PrimeChoice Plus Formulary - Prime Therapeutics
PrimeChoice Plus Formulary - Prime Therapeutics
PrimeChoice Plus Formulary - Prime Therapeutics
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<strong><strong>Prime</strong>Choice</strong> <strong>Plus</strong> Formular y, April 2013<br />
Questions may be direc ted to <strong>Prime</strong> T her apeutics LLC , P.O. Box 64812, St. Paul, MN 55164-0812. Phone: 800.858.0723. T hank you for your cooperation.<br />
DR ................................................. Delayed-release<br />
ER ................................................ E x tended-release<br />
IR ................................................ Immediate-release<br />
NF ................................................... Non-for mular y<br />
ODT ..................................... Orally disintegrating tablet s<br />
SL ...................................................... Sublingual<br />
This formular y list was cur rent at time of printing and is subjec t to change.<br />
To access a searchable ver sion of this for mular y v isit our website at<br />
My<strong>Prime</strong>.com.<br />
GENERIC<br />
BRAND<br />
ANTI-INFECTIVE AGENTS<br />
PENICILLINS<br />
amoxicillin caps, susp, tabs<br />
AMOXICILLIN chew tabs<br />
amoxicillin/potassium clavulanate IR, ER AMPICILLIN susp<br />
ampicillin caps<br />
AUGMENTIN susp, 125 mg/5 mL<br />
dicloxacillin<br />
penicillin v potassium<br />
CEPHALOSPORINS<br />
cefadroxil<br />
SUPRA X<br />
cefdinir<br />
cefpodoxime<br />
cefprozil<br />
ceftriaxone<br />
cefuroxime<br />
cephalexin, NF = tabs<br />
MACROLIDES<br />
azithromycin susp, tabs<br />
DIFICID<br />
clarithromycin IR, ER E.E.S. 400<br />
ERY-TAB<br />
ERYTHROCIN STEARATE<br />
ERYTHROMYCIN BASE<br />
ERY THROMYCIN DR caps<br />
ERYTHROMYCIN ETHYLSUCCINATE<br />
ZITHROMA X packets<br />
TETR ACYCLINES<br />
demeclocycline<br />
TETRACYCLINE<br />
doxycycline hyclate IR<br />
minocycline IR<br />
FLUOROQUINOLONES<br />
ciprofloxacin, NF = IR tabs, 100 mg; ER tabs AVELOX<br />
levofloxacin<br />
CIPRO susp<br />
AMINOGLYCOSIDES<br />
neomycin sulfate<br />
TOBI<br />
paromomycin<br />
ANTIMYCOBACTERIAL AGENTS<br />
ethambutol<br />
ISONIAZID syrup<br />
isoniazid tabs<br />
MYCOBUTIN<br />
isoniazid/rifampin<br />
PRIF TIN<br />
pyrazinamide<br />
rifampin<br />
ANT IFUNGAL S<br />
fluconazole<br />
L AMISIL granules<br />
flucytosine<br />
NOX AFIL<br />
griseofulvin microsize<br />
SPOR ANOX soln<br />
itraconazole<br />
VFEND susp<br />
ketoconazole tabs<br />
nystatin oral<br />
terbinafine<br />
voriconazole<br />
GENERIC BRAND GENERIC BRAND<br />
ANT IVIR AL S<br />
mercaptopurine<br />
ETOPOSIDE caps<br />
abacavir<br />
APTIVUS methotrexate FARE S TON<br />
acyclovir<br />
ATRIPLA tamoxifen GLEEVEC<br />
didanosine<br />
BARACLUDE tretinoin caps HE X ALEN<br />
famciclovir<br />
COMPLERA<br />
HYCAMTIN caps<br />
lamivudine<br />
CRIXIVAN<br />
ICLUSIG<br />
lamivudine/zidovudine<br />
EDURANT<br />
INLY TA<br />
nevirapine<br />
EMTRIVA<br />
INTRON A<br />
ribavirin<br />
EPIVIR soln<br />
JAKAFI<br />
stavudine<br />
EPIVIR-HBV<br />
LEUCOVORIN CALCIUM tabs, 10 mg, 15 mg<br />
valacyclovir<br />
EPZICOM<br />
LEUKERAN<br />
zidovudine<br />
FUZEON<br />
LUPRON DEPOT<br />
HEPSERA<br />
LYSODREN<br />
INCIVEK<br />
MATUL ANE<br />
INTELENCE<br />
MESNE X tabs<br />
INVIRASE<br />
MYLER AN<br />
ISENTRESS<br />
NE X AVAR<br />
KALETRA<br />
NILANDRON<br />
LE XIVA<br />
SPRYCEL<br />
NORVIR<br />
STIVARGA<br />
PEG-INTRON<br />
SUTENT<br />
PEGA SYS<br />
SYL ATRON<br />
PREZISTA<br />
SYNRIBO<br />
RESCRIPTOR<br />
TABLOID<br />
RE YATAZ<br />
TARCEVA<br />
SELZENTRY<br />
TARGRETIN<br />
STRIBILD<br />
TA SIGNA<br />
SUSTIVA<br />
TEMODAR<br />
TAMIFLU<br />
T YKERB<br />
TRIZIVIR<br />
VOTRIENT<br />
TRUVADA<br />
X ALKORI<br />
VALC Y TE<br />
XELODA<br />
VICTRELIS<br />
XTANDI<br />
VIDEX<br />
ZELBORAF<br />
VIR ACEPT<br />
ZOLINZA<br />
VIRAMUNE susp<br />
ZY TIGA<br />
VIRAMUNE XR<br />
ENDOCRINE AND METABOLIC DRUGS<br />
VIREAD<br />
CORTICOSTEROIDS<br />
ANT IMAL ARIAL S<br />
atovaquone/proguanil 250-100 mg<br />
chloroquine phosphate<br />
hydroxychloroquine<br />
mefloquine<br />
ANTHEL MINTIC S<br />
ANTI-INFECTIVE AGENTS – MISC.<br />
clindamycin<br />
er ythromycin/sulfisoxazole<br />
metronidazole<br />
sulfamethoxazole/trimethoprim<br />
trimethoprim<br />
vancomycin<br />
ANTINEOPL ASTIC AGENTS<br />
anastrozole<br />
bicalutamide<br />
exemestane<br />
flutamide<br />
hydroxyurea<br />
letrozole<br />
leucovorin calcium tabs, 5 mg, 25 mg<br />
leuprolide acetate<br />
megestrol<br />
ZIAGEN soln<br />
ATOVAQUONE/PROGUANIL 62.5-25 mg<br />
COARTEM<br />
DARAPRIM<br />
MALARONE 62.5-25 mg<br />
PRIMAQUINE<br />
ALBENZA<br />
BILTRICIDE<br />
STROMEC TOL<br />
DAPSONE<br />
NEBUPENT<br />
XIFA X AN 550 mg<br />
Z Y VOX<br />
AFINITOR<br />
ALKERAN tabs<br />
BOSULIF<br />
CAPRELSA<br />
CEENU<br />
COMETRIQ<br />
CYCLOPHOSPHAMIDE<br />
EMCY T<br />
ERIVEDGE<br />
budesonide ER<br />
CORTISONE<br />
dexamethasone elixir; tabs, 0.5 mg, 0.75 mg, DEX AMETHASONE soln; tabs, 1 mg, 2 mg<br />
1.5 mg, 4 mg, 6 mg<br />
DEXAMETHASONE INTENSOL<br />
fludrocor tisone<br />
PREDNISOLONE soln, 5 mg/5 mL<br />
hydrocor tisone<br />
PREDNISONE soln, 5 mg/5 mL; tabs, 50 mg<br />
methylprednisolone<br />
prednisolone soln, 15 mg/5 mL; syrup<br />
prednisone tabs, 1 mg, 2.5 mg, 5 mg,<br />
10 mg, 20 mg<br />
ANDROGEN-ANABOLIC<br />
danazol<br />
testosterone cypionate<br />
testosterone enanthate<br />
EST ROGENS<br />
estradiol<br />
estradiol/norethindrone acetate<br />
estropipate 0.75 mg, 1.5 mg<br />
ANDRODERM<br />
ANDROGEL<br />
ANDROID<br />
ANDROXY<br />
METHITEST<br />
TESTIM<br />
CLIMARA PRO<br />
DIVIGEL<br />
ENJUVIA<br />
ESTROPIPATE 3 mg<br />
FEMHRT LOW DOSE<br />
JINTELI<br />
PREMARIN tabs<br />
PREMPHASE<br />
PREMPRO<br />
VIVELLE-DOT<br />
{continued}<br />
4550 © <strong>Prime</strong> Ther apeutics LLC 02/13 Pr imeChoice <strong>Plus</strong> Page 1 of 4
GENERIC<br />
BRAND<br />
CONTRACEPTIVES<br />
levonorgestrel<br />
ELLA<br />
medroxyprogesterone inj, 150 mg/mL LO LOESTRIN FE<br />
oral contraceptive generics, NF =<br />
LOESTRIN 24 FE<br />
Amethia Lo, Camrese, Camrese Lo, MIRENA<br />
levonorgestrel/ethinyl estradiol ( generics NECON 10/11, 1/50<br />
of Loseasonique), Tilia Fe, Tri-Legest Fe, NUVARING<br />
Wymzya Fe, Zenchent Fe, Zeosa<br />
OGESTREL<br />
ORTHO EVRA<br />
ORTHO TRI-CYCLEN LO<br />
ZOVIA 1/50E<br />
PROGESTINS<br />
medroxyprogesterone acetate tabs<br />
norethindrone acetate<br />
progesterone micronized<br />
ANTIDIABETICS<br />
acarbose<br />
BYDUREON<br />
glimepiride<br />
BYE T TA<br />
glipizide IR, ER<br />
GLUCAGON EMERGENCY KIT<br />
glipizide/metformin<br />
GLYBURIDE, distributor of Diabeta<br />
glyburide micronized<br />
JANUMET<br />
glyburide/metformin<br />
JANUMET XR<br />
glyburide, generics of Micronase<br />
JANUVIA<br />
metformin IR, ER<br />
JUVISYNC<br />
nateglinide<br />
KOMBIGLYZE XR<br />
pioglitazone<br />
ONGLYZA<br />
pioglitazone/metformin<br />
PRANDIN<br />
VICTOZA<br />
Rapid-Acting Insulins<br />
HUMALOG<br />
NOVOLOG<br />
Short-Acting Insulins<br />
HUMULIN R<br />
NOVOLIN R<br />
Intermediate-Acting Insulins<br />
HUMALOG MIX 50/50, 75/25<br />
HUMULIN N<br />
HUMULIN 70/30<br />
NOVOLIN N<br />
NOVOLIN 70/30<br />
NOVOLOG MIX 70/30<br />
Basal Insulins<br />
L ANTUS<br />
LEVEMIR<br />
THYROID AGENTS<br />
levothyroxine<br />
liothyronine<br />
methimazole<br />
propylthiouracil<br />
OXY TOCICS<br />
methylergonovine<br />
ENDOCRINE AND METABOLIC AGENTS – MISC.<br />
alendronate 5 mg, 10 mg, 35 mg, 70 mg AC TONEL<br />
cabergoline<br />
ALENDRONATE 40 mg<br />
calcitonin-salmon<br />
ATELVIA<br />
calcitriol<br />
CETROTIDE<br />
chorionic gonadotropin<br />
ETIDRONATE 200 mg<br />
clomiphene<br />
E VISTA<br />
desmopressin<br />
FOLLISTIM AQ<br />
etidronate 400 mg<br />
FORTEO<br />
ibandronate<br />
GONAL-F<br />
levocarnitine<br />
INCRELEX<br />
octreotide<br />
LUPRON DEPOT-PED<br />
NORDITROPIN<br />
NUTROPIN<br />
NUTROPIN AQ<br />
ORFADIN<br />
OVIDREL<br />
REPRONEX<br />
SANDOSTATIN LAR DEPOT<br />
SENSIPAR<br />
GENERIC<br />
CARDIOVASCULAR AGENTS<br />
CARDIOTONICS<br />
digoxin tabs<br />
ANTIANGINAL AGENTS<br />
isosorbide dinitrate IR; NF = ER, SL<br />
isosorbide mononitrate<br />
nitroglycerin patches<br />
BETA BLOCKERS<br />
acebutolol<br />
atenolol<br />
bisoprolol<br />
car vedilol<br />
labetalol<br />
metoprolol succinate ER<br />
metoprolol tartrate<br />
nadolol<br />
propranolol IR, ER<br />
sotalol<br />
sotalol AF<br />
CALCIUM CHANNEL BLOCKERS<br />
amlodipine<br />
diltiazem IR, ER caps – 24 hr dosing<br />
felodipine ER<br />
nifedipine ER<br />
verapamil 80 mg, 120 mg<br />
verapamil ER, NF = caps, 100, 200, 300 mg<br />
ANTIARRHYTHMICS<br />
amiodarone<br />
disopyramide<br />
flecainide<br />
propafenone IR, ER<br />
quinidine gluconate ER<br />
quinidine sulfate IR<br />
ANTIHYPERTENSIVES<br />
amlodipine/benazepril<br />
atenolol/chlorthalidone<br />
benazepril<br />
benazepril/hydrochlorothiazide<br />
bisoprolol/hydrochlorothiazide<br />
captopril<br />
clonidine<br />
doxazosin<br />
enalapril<br />
enalapril/hydrochlorothiazide<br />
eplerenone<br />
fosinopril<br />
fosinopril/hydrochlorothiazide<br />
guanfacine<br />
hydralazine<br />
irbesar tan<br />
irbesar tan/hydrochlorothiazide<br />
lisinopril<br />
lisinopril/hydrochlorothiazide<br />
losartan<br />
losartan/hydrochlorothiazide<br />
methyldopa<br />
minoxidil<br />
moexipril<br />
moexipril/hydrochlorothiazide<br />
perindopril<br />
prazosin<br />
quinapril<br />
quinapril/hydrochlorothiazide<br />
ramipril<br />
terazosin<br />
trandolapril<br />
valsartan/hydrochlorothiazide<br />
BRAND<br />
STIMATE<br />
SYNAREL<br />
ZEMPLAR<br />
DIGOXIN soln<br />
L ANOXIN tabs<br />
NITRO-BID<br />
NITROSTAT<br />
RANEXA<br />
BYSTOLIC<br />
PINDOLOL<br />
PROPRANOLOL soln<br />
TIMOLOL<br />
VERAPAMIL 40 mg<br />
MEXILETINE<br />
MULTAQ<br />
NORPACE CR 100 mg<br />
QUINIDINE SULFATE ER<br />
AZOR<br />
BENICAR<br />
BENICAR HCT<br />
CAPTOPRIL/HYDROCHLOROTHIAZIDE<br />
DIBENZYLINE<br />
DIOVAN<br />
EXFORGE<br />
EXFORGE HCT<br />
MICARDIS<br />
MICARDIS HCT<br />
PROPRANOLOL/HYDROCHLOROTHIAZIDE<br />
GENERIC<br />
DIURETICS<br />
acetazolamide IR, 250 mg; ER<br />
amiloride<br />
amiloride/hydrochlorothiazide<br />
bumetanide<br />
chlorothiazide<br />
chlorthalidone 25 mg<br />
furosemide, NF = soln, 8 mg/mL<br />
hydrochlorothiazide, NF = tabs, 12.5 mg<br />
indapamide<br />
methazolamide<br />
metolazone<br />
spironolactone<br />
spironolactone/hydrochlorothiazide<br />
torsemide<br />
triamterene/hydrochlorothiazide<br />
VASOPRESSORS<br />
midodrine<br />
ANTIHYPERLIPIDEMICS<br />
ator vastatin<br />
cholest yramine<br />
colestipol<br />
fenofibrate<br />
fenofibrate micronized<br />
gemfibrozil<br />
lovastatin<br />
pravastatin<br />
simvastatin<br />
CARDIOVASCULAR AGENTS – MISC.<br />
sildenafil 20 mg<br />
RESPIRATORY AGENTS<br />
ANTIHISTAMINES<br />
cetirizine syrup<br />
cyproheptadine<br />
promethazine supp, 12.5 mg, 25 mg; syrup;<br />
tabs<br />
PROMETHEGAN 50 mg<br />
NASAL AGENTS –SYSTEMIC AND TOPIC AL<br />
BRAND<br />
ACETAZOL AMIDE 125 mg<br />
CHLORTHALIDONE 50 mg<br />
EPIPEN<br />
EPIPEN-JR<br />
CRESTOR<br />
LOVAZA<br />
NIASPAN<br />
TRILIPIX<br />
WELCHOL<br />
ZETIA<br />
ADCIRC A<br />
CADUET<br />
CAVERJECT<br />
CIALIS<br />
LE TAIRIS<br />
MUSE<br />
TRACLEER<br />
azelastine<br />
fluticasone propionate<br />
ipratropium<br />
triamcinolone spray<br />
COUGH/COLD/ALLERGY<br />
acetylcysteine<br />
ANTIASTHMATIC AND BRONCHODIL ATOR AGENTS<br />
albuterol, NF = ER<br />
budesonide<br />
cromolyn sodium inhal soln<br />
ipratropium inhal soln<br />
ipratropium/albuterol<br />
montelukast<br />
terbutaline<br />
theophylline ER<br />
zafirlukast<br />
ASTEPRO<br />
BACTROBAN NASAL<br />
FLUNISOLIDE<br />
NASONEX<br />
ADVAIR DISKUS<br />
ADVAIR HFA<br />
ASMANEX<br />
ATROVENT HFA<br />
COMBIVENT<br />
COMBIVENT RESPIMAT<br />
DULERA<br />
FLOVENT DISKUS<br />
FLOVENT HFA<br />
FOR ADIL AEROLIZER<br />
PROAIR HFA<br />
PULMICORT RESPULES 1 mg/2 mL<br />
QVAR<br />
SEREVENT DISKUS<br />
SPIRIVA HANDIHALER<br />
SYMBICORT<br />
VENTOLIN HFA<br />
RESPIRATORY AGENTS – MISC.<br />
FIRAZYR<br />
K ALYDECO<br />
PULMOZYME<br />
{continued}<br />
4550 © <strong>Prime</strong> <strong>Therapeutics</strong> LLC 02/13 <strong><strong>Prime</strong>Choice</strong> <strong>Plus</strong> Page 2 of 4
GENERIC<br />
GASTROINTESTINAL AGENTS<br />
L A X AT IVE S<br />
lactulose<br />
PEG-electrolytes for soln, generics of Colyte,<br />
Golytely, Nulytely<br />
ANTIDIARRHEALS<br />
diphenoxylate/atropine tabs<br />
loperamide<br />
ULCER DRUGS<br />
cimetidine, NF = 200 mg<br />
dicyclomine caps, tabs<br />
famotidine tabs<br />
glycopyrrolate<br />
hyoscyamine IR, ER; NF = Duotab, ODT<br />
lansoprazole DR<br />
methscopolamine<br />
misoprostol<br />
omeprazole DR<br />
pantoprazole DR<br />
ranitidine<br />
sucralfate<br />
ANTIEMETICS<br />
granisetron<br />
meclizine<br />
ondansetron<br />
trimethobenzamide<br />
DIGESTIVE AIDS<br />
GASTROINTESTINAL AGENTS – MISC.<br />
balsalazide<br />
calcium acetate<br />
lactulose<br />
mesalamine<br />
metoclopramide<br />
sulfasalazine<br />
sulfasalazine DR<br />
ursodiol<br />
BRAND<br />
MOVIPREP<br />
DIPHENOX YL ATE/ATROPINE soln<br />
CARAFATE susp<br />
DICYCLOMINE soln<br />
NEXIUM<br />
OMECL AMOX-PAK<br />
PROPANTHELINE<br />
PROTONIX packets<br />
PYLERA<br />
EMEND<br />
TRANSDERM-SCOP<br />
CREON<br />
ZENPEP<br />
ASACOL<br />
ASACOL HD<br />
CANASA<br />
CHENODAL<br />
CIMZIA<br />
DELZICOL<br />
LIALDA<br />
PENTASA<br />
RENVEL A<br />
GENITOURINARY AGENTS<br />
URINARY ANTI-INFECTIVES<br />
nitrofurantoin susp<br />
MACRODANTIN 25 mg<br />
nitrofurantoin macrocr ystalline 50 mg,<br />
100 mg<br />
nitrofurantoin monohydrate/macrocrystalline<br />
URINARY ANTISPASMODICS<br />
oxybutynin IR, ER<br />
DETROL LA<br />
tolterodine<br />
TOVIAZ<br />
VESICARE<br />
VAGINAL PRODUCTS<br />
clindamycin crm<br />
ACID JELLY<br />
metronidazole gel<br />
CLEOCIN supp<br />
terconazole<br />
CRINONE<br />
ESTRACE crm<br />
VAGIFEM<br />
GENITOURINARY AGENTS – MISC.<br />
alfuzosin ER<br />
finasteride<br />
potassium citrate/citric acid<br />
sodium citrate/citric acid<br />
tamsulosin<br />
CENTR AL NERVOUS SYSTEM DRUGS<br />
ANTIANXIET Y AGENTS<br />
alprazolam IR, ER; NF = ODT<br />
buspirone, NF = 7.5 mg<br />
diazepam tabs<br />
AVODART<br />
C YSTAGON<br />
CY TRA-K soln<br />
CY TRA-3<br />
ELMIRON<br />
K-PHOS MF<br />
K-PHOS NO. 2<br />
POTASSIUM CITRATE ER<br />
TRICITRATES<br />
DIAZEPAM soln<br />
HYDROXYZINE PAMOATE 100 mg<br />
GENERIC<br />
BRAND<br />
hydroxyzine hcl<br />
hydroxyzine pamoate 25 mg, 50 mg<br />
lorazepam<br />
ANTIDEPRESSANTS<br />
amitript yline<br />
CYMBALTA<br />
bupropion IR, ER<br />
DOXEPIN 75 mg<br />
citalopram<br />
NORTRIPT YLINE soln<br />
clomipramine<br />
PRISTIQ<br />
desipramine<br />
doxepin, NF = 150 mg<br />
escitalopram<br />
fluoxetine, NF = IR, 60 mg; ER<br />
fluvoxamine<br />
imipramine hcl<br />
mir tazapine, NF = ODT<br />
nortriptyline caps<br />
paroxetine hcl IR, ER<br />
phenelzine<br />
sertraline<br />
tranylcypromine<br />
trazodone<br />
venlafaxine IR, ER; NF = 225 mg<br />
ANTIPSYCHOTICS<br />
chlorpromazine<br />
FLUPHENAZINE DECANOATE<br />
clozapine<br />
FLUPHENAZINE HCL conc, elixir<br />
fluphenazine hcl tabs<br />
LITHIUM C ARBONATE caps, 150 mg<br />
haloperidol<br />
LITHIUM CITRATE<br />
haloperidol decanoate<br />
SEROQUEL XR<br />
haloperidol lactate conc<br />
lithium carbonate IR, ER<br />
loxapine<br />
olanzapine IR, ODT<br />
perphenazine<br />
prochlorperazine<br />
quetiapine<br />
risperidone, NF = ODT, 0.25 mg<br />
thiothixene<br />
trif luoperazine<br />
ziprasidone<br />
HYPNOTICS<br />
estazolam<br />
phenobarbital, NF = 64.8 mg, 97.2 mg<br />
temazepam<br />
zaleplon<br />
zolpidem IR, ER<br />
ADHD/ANTI-NARCOLEPSY/ANTI-OBESIT Y/ANOREXIANTS<br />
amphetamine/dextroamphetamine IR, ER ADDERALL XR<br />
caffeine citrate<br />
INTUNIV<br />
dextroamphetamine IR tabs, 5 mg; ER METHYLPHENIDATE ER tabs, 10 mg<br />
methylphenidate IR tabs; ER tabs, 20 mg STRAT TERA<br />
modafinil<br />
VYVANSE<br />
PSYCHOTHER APEUTIC AND NEUROLOGICAL AGENTS – MISC.<br />
bupropion ER – smoking deterrent<br />
ARICEPT 23 mg<br />
disulfiram<br />
BETASERON<br />
donepezil<br />
CHANTIX<br />
galantamine IR, ER, soln<br />
COPAXONE<br />
naltrexone<br />
NAMENDA<br />
rivastigmine<br />
NICOTROL INHALER<br />
NICOTROL NS<br />
NUEDEXTA<br />
ORAP<br />
REBIF<br />
XENAZINE<br />
ANALGESICS AND ANESTHETICS<br />
ANALGESICS –NON-NARCOTIC<br />
butalbital/acetaminophen<br />
butalbital/acetaminophen/caffeine,<br />
NF = caps, 50-500-40 mg<br />
butalbital/aspirin/caffeine<br />
salsalate<br />
GENERIC<br />
ANALGESICS –NARCOTIC<br />
acetaminophen/codeine<br />
buprenorphine<br />
butalbital/aspirin/caffeine/codeine<br />
fentanyl<br />
fentanyl citrate<br />
hydrocodone/acetaminophen, NF = soln,<br />
7.5-325 mg/15 mL; tabs, 5-300 mg,<br />
7.5-300 mg, 10-300 mg<br />
hydrocodone/ibuprofen<br />
hydromorphone soln, tabs<br />
methadone conc, soln, tabs<br />
morphine sulfate conc, ER, soln<br />
oxycodone caps; conc; tabs, 5 mg, 15 mg,<br />
30 mg<br />
oxycodone/acetaminophen, NF = 2.5-325 mg<br />
oxycodone/aspirin<br />
tramadol<br />
tramadol/acetaminophen<br />
ANALGESICS –ANTI-INFLAMMATORY<br />
diclofenac potassium<br />
diclofenac sodium DR, ER<br />
etodolac, NF = ER<br />
flurbiprofen<br />
ibuprofen<br />
indomethacin, NF = ER<br />
ketoprofen, NF = ER<br />
lef lunomide<br />
meloxicam<br />
nabumetone<br />
naproxen DR, IR<br />
naproxen sodium<br />
oxaprozin<br />
piroxicam<br />
sulindac<br />
MIGRAINE PRODUCTS<br />
acetaminophen/isometheptene/<br />
dichloralphenazone<br />
naratriptan<br />
rizatriptan ODT, tabs<br />
sumatriptan inj, tabs<br />
GOUT AGENTS<br />
allopurinol<br />
probenecid<br />
probenecid/colchicine<br />
NEUROMUSCUL AR DRUGS<br />
ANTICONVULSANTS<br />
carbamazepine IR, ER<br />
clonazepam, NF = ODT<br />
divalproex DR, ER<br />
ethosuximide<br />
gabapentin<br />
lamotrigine<br />
levetiracetam IR, ER<br />
oxcarbazepine<br />
pheny toin susp<br />
phenytoin chew tabs<br />
pheny toin sodium ER<br />
primidone<br />
topiramate<br />
valproic acid<br />
zonisamide<br />
ANTIPARKINSON AGENTS<br />
amantadine, NF = tabs<br />
benztropine<br />
bromocriptine<br />
carbidopa/levodopa IR, ER, ODT<br />
pramipexole<br />
ropinirole<br />
selegiline<br />
trihexyphenidyl<br />
BRAND<br />
AVINZA<br />
CODEINE SULFATE<br />
HYDROMORPHONE supp<br />
MORPHINE SULFATE IR, supp<br />
NUCYNTA ER<br />
OXYCODONE conc, soln<br />
OXYCONTIN<br />
SUBOXONE<br />
CELEBREX<br />
HUMIRA<br />
VIMOVO<br />
IMITRE X nasal<br />
MIGRANAL<br />
COLCRYS<br />
BANZEL tabs<br />
CELONTIN<br />
DIASTAT<br />
DILANTIN, NF = chew tabs<br />
LYRICA<br />
SABRIL<br />
TEGRETOL-XR 100 mg<br />
APOK YN<br />
A ZILEC T<br />
COMTAN<br />
STALEVO<br />
NEUROMUSCULAR AGENTS<br />
RILUTEK<br />
{continued}<br />
4550 © <strong>Prime</strong> <strong>Therapeutics</strong> LLC 02/13 <strong><strong>Prime</strong>Choice</strong> <strong>Plus</strong> Page 3 of 4
GENERIC BRAND GENERIC BRAND GENERIC BRAND<br />
MUSCULOSKELETAL THER APY AGENTS fluorometholone susp, 0.1 % TR AVATAN Z<br />
baclofen ORPHENADRINE/ASPIRIN/CAFFEINE tabs, flurbiprofen soln VIGAMOX<br />
chlorzoxazone 50-770-60 mg gentamicin oint, soln ZYLET<br />
cyclobenzaprine<br />
homatropine soln<br />
dantrolene<br />
ketorolac soln<br />
metaxalone<br />
latanoprost soln<br />
methocarbamol levobunolol soln, 0.5%<br />
orphenadrine ER<br />
orphenadrine/aspirin/caffeine tabs,<br />
25-385-30 mg<br />
tizanidine tabs<br />
hydrocor tisone oint<br />
ANTIMYASTHENIC AGENTS<br />
pyridostigmine<br />
NUTRITIONAL PRODUCTS<br />
VITAMINS<br />
ergocalciferol<br />
MULTIVITAMINS<br />
pediatric multivitamins<br />
pediatric vitamins ADC<br />
MESTINON syrup<br />
MESTINON TIMESPAN<br />
MEPHY TON<br />
NEX A SELECT<br />
POLY-VITAMIN/FLUORIDE/IRON drops,<br />
0.5-10 mg/mL<br />
PRENAPLUS<br />
PRENATABS FA/RX<br />
PRENATAL 19/AD/PLUS/PLUS-IRON/U/<br />
VITAMINS PLUS<br />
SE-NATAL 19<br />
TRI-VIT/FLUORIDE/IRON<br />
TRINATE<br />
VINATE GT/II/M/ONE/ULTRA<br />
metipranolol soln<br />
neomycin/polymyxin B/bacitracin oint<br />
neomycin/polymyxin B/bacitracin/<br />
neomycin/polymyxin B/dexamethasone<br />
oint, susp<br />
neomycin/polymyxin B/gramicidin soln<br />
of loxacin soln<br />
pilocarpine soln, 1%, 2%, 4%<br />
polymyxin B/trimethoprim soln<br />
prednisolone acetate susp<br />
sulfacetamide sodium soln<br />
sulfacetamide sodium/prednisolone soln<br />
timolol maleate soln, gel-forming soln<br />
tobramycin soln<br />
tobramycin/dexamethasone susp<br />
trifluridine soln<br />
OTIC AGENTS<br />
acetic acid<br />
benzocaine/antipyrine<br />
hydrocor tisone/acetic acid<br />
neomycin/polymyxin B/hydrocortisone<br />
of loxacin<br />
MOUTH/THROAT/DENTAL AGENTS<br />
cevimeline<br />
MINER ALS AND ELECTROLY TES<br />
potassium bicarbonate/chloride effer vescent, FLUOR-A-DAY<br />
25 mEq FLURA-DROPS 0.55 mg/drop chlorhexidine<br />
potassium chloride ER; packets; soln, 10% K-PHOS clotrimazole troche<br />
potassium phosphate/sodium phosphates POTASSIUM CHLORIDE soln, 20% lidocaine viscous<br />
sodium fluoride chew tabs; soln, SODIUM FLUORIDE tabs nystatin oral<br />
CIPRO HC<br />
CIPRODEX<br />
0.275 mg/drop, 1.1 mg/mL SSKI<br />
pilocarpine tabs<br />
HEMATOLOGICAL AGENTS<br />
sodium fluoride<br />
HEMATOPOIETIC AGENTS<br />
triamcinolone dental paste<br />
cyanocobalamin inj<br />
ARANESP<br />
ANORECTAL AGENTS<br />
folic acid 1 mg<br />
NEUL ASTA<br />
hydrocor tisone crm, 2.5%; enema<br />
CORTIFOAM<br />
hydrocor tisone acetate supp, 25 mg<br />
NEUMEGA<br />
DERMATOLOGICALS<br />
NEUPOGEN<br />
adapalene crm; gel, 0.1%<br />
BACTROBAN crm<br />
PROCRIT<br />
alclometasone BETAMETHASONE VALERATE oint, 0.1%<br />
ANTICOAGUL ANTS<br />
aluminum chloride<br />
C ARAC<br />
enoxaparin<br />
X ARELTO<br />
amcinonide crm<br />
CL AR AVIS caps, 30 mg<br />
warfarin<br />
betamethasone dipropionate DESOXIMETASONE crm, 0.05%<br />
HEMATOLOGICAL AGENTS – MISC. betamethasone dipropionate, augmented DIFFERIN gel, 0.3%; lotn<br />
anagrelide EFFIENT betamethasone valerate crm, lotn DIFLORASONE crm<br />
cilostazol calcipotriene crm, soln ELIDEL<br />
clopidogrel 75 mg ciclopirox, NF = topical kit EPIDUO<br />
dipyridamole clindamycin ERY THROMYCIN gel<br />
pentoxif ylline ER clindamycin/benzoyl peroxide FINACEA<br />
TOPICAL PRODUCTS clobetasol FLUOROPLEX<br />
OPHTHALMIC AGENTS desonide GENTAMICIN topical<br />
atropine sulfate soln<br />
azelastine soln<br />
bacitracin/polymyxin B oint<br />
brimonidine soln<br />
car teolol soln<br />
ciprofloxacin soln<br />
cromolyn sodium soln<br />
cyclopentolate soln, 1%<br />
dexamethasone sodium phosphate soln<br />
diclofenac soln<br />
dorzolamide soln<br />
dorzolamide/timolol maleate soln<br />
er ythromycin oint<br />
ALPHAGAN P 0.1%<br />
ALREX<br />
ATROPINE SULFATE oint<br />
AZASITE<br />
AZOPT<br />
BACITRACIN oint<br />
CILOX AN oint<br />
LEVOBUNOLOL soln, 0.25%<br />
LOTEM A X<br />
LUMIGAN<br />
NATAC YN<br />
PATADAY<br />
TOBREX oint<br />
desoximetasone crm, 0.25%; gel; oint, 0.25% LIDOCAINE/PRILOCAINE kit<br />
dif lorasone oint<br />
LIDODERM<br />
econazole METROGEL 1%<br />
er ythromycin pads, soln<br />
NYSTATIN/TRIAMCINOLONE<br />
er ythromycin/benzoyl peroxide<br />
OR ACE A<br />
fluocinolone<br />
PANRETIN<br />
f luocinonide<br />
PICATO<br />
f luorouracil<br />
PROTOPIC<br />
fluticasone propionate<br />
RETIN-A MICRO<br />
halobetasol<br />
SOLAR AZE<br />
hydrocor tisone 2.5%<br />
SORIATANE<br />
hydrocor tisone valerate<br />
SULFACETAMIDE SODIUM/SULFUR susp,<br />
imiquimod 10%-5%<br />
isotretinoin caps, 10 mg, 20 mg, 40 mg<br />
ketoconazole crm; shampoo, 2%<br />
lidocaine jelly, 2%; oint, 5%; soln, 4%<br />
lidocaine/prilocaine crm<br />
lindane lotn<br />
malathion<br />
metronidazole crm, gel, lotn, 0.75%<br />
mometasone<br />
mupirocin, NF = Centany<br />
nystatin topical<br />
permethrin crm, 5%<br />
podofilox<br />
selenium sulfide<br />
silver sulfadiazine<br />
sulfacetamide sodium/sulfur crm; emulsion;<br />
lotn, 10%-5%<br />
tretinoin, NF = emollient crm; Avita gel<br />
triamcinolone, NF = oint, 0.05%<br />
MISCELLANEOUS PRODUCTS<br />
ANTIDOTES<br />
DIABETIC SUPPLIES<br />
MEDICAL DEVICES<br />
ASSORTED CLASSES<br />
azathioprine<br />
cyclosporine<br />
cyclosporine modified caps, 25 mg,<br />
100 mg; soln<br />
mycophenolate mofetil<br />
sodium polystyrene sulfonate<br />
tacrolimus caps<br />
SYNALAR crm, oint<br />
TACLONE X<br />
TARGRETIN gel<br />
TA ZOR AC<br />
TRIAMCINOLONE oint, 0.5%<br />
ULESFIA<br />
VOLTAREN gel<br />
XERAC AC<br />
Z YCL AR A<br />
CHEMET<br />
INSULIN SYRINGES -VARIOUS<br />
L ANCETS -VARIOUS<br />
LIFESCAN FAST TAKE blood glucose meter<br />
LIFESCAN FAST TAKE, SURESTEP test strips<br />
LIFESCAN ONETOUCH BASIC/PROFILE/<br />
ONE TOUCH II, ULTRA BLUE, VERIO,<br />
VERIO IQ test strips<br />
LIFESCAN ONETOUCH ULTRA ,<br />
VERIO calibration liquid<br />
LIFESCAN ONETOUCH BASIC, PROFILE,<br />
ULTRA , ULTRA 2, ULTRA MINI, ULTRALINK,<br />
ULTRA SMART, VERIO IQ blood glucose<br />
meters<br />
LIFESCAN ONETOUCH COMBO PACK, DELICA ,<br />
FINEPOINT, ULTR ASOF T lancets<br />
LIFESCAN SURESTEP calibration liquid<br />
LIFESCAN UNISTIK 2 lancets<br />
PEN NEEDLES -VARIOUS<br />
ROCHE ACCU-CHEK ACTIVE, AVIVA,<br />
COMFORT CURVE, COMPACT, INSTANT,<br />
SMART VIEW calibration liquid<br />
ROCHE ACCU-CHEK ACTIVE, AVIVA,<br />
AVIVA PLUS, COMFORT CURVE, COMPACT,<br />
SMART VIEW test strips<br />
ROCHE ACCU-CHEK AVIVA PLUS, NANO<br />
SMART VIEW, VOICEMATE blood glucose<br />
meters<br />
ROCHE ACCU-CHEK MULTICLIX, SOF T TOUCH,<br />
SOF TCLIX lancets<br />
ROCHE ACCUTREND calibration liquid;<br />
test strips<br />
INHALER ASSIST DEVICES – SPACERS<br />
CELLCEPT oral susp<br />
CUPRIMINE<br />
CYCLOSPORINE MODIFIED caps, 50 mg<br />
MYFORTIC<br />
PROGR AF inj<br />
RAPAMUNE<br />
REVLIMID<br />
SYPRINE<br />
THALOMID<br />
ZORTRESS<br />
4550 © <strong>Prime</strong> <strong>Therapeutics</strong> LLC 02/13 <strong><strong>Prime</strong>Choice</strong> <strong>Plus</strong> Page 4 of 4
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