COMPREHENSIVE FORMULARY - RxAmerica
COMPREHENSIVE FORMULARY - RxAmerica
COMPREHENSIVE FORMULARY - RxAmerica
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www.Meds4Medicare.com<br />
<strong>COMPREHENSIVE</strong> <strong>FORMULARY</strong><br />
2007<br />
ADVANTAGE FREEDOM<br />
11/2006<br />
S5644_CFF252
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE<br />
COVER IN THIS PLAN<br />
Note to existing members: This formulary has changed since last year. Please<br />
review this document to make sure that it still contains the drugs you take.<br />
What is the <strong>RxAmerica</strong> Formulary?<br />
A formulary is a list of covered drugs selected by <strong>RxAmerica</strong> in consultation with a<br />
team of health care providers, which represents the prescription therapies believed<br />
to be a necessary part of a quality treatment program. <strong>RxAmerica</strong> will generally cover<br />
the drugs listed in our formulary as long as the drug is medically necessary, the<br />
prescription is filled at an <strong>RxAmerica</strong> network pharmacy, and other plan rules are<br />
followed. For more information on how to fill your prescriptions, please review your<br />
Evidence of Coverage.<br />
Can the Formulary change?<br />
Generally, if you are taking a drug on our 2007 formulary that was covered at the<br />
beginning of the year, we will not discontinue or reduce coverage of the drug during<br />
the 2007 coverage year except when a new, less expensive generic drug becomes<br />
available or when new adverse information about the safety or effectiveness of a<br />
drug is released. Other types of formulary changes, such as removing a drug from our<br />
formulary, will not affect members who are currently taking the drug. It will remain<br />
available at the same cost-sharing for those members taking it for the remainder of<br />
the coverage year. We feel it is important that you have continued access for the<br />
remainder of the coverage year to the formulary drugs that were available when you<br />
chose our plan, except for cases in which you can save additional money or improve<br />
the safety of your drugs.<br />
S5644_CFF252<br />
11/2006<br />
Last Updated 7/15/07<br />
1
If we remove drugs from our formulary, or add prior authorization, quantity limits<br />
and/or step therapy restrictions on a drug or move a drug to a higher costsharing<br />
tier, we must notify affected members of the change at least 60 days<br />
before the change becomes effective, or at the time the member requests a<br />
refill of the drug, at which time the member will receive a 60-day supply of the<br />
drug. If the Food and Drug Administration deems a drug on our formulary to be<br />
unsafe or the drug’s manufacturer removes the drug from the market, we will<br />
immediately remove the drug from our formulary and provide notice to members<br />
who take the drug. The enclosed formulary is current as of July 15, 2007.<br />
To get updated information about the drugs covered by <strong>RxAmerica</strong>, please visit<br />
our Web site at www.Meds4Medicare.com or call Customer Service at 1-800-<br />
429-6686, 8 a.m. to 8 p.m. (local time), seven days a week. TTY/TDD users<br />
should call 1-877-279-0371.<br />
How do I use the Formulary?<br />
There are two ways to find your drug within the formulary:<br />
Medical Condition<br />
The formulary begins on page 8. The drugs in this formulary are grouped into<br />
categories depending on the type of medical conditions that they are used to<br />
treat. For example, drugs used to treat a heart condition are listed under the<br />
category, ”Cardiovascular Drugs”. If you know what your drug is used for, look for<br />
the category name in the list that begins on page number 7. Then look under the<br />
category name for your drug.<br />
Alphabetical Listing<br />
If you are not sure what category to look under, you should look for your drug in<br />
the Index that begins on page 121. The Index provides an alphabetical list of all<br />
of the drugs included in this document. Both brand-name drugs and generic<br />
drugs are listed in the Index. Look in the Index and find your drug. Next to your<br />
drug, you will see the page number where you can find coverage information. Turn<br />
to the page listed in the Index and find the name of your drug in the first column<br />
of the list.<br />
What are generic drugs?<br />
<strong>RxAmerica</strong> covers both brand-name drugs and generic drugs. A generic drug has<br />
the same active-ingredient as the brand name drug. Generic drugs usually cost<br />
less than brand name drugs and are approved by the Food and Drug<br />
Administration (FDA).<br />
How much will I pay for <strong>RxAmerica</strong> Covered Drugs?<br />
If you qualified for extra help with your drug costs, your costs for your drugs may be<br />
different than those described below. Please refer to your Evidence of Coverage or<br />
call Customer Service to find out what your costs are.<br />
2
After you meet your yearly deductible of $265, <strong>RxAmerica</strong> will pay part of the costs<br />
for your covered drugs and you will pay part.<br />
The amount you pay depends on which drug tier your drug is in under our plan. (You<br />
can find out which drug tier your drug is in by looking in the formulary that begins on<br />
page 8.)<br />
Advantage Freedom Plan<br />
<strong>RxAmerica</strong> offers two over-the-counter (OTC) drugs, Prilosec OTC and Loratadine, at a<br />
$0 co-pay as part of our Step Therapy (STC) program.<br />
Drug Tier<br />
In-Network Retail<br />
Pharmacy Co-payment<br />
Preferred Mail Order<br />
Co-payment<br />
30-day 90-day 30-day 90-day<br />
Tier 1 – Formulary Generics $5 co-pay $10 co-pay $5 co-pay $10 co-pay<br />
Tier 2 – Formulary Preferred<br />
Brands<br />
$20 co-pay $50 co-pay $20 co-pay $50 co-pay<br />
Tier 3 - Specialty 25% co- pay 25% co- pay 25% co- pay 25% co- pay<br />
Tier 4 – Non-Preferred Brands $40 co-pay $100 co-pay $40 co-pay $100 co-pay<br />
You will pay the co-payment amount above for your drugs until your total drug<br />
costs (the amount you paid, including the deductible, plus the amount <strong>RxAmerica</strong> has<br />
paid) reach $2,400. Once your total drug costs reach $2,400, there is a gap in<br />
your coverage. This means you have to pay the full amount for your drugs. You pay<br />
the full amount until you have paid $3,850 out of pocket. After you have paid<br />
$3,850 out of pocket, you will generally pay a 5% co-payment.<br />
You can ask <strong>RxAmerica</strong> to make an exception to your drug’s tier placement. See the<br />
section, “How do I request an exception to the <strong>RxAmerica</strong> Formulary?,” for<br />
information about how to request an exception.<br />
Are there any restrictions on my coverage?<br />
Some covered drugs may have additional requirements or limits on coverage. These<br />
requirements and limits may include:<br />
<br />
<br />
<br />
Prior Authorization: <strong>RxAmerica</strong> requires you (or your physician) to get prior<br />
authorization for certain drugs. This means that you will need to get approval<br />
from <strong>RxAmerica</strong> before you fill your prescriptions. If you don’t get approval,<br />
<strong>RxAmerica</strong> may not cover the drug.<br />
Quantity Limits: For certain drugs, <strong>RxAmerica</strong> limits the amount of the drug<br />
that <strong>RxAmerica</strong> will cover. For example, <strong>RxAmerica</strong> provides 9 tablets every 14<br />
days per prescription for Imitrix. This may be in addition to a standard one<br />
month or three month supply.<br />
Step Therapy: In some cases, <strong>RxAmerica</strong> requires you to first try certain drugs<br />
to treat your medical condition before we will cover another drug for that<br />
3
condition. For example, if Drug A and Drug B both treat your medical<br />
condition, <strong>RxAmerica</strong> may not cover drug B unless you try Drug A first. If Drug<br />
A does not work for you, <strong>RxAmerica</strong> will then cover Drug B.<br />
You can find out if your drug has any additional requirements or limits by looking in<br />
the formulary that begins on page 8.<br />
You can ask <strong>RxAmerica</strong> to make an exception to these restrictions or limits. See the<br />
section, “How do I request an exception to the <strong>RxAmerica</strong> formulary?” below for<br />
information about how to request an exception.<br />
What if my drug is not on the Formulary?<br />
If your drug is not included in this formulary, you should first contact Customer<br />
Service and ask if your drug is covered. If you learn that <strong>RxAmerica</strong> does not cover<br />
your drug, you have two options:<br />
<br />
<br />
You can ask Customer Service for a list of similar drugs that are covered by<br />
<strong>RxAmerica</strong>. When you receive the list, show it to your doctor and ask him or<br />
her to prescribe a similar drug that is covered by <strong>RxAmerica</strong>.<br />
You can ask <strong>RxAmerica</strong> to make an exception and cover your drug. See below<br />
for information about how to request an exception.<br />
NOTE: Due to a change in Medicare, most Medicare Drug Plans will no longer cover<br />
erectile dysfunction (ED) drugs like Viagra, Cilais, Levitra, and Caverject starting<br />
January 1, 2007. Call your Medicare Drug Plan for more information.<br />
How do I request an exception to the <strong>RxAmerica</strong> Formulary?<br />
You can ask <strong>RxAmerica</strong> to make an exception to our coverage rules. There are<br />
several types of exceptions that you can ask us to make.<br />
<br />
<br />
You can ask us to cover your drug even if it is not on our formulary.<br />
You can ask us to waive coverage restrictions or limits on your drug. For<br />
example, for certain drugs, <strong>RxAmerica</strong> limits the amount of the drug that we<br />
will cover. If your drug has a quantity limit, you can ask us to waive the limit<br />
and cover more.<br />
Generally, <strong>RxAmerica</strong> will only approve your request for an exception if the alternative<br />
drugs included on the plan’s formulary, the lower-tiered drug or additional utilization<br />
restrictions would not be as effective in treating your condition and/or would cause<br />
you to have adverse medical effects.<br />
You should contact us to ask us for an initial coverage decision for a formulary,<br />
tiering or utilization restriction exception. When you are requesting a formulary,<br />
4
tiering or utilization restriction exception you should submit a statement from your<br />
physician supporting your request. Generally, we must make our decision within 72<br />
hours of getting your prescribing physician’s supporting statement. You can request<br />
an expedited (fast) exception if you or your doctor believe that your health could be<br />
seriously harmed by waiting up to 72 hours for a decision. If your request to expedite<br />
is granted, we must give you a decision no later than 24 hours after we get your<br />
prescribing physician’s supporting statement.<br />
What do I do before I can talk to my doctor about changing my drugs or<br />
requesting an exception?<br />
As a new or continuing member in our plan you may be taking drugs that are not on<br />
our formulary. Or, you may be taking a drug that is on our formulary but your ability to<br />
get it is limited. For example, you may need a prior authorization from us before you<br />
can fill your prescription. You should talk to your doctor to decide if you should switch<br />
to an appropriate drug that we cover or request a formulary exception so that we will<br />
cover the drug you take. While you talk to your doctor to determine the right course of<br />
action for you, we may cover your drug in certain cases during the first 90 days you<br />
are a member of our plan.<br />
For each of your drugs that is not on our formulary or if your ability to get your drugs<br />
is limited, we will cover a temporary 30-day supply (unless you have a prescription<br />
written for fewer days) when you go to a network pharmacy. After your first 30-day<br />
supply, we will not pay for these drugs, even if you have been a member of the plan<br />
less than 90 days.<br />
If you are a resident of a long-term care facility, we will cover a 31-day transition<br />
supply (unless you have a prescription written for fewer days). We will cover more<br />
than one refill of these drugs for the first 90 days you are a member of our plan. If<br />
you need a drug that is not on our formulary or if your ability to get your drugs is<br />
limited, but you are past the first 90 days of membership in our plan, we will cover a<br />
31-day emergency supply of that drug (unless you have a prescription for fewer days)<br />
while you pursue a formulary exception.<br />
For more information<br />
For more detailed information about your <strong>RxAmerica</strong> prescription drug coverage,<br />
please review your Evidence of Coverage and other plan materials.<br />
If you have questions about <strong>RxAmerica</strong>, please call Customer Service at 1-800-429-<br />
6686, 8 a.m. to 8 p.m. (local time), seven days a week. TTY/TDD users should call 1-<br />
877-279-0371. Or visit www.Meds4Medicare.com.<br />
If you have general questions about Medicare prescription drug coverage, please call<br />
Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week.<br />
TTY/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov.<br />
5
<strong>RxAmerica</strong>’s Formulary<br />
The formulary that begins on the next page provides coverage information about<br />
some of the drugs covered by <strong>RxAmerica</strong>. If you have trouble finding your drug in the<br />
list, turn to the Index that begins on page 121.<br />
The first column of the chart lists the drug name. Brand-name drugs are capitalized<br />
(e.g. AMOXIL) and generic drugs are listed in lower-case italics (e.g., amoxicillin).<br />
The information in the Notes column tells you if <strong>RxAmerica</strong> has any special<br />
requirements for coverage of your drug.<br />
PA - Prior authorization required (see page 3).<br />
QL - Drug has quantity limit (see page 3).<br />
STC - Step therapy required (see page 3).<br />
6
<strong>RxAmerica</strong>’s Formulary<br />
List of Covered Drugs<br />
Drug Category<br />
Page<br />
Antihistamine Drugs….……………………………………………..………………….…………… 8<br />
Anti-Infective Agents….……………………………………………………………….…………..… 8<br />
Antineoplastic Agents….………………………………………….………………….….…………. 24<br />
Autonomic Drugs….…………………………………………………………………….……………. 29<br />
Blood Formation, Coagulation & Thrombosis….….…….…………………....…………. 33<br />
Cardiovascular Drugs….……………..………………...……………………...….………………. 36<br />
Central Nervous System Agents….……………………………………..….………………….. 49<br />
Electrolytic, Caloric and Water Balance…..……………………….…………….………….. 70<br />
Enzymes….…………………………………………………………………..…………….……………. 76<br />
Respiratory Tract Agents…….…………………………………….………...……….…………… 76<br />
Eye, Ear, Nose and Throat Preparations…..………………………...…………...………… 77<br />
Gastrointestinal Drugs…..…………………………………….…..…………….…….………….. 81<br />
Gold Compounds…..…………………………………………………………………….…………… 85<br />
Heavy Metal Antagonists…..……………………………….….…………….…….…………….. 85<br />
Hormones and Synthetic Substitutes…..……………………..……………..……………… 86<br />
Local Anesthetics….….…………………..…………………………..…………….….…………… 97<br />
Oxytocics….….……………………………….…………………………..………………..…………… 97<br />
Serums, Toxoids and Vaccines…..……………………………...……………….……………. 97<br />
Skin and Mucous Membrane Preparations…..……………………...……....………….. 99<br />
Smooth Muscle Relaxants….….……………………………………………...….…………….. 109<br />
Vitamins…..………………………………………………….……………….………….…………….. 110<br />
Miscellaneous Therapeutic Agents……..……………………………...……………………. 111<br />
Devices…..…………………………………………………………....………...…….……………….. 115<br />
Pharmaceutical Aids…..………………………..……….……………………....……….…..….. 115<br />
Index………………………………………………………….………………..…………………………. 125<br />
7
Drug Name Drug Tier Notes<br />
Antihistamine Drugs<br />
ALLEGRA SUS 30MG/5ML(Fexofenadine HCl)<br />
ALLEGRA TAB 180MG(Fexofenadine HCl)<br />
ALLEGRA TAB 30MG(Fexofenadine HCl)<br />
ALLEGRA TAB 60MG(Fexofenadine HCl)<br />
ALLEGRA-D TAB 12 HOUR(Fexofenadine-Pseudoephedrine)<br />
ALLEGRA-D TAB 24 HOUR(Fexofenadine-Pseudoephedrine)<br />
CLARINEX SYP 0.5MG/ML(Desloratadine)<br />
CLARINEX TAB 5MG(Desloratadine)<br />
CLARINEX RDT TAB 2.5MG(Desloratadine)<br />
CLARINEX RDT TAB 5MG(Desloratadine)<br />
CLARINEX-D TAB 2.5-120(Desloratadine-Pseudoephedrine)<br />
CLARINEX-D TAB 5-240MG(Desloratadine-Pseudoephedrine)<br />
CLARITIN CHW 5MG(Loratadine)<br />
CLARITIN TAB 10MG(Loratadine)<br />
CLARITIN RDT TAB 10MG(Loratadine)<br />
CLARITIN-D TAB 5-120MG(Loratadine & Pseudoephedrine)<br />
DEXODRYL CHW 2-1.5MG(Chlorpheniramine Tannate-Methscopolamine)<br />
DEXODRYL SUS(Chlorpheniramine Tannate-Methscopolamine)<br />
fexofenadine hcl tab 180 mg<br />
fexofenadine hcl tab 30 mg<br />
fexofenadine hcl tab 60 mg<br />
loratadine & pseudoephedrine tab sr 12hr 5-120 mg<br />
loratadine & pseudoephedrine tab sr 24hr 10-240 mg<br />
loratadine rapidly-disintegrating tab 10 mg<br />
loratadine syrup 10 mg/10ml<br />
loratadine tab 10 mg<br />
PEDIOX-S SUS 4MG/5ML(Chlorpheniramine Maleate Tannate)<br />
PHENERGAN INJ 25MG/ML(Promethazine HCl)<br />
PHENERGAN INJ 50MG/ML(Promethazine HCl)<br />
POLY TAN SUS(Dexbrompheniramine Tannate-Pyrilamine Maleate)<br />
promethazine hcl inj 25 mg/ml<br />
promethazine hcl inj 50 mg/ml<br />
promethazine hcl suppos 12.5 mg<br />
promethazine hcl suppos 25 mg<br />
promethazine hcl suppos 50 mg<br />
promethazine hcl syrup 6.25 mg/5ml<br />
promethazine hcl tab 12.5 mg<br />
promethazine hcl tab 25 mg<br />
promethazine hcl tab 50 mg<br />
PYRLEX SUS 12MG/5ML(Pyrilamine Tannate)<br />
SEMPREX-D CAP 8-60MG(Acrivastine & Pseudoephedrine)<br />
ZYMINE XR SUS 2.5MG(Triprolidine Tannate)<br />
ZYRTEC CHW 10MG(Cetirizine HCl)<br />
ZYRTEC CHW 5MG(Cetirizine HCl)<br />
ZYRTEC SYP 1MG/ML(Cetirizine HCl)<br />
ZYRTEC TAB 10MG(Cetirizine HCl)<br />
ZYRTEC TAB 5MG(Cetirizine HCl)<br />
ZYRTEC-D TAB 5-120MG(Cetirizine-Pseudoephedrine)<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
00<br />
00<br />
00<br />
00<br />
04<br />
04<br />
01<br />
01<br />
01<br />
00<br />
00<br />
00<br />
00<br />
00<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
02<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(PA)<br />
(PA)<br />
(STC)<br />
(STC)<br />
(STC)<br />
8
Drug Name Drug Tier Notes<br />
Anti-infective Agents<br />
ABELCET INJ 5MG/ML(Amphotericin B Lipid)<br />
acyclovir cap 200 mg<br />
acyclovir sodium for inj 1000 mg<br />
acyclovir sodium for inj 500 mg<br />
acyclovir sodium iv soln 50 mg/ml<br />
acyclovir susp 200 mg/5ml<br />
acyclovir tab 400 mg<br />
acyclovir tab 800 mg<br />
ADOXA TAB 75MG(Doxycycline (Monohydrate))<br />
ADOXA PAK TAB 1/150MG(Doxycycline (Monohydrate))<br />
AGENERASE CAP 50MG(Amprenavir)<br />
AGENERASE SOL 15MG/ML(Amprenavir)<br />
ALBENZA TAB 200MG(Albendazole)<br />
ALINIA SUS 100MG/5M(Nitazoxanide)<br />
ALINIA TAB 500MG(Nitazoxanide)<br />
ALODOX KIT 20MG(Doxycycline Hyclate w/ Eyelid Cleansers)<br />
AMANTADINE TAB 100MG(Amantadine HCl)<br />
amantadine hcl cap 100 mg<br />
amantadine hcl syrup 50 mg/5ml<br />
amantadine hcl tab 100 mg<br />
AMBISOME INJ 50MG(Amphotericin B Liposome)<br />
amikacin sulfate inj 250 mg/ml<br />
amikacin sulfate inj 50 mg/ml<br />
AMIKIN INJ 100/2ML(Amikacin Sulfate)<br />
AMIKIN INJ 1GM/4ML(Amikacin Sulfate)<br />
amoxicillin & k clavulanate chew tab 200-28.5 mg<br />
amoxicillin & k clavulanate chew tab 400-57 mg<br />
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml<br />
amoxicillin & k clavulanate for susp 400-57 mg/5ml<br />
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml<br />
amoxicillin & k clavulanate tab 250-125 mg<br />
amoxicillin & k clavulanate tab 500-125 mg<br />
amoxicillin & k clavulanate tab 875-125 mg<br />
amoxicillin (trihydrate) cap 250 mg<br />
amoxicillin (trihydrate) cap 500 mg<br />
amoxicillin (trihydrate) chew tab 125 mg<br />
amoxicillin (trihydrate) chew tab 200 mg<br />
amoxicillin (trihydrate) chew tab 250 mg<br />
amoxicillin (trihydrate) chew tab 400 mg<br />
amoxicillin (trihydrate) for susp 125 mg/5ml<br />
amoxicillin (trihydrate) for susp 200 mg/5ml<br />
amoxicillin (trihydrate) for susp 250 mg/5ml<br />
amoxicillin (trihydrate) for susp 400 mg/5ml<br />
amoxicillin (trihydrate) for susp 50 mg/ml<br />
amoxicillin (trihydrate) tab 500 mg<br />
amoxicillin (trihydrate) tab 875 mg<br />
AMOXIL CHW 200MG(Amoxicillin)<br />
AMOXIL CHW 400MG(Amoxicillin)<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
01<br />
01<br />
01<br />
02<br />
01<br />
01<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
9
Drug Name Drug Tier Notes<br />
AMOXIL SUS 400/5ML(Amoxicillin)<br />
AMOXIL TAB 500MG(Amoxicillin)<br />
AMOXIL TAB 875MG(Amoxicillin)<br />
AMPHOTEC INJ 100MG(Amphotericin B Cholesteryl Sulfate Complex)<br />
AMPHOTEC INJ 50MG(Amphotericin B Cholesteryl Sulfate Complex)<br />
amphotericin b for inj 50 mg<br />
ampicillin & sulbactam sodium for inj 1-0.5 gm<br />
ampicillin & sulbactam sodium for inj 10-5 gm<br />
ampicillin & sulbactam sodium for inj 2-1 gm<br />
ampicillin cap 250 mg<br />
ampicillin cap 500 mg<br />
ampicillin for susp 125 mg/5ml<br />
ampicillin for susp 250 mg/5ml<br />
ampicillin sodium for inj 1 gm<br />
ampicillin sodium for inj 10 gm<br />
ampicillin sodium for inj 125 mg<br />
ampicillin sodium for inj 2 gm<br />
ampicillin sodium for inj 250 mg<br />
ampicillin sodium for inj 500 mg<br />
ampicillin sodium for iv soln 1 gm<br />
ampicillin sodium for iv soln 2 gm<br />
ANCOBON CAP 250MG(Flucytosine)<br />
ANCOBON CAP 500MG(Flucytosine)<br />
APTIVUS CAP 250MG(Tipranavir)<br />
ARALEN TAB 500MG(Chloroquine Phosphate)<br />
ATRIPLA TAB(Efavirenz-Emtricitabine-Tenofovir Disoproxil Fumarate)<br />
AUGMENTIN CHW 250MG(Amoxicillin & Pot Clavulanate)<br />
AUGMENTIN SUS 125/5ML(Amoxicillin & Pot Clavulanate)<br />
AUGMENTIN SUS 200/5ML(Amoxicillin & Pot Clavulanate)<br />
AUGMENTIN SUS 250/5ML(Amoxicillin & Pot Clavulanate)<br />
AUGMENTIN SUS 400/5ML(Amoxicillin & Pot Clavulanate)<br />
AUGMENTIN SUS ES-600(Amoxicillin & Pot Clavulanate)<br />
AUGMENTIN TAB 250MG(Amoxicillin & Pot Clavulanate)<br />
AUGMENTIN TAB 500MG(Amoxicillin & Pot Clavulanate)<br />
AUGMENTIN TAB 875MG(Amoxicillin & Pot Clavulanate)<br />
AUGMENTIN XR TAB SR 12HR(Amoxicillin & Pot Clavulanate)<br />
AVELOX INJ(Moxifloxacin HCl in Sodium Chloride)<br />
AVELOX TAB 400MG(Moxifloxacin HCl)<br />
AVELOX ABC TAB 400MG(Moxifloxacin HCl)<br />
AZACTAM INJ 1GM(Aztreonam)<br />
AZACTAM INJ 2GM(Aztreonam)<br />
AZACTAM/DEX INJ 1GM(Aztreonam in Dextrose)<br />
AZACTAM/DEX INJ 2GM(Aztreonam in Dextrose)<br />
azithromycin for susp 100 mg/5ml<br />
azithromycin for susp 200 mg/5ml<br />
AZITHROMYCIN INJ 2.5GM(Azithromycin Hydrogencitrate)<br />
AZITHROMYCIN INJ 500MG(Azithromycin Hydrogencitrate)<br />
azithromycin iv for soln 500 mg<br />
azithromycin powd pack for susp 1 gm<br />
azithromycin tab 250 mg<br />
04<br />
04<br />
04<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
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01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
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02<br />
02<br />
02<br />
04<br />
02<br />
04<br />
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04<br />
04<br />
04<br />
02<br />
04<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
04<br />
04<br />
01<br />
01<br />
01<br />
(PA)<br />
(PA)<br />
(PA)<br />
(QL)<br />
10
Drug Name Drug Tier Notes<br />
azithromycin tab 500 mg<br />
azithromycin tab 600 mg<br />
AZULFIDINE TAB 500MG(Sulfasalazine)<br />
AZULFIDINE TAB 500MG EN(Sulfasalazine)<br />
BACITRACIN INJ 50000UNT(Bacitracin)<br />
bacitracin intramuscular for soln 50000 unit<br />
BACTOCILL INJ DEX 1GM(Oxacillin Sodium in Dextrose)<br />
BACTOCILL INJ DEX 2GM(Oxacillin Sodium in Dextrose)<br />
BACTRIM TAB 400-80MG(Sulfamethoxazole-Trimethoprim)<br />
BACTRIM DS TAB 800-160(Sulfamethoxazole-Trimethoprim)<br />
BARACLUDE SOL .05MG/ML(Entecavir)<br />
BARACLUDE TAB 0.5MG(Entecavir)<br />
BARACLUDE TAB 1MG(Entecavir)<br />
BIAXIN SUS 125/5ML(Clarithromycin)<br />
BIAXIN SUS 250/5ML(Clarithromycin)<br />
BIAXIN TAB 250MG(Clarithromycin)<br />
BIAXIN TAB 500MG(Clarithromycin)<br />
BIAXIN XL TAB 500MG(Clarithromycin)<br />
BIAXIN XL TAB PAC 500(Clarithromycin)<br />
BICILLIN C-R INJ 1200000(Penicillin G Procaine & Benzathine)<br />
BICILLIN C-R INJ 2400000(Penicillin G Procaine & Benzathine)<br />
BICILLIN C-R INJ 600000(Penicillin G Procaine & Benzathine)<br />
BICILLIN C-R INJ 900/300(Penicillin G Procaine & Benzathine)<br />
BICILLIN L-A INJ 1200000(Penicillin G Benzathine)<br />
BICILLIN L-A INJ 2400000(Penicillin G Benzathine)<br />
BICILLIN L-A INJ 600000(Penicillin G Benzathine)<br />
BILTRICIDE TAB 600MG(Praziquantel)<br />
BIO-STATIN CAP 1000000(Nystatin)<br />
BIO-STATIN CAP 500000(Nystatin)<br />
CANCIDAS INJ 50MG(Caspofungin Acetate)<br />
CANCIDAS INJ 70MG(Caspofungin Acetate)<br />
CAPASTAT SUL INJ 1GM(Capreomycin Sulfate)<br />
CEDAX CAP 400MG(Ceftibuten)<br />
CEDAX SUS 90MG/5ML(Ceftibuten)<br />
cefaclor cap 250 mg<br />
cefaclor cap 500 mg<br />
cefaclor for susp 125 mg/5ml<br />
cefaclor for susp 250 mg/5ml<br />
cefaclor for susp 375 mg/5ml<br />
cefaclor monohydrate tab sr 12hr 500 mg<br />
cefadroxil cap 500 mg<br />
cefadroxil for susp 250 mg/5ml<br />
cefadroxil for susp 500 mg/5ml<br />
cefadroxil tab 1 gm<br />
cefazolin in d5w inj 1 gm/50ml<br />
cefazolin in d5w inj 500 mg/50ml<br />
cefazolin sodium for inj 1 gm<br />
cefazolin sodium for inj 10 gm<br />
cefazolin sodium for inj 20 gm<br />
cefazolin sodium for inj 500 mg<br />
01<br />
01<br />
04<br />
04<br />
04<br />
01<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
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04<br />
04<br />
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02<br />
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04<br />
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02<br />
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01<br />
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01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
11
Drug Name Drug Tier Notes<br />
cefazolin sodium for iv soln 1 gm<br />
cefazolin sodium for iv soln 1 gm and dextrose 4%<br />
cefdinir cap 300 mg<br />
cefdinir for susp 125 mg/5ml<br />
cefdinir for susp 250 mg/5ml<br />
cefepime hcl for inj 1 gm<br />
cefepime hcl for inj 2 gm<br />
CEFIZOX/D5W INJ 1GM(Ceftizoxime in D5W)<br />
CEFIZOX/D5W INJ 2GM(Ceftizoxime in D5W)<br />
cefotaxime sodium for inj 1 gm<br />
cefotaxime sodium for inj 10 gm<br />
cefotaxime sodium for inj 2 gm<br />
cefotaxime sodium for inj 20 gm<br />
cefotaxime sodium for inj 500 mg<br />
cefoxitin sodium for inj 1 gm<br />
cefoxitin sodium for inj 10 gm<br />
cefoxitin sodium for inj 2 gm<br />
cefpodoxime proxetil for susp 100 mg/5ml<br />
cefpodoxime proxetil for susp 50 mg/5ml<br />
cefpodoxime proxetil tab 100 mg<br />
cefpodoxime proxetil tab 200 mg<br />
cefprozil for susp 125 mg/5ml<br />
cefprozil for susp 250 mg/5ml<br />
cefprozil tab 250 mg<br />
cefprozil tab 500 mg<br />
ceftazidime for inj 1 gm<br />
ceftazidime for inj 2 gm<br />
ceftazidime for inj 500 mg<br />
ceftazidime for inj 6 gm<br />
ceftazidime for iv soln 1 gm<br />
ceftazidime for iv soln 2 gm<br />
CEFTIN SUS 125/5ML(Cefuroxime Axetil)<br />
CEFTIN SUS 250/5ML(Cefuroxime Axetil)<br />
CEFTIN TAB 250MG(Cefuroxime Axetil)<br />
CEFTIN TAB 500MG(Cefuroxime Axetil)<br />
CEFTRIAXONE INJ 100GM(Ceftriaxone Sodium)<br />
ceftriaxone sodium for inj 1 gm<br />
ceftriaxone sodium for inj 10 gm<br />
ceftriaxone sodium for inj 2 gm<br />
ceftriaxone sodium for inj 250 mg<br />
ceftriaxone sodium for inj 500 mg<br />
ceftriaxone sodium for iv soln 1 gm and dextrose 3.74%<br />
ceftriaxone sodium for iv soln 2 gm and dextrose 2.22%<br />
ceftriaxone sodium in dextrose inj 20 mg/ml<br />
ceftriaxone sodium in dextrose inj 40 mg/ml<br />
cefuroxime axetil tab 250 mg<br />
cefuroxime axetil tab 500 mg<br />
cefuroxime sodium 1.5 gm and dextrose 2.9% for iv soln<br />
cefuroxime sodium 750 mg and dextrose 4.1% for iv soln<br />
cefuroxime sodium for inj 1.5 gm<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
01<br />
01<br />
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01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
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01<br />
01<br />
01<br />
01<br />
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01<br />
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02<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
(PA)<br />
(PA)<br />
12
Drug Name Drug Tier Notes<br />
cefuroxime sodium for inj 7.5 gm<br />
cefuroxime sodium for inj 750 mg<br />
CEFZIL SUS 125/5ML(Cefprozil)<br />
CEFZIL SUS 250/5ML(Cefprozil)<br />
CEFZIL TAB 250MG FC(Cefprozil)<br />
CEFZIL TAB 500MG FC(Cefprozil)<br />
CEPHALEXIN TAB 500MG(Cephalexin)<br />
cephalexin cap 250 mg<br />
cephalexin cap 500 mg<br />
cephalexin for susp 125 mg/5ml<br />
cephalexin for susp 250 mg/5ml<br />
cephalexin tab 250 mg<br />
cephalexin tab 500 mg<br />
chloramphenicol sodium succinate for iv inj 1 gm<br />
chloroquine phosphate tab 250 mg<br />
chloroquine phosphate tab 500 mg<br />
CIPRO TAB 250MG(Ciprofloxacin HCl)<br />
CIPRO TAB 500MG(Ciprofloxacin HCl)<br />
CIPRO TAB 750MG(Ciprofloxacin HCl)<br />
CIPRO (5%) SUS 250MG/5(Ciprofloxacin)<br />
CIPRO I.V. INJ 200MG(Ciprofloxacin)<br />
CIPRO I.V. INJ 400MG(Ciprofloxacin)<br />
CIPRO I.V. SOL 200MG(Ciprofloxacin in D5W)<br />
CIPRO I.V. SOL 400MG(Ciprofloxacin in D5W)<br />
CIPRO XR TAB 1000MG(Ciprofloxacin-Ciprofloxacin HCl)<br />
CIPRO XR TAB 500MG(Ciprofloxacin-Ciprofloxacin HCl)<br />
ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml)<br />
ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml)<br />
ciprofloxacin hcl tab 100 mg (base equiv)<br />
ciprofloxacin hcl tab 250 mg (base equiv)<br />
ciprofloxacin hcl tab 500 mg (base equiv)<br />
ciprofloxacin hcl tab 750 mg (base equiv)<br />
ciprofloxacin iv soln 1%<br />
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq)<br />
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq)<br />
CLAFORAN INJ 10GM(Cefotaxime Sodium)<br />
CLAFORAN INJ 1GM(Cefotaxime Sodium)<br />
CLAFORAN INJ 1GM(Cefotaxime Sodium)<br />
CLAFORAN INJ 2GM(Cefotaxime Sodium)<br />
CLAFORAN INJ 2GM(Cefotaxime Sodium)<br />
CLAFORAN INJ 500MG(Cefotaxime Sodium)<br />
CLAFORAN/D5W INJ 1GM(Cefotaxime Sodium in D5W)<br />
CLAFORAN/D5W INJ 2GM(Cefotaxime Sodium in D5W)<br />
CLARITHROMYC SUS 250/5ML(Clarithromycin)<br />
clarithromycin for susp 125 mg/5ml<br />
clarithromycin for susp 250 mg/5ml<br />
clarithromycin tab 250 mg<br />
clarithromycin tab 500 mg<br />
clarithromycin tab sr 24hr 500 mg<br />
CLEERAVUE-M KIT 50MG(Minocycline HCl w/ Eyelid Cleanser)<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
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04<br />
04<br />
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04<br />
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04<br />
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01<br />
01<br />
01<br />
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01<br />
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01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
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04<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
13
Drug Name Drug Tier Notes<br />
CLEOCIN CAP 150MG(Clindamycin HCl)<br />
CLEOCIN CAP 300MG(Clindamycin HCl)<br />
CLEOCIN CAP 75MG(Clindamycin HCl)<br />
CLEOCIN INJ 300MG(Clindamycin Phosphate in D5W)<br />
CLEOCIN INJ 600MG(Clindamycin Phosphate in D5W)<br />
CLEOCIN INJ 900MG(Clindamycin Phosphate in D5W)<br />
CLEOCIN PED SOL 75MG/5ML(Clindamycin Palmitate Hydrochloride)<br />
CLEOCIN PHOS INJ 150MG/ML(Clindamycin Phosphate)<br />
CLEOCIN PHOS INJ 300MG(Clindamycin Phosphate)<br />
CLEOCIN PHOS INJ 600MG(Clindamycin Phosphate)<br />
CLEOCIN PHOS INJ 900MG(Clindamycin Phosphate)<br />
CLEOCIN PHOS INJ 9GM(Clindamycin Phosphate)<br />
clindamycin hcl cap 150 mg<br />
clindamycin hcl cap 300 mg<br />
clindamycin phosphate inj 150 mg/ml<br />
clindamycin phosphate iv soln 150 mg/ml<br />
colistimethate sodium for inj 150 mg<br />
COLY-MYCIN-M INJ 150MG(Colistimethate Sodium)<br />
COMBIVIR TAB(Lamivudine-Zidovudine)<br />
COPEGUS TAB 200MG(Ribavirin (Hepatitis C))<br />
CRIXIVAN CAP 100MG(Indinavir Sulfate)<br />
CRIXIVAN CAP 200MG(Indinavir Sulfate)<br />
CRIXIVAN CAP 333MG(Indinavir Sulfate)<br />
CRIXIVAN CAP 400MG(Indinavir Sulfate)<br />
CUBICIN SOL 500MG(Daptomycin)<br />
CYTOVENE INJ 500MG(Ganciclovir Sodium)<br />
dapsone tab 100 mg<br />
dapsone tab 25 mg<br />
DARAPRIM TAB 25MG(Pyrimethamine)<br />
DECLOMYCIN TAB 150MG(Demeclocycline HCl)<br />
DECLOMYCIN TAB 300MG(Demeclocycline HCl)<br />
demeclocycline hcl tab 150 mg<br />
demeclocycline hcl tab 300 mg<br />
dicloxacillin sodium cap 250 mg<br />
dicloxacillin sodium cap 500 mg<br />
didanosine delayed release capsule 200 mg<br />
didanosine delayed release capsule 250 mg<br />
didanosine delayed release capsule 400 mg<br />
DIFLUCAN SUS 10MG/ML(Fluconazole)<br />
DIFLUCAN SUS 40MG/ML(Fluconazole)<br />
DIFLUCAN TAB 100MG(Fluconazole)<br />
DIFLUCAN TAB 150MG(Fluconazole)<br />
DIFLUCAN TAB 200MG(Fluconazole)<br />
DIFLUCAN TAB 50MG(Fluconazole)<br />
DIFLUCAN/ INJ NACL 200(Fluconazole in NaCl)<br />
DIFLUCAN/ INJ NACL 400(Fluconazole in NaCl)<br />
DIFLUCAN/DEX INJ 2MG/ML(Fluconazole in Dextrose)<br />
DORYX TAB 100MG(Doxycycline Hyclate)<br />
DORYX TAB 75MG(Doxycycline Hyclate)<br />
DOXYCYCL HYC CAP 100MG(Doxycycline Hyclate)<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
01<br />
01<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
(PA)<br />
14
Drug Name Drug Tier Notes<br />
DOXYCYCL HYC CAP 75MG(Doxycycline Hyclate)<br />
doxycycline hyclate cap 100 mg<br />
doxycycline hyclate cap 50 mg<br />
doxycycline hyclate for inj 100 mg<br />
doxycycline hyclate tab 100 mg<br />
doxycycline hyclate tab 20 mg<br />
doxycycline monohydrate cap 100 mg<br />
doxycycline monohydrate cap 50 mg<br />
doxycycline monohydrate tab 100 mg<br />
doxycycline monohydrate tab 150 mg<br />
doxycycline monohydrate tab 50 mg<br />
doxycycline monohydrate tab 75 mg<br />
DURICEF SUS 250/5ML(Cefadroxil)<br />
DURICEF SUS 500/5ML(Cefadroxil)<br />
DYNABAC TAB 250MG EC(Dirithromycin)<br />
DYNACIN CAP 75MG(Minocycline HCl)<br />
DYNACIN TAB 100MG(Minocycline HCl)<br />
DYNACIN TAB 50MG(Minocycline HCl)<br />
DYNACIN TAB 75MG(Minocycline HCl)<br />
E.E.S. GRAN SUS 200/5ML(Erythromycin Ethylsuccinate)<br />
EMTRIVA CAP 200MG(Emtricitabine)<br />
EMTRIVA SOL 10MG/ML(Emtricitabine)<br />
EPIVIR SOL 10MG/ML(Lamivudine)<br />
EPIVIR TAB 150MG(Lamivudine)<br />
EPIVIR TAB 300MG(Lamivudine)<br />
EPIVIR HBV SOL 5MG/ML(Lamivudine)<br />
EPIVIR HBV TAB 100MG(Lamivudine)<br />
EPZICOM TAB(Abacavir Sulfate-Lamivudine)<br />
ERAXIS INJ 50MG(Anidulafungin)<br />
ERY-TAB TAB 500MG EC(Erythromycin Base)<br />
ERYPED 200 SUS 200/5ML(Erythromycin Ethylsuccinate)<br />
ERYTHROCIN INJ 1000MG(Erythromycin Lactobionate)<br />
ERYTHROCIN INJ 500MG(Erythromycin Lactobionate)<br />
ERYTHROMYCIN CAP 250MG EC(Erythromycin Base)<br />
erythromycin ethylsuccinate for susp 100 mg/2.5ml<br />
erythromycin ethylsuccinate for susp 400 mg/5ml<br />
erythromycin ethylsuccinate susp 200 mg/5ml<br />
erythromycin ethylsuccinate susp 400 mg/5ml<br />
erythromycin ethylsuccinate tab 400 mg<br />
erythromycin lactobionate for inj 500 mg<br />
erythromycin stearate tab 250 mg<br />
erythromycin stearate tab 500 mg<br />
erythromycin tab 250 mg<br />
ERYTHROMYCIN TAB 250MG(Erythromycin Base)<br />
erythromycin tab 500 mg<br />
erythromycin tab delayed release 250 mg<br />
erythromycin tab delayed release 333 mg<br />
erythromycin tab delayed release 500 mg<br />
erythromycin w/ delayed release particles cap 250 mg<br />
erythromycin-sulfisoxazole for susp 200-600 mg/5ml<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
(PA)<br />
15
Drug Name Drug Tier Notes<br />
ethambutol hcl tab 100 mg<br />
ethambutol hcl tab 400 mg<br />
FACTIVE TAB 320MG(Gemifloxacin Mesylate)<br />
FAMVIR TAB 125MG(Famciclovir)<br />
FAMVIR TAB 250MG(Famciclovir)<br />
FAMVIR TAB 500MG(Famciclovir)<br />
FANSIDAR TAB 500/25(Sulfadoxine & Pyrimethamine)<br />
FLAGYL CAP 375MG(Metronidazole)<br />
FLAGYL TAB 250MG(Metronidazole)<br />
FLAGYL TAB 500MG(Metronidazole)<br />
FLAGYL ER TAB 750MG(Metronidazole)<br />
fluconazole for susp 10 mg/ml<br />
fluconazole for susp 40 mg/ml<br />
fluconazole in dextrose inj 200 mg/100ml<br />
fluconazole in dextrose inj 400 mg/200ml<br />
fluconazole in nacl 0.9% inj 200 mg/100ml<br />
fluconazole in nacl 0.9% inj 400 mg/200ml<br />
fluconazole tab 100 mg<br />
fluconazole tab 150 mg<br />
fluconazole tab 200 mg<br />
fluconazole tab 50 mg<br />
FLUMADINE SYP 50MG/5ML(Rimantadine Hydrochloride)<br />
FLUMADINE TAB 100MG(Rimantadine Hydrochloride)<br />
FORTAZ INJ 1GM(Ceftazidime)<br />
FORTAZ INJ 1GM(Ceftazidime Sodium in D5W)<br />
FORTAZ INJ 2GM(Ceftazidime)<br />
FORTAZ INJ 2GM(Ceftazidime Sodium in D5W)<br />
FORTAZ INJ 6GM(Ceftazidime)<br />
foscarnet sodium inj 24 mg/ml<br />
FOSCAVIR INJ 24MG/ML(Foscarnet Sodium)<br />
FUNGIZONE INJ 50MG(Amphotericin B)<br />
FURADANTIN SUS 25MG/5ML(Nitrofurantoin)<br />
FUZEON KIT(Enfuvirtide)<br />
ganciclovir cap 250 mg<br />
ganciclovir cap 500 mg<br />
GANTRIS PED SUS 500/5ML(Sulfisoxazole Acetyl)<br />
gentamicin in saline inj 0.6 mg/ml<br />
gentamicin in saline inj 0.8 mg/ml<br />
gentamicin in saline inj 0.9 mg/ml<br />
gentamicin in saline inj 1 mg/ml<br />
gentamicin in saline inj 1.2 mg/ml<br />
gentamicin in saline inj 1.4 mg/ml<br />
gentamicin in saline inj 1.6 mg/ml<br />
gentamicin in saline inj 2 mg/ml<br />
gentamicin sulfate inj 10 mg/ml<br />
gentamicin sulfate inj 40 mg/ml<br />
gentamicin sulfate iv soln 10 mg/ml<br />
GEOCILLIN TAB 382MG(Carbenicillin Indanyl Sodium)<br />
GRIFULVIN V SUS 125/5ML(Griseofulvin Microsize)<br />
GRIFULVIN V TAB 500MG(Griseofulvin Microsize)<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
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04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
04<br />
02<br />
04<br />
03<br />
01<br />
01<br />
04<br />
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01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
04<br />
02<br />
(PA)<br />
(PA)<br />
16
Drug Name Drug Tier Notes<br />
GRIS-PEG TAB 125MG(Griseofulvin Ultramicrosize)<br />
GRIS-PEG TAB 250MG(Griseofulvin Ultramicrosize)<br />
griseofulvin microsize susp 125 mg/5ml<br />
HELIDAC MIS(Metronidazole-Tetracycline w/ Bismuth Subsalicylate)<br />
HEPSERA TAB 10MG(Adefovir Dipivoxil)<br />
HIPREX TAB 1GM(Methenamine Hippurate)<br />
HUMATIN CAP 250MG(Paromomycin Sulfate)<br />
hydroxychloroquine sulfate tab 200 mg<br />
INFERGEN INJ 15MCG(Interferon alfacon-1)<br />
INFERGEN INJ 9MCG(Interferon alfacon-1)<br />
INVANZ INJ 1GM(Ertapenem Sodium)<br />
INVIRASE CAP 200MG(Saquinavir Mesylate)<br />
INVIRASE TAB 500MG(Saquinavir Mesylate)<br />
isoniazid & rifampin cap 150-300 mg<br />
isoniazid inj 100 mg/ml<br />
isoniazid syrup 50 mg/5ml<br />
isoniazid tab 100 mg<br />
isoniazid tab 300 mg<br />
itraconazole cap 100 mg<br />
KALETRA CAP(Lopinavir-Ritonavir)<br />
KALETRA SOL(Lopinavir-Ritonavir)<br />
KALETRA TAB 200-50MG(Lopinavir-Ritonavir)<br />
kanamycin sulfate inj 333 mg/ml<br />
KEFLEX CAP 250MG(Cephalexin)<br />
KEFLEX CAP 500MG(Cephalexin)<br />
KEFLEX CAP 750MG(Cephalexin)<br />
KEFLEX SUS 125/5ML(Cephalexin)<br />
KEFLEX SUS 250/5ML(Cephalexin)<br />
KETEK TAB 300MG(Telithromycin)<br />
KETEK TAB 400MG(Telithromycin)<br />
ketoconazole tab 200 mg<br />
LAMISIL TAB 250MG(Terbinafine HCl)<br />
LARIAM TAB 250MG(Mefloquine HCl)<br />
LEVAQUIN INJ 25MG/ML(Levofloxacin)<br />
LEVAQUIN SOL 25MG/ML(Levofloxacin)<br />
LEVAQUIN TAB 250MG(Levofloxacin)<br />
LEVAQUIN TAB 500MG(Levofloxacin)<br />
LEVAQUIN TAB 750MG(Levofloxacin)<br />
LEVAQUIN TAB LEVA-PAK(Levofloxacin)<br />
LEVAQUIN/D5W INJ 250/50ML(Levofloxacin in D5W)<br />
LEVAQUIN/D5W INJ 500/100(Levofloxacin in D5W)<br />
LEVAQUIN/D5W INJ 750/150(Levofloxacin in D5W)<br />
LEXIVA TAB 700MG(Fosamprenavir Calcium)<br />
LINCOCIN INJ 300MG/ML(Lincomycin HCl)<br />
MACROBID CAP 100MG(Nitrofurantoin Monohyd Macro)<br />
MACRODANTIN CAP 100MG(Nitrofurantoin Macrocrystal)<br />
MACRODANTIN CAP 25MG(Nitrofurantoin Macrocrystal)<br />
MACRODANTIN CAP 50MG(Nitrofurantoin Macrocrystal)<br />
MALARONE TAB 250-100(Atovaquone-Proguanil HCl)<br />
MALARONE TAB 62.5/25(Atovaquone-Proguanil HCl)<br />
02<br />
02<br />
01<br />
04<br />
03<br />
04<br />
04<br />
01<br />
04<br />
04<br />
04<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
04<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
01<br />
02<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
17
Drug Name Drug Tier Notes<br />
MANDELAMINE TAB 0.5GM(Methenamine Mandelate)<br />
MANDELAMINE TAB 1GM(Methenamine Mandelate)<br />
MANDOL/D5W INJ 1GM(Cefamandole Nafate in D5W)<br />
MAXIPIME INJ 1GM(Cefepime HCl)<br />
MAXIPIME INJ 1GM(Cefepime HCl)<br />
MAXIPIME INJ 2GM(Cefepime HCl)<br />
MAXIPIME INJ 2GM(Cefepime HCl)<br />
MAXIPIME INJ 500MG(Cefepime HCl)<br />
mebendazole chew tab 100 mg<br />
mefloquine hcl tab 250 mg<br />
MEFOXIN INJ 10GM(Cefoxitin Sodium)<br />
MEFOXIN INJ 1GM(Cefoxitin Sodium)<br />
MEFOXIN INJ 2GM(Cefoxitin Sodium)<br />
MEFOXIN/DEX INJ 1GM(Cefoxitin Sodium in Dextrose)<br />
MEFOXIN/DEX INJ 2GM(Cefoxitin Sodium in Dextrose)<br />
MEPRON SUS(Atovaquone)<br />
MERREM INJ 1GM(Meropenem)<br />
MERREM INJ 500MG(Meropenem)<br />
methenamine hippurate tab 1 gm<br />
methenamine mandelate tab 0.5 gm<br />
methenamine mandelate tab 1 gm<br />
methenamine mandelate-sodium biphosphate tab 500-500 mg<br />
methenamine-bella alk-meth blue-phenyl sal tab<br />
methenamine-hyosc-meth blue-sod phos-phenyl sal tab 120 mg<br />
methenamine-hyosc-meth blue-sod phos-phenyl sal tab 81.6 mg<br />
METRO IV INJ 5MG/ML(Metronidazole in NaCl)<br />
metronidazole cap 375 mg<br />
metronidazole in nacl 0.79% iv soln 500 mg/100ml<br />
metronidazole tab 250 mg<br />
metronidazole tab 500 mg<br />
MINOCIN CAP 100MG(Minocycline HCl)<br />
MINOCIN CAP 50MG(Minocycline HCl)<br />
MINOCIN PAC KIT 100MG(Minocycline HCl w/ Acne Care Products)<br />
MINOCIN PAC KIT 50MG(Minocycline HCl w/ Acne Care Products)<br />
minocycline hcl cap 100 mg<br />
minocycline hcl cap 50 mg<br />
minocycline hcl cap 75 mg<br />
minocycline hcl tab 100 mg<br />
minocycline hcl tab 50 mg<br />
minocycline hcl tab 75 mg<br />
MINTEZOL CHW 500MG(Thiabendazole)<br />
MINTEZOL SUS 500/5ML(Thiabendazole)<br />
MONODOX CAP 100MG(Doxycycline (Monohydrate))<br />
MONODOX CAP 50MG(Doxycycline (Monohydrate))<br />
MONODOX CAP 75MG(Doxycycline (Monohydrate))<br />
MONUROL PAK GRANULES(Fosfomycin Tromethamine)<br />
MYAMBUTOL TAB 100MG(Ethambutol HCl)<br />
MYAMBUTOL TAB 400MG(Ethambutol HCl)<br />
MYCAMINE INJ 100MG(Micafungin Sodium)<br />
MYCAMINE INJ 50MG(Micafungin Sodium)<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
18
Drug Name Drug Tier Notes<br />
MYCOBUTIN CAP 150MG(Rifabutin)<br />
nafcillin sodium for inj 1 gm<br />
nafcillin sodium for inj 10 gm<br />
nafcillin sodium for inj 2 gm<br />
nafcillin sodium for inj 200 gm<br />
nafcillin sodium for iv soln 1 gm<br />
nafcillin sodium for iv soln 2 gm<br />
NALLPEN/DEX INJ 1GM/50ML(Nafcillin Sodium in Dextrose)<br />
NALLPEN/DEX INJ 2GM(Nafcillin Sodium in Dextrose)<br />
NALLPEN/DEX INJ 2GM/100(Nafcillin Sodium in Dextrose)<br />
NEBUPENT INH 300MG(Pentamidine Isethionate)<br />
NEO-FRADIN SOL 125/5ML(Neomycin Sulfate)<br />
neomycin sulfate tab 500 mg<br />
NEUTREXIN INJ 25MG(Trimetrexate Glucuronate)<br />
nitrofurantoin macrocrystalline cap 100 mg<br />
nitrofurantoin macrocrystalline cap 50 mg<br />
nitrofurantoin monohydrate macrocrystalline cap 100 mg<br />
NIZORAL TAB 200MG(Ketoconazole)<br />
NOROXIN TAB 400MG(Norfloxacin)<br />
NORVIR CAP 100MG(Ritonavir)<br />
NORVIR SOL 80MG/ML(Ritonavir)<br />
nystatin susp 100000 unit/ml<br />
nystatin tab 500000 unit<br />
ofloxacin tab 200 mg<br />
ofloxacin tab 300 mg<br />
ofloxacin tab 400 mg<br />
OMNI-PAC CAP 300MG(Cefdinir)<br />
OMNICEF CAP 300MG(Cefdinir)<br />
OMNICEF SUS 125/5ML(Cefdinir)<br />
OMNICEF SUS 250/5ML(Cefdinir)<br />
ORACEA CAP 40MG(Doxycycline (Rosacea))<br />
OXACILLIN INJ 10GM(Oxacillin Sodium)<br />
OXACILLIN INJ 1GM(Oxacillin Sodium)<br />
OXACILLIN INJ 2GM(Oxacillin Sodium)<br />
oxacillin sodium for inj 1 gm<br />
oxacillin sodium for inj 10 gm<br />
oxacillin sodium for inj 2 gm<br />
oxacillin sodium for iv soln 1 gm<br />
oxacillin sodium for iv soln 2 gm<br />
paromomycin sulfate cap 250 mg<br />
PASER GRA 4GM(Aminosalicylic Acid)<br />
PCE TAB 333MG EC(Erythromycin Base (Coated))<br />
PCE TAB 500MG EC(Erythromycin Base (Coated))<br />
PEDIAZOLE SUS 200/600(Erythromycin-Sulfisoxazole)<br />
PEG-INTRON KIT 120 RP(Peginterferon alfa-2b)<br />
PEG-INTRON KIT 120MCG(Peginterferon alfa-2b)<br />
PEG-INTRON KIT 150 RP(Peginterferon alfa-2b)<br />
PEG-INTRON KIT 150MCG(Peginterferon alfa-2b)<br />
PEG-INTRON KIT 50MCG(Peginterferon alfa-2b)<br />
PEG-INTRON KIT 50MCG RP(Peginterferon alfa-2b)<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
02<br />
01<br />
04<br />
01<br />
01<br />
01<br />
04<br />
04<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
19
Drug Name Drug Tier Notes<br />
PEG-INTRON KIT 80MCG(Peginterferon alfa-2b)<br />
PEG-INTRON KIT 80MCG RP(Peginterferon alfa-2b)<br />
PEGASYS INJ 180MCG/M(Peginterferon alfa-2a)<br />
PEGASYS KIT(Peginterferon alfa-2a)<br />
PEN G PROC INJ 600000(Penicillin G Procaine)<br />
penicillin g potassium for inj 20 mu<br />
penicillin g potassium for inj 5000000 unit<br />
penicillin g potassium inj 20000 unit/ml in dextrose<br />
penicillin g potassium inj 40000 unit/ml in dextrose<br />
penicillin g potassium inj 60000 unit/ml in dextrose<br />
penicillin g sodium for inj 5000000 unit<br />
penicillin v potassium for soln 125 mg/5ml<br />
penicillin v potassium for soln 250 mg/5ml<br />
penicillin v potassium tab 250 mg<br />
penicillin v potassium tab 500 mg<br />
PENTAM 300 INJ 300MG(Pentamidine Isethionate)<br />
pentamidine isethionate for soln 300 mg<br />
PERIOSTAT TAB(Doxycycline Hyclate)<br />
PFIZERPEN G INJ 20MU(Penicillin G Potassium)<br />
piperacillin sodium 40 mg/ml-d5w iv soln<br />
piperacillin sodium for inj 2 gm<br />
piperacillin sodium for inj 3 gm<br />
piperacillin sodium for inj 4 gm<br />
piperacillin sodium for iv soln 40 gm<br />
PLAQUENIL TAB 200MG(Hydroxychloroquine Sulfate)<br />
polymyxin b sulfate for inj 500000 unit<br />
PREZISTA TAB 300MG(Darunavir)<br />
PRIFTIN TAB 150MG(Rifapentine)<br />
primaquine phosphate tab 26.3 mg<br />
PRIMAXIN IM INJ 500MG(Imipenem-Cilastatin)<br />
PRIMAXIN IM INJ 750MG(Imipenem-Cilastatin)<br />
PRIMAXIN IV INJ 250MG(Imipenem-Cilastatin)<br />
PRIMAXIN IV INJ 500MG(Imipenem-Cilastatin)<br />
PRIMSOL SOL 50MG/5ML(Trimethoprim HCl)<br />
PROQUIN XR TAB 500MG(Ciprofloxacin HCl)<br />
PROSED/DS TAB(Methenamine-Hyosc-Methylene Blue-Benzoic Acid-Phenyl<br />
Sal)<br />
PYLERA CAP(Bismuth Subcitrate Potassium-Metronidazole-Tetracycline)<br />
pyrazinamide tab 500 mg<br />
QUALAQUIN CAP 324MG(Quinine Sulfate)<br />
QUINERVA TAB 260MG(Quinine Sulfate)<br />
RANICLOR CHW 250MG(Cefaclor)<br />
RANICLOR CHW 375MG(Cefaclor)<br />
REBETOL CAP 200MG(Ribavirin (Hepatitis C))<br />
REBETOL SOL 40MG/ML(Ribavirin (Hepatitis C))<br />
RELENZA MIS DISKHALE(Zanamivir)<br />
RESCRIPTOR TAB 100 MG(Delavirdine Mesylate)<br />
RESCRIPTOR TAB 200MG(Delavirdine Mesylate)<br />
RETROVIR CAP 100MG(Zidovudine)<br />
RETROVIR INJ 10MG/ML(Zidovudine)<br />
03<br />
03<br />
03<br />
03<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
01<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
01<br />
02<br />
04<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
04<br />
02<br />
02<br />
04<br />
02<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
20
Drug Name Drug Tier Notes<br />
sulfasalazine tab delayed release 500 mg<br />
SUPRAX SUS 100/5ML(Cefixime)<br />
SUPRAX SUS 200/5ML(Cefixime)<br />
SUSTIVA CAP 100MG(Efavirenz)<br />
SUSTIVA CAP 200MG(Efavirenz)<br />
SUSTIVA CAP 50MG(Efavirenz)<br />
SUSTIVA TAB 600MG(Efavirenz)<br />
SYNAGIS INJ 100MG/ML(Palivizumab)<br />
SYNAGIS INJ 50MG(Palivizumab)<br />
SYNERCID INJ 500MG(Quinupristin-Dalfopristin)<br />
TAMIFLU CAP 75MG(Oseltamivir Phosphate)<br />
TAMIFLU SUS 12MG/ML(Oseltamivir Phosphate)<br />
TAZICEF INJ 1GM/50ML(Ceftazidime Sodium in Dextrose)<br />
TAZICEF INJ 2GM/50ML(Ceftazidime Sodium in Dextrose)<br />
terbinafine hcl tab 250 mg<br />
tetracycline hcl cap 250 mg<br />
tetracycline hcl cap 500 mg<br />
tetracycline hcl syrup 125 mg/5ml<br />
tetracycline hcl tab 250 mg<br />
tetracycline hcl tab 500 mg<br />
TIMENTIN INJ 3.1GM(Ticarcillin & Pot Clavulanate)<br />
TIMENTIN INJ 31GM(Ticarcillin & Pot Clavulanate)<br />
TINDAMAX TAB 250MG(Tinidazole)<br />
TINDAMAX TAB 500MG(Tinidazole)<br />
TOBI NEB 300/5ML(Tobramycin)<br />
tobramycin sulfate for inj 1.2 gm<br />
tobramycin sulfate inj 0.8 mg/ml in saline<br />
tobramycin sulfate inj 1.2 mg/ml in saline<br />
tobramycin sulfate inj 10 mg/ml<br />
tobramycin sulfate inj 40 mg/ml<br />
tobramycin sulfate iv soln 10 mg/ml<br />
TRECATOR TAB 250MG(Ethionamide)<br />
trimethoprim tab 100 mg<br />
TRIZIVIR TAB(Abacavir Sulfate-Lamivudine-Zidovudine)<br />
TRUVADA TAB(Emtricitabine-Tenofovir Disoproxil Fumarate)<br />
TYGACIL INJ 50MG(Tigecycline)<br />
TYZEKA TAB 600MG(Telbivudine)<br />
UNASYN INJ 1.5GM(Ampicillin & Sulbactam Sodium)<br />
UNASYN INJ 1.5GM(Ampicillin & Sulbactam Sodium)<br />
UNASYN INJ 1.5GM PB(Ampicillin & Sulbactam Sodium)<br />
UNASYN INJ 15GM(Ampicillin & Sulbactam Sodium)<br />
UNASYN INJ 3GM(Ampicillin & Sulbactam Sodium)<br />
UNASYN INJ 3GM(Ampicillin & Sulbactam Sodium)<br />
UNASYN INJ 3GM PBU(Ampicillin & Sulbactam Sodium)<br />
URELLE TAB(Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl Sal)<br />
URETRON D/S TAB(Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl<br />
Sal)<br />
UREX TAB 1GM(Methenamine Hippurate)<br />
URISED TAB(Meth-Bell-Meth Bl-Phenyl Sal)<br />
01<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
02<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
01<br />
02<br />
02<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
22
Drug Name Drug Tier Notes<br />
URISYM CAP(Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl Sal)<br />
URITACT DS TAB(Methenamine-Methylene Blue-Benz Acd-Phenyl Sal-Atrop<br />
-Hyosc)<br />
URITACT-EC TAB(Methenamine-Methylene Blue-Benz Acd-Phenyl Sal-Atrop<br />
-Hyosc)<br />
UROQID #2 TAB(Methenamine Mandelate-Sodium Biphosphate)<br />
UTA CAP(Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl Sal)<br />
UTIRA TAB(Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl Sal)<br />
VALCYTE TAB 450MG(Valganciclovir HCl)<br />
VALTREX TAB 1GM(Valacyclovir HCl)<br />
VALTREX TAB 500MG(Valacyclovir HCl)<br />
VANCOCIN HCL CAP 125MG(Vancomycin HCl)<br />
VANCOCIN HCL CAP 250MG(Vancomycin HCl)<br />
VANCOCIN HCL INJ(Vancomycin HCl in Dextrose)<br />
VANCOCIN/DEX INJ 500MG(Vancomycin HCl in Dextrose)<br />
vancomycin hcl for inj 10 gm<br />
vancomycin hcl for inj 1000 mg<br />
vancomycin hcl for inj 500 mg<br />
vancomycin hcl for inj 5000 mg<br />
VANTIN SUS 100/5ML(Cefpodoxime Proxetil)<br />
VANTIN SUS 50MG/5ML(Cefpodoxime Proxetil)<br />
VANTIN TAB 100MG(Cefpodoxime Proxetil)<br />
VANTIN TAB 200MG(Cefpodoxime Proxetil)<br />
VFEND SUS 40MG/ML(Voriconazole)<br />
VFEND TAB 200MG(Voriconazole)<br />
VFEND TAB 50MG(Voriconazole)<br />
VFEND IV INJ 200MG(Voriconazole)<br />
VIBRAMYCIN CAP 100MG(Doxycycline Hyclate)<br />
VIBRAMYCIN SUS 25MG/5ML(Doxycycline (Monohydrate))<br />
VIBRAMYCIN SYP 50MG/5ML(Doxycycline Calcium)<br />
VIBRATAB TAB 100MG(Doxycycline Hyclate)<br />
VIDEX SOL 2GM(Didanosine)<br />
VIDEX SOL 4GM(Didanosine)<br />
VIDEX EC CAP 125MG(Didanosine)<br />
VIDEX EC CAP 200MG(Didanosine)<br />
VIDEX EC CAP 250MG(Didanosine)<br />
VIDEX EC CAP 400MG(Didanosine)<br />
VIRACEPT POW 50MG/GM(Nelfinavir Mesylate)<br />
VIRACEPT TAB 250MG(Nelfinavir Mesylate)<br />
VIRACEPT TAB 625MG(Nelfinavir Mesylate)<br />
VIRAMUNE SUS 50MG/5ML(Nevirapine)<br />
VIRAMUNE TAB 200MG(Nevirapine)<br />
VIRAZOLE INH 6GM(Ribavirin)<br />
VIREAD TAB 300MG(Tenofovir Disoproxil Fumarate)<br />
VISTIDE INJ 75MG/ML(Cidofovir)<br />
XIFAXAN TAB 200MG(Rifaximin)<br />
YODOXIN TAB 210MG(Iodoquinol)<br />
YODOXIN TAB 650MG(Iodoquinol)<br />
ZERIT CAP 15MG(Stavudine)<br />
ZERIT CAP 20MG(Stavudine)<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
03<br />
04<br />
02<br />
02<br />
02<br />
02<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
23
Drug Name Drug Tier Notes<br />
ZERIT CAP 30MG(Stavudine)<br />
ZERIT CAP 40MG(Stavudine)<br />
ZERIT SOL 1MG/ML(Stavudine)<br />
ZIAGEN SOL 20MG/ML(Abacavir Sulfate)<br />
ZIAGEN TAB 300MG(Abacavir Sulfate)<br />
zidovudine cap 100 mg<br />
zidovudine syrup 10 mg/ml<br />
zidovudine tab 300 mg<br />
ZINACEF INJ 1.5GM(Cefuroxime Sodium)<br />
ZINACEF INJ 1.5GM(Cefuroxime Sodium)<br />
ZINACEF INJ 750MG(Cefuroxime Sodium)<br />
ZINACEF INJ 750MG(Cefuroxime Sodium)<br />
ZINACEF/D5W INJ 1.5GM(Cefuroxime Sodium in D5W)<br />
ZINACEF/D5W INJ 750MG PB(Cefuroxime Sodium in D5W)<br />
ZINACEF/H20 INJ 1.5GM PB(Cefuroxime in Sterile Water)<br />
ZITHROMAX INJ 500MG(Azithromycin)<br />
ZITHROMAX POW 1GM PAK(Azithromycin)<br />
ZITHROMAX SUS 100/5ML(Azithromycin)<br />
ZITHROMAX SUS 200/5ML(Azithromycin)<br />
ZITHROMAX TAB 250MG(Azithromycin)<br />
ZITHROMAX TAB 500MG(Azithromycin)<br />
ZITHROMAX TAB 600MG(Azithromycin)<br />
ZITHROMAX TAB TRI-PAK(Azithromycin)<br />
ZITHROMAX TAB Z-PAK(Azithromycin)<br />
ZMAX SUS 2GM(Azithromycin)<br />
ZOSYN INJ 2G-0.25G(Piperacillin Sodium-Tazobactam Sodium)<br />
ZOSYN INJ 3-0.375G(Piperacillin Sodium-Tazobactam Sodium)<br />
ZOSYN INJ 36-4.5GM(Piperacillin Sodium-Tazobactam Sodium)<br />
ZOSYN INJ 4GM/0.5G(Piperacillin Sodium-Tazobactam Sodium)<br />
ZOSYN SOL 2-0.25GM(Piperacillin Sodium-Tazobactam Sodium in<br />
Dextrose)<br />
ZOSYN SOL 3-0.375G(Piperacillin Sodium-Tazobactam Sodium in<br />
Dextrose)<br />
ZOSYN SOL 4-0.50GM(Piperacillin Sodium-Tazobactam Sodium in<br />
Dextrose)<br />
ZOVIRAX CAP 200MG(Acyclovir)<br />
ZOVIRAX SUS 200/5ML(Acyclovir)<br />
ZOVIRAX TAB 400MG(Acyclovir)<br />
ZOVIRAX TAB 800MG(Acyclovir)<br />
ZYVOX SOL 2MG/ML(Linezolid)<br />
ZYVOX SUS 100MG/5M(Linezolid)<br />
ZYVOX TAB 600MG(Linezolid)<br />
Antineoplastic Agents<br />
ABRAXANE INJ 100MG(Paclitaxel Protein-Bound Particles)<br />
ADRIAMYCIN INJ 20MG(Doxorubicin HCl)<br />
ALFERON N INJ 5MU/ML(Interferon Alfa-n3)<br />
ALIMTA INJ 500MG(Pemetrexed Disodium)<br />
ALKERAN INJ 50MG(Melphalan HCl)<br />
ALKERAN TAB 2MG(Melphalan)<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
04<br />
02<br />
03<br />
04<br />
02<br />
02<br />
(QL)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
24
Drug Name Drug Tier Notes<br />
ARIMIDEX TAB 1MG(Anastrozole)<br />
AROMASIN TAB 25MG(Exemestane)<br />
ARRANON INJ 5MG/ML(Nelarabine)<br />
AVASTIN INJ(Bevacizumab)<br />
BEXXAR CON 14MG/ML(Tositumomab)<br />
BEXXAR 131 I INJ 0.61/ML(Iodine I 131 Tositumomab)<br />
BEXXAR 131 I INJ 5.6MCI/M(Iodine I 131 Tositumomab)<br />
BICNU INJ 100MG(Carmustine)<br />
BLENOXANE INJ 15UNIT(Bleomycin Sulfate)<br />
bleomycin sulfate for inj 15 unit<br />
bleomycin sulfate for inj 30 unit<br />
busulfan inj 6 mg/ml<br />
CAMPATH INJ 10MG/ML(Alemtuzumab)<br />
CAMPATH INJ 30MG/ML(Alemtuzumab)<br />
CAMPTOSAR INJ 20MG/ML(Irinotecan HCl)<br />
carboplatin iv for inj 150 mg<br />
carboplatin iv for inj 450 mg<br />
carboplatin iv for inj 50 mg<br />
carboplatin iv soln 10 mg/ml<br />
CASODEX TAB 50MG(Bicalutamide)<br />
CEENU CAP 100MG(Lomustine)<br />
CEENU CAP 10MG(Lomustine)<br />
CEENU CAP 40MG(Lomustine)<br />
CEENU PAK DOSEPACK(Lomustine)<br />
CERUBIDINE INJ 20MG(Daunorubicin HCl)<br />
cisplatin inj 1 mg/ml<br />
cladribine inj 1 mg/ml<br />
CLOLAR INJ 1MG/ML(Clofarabine)<br />
COSMEGEN INJ 0.5MG(Dactinomycin)<br />
cyclophosphamide for inj 1 gm<br />
cyclophosphamide for inj 2 gm<br />
cyclophosphamide for inj 500 mg<br />
cyclophosphamide tab 25 mg<br />
cyclophosphamide tab 50 mg<br />
CYTARABINE INJ 100MG/ML(Cytarabine)<br />
cytarabine for inj 1 gm<br />
cytarabine for inj 100 mg<br />
cytarabine for inj 2 gm<br />
cytarabine for inj 500 mg<br />
cytarabine inj 100 mg/ml<br />
cytarabine inj 20 mg/ml<br />
CYTOXAN INJ 1GM(Cyclophosphamide)<br />
CYTOXAN INJ 2GM(Cyclophosphamide)<br />
CYTOXAN INJ 500MG(Cyclophosphamide)<br />
CYTOXAN TAB 25MG(Cyclophosphamide)<br />
CYTOXAN TAB 50MG(Cyclophosphamide)<br />
dacarbazine for inj 100 mg<br />
dacarbazine for inj 200 mg<br />
DACOGEN INJ 50MG(Decitabine)<br />
daunorubicin hcl for inj 20 mg<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
01<br />
01<br />
01<br />
04<br />
04<br />
03<br />
03<br />
03<br />
03<br />
03<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
01<br />
01<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
03<br />
01<br />
03<br />
03<br />
01<br />
01<br />
04<br />
04<br />
04<br />
02<br />
02<br />
01<br />
01<br />
02<br />
01<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
25
Drug Name Drug Tier Notes<br />
daunorubicin hcl inj 5 mg/ml (base equiv)<br />
DAUNOXOME INJ 2MG/ML(Daunorubicin Citrate Liposome)<br />
DEPOCYT INJ 50MG/5ML(Cytarabine Liposome)<br />
DOXIL INJ 2MG/ML(Doxorubicin HCl Liposomal)<br />
doxorubicin hcl for inj 10 mg<br />
doxorubicin hcl for inj 50 mg<br />
doxorubicin hcl inj 2 mg/ml<br />
DROXIA CAP 200MG(Hydroxyurea (Sickle Cell Anemia))<br />
DROXIA CAP 300MG(Hydroxyurea (Sickle Cell Anemia))<br />
DROXIA CAP 400MG(Hydroxyurea (Sickle Cell Anemia))<br />
DTIC-DOME INJ 200MG(Dacarbazine)<br />
ELIGARD INJ 22.5MG(Leuprolide Acetate (3 Month))<br />
ELIGARD INJ 30MG(Leuprolide Acetate (4 Month))<br />
ELIGARD INJ 45MG(Leuprolide Acetate (6 Month))<br />
ELIGARD INJ 7.5MG(Leuprolide Acetate)<br />
ELLENCE INJ 2MG/ML(Epirubicin HCl)<br />
ELOXATIN INJ 100MG(Oxaliplatin)<br />
ELOXATIN INJ 50MG(Oxaliplatin)<br />
ELSPAR INJ 10000UNT(Asparaginase)<br />
EMCYT CAP 140MG(Estramustine Phosphate Sodium)<br />
EPIRUBICIN INJ 200MG(Epirubicin HCl)<br />
EPIRUBICIN INJ 50MG(Epirubicin HCl)<br />
ERBITUX INJ 100MG(Cetuximab)<br />
ERBITUX INJ 200MG(Cetuximab)<br />
ETOPOPHOS INJ 100MG(Etoposide Phosphate)<br />
etoposide cap 50 mg<br />
etoposide inj 20 mg/ml<br />
FARESTON TAB 60MG(Toremifene Citrate)<br />
FASLODEX INJ 125MG(Fulvestrant)<br />
FASLODEX INJ 250MG(Fulvestrant)<br />
FEMARA TAB 2.5MG(Letrozole)<br />
floxuridine for inj 0.5 gm<br />
FLUDARA INJ 50MG(Fludarabine Phosphate)<br />
FLUDARABINE INJ 50MG/2ML(Fludarabine Phosphate)<br />
fludarabine phosphate for inj 50 mg<br />
fludarabine phosphate inj 25 mg/ml<br />
fluorouracil inj 50 mg/ml<br />
FLUOROURACIL INJ 50MG/ML(Fluorouracil)<br />
flutamide cap 125 mg<br />
FUDR INJ 0.5GM(Floxuridine)<br />
GEMZAR INJ 1 GM(Gemcitabine HCl)<br />
GEMZAR INJ 200MG(Gemcitabine HCl)<br />
GLEEVEC TAB 100MG(Imatinib Mesylate)<br />
GLEEVEC TAB 400MG(Imatinib Mesylate)<br />
GLIADEL WAF WAFER(Carmustine in Polifeprosan)<br />
HERCEPTIN INJ 440MG(Trastuzumab)<br />
HEXALEN CAP 50MG(Altretamine)<br />
HYCAMTIN INJ 4MG(Topotecan HCl)<br />
HYDREA CAP 500MG(Hydroxyurea)<br />
hydroxyurea cap 500 mg<br />
01<br />
04<br />
02<br />
02<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
03<br />
03<br />
02<br />
03<br />
03<br />
03<br />
03<br />
04<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
01<br />
01<br />
02<br />
03<br />
03<br />
02<br />
01<br />
03<br />
02<br />
03<br />
01<br />
01<br />
02<br />
01<br />
02<br />
03<br />
03<br />
03<br />
03<br />
02<br />
04<br />
02<br />
04<br />
04<br />
01<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
26
Drug Name Drug Tier Notes<br />
IDAMYCIN PFS INJ 1MG/ML(Idarubicin HCl)<br />
idarubicin hcl iv inj 1 mg/ml<br />
IFEX INJ 1GM(Ifosfamide)<br />
IFEX INJ 3GM(Ifosfamide)<br />
IFEX/MESNEX KIT(Ifosfamide & Mesna)<br />
ifosfamide & mesna inj kit 1000-1000 mg<br />
ifosfamide & mesna inj kit 3000-1000 mg<br />
ifosfamide for inj 1 gm<br />
ifosfamide for inj 3 gm<br />
INTRON-A INJ 10MU(Interferon Alfa-2B)<br />
INTRON-A INJ 10MU PEN(Interferon Alfa-2B)<br />
INTRON-A INJ 18MU(Interferon Alfa-2B)<br />
INTRON-A INJ 25MU(Interferon Alfa-2B)<br />
INTRON-A INJ 3MU PEN(Interferon Alfa-2B)<br />
INTRON-A INJ 50MU(Interferon Alfa-2B)<br />
INTRON-A INJ 5MU PEN(Interferon Alfa-2B)<br />
INTRON-A KIT 10MU/ML(Interferon Alfa-2B)<br />
IRESSA TAB 250MG(Gefitinib)<br />
LEUKERAN TAB 2MG(Chlorambucil)<br />
leuprolide acetate inj 5 mg/ml<br />
leuprolide acetate inj kit 5 mg/ml<br />
LEUSTATIN INJ 1MG/ML(Cladribine)<br />
LUPR DEP-PED INJ 11.25MG(Leuprolide Acetate)<br />
LUPR DEP-PED INJ 15MG(Leuprolide Acetate)<br />
LUPR DEP-PED INJ 7.5MG(Leuprolide Acetate)<br />
LUPRON INJ 2 WEEK(Leuprolide Acetate)<br />
LUPRON 6-PK INJ 5MG/ML(Leuprolide Acetate)<br />
LUPRON DEPOT INJ 11.25MG(Leuprolide Acetate (3 Month))<br />
LUPRON DEPOT INJ 22.5MG(Leuprolide Acetate (3 Month))<br />
LUPRON DEPOT INJ 3.75MG(Leuprolide Acetate)<br />
LUPRON DEPOT INJ 30MG(Leuprolide Acetate (4 Month))<br />
LUPRON DEPOT INJ 7.5MG(Leuprolide Acetate)<br />
LYSODREN TAB 500MG(Mitotane)<br />
MATULANE CAP 50MG(Procarbazine HCl)<br />
MEGACE ORAL SUS 40MG/ML(Megestrol Acetate)<br />
megestrol acetate susp 40 mg/ml<br />
megestrol acetate tab 20 mg<br />
megestrol acetate tab 40 mg<br />
mercaptopurine tab 50 mg<br />
methotrexate sodium for inj 1 gm<br />
methotrexate sodium inj 25 mg/ml<br />
methotrexate sodium tab 2.5 mg (base equiv)<br />
mitomycin for inj 20 mg<br />
mitomycin for inj 40 mg<br />
mitomycin for inj 5 mg<br />
mitoxantrone hcl inj conc 2 mg/ml<br />
MUSTARGEN INJ 10MG(Mechlorethamine HCl)<br />
MYLERAN TAB 2MG(Busulfan)<br />
MYLOTARG SOL 5MG(Gemtuzumab Ozogamicin)<br />
NAVELBINE INJ 10MG/ML(Vinorelbine Tartrate)<br />
04<br />
01<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
04<br />
02<br />
03<br />
03<br />
02<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
02<br />
02<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
03<br />
04<br />
02<br />
03<br />
04<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
27
Drug Name Drug Tier Notes<br />
NEXAVAR TAB 200MG(Sorafenib Tosylate)<br />
NILANDRON TAB 150MG(Nilutamide)<br />
NIPENT INJ 10MG(Pentostatin)<br />
NOVANTRONE INJ 2MG/ML(Mitoxantrone HCl)<br />
ONCASPAR INJ 750/ML(Pegaspargase)<br />
ONTAK INJ 150/ML(Denileukin Diftitox)<br />
paclitaxel iv conc 6 mg/ml<br />
PARAPLATIN INJ 150/15ML(Carboplatin)<br />
PARAPLATIN INJ 150MG(Carboplatin)<br />
PARAPLATIN INJ 450/45ML(Carboplatin)<br />
PARAPLATIN INJ 450MG(Carboplatin)<br />
PARAPLATIN INJ 50MG(Carboplatin)<br />
PARAPLATIN INJ 50MG/5ML(Carboplatin)<br />
PHOTOFRIN INJ 75MG(Porfimer Sodium)<br />
PLATINOL AQ INJ 100MG(Cisplatin)<br />
PLATINOL AQ INJ 50MG(Cisplatin)<br />
PLENAXIS INJ 100MG(Abarelix)<br />
PROLEUKIN INJ 22MU(Aldesleukin)<br />
PURINETHOL TAB 50MG(Mercaptopurine)<br />
RHEUMATREX TAB 2.5MG(Methotrexate Sodium (Antirheumatic))<br />
RITUXAN INJ 100MG(Rituximab)<br />
RITUXAN INJ 500MG(Rituximab)<br />
ROFERON-A KIT 3MU/0.5(Interferon Alfa-2A)<br />
ROFERON-A KIT 6MU/0.5(Interferon Alfa-2A)<br />
ROFERON-A KIT 9MU/0.5(Interferon Alfa-2A)<br />
SOLTAMOX SOL 10MG/5ML(Tamoxifen Citrate)<br />
SPRYCEL TAB 20MG(Dasatinib)<br />
SPRYCEL TAB 50MG(Dasatinib)<br />
SPRYCEL TAB 70MG(Dasatinib)<br />
SUPPRELIN LA KIT 50MG(Histrelin Acetate)<br />
SUTENT CAP 12.5MG(Sunitinib Malate)<br />
SUTENT CAP 25MG(Sunitinib Malate)<br />
SUTENT CAP 50MG(Sunitinib Malate)<br />
tamoxifen citrate tab 10 mg (base equivalent)<br />
tamoxifen citrate tab 20 mg (base equivalent)<br />
TARCEVA TAB 100MG(Erlotinib)<br />
TARCEVA TAB 150MG(Erlotinib)<br />
TARCEVA TAB 25MG(Erlotinib)<br />
TARGRETIN CAP 75MG(Bexarotene)<br />
TAXOL INJ 100/17ML(Paclitaxel)<br />
TAXOL INJ 30MG/5ML(Paclitaxel)<br />
TAXOL INJ 6MG/ML(Paclitaxel)<br />
TAXOTERE INJ 20/0.5ML(Docetaxel)<br />
TAXOTERE INJ 80MG/2ML(Docetaxel)<br />
TEMODAR CAP 100MG(Temozolomide)<br />
TEMODAR CAP 140MG(Temozolomide)<br />
TEMODAR CAP 180MG(Temozolomide)<br />
TEMODAR CAP 20MG(Temozolomide)<br />
TEMODAR CAP 250MG(Temozolomide)<br />
TEMODAR CAP 5MG(Temozolomide)<br />
02<br />
02<br />
04<br />
03<br />
04<br />
03<br />
01<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
04<br />
04<br />
04<br />
02<br />
03<br />
04<br />
02<br />
03<br />
02<br />
03<br />
03<br />
03<br />
02<br />
02<br />
02<br />
02<br />
04<br />
02<br />
03<br />
02<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
28
Drug Name Drug Tier Notes<br />
TESLAC TAB 50MG(Testolactone)<br />
thioguanine tab 40 mg<br />
thiotepa for inj 15 mg<br />
TORISEL SOL 25MG/ML(Temsirolimus)<br />
TRELSTAR DEP INJ 3.75MG(Triptorelin Pamoate)<br />
TRELSTAR LA INJ 11.25MG(Triptorelin Pamoate)<br />
tretinoin cap 10 mg<br />
TREXALL TAB 10MG(Methotrexate Sodium)<br />
TREXALL TAB 15MG(Methotrexate Sodium)<br />
TREXALL TAB 5MG(Methotrexate Sodium)<br />
TREXALL TAB 7.5MG(Methotrexate Sodium)<br />
TRISENOX SOL 10MG/10M(Arsenic Trioxide)<br />
TYKERB TAB 250MG(Lapatinib Ditosylate)<br />
VANTAS KIT 50MG(Histrelin Acetate)<br />
VECTIBIX INJ 100MG(Panitumumab)<br />
VECTIBIX INJ 200MG(Panitumumab)<br />
VECTIBIX INJ 400MG(Panitumumab)<br />
VELCADE INJ 3.5MG(Bortezomib)<br />
VEPESID CAP 50MG(Etoposide)<br />
VESANOID CAP 10 MG(Tretinoin (Chemotherapy))<br />
VIADUR KIT(Leuprolide Acetate)<br />
VIDAZA INJ 100MG(Azacitidine)<br />
vinblastine sulfate for inj 10 mg<br />
vinblastine sulfate inj 1 mg/ml<br />
vincristine sulfate iv soln 1 mg/ml<br />
VINORELBINE INJ 50MG/ML(Vinorelbine Tartrate)<br />
vinorelbine tartrate inj 10 mg/ml<br />
VUMON INJ 50MG/5ML(Teniposide)<br />
XELODA TAB 150MG(Capecitabine)<br />
XELODA TAB 500MG(Capecitabine)<br />
ZANOSAR INJ 1GM(Streptozocin)<br />
ZEVALIN KIT IN-111(Ibritumomab Tiuxetan for Indium-111 (In-111))<br />
ZEVALIN KIT Y-90(Ibritumomab Tiuxetan for Yttrium-90 (Y-90))<br />
ZOLADEX IMP 10.8MG(Goserelin Acetate)<br />
ZOLADEX IMP 3.6MG(Goserelin Acetate)<br />
ZOLINZA CAP 100MG(Vorinostat)<br />
Autonomic Drugs<br />
ACCUNEB NEB 0.63MG/3(Albuterol Sulfate)<br />
ACCUNEB NEB 1.25MG/3(Albuterol Sulfate)<br />
ADRENALIN INJ 1MG/ML(Epinephrine HCl)<br />
ADVAIR DISKU MIS 100/50(Fluticasone-Salmeterol)<br />
ADVAIR DISKU MIS 250/50(Fluticasone-Salmeterol)<br />
ADVAIR DISKU MIS 500/50(Fluticasone-Salmeterol)<br />
ADVAIR HFA AER 115/21(Fluticasone-Salmeterol)<br />
ADVAIR HFA AER 230/21(Fluticasone-Salmeterol)<br />
ADVAIR HFA AER 45/21(Fluticasone-Salmeterol)<br />
AKINETON TAB 2MG(Biperiden HCl)<br />
albuterol inhal aerosol 90 mcg/act<br />
albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv)<br />
02<br />
01<br />
01<br />
02<br />
04<br />
04<br />
01<br />
02<br />
02<br />
02<br />
02<br />
03<br />
02<br />
04<br />
02<br />
02<br />
02<br />
03<br />
02<br />
02<br />
03<br />
04<br />
01<br />
01<br />
01<br />
04<br />
01<br />
02<br />
02<br />
02<br />
04<br />
03<br />
03<br />
03<br />
03<br />
02<br />
02<br />
02<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
01<br />
01<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
29
Drug Name Drug Tier Notes<br />
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)<br />
albuterol sulfate soln nebu 0.5% (5 mg/ml)<br />
albuterol sulfate soln nebu 1.25 mg/3ml (base equiv)<br />
albuterol sulfate syrup 2 mg/5ml<br />
albuterol sulfate tab 2 mg<br />
albuterol sulfate tab 4 mg<br />
albuterol sulfate tab sr 12hr 4 mg<br />
albuterol sulfate tab sr 12hr 8 mg<br />
ALBUTEROL/ SOL IPRATROP(Albuterol-Ipratropium)<br />
ALUPENT INH AER 0.65/ACT(Metaproterenol Sulfate)<br />
ANASPAZ TAB 0.125MG(Hyoscyamine Sulfate)<br />
ARICEPT TAB 10MG(Donepezil Hydrochloride)<br />
ARICEPT TAB 5MG(Donepezil Hydrochloride)<br />
ARICEPT ODT TAB 10MG(Donepezil Hydrochloride)<br />
ARICEPT ODT TAB 5MG(Donepezil Hydrochloride)<br />
ATROVENT HFA AER 17MCG(Ipratropium Bromide HFA)<br />
B & O 15-A SUP SUPPRETT(Belladonna Alkaloids & Opium)<br />
B & O 16-A SUP SUPPRETT(Belladonna Alkaloids & Opium)<br />
baclofen tab 10 mg<br />
baclofen tab 20 mg<br />
belladonna alkaloids & opium suppos 16.2-30 mg<br />
belladonna alkaloids & opium suppos 16.2-60 mg<br />
BENTYL CAP 10MG(Dicyclomine HCl)<br />
BENTYL INJ 10MG/ML(Dicyclomine HCl)<br />
BENTYL SYP 10MG/5ML(Dicyclomine HCl)<br />
BENTYL TAB 20MG(Dicyclomine HCl)<br />
benztropine mesylate tab 0.5 mg<br />
benztropine mesylate tab 1 mg<br />
benztropine mesylate tab 2 mg<br />
bethanechol chloride tab 10 mg<br />
bethanechol chloride tab 25 mg<br />
bethanechol chloride tab 5 mg<br />
bethanechol chloride tab 50 mg<br />
BRETHINE INJ 1MG/ML(Terbutaline Sulfate)<br />
BRETHINE TAB 2.5MG(Terbutaline Sulfate)<br />
BRETHINE TAB 5MG(Terbutaline Sulfate)<br />
BROVANA NEB 15MCG(Arformoterol Tartrate)<br />
CANTIL TAB(Mepenzolate Bromide)<br />
carisoprodol tab 350 mg<br />
carisoprodol w/ aspirin & codeine tab 200-325-16 mg<br />
carisoprodol w/ aspirin tab 200-325 mg<br />
CHANTIX PAK(Varenicline Tartrate)<br />
CHANTIX PAK 1MG(Varenicline Tartrate)<br />
CHANTIX TAB 0.5MG(Varenicline Tartrate)<br />
CHANTIX TAB 1MG(Varenicline Tartrate)<br />
chlorzoxazone tab 250 mg<br />
chlorzoxazone tab 500 mg<br />
COGENTIN INJ 1MG/ML(Benztropine Mesylate)<br />
COGNEX CAP 10MG(Tacrine Hydrochloride)<br />
COGNEX CAP 20MG(Tacrine Hydrochloride)<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
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01<br />
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(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
30
Drug Name Drug Tier Notes<br />
COGNEX CAP 30MG(Tacrine Hydrochloride)<br />
COGNEX CAP 40MG(Tacrine Hydrochloride)<br />
COLYTROL SUS(Atropine-Hyoscyamine-Scopolamine)<br />
COLYTROL TAB(Atropine-Hyoscyamine-Scopolamine)<br />
COMBIVENT AER(Albuterol-Ipratropium)<br />
cyclobenzaprine hcl tab 10 mg<br />
cyclobenzaprine hcl tab 5 mg<br />
CYSTOSPAZ TAB 0.15MG(Hyoscyamine)<br />
DANTRIUM CAP 100MG(Dantrolene Sodium)<br />
DANTRIUM CAP 25MG(Dantrolene Sodium)<br />
DANTRIUM CAP 50MG(Dantrolene Sodium)<br />
dantrolene sodium cap 100 mg<br />
dantrolene sodium cap 25 mg<br />
dantrolene sodium cap 50 mg<br />
DIBENZYLINE CAP 10MG(Phenoxybenzamine HCl)<br />
dicyclomine hcl cap 10 mg<br />
dicyclomine hcl inj 10 mg/ml<br />
dicyclomine hcl oral soln 10 mg/5ml<br />
dicyclomine hcl tab 20 mg<br />
DUONEB SOL(Albuterol-Ipratropium)<br />
ENLON-PLUS INJ(Edrophonium Chloride w/ Atropine)<br />
epinephrine hcl inj 0.1 mg/ml<br />
epinephrine hcl inj 1 mg/ml<br />
EPIPEN INJ 0.3MG(Epinephrine HCl (Anaphylaxis))<br />
EPIPEN 2-PAK INJ 0.3MG(Epinephrine HCl (Anaphylaxis))<br />
EPIPEN-JR INJ 0.15MG(Epinephrine HCl (Anaphylaxis))<br />
EPIPEN-JR INJ 2-PAK(Epinephrine HCl (Anaphylaxis))<br />
ergoloid mesylates tab 1 mg<br />
EVOXAC CAP 30MG(Cevimeline HCl)<br />
EXELON CAP 1.5MG(Rivastigmine Tartrate)<br />
EXELON CAP 3MG(Rivastigmine Tartrate)<br />
EXELON CAP 4.5MG(Rivastigmine Tartrate)<br />
EXELON CAP 6MG(Rivastigmine Tartrate)<br />
EXELON SOL 2MG/ML(Rivastigmine Tartrate)<br />
FEXMID TAB 7.5MG(Cyclobenzaprine HCl)<br />
FLEXERIL TAB 10MG(Cyclobenzaprine HCl)<br />
FLEXERIL TAB 5MG(Cyclobenzaprine HCl)<br />
FORADIL CAP AEROLIZE(Formoterol Fumarate)<br />
glycopyrrolate inj 0.2 mg/ml<br />
glycopyrrolate tab 1 mg<br />
glycopyrrolate tab 2 mg<br />
guanidine hcl tab 125 mg<br />
homatropine methylbromide tab 10 mg<br />
hyoscyamine sulfate cap sr 12hr 0.375 mg<br />
hyoscyamine sulfate elixir 0.125 mg/5ml<br />
hyoscyamine sulfate orally disintegrating tab 0.125 mg<br />
hyoscyamine sulfate soln 0.031 mg/ml<br />
hyoscyamine sulfate soln 0.125 mg/ml<br />
hyoscyamine sulfate tab 0.125 mg<br />
hyoscyamine sulfate tab cr 0.375 mg<br />
04<br />
04<br />
04<br />
04<br />
02<br />
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01<br />
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04<br />
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01<br />
01<br />
01<br />
01<br />
01<br />
(PA)<br />
31
Drug Name Drug Tier Notes<br />
hyoscyamine sulfate tab disp 0.25 mg<br />
hyoscyamine sulfate tab sl 0.125 mg<br />
hyoscyamine sulfate tab sr 12hr 0.375 mg<br />
hyoscyamine tab 0.15 mg<br />
ipratropium bromide inhal soln 0.02%<br />
ISUPREL INJ 0.2MG/ML(Isoproterenol HCl)<br />
KEMADRIN TAB 5MG(Procyclidine HCl)<br />
LEVBID TAB 0.375 ER(Hyoscyamine Sulfate)<br />
LEVSIN DRO 0.125/ML(Hyoscyamine Sulfate)<br />
LEVSIN ELX 0.125/5(Hyoscyamine Sulfate)<br />
LEVSIN INJ 0.5MG/ML(Hyoscyamine Sulfate)<br />
LEVSIN TAB 0.125MG(Hyoscyamine Sulfate)<br />
LEVSIN/SL SUB 0.125MG(Hyoscyamine Sulfate)<br />
LEVSINEX CAP 0.375 CR(Hyoscyamine Sulfate)<br />
MAXAIR AUTOH AER 200MCG(Pirbuterol Acetate)<br />
MESTINON SYP 60MG/5ML(Pyridostigmine Bromide)<br />
MESTINON TAB 60MG(Pyridostigmine Bromide)<br />
MESTINON TAB TIMESPAN(Pyridostigmine Bromide)<br />
metaproterenol sulfate soln nebu 0.4%<br />
metaproterenol sulfate soln nebu 0.6%<br />
metaproterenol sulfate syrup 10 mg/5ml<br />
metaproterenol sulfate tab 10 mg<br />
metaproterenol sulfate tab 20 mg<br />
methocarbamol tab 500 mg<br />
methocarbamol tab 750 mg<br />
methscopolamine bromide tab 2.5 mg<br />
methscopolamine bromide tab 5 mg<br />
midodrine hcl tab 10 mg<br />
midodrine hcl tab 2.5 mg<br />
midodrine hcl tab 5 mg<br />
MYTELASE TAB 10MG(Ambenonium Chloride)<br />
NASOP12 CHW 10MG(Phenylephrine Tannate)<br />
neostigmine methylsulfate inj 0.5 mg/ml (1:2000)<br />
neostigmine methylsulfate inj 1 mg/ml<br />
NICOTROL INH(Nicotine)<br />
NICOTROL NS SPR 10MG/ML(Nicotine)<br />
NORFLEX INJ 30MG/ML(Orphenadrine Citrate)<br />
NULEV TAB 0.125MG(Hyoscyamine Sulfate)<br />
orphenadrine citrate inj 30 mg/ml<br />
orphenadrine citrate tab sr 12hr 100 mg<br />
PAMINE TAB 2.5MG(Methscopolamine Bromide)<br />
PAMINE FORTE TAB 5MG(Methscopolamine Bromide)<br />
PARAFON FORT TAB DSC(Chlorzoxazone)<br />
pilocarpine hcl tab 5 mg<br />
pilocarpine hcl tab 7.5 mg<br />
PRO-BANTHINE TAB 7.5MG(Propantheline Bromide)<br />
PROAIR HFA AER(Albuterol Sulfate)<br />
PROAMATINE TAB 10MG(Midodrine HCl)<br />
PROAMATINE TAB 2.5MG(Midodrine HCl)<br />
PROAMATINE TAB 5MG(Midodrine HCl)<br />
01<br />
01<br />
01<br />
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01<br />
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04<br />
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(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
32
Drug Name Drug Tier Notes<br />
PROSTIGMIN INJ 0.5MG/ML(Neostigmine Methylsulfate)<br />
PROSTIGMIN INJ 1MG/ML(Neostigmine Methylsulfate)<br />
PROSTIGMIN TAB 15MG(Neostigmine Bromide)<br />
PROVENTIL AER 90MCG(Albuterol)<br />
PROVENTIL AER HFA(Albuterol Sulfate)<br />
PROVENTIL NEB 0.083%(Albuterol Sulfate)<br />
pyridostigmine bromide tab 60 mg<br />
RAZADYNE SOL 4MG/ML(Galantamine Hydrobromide)<br />
RAZADYNE TAB 12MG(Galantamine Hydrobromide)<br />
RAZADYNE TAB 4MG(Galantamine Hydrobromide)<br />
RAZADYNE TAB 8MG(Galantamine Hydrobromide)<br />
RAZADYNE ER CAP 16MG(Galantamine Hydrobromide)<br />
RAZADYNE ER CAP 24MG(Galantamine Hydrobromide)<br />
RAZADYNE ER CAP 8MG(Galantamine Hydrobromide)<br />
REGONOL INJ 5MG/ML(Pyridostigmine Bromide)<br />
ROBAXIN INJ 100MG/ML(Methocarbamol)<br />
ROBAXIN TAB 500MG(Methocarbamol)<br />
ROBAXIN-750 TAB 750MG(Methocarbamol)<br />
ROBINUL INJ 0.2MG/ML(Glycopyrrolate)<br />
ROBINUL TAB 1MG(Glycopyrrolate)<br />
ROBINUL FORT TAB 2MG(Glycopyrrolate)<br />
SAL-TROPINE TAB 0.4MG(Atropine Sulfate)<br />
SALAGEN TAB 5MG(Pilocarpine HCl (Oral))<br />
SALAGEN TAB 7.5MG(Pilocarpine HCl (Oral))<br />
scopolamine hbr inj 0.4 mg/ml<br />
SEREVENT DIS AER 50MCG(Salmeterol Xinafoate)<br />
SKELAXIN TAB 800MG(Metaxalone)<br />
SOMA TAB 350MG(Carisoprodol)<br />
SOMA CPD TAB(Carisoprodol w/ Aspirin)<br />
SOMA CPD/COD TAB(Carisoprodol w/ Aspirin & Codeine)<br />
SPIRIVA CAP HANDIHLR(Tiotropium Bromide Monohydrate)<br />
terbutaline sulfate inj 1 mg/ml<br />
terbutaline sulfate tab 2.5 mg<br />
terbutaline sulfate tab 5 mg<br />
THERABENZAPR PAK -60(Cyclobenzaprine-Nutritional Supplement)<br />
THERABENZAPR PAK -90(Cyclobenzaprine-Nutritional Supplement)<br />
tizanidine hcl tab 2 mg<br />
tizanidine hcl tab 4 mg<br />
trihexyphenidyl hcl elixir 0.4 mg/ml<br />
trihexyphenidyl hcl tab 2 mg<br />
trihexyphenidyl hcl tab 5 mg<br />
TWINJECT INJ 0.15MG(Epinephrine)<br />
TWINJECT INJ 0.3MG(Epinephrine)<br />
URECHOLINE TAB 10MG(Bethanechol Chloride)<br />
URECHOLINE TAB 25MG(Bethanechol Chloride)<br />
URECHOLINE TAB 50MG(Bethanechol Chloride)<br />
URECHOLINE TAB 5MG(Bethanechol Chloride)<br />
VENTOLIN HFA AER(Albuterol Sulfate)<br />
VOSPIRE ER TAB 4MG(Albuterol Sulfate)<br />
VOSPIRE ER TAB 8MG(Albuterol Sulfate)<br />
04<br />
04<br />
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04<br />
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02<br />
04<br />
04<br />
(PA)<br />
33
Drug Name Drug Tier Notes<br />
XOPENEX NEB 0.31MG(Levalbuterol HCl)<br />
XOPENEX NEB 0.63MG(Levalbuterol HCl)<br />
XOPENEX NEB 1.25/3ML(Levalbuterol HCl)<br />
XOPENEX CONC NEB 1.25/0.5(Levalbuterol HCl)<br />
XOPENEX HFA AER(Levalbuterol Tartrate)<br />
ZANAFLEX CAP 2MG(Tizanidine HCl)<br />
ZANAFLEX CAP 4MG(Tizanidine HCl)<br />
ZANAFLEX CAP 6MG(Tizanidine HCl)<br />
ZANAFLEX TAB 2MG(Tizanidine HCl)<br />
ZANAFLEX TAB 4MG(Tizanidine HCl)<br />
Blood Formation, Coagulation & Thrombosis<br />
ABBOKINASE INJ 250000(Urokinase)<br />
ACD-A SOL(Anticoagulant Citrate Dextrose Solution A)<br />
AGGRENOX CAP 25-200MG(Aspirin-Dipyridamole)<br />
AGRYLIN CAP 0.5MG(Anagrelide HCl)<br />
AGRYLIN CAP 1MG(Anagrelide HCl)<br />
AMICAR TAB 1000MG(Aminocaproic Acid)<br />
AMICAR TAB 500MG(Aminocaproic Acid)<br />
aminocaproic acid tab 500 mg<br />
anagrelide hcl cap 0.5 mg<br />
anagrelide hcl cap 1 mg<br />
ANGIOMAX INJ 250MG(Bivalirudin)<br />
ARANESP INJ 100MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 100MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 100MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 150MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 150MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 200MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 200MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 200MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 25MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 25MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 25MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 300MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 300MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 300MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 40MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 40MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 40MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 500MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 60MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 60MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARANESP INJ 60MCG(Darbepoetin Alfa-Polysorbate 80)<br />
ARIXTRA SOL 10/0.8(Fondaparinux Sodium)<br />
ARIXTRA SOL 2.5/0.5(Fondaparinux Sodium)<br />
ARIXTRA SOL 5.0/0.4(Fondaparinux Sodium)<br />
ARIXTRA SOL 7.5/0.6(Fondaparinux Sodium)<br />
BENEFIX INJ 2000UNIT(Coagulation Factor IX (Recombinant))<br />
cilostazol tab 100 mg<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
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01<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
34
Drug Name Drug Tier Notes<br />
cilostazol tab 50 mg<br />
COUMADIN INJ 5 MG(Warfarin Sodium)<br />
COUMADIN TAB 10MG(Warfarin Sodium)<br />
COUMADIN TAB 1MG(Warfarin Sodium)<br />
COUMADIN TAB 2.5MG(Warfarin Sodium)<br />
COUMADIN TAB 2.5MG(Warfarin Sodium)<br />
COUMADIN TAB 2MG(Warfarin Sodium)<br />
COUMADIN TAB 2MG(Warfarin Sodium)<br />
COUMADIN TAB 3MG(Warfarin Sodium)<br />
COUMADIN TAB 4MG(Warfarin Sodium)<br />
COUMADIN TAB 4MG(Warfarin Sodium)<br />
COUMADIN TAB 5MG(Warfarin Sodium)<br />
COUMADIN TAB 5MG(Warfarin Sodium)<br />
COUMADIN TAB 6MG(Warfarin Sodium)<br />
COUMADIN TAB 6MG(Warfarin Sodium)<br />
COUMADIN TAB 7.5MG(Warfarin Sodium)<br />
EPOGEN INJ 10000/ML(Epoetin Alfa)<br />
EPOGEN INJ 2000/ML(Epoetin Alfa)<br />
EPOGEN INJ 20000/ML(Epoetin Alfa)<br />
EPOGEN INJ 3000/ML(Epoetin Alfa)<br />
EPOGEN INJ 4000/ML(Epoetin Alfa)<br />
EPOGEN INJ 40000/ML(Epoetin Alfa)<br />
FRAGMIN INJ 10000/ML(Dalteparin Sodium)<br />
FRAGMIN INJ 2500/0.2(Dalteparin Sodium)<br />
FRAGMIN INJ 25000/ML(Dalteparin Sodium)<br />
FRAGMIN INJ 5000/0.2(Dalteparin Sodium)<br />
FRAGMIN INJ 7500/0.3(Dalteparin Sodium)<br />
HEP SOD/D5W INJ 100/ML(Heparin Sod (Porcine) in D5W)<br />
HEP SOD/D5W INJ 25000UNT(Heparin Sod (Porcine) in D5W)<br />
HEP SOD/D5W INJ 50UNT/ML(Heparin Sod (Porcine) in D5W)<br />
HEP SOD/NACL INJ 1000UNIT(Heparin (Porcine) in Sodium Chloride)<br />
HEP SOD/NACL INJ 2000UNIT(Heparin (Porcine) in Sodium Chloride)<br />
HEPARIN SOD INJ 2000/ML(Heparin Sodium (Porcine))<br />
heparin sodium (porcine) 10 unit/ml in sodium chloride 0.9%<br />
heparin sodium (porcine) 100 unit/ml in d5w<br />
heparin sodium (porcine) 100 unit/ml in sodium chloride 0.9%<br />
heparin sodium (porcine) 100 unt/ml in sodium chloride 0.45%<br />
heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9%<br />
heparin sodium (porcine) 40 unit/ml in d5w<br />
heparin sodium (porcine) 50 unit/ml in d5w<br />
heparin sodium (porcine) 50 unit/ml in sodium chloride 0.45%<br />
heparin sodium (porcine) inj 1000 unit/ml<br />
heparin sodium (porcine) inj 10000 unit/ml<br />
heparin sodium (porcine) inj 20000 unit/ml<br />
heparin sodium (porcine) inj 25000 unit/ml<br />
heparin sodium (porcine) inj 5000 unit/ml<br />
heparin sodium (porcine) lock flush iv soln 10 unit/ml<br />
heparin sodium (porcine) lock flush iv soln 100 unit/ml<br />
heparin sodium (porcine) lock flush soln 10 unit/ml<br />
heparin sodium (porcine) lock flush soln 100 unit/ml<br />
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02<br />
02<br />
02<br />
02<br />
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04<br />
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01<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
35
Drug Name Drug Tier Notes<br />
heparin sodium (porcine) w/ nacl lock flush kit 10 unit/ml<br />
heparin sodium (porcine) w/ nacl lock flush kit 100 unit/ml<br />
INNOHEP INJ 20000/ML(Tinzaparin Sodium)<br />
LEUKINE INJ 250MCG(Sargramostim)<br />
LEUKINE INJ 500 MCG(Sargramostim)<br />
LEUKINE SOL 500MCG(Sargramostim)<br />
LOVENOX INJ 100/1ML(Enoxaparin Sodium)<br />
LOVENOX INJ 120/0.8(Enoxaparin Sodium)<br />
LOVENOX INJ 150/1ML(Enoxaparin Sodium)<br />
LOVENOX INJ 30/0.3ML(Enoxaparin Sodium)<br />
LOVENOX INJ 300/3ML(Enoxaparin Sodium)<br />
LOVENOX INJ 40/0.4ML(Enoxaparin Sodium)<br />
LOVENOX INJ 60/0.6ML(Enoxaparin Sodium)<br />
LOVENOX INJ 80/0.8ML(Enoxaparin Sodium)<br />
NEULASTA INJ 6MG/0.6M(Pegfilgrastim)<br />
NEUMEGA INJ 5MG(Oprelvekin)<br />
NEUPOGEN INJ 300/0.5(Filgrastim)<br />
NEUPOGEN INJ 300MCG(Filgrastim)<br />
NEUPOGEN INJ 480/0.8(Filgrastim)<br />
NEUPOGEN INJ 480MCG(Filgrastim)<br />
pentoxifylline tab cr 400 mg<br />
PLAVIX TAB 75MG(Clopidogrel Bisulfate)<br />
PLETAL TAB 100MG(Cilostazol)<br />
PLETAL TAB 50MG(Cilostazol)<br />
PROCRIT INJ 10000/ML(Epoetin Alfa)<br />
PROCRIT INJ 2000/ML(Epoetin Alfa)<br />
PROCRIT INJ 20000/ML(Epoetin Alfa)<br />
PROCRIT INJ 3000/ML(Epoetin Alfa)<br />
PROCRIT INJ 4000/ML(Epoetin Alfa)<br />
PROCRIT INJ 40000/ML(Epoetin Alfa)<br />
REFLUDAN INJ 50MG(Lepirudin)<br />
THROMBI-GEL PAD 10(Thrombin-Sodium Carboxymethylcellulose (CMC)-<br />
CaCl-Gelatin)<br />
THROMBI-GEL PAD 100(Thrombin-Sodium Carboxymethylcellulose (CMC)-<br />
CaCl-Gelatin)<br />
THROMBI-GEL PAD 40(Thrombin-Sodium Carboxymethylcellulose (CMC)-<br />
CaCl-Gelatin)<br />
THROMBI-PAD PAD 3"X3"(Thrombin-Sodium Carboxymethylcellulose<br />
(CMC)-CaCl)<br />
TICLID TAB 250MG(Ticlopidine HCl)<br />
ticlopidine hcl tab 250 mg<br />
TISSEEL SOL(Fibrin Sealant Component)<br />
TRENTAL TAB 400MG CR(Pentoxifylline)<br />
warfarin sodium tab 1 mg<br />
warfarin sodium tab 10 mg<br />
warfarin sodium tab 2 mg<br />
warfarin sodium tab 2.5 mg<br />
warfarin sodium tab 3 mg<br />
warfarin sodium tab 4 mg<br />
warfarin sodium tab 5 mg<br />
01<br />
01<br />
03<br />
03<br />
04<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
01<br />
02<br />
04<br />
04<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
36
Drug Name Drug Tier Notes<br />
warfarin sodium tab 6 mg<br />
warfarin sodium tab 7.5 mg<br />
Cardiovascular Drugs<br />
ACCUPRIL TAB 10MG(Quinapril HCl)<br />
ACCUPRIL TAB 20MG(Quinapril HCl)<br />
ACCUPRIL TAB 40MG(Quinapril HCl)<br />
ACCUPRIL TAB 5MG(Quinapril HCl)<br />
ACCURETIC TAB 10/12.5(Quinapril-Hydrochlorothiazide)<br />
ACCURETIC TAB 20-25MG(Quinapril-Hydrochlorothiazide)<br />
ACCURETIC TAB 20/12.5(Quinapril-Hydrochlorothiazide)<br />
acebutolol hcl cap 200 mg<br />
acebutolol hcl cap 400 mg<br />
ACEON TAB 2MG(Perindopril Erbumine)<br />
ACEON TAB 4MG(Perindopril Erbumine)<br />
ACEON TAB 8MG(Perindopril Erbumine)<br />
acetazolamide tab 125 mg<br />
acetazolamide tab 250 mg<br />
ADALAT CC TAB 30MG ER(Nifedipine)<br />
ADALAT CC TAB 60MG ER(Nifedipine)<br />
ADALAT CC TAB 90MG ER(Nifedipine)<br />
ADVICOR TAB 1000-20(Niacin-Lovastatin)<br />
ADVICOR TAB 1000-40(Niacin-Lovastatin)<br />
ADVICOR TAB 500-20MG(Niacin-Lovastatin)<br />
ADVICOR TAB 750-20MG(Niacin-Lovastatin)<br />
ALDACTAZIDE TAB 25/25(Spironolactone & Hydrochlorothiazide)<br />
ALDACTAZIDE TAB 50/50(Spironolactone & Hydrochlorothiazide)<br />
ALDACTONE TAB 100MG(Spironolactone)<br />
ALDACTONE TAB 25MG(Spironolactone)<br />
ALDACTONE TAB 50MG(Spironolactone)<br />
ALTACE CAP 1.25MG(Ramipril)<br />
ALTACE CAP 10MG(Ramipril)<br />
ALTACE CAP 2.5MG(Ramipril)<br />
ALTACE CAP 5MG(Ramipril)<br />
ALTOPREV TAB 20MG ER(Lovastatin)<br />
ALTOPREV TAB 40MG ER(Lovastatin)<br />
ALTOPREV TAB 60MG ER(Lovastatin)<br />
amiodarone hcl inj 50 mg/ml<br />
amiodarone hcl tab 100 mg<br />
amiodarone hcl tab 200 mg<br />
amiodarone hcl tab 300 mg<br />
amiodarone hcl tab 400 mg<br />
amlodipine besylate tab 10 mg<br />
amlodipine besylate tab 2.5 mg<br />
amlodipine besylate tab 5 mg<br />
amlodipine besylate-benazepril hcl cap 10-20 mg<br />
amlodipine besylate-benazepril hcl cap 2.5-10 mg<br />
amlodipine besylate-benazepril hcl cap 5-10 mg<br />
amlodipine besylate-benazepril hcl cap 5-20 mg<br />
ANTARA CAP 130MG(Fenofibrate Micronized)<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
04<br />
04<br />
04<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
37
Drug Name Drug Tier Notes<br />
ANTARA CAP 43MG(Fenofibrate Micronized)<br />
ATACAND TAB 16MG(Candesartan Cilexetil)<br />
ATACAND TAB 32MG(Candesartan Cilexetil)<br />
ATACAND TAB 4MG(Candesartan Cilexetil)<br />
ATACAND TAB 8MG(Candesartan Cilexetil)<br />
ATACAND HCT TAB 16-12.5(Candesartan Cilexetil-Hydrochlorothiazide)<br />
ATACAND HCT TAB 32-12.5(Candesartan Cilexetil-Hydrochlorothiazide)<br />
atenolol & chlorthalidone tab 100-25 mg<br />
atenolol & chlorthalidone tab 50-25 mg<br />
atenolol tab 100 mg<br />
atenolol tab 25 mg<br />
atenolol tab 50 mg<br />
AVALIDE TAB 150-12.5(Irbesartan-Hydrochlorothiazide)<br />
AVALIDE TAB 300-12.5(Irbesartan-Hydrochlorothiazide)<br />
AVALIDE TAB 300-25MG(Irbesartan-Hydrochlorothiazide)<br />
AVAPRO TAB 150MG(Irbesartan)<br />
AVAPRO TAB 300MG(Irbesartan)<br />
AVAPRO TAB 75MG(Irbesartan)<br />
benazepril & hydrochlorothiazide tab 10-12.5 mg<br />
benazepril & hydrochlorothiazide tab 20-12.5 mg<br />
benazepril & hydrochlorothiazide tab 20-25 mg<br />
benazepril & hydrochlorothiazide tab 5-6.25 mg<br />
benazepril hcl tab 10 mg<br />
benazepril hcl tab 20 mg<br />
benazepril hcl tab 40 mg<br />
benazepril hcl tab 5 mg<br />
bendroflumethiazide & rauwolfia tab 4-50 mg<br />
BENICAR TAB 20MG(Olmesartan Medoxomil)<br />
BENICAR TAB 40MG(Olmesartan Medoxomil)<br />
BENICAR TAB 5MG(Olmesartan Medoxomil)<br />
BENICAR HCT TAB 20-12.5(Olmesartan Medoxomil-Hydrochlorothiazide)<br />
BENICAR HCT TAB 40-12.5(Olmesartan Medoxomil-Hydrochlorothiazide)<br />
BENICAR HCT TAB 40-25MG(Olmesartan Medoxomil-Hydrochlorothiazide)<br />
BETAPACE TAB 120MG(Sotalol HCl)<br />
BETAPACE TAB 160MG(Sotalol HCl)<br />
BETAPACE TAB 240MG(Sotalol HCl)<br />
BETAPACE TAB 80MG(Sotalol HCl)<br />
BETAPACE AF TAB 120MG(Sotalol HCl (AFIB/AFL))<br />
BETAPACE AF TAB 160MG(Sotalol HCl (AFIB/AFL))<br />
BETAPACE AF TAB 80MG(Sotalol HCl (AFIB/AFL))<br />
betaxolol hcl tab 10 mg<br />
betaxolol hcl tab 20 mg<br />
BIDIL TAB(Isosorbide Dinitrate-Hydralazine HCl)<br />
bisoprolol & hydrochlorothiazide tab 10-6.25 mg<br />
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg<br />
bisoprolol & hydrochlorothiazide tab 5-6.25 mg<br />
bisoprolol fumarate tab 10 mg<br />
bisoprolol fumarate tab 5 mg<br />
CADUET TAB 10/10MG(Amlodipine Besylate-Atorvastatin Calcium)<br />
CADUET TAB 10/20MG(Amlodipine Besylate-Atorvastatin Calcium)<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
38
Drug Name Drug Tier Notes<br />
CADUET TAB 10/40MG(Amlodipine Besylate-Atorvastatin Calcium)<br />
CADUET TAB 10/80MG(Amlodipine Besylate-Atorvastatin Calcium)<br />
CADUET TAB 2.5/10MG(Amlodipine Besylate-Atorvastatin Calcium)<br />
CADUET TAB 2.5/20MG(Amlodipine Besylate-Atorvastatin Calcium)<br />
CADUET TAB 2.5/40MG(Amlodipine Besylate-Atorvastatin Calcium)<br />
CADUET TAB 5MG/10MG(Amlodipine Besylate-Atorvastatin Calcium)<br />
CADUET TAB 5MG/20MG(Amlodipine Besylate-Atorvastatin Calcium)<br />
CADUET TAB 5MG/40MG(Amlodipine Besylate-Atorvastatin Calcium)<br />
CADUET TAB 5MG/80MG(Amlodipine Besylate-Atorvastatin Calcium)<br />
CALAN TAB 120MG(Verapamil HCl)<br />
CALAN TAB 40MG(Verapamil HCl)<br />
CALAN TAB 80MG(Verapamil HCl)<br />
CALAN SR TAB 120MG(Verapamil HCl)<br />
CALAN SR TAB 180MG(Verapamil HCl)<br />
CALAN SR TAB 240MG(Verapamil HCl)<br />
CAPOTEN TAB 100MG(Captopril)<br />
CAPOTEN TAB 12.5MG(Captopril)<br />
CAPOTEN TAB 25MG(Captopril)<br />
CAPOTEN TAB 50MG(Captopril)<br />
CAPOZIDE TAB 25/15MG(Captopril & Hydrochlorothiazide)<br />
CAPOZIDE TAB 25/25MG(Captopril & Hydrochlorothiazide)<br />
CAPOZIDE TAB 50/15MG(Captopril & Hydrochlorothiazide)<br />
CAPOZIDE TAB 50/25MG(Captopril & Hydrochlorothiazide)<br />
captopril & hydrochlorothiazide tab 25-15 mg<br />
captopril & hydrochlorothiazide tab 25-25 mg<br />
captopril & hydrochlorothiazide tab 50-15 mg<br />
captopril & hydrochlorothiazide tab 50-25 mg<br />
captopril tab 100 mg<br />
captopril tab 12.5 mg<br />
captopril tab 25 mg<br />
captopril tab 50 mg<br />
CARDENE CAP 20MG(Nicardipine HCl)<br />
CARDENE CAP 30MG(Nicardipine HCl)<br />
CARDENE SR CAP 30MG(Nicardipine HCl)<br />
CARDENE SR CAP 45MG(Nicardipine HCl)<br />
CARDENE SR CAP 60MG(Nicardipine HCl)<br />
CARDIZEM TAB 120MG(Diltiazem HCl)<br />
CARDIZEM TAB 30MG(Diltiazem HCl)<br />
CARDIZEM TAB 60MG(Diltiazem HCl)<br />
CARDIZEM TAB 90MG(Diltiazem HCl)<br />
CARDIZEM CD CAP 120MG/24(Diltiazem HCl Coated Beads)<br />
CARDIZEM CD CAP 180MG/24(Diltiazem HCl Coated Beads)<br />
CARDIZEM CD CAP 240MG/24(Diltiazem HCl Coated Beads)<br />
CARDIZEM CD CAP 300MG/24(Diltiazem HCl Coated Beads)<br />
CARDIZEM CD CAP 360MG/24(Diltiazem HCl Coated Beads)<br />
CARDIZEM LA TAB 120MG(Diltiazem HCl Coated Beads)<br />
CARDIZEM LA TAB 180MG(Diltiazem HCl Coated Beads)<br />
CARDIZEM LA TAB 240MG(Diltiazem HCl Coated Beads)<br />
CARDIZEM LA TAB 300MG(Diltiazem HCl Coated Beads)<br />
CARDIZEM LA TAB 360MG(Diltiazem HCl Coated Beads)<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
39
Drug Name Drug Tier Notes<br />
CARDIZEM LA TAB 420MG(Diltiazem HCl Coated Beads)<br />
CARDURA TAB 1MG(Doxazosin Mesylate)<br />
CARDURA TAB 2MG(Doxazosin Mesylate)<br />
CARDURA TAB 4MG(Doxazosin Mesylate)<br />
CARDURA TAB 8MG(Doxazosin Mesylate)<br />
CARDURA XL TAB 4MG(Doxazosin Mesylate (BPH))<br />
CARDURA XL TAB 8MG(Doxazosin Mesylate (BPH))<br />
CARTROL TAB 2.5MG(Carteolol HCl)<br />
CARTROL TAB 5MG(Carteolol HCl)<br />
CATAPRES TAB 0.1MG(Clonidine HCl)<br />
CATAPRES TAB 0.2MG(Clonidine HCl)<br />
CATAPRES TAB 0.3MG(Clonidine HCl)<br />
CATAPRES-TTS DIS 0.1/24HR(Clonidine HCl)<br />
CATAPRES-TTS DIS 0.2/24HR(Clonidine HCl)<br />
CATAPRES-TTS DIS 0.3/24HR(Clonidine HCl)<br />
cholestyramine light powder 4 gm/dose<br />
cholestyramine light powder packets 4 gm<br />
cholestyramine powder 4 gm/dose<br />
cholestyramine powder packets 4 gm<br />
clonidine hcl tab 0.1 mg<br />
clonidine hcl tab 0.2 mg<br />
clonidine hcl tab 0.3 mg<br />
CLORPRES TAB 0.1-15MG(Clonidine & Chlorthalidone)<br />
CLORPRES TAB 0.2-15MG(Clonidine & Chlorthalidone)<br />
CLORPRES TAB 0.3-15MG(Clonidine & Chlorthalidone)<br />
COLESTID GRA 5GM(Colestipol HCl)<br />
COLESTID POW 5GM(Colestipol HCl)<br />
COLESTID TAB 1GM(Colestipol HCl)<br />
COLESTID FLA GRA 5/7.5GM(Colestipol HCl)<br />
COLESTID FLA GRA 5GM(Colestipol HCl)<br />
colestipol hcl granule packets 5 gm<br />
colestipol hcl granules 5 gm<br />
colestipol hcl tab 1 gm<br />
CORDARONE TAB 200MG(Amiodarone HCl)<br />
COREG TAB 12.5MG(Carvedilol)<br />
COREG TAB 25MG(Carvedilol)<br />
COREG TAB 3.125MG(Carvedilol)<br />
COREG TAB 6.25MG(Carvedilol)<br />
COREG CR CAP 10MG(Carvedilol Phosphate)<br />
COREG CR CAP 20MG(Carvedilol Phosphate)<br />
COREG CR CAP 40MG(Carvedilol Phosphate)<br />
COREG CR CAP 80MG(Carvedilol Phosphate)<br />
CORGARD TAB 20MG(Nadolol)<br />
CORGARD TAB 40MG(Nadolol)<br />
CORGARD TAB 80MG(Nadolol)<br />
CORZIDE TAB 40/5(Nadolol & Bendroflumethiazide)<br />
CORZIDE TAB 80/5(Nadolol & Bendroflumethiazide)<br />
COVERA-HS TAB 180MG(Verapamil HCl)<br />
COVERA-HS TAB 240MG(Verapamil HCl)<br />
COZAAR TAB 100MG(Losartan Potassium)<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
04<br />
40
Drug Name Drug Tier Notes<br />
COZAAR TAB 25MG(Losartan Potassium)<br />
COZAAR TAB 50MG(Losartan Potassium)<br />
CRESTOR TAB 10MG(Rosuvastatin Calcium)<br />
CRESTOR TAB 20MG(Rosuvastatin Calcium)<br />
CRESTOR TAB 40MG(Rosuvastatin Calcium)<br />
CRESTOR TAB 5MG(Rosuvastatin Calcium)<br />
DIAMOX CAP 500MG CR(Acetazolamide)<br />
digoxin inj 0.1 mg/ml<br />
digoxin inj 0.25 mg/ml<br />
digoxin oral soln 0.05 mg/ml<br />
digoxin tab 0.125 mg<br />
digoxin tab 0.25 mg<br />
DILACOR XR CAP 120MG/24(Diltiazem HCl)<br />
DILACOR XR CAP 180MG/24(Diltiazem HCl)<br />
DILACOR XR CAP 240MG/24(Diltiazem HCl)<br />
DILATRATE SR CAP 40MG(Isosorbide Dinitrate)<br />
diltiazem hcl cap sr 12hr 120 mg<br />
diltiazem hcl cap sr 12hr 60 mg<br />
diltiazem hcl cap sr 12hr 90 mg<br />
diltiazem hcl cap sr 24hr 120 mg<br />
diltiazem hcl cap sr 24hr 180 mg<br />
diltiazem hcl cap sr 24hr 240 mg<br />
diltiazem hcl coated beads cap sr 24hr 120 mg<br />
diltiazem hcl coated beads cap sr 24hr 180 mg<br />
diltiazem hcl coated beads cap sr 24hr 240 mg<br />
diltiazem hcl coated beads cap sr 24hr 300 mg<br />
diltiazem hcl extended release beads cap sr 24hr 120 mg<br />
diltiazem hcl extended release beads cap sr 24hr 180 mg<br />
diltiazem hcl extended release beads cap sr 24hr 240 mg<br />
diltiazem hcl extended release beads cap sr 24hr 300 mg<br />
diltiazem hcl extended release beads cap sr 24hr 360 mg<br />
diltiazem hcl extended release beads cap sr 24hr 420 mg<br />
diltiazem hcl iv soln 5 mg/ml<br />
diltiazem hcl tab 120 mg<br />
diltiazem hcl tab 30 mg<br />
diltiazem hcl tab 60 mg<br />
diltiazem hcl tab 90 mg<br />
DIOVAN TAB 160MG(Valsartan)<br />
DIOVAN TAB 320MG(Valsartan)<br />
DIOVAN TAB 40MG(Valsartan)<br />
DIOVAN TAB 80MG(Valsartan)<br />
DIOVAN HCT TAB 160/12.5(Valsartan-Hydrochlorothiazide)<br />
DIOVAN HCT TAB 160/25MG(Valsartan-Hydrochlorothiazide)<br />
DIOVAN HCT TAB 320/12.5(Valsartan-Hydrochlorothiazide)<br />
DIOVAN HCT TAB 320/25MG(Valsartan-Hydrochlorothiazide)<br />
DIOVAN HCT TAB 80/12.5(Valsartan-Hydrochlorothiazide)<br />
dipyridamole tab 25 mg<br />
dipyridamole tab 50 mg<br />
dipyridamole tab 75 mg<br />
disopyramide phosphate cap 100 mg<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
41
Drug Name Drug Tier Notes<br />
disopyramide phosphate cap 150 mg<br />
disopyramide phosphate cap sr 12hr 150 mg<br />
doxazosin mesylate tab 1 mg<br />
doxazosin mesylate tab 2 mg<br />
doxazosin mesylate tab 4 mg<br />
doxazosin mesylate tab 8 mg<br />
DYNACIRC CR TAB 10MG(Isradipine)<br />
DYNACIRC CR TAB 5MG(Isradipine)<br />
enalapril maleate & hydrochlorothiazide tab 10-25 mg<br />
enalapril maleate & hydrochlorothiazide tab 5-12.5 mg<br />
enalapril maleate tab 10 mg<br />
enalapril maleate tab 2.5 mg<br />
enalapril maleate tab 20 mg<br />
enalapril maleate tab 5 mg<br />
ETHMOZINE TAB 200MG(Moricizine HCl)<br />
ETHMOZINE TAB 250MG(Moricizine HCl)<br />
ETHMOZINE TAB 300MG(Moricizine HCl)<br />
EXFORGE TAB 10-160MG(Amlodipine Besylate-Valsartan)<br />
EXFORGE TAB 10-320MG(Amlodipine Besylate-Valsartan)<br />
EXFORGE TAB 5-160MG(Amlodipine Besylate-Valsartan)<br />
EXFORGE TAB 5-320MG(Amlodipine Besylate-Valsartan)<br />
felodipine tab sr 24hr 10 mg<br />
felodipine tab sr 24hr 2.5 mg<br />
felodipine tab sr 24hr 5 mg<br />
fenofibrate micronized cap 134 mg<br />
fenofibrate micronized cap 200 mg<br />
fenofibrate micronized cap 67 mg<br />
fenofibrate tab 160 mg<br />
fenofibrate tab 54 mg<br />
flecainide acetate tab 100 mg<br />
flecainide acetate tab 150 mg<br />
flecainide acetate tab 50 mg<br />
fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg<br />
fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg<br />
fosinopril sodium tab 10 mg<br />
fosinopril sodium tab 20 mg<br />
fosinopril sodium tab 40 mg<br />
gemfibrozil tab 600 mg<br />
guanabenz acetate tab 4 mg<br />
guanabenz acetate tab 8 mg<br />
guanfacine hcl tab 1 mg<br />
guanfacine hcl tab 2 mg<br />
hydralazine & hydrochlorothiazide cap 100-50 mg<br />
hydralazine & hydrochlorothiazide cap 25-25 mg<br />
hydralazine & hydrochlorothiazide cap 50-50 mg<br />
hydralazine hcl inj 20 mg/ml<br />
hydralazine hcl tab 10 mg<br />
hydralazine hcl tab 100 mg<br />
hydralazine hcl tab 25 mg<br />
hydralazine hcl tab 50 mg<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
42
Drug Name Drug Tier Notes<br />
HYPERTENSOLO PAK(Metoprolol Tartrate-Nutritional Supplement)<br />
HYTRIN CAP 10MG(Terazosin HCl)<br />
HYTRIN CAP 1MG(Terazosin HCl)<br />
HYTRIN CAP 2MG(Terazosin HCl)<br />
HYTRIN CAP 5MG(Terazosin HCl)<br />
HYZAAR TAB 100-12.5(Losartan Potassium & Hydrochlorothiazide)<br />
HYZAAR TAB 100-25(Losartan Potassium & Hydrochlorothiazide)<br />
HYZAAR TAB 50-12.5(Losartan Potassium & Hydrochlorothiazide)<br />
IMDUR TAB 120MG ER(Isosorbide Mononitrate)<br />
IMDUR TAB 30MG ER(Isosorbide Mononitrate)<br />
IMDUR TAB 60MG ER(Isosorbide Mononitrate)<br />
INDERAL TAB 60MG(Propranolol HCl)<br />
INDERAL LA CAP 120MG(Propranolol HCl)<br />
INDERAL LA CAP 160MG(Propranolol HCl)<br />
INDERAL LA CAP 60MG(Propranolol HCl)<br />
INDERAL LA CAP 80MG(Propranolol HCl)<br />
INDERIDE TAB 40/25(Propranolol & Hydrochlorothiazide)<br />
INNOPRAN XL CAP 120MG(Propranolol HCl Sustained-Release Beads)<br />
INNOPRAN XL CAP 80MG(Propranolol HCl Sustained-Release Beads)<br />
INSPRA TAB 25MG(Eplerenone)<br />
INSPRA TAB 50MG(Eplerenone)<br />
INVERSINE TAB 2.5MG(Mecamylamine HCl)<br />
ISMO TAB 20MG(Isosorbide Mononitrate)<br />
ISOPTIN SR TAB 120MG(Verapamil HCl)<br />
ISOPTIN SR TAB 180MG(Verapamil HCl)<br />
ISOPTIN SR TAB 240MG(Verapamil HCl)<br />
ISORDIL TAB 40MG(Isosorbide Dinitrate)<br />
ISORDIL TAB 5MG(Isosorbide Dinitrate)<br />
isosorbide dinitrate sl tab 2.5 mg<br />
isosorbide dinitrate sl tab 5 mg<br />
isosorbide dinitrate tab 10 mg<br />
isosorbide dinitrate tab 20 mg<br />
isosorbide dinitrate tab 30 mg<br />
isosorbide dinitrate tab 5 mg<br />
isosorbide dinitrate tab cr 40 mg<br />
isosorbide mononitrate tab 10 mg<br />
isosorbide mononitrate tab 20 mg<br />
isosorbide mononitrate tab sr 24hr 120 mg<br />
isosorbide mononitrate tab sr 24hr 30 mg<br />
isosorbide mononitrate tab sr 24hr 60 mg<br />
isradipine cap 2.5 mg<br />
isradipine cap 5 mg<br />
KERLONE TAB 10MG(Betaxolol HCl)<br />
KERLONE TAB 20MG(Betaxolol HCl)<br />
labetalol hcl iv soln 5 mg/ml<br />
labetalol hcl tab 100 mg<br />
labetalol hcl tab 200 mg<br />
labetalol hcl tab 300 mg<br />
LANOXICAPS CAP 0.1MG(Digoxin)<br />
LANOXICAPS CAP 0.2MG(Digoxin)<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
43
Drug Name Drug Tier Notes<br />
LANOXIN INJ 0.25MG/1(Digoxin)<br />
LANOXIN TAB 0.125MG(Digoxin)<br />
LANOXIN TAB 0.125MG(Digoxin)<br />
LANOXIN TAB 0.25MG(Digoxin)<br />
LANOXIN TAB 0.25MG(Digoxin)<br />
LESCOL CAP 20MG(Fluvastatin Sodium)<br />
LESCOL CAP 40MG(Fluvastatin Sodium)<br />
LESCOL XL TAB 80MG(Fluvastatin Sodium)<br />
LETAIRIS TAB 10MG(Ambrisentan)<br />
LETAIRIS TAB 5MG(Ambrisentan)<br />
LEVATOL TAB 20MG(Penbutolol Sulfate)<br />
LEXXEL TAB 5-5MG(Enalapril Maleate-Felodipine)<br />
lidocaine hcl iv inj 10 mg/ml<br />
lidocaine hcl iv inj 20 mg/ml<br />
LIPITOR TAB 10MG(Atorvastatin Calcium)<br />
LIPITOR TAB 20MG(Atorvastatin Calcium)<br />
LIPITOR TAB 40MG(Atorvastatin Calcium)<br />
LIPITOR TAB 80MG(Atorvastatin Calcium)<br />
lisinopril & hydrochlorothiazide tab 10-12.5 mg<br />
lisinopril & hydrochlorothiazide tab 20-12.5 mg<br />
lisinopril & hydrochlorothiazide tab 20-25 mg<br />
lisinopril tab 10 mg<br />
lisinopril tab 2.5 mg<br />
lisinopril tab 20 mg<br />
lisinopril tab 30 mg<br />
lisinopril tab 40 mg<br />
lisinopril tab 5 mg<br />
LOFIBRA CAP 134MG(Fenofibrate Micronized)<br />
LOFIBRA CAP 200MG(Fenofibrate Micronized)<br />
LOFIBRA CAP 67MG(Fenofibrate Micronized)<br />
LOFIBRA TAB 160MG(Fenofibrate)<br />
LOFIBRA TAB 54MG(Fenofibrate)<br />
LOPID TAB 600MG(Gemfibrozil)<br />
LOPRESS HCT TAB 100/25MG(Metoprolol & Hydrochlorothiazide)<br />
LOPRESS HCT TAB 100/50MG(Metoprolol & Hydrochlorothiazide)<br />
LOPRESS HCT TAB 50-25MG(Metoprolol & Hydrochlorothiazide)<br />
LOPRESSOR INJ 5MG/5ML(Metoprolol Tartrate)<br />
LOPRESSOR TAB 100MG(Metoprolol Tartrate)<br />
LOPRESSOR TAB 50MG(Metoprolol Tartrate)<br />
LOTENSIN TAB 10MG(Benazepril HCl)<br />
LOTENSIN TAB 20MG(Benazepril HCl)<br />
LOTENSIN TAB 40MG(Benazepril HCl)<br />
LOTENSIN TAB 5MG(Benazepril HCl)<br />
LOTENSIN HCT TAB 10-12.5(Benazepril & Hydrochlorothiazide)<br />
LOTENSIN HCT TAB 20-12.5(Benazepril & Hydrochlorothiazide)<br />
LOTENSIN HCT TAB 20-25MG(Benazepril & Hydrochlorothiazide)<br />
LOTENSIN HCT TAB 5-6.25MG(Benazepril & Hydrochlorothiazide)<br />
LOTREL CAP 10-20MG(Amlodipine Besylate-Benazepril HCl)<br />
LOTREL CAP 10-40MG(Amlodipine Besylate-Benazepril HCl)<br />
LOTREL CAP 2.5-10MG(Amlodipine Besylate-Benazepril HCl)<br />
04<br />
02<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
44
Drug Name Drug Tier Notes<br />
LOTREL CAP 5-10MG(Amlodipine Besylate-Benazepril HCl)<br />
LOTREL CAP 5-20MG(Amlodipine Besylate-Benazepril HCl)<br />
LOTREL CAP 5-40MG(Amlodipine Besylate-Benazepril HCl)<br />
lovastatin tab 10 mg<br />
lovastatin tab 20 mg<br />
lovastatin tab 40 mg<br />
LOVAZA CAP 1GM(Omega-3-acid Ethyl Esters)<br />
MAVIK TAB 1MG(Trandolapril)<br />
MAVIK TAB 2MG(Trandolapril)<br />
MAVIK TAB 4MG(Trandolapril)<br />
methazolamide tab 25 mg<br />
methazolamide tab 50 mg<br />
methyldopa & hydrochlorothiazide tab 250-15 mg<br />
methyldopa & hydrochlorothiazide tab 250-25 mg<br />
methyldopa tab 250 mg<br />
methyldopa tab 500 mg<br />
METHYLDOPATE INJ 250/5ML(Methyldopate HCl)<br />
METOPROLOL TAB 100MG ER(Metoprolol Succinate)<br />
METOPROLOL TAB 200MG ER(Metoprolol Succinate)<br />
METOPROLOL TAB 50MG ER(Metoprolol Succinate)<br />
metoprolol & hydrochlorothiazide tab 100-25 mg<br />
metoprolol & hydrochlorothiazide tab 100-50 mg<br />
metoprolol & hydrochlorothiazide tab 50-25 mg<br />
metoprolol succinate tab sr 24hr 25 mg<br />
metoprolol tartrate inj 1 mg/ml<br />
metoprolol tartrate tab 100 mg<br />
metoprolol tartrate tab 25 mg<br />
metoprolol tartrate tab 50 mg<br />
MEVACOR TAB 10MG(Lovastatin)<br />
MEVACOR TAB 20MG(Lovastatin)<br />
MEVACOR TAB 40MG(Lovastatin)<br />
MEXILETINE CAP 150MG(Mexiletine HCl)<br />
MEXILETINE CAP 200MG(Mexiletine HCl)<br />
MEXILETINE CAP 250MG(Mexiletine HCl)<br />
mexiletine hcl cap 150 mg<br />
mexiletine hcl cap 200 mg<br />
mexiletine hcl cap 250 mg<br />
MICARDIS TAB 20MG(Telmisartan)<br />
MICARDIS TAB 40MG(Telmisartan)<br />
MICARDIS TAB 80MG(Telmisartan)<br />
MICARDIS HCT TAB 40/12.5(Telmisartan-Hydrochlorothiazide)<br />
MICARDIS HCT TAB 80/12.5(Telmisartan-Hydrochlorothiazide)<br />
MICARDIS HCT TAB 80/25MG(Telmisartan-Hydrochlorothiazide)<br />
MINIPRESS CAP 1MG(Prazosin HCl)<br />
MINIPRESS CAP 2MG(Prazosin HCl)<br />
MINIPRESS CAP 5MG(Prazosin HCl)<br />
minoxidil tab 10 mg<br />
minoxidil tab 2.5 mg<br />
moexipril hcl tab 15 mg<br />
moexipril hcl tab 7.5 mg<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
02<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
(PA)<br />
45
Drug Name Drug Tier Notes<br />
moexipril-hydrochlorothiazide tab 15-12.5 mg<br />
moexipril-hydrochlorothiazide tab 15-25 mg<br />
moexipril-hydrochlorothiazide tab 7.5-12.5 mg<br />
MONOKET TAB 10MG(Isosorbide Mononitrate)<br />
MONOKET TAB 20MG(Isosorbide Mononitrate)<br />
MONOPRIL TAB 10MG(Fosinopril Sodium)<br />
MONOPRIL TAB 20MG(Fosinopril Sodium)<br />
MONOPRIL TAB 40MG(Fosinopril Sodium)<br />
MONOPRIL HCT TAB 10/12.5(Fosinopril Sodium & Hydrochlorothiazide)<br />
MONOPRIL HCT TAB 20/12.5(Fosinopril Sodium & Hydrochlorothiazide)<br />
nadolol tab 160 mg<br />
nadolol tab 20 mg<br />
nadolol tab 40 mg<br />
nadolol tab 80 mg<br />
NIASPAN TAB 1000 ER(Niacin (Antihyperlipidemic))<br />
NIASPAN TAB 500MG ER(Niacin (Antihyperlipidemic))<br />
NIASPAN TAB 750MG ER(Niacin (Antihyperlipidemic))<br />
nicardipine hcl cap 20 mg<br />
nicardipine hcl cap 30 mg<br />
nifedipine cap 10 mg<br />
nifedipine cap 20 mg<br />
nifedipine tab sr 24hr 30 mg<br />
nifedipine tab sr 24hr 60 mg<br />
nifedipine tab sr 24hr 90 mg<br />
nifedipine tab sr 24hr osmotic 30 mg<br />
nifedipine tab sr 24hr osmotic 60 mg<br />
nifedipine tab sr 24hr osmotic 90 mg<br />
nimodipine cap 30 mg<br />
NIMOTOP CAP 30MG(Nimodipine)<br />
NITRO-DUR DIS 0.1MG/HR(Nitroglycerin)<br />
NITRO-DUR DIS 0.2MG/HR(Nitroglycerin)<br />
NITRO-DUR DIS 0.3MG/HR(Nitroglycerin)<br />
NITRO-DUR DIS 0.4MG/HR(Nitroglycerin)<br />
NITRO-DUR DIS 0.6MG/HR(Nitroglycerin)<br />
NITRO-DUR DIS 0.8MG/HR(Nitroglycerin)<br />
nitroglycerin cap cr 2.5 mg<br />
nitroglycerin cap cr 6.5 mg<br />
nitroglycerin cap cr 9 mg<br />
nitroglycerin iv soln 5 mg/ml<br />
nitroglycerin oint 2%<br />
nitroglycerin sl tab 0.3 mg<br />
nitroglycerin sl tab 0.4 mg<br />
nitroglycerin sl tab 0.6 mg<br />
nitroglycerin td patch 24hr 0.1 mg/hr<br />
nitroglycerin td patch 24hr 0.2 mg/hr<br />
nitroglycerin td patch 24hr 0.4 mg/hr<br />
nitroglycerin td patch 24hr 0.6 mg/hr<br />
NITROLINGUAL SPR PUMPSPRA(Nitroglycerin)<br />
NITROSTAT SUB 0.3MG(Nitroglycerin)<br />
NITROSTAT SUB 0.4MG(Nitroglycerin)<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
46
Drug Name Drug Tier Notes<br />
NITROSTAT SUB 0.6MG(Nitroglycerin)<br />
NORPACE CAP 100MG(Disopyramide Phosphate)<br />
NORPACE CAP 100MG CR(Disopyramide Phosphate)<br />
NORPACE CAP 150MG(Disopyramide Phosphate)<br />
NORPACE CAP 150MG CR(Disopyramide Phosphate)<br />
NORVASC TAB 10MG(Amlodipine Besylate)<br />
NORVASC TAB 2.5MG(Amlodipine Besylate)<br />
NORVASC TAB 5MG(Amlodipine Besylate)<br />
PACERONE TAB 400MG(Amiodarone HCl)<br />
papaverine hcl cap cr 150 mg<br />
papaverine hcl inj 30 mg/ml<br />
PERSANTINE TAB 25MG(Dipyridamole)<br />
PERSANTINE TAB 50MG(Dipyridamole)<br />
PERSANTINE TAB 75MG(Dipyridamole)<br />
pindolol tab 10 mg<br />
pindolol tab 5 mg<br />
PLENDIL TAB 10MG CR(Felodipine)<br />
PLENDIL TAB 2.5MG CR(Felodipine)<br />
PLENDIL TAB 5MG CR(Felodipine)<br />
PRAVACHOL TAB 10MG(Pravastatin Sodium)<br />
PRAVACHOL TAB 20MG(Pravastatin Sodium)<br />
PRAVACHOL TAB 40MG(Pravastatin Sodium)<br />
PRAVACHOL TAB 80MG(Pravastatin Sodium)<br />
pravastatin sodium tab 10 mg<br />
pravastatin sodium tab 20 mg<br />
pravastatin sodium tab 40 mg<br />
pravastatin sodium tab 80 mg<br />
prazosin hcl cap 1 mg<br />
prazosin hcl cap 2 mg<br />
prazosin hcl cap 5 mg<br />
PRINIVIL TAB 10MG(Lisinopril)<br />
PRINIVIL TAB 20MG(Lisinopril)<br />
PRINIVIL TAB 5MG(Lisinopril)<br />
PRINZIDE TAB 10/12.5(Lisinopril & Hydrochlorothiazide)<br />
PRINZIDE TAB 20-12.5(Lisinopril & Hydrochlorothiazide)<br />
PRINZIDE TAB 20-25MG(Lisinopril & Hydrochlorothiazide)<br />
procainamide hcl cap 250 mg<br />
procainamide hcl cap 500 mg<br />
procainamide hcl inj 100 mg/ml<br />
procainamide hcl inj 500 mg/ml<br />
procainamide hcl tab cr 500 mg<br />
procainamide hcl tab cr 750 mg<br />
PROCANBID TAB 1000 MG(Procainamide HCl)<br />
PROCANBID TAB 500MG CR(Procainamide HCl)<br />
PROCARDIA CAP 10MG(Nifedipine)<br />
PROCARDIA XL TAB 30MG CR(Nifedipine)<br />
PROCARDIA XL TAB 60MG CR(Nifedipine)<br />
PROCARDIA XL TAB 90MG CR(Nifedipine)<br />
PRONESTYL CAP 250MG(Procainamide HCl)<br />
PRONESTYL CAP 375MG(Procainamide HCl)<br />
02<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
04<br />
04<br />
04<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
47
Drug Name Drug Tier Notes<br />
PRONESTYL TAB 375MG(Procainamide HCl)<br />
PRONESTYL TAB 500MG(Procainamide HCl)<br />
propafenone hcl tab 150 mg<br />
propafenone hcl tab 225 mg<br />
propafenone hcl tab 300 mg<br />
propranolol & hydrochlorothiazide tab 40-25 mg<br />
propranolol & hydrochlorothiazide tab 80-25 mg<br />
propranolol hcl cap sr 24hr 120 mg<br />
propranolol hcl cap sr 24hr 160 mg<br />
propranolol hcl cap sr 24hr 60 mg<br />
propranolol hcl cap sr 24hr 80 mg<br />
propranolol hcl inj 1 mg/ml<br />
propranolol hcl tab 10 mg<br />
propranolol hcl tab 20 mg<br />
propranolol hcl tab 40 mg<br />
propranolol hcl tab 60 mg<br />
propranolol hcl tab 80 mg<br />
QUESTRAN POW 4GM(Cholestyramine)<br />
QUESTRAN POW 4GM LITE(Cholestyramine Light)<br />
quinapril hcl tab 10 mg<br />
quinapril hcl tab 20 mg<br />
quinapril hcl tab 40 mg<br />
quinapril hcl tab 5 mg<br />
quinapril-hydrochlorothiazide tab 10-12.5 mg<br />
quinapril-hydrochlorothiazide tab 20-12.5 mg<br />
quinapril-hydrochlorothiazide tab 20-25 mg<br />
quinidine gluconate inj 80 mg/ml<br />
quinidine gluconate tab cr 324 mg<br />
quinidine sulfate tab 200 mg<br />
quinidine sulfate tab 300 mg<br />
quinidine sulfate tab cr 300 mg<br />
RANEXA TAB 500MG(Ranolazine)<br />
reserpine tab 0.1 mg<br />
reserpine tab 0.25 mg<br />
REVATIO TAB 20MG(Sildenafil Citrate (Pulmonary Hypertension))<br />
RYTHMOL TAB 150MG(Propafenone HCl)<br />
RYTHMOL TAB 225MG(Propafenone HCl)<br />
RYTHMOL TAB 300MG(Propafenone HCl)<br />
RYTHMOL SR CAP 225MG(Propafenone HCl)<br />
RYTHMOL SR CAP 325MG(Propafenone HCl)<br />
RYTHMOL SR CAP 425MG(Propafenone HCl)<br />
SECTRAL CAP 200MG(Acebutolol HCl)<br />
SECTRAL CAP 400MG(Acebutolol HCl)<br />
simvastatin tab 10 mg<br />
simvastatin tab 20 mg<br />
simvastatin tab 40 mg<br />
simvastatin tab 5 mg<br />
simvastatin tab 80 mg<br />
sotalol hcl (afib/afl) tab 120 mg<br />
sotalol hcl (afib/afl) tab 160 mg<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
01<br />
01<br />
02<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
(PA)<br />
(PA)<br />
48
Drug Name Drug Tier Notes<br />
sotalol hcl (afib/afl) tab 80 mg<br />
sotalol hcl tab 120 mg<br />
sotalol hcl tab 160 mg<br />
sotalol hcl tab 240 mg<br />
sotalol hcl tab 80 mg<br />
spironolactone & hydrochlorothiazide tab 25-25 mg<br />
spironolactone tab 100 mg<br />
spironolactone tab 25 mg<br />
spironolactone tab 50 mg<br />
SULAR TAB 10MG CR(Nisoldipine)<br />
SULAR TAB 20MG CR(Nisoldipine)<br />
SULAR TAB 30MG CR(Nisoldipine)<br />
SULAR TAB 40MG CR(Nisoldipine)<br />
TAMBOCOR TAB 100MG(Flecainide Acetate)<br />
TAMBOCOR TAB 150MG(Flecainide Acetate)<br />
TAMBOCOR TAB 50MG(Flecainide Acetate)<br />
TARKA TAB 1-240 CR(Trandolapril-Verapamil HCl)<br />
TARKA TAB 2-180 CR(Trandolapril-Verapamil HCl)<br />
TARKA TAB 2-240 CR(Trandolapril-Verapamil HCl)<br />
TARKA TAB 4-240 CR(Trandolapril-Verapamil HCl)<br />
TEKTURNA TAB 150MG(Aliskiren Fumarate)<br />
TEKTURNA TAB 300MG(Aliskiren Fumarate)<br />
TENEX TAB 1MG(Guanfacine HCl)<br />
TENEX TAB 2MG(Guanfacine HCl)<br />
TENORETIC TAB -100(Atenolol & Chlorthalidone)<br />
TENORETIC TAB -50(Atenolol & Chlorthalidone)<br />
TENORMIN INJ 5MG/10ML(Atenolol)<br />
TENORMIN TAB 100MG(Atenolol)<br />
TENORMIN TAB 25MG(Atenolol)<br />
TENORMIN TAB 50MG(Atenolol)<br />
terazosin hcl cap 1 mg<br />
terazosin hcl cap 10 mg<br />
terazosin hcl cap 2 mg<br />
terazosin hcl cap 5 mg<br />
TEVETEN TAB 400MG(Eprosartan Mesylate)<br />
TEVETEN TAB 600MG(Eprosartan Mesylate)<br />
TEVETEN HCT TAB 600-12.5(Eprosartan Mesylate-Hydrochlorothiazide)<br />
TEVETEN HCT TAB 600-25MG(Eprosartan Mesylate-Hydrochlorothiazide)<br />
TIAZAC CAP 120MG/24(Diltiazem HCl Extended Release Beads)<br />
TIAZAC CAP 180MG/24(Diltiazem HCl Extended Release Beads)<br />
TIAZAC CAP 240MG/24(Diltiazem HCl Extended Release Beads)<br />
TIAZAC CAP 300MG/24(Diltiazem HCl Extended Release Beads)<br />
TIAZAC CAP 360MG/24(Diltiazem HCl Extended Release Beads)<br />
TIAZAC CAP 420MG/24(Diltiazem HCl Extended Release Beads)<br />
TIKOSYN CAP 125MCG(Dofetilide)<br />
TIKOSYN CAP 250MCG(Dofetilide)<br />
TIKOSYN CAP 500MCG(Dofetilide)<br />
TIMOLIDE TAB 10/25(Timolol & Hydrochlorothiazide)<br />
timolol maleate tab 10 mg<br />
timolol maleate tab 20 mg<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
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02<br />
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04<br />
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04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
49
Drug Name Drug Tier Notes<br />
timolol maleate tab 5 mg<br />
TOPROL XL TAB 100MG(Metoprolol Succinate)<br />
TOPROL XL TAB 200MG(Metoprolol Succinate)<br />
TOPROL XL TAB 25MG(Metoprolol Succinate)<br />
TOPROL XL TAB 50MG(Metoprolol Succinate)<br />
TRACLEER TAB 125MG(Bosentan)<br />
TRACLEER TAB 62.5MG(Bosentan)<br />
TRANDATE TAB 100MG(Labetalol HCl)<br />
TRANDATE TAB 200MG(Labetalol HCl)<br />
TRANDATE TAB 300MG(Labetalol HCl)<br />
TRANDATE IV INJ 5MG/ML(Labetalol HCl)<br />
trandolapril tab 1 mg<br />
trandolapril tab 2 mg<br />
trandolapril tab 4 mg<br />
TRICOR TAB 145MG(Fenofibrate)<br />
TRICOR TAB 48MG(Fenofibrate)<br />
TRIGLIDE TAB 160MG(Fenofibrate)<br />
TRIGLIDE TAB 50MG(Fenofibrate)<br />
UNIRETIC TAB 15-12.5(Moexipril-Hydrochlorothiazide)<br />
UNIRETIC TAB 15/25MG(Moexipril-Hydrochlorothiazide)<br />
UNIRETIC TAB 7.5/12.5(Moexipril-Hydrochlorothiazide)<br />
UNIVASC TAB 15MG(Moexipril HCl)<br />
UNIVASC TAB 7.5MG(Moexipril HCl)<br />
VASERETIC TAB 10-25MG(Enalapril Maleate & Hydrochlorothiazide)<br />
VASOTEC TAB 10MG(Enalapril Maleate)<br />
VASOTEC TAB 2.5MG(Enalapril Maleate)<br />
VASOTEC TAB 20MG(Enalapril Maleate)<br />
VASOTEC TAB 5MG(Enalapril Maleate)<br />
verapamil hcl cap sr 24hr 120 mg<br />
verapamil hcl cap sr 24hr 180 mg<br />
verapamil hcl cap sr 24hr 240 mg<br />
verapamil hcl cap sr 24hr 360 mg<br />
verapamil hcl iv soln 2.5 mg/ml<br />
verapamil hcl tab 120 mg<br />
verapamil hcl tab 40 mg<br />
verapamil hcl tab 80 mg<br />
verapamil hcl tab cr 120 mg<br />
verapamil hcl tab cr 180 mg<br />
verapamil hcl tab cr 240 mg<br />
VERELAN CAP 120MG SR(Verapamil HCl)<br />
VERELAN CAP 180MG(Verapamil HCl)<br />
VERELAN CAP 240MG SR(Verapamil HCl)<br />
VERELAN CAP 360MG SR(Verapamil HCl)<br />
VERELAN PM CAP 100MG(Verapamil HCl)<br />
VERELAN PM CAP 200MG(Verapamil HCl)<br />
VERELAN PM CAP 300MG(Verapamil HCl)<br />
VYTORIN TAB 10-10MG(Ezetimibe-Simvastatin)<br />
VYTORIN TAB 10-20MG(Ezetimibe-Simvastatin)<br />
VYTORIN TAB 10-40MG(Ezetimibe-Simvastatin)<br />
VYTORIN TAB 10-80MG(Ezetimibe-Simvastatin)<br />
01<br />
02<br />
02<br />
04<br />
02<br />
02<br />
02<br />
04<br />
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04<br />
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01<br />
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02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
(PA)<br />
(PA)<br />
50
Drug Name Drug Tier Notes<br />
WELCHOL TAB 625MG(Colesevelam HCl)<br />
XYLOCAINE INJ 2%(Lidocaine HCl (Cardiac))<br />
ZEBETA TAB 10MG(Bisoprolol Fumarate)<br />
ZEBETA TAB 5MG(Bisoprolol Fumarate)<br />
ZESTORETIC TAB 10/12.5(Lisinopril & Hydrochlorothiazide)<br />
ZESTORETIC TAB 20-12.5(Lisinopril & Hydrochlorothiazide)<br />
ZESTORETIC TAB 20-25MG(Lisinopril & Hydrochlorothiazide)<br />
ZESTRIL TAB 10MG(Lisinopril)<br />
ZESTRIL TAB 2.5MG(Lisinopril)<br />
ZESTRIL TAB 20MG(Lisinopril)<br />
ZESTRIL TAB 30MG(Lisinopril)<br />
ZESTRIL TAB 40MG(Lisinopril)<br />
ZESTRIL TAB 5MG(Lisinopril)<br />
ZETIA TAB 10MG(Ezetimibe)<br />
ZIAC TAB 10/6.25(Bisoprolol & Hydrochlorothiazide)<br />
ZIAC TAB 2.5/6.25(Bisoprolol & Hydrochlorothiazide)<br />
ZIAC TAB 5/6.25MG(Bisoprolol & Hydrochlorothiazide)<br />
ZOCOR TAB 10MG(Simvastatin)<br />
ZOCOR TAB 20MG(Simvastatin)<br />
ZOCOR TAB 40MG(Simvastatin)<br />
ZOCOR TAB 5MG(Simvastatin)<br />
ZOCOR TAB 80MG(Simvastatin)<br />
Central Nervous System Agents<br />
ABILIFY INJ 9.75MG(Aripiprazole)<br />
ABILIFY SOL 1MG/ML(Aripiprazole)<br />
ABILIFY TAB 10MG(Aripiprazole)<br />
ABILIFY TAB 15MG(Aripiprazole)<br />
ABILIFY TAB 20MG(Aripiprazole)<br />
ABILIFY TAB 2MG(Aripiprazole)<br />
ABILIFY TAB 30MG(Aripiprazole)<br />
ABILIFY TAB 5MG(Aripiprazole)<br />
ABILIFY DISC TAB 10MG(Aripiprazole)<br />
ABILIFY DISC TAB 15MG(Aripiprazole)<br />
acetaminophen w/ codeine soln 120-12 mg/5ml<br />
acetaminophen w/ codeine susp 120-12 mg/5ml<br />
acetaminophen w/ codeine tab 300-15 mg<br />
acetaminophen w/ codeine tab 300-30 mg<br />
acetaminophen w/ codeine tab 300-60 mg<br />
acetaminophen w/ codeine tab 650-30 mg<br />
acetaminophen-caffeine-dihydrocodeine tab 712.8-60-32 mg<br />
ADDERALL TAB 10MG(Amphetamine-Dextroamphetamine)<br />
ADDERALL TAB 12.5MG(Amphetamine-Dextroamphetamine)<br />
ADDERALL TAB 15MG(Amphetamine-Dextroamphetamine)<br />
ADDERALL TAB 20MG(Amphetamine-Dextroamphetamine)<br />
ADDERALL TAB 30MG(Amphetamine-Dextroamphetamine)<br />
ADDERALL TAB 5MG(Amphetamine-Dextroamphetamine)<br />
ADDERALL TAB 7.5MG(Amphetamine-Dextroamphetamine)<br />
ADDERALL XR CAP 10MG(Amphetamine-Dextroamphetamine)<br />
ADDERALL XR CAP 15MG(Amphetamine-Dextroamphetamine)<br />
04<br />
04<br />
04<br />
04<br />
04<br />
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02<br />
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02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
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01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
(STC)<br />
51
Drug Name Drug Tier Notes<br />
ADDERALL XR CAP 20MG(Amphetamine-Dextroamphetamine)<br />
ADDERALL XR CAP 25MG(Amphetamine-Dextroamphetamine)<br />
ADDERALL XR CAP 30MG(Amphetamine-Dextroamphetamine)<br />
ADDERALL XR CAP 5MG(Amphetamine-Dextroamphetamine)<br />
ALCET TAB 10-500MG(Oxycodone w/ Acetaminophen)<br />
AMBIEN TAB 10MG(Zolpidem Tartrate)<br />
AMBIEN TAB 5MG(Zolpidem Tartrate)<br />
AMBIEN CR TAB 12.5MG(Zolpidem Tartrate)<br />
AMBIEN CR TAB 6.25MG(Zolpidem Tartrate)<br />
AMERGE TAB 1MG(Naratriptan HCl)<br />
AMERGE TAB 2.5MG(Naratriptan HCl)<br />
amitriptyline hcl tab 10 mg<br />
amitriptyline hcl tab 100 mg<br />
amitriptyline hcl tab 150 mg<br />
amitriptyline hcl tab 25 mg<br />
amitriptyline hcl tab 50 mg<br />
amitriptyline hcl tab 75 mg<br />
amoxapine tab 100 mg<br />
amoxapine tab 150 mg<br />
amoxapine tab 25 mg<br />
amoxapine tab 50 mg<br />
amphetamine-dextroamphetamine tab 10 mg<br />
amphetamine-dextroamphetamine tab 12.5 mg<br />
amphetamine-dextroamphetamine tab 15 mg<br />
amphetamine-dextroamphetamine tab 20 mg<br />
amphetamine-dextroamphetamine tab 30 mg<br />
amphetamine-dextroamphetamine tab 5 mg<br />
amphetamine-dextroamphetamine tab 7.5 mg<br />
ANAFRANIL CAP 25MG(Clomipramine HCl)<br />
ANAFRANIL CAP 50MG(Clomipramine HCl)<br />
ANAFRANIL CAP 75MG(Clomipramine HCl)<br />
ANAPROX TAB 275MG(Naproxen Sodium)<br />
ANAPROX DS TAB 550MG(Naproxen Sodium)<br />
ANSAID TAB 100MG(Flurbiprofen)<br />
apap-salicylamide-phenyltolox-caffeine cap 325-250-20-50 mg<br />
APOKYN INJ(Apomorphine Hydrochloride)<br />
APPBUTAMONE PAK(Bupropion HCl-Nutritional Supplement)<br />
APPBUTAMONE PAK -D(Bupropion HCl-Nutritional Supplement)<br />
AQUACHLORAL SUP 325MG(Chloral Hydrate)<br />
ARTHROTEC 50 TAB(Diclofenac w/ Misoprostol)<br />
ARTHROTEC 75 TAB(Diclofenac w/ Misoprostol)<br />
aspirin w/ codeine tab 325-30 mg<br />
aspirin w/ codeine tab 325-60 mg<br />
AVINZA CAP 120MG ER(Morphine Sulfate Beads)<br />
AVINZA CAP 30MG ER(Morphine Sulfate Beads)<br />
AVINZA CAP 60MG ER(Morphine Sulfate Beads)<br />
AVINZA CAP 90MG CR(Morphine Sulfate Beads)<br />
AVINZA CAP 90MG ER(Morphine Sulfate Beads)<br />
AXERT TAB 12.5MG(Almotriptan Malate)<br />
AXERT TAB 6.25MG(Almotriptan Malate)<br />
02<br />
02<br />
02<br />
02<br />
04<br />
02<br />
02<br />
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04<br />
04<br />
04<br />
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02<br />
02<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
52
Drug Name Drug Tier Notes<br />
AZILECT TAB 0.5MG(Rasagiline Mesylate)<br />
AZILECT TAB 1MG(Rasagiline Mesylate)<br />
BALACET 325 TAB(Propoxyphene-N w/ APAP)<br />
BUPRENEX INJ 0.324/ML(Buprenorphine HCl)<br />
buprenorphine hcl inj 0.324 mg/ml (0.3 mg/ml base equiv)<br />
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg<br />
bupropion hcl tab 100 mg<br />
bupropion hcl tab 75 mg<br />
bupropion hcl tab sr 12hr 100 mg<br />
bupropion hcl tab sr 12hr 150 mg<br />
bupropion hcl tab sr 12hr 200 mg<br />
bupropion hcl tab sr 24hr 300 mg<br />
bupropion xl tab 300mg<br />
BUSPAR TAB 10MG(Buspirone HCl)<br />
BUSPAR TAB 15MG(Buspirone HCl)<br />
BUSPAR TAB 30MG(Buspirone HCl)<br />
BUSPAR TAB 5MG(Buspirone HCl)<br />
buspirone hcl tab 10 mg<br />
buspirone hcl tab 15 mg<br />
buspirone hcl tab 30 mg<br />
buspirone hcl tab 5 mg<br />
buspirone hcl tab 7.5 mg<br />
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg<br />
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg<br />
butorphanol tartrate inj 1 mg/ml<br />
butorphanol tartrate inj 2 mg/ml<br />
butorphanol tartrate nasal soln 10 mg/ml<br />
CAFERGOT TAB 1-100MG(Ergotamine w/ Caffeine)<br />
CAFFEINE/SOD INJ BENZOATE(Caffeine & Sodium Benzoate)<br />
CAMPRAL TAB 333MG(Acamprosate Calcium)<br />
carbamazepine chew tab 100 mg<br />
carbamazepine susp 100 mg/5ml<br />
carbamazepine tab 200 mg<br />
CARBATROL CAP 100MG(Carbamazepine)<br />
CARBATROL CAP 200MG(Carbamazepine)<br />
CARBATROL CAP 300MG(Carbamazepine)<br />
carbidopa & levodopa orally disintegrating tab 10-100 mg<br />
carbidopa & levodopa orally disintegrating tab 25-100 mg<br />
carbidopa & levodopa orally disintegrating tab 25-250 mg<br />
carbidopa & levodopa tab 10-100 mg<br />
carbidopa & levodopa tab 25-100 mg<br />
carbidopa & levodopa tab 25-250 mg<br />
carbidopa & levodopa tab cr 25-100 mg<br />
carbidopa & levodopa tab cr 50-200 mg<br />
carbidopa tab 25 mg<br />
CATAFLAM TAB 50MG(Diclofenac Potassium)<br />
CELEBREX CAP 100MG(Celecoxib)<br />
CELEBREX CAP 200MG(Celecoxib)<br />
CELEBREX CAP 400MG(Celecoxib)<br />
CELEBREX CAP 50MG(Celecoxib)<br />
04<br />
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04<br />
02<br />
02<br />
02<br />
02<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
53
Drug Name Drug Tier Notes<br />
CELEXA SOL 10MG/5ML(Citalopram Hydrobromide)<br />
CELEXA TAB 10MG(Citalopram Hydrobromide)<br />
CELEXA TAB 20MG(Citalopram Hydrobromide)<br />
CELEXA TAB 40MG(Citalopram Hydrobromide)<br />
CELONTIN CAP 300MG(Methsuximide)<br />
CEREBYX INJ 50MG/ML(Fosphenytoin Sodium)<br />
chloral hydrate cap 500 mg<br />
chloral hydrate suppos 500 mg<br />
chloral hydrate syrup 500 mg/5ml<br />
chlordiazepoxide-amitriptyline tab 10-25 mg<br />
chlordiazepoxide-amitriptyline tab 5-12.5 mg<br />
CHLORPROMAZ INJ 25MG/ML(Chlorpromazine HCl)<br />
chlorpromazine hcl tab 10 mg<br />
chlorpromazine hcl tab 100 mg<br />
chlorpromazine hcl tab 200 mg<br />
chlorpromazine hcl tab 25 mg<br />
chlorpromazine hcl tab 50 mg<br />
choline & magnesium salicylates liq 500 mg/5ml<br />
choline & magnesium salicylates tab 1000 mg<br />
choline & magnesium salicylates tab 500 mg<br />
choline & magnesium salicylates tab 750 mg<br />
citalopram hydrobromide oral soln 10 mg/5ml<br />
citalopram hydrobromide tab 10 mg (base equiv)<br />
citalopram hydrobromide tab 20 mg (base equiv)<br />
citalopram hydrobromide tab 40 mg (base equiv)<br />
CLINORIL TAB 200MG(Sulindac)<br />
clomipramine hcl cap 25 mg<br />
clomipramine hcl cap 50 mg<br />
clomipramine hcl cap 75 mg<br />
clozapine tab 100 mg<br />
clozapine tab 200 mg<br />
clozapine tab 25 mg<br />
clozapine tab 50 mg<br />
CLOZARIL TAB 100MG(Clozapine)<br />
CLOZARIL TAB 25MG(Clozapine)<br />
CODEINE PHOS INJ 30MG/2ML(Codeine Phosphate)<br />
CODEINE PHOS INJ 60MG/2ML(Codeine Phosphate)<br />
CODEINE PHOS TAB SOL 30MG(Codeine Phosphate)<br />
CODEINE PHOS TAB SOL 60MG(Codeine Phosphate)<br />
codeine phosphate inj 15 mg/ml<br />
codeine phosphate inj 30 mg/ml<br />
codeine sulfate tab 15 mg<br />
codeine sulfate tab 30 mg<br />
codeine sulfate tab 60 mg<br />
COMBUNOX TAB 5/400MG(Oxycodone-Ibuprofen)<br />
COMTAN TAB 200MG(Entacapone)<br />
CONCERTA TAB 18MG(Methylphenidate HCl)<br />
CONCERTA TAB 27MG(Methylphenidate HCl)<br />
CONCERTA TAB 36MG(Methylphenidate HCl)<br />
CONCERTA TAB 54MG(Methylphenidate HCl)<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
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01<br />
01<br />
01<br />
01<br />
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01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
54
Drug Name Drug Tier Notes<br />
CYMBALTA CAP 20MG(Duloxetine HCl)<br />
CYMBALTA CAP 30MG(Duloxetine HCl)<br />
CYMBALTA CAP 60MG(Duloxetine HCl)<br />
D.H.E. 45 INJ 1MG/ML(Dihydroergotamine Mesylate)<br />
DARVOCET TAB A500(Propoxyphene-N w/ APAP)<br />
DARVOCET-N TAB 100(Propoxyphene-N w/ APAP)<br />
DARVOCET-N TAB 50(Propoxyphene-N w/ APAP)<br />
DARVON CAP 65MG(Propoxyphene HCl)<br />
DARVON-N TAB 100MG(Propoxyphene Napsylate)<br />
DAYPRO TAB 600MG(Oxaprozin)<br />
DEMEROL INJ 100MG/ML(Meperidine HCl)<br />
DEMEROL INJ 25MG/ML(Meperidine HCl)<br />
DEMEROL INJ 50MG/ML(Meperidine HCl)<br />
DEMEROL INJ 75MG/1.5(Meperidine HCl)<br />
DEMEROL INJ 75MG/ML(Meperidine HCl)<br />
DEMEROL SYP 50MG/5ML(Meperidine HCl)<br />
DEMEROL TAB 100MG(Meperidine HCl)<br />
DEMEROL TAB 50MG(Meperidine HCl)<br />
DEPACON INJ 100MG/ML(Valproate Sodium)<br />
DEPAKENE CAP 250MG(Valproic Acid)<br />
DEPAKENE SYP 250/5ML(Valproate Sodium)<br />
DEPAKOTE TAB 125MG DR(Divalproex Sodium)<br />
DEPAKOTE TAB 250MG DR(Divalproex Sodium)<br />
DEPAKOTE TAB 500MG DR(Divalproex Sodium)<br />
DEPAKOTE ER TAB 250 MG(Divalproex Sodium (Migraine))<br />
DEPAKOTE ER TAB 500MG(Divalproex Sodium (Migraine))<br />
DEPAKOTE SPR CAP 125 MG(Divalproex Sodium)<br />
DEPODUR INJ 10MG/ML(Morphine Sulfate Liposome)<br />
DEPODUR INJ 15/1.5ML(Morphine Sulfate Liposome)<br />
desipramine hcl tab 10 mg<br />
desipramine hcl tab 100 mg<br />
desipramine hcl tab 150 mg<br />
desipramine hcl tab 25 mg<br />
desipramine hcl tab 50 mg<br />
desipramine hcl tab 75 mg<br />
DESOXYN TAB 5MG(Methamphetamine HCl)<br />
DEXEDRINE CAP 10MG(Dextroamphetamine Sulfate)<br />
DEXEDRINE CAP 15MG CR(Dextroamphetamine Sulfate)<br />
DEXEDRINE CAP 5MG CR(Dextroamphetamine Sulfate)<br />
dexmedetomidine hcl inj 100 mcg/ml (for iv infusion)<br />
dexmethylphenidate hcl tab 10 mg<br />
dexmethylphenidate hcl tab 2.5 mg<br />
dexmethylphenidate hcl tab 5 mg<br />
dextroamphetamine sulfate cap sr 24hr 10 mg<br />
dextroamphetamine sulfate cap sr 24hr 15 mg<br />
dextroamphetamine sulfate cap sr 24hr 5 mg<br />
dextroamphetamine sulfate tab 10 mg<br />
dextroamphetamine sulfate tab 5 mg<br />
DEXTROSTAT TAB 10MG(Dextroamphetamine Sulfate)<br />
diclofenac potassium tab 50 mg<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
01<br />
55
Drug Name Drug Tier Notes<br />
diclofenac sodium tab delayed release 25 mg<br />
diclofenac sodium tab delayed release 50 mg<br />
diclofenac sodium tab delayed release 75 mg<br />
diclofenac sodium tab sr 24hr 100 mg<br />
diflunisal tab 500 mg<br />
dihydroergotamine mesylate inj 1 mg/ml<br />
DILANTIN CAP 100MG(Phenytoin Sodium Extended)<br />
DILANTIN CAP 100MG(Phenytoin Sodium Extended)<br />
DILANTIN CAP 30MG(Phenytoin Sodium Extended)<br />
DILANTIN CHW 50MG(Phenytoin)<br />
DILANTIN-125 SUS 125/5ML(Phenytoin)<br />
DILAUDID INJ 1MG/ML(Hydromorphone HCl)<br />
DILAUDID INJ 2MG/ML(Hydromorphone HCl)<br />
DILAUDID INJ 4MG/ML(Hydromorphone HCl)<br />
DILAUDID SUP 3MG(Hydromorphone HCl)<br />
DILAUDID TAB 2MG(Hydromorphone HCl)<br />
DILAUDID TAB 4MG(Hydromorphone HCl)<br />
DILAUDID TAB 8MG(Hydromorphone HCl)<br />
DILAUDID-5 LIQ 1MG/ML(Hydromorphone HCl)<br />
DILAUDID-HP INJ 10MG/ML(Hydromorphone HCl)<br />
DILAUDID-HP INJ 250MG(Hydromorphone HCl)<br />
DOLOPHINE TAB 10MG(Methadone HCl)<br />
DOLOPHINE TAB 5MG(Methadone HCl)<br />
doxepin hcl cap 10 mg<br />
doxepin hcl cap 100 mg<br />
doxepin hcl cap 150 mg<br />
doxepin hcl cap 25 mg<br />
doxepin hcl cap 50 mg<br />
doxepin hcl cap 75 mg<br />
doxepin hcl conc 10 mg/ml<br />
droperidol inj 2.5 mg/ml<br />
duloxetine hcl enteric coated pellets cap 60 mg<br />
DURABAC CAP(Acetaminophen-Salicylamide-Phenyltoloxamine-Caffeine)<br />
DURAGESIC DIS 100MCG/H(Fentanyl)<br />
DURAGESIC DIS 12(12.5)(Fentanyl)<br />
DURAGESIC DIS 25MCG/HR(Fentanyl)<br />
DURAGESIC DIS 50MCG/HR(Fentanyl)<br />
DURAGESIC DIS 75MCG/HR(Fentanyl)<br />
EC-NAPROSYN TAB 375MG(Naproxen)<br />
EC-NAPROSYN TAB 500MG(Naproxen)<br />
EFFEXOR TAB 100MG(Venlafaxine HCl)<br />
EFFEXOR TAB 25MG(Venlafaxine HCl)<br />
EFFEXOR TAB 37.5MG(Venlafaxine HCl)<br />
EFFEXOR TAB 50MG(Venlafaxine HCl)<br />
EFFEXOR TAB 75MG(Venlafaxine HCl)<br />
EFFEXOR XR CAP 150MG(Venlafaxine HCl)<br />
EFFEXOR XR CAP 37.5MG(Venlafaxine HCl)<br />
EFFEXOR XR CAP 75MG(Venlafaxine HCl)<br />
ELDEPRYL CAP 5MG(Selegiline HCl)<br />
EMSAM DIS 12MG/24H(Selegiline)<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
02<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(PA)<br />
56
Drug Name Drug Tier Notes<br />
EMSAM DIS 6MG/24HR(Selegiline)<br />
EMSAM DIS 9MG/24HR(Selegiline)<br />
EQUETRO CAP 100MG(Carbamazepine (Antipsychotic))<br />
EQUETRO CAP 200MG(Carbamazepine (Antipsychotic))<br />
EQUETRO CAP 300MG(Carbamazepine (Antipsychotic))<br />
ergotamine tartrate sl tab 2 mg<br />
ergotamine w/ caffeine tab 1-100 mg<br />
ethosuximide cap 250 mg<br />
ethosuximide soln 250 mg/5ml<br />
etodolac cap 200 mg<br />
etodolac cap 300 mg<br />
etodolac tab 400 mg<br />
etodolac tab 500 mg<br />
etodolac tab sr 24hr 400 mg<br />
etodolac tab sr 24hr 500 mg<br />
etodolac tab sr 24hr 600 mg<br />
FAZACLO TAB 100MG(Clozapine)<br />
FAZACLO TAB 25MG(Clozapine)<br />
FELBATOL SUS 600/5ML(Felbamate)<br />
FELBATOL TAB 400MG(Felbamate)<br />
FELBATOL TAB 600MG(Felbamate)<br />
FELDENE CAP 10MG(Piroxicam)<br />
FELDENE CAP 20MG(Piroxicam)<br />
fenoprofen calcium tab 600 mg<br />
fentanyl citrate 2 mcg/ml-bupivacaine 0.125%-nacl 0.9% inj<br />
fentanyl citrate 2 mcg/ml-bupivacaine hcl 0.1%-nacl 0.9% inj<br />
fentanyl citrate 2 mcg/ml-ropivacaine 0.2%-nacl 0.9% inj<br />
fentanyl citrate 4 mcg/ml-bupivacaine 0.0625%-nacl 0.9% inj<br />
fentanyl citrate 5 mcg/ml-bupivacaine 0.0625%-nacl 0.9% inj<br />
fentanyl citrate 5 mcg/ml-bupivacaine 0.125%-nacl 0.9% inj<br />
fentanyl citrate 5 mcg/ml-bupivacaine hcl 0.1%-nacl 0.9% inj<br />
fentanyl citrate 5 mcg/ml-ropivacaine 0.0625%-nacl 0.9% inj<br />
fentanyl citrate 5 mcg/ml-ropivacaine 0.1%-nacl 0.9% inj<br />
fentanyl citrate 6 mcg/ml-ropivacaine 0.1%-nacl 0.9% inj<br />
fentanyl citrate inj 0.05 mg/ml<br />
fentanyl citrate lollipop 1200 mcg<br />
fentanyl citrate lollipop 1600 mcg<br />
fentanyl citrate lollipop 200 mcg<br />
fentanyl citrate lollipop 400 mcg<br />
fentanyl citrate lollipop 600 mcg<br />
fentanyl citrate lollipop 800 mcg<br />
fentanyl td patch 72hr 100 mcg/hr<br />
fentanyl td patch 72hr 12 (12.5) mcg/hr<br />
fentanyl td patch 72hr 25 mcg/hr<br />
fentanyl td patch 72hr 50 mcg/hr<br />
fentanyl td patch 72hr 75 mcg/hr<br />
FENTORA TAB 100MCG(Fentanyl Citrate)<br />
FENTORA TAB 200MCG(Fentanyl Citrate)<br />
FENTORA TAB 400MCG(Fentanyl Citrate)<br />
FENTORA TAB 600MCG(Fentanyl Citrate)<br />
02<br />
02<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
57
Drug Name Drug Tier Notes<br />
FENTORA TAB 800MCG(Fentanyl Citrate)<br />
FIORICET/COD CAP(Butalbital-Acetaminophen-Caffeine w/ Codeine)<br />
FIORINAL/COD CAP 30MG(Butalbital-Aspirin-Caffeine w/Cod)<br />
fluoxetine hcl cap 10 mg<br />
fluoxetine hcl cap 20 mg<br />
fluoxetine hcl cap 40 mg<br />
fluoxetine hcl solution 20 mg/5ml<br />
fluoxetine hcl tab 10 mg<br />
fluoxetine hcl tab 20 mg<br />
fluphenazine decanoate inj 25 mg/ml<br />
fluphenazine hcl elixir 2.5 mg/5ml<br />
fluphenazine hcl inj 2.5 mg/ml<br />
fluphenazine hcl oral conc 5 mg/ml<br />
fluphenazine hcl tab 1 mg<br />
fluphenazine hcl tab 10 mg<br />
fluphenazine hcl tab 2.5 mg<br />
fluphenazine hcl tab 5 mg<br />
flurbiprofen tab 100 mg<br />
flurbiprofen tab 50 mg<br />
fluvoxamine maleate tab 100 mg<br />
fluvoxamine maleate tab 25 mg<br />
fluvoxamine maleate tab 50 mg<br />
FOCALIN TAB 10MG(Dexmethylphenidate HCl)<br />
FOCALIN TAB 2.5MG(Dexmethylphenidate HCl)<br />
FOCALIN TAB 5MG(Dexmethylphenidate HCl)<br />
FOCALIN XR CAP 10MG(Dexmethylphenidate HCl)<br />
FOCALIN XR CAP 20MG(Dexmethylphenidate HCl)<br />
FOCALIN XR CAP 5MG(Dexmethylphenidate HCl)<br />
FROVA TAB 2.5MG(Frovatriptan Succinate)<br />
gabapentin cap 100 mg<br />
gabapentin cap 300 mg<br />
gabapentin cap 400 mg<br />
gabapentin tab 100 mg<br />
gabapentin tab 300 mg<br />
gabapentin tab 400 mg<br />
gabapentin tab 600 mg<br />
gabapentin tab 800 mg<br />
GABARONE TAB 100MG(Gabapentin)<br />
GABARONE TAB 300MG(Gabapentin)<br />
GABARONE TAB 400MG(Gabapentin)<br />
GABAZOLAMINE PAK(Alprazolam-Nutritional Supplement)<br />
GABITRIL TAB 12MG(Tiagabine HCl)<br />
GABITRIL TAB 16MG(Tiagabine HCl)<br />
GABITRIL TAB 2MG(Tiagabine HCl)<br />
GABITRIL TAB 4MG(Tiagabine HCl)<br />
GABOXETINE PAK(Fluoxetine HCl-Nutritional Supplement)<br />
GEODON CAP 20MG(Ziprasidone HCl)<br />
GEODON CAP 40MG(Ziprasidone HCl)<br />
GEODON CAP 60MG(Ziprasidone HCl)<br />
GEODON CAP 80MG(Ziprasidone HCl)<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
04<br />
02<br />
02<br />
02<br />
02<br />
(PA)<br />
58
Drug Name Drug Tier Notes<br />
GEODON INJ 20MG(Ziprasidone Mesylate)<br />
HALDOL INJ 5MG/ML(Haloperidol Lactate)<br />
HALDOL DECAN INJ 100MG/ML(Haloperidol Decanoate)<br />
HALDOL DECAN INJ 50MG/ML(Haloperidol Decanoate)<br />
haloperidol decanoate im soln 100 mg/ml<br />
haloperidol decanoate im soln 50 mg/ml<br />
haloperidol lactate inj 5 mg/ml<br />
haloperidol lactate oral conc 2 mg/ml<br />
haloperidol tab 0.5 mg<br />
haloperidol tab 1 mg<br />
haloperidol tab 10 mg<br />
haloperidol tab 2 mg<br />
haloperidol tab 20 mg<br />
haloperidol tab 5 mg<br />
HYCET SOL 7.5-325(Hydrocodone-Acetaminophen)<br />
hydrocodone-acetaminophen cap 5-500 mg<br />
hydrocodone-acetaminophen soln 7.5-500 mg/15ml<br />
hydrocodone-acetaminophen tab 10-325 mg<br />
hydrocodone-acetaminophen tab 10-500 mg<br />
hydrocodone-acetaminophen tab 10-650 mg<br />
hydrocodone-acetaminophen tab 10-660 mg<br />
hydrocodone-acetaminophen tab 10-750 mg<br />
hydrocodone-acetaminophen tab 2.5-500 mg<br />
hydrocodone-acetaminophen tab 5-325 mg<br />
hydrocodone-acetaminophen tab 5-500 mg<br />
hydrocodone-acetaminophen tab 7.5-325 mg<br />
hydrocodone-acetaminophen tab 7.5-500 mg<br />
hydrocodone-acetaminophen tab 7.5-650 mg<br />
hydrocodone-acetaminophen tab 7.5-750 mg<br />
hydrocodone-ibuprofen tab 7.5-200 mg<br />
hydromorphone hcl 20 mcg/ml-bupivacaine 0.06%-nacl 0.9% inj<br />
hydromorphone hcl 20 mcg/ml-bupivacaine 0.125%-nacl 0.9% inj<br />
hydromorphone hcl inj 1 mg/ml<br />
hydromorphone hcl inj 10 mg/ml<br />
hydromorphone hcl inj 2 mg/ml<br />
hydromorphone hcl inj 4 mg/ml<br />
hydromorphone hcl suppos 3 mg<br />
hydromorphone hcl tab 2 mg<br />
hydromorphone hcl tab 4 mg<br />
hydromorphone hcl tab 8 mg<br />
hydromorphone hcl-sodium chloride 0.9% inj 0.2 mg/ml<br />
hydromorphone hcl-sodium chloride 0.9% inj 1 mg/ml<br />
hydroxyzine hcl im soln 25 mg/ml<br />
hydroxyzine hcl im soln 50 mg/ml<br />
hydroxyzine hcl syrup 10 mg/5ml<br />
hydroxyzine hcl tab 10 mg<br />
hydroxyzine hcl tab 25 mg<br />
hydroxyzine hcl tab 50 mg<br />
hydroxyzine pamoate cap 100 mg<br />
hydroxyzine pamoate cap 25 mg<br />
02<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
59
Drug Name Drug Tier Notes<br />
hydroxyzine pamoate cap 50 mg<br />
ibuprofen tab 400 mg<br />
ibuprofen tab 600 mg<br />
ibuprofen tab 800 mg<br />
imipramine hcl tab 10 mg<br />
imipramine hcl tab 25 mg<br />
imipramine hcl tab 50 mg<br />
imipramine pamoate cap 100 mg<br />
imipramine pamoate cap 125 mg<br />
imipramine pamoate cap 150 mg<br />
imipramine pamoate cap 75 mg<br />
IMITREX INJ 6MG/0.5(Sumatriptan Succinate)<br />
IMITREX KIT 4MG/0.5(Sumatriptan Succinate)<br />
IMITREX KIT 6MG/0.5(Sumatriptan Succinate)<br />
IMITREX KIT RF(Sumatriptan Succinate)<br />
IMITREX SPR 20MG/ACT(Sumatriptan)<br />
IMITREX SPR 5MG/ACT(Sumatriptan)<br />
IMITREX TAB 100MG(Sumatriptan Succinate)<br />
IMITREX TAB 25MG(Sumatriptan Succinate)<br />
IMITREX TAB 50MG(Sumatriptan Succinate)<br />
INAPSINE INJ 2.5MG/ML(Droperidol)<br />
INDOCIN SUS 25MG/5ML(Indomethacin)<br />
INDOCIN IV INJ 1MG(Indomethacin Sodium)<br />
INDOCIN SR CAP 75MG(Indomethacin)<br />
indomethacin cap 25 mg<br />
indomethacin cap 50 mg<br />
indomethacin cap cr 75 mg<br />
INDOMETHACIN SUP 50MG(Indomethacin)<br />
INFUMORPH INJ 10MG/ML(Morphine Sulfate For Continuous<br />
Microinfusion)<br />
INFUMORPH INJ 25MG/ML(Morphine Sulfate For Continuous<br />
Microinfusion)<br />
INVEGA TAB 3MG(Paliperidone)<br />
INVEGA TAB 6MG(Paliperidone)<br />
INVEGA TAB 9MG(Paliperidone)<br />
KADIAN CAP 100MG CR(Morphine Sulfate)<br />
KADIAN CAP 200MG CR(Morphine Sulfate)<br />
KADIAN CAP 20MG CR(Morphine Sulfate)<br />
KADIAN CAP 30MG CR(Morphine Sulfate)<br />
KADIAN CAP 50MG CR(Morphine Sulfate)<br />
KADIAN CAP 60MG CR(Morphine Sulfate)<br />
KADIAN CAP 80MG(Morphine Sulfate)<br />
KEPPRA INJ 500/5ML(Levetiracetam)<br />
KEPPRA SOL 100MG/ML(Levetiracetam)<br />
KEPPRA TAB 1000MG(Levetiracetam)<br />
KEPPRA TAB 250MG(Levetiracetam)<br />
KEPPRA TAB 500MG(Levetiracetam)<br />
KEPPRA TAB 750MG(Levetiracetam)<br />
ketoprofen cap 50 mg<br />
ketoprofen cap 75 mg<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
60
Drug Name Drug Tier Notes<br />
ketoprofen cap sr 24hr 200 mg<br />
ketorolac tromethamine im inj 30 mg/ml<br />
ketorolac tromethamine inj 15 mg/ml<br />
ketorolac tromethamine inj 30 mg/ml<br />
ketorolac tromethamine tab 10 mg<br />
LAMICTAL CHW 2MG(Lamotrigine)<br />
LAMICTAL KIT START 35(Lamotrigine)<br />
LAMICTAL KIT START 49(Lamotrigine)<br />
LAMICTAL KIT START 98(Lamotrigine)<br />
LAMICTAL TAB 100MG(Lamotrigine)<br />
LAMICTAL TAB 150MG(Lamotrigine)<br />
LAMICTAL TAB 200MG(Lamotrigine)<br />
LAMICTAL TAB 25MG(Lamotrigine)<br />
lamotrigine tab disp 25 mg<br />
lamotrigine tab disp 5 mg<br />
LEVACET TAB(Aspirin-APAP-Salicyl-Caff)<br />
LEVO DROMORA INJ 2MG/ML(Levorphanol Tartrate)<br />
LEVO-DROMORA TAB 2MG(Levorphanol Tartrate)<br />
levorphanol tartrate tab 2 mg<br />
LEXAPRO SOL 5MG/5ML(Escitalopram Oxalate)<br />
LEXAPRO TAB 10MG(Escitalopram Oxalate)<br />
LEXAPRO TAB 20MG(Escitalopram Oxalate)<br />
LEXAPRO TAB 5MG(Escitalopram Oxalate)<br />
LIMBITROL TAB 5-12.5MG(Chlordiazepoxide-Amitriptyline)<br />
LIMBITROL DS TAB 10-25MG(Chlordiazepoxide-Amitriptyline)<br />
LIQUICET SOL 10-500MG(Hydrocodone-Acetaminophen)<br />
lithium carbonate cap 150 mg<br />
lithium carbonate cap 300 mg<br />
lithium carbonate cap 600 mg<br />
lithium carbonate tab 300 mg<br />
lithium carbonate tab cr 300 mg<br />
lithium carbonate tab cr 450 mg<br />
lithium citrate oral soln 8 meq/5ml<br />
LITHOBID TAB 300MG CR(Lithium Carbonate)<br />
LORCET TAB 10/650(Hydrocodone-Acetaminophen)<br />
LORCET PLUS TAB 7.5-650(Hydrocodone-Acetaminophen)<br />
LORTAB ELX(Hydrocodone-Acetaminophen)<br />
LORTAB 10 TAB(Hydrocodone-Acetaminophen)<br />
LORTAB 2.5 TAB(Hydrocodone-Acetaminophen)<br />
LORTAB 5 TAB(Hydrocodone-Acetaminophen)<br />
LORTAB 7.5 TAB(Hydrocodone-Acetaminophen)<br />
loxapine succinate cap 10 mg<br />
loxapine succinate cap 25 mg<br />
loxapine succinate cap 5 mg<br />
loxapine succinate cap 50 mg<br />
LOXITANE CAP 10MG(Loxapine Succinate)<br />
LOXITANE CAP 25MG(Loxapine Succinate)<br />
LOXITANE CAP 50MG(Loxapine Succinate)<br />
LOXITANE CAP 5MG(Loxapine Succinate)<br />
LUNESTA TAB 1MG(Eszopiclone)<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
04<br />
04<br />
04<br />
01<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
02<br />
61
Drug Name Drug Tier Notes<br />
LUNESTA TAB 2MG(Eszopiclone)<br />
LUNESTA TAB 3MG(Eszopiclone)<br />
LYNOX TAB 10-300MG(Oxycodone w/ Acetaminophen)<br />
LYNOX TAB 2.5-300(Oxycodone w/ Acetaminophen)<br />
LYNOX TAB 5-300MG(Oxycodone w/ Acetaminophen)<br />
LYNOX TAB 7.5-300(Oxycodone w/ Acetaminophen)<br />
LYRICA CAP 100MG(Pregabalin)<br />
LYRICA CAP 150MG(Pregabalin)<br />
LYRICA CAP 200MG(Pregabalin)<br />
LYRICA CAP 225MG(Pregabalin)<br />
LYRICA CAP 25MG(Pregabalin)<br />
LYRICA CAP 300MG(Pregabalin)<br />
LYRICA CAP 50MG(Pregabalin)<br />
LYRICA CAP 75MG(Pregabalin)<br />
MAGNACET TAB 10-400MG(Oxycodone w/ Acetaminophen)<br />
MAGNACET TAB 2.5-400(Oxycodone w/ Acetaminophen)<br />
MAGNACET TAB 5-400MG(Oxycodone w/ Acetaminophen)<br />
MAGNACET TAB 7.5-400(Oxycodone w/ Acetaminophen)<br />
magnesium salicylate tab 600 mg<br />
maprotiline hcl tab 25 mg<br />
maprotiline hcl tab 50 mg<br />
maprotiline hcl tab 75 mg<br />
MARPLAN TAB 10MG(Isocarboxazid)<br />
MAXALT TAB 10MG(Rizatriptan Benzoate)<br />
MAXALT TAB 5MG(Rizatriptan Benzoate)<br />
MAXALT-MLT TAB 10MG(Rizatriptan Benzoate)<br />
MAXALT-MLT TAB 5MG(Rizatriptan Benzoate)<br />
MAXIDONE TAB(Hydrocodone-Acetaminophen)<br />
meclofenamate sodium cap 100 mg<br />
meclofenamate sodium cap 50 mg<br />
MEFENAM ACID CAP 250MG(Mefenamic Acid)<br />
meloxicam susp 7.5 mg/5ml<br />
meloxicam tab 15 mg<br />
meloxicam tab 7.5 mg<br />
meperidine hcl inj 10 mg/ml<br />
meperidine hcl inj 100 mg/ml<br />
meperidine hcl inj 25 mg/ml<br />
meperidine hcl inj 50 mg/ml<br />
meperidine hcl inj 75 mg/ml<br />
meperidine hcl oral soln 50 mg/5ml<br />
meperidine hcl tab 100 mg<br />
meperidine hcl tab 50 mg<br />
meperidine hcl-sodium chloride 0.9% inj 10 mg/ml<br />
meperidine hcl-sodium chloride 0.9% iv soln 1000 mg/0.1l<br />
MEPROBAMATE TAB 400MG(Meprobamate)<br />
meprobamate tab 200 mg<br />
meprobamate tab 400 mg<br />
METADATE TAB 10MG ER(Methylphenidate HCl)<br />
METADATE CD CAP 10MG(Methylphenidate HCl)<br />
METADATE CD CAP 20MG(Methylphenidate HCl)<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
01<br />
01<br />
04<br />
02<br />
02<br />
62
Drug Name Drug Tier Notes<br />
METADATE CD CAP 30MG(Methylphenidate HCl)<br />
methadone hcl conc 10 mg/ml<br />
methadone hcl inj 10 mg/ml<br />
methadone hcl soln 10 mg/5ml<br />
methadone hcl soln 5 mg/5ml<br />
methadone hcl tab 10 mg<br />
methadone hcl tab 5 mg<br />
methadone hcl tab for oral susp 40 mg<br />
METHYLIN CHW 10MG(Methylphenidate HCl)<br />
METHYLIN CHW 2.5MG(Methylphenidate HCl)<br />
METHYLIN CHW 5MG(Methylphenidate HCl)<br />
METHYLIN SOL 10MG/5ML(Methylphenidate HCl)<br />
METHYLIN SOL 5MG/5ML(Methylphenidate HCl)<br />
methylphenidate hcl tab 10 mg<br />
methylphenidate hcl tab 20 mg<br />
methylphenidate hcl tab 5 mg<br />
methylphenidate hcl tab cr 10 mg<br />
methylphenidate hcl tab cr 20 mg<br />
MIGERGOT SUP 2/100(Ergotamine w/ Caffeine)<br />
MIGRANAL SPR 4MG/ML(Dihydroergotamine Mesylate)<br />
MIRAPEX TAB 0.125MG(Pramipexole Dihydrochloride)<br />
MIRAPEX TAB 0.25MG(Pramipexole Dihydrochloride)<br />
MIRAPEX TAB 0.5MG(Pramipexole Dihydrochloride)<br />
MIRAPEX TAB 1.5MG(Pramipexole Dihydrochloride)<br />
MIRAPEX TAB 1MG(Pramipexole Dihydrochloride)<br />
mirtazapine orally disintegrating tab 15 mg<br />
mirtazapine orally disintegrating tab 30 mg<br />
mirtazapine orally disintegrating tab 45 mg<br />
mirtazapine tab 15 mg<br />
mirtazapine tab 30 mg<br />
mirtazapine tab 45 mg<br />
mirtazapine tab 7.5 mg<br />
MOBAN TAB 10MG(Molindone HCl)<br />
MOBAN TAB 25MG(Molindone HCl)<br />
MOBAN TAB 50MG(Molindone HCl)<br />
MOBAN TAB 5MG(Molindone HCl)<br />
MOBIC SUS 7.5/5ML(Meloxicam)<br />
MOBIC TAB 15MG(Meloxicam)<br />
MOBIC TAB 7.5MG(Meloxicam)<br />
morphine sulfate in dextrose iv soln 1 mg/ml<br />
morphine sulfate inj 10 mg/ml<br />
morphine sulfate inj 15 mg/ml<br />
morphine sulfate inj 2 mg/ml<br />
morphine sulfate inj 5 mg/ml<br />
morphine sulfate inj 8 mg/ml<br />
morphine sulfate inj pf 0.5 mg/ml<br />
morphine sulfate inj pf 1 mg/ml<br />
morphine sulfate iv soln 1 mg/ml<br />
morphine sulfate iv soln 25 mg/ml<br />
morphine sulfate iv soln 5 mg/ml<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
63
Drug Name Drug Tier Notes<br />
morphine sulfate iv soln 50 mg/ml<br />
morphine sulfate oral soln 10 mg/5ml<br />
morphine sulfate oral soln 20 mg/ml<br />
morphine sulfate suppos 10 mg<br />
morphine sulfate suppos 20 mg<br />
morphine sulfate suppos 30 mg<br />
morphine sulfate suppos 5 mg<br />
morphine sulfate tab 15 mg<br />
morphine sulfate tab 30 mg<br />
morphine sulfate tab sol 10 mg<br />
morphine sulfate tab sol 15 mg<br />
morphine sulfate tab sol 30 mg<br />
morphine sulfate tab sr 12hr 100 mg<br />
morphine sulfate tab sr 12hr 15 mg<br />
morphine sulfate tab sr 12hr 200 mg<br />
morphine sulfate tab sr 12hr 30 mg<br />
morphine sulfate tab sr 12hr 60 mg<br />
MORPHINE/D5W INJ 1MG/ML(Morphine Sulfate in Dextrose)<br />
MOTRIN TAB 600MG(Ibuprofen)<br />
MOTRIN TAB 800MG(Ibuprofen)<br />
MS CONTIN TAB 100MG CR(Morphine Sulfate)<br />
MS CONTIN TAB 15MG CR(Morphine Sulfate)<br />
MS CONTIN TAB 200MG CR(Morphine Sulfate)<br />
MS CONTIN TAB 30MG CR(Morphine Sulfate)<br />
MS CONTIN TAB 60MG CR(Morphine Sulfate)<br />
MYSOLINE TAB 250MG(Primidone)<br />
MYSOLINE TAB 50MG(Primidone)<br />
nabumetone tab 500 mg<br />
nabumetone tab 750 mg<br />
nalbuphine hcl inj 10 mg/ml<br />
nalbuphine hcl inj 20 mg/ml<br />
NALFON CAP 200MG(Fenoprofen Calcium)<br />
naloxone hcl inj 0.4 mg/ml<br />
naloxone hcl inj 1 mg/ml<br />
naltrexone hcl tab 50 mg<br />
NAMENDA SOL 10MG/5ML(Memantine HCl)<br />
NAMENDA TAB 10MG(Memantine HCl)<br />
NAMENDA TAB 5-10MG(Memantine HCl)<br />
NAMENDA TAB 5MG(Memantine HCl)<br />
NAPRELAN TAB 375MG CR(Naproxen Sodium)<br />
NAPRELAN TAB 500MG CR(Naproxen Sodium)<br />
NAPROSYN SUS 125/5ML(Naproxen)<br />
NAPROSYN TAB 250MG(Naproxen)<br />
NAPROSYN TAB 375MG(Naproxen)<br />
NAPROSYN TAB 500MG(Naproxen)<br />
naproxen sodium tab 220 mg<br />
naproxen sodium tab 275 mg<br />
naproxen sodium tab 550 mg<br />
naproxen sodium tab sr 24hr 500 mg (base equiv)<br />
naproxen susp 125 mg/5ml<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
04<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
(PA)<br />
(PA)<br />
(PA)<br />
64
Drug Name Drug Tier Notes<br />
naproxen tab 250 mg<br />
naproxen tab 375 mg<br />
naproxen tab 500 mg<br />
naproxen tab ec 375 mg<br />
naproxen tab ec 500 mg<br />
NARDIL TAB 15MG(Phenelzine Sulfate)<br />
NAVANE CAP 10MG(Thiothixene)<br />
NAVANE CAP 20MG(Thiothixene)<br />
NAVANE CAP 2MG(Thiothixene)<br />
NAVANE CAP 5MG(Thiothixene)<br />
nefazodone hcl tab 100 mg<br />
nefazodone hcl tab 150 mg<br />
nefazodone hcl tab 200 mg<br />
nefazodone hcl tab 250 mg<br />
nefazodone hcl tab 50 mg<br />
NEOPROFEN SOL 10MG/ML(Ibuprofen Lysine)<br />
NEUPRO DIS 2MG/24HR(Rotigotine)<br />
NEUPRO DIS 4MG/24HR(Rotigotine)<br />
NEUPRO DIS 6MG/24HR(Rotigotine)<br />
NEURONTIN CAP 100MG(Gabapentin)<br />
NEURONTIN CAP 100MG(Gabapentin)<br />
NEURONTIN CAP 300MG(Gabapentin)<br />
NEURONTIN CAP 300MG(Gabapentin)<br />
NEURONTIN CAP 400MG(Gabapentin)<br />
NEURONTIN CAP 400MG(Gabapentin)<br />
NEURONTIN SOL 250/5ML(Gabapentin)<br />
NEURONTIN TAB 600MG(Gabapentin)<br />
NEURONTIN TAB 800MG(Gabapentin)<br />
NORCO TAB 10-325MG(Hydrocodone-Acetaminophen)<br />
NORCO TAB 5-325MG(Hydrocodone-Acetaminophen)<br />
NORCO TAB 7.5-325(Hydrocodone-Acetaminophen)<br />
NORPRAMIN TAB 100MG(Desipramine HCl)<br />
NORPRAMIN TAB 10MG(Desipramine HCl)<br />
NORPRAMIN TAB 150MG(Desipramine HCl)<br />
NORPRAMIN TAB 25MG(Desipramine HCl)<br />
NORPRAMIN TAB 50MG(Desipramine HCl)<br />
NORPRAMIN TAB 75MG(Desipramine HCl)<br />
nortriptyline hcl cap 10 mg<br />
nortriptyline hcl cap 25 mg<br />
nortriptyline hcl cap 50 mg<br />
nortriptyline hcl cap 75 mg<br />
nortriptyline hcl soln 10 mg/5ml<br />
NOVASAL TAB 600MG(Magnesium Salicylate)<br />
NUMORPHAN INJ 1MG/ML(Oxymorphone HCl)<br />
OPANA INJ 1MG/ML(Oxymorphone HCl)<br />
OPANA TAB 10MG(Oxymorphone HCl)<br />
OPANA TAB 5MG(Oxymorphone HCl)<br />
OPANA ER TAB 10MG(Oxymorphone HCl)<br />
OPANA ER TAB 20MG(Oxymorphone HCl)<br />
OPANA ER TAB 40MG(Oxymorphone HCl)<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
04<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
02<br />
04<br />
02<br />
04<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
65
Drug Name Drug Tier Notes<br />
OPANA ER TAB 5MG(Oxymorphone HCl)<br />
ORAMORPH SR TAB 100MG(Morphine Sulfate)<br />
ORAMORPH SR TAB 15MG(Morphine Sulfate)<br />
ORAMORPH SR TAB 30MG(Morphine Sulfate)<br />
ORAMORPH SR TAB 60MG(Morphine Sulfate)<br />
ORAP TAB 1MG(Pimozide)<br />
ORAP TAB 2MG(Pimozide)<br />
orphenadrine w/ aspirin & caffeine tab 25-385-30 mg<br />
orphenadrine w/ aspirin & caffeine tab 50-770-60 mg<br />
oxaprozin tab 600 mg<br />
oxycodone hcl cap 5 mg<br />
oxycodone hcl conc 20 mg/ml<br />
oxycodone hcl soln 5 mg/5ml<br />
oxycodone hcl tab 15 mg<br />
oxycodone hcl tab 30 mg<br />
oxycodone hcl tab 5 mg<br />
oxycodone hcl tab sr 12hr 10 mg<br />
oxycodone hcl tab sr 12hr 20 mg<br />
oxycodone hcl tab sr 12hr 40 mg<br />
oxycodone hcl tab sr 12hr 80 mg<br />
oxycodone w/ acetaminophen cap 5-500 mg<br />
oxycodone w/ acetaminophen soln 5-325 mg/5ml<br />
oxycodone w/ acetaminophen tab 10-325 mg<br />
oxycodone w/ acetaminophen tab 10-500 mg<br />
oxycodone w/ acetaminophen tab 10-650 mg<br />
oxycodone w/ acetaminophen tab 5-325 mg<br />
oxycodone w/ acetaminophen tab 5-500 mg<br />
oxycodone w/ acetaminophen tab 7.5-325 mg<br />
oxycodone w/ acetaminophen tab 7.5-500 mg<br />
oxycodone w/ aspirin tab full strength<br />
OXYCONTIN TAB 10MG CR(Oxycodone HCl)<br />
OXYCONTIN TAB 20MG CR(Oxycodone HCl)<br />
OXYCONTIN TAB 40MG CR(Oxycodone HCl)<br />
OXYCONTIN TAB 80MG CR(Oxycodone HCl)<br />
OXYIR CAP 5MG(Oxycodone HCl)<br />
PAMELOR CAP 10MG(Nortriptyline HCl)<br />
PAMELOR CAP 25MG(Nortriptyline HCl)<br />
PAMELOR CAP 50MG(Nortriptyline HCl)<br />
PAMELOR CAP 75MG(Nortriptyline HCl)<br />
PAMELOR SOL 10MG/5ML(Nortriptyline HCl)<br />
PANLOR DC CAP(Acetaminophen-Caff-Dihydrocod)<br />
PANLOR SS TAB(Acetaminophen-Caff-Dihydrocod)<br />
PARNATE TAB 10MG(Tranylcypromine Sulfate)<br />
paroxetine hcl oral susp 10 mg/5ml (base equiv)<br />
paroxetine hcl tab 10 mg<br />
paroxetine hcl tab 20 mg<br />
paroxetine hcl tab 30 mg<br />
paroxetine hcl tab 40 mg<br />
PAXIL SUS 10MG/5ML(Paroxetine HCl)<br />
PAXIL TAB 10MG(Paroxetine HCl)<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
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01<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
66
Drug Name Drug Tier Notes<br />
PAXIL TAB 20MG(Paroxetine HCl)<br />
PAXIL TAB 30MG(Paroxetine HCl)<br />
PAXIL TAB 40MG(Paroxetine HCl)<br />
PAXIL CR TAB 12.5MG(Paroxetine HCl)<br />
PAXIL CR TAB 25MG(Paroxetine HCl)<br />
PAXIL CR TAB 37.5MG(Paroxetine HCl)<br />
PEGANONE TAB 250MG(Ethotoin)<br />
pentazocine w/ apap tab 25-650 mg<br />
pentazocine w/ naloxone tab 50-0.5 mg<br />
PERCOCET TAB 10-325MG(Oxycodone w/ Acetaminophen)<br />
PERCOCET TAB 10-650MG(Oxycodone w/ Acetaminophen)<br />
PERCOCET TAB 2.5-325(Oxycodone w/ Acetaminophen)<br />
PERCOCET TAB 5-325MG(Oxycodone w/ Acetaminophen)<br />
PERCOCET TAB 7.5-325M(Oxycodone w/ Acetaminophen)<br />
PERCOCET TAB 7.5-500(Oxycodone w/ Acetaminophen)<br />
PERCODAN TAB(Oxycodone w/ Aspirin)<br />
PERLOXX TAB 10/300MG(Oxycodone w/ Acetaminophen)<br />
PERLOXX TAB 2.5/300(Oxycodone w/ Acetaminophen)<br />
PERLOXX TAB 5/300MG(Oxycodone w/ Acetaminophen)<br />
PERLOXX TAB 7.5/300(Oxycodone w/ Acetaminophen)<br />
perphenazine tab 16 mg<br />
perphenazine tab 2 mg<br />
perphenazine tab 4 mg<br />
perphenazine tab 8 mg<br />
perphenazine-amitriptyline tab 2-10 mg<br />
perphenazine-amitriptyline tab 2-25 mg<br />
perphenazine-amitriptyline tab 4-25 mg<br />
PEXEVA TAB 10MG(Paroxetine Mesylate)<br />
PEXEVA TAB 20MG(Paroxetine Mesylate)<br />
PEXEVA TAB 30MG(Paroxetine Mesylate)<br />
PEXEVA TAB 40MG(Paroxetine Mesylate)<br />
PHENYTEK CAP 300MG(Phenytoin Sodium Extended)<br />
phenytoin sodium extended cap 100 mg<br />
phenytoin sodium extended cap 200 mg<br />
phenytoin sodium extended cap 300 mg<br />
phenytoin sodium inj 50 mg/ml<br />
phenytoin susp 125 mg/5ml<br />
piroxicam cap 10 mg<br />
piroxicam cap 20 mg<br />
PONSTEL CAP 250MG(Mefenamic Acid)<br />
PREVACID NAP KIT 500MG(Lansoprazole-Naproxen)<br />
primidone tab 250 mg<br />
primidone tab 50 mg<br />
prochlorperazine edisylate inj 5 mg/ml<br />
prochlorperazine maleate tab 10 mg<br />
prochlorperazine maleate tab 5 mg<br />
prochlorperazine suppos 25 mg<br />
propoxyphene hcl cap 65 mg<br />
propoxyphene hcl w/ apap tab 65-650 mg<br />
propoxyphene-n w/ apap tab 100-500 mg<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
67
Drug Name Drug Tier Notes<br />
propoxyphene-n w/ apap tab 100-650 mg<br />
propoxyphene-n w/ apap tab 50-325 mg<br />
PROVIGIL TAB 100MG(Modafinil)<br />
PROVIGIL TAB 200MG(Modafinil)<br />
PROZAC CAP 10MG(Fluoxetine HCl)<br />
PROZAC CAP 20MG(Fluoxetine HCl)<br />
PROZAC CAP 40MG(Fluoxetine HCl)<br />
PROZAC SOL 20MG/5ML(Fluoxetine HCl)<br />
PROZAC TAB 10MG(Fluoxetine HCl)<br />
PROZAC WEEKL CAP 90MG(Fluoxetine HCl)<br />
RAPIFLUX TAB 20MG(Fluoxetine HCl)<br />
RELPAX TAB 20MG(Eletriptan Hydrobromide)<br />
RELPAX TAB 40MG(Eletriptan Hydrobromide)<br />
REMERON TAB 15MG(Mirtazapine)<br />
REMERON TAB 30MG(Mirtazapine)<br />
REMERON TAB 45MG(Mirtazapine)<br />
REMERON SLTB TAB 15MG(Mirtazapine)<br />
REMERON SLTB TAB 30MG(Mirtazapine)<br />
REMERON SLTB TAB 45MG(Mirtazapine)<br />
REPREXAIN TAB 5-200MG(Hydrocodone-Ibuprofen)<br />
REQUIP TAB 0.25MG(Ropinirole Hydrochloride)<br />
REQUIP TAB 0.5MG(Ropinirole Hydrochloride)<br />
REQUIP TAB 1MG(Ropinirole Hydrochloride)<br />
REQUIP TAB 2MG(Ropinirole Hydrochloride)<br />
REQUIP TAB 3MG(Ropinirole Hydrochloride)<br />
REQUIP TAB 4MG(Ropinirole Hydrochloride)<br />
REQUIP TAB 5MG(Ropinirole Hydrochloride)<br />
REVEX INJ 100MCG(Nalmefene HCl)<br />
REVEX INJ 1MG/ML(Nalmefene HCl)<br />
REVIA TAB 50MG(Naltrexone HCl)<br />
RID-A-PAIN TAB(Aspirin-APAP-Salicyl-Caff w/Cod)<br />
RILUTEK TAB 50MG(Riluzole)<br />
RISPERDAL INJ 12.5MG(Risperidone Microspheres)<br />
RISPERDAL INJ 25MG(Risperidone Microspheres)<br />
RISPERDAL INJ 37.5MG(Risperidone Microspheres)<br />
RISPERDAL INJ 50MG(Risperidone Microspheres)<br />
RISPERDAL SOL 1MG/ML(Risperidone)<br />
RISPERDAL TAB 0.25MG(Risperidone)<br />
RISPERDAL TAB 0.5MG(Risperidone)<br />
RISPERDAL TAB 1MG(Risperidone)<br />
RISPERDAL TAB 2MG(Risperidone)<br />
RISPERDAL TAB 3MG(Risperidone)<br />
RISPERDAL TAB 4MG(Risperidone)<br />
RISPERDAL M TAB 0.5MG(Risperidone)<br />
RISPERDAL M TAB 1MG(Risperidone)<br />
RISPERDAL M TAB 2MG(Risperidone)<br />
RISPERDAL M TAB 3MG(Risperidone)<br />
RISPERDAL M TAB 4MG(Risperidone)<br />
RITALIN TAB 10MG(Methylphenidate HCl)<br />
RITALIN TAB 20MG(Methylphenidate HCl)<br />
01<br />
01<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
02<br />
03<br />
03<br />
03<br />
03<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
(PA)<br />
(PA)<br />
(QL)<br />
(QL)<br />
(QL)<br />
68
Drug Name Drug Tier Notes<br />
RITALIN TAB 5MG(Methylphenidate HCl)<br />
RITALIN LA CAP 10MG(Methylphenidate HCl)<br />
RITALIN LA CAP 20MG(Methylphenidate HCl)<br />
RITALIN LA CAP 30MG(Methylphenidate HCl)<br />
RITALIN LA CAP 40MG(Methylphenidate HCl)<br />
RITALIN SR TAB 20MG(Methylphenidate HCl)<br />
ROXANOL SOL 20MG/ML(Morphine Sulfate)<br />
ROXICODONE CON 20MG/ML(Oxycodone HCl)<br />
ROXICODONE SOL 5MG/5ML(Oxycodone HCl)<br />
ROXICODONE TAB 15MG(Oxycodone HCl)<br />
ROXICODONE TAB 30MG(Oxycodone HCl)<br />
ROXICODONE TAB 5MG(Oxycodone HCl)<br />
ROZEREM TAB 8MG(Ramelteon)<br />
salsalate tab 500 mg<br />
salsalate tab 750 mg<br />
SARAFEM CAP 10MG(Fluoxetine HCl (PMDD))<br />
SARAFEM CAP 20MG(Fluoxetine HCl (PMDD))<br />
selegiline hcl cap 5 mg<br />
selegiline hcl tab 5 mg<br />
SENTROXATINE PAK(Fluoxetine HCl-Nutritional Supplement)<br />
SEROQUEL TAB 100MG(Quetiapine Fumarate)<br />
SEROQUEL TAB 200MG(Quetiapine Fumarate)<br />
SEROQUEL TAB 25MG(Quetiapine Fumarate)<br />
SEROQUEL TAB 300MG(Quetiapine Fumarate)<br />
SEROQUEL TAB 400MG(Quetiapine Fumarate)<br />
SEROQUEL TAB 50MG(Quetiapine Fumarate)<br />
SEROQUEL XR TAB 200MG(Quetiapine Fumarate)<br />
SEROQUEL XR TAB 300MG(Quetiapine Fumarate)<br />
SEROQUEL XR TAB 400MG(Quetiapine Fumarate)<br />
sertraline hcl oral conc 20 mg/ml<br />
sertraline hcl tab 100 mg<br />
sertraline hcl tab 25 mg<br />
sertraline hcl tab 50 mg<br />
SINEMET TAB 10/100(Carbidopa-Levodopa)<br />
SINEMET TAB 25/100(Carbidopa-Levodopa)<br />
SINEMET TAB 25/250(Carbidopa-Levodopa)<br />
SINEMET CR TAB 25/100(Carbidopa-Levodopa)<br />
SINEMET CR TAB 50/200(Carbidopa-Levodopa)<br />
SONATA CAP 10MG(Zaleplon)<br />
SONATA CAP 5MG(Zaleplon)<br />
STADOL INJ 2MG/ML(Butorphanol Tartrate)<br />
STALEVO 100 TAB(Carbidopa-Levodopa-Entacapone)<br />
STALEVO 150 TAB(Carbidopa-Levodopa-Entacapone)<br />
STALEVO 50 TAB(Carbidopa-Levodopa-Entacapone)<br />
STRATTERA CAP 100MG(Atomoxetine HCl)<br />
STRATTERA CAP 10MG(Atomoxetine HCl)<br />
STRATTERA CAP 18MG(Atomoxetine HCl)<br />
STRATTERA CAP 25MG(Atomoxetine HCl)<br />
STRATTERA CAP 40MG(Atomoxetine HCl)<br />
STRATTERA CAP 60MG(Atomoxetine HCl)<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
04<br />
04<br />
01<br />
01<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
(PA)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
69
Drug Name Drug Tier Notes<br />
STRATTERA CAP 80MG(Atomoxetine HCl)<br />
SUBLIMAZE INJ 0.05MG/1(Fentanyl Citrate)<br />
SUBOXONE SUB 2-0.5MG(Buprenorphine HCl-Naloxone HCl Dihydrate)<br />
SUBOXONE SUB 8-2MG(Buprenorphine HCl-Naloxone HCl Dihydrate)<br />
SUBUTEX SUB 2MG(Buprenorphine HCl)<br />
SUBUTEX SUB 8MG(Buprenorphine HCl)<br />
SUFENTA INJ 50MCG/ML(Sufentanil Citrate)<br />
sufentanil citrate inj 50 mcg/ml<br />
sulindac tab 150 mg<br />
sulindac tab 200 mg<br />
SURMONTIL CAP 100MG(Trimipramine Maleate)<br />
SURMONTIL CAP 25MG(Trimipramine Maleate)<br />
SURMONTIL CAP 50MG(Trimipramine Maleate)<br />
SYMBYAX CAP 12-25MG(Olanzapine-Fluoxetine HCl)<br />
SYMBYAX CAP 12-50MG(Olanzapine-Fluoxetine HCl)<br />
SYMBYAX CAP 6-25MG(Olanzapine-Fluoxetine HCl)<br />
SYMBYAX CAP 6-50MG(Olanzapine-Fluoxetine HCl)<br />
SYNALGOS DC CAP(Dihydrocodeine Compound)<br />
TALACEN TAB(Pentazocine w/ APAP)<br />
TALWIN INJ 30MG/ML(Pentazocine Lactate)<br />
TALWIN NX TAB(Pentazocine w/ Naloxone)<br />
TASMAR TAB 100MG(Tolcapone)<br />
TASMAR TAB 200MG(Tolcapone)<br />
TEGRETOL CHW 100MG(Carbamazepine)<br />
TEGRETOL SUS 100/5ML(Carbamazepine)<br />
TEGRETOL TAB 200MG(Carbamazepine)<br />
TEGRETOL TAB 200MG(Carbamazepine)<br />
TEGRETOL XR TAB 100MG(Carbamazepine)<br />
TEGRETOL XR TAB 200MG(Carbamazepine)<br />
TEGRETOL XR TAB 400MG(Carbamazepine)<br />
THERACODOPHN PAK -325(Hydrocodone-Acetaminophen-Nutritional<br />
Supplement)<br />
THERACODOPHN PAK -650(Hydrocodone-Acetaminophen-Nutritional<br />
Supplement)<br />
THERACODOPHN PAK -LOW-90(Hydrocodone-Acetaminophen-Nutritional<br />
Supplement)<br />
THERAFELDAMI PAK(Piroxicam-Nutritional Supplement)<br />
THERAPENTIN PAK -60(Gabapentin-Nutritional Supplement)<br />
THERAPENTIN PAK -90(Gabapentin-Nutritional Supplement)<br />
THERAPROFEN PAK -60(Ibuprofen-Nutritional Supplement)<br />
THERAPROFEN PAK -90(Ibuprofen-Nutritional Supplement)<br />
THERAPROXEN PAK(Naproxen-Nutritional Supplement)<br />
THERAPROXEN PAK -90(Naproxen-Nutritional Supplement)<br />
THERATRAMADO PAK -60(Tramadol HCl-Nutritional Supplement)<br />
THERATRAMADO PAK -90(Tramadol HCl-Nutritional Supplement)<br />
thioridazine hcl tab 10 mg<br />
thioridazine hcl tab 100 mg<br />
thioridazine hcl tab 25 mg<br />
thioridazine hcl tab 50 mg<br />
thiothixene cap 1 mg<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
02<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
(QL)<br />
(PA)<br />
70
Drug Name Drug Tier Notes<br />
thiothixene cap 10 mg<br />
thiothixene cap 2 mg<br />
thiothixene cap 5 mg<br />
THORAZINE SUP 100MG(Chlorpromazine)<br />
THORAZINE TAB 200MG(Chlorpromazine HCl)<br />
TOFRANIL TAB 10MG(Imipramine HCl)<br />
TOFRANIL TAB 25MG(Imipramine HCl)<br />
TOFRANIL TAB 50MG(Imipramine HCl)<br />
TOFRANIL-PM CAP 100MG(Imipramine Pamoate)<br />
TOFRANIL-PM CAP 125MG(Imipramine Pamoate)<br />
TOFRANIL-PM CAP 150MG(Imipramine Pamoate)<br />
TOFRANIL-PM CAP 75MG(Imipramine Pamoate)<br />
tolmetin sodium cap 400 mg<br />
tolmetin sodium tab 200 mg<br />
tolmetin sodium tab 600 mg<br />
TOPAMAX TAB 100MG(Topiramate)<br />
TOPAMAX TAB 200MG(Topiramate)<br />
TOPAMAX TAB 25MG(Topiramate)<br />
TOPAMAX TAB 50MG(Topiramate)<br />
TOPAMAX SPR CAP 15MG(Topiramate)<br />
TOPAMAX SPR CAP 25MG(Topiramate)<br />
tramadol hcl tab 50 mg<br />
tramadol-acetaminophen tab 37.5-325 mg<br />
tranylcypromine sulfate tab 10 mg<br />
TRAZAMINE PAK(Trazodone HCl-Nutritional Supplement)<br />
trazodone hcl tab 100 mg<br />
trazodone hcl tab 150 mg<br />
trazodone hcl tab 300 mg<br />
trazodone hcl tab 50 mg<br />
trifluoperazine hcl tab 1 mg<br />
trifluoperazine hcl tab 10 mg<br />
trifluoperazine hcl tab 2 mg<br />
trifluoperazine hcl tab 5 mg<br />
TRILEPTAL SUS 300MG/5M(Oxcarbazepine)<br />
TRILEPTAL TAB 150MG(Oxcarbazepine)<br />
TRILEPTAL TAB 300MG(Oxcarbazepine)<br />
TRILEPTAL TAB 600MG(Oxcarbazepine)<br />
trimipramine maleate cap 25 mg<br />
trimipramine maleate cap 50 mg<br />
TYLENOL/COD TAB #3(Acetaminophen w/ Codeine)<br />
TYLENOL/COD TAB #4(Acetaminophen w/ Codeine)<br />
TYLOX CAP 5-500MG(Oxycodone w/ Acetaminophen)<br />
ULTRACET TAB(Tramadol-Acetaminophen)<br />
ULTRAM TAB 50MG(Tramadol HCl)<br />
ULTRAM ER TAB 100MG(Tramadol HCl)<br />
ULTRAM ER TAB 200MG(Tramadol HCl)<br />
ULTRAM ER TAB 300MG(Tramadol HCl)<br />
valproate sodium inj 100 mg/ml<br />
valproate sodium syrup 250 mg/5ml<br />
valproic acid cap 250 mg<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
71
Drug Name Drug Tier Notes<br />
VANSPAR TAB 7.5MG(Buspirone HCl)<br />
venlafaxine hcl tab 100 mg<br />
venlafaxine hcl tab 25 mg<br />
venlafaxine hcl tab 37.5 mg<br />
venlafaxine hcl tab 50 mg<br />
venlafaxine hcl tab 75 mg<br />
VICODIN TAB 5-500MG(Hydrocodone-Acetaminophen)<br />
VICODIN ES TAB 7.5-750(Hydrocodone-Acetaminophen)<br />
VICOPROFEN TAB(Hydrocodone-Ibuprofen)<br />
VISTARIL CAP 25MG(Hydroxyzine Pamoate)<br />
VISTARIL CAP 50MG(Hydroxyzine Pamoate)<br />
VIVACTIL TAB 10MG(Protriptyline HCl)<br />
VIVACTIL TAB 5MG(Protriptyline HCl)<br />
VOLTAREN TAB 75MG EC(Diclofenac Sodium)<br />
VOLTAREN-XR TAB 100MG(Diclofenac Sodium)<br />
VYVANSE CAP 30MG(Lisdexamfetamine Dimesylate)<br />
VYVANSE CAP 50MG(Lisdexamfetamine Dimesylate)<br />
VYVANSE CAP 70MG(Lisdexamfetamine Dimesylate)<br />
WELLBUTRIN TAB 100MG(Bupropion HCl)<br />
WELLBUTRIN TAB 100MG SR(Bupropion HCl)<br />
WELLBUTRIN TAB 150MG SR(Bupropion HCl)<br />
WELLBUTRIN TAB 200MG SR(Bupropion HCl)<br />
WELLBUTRIN TAB 75MG(Bupropion HCl)<br />
WELLBUTRIN TAB XL 150MG(Bupropion HCl)<br />
WELLBUTRIN TAB XL 300MG(Bupropion HCl)<br />
XODOL TAB 10-300MG(Hydrocodone-Acetaminophen)<br />
XODOL TAB 5-300MG(Hydrocodone-Acetaminophen)<br />
XODOL TAB 7.5-300(Hydrocodone-Acetaminophen)<br />
XYREM SOL 500MG/ML(Sodium Oxybate)<br />
ZARONTIN CAP 250MG(Ethosuximide)<br />
ZARONTIN SOL 250/5ML(Ethosuximide)<br />
ZELAPAR TAB 1.25MG(Selegiline HCl)<br />
ZOLOFT CON 20MG/ML(Sertraline HCl)<br />
ZOLOFT TAB 100MG(Sertraline HCl)<br />
ZOLOFT TAB 25MG(Sertraline HCl)<br />
ZOLOFT TAB 50MG(Sertraline HCl)<br />
zolpidem tartrate tab 10 mg<br />
zolpidem tartrate tab 5 mg<br />
ZOMIG SPR 5MG(Zolmitriptan)<br />
ZOMIG TAB 2.5MG(Zolmitriptan)<br />
ZOMIG TAB 5MG(Zolmitriptan)<br />
ZOMIG ZMT TAB 2.5 MG(Zolmitriptan)<br />
ZOMIG ZMT TAB 5MG(Zolmitriptan)<br />
ZONEGRAN CAP 100MG(Zonisamide)<br />
ZONEGRAN CAP 25MG(Zonisamide)<br />
zonisamide cap 100 mg<br />
zonisamide cap 25 mg<br />
zonisamide cap 50 mg<br />
ZYBAN TAB 150MG SR(Bupropion HCl (Smoking Deterrent))<br />
ZYDONE TAB 10-400MG(Hydrocodone-Acetaminophen)<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
04<br />
02<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
72
Drug Name Drug Tier Notes<br />
ZYDONE TAB 5-400MG(Hydrocodone-Acetaminophen)<br />
ZYDONE TAB 7.5-400(Hydrocodone-Acetaminophen)<br />
ZYPREXA INJ 10MG(Olanzapine)<br />
ZYPREXA TAB 10MG(Olanzapine)<br />
ZYPREXA TAB 15MG(Olanzapine)<br />
ZYPREXA TAB 2.5MG(Olanzapine)<br />
ZYPREXA TAB 20MG(Olanzapine)<br />
ZYPREXA TAB 5MG(Olanzapine)<br />
ZYPREXA TAB 7.5MG(Olanzapine)<br />
ZYPREXA ZYDI TAB 10MG(Olanzapine)<br />
ZYPREXA ZYDI TAB 15MG(Olanzapine)<br />
ZYPREXA ZYDI TAB 20MG(Olanzapine)<br />
ZYPREXA ZYDI TAB 5MG(Olanzapine)<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
Dental Agents<br />
FLUORIDEX GEL SENSITIV(Sodium Fluoride-Potassium Nitrate) 04<br />
Diagnostic Agents<br />
CONRAY INJ 60%(Iothalamate Meglumine)<br />
CONRAY 30 INJ 30%(Iothalamate Meglumine)<br />
CONRAY 43 INJ 43%(Iothalamate Meglumine)<br />
CYSTO-CONRAY INJ II 17.2%(Iothalamate Meglumine)<br />
GASTROMARK SUS 175MCG(Ferumoxsil)<br />
OPTISON INJ(Perflutren Protein-Type A Microspheres)<br />
Electrolytic, Caloric and Water Balance<br />
*amino acid electrolyte infusion 3.5%***<br />
*amino acid electrolyte infusion 8.5%***<br />
*amino acid electrolyte w/cal infusion 4.25% in d25w***<br />
*amino acid infusion 15%***<br />
*amino acid infusion 4.25% in d10w***<br />
*amino acid infusion 4.25% in d20w***<br />
*amino acid infusion 4.25% in d25w***<br />
*amino acid infusion 6%***<br />
*amino acid infusion 8%***<br />
*amino acid infusion 8.5%***<br />
*irrigation solution, physiological**<br />
*parenteral electrolyte conc***<br />
*parenteral electrolyte soln***<br />
*peritoneal dialysis solutions 346 mosm/l**<br />
*peritoneal dialysis solutions 347 mosm/l**<br />
*peritoneal dialysis solutions 396 mosm/l**<br />
*peritoneal dialysis solutions 398 mosm/l**<br />
*peritoneal dialysis solutions 483 mosm/l**<br />
*peritoneal dialysis solutions 485 mosm/l**<br />
*peritoneal dialysis solutions**<br />
ALCOHOL/D5W INJ 5%(Alcohol in D5W)<br />
AMILORIDE TAB 5MG(Amiloride HCl)<br />
amiloride & hydrochlorothiazide tab 5-50 mg<br />
amiloride hcl tab 5 mg<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
03<br />
03<br />
01<br />
01<br />
03<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
01<br />
01<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
73
Drug Name Drug Tier Notes<br />
AMINESS INJ 5.2%(Amino Acid Infusion)<br />
AMINOSYN INJ 10%(Amino Acid Infusion)<br />
AMINOSYN INJ 3.5%(Amino Acid Infusion)<br />
AMINOSYN INJ 5%(Amino Acid Infusion)<br />
AMINOSYN INJ 7%(Amino Acid Infusion)<br />
AMINOSYN INJ 8.5%(Amino Acid Infusion)<br />
AMINOSYN 2-M INJ 4.25/D10(Amino Acid Electrolyte Infusion in D10W)<br />
AMINOSYN 7% INJ /LYTES(Amino Acid Electrolyte Infusion)<br />
AMINOSYN II INJ 10%(Amino Acid Infusion)<br />
AMINOSYN II INJ 15%(Amino Acid Infusion)<br />
AMINOSYN II INJ 3.5/D25(Amino Acid Infusion in D25W)<br />
AMINOSYN II INJ 3.5/D5(Amino Acid Infusion in D5W)<br />
AMINOSYN II INJ 5/D25(Amino Acid Electrolyte Infusion in D25W)<br />
AMINOSYN II INJ 7%(Amino Acid Infusion)<br />
AMINOSYN II INJ 8.5%(Amino Acid Infusion)<br />
AMINOSYN IIM INJ 3.5%/D5W(Amino Acid Electrolyte Infusion in D5W)<br />
AMINOSYN M INJ 3.5%(Amino Acid Electrolyte Infusion)<br />
AMINOSYN-HBC INJ 7%(Amino Acid Infusion)<br />
AMINOSYN-PF INJ 10%(Amino Acid Infusion)<br />
AMINOSYN-PF INJ 7%(Amino Acid Infusion)<br />
AMINOSYN-RF INJ 5.2%(Amino Acid Infusion)<br />
AMINOSYN/D25 INJ II 3.5%(Amino Acid Electrolyte w/ Calcium Infusion in<br />
D25W)<br />
AMINOSYN/D25 INJ II 4.25%(Amino Acid Electrolyte w/ Calcium Infusion in<br />
D25W)<br />
AMMONUL INJ 10%(Sod Benzoate & Sod Phenylacetate)<br />
BICITRA SOL(Sodium Citrate & Citric Acid)<br />
bumetanide inj 0.25 mg/ml<br />
bumetanide tab 0.5 mg<br />
bumetanide tab 1 mg<br />
bumetanide tab 2 mg<br />
BUMEX TAB 0.5MG(Bumetanide)<br />
BUMEX TAB 1MG(Bumetanide)<br />
BUMEX TAB 2MG(Bumetanide)<br />
BUPHENYL TAB 500MG(Sodium Phenylbutyrate)<br />
chlorothiazide tab 250 mg<br />
chlorothiazide tab 500 mg<br />
chlorthalidone tab 100 mg<br />
chlorthalidone tab 15 mg<br />
chlorthalidone tab 25 mg<br />
chlorthalidone tab 50 mg<br />
CITROLITH TAB(Potassium & Sodium Citrates)<br />
CLINIMIX INJ 2.75/D5W(Amino Acid Infusion)<br />
CLINIMIX INJ 4.25/D5W(Amino Acid Infusion in D5W)<br />
CLINIMIX INJ 5%/D15W(Amino Acid Infusion in D15W)<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
03<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
03<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
02<br />
02<br />
02<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
74
Drug Name Drug Tier Notes<br />
CLINIMIX INJ 5%/D20W(Amino Acid Infusion in D20W)<br />
CLINIMIX INJ 5%/D25W(Amino Acid Infusion in D25W)<br />
CLINIMIX E INJ 2.75/D10(Amino Acid Electrolyte w/ Calcium Infusion in<br />
D10W)<br />
CLINIMIX E INJ 2.75/D5W(Amino Acid Electrolyte w/ Calcium Infusion in<br />
D5W)<br />
CLINIMIX E INJ 4.25/D5W(Amino Acid Electrolyte w/ Calcium Infusion in<br />
D5W)<br />
CLINIMIX E INJ 4.25/D5W(Amino Acid Electrolyte w/ Calcium Infusion in<br />
D5W)<br />
CLINIMIX E INJ 5%/D15W(Amino Acid Electrolyte w/ Calcium Infusion in<br />
D15W)<br />
CLINIMIX E INJ 5%/D20W(Amino Acid Electrolyte w/ Calcium Infusion in<br />
D20W)<br />
CLINIMIX E INJ 5%/D25W(Amino Acid Electrolyte w/ Calcium Infusion in<br />
D25W)<br />
CLINIMIX E INJ 5%/D35W(Amino Acid Electrolyte w/ Calcium Infusion in<br />
D35W)<br />
colchicine w/ probenecid tab 0.5-500 mg<br />
D5W/NACL INJ 0.225%(Dextrose w/ Sodium Chloride)<br />
DEMADEX INJ 50MG/5ML(Torsemide)<br />
DEMADEX TAB 100MG(Torsemide)<br />
DEMADEX TAB 10MG(Torsemide)<br />
DEMADEX TAB 20MG(Torsemide)<br />
DEMADEX TAB 5MG(Torsemide)<br />
dextrose 10% w/ sodium chloride 0.2%<br />
dextrose 10% w/ sodium chloride 0.9%<br />
dextrose 2.5% in lactated ringers 1/2 strength<br />
dextrose 2.5% w/ sodium chloride 0.45%<br />
dextrose 5% in lactated ringers<br />
dextrose 5% w/ sodium chloride 0.2%<br />
dextrose 5% w/ sodium chloride 0.33%<br />
dextrose 5% w/ sodium chloride 0.45%<br />
dextrose 5% w/ sodium chloride 0.9%<br />
dextrose inj 10%<br />
dextrose inj 2.5%<br />
dextrose inj 5%<br />
DIANEAL SOL LOW CALC(Peritoneal Dialysis Solutions)<br />
DIANEAL SOL LOW CALC(Peritoneal Dialysis Solutions)<br />
DIANEAL SOL LOW CALC(Peritoneal Dialysis Solutions)<br />
DIANEAL PD-2 SOL 1.5% DEX(Peritoneal Dialysis Solutions)<br />
DIANEAL PD-2 SOL 2.5% DEX(Peritoneal Dialysis Solutions)<br />
DIANEAL PD-2 SOL 3.5% DEX(Peritoneal Dialysis Solutions)<br />
DIANEAL PD-2 SOL 4.25%DEX(Peritoneal Dialysis Solutions)<br />
DIURIL SUS 250/5ML(Chlorothiazide)<br />
DIURIL IV INJ 500MG(Chlorothiazide Sodium)<br />
DYAZIDE CAP 37.5-25(Triamterene & Hydrochlorothiazide)<br />
DYRENIUM CAP 100MG(Triamterene)<br />
DYRENIUM CAP 50MG(Triamterene)<br />
EDECRIN TAB 25MG(Ethacrynic Acid)<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
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04<br />
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02<br />
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04<br />
04<br />
04<br />
04<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
75
Drug Name Drug Tier Notes<br />
fat emulsion iv soln 10%<br />
fat emulsion iv soln 20%<br />
fat emulsion iv soln 30%<br />
FOSRENOL CHW 1000MG(Lanthanum Carbonate)<br />
FOSRENOL CHW 250MG(Lanthanum Carbonate)<br />
FOSRENOL CHW 500MG(Lanthanum Carbonate)<br />
FOSRENOL CHW 750MG(Lanthanum Carbonate)<br />
FREAMINE III INJ 10%(Amino Acid Infusion)<br />
FREAMINE III INJ 3%(Amino Acid Electrolyte Infusion)<br />
FREAMINE III INJ 8.5%/D50(Amino Acid Infusion)<br />
furosemide inj 10 mg/ml<br />
furosemide oral soln 10 mg/ml<br />
furosemide oral soln 8 mg/ml<br />
furosemide tab 20 mg<br />
furosemide tab 40 mg<br />
furosemide tab 80 mg<br />
HYDROCHLOROT TAB 12.5MG(Hydrochlorothiazide)<br />
hydrochlorothiazide cap 12.5 mg<br />
hydrochlorothiazide tab 25 mg<br />
hydrochlorothiazide tab 50 mg<br />
HYSKON SOL(Dextran 70/Dextrose)<br />
indapamide tab 1.25 mg<br />
indapamide tab 2.5 mg<br />
INTRALIPID INJ 30%(Fat Emulsion)<br />
invert sugar inj 10%<br />
K-LOR POW 20MEQ(Potassium Chloride)<br />
K-LOR POW 20MEQ(Potassium Chloride)<br />
K-LYTE DS TAB 50MEQ OR(Potassium Bicarbonate)<br />
K-LYTE-ORANG TAB 25MEQ EF(Potassium Bicarbonate)<br />
K-LYTE/CL TAB CITRUS(Potassium Bicarb & Chloride)<br />
K-LYTE/CL TAB FRUIT(Potassium Bicarb & Chloride)<br />
K-PHOS TAB MF(Potassium & Sodium Acid Phosphates)<br />
K-PHOS TAB NO 2(Potassium & Sodium Acid Phosphates)<br />
K-TABS TAB 10MEQ CR(Potassium Chloride)<br />
KAYEXALATE POW(Sodium Polystyrene Sulfonate)<br />
KLOR-CON M15 TAB(Potassium Chloride Microencapsulated Crystals CR)<br />
KLOR-CON-25 POW 25MEQ(Potassium Chloride)<br />
KRISTALOSE PAK 10GM(Lactulose)<br />
KRISTALOSE PAK 20GM(Lactulose)<br />
lactated ringer`s for irrigation<br />
lactated ringer`s solution<br />
lactulose (encephalopathy) solution 10 gm/15ml<br />
lactulose solution 10 gm/15ml<br />
LASIX TAB 20MG(Furosemide)<br />
LASIX TAB 40MG(Furosemide)<br />
LASIX TAB 80MG(Furosemide)<br />
LIPOSYN II INJ 10%(Fat Emulsion)<br />
LIPOSYN II INJ 20%(Fat Emulsion)<br />
LIPOSYN III INJ 10%(Fat Emulsion)<br />
LIPOSYN III INJ 20%(Fat Emulsion)<br />
01<br />
01<br />
01<br />
04<br />
04<br />
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04<br />
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01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
76
Drug Name Drug Tier Notes<br />
LITHOSTAT TAB 250MG(Acetohydroxamic Acid)<br />
MAXZIDE TAB 75-50(Triamterene & Hydrochlorothiazide)<br />
MAXZIDE-25 TAB(Triamterene & Hydrochlorothiazide)<br />
metolazone tab 10 mg<br />
metolazone tab 2.5 mg<br />
metolazone tab 5 mg<br />
MICRO-K CAP 10MEQ CR(Potassium Chloride)<br />
MICRO-K CAP 8MEQ CR(Potassium Chloride)<br />
MICROZIDE CAP(Hydrochlorothiazide)<br />
NEPHRAMINE INJ 5.4%(Amino Acid Infusion)<br />
ORACIT SOL(Sodium Citrate & Citric Acid)<br />
PHOSLO CAP 667MG(Calcium Acetate (Phosphate Binder))<br />
PHYSIOSOL SOL IRRIGAT(Irrigation Solutions, Physiological)<br />
POLYCITRA SYP(Pot & Sod Citrates w/Citric Ac)<br />
POLYCITRA-K POW CRYSTALS(Potassium Citrate-Citric Acid)<br />
POLYCITRA-K SOL(Potassium Citrate-Citric Acid)<br />
POLYCITRA-LC SOL(Pot & Sod Citrates w/Citric Ac)<br />
pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml<br />
pot & sod citrates w/ cit ac syrup 550-500-334 mg/5ml<br />
pot bicarbonate & chloride effer tab 25 meq<br />
POT CHLORIDE INJ 10MEQ(Potassium Chloride)<br />
POT CHLORIDE INJ 20MEQ(Potassium Chloride)<br />
POT CHLORIDE INJ 30MEQ(Potassium Chloride)<br />
POT CHLORIDE INJ 40MEQ(Potassium Chloride)<br />
potassium bicarbonate effer tab 25 meq<br />
potassium chloride cap cr 10 meq<br />
potassium chloride inj 10 meq/100 ml<br />
potassium chloride inj 2 meq/ml<br />
potassium chloride inj 20 meq/50 ml<br />
potassium chloride inj 30 meq/100 ml<br />
potassium chloride inj 40 meq/100 ml<br />
potassium chloride microencapsulated crys cr tab 10 meq<br />
potassium chloride microencapsulated crys cr tab 20 meq<br />
potassium chloride oral liq 10% (20 meq/15ml)<br />
potassium chloride oral liq 20% (40 meq/15ml)<br />
potassium chloride powder packet 20 meq<br />
potassium chloride tab cr 10 meq<br />
potassium chloride tab cr 8 meq (600 mg)<br />
potassium citrate & citric acid powder pack 3300-1002 mg<br />
potassium citrate & citric acid soln 1100-334 mg/5ml<br />
potassium citrate tab cr 1080 mg (10 meq)<br />
potassium citrate tab cr 540 mg (5 meq)<br />
PREMASOL SOL 10%(Amino Acid Infusion)<br />
probenecid tab 500 mg<br />
PROCALAMINE INJ 3%(Amino Acid Electrolyte Infusion)<br />
RENAGEL TAB 400MG(Sevelamer HCl)<br />
RENAGEL TAB 800MG(Sevelamer HCl)<br />
RENAMIN INJ 6.5%(Amino Acid Infusion)<br />
ringer`s solution for irrigation<br />
saline injection bacteriostatic<br />
02<br />
04<br />
04<br />
01<br />
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02<br />
01<br />
01<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
77
Drug Name Drug Tier Notes<br />
saline injection w/ benzyl alcohol<br />
SHOHL`S SOL MODIFIED(Sodium Citrate & Citric Acid)<br />
SOD CHLORIDE INJ 23.4%(Sodium Chloride)<br />
SOD EDECRIN INJ 50MG(Ethacrynate Sodium)<br />
sodium chloride inj 0.45%<br />
sodium chloride inj 3%<br />
sodium chloride inj 4 meq/ml (23.4%)<br />
sodium chloride inj 5%<br />
sodium chloride irrigation soln 0.45%<br />
sodium chloride irrigation soln 0.9%<br />
sodium chloride iv soln 0.9%<br />
sodium citrate & citric acid soln 500-334 mg/5ml<br />
sodium polystyrene sulfonate oral susp 15 gm/60ml<br />
sodium polystyrene sulfonate powder<br />
sodium polystyrene sulfonate rectal susp 30 gm/120ml<br />
torsemide tab 10 mg<br />
torsemide tab 100 mg<br />
torsemide tab 20 mg<br />
torsemide tab 5 mg<br />
TRAVASOL INJ 10%(Amino Acid Infusion)<br />
TRAVASOL INJ 5.5%(Amino Acid Infusion)<br />
TRAVASOL 5.5 INJ /LYTES(Amino Acid Electrolyte Infusion)<br />
TRAVASOL/D10 INJ 2.75%(Amino Acid Electrolyte Infusion in D10W)<br />
TRAVASOL/D10 INJ 4.25%(Amino Acid Electrolyte Infusion in D10W)<br />
TRAVASOL/D10 INJ 5.5%(Amino Acid Infusion in D10W)<br />
TRAVASOL/D10 INJ 8.5%(Amino Acid Infusion in D10W)<br />
TRAVASOL/D20 INJ 5.5%(Amino Acid Infusion in D20W)<br />
TRAVASOL/D20 INJ 8.5%(Amino Acid Infusion in D20W)<br />
TRAVASOL/D25 INJ 4.25%(Amino Acid Electrolyte Infusion in D25W)<br />
TRAVASOL/D5 INJ 2.75%(Amino Acid Electrolyte Infusion in D5W)<br />
TRAVASOL/D5 INJ 4.25%(Amino Acid Electrolyte Infusion in D5W)<br />
TRAVASOL/D50 INJ 8.5%(Amino Acid Infusion in D50W)<br />
triamterene & hydrochlorothiazide cap 37.5-25 mg<br />
triamterene & hydrochlorothiazide cap 50-25 mg<br />
triamterene & hydrochlorothiazide tab 37.5-25 mg<br />
triamterene & hydrochlorothiazide tab 75-50 mg<br />
TROPHAMINE INJ 10%(Amino Acid Infusion)<br />
TROPHAMINE INJ 6%(Amino Acid Infusion)<br />
ULTRABAG/ SOL DIANEAL(Peritoneal Dialysis Solutions)<br />
ULTRABAG/PD2 SOL DIANEAL(Peritoneal Dialysis Solutions)<br />
ULTRABAG/PD2 SOL DIANEAL(Peritoneal Dialysis Solutions)<br />
ULTRABAG/PD2 SOL DIANEAL(Peritoneal Dialysis Solutions)<br />
UROCIT-K 10 TAB(Potassium Citrate (Alkalinizer))<br />
UROCIT-K 5 TAB(Potassium Citrate (Alkalinizer))<br />
water for irrigation, sterile irrigation soln<br />
ZAROXOLYN TAB 10MG(Metolazone)<br />
ZAROXOLYN TAB 2.5MG(Metolazone)<br />
ZAROXOLYN TAB 5MG(Metolazone)<br />
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04<br />
01<br />
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04<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
78
Drug Name Drug Tier Notes<br />
Enzymes<br />
ALDURAZYME INJ 2.9MG/5M(Laronidase)<br />
CEREDASE INJ 10UNT/ML(Alglucerase)<br />
CEREDASE INJ 80UNT/ML(Alglucerase)<br />
ELAPRASE INJ 6MG/3ML(Idursulfase)<br />
ELITEK INJ 1.5MG(Rasburicase)<br />
ELITEK INJ 7.5MG(Rasburicase)<br />
FABRAZYME INJ 35MG(Agalsidase beta)<br />
FABRAZYME INJ 5MG(Agalsidase beta)<br />
MYOZYME SOL 50MG(Alglucosidase Alfa)<br />
NAGLAZYME INJ 1MG/ML(Galsulfase)<br />
PULMOZYME SOL 1MG/ML(Dornase Alfa)<br />
SUCRAID SOL 8500/ML(Sacrosidase)<br />
Respiratory Tract Agents<br />
ACCOLATE TAB 10MG(Zafirlukast)<br />
ACCOLATE TAB 20MG(Zafirlukast)<br />
acetylcysteine inhal soln 10%<br />
acetylcysteine inhal soln 20%<br />
ATROVENT NAS SOL 0.03%(Ipratropium Bromide (Nasal))<br />
ATROVENT NAS SOL 0.06%(Ipratropium Bromide (Nasal))<br />
cromolyn sodium soln nebu 20 mg/2ml<br />
G/P TAB 1200-75(Pseudoephedrine-Guaifenesin)<br />
GFN800/PSE60 TAB(Pseudoephedrine-Guaifenesin)<br />
HISTEX DA TAB 60-500MG(Pseudoephedrine-Guaifenesin)<br />
INTAL NEB 20MG/2ML(Cromolyn Sodium)<br />
INTAL INH AER 800MCG(Cromolyn Sodium)<br />
ipratropium bromide nasal soln 0.03% (21 mcg/spray)<br />
ipratropium bromide nasal soln 0.06% (42 mcg/spray)<br />
LEVALL G CAP 90-400MG(Pseudoephedrine-Guaifenesin)<br />
MAXIFED TAB 80-780MG(Pseudoephedrine-Guaifenesin)<br />
MAXIFED-G TAB 60-580CR(Pseudoephedrine-Guaifenesin)<br />
MUCOMYST-10 SOL 10%(Acetylcysteine)<br />
NASATAB LA TAB(Pseudoephedrine-Guaifenesin)<br />
PROFEN II TAB 45-800MG(Pseudoephedrine-Guaifenesin)<br />
PSE-GG TAB 90-800MG(Pseudoephedrine-Guaifenesin)<br />
pseudoephedrine-guaifenesin cap cr 120-250 mg<br />
pseudoephedrine-guaifenesin cap cr 60-300 mg<br />
pseudoephedrine-guaifenesin cap sr 12hr 120-400 mg<br />
pseudoephedrine-guaifenesin cap sr 12hr 90-400 mg<br />
pseudoephedrine-guaifenesin liqd 5-50 mg/ml<br />
pseudoephedrine-guaifenesin syrup 40-200 mg/5ml<br />
pseudoephedrine-guaifenesin tab sr 12hr 120-1200 mg<br />
pseudoephedrine-guaifenesin tab sr 12hr 120-600 mg<br />
pseudoephedrine-guaifenesin tab sr 12hr 45-600 mg<br />
pseudoephedrine-guaifenesin tab sr 12hr 45-800 mg<br />
pseudoephedrine-guaifenesin tab sr 12hr 48-595 mg<br />
pseudoephedrine-guaifenesin tab sr 12hr 50-1200 mg<br />
pseudoephedrine-guaifenesin tab sr 12hr 60-1000 mg<br />
04<br />
04<br />
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04<br />
02<br />
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01<br />
01<br />
01<br />
01<br />
01<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
79
Drug Name Drug Tier Notes<br />
pseudoephedrine-guaifenesin tab sr 12hr 60-1200 mg<br />
pseudoephedrine-guaifenesin tab sr 12hr 60-500 mg<br />
pseudoephedrine-guaifenesin tab sr 12hr 60-580 mg<br />
pseudoephedrine-guaifenesin tab sr 12hr 60-600 mg<br />
pseudoephedrine-guaifenesin tab sr 12hr 80-700 mg<br />
pseudoephedrine-guaifenesin tab sr 12hr 80-780 mg<br />
pseudoephedrine-guaifenesin tab sr 12hr 80-800 mg<br />
pseudoephedrine-guaifenesin tab sr 12hr 85-795 mg<br />
SINGULAIR CHW 4MG(Montelukast Sodium)<br />
SINGULAIR CHW 5MG(Montelukast Sodium)<br />
SINGULAIR GRA 4MG(Montelukast Sodium)<br />
SINGULAIR TAB 10MG(Montelukast Sodium)<br />
TILADE AER 1.75/ACT(Nedocromil Sodium)<br />
TUSNEL PEDI DRO 5-10MG/M(Pseudoephedrine-Guaifenesin)<br />
XOLAIR SOL 150MG(Omalizumab)<br />
ZYFLO TAB 600MG(Zileuton)<br />
Eye, Ear, Nose & Throat Preparations<br />
*acetic ac-al acetate-boric ac-propylene glycol otic soln**<br />
acetic acid 2% in aluminum acetate otic soln<br />
acetic acid otic soln 2%<br />
ACULAR SOL 0.5% OP(Ketorolac Tromethamine (Ophth))<br />
ACULAR LS SOL 0.4%(Ketorolac Tromethamine (Ophth))<br />
ACULAR PF SOL 0.5% OP(Ketorolac Tromethamine (Ophth))<br />
ALAMAST DRO 0.1%(Pemirolast Potassium)<br />
ALBALON SOL LIQUIFLM(Naphazoline HCl)<br />
ALCAINE SOL 0.5% OP(Proparacaine HCl)<br />
ALOCRIL SOL 2%(Nedocromil Sodium (Ophth))<br />
ALOMIDE SOL 0.1% OP(Lodoxamide Tromethamine)<br />
ALPHAGAN P SOL 0.1%(Brimonidine Tartrate)<br />
ALPHAGAN P SOL 0.15%(Brimonidine Tartrate)<br />
ALREX SUS 0.2%(Loteprednol Etabonate)<br />
ASTELIN NASA SPR 137MCG(Azelastine HCl)<br />
atropine sulfate ophth oint 1%<br />
atropine sulfate ophth soln 1%<br />
AZASITE SOL 1%(Azithromycin (Ophth))<br />
AZOPT SUS 1% OP(Brinzolamide)<br />
bacitracin ophth oint 500 unit/gm<br />
bacitracin-polymyxin b ophth oint<br />
bacitracin-polymyxin-neomycin-hc ophth oint 1%<br />
BECONASE AQ SUS 0.042%(Beclomethasone Diprop Monohyd)<br />
benzocaine otic soln 20%<br />
benzocaine-antipyrine otic soln 1.4-5.4%<br />
benzocaine-pe-antipyrine otic soln<br />
BETAGAN SOL 0.25% OP(Levobunolol HCl)<br />
BETAGAN SOL 0.5% OP(Levobunolol HCl)<br />
betaxolol hcl ophth soln 0.5%<br />
BETIMOL SOL 0.25%(Timolol)<br />
BETIMOL SOL 0.5%(Timolol)<br />
BETOPTIC-S SUS 0.25% OP(Betaxolol HCl (Ophth))<br />
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01<br />
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01<br />
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04<br />
01<br />
02<br />
02<br />
02<br />
(PA)<br />
(PA)<br />
80
Drug Name Drug Tier Notes<br />
BLEPH-10 SOL 10% OP(Sulfacetamide Sodium (Ophth))<br />
BLEPHAMIDE SUS OP(Sulfacetamide Sod-Prednisolone)<br />
brimonidine tartrate ophth soln 0.2%<br />
CAPHOSOL SOL(Artificial Saliva)<br />
carbachol intraocular inj 0.01%<br />
carbachol ophth soln 3%<br />
carteolol hcl ophth soln 1%<br />
CELLUGEL SOL 2%(Hydroxypropyl Methylcellulose (Intraocular))<br />
chlorhexidine gluconate soln 0.12%<br />
CILOXAN OIN 0.3% OP(Ciprofloxacin HCl (Ophth))<br />
CILOXAN SOL 0.3% OP(Ciprofloxacin HCl (Ophth))<br />
CIPRO HC SUS OTIC(Ciprofloxacin-Hydrocortisone)<br />
CIPRODEX SUS 0.3-0.1%(Ciprofloxacin-Dexamethasone)<br />
ciprofloxacin hcl ophth soln 0.3%<br />
COLY-MYCIN-S SUS OTIC(Neomycin-Colistin-HC)<br />
CORTISPORIN SOL 1% OTIC(Neomycin-Polymyxin-HC (Otic))<br />
CORTISPORIN SUS -TC OTIC(Neomycin-Colistin-HC-Thonzonium)<br />
CORTISPORIN SUS 1% OTIC(Neomycin-Polymyxin-HC (Otic))<br />
CORTISPORIN SUS OP 1%(Neomycin-Polymyxin-HC (Ophth))<br />
COSOPT SOL 2-0.5%OP(Dorzolamide-Timolol)<br />
CRESYLATE SOL 25% OTIC(Cresyl Acetate)<br />
CROLOM SOL 4% OP(Cromolyn Sodium (Ophth))<br />
cromolyn sodium ophth soln 4%<br />
CYCLOGYL SOL 0.5% OP(Cyclopentolate HCl)<br />
CYCLOGYL SOL 1% OP(Cyclopentolate HCl)<br />
CYCLOGYL SOL 2% OP(Cyclopentolate HCl)<br />
cyclopentolate hcl ophth soln 1%<br />
DEBACTEROL SOL 30-50%(Sulfuric Acid-Sulfonated Phenolics)<br />
DERMOTIC OIL 0.01%(Fluocinolone Acetonide (Otic))<br />
dexamethasone sodium phosphate ophth soln 0.1%<br />
dipivefrin hcl ophth soln 0.1%<br />
DUOVISC KIT 0.35/0.4(Na Hyaluronate & Na Chondroitin Sulfate-Na<br />
Hyaluronate)<br />
DUOVISC KIT 0.5/0.55(Na Hyaluronate & Na Chondroitin Sulfate-Na<br />
Hyaluronate)<br />
ECONOPRED PL SUS 1% OP(Prednisolone Acetate (Ophth))<br />
ELESTAT DRO 0.05%(Epinastine HCl (Ophth))<br />
EMADINE SOL 0.05% OP(Emedastine Difumarate)<br />
erythromycin ophth oint 5 mg/gm<br />
FLAREX SUS 0.1% OP(Fluorometholone Acetate)<br />
FLONASE SPR 0.05%(Fluticasone Propionate (Nasal))<br />
FLOXIN OTIC SOL 0.3%(Ofloxacin (Otic))<br />
FLOXIN OTIC SOL SINGLES(Ofloxacin (Otic))<br />
flunisolide nasal soln 0.025%<br />
fluorometholone ophth susp 0.1%<br />
flurbiprofen sodium ophth soln 0.03%<br />
fluticasone propionate nasal susp 50 mcg/act<br />
FML FORTE SUS 0.25% OP(Fluorometholone (Ophth))<br />
FML LIQUIFLM SUS 0.1% OP(Fluorometholone (Ophth))<br />
FML S.O.P. OIN 0.1% OP(Fluorometholone (Ophth))<br />
04<br />
02<br />
01<br />
04<br />
01<br />
01<br />
01<br />
04<br />
01<br />
04<br />
04<br />
04<br />
04<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
04<br />
04<br />
04<br />
01<br />
04<br />
04<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
04<br />
04<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
02<br />
04<br />
02<br />
81
Drug Name Drug Tier Notes<br />
gentamicin sulfate ophth oint 0.3%<br />
gentamicin sulfate ophth soln 0.3%<br />
homatropine hbr ophth soln 5%<br />
hydrocortisone w/ acetic acid otic soln 1-2%<br />
IOPIDINE SOL 0.5% OP(Apraclonidine HCl)<br />
IOPIDINE SOL 1% OP(Apraclonidine HCl)<br />
ISO ATROPINE SOL 1% OP(Atropine Sulfate (Ophthalmic))<br />
ISO CARBACHO SOL 1.5% OP(Carbachol (Ophth))<br />
ISO CARBACHO SOL 3% OP(Carbachol (Ophth))<br />
ISO HOMATROP SOL 2% OP(Homatropine HBr)<br />
ISO HOMATROP SOL 5% OP(Homatropine HBr)<br />
ISO HYOSCINE SOL 0.25% OP(Scopolamine HBr (Ophth))<br />
ISOPTO CARP SOL 1% OP(Pilocarpine HCl)<br />
ISOPTO CARP SOL 2% OP(Pilocarpine HCl)<br />
ISOPTO CARP SOL 4% OP(Pilocarpine HCl)<br />
ISTALOL SOL 0.5% OP(Timolol Maleate (Ophth))<br />
ketotifen fumarate ophth soln 0.025% (base equiv)<br />
LACRISERT MIS 5MG OP(Artificial Tear Insert)<br />
levobunolol hcl ophth soln 0.25%<br />
levobunolol hcl ophth soln 0.5%<br />
lidocaine hcl viscous soln 2%<br />
LOTEMAX SUS 0.5%(Loteprednol Etabonate)<br />
LUCENTIS SOL(Ranibizumab)<br />
LUMIGAN SOL 0.03%(Bimatoprost)<br />
MACUGEN INJ(Pegaptanib Sodium)<br />
MAXIDEX SUS 0.1% OP(Dexamethasone (Ophth))<br />
MAXITROL OIN 0.1% OP(Neomycin-Polymy-Dexameth)<br />
MAXITROL SUS 0.1% OP(Neomycin-Polymy-Dexameth)<br />
metipranolol ophth soln 0.3%<br />
MIOSTAT SOL 0.01% OP(Carbachol (Ophth))<br />
MYDRIACYL SOL 1% OP(Tropicamide)<br />
naphazoline hcl ophth soln 0.1%<br />
NASACORT AQ AER 55MCG/AC(Triamcinolone Acetonide (Nasal))<br />
NASAREL SPR 29MCG(Flunisolide (Nasal))<br />
NASONEX SPR 50MCG/AC(Mometasone Furoate (Nasal))<br />
NATACYN SUS 5% OP(Natamycin)<br />
neomycin-bacitrac zn-polymyx 3.5(5)mg-400unt-10000unt op oin<br />
neomycin-polymyxin b-gramicidin ophth soln<br />
neomycin-polymyxin-dexamethasone ophth oint 0.1%<br />
neomycin-polymyxin-dexamethasone ophth susp 0.1%<br />
neomycin-polymyxin-hc ophth susp<br />
neomycin-polymyxin-hc otic soln 1%<br />
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%<br />
NEOSPORIN SOL OP(Neomycin-Polymy-Gramicid)<br />
NEVANAC SUS 0.1%(Nepafenac)<br />
NUMOISYN LIQ(Artificial Saliva)<br />
OCUFEN SOL 0.03% OP(Flurbiprofen Sodium)<br />
OCUFLOX SOL 0.3% OP(Ofloxacin (Ophth))<br />
ofloxacin ophth soln 0.3%<br />
OPHTHETIC SOL 0.5% OP(Proparacaine HCl)<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
01<br />
04<br />
01<br />
01<br />
01<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
01<br />
04<br />
04<br />
01<br />
02<br />
04<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
04<br />
82
Drug Name Drug Tier Notes<br />
OPTIPRANOLOL SOL 0.3% OP(Metipranolol)<br />
OPTIVAR DRO 0.05%(Azelastine HCl (Ophth))<br />
PATADAY SOL(Olopatadine HCl)<br />
PATANOL SOL 0.1% OP(Olopatadine HCl)<br />
PEDIOTIC SUS 1% OTIC(Neomycin-Polymyxin-HC (Otic))<br />
PERIDEX SOL 0.12%(Chlorhexidine Gluconate (Mouth-Throat))<br />
PHOSPHOLINE SOL 0.125%OP(Echothiophate Iodide)<br />
pilocarpine hcl ophth soln 0.5%<br />
pilocarpine hcl ophth soln 1%<br />
pilocarpine hcl ophth soln 2%<br />
pilocarpine hcl ophth soln 3%<br />
pilocarpine hcl ophth soln 4%<br />
pilocarpine hcl ophth soln 6%<br />
PILOPINE HS GEL 4% OP(Pilocarpine HCl)<br />
POLY-PRED SUS OP(Neomycin-Polymyx-Pred Acetate)<br />
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%<br />
POLYTRIM SOL OP(Polymyxin B-Trimethoprim)<br />
PRAMOTIC DRO 1-0.1%(Pramoxine-Chloroxylenol)<br />
pramoxine-acetic acid otic soln<br />
pramoxine-chloroxylenol otic liquid 1-0.1%<br />
PRED FORTE SUS 1% OP(Prednisolone Acetate (Ophth))<br />
PRED MILD SUS 0.12% OP(Prednisolone Acetate (Ophth))<br />
PRED-G SUS OP(Gentamicin-Prednisolone Acetate)<br />
PRED-G S.O.P OIN OP(Gentamicin-Prednisolone Acetate)<br />
prednisolone acetate ophth susp 1%<br />
prednisolone sodium phosphate ophth soln 1%<br />
proparacaine hcl ophth soln 0.5%<br />
PROPINE SOL 0.1% OP(Dipivefrin HCl)<br />
QUIXIN SOL 0.5%(Levofloxacin (Ophth))<br />
RESTASIS EMU 0.05%(Cyclosporine (Ophth))<br />
RETISERT IMP 0.59MG(Fluocinolone Acetonide (Ophth))<br />
RHINOCORT SUS AQUA(Budesonide (Nasal))<br />
silver nitrate oint 10%<br />
silver nitrate soln 0.5%<br />
silver nitrate soln 10%<br />
silver nitrate soln 25%<br />
silver nitrate soln 50%<br />
SULFACET SOD OIN 10% OP(Sulfacetamide Sodium (Ophth))<br />
sulfacetamide sodium ophth oint 10%<br />
sulfacetamide sodium ophth soln 10%<br />
sulfacetamide sodium-prednisolone ophth oint 10-0.2%<br />
sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%<br />
tetracaine hcl ophth soln 0.5%<br />
timolol maleate ophth gel forming soln 0.25%<br />
timolol maleate ophth gel forming soln 0.5%<br />
timolol maleate ophth soln 0.25%<br />
timolol maleate ophth soln 0.5%<br />
timolol maleate ophth soln 0.5% (once-daily)<br />
TIMOPTIC SOL 0.25% OP(Timolol Maleate (Ophth))<br />
TIMOPTIC SOL 0.5% OP(Timolol Maleate (Ophth))<br />
04<br />
04<br />
02<br />
02<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
04<br />
01<br />
04<br />
04<br />
01<br />
01<br />
04<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
04<br />
04<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
83
Drug Name Drug Tier Notes<br />
TIMOPTIC OCU SOL 0.25% OP(Timolol Maleate (Ophth))<br />
TIMOPTIC OCU SOL 0.5% OP(Timolol Maleate (Ophth))<br />
TIMOPTIC-XE SOL 0.25% OP(Timolol Maleate (Ophth))<br />
TIMOPTIC-XE SOL 0.5% OP(Timolol Maleate (Ophth))<br />
TOBRADEX OIN OP(Tobramycin-Dexamethasone)<br />
TOBRADEX SUS OP(Tobramycin-Dexamethasone)<br />
tobramycin sulfate ophth soln 0.3%<br />
TOBREX OIN 0.3% OP(Tobramycin Sulfate (Ophth))<br />
TOBREX SOL 0.3% OP(Tobramycin Sulfate (Ophth))<br />
TRAVATAN SOL 0.004%(Travoprost)<br />
TRAVATAN Z SOL 0.004%(Travoprost)<br />
trifluridine ophth soln 1%<br />
tropicamide ophth soln 0.5%<br />
tropicamide ophth soln 1%<br />
TRUSOPT SOL(Dorzolamide HCl)<br />
VERAMYST SPR 27.5MCG(Fluticasone Furoate)<br />
VEXOL SUS 1% OP(Rimexolone)<br />
VIGAMOX DRO 0.5%(Moxifloxacin HCl (Ophth))<br />
VIROPTIC SOL 1% OP(Trifluridine)<br />
VISUDYNE INJ 15MG(Verteporfin)<br />
VITRASERT IMP 4.5MG(Ganciclovir Ophthalmic)<br />
VOLTAREN SOL 0.1% OP(Diclofenac Sodium (Ophth))<br />
XALATAN SOL 0.005%(Latanoprost)<br />
XIBROM SOL 0.09%(Bromfenac Sodium (Ophth))<br />
XYLOCAINE SOL 2% VISC(Lidocaine HCl (Mouth-Throat))<br />
ZINOTIC DRO(Chloroxylenol-Pramoxine-Zinc Acetate)<br />
ZYLET SUS 0.5-0.3%(Loteprednol Etabonate-Tobramycin)<br />
ZYMAR DRO 0.3%(Gatifloxacin (Ophth))<br />
Gastrointestinal Drugs<br />
ACIPHEX TAB 20MG(Rabeprazole Sodium)<br />
ACTIGALL CAP 300MG(Ursodiol)<br />
AMITIZA CAP 24MCG(Lubiprostone)<br />
amy-lip-prot dr particles cap 16600-5000-18750 unit<br />
amy-lip-prot dr particles cap 20000-4500-25000 unit<br />
amy-lip-prot dr particles cap 25000-4000-25000 unit<br />
amy-lip-prot dr particles cap 30000-10000-30000 unit<br />
amy-lip-prot dr particles cap 33200-10000-37500 unit<br />
amy-lip-prot dr particles cap 39000-12000-39000 unit<br />
amy-lip-prot dr particles cap 40000-8000-45000 unit<br />
amy-lip-prot dr particles cap 48000-16000-48000 unit<br />
amy-lip-prot dr particles cap 52000-16000-52000 unit<br />
amy-lip-prot dr particles cap 56000-20000-44000 unit<br />
amy-lip-prot dr particles cap 58500-18000-58500 unit<br />
amy-lip-prot dr particles cap 65000-20000-65000 unit<br />
amy-lip-prot dr particles cap 66400-20000-75000 unit<br />
amylase-lipase-protease cap 15000-1200-15000 unit<br />
amylase-lipase-protease cap 20000-4000-25000 unit<br />
amylase-lipase-protease cap 30000-2400-30000 unit<br />
amylase-lipase-protease cap 30000-8000-30000 unit<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
01<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
(PA)<br />
(PA)<br />
(STC)<br />
(PA)<br />
84
Drug Name Drug Tier Notes<br />
amylase-lipase-protease powd 70000-16800-70000 unit<br />
amylase-lipase-protease tab 30000-8000-30000 unit<br />
amylase-lipase-protease tab 60000-16000-60000 unit<br />
ANTIVERT TAB 12.5MG(Meclizine HCl)<br />
ANTIVERT TAB 25MG(Meclizine HCl)<br />
ANTIVERT TAB 50MG(Meclizine HCl)<br />
ANZEMET INJ 20MG/ML(Dolasetron Mesylate)<br />
ANZEMET SOL 20MG/ML(Dolasetron Mesylate)<br />
ANZEMET TAB 100MG(Dolasetron Mesylate)<br />
ANZEMET TAB 50MG(Dolasetron Mesylate)<br />
ASACOL TAB 400MG DR(Mesalamine)<br />
AXID CAP 150MG(Nizatidine)<br />
AXID CAP 300MG(Nizatidine)<br />
AXID SOL 15MG/ML(Nizatidine)<br />
CANASA SUP 1000MG(Mesalamine)<br />
CARAFATE SUS 1GM/10ML(Sucralfate)<br />
CARAFATE TAB 1GM(Sucralfate)<br />
CIMETID/NACL INJ 300/50ML(Cimetidine in Saline)<br />
cimetidine hcl inj 150 mg/ml<br />
cimetidine hcl soln 300 mg/5ml<br />
cimetidine tab 200 mg<br />
cimetidine tab 300 mg<br />
cimetidine tab 400 mg<br />
cimetidine tab 800 mg<br />
COLAZAL CAP 750MG(Balsalazide Disodium)<br />
COLYTE SOL(PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)<br />
COLYTE/FLAVR SOL PACKS(PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod<br />
Sulfate)<br />
CREON 10 CAP EC(Amylase-Lipase-Protease)<br />
CYTOTEC TAB 100MCG(Misoprostol)<br />
CYTOTEC TAB 200MCG(Misoprostol)<br />
DIPENTUM CAP 250MG(Olsalazine Sodium)<br />
diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml<br />
diphenoxylate w/ atropine tab 2.5-0.025 mg<br />
EMEND CAP 125MG(Aprepitant)<br />
EMEND CAP 40MG(Aprepitant)<br />
EMEND CAP 80-125MG(Aprepitant)<br />
EMEND CAP 80MG(Aprepitant)<br />
famotidine inj 10 mg/ml<br />
famotidine tab 20 mg<br />
famotidine tab 40 mg<br />
GABITIDINE PAK(Ranitidine HCl-Nutritional Supplement)<br />
GOLYTELY SOL(PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)<br />
GOLYTELY SOL PINEAPPL(PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod<br />
Sulfate)<br />
HALFLYTELY KIT BWL-PREP(Bisacodyl-PEG 3350-Pot Chloride-Sod<br />
Bicarb-Sod Chloride)<br />
KYTRIL INJ 0.1MG/ML(Granisetron HCl)<br />
KYTRIL INJ 1MG/ML(Granisetron HCl)<br />
KYTRIL SOL 2MG/10ML(Granisetron HCl)<br />
01<br />
01<br />
01<br />
04<br />
04<br />
02<br />
03<br />
03<br />
03<br />
03<br />
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04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
02<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
04<br />
02<br />
04<br />
04<br />
02<br />
02<br />
02<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
85
Drug Name Drug Tier Notes<br />
KYTRIL TAB 1MG(Granisetron HCl)<br />
LIALDA TAB 1.2GM(Mesalamine)<br />
LOMOTIL LIQ 2.5/5(Diphenoxylate w/ Atropine)<br />
LOMOTIL TAB 2.5MG(Diphenoxylate w/ Atropine)<br />
loperamide hcl cap 2 mg<br />
LOTRONEX TAB 0.5MG(Alosetron HCl)<br />
LOTRONEX TAB 1MG(Alosetron HCl)<br />
MARINOL CAP 10MG(Dronabinol)<br />
MARINOL CAP 2.5MG(Dronabinol)<br />
MARINOL CAP 5MG(Dronabinol)<br />
meclizine hcl tab 12.5 mg<br />
meclizine hcl tab 25 mg<br />
meclizine hcl tab 32 mg<br />
mesalamine enema 4 gm<br />
metoclopramide hcl inj 5 mg/ml<br />
metoclopramide hcl soln 5 mg/5ml<br />
metoclopramide hcl tab 10 mg<br />
metoclopramide hcl tab 5 mg<br />
misoprostol tab 100 mcg<br />
misoprostol tab 200 mcg<br />
MOVIPREP SOL(PEG 3350-KCl-NaCl-Na Sulfate-Na Ascorbate-Ascorbic<br />
Acid)<br />
NEXIUM CAP 20MG(Esomeprazole Magnesium)<br />
NEXIUM CAP 40MG(Esomeprazole Magnesium)<br />
NEXIUM GRA 20MG DR(Esomeprazole Magnesium)<br />
NEXIUM GRA 40MG DR(Esomeprazole Magnesium)<br />
NEXIUM I.V. SOL 20MG(Esomeprazole Sodium)<br />
NEXIUM I.V. SOL 40MG(Esomeprazole Sodium)<br />
nizatidine cap 150 mg<br />
nizatidine cap 300 mg<br />
NULYTELY SOL(PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod<br />
Chloride)<br />
NULYTELY SOL CHERRY(PEG 3350-Potassium Chloride-Sod<br />
Bicarbonate-Sod Chloride)<br />
NULYTELY SOL LMN/LIME(PEG 3350-Potassium Chloride-Sod<br />
Bicarbonate-Sod Chloride)<br />
NULYTELY SOL ORANGE(PEG 3350-Potassium Chloride-Sod<br />
Bicarbonate-Sod Chloride)<br />
OCL SOL(PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)<br />
omeprazole cap delayed release 10 mg<br />
omeprazole cap delayed release 20 mg<br />
ONDANSETRON SOL 32MG/50M(Ondansetron HCl and Sodium Chloride)<br />
ONDANSETRON TAB 24MG(Ondansetron HCl)<br />
ondansetron hcl and dextrose inj 32 mg/50ml<br />
ondansetron hcl inj 2 mg/ml<br />
ondansetron hcl oral soln 4 mg/5ml<br />
ondansetron hcl tab 4 mg<br />
ondansetron hcl tab 8 mg<br />
ondansetron orally disintegrating tab 4 mg<br />
ondansetron orally disintegrating tab 8 mg<br />
02<br />
02<br />
04<br />
04<br />
01<br />
03<br />
03<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
02<br />
02<br />
04<br />
04<br />
02<br />
02<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
04<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(QL) (PA)<br />
(QL) (PA)<br />
(QL) (PA)<br />
(QL) (PA)<br />
(QL) (PA)<br />
(QL) (PA)<br />
(QL) (PA)<br />
(QL) (PA)<br />
86
Drug Name Drug Tier Notes<br />
opium tincture 10%<br />
PANCREASE MT CAP 10(Amylase-Lipase-Protease)<br />
PANCREASE MT CAP 16(Amylase-Lipase-Protease)<br />
PANCREASE MT CAP 20(Amylase-Lipase-Protease)<br />
PANCREASE MT CAP 4(Amylase-Lipase-Protease)<br />
PANCRECARB CAP MS-16(Amylase-Lipase-Protease)<br />
PANGESTYM EC CAP(Amylase-Lipase-Protease)<br />
paregoric 2 mg/5ml<br />
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm<br />
peg 3350-kcl-sod bicarb-nacl for soln 420 gm<br />
PENTASA CAP 250MG CR(Mesalamine)<br />
PENTASA CAP 500MG CR(Mesalamine)<br />
PEPCID SUS 40MG/5ML(Famotidine)<br />
PEPCID TAB 20MG(Famotidine)<br />
PEPCID TAB 40MG(Famotidine)<br />
PEPCID I.V. INJ 10MG/ML(Famotidine)<br />
PEPCID I.V. INJ 20MG/2ML(Famotidine)<br />
polyethylene glycol 3350 oral packet<br />
polyethylene glycol 3350 oral powder<br />
PREVACID CAP 15MG DR(Lansoprazole)<br />
PREVACID CAP 30MG DR(Lansoprazole)<br />
PREVACID GRA 15MG(Lansoprazole)<br />
PREVACID GRA 30MG(Lansoprazole)<br />
PREVACID TAB 15MG STB(Lansoprazole)<br />
PREVACID TAB 30MG STB(Lansoprazole)<br />
PREVACID I.V INJ 30MG(Lansoprazole)<br />
PREVPAC MIS(Amoxicillin-Clarithromycin w/ Lansoprazole)<br />
PRILOSEC CAP 10MG CR(Omeprazole)<br />
PRILOSEC CAP 20MG CR(Omeprazole)<br />
PRILOSEC CAP 40MG CR(Omeprazole)<br />
PRILOSEC OTC TAB 20MG(Omeprazole Magnesium)<br />
PROTONIX INJ 40MG(Pantoprazole Sodium)<br />
PROTONIX TAB 20MG(Pantoprazole Sodium)<br />
PROTONIX TAB 40MG(Pantoprazole Sodium)<br />
ranitidine hcl cap 150 mg<br />
ranitidine hcl cap 300 mg<br />
ranitidine hcl inj 25 mg/ml<br />
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)<br />
ranitidine hcl tab 150 mg<br />
ranitidine hcl tab 300 mg<br />
REGLAN INJ 5MG/ML(Metoclopramide HCl)<br />
REGLAN TAB 10MG(Metoclopramide HCl)<br />
REGLAN TAB 5MG(Metoclopramide HCl)<br />
ROWASA ENE 4GM(Mesalamine)<br />
SCOPACE TAB 0.4MG(Scopolamine Hydrobromide)<br />
scopolamine hydrobromide tab 0.4 mg<br />
SENTRADINE PAK(Ranitidine HCl-Nutritional Supplement)<br />
SUCRALFATE SUS 1GM/10ML(Sucralfate)<br />
sucralfate tab 1 gm<br />
TALADINE CAP 150MG(Ranitidine HCl)<br />
01<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
00<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
04<br />
04<br />
01<br />
04<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(QL)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
87
Drug Name Drug Tier Notes<br />
TALADINE CAP 300MG(Ranitidine HCl)<br />
TRANSDERM-SC DIS 1.5MG(Scopolamine)<br />
ULTRASE MT20 CAP(Amylase-Lipase-Protease)<br />
URSO 250 TAB 250MG(Ursodiol)<br />
URSO FORTE TAB 500MG(Ursodiol)<br />
ursodiol cap 300 mg<br />
ursodiol tab 250 mg<br />
ZANTAC GRA 150MG(Ranitidine HCl)<br />
ZANTAC INJ 25MG/ML(Ranitidine HCl)<br />
ZANTAC INJ 50/50ML(Ranitidine HCl in NaCl)<br />
ZANTAC SYP 15MG/ML(Ranitidine HCl)<br />
ZANTAC TAB 150MG(Ranitidine HCl)<br />
ZANTAC TAB 25MG EF(Ranitidine HCl)<br />
ZANTAC TAB 300MG(Ranitidine HCl)<br />
ZEGERID CAP 20-1100(Omeprazole-Sodium Bicarbonate)<br />
ZEGERID CAP 40-1100(Omeprazole-Sodium Bicarbonate)<br />
ZEGERID POW 20-1680(Omeprazole-Sodium Bicarbonate)<br />
ZEGERID POW 40-1680(Omeprazole-Sodium Bicarbonate)<br />
ZOFRAN INJ 2MG/ML(Ondansetron HCl)<br />
ZOFRAN INJ 32/50ML(Ondansetron HCl and Dextrose)<br />
ZOFRAN SOL 4MG/5ML(Ondansetron HCl)<br />
ZOFRAN TAB 4MG(Ondansetron HCl)<br />
ZOFRAN TAB 8MG(Ondansetron HCl)<br />
ZOFRAN ODT TAB 4MG(Ondansetron)<br />
ZOFRAN ODT TAB 8MG(Ondansetron)<br />
Gold Compounds<br />
gold sodium thiomalate inj 50 mg/ml<br />
MYOCHRYSINE INJ 50MG/ML(Gold Sodium Thiomalate)<br />
RIDAURA CAP 3MG(Auranofin)<br />
Heavy Metal Antagonists<br />
CHEMET CAP 100MG(Succimer)<br />
CUPRIMINE CAP 125MG(Penicillamine)<br />
CUPRIMINE CAP 250MG(Penicillamine)<br />
deferoxamine mesylate for inj 2 gm<br />
deferoxamine mesylate for inj 500 mg<br />
DEPEN TITRA TAB 250MG(Penicillamine)<br />
DESFERAL INJ 2GM(Deferoxamine Mesylate)<br />
DESFERAL INJ 500MG(Deferoxamine Mesylate)<br />
edetate calcium disodium inj 200 mg/ml<br />
edetate disodium inj 150 mg/ml<br />
ENDRATE INJ 150MG/ML(Edetate Disodium)<br />
EXJADE TAB 125MG(Deferasirox)<br />
EXJADE TAB 250MG(Deferasirox)<br />
EXJADE TAB 500MG(Deferasirox)<br />
pentetate calcium trisodium iv or inhalation soln 200 mg/ml<br />
pentetate zinc trisodium iv or inhalation soln 200 mg/ml<br />
sodium nitrite inj 30 mg/ml<br />
sodium thiosulfate inj 10%<br />
04<br />
04<br />
04<br />
04<br />
02<br />
01<br />
01<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
04<br />
02<br />
04<br />
02<br />
02<br />
01<br />
01<br />
02<br />
04<br />
04<br />
01<br />
01<br />
04<br />
03<br />
03<br />
03<br />
01<br />
01<br />
01<br />
01<br />
(STC)<br />
(STC)<br />
(STC)<br />
(STC)<br />
(QL) (PA)<br />
(QL) (PA)<br />
(QL) (PA)<br />
(QL) (PA)<br />
(QL) (PA)<br />
(QL) (PA)<br />
(QL) (PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
88
Drug Name Drug Tier Notes<br />
sodium thiosulfate inj 25%<br />
SYPRINE CAP 250MG(Trientine HCl)<br />
Hormones and Synthetic Substitutes<br />
ACTIVELLA TAB 0.5-0.1(Estradiol & Norethindrone Acetate)<br />
ACTIVELLA TAB 1-0.5MG(Estradiol & Norethindrone Acetate)<br />
ACTOPLUS MET TAB 15/500MG(Pioglitazone HCl-Metformin HCl)<br />
ACTOPLUS MET TAB 15/850MG(Pioglitazone HCl-Metformin HCl)<br />
ACTOS TAB 15MG(Pioglitazone HCl)<br />
ACTOS TAB 30MG(Pioglitazone HCl)<br />
ACTOS TAB 45MG(Pioglitazone HCl)<br />
AEROBID AER 250MCG(Flunisolide)<br />
AEROBID-M AER 250MCG(Flunisolide)<br />
ALESSE TAB -28(Levonorgestrel & Eth Estradiol)<br />
ALORA DIS 0.025MG(Estradiol)<br />
ALORA DIS 0.05MG(Estradiol)<br />
ALORA DIS 0.075MG(Estradiol)<br />
ALORA DIS 0.1MG(Estradiol)<br />
AMARYL TAB 1MG(Glimepiride)<br />
AMARYL TAB 2MG(Glimepiride)<br />
AMARYL TAB 4MG(Glimepiride)<br />
ANADROL-50 TAB 50MG(Oxymetholone)<br />
ANDRODERM DIS 2.5MG/24(Testosterone)<br />
ANDRODERM DIS 5MG/24HR(Testosterone)<br />
ANDROGEL GEL 1%(25MG)(Testosterone)<br />
ANDROGEL GEL 1%(50MG)(Testosterone)<br />
ANDROGEL GEL PUMP 1%(Testosterone)<br />
ANDROID CAP 10MG(Methyltestosterone)<br />
ANDROXY TAB 10MG(Fluoxymesterone)<br />
ANGELIQ TAB 0.5-1MG(Drospirenone-Estradiol)<br />
APIDRA INJ(Insulin Glulisine)<br />
APIDRA INJ U-100(Insulin Glulisine)<br />
APPFORMIN PAK(Metformin HCl-Nutritional Supplement)<br />
APPFORMIN-D PAK(Metformin HCl-Nutritional Supplement)<br />
ARISTOSPAN INJ 20MG/ML(Triamcinolone Hexacetonide)<br />
ARISTOSPAN INJ 5MG/ML(Triamcinolone Hexacetonide)<br />
ARMOUR THYRO TAB 120MG(Thyroid)<br />
ARMOUR THYRO TAB 15MG(Thyroid)<br />
ARMOUR THYRO TAB 180MG(Thyroid)<br />
ARMOUR THYRO TAB 240MG(Thyroid)<br />
ARMOUR THYRO TAB 300MG(Thyroid)<br />
ARMOUR THYRO TAB 30MG(Thyroid)<br />
ARMOUR THYRO TAB 60MG(Thyroid)<br />
ARMOUR THYRO TAB 90MG(Thyroid)<br />
ASMANEX 120 AER 220MCG(Mometasone Furoate (Inhalation))<br />
ASMANEX 14 AER 220MCG(Mometasone Furoate (Inhalation))<br />
ASMANEX 30 AER 220MCG(Mometasone Furoate (Inhalation))<br />
ASMANEX 60 AER 220MCG(Mometasone Furoate (Inhalation))<br />
AVANDAMET TAB 2-1000MG(Rosiglitazone Maleate-Metformin HCl)<br />
AVANDAMET TAB 2-500MG(Rosiglitazone Maleate-Metformin HCl)<br />
01<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
(QL)<br />
(QL)<br />
89
Drug Name Drug Tier Notes<br />
AVANDAMET TAB 4-1000MG(Rosiglitazone Maleate-Metformin HCl)<br />
AVANDAMET TAB 4-500MG(Rosiglitazone Maleate-Metformin HCl)<br />
AVANDARYL TAB 4-1MG(Rosiglitazone Maleate-Glimepiride)<br />
AVANDARYL TAB 4-2MG(Rosiglitazone Maleate-Glimepiride)<br />
AVANDARYL TAB 4-4MG(Rosiglitazone Maleate-Glimepiride)<br />
AVANDARYL TAB 8-2MG(Rosiglitazone Maleate-Glimepiride)<br />
AVANDARYL TAB 8-4MG(Rosiglitazone Maleate-Glimepiride)<br />
AVANDIA TAB 2MG(Rosiglitazone Maleate)<br />
AVANDIA TAB 4MG(Rosiglitazone Maleate)<br />
AVANDIA TAB 8MG(Rosiglitazone Maleate)<br />
AYGESTIN TAB 5MG(Norethindrone Acetate)<br />
AZMACORT AER 100MCG(Triamcinolone Acetonide (Inhalant))<br />
BIO-THROID CAP 120MG(Thyroid (Pork))<br />
BIO-THROID CAP 150MG(Thyroid (Pork))<br />
BIO-THROID CAP 15MG(Thyroid (Pork))<br />
BIO-THROID CAP 180MG(Thyroid (Pork))<br />
BIO-THROID CAP 240MG(Thyroid (Pork))<br />
BIO-THROID CAP 30MG(Thyroid (Pork))<br />
BIO-THROID CAP 60MG(Thyroid (Pork))<br />
BIO-THROID CAP 8MG(Thyroid (Pork))<br />
BIO-THROID CAP 90MG(Thyroid (Pork))<br />
BREVICON TAB 0.5/35(Norethindrone & Eth Estradiol)<br />
BYETTA INJ 10MCG(Exenatide)<br />
BYETTA INJ 5MCG(Exenatide)<br />
calcitonin (salmon) nasal soln 200 unit/act<br />
CELESTONE INJ SOLUSPAN(Betamethasone Acetate & Sod Phosphate)<br />
CELESTONE SOL 0.6MG/5(Betamethasone)<br />
CENESTIN TAB 0.3MG(Estrogens, Conjugated Synthetic A)<br />
CENESTIN TAB 0.45MG(Estrogens, Conjugated Synthetic A)<br />
CENESTIN TAB 0.625MG(Estrogens, Conjugated Synthetic A)<br />
CENESTIN TAB 0.9MG(Estrogens, Conjugated Synthetic A)<br />
CENESTIN TAB 1.25MG(Estrogens, Conjugated Synthetic A)<br />
chlorpropamide tab 100 mg<br />
chlorpropamide tab 250 mg<br />
chorionic gonadotropin for inj 10000 unit<br />
CLIMARA DIS 0.025MG(Estradiol)<br />
CLIMARA DIS 0.0375MG(Estradiol)<br />
CLIMARA DIS 0.05MG(Estradiol)<br />
CLIMARA DIS 0.06MG(Estradiol)<br />
CLIMARA DIS 0.075MG(Estradiol)<br />
CLIMARA DIS 0.1MG(Estradiol)<br />
CLIMARA PRO DIS WEEKLY(Estradiol-Levonorgestrel)<br />
COMBIPATCH DIS .05/.14(Estradiol & Norethindrone Acetate)<br />
COMBIPATCH DIS .05/.25(Estradiol & Norethindrone Acetate)<br />
CORTEF TAB 10MG(Hydrocortisone)<br />
CORTEF TAB 20MG(Hydrocortisone)<br />
CORTEF TAB 5MG(Hydrocortisone)<br />
cortisone acetate tab 25 mg<br />
CRINONE GEL 8% VAG(Progesterone (Vaginal))<br />
CYCLESSA PAK(Desogestrel-Ethinyl Estradiol (Triphasic))<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
04<br />
04<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(QL)<br />
(PA)<br />
(PA)<br />
(PA)<br />
90
Drug Name Drug Tier Notes<br />
CYTOMEL TAB 25MCG(Liothyronine Sodium)<br />
CYTOMEL TAB 50MCG(Liothyronine Sodium)<br />
CYTOMEL TAB 5MCG(Liothyronine Sodium)<br />
danazol cap 100 mg<br />
danazol cap 200 mg<br />
danazol cap 50 mg<br />
DDAVP INJ 4MCG/ML(Desmopressin Acetate)<br />
DDAVP SPR 0.01%(Desmopressin Acetate Spray)<br />
DDAVP TAB 0.1MG(Desmopressin Acetate)<br />
DDAVP TAB 0.2MG(Desmopressin Acetate)<br />
DELATESTRYL INJ 200MG/ML(Testosterone Enanthate)<br />
DELESTROGEN INJ 10MG/ML(Estradiol Valerate)<br />
DELESTROGEN INJ 20MG/ML(Estradiol Valerate)<br />
DELESTROGEN INJ 40MG/ML(Estradiol Valerate)<br />
DEMULEN TAB 1/35-28(Ethynodiol Diacet & Eth Estrad)<br />
DEPO-ESTRADI INJ 5MG/ML(Estradiol Cypionate)<br />
DEPO-MEDROL INJ 20MG/ML(Methylprednisolone Acetate)<br />
DEPO-MEDROL INJ 40MG/ML(Methylprednisolone Acetate)<br />
DEPO-MEDROL INJ 80MG/ML(Methylprednisolone Acetate)<br />
DEPO-PROVERA INJ 150MG/ML(Medroxyprogesterone Acetate<br />
(Contraceptive))<br />
DEPO-PROVERA INJ 400/ML(Medroxyprogesterone Acetate (Antineoplastic))<br />
DEPO-SQ PROV INJ 104(Medroxyprogesterone Acetate (Contraceptive))<br />
DEPO-TESTOST INJ 100MG/ML(Testosterone Cypionate)<br />
DEPO-TESTOST INJ 200MG/ML(Testosterone Cypionate)<br />
desmopressin acetate inj 4 mcg/ml<br />
desmopressin acetate nasal spray soln 0.01%<br />
desmopressin acetate nasal spray soln 0.01% (refrigerated)<br />
desmopressin acetate tab 0.1 mg<br />
desmopressin acetate tab 0.2 mg<br />
DESOGEN-28 TAB(Desogestrel & Ethinyl Estradiol)<br />
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)<br />
desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg<br />
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg<br />
dexamethasone conc 1 mg/ml<br />
dexamethasone elixir 0.5 mg/5ml<br />
dexamethasone sodium phosphate inj 10 mg/ml<br />
dexamethasone sodium phosphate inj 4 mg/ml<br />
dexamethasone soln 0.5 mg/5ml<br />
dexamethasone tab 0.5 mg<br />
dexamethasone tab 0.75 mg<br />
dexamethasone tab 1 mg<br />
dexamethasone tab 1.5 mg<br />
dexamethasone tab 2 mg<br />
dexamethasone tab 4 mg<br />
dexamethasone tab 6 mg<br />
DEXPAK PAK 13 DAY(Dexamethasone)<br />
DEXPAK JR PAK 10 DAY(Dexamethasone)<br />
DIABETA TAB 1.25MG(Glyburide)<br />
DIABETA TAB 2.5MG(Glyburide)<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
04<br />
04<br />
(PA)<br />
(PA)<br />
(PA)<br />
(QL)<br />
(PA)<br />
(QL)<br />
(PA)<br />
(PA)<br />
91
Drug Name Drug Tier Notes<br />
DIABETA TAB 5MG(Glyburide)<br />
DIABINESE TAB 100MG(Chlorpropamide)<br />
DIABINESE TAB 250MG(Chlorpropamide)<br />
DIVIGEL GEL 0.25MG(Estradiol)<br />
DIVIGEL GEL 0.5MG(Estradiol)<br />
DIVIGEL GEL 1MG/GM(Estradiol)<br />
DUETACT TAB 30-2MG(Pioglitazone HCl-Glimepiride)<br />
DUETACT TAB 30-4MG(Pioglitazone HCl-Glimepiride)<br />
ELESTRIN GEL(Estradiol)<br />
ENDOMETRIN SUP 100MG(Progesterone (Vaginal))<br />
ENJUVIA TAB 0.3MG(Estrogens, Conjugated Synthetic B)<br />
ENJUVIA TAB 0.45MG(Estrogens, Conjugated Synthetic B)<br />
ENJUVIA TAB 0.625MG(Estrogens, Conjugated Synthetic B)<br />
ENJUVIA TAB 1.25MG(Estrogens, Conjugated Synthetic B)<br />
ENTOCORT EC CAP 3MG/24HR(Budesonide)<br />
ESCLIM DIS 0.025MG(Estradiol)<br />
ESCLIM DIS 0.0375MG(Estradiol)<br />
ESCLIM DIS 0.05MG(Estradiol)<br />
ESCLIM DIS 0.075MG(Estradiol)<br />
ESCLIM DIS 0.1MG(Estradiol)<br />
ESTRACE TAB 0.5MG(Estradiol)<br />
ESTRACE TAB 1MG(Estradiol)<br />
ESTRACE TAB 2MG(Estradiol)<br />
ESTRACE VAG CRE 0.1MG/GM(Estradiol Vaginal)<br />
ESTRADERM DIS 0.05MG(Estradiol)<br />
ESTRADERM DIS 0.1MG(Estradiol)<br />
estradiol tab 0.5 mg<br />
estradiol tab 1 mg<br />
estradiol tab 2 mg<br />
estradiol td patch weekly 0.025 mg/24hr<br />
estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)<br />
estradiol td patch weekly 0.05 mg/24hr<br />
estradiol td patch weekly 0.06 mg/24hr<br />
estradiol td patch weekly 0.075 mg/24hr<br />
estradiol td patch weekly 0.1 mg/24hr<br />
ESTRASORB EMU(Estradiol)<br />
ESTRING MIS 2MG(Estradiol Vaginal)<br />
ESTROGEL GEL(Estradiol)<br />
estropipate tab 0.75 mg<br />
estropipate tab 1.5 mg<br />
estropipate tab 3 mg<br />
ESTROSTEP FE TAB(Norethindrone Acetate-Ethinyl Estradiol-Fe)<br />
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg<br />
ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg<br />
EVISTA TAB 60MG(Raloxifene HCl)<br />
EXUBERA POW KIT(Insulin Regular (Human))<br />
EXUBERA COMB POW PACK 12(Insulin Regular (Human))<br />
EXUBERA COMB POW PACK 15(Insulin Regular (Human))<br />
EXUBERA PT POW PACK 1MG(Insulin Regular (Human))<br />
EXUBERA PT POW PACK 3MG(Insulin Regular (Human))<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
04<br />
02<br />
01<br />
01<br />
01<br />
02<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
(QL)<br />
(QL)<br />
(PA)<br />
(PA)<br />
(PA)<br />
92
Drug Name Drug Tier Notes<br />
FEMCON FE CHW(Norethindrone & Ethinyl Estradiol-Fe)<br />
FEMHRT TAB 0.5-2.5(Norethindrone Acetate-Ethinyl Estradiol)<br />
FEMHRT 1/5 TAB(Norethindrone Acetate-Ethinyl Estradiol)<br />
FEMRING MIS 0.05/24H(Estradiol Acetate Vaginal)<br />
FEMRING MIS 0.1MG/24(Estradiol Acetate Vaginal)<br />
FEMTRACE TAB 0.45MG(Estradiol Acetate)<br />
FEMTRACE TAB 0.9MG(Estradiol Acetate)<br />
FEMTRACE TAB 1.8MG(Estradiol Acetate)<br />
FIRST-TESTOS CRE MC 2%(Testosterone Propionate)<br />
FIRST-TESTOS OIN 2%(Testosterone Propionate)<br />
FLORINEF TAB 0.1MG(Fludrocortisone Acetate)<br />
FLOVENT DISK AER 50MCG(Fluticasone Propionate (Inhalation))<br />
FLOVENT HFA AER 110MCG(Fluticasone Propionate HFA)<br />
FLOVENT HFA AER 220MCG(Fluticasone Propionate HFA)<br />
FLOVENT HFA AER 44MCG(Fluticasone Propionate HFA)<br />
fludrocortisone acetate tab 0.1 mg<br />
FORTAMET TAB 1000MG(Metformin HCl)<br />
FORTAMET TAB 500MG(Metformin HCl)<br />
FORTEO SOL 750/3ML(Teriparatide (Recombinant))<br />
GENOTROPIN INJ 0.2MG(Somatropin)<br />
GENOTROPIN INJ 0.4MG(Somatropin)<br />
GENOTROPIN INJ 0.6MG(Somatropin)<br />
GENOTROPIN INJ 0.8MG(Somatropin)<br />
GENOTROPIN INJ 1.2MG(Somatropin)<br />
GENOTROPIN INJ 1.4MG(Somatropin)<br />
GENOTROPIN INJ 1.6MG(Somatropin)<br />
GENOTROPIN INJ 1.8MG(Somatropin)<br />
GENOTROPIN INJ 13.8MG(Somatropin)<br />
GENOTROPIN INJ 1MG(Somatropin)<br />
GENOTROPIN INJ 2MG(Somatropin)<br />
GENOTROPIN INJ 5.8MG(Somatropin)<br />
glimepiride tab 1 mg<br />
glimepiride tab 2 mg<br />
glimepiride tab 4 mg<br />
glipizide tab 10 mg<br />
glipizide tab 5 mg<br />
glipizide tab sr 24hr 10 mg<br />
glipizide tab sr 24hr 2.5 mg<br />
glipizide tab sr 24hr 5 mg<br />
glipizide-metformin hcl tab 2.5-250 mg<br />
glipizide-metformin hcl tab 2.5-500 mg<br />
glipizide-metformin hcl tab 5-500 mg<br />
GLUCAGEN INJ HYPOKIT(Glucagon HCl (rDNA))<br />
glucagon (rdna) for inj kit 1 mg<br />
GLUCOPHAGE TAB 1000MG(Metformin HCl)<br />
GLUCOPHAGE TAB 500MG(Metformin HCl)<br />
GLUCOPHAGE TAB 850MG(Metformin HCl)<br />
GLUCOPHAGE TAB XR 500MG(Metformin HCl)<br />
GLUCOPHAGE TAB XR 750MG(Metformin HCl)<br />
GLUCOTROL TAB 10MG(Glipizide)<br />
04<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
01<br />
02<br />
02<br />
03<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
03<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
93
Drug Name Drug Tier Notes<br />
GLUCOTROL TAB 5MG(Glipizide)<br />
GLUCOTROL XL TAB 10MG(Glipizide)<br />
GLUCOTROL XL TAB 2.5MG(Glipizide)<br />
GLUCOTROL XL TAB 5MG(Glipizide)<br />
GLUCOVANCE TAB 1.25/250(Glyburide-Metformin)<br />
GLUCOVANCE TAB 2.5/500(Glyburide-Metformin)<br />
GLUCOVANCE TAB 5/500MG(Glyburide-Metformin)<br />
GLUMETZA TAB 500MG(Metformin HCl)<br />
GLUMETZA TAB 500MG(Metformin HCl)<br />
glyburide micronized tab 1.5 mg<br />
glyburide micronized tab 3 mg<br />
glyburide micronized tab 6 mg<br />
glyburide tab 1.25 mg<br />
glyburide tab 2.5 mg<br />
glyburide tab 5 mg<br />
glyburide-metformin tab 1.25-250 mg<br />
glyburide-metformin tab 2.5-500 mg<br />
glyburide-metformin tab 5-500 mg<br />
GLYCRON TAB 4.5MG(Glyburide Micronized)<br />
GLYNASE TAB 1.5MG(Glyburide Micronized)<br />
GLYNASE TAB 3MG(Glyburide Micronized)<br />
GLYNASE TAB 6MG(Glyburide Micronized)<br />
GLYSET TAB 100MG(Miglitol)<br />
GLYSET TAB 25MG(Miglitol)<br />
GLYSET TAB 50MG(Miglitol)<br />
GYNODIOL TAB 1.5MG(Estradiol)<br />
HUMALOG INJ 100/ML(Insulin Lispro (Human))<br />
HUMALOG MIX INJ 50/50(Insulin Lispro Protamine & Lispro (Human))<br />
HUMALOG MIX SUS 75/25(Insulin Lispro Protamine & Lispro (Human))<br />
HUMALOG PEN INJ 100/ML(Insulin Lispro (Human))<br />
HUMALOG PEN INJ 50/50(Insulin Lispro Protamine & Lispro (Human))<br />
HUMALOG PEN INJ 75/25(Insulin Lispro Protamine & Lispro (Human))<br />
HUMATROPE INJ 12MG(Somatropin)<br />
HUMATROPE INJ 24MG(Somatropin)<br />
HUMATROPE INJ 5MG(Somatropin)<br />
HUMATROPE INJ 6MG(Somatropin)<br />
HUMULIN INJ 50/50(Insulin Isophane & Reg (Human))<br />
HUMULIN INJ 70/30(Insulin Isophane & Reg (Human))<br />
HUMULIN N INJ U-100(Insulin Isophane (Human))<br />
HUMULIN N PN INJ U-100(Insulin Isophane (Human))<br />
HUMULIN PEN INJ 70/30(Insulin Isophane & Reg (Human))<br />
HUMULIN R INJ U-100(Insulin Regular (Human))<br />
HUMULIN R INJ U-500(Insulin Regular (Human))<br />
hydrocortisone sodium succinate for inj 100 mg<br />
hydrocortisone tab 10 mg<br />
hydrocortisone tab 20 mg<br />
hydrocortisone tab 5 mg<br />
IMPLANON IMP 68MG(Etonogestrel)<br />
INCRELEX INJ 40MG/4ML(Mecasermin)<br />
JANUMET TAB 50-1000(Sitagliptin-Metformin HCl)<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
03<br />
03<br />
03<br />
03<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
02<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
94
Drug Name Drug Tier Notes<br />
JANUMET TAB 50-500MG(Sitagliptin-Metformin HCl)<br />
JANUVIA TAB 100MG(Sitagliptin Phosphate)<br />
JANUVIA TAB 25MG(Sitagliptin Phosphate)<br />
JANUVIA TAB 50MG(Sitagliptin Phosphate)<br />
KENALOG-10 INJ 10MG/ML(Triamcinolone Acetonide)<br />
KENALOG-40 INJ 40MG/ML(Triamcinolone Acetonide)<br />
LANTUS INJ 100/ML(Insulin Glargine)<br />
LANTUS INJ OPTICLIK(Insulin Glargine)<br />
LEVEMIR INJ(Insulin Detemir)<br />
LEVEMIR INJ FLEXPEN(Insulin Detemir)<br />
LEVLEN TAB CONTR PK(Levonorgestrel & Eth Estradiol)<br />
LEVLEN-28 TAB(Levonorgestrel & Eth Estradiol)<br />
LEVLITE TAB -28(Levonorgestrel & Eth Estradiol)<br />
levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg<br />
levonorgestrel & ethinyl estradiol tab 0.10 mg-20 mcg<br />
levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg<br />
levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg<br />
levothyroxine sodium for inj 200 mcg<br />
levothyroxine sodium for inj 500 mcg<br />
levothyroxine sodium tab 100 mcg<br />
levothyroxine sodium tab 112 mcg<br />
levothyroxine sodium tab 125 mcg<br />
levothyroxine sodium tab 137 mcg<br />
levothyroxine sodium tab 150 mcg<br />
levothyroxine sodium tab 175 mcg<br />
levothyroxine sodium tab 200 mcg<br />
levothyroxine sodium tab 25 mcg<br />
levothyroxine sodium tab 300 mcg<br />
levothyroxine sodium tab 50 mcg<br />
levothyroxine sodium tab 75 mcg<br />
levothyroxine sodium tab 88 mcg<br />
LEVOXYL TAB 100MCG(Levothyroxine Sodium)<br />
LEVOXYL TAB 112MCG(Levothyroxine Sodium)<br />
LEVOXYL TAB 125MCG(Levothyroxine Sodium)<br />
LEVOXYL TAB 137MCG(Levothyroxine Sodium)<br />
LEVOXYL TAB 150MCG(Levothyroxine Sodium)<br />
LEVOXYL TAB 175MCG(Levothyroxine Sodium)<br />
LEVOXYL TAB 200MCG(Levothyroxine Sodium)<br />
LEVOXYL TAB 25MCG(Levothyroxine Sodium)<br />
LEVOXYL TAB 50MCG(Levothyroxine Sodium)<br />
LEVOXYL TAB 75MCG(Levothyroxine Sodium)<br />
LEVOXYL TAB 88MCG(Levothyroxine Sodium)<br />
liothyronine sodium iv soln 10 mcg/ml<br />
LO/OVRAL-28 TAB(Norgestrel & Ethinyl Estradiol)<br />
LOESTRIN TAB 1/20-21(Norethindrone Acet & Eth Estra)<br />
LOESTRIN 21 TAB 1.5/30(Norethindrone Acet & Eth Estra)<br />
LOESTRIN 24 TAB FE(Norethin Acet & Estrad-Fe)<br />
LOESTRIN FE TAB 1.5/30(Norethin Acet & Estrad-Fe)<br />
LOESTRIN FE TAB 1/20(Norethin Acet & Estrad-Fe)<br />
LYBREL TAB 90-20MCG(Levonorgestrel-Ethinyl Estradiol (Continuous))<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
95
Drug Name Drug Tier Notes<br />
MEDROL PAK 4MG(Methylprednisolone)<br />
MEDROL TAB 16MG(Methylprednisolone)<br />
MEDROL TAB 2MG(Methylprednisolone)<br />
MEDROL TAB 32MG(Methylprednisolone)<br />
MEDROL TAB 4MG(Methylprednisolone)<br />
MEDROL TAB 8MG(Methylprednisolone)<br />
medroxyprogesterone acetate im susp 150 mg/ml<br />
medroxyprogesterone acetate tab 10 mg<br />
medroxyprogesterone acetate tab 2.5 mg<br />
medroxyprogesterone acetate tab 5 mg<br />
MEGACE ES SUS(Megestrol Acetate (Appetite))<br />
MENEST TAB 0.3MG(Esterified Estrogens)<br />
MENEST TAB 0.625MG(Esterified Estrogens)<br />
MENEST TAB 1.25MG(Esterified Estrogens)<br />
MENEST TAB 2.5MG(Esterified Estrogens)<br />
MENOSTAR DIS 14MCG(Estradiol)<br />
METAGLIP TAB 2.5-250M(Glipizide-Metformin HCl)<br />
METAGLIP TAB 2.5-500M(Glipizide-Metformin HCl)<br />
METAGLIP TAB 5-500MG(Glipizide-Metformin HCl)<br />
metformin hcl tab 1000 mg<br />
metformin hcl tab 500 mg<br />
metformin hcl tab 850 mg<br />
metformin hcl tab sr 24hr 500 mg<br />
metformin hcl tab sr 24hr 750 mg<br />
methimazole tab 10 mg<br />
methimazole tab 5 mg<br />
methylprednisolone acetate inj susp 40 mg/ml<br />
methylprednisolone acetate inj susp 80 mg/ml<br />
methylprednisolone sodium succinate for inj 1000 mg<br />
methylprednisolone sodium succinate for inj 125 mg<br />
methylprednisolone sodium succinate for inj 40 mg<br />
methylprednisolone sodium succinate for inj 500 mg<br />
methylprednisolone tab 4 mg<br />
methylprednisolone tab 4 mg dose pack<br />
methylprednisolone tab 8 mg<br />
methyltestosterone oral tab 10 mg<br />
MIACALCIN INJ 200/ML(Calcitonin (Salmon))<br />
MIACALCIN SPR 200/ACT(Calcitonin (Salmon))<br />
MICRONASE TAB 1.25MG(Glyburide)<br />
MICRONASE TAB 2.5MG(Glyburide)<br />
MICRONASE TAB 5MG(Glyburide)<br />
MIRCETTE TAB 28 DAY(Desogestrel & Ethinyl Estradiol)<br />
MIRENA IUD SYSTEM(Levonorgestrel (IUD))<br />
MODICON TAB 0.5/35(Norethindrone & Eth Estradiol)<br />
NECON TAB 10/11-28(Norethindrone-Eth Estradiol (Biphasic))<br />
NOR-QD TAB 0.35MG(Norethindrone (Contraceptive))<br />
NORDETTE-28 TAB(Levonorgestrel & Eth Estradiol)<br />
NORDITROPIN INJ 10/1.5ML(Somatropin)<br />
NORDITROPIN INJ 15/1.5ML(Somatropin)<br />
NORDITROPIN INJ 15/1.5ML(Somatropin)<br />
04<br />
02<br />
02<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
04<br />
03<br />
02<br />
02<br />
(QL)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
96
Drug Name Drug Tier Notes<br />
NORDITROPIN INJ 5/1.5ML(Somatropin)<br />
NORDITROPIN INJ 5/1.5ML(Somatropin)<br />
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg<br />
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg<br />
norethindrone & ethinyl estradiol tab 1 mg-35 mcg<br />
norethindrone & mestranol tab 1 mg-50 mcg<br />
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg<br />
norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg<br />
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg<br />
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg<br />
norethindrone acetate tab 5 mg<br />
norethindrone tab 0.35 mg<br />
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg<br />
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg<br />
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg<br />
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg<br />
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg<br />
norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg<br />
NORINYL TAB 1+35-28(Norethindrone & Eth Estradiol)<br />
NORINYL TAB 1+50-28(Norethindrone & Mestranol)<br />
NOVOLIN INJ 70/30(Insulin Isophane & Reg (Human))<br />
NOVOLIN 70/ INJ 30 INNLT(Insulin Isophane & Reg (Human))<br />
NOVOLIN 70/ INJ 30 PNFIL(Insulin Isophane & Reg (Human))<br />
NOVOLIN N INJ INNOLET(Insulin Isophane (Human))<br />
NOVOLIN N INJ PENFILL(Insulin Isophane (Human))<br />
NOVOLIN N INJ U-100(Insulin Isophane (Human))<br />
NOVOLIN R INJ INNOLET(Insulin Regular (Human))<br />
NOVOLIN R INJ PENFILL(Insulin Regular (Human))<br />
NOVOLIN R INJ U-100(Insulin Regular (Human))<br />
NOVOLOG INJ 100/ML(Insulin Aspart)<br />
NOVOLOG INJ FLEXPEN(Insulin Aspart)<br />
NOVOLOG INJ PENFILL(Insulin Aspart)<br />
NOVOLOG MIX INJ 70/30(Insulin Aspart Protamine & Aspart (Human))<br />
NOVOLOG MIX INJ FLEXPEN(Insulin Aspart Protamine & Aspart (Human))<br />
NOVOLOG MIX INJ PENFILL(Insulin Aspart Protamine & Aspart (Human))<br />
NUTROPIN INJ 10MG(Somatropin)<br />
NUTROPIN INJ 5MG(Somatropin)<br />
NUTROPIN AQ INJ 10MG/2ML(Somatropin)<br />
NUVARING MIS(Etonogestrel-Ethinyl Estradiol)<br />
OGEN TAB 0.625(Estropipate)<br />
OGEN TAB 1.25(Estropipate)<br />
OGEN TAB 2.5(Estropipate)<br />
OMNITROPE INJ 5.8MG(Somatropin)<br />
ORAPRED SOL 15MG/5ML(Prednisolone Sodium Phosphate)<br />
ORAPRED ODT TAB 10MG(Prednisolone Sodium Phosphate)<br />
ORAPRED ODT TAB 15MG(Prednisolone Sodium Phosphate)<br />
ORAPRED ODT TAB 30MG(Prednisolone Sodium Phosphate)<br />
ORTHO EVRA DIS WEEK(Norelgestromin-Ethinyl Estradiol)<br />
ORTHO MICRON TAB DIALPAK(Norethindrone (Contraceptive))<br />
ORTHO TRI- TAB CYCLEN(Norgestimate-Ethinyl Estradiol (Triphasic))<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
03<br />
02<br />
02<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
04<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
97
Drug Name Drug Tier Notes<br />
ORTHO TRI-CY TAB LO(Norgestimate-Ethinyl Estradiol (Triphasic))<br />
ORTHO-CEPT TAB 28(Desogestrel & Ethinyl Estradiol)<br />
ORTHO-CYCLEN TAB 0.25/35(Norgestimate-Ethinyl Estradiol)<br />
ORTHO-NOVUM TAB 1/35-28(Norethindrone & Eth Estradiol)<br />
ORTHO-NOVUM TAB 1/50-28(Norethindrone & Mestranol)<br />
ORTHO-NOVUM TAB 7/7/7-28(Norethindrone-Eth Estradiol (Triphasic))<br />
OVCON 50 TAB 28(Norethindrone & Eth Estradiol)<br />
OVCON-35 TAB(Norethindrone & Eth Estradiol)<br />
OXANDRIN TAB 10MG(Oxandrolone)<br />
OXANDRIN TAB 2.5MG(Oxandrolone)<br />
oxandrolone tab 10 mg<br />
oxandrolone tab 2.5 mg<br />
PEDIAPRED LIQ 6.7/5ML(Prednisolone Sodium Phosphate)<br />
PLAN B TAB 0.75MG(Levonorgestrel (Emergency OC))<br />
PRANDIN TAB 0.5MG(Repaglinide)<br />
PRANDIN TAB 1MG(Repaglinide)<br />
PRANDIN TAB 2MG(Repaglinide)<br />
PRECOSE TAB 100MG(Acarbose)<br />
PRECOSE TAB 25MG(Acarbose)<br />
PRECOSE TAB 50MG(Acarbose)<br />
prednisolone sod phosphate liq 6.7 mg/5ml (5mg/5ml base eq)<br />
prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)<br />
prednisolone syrup 15 mg/5ml<br />
prednisolone syrup 5 mg/5ml<br />
prednisolone tab 5 mg<br />
PREDNISONE TAB 50MG(Prednisone)<br />
prednisone conc 5 mg/ml<br />
prednisone oral soln 5 mg/5ml<br />
prednisone tab 1 mg<br />
prednisone tab 10 mg<br />
prednisone tab 10 mg dose pack<br />
prednisone tab 2.5 mg<br />
prednisone tab 20 mg<br />
prednisone tab 5 mg<br />
prednisone tab 5 mg dose pack<br />
prednisone tab 50 mg<br />
PREFEST TAB(Estradiol-Norgestimate)<br />
PRELONE SYP 15MG/5ML(Prednisolone)<br />
PREMARIN INJ 25MG(Estrogens, Conjugated)<br />
PREMARIN TAB 0.3MG(Estrogens, Conjugated)<br />
PREMARIN TAB 0.45MG(Estrogens, Conjugated)<br />
PREMARIN TAB 0.625MG(Estrogens, Conjugated)<br />
PREMARIN TAB 0.9MG(Estrogens, Conjugated)<br />
PREMARIN TAB 1.25MG(Estrogens, Conjugated)<br />
PREMARIN VAG CRE 0.625MG(Estrogens, Conjugated Vaginal)<br />
PREMPHASE TAB(Conjugated Estrogens-Medroxyprogesterone Acetate)<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
01<br />
01<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
(QL)<br />
98
Drug Name Drug Tier Notes<br />
PREMPRO TAB .625-2.5(Conjugated Estrogens-Medroxyprogesterone<br />
Acetate)<br />
PREMPRO TAB 0.3-1.5(Conjugated Estrogens-Medroxyprogesterone<br />
Acetate)<br />
PREMPRO TAB 0.45-1.5(Conjugated Estrogens-Medroxyprogesterone<br />
Acetate)<br />
PREMPRO TAB 0.625-5(Conjugated Estrogens-Medroxyprogesterone<br />
Acetate)<br />
PROCHIEVE GEL 4%(Progesterone (Vaginal))<br />
PROCHIEVE GEL 8% VAG(Progesterone (Vaginal))<br />
PROGESTERONE SUP VGS 100(Progesterone (Vaginal))<br />
PROGESTERONE SUP VGS 200(Progesterone (Vaginal))<br />
PROGESTERONE SUP VGS 25(Progesterone (Vaginal))<br />
PROGESTERONE SUP VGS 400(Progesterone (Vaginal))<br />
PROGESTERONE SUP VGS 50(Progesterone (Vaginal))<br />
PROMETRIUM CAP 100MG(Progesterone Micronized)<br />
PROMETRIUM CAP 200MG(Progesterone Micronized)<br />
propylthiouracil tab 50 mg<br />
PROVERA TAB 10MG(Medroxyprogesterone Acetate)<br />
PROVERA TAB 2.5MG(Medroxyprogesterone Acetate)<br />
PROVERA TAB 5MG(Medroxyprogesterone Acetate)<br />
PULMICORT INH 180MCG(Budesonide (Inhalation))<br />
PULMICORT INH 90MCG(Budesonide (Inhalation))<br />
PULMICORT SUS 0.25MG/2(Budesonide (Inhalation))<br />
PULMICORT SUS 0.5MG/2(Budesonide (Inhalation))<br />
QVAR AER 40MCG(Beclomethasone Dipropionate)<br />
QVAR AER 80MCG(Beclomethasone Dipropionate)<br />
RELION 70/30 INJ 100/ML(Insulin Isophane & Reg (Human))<br />
RELION 70/30 INJ INNOLET(Insulin Isophane & Reg (Human))<br />
RELION N INJ 100/ML(Insulin Isophane (Human))<br />
RELION N INJ INNOLET(Insulin Isophane (Human))<br />
RELION R INJ 100/ML(Insulin Regular (Human))<br />
RIOMET SOL(Metformin HCl)<br />
SAIZEN INJ 5MG(Somatropin (Non-Refrigerated))<br />
SAIZEN INJ 8.8MG(Somatropin (Non-Refrigerated))<br />
SEASONALE TAB(Levonorgestrel-Ethinyl Estradiol (91-Day))<br />
SEROSTIM INJ 4MG(Somatropin (Non-Refrigerated))<br />
SEROSTIM INJ 5MG(Somatropin (Non-Refrigerated))<br />
SEROSTIM INJ 6MG(Somatropin (Non-Refrigerated))<br />
SOLU-CORTEF INJ 1000MG(Hydrocortisone Sod Succinate)<br />
SOLU-CORTEF INJ 100MG(Hydrocortisone Sod Succinate)<br />
SOLU-CORTEF INJ 250MG(Hydrocortisone Sod Succinate)<br />
SOLU-CORTEF INJ 500MG(Hydrocortisone Sod Succinate)<br />
SOLU-MEDROL INJ 1000MG(Methylprednisolone Sod Succ)<br />
SOLU-MEDROL INJ 125MG(Methylprednisolone Sod Succ)<br />
SOLU-MEDROL INJ 2GM(Methylprednisolone Sod Succ)<br />
SOLU-MEDROL INJ 40MG(Methylprednisolone Sod Succ)<br />
SOLU-MEDROL INJ 500MG(Methylprednisolone Sod Succ)<br />
SOMAVERT INJ 10MG(Pegvisomant)<br />
SOMAVERT INJ 15MG(Pegvisomant)<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
99
Drug Name Drug Tier Notes<br />
SOMAVERT INJ 20MG(Pegvisomant)<br />
STARLIX TAB 120MG(Nateglinide)<br />
STARLIX TAB 60MG(Nateglinide)<br />
STERAPRED PAK 5MG(Prednisone)<br />
STERAPRED PAK 5MG 12DY(Prednisone)<br />
STERAPRED DS PAK 10MG(Prednisone)<br />
STERAPRED DS PAK 10MG 12D(Prednisone)<br />
STIMATE SOL 1.5MG/ML(Desmopressin Acetate)<br />
STRIANT MIS 30MG(Testosterone)<br />
SYMBICORT AER 160-4.5(Budesonide-Formoterol Fumarate Dihydrate)<br />
SYMBICORT AER 80-4.5(Budesonide-Formoterol Fumarate Dihydrate)<br />
SYMLIN INJ 0.6MG/ML(Pramlintide Acetate)<br />
SYNAREL SOL 2MG/ML(Nafarelin Acetate)<br />
SYNTHROID TAB 100MCG(Levothyroxine Sodium)<br />
SYNTHROID TAB 100MCG(Levothyroxine Sodium)<br />
SYNTHROID TAB 112MCG(Levothyroxine Sodium)<br />
SYNTHROID TAB 125MCG(Levothyroxine Sodium)<br />
SYNTHROID TAB 125MCG(Levothyroxine Sodium)<br />
SYNTHROID TAB 137MCG(Levothyroxine Sodium)<br />
SYNTHROID TAB 150MCG(Levothyroxine Sodium)<br />
SYNTHROID TAB 175MCG(Levothyroxine Sodium)<br />
SYNTHROID TAB 175MCG(Levothyroxine Sodium)<br />
SYNTHROID TAB 200MCG(Levothyroxine Sodium)<br />
SYNTHROID TAB 25MCG(Levothyroxine Sodium)<br />
SYNTHROID TAB 300MCG(Levothyroxine Sodium)<br />
SYNTHROID TAB 50MCG(Levothyroxine Sodium)<br />
SYNTHROID TAB 75MCG(Levothyroxine Sodium)<br />
SYNTHROID TAB 88MCG(Levothyroxine Sodium)<br />
TAPAZOLE TAB 10MG(Methimazole)<br />
TAPAZOLE TAB 5MG(Methimazole)<br />
TESTIM GEL 1%(50MG)(Testosterone)<br />
testosterone cypionate im in oil 100 mg/ml<br />
testosterone cypionate im in oil 200 mg/ml<br />
testosterone enanthate im in oil 200 mg/ml<br />
TESTRED CAP 10MG(Methyltestosterone)<br />
TEV-TROPIN INJ 5MG(Somatropin)<br />
thyroid tab 120 mg (2 grain)<br />
thyroid tab 15 mg (1/4 grain)<br />
thyroid tab 180 mg (3 grain)<br />
thyroid tab 240 mg (4 grain)<br />
thyroid tab 30 mg (1/2 grain)<br />
thyroid tab 60 mg (1 grain)<br />
thyroid tab 90 mg (1 1/2 grain)<br />
THYROLAR-1 TAB 60MG(Liotrix)<br />
THYROLAR-1/2 TAB 30MG(Liotrix)<br />
THYROLAR-1/4 TAB 15MG(Liotrix)<br />
THYROLAR-2 TAB 120MG(Liotrix)<br />
THYROLAR-3 TAB 180MG(Liotrix)<br />
tolazamide tab 250 mg<br />
tolazamide tab 500 mg<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
04<br />
04<br />
02<br />
03<br />
02<br />
04<br />
02<br />
02<br />
04<br />
02<br />
02<br />
02<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
02<br />
01<br />
01<br />
01<br />
02<br />
03<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
100
Drug Name Drug Tier Notes<br />
tolbutamide tab 500 mg<br />
TRI-LEVLEN TAB 28(Levonorgestrel-Eth Estradiol (Triphasic))<br />
TRI-LEVLEN TAB CONTR PK(Levonorgestrel-Eth Estradiol (Triphasic))<br />
TRI-NORINYL TAB 28(Norethindrone-Eth Estradiol (Triphasic))<br />
TRIOSTAT INJ 10MCG/ML(Liothyronine Sodium)<br />
TRIPHASIL 28 TAB(Levonorgestrel-Eth Estradiol (Triphasic))<br />
VAGIFEM TAB 25MCG(Estradiol Vaginal)<br />
VIVELLE DIS 0.05MG(Estradiol)<br />
VIVELLE DIS 0.1MG(Estradiol)<br />
VIVELLE-DOT DIS 0.025MG(Estradiol)<br />
VIVELLE-DOT DIS 0.0375MG(Estradiol)<br />
VIVELLE-DOT DIS 0.05MG(Estradiol)<br />
VIVELLE-DOT DIS 0.075MG(Estradiol)<br />
VIVELLE-DOT DIS 0.1MG(Estradiol)<br />
YASMIN 28 TAB 3-0.03MG(Drospirenone-Ethinyl Estradiol)<br />
YAZ TAB 3-0.02MG(Drospirenone-Ethinyl Estradiol)<br />
ZORBTIVE INJ(Somatropin (Non-Refrigerated))<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
02 (PA)<br />
Local Anesthetics<br />
LIDO/DEXTROS INJ 5-7.5%(Lidocaine in Dextrose)<br />
lidocaine hcl local inj 0.5%<br />
lidocaine hcl local inj 1%<br />
lidocaine hcl local inj 1.5%<br />
lidocaine hcl local inj 2%<br />
lidocaine hcl local inj 4%<br />
XYLOCAINE INJ -MPF 1%(Lidocaine HCl (Local Anesth.))<br />
XYLOCAINE INJ -MPF 2%(Lidocaine HCl (Local Anesth.))<br />
XYLOCAINE INJ -MPF 4%(Lidocaine HCl (Local Anesth.))<br />
XYLOCAINE INJ 0.5%(Lidocaine HCl (Local Anesth.))<br />
XYLOCAINE INJ 1%(Lidocaine HCl (Local Anesth.))<br />
XYLOCAINE INJ 2%(Lidocaine HCl (Local Anesth.))<br />
XYLOCAINE INJ MPF 0.5%(Lidocaine HCl (Local Anesth.))<br />
XYLOCAINE INJ MPF 1.5%(Lidocaine HCl (Local Anesth.))<br />
Oxytocics<br />
METHERGINE INJ 0.2MG/ML(Methylergonovine Maleate)<br />
METHERGINE TAB 0.2MG(Methylergonovine Maleate)<br />
oxytocin inj 10 unit/ml<br />
PITOCIN INJ 10UNT/ML(Oxytocin)<br />
Serums, Toxoids and Vaccines<br />
ACTHIB INJ(Haemophilus B Polysac Conj Vac)<br />
ADACEL INJ(Tetanus Toxoid-Diphtheria-Acellular Pertussis Adsorb<br />
(Tdap))<br />
ATTENUVAX INJ LIVE(Measles Virus Vaccine)<br />
BOOSTRIX SUS(Tetanus Toxoid-Diphtheria-Acellular Pertussis Adsorb<br />
(Tdap))<br />
CARIMUNE NF INJ 12GM(Immune Globulin (Human) IV)<br />
CARIMUNE NF INJ 1GM(Immune Globulin (Human) IV)<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
01<br />
02<br />
04<br />
04<br />
02<br />
04<br />
03<br />
03<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
101
Drug Name Drug Tier Notes<br />
CARIMUNE NF INJ 3GM(Immune Globulin (Human) IV)<br />
CARIMUNE NF INJ 6GM(Immune Globulin (Human) IV)<br />
COMVAX INJ(Haemophilus B Polysac Conj-Hepatitis B (Recomb)<br />
Vaccines)<br />
DAPTACEL INJ(Diphtheria, Acellular Pertussis & Tetanus Toxoids)<br />
DECAVAC INJ 5-2LF(Tetanus-Diphtheria Toxoids (Td))<br />
DIP/TET PED INJ 6.7-5LF(Diphtheria-Tetanus Toxoids (DT))<br />
ENGERIX-B INJ 10/0.5ML(Hepatitis B Vaccine (Recomb))<br />
ENGERIX-B INJ 20MCG/ML(Hepatitis B Vaccine (Recomb))<br />
FLBGAMMA DIF INJ 5%(Immune Globulin (Human) IV)<br />
FLEBOGAMMA INJ 5%(Immune Globulin (Human) IV)<br />
GAMASTAN S/D INJ(Immune Globulin (Human))<br />
GAMMAGARD INJ 10GM/100(Immune Globulin (Human) IV)<br />
GAMMAGARD INJ 1G/10ML(Immune Globulin (Human) IV)<br />
GAMMAGARD INJ 2.5GM/25(Immune Globulin (Human) IV)<br />
GAMMAGARD INJ 20GM/200(Immune Globulin (Human) IV)<br />
GAMMAGARD INJ 5GM/50ML(Immune Globulin (Human) IV)<br />
GAMMAGARD SD INJ 0.5GM HU(Immune Globulin (Human) IV)<br />
GAMMAGARD SD INJ 10GM HU(Immune Globulin (Human) IV)<br />
GAMMAGARD SD INJ 2.5GM HU(Immune Globulin (Human) IV)<br />
GAMMAGARD SD INJ 5GM HU(Immune Globulin (Human) IV)<br />
GAMUNEX INJ 10%(Immune Globulin (Human) IV)<br />
GARDASIL INJ(Quadrivalent Human Papillomavirus (HPV) Recombinant<br />
Vaccine)<br />
HAVRIX INJ 1440UNIT(Hepatitis A Vaccine)<br />
HAVRIX INJ 720UNIT(Hepatitis A Vaccine)<br />
HIBTITER INJ(Haemophilus B Oligosaccharide Conjugate Vaccine)<br />
IMMUNE GLOBU INJ HUMAN(Immune Globulin (Human))<br />
IMOVAX RABIE INJ 2.5/ML(Rabies Virus Vaccine, HDC)<br />
INFANRIX INJ(Diphtheria, Acellular Pertussis & Tetanus Toxoids)<br />
IPOL INJ INACTIVE(Poliovirus Vaccine, IPV)<br />
IVEEGAM EN INJ 5GM HU(Immune Globulin (Human) IV)<br />
JE-VAX INJ(Japanese Encephalitis Virus Vaccine)<br />
M-M-R II INJ LIVE(Measles, Mumps & Rubella Virus Vaccines)<br />
M-M-R II INJ LIVE(Measles, Mumps & Rubella Virus Vaccines)<br />
M-R-VAX II INJ(Measles & Rubella Vaccines)<br />
MENACTRA INJ(Meningococcal (A,C,Y&W-135) Polysaccharide Conjugate<br />
Vaccine)<br />
MENOMUNE INJ A/C/Y/W(Meningococcal Vac A,C,Y&W-135)<br />
MERUVAX II INJ LIVE(Rubella Virus Vaccine)<br />
MERUVAX II INJ LIVE(Rubella Virus Vaccine)<br />
MUMPSVAX INJ LIVE(Mumps Virus Vaccine Live)<br />
MUMPSVAX INJ LIVE(Mumps Virus Vaccine Live)<br />
OCTAGAM INJ 10GM(Immune Globulin (Human) IV)<br />
OCTAGAM INJ 1GM(Immune Globulin (Human) IV)<br />
OCTAGAM INJ 2.5GM(Immune Globulin (Human) IV)<br />
OCTAGAM INJ 5GM(Immune Globulin (Human) IV)<br />
PANGLOBULIN INJ 12GM(Immune Globulin (Human) IV)<br />
PANGLOBULIN INJ 1GM(Immune Globulin (Human) IV)<br />
PANGLOBULIN INJ 3GM(Immune Globulin (Human) IV)<br />
03<br />
03<br />
02<br />
02<br />
04<br />
04<br />
02<br />
02<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
04<br />
02<br />
02<br />
02<br />
03<br />
04<br />
02<br />
02<br />
03<br />
02<br />
02<br />
02<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
03<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
102
Drug Name Drug Tier Notes<br />
PANGLOBULIN INJ 6GM(Immune Globulin (Human) IV)<br />
PANGLOBULIN SOL 12GM(Immune Globulin (Human) IV)<br />
PANGLOBULIN SOL 6GM(Immune Globulin (Human) IV)<br />
PEDIARIX INJ 0.5ML(Diph-Tetanus Tox-Acell Pert-Hepatitis B Recomb-<br />
Polio IPV Vac)<br />
PEDVAX HIB INJ(Haemophilus B Polysac Conj Vac)<br />
POLYGAM S/D SOL 0.5GM(Immune Globulin (Human) IV)<br />
POLYGAM S/D SOL 10GM(Immune Globulin (Human) IV)<br />
POLYGAM S/D SOL 2.5GM(Immune Globulin (Human) IV)<br />
POLYGAM S/D SOL 5GM(Immune Globulin (Human) IV)<br />
PROQUAD INJ(Measles-Mumps-Rubella-Varicella Virus Vaccines)<br />
RABAVERT INJ(Rabies Vaccine, PCEC)<br />
RECOMBIVA HB INJ 10MCG/ML(Hepatitis B Vaccine (Recomb))<br />
RECOMBIVA HB INJ 5MCG/0.5(Hepatitis B Vaccine (Recomb))<br />
RECOMBIVA-HB INJ 10MCG/ML(Hepatitis B Vaccine (Recomb))<br />
RECOMBIVA-HB INJ 40MCG/ML(Hepatitis B Vaccine (Recomb))<br />
ROTATEQ SUS(Rotavirus Vaccine, Live Oral Pentavalent)<br />
TE ANATOXAL INJ BERNA(Tetanus Toxoid Adsorbed)<br />
TET/DIP TOX INJ 2-2 LF(Tetanus-Diphtheria Toxoids (Td))<br />
TETANUS TOX INJ 5LF ADS(Tetanus Toxoid Adsorbed)<br />
tetanus toxoid fluid inj 5 lf<br />
THERACYS INJ(BCG Vaccine Intravesical)<br />
TICE BCG INJ(BCG Vaccine Intravesical)<br />
TRIHIBIT KIT P/F(Diph, Acellular Pertussis, Tetanus Tox & Haemophilus B<br />
Poly)<br />
TRIPEDIA SUS P/F(Diphtheria, Acellular Pertussis & Tetanus Toxoids)<br />
TWINRIX INJ(Hepatitis A (Inactivated)-Hepatitis B (Recombinant)<br />
Vaccines)<br />
TYPHIM VI INJ(Typhoid VI Polysaccharide Vaccine)<br />
VAQTA INJ 25/0.5ML(Hepatitis A Vaccine)<br />
VAQTA INJ 50UNT/ML(Hepatitis A Vaccine)<br />
varicella-zoster immune globulin (human ) inj 125 unit/2.5ml<br />
varicella-zoster immune globulin (human ) inj 625 unit/10ml<br />
VARIVAX INJ(Varicella Virus Vaccine Live)<br />
VENOGLOBUL-S INJ 10%(Immune Globulin (Human) IV)<br />
VIVAGLOBIN SOL 160MG/ML(Immune Globulin (Human) Subcutaneous)<br />
VIVOTIF BERN CAP EC(Typhoid Vaccine)<br />
YF-VAX INJ(Yellow Fever Vaccine)<br />
ZOSTAVAX INJ(Zoster Vaccine Live)<br />
Skin and Mucous Membrane Preparations<br />
*papain-urea-chlorophyllin liquid***<br />
*papain-urea-chlorophyllin ointment***<br />
*sulfacetamide sodium-sulfur w/ sunscreens cream 10-5%***<br />
8-MOP CAP 10MG(Methoxsalen)<br />
ACCUTANE CAP 10MG(Isotretinoin)<br />
ACCUTANE CAP 20MG(Isotretinoin)<br />
ACCUTANE CAP 40MG(Isotretinoin)<br />
ACCUZYME OIN(Papain-Urea)<br />
ACCUZYME SPR(Papain-Urea)<br />
03<br />
03<br />
03<br />
02<br />
04<br />
03<br />
03<br />
03<br />
03<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
02<br />
01<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
02<br />
03<br />
02<br />
04<br />
04<br />
02<br />
01<br />
01<br />
01<br />
04<br />
02<br />
02<br />
02<br />
04<br />
04<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
103
Drug Name Drug Tier Notes<br />
ACLOVATE CRE 0.05%(Alclometasone Dipropionate)<br />
ACLOVATE OIN 0.05%(Alclometasone Dipropionate)<br />
ACLOVATE OIN 0.05%(Alclometasone Dipropionate)<br />
AKNE-MYCIN OIN 2%(Erythromycin (Acne Aid))<br />
ALA-SCALP LOT 2%(Hydrocortisone (Topical))<br />
alclometasone dipropionate cream 0.05%<br />
alclometasone dipropionate oint 0.05%<br />
ALDARA CRE 5%(Imiquimod)<br />
ALTABAX OIN 1%(Retapamulin)<br />
aluminum chloride soln 20%<br />
AMCINONIDE LOT 0.1%(Amcinonide)<br />
amcinonide cream 0.1%<br />
amcinonide oint 0.1%<br />
AMERICAINE GEL 20%(Benzocaine (Topical))<br />
AMEVIVE INJ 15MG(Alefacept)<br />
ANACAINE OIN(Benzocaine (Topical))<br />
anthralin cream 1%<br />
ANUSOL-HC CRE 2.5%(Hydrocortisone (Rectal))<br />
augmented betamethasone dipropionate cream 0.05%<br />
augmented betamethasone dipropionate gel 0.05%<br />
augmented betamethasone dipropionate lotion 0.05%<br />
augmented betamethasone dipropionate oint 0.05%<br />
AVAR GEL 10-5%(Sulfacetamide Sodium w/ Sulfur)<br />
AZELEX CRE 20%(Azelaic Acid (Acne))<br />
BACTROBAN CRE 2%(Mupirocin Calcium (Topical))<br />
BACTROBAN OIN 2%(Mupirocin)<br />
BACTROBAN OIN NASAL 2%(Mupirocin Calcium)<br />
BENZAC AC GEL 10%(Benzoyl Peroxide)<br />
BENZAC AC GEL 2.5%(Benzoyl Peroxide)<br />
BENZAC AC GEL 5%(Benzoyl Peroxide)<br />
BENZAC W GEL 10%(Benzoyl Peroxide)<br />
BENZAC W GEL 2.5%(Benzoyl Peroxide)<br />
BENZAC W GEL 5%(Benzoyl Peroxide)<br />
BENZACLIN GEL 1-5%(Clindamycin Phosphate-Benzoyl Peroxide)<br />
BENZACLIN GEL 1-5%PUMP(Clindamycin Phosphate-Benzoyl Peroxide)<br />
BENZAGEL-10 GEL 10%(Benzoyl Peroxide)<br />
BENZAGEL-5 GEL 5%(Benzoyl Peroxide)<br />
BENZAMYCIN GEL(Benzoyl Peroxide-Erythromycin)<br />
BENZAMYCIN GEL PAK(Benzoyl Peroxide-Erythromycin)<br />
BENZIQ GEL 5.25%(Benzoyl Peroxide)<br />
BENZIQ LS GEL 2.75%(Benzoyl Peroxide)<br />
benzoyl peroxide gel 10%<br />
benzoyl peroxide gel 2.5%<br />
benzoyl peroxide gel 2.75%<br />
benzoyl peroxide gel 5%<br />
benzoyl peroxide gel 5.25 %<br />
benzoyl peroxide lotion 3%<br />
benzoyl peroxide lotion 6%<br />
benzoyl peroxide lotion 9%<br />
benzoyl peroxide pad 3%<br />
04<br />
04<br />
04<br />
02<br />
02<br />
01<br />
01<br />
02<br />
04<br />
01<br />
04<br />
01<br />
01<br />
02<br />
04<br />
02<br />
01<br />
04<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
(PA)<br />
(PA)<br />
104
Drug Name Drug Tier Notes<br />
benzoyl peroxide pad 6%<br />
benzoyl peroxide pad 9%<br />
benzoyl peroxide-erythromycin gel 5-3%<br />
benzoyl peroxide-urea cleanser 4.5-10%<br />
benzoyl peroxide-urea cleanser 6.5-10%<br />
benzoyl peroxide-urea cleanser 8.5-10%<br />
benzoyl peroxide-urea cream 6.5-10%<br />
benzoyl peroxide-urea cream 8.5-10%<br />
benzoyl peroxide-urea gel 4.5-10%<br />
benzoyl peroxide-urea gel 6.5-10%<br />
benzoyl peroxide-urea gel 8.5-10%<br />
benzoyl peroxide-urea pad 4.5-10%<br />
benzoyl peroxide-urea pad 6.5-10%<br />
benzoyl peroxide-urea pad 8.5-10%<br />
betamethasone dipropionate cream 0.05%<br />
betamethasone dipropionate lotion 0.05%<br />
betamethasone dipropionate oint 0.05%<br />
betamethasone valerate cream 0.1%<br />
betamethasone valerate lotion 0.1%<br />
betamethasone valerate oint 0.1%<br />
BREVOXYL GEL 4%(Benzoyl Peroxide)<br />
BREVOXYL GEL 8%(Benzoyl Peroxide)<br />
BREVOXYL-4 KIT ACNE WSH(Benzoyl Peroxide w/ Cleanser)<br />
BREVOXYL-8 KIT ACNE WSH(Benzoyl Peroxide w/ Cleanser)<br />
butamben-tetracaine-benzocaine aerosol spray 2-2-14%<br />
CAPEX SHA 0.01%(Fluocinolone Acetonide)<br />
CARAC CRE 0.5%(Fluorouracil (Topical))<br />
CARMOL 40 GEL 40%(Urea)<br />
CARMOL 40 LOT(Urea)<br />
CARMOL SCALP KIT TREATMNT(Sulfacetamide Sodium-Urea)<br />
CARMOL SCALP LOT TREATMEN(Sulfacetamide Sodium-Urea)<br />
CARMOL-HC CRE 1%(Urea-HC Acetate)<br />
CENTANY KIT 2%(Mupirocin)<br />
ciclopirox olamine cream 0.77% (base equiv)<br />
ciclopirox olamine susp 0.77% (base equiv)<br />
CLARIFOAM EF AER 10-5%(Sulfacetamide Sodium w/ Sulfur)<br />
CLEOCIN SUP 100MG(Clindamycin Phosphate Vaginal)<br />
CLEOCIN VAG CRE 2%(Clindamycin Phosphate Vaginal)<br />
CLEOCIN-T GEL 1%(Clindamycin Phosphate (Topical))<br />
CLEOCIN-T LOT 1%(Clindamycin Phosphate (Topical))<br />
CLEOCIN-T PAD 1%(Clindamycin Phosphate (Topical))<br />
CLEOCIN-T SOL 1%(Clindamycin Phosphate (Topical))<br />
CLINAC BPO GEL 7%(Benzoyl Peroxide)<br />
CLINDAGEL<br />
clindamycin phosphate gel 1%<br />
clindamycin phosphate lotion 1%<br />
clindamycin phosphate soln 1%<br />
clindamycin phosphate swab 1%<br />
GEL 1%(Clindamycin Phosphate (Topical))<br />
clindamycin phosphate vaginal cream 2%<br />
CLINDESSE CRE 2%(Clindamycin Phosphate (One Dose))<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
01<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
105
Drug Name Drug Tier Notes<br />
clobetasol propionate cream 0.05%<br />
clobetasol propionate emollient base cream 0.05%<br />
clobetasol propionate gel 0.05%<br />
clobetasol propionate oint 0.05%<br />
clobetasol propionate soln 0.05%<br />
CLOBEX LOT 0.05%(Clobetasol Propionate)<br />
CLOBEX SHA 0.05%(Clobetasol Propionate)<br />
CLOBEX SPR 0.05%(Clobetasol Propionate)<br />
CLODERM CRE 0.1%(Clocortolone Pivalate)<br />
clotrimazole troche 10 mg<br />
clotrimazole w/ betamethasone cream 1-0.05%<br />
clotrimazole w/ betamethasone lotion 1-0.05%<br />
CONDYLOX GEL 0.5%(Podofilox)<br />
CONDYLOX SOL 0.5%(Podofilox)<br />
CORDRAN LOT 0.05%(Flurandrenolide)<br />
CORDRAN OIN 0.05%(Flurandrenolide)<br />
CORDRAN 24X3 TAP 4MCG/CM(Flurandrenolide)<br />
CORDRAN 80X3 TAP 4MCG/CM(Flurandrenolide)<br />
CORDRAN SP CRE 0.05%(Flurandrenolide)<br />
CORTIFOAM AER 90MG(Hydrocortisone Acetate (Intrarectal))<br />
CUTIVATE CRE 0.05%(Fluticasone Propionate)<br />
CUTIVATE LOT 0.05%(Fluticasone Propionate)<br />
CUTIVATE OIN 0.005%(Fluticasone Propionate)<br />
DENAVIR CRE 1%(Penciclovir)<br />
DERMA-SMOOTH OIL /FS(Fluocinolone Acetonide)<br />
DERMA-SMOOTH OIL /FS(Fluocinolone Acetonide)<br />
DERMATOP CRE 0.1%(Prednicarbate)<br />
DERMATOP OIN 0.1%(Prednicarbate)<br />
DESONATE GEL 0.05%(Desonide)<br />
desonide cream 0.05%<br />
desonide lotion 0.05%<br />
desonide oint 0.05%<br />
DESOWEN CRE 0.05%(Desonide)<br />
DESOWEN LOT 0.05%(Desonide)<br />
DESOWEN OIN 0.05%(Desonide)<br />
desoximetasone cream 0.05%<br />
desoximetasone cream 0.25%<br />
desoximetasone gel 0.05%<br />
desoximetasone oint 0.25%<br />
DESQUAM-E GEL 5%(Benzoyl Peroxide)<br />
DESQUAM-X GEL 10%(Benzoyl Peroxide)<br />
DESQUAM-X GEL 5%(Benzoyl Peroxide)<br />
DIFFERIN CRE 0.1%(Adapalene)<br />
DIFFERIN GEL 0.1%(Adapalene)<br />
DIFFERIN GEL 0.3%(Adapalene)<br />
diflorasone diacetate cream 0.05%<br />
diflorasone diacetate emollient base cream 0.05%<br />
diflorasone diacetate oint 0.05%<br />
DIPROLENE LOT 0.05%(Aug Betamethasone Dipropionate)<br />
DIPROLENE OIN 0.05%(Aug Betamethasone Dipropionate)<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
04<br />
04<br />
106
Drug Name Drug Tier Notes<br />
DIPROLENE AF CRE 0.05%(Aug Betamethasone Dipropionate)<br />
DOVONEX CRE 0.005%(Calcipotriene)<br />
DOVONEX SOL 0.005%(Calcipotriene)<br />
doxepin hcl cream 5%<br />
DRITHO-SCALP CRE 0.5%(Anthralin)<br />
DRYSOL SOL 20%(Aluminum Chloride)<br />
DUAC GEL 1-5%(Clindamycin Phosphate-Benzoyl Peroxide<br />
(Refrigerate))<br />
econazole nitrate cream 1%<br />
EFUDEX CRE 5%(Fluorouracil (Topical))<br />
EFUDEX KIT OCCLUSIO(Fluorouracil (Topical))<br />
EFUDEX SOL 2%(Fluorouracil (Topical))<br />
EFUDEX SOL 5%(Fluorouracil (Topical))<br />
ELIDEL CRE 1%(Pimecrolimus)<br />
ELIMITE CRE 5%(Permethrin)<br />
ELOCON CRE 0.1%(Mometasone Furoate)<br />
ELOCON LOT 0.1%(Mometasone Furoate)<br />
ELOCON OIN 0.1%(Mometasone Furoate)<br />
EMLA CRE(Lidocaine-Prilocaine)<br />
EMLA KIT TEGADERM(Lidocaine-Prilocaine)<br />
EPIFOAM AER 1%(Pramoxine-HC)<br />
ERYGEL GEL 2%(Erythromycin (Acne Aid))<br />
erythromycin gel 2%<br />
erythromycin pads 2%<br />
erythromycin soln 2%<br />
EURAX CRE 10%(Crotamiton)<br />
EURAX LOT 10%(Crotamiton)<br />
EVOCLIN AER 1%(Clindamycin Phosphate (Topical))<br />
EXELDERM CRE 1%(Sulconazole Nitrate)<br />
EXELDERM SOL 1%(Sulconazole Nitrate)<br />
FINACEA GEL 15%(Azelaic Acid)<br />
fluocinolone acetonide cream 0.01%<br />
fluocinolone acetonide cream 0.025%<br />
fluocinolone acetonide oint 0.025%<br />
fluocinolone acetonide soln 0.01%<br />
fluocinonide cream 0.05%<br />
fluocinonide emulsified base cream 0.05%<br />
fluocinonide gel 0.05%<br />
fluocinonide oint 0.05%<br />
fluocinonide soln 0.05%<br />
FLUOROPLEX CRE 1%(Fluorouracil (Topical))<br />
fluorouracil cream 5%<br />
fluorouracil soln 2%<br />
fluorouracil soln 5%<br />
fluticasone propionate cream 0.05%<br />
fluticasone propionate oint 0.005%<br />
FRST-HYDRCRT GEL 10%(Hydrocortisone (Topical))<br />
gentamicin sulfate cream 0.1%<br />
gentamicin sulfate oint 0.1%<br />
GORDONS UREA OIN 40%(Urea)<br />
02<br />
02<br />
02<br />
01<br />
02<br />
04<br />
04<br />
01<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
01<br />
01<br />
02<br />
(PA)<br />
107
Drug Name Drug Tier Notes<br />
halobetasol propionate cream 0.05%<br />
halobetasol propionate oint 0.05%<br />
HALOG CRE 0.1%(Halcinonide)<br />
HALOG OIN 0.1%(Halcinonide)<br />
HALOG SOL 0.1%(Halcinonide)<br />
HYDRO 40 AER FOAM(Urea)<br />
hydrocortisone butyrate cream 0.1%<br />
hydrocortisone butyrate oint 0.1%<br />
hydrocortisone butyrate soln 0.1%<br />
hydrocortisone cream 1%<br />
hydrocortisone cream 2.5%<br />
hydrocortisone lotion 1%<br />
hydrocortisone lotion 2.5%<br />
hydrocortisone oint 1%<br />
hydrocortisone oint 2.5%<br />
hydrocortisone rectal cream 2.5%<br />
hydrocortisone soln 1%<br />
hydrocortisone valerate cream 0.2%<br />
hydrocortisone valerate oint 0.2%<br />
HYTONE CRE 2.5%(Hydrocortisone (Topical))<br />
INOVA PAD 4%(Benzoyl Peroxide)<br />
INOVA 4/1 PAD ACNE CON(Salicylic Acid-Benzoyl Peroxide)<br />
isotretinoin cap 10 mg<br />
isotretinoin cap 20 mg<br />
isotretinoin cap 30 mg<br />
isotretinoin cap 40 mg<br />
KENALOG AER SPRAY(Triamcinolone Acetonide (Topical))<br />
KENALOG CRE 0.1%(Triamcinolone Acetonide (Topical))<br />
KEPIVANCE INJ 6.25MG(Palifermin)<br />
KERAFOAM AER 30%(Urea)<br />
KERALAC CRE(Urea)<br />
KERALAC GEL(Urea)<br />
KERALAC LOT(Urea)<br />
KERALAC OIN 50%(Urea)<br />
KERALAC SOL NAILSTIK(Urea)<br />
KERALYT GEL 6%(Salicylic Acid)<br />
KEROL SUS 50%(Urea in Lactic Acid-Salicylic Acid Vehicle)<br />
ketoconazole cream 2%<br />
ketoconazole shampoo 2%<br />
KLARON LOT 10%(Sulfacetamide Sodium (Acne))<br />
LAC-HYDRIN CRE 12%(Lactic Acid (Ammonium Lactate))<br />
LAC-HYDRIN LOT 12%(Lactic Acid (Ammonium Lactate))<br />
lactic acid (ammonium lactate) cream 12%<br />
lactic acid (ammonium lactate) lotion 10%<br />
lactic acid (ammonium lactate) lotion 12%<br />
LACTINOL LOT 10%(Lactic Acid (Ammonium Lactate))<br />
LAMISIL SPR 1%(Terbinafine HCl (Topical))<br />
LEVULAN KERA SOL 20%(Aminolevulinic Acid HCl)<br />
LIDAMANTLE CRE 3%(Lidocaine HCl)<br />
lidocaine hcl cream 3%<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
02<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
04<br />
04<br />
02<br />
02<br />
01<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
108
Drug Name Drug Tier Notes<br />
lidocaine hcl gel 2%<br />
lidocaine hcl soln 4%<br />
lidocaine oint 5%<br />
lidocaine-prilocaine cream 2.5-2.5%<br />
LIDODERM DIS 5%(Lidocaine)<br />
lindane lotion 1%<br />
lindane shampoo 1%<br />
LOCOID LIPO CRE 0.1%(Hydrocortisone Butyrate Hydrophilic Lipo Base)<br />
LOPROX CRE 0.77%(Ciclopirox Olamine)<br />
LOPROX GEL TOPICAL(Ciclopirox)<br />
LOPROX SHA 1%(Ciclopirox)<br />
LOPROX SUS 0.77%(Ciclopirox Olamine)<br />
LOTRISONE CRE(Clotrimazole w/ Betamethasone)<br />
LOTRISONE LOT(Clotrimazole w/ Betamethasone)<br />
LUXIQ AER 0.12%(Betamethasone Valerate)<br />
MENTAX CRE 1%(Butenafine HCl)<br />
METROCREAM CRE 0.75%(Metronidazole (Topical))<br />
METROGEL GEL 1%(Metronidazole (Topical))<br />
METROGEL KIT 1%(Metronidazole w/ Cleanser (Topical))<br />
METROGEL VAG GEL 0.75%(Metronidazole Vaginal)<br />
METROLOTION LOT 0.75%(Metronidazole (Topical))<br />
metronidazole cream 0.75%<br />
metronidazole gel 0.75%<br />
metronidazole lotion 0.75%<br />
metronidazole vaginal gel 0.75%<br />
MICONAZOLE 3 SUP 200MG(Miconazole Nitrate Vaginal)<br />
miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit<br />
mometasone furoate cream 0.1%<br />
mometasone furoate oint 0.1%<br />
mometasone furoate solution 0.1% (lotion)<br />
mupirocin oint 2%<br />
MYCELEX TRO 10MG(Clotrimazole)<br />
MYCOSTATIN CRE 100000(Nystatin (Topical))<br />
MYCOSTATIN POW 100000(Nystatin (Topical))<br />
NAFTIN CRE 1%(Naftifine HCl)<br />
NAFTIN GEL 1%(Naftifine HCl)<br />
NAFTIN-MP CRE 1%(Naftifine HCl)<br />
NIZORAL SHA 2%(Ketoconazole (Topical))<br />
NORITATE CRE 1%(Metronidazole (Topical))<br />
NUOX GEL 6-3%(Benzoyl Peroxide-Sulfur)<br />
NYSTATIN TAB 100000(Nystatin Vaginal)<br />
nystatin cream 100000 unit/gm<br />
nystatin oint 100000 unit/gm<br />
nystatin topical powder<br />
nystatin vaginal tab 100000 unit<br />
nystatin-triamcinolone cream 100000-0.1 unit/gm-%<br />
nystatin-triamcinolone oint 100000-0.1 unit/gm-%<br />
OLUX AER 0.05%(Clobetasol Propionate)<br />
OLUX-E AER 0.05%(Clobetasol Propionate Emulsion)<br />
OVACE WASH LIQ 10%(Sulfacetamide Sodium)<br />
01<br />
01<br />
01<br />
01<br />
02<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
02<br />
04<br />
02<br />
04<br />
01<br />
01<br />
01<br />
01<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
04<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
04<br />
04<br />
(PA)<br />
(PA)<br />
(PA)<br />
109
Drug Name Drug Tier Notes<br />
OVIDE LOT 0.5%(Malathion)<br />
OXISTAT CRE 1%(Oxiconazole Nitrate)<br />
OXISTAT LOT 1%(Oxiconazole Nitrate)<br />
OXSORALEN LOT 1%(Methoxsalen (Topical))<br />
OXSORALEN-UL CAP 10MG(Methoxsalen Rapid)<br />
PANAFIL OIN(Papain-Urea-Chlorophyllin)<br />
PANAFIL SPR(Papain-Urea-Chlorophyllin)<br />
PANDEL CRE 0.1%(Hydrocortisone Probutate)<br />
PANRETIN GEL 0.1%(Alitretinoin)<br />
papain-urea ointment 650000 unit/gm-10%<br />
papain-urea ointment 830000 unit/gm-100 mg/gm<br />
papain-urea spray 650000 unit/gm-10%<br />
PENLAC SOL 8%(Ciclopirox)<br />
PERANEX HC KIT 2-2%(Lidocaine-Hydrocortisone Acetate (Rectal))<br />
permethrin cream 5%<br />
phenazopyridine hcl tab 100 mg<br />
phenazopyridine hcl tab 200 mg<br />
phenazopyridine-butabarbital-hyoscyamine tab 150-15-0.3 mg<br />
PLEXION CLNS EMU 10-5%(Sulfacetamide Sodium w/ Sulfur)<br />
PLEXION CLTH MIS 10-5%(Sulfacetamide Sodium w/ Sulfur)<br />
PLEXION SCT CRE 10-5%(Sulfacetamide Sodium w/ Sulfur)<br />
PLEXION TS SUS 10-5%(Sulfacetamide Sodium w/ Sulfur)<br />
podofilox soln 0.5%<br />
prednicarbate cream 0.1%<br />
prednicarbate oint 0.1%<br />
PROCTOCORT CRE 1%(Hydrocortisone (Topical))<br />
PROTOPIC OIN 0.03%(Tacrolimus (Topical))<br />
PROTOPIC OIN 0.1%(Tacrolimus (Topical))<br />
PSORCON E CRE 0.05%(Diflorasone Diacetate Emollient Base)<br />
PSORIATEC CRE 1%(Anthralin)<br />
PYRIDIUM TAB 100MG(Phenazopyridine HCl)<br />
PYRIDIUM TAB 200MG(Phenazopyridine HCl)<br />
PYRIDIUM TAB PLUS(Phenazopyridine-Butabarbital-Hyoscyamine)<br />
RAPTIVA KIT 125MG(Efalizumab)<br />
REGRANEX GEL 0.01%(Becaplermin)<br />
RETIN-A CRE 0.025%(Tretinoin)<br />
RETIN-A CRE 0.05%(Tretinoin)<br />
RETIN-A CRE 0.1%(Tretinoin)<br />
RETIN-A GEL 0.01%(Tretinoin)<br />
RETIN-A GEL 0.025%(Tretinoin)<br />
RETIN-A MICR GEL 0.04%(Tretinoin Microsphere)<br />
RETIN-A MICR GEL 0.04%PMP(Tretinoin Microsphere)<br />
RETIN-A MICR GEL 0.1%(Tretinoin Microsphere)<br />
RETIN-A MICR GEL 0.1%PUMP(Tretinoin Microsphere)<br />
ROSAC CRE 10-5%(Sulfacetamide Sodium-Sulfur w/ Sunscreens)<br />
ROSAC WASH EMU 10-1%(Sulfacetamide Sodium w/ Sulfur)<br />
ROSULA EMU CLEANSER(Sulfacetamide Sodium-Sulfur in Urea Vehicle)<br />
ROSULA GEL 10-5%(Sulfacetamide Sodium-Sulfur in Urea Vehicle)<br />
ROSULA NS PAD(Sulfacetamide Sodium-Urea)<br />
ROSULA WASH EMU 10-4%(Sulfacetamide Sodium-Sulfur in Urea Vehicle)<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
02<br />
04<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
04<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
110
Drug Name Drug Tier Notes<br />
ROZEX EMULSI EMU 0.75%(Metronidazole (Topical))<br />
SALEX CRE 6%(Salicylic Acid)<br />
SALEX LOT 6%(Salicylic Acid)<br />
salicylic acid cream 6%<br />
salicylic acid lotion 6%<br />
SANTYL OIN 250/GM(Collagenase)<br />
SEB-PREV CRE 10%(Sulfacetamide Sodium)<br />
SEB-PREV GEL 10%(Sulfacetamide Sodium)<br />
SEB-PREV LOT 10%(Sulfacetamide Sodium)<br />
selenium sulfide lotion 2.5%<br />
selenium sulfide-pyrithione zinc in urea shampoo 2.25%<br />
SELSEB SHA 2.25%(Selenium Sulfide-Pyrithione Zinc in Urea Vehicle)<br />
SELSUN SHA 2.5%(Selenium Sulfide)<br />
SILVADENE CRE 1%(Silver Sulfadiazine)<br />
silver sulfadiazine cream 1%<br />
sodium thiosulfate-salicylic acid lotion 25-1%<br />
SOLAGE SOL 0.01-2%(Mequinol-Tretinoin)<br />
SOLARAZE GEL 3% W/W(Diclofenac Sodium (Actinic Keratoses))<br />
SULFACET-R LOT(Sulfacetamide Sodium w/ Sulfur)<br />
sulfacetamide sodium liquid 10%<br />
sulfacetamide sodium lot 10% & urea shampoo 10% kit<br />
sulfacetamide sodium lotion 10% (acne)<br />
sulfacetamide sodium w/ sulfur cleansing cloth 10-5%<br />
sulfacetamide sodium w/ sulfur cream 10-5%<br />
sulfacetamide sodium w/ sulfur emulsion 10-5%<br />
sulfacetamide sodium w/ sulfur lotion 10-5%<br />
sulfacetamide sodium w/ sulfur susp 10-5%<br />
sulfacetamide sodium-sulfur in urea emulsion 10-5%<br />
sulfacetamide sodium-sulfur in urea gel 10-5%<br />
sulfacetamide sodium-urea lotion 10-10%<br />
sulfacetamide sodium-urea pad 10-10%<br />
SULFAMYLON CRE 85MG/GM(Mafenide Acetate)<br />
SULFAMYLON PAK 5%(Mafenide Acetate)<br />
SULFOXYL LOT(Benzoyl Peroxide-Sulfur)<br />
SULFOXYL LOT STRONG(Benzoyl Peroxide-Sulfur)<br />
TARGRETIN GEL 1%(Bexarotene (Topical))<br />
TAZORAC CRE 0.05%(Tazarotene)<br />
TAZORAC CRE 0.1%(Tazarotene)<br />
TAZORAC GEL 0.05%(Tazarotene)<br />
TAZORAC GEL 0.1%(Tazarotene)<br />
TEMOVATE CRE 0.05%(Clobetasol Propionate)<br />
TEMOVATE GEL 0.05%(Clobetasol Propionate)<br />
TEMOVATE OIN 0.05%(Clobetasol Propionate)<br />
TEMOVATE SOL 0.05%(Clobetasol Propionate)<br />
TEMOVATE E CRE 0.05%EML(Clobetasol Propionate Emollient Base)<br />
TERAZOL 3 CRE 0.8%(Terconazole Vaginal)<br />
TERAZOL 3 SUP 80MG(Terconazole Vaginal)<br />
TERAZOL 7 CRE 0.4%(Terconazole Vaginal)<br />
terconazole vaginal cream 0.4%<br />
terconazole vaginal cream 0.8%<br />
02<br />
04<br />
04<br />
01<br />
01<br />
02<br />
04<br />
04<br />
04<br />
01<br />
01<br />
04<br />
04<br />
04<br />
01<br />
01<br />
04<br />
02<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
111
Drug Name Drug Tier Notes<br />
terconazole vaginal suppos 80 mg<br />
TEXACORT SOL 2.5%(Hydrocortisone (Topical))<br />
TOPICORT CRE 0.25%(Desoximetasone)<br />
TOPICORT GEL 0.05%(Desoximetasone)<br />
TOPICORT OIN 0.25%(Desoximetasone)<br />
TOPICORT LP CRE 0.05%(Desoximetasone)<br />
tretinoin cream 0.025%<br />
tretinoin cream 0.05%<br />
tretinoin cream 0.1%<br />
tretinoin gel 0.01%<br />
tretinoin gel 0.025%<br />
triamcinolone acetonide cream 0.025%<br />
triamcinolone acetonide cream 0.1%<br />
triamcinolone acetonide cream 0.5%<br />
triamcinolone acetonide in orabase 0.1%<br />
triamcinolone acetonide lotion 0.025%<br />
triamcinolone acetonide lotion 0.1%<br />
triamcinolone acetonide oint 0.025%<br />
triamcinolone acetonide oint 0.1%<br />
triamcinolone acetonide oint 0.5%<br />
TRIAZ PAD 3%(Benzoyl Peroxide)<br />
TRIAZ PAD 6%(Benzoyl Peroxide)<br />
TRIAZ PAD 9%(Benzoyl Peroxide)<br />
TRIAZ CLEANS LOT 3%(Benzoyl Peroxide)<br />
TRIAZ CLEANS LOT 6%(Benzoyl Peroxide)<br />
TRIAZ CLEANS LOT 9%(Benzoyl Peroxide)<br />
ULTRAVATE CRE 0.05%(Halobetasol Propionate)<br />
ULTRAVATE OIN 0.05%(Halobetasol Propionate)<br />
UMECTA EMU(Urea)<br />
UMECTA SUS 40%(Urea)<br />
UMECTA NAIL SUS 40%(Urea)<br />
UMECTA PD EMU 40%(Urea)<br />
UMECTA PD SUS 40%(Urea)<br />
urea cream 40%<br />
urea cream 50%<br />
urea gel 40%<br />
urea gel 50%<br />
urea lotion 35%<br />
urea lotion 40%<br />
urea ointment 50%<br />
urea soln 50%<br />
urea-hc acetate cream 1%<br />
UVADEX INJ 20MCG/ML(Methoxsalen (Photopheresis))<br />
VANOS CRE 0.1%(Fluocinonide)<br />
VANOXIDE-HC LOT(Benzoyl Peroxide-HC)<br />
VERDESO AER 0.05%(Desonide)<br />
WESTCORT CRE 0.2%(Hydrocortisone Valerate)<br />
WESTCORT OIN 0.2%(Hydrocortisone Valerate)<br />
XYLOCAINE GEL 2%(Lidocaine HCl)<br />
XYLOCAINE SOL 4%(Lidocaine HCl)<br />
01<br />
02<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
112
Drug Name Drug Tier Notes<br />
XYRALID LP KIT(Lidocaine-Hydrocortisone Acetate w/ Cleanser)<br />
XYRALID RC KIT(Lidocaine-Hydrocortisone Acetate-Psyllium)<br />
ZACLIR LOT 4%(Benzoyl Peroxide)<br />
ZACLIR LOT 8%(Benzoyl Peroxide)<br />
ZIANA GEL(Clindamycin Phosphate-Tretinoin)<br />
ZODERM CRE 4.5%-10%(Benzoyl Peroxide-Urea)<br />
ZODERM CRE 6.5%-10%(Benzoyl Peroxide-Urea)<br />
ZODERM CRE 8.5%-10%(Benzoyl Peroxide-Urea)<br />
ZODERM GEL 4.5%-10%(Benzoyl Peroxide-Urea)<br />
ZODERM GEL 6.5%-10%(Benzoyl Peroxide-Urea)<br />
ZODERM GEL 8.5%-10%(Benzoyl Peroxide-Urea)<br />
ZODERM LIQ 4.5%-10%(Benzoyl Peroxide-Urea)<br />
ZODERM LIQ 6.5%-10%(Benzoyl Peroxide-Urea)<br />
ZODERM LIQ 8.5%-10%(Benzoyl Peroxide-Urea)<br />
ZODERM PAD 4.5%(Benzoyl Peroxide-Urea)<br />
ZODERM PAD 6.5%(Benzoyl Peroxide-Urea)<br />
ZODERM PAD 8.5%(Benzoyl Peroxide-Urea)<br />
ZONALON CRE 5%(Doxepin HCl (Antipruritic))<br />
ZOVIRAX CRE 5%(Acyclovir Topical)<br />
ZOVIRAX OIN 5%(Acyclovir Topical)<br />
Smooth Muscle Relaxants<br />
aminophylline inj 25 mg/ml<br />
aminophylline tab 100 mg<br />
aminophylline tab 200 mg<br />
BRONCAP TAB 150-200(Theophylline-Guaifenesin)<br />
BRONCODUR SOL(Theophylline-Guaifenesin)<br />
DETROL TAB 1MG(Tolterodine Tartrate)<br />
DETROL TAB 2MG(Tolterodine Tartrate)<br />
DETROL LA CAP 2MG(Tolterodine Tartrate)<br />
DETROL LA CAP 4MG(Tolterodine Tartrate)<br />
DITROPAN SYP 5MG/5ML(Oxybutynin Chloride)<br />
DITROPAN TAB 5MG(Oxybutynin Chloride)<br />
DITROPAN XL TAB 10MG(Oxybutynin Chloride)<br />
DITROPAN XL TAB 15MG(Oxybutynin Chloride)<br />
DITROPAN XL TAB 5MG(Oxybutynin Chloride)<br />
dyphylline-guaifenesin cap 200-100 mg<br />
dyphylline-guaifenesin liqd 100-100 mg/15ml<br />
dyphylline-guaifenesin syrup 200-100 mg/5ml<br />
dyphylline-guaifenesin tab 200-300 mg<br />
dyphylline-guaifenesin tab 200-400 mg<br />
ELIXOPHYL GG SOL 100-100(Theophylline-Guaifenesin)<br />
ELIXOPHYLLIN ELX 80/15ML(Theophylline)<br />
ENABLEX TAB 15MG(Darifenacin Hydrobromide)<br />
ENABLEX TAB 7.5MG(Darifenacin Hydrobromide)<br />
flavoxate hcl tab 100 mg<br />
oxybutynin chloride syrup 5 mg/5ml<br />
oxybutynin chloride tab 5 mg<br />
oxybutynin chloride tab sr 24hr 10 mg<br />
oxybutynin chloride tab sr 24hr 15 mg<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
02<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
113
Drug Name Drug Tier Notes<br />
oxybutynin chloride tab sr 24hr 5 mg<br />
OXYTROL DIS 3.9MG/24(Oxybutynin)<br />
SANCTURA TAB 20MG(Trospium Chloride)<br />
THEO-24 CAP 100MG CR(Theophylline)<br />
THEO-24 CAP 200MG CR(Theophylline)<br />
THEO-24 CAP 300MG CR(Theophylline)<br />
THEO-24 CAP 400MG ER(Theophylline)<br />
THEOCAP CAP 200MG CR(Theophylline)<br />
theophylline cap sr 12hr 125 mg<br />
theophylline cap sr 12hr 300 mg<br />
theophylline sod glycinate-gg syrup 300-100 mg/15ml<br />
theophylline tab sr 12hr 100 mg<br />
theophylline tab sr 12hr 200 mg<br />
theophylline tab sr 12hr 300 mg<br />
theophylline tab sr 12hr 450 mg<br />
theophylline tab sr 24hr 400 mg<br />
theophylline tab sr 24hr 600 mg<br />
theophylline-guaifenesin liquid 150-90 mg/15ml<br />
UNIPHYL TAB 400MG CR(Theophylline)<br />
UNIPHYL TAB 600MG CR(Theophylline)<br />
URISPAS TAB 100MG(Flavoxate HCl)<br />
VESICARE TAB 10MG(Solifenacin Succinate)<br />
VESICARE TAB 5MG(Solifenacin Succinate)<br />
Vitamins<br />
*pediatric multiple vitamins w/ fluoride chew tab 0.25 mg***<br />
*pediatric multiple vitamins w/ fluoride chew tab 0.5 mg***<br />
*pediatric multiple vitamins w/ fluoride chew tab 1 mg***<br />
*pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml***<br />
*pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml***<br />
*pediatric vitamins acd w/ fluoride chew tab 1 mg***<br />
*pediatric vitamins acd w/ fluoride soln 0.25 mg/ml***<br />
*pediatric vitamins acd w/ fluoride soln 0.5 mg/ml***<br />
*prenatal multivitamins & minerals w/ iron & fa cap 1 mg***<br />
*prenatal multivitamins & minerals w/ iron & fa tab 1 mg***<br />
*prenatal multivitamins & minerals w/iron & fa tab 0.8 mg***<br />
*prenatal vit w/ fe polysac cmplx-fa tab 60-1 mg***<br />
*prenatal w/o a vit w/ fe fumarate-fa cap 106-1 mg***<br />
CALCIJEX INJ 1MCG/ML(Calcitriol)<br />
calcitriol cap 0.25 mcg<br />
calcitriol cap 0.5 mcg<br />
calcitriol inj 1 mcg/ml<br />
calcitriol oral soln 1 mcg/ml<br />
CENOGEN ULTR CAP(Prenatal without A Vit w/ Fe Fumarate-Folic Acid)<br />
cyanocobalamin inj 1000 mcg/ml<br />
HECTOROL CAP 0.5MCG(Doxercalciferol)<br />
HECTOROL CAP 2.5MCG(Doxercalciferol)<br />
HECTOROL INJ 4MCG/2ML(Doxercalciferol)<br />
hydroxocobalamin inj 1000 mcg/ml<br />
MYNATAL CAP(Prenatal Multivit-Min w/Fe-FA)<br />
01<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
02<br />
02<br />
04<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
01<br />
01<br />
01<br />
01<br />
04<br />
01<br />
02<br />
02<br />
02<br />
01<br />
04<br />
114
Drug Name Drug Tier Notes<br />
NASCOBAL GEL(Cyanocobalamin)<br />
NASCOBAL SPR 500MCG(Cyanocobalamin)<br />
niacin tab 500 mg<br />
PRECARE CHW(Prenatal without A Vit w/ Fe Fumarate-Folic Acid)<br />
ROCALTROL CAP 0.25MCG(Calcitriol)<br />
ROCALTROL CAP 0.5MCG(Calcitriol)<br />
ROCALTROL SOL 1MCG/ML(Calcitriol)<br />
ZEMPLAR CAP 1MCG(Paricalcitol)<br />
ZEMPLAR CAP 2MCG(Paricalcitol)<br />
ZEMPLAR CAP 4MCG(Paricalcitol)<br />
ZEMPLAR INJ 2MCG/ML(Paricalcitol)<br />
ZEMPLAR INJ 5MCG/ML(Paricalcitol)<br />
Miscellaneous Therapeutic Agents<br />
ACTIMMUNE INJ 2MU/0.5(Interferon Gamma-1B)<br />
ACTONEL TAB 30MG(Risedronate Sodium)<br />
ACTONEL TAB 35MG(Risedronate Sodium)<br />
ACTONEL TAB 5MG(Risedronate Sodium)<br />
ACTONEL TAB 75MG(Risedronate Sodium)<br />
ACTONEL WITH TAB CALCIUM(Risedronate Sodium with Calcium<br />
Carbonate)<br />
allopurinol sodium for inj 500 mg<br />
allopurinol tab 100 mg<br />
allopurinol tab 300 mg<br />
ALOPRIM INJ 500MG(Allopurinol Sodium)<br />
ANTABUSE TAB 250MG(Disulfiram)<br />
ANTABUSE TAB 500MG(Disulfiram)<br />
APHTHASOL PST 5%(Amlexanox)<br />
ARALAST INJ 400MG(Proteinase Inhibitor (Human))<br />
ARALAST INJ 800MG(Proteinase Inhibitor (Human))<br />
ARAVA TAB 10MG(Leflunomide)<br />
ARAVA TAB 20MG(Leflunomide)<br />
AREDIA INJ 30MG(Pamidronate Disodium)<br />
AREDIA INJ 90MG(Pamidronate Disodium)<br />
ATGAM INJ 250MG(Lymphocyte Immune Globulin,Anti-Thymocyte<br />
Globulin (Equine))<br />
AVODART CAP 0.5MG(Dutasteride)<br />
AVONEX INJ 30MCG(Interferon Beta-1a)<br />
AVONEX KIT(Interferon Beta-1a)<br />
azathioprine sodium for inj 100 mg<br />
azathioprine tab 100 mg<br />
azathioprine tab 50 mg<br />
azathioprine tab 75 mg<br />
BETASERON INJ 0.3MG(Interferon Beta-1b)<br />
BONIVA KIT 3MG/3ML(Ibandronate Sodium)<br />
BONIVA TAB 150MG(Ibandronate Sodium)<br />
BONIVA TAB 2.5MG(Ibandronate Sodium)<br />
bromocriptine mesylate cap 5 mg<br />
bromocriptine mesylate tab 2.5 mg<br />
cabergoline tab 0.5 mg<br />
04<br />
04<br />
03<br />
02<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
02<br />
03<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
04<br />
02<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
03<br />
03<br />
02<br />
02<br />
03<br />
03<br />
01<br />
03<br />
03<br />
03<br />
03<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
115
Drug Name Drug Tier Notes<br />
CARNITOR TAB 330MG(Levocarnitine (Metabolic Modifiers))<br />
CELLCEPT CAP 250MG(Mycophenolate Mofetil)<br />
CELLCEPT SUS 200MG/ML(Mycophenolate Mofetil)<br />
CELLCEPT TAB 500MG(Mycophenolate Mofetil)<br />
CELLCEPT IV INJ 500MG(Mycophenolate Mofetil HCl)<br />
CEPROTIN INJ 1000UNIT(Protein C Concentrate (Human))<br />
CEPROTIN INJ 500 UNIT(Protein C Concentrate (Human))<br />
CEREZYME INJ 200UNIT(Imiglucerase)<br />
CEREZYME INJ 400UNIT(Imiglucerase)<br />
colchicine inj 0.5 mg/ml<br />
colchicine tab 0.6 mg<br />
COPAXONE KIT 20MG/ML(Glatiramer Acetate)<br />
CYANOKIT INJ 5GM(Hydroxocobalamin (Antidote))<br />
cyclosporine cap 100 mg<br />
cyclosporine cap 25 mg<br />
cyclosporine iv soln 50 mg/ml<br />
cyclosporine modified cap 100 mg<br />
cyclosporine modified cap 25 mg<br />
cyclosporine modified cap 50 mg<br />
cyclosporine modified oral soln 100 mg/ml<br />
cyclosporine oral soln 100 mg/ml<br />
dexrazoxane for inj 250 mg<br />
dexrazoxane for inj 500 mg<br />
DIDRONEL TAB 200MG(Etidronate Disodium)<br />
DIDRONEL TAB 400MG(Etidronate Disodium)<br />
DIDRONEL IV INJ 50MG/ML(Etidronate Disodium)<br />
DOSTINEX TAB 0.5MG(Cabergoline)<br />
ELMIRON CAP 100MG(Pentosan Polysulfate Sodium)<br />
ENBREL INJ 25/0.5ML(Etanercept)<br />
ENBREL INJ 25MG(Etanercept)<br />
ENBREL INJ 50MG/ML(Etanercept)<br />
ETHYOL INJ 500MG(Amifostine Crystalline)<br />
etidronate disodium tab 200 mg<br />
etidronate disodium tab 400 mg<br />
finasteride tab 5 mg<br />
FLOMAX CAP 0.4MG(Tamsulosin HCl)<br />
FLUORABON DRO(Sodium Fluoride)<br />
FLURA-DROPS DRO 0.25MG(Sodium Fluoride)<br />
FOSAMAX SOL(Alendronate Sodium)<br />
FOSAMAX TAB 10MG(Alendronate Sodium)<br />
FOSAMAX TAB 35MG(Alendronate Sodium)<br />
FOSAMAX TAB 40MG(Alendronate Sodium)<br />
FOSAMAX TAB 5MG(Alendronate Sodium)<br />
FOSAMAX TAB 70MG(Alendronate Sodium)<br />
FOSAMAX PLUS TAB D(Alendronate Sodium-Cholecalciferol)<br />
FOSAMAX PLUS TAB D(Alendronate Sodium-Cholecalciferol)<br />
GASTROCROM CON 100/5ML(Cromolyn Sodium (Mastocytosis))<br />
HUMIRA KIT 40MG/0.8(Adalimumab)<br />
HUMIRA PEN KIT 40MG/0.8(Adalimumab)<br />
HUMIRA PEN KIT STARTER(Adalimumab)<br />
04<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
02<br />
02<br />
01<br />
01<br />
03<br />
04<br />
03<br />
03<br />
03<br />
01<br />
01<br />
01<br />
01<br />
03<br />
01<br />
01<br />
04<br />
04<br />
02<br />
04<br />
04<br />
03<br />
03<br />
03<br />
03<br />
01<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
04<br />
04<br />
03<br />
03<br />
03<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
116
Drug Name Drug Tier Notes<br />
IMURAN TAB 50MG(Azathioprine)<br />
KINERET INJ(Anakinra)<br />
leflunomide tab 10 mg<br />
leflunomide tab 20 mg<br />
leucovorin calcium for inj 100 mg<br />
leucovorin calcium for inj 200 mg<br />
leucovorin calcium for inj 350 mg<br />
leucovorin calcium for inj 50 mg<br />
leucovorin calcium for inj 500 mg<br />
leucovorin calcium inj 10 mg/ml<br />
leucovorin calcium tab 10 mg<br />
leucovorin calcium tab 15 mg<br />
leucovorin calcium tab 25 mg<br />
leucovorin calcium tab 5 mg<br />
levocarnitine tab 330 mg<br />
LURIDE CHW 0.25MG(Sodium Fluoride)<br />
LURIDE CHW 0.5MG(Sodium Fluoride)<br />
LURIDE CHW 1MG(Sodium Fluoride)<br />
LURIDE DRO 0.5MG/ML(Sodium Fluoride)<br />
mesna inj 100 mg/ml<br />
MESNEX INJ 1GM(Mesna)<br />
MESNEX TAB 400MG(Mesna)<br />
MYFORTIC TAB 180MG(Mycophenolate Sodium)<br />
MYFORTIC TAB 360MG(Mycophenolate Sodium)<br />
NEORAL CAP 100MG(Cyclosporine Modified (For Microemulsion))<br />
NEORAL CAP 25MG(Cyclosporine Modified (For Microemulsion))<br />
NEORAL SOL 100MG/ML(Cyclosporine Modified (For Microemulsion))<br />
octreotide acetate inj 0.05 mg/ml<br />
octreotide acetate inj 0.1 mg/ml<br />
octreotide acetate inj 0.2 mg/ml<br />
octreotide acetate inj 0.5 mg/ml<br />
octreotide acetate inj 1 mg/ml<br />
ORENCIA INJ 250MG(Abatacept)<br />
ORFADIN CAP 10MG(Nitisinone)<br />
ORFADIN CAP 2MG(Nitisinone)<br />
ORFADIN CAP 5MG(Nitisinone)<br />
ORTHOCLONE INJ OKT3(Muromonab CD3)<br />
pamidronate disodium for inj 30 mg<br />
pamidronate disodium for inj 90 mg<br />
pamidronate disodium iv soln 3 mg/ml<br />
pamidronate disodium iv soln 6 mg/ml<br />
pamidronate disodium iv soln 9 mg/ml<br />
PARLODEL CAP 5MG(Bromocriptine Mesylate)<br />
PARLODEL TAB 2.5MG(Bromocriptine Mesylate)<br />
PREVIDENT CRE 5000 PLS(Sodium Fluoride (Dental))<br />
PREVIDENT SOL RINSE(Sodium Fluoride (Dental))<br />
PROGRAF CAP 0.5MG(Tacrolimus)<br />
PROGRAF CAP 1MG(Tacrolimus)<br />
PROGRAF CAP 5MG(Tacrolimus)<br />
PROGRAF INJ 5MG/ML(Tacrolimus)<br />
03<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
01<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
02<br />
03<br />
03<br />
01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
02<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
117
Drug Name Drug Tier Notes<br />
PROLASTIN INJ 1000MG(Proteinase Inhibitor (Human))<br />
PROLASTIN INJ 500MG(Proteinase Inhibitor (Human))<br />
PROSCAR TAB 5MG(Finasteride)<br />
PROSTASCINT KIT(Capromab Pendetide)<br />
QUADRAMET INJ VIAL(Samarium Sm 153 Lexidronam)<br />
RAPAMUNE SOL 1MG/ML(Sirolimus)<br />
RAPAMUNE TAB 1MG(Sirolimus)<br />
RAPAMUNE TAB 2MG(Sirolimus)<br />
REBIF INJ 22/0.5(Interferon Beta-1a)<br />
REBIF INJ 44/0.5(Interferon Beta-1a)<br />
REBIF TITRTN SOL PACK(Interferon Beta-1a)<br />
RECLAST INJ 5/100ML(Zoledronic Acid)<br />
RELAMINE TAB(Glucosamine-Chondroitin-PABA-Vit E-Alpha Lipoic Acid)<br />
REMICADE INJ 100MG(Infliximab)<br />
REVLIMID CAP 10MG(Lenalidomide)<br />
REVLIMID CAP 15MG(Lenalidomide)<br />
REVLIMID CAP 25MG(Lenalidomide)<br />
REVLIMID CAP 5MG(Lenalidomide)<br />
RIMSO-50 SOL 50%(Dimethyl Sulfoxide)<br />
SANDIMMUNE CAP 100MG(Cyclosporine)<br />
SANDIMMUNE CAP 25MG(Cyclosporine)<br />
SANDIMMUNE INJ 50MG/ML(Cyclosporine)<br />
SANDIMMUNE SOL 100MG/ML(Cyclosporine)<br />
SANDOSTATIN INJ 0.2MG/ML(Octreotide Acetate)<br />
SANDOSTATIN INJ 100MCG(Octreotide Acetate)<br />
SANDOSTATIN INJ 1MG/ML(Octreotide Acetate)<br />
SANDOSTATIN INJ 500MCG(Octreotide Acetate)<br />
SANDOSTATIN INJ 50MCG/ML(Octreotide Acetate)<br />
SANDOSTATIN KIT LAR 10MG(Octreotide Acetate)<br />
SANDOSTATIN KIT LAR 20MG(Octreotide Acetate)<br />
SANDOSTATIN KIT LAR 30MG(Octreotide Acetate)<br />
SENSIPAR TAB 30MG(Cinacalcet HCl)<br />
SENSIPAR TAB 60MG(Cinacalcet HCl)<br />
SENSIPAR TAB 90MG(Cinacalcet HCl)<br />
SIMULECT INJ 10MG(Basiliximab)<br />
SIMULECT INJ 20MG(Basiliximab)<br />
SKELID TAB 200MG(Tiludronate Disodium)<br />
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)<br />
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)<br />
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)<br />
sodium fluoride cream 1.1%<br />
sodium fluoride lozenge 1 mg f (from 2.2 mg naf)<br />
sodium fluoride rinse 0.2%<br />
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf)<br />
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)<br />
sodium fluoride tab 1 mg f (from 2.2 mg naf)<br />
SOLIRIS INJ 10MG/ML(Eculizumab)<br />
SORIATANE CAP 10MG(Acitretin)<br />
SORIATANE CAP 25MG(Acitretin)<br />
THALOMID CAP 100MG(Thalidomide)<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
02<br />
02<br />
03<br />
03<br />
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04<br />
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04<br />
04<br />
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02<br />
02<br />
02<br />
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02<br />
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02<br />
02<br />
02<br />
03<br />
03<br />
04<br />
01<br />
01<br />
01<br />
01<br />
01<br />
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01<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
(PA)<br />
118
Drug Name Drug Tier Notes<br />
THALOMID CAP 150MG(Thalidomide)<br />
THALOMID CAP 200MG(Thalidomide)<br />
THALOMID CAP 50MG(Thalidomide)<br />
THYMOGLOBULN INJ 25MG(Anti-Thymocyte Globulin (Rabbit), Lymphocyte<br />
Immune Globulin)<br />
UROLENE BLUE TAB 65MG(Methylene Blue)<br />
UROXATRAL TAB 10MG(Alfuzosin HCl)<br />
ZAVESCA CAP 100MG(Miglustat)<br />
ZEMAIRA SOL 1000MG(Proteinase Inhibitor (Human))<br />
ZENAPAX INJ 25MG/5ML(Daclizumab)<br />
ZINECARD INJ 250MG(Dexrazoxane)<br />
ZINECARD INJ 500MG(Dexrazoxane)<br />
ZOMETA INJ 4MG/5ML(Zoledronic Acid)<br />
ZYLOPRIM TAB 100MG(Allopurinol)<br />
ZYLOPRIM TAB 300MG(Allopurinol)<br />
Devices<br />
*alcohol swabs***<br />
*gauze pads & dressings - pads 2" x 2"***<br />
AUTOPEN MIS 1 UNIT(Injection Device for Insulin)<br />
AUTOPEN MIS 1-21UNIT(Injection Device for Insulin)<br />
AUTOPEN MIS 2 UNIT(Injection Device for Insulin)<br />
AUTOPEN MIS 2-16UNIT(Injection Device for Insulin)<br />
AUTOPEN MIS 2-32UNIT(Injection Device for Insulin)<br />
AUTOPEN MIS 2-42UNIT(Injection Device for Insulin)<br />
BD PEN MIS(Injection Device for Insulin)<br />
BD PEN MINI MIS(Injection Device for Insulin)<br />
BD UF MINI MIS PENNEEDL(Insulin Pen Needle)<br />
BD UF ORIG MIS PENNEEDL(Insulin Pen Needle)<br />
BD UF SHORT MIS PENNEEDL(Insulin Pen Needle)<br />
BL STERILE PAD 2"X2"(Gauze Pads & Dressings)<br />
CURITY GAUZE PAD 2"X2"(Gauze Pads & Dressings)<br />
ECK STERILE PAD 2"X2"(Gauze Pads & Dressings)<br />
GAUZE PAD PAD 2"X2"(Gauze Pads & Dressings)<br />
GNP STERILE PAD 2"X2"(Gauze Pads & Dressings)<br />
HUMAPEN MIS LUXURA(Injection Device for Insulin)<br />
HUMAPEN MIS MEMOIR(Injection Device for Insulin)<br />
INJEX 30 NF MIS SYSTEM(Injection Device Needle-Free for Insulin)<br />
INSULIN PEN MIS 29GX1/2"(Insulin Pen Needle)<br />
INSULIN PEN MIS 31GX1/3"(Insulin Pen Needle)<br />
INSULIN PEN MIS 31GX1/4"(Insulin Pen Needle)<br />
INSULIN SYRG MIS 0.3/31G(Insulin Syringe/Needle U-100)<br />
INSULIN SYRG MIS 0.5/28G(Insulin Syringe/Needle U-100)<br />
INSULIN SYRG MIS 0.5/30G(Insulin Syringes (Disposable))<br />
INSULIN SYRG MIS 0.5/31G(Insulin Syringe/Needle U-100)<br />
INSULIN SYRG MIS 1ML(Insulin Syringes (Disposable))<br />
INSULIN SYRG MIS 1ML(Insulin Syringes (Disposable))<br />
INSULIN SYRG MIS 1ML(Insulin Syringes (Disposable))<br />
INSULIN SYRG MIS 1ML(Insulin Syringes (Disposable))<br />
INSULIN SYRG MIS 1ML/29G(Insulin Syringe/Needle U-100)<br />
04<br />
04<br />
04<br />
02<br />
04<br />
02<br />
04<br />
04<br />
03<br />
04<br />
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03<br />
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01<br />
01<br />
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02<br />
02<br />
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02<br />
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02<br />
02<br />
02<br />
02<br />
(PA)<br />
(PA)<br />
(PA)<br />
119
Drug Name Drug Tier Notes<br />
INSULIN SYRG MIS 1ML/29G(Insulin Syringes (Disposable))<br />
INSULIN SYRG MIS 1ML/30G(Insulin Syringe/Needle U-100)<br />
INSULIN SYRG MIS 1ML/30G(Insulin Syringe/Needle U-100)<br />
INSULIN SYRG MIS 1ML/31G(Insulin Syringe/Needle U-100)<br />
insulin syringe (disp) u-100 0.3 ml<br />
insulin syringe (disp) u-100 1 ml<br />
insulin syringe (disp) u-100 1/2 ml<br />
insulin syringe/needle u-100 0.3 ml 28 g x 1"<br />
insulin syringe/needle u-100 0.3 ml 28 x 1/2"<br />
insulin syringe/needle u-100 0.3 ml 29 g<br />
insulin syringe/needle u-100 0.3 ml 29 x 1"<br />
insulin syringe/needle u-100 0.3 ml 29 x 1/2"<br />
insulin syringe/needle u-100 0.3 ml 29 x 5/16"<br />
insulin syringe/needle u-100 0.3 ml 29 x 7/16"<br />
insulin syringe/needle u-100 0.3 ml 30 g<br />
insulin syringe/needle u-100 0.3 ml 30 x 1"<br />
insulin syringe/needle u-100 0.3 ml 30 x 1/2"<br />
insulin syringe/needle u-100 0.3 ml 30 x 3/8"<br />
insulin syringe/needle u-100 0.3 ml 30 x 5/16"<br />
insulin syringe/needle u-100 0.3 ml 30 x 7/16"<br />
insulin syringe/needle u-100 0.3 ml 31 x 5/16"<br />
insulin syringe/needle u-100 1 ml 25 x 1"<br />
insulin syringe/needle u-100 1 ml 25 x 5/8"<br />
insulin syringe/needle u-100 1 ml 26 x 1/2"<br />
insulin syringe/needle u-100 1 ml 27 x 1/2"<br />
insulin syringe/needle u-100 1 ml 27 x 5/8"<br />
insulin syringe/needle u-100 1 ml 28 x 1/2"<br />
insulin syringe/needle u-100 1 ml 28 x 5/16"<br />
insulin syringe/needle u-100 1 ml 29 x 1"<br />
insulin syringe/needle u-100 1 ml 29 x 1/2"<br />
insulin syringe/needle u-100 1 ml 29 x 5/16"<br />
insulin syringe/needle u-100 1 ml 29 x 7/16"<br />
insulin syringe/needle u-100 1 ml 30 g<br />
insulin syringe/needle u-100 1 ml 30 g x 1"<br />
insulin syringe/needle u-100 1 ml 30 x 1/2"<br />
insulin syringe/needle u-100 1 ml 30 x 5/16"<br />
insulin syringe/needle u-100 1 ml 30 x 7/16"<br />
insulin syringe/needle u-100 1 ml 31 x 5/16"<br />
insulin syringe/needle u-100 1/2 ml 27 x 1/2"<br />
insulin syringe/needle u-100 1/2 ml 28 x 1"<br />
insulin syringe/needle u-100 1/2 ml 28 x 1/2"<br />
insulin syringe/needle u-100 1/2 ml 29 g<br />
insulin syringe/needle u-100 1/2 ml 29 x 1"<br />
insulin syringe/needle u-100 1/2 ml 29 x 1/2"<br />
insulin syringe/needle u-100 1/2 ml 29 x 5/16"<br />
insulin syringe/needle u-100 1/2 ml 29 x 7/16"<br />
insulin syringe/needle u-100 1/2 ml 30 g<br />
insulin syringe/needle u-100 1/2 ml 30 g x 1"<br />
insulin syringe/needle u-100 1/2 ml 30 x 1/2"<br />
insulin syringe/needle u-100 1/2 ml 30 x 3/8"<br />
02<br />
02<br />
02<br />
02<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
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01<br />
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01<br />
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01<br />
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01<br />
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01<br />
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01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
01<br />
120
Drug Name Drug Tier Notes<br />
insulin syringe/needle u-100 1/2 ml 30 x 5/16"<br />
insulin syringe/needle u-100 1/2 ml 30 x 7/16"<br />
insulin syringe/needle u-100 1/2 ml 31 x 5/16"<br />
insulin syringe/needle u-100 2 ml 27.5 x 5/8"<br />
insulin syringe/needle u-100 2 ml 29 x 1/2"<br />
insulin syringe/needle u-40 1 ml 26 x 1/2"<br />
ISLAND GARD PAD 2"X2"(Gauze Pads & Dressings)<br />
J&J GAUZE PAD 2" X 2"(Gauze Pads & Dressings)<br />
LYOFOAM A PAD 2"X2"(Gauze Pads & Dressings)<br />
MEDI-JECTOR MIS CHOICE(Injection Device Needle-Free for Insulin)<br />
MEDI-JECTOR MIS VISION(Injection Device for Insulin)<br />
MIRASORB MIS 2" X 2"(Gauze Pads & Dressings)<br />
MIRASORB MIS 2" X 2"(Gauze Pads & Dressings)<br />
NEXCARE GAUZ PAD 2"X2"(Gauze Pads & Dressings)<br />
NOVOFINE 30 MIS DISPOS(Insulin Pen Needle)<br />
NOVOFINE 31 MIS DISPOS(Insulin Pen Needle)<br />
NOVOPEN 3 MIS(Injection Device for Insulin)<br />
NOVOPEN 3 MIS PENMATE(Injection Device for Insulin)<br />
NOVOPEN JR MIS DEVICE(Injection Device for Insulin)<br />
NOVOPEN JR MIS DEVICE(Injection Device for Insulin)<br />
PEN NEEDLES MIS 29G(Insulin Pen Needle)<br />
PEN NEEDLES MIS 29GX1/2"(Insulin Pen Needle)<br />
PEN NEEDLES MIS 29GX12MM(Insulin Pen Needle)<br />
PEN NEEDLES MIS 29GX12MM(Insulin Pen Needle)<br />
PEN NEEDLES MIS 29GX12MM(Insulin Pen Needle)<br />
PEN NEEDLES MIS 31G(Insulin Pen Needle)<br />
PEN NEEDLES MIS 31GX1/4"(Insulin Pen Needle)<br />
PEN NEEDLES MIS 31GX5/16(Insulin Pen Needle)<br />
PEN NEEDLES MIS 31GX6MM(Insulin Pen Needle)<br />
PEN NEEDLES MIS 31GX6MM(Insulin Pen Needle)<br />
PEN NEEDLES MIS 31GX6MM(Insulin Pen Needle)<br />
PEN NEEDLES MIS 31GX8MM(Insulin Pen Needle)<br />
PEN NEEDLES MIS 31GX8MM(Insulin Pen Needle)<br />
PEN NEEDLES MIS 31GX8MM(Insulin Pen Needle)<br />
PUBLIX PEN MIS 29GX12MM(Insulin Pen Needle)<br />
PUBLIX PEN MIS 31GX8MM(Insulin Pen Needle)<br />
QC STERILE PAD 2"X2"(Gauze Pads & Dressings)<br />
RA STERILE PAD 2"X2"(Gauze Pads & Dressings)<br />
RELION PEN MIS 29GX12MM(Insulin Pen Needle)<br />
RELION PEN MIS 31GX8MM(Insulin Pen Needle)<br />
SM GAUZE PAD 2 X 2(Gauze Pads & Dressings)<br />
STERI-PAD PAD STERILE(Gauze Pads & Dressings)<br />
STERI-PAD PAD STERILE(Gauze Pads & Dressings)<br />
STERILE PAD 2"X2"(Gauze Pads & Dressings)<br />
STERILE GAUZ PAD 2"X2"(Gauze Pads & Dressings)<br />
TEGADERM FM PAD 2"X2"(Gauze Pads & Dressings)<br />
ULTILET PEN MIS NEEDLE(Insulin Pen Needle)<br />
UNIFINE PNTP MIS 12MM(Insulin Pen Needle)<br />
UNIFINE PNTP MIS 12MM(Insulin Pen Needle)<br />
UNIFINE PNTP MIS 29GX1/2"(Insulin Pen Needle)<br />
01<br />
01<br />
01<br />
01<br />
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02<br />
02<br />
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02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
121
Drug Name Drug Tier Notes<br />
UNIFINE PNTP MIS 29GX12MM(Insulin Pen Needle)<br />
UNIFINE PNTP MIS 29GX12MM(Insulin Pen Needle)<br />
UNIFINE PNTP MIS 31GX6MM(Insulin Pen Needle)<br />
UNIFINE PNTP MIS 31GX6MM(Insulin Pen Needle)<br />
UNIFINE PNTP MIS 31GX6MM(Insulin Pen Needle)<br />
UNIFINE PNTP MIS 31GX8MM(Insulin Pen Needle)<br />
UNIFINE PNTP MIS 31GX8MM(Insulin Pen Needle)<br />
UNIFINE PNTP MIS 31GX8MM(Insulin Pen Needle)<br />
UNIFINE PNTP MIS 6MM(Insulin Pen Needle)<br />
UNIFINE PNTP MIS 6MM(Insulin Pen Needle)<br />
UNIFINE PNTP MIS 8MM(Insulin Pen Needle)<br />
UNIFINE PNTP MIS 8MM(Insulin Pen Needle)<br />
Pharmaceutical Aids<br />
*potassium chloride powder packet 13.4 meq/gm (dialysis)**<br />
5-AMINOSALIC POW ACID(Mesalamine)<br />
5-HYDROXY-L- POW TRYPTOPH(Hydroxytryptophan)<br />
acetic acid soln<br />
acetone soln<br />
ALBUTEROL POW(Albuterol)<br />
AMIKACIN POW USP(Amikacin)<br />
AMINOPHYLLIN POW ANHYDROU(Aminophylline)<br />
AMITRIPTYLIN POW HCL(Amitriptyline HCl)<br />
ammonium lactate solution 70%<br />
AMOXICILLIN POW TRIHYDRA(Amoxicillin)<br />
AMOXICILLIN POW USP(Amoxicillin)<br />
AMOXICILLIN POW USP(Amoxicillin)<br />
AMPHOTERICIN POW B(Amphotericin B (Mouth-Throat))<br />
AMPHOTERICIN POW B(Amphotericin B (Mouth-Throat))<br />
AMPHOTERICIN POW B(Amphotericin B (Mouth-Throat))<br />
AMPICILLIN POW ANHYDR(Ampicillin)<br />
AMPICILLIN POW MICRONIZ(Ampicillin)<br />
AMPICILLIN POW TRIHYDRA(Ampicillin)<br />
ANDROSTERONE POW(Androsterone)<br />
ANTHRALIN POW(Anthralin)<br />
ATROPINE CRY USP NF(Atropine)<br />
ATROPINE POW SULFATE(Atropine Sulfate)<br />
ATROPINE POW USP(Atropine)<br />
ATROPINE SUL POW MONOHYDT(Atropine Sulfate Monohydrate)<br />
AZATHIOPRINE POW(Azathioprine)<br />
BACI-RX POW 5MU(Bacitracin (Topical))<br />
BACITRACIN POW 5MU(Bacitracin (Topical))<br />
BACITRACIN POW USP(Bacitracin (Topical))<br />
BACITRACIN POW ZINC USP(Bacitracin Zinc)<br />
BACLOFEN POW(Baclofen)<br />
BACTER WATER INJ BENZ ALC(Water For Inject, Bacteriostatic Benzyl<br />
Alcohol)<br />
BASE D PEG POW 4500(Polyethylene Glycol 4500)<br />
BENZOCAINE CRY(Benzocaine (Topical))<br />
BENZOCAINE POW(Benzocaine (Topical))<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
02<br />
01<br />
04<br />
04<br />
01<br />
01<br />
02<br />
02<br />
02<br />
02<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
122
Drug Name Drug Tier Notes<br />
BENZOIC ACID CRY(Benzoic Acid)<br />
BENZOIC ACID POW(Benzoic Acid)<br />
BENZOYL PER POW 70%(Benzoyl Peroxide)<br />
BENZOYL PER POW HYDROUS(Benzoyl Peroxide)<br />
BENZTROPINE POW MESYLATE(Benztropine Mesylate)<br />
BETAMETH DIP POW(Betamethasone Dipropionate (Topical))<br />
BETAMETH DIP POW MICRONIZ(Betamethasone Dipropionate (Topical))<br />
BETAMETH DIP POW MICRONIZ(Betamethasone Dipropionate (Topical))<br />
BETAMETH DIP POW USP NF(Betamethasone Dipropionate (Topical))<br />
BETAMETH VAL POW(Betamethasone Valerate)<br />
BETAMETH VAL POW MICRONIZ(Betamethasone Valerate)<br />
BETAMETH VAL POW USP NF(Betamethasone Valerate)<br />
BETHANECHOL POW CHLORIDE(Bethanechol Chloride)<br />
BHA POW NF(Butylated Hydroxyanisole)<br />
BROMOCRIPTIN POW MESYLATE(Bromocriptine Mesylate)<br />
CARBAMAZEPIN POW(Carbamazepine)<br />
CARBAMAZEPIN POW USP(Carbamazepine)<br />
CARBAMAZEPIN POW USP NF(Carbamazepine)<br />
CARISOPRODOL POW(Carisoprodol)<br />
CEFACLOR POW USP(Cefaclor Monohydrate)<br />
CEFADROXIL POW MONOHYDR(Cefadroxil)<br />
CHLORAL CRY HYDRATE(Chloral Hydrate)<br />
CHLORHEX DIG SOL 20%(Chlorhexidine Gluconate)<br />
CHLORHEX GLU SOL 20%(Chlorhexidine Gluconate)<br />
chlorhexidine gluconate soln 20%<br />
chlorhexidine gluconate solution<br />
CHLORPROMAZ POW HCL(Chlorpromazine HCl)<br />
CHLORZOXAZON POW(Chlorzoxazone)<br />
CICLOPIROX POW OLAMINE(Ciclopirox Olamine)<br />
CIMETIDINE POW(Cimetidine)<br />
CLIOQUINOL POW(Clioquinol)<br />
CLOBETASOL POW PROPIONA(Clobetasol Propionate)<br />
CLOBETASOL POW PROPIONA(Clobetasol Propionate)<br />
CLOBETASOL POW PROPIONA(Clobetasol Propionate)<br />
CLOTRIMAZOLE CRY(Clotrimazole (Topical))<br />
CLOTRIMAZOLE POW(Clotrimazole (Topical))<br />
coal tar (crude) solution<br />
coal tar (crude) tar<br />
CODEINE POW PHOSPHAT(Codeine Phosphate)<br />
COLCHICINE POW(Colchicine)<br />
COUMARIN POW(Coumarin)<br />
CROMOLYN SOD POW(Cromolyn Sodium)<br />
CYANOCOBAL POW(Cyanocobalamin)<br />
CYANOCOBALAM CRY(Cyanocobalamin)<br />
CYCLOBENZAPR POW HCL(Cyclobenzaprine HCl)<br />
DACARBAZINE POW(Dacarbazine)<br />
DESIPRAMINE POW(Desipramine HCl)<br />
DESONIDE POW MICRONIZ(Desonide)<br />
DICLOFENAC POW SODIUM(Diclofenac Sodium)<br />
diflunisal powder<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
01<br />
(PA)<br />
123
Drug Name Drug Tier Notes<br />
DIHYDROERGOT CRY MESYLATE(Dihydroergotamine Mesylate)<br />
DIHYDROERGOT POW MESYLATE(Dihydroergotamine Mesylate)<br />
DIHYDROTEST POW PROPIONA(Dihydrotestosterone Propionate)<br />
DIHYROTESTOS POW(Androstanolone)<br />
DILAUDID POW(Hydromorphone HCl)<br />
DISOPYRAMIDE POW PHOSPHAT(Disopyramide Phosphate)<br />
DOXEPIN HCL POW(Doxepin HCl)<br />
DOXYCYCLINE POW HYCLATE(Doxycycline Hyclate)<br />
DOXYL SUCCIN POW(Doxylamine Succinate)<br />
DOXYL SUCCIN POW USP(Doxylamine Succinate)<br />
DROPERIDOL POW(Droperidol)<br />
DROPERIDOL POW USP(Droperidol)<br />
ECONAZOLE POW NITRATE(Econazole Nitrate)<br />
ERGOTAMINE POW TARTRATE(Ergotamine Tartrate)<br />
ERYTHROMYCIN POW ETHYLSUC(Erythromycin Ethylsuccinate)<br />
ESTRADIOL POW MICRONIZ(Estradiol Micronized)<br />
FENOPROFEN POW CALCIUM(Fenoprofen Calcium)<br />
FENTANYL POW CITRATE(Fentanyl Citrate)<br />
FLUNISOLIDE POW(Flunisolide)<br />
FLUNISOLIDE POW ANHYDR(Flunisolide)<br />
FLUOCINOLONE POW ACETONID(Fluocinolone Acetonide)<br />
FLUOCINONIDE POW MICRONIZ(Fluocinonide)<br />
FLURBIPROFEN POW(Flurbiprofen)<br />
FLURBIPROFEN POW USP/NF(Flurbiprofen)<br />
GENTAMICIN POW SULF MIC(Gentamicin Sulfate (Topical))<br />
GENTAMICIN POW SULFATE(Gentamicin Sulfate (Topical))<br />
GRAMICIDIN D POW(Gramicidin D)<br />
GRISEOFULVIN POW MICRONIZ(Griseofulvin Micronized)<br />
GRISEOFULVIN POW USP(Griseofulvin Micronized)<br />
guaiacol solution<br />
HALOPERIDOL POW(Haloperidol)<br />
HYDROCORT POW(Hydrocortisone (Topical))<br />
HYDROCORT POW(Hydrocortisone (Topical))<br />
HYDROCORT POW MICRONIZ(Hydrocortisone (Topical))<br />
HYDROCORT POW USP(Hydrocortisone (Topical))<br />
HYDROCORT POW USP(Hydrocortisone (Topical))<br />
HYDROCORT AC POW(Hydrocortisone Acetate (Topical))<br />
HYDROCORT AC POW MICRONIZ(Hydrocortisone Acetate (Topical))<br />
HYDROCORT AC POW MICRONIZ(Hydrocortisone Acetate (Topical))<br />
HYDROCORT AC POW USP(Hydrocortisone Acetate (Topical))<br />
HYDROMORPHON POW HCL(Hydromorphone HCl)<br />
HYDROXY CELL POW 150-400(Hydroxypropyl Cellulose)<br />
HYDROXY CELL POW 1500 CPS(Hydroxypropyl Cellulose)<br />
HYDROXY CELL POW 4K-6500(Hydroxypropyl Cellulose)<br />
HYDROXY CELL POW 75-100(Hydroxypropyl Cellulose)<br />
HYDROXY CELL POW NF(Hydroxypropyl Cellulose)<br />
HYDROXYANISO POW BUTYLATE(Butylated Hydroxyanisole)<br />
HYDROXYTRYPT POW(Hydroxytryptophan)<br />
HYDROXYTRYPT POW(Hydroxytryptophan)<br />
HYDROXYZINE POW PAMOATE(Hydroxyzine Pamoate)<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
124
Drug Name Drug Tier Notes<br />
HYOSCYAMINE POW SULFATE(Hyoscyamine Sulfate)<br />
HYPROMELLOSE POW 100K CPS(Hydroxypropyl Cellulose)<br />
HYPROMELLOSE POW 4300CPS(Hydroxypropyl Cellulose)<br />
IBUPROFEN POW(Ibuprofen)<br />
IMIPRAMINE POW HCL(Imipramine HCl)<br />
INDAPAMIDE POW(Indapamide)<br />
INDOMETHACIN POW(Indomethacin)<br />
IODOFORM POW(Iodoform)<br />
IPRATROPIUM POW BROMIDE(Ipratropium Bromide)<br />
ISOPROPAMIDE POW IODIDE(Isopropamide Iodide)<br />
ISOPROTEREN POW SULFATE(Isoproterenol Sulfate)<br />
KETOPROFEN POW(Ketoprofen)<br />
LEVAMISOLE POW HCL(Levamisole HCl)<br />
LEVODOPA POW(Levodopa)<br />
LIDOCAINE POW HCL(Lidocaine HCl)<br />
LIDOCAINE POW HCL(Lidocaine HCl)<br />
MECLIZINE POW HCL(Meclizine HCl)<br />
MECLIZINE POW HCL MONO(Meclizine HCl)<br />
MECLOFEN SOD POW(Meclofenamate Sodium)<br />
MECLOFEN SOD POW(Meclofenamate Sodium)<br />
MEDROXYPROG POW MICRONIZ(Medroxyprogesterone Micronized)<br />
MEFENAMIC POW ACID(Mefenamic Acid)<br />
MEPERIDINE POW(Meperidine HCl)<br />
MEPIVACAINE POW(Mepivacaine HCl)<br />
MESALAMINE POW USP(Mesalamine)<br />
METAPROTEREN POW SULFATE(Metaproterenol Sulfate)<br />
METHACHOLINE CRY CHLORIDE(Methacholine Chloride)<br />
METHACHOLINE POW CHLORIDE(Methacholine Chloride)<br />
METHADONE POW(Methadone HCl)<br />
METHENAMINE GRA(Methenamine)<br />
METHENAMINE POW(Methenamine)<br />
METHOCEL POW K100M(Methylcellulose)<br />
METHOXSALEN POW(Methoxsalen (Topical))<br />
METHOXSALEN POW USP(Methoxsalen (Topical))<br />
methyl ethyl ketone liq<br />
METHYLCELLUL POW(Methylcellulose)<br />
METHYLCELLUL POW 1500CPS(Methylcellulose)<br />
METHYLCELLUL POW 4000 CPS(Methylcellulose)<br />
METOCLOPRAM POW MONOHYDR(Metoclopramide HCl Monohydrate)<br />
METOCLOPRAMI POW HCL USP(Metoclopramide HCl)<br />
METRONIDAZOL POW BENZOATE(Metronidazole Benzoate (Topical))<br />
MICONAZOLE POW NITRATE(Miconazole Nitrate (Topical))<br />
MINOCYCLINE POW(Minocycline HCl)<br />
MORPHINE POW SULFATE(Morphine Sulfate)<br />
NALIDIXIC POW ACID(Nalidixic Acid)<br />
NAPROXEN POW(Naproxen)<br />
NAPROXEN POW SODIUM(Naproxen Sodium)<br />
NAPROXEN POW USP(Naproxen)<br />
NEO-RX POW(Neomycin Sulfate (Topical))<br />
NEOMYCIN POW SULFATE(Neomycin Sulfate (Topical))<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
02<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
(PA)<br />
125
Drug Name Drug Tier Notes<br />
NITROFURAN POW ANHYDROU(Nitrofurantoin Macrocrystal)<br />
NORTRIPTYLIN POW HCL(Nortriptyline HCl)<br />
ORPHENADRINE POW CITRATE(Orphenadrine Citrate)<br />
OXYBUTININ POW CHLORIDE(Oxybutynin Chloride)<br />
OXYCODONE POW HCL(Oxycodone HCl)<br />
OXYTETRACYC POW HCL(Oxytetracycline HCl)<br />
PEG POW 4500(Polyethylene Glycol 4500)<br />
PEG 1000 POW BASE J(Polyethylene Glycol 1000)<br />
PEG 1000 POW USP/NF(Polyethylene Glycol 1000)<br />
PEG 400 POW MONOSTEA(Polyoxyl 40 Stearate)<br />
PENICILLAMIN POW(Penicillamine)<br />
PILOCARPINE CRY HCL(Pilocarpine Hydrochloride)<br />
PILOCARPINE POW HCL(Pilocarpine Hydrochloride)<br />
POLYOXYL 40 POW STEARATE(Polyoxyl 40 Stearate)<br />
PREGNENOLONE POW MICRONIZ(Pregnenolone (Micronized))<br />
PROCHLORPER POW MALEATE(Prochlorperazine Maleate)<br />
PROMETHAZINE POW HCL(Promethazine HCl)<br />
PROPANTHELIN POW BROMIDE(Propantheline Bromide)<br />
RETINOIC ACD POW(Tretinoin)<br />
RETINOIC ACD POW(Tretinoin)<br />
SALICYLIC CRY ACID(Salicylic Acid)<br />
SALICYLIC POW ACID(Salicylic Acid)<br />
SCOPALAMINE CRY HBR(Scopolamine HBr)<br />
SCOPOLAMINE POW HBR(Scopolamine HBr)<br />
SELEGILINE POW HCL(Selegiline HCl)<br />
SILVER CRY NITRATE(Silver Nitrate)<br />
SORBITOL MIS LOLLIPOP(Sorbitol Lollipop Base)<br />
SORBITOL POW(Sorbitol Solid)<br />
STERILE DILU SOL FLOLAN(Glycine Diluent)<br />
SUCRALFATE POW(Sucralfate)<br />
SUCRALFATE POW USP(Sucralfate)<br />
SULFACET SOD POW(Sulfacetamide Sodium)<br />
SULFACET SOD POW USP(Sulfacetamide Sodium)<br />
SULFASALAZIN POW(Sulfasalazine)<br />
SULFASALAZIN POW USP(Sulfasalazine)<br />
SULFASALAZIN POW USP/NF(Sulfasalazine)<br />
TRAZODONE POW(Trazodone HCl)<br />
TRAZODONE POW USP(Trazodone HCl)<br />
TRAZODONE POW USP/NF(Trazodone HCl)<br />
TRETINOIN POW(Tretinoin)<br />
TRIAMCINOLON POW ACETONID(Triamcinolone Acetonide (Topical))<br />
TRIMIPRAMINE POW MALEATE(Trimipramine Maleate)<br />
WARFARIN POW SODIUM(Warfarin Sodium)<br />
WARFARIN POW SODIUM(Warfarin Sodium)<br />
WARFARIN POW SODIUM(Warfarin Sodium)<br />
water for inject, bacteriostatic<br />
water for inject, bacteriostatic parabens<br />
water for injection<br />
water for iv injection<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
04<br />
01<br />
01<br />
01<br />
01<br />
126
INDEX<br />
A<br />
ABBOKINASE 34<br />
ABELCET 9<br />
ABILIFY DISC 51<br />
ABILIFY 51<br />
ABRAXANE 24<br />
ACCOLATE 79<br />
ACCUNEB 29<br />
ACCUPRIL 37<br />
ACCURETIC 37<br />
ACCUTANE 103<br />
ACCUZYME 103<br />
ACD-A 34<br />
acebutolol hcl 37<br />
ACEON 37<br />
acetaminophen w/ codeine 51<br />
acetaminophen-caff-dihydrocod 51<br />
acetaminophen-salicylamidephenyltoloxamine-caffeine<br />
52<br />
acetazolamide 37<br />
acetic acid (bulk) 122<br />
acetic acid (otic) 80<br />
acetic acid-aluminum acetate-boric<br />
acid-propylene glycol 80<br />
acetic acid-aluminum acetate 80<br />
acetone 122<br />
acetylcysteine 79<br />
ACIPHEX 84<br />
ACLOVATE 104<br />
ACTHIB 101<br />
ACTIGALL 84<br />
ACTIMMUNE 115<br />
ACTIVELLA 89<br />
ACTONEL WITH CALCIUM 115<br />
ACTONEL 115<br />
ACTOPLUS MET 89<br />
ACTOS 89<br />
ACULAR LS 80<br />
ACULAR PF 80<br />
ACULAR 80<br />
acyclovir sodium 9<br />
acyclovir 9<br />
ADACEL 101<br />
ADALAT CC 37<br />
ADDERALL XR 51<br />
ADDERALL XR 52<br />
ADDERALL 51<br />
ADOXA PAK 1/150 9<br />
ADRENALIN 29<br />
ADRIAMYCIN 24<br />
ADVAIR DISKUS 29<br />
ADVAIR HFA 29<br />
ADVICOR 37<br />
AEROBID-M 89<br />
AEROBID 89<br />
AGENERASE 9<br />
AGGRENOX 34<br />
AGRYLIN 34<br />
AKINETON 29<br />
AKNE-MYCIN 104<br />
ALA-SCALP 104<br />
ALAMAST 80<br />
ALBALON 80<br />
ALBENZA 9<br />
ALBUTEROL SULFATE/IPRATRO 30<br />
albuterol sulfate 29<br />
albuterol sulfate 30<br />
ALBUTEROL 122<br />
albuterol 29<br />
ALCAINE 80<br />
ALCET 52<br />
alclometasone dipropionate 104<br />
ALCOHOL 5%/DEXTROSE 5% 73<br />
alcohol swabs 119<br />
ALDACTAZIDE 37<br />
ALDACTONE 37<br />
ALDARA 104<br />
ALDURAZYME 79<br />
ALESSE-28 89<br />
ALFERON N 24<br />
ALIMTA 24<br />
ALINIA 9<br />
ALKERAN 24<br />
ALLEGRA-D 8<br />
ALLEGRA 8<br />
allopurinol sodium 115<br />
allopurinol 115<br />
ALOCRIL 80<br />
ALODOX 9<br />
ALOMIDE 80<br />
ALOPRIM 115<br />
ALORA 89<br />
ALPHAGAN P 80<br />
ALREX 80<br />
ALTABAX 104<br />
ALTACE 37<br />
ALTOPREV 37<br />
ALUPENT INH 30<br />
amantadine hcl 9<br />
AMANTADINE 9<br />
AMARYL 89<br />
AMBIEN CR 52<br />
AMBIEN 52<br />
AMBISOME 9<br />
AMCINONIDE 104<br />
amcinonide 104<br />
AMERGE 52<br />
AMERICAINE 104<br />
AMEVIVE 104<br />
AMICAR 34<br />
amikacin sulfate 9<br />
AMIKACIN 122<br />
AMIKIN 9<br />
amiloride & hydrochlorothiazide 73<br />
amiloride hcl 73<br />
AMILORIDE 73<br />
AMINESS 74<br />
amino acid electrolyte infusion 73<br />
amino acid electrolyte w/ calcium<br />
infusion in d25w 73<br />
amino acid infusion in d10w 73<br />
amino acid infusion in d20w 73<br />
amino acid infusion in d25w 73<br />
amino acid infusion 73<br />
aminocaproic acid 34<br />
AMINOPHYLLINE ANHYDROUS 122<br />
aminophylline 113<br />
AMINOSYN 7%/ELECTROLYTES 74<br />
AMINOSYN II 3.5% 74<br />
AMINOSYN II 3.5 74<br />
AMINOSYN II 4.25 74<br />
AMINOSYN II 5/DEXTROSE 25 74<br />
AMINOSYN II M 3.5%/DEXTRO 74<br />
AMINOSYN II M 4.25/DEXTRO 74<br />
AMINOSYN II 74<br />
AMINOSYN M 74<br />
AMINOSYN-HBC 74<br />
AMINOSYN-PF 7% 74<br />
AMINOSYN-PF 74<br />
AMINOSYN-RF 74<br />
AMINOSYN 74<br />
amiodarone hcl 37<br />
AMITIZA 84<br />
AMITRIPTYLINE HCL 122<br />
amitriptyline hcl 52<br />
amlodipine besylate-benazepril hcl<br />
37<br />
127
ammonium lactate 122<br />
AMMONUL 74<br />
amoxapine 52<br />
amoxicillin & pot clavulanate 9<br />
AMOXICILLIN TRIHYDRATE 122<br />
AMOXICILLIN 122<br />
amoxicillin 9<br />
AMOXIL 10<br />
AMOXIL 9<br />
amphetamine-dextroamphetamine 52<br />
AMPHOTEC 10<br />
AMPHOTERICIN B ORAL GRADE 122<br />
AMPHOTERICIN B SOLUBILIZE 122<br />
amphotericin b 10<br />
AMPHOTERICIN B 122<br />
ampicillin & sulbactam sodium 10<br />
AMPICILLIN ANHYDROUS 122<br />
ampicillin sodium 10<br />
AMPICILLIN TRIHYDRATE 122<br />
ampicillin 10<br />
amylase-lipase-protease 84<br />
amylase-lipase-protease 85<br />
ANACAINE 104<br />
ANADROL-50 89<br />
ANAFRANIL 52<br />
anagrelide hcl 34<br />
ANAPROX DS 52<br />
ANAPROX 52<br />
ANASPAZ 30<br />
ANCOBON 10<br />
ANDRODERM 89<br />
ANDROGEL PUMP 89<br />
ANDROGEL 89<br />
ANDROID 89<br />
ANDROSTERONE 122<br />
ANDROXY 89<br />
ANGELIQ 89<br />
ANGIOMAX 34<br />
ANSAID 52<br />
ANTABUSE 115<br />
ANTARA 37<br />
ANTARA 38<br />
anthralin 104<br />
ANTHRALIN 122<br />
ANTIVERT 85<br />
ANUSOL-HC 104<br />
ANZEMET 85<br />
APHTHASOL 115<br />
APIDRA 89<br />
APPBUTAMONE-D 52<br />
APPBUTAMONE 52<br />
APPFORMIN-D 89<br />
APPFORMIN 89<br />
APTIVUS 10<br />
AQUACHLORAL 52<br />
ARALAST 115<br />
ARALEN 10<br />
ARANESP ALBUMIN FREE SURE 34<br />
ARANESP ALBUMIN FREE 34<br />
ARANESP 34<br />
ARAVA 115<br />
AREDIA 115<br />
ARICEPT ODT 30<br />
ARICEPT 30<br />
ARIMIDEX 25<br />
ARISTOSPAN 89<br />
ARIXTRA 34<br />
ARMOUR THYRO 89<br />
AROMASIN 25<br />
ARRANON 25<br />
ARTHROTEC 50 52<br />
ARTHROTEC 75 52<br />
ASACOL 85<br />
ASMANEX 120 METERED DOSES 89<br />
ASMANEX 14 METERED DOSES 89<br />
ASMANEX 30 METERED DOSES 89<br />
ASMANEX 60 METERED DOSES 89<br />
aspirin w/ codeine 52<br />
ASTELIN 80<br />
ATACAND HCT 38<br />
ATACAND 38<br />
atenolol & chlorthalidone 38<br />
atenolol 38<br />
ATGAM 115<br />
ATRIPLA 10<br />
atropine sulfate (ophthalmic) 80<br />
ATROPINE SULFATE MONOHYDR 122<br />
ATROPINE SULFATE 122<br />
ATROPINE 122<br />
ATROVENT HFA 30<br />
ATROVENT NAS 79<br />
ATTENUVAX 101<br />
aug betamethasone dipropionate 104<br />
AUGMENTIN ES-600 10<br />
AUGMENTIN XR 10<br />
AUGMENTIN 10<br />
AUTOPEN 119<br />
AVALIDE 38<br />
AVANDAMET 90<br />
AVANDARYL 90<br />
AVANDIA 90<br />
AVAPRO 38<br />
AVAR 104<br />
AVASTIN 25<br />
AVELOX 10<br />
AVINZA 52<br />
AVODART 115<br />
AVONEX 115<br />
AXERT 52<br />
AXID 85<br />
AYGESTIN 90<br />
AZACTAM 10<br />
AZASITE 80<br />
azathioprine sodium 115<br />
azathioprine 115<br />
AZATHIOPRINE 122<br />
AZELEX 104<br />
AZILECT 53<br />
AZITHROMYCIN 10<br />
azithromycin 10<br />
azithromycin 11<br />
AZMACORT 90<br />
AZOPT 80<br />
AZULFIDINE 11<br />
B<br />
B & O 15-A SUPPRETTE 30<br />
B & O 16-A SUPPRETTE 30<br />
BACI-RX 122<br />
bacitracin (ophthalmic) 80<br />
BACITRACIN ZINC 122<br />
bacitracin-poly-neomycin-hc 80<br />
bacitracin-polymyxin b (ophth) 80<br />
BACITRACIN 11<br />
bacitracin 11<br />
BACITRACIN 122<br />
BACLOFEN 122<br />
baclofen 30<br />
BACTERIOSTATIC WATER FOR 122<br />
BACTOCILL 11<br />
BACTRIM DS 11<br />
BACTRIM 11<br />
BACTROBAN NASAL 104<br />
BACTROBAN 104<br />
BALACET 325 53<br />
BARACLUDE 11<br />
BASE D POLYETHYLENE GLYCO 122<br />
128
BD PEN MINI 119<br />
BD PEN 119<br />
BD ULTRAFINE III MINI PEN 119<br />
BD ULTRAFINE III SHORT PE 119<br />
BD ULTRAFINE ORIGINAL PEN 119<br />
BECONASE AQ 80<br />
belladonna alkaloids & opium 30<br />
benazepril & hydrochlorothiazide 38<br />
benazepril hcl 38<br />
bendroflumethiazide/rauwolfia 38<br />
BENEFIX 34<br />
BENICAR HCT 38<br />
BENICAR 38<br />
BENTYL 30<br />
BENZAC AC 104<br />
BENZAC W 104<br />
BENZACLIN WITH PUMP 104<br />
BENZACLIN 104<br />
BENZAGEL-10 104<br />
BENZAGEL-5 104<br />
BENZAMYCIN 104<br />
BENZAMYCINPAK 104<br />
BENZIQ LS 104<br />
BENZIQ 104<br />
benzocaine & antipyrine 80<br />
benzocaine (otic) 80<br />
benzocaine-phenylephrine-antipyrine<br />
80<br />
BENZOCAINE 122<br />
BENZOIC ACID 123<br />
BENZOYL PER 123<br />
BENZOYL PEROXIDE HYDROUS 123<br />
benzoyl peroxide-erythromycin 105<br />
benzoyl peroxide-urea 105<br />
benzoyl peroxide 104<br />
benzoyl peroxide 105<br />
BENZTROPINE MESYLATE 123<br />
benztropine mesylate 30<br />
BETAGAN 80<br />
BETAMETHASONE DIPROPIONAT 123<br />
betamethasone dipropionate (topical)<br />
105<br />
betamethasone valerate 105<br />
BETAMETHASONE VALERATE 123<br />
BETAMETHASONE 123<br />
BETAPACE AF 38<br />
BETAPACE 38<br />
BETASERON 115<br />
betaxolol hcl (ophth) 80<br />
BETHANECHOL CHLORIDE 123<br />
bethanechol chloride 30<br />
BETIMOL 80<br />
BETOPTIC-S 80<br />
BEXXAR 131 IODINE 25<br />
BEXXAR 25<br />
BHA 123<br />
BIAXIN XL 11<br />
BIAXIN 11<br />
BICILLIN C-R 11<br />
BICILLIN L-A 11<br />
BICITRA 74<br />
BICNU 25<br />
BIDIL 38<br />
BILTRICIDE 11<br />
BIO-STATIN 11<br />
BIO-THROID 90<br />
bisoprolol & hydrochlorothiazide 38<br />
bisoprolol fumarate 38<br />
BL STERILE PADS 2"X2" 119<br />
BLENOXANE 25<br />
bleomycin sulfate 25<br />
BLEPH- 81<br />
BLEPHAMIDE 81<br />
BONIVA 115<br />
BOOSTRIX 101<br />
BRETHINE 30<br />
BREVICON-28 90<br />
BREVOXYL-4 ACNE WASH KIT 105<br />
BREVOXYL-8 ACNE WASH KIT 105<br />
BREVOXYL 105<br />
brimonidine tartrate 81<br />
bromocriptine mesylate 115<br />
BROMOCRIPTINE MESYLATE 123<br />
BRONCAP 113<br />
BRONCODUR 113<br />
BROVANA 30<br />
bumetanide 74<br />
BUMEX 74<br />
BUPHENYL 74<br />
BUPRENEX 53<br />
buprenorphine hcl 53<br />
bupropion hcl (smoking deterrent) 53<br />
bupropion hcl 53<br />
BUSPAR 53<br />
buspirone hcl 53<br />
busulfan 25<br />
butalbital-acetaminophen-caffeine w/<br />
codeine 53<br />
butamben-tetracaine-benzocaine 105<br />
butorphanol tartrate 53<br />
BUTYLATED HYDROXYANISOLE 124<br />
BYETTA 90<br />
C<br />
cabergoline 115<br />
CADUET 38<br />
CADUET 39<br />
CAFERGOT 53<br />
CAFFEINE/SODIUM BENZOATE 53<br />
CALAN SR 39<br />
CALAN 39<br />
CALCIJEX 114<br />
calcitonin (salmon) 90<br />
calcitriol 114<br />
CAMPATH 25<br />
CAMPRAL 53<br />
CAMPTOSAR 25<br />
CANASA 85<br />
CANCIDAS 11<br />
CANTIL 30<br />
CAPASTAT SUL 11<br />
CAPEX 105<br />
CAPHOSOL 81<br />
CAPOTEN 39<br />
CAPOZIDE 39<br />
captopril & hydrochlorothiazide 39<br />
captopril 39<br />
CARAC 105<br />
CARAFATE 85<br />
carbachol (ophth) 81<br />
CARBAMAZEPINE 123<br />
carbamazepine 53<br />
CARBATROL 53<br />
carbidopa-levodopa 53<br />
carbidopa 53<br />
carboplatin 25<br />
CARDENE SR 39<br />
CARDENE 39<br />
CARDIZEM CD 39<br />
CARDIZEM LA 39<br />
CARDIZEM LA 40<br />
CARDIZEM 39<br />
CARDURA XL 40<br />
CARDURA 40<br />
CARIMUNE NF 101<br />
CARIMUNE NF 102<br />
carisoprodol w/ aspirin & codeine 30<br />
129
CARISOPRODOL 123<br />
carisoprodol 30<br />
CARMOL SCALP TREATMENT 105<br />
CARMOL-HC 105<br />
CARMOL 105<br />
CARNITOR 116<br />
carteolol hcl (ophth) 81<br />
CARTROL 40<br />
CASODEX 25<br />
CATAFLAM 53<br />
CATAPRES-TTS-1 40<br />
CATAPRES-TTS-2 40<br />
CATAPRES-TTS-3 40<br />
CATAPRES 40<br />
CEDAX 11<br />
CEENU 25<br />
cefaclor monohydrate 11<br />
cefaclor 11<br />
CEFACLOR 123<br />
CEFADROXIL MONOHYDRATE 123<br />
cefadroxil 11<br />
cefazolin in d5w 11<br />
cefazolin sodium and dextrose 12<br />
cefazolin sodium 11<br />
cefazolin sodium 12<br />
cefdinir 12<br />
cefepime hcl 12<br />
CEFIZOX 12<br />
cefotaxime sodium 12<br />
cefoxitin sodium 12<br />
cefpodoxime proxetil 12<br />
cefprozil 12<br />
ceftazidime 12<br />
CEFTIN 12<br />
ceftriaxone sodium and dextrose 12<br />
ceftriaxone sodium in dextrose 12<br />
ceftriaxone sodium 12<br />
CEFTRIAXONE 12<br />
cefuroxime axetil 12<br />
cefuroxime sodium and dextrose 12<br />
cefuroxime sodium 12<br />
cefuroxime sodium 13<br />
CEFZIL 13<br />
CELEBREX 53<br />
CELESTONE-SOLUSPAN 90<br />
CELESTONE 90<br />
CELEXA 54<br />
CELLCEPT IV 116<br />
CELLCEPT 116<br />
CELONTIN 54<br />
CENESTIN 90<br />
CENOGEN ULTRA 114<br />
CENTANY 105<br />
CEPHALEXIN 13<br />
cephalexin 13<br />
CEPROTIN 116<br />
CEREBYX 54<br />
CEREDASE 79<br />
CEREZYME 116<br />
CERUBIDINE 25<br />
CHANTIX 30<br />
CHEMET 88<br />
CHLORAL HYDRATE 123<br />
chloral hydrate 54<br />
chloramphenicol sodium succinate 13<br />
chlordiazepoxide-amitriptyline 54<br />
CHLORHEX DIG 123<br />
CHLORHEX GLU 123<br />
chlorhexidine gluconate (bulk) 123<br />
chlorhexidine gluconate (mouththroat)<br />
81<br />
chlorhexidine gluconate 123<br />
chloroquine phosphate 13<br />
chlorothiazide 74<br />
CHLORPROMAZ 54<br />
CHLORPROMAZINE HCL 123<br />
chlorpromazine hcl 54<br />
chlorpropamide 90<br />
chlorthalidone 74<br />
CHLORZOXAZONE 123<br />
chlorzoxazone 30<br />
cholestyramine light 40<br />
cholestyramine 40<br />
choline & mag salicylate 54<br />
chorionic gonadotropin 90<br />
ciclopirox olamine 105<br />
CICLOPIROX OLAMINE 123<br />
cilostazol 34<br />
cilostazol 35<br />
CILOXAN 81<br />
CIMETIDINE HCL/NACL 85<br />
cimetidine hcl 85<br />
CIMETIDINE 123<br />
cimetidine 85<br />
CIPRO HC 81<br />
CIPRO I.V.-IN D5W 13<br />
CIPRO I.V. 13<br />
CIPRO XR 13<br />
CIPRODEX 81<br />
ciprofloxacin hcl (ophth) 81<br />
ciprofloxacin hcl 13<br />
ciprofloxacin-ciprofloxacin hcl 13<br />
ciprofloxacin 13<br />
cisplatin 25<br />
citalopram hydrobromide 54<br />
CITROLITH 74<br />
cladribine 25<br />
CLAFORAN/D5W 13<br />
CLAFORAN 13<br />
CLARIFOAM EF 105<br />
CLARINEX-D 8<br />
CLARINEX 8<br />
CLARITHROMYC 13<br />
clarithromycin 13<br />
CLARITIN-D 8<br />
CLARITIN 8<br />
CLEERAVUE-M 13<br />
CLEOCIN PED 14<br />
CLEOCIN PHOS 14<br />
CLEOCIN PHOSPHATE 14<br />
CLEOCIN VAG 105<br />
CLEOCIN-T 105<br />
CLEOCIN 105<br />
CLEOCIN 14<br />
CLIMARA PRO 90<br />
CLIMARA 90<br />
CLIMIMIX E 4.25% 75<br />
CLINAC BPO 105<br />
CLINDA 105<br />
clindamycin hcl 14<br />
clindamycin phosphate (topical) 105<br />
clindamycin phosphate vaginal 105<br />
clindamycin phosphate 14<br />
CLINDESSE 105<br />
CLINIMIX 2.75%/DEXTROSE 5 74<br />
CLINIMIX 4.25%/DEXTROSE 5 74<br />
CLINIMIX 5%/DEXTROSE 15% 74<br />
CLINIMIX 5%/DEXTROSE 20% 75<br />
CLINIMIX 5%/DEXTROSE 25% 75<br />
CLINIMIX E 2.75% 75<br />
CLINIMIX E 4.25% 75<br />
CLINIMIX E 5%/DEXTROSE 15 75<br />
CLINIMIX E 5%/DEXTROSE 20 75<br />
CLINIMIX E 5%/DEXTROSE 25 75<br />
CLINIMIX E 5%/DEXTROSE 35 75<br />
CLINORIL 54<br />
CLIOQUINOL 123<br />
130
clobetasol propionate emollient base<br />
106<br />
CLOBETASOL PROPIONATE MIC 123<br />
clobetasol propionate 106<br />
CLOBETASOL PROPIONATE 123<br />
CLOBEX 106<br />
CLODERM 106<br />
CLOLAR 25<br />
clomipramine hcl 54<br />
clonidine hcl 40<br />
CLORPRES 40<br />
clotrimazole w/ betamethasone 106<br />
clotrimazole 106<br />
CLOTRIMAZOLE 123<br />
clozapine 54<br />
CLOZARIL 54<br />
coal tar (crude) 123<br />
CODEINE PHOS TAB SOL 54<br />
CODEINE PHOSPHATE 123<br />
CODEINE PHOSPHATE 54<br />
codeine phosphate 54<br />
codeine sulfate 54<br />
COGENTIN 30<br />
COGNEX 30<br />
COGNEX 31<br />
COLAZAL 85<br />
colchicine w/ probenecid 75<br />
colchicine 116<br />
COLCHICINE 123<br />
COLESTID FLA 40<br />
COLESTID FLAVORED 40<br />
COLESTID 40<br />
colestipol hcl 40<br />
colistimethate sodium 14<br />
COLY-MYCIN-M 14<br />
COLY-MYCIN-S 81<br />
COLYTE-FLAVOR PACKS 85<br />
COLYTE 85<br />
COLYTROL 31<br />
COMBIPATCH 90<br />
COMBIVENT 31<br />
COMBIVIR 14<br />
COMBUNOX 54<br />
COMTAN 54<br />
COMVAX 102<br />
CONCERTA 54<br />
CONDYLOX 106<br />
CONRAY 73<br />
COPAXONE 116<br />
CORDARONE 40<br />
CORDRAN SP 106<br />
CORDRAN TAPE 106<br />
CORDRAN 106<br />
COREG CR 40<br />
COREG 40<br />
CORGARD 40<br />
CORTEF 90<br />
CORTIFOAM 106<br />
cortisone acetate 90<br />
CORTISPORIN-TC 81<br />
CORTISPORIN 81<br />
CORZIDE 40<br />
COSMEGEN 25<br />
COSOPT 81<br />
COUMADIN 35<br />
COUMARIN 123<br />
COVERA-HS 40<br />
COZAAR 40<br />
COZAAR 41<br />
CREON 10 85<br />
CRESTOR 41<br />
CRESYLATE 81<br />
CRINONE 90<br />
CRIXIVAN 14<br />
CROLOM 81<br />
cromolyn sodium (ophth) 81<br />
CROMOLYN SODIUM 123<br />
cromolyn sodium 79<br />
CUBICIN 14<br />
CUPRIMINE 88<br />
CURITY GAUZE PADS/2"X2" 119<br />
CUTIVATE 106<br />
CVS GAUZE PAD STERILE 2"X 119<br />
cyanocobalamin 114<br />
CYANOCOBALAMIN 123<br />
CYANOKIT 116<br />
CYCLESSA 90<br />
CYCLOBENZAPRINE HCL 123<br />
cyclobenzaprine hcl 31<br />
CYCLOGYL 81<br />
cyclopentolate hcl 81<br />
cyclophosphamide 25<br />
cyclosporine modified (for<br />
microemulsion) 116<br />
cyclosporine 116<br />
CYMBALTA 55<br />
CYSTO-CONRAY II 73<br />
CYSTOSPAZ 31<br />
cytarabine 25<br />
CYTOMEL 91<br />
CYTOTEC 85<br />
CYTOVENE 14<br />
CYTOXAN 25<br />
D<br />
D.H.E. 45 55<br />
DACARBAZINE 123<br />
dacarbazine 25<br />
DACOGEN 25<br />
danazol 91<br />
DANTRIUM 31<br />
dantrolene sodium 31<br />
dapsone 14<br />
DAPTACEL 102<br />
DARAPRIM 14<br />
DARVOCET A500 55<br />
DARVOCET-N 100 55<br />
DARVOCET-N 50 55<br />
DARVON-N 55<br />
DARVON 55<br />
daunorubicin hcl 25<br />
daunorubicin hcl 26<br />
DAUNOXOME 26<br />
DAYPRO 55<br />
DDAVP 91<br />
DEBACTEROL 81<br />
DECAVAC 102<br />
DECLOMYCIN 14<br />
deferoxamine mesylate 88<br />
DELATESTRYL 91<br />
DELESTROGEN 91<br />
DEMADEX 75<br />
demeclocycline hcl 14<br />
DEMEROL 55<br />
DEMULEN 1/35-28 91<br />
DENAVIR 106<br />
DEPACON 55<br />
DEPAKENE 55<br />
DEPAKOTE ER 55<br />
DEPAKOTE SPR CAP 55<br />
DEPAKOTE 55<br />
DEPEN TITRA 88<br />
DEPO-ESTRADI 91<br />
DEPO-MEDROL 91<br />
DEPO-PROVERA 91<br />
DEPO-SQ PROV 91<br />
DEPO-TESTOST 91<br />
131
DEPODUR 55<br />
DERMA-SMOOTHE/FS BODY OIL 106<br />
DERMA-SMOOTHE/FS SCALP OI 106<br />
DERMATOP 106<br />
DERMOTIC 81<br />
DESFERAL 88<br />
DESIPRAMINE HCL 123<br />
desipramine hcl 55<br />
desmopressin acetate spray<br />
refrigerated 91<br />
desmopressin acetate spray 91<br />
desmopressin acetate 91<br />
DESOGEN 91<br />
desogestrel & ethinyl estradiol 91<br />
desogestrel-ethinyl estradiol<br />
(triphasic) 91<br />
DESONATE 106<br />
desonide 106<br />
DESONIDE 123<br />
DESOWEN 106<br />
desoximetasone 106<br />
DESOXYN 55<br />
DESQUAM-E 106<br />
DESQUAM-X 106<br />
DETROL LA 113<br />
DETROL 113<br />
dexamethasone sodium phosphate<br />
(ophth) 81<br />
dexamethasone sodium phosphate 91<br />
dexamethasone 91<br />
DEXEDRINE 55<br />
dexmedetomidine hcl 55<br />
dexmethylphenidate hcl 55<br />
DEXODRYL 8<br />
DEXPAK 13 DAY 91<br />
DEXPAK JR 10 DAY 91<br />
dexrazoxane 116<br />
dextroamphetamine sulfate 55<br />
DEXTROSE 5%/NACL 0.225% 75<br />
dextrose in lactated ringers 75<br />
dextrose w/ sodium chloride 75<br />
dextrose 75<br />
DEXTROSTAT 55<br />
DIABETA 91<br />
DIABETA 92<br />
DIABINESE 92<br />
DIAMOX 41<br />
DIANEAL LOW CALCIUM/1.5% 75<br />
DIANEAL LOW CALCIUM/2.5% 75<br />
DIANEAL PD-2/1.5% DEXTROS 75<br />
DIANEAL PD-2/2.5% DEXTROS 75<br />
DIANEAL PD-2/3.5% DEXTROS 75<br />
DIANEAL PD-2/4.25% DEXTRO 75<br />
DIBENZYLINE 31<br />
diclofenac potassium 55<br />
DICLOFENAC SODIUM 123<br />
diclofenac sodium 56<br />
dicloxacillin sodium 14<br />
dicyclomine hcl 31<br />
didanosine 14<br />
DIDRONEL IV 116<br />
DIDRONEL 116<br />
DIFFERIN 106<br />
diflorasone diacetate emollient base<br />
106<br />
diflorasone diacetate 106<br />
DIFLUCAN IN ISO-OSMOTIC D 14<br />
DIFLUCAN IN NACL 14<br />
DIFLUCAN 14<br />
diflunisal 123<br />
diflunisal 56<br />
digoxin 41<br />
DIHYDROERGOTAMINE MESYLAT 124<br />
dihydroergotamine mesylate 56<br />
DIHYDROTESTOSTERONE PROPI 124<br />
DILACOR XR 41<br />
DILANTIN 56<br />
DILATRATE SR 41<br />
DILAUDID-5 56<br />
DILAUDID-HP 56<br />
DILAUDID 124<br />
DILAUDID 56<br />
diltiazem hcl coated beads 41<br />
diltiazem hcl extended release beads<br />
41<br />
diltiazem hcl 41<br />
DIOVAN HCT 41<br />
DIOVAN 41<br />
DIPENTUM 85<br />
diphenoxylate w/ atropine 85<br />
dipivefrin hcl 81<br />
DIPROLENE AF 107<br />
DIPROLENE 106<br />
DIPTHERIA/TETANUS TOXOID 102<br />
dipyridamole 41<br />
DISOPYRAMIDE PHOSPHATE 124<br />
disopyramide phosphate 41<br />
disopyramide phosphate 42<br />
DITROPAN 113<br />
DIURIL IV 75<br />
DIURIL 75<br />
DIVI 92<br />
DIVIGEL 92<br />
DOLOPHINE 56<br />
DORYX 14<br />
DOSTINEX 116<br />
DOVONEX 107<br />
doxazosin mesylate 42<br />
doxepin hcl (antipruritic) 107<br />
DOXEPIN HCL 124<br />
doxepin hcl 56<br />
DOXIL 26<br />
doxorubicin hcl 26<br />
DOXYCYCL HYC CAP 14<br />
DOXYCYCL HYC CAP 15<br />
doxycycline (monohydrate) 15<br />
DOXYCYCLINE HYCLATE 124<br />
doxycycline hyclate 15<br />
DOXYLAMINE SUCCINATE 124<br />
DRITHO-SCALP 107<br />
DROPERIDOL 124<br />
droperidol 56<br />
DROXIA 26<br />
DRY 107<br />
DTIC-DOME 26<br />
DUAC 107<br />
DUANE READE UNIFINE PENTI 122<br />
DUETACT 92<br />
duloxetine hcl 56<br />
DUONEB 31<br />
DUOVISC 81<br />
DURABAC 56<br />
DURAGESIC 56<br />
DURICEF 15<br />
DYAZIDE 75<br />
DYNABAC 15<br />
DYNACIN 15<br />
DYNACIRC CR 42<br />
dyphylline-guaifenesin 113<br />
DYRENIUM 75<br />
E<br />
E.E.S. GRAN 15<br />
EC-NAPROSYN 56<br />
ECK STERILE PADS 2"X2" 119<br />
econazole nitrate 107<br />
ECONAZOLE NITRATE 124<br />
132
EDECRIN 75<br />
edetate calcium disodium 88<br />
edetate disodium 88<br />
EFFEXOR XR 56<br />
EFFEXOR 56<br />
EFUDEX OCCLUSION PACK 107<br />
EFUDEX 107<br />
ELAPRASE 79<br />
ELDEPRYL 56<br />
ELESTAT 81<br />
ELESTRIN 92<br />
ELIDEL 107<br />
ELIGARD 26<br />
ELIMITE 107<br />
ELITE-THIN INSULIN SYRING 119<br />
ELITEK 79<br />
ELIXOPHYLLIN-GG 113<br />
ELIXOPHYLLIN 113<br />
ELLENCE 26<br />
ELMIRON 116<br />
ELOCON 107<br />
ELOXATIN 26<br />
ELSPAR 26<br />
EMADINE 81<br />
EMCYT 26<br />
EMEND 85<br />
EMLA/TEGADERM 107<br />
EMLA 107<br />
EMSAM 56<br />
EMSAM 57<br />
EMTRIVA 15<br />
ENABLEX 113<br />
enalapril maleate &<br />
hydrochlorothiazide 42<br />
enalapril maleate 42<br />
ENBREL 116<br />
ENDOMETRIN 92<br />
ENDRATE 88<br />
ENGERIX-B 102<br />
ENJUVIA 92<br />
ENLON-PLUS 31<br />
ENTOCORT EC 92<br />
EPIFOAM 107<br />
epinephrine hcl 31<br />
EPIPEN 2-PAK INJ 0.3MG 31<br />
EPIPEN-JR 2-PAK 31<br />
EPIPEN-JR 31<br />
EPIPEN 31<br />
EPIRUBICIN 26<br />
EPIVIR 15<br />
EPOGEN 35<br />
EPZICOM 15<br />
EQUETRO 57<br />
ERAXIS 15<br />
ERBITUX 26<br />
ergoloid mesylates 31<br />
ERGOTAMINE TARTRATE 124<br />
ergotamine tartrate 57<br />
ergotamine w/ caffeine 57<br />
ERY-TAB 15<br />
ERY 107<br />
ERYPED 15<br />
ERYTHROCIN 15<br />
erythromycin (acne aid) 107<br />
erythromycin (ophth) 81<br />
erythromycin base 15<br />
ERYTHROMYCIN CAP 15<br />
ERYTHROMYCIN ETHYLSUCCINA 124<br />
erythromycin ethylsuccinate 15<br />
erythromycin lactobionate 15<br />
erythromycin stearate 15<br />
erythromycin-sulfisoxazole 15<br />
ERYTHROMYCIN 15<br />
ESCLIM 92<br />
ESTRACE VAG 92<br />
ESTRACE 92<br />
ESTRADERM 92<br />
ESTRADIOL MICRONIZED 124<br />
estradiol 92<br />
ESTRASORB 92<br />
ESTRING 92<br />
ESTRO 92<br />
estropipate 92<br />
ESTROSTEP FE 92<br />
ethambutol hcl 16<br />
ETHMOZINE 42<br />
ethosuximide 57<br />
ethynodiol diacet & eth estrad 92<br />
ETHYOL 116<br />
etidronate disodium 116<br />
etodolac 57<br />
ETOPOPHOS 26<br />
etoposide 26<br />
EURAX 107<br />
EVISTA 92<br />
EVOCLIN 107<br />
EVOXAC 31<br />
EXEL INSULIN PEN NEEDLES 119<br />
EXELON 31<br />
EXFORGE 42<br />
EXJADE 88<br />
EXUBERA COMBINATION PACK 92<br />
EXUBERA KIT 92<br />
EXUBERA PATIENT PACK 92<br />
F<br />
FABRAZYME 79<br />
FACTIVE 16<br />
famotidine 85<br />
FAMVIR 16<br />
FANSIDAR 16<br />
FARESTON 26<br />
FASLODEX 26<br />
fat emulsion 76<br />
FAZACLO 57<br />
FELBATOL 57<br />
FELDENE 57<br />
felodipine 42<br />
FEMARA 26<br />
FEMCON FE 93<br />
FEMHRT 1/5 93<br />
FEMHRT LOW DOSE 93<br />
FEMRING 93<br />
FEMTRACE 93<br />
fenofibrate micronized 42<br />
fenofibrate 42<br />
FENOPROFEN CALCIUM 124<br />
fenoprofen calcium 57<br />
fentanyl citrate-bupivacaine hclsodium<br />
chloride 57<br />
fentanyl citrate-ropivacaine hclsodium<br />
chloride 57<br />
FENTANYL CITRATE 124<br />
fentanyl citrate 57<br />
fentanyl 57<br />
FENTORA 57<br />
FENTORA 58<br />
FEXMID 31<br />
fexofenadine hcl 8<br />
FINACEA 107<br />
finasteride 116<br />
FIORICET/CODEINE 58<br />
FIORINAL/CODEINE #3 58<br />
FIRST-PROGESTERONE VGS 10 99<br />
FIRST-PROGESTERONE VGS 20 99<br />
133
FIRST-PROGESTERONE VGS 25 99<br />
FIRST-PROGESTERONE VGS 40 99<br />
FIRST-TESTOS 93<br />
FIRST-TESTOSTERONE MC COM 93<br />
FLAGYL ER 16<br />
FLAGYL 16<br />
FLAREX 81<br />
flavoxate hcl 113<br />
FLBGAMMA DIF 102<br />
FLEBOGAMMA 102<br />
flecainide acetate 42<br />
FLEXERIL 31<br />
FLOMAX 116<br />
FLONASE 81<br />
FLORINEF 93<br />
FLOVENT DISKUS 93<br />
FLOVENT HFA 93<br />
FLOXIN OTIC SINGLES 81<br />
FLOXIN OTIC 81<br />
floxuridine 26<br />
fluconazole in dextrose 16<br />
fluconazole in nacl 16<br />
fluconazole 16<br />
FLUDARA 26<br />
fludarabine phosphate 26<br />
FLUDARABINE 26<br />
fludrocortisone acetate 93<br />
FLUMADINE 16<br />
flunisolide (nasal) 81<br />
FLUNISOLIDE ANHYDROUS 124<br />
FLUNISOLIDE 124<br />
fluocinolone acetonide 107<br />
FLUOCINOLONE ACETONIDE 124<br />
fluocinonide emulsified base 107<br />
fluocinonide 107<br />
FLUOCINONIDE 124<br />
FLUORABON 116<br />
FLUORIDEX DAILY DEFENSE S 73<br />
fluorometholone (ophth) 81<br />
FLUOROPLEX 107<br />
fluorouracil (topical) 107<br />
FLUOROURACIL 26<br />
fluorouracil 26<br />
fluoxetine hcl 58<br />
fluphenazine decanoate 58<br />
fluphenazine hcl 58<br />
FLURA-DROPS 116<br />
flurbiprofen sodium 81<br />
FLURBIPROFEN 124<br />
flurbiprofen 58<br />
flutamide 26<br />
fluticasone propionate 107<br />
fluvoxamine maleate 58<br />
FML FORTE 81<br />
FML LIQUIFLM 81<br />
FML S.O.P. 81<br />
FOCALIN XR 58<br />
FOCALIN 58<br />
FORADIL AEROLIZER 31<br />
FORTAMET 93<br />
FORTAZ 16<br />
FORTEO 93<br />
FOSAMAX PLUS D 116<br />
FOSAMAX 116<br />
foscarnet sodium 16<br />
FOSCAVIR 16<br />
fosinopril sodium &<br />
hydrochlorothiazide 42<br />
fosinopril sodium 42<br />
FOSRENOL 76<br />
FRAGMIN 35<br />
FREAMINE III 3% 76<br />
FREAMINE III 8.5%/DEXTROS 76<br />
FREAMINE III 76<br />
FROVA 58<br />
FRST-HYDRCRT 107<br />
FUDR 26<br />
FUNGIZONE 16<br />
FURADANTIN 16<br />
furosemide 76<br />
FUZEON 16<br />
G<br />
G/P 79<br />
gabapentin 58<br />
GABARONE 58<br />
GABAZOLAMINE 58<br />
GABITIDINE 85<br />
GABITRIL 58<br />
GABOXETINE 58<br />
GAMASTAN S/D 102<br />
GAMMAGARD LIQUID 102<br />
GAMMAGARD S/D 102<br />
GAMMAGARD 102<br />
GAMUNEX 102<br />
ganciclovir 16<br />
GANTRIS PED 16<br />
GARDASIL 102<br />
GASTROCROM 116<br />
GASTROMARK 73<br />
gemfibrozil 42<br />
GEMZAR 26<br />
GENOTROPIN 93<br />
gentamicin in saline 16<br />
gentamicin sulfate (ophth) 82<br />
gentamicin sulfate (topical) 107<br />
GENTAMICIN SULFATE MICRON 124<br />
GENTAMICIN SULFATE 124<br />
gentamicin sulfate 16<br />
GEOCILLIN 16<br />
GEODON 58<br />
GEODON 59<br />
GFN 800/PSE 60 79<br />
GLEEVEC 26<br />
GLIADEL WAFER 26<br />
glimepiride 93<br />
glipizide-metformin hcl 93<br />
glipizide 93<br />
GLUCAGEN HYPOKIT 93<br />
glucagon (rdna) 93<br />
GLUCOPHAGE XR 93<br />
GLUCOPHAGE 93<br />
GLUCOTROL XL 94<br />
GLUCOTROL 93<br />
GLUCOTROL 94<br />
GLUCOVANCE 94<br />
GLUMETZA 94<br />
glyburide micronized 94<br />
glyburide-metformin 94<br />
glyburide 94<br />
glycopyrrolate 31<br />
GLYCRON 94<br />
GLYNASE 94<br />
GLYSET 94<br />
GNP STERILE PADS 2"X2" 119<br />
gold sodium thiomalate 88<br />
GOLYTELY 85<br />
GORDONS UREA 107<br />
GRAMICIDIN D 124<br />
GRIFULVIN 16<br />
GRIS-PEG 17<br />
griseofulvin microsize 17<br />
GRISEOFULVIN 124<br />
guaiacol 124<br />
guanabenz acetate 42<br />
guanfacine hcl 42<br />
guanidine hcl 31<br />
GYNODIOL 94<br />
H<br />
134
HALDOL DECAN 59<br />
HALDOL 59<br />
HALFLYTELY BOWEL PREP KIT 85<br />
halobetasol propionate 108<br />
HALOG 108<br />
haloperidol decanoate 59<br />
haloperidol lactate 59<br />
HALOPERIDOL 124<br />
haloperidol 59<br />
HAVRIX 102<br />
HECTOROL 114<br />
HELIDAC 17<br />
heparin (porcine) in sodium chloride<br />
35<br />
heparin sod (porcine) in d5w 35<br />
heparin sodium (porcine) 35<br />
heparin sodium (porcine) 36<br />
HEPARIN SODIUM/D5W 35<br />
HEPARIN SODIUM/SODIUM CHL 35<br />
HEPARIN SODIUM 35<br />
HEPSERA 17<br />
HERCEPTIN 26<br />
HEXALEN 26<br />
HIBTITER 102<br />
HIPREX 17<br />
HISTEX DA 79<br />
homatropine hbr 82<br />
homatropine methylbromide 31<br />
HUMALOG MIX 50/50 PEN 94<br />
HUMALOG MIX 50/50 94<br />
HUMALOG MIX 75/25 PEN 94<br />
HUMALOG MIX 75/25 94<br />
HUMALOG PEN 94<br />
HUMALOG 94<br />
HUMAPEN LUXURA HD 119<br />
HUMAPEN MEMOIR 119<br />
HUMATIN 17<br />
HUMATROPE 94<br />
HUMIRA PEN-CROHNS DISEASE 116<br />
HUMIRA PEN 116<br />
HUMIRA 116<br />
HUMULIN 50/50 94<br />
HUMULIN 70/30 PEN 94<br />
HUMULIN 70/30 94<br />
HUMULIN N U-100 PEN 94<br />
HUMULIN N 94<br />
HUMULIN R 94<br />
HYCAMTIN 26<br />
HYCET 59<br />
hydralazine hcl 42<br />
HYDREA 26<br />
HYDRO 40 FOAM 108<br />
HYDROCHLOROT 76<br />
hydrochlorothiazide 76<br />
hydrocodone-acetaminophen 59<br />
hydrocodone-ibuprofen 59<br />
hydrocortisone (rectal) 108<br />
hydrocortisone (topical) 108<br />
HYDROCORTISONE ACETATE MI 124<br />
HYDROCORTISONE ACETATE 124<br />
hydrocortisone butyrate 108<br />
HYDROCORTISONE MICRONIZED 124<br />
hydrocortisone sod succinate 94<br />
hydrocortisone valerate 108<br />
hydrocortisone w/acetic acid 82<br />
HYDROCORTISONE 124<br />
hydrocortisone 94<br />
hydromorphone hcl-bupivacaine hclsodium<br />
chloride 59<br />
hydromorphone hcl-sodium chloride<br />
59<br />
HYDROMORPHONE HCL 124<br />
hydromorphone hcl 59<br />
hydroxocobalamin 114<br />
hydroxychloroquine sulfate 17<br />
HYDROXYPROPYL CELLULOSE 1 124<br />
HYDROXYPROPYL CELLULOSE 4 124<br />
HYDROXYPROPYL CELLULOSE 7 124<br />
HYDROXYPROPYL CELLULOSE 124<br />
HYDROXYTRYPTOPHAN L-5 124<br />
HYDROXYTRYPTOPHAN 124<br />
hydroxyurea 26<br />
hydroxyzine hcl 59<br />
HYDROXYZINE PAMOATE 124<br />
hydroxyzine pamoate 59<br />
hydroxyzine pamoate 60<br />
HYOSCYAMINE SULFATE 125<br />
hyoscyamine sulfate 31<br />
hyoscyamine sulfate 32<br />
hyoscyamine 32<br />
HYPERTENSOLOL 43<br />
HYPROMELLOSE 100000CPS 125<br />
HYPROMELLOSE 4300CPS 125<br />
HYSKON 76<br />
HYTONE 108<br />
HYTRIN 43<br />
HYZAAR 43<br />
I<br />
IBUPROFEN 125<br />
ibuprofen 60<br />
IDAMYCIN PFS 27<br />
idarubicin hcl 27<br />
IFEX/MESNEX COMBO PACK 27<br />
IFEX 27<br />
ifosfamide & mesna 27<br />
ifosfamide 27<br />
IMDUR 43<br />
IMIPRAMINE HCL 125<br />
imipramine hcl 60<br />
imipramine pamoate 60<br />
IMITREX STATDOSE PEN 60<br />
IMITREX 60<br />
IMMUNE GLOBULIN 102<br />
IMOVAX RABIES (H.D.C.V.) 102<br />
IMPLANON 94<br />
IMURAN 117<br />
INAPSINE 60<br />
INCRELEX 94<br />
INDAPAMIDE 125<br />
indapamide 76<br />
INDERAL LA 43<br />
INDERAL 43<br />
INDERIDE 40/25 43<br />
INDOCIN IV 60<br />
INDOCIN SR 60<br />
INDOCIN 60<br />
INDOMETHACIN 125<br />
INDOMETHACIN 60<br />
indomethacin 60<br />
INFANRIX 102<br />
INFERGEN 17<br />
INFUMORPH 60<br />
INJEX 30 NEEDLE FREE SYST 119<br />
INNOHEP 36<br />
INNOPRAN XL 43<br />
INOVA 4/1 ACNE CONTROL TH 108<br />
INOVA 108<br />
INSPRA 43<br />
INSULIN SYRINGE LUER-LOK/ 119<br />
insulin syringe/needle u-100 120<br />
insulin syringe/needle u-100 121<br />
insulin syringe/needle u-40 121<br />
insulin syringes (disposable) 120<br />
INTAL INH 79<br />
INTAL 79<br />
135
INTRON-A 27<br />
INVANZ 17<br />
INVEGA 60<br />
INVERSINE 43<br />
invert sugar 76<br />
INVIRASE 17<br />
IODOFORM 125<br />
IOPIDINE 82<br />
IPOL INACTIVATED IPV 102<br />
ipratropium bromide (nasal) 79<br />
IPRATROPIUM BROMIDE 125<br />
ipratropium bromide 32<br />
IRESSA 27<br />
irrigation solutions, physiological 73<br />
ISLAND GARD-GRX 121<br />
ISMO 43<br />
ISO ATROPINE 82<br />
ISO CARBACHO 82<br />
ISO HOMATROP 82<br />
ISO HYOSCINE 82<br />
isoniazid & rifampin 17<br />
isoniazid 17<br />
ISOPROPAMIDE IODIDE 125<br />
ISOPROTERENOL SULFATE 125<br />
ISOPTIN SR 43<br />
ISOPTO CARP 82<br />
ISORDIL 43<br />
isosorbide dinitrate 43<br />
isosorbide mononitrate 43<br />
isotretinoin 108<br />
isradipine 43<br />
ISTALOL 82<br />
ISUPREL 32<br />
itraconazole 17<br />
IVEEGAM EN 102<br />
J<br />
J & J GAUZE NONSTERILE 8- 121<br />
JANUMET 94<br />
JANUMET 95<br />
JANUVIA 95<br />
JE-VAX 102<br />
K<br />
K-LOR HOSPITAL PACK 76<br />
K-LOR 76<br />
K-LYTE DS 76<br />
K-LYTE-ORANG 76<br />
K-LYTE/CL 76<br />
K-PHOS NO 2 76<br />
K-TABS 76<br />
KADIAN 60<br />
KALETRA 17<br />
kanamycin sulfate 17<br />
KAYEXALATE 76<br />
KEFLEX 17<br />
KEMADRIN 32<br />
KENALOG-10 95<br />
KENALOG-40 95<br />
KENALOG 108<br />
KEPIVANCE 108<br />
KEPPRA 60<br />
KERAFOAM 108<br />
KERALAC NAILSTIK 108<br />
KERALAC 108<br />
KERALYT 108<br />
KERLONE 43<br />
KEROL 108<br />
KETEK 17<br />
ketoconazole (topical) 108<br />
ketoconazole 17<br />
KETOPROFEN 125<br />
ketoprofen 60<br />
ketoprofen 61<br />
ketorolac tromethamine 61<br />
ketotifen fumarate (ophth) 82<br />
KINERET 117<br />
KLARON 108<br />
KLOR-CON 25 76<br />
KLOR-CON M 76<br />
KMART VALU PLUS INSULIN S 119<br />
KMART VALU PLUS INSULIN S 120<br />
KRISTALOSE 76<br />
KROGER PEN NEEDLES 29G 121<br />
KROGER PEN NEEDLES 31G 121<br />
KYTRIL 85<br />
KYTRIL 86<br />
L<br />
labetalol hcl 43<br />
LAC-HYDRIN 108<br />
LACRISERT 82<br />
lactated ringer's (irrigation) 76<br />
lactated ringer's 76<br />
lactic acid (ammonium lactate) 108<br />
LACTINOL 108<br />
lactulose (encephalopathy) 76<br />
lactulose 76<br />
LAMICTAL STARTER/TAKING C 61<br />
LAMICTAL STARTER/TAKING 61<br />
LAMICTAL 61<br />
LAMISIL 108<br />
LAMISIL 17<br />
lamotrigine 61<br />
LANOXICAPS 43<br />
LANOXIN 44<br />
LANTUS OPTICLIK 95<br />
LANTUS 95<br />
LARIAM 17<br />
LASIX 76<br />
leflunomide 117<br />
LESCOL XL 44<br />
LESCOL 44<br />
LETAIRIS 44<br />
leucovorin calcium 117<br />
LEUKERAN 27<br />
LEUKINE 36<br />
leuprolide acetate 27<br />
LEUSTATIN 27<br />
LEVACET 61<br />
LEVALL G 79<br />
LEVAMISOLE HCL 125<br />
LEVAQUIN 17<br />
LEVATOL 44<br />
LEVBID 32<br />
LEVEMIR FLEXPEN 95<br />
LEVEMIR 95<br />
LEVLEN CONTRACT PACK 95<br />
LEVLEN-28 95<br />
LEVLITE-28 95<br />
LEVO DROMORA 61<br />
LEVO-DROMORA 61<br />
levobunolol hcl 82<br />
levocarnitine (metabolic modifiers)<br />
117<br />
LEVODOPA 125<br />
levonorgestrel & eth estradiol 95<br />
levonorgestrel-eth estradiol<br />
(triphasic) 95<br />
levonorgestrel-ethinyl estradiol (91-<br />
day) 95<br />
levorphanol tartrate 61<br />
levothyroxine sodium 95<br />
LEVOXYL 95<br />
LEVSIN/SL 32<br />
LEVSIN 32<br />
LEVSINEX 32<br />
136
LEXAPRO 61<br />
LEXIVA 17<br />
LEXXEL 44<br />
LIALDA 86<br />
LIDAMANTLE 108<br />
lidocaine hcl (cardiac) 44<br />
lidocaine hcl (local anesth.) 101<br />
lidocaine hcl (mouth-throat) 82<br />
LIDOCAINE HCL MONOHYDRATE 125<br />
LIDOCAINE HCL 101<br />
lidocaine hcl 108<br />
lidocaine hcl 109<br />
LIDOCAINE HCL 125<br />
lidocaine-prilocaine 109<br />
lidocaine 109<br />
LIDODERM 109<br />
LIMBITROL DS 61<br />
LIMBITROL 61<br />
LINCOCIN 17<br />
lindane 109<br />
liothyronine sodium 95<br />
LIPITOR 44<br />
LIPOSYN II 76<br />
LIPOSYN III 76<br />
LIQUICET 61<br />
lisinopril & hydrochlorothiazide 44<br />
lisinopril 44<br />
lithium carbonate 61<br />
lithium citrate 61<br />
LITHOBID 61<br />
LITHOSTAT 77<br />
LO/OVRAL-28 95<br />
LOCOID LIPO 109<br />
LOESTRIN 1.5/30-21 95<br />
LOESTRIN 1/20-21 95<br />
LOESTRIN 24 FE 95<br />
LOESTRIN FE 1.5/30 95<br />
LOESTRIN FE 1/20 95<br />
LOFIBRA 44<br />
LOMOTIL 86<br />
loperamide hcl 86<br />
LOPID 44<br />
LOPRESSOR HCT 44<br />
LOPRESSOR 44<br />
LOPROX 109<br />
loratadine & pseudoephedrine 8<br />
loratadine 8<br />
LORCET 10/650 61<br />
LORCET PLUS 61<br />
LORTAB 2.5 61<br />
LORTAB 5 61<br />
LORTAB 7.5 61<br />
LORTAB 61<br />
LOTEMAX 82<br />
LOTENSIN HCT 44<br />
LOTENSIN 44<br />
LOTREL 44<br />
LOTREL 45<br />
LOTRISONE 109<br />
LOTRONEX 86<br />
lovastatin 45<br />
LOVAZA 45<br />
LOVENOX 36<br />
loxapine succinate 61<br />
LOXITANE 61<br />
LUCENTIS 82<br />
LUMIGAN 82<br />
LUNESTA 61<br />
LUNESTA 62<br />
LUPR DEP-PED INJ 27<br />
LUPRON 2 WEEK SUPPLY 27<br />
LUPRON 6-PK 27<br />
LUPRON DEPOT INJ 27<br />
LURIDE 117<br />
LUXIQ 109<br />
LYBREL 95<br />
LYNOX 62<br />
LYOFOAM A POLYURETHANE FO 121<br />
LYRICA 62<br />
LYSODREN 27<br />
M<br />
M-M-R II W/DILUENT 1 DOSE 102<br />
M-M-R II W/DILUENT 10 DOS 102<br />
M-R-VAX II 102<br />
MACROBID 17<br />
MACRODANTIN 17<br />
MACUGEN 82<br />
MAGNACET 62<br />
magnesium salicylate 62<br />
MALARONE 17<br />
MANDELAMINE 18<br />
MANDOL/D5W 18<br />
maprotiline hcl 62<br />
MARINOL 86<br />
MARPLAN 62<br />
MATULANE 27<br />
MAVIK 45<br />
MAXALT-MLT 62<br />
MAXALT 62<br />
MAXIDEX 82<br />
MAXIDONE 62<br />
MAXIFED-G 79<br />
MAXIFED 79<br />
MAXIPIME 18<br />
MAXITROL 82<br />
MAXZIDE-25 77<br />
MAXZIDE 77<br />
mebendazole 18<br />
MECLIZINE HCL MONOHYDRATE 125<br />
MECLIZINE HCL 125<br />
meclizine hcl 86<br />
MECLOFENAMATE SODIUM MONO<br />
125<br />
MECLOFENAMATE SODIUM 125<br />
meclofenamate sodium 62<br />
MEDI-JECTOR CHOICE 121<br />
MEDI-JECTOR VISION 121<br />
MEDICINE SHOPPE PEN NEEDL 121<br />
MEDROL DOSEPAK 96<br />
MEDROL 96<br />
medroxyprogesterone acetate<br />
(contraceptive) 96<br />
medroxyprogesterone acetate 96<br />
MEDROXYPROGESTERONE MICRO<br />
125<br />
MEFENAM ACID 62<br />
MEFENAMIC ACID 125<br />
mefloquine hcl 18<br />
MEFOXIN 18<br />
MEGACE ES 96<br />
MEGACE ORAL 27<br />
megestrol acetate 27<br />
MEIJER PEN NEEDLES 29GX12 121<br />
MEIJER PEN NEEDLES 31GX6M 121<br />
MEIJER PEN NEEDLES 31GX8M 121<br />
meloxicam 62<br />
MENACTRA 102<br />
MENEST 96<br />
MENOMUNE-A/C/Y/W-135 102<br />
MENOSTAR 96<br />
MENTAX 109<br />
meperidine hcl-sodium chloride 62<br />
MEPERIDINE HCL 125<br />
meperidine hcl 62<br />
MEPIVACAINE HCL 125<br />
MEPROBAMATE 62<br />
meprobamate 62<br />
MEPRON 18<br />
137
MERREM 18<br />
MERUVAX II W/DILUENT 1 DO 102<br />
MERUVAX II W/DILUENT 10 D 102<br />
MESALAMINE 125<br />
mesalamine 86<br />
mesna 117<br />
MESNEX 117<br />
MESTINON TIMESPAN 32<br />
MESTINON 32<br />
METADATE CD 62<br />
METADATE CD 63<br />
METADATE 62<br />
METAGLIP 96<br />
METAPROTERENOL SULFATE 125<br />
metaproterenol sulfate 32<br />
metformin hcl 96<br />
meth-bell-meth bl-phenyl sal 18<br />
METHACHOLINE CHLORIDE 125<br />
METHADONE HCL 125<br />
methadone hcl 63<br />
methazolamide 45<br />
methenamine hippurate 18<br />
methenamine mandelate-sodium<br />
biphosphate 18<br />
methenamine mandelate 18<br />
methenamine-hyosc-methylene bluesod<br />
phos-phenyl sal 18<br />
METHENAMINE 125<br />
METHERGINE 101<br />
methimazole 96<br />
methocarbamol 32<br />
METHOCEL K100M PREMIUM 125<br />
methotrexate sodium 27<br />
METHOXSALEN 125<br />
methscopolamine bromide 32<br />
methyl ethyl ketone 125<br />
METHYLCELLULOSE 125<br />
methyldopa & hydrochlorothiazide 45<br />
methyldopa 45<br />
METHYLDOPATE 45<br />
METHYLIN 63<br />
methylphenidate hcl 63<br />
methylprednisolone acetate 96<br />
methylprednisolone sod succ 96<br />
methylprednisolone 96<br />
methyltestosterone 96<br />
metipranolol 82<br />
METOCLOPRAMIDE HCL MONOHY 125<br />
METOCLOPRAMIDE HCL 125<br />
metolazone 77<br />
metoprolol & hydrochlorothiazide 45<br />
metoprolol succinate 45<br />
metoprolol tartrate 45<br />
METOPROLOL 45<br />
METRO IV 18<br />
METRO 109<br />
METROCREAM 109<br />
METROGEL VAGINAL 109<br />
METROGEL 109<br />
METROLOTION 109<br />
metronidazole (topical) 109<br />
METRONIDAZOLE BENZOATE 125<br />
metronidazole in nacl 18<br />
metronidazole vaginal 109<br />
metronidazole 18<br />
MEVACOR 45<br />
mexiletine hcl 45<br />
MEXILETINE 45<br />
MIACALCIN 96<br />
MICARDIS HCT 45<br />
MICARDIS 45<br />
MICONAZOLE 3 109<br />
miconazole nitrate vaginal 109<br />
MICONAZOLE NITRATE 125<br />
MICRO-K 77<br />
MICRONASE 96<br />
MICROZIDE 77<br />
midodrine hcl 32<br />
MIGERGOT 63<br />
MIGRANAL 63<br />
MINIPRESS 45<br />
MINOCIN 18<br />
MINOCYCLINE HCL 125<br />
minocycline hcl 18<br />
minoxidil 45<br />
MINTEZOL 18<br />
MIOSTAT 82<br />
MIRAPEX 63<br />
MIRASORB SONGES 2" X 2" 121<br />
MIRASORB SPONGES 2" X 2" 121<br />
MIRCETTE 96<br />
MIRENA 96<br />
mirtazapine 63<br />
misoprostol 86<br />
mitomycin 27<br />
mitoxantrone hcl 27<br />
MOBAN 63<br />
MOBIC 63<br />
moexipril hcl 45<br />
moexipril-hydrochlorothiazide 46<br />
mometasone furoate 109<br />
MONODOX 18<br />
MONOJECT INSUIN SYRINGE R 119<br />
MONOJECT INSULIN SYRINGE/ 119<br />
MONOKET 46<br />
MONOPRIL HCT 46<br />
MONOPRIL 46<br />
MONUROL 18<br />
MORPHINE SULFATE IN DEXTR 64<br />
morphine sulfate in dextrose 63<br />
MORPHINE SULFATE 125<br />
morphine sulfate 63<br />
morphine sulfate 64<br />
MOTRIN 64<br />
MOVIPREP 86<br />
MS CONTIN 64<br />
MUCOMYST-10 79<br />
MUMPSVAX W/DILUENT 1 DOSE 102<br />
MUMPSVAX W/DILUENT 10 DOS 102<br />
mupirocin 109<br />
MUSTARGEN 27<br />
MYAMBUTOL 18<br />
MYCAMINE 18<br />
MYCELEX 109<br />
MYCOBUTIN 19<br />
MYCOSTATIN 109<br />
MYDRIACYL 82<br />
MYFORTIC 117<br />
MYLERAN 27<br />
MYLOTARG 27<br />
MYNATAL 114<br />
MYOCHRYSINE 88<br />
MYOZYME 79<br />
MYSOLINE 64<br />
MYTELASE 32<br />
N<br />
nabumetone 64<br />
nadolol 46<br />
nafcillin sodium 19<br />
NAFTIN-MP 109<br />
NAFTIN 109<br />
NAGLAZYME 79<br />
nalbuphine hcl 64<br />
NALFON 64<br />
NALIDIXIC ACID 125<br />
NALLPEN ISO-OSMOTIC IN DE 19<br />
138
naloxone hcl 64<br />
naltrexone hcl 64<br />
NAMENDA TITRATION 64<br />
NAMENDA 64<br />
naphazoline hcl 82<br />
NAPRELAN 64<br />
NAPROSYN 64<br />
NAPROXEN SODIUM 125<br />
naproxen sodium 64<br />
NAPROXEN 125<br />
naproxen 64<br />
naproxen 65<br />
NARDIL 65<br />
NASACORT AQ 82<br />
NASAREL 82<br />
NASATAB LA 79<br />
NASCOBAL 115<br />
NASONEX 82<br />
NASOP12 32<br />
NATACYN 82<br />
NAVANE 65<br />
NAVELBINE 27<br />
NEBUPENT 19<br />
NECON 10/11-28 96<br />
nefazodone hcl 65<br />
NEO-FRADIN 19<br />
NEO-RX 125<br />
NEOMYCIN SULFATE 125<br />
neomycin sulfate 19<br />
neomycin-bacitracin zn-polymyxin 82<br />
neomycin-polymy-dexameth 82<br />
neomycin-polymy-gramicid 82<br />
neomycin-polymyxin-hc (ophth) 82<br />
neomycin-polymyxin-hc (otic) 82<br />
NEOPROFEN 65<br />
NEORAL 117<br />
NEOSPORIN 82<br />
neostigmine methylsulfate 32<br />
NEPHRAMINE 77<br />
NEULASTA 36<br />
NEUMEGA 36<br />
NEUPOGEN 36<br />
NEUPRO 65<br />
NEURONTIN 65<br />
NEUTREXIN 19<br />
NEVANAC 82<br />
NEXAVAR 28<br />
NEXCARE HIGH PERFORMANCE 121<br />
NEXIUM I.V. 86<br />
niacin 115<br />
NIASPAN 46<br />
nicardipine hcl 46<br />
NICOTROL INHALER 32<br />
NICOTROL NS 32<br />
nifedipine 46<br />
NILANDRON 28<br />
nimodipine 46<br />
NIMOTOP 46<br />
NIPENT 28<br />
NITRO-DUR 46<br />
NITROFURANTOIN MACROCRYST 126<br />
nitrofurantoin macrocrystal 19<br />
nitrofurantoin monohyd macro 19<br />
nitroglycerin 46<br />
NITROLINGUAL PUMPSPRAY 46<br />
NITROSTAT 46<br />
NITROSTAT 47<br />
nizatidine 86<br />
NIZORAL 109<br />
NIZORAL 19<br />
NOR-QD 96<br />
NORCO 65<br />
NORDETTE-28 96<br />
NORDITROPIN CARTRIDGE 96<br />
NORDITROPIN CARTRIDGE 97<br />
NORDITROPIN NORDIFLEX PEN 96<br />
NORDITROPIN NORDIFLEX PEN 97<br />
NORDITROPIN NORDIFLEX 96<br />
norethin acet & estrad-fe 97<br />
norethindrone & eth estradiol 97<br />
norethindrone & mestranol 97<br />
norethindrone (contraceptive) 97<br />
norethindrone acet & eth estra 97<br />
norethindrone acetate 97<br />
norethindrone-eth estradiol (triphasic)<br />
97<br />
NORFLEX 32<br />
norgestimate-ethinyl estradiol<br />
(triphasic) 97<br />
norgestimate-ethinyl estradiol 97<br />
norgestrel & ethinyl estradiol 97<br />
NORINYL 1+35 97<br />
NORINYL 1+50 97<br />
NORITATE 109<br />
NOROXIN 19<br />
NORPACE 47<br />
NORPRAMIN 65<br />
NORTRIPTYLINE HCL 126<br />
NORVASC 47<br />
NORVIR 19<br />
NOVANTRONE 28<br />
NOVASAL 65<br />
NOVOFINE 30 121<br />
NOVOFINE 31 121<br />
NOVOLIN 70/30 INNOLET 97<br />
NOVOLIN 70/30 PENFILL 97<br />
NOVOLIN 70/30 97<br />
NOVOLIN N INNOLET 97<br />
NOVOLIN N U-100 PENFILL 97<br />
NOVOLIN N 97<br />
NOVOLIN R INNOLET 97<br />
NOVOLIN R U-100 PENFILL 97<br />
NOVOLIN R 97<br />
NOVOLOG FLEXPEN 97<br />
NOVOLOG MIX 70/30 PENFILL 97<br />
NOVOLOG MIX 70/30 PREFILL 97<br />
NOVOLOG MIX 70/30 97<br />
NOVOLOG PENFILL 97<br />
NOVOLOG 97<br />
NOVOPEN 3 INSULIN DELIVER 121<br />
NOVOPEN 3 PENMATE 121<br />
NOVOPEN JR (GREEN) 121<br />
NOVOPEN JR (YELLOW) 121<br />
NULEV 32<br />
NULYTELY 86<br />
NUMOISYN 82<br />
NUMORPHAN 65<br />
NUOX 109<br />
NUTROPIN AQ 97<br />
NUTROPIN 97<br />
NUVARING 97<br />
nystatin (mouth-throat) 19<br />
nystatin (topical) 109<br />
nystatin vaginal 109<br />
nystatin-triamcinolone 109<br />
NYSTATIN 109<br />
nystatin 19<br />
O<br />
OCL 86<br />
OCTAGAM 102<br />
octreotide acetate 117<br />
OCUFEN 82<br />
OCUFLOX 82<br />
ofloxacin (ophth) 82<br />
ofloxacin 19<br />
OGEN 97<br />
139
OLUX 109<br />
omeprazole 86<br />
OMNI-PAC 19<br />
OMNICEF 19<br />
OMNITROPE 97<br />
ONCASPAR 28<br />
ondansetron hcl and dextrose 86<br />
ONDANSETRON HCL 86<br />
ondansetron hcl 86<br />
ONDANSETRON 86<br />
ondansetron 86<br />
ONTAK 28<br />
OPANA ER 65<br />
OPANA ER 66<br />
OPANA 65<br />
OPHTHETIC 82<br />
opium tincture 87<br />
OPTIPRANOLOL 83<br />
OPTISON 73<br />
OPTIVAR 83<br />
ORACEA 19<br />
ORACIT 77<br />
ORAMORPH SR 66<br />
ORAP 66<br />
ORAPRED ODT 97<br />
ORAPRED 97<br />
ORENCIA 117<br />
ORFADIN 117<br />
ORPHENADRINE CITRATE 126<br />
orphenadrine citrate 32<br />
orphenadrine w/ aspirin & caff 66<br />
ORTHO EVRA 97<br />
ORTHO MICRONOR 97<br />
ORTHO TRI-CYCLEN LO 98<br />
ORTHO TRI-CYCLEN 97<br />
ORTHO-CEPT-28 98<br />
ORTHO-CYCLEN-28 98<br />
ORTHO-NOVUM 1/35-28 98<br />
ORTHO-NOVUM 1/50-28 98<br />
ORTHO-NOVUM 7/7/7-28 98<br />
ORTHOCLONE OKT3 117<br />
OVACE WASH 109<br />
OVCON-35 98<br />
OVCON-50 28 98<br />
OVIDE 110<br />
oxacillin sodium 19<br />
OXACILLIN 19<br />
OXANDRIN 98<br />
oxandrolone 98<br />
OXISTAT 110<br />
OXSORALEN-UL 110<br />
OXSORALEN 110<br />
OXYBUTININ CHLORIDE 126<br />
oxybutynin chloride 113<br />
oxybutynin chloride 114<br />
OXYCODONE HCL 126<br />
oxycodone hcl 66<br />
oxycodone w/ acetaminophen 66<br />
oxycodone w/ aspirin 66<br />
OXYCONTIN 66<br />
OXYIR 66<br />
OXYTETRACYCLINE HCL 126<br />
oxytocin 101<br />
OXYTROL 114<br />
P<br />
PACERONE 47<br />
paclitaxel 28<br />
PAMELOR 66<br />
pamidronate disodium 117<br />
PAMINE FORTE 32<br />
PAMINE 32<br />
PANAFIL 110<br />
PANCREASE MT 10 87<br />
PANCREASE MT 16 87<br />
PANCREASE MT 20 87<br />
PANCREASE MT 4 87<br />
PANCRECARB MS-16 87<br />
PANDEL 110<br />
PANGESTYME EC 87<br />
PANGLOBULIN 102<br />
PANGLOBULIN 103<br />
PANLOR DC 66<br />
PANLOR SS 66<br />
PANRETIN 110<br />
papain-urea-chlorophyllin 103<br />
papain-urea 110<br />
papaverine hcl 47<br />
PARAFON FORTE DSC 32<br />
PARAPLATIN 28<br />
paregoric 87<br />
parenteral electrolytes 73<br />
PARLODEL 117<br />
PARNATE 66<br />
paromomycin sulfate 19<br />
paroxetine hcl 66<br />
PASER 19<br />
PATADAY 83<br />
PAXIL CR 67<br />
PAXIL 66<br />
PAXIL 67<br />
PC UNIFINE PENTIPS 29GX1/ 121<br />
PC UNIFINE PENTIPS 31GX6M 122<br />
PC UNIFINE PENTIPS 31GX8M 122<br />
PCCA SORBITOL LOLLIPOP BA 126<br />
PCE 19<br />
PEDIAPRED 98<br />
PEDIARIX 103<br />
pediatric multivitamins w/fl 114<br />
pediatric vitamins acd w/ fluoride<br />
114<br />
PEDIAZOLE 19<br />
PEDIOTIC 83<br />
PEDIOX-S 8<br />
PEDVAX HIB 103<br />
peg 3350-kcl-sod bicarb-sod<br />
chloride-sod sulfate 87<br />
peg 3350-potassium chloride-sod<br />
bicarbonate-sod chloride 87<br />
PEG 400 MONOSTEARATE 126<br />
PEG-INTRON 19<br />
PEG-INTRON 20<br />
PEGANONE 67<br />
PEGASYS 20<br />
PEN G PROC 20<br />
PEN NEEDLES 29GX1/2" 121<br />
PEN NEEDLES 31G X 1/4" SH 121<br />
PEN NEEDLES 31GX5/16" 121<br />
PENICILLAMINE 126<br />
penicillin g pot in dextrose 20<br />
penicillin g potassium 20<br />
penicillin g sodium 20<br />
penicillin v potassium 20<br />
PENLAC 110<br />
PENTAM 20<br />
pentamidine isethionate 20<br />
PENTASA 87<br />
pentazocine w/ apap 67<br />
pentazocine w/ naloxone 67<br />
pentetate calcium trisodium 88<br />
pentetate zinc trisodium 88<br />
pentoxifylline 36<br />
PEPCID I.V. 87<br />
PEPCID 87<br />
PERANEX HC 110<br />
PERCOCET 67<br />
PERCODAN 67<br />
PERIDEX 83<br />
140
peritoneal dialysis solutions 73<br />
PERLOXX 67<br />
permethrin 110<br />
perphenazine-amitriptyline 67<br />
perphenazine 67<br />
PERSANTINE 47<br />
PEXEVA 67<br />
PFIZERPEN G 20<br />
phenazopyridine hcl 110<br />
phenazopyridine-butabarbitalhyoscyamine<br />
110<br />
PHENERGAN 8<br />
PHENYTEK 67<br />
phenytoin sodium extended 67<br />
phenytoin sodium 67<br />
phenytoin 67<br />
PHOSLO 77<br />
PHOSPHOLINE 83<br />
PHOTOFRIN 28<br />
PHYSIOSOL IRRIGATION PH 7 77<br />
pilocarpine hcl (oral) 32<br />
PILOCARPINE HCL 126<br />
pilocarpine hcl 83<br />
PILOPINE HS 83<br />
pindolol 47<br />
piperacillin sodium-d5w 20<br />
piperacillin sodium 20<br />
piroxicam 67<br />
PITOCIN 101<br />
PLAN B 98<br />
PLAQUENIL 20<br />
PLATINOL AQ 28<br />
PLAVIX 36<br />
PLENAXIS 28<br />
PLENDIL 47<br />
PLETAL 36<br />
PLEXION CLEANSER 110<br />
PLEXION CLEANSING CLOTH 110<br />
PLEXION SCT 110<br />
PLEXION TS 110<br />
podofilox 110<br />
POLY TAN 8<br />
POLY-PRED 83<br />
POLYCITRA-K CRYSTALS 77<br />
POLYCITRA-K 77<br />
POLYCITRA-LC 77<br />
POLYCITRA 77<br />
POLYETHYLENE GLYCOL 1000 126<br />
polyethylene glycol 3350 87<br />
POLYGAM S/D 103<br />
prenatal without a vit w/ fe fumarate<br />
polymyxin b sulfate 20<br />
-folic acid 114<br />
polymyxin b-trimethoprim 83 PREVACID I.V 87<br />
POLYOXYL 40 STEARATE 126 PREVACID NAPRAPAC 67<br />
POLYTRIM 83<br />
PREVACID SOLUTAB 87<br />
PONSTEL 67<br />
PREVACID 87<br />
pot & sod citrates w/citric ac 77 PREVIDENT 5000 PLUS 117<br />
potassium bicarb & chloride 77 PREVIDENT 117<br />
potassium bicarbonate 77<br />
PREVPAC 87<br />
potassium chloride microencapsulated PREZISTA 20<br />
crystals cr 77<br />
PRIFTIN 20<br />
potassium chloride 122<br />
PRILOSEC OTC 87<br />
POTASSIUM CHLORIDE 77<br />
PRILOSEC 87<br />
potassium chloride 77<br />
PRIM 20<br />
potassium citrate (alkalinizer) 77 primaquine phosphate 20<br />
potassium citrate-citric acid 77 PRIMAXIN I.M. 20<br />
PRAMOTIC 83<br />
PRIMAXIN IV 20<br />
pramoxine-acetic acid 83<br />
primidone 67<br />
pramoxine-chloroxylenol 83<br />
PRINIVIL 47<br />
PRANDIN 98<br />
PRINZIDE 47<br />
PRAVACHOL 47<br />
PRO-BANTHINE 32<br />
pravastatin sodium 47<br />
PROAIR HFA 32<br />
prazosin hcl 47<br />
PROAMATINE 32<br />
PRECARE 115<br />
probenecid 77<br />
PRECOSE 98<br />
procainamide hcl 47<br />
PRED FORTE 83<br />
PROCALAMINE 77<br />
PRED MILD 83<br />
PROCANBID 47<br />
PRED-G S.O.P. 83<br />
PROCARDIA XL 47<br />
PRED-G 83<br />
PROCARDIA 47<br />
prednicarbate 110<br />
PROCHIEVE 99<br />
prednisolone acetate (ophth) 83 prochlorperazine edisylate 67<br />
prednisolone sodium phosphate PROCHLORPERAZINE MALEATE 126<br />
(ophth) 83<br />
prochlorperazine maleate 67<br />
prednisolone sodium phosphate 98 prochlorperazine 67<br />
prednisolone 98<br />
PROCRIT 36<br />
PREDNISONE 98<br />
PROCTOCORT 110<br />
prednisone 98<br />
PROFEN II 79<br />
PREFERRED PLUS UNIFINE PE 122 PROGRAF 117<br />
PREFEST 98<br />
PROLASTIN 118<br />
PREGNENOLONE MICRONIZED 126 PROLEUKIN 28<br />
PRELONE 98<br />
PROMETHAZINE HCL 126<br />
PREMARIN W/APPLICATOR 98 promethazine hcl 8<br />
PREMARIN 98<br />
PROMETRIUM 99<br />
PREMASOL 77<br />
PRONESTYL 47<br />
PREMPHASE 98<br />
PRONESTYL 48<br />
PREMPRO 99<br />
propafenone hcl 48<br />
prenatal multivit-min w/fe-fa 114 PROPANTHELINE BROMIDE 126<br />
proparacaine hcl 83<br />
PROPINE 83<br />
141
propoxyphene hcl 67<br />
propoxyphene-n w/ apap 67<br />
propoxyphene-n w/ apap 68<br />
propranolol & hydrochlorothiazide 48<br />
propranolol hcl 48<br />
propylthiouracil 99<br />
PROQUAD 103<br />
PROQUIN XR 20<br />
PROSCAR 118<br />
PROSED/DS (ATROPINE FREE) 20<br />
PROSTASCINT 118<br />
PROSTIGMIN 33<br />
PROTONIX 87<br />
PROTOPIC 110<br />
PROVENTIL HFA 33<br />
PROVENTIL 33<br />
PROVERA 99<br />
PROVIGIL 68<br />
PROZAC WEEKL 68<br />
PROZAC 68<br />
PSEUDOEPHEDRINE HCL/GUAIF 79<br />
pseudoephedrine-guaifenesin 79<br />
pseudoephedrine-guaifenesin 80<br />
PSORCON E 110<br />
PSORIATEC 110<br />
PUBLIX PEN NEEDLE 29GX12M 121<br />
PUBLIX PEN NEEDLE 31G/8MM 121<br />
PULMICORT FLEXHALER 99<br />
PULMICORT 99<br />
PULMOZYME 79<br />
PURINETHOL 28<br />
PYLERA 20<br />
pyrazinamide 20<br />
PYRIDIUM PLUS 110<br />
PYRIDIUM 110<br />
pyridostigmine bromide 33<br />
PYRLEX 8<br />
Q<br />
QC INSULIN SYRINGE 1ML/29 119<br />
QC STERILE PADS 2"X2" 121<br />
QUADRAMET 118<br />
QUALAQUIN 20<br />
QUESTRAN LIGHT 48<br />
QUESTRAN 48<br />
quinapril hcl 48<br />
quinapril-hydrochlorothiazide 48<br />
QUINERVA 20<br />
quinidine gluconate 48<br />
QUIXIN 83<br />
QVAR 99<br />
R<br />
RA STERILE PADS 2"X2" 121<br />
RABAVERT 103<br />
RANEXA 48<br />
RANICLOR 20<br />
ranitidine hcl 87<br />
RAPAMUNE 118<br />
RAPIFLUX 68<br />
RAPTIVA 110<br />
RAZADYNE ER 33<br />
RAZADYNE 33<br />
REBETOL 20<br />
REBIF TITRATION PACK 118<br />
REBIF 118<br />
RECLAST 118<br />
RECOMBIVA HB 103<br />
RECOMBIVA-HB 103<br />
RECOMBIVAX HB 103<br />
REFLUDAN 36<br />
REGLAN 87<br />
REGONOL 33<br />
REGRANEX 110<br />
RELAMINE 118<br />
RELENZA DISKHALER 20<br />
RELION 70/30 INNOLET 99<br />
RELION 70/30 99<br />
RELION N INNOLET 99<br />
RELION N 99<br />
RELION PEN NEEDLE 29GX12M 121<br />
RELION PEN NEEDLE 31GX8MM 121<br />
RELION R 99<br />
RELPAX 68<br />
REMERON SLTB 68<br />
REMERON 68<br />
REMICADE 118<br />
RENAGEL 77<br />
RENAMIN 77<br />
REPREXAIN 68<br />
REQUIP 68<br />
RESCRIPTOR 20<br />
reserpine 48<br />
RESTASIS 83<br />
RETIN-A MICR 110<br />
RETIN-A MICRO PUMP 110<br />
RETIN-A 110<br />
RETINOIC ACID-ALL TRANS 126<br />
RETISERT 83<br />
RETROVIR 20<br />
RETROVIR 21<br />
REVATIO 48<br />
REVEX 68<br />
REVIA 68<br />
REVLIMID 118<br />
REYATAZ 21<br />
RHEUMATREX 28<br />
RHINOCORT AQUA 83<br />
ribavirin (hepatitis c) 21<br />
RID-A-PAIN 68<br />
RIDAURA 88<br />
RIFADIN 21<br />
RIFAMATE 21<br />
rifampin 21<br />
RIFATER 21<br />
RILUTEK 68<br />
rimantadine hydrochloride 21<br />
RIMANTALIST 21<br />
RIMSO-50 118<br />
ringer's irrigation 77<br />
RIOMET 99<br />
RISPERDAL M 68<br />
RISPERDAL 68<br />
RITALIN LA 69<br />
RITALIN SR 69<br />
RITALIN 68<br />
RITALIN 69<br />
RITUXAN 28<br />
ROBAXIN-750 33<br />
ROBAXIN 33<br />
ROBINUL FORT 33<br />
ROBINUL 33<br />
ROCALTROL 115<br />
ROCEPHIN IN ISO-OSMOTIC D 21<br />
ROCEPHIN 21<br />
ROFERON-A 28<br />
ROSAC WASH 110<br />
ROSAC 110<br />
ROSULA CLARIFYING WASH 110<br />
ROSULA NS 110<br />
ROSULA 110<br />
ROTATEQ 103<br />
ROWASA 87<br />
ROXANOL 69<br />
ROXICODONE 69<br />
ROZEREM 69<br />
ROZEX 111<br />
RYTHMOL SR 48<br />
RYTHMOL 48<br />
142
S<br />
SAIZEN 99<br />
SAL-TROPINE 33<br />
SALAGEN 33<br />
SALEX 111<br />
salicylic acid 111<br />
SALICYLIC ACID 126<br />
saline w/ benzyl alcohol 78<br />
saline, bacteriostatic 77<br />
salsalate 69<br />
SANCTURA 114<br />
SANDIMMUNE 118<br />
SANDOSTATIN LAR DEPOT 118<br />
SANDOSTATIN 118<br />
SANTYL 111<br />
SARAFEM 69<br />
SCOPACE 87<br />
SCOPOLAMINE HBR 126<br />
scopolamine hbr 33<br />
SCOPOLAMINE HYDROBROMIDE 126<br />
scopolamine hydrobromide 87<br />
SEASONALE 99<br />
SEB-PREV 111<br />
SECTRAL 48<br />
SELEGILINE HCL 126<br />
selegiline hcl 69<br />
selenium sulfide-pyrithione zinc in<br />
urea vehicle 111<br />
selenium sulfide 111<br />
SELSEB 111<br />
SELSUN SHAMPOO 111<br />
SEMPREX-D 8<br />
SENSIPAR 118<br />
SENTRADINE 87<br />
SENTROXATINE 69<br />
SEPTRA DS 21<br />
SEPTRA 21<br />
SEREVENT DISKUS 33<br />
SEROMYCIN 21<br />
SEROQUEL XR 69<br />
SEROQUEL 69<br />
SEROSTIM 99<br />
sertraline hcl 69<br />
SHOHL'S SOLUTION MODIFIED 78<br />
SILVADENE 111<br />
SILVER NITRATE 126<br />
silver nitrate 83<br />
silver sulfadiazine 111<br />
simvastatin 48<br />
SINEMET CR 69<br />
SINEMET 69<br />
SINGULAIR 80<br />
SKELAXIN 33<br />
SKELID 118<br />
SM GAUZE PADS 121<br />
SOD EDECRIN 78<br />
sodium chloride (gu irrigant) 78<br />
SODIUM CHLORIDE 78<br />
sodium chloride 78<br />
sodium citrate & citric acid 78<br />
sodium fluoride (dental) 118<br />
sodium fluoride 118<br />
sodium nitrite 88<br />
sodium polystyrene sulfonate 78<br />
sodium thiosulfate-salicylic acid 111<br />
sodium thiosulfate 88<br />
sodium thiosulfate 89<br />
SOLAGE 111<br />
SOLARAZE 111<br />
SOLIRIS 118<br />
SOLODYN 21<br />
SOLTAMOX 28<br />
SOLU-CORTEF 99<br />
SOLU-MEDROL 99<br />
SOMA COMPOUND/CODEINE 33<br />
SOMA COMPOUND 33<br />
SOMA 33<br />
SOMAVERT 100<br />
SOMAVERT 99<br />
SONATA 69<br />
SORBITOL 126<br />
SORIATANE 118<br />
sotalol hcl (afib/afl) 48<br />
sotalol hcl (afib/afl) 49<br />
sotalol hcl 49<br />
SPECTRACEF 21<br />
SPIRIVA HANDIHALER 33<br />
spironolactone & hydrochlorothiazide<br />
49<br />
spironolactone 49<br />
SPORANOX PULSEPAK 21<br />
SPORANOX 21<br />
SPRYCEL 28<br />
STADOL 69<br />
STALEVO 100 69<br />
STALEVO 150 69<br />
STALEVO 50 69<br />
STERAPRED 12 DAY 100<br />
STERAPRED DS 12 DAY 100<br />
STERAPRED DS 100<br />
STERAPRED 100<br />
STERI-PAD STERILE PADS 10 121<br />
STERI-PAD STERILE PADS 25 121<br />
STERILE DILUENT FOR FLOLA 126<br />
STERILE GAUZE PADS 2"X2" 121<br />
STERILE PADS 2"X2" 121<br />
STIMATE 100<br />
STRATTERA 69<br />
STRATTERA 70<br />
streptomycin sulfate 21<br />
STRIANT 100<br />
STROMECTOL 21<br />
SUBLIMAZE 70<br />
SUBOXONE 70<br />
SUBUTEX 70<br />
SUCRAID 79<br />
SUCRALFATE 126<br />
SUCRALFATE 87<br />
sucralfate 87<br />
SUFENTA 70<br />
sufentanil citrate 70<br />
SULAR 49<br />
SULFACET SOD 83<br />
SULFACET-R 111<br />
sulfacetamide sod-prednisolone 83<br />
sulfacetamide sodium (acne) 111<br />
sulfacetamide sodium (ophth) 83<br />
sulfacetamide sodium w/ sulfur 111<br />
sulfacetamide sodium-sulfur in urea<br />
vehicle 111<br />
sulfacetamide sodium-sulfur w/<br />
sunscreens 103<br />
sulfacetamide sodium-urea 111<br />
sulfacetamide sodium 111<br />
SULFACETAMIDE SODIUM 126<br />
sulfadiazine 21<br />
sulfamethoxazole-trimethoprim 21<br />
SULFAMYLON 111<br />
SULFASALAZINE 126<br />
sulfasalazine 21<br />
sulfasalazine 22<br />
SULFOXYL REGULAR 111<br />
SULFOXYL STRONG 111<br />
sulindac 70<br />
SUPPRELIN LA 28<br />
SUPRAX 22<br />
143
SUSTIVA 22<br />
SUTENT 28<br />
SYMBICORT 100<br />
SYMBYAX 70<br />
SYMLIN 100<br />
SYNAGIS 22<br />
SYNALGOS-DC 70<br />
SYNAREL 100<br />
SYNERCID 22<br />
SYNTHROID 100<br />
SYPRINE 89<br />
T<br />
TALACEN 70<br />
TALADINE 87<br />
TALADINE 88<br />
TALWIN NX 70<br />
TALWIN 70<br />
TAMBOCOR 49<br />
TAMIFLU 22<br />
tamoxifen citrate 28<br />
TAPAZOLE 100<br />
TARCEVA 28<br />
TARGRETIN 111<br />
TARGRETIN 28<br />
TARKA 49<br />
TASMAR 70<br />
TAXOL 28<br />
TAXOTERE 28<br />
TAZICEF 22<br />
TAZORAC 111<br />
TE ANATOXAL BERNA 103<br />
TEGADERM FOAM DRESSING 2" 121<br />
TEGRETOL XR 70<br />
TEGRETOL 70<br />
TEKTURNA 49<br />
TEMODAR 28<br />
TEMOVATE E 111<br />
TEMOVATE 111<br />
TENEX 49<br />
TENORETIC 100 49<br />
TENORETIC 50 49<br />
TENORMIN 49<br />
TERAZOL 3 111<br />
TERAZOL 7 111<br />
terazosin hcl 49<br />
terbinafine hcl 22<br />
terbutaline sulfate 33<br />
terconazole vaginal 111<br />
TERUMO INSULIN SYRINGE/1M 120<br />
TESLAC 29<br />
TESTIM 100<br />
testosterone cypionate 100<br />
testosterone enanthate 100<br />
TESTRED 100<br />
TETANUS TOXOID ADSORBED 103<br />
tetanus toxoid fluid 103<br />
TETANUS/DIPHTHERIA TOXOID 103<br />
tetracaine hcl (ophth) 83<br />
tetracycline hcl 22<br />
TEV-TROPIN 100<br />
TEVETEN HCT 49<br />
TEVETEN 49<br />
TEXACORT 112<br />
THALOMID 118<br />
THALOMID 119<br />
THEO-24 114<br />
THEO 114<br />
theophylline sodium glycinate-gg 114<br />
theophylline-guaifenesin 114<br />
theophylline 114<br />
THERABENZAPRINE-60 33<br />
THERABENZAPRINE-90 33<br />
THERACODOPHEN-325 70<br />
THERACODOPHEN-650 70<br />
THERACODOPHEN-LOW-90 70<br />
THERACYS 103<br />
THERAFELDAMINE 70<br />
THERAPENTIN-60 70<br />
THERAPENTIN-90 70<br />
THERAPROFEN-60 70<br />
THERAPROFEN-90 70<br />
THERAPROXEN-90 70<br />
THERAPROXEN 70<br />
THERATRAMADOL-60 70<br />
THERATRAMADOL-90 70<br />
THINPRO INSULIN SYRINGE/0 119<br />
THINPRO INSULIN SYRINGE/1 120<br />
thioguanine 29<br />
thioridazine hcl 70<br />
thiotepa 29<br />
thiothixene 70<br />
thiothixene 71<br />
THORAZINE 71<br />
THROMBI-GEL 100 36<br />
THROMBI-GEL 10 36<br />
THROMBI-GEL 40 36<br />
THROMBI-PAD 36<br />
thyroid 100<br />
THYROLAR-1/2 100<br />
THYROLAR-1/4 100<br />
THYROLAR-1 100<br />
THYROLAR-2 100<br />
THYROLAR-3 100<br />
TIAZAC 49<br />
TICE BCG 103<br />
TICLID 36<br />
ticlopidine hcl 36<br />
TIKOSYN 49<br />
TILADE 80<br />
TIMENTIN 22<br />
TIMOLIDE 10/25 49<br />
timolol maleate (ophth) 83<br />
timolol maleate 49<br />
timolol maleate 50<br />
TIMOPTIC OCU 84<br />
TIMOPTIC-XE 84<br />
TIMOPTIC 83<br />
TINDAMAX 22<br />
TISSEEL 36<br />
tizanidine hcl 33<br />
TOBI 22<br />
TOBRADEX 84<br />
tobramycin sulfate (ophth) 84<br />
tobramycin sulfate in saline 22<br />
tobramycin sulfate 22<br />
TOBREX 84<br />
TOFRANIL-PM 71<br />
TOFRANIL 71<br />
tolazamide 100<br />
tolbutamide 101<br />
tolmetin sodium 71<br />
TOPAMAX SPRINKLE 71<br />
TOPAMAX 71<br />
TOPICORT LP 112<br />
TOPICORT 112<br />
TOPROL XL 50<br />
TORISEL 29<br />
torsemide 78<br />
TRACLEER 50<br />
tramadol hcl 71<br />
tramadol-acetaminophen 71<br />
TRANDATE IV 50<br />
TRANDATE 50<br />
trandolapril 50<br />
TRANSDERM-SC DIS 88<br />
tranylcypromine sulfate 71<br />
144
TRAVASOL 2.75%/DEXTROSE 5 78<br />
TRAVASOL 4.25%/DEXTROSE 1 78<br />
TRAVASOL 4.25%/DEXTROSE 2 78<br />
TRAVASOL 4.25%/DEXTROSE 5 78<br />
TRAVASOL 5.5%/DEXTROSE 10 78<br />
TRAVASOL 5.5%/DEXTROSE 20 78<br />
TRAVASOL 5.5%/ELECTROLYTE 78<br />
TRAVASOL 8.5%/DEXTROSE 10 78<br />
TRAVASOL 8.5%/DEXTROSE 20 78<br />
TRAVASOL 8.5%/DEXTROSE 50 78<br />
TRAVASOL 78<br />
TRAVATAN Z 84<br />
TRAVATAN 84<br />
TRAZAMINE 71<br />
TRAZODONE HCL 126<br />
trazodone hcl 71<br />
TRECATOR 22<br />
TRELSTAR DEP 29<br />
TRELSTAR LA 29<br />
TRENTAL 36<br />
tretinoin (chemotherapy) 29<br />
tretinoin 112<br />
TRETINOIN 126<br />
TREXALL 29<br />
TRI-LEVLEN CONTRACT PACK 101<br />
TRI-LEVLEN 101<br />
TRI-NORINYL 28 101<br />
triamcinolone acetonide (mouth) 112<br />
triamcinolone acetonide (topical) 112<br />
TRIAMCINOLONE ACETONIDE 126<br />
triamterene & hydrochlorothiazide 78<br />
TRIAZ CLEANS 112<br />
TRIAZ 112<br />
TRICOR 50<br />
trifluoperazine hcl 71<br />
trifluridine 84<br />
TRIGLIDE 50<br />
trihexyphenidyl hcl 33<br />
TRIHIBIT 103<br />
TRILEPTAL 71<br />
trimethoprim 22<br />
TRIMIPRAMINE MALEATE 126<br />
trimipramine maleate 71<br />
TRIOSTAT 101<br />
TRIPEDIA 103<br />
TRIPHASIL 28 101<br />
TRISENOX 29<br />
TRIZIVIR 22<br />
TROPHAMINE 78<br />
TRUSOPT 84<br />
TRUVADA 22<br />
TUSNEL PEDIATRIC 80<br />
TWINJECT 33<br />
TWINRIX 103<br />
TYGACIL 22<br />
TYKERB 29<br />
TYLENOL/CODEINE #3 71<br />
TYLENOL/CODEINE #4 71<br />
TYLOX 71<br />
TYPHIM VI 103<br />
TYZEKA 22<br />
U<br />
ULTICARE MINI PEN NEEDLES 121<br />
ULTICARE ORIGINAL PEN NEE 121<br />
ULTICARE SHORT PEN NEEDLE 121<br />
ULTILET PEN NEEDLE 121<br />
ULTRABAG/DIANEAL LOW CALC 78<br />
ULTRABAG/DIANEAL PD-2/1.5 78<br />
ULTRABAG/DIANEAL PD-2/2.5 78<br />
ULTRABAG/DIANEAL PD-2/4.2 78<br />
ULTRACET 71<br />
ULTRAM ER 71<br />
ULTRAM 71<br />
ULTRASE MT 20 88<br />
ULTRAVATE 112<br />
UMECTA NAIL 112<br />
UMECTA PD 112<br />
UMECTA 112<br />
UNASYN BULK PACK 22<br />
UNASYN PIGGYBACK UNIT 22<br />
UNASYN 22<br />
UNIFINE PENTIPS 6MM 122<br />
UNIFINE PENTIPS/12MM 121<br />
UNIFINE PENTIPS/8MM 122<br />
UNIFINE PENTIPS 121<br />
UNIFINE PENTIPS 122<br />
UNIPHYL 114<br />
UNIRETIC 50<br />
UNIVASC 50<br />
urea-hc acetate 112<br />
urea 112<br />
URECHOLINE 33<br />
URELLE 22<br />
URETRON D/S 22<br />
UREX 22<br />
URISED 22<br />
URISPAS 114<br />
URITACT DS 23<br />
URITACT-EC 23<br />
UROCIT-K 10 78<br />
UROCIT-K 5 78<br />
UROLENE BLUE 119<br />
UROQID #2 23<br />
UROXATRAL 119<br />
URSO FORTE 88<br />
URSO 88<br />
ursodiol 88<br />
UTA 23<br />
UTIRA 23<br />
UVADEX 112<br />
V<br />
VAGIFEM 101<br />
VALCYTE 23<br />
valproate sodium 71<br />
valproic acid 71<br />
VALTREX 23<br />
VANCOCIN HCL ISO-OSMOTIC 23<br />
VANCOCIN HCL 23<br />
vancomycin hcl 23<br />
VANOS 112<br />
VANOXIDE-HC 112<br />
VANSPAR 72<br />
VANTAS 29<br />
VANTIN 23<br />
VAQTA 103<br />
varicella-zoster immune globulin<br />
(human) 103<br />
VARIVAX 103<br />
VASERETIC 50<br />
VASOTEC 50<br />
VECTIBIX 29<br />
VELCADE 29<br />
venlafaxine hcl 72<br />
VENOGLOBUL-S 103<br />
VENTOLIN HFA 33<br />
VEPESID 29<br />
VERAMYST 84<br />
verapamil hcl 50<br />
VERDESO 112<br />
VERELAN PM 50<br />
VERELAN 50<br />
VESANOID 29<br />
VESICARE 114<br />
VEXOL 84<br />
145
VFEND IV 23<br />
VIADUR 29<br />
VIBRA 23<br />
VIBRAMYCIN 23<br />
VICODIN ES 72<br />
VICODIN 72<br />
VICOPROFEN 72<br />
VIDAZA 29<br />
VIDEX EC 23<br />
VIDEX 23<br />
VIGAMOX 84<br />
vinblastine sulfate 29<br />
vincristine sulfate 29<br />
vinorelbine tartrate 29<br />
VINORELBINE 29<br />
VIRACEPT 23<br />
VIRAMUNE 23<br />
VIRAZOLE 23<br />
VIREAD 23<br />
VIROPTIC 84<br />
VISTARIL 72<br />
VISTIDE 23<br />
VISUDYNE 84<br />
VITRASERT 84<br />
VIVACTIL 72<br />
VIVAGLOBIN 103<br />
VIVELLE-DOT 101<br />
VIVELLE 101<br />
VIVOTIF BERNA 103<br />
VOLTAREN-XR 72<br />
VOLTAREN 72<br />
VOLTAREN 84<br />
VOSPIRE ER 33<br />
VUMON 29<br />
VYTORIN 50<br />
VYVANSE 72<br />
W<br />
WARFARIN SODIUM AMORPHOUS 126<br />
WARFARIN SODIUM CLATHRATE 126<br />
WARFARIN SODIUM 126<br />
warfarin sodium 36<br />
warfarin sodium 37<br />
water for inject, bacteriostatic<br />
parabens 126<br />
water for inject, bacteriostatic 126<br />
water for injection, sterile 126<br />
water for irrigation, sterile 78<br />
WELCHOL 51<br />
WELLBUTRIN XL 72<br />
WELLBUTRIN 72<br />
WESTCORT 112<br />
X<br />
XALATAN 84<br />
XELODA 29<br />
XIBROM 84<br />
XIFAXAN 23<br />
XODOL 72<br />
XOLAIR 80<br />
XOPENEX CONCENTRATE 34<br />
XOPENEX HFA 34<br />
XOPENEX 34<br />
XYLOCAINE VISCOUS 84<br />
XYLOCAINE-MPF 101<br />
XYLOCAINE 101<br />
XYLOCAINE 112<br />
XYLOCAINE 51<br />
XYRALID LP 113<br />
XYRALID RC 113<br />
XYREM 72<br />
Y<br />
YASMIN 28 101<br />
YAZ 101<br />
YF-VAX 103<br />
YODOXIN 23<br />
Z<br />
ZACLIR 113<br />
ZANAFLEX 34<br />
ZANOSAR 29<br />
ZANTAC 88<br />
ZARONTIN 72<br />
ZAROXOLYN 78<br />
ZAVESCA 119<br />
ZEBETA 51<br />
ZEGERID 88<br />
ZELAPAR 72<br />
ZEMAIRA 119<br />
ZEMPLAR 115<br />
ZENAPAX 119<br />
ZERIT 23<br />
ZERIT 24<br />
ZESTORETIC 51<br />
ZESTRIL 51<br />
ZETIA 51<br />
ZEVALIN IN-111 29<br />
ZEVALIN Y-90 29<br />
ZIAC 51<br />
ZIAGEN 24<br />
ZIANA 113<br />
ZINACEF/D5W 24<br />
ZINACEF 24<br />
ZINECARD 119<br />
ZINOTIC 84<br />
ZITHROMAX TRI-PAK 24<br />
ZITHROMAX Z-PAK 24<br />
ZITHROMAX 24<br />
ZMAX 24<br />
ZOCOR 51<br />
ZODERM CLEANSER 113<br />
ZODERM 113<br />
ZOFRAN ODT 88<br />
ZOFRAN 88<br />
ZOLADEX 29<br />
ZOLINZA 29<br />
ZOLOFT 72<br />
zolpidem tartrate 72<br />
ZOMETA 119<br />
ZOMIG ZMT 72<br />
ZOMIG 72<br />
ZONALON 113<br />
ZONEGRAN 72<br />
zonisamide 72<br />
ZORBTIVE 101<br />
ZOSTAVAX 103<br />
ZOSYN 24<br />
ZOVIRAX 113<br />
ZOVIRAX 24<br />
ZYBAN 72<br />
ZYDONE 72<br />
ZYDONE 73<br />
ZYFLO 80<br />
ZYLET 84<br />
ZYLOPRIM 119<br />
ZYMAR 84<br />
ZYMINE XR 8<br />
ZYPREXA ZYDI 73<br />
ZYPREXA 73<br />
ZYRTEC-D 8<br />
ZYRTEC 8<br />
ZYVOX 24<br />
146