Agents, Suppressant (Adrenal) 

LYSODREN 3 

HORMONAL AGENTS, SUPPRESSANT (PARATHYROID) 

Hormonal Agents, Suppressant (Parathyroid) 

SENSIPAR 30 MG 3 QL 60 

SENSIPAR 60 MG 5 QL 60 

SENSIPAR 90 MG 5 QL 124/31 

HORMONAL AGENTS, SUPPRESSANT (PITUITARY) 

Hormonal Agents, Suppressant (Pituitary) 

FIRMAGON 4 PA 

leuprolide acetate 2 PA 

LUPRON DEPOT 4 PA 

LUPRON DEPOT-PED 5 PA 

octreotide acetate 1 PA GC 

SANDOSTATIN 5 PA 

SANDOSTATIN 0.05 MG/ML 4 PA 

SOMATULINE 120 MG/.5ML 5 PA 

SOMATULINE 60 MG/0.2ML 4 PA 

SOMAVERT 5 PA QL 30 SP 

SYNAREL 5 

HORMONAL AGENTS, SUPPRESSANT (SEX HORMONES/MODIFIERS) 

Antiandrogens 

bicalutamide 2 QL 30 

FASLODEX 2 

flutamide 2 

NILANDRON 4 QL 60 

ZYTIGA 5 

HORMONAL AGENTS, SUPPRESSANT (THYROID) 

Antithyroid Agents 

methimazole 2 









34


propylthiouracil 2 

IMMUNOLOGICAL AGENTS 

Immune Suppressants 

ATGAM 3 BD 

azathioprine 2 BD 

CELLCEPT SUSP 5 BD 

cyclosporine 2 BD 

ENBREL 25 MG 5 PA 

ENBREL 25 MG/0.5ML 5 PA QL 8 

ENBREL 50 MG/ML 4 PA QL 7.84/28 

gengraf 2 BD 

HUMIRA 20 MG/0.4ML 5 PA QL 2/28 

HUMIRA 40 MG/0.8ML 5 PA QL 6/28 

HUMIRA PEN-CROHNS 5 PA 

IMURAN 4 PA 

mercaptopurine 2 

methotrexate 1 GC 

methotrexate 50 mg/ml inj 2 

mycophenolate mofetil 2 BD 

MYFORTIC 3 BD 

NEORAL 4 BD 

ORENCIA 5 PA 

ORTHOCLONE OKT3 5 BD 

PROGRAF 4 BD 

PURINETHOL 4 

RAPAMUNE 0.5 MG TAB 4 

RAPAMUNE 1, 2 MG TAB 4 BD 

RAPAMUNE SOL 4 BD 

REMICADE 5 QL 7 

SANDIMMUNE CAP, SOL 4 BD 

SANDIMMUNE INJ 4 

SIMPONI 5 PA 

SIMULECT 5 BD 

tacrolimus 2 BD 

TORISEL 5 BD 

ZORTRESS 4 BD 

Immunizing Agents, Passive 

GAMASTAN S/D 4 BD 

GAMMAGARD LIQUID 5 BD 

GAMUNEX 4 PA 

PRIVIGEN 4 PA 










35


THYMOGLOBULIN 5 BD 

VIVAGLOBIN 5 BD 

Immunomodulators 

ACTIMMUNE 5 PA SP 

ARCALYST 5 PA 

INTRON A 10 MU INJ 5 

INTRON A 18 MU INJ 4 

INTRON A PEN 4 

KINERET 5 PA QL 20.77/31 

leflunomide 2 QL 30 

Vaccines 

ACTHIB 4 

ADACEL 4 

BOOSTRIX 4 

CERVARIX 4 

COMVAX 4 

DAPTACEL 4 

DECAVAC 4 

DIPHTHERIA/TETANUS TOXOID 2 

ENGERIX-B VACC 4 

GARDASIL 4 

HAVRIX 4 

IMOVAX RABIES (H.D.C.V.) 3 

INFANRIX 4 

IPOL INACTIVATED IPV 4 

IXIARO 4 

JE-VAX 4 

M-M-R II 4 

MENACTRA 4 

MENOMUNE-A/C/Y/W-135 4 

MENVEO INJ 4 

PEDVAX HIB 4 

PROQUAD 4 

RABAVERT 3 

RECOMBIVAX HB 4 

ROTATEQ 4 

TETANUS TOXOID ADSORBED 4 

TETANUS/DIPHTHERIA TOXOID 4 

TRIPEDIA 4 

TWINRIX 4 

TYPHIM VI 4 









36


VAQTA 4 

VARIVAX 3 

YF-VAX 4 

ZOSTAVAX 4 QL 1 

INFLAMMATORY BOWEL DISEASE AGENTS 

Glucocorticoids 

dexamethasone 2 

procto-pak 1 GC 

proctocream-hc 1 GC 

proctosol hc 1 GC 

proctozone-hc 1 GC 

Salicylates 

APRISO 3 QL 120 

ASACOL DR 400 MG 4 QL 180 

ASACOL HD 800 MG 4 QL 150 

balsalazide disodium 2 

LIALDA 3 

mesalamine 2 

PENTASA 4 

ROWASA 4 

Sulfonamides 

sulfasalazine 2 

sulfazine ec 2 

METABOLIC BONE DISEASE AGENTS 

Metabolic Bone Disease Agents 

alendronate 35, 70 mg 2 QL 4/28 

alendronate 5, 10, 40 mg 2 QL 30 

calcitonin-salmon 2 QL 3.8/31 BD 

calcitriol 2 BD 

FORTEO 4 

fortical 3 BD 

FOSAMAX 4 PA 

FOSAMAX PLUS D 70-2800 MG 4 QL 4 ST 

FOSAMAX PLUS D 70-5600 MG 4 QL 4/28 ST 

HECTOROL 3 BD 

MIACALCIN 4 BD 

pamidronate disodium 1 GC 

PROLIA 4 

ROCALTROL 4 BD 

SKELID 4 

XGEVA 5 










37


ZEMPLAR 3 BD 

ZOMETA 5 BD 

MISCELLANEOUS THERAPEUTIC AGENTS 

Miscellaneous Therapeutic Agents 

FEMHRT 4 

jinteli 2 

junel 2 

kariva 2 

kelnor 2 

leena 3 

lessina 4 

levora 1 GC 

LO/OVRAL 4 

LOESTRIN 4 

LOSEASONIQUE 4 

low-ogestrel 2 

lutera 28 day 2 

LYBREL 4 

microgestin 2 

MODICON 4 

mononessa 2 

neomycin/polymyxin b sulf 1 GC 

NORDETTE 4 

NORINYL 4 

nortrel 2 

NUVARING 4 

ocella 2 

ogestrel 2 

ORTHO EVRA 4 

ORTHO TRI-CYCLEN LO 4 

ORTHO-CEPT 4 

ORTHO-CYCLEN 4 

ORTHO-NOVUM 4 

OVCON 4 

PREFEST 4 

PREMPHASE 3 

PREMPRO 3 

previfem 2 

solia 2 

sprintec 2 

sronyx 2 









38


NUTRIENTS/ MINERALS/ ELECTROLYTES 

Vitamins 

PRENATABS OBN 3 

OPHTHALMIC AGENTS 

Ophthalmic Agents, Other 

ak-con 1 GC 

bacitracin/neomycin/polym 1 GC 

bacitracin/polymyxin b 1 GC 

MAXITROL 4 

MYDRIACYL 1 GC 

neomycin/polymyxin/dexame 1 GC 

neomycin/polymyxin/gramic 2 

neomycin/polymyxin/hc 2 

NEOSPORIN SOL 2 

parcaine 1 GC 

POLY PRED 4 

poly-dex 1 GC 

PRED-G 4 

RESTASIS 3 

sulfacetamide sodium/pred 1 GC 

tobramycin/dexamethasone 2 

trimethoprim sulfate/poly 2 

tropicamide 1 GC 

Ophthalmic Anti-allergy Agents 

azelastine ophth sol 2 

cromolyn sodium 2 

OPTIVAR 4 

PATADAY 3 

PATANOL 4 

Ophthalmic Anti-inflammatories 

dexamethasone sod phos 1 GC 

FLAREX 4 

fluorometholone 1 GC 

flurbiprofen sodium 1 GC 

FML 4 

ketorolac 1 GC 

LOTEMAX 4 

MAXIDEX 4 

NEVANAC 4 

OCUFEN 4 

OMNIPRED 4 










39


ORAPRED 4 

PRED FORTE 4 

PRED MILD 4 

prednisolone acetate 1 GC 

prednisolone sod phosp op 1 GC 

Ophthalmic Antiglaucoma Agents 

ALPHAGAN P 3 

apraclonidine 2 

AZOPT 3 

betaxolol hcl 2 

brimonidine tartrate 2 

carteolol hcl 1 GC 

COMBIGAN 3 

dorzolamide hcl 2 

dorzolamide hcl/timolol malea 2 QL 10 

IOPIDINE 4 

ISTALOL 4 

LEVOBUNOLOL HCL 3 

levobunolol hcl 0.5% op sol 1 GC 

metipranolol 2 

OPTIPRANOLOL 4 

PHOSPHOLINE IODIDE 4 

PILOPINE HS 4 

PROPINE 4 

timolol 2 

timolol maleate op 2 

Ophthalmic Prostaglandin and Prostamide Analogs 

latanoprost 2 

LUMIGAN 2 

TRAVATAN Z 3 QL 5 

OTIC AGENTS 

Otic Agents 

acetasol hc 2 

cortomycin 1 GC 

DERMOTIC 4 

neomycin/polymyxin/hc 2 

RESPIRATORY TRACT AGENTS 

Anti-inflammatories, Inhaled Corticosteroids 

ASMANEX 4 

FLONASE 4 

FLOVENT 3 QL 60 









40


FLOVENT HFA 110, 220 MCG 3 QL 12 

FLOVENT HFA 44 MCG 3 QL 10.6 

flunisolide 2 QL 25/25 

fluticasone propionate 2 QL 32 

NASACORT 4 

NASONEX 3 

OMNARIS 4 

PULMICORT 4 

PULMICORT INH SUSP 4 BD 

QVAR 40 MCG AER 3 QL 14.6 

QVAR 80 MCG AER 3 QL 21.9 

RHINOCORT AQUA 4 QL 18 

Antihistamines 

ASTELIN 4 QL 60/31 

ASTEPRO 3 QL 60/31 

azelastine nasal spr 2 QL 30/25 

cetirizine hcl 2 QL 300 

clemastine fumarate 2 

fexofenadine 180 mg 2 QL 30 

fexofenadine 30, 60 mg 2 QL 60 

palgic liq 2 

palgic tab 4 

PATANASE 4 

SEMPREX-D 4 

Antileukotrienes 

ACCOLATE 3 QL 60 

SINGULAIR 4 QL 30 ST 

SINGULAIR CHW 5MG 4 QL 60 ST 

zafirlukast 2 

ZYFLO CR 4 QL 120 

Bronchodilators, Anticholinergic 

ATROVENT HFA 4 QL 25.8/31 

ipratropium bromide inh sol 2 BD 

ipratropium bromide nasal spr 2 QL 30 

SPIRIVA HANDIHALER 3 QL 60 

Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) 

aminophylline 1 GC 

LUFYLLIN 4 

theochron 1 GC 

theophylline er 2 

theophylline er 400, 600 mg 1 GC 










41


Bronchodilators, Sympathomimetic 

ADVAIR DISKUS 3 QL 60 

ADVAIR HFA 3 QL 12 

albuterol sulfate er 2 

albuterol sulfate neb 1 GC BD 

albuterol sulfate syrup, tab 1 GC 

albuterol sulfate/ipratro 1 GC BD 

COMBIVENT 3 QL 29.4/31 

FORADIL 4 

levalbuterol inh sol 2 BD 

MAXAIR 4 

metaproterenol sulfate 2 

PERFOROMIST 4 BD 

PROAIR HFA 3 QL 17 

PROVENTIL HFA 4 QL 13.4 

SEREVENT DISKUS 3 QL 60 

SYMBICORT 3 QL 10.2 

terbutaline sulfate 2 

VENTOLIN HFA 3 QL 36 

Mast Cell Stabilizers 

cromolyn sodium 2 BD 

GASTROCROM 4 

Pulmonary Antihypertensives 

LETAIRIS 5 PA QL 31/31 

REVATIO INJ 3 PA QL 1125 

REVATIO TAB 5 PA QL 90 

TRACLEER 5 PA QL 60 SP 

VENTAVIS 5 BD 

Respiratory Tract Agents, Other 

benzonatate 1 E GC 

hydroco/homatropine 1 E GC 

hydromet 1 E GC 

PROLASTIN 5 SP 

promethazine vc/codeine 1 E GC 

promethazine/codeine 1 E GC 

PULMOZYME 5 BD 

TOBI 2 BD 

TYZINE 3 

TYZINE PED NASAL DRO 4 

XOLAIR 5 PA QL 7/28 SP 

SEDATIVES/HYPNOTICS 









42


Sedatives/Hypnotics 

estazolam 1 E GC 

flurazepam 1 E GC 

LUNESTA 4 

NUVIGIL 4 PA 

PROVIGIL 100 MG 4 PA QL 60 

PROVIGIL 200 MG 4 PA QL 30 

ROZEREM 4 ST 

SONATA 4 PA 

temazepam 1 E GC 

triazolam 1 E GC 

XYREM 5 SP 

zaleplon 10 mg 2 QL 60 

zaleplon 5 mg 2 QL 30 

zolpidem tartrate 1 QL 30 GC 

SKELETAL MUSCLE RELAXANTS 

Skeletal Muscle Relaxants 

cyclobenzaprine hcl 1 GC 

FEXMID 4 PA 

FLEXERIL 4 

metaxalone 2 ST 

methocarbamol 1 GC 

NORFLEX 4 

orphenadrine citrate 2 

PARAFON FORTE DSC 4 

ROBAXIN 4 

SKELAXIN 4 

SOMA 4 PA 

THERAPEUTIC NUTRIENTS/ MINERALS/ ELECTROLYTES 

Electrolyte/Mineral Modifiers 

KAYEXALATE 4 

kionex 2 

SAMSCA 5 PA QL 60 

sodium polystyrene sulfon 2 

Electrolyte/Mineral Replacement 

AMINOSYN 4 BD 

AMINOSYN II 4 BD 

AMINOSYN II M 3.5%/DEXTRO 

4 BD 

AMINOSYN II/DEXTROSE 4 BD 

AMINOSYN IIM INJ 3.5%/D5W 4 










43


AMINOSYN M 4 BD 

AMINOSYN-HBC 4 BD 

aminosyn-hf 2 BD 

AMINOSYN-PF 4 BD 

aminosyn/electrolyte 2 BD 

CLINIMIX/DEXTROSE 4 BD 

clinisol sf 15% 4 BD 

dextrose 1 GC 

dextrose/nacl inj 1 GC BD 

folic acid 1 E GC 

freamine iii 2 BD 

FREAMINE III 3% 4 BD 

hepatamine 2 BD 

INTRALIPID 4 

intralipid 20% inj 2 

IONOSOL-MB 4 

IONOSOL-T 4 

isolyte-h/dextrose 5% 2 

isolyte-m/dextrose 5% 2 

ISOLYTE-P/DEXTROSE 5% 4 

ISOLYTE-S 4 

ISOLYTE-S/DEXTROSE 5% 4 

K-TAB 4 

kcl/d5w 1 GC 

kcl/d5w/lr inj 1 GC BD 

kcl/d5w/nacl 1 GC 

kcl/nacl 0.3-0.9 inj 2 

kcl/nacl inj 1 GC 

klor-con 1 GC 

lactated ringer's irr 1 GC 

lactated ringer's viaflex 1 GC 

levocarnitine 2 BD 

liposyn 4 

magnesium sulfate 1 GC 

NEPHRAMINE 4 BD 

normosol-m in d5w 2 

NORMOSOL-R 4 

normosol-r in d5w 2 

OSMOPREP 3 

physiolyte 1 GC 

physiosol irrigation 1 GC 









44


PLASMA-LYTE 56 4 

PLASMA-LYTE A 4 

PLASMA-LYTE-148 4 

PLASMA-LYTE-148/D5W 4 

PLASMA-LYTE-56/D5W 4 

plasma-lyte-r 2 

potassium chloride 1 GC 

potassium citrate er 2 

premasol 1 GC BD 

PROCALAMINE 4 BD 

PROSOL 4 BD 

ringer's injection 1 GC 

ringer's irrigation 1 GC 

sodium bicarbonate 1 GC 

sodium chloride 0.9% irr 1 GC 

sodium chloride 0.45%,0.9%,3% 1 GC BD 

sodium chloride 2.5 meq/ml 2 BD 

sodium chloride 5% 1 GC 

SODIUM FLUORIDE 1 

sodium lactate 1 GC 

TRAVASOL 4 BD 

vitamin d 1 E GC 










45

8 

8-mop .................................... 28 

A 

abilify discmelt ........................ 8 

abilify inj ................................. 8 

abilify sol ................................ 8 

abilify tab ................................ 8 

acarbose ................................. 20 

accolate ................................. 41 

acebutolol hcl ........................ 24 

acetasol hc ............................. 40 

acetazolamide ........................ 25 

acetic acid ................................ 4 

acthib ..................................... 36 

acticin .................................... 16 

actimmune ............................. 36 

actoplus met .......................... 20 

actos ...................................... 20 

actos 15 mg ........................... 20 

acyclovir ................................ 19 

adacel .................................... 36 

adagen ................................... 30 

advair diskus ......................... 42 

advair hfa .............................. 42 

afeditab cr .............................. 24 

afinitor 2.5 mg ....................... 15 

afinitor 5 mg, 10 mg.............. 15 

aggrenox ................................ 23 

ak-con .................................... 39 

ak-tob ...................................... 3 

ala-cort .................................. 28 

albenza .................................. 16 

albuterol sulfate er ................. 42 

albuterol sulfate neb .............. 42 

albuterol sulfate syrup, tab .... 42 

albuterol sulfate/ipratro ......... 42 

alclometasone dipropionate .. 28 

alcohol swabs ........................ 20 

aldara ..................................... 28 

aldurazyme ............................ 30 

alendronate 35, 70 mg ........... 37 

alendronate 5, 10, 40 mg ....... 37 

alimta..................................... 14 

allopurinol ............................. 12 

alphagan p ............................. 40 

alprazolam ............................. 19 

amantadine ............................ 16 

amcinonide ............................ 28 

amifostine .............................. 14 

amiloride hcl ......................... 25 

amiloride/hctz ....................... 25 

aminophylline ....................... 41 

aminosyn ............................... 43 

aminosyn ii ............................ 43 

aminosyn ii m 3.5%/dextro ... 43 

aminosyn ii/dextrose ............. 43 

aminosyn iim inj 3.5%/d5w .. 43 

aminosyn m ........................... 44 

aminosyn/electrolyte ............. 44 

aminosyn-hbc ........................ 44 

aminosyn-hf .......................... 44 

aminosyn-pf .......................... 44 

amiodarone hcl ...................... 23 

amitiza ................................... 31 

amitriptyline hcl ...................... 9 

amlodipine besylate .............. 25 

amlodipine besylate/benaz .... 25 

amoxapine ............................... 9 

amoxicillin 200mg chw tab ..... 5 

amoxicillin cap, susp, tab ........ 5 

amoxicillin/clavulanate p ........ 5 

amphetamine salts combo ..... 27 

amphotericin b ...................... 11 

ampicillin ................................ 5 

ampicillin/sulbactam 10-5 gm . 5 

ampyra................................... 28 

anadrol-50 ............................. 33 

anagrelide .............................. 22 

anastrozole ............................ 15 

ancobon ................................. 11 

androderm ............................. 33 

androxy ................................. 33 

antabuse................................. 10 

apap/cod 300-15 mg tab .......... 1 

apap/cod 300-30 mg tab .......... 1 

apap/cod 300-60 mg tab .......... 1 

apap/cod sol ............................ 1 

apidra..................................... 21 

apidra solostar ....................... 21 

aplenzin ................................... 8 

apokyn ................................... 16 

apraclonidine ......................... 40 

apriso ..................................... 37 

aptivus ................................... 18 

arcalyst .................................. 36 

aricept ...................................... 8 

arimidex ................................ 15 

arixtra 2.5 mg/0.5ml .............. 22 

arixtra 5 mg/0.4ml ................. 22 

arixtra 5.0 mg/0.4ml .............. 22 

arixtra 7.5 mg/0.6ml .............. 22 

arthrotec .................................. 1 

arzerra ................................... 15 

asacol dr 400 mg ................... 37 

asacol hd 800 mg .................. 37 

ascomp/codeine ....................... 1 

asmanex................................. 40 

astelin .................................... 41 

astepro ................................... 41 

astramorph............................... 1 

atenolol .................................. 24 

atenolol/chlorthalidone ......... 24 

atgam ..................................... 35 

atripla .................................... 18 

atropine sulfate ...................... 30 

atrovent hfa ........................... 41 

avandamet ............................. 20 

avandamet 2/500 mg ............. 20 

avandaryl ............................... 20 

avandaryl 4/2 mg................... 20 

avandia 2 mg ......................... 20 

avandia 4 mg ......................... 20 

avandia 8 mg ......................... 20 

avastin ................................... 14 

avodart................................... 32 

avonex kit 30 mcg ................. 28 

avonex prefl kit 30 mcg ........ 28 

aygestin ................................. 33 

azactam in dextrose ................. 5 

azathioprine ........................... 35 

azelastine nasal spr ................ 41 

azelastine ophth sol ............... 39 

azilect .................................... 16 

azithromycin ........................... 5 

azopt ...................................... 40 

B 

baciim ...................................... 4 

bacitracin ................................. 4 

bacitracin/neomycin/polym... 39 

bacitracin/polymyxin b ......... 39 

baclofen ................................. 17 

balsalazide disodium ............. 37 

banzel 200 mg tab ................... 7 

banzel 400 mg tab ................... 7 

banzel susp .............................. 8 

baraclude sol ......................... 19 

baraclude tab ......................... 19 

46

enazepril hcl ........................ 26 

benazepril hcl/hztc ................ 23 

benicar ................................... 26 

benicar hct ............................. 26 

benzonatate ........................... 42 

benztropine mesylate ............ 16 

betamethasone dipropionate .. 28 

betamethasone valerate ......... 28 

betaseron ............................... 28 

betaxolol hcl .................... 24, 40 

bicalutamide .......................... 34 

bisoprolol fumarate ............... 24 

bisoprolol fumarate/hctz ....... 24 

bleomycin sulfate .................. 14 

boostrix ................................. 36 

brimonidine tartrate ............... 40 

bromocriptine mesylate ......... 16 

budeprion ................................ 8 

bumetanide ............................ 25 

buphenyl ................................ 30 

buprenorphine ....................... 10 

bupropion ................................ 8 

bupropion sr 100 mg tab ......... 8 



buspirone ............................... 19 

busulfex ................................. 13 

butalbital/apap/caff ................. 2 

byetta 10 mcg ........................ 20 

byetta 5 mcg .......................... 20 

bystolic 10 mg ....................... 24 

bystolic 2.5, 5 mg .................. 24 

bystolic 20mg ........................ 24 

C 

calcipotriene .......................... 28 

calcitonin-salmon .................. 37 

calcitriol ................................ 37 

calcium acetate ...................... 32 

campath ................................. 15 

capastat sulfate ...................... 13 

captopril ................................ 26 

captopril/hctz......................... 23 

carafate .................................. 31 

carbamazepine ......................... 7 

carbatrol 100, 200 mg ............. 7 

carbatrol 300 mg ..................... 7 

carbidopa/levodopa ............... 16 

carteolol hcl ........................... 40 

cartia xt.................................. 25 

carvedilol............................... 24 

ceenu ..................................... 13 

cefaclor .................................... 5 

cefazolin sodium ..................... 5 

cefdinir .................................... 5 

cefepime .................................. 5 

cefoxitin sodium...................... 5 

cefpodoxime ............................ 5 

ceftriaxone sodium .................. 5 

cefuroxime axetil .................... 5 

cefuroxime sodium.................. 5 

celebrex 100, 200 mg .............. 1 

celebrex 50, 400 mg ................ 1 

cellcept inj ............................. 10 

cellcept susp .......................... 35 

celontin .................................... 7 

cephalexin ............................... 5 

ceredase ................................. 30 

cerezyme ............................... 30 

cervarix ................................. 36 

cetirizine hcl .......................... 41 

chantix 0.5 mg ......................... 4 

chantix 1 mg .......................... 10 

chantix pak ............................ 10 

chlordiazepoxide hcl ............. 19 

chlordiazepoxide/amitript ....... 9 

chlorhexadine gluconate ....... 28 

chloroquine phosphate .......... 16 

chlorothiazide ........................ 25 

chlorpromazine 10, 25mg tab 10 

chlorpromazine inj, tab ......... 10 

chlorthalidone ....................... 25 

chorionic gonadotropin ......... 32 

cialis ...................................... 32 

ciclopirox .............................. 11 

cilostazol ............................... 23 

ciprofloxacin ........................... 6 

citalopram 10 mg tab .............. 9 



citalopram sol .......................... 9 

claravis .................................. 28 

clemastine fumarate .............. 41 

clindamycin hcl ....................... 4 

clindamycin phosphate............ 4 

clinimix/dextrose................... 44 

clinisol sf 15%....................... 44 

clobetasol propionate ............ 28 

clomipramine hcl .................... 9 

clonidine hcl .......................... 23 

cloraepate dipotassium .......... 20 

clotrimazole ........................... 11 

clotrimazole/beta crm ............ 29 

clotrimazole/beta lot .............. 29 

clozapine ............................... 17 

clozazepam ............................ 20 

co-gesic ................................... 2 

colcrys ................................... 12 

colistimethate sodium ............. 4 

combigan ............................... 40 

combivent .............................. 42 

combivir tab .......................... 18 

comtan ................................... 16 

comvax .................................. 36 

condylox ................................ 29 

copaxone ............................... 28 

cortomycin ............................ 40 

crestor .................................... 26 

crixivan ................................. 18 

cromolyn sodium ............ 39, 42 

cuprimine .............................. 32 

cyclobenzaprine hcl .............. 43 

cyclophosphamide................. 13 

cyclosporine .......................... 35 

cyklokapron........................... 23 

cymbalta 20, 30 mg ................. 9 

cymbalta 60 mg ....................... 9 

D 

danazol .................................. 33 

dapsone ................................. 13 

daptacel ................................. 36 

daraprim ................................ 16 

decavac .................................. 36 

dermotic ................................ 40 

desipramine hcl ....................... 9 

desmopressin acetate ............. 32 

desonide ................................ 29 

desoximetasone ..................... 29 

detrol ..................................... 31 

detrol la ................................. 31 

dexamethasone ................ 12, 37 

dexamethasone sod phos . 12, 39 

dexilant .................................. 31 

dextroamphetamine sulfate ... 27 

dextrose ................................. 44 

dextrose/nacl inj .................... 44 

diazepam ............................... 20 

diclofenac potassium ............... 1 

diclofenac sodium ................... 1 

dicloxacillin sodium ................ 5 

dicyclomine hcl ..................... 30 

47

didanosine ............................. 18 

diflorasone diacetate ............. 29 

diflunisal ................................. 1 

digoxin .................................. 25 

dihydroergotamine mesylate . 12 

dilantin infatabs ....................... 7 

diltiazem cd ........................... 25 

diltiazem er 360, 420 mg cap 25 

diltiazem er cap ..................... 25 

diltiazem inj, tab .................... 25 

dilt-xr..................................... 25 

diovan .................................... 26 

diovan 320 mg....................... 27 

diovan hct .............................. 27 

diovan hct 320-12.5, 320-25mg 

........................................... 27 

diphenhydramine hcl ............. 10 

diphenoxylate/atropine .......... 30 

diphtheria/tetanus toxoid ....... 36 

dipyridamole ......................... 23 

disopyramide phosphate........ 23 

divalproex sodium ................... 7 

docetaxel ............................... 14 

donepezil ................................. 8 

dorzolamide hcl ..................... 40 

dorzolamide hcl/timolol malea 

........................................... 40 

dovonex ................................. 29 

doxazosin mesylate ............... 23 

doxepin hcl .............................. 9 

doxycycline 10 mg/ml inj ....... 6 

doxycycline hyclate ................ 6 

doxycycline monohydrate ....... 6 

dronabinol 10 mg .................. 10 

dronabinol 2.5, 5 mg ............. 10 

duetact ................................... 20 

duramorph ............................... 2 

dyrenium ............................... 25 

E 

econazole nitrate ................... 11 

edecrin sodium ...................... 25 

edurant................................... 18 

effient .................................... 23 

elitek ...................................... 14 

elmiron .................................. 30 

embeda .................................... 2 

emcyt ..................................... 14 

emend 125 mg ....................... 10 

emend 40 mg ......................... 10 

emend 80 mg ......................... 10 

emend pak ............................. 10 

emsam ..................................... 8 

emtriva .................................. 18 

enalapril maleate ................... 27 

enalapril maleate/hctz ........... 23 

enbrel 25 mg ......................... 35 

enbrel 25 mg/0.5ml ............... 35 

enbrel 50 mg/ml .................... 35 

endocet .................................... 2 

endocet 10-650 mg .................. 2 

endocet 7.5-500 mg ................. 2 

engerix-b vacc ....................... 36 

enoxaparin ............................. 22 

entocort ec ............................. 30 

epivir ..................................... 18 

epivir hbv .............................. 19 

eplerenone ............................. 25 

epzicom tab ........................... 18 

erythrocin stearate ................... 5 

erythromycin ........................... 6 

erythromycin ethylsuccinate ... 6 

erythromycin/benzoyl pero ... 29 

erythromycin/sulfisoxazole ..... 6 

estazolam............................... 43 

estrace ................................... 33 

estradiol 0.0375, 0.06 mg dis 33 

estradiol dis ........................... 33 

estradiol tab ........................... 33 

ethambutol hcl ....................... 13 

ethosuximide ........................... 7 

etodolac ................................... 1 

etoposide ............................... 15 

eurax ...................................... 16 

evista ..................................... 34 

exelon ...................................... 8 

exemestane ............................ 15 

exjade 125 mg tab ................. 10 

exjade 250, 500 mg tab ......... 10 

F 

fabrazyme .............................. 30 

famciclovir ............................ 19 

famotidine ............................. 31 

fanapt..................................... 17 

fareston .................................. 14 

faslodex ................................. 34 

fazaclo ................................... 17 

felbatol .................................... 7 

feldene ..................................... 1 

felodipine er .......................... 25 

femhrt .................................... 38 

femring .................................. 33 

femtrace ................................. 33 

fenofibrate ............................. 26 

fenoprofen calcium ................. 1 

fentanyl lozenge ...................... 2 

fentanyl lozenge 0.2 mg .......... 2 

fentanyl transdermal patch ...... 2 

fentora ..................................... 2 

fexmid ................................... 43 

fexofenadine 180 mg ............. 41 

fexofenadine 30, 60 mg ......... 41 

finacea ................................... 29 

finasteride .............................. 32 

fioricet/codeine ....................... 2 

fiorinal/codeine ....................... 2 

firmagon ................................ 34 

flagyl ....................................... 4 

flarex ..................................... 39 

flavoxate ................................ 31 

flecainide acetate ................... 23 

flector ...................................... 1 

flexeril ................................... 43 

flomax ................................... 32 

flonase ................................... 40 

flovent ................................... 40 

flovent hfa 110, 220 mcg ...... 41 

flovent hfa 44 mcg ................ 41 

fluconazole ............................ 11 

fluconazole 2 mg/ml inj ........ 11 

fludrocortisone ...................... 32 

flunisolide ............................. 41 

fluocinolone acetonide .......... 29 

fluocinonide .......................... 29 

fluocinonide emollient ba ..... 29 

fluorometholone .................... 39 

fluorouracil ............................ 29 

fluoxetine 10 mg cap ............... 9 



fluoxetine sol, tab .................... 9 

fluphenazine .......................... 17 

fluphenazine decanoate ......... 17 

flurazepam ............................. 43 

flurbiprofen ............................. 1 

flurbiprofen sodium .............. 39 

flutamide ............................... 34 

fluticasone propionate ..... 29, 41 

fluvoxamine maleate ............... 9 

fml ......................................... 39 

focalin ................................... 27 

48

folic acid................................ 44 

fomepizole............................. 10 

foradil .................................... 42 

fortamet ................................. 20 

fortaz ....................................... 5 

forteo ..................................... 37 

fortical ................................... 37 

fosamax ................................. 37 

fosamax plus d 70-2800 mg .. 37 

fosamax plus d 70-5600 mg .. 37 

foscarnet sodium ................... 18 

fosinopril sodium .................. 27 

fosinopril sodium/hctz .......... 23 

fosphenytoin sodium ............... 7 

fosrenol ................................. 32 

fragmin 10000 u .................... 22 

fragmin 12500, 15000, 18000 u 

........................................... 22 

fragmin 2500 u/0.2ml, 25000 u 

........................................... 22 

fragmin 7500 u/0.3ml............ 22 

freamine iii ............................ 44 

freamine iii 3% ...................... 44 

frova ...................................... 12 

furosemide............................. 25 

fuzeon .................................... 18 

G 

gabapentin ............................... 7 

gabitril 12 mg .......................... 7 

gabitril 2, 16 mg ...................... 7 

gabitril 4 mg ............................ 7 

galantamine 12 mg tab ............ 8 

galantamine 4 mg tab .............. 8 

galantamine 8 mg tab .............. 8 

galantamine er cap .................. 8 

gamastan s/d .......................... 35 

gammagard liquid ................. 35 

gamunex ................................ 35 

ganciclovir............................. 18 

gardasil .................................. 36 

gastrocrom............................. 42 

gauze pads ............................. 20 

gaviltye-g .............................. 30 

gavilyte-c............................... 30 

gavilyte-n .............................. 30 

gelnique ................................. 31 

gemfibrozil ............................ 26 

gemzar ................................... 14 

gengraf .................................. 35 

gentak ...................................... 3 

gentamicin ............................... 4 

gentamicin/nacl 100 mg .......... 4 

gentamicin/nacl 60, 80 mg ...... 4 

gentasol ................................... 4 

geodon ................................... 17 

gilenya ................................... 28 

gleevec 100 mg ..................... 15 

gleevec 400 mg ..................... 15 

glimepiride ............................ 20 

glipizide................................. 20 

glipizide/metformin hcl ......... 20 

glucagen hypokit ................... 21 

glucagon emergency kit ........ 21 

glucophage ............................ 20 

glucotrol ................................ 20 

glucovance ............................ 20 

glumetza ................................ 20 

glyburide ............................... 20 

glyburide micronized ............ 20 

glyburide/metformin hcl ....... 21 

glycopyrrolate ....................... 30 

glynase .................................. 21 

glyset ..................................... 21 

golytely ................................. 30 

granisetron 0.1mg/ml inj, tab 10 

granisetron 1mg/ml inj .......... 10 

granisol .................................. 10 

grifulvin v.............................. 11 

griseofulvin microsize ........... 11 

gris-peg ................................. 11 

guanabenz ............................. 23 

gynazole-1 ............................. 11 

H 

halaven .................................. 14 

haldol..................................... 17 

halobetasol propionate .......... 29 

halog ...................................... 29 

haloperidol decanoate ........... 17 

haloperidol lactate ................. 17 

haloperidol oral conc ............. 17 

haloperidol tab ...................... 17 

havrix .................................... 36 

hctz ........................................ 25 

hectorol ................................. 37 

helidac therapy ...................... 30 

heparin sodium ...................... 22 

heparin sodium/d5w .............. 22 

heparin sodium/nacl .............. 22 

hepatamine ............................ 44 

hepsera .................................. 19 

herceptin ................................ 14 

hexalen .................................. 13 

hiprex ...................................... 4 

humalog................................. 21 

humalog mix ......................... 21 

humalog pen .......................... 21 

humatrope 12 mg .................. 32 

humatrope 6, 24 mg .............. 32 

humatrope combo pack ......... 32 

humira 20 mg/0.4ml .............. 35 

humira 40 mg/0.8ml .............. 35 

humira pen-crohns ................ 35 

humulin 70/30 ....................... 21 

humulin n .............................. 21 

humulin r ............................... 21 

hycamtin ................................ 15 

hydralazine hcl ...................... 27 

hydrea .................................... 14 

hydroco/apap 10-325 mg ........ 2 




hydroco/apap 2.5-500 mg ....... 2 

hydroco/apap 5-325 mg .......... 2 

hydroco/apap 5-500 mg .......... 2 





hydroco/apap sol ..................... 2 

hydroco/homatropine ............ 42 

hydroco/ibuprofen ................... 2 

hydrocortisone................. 29, 32 

hydrocortisone butyrate ........ 29 

hydrocortisone valerate ......... 29 

hydromet ............................... 42 

hydromorphone hcl ................. 2 

hydroxychloroquine sulfate .. 16 

hydroxyurea .......................... 14 

hydroxyzine hcl ..................... 10 

hydroxyzine pamoate ............ 10 

hyzaar .................................... 27 

I 

ibuprofen ................................. 1 

idamycin ................................ 14 

idarubicin hcl ........................ 14 

ifex ........................................ 14 

ifosfamide 50 mg/ml ............. 14 

ifosfamide/mesna 1 gm ......... 14 

ifosfamide/mesna 3 gm ......... 14 

49

imipramine hcl ........................ 9 

imipramine pamoate ................ 9 

imiquimod ............................. 29 

imitrex ................................... 12 

imovax rabies (h.d.c.v.)......... 36 

imuran ................................... 35 

increlex .................................. 33 

indapamide ............................ 26 

inderal ................................... 24 

indocin..................................... 1 

indomethacin ........................... 1 

infanrix .................................. 36 

infergen ................................. 19 

infumorph ................................ 2 

innohep .................................. 22 

innopran ................................ 24 

inspra ..................................... 26 

insulin pen needles ................ 21 

insulin syrg/needles ............... 21 

intelence ................................ 18 

intralipid ................................ 44 

intralipid 20% inj .................. 44 

intron a 10 mu inj .................. 36 

intron a 18 mu inj .................. 36 

intron a pen ........................... 36 

intuniv ................................... 28 

invanz ...................................... 5 

invega 6 mg tab ..................... 17 

invega inj ............................... 17 

invega tab .............................. 17 

invirase cap ........................... 18 

invirase tab ............................ 18 

ionosol-mb ............................ 44 

ionosol-t ................................ 44 

iopidine ................................. 40 

ipol inactivated ipv ................ 36 

ipratropium bromide inh sol .. 41 

ipratropium bromide nasal spr 

........................................... 41 

iquix ........................................ 6 

iressa ..................................... 15 

irinotecan hcl inj ................... 14 

isentress ................................. 18 

isochron ................................. 27 

isolyte-h/dextrose 5% ............ 44 

isolyte-m/dextrose 5% .......... 44 

isolyte-p/dextrose 5% ............ 44 

isolyte-s ................................. 44 

isolyte-s/dextrose 5% ............ 44 

isonarif .................................. 13 

isoniazid ................................ 13 

isoptin .................................... 25 

isordil .................................... 27 

isosorbide dinitrate ................ 27 

isosorbide mononitrate .......... 27 

isradipine ............................... 25 

istalol ..................................... 40 

istodax ................................... 15 

itraconazole ........................... 11 

ixempra ................................. 14 

ixiaro ..................................... 36 

J 

jalyn....................................... 32 

jantoven ................................. 22 

janumet .................................. 21 

januvia ................................... 21 

je-vax..................................... 36 

jinteli ..................................... 38 

jolivette ................................. 33 

junel....................................... 38 

K 

kadian cr 10, 50, 80 mg ........... 2 

kadian cr 100, 200 mg ............. 2 

kadian cr 20, 30, 60 mg ........... 2 

kaletra .................................... 18 

kanamycin sulfate ................... 4 

kariva..................................... 38 

kayexalate ............................. 43 

kcl/d5w .................................. 44 

kcl/d5w/lr inj ......................... 44 

kcl/d5w/nacl .......................... 44 

kcl/nacl 0.3-0.9 inj ................ 44 

kcl/nacl inj ............................. 44 

keflex....................................... 5 

kelnor .................................... 38 

kenalog .................................. 29 

kepivance .............................. 28 

keppra ...................................... 6 

keppra xr 500 mg .................... 6 

kerlone................................... 24 

ketek ........................................ 6 

ketoconazole ......................... 11 

ketoprofen ............................... 1 

ketoprofen er ........................... 1 

ketorolac ................................ 39 

ketorolac tromethamine inj ..... 1 

ketorolac tromethamine tab ..... 1 

kineret ................................... 36 

kionex .................................... 43 

klaron ...................................... 6 

klor-con ................................. 44 

kristalose ............................... 30 

k-tab ...................................... 44 

kuvan ..................................... 30 

L 

labetalol hcl ........................... 24 

lac-hydrin .............................. 29 

laclotion................................. 29 

lacrisert .................................. 16 

lactated ringer's irr ................ 44 

lactated ringer's viaflex ......... 44 

lactulose ................................ 30 

lamictal .................................... 7 

lamictal kit .............................. 7 

lamisil .................................... 11 

lamotrigine .............................. 7 

lamotrigine 150, 200 mg ......... 7 

lanoxin................................... 25 

lansoprazole .......................... 31 

lantus ..................................... 21 

lantus solostar ........................ 21 

lasix 20, 40 mg ...................... 26 

lasix 80 mg ............................ 26 

latanoprost ............................. 40 

latuda ..................................... 17 

leena ...................................... 38 

leflunomide ........................... 36 

lescol ..................................... 26 

lessina .................................... 38 

letairis .................................... 42 

letrozole................................. 15 

leucovorin inj ........................ 14 

leucovorin tab........................ 14 

leukeran ................................. 13 

leukine 250 mcg .................... 22 

leukine 500 mcg .................... 22 

leuprolide acetate .................. 34 

leustatin ................................. 14 

levalbuterol inh sol ................ 42 

levaquin inj, tab ....................... 6 

levaquin sol, premix ................ 6 

levatol .................................... 24 

levemir .................................. 21 

levetiracetam ........................... 6 

levobunolol hcl ...................... 40 

levobunolol hcl 0.5% op sol . 40 

levocarnitine .......................... 44 

levora..................................... 38 

levorphanol ............................. 2 

levothroid .............................. 32 

50

levothyroxine sodium............ 32 

levoxyl................................... 32 

lexapro sol ............................... 9 

lexapro tab ............................... 9 

lexiva ..................................... 18 

lialda ...................................... 37 

lidocaine .................................. 3 

lidocaine/prilocaine ................. 3 

lidoderm .................................. 3 

lincocin .................................... 4 

lindane ................................... 16 

liothyronine sodium inj ......... 32 

liothyronine sodium tab ........ 32 

lipitor ..................................... 26 

lipofen ................................... 26 

liposyn ................................... 44 

lisinopril ................................ 27 

lisinopril/hctz ........................ 23 

lithium carbonate .................. 20 

lithium citrate ........................ 20 

livalo ..................................... 26 

lo/ovral .................................. 38 

locoid..................................... 29 

loestrin................................... 38 

lofibra .................................... 26 

lokara..................................... 29 

lomotil ................................... 30 

loperamide hcl ....................... 31 

lopid ...................................... 26 

lopressor ................................ 24 

loprox gel .............................. 11 

loprox shampoo ..................... 11 

lorazepam .............................. 20 

lorcet ....................................... 2 

lortab ....................................... 2 

losartan .................................. 27 

losartan/hctz .......................... 27 

loseasonique .......................... 38 

lotemax .................................. 39 

lotensin .................................. 27 

lotensin hct ............................ 23 

lotrel ...................................... 25 

lotrisone................................. 29 

lotronex ................................. 31 

lovastatin ............................... 26 

lovaza .................................... 26 

lovenox 100 mg/ml ............... 22 

lovenox 120 mg/0.8ml .......... 22 

lovenox 150 mg/ml ............... 22 

lovenox 30 mg/0.3ml ............ 22 

lovenox 300 mg/3ml ............. 22 

lovenox 40 mg/0.4ml ............ 22 

lovenox 60 mg/0.6ml ............ 22 

lovenox 80 mg/0.8ml ............ 22 

low-ogestrel........................... 38 

loxapine succinate ................. 17 

loxitane .................................. 17 

lufyllin ................................... 41 

lumigan ................................. 40 

lunesta ................................... 43 

lupron depot .......................... 34 

lupron depot-ped ................... 34 

lutera 28 day .......................... 38 

luvox ....................................... 9 

luxiq ...................................... 29 

lybrel ..................................... 38 

lyrica ....................................... 7 

lysodren ................................. 34 

M 

macrobid ................................. 4 

macrodantin............................. 4 

magnacet ................................. 2 

magnesium sulfate ................ 44 

malarone ................................ 16 

malathion............................... 16 

maprotiline hcl ........................ 8 

margesic-h ............................... 2 

marinol .................................. 10 

marplan ................................... 8 

matulane ................................ 13 

mavik..................................... 27 

maxair ................................... 42 

maxalt .................................... 12 

maxidex ................................. 39 

maxidone ................................. 2 

maxitrol ................................. 39 

maxzide ................................. 26 

mebendazole ......................... 16 

meclizine hcl ......................... 10 

meclofenamate sodium ........... 1 

medroxyprogesterone ac inj .. 33 

medroxyprogesterone ac tab . 33 

mefloquine hcl ...................... 16 

megace .................................. 33 

megestrol acetate ................... 34 

meloxicam susp ....................... 1 

meloxicam tab ......................... 1 

melphalan .............................. 13 

menactra ................................ 36 

menest ................................... 33 

menomune-a/c/y/w-135 ........ 36 

menostar ................................ 33 

menveo inj ............................. 36 

meprobamate ......................... 20 

mepron .................................. 16 

mercaptopurine ..................... 35 

merrem .................................... 5 

mesalamine ........................... 37 

mesna inj ............................... 14 

mesnex inj ............................. 14 

mesnex tab ............................ 14 

mestinon ................................ 13 

mestinon 60 mg tab ............... 13 

metadate cap .......................... 28 

metadate tab .......................... 28 

metaglip................................. 21 

metaproterenol sulfate ........... 42 

metaxalone ............................ 43 

metformin hcl ........................ 21 

metformin hcl er 500 mg ....... 21 

metformin hcl er 750 mg ....... 21 

methadone hcl ......................... 2 

methadose ............................... 2 

methamphetamine hcl ........... 27 

methazolamide ...................... 26 

methenamine hippurate ........... 4 

methergine............................. 32 

methimazole .......................... 34 

methitest ................................ 33 

methocarbamol ...................... 43 

methotrexate .......................... 35 

methotrexate 50 mg/ml inj .... 35 

methscopolamine .................. 30 

methyclothiazide ................... 26 

methyldopa ............................ 23 

methyldopa/hctz .................... 23 

methyldopate hcl ................... 23 

methylin ................................ 28 

methylphenidate hcl .............. 28 

methylprednisolone ............... 12 

methylprednisolone ac .......... 12 

metipranolol .......................... 40 

metoclopramide hcl ............... 10 

metolazone ............................ 26 

metoprolol succinate er ......... 24 

metoprolol tartrate ................. 24 

metoprolol/hctz ..................... 24 

metozolv ................................ 11 

metrocream ............................. 4 

metrogel .................................. 4 

51

metrolotion .............................. 4 

metronidazole cap, tab ............ 4 

metronidazole crm .................. 4 

mevacor ................................. 26 

mexiletine hcl ........................ 23 

miacalcin ............................... 37 

micardis ................................. 27 

micardis hct ........................... 27 

miconazole ............................ 11 

microgestin ............................ 38 

microzide............................... 26 

midodrine hcl ........................ 23 

migergot ................................ 12 

migranal ................................ 12 

millipred ................................ 12 

minipress ............................... 23 

minitran ................................. 27 

minocin ................................... 6 

minocycline ............................. 6 

minoxidil ............................... 27 

mirapex ................................. 16 

mirapex er ............................. 16 

mirtazapine .............................. 8 

misoprostol ............................ 31 

mitoxantrone hcl ................... 14 

m-m-r ii ................................. 36 

mobic....................................... 1 

modicon................................. 38 

moexipril hcl ......................... 27 

moexipril/hctz ....................... 23 

mometasone furoate .............. 29 

monodox ................................. 6 

monoket................................. 27 

mononessa ............................. 38 

morphine sulfate ...................... 2 

morphine sulfate inj ................ 2 

motofen ................................. 31 

moviprep ............................... 31 

moxatag ................................... 5 

mozobil ................................. 22 

ms contin ................................. 3 

multaq ................................... 23 

mupirocin ................................ 4 

mustargen .............................. 14 

myambutol ............................ 13 

mycamine .............................. 11 

mycobutin ............................. 13 

mycophenolate mofetil.......... 35 

mydriacyl .............................. 39 

myfortic ................................. 35 

myozyme ............................... 30 

mysoline .................................. 7 

mytelase ................................ 13 

N 

nabumetone ............................. 1 

nadolol................................... 24 

nadolol/bend .......................... 24 

nafcillin 1, 10 gm .................... 5 

nafcillin 20 mg/ml ................... 5 

naftin ..................................... 11 

naglazyme ............................. 30 

nalbuphine hcl ......................... 3 

nalfon ...................................... 1 

naloxone hcl .......................... 10 

naltrexone hcl ........................ 10 

namenda sol ............................ 8 

namenda tab ............................ 8 

naprelan ................................... 1 

naprosyn .................................. 1 

naproxen .................................. 1 

nasacort ................................. 41 

nasonex ................................. 41 

natacyn .................................. 11 

nateglinide ............................. 21 

navane ................................... 17 

nebupent ................................ 16 

nefazodone hcl ........................ 8 

neomycin sulfate ..................... 4 

neomycin/polymyxin b sulf .. 38 

neomycin/polymyxin/dexame 39 

neomycin/polymyxin/gramic 39 

neomycin/polymyxin/hc . 39, 40 

neoral..................................... 35 

neosporin sol ......................... 39 

nephramine ............................ 44 

neulasta ................................. 22 

neumega ................................ 22 

neupogen ............................... 22 

neupogen 480 mcg/1.6ml ...... 22 

neurontin ................................. 7 

neurontin sol............................ 7 

nevanac ................................. 39 

nexavar .................................. 15 

nexium................................... 31 

nexium inj ............................. 31 

niacor..................................... 26 

niaspan .................................. 26 

nicardipine hcl ....................... 25 

nicotrol .................................. 10 

nifediac cc ............................. 25 

nifedical xl ............................ 25 

nifedipine .............................. 25 

nifedipine er .......................... 25 

nilandron ............................... 34 

nimodipine ............................ 25 

nipent..................................... 14 

nisoldipine ............................. 25 

nitro-bid................................. 27 

nitro-dur ................................ 27 

nitrofurantoin .......................... 4 

nitrofurantoin macrocrystal ..... 4 

nitrofurantoin monohydrate .... 4 

nitroglycerin .......................... 27 

nitrolingual pumpspray ......... 27 

nitrostat ................................. 27 

nizatidine 150 mg .................. 31 

nizatidine 300 mg .................. 31 

nizoral ................................... 11 

nora-be .................................. 34 

norco ....................................... 3 

nordette ................................. 38 

norditropin............................. 33 

norethindrone acetate ............ 34 

norflex ................................... 43 

norinyl ................................... 38 

noritate .................................... 4 

normosol-m in d5w ............... 44 

normosol-r ............................. 44 

normosol-r in d5w ................. 44 

noroxin .................................... 6 

norpace .................................. 24 

norpramin ................................ 9 

nor-qd .................................... 34 

nortrel .................................... 38 

nortriptyline hcl ..................... 10 

norvasc .................................. 25 

norvir ..................................... 18 

novantrone............................. 14 

novarel................................... 33 

novolin 70/30 ........................ 21 

novolin n ............................... 21 

novolin r ................................ 21 

novolog ................................. 21 

novolog mix 70/30 ................ 21 

noxafil ................................... 11 

nucynta .................................... 3 

nulytely ................................. 31 

nutropin ................................. 33 

nutropin aq ............................ 33 

nuvaring ................................ 38 

52

nuvigil ................................... 43 

nyamyc .................................. 11 

nystatin .................................. 12 

nystatin powder, tab .............. 12 

nystatin/triamcinolone ........... 29 

nystop .................................... 12 

O 

ocella ..................................... 38 

octreotide acetate .................. 34 

ocufen .................................... 39 

ocuflox .................................... 6 

ofloxacin ................................. 6 

ogestrel .................................. 38 

oleptro ..................................... 8 

olux ....................................... 29 

omeprazole ............................ 31 

omnaris .................................. 41 

omnipred ............................... 39 

omnitrope .............................. 33 

omnitrope 5.8 mg .................. 33 

ondansetron inj ..................... 11 

ondansetron 24 mg tab .......... 11 

ondansetron 4 mg tab ............ 11 

ondansetron 8 mg tab ............ 11 

ondansetron odt ..................... 11 

ondansetron sol ..................... 11 

onglyza .................................. 21 

onsolis ..................................... 3 

ontak ...................................... 14 

opana ....................................... 3 

opana er 30 mg ........................ 3 

opana er 5, 10, 20, 40 mg ........ 3 

optipranolol ........................... 40 

optivar ................................... 39 

oracea ...................................... 6 

oramorph ................................. 3 

orap ....................................... 17 

orapred ............................ 12, 40 

oravig .................................... 12 

orencia ................................... 35 

orfadin ................................... 30 

orphenadrine citrate .............. 43 

orphenadrine/asa/caff .............. 3 

ortho evra .............................. 38 

ortho micronor ...................... 34 

ortho tri-cyclen lo .................. 38 

ortho-cept .............................. 38 

orthoclone okt3 ..................... 35 

ortho-cyclen .......................... 38 

ortho-novum .......................... 38 

osmoprep ............................... 44 

ovcon ..................................... 38 

ovide ...................................... 16 

oxacillin inj ............................ 5 

oxacillin dex inj....................... 5 

oxaliplatin inj ........................ 14 

oxandrin ................................ 33 

oxandrolone 10mg tab........... 33 

oxandrolone 2.5mg tab.......... 33 

oxaprozin................................. 1 

oxazepam .............................. 20 

oxcarbazepine ......................... 7 

oxistat .................................... 12 

oxsoralen ............................... 29 

oxsoralen ultra ....................... 29 

oxybutynin chloride .............. 31 

oxybutynin chloride er .......... 31 

oxycodone hcl ......................... 3 

oxycodone hcl sol ................... 3 

oxycodone hcl/ibuprofen ........ 1 

oxycodone/apap ...................... 3 

oxycodone/apap 7.5-500mg .... 3 

oxycontin cr ............................ 3 

oxycontin cr 80 mg ................. 3 

oxymorphone .......................... 3 

oxytrol ................................... 32 

P 

pacerone ................................ 24 

paclitaxel ............................... 14 

palgic liq................................ 41 

palgic tab ............................... 41 

pamelor ................................. 10 

pamidronate disodium ........... 37 

pamine ................................... 30 

pancreaze ............................... 30 

pandel .................................... 29 

panlor ss .................................. 3 

panretin ................................. 15 

pantoprazole sodium ............. 31 

parafon forte dsc ................... 43 

parcaine ................................. 39 

parcopa .................................. 16 

parlodel ................................. 16 

parnate ..................................... 9 

paromomycin .......................... 4 

paroxetine 10 tab ................... 19 

paroxetine er 12.5 mg tab ........ 8 

paroxetine er 25 mg tab ........... 9 

paroxetine er 37.5 mg tab ........ 9 

paroxetine susp...................... 19 

paroxetine tab ........................ 19 

paser ...................................... 13 

pataday .................................. 39 

patanase ................................. 41 

patanol ................................... 39 

paxil................................... 9, 19 

pce ........................................... 6 

pediapred ............................... 12 

pedi-dri .................................. 12 

pedvax hib ............................. 36 

peganone ................................. 7 

pegasys .................................. 19 

pegintron ............................... 19 

penicillin g potassium ............. 5 

penicillin g sodium .................. 5 

penicillin v potassium ............. 5 

penlac nail lacquer ................ 12 

pentam ................................... 16 

pentasa................................... 37 

pentazocine/apap ..................... 3 

pentazocine/naloxone hcl ...... 10 

pentostatin inj ........................ 14 

pentoxifylline er .................... 25 

pepcid .................................... 31 

percocet ................................... 3 

percodan .................................. 3 

perforomist ............................ 42 

perindopril erbumine ............. 27 

periogard ............................... 28 

periostat ................................... 6 

permethrin ............................. 16 

perphenazine ......................... 11 

perphenazine/amitriptylin ..... 10 

persantine .............................. 23 

pexeva ................................... 19 

pexeva 10 mg ........................ 19 

pfizerpen ................................. 5 

phenadoz ............................... 11 

phenelzine ............................... 9 

phenergan .............................. 11 

phenobarbital ........................... 7 

phenytek .................................. 7 

phenytoin................................. 7 

phenytoin er 200mg cap .......... 7 

phenytoin susp ........................ 7 

phoslo .................................... 32 

phospholine iodide ................ 40 

photofrin ................................ 15 

physiolyte .............................. 44 

physiosol irrigation ............... 44 

53

pilocarpine hcl ....................... 28 

pilopine hs ............................. 40 

pindolol ................................. 24 

piperacillin sodium.................. 5 

piroxicam ................................ 1 

plaquenil ................................ 16 

plasma-lyte 56 ....................... 45 

plasma-lyte a ......................... 45 

plasma-lyte-148..................... 45 

plasma-lyte-148/d5w............. 45 

plasma-lyte-56/d5w............... 45 

plasma-lyte-r ......................... 45 

plavix..................................... 23 

pletal ...................................... 23 

podofilox ............................... 29 

poly pred ............................... 39 

poly-dex ................................ 39 

polyethylene glycol ............... 31 

potassium chloride ................ 45 

potassium citrate er ............... 45 

pradaxa .................................. 22 

pramipexole........................... 16 

prandin .................................. 21 

pravachol ............................... 26 

pravastatin sodium ................ 26 

prazosin hcl ........................... 23 

precose .................................. 21 

pred forte ............................... 40 

pred mild ............................... 40 

pred-g .................................... 39 

prednicarbate ......................... 29 

prednisolone acetate .............. 40 

prednisolone sod phosp ......... 12 

prednisolone sod phosp op .... 40 

prednisone ............................. 12 

prefest .................................... 38 

pregnyl .................................. 33 

premarin ................................ 33 

premasol ................................ 45 

premphase ............................. 38 

prempro ................................. 38 

prenatabs obn ........................ 39 

prevalite................................. 26 

previfem ................................ 38 

prevpac .................................. 31 

prezista ............................ 15, 18 

priftin..................................... 13 

prilosec .................................. 31 

primaxin .................................. 5 

primidone ................................ 7 

pristiq ...................................... 9 

privigen ................................. 35 

proair hfa ............................... 42 

probenecid ............................. 12 

procainamide hcl ................... 24 

procalamine ........................... 45 

procardia ............................... 25 

procardia xl ........................... 25 

prochlorperazine ................... 11 

prochlorperazine edisylate .... 11 

prochlorperazine maleate ...... 11 

procrit 10000/ml.................... 22 

procrit 2000/ml...................... 22 

procrit 20000/ml.................... 22 

procrit 3000/ml...................... 22 

procrit 4000/ml...................... 22 

procrit 40000/ml.................... 23 

proctocream-hc ..................... 37 

procto-pak ............................. 37 

proctosol hc ........................... 37 

proctozone-hc ........................ 37 

proglycem ............................. 21 

prograf ................................... 35 

prolastin................................. 42 

proleukin ............................... 15 

prolia ..................................... 37 

promacta ................................ 23 

promethazine hcl ................... 11 

promethazine vc/codeine ...... 42 

promethazine/codeine ........... 42 

promethegan .......................... 11 

prometrium ............................ 34 

propafenone hcl ..................... 24 

propine .................................. 40 

propranolol 20 mg/5ml sol .... 24 

propranolol 40 mg/5ml sol .... 24 

propranolol er ........................ 24 

propranolol inj, tab ................ 24 

propranolol/hctz .................... 24 

propylthiouracil ..................... 35 

proquad ................................. 36 

proquin .................................... 6 

proscar ................................... 32 

prosol..................................... 45 

protonix ................................. 31 

protopic ................................. 29 

protriptyline hcl ..................... 10 

proventil hfa .......................... 42 

provera .................................. 34 

provigil 100 mg ..................... 43 

provigil 200 mg ..................... 43 

prozac ...................................... 9 

prozac weekly ......................... 9 

pulmicort ............................... 41 

pulmicort inh susp ................. 41 

pulmozyme ............................ 42 

purinethol .............................. 35 

pylera..................................... 31 

pyrazinamide ......................... 13 

pyridostigmine bromide ........ 13 

Q 

quinapril hcl .......................... 27 

quinapril/hctz ........................ 23 

quinidine gluconate cr ........... 24 

quinidine sulfate .................... 24 

qvar 40 mcg aer ..................... 41 

qvar 80 mcg aer ..................... 41 

R 

rabavert ................................. 36 

ramipril .................................. 27 

ranexa .................................... 25 

ranitidine ............................... 31 

ranitidine 150 mg cap ............ 31 

ranitidine syr ......................... 31 

rapamune 0.5 mg tab ............. 35 

rapamune 1, 2 mg tab ............ 35 

rapamune sol ......................... 35 

razadyne .................................. 8 

rebif ....................................... 28 

recombivax hb ....................... 36 

regranex ................................. 29 

relistor ................................... 31 

relpax..................................... 12 

remicade ................................ 35 

renvela ................................... 32 

repan ........................................ 3 

rescriptor ............................... 18 

restasis ................................... 39 

retrovir iv infusion ................ 18 

revatio inj .............................. 42 

revatio tab.............................. 42 

revlimid ................................. 13 

reyataz ................................... 19 

rhinocort aqua ....................... 41 

ribapak 400, 600 mg ............. 19 

ribapak pak ............................ 19 

ribasphere 200 mg cap, tab ... 19 

ribasphere 400, 600mg tab .... 19 

ribavirin ................................. 19 

rifampin ................................. 13 

54

ilutek .................................... 28 

rimantadine hcl ...................... 19 

ringer's injection .................... 45 

ringer's irrigation ................... 45 

risperdal................................. 17 

risperdal consta ..................... 17 

risperidone............................. 17 

risperidone sol ....................... 17 

ritalin cap .............................. 28 

ritalin tab ............................... 28 

rituxan ................................... 15 

robaxin .................................. 43 

robinul ................................... 30 

rocaltrol ................................. 37 

rocephin................................... 5 

romycin ................................... 6 

ropinirole hcl ......................... 16 

rotateq ................................... 36 

rowasa ................................... 37 

roxicet 5-325 mg tab ............... 3 

roxicet 5-500 mg tab ............... 3 

roxicet sol ................................ 3 

roxicodone 15, 30 mg tab........ 3 

roxicodone 5mg tab................. 3 

rozerem ................................. 43 

rythmol cap ........................... 24 

rythmol tab ............................ 24 

ryzolt ....................................... 3 

S 

sabril 500 mg tab ..................... 7 

sabril sol .................................. 7 

saizen 5 mg ........................... 33 

saizen 8.8 mg ........................ 33 

samsca ................................... 43 

sanctura ................................. 32 

sancuso .................................. 11 

sandimmune cap, sol ............. 35 

sandimmune inj ..................... 35 

sandostatin............................. 34 

sandostatin 0.05 mg/ml ......... 34 

santyl ..................................... 29 

saphris ................................... 20 

sarafem .................................... 9 

savella ................................... 28 

savella 4-week titration ......... 28 

selegiline hcl ......................... 16 

selenium sulfide .................... 29 

selfemra ................................... 9 

selzentry 150 mg ................... 18 

selzentry 300 mg ................... 18 

semprex-d .............................. 41 

sensipar 30 mg ...................... 34 

sensipar 60 mg ...................... 34 

sensipar 90 mg ...................... 34 

serevent diskus ...................... 42 

seromycin .............................. 13 

seroquel ................................. 17 

seroquel 300, 400 mg ............ 17 

seroquel xr ............................... 8 

serostim ................................. 33 

sertraline hcl .......................... 19 

sertraline hcl conc ................. 20 

silvadene ................................. 6 

silver sulfadiazine ................... 6 

simcor 1000/40 mg ............... 26 

simcor 500/20, 750/20 mg .... 26 

simponi .................................. 35 

simulect ................................. 35 

simvastatin ............................ 26 

sinemet .................................. 16 

sinemet cr .............................. 16 

singulair................................. 41 

singulair chw 5mg ................. 41 

skelaxin ................................. 43 

skelid ..................................... 37 

sodium bicarbonate ............... 45 

sodium chloride 0.9% irr...... 45 

sodium chloride 

0.45%,0.9%,3%................. 45 

sodium chloride 2.5 meq/ml . 45 

sodium chloride 5% .............. 45 

sodium fluoride ..................... 45 

sodium lactate ....................... 45 

sodium polystyrene sulfon .... 43 

solaraze ................................. 29 

solia ....................................... 38 

solodyn 105 mg ....................... 6 

solodyn 45, 90, 135 mg ........... 6 

solodyn 65, 115 mg ................. 6 

solu-cortef ............................. 12 

solu-medrol ........................... 12 

soma ...................................... 43 

somatuline 120 mg/.5ml........ 34 

somatuline 60 mg/0.2ml........ 34 

somavert ................................ 34 

sonata .................................... 43 

soriatane ................................ 29 

sorine ..................................... 24 

sotalol hcl .............................. 24 

sotret ...................................... 30 

spectracef ................................ 5 

spiriva handihaler .................. 41 

spironolactone ....................... 26 

sporanox ................................ 12 

sprintec .................................. 38 

sprycel 100 mg ...................... 15 

sprycel 20, 50, 70 mg ............ 15 

sprycel 80, 140 mg ................ 15 

sronyx .................................... 38 

ssd ........................................... 6 

stagesic .................................... 3 

stalevo ................................... 17 

starlix..................................... 21 

stavudine ............................... 18 

strattera 10, 18, 25 mg........... 28 

strattera 40, 60, 80, 100 mg... 28 

stromectol .............................. 16 

suboxone ............................... 10 

sucralfate ............................... 31 

sulfacetamide sodium/pred ... 39 

sulfadiazine ............................. 6 

sulfamethoxazole/trimetho ...... 6 

sulfasalazine .......................... 37 

sulfazine ec ............................ 37 

sulindac ................................... 1 

sumatriptan succ inj .............. 13 

sumatriptan succ tab .............. 13 

suprax ...................................... 5 

surmontil ............................... 10 

sustiva ................................... 18 

sutent ..................................... 15 

symbicort............................... 42 

symbyax .................................. 8 

symlin 120 inj 1000 mcg....... 21 

symlin 600 mcg inj ................ 21 

symlinpen 60 inj 1000 mcg ... 21 

synarel ................................... 34 

synthroid ............................... 32 

T 

tabloid ................................... 14 

tacrolimus .............................. 35 

tamiflu 30 mg ........................ 19 

tamiflu 45 mg ........................ 19 

tamiflu 75 mg ........................ 19 

tamoxifen citrate ................... 14 

tamsulosin ............................. 32 

tarceva ................................... 15 

targretin ................................. 15 

tasigna ................................... 15 

taxotere 80 mg/2ml inj .......... 15 

55

taxotere 80 mg/4ml inj .......... 15 

tazorac ................................... 30 

taztia xt .................................. 25 

tegretol .................................... 8 

tekturna ................................. 27 

tekturna hct............................ 27 

temazepam ............................ 43 

terazosin hcl .......................... 23 

terbinafine ............................. 12 

terbutaline sulfate .................. 42 

terconazole ............................ 12 

testosterone cypionate ........... 33 

testosterone enanthate ........... 33 

tetanus toxoid adsorbed......... 36 

tetanus/diphtheria toxoid ....... 36 

tetracycline hcl ........................ 6 

thalomid ................................ 13 

thalomid 200 mg ................... 14 

theochron............................... 41 

theophylline er ...................... 41 

theophylline er 400, 600 mg . 41 

thermazene .............................. 6 

thioridazine hcl ...................... 17 

thiothixene............................. 17 

thymoglobulin ....................... 36 

ticlopidine hcl ........................ 23 

tikosyn ................................... 24 

timolol ................................... 40 

timolol maleate ...................... 13 

timolol maleate op ................. 40 

tizanidine hcl ......................... 17 

tobi ........................................ 42 

tobramycin inj ......................... 4 

tobramycin sulfate ................... 4 

tobramycin/dexamethasone ... 39 

tobrasol .................................... 4 

tolmetin sodium ...................... 1 

topiramate 50 mg tab ............ 13 

topiramate cap ......................... 7 

topiramate tab........................ 13 

torisel..................................... 35 

torsemide ............................... 26 

tracleer ................................... 42 

tramadol hcl ............................ 3 

tramadol hcl er ........................ 3 

tramadol hcl/apap .................... 3 

trandolapril ............................ 27 

tranylcypromine sulfate .......... 9 

travasol .................................. 45 

travatan z ............................... 40 

trazodone hcl ........................... 8 

trecator .................................. 13 

tretinoin ................................. 15 

triamcinolone acetonide ........ 30 

triamcinolone in orabase ....... 28 

triamterene/hctz ..................... 26 

triazolam ............................... 43 

tricor ...................................... 26 

triderm ................................... 30 

trifluoperazine hcl ................. 17 

trifluridine ............................. 19 

trihexyphenidyl hcl ............... 17 

trimethoprim ........................... 4 

trimethoprim sulfate/poly...... 39 

tripedia .................................. 36 

trisenox .................................. 15 

trizivir .................................... 18 

tropicamide ........................... 39 

truvada................................... 18 

twinrix ................................... 36 

tykerb .................................... 15 

typhim vi ............................... 36 

tyzeka .................................... 19 

tyzine ..................................... 42 

tyzine ped nasal dro .............. 42 

U 

u-cort ..................................... 30 

uloric ..................................... 12 

unithroid ................................ 32 

V 

valacyclovir 1 gm tab ............ 19 

valacyclovir 500 mg tab ........ 19 

valcyte sol ............................. 18 

valcyte tab ............................. 18 

valproate sodium ..................... 7 

valproic acid ............................ 7 

vancocin hcl cap ...................... 4 

vancocin hcl inj ....................... 4 

vancomycin hcl ....................... 4 

vandazole ................................ 4 

vandetanib ............................. 15 

vaqta ...................................... 37 

varivax................................... 37 

velcade .................................. 15 

venlafaxine .............................. 9 

venlafaxine er 150 mg tab ...... 9 

venlafaxine er 225 mg tab ...... 9 

venlafaxine er 37.5,75 mg tab . 9 

ventavis ................................. 42 

ventolin hfa ........................... 42 

verapamil hcl ......................... 25 

vesicare ................................. 32 

viagra..................................... 32 

vidaza .................................... 15 

videx ...................................... 18 

viibryd ..................................... 9 

vimpat inj, oral sol .................. 8 

vimpat tab................................ 8 

viracept .................................. 19 

viracept 625 mg tab ............... 19 

viramune ............................... 18 

viread..................................... 18 

vitamin d ............................... 45 

vivaglobin ............................. 36 

voltaren ................................. 30 

votrient .................................. 15 

W 

warfarin sodium .................... 22 

welchol .................................. 21 

X 

xenazine 12.5 mg .................. 28 

xenazine 25 mg ..................... 28 

xgeva ..................................... 37 

xifaxan................................... 31 

xolair ..................................... 42 

xyrem .................................... 43 

Y 

yf-vax .................................... 37 

Z 

zafirlukast .............................. 41 

zaleplon 10 mg ...................... 43 

zaleplon 5 mg ........................ 43 

zavesca .................................. 30 

zazole .................................... 12 

zemplar .................................. 38 

zenpep ................................... 30 

zetia ....................................... 26 

ziagen .................................... 18 

zidovudine ............................. 18 

zinacef ..................................... 5 

zirgan..................................... 18 

zolinza ................................... 12 

zolpidem tartrate ................... 43 

zometa ................................... 38 

zonisamide .............................. 7 

zortress .................................. 35 

zostavax................................. 37 

zyflo cr .................................. 41 

zyprexa .................................. 17 

zyprexa zydis ........................ 17 

56

zytiga ..................................... 34 zyvox ....................................... 4 

57

Simply Healthcare Plans, Inc

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