DRUG - UnitedHealthcare MedicareRx for Groups

2008 

formulary 

(COMPLETE LIST OF COVERED DRUGS) 

UNITEDHEALTH RX FOR GROUPS 

Inside: 

Tiers and copays. 

Drug list. 

Lower-cost options. 

My Medications worksheet. 

COMPLETE DRUG LIST EFFECTIVE JANUARY 1 THROUGH DECEMBER 31, 2008 

AND IS CURRENT AS OF JANUARY 1, 2008 

Please Read: This document contains information about the drugs we cover in this plan. 

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

document to make sure it still contains the drugs you take.

2 

About this complete drug list. 

UnitedHealth Rx for Groups helps members like you lower prescription drug costs. 

This complete formulary is a list of drugs covered by UnitedHealth Rx for Groups. 

UnitedHealth Rx for Groups selected the drugs in consultation with a team of health 

care providers with expertise in the prescription drug needs of people on Medicare. For 

more information, go to www.UnitedHealthRxforGroups.com or call Customer Care 

using the number on the bottom of the next page. 

The UnitedHealth Rx for Groups drug list includes 100% of the drugs covered by 

Medicare Part D. For your prescription drugs to be covered by this plan, the drugs must 

be included in the drug list and in most cases the prescriptions must be filled at one of 

our network pharmacies. 

UnitedHealth Rx for Groups includes over 60,000 network pharmacies for your 

convenience. Some of our network retail pharmacies include: 

Brooks 

Costco 

CVS 

HEB Pharmacy 

Kmart 

Kroger 

Longs 

Medicine Shoppe 

Publix 

Rite Aid 

Safeway 

Shopko/Pamida 

Target 

Walgreens 

Wal-Mart 

Winn Dixie 

and more ... 

Plus thousands of independent 

neighborhood pharmacies! To find a 

pharmacy location within our network, 

call Customer Care or visit us online at 

www.UnitedHealthRxforGroups.com. 

This is a complete drug formulary as of January 1, 2008. 

For more information, call 1-888-556-6648, 24 hours a day, 7 days a week. 

TTY users should call 1-877-730-4203. or visit us online at www.UnitedHealthRxforGroups.com.

HOW TO FIND OUT IF YOUR DRUG IS COVERED. 

There are two ways to find your prescription 

drugs within the drug list. 

1. Look for a drug by name in the Drug Index, 

which begins on page 54. 

2. Look for a drug by the health condition in 

the category section. For example, if you 

want to find drugs used to treat chest pain, 

turn to the category listing and look for 

“Chest Pain Drugs”. 

Brand-name drugs are in bold type (e.g., Lipitor) 

while generic drugs are not (e.g., Furosemide). 

If you cannot find your drug in this complete 

drug list, contact Customer Care for 

assistance in finding your drug. If your drug is 

not in the complete drug list, you should talk 

with your doctor to see if the drug list includes 

an alternative drug choice that is right for you. 

Note: If your plan has an open formulary, 

many additional drugs not usually covered 

by a Medicare Part D plan are covered. With 

open formulary plans, all Food and Drug 

Administration (FDA) approved prescription 

drugs will be covered except those listed on 

the Limitations and Exclusions document. 

Only drugs covered under the Medicare Part D 

program are eligible when calculating true 

out-of-pocket (TrOOP) costs, will help you 

move into or out of the coverage gap, and 

qualify for catastrophic coverage. In addition, 

only drugs covered under the Medicare Part D 

program are eligible for the Medicare Appeals 

process. All other drugs are eligible for the 

UnitedHealth Rx for Groups grievance process. 

Please refer to your Summary of Benefits or 

contact Customer Care if you have specific 

questions about your prescription drugs. 

Your copay. 

During the initial coverage period, 

UnitedHealth Rx for Groups pays part of the 

costs for your covered drugs and you pay 

part. Your copayment (copay) depends on the 

tier (or coverage level) assigned to your 

prescription drug. 

This complete drug list includes four tiers. 

Each tier has a different copay amount. The 

Summary of Benefits lists the copays that 

apply to each tier. If you qualify for extra help 

in paying for your prescription drugs, your 

copays may be different than those described 

in the Summary of Benefits. Please contact 

Customer Care to find out what your costs are 

in this situation. 



TTY users should call 1-877-730-4203. or visit us online at www.UnitedHealthRxforGroups.com. 

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4 

TIER 1 Lowest Copay 

Includes most generic prescription drugs. Generic drugs 

usually cost less than brand-name drugs. 

TIER 2 Medium Copay 

Includes preferred brand-name prescription drugs. Tier 2 

drugs offer clinical advantages and/or lower prices than 

Tier 3 drugs. Brand-name drugs are in bold type (e.g., 

Lipitor). 

TIER 3 Highest Copay 

Tier 3 drugs include non-preferred drugs that have clinical 

disadvantages and/or higher prices than Tier 1 and/or Tier 

2 drugs. If you are taking a Tier 3 drug, ask your doctor if a 

Tier 1 or Tier 2 drug could be an alternative. See page 73 

for a partial listing of lower-cost drug options. 

SPECIALTY TIER (SP) Coinsurance 

Includes unique and/or very high-cost drugs. You and the 

plan share in the cost of the drug. 

Generic drugs. 

UnitedHealth Rx for Groups covers both brandname 

and generic drugs. A generic drug has 

the same active ingredient as its brand-name 

equivalent. Generic drugs usually cost less 

than brand-name drugs and are approved by 

the FDA. If a generic equivalent drug is not 

available, a generic alternative can be a good 

option. Generic alternatives contain different 

active ingredients than brand-name drugs, but 

come from the same chemical family and can 

provide similar results. 

To help manage drug costs and what you pay 

out of pocket, you may want to consult with 

your doctor to determine whether any of the 

brand-name drugs you take are available as 

generics. Using generic drugs may save you 

money. 

Coverage determination process. 

A coverage determination allows you to 

request an exception to waive coverage 

restrictions or limits on your drug. A coverage 

determination applies to prior authorization, 

step therapy, quantity limits and Medicare 

Part B/Part D. You, your pharmacist, your 

doctor or your authorized representative can 

initiate a coverage determination by contacting 

Customer Care at the number listed below. 

Please note: Due to a change in Medicare, 

most Medicare Drug Plans no longer cover 

erectile dysfunction (ED) drugs like Viagra, 

Cialis, Levitra, and Caverject. For more 

information, call 1-866-863-1406, 

24 hours a day, 7 days a week. TTY users 

should call 1-877-730-4203. 

Coverage determination 

requirements for certain drugs. 

Some covered drugs may have additional 

requirements or limits that help ensure safe 

and effective drug use. These drugs may 

require a coverage determination by your 

Medicare Part D plan. You can find out if your 

drug has any additional requirements or limits 

by looking for abbreviations next to the drug 

names within the drug list in this booklet. 




These requirements and limits apply to retail 

and mail order service and may include: 

PRIOR AUTHORIZATION 

PA 

Prior authorization requires certain criteria be met before 

the plan sponsor covers a particular drug. Some drugs 

require prior authorization due to coverage, clinical 

effectiveness or safety considerations. Prior authorization 

requires you or your doctor to get approval from the plan 

before you fill your prescription. If you do not get approval, 

your drug may not be covered by the plan. 

QUANTITY LIMITS 

QL 

Quantity limits manage the quantity of certain drugs a 

member receives for a copay or defined period of time. 

Quantity limits are based upon FDA-approved dosing and 

standard professional treatment guidelines. 

STEP THERAPY 

ST 

In some cases, you are required to treat your medical 

condition with certain drugs before the plan will cover 

another drug for that condition. 

MEDICARE PART B/D COVERAGE 

DETERMINATION 

B/D 

Some drugs may be billed to the Medicare Part B or 

Part D benefit, depending on the intended use and 

other factors. Claims for a drug may be stopped at the 

pharmacy to determine which Medicare benefit should 

cover the drug. Your doctor may need to supply additional 

information before a drug is covered by the Part D plan. 

Part D exception process. 

You can ask to make an exception to the plan’s 

coverage rules. 

• You can ask to have your drug covered even 

if it is not on the drug list. If an exception is 

approved, you would get the prescription 

drug at the Tier 3 copay level. 

You can ask us to waive coverage 

restrictions or limits on your drug. For 

example, for certain drugs, we may limit 

the amount of the drug that we will cover. 

If your drug has a quantity limit, you can 

ask us to waive the limit and cover more. 




• 

• You can ask for a higher level of coverage 

for your drug. If your drug is in Tier 3, you 

can ask that the plan cover it as a Tier 2 drug 

instead. This would lower the amount you 

must pay for your drug. The tier exception 

process only applies to Tier 3 drugs. If the 

plan grants your request to cover a drug 

that is not on the drug list, you may not 

ask the plan to provide a higher level of 

coverage for the drug. Also, you may not 

ask us to provide a higher level of coverage 

for drugs that are in the specialty tier. 

Generally, your request for an exception will 

be approved only if the alternative drugs 

included on the plan’s drug list or the 

lower-tiered drug would not be as effective 

in treating your condition and/or would cause 

you to have adverse medical effects. 

When requesting a drug list or tiering 

exception, please submit a statement 

from your doctor supporting your request. 

Generally, the coverage decision is made 

within 72 hours of getting your prescribing 

5

6 

physician’s supporting statement. You can 

request an expedited (fast) exception if you or 

your doctor believe that your health could be 

seriously harmed by waiting up to 72 hours 

for a decision. If your request to expedite 

is granted, we must give you a decision no 

later than 24 hours after we receive your 

prescribing physician’s supporting statement. 

Visit www.UnitedHealthRxforGroups.com or 

call Customer Care at the number below for 

more information and to access the Exception 

Request Form. 

Transition process for changing 

the drugs you take. 

If you are a new member in our plan, you may 

be taking drugs that are not on our drug list. Or, 

you may be taking a drug that is on our drug 

list but a coverage determination may apply. 

For example, you may need prior authorization 

before the plan covers the drug.You should talk 

to your doctor to decide if you should switch 

to an appropriate drug that we cover or to 

request an exception so that we may cover the 

drug you take. While you talk to your doctor 

to determine the right choice for you, we may 

cover your drug in certain cases during the 

first 90 days you are a member of our plan. For 

each of your drugs that is not on our drug list 

or if your ability to get your drugs is limited, we 

will cover a temporary 31-day supply (unless 

you have a prescription written for fewer days) 

when you go to a network pharmacy. After 

your first 31-day supply, we will not pay for 

these drugs, even if you have been a member 

of the plan less than 90 days. 

If you are a resident of a long-term care facility, 

we will cover a temporary 31-day transition 

supply (unless you have a prescription written 

for fewer days). We will cover more than one 

refill of these drugs for the first 90 days you 

are a member of our plan. If you need a drug 

that is not on our drug list or your ability to get 

your drugs is limited but you are past the first 

90 days of membership in our plan, we will 

cover a 31-day emergency supply of that drug 

(unless you have a prescription for fewer days) 

while you pursue an exception. 

There may be unplanned transitions such as 

hospital discharges or level of care changes 

that occur after the first 90 days that you are 

enrolled as a member of our plan. If you are 

prescribed a drug that is not on our drug list or 

your ability to get your drugs is limited, 

you are required to use the plan’s exception 

process. You may request a one-time 

emergency supply of up to 31 days to allow 

you time to discuss alternative treatment with 

your doctor or to pursue a drug list exception. 

If you are a continuing member in the plan, 

you receive an Annual Notification of changes 

to your plan. You may notice that a formulary 

medication which you are currently taking 

is either not on the 2008 formulary or its 

cost sharing or coverage is limited in the 

upcoming year. For coverage requests we 

receive by December 15, 2007 and approve, 

the plan will cover the drug as of January 1, 

2008. For coverage requests initiated on or 

after December 16, 2007, normal timeframes 

for resolution apply: you will receive an answer 

within 24 hours for urgent requests and 72 

hours for all other request. If your request is 

still in process on January 1, 2008, you may 

receive a temporary supply of the drug for your 

current plan cost-sharing until we answer your 

request. 




Drug list changes. 

UnitedHealth Rx for Groups recognizes that 

drug list stability is important to you. It is our 

intention to make as few changes to the drug 

list as possible. From time to time, however, 

drug list changes are necessary for safety 

or other reasons. For example, the FDA 

may declare a drug to be unsafe. When that 

happens, we will immediately remove that 

drug from our drug list and provide notice to 

members who take the drug. For other 

changes, such as if a drug is moved to a 

higher-cost tier, UnitedHealth Rx for Groups 

will notify affected members at least 60 days 

before the change becomes effective, or at the 

time you request a refill of the drug, at which 

time you will receive a 60-day supply of the 

drug. If there are any changes to the drugs you 

take, they will be listed in your Explanation of 

Benefits. 

The drug list may change throughout the 

year when the plan: 

• Modifies the limitations or restrictions 

for a drug. 

• Adds or removes a drug. 

• Moves a drug to a lower or higher-cost tier. 

Generally, if you are taking a drug on our 2008 

drug list that was covered at the beginning 

of the year, we will not discontinue or reduce 

coverage of the drug during the 2008 coverage 

year. Exceptions include the availability of a 

new, less expensive generic equivalent drug or 

the release of new adverse information about 

the safety or effectiveness of a drug. Other 

types of drug list changes, such as adding prior 

authorization to a drug, will not affect members 

who are currently taking the drug. It will remain 

available at the same copay for those members 

taking it for the remainder of the coverage year. 

For more information. 

For more detailed information about 

UnitedHealth Rx for Groups drug coverage, 

please review your Evidence of Coverage, 

Summary of Benefits and other plan materials. 

To obtain updated formulary information, 

please visit our Web site or call Customer Care 

at the phone number listed below. 

If you have general questions about Medicare 

prescription drug coverage, please call Medicare 

at 1-800-MEDICARE (1-800-633-4227) 24 hours 

a day, seven days a week. TTY/TDD users should 

call 1-877-486-2048. Or visit www.medicare.gov. 

If you have special needs, this document may 

be available in alternative formats. For more 

information, call Customer Care at the phone 

number listed below. 




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8 

THE DRUG LIST 

DRUG 

UnitedHealth Rx 

for Groups 

TIER LIMITS 

AnTIHISTAMInE DRUGS - 

DRUGS To TREAT ALLERGIES AnD ITcHInG 

Ethanolamine Derivatives - Allergy Drugs 

Benadryl 3 

Clemastine Fumarate 1 

Diphenhydramine HCl 3 

Palgic (Liquid) 1 

Palgic (Tablet) 2 

Miscellaneous Derivatives - Allergy Drugs 

Cyproheptadine HCl 

Phenothiazine Derivatives - 

nausea and Vomiting Drugs 

3 

Phenadoz 3 

Phenergan 3 

Promethazine HCl 3 

Promethazine HCl Plain 3 

Promethazine VC 3 

Promethegan 3 

Propylamine Derivatives - Allergy Drugs 

Dexchlorpheniramine 

Maleate 

3 

Second Generation Antihistamines - Allergy Drugs 

Allegra (Suspension) 3 QL 

Allegra (Tablet) 3 

Allegra-D 12 Hour 3 QL 

Allegra-D 24 Hour 3 QL 

clarinex* 3 QL 

clarinex Reditabs 3 QL 

clarinex-D 12 Hour 3 QL 

clarinex-D 24 Hour 3 QL 


Fexofenadine HCl 1 

Semprex-D 3 



TIER LIMITS 

Zyrtec 3 QL 

Zyrtec-D 3 QL 

AnTI-InFEcTIVE AGEnTS - 

DRUGS To TREAT InFEcTIonS 

Adamantanes - Flu Drugs 

Amantadine HCl 1 

Flumadine 3 

Rimantadine HCl 1 

Symmetrel 3 

Allylamines - Antifungals 

Lamisil 3 

Terbinafine (Tablet) 1 

Amebicides 

Humatin 3 

Paromomycin Sulfate 1 

Aminoglycosides - Antibiotics 

Amikacin Sulfate 1 

Amikin 3 

Gentamicin Sulfate/0.9% 

NaCl 

(0.6 mg/ml; 0.9% Solution, 

0.8 mg/ml; 0.9% Solution, 1 

1 mg/ml; 0.9% Solution, 

1.2 mg/ml; 0.9% Solution, 

1.6 mg/ml; 0.9% Solution) 

Gentamicin Sulfate/0.9% 

nacl (0.9 mg/ml; 0.9% 

3 

Solution, 1.4 mg/ml; 0.9% 

Solution) 

Gentamicin Sulfate/NaCl 1 

*For Lower-cost Drug Options see Page 73 

PA = Prior Authorization QL = Quantity Limits ST = Step Therapy B/D = Medicare Part B


Gentamicin Sulfate 1 

Kanamycin Sulfate 1 

neo-Fradin 3 

Neomycin Sulfate 1 

Streptomycin Sulfate 3 



TIER LIMITS 

Tobi 4 B/D, PA 

Tobramycin Sulfate 1 

Tobramycin Sulfate/nacl 3 

Tobramycin Sulfate 

Add-Vantage 

3 

Tobramycin Sulfate Fliptop 

Anthelmintics - 

Drugs to Treat Worm Infections 

1 

Albenza 2 

Biltricide 2 

Mebendazole 1 

Mintezol 2 

Stromectol 

Antimalarials - Malaria Drugs 

2 

Aralen 3 

Chloroquine Phosphate 1 

Daraprim 2 

Fansidar 3 

Hydroxychloroquine Sulfate 1 

Lariam 3 

Malarone 2 

Mefloquine HCl 1 

Plaquenil 3 

Primaquine Phosphate 2 

Qualaquin 

Antiretrovirals - HIV Drugs 

3 PA 

Agenerase 3 

Aptivus 4 

Atripla 4 

combivir 4 


crixivan 2 

Didanosine 1 

Emtriva 2 

Epivir 2 

Epivir HBV 2 

Epzicom 4 

Fuzeon 4 

Invirase 4 

Isentress 4 

Kaletra 4 

Lexiva 4 

norvir (capsule) 3 

norvir (Solution) 4 

Prezista 4 

Rescriptor 2 

Retrovir 3 

Retrovir IV Infusion 2 

Reyataz 4 

Selzentry 4 

Sustiva 2 

Trizivir 4 

Truvada 4 

Videx Ec 3 

Videx Pediatric 2 

Viracept 4 

Viramune 2 

Viread 3 

Zerit 2 

Ziagen 2 

Zidovudine 1 

Antituberculosis Agents 

capastat Sulfate 4 

Ethambutol HCl 1 

Isonarif 1 

Isoniazid 1 


PA = Prior Authorization QL = Quantity Limits ST = Step Therapy B/D = Medicare Part B 



TIER LIMITS 

9

10 


Myambutol 3 

Mycobutin 2 

nydrazid 3 

Paser 3 

Priftin 3 

Pyrazinamide 1 

Rifadin 3 

Rifamate 3 

Rifampin 1 

Rifater 3 

Seromycin 3 

Trecator 3 



TIER LIMITS 

Azoles - Antifungals 

Diflucan (50 mg Tablet, 

100 mg Tablet, 200 mg 

Tablet, Suspension for 

Reconstitution) 

3 

Diflucan (150 mg Tablet) 3 QL 

Diflucan in Iso-osmotic 

Dextrose 

3 

Diflucan in nacl 

Fluconazole 

3 

(50 mg Tablet, 100 mg Tablet, 

200 mg Tablet, Suspension 

for Reconstitution) 

1 

Fluconazole 

(150 mg Tablet) 

1 QL 

Fluconazole in Dextrose 1 

Fluconazole in NaCl 1 

Itraconazole 1 

Ketoconazole 1 

nizoral 3 

noxafil 4 

Sporanox (capsule) 3 

Sporanox (Kit) 4 

Sporanox (Solution) 3 PA 


Sporanox Pulsepak 3 

Vfend 4 

Vfend IV 4 

cephalosporins - Antibiotics 

cedax 3 

Cefaclor 1 

Cefaclor ER 1 

Cefadroxil 1 

Cefazolin 1 

Cefdinir 

(Generic for Omnicef) 

1 

cefizox in Dextrose 5% 3 

Cefotaxime Sodium 1 

cefotetan 3 

Cefpodoxime Proxetil 1 

Cefprozil 1 

ceftin 3 

Ceftriaxone in Iso-Osmotic 

Dextrose 

1 

Ceftriaxone Sodium 1 

Ceftriaxone/Dextrose 1 

Cefuroxime Axetil 1 

Cefuroxime Sodium 1 

Cefuroxime/Dextrose 1 

cefzil 3 

Cephalexin 1 

claforan 3 

claforan Infusion Bottles 3 

claforan/D5W Galaxy 3 

Duricef 

Fortaz (1 gm Solution 

for Reconstitution, 2 gm 

3 

Solution for Reconstitution, 

6 gm Solution for 


3 



TIER LIMITS 






TIER LIMITS 

Fortaz 

(500 mg Solution for 

Reconstitution, Solution) 

2 

Fortaz Infusion Pack 

Keflex 

3 

(250 mg capsule, 500 mg 

capsule, Suspension for 


3 

Keflex (750 mg capsule) 3 QL 

Maxipime 2 

omnicef 3 

omni-PAc 3 

Panixine Disperdose 3 

Raniclor 3 

Rocephin (1 gm Solution for 


Rocephin (1 gm Solution 

3 

for Reconstitution, 2 gm 

Solution for Reconstitution) 

2 

Rocephin in Iso-osmotic 

Dextrose 

Rocephin 


Reconstitution, 500 mg 

3 



Reconstitution, 



3 

Spectracef 2 

Suprax 3 

Tazicef 

(Solution for Reconstitution) 

1 

Tazicef (Solution) 2 

Vantin 3 

Zinacef (7.5 gm Solution for 


1 






TIER LIMITS 

Zinacef in Iso-osmotic 

Dextrose 

3 

Zinacef in Iso-osmotic 

Diluent 

3 

Zinacef/D5W 

Zinacef (750 mg Solution 

3 

for Reconstitution, 1.5 gm 

Solution for Reconstitution ) 

chloramphenicol - Antibiotics 

3 

Chloramphenicol Sodium 

Succinate 

Echinocandins - Antifungals 

1 

cancidas 4 

Eraxis 4 

Mycamine 

Interferons - Hepatitis Drugs 

4 

Infergen 4 PA 

Pegasys 4 PA 

Peg-Intron 4 PA 

Peg-Intron Redipen 4 PA 

Peg-Intron Redipen Pak 4 4 PA 

Roferon-A 

(3MU/0.5, 6MU/0.5) 

3 PA 

Roferon-A (9MU/0.5) 

Macrolides - Antibiotics 

4 PA 

Azasite 

Azithromycin 

3 

(Pack, Solution for 

Reconstitution, Suspension 


1 

Azithromycin (Tablet) 1 QL 

Biaxin 3 

Biaxin XL 3 

Biaxin XL PAc 3 

Clarithromycin 1 

Clarithromycin ER 1 

Dynabac D5-Pak 3 

11

12 


E.E.S. 200 1 

E.E.S. 400 1 

E.E.S. Granules 3 

Eryc 3 

Eryped 2 

Eryped 200 3 

Eryped 400 2 

Ery-Tab 2 

Erythrocin 2 

Erythrocin Lactobionate 2 

Erythrocin Stearate 1 

Erythromycin 1 

Erythromycin Base 1 

Erythromycin Ethylsuccinate 1 

Erythromycin Lactobionate 2 

Erythromycin/Sulfisoxazole 1 



TIER LIMITS 

Ketek 3 PA, QL 

Ketek Pak 3 PA, QL 

PcE 3 

Pediazole 3 

Zithromax (Pack, Solution 

for Reconstitution, 

Suspension for 


3 

Zithromax (Tablet) 3 QL 

Zithromax Tri-Pak 3 QL 

Zithromax Z-Pak 3 QL 

Zmax 

Miscellaneous Antibacterials 

3 QL 

Baciim 1 

Bacitracin (Solution for 


3 

cleocin (75 mg capsule, 

Suppository) 

2 


300 mg capsule, cream) 

3 


cleocin Galaxy 2 

cleocin Pediatric Granules 2 

cleocin Phosphate 3 

Clindamycin HCl 1 

Clindamycin Phosphate 1 



TIER LIMITS 

Clindamycin Phosphate 

Add-Vantage 

1 

Colistimethate Sodium 1 

coly-Mycin-M 3 

cubicin 4 

Grifulvin V (Suspension) 3 

Grifulvin V (Tablet) 2 

Lincocin 3 

Polymyxin B Sulfate 3 

Synercid 4 

Vancocin Hcl (capsule) 4 

Vancocin Hcl (Solution) 3 

Vancocin Hcl Iso-osmotic 

Dextrose 

3 

Vancomycin HCl 1 

Xifaxan 3 QL 

Zyvox 

Miscellaneous Antifungals 

4 

Griseofulvin Microsize 1 

Gris-Peg 

Miscellaneous Anti-Infectives 

2 

Helidac 3 QL 

Pylera 3 

Miscellaneous Antimycobacterials - 

Drugs to Treat Miscellaneous Infections 

Dapsone 

Miscellaneous Antiprotozoals 

2 

Alinia 3 QL 

Flagyl 3 

Flagyl ER 3 




Mepron 4 

Metro IV 3 

Metronidazole 1 

Metronidazole in NaCl 0.79% 1 



TIER LIMITS 

nebupent 3 B/D, PA 

neutrexin 4 

Pentam 300 3 

Pentamidine Isethionate 1 

Tindamax 2 QL 

Miscellaneous Antivirals 

Foscarnet Sodium 1 

Foscavir 3 

Miscellaneous B-Lactams - Antibiotics 

Azactam 2 

Azactam in Dextrose 

Cefoxitin 

3 

(1 gm Injectable; 

2 gm Injectable; 

10 gm Injectable) 

1 

Doribax 4 

Invanz 3 

Mefoxin 3 

Mefoxin Add-Vantage 3 

Mefoxin in Dextrose 2.2% 3 

Mefoxin in Dextrose 3.9% 3 

Merrem 4 

Primaxin I.M. 4 

Primaxin IV 4 

Primaxin IV Add-Vantage 

Monoclonal Antibodies - 

Respiratory Syncytial Virus Drugs 

4 

Synagis 4 

neuraminidase Inhibitors - Flu Drugs 

Relenza Diskhaler 3 QL 

Tamiflu 2 QL 






TIER LIMITS 

nucleosides and nucleotides - 

Herpes and Hepatitis Drugs 

Acyclovir 1 

Baraclude 4 

copegus 4 PA 

cytovene 3 

Famvir 3 

Ganciclovir 4 

Hepsera 4 

Rebetol 4 PA 

Ribapak 4 PA 

Ribasphere 1 PA 

Ribatab (Pack) 4 PA 

Ribatab (Tablet) 1 PA 

Ribavirin 1 PA 

Tyzeka 3 

Valcyte 4 

Valtrex 2 

Virazole 4 

Vistide 4 

Zovirax (capsule, 

Suspension, Tablet) 

Penicillins - Antibiotics 

3 

Amoclan 1 

Amoxicillin 1 

Amoxicillin/Clavulanate 

Potassium 

Amoxil (50 mg/ 

ml Suspension for 

Reconstitution, 200 

1 

mg/5ml Suspension 

for Reconstitution, 400 

mg/5ml Suspension for 

Reconstitution, chewable 

Tablet, Tablet) 

3 

13

14 


Amoxil 

(250 mg/5ml Suspension for 

Reconstitution, Capsule) 

1 

Ampicillin 1 

Ampicillin-Sulbactam 1 

Augmentin 3 

Augmentin ES-600 3 

Augmentin XR 3 

Bactocill in Dextrose 3 

Bicillin c-R 2 

Bicillin L-A 2 

Dicloxacillin Sodium 1 

Dispermox 3 

Geocillin 

Nafcillin Sodium 

(1 gm Solution for 

3 

Reconstitution, 2 gm 




1 

nallpen Iso-osmotic 

in Dextrose 

4 

nallpen/Dextrose 4 

oxacillin Sodium 3 

Penicillin G Potassium 1 

Penicillin G Potassium in 

Iso-Osmotic Dextrose 

1 

Penicillin G Procaine 3 

Penicillin G Sodium 1 

Penicillin V Potassium 1 

Pfizerpen-G 3 

Piperacillin Sodium 3 

Timentin 2 

Trimox 1 

Unasyn 3 

Unasyn Add-Vantage 3 

Unasyn Bulk Pack 3 



TIER LIMITS 


Unasyn Piggyback Unit 3 

Veetids 1 

Zosyn 2 



TIER LIMITS 

Polyenes - Antifungals 

Abelcet 4 

Ambisome 4 B/D 

Amphocin 1 

Amphotec 3 

Amphotericin B 1 

Bio-Statin 3 

Nystatin 

Pyrimidines - Antifungals 

1 

Ancobon 

Quinolones - Antibiotics 

4 

Avelox (Solution) 2 

Avelox (Tablet) 2 QL 

Avelox ABc Pack 2 QL 

cipro 3 

cipro I.V. 3 

cipro I.V.-in D5W 3 

cipro XR 3 

Ciprofloxacin (Injection) 1 

Ciprofloxacin ER 1 

Ciprofloxacin HCl 1 

Factive 3 QL 

Levaquin (Solution) 2 

Levaquin (Tablet) 2 QL 

Levaquin Leva-Pak 2 QL 

Levaquin Premix 2 

noroxin 3 QL 

Ofloxacin 1 

Proquin XR 3 QL 

Sulfonamides (Systemic) - Antibiotics 

Azulfidine 3 

Azulfidine En-Tabs 3 




Bactrim 3 

Bactrim DS 3 

Gantrisin Pediatric 2 

Septra 3 

Septra DS 3 

Sulfadiazine 1 

Sulfamethoxazole/ 

Trimethoprim 

1 


Trimethoprim DS 

1 

Sulfasalazine 1 

Sulfatrim 1 

Sulfazine 1 

Sulfazine EC 1 

Trimethoprim/ 

Sulfamethoxazole DS 

Tetracyclines - Antibiotics 

1 

Adoxa 3 

Adoxa Pak 1/75 3 




Declomycin 3 

Demeclocycline HCl 4 

Doryx 3 

Doxy-Caps 1 

Doxycycline Hyclate 1 

Doxycycline Monohydrate 1 

Dynacin 

(75 mg capsule, Tablet) 

3 

Dynacin (100 mg Capsule) 1 

Minocin 3 

Minocin PAc 3 

Minocycline HCl 1 

Monodox 3 

Myrac 1 



TIER LIMITS 


oracea 2 

Periostat 3 

Solodyn 3 

Sumycin (Syrup) 1 

Sumycin (Tablet) 2 

Tetracycline HCl 1 

Tygacil 3 

Vibramycin 3 

Vibratab 3 

Urinary Anti-Infectives - Antibiotics 

Furadantin 3 

Hiprex 3 

Macrobid 3 

Macrodantin 3 

Methenamine Hippurate 1 

Monurol 3 

Nitrofurantoin 

Macrocrystalline 

3 

Nitrofurantoin Monohydrate 3 

Primsol 3 

Trimethoprim 1 

Urex 3 

AnTInEoPLASTIc AGEnTS - 

DRUGS To TREAT cAncER oR cAncER 

TREATMEnT SIDE EFFEcTS 

Antineoplastics - cancer Drugs 

Abraxane 4 

Adriamycin 1 

Alferon n 4 

Alimta 4 

Alkeran 2 

Arimidex 2 

Aromasin 2 

Arranon 4 

Avastin 4 





TIER LIMITS 

15

16 


Bexxar 4 



TIER LIMITS 

Bicnu w/Diluent 

Absolute Ethanol 

3 

Blenoxane 3 

Bleomycin Sulfate 1 

Busulfex 4 

campath 4 

camptosar 4 

Carboplatin 3 

casodex 2 

ceenu 2 

cerubidine 3 

Cisplatin 1 

Cisplatin AQ 1 

Cladribine 1 

clolar 4 

cosmegen 3 

Cyclophosphamide 


1 

Cyclophosphamide (Tablet) 1 B/D 

Cytarabine 1 

Cytarabine Aqueous 1 

cytoxan (Solution for 


3 

cytoxan (Tablet) 

Dacarbazine 

3 B/D 



3 

Dacarbazine (200 mg 


1 

Dacogen 4 

Daunorubicin Hcl (Injection) 3 

Daunorubicin HCl 


1 

Daunoxome 3 

Doxil 4 B/D 


Doxorubicin HCl 1 

Droxia 2 

DTIc-Dome 3 

Eligard 3 

Ellence 4 

Eloxatin 4 

Elspar 3 

Emcyt 2 

Epirubicin Hcl 4 

Erbitux 4 

Etopophos 4 

Etoposide 1 

Fareston 2 

Faslodex 4 

Femara 2 

Floxuridine 1 

Fludara 3 

Fludarabine Phosphate 4 

Fluorouracil 1 

Flutamide 1 

FUDR 3 

Gemzar 4 

Gleevec 4 

Herceptin 4 

Hexalen 4 

Hycamtin 4 

Hydrea 3 

Hydroxyurea 1 

Idamycin PFS 3 

Idarubicin 4 

Ifex 3 

Ifex/Mesnex combo Pack 4 

Ifosfamide (Solution for 


1 

Ifosfamide (Solution) 3 



TIER LIMITS 




Ifosfamide/Mesna 4 



TIER LIMITS 

Intron-A 4 PA 

Intron-A w/Diluent 4 PA 

Iressa 4 

Ixempra Kit 4 

Leukeran 2 

Leuprolide Acetate 1 

Leustatin 3 

Lupron 2 Week Supply 3 

Lupron 6-Pack 3 

Lupron Depot 3 

Lupron Depot-PED 4 

Lysodren 2 

Matulane 4 

Megace oral 3 

Megestrol Acetate 1 

Mercaptopurine 1 

Methotrexate 1 

Mitomycin 1 

Mitoxantrone HCl 1 

Mustargen 3 

Mutamycin 3 

Mylotarg 4 

navelbine 4 

nexavar 4 

nilandron 2 

nipent 4 

novantrone 3 

oncaspar 4 

ontak 4 

Onxol 4 

Paclitaxel 4 

Paraplatin 4 

Pentostatin 4 

Photofrin 4 


Platinol AQ 3 

Plenaxis 4 

Proleukin 4 

Purinethol 3 

Rheumatrex 3 

Rituxan 4 

Soltamox 3 

Sprycel 4 

Sutent 4 

Tabloid 2 

Tamoxifen Citrate 1 

Tarceva 4 

Targretin 4 





TIER LIMITS 

Tasigna 4 PA 

Taxol 3 

Taxotere 4 

Teslac 3 

Thiotepa 4 

Toposar 1 

Torisel 4 

Trelstar Depot 3 

Trelstar LA 3 

Tretinoin Capsule 4 

Trexall 2 

Trisenox 4 

Tykerb 3 PA 

Vantas 3 

Vectibix 4 PA 

Velcade 4 

Vesanoid 4 

Viadur 3 

Vidaza 4 

Vinblastine Sulfate 1 

Vincasar PFS 1 

Vincristine Sulfate 1 

17

18 


Vinorelbine Tartrate 4 

Vumon 4 

Zanosar 3 

Zoladex 4 



TIER LIMITS 

Zolinza 4 PA 

AUTonoMIc DRUGS - 

DRUGS To TREAT oRGAn DISoRDERS 

Antimuscarinics/Antispasmotics - 

Miscellaneous Disorders 

Atreza 3 

Atrovent 3 

Atrovent HFA 2 

Bentyl 3 

cantil 3 

Dicyclomine HCl 3 

Glycopyrrolate 1 

Ipratropium Bromide 

(0.02% Solution) 


1 B/D 

(0.03% Solution, 

0.06% Solution) 

1 

Methscopolamine Bromide 1 

Pamine 3 

Pamine Forte 3 

Pro-Banthine 3 

Propantheline Bromide 3 

Robinul 3 

Robinul Forte 3 

Spiriva Handihaler 

Antiparkinsonian Agents - 

2 

Drugs to Treat Parkinson’s Disease 

Akineton 2 

Benztropine Mesylate 1 

cogentin 2 

Kemadrin 3 

Trihexyphenidyl HCl 1 




TIER LIMITS 

Bronchodilators, combinations - 

Drugs to Treat Asthma/coPD 

Advair Diskus 2 ST 

Albuterol Sulfate/ 


1 B/D 

Brovana 3 B/D,PA 

combivent 2 

Duoneb 3 B/D,PA 

Symbicort 2 ST 

Miscellaneous Autonomic Drugs - 

Smoking cessation Drugs 

chantix 3 QL 

Nicotine 1 

nicotrol Inhaler 3 

nicotrol nS 3 

Zyban 3 

Parasympathomimetic (cholinergic) Agents 

Aricept 2 QL 

Aricept oDT 2 QL 

Bethanechol Chloride 1 

cognex 3 

Enlon-Plus 3 

Evoxac 3 

Exelon* (capsule, Patch) 3 QL 

Exelon* (Solution) 3 

Guanidine Hcl 3 

Mestinon (Syrup) 2 

Mestinon (Tablet) 3 

Mestinon Timespan 2 

Mytelase 3 

Pilocarpine HCl 1 

Pyridostigmine Bromide 1 

Razadyne (Solution) 2 

Razadyne (Tablet) 2 QL 

Razadyne ER 2 QL 

Regonol 1 




Salagen 3 

Urecholine 3 



TIER LIMITS 

Skeletal Muscle Relaxants - 

Drugs to Treat Muscle Spasms 

Amrix 3 ST 

Baclofen 1 

Carisoprodol 1 

Carisoprodol/Aspirin 3 

Carisoprodol/Aspirin/ 

Codeine 

3 

Chlorzoxazone 3 

Cyclobenzaprine HCl 3 

Dantrium 3 

Dantrolene Sodium 1 

Flexeril 3 

Methocarbamol 3 

norflex 3 

Orphenadrine Citrate 3 

Orphenadrine Citrate ER 3 

Orphenadrine/Aspirin/ 

Caffeine 

3 

Parafon Forte DSc 3 

Robaxin 3 

Robaxin-750 3 

Skelaxin 3 

Soma 3 

Soma compound 3 

Soma compound/codeine 3 

Tizanidine HCl 1 

Zanaflex 3 

Sympathomimetic (Adrenergic Blocking) Agents - 

Miscellaneous Disorders 

Dibenzyline 3 

Ergoloid Mesylates 1 






TIER LIMITS 

Sympathomimetic (Adrenergic) Agents - 

Breathing Disorder Drugs 

Accuneb 3 B/D 

Adrenalin 3 

Advair HFA 2 ST 

Airet 1 B/D 

Albuterol 1 

Albuterol Sulfate 

(Nebulizer Solution) 

Albuterol Sulfate 

1 B/D 

(Syrup, Extended-Release 

Tablet, Tablet) 

1 

Alupent 3 

Brethine 3 

Epinephrine HCl 1 

Epipen 2-Pak 2 

Epipen-Jr 2-Pak 2 

Foradil Aerolizer 2 PA 

Isuprel 3 

Maxair Autohaler 3 

Metaproterenol Sulfate 


1 B/D,PA 

Metaproterenol Sulfate 

(Syrup, Tablet) 

1 

Proair HFA 2 

Proventil (Aerosol Solution) 3 

Proventil 

(nebulizer Solution) 

3 B/D 

Proventil HFA 2 

Serevent Diskus 2 PA 

Terbutaline Sulfate 1 

Ventolin HFA 3 

Vospire ER 3 

Xopenex 


2 B/D,PA 

Xopenex concentrate 


2 B/D,PA 

19

20 


Xopenex HFA 2 

Vasopressors - Heart Regulation Drugs 

Midodrine HCl 1 

Proamatine 3 

Twinject 3 



TIER LIMITS 

BLooD FoRMATIon AnD coAGULATIon - 

DRUGS To TREAT BLooD DISoRDERS 

Anticoagulants - Blood Thinners 

Arixtra 4 QL 

Heparin Sodium 1 

Heparin Sodium DCU 1 

Heparin Sodium/D5W 1 

Heparin Sodium/NaCl 

0.45% 

1 

Innohep 4 QL 

coumadin 2 

Fragmin 2 QL 

Jantoven 1 

Lovenox 4 QL 

Warfarin Sodium 1 

Antihemorrhagic Agents - Drugs to Prevent Bleeding 

cyklokapron 2 

Antiplatelet Agents - Blood Thinners 

Anagrelide HCl 1 

Agrylin 4 

Persantine 3 

Pletal 3 

Ticlid 3 

Ticlopidine HCl 1 

Aggrenox 2 QL 

Cilostazol 1 

Dipyridamole 1 

Plavix 2 QL 




TIER LIMITS 

Hematopoietic Agents - Blood Formation Drugs 

Aranesp 4 B/D, PA 

Aranesp Albumin Free 4 B/D, PA 

Aranesp Albumin Free 

Sureclick 

Epogen (2000 unit/ml, 

4 B/D, PA 

3000 unit/ml, 4000 unit/ml 

Injectable Solution) 

Epogen (10000 unit/ml, 

3 B/D, PA, QL 



3 B/D, PA 

Leukine 4 

neulasta 4 

neumega 4 

neupogen 

Procrit (2000 unit/ml, 

4 



Procrit (10000 unit/ml, 

3 B/D, PA, QL 



Hemorrheologic Agents - 

Blood Thinners 

3 B/D, PA 

Pentopak 1 

Pentoxifylline CR 1 

Pentoxifylline ER 1 

Pentoxil 1 

Trental 3 

cARDIoVAScULAR DRUGS - DRUGS To TREAT 

HEART oR cIRcULATIon conDITIonS 

Alpha-Adrenergic Blocking Agents - 

Blood Pressure Drugs 

cardura 3 

cardura XL 3 

Doxazosin Mesylate 1 

Hytrin 3 




Minipress 3 

Prazosin HCl 1 

Terazosin HCl 1 



TIER LIMITS 

Angiotensin II Receptor Antagonists - 


Atacand 3 QL, ST 

Atacand HcT 3 QL, ST 

Avalide* 3 QL, ST 

Avapro* 3 QL, ST 

Benicar 2 QL, ST 

Benicar HcT 2 QL, ST 

cozaar* 3 QL, ST 

Diovan 2 QL, ST 

Diovan HcT 2 QL, ST 

Hyzaar* 3 QL, ST 

Micardis 3 QL, ST 

Micardis HcT 3 QL, ST 

Teveten 3 QL, ST 

Teveten HcT 3 QL, ST 

Angiotensin-converting Enzyme Inhibitors - 


Accupril 3 

Accuretic 3 

Aceon 2 

Altace 2 

Benazepril HCl 1 

Benazepril HCl/ 

Hydrochlorothiazide 

1 

capoten 3 

capozide 3 

Captopril 1 

Captopril/ 


1 

Enalapril Maleate 1 

Enalapril Maleate/ 


1 


Fosinopril Sodium 1 





TIER LIMITS 

Fosinopril Sodium/ 


1 

Lisinopril 1 

Lisinopril/ 


1 

Lotensin 3 

Lotensin HcT 3 

Mavik* 3 

Moexipril HCl 1 

Moexipril HCl/ 


1 

Monopril 3 

Monopril HcT 3 

Prinivil 3 

Prinzide 3 

Quinapril HCl 1 

Quinapril/ 


1 

Quinaretic 1 

Trandolapril 1 

Uniretic 3 

Univasc 3 

Vaseretic 3 

Vasotec 3 

Zestoretic 3 

Zestril 3 

Antiarrhythmic Agents - Heart Regulation Drugs 

Amiodarone HCl 1 

cordarone 3 

Disopyramide Phosphate 1 

Disopyramide Phosphate ER 1 

Ethmozine 3 

Flecainide Acetate 1 

Mexiletine HCl 1 

norpace 3 

21

22 




TIER LIMITS 

norpace cR 

(100 mg 12-Hour capsule) 

2 

norpace cR 

(150 mg 12-Hour capsule) 

3 

Pacerone (100 mg Tablet, 

300 mg Tablet) 

2 

Pacerone (200 mg Tablet) 1 

Pacerone (400 mg Tablet) 3 

Procainamide HCl 1 

Procainamide HCl ER 1 

Procainamide HCl SR 1 

Procanbid 2 

Pronestyl 3 

Pronestyl SR 3 

Propafenone HCl 1 

Quinidine Gluconate 3 

Quinidine Gluconate CR 1 

Quinidine Gluconate ER 1 

Quinidine Gluconate SA 1 

Quinidine Sulfate 1 

Quinidine Sulfate ER 1 

Rythmol 3 

Rythmol SR 2 

Tambocor 3 

Tikosyn 2 

Beta-Adrenergic Blocking Agents - 

Blood Pressure and Heart Regulation Drugs 

Acebutolol HCl 1 

Atenolol 1 

Atenolol/Chlorthalidone 1 

Betapace 3 

Betapace AF 3 

Betaxolol HCl 1 

Bisoprolol Fumarate 1 

Bisoprolol Fumarate/ 


1 


cartrol 3 

Carvedilol 1 

coreg 2 



TIER LIMITS 

coreg cR* 3 QL 

corgard 3 

corzide 3 

Inderal 3 

Inderal LA 3 

Inderide 40/25 3 

Innopran XL 3 

Kerlone 3 

Labetalol HCl 1 

Levatol 3 

Lopressor 3 

Lopressor HcT 3 

Metoprolol Succinate ER 1 

Metoprolol Tartrate 1 

Metoprolol/ 


1 

Nadolol 1 

Pindolol 1 

Propranolol HCl 1 

Propranolol HCl ER 1 

Propranolol/ 


1 

Sectral 3 

Sorine 1 

Sotalol HCl 1 

Sotalol HCl (AF) 1 

Tenoretic 50 3 

Tenoretic 100 3 

Tenormin 3 

Timolide 10/25 3 

Timolol Maleate 1 

Toprol XL 3 




Trandate 3 

Trandate IV 3 

Zebeta 3 

Ziac 3 



TIER LIMITS 

Bile Acid Sequestrants - cholesterol control Drugs 

colestid 3 

colestid Flavored 3 

Colestipol HCl 1 

Cholestyramine 1 

Cholestyramine Light 1 

Prevalite 1 

Questran 3 

Questran Light 3 

Welchol 2 

cardiotonic Agents - Heart Regulation Drugs 

Digitek 1 

Digoxin 1 

Lanoxicaps 2 

Lanoxin 2 

central Alpha-Agonists - Blood Pressure Drugs 

catapres 3 

catapres-TTS-1 2 QL 



Clonidine HCl 1 

clorpres 3 

Guanabenz Acetate 1 

Guanfacine HCl 1 

Methyldopa 1 

Methyldopa/ 


1 

Methyldopate HCl 1 

Tenex 3 






TIER LIMITS 

cholesterol Absorption Inhibitors - 

cholesterol control Drugs 

Zetia 2 QL 

Dihydropyridines - Blood Pressure Drugs 

Adalat cc 3 

Afeditab CR 1 

Amlodipine Besylate 

(Generic for Norvasc) 

1 

Amlodipine Besylate/ 

Benazepril HCl 

1 

Azor 3 QL, ST 

caduet 3 QL 

cardene 3 

cardene I.V. 3 

cardene SR 3 QL 

Dynacirc cR 3 QL 

Exforge 2 QL, ST 

Felodipine ER 1 

Isradipine 1 

Lexxel 

Lotrel (2.5 mg/10 mg, 

3 

5 mg/10 mg, 5 mg/20 mg, 

10 mg/20 mg capsules) 

Lotrel 

3 

(5 mg/40 mg capsule, 

10 mg/40 mg capsule) 

2 QL 

Nicardipine HCl 1 

Nifediac CC 1 

Nifedical XL 1 

Nifedipine 3 

Nifedipine ER 1 

Nimodipine 4 

nimotop 4 

norvasc 3 

Plendil 3 

Procardia 3 

23

24 


Procardia XL 3 



TIER LIMITS 

Sular 2 QL 

Direct Vasodilators - Blood Pressure Drugs 

Hydralazine HCl 1 

Minoxidil 1 

Fibric Acid Derivatives - cholesterol control Drugs 

Antara 2 

Fenofibrate 1 

Gemfibrozil 1 

Lofibra 3 

Lopid 3 

Tricor 2 

Triglide 3 

HMG-coA Reductase Inhibitors - 


Advicor 2 QL 

Altoprev 3 QL 

crestor* 3 QL 

Lescol* 3 QL 

Lescol XL* 3 QL 

Lipitor 2 QL 

Lovastatin 1 

Mevacor 3 

Pravachol 3 

Pravastatin 1 

Simvastatin 1 

Vytorin 2 QL 

Zocor 3 

Mineralocorticoid (Aldosterone) Receptor 

Antagonists - Blood Pressure Drugs 

Aldactazide 3 

Aldactone 3 

Inspra 3 ST 

Spironolactone 1 




TIER LIMITS 

Spironolactone/ 


1 

Miscellaneous Antilipemic Agents - 


Lovaza 3 

niaspan 2 

Miscellaneous calcium-channel Blockers - 


calan 3 

calan SR 3 

cardizem 3 

cardizem cD 3 

cardizem LA 2 QL 

Cartia XT 1 

covera-HS 3 QL 

Dilacor XR 3 

Dilt-CD 1 

Dilt-XR 1 

Diltia XT 1 

Diltiazem CD 1 

Diltiazem HCl 1 

Diltiazem HCl ER 1 

Isoptin SR 3 

Tarka 3 

Taztia XT 1 

Tiazac 3 

Verapamil HCl 1 

Verapamil HCl ER 1 

Verelan PM 3 

Verelan 3 

Miscellaneous cardiac Drugs - chest Pain Drugs 

Ranexa 3 

Miscellaneous Hypotensive Agents - 


Inversine 3 

Tekturna 2 QL, ST 






TIER LIMITS 

Miscellaneous Vasodilating Agents - 

Pulmonary Hypertension Drugs 

Letairis 4 PA 

Papaverine HCl 1 

Remodulin 4 B/D, PA 

Tracleer 4 PA 

Ventavis 4 B/D, PA 

nitrates and nitrites - chest Pain Drugs 

Bidil 2 

Dilatrate SR 3 

Imdur 3 

Ismo 3 

Isochron 1 

Isordil Titradose 3 

Isosorbide Dinitrate 1 

Isosorbide Dinitrate ER 1 

Isosorbide Mononitrate 1 

Isosorbide Mononitrate ER 1 

Minitran 1 

Monoket 3 

Nitrek 1 

nitrobid 2 

nitro-Dur 3 

Nitroglycerin 1 

Nitroglycerin CR 

(9mg Capsules) 

1 

Nitroglycerin TD 1 

Nitroglycerin Transdermal 1 

nitrolingual Pumpspray 3 

nitrostat 3 

Nitro-Time 1 

Peripheral Adrenergic Inhibitors - 


Rauwolfia/ 

Bendroflumethiazide 

3 

Reserpine 1 






TIER LIMITS 

Phosphodiesterase Inhibitors - 

Pulmonary Hypertension Drugs 

Revatio 4 PA 

cEnTRAL nERVoUS SYSTEM AGEnTS - 

DRUGS To TREAT nERVE conDITIonS 

Amphetamines - Stimulant Drugs 

Adderall 3 

Adderall XR 3 QL 

Amphetamine Salts Combo 1 

Desoxyn 3 

Dexedrine 3 

Dextroamphetamine 

Sulfate 

1 

Dextroamphetamine 

Sulfate CR 

1 

Dextrostat (5 mg Tablet) 1 

Dextrostat (10 mg Tablet) 3 

Vyvanse 

Antidepressants 

3 QL 

Amitriptyline HCl 1 

Amoxapine 1 

Anafranil 3 

Budeprion SR 1 

Budeprion XL 1 

Buproban 1 

Bupropion HCl 1 

Bupropion HCl SR 1 

celexa 3 

Chlordiazepoxide/ 

Amitriptyline 

3 

Citalopram Hydrobromide 1 

Clomipramine HCl 1 

cymbalta 2 

Desipramine HCl 1 

Doxepin HCl 1 

25

26 


Effexor 3 



TIER LIMITS 

Effexor XR 2 QL 

Emsam 3 QL 

Fluoxetine HCl 1 

Fluvoxamine Maleate 1 

Imipramine HCl 1 

Imipramine Pamoate 1 

Lexapro 2 

Limbitrol 3 

Limbitrol DS 3 

Maprotiline HCl 1 

Marplan 2 

Mirtazapine 1 

nardil 2 

Nefazodone HCl 1 

norpramin 3 

Nortriptyline HCl 1 

Pamelor 3 

Parnate 3 

Paroxetine HCl 1 

Paxil 3 

Paxil cR 3 QL 

Perphenazine/Amitriptyline 1 

Pexeva 3 

Prozac 3 

Prozac Weekly 3 QL 

Rapiflux 3 

Remeron 3 

Remeron Soltab 3 

Sarafem 3 QL 

Sertraline HCl 1 

Surmontil 2 

Symbyax 3 

Tofranil 3 

Tofranil-PM 3 


Tranylcypromine Sulfate 1 

Trazodone HCl 1 

Trimipramine Maleate 1 

Venlafaxine HCl 1 

Vivactil 2 

Wellbutrin 3 

Wellbutrin SR 3 



TIER LIMITS 

Wellbutrin XL 

(150 mg 24-Hour Tablet) 

2 QL 

Wellbutrin XL (300 mg 

24-Hour Tablet) 

3 QL 

Zoloft 3 

Antimanic Agents - Mood Stabilizers 

Lithium Carbonate 1 

Lithium Carbonate ER 1 

Lithium Citrate (Syrup) 1 

Lithobid 

Antipsychotic Agents 

2 

Abilify 3 

Abilify Discmelt 3 

Chlorpromazine HCl 1 

Clozapine 1 

clozaril 3 

Equetro 2 

Fazaclo 2 

Fluphenazine Decanoate 1 

Fluphenazine HCl 1 

Geodon 3 

Haldol 3 

Haldol Decanoate-50 3 

Haldol Decanoate-100 3 

Haloperidol 1 

Invega 3 

Loxapine Succinate 1 

Loxitane 3 




Moban 2 

navane 3 

orap 2 

Perphenazine 1 

Prochlorperazine 1 

Prochlorperazine Edisylate 1 

Prochlorperazine Maleate 1 

Risperdal 2 

Risperdal consta 4 

Risperdal M-Tab 2 

Seroquel 2 

Seroquel XR 2 

Thioridazine HCl 3 

Thiothixene 1 

Trifluoperazine HCl 1 

Zyprexa 2 

Zyprexa Zydis 2 



TIER LIMITS 

Barbituates (Anticonvulsants) - 

Seizure control Drugs 

Mysoline 3 

Primidone 1 

Hydantoins - Seizure control Drugs 

cerebyx 3 

Dilantin 2 

Dilantin Infatabs 2 

Peganone 2 

Phenytek 2 

Phenytoin 1 

Miscellaneous Analgesics - Pain control Drugs 

Duraclon 4 

Miscellaneous Anorexigenic Agents 

and cerebral Stimulants 

concerta 3 QL 

Daytrana 3 QL 

Dexmethylphenidate HCl 1 


Focalin 3 





TIER LIMITS 

Focalin XR 3 QL 

Metadate cD 3 QL 

Metadate ER (10 mg 

Controlled Release Tablet) 

1 

Metadate ER (20 mg 

controlled Release Tablet) 

3 

Methylin 

(chewable Tablet) 

3 

Methylin (Solution) 3 

Methylin (Tablet) 1 

Methylin ER 1 

Methylphenidate HCl 1 

Methylphenidate HCl ER 1 

Provigil 2 PA, QL 

Ritalin 3 

Ritalin LA 3 QL 

Ritalin SR 3 

Miscellaneous Anticonvulsants - 

Seizure control Drugs 

Carbamazepine 1 

carbatrol 2 

Depacon 3 

Depakene 3 

Depakote 2 

Depakote Sprinkles 2 

Epitol 1 

Felbatol (Suspension) 3 

Felbatol (Tablet) 2 

Gabapentin 1 

Gabitril 2 

Keppra 2 

Lamictal 2 

Lamictal chewable 

Dispersible 

3 

27

28 


Lamictal Starter Kits 2 



TIER LIMITS 

Lamotrigine Chewable 

Dispersible 

1 

Lyrica 2 

neurontin 

(capsule, Tablet) 

3 

neurontin (Solution) 2 

Oxcarbazepine (Tablet) 1 

Tegretol 2 

Tegretol-XR 2 

Topamax 2 

Topamax Sprinkle 2 

Trileptal 2 

Valproate Sodium 1 

Valproic Acid 1 

Zonegran 3 

Zonisamide 1 

Miscellaneous Antimigraine Agents 

cafergot 3 

D.H.E. 45 4 

Depakote ER 2 

Dihydroergotamine 

Mesylate 

1 

Ergomar 3 

Ergotamine Tartrate/ 

Caffeine 

1 

Migergot 1 

Migranal 2 QL 

Miscellaneous Anxiolytics, Sedatives, and 

Hypnotics - Drugs for Anxiety, Sedation, and Sleep 

Ambien 3 

Ambien cR 2 QL 

Buspar 3 

Buspirone HCl 1 

Equagesic 3 

Hydroxyzine HCl 3 


Hydroxyzine Pamoate 3 



TIER LIMITS 

Lunesta 2 QL 

Meprobamate 3 

Rozerem 3 QL 

Sonata* 3 QL 

Vanspar 3 

Vistaril 3 

Zolpidem Tartrate 

(Generic for Ambien) 

1 

Miscellaneous central nervous System Agents 

Apokyn 4 PA 

Atamet 1 

Azilect 2 

campral 2 

Carbidopa/Levodopa 1 

Carbidopa/Levodopa CR 1 

Carbidopa/Levodopa ER 1 

Carbidopa/Levodopa SR 1 

comtan 2 

Eldepryl 3 

Lodosyn 2 

Mirapex 2 

namenda (Solution) 2 

namenda (Tablet) 2 QL 

namenda Titration Pak 2 QL 

neupro 3 QL, ST 

Parcopa 3 

Prialt 4 B/D 

Requip 2 

Rilutek 4 

Selegiline HCl 1 

Sinemet 3 

Sinemet cR 3 

Stalevo 50 2 

Stalevo 100 2 




Stalevo 150 2 

Stalevo 200 2 



TIER LIMITS 

Strattera 3 QL, ST 

Tasmar 3 

Xyrem 3 QL 

Zelapar 3 

nonsteroidal Anti-Inflammatory Agents 

Anaprox 3 

Anaprox DS 3 

Ansaid 3 

Arthrotec 50 3 

Arthrotec 75 3 

cataflam 3 

celebrex 3 QL 

clinoril 3 

Daypro 3 

Diclofenac Potassium 1 

Diclofenac Sodium 1 

Diclofenac Sodium DR 1 

Diclofenac Sodium EC 1 

Diclofenac Sodium ER 1 

Diclofenac Sodium XR 1 

Diflunisal 1 

Ec-naprosyn 3 

Etodolac 1 

Etodolac ER 1 

Feldene 3 

Fenoprofen Calcium 1 

Flurbiprofen 1 

Ibuprofen 1 

Indocin 3 

Indocin SR 3 

Indomethacin 1 

Indomethacin ER 1 

Ketoprofen 1 


Ketoprofen ER 1 





TIER LIMITS 

Ketorolac Tromethamine 3 QL 

Meclofenamate Sodium 1 

Meloxicam 1 

Mobic 3 

Motrin 3 

MST 600 1 

Nabumetone 1 

nalfon 3 

naprelan 3 

naprosyn 3 

Naproxen 1 

Naproxen DR 1 

Orphenadrine Compound 3 

Orphenadrine Compound DS 3 

Orphengesic 3 

Orphengesic Forte 3 

Oxaprozin 1 

Piroxicam 1 

Ponstel 3 

Prevacid naprapac 2 QL 

Sulindac 1 

Tolmetin Sodium 1 

Voltaren 

(Delayed Release Tablet) 

3 

Voltaren-XR 3 

opiate Agonists - narcotic Pain Relievers 

Acetaminophen/Codeine 1 

Acetaminophen/Codeine #2 1 



Actiq 4 PA, QL 

Anexsia 1 

Ascomp/Codeine 1 

Aspirin/Codeine 1 

29

30 


Astramorph 1 



TIER LIMITS 

Avinza 2 QL 

Balacet 325 1 

Buprenex 3 

Butalbital/Acetaminophen/ 

Caffeine/Codeine 

1 

Butalbital/Aspirin/Caffeine/ 

Codeine 

1 

capital/codeine 2 

Co-Gesic 1 

combunox 3 

Darvocet A500 3 

Darvocet-n 50 3 

Darvocet-n 100 3 

Darvon 3 

Darvon-n 3 

Demerol 3 

Depodur 4 

Dilaudid 3 

Dilaudid-5 3 

Dilaudid-HP 4 

Dolacet 1 

Dolagesic 1 

Dolophine 3 

Dolorex Forte 1 

Duragesic 3 QL 

Duramorph 1 

Endocet 1 

Eth-Oxydose 1 

Fentanyl (Patch) 1 QL 

Fentanyl Citrate (Injectable) 1 

Fentanyl Citrate Oral 

Transmucosal 

4 PA, QL 

Fentora 4 PA, QL 

Fioricet/codeine 3 


Fiorinal/codeine #3 3 

Hycet 3 

Hydrocet 1 



TIER LIMITS 

Hydrocodone Bitartrate/ 

Acetaminophen 

1 

Hydrocodone/ 

Acetaminophen 

1 

Hydrocodone/ 

Acetaminophen-HS 

1 

Hydrocodone/Ibuprofen 1 

Hydromorphone HCl 1 

Infumorph 200 3 

Infumorph 500 3 

Kadian 2 QL 

Levo-Dromoran 3 

Levorphanol Tartrate 1 

Lorcet 10/650 3 

Lorcet Plus 3 

Lortab 3 

Lortab 2.5 3 

Lortab 5 3 

Lortab 7.5 3 

Lortab 10 3 

Lynox 3 

Margesic-H 1 

Maxidone 3 

Meperidine HCl 1 

Meperitab 1 

Methadone HCl 1 

Methadose 1 

Morphine/D5W 1 

Morphine Sulfate 1 

Morphine Sulfate 

Add-Vantage 

1 


Dilute-A-Jet 

1 




Morphine Sulfate/D5W 1 



TIER LIMITS 

Morphine Sulfate ER 1 QL 

Morphine Sulfate in 

Dextrose 5% 

1 

Morphine Sulfate/NS 1 


Stick-Gard 

1 

MS contin 3 QL 

Nalbuphine HCl 1 

Narvox 1 

norco 3 

nubain 3 

numorphan 3 

opana 3 QL 

opana ER 2 QL 

oramorph SR 3 QL 

Oxycodone HCl 1 

Oxycodone HCl CR 1 QL 

Oxycodone HCl ER 1 QL 

Oxycodone/ 

Acetaminophen 

1 

Oxycodone/Aspirin 1 

oxycontin 3 QL 

Oxyfast 1 

oxyIR 3 

Panlor Dc 3 

Panlor SS 3 

Percocet 

(325 mg; 2.5 mg Tablet) 

Percocet 

(325 mg; 5 mg Tablet, 

2 

325 mg; 7.5 mg Tablet, 500 

mg; 7.5 mg, 325 mg; 10 mg 

Tablet, Tablet, 

650 mg; 10 mg Tablet) 

3 

Percodan 3 

Percolone 1 


Perloxx 1 

Phrenilin w/Caffeine/ 

Codeine 

1 

Propoxyphene HCl 1 

Propoxyphene/ 

Acetaminophen 

1 

Propoxyphene-N/ 

Acetaminophen 

1 

Reprexain 3 

RMS 3 

Roxanol 3 

Roxicet (Solution) 2 

Roxicet (Tablet) 1 

Roxicodone 3 

Roxicodone Intensol 3 

Stadol 4 

Stagesic 1 

Suboxone 3 

Subutex 3 

Synalgos-Dc 3 

Talacen 3 

Talwin 2 

Talwin nX 3 

Tramadol HCl 1 

Tramadol HCl/ 

Acetaminophen 

1 

Tylenol/codeine #3 3 

Tylenol/codeine #4 3 

Tylox 3 

Ultracet 3 

Ultram 3 

Ultram ER 3 

Vanacet 1 

Vicodin 3 

Vicodin ES 3 

Vicodin HP 3 





TIER LIMITS 

31

32 


Vicoprofen 3 

Vopac 2 

Xodol 3 

Zerlor 1 

Zydone 3 



TIER LIMITS 

opiate Antagonists - narcotic Pain Relievers 

Depade 1 

Naloxone HCl 1 

Naltrexone HCl 1 

narcan 3 

Revex 3 

Revia 3 

Vivitrol 4 

opiate Partial Agonists - narcotic Pain Relievers 

Buprenorphine HCl 1 

Butorphanol Tartrate 1 

Pentazocine/ 

Acetaminophen 

1 

Pentazocine/Naloxone HCl 

Selective Serotonin Agonists - 

Migraine and Headache Drugs 

1 

Amerge 3 QL 

Axert 3 QL 

Frova 3 QL 

Imitrex 2 QL 

Imitrex Statdose Pen 2 QL 

Imitrex Statdose Refill 2 QL 

Maxalt 2 QL 

Maxalt-MLT 2 QL 

Relpax 3 QL 

Zomig 3 QL 

Zomig ZMT 3 QL 

Succinimides - Seizure control Drugs 

celontin 2 

Ethosuximide 1 


Zarontin 3 

DEVIcES 

Devices 

Alcohol Swabs 1 

BD Insulin needles, Pens, 

1 

Syringes, Safety Syringes 

Insulin needles, Pens, 

Syringes, Safety Syringes 2 

(non-BD Brand Products) 

Gauze Pads 1 

ELEcTRoLYTIc, cALoRIc, AnD 

WATER BALAncE 

Acidifying Agents 

Ammonium chloride 

Alkalinizing Agents 

3 

Potassium Citrate 

Extended-Release 

1 

Urocit-K 5 3 

Urocit-K 10 

Ammonia Detoxicants 

3 

Buphenyl (Powder) 4 

Buphenyl (Tablet) 3 

Constulose 1 

Enulose 1 

Generlac 1 

Kristalose 2 

Lactulose 1 

Lithostat 3 

Diuretics - Drugs for Water Balance 

Amiloride HCl 1 

Amiloride/ 


1 

Bumetanide 1 

Bumex 3 



TIER LIMITS 




Chlorothiazide 1 

Chlorthalidone 1 

Demadex 3 

Diuril 2 

Diuril IV 3 

Dyazide 3 

Dyrenium 3 

Edecrin 3 

Furosemide 1 

Hydrochlorothiazide 1 

Indapamide 1 

Ismotic 3 

Lasix 3 

Maxzide 3 

Maxzide-25 3 

Methyclothiazide 1 

Metolazone 1 

Microzide 3 

Thalitone 3 

Torsemide 1 

Triamterene/ 


1 

Zaroxolyn 

Irrigating Solutions 

3 

Brand Irrigation Solutions 2 

Generic Irrigation 

Solutions 

Phosphate-Removing Agents 

1 

Fosrenol 2 

Renagel 

Potassium-Removing Agents 

2 

Kayexalate 3 

Kionex 1 

Sodium Polystyrene 

Sulfonate 

1 



TIER LIMITS 






TIER LIMITS 

Replacement Preparations 

Brand Injectable 

Replacement Therapies 

2 

Generic Injectable 

Replacement Therapies 

1 

Ed K+10 1 

Kaon-Cl-10 1 

KCl 1 

KCl CR 1 

KCl ER 1 

KCl SA 1 

KCl SR 1 

Klor-Con 8 1 

Klor-Con 10 1 

Klor-Con M10 1 

Klor-con M15 2 

Klor-Con M20 1 

Klotrix 3 

K-Tabs 3 

K-Vescent 1 

Magnesium Sulfate 

in D5W 

Micro-K 

1 

(8 meq controlled Release 

capsule) 

Micro-K 

2 

(10 meq controlled Release 

capsule) 

3 

NaCl 0.9% 1 

NaCl Bacteriostatic 1 

PhosLo 2 

Uricosuric Agents - Drugs to Decrease Uric Acid 

Probenecid 1 

Probenecid/Colchicine 1 

33

EnZYMES 

34 




TIER LIMITS 

Enzyme Deficiency Drugs 

Adagen 4 

Aldurazyme 4 

ceredase 4 

cerezyme 4 

Elaprase 4 

Elitek 4 

Fabrazyme 4 

Myozyme 4 

naglazyme 4 

Pulmozyme 4 B/D, PA 

Sucraid 

EYE, EAR, noSE & THRoAT 

PREPARATIonS - EEnT DRUGS 

4 

Antiallergic Agents - Drugs to Treat Allergies 

Alamast 3 

Alocril 2 

Alomide 2 

Astelin 2 QL 

crolom 3 

Cromolyn Sodium (Solution) 1 

Elestat 3 

Emadine 3 

Ketotifen Fumarate 1 

optivar 2 

Pataday 2 

Patanol 

Antibacterials (EEnT) - 

2 

Drugs to Treat Bacterial Infections 

Ak-Poly-Bac 1 

Ak-Tob 1 

Arestin 3 

Atridox 3 


Bacitracin (Ointment) 1 



TIER LIMITS 

Bacitracin/Neomycin/ 

Polymyxin 

1 

Bacitracin/Polymyxin B 1 

Bleph-10 3 

ciloxan (ointment) 2 

ciloxan (Solution) 3 

Ciprofloxacin HCl 1 

Erythromycin 1 

Floxin otic 2 ST 

Floxin otic Singles 2 ST 

Genoptic 1 

Gentak 1 


Gentasol 1 

Neocin 1 

Neocin-PG 1 

Neomycin/Bacitracin/ 

Polymyxin 

1 

Neomycin/Polymyxin/ 

Gramicidin 

1 

Neomycin/Polymycin/ 

Bacitracin/Hydrocortisone 

1 

Neomycin/Bacitracin Zinc/ 

Polymyxin 

1 

neosporin 3 

ocuflox 3 

Ocusulf-10 1 

Ofloxacin 

(Ophthalmic Solution) 

1 

Ofloxacin (Otic Solution) 1 ST 

Polycin B 1 

Polymyxin B Sulfate/ 

Trimethoprim Sulfate 

1 

Polytrim 3 

Quixin 3 




Romycin 1 

Sulf-10 1 

Sulfacetamide Sodium 1 

Tobramycin Sulfate 1 

Tobrasol 1 

Tobrex (ointment) 2 

Tobrex (Solution) 3 



TIER LIMITS 

Trimethoprim Sulfate/ 

Polymyxin B Sulfate 

1 

Vigamox 2 

Zymar 

Antifungals (EEnT) - 

Drugs to Treat Fungal Infections 

2 

natacyn 

Antivirals (EEnT) - 

Drugs to Treat Viral Infections 

2 

Trifluridine 1 

Viroptic 3 

corticosteroids - Anti-Inflammatory Drugs 

Acetic Acid/ 

Hydrocortisone 

1 

Alrex 2 

Antibiotic Ear 1 

Beconase AQ 3 QL 

Blephamide 2 

Blephamide S.o.P. 2 

cipro Hc 2 

ciprodex 2 

coly-Mycin-S 

cortisporin 

3 

(1%; 5 mg/ml; 10000 unit/ml 

Suspension) 

cortisporin (1%/3.5 

3 

mg/ml/10000 unit/ml 

Suspension, Solution) 

3 

cortisporin-Tc 3 

Cortomycin 1 


Dermotic 2 





TIER LIMITS 

Dexamethasone Sodium 

Phosphate 

1 

Dexasol 1 

Dexasporin 1 

Econopred Plus 3 

Flarex 2 

Flonase 3 

Flunisolide 1 ST 

Fluorometholone 1 

Fluor-Op 1 

Fluticasone Propionate 1 

FML Forte 2 

FML Liquifilm 3 

FML S.o.P. 2 

Lotemax 2 

Maxidex 2 

Maxitrol 3 

nasacort AQ 3 QL 

nasarel 3 QL 

nasonex 2 QL 


Dexamethasone 

1 




1 


(1%; 3.5 mg/ml; 

10000 unit/ml Suspension) 

1 

Oticin HC 1 

Pediotic 3 

Poly-Dex 1 

Poly-Pred 2 

Pred Forte 3 

Pred Mild 2 

Pred-G 2 

35

36 


Pred-G S.o.P. 2 

Prednisol 1 

Prednisolone 1 

Prednisolone Acetate 1 



TIER LIMITS 

Prednisolone Sodium 

Phosphate 

1 

Rhinocort Aqua 

Sulfacetamide Sodium/ 

2 QL 


Phosphate 

1 

Tobradex 2 

Veramyst 3 

Vexol 2 

Zylet 

EEnT - Glaucoma Drugs 

2 

Acetazolamide 1 

Alphagan P 2 

Azopt 2 

Betagan 3 

Betagan c cap QD 3 

Betagan Without c cap 3 

Betaxolol HCl 1 

Betimol 3 

Betoptic-S 2 

Brimonidine Tartrate 1 

Carteolol HCl 1 

cosopt 2 

Diamox 2 

Istalol 3 

Levobunolol HCl 1 

Lumigan 2 QL 

Methazolamide 1 

Metipranolol 1 

optipranolol 3 

Timolol Maleate 1 




TIER LIMITS 

Timolol Maleate 

Ophthalmic Gel Forming 

1 

Timoptic 3 

Timoptic ocudose 3 

Timoptic-XE 3 

Travatan 2 QL 

Travatan Z 2 QL 

Trusopt* 3 

Xalatan* 

Local Anesthetics (EEnT) 

3 QL 

Alcaine 3 

Lidomar Viscous 1 

Parcaine 1 

Proparacaine HCl 1 

Uni-Otic 1 

Xylocaine Viscous 

Miotics 

3 

Carbastat 1 

Miostat 3 

Phospholine Iodide 2 

Pilopine HS 

Miscellaneous Anti-Infectives 

2 

Chlorhexidine Gluconate 1 

Peridex oral Rinse 3 

Periogard 1 

Miscellaneous Anti-Inflammatory Agents 

Restasis 

Miscellaneous EEnT Drugs 

2 

Acetic Acid 1 

Borofair 1 

Iopidine 2 

Lacrisert 

Mydriatics 

2 

Atropine Sulfate 3 

Dipivefrin HCl 1 




Mydral 1 

Mydriacyl 3 

Propine 3 

Tropicacyl 1 

Tropicamide 1 

nonsteroidal Anti-Inflammatory Agents 

Acular 2 

Acular LS 2 

Acular PF 2 

Flurbiprofen Sodium 1 

nevanac 3 

Voltaren (Solution) 2 

Xibrom 

Vasoconstrictors 

3 

Adrenalin 3 

Ak-Con 1 

Albalon 3 

Naphazoline HCl 1 

ocufen 3 

Tyzine 2 

Tyzine Pediatric nasal 

Drops 

2 



TIER LIMITS 

GASTRoInTESTInAL AGEnTS - DRUGS To TREAT 

BoWEL, InTESTInE oR SToMAcH conDITIonS 

5-HT3 Receptor Antagonists - 

nausea and Vomiting Prevention Drugs 

Aloxi 4 

Anzemet (Solution) 3 

Anzemet (Tablet) 

Kytril 

3 B/D, PA, QL 

(0.1 mg/ml Solution, 

1 mg/ml Solution) 

4 

Kytril (2 mg/10ml oral 

Solution, Tablet) 

4 B/D, PA, QL 






TIER LIMITS 

Ondansetron HCl 

(2 mg/ml Solution, 

32 mg/50ml Solution) 

Ondansetron HCl 

1 

(4 mg/5ml Oral Solution, 

Tablet) 

1 B/D, PA, QL 

Ondansetron ODT 1 B/D, PA, QL 

Zofran (2 mg/ml Solution, 

32 mg/50ml Solution) 

4 

Zofran (4 mg/5ml Solution, 

Tablet) 

4 B/D, PA, QL 

Zofran oDT 

Antidiarrhea Agents 

4 B/D, PA, QL 

Diphenoxylate/Atropine 3 

Lofene 3 

Lomotil 3 

Lonox 3 

Loperamide HCl 1 

Motofen 3 

opium Tincture 3 

Paregoric 

Antihistamines (GI Drugs) - 

1 


Antivert (12.5 mg Tablet, 

25 mg Tablet) 

3 

Antivert (50 mg Tablet) 2 

Meclizine HCl 1 

Tigan 3 

Trimethobenzamide HCl 3 

Anti-Inflammatory Agents - Bowel Treatment Drugs 

Asacol 2 

canasa 2 

colazal 2 

Dipentum 2 

Lialda 3 

37

38 


Mesalamine 1 

Pentasa 3 

Rowasa 3 



TIER LIMITS 

cathartics and Laxatives - Bowel Treatment Drugs 

Amitiza 3 PA,QL 

colyte 3 

colyte-Flavor Packs 3 

Glycolax 

Golytely (227.1 gm; 

1 

2.82 gm; 6.36 gm; 5.53 

gm; 21.5 gm Solution for 


Golytely (236 gm; 2.97 gm; 

3 

6.74 gm; 5.86 gm; 22.74 gm 


2 

Halflytely Bowel Prep Kit 2 

Moviprep 2 

nulytely 2 

osmoprep 2 

Polyethylene Glycol 3350 1 

Polyethylene Glycol 3350/ 

Electrolytes 

1 

Trilyte 2 

Visicol 2 

cholelitholytic Agents - Drugs to Treat Gall Stones 

Actigall 3 

Urso 250 2 

Urso Forte 2 

Ursodiol 

Digestants - Digestive Enzymes 

1 

creon 5 2 

creon 10 2 

creon 20 2 

Dygase 3 

Enzycap 3 

Enzymax 3 


Kutrase 3 

Ku-Zyme 3 

Ku-Zyme HP 3 

Lapase 3 

Lipram 4500 3 

Lipram-Pn10 3 

Lipram-Pn16 3 

Lipram-Pn20 3 

Lipram-UL12 3 

Lipram-UL18 3 

Lipram-UL20 3 

Palcaps 10 3 

Palcaps 20 3 

Palipase 3 

Palipase MT 16 3 

Palipase MT 20 3 

Palpeon DR 10 3 

Palpeon DR 20 3 

Palpeon MT 20 3 

Paltrase V8 3 

Pancrease MT 4 3 




Pancrecarb MS-4 3 



Pancrelipase 3 

Pancrelipase MST-16 3 

Pancron 10 3 

Pancron 20 3 

Pangestyme cn 10 3 

Pangestyme cn 20 3 

Pangestyme Ec 3 

Pangestyme MT 16 3 



TIER LIMITS 




Pangestyme UL 12 3 



Panocaps 3 

Panocaps MT 16 3 

Panocaps MT 20 3 

Panokase 3 

Panokase-16 3 

Plaretase 8000 3 

Ultracaps MT 20 3 

Ultrase 2 

Ultrase MT 12 2 



Viokase 3 

Viokase 8 3 

Viokase 16 3 



TIER LIMITS 

Histamine H2-Antagonists - 

Ulcer and Stomach Acid Drugs 

Axid 3 

Cimetidine 1 

Famotidine 1 

Famotidine Premixed 1 

Nizatidine 1 

Pepcid 

(Tablet, Suspension) 

3 

Pepcid Premixed 3 

Ranitidine HCl 1 

Tagamet 3 

Taladine 3 

Zantac 

Miscellaneous Antiemetics - 

3 


cesamet 3 B/D, PA, QL 

Compro 1 






TIER LIMITS 

Emend 2 B/D, PA, QL 

Marinol 4 B/D, PA 

Transderm-Scop 3 

Miscellaneous GI Drugs - Gastrointestinal Drugs 

Lotronex 2 QL 

Prochlorperazine 1 

Xenical 

Prokinetic Agents - 

3 


Metoclopramide HCl 1 

Reglan 3 

Prostaglandins - Ulcer and Stomach Acid Drugs 

cytotec 3 

Misoprostol 1 

Protectants - Ulcer and Stomach Acid Drugs 

carafate 3 

Sucralfate 

Proton-Pump Inhibitors - 

Ulcer and Stomach Acid Drugs 

1 

Aciphex* 3 QL 

nexium 2 QL 

nexium I.V. 3 

Omeprazole 1 QL 

Prevacid 2 QL 

Prevacid I.V. 2 

Prevacid Solutab 2 QL 

Prilosec 3 QL 

Protonix 

(Delayed Release Tablet) 

2 QL 

Protonix (Solution for 


3 

Prevpac 2 QL 

Zegerid 3 QL 

39

40 


GoLD coMPoUnDS 

Gold compounds - Arthritis Drugs 

Ridaura 2 

HEAVY METAL AnTAGonISTS 

Heavy Metal Antagonists 

chemet 3 

cuprimine 2 

Depen Titratabs 2 

Exjade 4 

Syprine 3 



TIER LIMITS 

HoRMonES AnD SYnTHETIc SUBSTITUTES 

Adrenals - corticosteroids - Anti-Inflammatory Drugs 

Aerobid 3 

Aerobid-M 3 

A-Methapred 1 

Aristospan Intra-Articular 3 

Aristospan Intralesional 3 

Asmanex 

14 Metered Doses 

2 QL 

Asmanex 


2 QL 

Asmanex 


2 QL 

Asmanex 


2 QL 

Azmacort 3 

celestone 3 

cortef 3 

Cortisone Acetate 1 

Depo-Medrol 

(20 mg/ml Suspension) 

2 




TIER LIMITS 

Depo-Medrol 

(40 mg/ml Suspension, 

80 mg/ml Suspension) 

3 

Dexamethasone 1 

Dexamethasone Intensol 1 


Phosphate 

1 

Dexpak 13 Day 3 

Entocort Ec 3 

Florinef 3 

Flovent HFA 2 

Fludrocortisone Acetate 1 


(Enema, Tablet) 

1 

Kenalog-10 2 

Kenalog-40 2 

Medrol 3 

Medrol Dosepak 3 

Methylprednisolone 1 

Methylprednisolone 

Acetate 

1 

Methylprednisolone 

Sodium Succinate 

1 

orapred 3 

orapred oDT 3 

Pediapred 3 

Prednisone 1 

Prednisone Intensol 1 

Prelone 3 

Pulmicort Respules 3 B/D, PA 

Pulmicort Flexhaler 3 

QVAR 2 

Solu-cortef 2 

Solu-Medrol (2 gm Solution 


2 

Solu-Medrol Act-o-Vial 3 






TIER LIMITS 

Solu-Medrol 




125 mg Solution for 



3 

Sterapred 3 

Sterapred 12 Day 3 

Sterapred DS 3 

Sterapred DS 12 Day 3 

Alpha-Glucosidase Inhibitors - Diabetes Drugs 

Glyset 3 

Precose 

Androgens - Testosterone Drugs 

2 

Anadrol-50 4 PA 

Androderm 2 

Androgel 2 

Androgel Pump 2 

Android 2 

Androxy 1 

Danazol 1 

Depo-Testosterone 3 

Methitest 3 

nandrolone Decanoate 2 

oxandrin 4 PA 

Oxandrolone 4 PA 

Striant 3 

Testim 3 

Testopel 3 

Testosterone Cypionate 1 

Testosterone Enanthate 1 

Testred 

Antithyroid Agents 

2 

Methimazole 1 

Propylthiouracil 1 


Tapazole 3 

Biguanides - Diabetes Drugs 

Fortamet 3 

Glucophage 3 

Glucophage XR 3 

Glumetza 3 

Metformin HCl 1 

Metformin HCl ER 1 

Riomet 3 

contraceptives - Birth control Drugs 

Alesse-28 3 

Apri 1 

Aranelle 1 

Aviane 1 

Balziva 1 

Brevicon-28 3 

Camila 1 

Cesia 1 

Cryselle-28 1 

cyclessa 3 

Desogen 3 

Enpresse-28 1 

Errinv 1 

Estrostep Fe 2 

Femcon Fe 3 

Jolessa 1 

Jolivette 1 

Junel 1.5/30 1 

Junel 1/20 1 

Junel Fe 1.5/30 1 

Junel Fe 1/20 1 

Kariva 1 

Kelnor 1/35 1 

Leena 1 

Lessina-28 1 





TIER LIMITS 

41

42 


Levlite-28 3 

Levora 0.15/30-28 1 

Lo/ovral-28 3 

Loestrin 1.5/30-21 3 

Loestrin 1/20-21 3 

Loestrin 24 Fe 3 

Loestrin Fe 1.5/30 3 

Loestrin Fe 1/20 3 

Low-Ogestrel 1 

Lutera 1 

Microgestin 1.5/30 1 

Microgestin 1/20 1 

Microgestin Fe 1 

Microgestin Fe 1.5/30 1 

Modicon-28 3 

MonoNessa 1 

Necon 0.5/35-28 1 

Necon 1/35-28v 1 

Necon 1/50-28 1 

Necon 10/11-28 1 

Necon 7/7/7 1 

Nora-BE 1 

nordette-28 3 

norinyl 1+35 3 

nor-QD 3 

Nortrel 0.5/35 (28) 1 

Nortrel 1/35 (21) 1 

Nortrel 1/35 (28) 1 

Nortrel 7/7/7 1 

Ogestrel 1 

ortho Evra 2 

ortho Micronor 3 

ortho Tri-cyclen 3 

ortho Tri-cyclen Lo 3 

ortho-cept-28 3 



TIER LIMITS 


ortho-cyclen-28 3 

ortho-novum 1/35-28 3 

ortho-novum 1/50-28 3 

ortho-novum 7/7/7-28 3 

ovcon-35 3 

ovcon-50 28 3 

Plan B 3 

Portia-28 1 

Previfem 1 

Quasense 1 

Reclipsen 1 

Seasonale 3 

Seasonique 3 

Solia 1 

Sprintec 28 1 

Sronyx 1 

Tri-Legest FE 1 

Tri-Levlen 3 

Tri-Levlen contract Pack 3 

TriNessa 1 

Tri-norinyl 28 3 

Triphasil 28 3 

Tri-Previfem 1 

Tri-Sprintec 1 

Trivora-28 1 

Velivet 1 

Yasmin 28 2 

Yaz 2 

Zovia 1/35E 1 

Zovia 1/50E 1 

nuvaRing 2 



TIER LIMITS 

Estrogen Agonist-Antagonists 

Evista 

Estrogens 

2 QL 

Activella 3 




Alora 2 

Angeliq 3 

cenestin 2 

climara 3 

climara Pro 3 

combipatch 3 

Delestrogen 3 

Depo-Estradiol 3 



TIER LIMITS 

Divigel 3 QL 

Elestrin 3 QL 

Enjuvia 3 

Esclim 3 

Estrace (cream) 2 

Estrace (Tablet) 3 

Estraderm 2 

Estradiol 1 

Estrasorb 3 

Estring 2 QL 

Estrogel 3 QL 

Estropipate 1 

Femhrt 1/5 2 

Femhrt Low Dose 2 

Femring 3 QL 

Femtrace 3 

Gynodiol (0.5 mg Tablet, 

1 mg Tablet, 2 mg Tablet) 

1 

Gynodiol (1.5 mg Tablet) 2 

Lybrel 3 

Menest 2 

Menostar 3 

ogen 3 

Ortho-Est 1 

Prefest 2 

Premarin 2 

Premarin w/Applicator 2 


Premphase 2 

Prempro 2 

Vagifem 2 

Vivelle 3 

Vivelle-Dot 2 





TIER LIMITS 

Glycogenolytic Agents - Diabetes Drugs 

Glucagen Hypokit 2 

Glucagon Emergency Kit 2 

Gonadotropins - Hormone Regulation Drugs 

Chorionic Gonadotropin 1 

Novarel 1 

Pregnyl w/Diluent Benzyl 

Alcohol/NaCl 

1 

Synarel 

Insulins 

4 

Apidra 3 

Exubera combination 

Pack 15 

3 PA 

Exubera Kit 3 PA 

Humalog 2 

Humalog Mix 50/50 2 

Humalog Mix 50/50 Pen 2 

Humalog Mix 75/25 2 

Humalog Mix 75/25 Pen 2 

Humalog Pen 2 

Humulin 50/50 2 

Humulin 70/30 2 

Humulin 70/30 Pen 2 

Humulin n 2 

Humulin n U-100 Pen 2 

Humulin R 2 

Lantus 2 

Lantus opticlik 2 

Levemir 2 

Levemir FlexPen 2 

43

44 


novolin 70/30 2 

novolin 70/30 Innolet 2 

novolin 70/30 Penfill 2 

novolin n 2 

novolin n Innolet 2 

novolin n U-100 Penfill 2 

novolin R 2 

novolin R Innolet 2 

novolin R U-100 2 

novolin R U-100 Penfill 2 

novolog 2 

novolog FlexPen 2 

novolog Mix 70/30 2 

novolog Mix 70/30 Penfill 2 



TIER LIMITS 

novolog Mix 70/30 Prefilled 

FlexPen 

2 

novolog Penfill 2 

Relion 70/30 3 

Relion 70/30 Innolet 3 

Relion n 3 

Relion n Innolet 3 

Relion R 

Meglitinides - Diabetes Drugs 

3 

Prandin 3 QL 

Starlix 

Miscellaneous Diabetes Drugs 

2 QL 

Byetta 2 ST 

Januvia 3 

Janumet 3 

Symlin 2 PA 

Miscellaneous Antihypoglycemic Agents 

Proglycem 

Parathyroid 

3 

Forteo 4 B/D, PA 

Fortical 2 QL 




TIER LIMITS 

Miacalcin* (200 unit/ml 


3 B/D, PA 

Miacalcin* (200 unit/act 

nasal Solution) 

Pituitary 

3 QL 

DDAVP 3 

Desmopressin Acetate 1 

Minirin 1 

Stimate 

Progestins 

4 

Aygestin 3 

crinone 2 

Depo-Provera 2 

Depo-Provera contraceptive 3 

Depo-Subq Provera 104 3 

Endometrin 3 

Medroxyprogesterone 

Acetate 

1 

Megace ES 3 

Norethindrone Acetate 1 

Prochieve 2 

Prometrium 2 

Provera 3 

Somatotropin Agonists - Growth Deficiency Drugs 

Genotropin 4 PA 

Genotropin Miniquick 4 PA 

Humatrope 4 PA 

Humatrope combo Pack 4 PA 

Increlex 4 PA 

Iplex 4 PA 

norditropin cartridge 4 PA 

norditropin nordiflex 4 PA 

norditropin nordiflex Pen 4 PA 

nutropin 4 PA 

nutropin AQ 4 PA 






TIER LIMITS 

nutropin AQ Pen 4 PA 

Saizen 4 PA 

Saizen click.Easy 4 PA 

Serostim 4 PA 

Tev-Tropin 4 PA 

Zorbtive 4 PA 

Somatotropin Antagonists 

Somavert 

Sulfonylureas - Diabetes Drugs 

4 

Amaryl 3 

Chlorpropamide 1 

Diabeta 3 

Diabinese 3 

Glimepiride 1 

Glipizide 1 

Glipizide ER 1 

Glipizide XL 1 

Glipizide/Metformin HCl 1 

Glucotrol 3 

Glucotrol XL 3 

Glucovance 3 

Glyburide 1 

Glyburide Micronized 1 

Glyburide/Metformin HCl 1 

Glycron (1.5 mg Tablet, 

3 mg Tablet, 6 mg Tablet) 

1 

Glycron (4.5 mg Tablet) 2 

Glynase 3 

Metaglip 3 

Micronase 3 

Tolazamide 1 

Tolbutamide 1 

Thiazolidinediones - Diabetes Drugs 

Actoplus Met 2 

Actos 2 QL 


Avandamet 2 

Avandaryl 2 





TIER LIMITS 

Avandia 2 QL 

Duetact 2 

Thyroid Agents 

cytomel 2 

Levothroid 2 

Levothyroxine Sodium 1 

Levoxyl 1 

Liothyronine Sodium 1 

Synthroid 2 

Thyrolar-1/4 2 

Thyrolar-1/2 2 

Thyrolar-1 2 

Thyrolar-2 2 

Thyrolar-3 2 

Unithroid 1 

LocAL AnESTHETIcS 

Local Anesthetics 

Lidocaine HCl 1 

Xylocaine 3 

MIScELLAnEoUS THERAPEUTIc AGEnTS 

Miscellaneous Therapeutic Agents 

Acetadote 3 

Actimmune 4 

Actonel 2 QL 

Actonel With calcium 2 QL 

Allopurinol 1 

Aloprim 3 

Antabuse 2 

Antizol 4 

Aphthasol 2 

Aralast 4 

45

46 


Arava 3 

Aredia 4 



TIER LIMITS 

Atgam 4 B/D, PA 

Avodart 2 QL 

Avonex 4 

Azasan 2 

Azathioprine 1 

Betaseron 4 

Boniva* (Kit) 3 

Boniva* (Tablet) 3 QL 

Botox 4 PA 

Bromocriptine Mesylate 1 

Cabergoline 1 

carnitor 3 

cellcept 4 B/D, PA 

cellcept Intravenous 4 B/D, PA 

Colchicine 1 

copaxone 4 

Cyclosporine 1 B/D, PA 

Cyclosporine Modified 1 B/D, PA 

cystadane 3 

cystagon 3 

Demser 3 

Dexrazoxane 1 

Didronel (Tablets) 3 

Dostinex 3 

Elmiron 2 

Enbrel 4 PA 

Enbrel Sureclick 4 PA 

Ethyol 4 

Etidronate Disodium 1 

Finasteride 1 

Flomax 2 QL 

Fosamax 2 QL 

Fosamax Plus D 2 QL 


Gastrocrom 3 



TIER LIMITS 

Gengraf 1 B/D, PA 

Humira 4 PA 

Humira Pen 4 PA 

Imuran 3 

Kineret 4 PA 

Leflunomide 1 

Leucovorin Calcium 1 

Levocarnitine 1 

Mesna 4 

Mesnex 4 

Myfortic 3 B/D, PA 

Myobloc 3 

neoral 3 B/D, PA 

Octreotide Acetate 4 

orencia 4 PA 

orfadin 4 

orthoclone oKT3 4 B/D, PA 

Pamidronate Disodium 

(30 mg/10ml Solution, 

90 mg/10ml Solution, 


1 

Pamidronate Disodium 

(6 mg/ml Solution) 

4 

Parlodel 3 

Prograf 4 B/D, PA 

Prolastin 4 

Proscar 3 

Quadramet 4 

Rapamune 3 B/D, PA 

Rebif 4 

Rebif Titration Pack 4 

Reclast 4 

Remicade 4 PA 

Revlimid 4 PA 

Sandimmune 3 B/D, PA 




Sandostatin 4 

Sandostatin LAR Depot 4 

Sensipar 2 



TIER LIMITS 

Simulect 4 B/D, PA 

Skelid 3 

Sodium Fluoride 3 

Somatuline Depot 4 PA 

Soriatane 4 

Thalomid 4 PA 

Thiola 3 

Thymoglobulin 4 B/D, PA 

Tysabri 4 

Uroxatral* 3 QL 

Zavesca 4 

Zemaira 4 

Zenapax 3 B/D, PA 

Zinecard 3 

Zometa 4 

Zyloprim 3 

oXYTocIcS 

oxytocics - Drugs for Labor and Delivery 

Methergine 2 

Oxytocin 1 

Pitocin 3 

PHARMAcEUTIcAL AIDS 

Pharmaceutical Aids 

NaCl Bacteriostatic/ 

Benzyl Alcohol 

RESPIRAToRY AGEnTS - 

DRUGS To TREAT LUnG conDITIonS 

Antileukotrienes - Asthma Drugs 

Accolate 3 QL, ST 

Singulair 2 QL, ST 

1 






TIER LIMITS 

Zyflo 3 ST 

Zyflo cR 3 ST 

Mast cell Stabilizers - Asthma Drugs 

Cromolyn Sodium 


1 B/D 

Intal 3 B/D 

Intal Inhaler 2 

Tilade 2 

Miscellaneous Respiratory Agents - Asthma Drugs 

Xolair 4 PA 

Mucolytic Agents - Mucus Dissolving Drugs 

Acetylcysteine 1 B/D 

Mucomyst-10 3 B/D 

SERUMS, ToXoIDS AnD VAccInES 

Serums - Immune System Drugs 

carimune 4 B/D, PA 

carimune nanofiltered 4 B/D, PA 

Flebogamma 4 B/D, PA 

Gamastan S/D 3 B/D, PA 

Gammagard Liquid 4 B/D, PA 

Gammagard S/D 4 B/D, PA 

Gamunex 4 B/D, PA 

Immune Globulin 1 B/D, PA 

Iveegam En 4 B/D, PA 

octagam 4 B/D, PA 

Panglobulin 4 B/D, PA 

Panglobulin nF 4 B/D, PA 

Polygam S/D 4 B/D, PA 

Venoglobulin-S 4 B/D, PA 

Vivaglobin 

Toxoids - Vaccines 

4 B/D, PA 

Adacel 2 

Boostrix 2 

Daptacel 2 

47

48 


Decavac 2 



TIER LIMITS 

Diptheria/Tetanus 

Toxoid Pediatric 

2 

Infanrix 2 

Tetanus Toxoid 2 

Tetanus Toxoid Adsorbed 2 

Tetanus/Diphtheria Toxoids- 

Absorbed Adult 

2 

TriHiBit 2 

Tripedia 

Vaccines 

2 

Acthib 2 

Attenuvax 2 

comvax 2 

Engerix-B 2 B/D, PA 

Gardasil 2 

Havrix 2 

Hibtiter 2 

Imovax Rabies (H.D.c.V.) 2 

Ipol Inactivated IPV 2 

Je-Vax 2 

Menactra 2 

Menomune-A/c/Y/W-135 2 

Meruvax II w/Diluent 

1 Dose 

2 

Meruvax II w/Diluent 

10 Dose 

2 

M-M-R II w/Diluent 

1 Dose 

2 

M-M-R II w/Diluent 

10 Dose 

2 

M-R-Vax II 2 

Mumpsvax w/Diluent 

1 Dose 

2 

Mumpsvax w/Diluent 

10 Dose 

2 

Pediarix 2 


Pedvax HIB 2 

ProQuad 2 

Rabavert 2 



TIER LIMITS 

Recombivax HB 2 B/D, PA 

RotaTeq 2 

Theracys 3 

Tice BcG 3 

Twinrix 2 

Typhim Vi 2 

Vaqta 2 

Varivax 2 

Vivotif Berna 2 

YF-Vax 2 

Zostavax 2 

SKIn AnD MUcoUS MEMBRAnE PREPARATIonS 

Antibacterials (Skin & Mucous Membrane Agents) - 

Bacterial Infection Drugs 

Akne-Mycin 2 

Altabax 3 

Bactroban (cream) 2 

Bactroban (ointment) 3 

Bactroban nasal 2 

Benzaclin 2 

Benzamycin 3 


Suppository) 

2 


300 mg capsule, cream) 

3 

cleocin-T 3 

Clindagel 1 

Clindamycin Phosphate 1 

clindesse 3 

Clindets 1 

Duac 2 

Eryderm 1 




Erygel 3 



TIER LIMITS 

Erythromycin/Benzoyl 

Peroxide 

1 

Evoclin 3 


Klaron 3 

Metrocream 3 

Metrogel 2 

Metrogel Vaginal 3 

Metrolotion 3 

Metronidazole 1 

Metronidazole Vaginal 1 

Mupirocin 1 

noritate 3 

Rozex 3 

Vandazole 1 

Z-clinz 5 3 

Z-clinz 10 3 

Antifungals (Skin & Mucous Membrane Agents) - 

Fungal Infection Drugs 

Ciclopirox (Nail Laquer) 1 

Ciclopirox (Suspension) 1 

Ciclopirox Olamine 1 

Clotrimazole 1 

Clotrimazole/Betamethasone 

Dipropionate 

1 

Econazole Nitrate 1 

Ertaczo 2 

Exelderm 3 

Extina 3 

Gynazole-1 2 

Ketoconazole 1 

Kuric 1 

Lamisil (Spray) 3 

Loprox 3 

Loprox Shampoo 3 


Lotrisone 3 

Mentax 3 

Miconazole 3 1 





TIER LIMITS 

Monistat 7 

combination Pack 

2 

Mycelex 3 

Mycostatin 3 

naftin 2 

naftin-MP 2 

nizoral 3 

Nyamyc 1 

Nystatin 1 

Nystop 1 

oxistat 3 

Pedi-Dri 1 

Penlac nail Lacquer 3 QL 

Terazol 3 3 

Terazol 7 3 

Terconazole 1 

Xolegel 3 

Zazole 

Anti-Inflammatory Agents 

1 

Aclovate 3 

Ala-Cort 1 

Ala-Scalp 2 

Alclometasone 

Dipropionate 

1 

Alphatrex 1 

Amcinonide 1 

Anusol-Hc 3 

Augmented Betamethasone 

Dipropionate 

1 

Betamethasone 

Dipropionate 

1 

Betamethasone Valerate 1 

Beta-Val 1 

49

50 


capex 3 

carmol-Hc 3 

Cetacort 1 

Clobetasol Propionate 1 

Clobetasol Propionate E 1 

Clobetasol Propionate 

Emollient 

1 

Clobevate 1 

clobex 3 

cloderm 3 

Colocort 1 

cordran 3 

cordran SP 3 

cordran Tape 3 

Cormax 1 

cortifoam 2 

cortisporin 

(cream, ointment) 

2 

cutivate 3 

Del-Beta 1 

Derma-Smoothe/ 

FS Body oil 

3 

Derma-Smoothe/ 

FS Scalp oil 

3 

Dermatop 3 

Desonate 3 

Desonide 1 

Desowen 3 

Desoximetasone 1 

Diflorasone Diacetate 1 

Diprolene 3 

Diprolene AF 3 

Elocon 3 

Fluocinolone Acetonide 1 

Fluocinonide 1 



TIER LIMITS 


Fluocinonide 

Emollient Base 

1 

Fluocinonide-E 1 

Fluticasone Propionate 1 

Halobetasol Propionate 1 

Halog 3 


(Cream, Lotion, Ointment) 

1 


(Enema, Tablet) 

1 

Hydrocortisone Butyrate 1 

Hydrocortisone in 

Absorbase 

1 

Hydrocortisone Valerate 1 

Hytone 3 

Isovate 1 

Kenalog 

(Aerosol Solution) 

2 

Kenalog 

(cream, Lotion, ointment) 

3 

Lacticare-HC 1 

Lidex 3 

Lidex-E 3 

Locoid 3 

Locoid Lipocream 2 

Lokara 1 

Luxiq 3 

Mometasone Furoate 1 

Nystatin/Triamcinolone 1 

olux 3 

olux-E 3 

Pandel 3 

Prednicarbate 1 

Proctocort 3 

Proctocream-HC 1 

Procto-Kit 1 



TIER LIMITS 




Procto-Pak 1 

Proctosol HC 1 

Proctozone-HC 1 

Psorcon E 3 

Synalar 3 

Taclonex 3 

Temovate 3 

Temovate E 3 

Texacort (1% Solution) 1 

Texacort (2.5% Solution) 3 

Topicort 3 

Topicort LP 3 

Triamcinolone Acetonide 1 



TIER LIMITS 

Triamcinolone Acetonide 

in Absorbase 

1 

Triamcinolone in Orabase 1 

Triderm 1 

U-Cort 1 

Ultravate 3 

Vanos 3 

Verdeso 3 

Westcort 3 

Antipruritics and Local Anesthetics 

Emla 3 

Emla/Tegaderm 3 

Lidocaine 1 

Lidocaine HCl Jelly 1 

Lidocaine/Prilocaine 1 

Lidoderm 2 QL 

Phenazopyridine HCl 1 

Pyridium 3 

Synera 3 

Xylocaine Jelly 3 

Zonalon 3 






TIER LIMITS 

Antivirals (Skin & Mucous Membrane Agents) - 

Viral Infection Drugs 

Denavir 2 

Zovirax (cream, ointment) 

Basic Lotions and Liniments 

2 

Ammonium Lactate 1 

LACcream 1 

LAc-Hydrin 3 

LAClotion 

cell Stimulants And Proliferants 

1 

Avita (Cream) 1 

Avita (Gel) 3 

Kepivance 4 

Retin-A 3 

Retin-A Micro 2 

Tretinoin (Cream, Gel) 

Depigmenting Agents 

1 

Benoquin 3 

Miscellaneous Local Anti-Infectives 

Selenium Sulfide 1 

Selsun Shampoo 3 

Silvadene 3 

Silver Sulfadiazine 1 

SSD 1 

SSD AF 1 

Sulfamylon (cream) 2 

Sulfamylon (Pack) 3 

Thermazene 1 

Miscellaneous Skin and Mucous Membrane Agents 

Accutane 4 

Aldara 2 

Amevive 4 PA 

Amnesteem 1 

Azelex 2 

carac 2 

51

52 


Claravis 1 

condylox (0.5% Gel) 2 



TIER LIMITS 

condylox w/Applicators 

(0.5% Solution) 

3 

Differin 2 

Dovonex 2 

Efudex 3 

Efudex occlusion Pack 2 

Elidel 3 ST 

Finacea 3 

Fluoroplex 2 

Fluorouracil 1 

Levulan Kerastick 3 

Panretin 4 

Podocon 25 in Benzoin 

Tincture 

1 

Podofilox 1 

Protopic 2 ST 

Raptiva 4 PA 

Regranex 4 PA,QL 

Santyl 3 

Solaraze 

Sotret 

3 

(10 mg Capsule, 20 mg 

Capsule, 40 mg Capsule) 

1 

Sotret (30 mg capsule) 2 

Targretin 4 

Tazorac 2 

Ziana 

Pigmenting Agents 

3 

8-Mop 4 

oxsoralen 2 

oxsoralen Ultra 4 

Uvadex 3 


Scabicides and Pediculicides - 

Scabies and Lice Drugs 

Acticin 1 

Elimite 3 

Eurax 2 

Lindane 1 

ovide 3 

Permethrin 1 

SMooTH MUScLE RELAXAnTS 



TIER LIMITS 

Genitourinary Smooth Muscle Relaxants - 

Bladder control Drugs 

Detrol 2 QL 

Detrol LA 2 QL 

Ditropan 3 

Ditropan XL 3 

Enablex 2 QL 

Flavoxate HCl 1 

Oxybutynin Chloride 1 

Oxybutynin Chloride ER 1 

oxytrol 2 QL 

Sanctura* 3 QL 

Urispas 3 

Vesicare* 3 QL 

Respiratory Smooth Muscle - Asthma Drugs 

Aminophylline 1 

Dilor 1 

Elixophyllin 2 

Lufyllin 3 

Theo-24 2 

Theocap 1 

Theochron 1 

Theophylline CR 1 

Theophylline ER 1 

Theophylline TD 1 




Uniphyl 2 

VITAMInS 



TIER LIMITS 

Miscellaneous Vitamins 

Brand nutritional 

Supplements 

Brand nutritional 

2 B/D 

Supplements with Generic 

Availability 

3 B/D 

Brand Prenatal Vitamins 3 

Brand Prenatal Vitamins 

with Generic Availability 

3 

Generic Nutritional 

Supplements 

1 B/D 

Generic Prenatal Vitamins 

Vitamin B complex 

1 

Niacor 

Vitamin D - Renal Disease Drugs 

1 

calcijex 3 

Calcitriol 1 

Hectorol 2 

Rocaltrol 3 

Zemplar 3 



53

54 

DRUG INDEX 

8-Mop ................................................52 

A 

Abelcet..............................................14 

Abilify ................................................26 

Abilify Discmelt................................26 

Abraxane ..........................................15 

Accolate ...........................................47 

Accuneb ...........................................19 

Accupril ............................................21 

Accuretic ..........................................21 

Accutane ..........................................51 

Acebutolol HCl .................................22 

Aceon ................................................21 

Acetadote .........................................45 

Acetaminophen/Codeine ...............29 

Acetaminophen/Codeine #2 ..........29 



Acetazolamide .................................36 

Acetic Acid.......................................36 

Acetic Acid/Hydrocortisone .........35 

Acetylcysteine .................................47 

Aciphex .............................................39 

Aclovate............................................49 

Acthib ................................................48 

Acticin ...............................................52 

Actigall ..............................................38 

Actimmune .......................................45 

Actiq ..................................................29 

Activella ............................................42 

Actonel..............................................45 

Actonel With Calcium ....................45 

Actoplus Met ...................................45 

Actos .................................................45 

Acular................................................37 

Acular LS ..........................................37 

Acular PF ..........................................37 

Acyclovir...........................................13 

Adacel ...............................................47 

Adagen..............................................34 

Adalat CC ..........................................23 

Adderall ............................................25 

Adderall XR ......................................25 

Adoxa ................................................15 

Adoxa Pak 1/75 ................................15 

Adoxa Pak 1/100 ..............................15 

Adoxa Pak 1/150 ..............................15 

Adoxa Pak 2/100 ..............................15 

Adrenalin ....................................19, 37 

Adriamycin .......................................15 

Advair Diskus ...................................18 

Advair HFA .......................................19 

Advicor..............................................24 

Aerobid .............................................40 

Aerobid-M ........................................40 

Afeditab CR ......................................23 

Agenerase ..........................................9 

Aggrenox ..........................................20 

Agrylin ...............................................20 

Airet ...................................................19 

Ak-Con ..............................................37 

Akineton............................................18 

Akne-Mycin......................................48 

Ak-Poly-Bac .....................................34 

Ak-Tob ...............................................34 

Ala-Cort.............................................49 

Alamast .............................................34 

Ala-Scalp ..........................................49 

Albalon ..............................................37 

Albenza ...............................................9 

Albuterol ...........................................19 

Albuterol Sulfate .............................19 

Albuterol Sulfate/Ipratropium 

Bromide .........................................18 

Alcaine ..............................................36 

Alclometasone Dipropionate ........49 

Alcohol Swabs.................................32 

Aldactazide ......................................24 

Aldactone .........................................24 

Aldara................................................51 

Aldurazyme ......................................34 

Alesse-28 ..........................................41 

Alferon N ..........................................15 

Alimta ................................................15 

Alinia .................................................12 

Alkeran..............................................15 

Allegra.................................................8 

Allegra-D 12 Hour..............................8 

Allegra-D 24 Hour..............................8 

Allopurinol ........................................45 

Alocril ................................................34 

Alomide .............................................34 

Aloprim..............................................45 

Alora ..................................................43 

Aloxi...................................................37 

Alphagan P .......................................36 

Alphatrex ..........................................49 

Alrex ..................................................35 

Altabax ..............................................48 

Altace ................................................21 

Altoprev ............................................24 

Alupent..............................................19 

Amantadine HCl.................................8 

Amaryl ...............................................45 

Ambien ..............................................28 

Ambien CR ........................................28 

Ambisome.........................................14 

Amcinonide ......................................49 

Amerge .............................................32 

A-Methapred ...................................40 

Amevive ............................................51 

Amikacin Sulfate ...............................8 

Amikin .................................................8 

Amiloride HCl ...................................32 

Amiloride/Hydrochlorothiazide .....32 

Aminophylline ..................................52 

Amiodarone HCl ..............................21 

Amitiza ..............................................38 

Amitriptyline HCl..............................25 

Amlodipine Besylate ......................23 

Amlodipine Besylate/ 

Benazepril HCl ..............................23 

Ammonium Chloride .......................32 

Ammonium Lactate .........................51 

Amnesteem ......................................51

Amoclan............................................13 

Amoxapine .......................................25 

Amoxicillin ........................................13 

Amoxicillin/Clavulanate 

Potassium .....................................13 

Amoxil .........................................13, 14 

Amphetamine Salts Combo ...........25 

Amphocin .........................................14 

Amphotec .........................................14 

Amphotericin B................................14 

Ampicillin ..........................................14 

Ampicillin-Sulbactam .....................14 

Amrix .................................................19 

Anadrol-50 ........................................41 

Anafranil ...........................................25 

Anagrelide HCl.................................20 

Anaprox ............................................29 

Anaprox DS ......................................29 

Ancobon ...........................................14 

Androderm .......................................41 

Androgel ...........................................41 

Androgel Pump ................................41 

Android .............................................41 

Androxy.............................................41 

Anexsia .............................................29 

Angeliq ..............................................43 

Ansaid ...............................................29 

Antabuse ..........................................45 

Antara ...............................................24 

Antibiotic Ear ...................................35 

Antivert .............................................37 

Antizol ...............................................45 

Anusol-HC ........................................49 

Anzemet ............................................37 

Aphthasol .........................................45 

Apidra................................................43 

Apokyn ..............................................28 

Apri ....................................................41 

Aptivus ................................................9 

Aralast...............................................45 

Aralen..................................................9 

Aranelle ............................................41 

Aranesp ............................................20 

Aranesp Albumin Free....................20 

Aranesp Albumin Free 

SureClick .......................................20 

Arava .................................................46 

Aredia................................................46 

Arestin...............................................34 

Aricept ..............................................18 

Aricept ODT......................................18 

Arimidex............................................15 

Aristospan Intra-Articular .............40 

Aristospan Intralesional.................40 

Arixtra ...............................................20 

Aromasin ..........................................15 

Arranon .............................................15 

Arthrotec 50 .....................................29 

Arthrotec 75 .....................................29 

Asacol ...............................................37 

Ascomp/Codeine .............................29 

Asmanex 14 Metered Doses .........40 



Asmanex 120 Metered Doses .......40 

Aspirin/Codeine ...............................29 

Astelin ...............................................34 

Astramorph ......................................30 

Atacand ............................................21 

Atacand HCT ....................................21 

Atamet...............................................28 

Atenolol.............................................22 

Atenolol/Chlorthalidone .................22 

Atgam ................................................46 

Atreza ................................................18 

Atridox...............................................34 

Atripla..................................................9 

Atropine Sulfate ..............................36 

Atrovent ............................................18 

Atrovent HFA ....................................18 

Attenuvax .........................................48 

Augmented Betamethasone 

Dipropionate .................................49 

Augmentin ........................................14 

Augmentin ES-600 ...........................14 

Augmentin XR ..................................14 

Avalide ..............................................21 

Avandamet .......................................45 

Avandaryl .........................................45 

Avandia .............................................45 

Avapro ...............................................21 

Avastin ..............................................15 

Avelox ABC Pack ............................14 

Avelox ...............................................14 

Aviane ...............................................41 

Avinza ................................................30 

Avita ..................................................51 

Avodart .............................................46 

Avonex ..............................................46 

Axert ..................................................32 

Axid....................................................39 

Aygestin ............................................44 

Azactam ............................................13 

Azactam in Dextrose ......................13 

Azasan ..............................................46 

Azasite ..............................................11 

Azathioprine .....................................46 

Azelex................................................51 

Azilect ...............................................28 

Azithromycin ....................................11 

Azmacort ..........................................40 

Azopt .................................................36 

Azor ...................................................23 

Azulfidine ..........................................14 

Azulfidine EN-Tabs ..........................14 

B 

Baciim ...............................................12 

Bacitracin ...................................12, 34 

Bacitracin/Neomycin/ 

Polymyxin ......................................34 

Bacitracin/Polymyxin B..................34 

Baclofen ...........................................19 

Bactocill in Dextrose ......................14 

Bactrim .............................................15 

Bactrim DS .......................................15 

Bactroban.........................................48 

Bactroban Nasal .............................48 

Balacet 325.......................................30 

Balziva...............................................41 

Baraclude .........................................13 

BD Insulin Needles, Pens, 

Syringes, Safety Syringes ..........32 

Beconase AQ ...................................35 

Benadryl .............................................8 

Benazepril HCl .................................21 

Benazepril HCl/ 

Hydrochlorothiazide ....................21 

Benicar .............................................21 

Benicar HCT .....................................21 

55

Benoquin ..........................................51 

Bentyl ................................................18 

Benzaclin ..........................................48 

Benzamycin......................................48 

Benztropine Mesylate ....................18 

Betagan ............................................36 

Betagan C Cap QD ..........................36 

Betagan Without C Cap .................36 

Betamethasone Dipropionate .......49 

Betamethasone Valerate ...............49 

Betapace ..........................................22 

Betapace AF ....................................22 

Betaseron .........................................46 

Beta-Val ............................................49 

Betaxolol HCl .............................22, 36 

Bethanechol Chloride ....................18 

Betimol ..............................................36 

Betoptic-S ........................................36 

Bexxar ...............................................16 

Biaxin ................................................11 

Biaxin XL ...........................................11 

Biaxin XL PAC ..................................11 

Bicillin C-R ........................................14 

Bicillin L-A ........................................14 

Bicnu w/Diluent 

Absolute Ethanol ..........................16 

Bidil....................................................25 

Biltricide .............................................9 

Bio-Statin..........................................14 

Bisoprolol Fumarate .......................22 

Bisoprolol Fumarate/ 


Blenoxane ........................................16 

Bleomycin Sulfate ...........................16 

Bleph-10............................................34 

Blephamide ......................................35 

Blephamide S.O.P. ...........................35 

Boniva ...............................................46 

Boostrix.............................................47 

Borofair .............................................36 

Botox .................................................46 

Brand Injectable Replacement 

Therapies ......................................33 

Brand Irrigation Solutions .............33 

Brand Nutritional Supplements ....53 

Brand Nutritional Supplements 

with Generic Availability ............53 

56 

Brand Prenatal Vitamins ................53 

Brand Prenatal Vitamins with 

Generic Availability .....................53 

Brethine ............................................19 

Brevicon-28 ......................................41 

Brimonidine Tartrate .......................36 

Bromocriptine Mesylate ................46 

Brovana ............................................18 

Budeprion SR ...................................25 

Budeprion XL ...................................25 

Bumetanide ......................................32 

Bumex ...............................................32 

Buphenyl...........................................32 

Buprenex ..........................................30 

Buprenorphine HCl .........................32 

Buproban ..........................................25 

Bupropion HCl..................................25 

Bupropion HCl SR............................25 

Buspar...............................................28 

Buspirone HCl ..................................28 

Busulfex ............................................16 

Butalbital/Acetaminophen/ 

Caffeine/Codeine .........................30 

Butalbital/Aspirin/ 

Caffeine/Codeine .........................30 

Butorphanol Tartrate ......................32 

Byetta ................................................44 

C 

Cabergoline ......................................46 

Caduet ...............................................23 

Cafergot ............................................28 

Calan .................................................24 

Calan SR ...........................................24 

Calcijex .............................................53 

Calcitriol............................................53 

Camila ...............................................41 

Campath............................................16 

Campral.............................................28 

Camptosar ........................................16 

Canasa ..............................................37 

Cancidas ...........................................11 

Cantil .................................................18 

Capastat Sulfate ................................9 

Capex ................................................50 

Capital/Codeine ...............................30 

Capoten.............................................21 

Capozide ...........................................21 

Captopril ...........................................21 

Captopril/Hydrochlorothiazide ......21 

Carac .................................................51 

Carafate ............................................39 

Carbamazepine................................27 

Carbastat ..........................................36 

Carbatrol ...........................................27 

Carbidopa/Levodopa ......................28 

Carbidopa/Levodopa CR ................28 

Carbidopa/Levodopa ER ................28 

Carbidopa/Levodopa SR ................28 

Carboplatin .......................................16 

Cardene ............................................23 

Cardene I.V. ......................................23 

Cardene SR ......................................23 

Cardizem ...........................................24 

Cardizem CD.....................................24 

Cardizem LA .....................................24 

Cardura .............................................20 

Cardura XL........................................20 

Carimune ..........................................47 

Carimune Nanofiltered ...................47 

Carisoprodol.....................................19 

Carisoprodol/Aspirin.......................19 

Carisoprodol/Aspirin/Codeine ......19 

Carmol-HC ........................................50 

Carnitor .............................................46 

Carteolol HCl ....................................36 

Cartia XT ...........................................24 

Cartrol ...............................................22 

Carvedilol..........................................22 

Casodex ............................................16 

Cataflam............................................29 

Catapres ...........................................23 

Catapres-TTS-1 ...............................23 

Catapres-TTS-2 ...............................23 

Catapres-TTS-3 ...............................23 

Cedax ................................................10 

Ceenu ................................................16 

Cefaclor ............................................10 

Cefaclor ER.......................................10 

Cefadroxil .........................................10 

Cefazolin ...........................................10 

Cefdinir..............................................10 

Cefizox in Dextrose 5%...................10

Cefotaxime Sodium .........................10 

Cefotetan ..........................................10 

Cefoxitin ............................................13 

Cefpodoxime Proxetil .....................10 

Cefprozil ............................................10 

Ceftin .................................................10 

Ceftriaxone/Dextrose .....................10 

Ceftriaxone in 

Iso-Osmotic Dextrose .................10 

Ceftriaxone Sodium ........................10 

Cefuroxime Axetil ............................10 

Cefuroxime/Dextrose......................10 

Cefuroxime Sodium.........................10 

Cefzil ..................................................10 

Celebrex............................................29 

Celestone..........................................40 

Celexa ...............................................25 

Cellcept .............................................46 

Cellcept Intravenous ......................46 

Celontin .............................................32 

Cenestin ............................................43 

Cephalexin........................................10 

Cerebyx .............................................27 

Ceredase ..........................................34 

Cerezyme ..........................................34 

Cerubidine ........................................16 

Cesamet ............................................39 

Cesia..................................................41 

Cetacort ............................................50 

Chantix ..............................................18 

Chemet ..............................................40 

Chloramphenicol Sodium 

Succinate ......................................11 

Chlordiazepoxide/Amitriptyline ....25 

Chlorhexidine Gluconate ...............36 

Chloroquine Phosphate ...................9 

Chlorothiazide ..................................33 

Chlorpromazine HCl ........................26 

Chlorpropamide ...............................45 

Chlorthalidone .................................33 

Chlorzoxazone .................................19 

Cholestyramine................................23 

Cholestyramine Light ......................23 

Chorionic Gonadotropin .................43 

Ciclopirox..........................................49 

Cilostazol ..........................................20 

Ciloxan ..............................................34 

Cimetidine.........................................39 

Cipro ..................................................14 

Ciprodex............................................35 

Ciprofloxacin ....................................14 

Ciprofloxacin ER ..............................14 

Ciprofloxacin HCl.............................14 

Ciprofloxacin HCl.............................34 

Cipro HC ............................................35 

Cipro I.V. ............................................14 

Cipro I.V.-in D5W .............................14 

Cipro XR ............................................14 

Cisplatin ............................................16 

Cisplatin AQ......................................16 

Citalopram Hydrobromide .............25 

Cladribine .........................................16 

Claforan ............................................10 

Claforan/D5W Galaxy .....................10 

Claforan Infusion Bottles ...............10 

Claravis .............................................52 

Clarinex ...............................................8 

Clarinex-D 12 Hour ............................8 

Clarinex-D 24 Hour ............................8 

Clarinex Reditabs ..............................8 

Clarithromycin .................................11 

Clarithromycin ER............................11 

Clemastine Fumarate........................8 

Cleocin ........................................12, 48 

Cleocin Galaxy .................................12 

Cleocin Pediatric Granules ...........12 

Cleocin Phosphate ..........................12 

Cleocin-T ..........................................48 

Climara ..............................................43 

Climara Pro.......................................43 

Clindagel ...........................................48 

Clindamycin HCl ..............................12 

Clindamycin Phosphate .................12 

Clindamycin Phosphate .................48 

Clindamycin Phosphate 

Add-Vantage .................................12 

Clindesse ..........................................48 

Clindets .............................................48 

Clinoril ...............................................29 

Clobetasol Propionate ....................50 

Clobetasol Propionate E ................50 

Clobetasol Propionate Emollient ..50 

Clobevate..........................................50 

Clobex ...............................................50 

Cloderm.............................................50 

Clolar .................................................16 

Clomipramine HCl............................25 

Clonidine HCl....................................23 

Clorpres ............................................23 

Clotrimazole .....................................49 

Clotrimazole/Betamethasone 

Dipropionate .................................49 

Clozapine ..........................................26 

Cogentin............................................18 

Co-Gesic ...........................................30 

Cognex ..............................................18 

Colazal...............................................37 

Colchicine.........................................46 

Colestid .............................................23 

Colestid Flavored.............................23 

Colestipol HCl...................................23 

Colistimethate Sodium ...................12 

Colocort ............................................50 

Coly-Mycin-M ..................................12 

Coly-Mycin-S ...................................35 

Colyte ................................................38 

Colyte-Flavor Packs ........................38 

Combipatch ......................................43 

Combivent.........................................18 

Combivir ..............................................9 

Combunox.........................................30 

Compro..............................................39 

Comtan ..............................................28 

Comvax .............................................48 

Concerta ...........................................27 

Condylox ...........................................52 

Condylox w/Applicators .................52 

Constulose........................................32 

Copaxone..........................................46 

Copegus ............................................13 

Cordarone.........................................21 

Cordran .............................................50 

Cordran SP .......................................50 

Cordran Tape ...................................50 

Coreg .................................................22 

Coreg CR ...........................................22 

Corgard .............................................22 

Cormax ..............................................50 

Cortef.................................................40 

Cortifoam ..........................................50 

Cortisone Acetate ...........................40 

57

Cortisporin ..................................35, 50 

Cortisporin-TC..................................35 

Cortomycin .......................................35 

Corzide ..............................................22 

Cosmegen.........................................16 

Cosopt ...............................................36 

Coumadin..........................................20 

Covera-HS ........................................24 

Cozaar ...............................................21 

Creon 5 ..............................................38 

Creon 10 ............................................38 

Creon 20 ............................................38 

Crestor ..............................................24 

Crinone..............................................44 

Crixivan ...............................................9 

Crolom ...............................................34 

Cromolyn Sodium ......................34, 47 

Cryselle-28........................................41 

Cubicin ..............................................12 

Cuprimine .........................................40 

Cutivate .............................................50 

Cyclessa ...........................................41 

Cyclobenzaprine HCl ......................19 

Cyclophosphamide .........................16 

Cyclosporine ....................................46 

Cyclosporine Modified ...................46 

Cyklokapron .....................................20 

Cymbalta ...........................................25 

Cyproheptadine HCl ..........................8 

Cystadane.........................................46 

Cystagon ...........................................46 

Cytarabine ........................................16 

Cytarabine Aqueous .......................16 

Cytomel .............................................45 

Cytotec ..............................................39 

Cytovene ...........................................13 

Cytoxan .............................................16 

D 

Dacarbazine .....................................16 

Dacogen ...........................................16 

Danazol .............................................41 

Dantrium ...........................................19 

Dantrolene Sodium .........................19 

Dapsone............................................12 

Daptacel ...........................................47 

58 

Daraprim .............................................9 

Darvocet A500 .................................30 

Darvocet-N 50..................................30 

Darvocet-N 100................................30 

Darvon...............................................30 

Darvon-N ..........................................30 

Daunorubicin HCl ............................16 

Daunoxome ......................................16 

Daypro...............................................29 

Daytrana ...........................................27 

DDAVP ..............................................44 

Decavac............................................48 

Declomycin ......................................15 

Del-Beta............................................50 

Delestrogen......................................43 

Demadex...........................................33 

Demeclocycline HCl .......................15 

Demerol ............................................30 

Demser..............................................46 

Denavir..............................................51 

Depacon ...........................................27 

Depade..............................................32 

Depakene .........................................27 

Depakote ..........................................27 

Depakote ER.....................................28 

Depakote Sprinkles.........................27 

Depen Titratabs ...............................40 

Depodur ............................................30 

Depo-Estradiol .................................43 

Depo-Medrol....................................40 

Depo-Provera ..................................44 

Depo-Provera Contraceptive ........44 

Depo-Subq Provera 104 .................44 

Depo-Testosterone .........................41 

Derma-Smoothe/FS Body Oil ........50 

Derma-Smoothe/FS Scalp Oil .......50 

Dermatop ..........................................50 

Dermotic ...........................................35 

Desipramine HCl..............................25 

Desmopressin Acetate...................44 

Desogen............................................41 

Desonate ..........................................50 

Desonide...........................................50 

Desowen...........................................50 

Desoximetasone..............................50 

Desoxyn ............................................25 

Detrol.................................................52 

Detrol LA ...........................................52 

Dexamethasone ..............................40 

Dexamethasone Intensol ...............40 


Phosphate ...............................35, 40 

Dexasol .............................................35 

Dexasporin .......................................35 

Dexchlorpheniramine Maleate .......8 

Dexedrine .........................................25 

Dexmethylphenidate HCl ...............27 

Dexpak 13 Day .................................40 

Dexrazoxane ....................................46 

Dextroamphetamine Sulfate .........25 

Dextroamphetamine Sulfate CR ...25 

Dextrostat .........................................25 

D.H.E. 45 ............................................28 

Diabeta..............................................45 

Diabinese..........................................45 

Diamox ..............................................36 

Dibenzyline .......................................19 

Diclofenac Potassium ....................29 

Diclofenac Sodium..........................29 

Diclofenac Sodium DR ...................29 

Diclofenac Sodium EC ....................29 

Diclofenac Sodium ER ....................29 

Diclofenac Sodium XR ...................29 

Dicloxacillin Sodium .......................14 

Dicyclomine HCl ..............................18 

Didanosine .........................................9 

Didronel ...........................................46 

Differin ..............................................52 

Diflorasone Diacetate ....................50 

Diflucan.............................................10 

Diflucan in 


Diflucan in NaCl...............................10 

Diflunisal ...........................................29 

Digitek ...............................................23 

Digoxin ..............................................23 

Dihydroergotamine Mesylate .......28 

Dilacor XR.........................................24 

Dilantin ..............................................27 

Dilantin Infatabs ..............................27 

Dilatrate SR ......................................25 

Dilaudid .............................................30 

Dilaudid-5 .........................................30 

Dilaudid-HP ......................................30

Dilor ...................................................52 

Dilt-CD ...............................................24 

Diltia XT.............................................24 

Diltiazem CD .....................................24 

Diltiazem HCl ....................................24 

Diltiazem HCl ER ..............................24 

Dilt-XR ...............................................24 

Diovan ...............................................21 

Diovan HCT.......................................21 

Dipentum ..........................................37 

Diphenhydramine HCl.......................8 

Diphenoxylate/Atropine .................37 

Dipivefrin HCl ...................................36 

Diprolene ..........................................50 

Diprolene AF ....................................50 

Diptheria/Tetanus 

Toxoid Pediatric ...........................48 

Dipyridamole ....................................20 

Disopyramide Phosphate ..............21 

Disopyramide Phosphate ER .........21 

Dispermox ........................................14 

Ditropan ............................................52 

Ditropan XL.......................................52 

Diuril ..................................................33 

Diuril IV .............................................33 

Divigel ...............................................43 

Dolacet..............................................30 

Dolagesic..........................................30 

Dolophine .........................................30 

Dolorex Forte ...................................30 

Doribax..............................................13 

Doryx .................................................15 

Dostinex ............................................46 

Dovonex ............................................52 

Doxazosin Mesylate .......................20 

Doxepin HCl......................................25 

Doxil...................................................16 

Doxorubicin HCl...............................16 

Doxy-Caps ........................................15 

Doxycycline Hyclate .......................15 

Doxycycline Monohydrate ............15 

Droxia ................................................16 

DTIC-Dome .......................................16 

Duac ..................................................48 

Duetact .............................................45 

Duoneb..............................................18 

Duraclon ...........................................27 

Duragesic .........................................30 

Duramorph .......................................30 

Duricef ..............................................10 

Dyazide .............................................33 

Dygase ..............................................38 

Dynabac D5-Pak..............................11 

Dynacin .............................................15 

Dynacirc CR .....................................23 

Dyrenium ..........................................33 

E 

EC-Naprosyn ....................................29 

Econazole Nitrate............................49 

Econopred Plus ...............................35 

Edecrin .............................................33 

Ed K+10 .............................................33 

E.E.S. 200...........................................12 

E.E.S. 400...........................................12 

E.E.S. Granules ................................12 

Effexor ...............................................26 

Effexor XR .........................................26 

Efudex ...............................................52 

Efudex Occlusion Pack ..................52 

Elaprase ............................................34 

Eldepryl .............................................28 

Elestat ...............................................34 

Elestrin ..............................................43 

Elidel ..................................................52 

Eligard ...............................................16 

Elimite................................................52 

Elitek ..................................................34 

Elixophyllin .......................................52 

Ellence ..............................................16 

Elmiron ..............................................46 

Elocon ...............................................50 

Eloxatin .............................................16 

Elspar ................................................16 

Emadine ............................................34 

Emcyt.................................................16 

Emend ...............................................39 

Emla ...................................................51 

Emla/Tegaderm ................................51 

Emsam...............................................26 

Emtriva ................................................9 

Enablex .............................................52 

Enalapril Maleate ............................21 

Enalapril Maleate/ 


Enbrel ................................................46 

Enbrel SureClick ..............................46 

Endocet .............................................30 

Endometrin .......................................44 

Engerix-B ..........................................48 

Enjuvia...............................................43 

Enlon-Plus ........................................18 

Enpresse-28 .....................................41 

Entocort EC.......................................40 

Enulose .............................................32 

Enzycap.............................................38 

Enzymax ............................................38 

Epinephrine HCl ...............................19 

Epipen 2-Pak ....................................19 

Epipen-Jr 2-Pak ...............................19 

Epirubicin HCl ..................................16 

Epitol..................................................27 

Epivir....................................................9 

Epivir HBV...........................................9 

Epogen ..............................................20 

Epzicom...............................................9 

Equagesic .........................................28 

Eraxis.................................................11 

Erbitux ...............................................16 

Ergoloid Mesylates .........................19 

Ergomar ............................................28 

Ergotamine Tartrate/Caffeine ........28 

Errinv .................................................41 

Ertaczo ..............................................49 

Eryc....................................................12 

Eryderm.............................................48 

Erygel ................................................49 

Eryped ...............................................12 

Eryped 200 ........................................12 

Eryped 400 ........................................12 

Ery-Tab ..............................................12 

Erythrocin .........................................12 

Erythrocin Lactobionate ................12 

Erythrocin Stearate.........................12 

Erythromycin ..............................12, 34 

Erythromycin Base..........................12 

Erythromycin/Benzoyl Peroxide ...49 

Erythromycin Ethylsuccinate ........12 

Erythromycin Lactobionate ...........12 

Erythromycin/Sulfisoxazole ...........12 

59

Esclim ................................................43 

Estrace ..............................................43 

Estraderm .........................................43 

Estradiol ............................................43 

Estrasorb ..........................................43 

Estring ...............................................43 

Estrogel .............................................43 

Estropipate .......................................43 

Estrostep Fe .....................................41 

Ethambutol HCl ..................................9 

Ethmozine .........................................21 

Ethosuximide....................................32 

Eth-Oxydose .....................................30 

Ethyol.................................................46 

Etidronate Disodium .......................46 

Etodolac ............................................29 

Etodolac ER ......................................29 

Etopophos.........................................16 

Etoposide ..........................................16 

Eurax .................................................52 

Evista .................................................42 

Evoclin...............................................49 

Evoxac...............................................18 

Exelderm ...........................................49 

Exelon................................................18 

Exforge .............................................23 

Exjade................................................40 

Extina.................................................49 

Exubera Combination Pack 15 ......43 

Exubera Kit .......................................43 

F 

Fabrazyme ........................................34 

Factive...............................................14 

Famotidine ........................................39 

Famotidine Premixed ......................39 

Famvir................................................13 

Fansidar ..............................................9 

Fareston ............................................16 

Faslodex............................................16 

Fazaclo ..............................................26 

Felbatol .............................................27 

Feldene .............................................29 

Felodipine ER ...................................23 

Femara ..............................................16 

Femcon Fe ........................................41 

60 

Femhrt 1/5 .........................................43 

Femhrt Low Dose ............................43 

Femring .............................................43 

Femtrace...........................................43 

Fenofibrate .......................................24 

Fenoprofen Calcium........................29 

Fentanyl ............................................30 

Fentanyl Citrate ...............................30 

Fentanyl Citrate 

Oral Transmucosal ......................30 

Fentora ..............................................30 

Fexofenadine HCl ..............................8 

Finacea .............................................52 

Finasteride........................................46 

Fioricet/Codeine ..............................30 

Fiorinal/Codeine #3 .........................30 

Flagyl .................................................12 

Flagyl ER ...........................................12 

Flarex.................................................35 

Flavoxate HCl ...................................52 

Flebogamma.....................................47 

Flecainide Acetate ..........................21 

Flexeril...............................................19 

Flomax ...............................................46 

Flonase..............................................35 

Florinef ..............................................40 

Flovent HFA ......................................40 

Floxin Otic .........................................34 

Floxin Otic Singles...........................34 

Floxuridine ........................................16 

Fluconazole ......................................10 

Fluconazole in Dextrose.................10 

Fluconazole in NaCl ........................10 

Fludara ..............................................16 

Fludarabine Phosphate ..................16 

Fludrocortisone Acetate ................40 

Flumadine ...........................................8 

Flunisolide ........................................35 

Fluocinolone Acetonide .................50 

Fluocinonide.....................................50 

Fluocinonide-E .................................50 

Fluocinonide Emollient Base .........50 

Fluorometholone .............................35 

Fluor-Op ............................................35 

Fluoroplex .........................................52 

Fluorouracil ................................16, 52 

Fluoxetine HCl ..................................26 

Fluphenazine Decanoate ...............26 

Fluphenazine HCl.............................26 

Flurbiprofen ......................................29 

Flurbiprofen Sodium .......................37 

Flutamide ..........................................16 

Fluticasone Propionate ............35, 50 

Fluvoxamine Maleate .....................26 

FML Forte..........................................35 

FML Liquifilm ....................................35 

FML S.O.P. .........................................35 

Focalin...............................................27 

Focalin XR.........................................27 

Foradil Aerolizer ..............................19 

Fortamet............................................41 

Fortaz...........................................10, 11 

Fortaz Infusion Pack .......................11 

Forteo ................................................44 

Fortical ..............................................44 

Fosamax............................................46 

Fosamax Plus D ...............................46 

Foscarnet Sodium ...........................13 

Foscavir ............................................13 

Fosinopril Sodium............................21 

Fosinopril Sodium/ 


Fosrenol ............................................33 

Fragmin .............................................20 

Frova..................................................32 

FUDR..................................................16 

Furadantin ........................................15 

Furosemide.......................................33 

Fuzeon .................................................9 

G 

Gabapentin .......................................27 

Gabitril...............................................27 

Gamastan S/D ..................................47 

Gammagard Liquid ..........................47 

Gammagard S/D ..............................47 

Gamunex...........................................47 

Ganciclovir .......................................13 

Gantrisin Pediatric ..........................15 

Gardasil.............................................48 

Gastrocrom ......................................46 

Gauze Pads ......................................32 

Gemfibrozil .......................................24

Gemzar ..............................................16 

Generic Injectable 

Replacement Therapies .............33 

Generic Irrigation Solutions ..........33 

Generic Nutritional 

Supplements .................................53 

Generic Prenatal Vitamins .............53 

Generlac ...........................................32 

Gengraf .............................................46 

Genoptic ...........................................34 

Genotropin........................................44 

Genotropin Miniquick .....................44 

Gentak ...............................................34 

Gentamicin Sulfate ...............9, 34, 49 

Gentamicin Sulfate/0.9% NaCl ........8 

Gentamicin Sulfate/NaCl .................8 

Gentasol............................................34 

Geocillin ............................................14 

Geodon..............................................26 

Gleevec .............................................16 

Glimepiride .......................................45 

Glipizide ............................................45 

Glipizide ER.......................................45 

Glipizide/Metformin HCl .................45 

Glipizide XL .......................................45 

Glucagen Hypokit ............................43 

Glucagon Emergency Kit ...............43 

Glucophage ......................................41 

Glucophage XR ................................41 

Glucotrol ...........................................45 

Glucotrol XL......................................45 

Glucovance ......................................45 

Glumetza ...........................................41 

Glyburide ..........................................45 

Glyburide/Metformin HCl ...............45 

Glyburide Micronized .....................45 

Glycolax ............................................38 

Glycopyrrolate .................................18 

Glycron..............................................45 

Glynase .............................................45 

Glyset ................................................41 

Golytely .............................................38 

Grifulvin V .........................................12 

Griseofulvin Microsize ...................12 

Gris-Peg ............................................12 

Guanabenz Acetate ........................23 

Guanfacine HCl................................23 

Guanidine HCl ..................................18 

Gynazole-1........................................49 

Gynodiol ............................................43 

H 

Haldol ................................................26 

Haldol Decanoate-50 ......................26 

Haldol Decanoate-100 ....................26 

Halflytely Bowel Prep Kit ...............38 

Halobetasol Propionate .................50 

Halog .................................................50 

Haloperidol .......................................26 

Havrix ................................................48 

Hectorol ............................................53 

Helidac ..............................................12 

Heparin Sodium ...............................20 

Heparin Sodium/D5W .....................20 

Heparin Sodium DCU ......................20 

Heparin Sodium/NaCl 0.45% .........20 

Hepsera ............................................13 

Herceptin ..........................................16 

Hexalen .............................................16 

Hibtiter ..............................................48 

Hiprex ................................................15 

Humalog............................................43 

Humalog Mix 50/50..........................43 

Humalog Mix 50/50 Pen..................43 

Humalog Mix 75/25..........................43 

Humalog Mix 75/25 Pen..................43 

Humalog Pen....................................43 

Humatin...............................................8 

Humatrope........................................44 

Humatrope Combo Pack ................44 

Humira...............................................46 

Humira Pen.......................................46 

Humulin 50/50...................................43 

Humulin 70/30...................................43 

Humulin 70/30 Pen...........................43 

Humulin N .........................................43 

Humulin N U-100 Pen......................43 

Humulin R .........................................43 

Hycamtin...........................................16 

Hycet .................................................30 

Hydralazine HCl ...............................24 

Hydrea...............................................16 

Hydrocet ...........................................30 

Hydrochlorothiazide ......................33 

Hydrocodone/Acetaminophen .....30 

Hydrocodone/ 

Acetaminophen-HS .....................30 

Hydrocodone Bitartrate/ 

Acetaminophen ............................30 

Hydrocodone/Ibuprofen ................30 

Hydrocortisone ..........................40, 50 

Hydrocortisone Butyrate ...............50 

Hydrocortisone in Absorbase .......50 

Hydrocortisone Valerate ................50 

Hydromorphone HCl .......................30 

Hydroxychloroquine Sulfate ...........9 

Hydroxyurea.....................................16 

Hydroxyzine HCl ..............................28 

Hydroxyzine Pamoate.....................28 

Hytone ...............................................50 

Hytrin .................................................20 

Hyzaar ...............................................21 

I 

Ibuprofen ..........................................29 

Idamycin PFS ...................................16 

Idarubicin .........................................16 

Ifex .....................................................16 

Ifex/Mesnex Combo Pack .............16 

Ifosfamide.........................................16 

Ifosfamide/Mesna ...........................17 

Imdur .................................................25 

Imipramine HCl ................................26 

Imipramine Pamoate ......................26 

Imitrex ...............................................32 

Imitrex Statdose Pen ......................32 

Imitrex Statdose Refill ....................32 

Immune Globulin .............................47 

Imovax Rabies (H.D.C.V.) ................48 

Imuran ...............................................46 

Increlex .............................................44 

Indapamide ......................................33 

Inderal ...............................................22 

Inderal LA .........................................22 

Inderide 40/25 ..................................22 

Indocin ..............................................29 

Indocin SR ........................................29 

Indomethacin ...................................29 

Indomethacin ER .............................29 

Infanrix ..............................................48 

Infergen ............................................11 

Infumorph 200 ..................................30 

61

Infumorph 500 ..................................30 

Innohep .............................................20 

Innopran XL ......................................22 

Inspra ................................................24 

Insulin Needles, Pens, Syringes, 

Safety Syringes ............................32 

Intal....................................................47 

Intal Inhaler ......................................47 

Intron-A.............................................17 

Intron-A w/Diluent ..........................17 

Invanz ................................................13 

Invega ...............................................26 

Inversine ...........................................24 

Invirase ...............................................9 

Iopidine .............................................36 

Iplex ...................................................44 

Ipol Inactivated IPV ........................48 

Ipratropium Bromide ......................18 

Iressa ................................................17 

Isentress .............................................9 

Ismo ...................................................25 

Ismotic ..............................................33 

Isochron............................................25 

Isonarif ................................................9 

Isoniazid..............................................9 

Isoptin SR .........................................24 

Isordil Titradose...............................25 

Isosorbide Dinitrate ........................25 

Isosorbide Dinitrate ER ..................25 

Isosorbide Mononitrate .................25 

Isosorbide Mononitrate ER ...........25 

Isovate ..............................................50 

Isradipine..........................................23 

Istalol.................................................36 

Isuprel ...............................................19 

Itraconazole .....................................10 

Iveegam EN ......................................47 

Ixempra Kit .......................................17 

J 

Jantoven ...........................................20 

Janumet ............................................44 

Januvia .............................................44 

Je-Vax ...............................................48 

Jolessa..............................................41 

Jolivette ............................................41 

62 

Junel 1.5/30 ......................................41 

Junel 1/20 .........................................41 

Junel Fe 1.5/30 .................................41 

Junel Fe 1/20 ....................................41 

K 

Kadian ...............................................30 

Kaletra.................................................9 

Kanamycin Sulfate ............................9 

Kaon-Cl-10 ........................................33 

Kariva ................................................41 

Kayexalate........................................33 

KCl......................................................33 

KCl CR................................................33 

KCl ER ................................................33 

KCl SA ...............................................33 

KCl SR................................................33 

Keflex ................................................11 

Kelnor 1/35........................................41 

Kemadrin ..........................................18 

Kenalog-10 .......................................40 

Kenalog-40 .......................................40 

Kenalog .............................................50 

Kepivance.........................................51 

Keppra...............................................27 

Kerlone..............................................22 

Ketek .................................................12 

Ketek Pak..........................................12 

Ketoconazole .............................10, 49 

Ketoprofen........................................29 

Ketoprofen ER ..................................29 

Ketorolac Tromethamine ...............29 

Ketotifen Fumarate .........................34 

Kineret...............................................46 

Kionex ...............................................33 

Klaron ................................................49 

Klor-Con 8 .........................................33 

Klor-Con 10 .......................................33 

Klor-Con M10 ...................................33 

Klor-Con M15 ...................................33 

Klor-Con M20 ...................................33 

Klotrix ................................................33 

Kristalose..........................................32 

K-Tabs ...............................................33 

Kuric ..................................................49 

Kutrase..............................................38 

Ku-Zyme............................................38 

Ku-Zyme HP .....................................38 

K-Vescent .........................................33 

Kytril ..................................................37 

L 

Labetalol HCl ...................................22 

LACcream .........................................51 

LAC-Hydrin .......................................51 

LAClotion ..........................................51 

Lacrisert............................................36 

Lacticare-HC ....................................50 

Lactulose ..........................................32 

Lamictal ............................................27 

Lamictal Chewable Dispersible ....27 

Lamictal Starter Kits .......................28 

Lamisil ...........................................8, 49 

Lamotrigine Chewable 

Dispersible ....................................28 

Lanoxicaps .......................................23 

Lanoxin..............................................23 

Lantus................................................43 

Lantus OptiClik .................................43 

Lapase...............................................38 

Lariam .................................................9 

Lasix ..................................................33 

Leena.................................................41 

Leflunomide......................................46 

Lescol ................................................24 

Lescol XL ..........................................24 

Lessina-28 ........................................41 

Letairis ..............................................25 

Leucovorin Calcium ........................46 

Leukeran ...........................................17 

Leukine..............................................20 

Leuprolide Acetate .........................17 

Leustatin ...........................................17 

Levaquin ...........................................14 

Levaquin Leva-Pak..........................14 

Levaquin Premix ..............................14 

Levatol...............................................22 

Levemir .............................................43 

Levemir FlexPen ..............................43 

Levlite-28 ..........................................42 

Levobunolol HCl...............................36 

Levocarnitine ...................................46

Levo-Dromoran................................30 

Levora 0.15/30-28.............................42 

Levorphanol Tartrate ......................30 

Levothroid.........................................45 

Levothyroxine Sodium ....................45 

Levoxyl ..............................................45 

Levulan Kerastick............................52 

Lexapro .............................................26 

Lexiva ..................................................9 

Lexxel ................................................23 

Lialda .................................................37 

Lidex ..................................................50 

Lidex-E ..............................................50 

Lidocaine ..........................................51 

Lidocaine HCl ...................................45 

Lidocaine HCl Jelly .........................51 

Lidocaine/Prilocaine.......................51 

Lidoderm ...........................................51 

Lidomar Viscous ..............................36 

Limbitrol ............................................26 

Limbitrol DS ......................................26 

Lincocin ............................................12 

Lindane .............................................52 

Liothyronine Sodium .......................45 

Lipitor ................................................24 

Lipram 4500 ......................................38 

Lipram-PN10 ....................................38 

Lipram-PN16 ....................................38 

Lipram-PN20 ....................................38 

Lipram-UL12 .....................................38 

Lipram-UL18 .....................................38 

Lipram-UL20 .....................................38 

Lisinopril ...........................................21 

Lisinopril/Hydrochlorothiazide ......21 

Lithium Carbonate ...........................26 

Lithium Carbonate ER .....................26 

Lithium Citrate..................................26 

Lithobid .............................................26 

Lithostat ............................................32 

Locoid................................................50 

Locoid Lipocream............................50 

Lodosyn.............................................28 

Loestrin 1.5/30-21 ............................42 

Loestrin 1/20-21 ...............................42 

Loestrin 24 Fe ...................................42 

Loestrin Fe 1.5/30.............................42 

Loestrin Fe 1/20................................42 

Lofene ...............................................37 

Lofibra ...............................................24 

Lokara ...............................................50 

Lomotil...............................................37 

Lonox .................................................37 

Lo/Ovral-28 .......................................42 

Loperamide HCl ...............................37 

Lopid ..................................................24 

Lopressor..........................................22 

Lopressor HCT .................................22 

Loprox ...............................................49 

Loprox Shampoo .............................49 

Lorcet 10/650 ....................................30 

Lorcet Plus .......................................30 

Lortab ................................................30 

Lortab 2.5 ..........................................30 

Lortab 5 .............................................30 

Lortab 7.5 ..........................................30 

Lortab 10 ...........................................30 

Lotemax ............................................35 

Lotensin ............................................21 

Lotensin HCT ....................................21 

Lotrel .................................................23 

Lotrisone ...........................................49 

Lotronex ............................................39 

Lovastatin .........................................24 

Lovaza ..............................................24 

Lovenox.............................................20 

Low-Ogestrel ...................................42 

Loxapine Succinate ........................26 

Loxitane ............................................26 

Lufyllin ...............................................52 

Lumigan ............................................36 

Lunesta .............................................28 

Lupron 2 Week Supply ...................17 

Lupron 6-Pack..................................17 

Lupron Depot ...................................17 

Lupron Depot-PED ..........................17 

Lutera ................................................42 

Luxiq ..................................................50 

Lybrel .................................................43 

Lynox .................................................30 

Lyrica .................................................28 

Lysodren ...........................................17 

M 

Macrobid ..........................................15 

Macrodantin ....................................15 

Magnesium Sulfate in D5W ..........33 

Malarone ............................................9 

Maprotiline HCl................................26 

Margesic-H ......................................30 

Marinol..............................................39 

Marplan ............................................26 

Matulane ..........................................17 

Mavik.................................................21 

Maxair Autohaler ............................19 

Maxalt ...............................................32 

Maxalt-MLT ......................................32 

Maxidex ............................................35 

Maxidone..........................................30 

Maxipime ..........................................11 

Maxitrol.............................................35 

Maxzide ............................................33 

Maxzide-25 .......................................33 

Mebendazole .....................................9 

Meclizine HCl ...................................37 

Meclofenamate Sodium ................29 

Medrol...............................................40 

Medrol Dosepak ..............................40 

Medroxyprogesterone Acetate ....44 

Mefloquine HCl ..................................9 

Mefoxin .............................................13 

Mefoxin Add-Vantage ....................13 

Mefoxin in Dextrose 2.2% ..............13 

Mefoxin in Dextrose 3.9% ..............13 

Megace ES .......................................44 

Megace Oral ....................................17 

Megestrol Acetate ..........................17 

Meloxicam........................................29 

Menactra ..........................................48 

Menest ..............................................43 

Menomune-A/C/Y/W-135 ...............48 

Menostar ..........................................43 

Mentax ..............................................49 

Meperidine HCl................................30 

Meperitab .........................................30 

Meprobamate ..................................28 

Mepron .............................................13 

Mercaptopurine ..............................17 

Merrem .............................................13 

Meruvax II w/Diluent 1 Dose ........48 

Meruvax II w/Diluent 10 Dose ......48 

Mesalamine .....................................38 

Mesna ...............................................46 

Mesnex .............................................46 

63

Mestinon...........................................18 

Mestinon Timespan ........................18 

Metadate CD ....................................27 

Metadate ER ....................................27 

Metaglip............................................45 

Metaproterenol Sulfate .................19 

Metformin HCl..................................41 

Metformin HCl ER ............................41 

Methadone HCl................................30 

Methadose .......................................30 

Methazolamide ................................36 

Methenamine Hippurate ................15 

Methergine.......................................47 

Methimazole ....................................41 

Methitest ..........................................41 

Methocarbamol ...............................19 

Methotrexate ...................................17 

Methscopolamine Bromide ...........18 

Methyclothiazide.............................33 

Methyldopa ......................................23 

Methyldopa/ 


Methyldopate HCl ...........................23 

Methylin ............................................27 

Methylin ER ......................................27 

Methylphenidate HCl ......................27 

Methylphenidate HCl ER ................27 

Methylprednisolone........................40 

Methylprednisolone Acetate ........40 

Methylprednisolone Sodium 

Succinate ......................................40 

Metipranolol.....................................36 

Metoclopramide HCl.......................39 

Metolazone ......................................33 

Metoprolol/Hydrochlorothiazide ..22 

Metoprolol Succinate ER ...............22 

Metoprolol Tartrate .........................22 

Metrocream .....................................49 

Metrogel ...........................................49 

Metrogel Vaginal .............................49 

Metro IV ............................................13 

Metrolotion.......................................49 

Metronidazole............................13, 49 

Metronidazole in NaCl 0.79% ........13 

Metronidazole Vaginal ...................49 

Mevacor ...........................................24 

Mexiletine HCl .................................21 

64 

Miacalcin..........................................44 

Micardis............................................21 

Micardis HCT ...................................21 

Miconazole 3....................................49 

Microgestin 1.5/30...........................42 

Microgestin 1/20..............................42 

Microgestin Fe.................................42 

Microgestin Fe 1.5/30 .....................42 

Micro-K .............................................33 

Micronase ........................................45 

Microzide..........................................33 

Midodrine HCl ..................................20 

Migergot ...........................................28 

Migranal ...........................................28 

Minipress..........................................21 

Minirin ...............................................44 

Minitran ............................................25 

Minocin .............................................15 

Minocin PAC ....................................15 

Minocycline HCl ..............................15 

Minoxidil ...........................................24 

Mintezol ..............................................9 

Miostat ..............................................36 

Mirapex.............................................28 

Mirtazapine ......................................26 

Misoprostol ......................................39 

Mitomycin.........................................17 

Mitoxantrone HCl ............................17 

M-M-R II w/Diluent 1 Dose ...........48 

M-M-R II w/Diluent 10 Dose .........48 

Moban ...............................................27 

Mobic ................................................29 

Modicon-28 ......................................42 

Moexipril HCl ...................................21 

Moexipril HCl/ 


Mometasone Furoate .....................50 

Monistat 7 Combination Pack .......49 

Monodox...........................................15 

Monoket............................................25 

MonoNessa......................................42 

Monopril ...........................................21 

Monopril HCT ...................................21 

Monurol ............................................15 

Morphine/D5W ................................30 

Morphine Sulfate ............................30 

Morphine Sulfate Add-Vantage ....30 

Morphine Sulfate/D5W ..................31 

Morphine Sulfate Dilute-A-Jet .....30 

Morphine Sulfate ER ......................31 

Morphine Sulfate in 

Dextrose 5% .................................31 

Morphine Sulfate/NS .....................31 

Morphine Sulfate Stick-Gard ........31 

Motofen ............................................37 

Motrin................................................29 

Moviprep ..........................................38 

M-R-Vax II ........................................48 

MS Contin .........................................31 

MST 600 ............................................29 

Mucomyst-10 ...................................47 

Mumpsvax w/Diluent 1 Dose ........48 

Mumpsvax w/Diluent 10 Dose ......48 

Mupirocin .........................................49 

Mustargen ........................................17 

Mutamycin .......................................17 

Myambutol .......................................10 

Mycamine.........................................11 

Mycelex ............................................49 

Mycobutin ........................................10 

Mycostatin .......................................49 

Mydral ...............................................37 

Mydriacyl..........................................37 

Myfortic ............................................46 

Mylotarg ...........................................17 

Myobloc ............................................46 

Myozyme ..........................................34 

Myrac ................................................15 

Mysoline ...........................................27 

Mytelase ...........................................18 

N 

Nabumetone ....................................29 

NaCl 0.9% .........................................33 

NaCl Bacteriostatic ........................33 

NaCl Bacteriostatic/ 

Benzyl Alcohol .............................47 

Nadolol..............................................22 

Nafcillin Sodium ..............................14 

Naftin.................................................49 

Naftin-MP .........................................49 

Naglazyme........................................34 

Nalbuphine HCl................................31

Nalfon................................................29 

Nallpen/Dextrose ............................14 

Nallpen Iso-Osmotic 

in Dextrose ....................................14 

Naloxone HCl ...................................32 

Naltrexone HCl ................................32 

Namenda ..........................................28 

Namenda Titration Pak...................28 

Nandrolone Decanoate .................41 

Naphazoline HCl ..............................37 

Naprelan ...........................................29 

Naprosyn ..........................................29 

Naproxen ..........................................29 

Naproxen DR....................................29 

Narcan ..............................................32 

Nardil.................................................26 

Narvox...............................................31 

Nasacort AQ ....................................35 

Nasarel .............................................35 

Nasonex............................................35 

Natacyn ............................................35 

Navane..............................................27 

Navelbine .........................................17 

Nebupent ..........................................13 

Necon 0.5/35-28 ...............................42 

Necon 1/35-28v ................................42 

Necon 1/50-28 ..................................42 

Necon 7/7/7 ......................................42 

Necon 10/11-28 ................................42 

Nefazodone HCl...............................26 

Neocin...............................................34 

Neocin-PG ........................................34 

Neo-Fradin .........................................9 

Neomycin/Bacitracin/ 

Polymyxin ......................................34 

Neomycin/Bacitracin Zinc/ 

Polymyxin ......................................34 

Neomycin/Polymycin/ 

Bacitracin/Hydrocortisone ........34 


Dexamethasone ...........................35 


Gramicidin .....................................34 


Hydrocortisone ............................35 

Neomycin Sulfate..............................9 

Neoral ...............................................46 

Neosporin .........................................34 

Neulasta ...........................................20 

Neumega ..........................................20 

Neupogen .........................................20 

Neupro ..............................................28 

Neurontin..........................................28 

Neutrexin ..........................................13 

Nevanac ...........................................37 

Nexavar ............................................17 

Nexium ..............................................39 

Nexium I.V. .......................................39 

Niacor .............................................53 

Niaspan.............................................24 

Nicardipine HCl ...............................23 

Nicotine ............................................18 

Nicotrol Inhaler ...............................18 

Nicotrol NS.......................................18 

Nifediac CC ......................................23 

Nifedical XL ......................................23 

Nifedipine .........................................23 

Nifedipine ER ...................................23 

Nilandron ..........................................17 

Nimodipine .......................................23 

Nimotop ............................................23 

Nipent................................................17 

Nitrek.................................................25 

Nitrobid .............................................25 

Nitro-Dur...........................................25 

Nitrofurantoin Macrocrystalline ..15 

Nitrofurantoin Monohydrate .........15 

Nitroglycerin ....................................25 

Nitroglycerin CR ..............................25 

Nitroglycerin TD ..............................25 

Nitroglycerin Transdermal .............25 

Nitrolingual Pumpspray .................25 

Nitrostat ............................................25 

Nitro-Time .........................................25 

Nizatidine..........................................39 

Nizoral ...............................................10 

Nizoral ...............................................49 

Nora-BE ............................................42 

Norco ................................................31 

Nordette-28 ......................................42 

Norditropin Cartridge .....................44 

Norditropin Nordiflex......................44 

Norditropin Nordiflex Pen .............44 

Norethindrone Acetate ..................44 

Norflex ..............................................19 

Norinyl 1+35 .....................................42 

Noritate .............................................49 

Noroxin .............................................14 

Norpace ............................................21 

Norpace CR ......................................22 

Norpramin ........................................26 

Nor-QD ..............................................42 

Nortrel 0.5/35....................................42 

Nortrel 1/35 ......................................42 

Nortrel 1/35.......................................42 

Nortrel 7/7/7 .....................................42 

Nortriptyline HCl ..............................26 

Norvasc ............................................23 

Norvir ..................................................9 

Novantrone ......................................17 

Novarel .............................................43 

Novolin 70/30....................................44 

Novolin 70/30 Innolet ......................44 

Novolin 70/30 Penfill .......................44 

Novolin N ..........................................44 

Novolin N Innolet ............................44 

Novolin N U-100 Penfill ..................44 

Novolin R ..........................................44 

Novolin R Innolet .............................44 

Novolin R U-100 ...............................44 

Novolin R U-100 Penfill ...................44 

Novolog.............................................44 

Novolog FlexPen .............................44 

Novolog Mix 70/30...........................44 

Novolog Mix 70/30 Penfill ..............44 

Novolog Mix 70/30 

Prefilled FlexPen ..........................44 

Novolog Penfill ................................44 

Noxafil ...............................................10 

Nubain...............................................31 

Nulytely .............................................38 

Numorphan ......................................31 

Nutropin ............................................44 

Nutropin AQ .....................................44 

Nutropin AQ Pen .............................45 

NuvaRing ..........................................42 

Nyamyc .............................................49 

Nydrazid............................................10 

Nystatin.......................................14, 49 

Nystatin/Triamcinolone ..................50 

Nystop ...............................................49 

65

66 

O 

Octagam ...........................................47 

Octreotide Acetate .........................46 

Ocufen...............................................37 

Ocuflox ..............................................34 

Ocusulf-10 ........................................34 

Ofloxacin...........................................14 

Ofloxacin...........................................34 

Ogen ..................................................43 

Ogestrel ............................................42 

Olux....................................................50 

Olux-E ................................................50 

Omeprazole ......................................39 

Omnicef.............................................11 

Omni-PAC .........................................11 

Oncaspar ..........................................17 

Ondansetron HCl .............................37 

Ondansetron ODT............................37 

Ontak .................................................17 

Onxol .................................................17 

Opana ................................................31 

Opana ER ..........................................31 

Opium Tincture ................................37 

Optipranolol......................................36 

Optivar...............................................34 

Oracea ..............................................15 

Oramorph SR....................................31 

Orap ...................................................27 

Orapred .............................................40 

Orapred ODT ....................................40 

Orencia .............................................46 

Orfadin ..............................................46 

Orphenadrine/Aspirin/Caffeine ....19 

Orphenadrine Citrate ......................19 

Orphenadrine Citrate ER ................19 

Orphenadrine Compound ..............29 

Orphenadrine Compound DS ........29 

Orphengesic.....................................29 

Orphengesic Forte ..........................29 

Ortho-Cept-28 ..................................42 

Orthoclone OKT3 .............................46 

Ortho-Cyclen-28 ..............................42 

Ortho-Est...........................................43 

Ortho Evra.........................................42 

Ortho Micronor ................................42 

Ortho-Novum 1/35-28......................42 

Ortho-Novum 1/50-28......................42 

Ortho-Novum 7/7/7-28 ....................42 

Ortho Tri-Cyclen ..............................42 

Ortho Tri-Cyclen Lo .........................42 

Osmoprep .........................................38 

Oticin HC ...........................................35 

Ovcon-35...........................................42 

Ovcon-50 28......................................42 

Ovide .................................................52 

Oxacillin Sodium..............................14 

Oxandrin ...........................................41 

Oxandrolone.....................................41 

Oxaprozin..........................................29 

Oxcarbazepine.................................28 

Oxistat ...............................................49 

Oxsoralen .........................................52 

Oxsoralen Ultra................................52 

Oxybutynin Chloride........................52 

Oxybutynin Chloride ER ..................52 

Oxycodone/Acetaminophen .........31 

Oxycodone/Aspirin .........................31 

Oxycodone HCl ................................31 

Oxycodone HCl CR ..........................31 

Oxycodone HCl ER ..........................31 

Oxycontin..........................................31 

Oxyfast ..............................................31 

OxyIR .................................................31 

Oxytocin ............................................47 

Oxytrol ...............................................52 

P 

Pacerone ..........................................22 

Paclitaxel ..........................................17 

Palcaps 10 ........................................38 

Palcaps 20 ........................................38 

Palgic ..................................................8 

Palipase ............................................38 

Palipase MT 16 ................................38 

Palipase MT 20 ................................38 

Palpeon DR 10..................................38 

Palpeon DR 20..................................38 

Palpeon MT 20 .................................38 

Paltrase V8 .......................................38 

Pamelor.............................................26 

Pamidronate Disodium ...................46 

Pamine ..............................................18 

Pamine Forte ....................................18 

Pancrease MT 4 ..............................38 

Pancrease MT 10 ............................38 

Pancrease MT 16 ............................38 

Pancrease MT 20 ............................38 

Pancrecarb MS-4............................38 

Pancrecarb MS-8............................38 

Pancrecarb MS-16..........................38 

Pancrelipase ....................................38 

Pancrelipase MST-16 .....................38 

Pancron 10 .......................................38 

Pancron 20 .......................................38 

Pandel ...............................................50 

Pangestyme CN 10 ..........................38 

Pangestyme CN 20 ..........................38 

Pangestyme EC................................38 

Pangestyme MT 16 .........................38 

Pangestyme UL 12...........................39 

Pangestyme UL 18...........................39 

Pangestyme UL 20...........................39 

Panglobulin ......................................47 

Panglobulin NF ................................47 

Panixine Disperdose.......................11 

Panlor DC..........................................31 

Panlor SS ..........................................31 

Panocaps..........................................39 

Panocaps MT 16..............................39 

Panocaps MT 20..............................39 

Panokase ..........................................39 

Panokase-16 ....................................39 

Panretin ............................................52 

Papaverine HCl ................................25 

Parafon Forte DSC ..........................19 

Paraplatin .........................................17 

Parcaine ...........................................36 

Parcopa ............................................28 

Paregoric ..........................................37 

Parlodel.............................................46 

Parnate .............................................26 

Paromomycin Sulfate .......................8 

Paroxetine HCl .................................26 

Paser .................................................10 

Pataday .............................................34 

Patanol ..............................................34 

Paxil ...................................................26 

Paxil CR .............................................26 

PCE ....................................................12 

Pediapred .........................................40

Pediarix .............................................48 

Pediazole ..........................................12 

Pedi-Dri .............................................49 

Pediotic .............................................35 

Pedvax HIB.......................................48 

Peganone .........................................27 

Pegasys ............................................11 

Peg-Intron ........................................11 

Peg-Intron Redipen ........................11 

Peg-Intron Redipen Pak 4 ..............11 

Penicillin G Potassium....................14 

Penicillin G Potassium in 


Penicillin G Procaine ......................14 

Penicillin G Sodium .........................14 

Penicillin V Potassium ....................14 

Penlac Nail Lacquer .......................49 

Pentam 300 .......................................13 

Pentamidine Isethionate ................13 

Pentasa .............................................38 

Pentazocine/Acetaminophen .......32 

Pentazocine/Naloxone HCl ...........32 

Pentopak...........................................20 

Pentostatin .......................................17 

Pentoxifylline CR .............................20 

Pentoxifylline ER..............................20 

Pentoxil .............................................20 

Pepcid ...............................................39 

Pepcid Premixed .............................39 

Percocet ...........................................31 

Percodan ..........................................31 

Percolone .........................................31 

Peridex Oral Rinse ..........................36 

Periogard ..........................................36 

Periostat ...........................................15 

Perloxx ..............................................31 

Permethrin........................................52 

Perphenazine ...................................27 

Perphenazine/Amitriptyline ...........26 

Persantine ........................................20 

Pexeva ..............................................26 

Pfizerpen-G ......................................14 

Phenadoz ............................................8 

Phenazopyridine HCl ......................51 

Phenergan ..........................................8 

Phenytek ...........................................27 

Phenytoin..........................................27 

PhosLo ..............................................33 

Phospholine Iodide .........................36 

Photofrin ...........................................17 

Phrenilin w/Caffeine/Codeine .......31 

Pilocarpine HCl ................................18 

Pilopine HS .......................................36 

Pindolol .............................................22 

Piperacillin Sodium .........................14 

Piroxicam..........................................29 

Pitocin ...............................................47 

Plan B ................................................42 

Plaquenil .............................................9 

Plaretase 8000 .................................39 

Platinol AQ........................................17 

Plavix .................................................20 

Plenaxis ............................................17 

Plendil ...............................................23 

Pletal .................................................20 

Podocon 25 in Benzoin Tincture ...52 

Podofilox ...........................................52 

Polycin B...........................................34 

Poly-Dex ...........................................35 

Polyethylene Glycol 3350 ...............38 

Polyethylene Glycol 3350/ 

Electrolytes ...................................38 

Polygam S/D.....................................47 

Polymyxin B Sulfate ........................12 

Polymyxin B Sulfate/ 

Trimethoprim Sulfate ...................34 

Poly-Pred ..........................................35 

Polytrim .............................................34 

Ponstel ..............................................29 

Portia-28 ...........................................42 

Potassium Citrate 

Extended-Release .......................32 

Prandin..............................................44 

Pravachol .........................................24 

Pravastatin .......................................24 

Prazosin HCl .....................................21 

Precose.............................................41 

Pred Forte .........................................35 

Pred-G ...............................................35 

Pred-G S.O.P. ....................................36 

Pred Mild ..........................................35 

Prednicarbate ..................................50 

Prednisol...........................................36 

Prednisolone ....................................36 

Prednisolone Acetate ....................36 

Prednisolone 

Sodium Phosphate ......................36 

Prednisone .......................................40 

Prednisone Intensol........................40 

Prefest...............................................43 

Pregnyl w/Diluent 

Benzyl Alcohol/NaCl ...................43 

Prelone..............................................40 

Premarin ...........................................43 

Premarin w/Applicator ...................43 

Premphase .......................................43 

Prempro ............................................43 

Prevacid............................................39 

Prevacid I.V. .....................................39 

Prevacid Naprapac.........................29 

Prevacid Solutab .............................39 

Prevalite............................................23 

Previfem............................................42 

Prevpac.............................................39 

Prezista ...............................................9 

Prialt ..................................................28 

Priftin .................................................10 

Prilosec .............................................39 

Primaquine Phosphate .....................9 

Primaxin I.M. ....................................13 

Primaxin IV .......................................13 

Primaxin IV Add-Vantage ..............13 

Primidone .........................................27 

Primsol ..............................................15 

Prinivil ...............................................21 

Prinzide .............................................21 

Proair HFA ........................................19 

Proamatine .......................................20 

Pro-Banthine....................................18 

Probenecid .......................................33 

Probenecid/Colchicine ..................33 

Procainamide HCl ...........................22 

Procainamide HCl ER .....................22 

Procainamide HCl SR .....................22 

Procanbid .........................................22 

Procardia ..........................................23 

Procardia XL ....................................24 

Prochieve .........................................44 

Prochlorperazine.......................27, 39 

Prochlorperazine Edisylate ...........27 

Prochlorperazine Maleate ............27 

Procrit ...............................................20 

Proctocort ........................................50 

67

Proctocream-HC .............................50 

Procto-Kit .........................................50 

Procto-Pak .......................................51 

Proctosol HC ....................................51 

Proctozone-HC ................................51 

Proglycem ........................................44 

Prograf ..............................................46 

Prolastin............................................46 

Proleukin...........................................17 

Promethazine HCl..............................8 

Promethazine HCl Plain ...................8 

Promethazine VC ...............................8 

Promethegan .....................................8 

Prometrium.......................................44 

Pronestyl...........................................22 

Pronestyl SR.....................................22 

Propafenone HCl .............................22 

Propantheline Bromide ..................18 

Proparacaine HCl ............................36 

Propine..............................................37 

Propoxyphene/Acetaminophen ....31 

Propoxyphene HCl ..........................31 

Propoxyphene-N/ 

Acetaminophen ............................31 

Propranolol HCl ...............................22 

Propranolol HCl ER..........................22 

Propranolol/ 


Propylthiouracil ...............................41 

ProQuad ............................................48 

Proquin XR........................................14 

Proscar .............................................46 

Protonix.............................................39 

Protopic ............................................52 

Proventil............................................19 

Proventil HFA ...................................19 

Provera .............................................44 

Provigil ..............................................27 

Prozac ...............................................26 

Prozac Weekly .................................26 

Psorcon E .........................................51 

Pulmicort Flexhaler ........................40 

Pulmicort Respules .........................40 

Pulmozyme .......................................34 

Purinethol .........................................17 

Pylera ................................................12 

Pyrazinamide ...................................10 

68 

Pyridium ............................................51 

Pyridostigmine Bromide.................18 

Q 

Quadramet........................................46 

Qualaquin ...........................................9 

Quasense..........................................42 

Questran ...........................................23 

Questran Light .................................23 

Quinapril HCl ....................................21 

Quinapril/Hydrochlorothiazide ......21 

Quinaretic .........................................21 

Quinidine Gluconate .......................22 

Quinidine Gluconate CR .................22 

Quinidine Gluconate ER .................22 

Quinidine Gluconate SA .................22 

Quinidine Sulfate .............................22 

Quinidine Sulfate ER .......................22 

Quixin ................................................34 

QVAR .................................................40 

R 

Rabavert ...........................................48 

Ranexa ..............................................24 

Raniclor.............................................11 

Ranitidine HCl ..................................39 

Rapamune ........................................46 

Rapiflux .............................................26 

Raptiva ..............................................52 

Rauwolfia/Bendroflumethiazide ...25 

Razadyne ER ....................................18 

Razadyne ..........................................18 

Rebetol ..............................................13 

Rebif ..................................................46 

Rebif Titration Pack.........................46 

Reclast ..............................................46 

Reclipsen ..........................................42 

Recombivax HB ...............................48 

Reglan ...............................................39 

Regonol .............................................18 

Regranex ..........................................52 

Relenza Diskhaler ...........................13 

Relion 70/30 ......................................44 

Relion 70/30 Innolet.........................44 

Relion N ............................................44 

Relion N Innolet ...............................44 

Relion R .............................................44 

Relpax ...............................................32 

Remeron ...........................................26 

Remeron Soltab ...............................26 

Remicade..........................................46 

Remodulin.........................................25 

Renagel .............................................33 

Reprexain .........................................31 

Requip ...............................................28 

Rescriptor ...........................................9 

Reserpine .........................................25 

Restasis ............................................36 

Retin-A ..............................................51 

Retin-A Micro ..................................51 

Retrovir ...............................................9 

Retrovir IV Infusion ...........................9 

Revatio ..............................................25 

Revex.................................................32 

Revia..................................................32 

Revlimid ............................................46 

Reyataz ...............................................9 

Rheumatrex ......................................17 

Rhinocort Aqua................................36 

Ribapak .............................................13 

Ribasphere .......................................13 

Ribatab ..............................................13 

Ribavirin ............................................13 

Ridaura..............................................40 

Rifadin ...............................................10 

Rifamate............................................10 

Rifampin ............................................10 

Rifater................................................10 

Rilutek ...............................................28 

Rimantadine HCl ................................8 

Riomet ...............................................41 

Risperdal...........................................27 

Risperdal Consta .............................27 

Risperdal M-Tab ..............................27 

Ritalin ................................................27 

Ritalin LA...........................................27 

Ritalin SR ..........................................27 

Rituxan ..............................................17 

RMS ...................................................31 

Robaxin .............................................19 

Robaxin-750......................................19 

Robinul ..............................................18

Robinul Forte ....................................18 

Rocaltrol ...........................................53 

Rocephin...........................................11 

Rocephin in 


Roferon-A .........................................11 

Romycin ............................................35 

RotaTeq .............................................48 

Rowasa .............................................38 

Roxanol .............................................31 

Roxicet ..............................................31 

Roxicodone ......................................31 

Roxicodone Intensol .......................31 

Rozerem ............................................28 

Rozex .................................................49 

Rythmol .............................................22 

Rythmol SR .......................................22 

S 

Saizen................................................45 

Saizen Click.Easy ............................45 

Salagen .............................................19 

Sanctura ...........................................52 

Sandimmune ....................................46 

Sandostatin ......................................47 

Sandostatin LAR Depot ..................47 

Santyl ................................................52 

Sarafem ............................................26 

Seasonale.........................................42 

Seasonique ......................................42 

Sectral...............................................22 

Selegiline HCl...................................28 

Selenium Sulfide .............................51 

Selsun Shampoo .............................51 

Selzentry .............................................9 

Semprex-D .........................................8 

Sensipar............................................47 

Septra................................................15 

Septra DS .........................................15 

Serevent Diskus ..............................19 

Seromycin ........................................10 

Seroquel ...........................................27 

Seroquel XR ....................................27 

Serostim............................................45 

Sertraline HCl...................................26 

Silvadene ..........................................51 

Silver Sulfadiazine ..........................51 

Simulect ............................................47 

Simvastatin.......................................24 

Sinemet .............................................28 

Sinemet CR .......................................28 

Singulair............................................47 

Skelaxin ............................................19 

Skelid.................................................47 

Sodium Fluoride...............................47 

Sodium Polystyrene Sulfonate .....33 

Solaraze ............................................52 

Solia...................................................42 

Solodyn .............................................15 

Soltamox ...........................................17 

Solu-Cortef .......................................40 

Solu-Medrol ...............................40, 41 

Solu-Medrol Act-O-Vial .................40 

Soma .................................................19 

Soma Compound .............................19 

Soma Compound/Codeine .............19 

Somatuline Depot............................47 

Somavert ..........................................45 

Sonata ...............................................28 

Soriatane ..........................................47 

Sorine ................................................22 

Sotalol HCl ........................................22 

Sotret.................................................52 

Spectracef........................................11 

Spiriva Handihaler ..........................18 

Spironolactone ................................24 

Spironolactone/ 


Sporanox ..........................................10 

Sporanox Pulsepak .........................10 

Sprintec 28 .......................................42 

Sprycel ..............................................17 

Sronyx ...............................................42 

SSD ....................................................51 

SSD AF ..............................................51 

Stadol ................................................31 

Stagesic ............................................31 

Stalevo 50 .........................................28 

Stalevo 100 .......................................28 

Stalevo 150 .......................................29 

Stalevo 200 .......................................29 

Starlix ................................................44 

Sterapred..........................................41 

Sterapred 12 Day.............................41 

Sterapred DS ...................................41 

Sterapred DS 12 Day ......................41 

Stimate ..............................................44 

Strattera............................................29 

Streptomycin Sulfate ........................9 

Striant................................................41 

Stromectol ..........................................9 

Suboxone..........................................31 

Subutex .............................................31 

Sucraid..............................................34 

Sucralfate .........................................39 

Sular ..................................................24 

Sulf-10 ...............................................35 

Sulfacetamide Sodium ...................35 

Sulfacetamide Sodium/ 


Phosphate .....................................36 

Sulfadiazine......................................15 

Sulfamethoxazole/Trimethoprim ...15 


Trimethoprim DS ..........................15 

Sulfamylon........................................51 

Sulfasalazine....................................15 

Sulfatrim ...........................................15 

Sulfazine ...........................................15 

Sulfazine EC .....................................15 

Sulindac ............................................29 

Sumycin ............................................15 

Suprax ...............................................11 

Surmontil ..........................................26 

Sustiva ................................................9 

Sutent ................................................17 

Symbicort .........................................18 

Symbyax ...........................................26 

Symlin................................................44 

Symmetrel ..........................................8 

Synagis .............................................13 

Synalar ..............................................51 

Synalgos-DC ....................................31 

Synarel ..............................................43 

Synera ...............................................51 

Synercid............................................12 

Synthroid ..........................................45 

Syprine ..............................................40 

69

T 

Tabloid ...............................................17 

Taclonex ...........................................51 

Tagamet ............................................39 

Talacen .............................................31 

Taladine ............................................39 

Talwin ................................................31 

Talwin NX .........................................31 

Tambocor ..........................................22 

Tamiflu ...............................................13 

Tamoxifen Citrate ............................17 

Tapazole ............................................41 

Tarceva .............................................17 

Targretin .....................................17, 52 

Tarka ..................................................24 

Tasigna ..............................................17 

Tasmar ..............................................29 

Taxol ..................................................17 

Taxotere ............................................17 

Tazicef ...............................................11 

Tazorac .............................................52 

Taztia XT ...........................................24 

Tegretol .............................................28 

Tegretol-XR ......................................28 

Tekturna ............................................24 

Temovate ..........................................51 

Temovate E .......................................51 

Tenex .................................................23 

Tenoretic 50 ......................................22 

Tenoretic 100 ....................................22 

Tenormin ...........................................22 

Terazol 3 ............................................49 

Terazol 7 ............................................49 

Terazosin HCl ...................................21 

Terbinafine .........................................8 

Terbutaline Sulfate ..........................19 

Terconazole ......................................49 

Teslac ................................................17 

Testim ................................................41 

Testopel ............................................41 

Testosterone Cypionate .................41 

Testosterone Enanthate .................41 

Testred ..............................................41 

Tetanus/Diphtheria Toxoids- 

Absorbed Adult ............................48 

Tetanus Toxoid .................................48 

Tetanus Toxoid Adsorbed ..............48 

70 

Tetracycline HCl ..............................15 

Teveten .............................................21 

Teveten HCT .....................................21 

Tev-Tropin .........................................45 

Texacort ............................................51 

Thalitone ...........................................33 

Thalomid ...........................................47 

Theo-24 .............................................52 

Theocap ............................................52 

Theochron ........................................52 

Theophylline CR...............................52 

Theophylline ER ...............................52 

Theophylline TD...............................52 

Theracys ...........................................48 

Thermazene .....................................51 

Thiola.................................................47 

Thioridazine HCl ..............................27 

Thiotepa ............................................17 

Thiothixene.......................................27 

Thymoglobulin .................................47 

Thyrolar-1 .........................................45 

Thyrolar-1/2 ......................................45 

Thyrolar-1/4 ......................................45 

Thyrolar-2 .........................................45 

Thyrolar-3 .........................................45 

Tiazac ................................................24 

Tice BCG ...........................................48 

Ticlid ..................................................20 

Ticlopidine HCl .................................20 

Tigan ..................................................37 

Tikosyn ..............................................22 

Tilade .................................................47 

Timentin ............................................14 

Timolide 10/25 ..................................22 

Timolol Maleate .........................22, 36 

Timolol Maleate Ophthalmic 

Gel Forming ...................................36 

Timoptic ............................................36 

Timoptic Ocudose ...........................36 

Timoptic-XE ......................................36 

Tindamax ..........................................13 

Tizanidine HCl ..................................19 

Tobi ......................................................9 

Tobradex ...........................................36 

Tobramycin Sulfate ...........................9 

Tobramycin Sulfate .........................35 

Tobramycin Sulfate Add-Vantage ..9 

Tobramycin Sulfate Fliptop ..............9 

Tobramycin Sulfate/NaCl .................9 

Tobrasol ............................................35 

Tobrex ...............................................35 

Tofranil ..............................................26 

Tofranil-PM ......................................26 

Tolazamide .......................................45 

Tolbutamide ......................................45 

Tolmetin Sodium ..............................29 

Topamax ...........................................28 

Topamax Sprinkle ............................28 

Topicort .............................................51 

Topicort LP .......................................51 

Toposar .............................................17 

Toprol XL ..........................................22 

Torisel ................................................17 

Torsemide .........................................33 

Tracleer .............................................25 

Tramadol HCl ....................................31 

Tramadol HCl/Acetaminophen ......31 

Trandate ............................................23 

Trandate IV .......................................23 

Trandolapril ......................................21 

Transderm-Scop ..............................39 

Tranylcypromine Sulfate ................26 

Travatan ...........................................36 

Travatan Z .........................................36 

Trazodone HCl ..................................26 

Trecator ............................................10 

Trelstar Depot ..................................17 

Trelstar LA ........................................17 

Trental ...............................................20 

Tretinoin ............................................51 

Tretinoin Capsule ............................17 

Trexall ................................................17 

Triamcinolone Acetonide ...............51 

Triamcinolone Acetonide in 

Absorbase .....................................51 

Triamcinolone in Orabase ..............51 

Triamterene/ 

Hydrochlorothiazide .......................33 

Tricor .................................................24 

Triderm ..............................................51 

Trifluoperazine HCl ..........................27 

Trifluridine ........................................35 

Triglide ..............................................24 

Trihexyphenidyl HCl ........................18

TriHiBit ..............................................48 

Tri-Legest FE ....................................42 

Trileptal .............................................28 

Tri-Levlen ..........................................42 

Tri-Levlen Contract Pack ...............42 

Trilyte .................................................38 

Trimethobenzamide HCl .................37 

Trimethoprim ....................................15 

Trimethoprim/ 

Sulfamethoxazole DS ..................15 

Trimethoprim Sulfate/ 

Polymyxin B Sulfate ....................35 

Trimipramine Maleate ....................26 

Trimox ................................................14 

TriNessa ............................................42 

Tri-Norinyl 28 ....................................42 

Tripedia .............................................48 

Triphasil 28 .......................................42 

Tri-Previfem ......................................42 

Trisenox ............................................17 

Tri-Sprintec ......................................42 

Trivora-28 ..........................................42 

Trizivir ..................................................9 

Tropicacyl .........................................37 

Tropicamide .....................................37 

Trusopt ..............................................36 

Truvada ...............................................9 

Twinject ............................................20 

Twinrix ...............................................48 

Tygacil ...............................................15 

Tykerb ...............................................17 

Tylenol/Codeine #3 ..........................31 

Tylenol/Codeine #4 ..........................31 

Tylox ..................................................31 

Typhim Vi .........................................48 

Tysabri ...............................................47 

Tyzeka ...............................................13 

Tyzine ................................................37 

Tyzine Pediatric Nasal Drops ........37 

U 

U-Cort ................................................51 

Ultracaps MT 20 ..............................39 

Ultracet .............................................31 

Ultram................................................31 

Ultram ER ..........................................31 

Ultrase...............................................39 

Ultrase MT 12...................................39 

Ultrase MT 18...................................39 

Ultrase MT 20...................................39 

Ultravate ...........................................51 

Unasyn ..............................................14 

Unasyn Add-Vantage .....................14 

Unasyn Bulk Pack ...........................14 

Unasyn Piggyback Unit ..................14 

Uni-Otic .............................................36 

Uniphyl ..............................................53 

Uniretic .............................................21 

Unithroid ...........................................45 

Univasc .............................................21 

Urecholine ........................................19 

Urex ...................................................15 

Urispas ..............................................52 

Urocit-K 5..........................................32 

Urocit-K 10........................................32 

Uroxatral ...........................................47 

Urso 250 ............................................38 

Ursodiol.............................................38 

Urso Forte .........................................38 

Uvadex ..............................................52 

V 

Vagifem .............................................43 

Valcyte ..............................................13 

Valproate Sodium ............................28 

Valproic Acid ...................................28 

Valtrex ...............................................13 

Vanacet .............................................31 

Vancocin HCl ...................................12 

Vancocin HCl 


Vancomycin HCl ..............................12 

Vandazole .........................................49 

Vanos ................................................51 

Vanspar .............................................28 

Vantas ...............................................17 

Vantin ................................................11 

Vaqta .................................................48 

Varivax ..............................................48 

Vaseretic ..........................................21 

Vasotec .............................................21 

Vectibix .............................................17 

Veetids ..............................................14 

Velcade .............................................17 

Velivet ...............................................42 

Venlafaxine HCl ...............................26 

Venoglobulin-S ................................47 

Ventavis ............................................25 

Ventolin HFA .....................................19 

Veramyst ...........................................36 

Verapamil HCl ..................................24 

Verapamil HCl ER ............................24 

Verdeso .............................................51 

Verelan ..............................................24 

Verelan PM ......................................24 

Vesanoid ...........................................17 

Vesicare ............................................52 

Vexol ..................................................36 

Vfend .................................................10 

Vfend IV ............................................10 

Viadur ................................................17 

Vibramycin .......................................15 

Vibratab ............................................15 

Vicodin ..............................................31 

Vicodin ES ........................................31 

Vicodin HP ........................................31 

Vicoprofen ........................................32 

Vidaza ................................................17 

Videx EC ..............................................9 

Videx Pediatric ..................................9 

Vigamox ............................................35 

Vinblastine Sulfate ..........................17 

Vincasar PFS ....................................17 

Vincristine Sulfate ...........................17 

Vinorelbine Tartrate ........................18 

Viokase .............................................39 

Viokase 8 ..........................................39 

Viokase 16 ........................................39 

Viracept ..............................................9 

Viramune ............................................9 

Virazole .............................................13 

Viread ..................................................9 

Viroptic ..............................................35 

Visicol ................................................38 

Vistaril ...............................................28 

Vistide ...............................................13 

Vivactil ..............................................26 

Vivaglobin .........................................47 

Vivelle ................................................43 

Vivelle-Dot ........................................43 

Vivitrol ...............................................32 

Vivotif Berna ....................................48 

71

Voltaren ......................................29, 37 

Voltaren-XR ......................................29 

Vopac ................................................32 

Vospire ER ........................................19 

Vumon ...............................................18 

Vytorin ...............................................24 

Vyvanse ...........................................25 

W 

Warfarin Sodium .............................20 

Welchol .............................................23 

Wellbutrin .........................................26 

Wellbutrin SR ...................................26 

Wellbutrin XL ...................................26 

Westcort ...........................................51 

X 

Xalatan ..............................................36 

Xenical ..............................................39 

Xibrom ...............................................37 

Xifaxan ..............................................12 

Xodol .................................................32 

Xolair .................................................47 

Xolegel ..............................................49 

Xopenex ............................................19 

Xopenex Concentrate ....................19 

Xopenex HFA ...................................20 

Xylocaine ..........................................45 

Xylocaine Jelly ................................51 

Xylocaine Viscous ...........................36 

Xyrem ................................................29 

Y 

Yasmin 28 ..........................................42 

Yaz......................................................42 

YF-Vax ...............................................48 

Z 

Zanaflex ............................................19 

Zanosar .............................................18 

Zantac ...............................................39 

Zarontin.............................................32 

Zaroxolyn ..........................................33 

72 

Zavesca ............................................47 

Zazole ................................................49 

Z-Clinz 5 ............................................49 

Z-Clinz 10 ..........................................49 

Zebeta ...............................................23 

Zegerid ..............................................39 

Zelapar ..............................................29 

Zemaira .............................................47 

Zemplar .............................................53 

Zenapax ............................................47 

Zerit .....................................................9 

Zerlor .................................................32 

Zestoretic .........................................21 

Zestril ................................................21 

Zetia...................................................23 

Ziac ....................................................23 

Ziagen .................................................9 

Ziana..................................................52 

Zidovudine ..........................................9 

Zinacef ..............................................11 

Zinacef/D5W ....................................11 

Zinacef in Iso-Osmotic Dextrose ..11 

Zinacef in Iso-Osmotic Diluent .....11 

Zinecard............................................47 

Zithromax..........................................12 

Zithromax Tri-Pak ............................12 

Zithromax Z-Pak ..............................12 

Zmax ..................................................12 

Zocor .................................................24 

Zofran ................................................37 

Zofran ODT .......................................37 

Zoladex .............................................18 

Zolinza ...............................................18 

Zoloft .................................................26 

Zolpidem Tartrate ............................28 

Zometa ..............................................47 

Zomig.................................................32 

Zomig ZMT .......................................32 

Zonalon .............................................51 

Zonegran ..........................................28 

Zonisamide .......................................28 

Zorbtive .............................................45 

Zostavax ...........................................48 

Zosyn .................................................14 

Zovia 1/35E .......................................42 

Zovia 1/50E .......................................42 

Zovirax ........................................13, 51 

Zyban.................................................18 

Zydone ..............................................32 

Zyflo ...................................................47 

Zyflo CR .............................................47 

Zylet ...................................................36 

Zyloprim ............................................47 

Zymar ................................................35 

Zyprexa .............................................27 

Zyprexa Zydis...................................27 

Zyrtec ..................................................8 

Zyrtec-D ..............................................8 

Zyvox .................................................12

LOWER-COST OPTION(S) 

Tier 3 Drug Lower-cost Option(s) 

Talk to your doctor or pharmacist about these lower-cost options. 

Aciphex nexium, Omeprazole, Prevacid, Protonix 

Avapro Benicar, Diovan 

Avalide Benicar HcT, Diovan HcT 

Boniva Actonel, Fosamax 

clarinex Fexofenadine 

coreg cR Carvedilol 

cozaar Benicar, Diovan 

crestor Lipitor, Simvastatin, Vytorin 

Exelon Aricept, Razadyne 

Hyzaar Benicar HcT, Diovan HcT 

Lescol Lovastatin, Pravastatin, Simvastatin 

Lescol XL Lovastatin, Pravastatin, Simvastatin 

Mavik Benazepril, Enalapril, Lisinopril 

Miacalcin Fortical 

Sanctura Detrol LA, Enablex, Oxybutynin ER 

Sonata Ambien cR, Lunesta, Zolpidem 

Trusopt Azopt 

Uroxatral Doxazosin, Flomax, Terazosin 

Vesicare Detrol LA, Enablex, Oxybutynin ER 

Xalatan Travatan 

73

74 

“MY MEDICATIONS” WORKSHEET 

Take this worksheet with you each time you visit a doctor. Each of your doctors should be aware of every prescription you 

take and you should have a record as well. 

I take this medicine for Directions Doctor 

Copay 

Level 

Name of Medicine 

and Strength 

Example: Lisinopril Tier 1 High blood pressure one tablet daily Dr. Johnson

This document includes: 

UnitedHealth Rx for Groups complete formulary as of January 1, 2008. 

For more information including updated formulary information, please visit us 

online at www.UnitedHealthRxforGroups.com or call 1-888-556-6648, 24 hours 

a day, 7 days a week. TTY/TDD users should call 1-877-730-4203. 

Or write us at: 

UnitedHealth Rx for Groups 

P.O. Box 29350 

Hot Springs, AR 71903-9350 

This Medicare Prescription Drug Plan (PDP) is insured by United HealthCare Insurance 

Company or United HealthCare Insurance Company of New York for New York 

residents (together called “UnitedHealthcare”). UnitedHealthcare receives rebates 

from drug manufacturers that it passes on to its enrollees through reductions in 

premiums and to Medicare to reduce Medicare program costs. UnitedHealthcare 

contracts with the Federal government as a PDP sponsor. All decisions about 

prescription drugs are between you and your physician or other health care provider. 

FLPDE3023177_XUHE002 

S5820S5805S5921_PDP3023177_001

DRUG - UnitedHealthcare MedicareRx for Groups

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