INDEPENDENT HEALTH’S 2014 Drug Formulary restrictions or coverage limits may apply ... PAR – Prior Authorization must be obtained in order for the drug to be ... bicalutamide (Restricted

Family Health Plus Formulary – June 2014 1

INDEPENDENT HEALTH’S Family Health Plus

2014 Drug Formulary

This drug formulary lists covered generic and brand name drugs under our Prescription Drug Plan.

Covered generic drugs appear in lower case, covered brand name drugs start with a capital letter.

Independent Health’s Family Health Plus benefit allows coverage only for over‐the‐counter drugs that are listed in the formulary. Covered over‐the‐counter drugs must have a prescription.

When a generic drug becomes available for a formulary brand name drug, the generic will be covered and the brand will become non‐formulary and will require prior authorization to be covered.

Independent Health makes every attempt to provide you with as accurate a listing of drugs as possible. However, the list of drugs and availability of generics can change frequently. Please discuss any questions you may have about the formulary with your physician.

In order to ensure the safest and most appropriate care, Independent Health’s drug coverage criteria is limited to medically‐accepted indications based on FDA approved labeling and guidelines, that is not otherwise excluded from New York State Medicaid. Independent Health also relies on support by one or more official compendia citations to provide guidelines when a drug or indication is not FDA approved.

Replacement of lost, stolen or damaged medications is the responsibility of the member.

Compounded prescriptions (medications that are not commercially manufactured) must be prepared by a participating pharmacy and contain at least one prescription component. The dispensing pharmacy is required to submit for prior approval and when covered, will take the applicable copayment. Coverage is provided in accordance with our Compounding Drug Products Policy. Bulk products and powders are excluded from coverage because they are not prescription drug products that are approved under sections 505, 505 (j) or 507 of the Federal Food Drug and Cosmetic Act.

Prior authorization cannot be used to obtain early refills for lost, stolen or damaged medication; or for extended supplies or vacation supplies.

ER Scripts are limited to a 10 day supply.

This formulary is subject to change. Drugs may be added or removed as necessary.

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

The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, “Cardiovascular Agents”.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the index. The index provides an alphabetical list of all of the drugs included in this document. Both covered brand name drugs and covered generic drugs are listed in the index. Next to your drug, you will see the page number where you can find your drug in the formulary.

Additional restrictions or coverage limits may apply: Prior Authorization

This formulary requires prior authorization for certain drugs (listed in the formulary with the symbol “PA”). In addition, drugs not listed in the formulary are considered “non‐covered” and require prior authorization. To obtain coverage for a drug requiring prior authorization or for non‐covered drugs, a prior authorization request for medical exception from the prescribing doctor must be submitted to and approved by Independent Health’s Medical Director.

Step Therapy Some drugs are only covered after you have tried certain other drugs to treat your medical condition (listed in the formulary with the symbol “ST”). For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first.

Quantity Limits Certain drugs have a limit on the amount of drug that is covered based on Food and Drug Administration (FDA) guidelines (listed in the formulary with the symbol “QL”).


Formulary Symbols + ‐ Maintenance drug, a 90‐day supply may be prescribed and dispensed. QL – Quantity Limit applies PAR – Prior Authorization must be obtained in order for the drug to be covered. ST – Pharmacy Step Therapy Program Benefit Exclusions:

Amphetamine and amphetamine‐like drugs which are used for the treatment of obesity

Drugs whose sole clinical use is the reduction of weight;

Drugs used for cosmetic purposes

Any item marked “sample” or “not for sale”

Any contrast agents, used for radiological testing (these are included in the radiologist’s fee)

Any drug which does not have a National Drug Code

Drugs packaged in unit doses for which bulk product exists

Any drug regularly supplied to the general public free of charge must also be provided free of charge to Medicaid beneficiaries

Any controlled substance stamped or preprinted on a prescription blank

Drugs used for the treatment of erectile dysfunction

Drugs used to promote fertility

Drugs or supplies drugs used for gender reassignment

Vacation supplies are not covered under this benefit

Growth Hormones are excluded from coverage when prescribed for the treatment of short stature. Pharmacy Administered Immunizations: Influenza and Pneumococcal vaccinations administered by licensed pharmacists who obtain additional certification to administer influenza and pneumococcal to adults 18 years of age and older. Enteral and Parenteral Nutritional Formula Benefit: Enteral Nutritional Formula benefit coverage is based on medical necessity, prior authorization is required. Enteral Feeding Supplies – Supplies that are necessary to administer the specific type of feeding and maintain the feeding site. This includes, but is not limited to: syringes, measuring containers, tip adapters, anchoring device, gauze pads, protective‐dressing wipes, tape and tube cleaning brushes. Parenteral Nutritional Formula – Benefit coverage is based on medical necessity, prior authorization is required.

Family Health Plus Formulary – January 2014 3

TABLE OF CONTENTS

CHAPTER 1 ‐ Anti‐Infective Agents ........................................................................................................................................ 4 CHAPTER 2 ‐ Antihistamine Drugs ......................................................................................................................................... 5 CHAPTER 3 ‐ Antineoplastic Agents ....................................................................................................................................... 6 CHAPTER 4 ‐ Autonomic Drugs............................................................................................................................................... 6 CHAPTER 5 ‐ Blood Formation, Coagulation & Thrombosis .................................................................................................. 8 CHAPTER 6 ‐ Cardiovascular Drugs ........................................................................................................................................ 8 CHAPTER 7 ‐ Central Nervous System Agents ..................................................................................................................... 11 CHAPTER 8 ‐ Electrolytic, Caloric and Water Balance ......................................................................................................... 16 CHAPTER 9 – Enzymes .......................................................................................................................................................... 17 CHAPTER 10 ‐ Eye, Ear, Nose and Throat Preparations ....................................................................................................... 18 CHAPTER 11 ‐ Gastrointestinal Drugs ................................................................................................................................. 19 CHAPTER 12 ‐ Gold Compounds ........................................................................................................................................... 20 CHAPTER 13 ‐ Heavy Metal Antagonists .............................................................................................................................. 21 CHAPTER 14 ‐ Hormones and Synthetic Substitutes ........................................................................................................... 21 CHAPTER 15 ‐ Miscellaneous Therapeutic Agents .............................................................................................................. 23 CHAPTER 16 ‐ Respiratory Tract Agents .............................................................................................................................. 25 CHAPTER 17 ‐ Skin and Mucous Membrane Preparations .................................................................................................. 26 CHAPTER 18 ‐ Smooth Muscle Relaxants............................................................................................................................. 28 CHAPTER 19 – Vitamins ........................................................................................................................................................ 29 NON‐PRESCRIPTION DRUGS/OTC DRUGS ........................................................................................................................... 30 MEDICAL SUPPLIES ............................................................................................................................................................... 30


CHAPTER 1 ‐ Anti‐Infective Agents

1.A Anthelmintics

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands mebendazole chew (QL) Stromectol® tabs

Albenza®

1.B Antibacterials

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands amoxicillin (QL) amoxicillin/clavulanate potassium (QL) amoxicillin/clavulanate potassium er (QL) ampicillin (QL) avidoxy azithromycin (QL) cefaclor (QL) cefaclor er (QL) cefadroxil (QL) cefdinir (QL) cefpodoxime proxetil (QL) cefprozil (QL) cefuroxime axetil (QL) cephalexin (QL) ciprofloxacin er (QL) ciprofloxacin hcl (QL) clarithromycin (QL) clarithromycin er (QL) cleocin pediatric granules clindamycin hcl clindamycin palmitate hcl demeclocycline hcl dicloxacillin sodium (QL) doxycycline doxycycline hyclate doxycycline monohydrate e.e.s. 400 (QL) e.s.p. (QL) erythromycin (QL) erythromycin base (QL) erythromycin ethylsuccinate (QL) erythromycin/sulfisoxazole (QL) levofloxacin (QL) minocycline hcl minocycline hcl er morgidox neomycin sulfate ofloxacin (QL) penicillin v potassium (QL) sulfamethoxazole/trimethoprim (QL) sulfamethoxazole/trimethoprim ds (QL) sulfasalazine sulfazine sulfazine ec tetracycline hcl tobramycin (PAR, QL) vancomycin hcl caps (PAR)

Cayston® (PAR, Minimum age of 7 years)

Ceftin® Cleocin® erythrocin sterate (QL) Sulfadiazine

® Suprax® (QL)

1.C Antifungals

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands bio‐statin fluconazole fluconazole 150mg (QL) griseofulvin griseofulvin microsize itraconazole (PAR) ketoconazole (PAR)

nystatin terbinafine hcl (PAR) voriconazole (PAR)

Noxafil® (PAR) Vfend

® (PAR)


1.D Antimycobacterials

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands dapsone ethambutol hcl isonarif isoniazid pyrazinamide rifabutin (PAR) rifampin

Rifater®

1.E Antiprotozoals

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands atovaquone (PAR) chloroquine phosphate (+) hydroxychloroquine sulfate (+) mefloquine hcl (+) metronidazole paromomycin sulfate primaquine phosphate (+) quinine sulfate (PAR, QL, Minimum age of 16 years) tinidazole tabs

Alinia® (PAR) Coartem®

(QL, +) Daraprim®

(+) Nebupent® (PAR) Yodoxin®

1.F Antivirals

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands abacavir sulfate abacavir sulfate/lamivudine/zidovudine (PAR) acyclovir adefovir dipivoxil tab (PAR) didanosine famciclovir famciclovir 500mg (QL) ganciclovir lamivudine (PAR) nevirapine susp, tabs nevirapine er ribasphere (PAR) ribavirin (PAR) rimantadine hcl stavudine valacyclovir hcl (QL) zidovudine

Alferon® N (PAR)

Aptivus®

Atripla® Baraclude® (PAR) Combivir

® Crixivan® Emtriva

® Epivir

®HBV soln only (PAR) Epzicom® Fuzeon® (PAR) Incivek

® (PAR) Infergen® (PAR) Intelence

® Invirase® Isentress® Kaletra

® Lexiva

® Norvir

® Peg‐Intron® (PAR) Pegasys® (PAR)

Prezista® (ST) Relenza

® Diskhaler (QL) Rescriptor® Reyataz® Selzentry

® StribildTM Sustiva

®

Tamiflu® (QL) Tivicay® Truvada® Tyzeka

® (PAR)

Valcyte® (PAR) Victrelis

® (PAR)

Videx® Pediatric Viracept® Viread

®

1.G Urinary Anti‐Infectives

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands methenamine mandelate nitrofurantoin (QL,Maximum age of 64 years) nitrofurantoin macrocrystal (QL,Maximum age of 64 years) nitrofurantoin macrocrystalline (QL,Maximum age of 64 years) nitrofurantoin monohydrate (QL) nitrofurantoin monohydrate/macrocrystals (QL) trimethoprim

CHAPTER 2 ‐ Antihistamine Drugs

2.A Antihistamines

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands cyproheptadine levocetirizine dihydrochloride (PAR)


CHAPTER 3 ‐ Antineoplastic Agents

3.A Antineoplastic Agents Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands

anastrozole (PAR, Restricted to female patients only) bicalutamide (Restricted to male patients only) capecitabine (PAR) cyclophosphamide exemestane (PAR, Restricted to female patients only) flutamide (Restricted to male patients only) hydroxyurea letrozole (PAR, QL, Restricted to female patients only) lomustine megestrol acetate mercaptopurine methotrexate tamoxifen citrate temozolomide tretinoin

Afinitor® (PAR)

Alkeran®

Caprelsa® (PAR) Emcyt® Erivedge

TM (PAR)

Etoposide® Fareston

® (Restricted to female patients only)

Firmagon® (PAR) Gleevec® (PAR) Hexalen® Hycamtin® (PAR) Intron‐A®

(PAR) Jakafi® (PAR) Leukeran® Lysodren® Matulane® Myleran® Nilandron® (PAR) Revlimid® (PAR) Sprycel

® (ST)

Sutent® (PAR) Tabloid® Tarceva

® (PAR)

Tasigna® (PAR) Trexall®

Tykerb® (PAR) Votrient® (PAR) Xalkori® (PAR) Zolinza

® (PAR)

Zytiga® (PAR)

CHAPTER 4 ‐ Autonomic Drugs

4.A Anticholinergic Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands belladonna alkaloids/phenobarbital (+) chlordiazepoxide hcl/clidinium bromide (+) chlordiazepoxide/clidinium (+) colidrips pediatric (+) dicyclomine hcl (+) glycopyrrolate (+) hyomax (+) hyoscyamine sulfate (+) (Maximum age of 64) hyosyne (+) ipratropium bromide (+) methscopolamine bromide (+) oscimin (+) propantheline bromide (+)

Anoro® Ellipta (Minimum age of 45) Atropen® Atrovent®HFA (+) belladonna & opium suppositories (+) belladonna alkaloids (+) belladonna alkaloids & opium (+) Donnatal® Extentabs Spiriva

® Handihaler (+, Minimum age of 45)

Tudorza® (Minimum age of 45)

4.B Autonomic Drugs, Miscellaneous

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands Chantix® (QL)


4.C Parasympathomimetic (Cholinergic) Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands bethanechol chloride (+) cevimeline (QL) donepezil (+) donepezil hcl 23mg (ST, +) galantamine hydrobromide (+) guanidine hcl (+) pilocarpine hcl (+) pilocarpine hydrochloride (+) pyridostigmine bromide (+)

Mestinon® (+)

Prostigmin® (+)

4.D Skeletal Muscle Relaxants

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands baclofen carisoprodol carisoprodol/aspirin carisoprodol/aspirin/codeine chlorzoxazone (Maximum age of 64) cyclobenzaprine hcl (Maximum age of 64) dantrolene sodium ed baclofen metaxalone methocarbamol orphenadrine citrate er tizanidine hcl tablets

4.E Sympatholytic (Adrenergic Blocking) Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands alfuzosin hcl er (+)Restricted to male patients only tamsulosin hcl (+)Restricted to male patients only

Dibenzyline®

4.F Sympathomimetic (Adrenergic) Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands albuterol sulfate (+) albuterol sulfate er (+) ipratropium bromide/albuterol sulfate (+) metaproterenol sulfate (+) midodrine hcl respivent‐d terbutaline sulfate (+)

Adrenaclick® (QL) Advair

® Diskus (+) Advair

® HFA (+) Arcapta

® Neohaler (Minimum patient age of 45) Auvi‐QTM Combivent® (+) Epinephrine® (QL) Epipen

® (QL)

Epipen® Jr (QL) Foradil® (ST, +) Maxair® Autohaler (+) Proair

® HFA (+) Proventil® HFA (+) Serevent® Diskus (ST, +) Twinject

® (QL)

Ventolin® HFA (+)


CHAPTER 5 ‐ Blood Formation, Coagulation & Thrombosis

5.A Antianemia Drugs

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands corvita 150 fec c plus ferocon ferotin ferrex 150 forte ferrogels forte folitab foltrin hematogen hematogen forte iferex 150 forte martinic myferon 150 forte poly‐iron 150 forte purevit dualfe plus se‐tan plus tl icon tl‐fol 500 tl‐hem 150 tricon tigels‐f forte

5.B Antihemorrhagic Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands aminocaproic acid

5.C Antithrombotic Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands anagrelide hydrochloride (PAR) cilostazol (+) enoxaparin sodium (QL) fondaparinux sodium (QL) jantoven (+) ticlopidine hcl (+) warfarin sodium (+)

Aggrenox® (PAR, +) Brilinta

® (+)

Effient® (+) Eliquis

® Fragmin® (QL except for Oncology) Plavix® (+) Pradaxa

® Xarelto

®

5.D Hematopoietic Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands Aranesp® (PAR)

Epogen® (PAR)

Neulasta® (PAR) Neupogen® (PAR) Procrit® (PAR) Promacta

® (PAR)

5.E Hemorrheologic Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands pentoxifylline er

CHAPTER 6 ‐ Cardiovascular Drugs

6.A Alpha‐Adrenergic Blocking Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands doxazosin mesylate (+) prazosin hcl (+) terazosin hcl (+)


6.B Antilipemic Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands atorvastatin calcium (+) cholestyramine (+) cholestyramine light (+) colestipol hcl (+) fenofibrate tabs 54mg, 160mg (+) fenofibrate caps 67mg, 134mg, 200mg (+) gemfibrozil (+) lofibra (+) lovastatin (+) micronized colestipol hcl (+) pravastatin sodium (+) prevalite (+) simvastatin (+)

Welchol® (+) Zetia® (+)

6.C Beta‐Andrenergic Blocking Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands acebutolol hcl (+) atenolol (+) atenolol/chlorthalidone (+) betaxolol hcl (+) bisoprolol fumarate (+) bisoprolol fumarate/hydrochlorothiazide (+) carvedilol (+) labetolol hcl (+) metoprolol succinate er (+) metoprolol tartrate (+) metoprolol/hydrochlorothiazide (+) nadolol (+) nadolol/bendroflumethiazide (+) pindolol (+) propranolol hcl (+) propranolol hcl er (+) sorine (+) sotalol hcl (+) timolol maleate (+)

Dutoprol®(+)

6.D Calcium‐Channel Blocking Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands afeditab cr (+) amlodipine besylate (+) amlodipine besylate/benazepril hcl (+) amlodipine besylate/atorvastatin calcium tabs cartia xt (+) dilt‐cd (+) dilt‐xr (+) diltiazem cd (+) diltiazem hcl (+) diltiazem hcl er (+) diltzac (+) felodipine er (+) isradipine (+) matzim la (+) nicardipine hcl (+) nifediac cc (+) nifedical xl (+) nifedipine nifedipine er (+) nimodipine (PAR, +) nisoldipine (+) nislodipine er (+) taztia xt (+) verapamil hcl (+) verapamil hcl er (+) verapamil hcl sr (+)


6.E Cardiac Drugs

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands amiodarone hcl (+) digoxin (+) disopyramide phosphate (+) flecainide acetate (+) mexiletine hcl (+) pacerone (+) propafenone hcl (+) propafenone hcl er (+) quinidine gluconate cr (+) quinidine gluconate er (+) quinidine sulfate (+) quinidine sulfate er (+)

Norpace® CR (+) Tekturna® (ST) Tekturna® HCT (ST) Tikosyn® (+)

6.F Hypotensive Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands clonidine hcl (+) guanfacine hcl (+) hydralazine hcl (+) methyldopa (+) methyldopa/hydrochlorothiazide (+) minoxidil (+)

Reserpine® (+)

6.G Renin‐Angiotensin‐Aldosterone

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands benazepril hcl (+) benazepril hcl/hydrochlorothiazide (+) candesartan cilexetil/hydrochlorothiazide (ST) captopril (+) captopril/hydrochlorothiazide (+) enalapril maleate (+) enalapril maleate/hydrochlorothiazide (+) eplerenone (PAR, +) eprosartan mesylate (ST) fosinopril sodium (+) fosinopril sodium/hydrochlorothiazide (+) irbesartan (+) irbesartan/hctz (+) lisinopril (+) lisinopril/hydrochlorothiazide (+) losartan potassium (+) losartan potassium/hydrochlorothiazide (+) moexipril hcl (+) moexipril/hydrochlorothiazide (+) perindopril erbumine (+) quinapril hcl (+) quinapril/hydrochlorothiazide (+) ramipril (+) spironolactone (+) spironolactone/hydrochlorothiazide (+) telmisartan (ST) telmisartan/amlodipine (ST) telmisartan/hydrochlorothiazide (ST) trandolapril (+) valsartan/hctz (+)

Aldactazine® (+) Diovan® (ST, +)


6.H Vasodilating Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands dilatrate sr (+) dipyridamole (+) isochron (+) isoditrate er (+) isordil titradose (+) isosorbide dinitrate (+) isosorbide dinitrate er (+) isosorbide mononitrate (+) isosorbide mononitrate er (+) isoxsuprine hcl (+) nitro‐time (+) nitroglycerin (+) nitroglycerin cr, er, sr (+) nitroglycerin transdermal (+) sildenafil (PAR, + Minimum patient age of 18 years)

Adcirca® (PAR)

Letairis® (PAR) Nitro‐Bid® (+) Nitrostat® (+) Tracleer® (PAR)

CHAPTER 7 ‐ Central Nervous System Agents

7.A Analgesics and Antipyretics

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands acetaminophen/caffeine/dihydrochodein/bitartrate acetaminophen/codeine acetaminophen/codeine phosphate anolor 300 ascomp/codeine bupap buprenorphine hcl (PAR) buprenorphine/naloxone (PAR) butal/asa/caff (+) butalbital compound (+) butalbital/acetaminophen butalbital/acetaminophen/caffeine butalbital/acetaminophen/caffeine/codeine butalbital/apap/caffeine butalbital/asa/caffeine (+) butalbital/aspirin/caffeine (+) butalbital/aspirin/caffeine/codeine butorphanol tartrate (PAR) cafgesic cafgesic forte cephadyn choline magnesium trisalicylate (+) co‐gesic codeine sulfate diclofenac misoprostol (+) diclofenac potassium (+) diclofenac sodium (+) diclofenac sodium dr (+) diclofenac sodium ec (+) diclofenac sodium er (+) diclofenac sodium xr (+) diflunisal (+) duraxin ed‐flex endocet endodan etodolac (+) etodolac er (+) fenoprofen calcium(+)

Indocin® (+) Nalfon® (+) Naprelan® (+) Nucynta

® Nucynta® ER Oxycontin® Oxycontin

®60mg, 80mg (ST) Suboxone® (PAR) Voltaren® Gel (QL) Zubsolv

® (PAR)


fentanyl (ST) fentanyl citrate oral transmucosal (PAR) flurbiprofen (+) hydrocodone bitartrate/acetaminophen hydrocodone bitartrate/apap hydrocodone/acetaminophen hydrocodone/ibuprofen hydrogesic hydromorphone hcl ibuprofen (+) indomethacin (+) indomethacin er (+) ketoprofen (+) ketoprofen er (+) ketorolac tromethamine (PAR, +) levorphanol tartrate

7.A Analgesics and Antipyretics (cont.)

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands margesic marten‐tab meclofenamate sodium (+) mefenamic acid (+) meloxicam (+) methadone hcl methadose morphine sulfate morphine sulfate er 100mg and 200mg (ST) nabumetone (+) naproxen (+) naproxen dr (+) naproxen sodium (+) orphenadrine/asa/caffeine (+) oxaprozin (+) oxycodone hcl oxycodone/acetaminophen oxycodone/aspirin oxycodone/ibuprofen (QL) oxymorphone hydrochloride (PAR) oxymorphone hydrochloride er pentazocine/acetaminophen pentazocine/naloxone hcl piroxicam (+) repan reprexain roxicet salsalate (+) sulindac (+) tolmetin sodium (+) tramadol hcl tramadol hcl er tablets (ST) tramadol hydrochloride/acetaminophen (PAR) vicodin hp zebutal


7.B Anorexigenics, Respiratory & Cerebral Stimulants

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands amphetamine/dextroamphetamine (Minimum age of 3 years) amphetamine/dextroamphetamine er (Minimum age of 3 years) dexmethylphenidate hcl (Minimum age of 6 years) dexmethylphenidate hcl er (Minimum age of 6 years) dextroamphetamine sulfate (Minimum age of 3 years) dextroamphetamine sulfate er (Minimum age of 3 years) generic metadate cd (Minimum age of 6 years) generic metadate er (Minimum age of 6 years) methamphetamine (Minimum age of 6 years) methylphenidate hcl (Minimum age of 6 years) methylphenidate hcl er (Minimum age of 6 years) methylphenidate hcl sr (Minimum age of 6 years) methylphenidate hydrochloride (Minimum age of 6 years)

Nuvigil® (PAR, Minimum patient age of 17 years)

7.C Anticonvulsants

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands carbamazepine (+) carbamazepine er (+) clonazepam clonazepam odt divalproex sodium (+) divalproex sodium er (+) divalproex sodium dr (+) epitol (+) ethosuximide felbamate (+) gabapentin (+) lamotrigine (+) levetiracetam (+) oxcarbazepine (+) phenytoin (+) phenytoin sodium extended (+) primidone tiagabine (PAR, +) topiragen (+) topiramate (+) topiramate sprinkles (PAR for patients over 12 years of age, + ) valproic acid (+) zonisamide (PAR, +)

Banzel® (PAR, +) Celontin® Dilantin

® (+)

Dilantin® Infatabs (+)

Lyrica® (ST)

Peganone® (+) Sabril® (PAR, Available through Accredo Pharmacy)

Vimpat® (PAR, +, Minimum age of 17 years)

7.D Antimanic Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands lithium carbonate (+) lithium carbonate er (+) lithium citrate (+)

7.E Antimigraine Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands epidrin ergotamine tartrate/caffeine isometheptene/caffeine/acetaminophen isomethaptene/dichloralphenazone/acetaminophen migragesic ida naratriptan hcl (QL) nodolor rizatriptan (QL) sumatriptan succinate (QL) zolmitriptan (QL)

Ergomar® Migranal® (PAR, QL)


7.F Antiparkinsonian Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands amantadine hcl (+) benztropine mesylate (+) bromocriptine mesylate (+) cabergoline (PAR, QL, +) carbidopa/levodopa (+) carbidopa/levodopa cr (+) carbidopa/levodopa er (+) carbidopa/levodopa sr (+) carbidopa/levodopa/entacapone tabs (+) carbidopa/levodopa odt (ST) entacapone (ST) pramipexole dihydrochloride (PAR) ropinirole hcl (PAR) selegiline hcl trihexyphenidyl hcl (+)

Apokyn® (PAR) Azilect® (PAR) Comtan® (ST) Zelapar® (PAR)

7.G Anxiolytics, Sedatives and Hypnotics

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands alprazolam alprazolam er alprazolam odt alprazolam xr buspirone hcl butisol sodium chloral hydrate chlordiazepoxide hcl clorazepate dipotassium diazepam (Maximum age of 64 years) diazepam intensol (Maximum age of 64 years) estazolam flurazepam hcl (QL, Maximum age of 64 years) hydroxyzine hcl (Maximum age of 64 years) hydroxyzine pamoate (Maximum age of 64 years) lorazepam meprobamate (Maximum age of 64 years) midazolam hcl oxazepam phenobarbital temazepam (QL) triazolam (QL) zaleplon (QL) zolpidem tartrate (QL) zolpidem tartrate er (ST, QL)

Mebaral®

Rozerem® (QL)

Seconal®

7.H Central Nervous System Agents, Miscellaneous

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands acamprosate calcium tab dr (PAR, +) ergoloid mesylates memantine (+) riluzole (+)

Nuedexta® (PAR, +) OnfiTM (PAR) Strattera® (Minimum patient age of 6 years) Xenazine

® (PAR, QL, Must be obtained through Accredo Pharmacy only)

Xyrem® (PAR)

7.I Fibromyalgia Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands Savella®

Savella® Titration Pack


7.J Opiate Antagonists

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands depade (PAR) naltrexone hcl (PAR)

7.K Psychotherapeutic Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands amitriptyline hcl amoxapine budeprion sr (+) budeprion xl (+) buproban (QL, +) bupropion hcl (+) bupropion hcl er (+) bupropion hcl sr (+) bupropion hcl xl (+) chlordiazepoxide/amitriptyline chlorpromazine hcl (+) citalopram hydrobromide (+) clomipramine hcl clozapine (PAR, +) compro (+) desipramine hcl doxepin hcl duloxetine hcl (PAR,+) escitalopram oxalate (+) fluoxetine 10mg, 20mg (+) fluoxetine dr (+) fluoxetine hcl (+) fluphenazine hcl (+) fluvoxamine maleate (+) haloperidol (+) imipramine hcl imipramine pamoate loxapine succinate (+) maprotiline hcl (PAR) mirtazapine (+) mirtazapine odt (+) nefazodone (PAR) nortriptyline hcl olanzapine (+) olanzapine ODT (PAR) paroxetine hcl (+) paroxetine hcl er (ST, +) perphenazine (+) perphenazine/amitriptyline phenelzine sulfate prochlorperazine (+) prochlorperazine maleate (+) protriptyline hcl quetiapine fumarate (+) risperidone (+) risperidone m‐tab (PAR) risperidone odt (PAR) sertraline hcl (+) thioridazine hcl (+, Maximum patient age of 64) thiothixene

Orap®(+)


tranylcypromine sulfate trazodone hcl (+) trifluoperazine hcl (+) venlafaxine hcl (+) venlafaxine hcl er (+) ziprasidone (+)

CHAPTER 8 ‐ Electrolytic, Caloric and Water Balance

8.A Alkalinizing Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands citric acid/sodium citrate cytra k crystals cytra‐2 cytra‐3 cytra‐k potassium citrate potassium citrate/citric acid taron‐crystals tricitrates

Oracit®

8.B Ammonia Detoxicants

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands constulose enulose generlac lactulose

Carbaglu®(PAR)

Kristalose®

8.C Diuretics

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands amiloride hcl (+) amiloride/hctz (+) bumetanide (+) chlorothiazide (+) chlorthalidone (+) furosemide (+) hydrochlorothiazide (+) indapamide (+) metolazone (+) torsemide (+) triamterene/hctz

Diuril® (+)

8.D Ion‐Removing Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands kalexate kionex sodium polystyrene sulfonate

Fosrenol® Renagel® Renvela

® SPS®

8.E Irrigating Solutions

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands acetic acid 0.25% aminoacetic acid glycine lactated ringers injection physiolyte physiosol irrigation ringers irrigation sodium chloride 0.45% sterile water for irrigation tis‐u‐sol tis‐u‐sol viaflex

Renacidin® Sorbitol® Sorbitol‐Mannitol®


8.F Replacement Preparations

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands calcium acetate (+) ed k+10 (+) effer‐k (+) effervescent pot chloride (+) effervescent potassium (+) effervescent potassium/chloride (+) epiklor (+) epiklor/25 (+) k‐effervescent (+) k‐prime (+) k‐vescent (+) klor‐con (+) klor‐con/ef (+) phospha 250 neutral (+) potassium bicarbonate (+) potassium chloride (+) potassium chloride cr (+) potassium chloride er (+) potassium chloride sr (+)

Galzin®(+)

Phoslyra® (+)

8.G Uricosuric Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands probenecid probenicid/colchicine

CHAPTER 9 – Enzymes

9.A Enzymes

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands Pulmozyme®

Sucraid® (PAR, Must be obtained through Accredo pharmacy only)


CHAPTER 10 ‐ Eye, Ear, Nose and Throat Preparations

10.A Anti‐Infectives

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands ak‐poly‐bac ak‐tob bacitracin/polymyxin b chlorhexidine gluconate ciprofloxacin hcl otic soln erythromycin garamycin gentak gentamicin sulfate ilotycin levofloxacin neo‐polycin neomycin/bacitracin/polymyxin neomycin/polymyxin/gramicidin ofloxacin (PAR) periogard polycin b polymyxin b sulfate/trimethoprim sulfate romycin sodium sulfacetamide sulfacetamide sodium tobramycin sulfate tobrasol trifluridine trimethoprim sulfate/polymyxin b sulfate

Bacitracin®

Natacyn® (PAR) Silver Nitrate

10.B Anti‐Inflammatory Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands acetasol hc dexamethasone sodium phosphate diclofenac sodium (PAR) fluor‐op fluorometholone flurbiprofen sodium fluticasone propionate hydrocortisone/acetic acid ketorolac tromethamine (PAR) neomycin/polymyxin/bacitracin/hydrocortisone neomycin/polymyxin/dexamethasone neomycin/polymyxin/hc neomycin/polymyxin/hydrocortisone poly‐dex prednisolone acetate prednisolone sodium phosphate sulfacetamide sodium/prednisolone sodium phosphate tobramycin/dexamethasone triamcinolone acetonide

Acuvail®(PAR)

Alrex® (PAR) Blephamide® Blephamide

® S.O.P. Bromfenac

® (PAR except Ophthalmology)

Ciprodex® (PAR) Dermotic

® Flarex® Flunisolide

® FML® FML

® Forte Ilevro® (PAR) Maximum of 2 fills per year Lacrisert

® Lotemax

®

Nasonex® Nevanac® (PAR) Maximum of 2 fills per year Poly‐Pred

® Pred Mild® Restasis® (PAR) Vexol®

10.C Antiallergic Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands azelastine hcl (+) cromolyn sodium (+) epinastine hcl

Alomide® (PAR, +)


10.D Antiglaucoma Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands acetazolamide acetazolamide er brimonidine tartrate carteolol hcl dorzolamide hcl dorzolamide hcl/timolol maleate latanoprost (PAR for patients less than 50 years old) levobunolol hcl methazolamide metipranolol phospholine iodide pilocarpine hcl timolol maleate timolol maleate ophthalmic gel forming

Alphagan® P Azopt® Betimol® Betopic‐S® Combigan® (QL) Isopto® Carbechol Lumigan

® (PAR for patients less than 50 years old)

Pilopine® HS Simbrinza® Travatan

® Z (PAR for patients less than 50 years old)

10.E Eye, Ear, Nose and Throat Drugs, Miscellaneous

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands acetic acid acetic acid/aluminum acetate acorn balanced salt solution apraclonidine balanced salt solution homatropine tropicamide

Cystaran® Lacrisert®

10.F Local Anesthetics

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands antipyrine/benzocaine lidocaine viscous

10.G Vasoconstrictors

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands ak‐dilate altafrin neofrin phenylephrine hcl

CHAPTER 11 ‐ Gastrointestinal Drugs

11.A Anti‐Inflammatory Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands balsalazide disodium (+, Minimum patient age of 5 years) mesalamine (+)

Apriso®(+)

Asacol® (+) Asacol

® HD (+) Canasa

® (+)

Delzicol®

Pentasa® (+) SF Rowasa

® (+)

11.B Antidiarrhea Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands diphenoxylate/atropine lofene lonox loperamide hcl opium opium tincture paregoric


11.C Antiemetics

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands dronabinol granisetron hcl (ST, QL) meclizine (+) ondansetron hcl (QL, quantity limit does not apply to 4mg and 8mg when prescribed by an oncologist or hemotologist)

ondansetron odt (QL) trimethobenzamide hcl (PAR, +) univert (+)

Emend®(ST, QL)

Emend® 40mg, 80mg, 125mg (ST, QL)

11.D Antiulcer Agents and Acid Suppressants

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands amoxicillin cap/clarithro tab/lansoprazole cap dr cimetidine (+) cimetidine hcl (+) famotidine (+) lansoprazole lansoprazole odt misoprostol nizatidine (+) omeprazole omeprazole/sodium bicarbonate pantoprazole sodium rabeprazole sodium ranitidine hcl tabs, soln (+) sucralfate (+)

11.E Cathartics and Laxatives

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands gavalyte‐c gavilyte‐g gavilyte‐n/flavor pack peg 3350/electrolytes peg 3350/nacl/na bicarbonate/kcl trilyte

Colyte® Flavor Packs

Osmoprep®

Suprep® Bowl Prep Visicol®

11.F Cholelitholytic Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands ursodiol

11.G Digestants

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands Creon® (+)

Cystadane® (PAR) Pancreaze

® (+)

Pertzye® (+) Zenpep® (+)

11.F GI Drugs, Miscellaneous

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands Relistor®

11.G Prokinetic Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands metoclopramide hcl

CHAPTER 12 ‐ Gold Compounds

12.A Gold Compounds

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands Ridaura®


CHAPTER 13 ‐ Heavy Metal Antagonists

13.A Heavy Metal Antagonists

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands Chemet® (+)

Cuprimine® Depen® Titratabs (+)

Exjade®

(PAR) Syprine® (+,PAR) Thiola

TM

CHAPTER 14 ‐ Hormones and Synthetic Substitutes

14.A Adrenals

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands asmalpred plus baycadron budesonide (PAR) budesonide suspension (QL, Limited to patients < 8 years) dexamethasone fludrocortisone acetate hydrocortisone methylprenisolone prednisolone prednisolone sodium phosphate prednisone

Alvesco® Asmanex® Cortisone® Acetate Dexpak® Dulera® (Minimum patient age of 12 years) Flovent

® Diskus Flovent® HFA Pulmicort

® (QL)

Pulmicort® Flexhaler Qvar

® Symbicort®

14.B Androgens

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands danazol oxandrolone

Androderm® (PAR, Restricted to male patients only)

Androgel® (PAR, Restricted to male patients only) Android® (PAR, Restricted to male patients only)

Androxy® (PAR, Restricted to male patients only) Methitest® (PAR, Restricted to male patients only) Straint® (PAR, Restricted to male patients only) Testim

® (PAR, Restricted to male patients only) Testred® (PAR, Restricted to male patients only)

14.C Antidiabetic Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands acarbose (+) chlorpropamide (PAR, +) glimepiride (+) glimepiride/pioglitaone (+) glipizide (+) glipizide er (+) glipizide xl (+) glipizide/metformin hcl (+) glucagon glyburide (+) glyburide micronized (+) glyburide/metformin hcl (+) metformin hcl 500mg, 700mg(+) metformin hcl er (+) metformin tb24 (+) nateglinide (PAR) pioglitazone hcl (+) pioglitazone hcl/metformin hcl (+) repaglinide (+)

Actoplus® Met XR (+)

Bydureon® (ST, +) Byetta® (ST) Humalog

® (+) Humulin® (+) Janumet® (+) Janumet® XR (+) Januvia® (+) Jentadueto®(+) Kombiglyze

® XR (+) Korlym® (PAR) Lantus® (+) Lantus

® Solostar (+)

Levemir® (+) Levemir® Flexpen (+) Novolin® (+) Novolog

® (+) Onglyza® (+) Prandimet® (+) Proglycem

®

(PAR except Endocrinologists) Riomet® (+) Symlin® (PAR, +) Tolbutamide

® (+) Tradjenta® Victoza® (ST)


14.D Contraceptives

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands altavera (+) amethia (+) amethyst (+) apri (+) aranelle (+) avaine (+) azurette (+) balziva (+) briellyn (+) camila (+) camrese (+) caziant (+) cesia (+) cryselle‐28 (+) cyclafem 1/35 (+) cyclafem 7/7/7 (+) emoquette (+) enpresse‐28 (+) errin (+) gianvi (+) gildess fe 1.5/30 (+) gildess fe 1/20 (+) heather (+) introvale (+) jolessa (+) jolivette (+) junel 1.5/30 (+) junel 1/20 (+) junel fe 1.5/30 (+) junel fe 1/20 (+) kariva (+) kelnor 1/35 (+) leena (+) lessina‐28 (+) levonorgestrel (QL) levora 0.15/30‐28 (+) loryna (+) low‐ogestrel (+)

lutera (+) microgestin 1.5/30 (+) microgestin 1/20 (+) microgestin fe (+) microgestin fe 1.5/30 (+) mononessa (+) necon 0.5/35‐28 (+) necon 7/7/7 (+) next choice (QL) nora‐be (+) norethindrone (+) norgestimate/ ethinyl estradiol (+)

norgestrel/ ethinyl estradiol (+)

nortrel 0.5/35 (+) nortrel 1/35 (+) nortrel 7/7/7 (+) ocella (+) orsythia (+) portia‐28 (+) previfem (+) quasense (+) reclipsen (+) solia (+) sprintec 28 (+) sronyx (+) syeda (+) tilia fe (+) tri‐legest fe (+) tri‐previfem (+) tri‐sprintec (+) trinessa (+) trivora‐28 (+) velivet (+) zarah (+) zenchent (+) zeosa (+)

Ella® (QL) Lo Loestrin® FE (+) Necon® 1/50‐28 (+) Necon® 10/11‐28 (+) Nuvaring® (QL) OrthoEvra® Patch Ortho Tri‐cyclen

® Lo (+) Plan

® B One Step (QL)

14.E Estrogens and Antiestrogens

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands covaryx (+) covaryx hs (+) eemt (+) eemt hs (+) essian (+) essian h.s. (+) esterified estrogens/methyltestosterone (+) esterified estrogens/methyltestosterone ds (+) esterified estrogens/methyltestosterone hs (+) estradiol (+) estradiol/norethindrone acetate (+) estropipate (+) jevantique (+) jinteli (+) methyltestosterone/esterified estrogens (+) methyltestosterone/esterified estrogens hs (+) mimvey (+) ortho‐est (+) raloxifene hcl

Alora®(+)

Angeliq® (+)

Combipatch® (+) Estraderm®

(+) Estring

® (+)

Femhrt® Low Dose (Restricted to female patients) Femring® (+) Menostar

® (+)

Minivelle® Premarin® (+) Premphase

® (+)

Prempro® (+, Maximum patient age of 64) Vagifem®

(+) Vivelle‐Dot® (+)


14.F Gonadotropins

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands Synarel® (PAR)

14.G Parathyroid

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands calcitonin‐salmon (+) fortical (+)

Forteo® (PAR)

14.H Pituitary

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands desmopressin acetate (+) minirin (+) octreotide (PAR)

Stimate® (+)

14.I Progestins

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands medroxyprogesterone acetate (+) norethindrone acetate (+) progesterone micronized (+)

14.J Sodium‐Glucose Cotransporter 2 Inhibitors

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands Invokana® (PAR)

14.K Somatotropin Agonists and Antagonists

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands Genotropin® (PAR)

Increlex® (PAR)

Norditropin® (PAR) Somavert

® (PAR)

14.L Thyroid and Antithyroid Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands levothroid (+) levothyroxine sodium (+) levoxyl (+) liothyronine sodium (+) methimazole np thyroid (+) propylthiouracil unithroid (+) unithroid direct (+)

Armour® Thyroid (+) Synthroid® (+)

CHAPTER 15 ‐ Miscellaneous Therapeutic Agents

15.A 5‐Alpha‐Reductase Inhibitors

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands finasteride (+, Restricted to male patients only) Avodart® (+, Restricted to male patients only)

15.B Alcohol Deterrents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands disulfiram (PAR)


15.C Antidotes

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands acetylcysteine leucovorin calcium

15.D Antigout Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands allopurinol Colcrys®

Uloric® (ST)

15.E Biologic Response Modifiers

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands Actimmune® (PAR)

Avonex® (PAR) Copaxone® (PAR) GilenyaTM

(PAR) Tecfidera® (PAR) Thalomid®

15.F Bone Resorption Inhibitors

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands alendronate sodium (+) etidronate disodium (+)

Actonel® (ST +) Atelvia® (ST +) Fosamax

® Plus D (+)

15.G Disease‐Modifying Antirheumatic Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands leflunomide (PAR) Enbrel® (PAR)

Enbrel® Sureclick (PAR) Humira® (PAR) Humira

® Pen (PAR)

15.H Immunosuppressive Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands azathioprine cyclosporine cyclosporine modified gengraf mycophenolate mofetil (+) sirolimus (PAR) tacrolimus

Azasan®

Zortress® (PAR)


15.I Other Miscellaneous Therapeutic Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands mycophenolic acid dr (PAR) Ampyra® (PAR)

Arcalyst® (PAR) Elmiron® (PAR, QL, +) Kuvan® (PAR, +) Orfadin® (PAR) Sensipar® (+) Synagis® (PAR)

15.J Protective Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands Mesnex® (PAR)

CHAPTER 16 ‐ Respiratory Tract Agents

16.A Anti‐Inflammatory Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands cromolyn sodium (PAR) cromolyn sodium oral montelukast sodium (+ ) montelukast sodium chews (+, limited to ages 1‐5 years ) zafirlukast

16.B Antitussives

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands benzonatate chlordex gp de‐chlor dr dm‐pe‐chlor entre‐s hydrocodone polistirex/chlorpheniramine polistirex p chlor dm pseudo cough qual‐tussin relacon‐dm nr relasin dm sutan‐dm tl‐dex dm zotex‐12d

Broncopectol®

Despec‐EXP® Giltuss

® Giltuss

® Pediatric Giltuss® TR Lartus

® Neotuss® Plus Nortuss‐EX

® Rezira® Tanafed

® DMX Tussicaps® Tusso‐DMR

® Z‐Cof

® DMX Zonatuss

® Zotex‐DM® Zotex‐EX

® Zotex‐G®

16.C Mucolytic Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands sodium chloride 0.9%, 3%, 7%, 10%


16.D Respiratory, Other

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands Kalydeco® (PAR)

CHAPTER 17 ‐ Skin and Mucous Membrane Preparations

17.A Anti‐Infectives

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands acticin acyclovir ointment benzoyl peroxide cleanser, wash centany ciclopirox nail laquer, olamine, topical soln kit clearplex x clindacin‐p clindamax clindamycin phosphate clindamycin/benzoyl peroxide clotrimazole clotrimazole/betamethasone diproprionate econazole nitrate ery erythromycin erythromycin/benzoyl peroxide exoderm fungicure intensive with nail guard gentamicin sulfate isopropyl alcohol ketoconazole (PAR) lavoclen‐4 creamy wash lavoclen‐8 creamy wash lindane malathion metronidazole mexar wash mupirocin neomycin/polymyxin b sulfates nuzole nyamyc nystatin‐triamcinolone cream oscion pacnex wash pedi‐dri permethrin pr benzoyl peroxide wash se bpo wash seb‐prev wash selenium sulfide silver sulfadiazine sodium sulfacetamide sodium sulfacetamide wash ssd ssd af sulfacetamide sodium terconazole thermazene tl bpo mx cleanser vandazole versiclear vitazol zaclir cleansing zazole

Acanya®

Acid Jelly®

Akne‐Mycin® Ala® Quin AVC® Benzalkonium

® Chloride Boric® Acid Cleocin® Eurax® Noritate®


17.B Anti‐Inflammatory Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands ala‐cort alclometasone diproprionate alphatrex amcinonide anucort‐hc apexicon augmented betamethasone diproprionate betamethasone valerate clobetasol propionate cream, oint, gel, soln clobetasol propionate emollient colocort cormax cortalo desonide desoximetasone diflorasone diacetate fluocinonide cream 0.05% fluocinonide emollient base fluocinonide‐e fluticasone propionate fluticasone propionate lotion 0.05% halac halobetasol propionate halonate pac hemril‐30 hydrocortisone hydrocortisone acetate hydrocortisone acetate/aloe hydrocortisone butyrate hydrocortisone in absorbase hydrocortisone valerate lokara mometasone furoate oralone prednicarbate procto‐pak proctocream hc proctosol hc proctozone‐hc scalacort triamcinolone acetonide triamcinolone in orabase triderm

Capex®

Cordran® Tape Derma‐Smoothe® Halog® Nystatin®

17.C Antipruritics and Local Anesthetics

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands ethyl chloride exacatacain lidazone hc lidocaine lidocaine hcl lidocaine hcl jelly lidocaine patch lidocaine hcl/hydrocortisone acetate lidocaine/prilocaine phenazopyridine hcl (+) topex topical anesthetic

Anacaine®

Orasep® Pontocaine

®


17.D Astringents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands hypercare

17.E Cell Stimulants and Proliferants

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands avita tretinoin tretinoin emollient tretinoin microsphere gel

17.F Keratolytic Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands aliclen bp 10‐1 cerisa wash clenia prascion rosanil cleanser salacyn salicylic acid cream, lotion se 10‐5 ss sodium sulfacetamide/sulfur sodium sulfacetamide/sulfer cleanser in urea sodium sulfacetamide/sulfer cleansing cloths sodium sulfacetamide/sulfur wash sulfacetamide sodium/sulfer cleanser sulfacleanse 8/4 suphera zencia

17.G Keratoplastic Agents

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands Coal® Tar

Coal® Tar Base

17.H Skin and Mucous Membrane Agents, Miscellaneous

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands acitretin (PAR) adapalene ammonium lactate cream, lotion amnesteem (PAR) calcipotriene (PAR) calcipotriene 0.005% (PAR except Dermatology) calcitriol ointment (PAR) claravis (PAR) diclofenac sodium (PAR) fluorouracil imiquimod (PAR, QL) myorisan (PAR except Dermatology) podofilox sotret (PAR) zenatane (PAR except Dermatology)

Azelex®

Carac®

Condylox®

Elidel® (PAR) Fabior® (PAR QL) Finacea® Finacea® Plus Protopic

® (PAR)

Veregen® Ziana®

CHAPTER 18 ‐ Smooth Muscle Relaxants

18.A Genitourinary Smooth Muscle Relaxants

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands flavoxate hcl (+) oxybutynin chloride (+) oxybutynin chloride er (ST, +) tolterodine tartrate (ST, +) tolterodine tartrate er (ST, +) trospium chloride (ST, +) trospium chloride er (ST, +)

Enablex® (ST, +)


18.B Respiratory Smooth Muscle Relaxants

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands aminophylline (+) theochron (+) theophylline (+) theophylline cr (+) theophylline er (+)

CHAPTER 19 – Vitamins

19.A Multivitamin Preparations

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands ferrogels (+) hematogen (+)multivitamin with fluoride (prescription versions only) sodium fluoride chew tabs (prescription versions only) trigels (+)

Rena‐Vite® (PAR, +) Dialyvite

® (PAR, +)

Nephronex® (PAR, +) Vol‐Care® (PAR, +)

19.B Vitamin B Complex

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands airavite (+) bp vit 3 (+) cyanocobalamin inj fabb (+) folbee (+) folbic (+) folcaps (+) folic acid (+) folic acid/vitamin b‐6/vitamin b‐12 (+) mi‐omega nf (+) niacor (+) nufol (+) tl gard rx (+)

19.C Vitamin D

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands calcitriol (+) ergocalciferol (+) paricalcitrol (ST, +) vitamin d (+)

19.D Vitamin K Activity

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands mephyton (+)

19.E Vitamins, Miscellaneous

Tier 1 ‐ Covered Generics Tier 2 ‐ Covered Brands levocarnitine 330mg (PAR) polysaccharide iron forte (+)

Ferrex® 150 Forte (+) Myferon® 150 Forte (+) Pol‐iron® 150 Forte (+) iFerex

® 150 Forte (+)


ADDITIONAL SERVICE FOR FAMILY HEALTH PLUS® MEMBERS

NON‐PRESCRIPTION DRUGS/OTC DRUGS

Independent Health’s Family Health Plus benefit allows coverage only for over‐the‐counter drugs that are listed in the formulary. Covered over‐the‐counter drugs must have a prescription.

ANTIHISTAMINE INSULIN

Antihistamine and decongestant syrup Insulin injection U‐100

Brompheniramine Tabs Insulin suspension isophane 70% with insulin injection 30% U‐100 Chlorpheniramine Tabs

Diphenhydramine Caps, Liquid Insulin suspension, isophane U‐100

Loratadine Tabs, Syrup Insulin zinc suspension 70%/30%

Loratadine/P‐Ephedrine SMOKING CESSATION AGENTS

FAMILY PLANNING Nicotine Gum, Lozenges

Contraceptive Cream Transdermal Nicotine

Contraceptive Foam Kit MISCELLANEOUS

Contraceptive Jelly Plan B (no prescription required for age 17 years or older)

Contraceptive Suppositories

MEDICAL SUPPLIES

DIABETIC DIAGNOSTICS HEARING AID BATTERY

Blood Glucose Monitors and Blood Glucose/Reagent Strips*Preferred Meters Only* Accu‐Chek®: Active, Advantage, Aviva Plus, Compact, and Nano SmartView OneTouch®: Ultra, Ultra 2, UltraMini, Ultra Smart, Verio IQ, and Verio Sync

Battery for use in hearing device

Zinc Air Battery for Cochlear

DIABETIC DAILY CARE

Alcohol or peroxide, per pint

Blood or ketone test or reagent strips

Alcohol wipes

Infusion set for external insulin pump

Insulin pen, reusable

Insulin syringes

Urine Test or Reagent strips or tablets Lancets

Normal, low and high calibrator solution/chips Needle, sterile any size

Replacement battery for use with home blood glucose monitor

Spring‐powered device for lancet

Supplies for self administration

Syringe, with or without needle


INDEX

A

abacavir sulfate .................................................................................. 5 abacavir sulfate/lamivudine/zidovudine ............................................ 5 acamprosate calcium tab dr ............................................................. 14 Acanya

® ............................................................................................. 26 acarbose ........................................................................................... 21 acebutolol hcl ..................................................................................... 9 acetaminophen/caffeine/dihydrochodein/bitartrate ...................... 11 acetaminophen/codeine .................................................................. 11 acetaminophen/codeine phosphate ................................................ 11 acetasol hc ........................................................................................ 18 acetazolamide .................................................................................. 19 acetazolamide er .............................................................................. 19 acetic acid ......................................................................................... 19 acetic acid 0.25% .............................................................................. 16 acetic acid/aluminum acetate .......................................................... 19 acetylcysteine ................................................................................... 24 Acid Jelly

® .......................................................................................... 26 acitretin ............................................................................................ 28 acorn balanced salt solution ............................................................. 19 acticin ............................................................................................... 26 Actimmune

® ...................................................................................... 24 Actonel® ............................................................................................ 24 Actoplus

® Met XR ............................................................................. 21 Acuvail® ............................................................................................. 18 acyclovir .............................................................................................. 5 acyclovir ointment ............................................................................ 26 adapalene ......................................................................................... 28 Adcirca

®............................................................................................. 11 adefovir dipivoxil tab .......................................................................... 5 Adrenaclick

® ........................................................................................ 7 Advair

® Diskus ..................................................................................... 7 Advair

® HFA ......................................................................................... 7 afeditab cr .......................................................................................... 9 Afinitor® .............................................................................................. 6 Aggrenox

® ........................................................................................... 8 airavite .............................................................................................. 29 ak‐dilate ............................................................................................ 19 Akne‐Mycin

® ..................................................................................... 26 ak‐poly‐bac ....................................................................................... 18 ak‐tob ............................................................................................... 18 Ala

® Quin ........................................................................................... 26 ala‐cort ............................................................................................. 27 Albenza

® .............................................................................................. 4 albuterol sulfate ................................................................................. 7 albuterol sulfate er ............................................................................. 7 alclometasone diproprionate ........................................................... 27 Aldactazine® ...................................................................................... 10 alendronate sodium ......................................................................... 24 Alferon

® N ........................................................................................... 5 alfuzosin hcl er .................................................................................... 7 aliclen ............................................................................................... 28 Alinia

® ................................................................................................. 5 Alkeran

® .............................................................................................. 6 allopurinol ........................................................................................ 24 Alomide® ........................................................................................... 18 Alora

® ................................................................................................ 22 Alphagan® P ....................................................................................... 19 alphatrex........................................................................................... 27 alprazolam ........................................................................................ 14 alprazolam er .................................................................................... 14

alprazolam odt ................................................................................. 14 alprazolam xr .................................................................................... 14 Alrex® ................................................................................................ 18 altafrin .............................................................................................. 19 altavera ............................................................................................ 22 Alvesco® ............................................................................................ 21 amantadine hcl ................................................................................. 14 amcinonide ....................................................................................... 27 amethia ............................................................................................ 22 amethyst .......................................................................................... 22 amiloride hcl ..................................................................................... 16 amiloride/hctz .................................................................................. 16 aminoacetic acid .............................................................................. 16 aminocaproic acid .............................................................................. 8 aminophylline ................................................................................... 29 amiodarone hcl ................................................................................ 10 amitriptyline hcl ............................................................................... 15 amlodipine besylate ........................................................................... 9 amlodipine besylate/atorvastatin calcium tabs ................................. 9 amlodipine besylate/benazepril hcl ................................................... 9 ammonium lactate cream, lotion ..................................................... 28 amnesteem ...................................................................................... 28 amoxapine ........................................................................................ 15 amoxicillin .......................................................................................... 4 amoxicillin cap/clarithro tab/lansoprazole cap dr ............................ 20 amoxicillin/clavulanate potassium ..................................................... 4 amoxicillin/clavulanate potassium er ................................................. 4 amphetamine/dextroamphetamine ................................................ 13 amphetamine/dextroamphetamine er ............................................ 13 ampicillin ............................................................................................ 4 Ampyra

®............................................................................................ 25 Anacaine® ......................................................................................... 27 anagrelide hydrochloride ................................................................... 8 anastrozole ......................................................................................... 6 Androderm

® ...................................................................................... 21 Androgel

® ......................................................................................... 21 Android

® ........................................................................................... 21 Androxy® ........................................................................................... 21 Angeliq® ............................................................................................ 22 anolor 300 ........................................................................................ 11 Anoro® Ellipta ..................................................................................... 6 Antihistamine and decongestant syrup ............................................ 30 antipyrine/benzocaine ..................................................................... 19 anucort‐hc ........................................................................................ 27 apexicon ........................................................................................... 27 Apokyn

® ............................................................................................ 14 apraclonidine.................................................................................... 19 apri ................................................................................................... 22 Apriso® .............................................................................................. 19 Aptivus

® .............................................................................................. 5 aranelle ............................................................................................ 22 Aranesp® ............................................................................................. 8 Arcalyst

® ........................................................................................... 25 Arcapta® Neohaler .......................................................................... See Armour

® Thyroid ............................................................................... 23 Asacol® .............................................................................................. 19 Asacol® HD ........................................................................................ 19 ascomp/codeine ............................................................................... 11 asmalpred plus ................................................................................. 21 Asmanex® ......................................................................................... 21 Atelvia

® ............................................................................................. 24 atenolol .............................................................................................. 9 atenolol/chlorthalidone ..................................................................... 9


atorvastatin calcium ........................................................................... 9 atovaquone ........................................................................................ 5 Atripla® ................................................................................................ 5 Atropen® ............................................................................................. 6 Atrovent®HFA ...................................................................................... 6 augmented betamethasone diproprionate ...................................... 27 Auvi‐Q

TM ............................................................................................. 7 avaine ............................................................................................... 22 AVC® .................................................................................................. 26 avidoxy ............................................................................................... 4 avita .................................................................................................. 28 Avodart® ............................................................................................ 23 Avonex® ............................................................................................ 24 Azasan® ............................................................................................. 24 azathioprine ...................................................................................... 24 azelastine hcl .................................................................................... 18 Azelex

® .............................................................................................. 28 Azilect® .............................................................................................. 14 azithromycin ....................................................................................... 4 Azopt

® ............................................................................................... 19 azurette ............................................................................................ 22

B

bacitracin/polymyxin b ..................................................................... 18 Bacitracin® ......................................................................................... 18 baclofen .............................................................................................. 7 balanced salt solution ....................................................................... 19 balsalazide disodium ........................................................................ 19 balziva ............................................................................................... 22 Banzel

® .............................................................................................. 13 Baraclude® .......................................................................................... 5 baycadron ......................................................................................... 21 belladonna & opium suppositories ..................................................... 6 belladonna alkaloids ........................................................................... 6 belladonna alkaloids & opium ............................................................ 6 belladonna alkaloids/phenobarbital ................................................... 6 benazepril hcl ................................................................................... 10 benazepril hcl/hydrochlorothiazide .................................................. 10 Benzalkonium

® Chloride .................................................................... 26 benzonatate...................................................................................... 25 benzoyl peroxide cleanser, wash ...................................................... 26 benztropine mesylate ....................................................................... 14 betamethasone valerate .................................................................. 27 betaxolol hcl ....................................................................................... 9 bethanechol chloride .......................................................................... 7 Betimol

® ............................................................................................ 19 Betopic‐S® ......................................................................................... 19 bicalutamide ....................................................................................... 6 bio‐statin ............................................................................................ 4 bisoprolol fumarate ............................................................................ 9 bisoprolol fumarate/hydrochlorothiazide .......................................... 9 Blephamide

® ..................................................................................... 18 Blephamide® S.O.P. ........................................................................... 18 Boric

® Acid ......................................................................................... 26 bp 10‐1 ............................................................................................. 28 bp 8 cough ........................................................................................ 25 bp vit 3 .............................................................................................. 29 briellyn .............................................................................................. 22 Brilinta® ............................................................................................... 8 brimonidine tartrate ......................................................................... 19 Bromfenac

® ....................................................................................... 18 bromocriptine mesylate ................................................................... 14 Brompheniramine Tabs .................................................................... 30 Broncopectol® ................................................................................... 25

budeprion sr ..................................................................................... 15 budeprion xl ..................................................................................... 15 budesonide ....................................................................................... 21 budesonide suspension .................................................................... 21 bumetanide ...................................................................................... 16 bupap ............................................................................................... 11 buprenorphine hcl ............................................................................ 11 buprenorphine/naloxone ................................................................. 11 buproban .......................................................................................... 15 bupropion hcl ................................................................................... 15 bupropion hcl er ............................................................................... 15 bupropion hcl sr ............................................................................... 15 bupropion hcl xl ................................................................................ 15 buspirone hcl .................................................................................... 14 butal/asa/caff ................................................................................... 11 butalbital compound ........................................................................ 11 butalbital/acetaminophen ............................................................... 11 butalbital/acetaminophen/caffeine ................................................. 11 butalbital/acetaminophen/caffeine/codeine ................................... 11 butalbital/apap/caffeine .................................................................. 11 butalbital/asa/caffeine ..................................................................... 11 butalbital/aspirin/caffeine ............................................................... 11 butalbital/aspirin/caffeine/codeine ................................................. 11 butisol sodium .................................................................................. 14 butorphanol tartrate ........................................................................ 11 Bydureon

® ........................................................................................ 21 Byetta® .............................................................................................. 21

C

cabergoline ....................................................................................... 14 cafgesic ............................................................................................. 11 cafgesic forte .................................................................................... 11 calcipotriene ..................................................................................... 28 calcipotriene 0.005% ........................................................................ 28 calcitonin‐salmon ............................................................................. 23 calcitriol ............................................................................................ 29 calcitriol ointment ............................................................................ 28 calcium acetate ................................................................................ 17 camila ............................................................................................... 22 camrese ............................................................................................ 22 Canasa

® ............................................................................................. 19 candesartan cilexetil/hydrochlorothiazide ....................................... 10 capecitabine ....................................................................................... 6 Capex

® .............................................................................................. 27 Caprelsa

® ............................................................................................ 6 captopril ........................................................................................... 10 captopril/hydrochlorothiazide ......................................................... 10 Carac® ............................................................................................... 28 Carbaglu® .......................................................................................... 16 carbamazepine ................................................................................. 13 carbamazepine er ............................................................................. 13 carbidopa/levodopa ......................................................................... 14 carbidopa/levodopa cr ..................................................................... 14 carbidopa/levodopa er ..................................................................... 14 carbidopa/levodopa odt ................................................................... 14 carbidopa/levodopa sr ..................................................................... 14 carbidopa/levodopa/entacapone tabs ............................................. 14 carisoprodol ....................................................................................... 7 carisoprodol/aspirin ........................................................................... 7 carisoprodol/aspirin/codeine ............................................................. 7 carteolol hcl ...................................................................................... 19 cartia xt .............................................................................................. 9 carvedilol ............................................................................................ 9 Cayston® ............................................................................................. 4


caziant .............................................................................................. 22 cefaclor ............................................................................................... 4 cefaclor er ........................................................................................... 4 cefadroxil ............................................................................................ 4 cefdinir ................................................................................................ 4 cefpodoxime proxetil .......................................................................... 4 cefprozil .............................................................................................. 4 Ceftin

® ................................................................................................. 4 cefuroxime axetil ................................................................................ 4 Celontin® ........................................................................................... 13 centany ............................................................................................. 26 cephadyn .......................................................................................... 11 cephalexin .......................................................................................... 4 cerisa wash ....................................................................................... 28 cesia .................................................................................................. 22 cevimeline .......................................................................................... 7 Chantix

® .............................................................................................. 6 Chemet® ............................................................................................ 21 cheratussin dac ................................................................................. 25 chloral hydrate ................................................................................. 14 chlordex gp ....................................................................................... 25 chlordiazepoxide hcl ......................................................................... 14 chlordiazepoxide hcl/clidinium bromide ............................................ 6 chlordiazepoxide/amitriptyline ........................................................ 15 chlordiazepoxide/clidinium ................................................................ 6 chlorhexidine gluconate ................................................................... 18 chloroquine phosphate ...................................................................... 5 chlorothiazide ................................................................................... 16 Chlorpheniramine Tabs .................................................................... 30 chlorpromazine hcl ........................................................................... 15 chlorpropamide ................................................................................ 21 chlorthalidone .................................................................................. 16 chlorzoxazone ..................................................................................... 7 cholestyramine ................................................................................... 9 cholestyramine light ........................................................................... 9 choline magnesium trisalicylate ....................................................... 11 ciclopirox nail laquer, olamine, topical soln kit................................. 26 cilostazol ............................................................................................. 8 cimetidine ......................................................................................... 20 cimetidine hcl ................................................................................... 20 Ciprodex

® .......................................................................................... 18 ciprofloxacin er ................................................................................... 4 ciprofloxacin hcl .................................................................................. 4 ciprofloxacin hcl otic soln ................................................................. 18 citalopram hydrobromide ................................................................. 15 citric acid/sodium citrate .................................................................. 16 claravis .............................................................................................. 28 clarithromycin ..................................................................................... 4 clarithromycin er ................................................................................ 4 clearplex x ......................................................................................... 26 clenia ................................................................................................ 28 cleocin pediatric granules ................................................................... 4 Cleocin

® ......................................................................................... 4, 26 clindacin‐p ........................................................................................ 26 clindamax ......................................................................................... 26 clindamycin hcl ................................................................................... 4 clindamycin palmitate hcl ................................................................... 4 clindamycin phosphate ..................................................................... 26 clindamycin/benzoyl peroxide .......................................................... 26 clobetasol propionate cream, oint, gel, soln .................................... 27 clobetasol propionate emollient ...................................................... 27 clomipramine hcl .............................................................................. 15 clonazepam ...................................................................................... 13 clonazepam odt ................................................................................ 13 clonidine hcl ...................................................................................... 10

clorazepate dipotassium .................................................................. 14 clotrimazole ...................................................................................... 26 clotrimazole/betamethasone diproprionate .................................... 26 clozapine .......................................................................................... 15 Coal® Tar ........................................................................................... 28 Coal

® Tar Base ................................................................................... 28 Coartem® ............................................................................................ 5 codeine sulfate ................................................................................. 11 co‐gesic............................................................................................. 11 Colcrys® ............................................................................................. 24 colestipol hcl ...................................................................................... 9 colidrips pediatric ............................................................................... 6 colocort ............................................................................................ 27 Colyte® Flavor Packs .......................................................................... 20 Combigan® ........................................................................................ 19 Combipatch

® ..................................................................................... 22 Combivent® ......................................................................................... 7 Combivir® ............................................................................................ 5 compro ............................................................................................. 15 Comtan

® ........................................................................................... 14 Condylox® ......................................................................................... 28 constulose ........................................................................................ 16 Contraceptive Cream........................................................................ 30 Contraceptive Foam Kit .................................................................... 30 Contraceptive Jelly ........................................................................... 30 Contraceptive Suppositories ............................................................ 30 Copaxone

® ........................................................................................ 24 Cordran® Tape ................................................................................... 27 cormax .............................................................................................. 27 cortalo .............................................................................................. 27 Cortisone

® Acetate ............................................................................ 21 corvita 150 ......................................................................................... 8 covaryx ............................................................................................. 22 covaryx hs ......................................................................................... 22 Creon

® .............................................................................................. 20 Crixivan

® ............................................................................................. 5 cromolyn sodium ........................................................................ 18, 25 cromolyn sodium oral ...................................................................... 25 cryselle‐28 ........................................................................................ 22 Cuprimine

® ....................................................................................... 21 Cutivate

® ........................................................................................... 27 cyanocobalamin inj .......................................................................... 29 cyclafem 1/35 ................................................................................... 22 cyclafem 7/7/7 ................................................................................. 22 cyclobenzaprine hcl ............................................................................ 7 cyclophosphamide ............................................................................. 6 cyclosporine ..................................................................................... 24 cyclosporine modified ...................................................................... 24 cyproheptadine .................................................................................. 5 Cystadane

® ....................................................................................... 20 Cystaran® .......................................................................................... 19 cytra k crystals .................................................................................. 16 cytra‐2 .............................................................................................. 16 cytra‐3 .............................................................................................. 16 cytra‐k .............................................................................................. 16

D

danazol ............................................................................................. 21 dantrolene sodium ............................................................................. 7 dapsone .............................................................................................. 5 Daraprim

® ........................................................................................... 5 de‐chlor dr ........................................................................................ 25 Delzicol® ............................................................................................ 19 demeclocycline hcl ............................................................................. 4


depade .............................................................................................. 15 Depen® Titratabs ............................................................................... 21 Derma‐Smoothe® .............................................................................. 27 Dermotic® ......................................................................................... 18 desipramine hcl ................................................................................ 15 desmopressin acetate....................................................................... 23 desonide ........................................................................................... 27 desoximetasone ............................................................................... 27 Despec‐EXP

®...................................................................................... 25 dexamethasone ................................................................................ 21 dexamethasone sodium phosphate ................................................. 18 dexmethylphenidate hcl ................................................................... 13 dexmethylphenidate hcl er ............................................................... 13 Dexpak® ............................................................................................. 21 dextroamphetamine sulfate ............................................................. 13 dextroamphetamine sulfate er ......................................................... 13 dextromethorphan hbr/chlorpheniramine/phenylephrine hcl ........ 25 dextromethorphan hbr/phenylephrine hcl/chlorpheniramine ........ 25 DIABETIC DAILY CARE ...................................................................... 30 DIABETIC DIAGNOSTICS ................................................................... 30 Dialyvite

® .......................................................................................... 29 diazepam .......................................................................................... 14 diazepam intensol ............................................................................ 14 Dibenzyline® ........................................................................................ 7 diclofenac misoprostol ..................................................................... 11 diclofenac potassium ........................................................................ 11 diclofenac sodium ................................................................. 11, 18, 28 diclofenac sodium dr ........................................................................ 11 diclofenac sodium ec ........................................................................ 11 diclofenac sodium er ........................................................................ 11 diclofenac sodium xr ......................................................................... 11 dicloxacillin sodium ............................................................................ 4 dicyclomine hcl ................................................................................... 6 didanosine .......................................................................................... 5 diflorasone diacetate ........................................................................ 27 diflunisal ........................................................................................... 11 digoxin .............................................................................................. 10 Dilantin

® ............................................................................................ 13 Dilantin® Infatabs .............................................................................. 13 dilatrate sr ........................................................................................ 11 dilt‐cd .................................................................................................. 9 diltiazem cd ........................................................................................ 9 diltiazem hcl........................................................................................ 9 diltiazem hcl er ................................................................................... 9 dilt‐xr .................................................................................................. 9 diltzac ................................................................................................. 9 Diovan

® ............................................................................................. 10 Diphenhydramine Caps, Liquid ......................................................... 30 diphenoxylate/atropine .................................................................... 19 dipyridamole ..................................................................................... 11 disopyramide phosphate .................................................................. 10 disulfiram .......................................................................................... 23 Diuril® ................................................................................................ 16 divalproex sodium ............................................................................ 13 divalproex sodium dr ........................................................................ 13 divalproex sodium er ........................................................................ 13 dm‐pe‐chlor ...................................................................................... 25 donepezil ............................................................................................ 7 Donnatal® Extentabs .......................................................................... 6 dorzolamide hcl ................................................................................ 19 dorzolamide hcl/timolol maleate ..................................................... 19 doxazosin mesylate ............................................................................ 8 doxepin hcl ....................................................................................... 15 doxycycline ......................................................................................... 4 doxycycline hyclate ............................................................................. 4

doxycycline monohydrate .................................................................. 4 dronabinol ........................................................................................ 20 Dulera® ............................................................................................. 21 duloxetine hcl ................................................................................... 15 duraxin ............................................................................................. 11 Dutoprol

® ............................................................................................ 9

E

e.e.s. 400 ............................................................................................ 4 e.s.p. ................................................................................................... 4 econazole nitrate ............................................................................. 26 ed baclofen ......................................................................................... 7 ed k+10 ............................................................................................. 17 ed‐flex .............................................................................................. 11 eemt ................................................................................................. 22 eemt hs ............................................................................................ 22 effer‐k ............................................................................................... 17 effervescent pot chloride ................................................................. 17 effervescent potassium .................................................................... 17 effervescent potassium/chloride ..................................................... 17 Effient

® ............................................................................................... 8 Elidel® ............................................................................................... 28 Eliquis

® ................................................................................................ 8 Ella

® .................................................................................................. 22 Elmiron® ............................................................................................ 25 Emcyt® ................................................................................................ 6 Emend

® ............................................................................................. 20 Emend® 40mg, 80mg, 125mg............................................................ 20 emoquette ....................................................................................... 22 Emtriva

® .............................................................................................. 5 Enablex® ............................................................................................ 28 enalapril maleate ............................................................................. 10 enalapril maleate/hydrochlorothiazide ............................................ 10 Enbrel

® .............................................................................................. 24 Enbrel

® Sureclick ............................................................................... 24 endocet ............................................................................................ 11 endodan ........................................................................................... 11 enoxaparin sodium ............................................................................. 8 enpresse‐28 ...................................................................................... 22 entacapone ...................................................................................... 14 entre‐s .............................................................................................. 25 enulose ............................................................................................. 16 epidrin .............................................................................................. 13 epiklor .............................................................................................. 17 epiklor/25 ......................................................................................... 17 epinastine hcl ................................................................................... 18 Epinephrine

® ....................................................................................... 7 Epipen

® ............................................................................................... 7 Epipen® Jr ............................................................................................ 7 epitol ................................................................................................ 13 Epivir

® ................................................................................................. 5 Epivir®HBV soln only ........................................................................... 5 eplerenone ....................................................................................... 10 Epogen

® .............................................................................................. 8 eprosartan mesylate ........................................................................ 10 Epzicom® ............................................................................................. 5 ergocalciferol .................................................................................... 29 ergoloid mesylates ........................................................................... 14 Ergomar® .......................................................................................... 13 ergotamine tartrate/caffeine ........................................................... 13 Erivedge

TM .......................................................................................... 6 errin .................................................................................................. 22 ery 26 erythrocin sterate............................................................................... 4


erythromycin .......................................................................... 4, 18, 26 erythromycin base .............................................................................. 4 erythromycin ethylsuccinate .............................................................. 4 erythromycin/benzoyl peroxide ....................................................... 26 erythromycin/sulfisoxazole ................................................................ 4 escitalopram oxalate ........................................................................ 15 essian ................................................................................................ 22 essian h.s. ......................................................................................... 22 estazolam ......................................................................................... 14 esterified estrogens/methyltestosterone ......................................... 22 esterified estrogens/methyltestosterone ds .................................... 22 esterified estrogens/methyltestosterone hs .................................... 22 Estraderm

® ........................................................................................ 22 estradiol ............................................................................................ 22 estradiol/norethindrone acetate ...................................................... 22 Estring

® ............................................................................................. 22 estropipate ....................................................................................... 22 ethambutol hcl ................................................................................... 5 ethosuximide .................................................................................... 13 ethyl chloride .................................................................................... 27 etidronate disodium ......................................................................... 24 etodolac ............................................................................................ 11 etodolac er........................................................................................ 11 Etoposide® .......................................................................................... 6 Eurax

® ............................................................................................... 26 exacatacain ....................................................................................... 27 exemestane ........................................................................................ 6 Exjade

® .............................................................................................. 21 exoderm ........................................................................................... 26

F

fabb .................................................................................................. 29 Fabior® .............................................................................................. 28 famciclovir .......................................................................................... 5 famciclovir 500mg .............................................................................. 5 famotidine ........................................................................................ 20 Fareston

® ............................................................................................ 6 fe c .................................................................................................... 29 fec c plus ............................................................................................. 8 felbamate ......................................................................................... 13 felodipine er ....................................................................................... 9 Femhrt

® Low Dose ............................................................................. 22 Femring® ........................................................................................... 22 fenofibrate caps, tabs ......................................................................... 9 fenoprofen calcium .......................................................................... 11 fentanyl............................................................................................. 11 fentanyl citrate oral transmucosal .................................................... 11 ferocon ............................................................................................... 8 ferotin ................................................................................................. 8 ferrex 150 forte .................................................................................. 8 Ferrex

® 150 Forte .............................................................................. 29 ferrogels ........................................................................................... 29 ferrogels forte ..................................................................................... 8 Finacea® ............................................................................................ 28 Finacea® Plus ..................................................................................... 28 finasteride ........................................................................................ 23 Firmagon® ........................................................................................... 6 Flarex® ............................................................................................... 18 flavoxate hcl ..................................................................................... 28 flecainide acetate ............................................................................. 10 Flovent

® Diskus .................................................................................. 21 Flovent

® HFA ..................................................................................... 21 fluconazole ......................................................................................... 4 fluconazole 150mg ............................................................................. 4

fludrocortisone acetate .................................................................... 21 Flunisolide® ....................................................................................... 18 fluocinonide cream 0.05% ................................................................ 27 fluocinonide emollient base ............................................................. 27 fluocinonide‐e .................................................................................. 27 fluorometholone .............................................................................. 18 fluor‐op ............................................................................................ 18 fluorouracil ....................................................................................... 28 fluoxetine 10mg, 20mg .................................................................... 15 fluoxetine dr ..................................................................................... 15 fluoxetine hcl .................................................................................... 15 fluphenazine hcl ............................................................................... 15 flurazepam hcl .................................................................................. 14 flurbiprofen ...................................................................................... 11 flurbiprofen sodium ......................................................................... 18 flutamide ............................................................................................ 6 fluticasone propionate ..................................................................... 18 fluticasone propionate lotion 0.05% ................................................ 27 fluvoxamine maleate ........................................................................ 15 FML

® ................................................................................................. 18 FML® Forte ........................................................................................ 18 folbee ............................................................................................... 29 folbic ................................................................................................. 29 folcaps .............................................................................................. 29 folic acid ........................................................................................... 29 folic acid/vitamin b‐6/vitamin b‐12 .................................................. 29 folitab ................................................................................................. 8 foltrin .................................................................................................. 8 fondaparinux sodium ......................................................................... 8 Foradil

® ............................................................................................... 7 Forteo® ............................................................................................. 23 fortical .............................................................................................. 23 Fosamax

® Plus D................................................................................ 24 fosinopril sodium.............................................................................. 10 fosinopril sodium/hydrochlorothiazide ............................................ 10 Fosrenol

® .......................................................................................... 16 Fragmin® ............................................................................................. 8 fungicure intensive with nail guard .................................................. 26 furosemide ....................................................................................... 16 Fuzeon

®............................................................................................... 5

G

gabapentin ....................................................................................... 13 galantamine hydrobromide ................................................................ 7 Galzin

® .............................................................................................. 17 ganciclovir .......................................................................................... 5 garamycin ......................................................................................... 18 gavalyte‐c ......................................................................................... 20 gavilyte‐g .......................................................................................... 20 gavilyte‐n/flavor pack ....................................................................... 20 gemfibrozil ......................................................................................... 9 generic metadate cd ........................................................................ 13 generic metadate er ......................................................................... 13 generlac ............................................................................................ 16 gengraf ............................................................................................. 24 Genotropin

® ...................................................................................... 23 gentak............................................................................................... 18 gentamicin sulfate ...................................................................... 18, 26 gianvi ................................................................................................ 22 gildess fe 1.5/30 ............................................................................... 22 gildess fe 1/20 .................................................................................. 22 Gilenya

TM .......................................................................................... 24 Giltuss® ............................................................................................. 25 Giltuss® Pediatric ............................................................................... 25


Giltuss® TR ......................................................................................... 25 Gleevec® .............................................................................................. 6 glimepiride ........................................................................................ 21 glimepiride/pioglitaone .................................................................... 21 glipizide ............................................................................................. 21 glipizide er ........................................................................................ 21 glipizide xl ......................................................................................... 21 glipizide/metformin hcl .................................................................... 21 glucagon ........................................................................................... 21 glyburide ........................................................................................... 21 glyburide micronized ........................................................................ 21 glyburide/metformin hcl .................................................................. 21 glycine ............................................................................................... 16 glycopyrrolate ..................................................................................... 6 granisetron hcl .................................................................................. 20 griseofulvin ......................................................................................... 4 griseofulvin microsize ......................................................................... 4 guanfacine hcl ................................................................................... 10 guanidine hcl ...................................................................................... 7

H

halac ................................................................................................. 27 halobetasol propionate .................................................................... 27 Halog

® ............................................................................................... 27 halonate pac ..................................................................................... 27 haloperidol ....................................................................................... 15 HEARING AID BATTERY .................................................................... 30 heather ............................................................................................. 22 hematogen ................................................................................... 8, 29 hematogen forte ................................................................................ 8 hemril‐30 .......................................................................................... 27 Hexalen

® ............................................................................................. 6 homatropine ..................................................................................... 19 Humalog® .......................................................................................... 21 Humira

® ............................................................................................. 24 Humira® Pen ...................................................................................... 24 Humulin® ........................................................................................... 21 Hycamtin

® ........................................................................................... 6 hydralazine hcl .................................................................................. 10 hydrochlorothiazide ......................................................................... 16 hydrocodone bitartrate/acetaminophen ......................................... 11 hydrocodone bitartrate/apap ........................................................... 11 hydrocodone polistirex/chlorpheniramine polistirex ....................... 25 hydrocodone/acetaminophen .......................................................... 11 hydrocodone/ibuprofen ................................................................... 11 hydrocortisone ................................................................................. 27 hydrocortisone acetate .................................................................... 27 hydrocortisone acetate/aloe ............................................................ 27 hydrocortisone butyrate ................................................................... 27 hydrocortisone in absorbase ............................................................ 27 hydrocortisone methylprenisolone .................................................. 21 hydrocortisone valerate ................................................................... 27 hydrocortisone/acetic acid ............................................................... 18 hydrogesic ........................................................................................ 11 hydromorphone hcl .......................................................................... 11 hydroxychloroquine sulfate ................................................................ 5 hydroxyurea ........................................................................................ 6 hydroxyzine hcl ................................................................................. 14 hydroxyzine pamoate ....................................................................... 14 hyomax ............................................................................................... 6 hyoscyamine sulfate ........................................................................... 6 hyosyne .............................................................................................. 6 hypercare .......................................................................................... 28

I

ibuprofen .......................................................................................... 11 iferex 150 forte ................................................................................... 8 iFerex

® 150 Forte .............................................................................. 29 Ilevro® ............................................................................................... 18 ilotycin .............................................................................................. 18 imipramine hcl ................................................................................. 15 imipramine pamoate ........................................................................ 15 imiquimod ........................................................................................ 28 Incivek® ............................................................................................... 5 Increlex® ........................................................................................... 23 indapamide ...................................................................................... 16 Indocin

® ............................................................................................ 11 indomethacin ................................................................................... 11 indomethacin er ............................................................................... 11 Infergen® ............................................................................................. 5 Insulin injection U‐100 ..................................................................... 30 Insulin suspension isophane 70% with insulin injection 30% U‐100 30 Insulin suspension, isophane U‐100 ................................................. 30 Insulin zinc suspension 70%/30% ..................................................... 30 Intelence® ........................................................................................... 5 Intron‐A

® ............................................................................................. 6 introvale ........................................................................................... 22 Invirase

® .............................................................................................. 5 ipratropium bromide .......................................................................... 6 ipratropium bromide/albuterol sulfate .............................................. 7 irbesartan ......................................................................................... 10 irbesartan/hctz ................................................................................. 10 Isentress

® ............................................................................................ 5 isochron ............................................................................................ 11 isoditrate er ...................................................................................... 11 isomethaptene/dichloralphenazone/acetaminophen ..................... 13 isometheptene/caffeine/acetaminophen ........................................ 13 isonarif ............................................................................................... 5 isoniazid ............................................................................................. 5 isopropyl alcohol .............................................................................. 26 Isopto

® Carbechol ............................................................................. 19 isordil titradose ................................................................................ 11 isosorbide dinitrate .......................................................................... 11 isosorbide dinitrate er ...................................................................... 11 isosorbide mononitrate .................................................................... 11 isosorbide mononitrate er ............................................................... 11 isoxsuprine hcl .................................................................................. 11 isradipine ............................................................................................ 9 itraconazole ........................................................................................ 4

J

Jakafi® ................................................................................................. 6 jantoven ............................................................................................. 8 Janumet® .......................................................................................... 21 Janumet

® XR ..................................................................................... 21 Januvia® ............................................................................................ 21 Jentadueto® ...................................................................................... 21 jevantique ........................................................................................ 22 jinteli ................................................................................................ 22 jolessa ............................................................................................... 22 jolivette ............................................................................................ 22 junel 1.5/30 ...................................................................................... 22 junel 1/20 ......................................................................................... 22 junel fe 1.5/30 .................................................................................. 22 junel fe 1/20 ..................................................................................... 22


K

Kaletra® ............................................................................................... 5 kalexate ............................................................................................ 16 Kalydeco

® .......................................................................................... 26 kariva ................................................................................................ 22 k‐effervescent ................................................................................... 17 kelnor 1/35 ....................................................................................... 22 ketoconazole ................................................................................ 4, 26 ketoprofen ........................................................................................ 11 ketoprofen er .................................................................................... 11 ketorolac tromethamine ............................................................ 11, 18 kionex ............................................................................................... 16 klor‐con ............................................................................................. 17 klor‐con/ef ........................................................................................ 17 Kombiglyze

® XR ................................................................................ 21 Korlym® ............................................................................................. 21 k‐prime ............................................................................................. 17 Kristalose® ......................................................................................... 16 Kuvan®............................................................................................... 25 k‐vescent .......................................................................................... 17

L

labetolol hcl ........................................................................................ 9 Lacrisert® ..................................................................................... 18, 19 lactated ringers injection .................................................................. 16 lactulose ........................................................................................... 16 lamivudine .......................................................................................... 5 lamotrigine ....................................................................................... 13 lansoprazole ..................................................................................... 20 lansoprazole odt ............................................................................... 20 Lantus

® .............................................................................................. 21 Lantus® Solostar ............................................................................... 21 Lartus®............................................................................................... 25 latanoprost ....................................................................................... 19 lavoclen‐4 creamy wash ................................................................... 26 lavoclen‐8 creamy wash ................................................................... 26 leena ................................................................................................. 22 leflunomide ...................................................................................... 24 lessina‐28 .......................................................................................... 22 Letairis

® ............................................................................................. 11 letrozole .............................................................................................. 6 leucovorin calcium ............................................................................ 24 Leukeran® ............................................................................................ 6 Levemir

® ............................................................................................ 21 Levemir® Flexpen .............................................................................. 21 levetiracetam .................................................................................... 13 levobunolol hcl ................................................................................. 19 levocarnitine 330mg ......................................................................... 29 levocetirizine dihydrochloride ............................................................ 5 levofloxacin ................................................................................... 4, 18 levonorgestrel................................................................................... 22 levora 0.15/30‐28 ............................................................................. 22 levorphanol tartrate ................................................................... 11, 12 levothroid ......................................................................................... 23 levothyroxine sodium ....................................................................... 23 levoxyl ............................................................................................... 23 Lexiva

® ................................................................................................ 5 lidazone hc ........................................................................................ 27 lidocaine ........................................................................................... 27 lidocaine hcl ...................................................................................... 27 lidocaine hcl jelly .............................................................................. 27 lidocaine hcl/hydrocortisone acetate ............................................... 27 lidocaine patch ................................................................................. 27

lidocaine viscous .............................................................................. 19 lidocaine/prilocaine .......................................................................... 27 lindane.............................................................................................. 26 liothyronine sodium ......................................................................... 23 lisinopril ............................................................................................ 10 lisinopril/hydrochlorothiazide .......................................................... 10 lithium carbonate ............................................................................. 13 lithium carbonate er ......................................................................... 13 lithium citrate ................................................................................... 13 Lo Loestrin® FE ................................................................................. 22 lofene ............................................................................................... 19 lofibra ................................................................................................. 9 lokara ............................................................................................... 27 lomustine ........................................................................................... 6 lonox ................................................................................................. 19 loperamide hcl ................................................................................. 19 Loratadine Tabs, Syrup ..................................................................... 30 Loratadine/P‐Ephedrine ................................................................... 30 lorazepam......................................................................................... 14 loryna ............................................................................................... 22 losartan potassium ........................................................................... 10 losartan potassium/hydrochlorothiazide ......................................... 10 Lotemax

® .......................................................................................... 18 lovastatin ............................................................................................ 9 low‐ogestrel ..................................................................................... 22 loxapine succinate ............................................................................ 15 Lumigan

® .......................................................................................... 19 lutera ................................................................................................ 22 Lyrica® ............................................................................................... 13 Lysodren

®............................................................................................ 6

M

malathion ......................................................................................... 26 maprotiline hcl ................................................................................. 15 margesic ........................................................................................... 12 marten‐tab ....................................................................................... 12 martinic .............................................................................................. 8 Matulane

® ........................................................................................... 6 matzim la ............................................................................................ 9 Maxair® Autohaler .............................................................................. 7 Mebaral

® ........................................................................................... 14 mebendazole chew ............................................................................ 4 meclizine .......................................................................................... 20 meclofenamate sodium ................................................................... 12 medroxyprogesterone acetate ......................................................... 23 mefenamic acid ................................................................................ 12 mefloquine hcl ................................................................................... 5 megestrol acetate .............................................................................. 6 meloxicam ........................................................................................ 12 memantine ....................................................................................... 14 Menostar

® ........................................................................................ 22 mephyton ......................................................................................... 29 meprobamate .................................................................................. 14 mercaptopurine ................................................................................. 6 mesalamine ...................................................................................... 19 Mesnex® ........................................................................................... 25 Mestinon® ........................................................................................... 7 metaproterenol sulfate ...................................................................... 7 metaxalone ........................................................................................ 7 metformin hcl ................................................................................... 21 metformin hcl er .............................................................................. 21 metformin tb24 ................................................................................ 21 methadone hcl ................................................................................. 12 methadose ....................................................................................... 12


methamphetamine ........................................................................... 13 methazolamide ................................................................................. 19 methenamine mandelate ................................................................... 5 methimazole ..................................................................................... 23 Methitest® ......................................................................................... 21 methocarbamol .................................................................................. 7 methotrexate ...................................................................................... 6 methscopolamine bromide ................................................................ 6 methyldopa ...................................................................................... 10 methyldopa/hydrochlorothiazide ..................................................... 10 methylphenidate hcl ......................................................................... 13 methylphenidate hcl er .................................................................... 13 methylphenidate hcl sr ..................................................................... 13 methylphenidate hydrochloride ....................................................... 13 methyltestosterone/esterified estrogens ......................................... 22 methyltestosterone/esterified estrogens hs .................................... 22 metipranolol ..................................................................................... 19 metoclopramide hcl .......................................................................... 20 metolazone ....................................................................................... 16 metoprolol succinate er ...................................................................... 9 metoprolol tartrate ............................................................................ 9 metoprolol/hydrochlorothiazide ........................................................ 9 metronidazole .............................................................................. 5, 26 mexar wash ...................................................................................... 26 mexiletine hcl ................................................................................... 10 microgestin 1.5/30 ........................................................................... 22 microgestin 1/20 .............................................................................. 22 microgestin fe ................................................................................... 22 microgestin fe 1.5/30 ....................................................................... 22 micronized colestipol hcl .................................................................... 9 midazolam hcl ................................................................................... 14 midodrine hcl ...................................................................................... 7 migragesic ida ................................................................................... 13 Migranal

® .......................................................................................... 13 mimvey ............................................................................................. 22 minirin .............................................................................................. 23 Minivelle

® .......................................................................................... 22 minocycline hcl ................................................................................... 4 minocycline hcl er ............................................................................... 4 minoxidil ........................................................................................... 10 mi‐omega nf ..................................................................................... 29 mirtazapine ....................................................................................... 15 mirtazapine odt ................................................................................ 15 misoprostol ....................................................................................... 20 moexipril hcl ..................................................................................... 10 moexipril/hydrochlorothiazide ......................................................... 10 mometasone furoate ........................................................................ 27 mononessa ....................................................................................... 22 montelukast sodium ......................................................................... 25 montelukast sodium chews .............................................................. 25 morgidox ............................................................................................ 4 morphine sulfate .............................................................................. 12 morphine sulfate er 100mg and 200mg ........................................... 12 multivitamin with fluoride (prescription versions only) ................... 29 mupirocin ......................................................................................... 26 mycophenolate mofetil .................................................................... 24 mycophenolic acid dr........................................................................ 25 myferon 150 forte .............................................................................. 8 Myferon

® 150 Forte .......................................................................... 29 Myleran® ............................................................................................. 6 myorisan ........................................................................................... 28

N

nabumetone ..................................................................................... 12

nadolol ............................................................................................... 9 nadolol/bendroflumethiazide ............................................................ 9 Nalfon® ............................................................................................. 11 naltrexone hcl................................................................................... 15 Naprelan® ......................................................................................... 11 naproxen .......................................................................................... 12 naproxen dr ...................................................................................... 12 naproxen sodium ............................................................................. 12 naratriptan hcl .................................................................................. 13 Nasonex

® .......................................................................................... 18 Natacyn

® ........................................................................................... 18 nateglinide ....................................................................................... 21 Nebupent® .......................................................................................... 5 Nebusal® ........................................................................................... 25 necon 0.5/35‐28 ............................................................................... 22 necon 7/7/7 ...................................................................................... 22 Necon

® 1/50‐28................................................................................ 22 Necon® 10/11‐28.............................................................................. 22 nefazodone ...................................................................................... 15 neofrin .............................................................................................. 19 neomycin sulfate ................................................................................ 4 neomycin/bacitracin/polymyxin ...................................................... 18 neomycin/polymyxin b sulfates ....................................................... 26 neomycin/polymyxin/bacitracin/hydrocortisone ............................ 18 neomycin/polymyxin/dexamethasone ............................................ 18 neomycin/polymyxin/gramicidin ..................................................... 18 neomycin/polymyxin/hc .................................................................. 18 neomycin/polymyxin/hydrocortisone .............................................. 18 neo‐polycin ....................................................................................... 18 Neotuss

® Plus .................................................................................... 25 Neotuss‐D® ....................................................................................... 25 Nephronex® ...................................................................................... 29 Neulasta

® ............................................................................................ 8 Neupogen® ......................................................................................... 8 Nevanac

® .......................................................................................... 18 nevirapine er ...................................................................................... 5 nevirapine susp, tabs .......................................................................... 5 next choice ....................................................................................... 22 niacor ............................................................................................... 29 nicardipine hcl .................................................................................... 9 Nicotine Gum, Lozenges ................................................................... 30 nifediac cc .......................................................................................... 9 nifedical xl .......................................................................................... 9 nifedipine ........................................................................................... 9 nifedipine er ....................................................................................... 9 Nilandron

® .......................................................................................... 6

nimodipine ......................................................................................... 9 nislodipine er ...................................................................................... 9 nisoldipine .......................................................................................... 9 Nitro‐Bid®.......................................................................................... 11 nitrofurantoin ..................................................................................... 5 nitrofurantoin macrocrystal ............................................................... 5 nitrofurantoin macrocrystalline ......................................................... 5 nitrofurantoin monohydrate .............................................................. 5 nitrofurantoin monohydrate/macrocrystals ...................................... 5 nitroglycerin ..................................................................................... 11 nitroglycerin cr ................................................................................. 11 nitroglycerin transdermal ................................................................. 11 Nitrostat

® .......................................................................................... 11 nitro‐time ......................................................................................... 11 nizatidine .......................................................................................... 20 nodolor ............................................................................................. 13 nora‐be ............................................................................................. 22 Norditropin

® ..................................................................................... 23 norethindrone .................................................................................. 22


norethindrone acetate ..................................................................... 23 norgestimate/ethinyl estradiol ......................................................... 22 norgestrel/ethinyl estradiol .............................................................. 22 Noritate® ........................................................................................... 26 Norpace® CR ...................................................................................... 10 nortrel 0.5/35 ................................................................................... 22 nortrel 1/35 ...................................................................................... 22 nortrel 7/7/7 ..................................................................................... 22 nortriptyline hcl ................................................................................ 15 Nortuss‐EX

® ....................................................................................... 25 Norvir

® ................................................................................................ 5 Novolin® ............................................................................................ 21 Novolog® ........................................................................................... 21 Noxafil® ............................................................................................... 4 np thyroid ......................................................................................... 23 Nucynta

® ........................................................................................... 11 Nucynta® ER ...................................................................................... 11 Nuedexta® ......................................................................................... 14 nufol ................................................................................................. 29 Nuvaring

® .......................................................................................... 22 Nuvigil® ............................................................................................. 13 nuzole ............................................................................................... 26 nyamyc ............................................................................................. 26 nystatin ............................................................................................... 4 Nystatin

® ........................................................................................... 27 nystatin‐triamcinolone cream .......................................................... 26

O

ocella ................................................................................................ 22 octreotide ......................................................................................... 23 ofloxacin ....................................................................................... 4, 18 olanzapine ODT ................................................................................ 15 omeprazole ....................................................................................... 20 omeprazole/sodium bicarbonate ..................................................... 20 ondansetron hcl ................................................................................ 20 ondansetron odt ............................................................................... 20 Onfi

TM ............................................................................................... 14 Onglyza

® ............................................................................................ 21 opium ............................................................................................... 19 opium tincture .................................................................................. 19 Oracit

® ............................................................................................... 16 oralone ............................................................................................. 27 Orap

® ................................................................................................ 15 Orasep® ............................................................................................. 27 Orfadin

® ............................................................................................ 25 orphenadrine citrate er ...................................................................... 7 orphenadrine/asa/caffeine ............................................................... 12 orsythia ............................................................................................. 22 Ortho Tri‐cyclen® Lo .......................................................................... 22 ortho‐est ........................................................................................... 22 OrthoEvra

® Patch .............................................................................. 22 oscimin ............................................................................................... 6 oscion ............................................................................................... 26 Osmoprep®........................................................................................ 20 oxandrolone ..................................................................................... 21 oxaprozin .......................................................................................... 12 oxazepam ......................................................................................... 14 oxcarbazepine .................................................................................. 13 oxybutynin chloride .......................................................................... 28 oxybutynin chloride er ...................................................................... 28 oxycodone hcl ................................................................................... 12 oxycodone/acetaminophen .............................................................. 12 oxycodone/aspirin ............................................................................ 12 oxycodone/ibuprofen ....................................................................... 12

Oxycontin® ........................................................................................ 11 Oxycontin®60mg, 80mg .................................................................... 11 oxymorphone hydrochloride ............................................................ 12 oxymorphone hydrochloride er ....................................................... 12

P

p chlor dm ........................................................................................ 25 pacerone .......................................................................................... 10 pacnex wash ..................................................................................... 26 Pancreaze® ........................................................................................ 20 pantoprazole sodium ....................................................................... 20 paregoric .......................................................................................... 19 paricalcitrol ...................................................................................... 29 paromomycin sulfate ......................................................................... 5 paroxetine hcl................................................................................... 15 paroxetine hcl er .............................................................................. 15 pedi‐dri ............................................................................................. 26 peg 3350/electrolytes ...................................................................... 20 peg 3350/nacl/na bicarbonate/kcl ................................................... 20 Peganone

® ........................................................................................ 13 Pegasys

® ............................................................................................. 5 Peg‐Intron® ......................................................................................... 5 penicillin v potassium ......................................................................... 4 Pentasa

® ........................................................................................... 19 pentazocine/acetaminophen ........................................................... 12 pentazocine/naloxone hcl ................................................................ 12 pentoxifylline er ................................................................................. 8 perindopril erbumine ....................................................................... 10 periogard .......................................................................................... 18 permethrin ....................................................................................... 26 perphenazine ................................................................................... 15 perphenazine/amitriptyline ............................................................. 15 Pertzye

® ............................................................................................ 20 phenazopyridine hcl ......................................................................... 27 phenelzine sulfate ............................................................................ 15 phenobarbital ................................................................................... 14 phenylephrine hcl ............................................................................. 19 phenytoin ......................................................................................... 13 phenytoin sodium extended ............................................................ 13 Phoslyra

® .......................................................................................... 17 phospha 250 neutral ........................................................................ 17 phospholine iodide ........................................................................... 19 physiolyte ......................................................................................... 16 physiosol irrigation ........................................................................... 16 pilocarpine hcl .............................................................................. 7, 19 pilocarpine hydrochloride .................................................................. 7 Pilopine

® HS ...................................................................................... 19 pindolol .............................................................................................. 9 pioglitazone hcl ................................................................................ 21 pioglitazone hcl/metformin hcl ........................................................ 21 piroxicam .......................................................................................... 12 Plan B ............................................................................................... 30 Plan

® B One Step .............................................................................. 22 Plavix

® ................................................................................................. 8 podofilox .......................................................................................... 28 Pol‐iron® 150 Forte ........................................................................... 29 polycin b ........................................................................................... 18 poly‐dex ............................................................................................ 18 poly‐iron 150 forte ............................................................................. 8 polymyxin b sulfate/trimethoprim sulfate ....................................... 18 Poly‐Pred

® ......................................................................................... 18 polysaccharide iron forte ................................................................. 29 Pontocaine® ...................................................................................... 27 portia‐28 ........................................................................................... 22


potassium bicarbonate ..................................................................... 17 potassium chloride ........................................................................... 17 potassium chloride cr ....................................................................... 17 potassium chloride er ....................................................................... 17 potassium chloride sr ....................................................................... 17 potassium citrate .............................................................................. 16 potassium citrate/citric acid ............................................................. 16 pr benzoyl peroxide wash ................................................................. 26 Pradaxa

®.............................................................................................. 8 pramipexole dihydrochloride ........................................................... 14 Prandimet

® ........................................................................................ 21 prascion ............................................................................................ 28 pravastatin sodium ............................................................................. 9 prazosin hcl ......................................................................................... 8 Pred Mild® ......................................................................................... 18 prednicarbate ................................................................................... 27 prednisolone ..................................................................................... 21 prednisolone acetate ........................................................................ 18 prednisolone sodium phosphate ................................................ 18, 21 prednisone ........................................................................................ 21 Premarin

® .......................................................................................... 22 Premphase® ...................................................................................... 22 Prempro

® .......................................................................................... 22 prevalite .............................................................................................. 9 previfem ........................................................................................... 22 Prevpac

® ............................................................................................ 20 Prezista® .............................................................................................. 5 primaquine phosphate ....................................................................... 5 primidone ......................................................................................... 13 Proair

® HFA .......................................................................................... 7 probenecid ....................................................................................... 17 probenicid/colchicine ....................................................................... 17 prochlorperazine .............................................................................. 15 prochlorperazine maleate ................................................................ 15 Procrit

® ................................................................................................ 8 proctocream hc ................................................................................ 27 procto‐pak ........................................................................................ 27 proctosol hc ...................................................................................... 27 proctozone‐hc .................................................................................. 27 progesterone micronized ................................................................. 23 Proglycem

® ........................................................................................ 21 Promacta® ........................................................................................... 8 propafenone hcl ............................................................................... 10 propafenone hcl er ........................................................................... 10 propantheline bromide ...................................................................... 6 propranolol hcl ................................................................................... 9 propranolol hcl er ............................................................................... 9 propylthiouracil ................................................................................ 23 Prostigmin

® ......................................................................................... 7 Protopic

® ........................................................................................... 28 protriptyline hcl ................................................................................ 15 Proventil® HFA ..................................................................................... 7 pseudo cough ................................................................................... 25 Pulmicort

® ......................................................................................... 21 Pulmicort® Flexhaler .......................................................................... 21 Pulmozyme® ...................................................................................... 17 purevit dualfe plus .............................................................................. 8 pyrazinamide ...................................................................................... 5 pyridostigmine bromide ..................................................................... 7

Q

qual‐tussin ........................................................................................ 25 quasense ........................................................................................... 22 quetiapine fumarate ......................................................................... 15

quinapril hcl ...................................................................................... 10 quinapril/hydrochlorothiazide ......................................................... 10 quinidine gluconate cr ...................................................................... 10 quinidine gluconate er ..................................................................... 10 quinidine sulfate ............................................................................... 10 quinidine sulfate er .......................................................................... 10 quinine sulfate .................................................................................... 5 Qvar® ................................................................................................ 21

R

rabeprazole sodium.......................................................................... 20 raloxifene hcl .................................................................................... 22 ramipril ............................................................................................. 10 ranitidine hcl .................................................................................... 20 reclipsen ........................................................................................... 22 relacon‐dm nr ................................................................................... 25 relasin dm ......................................................................................... 25 Relenza

® Diskhaler .............................................................................. 5 Relistor® ............................................................................................ 20 Renacidin® ........................................................................................ 16 Renagel

® ........................................................................................... 16 Rena‐Vite® ........................................................................................ 29 Renvela

® ........................................................................................... 16 repaglinide ....................................................................................... 21 repan ................................................................................................ 12 reprexain .......................................................................................... 12 Rescriptor

® .......................................................................................... 5 Reserpine® ........................................................................................ 10 respivent‐d ......................................................................................... 7 Restasis

® ........................................................................................... 18 Revlimid® ............................................................................................ 6 Reyataz

®.............................................................................................. 5 Rezira® .............................................................................................. 25 ribasphere .......................................................................................... 5 ribavirin .............................................................................................. 5 Ridaura

® ............................................................................................ 20 rifabutin .............................................................................................. 5 rifampin .............................................................................................. 5 Rifater

® ............................................................................................... 5 riluzole .............................................................................................. 14 rimantadine hcl .................................................................................. 5 ringers irrigation ............................................................................... 16 Riomet

®............................................................................................. 21 risperidone ....................................................................................... 15 risperidone m‐tab............................................................................. 15 risperidone odt ................................................................................. 15 rizatriptan ......................................................................................... 13 romycin ............................................................................................ 18 ropinirole hcl .................................................................................... 14 rosanil cleanser ................................................................................ 28 roxicet .............................................................................................. 12 Rozerem

® .......................................................................................... 14

S

Sabril® ............................................................................................... 13 salacyn .............................................................................................. 28 salicylic acid cream, lotion ................................................................ 28 salsalate ............................................................................................ 12 Savella

® ............................................................................................. 14 Savella® Titration Pack ...................................................................... 14 scalacort ........................................................................................... 27 se 10‐5 ss .......................................................................................... 28 se bpo wash ...................................................................................... 26


seb‐prev wash................................................................................... 26 Seconal® ............................................................................................ 14 selegiline hcl ..................................................................................... 14 selenium sulfide ................................................................................ 26 Selzentry® ............................................................................................ 5 Sensipar

® ........................................................................................... 25 Serevent® Diskus ................................................................................. 7 sertraline hcl ..................................................................................... 15 se‐tan plus .......................................................................................... 8 SF Rowasa® ....................................................................................... 19 sildec pe‐dm ..................................................................................... 25 sildenafil ........................................................................................... 11 Silver Nitrate ..................................................................................... 18 silver sulfadiazine ............................................................................. 26 Simbrinza® ......................................................................................... 19 simvastatin ......................................................................................... 9 sirolimus ........................................................................................... 24 sodium chloride 0.45% ..................................................................... 16 sodium chloride 0.9%, 3%, 7%, 10% ................................................. 25 sodium fluoride chew tabs (prescription versions only) ................... 29 sodium polystyrene sulfonate .......................................................... 16 sodium sulfacetamide ................................................................ 18, 26 sodium sulfacetamide wash ............................................................. 26 sodium sulfacetamide/sulfer cleanser in urea.................................. 28 sodium sulfacetamide/sulfer cleansing cloths .................................. 28 sodium sulfacetamide/sulfur ............................................................ 28 sodium sulfacetamide/sulfur wash ................................................... 28 solia .................................................................................................. 22 Somavert

® ......................................................................................... 23 Sorbitol

® ............................................................................................ 16 Sorbitol‐Mannitol® ............................................................................ 16 sorine .................................................................................................. 9 sotalol hcl ........................................................................................... 9 sotret ................................................................................................ 28 Spiriva

® Handihaler ............................................................................. 6 spironolactone .................................................................................. 10 spironolactone/hydrochlorothiazide ................................................ 10 sprintec 28 ........................................................................................ 22 Sprycel

® ............................................................................................... 6 SPS® ................................................................................................... 16 sronyx ............................................................................................... 22 ssd 26 ssd af ................................................................................................. 26 stavudine ............................................................................................ 5 sterile water for irrigation ................................................................ 16 Stimate

® ............................................................................................ 23

Straint® .............................................................................................. 21 Strattera® .......................................................................................... 14 StribildTM ............................................................................................. 5 Stromectol

® tabs ................................................................................. 4 Suboxone®......................................................................................... 11 Sucraid® ............................................................................................. 17 sucralfate .......................................................................................... 20 sulfacetamide sodium ................................................................ 18, 26 sulfacetamide sodium/prednisolone sodium phosphate ................. 18 sulfacetamide sodium/sulfer cleanser .............................................. 28 sulfacleanse 8/4 ................................................................................ 28 Sulfadiazine

® ....................................................................................... 4 sulfamethoxazole/trimethoprim ........................................................ 4 sulfamethoxazole/trimethoprim ds .................................................... 4 sulfasalazine ....................................................................................... 4 sulfazine .............................................................................................. 4 sulfazine ec ......................................................................................... 4 sulindac ............................................................................................. 12 sumatriptan succinate ...................................................................... 13

suphera ............................................................................................ 28 Suprax® ............................................................................................... 4 Suprep® Bowl Prep ............................................................................ 20 Sustiva® ............................................................................................... 5 sutan‐dm .......................................................................................... 25 Sutent

®................................................................................................ 6 syeda ................................................................................................ 22 Symbicort® ........................................................................................ 21 Symlin® ............................................................................................. 21 Synagis® ............................................................................................ 25 Synarel

® ............................................................................................ 23 Synthroid® ......................................................................................... 23 Syprine® ............................................................................................ 21

T

Tabloid® .............................................................................................. 6 tacrolimus ........................................................................................ 24 Tamiflu® .............................................................................................. 5 tamoxifen citrate ................................................................................ 6 tamsulosin hcl .................................................................................... 7 Tanafed

® DMX ................................................................................... 25 Tarceva® .............................................................................................. 6 taron‐crystals ................................................................................... 16 Tasigna

® .............................................................................................. 6 taztia xt ............................................................................................... 9 Tecfidera® ......................................................................................... 24 Tekturna

® .......................................................................................... 10 telmisartan ....................................................................................... 10 telmisartan/amlodipine.................................................................... 10 telmisartan/hydrochlorothiazide ..................................................... 10 temazepam ...................................................................................... 14 temozolomide .................................................................................... 6 terazosin hcl ....................................................................................... 8 terbinafine hcl .................................................................................... 4 terbutaline sulfate .............................................................................. 7 terconazole....................................................................................... 26 Testim

® ............................................................................................. 21 Testred

® ............................................................................................ 21 tetracycline hcl ................................................................................... 4 Thalomid® ......................................................................................... 24 theochron ......................................................................................... 29 theophylline ..................................................................................... 29 theophylline cr ................................................................................. 29 theophylline er ................................................................................. 29 thermazene ...................................................................................... 26 Thiola

TM ............................................................................................ 21 thioridazine hcl ................................................................................. 15 thiothixene ....................................................................................... 15 tiagabine........................................................................................... 13 ticlopidine hcl ..................................................................................... 8 tigels‐f forte ........................................................................................ 8 Tikosyn

® ............................................................................................ 10 tilia fe ............................................................................................... 22 timolol maleate ............................................................................ 9, 19 timolol maleate ophthalmic gel forming .......................................... 19 tinidazole tabs .................................................................................... 5 tis‐u‐sol ............................................................................................. 16 tis‐u‐sol viaflex ................................................................................. 16 Tivicay

® ............................................................................................... 5 tizanidine hcl tablets .......................................................................... 7 tl bpo mx cleanser ............................................................................ 26 tl gard rx ........................................................................................... 29 tl icon .................................................................................................. 8 tl‐dex dm .......................................................................................... 25


tl‐fol 500 ............................................................................................. 8 tl‐hem 150 .......................................................................................... 8 tobramycin ......................................................................................... 4 tobramycin sulfate ............................................................................ 18 tobramycin/dexamethasone ............................................................ 18 tobrasol ............................................................................................ 18 Tolbutamide

® .................................................................................... 21 tolmetin sodium ............................................................................... 12 tolterodine tartrate .......................................................................... 28 tolterodine tartrate er ...................................................................... 28 topex topical anesthetic ................................................................... 27 topiragen .......................................................................................... 13 topiramate ........................................................................................ 13 topiramate sprinkles ......................................................................... 13 torsemide ......................................................................................... 16 Tracleer

® ........................................................................................... 11 Tradjenta® ......................................................................................... 21 tramadol hcl ..................................................................................... 12 tramadol hcl er ................................................................................. 12 tramadol hydrochloride/acetaminophen ......................................... 12 trandolapril ....................................................................................... 10 Transdermal Nicotine ....................................................................... 30 tranylcypromine sulfate ................................................................... 15 Travatan® Z ........................................................................................ 19 trazodone hcl .................................................................................... 15 tretinoin ........................................................................................ 6, 28 tretinoin emollient ............................................................................ 28 tretinoin microsphere gel ................................................................. 28 Trexall

® ................................................................................................ 6 triamcinolone acetonide ............................................................ 18, 27 triamcinolone in orabase .................................................................. 27 triamterene/hctz .............................................................................. 16 triazolam ........................................................................................... 14 tricitrates .......................................................................................... 16 tricon .................................................................................................. 8 triderm .............................................................................................. 27 trifluoperazine hcl............................................................................. 15 trifluridine ......................................................................................... 18 trigels ................................................................................................ 29 trihexyphenidyl hcl ........................................................................... 14 tri‐legest fe ....................................................................................... 22 trilyte ................................................................................................ 20 trimethobenzamide hcl .................................................................... 20 trimethoprim ...................................................................................... 5 trimethoprim sulfate/polymyxin b sulfate ....................................... 18 trinessa ............................................................................................. 22 tri‐previfem ...................................................................................... 22 tri‐sprintec ........................................................................................ 22 trivora‐28 .......................................................................................... 22 tropicamide ...................................................................................... 19 trospium chloride ............................................................................. 28 trospium chloride er ......................................................................... 28 Truvada

® ............................................................................................. 5 Tudorza

® ............................................................................................. 6 Tussicaps® ......................................................................................... 25 Tusso‐C® ............................................................................................ 25 Tusso‐DMR

® ...................................................................................... 25 Twinject® ............................................................................................. 7 Tykerb

® ............................................................................................... 6 Tyzeka® ............................................................................................... 5

U

Uloric® ............................................................................................... 24 unithroid ........................................................................................... 23

unithroid direct ................................................................................ 23 univert .............................................................................................. 20 Urocit‐K® 15 ...................................................................................... 16 ursodiol ............................................................................................ 20

V

Vagifem® ........................................................................................... 22 valacyclovir hcl ................................................................................... 5 Valcyte® .............................................................................................. 5 valproic acid ..................................................................................... 13 valsartan/hctz ................................................................................... 10 vancomycin hcl caps ........................................................................... 4 vandazole ......................................................................................... 26 velivet ............................................................................................... 22 venlafaxine hcl.................................................................................. 15 venlafaxine hcl er ............................................................................. 15 Ventolin

® HFA ..................................................................................... 7 verapamil hcl ...................................................................................... 9 verapamil hcl er .................................................................................. 9 verapamil hcl sr .................................................................................. 9 Veregen

® ........................................................................................... 28 versiclear .......................................................................................... 26 Vexol

® ............................................................................................... 18 Vfend

®................................................................................................. 4 vicodin hp ......................................................................................... 12 Victoza® ............................................................................................ 21 Victrelis

® ............................................................................................. 5 Videx® Pediatric .................................................................................. 5 Vimpat

® ............................................................................................ 13 Viracept® ............................................................................................. 5 Viread® ................................................................................................ 5 Visicol

® .............................................................................................. 20 vitamin d .......................................................................................... 29 vitazol ............................................................................................... 26 Vivelle‐Dot

® ...................................................................................... 22 Vol‐Care® .......................................................................................... 29 Voltaren® Gel .................................................................................... 11 voriconazole ....................................................................................... 4 Votrient

® ............................................................................................. 6

W

warfarin sodium ................................................................................. 8 Welchol® ............................................................................................. 9

X

Xalkori® ............................................................................................... 6 Xarelto® .............................................................................................. 8 Xenazine® .......................................................................................... 14 Xyrem

® .............................................................................................. 14

Y

Yodoxin® ............................................................................................. 5

Z

zaclir cleansing ................................................................................. 26 zafirlukast ......................................................................................... 25 zaleplon ............................................................................................ 14 zarah ................................................................................................. 22 zazole ............................................................................................... 26 Z‐Cof

® DMX ....................................................................................... 25


zebutal .............................................................................................. 12 Zelapar® ............................................................................................ 14 zenatane ........................................................................................... 28 zenchent ........................................................................................... 22 zencia ................................................................................................ 28 Zenpep

® ............................................................................................ 20 zeosa ................................................................................................. 22 Zetia® .................................................................................................. 9 Ziana® ................................................................................................ 28 zidovudine .......................................................................................... 5 ziprasidone ....................................................................................... 15 Zodryl® DEC ....................................................................................... 25

Zolinza® ............................................................................................... 6 zolmitriptan ...................................................................................... 13 zolpidem tartrate ............................................................................. 14 zolpidem tartrate er ......................................................................... 14 Zonatuss® .......................................................................................... 25 zonisamide ....................................................................................... 13 Zortress

® ........................................................................................... 24 Zotex‐DM® ........................................................................................ 25 Zotex‐EX® .......................................................................................... 25 Zotex‐G® ........................................................................................... 25 Zubsolv

® ............................................................................................ 11 Zytiga® ................................................................................................ 6

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INDEPENDENT HEALTH’S 2014 Drug Formulary restrictions or coverage limits may apply ... PAR – Prior Authorization must be obtained in order for the drug to be ... bicalutamide (Restricted