Comprehensive Alliance Drug Formulary - Alameda Alliance for ...

AAH01
ALAMEDA ALLIANCE FOR HEALTH
DRUG FORMULARY
April 2012
INTRODUCTION
Foreword
This document provides physicians and pharmacists with a method to begin to evaluate the
various drug products available. The medical treatment of patients is frequently relative to the
practical application of drug therapy. Due to the vast availability of medication therapy and
treatment modalities, a reasonable program of drug product selection and drug usage must be
developed. The goal of the Drug Formulary is to enhance the physician and pharmacist’s
abilities to provide optimal cost effective drug therapy for patients.
The development, maintenance, and improvement of this process are evolutionary and require
constant attention. The Formulary is a continually reviewed and revised list of drugs, which
mirror the prevailing clinical opinion of the P & T and Formulary Committees. Unfortunately, this
dynamic process does not allow this document to be completely accurate at all times. To
accommodate the necessary changes of this document, updates are sent regularly.
How to Use the Drug Formulary
The Drug Formulary is a list of covered and preferred drug agents for members. All drugs are
listed by their generic names and most common proprietary (branded) name. The Drug
Formulary may be accessed by using either the generic or proprietary name (in small capital
letters) and by therapeutic drug category. The brand names listed are for reference use only,
and do not denote coverage, unless specifically noted. Any drug not found in this Formulary
listing shall be considered a Non-Formulary drug.
All drugs are listed in each category in alphabetical order by generic name. Where an FDA
approved generic is available for the listed generic name, the generic name is bolded.
For certain agents within the Drug Formulary, a recommended prescribing guideline may apply.
These are denoted throughout the document using the following symbols:
Age Edit
Coverage may depend on patient age
AGE
G Gender Edit Coverage may depend on patient gender
MD Physician Specialty Edit Coverage may depend on prescribing physician’s specialty or board certification
PA Prior Authorization Requires specific physician request process
QL Quantity Limit Coverage may be limited to specific quantities per prescription and/or time period

Comprehensive Alliance Drug Formulary – April 2012
ST Step Therapy Coverage may depend on previous use of another drug
F Formulary
Benefit Coverage and Limitations
This printed Formulary does not provide information regarding the specific coverage and
limitations an individual member may have. Many members have specific benefit inclusions,
exclusions, copays, or a lack of coverage, which are not reflected in the Drug Formulary.
The Drug Formulary applies only to outpatient drugs provided to members, and does not apply
to medications used in inpatient settings. If a member has any specific questions regarding
their coverage, they should contact their Plan Sponsor or MedImpact at (800) 788-2949.
ALLERGY
2nd Gen Antihistamine & Decongestant Combinations
QL loratadine/pseudoephedrine CLARITIN-D 12 HOUR TAB ER 12H 5
MG-120MG
QL loratadine/pseudoephedrine CLARITIN-D 12 HOUR TAB ER 24H
10MG-240MG
Antihistamines
tripelennamine hcl TRIPELENNAMINE HCL TABLET
50MG
Antihistamines - 1st Generation
carbinoxamine maleate PALGIC LIQUID
4MG/5ML
chlorpheniramine maleate CHLOR-TRIMETON CAPSULE SA
12MG
chlorpheniramine maleate CHLOR-TRIMETON SYRUP 2
MG/5 ML
chlorpheniramine maleate CHLOR-TRIMETON TABLET 4
MG
clemastine fumarate TAVIST-1 TABLET 1.34
MG
clemastine fumarate TAVIST-1 SYRUP
0.67MG/5ML
cyproheptadine hcl CYPROHEPTADINE HCL SYRUP 2
MG/5 ML
cyproheptadine hcl CYPROHEPTADINE HCL TABLET 4
MG
diphenhydramine hcl BENADRYL CAPSULE 25
MG
diphenhydramine hcl BENADRYL CAPSULE 50
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Comprehensive Alliance Drug Formulary – April 2012
MG
diphenhydramine hcl BENADRYL LIQUID
12.5MG/5ML
diphenhydramine hcl BENADRYL TAB CHEW
12.5 MG
diphenhydramine hcl BENADRYL SYRUP
12.5MG/5ML
diphenhydramine hcl BENADRYL TABLET 25
MG
diphenhydramine hcl BENADRYL TABLET 50
MG
diphenhydramine hcl BENADRYL LIQUID
12.5MG/5ML
hydroxyzine hcl HYZINE SYRUP 10
MG/5 ML
hydroxyzine hcl HYZINE TABLET 10
MG
hydroxyzine hcl HYZINE TABLET 25
MG
hydroxyzine hcl HYZINE TABLET 50
MG
hydroxyzine pamoate VISTARIL CAPSULE 100
MG
hydroxyzine pamoate VISTARIL CAPSULE 25
MG
hydroxyzine pamoate VISTARIL CAPSULE 50
MG
promethazine hcl PHENERGAN SYRUP
6.25MG/5ML
promethazine hcl PHENERGAN TABLET 12.5
MG
promethazine hcl PHENERGAN TABLET 25
MG
promethazine hcl PHENERGAN TABLET 50
MG
Antihistamines - 2nd Generation
QL cetirizine hcl CHILDREN'S ZYRTEC SOLUTION 1
MG/ML
QL cetirizine hcl CHILDREN'S ZYRTEC TABLET 10
MG
QL cetirizine hcl CHILDREN'S ZYRTEC TABLET 5
MG
PA fexofenadine hcl ALLEGRA TABLET 30
MG
PA fexofenadine hcl ALLEGRA TABLET 60
MG
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Comprehensive Alliance Drug Formulary – April 2012
PA fexofenadine hcl ALLEGRA TABLET 180
MG
QL loratadine CLARITIN TAB RAPDIS
10 MG
QL loratadine CLARITIN SOLUTION 5
MG/5 ML
QL loratadine CLARITIN TABLET 10
MG
Nasal Anti-Inflammatory Steroids
flunisolide NASAREL SPRAY
29MCG
flunisolide NASAREL SPRAY 25
MCG
fluticasone propionate FLONASE SPRAY SUSP
AGE+
QL
50 MCG
mometasone furoate NASONEX SPRAY/PUMP
50 MCG
Nasal Mast Cell Stabilizers Agents
cromolyn sodium NASALCROM SPRAY/PUMP
5.2 MG
ANTIEMESIS/ANTIVERTIGO
Antiemetic/Antivertigo Agents
dimenhydrinate DRAMAMINE TABLET
50MG
meclizine hcl ANTIVERT TABLET 12.5
MG
meclizine hcl ANTIVERT TABLET 25
MG
PA meclizine hcl ANTIVERT TABLET 50
MG
meclizine hcl ANTIVERT TAB CHEW
25 MG
QL ondansetron ZOFRAN ODT TAB RAPDIS
4 MG
QL ondansetron ZOFRAN ODT TAB RAPDIS
8 MG
QL ondansetron hcl ZOFRAN TABLET 4
MG
QL ondansetron hcl ZOFRAN TABLET 8
QL+
ST
MG
ondansetron hcl ZOFRAN TABLET 24
MG
prochlorperazine edisylate COMPAZINE SYRUP 5
MG/5 ML
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Comprehensive Alliance Drug Formulary – April 2012
prochlorperazine maleate COMPAZINE SUPP.RECT
25 MG
prochlorperazine maleate COMPAZINE TABLET 10
MG
prochlorperazine maleate COMPAZINE TABLET 5
MG
promethazine hcl PHENERGAN SUPP.RECT
25 MG
promethazine hcl PHENERGAN SUPP.RECT
50 MG
promethazine hcl PHENERGAN SUPP.RECT
12.5 MG
trimethobenzamide hcl/b-caine TEBAMIDE SUPP.RECT
100MG-2%
trimethobenzamide hcl/b-caine TEBAMIDE SUPP.RECT
200 MG-2 %
ASTHMA
Adrenergic Agents,Catecholamines
isoetharine hcl ISOETHARINE HCL SOLUTION
10MG/ML
isoproterenol hcl ISUPREL AMPUL 0.2
MG/ML
Beta-Adrenergic Agents
albuterol sulfate VOSPIRE ER VIAL-NEB
0.63MG/3ML
albuterol sulfate VOSPIRE ER VIAL-NEB
1.25MG/3ML
albuterol sulfate VOSPIRE ER TABLET 2
MG
albuterol sulfate VOSPIRE ER TABLET 4
MG
albuterol sulfate VOSPIRE ER SYRUP 2
QL+
ST
MG/5 ML
HFA AER AD
90 MCG
albuterol sulfate
PROAIR HFA
VENTOLIN HFA
albuterol sulfate VOSPIRE ER VIAL-NEB 2.5
MG/0.5
albuterol sulfate VOSPIRE ER VIAL-NEB 2.5
MG/3ML
formoterol fumarate FORADIL CAP W/DEV
12 MCG
metaproterenol sulfate ALUPENT SYRUP 10
MG/5 ML
metaproterenol sulfate ALUPENT TABLET 10
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Comprehensive Alliance Drug Formulary – April 2012
MG
metaproterenol sulfate ALUPENT TABLET
20MG
ST salmeterol xinafoate SEREVENT DISKUS DISK W/DEV
50 MCG
terbutaline sulfate BRETHINE TABLET 5
MG
terbutaline sulfate BRETHINE TABLET 2.5
MG
Beta-Adrenergic And Anticholinergic Combinations
ipratropium/albuterol sulfate DUONEB AMPUL-NEB
0.5-3MG/3
ipratropium/albuterol sulfate COMBIVENT AER W/ADAP
18-103MCG
Beta-Adrenergic And Glucocorticoid Combinations
QL+
ST
QL+
ST
QL+
ST
QL+
ST
QL+
ST
QL+
ST
fluticasone/salmeterol ADVAIR DISKUS DISK W/DEV
100-50 MCG
fluticasone/salmeterol ADVAIR DISKUS DISK W/DEV
250-50 MCG
fluticasone/salmeterol ADVAIR DISKUS DISK W/DEV
500-50 MCG
fluticasone/salmeterol ADVAIR HFA HFA AER AD
45-21MCG
fluticasone/salmeterol ADVAIR HFA HFA AER AD
115-21MCG
fluticasone/salmeterol ADVAIR HFA HFA AER AD
230-21MCG
General Bronchodilator Agents
QL epinephrine PRIMATENE MIST AER W/ADAP
0.22MG
ipratropium bromide ATROVENT HFA HFA AER AD
17MCG
ipratropium bromide IPRATROPIUM BROMIDE SOLUTION
0.2 MG/ML
ST tiotropium bromide SPIRIVA CAP W/DEV
18 MCG
Glucocorticoids, Orally Inhaled
beclomethasone dipropionate QVAR AER W/ADAP
40 MCG
beclomethasone dipropionate QVAR AER W/ADAP
80 MCG
AGE+ fluticasone propionate FLOVENT DISKUS DISK W/DEV
ST
100 MCG
AGE+ fluticasone propionate FLOVENT DISKUS DISK W/DEV
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Comprehensive Alliance Drug Formulary – April 2012
ST
50 MCG
AGE+ fluticasone propionate FLOVENT HFA AER W/ADAP
ST
110MCG
AGE+ fluticasone propionate FLOVENT HFA AER W/ADAP
ST
44MCG
AGE+ fluticasone propionate FLOVENT HFA AER W/ADAP
ST
220 MCG
Leukotriene Receptor Antagonists
AGE+ montelukast sodium SINGULAIR GRAN PACK
QL+
4 MG
ST
AGE+ montelukast sodium SINGULAIR TAB CHEW 4
QL+
MG
ST
AGE+ montelukast sodium SINGULAIR TAB CHEW 5
QL+
MG
ST
AGE+ montelukast sodium SINGULAIR TABLET 10
QL+
ST
MG
Mast Cell Stabilizers
cromolyn sodium GASTROCROM AMPUL-NEB
20 MG/2 ML
Monoclonal Antibodies To Immunoglobulin E(ige)
AGE omalizumab XOLAIR VIAL 150 MG
Oral Inhaled Corticosteroids(dosage Form 408 Only)
AGE budesonide PULMICORT AMPUL-NEB
0.25MG/2ML
AGE budesonide PULMICORT AMPUL-NEB
0.5 MG/2ML
PA mometasone furoate ASMANEX AER POW BA
220MCG(14)
PA mometasone furoate ASMANEX AER POW BA
220MCG(30)
PA mometasone furoate ASMANEX AER POW BA
220MCG(60)
Respiratory Aids,Devices,Equipment
QL compressor, for nebulizer DEVILBISS COMPACT
DEVILBISS PULMO-AIDE
DEVILBISS PULMOMATE
PULMO-AIDE
SUNRISE COMPRESSOR-NEBULIZER
QL compressor, for nebulizer DEVILBISS COMPACT
DEVILBISS PULMO-AIDE
EACH
EACH
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Comprehensive Alliance Drug Formulary – April 2012
DEVILBISS PULMOMATE
PULMO-AIDE
SUNRISE COMPRESSOR-NEBULIZER
QL inhaler, assist devices EASIVENT SPACER
QL peak flow meter ASSESS
PEAK-AIR
PERSONAL BEST
POCKET PEAK
TRUZONE PEAK FLOW METER
EACH
Xanthines
theophylline anhydrous THEO-24 CAP ER 24H
400 MG
theophylline anhydrous THEO-24 CAP ER 24H
100 MG
theophylline anhydrous THEO-24 CAP ER 24H
200 MG
theophylline anhydrous THEO-24 CAP ER 24H
300 MG
theophylline anhydrous UNIPHYL ELIXIR 80
MG/15ML
theophylline anhydrous UNIPHYL TAB ER 12H
100 MG
theophylline anhydrous UNIPHYL TAB ER 12H
200 MG
theophylline anhydrous UNIPHYL TAB ER 12H
300 MG
theophylline anhydrous UNIPHYL TABLET ER
400 MG
theophylline anhydrous UNIPHYL TAB ER 12H
450 MG
theophylline anhydrous UNIPHYL TABLET ER
400 MG
theophylline anhydrous UNIPHYL TABLET ER
600 MG
theophylline anhydrous UNIPHYL SOLUTION 80
MG/15ML
AUTONOMIC NERVOUS SYSTEM
DISORDERS
Cholinesterase Inhibitors
pyridostigmine bromide MESTINON SYRUP 60
MG/5 ML
pyridostigmine bromide MESTINON TABLET 60
MG
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Comprehensive Alliance Drug Formulary – April 2012
BEHAVIORAL HEALTH - ANTIDEPRESSANTS
Alpha-2 Receptor Antagonist Antidepressants
mirtazapine REMERON TAB RAPDIS
15 MG
mirtazapine REMERON TAB RAPDIS
30 MG
mirtazapine REMERON TAB RAPDIS
45 MG
mirtazapine REMERON TABLET 15
MG
mirtazapine REMERON TABLET
30MG
mirtazapine REMERON TABLET 45
MG
Norepinephrine And Dopamine Reuptake Inhib (ndris)
bupropion hcl WELLBUTRIN SR TABLET 75
MG
bupropion hcl WELLBUTRIN SR TABLET 100
MG
bupropion hcl WELLBUTRIN SR TABLET ER
150 MG
bupropion hcl WELLBUTRIN SR TABLET ER
100 MG
bupropion hcl WELLBUTRIN SR TABLET ER
200 MG
ST bupropion hcl WELLBUTRIN SR TAB ER 24H
150 MG
ST bupropion hcl WELLBUTRIN SR TAB ER 24H
300 MG
Selective Serotonin Reuptake Inhibitor (ssris)
QL citalopram hydrobromide CELEXA TABLET 20
MG
citalopram hydrobromide CELEXA TABLET 40
MG
citalopram hydrobromide CELEXA SOLUTION 10
MG/5 ML
QL citalopram hydrobromide CELEXA TABLET 10
MG
PA escitalopram oxalate LEXAPRO TABLET 10
MG
PA escitalopram oxalate LEXAPRO TABLET 20
MG
PA escitalopram oxalate LEXAPRO TABLET 5
MG
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Comprehensive Alliance Drug Formulary – April 2012
fluoxetine hcl RAPIFLUX CAPSULE 10
MG
fluoxetine hcl RAPIFLUX CAPSULE 20
MG
QL fluoxetine hcl RAPIFLUX SOLUTION 20
MG/5 ML
fluvoxamine maleate FLUVOXAMINE MALEATE TABLET 25
MG
fluvoxamine maleate FLUVOXAMINE MALEATE TABLET 50
MG
fluvoxamine maleate FLUVOXAMINE MALEATE TABLET 100
MG
paroxetine hcl PAXIL CR TABLET 10
MG
paroxetine hcl PAXIL CR TABLET 20
MG
paroxetine hcl PAXIL CR TABLET 30
MG
paroxetine hcl PAXIL CR TABLET 40
MG
AGE paroxetine hcl PAXIL ORAL SUSP
10 MG/5 ML
PA paroxetine hcl PAXIL CR TAB ER 24H
25 MG
PA paroxetine hcl PAXIL CR TAB ER 24H
37.5 MG
PA paroxetine mesylate PEXEVA TABLET 10
MG
PA paroxetine mesylate PEXEVA TABLET 20
MG
PA paroxetine mesylate PEXEVA TABLET 30
MG
PA paroxetine mesylate PEXEVA TABLET 40
MG
QL sertraline hcl ZOLOFT CONC TABLET 25
MG
QL sertraline hcl ZOLOFT CONC TABLET 50
MG
QL sertraline hcl ZOLOFT CONC TABLET 100
MG
sertraline hcl ZOLOFT CONC ORAL CONC
20 MG/ML
Serotonin-2 Antagonist/Reuptake Inhibitors (saris)
trazodone hcl DESYREL 300MG TABLET 50
MG
trazodone hcl DESYREL 300MG TABLET 100
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Comprehensive Alliance Drug Formulary – April 2012
MG
trazodone hcl DESYREL 300MG TABLET 150
MG
Serotonin-Norepinephrine Reuptake-Inhib (snris)
PA desvenlafaxine succinate PRISTIQ ER TAB ER 24H
50 MG
PA desvenlafaxine succinate PRISTIQ ER TAB ER 24H
100 MG
PA duloxetine hcl CYMBALTA CAPSULE DR
20 MG
PA duloxetine hcl CYMBALTA CAPSULE DR
30 MG
PA duloxetine hcl CYMBALTA CAPSULE DR
60 MG
PA venlafaxine hcl EFFEXOR 25MG TAB ER 24
37.5 MG
PA venlafaxine hcl EFFEXOR 25MG TAB ER 24 75
MG
PA venlafaxine hcl EFFEXOR 25MG TAB ER 24
150 MG
PA venlafaxine hcl EFFEXOR 25MG TAB ER 24
225 MG
venlafaxine hcl EFFEXOR 25MG TABLET 25
MG
venlafaxine hcl EFFEXOR 25MG TABLET 37.5
MG
venlafaxine hcl EFFEXOR 25MG TABLET 50
MG
venlafaxine hcl EFFEXOR 25MG TABLET 75
MG
venlafaxine hcl EFFEXOR 25MG TABLET 100
MG
venlafaxine hcl EFFEXOR 25MG CAP ER 24H
37.5 MG
venlafaxine hcl EFFEXOR 25MG CAP ER 24H
75 MG
venlafaxine hcl EFFEXOR 25MG CAP ER 24H
150 MG
Tricyclic Antidepressant/Phenothiazine Combinatns
perphenazine/amitriptyline hcl PERPHENAZINE/AMITRIPTYLINE HCL TABLET 2
MG-10 MG
perphenazine/amitriptyline hcl PERPHENAZINE/AMITRIPTYLINE HCL TABLET
4MG-10MG
perphenazine/amitriptyline hcl PERPHENAZINE/AMITRIPTYLINE HCL TABLET 2
MG-25 MG
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Comprehensive Alliance Drug Formulary – April 2012
perphenazine/amitriptyline hcl PERPHENAZINE/AMITRIPTYLINE HCL TABLET 4
MG-25 MG
perphenazine/amitriptyline hcl PERPHENAZINE/AMITRIPTYLINE HCL TABLET
4MG-50MG
Tricyclic Antidepressants & Rel. Non-Sel. Ru-Inhib
amitriptyline hcl AMITRIPTYLINE HCL TABLET 10
MG
amitriptyline hcl AMITRIPTYLINE HCL TABLET 100
MG
amitriptyline hcl AMITRIPTYLINE HCL TABLET 150
MG
amitriptyline hcl AMITRIPTYLINE HCL TABLET 25
MG
amitriptyline hcl AMITRIPTYLINE HCL TABLET 50
MG
amitriptyline hcl AMITRIPTYLINE HCL TABLET 75
MG
clomipramine hcl ANAFRANIL CAPSULE 25
MG
clomipramine hcl ANAFRANIL CAPSULE 50
MG
clomipramine hcl ANAFRANIL CAPSULE 75
MG
desipramine hcl NORPRAMIN TABLET 10
MG
desipramine hcl NORPRAMIN TABLET 100
MG
desipramine hcl NORPRAMIN TABLET 150
MG
desipramine hcl NORPRAMIN TABLET 25
MG
desipramine hcl NORPRAMIN TABLET 50
MG
desipramine hcl NORPRAMIN TABLET 75
MG
doxepin hcl DOXEPIN HCL CAPSULE 10
MG
doxepin hcl DOXEPIN HCL CAPSULE 100
MG
doxepin hcl DOXEPIN HCL CAPSULE 150
MG
doxepin hcl DOXEPIN HCL CAPSULE 25
MG
doxepin hcl DOXEPIN HCL CAPSULE 50
MG
doxepin hcl DOXEPIN HCL CAPSULE 75
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Comprehensive Alliance Drug Formulary – April 2012
MG
doxepin hcl DOXEPIN HCL ORAL CONC
10 MG/ML
imipramine hcl TOFRANIL TABLET 10
MG
imipramine hcl TOFRANIL TABLET 25
MG
imipramine hcl TOFRANIL TABLET 50
MG
nortriptyline hcl AVENTYL SOL CAPSULE 10
MG
nortriptyline hcl AVENTYL SOL CAPSULE 25
MG
nortriptyline hcl AVENTYL SOL CAPSULE 50
MG
nortriptyline hcl AVENTYL SOL CAPSULE 75
MG
nortriptyline hcl AVENTYL SOL SOLUTION 10
MG/5 ML
BEHAVIORAL HEALTH - OTHER
Adrenergics, Aromatic, Non-Catecholamine
AGE+ amphet asp/amphet/d-amphet ADDERALL CAP ER 24H
QL
10 MG
AGE+ amphet asp/amphet/d-amphet ADDERALL CAP ER 24H
QL
20 MG
AGE+ amphet asp/amphet/d-amphet ADDERALL CAP ER 24H
QL
30 MG
AGE+ amphet asp/amphet/d-amphet ADDERALL CAP ER 24H 5
QL
MG
AGE+ amphet asp/amphet/d-amphet ADDERALL CAP ER 24H
QL
15 MG
AGE+ amphet asp/amphet/d-amphet ADDERALL CAP ER 24H
QL
25 MG
QL amphet asp/amphet/d-amphet ADDERALL TABLET 7.5
MG
QL amphet asp/amphet/d-amphet ADDERALL TABLET 12.5
MG
QL amphet asp/amphet/d-amphet ADDERALL TABLET 15
MG
QL amphet asp/amphet/d-amphet ADDERALL TABLET 5
MG
QL amphet asp/amphet/d-amphet ADDERALL TABLET 10
MG
QL amphet asp/amphet/d-amphet ADDERALL TABLET 30
MG
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Comprehensive Alliance Drug Formulary – April 2012
QL amphet asp/amphet/d-amphet ADDERALL TABLET 20
MG
dextroamphetamine sulfate DEXEDRINE CAPSULE ER
10 MG
dextroamphetamine sulfate DEXEDRINE CAPSULE ER
15 MG
dextroamphetamine sulfate DEXEDRINE CAPSULE ER
5 MG
dextroamphetamine sulfate DEXEDRINE TABLET 10
MG
dextroamphetamine sulfate DEXEDRINE TABLET 5
MG
ST lisdexamfetamine dimesylate VYVANSE CAPSULE 30
MG
ST lisdexamfetamine dimesylate VYVANSE CAPSULE 50
MG
ST lisdexamfetamine dimesylate VYVANSE CAPSULE 70
MG
ST lisdexamfetamine dimesylate VYVANSE CAPSULE 20
MG
ST lisdexamfetamine dimesylate VYVANSE CAPSULE 40
MG
ST lisdexamfetamine dimesylate VYVANSE CAPSULE 60
MG
Anti-Alcoholic Preparations
disulfiram ANTABUSE TABLET 250
MG
disulfiram ANTABUSE TABLET 500
MG
Anti-Anxiety Drugs
alprazolam NIRAVAM TABLET 0.25
MG
alprazolam NIRAVAM TABLET 0.5
MG
alprazolam NIRAVAM TABLET 1
MG
alprazolam NIRAVAM TABLET 2
MG
alprazolam ALPRAZOLAM INTENSOL ORAL CONC
1 MG/ML
buspirone hcl VANSPAR TABLET 5
MG
buspirone hcl VANSPAR TABLET 10
MG
buspirone hcl VANSPAR TABLET 15
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Comprehensive Alliance Drug Formulary – April 2012
MG
PA buspirone hcl VANSPAR TABLET 30
MG
chlordiazepoxide LIBRITABS TABLET
25MG
chlordiazepoxide hcl LIBRIUM CAPSULE 10
MG
chlordiazepoxide hcl LIBRIUM CAPSULE 25
MG
chlordiazepoxide hcl LIBRIUM CAPSULE 5
MG
QL diazepam VALIUM TABLET 10
MG
QL diazepam VALIUM TABLET 2
MG
QL diazepam VALIUM TABLET 5
MG
lorazepam ATIVAN TABLET 0.5
MG
lorazepam ATIVAN TABLET 1
MG
lorazepam ATIVAN TABLET 2
MG
lorazepam ATIVAN ORAL CONC
2 MG/ML
PA oxazepam SERAX CAPSULE 10
MG
PA oxazepam SERAX CAPSULE 15
MG
PA oxazepam SERAX CAPSULE 30
MG
Barbiturates
phenobarbital PHENOBARBITAL ELIXIR 20
MG/5 ML
phenobarbital PHENOBARBITAL TABLET 15
MG
phenobarbital PHENOBARBITAL TABLET 60
MG
phenobarbital PHENOBARBITAL TABLET 30
MG
phenobarbital PHENOBARBITAL TABLET 100
MG
Sedative-Hypnotics,Non-Barbiturate
diphenhydramine hcl DIPHENHYDRAMINE HCL TABLET 50
MG
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Comprehensive Alliance Drug Formulary – April 2012
diphenhydramine hcl DIPHENHYDRAMINE HCL TABLET 25
MG
diphenhydramine hcl DIPHENHYDRAMINE HCL CAPSULE 50
MG
AGE flurazepam hcl DALMANE CAPSULE 15
MG
AGE flurazepam hcl DALMANE CAPSULE 30
MG
temazepam RESTORIL CAPSULE 15
MG
temazepam RESTORIL CAPSULE 30
MG
PA temazepam RESTORIL CAPSULE
22.5 MG
triazolam HALCION TABLET 0.25
MG
triazolam HALCION TABLET 0.125
MG
ST zaleplon SONATA CAPSULE 5
MG
ST zaleplon SONATA CAPSULE 10
MG
QL zolpidem tartrate AMBIEN CR TABLET 5
MG
QL zolpidem tartrate AMBIEN CR TABLET 10
MG
ST zolpidem tartrate AMBIEN CR TAB MPHASE
6.25 MG
ST zolpidem tartrate AMBIEN CR TAB MPHASE
12.5 MG
Tx For Attention Deficit-Hyperact(adhd)/Narcolepsy
QL dexmethylphenidate hcl FOCALIN TABLET 5
MG
QL dexmethylphenidate hcl FOCALIN TABLET 10
MG
ST methylphenidate DAYTRANA PATCH TD24
10MG/9HR
ST methylphenidate DAYTRANA PATCH TD24
15MG/9HR
ST methylphenidate DAYTRANA PATCH TD24
20 MG/9 HR
ST methylphenidate DAYTRANA PATCH TD24
30MG/9HR
AGE+ methylphenidate hcl RITALIN TAB ER 24 54
ST
MG
AGE+ methylphenidate hcl RITALIN TAB ER 24 18
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Comprehensive Alliance Drug Formulary – April 2012
ST
MG
AGE+ methylphenidate hcl RITALIN TAB ER 24 36
QL+
MG
ST
ST+
AGE
methylphenidate hcl METADATE CD CPMP 30-70
20 MG
methylphenidate hcl RITALIN TABLET 10
MG
methylphenidate hcl RITALIN TABLET 5
MG
methylphenidate hcl RITALIN TABLET 20
MG
QL methylphenidate hcl RITALIN TABLET ER
20 MG
AGE+ methylphenidate hcl RITALIN TAB ER 24 27
ST
MG
ST+
AGE
methylphenidate hcl METADATE CD CPMP 30-70
30 MG
ST+
AGE
methylphenidate hcl METADATE CD CPMP 30-70
10 MG
ST methylphenidate hcl RITALIN CPMP 50-50
20 MG
ST methylphenidate hcl RITALIN LA CPMP 50-50
10 MG
ST+
AGE
methylphenidate hcl METADATE CD CPMP 30-70
40 MG
ST+ methylphenidate hcl METADATE CD CPMP 30-70
AGE
ST+
AGE
50 MG
methylphenidate hcl METADATE CD CPMP 30-70
60 MG
QL methylphenidate hcl RITALIN TABLET ER
10 MG
CARDIOVASCULAR DISEASE -
ARRHYTHMIA
Antiarrhythmics
amiodarone hcl CORDARONE TABLET 200
MG
mexiletine hcl MEXITIL CAPSULE 150
MG
mexiletine hcl MEXITIL CAPSULE 200
MG
mexiletine hcl MEXITIL CAPSULE 250
MG
procainamide hcl PRONESTYL CAPSULE 375
Page 17 of 103

Comprehensive Alliance Drug Formulary – April 2012
MG
procainamide hcl PROCAINAMIDE HCL CAPSULE
500MG
procainamide hcl PROCAINAMIDE HCL TABLET SA
250MG
procainamide hcl PROCAINAMIDE HCL TABLET SA
500MG
propafenone hcl RYTHMOL SR TABLET 150
MG
propafenone hcl RYTHMOL SR TABLET 300
MG
propafenone hcl RYTHMOL SR TABLET 225
MG
quinidine gluconate QUINIDINE GLUCONATE TABLET ER
324 MG
quinidine sulfate QUINIDEX TABLET 200
MG
quinidine sulfate QUINIDEX TABLET 300
MG
quinidine sulfate QUINIDEX TABLET ER
300 MG
CARDIOVASCULAR DISEASE - CARDIAC
STIMULANT
Digitalis Glycosides
digoxin DIGOXIN SOLUTION 50
MCG/ML
digoxin LANOXIN TABLET 125
MCG
digoxin LANOXIN TABLET 250
MCG
CARDIOVASCULAR DISEASE -
HYPERTENSION
Ace Inhibitor/Calcium Channel Blocker Combination
PA amlodipine besylate/benazepril LOTREL CAPSULE
10MG-20MG
PA amlodipine besylate/benazepril LOTREL CAPSULE
5MG-40MG
PA amlodipine besylate/benazepril LOTREL CAPSULE
10MG-40MG
PA amlodipine besylate/benazepril LOTREL CAPSULE
5MG-20MG
Page 18 of 103

Comprehensive Alliance Drug Formulary – April 2012
PA amlodipine besylate/benazepril LOTREL CAPSULE 5
MG-10 MG
PA amlodipine besylate/benazepril LOTREL CAPSULE
2.5MG-10MG
Ace Inhibitor/Thiazide & Thiazide-Like Diuretic
benazepril/hydrochlorothiazide LOTENSIN HCT TABLET 5-
6.25MG
benazepril/hydrochlorothiazide LOTENSIN HCT TABLET 10-
12.5MG
benazepril/hydrochlorothiazide LOTENSIN HCT TABLET 20-
12.5 MG
benazepril/hydrochlorothiazide LOTENSIN HCT TABLET 20-
25MG
enalapril/hydrochlorothiazide VASERETIC TABLET
10MG-25MG
enalapril/hydrochlorothiazide VASERETIC TABLET
5MG-12.5MG
lisinopril/hydrochlorothiazide ZESTORETIC TABLET 20-
12.5 MG
lisinopril/hydrochlorothiazide ZESTORETIC TABLET 20-
25MG
lisinopril/hydrochlorothiazide ZESTORETIC TABLET 10-
12.5MG
Alpha-Adrenergic Blocking Agents
doxazosin mesylate CARDURA TABLET 1
MG
doxazosin mesylate CARDURA TABLET 2
MG
doxazosin mesylate CARDURA TABLET 4
MG
doxazosin mesylate CARDURA TABLET 8
MG
prazosin hcl MINIPRESS CAPSULE 1
MG
terazosin hcl HYTRIN CAPSULE 1
MG
terazosin hcl HYTRIN CAPSULE 2
MG
terazosin hcl HYTRIN CAPSULE 5
MG
terazosin hcl HYTRIN CAPSULE 10
MG
Alpha/Beta-Adrenergic Blocking Agents
carvedilol COREG TABLET 25
MG
Page 19 of 103

Comprehensive Alliance Drug Formulary – April 2012
carvedilol COREG TABLET 12.5
MG
carvedilol COREG TABLET 3.125
MG
carvedilol COREG TABLET 6.25
MG
PA carvedilol phosphate COREG CR CPMP 24HR
10 MG
PA carvedilol phosphate COREG CR CPMP 24HR
20 MG
PA carvedilol phosphate COREG CR CPMP 24HR
40 MG
PA carvedilol phosphate COREG CR CPMP 24HR
80 MG
labetalol hcl TRANDATE TABLET 300
MG
labetalol hcl TRANDATE TABLET 200
MG
labetalol hcl TRANDATE TABLET 100
MG
Angiotensin Receptor Antag./Thiazide Diuretic Comb
QL losartan/hydrochlorothiazide HYZAAR TABLET 50-
12.5 MG
QL losartan/hydrochlorothiazide HYZAAR TABLET
100MG-25MG
QL losartan/hydrochlorothiazide HYZAAR TABLET 100-
QL+
ST
QL+
ST
QL+
ST
QL+
ST
QL+
ST
12.5MG
valsartan/hydrochlorothiazide DIOVAN HCT TABLET 80-
12.5MG
valsartan/hydrochlorothiazide DIOVAN HCT TABLET 160-
12.5MG
valsartan/hydrochlorothiazide DIOVAN HCT TABLET 160-
25MG
valsartan/hydrochlorothiazide DIOVAN HCT TABLET
320MG-25MG
valsartan/hydrochlorothiazide DIOVAN HCT TABLET 320-
12.5MG
Antihypertensives, Ace Inhibitors
benazepril hcl LOTENSIN TABLET 5
MG
benazepril hcl LOTENSIN TABLET 10
MG
benazepril hcl LOTENSIN TABLET 20
MG
benazepril hcl LOTENSIN TABLET 40
Page 20 of 103

Comprehensive Alliance Drug Formulary – April 2012
MG
captopril CAPOTEN TABLET 100
MG
captopril CAPOTEN TABLET 25
MG
captopril CAPOTEN TABLET 50
MG
captopril CAPOTEN TABLET 12.5
MG
enalapril maleate VASOTEC TABLET 5
MG
enalapril maleate VASOTEC TABLET 10
MG
enalapril maleate VASOTEC TABLET 20
MG
enalapril maleate VASOTEC TABLET 2.5
MG
lisinopril PRINIVIL TABLET 5
MG
lisinopril PRINIVIL TABLET 10
MG
lisinopril PRINIVIL TABLET 20
MG
lisinopril PRINIVIL TABLET 40
MG
lisinopril PRINIVIL TABLET 2.5
MG
lisinopril PRINIVIL TABLET 30
MG
QL ramipril ALTACE CAPSULE
1.25 MG
QL ramipril ALTACE CAPSULE 2.5
MG
QL ramipril ALTACE CAPSULE 5
MG
ramipril ALTACE CAPSULE 10
MG
Antihypertensives, Angiotensin Receptor Antagonist
QL losartan potassium COZAAR TABLET 25
MG
QL losartan potassium COZAAR TABLET 50
MG
QL losartan potassium COZAAR TABLET 100
QL+
ST
MG
valsartan DIOVAN TABLET 320
MG
Page 21 of 103

Comprehensive Alliance Drug Formulary – April 2012
QL+
ST
QL+
ST
QL+
ST
valsartan DIOVAN TABLET 160
MG
valsartan DIOVAN TABLET 80
MG
valsartan DIOVAN TABLET 40
MG
Antihypertensives, Sympatholytic
QL+
ST
QL+
ST
QL+
ST
clonidine CATAPRES PATCH
TDWK
0.1MG/24HR
clonidine CATAPRES PATCH
TDWK
0.2MG/24HR
clonidine CATAPRES PATCH
TDWK
0.3MG/24HR
clonidine hcl CATAPRES TABLET 0.1
MG
clonidine hcl CATAPRES TABLET 0.2
MG
clonidine hcl CATAPRES TABLET 0.3
MG
guanfacine hcl TENEX TABLET 1
MG
guanfacine hcl TENEX TABLET 2
MG
methyldopa ALDOMET TABLET 125
MG
methyldopa ALDOMET TABLET 250
MG
methyldopa ALDOMET TABLET 500
MG
methyldopa/hydrochlorothiazide METHYLDOPA/HYDROCHLOROTHIAZIDE TABLET
methyldopa/hydrochlorothiazide
250MG-15MG
METHYLDOPA/HYDROCHLOROTHIAZIDE TABLET
250MG-25MG
methyldopa/hydrochlorothiazide ALDORIL-D50 TABLET
500MG-50MG
reserpine RESERPINE TABLET 0.25
MG
reserpine/hydrochlorothiazide RESERPINE/HYDROCHLOROTHIAZIDE TABLET
0.125-25MG
reserpine/hydrochlorothiazide RESERPINE/HYDROCHLOROTHIAZIDE TABLET
0.125-50MG
Antihypertensives, Vasodilators
Page 22 of 103

Comprehensive Alliance Drug Formulary – April 2012
hydralazine hcl APRESOLINE TABLET 10
MG
hydralazine hcl APRESOLINE TABLET 100
MG
hydralazine hcl APRESOLINE TABLET 25
MG
hydralazine hcl APRESOLINE TABLET 50
MG
minoxidil MINOXIDIL TABLET 10
MG
minoxidil MINOXIDIL TABLET 2.5
MG
Beta-Adrenergic Blocking Agents
atenolol TENORMIN TABLET 100
MG
atenolol TENORMIN TABLET 50
MG
atenolol TENORMIN TABLET 25
MG
ST metoprolol succinate TOPROL XL TAB ER 24H
25 MG
ST metoprolol succinate TOPROL XL TAB ER 24H
50 MG
ST metoprolol succinate TOPROL XL TAB ER 24H
100 MG
ST metoprolol succinate TOPROL XL TAB ER 24H
200 MG
metoprolol tartrate LOPRESSOR TABLET 25
MG
metoprolol tartrate LOPRESSOR TABLET 100
MG
metoprolol tartrate LOPRESSOR TABLET 50
MG
nadolol CORGARD TABLET 40
MG
nadolol CORGARD TABLET 80
MG
nadolol CORGARD TABLET 20
MG
PA nebivolol hcl BYSTOLIC TABLET 5
MG
PA nebivolol hcl BYSTOLIC TABLET 20
MG
PA nebivolol hcl BYSTOLIC TABLET 2.5
MG
PA nebivolol hcl BYSTOLIC TABLET 10
Page 23 of 103

Comprehensive Alliance Drug Formulary – April 2012
QL+
ST
QL+
ST
QL+
ST
QL+
ST
MG
pindolol PINDOLOL TABLET 10
MG
pindolol PINDOLOL TABLET 5
MG
propranolol hcl INDERAL LA CAP SA 24H
80 MG
propranolol hcl INDERAL LA CAP SA 24H
120 MG
propranolol hcl INDERAL LA CAP SA 24H
160 MG
propranolol hcl INDERAL LA CAP SA 24H
60 MG
propranolol hcl INDERAL LA TABLET 10
MG
propranolol hcl INDERAL LA TABLET 20
MG
propranolol hcl INDERAL LA TABLET 40
MG
propranolol hcl INDERAL LA TABLET 60
MG
propranolol hcl INDERAL LA TABLET 80
MG
propranolol hcl INDERAL LA SOLUTION 20
MG/5 ML
propranolol hcl INDERAL LA SOLUTION
40MG/5ML
QL sotalol hcl BETAPACE TABLET 160
MG
QL sotalol hcl BETAPACE TABLET 80
MG
QL sotalol hcl BETAPACE TABLET 240
MG
QL sotalol hcl BETAPACE TABLET 120
MG
Beta-Adrenergic Blocking Agents/Thiazide & Related
atenolol/chlorthalidone TENORETIC 50 TABLET 50
MG-25MG
atenolol/chlorthalidone TENORETIC 50 TABLET
100MG-25MG
bisoprolol fumarate/hctz ZIAC TABLET 2.5-
6.25MG
bisoprolol fumarate/hctz ZIAC TABLET 5-
6.25MG
bisoprolol fumarate/hctz ZIAC TABLET 10-
6.25MG
Page 24 of 103

Comprehensive Alliance Drug Formulary – April 2012
propranolol/hydrochlorothiazid INDERIDE-40/25 TABLET 40
MG-25MG
propranolol/hydrochlorothiazid INDERIDE-40/25 TABLET 80
MG-25MG
Calcium Channel Blocking Agents
QL amlodipine besylate NORVASC TABLET 2.5
MG
amlodipine besylate NORVASC TABLET 10
MG
QL amlodipine besylate NORVASC TABLET 5
MG
QL diltiazem hcl TIAZAC CAP ER 12H
90 MG
QL diltiazem hcl TIAZAC CAP ER 12H
120 MG
QL diltiazem hcl TIAZAC CAP ER 12H
60 MG
QL diltiazem hcl TIAZAC CAP ER 24H
180 MG
QL diltiazem hcl TIAZAC CAP ER 24H
240 MG
QL diltiazem hcl TIAZAC CAP ER 24H
300 MG
QL diltiazem hcl TIAZAC CAP ER 24H
120 MG
QL diltiazem hcl TIAZAC CAPSULE ER
360 MG
diltiazem hcl TIAZAC CAPSULE ER
300 MG
diltiazem hcl TIAZAC TABLET 30
MG
diltiazem hcl TIAZAC TABLET 60
MG
diltiazem hcl TIAZAC TABLET 90
MG
diltiazem hcl TIAZAC TABLET 120
MG
QL diltiazem hcl TIAZAC CAP ER DEG
180 MG
QL diltiazem hcl TIAZAC CAP ER DEG
240 MG
QL diltiazem hcl TIAZAC CAP ER DEG
120 MG
PA felodipine PLENDIL TAB ER 24H
2.5 MG
PA felodipine PLENDIL TAB ER 24H 5
Page 25 of 103

Comprehensive Alliance Drug Formulary – April 2012
MG
PA felodipine PLENDIL TAB ER 24H
10 MG
nicardipine hcl CARDENE I.V. CAPSULE 20
MG
nicardipine hcl CARDENE I.V. CAPSULE 30
MG
QL nifedipine ADALAT CC TAB ER 24 30
MG
QL nifedipine ADALAT CC TAB ER 24 60
MG
QL nifedipine ADALAT CC TAB ER 24 90
MG
QL nifedipine ADALAT CC TABLET ER
90 MG
QL nifedipine ADALAT CC TABLET ER
60 MG
QL nifedipine ADALAT CC TABLET ER
30 MG
QL nifedipine ADALAT CC CAPSULE 10
MG
QL nifedipine ADALAT CC CAPSULE 20
MG
verapamil hcl VERELAN TABLET 120
MG
verapamil hcl VERELAN TABLET 80
MG
QL verapamil hcl VERELAN CAP24H PEL
180 MG
verapamil hcl VERELAN CAP24H PEL
240 MG
QL verapamil hcl VERELAN CAP24H PEL
120 MG
QL verapamil hcl VERELAN CAP24H PEL
360 MG
verapamil hcl VERELAN TABLET ER
240 MG
QL verapamil hcl VERELAN TABLET ER
180 MG
QL verapamil hcl VERELAN TABLET ER
120 MG
verapamil hcl VERELAN TABLET 40
MG
Loop Diuretics
bumetanide BUMEX TABLET 0.5
MG
Page 26 of 103

Comprehensive Alliance Drug Formulary – April 2012
bumetanide BUMEX TABLET 1
MG
bumetanide BUMEX TABLET 2
MG
furosemide LASIX SOLUTION 10
MG/ML
furosemide LASIX TABLET 20
MG
furosemide LASIX TABLET 40
MG
furosemide LASIX TABLET 80
MG
Potassium Sparing Diuretics
spironolactone ALDACTONE TABLET 100
MG
spironolactone ALDACTONE TABLET 25
MG
spironolactone ALDACTONE TABLET 50
MG
Potassium Sparing Diuretics In Combination
spironolact/hydrochlorothiazid ALDACTAZIDE TABLET 25-
25MG
spironolact/hydrochlorothiazid ALDACTAZIDE TABLET 50
MG-50MG
triamterene/hydrochlorothiazid MAXZIDE CAPSULE
37.5-25MG
triamterene/hydrochlorothiazid MAXZIDE TABLET 75
MG-50MG
triamterene/hydrochlorothiazid MAXZIDE TABLET 37.5-
25MG
Pulm.anti-Htn,Sel.c-Gmp Phosphodiesterase T5 Inhib
AGE tadalafil ADCIRCA TABLET 20
MG
Pulmonary Anti-Htn, Endothelin Receptor Antagonist
AGE bosentan TRACLEER TABLET 125
MG
AGE bosentan TRACLEER TABLET 62.5
MG
Renin Inhibitor, Direct
PA aliskiren hemifumarate TEKTURNA TABLET 300
MG
PA aliskiren hemifumarate TEKTURNA TABLET 150
MG
Page 27 of 103

Comprehensive Alliance Drug Formulary – April 2012
Renin Inhibitor,Direct & Angiotensin Recept Antag.
PA aliskiren/valsartan VALTURNA TABLET 150-
160MG
PA aliskiren/valsartan VALTURNA TABLET 300-
320MG
Thiazide And Related Diuretics
chlorthalidone CHLORTHALIDONE TABLET 25
MG
chlorthalidone CHLORTHALIDONE TABLET 50
MG
hydrochlorothiazide MICROZIDE CAPSULE
12.5 MG
hydrochlorothiazide MICROZIDE TABLET 25
MG
hydrochlorothiazide MICROZIDE TABLET 50
MG
indapamide LOZOL TABLET 2.5
MG
indapamide LOZOL TABLET 1.25
QL+
ST
QL+
ST
QL+
ST
MG
metolazone ZAROXOLYN TABLET 10
MG
metolazone ZAROXOLYN TABLET 2.5
MG
metolazone ZAROXOLYN TABLET 5
MG
CARDIOVASCULAR DISEASE - LIPID
IRREGULARITY
Antihyperlipidemic - Hmg Coa Reductase Inhibitors
pravastatin sodium PRAVACHOL TABLET 80
MG
pravastatin sodium PRAVACHOL TABLET 10
MG
pravastatin sodium PRAVACHOL TABLET 20
MG
pravastatin sodium PRAVACHOL TABLET 40
MG
simvastatin ZOCOR TABLET 5
MG
simvastatin ZOCOR TABLET 10
MG
simvastatin ZOCOR TABLET 20
MG
Page 28 of 103

Comprehensive Alliance Drug Formulary – April 2012
simvastatin ZOCOR TABLET 40
MG
Bile Salt Sequestrants
cholestyramine (with sugar) QUESTRAN POWDER 4 G
QL cholestyramine/aspartame QUESTRAN LIGHT POWDER 4 G
QL cholestyramine/aspartame QUESTRAN LIGHT PACKET 4 G
colestipol hcl COLESTID PACKET 5 G
colestipol hcl COLESTID PACKET 7.5G
colestipol hcl COLESTID TABLET 1 G
colestipol hcl COLESTID GRANULES 5
G
Lipotropics
QL+
ST
QL+
ST
fenofibrate nanocrystallized TRICOR TABLET 48
MG
fenofibrate nanocrystallized TRICOR TABLET
145MG
gemfibrozil LOPID TABLET 600
MG
PA omega-3 acid ethyl esters LOVAZA CAPSULE 1 G
QL omega-3 fatty acids/fish oil FISH OIL OMEGA-3 CAPSULE
300-1000MG
QL omega-3 fatty acids/fish oil OMEGA-3 FATTY ACIDS/FISH OIL CAPSULE
340-1000MG
QL omega-3 fatty acids/fish oil FISH OIL OMEGA-3 CAPSULE
340-1000MG
QL omega-3 fatty acids/fish oil FISH OIL OMEGA-3 CAPSULE
396-1200MG
QL omega-3 fatty acids/vitamin e OMEGA-3 FATTY ACIDS/VITAMIN E CAPSULE
1000 MG
Niacin Preparations
niacin SLO-NIACIN CAPSULE ER
400 MG
niacin SLO-NIACIN CAPSULE ER
500 MG
niacin SLO-NIACIN CAPSULE ER
250 MG
niacin SLO-NIACIN CAPSULE ER
125 MG
niacin SLO-NIACIN TABLET 500
MG
niacin SLO-NIACIN TABLET
100MG
niacin SLO-NIACIN TABLET 250
MG
niacin SLO-NIACIN TABLET
Page 29 of 103

Comprehensive Alliance Drug Formulary – April 2012
50MG
niacin SLO-NIACIN TABLET ER
250 MG
niacin SLO-NIACIN TABLET ER
500 MG
niacin SLO-NIACIN TABLET ER
750 MG
niacin SLO-NIACIN TABLET ER
1000 MG
CARDIOVASCULAR DISEASE -
VASODILATION
Vasodilators,Coronary
isosorbide dinitrate ISORDIL TITRADOSE TABLET 10
MG
isosorbide dinitrate ISORDIL TITRADOSE TABLET 20
MG
isosorbide dinitrate ISORDIL TITRADOSE TABLET 5
MG
isosorbide dinitrate ISORDIL TITRADOSE TAB SUBL 5
MG
isosorbide dinitrate ISORDIL TITRADOSE TAB SUBL 2.5
MG
isosorbide mononitrate MONOKET TABLET 20
MG
isosorbide mononitrate MONOKET TABLET 10
MG
isosorbide mononitrate MONOKET TAB ER 24H
60 MG
isosorbide mononitrate MONOKET TAB ER 24H
120 MG
isosorbide mononitrate MONOKET TAB ER 24H
30 MG
nitroglycerin NITRO-DUR CAPSULE ER
2.5 MG
nitroglycerin NITRO-DUR CAPSULE ER
6.5 MG
nitroglycerin NITRO-DUR CAPSULE ER
9 MG
nitroglycerin NITRO-BID OINT. (G) 2 %
nitroglycerin NITRO-DUR PATCH TD24
0.4MG/HR
nitroglycerin NITRO-DUR PATCH TD24
0.2MG/HR
nitroglycerin NITRO-DUR PATCH TD24
Page 30 of 103

Comprehensive Alliance Drug Formulary – April 2012
0.3 MG/HR
nitroglycerin NITRO-DUR PATCH TD24
0.8MG/HR
nitroglycerin NITROSTAT TAB SUBL 0.3
MG
nitroglycerin NITROSTAT TAB SUBL 0.4
MG
nitroglycerin NITROSTAT TAB SUBL 0.6
MG
Vasodilators,Peripheral
ergoloid mesylates ERGOLOID MESYLATES TAB SUBL
1MG
CONTRACEPTION/OXYTOCICS
Contraceptives, Intravaginal, Systemic
etonogestrel/ethinyl estradiol NUVARING VAG RING
0.12-0.015
Contraceptives,Intravaginal
nonoxynol 9 DELFEN FOAM/APPL
12.5%
nonoxynol 9 GYNOL II JELLY/APPL
2 %
nonoxynol 9 GYNOL II JELLY/APPL
3 %
nonoxynol 9 SHUR-SEAL PACKET 2 %
Contraceptives,Oral
GEN desogestrel-ethinyl estradiol DESOGEN TABLET 0.15-
0.03
TABLET 0.03-
3MG
TABLET 0.02-
3(24)
PA+
GEN
ethinyl estradiol/drospirenone ETHINYL ESTRADIOL/DROSPIRENONE
YASMIN 28
PA+ ethinyl estradiol/drospirenone ETHINYL ESTRADIOL/DROSPIRENONE
GEN
YAZ
GEN ethynodiol d-ethinyl estradiol DEMULEN 1-50-21 TABLET 1
MG-35MCG
GEN ethynodiol d-ethinyl estradiol DEMULEN 1-50-21 TABLET 1
MG-50MCG
GEN levonorgestrel PLAN B ONE-STEP TABLET 1.5
MG
GEN levonorgestrel PLAN B TABLET 0.75
MG
GEN levonorgestrel-eth estradiol SEASONALE TABLET 0.15-
0.03
GEN levonorgestrel-eth estradiol SEASONALE TABLET 6-5-
10
Page 31 of 103

Comprehensive Alliance Drug Formulary – April 2012
GEN levonorgestrel-eth estradiol SEASONALE TABLET 0.1-
0.02
GEN noreth a-et estra/fe fumarate LOESTRIN FE TABLET 1.5-
0.03MG
GEN noreth a-et estra/fe fumarate LOESTRIN FE TABLET
1MG-20MCG
GEN noreth a-et estra/fe fumarate LOESTRIN FE TABLET 5-7-
9-7
GEN norethindrone MICRONOR TABLET 0.35
MG
GEN norethindrone a-e estradiol LOESTRIN TABLET 1.5-
0.03MG
GEN norethindrone a-e estradiol LOESTRIN TABLET
1MG-20MCG
GEN norethindrone-ethinyl estrad ORTHO-NOVUM TABLET 0.4-
0.035
GEN norethindrone-ethinyl estrad ORTHO-NOVUM TABLET 0.5-
0.035
GEN norethindrone-ethinyl estrad ORTHO-NOVUM TABLET 1
MG-35MCG
GEN norethindrone-ethinyl estrad OVCON-50 TABLET 1
MG-50MCG
GEN norethindrone-ethinyl estrad ORTHO-NOVUM TABLET 10-
11
GEN norethindrone-ethinyl estrad ORTHO-NOVUM TABLET 7
DAYS X 3
GEN norethindrone-ethinyl estrad ORTHO-NOVUM TABLET 7-9-5
GEN norethindrone-mestranol NORINYL 1+50 TABLET 1
MG-50MCG
GEN norgestimate-ethinyl estradiol ORTHO-CYCLEN TABLET 0.25-
0.035
GEN norgestimate-ethinyl estradiol ORTHO-CYCLEN TABLET
7DAYSX3 28
GEN norgestimate-ethinyl estradiol ORTHO TRI-CYCLEN LO TABLET
7DAYSX3 LO
GEN norgestrel-ethinyl estradiol LO-OVRAL-28 TABLET 0.3-
0.03MG
GEN norgestrel-ethinyl estradiol LO-OVRAL-28 TABLET 0.5-
0.05MG
Contraceptives,Transdermal
PA norelgestromin/ethin.estradiol ORTHO EVRA PATCH
TDWK 150-
20/24H
Diaphragms/Cervical Cap
diaphragm fitting set,arcsprng ORTHO ALL-FLEX EACH
Page 32 of 103

Comprehensive Alliance Drug Formulary – April 2012
WIDE SEAL DIAPHRAGM
Oxytocics
methylergonovine maleate METHERGINE TABLET 0.2
MG
COUGH AND COLD
1st Gen Antihistamine & Decongestant Combinations
p-ephed hcl/dp-hydram hcl BENADRYL-D TABLET 60-
25MG
p-ephed hcl/triprolidine hcl ZYMINE-D SYRUP 30-
1.25/5
p-ephed hcl/triprolidine hcl ZYMINE-D TABLET 60-
2.5MG
phenylephrine hcl/chlor-mal DALLERGY LIQUID 10-
4MG/5ML
phenylephrine hcl/prometh hcl PROMETHAZINE-PHENYLEPHRINE SYRUP 5-
6.25MG/5
pseudoephedrine hcl/chlor-mal TRIAMINIC COLD & ALLERGY SYRUP 15-
1MG/5ML
pseudoephedrine hcl/chlor-mal TRIAMINIC COLD & ALLERGY LIQUID 30-
2MG/5ML
pseudoephedrine hcl/chlor-mal TRIAMINIC COLD & ALLERGY TABLET 60
MG-4 MG
pseudoephedrine hcl/chlor-mal TRIAMINIC COLD & ALLERGY TABLET
60MG-4MG
pseudoephedrine/brompheniramin BROVEX PSB LIQUID 15-
1MG/5ML
1st Gen Antihistamine-Decongestant-Analgesic Comb
p-ephed hcl/acetaminophn/cp ACTIFED COLD & SINUS TABLET 30-
500-2MG
Antitussives,Non-Narcotic
dextromethorphan hbr SCOT-TUSSIN LIQUID 15
MG/5 ML
dextromethorphan hbr SCOT-TUSSIN SYRUP 10
MG/5 ML
dextromethorphan hbr SCOT-TUSSIN SYRUP 5
MG/5 ML
dextromethorphan hbr SCOT-TUSSIN SYRUP 15
MG/5 ML
dextromethorphan hbr SCOT-TUSSIN SYRUP
7.5MG/5ML
Cough And/Or Cold Preparations
dm hb/p-ephed hcl/apap/doxylam DM HB/P-EPHED HCL/APAP/DOXYLAM LIQUID
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Comprehensive Alliance Drug Formulary – April 2012
Decongestant-Expectorant Combinations
guaifenesin/p-ephed hcl POLY-VENT IR SYRUP 50-
15MG/5
guaifenesin/p-ephed hcl TUSNEL PEDIATRIC DROPS 50-
7.5MG/1
guaifenesin/p-ephed hcl POLY-VENT IR SYRUP 100-
30MG/5
guaifenesin/phenylephrine hcl LIQUIBID PD-R LIQUID 100-5
MG/5
guaifenesin/phenylephrine hcl NUMONYL LIQUID 225-
10MG/5
guaifenesin/phenylephrine hcl NUMONYL PEDIATRIC DROPS 45-
2MG/ML
Expectorants
guaifenesin MUCINEX SYRUP 100
MG/5ML
guaifenesin MUCINEX LIQUID 100
MG/5ML
guaifenesin MUCINEX LIQUID 100
MG/5ML
guaifenesin MUCINEX TABLET 400
MG
Narcotic Antituss-1st Gen. Antihistamine-Decongest
phenylephrine hcl/cod/prometh PHENYLEPHRINE HCL/COD/PROMETH SYRUP 5-10-
6.25
Narcotic Antitussive-1st Generation Antihistamine
codeine/promethazine hcl CODEINE/PROMETHAZINE HCL SYRUP 10-
6.25/5
Narcotic Antitussive-Anticholinergic Comb.
AGE hydrocodone bit/homatropine HYCODAN SYRUP 5-
1.5MG/5
Narcotic Antitussive-Expectorant Combination
guaifenesin/codeine phosphate PRO-CLEAR CAPS LIQUID 100-
10MG/5
guaifenesin/codeine phosphate PRO-CLEAR CAPS LIQUID 100-
10MG/5
Non-Narc Antitus-1st Gen Antihist-Decon-Analges Cb
dm/p-ephed/acetaminoph/doxylam VICKS NYQUIL LIQUID 15-
500/15
Non-Narc Antituss-1st Gen. Antihistamine-Decongest
d-methorphan hb/p-epd hcl/bpm DIMETANE-DX ELIXIR 5-15-
1MG/5
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Comprehensive Alliance Drug Formulary – April 2012
d-methorphan hb/p-ephed hcl/cp CHILD TRIAMINIC-D MT-SYM COLD SYRUP 15-15-
2/5
d-methorphan hb/p-ephed hcl/cp CHILD TRIAMINIC-D MT-SYM COLD LIQUID 5-10-
0.7/5
d-methorphan hb/p-ephed hcl/cp RESCON-DM LIQUID 10-30-
2/5
d-methorphan hb/p-ephed hcl/cp CHILD TRIAMINIC-D MT-SYM COLD SYRUP 15-30-
2/15
d-methorphan hb/p-ephed hcl/cp CHILD TRIAMINIC-D MT-SYM COLD LIQUID 7.5-
15-1/5
d-methorphan hb/p-ephed hcl/cp CHILD TRIAMINIC-D MT-SYM COLD LIQUID 5-15-
1MG/5
dm hb/p-ephed hcl/carbinox DM HB/P-EPHED HCL/CARBINOX SYRUP 15-60-
4/5
dm/phenyleph/chlorpheniramine ACCUHIST PDX SYRUP 15-10-
2/5
dm/phenyleph/chlorpheniramine ACCUHIST PDX LIQUID 15-10-
4/5
dm/phenyleph/chlorpheniramine ACCUHIST PDX SYRUP 15-5-
2MG/5
Non-Narc Antitussive-1st Gen Antihistamine Comb.
d-methorphan hb/prometh hcl PROMETHAZINE-DM SYRUP 15-
6.25/5
dextromethorphan hbr/chlor-mal CORICIDIN HBP LIQUID 15-
2MG/5ML
Non-Narcotic Antituss-Decongestant-Expectorant Cmb
guaifen/d-methorphan hb/pe BRONTUSS SF SYRUP 100-
10-5
guaifen/dm hb/p-ephedrine POLY-VENT DM LIQUID 67-10
guaifenesin/dm/pseudoephedrine POLY-VENT DM SYRUP 100-
10-30
guaifenesin/dm/pseudoephedrine RU-TUSS DM LIQUID 100-
15-45
Non-Narcotic Antitussive And Expectorant Comb.
guaifenesin/d-methorphan hb MUCINEX COUGH SYRUP 100-
10MG/5
guaifenesin/dextromethorphan MUCINEX COUGH SYRUP 200-
10MG/5
guaifenesin/dextromethorphan MUCINEX COUGH LIQUID 200-
10MG/5
guaifenesin/dextromethorphan MUCINEX COUGH SYRUP 100-
15MG/5
guaifenesin/dextromethorphan MUCINEX COUGH LIQUID 100-
10MG/5
guaifenesin/dextromethorphan MUCINEX COUGH LIQUID 200-
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Comprehensive Alliance Drug Formulary – April 2012
30MG/5
guaifenesin/dextromethorphan VICKS 44E COUGH & CHEST ELIXIR 66.7-
6.7/5
guaifenesin/dextromethorphan MUCINEX COUGH LIQUID 100-5
MG/5
guaifenesin/dextromethorphan MUCINEX COUGH LIQUID 100-
15MG/5
guaifenesin/dextromethorphan SCOT-TUSSIN SENIOR LIQUID 200-
15MG/5
Non-Narcotic Antitussive-Decongestant Combinations
d-methorphan hb/p-ephed hcl TRIAMINIC SYRUP 5-
15MG/5ML
d-methorphan hb/p-ephed hcl VICKS 44D COUGH & HEAD ELIXIR 10-
20MG/5
d-methorphan hb/p-ephed hcl PEDIACARE LIQUID 15-
30MG/5
d-methorphan hb/p-ephed hcl PEDIACARE DROPS 2.5-
7.5/.8
d-methorphan hb/p-ephed hcl PEDIACARE SYRUP 7.5-
15MG/5
Non-Narcotic Antitussive-Decongestant-Analgesic Cb
dm/pseudoephed/acetaminophen TYLENOL INFANTS PLUS COLD-COUG DROPS 5-15-
160MG
dm/pseudoephed/acetaminophen TYLENOL INFANTS PLUS COLD-COUG LIQUID 7.5-
15-160
Nose Preparations, Vasoconstrictors (rx)
QL epinephrine hcl ADRENALIN CHLORIDE SOLUTION
1:1000
Sympathomimetic Agents
ephedrine sulfate EPHEDRINE SULFATE CAPSULE 25
MG
phenylpropanolamine hcl PHENYLPROPANOLAMINE HCL TABLET
50MG
pseudoephedrine hcl SUDAFED DROPS
9.4MG/ML
pseudoephedrine hcl SUDAFED LIQUID 15
MG/5 ML
pseudoephedrine hcl SUDAFED SYRUP 30
MG/5 ML
pseudoephedrine hcl PSEUDOEPHEDRINE HCL TABLET 30
MG
pseudoephedrine hcl SUDAFED TABLET
60MG
pseudoephedrine hcl SUDAFED TABLET ER
Page 36 of 103

Comprehensive Alliance Drug Formulary – April 2012
120 MG
DERMATOLOGY - ACNE
Acne Agents,Topical
ST clindamycin phos/benzoyl perox BENZACLIN GEL (GRAM)
1 %-5 %
Astringents
aluminum acetate ALUMINUM ACETATE SOLUTION
Rosacea Agents, Topical
metronidazole METROLOTION GEL (GRAM)
0.75 %
metronidazole METROLOTION CREAM (G)
0.75 %
Topical Preparations,Antibacterials
chlorhexidine gluconate HIBICLENS LIQUID 4 %
chlorhexidine gluconate HIBICLENS LIQUID 4 %
chloroxylenol PERIGIENE LIQUID 0.5 %
chloroxylenol PERIGIENE CLEANSER
0.43%
Vitamin A Derivatives
AGE+ tretinoin RETIN-A GEL (GRAM)
QL
0.01 %
AGE+ tretinoin RETIN-A GEL (GRAM)
QL
0.025 %
AGE tretinoin RETIN-A CREAM (G)
0.05 %
AGE+ tretinoin RETIN-A CREAM (G)
QL
0.1 %
AGE+ tretinoin RETIN-A CREAM (G)
QL
0.025 %
AGE+ tretinoin microspheres
RETIN-A MICRO
GEL (GRAM)
QL
RETIN-A MICRO PUMP
0.04%
AGE+ tretinoin microspheres
RETIN-A MICRO
GEL (GRAM)
QL
RETIN-A MICRO PUMP
0.1 %
DERMATOLOGY - ANTIINFECTIVE
Topical Antibiotics
bacitracin BACITRACIN PACKET 500
UNIT/G
bacitracin BACITRACIN OINT. (G) 500
UNIT/G
bacitracin zinc BACITRACIN ZINC OINT. (G) 500
UNIT/G
Page 37 of 103

Comprehensive Alliance Drug Formulary – April 2012
bacitracin zinc BACITRACIN ZINC PACKET 500
UNIT/G
bacitracin zinc/polymyx b sulf BACITRACIN ZINC/POLYMYX B SULF OINT. (G) 500-
10K/G
bacitracin/polymyxin b sulfate POLYSPORIN OINT. (G) 500-
10K/G
bacitracin/polymyxin b sulfate POLYSPORIN PACKET
bacitracin/polymyxin b sulfate POLYSPORIN OINT. (G) 500-
10K/G
clindamycin phosphate EVOCLIN SOLUTION 1
%
clindamycin phosphate EVOCLIN LOTION 1 %
clindamycin phosphate EVOCLIN MED. SWAB 1
%
erythromycin base AKNE-MYCIN OINT. (G) 2 %
erythromycin base/ethanol ERYGEL GEL (GRAM)
2 %
erythromycin base/ethanol ERYGEL MED. SWAB 2
%
erythromycin base/ethanol ERYGEL SOLUTION 2
%
ST erythromycin/benzoyl peroxide BENZAMYCINPAK GEL (EA) 3 %-
5 %
ST erythromycin/benzoyl peroxide BENZAMYCIN GEL (GRAM)
3 %-5 %
gentamicin sulfate GENTAMICIN SULFATE CREAM (G)
0.1 %
gentamicin sulfate GENTAMICIN SULFATE OINT. (G) 0.1
%
Topical Antifungals
chloroxylenol SWEEN PREP MED. PAD 0.5
%
ciclopirox olamine LOPROX SUSPENSION
0.77%
clotrimazole MYCELEX CREAM (G) 1
%
clotrimazole MYCELEX SOLUTION 1
%
ketoconazole NIZORAL A-D SHAMPOO 1
%
ketoconazole NIZORAL SHAMPOO 2
%
ketoconazole NIZORAL CREAM (G) 2
%
miconazole nitrate FUNGOID TINCTURE CREAM (G) 2
%
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Comprehensive Alliance Drug Formulary – April 2012
miconazole nitrate FUNGOID TINCTURE POWDER 2 %
nystatin MYCOSTATIN CREAM (G)
100000/G
nystatin MYCOSTATIN OINT. (G)
100000/G
nystatin/triamcin MYCOGEN II CREAM (G)
100000-0.1
nystatin/triamcin MYCOGEN II OINT. (G)
100000-0.1
tolnaftate TINACTIN CREAM (G) 1
%
tolnaftate TINACTIN PACKET 1 %
tolnaftate TINACTIN SOLUTION 1
%
Topical Antiparasitics
crotamiton EURAX CREAM (G)
10 %
permethrin NIX CREAM (G) 5
%
permethrin NIX LIQUID 1 %
piperonyl butoxide/pyrethrins RID LIQUID 4%-
0.33%
piperonyl butoxide/pyrethrins RID SHAMPOO
4%-0.33%
piperonyl butoxide/pyrethrins RID SHAMPOO
4%-0.33%
piperonyl butoxide/pyrethrins RID LIQUID
piperonyl butoxide/pyrethrins RID SHAMPOO
4%-0.33%
Topical Sulfonamides
silver sulfadiazine SILVADENE CREAM (G) 1
%
DERMATOLOGY - ANTIINFLAMMATORY
Topical Anti-Inflammatory Steroidal
betamethasone dipropionate DIPROSONE CREAM (G)
0.05 %
betamethasone dipropionate DIPROSONE OINT. (G) 0.05
%
betamethasone dipropionate DIPROSONE LOTION 0.05
%
betamethasone valerate VALISONE CREAM (G)
0.1 %
betamethasone valerate VALISONE OINT. (G) 0.1
%
Page 39 of 103

Comprehensive Alliance Drug Formulary – April 2012
betamethasone valerate VALISONE LOTION 0.1 %
clobetasol propionate OLUX SOLUTION
0.05 %
clobetasol propionate OLUX OINT. (G) 0.05
%
clobetasol propionate OLUX CREAM (G)
0.05 %
desonide TRIDESILON CREAM (G)
0.05 %
desonide TRIDESILON OINT. (G) 0.05
%
fluocinolone acetonide DERMA-SMOOTHE-FS CREAM (G)
0.01 %
fluocinolone acetonide DERMA-SMOOTHE-FS CREAM (G)
0.025 %
fluocinolone acetonide DERMA-SMOOTHE-FS OINT. (G)
0.025 %
fluocinolone acetonide DERMA-SMOOTHE-FS SOLUTION
0.01 %
fluocinonide LIDEX GEL (GRAM)
0.05 %
fluocinonide LIDEX CREAM (G)
0.05 %
fluocinonide LIDEX OINT. (G) 0.05
%
fluocinonide LIDEX SOLUTION
0.05 %
fluocinonide/emollient LIDEX-E CREAM (G)
0.05 %
fluticasone propionate CUTIVATE CREAM (G)
0.05 %
fluticasone propionate CUTIVATE OINT. (G)
0.005 %
hc/mineral oil/petrolat,wht HC/MINERAL OIL/PETROLAT,WHT OINT. (G) 1 %
hydrocortisone CORTIZONE-10 SOLUTION 1
%
hydrocortisone CORTIZONE-10 LOTION 2 %
hydrocortisone CORTIZONE-10 SPRAY 1 %
hydrocortisone CORTIZONE-10 CREAM (G)
0.5 %
hydrocortisone CORTIZONE-10 CREAM (G) 1
%
QL hydrocortisone CORTIZONE-10 CREAM (G)
2.5 %
hydrocortisone CORTIZONE-10 OINT. (G) 0.5
%
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Comprehensive Alliance Drug Formulary – April 2012
hydrocortisone CORTIZONE-10 OINT. (G) 1 %
hydrocortisone CORTIZONE-10 OINT. (G) 2.5
%
hydrocortisone CORTIZONE-10 LOTION 1 %
hydrocortisone CORTIZONE-10 LOTION 2.5 %
QL hydrocortisone acetate CORTAID CREAM (G) 1
%
QL hydrocortisone acetate CORTAID CREAM (G)
0.5 %
QL hydrocortisone acetate CORTAID OINT. (G) 1 %
hydrocortisone acetate/alo ver NUZON OINT.(GM)
0.5%
hydrocortisone acetate/aloe v NUZON CREAM (G)
0.5 %
triamcinolone acetonide KENALOG CREAM (G)
0.025 %
triamcinolone acetonide KENALOG CREAM (G)
0.1 %
triamcinolone acetonide KENALOG CREAM (G)
0.5 %
triamcinolone acetonide KENALOG OINT. (G)
0.025 %
triamcinolone acetonide KENALOG OINT. (G) 0.1
%
triamcinolone acetonide KENALOG OINT. (G) 0.05
%
triamcinolone acetonide KENALOG CREAM 1%
triamcinolone acetonide KENALOG LOTION 0.025
%
triamcinolone acetonide KENALOG LOTION 0.1 %
DERMATOLOGY - ANTIPRURITIC DRUGS
Antipruritics,Topical
diphenhydramine hcl BENADRYL ITCH STOPPING CREAM (G) 2
%
diphenhydramine hcl BENADRYL ITCH STOPPING SPRAY 2%
diphenhydramine hcl BENADRYL SPRAY 1%
diphenhydramine hcl DERMA-PAX LOTION 0.5 %
diphenhydramine hcl BENADRYL ITCH STOPPING GEL (ML) 2 %
diphenhydramine hcl/zinc acet BENADRYL ITCH STOPPING CREAM (G) 2
%-0.1 %
DERMATOLOGY - MISCELLANEOUS
Antiseborrheic Agents
selenium sulfide SELSUN RX SUSPENSION
Page 41 of 103

Comprehensive Alliance Drug Formulary – April 2012
Antiseptics,General
alcohol antiseptic pads
ALCOHOL PREP PADS
ALCOHOL SWABS
SINGLE USE SWAB
SURE COMFORT ALCOHOL
WEBCOL
2.5 %
MED. PAD
Emollients
ammonium lactate LAC-HYDRIN LOTION 12%
Irrigants
sod chloride/b-6/zinc acet/ca WOUND CLEANSER SPRAY
QL sodium chloride irrig solution SODIUM CHLORIDE IRRIG SOLUTION IRRIG SOLN
0.9 %
Irritants/Counter-Irritants
coal tar CUTAR L.C.D. EMULSION
7.5 %
coal tar DHS TAR CREAM (G) 2
%
Keratolytics
benzoyl peroxide BENZAC AC GEL (GRAM)
10 %
benzoyl peroxide BENZAC AC GEL (GRAM)
5 %
benzoyl peroxide BENZAC AC GEL (GRAM)
2.5 %
benzoyl peroxide BENZAC AC CLEANSER 5
%
benzoyl peroxide BENZAC AC LOTION 10 %
benzoyl peroxide BENZAC AC LOTION 5 %
benzoyl peroxide ON-THE-SPOT CREAM (G)
2.5 %
podofilox CONDYLOX GEL (GRAM)
0.5 %
podofilox CONDYLOX SOLUTION
0.5 %
salicylic acid VIRASAL LIQUID 3 %
Protectives
calamine CALAMINE LOTION
zinc oxide ZINC OXIDE OINT. (G) 20
%
Topical Antineoplastic & Premalignant Lesion Agnts
fluorouracil CARAC CREAM (G)
0.5 %
Page 42 of 103

Comprehensive Alliance Drug Formulary – April 2012
fluorouracil FLUOROPLEX CREAM (G) 1
%
fluorouracil EFUDEX CREAM (G) 5
%
fluorouracil EFUDEX SOLUTION 2
%
fluorouracil EFUDEX SOLUTION 5
%
Topical Local Anesthetics
lidocaine hcl LIDAMANTLE SOLUTION 4
%
lidocaine hcl LIDAMANTLE OINT. (G) 5 %
Topical Preparations,Miscellaneous
calcium acetate/aluminum sulf DOMEBORO PACKET
DERMATOLOGY - PSORIASIS/ECZEMA
Antipsoriatics Agents
calcipotriene DOVONEX OINT. (G)
0.005 %
calcipotriene DOVONEX CREAM
0.005%
calcipotriene DOVONEX SOLUTION
0.005 %
Topical Immunosuppressive Agents
AGE+ pimecrolimus ELIDEL CREAM (G) 1
ST
%
AGE+ tacrolimus PROTOPIC OINT. (G) 0.03
QL+
%
ST
AGE+ tacrolimus PROTOPIC OINT. (G) 0.1
QL+
ST
%
DIABETES
Antihypergly, (dpp-4) Inhibitor & Biguanide Comb.
QL+
ST
QL+
ST
sitagliptin phos/metformin hcl JANUMET TABLET
50MG-500MG
sitagliptin phos/metformin hcl JANUMET TABLET 50-
1000 MG
Antihyperglycemic, Alpha-Glucosidase Inhib (n-S)
ST acarbose PRECOSE TABLET 100
MG
ST acarbose PRECOSE TABLET 50
Page 43 of 103

Comprehensive Alliance Drug Formulary – April 2012
MG
ST acarbose PRECOSE TABLET 25
MG
Antihyperglycemic, Dpp-4 Inhibitors
PA linagliptin TRADJENTA TABLET 5
MG
PA saxagliptin hcl ONGLYZA TABLET 2.5
MG
PA saxagliptin hcl ONGLYZA TABLET 5
QL+
ST
QL+
ST
QL+
ST
MG
sitagliptin phosphate JANUVIA TABLET 25
MG
sitagliptin phosphate JANUVIA TABLET 50
MG
sitagliptin phosphate JANUVIA TABLET 100
MG
Antihyperglycemic, Insulin-Release Stimulant Type
chlorpropamide DIABINESE TABLET 100
MG
chlorpropamide DIABINESE TABLET 250
MG
glimepiride AMARYL TABLET 1
MG
glimepiride AMARYL TABLET 2
MG
glimepiride AMARYL TABLET 4
MG
glipizide GLUCOTROL XL TABLET 5
MG
glipizide GLUCOTROL XL TABLET 10
MG
glipizide GLUCOTROL XL TAB ER 24 10
MG
glipizide GLUCOTROL XL TAB ER 24 5
MG
glipizide GLUCOTROL XL TAB ER 24 2.5
MG
glyburide MICRONASE TABLET 1.25
MG
glyburide MICRONASE TABLET 2.5
MG
glyburide MICRONASE TABLET 5
MG
glyburide,micronized GLYNASE TABLET 1.5
MG
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Comprehensive Alliance Drug Formulary – April 2012
glyburide,micronized GLYNASE TABLET 3
MG
glyburide,micronized GLYNASE TABLET 6
MG
tolazamide TOLAZAMIDE TABLET 250
MG
tolazamide TOLAZAMIDE TABLET 500
MG
tolbutamide TOLBUTAMIDE TABLET 500
MG
Antihyperglycemic, Insulin-Response Enhancer (n-S)
QL+
ST
QL+
ST
QL+
ST
QL+
ST
QL+
ST
QL+
ST
pioglitazone hcl ACTOS TABLET 15
MG
pioglitazone hcl ACTOS TABLET 30
MG
pioglitazone hcl ACTOS TABLET 45
MG
rosiglitazone maleate AVANDIA TABLET 2
MG
rosiglitazone maleate AVANDIA TABLET 4
MG
rosiglitazone maleate AVANDIA TABLET 8
MG
Antihyperglycemic,Biguanide Type(non-Sulfonylurea)
metformin hcl GLUCOPHAGE TABLET 500
MG
metformin hcl GLUCOPHAGE TABLET 850
MG
metformin hcl GLUCOPHAGE TABLET 1000
MG
QL metformin hcl GLUCOPHAGE TAB ER 24H
750 MG
QL metformin hcl GLUCOPHAGE TAB ER 24H
500 MG
Antihyperglycemic,Insulin-Rel Stim.& Biguanide Cmb
QL glyburide/metformin hcl GLUCOVANCE TABLET 1.25-
250MG
glyburide/metformin hcl GLUCOVANCE TABLET 5
MG-500MG
QL glyburide/metformin hcl GLUCOVANCE TABLET 2.5-
500 MG
Antihyperglycm,Insul-Resp.enhancer & Biguanide Cmb
QL+
ST
pioglitazone hcl/metformin hcl ACTOPLUS MET TABLET
15MG-500MG
Page 45 of 103

Comprehensive Alliance Drug Formulary – April 2012
QL+
ST
QL+
ST
QL+
ST
QL+
ST
QL+
ST
pioglitazone hcl/metformin hcl ACTOPLUS MET TABLET
15MG-850MG
rosiglitazone/metformin hcl AVANDAMET TABLET 2-
1000MG
rosiglitazone/metformin hcl AVANDAMET TABLET 4-
1000MG
rosiglitazone/metformin hcl AVANDAMET TABLET 2
MG-500MG
rosiglitazone/metformin hcl AVANDAMET TABLET 4-
500MG
Blood Sugar Diagnostics
PA+
QL
blood sugar diagnostic
ACCU-CHEK AVIVA
CONTOUR
FREESTYLE LITE STRIPS
ONE TOUCH ULTRA TEST STRIPS
TRUETRACK TEST STRIP
Diabetic Supplies
QL blood-glucose meter TRUETRACK SMART SYSTEM KIT
diabetic supplies,miscell NEEDLE FREE INSULIN SYR KIT KIT
Hyperglycemics
QL glucagon,human recombinant GLUCAGEN
GLUCAGON EMERGENCY KIT
Insulins
QL hum insulin nph/reg insulin hm HUMULIN 70-30
NOVOLIN 70-30
STRIP
KIT 1 MG
VIAL 70-
30/ML
QL insulin aspart NOVOLOG VIAL 100/ML
PA insulin detemir LEVEMIR INSULN PEN
100/ML (3)
QL+ insulin detemir LEVEMIR VIAL 100/ML
ST
QL insulin glargine,hum.rec.anlog LANTUS VIAL 100/ML
QL insulin lispro HUMALOG VIAL 100/ML
QL insulin npl/insulin lispro HUMALOG MIX 75-25 VIAL 75-
25/ML
QL insulin npl/insulin lispro HUMALOG MIX 50-50 VIAL 50-
50/ML
QL insulin regular, human HUMULIN R VIAL 500/ML
QL insulin regular, human HUMULIN R
VIAL 100/ML
NOVOLIN R
QL insuln asp prt/insulin aspart NOVOLOG MIX 70-30 VIAL 70-
30/ML
QL nph, human insulin isophane HUMULIN N
NOVOLIN N
VIAL 100/ML
Urine Glucose Test Aids
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Comprehensive Alliance Drug Formulary – April 2012
urine glucose test,strip
DIASCREEN 1G REAGENT
DIASTIX REAGENT
STRIP
EAR - GENERAL DISORDERS
Ear Preparations, Misc. Anti-Infectives
acetic acid ACETIC ACID SOLUTION 2
%
acetic acid/aluminum acetate DOMEBORO DROPS 2 %
acetic acid/hydrocortisone VOSOL HC DROPS 2 %-1
%
Ear Preparations,Antibiotics
neomycin/polymyxin b sulf/hc CORTISPORIN SOLUTION
3.5-10K-1
neomycin/polymyxin b sulf/hc CORTISPORIN DROPS SUSP
3.5-10K-1
ofloxacin FLOXIN DROPS 0.3 %
Ear Preparations,Local Anesthetics
antipyrine/benzocaine/glycerin OTRA NR DROPS 5.4 %-
1.4%
ELECTROLYTE REGULATION
Electrolyte Depleters
calcium acetate PHOSLO TABLET 667
MG
calcium acetate PHOSLO CAPSULE 667
MG
calcium acetate PHOSLO TABLET 667
MG
Electrolyte Maintenance
electrolyte,oral PEDIALYTE SOLUTION
Potassium Replacement
potassium bicarbonate QUIC-K TABLET EFF
6.5MEQ
potassium chloride MICRO-K CAPSULE ER
8 MEQ
potassium chloride MICRO-K CAPSULE ER
10 MEQ
potassium chloride MICRO-K PACKET 20
MEQ
potassium chloride MICRO-K PACKET 25
MEQ
potassium chloride MICRO-K LIQUID
40MEQ/15ML
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Comprehensive Alliance Drug Formulary – April 2012
potassium chloride MICRO-K LIQUID
20MEQ/15ML
potassium chloride MICRO-K TABLET SA
10MEQ
potassium chloride MICRO-K TAB ER PRT
10 MEQ
potassium chloride MICRO-K TAB ER PRT
20 MEQ
potassium chloride MICRO-K TABLET ER 8
MEQ
ENDOCRINE DISORDER - OTHER
Antidiuretic And Vasopressor Hormones
ST desmopressin (nonrefrigerated) DDAVP SPRAY/PUMP
10/SPRAY
ST desmopressin acetate DDAVP SOLUTION
0.1 MG/ML
ST desmopressin acetate DDAVP TABLET 0.1
MG
ST desmopressin acetate DDAVP TABLET 0.2
MG
Bone Resorption Inhibitors
QL alendronate sodium FOSAMAX TABLET 35
MG
QL alendronate sodium FOSAMAX SOLUTION 70
MG/75ML
QL alendronate sodium FOSAMAX TABLET 10
MG
QL alendronate sodium FOSAMAX TABLET 40
MG
QL alendronate sodium FOSAMAX TABLET 5
MG
QL alendronate sodium FOSAMAX TABLET 70
PA calcitonin,salmon,synthetic CALCITONIN,SALMON,SYNTHETIC
MIACALCIN
FORTICAL
MG
SPRAY/PUMP
200/DOSE
PA raloxifene hcl EVISTA TABLET 60
MG
ENDOCRINE DISORDER - THYROID
Antithyroid Preparations
methimazole TAPAZOLE TABLET 20
MG
methimazole TAPAZOLE TABLET 10
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Comprehensive Alliance Drug Formulary – April 2012
MG
methimazole TAPAZOLE TABLET 5
MG
propylthiouracil PROPYLTHIOURACIL TABLET 50
MG
Iodine Containing Agents
potassium iodide POTASSIUM IODIDE SOLUTION
1G/ML
Thyroid Hormones
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
levothyroxine sodium
LEVOTHROID
LEVOXYL
SYNTHROID
LEVOTHROID
LEVOXYL
SYNTHROID
LEVOTHROID
LEVOXYL
SYNTHROID
LEVOTHROID
LEVOXYL
SYNTHROID
LEVOTHROID
LEVOXYL
SYNTHROID
LEVOTHROID
LEVOXYL
SYNTHROID
LEVOTHROID
LEVOXYL
SYNTHROID
LEVOTHROID
LEVOXYL
SYNTHROID
LEVOTHROID
LEVOXYL
SYNTHROID
LEVOTHROID
SYNTHROID
UNITHROID
LEVOTHROID
LEVOXYL
SYNTHROID
LEVOTHROID
LEVOXYL
SYNTHROID
TABLET 112
MCG
TABLET 25
MCG
TABLET 50
MCG
TABLET 100
MCG
TABLET 75
MCG
TABLET 200
MCG
TABLET 125
MCG
TABLET 150
MCG
TABLET
175MCG
TABLET 300
MCG
TABLET 88
MCG
TABLET 137
MCG
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Comprehensive Alliance Drug Formulary – April 2012
liothyronine sodium CYTOMEL TABLET 25
MCG
liothyronine sodium CYTOMEL TABLET 5
MCG
liothyronine sodium CYTOMEL TABLET 50
MCG
thyroid,pork ARMOUR THYROID TABLET 120
MG
thyroid,pork ARMOUR THYROID TABLET 30
MG
thyroid,pork ARMOUR THYROID TABLET 300
MG
thyroid,pork ARMOUR THYROID TABLET 60
MG
thyroid,pork ARMOUR THYROID TABLET 15
MG
thyroid,pork ARMOUR THYROID TABLET 90
MG
thyroid,pork ARMOUR THYROID TABLET 180
MG
thyroid,pork ARMOUR THYROID TABLET 240
MG
thyroid,pork ARMOUR THYROID TABLET 195
MG
thyroid,pork ARMOUR THYROID TABLET 16.25
MG
thyroid,pork ARMOUR THYROID TABLET 32.5
MG
thyroid,pork ARMOUR THYROID TABLET 65
MG
thyroid,pork ARMOUR THYROID TABLET 130
MG
EYE - GENERAL DISORDERS
Eye Antibiotic-Corticoid Combinations
gentamicin/prednisol ac PRED-G DROPS SUSP
0.3%-1%
gentamicin/prednisol ac PRED-G OINT. (G) 0.3-
0.6%
neo/polymyx b sulf/dexameth MAXITROL OINT. (G) 3.5-
10K-.1
neo/polymyx b sulf/dexameth MAXITROL DROPS SUSP
0.1 %
neomy sulf/bacitrac zn/poly/hc TRIPLE ANTIBIOTIC HC OINT. (G) 3.5-
10K-1
neomycin sulfate/dex na ph NEOMYCIN SULFATE/DEX NA PH DROPS 0.35-
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Comprehensive Alliance Drug Formulary – April 2012
0.1%
tobramycin sulf/dexamethasone TOBRADEX OINT. (G)
0.3%-0.1%
Eye Antihistamines
QL ketotifen fumarate ZADITOR DROPS 0.025
%
Eye Antiinflammatory Agents
PA dexamethasone MAXIDEX DROPS SUSP
0.1 %
dexamethasone sod phosphate DECADRON OINT. (G) 0.05
%
dexamethasone sod phosphate DEXASOL DROPS 0.1 %
ST diclofenac sodium VOLTAREN DROPS 0.1 %
fluorometholone FLUOROMETHOLONE DROPS SUSP
0.1 %
flurbiprofen sodium OCUFEN DROPS 0.03 %
ST ketorolac tromethamine ACULAR LS DROPS 0.4 %
ST ketorolac tromethamine ACULAR LS DROPS 0.5 %
prednisolone acetate PRED MILD DROPS SUSP
0.12 %
prednisolone acetate PRED FORTE DROPS SUSP
1 %
prednisolone sod phosphate PREDNISOL DROPS 1 %
Eye Antivirals
trifluridine VIROPTIC DROPS 1 %
Eye Local Anesthetics
proparacaine hcl OPHTHETIC DROPS 0.5 %
tetracaine hcl TETRAVISC DROPS 0.5 %
Eye Sulfonamides
na sulfacetm/prednis sp NA SULFACETM/PREDNIS SP DROPS 10-
0.25%
sulfacetamide sodium SULFAC OINT. (G) 10
%
sulfacetamide sodium SULFAC DROPS 10 %
sulfacetm na/prednisol ac BLEPHAMIDE S.O.P. OINT. (G) 10
%-0.2 %
PA sulfacetm na/prednisol ac BLEPHAMIDE DROPS SUSP
10 %-0.2 %
Eye Vasoconstrictors (otc Only)
naphazoline hcl NAPHCON DROPS
0.012%
naphazoline hcl/phenir mal OPCON-A DROPS .0268-
.315
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Comprehensive Alliance Drug Formulary – April 2012
naphazoline hcl/phenir mal OPCON-A DROPS .0268-
.315
Eye Vasoconstrictors (rx Only)
naphazoline hcl ALBALON DROPS 0.1 %
phenylephrine hcl MYDFRIN DROPS 10 %
phenylephrine hcl MYDFRIN DROPS 2.5 %
Ophthalmic Antibiotics
bacitracin BACITRACIN OINT. (G) 500
UNIT/G
bacitracin/polymyxin b sulfate POLYSPORIN OINT. (G) 500-
10K/G
bacitracin/polymyxin b sulfate POLYSPORIN OINT. (G) 500-
10K/G
ST ciprofloxacin hcl CILOXAN OINT. (G) 0.3
%
QL ciprofloxacin hcl CILOXAN DROPS 0.3 %
erythromycin base ILOTYCIN OINT. (G)
5MG/G
gentamicin sulfate GARAMYCIN OINT. (G) 0.3
%
gentamicin sulfate GARAMYCIN DROPS 0.3 %
neomy sulf/bacitra/polymyxin b NEOSPORIN OINT. (G)
neomycin/polymyxn b/gramicidin
3.5MG-400
NEOMYCIN/POLYMYXN B/GRAMICIDIN DROPS
1.75MG-10K
QL ofloxacin OCUFLOX DROPS 0.3 %
polymyxin b sulfate/tmp POLYTRIM DROPS
10K/ML-0.1
tobramycin sulfate TOBREX DROPS 0.3 %
Ophthalmic Mast Cell Stabilizers
cromolyn sodium CROMOLYN SODIUM DROPS 4 %
Ophthalmic Preparations, Miscellaneous
sodium chloride SODIUM CHLORIDE OINT. (G) 5 %
sodium chloride SODIUM CHLORIDE DROPS 5 %
EYE - GLAUCOMA
Carbonic Anhydrase Inhibitors
acetazolamide DIAMOX SEQUELS CAPSULE ER
500 MG
acetazolamide DIAMOX SEQUELS TABLET 125
MG
acetazolamide DIAMOX SEQUELS TABLET 250
MG
methazolamide NEPTAZANE TABLET 50
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Comprehensive Alliance Drug Formulary – April 2012
MG
methazolamide NEPTAZANE TABLET 25
MG
Miotics/Other Intraoc. Pressure Reducers
PA apraclonidine hcl IOPIDINE DROPERETTE
1 %
brimonidine tartrate ALPHAGAN P DROPS 0.2 %
PA brinzolamide AZOPT DROPS SUSP
1 %
PA carbachol ISOPTO CARBACHOL DROPS 1.5 %
carbachol ISOPTO CARBACHOL DROPS 3 %
dorzolamide hcl TRUSOPT DROPS 2 %
dorzolamide hcl/timolol maleat COSOPT DROPS 2%-
0.5%
echothiophate iodide PHOSPHOLINE IODIDE DROPS 0.125
%
latanoprost XALATAN DROPS 0.005
%
levobunolol hcl BETAGAN DROPS 0.5 %
levobunolol hcl BETAGAN DROPS 0.25 %
metipranolol OPTIPRANOLOL DROPS 0.3 %
pilocarpine hcl ISOPTO CARPINE DROPS 1 %
pilocarpine hcl ISOPTO CARPINE DROPS 2%
pilocarpine hcl ISOPTO CARPINE DROPS 4%
pilocarpine hcl ISOPTO CARPINE DROPS 8 %
timolol maleate TIMOPTIC-XE DROPS 0.25 %
timolol maleate TIMOPTIC-XE DROPS 0.5 %
PA timolol maleate/pf TIMOPTIC OCUDOSE DROPERETTE
0.25 %
PA timolol maleate/pf TIMOPTIC OCUDOSE DROPERETTE
0.5 %
Mydriatics
atropine sulfate ISOPTO ATROPINE OINT. (G) 1 %
atropine sulfate ISOPTO ATROPINE DROPS 1 %
cyclopentolate hcl CYCLOGYL DROPS 0.5 %
cyclopentolate hcl CYCLOGYL DROPS 1 %
cyclopentolate hcl CYCLOGYL DROPS 2 %
homatropine hbr ISOPTO HOMATROPINE DROPS 2 %
homatropine hbr ISOPTO HOMATROPINE DROPS 5 %
scopolamine hydrobromide ISOPTO HYOSCINE DROPS 0.25 %
tropicamide MYDRIACYL DROPS 0.5 %
tropicamide MYDRIACYL DROPS 1 %
EYE - MISCELLANEOUS
Artificial Tears
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Comprehensive Alliance Drug Formulary – April 2012
glycerin/propylene glycol HYPOTEARS DROPS 0.3%-
1%
Contact Lens Preparations
sodium chloride SODIUM CHLORIDE SPRAY 0.9 %
Eye Preparations, Miscellaneous (otc)
tyloxapol ENUCLENE DROPS 0.25 %
GOUT AND RELATED DISEASES
Colchicine
colchicine COLCHICINE TABLET
0.6MG
colchicine/probenecid COLCHICINE/PROBENECID TABLET 0.5-
500MG
Hyperuricemia Tx - Purine Inhibitors
allopurinol ZYLOPRIM TABLET 100
MG
allopurinol ZYLOPRIM TABLET 300
MG
Uricosuric Agents
probenecid PROBENECID TABLET 500
MG
HEMATOLOGICAL DISORDERS
Anticoagulants,Coumarin Type
warfarin sodium COUMADIN TABLET 10
MG
warfarin sodium COUMADIN TABLET 2
MG
warfarin sodium COUMADIN TABLET 1
MG
warfarin sodium COUMADIN TABLET 5
MG
warfarin sodium COUMADIN TABLET 2.5
MG
warfarin sodium COUMADIN TABLET 7.5
MG
warfarin sodium COUMADIN TABLET 3
MG
warfarin sodium COUMADIN TABLET 4
MG
warfarin sodium COUMADIN TABLET 6
MG
Hemorrheologic Agents
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Comprehensive Alliance Drug Formulary – April 2012
pentoxifylline TRENTAL TABLET ER
400 MG
Heparin And Related Preparations
QL enoxaparin sodium LOVENOX DISP SYRIN
30MG/0.3ML
QL enoxaparin sodium LOVENOX DISP SYRIN
150 MG/ML
QL enoxaparin sodium LOVENOX DISP SYRIN
120MG/.8ML
QL enoxaparin sodium LOVENOX DISP SYRIN
60MG/0.6ML
QL enoxaparin sodium LOVENOX DISP SYRIN
80MG/0.8ML
QL enoxaparin sodium LOVENOX DISP SYRIN
100 MG/ML
QL enoxaparin sodium LOVENOX DISP SYRIN
40MG/0.4ML
heparin sodium,porcine HEP-LOCK DISP SYRIN
10 UNIT/ML
heparin sodium,porcine HEP-LOCK VIAL
5000/ML
Platelet Aggregation Inhibitors
clopidogrel bisulfate PLAVIX TABLET 75
MG
dipyridamole PERSANTINE TABLET 25
MG
dipyridamole PERSANTINE TABLET 50
MG
dipyridamole PERSANTINE TABLET 75
MG
PA prasugrel hcl EFFIENT TABLET 10
MG
Sickle Cell Anemia Agents
hydroxyurea DROXIA CAPSULE 200
MG
hydroxyurea DROXIA CAPSULE 300
MG
hydroxyurea DROXIA CAPSULE 400
MG
Thrombin Inhibitors,Selective,Direct, & Reversible
PA dabigatran etexilate mesylate PRADAXA CAPSULE 150
MG
PA dabigatran etexilate mesylate PRADAXA CAPSULE 75
MG
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Comprehensive Alliance Drug Formulary – April 2012
Vitamin K Preparations
phytonadione MEPHYTON TABLET 5
MG
HORMONAL DEFICIENCY
Androgenic Agents
fluoxymesterone FLUOXYMESTERONE TABLET 10
MG
methyltestosterone METHITEST TABLET 10
MG
PA testosterone TESTOPEL PELLET(EA)
75 MG
PA testosterone STRIANT MUC ER 12H
30 MG
PA testosterone ANDROGEL GEL MD PMP
1.25G (1%)
PA testosterone ANDRODERM PATCH TD24
4 MG/24 HR
PA testosterone ANDROGEL GEL MD PMP
20.25/1.25
PA testosterone ANDROGEL GEL PACKET
PA testosterone ANDROGEL
TESTIM
25MG(1%)
GEL PACKET
50 MG (1%)
Estrogen/Androgen Combinations
estrogen,ester/me-testosterone ESTRATEST TABLET
0.625-1.25
estrogen,ester/me-testosterone ESTRATEST TABLET 1.25-
2.5MG
Estrogenic Agents
estradiol CLIMARA TABLET 1
MG
estradiol CLIMARA TABLET 2
MG
estradiol CLIMARA TABLET 0.5
MG
PA estradiol DIVIGEL GEL PACKET
PA estradiol ALORA
VIVELLE-DOT
PA estradiol ALORA
VIVELLE-DOT
PA estradiol ALORA
VIVELLE-DOT
0.5MG(0.1)
PATCH TDSW
0.05MG/24H
PATCH TDSW
0.1MG/24HR
PATCH TDSW
.025MG/24H
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Comprehensive Alliance Drug Formulary – April 2012
PA estradiol CLIMARA PATCH
TDWK
0.1MG/24HR
PA estradiol VIVELLE-DOT PATCH TDSW
.0375MG/24
estrogen,con/m-progest acet PREMPRO TABLET 0.45-
1.5MG
estrogen,con/m-progest acet PREMPRO TABLET 0.3-
1.5MG
estrogen,con/m-progest acet PREMPRO TABLET
0.625-5MG
estrogen,con/m-progest acet PREMPRO TABLET
0.625-2.5
estrogen,con/m-progest acet PREMPHASE TABLET 0.625
(14)
estrogens,conjugated PREMARIN TABLET 0.625
MG
estrogens,conjugated PREMARIN TABLET 0.3
MG
estrogens,conjugated PREMARIN TABLET 0.9
MG
estrogens,conjugated PREMARIN TABLET 1.25
MG
estrogens,conjugated PREMARIN TABLET
0.45MG
estrogens,esterified MENEST TABLET 0.3
MG
estrogens,esterified MENEST TABLET 0.625
MG
estrogens,esterified MENEST TABLET 1.25
MG
estrogens,esterified MENEST TABLET 2.5
MG
norethind ac/ethinyl estradiol FEMHRT TABLET
1MG-5MCG
Progestational Agents
medroxyprogesterone acet PROVERA TABLET
10MG
medroxyprogesterone acet PROVERA TABLET 2.5
MG
medroxyprogesterone acet PROVERA TABLET 5
MG
norethindrone acetate AYGESTIN TABLET 5
MG
IMMUNIZATION
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Comprehensive Alliance Drug Formulary – April 2012
Influenza Virus Vaccines
AGE+
QL
flu vaccine 2011 (36 mos+)/pf
FLUZONE 2011-2012 (PF)
FLUARIX 2011-2012 (PF)
FLUVIRIN 2011-2012 (PF)
AFLURIA 2011-2012 (PF)
DISP SYRIN
45MCG/.5ML
AGE+ flu vaccine 2011 (36 mos+)/pf FLUZONE 2011-2012 (PF) VIAL
QL
45MCG/.5ML
AGE+ flu vaccine 2011(6-35 mos)/pf FLUZONE 2011-2012 (PF) DISP SYRIN
QL
PED-0.25ML
AGE+ flu vaccine ts 2011-12 (4 yr+) FLUVIRIN 2011-2012
VIAL
QL
45MCG/.5ML
FLULAVAL 2011-2012
FLUZONE 2011-2012
AFLURIA 2011-2012
AGE+ influenza tvs 11-12 vaccine/pf FLUZONE INTRADERMAL DISP SYRIN
QL
27MCG/.1ML
AGE+ influenza tvs 11-12 vaccine/pf FLUZONE HIGH-DOSE 2011-12 (PF) DISP SYRIN
QL
180MCG/0.5
AGE+ influenza vacc,tri 2011 (live) FLUMIST SPRAY
QL
10E6.5-7.5
IMMUNOSUPPRESSION/MODULATION
Immunomodulators
imiquimod ALDARA CREAM
PACK 5 %
Immunosuppressives
AGE azathioprine AZASAN TABLET 75
MG
AGE azathioprine AZASAN TABLET 100
MG
AGE azathioprine IMURAN TABLET 50
MG
AGE cyclosporine SANDIMMUNE CAPSULE 100
MG
AGE cyclosporine SANDIMMUNE CAPSULE 25
MG
AGE cyclosporine, modified NEORAL CAPSULE 50
MG
AGE cyclosporine, modified NEORAL SOLUTION
100 MG/ML
AGE cyclosporine, modified NEORAL CAPSULE 25
MG
AGE cyclosporine, modified NEORAL CAPSULE 100
MG
AGE mycophenolate mofetil CELLCEPT CAPSULE 250
MG
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Comprehensive Alliance Drug Formulary – April 2012
AGE mycophenolate mofetil CELLCEPT TABLET 500
MG
AGE mycophenolate mofetil CELLCEPT SUSP RECON
200 MG/ML
AGE mycophenolate sodium MYFORTIC TABLET DR
180 MG
AGE mycophenolate sodium MYFORTIC TABLET DR
360 MG
AGE sirolimus RAPAMUNE TABLET 1
MG
AGE sirolimus RAPAMUNE TABLET 2
MG
AGE sirolimus RAPAMUNE TABLET 0.5
MG
AGE sirolimus RAPAMUNE SOLUTION 1
MG/ML
AGE tacrolimus PROGRAF CAPSULE 1
MG
AGE tacrolimus PROGRAF CAPSULE 5
MG
AGE tacrolimus PROGRAF CAPSULE 0.5
MG
INFECTIOUS DISEASE - BACTERIAL
Absorbable Sulfonamides
sulfamethoxazole/trimethoprim BACTRIM ORAL SUSP
200-40MG/5
sulfamethoxazole/trimethoprim BACTRIM TABLET
400MG-80MG
sulfamethoxazole/trimethoprim BACTRIM TABLET 800-
160 MG
Cephalosporins - 1st Generation
cefazolin sodium ANCEF VIAL 1 G
cephalexin KEFLEX CAPSULE 250
MG
cephalexin KEFLEX CAPSULE 500
MG
cephalexin KEFLEX SUSP RECON
125 MG/5ML
cephalexin KEFLEX SUSP RECON
250 MG/5ML
cephalexin KEFLEX TABLET 500
MG
cephalexin KEFLEX TABLET 250
MG
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Comprehensive Alliance Drug Formulary – April 2012
Cephalosporins - 2nd Generation
cefaclor CECLOR CAPSULE 250
MG
cefaclor CECLOR CAPSULE 500
MG
Cephalosporins - 3rd Generation
cefdinir OMNICEF SUSP RECON
250 MG/5ML
cefdinir OMNICEF CAPSULE 300
MG
cefdinir OMNICEF SUSP RECON
125 MG/5ML
cefixime SUPRAX TABLET 400
MG
cefixime SUPRAX SUSP RECON
100 MG/5ML
cefixime SUPRAX SUSP RECON
200 MG/5ML
Chemotherapeutics, Antibacterial, Misc.
methenamine mandelate MANDELAMINE TABLET 1 G
methenamine mandelate MANDELAMINE TABLET 500
MG
trimethoprim PROLOPRIM TABLET 100
MG
trimethoprim PRIMSOL SOLUTION 50
MG/5 ML
Macrolides
QL azithromycin ZITHROMAX PACKET 1 G
QL azithromycin ZITHROMAX SUSP RECON
100 MG/5ML
QL azithromycin ZITHROMAX TABLET 250
MG
QL azithromycin ZITHROMAX TABLET 600
MG
QL azithromycin ZITHROMAX TABLET 500
MG
QL azithromycin ZITHROMAX SUSP RECON
200 MG/5ML
QL clarithromycin BIAXIN XL TABLET 500
MG
QL clarithromycin BIAXIN XL TABLET 250
MG
ery e-succ/sulfisoxazole PEDIAZOLE SUSP RECON
200-600/5
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Comprehensive Alliance Drug Formulary – April 2012
erythromycin base ERYC CAPSULE DR
250 MG
erythromycin base ERYC TABLET 250
MG
erythromycin base ERYC TABLET 500
MG
erythromycin base ERYC TABLET DR
250 MG
erythromycin base ERY-TAB TABLET DR
333 MG
erythromycin base ERYC TABLET DR
500 MG
erythromycin ethylsuccinate ERYPED SUSP RECON
200 MG/5ML
erythromycin ethylsuccinate ERYPED 400 SUSP RECON
400 MG/5ML
erythromycin ethylsuccinate ERYPED TABLET 400
MG
erythromycin stearate ERYTHROMYCIN STEARATE TABLET 250
MG
Nitrofuran Derivatives
nitrofurantoin FURADANTIN ORAL SUSP
25 MG/5 ML
nitrofurantoin macrocrystal MACRODANTIN CAPSULE 100
MG
nitrofurantoin macrocrystal MACRODANTIN CAPSULE 25
MG
nitrofurantoin macrocrystal MACRODANTIN CAPSULE 50
MG
nitrofurantoin monohyd/m-cryst MACROBID CAPSULE 100
MG
Penicillins
amoxicillin AMOXIL TABLET
875MG
amoxicillin AMOXIL TAB CHEW
125 MG
amoxicillin AMOXIL TAB CHEW
250 MG
amoxicillin AMOXIL CAPSULE 250
MG
amoxicillin AMOXIL CAPSULE 500
MG
amoxicillin AMOXIL SUSP RECON
125 MG/5ML
amoxicillin AMOXIL SUSP RECON
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Comprehensive Alliance Drug Formulary – April 2012
250 MG/5ML
amoxicillin AMOXIL SUSP RECON
400 MG/5ML
amoxicillin AMOXIL SUSP RECON
200 MG/5ML
amoxicillin/potassium clav AUGMENTIN SUSP RECON
600-42.9/5
amoxicillin/potassium clav AUGMENTIN TABLET 250-
125MG
amoxicillin/potassium clav AUGMENTIN TABLET 500-
125 MG
amoxicillin/potassium clav AUGMENTIN TABLET 875-
125 MG
amoxicillin/potassium clav AUGMENTIN TAB CHEW
400-57MG
amoxicillin/potassium clav AUGMENTIN TAB CHEW
200-28.5MG
amoxicillin/potassium clav AUGMENTIN SUSP RECON
125-31.25/
amoxicillin/potassium clav AUGMENTIN SUSP RECON
250-62.5/5
amoxicillin/potassium clav AUGMENTIN SUSP RECON
400-57MG/5
amoxicillin/potassium clav AUGMENTIN SUSP RECON
200-28.5/5
ampicillin trihydrate AMPICILLIN TRIHYDRATE CAPSULE 250
MG
ampicillin trihydrate AMPICILLIN TRIHYDRATE CAPSULE 500
MG
ampicillin trihydrate AMPICILLIN TRIHYDRATE SUSP RECON
125MG/5ML
ampicillin trihydrate AMPICILLIN TRIHYDRATE SUSP RECON
250MG/5ML
dicloxacillin sodium DICLOXACILLIN SODIUM CAPSULE 250
MG
dicloxacillin sodium DICLOXACILLIN SODIUM CAPSULE 500
MG
penicillin v potassium VEETIDS 250 SUSP RECON
125 MG/5ML
penicillin v potassium VEETIDS 250 SUSP RECON
250 MG/5ML
penicillin v potassium VEETIDS 250 TABLET 250
MG
penicillin v potassium VEETIDS 250 TABLET 500
MG
Quinolones
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Comprehensive Alliance Drug Formulary – April 2012
QL ciprofloxacin hcl CIPRO TABLET 250
MG
QL ciprofloxacin hcl CIPRO TABLET 500
MG
QL ciprofloxacin hcl CIPRO TABLET 750
MG
ciprofloxacin hcl CIPRO TABLET 100
MG
levofloxacin LEVAQUIN TABLET 250
MG
levofloxacin LEVAQUIN TABLET 500
MG
levofloxacin LEVAQUIN TABLET
750MG
ofloxacin FLOXIN TABLET 200
MG
ofloxacin FLOXIN TABLET 300
MG
ofloxacin FLOXIN TABLET 400
MG
Tetracyclines
doxycycline hyclate VIBRAMYCIN CAPSULE 100
MG
doxycycline hyclate VIBRAMYCIN CAPSULE
50MG
doxycycline hyclate VIBRAMYCIN TABLET 100
MG
QL+
ST
minocycline hcl SOLODYN CAPSULE 100
MG
tetracycline hcl ALA-TET CAPSULE 250
MG
tetracycline hcl ALA-TET CAPSULE 500
MG
tetracycline hcl ALA-TET ORAL SUSP
125 MG/5ML
INFECTIOUS DISEASE - FUNGAL
Antifungal Agents
clotrimazole MYCELEX TROCHE 10
MG
fluconazole DIFLUCAN TABLET 100
MG
fluconazole DIFLUCAN TABLET 200
MG
fluconazole DIFLUCAN TABLET 50
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Comprehensive Alliance Drug Formulary – April 2012
MG
fluconazole DIFLUCAN TABLET 150
MG
fluconazole DIFLUCAN SUSP RECON
40 MG/ML
fluconazole DIFLUCAN SUSP RECON
10 MG/ML
itraconazole SPORANOX SOLUTION 10
MG/ML
itraconazole SPORANOX CAPSULE 100
MG
ketoconazole NIZORAL TABLET 200
MG
Antifungal Antibiotics
griseofulvin ultramicrosize GRIS-PEG TABLET 125
MG
griseofulvin ultramicrosize GRIS-PEG TABLET 250
MG
griseofulvin,microsize GRIFULVIN V ORAL SUSP
125 MG/5ML
griseofulvin,microsize FULVICIN U/F TABLET 250
MG
griseofulvin,microsize GRIFULVIN V TABLET 500
MG
nystatin MYCOSTATIN ORAL SUSP
100000/ML
nystatin MYCOSTATIN TABLET 500K
UNIT
INFECTIOUS DISEASE - MISCELLANEOUS
Anti-Mycobacterium Agents
ethambutol hcl MYAMBUTOL TABLET 100
MG
ethambutol hcl MYAMBUTOL TABLET 400
MG
isoniazid ISONIAZID SYRUP 50
MG/5 ML
isoniazid ISONIAZID TABLET 100
MG
isoniazid ISONIAZID TABLET 300
MG
pyrazinamide PYRAZINAMIDE TABLET 500
MG
rifabutin MYCOBUTIN CAPSULE 150
MG
Page 64 of 103

Comprehensive Alliance Drug Formulary – April 2012
Antileprotics
dapsone DAPSONE TABLET 100
MG
dapsone DAPSONE TABLET 25
MG
Antitubercular Antibiotics
rifampin RIFADIN CAPSULE 150
MG
rifampin RIFADIN CAPSULE 300
MG
rifampin/isoniazid RIFAMATE CAPSULE
300-150 MG
rifampin/isoniazid/pyrazinamid RIFATER TABLET 120-
50-300
Lincosamides
clindamycin hcl CLEOCIN HCL CAPSULE 150
MG
AGE clindamycin palmitate hcl CLEOCIN PALMITATE SOLN RECON
75 MG/5 ML
INFECTIOUS DISEASE - PARASITIC
Amebacides
iodoquinol YODOXIN TABLET 210
MG
iodoquinol YODOXIN TABLET 650
MG
Anaerobic Antiprotozoal-Antibacterial Agents
metronidazole FLAGYL TABLET 250
MG
metronidazole FLAGYL TABLET 500
MG
Antimalarial Drugs
chloroquine phosphate ARALEN PHOSPHATE TABLET 250
MG
chloroquine phosphate ARALEN PHOSPHATE TABLET 500
MG
hydroxychloroquine sulfate PLAQUENIL TABLET 200
MG
primaquine phosphate PRIMAQUINE TABLET 26.3
MG
pyrimethamine DARAPRIM TABLET 25
MG
Antiprotozoal Drugs,Miscellaneous
Page 65 of 103

Comprehensive Alliance Drug Formulary – April 2012
atovaquone MEPRON ORAL SUSP
750 MG/5ML
INFECTIOUS DISEASE - VIRAL
Antivirals, General
acyclovir ZOVIRAX TABLET 800
MG
acyclovir ZOVIRAX TABLET 400
MG
acyclovir ZOVIRAX ORAL SUSP
200 MG/5ML
acyclovir ZOVIRAX CAPSULE 200
MG
QL oseltamivir phosphate TAMIFLU CAPSULE 75
MG
QL oseltamivir phosphate TAMIFLU CAPSULE 30
MG
QL oseltamivir phosphate TAMIFLU CAPSULE 45
MG
zanamivir RELENZA DISK W/DEV
5 MG
Antivirals, Hiv-Specific, Nucleoside Analog, Rti
didanosine VIDEX SOLN RECON
FNL10MG/ML
didanosine VIDEX EC CAPSULE DR
250 MG
didanosine VIDEX EC CAPSULE DR
400 MG
didanosine VIDEX EC CAPSULE DR
125 MG
didanosine VIDEX EC CAPSULE DR
200 MG
zidovudine RETROVIR SYRUP 10
MG/ML
zidovudine RETROVIR CAPSULE 100
MG
zidovudine RETROVIR TABLET 300
MG
Antivirals, Hiv-Specific, Nucleotide Analog, Rti
PA tenofovir disoproxil fumarate VIREAD TABLET 300
MG
Hepatitis B Treatment Agents
ST adefovir dipivoxil HEPSERA TABLET 10
MG
Page 66 of 103

Comprehensive Alliance Drug Formulary – April 2012
PA entecavir BARACLUDE SOLUTION
0.05MG/ML
PA entecavir BARACLUDE TABLET 0.5
MG
PA entecavir BARACLUDE TABLET 1
MG
INFLAMMATORY DISEASE
Anti-Arthritic And Chelating Agents
penicillamine CUPRIMINE CAPSULE 250
MG
penicillamine DEPEN TABLET 250
MG
Anti-Arthritic, Folate Antagonist Agents
methotrexate sodium RHEUMATREX TAB DS PK
2.5MG
Glucocorticoids
dexamethasone DEXPAK TAB DS PK
1.5MG (51)
dexamethasone DEXAMETHASONE ELIXIR 0.5
MG/5ML
dexamethasone DEXAMETHASONE SOLUTION
0.5 MG/5ML
dexamethasone DEXAMETHASONE TABLET 0.5
MG
dexamethasone DEXAMETHASONE TABLET 1
MG
dexamethasone DEXAMETHASONE TABLET 0.75
MG
dexamethasone DEXAMETHASONE TABLET 2
MG
dexamethasone DEXAMETHASONE TABLET 1.5
MG
dexamethasone DEXAMETHASONE TABLET 4
MG
dexamethasone DEXAMETHASONE TABLET 6
MG
hydrocortisone CORTEF TABLET 10
MG
hydrocortisone CORTEF TABLET 20
MG
hydrocortisone CORTEF TABLET 5
MG
methylprednisolone MEDROL TABLET 16
MG
Page 67 of 103

Comprehensive Alliance Drug Formulary – April 2012
methylprednisolone MEDROL TABLET 2
MG
methylprednisolone MEDROL TABLET 32
MG
methylprednisolone MEDROL TABLET 4
MG
methylprednisolone MEDROL TABLET 8
MG
methylprednisolone MEDROL TAB DS PK 4
MG
prednisolone PRELONE SOLUTION 15
MG/5 ML
prednisolone MILLIPRED DP TABLET 5
MG
prednisolone sod phosphate ORAPRED SOLUTION 5
MG/5 ML
prednisolone sod phosphate ORAPRED SOLUTION 15
MG/5 ML
prednisone STERAPRED DS SOLUTION 5
MG/5 ML
prednisone PREDNISONE INTENSOL ORAL CONC
5 MG/ML
prednisone STERAPRED DS TABLET 1
MG
prednisone STERAPRED DS TABLET 10
MG
prednisone STERAPRED DS TABLET 2.5
MG
prednisone STERAPRED DS TABLET 20
MG
prednisone STERAPRED DS TABLET 5
MG
prednisone STERAPRED DS TABLET 50
MG
prednisone STERAPRED DS TAB DS PK 5
MG
prednisone STERAPRED DS TAB DS PK 10
MG
Gold Salts
auranofin RIDAURA CAPSULE 3
MG
Mineralocorticoids
fludrocortisone acetate FLORINEF ACETATE TABLET 0.1
MG
Nsaids, Cyclooxygenase Inhibitor-Type
Page 68 of 103

Comprehensive Alliance Drug Formulary – April 2012
AGE celecoxib CELEBREX CAPSULE 400
MG
AGE celecoxib CELEBREX CAPSULE 100
MG
AGE celecoxib CELEBREX CAPSULE 200
MG
AGE celecoxib CELEBREX CAPSULE 50
MG
diclofenac sodium VOLTAREN-XR TABLET DR
25MG
diclofenac sodium VOLTAREN-XR TABLET DR
50 MG
diclofenac sodium VOLTAREN-XR TABLET DR
75 MG
etodolac ETODOLAC CAPSULE 200
MG
etodolac ETODOLAC CAPSULE 300
MG
etodolac ETODOLAC TABLET 400
MG
etodolac ETODOLAC TABLET 500
MG
ibuprofen CHILDREN'S MOTRIN CAPSULE 200
MG
ibuprofen CHILDREN'S MOTRIN TABLET 400
MG
ibuprofen CHILDREN'S MOTRIN TABLET 600
MG
QL ibuprofen CHILDREN'S MOTRIN TABLET 200
MG
ibuprofen CHILDREN'S MOTRIN TABLET 800
MG
ibuprofen CHILDREN'S MOTRIN TABLET 100
MG
ibuprofen CHILDREN'S MOTRIN TAB CHEW
100 MG
ibuprofen CHILDREN'S MOTRIN ORAL SUSP
100 MG/5ML
ibuprofen CHILDREN'S MOTRIN DROPS SUSP
50 MG/1.25
indomethacin INDOCIN SR CAPSULE 25
MG
indomethacin INDOCIN SR CAPSULE 50
MG
ketoprofen ORUDIS KT CAPSULE 75
MG
Page 69 of 103

Comprehensive Alliance Drug Formulary – April 2012
QL ketorolac tromethamine TORADOL TABLET 10
MG
meloxicam MOBIC TABLET 7.5
MG
meloxicam MOBIC TABLET 15
MG
nabumetone RELAFEN TABLET 500
MG
nabumetone RELAFEN TABLET 750
MG
naproxen EC-NAPROSYN TABLET 250
MG
naproxen EC-NAPROSYN TABLET 375
MG
naproxen EC-NAPROSYN TABLET 500
MG
piroxicam FELDENE CAPSULE 10
MG
piroxicam FELDENE CAPSULE 20
MG
sulindac CLINORIL TABLET 150
MG
sulindac CLINORIL TABLET 200
MG
LOCAL ANESTHESIA
Local Anesthetics
lidocaine hcl XYLOCAINE JEL (ML) 2 %
lidocaine hcl XYLOCAINE SOLUTION 20
MG/ML
lidocaine hcl XYLOCAINE SOLUTION 40
MG/ML
QL phenol PHENOL SPRAY 1.4 %
LOWER GASTROINTESTINAL DISORDERS -
BOWEL INFLAMMAT
Absorbable Sulfonamides
sulfamethoxazole/trimethoprim SEPTRA DS TABLET 800-
160 MG
Bowel Antiinflamatory Agents
sulfasalazine AZULFIDINE TABLET 500
MG
sulfasalazine AZULFIDINE TABLET DR
500 MG
Page 70 of 103

Comprehensive Alliance Drug Formulary – April 2012
Drug Tx-Chronic Inflam. Colon Dx,5-Aminosalicylat
AGE mesalamine ASACOL TABLET DR
400 MG
Hemorrhoidal Prep, Anti-Infam Steroid/Local Anesth
PA hydrocortisone/pramoxine PROCTOFOAM-HC FOAM 1 %-1
%
Rectal Preparations
QL hydrocortisone ANUSOL-HC CREAM (G)
2.5 %
hydrocortisone ANUSOL-HC CREAM (G) 1
%
hydrocortisone acetate PROCTOCORT SUPP.RECT
25 MG
PA hydrocortisone acetate PROCTOCORT SUPP.RECT
30 MG
QL hydrocortisone acetate PROCTOCORT OINT. (G) 1 %
Rectal/Lower Bowel Prep.,Glucocort. (non-Hemorr)
hydrocortisone CORTENEMA ENEMA
100MG/60ML
LOWER GASTROINTESTINAL DISORDERS -
OTHER
Ammonia Inhibitors
lactulose LACTULOSE SOLUTION 10
G/15 ML
lactulose LACTULOSE SOLUTION
10G/15ML
Antidiarrheals
bismuth subsalicylate PEPTO-BISMOL TAB CHEW
262 MG
bismuth subsalicylate PEPTO-BISMOL TABLET 262
MG
bismuth subsalicylate PEPTO-BISMOL ORAL SUSP
262MG/15ML
bismuth subsalicylate PEPTO-BISMOL ORAL SUSP
525MG/15ML
diphenoxylate hcl/atropine LOMOTIL LIQUID 2.5-
.025/5
diphenoxylate hcl/atropine LOMOTIL TABLET 2.5-
.025MG
Bile Salts
ursodiol ACTIGALL CAPSULE 300
Page 71 of 103

Comprehensive Alliance Drug Formulary – April 2012
Laxatives And Cathartics
bisacodyl DULCOLAX TABLET DR 5
MG
calcium polycarbophil FIBERCON TABLET 625
MG
casanthranol/docusate sodium CASANTHRANOL/DOCUSATE SODIUM CAPSULE 30-
100MG
casanthranol/docusate sodium CASANTHRANOL/DOCUSATE SODIUM TABLET 30-
100MG
cascara sagrada CASCARA SAGRADA CAPSULE
500MG
cascara sagrada CASCARA SAGRADA FL EXTRACT
325MG/5ML
cascara sagrada CASCARA SAGRADA TABLET
325MG
docusate sodium COLACE CAPSULE 100
MG
docusate sodium COLACE CAPSULE 250
MG
docusate sodium COLACE CAPSULE 50
MG
docusate sodium COLACE LIQUID 50
MG/5 ML
docusate sodium COLACE SYRUP 60
MG/15ML
docusate sodium COLACE SYRUP
50MG/15ML
docusate sodium COLACE TABLET 100
MG
lactulose LACTULOSE SOLUTION 10
G/CUP
lactulose LACTULOSE SOLUTION 10
G/15 ML
lactulose LACTULOSE SOLUTION 10
G/CUP
magnesium citrate MAGNESIUM CITRATE SOLUTION
magnesium hydroxide PHILLIPS' MILK OF MAGNESIA ORAL SUSP
400 MG/5ML
mineral oil MINERAL OIL OIL
QL peg 3350/na sulf,bicarb,cl/kcl COLYTE WITH FLAVOR PACKETS SOLN RECON
240-22.72G
QL peg 3350/na sulf,bicarb,cl/kcl COLYTE WITH FLAVOR PACKETS SOLN RECON
QL polyethylene glycol 3350 GAVILAX
MIRALAX
MG
236-22.74G
POWDER
17G/DOSE
Page 72 of 103

Comprehensive Alliance Drug Formulary – April 2012
psyllium husk METAMUCIL CAPSULE
0.52G
psyllium husk/ca carbonate FIBER PLUS CALCIUM CAPSULE 1G-
60MG
psyllium seed WAL-MUCIL POWDER
psyllium seed METAMUCIL PACKET
psyllium seed (with dextrose) KONSYL-D PACKET
psyllium seed (with sugar) METAMUCIL WAFER
psyllium seed (with sugar) METAMUCIL PACKET
psyllium seed (with sugar) METAMUCIL POWDER 3.4
G/12 G
psyllium seed/sod bicarb PSYLLIUM SEED/SOD BICARB PACKET
sennosides EX-LAX TABLET 8.6
MG
sennosides EX-LAX SYRUP
8.8MG/5ML
sodium chloride/nahco3/kcl/peg NULYTELY WITH FLAVOR PACKS SOLN RECON
420G
Laxatives, Local/Rectal
bisacodyl DULCOLAX SUPP.RECT
10 MG
docusate sodium DOCUSATE SODIUM ENEMA 283
MG
docusate sodium COLACE ENEMA 200
MG/5ML
glycerin GLYCERIN SUPP.RECT
ADULT
glycerin GLYCERIN SUPP.RECT
PEDIATRIC
na phos,m-b/na phos,di-ba PEDIA-LAX ENEMA ENEMA 19G-
7G/118
MEDICAL SUPPLIES
Durable Medical Equipment,Misc
container,empty
PILL DIVIDER WITH PILL BOX
CUT N CRUSH
TABLET CUTTER
QL nebulizer accessories A.I.R.S. NEBULIZER
BUBBLES THE FISH II
EASIVENT
OPTICHAMBER
PARI LC PLUS NEBULIZER
QL nebulizer accessories A.I.R.S. NEBULIZER
BUBBLES THE FISH II
EASIVENT
EACH
KIT
EACH
Page 73 of 103

Comprehensive Alliance Drug Formulary – April 2012
OPTICHAMBER
PARI LC PLUS NEBULIZER
QL nebulizer accessories EASIVENT EACH
Durable Medical Equipment,Misc(group 1)
lancets
LANCETS
SURE-LANCE
TECHLITE
THIN LANCETS
EACH
Incontinence Supplies
QL incontinence alarms WET-STOP 3 KIT N/A
incontinence pants, reusable SLEEP PANTS EACH
Syringes And Accessories
syr,ndl,ins,safe,disp un, 1 ml
MAGELLAN INSULIN SAFETY SYRNG
SAFESNAP INSULIN SYRINGE
DISP SYRIN
28GX1/2"
syring w-ndl,disp,insul,0.5ml GLUCOPRO DISP SYRIN
31GX5/16"
MISCELLANEOUS AGENTS
Anaphylaxis Therapy Agents
QL epinephrine EPIPEN JR
TWINJECT
QL epinephrine EPIPEN
TWINJECT
PEN INJCTR
0.15MG/0.3
PEN INJCTR
0.3MG/0.3
Parasympathetic Agents
bethanechol chloride URECHOLINE TABLET 10
MG
bethanechol chloride URECHOLINE TABLET 25
MG
bethanechol chloride URECHOLINE TABLET 5
MG
bethanechol chloride URECHOLINE TABLET 50
MG
NEOPLASTIC DISEASE
Alkylating Agents
busulfan MYLERAN TABLET 2
MG
AGE chlorambucil LEUKERAN TABLET 2
MG
AGE cyclophosphamide CYTOXAN TABLET 25
MG
AGE cyclophosphamide CYTOXAN TABLET 50
MG
Page 74 of 103

Comprehensive Alliance Drug Formulary – April 2012
AGE hydroxyurea HYDREA CAPSULE 500
MG
lomustine CEENU CAPSULE 40
MG
AGE temozolomide TEMODAR CAPSULE 5
MG
AGE temozolomide TEMODAR CAPSULE 180
MG
Antiandrogenic Agents
bicalutamide CASODEX TABLET 50
MG
flutamide FLUTAMIDE CAPSULE 125
MG
nilutamide NILANDRON TABLET 150
MG
Antimetabolites
mercaptopurine PURINETHOL TABLET 50
MG
methotrexate sodium TREXALL TABLET 10
MG
methotrexate sodium TREXALL TABLET 5
MG
methotrexate sodium TREXALL TABLET 15
MG
methotrexate sodium TREXALL TABLET 7.5
MG
methotrexate sodium METHOTREXATE SODIUM TABLET 2.5
MG
thioguanine TABLOID TABLET 40
MG
Antineoplastic Aromatase Inhibitors
anastrozole ARIMIDEX TABLET 1
MG
exemestane AROMASIN TABLET 25
MG
letrozole FEMARA TABLET 2.5
MG
Antineoplastic - Mtor Kinase Inhibitors
everolimus AFINITOR TABLET 5
MG
everolimus AFINITOR TABLET 10
MG
Antineoplastic - Topoisomerase I Inhibitors
topotecan hcl HYCAMTIN CAPSULE
Page 75 of 103

Comprehensive Alliance Drug Formulary – April 2012
0.25 MG
Antineoplastic Systemic Enzyme Inhibitors
dasatinib SPRYCEL TABLET 20
MG
dasatinib SPRYCEL TABLET 50
MG
dasatinib SPRYCEL TABLET 70
MG
AGE dasatinib SPRYCEL TABLET 100
MG
AGE erlotinib hcl TARCEVA TABLET 100
MG
AGE erlotinib hcl TARCEVA TABLET 25
MG
AGE nilotinib hcl TASIGNA CAPSULE 150
MG
nilotinib hcl TASIGNA CAPSULE 200
MG
AGE vandetanib CAPRELSA TABLET 100
MG
AGE vandetanib CAPRELSA TABLET 300
MG
Antineoplastic,Histone Deacetylase Inhibitors,Hdis
vorinostat ZOLINZA CAPSULE 100
MG
Antineoplastics,Miscellaneous
etoposide VEPESID CAPSULE 50
MG
mitotane LYSODREN TABLET 500
MG
Chemotherapy Rescue/Antidote Agents
AGE leucovorin calcium LEUCOVORIN CALCIUM TABLET 10
MG
leucovorin calcium LEUCOVORIN CALCIUM TABLET
15MG
leucovorin calcium LEUCOVORIN CALCIUM TABLET 25
MG
AGE leucovorin calcium LEUCOVORIN CALCIUM TABLET 5
MG
AGE mesna MESNEX TABLET 400
MG
Selective Estrogen Receptor Modulators (serm)
tamoxifen citrate NOLVADEX TABLET 10
MG
Page 76 of 103

Comprehensive Alliance Drug Formulary – April 2012
tamoxifen citrate NOLVADEX TABLET 20
MG
Selective Retinoid X Receptor Agonists (rxr)
bexarotene TARGRETIN CAPSULE 75
MG
Steroid Antineoplastics
estramustine phosphate sodium EMCYT CAPSULE 140
MG
megestrol acetate MEGESTROL ACETATE TABLET 20
MG
megestrol acetate MEGESTROL ACETATE TABLET 40
MG
OTHER DRUGS
Appetite Stim. For Anorexia,Cachexia,Wasting Synd.
megestrol acetate MEGACE ORAL SUSP
400MG/10ML
Blood Testing Preparations,In-Vitro
QL blood ketone test,strips PRECISION XTRA STRIP
Bulk Chemicals
aromatic cascara fluid extract CASCARA SAGRADA FL EXTRACT
100 %
Condoms
condoms, female
FC CONDOM, FEMALE
REALITY
EACH
Dietary Supplement, Miscellaneous
PA caloric supplement DUOCAL LIQUID
7KCAL/ML
PA fos/inulin/nutrit supp/fiber FOS/INULIN/NUTRIT SUPP/FIBER ORAL SUSP
0.06G-1.5
PA fos/inulin/nutrit supp/fiber FOS/INULIN/NUTRIT SUPP/FIBER ORAL SUSP
0.03G-1/ML
PA lipase/protease/amylase TRI-PASE 8 TABLET 8K-
30K-30K
PA lipase/protease/amylase TRI-PASE 16 TABLET 16-
60-60K
PA milk based formula MILK BASED FORMULA LIQUID
PA ns comb1/fos/inulin PEPTAMEN AF ORAL SUSP
0.0756-1.2
PA nutritional supplement ENFAGROW GENTLEASE LIPIL ORAL SUSP
0.03G-1/ML
QL salmon oil/omega-3 fatty acids SALMON OIL/OMEGA-3 FATTY ACIDS CAPSULE
500-100 MG
Page 77 of 103

Comprehensive Alliance Drug Formulary – April 2012
General Inhalation Agents
sodium chloride for inhalation SODIUM CHLORIDE VIAL-NEB 0.9
%
Metallic Poison,Agents To Treat
PA deferasirox EXJADE TAB DISPER
125 MG
PA deferasirox EXJADE TAB DISPER
250 MG
PA deferasirox EXJADE TAB DISPER
500 MG
Needles/Needleless Devices
needleless access. dev,insulin
MEDI-JECTOR NEEDLE-FREE SYR B
MEDI-JECTOR NEEDLE-FREE SYR C
PEN NEEDLE
PRODIGY PEN NEEDLE
NOVOFINE AUTOCOVER
EACH
Nose Preparations, Miscellaneous (otc)
sodium chloride LITTLE NOSES SPRAY 0.65 %
sodium chloride LITTLE NOSES DROPS 0.65 %
Nut.tx Phenylketonuria (pku) Formulations
PA infant form.for pku,iron no.4 PERIFLEX INFANT POWDER
13G-421
PA nut. tx for pku with iron #10 NUT. TX FOR PKU WITH IRON #10 POWDER
16.2G-500
PA nut. tx for pku with iron #13 EAA POWD PACK
5G-36KCAL
PA nut. tx for pku with iron #2 XPHE MAXAMUM LIQUID
0.06G-0.64
PA nut. tx for pku with iron #20 PERIFLEX ADVANCE POWDER
35G-385
PA nut. tx for pku with iron #20 PERIFLEX ADVANCE POWDER 35
G-369
PA nut. tx for pku with iron #27 PHENYLADE60 POWD PACK
10G-49
PA nut. tx for pku with iron #27 PHENYLADE60 POWDER
60G-295
PA nut. tx for pku with iron #27 PHENYLADE60 POWDER
60G-327
PA nut. tx for pku with iron #3 PERIFLEX JUNIOR POWDER 25
G-374
PA nut. tx for pku with iron #3 PERIFLEX JUNIOR POWDER 25
G-394
PA nut. tx for pku with iron #3 PERIFLEX JUNIOR POWDER 25
G-374
Page 78 of 103

Comprehensive Alliance Drug Formulary – April 2012
PA nut. tx for pku with iron #33 PHENYLENE POWDER
31.1G-422
PA nut. tx for pku with iron #34 PHENYLENE 75 POWDER
74.97G-301
PA nut. tx for pku with iron #35 PHENYLADE ESSENTIAL POWDER
25G-390
PA nut. tx for pku with iron #35 PHENYLADE ESSENTIAL POWD PACK
10G-156/40
PA nut. tx for pku with iron #36 ADD-INS POWD PACK
10G-86
PA nut. tx for pku with iron #4 NUT. TX FOR PKU WITH IRON #4
PKU COOLER 10
PKU COOLER 15
PKU COOLER 20
ORAL SUSP
0.12G-0.71
PA nut. tx for pku with iron #40 PKU LOPHLEX LIQUID PKT
20-116/125
PA nut. tx for pku with iron #41 CAMINO PRO 15 PKU POWD PACK
15G-140/49
PA nut. tx for pku with iron #42 PKU LOPHLEX LIQUID PKT
20-115/125
PA nut. tx for pku with iron #45 PHENYL-FREE 2 POWDER
22G-410
PA nut. tx for pku with iron #45 PHENYL-FREE 2HP POWDER
40G-390
PA nut. tx for pku with iron #48 PKU TRIO POWDER 30
G-404
PA nut. tx for pku with iron, #26 CAMINO PRO 15 ORAL SUSP
0.11G-1.06
PA nut. tx for pku, #22 PREKUNIL TABLET 0.4G-
2.2
PA nut. tx for pku, #23 NEOPHE TABLET 0.4G-
2.1
PA nut. tx for pku, #38 NEOPHE POWDER
60G-315
PA nut. tx for pku, #43 PHENYLADE PHEBLOC POWD PACK
2.2G-10/3G
PA nut. tx for pku, #46 CAMINO-PRO RESTORE LIQUID 2G-
36/100
Nutritional Therapy, Med Cond Special Formulation
PA nut.tx. metabolic disorder,soy PERATIVE LIQUID
0.067G-1.3
PA nut.tx.comp. immune systm,soy CRUCIAL LIQUID
PA nut.tx.gluc.intoler,lac-fr,reg DIABETISOURCE LIQUID
PA nut.tx.gluc.intoler,lac-fr,soy GLUCERNA HUNGER SMART LIQUID
PA nut.tx.glucose intol,soy/fiber DIABETISOURCE AC
LIQUID
RESOURCE DIABETIC TF
0.06G-1.2
Page 79 of 103

Comprehensive Alliance Drug Formulary – April 2012
PA nut.tx.imp.renal fxn,lac-free NUT.TX.IMP.RENAL FXN,LAC-FREE
PRO-STAT RC
LIQUID
0.08G-2/ML
PA nut.tx.imp.renal fxn,lac-free NUT.TX.IMP.RENAL FXN,LAC-FREE
NUTREN PULMONARY
LIQUID
0.08G-2/ML
PA nut.tx.impaired digest fxn,soy VIVONEX RTF LIQUID
0.05G-1/ML
PA nut.tx.impaired digest fxn,soy PEPDITE JUNIOR POWD PACK
7.4G-240
PA nut.tx.impaired hepatic fxn NUT.TX.IMPAIRED HEPATIC FXN LIQUID
0.16G-1.5
PA nut.tx.impaired renal fxn,soy NEPRO
NEPRO CARB STEADY
SUPLENA CARB STEADY
LIQUID
0.08G-1.80
PA nut.tx.pulm.disord.soy,lac-fr NUT.TX.PULM.DISORD.SOY,LAC-FR LIQUID
Solvents
isopropyl alcohol INSTACLEAN SOLUTION
mineral oil MINERAL OIL HEAVY OIL
Urine Acetone Test Aids
QL urine acetone test,strips DIASCREEN 1K REAGENT STRIP
Vehicles
sorbitol solution SORBITOL SOLUTION 70
%
PAIN MANAGEMENT - ANALGESICS
Analgesic, Salicylate, Barbiturate,& Xanthine Cmb
butalbital/aspirin/caffeine FIORINAL CAPSULE 50-
325-40
butalbital/aspirin/caffeine FIORINAL TABLET 50-
325-40
Analgesic,Non-Salicylate,Barbiturate,&xanthine Cmb
acetaminophen/caffeine/butalb ESGIC-PLUS TABLET 325-
40-50
Analgesic/Antipyretics, Salicylates
asa/calcium carb/mag/al hydrox ASCRIPTIN TABLET 325
MG
QL aspirin BAYER ASPIRIN TABLET DR
81 MG
QL aspirin BAYER ASPIRIN TABLET
325MG
QL aspirin BAYER ASPIRIN TABLET 500
MG
QL aspirin BAYER ASPIRIN TAB CHEW
81 MG
Page 80 of 103

Comprehensive Alliance Drug Formulary – April 2012
QL aspirin BAYER ASPIRIN TABLET DR
325 MG
QL aspirin BAYER ASPIRIN TABLET DR
500MG
QL aspirin BAYER ASPIRIN TABLET DR
650 MG
QL aspirin BAYER ASPIRIN TABLET DR
975 MG
aspirin/acetaminophen/caffeine EXCEDRIN MIGRAINE TABLET
aspirin/mag carb/al aminoacet ASPIRIN/MAG CARB/AL AMINOACET TABLET 325
MG
choline sal/mag salicylate CHOLINE SAL/MAG SALICYLATE LIQUID 500
MG/5ML
salsalate SALFLEX TABLET 500
MG
salsalate SALFLEX TABLET 750
MG
Analgesic/Antipyretics,Non-Salicylate
acetaminophen ACETAMINOPHEN CAPSULE
500MG
acetaminophen ACETAMINOPHEN SUPP.RECT
120 MG
acetaminophen ACETAMINOPHEN SUPP.RECT
325 MG
acetaminophen ACETAMINOPHEN SUPP.RECT
650 MG
acetaminophen FEVERALL SUPP.RECT
80 MG
acetaminophen ACETAMINOPHEN TABLET ER
650 MG
acetaminophen ACETAMINOPHEN ELIXIR
160MG/5ML
acetaminophen ACETAMINOPHEN LIQUID 500
MG/5ML
acetaminophen ACETAMINOPHEN SOLUTION
160 MG/CUP
acetaminophen ACETAMINOPHEN LIQUID
160MG/5ML
acetaminophen ACETAMINOPHEN LIQUID
500MG/15ML
acetaminophen ACETAMINOPHEN DROPS SUSP
80MG/0.8ML
acetaminophen ACETAMINOPHEN TABLET
325MG
acetaminophen ACETAMINOPHEN TABLET 500
MG
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Comprehensive Alliance Drug Formulary – April 2012
acetaminophen ACETAMINOPHEN TABLET 650
MG
acetaminophen ACETAMINOPHEN TAB CHEW
160 MG
acetaminophen ACETAMINOPHEN ORAL SUSP
160 MG/5ML
acetaminophen ACETAMINOPHEN DROPS SUSP
80MG/0.8ML
Analgesics,Narcotics
QL+ fentanyl DURAGESIC PATCH TD72
ST
25MCG/HR
QL+ fentanyl DURAGESIC PATCH TD72
ST
50MCG/HR
QL+ fentanyl DURAGESIC PATCH TD72
ST
75MCG/HR
QL+ fentanyl DURAGESIC PATCH TD72
ST
100 MCG/HR
QL+ fentanyl DURAGESIC PATCH TD72
ST
12 MCG/HR
QL hydrocodone bit/acetaminophen VICODIN TABLET
5MG-325MG
QL hydrocodone bit/acetaminophen VICODIN TABLET 7.5-
325MG
hydrocodone bit/acetaminophen VICODIN CAPSULE 5
MG-500MG
QL hydrocodone bit/acetaminophen VICODIN TABLET
10MG-325MG
QL hydrocodone bit/acetaminophen VICODIN TABLET 5
MG-500MG
QL hydrocodone bit/acetaminophen VICODIN TABLET
10MG-650MG
QL hydrocodone bit/acetaminophen VICODIN TABLET 7.5-
650 MG
QL hydrocodone bit/acetaminophen VICODIN TABLET
10MG-500MG
QL hydrocodone bit/acetaminophen VICODIN TABLET 7.5-
750MG
QL hydrocodone bit/acetaminophen VICODIN TABLET 7.5-
500MG
QL hydrocodone bit/acetaminophen VICODIN SOLUTION
7.5-500/15
QL hydrocodone bit/acetaminophen VICODIN TABLET 10-
660MG
QL hydromorphone hcl DILAUDID SUPP.RECT 3
MG
QL hydromorphone hcl DILAUDID TABLET 2
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Comprehensive Alliance Drug Formulary – April 2012
MG
QL hydromorphone hcl DILAUDID TABLET 4
MG
QL hydromorphone hcl DILAUDID TABLET 8
MG
methadone hcl DOLOPHINE HCL SOLUTION 5
MG/5 ML
methadone hcl DOLOPHINE HCL SOLUTION 10
MG/5 ML
methadone hcl DOLOPHINE HCL TABLET 10
MG
methadone hcl DOLOPHINE HCL TABLET 5
MG
methadone hcl DOLOPHINE HCL TABLET SOL
40 MG
PA morphine sulfate MS CONTIN CAP ER PEL
30 MG
PA morphine sulfate MS CONTIN CAP ER PEL
60 MG
PA morphine sulfate MS CONTIN CAP ER PEL
100 MG
PA morphine sulfate MS CONTIN CAP ER PEL
50 MG
PA morphine sulfate MS CONTIN CAP ER PEL
20 MG
morphine sulfate MS CONTIN SOLUTION 10
MG/5 ML
morphine sulfate MS CONTIN SOLUTION 20
MG/5 ML
morphine sulfate MS CONTIN SOLUTION
100 MG/5ML
morphine sulfate MS CONTIN TABLET 15
MG
morphine sulfate MS CONTIN TABLET 30
MG
QL morphine sulfate MS CONTIN TABLET ER
200 MG
PA morphine sulfate AVINZA CPMP 24HR
45 MG
PA morphine sulfate AVINZA CPMP 24HR
75 MG
QL morphine sulfate MS CONTIN TABLET ER
30 MG
QL morphine sulfate MS CONTIN TABLET ER
60 MG
QL morphine sulfate MS CONTIN TABLET ER
Page 83 of 103

Comprehensive Alliance Drug Formulary – April 2012
100 MG
QL morphine sulfate MS CONTIN TABLET ER
15 MG
PA morphine sulfate AVINZA CPMP 24HR
120 MG
PA morphine sulfate AVINZA CPMP 24HR
90 MG
PA morphine sulfate AVINZA CPMP 24HR
60 MG
PA morphine sulfate AVINZA CPMP 24HR
30 MG
PA morphine sulfate KADIAN CAP ER PEL
10 MG
PA morphine sulfate MS CONTIN CAP ER PEL
80 MG
PA morphine sulfate KADIAN CAP ER PEL
200 MG
QL oxycodone hcl/acetaminophen TYLOX TABLET 7.5-
325MG
QL oxycodone hcl/acetaminophen TYLOX TABLET
10MG-325MG
QL oxycodone hcl/acetaminophen TYLOX TABLET 7.5-
500MG
QL oxycodone hcl/acetaminophen TYLOX TABLET
10MG-650MG
oxycodone hcl/acetaminophen TYLOX SOLUTION 5-
325/5ML
QL oxycodone hcl/acetaminophen TYLOX TABLET 5
MG-500MG
QL oxycodone hcl/acetaminophen TYLOX TABLET
5MG-325MG
QL oxycodone hcl/acetaminophen TYLOX CAPSULE 5
MG-500MG
QL oxycodone hcl/aspirin ENDODAN TABLET
4.8355-325
pentazocine hcl/naloxone hcl TALWIN NX TABLET
50MG-0.5MG
QL tramadol hcl ULTRAM ER TABLET 50
MG
Antimigraine Preparations
QL+ almotriptan malate AXERT TABLET 12.5
ST
MG
QL+ almotriptan malate AXERT TABLET 6.25
ST
MG
QL eletriptan hydrobromide RELPAX TABLET 20
MG
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Comprehensive Alliance Drug Formulary – April 2012
QL eletriptan hydrobromide RELPAX TABLET 40
MG
ergotamine tartrate ERGOMAR TAB SUBL 2
MG
ergotamine tartrate/caffeine CAFERGOT SUPP.RECT 2-
100MG
ergotamine tartrate/caffeine CAFERGOT TABLET
1MG-100MG
QL+
ST
frovatriptan succinate FROVA TABLET 2.5
MG
isomethept/acetaminop/dichlphn MIDRIN CAPSULE 65-
325-100
isometheptene/acetaminoph/caff PRODRIN TABLET 130-
500-20
QL+ rizatriptan benzoate MAXALT TABLET 5
ST
MG
QL+ rizatriptan benzoate MAXALT TABLET 10
ST
MG
QL+ rizatriptan benzoate MAXALT MLT TAB RAPDIS
ST
5 MG
QL+ rizatriptan benzoate MAXALT MLT TAB RAPDIS
ST
10 MG
QL+ sumatriptan IMITREX SPRAY 5 MG
ST
QL+
ST
QL sumatriptan succinate IMITREX TABLET 50
MG
QL sumatriptan succinate IMITREX TABLET 100
MG
QL sumatriptan succinate IMITREX TABLET 25
MG
QL+
ST
QL+
ST
QL+
ST
sumatriptan IMITREX SPRAY 20 MG
sumatriptan succinate IMITREX CARTRIDGE
6 MG/0.5ML
zolmitriptan ZOMIG ZMT TAB RAPDIS
5 MG
zolmitriptan ZOMIG ZMT TAB RAPDIS
2.5 MG
Narc.& Non-Sal.analgesic,Barbiturate &xanthine Cmb
codeine/butalbit/acetamin/caff FIORICET WITH CODEINE CAPSULE 30-
50-325
Narcotic & Salicylate Analgesics, Barb.& Xanthine
codeine/butalbital/asa/caffein FIORINAL WITH CODEINE #3 CAPSULE 30-
50-325
Narcotic Analgesic & Non-Salicylate Analgesic Comb
Page 85 of 103

Comprehensive Alliance Drug Formulary – April 2012
QL acetaminophen with codeine TYLENOL-CODEINE NO.4 ELIXIR 120-
12MG/5
acetaminophen with codeine CAPITAL W-CODEINE ORAL SUSP
120-12MG/5
QL acetaminophen with codeine TYLENOL-CODEINE NO.4 TABLET
300MG-15MG
QL acetaminophen with codeine TYLENOL-CODEINE NO.4 TABLET
300MG-30MG
acetaminophen with codeine TYLENOL-CODEINE NO.4 TABLET
650MG-30MG
QL acetaminophen with codeine TYLENOL-CODEINE NO.4 TABLET
300MG-60MG
PARKINSONS DISEASE
Antiparkinsonism Drugs,Other
PA bromocriptine mesylate PARLODEL CAPSULE 5
MG
bromocriptine mesylate PARLODEL TABLET 2.5
MG
carbidopa/levodopa PARCOPA TABLET ER
50MG-200MG
carbidopa/levodopa PARCOPA TABLET ER
25MG-100MG
carbidopa/levodopa PARCOPA TABLET
10MG-100MG
carbidopa/levodopa PARCOPA TABLET
25MG-100MG
carbidopa/levodopa PARCOPA TABLET
25MG-250MG
ST carbidopa/levodopa/entacapone STALEVO 75 TABLET
18.75-75MG
ST carbidopa/levodopa/entacapone STALEVO 125 TABLET
31.25-125
ST carbidopa/levodopa/entacapone STALEVO 150 TABLET 37.5-
150MG
ST carbidopa/levodopa/entacapone STALEVO 100 TABLET 25-
100-200
ST carbidopa/levodopa/entacapone STALEVO 50 TABLET 12.5-
50MG
ST carbidopa/levodopa/entacapone STALEVO 200 TABLET 50-
200-200
ST entacapone COMTAN TABLET 200
MG
ropinirole hcl REQUIP TABLET 0.25
MG
ropinirole hcl REQUIP TABLET 1
Page 86 of 103

Comprehensive Alliance Drug Formulary – April 2012
MG
ropinirole hcl REQUIP TABLET 2
MG
ropinirole hcl REQUIP TABLET 5
MG
ropinirole hcl REQUIP TABLET 0.5
MG
ropinirole hcl REQUIP TABLET 4
MG
ropinirole hcl REQUIP TABLET 3
MG
selegiline hcl ELDEPRYL TABLET 5
MG
selegiline hcl ELDEPRYL CAPSULE 5
MG
SEIZURE DISORDER
Anticonvulsants
carbamazepine CARBATROL TABLET 200
MG
carbamazepine CARBATROL TAB CHEW
100 MG
PA carbamazepine TEGRETOL XR TAB ER 12H
100 MG
PA carbamazepine CARBAMAZEPINE
TEGRETOL XR
TAB ER 12H
200 MG
PA carbamazepine CARBAMAZEPINE
TEGRETOL XR
TAB ER 12H
400 MG
carbamazepine CARBATROL ORAL SUSP
100 MG/5ML
clonazepam KLONOPIN TABLET 0.5
MG
clonazepam KLONOPIN TABLET 1
MG
clonazepam KLONOPIN TABLET 2
MG
QL diazepam DIASTAT ACUDIAL KIT 5-7.5-
10MG
QL diazepam DIASTAT ACUDIAL KIT 12.5-15-20
QL diazepam DIASTAT KIT 2.5 MG
QL diazepam DIASTAT KIT 5-7.5-
10MG
QL diazepam DIASTAT KIT 12.5-15-20
divalproex sodium DEPAKOTE TABLET DR
250 MG
divalproex sodium DEPAKOTE TABLET DR
Page 87 of 103

Comprehensive Alliance Drug Formulary – April 2012
500 MG
divalproex sodium DEPAKOTE TABLET DR
125 MG
divalproex sodium DEPAKOTE CAP SPRINK
125 MG
divalproex sodium DEPAKOTE TAB ER 24H
500 MG
divalproex sodium DEPAKOTE TAB ER 24H
250 MG
ethosuximide ZARONTIN CAPSULE 250
MG
ethosuximide ZARONTIN SYRUP 250
MG/5ML
QL gabapentin NEURONTIN CAPSULE 100
MG
QL gabapentin NEURONTIN CAPSULE 300
MG
QL gabapentin NEURONTIN CAPSULE 400
MG
QL gabapentin NEURONTIN TABLET 800
MG
QL gabapentin NEURONTIN TABLET 600
MG
PA lacosamide VIMPAT TABLET 50
MG
PA lacosamide VIMPAT TABLET 100
MG
PA lacosamide VIMPAT TABLET 150
MG
PA lacosamide VIMPAT TABLET 200
MG
PA lacosamide VIMPAT SOLUTION 10
MG/ML
PA lamotrigine LAMICTAL XR TAB ER 24 25
MG
PA lamotrigine LAMICTAL XR TAB ER 24 50
MG
PA lamotrigine LAMICTAL XR TAB ER 24
100 MG
PA lamotrigine LAMICTAL XR TAB ER 24
200 MG
PA lamotrigine LAMICTAL XR TAB ER 24
300 MG
PA lamotrigine LAMICTAL XR TAB ER 24
250 MG
AGE+ lamotrigine LAMICTAL TABLET 100
Page 88 of 103

Comprehensive Alliance Drug Formulary – April 2012
QL
MG
AGE+ lamotrigine LAMICTAL TABLET 25
QL
MG
AGE+ lamotrigine LAMICTAL TB CHW DSP
QL
5 MG
AGE+ lamotrigine LAMICTAL TABLET 150
QL
MG
AGE+ lamotrigine LAMICTAL TABLET 200
QL
MG
AGE+ levetiracetam KEPPRA XR TAB ER 24H
QL+
500 MG
ST
AGE+ levetiracetam KEPPRA SOLUTION
QL
100 MG/ML
AGE+ levetiracetam KEPPRA XR TAB ER 24H
QL+
750 MG
ST
AGE+ levetiracetam KEPPRA TABLET 750
QL
MG
AGE+ levetiracetam KEPPRA TABLET 250
QL
MG
AGE+ levetiracetam KEPPRA TABLET
QL
500MG
AGE+ levetiracetam KEPPRA TABLET 1000
QL
MG
AGE+ oxcarbazepine TRILEPTAL TABLET 300
QL
MG
AGE+ oxcarbazepine TRILEPTAL TABLET 600
QL
MG
AGE+ oxcarbazepine TRILEPTAL TABLET 150
QL
MG
phenytoin DILANTIN-125 ORAL SUSP
125 MG/5ML
phenytoin DILANTIN TAB CHEW
50 MG
phenytoin sodium extended DILANTIN CAPSULE 300
MG
phenytoin sodium extended DILANTIN CAPSULE 200
MG
phenytoin sodium extended DILANTIN CAPSULE 100
MG
phenytoin sodium extended DILANTIN CAPSULE 30
MG
primidone MYSOLINE TABLET 250
MG
primidone MYSOLINE TABLET 50
Page 89 of 103

Comprehensive Alliance Drug Formulary – April 2012
MG
PA rufinamide BANZEL TABLET 200
MG
PA rufinamide BANZEL TABLET 400
MG
PA tiagabine hcl GABITRIL TABLET 4
MG
PA tiagabine hcl GABITRIL TABLET 12
MG
PA tiagabine hcl GABITRIL TABLET 16
MG
PA tiagabine hcl GABITRIL TABLET 2
MG
QL+ topiramate TOPAMAX TABLET 50
AGE
MG
QL+ topiramate TOPAMAX TABLET 100
AGE
MG
QL+ topiramate TOPAMAX TABLET 200
AGE
MG
QL+ topiramate TOPAMAX TABLET 25
AGE
MG
PA topiramate TOPAMAX CAP SPRINK
15 MG
PA topiramate TOPAMAX CAP SPRINK
25 MG
valproate sodium DEPACON SOLUTION
250 MG/5ML
valproic acid DEPAKENE CAPSULE 250
MG
AGE+ zonisamide ZONEGRAN CAPSULE 25
QL
MG
AGE+ zonisamide ZONEGRAN CAPSULE 50
QL
AGE+
QL
MG
zonisamide ZONEGRAN CAPSULE 100
MG
SKELETAL MUSCLE DISORDER
Skeletal Muscle Relaxants
baclofen BACLOFEN TABLET 10
MG
baclofen BACLOFEN TABLET 20
MG
carisoprodol SOMA TABLET 350
MG
cyclobenzaprine hcl FLEXERIL TABLET 10
MG
Page 90 of 103

Comprehensive Alliance Drug Formulary – April 2012
methocarbamol ROBAXIN-750 TABLET 500
MG
methocarbamol ROBAXIN-750 TABLET 750
MG
SMOKING CESSATION
Smoking Deterrent Agents (ganglionic Stim,Others)
QL nicotine NICODERM CQ PATCH TD24
7MG/24HR
QL nicotine NICODERM CQ PATCH TD24
14MG/24HR
QL nicotine NICODERM CQ PATCH TD24
21 MG/24HR
QL nicotine polacrilex NICORETTE GUM 2MG
QL nicotine polacrilex NICORETTE GUM 4 MG
Smoking Deterrents, Other
bupropion hcl ZYBAN TABLET ER
150 MG
UPPER GASTROINTESTINAL DISORDERS -
DIGESTIVE
Antiflatulents
simethicone INFANTS' MYLICON DROPS SUSP
40MG/0.6ML
simethicone INFANTS' MYLICON CAPSULE 125
MG
Pancreatic Enzymes
AGE lipase/protease/amylase ULTRASE MT 20 CAPSULE DR
371 MG
AGE lipase/protease/amylase ULTRASE MT 12 CAPSULE DR
223MG
AGE lipase/protease/amylase VIOKASE TABLET
468MG
AGE lipase/protease/amylase ULTRASE MT 18 CAPSULE DR
333 MG
AGE lipase/protease/amylase VIOKASE TABLET 935
MG
AGE lipase/protease/amylase CREON CAPSULE DR
6K-19K-30K
AGE lipase/protease/amylase CREON CAPSULE DR
12K-38K-60
AGE lipase/protease/amylase CREON CAPSULE DR
24-76-120K
Page 91 of 103

Comprehensive Alliance Drug Formulary – April 2012
AGE lipase/protease/amylase ZENPEP CAPSULE DR
5K-17K-27K
AGE lipase/protease/amylase ZENPEP CAPSULE DR
10-34-55K
AGE lipase/protease/amylase ZENPEP CAPSULE DR
15-51-82K
AGE lipase/protease/amylase ZENPEP CAPSULE DR
20-68-109K
AGE lipase/protease/amylase PANCREAZE CAPSULE DR
16.8-40-70
AGE lipase/protease/amylase PANCREAZE CAPSULE DR
21-37-61K
AGE lipase/protease/amylase PANCREAZE CAPSULE DR
10.5K-25K
AGE lipase/protease/amylase PANCREAZE CAPSULE DR
4.2K-10K
AGE lipase/protease/amylase CREON CAPSULE DR
3-9.5-15K
AGE lipase/protease/amylase ZENPEP CAPSULE DR
3K-10K-16K
AGE lipase/protease/amylase ZENPEP CAPSULE DR
25-85-136K
AGE lipase/protease/amylase ULTRASE CAPSULE DR
250 MG
AGE pancreatin/potass/sod bicarb KARBOZYME TABLET
UPPER GASTROINTESTINAL DISORDERS -
SPASTIC DISEASE
Anticholinergics/Antispasmodics
dicyclomine hcl BENTYL CAPSULE 10
MG
dicyclomine hcl BENTYL SYRUP 10
MG/5 ML
dicyclomine hcl BENTYL TABLET 20
MG
Belladonna Alkaloids
belladonna alkaloids/phenobarb DONNATAL TABLET
16.2MG
hyoscyamine sulfate SYMAX DUOTAB ELIXIR
125MCG/5ML
hyoscyamine sulfate SYMAX DUOTAB DROPS
0.125MG/ML
hyoscyamine sulfate SYMAX DUOTAB TAB ER 12H
0.375 MG
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Comprehensive Alliance Drug Formulary – April 2012
hyoscyamine sulfate SYMAX DUOTAB TABLET 0.125
MG
hyoscyamine sulfate SYMAX DUOTAB TAB SUBL
0.125 MG
phenobarb/hyoscy/atropine/scop DONNATAL ELIXIR
16.2MG/5ML
UPPER GASTROINTESTINAL DISORDERS -
ULCER DISEASE
Antacids
aluminum hydroxide ALTERNAGEL ORAL SUSP
320MG/5ML
aluminum hydroxide ALTERNAGEL ORAL SUSP
600MG/5ML
calcium carbonate TUMS TAB CHEW
168(420)MG
calcium carbonate TUMS TAB CHEW
200(500)MG
calcium carbonate TUMS TAB CHEW
300MG(750)
calcium carbonate TUMS TAB CHEW
400(1000)
calcium carbonate TUMS TAB CHEW
600 MG
TAB CHEW
1000-60MG
calcium carbonate/simethicone MAALOX
MAALOX ADVANCED
mag hydrox/al hydrox/simeth MYLANTA DOUBLE-STRENGTH ORAL SUSP
200-200-20
mag hydrox/al hydrox/simeth MYLANTA DOUBLE-STRENGTH ORAL SUSP
400-400-30
mag hydrox/al hydrox/simeth MYLANTA DOUBLE-STRENGTH ORAL SUSP
400-400-40
mag hydrox/al hydrox/simeth MYLANTA DOUBLE-STRENGTH ORAL SUSP
200-225-25
mag hydrox/al hydrox/simeth MYLANTA DOUBLE-STRENGTH ORAL SUSP
450-500-40
mag hydrox/al hydrox/simeth MYLANTA DOUBLE-STRENGTH TAB CHEW
200-200-20
mag hydrox/al hydrox/simeth MYLANTA DOUBLE-STRENGTH TAB CHEW
200-200-25
mag hydrox/al hydrox/simeth MYLANTA DOUBLE-STRENGTH TAB CHEW
400-400-40
mag hydrox/al hydrox/simeth MYLANTA DOUBLE-STRENGTH ORAL SUSP
200-200-20
magnesium carbonate/al hydrox GAVISCON TAB CHEW
Page 93 of 103

Comprehensive Alliance Drug Formulary – April 2012
105-160MG
magnesium hydroxide/al hydrox ALAMAG TAB CHEW
150-300MG
mg trisilicate/alh/nahco3/aa GAVISCON TAB CHEW
20-80MG
sodium bicarbonate SODIUM BICARBONATE TABLET 650
MG
Anti-Ulcer Preparations
misoprostol CYTOTEC TABLET 200
MCG
misoprostol CYTOTEC TABLET 100
MCG
sucralfate CARAFATE ORAL SUSP 1
G/10 ML
sucralfate CARAFATE TABLET 1 G
Anti-Ulcer-H.pylori Agents
QL lansoprazole/amoxiciln/clarith PREVPAC COMBO. PKG
30-500-500
Anticholinergics,Quaternary Ammonium
propantheline bromide PROPANTHELINE BROMIDE TABLET 15
MG
propantheline bromide PRO-BANTHINE TABLET 7.5
MG
Histamine H2-Receptor Inhibitors
cimetidine TAGAMET TABLET 200
MG
cimetidine TAGAMET TABLET 300
MG
cimetidine TAGAMET TABLET 400
MG
cimetidine TAGAMET TABLET 800
MG
cimetidine hcl CIMETIDINE HCL SOLUTION
300 MG/5ML
famotidine PEPCID TABLET 20
MG
famotidine PEPCID TABLET 40
MG
famotidine PEPCID TABLET 10
MG
ranitidine ZANTAC TABLET 150
ranitidine hcl ZANTAC TABLET 300
MG
ranitidine hcl ZANTAC SYRUP 15
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Comprehensive Alliance Drug Formulary – April 2012
MG/ML
ranitidine hcl ZANTAC CAPSULE 150
MG
ranitidine hcl ZANTAC CAPSULE 300
MG
Intestinal Motility Stimulants
metoclopramide hcl REGLAN SOLUTION
5MG/5ML
metoclopramide hcl REGLAN TABLET 10
MG
metoclopramide hcl REGLAN TABLET 5
MG
Proton-Pump Inhibitors
lansoprazole PREVACID 24HR CAPSULE DR
15 MG
omeprazole PRILOSEC CAPSULE DR
20 MG
omeprazole PRILOSEC TABLET DR
20 MG
omeprazole magnesium PRILOSEC OTC TABLET DR
20 MG
QL pantoprazole sodium PROTONIX TABLET DR
40 MG
QL pantoprazole sodium PROTONIX TABLET DR
20 MG
URINARY TRACT - FUNCTIONAL
DISORDERS
Benign Prostatic Hypertrophy/Micturition Agents
ST+
QL
QL+
ST
finasteride PROSCAR TABLET 5
MG
tamsulosin hcl FLOMAX CAP ER 24H
0.4 MG
Urinary Ph Modifiers
QL potassium citrate UROCIT-K TABLET ER 5
MEQ
QL potassium citrate UROCIT-K TABLET ER
10 MEQ
potassium phosphate,monobasic K-PHOS ORIGINAL TABLET SOL
500 MG
Urinary Tract Anesthetic/Analgesic Agnt (azo-Dye)
phenazopyridine hcl AZO STANDARD TABLET 100
MG
Page 95 of 103

Comprehensive Alliance Drug Formulary – April 2012
phenazopyridine hcl AZO STANDARD TABLET 200
MG
Urinary Tract Antispasmodic/Antiincontinence Agent
oxybutynin chloride DITROPAN XL SYRUP 5
MG/5 ML
oxybutynin chloride DITROPAN XL TABLET 5
QL+
ST
QL+
ST
QL+
ST
MG
oxybutynin chloride DITROPAN XL TAB ER 24 5
MG
oxybutynin chloride DITROPAN XL TAB ER 24 10
MG
oxybutynin chloride DITROPAN XL TAB ER 24 15
MG
VAGINAL DISORDERS
Vaginal Antibiotics
clindamycin phosphate CLEOCIN CREAM/APPL
2 %
metronidazole METRONIDAZOLE GEL W/APPL
0.75 %
Vaginal Antifungals
butoconazole nitrate MYCELEX-3 CREAM/APPL
2 %
butoconazole nitrate FEMSTAT 3 CRM/PF APP
2 %
clotrimazole FEMCARE CREAM/APPL
1 %
clotrimazole FEMCARE CREAM/APPL
2 %
clotrimazole FEMCARE TABLET 100
MG
clotrimazole FEMCARE COMBO. PKG
100MG-1%
clotrimazole FEMCARE COMBO. PKG
200 MG-1 %
miconazole nitrate MONISTAT 3 CREAM/APPL
2 %
miconazole nitrate MONISTAT 3 CREAM/APPL
4 %
miconazole nitrate MONISTAT 3 SUPP.VAG
100 MG
miconazole nitrate MONISTAT 3 SUPP.VAG
200 MG
miconazole nitrate MONISTAT 3 COMBO. PKG
200 MG-2 %
Page 96 of 103

Comprehensive Alliance Drug Formulary – April 2012
miconazole nitrate MONISTAT 3 COMBO. PKG
1200MG-2%
nystatin NYSTATIN TABLET 100K
UNIT
terconazole TERAZOL 3 SUPP.VAG 80
MG
terconazole TERAZOL 3 CREAM/APPL
0.4 %
terconazole TERAZOL 3 CREAM/APPL
0.8%
tioconazole VAGISTAT-1 OIN/PF APP
6.5 %
Vaginal Estrogen Preparations
estradiol ESTRACE CREAM/APPL
0.01 %
estrogens,conjugated PREMARIN CREAM/APPL
0.625 MG/G
VITAMIN AND/OR MINERAL DEFICIENCY
Bioflavonoids
PA bioflav,lemon/vit bcomp&c BIOFLAV,LEMON/VIT BCOMP&C TABLET 200-
100MG
Calcium Replacement
calcium CALCIUM TABLET 500
MG
calcium carb&gluc/vitamin d2 OS-CAL 500+D TABLET 500
MG-200
calcium carbonate CALTRATE 600 TABLET
500(1250)
calcium carbonate CALTRATE 600 TABLET 600
MG
calcium carbonate CALTRATE 600 TABLET 600
MG
calcium carbonate CALTRATE 600 TABLET 648
MG
calcium carbonate CALTRATE 600 TAB CHEW
300MG(750)
calcium carbonate CALTRATE 600 TAB CHEW
500(1250)
calcium carbonate CALCIUM CARBONATE ORAL SUSP
500 MG/5ML
calcium carbonate CALCIUM CARBONATE TAB CHEW
500(1250)
calcium carbonate/vitamin d2 OS-CAL 500+D TABLET 250
MG-125
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Comprehensive Alliance Drug Formulary – April 2012
calcium carbonate/vitamin d2 OS-CAL 500+D TABLET 500
MG-125
calcium carbonate/vitamin d3 OS-CAL 500+D TABLET 500
MG-200
calcium carbonate/vitamin d3 OS-CAL 500+D TABLET 250
MG-125
calcium carbonate/vitamin d3 OS-CAL 500+D TABLET 600
MG-200
calcium carbonate/vitamin d3 OS-CAL 500+D TABLET 600
MG-400
calcium carbonate/vitamin d3 CALCIUM WITH VITAMIN D TAB CHEW
500 MG-100
calcium citrate/vitamin d2 CALCIUM CITRATE/VITAMIN D2 TABLET
1500MG-200
calcium citrate/vitamin d3 CITRACAL + D TABLET
250MG-200
calcium citrate/vitamin d3 CITRACAL + D TABLET 315
MG-200
calcium gluconate CALCIUM GLUCONATE TABLET
45(500) MG
calcium gluconate CALCIUM GLUCONATE TABLET
60(648) MG
calcium lactate CALCIUM LACTATE TABLET 84
MG(648)
calcium phosphate/vitamin d3 CALCIUM PHOSPHATE/VITAMIN D3 TABLET 105
MG-120
Fluoride Preparations
sodium fluoride PREVIDENT SOLUTION
0.2 %
SOLUTION
0.05 %
sodium fluoride
NAFRINSE DAILY-NEUTRAL
PHOS-FLUR
sodium fluoride FLUORITAB DROPS
0.125/DROP
sodium fluoride FLURA-DROPS DROPS
0.25MG/DRP
sodium fluoride PREVIDENT DROPS 0.5
MG/ML
sodium fluoride FLUOR-A-DAY DROPS 2.5
MG/ML
sodium fluoride PREVIDENT TAB CHEW
0.25(0.55)
sodium fluoride PREVIDENT TAB CHEW
0.5(1.1)MG
sodium fluoride PREVIDENT TAB CHEW
1MG(2.2MG)
sodium fluoride PREVIDENT TABLET
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Comprehensive Alliance Drug Formulary – April 2012
1MG(2.2MG)
sodium fluoride PREVIDENT TAB CHEW
0.5(1.1)MG
Folic Acid Preparations
folic acid FOLIC ACID TABLET 1
MG
Iron Replacement
QL ferrous sulfate SLOW FE SOLUTION
220(44)/5
QL ferrous sulfate SLOW FE LIQUID 300
MG/5ML
QL ferrous sulfate SLOW FE DROPS 15
MG/ML
QL ferrous sulfate SLOW FE TABLET
325(65) MG
QL ferrous sulfate SLOW FE TABLET DR
325(65) MG
Magnesium Salts Replacement
PA magnesium oxide/mag aa chelate MG-PLUS-PROTEIN TABLET
133MG
Multivitamin Preparations
PA b complex with vitamin c BEROCCA TABLET
beta-carotene(a) w-c & e/min OCUVITE TABLET ER
folic acid/mv,fe,other min/lut FOLIC ACID/MV,FE,OTHER MIN/LUT TABLET 0.4-
18-250
QL multivitamins,ther w-minerals THERAPEUTIC-M TABLET
QL multivitamins,therapeutic MULTIVITAMINS,THERAPEUTIC TABLET
QL multivitamins,therapeutic MULTIVITAMINS,THERAPEUTIC LIQUID
QL multivits w-iron,hematinic CENTRUM TABLET
27MG-0.4MG
QL multivits,th w-fe,other min MULTIVITS,TH W-FE,OTHER MIN TABLET
Pediatric Vitamin Preparations
QL+
AGE
QL+
AGE
QL+
AGE
QL+
AGE
QL+
AGE
fluoride ion/multivitamins POLY-VI-FLOR DROPS
0.5MG/ML
fluoride/iron/vit a,c&d FLUORIDE/IRON/VIT A,C&D DROPS 0.25
MG/ML
iron/vitamins a,c,and d TRI-VI-SOL WITH IRON DROPS
multivitamin POLY-VI-SOL DROPS
multivitamins with fluoride POLY-VI-FLOR DROPS 0.25
MG/ML
multivitamins with fluoride MULTIVITAMINS WITH FLUORIDE DROPS 0.5
MG/ML
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Comprehensive Alliance Drug Formulary – April 2012
QL+ multivitamins with iron POLY-VI-SOL WITH IRON DROPS
AGE
QL+ multivits with iron & fluoride MULTIVITS WITH IRON & FLUORIDE DROPS 0.25
AGE
MG/ML
QL+ ped mv a,c,d3 #21 w-fluoride FLUORABON BASIC DROPS 0.5
AGE
MG/ML
QL+ ped mv a,c,d3 #21 w-fluoride FLUORABON BASIC DROPS 0.25
AGE
MG/ML
pedi m.vit no.17 with fluoride POLY-VI-FLOR TAB CHEW
0.5 MG
pedi m.vit no.17 with fluoride POLY-VI-FLOR TAB CHEW 1
MG
pedi m.vit no.17 with fluoride POLY-VI-FLOR TAB CHEW
0.25 MG
QL+ vitamins a,c,and d VITAMINS A,C,AND D DROPS 1500-
AGE
35
Prenatal Vitamin Preparations
QL+ pnv #14/ferrous fum/folic acid NATACHEW TAB CHEW
GEN+
29 MG-1 MG
AGE
QL+ pnv cmb#95/ferrous fumarate/fa PRENAVITE TABLET
GEN+
28MG-0.8MG
AGE
QL+ pnv cmb#95/ferrous fumarate/fa PRENAVITE TABLET
GEN+
28MG-0.8MG
AGE
QL+ pnv no.4/iron cbn&gluc/fa/doss CITRANATAL RX TABLET 27-1-
GEN+
50MG
AGE
QL+ pnv w-o ca no5/fe fumarate/fa PNV W-O CA NO5/FE FUMARATE/FA CAPSULE
GEN+
106.5-1MG
AGE
QL+ pnv with ca no.36/iron/fa P-D NATAL PLUS CAPSULE
GEN+
13.5-0.4MG
AGE
QL+ pnv with ca,no.71/iron/fa PRENAVITE TABLET 27
GEN+
MG-1 MG
AGE
QL+ pnv with ca,no.74/iron/fa PNV WITH CA,NO.74/IRON/FA TABLET 27
GEN+
MG-1 MG
AGE
QL+ pnv2/iron b-g suc-p/fa/omega-3 TRUST NATAL DHA COMBO. PKG
GEN+
29-1-250MG
AGE
GEN+ prenatal vit #76/iron,carb/fa NESTABS CBF TABLET 29
AGE+
MG-1 MG
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Comprehensive Alliance Drug Formulary – April 2012
QL
QL+ prenatal vit 15/iron cb/fa/dss PRENATAL VIT 15/IRON CB/FA/DSS TABLET 90-1-
GEN+
50 MG
AGE
QL+ prenatal vit no.73/iron/fa PRENAVITE TABLET 28
GEN+
MG-1 MG
AGE
QL+ prenatal vit no.78/iron/fa PRENAVITE TABLET 29
GEN+
MG-1 MG
AGE
QL+ prenatal vit/fe carb-feso4/fa PRENATAL VIT/FE CARB-FESO4/FA TABLET 60-
GEN+
1MG
AGE
QL+ prenatal vit/fe fum/doss/fa PRENATAL VIT/FE FUM/DOSS/FA TABLET ER
GEN+
90-50-1MG
AGE
QL+ prenatal vit/fe fumarate/fa PRENAVITE TABLET 60-
GEN+
0.8MG
AGE
QL+ prenatal vit/fe fumarate/fa PRENAVITE TABLET 65
GEN+
MG-1 MG
AGE
QL+ prenatal vit/fe fumarate/fa PRENAVITE TABLET 66-
GEN+
1MG
AGE
QL+ prenatal vit/fe fumarate/fa PRENAVITE TAB CHEW
GEN+
29 MG-1 MG
AGE
QL+ prenatal vit/fe fumarate/fa/se MATERNA TABLET 27
GEN+
MG-1 MG
AGE
QL+ prenatal vit/fe gluconate/fa PRENATAL VIT/FE GLUCONATE/FA TABLET 30-
GEN+
0.8MG
AGE
QL+ prenatal vit/fe ps cmplx/fa NIFEREX-PN FORTE TABLET 60
GEN+
MG-1 MG
AGE
QL+ prenatal vit27&calcium/iron/fa PRENAVITE TABLET 60
GEN+
MG-1 MG
AGE
QL+ prenatal vitamins/fe bisgly/fa NATELLE TABLET 29
GEN+
MG-1 MG
AGE
QL+ prenatal vitamins/fe bisgly/fa NATELLE TABLET 27
GEN+
AGE
MG-1 MG
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Comprehensive Alliance Drug Formulary – April 2012
QL+ pv w-o cal/ferrous fumarate/fa M-VIT TABLET 27
GEN+
MG-1 MG
AGE
Prenatal Vitamins Without Iron
QL+
GEN+
AGE
pnv w-o iron/fa/calcium/b6/b12 PREMESIS RX TBMP 24HR
1-200-75
Vitamin B Preparations
PA fa/vit b complex & c/rice bran ALLBEE C-800 TABLET
400MCG-500
PA vit b cmplx 3/fa/vit c/biotin NEPHROCAPS TABLET
1MG-60MG
Vitamin B1 Preparations
thiamine hcl THIAMINE HCL TABLET 100
MG
Vitamin B6 Preparations
pyridoxine hcl PYRIDOXINE HCL TABLET
100MG
pyridoxine hcl PYRIDOXINE HCL TABLET 500
MG
pyridoxine hcl PYRIDOXINE HCL TABLET 50
MG
pyridoxine hcl PYRIDOXINE HCL TABLET
25MG
Vitamin D Preparations
calcitriol ROCALTROL CAPSULE
0.25 MCG
calcitriol ROCALTROL CAPSULE 0.5
MCG
cholecalciferol VITAMIN D TABLET 1000
UNIT
dihydrotachysterol DHT TABLET
0.2MG
ergocalciferol (vitamin d2) DRISDOL DROPS
8000/ML
ergocalciferol (vitamin d2) DRISDOL CAPSULE
50000 UNIT
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