Medicaid Preferred Drug List - Florida Health Care Plans

Healthy Kids 

Preferred Drug List 

(List of Covered Drugs) 

Healthy Kids Approved 2010 

Healthy Kids Drug Formulary 

Last Updated: April 2, 2014

INTRODUCTION 

Florida Health Care Plans (FHCP) is pleased to provide this Preferred Drug List 

(PDL) to be used when prescribing for patients covered by the Collier County 

Healthy Kids pharmacy benefit plan offered by Florida Health Care Plans. This 

PDL is administered on behalf of FHCP by Express Scripts. The drugs listed in 

this PDL are intended to provide sufficient options to treat patients who require 

treatment with a drug from that pharmacologic or therapeutic class. The drugs 

listed in the Florida Health Care Plans PDL have been reviewed and approved by 

the FHCP Pharmacy and Therapeutics Committee. The drugs have been selected 

to provide the most clinically appropriate and cost-effective medications for 

patients who have their drug benefit administered through Florida Health Care 

Plans Collier County Healthy Kids program. It is also recognized there may be 

occasions where an unlisted drug is desired for proper medical management of a 

specific patient. In those infrequent instances, the unlisted medication may be 

requested through the Prior Authorization (PA) process. 

This edition incorporates drugs added to the PDL since the last edition as well as 

numerous revisions to the prescribing information based on changes in 

pharmacotherapy. Comments and suggestions from practicing physicians have 

also been incorporated to ensure that the Florida Health Care Plans Collier 

County Healthy Kids PDL is reflective of current medical practices. 

NOTICE 

The information contained in this PDL and its appendices is provided by Florida 

Health Care Plans, solely for the convenience of medical providers. Florida 

Health Care Plans does not warrant or assure accuracy of such information nor is 

it intended to be comprehensive in nature. 

This PDL is not intended to be a substitute for the knowledge, expertise, skill 

and judgment of the medical provider in their choice of prescription drugs. 

Florida Health Care Plans assumes no responsibility for the actions or omissions 

of any medical provider based upon reliance, in whole or in part, on the 

information contained herein. The medical provider should consult the drug 

manufacturer’s product literature or standard references for more detailed 

information. 

National guidelines can be found on the Web sites listed in the Web Site section 

or go to the National Guideline Clearinghouse site at http://guideline.gov. 

PREFACE 

The Florida Health Care Plans Collier County Healthy Kids PDL is organized by 

sections. Each section includes therapeutic groups identified by either a drug 

class or therapeutic class. 

Products are listed by generic name. Brand names are included as a reference to 

assist in product recognition. Unless exceptions are noted, generally all 

applicable dosage forms and strengths of the drug cited are included in the PDL. 

Generics are mandatory for prescribing. 

PHARMACY AND THERAPEUTIC (P&T) COMMITTEE 

The P&T Committee includes medical directors, physicians, pharmacists and 

administrators who are employees or agents of Florida Health Care Plans. They 

must adhere to the Ethics Policy standards of Florida Health Care Plans P&T 

Committee. The P&T Committee meets quarterly to discuss a variety of issues. 

Those issues pertaining to pharmaceutical selection and pharmacy program 

management and are communicated quarterly. This newsletter is distributed to 

all Collier County Healthy Kids participating physicians who have received the 

PDL. 

OUTPATIENT PRESCRIPTION DRUG BENEFIT-COVERED 

MEDICATIONS 

Outpatient prescription drugs are covered when prescribed by a provider licensed 

to prescribe federal legend drugs or medicines. Some items are covered only 

with prior authorization. 

PRODUCT SELECTION CRITERIA 

The P&T Committee considers clinical information on new-to-market drugs that 

are typically included in an outpatient pharmacy benefit. The evaluation includes 

all or part of the following: 

• Safety 

• Efficacy 

• Comparison studies 

• Approved indications 

• Adverse effects 

• Contraindications/Warnings/Precautions 

• Pharmacokinetics 

• Patient administration/compliance considerations 

• Medical outcome and pharmaco-economic studies 

Page 1 of 81 


When a new drug is considered for Healthy Kids PDL inclusion, it will be 

reviewed relative to similar drugs currently included in the Florida Health Care 

Plans’ PDL. This review process may result in deletion of drug(s) in a particular 

therapeutic class in an effort to continually promote the most clinically useful 

and cost-effective agents. 

All the information in the PDL is provided as a reference for drug therapy 

selection. Specific drug selection for an individual patient rests solely with the 

prescriber. 

PDL PRODUCT DESCRIPTIONS 

To assist in understanding which specific strengths and dosage forms are covered 

on the Florida Health Care Plans Collier County Healthy Kids PDL, examples 

are noted below. The general principles shown in the examples can then usually 

be extended to other entries in the book. Any exceptions are noted in the drug 

list. There may also be a statement associated with a drug list that gives 

additional information about which specific products or dosage forms are 

covered. 

Products covered include all strengths associated with the dosage form of 

the listed brand name product or the listed generic product unless otherwise 

noted. 

carvedilol 

COREG 

All strengths of carvedilol would be covered by this listing. 

When a strength or dosage form is specified, only the specified strength and 

dosage form is on the PDL. Other strengths/dosage forms of the reference 

product are not. 

cyclobenzaprine 10mg 

FLEXERIL 

GENERIC SUBSTITUTION 

The Florida Health Care Plans PDL requires generic substitution on the majority 

of products when a generic equivalent is available. 

Generic substitution is a pharmacy action whereby a generic equivalent is 

dispensed rather than the brand name product. 

PLAN EXCLUSIONS 

The following drug categories are excluded from coverage under the outpatient 

pharmacy benefit and are not part of the Florida Health Care Plans PDL. 

Anti-obesity agents 

Experimental/research drugs 

Cosmetic drugs (Accutane) 

Immunization agents 

Nutritional/diet supplements 

Blood and blood plasma products 

Agents used to promote fertility 

Agents used for erectile dysfunction 

Agents used for cosmetic hair growth 

Diagnostic products 

Medical supplies and DME except as listed: syringes, needles, lancets, 

alcohol swabs and glucometer test strips. 

DAYS SUPPLY DISPENSING LIMITATIONS 

Florida Health Care Plans Healthy Kids members may receive up to a one month 

supply (31 days) of a specific medication per prescription order or prescription 

refill. A medication may be reordered or refilled when seventy-five percent 

(75%) of the medication has been utilized. If a claim is submitted before 75% of 

the medication has been used, based on the original day supply submitted on the 

claim will reject with a “refill to soon” message. Please follow the Express 

Scripts Prior Authorization process noted below for questions, help with dosage 

change authorization or early fills for vacation supply. 

MANDATORY GENERIC SUBSTITUTION 

The Florida Health Care Plans Collier County Healthy Kids PDL requires 

mandatory generic substitution on branded products when a generic equivalent is 

available. BRAND NAME DRUGS, where a generic drug is available, are listed 

in all CAPITAL LETTERS. 

PRIOR AUTHORIZATION OF NON-PDL MEDICATIONS 

The drugs in the Florida Health Care Plans PDL have been selected to provide 

the most clinically appropriate and cost-effective medications for Healthy Kids 

patients who have their drug benefit administered through Express Scripts on 

behalf of Florida Health Care Plans. It is also recognized that there may be 

occasions where an unlisted drug is desired for the proper medical management 

of a specific patient. In those infrequent instances, the prior authorization process 

reviews requests for unlisted medications the physician may consider medically 

necessary for patient management. 

Page 2 of 81 


Any medication that is not on the formulary will require prior authorization. The 

process is as follows: 

• Express Scripts prefers that you call in the request for prior authorization to 

800-417-8164. Your calls will be handled promptly. 

• You may also fax your requests to 800-357-9577. Faxed request could take 48 

hours. 

• If you fax, it is necessary to use drug specific forms. 

There is also a miscellaneous form for use for drugs other than those on the 

Healthy Kids Formulary. A copy of the Florida Health Care Plans/Express 

Scripts forms is included with your Provider Information Packet and is also 

available online in Section 13 of the Collier County Healthy Kids Provider 

Handbook. The link to the Handbook is 

http://www.fhcp.com/providers/forms/providerHandbook/Healthy%20Kids%20 

Provider%20Handbook.pdf 

In order to obtain copies of prior authorization forms, or for assistance, please 

call Express Scripts at 1-800-417-8164. 

Physicians are requested to adhere to this PDL when prescribing for patients 

covered by their Healthy Kids pharmacy benefit plan offered by Florida Health 

Care Plans. If a pharmacist receives a prescription for a non-PDL drug, the 

pharmacist should contact the prescribing physician and request that the 

prescription be changed to a medication included in this PDL. If a PDL 

alternative is not appropriate the physician should then be instructed to contact 

Express Scripts for a prior authorization. 

QUANTITY LIMITATIONS (QL) 

Prescriptions for monthly quantities greater than the indicated limit require a 

prior authorization request. 

Quantity limits based on Efficient Medication Dosing 

The Efficient Medication Dosing Program is designed to consolidate medication 

dosage to the most efficient daily quantity to increase adherence to therapy and 

also promote the efficient use of health care dollars. 

The limits for the program are established based on FDA approval for dosing and 

the availability of the total daily dose in the last amount of tablets or capsules 

daily. Quantity Limits in the prescription claims processing system will limit the 

dispensing to consolidate dosing. The pharmacy claims processing system will 

prompt the pharmacist to request a new prescription order from the physician. 

Additions to the QL program drug list will be made from time to time and 

providers notified accordingly. As always, we recognize that a number of 

patient-specific variables must be taken into consideration when drug therapy is 

prescribed and therefore overrides will be available through the medical 

exception (PA) process. Please contact Express Scripts at 1-800-417-8164 with 

questions. 

Prior Auth Drugs 

ABILIFY, 

ABILIFY DISCMELT, 

ABILIFY MAINTENA, 

ACTIQ, 

ALBUKED-25, 

ALBUKED-5, 

ALBUMIN (HUMAN), 

ALBUMINAR-25, 

ALBUMINAR-5, 

ALBURX, 

ALBUTEIN, 

BIVIGAM, 

BOTOX, 

BOTOX COSMETIC, 

BUMINATE, 

BUPRENORPHINE HCL, 

BUPRENORPHINE-NALOXONE, 

CARIMUNE NF NANOFILTERED, 

CARISOPRODOL, 

CELEBREX, 

CLOZAPINE, 

CLOZAPINE ODT, 

CLOZARIL, 

CYTOGAM, 

EPOGEN, 

FAZACLO, 

FENTANYL CITRATE, 

FENTORA, 

FLEBOGAMMA DIF, 

FLEXBUMIN, 

FUZEON, 

GAMMAGARD LIQUID, 

GAMMAGARD S-D, 

GAMMAKED, 

GAMMAPLEX, 

Page 3 of 81 


GAMUNEX, 

GAMUNEX-C, 

GENOTROPIN, 

GEODON, 

HUMATROPE, 

INVEGA, 

INVEGA SUSTENNA, 

KEDBUMIN, 

LEUKINE, 

NEULASTA, 

NEUPOGEN, 

NORDITROPIN FLEXPRO, 

NORDITROPIN NORDIFLEX, 

NUTROPIN, 

NUTROPIN AQ, 

NUTROPIN AQ NUSPIN, 

OCTAGAM, OLANZAPINE, 

OLANZAPINE ODT, 

OMNITROPE, 

ORFADIN, 

OXYCONTIN, 

PANRETIN, 

PLASBUMIN-25, 

PLASBUMIN-5, 

PRIVIGEN, 

PROCRIT, 

PROLEUKIN, 

QUETIAPINE FUMARATE, 

REVATIO, 

RISPERDAL, 

RISPERDAL CONSTA, 

RISPERDAL M-TAB, 

RISPERIDONE, 

RISPERIDONE M-TAB, 

RISPERIDONE ODT, 

SAIZEN, 

SELZENTRY, 

SEROQUEL, 

SEROQUEL XR, 

SEROSTIM, 

SILDENAFIL, 

SOMA, 

SUBOXONE, 

SYNAGIS, 

ARANESP 

MYOBLOC 

EGRIFTA, 

GENOTROPIN, 

HUMATROPE, 

INCRELEX, 

NORDITROPIN FLEXPRO, 

NORDITROPIN NORDIFLEX, 

NUTROPIN, 

NUTROPIN AQ, 

NUTROPIN AQ NUSPIN, 

OMNITROPE, 

SAIZEN, 

SEROSTIM, 

TEV-TROPIN, 

ZORBTIVE 

ENBREL, 

HUMIRA, 

XELJANZ 

AUBAGIO, 

AVONEX, 

BETASERON, 

EXTAVIA, 

GILENYA, 

REBIF, 

ECFIDERA 

MODAFINIL, 

PROVIGIL 

ADCIRCA, 

LETAIRIS, 

TRACLEER 

Drugs that are part of this program and are on the PDL are identified in this 

booklet by the designation, prior authorization (PA). Request forms can be 

requested by calling Express Scripts at 1-800-417-8164. 

Page 4 of 81 


STEP THERAPY (ST) 

The following PDL drugs are routinely covered only after a sufficient trial of an 

indicated first-line agent has been adequately tried and failed. These medications 

may also be requested through the Prior authorization process. While lower cost 

PDL alternatives may be appropriate in many instances, other non- PDL 

alternatives are available with prior authorization (PA). 

Specialty Pharmaceutical Program Drug List 

INTUNIV, 

KAPVAY, 

STRATTERA, 

ADDERALL XR, 

CONCERTA, 

DAYTRANA, 

DEXEDRINE, 

FOCALIN XR, 

METADATE CD, 

QUILLIVANT XR, 

RITALIN LA, 

RITALIN-SR, 

VYVANSE, 

BECONASE AQ, 

DYMISTA, 

FLONASE, 

NASACORT AQ, 

NASONEX, 

OMNARIS, 

QNASL, 

RHINOCORT AQUA, 

VERAMYST, 

ZETONNA, 

ELIDEL, 

PROTOPIC, 

ALSUMA, 

AMERGE, 

AXERT, 

FROVA, 

IMITREX, 

MAXALT, 

MAXALT MLT, 

RELPAX, 

SUMAVEL DOSEPRO, 

TREXIMET, 

TYVASO, 

VENTAVIS, 

ZOMIG, 

ZOMIG ZMT 

LEGEND 

# Only the dosage forms/strengths of the brand name products noted 

are on the PDL 

OTC over-the-counter. 

delayed-rel delayed-release (also known as enteric coated) 

EC enteric-coated 

ext-rel extended-release (also known as sustained release) 

PA Prior Authorization required 

QL Quantity Limits apply 

ST 

SP 

Step Therapy, see pages V-VI for details 

Specialty Pharmaceuticals, see pages V for 

details. 

NOTICE 

The information contained in this document is proprietary information. The 

information may not be copied in whole or in part without the written 

permission of Florida Health Care Plans. All rights reserved. 

The drug names listed here are the registered and/or unregistered trademarks of 

third-party pharmaceutical companies unrelated to and unaffiliated with 

Florida Health Care Plans. These trademarked brand names are included here 

for informational purposes only and are not intended to imply or suggest any 

affiliation between Florida Health Care Plans and such third-party 

pharmaceutical companies. 

The most current PDL is available via FHCP’s web site 

(http://www.fhcp.com/plans_benefits/collier-healthy-kids). 

Page 5 of 81 


Florida Health Care Plan- FHCP 

Healthy Kids Formulary Effective 04-02-14 

(4:04.04) Antihistamine Drugs » First Generation Antihistamines » Ethanolamine Derivatives 

Product Name Form Strength Pref Coverage Details Comment 

CLEMASTINE FUMARATE SYRP 0.67MG/5ML T2 QL syrup only, (TAVIST) 

(4:04.12) Antihistamine Drugs » First Generation Antihistamines » Phenothiazine Derivatives 


PHENADOZ SUPP 25MG T2 QL (PHENERGAN) 

PROMETHAZINE HCL TABS 25MG T2 (PHENERGAN) 

PROMETHAZINE HCL TABS 12.5MG T2 (PHENERGAN) 

PROMETHAZINE HCL TABS 50MG T2 (PHENERGAN) 

PROMETHAZINE HCL SUPP 12.5MG T2 QL (PHENERGAN) 

PROMETHAZINE HCL SUPP 25MG T2 QL (PHENERGAN) 

PROMETHAZINE HCL PLAIN SYRP 6.25MG/5ML T2 QL (PHENERGAN) 

PROMETHAZINE VC PLAIN SYRP 5MG/5ML; 

6.25MG/5ML 

T2 QL (PHENERGAN) 

PROMETHEGAN SUPP 50MG T2 QL (PHENERGAN) 

PROMETHEGAN SUPP 25MG T2 QL (PHENERGAN) 

PROMETHEGAN SUPP 12.5MG T2 QL (PHENERGAN) 

(4:04.92) Antihistamine Drugs » First Generation Antihistamines » Derivatives, Miscellaneous 


CYPROHEPTADINE HCL TABS 4MG T2 (PERIACTIN) 

CYPROHEPTADINE HCL SYRP 2MG/5ML T2 QL (PERIACTIN) 

(4:08) Antihistamine Drugs » Second Generation Antihistamines 


LEVOCETIRIZINE DIHYDROCHLORIDE TABS 5MG T2 (XYZAL) 

(8:08) Anti-infective Agents » Anthelmintics 


ALBENZA TABS 200MG T4 

STROMECTOL TABS 3MG T4 QL 

(8:12.02) Anti-infective Agents » Antibacterials » Aminoglycosides 


Page 6 of 81 


NEOMYCIN SULFATE TABS 500MG T2 

TOBI NEBU 300MG/5ML T5 

(8:12.06.04) Anti-infective Agents » Antibacterials » Cephalosporins » First Generation Cephalosporins 


CEFADROXIL SUSR 250MG/5ML T2 QL Susp Only (DURICEF) 

CEFADROXIL SUSR 500MG/5ML T2 QL Susp Only (DURICEF) 

CEPHALEXIN CAPS 250MG T2 (KEFLEX) 

CEPHALEXIN CAPS 500MG T2 (KEFLEX) 

CEPHALEXIN SUSR 125MG/5ML T2 QL (KEFLEX) 

CEPHALEXIN SUSR 250MG/5ML T2 QL (KEFLEX) 

(8:12.06.08) Anti-infective Agents » Antibacterials » Cephalosporins » Second Generation Cephalosporins 


CEFACLOR CAPS 250MG T2 (CECLOR) 

CEFACLOR CAPS 500MG T2 (CECLOR) 

CEFPROZIL TABS 250MG T2 (CEFZIL) 

CEFPROZIL TABS 500MG T2 (CEFZIL) 

CEFPROZIL SUSR 125MG/5ML T2 QL (CEFZIL) 

CEFPROZIL SUSR 250MG/5ML T2 QL (CEFZIL) 

CEFUROXIME AXETIL TABS 250MG T2 tabs only, (CEFTIN) 

CEFUROXIME AXETIL TABS 500MG T2 tabs only, (CEFTIN) 

(8:12.06.12) Anti-infective Agents » Antibacterials » Cephalosporins » Third Generation Cephalosporins 


CEFDINIR CAPS 300MG T2 (OMNICEF) 

CEFDINIR SUSR 125MG/5ML T2 QL (OMNICEF) 

CEFDINIR SUSR 250MG/5ML T2 QL (OMNICEF) 

SUPRAX TABS 400MG T4 

SUPRAX SUSR 100MG/5ML T4 QL 

(8:12.12.04) Anti-infective Agents » Antibacterials » Macrolides » Erythromycins 


E.E.S. 400 TABS 400MG T3 

E.S.P. SUSR 200MG/5ML; 

600MG/5ML 

ERYTHROCIN STEARATE TABS 250MG T3 

T2 QL (PEDIAZOLE) 

Page 7 of 81 


ERYTHROMYCIN CPEP 250MG T3 

ERYTHROMYCIN ETHYLSUCCINATE TABS 400MG T3 

(8:12.12.92) Anti-infective Agents » Antibacterials » Macrolides » Other Macrolides 


AZITHROMYCIN TABS 250MG T2 (ZITHROMAX) 



AZITHROMYCIN SUSR 200MG/5ML T2 QL (ZITHROMAX) 

AZITHROMYCIN SUSR 100MG/5ML T2 QL (ZITHROMAX) 

CLARITHROMYCIN SUSR 125MG/5ML T2 QL (BIAXIN) 

CLARITHROMYCIN SUSR 250MG/5ML T2 QL (BIAXIN) 

CLARITHROMYCIN TABS 250MG T2 not XL, (BIAXIN) 

CLARITHROMYCIN TABS 500MG T2 not XL, (BIAXIN) 

(8:12.16.04) Anti-infective Agents » Antibacterials » Penicillins » Natural Penicillins 


PENICILLIN V POTASSIUM TABS 250MG T2 (PEN VEE K) 

PENICILLIN V POTASSIUM TABS 500MG T2 (PEN VEE K) 

PENICILLIN V POTASSIUM SOLR 125MG/5ML T2 QL (PEN VEE K) 

PENICILLIN V POTASSIUM SOLR 250MG/5ML T2 QL (PEN VEE K) 

(8:12.16.08) Anti-infective Agents » Antibacterials » Penicillins » Aminopenicillins 


AMOXICILLIN TABS 875MG T2 (AMOXIL) 

AMOXICILLIN CHEW 125MG T2 (AMOXIL) 

AMOXICILLIN CHEW 250MG T2 (AMOXIL) 

AMOXICILLIN CAPS 250MG T2 (AMOXIL) 

AMOXICILLIN CAPS 500MG T2 (AMOXIL) 

AMOXICILLIN SUSR 125MG/5ML T2 QL (AMOXIL) 




AMOXICILLIN/CLAVULANATE POTASSIUM CHEW 400MG; 57MG T2 (AUGMENTIN) 

AMOXICILLIN/CLAVULANATE POTASSIUM TABS 500MG; 125MG T2 (AUGMENTIN) 

Page 8 of 81 



AMOXICILLIN/CLAVULANATE POTASSIUM CHEW 200MG; 28.5MG T2 (AUGMENTIN) 


AMOXICILLIN/CLAVULANATE POTASSIUM SUSR 600MG/5ML; 

42.9MG/5ML 


28.5MG/5ML 


57MG/5ML 


62.5MG/5ML 

T2 QL (AUGMENTIN) 




AMOXICILLIN/CLAVULANATE POTASSIUM ER TB12 1000MG; 62.5MG T2 (AUGMENTIN XR) 

AMPICILLIN CAPS 250MG T2 (PRINCIPEN, OMNIPEN, 

POLYCILLIN) 

AMPICILLIN CAPS 500MG T2 (PRINCIPEN, OMNIPEN, 

POLYCILLIN) 

AMPICILLIN SUSR 125MG/5ML T2 QL (PRINCIPEN, OMNIPEN, 

POLYCILLIN) 

AMPICILLIN SUSR 250MG/5ML T2 QL (PRINCIPEN, OMNIPEN, 

POLYCILLIN) 

(8:12.16.12) Anti-infective Agents » Antibacterials » Penicillins » Penicillinase-resistant Penicillins 


DICLOXACILLIN SODIUM CAPS 250MG T2 (DYNAPEN/DYCILL) 

DICLOXACILLIN SODIUM CAPS 500MG T2 (DYNAPEN/DYCILL) 

(8:12.18) Anti-infective Agents » Antibacterials » Quinolones 


CIPROFLOXACIN HCL TABS 500MG T2 not Susp or XR, (CIPRO) 



LEVOFLOXACIN TABS 250MG T2 (LEVAQUIN) 

LEVOFLOXACIN SOLN 25MG/ML T2 (LEVAQUIN) 



(8:12.20) Anti-infective Agents » Antibacterials » Sulfonamides 


SULFADIAZINE TABS 500MG T2 

SULFAMETHOXAZOLE/TRIMETHOPRIM TABS 400MG; 80MG T2 (BACTRIM , SEPTRA) 

Page 9 of 81 


SULFAMETHOXAZOLE/TRIMETHOPRIM SUSP 200MG/5ML; 

40MG/5ML 

T2 

(BACTRIM , SEPTRA) 

SULFAMETHOXAZOLE/TRIMETHOPRIM DS TABS 800MG; 160MG T2 (BACTRIM DS, SEPTRA DS) 

SULFASALAZINE TABS 500MG T2 not EN, (AZULFIDINE) 

SULFAZINE TABS 500MG T2 not EN, (AZULFIDINE) 

(8:12.24) Anti-infective Agents » Antibacterials » Tetracyclines 


DOXYCYCLINE HYCLATE TABS 20MG T2 (PERIOSTAT) 

DOXYCYCLINE HYCLATE CAPS 50MG T2 (VIBRAMYCIN) 

DOXYCYCLINE HYCLATE CAPS 100MG T2 (VIBRAMYCIN) 

DOXYCYCLINE HYCLATE TABS 100MG T2 (VIBRATABS) 

MINOCYCLINE HCL CAPS 50MG T2 (MINOCIN) 

MINOCYCLINE HCL CAPS 100MG T2 (MINOCIN) 

TETRACYCLINE HCL CAPS 250MG T2 (SUMYCIN) 

TETRACYCLINE HCL CAPS 500MG T2 (SUMYCIN) 

(8:12.28.20) Anti-infective Agents » Antibacterials » Antibacterials, Miscellaneous » Lincomycins 


CLINDAMYCIN HCL CAPS 150MG T2 150mg caps and Suspension only, 

(CLEOCIN) 

CLINDAMYCIN PALMITATE HCL SOLR 75MG/5ML T2 (CLEOCIN) 

(8:12.28.24) Anti-infective Agents » Antibacterials » Antibacterials, Miscellaneous » Oxazolidinones 


ZYVOX TABS 600MG T3 PA 

ZYVOX SUSR 100MG/5ML T3 PA 

(8:14.04) Anti-infective Agents » Antifungals » Allylamines 


TERBINAFINE HCL TABS 250MG T2 (LAMISIL) 

(8:14.08) Anti-infective Agents » Antifungals » Azoles 


FLUCONAZOLE TABS 100MG T2 (DIFLUCAN) 



FLUCONAZOLE SUSR 10MG/ML T2 QL (DIFLUCAN) 

Page 10 of 81 


FLUCONAZOLE SUSR 40MG/ML T2 QL (DIFLUCAN) 

FLUCONAZOLE TABS 150MG T2 QL (DIFLUCAN) 

ITRACONAZOLE CAPS 100MG T2 PA (SPORONOX) 

KETOCONAZOLE TABS 200MG T2 not shampoo, (NIZORAL) 

SPORANOX SOLN 10MG/ML T4 PA 

(8:14.28) Anti-infective Agents » Antifungals » Polyenes 


NYSTATIN TABS 500000UNIT T2 not PWD 

NYSTATIN SUSP 100000UNIT/ML T2 not PWD 

(8:14.32) Anti-infective Agents » Antifungals » Pyrimidines 


FLUCYTOSINE CAPS 250MG T2 (ANCOBON) 

FLUCYTOSINE CAPS 500MG T2 (ANCOBON) 

(8:14.92) Anti-infective Agents » Antifungals » Antifungals, Miscellaneous 


GRISEOFULVIN MICROSIZE SUSP 125MG/5ML T2 (GRIFULVIN V SUSP) 

(8:16.04) Anti-infective Agents » Antimycobacterials » Antituberculosis Agents 


ETHAMBUTOL HCL TABS 400MG T2 (MYAMBUTAL) 

ETHAMBUTOL HCL TABS 100MG T2 (MYAMBUTAL) 

ISONIAZID TABS 100MG T2 (LANIAZID) 

ISONIAZID TABS 300MG T2 (LANIAZID) 

MYCOBUTIN CAPS 150MG T3 

PASER PACK 4GM T4 

PRIFTIN TABS 150MG T4 

PYRAZINAMIDE TABS 500MG T2 (RIFATER) 

RIFAMPIN CAPS 150MG T2 (RIFADIN) 

RIFAMPIN CAPS 300MG T2 (RIFADIN) 

SEROMYCIN CAPS 250MG T4 

TRECATOR TABS 250MG T4 

(8:16.92) Anti-infective Agents » Antimycobacterials » Antimycobacterials, Miscellaneous 


Page 11 of 81 


DAPSONE TABS 100MG T4 

DAPSONE TABS 25MG T4 

(8:18.04) Anti-infective Agents » Antivirals » Adamantanes 


RIMANTADINE HCL TABS 100MG T2 

(8:18.08.20) Anti-infective Agents » Antivirals » Antiretrovirals » Nucleoside and Nucleotide Reverse Transcriptase Inhibitors 


ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE TABS 300MG; 150MG; 

300MG 

T2 

(TRIZIVIR) 

LAMIVUDINE TABS 100MG T2 (EPIVIR HPV) 

(8:18.20) Anti-infective Agents » Antivirals » Interferons 


PEG-INTRON KIT 150MCG/0.5ML T5 PA 




PEG-INTRON REDIPEN KIT 120MCG/0.5ML T5 PA 



PEGASYS KIT 180MCG/0.5ML T5 PA 

PEGASYS SOLN 180MCG/0.5ML T5 PA 

(8:18.28) Anti-infective Agents » Antivirals » Neuraminidase Inhibitors 


RELENZA DISKHALER AEPB 5MG/BLISTER T4 

TAMIFLU SUSR 6MG/ML T4 QL under 2 years of age only, susp. 

only 

(8:18.32) Anti-infective Agents » Antivirals » Nucleosides and Nucleotides 


ACYCLOVIR CAPS 200MG T2 (ZOVIRAX) 

ACYCLOVIR TABS 400MG T2 (ZOVIRAX) 

ACYCLOVIR TABS 800MG T2 (ZOVIRAX) 

ACYCLOVIR SUSP 200MG/5ML T2 (ZOVIRAX) 

BARACLUDE TABS 0.5MG T3 

Page 12 of 81 


BARACLUDE TABS 1MG T3 

HEPSERA TABS 10MG T5 PA 

RIBAVIRIN TABS 200MG T6 

RIBAVIRIN CAPS 200MG T6 

TYZEKA TABS 600MG T4 PA 

VALACYCLOVIR HCL TABS 1GM T2 (VALTREX) 

VALACYCLOVIR HCL TABS 500MG T2 (VALTREX) 

VALCYTE TABS 450MG T3 

VALCYTE SOLR 50MG/ML T3 

(8:18.40) Anti-infective Agents » Antivirals » HCV Protease Inhibitors 


VICTRELIS CAPS 200MG T5 PA 

(8:30.04) Anti-infective Agents » Antiprotozoals » Amebicides 


PAROMOMYCIN SULFATE CAPS 250MG T3 

(8:30.08) Anti-infective Agents » Antiprotozoals » Antimalarials 


ATOVAQUONE/PROGUANIL HCL TABS 250MG; 100MG T2 (MALARONE) 

ATOVAQUONE/PROGUANIL HCL TABS 62.5MG; 25MG T2 (MALARONE) 

CHLOROQUINE PHOSPHATE TABS 500MG T2 (ARALEN) 

CHLOROQUINE PHOSPHATE TABS 250MG T2 (ARALEN) 

DARAPRIM TABS 25MG T4 

HYDROXYCHLOROQUINE SULFATE TABS 200MG T2 (PLAQUENIL) 

MEFLOQUINE HCL TABS 250MG T2 (LARIAM) 

(8:30.92) Anti-infective Agents » Antiprotozoals » Antiprotozoals, Miscellaneous 


ALINIA TABS 500MG T3 

MEPRON SUSP 750MG/5ML T3 

METRONIDAZOLE TABS 250MG T2 (FLAGYL) 

METRONIDAZOLE TABS 500MG T2 (FLAGYL) 

(8:36) Anti-infective Agents » Urinary Anti-infectives 


Page 13 of 81 


NITROFURANTOIN MACROCRYSTALS CAPS 50MG T2 (MACRODANTIN) 

NITROFURANTOIN MACROCRYSTALS CAPS 100MG T2 (MACRODANTIN) 

NITROFURANTOIN MONOHYDRATE CAPS 100MG T2 (MACROBID) 

TRIMETHOPRIM TABS 100MG T2 (TRIMPEX) 

UROQID #2 TABS 500MG; 500MG T3 

(12:04) Autonomic Drugs » Parasympathomimetic (Cholinergic) Agents 


BETHANECHOL CHLORIDE TABS 25MG T2 (URECHOLINE) 




DONEPEZIL HCL TABS 5MG T2 (ARICEPT) 

DONEPEZIL HCL TABS 10MG T2 (ARICEPT) 

DONEPEZIL HCL TBDP 5MG T2 (ARICEPT) 

DONEPEZIL HCL TBDP 10MG T2 (ARICEPT) 

GALANTAMINE HYDROBROMIDE CP24 8MG T2 (RAZADYNE ER) 



GALANTAMINE HYDROBROMIDE SOLN 4MG/ML T2 (RAZADYNE) 

GALANTAMINE HYDROBROMIDE TABS 4MG T2 (RAZADYNE) 



GUANIDINE HCL TABS 125MG T4 

MESTINON TIMESPAN TBCR 180MG T3 

PILOCARPINE HYDROCHLORIDE TABS 5MG T2 (SALAGEN) 

PYRIDOSTIGMINE BROMIDE TABS 60MG T2 (MESTINON) 

(12:08.08) Autonomic Drugs » Anticholinergic Agents » Antimuscarinics/Antispasmodics 


ATROVENT HFA AERS 17MCG/ACT T3 QL 

CHLORDIAZEPOXIDE HCL/CLIDINIUM BROMIDE CAPS 5MG; 2.5MG T2 (LIBRAX) 

DICYCLOMINE HCL CAPS 10MG T2 (BENTYL) 

Page 14 of 81 


DICYCLOMINE HCL TABS 20MG T2 (BENTYL) 

DICYCLOMINE HCL SOLN 10MG/5ML T2 (BENTYL) 

GLYCOPYRROLATE TABS 1MG T2 (ROBINUL) 

GLYCOPYRROLATE TABS 2MG T2 (ROBINUL) 

HYOMAX-SL SUBL 0.125MG T2 (LEVSIN) 

HYOSCYAMINE SULFATE ELIX 0.125MG/5ML T2 

HYOSCYAMINE SULFATE SOLN 0.125MG/ML T2 QL 

HYOSCYAMINE SULFATE TABS 0.125MG T2 (LEVSIN) 

HYOSCYAMINE SULFATE SUBL 0.125MG T2 (LEVSIN) 

HYOSCYAMINE SULFATE ER TB12 0.375MG T2 (LEVBID) 

HYOSCYAMINE SULFATE SR TB12 0.375MG T2 (LEVBID) 

HYOSYNE ELIX 0.125MG/5ML T2 

HYOSYNE SOLN 0.125MG/ML T2 QL 

IPRATROPIUM BROMIDE SOLN 0.03% T2 QL (ATROVENT NASAL) 

IPRATROPIUM BROMIDE SOLN 0.06% T2 QL (ATROVENT NASAL) 

IPRATROPIUM BROMIDE SOLN 0.02% T2 QL (ATROVENT NEB) 

OSCIMIN SR TB12 0.375MG T2 (LEVBID) 

PROPANTHELINE BROMIDE TABS 15MG T2 (PRO-BANTHINE) 

SPIRIVA HANDIHALER CAPS 18MCG T3 QL 

(12:12.04) Autonomic Drugs » Sympathomimetic (Adrenergic) Agents » alpha-Adrenergic Agonists 


MIDODRINE HCL TABS 2.5MG T2 (PRO-AMATINE) 

MIDODRINE HCL TABS 5MG T2 (PRO-AMATINE) 

MIDODRINE HCL TABS 10MG T2 (PRO-AMATINE) 

(12:12.08.12) Autonomic Drugs » Sympathomimetic (Adrenergic) Agents » beta-Adrenergic Agonists » Selective beta-2-Adrenergic Agonists 


ADVAIR DISKUS AEPB 100MCG/DOSE; 

50MCG/DOSE 


50MCG/DOSE 


50MCG/DOSE 

ADVAIR HFA AERO 45MCG/ACT; 

21MCG/ACT 

T4 

T4 

T4 

T4 

QL 

QL 

QL 

QL 

Page 15 of 81 



21MCG/ACT 


21MCG/ACT 

ALBUTEROL SULFATE SYRP 2MG/5ML T2 (VENTOLIN) 

ALBUTEROL SULFATE TABS 2MG T2 (VENTOLIN) 

ALBUTEROL SULFATE TABS 4MG T2 (VENTOLIN) 

ALBUTEROL SULFATE NEBU 0.083% T2 QL (VENTOLIN) 

ALBUTEROL SULFATE NEBU 0.5% T2 QL (VENTOLIN) 

METAPROTERENOL SULFATE TABS 10MG T2 (ALUPENT) 

METAPROTERENOL SULFATE TABS 20MG T2 (ALUPENT) 

SEREVENT DISKUS AEPB 50MCG/DOSE T3 QL 

TERBUTALINE SULFATE TABS 2.5MG T2 (BRETHINE) 

TERBUTALINE SULFATE TABS 5MG T2 (BRETHINE) 

VENTOLIN HFA AERS 108MCG/ACT T3 QL 

(12:12.12) Autonomic Drugs » Sympathomimetic (Adrenergic) Agents » alpha- and beta-Adrenergic Agonists 


EPIPEN DEVI 0.3MG/0.3ML T3 QL one pen per copay 

EPIPEN-JR DEVI 0.15MG/0.3ML T3 QL one pen per copay 

(12:16.04.04) Autonomic Drugs » Sympatholytic (Adrenergic Blocking) Agents » alpha-Adrenergic Blocking Agents » Non-selective alpha-Adrenergic Blocking 

Agents 


ERGOLOID MESYLATES TABS 1MG T2 (HYDERGINE) 

(12:16.04.12) Autonomic Drugs » Sympatholytic (Adrenergic Blocking) Agents » alpha-Adrenergic Blocking Agents » Selective alpha-1-Adrenergic Blocking 

Agents 


ALFUZOSIN HCL ER TB24 10MG T2 (UROXATRAL) 

TAMSULOSIN HCL CAPS 0.4MG T2 (FLOMAX) 

T4 

T4 

QL 

QL 

(12:20.04) Autonomic Drugs » Skeletal Muscle Relaxants » Centrally Acting Skeletal Muscle Relaxants 


CARISOPRODOL TABS 350MG T2 not cmpd or cod or 250mg 

(SOMA) 

CYCLOBENZAPRINE HCL TABS 10MG T2 not 5mg, (FLEXERIL) 

METHOCARBAMOL TABS 500MG T2 (ROBAXIN) 

Page 16 of 81 


METHOCARBAMOL TABS 750MG T2 (ROBAXIN) 

TIZANIDINE HCL TABS 2MG T2 (ZANAFLEX) 

TIZANIDINE HCL TABS 4MG T2 (ZANAFLEX) 

(12:20.08) Autonomic Drugs » Skeletal Muscle Relaxants » Direct-acting Skeletal Muscle Relaxants 


DANTROLENE SODIUM CAPS 50MG T2 (DANTRIUM) 

(12:20.12) Autonomic Drugs » Skeletal Muscle Relaxants » GABA-derivative Skeletal Muscle Relaxants 


BACLOFEN TABS 10MG T2 (LIORESAL) 

BACLOFEN TABS 20MG T2 (LIORESAL) 

(12:92) Autonomic Drugs » Autonomic Drugs, Miscellaneous 


CHANTIX TABS 0.5MG T4 PA 

CHANTIX CONTINUING MONTH PAK TABS 1MG T4 PA 

NICOTROL INHALER INHA 10MG T3 PA; QL 

(20:04.04) Blood Formation,Coagulation & Thrombosis » Antianemia Drugs » Iron Preparations 


FEROCON CAPS 75MG; 15MCG; 

110MG; 0.5MG; 

240MG 

FEROTRINSIC CAPS 75MG; 15MCG; 

110MG; 0.5MG; 

240MG 

TL ICON CAPS 75MG; 15MCG; 

110MG; 0.5MG; 

240MG 

TRICON CAPS 75MG; 15MCG; 

110MG; 0.5MG; 

240MG 

(20:12.04.08) Blood Formation,Coagulation & Thrombosis » Antithrombotic Agents » Anticoagulants » Coumarin Derivatives 


JANTOVEN TABS 1MG T1 (COUMADIN) 




WARFARIN SODIUM TABS 1MG T1 (COUMADIN) 

T2 

T2 

T2 

T2 

Page 17 of 81 


WARFARIN SODIUM TABS 2.5MG T1 (COUMADIN) 


WARFARIN SODIUM TABS 7.5MG T1 (COUMADIN) 






(20:12.04.12) Blood Formation,Coagulation & Thrombosis » Antithrombotic Agents » Anticoagulants » Direct Thrombin Inhibitors 


PRADAXA CAPS 150MG T4 PA 

PRADAXA CAPS 75MG T4 PA 

(20:12.04.14) Blood Formation,Coagulation & Thrombosis » Antithrombotic Agents » Anticoagulants » Direct Factor Xa Inhibitors 


ELIQUIS TABS 2.5MG T3 PA 

ELIQUIS TABS 5MG T3 PA 

FONDAPARINUX SODIUM SOLN 2.5MG/0.5ML T6 PA (ARIXTRA) 

FONDAPARINUX SODIUM SOLN 5MG/0.4ML T6 PA (ARIXTRA) 

FONDAPARINUX SODIUM SOLN 7.5MG/0.6ML T6 PA (ARIXTRA) 

FONDAPARINUX SODIUM SOLN 10MG/0.8ML T6 PA (ARIXTRA) 

XARELTO TABS 10MG T3 PA 

(20:12.04.16) Blood Formation,Coagulation & Thrombosis » Antithrombotic Agents » Anticoagulants » Heparins 


ENOXAPARIN SODIUM SOLN 30MG/0.3ML T6 QL (LOVENOX) 




ENOXAPARIN SODIUM SOLN 100MG/ML T6 QL (LOVENOX) 


ENOXAPARIN SODIUM SOLN 150MG/ML T6 QL (LOVENOX) 

(20:12.14) Blood Formation,Coagulation & Thrombosis » Antithrombotic Agents » Platelet-reducing Agents 


Page 18 of 81 


ANAGRELIDE HYDROCHLORIDE CAPS 1MG T2 (AGRYLIN) 

ANAGRELIDE HYDROCHLORIDE CAPS 0.5MG T2 (AGRYLIN) 

(20:12.18) Blood Formation,Coagulation & Thrombosis » Antithrombotic Agents » Platelet-Aggregation Inhibitors 


AGGRENOX CP12 25MG; 200MG T3 

CILOSTAZOL TABS 50MG T2 (PLETAL) 

CILOSTAZOL TABS 100MG T2 (PLETAL) 

CLOPIDOGREL TABS 75MG T2 (PLAVIX) 

TICLOPIDINE HCL TABS 250MG T2 for aspirin intolerant patients 

only, (TICLID) 

(20:16) Blood Formation,Coagulation & Thrombosis » Hematopoietic Agents 


ARANESP ALBUMIN FREE SOLN 200MCG/ML T5 PA 

ARANESP ALBUMIN FREE SOLN 300MCG/0.6ML T5 PA 




ARANESP ALBUMIN FREE SOLN 25MCG/0.42ML T6 PA 

NEULASTA SOLN 6MG/0.6ML T5 

NEUMEGA SOLR 5MG T5 

NEUPOGEN SOLN 300MCG/ML T5 

NEUPOGEN SOLN 480MCG/1.6ML T5 

PROCRIT SOLN 2000UNIT/ML T6 PA 






PROMACTA TABS 25MG T5 PA 



PROMACTA TABS 12.5MG T5 PA 

Page 19 of 81 


(20:24) Blood Formation,Coagulation & Thrombosis » Hemorrheologic Agents 


PENTOXIFYLLINE ER TBCR 400MG T2 (TRENTAL) 

(20:28.16) Blood Formation,Coagulation & Thrombosis » Antihemorrhagic Agents » Hemostatics 


AMINOCAPROIC ACID SYRP 25% T2 (AMICAR) 

AMINOCAPROIC ACID TABS 500MG T2 (AMICAR) 

AMINOCAPROIC ACID TABS 1000MG T2 (AMICAR) 

(24:04.04.04) Cardiovascular Drugs » Cardiac Drugs » Antiarrhythmic Agents » Class Ia Antiarrhythmics 


DISOPYRAMIDE PHOSPHATE CAPS 100MG T2 (NORPACE) 

DISOPYRAMIDE PHOSPHATE CAPS 150MG T2 (NORPACE) 

NORPACE CR CP12 100MG T4 

QUINIDINE GLUCONATE CR TBCR 324MG T2 (QUINAGLUTE) 

QUINIDINE SULFATE TABS 300MG T2 

QUINIDINE SULFATE TABS 200MG T2 

QUINIDINE SULFATE ER TBCR 300MG T2 

(24:04.04.08) Cardiovascular Drugs » Cardiac Drugs » Antiarrhythmic Agents » Class Ib Antiarrhythmics 


MEXILETINE HCL CAPS 150MG T2 (MEXITIL) 



(24:04.04.12) Cardiovascular Drugs » Cardiac Drugs » Antiarrhythmic Agents » Class Ic Antiarrhythmics 


FLECAINIDE ACETATE TABS 50MG T2 (TAMBOCOR) 



PROPAFENONE HCL TABS 150MG T2 not SR, (RYTHMOL) 



(24:04.04.20) Cardiovascular Drugs » Cardiac Drugs » Antiarrhythmic Agents » Class III Antiarrhythmics 


Page 20 of 81 


AMIODARONE HCL TABS 200MG T2 (CORDARONE) 

TIKOSYN CAPS 125MCG T4 



(24:04.08) Cardiovascular Drugs » Cardiac Drugs » Cardiotonic Agents 


DIGOX TABS 0.125MG T1 (LANOXIN) 

DIGOX TABS 0.25MG T1 (LANOXIN) 

DIGOXIN SOLN 0.05MG/ML T1 (LANOXIN) 

(24:04.92) Cardiovascular Drugs » Cardiac Drugs » Cardiac Drugs, Miscellaneous 


RANEXA TB12 500MG T3 PA 

RANEXA TB12 1000MG T3 PA 

(24:06.04) Cardiovascular Drugs » Antilipemic Agents » Bile Acid Sequestrants 


CHOLESTYRAMINE POWD 4GM/DOSE T2 QL (QUESTRAN) 

CHOLESTYRAMINE LIGHT POWD 4GM/DOSE T2 QL (QUESTRAN LITE) 

(24:06.05) Cardiovascular Drugs » Antilipemic Agents » Cholesterol Absorption Inhibitors 


ZETIA TABS 10MG T3 

(24:06.06) Cardiovascular Drugs » Antilipemic Agents » Fibric Acid Derivatives 


FENOFIBRATE TABS 145MG T2 (TRICOR) 

FENOFIBRATE TABS 48MG T2 (TRICOR) 

FENOFIBRIC ACID DR CPDR 45MG T2 (TRILIPIX) 

FENOFIBRIC ACID DR CPDR 135MG T2 (TRILIPIX) 

GEMFIBROZIL TABS 600MG T2 (LOPID) 

(24:06.08) Cardiovascular Drugs » Antilipemic Agents » HMG-CoA Reductase Inhibitors 


ATORVASTATIN CALCIUM TABS 10MG T2 (LIPITOR) 



Page 21 of 81 



CRESTOR TABS 10MG T3 




LOVASTATIN TABS 20MG T1 (MEVACOR) 



PRAVASTATIN SODIUM TABS 10MG T2 (PRAVACHOL) 




SIMVASTATIN TABS 10MG T2 (ZOCOR) 





(24:06.92) Cardiovascular Drugs » Antilipemic Agents » Antilipemic Agents, Miscellaneous 


LOVAZA CAPS 375MG; 465MG; 

1GM 

NIACIN ER TBCR 500MG T2 (NIASPAN) 



(24:08.16) Cardiovascular Drugs » Hypotensive Agents » Central Alpha-Agonists 


CLONIDINE HCL TABS 0.1MG T1 (CATAPRES) 



GUANFACINE HCL TABS 1MG T2 (TENEX) 

GUANFACINE HCL TABS 2MG T2 (TENEX) 

METHYLDOPA TABS 250MG T2 (ALDOMET) 

T3 

Page 22 of 81 


METHYLDOPA TABS 500MG T2 (ALDOMET) 

(24:08.20) Cardiovascular Drugs » Hypotensive Agents » Direct Vasodilators 


HYDRALAZINE HCL TABS 10MG T2 (APRESOLINE) 




MINOXIDIL TABS 2.5MG T2 (LONITEN) 

MINOXIDIL TABS 10MG T2 (LONITEN) 

PROGLYCEM SUSP 50MG/ML T4 

(24:08.32) Cardiovascular Drugs » Hypotensive Agents » Peripheral Adrenergic Inhibitors 


RESERPINE TABS 0.1MG T2 

RESERPINE TABS 0.25MG T2 

(24:12.08) Cardiovascular Drugs » Vasodilating Agents » Nitrates and Nitrites 


ISOSORBIDE DINITRATE SUBL 2.5MG T2 (ISORDIL) 

ISOSORBIDE DINITRATE TABS 5MG T2 (ISORDIL) 




ISOSORBIDE DINITRATE ER TBCR 40MG T2 (SORBITRATE) 

ISOSORBIDE MONONITRATE ER TB24 30MG T2 (IMDUR) 



NITRO-BID OINT 2% T2 QL 

NITRO-TIME CPCR 6.5MG T2 

NITROGLYCERIN PT24 0.4MG/HR T2 (MINITRAN) 

NITROGLYCERIN PT24 0.6MG/HR T2 (MINITRAN) 

NITROGLYCERIN ER CPCR 2.5MG T2 

NITROGLYCERIN ER CPCR 6.5MG T2 

NITROGLYCERIN ER CPCR 9MG T2 

Page 23 of 81 


NITROGLYCERIN TRANSDERMAL PT24 0.1MG/HR T2 (MINITRAN) 



NITROSTAT SUBL 0.3MG T3 



(24:12.12) Cardiovascular Drugs » Vasodilating Agents » Phosphodiesterase Type 5 Inhibitors 


SILDENAFIL CITRATE TABS 20MG T5 PA (REVATIO) 

(24:12.92) Cardiovascular Drugs » Vasodilating Agents » Vasodilating Agents, Miscellaneous 


DIPYRIDAMOLE TABS 25MG T2 (PERSANTINE) 



TRACLEER TABS 62.5MG T5 PA 

TRACLEER TABS 125MG T5 PA 

(24:20) Cardiovascular Drugs » alpha-Adrenergic Blocking Agents 


DOXAZOSIN MESYLATE TABS 1MG T1 not XL, (CARDURA) 




PRAZOSIN HCL CAPS 1MG T2 (MINIPRESS) 



TERAZOSIN HCL CAPS 10MG T1 (HYTRIN) 




(24:24) Cardiovascular Drugs » beta-Adrenergic Blocking Agents 


ACEBUTOLOL HCL CAPS 200MG T2 (SECTRAL) 

Page 24 of 81 


ACEBUTOLOL HCL CAPS 400MG T2 (SECTRAL) 

ATENOLOL TABS 25MG T1 (TENORMIN) 



CARVEDILOL TABS 3.125MG T1 (COREG) 



CARVEDILOL TABS 25MG T1 (COREG) 

COREG CR CP24 10MG T3 




LABETALOL HCL TABS 100MG T2 (TRANDATE) 



METOPROLOL TARTRATE TABS 50MG T1 not HCT, (LOPRESSOR) 



PROPRANOLOL HCL TABS 10MG T1 not LA, (INDERAL) 





PROPRANOLOL HCL SOLN 20MG/5ML T2 (INDERAL) 

PROPRANOLOL HCL SOLN 40MG/5ML T2 (INDERAL) 

PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS 25MG; 80MG T2 (INDERIDE) 

PROPRANOLOL/HYDROCHLOROTHIAZIDE TABS 25MG; 40MG T2 (INDERIDE) 

SOTALOL HCL TABS 120MG T2 (BETAPACE) 




(24:28.08) Cardiovascular Drugs » Calcium-Channel Blocking Agents » Dihydropyridines 

Page 25 of 81 



AFEDITAB CR TB24 30MG T2 (ADALAT CC) 

AFEDITAB CR TB24 60MG T2 (ADALAT CC) 

AMLODIPINE BESYLATE TABS 2.5MG T2 (NORVASC) 

AMLODIPINE BESYLATE TABS 5MG T2 (NORVASC) 

AMLODIPINE BESYLATE TABS 10MG T2 (NORVASC) 

NIFEDIAC CC TB24 60MG T2 (ADALAT CC) 



NIFEDIPINE CAPS 10MG T2 not XL, (PROCARDIA) 

NIFEDIPINE CAPS 20MG T2 not XL, (PROCARDIA) 

NIFEDIPINE ER TB24 90MG T2 (ADALAT CC) 



NIMODIPINE CAPS 30MG T4 

(24:28.92) Cardiovascular Drugs » Calcium-Channel Blocking Agents » Calcium-Channel Blocking Agents, Misc 


DILTIAZEM CD CP24 180MG T2 not 360, (CARDIZEM CD) 




DILTIAZEM HCL TABS 30MG T2 not SR, (CARDIZEM) 




DILTIAZEM HCL ER CP24 240MG T2 not 360, (CARDIZEM CD) 

VERAPAMIL HCL TABS 80MG T2 (CALAN) 



VERAPAMIL HCL ER TBCR 240MG T2 (CALAN-SR) 



Page 26 of 81 


(24:32.04) Cardiovascular Drugs » Renin-Angiotensin-Aldosterone Sys Inhib » Angiotensin-Converting Enzyme Inhibitors 


BENAZEPRIL HCL TABS 40MG T1 not HCT, (LOTENSIN) 




CAPTOPRIL TABS 12.5MG T1 (CAPOTEN) 

CAPTOPRIL TABS 50MG T1 (CAPOTEN) 



ENALAPRIL MALEATE TABS 2.5MG T1 (VASOTEC) 

ENALAPRIL MALEATE TABS 20MG T1 (VASOTEC) 



FOSINOPRIL SODIUM TABS 10MG T2 not HCT, (MONOPRIL) 



LISINOPRIL TABS 5MG T1 (PRINIVIL) 




LISINOPRIL TABS 2.5MG T1 (PRINIVIL) 

LISINOPRIL TABS 30MG T2 (ZESTRIL) 

LISINOPRIL/HYDROCHLOROTHIAZIDE TABS 12.5MG; 10MG T1 (ZESTORETIC) 

LISINOPRIL/HYDROCHLOROTHIAZIDE TABS 12.5MG; 20MG T1 (ZESTORETIC) 

LISINOPRIL/HYDROCHLOROTHIAZIDE TABS 25MG; 20MG T1 (ZESTORETIC) 

RAMIPRIL CAPS 1.25MG T2 (ALTACE) 

RAMIPRIL CAPS 2.5MG T2 (ALTACE) 

RAMIPRIL CAPS 5MG T2 (ALTACE) 

RAMIPRIL CAPS 10MG T2 (ALTACE) 

(24:32.08) Cardiovascular Drugs » Renin-Angiotensin-Aldosterone Sys Inhib » Angiotensin II Receptor Antagonists 


Page 27 of 81 


DIOVAN TABS 80MG T3 not HCT 




LOSARTAN POTASSIUM TABS 25MG T2 (COZAAR) 



LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE TABS 12.5MG; 50MG T2 (HYZAAR) 

LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE TABS 25MG; 100MG T2 (HYZAAR) 

LOSARTAN POTASSIUM/HYDROCHLOROTHIAZIDE TABS 12.5MG; 100MG T2 (HYZAAR) 

TELMISARTAN TABS 40MG T2 (MICARDIS) not HCT 

TELMISARTAN TABS 80MG T2 (MICARDIS) not HCT 

TELMISARTAN TABS 20MG T2 not HCT 

(24:32.20) Cardiovascular Drugs » Renin-Angiotensin-Aldosterone Sys Inhib » Mineralocorticoid (Aldost) Recept Antag 


SPIRONOLACTONE TABS 25MG T2 (ALDACTONE) 

SPIRONOLACTONE TABS 50MG T2 (ALDACTONE) 

SPIRONOLACTONE/HYDROCHLOROTHIAZIDE TABS 25MG; 25MG T2 (ALDACTAZIDE) 

(24:32.40) Cardiovascular Drugs » Renin-Angiotensin-Aldosterone Sys Inhib » Renin Inhibitors 


TEKTURNA TABS 150MG T4 ST 

TEKTURNA TABS 300MG T4 ST 

(28:08.04.24) Central Nervous System Agents » Analgesics and Antipyretics » Nonsteroidal Anti-inflammatory Agents » Salicylates 


BUTALBITAL/ASPIRIN/CAFFEINE TABS 325MG; 50MG; 

40MG 

T2 

(FIORINAL) 

SALSALATE TABS 500MG T2 (DISALCID) 

SALSALATE TABS 750MG T2 (DISALCID) 

(28:08.04.92) Central Nervous System Agents » Analgesics and Antipyretics » Nonsteroidal Anti-inflammatory Agents » Other Nonsteroidal Anti-inflammatory 

Agents 


Page 28 of 81 


DICLOFENAC SODIUM DR TBEC 50MG T2 not XR, (VOLTAREN) 



ETODOLAC TABS 400MG T2 (LODINE) 

ETODOLAC TABS 500MG T2 (LODINE) 

ETODOLAC CAPS 200MG T2 (LODINE) 

ETODOLAC CAPS 300MG T2 (LODINE) 

ETODOLAC ER TB24 600MG T2 (LODINE XL) 



FENOPROFEN CALCIUM TABS 600MG T2 (NALFON) 

IBUPROFEN TABS 400MG T1 (MOTRIN) 



INDOMETHACIN CAPS 25MG T2 (INDOCIN) 

INDOMETHACIN CAPS 50MG T2 (INDOCIN) 

INDOMETHACIN ER CPCR 75MG T2 (INDOCIN-SR) 

KETOPROFEN CAPS 50MG T2 not 25mg or ER 200mg, 

(ORUDIS) 

KETOPROFEN CAPS 75MG T2 not 25mg or ER 200mg, 

(ORUDIS) 

KETOROLAC TROMETHAMINE TABS 10MG T2 QL (TORADOL) 

MECLOFENAMATE SODIUM CAPS 50MG T2 (MECLOMEN) 

MECLOFENAMATE SODIUM CAPS 100MG T2 (MECLOMEN) 

MELOXICAM TABS 7.5MG T1 (MOBIC) 

MELOXICAM TABS 15MG T1 (MOBIC) 

MELOXICAM SUSP 7.5MG/5ML T2 QL (MOBIC) 

NABUMETONE TABS 500MG T2 (RELAFEN) 

NABUMETONE TABS 750MG T2 (RELAFEN) 

NAPROXEN TABS 500MG T1 (NAPROSYN) 


NAPROXEN SUSP 125MG/5ML T2 (NAPROSYN) 


Page 29 of 81 


NAPROXEN SODIUM TABS 550MG T2 (ANAPROX-DS) 

PIROXICAM CAPS 10MG T2 (FELDENE) 

PIROXICAM CAPS 20MG T2 (FELDENE) 

SULINDAC TABS 200MG T2 (CLINORIL) 

SULINDAC TABS 150MG T2 (CLINORIL) 

(28:08.08) Central Nervous System Agents » Analgesics and Antipyretics » Opiate Agonists 


ACETAMINOPHEN/CODEINE TABS 300MG; 15MG T2 (TYLENOL W/CODEINE) 

ACETAMINOPHEN/CODEINE TABS 300MG; 60MG T2 (TYLENOL W/CODEINE) 

ACETAMINOPHEN/CODEINE SOLN 120MG/5ML; 

12MG/5ML 

T2 

(TYLENOL W/CODEINE) 

ACETAMINOPHEN/CODEINE #3 TABS 300MG; 30MG T2 (TYLENOL W/CODEINE) 

ASCOMP/CODEINE CAPS 325MG; 50MG; 

40MG; 30MG 

BUTALBITAL/ASPIRIN/CAFFEINE/CODEINE CAPS 325MG; 50MG; 

40MG; 30MG 

CODEINE SULFATE TABS 15MG T2 

T2 

T2 

(FIORINAL W/CODEINE) 

(FIORINAL W/CODEINE) 

CODEINE SULFATE TABS 30MG T2 

DILAUDID LIQD 1MG/ML T3 

FENTANYL PT72 12MCG/HR T2 PA (DURAGESIC) 





HYDROCODONE/ACETAMINOPHEN TABS 325MG; 5MG T2 (NORCO) 

HYDROCODONE/ACETAMINOPHEN TABS 325MG; 7.5MG T2 (NORCO) 

HYDROCODONE/ACETAMINOPHEN TABS 325MG; 10MG T2 (NORCO) 

HYDROCODONE/ACETAMINOPHEN TABS 660MG; 10MG T2 old formulation, (VICODIN HP) 

HYDROCODONE/ACETAMINOPHEN TABS 500MG; 5MG T2 old formulation, (VICODIN) 

HYDROCODONE/ACETAMINOPHEN TABS 750MG; 7.5MG T2 old formulation, (VICODIN-ES) 

HYDROMORPHONE HCL TABS 4MG T2 (DILAUDID) 



Page 30 of 81 


MEPERIDINE HCL TABS 100MG T2 (DEMEROL) 

MEPERIDINE HCL TABS 50MG T2 (DEMEROL) 

MEPERITAB TABS 50MG T2 (DEMEROL) 

MEPERITAB TABS 100MG T2 (DEMEROL) 

METHADONE HCL SOLN 5MG/5ML T2 (DOLOPHINE) 

METHADONE HCL TABS 5MG T2 (DOLOPHINE) 

METHADONE HCL TABS 10MG T2 (DOLOPHINE) 

METHADOSE TABS 10MG T2 (DOLOPHINE) 

MORPHINE SULFATE TABS 15MG T2 (MSIR) 

MORPHINE SULFATE TABS 30MG T2 (MSIR) 

MORPHINE SULFATE SOLN 10MG/5ML T2 (ROXANOL) 


MORPHINE SULFATE SOLN 20MG/ML T2 (ROXANOL) 


MORPHINE SULFATE ER TBCR 15MG T2 (MS CONTIN) 





OXYCODONE/ACETAMINOPHEN TABS 325MG; 5MG T2 (PERCOCET) 

OXYCODONE/ACETAMINOPHEN CAPS 500MG; 5MG T2 (TYLOX) 

ROXICET SOLN 325MG/5ML; 

5MG/5ML 

ROXICET TABS 325MG; 5MG T2 (PERCOCET) 

TRAMADOL HCL TABS 50MG T2 (ULTRAM) 

(28:08.12) Central Nervous System Agents » Analgesics and Antipyretics » Opiate Partial Agonists 


BUPRENORPHINE HCL SUBL 2MG T2 PA (SUBUTEX) 

BUPRENORPHINE HCL SUBL 8MG T2 PA (SUBUTEX) 

BUPRENORPHINE HCL/NALOXONE HCL SUBL 8MG; 2MG T2 PA (SUBOXONE) 

BUPRENORPHINE HCL/NALOXONE HCL SUBL 2MG; 0.5MG T2 PA (SUBOXONE) 

SUBOXONE FILM 2MG; 0.5MG T4 PA 

T2 

Page 31 of 81 


SUBOXONE FILM 4MG; 1MG T4 PA 



(28:08.92) Central Nervous System Agents » Analgesics and Antipyretics » Analgesics and Antipyretics, Misc 


BUTALBITAL/ACETAMINOPHEN/CAFFEINE TABS 325MG; 50MG; 

40MG 

(28:10) Central Nervous System Agents » Opiate Antagonists 

T2 

(FIORICET) 


NALTREXONE HCL TABS 50MG T2 (REVIA) 

(28:12.04) Central Nervous System Agents » Anticonvulsants » Barbiturates 


PRIMIDONE TABS 250MG T2 (MYSOLINE) 

PRIMIDONE TABS 50MG T2 (MYSOLINE) 

(28:12.08) Central Nervous System Agents » Anticonvulsants » Benzodiazepines 


CLONAZEPAM TABS 0.5MG T2 (KLONOPIN) 

CLONAZEPAM TABS 1MG T2 (KLONOPIN) 

CLONAZEPAM TABS 2MG T2 (KLONOPIN) 

CLONAZEPAM ODT TBDP 0.125MG T2 (KLONOPIN) 



ONFI TABS 5MG T4 PA 



(28:12.12) Central Nervous System Agents » Anticonvulsants » Hydantoins 


DILANTIN CAPS 30MG T3 

PEGANONE TABS 250MG T4 

PHENYTOIN SUSP 125MG/5ML T2 (DILANTIN) 

PHENYTOIN INFATABS CHEW 50MG T2 (DILANTIN) 

PHENYTOIN SODIUM EXTENDED CAPS 100MG T2 (DILANTIN) 

(28:12.20) Central Nervous System Agents » Anticonvulsants » Succinimides 

Page 32 of 81 



CELONTIN CAPS 300MG T4 

ETHOSUXIMIDE SOLN 250MG/5ML T2 (ZARONTIN) 

ETHOSUXIMIDE CAPS 250MG T2 (ZARONTIN) 

(28:12.92) Central Nervous System Agents » Anticonvulsants » Anticonvulsants, Miscellaneous 


BANZEL TABS 400MG T4 PA 

BANZEL SUSP 40MG/ML T4 PA 

CARBAMAZEPINE TABS 200MG T2 not XR (TEGRETOL) 

CARBAMAZEPINE CHEW 100MG T2 not XR (TEGRETOL) 

CARBAMAZEPINE SUSP 100MG/5ML T2 not XR (TEGRETOL) 

DIVALPROEX SODIUM CPSP 125MG T2 (DEPAKOTE SPRINKLES) 

DIVALPROEX SODIUM DR TBEC 125MG T2 (DEPAKOTE) 



DIVALPROEX SODIUM ER TB24 250MG T2 (DEPAKOTE ER) 

DIVALPROEX SODIUM ER TB24 500MG T2 (DEPAKOTE ER) 

FELBAMATE SUSP 600MG/5ML T2 (FELBATOL) 

FELBAMATE TABS 400MG T2 (FELBATOL) 

FELBAMATE TABS 600MG T2 (FELBATOL) 

GABAPENTIN TABS 600MG T2 (NEURONTIN) 

GABAPENTIN CAPS 100MG T2 (NEURONTIN) 

GABAPENTIN TABS 800MG T2 (NEURONTIN) 



GABAPENTIN SOLN 250MG/5ML T2 (NEURONTIN) 

GABITRIL TABS 16MG T4 

LAMOTRIGINE TABS 25MG T2 not XR or ODT, (LAMICTAL) 

LAMOTRIGINE CHEW 25MG T2 not XR or ODT, (LAMICTAL) 




Page 33 of 81 


LAMOTRIGINE CHEW 5MG T2 not XR or ODT, (LAMICTAL) 

LEVETIRACETAM SOLN 100MG/ML T2 (KEPPRA) 

LEVETIRACETAM TABS 500MG T2 (KEPPRA) 




LEVETIRACETAM ER TB24 750MG T2 (KEPPRA ER) 

LEVETIRACETAM ER TB24 500MG T2 (KEPPRA ER) 

LYRICA SOLN 20MG/ML T4 PA 

LYRICA CAPS 25MG T4 PA; QL 








OXCARBAZEPINE TABS 150MG T2 (TRILEPTAL) 



OXCARBAZEPINE SUSP 60MG/ML T2 (TRILEPTAL) 

POTIGA TABS 50MG T4 




SABRIL TABS 500MG T4 PA 

SABRIL PACK 500MG T4 PA 

TIAGABINE HYDROCHLORIDE TABS 2MG T2 (GABITRIL) 

TIAGABINE HYDROCHLORIDE TABS 4MG T2 (GABITRIL) 

TOPIRAMATE CPSP 15MG T2 (TOPAMAX) 

TOPIRAMATE CPSP 25MG T2 (TOPAMAX) 

Page 34 of 81 


TOPIRAMATE TABS 200MG T2 (TOPAMAX) 




VALPROIC ACID SYRP 250MG/5ML T2 (DEPAKENE) 

VALPROIC ACID CAPS 250MG T2 (DEPAKENE) 

VIMPAT TABS 50MG T4 PA 




VIMPAT SOLN 10MG/ML T4 PA 

ZONISAMIDE CAPS 25MG T2 (ZONEGRAN) 



(28:16.04.12) Central Nervous System Agents » Psychotherapeutic Agents » Antidepressants » Monoamine Oxidase Inhibitors 


MARPLAN TABS 10MG T4 

PHENELZINE SULFATE TABS 15MG T2 (NARDIL) 

TRANYLCYPROMINE SULFATE TABS 10MG T2 (PARNATE) 

(28:16.04.16) Central Nervous System Agents » Psychotherapeutic Agents » Antidepressants » Selective Serotonin- and Norepinephrine-reuptake Inhibitors 


DESVENLAFAXINE ER TB24 50MG T2 

DESVENLAFAXINE ER TB24 100MG T2 

DULOXETINE HCL CPEP 20MG T2 (CYMBALTA) 



PRISTIQ TB24 50MG T3 

PRISTIQ TB24 100MG T3 

VENLAFAXINE HCL TABS 75MG T2 (EFFEXOR) 



Page 35 of 81 


VENLAFAXINE HCL TABS 37.5MG T2 (EFFEXOR) 


VENLAFAXINE HCL ER CP24 37.5MG T2 (EFFEXOR) 

VENLAFAXINE HCL ER CP24 75MG T2 (EFFEXOR) 

VENLAFAXINE HCL ER CP24 150MG T2 (EFFEXOR) 

(28:16.04.20) Central Nervous System Agents » Psychotherapeutic Agents » Antidepressants » Selective Serotonin-reuptake Inhibitors 


CITALOPRAM HYDROBROMIDE SOLN 10MG/5ML T1 (CELEXA) 

CITALOPRAM HYDROBROMIDE TABS 10MG T1 (CELEXA) 



ESCITALOPRAM OXALATE TABS 5MG T2 (LEXAPRO) 



ESCITALOPRAM OXALATE SOLN 5MG/5ML T2 (LEXAPRO) 

FLUOXETINE HCL CAPS 10MG T1 not 40mg, (PROZAC) 

FLUOXETINE HCL CAPS 20MG T1 not 40mg, (PROZAC) 

FLUOXETINE HCL SOLN 20MG/5ML T2 (PROZAC) 

FLUVOXAMINE MALEATE TABS 25MG T2 not CR, (LUVOX) 



PAROXETINE HCL TABS 10MG T2 (PAXIL) 




PAROXETINE HCL ER TB24 12.5MG T2 (PAXIL CR) 

PAROXETINE HCL ER TB24 25MG T2 (PAXIL CR) 

PAROXETINE HCL ER TB24 37.5MG T2 (PAXIL CR) 

PAXIL SUSP 10MG/5ML T4 

SERTRALINE HCL CONC 20MG/ML T2 (ZOLOFT) 

SERTRALINE HCL TABS 25MG T2 not 50mg, (ZOLOFT) 

SERTRALINE HCL TABS 100MG T2 not 50mg, (ZOLOFT) 

Page 36 of 81 


(28:16.04.24) Central Nervous System Agents » Psychotherapeutic Agents » Antidepressants » Serotonin Modulators 


NEFAZODONE HCL TABS 100MG T2 (SERZONE) 





TRAZODONE HCL TABS 100MG T1 not 300mg, (DESYREL) 



VIIBRYD KIT T4 

VIIBRYD TABS 10MG T4 



(28:16.04.28) Central Nervous System Agents » Psychotherapeutic Agents » Antidepressants » Tricyclics and Other Norepinephrine-reuptake Inhibitors 


AMITRIPTYLINE HCL TABS 10MG T1 (ELAVIL) 






AMOXAPINE TABS 25MG T2 (ASENDIN) 




CLOMIPRAMINE HCL CAPS 75MG T2 (ANAFRANIL) 



DESIPRAMINE HCL TABS 10MG T2 (NORPRAMIN) 


Page 37 of 81 






DOXEPIN HCL CAPS 10MG T1 (SINEQUAN) 



DOXEPIN HCL CONC 10MG/ML T2 (SINEQUAN) 




IMIPRAMINE HCL TABS 10MG T2 not PM, (TOFRANIL) 



MAPROTILINE HCL TABS 25MG T2 (LUDIOMIL) 



NORTRIPTYLINE HCL CAPS 10MG T1 (PAMELOR) 




NORTRIPTYLINE HCL SOLN 10MG/5ML T2 (PAMELOR) 

PERPHENAZINE/AMITRIPTYLINE TABS 10MG; 4MG T2 (TRIAVIL/ETRAFON) 





PROTRIPTYLINE HCL TABS 5MG T2 (VIVACTIL) 

PROTRIPTYLINE HCL TABS 10MG T2 (VIVACTIL) 

TRIMIPRAMINE MALEATE CAPS 25MG T2 (SURMONTIL) 


Page 38 of 81 



(28:16.04.92) Central Nervous System Agents » Psychotherapeutic Agents » Antidepressants » Miscellaneous Antidepressants 


BUDEPRION SR TB12 100MG T2 not 200mg (WELLBUTRIN SR) 

BUDEPRION SR TB12 150MG T2 not 200mg (WELLBUTRIN SR) 

BUPROBAN TB12 150MG T2 (ZYBAN) 

BUPROPION HCL TABS 75MG T2 (WELLBUTRIN) 

BUPROPION HCL TABS 100MG T2 (WELLBUTRIN) 

BUPROPION HCL ER TB12 100MG T2 not 200mg (WELLBUTRIN SR) 

BUPROPION HCL SR TB12 150MG T2 (ZYBAN) 

BUPROPION HCL SR TB12 100MG T2 not 200mg (WELLBUTRIN SR) 

BUPROPION HCL SR TB12 150MG T2 not 200mg (WELLBUTRIN SR) 

BUPROPION HCL XL TB24 150MG T2 (WELLBUTRIN XL) 

BUPROPION HCL XL TB24 300MG T2 (WELLBUTRIN XL) 

MIRTAZAPINE TABS 15MG T2 (REMERON) 



MIRTAZAPINE TABS 7.5MG T2 (REMERON) 

MIRTAZAPINE TBDP 15MG T2 (REMERON) 

MIRTAZAPINE ODT TBDP 30MG T2 (REMERON) 

MIRTAZAPINE ODT TBDP 45MG T2 (REMERON) 

(28:16.08.04) Central Nervous System Agents » Psychotherapeutic Agents » Antipsychotics » Atypical Antipsychotics 


ABILIFY TABS 2MG T4 PA 






ABILIFY SOLN 1MG/ML T4 PA 

ABILIFY DISCMELT TBDP 10MG T4 PA 

ABILIFY DISCMELT TBDP 15MG T4 PA 

Page 39 of 81 


CLOZAPINE TABS 25MG T2 (CLOZARIL) 

CLOZAPINE TABS 100MG T2 (CLOZARIL) 

FANAPT TABS 1MG T4 PA 







INVEGA TB24 3MG T3 



INVEGA SUSTENNA SUSP 234MG/1.5ML T6 

LATUDA TABS 20MG T4 PA 





OLANZAPINE TABS 2.5MG T2 PA (ZYPREXA) 

OLANZAPINE TABS 5MG T2 PA (ZYPREXA) 

OLANZAPINE TABS 7.5MG T2 PA (ZYPREXA) 




OLANZAPINE ODT TBDP 5MG T2 PA 

OLANZAPINE ODT TBDP 10MG T2 PA (ZYPREXA ODT) 

OLANZAPINE ODT TBDP 15MG T2 PA (ZYPREXA ODT) 

QUETIAPINE FUMARATE TABS 25MG T2 (SEROQUEL) 




Page 40 of 81 




RISPERIDONE TABS 0.25MG T2 (RISPERDAL) 

RISPERIDONE TABS 0.5MG T2 (RISPERDAL) 

RISPERIDONE TABS 1MG T2 (RISPERDAL) 




RISPERIDONE SOLN 1MG/ML T2 (RISPERDAL) 

RISPERIDONE M-TAB TBDP 0.5MG T2 (RISPERDAL-M) 

RISPERIDONE M-TAB TBDP 1MG T2 (RISPERDAL-M) 

RISPERIDONE M-TAB TBDP 2MG T2 (RISPERDAL-M) 

SAPHRIS SUBL 5MG T4 PA 

SAPHRIS SUBL 10MG T4 PA 

SEROQUEL XR TB24 50MG T4 PA 





ZIPRASIDONE HCL CAPS 20MG T2 PA (GEODON) 




(28:16.08.08) Central Nervous System Agents » Psychotherapeutic Agents » Antipsychotics » Butyrophenones 


HALOPERIDOL CONC 2MG/ML T2 (HALDOL) 

HALOPERIDOL TABS 2MG T2 (HALDOL) 



HALOPERIDOL TABS 0.5MG T2 (HALDOL) 



Page 41 of 81 


(28:16.08.24) Central Nervous System Agents » Psychotherapeutic Agents » Antipsychotics » Phenothiazines 


CHLORPROMAZINE HCL TABS 25MG T2 (THORAZINE) 





COMPRO SUPP 25MG T2 QL (COMPAZINE SUPPOSITORIES) 

FLUPHENAZINE HCL ELIX 2.5MG/5ML T2 (PROLIXIN) 

FLUPHENAZINE HCL TABS 1MG T2 (PROLIXIN) 

FLUPHENAZINE HCL TABS 2.5MG T2 (PROLIXIN) 



FLUPHENAZINE HCL CONC 5MG/ML T3 (PROLIXIN) 

PERPHENAZINE TABS 2MG T2 (TRILAFON) 



PROCHLORPERAZINE SUPP 25MG T2 QL (COMPAZINE SUPPOSITORIES) 

PROCHLORPERAZINE MALEATE TABS 5MG T2 (COMPAZINE) 

PROCHLORPERAZINE MALEATE TABS 10MG T2 (COMPAZINE) 

THIORIDAZINE HCL TABS 10MG T2 (MELLARIL) 




TRIFLUOPERAZINE HCL TABS 1MG T2 (STELAZINE) 




(28:16.08.32) Central Nervous System Agents » Psychotherapeutic Agents » Antipsychotics » Thioxanthenes 


THIOTHIXENE CAPS 1MG T2 (NAVANE) 


Page 42 of 81 




(28:16.08.92) Central Nervous System Agents » Psychotherapeutic Agents » Antipsychotics » Miscellaneous Antipsychotics 


LOXAPINE SUCCINATE CAPS 5MG T2 (LOXITANE) 




ORAP TABS 1MG T4 

ORAP TABS 2MG T4 

(28:20.04) Central Nervous System Agents » Anorexigenic Agents and Respiratory and CNS Stimulants » Amphetamines 


AMPHETAMINE/DEXTROAMPHETAMINE CP24 2.5MG; 2.5MG; 

2.5MG; 2.5MG 


3.75MG; 3.75MG 

AMPHETAMINE/DEXTROAMPHETAMINE CP24 5MG; 5MG; 5MG; 

5MG 


6.25MG; 6.25MG 


7.5MG; 7.5MG 

T2 QL (ADDERALL XR) 





DEXTROAMPHETAMINE SULFATE TABS 5MG T2 (DEXTROSTAT) 

DEXTROAMPHETAMINE SULFATE TABS 10MG T2 (DEXTROSTAT) 

DEXTROAMPHETAMINE SULFATE ER CP24 10MG T2 (DEXEDRINE CR) 



VYVANSE CAPS 20MG T3 QL 






(28:20.32) Central Nervous System Agents » Anorexigenic Agents and Respiratory and CNS Stimulants » Respiratory and CNS Stimulants 


Page 43 of 81 


METADATE ER TBCR 20MG T2 (RITALIN SR) 

METHYLPHENIDATE HCL TABS 5MG T2 (RITALIN) 



METHYLPHENIDATE HCL CD CPCR 50MG T2 QL (METADATE CD) 






METHYLPHENIDATE HCL ER TBCR 18MG T2 QL (CONCERTA) 




METHYLPHENIDATE HCL ER TBCR 20MG T2 (RITALIN SR) 

METHYLPHENIDATE HCL SR TBCR 20MG T2 (RITALIN SR) 

METHYLPHENIDATE HYDROCHLORIDE SOLN 10MG/5ML T2 (METHYLIN) 

(28:20.80) Central Nervous System Agents » Anorexigenic Agents and Respiratory and CNS Stimulants » Wakefulness-promoting Agents 


MODAFINIL TABS 100MG T2 PA; QL (PROVIGIL) 

MODAFINIL TABS 200MG T2 PA; QL (PROVIGIL) 

(28:24.04) Central Nervous System Agents » Anxiolytics, Sedatives, and Hypnotics » Barbiturates 


PHENOBARBITAL ELIX 20MG/5ML T2 

PHENOBARBITAL TABS 16.2MG T2 




PHENOBARBITAL SOLN 20MG/5ML T2 

(28:24.08) Central Nervous System Agents » Anxiolytics, Sedatives, and Hypnotics » Benzodiazepines 


ALPRAZOLAM TABS 2MG T2 not XR, (XANAX) 

Page 44 of 81 


ALPRAZOLAM TABS 0.5MG T2 not XR, (XANAX) 

ALPRAZOLAM TABS 1MG T2 not XR, (XANAX) 

ALPRAZOLAM TABS 0.25MG T2 not XR, (XANAX) 

CHLORDIAZEPOXIDE HCL CAPS 10MG T2 (LIBRIUM) 



CLORAZEPATE DIPOTASSIUM TABS 3.75MG T2 (TRANXENE) 

CLORAZEPATE DIPOTASSIUM TABS 7.5MG T2 (TRANXENE) 

CLORAZEPATE DIPOTASSIUM TABS 15MG T2 (TRANXENE) 

DIAZEPAM GEL 2.5MG T2 PA; QL (DIASTAT) 

DIAZEPAM GEL 10MG T2 PA; QL (DIASTAT) 

DIAZEPAM GEL 20MG T2 PA; QL (DIASTAT) 

DIAZEPAM SOLN 1MG/ML T2 (VALIUM) 

DIAZEPAM TABS 2MG T2 (VALIUM) 



FLURAZEPAM HCL CAPS 15MG T2 (DALMANE) 

FLURAZEPAM HCL CAPS 30MG T2 (DALMANE) 

LORAZEPAM TABS 2MG T2 (ATIVAN) 

LORAZEPAM TABS 0.5MG T2 (ATIVAN) 

LORAZEPAM TABS 1MG T2 (ATIVAN) 

TEMAZEPAM CAPS 30MG T2 not 7.5mg, (RESTORIL) 

TEMAZEPAM CAPS 15MG T2 not 7.5mg, (RESTORIL) 

(28:24.92) Central Nervous System Agents » Anxiolytics, Sedatives, and Hypnotics » Anxiolytics, Sedatives, & Hypnotics Misc 


BUSPIRONE HCL TABS 5MG T2 (BUSPAR) 




HYDROXYZINE HCL TABS 10MG T2 (ATARAX) 



Page 45 of 81 


HYDROXYZINE HCL SYRP 10MG/5ML T2 (ATARAX) 

HYDROXYZINE HCL SOLN 10MG/5ML T2 (ATARAX) 

HYDROXYZINE PAMOATE CAPS 25MG T2 (VISTARIL) 



MEPROBAMATE TABS 400MG T2 (EQUANIL) 

MEPROBAMATE TABS 200MG T2 (EQUANIL) 

SOMNOTE CAPS 500MG T2 

ZALEPLON CAPS 5MG T2 (SONATA) 

ZALEPLON CAPS 10MG T2 (SONATA) 

ZOLPIDEM TARTRATE TABS 5MG T2 (AMBIEN) 

ZOLPIDEM TARTRATE TABS 10MG T2 (AMBIEN) 

(28:28) Central Nervous System Agents » Antimanic Agents 


LITHIUM CARBONATE CAPS 300MG T1 (ESKALITH) 

LITHIUM CARBONATE CAPS 150MG T2 (ESKALITH) 

LITHIUM CARBONATE ER TBCR 450MG T2 (ESKALITH-CR) 

LITHIUM CARBONATE ER TBCR 300MG T2 (LITHOBID) 

LITHIUM CITRATE SOLN 8MEQ/5ML T2 

(28:32.28) Central Nervous System Agents » Antimigraine Agents » Selective Serotonin Agonists 


RIZATRIPTAN BENZOATE TABS 5MG T2 QL (MAXALT) 

RIZATRIPTAN BENZOATE TABS 10MG T2 QL (MAXALT) 

SUMATRIPTAN SOLN 20MG/ACT T2 QL (IMITREX) 

SUMATRIPTAN SOLN 5MG/ACT T2 QL (IMITREX) 

SUMATRIPTAN SUCCINATE SOLN 4MG/0.5ML T2 QL (IMITREX) 

SUMATRIPTAN SUCCINATE SOLN 6MG/0.5ML T2 QL (IMITREX) 

SUMATRIPTAN SUCCINATE TABS 50MG T2 QL (IMITREX) 



(28:32.92) Central Nervous System Agents » Antimigraine Agents » Antimigraine Agents, Miscellaneous 


Page 46 of 81 


ISOMETHEPTENE/DICHLORALPHENAZONE/ACETAMINOPHEN CAPS 325MG; 100MG; 0; 

65MG 

T2 

(MIDRIN) 

MIGERGOT SUPP 100MG; 2MG T2 QL (CAFERGOT) 

(28:36.04) Central Nervous System Agents » Antiparkinsonian Agents » Adamantanes 


AMANTADINE HCL CAPS 100MG T2 (SYMMETREL) 

AMANTADINE HCL TABS 100MG T2 (SYMMETREL) 

AMANTADINE HCL SYRP 50MG/5ML T2 (SYMMETREL) 

(28:36.08) Central Nervous System Agents » Antiparkinsonian Agents » Anticholinergic Agents 


BENZTROPINE MESYLATE TABS 0.5MG T2 (COGENTIN) 

BENZTROPINE MESYLATE TABS 1MG T2 (COGENTIN) 

BENZTROPINE MESYLATE TABS 2MG T2 (COGENTIN) 

TRIHEXYPHENIDYL HCL ELIX 0.4MG/ML T2 (ARTANE) 

TRIHEXYPHENIDYL HCL TABS 5MG T2 (ARTANE) 

TRIHEXYPHENIDYL HCL TABS 2MG T2 (ARTANE) 

(28:36.12) Central Nervous System Agents » Antiparkinsonian Agents » COMT Inhibitors 


ENTACAPONE TABS 200MG T2 (COMTAN) 

(28:36.16) Central Nervous System Agents » Antiparkinsonian Agents » Dopamine Precursors 


CARBIDOPA/LEVODOPA TABS 10MG; 100MG T2 (SINEMET) 



CARBIDOPA/LEVODOPA ER TBCR 50MG; 200MG T2 (SINEMET CR) 

CARBIDOPA/LEVODOPA ER TBCR 25MG; 100MG T2 (SINEMET CR) 

(28:36.20.04) Central Nervous System Agents » Antiparkinsonian Agents » Dopamine Receptor Agonists » Ergot-derivative Dopamine Receptor Agonists 


BROMOCRIPTINE MESYLATE TABS 2.5MG T2 (PARLODEL) 

BROMOCRIPTINE MESYLATE CAPS 5MG T2 (PARLODEL) 

CABERGOLINE TABS 0.5MG T2 (DOSTINEX) 

Page 47 of 81 


(28:36.20.08) Central Nervous System Agents » Antiparkinsonian Agents » Dopamine Receptor Agonists » Nonergot-derivative Dopamine Receptor Agonists 


PRAMIPEXOLE DIHYDROCHLORIDE TABS 0.125MG T2 (MIRAPEX) 



PRAMIPEXOLE DIHYDROCHLORIDE TABS 1MG T2 (MIRAPEX) 



ROPINIROLE ER TB24 6MG T2 (REQUIP-XL) 





ROPINIROLE HCL TABS 0.25MG T2 (REQUIP) 

ROPINIROLE HCL TABS 1MG T2 (REQUIP) 


ROPINIROLE HCL TABS 0.5MG T2 (REQUIP) 




(28:36.32) Central Nervous System Agents » Antiparkinsonian Agents » Monoamine Oxidase B Inhibitors 


EMSAM PT24 6MG/24HR T4 PA; QL 

EMSAM PT24 9MG/24HR T4 PA; QL 

SELEGILINE HCL TABS 5MG T2 (ELDEPRYL) 

SELEGILINE HCL CAPS 5MG T2 (ELDEPRYL) 

(28:40) Central Nervous System Agents » Fibromyalgia Agents 


SAVELLA TABS 100MG T4 PA 

SAVELLA TABS 12.5MG T4 PA 


Page 48 of 81 



SAVELLA TITRATION PACK MISC T4 PA; QL 

(28:92) Central Nervous System Agents » Central Nervous System Agents, Misc 


ACAMPROSATE CALCIUM DR TBEC 333MG T2 (CAMPRAL) 

INTUNIV TB24 1MG T4 PA 




NAMENDA SOLN 10MG/5ML T3 

NAMENDA TABS 5MG T3 not XR 

NAMENDA TABS 10MG T3 not XR 

NAMENDA TITRATION PAK TABS T3 

RILUTEK TABS 50MG T3 PA 

STRATTERA CAPS 10MG T3 







XENAZINE TABS 25MG T5 PA 

XYREM SOLN 500MG/ML T4 

(36:26) Diagnostic Agents » Diabetes Mellitus 


BAYER BREEZE 2 TEST DISC DISK T2 (TEST STRIPS) 

BAYER CONTOUR BLOOD GLUCOSE TEST STRIPS STRP T2 (TEST STRIPS) 

BAYER CONTOUR NEXT BLOOD GLUCOSE TEST STRP T2 (TEST STRIPS) 

(40:08) Electrolytic, Caloric, and Water Balance » Alkalinizing Agents 


CYTRA-K SOLN 334MG/5ML; 

1100MG/5ML 

T2 

Page 49 of 81 


POTASSIUM CITRATE TBCR 540MG T2 (UROCIT-K) 

POTASSIUM CITRATE TBCR 1080MG T2 (UROCIT-K) 

(40:10) Electrolytic, Caloric, and Water Balance » Ammonia Detoxicants 


BUPHENYL TABS 500MG T4 PA 

ENULOSE SOLN 10GM/15ML T2 QL limit 1pt/31days, (CEPHULAC) 

GENERLAC SOLN 10GM/15ML T2 QL limit 1pt/31days, (CEPHULAC) 

LACTULOSE SOLN 10GM/15ML T2 QL limit 1pt/31days, (CEPHULAC) 

(40:12) Electrolytic, Caloric, and Water Balance » Replacement Preparations 


CALCIUM ACETATE CAPS 667MG T2 (PHOSLO) 

K-EFFERVESCENT TBEF 25MEQ T2 (K-LYTE) 

K-PHOS TABS 500MG T4 

K-VESCENT TBEF 25MEQ T2 (K-LYTE) 

KLOR-CON PACK 20MEQ T2 

KLOR-CON 10 TBCR 10MEQ T2 (K-TAB) 

KLOR-CON 8 TBCR 8MEQ T2 (SLOW-K) 

KLOR-CON/EF TBEF 25MEQ T2 (K-LYTE) 

PHOSPHA 250 NEUTRAL TABS 155MG; 852MG; 

130MG 

POTASSIUM CHLORIDE LIQD 10% T2 

POTASSIUM CHLORIDE LIQD 20% T2 

POTASSIUM CHLORIDE SOLN 10% T2 

POTASSIUM CHLORIDE CR TBCR 10MEQ T2 (K-TAB) 

POTASSIUM CHLORIDE SR TBCR 8MEQ T2 (SLOW-K) 

(40:18.18) Electrolytic, Caloric, and Water Balance » Ion-removing Agents » Potassium-removing Agents 


KIONEX POWD T2 (KAYEXELATE) 

SPS SUSP 15GM/60ML T2 (KAYEXALATE) 

(40:18.19) Electrolytic, Caloric, and Water Balance » Ion-removing Agents » Phosphate-removing Agents 


FOSRENOL CHEW 500MG T4 PA 


T2 

Page 50 of 81 



(40:28.08) Electrolytic, Caloric, and Water Balance » Diuretics » Loop Diuretics 


BUMETANIDE TABS 0.5MG T1 (BUMEX) 

BUMETANIDE TABS 1MG T1 (BUMEX) 

BUMETANIDE TABS 2MG T2 (BUMEX) 

EDECRIN TABS 25MG T3 sulfa allergic pts 

FUROSEMIDE TABS 20MG T1 (LASIX) 



FUROSEMIDE SOLN 10MG/ML T2 (LASIX) 

FUROSEMIDE SOLN 8MG/ML T2 (LASIX) 

(40:28.16) Electrolytic, Caloric, and Water Balance » Diuretics » Potassium-sparing Diuretics 


AMILORIDE HCL TABS 5MG T2 (MIDAMOR) 

TRIAMTERENE/HYDROCHLOROTHIAZIDE CAPS 25MG; 37.5MG T1 (DYAZIDE) 

TRIAMTERENE/HYDROCHLOROTHIAZIDE TABS 25MG; 37.5MG T1 (MAXZIDE) 

TRIAMTERENE/HYDROCHLOROTHIAZIDE TABS 50MG; 75MG T1 (MAXZIDE) 

(40:28.20) Electrolytic, Caloric, and Water Balance » Diuretics » Thiazide Diuretics 


CHLOROTHIAZIDE TABS 250MG T2 (DIURIL) 

CHLOROTHIAZIDE TABS 500MG T2 (DIURIL) 

DIURIL SUSP 250MG/5ML T4 

HYDROCHLOROTHIAZIDE TABS 25MG T1 (HYDRODIURIL) 

HYDROCHLOROTHIAZIDE TABS 50MG T1 (HYDRODIURIL) 

METHYCLOTHIAZIDE TABS 5MG T2 (ENDURON) 

(40:28.24) Electrolytic, Caloric, and Water Balance » Diuretics » Thiazide-like Diuretics 


CHLORTHALIDONE TABS 50MG T1 (HYGROTON) 

CHLORTHALIDONE TABS 25MG T1 (HYGROTON) 

METOLAZONE TABS 2.5MG T2 (ZAROXOLYN) 

METOLAZONE TABS 10MG T2 (ZAROXOLYN) 

Page 51 of 81 


METOLAZONE TABS 5MG T2 (ZAROXOLYN) 

(40:40) Electrolytic, Caloric, and Water Balance » Uricosuric Agents 


PROBENECID TABS 500MG T2 (BENEMID) 

PROBENECID/COLCHICINE TABS 0.5MG; 500MG T2 (COLBENEMID) 

(48:08) Respiratory Tract Agents » Antitussives 


BENZONATATE CAPS 100MG T2 (TESSALON PERLES) 

BENZONATATE CAPS 200MG T2 (TESSALON PERLES) 

CHERATUSSIN AC SYRP 10MG/5ML; 

100MG/5ML 

CHERATUSSIN DAC SOLN 10MG/5ML; 

100MG/5ML; 

30MG/5ML 

GUAIFENESIN DAC SOLN 10MG/5ML; 

100MG/5ML; 

30MG/5ML 

GUAIFENESIN/CODEINE SOLN 10MG/5ML; 

100MG/5ML 

HYDROCODONE BITARTRATE/HOMATROPINE 

METHYLBROMIDE 

SYRP 

1.5MG/5ML; 

5MG/5ML 

T2 QL (ROBITUSSIN AC) 

T2 QL (ROBITUSSIN DAC) 


T2 QL (ROBITUSSIN AC) 

T2 QL (HYCODAN) 

HYDROMET SYRP 1.5MG/5ML; 

5MG/5ML 

MYTUSSIN DAC SOLN 10MG/5ML; 

100MG/5ML; 

30MG/5ML 

PROMETHAZINE VC/CODEINE SYRP 10MG/5ML; 

5MG/5ML; 

6.25MG/5ML 

PROMETHAZINE-DM SYRP 15MG/5ML; 

6.25MG/5ML 

PROMETHAZINE/CODEINE SYRP 10MG/5ML; 

6.25MG/5ML 

(48:10.24) Respiratory Tract Agents » Anti-inflammatory Agents » Leukotriene Modifiers 

T2 QL (HYCODAN) 






MONTELUKAST SODIUM CHEW 4MG T2 (SINGULAIR) 

MONTELUKAST SODIUM CHEW 5MG T2 (SINGULAIR) 

MONTELUKAST SODIUM TABS 10MG T2 (SINGULAIR) 

MONTELUKAST SODIUM PACK 4MG T2 (SINGULAIR) 

Page 52 of 81 


ZAFIRLUKAST TABS 10MG T2 (ACCOLATE) 

ZAFIRLUKAST TABS 20MG T2 (ACCOLATE) 

ZYFLO CR TB12 600MG T4 

(48:10.32) Respiratory Tract Agents » Anti-inflammatory Agents » Mast-cell Stabilizers 


CROMOLYN SODIUM CONC 100MG/5ML T2 (GASTROCROM) 

CROMOLYN SODIUM NEBU 20MG/2ML T2 (INTAL NEB) 

(48:24) Respiratory Tract Agents » Mucolytic Agents 


PULMOZYME SOLN 1MG/ML T6 PA; QL 

(48:92) Respiratory Tract Agents » Respiratory Tract Agents, Miscellaneous 


XOLAIR SOLR 150MG T5 PA 

(52:02) Eye, Ear, Nose & Throat Preparations » Antiallergic Agents 


ALOMIDE SOLN 0.1% T3 QL 

AZELASTINE HCL SOLN 137MCG/SPRAY T2 QL (ASTELIN) 

CROMOLYN SODIUM SOLN 4% T2 QL (CROLOM) 

PATANASE SOLN 0.6% T3 QL 

(52:04.04) Eye, Ear, Nose & Throat Preparations » Anti-infectives » Antibacterials 


AK-POLY-BAC OINT 500UNIT/GM; 

10000UNIT/GM 

BACITRACIN OINT 500UNIT/GM T2 QL (POLYSPORIN OPHTHALMIC) 

BACITRACIN/POLYMYXIN B OINT 500UNIT/GM; 

10000UNIT/GM 

CILOXAN OINT 0.3% T3 QL 

CIPROFLOXACIN HCL SOLN 0.3% T2 QL (CILOXAN) 

ERYTHROMYCIN OINT 5MG/GM T2 QL (ILOTYCIN) 

GENTAK OINT 0.3% T2 QL (GARAMYCIN) 

GENTAMICIN SULFATE SOLN 0.3% T2 QL (GARAMYCIN) 

LEVOFLOXACIN SOLN 0.5% T2 QL (LEVAQUIN) 

MOXEZA SOLN 0.5% T3 QL 

T2 

T2 

QL 

QL 

Page 53 of 81 


NEO-POLYCIN OINT 400UNIT/GM; 

3.5MG/GM; 

10000UNIT/GM 

NEOMYCIN/BACITRACIN/POLYMYXIN OINT 400UNIT/GM; 

5MG/GM; 

10000UNIT/GM 

NEOMYCIN/POLYMYXIN/GRAMICIDIN SOLN 0.025MG/ML; 

1.75MG/ML; 

10000UNIT/ML 

T2 QL (NEOSPORIN OPHTH OINT) 

T2 QL (NEOSPORIN OPHTH OINT) 

T2 QL (NEOSPORIN OPHTH SOLN) 

OFLOXACIN SOLN 0.3% T2 QL (FLOXIN) 

OFLOXACIN SOLN 0.3% T2 QL (OCUFLOX) 

POLYCIN OINT 500UNIT/GM; 

10000UNIT/GM 

POLYMYXIN B SULFATE/TRIMETHOPRIM SULFATE SOLN 10000UNIT/ML; 

0.1% 

POLYMYXIN B SULFATE/TRIMETHOPRIM SULFATE SOLN 10000UNIT/ML; 

0.1% 

T2 

QL 

T2 QL (POLYTRIM) 

T2 QL (POLYTRIM) 

SODIUM SULFACETAMIDE SOLN 10% T2 QL (BLEPH-10) 

SULFACETAMIDE SODIUM OINT 10% T2 QL (BLEPH-10) 

SULFACETAMIDE SODIUM SOLN 10% T2 QL (BLEPH-10) 

TOBRAMYCIN SULFATE SOLN 0.3% T2 QL (TOBREX) 

TOBREX OINT 0.3% T3 QL 

VIGAMOX SOLN 0.5% T3 QL 

(52:04.16) Eye, Ear, Nose & Throat Preparations » Anti-infectives » Antifungals 


NATACYN SUSP 5% T3 QL 

(52:04.20) Eye, Ear, Nose & Throat Preparations » Anti-infectives » Antivirals 


TRIFLURIDINE SOLN 1% T2 QL (VIROPTIC) 

ZIRGAN GEL 0.15% T4 QL 

(52:04.92) Eye, Ear, Nose & Throat Preparations » Anti-infectives » EENT Anti-infectives, Miscellaneous 


CHLORHEXIDINE GLUCONATE SOLN 0.12% T2 QL (PERIDEX) 

(52:08.08) Eye, Ear, Nose & Throat Preparations » Anti-inflammatory Agents » Corticosteroids 


ALREX SUSP 0.2% T4 QL 

BLEPHAMIDE SUSP 0.2%; 10% T3 QL 

Page 54 of 81 


BLEPHAMIDE S.O.P. OINT 0.2%; 10% T3 QL 

CIPRODEX SUSP 0.3%; 0.1% T3 QL 

DEXAMETHASONE SODIUM PHOSPHATE SOLN 0.1% T2 QL (DECADRON OPHTH) 

FLUNISOLIDE SOLN 0.025% T2 QL (NASALIDE) 

FLUOCINOLONE ACETONIDE OIL 0.01% T2 QL (DERMOTIC) 

FLUOROMETHOLONE SUSP 0.1% T2 QL (FML) 

FLUTICASONE PROPIONATE SUSP 50MCG/ACT T2 QL (FLONASE) 

FML OINT 0.1% T3 QL 

FML FORTE SUSP 0.25% T3 QL 

LOTEMAX SUSP 0.5% T4 QL 

LOTEMAX OINT 0.5% T4 QL 

LOTEMAX GEL 0.5% T4 QL 

NEO-POLYCIN HC OINT 400UNIT/GM; 1%; 

3.5MG/GM; 

10000UNIT/GM 

NEOMYCIN/POLYMYXIN/BACITRACIN/HYDROCORTISONE OINT 400UNIT/GM; 1%; 

0.5%; 

10000UNIT/GM 

NEOMYCIN/POLYMYXIN/DEXAMETHASONE OINT 0.1%; 3.5MG/GM; 

10000UNIT/GM 

T2 QL (CORTISPORIN) 


T2 QL (MAXITROL) 

NEOMYCIN/POLYMYXIN/DEXAMETHASONE SUSP 0.1%; 3.5MG/ML; 

10000UNIT/ML 

NEOMYCIN/POLYMYXIN/HC SOLN 1%; 3.5MG/ML; 

10000UNIT/ML 

NEOMYCIN/POLYMYXIN/HYDROCORTISONE SUSP 1%; 3.5MG/ML; 

10000UNIT/ML 

PRED MILD SUSP 0.12% T3 QL 

PRED-G SUSP 0.3%; 1% T3 QL 

PRED-G S.O.P. OINT 0.3%; 0.6% T3 QL 

T2 QL (MAXITROL) 



PREDNISOLONE ACETATE SUSP 1% T2 QL (PRED-FORTE) 

PREDNISOLONE SODIUM PHOSPHATE SOLN 1% T2 QL (INFLAMASE FORTE) 

SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM 

PHOSPHATE 

SOLN 0.23%; 10% T2 QL (VASOCIDIN) 

TOBRADEX OINT 0.1%; 0.3% T3 QL 

TOBRAMYCIN/DEXAMETHASONE SUSP 0.1%; 0.3% T2 QL (TOBRADEX) 

TRIAMCINOLONE ACETONIDE INHA 55MCG/ACT T2 QL (NASACORT) 

Page 55 of 81 


(52:08.20) Eye, Ear, Nose & Throat Preparations » Anti-inflammatory Agents » Nonsteroidal Anti-inflammatory Agents 


DICLOFENAC SODIUM SOLN 0.1% T2 QL not XR, (VOLTAREN) 

FLURBIPROFEN SODIUM SOLN 0.03% T2 QL (OCUFEN) 

ILEVRO SUSP 0.3% T3 QL 

KETOROLAC TROMETHAMINE SOLN 0.4% T2 QL (ACULAR LS) 

KETOROLAC TROMETHAMINE SOLN 0.5% T2 QL (ACULAR) 

NEVANAC SUSP 0.1% T3 QL 

(52:08.92) Eye, Ear, Nose & Throat Preparations » Anti-inflammatory Agents » EENT Anti-inflammatory Agents, Misc 


RESTASIS EMUL 0.05% T3 QL 

(52:16) Eye, Ear, Nose & Throat Preparations » Local Anesthetics 


ANTIPYRINE/BENZOCAINE SOLN 5.4%; 1.4% T2 QL (AURALGAN) 

LIDOCAINE VISCOUS SOLN 2% T2 QL (XYLOCAINE) 

PROPARACAINE HCL SOLN 0.5% T2 QL (ALCAINE) 

(52:24) Eye, Ear, Nose & Throat Preparations » Mydriatics 


ATROPINE SULFATE SOLN 1% T2 QL 

ATROPINE SULFATE OINT 1% T2 QL 

CYCLOGYL SOLN 0.5% T3 QL 

CYCLOPENTOLATE HCL SOLN 1% T2 QL 

ISOPTO HOMATROPINE SOLN 2% T3 QL 

ISOPTO HOMATROPINE SOLN 5% T3 QL 

TROPICAMIDE SOLN 0.5% T2 QL 

TROPICAMIDE SOLN 1% T2 QL 

(52:40.04) Eye, Ear, Nose & Throat Preparations » Antiglaucoma Agents » alpha-Adrenergic Agonists 


BRIMONIDINE TARTRATE SOLN 0.2% T2 QL not P, (ALPHAGAN) 

(52:40.08) Eye, Ear, Nose & Throat Preparations » Antiglaucoma Agents » beta-Adrenergic Blocking Agents 


BETAXOLOL HCL SOLN 0.5% T2 QL (KERLONE) 

Page 56 of 81 


BETOPTIC-S SUSP 0.25% T3 QL 

CARTEOLOL HCL SOLN 1% T2 QL (OCUPRESS) 

LEVOBUNOLOL HCL SOLN 0.5% T1 QL (BETAGAN) 

LEVOBUNOLOL HCL SOLN 0.25% T2 QL (BETAGAN) 

TIMOLOL MALEATE SOLN 0.25% T1 QL not XE, (TIMOPTIC) 

TIMOLOL MALEATE SOLN 0.5% T1 QL not XE, (TIMOPTIC) 

(52:40.12) Eye, Ear, Nose & Throat Preparations » Antiglaucoma Agents » Carbonic Anhydrase Inhibitors 


ACETAZOLAMIDE TABS 250MG T2 (DIAMOX) 

ACETAZOLAMIDE TABS 125MG T2 (DIAMOX) 

ACETAZOLAMIDE ER CP12 500MG T2 (DIAMOX CR) 

DORZOLAMIDE HCL SOLN 2% T2 QL (TRUSOPT) 

DORZOLAMIDE HCL/TIMOLOL MALEATE SOLN 22.3MG/ML; 

6.8MG/ML 

T2 QL (COSOPT) 

METHAZOLAMIDE TABS 50MG T2 (NEPTAZANE) 

METHAZOLAMIDE TABS 25MG T2 (NEPTAZANE) 

(52:40.20) Eye, Ear, Nose & Throat Preparations » Antiglaucoma Agents » Miotics 


ISOPTO CARBACHOL SOLN 1.5% T3 QL 

ISOPTO CARBACHOL SOLN 3% T3 QL 

PHOSPHOLINE IODIDE SOLR 0.125% T3 

PILOCARPINE HCL SOLN 1% T2 QL 



PILOPINE HS GEL 4% T3 QL 

(52:40.28) Eye, Ear, Nose & Throat Preparations » Antiglaucoma Agents » Prostaglandin Analogs 


LATANOPROST SOLN 0.005% T2 QL (XALATAN) 

TRAVATAN Z SOLN 0.004% T3 QL 

(52:92) Eye, Ear, Nose & Throat Preparations » EENT Drugs, Miscellaneous 


ACETIC ACID SOLN 2% T2 QL (VOSOL) 

ACETIC ACID/ALUMINUM ACETATE SOLN 2% T2 QL (DOMBORO OTIC) 

Page 57 of 81 


APRACLONIDINE SOLN 0.5% T2 QL (IOPIDINE) 

(56:08) Gastrointestinal Drugs » Antidiarrhea Agents 


DIPHENOXYLATE/ATROPINE LIQD 0.025MG/5ML; 

2.5MG/5ML 

T2 

(LOMOTIL) 

DIPHENOXYLATE/ATROPINE TABS 0.025MG; 2.5MG T2 (LOMOTIL) 

LOPERAMIDE HCL CAPS 2MG T2 (IMODIUM) 

(56:12) Gastrointestinal Drugs » Cathartics and Laxatives 


PEG-3350 SOLR 236GM; 2.97GM; 

6.74GM; 5.86GM; 

22.74GM 

(56:14) Gastrointestinal Drugs » Cholelitholytic Agents 


URSODIOL CAPS 300MG T2 (ACTIGALL) 

(56:16) Gastrointestinal Drugs » Digestants 


CREON CPEP 15000UNIT; 

3000UNIT; 

9500UNIT 


6000UNIT; 

19000UNIT 


12000UNIT; 

38000UNIT 


24000UNIT; 

76000UNIT 

PANCREAZE CPEP 43750UNIT; 

10500UNIT; 

25000UNIT 


16800UNIT; 

40000UNIT 


21000UNIT; 

37000UNIT 

ZENPEP CPEP 27000UNIT; 

5000UNIT; 

17000UNIT 

T2 

T3 

T3 

T3 

T3 

T3 

T3 

T3 

T4 

QL 

Page 58 of 81 



10000UNIT; 

34000UNIT 


15000UNIT; 

51000UNIT 


20000UNIT; 

68000UNIT 


25000UNIT; 

85000UNIT 

(56:22.08) Gastrointestinal Drugs » Antiemetics » Antihistamines 


TRIMETHOBENZAMIDE HCL CAPS 300MG T2 (TIGAN) 

(56:22.20) Gastrointestinal Drugs » Antiemetics » 5-HT3 Receptor Antagonists 


ONDANSETRON HCL TABS 4MG T2 QL (ZOFRAN) 

ONDANSETRON HCL TABS 8MG T2 QL (ZOFRAN) 

ONDANSETRON HCL SOLN 4MG/5ML T2 QL (ZOFRAN) 

ONDANSETRON ODT TBDP 4MG T2 QL (ZOFRAN) 

ONDANSETRON ODT TBDP 8MG T2 QL (ZOFRAN) 

(56:22.92) Gastrointestinal Drugs » Antiemetics » Antiemetics, Miscellaneous 


DRONABINOL CAPS 2.5MG T2 PA; QL (MARINOL) 

DRONABINOL CAPS 5MG T2 PA; QL (MARINOL) 

DRONABINOL CAPS 10MG T2 PA; QL (MARINOL) 

EMEND CAPS 80MG T6 PA 

EMEND CAPS 40MG T6 PA 

EMEND CAPS T6 PA 

(56:28.12) Gastrointestinal Drugs » Antiulcer Agents and Acid Suppressants » Histamine H2-Antagonists 


CIMETIDINE TABS 300MG T2 (TAGAMET) 



CIMETIDINE HCL SOLN 300MG/5ML T2 (TAGAMET) 

T4 

T4 

T4 

T4 

Page 59 of 81 


RANITIDINE HCL TABS 300MG T1 (ZANTAC) 

RANITIDINE HCL TABS 150MG T1 (ZANTAC) 

RANITIDINE HCL SYRP 75MG/5ML T2 (ZANTAC) 

RANITIDINE HCL SYRP 15MG/ML T2 (ZANTAC) 

(56:28.28) Gastrointestinal Drugs » Antiulcer Agents and Acid Suppressants » Prostaglandins 


MISOPROSTOL TABS 100MCG T2 (CYTOTEC) 

MISOPROSTOL TABS 200MCG T2 (CYTOTEC) 

(56:28.32) Gastrointestinal Drugs » Antiulcer Agents and Acid Suppressants » Protectants 


CARAFATE SUSP 1GM/10ML T3 

SUCRALFATE TABS 1GM T2 (CARAFATE) 

(56:28.36) Gastrointestinal Drugs » Antiulcer Agents and Acid Suppressants » Proton-pump Inhibitors 


LANSOPRAZOLE CPDR 15MG T2 not Solutab,(PREVACID) 

LANSOPRAZOLE CPDR 30MG T2 not Solutab,(PREVACID) 

OMEPRAZOLE CPDR 10MG T2 (PRILOSEC) 

OMEPRAZOLE CPDR 20MG T2 (PRILOSEC) 

PANTOPRAZOLE SODIUM TBEC 20MG T2 (PROTONIX) 

PANTOPRAZOLE SODIUM TBEC 40MG T2 (PROTONIX) 

PROTONIX PACK 40MG T3 

(56:32) Gastrointestinal Drugs » Prokinetic Agents 


METOCLOPRAMIDE HCL TABS 10MG T1 (REGLAN) 

METOCLOPRAMIDE HCL TABS 5MG T2 (REGLAN) 

METOCLOPRAMIDE HCL SOLN 5MG/5ML T2 (REGLAN) 

(56:36) Gastrointestinal Drugs » Anti-inflammatory Agents 


ASACOL TBEC 400MG T3 

ASACOL HD TBEC 800MG T3 

BALSALAZIDE DISODIUM CAPS 750MG T2 (COLAZAL) 

CANASA SUPP 1000MG T3 QL 

Page 60 of 81 


DIPENTUM CAPS 250MG T4 

LOTRONEX TABS 0.5MG T3 PA 

LOTRONEX TABS 1MG T3 PA 

MESALAMINE ENEM 4GM T2 QL (ROWASA) 

(56:92) Gastrointestinal Drugs » GI Drugs, Miscellaneous 


AMITIZA CAPS 8MCG T4 PA 

AMITIZA CAPS 24MCG T4 PA 

LINZESS CAPS 145MCG T3 PA 

LINZESS CAPS 290MCG T3 PA 

(64:00) Heavy Metal Antagonists 


CHEMET CAPS 100MG T3 

CUPRIMINE CAPS 250MG T3 

EXJADE TBSO 125MG T5 PA 



(68:04) Hormones and Synthetic Substitutes » Adrenals 


ASMANEX 120 METERED DOSES AEPB 220MCG/INH T3 QL 




BUDESONIDE CP24 3MG T2 PA (ENTOCORT EC) 

BUDESONIDE SUSP 0.25MG/2ML T2 PA; QL (PULMICORT RESPULES) 

BUDESONIDE SUSP 0.5MG/2ML T2 PA; QL (PULMICORT RESPULES) 

CORTISONE ACETATE TABS 25MG T2 (CORTONE) 

DEXAMETHASONE SOLN 0.5MG/5ML T2 (DECADRON) 

DEXAMETHASONE TABS 0.5MG T2 (DECADRON) 


DEXAMETHASONE TABS 1MG T2 (DECADRON) 


Page 61 of 81 




DEXAMETHASONE ELIX 0.5MG/5ML T2 (DECADRON) 

DEXAMETHASONE INTENSOL CONC 1MG/ML T2 QL (DECADRON) 

DULERA AERO 5MCG/ACT; 

200MCG/ACT 

DULERA AERO 5MCG/ACT; 

100MCG/ACT 

ENTOCORT EC CP24 3MG T4 PA (ENTOCORT EC) 

FLOVENT DISKUS AEPB 50MCG/BLIST T3 QL 



FLOVENT HFA AERO 44MCG/ACT T3 QL 



FLUDROCORTISONE ACETATE TABS 0.1MG T2 (FLORINEF) 

HYDROCORTISONE TABS 20MG T2 (CORTEF) 



METHYLPREDNISOLONE TABS 4MG T2 (MEDROL) 

METHYLPREDNISOLONE TABS 16MG T2 (MEDROL) 

METHYLPREDNISOLONE DOSE PACK TABS 4MG T2 (MEDROL) 

PREDNISOLONE SOLN 15MG/5ML T2 (PRELONE) 

PREDNISOLONE SODIUM PHOSPHATE SOLN 5MG/5ML T2 (ORAPRED) 

PREDNISONE TABS 10MG T2 (DELTASONE) 



PREDNISONE SOLN 5MG/5ML T2 (DELTASONE) 



PREDNISONE TABS 2.5MG T2 (DELTASONE) 

PULMICORT SUSP 1MG/2ML T3 PA; QL 

QVAR AERS 40MCG/ACT T4 QL 

T4 

T4 

QL 

QL 

Page 62 of 81 


QVAR AERS 80MCG/ACT T4 QL 

SYMBICORT AERO 160MCG/ACT; 

4.5MCG/ACT 

SYMBICORT AERO 80MCG/ACT; 

4.5MCG/ACT 

(68:08) Hormones and Synthetic Substitutes » Androgens 


ANADROL-50 TABS 50MG T4 PA 

ANDROGEL GEL 50MG/5GM T4 QL 

ANDROGEL GEL 40.5MG/2.5GM T4 QL 

ANDROXY TABS 10MG T2 (HALOTESTIN) 

DANAZOL CAPS 100MG T2 (DANOCRINE) 



OXANDRIN TABS 2.5MG T3 PA (OXANDRIN) 

OXANDROLONE TABS 2.5MG T2 PA (OXANDRIN) 

TESTIM GEL 1% T4 QL 

(68:12) Hormones and Synthetic Substitutes » Contraceptives 


APRI TABS 0.15MG; 30MCG T2 (DESOGEN) 

AVIANE TABS 20MCG; 0.1MG T2 (ALESSE) 

CAMILA TABS 0.35MG T2 (MICRONOR) 

CRYSELLE-28 TABS 30MCG; 0.3MG T2 (LO-OVRAL) 

CYCLAFEM 1/35 TABS 35MCG; 1MG T2 not 7/7/7, (ORTHO NOVUM) 

ENPRESSE-28 TABS T2 (TRIPHASIL) 

ERRIN TABS 0.35MG T2 (MICRONOR) 

GIANVI TABS 3MG; 0.02MG T2 (YAZ) 

GILDESS FE 1.5/30 TABS 30MCG; 75MG; 

1.5MG 

T4 

T4 

T2 

QL 

QL 

(LOESTRIN-FE) 

GILDESS FE 1/20 TABS 20MCG; 75MG; 1MG T2 (LOESTRIN-FE) 

JOLIVETTE TABS 0.35MG T2 (MICRONOR) 

JUNEL FE 1.5/30 TABS 30MCG; 75MG; 

1.5MG 

T2 

(LOESTRIN-FE) 

Page 63 of 81 


JUNEL FE 1/20 TABS 20MCG; 75MG; 1MG T2 (LOESTRIN-FE) 

KELNOR 1/35 TABS 35MCG; 1MG T2 (DEMULEN) 

LEVORA 0.15/30-28 TABS 30MCG; 0.15MG T2 (NORDETTE) 

LOW-OGESTREL TABS 30MCG; 0.3MG T2 (LO-OVRAL) 

LUTERA TABS 20MCG; 0.1MG T2 (ALESSE) 

MICROGESTIN FE TABS 20MCG; 75MG; 1MG T2 (LOESTRIN-FE) 

MICROGESTIN FE 1.5/30 TABS 30MCG; 75MG; 

1.5MG 

T2 

(LOESTRIN-FE) 

MONONESSA TABS 35MCG; 0.25MG T2 not LO, (ORTHO CYCLEN) 

MYZILRA TABS T2 (TRIPHASIL) 

NECON 0.5/35-28 TABS 35MCG; 0.5MG T2 not 7/7/7, (ORTHO NOVUM) 

NECON 1/35 TABS 35MCG; 1MG T2 not 7/7/7, (ORTHO NOVUM) 

NECON 1/50-28 TABS 50MCG; 1MG T2 not 7/7/7, (ORTHO NOVUM) 

NECON 10/11-28 TABS 35MCG T2 not 7/7/7, (ORTHO NOVUM) 

NORA-BE TABS 0.35MG T2 (MICRONOR) 

NORETHINDRONE TABS 0.35MG T2 (MICRONOR) 

NORTREL 0.5/35 (28) TABS 35MCG; 0.5MG T2 not 7/7/7, (ORTHO NOVUM) 

NORTREL 1/35 TABS 35MCG; 1MG T2 not 7/7/7, (ORTHO NOVUM) 

OGESTREL TABS 50MCG; 0.5MG T2 (OVRAL) 

ORSYTHIA TABS 20MCG; 0.1MG T2 (ALESSE) 

PORTIA-28 TABS 0.03MG; 0.15MG T2 (NORDETTE) 

PREVIFEM TABS 35MCG; 0.25MG T2 not LO, (ORTHO CYCLEN) 

RECLIPSEN TABS 0.15MG; 30MCG T2 (DESOGEN) 

SOLIA TABS 0.15MG; 30MCG T2 (DESOGEN) 

SPRINTEC 28 TABS 35MCG; 0.25MG T2 not LO, (ORTHO CYCLEN) 

SRONYX TABS 20MCG; 0.1MG T2 (ALESSE) 

TRI-SPRINTEC TABS T2 not LO, (ORTHO TRICYCLEN) 

TRIVORA-28 TABS T2 (TRIPHASIL) 

ZOVIA 1/35E TABS 35MCG; 1MG T2 (DEMULEN) 

ZOVIA 1/50E TABS 50MCG; 1MG T2 (DEMULEN) 

(68:16.04) Hormones and Synthetic Substitutes » Estrogens and Antiestrogens » Estrogens 

Page 64 of 81 



EEMT TABS 1.25MG; 2.5MG T2 (ESTRATEST) 

ESTERIFIED ESTROGENS/METHYLTESTOSTERONE TABS 1.25MG; 2.5MG T2 (ESTRATEST) 

ESTERIFIED ESTROGENS/METHYLTESTOSTERONE HS TABS 0.625MG; 1.25MG T2 (ESTRATEST HS) 

ESTRACE CREA 0.1MG/GM T4 QL 

ESTRADIOL TABS 0.5MG T1 (ESTRACE) 

ESTRADIOL TABS 1MG T1 (ESTRACE) 

ESTRADIOL TABS 2MG T1 (ESTRACE) 

ESTRADIOL PTWK 0.025MG/24HR T2 not PRO, (CLIMARA) 




ESTRADIOL PTWK 37.5MCG/24HR T2 not PRO, (CLIMARA) 


ESTROPIPATE TABS 0.75MG T2 (OGEN) 

ESTROPIPATE TABS 1.5MG T2 (OGEN) 

ESTROPIPATE TABS 3MG T2 (OGEN) 

MENEST TABS 0.3MG T4 PA 




PREMARIN TABS 0.3MG T3 





PREMARIN CREA 0.625MG/GM T3 QL 

PREMPHASE TABS 0.625MG; 5MG T3 

PREMPRO TABS 0.625MG; 5MG T3 

PREMPRO TABS 0.3MG; 1.5MG T3 


Page 65 of 81 



(68:16.12) Hormones and Synthetic Substitutes » Estrogens and Antiestrogens » Estrogen Agonist-Antagonists 


EVISTA TABS 60MG T3 

(68:18) Hormones and Synthetic Substitutes » Gonadotropins 


SYNAREL SOLN 2MG/ML T4 PA; QL 

(68:20.02) Hormones and Synthetic Substitutes » Antidiabetic Agents » Alpha-Glucosidase Inhibitors 


ACARBOSE TABS 50MG T2 (PRECOSE) 



(68:20.03) Hormones and Synthetic Substitutes » Antidiabetic Agents » Amylinomimetics 


SYMLINPEN 120 SOLN 2700MCG/2.7ML T3 PA 

SYMLINPEN 60 SOLN 1500MCG/1.5ML T3 PA 

(68:20.04) Hormones and Synthetic Substitutes » Antidiabetic Agents » Biguanides 


METFORMIN HCL TABS 500MG T1 (GLUCOPHAGE) 



METFORMIN HCL ER TB24 500MG T2 (GLUCOPHAGE) 

METFORMIN HCL ER TB24 750MG T2 (GLUCOPHAGE) 

(68:20.05) Hormones and Synthetic Substitutes » Antidiabetic Agents » Dipeptidyl Peptidase-4 (DPP-4) Inhibitors 


JANUVIA TABS 50MG T4 PA; QL 



ONGLYZA TABS 2.5MG T4 PA; QL 

ONGLYZA TABS 5MG T4 PA; QL 

TRADJENTA TABS 5MG T3 ST 

(68:20.06) Hormones and Synthetic Substitutes » Antidiabetic Agents » Incretin Mimetics 

Page 66 of 81 



BYDUREON SUSR 2MG T4 PA; QL 

BYETTA SOLN 5MCG/0.02ML T3 PA; QL 

BYETTA SOLN 10MCG/0.04ML T3 PA; QL 

(68:20.08) Hormones and Synthetic Substitutes » Antidiabetic Agents » Insulins 


HUMULIN R U-500 (CONCENTRATED) SOLN 500UNIT/ML T3 QL 

LANTUS SOLN 100UNIT/ML T4 QL no Pens 

LEVEMIR SOLN 100UNIT/ML T3 QL no Pens 

NOVOLIN 70/30 SUSP 30UNIT/ML; 

70UNIT/ML 

T3 QL no Pens 

NOVOLIN N SUSP 100UNIT/ML T3 QL no Pens 

NOVOLIN R SOLN 100UNIT/ML T3 QL no Pens 

NOVOLOG SOLN 100UNIT/ML T3 QL no Pens 

NOVOLOG MIX 70/30 SUSP 30UNIT/ML; 

70UNIT/ML 

T3 QL no Pens 

(68:20.16) Hormones and Synthetic Substitutes » Antidiabetic Agents » Meglitinides 


NATEGLINIDE TABS 60MG T2 (STARLIX) 

NATEGLINIDE TABS 120MG T2 (STARLIX) 

(68:20.20) Hormones and Synthetic Substitutes » Antidiabetic Agents » Sulfonylureas 


CHLORPROPAMIDE TABS 100MG T2 (DIABINESE) 

CHLORPROPAMIDE TABS 250MG T2 (DIABINESE) 

GLIMEPIRIDE TABS 1MG T1 (AMARYL) 



GLIPIZIDE TABS 5MG T1 (GLUCOTROL) 

GLIPIZIDE TABS 10MG T1 (GLUCOTROL) 

GLYBURIDE TABS 2.5MG T1 (DIABETA) 

GLYBURIDE TABS 5MG T1 (DIABETA) 

GLYBURIDE TABS 1.25MG T2 (DIABETA) 

GLYBURIDE MICRONIZED TABS 3MG T2 (MICRONASE) 

Page 67 of 81 


TOLAZAMIDE TABS 250MG T2 (TOLINASE) 

TOLAZAMIDE TABS 500MG T2 (TOLINASE) 

TOLBUTAMIDE TABS 500MG T2 (TOLINASE) 

(68:20.28) Hormones and Synthetic Substitutes » Antidiabetic Agents » Thiazolidinediones 


PIOGLITAZONE HCL TABS 45MG T2 ST (ACTOS) 



(68:22.12) Hormones and Synthetic Substitutes » Antihypoglycemic Agents » Glycogenolytic Agents 


GLUCAGON EMERGENCY KIT KIT 1MG T3 QL 

(68:24) Hormones and Synthetic Substitutes » Parathyroid 


CALCITONIN-SALMON SOLN 200UNIT/ACT T2 QL (MIACALCIN) 

FORTEO SOLN 600MCG/2.4ML T5 PA 

(68:28) Hormones and Synthetic Substitutes » Pituitary 


DESMOPRESSIN ACETATE TABS 0.1MG T2 (DDAVP) 

DESMOPRESSIN ACETATE TABS 0.2MG T2 (DDAVP) 

DESMOPRESSIN ACETATE SOLN 0.01% T2 QL (DDAVP) 

(68:30.04) Hormones and Synthetic Substitutes » Somatotropin Agonists and Antagonists » Somatotropin Agonists 


OMNITROPE SOLN 5MG/1.5ML T6 PA 

OMNITROPE SOLN 10MG/1.5ML T6 PA 

OMNITROPE SOLR 5.8MG T6 PA 

(68:30.08) Hormones and Synthetic Substitutes » Somatotropin Agonists and Antagonists » Somatotropin Antagonists 


SOMAVERT SOLR 10MG T5 PA 

(68:32) Hormones and Synthetic Substitutes » Progestins 


MEDROXYPROGESTERONE ACETATE TABS 10MG T1 (PROVERA) 

MEDROXYPROGESTERONE ACETATE TABS 5MG T1 (PROVERA) 

Page 68 of 81 


MEDROXYPROGESTERONE ACETATE TABS 2.5MG T1 (PROVERA) 

NORETHINDRONE ACETATE TABS 5MG T2 (AYGESTIN) 

(68:36.04) Hormones and Synthetic Substitutes » Thyroid and Antithyroid Agents » Thyroid Agents 


LEVOTHYROXINE SODIUM TABS 25MCG T1 (SYNTHROID, LEVOXYL, 

LEVOTHROID, UNITHROID 























LIOTHYRONINE SODIUM TABS 5MCG T2 (CYTOMEL) 



(68:36.08) Hormones and Synthetic Substitutes » Thyroid and Antithyroid Agents » Antithyroid Agents 


METHIMAZOLE TABS 5MG T2 (TAPAZOLE) 

METHIMAZOLE TABS 10MG T2 (TAPAZOLE) 

PROPYLTHIOURACIL TABS 50MG T2 (PTU) 

(76:00) Oxytocics 


METHYLERGONOVINE MALEATE TABS 0.2MG T2 (METHERGINE) 

Page 69 of 81 


(84:04.04) Skin and Mucous Membrane Preparations » Anti-infectives » Antibacterials 


CLINDAMYCIN PHOSPHATE CREA 2% T2 QL Vaginal only (CLEOCIN) 

ERYTHROMYCIN SOLN 2% T2 QL (A/T/S) 

GENTAMICIN SULFATE OINT 0.1% T2 QL (GARAMYCIN) 

GENTAMICIN SULFATE CREA 0.1% T2 QL (GARAMYCIN) 

METRONIDAZOLE GEL 1% T2 QL 

METRONIDAZOLE CREA 0.75% T2 QL (METROCREAM) 

METRONIDAZOLE GEL 0.75% T2 QL (METROGEL) 

METRONIDAZOLE LOTN 0.75% T2 QL (METROLOTION) 

METRONIDAZOLE VAGINAL GEL 0.75% T2 QL (METROGEL) 

MUPIROCIN OINT 2% T2 QL (BACTROBAN) 

MUPIROCIN CREA 2% T2 QL (BACTROBAN) 

VANDAZOLE GEL 0.75% T2 QL (METROGEL) 

VITAZOL CREA 0.75% T2 QL (METROCREAM) 

(84:04.06) Skin and Mucous Membrane Preparations » Anti-infectives » Antivirals 


ACYCLOVIR OINT 5% T2 QL not crm 

DENAVIR CREA 1% T4 QL 

(84:04.08.08) Skin and Mucous Membrane Preparations » Anti-infectives » Antifungals » Azoles 


CLOTRIMAZOLE LOZG 10MG T2 QL (MYCELEX TROCHES) 

CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREA 0.05%; 1% T2 QL (LOTRISONE) 

CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE LOTN 0.05%; 1% T2 QL (LOTRISONE) 

CLOTRIMAZOLE/BETAMETHASONE DIPROPIONATE CREA 0.05%; 1% T2 QL (LOTRISONE) 

ECONAZOLE NITRATE CREA 1% T2 QL (SPECTAZOLE) 

KETOCONAZOLE CREA 2% T2 QL not shampoo, (NIZORAL) 

OXISTAT LOTN 1% T3 QL 

OXISTAT CREA 1% T3 QL 

TERCONAZOLE CREA 0.4% T2 QL (TERAZOL) 

TERCONAZOLE CREA 0.8% T2 QL (TERAZOL) 

Page 70 of 81 


TERCONAZOLE SUPP 80MG T2 QL (TERAZOL) 

ZAZOLE CREA 0.4% T2 QL (TERAZOL) 

(84:04.08.20) Skin and Mucous Membrane Preparations » Anti-infectives » Antifungals » Hydroxypyridones 


CICLOPIROX GEL 0.77% T2 QL not Shampoo, (LOPROX) 

CICLOPIROX SUSP 0.77% T2 QL not Shampoo, (LOPROX) 

CICLOPIROX NAIL LACQUER SOLN 8% T2 QL (PENLAC) 

CICLOPIROX OLAMINE CREA 0.77% T2 QL not Shampoo, (LOPROX) 

(84:04.08.28) Skin and Mucous Membrane Preparations » Anti-infectives » Antifungals » Polyenes 


NYSTATIN OINT 100000UNIT/GM T2 QL not PWD 

NYSTATIN CREA 100000UNIT/GM T2 QL not PWD 

(84:04.12) Skin and Mucous Membrane Preparations » Anti-infectives » Scabicides and Pediculicides 


MALATHION LOTN 0.5% T2 QL (OVIDE) 

PERMETHRIN CREA 5% T2 QL (ELIMITE) 

(84:04.92) Skin and Mucous Membrane Preparations » Anti-infectives » Local Anti-infectives, Miscellaneous 


SELENIUM SULFIDE LOTN 2.5% T2 QL (SELSUN) 

SSD CREA 1% T2 QL (SILVADENE) 

(84:06) Skin and Mucous Membrane Preparations » Anti-inflammatory Agents 


ANUCORT-HC SUPP 25MG T2 QL (ANUSOL HC) 

BETAMETHASONE DIPROPIONATE CREA 0.05% T2 QL (DIPROSONE) 

BETAMETHASONE DIPROPIONATE OINT 0.05% T2 QL (DIPROSONE) 

BETAMETHASONE DIPROPIONATE LOTN 0.05% T2 QL (DIPROSONE) 

BETAMETHASONE VALERATE OINT 0.1% T2 QL (VALISONE) 

BETAMETHASONE VALERATE CREA 0.1% T2 QL (VALISONE) 

BETAMETHASONE VALERATE LOTN 0.1% T2 QL (VALISONE) 

CLOBETASOL PROPIONATE OINT 0.05% T2 QL (TEMOVATE) 

CLOBETASOL PROPIONATE SOLN 0.05% T2 QL (TEMOVATE) 

CLOBETASOL PROPIONATE GEL 0.05% T2 QL (TEMOVATE) 

Page 71 of 81 


CLOBETASOL PROPIONATE CREA 0.05% T2 QL (TEMOVATE) 

CLOBETASOL PROPIONATE LOTN 0.05% T2 QL (TEMOVATE) 

CLOBETASOL PROPIONATE EMOLLIENT CREA 0.05% T2 QL (TEMOVATE) 

COLOCORT ENEM 100MG/60ML T2 QL (CORTENEMA) 

CORDRAN TAPE TAPE 4MCG/SQCM T3 QL 

CORDRAN TAPE TAPE 4MCG/SQCM T3 QL 

CORTISPORIN OINT 400UNIT/GM; 1%; 

0.5%; 

5000UNIT/GM 

CORTISPORIN CREA 0.5%; 0.5%; 

10000UNIT/GM 

DESONIDE LOTN 0.05% T2 QL (TRIDESILON) 

DESONIDE CREA 0.05% T2 QL (TRIDESILON) 

DESONIDE OINT 0.05% T2 QL (TRIDESILON) 

DESOXIMETASONE CREA 0.25% T2 QL not spray, (TOPICORT) 

DESOXIMETASONE GEL 0.05% T2 QL not spray, (TOPICORT) 

DESOXIMETASONE OINT 0.25% T2 QL not spray, (TOPICORT) 

DESOXIMETASONE CREA 0.05% T2 QL not spray, (TOPICORT) 

DESOXIMETASONE OINT 0.05% T2 QL not spray, (TOPICORT) 

DIFLORASONE DIACETATE OINT 0.05% T2 QL (MAXIFLOR) 

DIFLORASONE DIACETATE CREA 0.05% T2 QL (MAXIFLOR) 

FLUOCINOLONE ACETONIDE CREA 0.01% T2 QL (SYNALAR) 

FLUOCINOLONE ACETONIDE SOLN 0.01% T2 QL (SYNALAR) 

FLUOCINOLONE ACETONIDE CREA 0.025% T2 QL (SYNALAR) 

FLUOCINOLONE ACETONIDE OINT 0.025% T2 QL (SYNALAR) 

FLUOCINONIDE CREA 0.05% T2 QL (LIDEX) 

FLUOCINONIDE OINT 0.05% T2 QL (LIDEX) 

FLUOCINONIDE GEL 0.05% T2 QL (LIDEX) 

FLUOCINONIDE SOLN 0.05% T2 QL (LIDEX) 

FLUOCINONIDE-E CREA 0.05% T2 QL (LIDEX-E) 

FLUTICASONE PROPIONATE LOTN 0.05% T2 QL (CUTIVATE) 

FLUTICASONE PROPIONATE OINT 0.005% T2 QL (CUTIVATE) 

FLUTICASONE PROPIONATE CREA 0.05% T2 QL (CUTIVATE) 

T3 

T3 

QL 

QL 

Page 72 of 81 


HYDROCORTISONE ENEM 100MG/60ML T2 QL (CORTENEMA) 

HYDROCORTISONE CREA 2.5% T2 QL (HYTONE) 

HYDROCORTISONE OINT 2.5% T2 QL (HYTONE) 

HYDROCORTISONE LOTN 2.5% T2 QL (HYTONE) 

HYDROCORTISONE ACETATE SUPP 25MG T2 QL (ANUSOL HC) 

HYDROCORTISONE BUTYRATE CREA 0.1% T2 QL (LOCOID) 

HYDROCORTISONE BUTYRATE SOLN 0.1% T2 QL (LOCOID) 

HYDROCORTISONE BUTYRATE OINT 0.1% T2 QL (LOCOID) 

MOMETASONE FUROATE SOLN 0.1% T2 QL (ELOCON) 

MOMETASONE FUROATE CREA 0.1% T2 QL (ELOCON) 

MOMETASONE FUROATE OINT 0.1% T2 QL (ELOCON) 

NYSTATIN/TRIAMCINOLONE CREA 100000UNIT/GM; 

1MG/GM 

NYSTATIN/TRIAMCINOLONE OINT 100000UNIT/GM; 

0.1% 

T2 QL not PWD, (MYCOLOG) 

T2 QL not PWD, (MYCOLOG) 

PROCTOZONE-HC CREA 2.5% T2 QL (ANUSOL HC) 

TRIAMCINOLONE ACETONIDE CREA 0.5% T2 QL (ARISTOCORT) 



TRIAMCINOLONE ACETONIDE OINT 0.025% T2 QL (ARISTOCORT) 


TRIAMCINOLONE ACETONIDE LOTN 0.025% T2 QL (ARISTOCORT) 

TRIAMCINOLONE ACETONIDE LOTN 0.1% T2 QL (ARISTOCORT) 


TRIAMCINOLONE ACETONIDE PSTE 0.1% T2 QL (KENALOG ORABASE) 

TRIAMCINOLONE IN ORABASE PSTE 0.1% T2 QL (KENALOG ORABASE) 

(84:08) Skin and Mucous Membrane Preparations » Antipruritics and Local Anesthetics 


LIDOCAINE PTCH 5% T2 PA (LIDODERM) 

LIDOCAINE OINT 5% T2 QL oint only, (XYLOCAINE) 

LIDOCAINE/PRILOCAINE CREA 2.5%; 2.5% T2 QL (EMLA) 

PHENAZOPYRIDINE HCL TABS 200MG T2 not 100mg, (PYRIDIUM) 

PRUDOXIN CREA 5% T2 QL 

Page 73 of 81 


(84:16) Skin and Mucous Membrane Preparations » Cell Stimulants and Proliferants 


TRETINOIN CREA 0.1% T2 PA; QL (RETIN-A) 



TRETINOIN GEL 0.025% T2 PA; QL (RETIN-A) 

TRETINOIN GEL 0.01% T2 PA; QL (RETIN-A) 

(84:28) Skin and Mucous Membrane Preparations » Keratolytic Agents 


X-VIATE LOTN 40% T2 QL 

X-VIATE CREA 40% T2 QL 

(84:50.06) Skin and Mucous Membrane Preparations » Depigmenting and Pigmenting Agents » Pigmenting Agents 


OXSORALEN LOTN 1% T3 QL 

OXSORALEN ULTRA CAPS 10MG T3 

(84:92) Skin and Mucous Membrane Preparations » Skin and Mucous Membrane Agents, Misc 


ACITRETIN CAPS 10MG T5 PA (SORIATANE) 

ACITRETIN CAPS 25MG T5 PA (SORIATANE) 

ACITRETIN CAPS 17.5MG T5 PA (SORIATANE) 

CALCIPOTRIENE SOLN 0.005% T2 QL (DOVONEX) 

CALCIPOTRIENE CREA 0.005% T2 QL (DOVONEX) 

CALCIPOTRIENE OINT 0.005% T2 QL (DOVONEX) 

DICLOFENAC SODIUM GEL 3% T2 PA; QL 

ELIDEL CREA 1% T4 QL 

FLUOROURACIL SOLN 2% T2 QL (EFUDEX) 

FLUOROURACIL SOLN 5% T2 QL (EFUDEX) 

FLUOROURACIL CREA 5% T2 QL (EFUDEX) 

IMIQUIMOD CREA 5% T2 QL (ALDARA) 

PANRETIN GEL 0.1% T3 

PODOFILOX SOLN 0.5% T2 QL (CONDYLOX) 

SANTYL OINT 250UNIT/GM T4 QL 

Page 74 of 81 


TARGRETIN GEL 1% T5 QL 

TAZORAC GEL 0.1% T4 PA; QL 

TAZORAC CREA 0.05% T4 PA; QL 

TAZORAC CREA 0.1% T4 PA; QL 

VASOLEX OINT 788MG/GM; 

87MG/GM; 

90UNIT/GM 

(86:12.04) Smooth Muscle Relaxants » Genitourinary Smooth Muscle Relaxants » Antimuscarinics 


FLAVOXATE HCL TABS 100MG T2 (URISPAS) 

OXYBUTYNIN CHLORIDE SYRP 5MG/5ML T2 (DITROPAN) 

OXYBUTYNIN CHLORIDE TABS 5MG T2 (DITROPAN) 

TOVIAZ TB24 4MG T3 

TOVIAZ TB24 8MG T3 

(86:16) Smooth Muscle Relaxants » Respiratory Smooth Muscle Relaxants 


THEOPHYLLINE CR TB12 200MG T2 (THEO-DUR) 

THEOPHYLLINE CR TB12 100MG T2 (THEO-DUR) 

THEOPHYLLINE ER TB12 450MG T2 (THEO-DUR) 

THEOPHYLLINE ER TB12 300MG T2 (THEO-DUR) 

(88:08) Vitamins » Vitamin B Complex 


FOLIC ACID TABS 1MG T2 

(88:16) Vitamins » Vitamin D 


CALCITRIOL CAPS 0.25MCG T2 (ROCALTROL) 

CALCITRIOL SOLN 1MCG/ML T2 (ROCALTROL) 

CALCITRIOL CAPS 0.5MCG T2 (ROCALTROL) 

PARICALCITOL CAPS 1MCG T2 PA 

PARICALCITOL CAPS 2MCG T2 PA 

PARICALCITOL CAPS 4MCG T2 PA (ZEMPLAR) 

VITAMIN D CAPS 50000UNIT T2 

(88:24) Vitamins » Vitamin K Activity 

T2 

QL 

Page 75 of 81 



MEPHYTON TABS 5MG T3 

(88:28) Vitamins » Multivitamin Preparations 


MULTI-VIT/FLUORIDE SOLN 35MG/ML; 

400UNIT/ML; 

2MCG/ML; 8MG/ML; 

0.4MG/ML; 

0.6MG/ML; 

0.25MG/ML; 

0.5MG/ML; 

5UNIT/ML; 

1500UNIT/ML 

T2 

QL 

MULTI-VIT/FLUORIDE SOLN 35MG/ML; 

400UNIT/ML; 

2MCG/ML; 8MG/ML; 

0.4MG/ML; 

0.6MG/ML; 

0.5MG/ML; 

0.5MG/ML; 

5UNIT/ML; 

1500UNIT/ML 

T2 

QL 

MULTI-VIT/IRON/FLUORIDE SOLN 35MG/ML; 

400UNIT/ML; 

10MG/ML; 8MG/ML; 

0.4MG/ML; 

0.6MG/ML; 

0.25MG/ML; 

0.5MG/ML; 

5UNIT/ML; 

1500UNIT/ML 

T2 

QL 

PRENATAL PLUS TABS 120MG; 0; 200MG; 

400UNIT; 2MG; 

12MCG; 27MG; 

1MG; 20MG; 10MG; 

3MG; 1.84MG; 

22MG; 4000UNIT; 

25MG 

T2 

(STUARTNATAL PLUS) 

Page 76 of 81 


TRI-VIT/FLUORIDE SOLN 35MG/ML; 

400UNIT/ML; 

0.25MG/ML; 

1500UNIT/ML 

TRI-VIT/FLUORIDE SOLN 35MG/ML; 

400UNIT/ML; 

0.5MG/ML; 

1500UNIT/ML 

TRI-VIT/FLUORIDE/IRON SOLN 35MG/ML; 

0.25MG/ML; 

10MG/ML; 

1500UNIT/ML; 

400UNIT/ML 

TRINATE TABS 120MG; 3000UNIT; 

200MG; 400UNIT; 

2MG; 12MCG; 

28MG; 1MG; 25MG; 

20MG; 25MG; 4MG; 

1.8MG; 22MG; 

25MG 

T2 QL (TRI-VI-FLOR) 

T2 QL (TRI-VI-FLOR) 

T2 QL (TRI-VI-FLOR W/IRON) 

T2 

(STUARTNATAL PLUS-3) 

(92:04) Miscellaneous Therapeutic Agents » Alcohol Deterrents 


DISULFIRAM TABS 250MG T2 (ANTABUSE) 

DISULFIRAM TABS 500MG T2 (ANTABUSE) 

(92:08) Miscellaneous Therapeutic Agents » 5-alpha-Reductase Inhibitors 


AVODART CAPS 0.5MG T3 

FINASTERIDE TABS 5MG T2 (PROSCAR) 

(92:12) Miscellaneous Therapeutic Agents » Antidotes 


ACETYLCYSTEINE SOLN 10% T2 (MUCOMYST) 

ACETYLCYSTEINE SOLN 20% T2 (MUCOMYST) 

LEUCOVORIN CALCIUM TABS 5MG T2 (WELLCOVORIN) 



(92:16) Miscellaneous Therapeutic Agents » Antigout Agents 


Page 77 of 81 


ALLOPURINOL TABS 100MG T1 (ZYLOPRIM) 

ALLOPURINOL TABS 300MG T1 (ZYLOPRIM) 

COLCRYS TABS 0.6MG T4 QL 

(92:20) Miscellaneous Therapeutic Agents » Immunomodulatory Agents 


ACTIMMUNE SOLN 2000000UNIT/0.5ML T5 PA 

AVONEX KIT 30MCG/VIAL T5 

AVONEX KIT 30MCG/0.5ML T5 

AVONEX PEN KIT 30MCG/0.5ML T5 

BETASERON KIT 0.3MG T5 

COPAXONE KIT 20MG/ML T5 

REBIF SOLN 22MCG/0.5ML T5 

REBIF SOLN 44MCG/0.5ML T5 

REBIF TITRATION PACK SOLN T5 

THALOMID CAPS 50MG T3 PA 




(92:24) Miscellaneous Therapeutic Agents » Bone Resorption Inhibitors 


ALENDRONATE SODIUM TABS 70MG T1 QL (FOSAMAX) 

ALENDRONATE SODIUM TABS 5MG T2 (FOSAMAX) 

ALENDRONATE SODIUM TABS 10MG T2 (FOSAMAX) 

ALENDRONATE SODIUM TABS 35MG T2 QL (FOSAMAX) 

(92:28) Miscellaneous Therapeutic Agents » Cariostatic Agents 


SF GEL 1.1% T2 QL (PREVIDENT) 

SODIUM FLUORIDE CHEW 0.25MG T2 (LURIDE) 

SODIUM FLUORIDE CHEW 1.1MG T2 (LURIDE) 

SODIUM FLUORIDE CHEW 1MG T2 (LURIDE) 

SODIUM FLUORIDE SOLN 0.5MG/ML T2 QL (LURIDE) 

(92:36) Miscellaneous Therapeutic Agents » Disease-modifying Antirheumatic Agents 

Page 78 of 81 



ENBREL KIT 25MG T5 PA 

ENBREL SOLN 50MG/ML T5 PA 

ENBREL SOLN 25MG/0.5ML T5 PA 

ENBREL SURECLICK SOLN 50MG/ML T5 PA 

HUMIRA KIT 40MG/0.8ML T5 PA 

HUMIRA KIT 20MG/0.4ML T5 PA 

HUMIRA PEN KIT 40MG/0.8ML T5 PA 

HUMIRA PEN-CROHNS DISEASESTARTER KIT 40MG/0.8ML T5 PA 

KINERET SOLN 100MG/0.67ML T6 PA 

LEFLUNOMIDE TABS 10MG T2 (ARAVA) 

LEFLUNOMIDE TABS 20MG T2 (ARAVA) 

ORENCIA SOLN 125MG/ML T5 PA 

(92:44) Miscellaneous Therapeutic Agents » Immunosuppressive Agents 


AZATHIOPRINE TABS 50MG T2 (IMURAN) 

CELLCEPT SUSR 200MG/ML T6 

CYCLOSPORINE MODIFIED CAPS 25MG T2 (NEORAL) 



CYCLOSPORINE MODIFIED SOLN 100MG/ML T2 (NEORAL) 

GENGRAF CAPS 25MG T2 (NEORAL) 

GENGRAF CAPS 100MG T2 (NEORAL) 

MYCOPHENOLATE MOFETIL CAPS 250MG T2 (CELLCEPT) 

MYCOPHENOLATE MOFETIL TABS 500MG T2 (CELLCEPT) 

MYCOPHENOLIC ACID DR TBEC 180MG T6 

MYCOPHENOLIC ACID DR TBEC 360MG T6 

RAPAMUNE SOLN 1MG/ML T6 

RAPAMUNE TABS 1MG T6 

RAPAMUNE TABS 2MG T6 

SIROLIMUS TABS 0.5MG T6 

TACROLIMUS CAPS 0.5MG T6 (PROGRAF) 

Page 79 of 81 


TACROLIMUS CAPS 1MG T6 (PROGRAF) 

TACROLIMUS CAPS 5MG T6 (PROGRAF) 

ZORTRESS TABS 0.5MG T6 



(92:56) Miscellaneous Therapeutic Agents » Protective Agents 


MESNEX TABS 400MG T4 

(92:92) Miscellaneous Therapeutic Agents » Other Miscellaneous Therapeutic Agents 


ARCALYST SOLR 220MG T5 PA 

CYSTADANE POWD T4 

CYSTAGON CAPS 150MG T2 

ELMIRON CAPS 100MG T4 PA 

KUVAN TBSO 100MG T5 PA 

ORFADIN CAPS 10MG T5 PA 

SENSIPAR TABS 30MG T3 PA 



ZAVESCA CAPS 100MG T4 PA 

Page 80 of 81

Medicaid Preferred Drug List - Florida Health Care Plans

Create successful ePaper yourself

Delete template?

Save as template?