COMPREHENSIVE FORMULARY - RxAmerica

www.Meds4Medicare.com
COMPREHENSIVE FORMULARY
2007
ADVANTAGE FREEDOM
11/2006
S5644_CFF252

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE
COVER IN THIS PLAN
Note to existing members: This formulary has changed since last year. Please
review this document to make sure that it still contains the drugs you take.
What is the RxAmerica Formulary?
A formulary is a list of covered drugs selected by RxAmerica in consultation with a
team of health care providers, which represents the prescription therapies believed
to be a necessary part of a quality treatment program. RxAmerica will generally cover
the drugs listed in our formulary as long as the drug is medically necessary, the
prescription is filled at an RxAmerica network pharmacy, and other plan rules are
followed. For more information on how to fill your prescriptions, please review your
Evidence of Coverage.
Can the Formulary change?
Generally, if you are taking a drug on our 2007 formulary that was covered at the
beginning of the year, we will not discontinue or reduce coverage of the drug during
the 2007 coverage year except when a new, less expensive generic drug becomes
available or when new adverse information about the safety or effectiveness of a
drug is released. Other types of formulary changes, such as removing a drug from our
formulary, will not affect members who are currently taking the drug. It will remain
available at the same cost-sharing for those members taking it for the remainder of
the coverage year. We feel it is important that you have continued access for the
remainder of the coverage year to the formulary drugs that were available when you
chose our plan, except for cases in which you can save additional money or improve
the safety of your drugs.
S5644_CFF252
11/2006
Last Updated 7/15/07
1

If we remove drugs from our formulary, or add prior authorization, quantity limits
and/or step therapy restrictions on a drug or move a drug to a higher costsharing
tier, we must notify affected members of the change at least 60 days
before the change becomes effective, or at the time the member requests a
refill of the drug, at which time the member will receive a 60-day supply of the
drug. If the Food and Drug Administration deems a drug on our formulary to be
unsafe or the drug’s manufacturer removes the drug from the market, we will
immediately remove the drug from our formulary and provide notice to members
who take the drug. The enclosed formulary is current as of July 15, 2007.
To get updated information about the drugs covered by RxAmerica, please visit
our Web site at www.Meds4Medicare.com or call Customer Service at 1-800-
429-6686, 8 a.m. to 8 p.m. (local time), seven days a week. TTY/TDD users
should call 1-877-279-0371.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 8. The drugs in this formulary are grouped into
categories depending on the type of medical conditions that they are used to
treat. For example, drugs used to treat a heart condition are listed under the
category, ”Cardiovascular Drugs”. If you know what your drug is used for, look for
the category name in the list that begins on page number 7. Then look under the
category name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in
the Index that begins on page 121. The Index provides an alphabetical list of all
of the drugs included in this document. Both brand-name drugs and generic
drugs are listed in the Index. Look in the Index and find your drug. Next to your
drug, you will see the page number where you can find coverage information. Turn
to the page listed in the Index and find the name of your drug in the first column
of the list.
What are generic drugs?
RxAmerica covers both brand-name drugs and generic drugs. A generic drug has
the same active-ingredient as the brand name drug. Generic drugs usually cost
less than brand name drugs and are approved by the Food and Drug
Administration (FDA).
How much will I pay for RxAmerica Covered Drugs?
If you qualified for extra help with your drug costs, your costs for your drugs may be
different than those described below. Please refer to your Evidence of Coverage or
call Customer Service to find out what your costs are.
2

After you meet your yearly deductible of $265, RxAmerica will pay part of the costs
for your covered drugs and you will pay part.
The amount you pay depends on which drug tier your drug is in under our plan. (You
can find out which drug tier your drug is in by looking in the formulary that begins on
page 8.)
Advantage Freedom Plan
RxAmerica offers two over-the-counter (OTC) drugs, Prilosec OTC and Loratadine, at a
$0 co-pay as part of our Step Therapy (STC) program.
Drug Tier
In-Network Retail
Pharmacy Co-payment
Preferred Mail Order
Co-payment
30-day 90-day 30-day 90-day
Tier 1 – Formulary Generics $5 co-pay $10 co-pay $5 co-pay $10 co-pay
Tier 2 – Formulary Preferred
Brands
$20 co-pay $50 co-pay $20 co-pay $50 co-pay
Tier 3 - Specialty 25% co- pay 25% co- pay 25% co- pay 25% co- pay
Tier 4 – Non-Preferred Brands $40 co-pay $100 co-pay $40 co-pay $100 co-pay
You will pay the co-payment amount above for your drugs until your total drug
costs (the amount you paid, including the deductible, plus the amount RxAmerica has
paid) reach $2,400. Once your total drug costs reach $2,400, there is a gap in
your coverage. This means you have to pay the full amount for your drugs. You pay
the full amount until you have paid $3,850 out of pocket. After you have paid
$3,850 out of pocket, you will generally pay a 5% co-payment.
You can ask RxAmerica to make an exception to your drug’s tier placement. See the
section, “How do I request an exception to the RxAmerica Formulary?,” for
information about how to request an exception.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These
requirements and limits may include:
Prior Authorization: RxAmerica requires you (or your physician) to get prior
authorization for certain drugs. This means that you will need to get approval
from RxAmerica before you fill your prescriptions. If you don’t get approval,
RxAmerica may not cover the drug.
Quantity Limits: For certain drugs, RxAmerica limits the amount of the drug
that RxAmerica will cover. For example, RxAmerica provides 9 tablets every 14
days per prescription for Imitrix. This may be in addition to a standard one
month or three month supply.
Step Therapy: In some cases, RxAmerica requires you to first try certain drugs
to treat your medical condition before we will cover another drug for that
3

condition. For example, if Drug A and Drug B both treat your medical
condition, RxAmerica may not cover drug B unless you try Drug A first. If Drug
A does not work for you, RxAmerica will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in
the formulary that begins on page 8.
You can ask RxAmerica to make an exception to these restrictions or limits. See the
section, “How do I request an exception to the RxAmerica formulary?” below for
information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should first contact Customer
Service and ask if your drug is covered. If you learn that RxAmerica does not cover
your drug, you have two options:
You can ask Customer Service for a list of similar drugs that are covered by
RxAmerica. When you receive the list, show it to your doctor and ask him or
her to prescribe a similar drug that is covered by RxAmerica.
You can ask RxAmerica to make an exception and cover your drug. See below
for information about how to request an exception.
NOTE: Due to a change in Medicare, most Medicare Drug Plans will no longer cover
erectile dysfunction (ED) drugs like Viagra, Cilais, Levitra, and Caverject starting
January 1, 2007. Call your Medicare Drug Plan for more information.
How do I request an exception to the RxAmerica Formulary?
You can ask RxAmerica to make an exception to our coverage rules. There are
several types of exceptions that you can ask us to make.
You can ask us to cover your drug even if it is not on our formulary.
You can ask us to waive coverage restrictions or limits on your drug. For
example, for certain drugs, RxAmerica limits the amount of the drug that we
will cover. If your drug has a quantity limit, you can ask us to waive the limit
and cover more.
Generally, RxAmerica will only approve your request for an exception if the alternative
drugs included on the plan’s formulary, the lower-tiered drug or additional utilization
restrictions would not be as effective in treating your condition and/or would cause
you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary,
tiering or utilization restriction exception. When you are requesting a formulary,
4

tiering or utilization restriction exception you should submit a statement from your
physician supporting your request. Generally, we must make our decision within 72
hours of getting your prescribing physician’s supporting statement. You can request
an expedited (fast) exception if you or your doctor believe that your health could be
seriously harmed by waiting up to 72 hours for a decision. If your request to expedite
is granted, we must give you a decision no later than 24 hours after we get your
prescribing physician’s supporting statement.
What do I do before I can talk to my doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on
our formulary. Or, you may be taking a drug that is on our formulary but your ability to
get it is limited. For example, you may need a prior authorization from us before you
can fill your prescription. You should talk to your doctor to decide if you should switch
to an appropriate drug that we cover or request a formulary exception so that we will
cover the drug you take. While you talk to your doctor to determine the right course of
action for you, we may cover your drug in certain cases during the first 90 days you
are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs
is limited, we will cover a temporary 30-day supply (unless you have a prescription
written for fewer days) when you go to a network pharmacy. After your first 30-day
supply, we will not pay for these drugs, even if you have been a member of the plan
less than 90 days.
If you are a resident of a long-term care facility, we will cover a 31-day transition
supply (unless you have a prescription written for fewer days). We will cover more
than one refill of these drugs for the first 90 days you are a member of our plan. If
you need a drug that is not on our formulary or if your ability to get your drugs is
limited, but you are past the first 90 days of membership in our plan, we will cover a
31-day emergency supply of that drug (unless you have a prescription for fewer days)
while you pursue a formulary exception.
For more information
For more detailed information about your RxAmerica prescription drug coverage,
please review your Evidence of Coverage and other plan materials.
If you have questions about RxAmerica, please call Customer Service at 1-800-429-
6686, 8 a.m. to 8 p.m. (local time), seven days a week. TTY/TDD users should call 1-
877-279-0371. Or visit www.Meds4Medicare.com.
If you have general questions about Medicare prescription drug coverage, please call
Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week.
TTY/TDD users should call 1-877-486-2048. Or, visit www.medicare.gov.
5

RxAmerica’s Formulary
The formulary that begins on the next page provides coverage information about
some of the drugs covered by RxAmerica. If you have trouble finding your drug in the
list, turn to the Index that begins on page 121.
The first column of the chart lists the drug name. Brand-name drugs are capitalized
(e.g. AMOXIL) and generic drugs are listed in lower-case italics (e.g., amoxicillin).
The information in the Notes column tells you if RxAmerica has any special
requirements for coverage of your drug.
PA - Prior authorization required (see page 3).
QL - Drug has quantity limit (see page 3).
STC - Step therapy required (see page 3).
6

RxAmerica’s Formulary
List of Covered Drugs
Drug Category
Page
Antihistamine Drugs….……………………………………………..………………….…………… 8
Anti-Infective Agents….……………………………………………………………….…………..… 8
Antineoplastic Agents….………………………………………….………………….….…………. 24
Autonomic Drugs….…………………………………………………………………….……………. 29
Blood Formation, Coagulation & Thrombosis….….…….…………………....…………. 33
Cardiovascular Drugs….……………..………………...……………………...….………………. 36
Central Nervous System Agents….……………………………………..….………………….. 49
Electrolytic, Caloric and Water Balance…..……………………….…………….………….. 70
Enzymes….…………………………………………………………………..…………….……………. 76
Respiratory Tract Agents…….…………………………………….………...……….…………… 76
Eye, Ear, Nose and Throat Preparations…..………………………...…………...………… 77
Gastrointestinal Drugs…..…………………………………….…..…………….…….………….. 81
Gold Compounds…..…………………………………………………………………….…………… 85
Heavy Metal Antagonists…..……………………………….….…………….…….…………….. 85
Hormones and Synthetic Substitutes…..……………………..……………..……………… 86
Local Anesthetics….….…………………..…………………………..…………….….…………… 97
Oxytocics….….……………………………….…………………………..………………..…………… 97
Serums, Toxoids and Vaccines…..……………………………...……………….……………. 97
Skin and Mucous Membrane Preparations…..……………………...……....………….. 99
Smooth Muscle Relaxants….….……………………………………………...….…………….. 109
Vitamins…..………………………………………………….……………….………….…………….. 110
Miscellaneous Therapeutic Agents……..……………………………...……………………. 111
Devices…..…………………………………………………………....………...…….……………….. 115
Pharmaceutical Aids…..………………………..……….……………………....……….…..….. 115
Index………………………………………………………….………………..…………………………. 125
7

Drug Name Drug Tier Notes
Antihistamine Drugs
ALLEGRA SUS 30MG/5ML(Fexofenadine HCl)
ALLEGRA TAB 180MG(Fexofenadine HCl)
ALLEGRA TAB 30MG(Fexofenadine HCl)
ALLEGRA TAB 60MG(Fexofenadine HCl)
ALLEGRA-D TAB 12 HOUR(Fexofenadine-Pseudoephedrine)
ALLEGRA-D TAB 24 HOUR(Fexofenadine-Pseudoephedrine)
CLARINEX SYP 0.5MG/ML(Desloratadine)
CLARINEX TAB 5MG(Desloratadine)
CLARINEX RDT TAB 2.5MG(Desloratadine)
CLARINEX RDT TAB 5MG(Desloratadine)
CLARINEX-D TAB 2.5-120(Desloratadine-Pseudoephedrine)
CLARINEX-D TAB 5-240MG(Desloratadine-Pseudoephedrine)
CLARITIN CHW 5MG(Loratadine)
CLARITIN TAB 10MG(Loratadine)
CLARITIN RDT TAB 10MG(Loratadine)
CLARITIN-D TAB 5-120MG(Loratadine & Pseudoephedrine)
DEXODRYL CHW 2-1.5MG(Chlorpheniramine Tannate-Methscopolamine)
DEXODRYL SUS(Chlorpheniramine Tannate-Methscopolamine)
fexofenadine hcl tab 180 mg
fexofenadine hcl tab 30 mg
fexofenadine hcl tab 60 mg
loratadine & pseudoephedrine tab sr 12hr 5-120 mg
loratadine & pseudoephedrine tab sr 24hr 10-240 mg
loratadine rapidly-disintegrating tab 10 mg
loratadine syrup 10 mg/10ml
loratadine tab 10 mg
PEDIOX-S SUS 4MG/5ML(Chlorpheniramine Maleate Tannate)
PHENERGAN INJ 25MG/ML(Promethazine HCl)
PHENERGAN INJ 50MG/ML(Promethazine HCl)
POLY TAN SUS(Dexbrompheniramine Tannate-Pyrilamine Maleate)
promethazine hcl inj 25 mg/ml
promethazine hcl inj 50 mg/ml
promethazine hcl suppos 12.5 mg
promethazine hcl suppos 25 mg
promethazine hcl suppos 50 mg
promethazine hcl syrup 6.25 mg/5ml
promethazine hcl tab 12.5 mg
promethazine hcl tab 25 mg
promethazine hcl tab 50 mg
PYRLEX SUS 12MG/5ML(Pyrilamine Tannate)
SEMPREX-D CAP 8-60MG(Acrivastine & Pseudoephedrine)
ZYMINE XR SUS 2.5MG(Triprolidine Tannate)
ZYRTEC CHW 10MG(Cetirizine HCl)
ZYRTEC CHW 5MG(Cetirizine HCl)
ZYRTEC SYP 1MG/ML(Cetirizine HCl)
ZYRTEC TAB 10MG(Cetirizine HCl)
ZYRTEC TAB 5MG(Cetirizine HCl)
ZYRTEC-D TAB 5-120MG(Cetirizine-Pseudoephedrine)
04
04
04
04
02
02
04
04
04
04
02
02
00
00
00
00
04
04
01
01
01
00
00
00
00
00
04
04
04
04
01
01
01
01
01
01
01
01
01
04
02
04
02
02
02
02
02
02
(STC)
(STC)
(STC)
(STC)
(STC)
(STC)
(PA)
(PA)
(STC)
(STC)
(STC)
8

Drug Name Drug Tier Notes
Anti-infective Agents
ABELCET INJ 5MG/ML(Amphotericin B Lipid)
acyclovir cap 200 mg
acyclovir sodium for inj 1000 mg
acyclovir sodium for inj 500 mg
acyclovir sodium iv soln 50 mg/ml
acyclovir susp 200 mg/5ml
acyclovir tab 400 mg
acyclovir tab 800 mg
ADOXA TAB 75MG(Doxycycline (Monohydrate))
ADOXA PAK TAB 1/150MG(Doxycycline (Monohydrate))
AGENERASE CAP 50MG(Amprenavir)
AGENERASE SOL 15MG/ML(Amprenavir)
ALBENZA TAB 200MG(Albendazole)
ALINIA SUS 100MG/5M(Nitazoxanide)
ALINIA TAB 500MG(Nitazoxanide)
ALODOX KIT 20MG(Doxycycline Hyclate w/ Eyelid Cleansers)
AMANTADINE TAB 100MG(Amantadine HCl)
amantadine hcl cap 100 mg
amantadine hcl syrup 50 mg/5ml
amantadine hcl tab 100 mg
AMBISOME INJ 50MG(Amphotericin B Liposome)
amikacin sulfate inj 250 mg/ml
amikacin sulfate inj 50 mg/ml
AMIKIN INJ 100/2ML(Amikacin Sulfate)
AMIKIN INJ 1GM/4ML(Amikacin Sulfate)
amoxicillin & k clavulanate chew tab 200-28.5 mg
amoxicillin & k clavulanate chew tab 400-57 mg
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml
amoxicillin & k clavulanate for susp 400-57 mg/5ml
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
amoxicillin & k clavulanate tab 250-125 mg
amoxicillin & k clavulanate tab 500-125 mg
amoxicillin & k clavulanate tab 875-125 mg
amoxicillin (trihydrate) cap 250 mg
amoxicillin (trihydrate) cap 500 mg
amoxicillin (trihydrate) chew tab 125 mg
amoxicillin (trihydrate) chew tab 200 mg
amoxicillin (trihydrate) chew tab 250 mg
amoxicillin (trihydrate) chew tab 400 mg
amoxicillin (trihydrate) for susp 125 mg/5ml
amoxicillin (trihydrate) for susp 200 mg/5ml
amoxicillin (trihydrate) for susp 250 mg/5ml
amoxicillin (trihydrate) for susp 400 mg/5ml
amoxicillin (trihydrate) for susp 50 mg/ml
amoxicillin (trihydrate) tab 500 mg
amoxicillin (trihydrate) tab 875 mg
AMOXIL CHW 200MG(Amoxicillin)
AMOXIL CHW 400MG(Amoxicillin)
02
01
01
01
01
01
01
01
04
04
02
02
04
04
04
04
02
01
01
01
02
01
01
02
02
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
04
04
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
9

Drug Name Drug Tier Notes
AMOXIL SUS 400/5ML(Amoxicillin)
AMOXIL TAB 500MG(Amoxicillin)
AMOXIL TAB 875MG(Amoxicillin)
AMPHOTEC INJ 100MG(Amphotericin B Cholesteryl Sulfate Complex)
AMPHOTEC INJ 50MG(Amphotericin B Cholesteryl Sulfate Complex)
amphotericin b for inj 50 mg
ampicillin & sulbactam sodium for inj 1-0.5 gm
ampicillin & sulbactam sodium for inj 10-5 gm
ampicillin & sulbactam sodium for inj 2-1 gm
ampicillin cap 250 mg
ampicillin cap 500 mg
ampicillin for susp 125 mg/5ml
ampicillin for susp 250 mg/5ml
ampicillin sodium for inj 1 gm
ampicillin sodium for inj 10 gm
ampicillin sodium for inj 125 mg
ampicillin sodium for inj 2 gm
ampicillin sodium for inj 250 mg
ampicillin sodium for inj 500 mg
ampicillin sodium for iv soln 1 gm
ampicillin sodium for iv soln 2 gm
ANCOBON CAP 250MG(Flucytosine)
ANCOBON CAP 500MG(Flucytosine)
APTIVUS CAP 250MG(Tipranavir)
ARALEN TAB 500MG(Chloroquine Phosphate)
ATRIPLA TAB(Efavirenz-Emtricitabine-Tenofovir Disoproxil Fumarate)
AUGMENTIN CHW 250MG(Amoxicillin & Pot Clavulanate)
AUGMENTIN SUS 125/5ML(Amoxicillin & Pot Clavulanate)
AUGMENTIN SUS 200/5ML(Amoxicillin & Pot Clavulanate)
AUGMENTIN SUS 250/5ML(Amoxicillin & Pot Clavulanate)
AUGMENTIN SUS 400/5ML(Amoxicillin & Pot Clavulanate)
AUGMENTIN SUS ES-600(Amoxicillin & Pot Clavulanate)
AUGMENTIN TAB 250MG(Amoxicillin & Pot Clavulanate)
AUGMENTIN TAB 500MG(Amoxicillin & Pot Clavulanate)
AUGMENTIN TAB 875MG(Amoxicillin & Pot Clavulanate)
AUGMENTIN XR TAB SR 12HR(Amoxicillin & Pot Clavulanate)
AVELOX INJ(Moxifloxacin HCl in Sodium Chloride)
AVELOX TAB 400MG(Moxifloxacin HCl)
AVELOX ABC TAB 400MG(Moxifloxacin HCl)
AZACTAM INJ 1GM(Aztreonam)
AZACTAM INJ 2GM(Aztreonam)
AZACTAM/DEX INJ 1GM(Aztreonam in Dextrose)
AZACTAM/DEX INJ 2GM(Aztreonam in Dextrose)
azithromycin for susp 100 mg/5ml
azithromycin for susp 200 mg/5ml
AZITHROMYCIN INJ 2.5GM(Azithromycin Hydrogencitrate)
AZITHROMYCIN INJ 500MG(Azithromycin Hydrogencitrate)
azithromycin iv for soln 500 mg
azithromycin powd pack for susp 1 gm
azithromycin tab 250 mg
04
04
04
02
02
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
02
02
02
04
02
02
02
04
02
04
04
04
04
04
02
04
02
02
04
04
04
04
01
01
04
04
01
01
01
(PA)
(PA)
(PA)
(QL)
10

Drug Name Drug Tier Notes
azithromycin tab 500 mg
azithromycin tab 600 mg
AZULFIDINE TAB 500MG(Sulfasalazine)
AZULFIDINE TAB 500MG EN(Sulfasalazine)
BACITRACIN INJ 50000UNT(Bacitracin)
bacitracin intramuscular for soln 50000 unit
BACTOCILL INJ DEX 1GM(Oxacillin Sodium in Dextrose)
BACTOCILL INJ DEX 2GM(Oxacillin Sodium in Dextrose)
BACTRIM TAB 400-80MG(Sulfamethoxazole-Trimethoprim)
BACTRIM DS TAB 800-160(Sulfamethoxazole-Trimethoprim)
BARACLUDE SOL .05MG/ML(Entecavir)
BARACLUDE TAB 0.5MG(Entecavir)
BARACLUDE TAB 1MG(Entecavir)
BIAXIN SUS 125/5ML(Clarithromycin)
BIAXIN SUS 250/5ML(Clarithromycin)
BIAXIN TAB 250MG(Clarithromycin)
BIAXIN TAB 500MG(Clarithromycin)
BIAXIN XL TAB 500MG(Clarithromycin)
BIAXIN XL TAB PAC 500(Clarithromycin)
BICILLIN C-R INJ 1200000(Penicillin G Procaine & Benzathine)
BICILLIN C-R INJ 2400000(Penicillin G Procaine & Benzathine)
BICILLIN C-R INJ 600000(Penicillin G Procaine & Benzathine)
BICILLIN C-R INJ 900/300(Penicillin G Procaine & Benzathine)
BICILLIN L-A INJ 1200000(Penicillin G Benzathine)
BICILLIN L-A INJ 2400000(Penicillin G Benzathine)
BICILLIN L-A INJ 600000(Penicillin G Benzathine)
BILTRICIDE TAB 600MG(Praziquantel)
BIO-STATIN CAP 1000000(Nystatin)
BIO-STATIN CAP 500000(Nystatin)
CANCIDAS INJ 50MG(Caspofungin Acetate)
CANCIDAS INJ 70MG(Caspofungin Acetate)
CAPASTAT SUL INJ 1GM(Capreomycin Sulfate)
CEDAX CAP 400MG(Ceftibuten)
CEDAX SUS 90MG/5ML(Ceftibuten)
cefaclor cap 250 mg
cefaclor cap 500 mg
cefaclor for susp 125 mg/5ml
cefaclor for susp 250 mg/5ml
cefaclor for susp 375 mg/5ml
cefaclor monohydrate tab sr 12hr 500 mg
cefadroxil cap 500 mg
cefadroxil for susp 250 mg/5ml
cefadroxil for susp 500 mg/5ml
cefadroxil tab 1 gm
cefazolin in d5w inj 1 gm/50ml
cefazolin in d5w inj 500 mg/50ml
cefazolin sodium for inj 1 gm
cefazolin sodium for inj 10 gm
cefazolin sodium for inj 20 gm
cefazolin sodium for inj 500 mg
01
01
04
04
04
01
04
04
04
04
02
02
02
04
04
04
04
02
02
04
04
04
04
04
04
04
02
04
04
04
04
02
04
04
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
11

Drug Name Drug Tier Notes
cefazolin sodium for iv soln 1 gm
cefazolin sodium for iv soln 1 gm and dextrose 4%
cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml
cefepime hcl for inj 1 gm
cefepime hcl for inj 2 gm
CEFIZOX/D5W INJ 1GM(Ceftizoxime in D5W)
CEFIZOX/D5W INJ 2GM(Ceftizoxime in D5W)
cefotaxime sodium for inj 1 gm
cefotaxime sodium for inj 10 gm
cefotaxime sodium for inj 2 gm
cefotaxime sodium for inj 20 gm
cefotaxime sodium for inj 500 mg
cefoxitin sodium for inj 1 gm
cefoxitin sodium for inj 10 gm
cefoxitin sodium for inj 2 gm
cefpodoxime proxetil for susp 100 mg/5ml
cefpodoxime proxetil for susp 50 mg/5ml
cefpodoxime proxetil tab 100 mg
cefpodoxime proxetil tab 200 mg
cefprozil for susp 125 mg/5ml
cefprozil for susp 250 mg/5ml
cefprozil tab 250 mg
cefprozil tab 500 mg
ceftazidime for inj 1 gm
ceftazidime for inj 2 gm
ceftazidime for inj 500 mg
ceftazidime for inj 6 gm
ceftazidime for iv soln 1 gm
ceftazidime for iv soln 2 gm
CEFTIN SUS 125/5ML(Cefuroxime Axetil)
CEFTIN SUS 250/5ML(Cefuroxime Axetil)
CEFTIN TAB 250MG(Cefuroxime Axetil)
CEFTIN TAB 500MG(Cefuroxime Axetil)
CEFTRIAXONE INJ 100GM(Ceftriaxone Sodium)
ceftriaxone sodium for inj 1 gm
ceftriaxone sodium for inj 10 gm
ceftriaxone sodium for inj 2 gm
ceftriaxone sodium for inj 250 mg
ceftriaxone sodium for inj 500 mg
ceftriaxone sodium for iv soln 1 gm and dextrose 3.74%
ceftriaxone sodium for iv soln 2 gm and dextrose 2.22%
ceftriaxone sodium in dextrose inj 20 mg/ml
ceftriaxone sodium in dextrose inj 40 mg/ml
cefuroxime axetil tab 250 mg
cefuroxime axetil tab 500 mg
cefuroxime sodium 1.5 gm and dextrose 2.9% for iv soln
cefuroxime sodium 750 mg and dextrose 4.1% for iv soln
cefuroxime sodium for inj 1.5 gm
01
01
01
01
01
01
01
04
04
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
02
02
04
04
04
01
01
01
01
01
01
01
01
01
01
01
01
01
01
(PA)
(PA)
12

Drug Name Drug Tier Notes
cefuroxime sodium for inj 7.5 gm
cefuroxime sodium for inj 750 mg
CEFZIL SUS 125/5ML(Cefprozil)
CEFZIL SUS 250/5ML(Cefprozil)
CEFZIL TAB 250MG FC(Cefprozil)
CEFZIL TAB 500MG FC(Cefprozil)
CEPHALEXIN TAB 500MG(Cephalexin)
cephalexin cap 250 mg
cephalexin cap 500 mg
cephalexin for susp 125 mg/5ml
cephalexin for susp 250 mg/5ml
cephalexin tab 250 mg
cephalexin tab 500 mg
chloramphenicol sodium succinate for iv inj 1 gm
chloroquine phosphate tab 250 mg
chloroquine phosphate tab 500 mg
CIPRO TAB 250MG(Ciprofloxacin HCl)
CIPRO TAB 500MG(Ciprofloxacin HCl)
CIPRO TAB 750MG(Ciprofloxacin HCl)
CIPRO (5%) SUS 250MG/5(Ciprofloxacin)
CIPRO I.V. INJ 200MG(Ciprofloxacin)
CIPRO I.V. INJ 400MG(Ciprofloxacin)
CIPRO I.V. SOL 200MG(Ciprofloxacin in D5W)
CIPRO I.V. SOL 400MG(Ciprofloxacin in D5W)
CIPRO XR TAB 1000MG(Ciprofloxacin-Ciprofloxacin HCl)
CIPRO XR TAB 500MG(Ciprofloxacin-Ciprofloxacin HCl)
ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml)
ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml)
ciprofloxacin hcl tab 100 mg (base equiv)
ciprofloxacin hcl tab 250 mg (base equiv)
ciprofloxacin hcl tab 500 mg (base equiv)
ciprofloxacin hcl tab 750 mg (base equiv)
ciprofloxacin iv soln 1%
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000 mg(base eq)
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg (base eq)
CLAFORAN INJ 10GM(Cefotaxime Sodium)
CLAFORAN INJ 1GM(Cefotaxime Sodium)
CLAFORAN INJ 1GM(Cefotaxime Sodium)
CLAFORAN INJ 2GM(Cefotaxime Sodium)
CLAFORAN INJ 2GM(Cefotaxime Sodium)
CLAFORAN INJ 500MG(Cefotaxime Sodium)
CLAFORAN/D5W INJ 1GM(Cefotaxime Sodium in D5W)
CLAFORAN/D5W INJ 2GM(Cefotaxime Sodium in D5W)
CLARITHROMYC SUS 250/5ML(Clarithromycin)
clarithromycin for susp 125 mg/5ml
clarithromycin for susp 250 mg/5ml
clarithromycin tab 250 mg
clarithromycin tab 500 mg
clarithromycin tab sr 24hr 500 mg
CLEERAVUE-M KIT 50MG(Minocycline HCl w/ Eyelid Cleanser)
01
01
04
04
04
04
04
01
01
01
01
01
01
01
01
01
04
04
04
04
04
04
04
04
04
04
01
01
01
01
01
01
01
01
01
04
04
04
04
04
04
04
04
02
01
01
01
01
01
04
13

Drug Name Drug Tier Notes
CLEOCIN CAP 150MG(Clindamycin HCl)
CLEOCIN CAP 300MG(Clindamycin HCl)
CLEOCIN CAP 75MG(Clindamycin HCl)
CLEOCIN INJ 300MG(Clindamycin Phosphate in D5W)
CLEOCIN INJ 600MG(Clindamycin Phosphate in D5W)
CLEOCIN INJ 900MG(Clindamycin Phosphate in D5W)
CLEOCIN PED SOL 75MG/5ML(Clindamycin Palmitate Hydrochloride)
CLEOCIN PHOS INJ 150MG/ML(Clindamycin Phosphate)
CLEOCIN PHOS INJ 300MG(Clindamycin Phosphate)
CLEOCIN PHOS INJ 600MG(Clindamycin Phosphate)
CLEOCIN PHOS INJ 900MG(Clindamycin Phosphate)
CLEOCIN PHOS INJ 9GM(Clindamycin Phosphate)
clindamycin hcl cap 150 mg
clindamycin hcl cap 300 mg
clindamycin phosphate inj 150 mg/ml
clindamycin phosphate iv soln 150 mg/ml
colistimethate sodium for inj 150 mg
COLY-MYCIN-M INJ 150MG(Colistimethate Sodium)
COMBIVIR TAB(Lamivudine-Zidovudine)
COPEGUS TAB 200MG(Ribavirin (Hepatitis C))
CRIXIVAN CAP 100MG(Indinavir Sulfate)
CRIXIVAN CAP 200MG(Indinavir Sulfate)
CRIXIVAN CAP 333MG(Indinavir Sulfate)
CRIXIVAN CAP 400MG(Indinavir Sulfate)
CUBICIN SOL 500MG(Daptomycin)
CYTOVENE INJ 500MG(Ganciclovir Sodium)
dapsone tab 100 mg
dapsone tab 25 mg
DARAPRIM TAB 25MG(Pyrimethamine)
DECLOMYCIN TAB 150MG(Demeclocycline HCl)
DECLOMYCIN TAB 300MG(Demeclocycline HCl)
demeclocycline hcl tab 150 mg
demeclocycline hcl tab 300 mg
dicloxacillin sodium cap 250 mg
dicloxacillin sodium cap 500 mg
didanosine delayed release capsule 200 mg
didanosine delayed release capsule 250 mg
didanosine delayed release capsule 400 mg
DIFLUCAN SUS 10MG/ML(Fluconazole)
DIFLUCAN SUS 40MG/ML(Fluconazole)
DIFLUCAN TAB 100MG(Fluconazole)
DIFLUCAN TAB 150MG(Fluconazole)
DIFLUCAN TAB 200MG(Fluconazole)
DIFLUCAN TAB 50MG(Fluconazole)
DIFLUCAN/ INJ NACL 200(Fluconazole in NaCl)
DIFLUCAN/ INJ NACL 400(Fluconazole in NaCl)
DIFLUCAN/DEX INJ 2MG/ML(Fluconazole in Dextrose)
DORYX TAB 100MG(Doxycycline Hyclate)
DORYX TAB 75MG(Doxycycline Hyclate)
DOXYCYCL HYC CAP 100MG(Doxycycline Hyclate)
04
04
02
04
04
04
04
04
04
04
04
04
01
01
01
01
01
04
02
02
02
02
02
02
04
04
01
01
02
04
04
01
01
01
01
01
01
01
04
04
04
04
04
04
04
04
04
04
04
04
(PA)
14

Drug Name Drug Tier Notes
DOXYCYCL HYC CAP 75MG(Doxycycline Hyclate)
doxycycline hyclate cap 100 mg
doxycycline hyclate cap 50 mg
doxycycline hyclate for inj 100 mg
doxycycline hyclate tab 100 mg
doxycycline hyclate tab 20 mg
doxycycline monohydrate cap 100 mg
doxycycline monohydrate cap 50 mg
doxycycline monohydrate tab 100 mg
doxycycline monohydrate tab 150 mg
doxycycline monohydrate tab 50 mg
doxycycline monohydrate tab 75 mg
DURICEF SUS 250/5ML(Cefadroxil)
DURICEF SUS 500/5ML(Cefadroxil)
DYNABAC TAB 250MG EC(Dirithromycin)
DYNACIN CAP 75MG(Minocycline HCl)
DYNACIN TAB 100MG(Minocycline HCl)
DYNACIN TAB 50MG(Minocycline HCl)
DYNACIN TAB 75MG(Minocycline HCl)
E.E.S. GRAN SUS 200/5ML(Erythromycin Ethylsuccinate)
EMTRIVA CAP 200MG(Emtricitabine)
EMTRIVA SOL 10MG/ML(Emtricitabine)
EPIVIR SOL 10MG/ML(Lamivudine)
EPIVIR TAB 150MG(Lamivudine)
EPIVIR TAB 300MG(Lamivudine)
EPIVIR HBV SOL 5MG/ML(Lamivudine)
EPIVIR HBV TAB 100MG(Lamivudine)
EPZICOM TAB(Abacavir Sulfate-Lamivudine)
ERAXIS INJ 50MG(Anidulafungin)
ERY-TAB TAB 500MG EC(Erythromycin Base)
ERYPED 200 SUS 200/5ML(Erythromycin Ethylsuccinate)
ERYTHROCIN INJ 1000MG(Erythromycin Lactobionate)
ERYTHROCIN INJ 500MG(Erythromycin Lactobionate)
ERYTHROMYCIN CAP 250MG EC(Erythromycin Base)
erythromycin ethylsuccinate for susp 100 mg/2.5ml
erythromycin ethylsuccinate for susp 400 mg/5ml
erythromycin ethylsuccinate susp 200 mg/5ml
erythromycin ethylsuccinate susp 400 mg/5ml
erythromycin ethylsuccinate tab 400 mg
erythromycin lactobionate for inj 500 mg
erythromycin stearate tab 250 mg
erythromycin stearate tab 500 mg
erythromycin tab 250 mg
ERYTHROMYCIN TAB 250MG(Erythromycin Base)
erythromycin tab 500 mg
erythromycin tab delayed release 250 mg
erythromycin tab delayed release 333 mg
erythromycin tab delayed release 500 mg
erythromycin w/ delayed release particles cap 250 mg
erythromycin-sulfisoxazole for susp 200-600 mg/5ml
04
01
01
01
01
01
01
01
01
01
01
01
04
04
04
04
04
04
04
04
02
04
02
02
02
02
02
02
02
02
04
04
04
02
01
01
01
01
01
01
01
01
01
02
01
01
01
01
01
01
(PA)
15

Drug Name Drug Tier Notes
ethambutol hcl tab 100 mg
ethambutol hcl tab 400 mg
FACTIVE TAB 320MG(Gemifloxacin Mesylate)
FAMVIR TAB 125MG(Famciclovir)
FAMVIR TAB 250MG(Famciclovir)
FAMVIR TAB 500MG(Famciclovir)
FANSIDAR TAB 500/25(Sulfadoxine & Pyrimethamine)
FLAGYL CAP 375MG(Metronidazole)
FLAGYL TAB 250MG(Metronidazole)
FLAGYL TAB 500MG(Metronidazole)
FLAGYL ER TAB 750MG(Metronidazole)
fluconazole for susp 10 mg/ml
fluconazole for susp 40 mg/ml
fluconazole in dextrose inj 200 mg/100ml
fluconazole in dextrose inj 400 mg/200ml
fluconazole in nacl 0.9% inj 200 mg/100ml
fluconazole in nacl 0.9% inj 400 mg/200ml
fluconazole tab 100 mg
fluconazole tab 150 mg
fluconazole tab 200 mg
fluconazole tab 50 mg
FLUMADINE SYP 50MG/5ML(Rimantadine Hydrochloride)
FLUMADINE TAB 100MG(Rimantadine Hydrochloride)
FORTAZ INJ 1GM(Ceftazidime)
FORTAZ INJ 1GM(Ceftazidime Sodium in D5W)
FORTAZ INJ 2GM(Ceftazidime)
FORTAZ INJ 2GM(Ceftazidime Sodium in D5W)
FORTAZ INJ 6GM(Ceftazidime)
foscarnet sodium inj 24 mg/ml
FOSCAVIR INJ 24MG/ML(Foscarnet Sodium)
FUNGIZONE INJ 50MG(Amphotericin B)
FURADANTIN SUS 25MG/5ML(Nitrofurantoin)
FUZEON KIT(Enfuvirtide)
ganciclovir cap 250 mg
ganciclovir cap 500 mg
GANTRIS PED SUS 500/5ML(Sulfisoxazole Acetyl)
gentamicin in saline inj 0.6 mg/ml
gentamicin in saline inj 0.8 mg/ml
gentamicin in saline inj 0.9 mg/ml
gentamicin in saline inj 1 mg/ml
gentamicin in saline inj 1.2 mg/ml
gentamicin in saline inj 1.4 mg/ml
gentamicin in saline inj 1.6 mg/ml
gentamicin in saline inj 2 mg/ml
gentamicin sulfate inj 10 mg/ml
gentamicin sulfate inj 40 mg/ml
gentamicin sulfate iv soln 10 mg/ml
GEOCILLIN TAB 382MG(Carbenicillin Indanyl Sodium)
GRIFULVIN V SUS 125/5ML(Griseofulvin Microsize)
GRIFULVIN V TAB 500MG(Griseofulvin Microsize)
01
01
04
04
04
04
02
04
04
04
04
01
01
01
01
01
01
01
01
01
01
02
04
04
04
04
04
04
01
04
02
04
03
01
01
04
01
01
01
01
01
01
01
01
01
01
01
02
04
02
(PA)
(PA)
16

Drug Name Drug Tier Notes
GRIS-PEG TAB 125MG(Griseofulvin Ultramicrosize)
GRIS-PEG TAB 250MG(Griseofulvin Ultramicrosize)
griseofulvin microsize susp 125 mg/5ml
HELIDAC MIS(Metronidazole-Tetracycline w/ Bismuth Subsalicylate)
HEPSERA TAB 10MG(Adefovir Dipivoxil)
HIPREX TAB 1GM(Methenamine Hippurate)
HUMATIN CAP 250MG(Paromomycin Sulfate)
hydroxychloroquine sulfate tab 200 mg
INFERGEN INJ 15MCG(Interferon alfacon-1)
INFERGEN INJ 9MCG(Interferon alfacon-1)
INVANZ INJ 1GM(Ertapenem Sodium)
INVIRASE CAP 200MG(Saquinavir Mesylate)
INVIRASE TAB 500MG(Saquinavir Mesylate)
isoniazid & rifampin cap 150-300 mg
isoniazid inj 100 mg/ml
isoniazid syrup 50 mg/5ml
isoniazid tab 100 mg
isoniazid tab 300 mg
itraconazole cap 100 mg
KALETRA CAP(Lopinavir-Ritonavir)
KALETRA SOL(Lopinavir-Ritonavir)
KALETRA TAB 200-50MG(Lopinavir-Ritonavir)
kanamycin sulfate inj 333 mg/ml
KEFLEX CAP 250MG(Cephalexin)
KEFLEX CAP 500MG(Cephalexin)
KEFLEX CAP 750MG(Cephalexin)
KEFLEX SUS 125/5ML(Cephalexin)
KEFLEX SUS 250/5ML(Cephalexin)
KETEK TAB 300MG(Telithromycin)
KETEK TAB 400MG(Telithromycin)
ketoconazole tab 200 mg
LAMISIL TAB 250MG(Terbinafine HCl)
LARIAM TAB 250MG(Mefloquine HCl)
LEVAQUIN INJ 25MG/ML(Levofloxacin)
LEVAQUIN SOL 25MG/ML(Levofloxacin)
LEVAQUIN TAB 250MG(Levofloxacin)
LEVAQUIN TAB 500MG(Levofloxacin)
LEVAQUIN TAB 750MG(Levofloxacin)
LEVAQUIN TAB LEVA-PAK(Levofloxacin)
LEVAQUIN/D5W INJ 250/50ML(Levofloxacin in D5W)
LEVAQUIN/D5W INJ 500/100(Levofloxacin in D5W)
LEVAQUIN/D5W INJ 750/150(Levofloxacin in D5W)
LEXIVA TAB 700MG(Fosamprenavir Calcium)
LINCOCIN INJ 300MG/ML(Lincomycin HCl)
MACROBID CAP 100MG(Nitrofurantoin Monohyd Macro)
MACRODANTIN CAP 100MG(Nitrofurantoin Macrocrystal)
MACRODANTIN CAP 25MG(Nitrofurantoin Macrocrystal)
MACRODANTIN CAP 50MG(Nitrofurantoin Macrocrystal)
MALARONE TAB 250-100(Atovaquone-Proguanil HCl)
MALARONE TAB 62.5/25(Atovaquone-Proguanil HCl)
02
02
01
04
03
04
04
01
04
04
04
02
02
01
01
01
01
01
01
02
02
04
01
04
04
04
04
04
02
02
01
02
04
02
02
02
02
02
02
04
04
04
02
04
04
04
02
04
04
04
(PA)
(PA)
(PA)
(PA)
(PA)
17

Drug Name Drug Tier Notes
MANDELAMINE TAB 0.5GM(Methenamine Mandelate)
MANDELAMINE TAB 1GM(Methenamine Mandelate)
MANDOL/D5W INJ 1GM(Cefamandole Nafate in D5W)
MAXIPIME INJ 1GM(Cefepime HCl)
MAXIPIME INJ 1GM(Cefepime HCl)
MAXIPIME INJ 2GM(Cefepime HCl)
MAXIPIME INJ 2GM(Cefepime HCl)
MAXIPIME INJ 500MG(Cefepime HCl)
mebendazole chew tab 100 mg
mefloquine hcl tab 250 mg
MEFOXIN INJ 10GM(Cefoxitin Sodium)
MEFOXIN INJ 1GM(Cefoxitin Sodium)
MEFOXIN INJ 2GM(Cefoxitin Sodium)
MEFOXIN/DEX INJ 1GM(Cefoxitin Sodium in Dextrose)
MEFOXIN/DEX INJ 2GM(Cefoxitin Sodium in Dextrose)
MEPRON SUS(Atovaquone)
MERREM INJ 1GM(Meropenem)
MERREM INJ 500MG(Meropenem)
methenamine hippurate tab 1 gm
methenamine mandelate tab 0.5 gm
methenamine mandelate tab 1 gm
methenamine mandelate-sodium biphosphate tab 500-500 mg
methenamine-bella alk-meth blue-phenyl sal tab
methenamine-hyosc-meth blue-sod phos-phenyl sal tab 120 mg
methenamine-hyosc-meth blue-sod phos-phenyl sal tab 81.6 mg
METRO IV INJ 5MG/ML(Metronidazole in NaCl)
metronidazole cap 375 mg
metronidazole in nacl 0.79% iv soln 500 mg/100ml
metronidazole tab 250 mg
metronidazole tab 500 mg
MINOCIN CAP 100MG(Minocycline HCl)
MINOCIN CAP 50MG(Minocycline HCl)
MINOCIN PAC KIT 100MG(Minocycline HCl w/ Acne Care Products)
MINOCIN PAC KIT 50MG(Minocycline HCl w/ Acne Care Products)
minocycline hcl cap 100 mg
minocycline hcl cap 50 mg
minocycline hcl cap 75 mg
minocycline hcl tab 100 mg
minocycline hcl tab 50 mg
minocycline hcl tab 75 mg
MINTEZOL CHW 500MG(Thiabendazole)
MINTEZOL SUS 500/5ML(Thiabendazole)
MONODOX CAP 100MG(Doxycycline (Monohydrate))
MONODOX CAP 50MG(Doxycycline (Monohydrate))
MONODOX CAP 75MG(Doxycycline (Monohydrate))
MONUROL PAK GRANULES(Fosfomycin Tromethamine)
MYAMBUTOL TAB 100MG(Ethambutol HCl)
MYAMBUTOL TAB 400MG(Ethambutol HCl)
MYCAMINE INJ 100MG(Micafungin Sodium)
MYCAMINE INJ 50MG(Micafungin Sodium)
04
04
04
02
02
02
02
02
01
01
04
04
04
04
04
02
04
04
01
01
01
01
01
01
01
04
01
01
01
01
04
04
04
04
01
01
01
01
01
01
02
02
04
04
04
04
04
04
04
04
(PA)
(PA)
(PA)
(PA)
(PA)
18

Drug Name Drug Tier Notes
MYCOBUTIN CAP 150MG(Rifabutin)
nafcillin sodium for inj 1 gm
nafcillin sodium for inj 10 gm
nafcillin sodium for inj 2 gm
nafcillin sodium for inj 200 gm
nafcillin sodium for iv soln 1 gm
nafcillin sodium for iv soln 2 gm
NALLPEN/DEX INJ 1GM/50ML(Nafcillin Sodium in Dextrose)
NALLPEN/DEX INJ 2GM(Nafcillin Sodium in Dextrose)
NALLPEN/DEX INJ 2GM/100(Nafcillin Sodium in Dextrose)
NEBUPENT INH 300MG(Pentamidine Isethionate)
NEO-FRADIN SOL 125/5ML(Neomycin Sulfate)
neomycin sulfate tab 500 mg
NEUTREXIN INJ 25MG(Trimetrexate Glucuronate)
nitrofurantoin macrocrystalline cap 100 mg
nitrofurantoin macrocrystalline cap 50 mg
nitrofurantoin monohydrate macrocrystalline cap 100 mg
NIZORAL TAB 200MG(Ketoconazole)
NOROXIN TAB 400MG(Norfloxacin)
NORVIR CAP 100MG(Ritonavir)
NORVIR SOL 80MG/ML(Ritonavir)
nystatin susp 100000 unit/ml
nystatin tab 500000 unit
ofloxacin tab 200 mg
ofloxacin tab 300 mg
ofloxacin tab 400 mg
OMNI-PAC CAP 300MG(Cefdinir)
OMNICEF CAP 300MG(Cefdinir)
OMNICEF SUS 125/5ML(Cefdinir)
OMNICEF SUS 250/5ML(Cefdinir)
ORACEA CAP 40MG(Doxycycline (Rosacea))
OXACILLIN INJ 10GM(Oxacillin Sodium)
OXACILLIN INJ 1GM(Oxacillin Sodium)
OXACILLIN INJ 2GM(Oxacillin Sodium)
oxacillin sodium for inj 1 gm
oxacillin sodium for inj 10 gm
oxacillin sodium for inj 2 gm
oxacillin sodium for iv soln 1 gm
oxacillin sodium for iv soln 2 gm
paromomycin sulfate cap 250 mg
PASER GRA 4GM(Aminosalicylic Acid)
PCE TAB 333MG EC(Erythromycin Base (Coated))
PCE TAB 500MG EC(Erythromycin Base (Coated))
PEDIAZOLE SUS 200/600(Erythromycin-Sulfisoxazole)
PEG-INTRON KIT 120 RP(Peginterferon alfa-2b)
PEG-INTRON KIT 120MCG(Peginterferon alfa-2b)
PEG-INTRON KIT 150 RP(Peginterferon alfa-2b)
PEG-INTRON KIT 150MCG(Peginterferon alfa-2b)
PEG-INTRON KIT 50MCG(Peginterferon alfa-2b)
PEG-INTRON KIT 50MCG RP(Peginterferon alfa-2b)
02
01
01
01
01
01
01
04
04
04
04
02
01
04
01
01
01
04
04
02
02
01
01
01
01
01
02
02
02
02
04
04
04
04
01
01
01
01
01
01
04
04
04
04
03
03
03
03
03
03
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
19

Drug Name Drug Tier Notes
PEG-INTRON KIT 80MCG(Peginterferon alfa-2b)
PEG-INTRON KIT 80MCG RP(Peginterferon alfa-2b)
PEGASYS INJ 180MCG/M(Peginterferon alfa-2a)
PEGASYS KIT(Peginterferon alfa-2a)
PEN G PROC INJ 600000(Penicillin G Procaine)
penicillin g potassium for inj 20 mu
penicillin g potassium for inj 5000000 unit
penicillin g potassium inj 20000 unit/ml in dextrose
penicillin g potassium inj 40000 unit/ml in dextrose
penicillin g potassium inj 60000 unit/ml in dextrose
penicillin g sodium for inj 5000000 unit
penicillin v potassium for soln 125 mg/5ml
penicillin v potassium for soln 250 mg/5ml
penicillin v potassium tab 250 mg
penicillin v potassium tab 500 mg
PENTAM 300 INJ 300MG(Pentamidine Isethionate)
pentamidine isethionate for soln 300 mg
PERIOSTAT TAB(Doxycycline Hyclate)
PFIZERPEN G INJ 20MU(Penicillin G Potassium)
piperacillin sodium 40 mg/ml-d5w iv soln
piperacillin sodium for inj 2 gm
piperacillin sodium for inj 3 gm
piperacillin sodium for inj 4 gm
piperacillin sodium for iv soln 40 gm
PLAQUENIL TAB 200MG(Hydroxychloroquine Sulfate)
polymyxin b sulfate for inj 500000 unit
PREZISTA TAB 300MG(Darunavir)
PRIFTIN TAB 150MG(Rifapentine)
primaquine phosphate tab 26.3 mg
PRIMAXIN IM INJ 500MG(Imipenem-Cilastatin)
PRIMAXIN IM INJ 750MG(Imipenem-Cilastatin)
PRIMAXIN IV INJ 250MG(Imipenem-Cilastatin)
PRIMAXIN IV INJ 500MG(Imipenem-Cilastatin)
PRIMSOL SOL 50MG/5ML(Trimethoprim HCl)
PROQUIN XR TAB 500MG(Ciprofloxacin HCl)
PROSED/DS TAB(Methenamine-Hyosc-Methylene Blue-Benzoic Acid-Phenyl
Sal)
PYLERA CAP(Bismuth Subcitrate Potassium-Metronidazole-Tetracycline)
pyrazinamide tab 500 mg
QUALAQUIN CAP 324MG(Quinine Sulfate)
QUINERVA TAB 260MG(Quinine Sulfate)
RANICLOR CHW 250MG(Cefaclor)
RANICLOR CHW 375MG(Cefaclor)
REBETOL CAP 200MG(Ribavirin (Hepatitis C))
REBETOL SOL 40MG/ML(Ribavirin (Hepatitis C))
RELENZA MIS DISKHALE(Zanamivir)
RESCRIPTOR TAB 100 MG(Delavirdine Mesylate)
RESCRIPTOR TAB 200MG(Delavirdine Mesylate)
RETROVIR CAP 100MG(Zidovudine)
RETROVIR INJ 10MG/ML(Zidovudine)
03
03
03
03
04
01
01
01
01
01
01
01
01
01
01
04
01
04
04
01
01
01
01
01
04
01
02
04
01
04
04
04
04
04
04
04
04
01
04
04
04
04
02
02
04
02
02
04
02
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
20

Drug Name Drug Tier Notes
sulfasalazine tab delayed release 500 mg
SUPRAX SUS 100/5ML(Cefixime)
SUPRAX SUS 200/5ML(Cefixime)
SUSTIVA CAP 100MG(Efavirenz)
SUSTIVA CAP 200MG(Efavirenz)
SUSTIVA CAP 50MG(Efavirenz)
SUSTIVA TAB 600MG(Efavirenz)
SYNAGIS INJ 100MG/ML(Palivizumab)
SYNAGIS INJ 50MG(Palivizumab)
SYNERCID INJ 500MG(Quinupristin-Dalfopristin)
TAMIFLU CAP 75MG(Oseltamivir Phosphate)
TAMIFLU SUS 12MG/ML(Oseltamivir Phosphate)
TAZICEF INJ 1GM/50ML(Ceftazidime Sodium in Dextrose)
TAZICEF INJ 2GM/50ML(Ceftazidime Sodium in Dextrose)
terbinafine hcl tab 250 mg
tetracycline hcl cap 250 mg
tetracycline hcl cap 500 mg
tetracycline hcl syrup 125 mg/5ml
tetracycline hcl tab 250 mg
tetracycline hcl tab 500 mg
TIMENTIN INJ 3.1GM(Ticarcillin & Pot Clavulanate)
TIMENTIN INJ 31GM(Ticarcillin & Pot Clavulanate)
TINDAMAX TAB 250MG(Tinidazole)
TINDAMAX TAB 500MG(Tinidazole)
TOBI NEB 300/5ML(Tobramycin)
tobramycin sulfate for inj 1.2 gm
tobramycin sulfate inj 0.8 mg/ml in saline
tobramycin sulfate inj 1.2 mg/ml in saline
tobramycin sulfate inj 10 mg/ml
tobramycin sulfate inj 40 mg/ml
tobramycin sulfate iv soln 10 mg/ml
TRECATOR TAB 250MG(Ethionamide)
trimethoprim tab 100 mg
TRIZIVIR TAB(Abacavir Sulfate-Lamivudine-Zidovudine)
TRUVADA TAB(Emtricitabine-Tenofovir Disoproxil Fumarate)
TYGACIL INJ 50MG(Tigecycline)
TYZEKA TAB 600MG(Telbivudine)
UNASYN INJ 1.5GM(Ampicillin & Sulbactam Sodium)
UNASYN INJ 1.5GM(Ampicillin & Sulbactam Sodium)
UNASYN INJ 1.5GM PB(Ampicillin & Sulbactam Sodium)
UNASYN INJ 15GM(Ampicillin & Sulbactam Sodium)
UNASYN INJ 3GM(Ampicillin & Sulbactam Sodium)
UNASYN INJ 3GM(Ampicillin & Sulbactam Sodium)
UNASYN INJ 3GM PBU(Ampicillin & Sulbactam Sodium)
URELLE TAB(Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl Sal)
URETRON D/S TAB(Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl
Sal)
UREX TAB 1GM(Methenamine Hippurate)
URISED TAB(Meth-Bell-Meth Bl-Phenyl Sal)
01
04
04
02
02
02
02
04
04
04
02
02
04
04
01
01
01
01
01
01
04
04
04
04
04
01
01
01
01
01
01
04
01
02
02
04
02
04
04
04
04
04
04
04
04
04
04
04
(PA)
(PA)
(PA)
(PA)
22

Drug Name Drug Tier Notes
URISYM CAP(Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl Sal)
URITACT DS TAB(Methenamine-Methylene Blue-Benz Acd-Phenyl Sal-Atrop
-Hyosc)
URITACT-EC TAB(Methenamine-Methylene Blue-Benz Acd-Phenyl Sal-Atrop
-Hyosc)
UROQID #2 TAB(Methenamine Mandelate-Sodium Biphosphate)
UTA CAP(Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl Sal)
UTIRA TAB(Methenamine-Hyosc-Methylene Blue-Sod Phos-Phenyl Sal)
VALCYTE TAB 450MG(Valganciclovir HCl)
VALTREX TAB 1GM(Valacyclovir HCl)
VALTREX TAB 500MG(Valacyclovir HCl)
VANCOCIN HCL CAP 125MG(Vancomycin HCl)
VANCOCIN HCL CAP 250MG(Vancomycin HCl)
VANCOCIN HCL INJ(Vancomycin HCl in Dextrose)
VANCOCIN/DEX INJ 500MG(Vancomycin HCl in Dextrose)
vancomycin hcl for inj 10 gm
vancomycin hcl for inj 1000 mg
vancomycin hcl for inj 500 mg
vancomycin hcl for inj 5000 mg
VANTIN SUS 100/5ML(Cefpodoxime Proxetil)
VANTIN SUS 50MG/5ML(Cefpodoxime Proxetil)
VANTIN TAB 100MG(Cefpodoxime Proxetil)
VANTIN TAB 200MG(Cefpodoxime Proxetil)
VFEND SUS 40MG/ML(Voriconazole)
VFEND TAB 200MG(Voriconazole)
VFEND TAB 50MG(Voriconazole)
VFEND IV INJ 200MG(Voriconazole)
VIBRAMYCIN CAP 100MG(Doxycycline Hyclate)
VIBRAMYCIN SUS 25MG/5ML(Doxycycline (Monohydrate))
VIBRAMYCIN SYP 50MG/5ML(Doxycycline Calcium)
VIBRATAB TAB 100MG(Doxycycline Hyclate)
VIDEX SOL 2GM(Didanosine)
VIDEX SOL 4GM(Didanosine)
VIDEX EC CAP 125MG(Didanosine)
VIDEX EC CAP 200MG(Didanosine)
VIDEX EC CAP 250MG(Didanosine)
VIDEX EC CAP 400MG(Didanosine)
VIRACEPT POW 50MG/GM(Nelfinavir Mesylate)
VIRACEPT TAB 250MG(Nelfinavir Mesylate)
VIRACEPT TAB 625MG(Nelfinavir Mesylate)
VIRAMUNE SUS 50MG/5ML(Nevirapine)
VIRAMUNE TAB 200MG(Nevirapine)
VIRAZOLE INH 6GM(Ribavirin)
VIREAD TAB 300MG(Tenofovir Disoproxil Fumarate)
VISTIDE INJ 75MG/ML(Cidofovir)
XIFAXAN TAB 200MG(Rifaximin)
YODOXIN TAB 210MG(Iodoquinol)
YODOXIN TAB 650MG(Iodoquinol)
ZERIT CAP 15MG(Stavudine)
ZERIT CAP 20MG(Stavudine)
04
04
04
04
04
04
02
02
02
02
02
04
04
01
01
01
01
04
04
04
04
02
02
02
02
04
04
04
04
02
02
02
04
04
04
04
02
02
02
02
02
02
03
04
02
02
02
02
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
23

Drug Name Drug Tier Notes
ZERIT CAP 30MG(Stavudine)
ZERIT CAP 40MG(Stavudine)
ZERIT SOL 1MG/ML(Stavudine)
ZIAGEN SOL 20MG/ML(Abacavir Sulfate)
ZIAGEN TAB 300MG(Abacavir Sulfate)
zidovudine cap 100 mg
zidovudine syrup 10 mg/ml
zidovudine tab 300 mg
ZINACEF INJ 1.5GM(Cefuroxime Sodium)
ZINACEF INJ 1.5GM(Cefuroxime Sodium)
ZINACEF INJ 750MG(Cefuroxime Sodium)
ZINACEF INJ 750MG(Cefuroxime Sodium)
ZINACEF/D5W INJ 1.5GM(Cefuroxime Sodium in D5W)
ZINACEF/D5W INJ 750MG PB(Cefuroxime Sodium in D5W)
ZINACEF/H20 INJ 1.5GM PB(Cefuroxime in Sterile Water)
ZITHROMAX INJ 500MG(Azithromycin)
ZITHROMAX POW 1GM PAK(Azithromycin)
ZITHROMAX SUS 100/5ML(Azithromycin)
ZITHROMAX SUS 200/5ML(Azithromycin)
ZITHROMAX TAB 250MG(Azithromycin)
ZITHROMAX TAB 500MG(Azithromycin)
ZITHROMAX TAB 600MG(Azithromycin)
ZITHROMAX TAB TRI-PAK(Azithromycin)
ZITHROMAX TAB Z-PAK(Azithromycin)
ZMAX SUS 2GM(Azithromycin)
ZOSYN INJ 2G-0.25G(Piperacillin Sodium-Tazobactam Sodium)
ZOSYN INJ 3-0.375G(Piperacillin Sodium-Tazobactam Sodium)
ZOSYN INJ 36-4.5GM(Piperacillin Sodium-Tazobactam Sodium)
ZOSYN INJ 4GM/0.5G(Piperacillin Sodium-Tazobactam Sodium)
ZOSYN SOL 2-0.25GM(Piperacillin Sodium-Tazobactam Sodium in
Dextrose)
ZOSYN SOL 3-0.375G(Piperacillin Sodium-Tazobactam Sodium in
Dextrose)
ZOSYN SOL 4-0.50GM(Piperacillin Sodium-Tazobactam Sodium in
Dextrose)
ZOVIRAX CAP 200MG(Acyclovir)
ZOVIRAX SUS 200/5ML(Acyclovir)
ZOVIRAX TAB 400MG(Acyclovir)
ZOVIRAX TAB 800MG(Acyclovir)
ZYVOX SOL 2MG/ML(Linezolid)
ZYVOX SUS 100MG/5M(Linezolid)
ZYVOX TAB 600MG(Linezolid)
Antineoplastic Agents
ABRAXANE INJ 100MG(Paclitaxel Protein-Bound Particles)
ADRIAMYCIN INJ 20MG(Doxorubicin HCl)
ALFERON N INJ 5MU/ML(Interferon Alfa-n3)
ALIMTA INJ 500MG(Pemetrexed Disodium)
ALKERAN INJ 50MG(Melphalan HCl)
ALKERAN TAB 2MG(Melphalan)
02
02
02
02
02
01
01
01
04
04
04
04
04
04
04
04
02
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
02
02
02
04
02
03
04
02
02
(QL)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
24

Drug Name Drug Tier Notes
ARIMIDEX TAB 1MG(Anastrozole)
AROMASIN TAB 25MG(Exemestane)
ARRANON INJ 5MG/ML(Nelarabine)
AVASTIN INJ(Bevacizumab)
BEXXAR CON 14MG/ML(Tositumomab)
BEXXAR 131 I INJ 0.61/ML(Iodine I 131 Tositumomab)
BEXXAR 131 I INJ 5.6MCI/M(Iodine I 131 Tositumomab)
BICNU INJ 100MG(Carmustine)
BLENOXANE INJ 15UNIT(Bleomycin Sulfate)
bleomycin sulfate for inj 15 unit
bleomycin sulfate for inj 30 unit
busulfan inj 6 mg/ml
CAMPATH INJ 10MG/ML(Alemtuzumab)
CAMPATH INJ 30MG/ML(Alemtuzumab)
CAMPTOSAR INJ 20MG/ML(Irinotecan HCl)
carboplatin iv for inj 150 mg
carboplatin iv for inj 450 mg
carboplatin iv for inj 50 mg
carboplatin iv soln 10 mg/ml
CASODEX TAB 50MG(Bicalutamide)
CEENU CAP 100MG(Lomustine)
CEENU CAP 10MG(Lomustine)
CEENU CAP 40MG(Lomustine)
CEENU PAK DOSEPACK(Lomustine)
CERUBIDINE INJ 20MG(Daunorubicin HCl)
cisplatin inj 1 mg/ml
cladribine inj 1 mg/ml
CLOLAR INJ 1MG/ML(Clofarabine)
COSMEGEN INJ 0.5MG(Dactinomycin)
cyclophosphamide for inj 1 gm
cyclophosphamide for inj 2 gm
cyclophosphamide for inj 500 mg
cyclophosphamide tab 25 mg
cyclophosphamide tab 50 mg
CYTARABINE INJ 100MG/ML(Cytarabine)
cytarabine for inj 1 gm
cytarabine for inj 100 mg
cytarabine for inj 2 gm
cytarabine for inj 500 mg
cytarabine inj 100 mg/ml
cytarabine inj 20 mg/ml
CYTOXAN INJ 1GM(Cyclophosphamide)
CYTOXAN INJ 2GM(Cyclophosphamide)
CYTOXAN INJ 500MG(Cyclophosphamide)
CYTOXAN TAB 25MG(Cyclophosphamide)
CYTOXAN TAB 50MG(Cyclophosphamide)
dacarbazine for inj 100 mg
dacarbazine for inj 200 mg
DACOGEN INJ 50MG(Decitabine)
daunorubicin hcl for inj 20 mg
02
02
02
02
04
04
04
04
02
01
01
01
04
04
03
03
03
03
03
02
02
02
02
02
04
01
01
04
04
01
01
01
01
01
02
03
01
03
03
01
01
04
04
04
02
02
01
01
02
01
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
25

Drug Name Drug Tier Notes
daunorubicin hcl inj 5 mg/ml (base equiv)
DAUNOXOME INJ 2MG/ML(Daunorubicin Citrate Liposome)
DEPOCYT INJ 50MG/5ML(Cytarabine Liposome)
DOXIL INJ 2MG/ML(Doxorubicin HCl Liposomal)
doxorubicin hcl for inj 10 mg
doxorubicin hcl for inj 50 mg
doxorubicin hcl inj 2 mg/ml
DROXIA CAP 200MG(Hydroxyurea (Sickle Cell Anemia))
DROXIA CAP 300MG(Hydroxyurea (Sickle Cell Anemia))
DROXIA CAP 400MG(Hydroxyurea (Sickle Cell Anemia))
DTIC-DOME INJ 200MG(Dacarbazine)
ELIGARD INJ 22.5MG(Leuprolide Acetate (3 Month))
ELIGARD INJ 30MG(Leuprolide Acetate (4 Month))
ELIGARD INJ 45MG(Leuprolide Acetate (6 Month))
ELIGARD INJ 7.5MG(Leuprolide Acetate)
ELLENCE INJ 2MG/ML(Epirubicin HCl)
ELOXATIN INJ 100MG(Oxaliplatin)
ELOXATIN INJ 50MG(Oxaliplatin)
ELSPAR INJ 10000UNT(Asparaginase)
EMCYT CAP 140MG(Estramustine Phosphate Sodium)
EPIRUBICIN INJ 200MG(Epirubicin HCl)
EPIRUBICIN INJ 50MG(Epirubicin HCl)
ERBITUX INJ 100MG(Cetuximab)
ERBITUX INJ 200MG(Cetuximab)
ETOPOPHOS INJ 100MG(Etoposide Phosphate)
etoposide cap 50 mg
etoposide inj 20 mg/ml
FARESTON TAB 60MG(Toremifene Citrate)
FASLODEX INJ 125MG(Fulvestrant)
FASLODEX INJ 250MG(Fulvestrant)
FEMARA TAB 2.5MG(Letrozole)
floxuridine for inj 0.5 gm
FLUDARA INJ 50MG(Fludarabine Phosphate)
FLUDARABINE INJ 50MG/2ML(Fludarabine Phosphate)
fludarabine phosphate for inj 50 mg
fludarabine phosphate inj 25 mg/ml
fluorouracil inj 50 mg/ml
FLUOROURACIL INJ 50MG/ML(Fluorouracil)
flutamide cap 125 mg
FUDR INJ 0.5GM(Floxuridine)
GEMZAR INJ 1 GM(Gemcitabine HCl)
GEMZAR INJ 200MG(Gemcitabine HCl)
GLEEVEC TAB 100MG(Imatinib Mesylate)
GLEEVEC TAB 400MG(Imatinib Mesylate)
GLIADEL WAF WAFER(Carmustine in Polifeprosan)
HERCEPTIN INJ 440MG(Trastuzumab)
HEXALEN CAP 50MG(Altretamine)
HYCAMTIN INJ 4MG(Topotecan HCl)
HYDREA CAP 500MG(Hydroxyurea)
hydroxyurea cap 500 mg
01
04
02
02
01
01
01
04
04
04
04
03
03
02
03
03
03
03
04
02
02
02
04
04
04
01
01
02
03
03
02
01
03
02
03
01
01
02
01
02
03
03
03
03
02
04
02
04
04
01
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
26

Drug Name Drug Tier Notes
IDAMYCIN PFS INJ 1MG/ML(Idarubicin HCl)
idarubicin hcl iv inj 1 mg/ml
IFEX INJ 1GM(Ifosfamide)
IFEX INJ 3GM(Ifosfamide)
IFEX/MESNEX KIT(Ifosfamide & Mesna)
ifosfamide & mesna inj kit 1000-1000 mg
ifosfamide & mesna inj kit 3000-1000 mg
ifosfamide for inj 1 gm
ifosfamide for inj 3 gm
INTRON-A INJ 10MU(Interferon Alfa-2B)
INTRON-A INJ 10MU PEN(Interferon Alfa-2B)
INTRON-A INJ 18MU(Interferon Alfa-2B)
INTRON-A INJ 25MU(Interferon Alfa-2B)
INTRON-A INJ 3MU PEN(Interferon Alfa-2B)
INTRON-A INJ 50MU(Interferon Alfa-2B)
INTRON-A INJ 5MU PEN(Interferon Alfa-2B)
INTRON-A KIT 10MU/ML(Interferon Alfa-2B)
IRESSA TAB 250MG(Gefitinib)
LEUKERAN TAB 2MG(Chlorambucil)
leuprolide acetate inj 5 mg/ml
leuprolide acetate inj kit 5 mg/ml
LEUSTATIN INJ 1MG/ML(Cladribine)
LUPR DEP-PED INJ 11.25MG(Leuprolide Acetate)
LUPR DEP-PED INJ 15MG(Leuprolide Acetate)
LUPR DEP-PED INJ 7.5MG(Leuprolide Acetate)
LUPRON INJ 2 WEEK(Leuprolide Acetate)
LUPRON 6-PK INJ 5MG/ML(Leuprolide Acetate)
LUPRON DEPOT INJ 11.25MG(Leuprolide Acetate (3 Month))
LUPRON DEPOT INJ 22.5MG(Leuprolide Acetate (3 Month))
LUPRON DEPOT INJ 3.75MG(Leuprolide Acetate)
LUPRON DEPOT INJ 30MG(Leuprolide Acetate (4 Month))
LUPRON DEPOT INJ 7.5MG(Leuprolide Acetate)
LYSODREN TAB 500MG(Mitotane)
MATULANE CAP 50MG(Procarbazine HCl)
MEGACE ORAL SUS 40MG/ML(Megestrol Acetate)
megestrol acetate susp 40 mg/ml
megestrol acetate tab 20 mg
megestrol acetate tab 40 mg
mercaptopurine tab 50 mg
methotrexate sodium for inj 1 gm
methotrexate sodium inj 25 mg/ml
methotrexate sodium tab 2.5 mg (base equiv)
mitomycin for inj 20 mg
mitomycin for inj 40 mg
mitomycin for inj 5 mg
mitoxantrone hcl inj conc 2 mg/ml
MUSTARGEN INJ 10MG(Mechlorethamine HCl)
MYLERAN TAB 2MG(Busulfan)
MYLOTARG SOL 5MG(Gemtuzumab Ozogamicin)
NAVELBINE INJ 10MG/ML(Vinorelbine Tartrate)
04
01
04
04
04
01
01
01
01
03
03
03
03
03
03
03
03
04
02
03
03
02
03
03
03
03
03
03
03
03
03
03
02
02
04
01
01
01
01
01
01
01
01
01
01
03
04
02
03
04
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
27

Drug Name Drug Tier Notes
NEXAVAR TAB 200MG(Sorafenib Tosylate)
NILANDRON TAB 150MG(Nilutamide)
NIPENT INJ 10MG(Pentostatin)
NOVANTRONE INJ 2MG/ML(Mitoxantrone HCl)
ONCASPAR INJ 750/ML(Pegaspargase)
ONTAK INJ 150/ML(Denileukin Diftitox)
paclitaxel iv conc 6 mg/ml
PARAPLATIN INJ 150/15ML(Carboplatin)
PARAPLATIN INJ 150MG(Carboplatin)
PARAPLATIN INJ 450/45ML(Carboplatin)
PARAPLATIN INJ 450MG(Carboplatin)
PARAPLATIN INJ 50MG(Carboplatin)
PARAPLATIN INJ 50MG/5ML(Carboplatin)
PHOTOFRIN INJ 75MG(Porfimer Sodium)
PLATINOL AQ INJ 100MG(Cisplatin)
PLATINOL AQ INJ 50MG(Cisplatin)
PLENAXIS INJ 100MG(Abarelix)
PROLEUKIN INJ 22MU(Aldesleukin)
PURINETHOL TAB 50MG(Mercaptopurine)
RHEUMATREX TAB 2.5MG(Methotrexate Sodium (Antirheumatic))
RITUXAN INJ 100MG(Rituximab)
RITUXAN INJ 500MG(Rituximab)
ROFERON-A KIT 3MU/0.5(Interferon Alfa-2A)
ROFERON-A KIT 6MU/0.5(Interferon Alfa-2A)
ROFERON-A KIT 9MU/0.5(Interferon Alfa-2A)
SOLTAMOX SOL 10MG/5ML(Tamoxifen Citrate)
SPRYCEL TAB 20MG(Dasatinib)
SPRYCEL TAB 50MG(Dasatinib)
SPRYCEL TAB 70MG(Dasatinib)
SUPPRELIN LA KIT 50MG(Histrelin Acetate)
SUTENT CAP 12.5MG(Sunitinib Malate)
SUTENT CAP 25MG(Sunitinib Malate)
SUTENT CAP 50MG(Sunitinib Malate)
tamoxifen citrate tab 10 mg (base equivalent)
tamoxifen citrate tab 20 mg (base equivalent)
TARCEVA TAB 100MG(Erlotinib)
TARCEVA TAB 150MG(Erlotinib)
TARCEVA TAB 25MG(Erlotinib)
TARGRETIN CAP 75MG(Bexarotene)
TAXOL INJ 100/17ML(Paclitaxel)
TAXOL INJ 30MG/5ML(Paclitaxel)
TAXOL INJ 6MG/ML(Paclitaxel)
TAXOTERE INJ 20/0.5ML(Docetaxel)
TAXOTERE INJ 80MG/2ML(Docetaxel)
TEMODAR CAP 100MG(Temozolomide)
TEMODAR CAP 140MG(Temozolomide)
TEMODAR CAP 180MG(Temozolomide)
TEMODAR CAP 20MG(Temozolomide)
TEMODAR CAP 250MG(Temozolomide)
TEMODAR CAP 5MG(Temozolomide)
02
02
04
03
04
03
01
03
03
03
03
03
03
04
04
04
02
03
04
02
03
02
03
03
03
02
02
02
02
04
02
03
02
01
01
02
02
02
02
04
04
04
04
04
02
02
02
02
02
02
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
28

Drug Name Drug Tier Notes
TESLAC TAB 50MG(Testolactone)
thioguanine tab 40 mg
thiotepa for inj 15 mg
TORISEL SOL 25MG/ML(Temsirolimus)
TRELSTAR DEP INJ 3.75MG(Triptorelin Pamoate)
TRELSTAR LA INJ 11.25MG(Triptorelin Pamoate)
tretinoin cap 10 mg
TREXALL TAB 10MG(Methotrexate Sodium)
TREXALL TAB 15MG(Methotrexate Sodium)
TREXALL TAB 5MG(Methotrexate Sodium)
TREXALL TAB 7.5MG(Methotrexate Sodium)
TRISENOX SOL 10MG/10M(Arsenic Trioxide)
TYKERB TAB 250MG(Lapatinib Ditosylate)
VANTAS KIT 50MG(Histrelin Acetate)
VECTIBIX INJ 100MG(Panitumumab)
VECTIBIX INJ 200MG(Panitumumab)
VECTIBIX INJ 400MG(Panitumumab)
VELCADE INJ 3.5MG(Bortezomib)
VEPESID CAP 50MG(Etoposide)
VESANOID CAP 10 MG(Tretinoin (Chemotherapy))
VIADUR KIT(Leuprolide Acetate)
VIDAZA INJ 100MG(Azacitidine)
vinblastine sulfate for inj 10 mg
vinblastine sulfate inj 1 mg/ml
vincristine sulfate iv soln 1 mg/ml
VINORELBINE INJ 50MG/ML(Vinorelbine Tartrate)
vinorelbine tartrate inj 10 mg/ml
VUMON INJ 50MG/5ML(Teniposide)
XELODA TAB 150MG(Capecitabine)
XELODA TAB 500MG(Capecitabine)
ZANOSAR INJ 1GM(Streptozocin)
ZEVALIN KIT IN-111(Ibritumomab Tiuxetan for Indium-111 (In-111))
ZEVALIN KIT Y-90(Ibritumomab Tiuxetan for Yttrium-90 (Y-90))
ZOLADEX IMP 10.8MG(Goserelin Acetate)
ZOLADEX IMP 3.6MG(Goserelin Acetate)
ZOLINZA CAP 100MG(Vorinostat)
Autonomic Drugs
ACCUNEB NEB 0.63MG/3(Albuterol Sulfate)
ACCUNEB NEB 1.25MG/3(Albuterol Sulfate)
ADRENALIN INJ 1MG/ML(Epinephrine HCl)
ADVAIR DISKU MIS 100/50(Fluticasone-Salmeterol)
ADVAIR DISKU MIS 250/50(Fluticasone-Salmeterol)
ADVAIR DISKU MIS 500/50(Fluticasone-Salmeterol)
ADVAIR HFA AER 115/21(Fluticasone-Salmeterol)
ADVAIR HFA AER 230/21(Fluticasone-Salmeterol)
ADVAIR HFA AER 45/21(Fluticasone-Salmeterol)
AKINETON TAB 2MG(Biperiden HCl)
albuterol inhal aerosol 90 mcg/act
albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv)
02
01
01
02
04
04
01
02
02
02
02
03
02
04
02
02
02
03
02
02
03
04
01
01
01
04
01
02
02
02
04
03
03
03
03
02
02
02
04
02
02
02
02
02
02
04
01
01
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
29

Drug Name Drug Tier Notes
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)
albuterol sulfate soln nebu 0.5% (5 mg/ml)
albuterol sulfate soln nebu 1.25 mg/3ml (base equiv)
albuterol sulfate syrup 2 mg/5ml
albuterol sulfate tab 2 mg
albuterol sulfate tab 4 mg
albuterol sulfate tab sr 12hr 4 mg
albuterol sulfate tab sr 12hr 8 mg
ALBUTEROL/ SOL IPRATROP(Albuterol-Ipratropium)
ALUPENT INH AER 0.65/ACT(Metaproterenol Sulfate)
ANASPAZ TAB 0.125MG(Hyoscyamine Sulfate)
ARICEPT TAB 10MG(Donepezil Hydrochloride)
ARICEPT TAB 5MG(Donepezil Hydrochloride)
ARICEPT ODT TAB 10MG(Donepezil Hydrochloride)
ARICEPT ODT TAB 5MG(Donepezil Hydrochloride)
ATROVENT HFA AER 17MCG(Ipratropium Bromide HFA)
B & O 15-A SUP SUPPRETT(Belladonna Alkaloids & Opium)
B & O 16-A SUP SUPPRETT(Belladonna Alkaloids & Opium)
baclofen tab 10 mg
baclofen tab 20 mg
belladonna alkaloids & opium suppos 16.2-30 mg
belladonna alkaloids & opium suppos 16.2-60 mg
BENTYL CAP 10MG(Dicyclomine HCl)
BENTYL INJ 10MG/ML(Dicyclomine HCl)
BENTYL SYP 10MG/5ML(Dicyclomine HCl)
BENTYL TAB 20MG(Dicyclomine HCl)
benztropine mesylate tab 0.5 mg
benztropine mesylate tab 1 mg
benztropine mesylate tab 2 mg
bethanechol chloride tab 10 mg
bethanechol chloride tab 25 mg
bethanechol chloride tab 5 mg
bethanechol chloride tab 50 mg
BRETHINE INJ 1MG/ML(Terbutaline Sulfate)
BRETHINE TAB 2.5MG(Terbutaline Sulfate)
BRETHINE TAB 5MG(Terbutaline Sulfate)
BROVANA NEB 15MCG(Arformoterol Tartrate)
CANTIL TAB(Mepenzolate Bromide)
carisoprodol tab 350 mg
carisoprodol w/ aspirin & codeine tab 200-325-16 mg
carisoprodol w/ aspirin tab 200-325 mg
CHANTIX PAK(Varenicline Tartrate)
CHANTIX PAK 1MG(Varenicline Tartrate)
CHANTIX TAB 0.5MG(Varenicline Tartrate)
CHANTIX TAB 1MG(Varenicline Tartrate)
chlorzoxazone tab 250 mg
chlorzoxazone tab 500 mg
COGENTIN INJ 1MG/ML(Benztropine Mesylate)
COGNEX CAP 10MG(Tacrine Hydrochloride)
COGNEX CAP 20MG(Tacrine Hydrochloride)
01
01
01
01
01
01
01
01
02
02
04
02
02
02
02
02
04
04
01
01
01
01
04
04
04
04
01
01
01
01
01
01
01
04
04
04
04
04
01
01
01
02
02
02
02
01
01
02
04
04
(PA)
(PA)
(PA)
(PA)
(QL)
(QL)
(QL)
(QL)
30

Drug Name Drug Tier Notes
COGNEX CAP 30MG(Tacrine Hydrochloride)
COGNEX CAP 40MG(Tacrine Hydrochloride)
COLYTROL SUS(Atropine-Hyoscyamine-Scopolamine)
COLYTROL TAB(Atropine-Hyoscyamine-Scopolamine)
COMBIVENT AER(Albuterol-Ipratropium)
cyclobenzaprine hcl tab 10 mg
cyclobenzaprine hcl tab 5 mg
CYSTOSPAZ TAB 0.15MG(Hyoscyamine)
DANTRIUM CAP 100MG(Dantrolene Sodium)
DANTRIUM CAP 25MG(Dantrolene Sodium)
DANTRIUM CAP 50MG(Dantrolene Sodium)
dantrolene sodium cap 100 mg
dantrolene sodium cap 25 mg
dantrolene sodium cap 50 mg
DIBENZYLINE CAP 10MG(Phenoxybenzamine HCl)
dicyclomine hcl cap 10 mg
dicyclomine hcl inj 10 mg/ml
dicyclomine hcl oral soln 10 mg/5ml
dicyclomine hcl tab 20 mg
DUONEB SOL(Albuterol-Ipratropium)
ENLON-PLUS INJ(Edrophonium Chloride w/ Atropine)
epinephrine hcl inj 0.1 mg/ml
epinephrine hcl inj 1 mg/ml
EPIPEN INJ 0.3MG(Epinephrine HCl (Anaphylaxis))
EPIPEN 2-PAK INJ 0.3MG(Epinephrine HCl (Anaphylaxis))
EPIPEN-JR INJ 0.15MG(Epinephrine HCl (Anaphylaxis))
EPIPEN-JR INJ 2-PAK(Epinephrine HCl (Anaphylaxis))
ergoloid mesylates tab 1 mg
EVOXAC CAP 30MG(Cevimeline HCl)
EXELON CAP 1.5MG(Rivastigmine Tartrate)
EXELON CAP 3MG(Rivastigmine Tartrate)
EXELON CAP 4.5MG(Rivastigmine Tartrate)
EXELON CAP 6MG(Rivastigmine Tartrate)
EXELON SOL 2MG/ML(Rivastigmine Tartrate)
FEXMID TAB 7.5MG(Cyclobenzaprine HCl)
FLEXERIL TAB 10MG(Cyclobenzaprine HCl)
FLEXERIL TAB 5MG(Cyclobenzaprine HCl)
FORADIL CAP AEROLIZE(Formoterol Fumarate)
glycopyrrolate inj 0.2 mg/ml
glycopyrrolate tab 1 mg
glycopyrrolate tab 2 mg
guanidine hcl tab 125 mg
homatropine methylbromide tab 10 mg
hyoscyamine sulfate cap sr 12hr 0.375 mg
hyoscyamine sulfate elixir 0.125 mg/5ml
hyoscyamine sulfate orally disintegrating tab 0.125 mg
hyoscyamine sulfate soln 0.031 mg/ml
hyoscyamine sulfate soln 0.125 mg/ml
hyoscyamine sulfate tab 0.125 mg
hyoscyamine sulfate tab cr 0.375 mg
04
04
04
04
02
01
01
04
04
04
04
01
01
01
02
01
01
01
01
02
04
01
01
04
04
04
04
01
04
02
02
02
02
02
02
04
04
02
01
01
01
01
01
01
01
01
01
01
01
01
(PA)
31

Drug Name Drug Tier Notes
hyoscyamine sulfate tab disp 0.25 mg
hyoscyamine sulfate tab sl 0.125 mg
hyoscyamine sulfate tab sr 12hr 0.375 mg
hyoscyamine tab 0.15 mg
ipratropium bromide inhal soln 0.02%
ISUPREL INJ 0.2MG/ML(Isoproterenol HCl)
KEMADRIN TAB 5MG(Procyclidine HCl)
LEVBID TAB 0.375 ER(Hyoscyamine Sulfate)
LEVSIN DRO 0.125/ML(Hyoscyamine Sulfate)
LEVSIN ELX 0.125/5(Hyoscyamine Sulfate)
LEVSIN INJ 0.5MG/ML(Hyoscyamine Sulfate)
LEVSIN TAB 0.125MG(Hyoscyamine Sulfate)
LEVSIN/SL SUB 0.125MG(Hyoscyamine Sulfate)
LEVSINEX CAP 0.375 CR(Hyoscyamine Sulfate)
MAXAIR AUTOH AER 200MCG(Pirbuterol Acetate)
MESTINON SYP 60MG/5ML(Pyridostigmine Bromide)
MESTINON TAB 60MG(Pyridostigmine Bromide)
MESTINON TAB TIMESPAN(Pyridostigmine Bromide)
metaproterenol sulfate soln nebu 0.4%
metaproterenol sulfate soln nebu 0.6%
metaproterenol sulfate syrup 10 mg/5ml
metaproterenol sulfate tab 10 mg
metaproterenol sulfate tab 20 mg
methocarbamol tab 500 mg
methocarbamol tab 750 mg
methscopolamine bromide tab 2.5 mg
methscopolamine bromide tab 5 mg
midodrine hcl tab 10 mg
midodrine hcl tab 2.5 mg
midodrine hcl tab 5 mg
MYTELASE TAB 10MG(Ambenonium Chloride)
NASOP12 CHW 10MG(Phenylephrine Tannate)
neostigmine methylsulfate inj 0.5 mg/ml (1:2000)
neostigmine methylsulfate inj 1 mg/ml
NICOTROL INH(Nicotine)
NICOTROL NS SPR 10MG/ML(Nicotine)
NORFLEX INJ 30MG/ML(Orphenadrine Citrate)
NULEV TAB 0.125MG(Hyoscyamine Sulfate)
orphenadrine citrate inj 30 mg/ml
orphenadrine citrate tab sr 12hr 100 mg
PAMINE TAB 2.5MG(Methscopolamine Bromide)
PAMINE FORTE TAB 5MG(Methscopolamine Bromide)
PARAFON FORT TAB DSC(Chlorzoxazone)
pilocarpine hcl tab 5 mg
pilocarpine hcl tab 7.5 mg
PRO-BANTHINE TAB 7.5MG(Propantheline Bromide)
PROAIR HFA AER(Albuterol Sulfate)
PROAMATINE TAB 10MG(Midodrine HCl)
PROAMATINE TAB 2.5MG(Midodrine HCl)
PROAMATINE TAB 5MG(Midodrine HCl)
01
01
01
01
01
02
04
04
04
04
02
04
04
04
02
02
04
02
01
01
01
01
01
01
01
01
01
01
01
01
04
04
01
01
02
02
04
04
01
01
04
04
04
01
01
02
02
04
04
04
(PA)
(PA)
(PA)
(PA)
(PA)
32

Drug Name Drug Tier Notes
PROSTIGMIN INJ 0.5MG/ML(Neostigmine Methylsulfate)
PROSTIGMIN INJ 1MG/ML(Neostigmine Methylsulfate)
PROSTIGMIN TAB 15MG(Neostigmine Bromide)
PROVENTIL AER 90MCG(Albuterol)
PROVENTIL AER HFA(Albuterol Sulfate)
PROVENTIL NEB 0.083%(Albuterol Sulfate)
pyridostigmine bromide tab 60 mg
RAZADYNE SOL 4MG/ML(Galantamine Hydrobromide)
RAZADYNE TAB 12MG(Galantamine Hydrobromide)
RAZADYNE TAB 4MG(Galantamine Hydrobromide)
RAZADYNE TAB 8MG(Galantamine Hydrobromide)
RAZADYNE ER CAP 16MG(Galantamine Hydrobromide)
RAZADYNE ER CAP 24MG(Galantamine Hydrobromide)
RAZADYNE ER CAP 8MG(Galantamine Hydrobromide)
REGONOL INJ 5MG/ML(Pyridostigmine Bromide)
ROBAXIN INJ 100MG/ML(Methocarbamol)
ROBAXIN TAB 500MG(Methocarbamol)
ROBAXIN-750 TAB 750MG(Methocarbamol)
ROBINUL INJ 0.2MG/ML(Glycopyrrolate)
ROBINUL TAB 1MG(Glycopyrrolate)
ROBINUL FORT TAB 2MG(Glycopyrrolate)
SAL-TROPINE TAB 0.4MG(Atropine Sulfate)
SALAGEN TAB 5MG(Pilocarpine HCl (Oral))
SALAGEN TAB 7.5MG(Pilocarpine HCl (Oral))
scopolamine hbr inj 0.4 mg/ml
SEREVENT DIS AER 50MCG(Salmeterol Xinafoate)
SKELAXIN TAB 800MG(Metaxalone)
SOMA TAB 350MG(Carisoprodol)
SOMA CPD TAB(Carisoprodol w/ Aspirin)
SOMA CPD/COD TAB(Carisoprodol w/ Aspirin & Codeine)
SPIRIVA CAP HANDIHLR(Tiotropium Bromide Monohydrate)
terbutaline sulfate inj 1 mg/ml
terbutaline sulfate tab 2.5 mg
terbutaline sulfate tab 5 mg
THERABENZAPR PAK -60(Cyclobenzaprine-Nutritional Supplement)
THERABENZAPR PAK -90(Cyclobenzaprine-Nutritional Supplement)
tizanidine hcl tab 2 mg
tizanidine hcl tab 4 mg
trihexyphenidyl hcl elixir 0.4 mg/ml
trihexyphenidyl hcl tab 2 mg
trihexyphenidyl hcl tab 5 mg
TWINJECT INJ 0.15MG(Epinephrine)
TWINJECT INJ 0.3MG(Epinephrine)
URECHOLINE TAB 10MG(Bethanechol Chloride)
URECHOLINE TAB 25MG(Bethanechol Chloride)
URECHOLINE TAB 50MG(Bethanechol Chloride)
URECHOLINE TAB 5MG(Bethanechol Chloride)
VENTOLIN HFA AER(Albuterol Sulfate)
VOSPIRE ER TAB 4MG(Albuterol Sulfate)
VOSPIRE ER TAB 8MG(Albuterol Sulfate)
04
04
02
04
02
02
01
02
02
02
02
02
02
02
02
02
04
04
04
04
04
04
04
04
01
02
04
04
04
04
02
01
01
01
04
04
01
01
01
01
01
04
04
04
04
04
04
02
04
04
(PA)
33

Drug Name Drug Tier Notes
XOPENEX NEB 0.31MG(Levalbuterol HCl)
XOPENEX NEB 0.63MG(Levalbuterol HCl)
XOPENEX NEB 1.25/3ML(Levalbuterol HCl)
XOPENEX CONC NEB 1.25/0.5(Levalbuterol HCl)
XOPENEX HFA AER(Levalbuterol Tartrate)
ZANAFLEX CAP 2MG(Tizanidine HCl)
ZANAFLEX CAP 4MG(Tizanidine HCl)
ZANAFLEX CAP 6MG(Tizanidine HCl)
ZANAFLEX TAB 2MG(Tizanidine HCl)
ZANAFLEX TAB 4MG(Tizanidine HCl)
Blood Formation, Coagulation & Thrombosis
ABBOKINASE INJ 250000(Urokinase)
ACD-A SOL(Anticoagulant Citrate Dextrose Solution A)
AGGRENOX CAP 25-200MG(Aspirin-Dipyridamole)
AGRYLIN CAP 0.5MG(Anagrelide HCl)
AGRYLIN CAP 1MG(Anagrelide HCl)
AMICAR TAB 1000MG(Aminocaproic Acid)
AMICAR TAB 500MG(Aminocaproic Acid)
aminocaproic acid tab 500 mg
anagrelide hcl cap 0.5 mg
anagrelide hcl cap 1 mg
ANGIOMAX INJ 250MG(Bivalirudin)
ARANESP INJ 100MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 100MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 100MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 150MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 150MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 200MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 200MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 200MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 25MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 25MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 25MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 300MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 300MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 300MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 40MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 40MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 40MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 500MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 60MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 60MCG(Darbepoetin Alfa-Polysorbate 80)
ARANESP INJ 60MCG(Darbepoetin Alfa-Polysorbate 80)
ARIXTRA SOL 10/0.8(Fondaparinux Sodium)
ARIXTRA SOL 2.5/0.5(Fondaparinux Sodium)
ARIXTRA SOL 5.0/0.4(Fondaparinux Sodium)
ARIXTRA SOL 7.5/0.6(Fondaparinux Sodium)
BENEFIX INJ 2000UNIT(Coagulation Factor IX (Recombinant))
cilostazol tab 100 mg
04
04
04
04
02
04
04
04
04
04
04
02
02
02
02
04
04
01
01
01
02
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
04
01
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(QL)
(QL)
(QL)
(QL)
34

Drug Name Drug Tier Notes
cilostazol tab 50 mg
COUMADIN INJ 5 MG(Warfarin Sodium)
COUMADIN TAB 10MG(Warfarin Sodium)
COUMADIN TAB 1MG(Warfarin Sodium)
COUMADIN TAB 2.5MG(Warfarin Sodium)
COUMADIN TAB 2.5MG(Warfarin Sodium)
COUMADIN TAB 2MG(Warfarin Sodium)
COUMADIN TAB 2MG(Warfarin Sodium)
COUMADIN TAB 3MG(Warfarin Sodium)
COUMADIN TAB 4MG(Warfarin Sodium)
COUMADIN TAB 4MG(Warfarin Sodium)
COUMADIN TAB 5MG(Warfarin Sodium)
COUMADIN TAB 5MG(Warfarin Sodium)
COUMADIN TAB 6MG(Warfarin Sodium)
COUMADIN TAB 6MG(Warfarin Sodium)
COUMADIN TAB 7.5MG(Warfarin Sodium)
EPOGEN INJ 10000/ML(Epoetin Alfa)
EPOGEN INJ 2000/ML(Epoetin Alfa)
EPOGEN INJ 20000/ML(Epoetin Alfa)
EPOGEN INJ 3000/ML(Epoetin Alfa)
EPOGEN INJ 4000/ML(Epoetin Alfa)
EPOGEN INJ 40000/ML(Epoetin Alfa)
FRAGMIN INJ 10000/ML(Dalteparin Sodium)
FRAGMIN INJ 2500/0.2(Dalteparin Sodium)
FRAGMIN INJ 25000/ML(Dalteparin Sodium)
FRAGMIN INJ 5000/0.2(Dalteparin Sodium)
FRAGMIN INJ 7500/0.3(Dalteparin Sodium)
HEP SOD/D5W INJ 100/ML(Heparin Sod (Porcine) in D5W)
HEP SOD/D5W INJ 25000UNT(Heparin Sod (Porcine) in D5W)
HEP SOD/D5W INJ 50UNT/ML(Heparin Sod (Porcine) in D5W)
HEP SOD/NACL INJ 1000UNIT(Heparin (Porcine) in Sodium Chloride)
HEP SOD/NACL INJ 2000UNIT(Heparin (Porcine) in Sodium Chloride)
HEPARIN SOD INJ 2000/ML(Heparin Sodium (Porcine))
heparin sodium (porcine) 10 unit/ml in sodium chloride 0.9%
heparin sodium (porcine) 100 unit/ml in d5w
heparin sodium (porcine) 100 unit/ml in sodium chloride 0.9%
heparin sodium (porcine) 100 unt/ml in sodium chloride 0.45%
heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9%
heparin sodium (porcine) 40 unit/ml in d5w
heparin sodium (porcine) 50 unit/ml in d5w
heparin sodium (porcine) 50 unit/ml in sodium chloride 0.45%
heparin sodium (porcine) inj 1000 unit/ml
heparin sodium (porcine) inj 10000 unit/ml
heparin sodium (porcine) inj 20000 unit/ml
heparin sodium (porcine) inj 25000 unit/ml
heparin sodium (porcine) inj 5000 unit/ml
heparin sodium (porcine) lock flush iv soln 10 unit/ml
heparin sodium (porcine) lock flush iv soln 100 unit/ml
heparin sodium (porcine) lock flush soln 10 unit/ml
heparin sodium (porcine) lock flush soln 100 unit/ml
01
02
02
02
02
04
02
04
02
02
04
02
04
02
04
02
03
03
03
03
03
03
03
03
03
03
03
02
02
02
02
02
02
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(QL)
(QL)
(QL)
(QL)
(QL)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
35

Drug Name Drug Tier Notes
heparin sodium (porcine) w/ nacl lock flush kit 10 unit/ml
heparin sodium (porcine) w/ nacl lock flush kit 100 unit/ml
INNOHEP INJ 20000/ML(Tinzaparin Sodium)
LEUKINE INJ 250MCG(Sargramostim)
LEUKINE INJ 500 MCG(Sargramostim)
LEUKINE SOL 500MCG(Sargramostim)
LOVENOX INJ 100/1ML(Enoxaparin Sodium)
LOVENOX INJ 120/0.8(Enoxaparin Sodium)
LOVENOX INJ 150/1ML(Enoxaparin Sodium)
LOVENOX INJ 30/0.3ML(Enoxaparin Sodium)
LOVENOX INJ 300/3ML(Enoxaparin Sodium)
LOVENOX INJ 40/0.4ML(Enoxaparin Sodium)
LOVENOX INJ 60/0.6ML(Enoxaparin Sodium)
LOVENOX INJ 80/0.8ML(Enoxaparin Sodium)
NEULASTA INJ 6MG/0.6M(Pegfilgrastim)
NEUMEGA INJ 5MG(Oprelvekin)
NEUPOGEN INJ 300/0.5(Filgrastim)
NEUPOGEN INJ 300MCG(Filgrastim)
NEUPOGEN INJ 480/0.8(Filgrastim)
NEUPOGEN INJ 480MCG(Filgrastim)
pentoxifylline tab cr 400 mg
PLAVIX TAB 75MG(Clopidogrel Bisulfate)
PLETAL TAB 100MG(Cilostazol)
PLETAL TAB 50MG(Cilostazol)
PROCRIT INJ 10000/ML(Epoetin Alfa)
PROCRIT INJ 2000/ML(Epoetin Alfa)
PROCRIT INJ 20000/ML(Epoetin Alfa)
PROCRIT INJ 3000/ML(Epoetin Alfa)
PROCRIT INJ 4000/ML(Epoetin Alfa)
PROCRIT INJ 40000/ML(Epoetin Alfa)
REFLUDAN INJ 50MG(Lepirudin)
THROMBI-GEL PAD 10(Thrombin-Sodium Carboxymethylcellulose (CMC)-
CaCl-Gelatin)
THROMBI-GEL PAD 100(Thrombin-Sodium Carboxymethylcellulose (CMC)-
CaCl-Gelatin)
THROMBI-GEL PAD 40(Thrombin-Sodium Carboxymethylcellulose (CMC)-
CaCl-Gelatin)
THROMBI-PAD PAD 3"X3"(Thrombin-Sodium Carboxymethylcellulose
(CMC)-CaCl)
TICLID TAB 250MG(Ticlopidine HCl)
ticlopidine hcl tab 250 mg
TISSEEL SOL(Fibrin Sealant Component)
TRENTAL TAB 400MG CR(Pentoxifylline)
warfarin sodium tab 1 mg
warfarin sodium tab 10 mg
warfarin sodium tab 2 mg
warfarin sodium tab 2.5 mg
warfarin sodium tab 3 mg
warfarin sodium tab 4 mg
warfarin sodium tab 5 mg
01
01
03
03
04
03
03
03
03
03
03
03
03
03
03
03
03
03
03
03
01
02
04
04
03
03
03
03
03
03
02
04
04
04
04
04
01
04
04
01
01
01
01
01
01
01
(QL)
(QL)
(QL)
(QL)
(QL)
(QL)
(QL)
(QL)
(QL)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
36

Drug Name Drug Tier Notes
warfarin sodium tab 6 mg
warfarin sodium tab 7.5 mg
Cardiovascular Drugs
ACCUPRIL TAB 10MG(Quinapril HCl)
ACCUPRIL TAB 20MG(Quinapril HCl)
ACCUPRIL TAB 40MG(Quinapril HCl)
ACCUPRIL TAB 5MG(Quinapril HCl)
ACCURETIC TAB 10/12.5(Quinapril-Hydrochlorothiazide)
ACCURETIC TAB 20-25MG(Quinapril-Hydrochlorothiazide)
ACCURETIC TAB 20/12.5(Quinapril-Hydrochlorothiazide)
acebutolol hcl cap 200 mg
acebutolol hcl cap 400 mg
ACEON TAB 2MG(Perindopril Erbumine)
ACEON TAB 4MG(Perindopril Erbumine)
ACEON TAB 8MG(Perindopril Erbumine)
acetazolamide tab 125 mg
acetazolamide tab 250 mg
ADALAT CC TAB 30MG ER(Nifedipine)
ADALAT CC TAB 60MG ER(Nifedipine)
ADALAT CC TAB 90MG ER(Nifedipine)
ADVICOR TAB 1000-20(Niacin-Lovastatin)
ADVICOR TAB 1000-40(Niacin-Lovastatin)
ADVICOR TAB 500-20MG(Niacin-Lovastatin)
ADVICOR TAB 750-20MG(Niacin-Lovastatin)
ALDACTAZIDE TAB 25/25(Spironolactone & Hydrochlorothiazide)
ALDACTAZIDE TAB 50/50(Spironolactone & Hydrochlorothiazide)
ALDACTONE TAB 100MG(Spironolactone)
ALDACTONE TAB 25MG(Spironolactone)
ALDACTONE TAB 50MG(Spironolactone)
ALTACE CAP 1.25MG(Ramipril)
ALTACE CAP 10MG(Ramipril)
ALTACE CAP 2.5MG(Ramipril)
ALTACE CAP 5MG(Ramipril)
ALTOPREV TAB 20MG ER(Lovastatin)
ALTOPREV TAB 40MG ER(Lovastatin)
ALTOPREV TAB 60MG ER(Lovastatin)
amiodarone hcl inj 50 mg/ml
amiodarone hcl tab 100 mg
amiodarone hcl tab 200 mg
amiodarone hcl tab 300 mg
amiodarone hcl tab 400 mg
amlodipine besylate tab 10 mg
amlodipine besylate tab 2.5 mg
amlodipine besylate tab 5 mg
amlodipine besylate-benazepril hcl cap 10-20 mg
amlodipine besylate-benazepril hcl cap 2.5-10 mg
amlodipine besylate-benazepril hcl cap 5-10 mg
amlodipine besylate-benazepril hcl cap 5-20 mg
ANTARA CAP 130MG(Fenofibrate Micronized)
01
01
04
04
04
04
04
04
04
01
01
04
04
04
01
01
04
04
04
04
04
04
04
04
02
04
04
04
04
04
04
04
04
04
04
01
01
01
01
01
01
01
01
01
01
01
01
02
37

Drug Name Drug Tier Notes
ANTARA CAP 43MG(Fenofibrate Micronized)
ATACAND TAB 16MG(Candesartan Cilexetil)
ATACAND TAB 32MG(Candesartan Cilexetil)
ATACAND TAB 4MG(Candesartan Cilexetil)
ATACAND TAB 8MG(Candesartan Cilexetil)
ATACAND HCT TAB 16-12.5(Candesartan Cilexetil-Hydrochlorothiazide)
ATACAND HCT TAB 32-12.5(Candesartan Cilexetil-Hydrochlorothiazide)
atenolol & chlorthalidone tab 100-25 mg
atenolol & chlorthalidone tab 50-25 mg
atenolol tab 100 mg
atenolol tab 25 mg
atenolol tab 50 mg
AVALIDE TAB 150-12.5(Irbesartan-Hydrochlorothiazide)
AVALIDE TAB 300-12.5(Irbesartan-Hydrochlorothiazide)
AVALIDE TAB 300-25MG(Irbesartan-Hydrochlorothiazide)
AVAPRO TAB 150MG(Irbesartan)
AVAPRO TAB 300MG(Irbesartan)
AVAPRO TAB 75MG(Irbesartan)
benazepril & hydrochlorothiazide tab 10-12.5 mg
benazepril & hydrochlorothiazide tab 20-12.5 mg
benazepril & hydrochlorothiazide tab 20-25 mg
benazepril & hydrochlorothiazide tab 5-6.25 mg
benazepril hcl tab 10 mg
benazepril hcl tab 20 mg
benazepril hcl tab 40 mg
benazepril hcl tab 5 mg
bendroflumethiazide & rauwolfia tab 4-50 mg
BENICAR TAB 20MG(Olmesartan Medoxomil)
BENICAR TAB 40MG(Olmesartan Medoxomil)
BENICAR TAB 5MG(Olmesartan Medoxomil)
BENICAR HCT TAB 20-12.5(Olmesartan Medoxomil-Hydrochlorothiazide)
BENICAR HCT TAB 40-12.5(Olmesartan Medoxomil-Hydrochlorothiazide)
BENICAR HCT TAB 40-25MG(Olmesartan Medoxomil-Hydrochlorothiazide)
BETAPACE TAB 120MG(Sotalol HCl)
BETAPACE TAB 160MG(Sotalol HCl)
BETAPACE TAB 240MG(Sotalol HCl)
BETAPACE TAB 80MG(Sotalol HCl)
BETAPACE AF TAB 120MG(Sotalol HCl (AFIB/AFL))
BETAPACE AF TAB 160MG(Sotalol HCl (AFIB/AFL))
BETAPACE AF TAB 80MG(Sotalol HCl (AFIB/AFL))
betaxolol hcl tab 10 mg
betaxolol hcl tab 20 mg
BIDIL TAB(Isosorbide Dinitrate-Hydralazine HCl)
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
bisoprolol fumarate tab 10 mg
bisoprolol fumarate tab 5 mg
CADUET TAB 10/10MG(Amlodipine Besylate-Atorvastatin Calcium)
CADUET TAB 10/20MG(Amlodipine Besylate-Atorvastatin Calcium)
02
04
04
04
04
04
04
01
01
01
01
01
04
04
04
04
04
04
01
01
01
01
01
01
01
01
01
02
02
02
02
02
02
04
04
04
04
04
04
04
01
01
02
01
01
01
01
01
04
04
38

Drug Name Drug Tier Notes
CADUET TAB 10/40MG(Amlodipine Besylate-Atorvastatin Calcium)
CADUET TAB 10/80MG(Amlodipine Besylate-Atorvastatin Calcium)
CADUET TAB 2.5/10MG(Amlodipine Besylate-Atorvastatin Calcium)
CADUET TAB 2.5/20MG(Amlodipine Besylate-Atorvastatin Calcium)
CADUET TAB 2.5/40MG(Amlodipine Besylate-Atorvastatin Calcium)
CADUET TAB 5MG/10MG(Amlodipine Besylate-Atorvastatin Calcium)
CADUET TAB 5MG/20MG(Amlodipine Besylate-Atorvastatin Calcium)
CADUET TAB 5MG/40MG(Amlodipine Besylate-Atorvastatin Calcium)
CADUET TAB 5MG/80MG(Amlodipine Besylate-Atorvastatin Calcium)
CALAN TAB 120MG(Verapamil HCl)
CALAN TAB 40MG(Verapamil HCl)
CALAN TAB 80MG(Verapamil HCl)
CALAN SR TAB 120MG(Verapamil HCl)
CALAN SR TAB 180MG(Verapamil HCl)
CALAN SR TAB 240MG(Verapamil HCl)
CAPOTEN TAB 100MG(Captopril)
CAPOTEN TAB 12.5MG(Captopril)
CAPOTEN TAB 25MG(Captopril)
CAPOTEN TAB 50MG(Captopril)
CAPOZIDE TAB 25/15MG(Captopril & Hydrochlorothiazide)
CAPOZIDE TAB 25/25MG(Captopril & Hydrochlorothiazide)
CAPOZIDE TAB 50/15MG(Captopril & Hydrochlorothiazide)
CAPOZIDE TAB 50/25MG(Captopril & Hydrochlorothiazide)
captopril & hydrochlorothiazide tab 25-15 mg
captopril & hydrochlorothiazide tab 25-25 mg
captopril & hydrochlorothiazide tab 50-15 mg
captopril & hydrochlorothiazide tab 50-25 mg
captopril tab 100 mg
captopril tab 12.5 mg
captopril tab 25 mg
captopril tab 50 mg
CARDENE CAP 20MG(Nicardipine HCl)
CARDENE CAP 30MG(Nicardipine HCl)
CARDENE SR CAP 30MG(Nicardipine HCl)
CARDENE SR CAP 45MG(Nicardipine HCl)
CARDENE SR CAP 60MG(Nicardipine HCl)
CARDIZEM TAB 120MG(Diltiazem HCl)
CARDIZEM TAB 30MG(Diltiazem HCl)
CARDIZEM TAB 60MG(Diltiazem HCl)
CARDIZEM TAB 90MG(Diltiazem HCl)
CARDIZEM CD CAP 120MG/24(Diltiazem HCl Coated Beads)
CARDIZEM CD CAP 180MG/24(Diltiazem HCl Coated Beads)
CARDIZEM CD CAP 240MG/24(Diltiazem HCl Coated Beads)
CARDIZEM CD CAP 300MG/24(Diltiazem HCl Coated Beads)
CARDIZEM CD CAP 360MG/24(Diltiazem HCl Coated Beads)
CARDIZEM LA TAB 120MG(Diltiazem HCl Coated Beads)
CARDIZEM LA TAB 180MG(Diltiazem HCl Coated Beads)
CARDIZEM LA TAB 240MG(Diltiazem HCl Coated Beads)
CARDIZEM LA TAB 300MG(Diltiazem HCl Coated Beads)
CARDIZEM LA TAB 360MG(Diltiazem HCl Coated Beads)
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
01
01
01
01
01
01
01
01
04
04
04
04
04
04
04
04
04
04
04
04
04
02
02
02
02
02
02
39

Drug Name Drug Tier Notes
CARDIZEM LA TAB 420MG(Diltiazem HCl Coated Beads)
CARDURA TAB 1MG(Doxazosin Mesylate)
CARDURA TAB 2MG(Doxazosin Mesylate)
CARDURA TAB 4MG(Doxazosin Mesylate)
CARDURA TAB 8MG(Doxazosin Mesylate)
CARDURA XL TAB 4MG(Doxazosin Mesylate (BPH))
CARDURA XL TAB 8MG(Doxazosin Mesylate (BPH))
CARTROL TAB 2.5MG(Carteolol HCl)
CARTROL TAB 5MG(Carteolol HCl)
CATAPRES TAB 0.1MG(Clonidine HCl)
CATAPRES TAB 0.2MG(Clonidine HCl)
CATAPRES TAB 0.3MG(Clonidine HCl)
CATAPRES-TTS DIS 0.1/24HR(Clonidine HCl)
CATAPRES-TTS DIS 0.2/24HR(Clonidine HCl)
CATAPRES-TTS DIS 0.3/24HR(Clonidine HCl)
cholestyramine light powder 4 gm/dose
cholestyramine light powder packets 4 gm
cholestyramine powder 4 gm/dose
cholestyramine powder packets 4 gm
clonidine hcl tab 0.1 mg
clonidine hcl tab 0.2 mg
clonidine hcl tab 0.3 mg
CLORPRES TAB 0.1-15MG(Clonidine & Chlorthalidone)
CLORPRES TAB 0.2-15MG(Clonidine & Chlorthalidone)
CLORPRES TAB 0.3-15MG(Clonidine & Chlorthalidone)
COLESTID GRA 5GM(Colestipol HCl)
COLESTID POW 5GM(Colestipol HCl)
COLESTID TAB 1GM(Colestipol HCl)
COLESTID FLA GRA 5/7.5GM(Colestipol HCl)
COLESTID FLA GRA 5GM(Colestipol HCl)
colestipol hcl granule packets 5 gm
colestipol hcl granules 5 gm
colestipol hcl tab 1 gm
CORDARONE TAB 200MG(Amiodarone HCl)
COREG TAB 12.5MG(Carvedilol)
COREG TAB 25MG(Carvedilol)
COREG TAB 3.125MG(Carvedilol)
COREG TAB 6.25MG(Carvedilol)
COREG CR CAP 10MG(Carvedilol Phosphate)
COREG CR CAP 20MG(Carvedilol Phosphate)
COREG CR CAP 40MG(Carvedilol Phosphate)
COREG CR CAP 80MG(Carvedilol Phosphate)
CORGARD TAB 20MG(Nadolol)
CORGARD TAB 40MG(Nadolol)
CORGARD TAB 80MG(Nadolol)
CORZIDE TAB 40/5(Nadolol & Bendroflumethiazide)
CORZIDE TAB 80/5(Nadolol & Bendroflumethiazide)
COVERA-HS TAB 180MG(Verapamil HCl)
COVERA-HS TAB 240MG(Verapamil HCl)
COZAAR TAB 100MG(Losartan Potassium)
02
04
04
04
04
04
04
04
04
04
04
04
02
02
02
01
01
01
01
01
01
01
04
04
04
04
04
04
04
04
01
01
01
04
02
02
02
02
02
02
02
02
04
04
04
04
04
02
02
04
40

Drug Name Drug Tier Notes
COZAAR TAB 25MG(Losartan Potassium)
COZAAR TAB 50MG(Losartan Potassium)
CRESTOR TAB 10MG(Rosuvastatin Calcium)
CRESTOR TAB 20MG(Rosuvastatin Calcium)
CRESTOR TAB 40MG(Rosuvastatin Calcium)
CRESTOR TAB 5MG(Rosuvastatin Calcium)
DIAMOX CAP 500MG CR(Acetazolamide)
digoxin inj 0.1 mg/ml
digoxin inj 0.25 mg/ml
digoxin oral soln 0.05 mg/ml
digoxin tab 0.125 mg
digoxin tab 0.25 mg
DILACOR XR CAP 120MG/24(Diltiazem HCl)
DILACOR XR CAP 180MG/24(Diltiazem HCl)
DILACOR XR CAP 240MG/24(Diltiazem HCl)
DILATRATE SR CAP 40MG(Isosorbide Dinitrate)
diltiazem hcl cap sr 12hr 120 mg
diltiazem hcl cap sr 12hr 60 mg
diltiazem hcl cap sr 12hr 90 mg
diltiazem hcl cap sr 24hr 120 mg
diltiazem hcl cap sr 24hr 180 mg
diltiazem hcl cap sr 24hr 240 mg
diltiazem hcl coated beads cap sr 24hr 120 mg
diltiazem hcl coated beads cap sr 24hr 180 mg
diltiazem hcl coated beads cap sr 24hr 240 mg
diltiazem hcl coated beads cap sr 24hr 300 mg
diltiazem hcl extended release beads cap sr 24hr 120 mg
diltiazem hcl extended release beads cap sr 24hr 180 mg
diltiazem hcl extended release beads cap sr 24hr 240 mg
diltiazem hcl extended release beads cap sr 24hr 300 mg
diltiazem hcl extended release beads cap sr 24hr 360 mg
diltiazem hcl extended release beads cap sr 24hr 420 mg
diltiazem hcl iv soln 5 mg/ml
diltiazem hcl tab 120 mg
diltiazem hcl tab 30 mg
diltiazem hcl tab 60 mg
diltiazem hcl tab 90 mg
DIOVAN TAB 160MG(Valsartan)
DIOVAN TAB 320MG(Valsartan)
DIOVAN TAB 40MG(Valsartan)
DIOVAN TAB 80MG(Valsartan)
DIOVAN HCT TAB 160/12.5(Valsartan-Hydrochlorothiazide)
DIOVAN HCT TAB 160/25MG(Valsartan-Hydrochlorothiazide)
DIOVAN HCT TAB 320/12.5(Valsartan-Hydrochlorothiazide)
DIOVAN HCT TAB 320/25MG(Valsartan-Hydrochlorothiazide)
DIOVAN HCT TAB 80/12.5(Valsartan-Hydrochlorothiazide)
dipyridamole tab 25 mg
dipyridamole tab 50 mg
dipyridamole tab 75 mg
disopyramide phosphate cap 100 mg
04
04
04
04
04
04
02
01
01
01
01
01
04
04
04
02
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
02
02
02
02
02
02
02
02
02
01
01
01
01
41

Drug Name Drug Tier Notes
disopyramide phosphate cap 150 mg
disopyramide phosphate cap sr 12hr 150 mg
doxazosin mesylate tab 1 mg
doxazosin mesylate tab 2 mg
doxazosin mesylate tab 4 mg
doxazosin mesylate tab 8 mg
DYNACIRC CR TAB 10MG(Isradipine)
DYNACIRC CR TAB 5MG(Isradipine)
enalapril maleate & hydrochlorothiazide tab 10-25 mg
enalapril maleate & hydrochlorothiazide tab 5-12.5 mg
enalapril maleate tab 10 mg
enalapril maleate tab 2.5 mg
enalapril maleate tab 20 mg
enalapril maleate tab 5 mg
ETHMOZINE TAB 200MG(Moricizine HCl)
ETHMOZINE TAB 250MG(Moricizine HCl)
ETHMOZINE TAB 300MG(Moricizine HCl)
EXFORGE TAB 10-160MG(Amlodipine Besylate-Valsartan)
EXFORGE TAB 10-320MG(Amlodipine Besylate-Valsartan)
EXFORGE TAB 5-160MG(Amlodipine Besylate-Valsartan)
EXFORGE TAB 5-320MG(Amlodipine Besylate-Valsartan)
felodipine tab sr 24hr 10 mg
felodipine tab sr 24hr 2.5 mg
felodipine tab sr 24hr 5 mg
fenofibrate micronized cap 134 mg
fenofibrate micronized cap 200 mg
fenofibrate micronized cap 67 mg
fenofibrate tab 160 mg
fenofibrate tab 54 mg
flecainide acetate tab 100 mg
flecainide acetate tab 150 mg
flecainide acetate tab 50 mg
fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg
fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg
fosinopril sodium tab 10 mg
fosinopril sodium tab 20 mg
fosinopril sodium tab 40 mg
gemfibrozil tab 600 mg
guanabenz acetate tab 4 mg
guanabenz acetate tab 8 mg
guanfacine hcl tab 1 mg
guanfacine hcl tab 2 mg
hydralazine & hydrochlorothiazide cap 100-50 mg
hydralazine & hydrochlorothiazide cap 25-25 mg
hydralazine & hydrochlorothiazide cap 50-50 mg
hydralazine hcl inj 20 mg/ml
hydralazine hcl tab 10 mg
hydralazine hcl tab 100 mg
hydralazine hcl tab 25 mg
hydralazine hcl tab 50 mg
01
01
01
01
01
01
02
02
01
01
01
01
01
01
04
04
04
04
04
04
04
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
42

Drug Name Drug Tier Notes
HYPERTENSOLO PAK(Metoprolol Tartrate-Nutritional Supplement)
HYTRIN CAP 10MG(Terazosin HCl)
HYTRIN CAP 1MG(Terazosin HCl)
HYTRIN CAP 2MG(Terazosin HCl)
HYTRIN CAP 5MG(Terazosin HCl)
HYZAAR TAB 100-12.5(Losartan Potassium & Hydrochlorothiazide)
HYZAAR TAB 100-25(Losartan Potassium & Hydrochlorothiazide)
HYZAAR TAB 50-12.5(Losartan Potassium & Hydrochlorothiazide)
IMDUR TAB 120MG ER(Isosorbide Mononitrate)
IMDUR TAB 30MG ER(Isosorbide Mononitrate)
IMDUR TAB 60MG ER(Isosorbide Mononitrate)
INDERAL TAB 60MG(Propranolol HCl)
INDERAL LA CAP 120MG(Propranolol HCl)
INDERAL LA CAP 160MG(Propranolol HCl)
INDERAL LA CAP 60MG(Propranolol HCl)
INDERAL LA CAP 80MG(Propranolol HCl)
INDERIDE TAB 40/25(Propranolol & Hydrochlorothiazide)
INNOPRAN XL CAP 120MG(Propranolol HCl Sustained-Release Beads)
INNOPRAN XL CAP 80MG(Propranolol HCl Sustained-Release Beads)
INSPRA TAB 25MG(Eplerenone)
INSPRA TAB 50MG(Eplerenone)
INVERSINE TAB 2.5MG(Mecamylamine HCl)
ISMO TAB 20MG(Isosorbide Mononitrate)
ISOPTIN SR TAB 120MG(Verapamil HCl)
ISOPTIN SR TAB 180MG(Verapamil HCl)
ISOPTIN SR TAB 240MG(Verapamil HCl)
ISORDIL TAB 40MG(Isosorbide Dinitrate)
ISORDIL TAB 5MG(Isosorbide Dinitrate)
isosorbide dinitrate sl tab 2.5 mg
isosorbide dinitrate sl tab 5 mg
isosorbide dinitrate tab 10 mg
isosorbide dinitrate tab 20 mg
isosorbide dinitrate tab 30 mg
isosorbide dinitrate tab 5 mg
isosorbide dinitrate tab cr 40 mg
isosorbide mononitrate tab 10 mg
isosorbide mononitrate tab 20 mg
isosorbide mononitrate tab sr 24hr 120 mg
isosorbide mononitrate tab sr 24hr 30 mg
isosorbide mononitrate tab sr 24hr 60 mg
isradipine cap 2.5 mg
isradipine cap 5 mg
KERLONE TAB 10MG(Betaxolol HCl)
KERLONE TAB 20MG(Betaxolol HCl)
labetalol hcl iv soln 5 mg/ml
labetalol hcl tab 100 mg
labetalol hcl tab 200 mg
labetalol hcl tab 300 mg
LANOXICAPS CAP 0.1MG(Digoxin)
LANOXICAPS CAP 0.2MG(Digoxin)
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
02
02
04
04
04
04
04
04
04
02
04
01
01
01
01
01
01
01
01
01
01
01
01
01
01
04
04
01
01
01
01
02
02
43

Drug Name Drug Tier Notes
LANOXIN INJ 0.25MG/1(Digoxin)
LANOXIN TAB 0.125MG(Digoxin)
LANOXIN TAB 0.125MG(Digoxin)
LANOXIN TAB 0.25MG(Digoxin)
LANOXIN TAB 0.25MG(Digoxin)
LESCOL CAP 20MG(Fluvastatin Sodium)
LESCOL CAP 40MG(Fluvastatin Sodium)
LESCOL XL TAB 80MG(Fluvastatin Sodium)
LETAIRIS TAB 10MG(Ambrisentan)
LETAIRIS TAB 5MG(Ambrisentan)
LEVATOL TAB 20MG(Penbutolol Sulfate)
LEXXEL TAB 5-5MG(Enalapril Maleate-Felodipine)
lidocaine hcl iv inj 10 mg/ml
lidocaine hcl iv inj 20 mg/ml
LIPITOR TAB 10MG(Atorvastatin Calcium)
LIPITOR TAB 20MG(Atorvastatin Calcium)
LIPITOR TAB 40MG(Atorvastatin Calcium)
LIPITOR TAB 80MG(Atorvastatin Calcium)
lisinopril & hydrochlorothiazide tab 10-12.5 mg
lisinopril & hydrochlorothiazide tab 20-12.5 mg
lisinopril & hydrochlorothiazide tab 20-25 mg
lisinopril tab 10 mg
lisinopril tab 2.5 mg
lisinopril tab 20 mg
lisinopril tab 30 mg
lisinopril tab 40 mg
lisinopril tab 5 mg
LOFIBRA CAP 134MG(Fenofibrate Micronized)
LOFIBRA CAP 200MG(Fenofibrate Micronized)
LOFIBRA CAP 67MG(Fenofibrate Micronized)
LOFIBRA TAB 160MG(Fenofibrate)
LOFIBRA TAB 54MG(Fenofibrate)
LOPID TAB 600MG(Gemfibrozil)
LOPRESS HCT TAB 100/25MG(Metoprolol & Hydrochlorothiazide)
LOPRESS HCT TAB 100/50MG(Metoprolol & Hydrochlorothiazide)
LOPRESS HCT TAB 50-25MG(Metoprolol & Hydrochlorothiazide)
LOPRESSOR INJ 5MG/5ML(Metoprolol Tartrate)
LOPRESSOR TAB 100MG(Metoprolol Tartrate)
LOPRESSOR TAB 50MG(Metoprolol Tartrate)
LOTENSIN TAB 10MG(Benazepril HCl)
LOTENSIN TAB 20MG(Benazepril HCl)
LOTENSIN TAB 40MG(Benazepril HCl)
LOTENSIN TAB 5MG(Benazepril HCl)
LOTENSIN HCT TAB 10-12.5(Benazepril & Hydrochlorothiazide)
LOTENSIN HCT TAB 20-12.5(Benazepril & Hydrochlorothiazide)
LOTENSIN HCT TAB 20-25MG(Benazepril & Hydrochlorothiazide)
LOTENSIN HCT TAB 5-6.25MG(Benazepril & Hydrochlorothiazide)
LOTREL CAP 10-20MG(Amlodipine Besylate-Benazepril HCl)
LOTREL CAP 10-40MG(Amlodipine Besylate-Benazepril HCl)
LOTREL CAP 2.5-10MG(Amlodipine Besylate-Benazepril HCl)
04
02
04
02
04
04
04
04
04
04
02
04
01
01
02
02
02
02
01
01
01
01
01
01
01
01
01
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
02
02
02
44

Drug Name Drug Tier Notes
LOTREL CAP 5-10MG(Amlodipine Besylate-Benazepril HCl)
LOTREL CAP 5-20MG(Amlodipine Besylate-Benazepril HCl)
LOTREL CAP 5-40MG(Amlodipine Besylate-Benazepril HCl)
lovastatin tab 10 mg
lovastatin tab 20 mg
lovastatin tab 40 mg
LOVAZA CAP 1GM(Omega-3-acid Ethyl Esters)
MAVIK TAB 1MG(Trandolapril)
MAVIK TAB 2MG(Trandolapril)
MAVIK TAB 4MG(Trandolapril)
methazolamide tab 25 mg
methazolamide tab 50 mg
methyldopa & hydrochlorothiazide tab 250-15 mg
methyldopa & hydrochlorothiazide tab 250-25 mg
methyldopa tab 250 mg
methyldopa tab 500 mg
METHYLDOPATE INJ 250/5ML(Methyldopate HCl)
METOPROLOL TAB 100MG ER(Metoprolol Succinate)
METOPROLOL TAB 200MG ER(Metoprolol Succinate)
METOPROLOL TAB 50MG ER(Metoprolol Succinate)
metoprolol & hydrochlorothiazide tab 100-25 mg
metoprolol & hydrochlorothiazide tab 100-50 mg
metoprolol & hydrochlorothiazide tab 50-25 mg
metoprolol succinate tab sr 24hr 25 mg
metoprolol tartrate inj 1 mg/ml
metoprolol tartrate tab 100 mg
metoprolol tartrate tab 25 mg
metoprolol tartrate tab 50 mg
MEVACOR TAB 10MG(Lovastatin)
MEVACOR TAB 20MG(Lovastatin)
MEVACOR TAB 40MG(Lovastatin)
MEXILETINE CAP 150MG(Mexiletine HCl)
MEXILETINE CAP 200MG(Mexiletine HCl)
MEXILETINE CAP 250MG(Mexiletine HCl)
mexiletine hcl cap 150 mg
mexiletine hcl cap 200 mg
mexiletine hcl cap 250 mg
MICARDIS TAB 20MG(Telmisartan)
MICARDIS TAB 40MG(Telmisartan)
MICARDIS TAB 80MG(Telmisartan)
MICARDIS HCT TAB 40/12.5(Telmisartan-Hydrochlorothiazide)
MICARDIS HCT TAB 80/12.5(Telmisartan-Hydrochlorothiazide)
MICARDIS HCT TAB 80/25MG(Telmisartan-Hydrochlorothiazide)
MINIPRESS CAP 1MG(Prazosin HCl)
MINIPRESS CAP 2MG(Prazosin HCl)
MINIPRESS CAP 5MG(Prazosin HCl)
minoxidil tab 10 mg
minoxidil tab 2.5 mg
moexipril hcl tab 15 mg
moexipril hcl tab 7.5 mg
02
02
02
01
01
01
02
04
04
04
01
01
01
01
01
01
04
02
02
02
01
01
01
01
01
01
01
01
04
04
04
02
02
02
01
01
01
02
02
02
02
02
02
04
04
04
01
01
01
01
(PA)
45

Drug Name Drug Tier Notes
moexipril-hydrochlorothiazide tab 15-12.5 mg
moexipril-hydrochlorothiazide tab 15-25 mg
moexipril-hydrochlorothiazide tab 7.5-12.5 mg
MONOKET TAB 10MG(Isosorbide Mononitrate)
MONOKET TAB 20MG(Isosorbide Mononitrate)
MONOPRIL TAB 10MG(Fosinopril Sodium)
MONOPRIL TAB 20MG(Fosinopril Sodium)
MONOPRIL TAB 40MG(Fosinopril Sodium)
MONOPRIL HCT TAB 10/12.5(Fosinopril Sodium & Hydrochlorothiazide)
MONOPRIL HCT TAB 20/12.5(Fosinopril Sodium & Hydrochlorothiazide)
nadolol tab 160 mg
nadolol tab 20 mg
nadolol tab 40 mg
nadolol tab 80 mg
NIASPAN TAB 1000 ER(Niacin (Antihyperlipidemic))
NIASPAN TAB 500MG ER(Niacin (Antihyperlipidemic))
NIASPAN TAB 750MG ER(Niacin (Antihyperlipidemic))
nicardipine hcl cap 20 mg
nicardipine hcl cap 30 mg
nifedipine cap 10 mg
nifedipine cap 20 mg
nifedipine tab sr 24hr 30 mg
nifedipine tab sr 24hr 60 mg
nifedipine tab sr 24hr 90 mg
nifedipine tab sr 24hr osmotic 30 mg
nifedipine tab sr 24hr osmotic 60 mg
nifedipine tab sr 24hr osmotic 90 mg
nimodipine cap 30 mg
NIMOTOP CAP 30MG(Nimodipine)
NITRO-DUR DIS 0.1MG/HR(Nitroglycerin)
NITRO-DUR DIS 0.2MG/HR(Nitroglycerin)
NITRO-DUR DIS 0.3MG/HR(Nitroglycerin)
NITRO-DUR DIS 0.4MG/HR(Nitroglycerin)
NITRO-DUR DIS 0.6MG/HR(Nitroglycerin)
NITRO-DUR DIS 0.8MG/HR(Nitroglycerin)
nitroglycerin cap cr 2.5 mg
nitroglycerin cap cr 6.5 mg
nitroglycerin cap cr 9 mg
nitroglycerin iv soln 5 mg/ml
nitroglycerin oint 2%
nitroglycerin sl tab 0.3 mg
nitroglycerin sl tab 0.4 mg
nitroglycerin sl tab 0.6 mg
nitroglycerin td patch 24hr 0.1 mg/hr
nitroglycerin td patch 24hr 0.2 mg/hr
nitroglycerin td patch 24hr 0.4 mg/hr
nitroglycerin td patch 24hr 0.6 mg/hr
NITROLINGUAL SPR PUMPSPRA(Nitroglycerin)
NITROSTAT SUB 0.3MG(Nitroglycerin)
NITROSTAT SUB 0.4MG(Nitroglycerin)
01
01
01
04
04
04
04
04
04
04
01
01
01
01
02
02
02
01
01
01
01
01
01
01
01
01
01
01
04
04
04
02
04
04
02
01
01
01
01
01
01
01
01
01
01
01
01
02
02
02
46

Drug Name Drug Tier Notes
NITROSTAT SUB 0.6MG(Nitroglycerin)
NORPACE CAP 100MG(Disopyramide Phosphate)
NORPACE CAP 100MG CR(Disopyramide Phosphate)
NORPACE CAP 150MG(Disopyramide Phosphate)
NORPACE CAP 150MG CR(Disopyramide Phosphate)
NORVASC TAB 10MG(Amlodipine Besylate)
NORVASC TAB 2.5MG(Amlodipine Besylate)
NORVASC TAB 5MG(Amlodipine Besylate)
PACERONE TAB 400MG(Amiodarone HCl)
papaverine hcl cap cr 150 mg
papaverine hcl inj 30 mg/ml
PERSANTINE TAB 25MG(Dipyridamole)
PERSANTINE TAB 50MG(Dipyridamole)
PERSANTINE TAB 75MG(Dipyridamole)
pindolol tab 10 mg
pindolol tab 5 mg
PLENDIL TAB 10MG CR(Felodipine)
PLENDIL TAB 2.5MG CR(Felodipine)
PLENDIL TAB 5MG CR(Felodipine)
PRAVACHOL TAB 10MG(Pravastatin Sodium)
PRAVACHOL TAB 20MG(Pravastatin Sodium)
PRAVACHOL TAB 40MG(Pravastatin Sodium)
PRAVACHOL TAB 80MG(Pravastatin Sodium)
pravastatin sodium tab 10 mg
pravastatin sodium tab 20 mg
pravastatin sodium tab 40 mg
pravastatin sodium tab 80 mg
prazosin hcl cap 1 mg
prazosin hcl cap 2 mg
prazosin hcl cap 5 mg
PRINIVIL TAB 10MG(Lisinopril)
PRINIVIL TAB 20MG(Lisinopril)
PRINIVIL TAB 5MG(Lisinopril)
PRINZIDE TAB 10/12.5(Lisinopril & Hydrochlorothiazide)
PRINZIDE TAB 20-12.5(Lisinopril & Hydrochlorothiazide)
PRINZIDE TAB 20-25MG(Lisinopril & Hydrochlorothiazide)
procainamide hcl cap 250 mg
procainamide hcl cap 500 mg
procainamide hcl inj 100 mg/ml
procainamide hcl inj 500 mg/ml
procainamide hcl tab cr 500 mg
procainamide hcl tab cr 750 mg
PROCANBID TAB 1000 MG(Procainamide HCl)
PROCANBID TAB 500MG CR(Procainamide HCl)
PROCARDIA CAP 10MG(Nifedipine)
PROCARDIA XL TAB 30MG CR(Nifedipine)
PROCARDIA XL TAB 60MG CR(Nifedipine)
PROCARDIA XL TAB 90MG CR(Nifedipine)
PRONESTYL CAP 250MG(Procainamide HCl)
PRONESTYL CAP 375MG(Procainamide HCl)
02
04
02
04
04
04
04
04
04
01
01
04
04
04
01
01
04
04
04
04
04
04
04
01
01
01
01
01
01
01
04
04
04
04
04
04
01
01
01
01
01
01
02
02
04
04
04
04
04
02
47

Drug Name Drug Tier Notes
PRONESTYL TAB 375MG(Procainamide HCl)
PRONESTYL TAB 500MG(Procainamide HCl)
propafenone hcl tab 150 mg
propafenone hcl tab 225 mg
propafenone hcl tab 300 mg
propranolol & hydrochlorothiazide tab 40-25 mg
propranolol & hydrochlorothiazide tab 80-25 mg
propranolol hcl cap sr 24hr 120 mg
propranolol hcl cap sr 24hr 160 mg
propranolol hcl cap sr 24hr 60 mg
propranolol hcl cap sr 24hr 80 mg
propranolol hcl inj 1 mg/ml
propranolol hcl tab 10 mg
propranolol hcl tab 20 mg
propranolol hcl tab 40 mg
propranolol hcl tab 60 mg
propranolol hcl tab 80 mg
QUESTRAN POW 4GM(Cholestyramine)
QUESTRAN POW 4GM LITE(Cholestyramine Light)
quinapril hcl tab 10 mg
quinapril hcl tab 20 mg
quinapril hcl tab 40 mg
quinapril hcl tab 5 mg
quinapril-hydrochlorothiazide tab 10-12.5 mg
quinapril-hydrochlorothiazide tab 20-12.5 mg
quinapril-hydrochlorothiazide tab 20-25 mg
quinidine gluconate inj 80 mg/ml
quinidine gluconate tab cr 324 mg
quinidine sulfate tab 200 mg
quinidine sulfate tab 300 mg
quinidine sulfate tab cr 300 mg
RANEXA TAB 500MG(Ranolazine)
reserpine tab 0.1 mg
reserpine tab 0.25 mg
REVATIO TAB 20MG(Sildenafil Citrate (Pulmonary Hypertension))
RYTHMOL TAB 150MG(Propafenone HCl)
RYTHMOL TAB 225MG(Propafenone HCl)
RYTHMOL TAB 300MG(Propafenone HCl)
RYTHMOL SR CAP 225MG(Propafenone HCl)
RYTHMOL SR CAP 325MG(Propafenone HCl)
RYTHMOL SR CAP 425MG(Propafenone HCl)
SECTRAL CAP 200MG(Acebutolol HCl)
SECTRAL CAP 400MG(Acebutolol HCl)
simvastatin tab 10 mg
simvastatin tab 20 mg
simvastatin tab 40 mg
simvastatin tab 5 mg
simvastatin tab 80 mg
sotalol hcl (afib/afl) tab 120 mg
sotalol hcl (afib/afl) tab 160 mg
02
02
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
04
04
01
01
01
01
01
01
01
01
01
01
01
01
02
01
01
02
04
04
04
02
02
02
04
04
01
01
01
01
01
01
01
(PA)
(PA)
48

Drug Name Drug Tier Notes
sotalol hcl (afib/afl) tab 80 mg
sotalol hcl tab 120 mg
sotalol hcl tab 160 mg
sotalol hcl tab 240 mg
sotalol hcl tab 80 mg
spironolactone & hydrochlorothiazide tab 25-25 mg
spironolactone tab 100 mg
spironolactone tab 25 mg
spironolactone tab 50 mg
SULAR TAB 10MG CR(Nisoldipine)
SULAR TAB 20MG CR(Nisoldipine)
SULAR TAB 30MG CR(Nisoldipine)
SULAR TAB 40MG CR(Nisoldipine)
TAMBOCOR TAB 100MG(Flecainide Acetate)
TAMBOCOR TAB 150MG(Flecainide Acetate)
TAMBOCOR TAB 50MG(Flecainide Acetate)
TARKA TAB 1-240 CR(Trandolapril-Verapamil HCl)
TARKA TAB 2-180 CR(Trandolapril-Verapamil HCl)
TARKA TAB 2-240 CR(Trandolapril-Verapamil HCl)
TARKA TAB 4-240 CR(Trandolapril-Verapamil HCl)
TEKTURNA TAB 150MG(Aliskiren Fumarate)
TEKTURNA TAB 300MG(Aliskiren Fumarate)
TENEX TAB 1MG(Guanfacine HCl)
TENEX TAB 2MG(Guanfacine HCl)
TENORETIC TAB -100(Atenolol & Chlorthalidone)
TENORETIC TAB -50(Atenolol & Chlorthalidone)
TENORMIN INJ 5MG/10ML(Atenolol)
TENORMIN TAB 100MG(Atenolol)
TENORMIN TAB 25MG(Atenolol)
TENORMIN TAB 50MG(Atenolol)
terazosin hcl cap 1 mg
terazosin hcl cap 10 mg
terazosin hcl cap 2 mg
terazosin hcl cap 5 mg
TEVETEN TAB 400MG(Eprosartan Mesylate)
TEVETEN TAB 600MG(Eprosartan Mesylate)
TEVETEN HCT TAB 600-12.5(Eprosartan Mesylate-Hydrochlorothiazide)
TEVETEN HCT TAB 600-25MG(Eprosartan Mesylate-Hydrochlorothiazide)
TIAZAC CAP 120MG/24(Diltiazem HCl Extended Release Beads)
TIAZAC CAP 180MG/24(Diltiazem HCl Extended Release Beads)
TIAZAC CAP 240MG/24(Diltiazem HCl Extended Release Beads)
TIAZAC CAP 300MG/24(Diltiazem HCl Extended Release Beads)
TIAZAC CAP 360MG/24(Diltiazem HCl Extended Release Beads)
TIAZAC CAP 420MG/24(Diltiazem HCl Extended Release Beads)
TIKOSYN CAP 125MCG(Dofetilide)
TIKOSYN CAP 250MCG(Dofetilide)
TIKOSYN CAP 500MCG(Dofetilide)
TIMOLIDE TAB 10/25(Timolol & Hydrochlorothiazide)
timolol maleate tab 10 mg
timolol maleate tab 20 mg
01
01
01
01
01
01
01
01
01
04
04
04
04
04
04
04
04
04
04
04
02
02
04
04
04
04
02
04
04
04
01
01
01
01
04
04
04
04
04
04
04
04
04
04
04
04
04
04
01
01
49

Drug Name Drug Tier Notes
timolol maleate tab 5 mg
TOPROL XL TAB 100MG(Metoprolol Succinate)
TOPROL XL TAB 200MG(Metoprolol Succinate)
TOPROL XL TAB 25MG(Metoprolol Succinate)
TOPROL XL TAB 50MG(Metoprolol Succinate)
TRACLEER TAB 125MG(Bosentan)
TRACLEER TAB 62.5MG(Bosentan)
TRANDATE TAB 100MG(Labetalol HCl)
TRANDATE TAB 200MG(Labetalol HCl)
TRANDATE TAB 300MG(Labetalol HCl)
TRANDATE IV INJ 5MG/ML(Labetalol HCl)
trandolapril tab 1 mg
trandolapril tab 2 mg
trandolapril tab 4 mg
TRICOR TAB 145MG(Fenofibrate)
TRICOR TAB 48MG(Fenofibrate)
TRIGLIDE TAB 160MG(Fenofibrate)
TRIGLIDE TAB 50MG(Fenofibrate)
UNIRETIC TAB 15-12.5(Moexipril-Hydrochlorothiazide)
UNIRETIC TAB 15/25MG(Moexipril-Hydrochlorothiazide)
UNIRETIC TAB 7.5/12.5(Moexipril-Hydrochlorothiazide)
UNIVASC TAB 15MG(Moexipril HCl)
UNIVASC TAB 7.5MG(Moexipril HCl)
VASERETIC TAB 10-25MG(Enalapril Maleate & Hydrochlorothiazide)
VASOTEC TAB 10MG(Enalapril Maleate)
VASOTEC TAB 2.5MG(Enalapril Maleate)
VASOTEC TAB 20MG(Enalapril Maleate)
VASOTEC TAB 5MG(Enalapril Maleate)
verapamil hcl cap sr 24hr 120 mg
verapamil hcl cap sr 24hr 180 mg
verapamil hcl cap sr 24hr 240 mg
verapamil hcl cap sr 24hr 360 mg
verapamil hcl iv soln 2.5 mg/ml
verapamil hcl tab 120 mg
verapamil hcl tab 40 mg
verapamil hcl tab 80 mg
verapamil hcl tab cr 120 mg
verapamil hcl tab cr 180 mg
verapamil hcl tab cr 240 mg
VERELAN CAP 120MG SR(Verapamil HCl)
VERELAN CAP 180MG(Verapamil HCl)
VERELAN CAP 240MG SR(Verapamil HCl)
VERELAN CAP 360MG SR(Verapamil HCl)
VERELAN PM CAP 100MG(Verapamil HCl)
VERELAN PM CAP 200MG(Verapamil HCl)
VERELAN PM CAP 300MG(Verapamil HCl)
VYTORIN TAB 10-10MG(Ezetimibe-Simvastatin)
VYTORIN TAB 10-20MG(Ezetimibe-Simvastatin)
VYTORIN TAB 10-40MG(Ezetimibe-Simvastatin)
VYTORIN TAB 10-80MG(Ezetimibe-Simvastatin)
01
02
02
04
02
02
02
04
04
04
04
01
01
01
02
02
02
02
04
04
04
04
04
04
04
04
04
04
01
01
01
01
01
01
01
01
01
01
01
04
04
04
04
02
02
02
02
02
02
02
(PA)
(PA)
50

Drug Name Drug Tier Notes
WELCHOL TAB 625MG(Colesevelam HCl)
XYLOCAINE INJ 2%(Lidocaine HCl (Cardiac))
ZEBETA TAB 10MG(Bisoprolol Fumarate)
ZEBETA TAB 5MG(Bisoprolol Fumarate)
ZESTORETIC TAB 10/12.5(Lisinopril & Hydrochlorothiazide)
ZESTORETIC TAB 20-12.5(Lisinopril & Hydrochlorothiazide)
ZESTORETIC TAB 20-25MG(Lisinopril & Hydrochlorothiazide)
ZESTRIL TAB 10MG(Lisinopril)
ZESTRIL TAB 2.5MG(Lisinopril)
ZESTRIL TAB 20MG(Lisinopril)
ZESTRIL TAB 30MG(Lisinopril)
ZESTRIL TAB 40MG(Lisinopril)
ZESTRIL TAB 5MG(Lisinopril)
ZETIA TAB 10MG(Ezetimibe)
ZIAC TAB 10/6.25(Bisoprolol & Hydrochlorothiazide)
ZIAC TAB 2.5/6.25(Bisoprolol & Hydrochlorothiazide)
ZIAC TAB 5/6.25MG(Bisoprolol & Hydrochlorothiazide)
ZOCOR TAB 10MG(Simvastatin)
ZOCOR TAB 20MG(Simvastatin)
ZOCOR TAB 40MG(Simvastatin)
ZOCOR TAB 5MG(Simvastatin)
ZOCOR TAB 80MG(Simvastatin)
Central Nervous System Agents
ABILIFY INJ 9.75MG(Aripiprazole)
ABILIFY SOL 1MG/ML(Aripiprazole)
ABILIFY TAB 10MG(Aripiprazole)
ABILIFY TAB 15MG(Aripiprazole)
ABILIFY TAB 20MG(Aripiprazole)
ABILIFY TAB 2MG(Aripiprazole)
ABILIFY TAB 30MG(Aripiprazole)
ABILIFY TAB 5MG(Aripiprazole)
ABILIFY DISC TAB 10MG(Aripiprazole)
ABILIFY DISC TAB 15MG(Aripiprazole)
acetaminophen w/ codeine soln 120-12 mg/5ml
acetaminophen w/ codeine susp 120-12 mg/5ml
acetaminophen w/ codeine tab 300-15 mg
acetaminophen w/ codeine tab 300-30 mg
acetaminophen w/ codeine tab 300-60 mg
acetaminophen w/ codeine tab 650-30 mg
acetaminophen-caffeine-dihydrocodeine tab 712.8-60-32 mg
ADDERALL TAB 10MG(Amphetamine-Dextroamphetamine)
ADDERALL TAB 12.5MG(Amphetamine-Dextroamphetamine)
ADDERALL TAB 15MG(Amphetamine-Dextroamphetamine)
ADDERALL TAB 20MG(Amphetamine-Dextroamphetamine)
ADDERALL TAB 30MG(Amphetamine-Dextroamphetamine)
ADDERALL TAB 5MG(Amphetamine-Dextroamphetamine)
ADDERALL TAB 7.5MG(Amphetamine-Dextroamphetamine)
ADDERALL XR CAP 10MG(Amphetamine-Dextroamphetamine)
ADDERALL XR CAP 15MG(Amphetamine-Dextroamphetamine)
04
04
04
04
04
04
04
04
04
04
04
04
04
02
04
04
04
04
04
04
04
04
02
02
02
02
02
02
02
02
02
02
01
01
01
01
01
01
01
04
04
04
04
04
04
04
02
02
(STC)
51

Drug Name Drug Tier Notes
ADDERALL XR CAP 20MG(Amphetamine-Dextroamphetamine)
ADDERALL XR CAP 25MG(Amphetamine-Dextroamphetamine)
ADDERALL XR CAP 30MG(Amphetamine-Dextroamphetamine)
ADDERALL XR CAP 5MG(Amphetamine-Dextroamphetamine)
ALCET TAB 10-500MG(Oxycodone w/ Acetaminophen)
AMBIEN TAB 10MG(Zolpidem Tartrate)
AMBIEN TAB 5MG(Zolpidem Tartrate)
AMBIEN CR TAB 12.5MG(Zolpidem Tartrate)
AMBIEN CR TAB 6.25MG(Zolpidem Tartrate)
AMERGE TAB 1MG(Naratriptan HCl)
AMERGE TAB 2.5MG(Naratriptan HCl)
amitriptyline hcl tab 10 mg
amitriptyline hcl tab 100 mg
amitriptyline hcl tab 150 mg
amitriptyline hcl tab 25 mg
amitriptyline hcl tab 50 mg
amitriptyline hcl tab 75 mg
amoxapine tab 100 mg
amoxapine tab 150 mg
amoxapine tab 25 mg
amoxapine tab 50 mg
amphetamine-dextroamphetamine tab 10 mg
amphetamine-dextroamphetamine tab 12.5 mg
amphetamine-dextroamphetamine tab 15 mg
amphetamine-dextroamphetamine tab 20 mg
amphetamine-dextroamphetamine tab 30 mg
amphetamine-dextroamphetamine tab 5 mg
amphetamine-dextroamphetamine tab 7.5 mg
ANAFRANIL CAP 25MG(Clomipramine HCl)
ANAFRANIL CAP 50MG(Clomipramine HCl)
ANAFRANIL CAP 75MG(Clomipramine HCl)
ANAPROX TAB 275MG(Naproxen Sodium)
ANAPROX DS TAB 550MG(Naproxen Sodium)
ANSAID TAB 100MG(Flurbiprofen)
apap-salicylamide-phenyltolox-caffeine cap 325-250-20-50 mg
APOKYN INJ(Apomorphine Hydrochloride)
APPBUTAMONE PAK(Bupropion HCl-Nutritional Supplement)
APPBUTAMONE PAK -D(Bupropion HCl-Nutritional Supplement)
AQUACHLORAL SUP 325MG(Chloral Hydrate)
ARTHROTEC 50 TAB(Diclofenac w/ Misoprostol)
ARTHROTEC 75 TAB(Diclofenac w/ Misoprostol)
aspirin w/ codeine tab 325-30 mg
aspirin w/ codeine tab 325-60 mg
AVINZA CAP 120MG ER(Morphine Sulfate Beads)
AVINZA CAP 30MG ER(Morphine Sulfate Beads)
AVINZA CAP 60MG ER(Morphine Sulfate Beads)
AVINZA CAP 90MG CR(Morphine Sulfate Beads)
AVINZA CAP 90MG ER(Morphine Sulfate Beads)
AXERT TAB 12.5MG(Almotriptan Malate)
AXERT TAB 6.25MG(Almotriptan Malate)
02
02
02
02
04
02
02
02
02
04
04
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
04
04
04
04
04
04
01
04
04
04
04
02
02
01
01
04
04
04
04
04
04
04
52

Drug Name Drug Tier Notes
AZILECT TAB 0.5MG(Rasagiline Mesylate)
AZILECT TAB 1MG(Rasagiline Mesylate)
BALACET 325 TAB(Propoxyphene-N w/ APAP)
BUPRENEX INJ 0.324/ML(Buprenorphine HCl)
buprenorphine hcl inj 0.324 mg/ml (0.3 mg/ml base equiv)
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
bupropion hcl tab 100 mg
bupropion hcl tab 75 mg
bupropion hcl tab sr 12hr 100 mg
bupropion hcl tab sr 12hr 150 mg
bupropion hcl tab sr 12hr 200 mg
bupropion hcl tab sr 24hr 300 mg
bupropion xl tab 300mg
BUSPAR TAB 10MG(Buspirone HCl)
BUSPAR TAB 15MG(Buspirone HCl)
BUSPAR TAB 30MG(Buspirone HCl)
BUSPAR TAB 5MG(Buspirone HCl)
buspirone hcl tab 10 mg
buspirone hcl tab 15 mg
buspirone hcl tab 30 mg
buspirone hcl tab 5 mg
buspirone hcl tab 7.5 mg
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
butorphanol tartrate inj 1 mg/ml
butorphanol tartrate inj 2 mg/ml
butorphanol tartrate nasal soln 10 mg/ml
CAFERGOT TAB 1-100MG(Ergotamine w/ Caffeine)
CAFFEINE/SOD INJ BENZOATE(Caffeine & Sodium Benzoate)
CAMPRAL TAB 333MG(Acamprosate Calcium)
carbamazepine chew tab 100 mg
carbamazepine susp 100 mg/5ml
carbamazepine tab 200 mg
CARBATROL CAP 100MG(Carbamazepine)
CARBATROL CAP 200MG(Carbamazepine)
CARBATROL CAP 300MG(Carbamazepine)
carbidopa & levodopa orally disintegrating tab 10-100 mg
carbidopa & levodopa orally disintegrating tab 25-100 mg
carbidopa & levodopa orally disintegrating tab 25-250 mg
carbidopa & levodopa tab 10-100 mg
carbidopa & levodopa tab 25-100 mg
carbidopa & levodopa tab 25-250 mg
carbidopa & levodopa tab cr 25-100 mg
carbidopa & levodopa tab cr 50-200 mg
carbidopa tab 25 mg
CATAFLAM TAB 50MG(Diclofenac Potassium)
CELEBREX CAP 100MG(Celecoxib)
CELEBREX CAP 200MG(Celecoxib)
CELEBREX CAP 400MG(Celecoxib)
CELEBREX CAP 50MG(Celecoxib)
04
04
02
04
01
01
01
01
01
01
01
01
01
04
04
04
04
01
01
01
01
01
01
01
01
01
01
04
02
02
01
01
01
02
02
02
01
01
01
01
01
01
01
01
01
04
02
02
02
02
(STC)
(STC)
(STC)
(STC)
53

Drug Name Drug Tier Notes
CELEXA SOL 10MG/5ML(Citalopram Hydrobromide)
CELEXA TAB 10MG(Citalopram Hydrobromide)
CELEXA TAB 20MG(Citalopram Hydrobromide)
CELEXA TAB 40MG(Citalopram Hydrobromide)
CELONTIN CAP 300MG(Methsuximide)
CEREBYX INJ 50MG/ML(Fosphenytoin Sodium)
chloral hydrate cap 500 mg
chloral hydrate suppos 500 mg
chloral hydrate syrup 500 mg/5ml
chlordiazepoxide-amitriptyline tab 10-25 mg
chlordiazepoxide-amitriptyline tab 5-12.5 mg
CHLORPROMAZ INJ 25MG/ML(Chlorpromazine HCl)
chlorpromazine hcl tab 10 mg
chlorpromazine hcl tab 100 mg
chlorpromazine hcl tab 200 mg
chlorpromazine hcl tab 25 mg
chlorpromazine hcl tab 50 mg
choline & magnesium salicylates liq 500 mg/5ml
choline & magnesium salicylates tab 1000 mg
choline & magnesium salicylates tab 500 mg
choline & magnesium salicylates tab 750 mg
citalopram hydrobromide oral soln 10 mg/5ml
citalopram hydrobromide tab 10 mg (base equiv)
citalopram hydrobromide tab 20 mg (base equiv)
citalopram hydrobromide tab 40 mg (base equiv)
CLINORIL TAB 200MG(Sulindac)
clomipramine hcl cap 25 mg
clomipramine hcl cap 50 mg
clomipramine hcl cap 75 mg
clozapine tab 100 mg
clozapine tab 200 mg
clozapine tab 25 mg
clozapine tab 50 mg
CLOZARIL TAB 100MG(Clozapine)
CLOZARIL TAB 25MG(Clozapine)
CODEINE PHOS INJ 30MG/2ML(Codeine Phosphate)
CODEINE PHOS INJ 60MG/2ML(Codeine Phosphate)
CODEINE PHOS TAB SOL 30MG(Codeine Phosphate)
CODEINE PHOS TAB SOL 60MG(Codeine Phosphate)
codeine phosphate inj 15 mg/ml
codeine phosphate inj 30 mg/ml
codeine sulfate tab 15 mg
codeine sulfate tab 30 mg
codeine sulfate tab 60 mg
COMBUNOX TAB 5/400MG(Oxycodone-Ibuprofen)
COMTAN TAB 200MG(Entacapone)
CONCERTA TAB 18MG(Methylphenidate HCl)
CONCERTA TAB 27MG(Methylphenidate HCl)
CONCERTA TAB 36MG(Methylphenidate HCl)
CONCERTA TAB 54MG(Methylphenidate HCl)
04
04
04
04
02
04
01
01
01
01
01
02
01
01
01
01
01
01
01
01
01
01
01
01
01
04
01
01
01
01
01
01
01
04
04
04
04
04
04
01
01
01
01
01
04
02
02
02
02
02
54

Drug Name Drug Tier Notes
CYMBALTA CAP 20MG(Duloxetine HCl)
CYMBALTA CAP 30MG(Duloxetine HCl)
CYMBALTA CAP 60MG(Duloxetine HCl)
D.H.E. 45 INJ 1MG/ML(Dihydroergotamine Mesylate)
DARVOCET TAB A500(Propoxyphene-N w/ APAP)
DARVOCET-N TAB 100(Propoxyphene-N w/ APAP)
DARVOCET-N TAB 50(Propoxyphene-N w/ APAP)
DARVON CAP 65MG(Propoxyphene HCl)
DARVON-N TAB 100MG(Propoxyphene Napsylate)
DAYPRO TAB 600MG(Oxaprozin)
DEMEROL INJ 100MG/ML(Meperidine HCl)
DEMEROL INJ 25MG/ML(Meperidine HCl)
DEMEROL INJ 50MG/ML(Meperidine HCl)
DEMEROL INJ 75MG/1.5(Meperidine HCl)
DEMEROL INJ 75MG/ML(Meperidine HCl)
DEMEROL SYP 50MG/5ML(Meperidine HCl)
DEMEROL TAB 100MG(Meperidine HCl)
DEMEROL TAB 50MG(Meperidine HCl)
DEPACON INJ 100MG/ML(Valproate Sodium)
DEPAKENE CAP 250MG(Valproic Acid)
DEPAKENE SYP 250/5ML(Valproate Sodium)
DEPAKOTE TAB 125MG DR(Divalproex Sodium)
DEPAKOTE TAB 250MG DR(Divalproex Sodium)
DEPAKOTE TAB 500MG DR(Divalproex Sodium)
DEPAKOTE ER TAB 250 MG(Divalproex Sodium (Migraine))
DEPAKOTE ER TAB 500MG(Divalproex Sodium (Migraine))
DEPAKOTE SPR CAP 125 MG(Divalproex Sodium)
DEPODUR INJ 10MG/ML(Morphine Sulfate Liposome)
DEPODUR INJ 15/1.5ML(Morphine Sulfate Liposome)
desipramine hcl tab 10 mg
desipramine hcl tab 100 mg
desipramine hcl tab 150 mg
desipramine hcl tab 25 mg
desipramine hcl tab 50 mg
desipramine hcl tab 75 mg
DESOXYN TAB 5MG(Methamphetamine HCl)
DEXEDRINE CAP 10MG(Dextroamphetamine Sulfate)
DEXEDRINE CAP 15MG CR(Dextroamphetamine Sulfate)
DEXEDRINE CAP 5MG CR(Dextroamphetamine Sulfate)
dexmedetomidine hcl inj 100 mcg/ml (for iv infusion)
dexmethylphenidate hcl tab 10 mg
dexmethylphenidate hcl tab 2.5 mg
dexmethylphenidate hcl tab 5 mg
dextroamphetamine sulfate cap sr 24hr 10 mg
dextroamphetamine sulfate cap sr 24hr 15 mg
dextroamphetamine sulfate cap sr 24hr 5 mg
dextroamphetamine sulfate tab 10 mg
dextroamphetamine sulfate tab 5 mg
DEXTROSTAT TAB 10MG(Dextroamphetamine Sulfate)
diclofenac potassium tab 50 mg
02
02
02
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
02
02
02
02
02
02
04
04
01
01
01
01
01
01
04
04
04
04
01
01
01
01
01
01
01
01
01
04
01
55

Drug Name Drug Tier Notes
diclofenac sodium tab delayed release 25 mg
diclofenac sodium tab delayed release 50 mg
diclofenac sodium tab delayed release 75 mg
diclofenac sodium tab sr 24hr 100 mg
diflunisal tab 500 mg
dihydroergotamine mesylate inj 1 mg/ml
DILANTIN CAP 100MG(Phenytoin Sodium Extended)
DILANTIN CAP 100MG(Phenytoin Sodium Extended)
DILANTIN CAP 30MG(Phenytoin Sodium Extended)
DILANTIN CHW 50MG(Phenytoin)
DILANTIN-125 SUS 125/5ML(Phenytoin)
DILAUDID INJ 1MG/ML(Hydromorphone HCl)
DILAUDID INJ 2MG/ML(Hydromorphone HCl)
DILAUDID INJ 4MG/ML(Hydromorphone HCl)
DILAUDID SUP 3MG(Hydromorphone HCl)
DILAUDID TAB 2MG(Hydromorphone HCl)
DILAUDID TAB 4MG(Hydromorphone HCl)
DILAUDID TAB 8MG(Hydromorphone HCl)
DILAUDID-5 LIQ 1MG/ML(Hydromorphone HCl)
DILAUDID-HP INJ 10MG/ML(Hydromorphone HCl)
DILAUDID-HP INJ 250MG(Hydromorphone HCl)
DOLOPHINE TAB 10MG(Methadone HCl)
DOLOPHINE TAB 5MG(Methadone HCl)
doxepin hcl cap 10 mg
doxepin hcl cap 100 mg
doxepin hcl cap 150 mg
doxepin hcl cap 25 mg
doxepin hcl cap 50 mg
doxepin hcl cap 75 mg
doxepin hcl conc 10 mg/ml
droperidol inj 2.5 mg/ml
duloxetine hcl enteric coated pellets cap 60 mg
DURABAC CAP(Acetaminophen-Salicylamide-Phenyltoloxamine-Caffeine)
DURAGESIC DIS 100MCG/H(Fentanyl)
DURAGESIC DIS 12(12.5)(Fentanyl)
DURAGESIC DIS 25MCG/HR(Fentanyl)
DURAGESIC DIS 50MCG/HR(Fentanyl)
DURAGESIC DIS 75MCG/HR(Fentanyl)
EC-NAPROSYN TAB 375MG(Naproxen)
EC-NAPROSYN TAB 500MG(Naproxen)
EFFEXOR TAB 100MG(Venlafaxine HCl)
EFFEXOR TAB 25MG(Venlafaxine HCl)
EFFEXOR TAB 37.5MG(Venlafaxine HCl)
EFFEXOR TAB 50MG(Venlafaxine HCl)
EFFEXOR TAB 75MG(Venlafaxine HCl)
EFFEXOR XR CAP 150MG(Venlafaxine HCl)
EFFEXOR XR CAP 37.5MG(Venlafaxine HCl)
EFFEXOR XR CAP 75MG(Venlafaxine HCl)
ELDEPRYL CAP 5MG(Selegiline HCl)
EMSAM DIS 12MG/24H(Selegiline)
01
01
01
01
01
01
02
04
02
02
02
02
02
02
04
04
04
04
02
02
02
04
04
01
01
01
01
01
01
01
01
01
04
04
04
04
04
04
04
04
02
02
02
02
02
02
02
02
04
02
(PA)
(PA)
(PA)
(PA)
(PA)
(STC)
(STC)
(STC)
(STC)
(STC)
(PA)
56

Drug Name Drug Tier Notes
EMSAM DIS 6MG/24HR(Selegiline)
EMSAM DIS 9MG/24HR(Selegiline)
EQUETRO CAP 100MG(Carbamazepine (Antipsychotic))
EQUETRO CAP 200MG(Carbamazepine (Antipsychotic))
EQUETRO CAP 300MG(Carbamazepine (Antipsychotic))
ergotamine tartrate sl tab 2 mg
ergotamine w/ caffeine tab 1-100 mg
ethosuximide cap 250 mg
ethosuximide soln 250 mg/5ml
etodolac cap 200 mg
etodolac cap 300 mg
etodolac tab 400 mg
etodolac tab 500 mg
etodolac tab sr 24hr 400 mg
etodolac tab sr 24hr 500 mg
etodolac tab sr 24hr 600 mg
FAZACLO TAB 100MG(Clozapine)
FAZACLO TAB 25MG(Clozapine)
FELBATOL SUS 600/5ML(Felbamate)
FELBATOL TAB 400MG(Felbamate)
FELBATOL TAB 600MG(Felbamate)
FELDENE CAP 10MG(Piroxicam)
FELDENE CAP 20MG(Piroxicam)
fenoprofen calcium tab 600 mg
fentanyl citrate 2 mcg/ml-bupivacaine 0.125%-nacl 0.9% inj
fentanyl citrate 2 mcg/ml-bupivacaine hcl 0.1%-nacl 0.9% inj
fentanyl citrate 2 mcg/ml-ropivacaine 0.2%-nacl 0.9% inj
fentanyl citrate 4 mcg/ml-bupivacaine 0.0625%-nacl 0.9% inj
fentanyl citrate 5 mcg/ml-bupivacaine 0.0625%-nacl 0.9% inj
fentanyl citrate 5 mcg/ml-bupivacaine 0.125%-nacl 0.9% inj
fentanyl citrate 5 mcg/ml-bupivacaine hcl 0.1%-nacl 0.9% inj
fentanyl citrate 5 mcg/ml-ropivacaine 0.0625%-nacl 0.9% inj
fentanyl citrate 5 mcg/ml-ropivacaine 0.1%-nacl 0.9% inj
fentanyl citrate 6 mcg/ml-ropivacaine 0.1%-nacl 0.9% inj
fentanyl citrate inj 0.05 mg/ml
fentanyl citrate lollipop 1200 mcg
fentanyl citrate lollipop 1600 mcg
fentanyl citrate lollipop 200 mcg
fentanyl citrate lollipop 400 mcg
fentanyl citrate lollipop 600 mcg
fentanyl citrate lollipop 800 mcg
fentanyl td patch 72hr 100 mcg/hr
fentanyl td patch 72hr 12 (12.5) mcg/hr
fentanyl td patch 72hr 25 mcg/hr
fentanyl td patch 72hr 50 mcg/hr
fentanyl td patch 72hr 75 mcg/hr
FENTORA TAB 100MCG(Fentanyl Citrate)
FENTORA TAB 200MCG(Fentanyl Citrate)
FENTORA TAB 400MCG(Fentanyl Citrate)
FENTORA TAB 600MCG(Fentanyl Citrate)
02
02
04
04
04
01
01
01
01
01
01
01
01
01
01
01
02
02
02
02
02
04
04
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
02
02
02
02
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(STC)
(STC)
(STC)
(STC)
(STC)
(PA)
(PA)
(PA)
(PA)
57

Drug Name Drug Tier Notes
FENTORA TAB 800MCG(Fentanyl Citrate)
FIORICET/COD CAP(Butalbital-Acetaminophen-Caffeine w/ Codeine)
FIORINAL/COD CAP 30MG(Butalbital-Aspirin-Caffeine w/Cod)
fluoxetine hcl cap 10 mg
fluoxetine hcl cap 20 mg
fluoxetine hcl cap 40 mg
fluoxetine hcl solution 20 mg/5ml
fluoxetine hcl tab 10 mg
fluoxetine hcl tab 20 mg
fluphenazine decanoate inj 25 mg/ml
fluphenazine hcl elixir 2.5 mg/5ml
fluphenazine hcl inj 2.5 mg/ml
fluphenazine hcl oral conc 5 mg/ml
fluphenazine hcl tab 1 mg
fluphenazine hcl tab 10 mg
fluphenazine hcl tab 2.5 mg
fluphenazine hcl tab 5 mg
flurbiprofen tab 100 mg
flurbiprofen tab 50 mg
fluvoxamine maleate tab 100 mg
fluvoxamine maleate tab 25 mg
fluvoxamine maleate tab 50 mg
FOCALIN TAB 10MG(Dexmethylphenidate HCl)
FOCALIN TAB 2.5MG(Dexmethylphenidate HCl)
FOCALIN TAB 5MG(Dexmethylphenidate HCl)
FOCALIN XR CAP 10MG(Dexmethylphenidate HCl)
FOCALIN XR CAP 20MG(Dexmethylphenidate HCl)
FOCALIN XR CAP 5MG(Dexmethylphenidate HCl)
FROVA TAB 2.5MG(Frovatriptan Succinate)
gabapentin cap 100 mg
gabapentin cap 300 mg
gabapentin cap 400 mg
gabapentin tab 100 mg
gabapentin tab 300 mg
gabapentin tab 400 mg
gabapentin tab 600 mg
gabapentin tab 800 mg
GABARONE TAB 100MG(Gabapentin)
GABARONE TAB 300MG(Gabapentin)
GABARONE TAB 400MG(Gabapentin)
GABAZOLAMINE PAK(Alprazolam-Nutritional Supplement)
GABITRIL TAB 12MG(Tiagabine HCl)
GABITRIL TAB 16MG(Tiagabine HCl)
GABITRIL TAB 2MG(Tiagabine HCl)
GABITRIL TAB 4MG(Tiagabine HCl)
GABOXETINE PAK(Fluoxetine HCl-Nutritional Supplement)
GEODON CAP 20MG(Ziprasidone HCl)
GEODON CAP 40MG(Ziprasidone HCl)
GEODON CAP 60MG(Ziprasidone HCl)
GEODON CAP 80MG(Ziprasidone HCl)
02
04
04
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
04
04
04
04
04
04
04
01
01
01
01
01
01
01
01
04
04
04
04
02
02
02
02
04
02
02
02
02
(PA)
58

Drug Name Drug Tier Notes
GEODON INJ 20MG(Ziprasidone Mesylate)
HALDOL INJ 5MG/ML(Haloperidol Lactate)
HALDOL DECAN INJ 100MG/ML(Haloperidol Decanoate)
HALDOL DECAN INJ 50MG/ML(Haloperidol Decanoate)
haloperidol decanoate im soln 100 mg/ml
haloperidol decanoate im soln 50 mg/ml
haloperidol lactate inj 5 mg/ml
haloperidol lactate oral conc 2 mg/ml
haloperidol tab 0.5 mg
haloperidol tab 1 mg
haloperidol tab 10 mg
haloperidol tab 2 mg
haloperidol tab 20 mg
haloperidol tab 5 mg
HYCET SOL 7.5-325(Hydrocodone-Acetaminophen)
hydrocodone-acetaminophen cap 5-500 mg
hydrocodone-acetaminophen soln 7.5-500 mg/15ml
hydrocodone-acetaminophen tab 10-325 mg
hydrocodone-acetaminophen tab 10-500 mg
hydrocodone-acetaminophen tab 10-650 mg
hydrocodone-acetaminophen tab 10-660 mg
hydrocodone-acetaminophen tab 10-750 mg
hydrocodone-acetaminophen tab 2.5-500 mg
hydrocodone-acetaminophen tab 5-325 mg
hydrocodone-acetaminophen tab 5-500 mg
hydrocodone-acetaminophen tab 7.5-325 mg
hydrocodone-acetaminophen tab 7.5-500 mg
hydrocodone-acetaminophen tab 7.5-650 mg
hydrocodone-acetaminophen tab 7.5-750 mg
hydrocodone-ibuprofen tab 7.5-200 mg
hydromorphone hcl 20 mcg/ml-bupivacaine 0.06%-nacl 0.9% inj
hydromorphone hcl 20 mcg/ml-bupivacaine 0.125%-nacl 0.9% inj
hydromorphone hcl inj 1 mg/ml
hydromorphone hcl inj 10 mg/ml
hydromorphone hcl inj 2 mg/ml
hydromorphone hcl inj 4 mg/ml
hydromorphone hcl suppos 3 mg
hydromorphone hcl tab 2 mg
hydromorphone hcl tab 4 mg
hydromorphone hcl tab 8 mg
hydromorphone hcl-sodium chloride 0.9% inj 0.2 mg/ml
hydromorphone hcl-sodium chloride 0.9% inj 1 mg/ml
hydroxyzine hcl im soln 25 mg/ml
hydroxyzine hcl im soln 50 mg/ml
hydroxyzine hcl syrup 10 mg/5ml
hydroxyzine hcl tab 10 mg
hydroxyzine hcl tab 25 mg
hydroxyzine hcl tab 50 mg
hydroxyzine pamoate cap 100 mg
hydroxyzine pamoate cap 25 mg
02
04
04
04
01
01
01
01
01
01
01
01
01
01
02
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
59

Drug Name Drug Tier Notes
hydroxyzine pamoate cap 50 mg
ibuprofen tab 400 mg
ibuprofen tab 600 mg
ibuprofen tab 800 mg
imipramine hcl tab 10 mg
imipramine hcl tab 25 mg
imipramine hcl tab 50 mg
imipramine pamoate cap 100 mg
imipramine pamoate cap 125 mg
imipramine pamoate cap 150 mg
imipramine pamoate cap 75 mg
IMITREX INJ 6MG/0.5(Sumatriptan Succinate)
IMITREX KIT 4MG/0.5(Sumatriptan Succinate)
IMITREX KIT 6MG/0.5(Sumatriptan Succinate)
IMITREX KIT RF(Sumatriptan Succinate)
IMITREX SPR 20MG/ACT(Sumatriptan)
IMITREX SPR 5MG/ACT(Sumatriptan)
IMITREX TAB 100MG(Sumatriptan Succinate)
IMITREX TAB 25MG(Sumatriptan Succinate)
IMITREX TAB 50MG(Sumatriptan Succinate)
INAPSINE INJ 2.5MG/ML(Droperidol)
INDOCIN SUS 25MG/5ML(Indomethacin)
INDOCIN IV INJ 1MG(Indomethacin Sodium)
INDOCIN SR CAP 75MG(Indomethacin)
indomethacin cap 25 mg
indomethacin cap 50 mg
indomethacin cap cr 75 mg
INDOMETHACIN SUP 50MG(Indomethacin)
INFUMORPH INJ 10MG/ML(Morphine Sulfate For Continuous
Microinfusion)
INFUMORPH INJ 25MG/ML(Morphine Sulfate For Continuous
Microinfusion)
INVEGA TAB 3MG(Paliperidone)
INVEGA TAB 6MG(Paliperidone)
INVEGA TAB 9MG(Paliperidone)
KADIAN CAP 100MG CR(Morphine Sulfate)
KADIAN CAP 200MG CR(Morphine Sulfate)
KADIAN CAP 20MG CR(Morphine Sulfate)
KADIAN CAP 30MG CR(Morphine Sulfate)
KADIAN CAP 50MG CR(Morphine Sulfate)
KADIAN CAP 60MG CR(Morphine Sulfate)
KADIAN CAP 80MG(Morphine Sulfate)
KEPPRA INJ 500/5ML(Levetiracetam)
KEPPRA SOL 100MG/ML(Levetiracetam)
KEPPRA TAB 1000MG(Levetiracetam)
KEPPRA TAB 250MG(Levetiracetam)
KEPPRA TAB 500MG(Levetiracetam)
KEPPRA TAB 750MG(Levetiracetam)
ketoprofen cap 50 mg
ketoprofen cap 75 mg
01
01
01
01
01
01
01
01
01
01
01
02
02
02
02
02
02
02
02
02
04
04
04
04
01
01
01
04
02
02
02
02
02
02
02
02
02
02
02
02
04
02
02
02
02
02
01
01
(QL)
(QL)
(QL)
(QL)
(QL)
(QL)
(QL)
(QL)
(QL)
(PA)
(PA)
(PA)
(PA)
(PA)
60

Drug Name Drug Tier Notes
ketoprofen cap sr 24hr 200 mg
ketorolac tromethamine im inj 30 mg/ml
ketorolac tromethamine inj 15 mg/ml
ketorolac tromethamine inj 30 mg/ml
ketorolac tromethamine tab 10 mg
LAMICTAL CHW 2MG(Lamotrigine)
LAMICTAL KIT START 35(Lamotrigine)
LAMICTAL KIT START 49(Lamotrigine)
LAMICTAL KIT START 98(Lamotrigine)
LAMICTAL TAB 100MG(Lamotrigine)
LAMICTAL TAB 150MG(Lamotrigine)
LAMICTAL TAB 200MG(Lamotrigine)
LAMICTAL TAB 25MG(Lamotrigine)
lamotrigine tab disp 25 mg
lamotrigine tab disp 5 mg
LEVACET TAB(Aspirin-APAP-Salicyl-Caff)
LEVO DROMORA INJ 2MG/ML(Levorphanol Tartrate)
LEVO-DROMORA TAB 2MG(Levorphanol Tartrate)
levorphanol tartrate tab 2 mg
LEXAPRO SOL 5MG/5ML(Escitalopram Oxalate)
LEXAPRO TAB 10MG(Escitalopram Oxalate)
LEXAPRO TAB 20MG(Escitalopram Oxalate)
LEXAPRO TAB 5MG(Escitalopram Oxalate)
LIMBITROL TAB 5-12.5MG(Chlordiazepoxide-Amitriptyline)
LIMBITROL DS TAB 10-25MG(Chlordiazepoxide-Amitriptyline)
LIQUICET SOL 10-500MG(Hydrocodone-Acetaminophen)
lithium carbonate cap 150 mg
lithium carbonate cap 300 mg
lithium carbonate cap 600 mg
lithium carbonate tab 300 mg
lithium carbonate tab cr 300 mg
lithium carbonate tab cr 450 mg
lithium citrate oral soln 8 meq/5ml
LITHOBID TAB 300MG CR(Lithium Carbonate)
LORCET TAB 10/650(Hydrocodone-Acetaminophen)
LORCET PLUS TAB 7.5-650(Hydrocodone-Acetaminophen)
LORTAB ELX(Hydrocodone-Acetaminophen)
LORTAB 10 TAB(Hydrocodone-Acetaminophen)
LORTAB 2.5 TAB(Hydrocodone-Acetaminophen)
LORTAB 5 TAB(Hydrocodone-Acetaminophen)
LORTAB 7.5 TAB(Hydrocodone-Acetaminophen)
loxapine succinate cap 10 mg
loxapine succinate cap 25 mg
loxapine succinate cap 5 mg
loxapine succinate cap 50 mg
LOXITANE CAP 10MG(Loxapine Succinate)
LOXITANE CAP 25MG(Loxapine Succinate)
LOXITANE CAP 50MG(Loxapine Succinate)
LOXITANE CAP 5MG(Loxapine Succinate)
LUNESTA TAB 1MG(Eszopiclone)
01
01
01
01
01
02
02
04
04
02
02
02
02
01
01
04
04
04
01
02
02
02
02
04
04
02
01
01
01
01
01
01
01
04
04
04
04
04
04
04
04
01
01
01
01
04
04
04
04
02
61

Drug Name Drug Tier Notes
LUNESTA TAB 2MG(Eszopiclone)
LUNESTA TAB 3MG(Eszopiclone)
LYNOX TAB 10-300MG(Oxycodone w/ Acetaminophen)
LYNOX TAB 2.5-300(Oxycodone w/ Acetaminophen)
LYNOX TAB 5-300MG(Oxycodone w/ Acetaminophen)
LYNOX TAB 7.5-300(Oxycodone w/ Acetaminophen)
LYRICA CAP 100MG(Pregabalin)
LYRICA CAP 150MG(Pregabalin)
LYRICA CAP 200MG(Pregabalin)
LYRICA CAP 225MG(Pregabalin)
LYRICA CAP 25MG(Pregabalin)
LYRICA CAP 300MG(Pregabalin)
LYRICA CAP 50MG(Pregabalin)
LYRICA CAP 75MG(Pregabalin)
MAGNACET TAB 10-400MG(Oxycodone w/ Acetaminophen)
MAGNACET TAB 2.5-400(Oxycodone w/ Acetaminophen)
MAGNACET TAB 5-400MG(Oxycodone w/ Acetaminophen)
MAGNACET TAB 7.5-400(Oxycodone w/ Acetaminophen)
magnesium salicylate tab 600 mg
maprotiline hcl tab 25 mg
maprotiline hcl tab 50 mg
maprotiline hcl tab 75 mg
MARPLAN TAB 10MG(Isocarboxazid)
MAXALT TAB 10MG(Rizatriptan Benzoate)
MAXALT TAB 5MG(Rizatriptan Benzoate)
MAXALT-MLT TAB 10MG(Rizatriptan Benzoate)
MAXALT-MLT TAB 5MG(Rizatriptan Benzoate)
MAXIDONE TAB(Hydrocodone-Acetaminophen)
meclofenamate sodium cap 100 mg
meclofenamate sodium cap 50 mg
MEFENAM ACID CAP 250MG(Mefenamic Acid)
meloxicam susp 7.5 mg/5ml
meloxicam tab 15 mg
meloxicam tab 7.5 mg
meperidine hcl inj 10 mg/ml
meperidine hcl inj 100 mg/ml
meperidine hcl inj 25 mg/ml
meperidine hcl inj 50 mg/ml
meperidine hcl inj 75 mg/ml
meperidine hcl oral soln 50 mg/5ml
meperidine hcl tab 100 mg
meperidine hcl tab 50 mg
meperidine hcl-sodium chloride 0.9% inj 10 mg/ml
meperidine hcl-sodium chloride 0.9% iv soln 1000 mg/0.1l
MEPROBAMATE TAB 400MG(Meprobamate)
meprobamate tab 200 mg
meprobamate tab 400 mg
METADATE TAB 10MG ER(Methylphenidate HCl)
METADATE CD CAP 10MG(Methylphenidate HCl)
METADATE CD CAP 20MG(Methylphenidate HCl)
02
02
04
04
04
04
02
02
02
02
02
02
02
02
04
04
04
04
01
01
01
01
02
04
04
04
04
04
01
01
04
01
01
01
01
01
01
01
01
01
01
01
01
01
02
01
01
04
02
02
62

Drug Name Drug Tier Notes
METADATE CD CAP 30MG(Methylphenidate HCl)
methadone hcl conc 10 mg/ml
methadone hcl inj 10 mg/ml
methadone hcl soln 10 mg/5ml
methadone hcl soln 5 mg/5ml
methadone hcl tab 10 mg
methadone hcl tab 5 mg
methadone hcl tab for oral susp 40 mg
METHYLIN CHW 10MG(Methylphenidate HCl)
METHYLIN CHW 2.5MG(Methylphenidate HCl)
METHYLIN CHW 5MG(Methylphenidate HCl)
METHYLIN SOL 10MG/5ML(Methylphenidate HCl)
METHYLIN SOL 5MG/5ML(Methylphenidate HCl)
methylphenidate hcl tab 10 mg
methylphenidate hcl tab 20 mg
methylphenidate hcl tab 5 mg
methylphenidate hcl tab cr 10 mg
methylphenidate hcl tab cr 20 mg
MIGERGOT SUP 2/100(Ergotamine w/ Caffeine)
MIGRANAL SPR 4MG/ML(Dihydroergotamine Mesylate)
MIRAPEX TAB 0.125MG(Pramipexole Dihydrochloride)
MIRAPEX TAB 0.25MG(Pramipexole Dihydrochloride)
MIRAPEX TAB 0.5MG(Pramipexole Dihydrochloride)
MIRAPEX TAB 1.5MG(Pramipexole Dihydrochloride)
MIRAPEX TAB 1MG(Pramipexole Dihydrochloride)
mirtazapine orally disintegrating tab 15 mg
mirtazapine orally disintegrating tab 30 mg
mirtazapine orally disintegrating tab 45 mg
mirtazapine tab 15 mg
mirtazapine tab 30 mg
mirtazapine tab 45 mg
mirtazapine tab 7.5 mg
MOBAN TAB 10MG(Molindone HCl)
MOBAN TAB 25MG(Molindone HCl)
MOBAN TAB 50MG(Molindone HCl)
MOBAN TAB 5MG(Molindone HCl)
MOBIC SUS 7.5/5ML(Meloxicam)
MOBIC TAB 15MG(Meloxicam)
MOBIC TAB 7.5MG(Meloxicam)
morphine sulfate in dextrose iv soln 1 mg/ml
morphine sulfate inj 10 mg/ml
morphine sulfate inj 15 mg/ml
morphine sulfate inj 2 mg/ml
morphine sulfate inj 5 mg/ml
morphine sulfate inj 8 mg/ml
morphine sulfate inj pf 0.5 mg/ml
morphine sulfate inj pf 1 mg/ml
morphine sulfate iv soln 1 mg/ml
morphine sulfate iv soln 25 mg/ml
morphine sulfate iv soln 5 mg/ml
02
01
01
01
01
01
01
01
02
02
02
02
02
01
01
01
01
01
02
02
02
02
02
02
02
01
01
01
01
01
01
01
02
02
02
02
04
04
04
01
01
01
01
01
01
01
01
01
01
01
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
63

Drug Name Drug Tier Notes
morphine sulfate iv soln 50 mg/ml
morphine sulfate oral soln 10 mg/5ml
morphine sulfate oral soln 20 mg/ml
morphine sulfate suppos 10 mg
morphine sulfate suppos 20 mg
morphine sulfate suppos 30 mg
morphine sulfate suppos 5 mg
morphine sulfate tab 15 mg
morphine sulfate tab 30 mg
morphine sulfate tab sol 10 mg
morphine sulfate tab sol 15 mg
morphine sulfate tab sol 30 mg
morphine sulfate tab sr 12hr 100 mg
morphine sulfate tab sr 12hr 15 mg
morphine sulfate tab sr 12hr 200 mg
morphine sulfate tab sr 12hr 30 mg
morphine sulfate tab sr 12hr 60 mg
MORPHINE/D5W INJ 1MG/ML(Morphine Sulfate in Dextrose)
MOTRIN TAB 600MG(Ibuprofen)
MOTRIN TAB 800MG(Ibuprofen)
MS CONTIN TAB 100MG CR(Morphine Sulfate)
MS CONTIN TAB 15MG CR(Morphine Sulfate)
MS CONTIN TAB 200MG CR(Morphine Sulfate)
MS CONTIN TAB 30MG CR(Morphine Sulfate)
MS CONTIN TAB 60MG CR(Morphine Sulfate)
MYSOLINE TAB 250MG(Primidone)
MYSOLINE TAB 50MG(Primidone)
nabumetone tab 500 mg
nabumetone tab 750 mg
nalbuphine hcl inj 10 mg/ml
nalbuphine hcl inj 20 mg/ml
NALFON CAP 200MG(Fenoprofen Calcium)
naloxone hcl inj 0.4 mg/ml
naloxone hcl inj 1 mg/ml
naltrexone hcl tab 50 mg
NAMENDA SOL 10MG/5ML(Memantine HCl)
NAMENDA TAB 10MG(Memantine HCl)
NAMENDA TAB 5-10MG(Memantine HCl)
NAMENDA TAB 5MG(Memantine HCl)
NAPRELAN TAB 375MG CR(Naproxen Sodium)
NAPRELAN TAB 500MG CR(Naproxen Sodium)
NAPROSYN SUS 125/5ML(Naproxen)
NAPROSYN TAB 250MG(Naproxen)
NAPROSYN TAB 375MG(Naproxen)
NAPROSYN TAB 500MG(Naproxen)
naproxen sodium tab 220 mg
naproxen sodium tab 275 mg
naproxen sodium tab 550 mg
naproxen sodium tab sr 24hr 500 mg (base equiv)
naproxen susp 125 mg/5ml
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
04
04
04
04
04
04
04
04
04
04
01
01
01
01
04
01
01
01
02
02
02
02
02
04
04
04
04
04
01
01
01
01
01
(PA)
(PA)
(PA)
64

Drug Name Drug Tier Notes
naproxen tab 250 mg
naproxen tab 375 mg
naproxen tab 500 mg
naproxen tab ec 375 mg
naproxen tab ec 500 mg
NARDIL TAB 15MG(Phenelzine Sulfate)
NAVANE CAP 10MG(Thiothixene)
NAVANE CAP 20MG(Thiothixene)
NAVANE CAP 2MG(Thiothixene)
NAVANE CAP 5MG(Thiothixene)
nefazodone hcl tab 100 mg
nefazodone hcl tab 150 mg
nefazodone hcl tab 200 mg
nefazodone hcl tab 250 mg
nefazodone hcl tab 50 mg
NEOPROFEN SOL 10MG/ML(Ibuprofen Lysine)
NEUPRO DIS 2MG/24HR(Rotigotine)
NEUPRO DIS 4MG/24HR(Rotigotine)
NEUPRO DIS 6MG/24HR(Rotigotine)
NEURONTIN CAP 100MG(Gabapentin)
NEURONTIN CAP 100MG(Gabapentin)
NEURONTIN CAP 300MG(Gabapentin)
NEURONTIN CAP 300MG(Gabapentin)
NEURONTIN CAP 400MG(Gabapentin)
NEURONTIN CAP 400MG(Gabapentin)
NEURONTIN SOL 250/5ML(Gabapentin)
NEURONTIN TAB 600MG(Gabapentin)
NEURONTIN TAB 800MG(Gabapentin)
NORCO TAB 10-325MG(Hydrocodone-Acetaminophen)
NORCO TAB 5-325MG(Hydrocodone-Acetaminophen)
NORCO TAB 7.5-325(Hydrocodone-Acetaminophen)
NORPRAMIN TAB 100MG(Desipramine HCl)
NORPRAMIN TAB 10MG(Desipramine HCl)
NORPRAMIN TAB 150MG(Desipramine HCl)
NORPRAMIN TAB 25MG(Desipramine HCl)
NORPRAMIN TAB 50MG(Desipramine HCl)
NORPRAMIN TAB 75MG(Desipramine HCl)
nortriptyline hcl cap 10 mg
nortriptyline hcl cap 25 mg
nortriptyline hcl cap 50 mg
nortriptyline hcl cap 75 mg
nortriptyline hcl soln 10 mg/5ml
NOVASAL TAB 600MG(Magnesium Salicylate)
NUMORPHAN INJ 1MG/ML(Oxymorphone HCl)
OPANA INJ 1MG/ML(Oxymorphone HCl)
OPANA TAB 10MG(Oxymorphone HCl)
OPANA TAB 5MG(Oxymorphone HCl)
OPANA ER TAB 10MG(Oxymorphone HCl)
OPANA ER TAB 20MG(Oxymorphone HCl)
OPANA ER TAB 40MG(Oxymorphone HCl)
01
01
01
01
01
02
04
02
04
04
01
01
01
01
01
04
04
04
04
02
04
02
04
02
04
02
02
02
04
04
04
04
04
04
04
04
04
01
01
01
01
01
04
04
04
02
02
02
02
02
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
65

Drug Name Drug Tier Notes
OPANA ER TAB 5MG(Oxymorphone HCl)
ORAMORPH SR TAB 100MG(Morphine Sulfate)
ORAMORPH SR TAB 15MG(Morphine Sulfate)
ORAMORPH SR TAB 30MG(Morphine Sulfate)
ORAMORPH SR TAB 60MG(Morphine Sulfate)
ORAP TAB 1MG(Pimozide)
ORAP TAB 2MG(Pimozide)
orphenadrine w/ aspirin & caffeine tab 25-385-30 mg
orphenadrine w/ aspirin & caffeine tab 50-770-60 mg
oxaprozin tab 600 mg
oxycodone hcl cap 5 mg
oxycodone hcl conc 20 mg/ml
oxycodone hcl soln 5 mg/5ml
oxycodone hcl tab 15 mg
oxycodone hcl tab 30 mg
oxycodone hcl tab 5 mg
oxycodone hcl tab sr 12hr 10 mg
oxycodone hcl tab sr 12hr 20 mg
oxycodone hcl tab sr 12hr 40 mg
oxycodone hcl tab sr 12hr 80 mg
oxycodone w/ acetaminophen cap 5-500 mg
oxycodone w/ acetaminophen soln 5-325 mg/5ml
oxycodone w/ acetaminophen tab 10-325 mg
oxycodone w/ acetaminophen tab 10-500 mg
oxycodone w/ acetaminophen tab 10-650 mg
oxycodone w/ acetaminophen tab 5-325 mg
oxycodone w/ acetaminophen tab 5-500 mg
oxycodone w/ acetaminophen tab 7.5-325 mg
oxycodone w/ acetaminophen tab 7.5-500 mg
oxycodone w/ aspirin tab full strength
OXYCONTIN TAB 10MG CR(Oxycodone HCl)
OXYCONTIN TAB 20MG CR(Oxycodone HCl)
OXYCONTIN TAB 40MG CR(Oxycodone HCl)
OXYCONTIN TAB 80MG CR(Oxycodone HCl)
OXYIR CAP 5MG(Oxycodone HCl)
PAMELOR CAP 10MG(Nortriptyline HCl)
PAMELOR CAP 25MG(Nortriptyline HCl)
PAMELOR CAP 50MG(Nortriptyline HCl)
PAMELOR CAP 75MG(Nortriptyline HCl)
PAMELOR SOL 10MG/5ML(Nortriptyline HCl)
PANLOR DC CAP(Acetaminophen-Caff-Dihydrocod)
PANLOR SS TAB(Acetaminophen-Caff-Dihydrocod)
PARNATE TAB 10MG(Tranylcypromine Sulfate)
paroxetine hcl oral susp 10 mg/5ml (base equiv)
paroxetine hcl tab 10 mg
paroxetine hcl tab 20 mg
paroxetine hcl tab 30 mg
paroxetine hcl tab 40 mg
PAXIL SUS 10MG/5ML(Paroxetine HCl)
PAXIL TAB 10MG(Paroxetine HCl)
02
04
04
04
04
02
02
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
02
02
02
02
04
04
04
04
04
04
04
04
04
01
01
01
01
01
04
04
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
66

Drug Name Drug Tier Notes
PAXIL TAB 20MG(Paroxetine HCl)
PAXIL TAB 30MG(Paroxetine HCl)
PAXIL TAB 40MG(Paroxetine HCl)
PAXIL CR TAB 12.5MG(Paroxetine HCl)
PAXIL CR TAB 25MG(Paroxetine HCl)
PAXIL CR TAB 37.5MG(Paroxetine HCl)
PEGANONE TAB 250MG(Ethotoin)
pentazocine w/ apap tab 25-650 mg
pentazocine w/ naloxone tab 50-0.5 mg
PERCOCET TAB 10-325MG(Oxycodone w/ Acetaminophen)
PERCOCET TAB 10-650MG(Oxycodone w/ Acetaminophen)
PERCOCET TAB 2.5-325(Oxycodone w/ Acetaminophen)
PERCOCET TAB 5-325MG(Oxycodone w/ Acetaminophen)
PERCOCET TAB 7.5-325M(Oxycodone w/ Acetaminophen)
PERCOCET TAB 7.5-500(Oxycodone w/ Acetaminophen)
PERCODAN TAB(Oxycodone w/ Aspirin)
PERLOXX TAB 10/300MG(Oxycodone w/ Acetaminophen)
PERLOXX TAB 2.5/300(Oxycodone w/ Acetaminophen)
PERLOXX TAB 5/300MG(Oxycodone w/ Acetaminophen)
PERLOXX TAB 7.5/300(Oxycodone w/ Acetaminophen)
perphenazine tab 16 mg
perphenazine tab 2 mg
perphenazine tab 4 mg
perphenazine tab 8 mg
perphenazine-amitriptyline tab 2-10 mg
perphenazine-amitriptyline tab 2-25 mg
perphenazine-amitriptyline tab 4-25 mg
PEXEVA TAB 10MG(Paroxetine Mesylate)
PEXEVA TAB 20MG(Paroxetine Mesylate)
PEXEVA TAB 30MG(Paroxetine Mesylate)
PEXEVA TAB 40MG(Paroxetine Mesylate)
PHENYTEK CAP 300MG(Phenytoin Sodium Extended)
phenytoin sodium extended cap 100 mg
phenytoin sodium extended cap 200 mg
phenytoin sodium extended cap 300 mg
phenytoin sodium inj 50 mg/ml
phenytoin susp 125 mg/5ml
piroxicam cap 10 mg
piroxicam cap 20 mg
PONSTEL CAP 250MG(Mefenamic Acid)
PREVACID NAP KIT 500MG(Lansoprazole-Naproxen)
primidone tab 250 mg
primidone tab 50 mg
prochlorperazine edisylate inj 5 mg/ml
prochlorperazine maleate tab 10 mg
prochlorperazine maleate tab 5 mg
prochlorperazine suppos 25 mg
propoxyphene hcl cap 65 mg
propoxyphene hcl w/ apap tab 65-650 mg
propoxyphene-n w/ apap tab 100-500 mg
04
04
04
02
02
02
02
01
01
04
04
04
04
04
04
04
04
04
04
04
01
01
01
01
01
01
01
04
04
04
04
04
01
01
01
01
01
01
01
04
04
01
01
01
01
01
01
01
01
01
67

Drug Name Drug Tier Notes
propoxyphene-n w/ apap tab 100-650 mg
propoxyphene-n w/ apap tab 50-325 mg
PROVIGIL TAB 100MG(Modafinil)
PROVIGIL TAB 200MG(Modafinil)
PROZAC CAP 10MG(Fluoxetine HCl)
PROZAC CAP 20MG(Fluoxetine HCl)
PROZAC CAP 40MG(Fluoxetine HCl)
PROZAC SOL 20MG/5ML(Fluoxetine HCl)
PROZAC TAB 10MG(Fluoxetine HCl)
PROZAC WEEKL CAP 90MG(Fluoxetine HCl)
RAPIFLUX TAB 20MG(Fluoxetine HCl)
RELPAX TAB 20MG(Eletriptan Hydrobromide)
RELPAX TAB 40MG(Eletriptan Hydrobromide)
REMERON TAB 15MG(Mirtazapine)
REMERON TAB 30MG(Mirtazapine)
REMERON TAB 45MG(Mirtazapine)
REMERON SLTB TAB 15MG(Mirtazapine)
REMERON SLTB TAB 30MG(Mirtazapine)
REMERON SLTB TAB 45MG(Mirtazapine)
REPREXAIN TAB 5-200MG(Hydrocodone-Ibuprofen)
REQUIP TAB 0.25MG(Ropinirole Hydrochloride)
REQUIP TAB 0.5MG(Ropinirole Hydrochloride)
REQUIP TAB 1MG(Ropinirole Hydrochloride)
REQUIP TAB 2MG(Ropinirole Hydrochloride)
REQUIP TAB 3MG(Ropinirole Hydrochloride)
REQUIP TAB 4MG(Ropinirole Hydrochloride)
REQUIP TAB 5MG(Ropinirole Hydrochloride)
REVEX INJ 100MCG(Nalmefene HCl)
REVEX INJ 1MG/ML(Nalmefene HCl)
REVIA TAB 50MG(Naltrexone HCl)
RID-A-PAIN TAB(Aspirin-APAP-Salicyl-Caff w/Cod)
RILUTEK TAB 50MG(Riluzole)
RISPERDAL INJ 12.5MG(Risperidone Microspheres)
RISPERDAL INJ 25MG(Risperidone Microspheres)
RISPERDAL INJ 37.5MG(Risperidone Microspheres)
RISPERDAL INJ 50MG(Risperidone Microspheres)
RISPERDAL SOL 1MG/ML(Risperidone)
RISPERDAL TAB 0.25MG(Risperidone)
RISPERDAL TAB 0.5MG(Risperidone)
RISPERDAL TAB 1MG(Risperidone)
RISPERDAL TAB 2MG(Risperidone)
RISPERDAL TAB 3MG(Risperidone)
RISPERDAL TAB 4MG(Risperidone)
RISPERDAL M TAB 0.5MG(Risperidone)
RISPERDAL M TAB 1MG(Risperidone)
RISPERDAL M TAB 2MG(Risperidone)
RISPERDAL M TAB 3MG(Risperidone)
RISPERDAL M TAB 4MG(Risperidone)
RITALIN TAB 10MG(Methylphenidate HCl)
RITALIN TAB 20MG(Methylphenidate HCl)
01
01
02
02
04
04
04
04
04
04
04
02
02
04
04
04
04
04
04
04
02
02
02
02
02
02
02
02
02
04
04
02
03
03
03
03
02
02
02
02
02
02
02
02
02
02
04
04
04
04
(PA)
(PA)
(QL)
(QL)
(QL)
68

Drug Name Drug Tier Notes
RITALIN TAB 5MG(Methylphenidate HCl)
RITALIN LA CAP 10MG(Methylphenidate HCl)
RITALIN LA CAP 20MG(Methylphenidate HCl)
RITALIN LA CAP 30MG(Methylphenidate HCl)
RITALIN LA CAP 40MG(Methylphenidate HCl)
RITALIN SR TAB 20MG(Methylphenidate HCl)
ROXANOL SOL 20MG/ML(Morphine Sulfate)
ROXICODONE CON 20MG/ML(Oxycodone HCl)
ROXICODONE SOL 5MG/5ML(Oxycodone HCl)
ROXICODONE TAB 15MG(Oxycodone HCl)
ROXICODONE TAB 30MG(Oxycodone HCl)
ROXICODONE TAB 5MG(Oxycodone HCl)
ROZEREM TAB 8MG(Ramelteon)
salsalate tab 500 mg
salsalate tab 750 mg
SARAFEM CAP 10MG(Fluoxetine HCl (PMDD))
SARAFEM CAP 20MG(Fluoxetine HCl (PMDD))
selegiline hcl cap 5 mg
selegiline hcl tab 5 mg
SENTROXATINE PAK(Fluoxetine HCl-Nutritional Supplement)
SEROQUEL TAB 100MG(Quetiapine Fumarate)
SEROQUEL TAB 200MG(Quetiapine Fumarate)
SEROQUEL TAB 25MG(Quetiapine Fumarate)
SEROQUEL TAB 300MG(Quetiapine Fumarate)
SEROQUEL TAB 400MG(Quetiapine Fumarate)
SEROQUEL TAB 50MG(Quetiapine Fumarate)
SEROQUEL XR TAB 200MG(Quetiapine Fumarate)
SEROQUEL XR TAB 300MG(Quetiapine Fumarate)
SEROQUEL XR TAB 400MG(Quetiapine Fumarate)
sertraline hcl oral conc 20 mg/ml
sertraline hcl tab 100 mg
sertraline hcl tab 25 mg
sertraline hcl tab 50 mg
SINEMET TAB 10/100(Carbidopa-Levodopa)
SINEMET TAB 25/100(Carbidopa-Levodopa)
SINEMET TAB 25/250(Carbidopa-Levodopa)
SINEMET CR TAB 25/100(Carbidopa-Levodopa)
SINEMET CR TAB 50/200(Carbidopa-Levodopa)
SONATA CAP 10MG(Zaleplon)
SONATA CAP 5MG(Zaleplon)
STADOL INJ 2MG/ML(Butorphanol Tartrate)
STALEVO 100 TAB(Carbidopa-Levodopa-Entacapone)
STALEVO 150 TAB(Carbidopa-Levodopa-Entacapone)
STALEVO 50 TAB(Carbidopa-Levodopa-Entacapone)
STRATTERA CAP 100MG(Atomoxetine HCl)
STRATTERA CAP 10MG(Atomoxetine HCl)
STRATTERA CAP 18MG(Atomoxetine HCl)
STRATTERA CAP 25MG(Atomoxetine HCl)
STRATTERA CAP 40MG(Atomoxetine HCl)
STRATTERA CAP 60MG(Atomoxetine HCl)
04
04
04
04
04
04
02
04
04
04
04
04
04
01
01
04
04
01
01
04
02
02
02
02
02
02
04
04
04
01
01
01
01
04
04
04
04
04
02
02
04
04
04
04
02
02
02
02
02
02
(PA)
(QL)
(QL)
(QL)
(QL)
(QL)
(QL)
69

Drug Name Drug Tier Notes
STRATTERA CAP 80MG(Atomoxetine HCl)
SUBLIMAZE INJ 0.05MG/1(Fentanyl Citrate)
SUBOXONE SUB 2-0.5MG(Buprenorphine HCl-Naloxone HCl Dihydrate)
SUBOXONE SUB 8-2MG(Buprenorphine HCl-Naloxone HCl Dihydrate)
SUBUTEX SUB 2MG(Buprenorphine HCl)
SUBUTEX SUB 8MG(Buprenorphine HCl)
SUFENTA INJ 50MCG/ML(Sufentanil Citrate)
sufentanil citrate inj 50 mcg/ml
sulindac tab 150 mg
sulindac tab 200 mg
SURMONTIL CAP 100MG(Trimipramine Maleate)
SURMONTIL CAP 25MG(Trimipramine Maleate)
SURMONTIL CAP 50MG(Trimipramine Maleate)
SYMBYAX CAP 12-25MG(Olanzapine-Fluoxetine HCl)
SYMBYAX CAP 12-50MG(Olanzapine-Fluoxetine HCl)
SYMBYAX CAP 6-25MG(Olanzapine-Fluoxetine HCl)
SYMBYAX CAP 6-50MG(Olanzapine-Fluoxetine HCl)
SYNALGOS DC CAP(Dihydrocodeine Compound)
TALACEN TAB(Pentazocine w/ APAP)
TALWIN INJ 30MG/ML(Pentazocine Lactate)
TALWIN NX TAB(Pentazocine w/ Naloxone)
TASMAR TAB 100MG(Tolcapone)
TASMAR TAB 200MG(Tolcapone)
TEGRETOL CHW 100MG(Carbamazepine)
TEGRETOL SUS 100/5ML(Carbamazepine)
TEGRETOL TAB 200MG(Carbamazepine)
TEGRETOL TAB 200MG(Carbamazepine)
TEGRETOL XR TAB 100MG(Carbamazepine)
TEGRETOL XR TAB 200MG(Carbamazepine)
TEGRETOL XR TAB 400MG(Carbamazepine)
THERACODOPHN PAK -325(Hydrocodone-Acetaminophen-Nutritional
Supplement)
THERACODOPHN PAK -650(Hydrocodone-Acetaminophen-Nutritional
Supplement)
THERACODOPHN PAK -LOW-90(Hydrocodone-Acetaminophen-Nutritional
Supplement)
THERAFELDAMI PAK(Piroxicam-Nutritional Supplement)
THERAPENTIN PAK -60(Gabapentin-Nutritional Supplement)
THERAPENTIN PAK -90(Gabapentin-Nutritional Supplement)
THERAPROFEN PAK -60(Ibuprofen-Nutritional Supplement)
THERAPROFEN PAK -90(Ibuprofen-Nutritional Supplement)
THERAPROXEN PAK(Naproxen-Nutritional Supplement)
THERAPROXEN PAK -90(Naproxen-Nutritional Supplement)
THERATRAMADO PAK -60(Tramadol HCl-Nutritional Supplement)
THERATRAMADO PAK -90(Tramadol HCl-Nutritional Supplement)
thioridazine hcl tab 10 mg
thioridazine hcl tab 100 mg
thioridazine hcl tab 25 mg
thioridazine hcl tab 50 mg
thiothixene cap 1 mg
02
02
04
04
04
04
04
01
01
01
02
04
04
02
02
02
02
04
04
04
04
02
02
02
02
02
04
02
02
02
04
04
04
04
04
04
04
04
04
04
04
04
01
01
01
01
01
(QL)
(PA)
70

Drug Name Drug Tier Notes
thiothixene cap 10 mg
thiothixene cap 2 mg
thiothixene cap 5 mg
THORAZINE SUP 100MG(Chlorpromazine)
THORAZINE TAB 200MG(Chlorpromazine HCl)
TOFRANIL TAB 10MG(Imipramine HCl)
TOFRANIL TAB 25MG(Imipramine HCl)
TOFRANIL TAB 50MG(Imipramine HCl)
TOFRANIL-PM CAP 100MG(Imipramine Pamoate)
TOFRANIL-PM CAP 125MG(Imipramine Pamoate)
TOFRANIL-PM CAP 150MG(Imipramine Pamoate)
TOFRANIL-PM CAP 75MG(Imipramine Pamoate)
tolmetin sodium cap 400 mg
tolmetin sodium tab 200 mg
tolmetin sodium tab 600 mg
TOPAMAX TAB 100MG(Topiramate)
TOPAMAX TAB 200MG(Topiramate)
TOPAMAX TAB 25MG(Topiramate)
TOPAMAX TAB 50MG(Topiramate)
TOPAMAX SPR CAP 15MG(Topiramate)
TOPAMAX SPR CAP 25MG(Topiramate)
tramadol hcl tab 50 mg
tramadol-acetaminophen tab 37.5-325 mg
tranylcypromine sulfate tab 10 mg
TRAZAMINE PAK(Trazodone HCl-Nutritional Supplement)
trazodone hcl tab 100 mg
trazodone hcl tab 150 mg
trazodone hcl tab 300 mg
trazodone hcl tab 50 mg
trifluoperazine hcl tab 1 mg
trifluoperazine hcl tab 10 mg
trifluoperazine hcl tab 2 mg
trifluoperazine hcl tab 5 mg
TRILEPTAL SUS 300MG/5M(Oxcarbazepine)
TRILEPTAL TAB 150MG(Oxcarbazepine)
TRILEPTAL TAB 300MG(Oxcarbazepine)
TRILEPTAL TAB 600MG(Oxcarbazepine)
trimipramine maleate cap 25 mg
trimipramine maleate cap 50 mg
TYLENOL/COD TAB #3(Acetaminophen w/ Codeine)
TYLENOL/COD TAB #4(Acetaminophen w/ Codeine)
TYLOX CAP 5-500MG(Oxycodone w/ Acetaminophen)
ULTRACET TAB(Tramadol-Acetaminophen)
ULTRAM TAB 50MG(Tramadol HCl)
ULTRAM ER TAB 100MG(Tramadol HCl)
ULTRAM ER TAB 200MG(Tramadol HCl)
ULTRAM ER TAB 300MG(Tramadol HCl)
valproate sodium inj 100 mg/ml
valproate sodium syrup 250 mg/5ml
valproic acid cap 250 mg
01
01
01
04
04
04
04
04
04
04
04
04
01
01
01
02
02
02
02
02
02
01
01
01
04
01
01
01
01
01
01
01
01
02
02
02
02
01
01
04
04
04
04
04
04
04
04
01
01
01
71

Drug Name Drug Tier Notes
VANSPAR TAB 7.5MG(Buspirone HCl)
venlafaxine hcl tab 100 mg
venlafaxine hcl tab 25 mg
venlafaxine hcl tab 37.5 mg
venlafaxine hcl tab 50 mg
venlafaxine hcl tab 75 mg
VICODIN TAB 5-500MG(Hydrocodone-Acetaminophen)
VICODIN ES TAB 7.5-750(Hydrocodone-Acetaminophen)
VICOPROFEN TAB(Hydrocodone-Ibuprofen)
VISTARIL CAP 25MG(Hydroxyzine Pamoate)
VISTARIL CAP 50MG(Hydroxyzine Pamoate)
VIVACTIL TAB 10MG(Protriptyline HCl)
VIVACTIL TAB 5MG(Protriptyline HCl)
VOLTAREN TAB 75MG EC(Diclofenac Sodium)
VOLTAREN-XR TAB 100MG(Diclofenac Sodium)
VYVANSE CAP 30MG(Lisdexamfetamine Dimesylate)
VYVANSE CAP 50MG(Lisdexamfetamine Dimesylate)
VYVANSE CAP 70MG(Lisdexamfetamine Dimesylate)
WELLBUTRIN TAB 100MG(Bupropion HCl)
WELLBUTRIN TAB 100MG SR(Bupropion HCl)
WELLBUTRIN TAB 150MG SR(Bupropion HCl)
WELLBUTRIN TAB 200MG SR(Bupropion HCl)
WELLBUTRIN TAB 75MG(Bupropion HCl)
WELLBUTRIN TAB XL 150MG(Bupropion HCl)
WELLBUTRIN TAB XL 300MG(Bupropion HCl)
XODOL TAB 10-300MG(Hydrocodone-Acetaminophen)
XODOL TAB 5-300MG(Hydrocodone-Acetaminophen)
XODOL TAB 7.5-300(Hydrocodone-Acetaminophen)
XYREM SOL 500MG/ML(Sodium Oxybate)
ZARONTIN CAP 250MG(Ethosuximide)
ZARONTIN SOL 250/5ML(Ethosuximide)
ZELAPAR TAB 1.25MG(Selegiline HCl)
ZOLOFT CON 20MG/ML(Sertraline HCl)
ZOLOFT TAB 100MG(Sertraline HCl)
ZOLOFT TAB 25MG(Sertraline HCl)
ZOLOFT TAB 50MG(Sertraline HCl)
zolpidem tartrate tab 10 mg
zolpidem tartrate tab 5 mg
ZOMIG SPR 5MG(Zolmitriptan)
ZOMIG TAB 2.5MG(Zolmitriptan)
ZOMIG TAB 5MG(Zolmitriptan)
ZOMIG ZMT TAB 2.5 MG(Zolmitriptan)
ZOMIG ZMT TAB 5MG(Zolmitriptan)
ZONEGRAN CAP 100MG(Zonisamide)
ZONEGRAN CAP 25MG(Zonisamide)
zonisamide cap 100 mg
zonisamide cap 25 mg
zonisamide cap 50 mg
ZYBAN TAB 150MG SR(Bupropion HCl (Smoking Deterrent))
ZYDONE TAB 10-400MG(Hydrocodone-Acetaminophen)
04
01
01
01
01
01
04
04
04
04
04
02
02
04
04
04
04
04
04
04
04
04
04
02
02
02
04
04
04
04
04
04
04
02
02
02
01
01
02
02
02
02
02
04
04
01
01
01
04
02
(QL)
(QL)
(QL)
(QL)
(QL)
72

Drug Name Drug Tier Notes
ZYDONE TAB 5-400MG(Hydrocodone-Acetaminophen)
ZYDONE TAB 7.5-400(Hydrocodone-Acetaminophen)
ZYPREXA INJ 10MG(Olanzapine)
ZYPREXA TAB 10MG(Olanzapine)
ZYPREXA TAB 15MG(Olanzapine)
ZYPREXA TAB 2.5MG(Olanzapine)
ZYPREXA TAB 20MG(Olanzapine)
ZYPREXA TAB 5MG(Olanzapine)
ZYPREXA TAB 7.5MG(Olanzapine)
ZYPREXA ZYDI TAB 10MG(Olanzapine)
ZYPREXA ZYDI TAB 15MG(Olanzapine)
ZYPREXA ZYDI TAB 20MG(Olanzapine)
ZYPREXA ZYDI TAB 5MG(Olanzapine)
02
02
02
02
02
02
02
02
02
02
02
02
02
Dental Agents
FLUORIDEX GEL SENSITIV(Sodium Fluoride-Potassium Nitrate) 04
Diagnostic Agents
CONRAY INJ 60%(Iothalamate Meglumine)
CONRAY 30 INJ 30%(Iothalamate Meglumine)
CONRAY 43 INJ 43%(Iothalamate Meglumine)
CYSTO-CONRAY INJ II 17.2%(Iothalamate Meglumine)
GASTROMARK SUS 175MCG(Ferumoxsil)
OPTISON INJ(Perflutren Protein-Type A Microspheres)
Electrolytic, Caloric and Water Balance
*amino acid electrolyte infusion 3.5%***
*amino acid electrolyte infusion 8.5%***
*amino acid electrolyte w/cal infusion 4.25% in d25w***
*amino acid infusion 15%***
*amino acid infusion 4.25% in d10w***
*amino acid infusion 4.25% in d20w***
*amino acid infusion 4.25% in d25w***
*amino acid infusion 6%***
*amino acid infusion 8%***
*amino acid infusion 8.5%***
*irrigation solution, physiological**
*parenteral electrolyte conc***
*parenteral electrolyte soln***
*peritoneal dialysis solutions 346 mosm/l**
*peritoneal dialysis solutions 347 mosm/l**
*peritoneal dialysis solutions 396 mosm/l**
*peritoneal dialysis solutions 398 mosm/l**
*peritoneal dialysis solutions 483 mosm/l**
*peritoneal dialysis solutions 485 mosm/l**
*peritoneal dialysis solutions**
ALCOHOL/D5W INJ 5%(Alcohol in D5W)
AMILORIDE TAB 5MG(Amiloride HCl)
amiloride & hydrochlorothiazide tab 5-50 mg
amiloride hcl tab 5 mg
04
04
04
04
04
04
03
03
01
01
03
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
04
04
01
01
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
73

Drug Name Drug Tier Notes
AMINESS INJ 5.2%(Amino Acid Infusion)
AMINOSYN INJ 10%(Amino Acid Infusion)
AMINOSYN INJ 3.5%(Amino Acid Infusion)
AMINOSYN INJ 5%(Amino Acid Infusion)
AMINOSYN INJ 7%(Amino Acid Infusion)
AMINOSYN INJ 8.5%(Amino Acid Infusion)
AMINOSYN 2-M INJ 4.25/D10(Amino Acid Electrolyte Infusion in D10W)
AMINOSYN 7% INJ /LYTES(Amino Acid Electrolyte Infusion)
AMINOSYN II INJ 10%(Amino Acid Infusion)
AMINOSYN II INJ 15%(Amino Acid Infusion)
AMINOSYN II INJ 3.5/D25(Amino Acid Infusion in D25W)
AMINOSYN II INJ 3.5/D5(Amino Acid Infusion in D5W)
AMINOSYN II INJ 5/D25(Amino Acid Electrolyte Infusion in D25W)
AMINOSYN II INJ 7%(Amino Acid Infusion)
AMINOSYN II INJ 8.5%(Amino Acid Infusion)
AMINOSYN IIM INJ 3.5%/D5W(Amino Acid Electrolyte Infusion in D5W)
AMINOSYN M INJ 3.5%(Amino Acid Electrolyte Infusion)
AMINOSYN-HBC INJ 7%(Amino Acid Infusion)
AMINOSYN-PF INJ 10%(Amino Acid Infusion)
AMINOSYN-PF INJ 7%(Amino Acid Infusion)
AMINOSYN-RF INJ 5.2%(Amino Acid Infusion)
AMINOSYN/D25 INJ II 3.5%(Amino Acid Electrolyte w/ Calcium Infusion in
D25W)
AMINOSYN/D25 INJ II 4.25%(Amino Acid Electrolyte w/ Calcium Infusion in
D25W)
AMMONUL INJ 10%(Sod Benzoate & Sod Phenylacetate)
BICITRA SOL(Sodium Citrate & Citric Acid)
bumetanide inj 0.25 mg/ml
bumetanide tab 0.5 mg
bumetanide tab 1 mg
bumetanide tab 2 mg
BUMEX TAB 0.5MG(Bumetanide)
BUMEX TAB 1MG(Bumetanide)
BUMEX TAB 2MG(Bumetanide)
BUPHENYL TAB 500MG(Sodium Phenylbutyrate)
chlorothiazide tab 250 mg
chlorothiazide tab 500 mg
chlorthalidone tab 100 mg
chlorthalidone tab 15 mg
chlorthalidone tab 25 mg
chlorthalidone tab 50 mg
CITROLITH TAB(Potassium & Sodium Citrates)
CLINIMIX INJ 2.75/D5W(Amino Acid Infusion)
CLINIMIX INJ 4.25/D5W(Amino Acid Infusion in D5W)
CLINIMIX INJ 5%/D15W(Amino Acid Infusion in D15W)
02
02
02
02
02
02
02
03
02
02
02
02
02
02
02
02
03
02
02
02
02
02
02
04
04
01
01
01
01
04
04
04
04
01
01
01
01
01
01
04
02
02
02
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
74

Drug Name Drug Tier Notes
CLINIMIX INJ 5%/D20W(Amino Acid Infusion in D20W)
CLINIMIX INJ 5%/D25W(Amino Acid Infusion in D25W)
CLINIMIX E INJ 2.75/D10(Amino Acid Electrolyte w/ Calcium Infusion in
D10W)
CLINIMIX E INJ 2.75/D5W(Amino Acid Electrolyte w/ Calcium Infusion in
D5W)
CLINIMIX E INJ 4.25/D5W(Amino Acid Electrolyte w/ Calcium Infusion in
D5W)
CLINIMIX E INJ 4.25/D5W(Amino Acid Electrolyte w/ Calcium Infusion in
D5W)
CLINIMIX E INJ 5%/D15W(Amino Acid Electrolyte w/ Calcium Infusion in
D15W)
CLINIMIX E INJ 5%/D20W(Amino Acid Electrolyte w/ Calcium Infusion in
D20W)
CLINIMIX E INJ 5%/D25W(Amino Acid Electrolyte w/ Calcium Infusion in
D25W)
CLINIMIX E INJ 5%/D35W(Amino Acid Electrolyte w/ Calcium Infusion in
D35W)
colchicine w/ probenecid tab 0.5-500 mg
D5W/NACL INJ 0.225%(Dextrose w/ Sodium Chloride)
DEMADEX INJ 50MG/5ML(Torsemide)
DEMADEX TAB 100MG(Torsemide)
DEMADEX TAB 10MG(Torsemide)
DEMADEX TAB 20MG(Torsemide)
DEMADEX TAB 5MG(Torsemide)
dextrose 10% w/ sodium chloride 0.2%
dextrose 10% w/ sodium chloride 0.9%
dextrose 2.5% in lactated ringers 1/2 strength
dextrose 2.5% w/ sodium chloride 0.45%
dextrose 5% in lactated ringers
dextrose 5% w/ sodium chloride 0.2%
dextrose 5% w/ sodium chloride 0.33%
dextrose 5% w/ sodium chloride 0.45%
dextrose 5% w/ sodium chloride 0.9%
dextrose inj 10%
dextrose inj 2.5%
dextrose inj 5%
DIANEAL SOL LOW CALC(Peritoneal Dialysis Solutions)
DIANEAL SOL LOW CALC(Peritoneal Dialysis Solutions)
DIANEAL SOL LOW CALC(Peritoneal Dialysis Solutions)
DIANEAL PD-2 SOL 1.5% DEX(Peritoneal Dialysis Solutions)
DIANEAL PD-2 SOL 2.5% DEX(Peritoneal Dialysis Solutions)
DIANEAL PD-2 SOL 3.5% DEX(Peritoneal Dialysis Solutions)
DIANEAL PD-2 SOL 4.25%DEX(Peritoneal Dialysis Solutions)
DIURIL SUS 250/5ML(Chlorothiazide)
DIURIL IV INJ 500MG(Chlorothiazide Sodium)
DYAZIDE CAP 37.5-25(Triamterene & Hydrochlorothiazide)
DYRENIUM CAP 100MG(Triamterene)
DYRENIUM CAP 50MG(Triamterene)
EDECRIN TAB 25MG(Ethacrynic Acid)
02
02
02
02
02
02
02
02
02
02
01
02
02
04
04
04
04
01
01
01
01
01
01
01
01
01
01
01
01
04
04
04
04
04
04
04
02
04
04
04
04
04
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
75

Drug Name Drug Tier Notes
fat emulsion iv soln 10%
fat emulsion iv soln 20%
fat emulsion iv soln 30%
FOSRENOL CHW 1000MG(Lanthanum Carbonate)
FOSRENOL CHW 250MG(Lanthanum Carbonate)
FOSRENOL CHW 500MG(Lanthanum Carbonate)
FOSRENOL CHW 750MG(Lanthanum Carbonate)
FREAMINE III INJ 10%(Amino Acid Infusion)
FREAMINE III INJ 3%(Amino Acid Electrolyte Infusion)
FREAMINE III INJ 8.5%/D50(Amino Acid Infusion)
furosemide inj 10 mg/ml
furosemide oral soln 10 mg/ml
furosemide oral soln 8 mg/ml
furosemide tab 20 mg
furosemide tab 40 mg
furosemide tab 80 mg
HYDROCHLOROT TAB 12.5MG(Hydrochlorothiazide)
hydrochlorothiazide cap 12.5 mg
hydrochlorothiazide tab 25 mg
hydrochlorothiazide tab 50 mg
HYSKON SOL(Dextran 70/Dextrose)
indapamide tab 1.25 mg
indapamide tab 2.5 mg
INTRALIPID INJ 30%(Fat Emulsion)
invert sugar inj 10%
K-LOR POW 20MEQ(Potassium Chloride)
K-LOR POW 20MEQ(Potassium Chloride)
K-LYTE DS TAB 50MEQ OR(Potassium Bicarbonate)
K-LYTE-ORANG TAB 25MEQ EF(Potassium Bicarbonate)
K-LYTE/CL TAB CITRUS(Potassium Bicarb & Chloride)
K-LYTE/CL TAB FRUIT(Potassium Bicarb & Chloride)
K-PHOS TAB MF(Potassium & Sodium Acid Phosphates)
K-PHOS TAB NO 2(Potassium & Sodium Acid Phosphates)
K-TABS TAB 10MEQ CR(Potassium Chloride)
KAYEXALATE POW(Sodium Polystyrene Sulfonate)
KLOR-CON M15 TAB(Potassium Chloride Microencapsulated Crystals CR)
KLOR-CON-25 POW 25MEQ(Potassium Chloride)
KRISTALOSE PAK 10GM(Lactulose)
KRISTALOSE PAK 20GM(Lactulose)
lactated ringer`s for irrigation
lactated ringer`s solution
lactulose (encephalopathy) solution 10 gm/15ml
lactulose solution 10 gm/15ml
LASIX TAB 20MG(Furosemide)
LASIX TAB 40MG(Furosemide)
LASIX TAB 80MG(Furosemide)
LIPOSYN II INJ 10%(Fat Emulsion)
LIPOSYN II INJ 20%(Fat Emulsion)
LIPOSYN III INJ 10%(Fat Emulsion)
LIPOSYN III INJ 20%(Fat Emulsion)
01
01
01
04
04
04
04
02
03
02
01
01
01
01
01
01
02
01
01
01
04
01
01
04
01
04
04
02
04
04
04
04
04
04
04
02
02
02
02
01
01
01
01
04
04
04
04
04
04
04
(PA)
(PA)
(PA)
(PA)
(PA)
76

Drug Name Drug Tier Notes
LITHOSTAT TAB 250MG(Acetohydroxamic Acid)
MAXZIDE TAB 75-50(Triamterene & Hydrochlorothiazide)
MAXZIDE-25 TAB(Triamterene & Hydrochlorothiazide)
metolazone tab 10 mg
metolazone tab 2.5 mg
metolazone tab 5 mg
MICRO-K CAP 10MEQ CR(Potassium Chloride)
MICRO-K CAP 8MEQ CR(Potassium Chloride)
MICROZIDE CAP(Hydrochlorothiazide)
NEPHRAMINE INJ 5.4%(Amino Acid Infusion)
ORACIT SOL(Sodium Citrate & Citric Acid)
PHOSLO CAP 667MG(Calcium Acetate (Phosphate Binder))
PHYSIOSOL SOL IRRIGAT(Irrigation Solutions, Physiological)
POLYCITRA SYP(Pot & Sod Citrates w/Citric Ac)
POLYCITRA-K POW CRYSTALS(Potassium Citrate-Citric Acid)
POLYCITRA-K SOL(Potassium Citrate-Citric Acid)
POLYCITRA-LC SOL(Pot & Sod Citrates w/Citric Ac)
pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml
pot & sod citrates w/ cit ac syrup 550-500-334 mg/5ml
pot bicarbonate & chloride effer tab 25 meq
POT CHLORIDE INJ 10MEQ(Potassium Chloride)
POT CHLORIDE INJ 20MEQ(Potassium Chloride)
POT CHLORIDE INJ 30MEQ(Potassium Chloride)
POT CHLORIDE INJ 40MEQ(Potassium Chloride)
potassium bicarbonate effer tab 25 meq
potassium chloride cap cr 10 meq
potassium chloride inj 10 meq/100 ml
potassium chloride inj 2 meq/ml
potassium chloride inj 20 meq/50 ml
potassium chloride inj 30 meq/100 ml
potassium chloride inj 40 meq/100 ml
potassium chloride microencapsulated crys cr tab 10 meq
potassium chloride microencapsulated crys cr tab 20 meq
potassium chloride oral liq 10% (20 meq/15ml)
potassium chloride oral liq 20% (40 meq/15ml)
potassium chloride powder packet 20 meq
potassium chloride tab cr 10 meq
potassium chloride tab cr 8 meq (600 mg)
potassium citrate & citric acid powder pack 3300-1002 mg
potassium citrate & citric acid soln 1100-334 mg/5ml
potassium citrate tab cr 1080 mg (10 meq)
potassium citrate tab cr 540 mg (5 meq)
PREMASOL SOL 10%(Amino Acid Infusion)
probenecid tab 500 mg
PROCALAMINE INJ 3%(Amino Acid Electrolyte Infusion)
RENAGEL TAB 400MG(Sevelamer HCl)
RENAGEL TAB 800MG(Sevelamer HCl)
RENAMIN INJ 6.5%(Amino Acid Infusion)
ringer`s solution for irrigation
saline injection bacteriostatic
02
04
04
01
01
01
04
02
04
02
04
02
04
04
04
04
04
01
01
01
04
04
04
04
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
02
01
03
02
02
02
01
01
(PA)
(PA)
(PA)
(PA)
77

Drug Name Drug Tier Notes
saline injection w/ benzyl alcohol
SHOHL`S SOL MODIFIED(Sodium Citrate & Citric Acid)
SOD CHLORIDE INJ 23.4%(Sodium Chloride)
SOD EDECRIN INJ 50MG(Ethacrynate Sodium)
sodium chloride inj 0.45%
sodium chloride inj 3%
sodium chloride inj 4 meq/ml (23.4%)
sodium chloride inj 5%
sodium chloride irrigation soln 0.45%
sodium chloride irrigation soln 0.9%
sodium chloride iv soln 0.9%
sodium citrate & citric acid soln 500-334 mg/5ml
sodium polystyrene sulfonate oral susp 15 gm/60ml
sodium polystyrene sulfonate powder
sodium polystyrene sulfonate rectal susp 30 gm/120ml
torsemide tab 10 mg
torsemide tab 100 mg
torsemide tab 20 mg
torsemide tab 5 mg
TRAVASOL INJ 10%(Amino Acid Infusion)
TRAVASOL INJ 5.5%(Amino Acid Infusion)
TRAVASOL 5.5 INJ /LYTES(Amino Acid Electrolyte Infusion)
TRAVASOL/D10 INJ 2.75%(Amino Acid Electrolyte Infusion in D10W)
TRAVASOL/D10 INJ 4.25%(Amino Acid Electrolyte Infusion in D10W)
TRAVASOL/D10 INJ 5.5%(Amino Acid Infusion in D10W)
TRAVASOL/D10 INJ 8.5%(Amino Acid Infusion in D10W)
TRAVASOL/D20 INJ 5.5%(Amino Acid Infusion in D20W)
TRAVASOL/D20 INJ 8.5%(Amino Acid Infusion in D20W)
TRAVASOL/D25 INJ 4.25%(Amino Acid Electrolyte Infusion in D25W)
TRAVASOL/D5 INJ 2.75%(Amino Acid Electrolyte Infusion in D5W)
TRAVASOL/D5 INJ 4.25%(Amino Acid Electrolyte Infusion in D5W)
TRAVASOL/D50 INJ 8.5%(Amino Acid Infusion in D50W)
triamterene & hydrochlorothiazide cap 37.5-25 mg
triamterene & hydrochlorothiazide cap 50-25 mg
triamterene & hydrochlorothiazide tab 37.5-25 mg
triamterene & hydrochlorothiazide tab 75-50 mg
TROPHAMINE INJ 10%(Amino Acid Infusion)
TROPHAMINE INJ 6%(Amino Acid Infusion)
ULTRABAG/ SOL DIANEAL(Peritoneal Dialysis Solutions)
ULTRABAG/PD2 SOL DIANEAL(Peritoneal Dialysis Solutions)
ULTRABAG/PD2 SOL DIANEAL(Peritoneal Dialysis Solutions)
ULTRABAG/PD2 SOL DIANEAL(Peritoneal Dialysis Solutions)
UROCIT-K 10 TAB(Potassium Citrate (Alkalinizer))
UROCIT-K 5 TAB(Potassium Citrate (Alkalinizer))
water for irrigation, sterile irrigation soln
ZAROXOLYN TAB 10MG(Metolazone)
ZAROXOLYN TAB 2.5MG(Metolazone)
ZAROXOLYN TAB 5MG(Metolazone)
01
04
02
04
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
02
02
03
02
02
03
03
02
02
02
02
02
02
01
01
01
01
02
02
04
04
04
04
04
04
01
04
04
04
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
78

Drug Name Drug Tier Notes
Enzymes
ALDURAZYME INJ 2.9MG/5M(Laronidase)
CEREDASE INJ 10UNT/ML(Alglucerase)
CEREDASE INJ 80UNT/ML(Alglucerase)
ELAPRASE INJ 6MG/3ML(Idursulfase)
ELITEK INJ 1.5MG(Rasburicase)
ELITEK INJ 7.5MG(Rasburicase)
FABRAZYME INJ 35MG(Agalsidase beta)
FABRAZYME INJ 5MG(Agalsidase beta)
MYOZYME SOL 50MG(Alglucosidase Alfa)
NAGLAZYME INJ 1MG/ML(Galsulfase)
PULMOZYME SOL 1MG/ML(Dornase Alfa)
SUCRAID SOL 8500/ML(Sacrosidase)
Respiratory Tract Agents
ACCOLATE TAB 10MG(Zafirlukast)
ACCOLATE TAB 20MG(Zafirlukast)
acetylcysteine inhal soln 10%
acetylcysteine inhal soln 20%
ATROVENT NAS SOL 0.03%(Ipratropium Bromide (Nasal))
ATROVENT NAS SOL 0.06%(Ipratropium Bromide (Nasal))
cromolyn sodium soln nebu 20 mg/2ml
G/P TAB 1200-75(Pseudoephedrine-Guaifenesin)
GFN800/PSE60 TAB(Pseudoephedrine-Guaifenesin)
HISTEX DA TAB 60-500MG(Pseudoephedrine-Guaifenesin)
INTAL NEB 20MG/2ML(Cromolyn Sodium)
INTAL INH AER 800MCG(Cromolyn Sodium)
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
LEVALL G CAP 90-400MG(Pseudoephedrine-Guaifenesin)
MAXIFED TAB 80-780MG(Pseudoephedrine-Guaifenesin)
MAXIFED-G TAB 60-580CR(Pseudoephedrine-Guaifenesin)
MUCOMYST-10 SOL 10%(Acetylcysteine)
NASATAB LA TAB(Pseudoephedrine-Guaifenesin)
PROFEN II TAB 45-800MG(Pseudoephedrine-Guaifenesin)
PSE-GG TAB 90-800MG(Pseudoephedrine-Guaifenesin)
pseudoephedrine-guaifenesin cap cr 120-250 mg
pseudoephedrine-guaifenesin cap cr 60-300 mg
pseudoephedrine-guaifenesin cap sr 12hr 120-400 mg
pseudoephedrine-guaifenesin cap sr 12hr 90-400 mg
pseudoephedrine-guaifenesin liqd 5-50 mg/ml
pseudoephedrine-guaifenesin syrup 40-200 mg/5ml
pseudoephedrine-guaifenesin tab sr 12hr 120-1200 mg
pseudoephedrine-guaifenesin tab sr 12hr 120-600 mg
pseudoephedrine-guaifenesin tab sr 12hr 45-600 mg
pseudoephedrine-guaifenesin tab sr 12hr 45-800 mg
pseudoephedrine-guaifenesin tab sr 12hr 48-595 mg
pseudoephedrine-guaifenesin tab sr 12hr 50-1200 mg
pseudoephedrine-guaifenesin tab sr 12hr 60-1000 mg
04
04
04
02
04
02
03
03
02
04
02
04
02
02
01
01
04
04
01
02
02
04
02
02
01
01
04
04
04
02
02
04
02
01
01
01
01
01
01
01
01
01
01
01
01
01
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
79

Drug Name Drug Tier Notes
pseudoephedrine-guaifenesin tab sr 12hr 60-1200 mg
pseudoephedrine-guaifenesin tab sr 12hr 60-500 mg
pseudoephedrine-guaifenesin tab sr 12hr 60-580 mg
pseudoephedrine-guaifenesin tab sr 12hr 60-600 mg
pseudoephedrine-guaifenesin tab sr 12hr 80-700 mg
pseudoephedrine-guaifenesin tab sr 12hr 80-780 mg
pseudoephedrine-guaifenesin tab sr 12hr 80-800 mg
pseudoephedrine-guaifenesin tab sr 12hr 85-795 mg
SINGULAIR CHW 4MG(Montelukast Sodium)
SINGULAIR CHW 5MG(Montelukast Sodium)
SINGULAIR GRA 4MG(Montelukast Sodium)
SINGULAIR TAB 10MG(Montelukast Sodium)
TILADE AER 1.75/ACT(Nedocromil Sodium)
TUSNEL PEDI DRO 5-10MG/M(Pseudoephedrine-Guaifenesin)
XOLAIR SOL 150MG(Omalizumab)
ZYFLO TAB 600MG(Zileuton)
Eye, Ear, Nose & Throat Preparations
*acetic ac-al acetate-boric ac-propylene glycol otic soln**
acetic acid 2% in aluminum acetate otic soln
acetic acid otic soln 2%
ACULAR SOL 0.5% OP(Ketorolac Tromethamine (Ophth))
ACULAR LS SOL 0.4%(Ketorolac Tromethamine (Ophth))
ACULAR PF SOL 0.5% OP(Ketorolac Tromethamine (Ophth))
ALAMAST DRO 0.1%(Pemirolast Potassium)
ALBALON SOL LIQUIFLM(Naphazoline HCl)
ALCAINE SOL 0.5% OP(Proparacaine HCl)
ALOCRIL SOL 2%(Nedocromil Sodium (Ophth))
ALOMIDE SOL 0.1% OP(Lodoxamide Tromethamine)
ALPHAGAN P SOL 0.1%(Brimonidine Tartrate)
ALPHAGAN P SOL 0.15%(Brimonidine Tartrate)
ALREX SUS 0.2%(Loteprednol Etabonate)
ASTELIN NASA SPR 137MCG(Azelastine HCl)
atropine sulfate ophth oint 1%
atropine sulfate ophth soln 1%
AZASITE SOL 1%(Azithromycin (Ophth))
AZOPT SUS 1% OP(Brinzolamide)
bacitracin ophth oint 500 unit/gm
bacitracin-polymyxin b ophth oint
bacitracin-polymyxin-neomycin-hc ophth oint 1%
BECONASE AQ SUS 0.042%(Beclomethasone Diprop Monohyd)
benzocaine otic soln 20%
benzocaine-antipyrine otic soln 1.4-5.4%
benzocaine-pe-antipyrine otic soln
BETAGAN SOL 0.25% OP(Levobunolol HCl)
BETAGAN SOL 0.5% OP(Levobunolol HCl)
betaxolol hcl ophth soln 0.5%
BETIMOL SOL 0.25%(Timolol)
BETIMOL SOL 0.5%(Timolol)
BETOPTIC-S SUS 0.25% OP(Betaxolol HCl (Ophth))
01
01
01
01
01
01
01
01
02
02
02
02
02
04
02
02
01
01
01
02
02
02
02
04
04
04
02
02
02
04
02
01
01
04
02
01
01
01
04
01
01
01
04
04
01
02
02
02
(PA)
(PA)
80

Drug Name Drug Tier Notes
BLEPH-10 SOL 10% OP(Sulfacetamide Sodium (Ophth))
BLEPHAMIDE SUS OP(Sulfacetamide Sod-Prednisolone)
brimonidine tartrate ophth soln 0.2%
CAPHOSOL SOL(Artificial Saliva)
carbachol intraocular inj 0.01%
carbachol ophth soln 3%
carteolol hcl ophth soln 1%
CELLUGEL SOL 2%(Hydroxypropyl Methylcellulose (Intraocular))
chlorhexidine gluconate soln 0.12%
CILOXAN OIN 0.3% OP(Ciprofloxacin HCl (Ophth))
CILOXAN SOL 0.3% OP(Ciprofloxacin HCl (Ophth))
CIPRO HC SUS OTIC(Ciprofloxacin-Hydrocortisone)
CIPRODEX SUS 0.3-0.1%(Ciprofloxacin-Dexamethasone)
ciprofloxacin hcl ophth soln 0.3%
COLY-MYCIN-S SUS OTIC(Neomycin-Colistin-HC)
CORTISPORIN SOL 1% OTIC(Neomycin-Polymyxin-HC (Otic))
CORTISPORIN SUS -TC OTIC(Neomycin-Colistin-HC-Thonzonium)
CORTISPORIN SUS 1% OTIC(Neomycin-Polymyxin-HC (Otic))
CORTISPORIN SUS OP 1%(Neomycin-Polymyxin-HC (Ophth))
COSOPT SOL 2-0.5%OP(Dorzolamide-Timolol)
CRESYLATE SOL 25% OTIC(Cresyl Acetate)
CROLOM SOL 4% OP(Cromolyn Sodium (Ophth))
cromolyn sodium ophth soln 4%
CYCLOGYL SOL 0.5% OP(Cyclopentolate HCl)
CYCLOGYL SOL 1% OP(Cyclopentolate HCl)
CYCLOGYL SOL 2% OP(Cyclopentolate HCl)
cyclopentolate hcl ophth soln 1%
DEBACTEROL SOL 30-50%(Sulfuric Acid-Sulfonated Phenolics)
DERMOTIC OIL 0.01%(Fluocinolone Acetonide (Otic))
dexamethasone sodium phosphate ophth soln 0.1%
dipivefrin hcl ophth soln 0.1%
DUOVISC KIT 0.35/0.4(Na Hyaluronate & Na Chondroitin Sulfate-Na
Hyaluronate)
DUOVISC KIT 0.5/0.55(Na Hyaluronate & Na Chondroitin Sulfate-Na
Hyaluronate)
ECONOPRED PL SUS 1% OP(Prednisolone Acetate (Ophth))
ELESTAT DRO 0.05%(Epinastine HCl (Ophth))
EMADINE SOL 0.05% OP(Emedastine Difumarate)
erythromycin ophth oint 5 mg/gm
FLAREX SUS 0.1% OP(Fluorometholone Acetate)
FLONASE SPR 0.05%(Fluticasone Propionate (Nasal))
FLOXIN OTIC SOL 0.3%(Ofloxacin (Otic))
FLOXIN OTIC SOL SINGLES(Ofloxacin (Otic))
flunisolide nasal soln 0.025%
fluorometholone ophth susp 0.1%
flurbiprofen sodium ophth soln 0.03%
fluticasone propionate nasal susp 50 mcg/act
FML FORTE SUS 0.25% OP(Fluorometholone (Ophth))
FML LIQUIFLM SUS 0.1% OP(Fluorometholone (Ophth))
FML S.O.P. OIN 0.1% OP(Fluorometholone (Ophth))
04
02
01
04
01
01
01
04
01
04
04
04
04
01
04
04
04
04
04
04
04
04
01
04
04
04
01
04
04
01
01
04
04
04
04
04
01
04
04
02
02
01
01
01
01
02
04
02
81

Drug Name Drug Tier Notes
gentamicin sulfate ophth oint 0.3%
gentamicin sulfate ophth soln 0.3%
homatropine hbr ophth soln 5%
hydrocortisone w/ acetic acid otic soln 1-2%
IOPIDINE SOL 0.5% OP(Apraclonidine HCl)
IOPIDINE SOL 1% OP(Apraclonidine HCl)
ISO ATROPINE SOL 1% OP(Atropine Sulfate (Ophthalmic))
ISO CARBACHO SOL 1.5% OP(Carbachol (Ophth))
ISO CARBACHO SOL 3% OP(Carbachol (Ophth))
ISO HOMATROP SOL 2% OP(Homatropine HBr)
ISO HOMATROP SOL 5% OP(Homatropine HBr)
ISO HYOSCINE SOL 0.25% OP(Scopolamine HBr (Ophth))
ISOPTO CARP SOL 1% OP(Pilocarpine HCl)
ISOPTO CARP SOL 2% OP(Pilocarpine HCl)
ISOPTO CARP SOL 4% OP(Pilocarpine HCl)
ISTALOL SOL 0.5% OP(Timolol Maleate (Ophth))
ketotifen fumarate ophth soln 0.025% (base equiv)
LACRISERT MIS 5MG OP(Artificial Tear Insert)
levobunolol hcl ophth soln 0.25%
levobunolol hcl ophth soln 0.5%
lidocaine hcl viscous soln 2%
LOTEMAX SUS 0.5%(Loteprednol Etabonate)
LUCENTIS SOL(Ranibizumab)
LUMIGAN SOL 0.03%(Bimatoprost)
MACUGEN INJ(Pegaptanib Sodium)
MAXIDEX SUS 0.1% OP(Dexamethasone (Ophth))
MAXITROL OIN 0.1% OP(Neomycin-Polymy-Dexameth)
MAXITROL SUS 0.1% OP(Neomycin-Polymy-Dexameth)
metipranolol ophth soln 0.3%
MIOSTAT SOL 0.01% OP(Carbachol (Ophth))
MYDRIACYL SOL 1% OP(Tropicamide)
naphazoline hcl ophth soln 0.1%
NASACORT AQ AER 55MCG/AC(Triamcinolone Acetonide (Nasal))
NASAREL SPR 29MCG(Flunisolide (Nasal))
NASONEX SPR 50MCG/AC(Mometasone Furoate (Nasal))
NATACYN SUS 5% OP(Natamycin)
neomycin-bacitrac zn-polymyx 3.5(5)mg-400unt-10000unt op oin
neomycin-polymyxin b-gramicidin ophth soln
neomycin-polymyxin-dexamethasone ophth oint 0.1%
neomycin-polymyxin-dexamethasone ophth susp 0.1%
neomycin-polymyxin-hc ophth susp
neomycin-polymyxin-hc otic soln 1%
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%
NEOSPORIN SOL OP(Neomycin-Polymy-Gramicid)
NEVANAC SUS 0.1%(Nepafenac)
NUMOISYN LIQ(Artificial Saliva)
OCUFEN SOL 0.03% OP(Flurbiprofen Sodium)
OCUFLOX SOL 0.3% OP(Ofloxacin (Ophth))
ofloxacin ophth soln 0.3%
OPHTHETIC SOL 0.5% OP(Proparacaine HCl)
01
01
01
01
04
04
04
02
04
04
04
04
04
04
04
02
01
04
01
01
01
04
04
02
04
04
04
04
01
04
04
01
02
04
02
02
01
01
01
01
01
01
01
04
04
04
04
04
01
04
82

Drug Name Drug Tier Notes
OPTIPRANOLOL SOL 0.3% OP(Metipranolol)
OPTIVAR DRO 0.05%(Azelastine HCl (Ophth))
PATADAY SOL(Olopatadine HCl)
PATANOL SOL 0.1% OP(Olopatadine HCl)
PEDIOTIC SUS 1% OTIC(Neomycin-Polymyxin-HC (Otic))
PERIDEX SOL 0.12%(Chlorhexidine Gluconate (Mouth-Throat))
PHOSPHOLINE SOL 0.125%OP(Echothiophate Iodide)
pilocarpine hcl ophth soln 0.5%
pilocarpine hcl ophth soln 1%
pilocarpine hcl ophth soln 2%
pilocarpine hcl ophth soln 3%
pilocarpine hcl ophth soln 4%
pilocarpine hcl ophth soln 6%
PILOPINE HS GEL 4% OP(Pilocarpine HCl)
POLY-PRED SUS OP(Neomycin-Polymyx-Pred Acetate)
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%
POLYTRIM SOL OP(Polymyxin B-Trimethoprim)
PRAMOTIC DRO 1-0.1%(Pramoxine-Chloroxylenol)
pramoxine-acetic acid otic soln
pramoxine-chloroxylenol otic liquid 1-0.1%
PRED FORTE SUS 1% OP(Prednisolone Acetate (Ophth))
PRED MILD SUS 0.12% OP(Prednisolone Acetate (Ophth))
PRED-G SUS OP(Gentamicin-Prednisolone Acetate)
PRED-G S.O.P OIN OP(Gentamicin-Prednisolone Acetate)
prednisolone acetate ophth susp 1%
prednisolone sodium phosphate ophth soln 1%
proparacaine hcl ophth soln 0.5%
PROPINE SOL 0.1% OP(Dipivefrin HCl)
QUIXIN SOL 0.5%(Levofloxacin (Ophth))
RESTASIS EMU 0.05%(Cyclosporine (Ophth))
RETISERT IMP 0.59MG(Fluocinolone Acetonide (Ophth))
RHINOCORT SUS AQUA(Budesonide (Nasal))
silver nitrate oint 10%
silver nitrate soln 0.5%
silver nitrate soln 10%
silver nitrate soln 25%
silver nitrate soln 50%
SULFACET SOD OIN 10% OP(Sulfacetamide Sodium (Ophth))
sulfacetamide sodium ophth oint 10%
sulfacetamide sodium ophth soln 10%
sulfacetamide sodium-prednisolone ophth oint 10-0.2%
sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%
tetracaine hcl ophth soln 0.5%
timolol maleate ophth gel forming soln 0.25%
timolol maleate ophth gel forming soln 0.5%
timolol maleate ophth soln 0.25%
timolol maleate ophth soln 0.5%
timolol maleate ophth soln 0.5% (once-daily)
TIMOPTIC SOL 0.25% OP(Timolol Maleate (Ophth))
TIMOPTIC SOL 0.5% OP(Timolol Maleate (Ophth))
04
04
02
02
04
04
04
01
01
01
01
01
01
02
04
01
04
04
01
01
04
02
04
04
01
01
01
04
04
02
04
04
01
01
01
01
01
02
01
01
01
01
01
01
01
01
01
01
04
04
83

Drug Name Drug Tier Notes
TIMOPTIC OCU SOL 0.25% OP(Timolol Maleate (Ophth))
TIMOPTIC OCU SOL 0.5% OP(Timolol Maleate (Ophth))
TIMOPTIC-XE SOL 0.25% OP(Timolol Maleate (Ophth))
TIMOPTIC-XE SOL 0.5% OP(Timolol Maleate (Ophth))
TOBRADEX OIN OP(Tobramycin-Dexamethasone)
TOBRADEX SUS OP(Tobramycin-Dexamethasone)
tobramycin sulfate ophth soln 0.3%
TOBREX OIN 0.3% OP(Tobramycin Sulfate (Ophth))
TOBREX SOL 0.3% OP(Tobramycin Sulfate (Ophth))
TRAVATAN SOL 0.004%(Travoprost)
TRAVATAN Z SOL 0.004%(Travoprost)
trifluridine ophth soln 1%
tropicamide ophth soln 0.5%
tropicamide ophth soln 1%
TRUSOPT SOL(Dorzolamide HCl)
VERAMYST SPR 27.5MCG(Fluticasone Furoate)
VEXOL SUS 1% OP(Rimexolone)
VIGAMOX DRO 0.5%(Moxifloxacin HCl (Ophth))
VIROPTIC SOL 1% OP(Trifluridine)
VISUDYNE INJ 15MG(Verteporfin)
VITRASERT IMP 4.5MG(Ganciclovir Ophthalmic)
VOLTAREN SOL 0.1% OP(Diclofenac Sodium (Ophth))
XALATAN SOL 0.005%(Latanoprost)
XIBROM SOL 0.09%(Bromfenac Sodium (Ophth))
XYLOCAINE SOL 2% VISC(Lidocaine HCl (Mouth-Throat))
ZINOTIC DRO(Chloroxylenol-Pramoxine-Zinc Acetate)
ZYLET SUS 0.5-0.3%(Loteprednol Etabonate-Tobramycin)
ZYMAR DRO 0.3%(Gatifloxacin (Ophth))
Gastrointestinal Drugs
ACIPHEX TAB 20MG(Rabeprazole Sodium)
ACTIGALL CAP 300MG(Ursodiol)
AMITIZA CAP 24MCG(Lubiprostone)
amy-lip-prot dr particles cap 16600-5000-18750 unit
amy-lip-prot dr particles cap 20000-4500-25000 unit
amy-lip-prot dr particles cap 25000-4000-25000 unit
amy-lip-prot dr particles cap 30000-10000-30000 unit
amy-lip-prot dr particles cap 33200-10000-37500 unit
amy-lip-prot dr particles cap 39000-12000-39000 unit
amy-lip-prot dr particles cap 40000-8000-45000 unit
amy-lip-prot dr particles cap 48000-16000-48000 unit
amy-lip-prot dr particles cap 52000-16000-52000 unit
amy-lip-prot dr particles cap 56000-20000-44000 unit
amy-lip-prot dr particles cap 58500-18000-58500 unit
amy-lip-prot dr particles cap 65000-20000-65000 unit
amy-lip-prot dr particles cap 66400-20000-75000 unit
amylase-lipase-protease cap 15000-1200-15000 unit
amylase-lipase-protease cap 20000-4000-25000 unit
amylase-lipase-protease cap 30000-2400-30000 unit
amylase-lipase-protease cap 30000-8000-30000 unit
04
04
04
04
02
02
01
04
04
04
04
01
01
01
04
04
04
04
04
02
04
04
02
04
04
04
04
02
04
04
02
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
(PA)
(PA)
(STC)
(PA)
84

Drug Name Drug Tier Notes
amylase-lipase-protease powd 70000-16800-70000 unit
amylase-lipase-protease tab 30000-8000-30000 unit
amylase-lipase-protease tab 60000-16000-60000 unit
ANTIVERT TAB 12.5MG(Meclizine HCl)
ANTIVERT TAB 25MG(Meclizine HCl)
ANTIVERT TAB 50MG(Meclizine HCl)
ANZEMET INJ 20MG/ML(Dolasetron Mesylate)
ANZEMET SOL 20MG/ML(Dolasetron Mesylate)
ANZEMET TAB 100MG(Dolasetron Mesylate)
ANZEMET TAB 50MG(Dolasetron Mesylate)
ASACOL TAB 400MG DR(Mesalamine)
AXID CAP 150MG(Nizatidine)
AXID CAP 300MG(Nizatidine)
AXID SOL 15MG/ML(Nizatidine)
CANASA SUP 1000MG(Mesalamine)
CARAFATE SUS 1GM/10ML(Sucralfate)
CARAFATE TAB 1GM(Sucralfate)
CIMETID/NACL INJ 300/50ML(Cimetidine in Saline)
cimetidine hcl inj 150 mg/ml
cimetidine hcl soln 300 mg/5ml
cimetidine tab 200 mg
cimetidine tab 300 mg
cimetidine tab 400 mg
cimetidine tab 800 mg
COLAZAL CAP 750MG(Balsalazide Disodium)
COLYTE SOL(PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)
COLYTE/FLAVR SOL PACKS(PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod
Sulfate)
CREON 10 CAP EC(Amylase-Lipase-Protease)
CYTOTEC TAB 100MCG(Misoprostol)
CYTOTEC TAB 200MCG(Misoprostol)
DIPENTUM CAP 250MG(Olsalazine Sodium)
diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml
diphenoxylate w/ atropine tab 2.5-0.025 mg
EMEND CAP 125MG(Aprepitant)
EMEND CAP 40MG(Aprepitant)
EMEND CAP 80-125MG(Aprepitant)
EMEND CAP 80MG(Aprepitant)
famotidine inj 10 mg/ml
famotidine tab 20 mg
famotidine tab 40 mg
GABITIDINE PAK(Ranitidine HCl-Nutritional Supplement)
GOLYTELY SOL(PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)
GOLYTELY SOL PINEAPPL(PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod
Sulfate)
HALFLYTELY KIT BWL-PREP(Bisacodyl-PEG 3350-Pot Chloride-Sod
Bicarb-Sod Chloride)
KYTRIL INJ 0.1MG/ML(Granisetron HCl)
KYTRIL INJ 1MG/ML(Granisetron HCl)
KYTRIL SOL 2MG/10ML(Granisetron HCl)
01
01
01
04
04
02
03
03
03
03
02
04
04
04
02
04
04
02
01
01
01
01
01
01
04
04
04
02
04
04
02
01
01
02
02
02
02
01
01
01
04
02
04
04
02
02
02
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
85

Drug Name Drug Tier Notes
KYTRIL TAB 1MG(Granisetron HCl)
LIALDA TAB 1.2GM(Mesalamine)
LOMOTIL LIQ 2.5/5(Diphenoxylate w/ Atropine)
LOMOTIL TAB 2.5MG(Diphenoxylate w/ Atropine)
loperamide hcl cap 2 mg
LOTRONEX TAB 0.5MG(Alosetron HCl)
LOTRONEX TAB 1MG(Alosetron HCl)
MARINOL CAP 10MG(Dronabinol)
MARINOL CAP 2.5MG(Dronabinol)
MARINOL CAP 5MG(Dronabinol)
meclizine hcl tab 12.5 mg
meclizine hcl tab 25 mg
meclizine hcl tab 32 mg
mesalamine enema 4 gm
metoclopramide hcl inj 5 mg/ml
metoclopramide hcl soln 5 mg/5ml
metoclopramide hcl tab 10 mg
metoclopramide hcl tab 5 mg
misoprostol tab 100 mcg
misoprostol tab 200 mcg
MOVIPREP SOL(PEG 3350-KCl-NaCl-Na Sulfate-Na Ascorbate-Ascorbic
Acid)
NEXIUM CAP 20MG(Esomeprazole Magnesium)
NEXIUM CAP 40MG(Esomeprazole Magnesium)
NEXIUM GRA 20MG DR(Esomeprazole Magnesium)
NEXIUM GRA 40MG DR(Esomeprazole Magnesium)
NEXIUM I.V. SOL 20MG(Esomeprazole Sodium)
NEXIUM I.V. SOL 40MG(Esomeprazole Sodium)
nizatidine cap 150 mg
nizatidine cap 300 mg
NULYTELY SOL(PEG 3350-Potassium Chloride-Sod Bicarbonate-Sod
Chloride)
NULYTELY SOL CHERRY(PEG 3350-Potassium Chloride-Sod
Bicarbonate-Sod Chloride)
NULYTELY SOL LMN/LIME(PEG 3350-Potassium Chloride-Sod
Bicarbonate-Sod Chloride)
NULYTELY SOL ORANGE(PEG 3350-Potassium Chloride-Sod
Bicarbonate-Sod Chloride)
OCL SOL(PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)
omeprazole cap delayed release 10 mg
omeprazole cap delayed release 20 mg
ONDANSETRON SOL 32MG/50M(Ondansetron HCl and Sodium Chloride)
ONDANSETRON TAB 24MG(Ondansetron HCl)
ondansetron hcl and dextrose inj 32 mg/50ml
ondansetron hcl inj 2 mg/ml
ondansetron hcl oral soln 4 mg/5ml
ondansetron hcl tab 4 mg
ondansetron hcl tab 8 mg
ondansetron orally disintegrating tab 4 mg
ondansetron orally disintegrating tab 8 mg
02
02
04
04
01
03
03
02
02
02
01
01
01
01
01
01
01
01
01
01
04
02
02
04
04
02
02
01
01
04
04
04
04
04
01
01
04
02
01
01
01
01
01
01
01
(PA)
(PA)
(PA)
(PA)
(STC)
(STC)
(STC)
(STC)
(STC)
(STC)
(STC)
(STC)
(QL) (PA)
(QL) (PA)
(QL) (PA)
(QL) (PA)
(QL) (PA)
(QL) (PA)
(QL) (PA)
(QL) (PA)
86

Drug Name Drug Tier Notes
opium tincture 10%
PANCREASE MT CAP 10(Amylase-Lipase-Protease)
PANCREASE MT CAP 16(Amylase-Lipase-Protease)
PANCREASE MT CAP 20(Amylase-Lipase-Protease)
PANCREASE MT CAP 4(Amylase-Lipase-Protease)
PANCRECARB CAP MS-16(Amylase-Lipase-Protease)
PANGESTYM EC CAP(Amylase-Lipase-Protease)
paregoric 2 mg/5ml
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
PENTASA CAP 250MG CR(Mesalamine)
PENTASA CAP 500MG CR(Mesalamine)
PEPCID SUS 40MG/5ML(Famotidine)
PEPCID TAB 20MG(Famotidine)
PEPCID TAB 40MG(Famotidine)
PEPCID I.V. INJ 10MG/ML(Famotidine)
PEPCID I.V. INJ 20MG/2ML(Famotidine)
polyethylene glycol 3350 oral packet
polyethylene glycol 3350 oral powder
PREVACID CAP 15MG DR(Lansoprazole)
PREVACID CAP 30MG DR(Lansoprazole)
PREVACID GRA 15MG(Lansoprazole)
PREVACID GRA 30MG(Lansoprazole)
PREVACID TAB 15MG STB(Lansoprazole)
PREVACID TAB 30MG STB(Lansoprazole)
PREVACID I.V INJ 30MG(Lansoprazole)
PREVPAC MIS(Amoxicillin-Clarithromycin w/ Lansoprazole)
PRILOSEC CAP 10MG CR(Omeprazole)
PRILOSEC CAP 20MG CR(Omeprazole)
PRILOSEC CAP 40MG CR(Omeprazole)
PRILOSEC OTC TAB 20MG(Omeprazole Magnesium)
PROTONIX INJ 40MG(Pantoprazole Sodium)
PROTONIX TAB 20MG(Pantoprazole Sodium)
PROTONIX TAB 40MG(Pantoprazole Sodium)
ranitidine hcl cap 150 mg
ranitidine hcl cap 300 mg
ranitidine hcl inj 25 mg/ml
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)
ranitidine hcl tab 150 mg
ranitidine hcl tab 300 mg
REGLAN INJ 5MG/ML(Metoclopramide HCl)
REGLAN TAB 10MG(Metoclopramide HCl)
REGLAN TAB 5MG(Metoclopramide HCl)
ROWASA ENE 4GM(Mesalamine)
SCOPACE TAB 0.4MG(Scopolamine Hydrobromide)
scopolamine hydrobromide tab 0.4 mg
SENTRADINE PAK(Ranitidine HCl-Nutritional Supplement)
SUCRALFATE SUS 1GM/10ML(Sucralfate)
sucralfate tab 1 gm
TALADINE CAP 150MG(Ranitidine HCl)
01
02
02
02
02
04
04
01
01
01
02
02
04
04
04
04
04
01
01
02
02
02
02
02
02
02
02
04
04
04
00
04
04
04
01
01
01
01
01
01
04
04
04
04
04
01
04
04
01
04
(STC)
(STC)
(STC)
(STC)
(STC)
(STC)
(STC)
(QL)
(STC)
(STC)
(STC)
(STC)
(STC)
(STC)
87

Drug Name Drug Tier Notes
TALADINE CAP 300MG(Ranitidine HCl)
TRANSDERM-SC DIS 1.5MG(Scopolamine)
ULTRASE MT20 CAP(Amylase-Lipase-Protease)
URSO 250 TAB 250MG(Ursodiol)
URSO FORTE TAB 500MG(Ursodiol)
ursodiol cap 300 mg
ursodiol tab 250 mg
ZANTAC GRA 150MG(Ranitidine HCl)
ZANTAC INJ 25MG/ML(Ranitidine HCl)
ZANTAC INJ 50/50ML(Ranitidine HCl in NaCl)
ZANTAC SYP 15MG/ML(Ranitidine HCl)
ZANTAC TAB 150MG(Ranitidine HCl)
ZANTAC TAB 25MG EF(Ranitidine HCl)
ZANTAC TAB 300MG(Ranitidine HCl)
ZEGERID CAP 20-1100(Omeprazole-Sodium Bicarbonate)
ZEGERID CAP 40-1100(Omeprazole-Sodium Bicarbonate)
ZEGERID POW 20-1680(Omeprazole-Sodium Bicarbonate)
ZEGERID POW 40-1680(Omeprazole-Sodium Bicarbonate)
ZOFRAN INJ 2MG/ML(Ondansetron HCl)
ZOFRAN INJ 32/50ML(Ondansetron HCl and Dextrose)
ZOFRAN SOL 4MG/5ML(Ondansetron HCl)
ZOFRAN TAB 4MG(Ondansetron HCl)
ZOFRAN TAB 8MG(Ondansetron HCl)
ZOFRAN ODT TAB 4MG(Ondansetron)
ZOFRAN ODT TAB 8MG(Ondansetron)
Gold Compounds
gold sodium thiomalate inj 50 mg/ml
MYOCHRYSINE INJ 50MG/ML(Gold Sodium Thiomalate)
RIDAURA CAP 3MG(Auranofin)
Heavy Metal Antagonists
CHEMET CAP 100MG(Succimer)
CUPRIMINE CAP 125MG(Penicillamine)
CUPRIMINE CAP 250MG(Penicillamine)
deferoxamine mesylate for inj 2 gm
deferoxamine mesylate for inj 500 mg
DEPEN TITRA TAB 250MG(Penicillamine)
DESFERAL INJ 2GM(Deferoxamine Mesylate)
DESFERAL INJ 500MG(Deferoxamine Mesylate)
edetate calcium disodium inj 200 mg/ml
edetate disodium inj 150 mg/ml
ENDRATE INJ 150MG/ML(Edetate Disodium)
EXJADE TAB 125MG(Deferasirox)
EXJADE TAB 250MG(Deferasirox)
EXJADE TAB 500MG(Deferasirox)
pentetate calcium trisodium iv or inhalation soln 200 mg/ml
pentetate zinc trisodium iv or inhalation soln 200 mg/ml
sodium nitrite inj 30 mg/ml
sodium thiosulfate inj 10%
04
04
04
04
02
01
01
02
04
04
04
04
02
04
04
04
04
04
02
02
02
02
02
02
02
01
04
02
04
02
02
01
01
02
04
04
01
01
04
03
03
03
01
01
01
01
(STC)
(STC)
(STC)
(STC)
(QL) (PA)
(QL) (PA)
(QL) (PA)
(QL) (PA)
(QL) (PA)
(QL) (PA)
(QL) (PA)
(PA)
(PA)
(PA)
88

Drug Name Drug Tier Notes
sodium thiosulfate inj 25%
SYPRINE CAP 250MG(Trientine HCl)
Hormones and Synthetic Substitutes
ACTIVELLA TAB 0.5-0.1(Estradiol & Norethindrone Acetate)
ACTIVELLA TAB 1-0.5MG(Estradiol & Norethindrone Acetate)
ACTOPLUS MET TAB 15/500MG(Pioglitazone HCl-Metformin HCl)
ACTOPLUS MET TAB 15/850MG(Pioglitazone HCl-Metformin HCl)
ACTOS TAB 15MG(Pioglitazone HCl)
ACTOS TAB 30MG(Pioglitazone HCl)
ACTOS TAB 45MG(Pioglitazone HCl)
AEROBID AER 250MCG(Flunisolide)
AEROBID-M AER 250MCG(Flunisolide)
ALESSE TAB -28(Levonorgestrel & Eth Estradiol)
ALORA DIS 0.025MG(Estradiol)
ALORA DIS 0.05MG(Estradiol)
ALORA DIS 0.075MG(Estradiol)
ALORA DIS 0.1MG(Estradiol)
AMARYL TAB 1MG(Glimepiride)
AMARYL TAB 2MG(Glimepiride)
AMARYL TAB 4MG(Glimepiride)
ANADROL-50 TAB 50MG(Oxymetholone)
ANDRODERM DIS 2.5MG/24(Testosterone)
ANDRODERM DIS 5MG/24HR(Testosterone)
ANDROGEL GEL 1%(25MG)(Testosterone)
ANDROGEL GEL 1%(50MG)(Testosterone)
ANDROGEL GEL PUMP 1%(Testosterone)
ANDROID CAP 10MG(Methyltestosterone)
ANDROXY TAB 10MG(Fluoxymesterone)
ANGELIQ TAB 0.5-1MG(Drospirenone-Estradiol)
APIDRA INJ(Insulin Glulisine)
APIDRA INJ U-100(Insulin Glulisine)
APPFORMIN PAK(Metformin HCl-Nutritional Supplement)
APPFORMIN-D PAK(Metformin HCl-Nutritional Supplement)
ARISTOSPAN INJ 20MG/ML(Triamcinolone Hexacetonide)
ARISTOSPAN INJ 5MG/ML(Triamcinolone Hexacetonide)
ARMOUR THYRO TAB 120MG(Thyroid)
ARMOUR THYRO TAB 15MG(Thyroid)
ARMOUR THYRO TAB 180MG(Thyroid)
ARMOUR THYRO TAB 240MG(Thyroid)
ARMOUR THYRO TAB 300MG(Thyroid)
ARMOUR THYRO TAB 30MG(Thyroid)
ARMOUR THYRO TAB 60MG(Thyroid)
ARMOUR THYRO TAB 90MG(Thyroid)
ASMANEX 120 AER 220MCG(Mometasone Furoate (Inhalation))
ASMANEX 14 AER 220MCG(Mometasone Furoate (Inhalation))
ASMANEX 30 AER 220MCG(Mometasone Furoate (Inhalation))
ASMANEX 60 AER 220MCG(Mometasone Furoate (Inhalation))
AVANDAMET TAB 2-1000MG(Rosiglitazone Maleate-Metformin HCl)
AVANDAMET TAB 2-500MG(Rosiglitazone Maleate-Metformin HCl)
01
04
04
04
02
02
02
02
02
02
02
04
02
02
02
02
04
04
04
04
02
02
02
02
02
02
02
04
04
04
04
04
04
04
02
02
02
02
02
02
02
02
04
04
04
04
02
02
(QL)
(QL)
89

Drug Name Drug Tier Notes
AVANDAMET TAB 4-1000MG(Rosiglitazone Maleate-Metformin HCl)
AVANDAMET TAB 4-500MG(Rosiglitazone Maleate-Metformin HCl)
AVANDARYL TAB 4-1MG(Rosiglitazone Maleate-Glimepiride)
AVANDARYL TAB 4-2MG(Rosiglitazone Maleate-Glimepiride)
AVANDARYL TAB 4-4MG(Rosiglitazone Maleate-Glimepiride)
AVANDARYL TAB 8-2MG(Rosiglitazone Maleate-Glimepiride)
AVANDARYL TAB 8-4MG(Rosiglitazone Maleate-Glimepiride)
AVANDIA TAB 2MG(Rosiglitazone Maleate)
AVANDIA TAB 4MG(Rosiglitazone Maleate)
AVANDIA TAB 8MG(Rosiglitazone Maleate)
AYGESTIN TAB 5MG(Norethindrone Acetate)
AZMACORT AER 100MCG(Triamcinolone Acetonide (Inhalant))
BIO-THROID CAP 120MG(Thyroid (Pork))
BIO-THROID CAP 150MG(Thyroid (Pork))
BIO-THROID CAP 15MG(Thyroid (Pork))
BIO-THROID CAP 180MG(Thyroid (Pork))
BIO-THROID CAP 240MG(Thyroid (Pork))
BIO-THROID CAP 30MG(Thyroid (Pork))
BIO-THROID CAP 60MG(Thyroid (Pork))
BIO-THROID CAP 8MG(Thyroid (Pork))
BIO-THROID CAP 90MG(Thyroid (Pork))
BREVICON TAB 0.5/35(Norethindrone & Eth Estradiol)
BYETTA INJ 10MCG(Exenatide)
BYETTA INJ 5MCG(Exenatide)
calcitonin (salmon) nasal soln 200 unit/act
CELESTONE INJ SOLUSPAN(Betamethasone Acetate & Sod Phosphate)
CELESTONE SOL 0.6MG/5(Betamethasone)
CENESTIN TAB 0.3MG(Estrogens, Conjugated Synthetic A)
CENESTIN TAB 0.45MG(Estrogens, Conjugated Synthetic A)
CENESTIN TAB 0.625MG(Estrogens, Conjugated Synthetic A)
CENESTIN TAB 0.9MG(Estrogens, Conjugated Synthetic A)
CENESTIN TAB 1.25MG(Estrogens, Conjugated Synthetic A)
chlorpropamide tab 100 mg
chlorpropamide tab 250 mg
chorionic gonadotropin for inj 10000 unit
CLIMARA DIS 0.025MG(Estradiol)
CLIMARA DIS 0.0375MG(Estradiol)
CLIMARA DIS 0.05MG(Estradiol)
CLIMARA DIS 0.06MG(Estradiol)
CLIMARA DIS 0.075MG(Estradiol)
CLIMARA DIS 0.1MG(Estradiol)
CLIMARA PRO DIS WEEKLY(Estradiol-Levonorgestrel)
COMBIPATCH DIS .05/.14(Estradiol & Norethindrone Acetate)
COMBIPATCH DIS .05/.25(Estradiol & Norethindrone Acetate)
CORTEF TAB 10MG(Hydrocortisone)
CORTEF TAB 20MG(Hydrocortisone)
CORTEF TAB 5MG(Hydrocortisone)
cortisone acetate tab 25 mg
CRINONE GEL 8% VAG(Progesterone (Vaginal))
CYCLESSA PAK(Desogestrel-Ethinyl Estradiol (Triphasic))
02
02
02
02
02
02
02
02
02
02
04
02
04
04
04
04
04
04
04
04
04
04
02
02
01
04
04
04
04
04
04
04
01
01
01
04
04
04
04
04
04
04
04
04
04
04
04
01
04
04
(QL)
(QL)
(QL)
(QL)
(QL)
(PA)
(PA)
(PA)
90

Drug Name Drug Tier Notes
CYTOMEL TAB 25MCG(Liothyronine Sodium)
CYTOMEL TAB 50MCG(Liothyronine Sodium)
CYTOMEL TAB 5MCG(Liothyronine Sodium)
danazol cap 100 mg
danazol cap 200 mg
danazol cap 50 mg
DDAVP INJ 4MCG/ML(Desmopressin Acetate)
DDAVP SPR 0.01%(Desmopressin Acetate Spray)
DDAVP TAB 0.1MG(Desmopressin Acetate)
DDAVP TAB 0.2MG(Desmopressin Acetate)
DELATESTRYL INJ 200MG/ML(Testosterone Enanthate)
DELESTROGEN INJ 10MG/ML(Estradiol Valerate)
DELESTROGEN INJ 20MG/ML(Estradiol Valerate)
DELESTROGEN INJ 40MG/ML(Estradiol Valerate)
DEMULEN TAB 1/35-28(Ethynodiol Diacet & Eth Estrad)
DEPO-ESTRADI INJ 5MG/ML(Estradiol Cypionate)
DEPO-MEDROL INJ 20MG/ML(Methylprednisolone Acetate)
DEPO-MEDROL INJ 40MG/ML(Methylprednisolone Acetate)
DEPO-MEDROL INJ 80MG/ML(Methylprednisolone Acetate)
DEPO-PROVERA INJ 150MG/ML(Medroxyprogesterone Acetate
(Contraceptive))
DEPO-PROVERA INJ 400/ML(Medroxyprogesterone Acetate (Antineoplastic))
DEPO-SQ PROV INJ 104(Medroxyprogesterone Acetate (Contraceptive))
DEPO-TESTOST INJ 100MG/ML(Testosterone Cypionate)
DEPO-TESTOST INJ 200MG/ML(Testosterone Cypionate)
desmopressin acetate inj 4 mcg/ml
desmopressin acetate nasal spray soln 0.01%
desmopressin acetate nasal spray soln 0.01% (refrigerated)
desmopressin acetate tab 0.1 mg
desmopressin acetate tab 0.2 mg
DESOGEN-28 TAB(Desogestrel & Ethinyl Estradiol)
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)
desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
dexamethasone conc 1 mg/ml
dexamethasone elixir 0.5 mg/5ml
dexamethasone sodium phosphate inj 10 mg/ml
dexamethasone sodium phosphate inj 4 mg/ml
dexamethasone soln 0.5 mg/5ml
dexamethasone tab 0.5 mg
dexamethasone tab 0.75 mg
dexamethasone tab 1 mg
dexamethasone tab 1.5 mg
dexamethasone tab 2 mg
dexamethasone tab 4 mg
dexamethasone tab 6 mg
DEXPAK PAK 13 DAY(Dexamethasone)
DEXPAK JR PAK 10 DAY(Dexamethasone)
DIABETA TAB 1.25MG(Glyburide)
DIABETA TAB 2.5MG(Glyburide)
02
02
02
01
01
01
04
04
04
04
04
04
04
04
04
04
02
02
02
02
02
02
02
02
01
01
01
01
01
04
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
02
02
04
04
(PA)
(PA)
(PA)
(QL)
(PA)
(QL)
(PA)
(PA)
91

Drug Name Drug Tier Notes
DIABETA TAB 5MG(Glyburide)
DIABINESE TAB 100MG(Chlorpropamide)
DIABINESE TAB 250MG(Chlorpropamide)
DIVIGEL GEL 0.25MG(Estradiol)
DIVIGEL GEL 0.5MG(Estradiol)
DIVIGEL GEL 1MG/GM(Estradiol)
DUETACT TAB 30-2MG(Pioglitazone HCl-Glimepiride)
DUETACT TAB 30-4MG(Pioglitazone HCl-Glimepiride)
ELESTRIN GEL(Estradiol)
ENDOMETRIN SUP 100MG(Progesterone (Vaginal))
ENJUVIA TAB 0.3MG(Estrogens, Conjugated Synthetic B)
ENJUVIA TAB 0.45MG(Estrogens, Conjugated Synthetic B)
ENJUVIA TAB 0.625MG(Estrogens, Conjugated Synthetic B)
ENJUVIA TAB 1.25MG(Estrogens, Conjugated Synthetic B)
ENTOCORT EC CAP 3MG/24HR(Budesonide)
ESCLIM DIS 0.025MG(Estradiol)
ESCLIM DIS 0.0375MG(Estradiol)
ESCLIM DIS 0.05MG(Estradiol)
ESCLIM DIS 0.075MG(Estradiol)
ESCLIM DIS 0.1MG(Estradiol)
ESTRACE TAB 0.5MG(Estradiol)
ESTRACE TAB 1MG(Estradiol)
ESTRACE TAB 2MG(Estradiol)
ESTRACE VAG CRE 0.1MG/GM(Estradiol Vaginal)
ESTRADERM DIS 0.05MG(Estradiol)
ESTRADERM DIS 0.1MG(Estradiol)
estradiol tab 0.5 mg
estradiol tab 1 mg
estradiol tab 2 mg
estradiol td patch weekly 0.025 mg/24hr
estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)
estradiol td patch weekly 0.05 mg/24hr
estradiol td patch weekly 0.06 mg/24hr
estradiol td patch weekly 0.075 mg/24hr
estradiol td patch weekly 0.1 mg/24hr
ESTRASORB EMU(Estradiol)
ESTRING MIS 2MG(Estradiol Vaginal)
ESTROGEL GEL(Estradiol)
estropipate tab 0.75 mg
estropipate tab 1.5 mg
estropipate tab 3 mg
ESTROSTEP FE TAB(Norethindrone Acetate-Ethinyl Estradiol-Fe)
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg
ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg
EVISTA TAB 60MG(Raloxifene HCl)
EXUBERA POW KIT(Insulin Regular (Human))
EXUBERA COMB POW PACK 12(Insulin Regular (Human))
EXUBERA COMB POW PACK 15(Insulin Regular (Human))
EXUBERA PT POW PACK 1MG(Insulin Regular (Human))
EXUBERA PT POW PACK 3MG(Insulin Regular (Human))
04
04
04
02
02
02
02
02
02
04
04
04
04
04
04
02
02
02
02
02
04
04
04
04
02
02
01
01
01
01
01
01
01
01
01
02
04
02
01
01
01
02
01
01
02
02
02
02
04
04
(QL)
(QL)
(PA)
(PA)
(PA)
92

Drug Name Drug Tier Notes
FEMCON FE CHW(Norethindrone & Ethinyl Estradiol-Fe)
FEMHRT TAB 0.5-2.5(Norethindrone Acetate-Ethinyl Estradiol)
FEMHRT 1/5 TAB(Norethindrone Acetate-Ethinyl Estradiol)
FEMRING MIS 0.05/24H(Estradiol Acetate Vaginal)
FEMRING MIS 0.1MG/24(Estradiol Acetate Vaginal)
FEMTRACE TAB 0.45MG(Estradiol Acetate)
FEMTRACE TAB 0.9MG(Estradiol Acetate)
FEMTRACE TAB 1.8MG(Estradiol Acetate)
FIRST-TESTOS CRE MC 2%(Testosterone Propionate)
FIRST-TESTOS OIN 2%(Testosterone Propionate)
FLORINEF TAB 0.1MG(Fludrocortisone Acetate)
FLOVENT DISK AER 50MCG(Fluticasone Propionate (Inhalation))
FLOVENT HFA AER 110MCG(Fluticasone Propionate HFA)
FLOVENT HFA AER 220MCG(Fluticasone Propionate HFA)
FLOVENT HFA AER 44MCG(Fluticasone Propionate HFA)
fludrocortisone acetate tab 0.1 mg
FORTAMET TAB 1000MG(Metformin HCl)
FORTAMET TAB 500MG(Metformin HCl)
FORTEO SOL 750/3ML(Teriparatide (Recombinant))
GENOTROPIN INJ 0.2MG(Somatropin)
GENOTROPIN INJ 0.4MG(Somatropin)
GENOTROPIN INJ 0.6MG(Somatropin)
GENOTROPIN INJ 0.8MG(Somatropin)
GENOTROPIN INJ 1.2MG(Somatropin)
GENOTROPIN INJ 1.4MG(Somatropin)
GENOTROPIN INJ 1.6MG(Somatropin)
GENOTROPIN INJ 1.8MG(Somatropin)
GENOTROPIN INJ 13.8MG(Somatropin)
GENOTROPIN INJ 1MG(Somatropin)
GENOTROPIN INJ 2MG(Somatropin)
GENOTROPIN INJ 5.8MG(Somatropin)
glimepiride tab 1 mg
glimepiride tab 2 mg
glimepiride tab 4 mg
glipizide tab 10 mg
glipizide tab 5 mg
glipizide tab sr 24hr 10 mg
glipizide tab sr 24hr 2.5 mg
glipizide tab sr 24hr 5 mg
glipizide-metformin hcl tab 2.5-250 mg
glipizide-metformin hcl tab 2.5-500 mg
glipizide-metformin hcl tab 5-500 mg
GLUCAGEN INJ HYPOKIT(Glucagon HCl (rDNA))
glucagon (rdna) for inj kit 1 mg
GLUCOPHAGE TAB 1000MG(Metformin HCl)
GLUCOPHAGE TAB 500MG(Metformin HCl)
GLUCOPHAGE TAB 850MG(Metformin HCl)
GLUCOPHAGE TAB XR 500MG(Metformin HCl)
GLUCOPHAGE TAB XR 750MG(Metformin HCl)
GLUCOTROL TAB 10MG(Glipizide)
04
02
02
04
04
04
04
04
04
04
04
02
02
02
02
01
02
02
03
02
02
02
02
02
02
02
02
03
02
02
02
01
01
01
01
01
01
01
01
01
01
01
02
01
04
04
04
04
04
04
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
93

Drug Name Drug Tier Notes
GLUCOTROL TAB 5MG(Glipizide)
GLUCOTROL XL TAB 10MG(Glipizide)
GLUCOTROL XL TAB 2.5MG(Glipizide)
GLUCOTROL XL TAB 5MG(Glipizide)
GLUCOVANCE TAB 1.25/250(Glyburide-Metformin)
GLUCOVANCE TAB 2.5/500(Glyburide-Metformin)
GLUCOVANCE TAB 5/500MG(Glyburide-Metformin)
GLUMETZA TAB 500MG(Metformin HCl)
GLUMETZA TAB 500MG(Metformin HCl)
glyburide micronized tab 1.5 mg
glyburide micronized tab 3 mg
glyburide micronized tab 6 mg
glyburide tab 1.25 mg
glyburide tab 2.5 mg
glyburide tab 5 mg
glyburide-metformin tab 1.25-250 mg
glyburide-metformin tab 2.5-500 mg
glyburide-metformin tab 5-500 mg
GLYCRON TAB 4.5MG(Glyburide Micronized)
GLYNASE TAB 1.5MG(Glyburide Micronized)
GLYNASE TAB 3MG(Glyburide Micronized)
GLYNASE TAB 6MG(Glyburide Micronized)
GLYSET TAB 100MG(Miglitol)
GLYSET TAB 25MG(Miglitol)
GLYSET TAB 50MG(Miglitol)
GYNODIOL TAB 1.5MG(Estradiol)
HUMALOG INJ 100/ML(Insulin Lispro (Human))
HUMALOG MIX INJ 50/50(Insulin Lispro Protamine & Lispro (Human))
HUMALOG MIX SUS 75/25(Insulin Lispro Protamine & Lispro (Human))
HUMALOG PEN INJ 100/ML(Insulin Lispro (Human))
HUMALOG PEN INJ 50/50(Insulin Lispro Protamine & Lispro (Human))
HUMALOG PEN INJ 75/25(Insulin Lispro Protamine & Lispro (Human))
HUMATROPE INJ 12MG(Somatropin)
HUMATROPE INJ 24MG(Somatropin)
HUMATROPE INJ 5MG(Somatropin)
HUMATROPE INJ 6MG(Somatropin)
HUMULIN INJ 50/50(Insulin Isophane & Reg (Human))
HUMULIN INJ 70/30(Insulin Isophane & Reg (Human))
HUMULIN N INJ U-100(Insulin Isophane (Human))
HUMULIN N PN INJ U-100(Insulin Isophane (Human))
HUMULIN PEN INJ 70/30(Insulin Isophane & Reg (Human))
HUMULIN R INJ U-100(Insulin Regular (Human))
HUMULIN R INJ U-500(Insulin Regular (Human))
hydrocortisone sodium succinate for inj 100 mg
hydrocortisone tab 10 mg
hydrocortisone tab 20 mg
hydrocortisone tab 5 mg
IMPLANON IMP 68MG(Etonogestrel)
INCRELEX INJ 40MG/4ML(Mecasermin)
JANUMET TAB 50-1000(Sitagliptin-Metformin HCl)
04
04
04
04
04
04
04
02
04
01
01
01
01
01
01
01
01
01
02
04
04
04
04
04
04
02
02
02
02
02
02
02
03
03
03
03
02
02
02
02
02
02
02
01
01
01
01
04
04
02
(PA)
(PA)
(PA)
(PA)
94

Drug Name Drug Tier Notes
JANUMET TAB 50-500MG(Sitagliptin-Metformin HCl)
JANUVIA TAB 100MG(Sitagliptin Phosphate)
JANUVIA TAB 25MG(Sitagliptin Phosphate)
JANUVIA TAB 50MG(Sitagliptin Phosphate)
KENALOG-10 INJ 10MG/ML(Triamcinolone Acetonide)
KENALOG-40 INJ 40MG/ML(Triamcinolone Acetonide)
LANTUS INJ 100/ML(Insulin Glargine)
LANTUS INJ OPTICLIK(Insulin Glargine)
LEVEMIR INJ(Insulin Detemir)
LEVEMIR INJ FLEXPEN(Insulin Detemir)
LEVLEN TAB CONTR PK(Levonorgestrel & Eth Estradiol)
LEVLEN-28 TAB(Levonorgestrel & Eth Estradiol)
LEVLITE TAB -28(Levonorgestrel & Eth Estradiol)
levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg
levonorgestrel & ethinyl estradiol tab 0.10 mg-20 mcg
levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg
levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg
levothyroxine sodium for inj 200 mcg
levothyroxine sodium for inj 500 mcg
levothyroxine sodium tab 100 mcg
levothyroxine sodium tab 112 mcg
levothyroxine sodium tab 125 mcg
levothyroxine sodium tab 137 mcg
levothyroxine sodium tab 150 mcg
levothyroxine sodium tab 175 mcg
levothyroxine sodium tab 200 mcg
levothyroxine sodium tab 25 mcg
levothyroxine sodium tab 300 mcg
levothyroxine sodium tab 50 mcg
levothyroxine sodium tab 75 mcg
levothyroxine sodium tab 88 mcg
LEVOXYL TAB 100MCG(Levothyroxine Sodium)
LEVOXYL TAB 112MCG(Levothyroxine Sodium)
LEVOXYL TAB 125MCG(Levothyroxine Sodium)
LEVOXYL TAB 137MCG(Levothyroxine Sodium)
LEVOXYL TAB 150MCG(Levothyroxine Sodium)
LEVOXYL TAB 175MCG(Levothyroxine Sodium)
LEVOXYL TAB 200MCG(Levothyroxine Sodium)
LEVOXYL TAB 25MCG(Levothyroxine Sodium)
LEVOXYL TAB 50MCG(Levothyroxine Sodium)
LEVOXYL TAB 75MCG(Levothyroxine Sodium)
LEVOXYL TAB 88MCG(Levothyroxine Sodium)
liothyronine sodium iv soln 10 mcg/ml
LO/OVRAL-28 TAB(Norgestrel & Ethinyl Estradiol)
LOESTRIN TAB 1/20-21(Norethindrone Acet & Eth Estra)
LOESTRIN 21 TAB 1.5/30(Norethindrone Acet & Eth Estra)
LOESTRIN 24 TAB FE(Norethin Acet & Estrad-Fe)
LOESTRIN FE TAB 1.5/30(Norethin Acet & Estrad-Fe)
LOESTRIN FE TAB 1/20(Norethin Acet & Estrad-Fe)
LYBREL TAB 90-20MCG(Levonorgestrel-Ethinyl Estradiol (Continuous))
02
02
02
02
04
04
02
02
02
02
04
04
04
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
02
02
02
02
02
02
02
02
02
02
02
01
04
04
04
04
04
04
04
95

Drug Name Drug Tier Notes
MEDROL PAK 4MG(Methylprednisolone)
MEDROL TAB 16MG(Methylprednisolone)
MEDROL TAB 2MG(Methylprednisolone)
MEDROL TAB 32MG(Methylprednisolone)
MEDROL TAB 4MG(Methylprednisolone)
MEDROL TAB 8MG(Methylprednisolone)
medroxyprogesterone acetate im susp 150 mg/ml
medroxyprogesterone acetate tab 10 mg
medroxyprogesterone acetate tab 2.5 mg
medroxyprogesterone acetate tab 5 mg
MEGACE ES SUS(Megestrol Acetate (Appetite))
MENEST TAB 0.3MG(Esterified Estrogens)
MENEST TAB 0.625MG(Esterified Estrogens)
MENEST TAB 1.25MG(Esterified Estrogens)
MENEST TAB 2.5MG(Esterified Estrogens)
MENOSTAR DIS 14MCG(Estradiol)
METAGLIP TAB 2.5-250M(Glipizide-Metformin HCl)
METAGLIP TAB 2.5-500M(Glipizide-Metformin HCl)
METAGLIP TAB 5-500MG(Glipizide-Metformin HCl)
metformin hcl tab 1000 mg
metformin hcl tab 500 mg
metformin hcl tab 850 mg
metformin hcl tab sr 24hr 500 mg
metformin hcl tab sr 24hr 750 mg
methimazole tab 10 mg
methimazole tab 5 mg
methylprednisolone acetate inj susp 40 mg/ml
methylprednisolone acetate inj susp 80 mg/ml
methylprednisolone sodium succinate for inj 1000 mg
methylprednisolone sodium succinate for inj 125 mg
methylprednisolone sodium succinate for inj 40 mg
methylprednisolone sodium succinate for inj 500 mg
methylprednisolone tab 4 mg
methylprednisolone tab 4 mg dose pack
methylprednisolone tab 8 mg
methyltestosterone oral tab 10 mg
MIACALCIN INJ 200/ML(Calcitonin (Salmon))
MIACALCIN SPR 200/ACT(Calcitonin (Salmon))
MICRONASE TAB 1.25MG(Glyburide)
MICRONASE TAB 2.5MG(Glyburide)
MICRONASE TAB 5MG(Glyburide)
MIRCETTE TAB 28 DAY(Desogestrel & Ethinyl Estradiol)
MIRENA IUD SYSTEM(Levonorgestrel (IUD))
MODICON TAB 0.5/35(Norethindrone & Eth Estradiol)
NECON TAB 10/11-28(Norethindrone-Eth Estradiol (Biphasic))
NOR-QD TAB 0.35MG(Norethindrone (Contraceptive))
NORDETTE-28 TAB(Levonorgestrel & Eth Estradiol)
NORDITROPIN INJ 10/1.5ML(Somatropin)
NORDITROPIN INJ 15/1.5ML(Somatropin)
NORDITROPIN INJ 15/1.5ML(Somatropin)
04
02
02
02
04
04
01
01
01
01
02
02
02
02
02
04
04
04
04
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
02
04
04
04
04
04
04
04
02
02
04
03
02
02
(QL)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
96

Drug Name Drug Tier Notes
NORDITROPIN INJ 5/1.5ML(Somatropin)
NORDITROPIN INJ 5/1.5ML(Somatropin)
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg
norethindrone & ethinyl estradiol tab 1 mg-35 mcg
norethindrone & mestranol tab 1 mg-50 mcg
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg
norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg
norethindrone acetate tab 5 mg
norethindrone tab 0.35 mg
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg
norgestrel & ethinyl estradiol tab 0.5 mg-50 mcg
NORINYL TAB 1+35-28(Norethindrone & Eth Estradiol)
NORINYL TAB 1+50-28(Norethindrone & Mestranol)
NOVOLIN INJ 70/30(Insulin Isophane & Reg (Human))
NOVOLIN 70/ INJ 30 INNLT(Insulin Isophane & Reg (Human))
NOVOLIN 70/ INJ 30 PNFIL(Insulin Isophane & Reg (Human))
NOVOLIN N INJ INNOLET(Insulin Isophane (Human))
NOVOLIN N INJ PENFILL(Insulin Isophane (Human))
NOVOLIN N INJ U-100(Insulin Isophane (Human))
NOVOLIN R INJ INNOLET(Insulin Regular (Human))
NOVOLIN R INJ PENFILL(Insulin Regular (Human))
NOVOLIN R INJ U-100(Insulin Regular (Human))
NOVOLOG INJ 100/ML(Insulin Aspart)
NOVOLOG INJ FLEXPEN(Insulin Aspart)
NOVOLOG INJ PENFILL(Insulin Aspart)
NOVOLOG MIX INJ 70/30(Insulin Aspart Protamine & Aspart (Human))
NOVOLOG MIX INJ FLEXPEN(Insulin Aspart Protamine & Aspart (Human))
NOVOLOG MIX INJ PENFILL(Insulin Aspart Protamine & Aspart (Human))
NUTROPIN INJ 10MG(Somatropin)
NUTROPIN INJ 5MG(Somatropin)
NUTROPIN AQ INJ 10MG/2ML(Somatropin)
NUVARING MIS(Etonogestrel-Ethinyl Estradiol)
OGEN TAB 0.625(Estropipate)
OGEN TAB 1.25(Estropipate)
OGEN TAB 2.5(Estropipate)
OMNITROPE INJ 5.8MG(Somatropin)
ORAPRED SOL 15MG/5ML(Prednisolone Sodium Phosphate)
ORAPRED ODT TAB 10MG(Prednisolone Sodium Phosphate)
ORAPRED ODT TAB 15MG(Prednisolone Sodium Phosphate)
ORAPRED ODT TAB 30MG(Prednisolone Sodium Phosphate)
ORTHO EVRA DIS WEEK(Norelgestromin-Ethinyl Estradiol)
ORTHO MICRON TAB DIALPAK(Norethindrone (Contraceptive))
ORTHO TRI- TAB CYCLEN(Norgestimate-Ethinyl Estradiol (Triphasic))
02
02
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
04
04
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
03
02
02
04
04
04
02
04
04
04
04
02
02
04
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
97

Drug Name Drug Tier Notes
ORTHO TRI-CY TAB LO(Norgestimate-Ethinyl Estradiol (Triphasic))
ORTHO-CEPT TAB 28(Desogestrel & Ethinyl Estradiol)
ORTHO-CYCLEN TAB 0.25/35(Norgestimate-Ethinyl Estradiol)
ORTHO-NOVUM TAB 1/35-28(Norethindrone & Eth Estradiol)
ORTHO-NOVUM TAB 1/50-28(Norethindrone & Mestranol)
ORTHO-NOVUM TAB 7/7/7-28(Norethindrone-Eth Estradiol (Triphasic))
OVCON 50 TAB 28(Norethindrone & Eth Estradiol)
OVCON-35 TAB(Norethindrone & Eth Estradiol)
OXANDRIN TAB 10MG(Oxandrolone)
OXANDRIN TAB 2.5MG(Oxandrolone)
oxandrolone tab 10 mg
oxandrolone tab 2.5 mg
PEDIAPRED LIQ 6.7/5ML(Prednisolone Sodium Phosphate)
PLAN B TAB 0.75MG(Levonorgestrel (Emergency OC))
PRANDIN TAB 0.5MG(Repaglinide)
PRANDIN TAB 1MG(Repaglinide)
PRANDIN TAB 2MG(Repaglinide)
PRECOSE TAB 100MG(Acarbose)
PRECOSE TAB 25MG(Acarbose)
PRECOSE TAB 50MG(Acarbose)
prednisolone sod phosphate liq 6.7 mg/5ml (5mg/5ml base eq)
prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)
prednisolone syrup 15 mg/5ml
prednisolone syrup 5 mg/5ml
prednisolone tab 5 mg
PREDNISONE TAB 50MG(Prednisone)
prednisone conc 5 mg/ml
prednisone oral soln 5 mg/5ml
prednisone tab 1 mg
prednisone tab 10 mg
prednisone tab 10 mg dose pack
prednisone tab 2.5 mg
prednisone tab 20 mg
prednisone tab 5 mg
prednisone tab 5 mg dose pack
prednisone tab 50 mg
PREFEST TAB(Estradiol-Norgestimate)
PRELONE SYP 15MG/5ML(Prednisolone)
PREMARIN INJ 25MG(Estrogens, Conjugated)
PREMARIN TAB 0.3MG(Estrogens, Conjugated)
PREMARIN TAB 0.45MG(Estrogens, Conjugated)
PREMARIN TAB 0.625MG(Estrogens, Conjugated)
PREMARIN TAB 0.9MG(Estrogens, Conjugated)
PREMARIN TAB 1.25MG(Estrogens, Conjugated)
PREMARIN VAG CRE 0.625MG(Estrogens, Conjugated Vaginal)
PREMPHASE TAB(Conjugated Estrogens-Medroxyprogesterone Acetate)
02
04
04
04
04
04
02
04
04
04
01
01
04
02
02
02
02
02
02
02
01
01
01
01
01
02
01
01
01
01
01
01
01
01
01
01
04
04
02
02
02
02
02
02
02
02
(QL)
98

Drug Name Drug Tier Notes
PREMPRO TAB .625-2.5(Conjugated Estrogens-Medroxyprogesterone
Acetate)
PREMPRO TAB 0.3-1.5(Conjugated Estrogens-Medroxyprogesterone
Acetate)
PREMPRO TAB 0.45-1.5(Conjugated Estrogens-Medroxyprogesterone
Acetate)
PREMPRO TAB 0.625-5(Conjugated Estrogens-Medroxyprogesterone
Acetate)
PROCHIEVE GEL 4%(Progesterone (Vaginal))
PROCHIEVE GEL 8% VAG(Progesterone (Vaginal))
PROGESTERONE SUP VGS 100(Progesterone (Vaginal))
PROGESTERONE SUP VGS 200(Progesterone (Vaginal))
PROGESTERONE SUP VGS 25(Progesterone (Vaginal))
PROGESTERONE SUP VGS 400(Progesterone (Vaginal))
PROGESTERONE SUP VGS 50(Progesterone (Vaginal))
PROMETRIUM CAP 100MG(Progesterone Micronized)
PROMETRIUM CAP 200MG(Progesterone Micronized)
propylthiouracil tab 50 mg
PROVERA TAB 10MG(Medroxyprogesterone Acetate)
PROVERA TAB 2.5MG(Medroxyprogesterone Acetate)
PROVERA TAB 5MG(Medroxyprogesterone Acetate)
PULMICORT INH 180MCG(Budesonide (Inhalation))
PULMICORT INH 90MCG(Budesonide (Inhalation))
PULMICORT SUS 0.25MG/2(Budesonide (Inhalation))
PULMICORT SUS 0.5MG/2(Budesonide (Inhalation))
QVAR AER 40MCG(Beclomethasone Dipropionate)
QVAR AER 80MCG(Beclomethasone Dipropionate)
RELION 70/30 INJ 100/ML(Insulin Isophane & Reg (Human))
RELION 70/30 INJ INNOLET(Insulin Isophane & Reg (Human))
RELION N INJ 100/ML(Insulin Isophane (Human))
RELION N INJ INNOLET(Insulin Isophane (Human))
RELION R INJ 100/ML(Insulin Regular (Human))
RIOMET SOL(Metformin HCl)
SAIZEN INJ 5MG(Somatropin (Non-Refrigerated))
SAIZEN INJ 8.8MG(Somatropin (Non-Refrigerated))
SEASONALE TAB(Levonorgestrel-Ethinyl Estradiol (91-Day))
SEROSTIM INJ 4MG(Somatropin (Non-Refrigerated))
SEROSTIM INJ 5MG(Somatropin (Non-Refrigerated))
SEROSTIM INJ 6MG(Somatropin (Non-Refrigerated))
SOLU-CORTEF INJ 1000MG(Hydrocortisone Sod Succinate)
SOLU-CORTEF INJ 100MG(Hydrocortisone Sod Succinate)
SOLU-CORTEF INJ 250MG(Hydrocortisone Sod Succinate)
SOLU-CORTEF INJ 500MG(Hydrocortisone Sod Succinate)
SOLU-MEDROL INJ 1000MG(Methylprednisolone Sod Succ)
SOLU-MEDROL INJ 125MG(Methylprednisolone Sod Succ)
SOLU-MEDROL INJ 2GM(Methylprednisolone Sod Succ)
SOLU-MEDROL INJ 40MG(Methylprednisolone Sod Succ)
SOLU-MEDROL INJ 500MG(Methylprednisolone Sod Succ)
SOMAVERT INJ 10MG(Pegvisomant)
SOMAVERT INJ 15MG(Pegvisomant)
02
02
02
02
04
04
04
04
04
04
04
02
02
01
04
04
04
04
04
02
02
04
04
02
02
02
02
02
02
02
02
04
02
02
02
04
04
04
04
02
02
02
02
02
02
02
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
99

Drug Name Drug Tier Notes
SOMAVERT INJ 20MG(Pegvisomant)
STARLIX TAB 120MG(Nateglinide)
STARLIX TAB 60MG(Nateglinide)
STERAPRED PAK 5MG(Prednisone)
STERAPRED PAK 5MG 12DY(Prednisone)
STERAPRED DS PAK 10MG(Prednisone)
STERAPRED DS PAK 10MG 12D(Prednisone)
STIMATE SOL 1.5MG/ML(Desmopressin Acetate)
STRIANT MIS 30MG(Testosterone)
SYMBICORT AER 160-4.5(Budesonide-Formoterol Fumarate Dihydrate)
SYMBICORT AER 80-4.5(Budesonide-Formoterol Fumarate Dihydrate)
SYMLIN INJ 0.6MG/ML(Pramlintide Acetate)
SYNAREL SOL 2MG/ML(Nafarelin Acetate)
SYNTHROID TAB 100MCG(Levothyroxine Sodium)
SYNTHROID TAB 100MCG(Levothyroxine Sodium)
SYNTHROID TAB 112MCG(Levothyroxine Sodium)
SYNTHROID TAB 125MCG(Levothyroxine Sodium)
SYNTHROID TAB 125MCG(Levothyroxine Sodium)
SYNTHROID TAB 137MCG(Levothyroxine Sodium)
SYNTHROID TAB 150MCG(Levothyroxine Sodium)
SYNTHROID TAB 175MCG(Levothyroxine Sodium)
SYNTHROID TAB 175MCG(Levothyroxine Sodium)
SYNTHROID TAB 200MCG(Levothyroxine Sodium)
SYNTHROID TAB 25MCG(Levothyroxine Sodium)
SYNTHROID TAB 300MCG(Levothyroxine Sodium)
SYNTHROID TAB 50MCG(Levothyroxine Sodium)
SYNTHROID TAB 75MCG(Levothyroxine Sodium)
SYNTHROID TAB 88MCG(Levothyroxine Sodium)
TAPAZOLE TAB 10MG(Methimazole)
TAPAZOLE TAB 5MG(Methimazole)
TESTIM GEL 1%(50MG)(Testosterone)
testosterone cypionate im in oil 100 mg/ml
testosterone cypionate im in oil 200 mg/ml
testosterone enanthate im in oil 200 mg/ml
TESTRED CAP 10MG(Methyltestosterone)
TEV-TROPIN INJ 5MG(Somatropin)
thyroid tab 120 mg (2 grain)
thyroid tab 15 mg (1/4 grain)
thyroid tab 180 mg (3 grain)
thyroid tab 240 mg (4 grain)
thyroid tab 30 mg (1/2 grain)
thyroid tab 60 mg (1 grain)
thyroid tab 90 mg (1 1/2 grain)
THYROLAR-1 TAB 60MG(Liotrix)
THYROLAR-1/2 TAB 30MG(Liotrix)
THYROLAR-1/4 TAB 15MG(Liotrix)
THYROLAR-2 TAB 120MG(Liotrix)
THYROLAR-3 TAB 180MG(Liotrix)
tolazamide tab 250 mg
tolazamide tab 500 mg
02
04
04
04
04
04
04
02
02
04
04
02
03
02
04
02
02
04
02
02
02
04
02
02
02
02
02
02
04
04
02
01
01
01
02
03
01
01
01
01
01
01
01
04
04
04
04
04
01
01
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
100

Drug Name Drug Tier Notes
tolbutamide tab 500 mg
TRI-LEVLEN TAB 28(Levonorgestrel-Eth Estradiol (Triphasic))
TRI-LEVLEN TAB CONTR PK(Levonorgestrel-Eth Estradiol (Triphasic))
TRI-NORINYL TAB 28(Norethindrone-Eth Estradiol (Triphasic))
TRIOSTAT INJ 10MCG/ML(Liothyronine Sodium)
TRIPHASIL 28 TAB(Levonorgestrel-Eth Estradiol (Triphasic))
VAGIFEM TAB 25MCG(Estradiol Vaginal)
VIVELLE DIS 0.05MG(Estradiol)
VIVELLE DIS 0.1MG(Estradiol)
VIVELLE-DOT DIS 0.025MG(Estradiol)
VIVELLE-DOT DIS 0.0375MG(Estradiol)
VIVELLE-DOT DIS 0.05MG(Estradiol)
VIVELLE-DOT DIS 0.075MG(Estradiol)
VIVELLE-DOT DIS 0.1MG(Estradiol)
YASMIN 28 TAB 3-0.03MG(Drospirenone-Ethinyl Estradiol)
YAZ TAB 3-0.02MG(Drospirenone-Ethinyl Estradiol)
ZORBTIVE INJ(Somatropin (Non-Refrigerated))
01
04
04
04
04
04
04
02
02
02
02
02
02
02
02
04
02 (PA)
Local Anesthetics
LIDO/DEXTROS INJ 5-7.5%(Lidocaine in Dextrose)
lidocaine hcl local inj 0.5%
lidocaine hcl local inj 1%
lidocaine hcl local inj 1.5%
lidocaine hcl local inj 2%
lidocaine hcl local inj 4%
XYLOCAINE INJ -MPF 1%(Lidocaine HCl (Local Anesth.))
XYLOCAINE INJ -MPF 2%(Lidocaine HCl (Local Anesth.))
XYLOCAINE INJ -MPF 4%(Lidocaine HCl (Local Anesth.))
XYLOCAINE INJ 0.5%(Lidocaine HCl (Local Anesth.))
XYLOCAINE INJ 1%(Lidocaine HCl (Local Anesth.))
XYLOCAINE INJ 2%(Lidocaine HCl (Local Anesth.))
XYLOCAINE INJ MPF 0.5%(Lidocaine HCl (Local Anesth.))
XYLOCAINE INJ MPF 1.5%(Lidocaine HCl (Local Anesth.))
Oxytocics
METHERGINE INJ 0.2MG/ML(Methylergonovine Maleate)
METHERGINE TAB 0.2MG(Methylergonovine Maleate)
oxytocin inj 10 unit/ml
PITOCIN INJ 10UNT/ML(Oxytocin)
Serums, Toxoids and Vaccines
ACTHIB INJ(Haemophilus B Polysac Conj Vac)
ADACEL INJ(Tetanus Toxoid-Diphtheria-Acellular Pertussis Adsorb
(Tdap))
ATTENUVAX INJ LIVE(Measles Virus Vaccine)
BOOSTRIX SUS(Tetanus Toxoid-Diphtheria-Acellular Pertussis Adsorb
(Tdap))
CARIMUNE NF INJ 12GM(Immune Globulin (Human) IV)
CARIMUNE NF INJ 1GM(Immune Globulin (Human) IV)
02
01
01
01
01
01
02
02
02
02
02
02
02
02
02
04
01
02
04
04
02
04
03
03
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
101

Drug Name Drug Tier Notes
CARIMUNE NF INJ 3GM(Immune Globulin (Human) IV)
CARIMUNE NF INJ 6GM(Immune Globulin (Human) IV)
COMVAX INJ(Haemophilus B Polysac Conj-Hepatitis B (Recomb)
Vaccines)
DAPTACEL INJ(Diphtheria, Acellular Pertussis & Tetanus Toxoids)
DECAVAC INJ 5-2LF(Tetanus-Diphtheria Toxoids (Td))
DIP/TET PED INJ 6.7-5LF(Diphtheria-Tetanus Toxoids (DT))
ENGERIX-B INJ 10/0.5ML(Hepatitis B Vaccine (Recomb))
ENGERIX-B INJ 20MCG/ML(Hepatitis B Vaccine (Recomb))
FLBGAMMA DIF INJ 5%(Immune Globulin (Human) IV)
FLEBOGAMMA INJ 5%(Immune Globulin (Human) IV)
GAMASTAN S/D INJ(Immune Globulin (Human))
GAMMAGARD INJ 10GM/100(Immune Globulin (Human) IV)
GAMMAGARD INJ 1G/10ML(Immune Globulin (Human) IV)
GAMMAGARD INJ 2.5GM/25(Immune Globulin (Human) IV)
GAMMAGARD INJ 20GM/200(Immune Globulin (Human) IV)
GAMMAGARD INJ 5GM/50ML(Immune Globulin (Human) IV)
GAMMAGARD SD INJ 0.5GM HU(Immune Globulin (Human) IV)
GAMMAGARD SD INJ 10GM HU(Immune Globulin (Human) IV)
GAMMAGARD SD INJ 2.5GM HU(Immune Globulin (Human) IV)
GAMMAGARD SD INJ 5GM HU(Immune Globulin (Human) IV)
GAMUNEX INJ 10%(Immune Globulin (Human) IV)
GARDASIL INJ(Quadrivalent Human Papillomavirus (HPV) Recombinant
Vaccine)
HAVRIX INJ 1440UNIT(Hepatitis A Vaccine)
HAVRIX INJ 720UNIT(Hepatitis A Vaccine)
HIBTITER INJ(Haemophilus B Oligosaccharide Conjugate Vaccine)
IMMUNE GLOBU INJ HUMAN(Immune Globulin (Human))
IMOVAX RABIE INJ 2.5/ML(Rabies Virus Vaccine, HDC)
INFANRIX INJ(Diphtheria, Acellular Pertussis & Tetanus Toxoids)
IPOL INJ INACTIVE(Poliovirus Vaccine, IPV)
IVEEGAM EN INJ 5GM HU(Immune Globulin (Human) IV)
JE-VAX INJ(Japanese Encephalitis Virus Vaccine)
M-M-R II INJ LIVE(Measles, Mumps & Rubella Virus Vaccines)
M-M-R II INJ LIVE(Measles, Mumps & Rubella Virus Vaccines)
M-R-VAX II INJ(Measles & Rubella Vaccines)
MENACTRA INJ(Meningococcal (A,C,Y&W-135) Polysaccharide Conjugate
Vaccine)
MENOMUNE INJ A/C/Y/W(Meningococcal Vac A,C,Y&W-135)
MERUVAX II INJ LIVE(Rubella Virus Vaccine)
MERUVAX II INJ LIVE(Rubella Virus Vaccine)
MUMPSVAX INJ LIVE(Mumps Virus Vaccine Live)
MUMPSVAX INJ LIVE(Mumps Virus Vaccine Live)
OCTAGAM INJ 10GM(Immune Globulin (Human) IV)
OCTAGAM INJ 1GM(Immune Globulin (Human) IV)
OCTAGAM INJ 2.5GM(Immune Globulin (Human) IV)
OCTAGAM INJ 5GM(Immune Globulin (Human) IV)
PANGLOBULIN INJ 12GM(Immune Globulin (Human) IV)
PANGLOBULIN INJ 1GM(Immune Globulin (Human) IV)
PANGLOBULIN INJ 3GM(Immune Globulin (Human) IV)
03
03
02
02
04
04
02
02
03
03
03
03
03
03
03
03
03
03
03
03
03
04
02
02
02
03
04
02
02
03
02
02
02
04
04
02
02
02
02
02
03
03
03
03
03
03
03
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
102

Drug Name Drug Tier Notes
PANGLOBULIN INJ 6GM(Immune Globulin (Human) IV)
PANGLOBULIN SOL 12GM(Immune Globulin (Human) IV)
PANGLOBULIN SOL 6GM(Immune Globulin (Human) IV)
PEDIARIX INJ 0.5ML(Diph-Tetanus Tox-Acell Pert-Hepatitis B Recomb-
Polio IPV Vac)
PEDVAX HIB INJ(Haemophilus B Polysac Conj Vac)
POLYGAM S/D SOL 0.5GM(Immune Globulin (Human) IV)
POLYGAM S/D SOL 10GM(Immune Globulin (Human) IV)
POLYGAM S/D SOL 2.5GM(Immune Globulin (Human) IV)
POLYGAM S/D SOL 5GM(Immune Globulin (Human) IV)
PROQUAD INJ(Measles-Mumps-Rubella-Varicella Virus Vaccines)
RABAVERT INJ(Rabies Vaccine, PCEC)
RECOMBIVA HB INJ 10MCG/ML(Hepatitis B Vaccine (Recomb))
RECOMBIVA HB INJ 5MCG/0.5(Hepatitis B Vaccine (Recomb))
RECOMBIVA-HB INJ 10MCG/ML(Hepatitis B Vaccine (Recomb))
RECOMBIVA-HB INJ 40MCG/ML(Hepatitis B Vaccine (Recomb))
ROTATEQ SUS(Rotavirus Vaccine, Live Oral Pentavalent)
TE ANATOXAL INJ BERNA(Tetanus Toxoid Adsorbed)
TET/DIP TOX INJ 2-2 LF(Tetanus-Diphtheria Toxoids (Td))
TETANUS TOX INJ 5LF ADS(Tetanus Toxoid Adsorbed)
tetanus toxoid fluid inj 5 lf
THERACYS INJ(BCG Vaccine Intravesical)
TICE BCG INJ(BCG Vaccine Intravesical)
TRIHIBIT KIT P/F(Diph, Acellular Pertussis, Tetanus Tox & Haemophilus B
Poly)
TRIPEDIA SUS P/F(Diphtheria, Acellular Pertussis & Tetanus Toxoids)
TWINRIX INJ(Hepatitis A (Inactivated)-Hepatitis B (Recombinant)
Vaccines)
TYPHIM VI INJ(Typhoid VI Polysaccharide Vaccine)
VAQTA INJ 25/0.5ML(Hepatitis A Vaccine)
VAQTA INJ 50UNT/ML(Hepatitis A Vaccine)
varicella-zoster immune globulin (human ) inj 125 unit/2.5ml
varicella-zoster immune globulin (human ) inj 625 unit/10ml
VARIVAX INJ(Varicella Virus Vaccine Live)
VENOGLOBUL-S INJ 10%(Immune Globulin (Human) IV)
VIVAGLOBIN SOL 160MG/ML(Immune Globulin (Human) Subcutaneous)
VIVOTIF BERN CAP EC(Typhoid Vaccine)
YF-VAX INJ(Yellow Fever Vaccine)
ZOSTAVAX INJ(Zoster Vaccine Live)
Skin and Mucous Membrane Preparations
*papain-urea-chlorophyllin liquid***
*papain-urea-chlorophyllin ointment***
*sulfacetamide sodium-sulfur w/ sunscreens cream 10-5%***
8-MOP CAP 10MG(Methoxsalen)
ACCUTANE CAP 10MG(Isotretinoin)
ACCUTANE CAP 20MG(Isotretinoin)
ACCUTANE CAP 40MG(Isotretinoin)
ACCUZYME OIN(Papain-Urea)
ACCUZYME SPR(Papain-Urea)
03
03
03
02
04
03
03
03
03
04
02
02
02
02
02
02
02
04
02
01
04
04
04
02
02
02
02
02
01
01
02
03
02
04
04
02
01
01
01
04
02
02
02
04
04
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
103

Drug Name Drug Tier Notes
ACLOVATE CRE 0.05%(Alclometasone Dipropionate)
ACLOVATE OIN 0.05%(Alclometasone Dipropionate)
ACLOVATE OIN 0.05%(Alclometasone Dipropionate)
AKNE-MYCIN OIN 2%(Erythromycin (Acne Aid))
ALA-SCALP LOT 2%(Hydrocortisone (Topical))
alclometasone dipropionate cream 0.05%
alclometasone dipropionate oint 0.05%
ALDARA CRE 5%(Imiquimod)
ALTABAX OIN 1%(Retapamulin)
aluminum chloride soln 20%
AMCINONIDE LOT 0.1%(Amcinonide)
amcinonide cream 0.1%
amcinonide oint 0.1%
AMERICAINE GEL 20%(Benzocaine (Topical))
AMEVIVE INJ 15MG(Alefacept)
ANACAINE OIN(Benzocaine (Topical))
anthralin cream 1%
ANUSOL-HC CRE 2.5%(Hydrocortisone (Rectal))
augmented betamethasone dipropionate cream 0.05%
augmented betamethasone dipropionate gel 0.05%
augmented betamethasone dipropionate lotion 0.05%
augmented betamethasone dipropionate oint 0.05%
AVAR GEL 10-5%(Sulfacetamide Sodium w/ Sulfur)
AZELEX CRE 20%(Azelaic Acid (Acne))
BACTROBAN CRE 2%(Mupirocin Calcium (Topical))
BACTROBAN OIN 2%(Mupirocin)
BACTROBAN OIN NASAL 2%(Mupirocin Calcium)
BENZAC AC GEL 10%(Benzoyl Peroxide)
BENZAC AC GEL 2.5%(Benzoyl Peroxide)
BENZAC AC GEL 5%(Benzoyl Peroxide)
BENZAC W GEL 10%(Benzoyl Peroxide)
BENZAC W GEL 2.5%(Benzoyl Peroxide)
BENZAC W GEL 5%(Benzoyl Peroxide)
BENZACLIN GEL 1-5%(Clindamycin Phosphate-Benzoyl Peroxide)
BENZACLIN GEL 1-5%PUMP(Clindamycin Phosphate-Benzoyl Peroxide)
BENZAGEL-10 GEL 10%(Benzoyl Peroxide)
BENZAGEL-5 GEL 5%(Benzoyl Peroxide)
BENZAMYCIN GEL(Benzoyl Peroxide-Erythromycin)
BENZAMYCIN GEL PAK(Benzoyl Peroxide-Erythromycin)
BENZIQ GEL 5.25%(Benzoyl Peroxide)
BENZIQ LS GEL 2.75%(Benzoyl Peroxide)
benzoyl peroxide gel 10%
benzoyl peroxide gel 2.5%
benzoyl peroxide gel 2.75%
benzoyl peroxide gel 5%
benzoyl peroxide gel 5.25 %
benzoyl peroxide lotion 3%
benzoyl peroxide lotion 6%
benzoyl peroxide lotion 9%
benzoyl peroxide pad 3%
04
04
04
02
02
01
01
02
04
01
04
01
01
02
04
02
01
04
01
01
01
01
04
04
02
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
01
01
01
01
01
01
01
01
01
(PA)
(PA)
104

Drug Name Drug Tier Notes
benzoyl peroxide pad 6%
benzoyl peroxide pad 9%
benzoyl peroxide-erythromycin gel 5-3%
benzoyl peroxide-urea cleanser 4.5-10%
benzoyl peroxide-urea cleanser 6.5-10%
benzoyl peroxide-urea cleanser 8.5-10%
benzoyl peroxide-urea cream 6.5-10%
benzoyl peroxide-urea cream 8.5-10%
benzoyl peroxide-urea gel 4.5-10%
benzoyl peroxide-urea gel 6.5-10%
benzoyl peroxide-urea gel 8.5-10%
benzoyl peroxide-urea pad 4.5-10%
benzoyl peroxide-urea pad 6.5-10%
benzoyl peroxide-urea pad 8.5-10%
betamethasone dipropionate cream 0.05%
betamethasone dipropionate lotion 0.05%
betamethasone dipropionate oint 0.05%
betamethasone valerate cream 0.1%
betamethasone valerate lotion 0.1%
betamethasone valerate oint 0.1%
BREVOXYL GEL 4%(Benzoyl Peroxide)
BREVOXYL GEL 8%(Benzoyl Peroxide)
BREVOXYL-4 KIT ACNE WSH(Benzoyl Peroxide w/ Cleanser)
BREVOXYL-8 KIT ACNE WSH(Benzoyl Peroxide w/ Cleanser)
butamben-tetracaine-benzocaine aerosol spray 2-2-14%
CAPEX SHA 0.01%(Fluocinolone Acetonide)
CARAC CRE 0.5%(Fluorouracil (Topical))
CARMOL 40 GEL 40%(Urea)
CARMOL 40 LOT(Urea)
CARMOL SCALP KIT TREATMNT(Sulfacetamide Sodium-Urea)
CARMOL SCALP LOT TREATMEN(Sulfacetamide Sodium-Urea)
CARMOL-HC CRE 1%(Urea-HC Acetate)
CENTANY KIT 2%(Mupirocin)
ciclopirox olamine cream 0.77% (base equiv)
ciclopirox olamine susp 0.77% (base equiv)
CLARIFOAM EF AER 10-5%(Sulfacetamide Sodium w/ Sulfur)
CLEOCIN SUP 100MG(Clindamycin Phosphate Vaginal)
CLEOCIN VAG CRE 2%(Clindamycin Phosphate Vaginal)
CLEOCIN-T GEL 1%(Clindamycin Phosphate (Topical))
CLEOCIN-T LOT 1%(Clindamycin Phosphate (Topical))
CLEOCIN-T PAD 1%(Clindamycin Phosphate (Topical))
CLEOCIN-T SOL 1%(Clindamycin Phosphate (Topical))
CLINAC BPO GEL 7%(Benzoyl Peroxide)
CLINDAGEL
clindamycin phosphate gel 1%
clindamycin phosphate lotion 1%
clindamycin phosphate soln 1%
clindamycin phosphate swab 1%
GEL 1%(Clindamycin Phosphate (Topical))
clindamycin phosphate vaginal cream 2%
CLINDESSE CRE 2%(Clindamycin Phosphate (One Dose))
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
04
04
04
04
01
02
02
04
04
04
04
04
04
01
01
04
02
04
04
04
04
04
04
02
01
01
01
01
01
04
105

Drug Name Drug Tier Notes
clobetasol propionate cream 0.05%
clobetasol propionate emollient base cream 0.05%
clobetasol propionate gel 0.05%
clobetasol propionate oint 0.05%
clobetasol propionate soln 0.05%
CLOBEX LOT 0.05%(Clobetasol Propionate)
CLOBEX SHA 0.05%(Clobetasol Propionate)
CLOBEX SPR 0.05%(Clobetasol Propionate)
CLODERM CRE 0.1%(Clocortolone Pivalate)
clotrimazole troche 10 mg
clotrimazole w/ betamethasone cream 1-0.05%
clotrimazole w/ betamethasone lotion 1-0.05%
CONDYLOX GEL 0.5%(Podofilox)
CONDYLOX SOL 0.5%(Podofilox)
CORDRAN LOT 0.05%(Flurandrenolide)
CORDRAN OIN 0.05%(Flurandrenolide)
CORDRAN 24X3 TAP 4MCG/CM(Flurandrenolide)
CORDRAN 80X3 TAP 4MCG/CM(Flurandrenolide)
CORDRAN SP CRE 0.05%(Flurandrenolide)
CORTIFOAM AER 90MG(Hydrocortisone Acetate (Intrarectal))
CUTIVATE CRE 0.05%(Fluticasone Propionate)
CUTIVATE LOT 0.05%(Fluticasone Propionate)
CUTIVATE OIN 0.005%(Fluticasone Propionate)
DENAVIR CRE 1%(Penciclovir)
DERMA-SMOOTH OIL /FS(Fluocinolone Acetonide)
DERMA-SMOOTH OIL /FS(Fluocinolone Acetonide)
DERMATOP CRE 0.1%(Prednicarbate)
DERMATOP OIN 0.1%(Prednicarbate)
DESONATE GEL 0.05%(Desonide)
desonide cream 0.05%
desonide lotion 0.05%
desonide oint 0.05%
DESOWEN CRE 0.05%(Desonide)
DESOWEN LOT 0.05%(Desonide)
DESOWEN OIN 0.05%(Desonide)
desoximetasone cream 0.05%
desoximetasone cream 0.25%
desoximetasone gel 0.05%
desoximetasone oint 0.25%
DESQUAM-E GEL 5%(Benzoyl Peroxide)
DESQUAM-X GEL 10%(Benzoyl Peroxide)
DESQUAM-X GEL 5%(Benzoyl Peroxide)
DIFFERIN CRE 0.1%(Adapalene)
DIFFERIN GEL 0.1%(Adapalene)
DIFFERIN GEL 0.3%(Adapalene)
diflorasone diacetate cream 0.05%
diflorasone diacetate emollient base cream 0.05%
diflorasone diacetate oint 0.05%
DIPROLENE LOT 0.05%(Aug Betamethasone Dipropionate)
DIPROLENE OIN 0.05%(Aug Betamethasone Dipropionate)
01
01
01
01
01
02
02
04
04
01
01
01
02
04
04
04
04
04
04
02
04
04
04
02
02
02
04
04
04
01
01
01
04
04
04
01
01
01
01
04
04
04
04
04
04
01
01
01
04
04
106

Drug Name Drug Tier Notes
DIPROLENE AF CRE 0.05%(Aug Betamethasone Dipropionate)
DOVONEX CRE 0.005%(Calcipotriene)
DOVONEX SOL 0.005%(Calcipotriene)
doxepin hcl cream 5%
DRITHO-SCALP CRE 0.5%(Anthralin)
DRYSOL SOL 20%(Aluminum Chloride)
DUAC GEL 1-5%(Clindamycin Phosphate-Benzoyl Peroxide
(Refrigerate))
econazole nitrate cream 1%
EFUDEX CRE 5%(Fluorouracil (Topical))
EFUDEX KIT OCCLUSIO(Fluorouracil (Topical))
EFUDEX SOL 2%(Fluorouracil (Topical))
EFUDEX SOL 5%(Fluorouracil (Topical))
ELIDEL CRE 1%(Pimecrolimus)
ELIMITE CRE 5%(Permethrin)
ELOCON CRE 0.1%(Mometasone Furoate)
ELOCON LOT 0.1%(Mometasone Furoate)
ELOCON OIN 0.1%(Mometasone Furoate)
EMLA CRE(Lidocaine-Prilocaine)
EMLA KIT TEGADERM(Lidocaine-Prilocaine)
EPIFOAM AER 1%(Pramoxine-HC)
ERYGEL GEL 2%(Erythromycin (Acne Aid))
erythromycin gel 2%
erythromycin pads 2%
erythromycin soln 2%
EURAX CRE 10%(Crotamiton)
EURAX LOT 10%(Crotamiton)
EVOCLIN AER 1%(Clindamycin Phosphate (Topical))
EXELDERM CRE 1%(Sulconazole Nitrate)
EXELDERM SOL 1%(Sulconazole Nitrate)
FINACEA GEL 15%(Azelaic Acid)
fluocinolone acetonide cream 0.01%
fluocinolone acetonide cream 0.025%
fluocinolone acetonide oint 0.025%
fluocinolone acetonide soln 0.01%
fluocinonide cream 0.05%
fluocinonide emulsified base cream 0.05%
fluocinonide gel 0.05%
fluocinonide oint 0.05%
fluocinonide soln 0.05%
FLUOROPLEX CRE 1%(Fluorouracil (Topical))
fluorouracil cream 5%
fluorouracil soln 2%
fluorouracil soln 5%
fluticasone propionate cream 0.05%
fluticasone propionate oint 0.005%
FRST-HYDRCRT GEL 10%(Hydrocortisone (Topical))
gentamicin sulfate cream 0.1%
gentamicin sulfate oint 0.1%
GORDONS UREA OIN 40%(Urea)
02
02
02
01
02
04
04
01
04
04
04
04
02
04
04
04
04
04
04
02
04
01
01
01
02
02
02
02
02
04
01
01
01
01
01
01
01
01
01
02
01
01
01
01
01
02
01
01
02
(PA)
107

Drug Name Drug Tier Notes
halobetasol propionate cream 0.05%
halobetasol propionate oint 0.05%
HALOG CRE 0.1%(Halcinonide)
HALOG OIN 0.1%(Halcinonide)
HALOG SOL 0.1%(Halcinonide)
HYDRO 40 AER FOAM(Urea)
hydrocortisone butyrate cream 0.1%
hydrocortisone butyrate oint 0.1%
hydrocortisone butyrate soln 0.1%
hydrocortisone cream 1%
hydrocortisone cream 2.5%
hydrocortisone lotion 1%
hydrocortisone lotion 2.5%
hydrocortisone oint 1%
hydrocortisone oint 2.5%
hydrocortisone rectal cream 2.5%
hydrocortisone soln 1%
hydrocortisone valerate cream 0.2%
hydrocortisone valerate oint 0.2%
HYTONE CRE 2.5%(Hydrocortisone (Topical))
INOVA PAD 4%(Benzoyl Peroxide)
INOVA 4/1 PAD ACNE CON(Salicylic Acid-Benzoyl Peroxide)
isotretinoin cap 10 mg
isotretinoin cap 20 mg
isotretinoin cap 30 mg
isotretinoin cap 40 mg
KENALOG AER SPRAY(Triamcinolone Acetonide (Topical))
KENALOG CRE 0.1%(Triamcinolone Acetonide (Topical))
KEPIVANCE INJ 6.25MG(Palifermin)
KERAFOAM AER 30%(Urea)
KERALAC CRE(Urea)
KERALAC GEL(Urea)
KERALAC LOT(Urea)
KERALAC OIN 50%(Urea)
KERALAC SOL NAILSTIK(Urea)
KERALYT GEL 6%(Salicylic Acid)
KEROL SUS 50%(Urea in Lactic Acid-Salicylic Acid Vehicle)
ketoconazole cream 2%
ketoconazole shampoo 2%
KLARON LOT 10%(Sulfacetamide Sodium (Acne))
LAC-HYDRIN CRE 12%(Lactic Acid (Ammonium Lactate))
LAC-HYDRIN LOT 12%(Lactic Acid (Ammonium Lactate))
lactic acid (ammonium lactate) cream 12%
lactic acid (ammonium lactate) lotion 10%
lactic acid (ammonium lactate) lotion 12%
LACTINOL LOT 10%(Lactic Acid (Ammonium Lactate))
LAMISIL SPR 1%(Terbinafine HCl (Topical))
LEVULAN KERA SOL 20%(Aminolevulinic Acid HCl)
LIDAMANTLE CRE 3%(Lidocaine HCl)
lidocaine hcl cream 3%
01
01
04
04
04
04
01
01
01
01
01
01
01
01
01
01
01
01
01
04
04
04
01
01
01
01
02
04
02
04
04
04
04
04
04
04
04
01
01
04
04
04
01
01
01
04
04
02
02
01
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
108

Drug Name Drug Tier Notes
lidocaine hcl gel 2%
lidocaine hcl soln 4%
lidocaine oint 5%
lidocaine-prilocaine cream 2.5-2.5%
LIDODERM DIS 5%(Lidocaine)
lindane lotion 1%
lindane shampoo 1%
LOCOID LIPO CRE 0.1%(Hydrocortisone Butyrate Hydrophilic Lipo Base)
LOPROX CRE 0.77%(Ciclopirox Olamine)
LOPROX GEL TOPICAL(Ciclopirox)
LOPROX SHA 1%(Ciclopirox)
LOPROX SUS 0.77%(Ciclopirox Olamine)
LOTRISONE CRE(Clotrimazole w/ Betamethasone)
LOTRISONE LOT(Clotrimazole w/ Betamethasone)
LUXIQ AER 0.12%(Betamethasone Valerate)
MENTAX CRE 1%(Butenafine HCl)
METROCREAM CRE 0.75%(Metronidazole (Topical))
METROGEL GEL 1%(Metronidazole (Topical))
METROGEL KIT 1%(Metronidazole w/ Cleanser (Topical))
METROGEL VAG GEL 0.75%(Metronidazole Vaginal)
METROLOTION LOT 0.75%(Metronidazole (Topical))
metronidazole cream 0.75%
metronidazole gel 0.75%
metronidazole lotion 0.75%
metronidazole vaginal gel 0.75%
MICONAZOLE 3 SUP 200MG(Miconazole Nitrate Vaginal)
miconazole nitrate vaginal supp 200 mg & 2% cream 9 gm kit
mometasone furoate cream 0.1%
mometasone furoate oint 0.1%
mometasone furoate solution 0.1% (lotion)
mupirocin oint 2%
MYCELEX TRO 10MG(Clotrimazole)
MYCOSTATIN CRE 100000(Nystatin (Topical))
MYCOSTATIN POW 100000(Nystatin (Topical))
NAFTIN CRE 1%(Naftifine HCl)
NAFTIN GEL 1%(Naftifine HCl)
NAFTIN-MP CRE 1%(Naftifine HCl)
NIZORAL SHA 2%(Ketoconazole (Topical))
NORITATE CRE 1%(Metronidazole (Topical))
NUOX GEL 6-3%(Benzoyl Peroxide-Sulfur)
NYSTATIN TAB 100000(Nystatin Vaginal)
nystatin cream 100000 unit/gm
nystatin oint 100000 unit/gm
nystatin topical powder
nystatin vaginal tab 100000 unit
nystatin-triamcinolone cream 100000-0.1 unit/gm-%
nystatin-triamcinolone oint 100000-0.1 unit/gm-%
OLUX AER 0.05%(Clobetasol Propionate)
OLUX-E AER 0.05%(Clobetasol Propionate Emulsion)
OVACE WASH LIQ 10%(Sulfacetamide Sodium)
01
01
01
01
02
01
01
04
04
04
04
04
04
04
02
04
04
02
04
02
04
01
01
01
01
04
01
01
01
01
01
04
04
04
02
02
02
04
02
04
04
01
01
01
01
01
01
02
04
04
(PA)
(PA)
(PA)
109

Drug Name Drug Tier Notes
OVIDE LOT 0.5%(Malathion)
OXISTAT CRE 1%(Oxiconazole Nitrate)
OXISTAT LOT 1%(Oxiconazole Nitrate)
OXSORALEN LOT 1%(Methoxsalen (Topical))
OXSORALEN-UL CAP 10MG(Methoxsalen Rapid)
PANAFIL OIN(Papain-Urea-Chlorophyllin)
PANAFIL SPR(Papain-Urea-Chlorophyllin)
PANDEL CRE 0.1%(Hydrocortisone Probutate)
PANRETIN GEL 0.1%(Alitretinoin)
papain-urea ointment 650000 unit/gm-10%
papain-urea ointment 830000 unit/gm-100 mg/gm
papain-urea spray 650000 unit/gm-10%
PENLAC SOL 8%(Ciclopirox)
PERANEX HC KIT 2-2%(Lidocaine-Hydrocortisone Acetate (Rectal))
permethrin cream 5%
phenazopyridine hcl tab 100 mg
phenazopyridine hcl tab 200 mg
phenazopyridine-butabarbital-hyoscyamine tab 150-15-0.3 mg
PLEXION CLNS EMU 10-5%(Sulfacetamide Sodium w/ Sulfur)
PLEXION CLTH MIS 10-5%(Sulfacetamide Sodium w/ Sulfur)
PLEXION SCT CRE 10-5%(Sulfacetamide Sodium w/ Sulfur)
PLEXION TS SUS 10-5%(Sulfacetamide Sodium w/ Sulfur)
podofilox soln 0.5%
prednicarbate cream 0.1%
prednicarbate oint 0.1%
PROCTOCORT CRE 1%(Hydrocortisone (Topical))
PROTOPIC OIN 0.03%(Tacrolimus (Topical))
PROTOPIC OIN 0.1%(Tacrolimus (Topical))
PSORCON E CRE 0.05%(Diflorasone Diacetate Emollient Base)
PSORIATEC CRE 1%(Anthralin)
PYRIDIUM TAB 100MG(Phenazopyridine HCl)
PYRIDIUM TAB 200MG(Phenazopyridine HCl)
PYRIDIUM TAB PLUS(Phenazopyridine-Butabarbital-Hyoscyamine)
RAPTIVA KIT 125MG(Efalizumab)
REGRANEX GEL 0.01%(Becaplermin)
RETIN-A CRE 0.025%(Tretinoin)
RETIN-A CRE 0.05%(Tretinoin)
RETIN-A CRE 0.1%(Tretinoin)
RETIN-A GEL 0.01%(Tretinoin)
RETIN-A GEL 0.025%(Tretinoin)
RETIN-A MICR GEL 0.04%(Tretinoin Microsphere)
RETIN-A MICR GEL 0.04%PMP(Tretinoin Microsphere)
RETIN-A MICR GEL 0.1%(Tretinoin Microsphere)
RETIN-A MICR GEL 0.1%PUMP(Tretinoin Microsphere)
ROSAC CRE 10-5%(Sulfacetamide Sodium-Sulfur w/ Sunscreens)
ROSAC WASH EMU 10-1%(Sulfacetamide Sodium w/ Sulfur)
ROSULA EMU CLEANSER(Sulfacetamide Sodium-Sulfur in Urea Vehicle)
ROSULA GEL 10-5%(Sulfacetamide Sodium-Sulfur in Urea Vehicle)
ROSULA NS PAD(Sulfacetamide Sodium-Urea)
ROSULA WASH EMU 10-4%(Sulfacetamide Sodium-Sulfur in Urea Vehicle)
02
02
02
02
02
04
04
04
04
01
01
01
02
04
01
01
01
01
04
04
04
04
01
01
01
04
02
02
04
04
04
04
04
04
02
02
02
02
02
02
04
04
04
04
04
04
04
04
04
04
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
110

Drug Name Drug Tier Notes
ROZEX EMULSI EMU 0.75%(Metronidazole (Topical))
SALEX CRE 6%(Salicylic Acid)
SALEX LOT 6%(Salicylic Acid)
salicylic acid cream 6%
salicylic acid lotion 6%
SANTYL OIN 250/GM(Collagenase)
SEB-PREV CRE 10%(Sulfacetamide Sodium)
SEB-PREV GEL 10%(Sulfacetamide Sodium)
SEB-PREV LOT 10%(Sulfacetamide Sodium)
selenium sulfide lotion 2.5%
selenium sulfide-pyrithione zinc in urea shampoo 2.25%
SELSEB SHA 2.25%(Selenium Sulfide-Pyrithione Zinc in Urea Vehicle)
SELSUN SHA 2.5%(Selenium Sulfide)
SILVADENE CRE 1%(Silver Sulfadiazine)
silver sulfadiazine cream 1%
sodium thiosulfate-salicylic acid lotion 25-1%
SOLAGE SOL 0.01-2%(Mequinol-Tretinoin)
SOLARAZE GEL 3% W/W(Diclofenac Sodium (Actinic Keratoses))
SULFACET-R LOT(Sulfacetamide Sodium w/ Sulfur)
sulfacetamide sodium liquid 10%
sulfacetamide sodium lot 10% & urea shampoo 10% kit
sulfacetamide sodium lotion 10% (acne)
sulfacetamide sodium w/ sulfur cleansing cloth 10-5%
sulfacetamide sodium w/ sulfur cream 10-5%
sulfacetamide sodium w/ sulfur emulsion 10-5%
sulfacetamide sodium w/ sulfur lotion 10-5%
sulfacetamide sodium w/ sulfur susp 10-5%
sulfacetamide sodium-sulfur in urea emulsion 10-5%
sulfacetamide sodium-sulfur in urea gel 10-5%
sulfacetamide sodium-urea lotion 10-10%
sulfacetamide sodium-urea pad 10-10%
SULFAMYLON CRE 85MG/GM(Mafenide Acetate)
SULFAMYLON PAK 5%(Mafenide Acetate)
SULFOXYL LOT(Benzoyl Peroxide-Sulfur)
SULFOXYL LOT STRONG(Benzoyl Peroxide-Sulfur)
TARGRETIN GEL 1%(Bexarotene (Topical))
TAZORAC CRE 0.05%(Tazarotene)
TAZORAC CRE 0.1%(Tazarotene)
TAZORAC GEL 0.05%(Tazarotene)
TAZORAC GEL 0.1%(Tazarotene)
TEMOVATE CRE 0.05%(Clobetasol Propionate)
TEMOVATE GEL 0.05%(Clobetasol Propionate)
TEMOVATE OIN 0.05%(Clobetasol Propionate)
TEMOVATE SOL 0.05%(Clobetasol Propionate)
TEMOVATE E CRE 0.05%EML(Clobetasol Propionate Emollient Base)
TERAZOL 3 CRE 0.8%(Terconazole Vaginal)
TERAZOL 3 SUP 80MG(Terconazole Vaginal)
TERAZOL 7 CRE 0.4%(Terconazole Vaginal)
terconazole vaginal cream 0.4%
terconazole vaginal cream 0.8%
02
04
04
01
01
02
04
04
04
01
01
04
04
04
01
01
04
02
04
01
01
01
01
01
01
01
01
01
01
01
01
04
04
04
04
02
02
02
02
02
04
04
04
04
04
04
04
04
01
01
(PA)
(PA)
(PA)
(PA)
(PA)
111

Drug Name Drug Tier Notes
terconazole vaginal suppos 80 mg
TEXACORT SOL 2.5%(Hydrocortisone (Topical))
TOPICORT CRE 0.25%(Desoximetasone)
TOPICORT GEL 0.05%(Desoximetasone)
TOPICORT OIN 0.25%(Desoximetasone)
TOPICORT LP CRE 0.05%(Desoximetasone)
tretinoin cream 0.025%
tretinoin cream 0.05%
tretinoin cream 0.1%
tretinoin gel 0.01%
tretinoin gel 0.025%
triamcinolone acetonide cream 0.025%
triamcinolone acetonide cream 0.1%
triamcinolone acetonide cream 0.5%
triamcinolone acetonide in orabase 0.1%
triamcinolone acetonide lotion 0.025%
triamcinolone acetonide lotion 0.1%
triamcinolone acetonide oint 0.025%
triamcinolone acetonide oint 0.1%
triamcinolone acetonide oint 0.5%
TRIAZ PAD 3%(Benzoyl Peroxide)
TRIAZ PAD 6%(Benzoyl Peroxide)
TRIAZ PAD 9%(Benzoyl Peroxide)
TRIAZ CLEANS LOT 3%(Benzoyl Peroxide)
TRIAZ CLEANS LOT 6%(Benzoyl Peroxide)
TRIAZ CLEANS LOT 9%(Benzoyl Peroxide)
ULTRAVATE CRE 0.05%(Halobetasol Propionate)
ULTRAVATE OIN 0.05%(Halobetasol Propionate)
UMECTA EMU(Urea)
UMECTA SUS 40%(Urea)
UMECTA NAIL SUS 40%(Urea)
UMECTA PD EMU 40%(Urea)
UMECTA PD SUS 40%(Urea)
urea cream 40%
urea cream 50%
urea gel 40%
urea gel 50%
urea lotion 35%
urea lotion 40%
urea ointment 50%
urea soln 50%
urea-hc acetate cream 1%
UVADEX INJ 20MCG/ML(Methoxsalen (Photopheresis))
VANOS CRE 0.1%(Fluocinonide)
VANOXIDE-HC LOT(Benzoyl Peroxide-HC)
VERDESO AER 0.05%(Desonide)
WESTCORT CRE 0.2%(Hydrocortisone Valerate)
WESTCORT OIN 0.2%(Hydrocortisone Valerate)
XYLOCAINE GEL 2%(Lidocaine HCl)
XYLOCAINE SOL 4%(Lidocaine HCl)
01
02
04
04
04
04
01
01
01
01
01
01
01
01
01
01
01
01
01
01
04
04
04
04
04
04
04
04
02
02
02
02
02
01
01
01
01
01
01
01
01
01
04
02
04
04
04
04
02
02
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
112

Drug Name Drug Tier Notes
XYRALID LP KIT(Lidocaine-Hydrocortisone Acetate w/ Cleanser)
XYRALID RC KIT(Lidocaine-Hydrocortisone Acetate-Psyllium)
ZACLIR LOT 4%(Benzoyl Peroxide)
ZACLIR LOT 8%(Benzoyl Peroxide)
ZIANA GEL(Clindamycin Phosphate-Tretinoin)
ZODERM CRE 4.5%-10%(Benzoyl Peroxide-Urea)
ZODERM CRE 6.5%-10%(Benzoyl Peroxide-Urea)
ZODERM CRE 8.5%-10%(Benzoyl Peroxide-Urea)
ZODERM GEL 4.5%-10%(Benzoyl Peroxide-Urea)
ZODERM GEL 6.5%-10%(Benzoyl Peroxide-Urea)
ZODERM GEL 8.5%-10%(Benzoyl Peroxide-Urea)
ZODERM LIQ 4.5%-10%(Benzoyl Peroxide-Urea)
ZODERM LIQ 6.5%-10%(Benzoyl Peroxide-Urea)
ZODERM LIQ 8.5%-10%(Benzoyl Peroxide-Urea)
ZODERM PAD 4.5%(Benzoyl Peroxide-Urea)
ZODERM PAD 6.5%(Benzoyl Peroxide-Urea)
ZODERM PAD 8.5%(Benzoyl Peroxide-Urea)
ZONALON CRE 5%(Doxepin HCl (Antipruritic))
ZOVIRAX CRE 5%(Acyclovir Topical)
ZOVIRAX OIN 5%(Acyclovir Topical)
Smooth Muscle Relaxants
aminophylline inj 25 mg/ml
aminophylline tab 100 mg
aminophylline tab 200 mg
BRONCAP TAB 150-200(Theophylline-Guaifenesin)
BRONCODUR SOL(Theophylline-Guaifenesin)
DETROL TAB 1MG(Tolterodine Tartrate)
DETROL TAB 2MG(Tolterodine Tartrate)
DETROL LA CAP 2MG(Tolterodine Tartrate)
DETROL LA CAP 4MG(Tolterodine Tartrate)
DITROPAN SYP 5MG/5ML(Oxybutynin Chloride)
DITROPAN TAB 5MG(Oxybutynin Chloride)
DITROPAN XL TAB 10MG(Oxybutynin Chloride)
DITROPAN XL TAB 15MG(Oxybutynin Chloride)
DITROPAN XL TAB 5MG(Oxybutynin Chloride)
dyphylline-guaifenesin cap 200-100 mg
dyphylline-guaifenesin liqd 100-100 mg/15ml
dyphylline-guaifenesin syrup 200-100 mg/5ml
dyphylline-guaifenesin tab 200-300 mg
dyphylline-guaifenesin tab 200-400 mg
ELIXOPHYL GG SOL 100-100(Theophylline-Guaifenesin)
ELIXOPHYLLIN ELX 80/15ML(Theophylline)
ENABLEX TAB 15MG(Darifenacin Hydrobromide)
ENABLEX TAB 7.5MG(Darifenacin Hydrobromide)
flavoxate hcl tab 100 mg
oxybutynin chloride syrup 5 mg/5ml
oxybutynin chloride tab 5 mg
oxybutynin chloride tab sr 24hr 10 mg
oxybutynin chloride tab sr 24hr 15 mg
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
01
01
01
04
04
02
02
02
02
04
04
04
04
04
01
01
01
01
01
04
02
04
04
01
01
01
01
01
113

Drug Name Drug Tier Notes
oxybutynin chloride tab sr 24hr 5 mg
OXYTROL DIS 3.9MG/24(Oxybutynin)
SANCTURA TAB 20MG(Trospium Chloride)
THEO-24 CAP 100MG CR(Theophylline)
THEO-24 CAP 200MG CR(Theophylline)
THEO-24 CAP 300MG CR(Theophylline)
THEO-24 CAP 400MG ER(Theophylline)
THEOCAP CAP 200MG CR(Theophylline)
theophylline cap sr 12hr 125 mg
theophylline cap sr 12hr 300 mg
theophylline sod glycinate-gg syrup 300-100 mg/15ml
theophylline tab sr 12hr 100 mg
theophylline tab sr 12hr 200 mg
theophylline tab sr 12hr 300 mg
theophylline tab sr 12hr 450 mg
theophylline tab sr 24hr 400 mg
theophylline tab sr 24hr 600 mg
theophylline-guaifenesin liquid 150-90 mg/15ml
UNIPHYL TAB 400MG CR(Theophylline)
UNIPHYL TAB 600MG CR(Theophylline)
URISPAS TAB 100MG(Flavoxate HCl)
VESICARE TAB 10MG(Solifenacin Succinate)
VESICARE TAB 5MG(Solifenacin Succinate)
Vitamins
*pediatric multiple vitamins w/ fluoride chew tab 0.25 mg***
*pediatric multiple vitamins w/ fluoride chew tab 0.5 mg***
*pediatric multiple vitamins w/ fluoride chew tab 1 mg***
*pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml***
*pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml***
*pediatric vitamins acd w/ fluoride chew tab 1 mg***
*pediatric vitamins acd w/ fluoride soln 0.25 mg/ml***
*pediatric vitamins acd w/ fluoride soln 0.5 mg/ml***
*prenatal multivitamins & minerals w/ iron & fa cap 1 mg***
*prenatal multivitamins & minerals w/ iron & fa tab 1 mg***
*prenatal multivitamins & minerals w/iron & fa tab 0.8 mg***
*prenatal vit w/ fe polysac cmplx-fa tab 60-1 mg***
*prenatal w/o a vit w/ fe fumarate-fa cap 106-1 mg***
CALCIJEX INJ 1MCG/ML(Calcitriol)
calcitriol cap 0.25 mcg
calcitriol cap 0.5 mcg
calcitriol inj 1 mcg/ml
calcitriol oral soln 1 mcg/ml
CENOGEN ULTR CAP(Prenatal without A Vit w/ Fe Fumarate-Folic Acid)
cyanocobalamin inj 1000 mcg/ml
HECTOROL CAP 0.5MCG(Doxercalciferol)
HECTOROL CAP 2.5MCG(Doxercalciferol)
HECTOROL INJ 4MCG/2ML(Doxercalciferol)
hydroxocobalamin inj 1000 mcg/ml
MYNATAL CAP(Prenatal Multivit-Min w/Fe-FA)
01
04
04
02
02
02
02
02
01
01
01
01
01
01
01
01
01
01
02
02
04
02
02
01
01
01
01
01
01
01
01
01
01
01
01
01
04
01
01
01
01
04
01
02
02
02
01
04
114

Drug Name Drug Tier Notes
NASCOBAL GEL(Cyanocobalamin)
NASCOBAL SPR 500MCG(Cyanocobalamin)
niacin tab 500 mg
PRECARE CHW(Prenatal without A Vit w/ Fe Fumarate-Folic Acid)
ROCALTROL CAP 0.25MCG(Calcitriol)
ROCALTROL CAP 0.5MCG(Calcitriol)
ROCALTROL SOL 1MCG/ML(Calcitriol)
ZEMPLAR CAP 1MCG(Paricalcitol)
ZEMPLAR CAP 2MCG(Paricalcitol)
ZEMPLAR CAP 4MCG(Paricalcitol)
ZEMPLAR INJ 2MCG/ML(Paricalcitol)
ZEMPLAR INJ 5MCG/ML(Paricalcitol)
Miscellaneous Therapeutic Agents
ACTIMMUNE INJ 2MU/0.5(Interferon Gamma-1B)
ACTONEL TAB 30MG(Risedronate Sodium)
ACTONEL TAB 35MG(Risedronate Sodium)
ACTONEL TAB 5MG(Risedronate Sodium)
ACTONEL TAB 75MG(Risedronate Sodium)
ACTONEL WITH TAB CALCIUM(Risedronate Sodium with Calcium
Carbonate)
allopurinol sodium for inj 500 mg
allopurinol tab 100 mg
allopurinol tab 300 mg
ALOPRIM INJ 500MG(Allopurinol Sodium)
ANTABUSE TAB 250MG(Disulfiram)
ANTABUSE TAB 500MG(Disulfiram)
APHTHASOL PST 5%(Amlexanox)
ARALAST INJ 400MG(Proteinase Inhibitor (Human))
ARALAST INJ 800MG(Proteinase Inhibitor (Human))
ARAVA TAB 10MG(Leflunomide)
ARAVA TAB 20MG(Leflunomide)
AREDIA INJ 30MG(Pamidronate Disodium)
AREDIA INJ 90MG(Pamidronate Disodium)
ATGAM INJ 250MG(Lymphocyte Immune Globulin,Anti-Thymocyte
Globulin (Equine))
AVODART CAP 0.5MG(Dutasteride)
AVONEX INJ 30MCG(Interferon Beta-1a)
AVONEX KIT(Interferon Beta-1a)
azathioprine sodium for inj 100 mg
azathioprine tab 100 mg
azathioprine tab 50 mg
azathioprine tab 75 mg
BETASERON INJ 0.3MG(Interferon Beta-1b)
BONIVA KIT 3MG/3ML(Ibandronate Sodium)
BONIVA TAB 150MG(Ibandronate Sodium)
BONIVA TAB 2.5MG(Ibandronate Sodium)
bromocriptine mesylate cap 5 mg
bromocriptine mesylate tab 2.5 mg
cabergoline tab 0.5 mg
04
04
03
02
04
04
04
02
02
02
02
02
03
02
02
02
02
02
01
01
01
04
02
02
04
04
04
04
04
03
03
02
02
03
03
01
03
03
03
03
02
02
02
01
01
01
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
115

Drug Name Drug Tier Notes
CARNITOR TAB 330MG(Levocarnitine (Metabolic Modifiers))
CELLCEPT CAP 250MG(Mycophenolate Mofetil)
CELLCEPT SUS 200MG/ML(Mycophenolate Mofetil)
CELLCEPT TAB 500MG(Mycophenolate Mofetil)
CELLCEPT IV INJ 500MG(Mycophenolate Mofetil HCl)
CEPROTIN INJ 1000UNIT(Protein C Concentrate (Human))
CEPROTIN INJ 500 UNIT(Protein C Concentrate (Human))
CEREZYME INJ 200UNIT(Imiglucerase)
CEREZYME INJ 400UNIT(Imiglucerase)
colchicine inj 0.5 mg/ml
colchicine tab 0.6 mg
COPAXONE KIT 20MG/ML(Glatiramer Acetate)
CYANOKIT INJ 5GM(Hydroxocobalamin (Antidote))
cyclosporine cap 100 mg
cyclosporine cap 25 mg
cyclosporine iv soln 50 mg/ml
cyclosporine modified cap 100 mg
cyclosporine modified cap 25 mg
cyclosporine modified cap 50 mg
cyclosporine modified oral soln 100 mg/ml
cyclosporine oral soln 100 mg/ml
dexrazoxane for inj 250 mg
dexrazoxane for inj 500 mg
DIDRONEL TAB 200MG(Etidronate Disodium)
DIDRONEL TAB 400MG(Etidronate Disodium)
DIDRONEL IV INJ 50MG/ML(Etidronate Disodium)
DOSTINEX TAB 0.5MG(Cabergoline)
ELMIRON CAP 100MG(Pentosan Polysulfate Sodium)
ENBREL INJ 25/0.5ML(Etanercept)
ENBREL INJ 25MG(Etanercept)
ENBREL INJ 50MG/ML(Etanercept)
ETHYOL INJ 500MG(Amifostine Crystalline)
etidronate disodium tab 200 mg
etidronate disodium tab 400 mg
finasteride tab 5 mg
FLOMAX CAP 0.4MG(Tamsulosin HCl)
FLUORABON DRO(Sodium Fluoride)
FLURA-DROPS DRO 0.25MG(Sodium Fluoride)
FOSAMAX SOL(Alendronate Sodium)
FOSAMAX TAB 10MG(Alendronate Sodium)
FOSAMAX TAB 35MG(Alendronate Sodium)
FOSAMAX TAB 40MG(Alendronate Sodium)
FOSAMAX TAB 5MG(Alendronate Sodium)
FOSAMAX TAB 70MG(Alendronate Sodium)
FOSAMAX PLUS TAB D(Alendronate Sodium-Cholecalciferol)
FOSAMAX PLUS TAB D(Alendronate Sodium-Cholecalciferol)
GASTROCROM CON 100/5ML(Cromolyn Sodium (Mastocytosis))
HUMIRA KIT 40MG/0.8(Adalimumab)
HUMIRA PEN KIT 40MG/0.8(Adalimumab)
HUMIRA PEN KIT STARTER(Adalimumab)
04
02
02
02
02
04
04
02
02
01
01
03
04
03
03
03
01
01
01
01
03
01
01
04
04
02
04
04
03
03
03
03
01
01
01
02
02
02
02
02
02
02
02
02
02
04
04
03
03
03
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
116

Drug Name Drug Tier Notes
IMURAN TAB 50MG(Azathioprine)
KINERET INJ(Anakinra)
leflunomide tab 10 mg
leflunomide tab 20 mg
leucovorin calcium for inj 100 mg
leucovorin calcium for inj 200 mg
leucovorin calcium for inj 350 mg
leucovorin calcium for inj 50 mg
leucovorin calcium for inj 500 mg
leucovorin calcium inj 10 mg/ml
leucovorin calcium tab 10 mg
leucovorin calcium tab 15 mg
leucovorin calcium tab 25 mg
leucovorin calcium tab 5 mg
levocarnitine tab 330 mg
LURIDE CHW 0.25MG(Sodium Fluoride)
LURIDE CHW 0.5MG(Sodium Fluoride)
LURIDE CHW 1MG(Sodium Fluoride)
LURIDE DRO 0.5MG/ML(Sodium Fluoride)
mesna inj 100 mg/ml
MESNEX INJ 1GM(Mesna)
MESNEX TAB 400MG(Mesna)
MYFORTIC TAB 180MG(Mycophenolate Sodium)
MYFORTIC TAB 360MG(Mycophenolate Sodium)
NEORAL CAP 100MG(Cyclosporine Modified (For Microemulsion))
NEORAL CAP 25MG(Cyclosporine Modified (For Microemulsion))
NEORAL SOL 100MG/ML(Cyclosporine Modified (For Microemulsion))
octreotide acetate inj 0.05 mg/ml
octreotide acetate inj 0.1 mg/ml
octreotide acetate inj 0.2 mg/ml
octreotide acetate inj 0.5 mg/ml
octreotide acetate inj 1 mg/ml
ORENCIA INJ 250MG(Abatacept)
ORFADIN CAP 10MG(Nitisinone)
ORFADIN CAP 2MG(Nitisinone)
ORFADIN CAP 5MG(Nitisinone)
ORTHOCLONE INJ OKT3(Muromonab CD3)
pamidronate disodium for inj 30 mg
pamidronate disodium for inj 90 mg
pamidronate disodium iv soln 3 mg/ml
pamidronate disodium iv soln 6 mg/ml
pamidronate disodium iv soln 9 mg/ml
PARLODEL CAP 5MG(Bromocriptine Mesylate)
PARLODEL TAB 2.5MG(Bromocriptine Mesylate)
PREVIDENT CRE 5000 PLS(Sodium Fluoride (Dental))
PREVIDENT SOL RINSE(Sodium Fluoride (Dental))
PROGRAF CAP 0.5MG(Tacrolimus)
PROGRAF CAP 1MG(Tacrolimus)
PROGRAF CAP 5MG(Tacrolimus)
PROGRAF INJ 5MG/ML(Tacrolimus)
03
04
01
01
01
01
01
01
01
01
01
01
01
01
01
04
04
04
04
01
02
02
02
02
02
02
02
01
01
01
01
01
04
04
04
04
02
03
03
01
01
01
04
04
04
04
02
02
02
02
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
117

Drug Name Drug Tier Notes
PROLASTIN INJ 1000MG(Proteinase Inhibitor (Human))
PROLASTIN INJ 500MG(Proteinase Inhibitor (Human))
PROSCAR TAB 5MG(Finasteride)
PROSTASCINT KIT(Capromab Pendetide)
QUADRAMET INJ VIAL(Samarium Sm 153 Lexidronam)
RAPAMUNE SOL 1MG/ML(Sirolimus)
RAPAMUNE TAB 1MG(Sirolimus)
RAPAMUNE TAB 2MG(Sirolimus)
REBIF INJ 22/0.5(Interferon Beta-1a)
REBIF INJ 44/0.5(Interferon Beta-1a)
REBIF TITRTN SOL PACK(Interferon Beta-1a)
RECLAST INJ 5/100ML(Zoledronic Acid)
RELAMINE TAB(Glucosamine-Chondroitin-PABA-Vit E-Alpha Lipoic Acid)
REMICADE INJ 100MG(Infliximab)
REVLIMID CAP 10MG(Lenalidomide)
REVLIMID CAP 15MG(Lenalidomide)
REVLIMID CAP 25MG(Lenalidomide)
REVLIMID CAP 5MG(Lenalidomide)
RIMSO-50 SOL 50%(Dimethyl Sulfoxide)
SANDIMMUNE CAP 100MG(Cyclosporine)
SANDIMMUNE CAP 25MG(Cyclosporine)
SANDIMMUNE INJ 50MG/ML(Cyclosporine)
SANDIMMUNE SOL 100MG/ML(Cyclosporine)
SANDOSTATIN INJ 0.2MG/ML(Octreotide Acetate)
SANDOSTATIN INJ 100MCG(Octreotide Acetate)
SANDOSTATIN INJ 1MG/ML(Octreotide Acetate)
SANDOSTATIN INJ 500MCG(Octreotide Acetate)
SANDOSTATIN INJ 50MCG/ML(Octreotide Acetate)
SANDOSTATIN KIT LAR 10MG(Octreotide Acetate)
SANDOSTATIN KIT LAR 20MG(Octreotide Acetate)
SANDOSTATIN KIT LAR 30MG(Octreotide Acetate)
SENSIPAR TAB 30MG(Cinacalcet HCl)
SENSIPAR TAB 60MG(Cinacalcet HCl)
SENSIPAR TAB 90MG(Cinacalcet HCl)
SIMULECT INJ 10MG(Basiliximab)
SIMULECT INJ 20MG(Basiliximab)
SKELID TAB 200MG(Tiludronate Disodium)
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
sodium fluoride cream 1.1%
sodium fluoride lozenge 1 mg f (from 2.2 mg naf)
sodium fluoride rinse 0.2%
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf)
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
sodium fluoride tab 1 mg f (from 2.2 mg naf)
SOLIRIS INJ 10MG/ML(Eculizumab)
SORIATANE CAP 10MG(Acitretin)
SORIATANE CAP 25MG(Acitretin)
THALOMID CAP 100MG(Thalidomide)
04
04
04
04
04
02
02
02
03
03
03
04
04
04
04
04
04
04
04
03
03
03
03
02
02
02
02
02
02
02
02
02
02
02
03
03
04
01
01
01
01
01
01
01
01
01
04
04
04
04
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
(PA)
118

Drug Name Drug Tier Notes
THALOMID CAP 150MG(Thalidomide)
THALOMID CAP 200MG(Thalidomide)
THALOMID CAP 50MG(Thalidomide)
THYMOGLOBULN INJ 25MG(Anti-Thymocyte Globulin (Rabbit), Lymphocyte
Immune Globulin)
UROLENE BLUE TAB 65MG(Methylene Blue)
UROXATRAL TAB 10MG(Alfuzosin HCl)
ZAVESCA CAP 100MG(Miglustat)
ZEMAIRA SOL 1000MG(Proteinase Inhibitor (Human))
ZENAPAX INJ 25MG/5ML(Daclizumab)
ZINECARD INJ 250MG(Dexrazoxane)
ZINECARD INJ 500MG(Dexrazoxane)
ZOMETA INJ 4MG/5ML(Zoledronic Acid)
ZYLOPRIM TAB 100MG(Allopurinol)
ZYLOPRIM TAB 300MG(Allopurinol)
Devices
*alcohol swabs***
*gauze pads & dressings - pads 2" x 2"***
AUTOPEN MIS 1 UNIT(Injection Device for Insulin)
AUTOPEN MIS 1-21UNIT(Injection Device for Insulin)
AUTOPEN MIS 2 UNIT(Injection Device for Insulin)
AUTOPEN MIS 2-16UNIT(Injection Device for Insulin)
AUTOPEN MIS 2-32UNIT(Injection Device for Insulin)
AUTOPEN MIS 2-42UNIT(Injection Device for Insulin)
BD PEN MIS(Injection Device for Insulin)
BD PEN MINI MIS(Injection Device for Insulin)
BD UF MINI MIS PENNEEDL(Insulin Pen Needle)
BD UF ORIG MIS PENNEEDL(Insulin Pen Needle)
BD UF SHORT MIS PENNEEDL(Insulin Pen Needle)
BL STERILE PAD 2"X2"(Gauze Pads & Dressings)
CURITY GAUZE PAD 2"X2"(Gauze Pads & Dressings)
ECK STERILE PAD 2"X2"(Gauze Pads & Dressings)
GAUZE PAD PAD 2"X2"(Gauze Pads & Dressings)
GNP STERILE PAD 2"X2"(Gauze Pads & Dressings)
HUMAPEN MIS LUXURA(Injection Device for Insulin)
HUMAPEN MIS MEMOIR(Injection Device for Insulin)
INJEX 30 NF MIS SYSTEM(Injection Device Needle-Free for Insulin)
INSULIN PEN MIS 29GX1/2"(Insulin Pen Needle)
INSULIN PEN MIS 31GX1/3"(Insulin Pen Needle)
INSULIN PEN MIS 31GX1/4"(Insulin Pen Needle)
INSULIN SYRG MIS 0.3/31G(Insulin Syringe/Needle U-100)
INSULIN SYRG MIS 0.5/28G(Insulin Syringe/Needle U-100)
INSULIN SYRG MIS 0.5/30G(Insulin Syringes (Disposable))
INSULIN SYRG MIS 0.5/31G(Insulin Syringe/Needle U-100)
INSULIN SYRG MIS 1ML(Insulin Syringes (Disposable))
INSULIN SYRG MIS 1ML(Insulin Syringes (Disposable))
INSULIN SYRG MIS 1ML(Insulin Syringes (Disposable))
INSULIN SYRG MIS 1ML(Insulin Syringes (Disposable))
INSULIN SYRG MIS 1ML/29G(Insulin Syringe/Needle U-100)
04
04
04
02
04
02
04
04
03
04
04
03
04
04
01
01
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
(PA)
(PA)
(PA)
119

Drug Name Drug Tier Notes
INSULIN SYRG MIS 1ML/29G(Insulin Syringes (Disposable))
INSULIN SYRG MIS 1ML/30G(Insulin Syringe/Needle U-100)
INSULIN SYRG MIS 1ML/30G(Insulin Syringe/Needle U-100)
INSULIN SYRG MIS 1ML/31G(Insulin Syringe/Needle U-100)
insulin syringe (disp) u-100 0.3 ml
insulin syringe (disp) u-100 1 ml
insulin syringe (disp) u-100 1/2 ml
insulin syringe/needle u-100 0.3 ml 28 g x 1"
insulin syringe/needle u-100 0.3 ml 28 x 1/2"
insulin syringe/needle u-100 0.3 ml 29 g
insulin syringe/needle u-100 0.3 ml 29 x 1"
insulin syringe/needle u-100 0.3 ml 29 x 1/2"
insulin syringe/needle u-100 0.3 ml 29 x 5/16"
insulin syringe/needle u-100 0.3 ml 29 x 7/16"
insulin syringe/needle u-100 0.3 ml 30 g
insulin syringe/needle u-100 0.3 ml 30 x 1"
insulin syringe/needle u-100 0.3 ml 30 x 1/2"
insulin syringe/needle u-100 0.3 ml 30 x 3/8"
insulin syringe/needle u-100 0.3 ml 30 x 5/16"
insulin syringe/needle u-100 0.3 ml 30 x 7/16"
insulin syringe/needle u-100 0.3 ml 31 x 5/16"
insulin syringe/needle u-100 1 ml 25 x 1"
insulin syringe/needle u-100 1 ml 25 x 5/8"
insulin syringe/needle u-100 1 ml 26 x 1/2"
insulin syringe/needle u-100 1 ml 27 x 1/2"
insulin syringe/needle u-100 1 ml 27 x 5/8"
insulin syringe/needle u-100 1 ml 28 x 1/2"
insulin syringe/needle u-100 1 ml 28 x 5/16"
insulin syringe/needle u-100 1 ml 29 x 1"
insulin syringe/needle u-100 1 ml 29 x 1/2"
insulin syringe/needle u-100 1 ml 29 x 5/16"
insulin syringe/needle u-100 1 ml 29 x 7/16"
insulin syringe/needle u-100 1 ml 30 g
insulin syringe/needle u-100 1 ml 30 g x 1"
insulin syringe/needle u-100 1 ml 30 x 1/2"
insulin syringe/needle u-100 1 ml 30 x 5/16"
insulin syringe/needle u-100 1 ml 30 x 7/16"
insulin syringe/needle u-100 1 ml 31 x 5/16"
insulin syringe/needle u-100 1/2 ml 27 x 1/2"
insulin syringe/needle u-100 1/2 ml 28 x 1"
insulin syringe/needle u-100 1/2 ml 28 x 1/2"
insulin syringe/needle u-100 1/2 ml 29 g
insulin syringe/needle u-100 1/2 ml 29 x 1"
insulin syringe/needle u-100 1/2 ml 29 x 1/2"
insulin syringe/needle u-100 1/2 ml 29 x 5/16"
insulin syringe/needle u-100 1/2 ml 29 x 7/16"
insulin syringe/needle u-100 1/2 ml 30 g
insulin syringe/needle u-100 1/2 ml 30 g x 1"
insulin syringe/needle u-100 1/2 ml 30 x 1/2"
insulin syringe/needle u-100 1/2 ml 30 x 3/8"
02
02
02
02
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
01
120

Drug Name Drug Tier Notes
insulin syringe/needle u-100 1/2 ml 30 x 5/16"
insulin syringe/needle u-100 1/2 ml 30 x 7/16"
insulin syringe/needle u-100 1/2 ml 31 x 5/16"
insulin syringe/needle u-100 2 ml 27.5 x 5/8"
insulin syringe/needle u-100 2 ml 29 x 1/2"
insulin syringe/needle u-40 1 ml 26 x 1/2"
ISLAND GARD PAD 2"X2"(Gauze Pads & Dressings)
J&J GAUZE PAD 2" X 2"(Gauze Pads & Dressings)
LYOFOAM A PAD 2"X2"(Gauze Pads & Dressings)
MEDI-JECTOR MIS CHOICE(Injection Device Needle-Free for Insulin)
MEDI-JECTOR MIS VISION(Injection Device for Insulin)
MIRASORB MIS 2" X 2"(Gauze Pads & Dressings)
MIRASORB MIS 2" X 2"(Gauze Pads & Dressings)
NEXCARE GAUZ PAD 2"X2"(Gauze Pads & Dressings)
NOVOFINE 30 MIS DISPOS(Insulin Pen Needle)
NOVOFINE 31 MIS DISPOS(Insulin Pen Needle)
NOVOPEN 3 MIS(Injection Device for Insulin)
NOVOPEN 3 MIS PENMATE(Injection Device for Insulin)
NOVOPEN JR MIS DEVICE(Injection Device for Insulin)
NOVOPEN JR MIS DEVICE(Injection Device for Insulin)
PEN NEEDLES MIS 29G(Insulin Pen Needle)
PEN NEEDLES MIS 29GX1/2"(Insulin Pen Needle)
PEN NEEDLES MIS 29GX12MM(Insulin Pen Needle)
PEN NEEDLES MIS 29GX12MM(Insulin Pen Needle)
PEN NEEDLES MIS 29GX12MM(Insulin Pen Needle)
PEN NEEDLES MIS 31G(Insulin Pen Needle)
PEN NEEDLES MIS 31GX1/4"(Insulin Pen Needle)
PEN NEEDLES MIS 31GX5/16(Insulin Pen Needle)
PEN NEEDLES MIS 31GX6MM(Insulin Pen Needle)
PEN NEEDLES MIS 31GX6MM(Insulin Pen Needle)
PEN NEEDLES MIS 31GX6MM(Insulin Pen Needle)
PEN NEEDLES MIS 31GX8MM(Insulin Pen Needle)
PEN NEEDLES MIS 31GX8MM(Insulin Pen Needle)
PEN NEEDLES MIS 31GX8MM(Insulin Pen Needle)
PUBLIX PEN MIS 29GX12MM(Insulin Pen Needle)
PUBLIX PEN MIS 31GX8MM(Insulin Pen Needle)
QC STERILE PAD 2"X2"(Gauze Pads & Dressings)
RA STERILE PAD 2"X2"(Gauze Pads & Dressings)
RELION PEN MIS 29GX12MM(Insulin Pen Needle)
RELION PEN MIS 31GX8MM(Insulin Pen Needle)
SM GAUZE PAD 2 X 2(Gauze Pads & Dressings)
STERI-PAD PAD STERILE(Gauze Pads & Dressings)
STERI-PAD PAD STERILE(Gauze Pads & Dressings)
STERILE PAD 2"X2"(Gauze Pads & Dressings)
STERILE GAUZ PAD 2"X2"(Gauze Pads & Dressings)
TEGADERM FM PAD 2"X2"(Gauze Pads & Dressings)
ULTILET PEN MIS NEEDLE(Insulin Pen Needle)
UNIFINE PNTP MIS 12MM(Insulin Pen Needle)
UNIFINE PNTP MIS 12MM(Insulin Pen Needle)
UNIFINE PNTP MIS 29GX1/2"(Insulin Pen Needle)
01
01
01
01
01
01
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
02
121

Drug Name Drug Tier Notes
UNIFINE PNTP MIS 29GX12MM(Insulin Pen Needle)
UNIFINE PNTP MIS 29GX12MM(Insulin Pen Needle)
UNIFINE PNTP MIS 31GX6MM(Insulin Pen Needle)
UNIFINE PNTP MIS 31GX6MM(Insulin Pen Needle)
UNIFINE PNTP MIS 31GX6MM(Insulin Pen Needle)
UNIFINE PNTP MIS 31GX8MM(Insulin Pen Needle)
UNIFINE PNTP MIS 31GX8MM(Insulin Pen Needle)
UNIFINE PNTP MIS 31GX8MM(Insulin Pen Needle)
UNIFINE PNTP MIS 6MM(Insulin Pen Needle)
UNIFINE PNTP MIS 6MM(Insulin Pen Needle)
UNIFINE PNTP MIS 8MM(Insulin Pen Needle)
UNIFINE PNTP MIS 8MM(Insulin Pen Needle)
Pharmaceutical Aids
*potassium chloride powder packet 13.4 meq/gm (dialysis)**
5-AMINOSALIC POW ACID(Mesalamine)
5-HYDROXY-L- POW TRYPTOPH(Hydroxytryptophan)
acetic acid soln
acetone soln
ALBUTEROL POW(Albuterol)
AMIKACIN POW USP(Amikacin)
AMINOPHYLLIN POW ANHYDROU(Aminophylline)
AMITRIPTYLIN POW HCL(Amitriptyline HCl)
ammonium lactate solution 70%
AMOXICILLIN POW TRIHYDRA(Amoxicillin)
AMOXICILLIN POW USP(Amoxicillin)
AMOXICILLIN POW USP(Amoxicillin)
AMPHOTERICIN POW B(Amphotericin B (Mouth-Throat))
AMPHOTERICIN POW B(Amphotericin B (Mouth-Throat))
AMPHOTERICIN POW B(Amphotericin B (Mouth-Throat))
AMPICILLIN POW ANHYDR(Ampicillin)
AMPICILLIN POW MICRONIZ(Ampicillin)
AMPICILLIN POW TRIHYDRA(Ampicillin)
ANDROSTERONE POW(Androsterone)
ANTHRALIN POW(Anthralin)
ATROPINE CRY USP NF(Atropine)
ATROPINE POW SULFATE(Atropine Sulfate)
ATROPINE POW USP(Atropine)
ATROPINE SUL POW MONOHYDT(Atropine Sulfate Monohydrate)
AZATHIOPRINE POW(Azathioprine)
BACI-RX POW 5MU(Bacitracin (Topical))
BACITRACIN POW 5MU(Bacitracin (Topical))
BACITRACIN POW USP(Bacitracin (Topical))
BACITRACIN POW ZINC USP(Bacitracin Zinc)
BACLOFEN POW(Baclofen)
BACTER WATER INJ BENZ ALC(Water For Inject, Bacteriostatic Benzyl
Alcohol)
BASE D PEG POW 4500(Polyethylene Glycol 4500)
BENZOCAINE CRY(Benzocaine (Topical))
BENZOCAINE POW(Benzocaine (Topical))
02
02
02
02
02
02
02
02
02
02
02
02
01
04
04
01
01
02
02
02
02
01
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
122

Drug Name Drug Tier Notes
BENZOIC ACID CRY(Benzoic Acid)
BENZOIC ACID POW(Benzoic Acid)
BENZOYL PER POW 70%(Benzoyl Peroxide)
BENZOYL PER POW HYDROUS(Benzoyl Peroxide)
BENZTROPINE POW MESYLATE(Benztropine Mesylate)
BETAMETH DIP POW(Betamethasone Dipropionate (Topical))
BETAMETH DIP POW MICRONIZ(Betamethasone Dipropionate (Topical))
BETAMETH DIP POW MICRONIZ(Betamethasone Dipropionate (Topical))
BETAMETH DIP POW USP NF(Betamethasone Dipropionate (Topical))
BETAMETH VAL POW(Betamethasone Valerate)
BETAMETH VAL POW MICRONIZ(Betamethasone Valerate)
BETAMETH VAL POW USP NF(Betamethasone Valerate)
BETHANECHOL POW CHLORIDE(Bethanechol Chloride)
BHA POW NF(Butylated Hydroxyanisole)
BROMOCRIPTIN POW MESYLATE(Bromocriptine Mesylate)
CARBAMAZEPIN POW(Carbamazepine)
CARBAMAZEPIN POW USP(Carbamazepine)
CARBAMAZEPIN POW USP NF(Carbamazepine)
CARISOPRODOL POW(Carisoprodol)
CEFACLOR POW USP(Cefaclor Monohydrate)
CEFADROXIL POW MONOHYDR(Cefadroxil)
CHLORAL CRY HYDRATE(Chloral Hydrate)
CHLORHEX DIG SOL 20%(Chlorhexidine Gluconate)
CHLORHEX GLU SOL 20%(Chlorhexidine Gluconate)
chlorhexidine gluconate soln 20%
chlorhexidine gluconate solution
CHLORPROMAZ POW HCL(Chlorpromazine HCl)
CHLORZOXAZON POW(Chlorzoxazone)
CICLOPIROX POW OLAMINE(Ciclopirox Olamine)
CIMETIDINE POW(Cimetidine)
CLIOQUINOL POW(Clioquinol)
CLOBETASOL POW PROPIONA(Clobetasol Propionate)
CLOBETASOL POW PROPIONA(Clobetasol Propionate)
CLOBETASOL POW PROPIONA(Clobetasol Propionate)
CLOTRIMAZOLE CRY(Clotrimazole (Topical))
CLOTRIMAZOLE POW(Clotrimazole (Topical))
coal tar (crude) solution
coal tar (crude) tar
CODEINE POW PHOSPHAT(Codeine Phosphate)
COLCHICINE POW(Colchicine)
COUMARIN POW(Coumarin)
CROMOLYN SOD POW(Cromolyn Sodium)
CYANOCOBAL POW(Cyanocobalamin)
CYANOCOBALAM CRY(Cyanocobalamin)
CYCLOBENZAPR POW HCL(Cyclobenzaprine HCl)
DACARBAZINE POW(Dacarbazine)
DESIPRAMINE POW(Desipramine HCl)
DESONIDE POW MICRONIZ(Desonide)
DICLOFENAC POW SODIUM(Diclofenac Sodium)
diflunisal powder
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
01
01
04
04
04
04
04
04
04
04
04
04
01
01
04
04
04
04
04
04
04
02
04
04
04
01
(PA)
123

Drug Name Drug Tier Notes
DIHYDROERGOT CRY MESYLATE(Dihydroergotamine Mesylate)
DIHYDROERGOT POW MESYLATE(Dihydroergotamine Mesylate)
DIHYDROTEST POW PROPIONA(Dihydrotestosterone Propionate)
DIHYROTESTOS POW(Androstanolone)
DILAUDID POW(Hydromorphone HCl)
DISOPYRAMIDE POW PHOSPHAT(Disopyramide Phosphate)
DOXEPIN HCL POW(Doxepin HCl)
DOXYCYCLINE POW HYCLATE(Doxycycline Hyclate)
DOXYL SUCCIN POW(Doxylamine Succinate)
DOXYL SUCCIN POW USP(Doxylamine Succinate)
DROPERIDOL POW(Droperidol)
DROPERIDOL POW USP(Droperidol)
ECONAZOLE POW NITRATE(Econazole Nitrate)
ERGOTAMINE POW TARTRATE(Ergotamine Tartrate)
ERYTHROMYCIN POW ETHYLSUC(Erythromycin Ethylsuccinate)
ESTRADIOL POW MICRONIZ(Estradiol Micronized)
FENOPROFEN POW CALCIUM(Fenoprofen Calcium)
FENTANYL POW CITRATE(Fentanyl Citrate)
FLUNISOLIDE POW(Flunisolide)
FLUNISOLIDE POW ANHYDR(Flunisolide)
FLUOCINOLONE POW ACETONID(Fluocinolone Acetonide)
FLUOCINONIDE POW MICRONIZ(Fluocinonide)
FLURBIPROFEN POW(Flurbiprofen)
FLURBIPROFEN POW USP/NF(Flurbiprofen)
GENTAMICIN POW SULF MIC(Gentamicin Sulfate (Topical))
GENTAMICIN POW SULFATE(Gentamicin Sulfate (Topical))
GRAMICIDIN D POW(Gramicidin D)
GRISEOFULVIN POW MICRONIZ(Griseofulvin Micronized)
GRISEOFULVIN POW USP(Griseofulvin Micronized)
guaiacol solution
HALOPERIDOL POW(Haloperidol)
HYDROCORT POW(Hydrocortisone (Topical))
HYDROCORT POW(Hydrocortisone (Topical))
HYDROCORT POW MICRONIZ(Hydrocortisone (Topical))
HYDROCORT POW USP(Hydrocortisone (Topical))
HYDROCORT POW USP(Hydrocortisone (Topical))
HYDROCORT AC POW(Hydrocortisone Acetate (Topical))
HYDROCORT AC POW MICRONIZ(Hydrocortisone Acetate (Topical))
HYDROCORT AC POW MICRONIZ(Hydrocortisone Acetate (Topical))
HYDROCORT AC POW USP(Hydrocortisone Acetate (Topical))
HYDROMORPHON POW HCL(Hydromorphone HCl)
HYDROXY CELL POW 150-400(Hydroxypropyl Cellulose)
HYDROXY CELL POW 1500 CPS(Hydroxypropyl Cellulose)
HYDROXY CELL POW 4K-6500(Hydroxypropyl Cellulose)
HYDROXY CELL POW 75-100(Hydroxypropyl Cellulose)
HYDROXY CELL POW NF(Hydroxypropyl Cellulose)
HYDROXYANISO POW BUTYLATE(Butylated Hydroxyanisole)
HYDROXYTRYPT POW(Hydroxytryptophan)
HYDROXYTRYPT POW(Hydroxytryptophan)
HYDROXYZINE POW PAMOATE(Hydroxyzine Pamoate)
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
01
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
124

Drug Name Drug Tier Notes
HYOSCYAMINE POW SULFATE(Hyoscyamine Sulfate)
HYPROMELLOSE POW 100K CPS(Hydroxypropyl Cellulose)
HYPROMELLOSE POW 4300CPS(Hydroxypropyl Cellulose)
IBUPROFEN POW(Ibuprofen)
IMIPRAMINE POW HCL(Imipramine HCl)
INDAPAMIDE POW(Indapamide)
INDOMETHACIN POW(Indomethacin)
IODOFORM POW(Iodoform)
IPRATROPIUM POW BROMIDE(Ipratropium Bromide)
ISOPROPAMIDE POW IODIDE(Isopropamide Iodide)
ISOPROTEREN POW SULFATE(Isoproterenol Sulfate)
KETOPROFEN POW(Ketoprofen)
LEVAMISOLE POW HCL(Levamisole HCl)
LEVODOPA POW(Levodopa)
LIDOCAINE POW HCL(Lidocaine HCl)
LIDOCAINE POW HCL(Lidocaine HCl)
MECLIZINE POW HCL(Meclizine HCl)
MECLIZINE POW HCL MONO(Meclizine HCl)
MECLOFEN SOD POW(Meclofenamate Sodium)
MECLOFEN SOD POW(Meclofenamate Sodium)
MEDROXYPROG POW MICRONIZ(Medroxyprogesterone Micronized)
MEFENAMIC POW ACID(Mefenamic Acid)
MEPERIDINE POW(Meperidine HCl)
MEPIVACAINE POW(Mepivacaine HCl)
MESALAMINE POW USP(Mesalamine)
METAPROTEREN POW SULFATE(Metaproterenol Sulfate)
METHACHOLINE CRY CHLORIDE(Methacholine Chloride)
METHACHOLINE POW CHLORIDE(Methacholine Chloride)
METHADONE POW(Methadone HCl)
METHENAMINE GRA(Methenamine)
METHENAMINE POW(Methenamine)
METHOCEL POW K100M(Methylcellulose)
METHOXSALEN POW(Methoxsalen (Topical))
METHOXSALEN POW USP(Methoxsalen (Topical))
methyl ethyl ketone liq
METHYLCELLUL POW(Methylcellulose)
METHYLCELLUL POW 1500CPS(Methylcellulose)
METHYLCELLUL POW 4000 CPS(Methylcellulose)
METOCLOPRAM POW MONOHYDR(Metoclopramide HCl Monohydrate)
METOCLOPRAMI POW HCL USP(Metoclopramide HCl)
METRONIDAZOL POW BENZOATE(Metronidazole Benzoate (Topical))
MICONAZOLE POW NITRATE(Miconazole Nitrate (Topical))
MINOCYCLINE POW(Minocycline HCl)
MORPHINE POW SULFATE(Morphine Sulfate)
NALIDIXIC POW ACID(Nalidixic Acid)
NAPROXEN POW(Naproxen)
NAPROXEN POW SODIUM(Naproxen Sodium)
NAPROXEN POW USP(Naproxen)
NEO-RX POW(Neomycin Sulfate (Topical))
NEOMYCIN POW SULFATE(Neomycin Sulfate (Topical))
04
04
04
04
04
04
04
04
04
04
04
04
02
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
01
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
(PA)
125

Drug Name Drug Tier Notes
NITROFURAN POW ANHYDROU(Nitrofurantoin Macrocrystal)
NORTRIPTYLIN POW HCL(Nortriptyline HCl)
ORPHENADRINE POW CITRATE(Orphenadrine Citrate)
OXYBUTININ POW CHLORIDE(Oxybutynin Chloride)
OXYCODONE POW HCL(Oxycodone HCl)
OXYTETRACYC POW HCL(Oxytetracycline HCl)
PEG POW 4500(Polyethylene Glycol 4500)
PEG 1000 POW BASE J(Polyethylene Glycol 1000)
PEG 1000 POW USP/NF(Polyethylene Glycol 1000)
PEG 400 POW MONOSTEA(Polyoxyl 40 Stearate)
PENICILLAMIN POW(Penicillamine)
PILOCARPINE CRY HCL(Pilocarpine Hydrochloride)
PILOCARPINE POW HCL(Pilocarpine Hydrochloride)
POLYOXYL 40 POW STEARATE(Polyoxyl 40 Stearate)
PREGNENOLONE POW MICRONIZ(Pregnenolone (Micronized))
PROCHLORPER POW MALEATE(Prochlorperazine Maleate)
PROMETHAZINE POW HCL(Promethazine HCl)
PROPANTHELIN POW BROMIDE(Propantheline Bromide)
RETINOIC ACD POW(Tretinoin)
RETINOIC ACD POW(Tretinoin)
SALICYLIC CRY ACID(Salicylic Acid)
SALICYLIC POW ACID(Salicylic Acid)
SCOPALAMINE CRY HBR(Scopolamine HBr)
SCOPOLAMINE POW HBR(Scopolamine HBr)
SELEGILINE POW HCL(Selegiline HCl)
SILVER CRY NITRATE(Silver Nitrate)
SORBITOL MIS LOLLIPOP(Sorbitol Lollipop Base)
SORBITOL POW(Sorbitol Solid)
STERILE DILU SOL FLOLAN(Glycine Diluent)
SUCRALFATE POW(Sucralfate)
SUCRALFATE POW USP(Sucralfate)
SULFACET SOD POW(Sulfacetamide Sodium)
SULFACET SOD POW USP(Sulfacetamide Sodium)
SULFASALAZIN POW(Sulfasalazine)
SULFASALAZIN POW USP(Sulfasalazine)
SULFASALAZIN POW USP/NF(Sulfasalazine)
TRAZODONE POW(Trazodone HCl)
TRAZODONE POW USP(Trazodone HCl)
TRAZODONE POW USP/NF(Trazodone HCl)
TRETINOIN POW(Tretinoin)
TRIAMCINOLON POW ACETONID(Triamcinolone Acetonide (Topical))
TRIMIPRAMINE POW MALEATE(Trimipramine Maleate)
WARFARIN POW SODIUM(Warfarin Sodium)
WARFARIN POW SODIUM(Warfarin Sodium)
WARFARIN POW SODIUM(Warfarin Sodium)
water for inject, bacteriostatic
water for inject, bacteriostatic parabens
water for injection
water for iv injection
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
04
01
01
01
01
126

INDEX
A
ABBOKINASE 34
ABELCET 9
ABILIFY DISC 51
ABILIFY 51
ABRAXANE 24
ACCOLATE 79
ACCUNEB 29
ACCUPRIL 37
ACCURETIC 37
ACCUTANE 103
ACCUZYME 103
ACD-A 34
acebutolol hcl 37
ACEON 37
acetaminophen w/ codeine 51
acetaminophen-caff-dihydrocod 51
acetaminophen-salicylamidephenyltoloxamine-caffeine
52
acetazolamide 37
acetic acid (bulk) 122
acetic acid (otic) 80
acetic acid-aluminum acetate-boric
acid-propylene glycol 80
acetic acid-aluminum acetate 80
acetone 122
acetylcysteine 79
ACIPHEX 84
ACLOVATE 104
ACTHIB 101
ACTIGALL 84
ACTIMMUNE 115
ACTIVELLA 89
ACTONEL WITH CALCIUM 115
ACTONEL 115
ACTOPLUS MET 89
ACTOS 89
ACULAR LS 80
ACULAR PF 80
ACULAR 80
acyclovir sodium 9
acyclovir 9
ADACEL 101
ADALAT CC 37
ADDERALL XR 51
ADDERALL XR 52
ADDERALL 51
ADOXA PAK 1/150 9
ADRENALIN 29
ADRIAMYCIN 24
ADVAIR DISKUS 29
ADVAIR HFA 29
ADVICOR 37
AEROBID-M 89
AEROBID 89
AGENERASE 9
AGGRENOX 34
AGRYLIN 34
AKINETON 29
AKNE-MYCIN 104
ALA-SCALP 104
ALAMAST 80
ALBALON 80
ALBENZA 9
ALBUTEROL SULFATE/IPRATRO 30
albuterol sulfate 29
albuterol sulfate 30
ALBUTEROL 122
albuterol 29
ALCAINE 80
ALCET 52
alclometasone dipropionate 104
ALCOHOL 5%/DEXTROSE 5% 73
alcohol swabs 119
ALDACTAZIDE 37
ALDACTONE 37
ALDARA 104
ALDURAZYME 79
ALESSE-28 89
ALFERON N 24
ALIMTA 24
ALINIA 9
ALKERAN 24
ALLEGRA-D 8
ALLEGRA 8
allopurinol sodium 115
allopurinol 115
ALOCRIL 80
ALODOX 9
ALOMIDE 80
ALOPRIM 115
ALORA 89
ALPHAGAN P 80
ALREX 80
ALTABAX 104
ALTACE 37
ALTOPREV 37
ALUPENT INH 30
amantadine hcl 9
AMANTADINE 9
AMARYL 89
AMBIEN CR 52
AMBIEN 52
AMBISOME 9
AMCINONIDE 104
amcinonide 104
AMERGE 52
AMERICAINE 104
AMEVIVE 104
AMICAR 34
amikacin sulfate 9
AMIKACIN 122
AMIKIN 9
amiloride & hydrochlorothiazide 73
amiloride hcl 73
AMILORIDE 73
AMINESS 74
amino acid electrolyte infusion 73
amino acid electrolyte w/ calcium
infusion in d25w 73
amino acid infusion in d10w 73
amino acid infusion in d20w 73
amino acid infusion in d25w 73
amino acid infusion 73
aminocaproic acid 34
AMINOPHYLLINE ANHYDROUS 122
aminophylline 113
AMINOSYN 7%/ELECTROLYTES 74
AMINOSYN II 3.5% 74
AMINOSYN II 3.5 74
AMINOSYN II 4.25 74
AMINOSYN II 5/DEXTROSE 25 74
AMINOSYN II M 3.5%/DEXTRO 74
AMINOSYN II M 4.25/DEXTRO 74
AMINOSYN II 74
AMINOSYN M 74
AMINOSYN-HBC 74
AMINOSYN-PF 7% 74
AMINOSYN-PF 74
AMINOSYN-RF 74
AMINOSYN 74
amiodarone hcl 37
AMITIZA 84
AMITRIPTYLINE HCL 122
amitriptyline hcl 52
amlodipine besylate-benazepril hcl
37
127

ammonium lactate 122
AMMONUL 74
amoxapine 52
amoxicillin & pot clavulanate 9
AMOXICILLIN TRIHYDRATE 122
AMOXICILLIN 122
amoxicillin 9
AMOXIL 10
AMOXIL 9
amphetamine-dextroamphetamine 52
AMPHOTEC 10
AMPHOTERICIN B ORAL GRADE 122
AMPHOTERICIN B SOLUBILIZE 122
amphotericin b 10
AMPHOTERICIN B 122
ampicillin & sulbactam sodium 10
AMPICILLIN ANHYDROUS 122
ampicillin sodium 10
AMPICILLIN TRIHYDRATE 122
ampicillin 10
amylase-lipase-protease 84
amylase-lipase-protease 85
ANACAINE 104
ANADROL-50 89
ANAFRANIL 52
anagrelide hcl 34
ANAPROX DS 52
ANAPROX 52
ANASPAZ 30
ANCOBON 10
ANDRODERM 89
ANDROGEL PUMP 89
ANDROGEL 89
ANDROID 89
ANDROSTERONE 122
ANDROXY 89
ANGELIQ 89
ANGIOMAX 34
ANSAID 52
ANTABUSE 115
ANTARA 37
ANTARA 38
anthralin 104
ANTHRALIN 122
ANTIVERT 85
ANUSOL-HC 104
ANZEMET 85
APHTHASOL 115
APIDRA 89
APPBUTAMONE-D 52
APPBUTAMONE 52
APPFORMIN-D 89
APPFORMIN 89
APTIVUS 10
AQUACHLORAL 52
ARALAST 115
ARALEN 10
ARANESP ALBUMIN FREE SURE 34
ARANESP ALBUMIN FREE 34
ARANESP 34
ARAVA 115
AREDIA 115
ARICEPT ODT 30
ARICEPT 30
ARIMIDEX 25
ARISTOSPAN 89
ARIXTRA 34
ARMOUR THYRO 89
AROMASIN 25
ARRANON 25
ARTHROTEC 50 52
ARTHROTEC 75 52
ASACOL 85
ASMANEX 120 METERED DOSES 89
ASMANEX 14 METERED DOSES 89
ASMANEX 30 METERED DOSES 89
ASMANEX 60 METERED DOSES 89
aspirin w/ codeine 52
ASTELIN 80
ATACAND HCT 38
ATACAND 38
atenolol & chlorthalidone 38
atenolol 38
ATGAM 115
ATRIPLA 10
atropine sulfate (ophthalmic) 80
ATROPINE SULFATE MONOHYDR 122
ATROPINE SULFATE 122
ATROPINE 122
ATROVENT HFA 30
ATROVENT NAS 79
ATTENUVAX 101
aug betamethasone dipropionate 104
AUGMENTIN ES-600 10
AUGMENTIN XR 10
AUGMENTIN 10
AUTOPEN 119
AVALIDE 38
AVANDAMET 90
AVANDARYL 90
AVANDIA 90
AVAPRO 38
AVAR 104
AVASTIN 25
AVELOX 10
AVINZA 52
AVODART 115
AVONEX 115
AXERT 52
AXID 85
AYGESTIN 90
AZACTAM 10
AZASITE 80
azathioprine sodium 115
azathioprine 115
AZATHIOPRINE 122
AZELEX 104
AZILECT 53
AZITHROMYCIN 10
azithromycin 10
azithromycin 11
AZMACORT 90
AZOPT 80
AZULFIDINE 11
B
B & O 15-A SUPPRETTE 30
B & O 16-A SUPPRETTE 30
BACI-RX 122
bacitracin (ophthalmic) 80
BACITRACIN ZINC 122
bacitracin-poly-neomycin-hc 80
bacitracin-polymyxin b (ophth) 80
BACITRACIN 11
bacitracin 11
BACITRACIN 122
BACLOFEN 122
baclofen 30
BACTERIOSTATIC WATER FOR 122
BACTOCILL 11
BACTRIM DS 11
BACTRIM 11
BACTROBAN NASAL 104
BACTROBAN 104
BALACET 325 53
BARACLUDE 11
BASE D POLYETHYLENE GLYCO 122
128

BD PEN MINI 119
BD PEN 119
BD ULTRAFINE III MINI PEN 119
BD ULTRAFINE III SHORT PE 119
BD ULTRAFINE ORIGINAL PEN 119
BECONASE AQ 80
belladonna alkaloids & opium 30
benazepril & hydrochlorothiazide 38
benazepril hcl 38
bendroflumethiazide/rauwolfia 38
BENEFIX 34
BENICAR HCT 38
BENICAR 38
BENTYL 30
BENZAC AC 104
BENZAC W 104
BENZACLIN WITH PUMP 104
BENZACLIN 104
BENZAGEL-10 104
BENZAGEL-5 104
BENZAMYCIN 104
BENZAMYCINPAK 104
BENZIQ LS 104
BENZIQ 104
benzocaine & antipyrine 80
benzocaine (otic) 80
benzocaine-phenylephrine-antipyrine
80
BENZOCAINE 122
BENZOIC ACID 123
BENZOYL PER 123
BENZOYL PEROXIDE HYDROUS 123
benzoyl peroxide-erythromycin 105
benzoyl peroxide-urea 105
benzoyl peroxide 104
benzoyl peroxide 105
BENZTROPINE MESYLATE 123
benztropine mesylate 30
BETAGAN 80
BETAMETHASONE DIPROPIONAT 123
betamethasone dipropionate (topical)
105
betamethasone valerate 105
BETAMETHASONE VALERATE 123
BETAMETHASONE 123
BETAPACE AF 38
BETAPACE 38
BETASERON 115
betaxolol hcl (ophth) 80
BETHANECHOL CHLORIDE 123
bethanechol chloride 30
BETIMOL 80
BETOPTIC-S 80
BEXXAR 131 IODINE 25
BEXXAR 25
BHA 123
BIAXIN XL 11
BIAXIN 11
BICILLIN C-R 11
BICILLIN L-A 11
BICITRA 74
BICNU 25
BIDIL 38
BILTRICIDE 11
BIO-STATIN 11
BIO-THROID 90
bisoprolol & hydrochlorothiazide 38
bisoprolol fumarate 38
BL STERILE PADS 2"X2" 119
BLENOXANE 25
bleomycin sulfate 25
BLEPH- 81
BLEPHAMIDE 81
BONIVA 115
BOOSTRIX 101
BRETHINE 30
BREVICON-28 90
BREVOXYL-4 ACNE WASH KIT 105
BREVOXYL-8 ACNE WASH KIT 105
BREVOXYL 105
brimonidine tartrate 81
bromocriptine mesylate 115
BROMOCRIPTINE MESYLATE 123
BRONCAP 113
BRONCODUR 113
BROVANA 30
bumetanide 74
BUMEX 74
BUPHENYL 74
BUPRENEX 53
buprenorphine hcl 53
bupropion hcl (smoking deterrent) 53
bupropion hcl 53
BUSPAR 53
buspirone hcl 53
busulfan 25
butalbital-acetaminophen-caffeine w/
codeine 53
butamben-tetracaine-benzocaine 105
butorphanol tartrate 53
BUTYLATED HYDROXYANISOLE 124
BYETTA 90
C
cabergoline 115
CADUET 38
CADUET 39
CAFERGOT 53
CAFFEINE/SODIUM BENZOATE 53
CALAN SR 39
CALAN 39
CALCIJEX 114
calcitonin (salmon) 90
calcitriol 114
CAMPATH 25
CAMPRAL 53
CAMPTOSAR 25
CANASA 85
CANCIDAS 11
CANTIL 30
CAPASTAT SUL 11
CAPEX 105
CAPHOSOL 81
CAPOTEN 39
CAPOZIDE 39
captopril & hydrochlorothiazide 39
captopril 39
CARAC 105
CARAFATE 85
carbachol (ophth) 81
CARBAMAZEPINE 123
carbamazepine 53
CARBATROL 53
carbidopa-levodopa 53
carbidopa 53
carboplatin 25
CARDENE SR 39
CARDENE 39
CARDIZEM CD 39
CARDIZEM LA 39
CARDIZEM LA 40
CARDIZEM 39
CARDURA XL 40
CARDURA 40
CARIMUNE NF 101
CARIMUNE NF 102
carisoprodol w/ aspirin & codeine 30
129

CARISOPRODOL 123
carisoprodol 30
CARMOL SCALP TREATMENT 105
CARMOL-HC 105
CARMOL 105
CARNITOR 116
carteolol hcl (ophth) 81
CARTROL 40
CASODEX 25
CATAFLAM 53
CATAPRES-TTS-1 40
CATAPRES-TTS-2 40
CATAPRES-TTS-3 40
CATAPRES 40
CEDAX 11
CEENU 25
cefaclor monohydrate 11
cefaclor 11
CEFACLOR 123
CEFADROXIL MONOHYDRATE 123
cefadroxil 11
cefazolin in d5w 11
cefazolin sodium and dextrose 12
cefazolin sodium 11
cefazolin sodium 12
cefdinir 12
cefepime hcl 12
CEFIZOX 12
cefotaxime sodium 12
cefoxitin sodium 12
cefpodoxime proxetil 12
cefprozil 12
ceftazidime 12
CEFTIN 12
ceftriaxone sodium and dextrose 12
ceftriaxone sodium in dextrose 12
ceftriaxone sodium 12
CEFTRIAXONE 12
cefuroxime axetil 12
cefuroxime sodium and dextrose 12
cefuroxime sodium 12
cefuroxime sodium 13
CEFZIL 13
CELEBREX 53
CELESTONE-SOLUSPAN 90
CELESTONE 90
CELEXA 54
CELLCEPT IV 116
CELLCEPT 116
CELONTIN 54
CENESTIN 90
CENOGEN ULTRA 114
CENTANY 105
CEPHALEXIN 13
cephalexin 13
CEPROTIN 116
CEREBYX 54
CEREDASE 79
CEREZYME 116
CERUBIDINE 25
CHANTIX 30
CHEMET 88
CHLORAL HYDRATE 123
chloral hydrate 54
chloramphenicol sodium succinate 13
chlordiazepoxide-amitriptyline 54
CHLORHEX DIG 123
CHLORHEX GLU 123
chlorhexidine gluconate (bulk) 123
chlorhexidine gluconate (mouththroat)
81
chlorhexidine gluconate 123
chloroquine phosphate 13
chlorothiazide 74
CHLORPROMAZ 54
CHLORPROMAZINE HCL 123
chlorpromazine hcl 54
chlorpropamide 90
chlorthalidone 74
CHLORZOXAZONE 123
chlorzoxazone 30
cholestyramine light 40
cholestyramine 40
choline & mag salicylate 54
chorionic gonadotropin 90
ciclopirox olamine 105
CICLOPIROX OLAMINE 123
cilostazol 34
cilostazol 35
CILOXAN 81
CIMETIDINE HCL/NACL 85
cimetidine hcl 85
CIMETIDINE 123
cimetidine 85
CIPRO HC 81
CIPRO I.V.-IN D5W 13
CIPRO I.V. 13
CIPRO XR 13
CIPRODEX 81
ciprofloxacin hcl (ophth) 81
ciprofloxacin hcl 13
ciprofloxacin-ciprofloxacin hcl 13
ciprofloxacin 13
cisplatin 25
citalopram hydrobromide 54
CITROLITH 74
cladribine 25
CLAFORAN/D5W 13
CLAFORAN 13
CLARIFOAM EF 105
CLARINEX-D 8
CLARINEX 8
CLARITHROMYC 13
clarithromycin 13
CLARITIN-D 8
CLARITIN 8
CLEERAVUE-M 13
CLEOCIN PED 14
CLEOCIN PHOS 14
CLEOCIN PHOSPHATE 14
CLEOCIN VAG 105
CLEOCIN-T 105
CLEOCIN 105
CLEOCIN 14
CLIMARA PRO 90
CLIMARA 90
CLIMIMIX E 4.25% 75
CLINAC BPO 105
CLINDA 105
clindamycin hcl 14
clindamycin phosphate (topical) 105
clindamycin phosphate vaginal 105
clindamycin phosphate 14
CLINDESSE 105
CLINIMIX 2.75%/DEXTROSE 5 74
CLINIMIX 4.25%/DEXTROSE 5 74
CLINIMIX 5%/DEXTROSE 15% 74
CLINIMIX 5%/DEXTROSE 20% 75
CLINIMIX 5%/DEXTROSE 25% 75
CLINIMIX E 2.75% 75
CLINIMIX E 4.25% 75
CLINIMIX E 5%/DEXTROSE 15 75
CLINIMIX E 5%/DEXTROSE 20 75
CLINIMIX E 5%/DEXTROSE 25 75
CLINIMIX E 5%/DEXTROSE 35 75
CLINORIL 54
CLIOQUINOL 123
130

clobetasol propionate emollient base
106
CLOBETASOL PROPIONATE MIC 123
clobetasol propionate 106
CLOBETASOL PROPIONATE 123
CLOBEX 106
CLODERM 106
CLOLAR 25
clomipramine hcl 54
clonidine hcl 40
CLORPRES 40
clotrimazole w/ betamethasone 106
clotrimazole 106
CLOTRIMAZOLE 123
clozapine 54
CLOZARIL 54
coal tar (crude) 123
CODEINE PHOS TAB SOL 54
CODEINE PHOSPHATE 123
CODEINE PHOSPHATE 54
codeine phosphate 54
codeine sulfate 54
COGENTIN 30
COGNEX 30
COGNEX 31
COLAZAL 85
colchicine w/ probenecid 75
colchicine 116
COLCHICINE 123
COLESTID FLA 40
COLESTID FLAVORED 40
COLESTID 40
colestipol hcl 40
colistimethate sodium 14
COLY-MYCIN-M 14
COLY-MYCIN-S 81
COLYTE-FLAVOR PACKS 85
COLYTE 85
COLYTROL 31
COMBIPATCH 90
COMBIVENT 31
COMBIVIR 14
COMBUNOX 54
COMTAN 54
COMVAX 102
CONCERTA 54
CONDYLOX 106
CONRAY 73
COPAXONE 116
CORDARONE 40
CORDRAN SP 106
CORDRAN TAPE 106
CORDRAN 106
COREG CR 40
COREG 40
CORGARD 40
CORTEF 90
CORTIFOAM 106
cortisone acetate 90
CORTISPORIN-TC 81
CORTISPORIN 81
CORZIDE 40
COSMEGEN 25
COSOPT 81
COUMADIN 35
COUMARIN 123
COVERA-HS 40
COZAAR 40
COZAAR 41
CREON 10 85
CRESTOR 41
CRESYLATE 81
CRINONE 90
CRIXIVAN 14
CROLOM 81
cromolyn sodium (ophth) 81
CROMOLYN SODIUM 123
cromolyn sodium 79
CUBICIN 14
CUPRIMINE 88
CURITY GAUZE PADS/2"X2" 119
CUTIVATE 106
CVS GAUZE PAD STERILE 2"X 119
cyanocobalamin 114
CYANOCOBALAMIN 123
CYANOKIT 116
CYCLESSA 90
CYCLOBENZAPRINE HCL 123
cyclobenzaprine hcl 31
CYCLOGYL 81
cyclopentolate hcl 81
cyclophosphamide 25
cyclosporine modified (for
microemulsion) 116
cyclosporine 116
CYMBALTA 55
CYSTO-CONRAY II 73
CYSTOSPAZ 31
cytarabine 25
CYTOMEL 91
CYTOTEC 85
CYTOVENE 14
CYTOXAN 25
D
D.H.E. 45 55
DACARBAZINE 123
dacarbazine 25
DACOGEN 25
danazol 91
DANTRIUM 31
dantrolene sodium 31
dapsone 14
DAPTACEL 102
DARAPRIM 14
DARVOCET A500 55
DARVOCET-N 100 55
DARVOCET-N 50 55
DARVON-N 55
DARVON 55
daunorubicin hcl 25
daunorubicin hcl 26
DAUNOXOME 26
DAYPRO 55
DDAVP 91
DEBACTEROL 81
DECAVAC 102
DECLOMYCIN 14
deferoxamine mesylate 88
DELATESTRYL 91
DELESTROGEN 91
DEMADEX 75
demeclocycline hcl 14
DEMEROL 55
DEMULEN 1/35-28 91
DENAVIR 106
DEPACON 55
DEPAKENE 55
DEPAKOTE ER 55
DEPAKOTE SPR CAP 55
DEPAKOTE 55
DEPEN TITRA 88
DEPO-ESTRADI 91
DEPO-MEDROL 91
DEPO-PROVERA 91
DEPO-SQ PROV 91
DEPO-TESTOST 91
131

DEPODUR 55
DERMA-SMOOTHE/FS BODY OIL 106
DERMA-SMOOTHE/FS SCALP OI 106
DERMATOP 106
DERMOTIC 81
DESFERAL 88
DESIPRAMINE HCL 123
desipramine hcl 55
desmopressin acetate spray
refrigerated 91
desmopressin acetate spray 91
desmopressin acetate 91
DESOGEN 91
desogestrel & ethinyl estradiol 91
desogestrel-ethinyl estradiol
(triphasic) 91
DESONATE 106
desonide 106
DESONIDE 123
DESOWEN 106
desoximetasone 106
DESOXYN 55
DESQUAM-E 106
DESQUAM-X 106
DETROL LA 113
DETROL 113
dexamethasone sodium phosphate
(ophth) 81
dexamethasone sodium phosphate 91
dexamethasone 91
DEXEDRINE 55
dexmedetomidine hcl 55
dexmethylphenidate hcl 55
DEXODRYL 8
DEXPAK 13 DAY 91
DEXPAK JR 10 DAY 91
dexrazoxane 116
dextroamphetamine sulfate 55
DEXTROSE 5%/NACL 0.225% 75
dextrose in lactated ringers 75
dextrose w/ sodium chloride 75
dextrose 75
DEXTROSTAT 55
DIABETA 91
DIABETA 92
DIABINESE 92
DIAMOX 41
DIANEAL LOW CALCIUM/1.5% 75
DIANEAL LOW CALCIUM/2.5% 75
DIANEAL PD-2/1.5% DEXTROS 75
DIANEAL PD-2/2.5% DEXTROS 75
DIANEAL PD-2/3.5% DEXTROS 75
DIANEAL PD-2/4.25% DEXTRO 75
DIBENZYLINE 31
diclofenac potassium 55
DICLOFENAC SODIUM 123
diclofenac sodium 56
dicloxacillin sodium 14
dicyclomine hcl 31
didanosine 14
DIDRONEL IV 116
DIDRONEL 116
DIFFERIN 106
diflorasone diacetate emollient base
106
diflorasone diacetate 106
DIFLUCAN IN ISO-OSMOTIC D 14
DIFLUCAN IN NACL 14
DIFLUCAN 14
diflunisal 123
diflunisal 56
digoxin 41
DIHYDROERGOTAMINE MESYLAT 124
dihydroergotamine mesylate 56
DIHYDROTESTOSTERONE PROPI 124
DILACOR XR 41
DILANTIN 56
DILATRATE SR 41
DILAUDID-5 56
DILAUDID-HP 56
DILAUDID 124
DILAUDID 56
diltiazem hcl coated beads 41
diltiazem hcl extended release beads
41
diltiazem hcl 41
DIOVAN HCT 41
DIOVAN 41
DIPENTUM 85
diphenoxylate w/ atropine 85
dipivefrin hcl 81
DIPROLENE AF 107
DIPROLENE 106
DIPTHERIA/TETANUS TOXOID 102
dipyridamole 41
DISOPYRAMIDE PHOSPHATE 124
disopyramide phosphate 41
disopyramide phosphate 42
DITROPAN 113
DIURIL IV 75
DIURIL 75
DIVI 92
DIVIGEL 92
DOLOPHINE 56
DORYX 14
DOSTINEX 116
DOVONEX 107
doxazosin mesylate 42
doxepin hcl (antipruritic) 107
DOXEPIN HCL 124
doxepin hcl 56
DOXIL 26
doxorubicin hcl 26
DOXYCYCL HYC CAP 14
DOXYCYCL HYC CAP 15
doxycycline (monohydrate) 15
DOXYCYCLINE HYCLATE 124
doxycycline hyclate 15
DOXYLAMINE SUCCINATE 124
DRITHO-SCALP 107
DROPERIDOL 124
droperidol 56
DROXIA 26
DRY 107
DTIC-DOME 26
DUAC 107
DUANE READE UNIFINE PENTI 122
DUETACT 92
duloxetine hcl 56
DUONEB 31
DUOVISC 81
DURABAC 56
DURAGESIC 56
DURICEF 15
DYAZIDE 75
DYNABAC 15
DYNACIN 15
DYNACIRC CR 42
dyphylline-guaifenesin 113
DYRENIUM 75
E
E.E.S. GRAN 15
EC-NAPROSYN 56
ECK STERILE PADS 2"X2" 119
econazole nitrate 107
ECONAZOLE NITRATE 124
132

EDECRIN 75
edetate calcium disodium 88
edetate disodium 88
EFFEXOR XR 56
EFFEXOR 56
EFUDEX OCCLUSION PACK 107
EFUDEX 107
ELAPRASE 79
ELDEPRYL 56
ELESTAT 81
ELESTRIN 92
ELIDEL 107
ELIGARD 26
ELIMITE 107
ELITE-THIN INSULIN SYRING 119
ELITEK 79
ELIXOPHYLLIN-GG 113
ELIXOPHYLLIN 113
ELLENCE 26
ELMIRON 116
ELOCON 107
ELOXATIN 26
ELSPAR 26
EMADINE 81
EMCYT 26
EMEND 85
EMLA/TEGADERM 107
EMLA 107
EMSAM 56
EMSAM 57
EMTRIVA 15
ENABLEX 113
enalapril maleate &
hydrochlorothiazide 42
enalapril maleate 42
ENBREL 116
ENDOMETRIN 92
ENDRATE 88
ENGERIX-B 102
ENJUVIA 92
ENLON-PLUS 31
ENTOCORT EC 92
EPIFOAM 107
epinephrine hcl 31
EPIPEN 2-PAK INJ 0.3MG 31
EPIPEN-JR 2-PAK 31
EPIPEN-JR 31
EPIPEN 31
EPIRUBICIN 26
EPIVIR 15
EPOGEN 35
EPZICOM 15
EQUETRO 57
ERAXIS 15
ERBITUX 26
ergoloid mesylates 31
ERGOTAMINE TARTRATE 124
ergotamine tartrate 57
ergotamine w/ caffeine 57
ERY-TAB 15
ERY 107
ERYPED 15
ERYTHROCIN 15
erythromycin (acne aid) 107
erythromycin (ophth) 81
erythromycin base 15
ERYTHROMYCIN CAP 15
ERYTHROMYCIN ETHYLSUCCINA 124
erythromycin ethylsuccinate 15
erythromycin lactobionate 15
erythromycin stearate 15
erythromycin-sulfisoxazole 15
ERYTHROMYCIN 15
ESCLIM 92
ESTRACE VAG 92
ESTRACE 92
ESTRADERM 92
ESTRADIOL MICRONIZED 124
estradiol 92
ESTRASORB 92
ESTRING 92
ESTRO 92
estropipate 92
ESTROSTEP FE 92
ethambutol hcl 16
ETHMOZINE 42
ethosuximide 57
ethynodiol diacet & eth estrad 92
ETHYOL 116
etidronate disodium 116
etodolac 57
ETOPOPHOS 26
etoposide 26
EURAX 107
EVISTA 92
EVOCLIN 107
EVOXAC 31
EXEL INSULIN PEN NEEDLES 119
EXELON 31
EXFORGE 42
EXJADE 88
EXUBERA COMBINATION PACK 92
EXUBERA KIT 92
EXUBERA PATIENT PACK 92
F
FABRAZYME 79
FACTIVE 16
famotidine 85
FAMVIR 16
FANSIDAR 16
FARESTON 26
FASLODEX 26
fat emulsion 76
FAZACLO 57
FELBATOL 57
FELDENE 57
felodipine 42
FEMARA 26
FEMCON FE 93
FEMHRT 1/5 93
FEMHRT LOW DOSE 93
FEMRING 93
FEMTRACE 93
fenofibrate micronized 42
fenofibrate 42
FENOPROFEN CALCIUM 124
fenoprofen calcium 57
fentanyl citrate-bupivacaine hclsodium
chloride 57
fentanyl citrate-ropivacaine hclsodium
chloride 57
FENTANYL CITRATE 124
fentanyl citrate 57
fentanyl 57
FENTORA 57
FENTORA 58
FEXMID 31
fexofenadine hcl 8
FINACEA 107
finasteride 116
FIORICET/CODEINE 58
FIORINAL/CODEINE #3 58
FIRST-PROGESTERONE VGS 10 99
FIRST-PROGESTERONE VGS 20 99
133

FIRST-PROGESTERONE VGS 25 99
FIRST-PROGESTERONE VGS 40 99
FIRST-TESTOS 93
FIRST-TESTOSTERONE MC COM 93
FLAGYL ER 16
FLAGYL 16
FLAREX 81
flavoxate hcl 113
FLBGAMMA DIF 102
FLEBOGAMMA 102
flecainide acetate 42
FLEXERIL 31
FLOMAX 116
FLONASE 81
FLORINEF 93
FLOVENT DISKUS 93
FLOVENT HFA 93
FLOXIN OTIC SINGLES 81
FLOXIN OTIC 81
floxuridine 26
fluconazole in dextrose 16
fluconazole in nacl 16
fluconazole 16
FLUDARA 26
fludarabine phosphate 26
FLUDARABINE 26
fludrocortisone acetate 93
FLUMADINE 16
flunisolide (nasal) 81
FLUNISOLIDE ANHYDROUS 124
FLUNISOLIDE 124
fluocinolone acetonide 107
FLUOCINOLONE ACETONIDE 124
fluocinonide emulsified base 107
fluocinonide 107
FLUOCINONIDE 124
FLUORABON 116
FLUORIDEX DAILY DEFENSE S 73
fluorometholone (ophth) 81
FLUOROPLEX 107
fluorouracil (topical) 107
FLUOROURACIL 26
fluorouracil 26
fluoxetine hcl 58
fluphenazine decanoate 58
fluphenazine hcl 58
FLURA-DROPS 116
flurbiprofen sodium 81
FLURBIPROFEN 124
flurbiprofen 58
flutamide 26
fluticasone propionate 107
fluvoxamine maleate 58
FML FORTE 81
FML LIQUIFLM 81
FML S.O.P. 81
FOCALIN XR 58
FOCALIN 58
FORADIL AEROLIZER 31
FORTAMET 93
FORTAZ 16
FORTEO 93
FOSAMAX PLUS D 116
FOSAMAX 116
foscarnet sodium 16
FOSCAVIR 16
fosinopril sodium &
hydrochlorothiazide 42
fosinopril sodium 42
FOSRENOL 76
FRAGMIN 35
FREAMINE III 3% 76
FREAMINE III 8.5%/DEXTROS 76
FREAMINE III 76
FROVA 58
FRST-HYDRCRT 107
FUDR 26
FUNGIZONE 16
FURADANTIN 16
furosemide 76
FUZEON 16
G
G/P 79
gabapentin 58
GABARONE 58
GABAZOLAMINE 58
GABITIDINE 85
GABITRIL 58
GABOXETINE 58
GAMASTAN S/D 102
GAMMAGARD LIQUID 102
GAMMAGARD S/D 102
GAMMAGARD 102
GAMUNEX 102
ganciclovir 16
GANTRIS PED 16
GARDASIL 102
GASTROCROM 116
GASTROMARK 73
gemfibrozil 42
GEMZAR 26
GENOTROPIN 93
gentamicin in saline 16
gentamicin sulfate (ophth) 82
gentamicin sulfate (topical) 107
GENTAMICIN SULFATE MICRON 124
GENTAMICIN SULFATE 124
gentamicin sulfate 16
GEOCILLIN 16
GEODON 58
GEODON 59
GFN 800/PSE 60 79
GLEEVEC 26
GLIADEL WAFER 26
glimepiride 93
glipizide-metformin hcl 93
glipizide 93
GLUCAGEN HYPOKIT 93
glucagon (rdna) 93
GLUCOPHAGE XR 93
GLUCOPHAGE 93
GLUCOTROL XL 94
GLUCOTROL 93
GLUCOTROL 94
GLUCOVANCE 94
GLUMETZA 94
glyburide micronized 94
glyburide-metformin 94
glyburide 94
glycopyrrolate 31
GLYCRON 94
GLYNASE 94
GLYSET 94
GNP STERILE PADS 2"X2" 119
gold sodium thiomalate 88
GOLYTELY 85
GORDONS UREA 107
GRAMICIDIN D 124
GRIFULVIN 16
GRIS-PEG 17
griseofulvin microsize 17
GRISEOFULVIN 124
guaiacol 124
guanabenz acetate 42
guanfacine hcl 42
guanidine hcl 31
GYNODIOL 94
H
134

HALDOL DECAN 59
HALDOL 59
HALFLYTELY BOWEL PREP KIT 85
halobetasol propionate 108
HALOG 108
haloperidol decanoate 59
haloperidol lactate 59
HALOPERIDOL 124
haloperidol 59
HAVRIX 102
HECTOROL 114
HELIDAC 17
heparin (porcine) in sodium chloride
35
heparin sod (porcine) in d5w 35
heparin sodium (porcine) 35
heparin sodium (porcine) 36
HEPARIN SODIUM/D5W 35
HEPARIN SODIUM/SODIUM CHL 35
HEPARIN SODIUM 35
HEPSERA 17
HERCEPTIN 26
HEXALEN 26
HIBTITER 102
HIPREX 17
HISTEX DA 79
homatropine hbr 82
homatropine methylbromide 31
HUMALOG MIX 50/50 PEN 94
HUMALOG MIX 50/50 94
HUMALOG MIX 75/25 PEN 94
HUMALOG MIX 75/25 94
HUMALOG PEN 94
HUMALOG 94
HUMAPEN LUXURA HD 119
HUMAPEN MEMOIR 119
HUMATIN 17
HUMATROPE 94
HUMIRA PEN-CROHNS DISEASE 116
HUMIRA PEN 116
HUMIRA 116
HUMULIN 50/50 94
HUMULIN 70/30 PEN 94
HUMULIN 70/30 94
HUMULIN N U-100 PEN 94
HUMULIN N 94
HUMULIN R 94
HYCAMTIN 26
HYCET 59
hydralazine hcl 42
HYDREA 26
HYDRO 40 FOAM 108
HYDROCHLOROT 76
hydrochlorothiazide 76
hydrocodone-acetaminophen 59
hydrocodone-ibuprofen 59
hydrocortisone (rectal) 108
hydrocortisone (topical) 108
HYDROCORTISONE ACETATE MI 124
HYDROCORTISONE ACETATE 124
hydrocortisone butyrate 108
HYDROCORTISONE MICRONIZED 124
hydrocortisone sod succinate 94
hydrocortisone valerate 108
hydrocortisone w/acetic acid 82
HYDROCORTISONE 124
hydrocortisone 94
hydromorphone hcl-bupivacaine hclsodium
chloride 59
hydromorphone hcl-sodium chloride
59
HYDROMORPHONE HCL 124
hydromorphone hcl 59
hydroxocobalamin 114
hydroxychloroquine sulfate 17
HYDROXYPROPYL CELLULOSE 1 124
HYDROXYPROPYL CELLULOSE 4 124
HYDROXYPROPYL CELLULOSE 7 124
HYDROXYPROPYL CELLULOSE 124
HYDROXYTRYPTOPHAN L-5 124
HYDROXYTRYPTOPHAN 124
hydroxyurea 26
hydroxyzine hcl 59
HYDROXYZINE PAMOATE 124
hydroxyzine pamoate 59
hydroxyzine pamoate 60
HYOSCYAMINE SULFATE 125
hyoscyamine sulfate 31
hyoscyamine sulfate 32
hyoscyamine 32
HYPERTENSOLOL 43
HYPROMELLOSE 100000CPS 125
HYPROMELLOSE 4300CPS 125
HYSKON 76
HYTONE 108
HYTRIN 43
HYZAAR 43
I
IBUPROFEN 125
ibuprofen 60
IDAMYCIN PFS 27
idarubicin hcl 27
IFEX/MESNEX COMBO PACK 27
IFEX 27
ifosfamide & mesna 27
ifosfamide 27
IMDUR 43
IMIPRAMINE HCL 125
imipramine hcl 60
imipramine pamoate 60
IMITREX STATDOSE PEN 60
IMITREX 60
IMMUNE GLOBULIN 102
IMOVAX RABIES (H.D.C.V.) 102
IMPLANON 94
IMURAN 117
INAPSINE 60
INCRELEX 94
INDAPAMIDE 125
indapamide 76
INDERAL LA 43
INDERAL 43
INDERIDE 40/25 43
INDOCIN IV 60
INDOCIN SR 60
INDOCIN 60
INDOMETHACIN 125
INDOMETHACIN 60
indomethacin 60
INFANRIX 102
INFERGEN 17
INFUMORPH 60
INJEX 30 NEEDLE FREE SYST 119
INNOHEP 36
INNOPRAN XL 43
INOVA 4/1 ACNE CONTROL TH 108
INOVA 108
INSPRA 43
INSULIN SYRINGE LUER-LOK/ 119
insulin syringe/needle u-100 120
insulin syringe/needle u-100 121
insulin syringe/needle u-40 121
insulin syringes (disposable) 120
INTAL INH 79
INTAL 79
135

INTRON-A 27
INVANZ 17
INVEGA 60
INVERSINE 43
invert sugar 76
INVIRASE 17
IODOFORM 125
IOPIDINE 82
IPOL INACTIVATED IPV 102
ipratropium bromide (nasal) 79
IPRATROPIUM BROMIDE 125
ipratropium bromide 32
IRESSA 27
irrigation solutions, physiological 73
ISLAND GARD-GRX 121
ISMO 43
ISO ATROPINE 82
ISO CARBACHO 82
ISO HOMATROP 82
ISO HYOSCINE 82
isoniazid & rifampin 17
isoniazid 17
ISOPROPAMIDE IODIDE 125
ISOPROTERENOL SULFATE 125
ISOPTIN SR 43
ISOPTO CARP 82
ISORDIL 43
isosorbide dinitrate 43
isosorbide mononitrate 43
isotretinoin 108
isradipine 43
ISTALOL 82
ISUPREL 32
itraconazole 17
IVEEGAM EN 102
J
J & J GAUZE NONSTERILE 8- 121
JANUMET 94
JANUMET 95
JANUVIA 95
JE-VAX 102
K
K-LOR HOSPITAL PACK 76
K-LOR 76
K-LYTE DS 76
K-LYTE-ORANG 76
K-LYTE/CL 76
K-PHOS NO 2 76
K-TABS 76
KADIAN 60
KALETRA 17
kanamycin sulfate 17
KAYEXALATE 76
KEFLEX 17
KEMADRIN 32
KENALOG-10 95
KENALOG-40 95
KENALOG 108
KEPIVANCE 108
KEPPRA 60
KERAFOAM 108
KERALAC NAILSTIK 108
KERALAC 108
KERALYT 108
KERLONE 43
KEROL 108
KETEK 17
ketoconazole (topical) 108
ketoconazole 17
KETOPROFEN 125
ketoprofen 60
ketoprofen 61
ketorolac tromethamine 61
ketotifen fumarate (ophth) 82
KINERET 117
KLARON 108
KLOR-CON 25 76
KLOR-CON M 76
KMART VALU PLUS INSULIN S 119
KMART VALU PLUS INSULIN S 120
KRISTALOSE 76
KROGER PEN NEEDLES 29G 121
KROGER PEN NEEDLES 31G 121
KYTRIL 85
KYTRIL 86
L
labetalol hcl 43
LAC-HYDRIN 108
LACRISERT 82
lactated ringer's (irrigation) 76
lactated ringer's 76
lactic acid (ammonium lactate) 108
LACTINOL 108
lactulose (encephalopathy) 76
lactulose 76
LAMICTAL STARTER/TAKING C 61
LAMICTAL STARTER/TAKING 61
LAMICTAL 61
LAMISIL 108
LAMISIL 17
lamotrigine 61
LANOXICAPS 43
LANOXIN 44
LANTUS OPTICLIK 95
LANTUS 95
LARIAM 17
LASIX 76
leflunomide 117
LESCOL XL 44
LESCOL 44
LETAIRIS 44
leucovorin calcium 117
LEUKERAN 27
LEUKINE 36
leuprolide acetate 27
LEUSTATIN 27
LEVACET 61
LEVALL G 79
LEVAMISOLE HCL 125
LEVAQUIN 17
LEVATOL 44
LEVBID 32
LEVEMIR FLEXPEN 95
LEVEMIR 95
LEVLEN CONTRACT PACK 95
LEVLEN-28 95
LEVLITE-28 95
LEVO DROMORA 61
LEVO-DROMORA 61
levobunolol hcl 82
levocarnitine (metabolic modifiers)
117
LEVODOPA 125
levonorgestrel & eth estradiol 95
levonorgestrel-eth estradiol
(triphasic) 95
levonorgestrel-ethinyl estradiol (91-
day) 95
levorphanol tartrate 61
levothyroxine sodium 95
LEVOXYL 95
LEVSIN/SL 32
LEVSIN 32
LEVSINEX 32
136

LEXAPRO 61
LEXIVA 17
LEXXEL 44
LIALDA 86
LIDAMANTLE 108
lidocaine hcl (cardiac) 44
lidocaine hcl (local anesth.) 101
lidocaine hcl (mouth-throat) 82
LIDOCAINE HCL MONOHYDRATE 125
LIDOCAINE HCL 101
lidocaine hcl 108
lidocaine hcl 109
LIDOCAINE HCL 125
lidocaine-prilocaine 109
lidocaine 109
LIDODERM 109
LIMBITROL DS 61
LIMBITROL 61
LINCOCIN 17
lindane 109
liothyronine sodium 95
LIPITOR 44
LIPOSYN II 76
LIPOSYN III 76
LIQUICET 61
lisinopril & hydrochlorothiazide 44
lisinopril 44
lithium carbonate 61
lithium citrate 61
LITHOBID 61
LITHOSTAT 77
LO/OVRAL-28 95
LOCOID LIPO 109
LOESTRIN 1.5/30-21 95
LOESTRIN 1/20-21 95
LOESTRIN 24 FE 95
LOESTRIN FE 1.5/30 95
LOESTRIN FE 1/20 95
LOFIBRA 44
LOMOTIL 86
loperamide hcl 86
LOPID 44
LOPRESSOR HCT 44
LOPRESSOR 44
LOPROX 109
loratadine & pseudoephedrine 8
loratadine 8
LORCET 10/650 61
LORCET PLUS 61
LORTAB 2.5 61
LORTAB 5 61
LORTAB 7.5 61
LORTAB 61
LOTEMAX 82
LOTENSIN HCT 44
LOTENSIN 44
LOTREL 44
LOTREL 45
LOTRISONE 109
LOTRONEX 86
lovastatin 45
LOVAZA 45
LOVENOX 36
loxapine succinate 61
LOXITANE 61
LUCENTIS 82
LUMIGAN 82
LUNESTA 61
LUNESTA 62
LUPR DEP-PED INJ 27
LUPRON 2 WEEK SUPPLY 27
LUPRON 6-PK 27
LUPRON DEPOT INJ 27
LURIDE 117
LUXIQ 109
LYBREL 95
LYNOX 62
LYOFOAM A POLYURETHANE FO 121
LYRICA 62
LYSODREN 27
M
M-M-R II W/DILUENT 1 DOSE 102
M-M-R II W/DILUENT 10 DOS 102
M-R-VAX II 102
MACROBID 17
MACRODANTIN 17
MACUGEN 82
MAGNACET 62
magnesium salicylate 62
MALARONE 17
MANDELAMINE 18
MANDOL/D5W 18
maprotiline hcl 62
MARINOL 86
MARPLAN 62
MATULANE 27
MAVIK 45
MAXALT-MLT 62
MAXALT 62
MAXIDEX 82
MAXIDONE 62
MAXIFED-G 79
MAXIFED 79
MAXIPIME 18
MAXITROL 82
MAXZIDE-25 77
MAXZIDE 77
mebendazole 18
MECLIZINE HCL MONOHYDRATE 125
MECLIZINE HCL 125
meclizine hcl 86
MECLOFENAMATE SODIUM MONO
125
MECLOFENAMATE SODIUM 125
meclofenamate sodium 62
MEDI-JECTOR CHOICE 121
MEDI-JECTOR VISION 121
MEDICINE SHOPPE PEN NEEDL 121
MEDROL DOSEPAK 96
MEDROL 96
medroxyprogesterone acetate
(contraceptive) 96
medroxyprogesterone acetate 96
MEDROXYPROGESTERONE MICRO
125
MEFENAM ACID 62
MEFENAMIC ACID 125
mefloquine hcl 18
MEFOXIN 18
MEGACE ES 96
MEGACE ORAL 27
megestrol acetate 27
MEIJER PEN NEEDLES 29GX12 121
MEIJER PEN NEEDLES 31GX6M 121
MEIJER PEN NEEDLES 31GX8M 121
meloxicam 62
MENACTRA 102
MENEST 96
MENOMUNE-A/C/Y/W-135 102
MENOSTAR 96
MENTAX 109
meperidine hcl-sodium chloride 62
MEPERIDINE HCL 125
meperidine hcl 62
MEPIVACAINE HCL 125
MEPROBAMATE 62
meprobamate 62
MEPRON 18
137

MERREM 18
MERUVAX II W/DILUENT 1 DO 102
MERUVAX II W/DILUENT 10 D 102
MESALAMINE 125
mesalamine 86
mesna 117
MESNEX 117
MESTINON TIMESPAN 32
MESTINON 32
METADATE CD 62
METADATE CD 63
METADATE 62
METAGLIP 96
METAPROTERENOL SULFATE 125
metaproterenol sulfate 32
metformin hcl 96
meth-bell-meth bl-phenyl sal 18
METHACHOLINE CHLORIDE 125
METHADONE HCL 125
methadone hcl 63
methazolamide 45
methenamine hippurate 18
methenamine mandelate-sodium
biphosphate 18
methenamine mandelate 18
methenamine-hyosc-methylene bluesod
phos-phenyl sal 18
METHENAMINE 125
METHERGINE 101
methimazole 96
methocarbamol 32
METHOCEL K100M PREMIUM 125
methotrexate sodium 27
METHOXSALEN 125
methscopolamine bromide 32
methyl ethyl ketone 125
METHYLCELLULOSE 125
methyldopa & hydrochlorothiazide 45
methyldopa 45
METHYLDOPATE 45
METHYLIN 63
methylphenidate hcl 63
methylprednisolone acetate 96
methylprednisolone sod succ 96
methylprednisolone 96
methyltestosterone 96
metipranolol 82
METOCLOPRAMIDE HCL MONOHY 125
METOCLOPRAMIDE HCL 125
metolazone 77
metoprolol & hydrochlorothiazide 45
metoprolol succinate 45
metoprolol tartrate 45
METOPROLOL 45
METRO IV 18
METRO 109
METROCREAM 109
METROGEL VAGINAL 109
METROGEL 109
METROLOTION 109
metronidazole (topical) 109
METRONIDAZOLE BENZOATE 125
metronidazole in nacl 18
metronidazole vaginal 109
metronidazole 18
MEVACOR 45
mexiletine hcl 45
MEXILETINE 45
MIACALCIN 96
MICARDIS HCT 45
MICARDIS 45
MICONAZOLE 3 109
miconazole nitrate vaginal 109
MICONAZOLE NITRATE 125
MICRO-K 77
MICRONASE 96
MICROZIDE 77
midodrine hcl 32
MIGERGOT 63
MIGRANAL 63
MINIPRESS 45
MINOCIN 18
MINOCYCLINE HCL 125
minocycline hcl 18
minoxidil 45
MINTEZOL 18
MIOSTAT 82
MIRAPEX 63
MIRASORB SONGES 2" X 2" 121
MIRASORB SPONGES 2" X 2" 121
MIRCETTE 96
MIRENA 96
mirtazapine 63
misoprostol 86
mitomycin 27
mitoxantrone hcl 27
MOBAN 63
MOBIC 63
moexipril hcl 45
moexipril-hydrochlorothiazide 46
mometasone furoate 109
MONODOX 18
MONOJECT INSUIN SYRINGE R 119
MONOJECT INSULIN SYRINGE/ 119
MONOKET 46
MONOPRIL HCT 46
MONOPRIL 46
MONUROL 18
MORPHINE SULFATE IN DEXTR 64
morphine sulfate in dextrose 63
MORPHINE SULFATE 125
morphine sulfate 63
morphine sulfate 64
MOTRIN 64
MOVIPREP 86
MS CONTIN 64
MUCOMYST-10 79
MUMPSVAX W/DILUENT 1 DOSE 102
MUMPSVAX W/DILUENT 10 DOS 102
mupirocin 109
MUSTARGEN 27
MYAMBUTOL 18
MYCAMINE 18
MYCELEX 109
MYCOBUTIN 19
MYCOSTATIN 109
MYDRIACYL 82
MYFORTIC 117
MYLERAN 27
MYLOTARG 27
MYNATAL 114
MYOCHRYSINE 88
MYOZYME 79
MYSOLINE 64
MYTELASE 32
N
nabumetone 64
nadolol 46
nafcillin sodium 19
NAFTIN-MP 109
NAFTIN 109
NAGLAZYME 79
nalbuphine hcl 64
NALFON 64
NALIDIXIC ACID 125
NALLPEN ISO-OSMOTIC IN DE 19
138

naloxone hcl 64
naltrexone hcl 64
NAMENDA TITRATION 64
NAMENDA 64
naphazoline hcl 82
NAPRELAN 64
NAPROSYN 64
NAPROXEN SODIUM 125
naproxen sodium 64
NAPROXEN 125
naproxen 64
naproxen 65
NARDIL 65
NASACORT AQ 82
NASAREL 82
NASATAB LA 79
NASCOBAL 115
NASONEX 82
NASOP12 32
NATACYN 82
NAVANE 65
NAVELBINE 27
NEBUPENT 19
NECON 10/11-28 96
nefazodone hcl 65
NEO-FRADIN 19
NEO-RX 125
NEOMYCIN SULFATE 125
neomycin sulfate 19
neomycin-bacitracin zn-polymyxin 82
neomycin-polymy-dexameth 82
neomycin-polymy-gramicid 82
neomycin-polymyxin-hc (ophth) 82
neomycin-polymyxin-hc (otic) 82
NEOPROFEN 65
NEORAL 117
NEOSPORIN 82
neostigmine methylsulfate 32
NEPHRAMINE 77
NEULASTA 36
NEUMEGA 36
NEUPOGEN 36
NEUPRO 65
NEURONTIN 65
NEUTREXIN 19
NEVANAC 82
NEXAVAR 28
NEXCARE HIGH PERFORMANCE 121
NEXIUM I.V. 86
niacin 115
NIASPAN 46
nicardipine hcl 46
NICOTROL INHALER 32
NICOTROL NS 32
nifedipine 46
NILANDRON 28
nimodipine 46
NIMOTOP 46
NIPENT 28
NITRO-DUR 46
NITROFURANTOIN MACROCRYST 126
nitrofurantoin macrocrystal 19
nitrofurantoin monohyd macro 19
nitroglycerin 46
NITROLINGUAL PUMPSPRAY 46
NITROSTAT 46
NITROSTAT 47
nizatidine 86
NIZORAL 109
NIZORAL 19
NOR-QD 96
NORCO 65
NORDETTE-28 96
NORDITROPIN CARTRIDGE 96
NORDITROPIN CARTRIDGE 97
NORDITROPIN NORDIFLEX PEN 96
NORDITROPIN NORDIFLEX PEN 97
NORDITROPIN NORDIFLEX 96
norethin acet & estrad-fe 97
norethindrone & eth estradiol 97
norethindrone & mestranol 97
norethindrone (contraceptive) 97
norethindrone acet & eth estra 97
norethindrone acetate 97
norethindrone-eth estradiol (triphasic)
97
NORFLEX 32
norgestimate-ethinyl estradiol
(triphasic) 97
norgestimate-ethinyl estradiol 97
norgestrel & ethinyl estradiol 97
NORINYL 1+35 97
NORINYL 1+50 97
NORITATE 109
NOROXIN 19
NORPACE 47
NORPRAMIN 65
NORTRIPTYLINE HCL 126
NORVASC 47
NORVIR 19
NOVANTRONE 28
NOVASAL 65
NOVOFINE 30 121
NOVOFINE 31 121
NOVOLIN 70/30 INNOLET 97
NOVOLIN 70/30 PENFILL 97
NOVOLIN 70/30 97
NOVOLIN N INNOLET 97
NOVOLIN N U-100 PENFILL 97
NOVOLIN N 97
NOVOLIN R INNOLET 97
NOVOLIN R U-100 PENFILL 97
NOVOLIN R 97
NOVOLOG FLEXPEN 97
NOVOLOG MIX 70/30 PENFILL 97
NOVOLOG MIX 70/30 PREFILL 97
NOVOLOG MIX 70/30 97
NOVOLOG PENFILL 97
NOVOLOG 97
NOVOPEN 3 INSULIN DELIVER 121
NOVOPEN 3 PENMATE 121
NOVOPEN JR (GREEN) 121
NOVOPEN JR (YELLOW) 121
NULEV 32
NULYTELY 86
NUMOISYN 82
NUMORPHAN 65
NUOX 109
NUTROPIN AQ 97
NUTROPIN 97
NUVARING 97
nystatin (mouth-throat) 19
nystatin (topical) 109
nystatin vaginal 109
nystatin-triamcinolone 109
NYSTATIN 109
nystatin 19
O
OCL 86
OCTAGAM 102
octreotide acetate 117
OCUFEN 82
OCUFLOX 82
ofloxacin (ophth) 82
ofloxacin 19
OGEN 97
139

OLUX 109
omeprazole 86
OMNI-PAC 19
OMNICEF 19
OMNITROPE 97
ONCASPAR 28
ondansetron hcl and dextrose 86
ONDANSETRON HCL 86
ondansetron hcl 86
ONDANSETRON 86
ondansetron 86
ONTAK 28
OPANA ER 65
OPANA ER 66
OPANA 65
OPHTHETIC 82
opium tincture 87
OPTIPRANOLOL 83
OPTISON 73
OPTIVAR 83
ORACEA 19
ORACIT 77
ORAMORPH SR 66
ORAP 66
ORAPRED ODT 97
ORAPRED 97
ORENCIA 117
ORFADIN 117
ORPHENADRINE CITRATE 126
orphenadrine citrate 32
orphenadrine w/ aspirin & caff 66
ORTHO EVRA 97
ORTHO MICRONOR 97
ORTHO TRI-CYCLEN LO 98
ORTHO TRI-CYCLEN 97
ORTHO-CEPT-28 98
ORTHO-CYCLEN-28 98
ORTHO-NOVUM 1/35-28 98
ORTHO-NOVUM 1/50-28 98
ORTHO-NOVUM 7/7/7-28 98
ORTHOCLONE OKT3 117
OVACE WASH 109
OVCON-35 98
OVCON-50 28 98
OVIDE 110
oxacillin sodium 19
OXACILLIN 19
OXANDRIN 98
oxandrolone 98
OXISTAT 110
OXSORALEN-UL 110
OXSORALEN 110
OXYBUTININ CHLORIDE 126
oxybutynin chloride 113
oxybutynin chloride 114
OXYCODONE HCL 126
oxycodone hcl 66
oxycodone w/ acetaminophen 66
oxycodone w/ aspirin 66
OXYCONTIN 66
OXYIR 66
OXYTETRACYCLINE HCL 126
oxytocin 101
OXYTROL 114
P
PACERONE 47
paclitaxel 28
PAMELOR 66
pamidronate disodium 117
PAMINE FORTE 32
PAMINE 32
PANAFIL 110
PANCREASE MT 10 87
PANCREASE MT 16 87
PANCREASE MT 20 87
PANCREASE MT 4 87
PANCRECARB MS-16 87
PANDEL 110
PANGESTYME EC 87
PANGLOBULIN 102
PANGLOBULIN 103
PANLOR DC 66
PANLOR SS 66
PANRETIN 110
papain-urea-chlorophyllin 103
papain-urea 110
papaverine hcl 47
PARAFON FORTE DSC 32
PARAPLATIN 28
paregoric 87
parenteral electrolytes 73
PARLODEL 117
PARNATE 66
paromomycin sulfate 19
paroxetine hcl 66
PASER 19
PATADAY 83
PAXIL CR 67
PAXIL 66
PAXIL 67
PC UNIFINE PENTIPS 29GX1/ 121
PC UNIFINE PENTIPS 31GX6M 122
PC UNIFINE PENTIPS 31GX8M 122
PCCA SORBITOL LOLLIPOP BA 126
PCE 19
PEDIAPRED 98
PEDIARIX 103
pediatric multivitamins w/fl 114
pediatric vitamins acd w/ fluoride
114
PEDIAZOLE 19
PEDIOTIC 83
PEDIOX-S 8
PEDVAX HIB 103
peg 3350-kcl-sod bicarb-sod
chloride-sod sulfate 87
peg 3350-potassium chloride-sod
bicarbonate-sod chloride 87
PEG 400 MONOSTEARATE 126
PEG-INTRON 19
PEG-INTRON 20
PEGANONE 67
PEGASYS 20
PEN G PROC 20
PEN NEEDLES 29GX1/2" 121
PEN NEEDLES 31G X 1/4" SH 121
PEN NEEDLES 31GX5/16" 121
PENICILLAMINE 126
penicillin g pot in dextrose 20
penicillin g potassium 20
penicillin g sodium 20
penicillin v potassium 20
PENLAC 110
PENTAM 20
pentamidine isethionate 20
PENTASA 87
pentazocine w/ apap 67
pentazocine w/ naloxone 67
pentetate calcium trisodium 88
pentetate zinc trisodium 88
pentoxifylline 36
PEPCID I.V. 87
PEPCID 87
PERANEX HC 110
PERCOCET 67
PERCODAN 67
PERIDEX 83
140

peritoneal dialysis solutions 73
PERLOXX 67
permethrin 110
perphenazine-amitriptyline 67
perphenazine 67
PERSANTINE 47
PEXEVA 67
PFIZERPEN G 20
phenazopyridine hcl 110
phenazopyridine-butabarbitalhyoscyamine
110
PHENERGAN 8
PHENYTEK 67
phenytoin sodium extended 67
phenytoin sodium 67
phenytoin 67
PHOSLO 77
PHOSPHOLINE 83
PHOTOFRIN 28
PHYSIOSOL IRRIGATION PH 7 77
pilocarpine hcl (oral) 32
PILOCARPINE HCL 126
pilocarpine hcl 83
PILOPINE HS 83
pindolol 47
piperacillin sodium-d5w 20
piperacillin sodium 20
piroxicam 67
PITOCIN 101
PLAN B 98
PLAQUENIL 20
PLATINOL AQ 28
PLAVIX 36
PLENAXIS 28
PLENDIL 47
PLETAL 36
PLEXION CLEANSER 110
PLEXION CLEANSING CLOTH 110
PLEXION SCT 110
PLEXION TS 110
podofilox 110
POLY TAN 8
POLY-PRED 83
POLYCITRA-K CRYSTALS 77
POLYCITRA-K 77
POLYCITRA-LC 77
POLYCITRA 77
POLYETHYLENE GLYCOL 1000 126
polyethylene glycol 3350 87
POLYGAM S/D 103
prenatal without a vit w/ fe fumarate
polymyxin b sulfate 20
-folic acid 114
polymyxin b-trimethoprim 83 PREVACID I.V 87
POLYOXYL 40 STEARATE 126 PREVACID NAPRAPAC 67
POLYTRIM 83
PREVACID SOLUTAB 87
PONSTEL 67
PREVACID 87
pot & sod citrates w/citric ac 77 PREVIDENT 5000 PLUS 117
potassium bicarb & chloride 77 PREVIDENT 117
potassium bicarbonate 77
PREVPAC 87
potassium chloride microencapsulated PREZISTA 20
crystals cr 77
PRIFTIN 20
potassium chloride 122
PRILOSEC OTC 87
POTASSIUM CHLORIDE 77
PRILOSEC 87
potassium chloride 77
PRIM 20
potassium citrate (alkalinizer) 77 primaquine phosphate 20
potassium citrate-citric acid 77 PRIMAXIN I.M. 20
PRAMOTIC 83
PRIMAXIN IV 20
pramoxine-acetic acid 83
primidone 67
pramoxine-chloroxylenol 83
PRINIVIL 47
PRANDIN 98
PRINZIDE 47
PRAVACHOL 47
PRO-BANTHINE 32
pravastatin sodium 47
PROAIR HFA 32
prazosin hcl 47
PROAMATINE 32
PRECARE 115
probenecid 77
PRECOSE 98
procainamide hcl 47
PRED FORTE 83
PROCALAMINE 77
PRED MILD 83
PROCANBID 47
PRED-G S.O.P. 83
PROCARDIA XL 47
PRED-G 83
PROCARDIA 47
prednicarbate 110
PROCHIEVE 99
prednisolone acetate (ophth) 83 prochlorperazine edisylate 67
prednisolone sodium phosphate PROCHLORPERAZINE MALEATE 126
(ophth) 83
prochlorperazine maleate 67
prednisolone sodium phosphate 98 prochlorperazine 67
prednisolone 98
PROCRIT 36
PREDNISONE 98
PROCTOCORT 110
prednisone 98
PROFEN II 79
PREFERRED PLUS UNIFINE PE 122 PROGRAF 117
PREFEST 98
PROLASTIN 118
PREGNENOLONE MICRONIZED 126 PROLEUKIN 28
PRELONE 98
PROMETHAZINE HCL 126
PREMARIN W/APPLICATOR 98 promethazine hcl 8
PREMARIN 98
PROMETRIUM 99
PREMASOL 77
PRONESTYL 47
PREMPHASE 98
PRONESTYL 48
PREMPRO 99
propafenone hcl 48
prenatal multivit-min w/fe-fa 114 PROPANTHELINE BROMIDE 126
proparacaine hcl 83
PROPINE 83
141

propoxyphene hcl 67
propoxyphene-n w/ apap 67
propoxyphene-n w/ apap 68
propranolol & hydrochlorothiazide 48
propranolol hcl 48
propylthiouracil 99
PROQUAD 103
PROQUIN XR 20
PROSCAR 118
PROSED/DS (ATROPINE FREE) 20
PROSTASCINT 118
PROSTIGMIN 33
PROTONIX 87
PROTOPIC 110
PROVENTIL HFA 33
PROVENTIL 33
PROVERA 99
PROVIGIL 68
PROZAC WEEKL 68
PROZAC 68
PSEUDOEPHEDRINE HCL/GUAIF 79
pseudoephedrine-guaifenesin 79
pseudoephedrine-guaifenesin 80
PSORCON E 110
PSORIATEC 110
PUBLIX PEN NEEDLE 29GX12M 121
PUBLIX PEN NEEDLE 31G/8MM 121
PULMICORT FLEXHALER 99
PULMICORT 99
PULMOZYME 79
PURINETHOL 28
PYLERA 20
pyrazinamide 20
PYRIDIUM PLUS 110
PYRIDIUM 110
pyridostigmine bromide 33
PYRLEX 8
Q
QC INSULIN SYRINGE 1ML/29 119
QC STERILE PADS 2"X2" 121
QUADRAMET 118
QUALAQUIN 20
QUESTRAN LIGHT 48
QUESTRAN 48
quinapril hcl 48
quinapril-hydrochlorothiazide 48
QUINERVA 20
quinidine gluconate 48
QUIXIN 83
QVAR 99
R
RA STERILE PADS 2"X2" 121
RABAVERT 103
RANEXA 48
RANICLOR 20
ranitidine hcl 87
RAPAMUNE 118
RAPIFLUX 68
RAPTIVA 110
RAZADYNE ER 33
RAZADYNE 33
REBETOL 20
REBIF TITRATION PACK 118
REBIF 118
RECLAST 118
RECOMBIVA HB 103
RECOMBIVA-HB 103
RECOMBIVAX HB 103
REFLUDAN 36
REGLAN 87
REGONOL 33
REGRANEX 110
RELAMINE 118
RELENZA DISKHALER 20
RELION 70/30 INNOLET 99
RELION 70/30 99
RELION N INNOLET 99
RELION N 99
RELION PEN NEEDLE 29GX12M 121
RELION PEN NEEDLE 31GX8MM 121
RELION R 99
RELPAX 68
REMERON SLTB 68
REMERON 68
REMICADE 118
RENAGEL 77
RENAMIN 77
REPREXAIN 68
REQUIP 68
RESCRIPTOR 20
reserpine 48
RESTASIS 83
RETIN-A MICR 110
RETIN-A MICRO PUMP 110
RETIN-A 110
RETINOIC ACID-ALL TRANS 126
RETISERT 83
RETROVIR 20
RETROVIR 21
REVATIO 48
REVEX 68
REVIA 68
REVLIMID 118
REYATAZ 21
RHEUMATREX 28
RHINOCORT AQUA 83
ribavirin (hepatitis c) 21
RID-A-PAIN 68
RIDAURA 88
RIFADIN 21
RIFAMATE 21
rifampin 21
RIFATER 21
RILUTEK 68
rimantadine hydrochloride 21
RIMANTALIST 21
RIMSO-50 118
ringer's irrigation 77
RIOMET 99
RISPERDAL M 68
RISPERDAL 68
RITALIN LA 69
RITALIN SR 69
RITALIN 68
RITALIN 69
RITUXAN 28
ROBAXIN-750 33
ROBAXIN 33
ROBINUL FORT 33
ROBINUL 33
ROCALTROL 115
ROCEPHIN IN ISO-OSMOTIC D 21
ROCEPHIN 21
ROFERON-A 28
ROSAC WASH 110
ROSAC 110
ROSULA CLARIFYING WASH 110
ROSULA NS 110
ROSULA 110
ROTATEQ 103
ROWASA 87
ROXANOL 69
ROXICODONE 69
ROZEREM 69
ROZEX 111
RYTHMOL SR 48
RYTHMOL 48
142

S
SAIZEN 99
SAL-TROPINE 33
SALAGEN 33
SALEX 111
salicylic acid 111
SALICYLIC ACID 126
saline w/ benzyl alcohol 78
saline, bacteriostatic 77
salsalate 69
SANCTURA 114
SANDIMMUNE 118
SANDOSTATIN LAR DEPOT 118
SANDOSTATIN 118
SANTYL 111
SARAFEM 69
SCOPACE 87
SCOPOLAMINE HBR 126
scopolamine hbr 33
SCOPOLAMINE HYDROBROMIDE 126
scopolamine hydrobromide 87
SEASONALE 99
SEB-PREV 111
SECTRAL 48
SELEGILINE HCL 126
selegiline hcl 69
selenium sulfide-pyrithione zinc in
urea vehicle 111
selenium sulfide 111
SELSEB 111
SELSUN SHAMPOO 111
SEMPREX-D 8
SENSIPAR 118
SENTRADINE 87
SENTROXATINE 69
SEPTRA DS 21
SEPTRA 21
SEREVENT DISKUS 33
SEROMYCIN 21
SEROQUEL XR 69
SEROQUEL 69
SEROSTIM 99
sertraline hcl 69
SHOHL'S SOLUTION MODIFIED 78
SILVADENE 111
SILVER NITRATE 126
silver nitrate 83
silver sulfadiazine 111
simvastatin 48
SINEMET CR 69
SINEMET 69
SINGULAIR 80
SKELAXIN 33
SKELID 118
SM GAUZE PADS 121
SOD EDECRIN 78
sodium chloride (gu irrigant) 78
SODIUM CHLORIDE 78
sodium chloride 78
sodium citrate & citric acid 78
sodium fluoride (dental) 118
sodium fluoride 118
sodium nitrite 88
sodium polystyrene sulfonate 78
sodium thiosulfate-salicylic acid 111
sodium thiosulfate 88
sodium thiosulfate 89
SOLAGE 111
SOLARAZE 111
SOLIRIS 118
SOLODYN 21
SOLTAMOX 28
SOLU-CORTEF 99
SOLU-MEDROL 99
SOMA COMPOUND/CODEINE 33
SOMA COMPOUND 33
SOMA 33
SOMAVERT 100
SOMAVERT 99
SONATA 69
SORBITOL 126
SORIATANE 118
sotalol hcl (afib/afl) 48
sotalol hcl (afib/afl) 49
sotalol hcl 49
SPECTRACEF 21
SPIRIVA HANDIHALER 33
spironolactone & hydrochlorothiazide
49
spironolactone 49
SPORANOX PULSEPAK 21
SPORANOX 21
SPRYCEL 28
STADOL 69
STALEVO 100 69
STALEVO 150 69
STALEVO 50 69
STERAPRED 12 DAY 100
STERAPRED DS 12 DAY 100
STERAPRED DS 100
STERAPRED 100
STERI-PAD STERILE PADS 10 121
STERI-PAD STERILE PADS 25 121
STERILE DILUENT FOR FLOLA 126
STERILE GAUZE PADS 2"X2" 121
STERILE PADS 2"X2" 121
STIMATE 100
STRATTERA 69
STRATTERA 70
streptomycin sulfate 21
STRIANT 100
STROMECTOL 21
SUBLIMAZE 70
SUBOXONE 70
SUBUTEX 70
SUCRAID 79
SUCRALFATE 126
SUCRALFATE 87
sucralfate 87
SUFENTA 70
sufentanil citrate 70
SULAR 49
SULFACET SOD 83
SULFACET-R 111
sulfacetamide sod-prednisolone 83
sulfacetamide sodium (acne) 111
sulfacetamide sodium (ophth) 83
sulfacetamide sodium w/ sulfur 111
sulfacetamide sodium-sulfur in urea
vehicle 111
sulfacetamide sodium-sulfur w/
sunscreens 103
sulfacetamide sodium-urea 111
sulfacetamide sodium 111
SULFACETAMIDE SODIUM 126
sulfadiazine 21
sulfamethoxazole-trimethoprim 21
SULFAMYLON 111
SULFASALAZINE 126
sulfasalazine 21
sulfasalazine 22
SULFOXYL REGULAR 111
SULFOXYL STRONG 111
sulindac 70
SUPPRELIN LA 28
SUPRAX 22
143

SUSTIVA 22
SUTENT 28
SYMBICORT 100
SYMBYAX 70
SYMLIN 100
SYNAGIS 22
SYNALGOS-DC 70
SYNAREL 100
SYNERCID 22
SYNTHROID 100
SYPRINE 89
T
TALACEN 70
TALADINE 87
TALADINE 88
TALWIN NX 70
TALWIN 70
TAMBOCOR 49
TAMIFLU 22
tamoxifen citrate 28
TAPAZOLE 100
TARCEVA 28
TARGRETIN 111
TARGRETIN 28
TARKA 49
TASMAR 70
TAXOL 28
TAXOTERE 28
TAZICEF 22
TAZORAC 111
TE ANATOXAL BERNA 103
TEGADERM FOAM DRESSING 2" 121
TEGRETOL XR 70
TEGRETOL 70
TEKTURNA 49
TEMODAR 28
TEMOVATE E 111
TEMOVATE 111
TENEX 49
TENORETIC 100 49
TENORETIC 50 49
TENORMIN 49
TERAZOL 3 111
TERAZOL 7 111
terazosin hcl 49
terbinafine hcl 22
terbutaline sulfate 33
terconazole vaginal 111
TERUMO INSULIN SYRINGE/1M 120
TESLAC 29
TESTIM 100
testosterone cypionate 100
testosterone enanthate 100
TESTRED 100
TETANUS TOXOID ADSORBED 103
tetanus toxoid fluid 103
TETANUS/DIPHTHERIA TOXOID 103
tetracaine hcl (ophth) 83
tetracycline hcl 22
TEV-TROPIN 100
TEVETEN HCT 49
TEVETEN 49
TEXACORT 112
THALOMID 118
THALOMID 119
THEO-24 114
THEO 114
theophylline sodium glycinate-gg 114
theophylline-guaifenesin 114
theophylline 114
THERABENZAPRINE-60 33
THERABENZAPRINE-90 33
THERACODOPHEN-325 70
THERACODOPHEN-650 70
THERACODOPHEN-LOW-90 70
THERACYS 103
THERAFELDAMINE 70
THERAPENTIN-60 70
THERAPENTIN-90 70
THERAPROFEN-60 70
THERAPROFEN-90 70
THERAPROXEN-90 70
THERAPROXEN 70
THERATRAMADOL-60 70
THERATRAMADOL-90 70
THINPRO INSULIN SYRINGE/0 119
THINPRO INSULIN SYRINGE/1 120
thioguanine 29
thioridazine hcl 70
thiotepa 29
thiothixene 70
thiothixene 71
THORAZINE 71
THROMBI-GEL 100 36
THROMBI-GEL 10 36
THROMBI-GEL 40 36
THROMBI-PAD 36
thyroid 100
THYROLAR-1/2 100
THYROLAR-1/4 100
THYROLAR-1 100
THYROLAR-2 100
THYROLAR-3 100
TIAZAC 49
TICE BCG 103
TICLID 36
ticlopidine hcl 36
TIKOSYN 49
TILADE 80
TIMENTIN 22
TIMOLIDE 10/25 49
timolol maleate (ophth) 83
timolol maleate 49
timolol maleate 50
TIMOPTIC OCU 84
TIMOPTIC-XE 84
TIMOPTIC 83
TINDAMAX 22
TISSEEL 36
tizanidine hcl 33
TOBI 22
TOBRADEX 84
tobramycin sulfate (ophth) 84
tobramycin sulfate in saline 22
tobramycin sulfate 22
TOBREX 84
TOFRANIL-PM 71
TOFRANIL 71
tolazamide 100
tolbutamide 101
tolmetin sodium 71
TOPAMAX SPRINKLE 71
TOPAMAX 71
TOPICORT LP 112
TOPICORT 112
TOPROL XL 50
TORISEL 29
torsemide 78
TRACLEER 50
tramadol hcl 71
tramadol-acetaminophen 71
TRANDATE IV 50
TRANDATE 50
trandolapril 50
TRANSDERM-SC DIS 88
tranylcypromine sulfate 71
144

TRAVASOL 2.75%/DEXTROSE 5 78
TRAVASOL 4.25%/DEXTROSE 1 78
TRAVASOL 4.25%/DEXTROSE 2 78
TRAVASOL 4.25%/DEXTROSE 5 78
TRAVASOL 5.5%/DEXTROSE 10 78
TRAVASOL 5.5%/DEXTROSE 20 78
TRAVASOL 5.5%/ELECTROLYTE 78
TRAVASOL 8.5%/DEXTROSE 10 78
TRAVASOL 8.5%/DEXTROSE 20 78
TRAVASOL 8.5%/DEXTROSE 50 78
TRAVASOL 78
TRAVATAN Z 84
TRAVATAN 84
TRAZAMINE 71
TRAZODONE HCL 126
trazodone hcl 71
TRECATOR 22
TRELSTAR DEP 29
TRELSTAR LA 29
TRENTAL 36
tretinoin (chemotherapy) 29
tretinoin 112
TRETINOIN 126
TREXALL 29
TRI-LEVLEN CONTRACT PACK 101
TRI-LEVLEN 101
TRI-NORINYL 28 101
triamcinolone acetonide (mouth) 112
triamcinolone acetonide (topical) 112
TRIAMCINOLONE ACETONIDE 126
triamterene & hydrochlorothiazide 78
TRIAZ CLEANS 112
TRIAZ 112
TRICOR 50
trifluoperazine hcl 71
trifluridine 84
TRIGLIDE 50
trihexyphenidyl hcl 33
TRIHIBIT 103
TRILEPTAL 71
trimethoprim 22
TRIMIPRAMINE MALEATE 126
trimipramine maleate 71
TRIOSTAT 101
TRIPEDIA 103
TRIPHASIL 28 101
TRISENOX 29
TRIZIVIR 22
TROPHAMINE 78
TRUSOPT 84
TRUVADA 22
TUSNEL PEDIATRIC 80
TWINJECT 33
TWINRIX 103
TYGACIL 22
TYKERB 29
TYLENOL/CODEINE #3 71
TYLENOL/CODEINE #4 71
TYLOX 71
TYPHIM VI 103
TYZEKA 22
U
ULTICARE MINI PEN NEEDLES 121
ULTICARE ORIGINAL PEN NEE 121
ULTICARE SHORT PEN NEEDLE 121
ULTILET PEN NEEDLE 121
ULTRABAG/DIANEAL LOW CALC 78
ULTRABAG/DIANEAL PD-2/1.5 78
ULTRABAG/DIANEAL PD-2/2.5 78
ULTRABAG/DIANEAL PD-2/4.2 78
ULTRACET 71
ULTRAM ER 71
ULTRAM 71
ULTRASE MT 20 88
ULTRAVATE 112
UMECTA NAIL 112
UMECTA PD 112
UMECTA 112
UNASYN BULK PACK 22
UNASYN PIGGYBACK UNIT 22
UNASYN 22
UNIFINE PENTIPS 6MM 122
UNIFINE PENTIPS/12MM 121
UNIFINE PENTIPS/8MM 122
UNIFINE PENTIPS 121
UNIFINE PENTIPS 122
UNIPHYL 114
UNIRETIC 50
UNIVASC 50
urea-hc acetate 112
urea 112
URECHOLINE 33
URELLE 22
URETRON D/S 22
UREX 22
URISED 22
URISPAS 114
URITACT DS 23
URITACT-EC 23
UROCIT-K 10 78
UROCIT-K 5 78
UROLENE BLUE 119
UROQID #2 23
UROXATRAL 119
URSO FORTE 88
URSO 88
ursodiol 88
UTA 23
UTIRA 23
UVADEX 112
V
VAGIFEM 101
VALCYTE 23
valproate sodium 71
valproic acid 71
VALTREX 23
VANCOCIN HCL ISO-OSMOTIC 23
VANCOCIN HCL 23
vancomycin hcl 23
VANOS 112
VANOXIDE-HC 112
VANSPAR 72
VANTAS 29
VANTIN 23
VAQTA 103
varicella-zoster immune globulin
(human) 103
VARIVAX 103
VASERETIC 50
VASOTEC 50
VECTIBIX 29
VELCADE 29
venlafaxine hcl 72
VENOGLOBUL-S 103
VENTOLIN HFA 33
VEPESID 29
VERAMYST 84
verapamil hcl 50
VERDESO 112
VERELAN PM 50
VERELAN 50
VESANOID 29
VESICARE 114
VEXOL 84
145

VFEND IV 23
VIADUR 29
VIBRA 23
VIBRAMYCIN 23
VICODIN ES 72
VICODIN 72
VICOPROFEN 72
VIDAZA 29
VIDEX EC 23
VIDEX 23
VIGAMOX 84
vinblastine sulfate 29
vincristine sulfate 29
vinorelbine tartrate 29
VINORELBINE 29
VIRACEPT 23
VIRAMUNE 23
VIRAZOLE 23
VIREAD 23
VIROPTIC 84
VISTARIL 72
VISTIDE 23
VISUDYNE 84
VITRASERT 84
VIVACTIL 72
VIVAGLOBIN 103
VIVELLE-DOT 101
VIVELLE 101
VIVOTIF BERNA 103
VOLTAREN-XR 72
VOLTAREN 72
VOLTAREN 84
VOSPIRE ER 33
VUMON 29
VYTORIN 50
VYVANSE 72
W
WARFARIN SODIUM AMORPHOUS 126
WARFARIN SODIUM CLATHRATE 126
WARFARIN SODIUM 126
warfarin sodium 36
warfarin sodium 37
water for inject, bacteriostatic
parabens 126
water for inject, bacteriostatic 126
water for injection, sterile 126
water for irrigation, sterile 78
WELCHOL 51
WELLBUTRIN XL 72
WELLBUTRIN 72
WESTCORT 112
X
XALATAN 84
XELODA 29
XIBROM 84
XIFAXAN 23
XODOL 72
XOLAIR 80
XOPENEX CONCENTRATE 34
XOPENEX HFA 34
XOPENEX 34
XYLOCAINE VISCOUS 84
XYLOCAINE-MPF 101
XYLOCAINE 101
XYLOCAINE 112
XYLOCAINE 51
XYRALID LP 113
XYRALID RC 113
XYREM 72
Y
YASMIN 28 101
YAZ 101
YF-VAX 103
YODOXIN 23
Z
ZACLIR 113
ZANAFLEX 34
ZANOSAR 29
ZANTAC 88
ZARONTIN 72
ZAROXOLYN 78
ZAVESCA 119
ZEBETA 51
ZEGERID 88
ZELAPAR 72
ZEMAIRA 119
ZEMPLAR 115
ZENAPAX 119
ZERIT 23
ZERIT 24
ZESTORETIC 51
ZESTRIL 51
ZETIA 51
ZEVALIN IN-111 29
ZEVALIN Y-90 29
ZIAC 51
ZIAGEN 24
ZIANA 113
ZINACEF/D5W 24
ZINACEF 24
ZINECARD 119
ZINOTIC 84
ZITHROMAX TRI-PAK 24
ZITHROMAX Z-PAK 24
ZITHROMAX 24
ZMAX 24
ZOCOR 51
ZODERM CLEANSER 113
ZODERM 113
ZOFRAN ODT 88
ZOFRAN 88
ZOLADEX 29
ZOLINZA 29
ZOLOFT 72
zolpidem tartrate 72
ZOMETA 119
ZOMIG ZMT 72
ZOMIG 72
ZONALON 113
ZONEGRAN 72
zonisamide 72
ZORBTIVE 101
ZOSTAVAX 103
ZOSYN 24
ZOVIRAX 113
ZOVIRAX 24
ZYBAN 72
ZYDONE 72
ZYDONE 73
ZYFLO 80
ZYLET 84
ZYLOPRIM 119
ZYMAR 84
ZYMINE XR 8
ZYPREXA ZYDI 73
ZYPREXA 73
ZYRTEC-D 8
ZYRTEC 8
ZYVOX 24
146