PrimeChoice Plus Formulary - Prime Therapeutics
PrimeChoice Plus Formulary - Prime Therapeutics
PrimeChoice Plus Formulary - Prime Therapeutics
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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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