Choice Plan - Express Scripts

Choice planExpress Scripts Medicare (PDP)2013 Formulary(List of Covered Drugs)PLEASE READ: THIS DOCUMENT CONTAINS INFORMATIONABOUT THE DRUGS WE COVER IN THIS PLANNote to existing members: This formulary has changed since last year. Please review thisdocument to make sure that it still contains the drugs you take.Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary,pharmacy network, premium, and/or copayments/coinsurance may change on January 1, 2014.A Medicare-approved Part D sponsorThis information is available for free in other languages. Please contact our Customer Service numbersat 1-800-758-4574 (TTY users only: 1-800-716-3231) for additional information. Customer Service isavailable 24 hours a day, 7 days a week.Esta información está disponible sin cargo en otros idiomas. Por favor comuníquese a los númerosde Servicio al cliente al 1-800-758-4574 (sólo los usuarios de TTY: 1-800-716-3231) para obtenerinformación adicional. El Servicio al cliente está disponible las 24 horas del día, los 7 días de la semana.This document is available in braille. Please call the Customer Service numbers listed above if you needplan information in another format.Y0046_F00SNC3A CMS Accepted Last Updated: October 15, 2013Formulary ID: 13107, V19

What is the Express Scripts Medicare formulary?A formulary is a list of covered drugs selected by Express Scripts Medicare in consultation with ateam of health care providers, which represents the prescription therapies believed to be a necessarypart of a quality treatment program. Express Scripts Medicare will generally cover the drugs listed inour formulary as long as the drug is medically necessary, the prescription is filled at a plan networkpharmacy, 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 2013 formulary that was covered at the beginning of the year,we will not discontinue or reduce coverage of the drug during the 2013 coverage year, except when anew, less expensive generic drug becomes available, or when new adverse information about the safetyor effectiveness of a drug is released. Other types of formulary changes, such as removing a drug fromour formulary, will not affect members who are currently taking the drug. It will remain available atthe same cost-sharing for those members taking it for the remainder of the coverage year. We feel it isimportant that you have continued access for the remainder of the coverage year to the formulary drugsthat were available when you chose our plan, except for cases in which you can save additional moneyor we can ensure your safety.If we remove drugs from our formulary, or add prior authorization, quantity limits, and/or steptherapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affectedmembers of the change at least 60 days before the change becomes effective, or at the time themember requests a refill of the drug, at which time the member will receive a 60-day supply ofthe drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe, or thedrug’s manufacturer removes the drug from the market, we will immediately remove the drug fromour formulary and provide notice to members who take the drug. The enclosed formulary is currentas of November 1, 2013. To get updated information about the drugs covered by Express ScriptsMedicare, please visit our website at http://www.Express-Scripts.com or call Customer Serviceat 1-800-758-4574, 24 hours a day, 7 days a week. Customer Service is available in English andother languages. TTY users should call 1-800-716-3231. If there are additional changes made to theformulary that affect you and are not mentioned above, you will also be notified in writing of thesechanges within a reasonable period of time from when the changes are made.How do I use the formulary?There are two ways to find your drug within the formulary:Medical ConditionThe formulary begins on page 1. The drugs in this formulary are grouped into categories dependingon the type of medical conditions that they are used to treat. For example, drugs used to treat a heartcondition are listed under the category “Cardiovascular, Hypertension/Lipids.” If you know whatyour drug is used for, look for the category name in the list that begins on page 1. Then look underthe category name for your drug.i

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index thatbegins on page 42. The Index provides an alphabetical list of all of the drugs included in thisdocument. Both brand-name drugs and generic drugs are listed in the Index. Look in the Indexand find your drug. Next to your drug, you will see the page number where you can find coverageinformation. Turn to the page listed in the Index and find the name of your drug in the first columnof the list.What are generic drugs?Express Scripts Medicare covers both brand-name drugs and generic drugs. A generic drug is approvedby the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs costless than brand-name drugs.Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements andlimits may include:• Prior Authorization: Express Scripts Medicare requires you or your physician to get priorauthorization for certain drugs. This means that you will need to get approval from Express ScriptsMedicare before you fill your prescriptions. If you don’t get approval, Express Scripts Medicaremay not cover the drug.• Quantity Limits: For certain drugs, Express Scripts Medicare limits the amount of the drugthat Express Scripts Medicare will cover. For example, Express Scripts Medicare provides twoinhalers (17 grams) for a one-month supply per prescription for PROAIR ® HFA. This may be inaddition to a standard one-month or three-month supply.• Step Therapy: In some cases, Express Scripts Medicare requires you to first try certain drugs totreat your medical condition before we will cover another drug for that condition. For example, ifDrug A and Drug B both treat your medical condition, Express Scripts Medicare may not coverDrug B unless you try Drug A first. If Drug A does not work for you, Express Scripts Medicarewill then cover Drug B.You can find out if your drug has any additional requirements or limits by looking in the formulary thatbegins on page 1. You can also get more information about the restrictions applied to specific covereddrugs by visiting our website at http://www.Express-Scripts.com.You can ask Express Scripts Medicare to make an exception to these restrictions or limits. See thesection “How do I request an exception to the Express Scripts Medicare formulary?” below forinformation about how to request an exception.ii

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 confirm thatyour drug is not covered. If you learn that Express Scripts Medicare does not cover your drug, you havetwo options:• You can ask Customer Service for a list of similar drugs that are covered by Express ScriptsMedicare. When you receive the list, show it to your doctor and ask him or her to prescribe asimilar drug that is covered by Express Scripts Medicare.• You can ask Express Scripts Medicare to make an exception and cover your drug. See below forinformation about how to request an exception.How do I request an exception to the Express Scripts Medicare formulary?You can ask Express Scripts Medicare to make an exception to our coverage rules. There are severaltypes 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 certaindrugs, Express Scripts Medicare limits the amount of the drug that we will cover. If your drughas a quantity limit, you can ask us to waive the limit and cover more.• You can ask us to provide a higher level of coverage for your drug. If your drug is contained inour Non-Preferred Brand Drug tier, you can ask us to cover it at the cost-sharing amount thatapplies to drugs in the Preferred Brand Drug tier instead. This would lower the amount youmust pay for your drug. Please note, if we grant your request to cover a drug that is not on ourformulary, you may not ask us to provide a higher level of coverage for the drug. Also, you maynot ask us to provide a higher level of coverage for drugs that are in the Specialty Drug tier.Generally, Express Scripts Medicare will only approve your request for an exception if the alternativedrugs included on the plan’s formulary, the lower-tiered drug, or additional utilization restrictions wouldnot 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 utilizationrestriction exception. When you are requesting a formulary, tiering, or utilization restrictionexception, you should submit a statement from your physician supporting your request. Generally,we must make our decision within 72 hours of getting your prescriber’s or prescribing physician’ssupporting statement. You can request an expedited (fast) exception if you or your doctor believesthat your health could be seriously harmed by waiting up to 72 hours for a decision. If your request toexpedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s orprescribing physician’s supporting statement.iii

What do I do before I can talk to my doctor about changing my drugsor 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 toyour doctor to decide if you should switch to an appropriate drug that we cover or request a formularyexception so that we will cover the drug you take. While you talk to your doctor to determine the rightcourse of action for you, we may cover your drug in certain cases during the first 90 days you are amember 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 willcover a temporary 31-day supply (unless you have a prescription written for fewer days) when you goto a network pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you havebeen a member of the plan less than 90 days.If you are a resident of a long-term care facility, we will allow you to refill your prescription until wehave provided you with a 98-day transition supply, consistent with the dispensing increment (unless youhave a prescription written for fewer days). We will cover more than one refill of these drugs for the first90 days you are a member of our plan. If you need a drug that is not on our formulary, or if your abilityto get your drugs is limited but you are past the first 90 days of membership in our plan, we will cover a31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursuea formulary exception.Other times when we will cover a temporary 31-day transition supply (or less, if you have a prescriptionwritten for fewer days) include:• When you enter a long-term care facility• When you leave a long-term care facility• When you are discharged from a hospital• When you leave a skilled nursing facility• When you cancel hospice care• When you are discharged from a psychiatric hospital with a medication regimen that is highly individualized The plan will send you a letter within 3 business days of your filling a temporary transition supply,notifying you that this was a temporary supply and explaining your options.For more informationFor more detailed information about your Express Scripts Medicare prescription drug coverage, pleasereview your Evidence of Coverage and other plan materials.If you have questions about Express Scripts Medicare, please call Customer Service at 1-800-758-4574,24 hours a day, 7 days a week. Customer Service is available in English and other languages. TTY usersshould call 1-800-716-3231. Or visit http://www.Express-Scripts.com.If you have general questions about Medicare prescription drug coverage, please call Medicareat 1-800-MEDICARE (1-800-633-4227), 24 hours a day/7 days a week. TTY users should call1-877-486-2048. Or visit www.medicare.gov.iv

Express Scripts Medicare’s formularyThe formulary that begins on page 1 provides coverage information about some of the drugs covered byExpress Scripts Medicare. If you have trouble finding your drug in the list, turn to the Index that beginson page 42.The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., NEXIUM ® )and generic drugs are listed in lowercase italics (e.g., omeprazole).The information in the Requirements/Limits column tells you if Express Scripts Medicare has anyspecial requirements for coverage of your drug.Your CostsThe amount you pay for a covered drug will depend on:• Your coverage stage. Express Scripts Medicare has different stages of coverage. In each stage,the amount you pay for a drug may change.• The drug tier for your drug. Each covered drug is in one of four drug tiers. Each tier may havea different copayment or coinsurance amount. The “Drug Tiers” chart below explains what typesof drugs are included in each tier and shows how costs may change with each tier.The Evidence of Coverage (EOC) has more information about the plan’s coverage stages and lists thecopayment and coinsurance amounts for each tier.If you qualify for Extra HelpIf you qualify for Extra Help for your prescription drugs, your copayments and coinsurance may belower. Members who qualify for Extra Help will receive the “Evidence of Coverage Rider for PeopleWho Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to find out what yourcosts are. You can also contact Customer Service for more information.Drug TiersTier Includes Helpful TipsTier 1:Generic DrugsThis tier includes manycommonly prescribed genericdrugs and may include otherlow-cost drugs.Use Tier 1 drugs for the lowest copayments.Tier 2:PreferredBrand DrugsTier 3:Non-PreferredBrand DrugsTier 4:SpecialtyTier DrugsThis tier includes preferredbrand-name drugs as well assome generic drugs.This tier includesnon-preferred brand-namedrugs as well as some genericdrugs.This tier includes veryhigh-cost drugs.Drugs in this tier will generally have lower copaymentsthan non-preferred drugs.Many non-preferred drugs have lower-costalternatives in Tiers 1 and 2. Ask your doctor ifswitching to a lower-cost generic or preferred branddrug may be right for you.To learn more about medications in this tier, youmay contact a pharmacist at the numbers listed onthe cover of this document.v

Below is a list of abbreviations that may appear on the following pages in the Requirements/Limitscolumn that tells you if there are any special requirements for coverage of your drug.List of AbbreviationsQL: Quantity Limit. For certain drugs, the plan limits the amount of the drug that we will cover.ST: Step Therapy. In some cases, the plan requires you to first try a certain drug to treat your medicalcondition before we will cover another drug for that condition. For example, if Drug A and Drug B bothtreat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does notwork for you, we will then cover Drug B.PA: Prior Authorization. The plan requires you or your doctor to get prior authorization for certaindrugs. This means that you will need to get approval before you fill your prescription. If you don’t getapproval, we may not cover the drug.HI: Home Infusion. This prescription drug may be covered under our medical benefit. For moreinformation, call Customer Service.GC: Gap Coverage. We provide coverage of this prescription drug in the Coverage Gap. Please refer toour Evidence of Coverage for more information about this coverage.LA: Limited Availability. This prescription drug may be available only at certain pharmacies. For moreinformation, call Customer Service at 1-800-758-4574, 24 hours a day, 7 days a week. (TTY usersshould call 1-800-716-3231.)FF: Free First Fill. This prescription drug may be provided at a reduced cost-sharing amount the firsttime you fill it.ED: Enhanced Drug. This prescription drug is not normally covered in a Medicare prescription drugplan. The amount you pay when you fill a prescription for this drug does not count toward your totaldrug costs (that is, the amount you pay does not help you qualify for Catastrophic Coverage). Inaddition, if you are receiving Extra Help to pay for your prescriptions, you will not get any Extra Help topay for this drug.CB: Capped Benefit. This prescription drug has a capped benefit limit.MO: Mail-Order Drug. This prescription drug is available through our mail-order service, as well asthrough our retail network pharmacies. Consider using mail order for your long-term (maintenance)medications (such as high blood pressure medications). Retail network pharmacies may be moreappropriate for short-term prescriptions (such as antibiotics).vi

Commonly Prescribed TherapeuticDrug CategoriesANTI - INFECTIVESANTIFUNGAL AGENTSDrugNameDrugTierRequirements/Limitsamphotericin b 1 GC PA MOANCOBON 2 MOclotrimazole troc 1 GC MOERAXIS INJ 100MG 2 MOfluconazole 1 GC MOfluconazole in dextrose inj 1 GC56mg/ml; 400mg/200mlflucytosine 1 GC MOGRIS-PEG 3 MOgriseofulvin microsize 1 GC MOgriseofulvin ultramicrosize 1 GC MOitraconazole 1 GC MOketoconazole 1 GC MONOXAFIL 2 MOnystatin susp 1 GC MOnystatin tabs 1 GC MOSPORANOX ORAL SOLN 2 MOterbinafine hcl tabs 1 GC MOVFEND IV 2 MOVFEND SUSR 2 MOvoriconazole 1 GC MOANTIVIRALSabacavir 1 GC QL(180per 90 days)MOacyclovir 1 GC MOacyclovir sodium inj 500mg 1 GC MOamantadine hcl 1 GC MOAPTIVUS CAPS 4 QL(360 per90 days)MOAPTIVUS ORAL SOLN 4 QL(950 per90 days)ATRIPLA 4 QL(90 per90 days)MODrugNameDrugTierRequirements/LimitsBARACLUDE ORAL SOLN 2 QL(1890per 90 days)MOBARACLUDE TABS 2 QL(90 per90 days)MOCIDOFOVIR 4 MOCOMPLERA 4 QL(90 per90 days)MOCRIXIVAN 2 MOdidanosine 1 GC QL(90per 90 days)MOEDURANT 4 QL(90 per90 days)MOEMTRIVA CAPS 2 QL(90 per90 days)MOEMTRIVA ORAL SOLN 2 QL(2210per 90 days)MOEPIVIR HBV 2 MOEPIVIR ORAL SOLN 2 QL(2880per 90 days)MOEPZICOM 4 QL(90 per90 days)MOfamciclovir 1 GC MOfoscarnet sodium 1 GC PA MOFUZEON 4 QL(180 per90 days)MOganciclovir 1 GC MOHEPSERA 4 QL(90 per90 days)MOINCIVEK 4 PA QL(504per 84 days)MOINTELENCE TABS 200MG 4 QL(180 per90 days)MO1

DrugNameDrugTierRequirements/LimitsINTELENCE TABS 100MG 4 QL(360 per90 days)MOINTELENCE TABS 25MG 2 QL(360 per90 days)INVIRASE CAPS 3 QL(900 per90 days)MOINVIRASE TABS 4 QL(360 per90 days)MOISENTRESS CHEW 100MG 4 QL(540 per90 days)MOISENTRESS CHEW 25MG 2 QL(540 per90 days)ISENTRESS TABS 4 QL(360 per90 days)MOKALETRA ORAL SOLN 4 QL(1280per 90 days)MOKALETRA TABS 200MG;50MGKALETRA TABS 100MG;25MG4 QL(360 per90 days)MO2 QL(900 per90 days)MOlamivudine tabs 300mg 1 GC QL(90per 90 days)MOlamivudine tabs 150mg 1 GC QL(180per 90 days)MOlamivudine/zidovudine 1 GC QL(180per 90 days)MOLEXIVA SUSP 2 QL(5175per 90 days)MOLEXIVA TABS 4 QL(360 per90 days)MOnevirapine tabs 1 GC QL(180per 90 days)MODrugNameDrugTierRequirements/LimitsNORVIR CAPS 2 QL(1080per 90 days)MONORVIR ORAL SOLN 2 QL(1440per 90 days)MONORVIR TABS 2 QL(1080per 90 days)MOPREZISTA SUSP 4 MOPREZISTA TABS 800MG 4 MOPREZISTA TABS 400MG,600MG4 QL(180 per90 days)MOPREZISTA TABS 150MG 2 QL(540 per90 days)MOPREZISTA TABS 75MG 2 QL(900 per90 days)MOREBETOL ORAL SOLN 2 PA MORELENZA DISKHALER 2 QL(300 per365 days)MORESCRIPTOR TABS 200MG 3 QL(540 per90 days)MORESCRIPTOR TABS 100MG 3 QL(1080per 90 days)MORETROVIR IV INFUSION 2REYATAZ CAPS 300MG 2 QL(90 per90 days)MOREYATAZ CAPS 150MG,200MG2 QL(180 per90 days)MOREYATAZ CAPS 100MG 2 QL(360 per90 days)MOribapak tabs 4 PA MOribasphere caps 1 GC PA MOribasphere tabs 400mg 1 GC PAribasphere tabs 200mg 1 GC PA MOribasphere tabs 600mg 4 PA MO2

DrugNameDrugTierRequirements/Limitsribavirin 1 GC PA MOrimantadine hcl 1 GC MOSELZENTRY TABS 150MG 4 QL(180 per90 days)MOSELZENTRY TABS 300MG 4 QL(360 per90 days)MOstavudine caps 1 GC QL(180per 90 days)MOstavudine oral soln 1 GCQL(7200per 90 days)MOSTRIBILD 4 QL(90 per90 days)MOSUSTIVA CAPS 200MG 2 QL(360 per90 days)MOSUSTIVA CAPS 50MG 2 QL(630 per90 days)MOSUSTIVA TABS 2 QL(90 per90 days)MOTAMIFLU CAPS 45MG, 75MG 2 QL(60 per365 days)MOTAMIFLU CAPS 30MG 2 QL(120 per365 days)MOTAMIFLU SUSR 2 QL(720 per365 days)MOTIVICAY 4 MOTRIZIVIR 4 QL(180 per90 days)MOTRUVADA 4 QL(90 per90 days)MOTYZEKA 4 MODrugNameDrugTierRequirements/Limitsvalacyclovir hcl tabs 1000mg 1 GC QL(100per 90 days)MOvalacyclovir hcl tabs 500mg 1 GC QL(200per 90 days)MOVALCYTE 4 MOVICTRELIS 4 PAQL(1008per 84 days)MOVIDEX PEDIATRIC ORALSOLN 2GM2 QL(3600per 90 days)MOVIRACEPT TABS 625MG 4 QL(360 per90 days)MOVIRACEPT TABS 250MG 4 QL(900 per90 days)MOVIRAMUNE SUSP 2 QL(3600per 90 days)MOVIRAMUNE XR 2 MOVIRAZOLE 4 MOVIREAD POWD 2 QL(720 per90 days)MOVIREAD TABS 2 QL(90 per90 days)MOZERIT ORAL SOLN 3 QL(7200per 90 days)MOZIAGEN ORAL SOLN 2 QL(2880per 90 days)MOZIAGEN TABS 2 QL(180 per90 days)MOzidovudine caps 1 GC QL(540per 90 days)MO3

DrugNameDrugTierRequirements/Limitszidovudine syrp 1 GCQL(5520per 90 days)MOzidovudine tabs 1 GC QL(180per 90 days)MOCEPHALOSPORINScefaclor caps 1 GC MOcefadroxil 1 GC MOcefazolin sodium inj 10gm, 1gm; 1 GC5%, 500mgcefazolin sodium inj 1gm 1 GC MOcefdinir 1 GC MOcefepime inj 2gm 1 GCcefepime inj 1gm 1 GC MOcefotaxime sodium inj 1gm, 2gm 1 GCcefotaxime sodium inj 10gm 1 GC MOcefoxitin sodium inj 10gm, 2gm 1 GCcefoxitin sodium inj 1gm 1 GC MOcefpodoxime proxetil 1 GC MOceftazidime inj 1gm, 6gm 1 GCceftazidime inj 2gm 1 GC MOceftriaxone sodium inj 10gm 1 GCceftriaxone sodium inj 1gm, 1 GC MO250mg, 2gm, 500mgcefuroxime axetil tabs 1 GC MOcefuroxime sodium inj 7.5gm 1 GCcefuroxime sodium inj 1.5gm, 1 GC MO750mgcephalexin caps 250mg, 500mg 1 GC MOcephalexin susr 1 GC MOcephalexin tabs 1 GC MOFORTAZ INJ 1GM/50ML; 5%, 22GM/50ML; 5%, 6GMSUPRAX CAPS 3SUPRAX SUSR 500MG/5ML 3SUPRAX SUSR 100MG/5ML, 3 MO200MG/5MLSUPRAX TABS 3 MOTEFLARO 2 MOZINACEF IN ISO-OSMOTICDEXTROSE2DrugNameDrugTierRequirements/LimitsZINACEF IN ISO-OSMOTIC 2DILUENTERYTHROMYCINS / OTHERMACROLIDESazithromycin inj 500mg 1 GCazithromycin susr 1 GC MOazithromycin tabs 1 GC MOclarithromycin 1 GC MOclarithromycin er 1 GC MODIFICID 2 QL(60 per90 days)MOe.e.s. 400 1 GC MOE.E.S. GRANULES 2 MOERY-TAB TBEC 500MG 2 MOery-tab tbec 250mg, 333mg 1 GC MOERYTHROCIN2LACTOBIONATE INJ 500MGerythrocin stearate 1 GC MOerythromycin base 1 GC MOerythromycin ethylsuccinate 1 GC MOZMAX 2 MOMISCELLANEOUS ANTIINFECTIVESALBENZA 2 MOALINIA 2 MOamikacin sulfate inj 1gm/4ml, 1 GC MO50mg/mlatovaquone/proguanil hcl tabs 1 GC MO250mg; 100mgAZACTAM IN ISO-OSMOTIC 2DEXTROSEAZACTAM INJ 2GM 2 MOaztreonam inj 1gm 1 GC MOBILTRICIDE 2 MOCAPASTAT SULFATE 3CAYSTON 4 LA MOchloroquine phosphate 1 GC MOCLEOCIN IN D5W 2CLEOCIN PEDIATRIC2 MOGRANULESclindamycin hcl 1 GC MOclindamycin palmitate hcl 1 GC MO4

DrugNameDrugTierRequirements/Limitsclindamycin phosphate1 GC MOaddvantageclindamycin phosphate in d5w inj 1 GC300mg/50ml; 5%, 600mg/50ml;5%clindamycin phosphate in d5w inj 1 GC MO900mg/50ml; 5%COARTEM 2 MOcolistimethate sodium 1 GC MOCUBICIN 2 PA MODAPSONE 2 MODARAPRIM 2 MOethambutol hcl 1 GC MOgentamicin sulfate inj 1 GC MOgentamicin sulfate/0.9% sodium 1 GCchloride inj 0.9mg/ml; 0.9%,1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%,1mg/ml; 0.9%hydroxychloroquine sulfate 1 GC MOimipenem/cilastatin 1 GC MOisoniazid syrp 1 GC MOisoniazid tabs 1 GC MOisotonic gentamicin inj 0.8mg/ml; 1 GC0.9%, 1.2mg/ml; 0.9%KETEK 2 QL(20 per30 days)MOMALARONE 2 MOmefloquine hcl 1 GC MOMEPRON 4 MOmeropenem inj 500mg 1 GC MOmetronidazole 1 GC MOmetronidazole in nacl 0.79% 1 GC MOMYCOBUTIN 2 MONEBUPENT 2 PA MOneomycin sulfate tabs 1 GC MOparomomycin sulfate 1 GC MOPASER 2 MOPRIMAQUINE PHOSPHATE 2 MOpyrazinamide 1 GC MOQUALAQUIN 2 MOquinine sulfate 1 GC MODrugNameDrugTierRequirements/Limitsrifampin 1 GC MOSEROMYCIN 2 MOSIRTURO 4 LA MOSTREPTOMYCIN SULFATE 2 MOSTROMECTOL 2 MOtinidazole 1 GC QL(60per 90 days)MOTOBI 4 PA MOtobramycin sulfate inj 10mg/ml, 1 GC MO80mg/2mltobramycin sulfate/sodium 1 GCchloride inj 0.9%; 1.2mg/mltobramycin sulfate/sodium 1 GC MOchloride inj 0.9%; 0.8mg/mlTRECATOR 2 MOTYGACIL 2 MOXIFAXAN TABS 200MG 2 QL(9 per 30days) MOXIFAXAN TABS 550MG 2 QL(180 per90 days)MOZYVOX INJ 2 MOZYVOX SUSR 2 QL(1800per 30 days)MOZYVOX TABS 2 QL(56 per30 days)MOPENICILLINSamoxicillin 1 GC MOamoxicillin/clavulanate potassium 1 GC MOchewamoxicillin/clavulanate potassium 1 GC MOeramoxicillin/clavulanate potassium 1 GC MOsusr 250mg/5ml; 62.5mg/5ml,400mg/5ml; 57mg/5ml,600mg/5ml; 42.9mg/5mlamoxicillin/clavulanate potassium 1 GC MOtabs 250mg; 125mgamoxicillin/potassium clavulanate 1 GC MOsusr 200mg/5ml; 28.5mg/5mlamoxicillin/potassium clavulanatetabs1 GC MO5

DrugNameDrugTierRequirements/Limitsampicillin 1 GC MOampicillin sodium inj 1gm 1 GCampicillin sodium inj 10gm, 1 GC MO125mgampicillin-sulbactam inj 10gm; 1 GC5gmampicillin-sulbactam inj 2gm; 1 GC MO1gmBICILLIN C-R 2 MOBICILLIN L-A 2 MOdicloxacillin sodium 1 GC MOnafcillin sodium inj 10gm, 1gm 1 GC MOnallpen/dextrose 1 GCPENICILLIN G POTASSIUM IN 2ISO-OSMOTIC DEXTROSE INJ0; 40000UNIT/ML, 0;60000UNIT/MLpenicillin g potassium inj 5mu 1 GC MOpenicillin g procaine 1 GC MOpenicillin g sodium 1 GC MOpenicillin v potassium 1 GC MOpfizerpen-g inj 20mu 1 GC MOpiperacillin sodium/tazobactam 1 GC MOsodium inj 3gm; 0.375gm, 4gm;0.5gmZOSYN INJ 5%; 2GM/50ML; 20.25GM/50MLZOSYN INJ 5%; 3GM/50ML; 2 MO0.375GM/50MLQUINOLONESAVELOX 2 MOAVELOX ABC PACK 2 MOCIPRO I.V.-IN D5W INJ 2200MG/100ML; 5%ciprofloxacin hcl 1 GC MOciprofloxacin i.v.-in d5w inj 1 GC MO200mg/100ml; 5%ciprofloxacin inj 400mg/40ml 1 GClevofloxacin 1 GC MOlevofloxacin in d5w inj 5%; 1 GC500mg/100mlNOROXIN 3 MOofloxacin 1 GC MODrugNameDrugTierRequirements/LimitsSULFA'S / RELATED AGENTSsulfadiazine 1 GC MOsulfamethoxazole/trimethoprim 1 GC MOsulfamethoxazole/trimethoprim ds 1 GC MOTETRACYCLINESdemeclocycline hcl 2 MOdoxycycline hyclate caps 1 GC MOdoxycycline hyclate dr 1 GC MOdoxycycline hyclate inj 1 GC MOdoxycycline hyclate tabs 1 GC MOdoxycycline monohydrate caps 1 GC MO75mgdoxycycline monohydrate susr 1 GC MOdoxycycline monohydrate tabs 1 GC MO150mg, 50mg, 75mgminocycline hcl 1 GC MOminocycline hcl er 1 GC MOtetracycline hcl 1 GC MOVIBRAMYCIN SUSR 2 MOVIBRAMYCIN SYRP 2 MOURINARY TRACT AGENTSMACRODANTIN CAPS 25MG 2 MOmethenamine hippurate 1 GC MOnitrofurantoin macrocrystalline 1 GC MOcaps 50mgnitrofurantoin monohydrate 1 GC MOnitrofurantoin susp 1 GC MOPRIMSOL 3 MOtrimethoprim 1 GC MOVANCOMYCINvancomycin hcl caps 1 GC MOvancomycin hcl inj 500mg 1 GC PAvancomycin hcl inj 1000mg, 10gm 1 GC PA MOVIBATIV INJ 250MG 2ANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGSADJUNCTIVE AGENTSamifostine 4 MOdexrazoxane inj 500mg 1 GC MOELITEK INJ 1.5MG 46

DrugNameDrugTierRequirements/LimitsFUSILEV 4 MOleucovorin calcium inj 100mg, 1 GC MO350mgleucovorin calcium tabs 1 GC MOmesna 1 GC MOMESNEX TABS 2 MOXGEVA 4 PA QL(8.5per 90 days)MOZINECARD INJ 250MG 2 MOANTINEOPLASTIC /IMMUNOSUPPRESSANT DRUGSABRAXANE 3 MOadriamycin inj 2mg/ml 1 GC MOAFINITOR DISPERZ 4 PA QL(360per 90 days)MOAFINITOR TABS 10MG, 7.5MG 4 PA QL(180per 90 days)MOAFINITOR TABS 2.5MG, 5MG 4 PA QL(270per 90 days)MOALIMTA INJ 500MG 3 MOALKERAN INJ 3anastrozole 1 GC MOARRANON 3ARZERRA INJ 100MG/5ML 2 MOAVASTIN INJ 100MG/4ML 3 MOazathioprine 1 GC PA MOazathioprine sodium 1 GC MObicalutamide 1 GC MOBICNU 3 MObleomycin sulfate inj 30unit 1 GC MOBOSULIF TABS 500MG 4 PA QL(90per 90 days)MOBOSULIF TABS 100MG 4 PA QL(360per 90 days)MOBUSULFEX 2CAMPATH 3 MODrugNameDrugTierRequirements/LimitsCAPRELSA TABS 300MG 4 QL(90 per90 days)MOCAPRELSA TABS 100MG 4 QL(180 per90 days)MOcarboplatin inj 150mg/15ml 1 GC MOCEENU 2 MOCELLCEPT INTRAVENOUS 2CELLCEPT SUSR 2 PA MOcisplatin inj 100mg/100ml 1 GC MOcladribine 1 GC MOCLOLAR 3 MOCOMETRIQ 4 PA MOCOSMEGEN 3 MOcyclophosphamide tabs 1 GC PA MOcyclosporine caps 1 GC PA MOcyclosporine inj 1 GCcyclosporine modified 1 GC PA MOcytarabine aqueous 1 GC MOcytarabine inj 500mg 1 GC MOdacarbazine inj 200mg 1 GC MODACOGEN 2 MOdaunorubicin hcl inj 5mg/ml 1 GCdecitabine 4 MODOCEFREZ 4docetaxel inj 80mg/8ml 1 GCdocetaxel inj 80mg/4ml 1 GC MODOXIL 2 MOdoxorubicin hcl inj 2mg/ml 1 GC MODROXIA 2 MOELLENCE INJ 200MG/100ML 3 MOELOXATIN INJ 100MG/20ML 3 MOELSPAR 3 MOEMCYT 2 MOepirubicin hcl inj 50mg/25ml 1 GC MOERBITUX INJ 100MG/50ML 3 MOERIVEDGE 4 PA MOETOPOPHOS 3 MOetoposide inj 500mg/25ml 1 GC MOexemestane 1 GC MO7

DrugNameDrugTierRequirements/LimitsFARESTON 3 MOFASLODEX 4 MOFIRMAGON INJ 120MG 4 QL(240 per84 days)MOFIRMAGON INJ 80MG 2 QL(240 per84 days)MOfludarabine phosphate inj 50mg 1 GC MOfluorouracil inj 2.5gm/50ml 1 GC MOflutamide 1 GC MOgemcitabine hcl inj 1gm 4 MOgengraf 1 GC PA MOGILOTRIF TABS 40MG 4 PA QL(31per 31 days)MOGILOTRIF TABS 30MG 4 PA QL(42per 31 days)MOGILOTRIF TABS 20MG 4 PA QL(62per 31 days)MOGLEEVEC 4 MOHALAVEN 4 MOHERCEPTIN 3 MOHEXALEN 4 MOhydroxyurea 1 GC MOICLUSIG 4 PA MOidarubicin hcl inj 10mg/10ml 1 GCIFEX INJ 3GM 3 MOifosfamide inj 1gm 1 GC MOINLYTA 4 PA MOirinotecan inj 100mg/5ml 4 MOISTODAX 2 MOIXEMPRA KIT INJ 45MG 4 MOJAKAFI 4 PA QL(180per 90 days)MOJEVTANA 4 MOKADCYLA INJ 100MG 4 MOletrozole 1 GC MOLEUKERAN 2 MOleuprolide acetate 1 GC MODrugNameDrugTierRequirements/LimitsLUPRON DEPOT INJ 3.75MG 2 MOLUPRON DEPOT INJ 22.5MG, 4 MO30MG, 45MG, 7.5MGLUPRON DEPOT-PED INJ 4 MO11.25MG, 15MGLYSODREN 2 MOMATULANE 4 MOMEGACE ES 2 QL(150 per30 days)MOmegestrol acetate 1 GC MOMEKINIST TABS 2MG 4 PA QL(30per 30 days)MOMEKINIST TABS 0.5MG 4 PA QL(120per 30 days)MOmelphalan hydrochloride 1 GCmercaptopurine 1 GC MOmethotrexate 1 GC PA MOmethotrexate sodium inj 25mg/ml 1 GC MOMETHOTREXATE SODIUM 3INJ 1GMmitomycin inj 20mg 1 GC MOmitoxantrone hcl 1 GC MOMUSTARGEN 3 MOmycophenolate mofetil 1 GC PA MOMYFORTIC 2 PA MONEORAL 2 PA MONEXAVAR 4 LA PAQL(360 per90 days)MONILANDRON 3 QL(120 per90 days)MONIPENT 3 MONULOJIX 4 MOoctreotide acetate inj4 MO1000mcg/ml, 500mcg/mloctreotide acetate inj 100mcg/ml, 1 GC MO200mcg/ml, 50mcg/mlONTAK 3oxaliplatin inj 100mg/20ml 4 MO8

DrugNameDrugTierRequirements/Limitspaclitaxel inj 300mg/50ml 1 GC MOpentostatin 1 GC MOPERJETA 4 PA MOPOMALYST 4 MOPROGRAF INJ 2 MORAPAMUNE 2 PA MOREVLIMID CAPS 2.5MG 4 LA MOREVLIMID CAPS 25MG 4 LA QL(21per 28 days)MOREVLIMID CAPS 10MG,15MG, 5MG4 LA QL(30per 30 days)MORHEUMATREX 3 MORITUXAN 2 PA MOSANDIMMUNE CAPS 2 PA MOSANDIMMUNE INJ 2 MOSANDIMMUNE ORAL SOLN 2 PA MOSANDOSTATIN LAR DEPOT 3 MOSIGNIFOR 4 PA MOSIMULECT INJ 20MG 2 MOSOLTAMOX 2 MOSOMATULINE DEPOT 4 MOSPRYCEL TABS 140MG,50MG, 70MG, 80MG4 QL(90 per90 days)MOSPRYCEL TABS 100MG, 20MG 4 QL(180 per90 days)MOSTIVARGA 4 PA QL(252per 90 days)MOSUTENT CAPS 25MG, 50MG 4 PA QL(90per 90 days)MOSUTENT CAPS 12.5MG 4 PA QL(270per 90 days)MOSYNRIBO 4 PA MOTABLOID 2 MOtacrolimus 1 GC PA MODrugNameDrugTierRequirements/LimitsTAFINLAR CAPS 75MG 4 PA QL(124per 31 days)MOTAFINLAR CAPS 50MG 4 PA QL(186per 31 days)MOtamoxifen citrate 1 GC MOTARCEVA TABS 100MG,150MG4 PA QL(90per 90 days)MOTARCEVA TABS 25MG 4 PA QL(180per 90 days)MOTARGRETIN 2 MOTASIGNA 4 QL(336 per84 days)MOTAXOTERE INJ 80MG/4ML 4 MOTHALOMID 4 PA MOthiotepa 1 GC MOtoposar inj 1gm/50ml 1 GC MOtopotecan hcl inj 4mg 1 GC MOTORISEL 4 PA MOTREANDA INJ 100MG 4 MOTRELSTAR DEPOT MIXJECT 3 MOTRELSTAR LA MIXJECT 3 MOTRELSTAR MIXJECT 3 MOtretinoin 1 GC MOTRISENOX 2 MOTYKERB 4 LA QL(540per 90 days)MOVECTIBIX INJ 100MG/5ML 4 MOVELCADE 3 MOVIDAZA 4 QL(4200per 90 days)MOvinblastine sulfate inj 10mg 1 GC MOvincasar pfs 1 GC MOvincristine sulfate 1 GC MOvinorelbine tartrate inj 50mg/5ml 1 GC MO9

DrugNameDrugTierRequirements/LimitsVOTRIENT 4 QL(360 per90 days)MOXALKORI 4 PA QL(180per 90 days)MOXTANDI 4 PA QL(360per 90 days)MOYERVOY INJ 50MG/10ML 4 PA MOZALTRAP INJ 100MG/4ML 4 PA MOZANOSAR 3 MOZELBORAF 4 PA QL(720per 90 days)MOZOLINZA 4 QL(360 per90 days)MOZORTRESS TABS 0.5MG, 4 PA MO0.75MGZORTRESS TABS 0.25MG 2 PA MOZYTIGA 4 PA QL(360per 90 days)MOAUTONOMIC / CNS DRUGS,NEUROLOGY / PSYCHANTICONVULSANTSBANZEL 2 MOcarbamazepine 1 GC MOcarbamazepine er 1 GC MOCARBATROL 2 MOCELONTIN 2 MOclonazepam 1 GC MOclonazepam odt 1 GC MOdiazepam gel 1 GC MODILANTIN CAPS 30MG 2 MODILANTIN INFATABS 2 MOdivalproex sodium 1 GC MOdivalproex sodium dr 1 GC MOdivalproex sodium er 1 GC MOepitol 1 GC MOethosuximide 1 GC MOfelbamate 1 GC MODrugNameDrugTierRequirements/LimitsFELBATOL 2 MOfosphenytoin sodium inj 100mg 1 GC MOpe/2mlgabapentin 1 GC MOGABITRIL 2 MOLAMICTAL ODT TBDP 2 MOLAMICTAL STARTER/NOT 2 MOTAKING CARBAMAZEPINELAMICTAL2 MOSTARTER/TAKINGCARBAMAZEPINE/NOTTAKING VALPROATELAMICTAL2 MOSTARTER/TAKINGVALPROATELAMICTAL XR 2 MOlamotrigine 1 GC MOlamotrigine er 1 GC MOlevetiracetam er 1 GC MOlevetiracetam inj 500mg/5ml 1 GC MOlevetiracetam oral soln 1 GC MOlevetiracetam tabs 1 GC MOLYRICA CAPS 225MG, 300MG 2 QL(180 per90 days)MOLYRICA CAPS 100MG, 150MG,200MG, 25MG, 50MG, 75MG2 QL(270 per90 days)MOLYRICA ORAL SOLN 2 QL(2880per 90 days)MOONFI 2 MOoxcarbazepine 1 GC MOPEGANONE 2 MOphenobarbital 1 GC PA MOphenytoin 1 GC MOphenytoin sodium 1 GCphenytoin sodium extended 1 GC MOPOTIGA 3 MOprimidone 1 GC MOSABRIL 2 MOTEGRETOL-XR TB12 100MG 2 MOtiagabine hydrochloride 1 GC MO10

DrugNameDrugTierRequirements/Limitstopiramate 1 GC MOTRILEPTAL SUSP 3 MOvalproate sodium 1 GC MOvalproic acid 1 GC MOVIMPAT INJ 2VIMPAT ORAL SOLN 2 MOVIMPAT TABS 2 MOzonisamide 1 GC MOANTIPARKINSONISM AGENTSAPOKYN 2 LA MOAZILECT 2 MObenztropine mesylate inj 1 GCbenztropine mesylate tabs 1 GC MObromocriptine mesylate 1 GC MOcarbidopa/levodopa 1 GC MOcarbidopa/levodopa er 1 GC MOcarbidopa/levodopa odt 1 GC MOCOMTAN 2 MOentacapone 1 GC MOLODOSYN 2 MOMIRAPEX ER 2 MOpramipexole dihydrochloride 1 GC MOropinirole er 1 GC MOropinirole hcl 1 GC MOselegiline hcl 1 GC MOSTALEVO 100 2 MOSTALEVO 125 2 MOSTALEVO 150 2 MOSTALEVO 200 2 MOSTALEVO 50 2 MOSTALEVO 75 2 MOtrihexyphenidyl hcl 1 GC MOZELAPAR 2 MOMIGRAINE / CLUSTER HEADACHETHERAPYdihydroergotamine mesylate inj 1 GC MOmigergot 1 GC MOMIGRANAL 3 QL(24 per90 days)MODrugNameDrugTierRequirements/Limitsnaratriptan hcl tabs 2.5mg 1 GC QL(24per 90 days)MOnaratriptan hcl tabs 1mg 1 GC QL(36per 90 days)MORELPAX 2 QL(36 per90 days)MOrizatriptan benzoate 1 GC QL(54per 90 days)MOrizatriptan benzoate odt 1 GC QL(54per 90 days)MOsumatriptan succinate inj6mg/0.5ml1 GC QL(12per 90 days)MOsumatriptan succinate tabs 100mg 1 GC QL(27per 90 days)MOsumatriptan succinate tabs 25mg,50mg1 GC QL(54per 90 days)MOMISCELLANEOUS NEUROLOGICALTHERAPYARICEPT TABS 23MG 2 QL(90 per90 days)MOCOPAXONE 4 PA QL(90per 90 days)MOdonepezil hcl 1 GC QL(90per 90 days)MOEXELON ORAL SOLN 2 MOEXELON PT24 2 QL(90 per90 days)MOgalantamine hydrobromide cp24 1 GC QL(90per 90 days)MOgalantamine hydrobromide oralsoln1 GC MO11

DrugNameDrugTierRequirements/Limitsgalantamine hydrobromide tabs 1 GC QL(180per 90 days)MOGILENYA 4 PA QL(28per 28 days)MOMYTELASE 2 MONAMENDA ORAL SOLN 2 MONAMENDA TABS 10MG 2 QL(180 per90 days)MONAMENDA TABS 5MG 2 QL(270 per90 days)MONAMENDA TITRATION PAK 2 MONAMENDA XR 2 MONAMENDA XR TITRATION 2 MOPACKNUEDEXTA 2 QL(180 per90 days)MOrivastigmine tartrate 1 GC QL(180per 90 days)MOTECFIDERA 4 PA MOTECFIDERA STARTER PACK 4 PA MOXENAZINE 4 LA MOMUSCLE RELAXANTS /ANTISPASMODIC THERAPYbaclofen 1 GC MOcyclobenzaprine hcl tabs 10mg, 1 GC MO5mgdantrolene sodium caps 1 GC MOLIORESAL INTRATHECAL INJ 2 PA0.05MG/MLLIORESAL INTRATHECAL INJ 2 PA MO10MG/20ML, 10MG/5MLMESTINON SYRP 2 MOMESTINON TIMESPAN 2 MOpyridostigmine bromide 1 GC MOregonol 1 GCtizanidine hcl 1 GC MONARCOTIC ANALGESICSacetaminophen/codeine #3 1 GC MODrugNameDrugTierRequirements/Limitsacetaminophen/codeine oral soln 1 GCacetaminophen/codeine tabs 1 GC MOascomp/codeine 1 GC MOBUPRENEX 2 MObuprenorphine hcl inj 1 GCbuprenorphine hcl subl 1 GC MOBUTRANS PTWK 10MCG/HR, 2 MO20MCG/HR, 5MCG/HRcodeine sulfate tabs 1 GC MODILAUDID INJ 2 MODILAUDID-5 2 MODILAUDID-HP INJ 10MG/ML 2duramorph inj 1mg/ml 1 GCduramorph inj 0.5mg/ml 1 GC MOendocet tabs 650mg; 10mg 1 GC QL(540per 90 days)MOendocet tabs 500mg; 7.5mg 1 GC QL(720per 90 days)MOendocet tabs 325mg; 10mg,325mg; 5mg, 325mg; 7.5mgEXALGO T24A 12MG, 16MG,8MGfentanyl citrate oral transmucosallpop 1200mcg, 1600mcg, 400mcg,600mcg, 800mcgfentanyl citrate oral transmucosallpop 200mcg1 GCQL(1080per 90 days)MO2 MO4 PA QL(360per 90 days)MO1 GC PAQL(360 per90 days)MOfentanyl patches 1 GC QL(30per 90 days)MOhydrocodonebitartrate/acetaminophen oralsolnhydrocodonebitartrate/acetaminophen tabs750mg; 10mg1 GCQL(5550per 30 days)MO1 GC QL(450per 90 days)MO12

DrugNamehydrocodonebitartrate/acetaminophen tabs300mg; 10mg, 300mg; 5mg,300mg; 7.5mghydrocodone/acetaminophen oralsolnhydrocodone/acetaminophen tabs750mg; 7.5mghydrocodone/acetaminophen tabs650mg; 10mg, 650mg; 7.5mg,660mg; 10mghydrocodone/acetaminophen tabs500mg; 10mg, 500mg; 2.5mg,500mg; 5mg, 500mg; 7.5mghydrocodone/acetaminophen tabs325mg; 10mg, 325mg; 5mg,325mg; 7.5mgDrugTierRequirements/Limits1 GCQL(1080per 90 days)MO1 GCQL(3600per 30 days)MO1 GC QL(450per 90 days)MO1 GC QL(540per 90 days)MO1 GC QL(720per 90 days)MO1 GCQL(1080per 90 days)MOhydrocodone/ibuprofen tabs 1 GC MO7.5mg; 200mghydromorphone hcl inj2500mg/50mlhydromorphone hcl tabs 1 GC MOLAZANDA 4 LA PAQL(31 per90 days)MOlevorphanol tartrate 1 GC MOmethadone hcl conc 1 GC MOmethadone hcl inj 1 GCmethadone hcl oral soln 1 GC MOmethadone hcl tabs 1 GC MOmethadose tabs 1 GC MOmorphine sulfate er cp24 10mg 1 GCmorphine sulfate er cp24 100mg, 1 GC MO20mg, 30mg, 50mg, 60mg, 80mgmorphine sulfate er tbcr 1 GC MOmorphine sulfate oral soln 1 GC MOmorphine sulfate tabs 1 GC MOONSOLIS FILM 1200MCG,400MCG, 600MCG, 800MCG2 PA QL(360per 90 days)MODrugNameDrugTierRequirements/LimitsONSOLIS FILM 200MCG 2 PA QL(720per 90 days)MOOPANA ER (CRUSHRESISTANT)2 QL(540 per90 days)MOoxycodone hcl caps 1 GCQL(1080per 90 days)MOoxycodone hcl conc 1 GCQL(1800per 90 days)MOoxycodone hcl oral soln 1 GCQL(3600per 90 days)MOoxycodone hcl tabs 10mg, 15mg,20mg, 30mg1 GC QL(540per 90 days)MOoxycodone hcl tabs 5mg 1 GCQL(1080per 90 days)MOoxycodone/acetaminophen caps 1 GC QL(720per 90 days)MOoxycodone/acetaminophen tabs650mg; 10mgoxycodone/acetaminophen tabs500mg; 7.5mgoxycodone/acetaminophen tabs325mg; 10mg, 325mg; 2.5mg,325mg; 5mg, 325mg; 7.5mg1 GC QL(540per 90 days)MO1 GC QL(720per 90 days)MO1 GCQL(1080per 90 days)MOoxycodone/aspirin 1 GC MOOXYCONTIN 2 QL(540 per90 days)MOoxymorphone hydrochloride 1 GC MOoxymorphone hydrochloride er 1 GC MOtb12 15mg, 7.5mgreprexain tabs 10mg; 200mg 1 GC MO13

DrugNameDrugTierRequirements/LimitsROXICET ORAL SOLN 2 QL(5580per 90 days)MOstagesic 1 GC QL(720per 90 days)MOvicodin 1 GCQL(1080per 90 days)MOvicodin es 1 GCQL(1080per 90 days)MOvicodin hp 1 GCQL(1080per 90 days)MONON-NARCOTIC ANALGESICSARTHROTEC 50 3 MOARTHROTEC 75 3 MObuprenorphine hcl/naloxone hcl 1 GC MObutorphanol tartrate nasal soln 1 GC PAQL(30 per90 days)MOCELEBREX 2 QL(180 per90 days)MOdiclofenac potassium 1 GC MOdiclofenac sodium dr 1 GC MOdiclofenac sodium er 1 GC MOdiclofenac sodium/misoprostol 1 GC MOdiflunisal 1 GC MOetodolac 1 GC MOetodolac er 1 GC MOfenoprofen calcium 1 GC MOFLECTOR 3 MOflurbiprofen 1 GC MOibuprofen susp 1 GC MOibuprofen tabs 400mg, 600mg, 1 GC MO800mgindomethacin caps 1 GC MOindomethacin er 1 GC MODrugNameDrugTierRequirements/Limitsketoprofen 1 GC MOketoprofen er 1 GC MOmeclofenamate sodium 1 GC MOmefenamic acid 1 GC MOmeloxicam 1 GC MOnabumetone 1 GC MOnaloxone hcl inj 1mg/ml 1 GC MOnaltrexone hcl 1 GC MOnaproxen 1 GC MOnaproxen dr 1 GC MOnaproxen sodium tabs 275mg, 1 GC MO550mgNUCYNTA 2 QL(541 per90 days)MONUCYNTA ER 2 QL(180 per90 days)MOoxaprozin 1 GC MOPENNSAID 2 MOpiroxicam 1 GC MOSUBOXONE 2 MOsulindac 1 GC MOtolmetin sodium 1 GC MOtramadol hcl 1 GC QL(720per 90 days)MOtramadol hcl er tb24 2 QL(90 per90 days)MOVIMOVO 2 QL(180 per90 days)MOVOLTAREN GEL GEL 2 MOPSYCHOTHERAPEUTIC DRUGSABILIFY DISCMELT TBDP15MG3 QL(180 per90 days)MOABILIFY DISCMELT TBDP10MG3 QL(270 per90 days)MOABILIFY INJ 3 MO14

DrugNameDrugTierRequirements/LimitsABILIFY MAINTENA INJ 4 MO300MGABILIFY ORAL SOLN 3 MOABILIFY TABS 20MG, 2MG,30MG, 5MG3 QL(90 per90 days)MOABILIFY TABS 15MG 3 QL(180 per90 days)MOABILIFY TABS 10MG 3 QL(270 per90 days)MOamitriptyline hcl 1 GC MOamoxapine 1 GC MObudeprion sr 1 GC QL(180per 90 days)MObupropion hcl 1 GC MObupropion hcl sr 1 GC QL(180per 90 days)MObupropion hcl xl tb24 300mg 1 GC QL(90per 90 days)MObupropion hcl xl tb24 150mg 1 GC QL(270per 90 days)MObuspirone hcl 1 GC MOchlordiazepoxide/amitriptyline 1 GC MOchlorpromazine hcl inj 1 GC MOchlorpromazine hcl tabs 1 GC MOcitalopram hydrobromide oralsolncitalopram hydrobromide tabs40mgcitalopram hydrobromide tabs10mgcitalopram hydrobromide tabs20mg1 GC MO1 GC QL(90per 90 days)MO1 GC QL(180per 90 days)MO1 GC QL(270per 90 days)MOclomipramine hcl 1 GC MOclorazepate dipotassium 1 GC MOclozapine 1 GCDrugNameDrugTierRequirements/LimitsCYMBALTA CPEP 60MG 2 QL(180 per90 days)MOCYMBALTA CPEP 30MG 2 QL(360 per90 days)MOCYMBALTA CPEP 20MG 2 QL(540 per90 days)MOdesipramine hcl 1 GC MOdextroamphetamine sulfate er 1 GC PA MOdextroamphetamine sulfate tabs 1 GC PA MOdiazepam intensol 1 GC MOdiazepam oral soln 1 GC MOdiazepam tabs 1 GC MOdoxepin hcl 1 GC MOEMSAM 3 QL(90 per90 days)MOescitalopram oxalate oral soln 1 GCQL(1920per 90 days)MOescitalopram oxalate tabs 1 GC QL(90per 90 days)MOFANAPT TABS 1MG, 2MG,4MGFANAPT TABS 10MG, 12MG,6MG, 8MG3 QL(90 per90 days)MO3 QL(180 per90 days)MOFANAPT TITRATION PACK 3FAZACLO 3fluoxetine dr 1 GC QL(12per 90 days)MOfluoxetine hcl caps 40mg 1 GC QL(180per 90 days)MOfluoxetine hcl caps 20mg 1 GC QL(360per 90 days)MO15

DrugNameDrugTierRequirements/Limitsfluoxetine hcl caps 10mg 1 GC QL(720per 90 days)MOfluoxetine hcl oral soln 1 GC MOfluoxetine hcl tabs 20mg 1 GC QL(360per 90 days)MOfluoxetine hcl tabs 10mg 1 GC QL(720per 90 days)MOfluphenazine decanoate 1 GC MOfluphenazine hcl conc 1 GCfluphenazine hcl elix 1 GC MOfluphenazine hcl inj 1 GC MOfluphenazine hcl tabs 1 GC MOfluvoxamine maleate 1 GC QL(270per 90 days)MOfluvoxamine maleate er cp24150mgfluvoxamine maleate er cp24100mg1 GC QL(180per 90 days)MO1 GC QL(270per 90 days)MOFOCALIN XR 2 PA MOFORFIVO XL 3 QL(90 per90 days)MOGEODON INJ 3 MOHALDOL 2 MOHALDOL DECANOATE 100 2 MOHALDOL DECANOATE 50 2 MOhaloperidol 1 GC MOhaloperidol decanoate 1 GC MOhaloperidol lactate 1 GC MOimipramine hcl 1 GC MOimipramine pamoate 2 MOINTUNIV 3 MOINVEGA SUSTENNA INJ39MG/0.25MLINVEGA SUSTENNA INJ78MG/0.5ML2 QL(0.75 per90 days)MO2 QL(1.5 per90 days)MODrugNameINVEGA SUSTENNA INJ117MG/0.75MLINVEGA SUSTENNA INJ156MG/MLINVEGA SUSTENNA INJ234MG/1.5MLINVEGA TB24 1.5MG, 3MG,9MGDrugTierRequirements/Limits2 QL(2.25 per90 days)MO2 QL(3 per 90days) MO2 QL(4.5 per90 days)MO3 QL(90 per90 days)MOINVEGA TB24 6MG 3 QL(180 per90 days)MOLATUDA TABS 120MG 2 QL(90 per90 days)MOLATUDA TABS 80MG 2 QL(180 per90 days)MOLATUDA TABS 40MG 2 QL(360 per90 days)MOLATUDA TABS 20MG 2 QL(720 per90 days)MOlithium carbonate 1 GC MOlithium carbonate er 1 GC MOlithium citrate 1 GC MOlorazepam intensol 1 GC MOlorazepam tabs 1 GC MOloxapine succinate 1 GC MOLUNESTA 3 QL(90 per90 days)MOmaprotiline hcl 1 GC MOMARPLAN 2 MOMETADATE CD CPCR 20MG, 3 PA MO30MG, 40MG, 50MG, 60MGmethylphenidate hcl 1 GC PA MOmethylphenidate hcl cd cpcr 1 GC PA MO50mg, 60mgmethylphenidate hcl er cp24 1 GC PA MOmethylphenidate hydrochloride 1 GC PA MO16

DrugNameDrugTierRequirements/Limitsmirtazapine 1 GC QL(90per 90 days)MOmirtazapine odt tbdp 30mg, 45mg 1 GC QL(90per 90 days)MOmodafinil 1 GC PAQL(90 per90 days)MOnefazodone hcl 1 GC QL(180per 90 days)MOnortriptyline hcl 1 GC MOolanzapine inj 1 GC MOolanzapine odt 1 GC QL(90per 90 days)MOolanzapine tabs 1 GC QL(90per 90 days)MOolanzapine/fluoxetine 1 GC QL(90per 90 days)MOORAP 2 MOparoxetine hcl er tb24 12.5mg,37.5mg1 GC QL(180per 90 days)MOparoxetine hcl er tb24 25mg 1 GC QL(270per 90 days)MOparoxetine hcl tabs 20mg, 40mg 1 GC QL(90per 90 days)MOparoxetine hcl tabs 10mg, 30mg 1 GC QL(180per 90 days)MOPAXIL SUSP 2 MOperphenazine 1 GC MOphenelzine sulfate 1 GC MOPRISTIQ 2 QL(90 per90 days)MOprocentra 1 GC PA MOprotriptyline hcl 1 GC MODrugNameDrugTierRequirements/LimitsPROVIGIL 2 PA QL(90per 90 days)MOquetiapine fumarate tabs 25mg,300mg, 400mgquetiapine fumarate tabs 100mg,200mg, 50mg1 GC QL(180per 90 days)MO1 GC QL(270per 90 days)MORISPERDAL CONSTA 2 QL(12 per84 days)MOrisperidone odt 1 GC QL(180per 90 days)MOrisperidone oral soln 1 GC MOrisperidone tabs 1 GC QL(180per 90 days)MORITALIN LA 3 PA MOSAPHRIS 2 QL(180 per90 days)MOSEROQUEL XR TB24 150MG,300MG, 400MGSEROQUEL XR TB24 200MG,50MG2 QL(180 per90 days)MO2 QL(270 per90 days)MOsertraline hcl conc 1 GC MOsertraline hcl tabs 100mg, 25mg 1 GC QL(180per 90 days)MOsertraline hcl tabs 50mg 1 GC QL(270per 90 days)MOSILENOR 3 QL(90 per90 days)MOSTRATTERA 2 MOSYMBYAX 3 QL(90 per90 days)MOtemazepam 1 GC MOthioridazine hcl 1 GC MO17

DrugNameDrugTierRequirements/Limitsthiothixene 1 GC MOtranylcypromine sulfate 1 GC MOtrazodone hcl 1 GC MOtrifluoperazine hcl 1 GC MOtrimipramine maleate 1 GC MOvenlafaxine hcl er cp24 150mg,37.5mg1 GC QL(90per 90 days)MOvenlafaxine hcl er cp24 75mg 1 GC QL(270per 90 days)MOvenlafaxine hcl tabs 100mg,25mg, 37.5mg1 GC QL(270per 90 days)MOvenlafaxine hcl tabs 75mg 1 GC QL(450per 90 days)MOvenlafaxine hcl tabs 50mg 1 GC QL(675per 90 days)MOVIIBRYD KIT 2 QL(30 per365 days)MOVIIBRYD TABS 2 QL(90 per90 days)MOXYREM 4 PA MOzaleplon caps 5mg 1 GC QL(90per 90 days)MOzaleplon caps 10mg 1 GC QL(180per 90 days)MOzenzedi 1 GC PA MOziprasidone hcl 1 GC QL(180per 90 days)MOzolpidem tartrate 1 GC QL(90per 90 days)MOzolpidem tartrate er 1 GC QL(90per 90 days)MOCARDIOVASCULAR,HYPERTENSION / LIPIDSDrugNameDrugTierRequirements/LimitsANTIARRHYTHMIC AGENTSamiodarone hcl inj 50mg/ml 1 GC MOamiodarone hcl tabs 200mg, 1 GC MO400mgdisopyramide phosphate 1 GC MOflecainide acetate 1 GC MOmexiletine hcl 1 GC MOMULTAQ 2 MONORPACE CR 2 MOpacerone tabs 100mg, 200mg 1 GC MOprocainamide hcl inj 500mg/ml 1 GCprocainamide hcl inj 100mg/ml 1 GC MOpropafenone hcl 1 GC MOpropafenone hcl er 1 GC MOquinidine gluconate cr 1 GC MOquinidine sulfate 1 GC MOquinidine sulfate er 1 GC MOsorine 1 GC MOsotalol hcl (af) tabs 120mg 1 GC MOsotalol hcl tabs 160mg, 240mg, 1 GC MO80mgTIKOSYN 3 MOANTIHYPERTENSIVE THERAPYacebutolol hcl 1 GC MOafeditab cr 1 GC MOamiloride hcl 1 GC MOamiloride/hydrochlorothiazide 1 GC MOamlodipine besylate 1 GC MOamlodipine besylate/benazeprilhcl1 GC QL(90per 90 days)amlodipine besylate/benazeprilhydrochlorideMO1 GC QL(90per 90 days)MOAMTURNIDE 2 QL(90 per90 days)MOatenolol 1 GC MOatenolol/chlorthalidone 1 GC MOAZOR 2 QL(90 per90 days)MO18

DrugNameDrugTierRequirements/Limitsbenazepril hcl 1 GC MObenazeprilhcl/hydrochlorothiazide tabs20mg; 12.5mg, 20mg; 25mgbenazeprilhcl/hydrochlorothiazide tabs10mg; 12.5mgbenazeprilhcl/hydrochlorothiazide tabs5mg; 6.25mg1 GC QL(360per 90 days)MO1 GC QL(720per 90 days)MO1 GCQL(1440per 90 days)MOBENICAR HCT 2 QL(90 per90 days)MOBENICAR TABS 20MG, 40MG 2 QL(90 per90 days)MOBENICAR TABS 5MG 2 QL(180 per90 days)MObetaxolol hcl 1 GC MOBIDIL 2 QL(540 per90 days)MObisoprolol fumarate 1 GC MObisoprolol1 GC MOfumarate/hydrochlorothiazidebumetanide 1 GC MOBYSTOLIC 2 MOcandesartan cilexetil 1 GC MOcandesartan1 GC MOcilexetil/hydrochlorothiazidecaptopril 1 GC MOcaptopril/hydrochlorothiazidetabs 25mg; 15mg, 25mg; 25mg,50mg; 15mg1 GC QL(90per 90 days)MOcaptopril/hydrochlorothiazidetabs 50mg; 25mg1 GC QL(270per 90 days)MOcartia xt 1 GC MOcarvedilol 1 GC MOchlorothiazide 1 GC MOchlorothiazide sodium 1 GC MOchlorthalidone tabs 25mg, 50mg 1 GC MODrugNameDrugTierRequirements/Limitsclonidine hcl ptwk 1 GC MOclonidine hcl tabs 1 GC MOCOREG CR 2 MODEMSER 2 MODIBENZYLINE 3 MOdilt-cd cp24 120mg, 300mg 1 GC MOdilt-xr cp24 180mg, 240mg 1 GC MOdiltiazem cd cp24 120mg, 240mg, 1 GC MO300mgdiltiazem hcl er cp12 1 GC MOdiltiazem hcl er cp24 180mg, 1 GC MO360mg, 420mgdiltiazem hcl inj 100mg,1 GC50mg/10mldiltiazem hcl tabs 1 GC MODIOVAN HCT 3 QL(90 per90 days)MODIOVAN TABS 320MG 2 QL(90 per90 days)MODIOVAN TABS 160MG, 40MG,80MG2 QL(180 per90 days)MOdoxazosin mesylate 1 GC QL(180per 90 days)MOEDECRIN 2 MOenalapril maleate 1 GC MOenalaprilmaleate/hydrochlorothiazide tabs5mg; 12.5mgenalaprilmaleate/hydrochlorothiazide tabs10mg; 25mg1 GC QL(90per 90 days)MO1 GC QL(180per 90 days)MOeplerenone 1 GC MOeprosartan mesylate 1 GC QL(90per 90 days)MOEXFORGE 2 QL(90 per90 days)MOEXFORGE HCT 2 QL(90 per90 days)MO19

DrugNameDrugTierRequirements/Limitsfelodipine er 1 GC MOfosinopril sodium 1 GC MOfosinoprilsodium/hydrochlorothiazide tabs10mg; 12.5mg1 GC QL(90per 90 days)MOfosinoprilsodium/hydrochlorothiazide tabs20mg; 12.5mg1 GC QL(360per 90 days)MOfurosemide 1 GC MOguanfacine hcl 1 GC MOhydralazine hcl 1 GC MOhydrochlorothiazide 1 GC MOindapamide 1 GC MOirbesartan 1 GC QL(90per 90 days)MOirbesartan/hydrochlorothiazide 1 GC QL(90per 90 days)MOisradipine 1 GC MOlabetalol hcl 1 GC MOlisinopril 1 GC MOlisinopril/hydrochlorothiazidetabs 12.5mg; 10mg, 12.5mg;20mglisinopril/hydrochlorothiazidetabs 25mg; 20mg1 GC QL(90per 90 days)MO1 GC QL(360per 90 days)MOlosartan potassium tabs 100mg 1 GC QL(90per 90 days)MOlosartan potassium tabs 25mg,50mglosartanpotassium/hydrochlorothiazidetabs 12.5mg; 100mg, 25mg;100mglosartanpotassium/hydrochlorothiazide1 GC QL(180per 90 days)MO1 GC QL(90per 90 days)MO1 GC QL(180per 90 days)MOtabs 12.5mg; 50mgmatzim la 1 GC MOmethyclothiazide 1 GC MOmetolazone 1 GC MODrugNameDrugTierRequirements/Limitsmetoprolol succinate er 1 GC MOmetoprolol tartrate inj 1 GCmetoprolol tartrate tabs 1 GC MOmetoprolol/hydrochlorothiazide 1 GC MOMICARDIS HCT 2 QL(90 per90 days)MOMICARDIS TABS 20MG, 40MG 2 QL(90 per90 days)MOMICARDIS TABS 80MG 2 QL(180 per90 days)MOminoxidil tabs 1 GC MOmoexipril hcl 1 GC MOmoexipril/hydrochlorothiazidetabs 12.5mg; 15mg, 12.5mg;7.5mgmoexipril/hydrochlorothiazidetabs 25mg; 15mg1 GC QL(90per 90 days)MO1 GC QL(180per 90 days)MOnadolol 1 GC MOnadolol/bendroflumethiazide 1 GC MOnicardipine hcl caps 1 GC MOnifediac cc tb24 90mg 1 GC MOnifedical xl 1 GC MOnifedipine 1 GC MOnifedipine er 1 GC MOnimodipine 1 GC MOnisoldipine 1 GC MOnisoldipine er 1 GC MOperindopril erbumine 1 GC MOpindolol 1 GC MOprazosin hcl 1 GC QL(360per 90 days)MOpropranolol hcl er 1 GC MOpropranolol hcl inj 1 GCpropranolol hcl oral soln 1 GC MOpropranolol hcl tabs 1 GC MOpropranolol/hydrochlorothiazide 1 GC MOquinapril hcl 1 GC MO20

DrugNameDrugTierRequirements/Limitsquinapril/hydrochlorothiazide 1 GC QL(90per 90 days)MOramipril 1 GC MOREMODULIN 4 PA MOreserpine 1 GC MOspironolactone 1 GC MOspironolactone/hydrochlorothiazi 1 GC MOdetaztia xt 1 GC MOTEKAMLO 2 QL(90 per90 days)MOTEKTURNA 2 QL(90 per90 days)MOTEKTURNA HCT 2 QL(90 per90 days)MOterazosin hcl 1 GC QL(180per 90 days)MOtimolol maleate 1 GC MOtorsemide tabs 1 GC MOtrandolapril 1 GC MOtriamterene/hydrochlorothiazide 1 GC MOTRIBENZOR 2 QL(90 per90 days)MOTWYNSTA 2 QL(90 per90 days)MOvalsartan/hydrochlorothiazide 1 GC QL(90per 90 days)MOverapamil hcl er 1 GC MOverapamil hcl inj 1 GCverapamil hcl sr cp24 360mg 1 GC MOverapamil hcl tabs 1 GC MOCARDIAC GLYCOSIDESdigoxin 1 GC MOLANOXIN 2 MOLANOXIN PEDIATRIC 2DrugNameDrugTierRequirements/LimitsCOAGULATION THERAPYAGGRENOX 2 MOBRILINTA 2 MOcilostazol 1 GC MOclopidogrel 1 GC MOCYKLOKAPRON 2 MOEFFIENT 2 MOELIQUIS 2 MOenoxaparin sodium inj1 GC MO300mg/3ml, 30mg/0.3ml,40mg/0.4ml, 60mg/0.6ml,80mg/0.8mlenoxaparin sodium inj 100mg/ml, 4 MO120mg/0.8ml, 150mg/mlfondaparinux sodium 1 GC MOFRAGMIN 2 MOheparin sodium inj 10000unit/ml, 1 GC MO1000unit/ml, 20000unit/ml,5000unit/mlheparin sodium/d5w inj 5%; 1 GC40unit/mlheparin sodium/nacl 0.45% 1 GCheparin sodium/sodium chloride 1 GC0.9% premixjantoven 1 GC MOLOVENOX INJ 300MG/3ML 2 MOpentoxifylline er 1 GC MOPRADAXA 2 MOPROMACTA 4 LA PAQL(90 per90 days)MOticlopidine hcl 1 GC MOwarfarin sodium 1 GC MOXARELTO 2 MOLIPID/CHOLESTEROL LOWERINGAGENTSatorvastatin calcium 1 GC QL(90per 90 days)MOcholestyramine light pack 1 GC MOcolestipol hcl 1 GC MO21

DrugNameDrugTierRequirements/LimitsCRESTOR 2 QL(90 per90 days)MOfenofibrate 1 GC MOfenofibrate micronized 1 GC MOfenofibric acid dr 1 GC MOfluvastatin 1 GC QL(90per 90 days)MOgemfibrozil 1 GC MOJUXTAPID 4 LA MOLIPOFEN 2 MOlovastatin tabs 10mg 1 GC QL(90per 90 days)MOlovastatin tabs 20mg, 40mg 1 GC QL(180per 90 days)MOLOVAZA 2 MONIASPAN 2 MOpravastatin sodium tabs 10mg,20mg, 80mg1 GC QL(90per 90 days)MOpravastatin sodium tabs 40mg 1 GC QL(180per 90 days)MOprevalite powd 1 GC MOSIMCOR TB24 1000MG; 40MG,500MG; 40MGSIMCOR TB24 1000MG; 20MG,500MG; 20MG, 750MG; 20MG2 QL(90 per90 days)MO2 QL(180 per90 days)MOsimvastatin 1 GC QL(90per 90 days)MOTRICOR 3 MOTRILIPIX 2 MOVASCEPA 2 MOVYTORIN 3 QL(90 per90 days) STMOWELCHOL 2 MODrugNameDrugTierRequirements/LimitsZETIA 2 QL(90 per90 days)MOMISCELLANEOUS CARDIOVASCULARAGENTSRANEXA 2 MONITRATESisosorbide dinitrate 1 GC MOisosorbide dinitrate er 1 GC MOisosorbide mononitrate 1 GC MOisosorbide mononitrate er 1 GC MOnitro-bid 1 GC MONITRO-DUR PT24 0.3MG/HR, 2 MO0.8MG/HRnitroglycerin inj 1 GC PAnitroglycerin pt24 1 GC MOnitroglycerin transdermal pt24 1 GC MO0.1mg/hrNITROLINGUAL PUMPSPRAY 2 MONITROSTAT 2 MODERMATOLOGICALS/TOPICALTHERAPYANTIPSORIATIC / ANTISEBORRHEICacitretin 1 GC MOcalcipotriene 1 GC MOselenium sulfide lotn 1 GC MOSORIATANE 2 MOBURN THERAPYsilver sulfadiazine 1 GC MOssd 1 GC MOMISCELLANEOUS DERMATOLOGICALS8-MOP 2 MOammonium lactate 1 GC MOCARAC 2 MOCARMOL-HC 2 MOCONDYLOX GEL 2 MOELIDEL 3 MOFLUOROPLEX 2 MOfluorouracil crea 1 GC MOfluorouracil external soln 1 GC MO22

DrugNameDrugTierRequirements/Limitsimiquimod 1 GC MOlaclotion 1 GC MOOXSORALEN ULTRA 4 MOPANRETIN 2 MOpodofilox 1 GC MOPROTOPIC 3 MOprudoxin 1 GC MOREGRANEX 2 PA MOSOLARAZE 3 MOUVADEX 3VEREGEN 3 MOTHERAPY FOR ACNEadapalene 1 GC MOamnesteem 1 GC MOavita crea 1 GC MOAZELEX 2 MOclaravis caps 10mg, 20mg, 40mg 2 MOclaravis caps 30mg 4 MOclindamycin phosphate external 1 GC MOsolnclindamycin phosphate foam 1 GC MOclindamycin phosphate gel 1 GC MOclindamycin phosphate lotn 1 GC MOclindamycin phosphate swab 1 GC MOclindamycin/benzoyl peroxide gel 1 GC MO5%; 1%DIFFERIN GEL 0.3% 2 MODIFFERIN LOTN 2 MOery 1 GC MOerythromycin external soln 1 GC MOerythromycin gel 1 GC MOerythromycin/benzoyl peroxide 1 GC MOFINACEA 2 MOMETROGEL 2 MOmetronidazole 1 GC MOmyorisan 1 GC MOTAZORAC 2 MOtretinoin 1 GC MOTOPICAL ANESTHETICSlidocaine hcl external soln 1 GC MOlidocaine hcl inj 0.5%, 1% 1 GC MODrugNameDrugTierRequirements/Limitslidocaine hcl jelly 1 GC MOlidocaine oint 1 GC MOlidocaine viscous 1 GC MOlidocaine/prilocaine crea 1 GC MOLIDODERM 2 PA MOTOPICAL ANTIBACTERIALSALTABAX 2 MOBACTROBAN CREA 2 MOgentamicin sulfate crea 1 GC MOgentamicin sulfate oint 0.1% 1 GC MOmafenide acetate 1 GC MOmupirocin 1 GC MOPHISOHEX 2 MOsulfacetamide sodium susp 1 GC MOSULFAMYLON 2 MOTOPICAL ANTIFUNGALSciclopirox 1 GC MOciclopirox nail lacquer 1 GC MOciclopirox olamine 1 GC MOclotrimazole external crea 1 GC MOclotrimazole external soln 1 GC MOclotrimazole/betamethasone 1 GC MOdipropionateeconazole nitrate 1 GC MOketoconazole 1 GC MOketodan kit 1 GC MONAFTIN CREA 1% 2 MONAFTIN GEL 2% 2NAFTIN GEL 1% 2 MOnyamyc 1 GC MOnystatin crea 1 GC MOnystatin oint 1 GC MOnystatin powd 100000unit/gm 1 GC MOnystatin/triamcinolone 1 GC MOnystop 1 GC MOpedi-dri 1 GC MOTOPICAL ANTIVIRALSacyclovir 1 GC MODENAVIR 2 MOZOVIRAX CREA 3 MO23

DrugNameDrugTierRequirements/LimitsZOVIRAX OINT 3 MOTOPICAL CORTICOSTEROIDSala cort 1 GC MOalclometasone dipropionate 1 GC MOamcinonide 1 GC MOaugmented betamethasone 1 GC MOdipropionatebetamethasone dipropionate 1 GC MObetamethasone valerate 1 GC MOCAPEX 2 MOclobetasol propionate e 1 GC MOclobetasol propionate external 1 GC MOsolnclobetasol propionate foam 1 GC MOclobetasol propionate gel 1 GC MOclobetasol propionate lotn 1 GC MOclobetasol propionate oint 1 GC MOclobetasol propionate sham 1 GC MOCORDRAN TAPE 2 MODERMA-SMOOTHE/FS BODY 2 MOOILdesonide 1 GC MOdesoximetasone 1 GC MOdiflorasone diacetate 1 GC MOfluocinolone acetonide 1 GC MOfluocinolone acetonide body 1 GC MOfluocinonide external soln 1 GC MOfluocinonide gel 1 GC MOfluocinonide oint 1 GC MOfluocinonide-e 1 GC MOfluticasone propionate 1 GC MOhalobetasol propionate 1 GC MOhydrocortisone butyrate 1 GC MOhydrocortisone crea 1%, 2.5% 1 GC MOhydrocortisone lotn 2.5% 1 GC MOhydrocortisone oint 1%, 2.5% 1 GC MOhydrocortisone valerate 1 GC MOLOCOID LOTN 2 MOLUXIQ 2 MOmometasone furoate crea 1 GC MOmometasone furoate external soln 1 GC MODrugNameDrugTierRequirements/Limitsmometasone furoate oint 1 GC MOPANDEL 2 MOprednicarbate 1 GC MOtriamcinolone acetonide crea 1 GC MOtriamcinolone acetonide lotn 1 GC MOtriamcinolone acetonide oint 1 GC MOtriderm 1 GC MOTOPICAL ENZYMESSANTYL 2 MOTOPICAL SCABICIDES / PEDICULICIDESEURAX 2 MOlindane 1 GCQL(1800per 365days) MOmalathion 1 GC MOpermethrin crea 1 GC MOSKLICE 2 MOspinosad 1 GC QL(720per 90 days)MOULESFIA 3 MODIAGNOSTICS / MISCELLANEOUSAGENTSMISCELLANEOUS AGENTSacamprosate calcium dr 1 GC QL(540per 90 days)MOACTONEL TABS 30MG 3 PA QL(60per 120days) MOADAGEN 4 LA MOalendronate sodium tabs 40mg 1 GC QL(180per 365days) MOanagrelide hydrochloride 1 GC MOANTABUSE TABS 250MG 2 MOARALAST NP INJ 400MG 4 LA MOBUPHENYL 2 MOCAMPRAL 2 QL(540 per90 days)MO24

DrugNameDrugTierRequirements/LimitsCARBAGLU 4 LA MOcevimeline hcl 1 GC MOCHEMET 2 MOCLINIMIX 4.25%/DEXTROSE 25%dextrose 10%/nacl 0.45% 1 GCdextrose 10% flex container 1 GCdextrose 10%/nacl 0.2% 1 GCdextrose 2.5%/sodium chloride 1 GC0.45%dextrose 5% 1 GC MOdextrose 5%/lactated ringers 1 GC MOdextrose 5%/nacl 0.2% 1 GCdextrose 5%/nacl 0.225% 1 GCdextrose 5%/nacl 0.33% 1 GCdextrose 5%/nacl 0.45% 1 GC MOdextrose 5%/nacl 0.9% 1 GC MOdisulfiram 1 GC MOetidronate disodium 1 GC MOEVOXAC 2 MOEXJADE TBSO 125MG 2 LA MOEXJADE TBSO 250MG, 500MG 4 LA MOFOSRENOL 2 MOINCRELEX 4 LA PA MOkionex powd 1 GC MOlevocarnitine oral soln 1 GC PA MOlevocarnitine tabs 1 GC PA MOmidodrine hcl 1 GC MOORFADIN 4 LA MOpilocarpine hcl tabs 1 GC MOpilocarpine hydrochloride 1 GC MOPROLASTIN-C 4 LA MORAVICTI 4 MORECLAST 3 MORENVELA 2 MORILUTEK 4 MOriluzole 1 GC MOSKELID 3 PA QL(180per 90 days)MOsodium chloride 0.9% 1 GC MODrugNameDrugTierRequirements/Limitssodium chloride inj 0.9% 1 GC MOsodium phenylbutyrate 1 GC MOsodium polystyrene sulfonate susp 1 GC MO15gm/60mlSYPRINE 2 MOzoledronic acid inj 5mg/100ml 1 GC MOSMOKING DETERRENTSbuproban 1 GC PAQL(180 per90 days)MOCHANTIX 2 PA QL(168per 90 days)MOCHANTIX STARTING MONTHPAK2 PA MONICOTROL INHALER 3 PAQL(1008per 90 days)MONICOTROL NS 3 PA QL(120per 90 days)MOEAR, NOSE / THROATMEDICATIONSMISCELLANEOUS AGENTSASTEPRO 2 MOazelastine hcl 1 GC MOBACTROBAN NASAL 2 MOchlorhexidine gluconate oral 1 GC MOrinseipratropium bromide nasal soln 1 GC MOperiogard 1 GC MOtriamcinolone in orabase 1 GC MOTYZINE 2 MOTYZINE PEDIATRIC NASAL 2 MODROPSMISCELLANEOUS OTICPREPARATIONSacetasol hc 1 GC MOacetic acid otic soln 1 GC MODERMOTIC 2 MOfluocinolone acetonide 1 GC MO25

DrugNameDrugTierRequirements/Limitshydrocortisone/acetic acid 1 GC MOofloxacin 1 GC MOOTIC STEROID / ANTIBIOTICCIPRO HC 3 MOCIPRODEX 2 MOCOLY-MYCIN S 2 MOCORTISPORIN-TC 2 MOneomycin/polymyxin/hc 1 GC MOneomycin/polymyxin/hydrocortisone otic susp1 GC MOENDOCRINE/DIABETESADRENAL HORMONESa-hydrocort 1 GC MOACTHAR HP 4 PA MOcortisone acetate 1 GC MODEPO-MEDROL 2 MOdexamethasone elix 1 GC MOdexamethasone intensol 1 GC MOdexamethasone sodium phosphate 1 GC MOinj 4mg/mldexamethasone tabs 1 GC MOfludrocortisone acetate 1 GC MOhydrocortisone tabs 1 GC MOmethylprednisolone 1 GC PA MOmethylprednisolone acetate 1 GC MOmethylprednisolone dose pack 1 GC MOmethylprednisolonesodiumsuccinate inj 125mg, 1gm,40mg1 GC MOprednisolone sodium phosphate 1 GC PAoral soln 25mg/5mlprednisolone sodium phosphate 1 GC PA MOoral soln 15mg/5ml, 5mg/5mlprednisone 1 GC PA MOprednisone intensol 1 GC PA MOSOLU-CORTEF INJ 100MG, 2 MO250MGSOLU-MEDROL INJ 2GM 2SOLU-MEDROL INJ 125MG, 2 MO40MG, 500MGANTITHYROID AGENTSmethimazole 1 GC MODrugNameDrugTierRequirements/Limitspropylthiouracil 1 GC MODIABETES THERAPYacarbose 1 GC QL(270per 90 days)MOACTOPLUS MET 2 QL(270 per90 days)MOACTOS 2 QL(90 per90 days)MOalcohol preps pads 1 GC MOAPIDRA 3 QL(180 per90 days)MOAPIDRA SOLOSTAR 3 QL(180 per90 days)MOAVANDAMET 2 QL(180 per90 days)MOAVANDARYL TABS 2MG;8MG, 4MG; 4MG, 4MG; 8MGAVANDARYL TABS 1MG;4MG, 2MG; 4MG2 QL(90 per90 days)MO2 QL(180 per90 days)MOAVANDIA TABS 8MG 2 QL(90 per90 days)MOAVANDIA TABS 2MG, 4MG 2 QL(180 per90 days)MOBYDUREON 2 MOBYETTA 2 MODUETACT 2 QL(90 per90 days)MOGAUZE PADS 2"X2" 2 MOglimepiride tabs 1mg, 2mg 1 GC QL(90per 90 days)MOglimepiride tabs 4mg 1 GC QL(180per 90 days)MO26

DrugNameDrugTierRequirements/Limitsglipizide er tb24 2.5mg, 5mg 1 GC QL(90per 90 days)MOglipizide er tb24 10mg 1 GC QL(180per 90 days)MOglipizide tabs 10mg 1 GC QL(360per 90 days)MOglipizide tabs 5mg 1 GC QL(720per 90 days)MOglipizide/metformin hcl 1 GC QL(360per 90 days)MOGLUCAGEN HYPOKIT 2 MOGLUCAGON EMERGENCY 2 MOKITglyburide micronized 1 GC QL(180per 90 days)MOglyburide tabs 1.25mg, 2.5mg 1 GC QL(180per 90 days)MOglyburide tabs 5mg 1 GC QL(360per 90 days)MOglyburide/metformin hcl tabs1.25mg; 250mg, 2.5mg; 500mgglyburide/metformin hcl tabs5mg; 500mg1 GC QL(180per 90 days)MO1 GC QL(360per 90 days)MOHUMALOG 2 QL(60 per30 days)MOHUMALOG KWIKPEN 2 QL(60 per30 days)MOHUMALOG MIX 50/50 2 QL(60 per30 days)MOHUMALOG MIX 50/50KWIKPEN2 QL(60 per30 days)MODrugNameDrugTierRequirements/LimitsHUMALOG MIX 75/25 2 QL(60 per30 days)MOHUMALOG MIX 75/25KWIKPEN2 QL(60 per30 days)MOHUMULIN 70/302 QL(60 per30 days)MOHUMULIN 70/30 PEN 2 QL(60 per30 days)MOHUMULIN N 2 QL(60 per30 days)MOHUMULIN N U-100 PEN 2 QL(60 per30 days)MOHUMULIN R 2 QL(60 per30 days)MOHUMULIN R U-500(CONCENTRATED)2 QL(60 per30 days)MOINSULIN PEN NEEDLE 2 MOINSULIN SYRINGE (DISP) U- 2 MO100 0.3 MLINSULIN SYRINGE (DISP) U- 2 MO100 1 MLINSULIN SYRINGE (DISP) U- 2 MO100 1/2 MLINVOKANA TABS 300MG 2 QL(90 per90 days)MOINVOKANA TABS 100MG 2 QL(270 per90 days)MOJANUMET 2 QL(180 per90 days)MOJANUMET XR TB24 1000MG;100MGJANUMET XR TB24 1000MG;50MG, 500MG; 50MG2 QL(90 per90 days)MO2 QL(180 per90 days)MO27

DrugNameDrugTierRequirements/LimitsJANUVIA 2 QL(90 per90 days)MOJENTADUETO 2 QL(180 per90 days)MOJUVISYNC TABS 10MG;50MG, 20MG; 50MG, 40MG;2 MO50MGJUVISYNC TABS 10MG;100MG, 20MG; 100MG, 40MG;100MGKOMBIGLYZE XR TB241000MG; 5MG, 500MG; 5MGKOMBIGLYZE XR TB241000MG; 2.5MG2 QL(90 per90 days)MO2 QL(90 per90 days)MO2 QL(180 per90 days)MOLANTUS 2 QL(30 per30 days)MOLANTUS SOLOSTAR 2 QL(30 per30 days)MOLEVEMIR 2 QL(90 per90 days)MOLEVEMIR FLEXPEN 2 QL(90 per90 days)MOmetformin hcl er tb24 1000mg 1 GC QL(180per 90 days)MOmetformin hcl er tb24 750mg 1 GC QL(270per 90 days)MOmetformin hcl er tb24 500mg 1 GC QL(450per 90 days)MOmetformin hcl tabs 1000mg 1 GC QL(180per 90 days)MOmetformin hcl tabs 850mg 1 GC QL(270per 90 days)MODrugNameDrugTierRequirements/Limitsmetformin hcl tabs 500mg 1 GC QL(450per 90 days)MOnateglinide 1 GC QL(270per 90 days)MONEEDLES, INSULIN DISP., 2 MOSAFETYNOVOLOG 2 QL(60 per30 days)MONOVOLOG FLEXPEN 2 QL(60 per30 days)MONOVOLOG MIX 70/30 2 QL(60 per30 days)MONOVOLOG MIX 70/30PREFILLED FLEXPEN2 QL(60 per30 days)MOONGLYZA 2 QL(90 per90 days)MOpioglitazone hcl 1 GC QL(90per 90 days)MOpioglitazone hcl-glimepiride 1 GC QL(90per 90 days)MOpioglitazone hcl/metformin hcl 1 GC QL(270per 90 days)MOPRANDIN TABS 0.5MG, 1MG 2 QL(360 per90 days)MOPRANDIN TABS 2MG 2 QL(720 per90 days)MOPROGLYCEM 2 MOrepaglinide tabs 0.5mg, 1mg 1 GC QL(360per 90 days)MOrepaglinide tabs 2mg 1 GC QL(720per 90 days)MO28

DrugNameDrugTierRequirements/LimitsSYMLINPEN 120 3 QL(33 per90 days)MOSYMLINPEN 60 3 QL(33 per90 days)MOtolazamide 1 GC MOtolbutamide 1 GC MOTRADJENTA 2 QL(90 per90 days)MOVICTOZA 2 MOMISCELLANEOUS HORMONESALDURAZYME 4 LA MOANDRODERM 2 PA MOANDROGEL GEL 50MG/5GM 2 PA MOANDROGEL PUMP GEL 1.62% 2 PA MOANDROID 2 PA MOandroxy 2 PA MOAXIRON 3 PA MOcabergoline 1 GC MOcalcitonin-salmon 1 GC QL(12per 90 days)MOcalcitriol caps 1 GC PA MOcalcitriol inj 1 GC PA MOcalcitriol oral soln 1 GC PA MOCEREZYME INJ 200UNIT 4 LA MOdanazol 1 GC MOdesmopressin acetate 1 GC MOFABRAZYME INJ 35MG 4 LA MOFORTESTA 3 PA MOfortical 1 GC QL(12per 90 days)MOKUVAN 4 LA MONAGLAZYME 4 LA MOoxandrolone tabs 10mg 4 PA MOoxandrolone tabs 2.5mg 2 PA MOSAMSCA TABS 30MG 4 QL(730 per365 days)MODrugNameDrugTierRequirements/LimitsSAMSCA TABS 15MG 4 QL(1460per 365days) MOSENSIPAR TABS 60MG, 90MG 4 MOSENSIPAR TABS 30MG 2 MOSOMAVERT 2 PA MOSTIMATE 2 MOSYNAREL 3 MOTESTIM 3 PA MOtestosterone cypionate 1 GC PA MOtestosterone enanthate 1 GC PA MOZAVESCA 2 LA MOZEMPLAR 2 PA MOzoledronic acid inj 4mg/5ml 1 GC QL(30per 90 days)MOZOMETA INJ 4MG/5ML 4 QL(30 per90 days)MOTHYROID HORMONESlevothyroxine sodium tabs 1 GC MOlevoxyl 1 GC MOliothyronine sodium tabs 1 GC MOunithroid tabs 100mcg, 112mcg,125mcg, 150mcg, 175mcg,200mcg, 25mcg, 300mcg, 50mcg,75mcg, 88mcg1 GC MOGASTROENTEROLOGYANTIDIARRHEALS / ANTISPASMODICSatropine sulfate inj 0.05mg/ml, 1 GC0.1mg/mldicyclomine hcl caps 1 GC MOdicyclomine hcl oral soln 1 GC MOglycopyrrolate inj 4mg/20ml 1 GC MOglycopyrrolate tabs 1 GC MOloperamide hcl caps 1 GC MOpropantheline bromide 1 GC MOMISCELLANEOUS GASTROINTESTINALAGENTSAMITIZA 2 MOAPRISO 2 MOASACOL 2 MO29

DrugNameDrugTierRequirements/LimitsASACOL HD 2 MObalsalazide disodium 1 GC MObudesonide cp24 1 GC MOCANASA 2 MOCIMZIA 4 PA QL(6per 28 days)MOcompro 1 GC MOconstulose 1 GC MOCORTIFOAM 2 MOCREON 2 MOcromolyn sodium conc 1 GC MOCYSTADANE 2 MODELZICOL 2 MODIPENTUM 3 MOdronabinol 1 GC PA MOEMEND CAPS 40MG 2 PA QL(3per 90 days)MOEMEND CAPS 125MG 2 PA QL(6per 90 days)MOEMEND CAPS 2 PA QL(18per 90 days)MOEMEND CAPS 80MG 2 PA QL(24per 90 days)MOENTOCORT EC 2 MOenulose 1 GC MOGASTROCROM 2 MOgavilyte-c 1 GCQL(4000per 30 days)MOgavilyte-g 1 GCQL(4000per 30 days)MOgavilyte-n/flavor pack 1 GCQL(4000per 30 days)MOgenerlac 1 GC MODrugNameDrugTierRequirements/Limitsgranisetron hcl inj 0.1mg/ml 1 GC QL(42per 90 days)granisetron hcl inj 1mg/ml 1 GC QL(42per 90 days)MOgranisetron hcl tabs 1 GC PAQL(180 per90 days)MOHALFLYTELY BOWELPREP/FLAVOR PACKS2 QL(6 per 90days) MOhydrocortisone enem 1 GC MOlactulose 1 GC MOLIALDA 2 MOLINZESS 2 MOLOTRONEX 2 QL(180 per90 days)MOmeclizine hcl tabs 1 GC MOmetoclopramide hcl 1 GC MOMOVIPREP 3 QL(6 per 90days) MOondansetron hcl inj 4mg/2ml 1 GC MOondansetron hcl oral soln 1 GC PA MOondansetron hcl tabs 24mg 1 GC PAQL(21 per90 days)ondansetron hcl tabs 4mg, 8mg 1 GC PAQL(135 per90 days)MOondansetron odt 1 GC PAQL(135 per90 days)MOPENTASA 2 MOpolyethylene glycol 3350 powd 1 GC MOprochlorperazine 1 GC MOprochlorperazine edisylate 1 GC MOprochlorperazine maleate 1 GC MOprocto-pak 1 GC MOproctozone-hc 1 GC MORECTIV 2 MORELISTOR INJ 12MG/0.6ML 2 MO30

DrugNameDrugTierRequirements/LimitsREMICADE 4 PA MOSANCUSO 2 QL(6 per 90days) MOSUCRAID 4 MOsulfasalazine tabs 1 GC MOsulfazine ec 1 GC MOSUPREP BOWEL PREP 2 MOTRANSDERM-SCOP 2 MOtrilyte 1 GCQL(4000per 30 days)MOUCERIS 4 MOursodiol 1 GC MOZENPEP 2 MOULCER THERAPYcarafate susp 1 GC MODEXILANT 3 QL(90 per90 days) STMOfamotidine inj 1 GC MOfamotidine premixed 1 GCfamotidine susr 1 GC MOfamotidine tabs 20mg, 40mg 1 GC MOlansoprazole 1 GC QL(180per 90 days)MOmisoprostol 1 GC MONEXIUM 2 QL(90 per90 days)MONEXIUM I.V. INJ 20MG 2NEXIUM I.V. INJ 40MG 2 MOnizatidine 1 GC MOomeprazole cpdr 40mg 1 GC QL(90per 90 days)MOomeprazole cpdr 10mg, 20mg 1 GC QL(180per 90 days)MOomeprazole/sodium bicarbonate 1 GC QL(90per 90 days)MODrugNameDrugTierRequirements/Limitspantoprazole sodium inj 1 GCpantoprazole sodium tbec 1 GC QL(180per 90 days)MOPREVPAC 3 MOPYLERA 2 MOranitidine hcl caps 1 GC MOranitidine hcl syrp 1 GC MOranitidine hcl tabs 150mg, 300mg 1 GC MOsucralfate tabs 1 GC MOZANTAC INJ 50MG/50ML;0.45%IMMUNOLOGY, VACCINES /BIOTECHNOLOGYBIOTECHNOLOGY DRUGS2 MOACTIMMUNE 4 LA MOARANESP ALBUMIN FREE 2 PA QL(3INJ 500MCG/MLper 90 days)ARANESP ALBUMIN FREEINJ 150MCG/0.3MLARANESP ALBUMIN FREEINJ 200MCG/0.4MLARANESP ALBUMIN FREEINJ 100MCG/0.5MLARANESP ALBUMIN FREEINJ 300MCG/0.6ML,60MCG/0.3MLARANESP ALBUMIN FREEINJ 40MCG/0.4MLARANESP ALBUMIN FREEINJ 25MCG/0.42MLARANESP ALBUMIN FREEINJ 100MCG/ML, 200MCG/ML,300MCG/MLARANESP ALBUMIN FREEINJ 25MCG/ML, 40MCG/ML,60MCG/MLMO2 PA QL(3.6per 90 days)MO2 PA QL(4.8per 90 days)MO2 PA QL(6per 90 days)MO2 PA QL(7.2per 90 days)MO2 PA QL(9.6per 90 days)MO2 PAQL(10.08per 90 days)MO2 PA QL(12per 90 days)MO2 PA QL(24per 90 days)MO31

DrugNameDrugTierRequirements/LimitsARCALYST 4 LA MOAVONEX 4 PA QL(12per 90 days)MOBETASERON 4 PA QL(45per 90 days)MOEPOGEN INJ 20000UNIT/ML,2000UNIT/ML, 3000UNIT/ML,4000UNIT/ML3 PA QL(36per 90 days)MOEPOGEN INJ 10000UNIT/ML 3 PA QL(72per 90 days)MOINTRON-A INJ 10MU/0.2ML 3 PAINTRON-A INJ 3MU/0.2ML 2 PAINTRON-A INJ2 PA MO6000000UNIT/MLINTRON-A INJ 5MU/0.2ML 4 PAINTRON-A W/DILUENT INJ 4 PA MO10MULEUKINE 4 PA MOMOZOBIL 4 QL(4.8 per90 days)MONEULASTA 3 PA QL(3.6per 90 days)MONEUMEGA 4 PA QL(63per 90 days)MONEUPOGEN INJ300MCG/0.5MLNEUPOGEN INJ480MCG/0.8ML4 PA QL(21per 90 days)MO4 PA QL(33.6per 90 days)MONEUPOGEN INJ480MCG/1.6ML4 PA QL(67.2per 90 days)MONORDITROPIN FLEXPRO 4 PA MONORDITROPIN NORDIFLEX 4 PA MOPENOMNITROPE INJ 5MG/1.5ML 3 PA MODrugNamePEG-INTRON INJ50MCG/0.5MLDrugTierRequirements/Limits4 PA QL(12per 90 days)MOPEG-INTRON REDIPEN 4 PA QL(12per 90 days)MOPEGASYS INJ 180MCG/0.5ML 4 PA QL(6per 90 days)MOPEGASYS INJ 180MCG/ML 4 PA QL(12per 90 days)MOPEGASYS PROCLICK INJ135MCG/0.5ML4 PA QL(12per 90 days)MOPROCRIT INJ 40000UNIT/ML 2 PA QL(18per 90 days)MOPROCRIT INJ 10000UNIT/ML,20000UNIT/ML, 2000UNIT/ML,3000UNIT/ML, 4000UNIT/ML2 PA QL(36per 90 days)MOPROLEUKIN 4 MOREBIF 4 PA QL(18per 90 days)MOREBIF TITRATION PACK 4 PA MOSYLATRON INJ 888MCG 4 PA QL(8per 90 days)MOSYLATRON INJ 296MCG,444MCG4 PA QL(12per 90 days)MOVACCINES / MISCELLANEOUSIMMUNOLOGICALSACTHIB 2 MOADACEL 2 MOBOOSTRIX 2 MOCERVARIX 2 PA MOCOMVAX 2 MODAPTACEL 2 MODECAVAC 2 MOENGERIX-B 2 PA MOGARDASIL 2 PA MOHAVRIX INJ 720ELU/0.5ML 232

DrugNameDrugTierRequirements/LimitsHAVRIX INJ 1440ELU/ML 2 MOIMOVAX RABIES (H.D.C.V.) 2 MOINFANRIX 2IPOL INACTIVATED IPV 2 MOIXIARO 2 MOM-M-R II W/DILUENT 10 2 MODOSEMENACTRA 2 MOMENOMUNE-A/C/Y/W-135 2 MOMENVEO 2 MOPEDVAX HIB 2 MOPRIVIGEN INJ 20GM/200ML 4 PA MOPROQUAD 2RABAVERT 2 MORECOMBIVAX HB INJ2 PA MO10MCG/ML, 40MCG/MLROTATEQ 2tetanus toxoid adsorbed 1 GC MOTETANUS/DIPHTHERIA 2 MOTOXOIDS-ADSORBED ADULTTHYMOGLOBULIN 2TWINRIX 2 MOTYPHIM VI 2VAQTA INJ 25UNIT/0.5ML 2 MOVARIVAX 2 MOYF-VAX 2 MOZOSTAVAX 2 PA MOMUSCULOSKELETAL /RHEUMATOLOGYGOUT THERAPYallopurinol 1 GC MOCOLCRYS 2 QL(360 per90 days)MOprobenecid 1 GC MOprobenecid/colchicine 1 GC MOULORIC 2 MOOSTEOPOROSIS THERAPYACTONEL TABS 150MG 2 QL(3 per 90days) MODrugNameDrugTierRequirements/LimitsACTONEL TABS 35MG 2 QL(12 per90 days)MOACTONEL TABS 5MG 2 QL(90 per90 days)MOalendronate sodium oral soln 1 GC MOalendronate sodium tabs 35mg,70mgalendronate sodium tabs 10mg,5mg1 GC QL(12per 90 days)MO1 GC QL(90per 90 days)MOATELVIA 2 QL(12 per90 days)MOEVISTA 2 QL(90 per90 days)MOFORTEO 2 QL(7.2 per90 days)MOFOSAMAX PLUS D 3 ST MOibandronate sodium 1 GC MOPROLIA 3 ST MOOTHER RHEUMATOLOGICALSDEPEN TITRATABS 2 MOENBREL 4 PA QL(600per 90 days)MOHUMIRA INJ 20MG/0.4ML 4 PA QL(2.4per 90 days)MOHUMIRA INJ 40MG/0.8ML 4 PA QL(4.8per 90 days)MOHUMIRA PEN-CROHNS 4 PA MODISEASESTARTERleflunomide tabs 10mg 1 GC QL(90per 90 days)MOleflunomide tabs 20mg 1 GC QL(102per 90 days)MO33

DrugNameDrugTierRequirements/LimitsORENCIA INJ 125MG/ML 4 PA QL(12per 90 days)MORIDAURA 3 MOSAVELLA 2 QL(180 per90 days)MOSAVELLA TITRATION PACK 2 MOSIMPONI ARIA 4 PA MOSIMPONI INJ 50MG/0.5ML 4 PA QL(1per 30 days)MOXELJANZ 4 PA MOOBSTETRICS / GYNECOLOGYESTROGENS / PROGESTINSALORA 2 MOcamila 1 GC MOCLIMARA PRO 2 MOCOMBIPATCH 2 MOCRINONE GEL 4% 2 MOCRINONE GEL 8% 2 PA MODELESTROGEN INJ 10MG/ML 3 MODEPO-PROVERA 400MG/ML 2 MODEPO-SUBQ PROVERA 104 3 MODIVIGEL GEL 1MG/GM 2 MOerrin 1 GC MOESTRACE CREA 2 MOestradiol 1 GC MOestradiol valerate 1 GC MOestradiol/norethindrone acetate 1 GC MOESTRASORB 3 MOESTRING 3 QL(1 per 90days) MOestropipate 1 GC MOjinteli 1 GC MOjolivette 1 GC MOlyza 1 GC MOmedroxyprogesterone acetate 1 GC MOMENEST 3 MOnora-be 1 GC MOnorethindrone 1 GC MODrugNameDrugTierRequirements/Limitsnorethindrone acetate 1 GC MOPREFEST 3 MOPREMARIN CREA 2 MOPREMARIN TABS 2 MOPREMPHASE 2 MOPREMPRO 2 MOprogesterone caps 1 GC MOVAGIFEM 2 MOVIVELLE-DOT 2 MOMISCELLANEOUS OB/GYNCLEOCIN SUPP 2 MOclindamycin phosphate crea 1 GC MOGYNAZOLE-1 2 MOLYSTEDA 3 QL(120 per90 days)MOmetronidazole vaginal 1 GC MOmiconazole 3 1 GC MONUVARING 3 MOORTHO EVRA 3 MOterconazole 1 GC MOtranexamic acid tabs 1 GC QL(120per 90 days)MOvandazole 1 GC MOzazole crea 0.4% 1 GCORAL CONTRACEPTIVES / RELATEDAGENTSamethia 1 GC MOamethyst 1 GC MOapri 1 GC MOaranelle 1 GC MOaviane 1 GC MObalziva 1 GC MObriellyn 1 GC MOcryselle-28 1 GC MOcyclafem 1/35 1 GC MOcyclafem 7/7/7 1 GC MOdrospirenone/ethinyl estradiol 1 GC MOELLA 2 MOemoquette 1 GC MO34

DrugNameDrugTierRequirements/Limitsenpresse-28 1 GC MOgianvi 1 GC MOgildagia 1 GC MOintrovale 1 GC MOjunel 1.5/30 1 GC MOjunel 1/20 1 GC MOjunel fe 1.5/30 1 GC MOjunel fe 1/20 1 GC MOkariva 1 GC MOkelnor 1/35 1 GC MOleena 1 GC MOlessina 1 GC MOlevonest 1 GC MOlevonorgestrel/ethinyl estradiol 1 GC MOtabs 0.03mg; 0.15mglevora 0.15/30-28 1 GC MOloryna 1 GC MOlow-ogestrel 1 GC MOlutera 1 GC MOmarlissa 1 GC MOmicrogestin 1.5/30 1 GC MOmicrogestin 1/20 1 GC MOmicrogestin fe 1 GC MOmicrogestin fe 1.5/30 1 GC MOmononessa 1 GC MOnecon 0.5/35-28 1 GC MOnecon 1/35 1 GC MOnecon 10/11-28 1 GC MOnecon 7/7/7 1 GC MOnortrel 0.5/35 (28) 1 GC MOnortrel 1/35 1 GC MOnortrel 7/7/7 1 GC MOocella 1 GC MOogestrel 1 GC MOorsythia 1 GC MOpirmella 1/35 1 GC MOportia-28 1 GC MOprevifem 1 GC MOquasense 1 GC MOreclipsen 1 GC MOsprintec 28 1 GC MODrugNameDrugTierRequirements/Limitssronyx 1 GC MOtri-legest fe 1 GC MOtri-previfem 1 GC MOtri-sprintec 1 GC MOtrinessa 1 GC MOtrivora-28 1 GC MOvelivet 1 GC MOvestura 1 GC MOzenchent fe 1 GC MOzeosa 1 GC MOzovia 1/35e 1 GC MOzovia 1/50e 1 GC MOOXYTOCICSMETHERGINE 2 MOmethylergonovine maleate tabs 1 GC MOOPHTHALMOLOGYANTIBIOTICSAZASITE 2 MObacitracin ophthalmic oint 1 GC MObacitracin/polymyxin b 1 GC MOBESIVANCE 2 MOCILOXAN OINT 2 MOciprofloxacin hcl 1 GC MOerythromycin oint 1 GC MOgentak oint 1 GC MOgentamicin sulfate ophthalmic 1 GC MOsolnlevofloxacin 1 GC MOMOXEZA 2 MONATACYN 2 MOneomycin/bacitracin/polymyxin 1 GC MOneomycin/polymyxin/gramicidin 1 GC MOofloxacin 1 GC MOtobramycin sulfate ophthalmic 1 GC MOsolnTOBREX OINT 2 MOtrimethoprim sulfate/polymyxin b 1 GC MOsulfateVIGAMOX 2 MOZYMAXID 2 MOANTIVIRALS35

DrugNameDrugTierRequirements/Limitstrifluridine 1 GC MOZIRGAN 3 MOBETA-BLOCKERSbetaxolol hcl 1 GC MOBETOPTIC-S 2 MOcarteolol hcl 1 GC MOISTALOL 2 MOlevobunolol hcl ophthalmic soln 1 GC MO0.5%metipranolol 1 GC MOtimolol maleate 1 GC MOtimolol maleate ophthalmic gel 1 GC MOformingTIMOPTIC OCUDOSE 2 MODIRECT ACTING MIOTICSPILOPINE HS 2 MOMISCELLANEOUS OPHTHALMOLOGICSALOCRIL 3 MOazelastine hcl 1 GC MOBEPREVE 2 MOcromolyn sodium ophthalmic soln 1 GC MOCYSTARAN 4 MOepinastine hcl 1 GC MOLACRISERT 2 MOLASTACAFT 2 MOPATADAY 2 MOPATANOL 2 MORESTASIS 2 MONON-STEROIDAL ANTIINFLAMMATORYAGENTSACUVAIL 2 MOBROMDAY 2 MObromfenac 1 GC MOdiclofenac sodium 1 GC MOflurbiprofen sodium 1 GC MOILEVRO 2 MOketorolac tromethamine1 GC MOophthalmic solnNEVANAC 2 MOPROLENSA 2 MOORAL DRUGS FOR GLAUCOMADrugNameDrugTierRequirements/Limitsacetazolamide 1 GC MOacetazolamide er 1 GC MOacetazolamide sodium 1 GCmethazolamide 1 GC MOOTHER GLAUCOMA DRUGSAZOPT 2 MOCOMBIGAN 2 MOdorzolamide hcl 1 GC MOdorzolamide hcl/timolol maleate 1 GC MOlatanoprost 1 GC MOLUMIGAN 2 MOSIMBRINZA 3 MOTRAVATAN Z 2 MOtravoprost 1 GC MOSTEROID-ANTIBIOTIC COMBINATIONSneomycin/polymyxin/bacitracin/h 1 GC MOydrocortisoneneomycin/polymyxin/dexamethaso 1 GC MOne1 GC MOneomycin/polymyxin/hydrocortisone ophthalmic suspTOBRADEX OINT 2 MOTOBRADEX ST 2 MOtobramycin/dexamethasone 1 GC MOZYLET 2 MOSTEROID-SULFONAMIDECOMBINATIONSBLEPHAMIDE 3 MOBLEPHAMIDE S.O.P. 3 MOsulfacetamide1 GC MOsodium/prednisolone sodiumphosphateSTEROIDSALREX 2 MOdexamethasone sodium phosphate 1 GC MOophthalmic solnDUREZOL 2 MOFML 2 MOFML FORTE 2 MOLOTEMAX 2 MOprednisolone acetate 1 GC MO36

DrugNameDrugTierRequirements/Limitsprednisolone sodium phosphate 1 GC MOophthalmic solnSULFONAMIDESBLEPH-10 2 MOsodium sulfacetamide ophthalmic 1 GC MOsolnsulfacetamide sodium oint 1 GC MOSYMPATHOMIMETICSALPHAGAN P 2 MOapraclonidine 1 GC MObrimonidine tartrate 1 GC MOIOPIDINE OPHTHALMICSOLN 1%3 MOVASOCONSTRICTOR DECONGESTANTSnaphazoline hcl 1 GC MORESPIRATORY AND ALLERGYANTIHISTAMINE / ANTIALLERGENICAGENTSadrenalin inj 1 GC MOcarbinoxamine maleate 1 GC MOcetirizine hcl syrp 1 GC MOclemastine fumarate syrp 1 GC MOclemastine fumarate tabs 2.68mg 1 GC MOdesloratadine 1 GC QL(90per 90 days)MOdesloratadine odt 1 GC MOepinephrine hcl inj 0.1mg/ml 1 GC MOEPIPEN 2-PAK 2 MOEPIPEN-JR 2-PAK 2 MOhydroxyzine hcl 1 GC MOlevocetirizine dihydrochloride 1 GC MOoral solnlevocetirizine dihydrochloridetabs1 GC QL(90per 90 days)MOpalgic oral soln 1 GC MOphenadoz 1 GC MOpromethazine hcl inj 25mg/ml 1 GCpromethazine hcl inj 50mg/ml 1 GC MOpromethazine hcl supp 1 GC MOpromethazine hcl syrp 1 GC MODrugNameDrugTierRequirements/Limitspromethazine hcl tabs 1 GC MOpromethegan supp 25mg, 50mg 1 GC MOTWINJECT 2 MOPULMONARY AGENTSacetylcysteine inhalation soln 1 GC PA MOADVAIR DISKUS 2 QL(180 per90 days)MOADVAIR HFA 2 QL(36 per90 days)MOalbuterol sulfate er 1 GC MOalbuterol sulfate nebu 1 GC PA MOalbuterol sulfate syrp 1 GC MOalbuterol sulfate tabs 1 GC MOALVESCO 3 QL(37 per90 days)MOARCAPTA NEOHALER 3 QL(90 per90 days)MOASMANEX 120 METEREDDOSES2 QL(3 per 90days) MOASMANEX 14 METEREDDOSES2 QL(3 per 90days) MOASMANEX 30 METEREDDOSES2 QL(3 per 90days) MOASMANEX 60 METEREDDOSES2 QL(3 per 90days) MOATROVENT HFA 2 QL(77.4 per90 days)MObudesonide susp 1 GC PA MOCINRYZE 4 LA PAQL(60 per90 days)MOCOMBIVENT 2 QL(88.2 per90 days)MOCOMBIVENT RESPIMAT 2 QL(20 per90 days)MOcromolyn sodium nebu 1 GC PA MO37

DrugNameDrugTierRequirements/LimitsDALIRESP 2 QL(90 per90 days)MODULERA 3 QL(39 per90 days)MOELIXOPHYLLIN 3 MOFIRAZYR 4 MOFLOVENT DISKUS 2 QL(360 per90 days)MOFLOVENT HFA 2 QL(72 per90 days)MOflunisolide 1 GC MOfluticasone propionate 1 GC MOFORADIL AEROLIZER 2 QL(180 per90 days)MOipratropium bromide inhalation 1 GC PA MOsolnipratropium bromide/albuterol 1 GC PA MOsulfateKALYDECO 4 PA QL(180per 90 days)MOLETAIRIS 4 LA PAQL(90 per90 days)MOlevalbuterol 1 GC PA MOlevalbuterol hcl nebu 0.31mg/3ml, 1 GC PA MO0.63mg/3mlmetaproterenol sulfate 1 GC MOmontelukast sodium 1 GC QL(90per 90 days)MONASONEX 2 MOPERFOROMIST 2 PA MOPROAIR HFA 2 QL(51 per90 days)MOPULMICORT FLEXHALER 3 QL(6 per 90days) MOPULMICORT SUSP 1MG/2ML 2 PA MODrugNameDrugTierRequirements/LimitsPULMOZYME 4 PA MOQVAR 2 QL(53 per90 days)MOREVATIO INJ 4 QL(3375per 90 days)MOREVATIO TABS 4 PA QL(270per 90 days)MORHINOCORT AQUA 3 ST MOSEREVENT DISKUS 2 QL(180 per90 days)MOsildenafil citrate 1 GC PAQL(270 per90 days)MOSINGULAIR 2 QL(90 per90 days)MOSPIRIVA HANDIHALER 2 QL(90 per90 days)MOSYMBICORT 2 QL(30.6 per90 days)MOterbutaline sulfate 1 GC MOtheophylline cr 1 GC MOtheophylline er tb12 300mg, 1 GC MO450mgtheophylline er tb24 1 GC MOTRACLEER 4 LA PAQL(180 per90 days)MOtriamcinolone acetonide inha 1 GC MOTUDORZA PRESSAIR 2 QL(27 per90 days)MOTYVASO 4 PA MOVERAMYST 2 MOXOLAIR 4 PA QL(7.2per 30 days)MO38

DrugNameDrugTierRequirements/LimitsXOPENEX HFA 2 QL(90 per90 days)MOzafirlukast 1 GC QL(180per 90 days)MOZYFLO 3 QL(360 per90 days)MOZYFLO CR 3 QL(360 per90 days)MOUROLOGICALSANTICHOLINERGICS /ANTISPASMODICSDETROL LA 2 QL(90 per90 days)MOENABLEX 2 QL(90 per90 days)MOflavoxate hcl 1 GC MOGELNIQUE GEL 10% 2 QL(90 per90 days)MOGELNIQUE GEL 3% 2 QL(276 per90 days)MOMYRBETRIQ 2 QL(90 per90 days)MOoxybutynin chloride er tb24 5mg 1 GC QL(90per 90 days)MOoxybutynin chloride er tb24 10mg,15mg1 GC QL(180per 90 days)MOoxybutynin chloride syrp 1 GC MOoxybutynin chloride tabs 1 GC QL(360per 90 days)MOOXYTROL 2 QL(32 per90 days)MODrugNameDrugTierRequirements/LimitsSANCTURA XR 3 QL(90 per90 days)MOtolterodine tartrate 1 GC QL(180per 90 days)MOTOVIAZ 2 QL(90 per90 days)MOtrospium chloride 1 GC QL(180per 90 days)MOtrospium chloride er 1 GC QL(90per 90 days)MOVESICARE 2 QL(90 per90 days)MOBENIGN PROSTATICHYPERPLASIA(BPH) THERAPYalfuzosin hcl er 1 GC QL(90per 90 days)MOAVODART 2 QL(90 per90 days)MOfinasteride tabs 5mg 1 GC QL(90per 90 days)MOJALYN 2 QL(90 per90 days)MORAPAFLO 2 QL(90 per90 days)MOtamsulosin hcl 1 GC QL(180per 90 days)MOUROXATRAL 2 QL(90 per90 days)MOCHOLINERGIC STIMULANTSbethanechol chloride 1 GC MOMISCELLANEOUS UROLOGICALS39

DrugNameDrugTierRequirements/LimitsCIALIS TABS 2.5MG, 5MG 2 PA QL(90per 90 days)MOCYSTAGON 2 LA MOELMIRON 2 MOpotassium citrate tbcr 1 GC MOVITAMINS, HEMATINICS /ELECTROLYTESELECTROLYTEScalcium acetate caps 1 GC MOdextrose 5%/potassium chloride 1 GC0.15%eliphos 1 GC MOK-TABS 3 MOkcl 0.075%/d5w/nacl 0.45% 1 GCkcl 0.15%/d5w/lr 1 GC MOkcl 0.15%/d5w/nacl 0.2% 1 GC MOkcl 0.15%/d5w/nacl 0.225% 1 GC MOkcl 0.15%/d5w/nacl 0.9% 1 GCkcl 0.3%/d5w/nacl 0.45% 1 GCkcl 0.3%/d5w/nacl 0.9% 1 GCklor-con 10 1 GC MOklor-con 8 1 GC MOKLOR-CON M15 3 MOklor-con m20 1 GC MOlactated ringers viaflex 1 GC MOmagnesium sulfate inj 50% 1 GCNORMOSOL-R IN D5W 2PHOSLYRA 2 MOpotassium chloride 0.15% /nacl0.45% viaflexpotassium chloride 0.15%d5w/nacl 0.33%potassium chloride 0.15%d5w/nacl 0.45% viaflexpotassium chloride 0.15% nacl0.9%potassium chloride 0.22%d5w/nacl 0.45%potassium chloride0.224%/dextrose 5% viaflex1 GC1 GC1 GC MO1 GC1 GC1 GCDrugNameDrugTierRequirements/Limitspotassium chloride 0.3%/ nacl 1 GC0.9%potassium chloride 0.3%/d5w 1 GCpotassium chloride er cpcr 1 GC MOpotassium chloride er tbcr 10meq, 1 GC MO20meqpotassium chloride inj 0.4meq/ml, 1 GC10meq/100ml, 10meq/50ml,30meq/100mlpotassium chloride inj 2meq/ml 1 GC MOringers injection 1 GCsodium chloride 0.45% viaflex 1 GC MOsodium chloride inj 5% 1 GCsodium chloride inj 2.5meq/ml, 1 GC MO3%MISCELLANEOUS NUTRITIONPRODUCTSAMINOSYN II 2AMINOSYN II28.5%/ELECTROLYTESAMINOSYN-HBC 2AMINOSYN-PF 2AMINOSYN-PF 7% 2CLINIMIX 2.75%/DEXTROSE 25%CLINIMIX 4.25%/DEXTROSE 210%CLINIMIX 4.25%/DEXTROSE 220%CLINIMIX 4.25%/DEXTROSE 225%CLINIMIX 5%/DEXTROSE 15% 2CLINIMIX 5%/DEXTROSE 20% 2CLINIMIX 5%/DEXTROSE 25% 2CLINISOL SF 15% 2 MO40

DrugNameDrugTierRequirements/LimitsFREAMINE III INJ 72MEQ/L; 2 MO600MG/100ML; 810MG/100ML;3MEQ/L; 14MG/100ML;1190MG/100ML;240MG/100ML; 590MG/100ML;770MG/100ML; 620MG/100ML;450MG/100ML; 480MG/100ML;10MMOLE/L; 115MG/100ML;950MG/100ML; 500MG/100ML;10MEQ/L; 340MG/100ML;130MG/100ML; 560MG/100MLHEPATAMINE 2HEPATASOL 2INTRALIPID INJ 1.7%; 30% 2intralipid inj 2.25%; 20% 1 GC MOIONOSOL-B/DEXTROSE 5% 2IONOSOL-MB/DEXTROSE 5% 2ISOLYTE-H/DEXTROSE 5% 2ISOLYTE-P/DEXTROSE 5% 2ISOLYTE-S 2ISOLYTE-S/DEXTROSE 5% 2liposyn iii inj 1.2%; 2.5%; 10% 1 GCNEPHRAMINE 2NORMOSOL-R 2PLASMA-LYTE A 2PLASMA-LYTE-148 2PLASMA-LYTE-56/D5W 2PREMASOL INJ 56MEQ/L;320MG/100ML; 730MG/100ML;190MG/100ML; 3MEQ/L;20MG/100ML; 300MG/100ML;220MG/100ML; 290MG/100ML;490MG/100ML; 840MG/100ML;490MG/100ML; 200MG/100ML;290MG/100ML; 410MG/100ML;230MG/100ML; 5MEQ/L;15MG/100ML; 250MG/100ML;120MG/100ML; 140MG/100ML;470MG/100ML2DrugNameDrugTierRequirements/Limitspremasol inj 52meq/l;1 GC1760mg/100ml; 880mg/100ml;34meq/l; 1760mg/100ml;372mg/100ml; 406mg/100ml;526mg/100ml; 492mg/100ml;492mg/100ml; 526mg/100ml;356mg/100ml; 356mg/100ml;390mg/100ml; 34mg/100ml;152mg/100mltravasol 2TROPHAMINE 2VITAMINS / HEMATINICSprenatabs obn 1 GCsodium fluoride tabs 1 GC41

8Index of Drugs8-MOP ................................................................. 22Aabacavir ................................................................. 1ABILIFY ........................................................ 14, 15ABILIFY DISCMELT......................................... 14ABILIFY MAINTENA ....................................... 15ABRAXANE ......................................................... 7acamprosate calcium dr ...................................... 24acarbose ............................................................... 26acebutolol hcl ....................................................... 18acetaminophen/codeine ....................................... 12acetaminophen/codeine #3 .................................. 12acetasol hc ........................................................... 25acetazolamide ...................................................... 36acetazolamide er .................................................. 36acetazolamide sodium .......................................... 36acetic acid ............................................................ 25acetylcysteine ....................................................... 37acitretin ................................................................ 22ACTHAR HP ....................................................... 26ACTHIB .............................................................. 32ACTIMMUNE ..................................................... 31ACTONEL ..................................................... 24, 33ACTOPLUS MET ............................................... 26ACTOS ................................................................ 26ACUVAIL ........................................................... 36acyclovir .......................................................... 1, 23acyclovir sodium .................................................... 1ADACEL ............................................................. 32ADAGEN ............................................................ 24adapalene ............................................................. 23adrenalin .............................................................. 37adriamycin ............................................................. 7ADVAIR DISKUS .............................................. 37ADVAIR HFA ..................................................... 37afeditab cr ............................................................ 18AFINITOR ............................................................. 7AFINITOR DISPERZ ........................................... 7AGGRENOX ....................................................... 21a-hydrocort .......................................................... 26ala cort ................................................................. 24ALBENZA ............................................................. 4albuterol sulfate ................................................... 37albuterol sulfate er ............................................... 37alclometasone dipropionate ................................. 24alcohol preps ....................................................... 26ALDURAZYME ................................................. 29alendronate sodium ....................................... 24, 33alfuzosin hcl er ..................................................... 39ALIMTA ................................................................ 7ALINIA .................................................................. 4ALKERAN ............................................................ 7allopurinol ........................................................... 33ALOCRIL ............................................................ 36ALORA ................................................................ 34ALPHAGAN P .................................................... 37ALREX ................................................................ 36ALTABAX .......................................................... 23ALVESCO ........................................................... 37amantadine hcl ....................................................... 1amcinonide ........................................................... 24amethia ................................................................ 34amethyst ............................................................... 34amifostine ............................................................... 6amikacin sulfate ..................................................... 4amiloride hcl ........................................................ 18amiloride/hydrochlorothiazide ............................ 18AMINOSYN II .................................................... 40AMINOSYN II 8.5%/ELECTROLYTES ........... 40AMINOSYN-HBC .............................................. 40AMINOSYN-PF .................................................. 40AMINOSYN-PF 7% ............................................ 40amiodarone hcl .................................................... 18AMITIZA ............................................................ 29amitriptyline hcl ................................................... 15amlodipine besylate ............................................. 18amlodipine besylate/benazepril hcl ..................... 18amlodipine besylate/benazepril hydrochloride .... 18ammonium lactate ................................................ 22amnesteem ............................................................ 23amoxapine ............................................................ 15amoxicillin ............................................................. 542

amoxicillin/clavulanate potassium ........................ 5amoxicillin/clavulanate potassium er .................... 5amoxicillin/potassium clavulanate ........................ 5amphotericin b ....................................................... 1ampicillin ............................................................... 6ampicillin sodium ................................................... 6ampicillin-sulbactam ............................................. 6AMTURNIDE ..................................................... 18anagrelide hydrochloride .................................... 24anastrozole ............................................................. 7ANCOBON............................................................ 1ANDRODERM.................................................... 29ANDROGEL ....................................................... 29ANDROGEL PUMP ........................................... 29ANDROID ........................................................... 29androxy ................................................................ 29ANTABUSE ........................................................ 24APIDRA .............................................................. 26APIDRA SOLOSTAR ......................................... 26APOKYN ............................................................. 11apraclonidine ....................................................... 37apri ....................................................................... 34APRISO ............................................................... 29APTIVUS .............................................................. 1ARALAST NP ..................................................... 24aranelle ................................................................ 34ARANESP ALBUMIN FREE ............................. 31ARCALYST ........................................................ 32ARCAPTA NEOHALER .................................... 37ARICEPT ............................................................. 11ARRANON............................................................ 7ARTHROTEC 50 ................................................ 14ARTHROTEC 75 ................................................ 14ARZERRA ............................................................. 7ASACOL ............................................................. 29ASACOL HD....................................................... 30ascomp/codeine .................................................... 12ASMANEX 120 METERED DOSES ................. 37ASMANEX 14 METERED DOSES ................... 37ASMANEX 30 METERED DOSES ................... 37ASMANEX 60 METERED DOSES ................... 37ASTEPRO............................................................ 25ATELVIA ............................................................ 33atenolol ................................................................ 18atenolol/chlorthalidone ........................................ 18atorvastatin calcium ............................................ 21atovaquone/proguanil hcl ...................................... 4ATRIPLA .............................................................. 1atropine sulfate .................................................... 29ATROVENT HFA ............................................... 37augmented betamethasone dipropionate ............. 24AVANDAMET .................................................... 26AVANDARYL .................................................... 26AVANDIA ........................................................... 26AVASTIN .............................................................. 7AVELOX ............................................................... 6AVELOX ABC PACK .......................................... 6aviane ................................................................... 34avita ..................................................................... 23AVODART .......................................................... 39AVONEX ............................................................ 32AXIRON .............................................................. 29AZACTAM ............................................................ 4AZACTAM IN ISO-OSMOTIC DEXTROSE ...... 4AZASITE ............................................................. 35azathioprine ........................................................... 7azathioprine sodium............................................... 7azelastine hcl ................................................. 25, 36AZELEX .............................................................. 23AZILECT ............................................................. 11azithromycin .......................................................... 4AZOPT ................................................................ 36AZOR .................................................................. 18aztreonam .............................................................. 4Bbacitracin ............................................................. 35bacitracin/polymyxin b ........................................ 35baclofen ................................................................ 12BACTROBAN ..................................................... 23BACTROBAN NASAL ...................................... 25balsalazide disodium ........................................... 30balziva .................................................................. 34BANZEL .............................................................. 10BARACLUDE ....................................................... 1benazepril hcl ....................................................... 1943

enazepril hcl/hydrochlorothiazide ..................... 19BENICAR ............................................................ 19BENICAR HCT ................................................... 19benztropine mesylate ........................................... 11BEPREVE............................................................ 36BESIVANCE ....................................................... 35betamethasone dipropionate ................................ 24betamethasone valerate ....................................... 24BETASERON ...................................................... 32betaxolol hcl ................................................... 19, 36bethanechol chloride ........................................... 39BETOPTIC-S ....................................................... 36bicalutamide .......................................................... 7BICILLIN C-R ....................................................... 6BICILLIN L-A ....................................................... 6BICNU ................................................................... 7BIDIL ................................................................... 19BILTRICIDE ......................................................... 4bisoprolol fumarate ............................................. 19bisoprolol fumarate/hydrochlorothiazide ............ 19bleomycin sulfate ................................................... 7BLEPH-10 ........................................................... 37BLEPHAMIDE .................................................... 36BLEPHAMIDE S.O.P ......................................... 36BOOSTRIX ......................................................... 32BOSULIF ............................................................... 7briellyn ................................................................. 34BRILINTA ........................................................... 21brimonidine tartrate ............................................. 37BROMDAY ......................................................... 36bromfenac ............................................................ 36bromocriptine mesylate ....................................... 11budeprion sr ......................................................... 15budesonide ..................................................... 30, 37bumetanide ........................................................... 19BUPHENYL ........................................................ 24BUPRENEX ........................................................ 12buprenorphine hcl ................................................ 12buprenorphine hcl/naloxone hcl .......................... 14buproban .............................................................. 25bupropion hcl ....................................................... 15bupropion hcl sr ................................................... 15bupropion hcl xl ................................................... 15buspirone hcl ....................................................... 15BUSULFEX ........................................................... 7butorphanol tartrate ............................................ 14BUTRANS ........................................................... 12BYDUREON ....................................................... 26BYETTA .............................................................. 26BYSTOLIC .......................................................... 19Ccabergoline .......................................................... 29calcipotriene ........................................................ 22calcitonin-salmon ................................................ 29calcitriol ............................................................... 29calcium acetate .................................................... 40camila .................................................................. 34CAMPATH ............................................................ 7CAMPRAL .......................................................... 24CANASA ............................................................. 30candesartan cilexetil ............................................ 19candesartan cilexetil/hydrochlorothiazide .......... 19CAPASTAT SULFATE ........................................ 4CAPEX ................................................................ 24CAPRELSA ........................................................... 7captopril ............................................................... 19captopril/hydrochlorothiazide ............................. 19CARAC................................................................ 22carafate ................................................................ 31CARBAGLU ....................................................... 25carbamazepine ..................................................... 10carbamazepine er ................................................. 10CARBATROL ..................................................... 10carbidopa/levodopa ............................................. 11carbidopa/levodopa er ......................................... 11carbidopa/levodopa odt ....................................... 11carbinoxamine maleate ........................................ 37carboplatin ............................................................. 7CARMOL-HC ..................................................... 22carteolol hcl ......................................................... 36cartia xt ................................................................ 19carvedilol ............................................................. 19CAYSTON ............................................................ 4CEENU .................................................................. 7cefaclor .................................................................. 444

cefadroxil ............................................................... 4cefazolin sodium .................................................... 4cefdinir ................................................................... 4cefepime ................................................................. 4cefotaxime sodium ................................................. 4cefoxitin sodium ..................................................... 4cefpodoxime proxetil .............................................. 4ceftazidime ............................................................. 4ceftriaxone sodium ................................................. 4cefuroxime axetil .................................................... 4cefuroxime sodium ................................................. 4CELEBREX ......................................................... 14CELLCEPT ............................................................ 7CELLCEPT INTRAVENOUS .............................. 7CELONTIN ......................................................... 10cephalexin .............................................................. 4CEREZYME ........................................................ 29CERVARIX ......................................................... 32cetirizine hcl ......................................................... 37cevimeline hcl ...................................................... 25CHANTIX ........................................................... 25CHANTIX STARTING MONTH PAK .............. 25CHEMET ............................................................. 25chlordiazepoxide/amitriptyline ............................ 15chlorhexidine gluconate oral rinse ...................... 25chloroquine phosphate ........................................... 4chlorothiazide ...................................................... 19chlorothiazide sodium .......................................... 19chlorpromazine hcl .............................................. 15chlorthalidone ...................................................... 19cholestyramine light ............................................. 21CIALIS ................................................................ 40ciclopirox ............................................................. 23ciclopirox nail lacquer ......................................... 23ciclopirox olamine ............................................... 23CIDOFOVIR.......................................................... 1cilostazol .............................................................. 21CILOXAN ........................................................... 35CIMZIA ............................................................... 30CINRYZE ............................................................ 37CIPRO HC ........................................................... 26CIPRO I.V.-IN D5W ............................................. 6CIPRODEX ......................................................... 26ciprofloxacin .......................................................... 6ciprofloxacin hcl .............................................. 6, 35ciprofloxacin i.v.-in d5w ........................................ 6cisplatin .................................................................. 7citalopram hydrobromide .................................... 15cladribine ............................................................... 7claravis ................................................................ 23clarithromycin ........................................................ 4clarithromycin er ................................................... 4clemastine fumarate ............................................. 37CLEOCIN ............................................................ 34CLEOCIN IN D5W ............................................... 4CLEOCIN PEDIATRIC GRANULES .................. 4CLIMARA PRO .................................................. 34clindamycin hcl ...................................................... 4clindamycin palmitate hcl ...................................... 4clindamycin phosphate .................................. 23, 34clindamycin phosphate add-vantage ..................... 5clindamycin phosphate in d5w............................... 5clindamycin/benzoyl peroxide ............................. 23CLINIMIX 2.75%/DEXTROSE 5% ................... 40CLINIMIX 4.25%/DEXTROSE 10% ................. 40CLINIMIX 4.25%/DEXTROSE 20% ................. 40CLINIMIX 4.25%/DEXTROSE 25% ................. 40CLINIMIX 4.25%/DEXTROSE 5% ................... 25CLINIMIX 5%/DEXTROSE 15% ...................... 40CLINIMIX 5%/DEXTROSE 20% ...................... 40CLINIMIX 5%/DEXTROSE 25% ...................... 40CLINISOL SF 15% ............................................. 40clobetasol propionate .......................................... 24clobetasol propionate e ........................................ 24CLOLAR ............................................................... 7clomipramine hcl ................................................. 15clonazepam .......................................................... 10clonazepam odt .................................................... 10clonidine hcl ......................................................... 19clopidogrel ........................................................... 21clorazepate dipotassium ...................................... 15clotrimazole ..................................................... 1, 23clotrimazole/betamethasone dipropionate ........... 23clozapine .............................................................. 15COARTEM ............................................................ 5codeine sulfate ..................................................... 1245

COLCRYS ........................................................... 33colestipol hcl ........................................................ 21colistimethate sodium ............................................ 5COLY-MYCIN S................................................. 26COMBIGAN........................................................ 36COMBIPATCH ................................................... 34COMBIVENT ...................................................... 37COMBIVENT RESPIMAT ................................. 37COMETRIQ .......................................................... 7COMPLERA.......................................................... 1compro ................................................................. 30COMTAN ............................................................ 11COMVAX............................................................ 32CONDYLOX ....................................................... 22constulose ............................................................ 30COPAXONE........................................................ 11CORDRAN TAPE ............................................... 24COREG CR ......................................................... 19CORTIFOAM ...................................................... 30cortisone acetate .................................................. 26CORTISPORIN-TC ............................................. 26COSMEGEN ......................................................... 7CREON ................................................................ 30CRESTOR ........................................................... 22CRINONE ............................................................ 34CRIXIVAN ............................................................ 1cromolyn sodium ...................................... 30, 36, 37cryselle-28 ............................................................ 34CUBICIN ............................................................... 5cyclafem 1/35 ....................................................... 34cyclafem 7/7/7 ...................................................... 34cyclobenzaprine hcl ............................................. 12cyclophosphamide .................................................. 7cyclosporine ........................................................... 7cyclosporine modified ............................................ 7CYKLOKAPRON ............................................... 21CYMBALTA ....................................................... 15CYSTADANE ..................................................... 30CYSTAGON........................................................ 40CYSTARAN ........................................................ 36cytarabine .............................................................. 7cytarabine aqueous ................................................ 7Ddacarbazine ............................................................ 7DACOGEN ............................................................ 7DALIRESP .......................................................... 38danazol ................................................................. 29dantrolene sodium ............................................... 12DAPSONE ............................................................. 5DAPTACEL ........................................................ 32DARAPRIM .......................................................... 5daunorubicin hcl .................................................... 7DECAVAC .......................................................... 32decitabine ............................................................... 7DELESTROGEN ................................................. 34DELZICOL .......................................................... 30demeclocycline hcl ................................................. 6DEMSER ............................................................. 19DENAVIR ........................................................... 23DEPEN TITRATABS ......................................... 33DEPO-MEDROL ................................................. 26DEPO-PROVERA 400MG/ML .......................... 34DEPO-SUBQ PROVERA 104 ............................ 34DERMA-SMOOTHE/FS BODY OIL ................. 24DERMOTIC ........................................................ 25desipramine hcl .................................................... 15desloratadine ....................................................... 37desloratadine odt ................................................. 37desmopressin acetate ........................................... 29desonide ............................................................... 24desoximetasone .................................................... 24DETROL LA ....................................................... 39dexamethasone ..................................................... 26dexamethasone intensol ....................................... 26dexamethasone sodium phosphate ................. 26, 36DEXILANT ......................................................... 31dexrazoxane ........................................................... 6dextroamphetamine sulfate .................................. 15dextroamphetamine sulfate er .............................. 15dextrose 10%/nacl 0.45% .................................... 25dextrose 10% flex container ................................ 25dextrose 10%/nacl 0.2% ...................................... 25dextrose 2.5%/sodium chloride 0.45% ................ 25dextrose 5% ......................................................... 25dextrose 5%/lactated ringers ............................... 2546

dextrose 5%/nacl 0.2% ........................................ 25dextrose 5%/nacl 0.225% .................................... 25dextrose 5%/nacl 0.33% ...................................... 25dextrose 5%/nacl 0.45% ...................................... 25dextrose 5%/nacl 0.9% ........................................ 25dextrose 5%/potassium chloride 0.15% .............. 40diazepam ........................................................ 10, 15diazepam intensol ................................................ 15DIBENZYLINE ................................................... 19diclofenac potassium ........................................... 14diclofenac sodium ................................................ 36diclofenac sodium dr ............................................ 14diclofenac sodium er ............................................ 14diclofenac sodium/misoprostol ............................ 14dicloxacillin sodium ............................................... 6dicyclomine hcl .................................................... 29didanosine .............................................................. 1DIFFERIN ........................................................... 23DIFICID ................................................................. 4diflorasone diacetate ........................................... 24diflunisal .............................................................. 14digoxin ................................................................. 21dihydroergotamine mesylate ................................ 11DILANTIN .......................................................... 10DILANTIN INFATABS ...................................... 10DILAUDID .......................................................... 12DILAUDID-5 ...................................................... 12DILAUDID-HP ................................................... 12dilt-cd ................................................................... 19diltiazem cd .......................................................... 19diltiazem hcl ......................................................... 19diltiazem hcl er .................................................... 19dilt-xr ................................................................... 19DIOVAN .............................................................. 19DIOVAN HCT ..................................................... 19DIPENTUM ......................................................... 30disopyramide phosphate ...................................... 18disulfiram ............................................................. 25divalproex sodium ................................................ 10divalproex sodium dr ........................................... 10divalproex sodium er ........................................... 10DIVIGEL ............................................................. 34DOCEFREZ ........................................................... 7docetaxel ................................................................ 7donepezil hcl ........................................................ 11dorzolamide hcl ................................................... 36dorzolamide hcl/timolol maleate ......................... 36doxazosin mesylate .............................................. 19doxepin hcl ........................................................... 15DOXIL ................................................................... 7doxorubicin hcl ...................................................... 7doxycycline hyclate ................................................ 6doxycycline hyclate dr ........................................... 6doxycycline monohydrate ...................................... 6dronabinol............................................................ 30drospirenone/ethinyl estradiol ............................. 34DROXIA ................................................................ 7DUETACT ........................................................... 26DULERA ............................................................. 38duramorph ........................................................... 12DUREZOL ........................................................... 36Ee.e.s. 400 ................................................................ 4E.E.S. GRANULES ............................................... 4econazole nitrate .................................................. 23EDECRIN ............................................................ 19EDURANT ............................................................ 1EFFIENT ............................................................. 21ELIDEL ............................................................... 22eliphos .................................................................. 40ELIQUIS .............................................................. 21ELITEK ................................................................. 6ELIXOPHYLLIN ................................................ 38ELLA ................................................................... 34ELLENCE .............................................................. 7ELMIRON ........................................................... 40ELOXATIN ........................................................... 7ELSPAR ................................................................ 7EMCYT ................................................................. 7EMEND ............................................................... 30emoquette ............................................................. 34EMSAM ............................................................... 15EMTRIVA ............................................................. 1ENABLEX ........................................................... 39enalapril maleate ................................................. 1947

enalapril maleate/hydrochlorothiazide ............... 19ENBREL .............................................................. 33endocet ................................................................. 12ENGERIX-B ........................................................ 32enoxaparin sodium ............................................... 21enpresse-28 .......................................................... 35entacapone ........................................................... 11ENTOCORT EC .................................................. 30enulose ................................................................. 30epinastine hcl ....................................................... 36epinephrine hcl .................................................... 37EPIPEN 2-PAK ................................................... 37EPIPEN-JR 2-PAK .............................................. 37epirubicin hcl ......................................................... 7epitol .................................................................... 10EPIVIR .................................................................. 1EPIVIR HBV ......................................................... 1eplerenone ............................................................ 19EPOGEN .............................................................. 32eprosartan mesylate ............................................. 19EPZICOM .............................................................. 1ERAXIS ................................................................. 1ERBITUX .............................................................. 7ERIVEDGE ........................................................... 7errin ..................................................................... 34ery ........................................................................ 23ERY-TAB .............................................................. 4ERYTHROCIN LACTOBIONATE ...................... 4erythrocin stearate ................................................. 4erythromycin .................................................. 23, 35erythromycin base .................................................. 4erythromycin ethylsuccinate .................................. 4erythromycin/benzoyl peroxide ............................ 23escitalopram oxalate ............................................ 15ESTRACE............................................................ 34estradiol ............................................................... 34estradiol valerate ................................................. 34estradiol/norethindrone acetate........................... 34ESTRASORB ...................................................... 34ESTRING ............................................................ 34estropipate ........................................................... 34ethambutol hcl ....................................................... 5ethosuximide ........................................................ 10etidronate disodium ............................................. 25etodolac ................................................................ 14etodolac er ........................................................... 14ETOPOPHOS ........................................................ 7etoposide ................................................................ 7EURAX ................................................................ 24EVISTA ............................................................... 33EVOXAC ............................................................. 25EXALGO ............................................................. 12EXELON ............................................................. 11exemestane ............................................................. 7EXFORGE ........................................................... 19EXFORGE HCT .................................................. 19EXJADE .............................................................. 25FFABRAZYME ..................................................... 29famciclovir ............................................................. 1famotidine ............................................................ 31famotidine premixed ............................................ 31FANAPT .............................................................. 15FANAPT TITRATION PACK ............................ 15FARESTON ........................................................... 8FASLODEX .......................................................... 8FAZACLO ........................................................... 15felbamate .............................................................. 10FELBATOL ......................................................... 10felodipine er ......................................................... 20fenofibrate ............................................................ 22fenofibrate micronized ......................................... 22fenofibric acid dr ................................................. 22fenoprofen calcium .............................................. 14fentanyl citrate oral transmucosal ....................... 12fentanyl patches ................................................... 12FINACEA ............................................................ 23finasteride ............................................................ 39FIRAZYR ............................................................ 38FIRMAGON .......................................................... 8flavoxate hcl ......................................................... 39flecainide acetate ................................................. 18FLECTOR............................................................ 14FLOVENT DISKUS ............................................ 38FLOVENT HFA .................................................. 3848

fluconazole ............................................................. 1fluconazole in dextrose .......................................... 1flucytosine .............................................................. 1fludarabine phosphate ........................................... 8fludrocortisone acetate ........................................ 26flunisolide ............................................................ 38fluocinolone acetonide ................................... 24, 25fluocinolone acetonide body ................................ 24fluocinonide ......................................................... 24fluocinonide-e ...................................................... 24FLUOROPLEX ................................................... 22fluorouracil ...................................................... 8, 22fluoxetine dr ......................................................... 15fluoxetine hcl .................................................. 15, 16fluphenazine decanoate ....................................... 16fluphenazine hcl ................................................... 16flurbiprofen .......................................................... 14flurbiprofen sodium ............................................. 36flutamide ................................................................ 8fluticasone propionate ................................... 24, 38fluvastatin ............................................................ 22fluvoxamine maleate ............................................ 16fluvoxamine maleate er ........................................ 16FML ..................................................................... 36FML FORTE ....................................................... 36FOCALIN XR ..................................................... 16fondaparinux sodium ........................................... 21FORADIL AEROLIZER ..................................... 38FORFIVO XL ...................................................... 16FORTAZ ................................................................ 4FORTEO .............................................................. 33FORTESTA ......................................................... 29fortical .................................................................. 29FOSAMAX PLUS D ........................................... 33foscarnet sodium .................................................... 1fosinopril sodium ................................................. 20fosinopril sodium/hydrochlorothiazide ................ 20fosphenytoin sodium ............................................ 10FOSRENOL ......................................................... 25FRAGMIN ........................................................... 21FREAMINE III .................................................... 41furosemide ............................................................ 20FUSILEV ............................................................... 7FUZEON ................................................................ 1Ggabapentin ........................................................... 10GABITRIL ........................................................... 10galantamine hydrobromide ............................ 11, 12ganciclovir ............................................................. 1GARDASIL ......................................................... 32GASTROCROM.................................................. 30GAUZE PADS 2.................................................. 26gavilyte-c .............................................................. 30gavilyte-g ............................................................. 30gavilyte-n/flavor pack .......................................... 30GELNIQUE ......................................................... 39gemcitabine hcl ...................................................... 8gemfibrozil ........................................................... 22generlac ............................................................... 30gengraf ................................................................... 8gentak ................................................................... 35gentamicin sulfate ...................................... 5, 23, 35gentamicin sulfate/0.9% sodium chloride .............. 5GEODON ............................................................ 16gianvi ................................................................... 35gildagia ................................................................ 35GILENYA ............................................................ 12GILOTRIF ............................................................. 8GLEEVEC ............................................................. 8glimepiride ........................................................... 26glipizide ................................................................ 27glipizide er ........................................................... 27glipizide/metformin hcl ........................................ 27GLUCAGEN HYPOKIT ..................................... 27GLUCAGON EMERGENCY KIT ..................... 27glyburide .............................................................. 27glyburide micronized ........................................... 27glyburide/metformin hcl ....................................... 27glycopyrrolate ...................................................... 29granisetron hcl ..................................................... 30griseofulvin microsize ............................................ 1griseofulvin ultramicrosize .................................... 1GRIS-PEG ............................................................. 1guanfacine hcl ...................................................... 20GYNAZOLE-1 .................................................... 3449

HHALAVEN ............................................................ 8HALDOL ............................................................. 16HALDOL DECANOATE 100 ............................ 16HALDOL DECANOATE 50 .............................. 16HALFLYTELY BOWEL PREP/FLAVORPACKS ................................................................ 30halobetasol propionate ........................................ 24haloperidol ........................................................... 16haloperidol decanoate ......................................... 16haloperidol lactate ............................................... 16HAVRIX ........................................................ 32, 33heparin sodium .................................................... 21heparin sodium/d5w............................................. 21heparin sodium/nacl 0.45% ................................. 21heparin sodium/sodium chloride 0.9% premix .... 21HEPATAMINE ................................................... 41HEPATASOL ...................................................... 41HEPSERA.............................................................. 1HERCEPTIN ......................................................... 8HEXALEN ............................................................ 8HUMALOG ......................................................... 27HUMALOG KWIKPEN ..................................... 27HUMALOG MIX 50/50 ...................................... 27HUMALOG MIX 50/50 KWIKPEN ................... 27HUMALOG MIX 75/25 ...................................... 27HUMALOG MIX 75/25 KWIKPEN ................... 27HUMIRA ............................................................. 33HUMIRA PEN-CROHNS DISEASESTARTER33HUMULIN 70/30 ................................................ 27HUMULIN 70/30 PEN ........................................ 27HUMULIN N ....................................................... 27HUMULIN N U-100 PEN ................................... 27HUMULIN R ....................................................... 27HUMULIN R U-500 (CONCENTRATED) ........ 27hydralazine hcl ..................................................... 20hydrochlorothiazide ............................................. 20hydrocodone bitartrate/acetaminophen ......... 12, 13hydrocodone/acetaminophen ............................... 13hydrocodone/ibuprofen ........................................ 13hydrocortisone ......................................... 24, 26, 30hydrocortisone butyrate ....................................... 24hydrocortisone valerate ....................................... 24hydrocortisone/acetic acid ................................... 26hydromorphone hcl .............................................. 13hydroxychloroquine sulfate ................................... 5hydroxyurea ........................................................... 8hydroxyzine hcl .................................................... 37Iibandronate sodium ............................................. 33ibuprofen .............................................................. 14ICLUSIG ................................................................ 8idarubicin hcl ......................................................... 8IFEX ...................................................................... 8ifosfamide ............................................................... 8ILEVRO ............................................................... 36imipenem/cilastatin ................................................ 5imipramine hcl ..................................................... 16imipramine pamoate ............................................ 16imiquimod ............................................................ 23IMOVAX RABIES (H.D.C.V.) ........................... 33INCIVEK ............................................................... 1INCRELEX .......................................................... 25indapamide .......................................................... 20indomethacin ........................................................ 14indomethacin er ................................................... 14INFANRIX .......................................................... 33INLYTA ................................................................ 8INSULIN PEN NEEDLE .................................... 27INSULIN SYRINGE (DISP) U-100 0.3 ML ...... 27INSULIN SYRINGE (DISP) U-100 1 ML ......... 27INSULIN SYRINGE (DISP) U-100 1/2 ML ...... 27INTELENCE ..................................................... 1, 2INTRALIPID ....................................................... 41INTRON-A .......................................................... 32INTRON-A W/DILUENT ................................... 32introvale ............................................................... 35INTUNIV ............................................................. 16INVEGA .............................................................. 16INVEGA SUSTENNA ........................................ 16INVIRASE ............................................................. 2INVOKANA ........................................................ 27IONOSOL-B/DEXTROSE 5% ........................... 41IONOSOL-MB/DEXTROSE 5% ........................ 41IOPIDINE ............................................................ 3750

IPOL INACTIVATED IPV ................................. 33ipratropium bromide ...................................... 25, 38ipratropium bromide/albuterol sulfate ................ 38irbesartan ............................................................. 20irbesartan/hydrochlorothiazide ........................... 20irinotecan ............................................................... 8ISENTRESS .......................................................... 2ISOLYTE-H/DEXTROSE 5% ............................ 41ISOLYTE-P/DEXTROSE 5% ............................. 41ISOLYTE-S ......................................................... 41ISOLYTE-S/DEXTROSE 5% ............................. 41isoniazid ................................................................. 5isosorbide dinitrate .............................................. 22isosorbide dinitrate er.......................................... 22isosorbide mononitrate ........................................ 22isosorbide mononitrate er .................................... 22isotonic gentamicin ................................................ 5isradipine ............................................................. 20ISTALOL ............................................................. 36ISTODAX .............................................................. 8itraconazole ........................................................... 1IXEMPRA KIT ...................................................... 8IXIARO ............................................................... 33JJAKAFI.................................................................. 8JALYN ................................................................. 39jantoven ................................................................ 21JANUMET ........................................................... 27JANUMET XR .................................................... 27JANUVIA ............................................................ 28JENTADUETO .................................................... 28JEVTANA ............................................................. 8jinteli .................................................................... 34jolivette ................................................................ 34junel 1.5/30 .......................................................... 35junel 1/20 ............................................................. 35junel fe 1.5/30 ...................................................... 35junel fe 1/20 ......................................................... 35JUVISYNC .......................................................... 28JUXTAPID .......................................................... 22KKADCYLA ............................................................ 8KALETRA ............................................................. 2KALYDECO ....................................................... 38kariva ................................................................... 35kcl 0.075%/d5w/nacl 0.45% ................................ 40kcl 0.15%/d5w/lr .................................................. 40kcl 0.15%/d5w/nacl 0.2% .................................... 40kcl 0.15%/d5w/nacl 0.225% ................................ 40kcl 0.15%/d5w/nacl 0.9% .................................... 40kcl 0.3%/d5w/nacl 0.45% .................................... 40kcl 0.3%/d5w/nacl 0.9% ...................................... 40kelnor 1/35 ........................................................... 35KETEK .................................................................. 5ketoconazole .................................................... 1, 23ketodan kit ............................................................ 23ketoprofen ............................................................ 14ketoprofen er ........................................................ 14ketorolac tromethamine ....................................... 36kionex ................................................................... 25klor-con 10 ........................................................... 40klor-con 8 ............................................................. 40KLOR-CON M15 ................................................ 40klor-con m20 ........................................................ 40KOMBIGLYZE XR ............................................ 28K-TABS ............................................................... 40KUVAN ............................................................... 29Llabetalol hcl ......................................................... 20laclotion ............................................................... 23LACRISERT........................................................ 36lactated ringers viaflex ........................................ 40lactulose ............................................................... 30LAMICTAL ODT ............................................... 10LAMICTAL STARTER/NOT TAKINGCARBAMAZEPINE ........................................... 10LAMICTAL STARTER/TAKINGCARBAMAZEPINE/NOT TAKINGVALPROATE ...................................................... 10LAMICTAL STARTER/TAKING VALPROATE............................................................................. 10LAMICTAL XR .................................................. 10lamivudine .............................................................. 2lamivudine/zidovudine ........................................... 251

lamotrigine ........................................................... 10lamotrigine er ...................................................... 10LANOXIN ........................................................... 21LANOXIN PEDIATRIC ..................................... 21lansoprazole ......................................................... 31LANTUS .............................................................. 28LANTUS SOLOSTAR ........................................ 28LASTACAFT ...................................................... 36latanoprost ........................................................... 36LATUDA ............................................................. 16LAZANDA .......................................................... 13leena ..................................................................... 35leflunomide .......................................................... 33lessina .................................................................. 35LETAIRIS ............................................................ 38letrozole ................................................................. 8leucovorin calcium ................................................. 7LEUKERAN .......................................................... 8LEUKINE ............................................................ 32leuprolide acetate .................................................. 8levalbuterol .......................................................... 38levalbuterol hcl .................................................... 38LEVEMIR ............................................................ 28LEVEMIR FLEXPEN ......................................... 28levetiracetam ........................................................ 10levetiracetam er ................................................... 10levobunolol hcl ..................................................... 36levocarnitine ........................................................ 25levocetirizine dihydrochloride ............................. 37levofloxacin ...................................................... 6, 35levofloxacin in d5w ................................................ 6levonest ................................................................ 35levonorgestrel/ethinyl estradiol ........................... 35levora 0.15/30-28 ................................................. 35levorphanol tartrate ............................................. 13levothyroxine sodium ........................................... 29levoxyl .................................................................. 29LEXIVA ................................................................ 2LIALDA .............................................................. 30lidocaine .............................................................. 23lidocaine hcl ......................................................... 23lidocaine hcl jelly ................................................. 23lidocaine viscous .................................................. 23lidocaine/prilocaine ............................................. 23LIDODERM ........................................................ 23lindane ................................................................. 24LINZESS ............................................................. 30LIORESAL INTRATHECAL ............................. 12liothyronine sodium ............................................. 29LIPOFEN ............................................................. 22liposyn iii ............................................................. 41lisinopril ............................................................... 20lisinopril/hydrochlorothiazide ............................. 20lithium carbonate ................................................. 16lithium carbonate er ............................................ 16lithium citrate ....................................................... 16LOCOID .............................................................. 24LODOSYN .......................................................... 11loperamide hcl ..................................................... 29lorazepam ............................................................ 16lorazepam intensol ............................................... 16loryna ................................................................... 35losartan potassium ............................................... 20losartan potassium/hydrochlorothiazide ............. 20LOTEMAX .......................................................... 36LOTRONEX ........................................................ 30lovastatin .............................................................. 22LOVAZA ............................................................. 22LOVENOX .......................................................... 21low-ogestrel ......................................................... 35loxapine succinate ............................................... 16LUMIGAN .......................................................... 36LUNESTA ........................................................... 16LUPRON DEPOT ................................................. 8LUPRON DEPOT-PED......................................... 8lutera .................................................................... 35LUXIQ ................................................................. 24LYRICA .............................................................. 10LYSODREN .......................................................... 8LYSTEDA ........................................................... 34lyza ....................................................................... 34MMACRODANTIN ................................................. 6mafenide acetate .................................................. 23magnesium sulfate ............................................... 4052

MALARONE ......................................................... 5malathion ............................................................. 24maprotiline hcl ..................................................... 16marlissa................................................................ 35MARPLAN .......................................................... 16MATULANE ......................................................... 8matzim la .............................................................. 20meclizine hcl ........................................................ 30meclofenamate sodium ......................................... 14medroxyprogesterone acetate .............................. 34mefenamic acid .................................................... 14mefloquine hcl ........................................................ 5MEGACE ES ......................................................... 8megestrol acetate ................................................... 8MEKINIST ............................................................ 8meloxicam ............................................................ 14melphalan hydrochloride ....................................... 8MENACTRA ....................................................... 33MENEST ............................................................. 34MENOMUNE-A/C/Y/W-135 .............................. 33MENVEO ............................................................ 33MEPRON ............................................................... 5mercaptopurine ...................................................... 8meropenem ............................................................. 5mesna ..................................................................... 7MESNEX ............................................................... 7MESTINON ......................................................... 12MESTINON TIMESPAN .................................... 12METADATE CD ................................................. 16metaproterenol sulfate ......................................... 38metformin hcl ....................................................... 28metformin hcl er ................................................... 28methadone hcl ...................................................... 13methadose ............................................................ 13methazolamide ..................................................... 36methenamine hippurate ......................................... 6METHERGINE ................................................... 35methimazole ......................................................... 26methotrexate .......................................................... 8methotrexate sodium .............................................. 8methyclothiazide .................................................. 20methylergonovine maleate ................................... 35methylphenidate hcl ............................................. 16methylphenidate hcl cd ........................................ 16methylphenidate hcl er ......................................... 16methylphenidate hydrochloride ........................... 16methylprednisolone .............................................. 26methylprednisolone acetate ................................. 26methylprednisolone dose pack ............................. 26methylprednisolone sodiumsuccinate .................. 26metipranolol ......................................................... 36metoclopramide hcl ............................................. 30metolazone ........................................................... 20metoprolol succinate er ....................................... 20metoprolol tartrate ............................................... 20metoprolol/hydrochlorothiazide .......................... 20METROGEL ........................................................ 23metronidazole .................................................. 5, 23metronidazole in nacl 0.79% ................................. 5metronidazole vaginal ......................................... 34mexiletine hcl ....................................................... 18MICARDIS .......................................................... 20MICARDIS HCT ................................................. 20miconazole 3 ........................................................ 34microgestin 1.5/30 ............................................... 35microgestin 1/20 .................................................. 35microgestin fe ....................................................... 35microgestin fe 1.5/30 ........................................... 35midodrine hcl ....................................................... 25migergot ............................................................... 11MIGRANAL ........................................................ 11minocycline hcl ...................................................... 6minocycline hcl er .................................................. 6minoxidil .............................................................. 20MIRAPEX ER ..................................................... 11mirtazapine .......................................................... 17mirtazapine odt .................................................... 17misoprostol .......................................................... 31mitomycin ............................................................... 8mitoxantrone hcl .................................................... 8M-M-R II W/DILUENT 10 DOSE ...................... 33modafinil .............................................................. 17moexipril hcl ........................................................ 20moexipril/hydrochlorothiazide ............................ 20mometasone furoate ............................................. 24mononessa ............................................................ 3553

montelukast sodium ............................................. 38morphine sulfate .................................................. 13morphine sulfate er .............................................. 13MOVIPREP ......................................................... 30MOXEZA ............................................................ 35MOZOBIL ........................................................... 32MULTAQ ............................................................ 18mupirocin ............................................................. 23MUSTARGEN ...................................................... 8MYCOBUTIN ....................................................... 5mycophenolate mofetil ........................................... 8MYFORTIC ........................................................... 8myorisan .............................................................. 23MYRBETRIQ ...................................................... 39MYTELASE ........................................................ 12Nnabumetone .......................................................... 14nadolol ................................................................. 20nadolol/bendroflumethiazide ............................... 20nafcillin sodium ..................................................... 6NAFTIN ............................................................... 23NAGLAZYME .................................................... 29nallpen/dextrose ..................................................... 6naloxone hcl ......................................................... 14naltrexone hcl ...................................................... 14NAMENDA ......................................................... 12NAMENDA TITRATION PAK .......................... 12NAMENDA XR .................................................. 12NAMENDA XR TITRATION PACK ................ 12naphazoline hcl .................................................... 37naproxen .............................................................. 14naproxen dr .......................................................... 14naproxen sodium .................................................. 14naratriptan hcl ..................................................... 11NASONEX .......................................................... 38NATACYN .......................................................... 35nateglinide ........................................................... 28NEBUPENT .......................................................... 5necon 0.5/35-28 ................................................... 35necon 1/35 ............................................................ 35necon 10/11-28 .................................................... 35necon 7/7/7 ........................................................... 35NEEDLES, INSULIN DISP., SAFETY .............. 28nefazodone hcl ..................................................... 17neomycin sulfate .................................................... 5neomycin/bacitracin/polymyxin ........................... 35neomycin/polymyxin/bacitracin/hydrocortisone .. 36neomycin/polymyxin/dexamethasone ................... 36neomycin/polymyxin/gramicidin .......................... 35neomycin/polymyxin/hc ........................................ 26neomycin/polymyxin/hydrocortisone ............. 26, 36NEORAL ............................................................... 8NEPHRAMINE ................................................... 41NEULASTA ........................................................ 32NEUMEGA ......................................................... 32NEUPOGEN ........................................................ 32NEVANAC .......................................................... 36nevirapine .............................................................. 2NEXAVAR ............................................................ 8NEXIUM ............................................................. 31NEXIUM I.V. ...................................................... 31NIASPAN ............................................................ 22nicardipine hcl ..................................................... 20NICOTROL INHALER ....................................... 25NICOTROL NS ................................................... 25nifediac cc ............................................................ 20nifedical xl ........................................................... 20nifedipine ............................................................. 20nifedipine er ......................................................... 20NILANDRON ........................................................ 8nimodipine ........................................................... 20NIPENT ................................................................. 8nisoldipine ............................................................ 20nisoldipine er ....................................................... 20nitro-bid ............................................................... 22NITRO-DUR ....................................................... 22nitrofurantoin macrocrystalline............................. 6nitrofurantoin monohydrate ................................... 6nitrofurantoin susp................................................. 6nitroglycerin ........................................................ 22nitroglycerin transdermal .................................... 22NITROLINGUAL PUMPSPRAY....................... 22NITROSTAT ....................................................... 22nizatidine .............................................................. 31nora-be ................................................................. 3454

NORDITROPIN FLEXPRO ............................... 32NORDITROPIN NORDIFLEX PEN .................. 32norethindrone ...................................................... 34norethindrone acetate .......................................... 34NORMOSOL-R ................................................... 41NORMOSOL-R IN D5W .................................... 40NOROXIN ............................................................. 6NORPACE CR .................................................... 18nortrel 0.5/35 (28) ............................................... 35nortrel 1/35 .......................................................... 35nortrel 7/7/7 ......................................................... 35nortriptyline hcl ................................................... 17NORVIR ................................................................ 2NOVOLOG .......................................................... 28NOVOLOG FLEXPEN ....................................... 28NOVOLOG MIX 70/30 ....................................... 28NOVOLOG MIX 70/30 PREFILLED FLEXPEN............................................................................. 28NOXAFIL .............................................................. 1NUCYNTA .......................................................... 14NUCYNTA ER .................................................... 14NUEDEXTA ........................................................ 12NULOJIX .............................................................. 8NUVARING ........................................................ 34nyamyc ................................................................. 23nystatin ............................................................. 1, 23nystatin/triamcinolone ......................................... 23nystop ................................................................... 23Oocella .................................................................... 35octreotide acetate ................................................... 8ofloxacin .................................................... 6, 26, 35ogestrel ................................................................ 35olanzapine ............................................................ 17olanzapine odt ...................................................... 17olanzapine/fluoxetine ........................................... 17omeprazole ........................................................... 31omeprazole/sodium bicarbonate .......................... 31OMNITROPE ...................................................... 32ondansetron hcl ................................................... 30ondansetron odt ................................................... 30ONFI .................................................................... 10ONGLYZA .......................................................... 28ONSOLIS ............................................................ 13ONTAK ................................................................. 8OPANA ER (CRUSH RESISTANT) .................. 13ORAP ................................................................... 17ORENCIA ............................................................ 34ORFADIN............................................................ 25orsythia ................................................................ 35ORTHO EVRA .................................................... 34oxaliplatin .............................................................. 8oxandrolone ......................................................... 29oxaprozin ............................................................. 14oxcarbazepine ...................................................... 10OXSORALEN ULTRA ....................................... 23oxybutynin chloride ............................................. 39oxybutynin chloride er ......................................... 39oxycodone hcl ...................................................... 13oxycodone/acetaminophen ................................... 13oxycodone/aspirin ................................................ 13OXYCONTIN ...................................................... 13oxymorphone hydrochloride ................................ 13oxymorphone hydrochloride er ............................ 13OXYTROL .......................................................... 39Ppacerone .............................................................. 18paclitaxel ................................................................ 9palgic ................................................................... 37PANDEL .............................................................. 24PANRETIN .......................................................... 23pantoprazole sodium ............................................ 31paromomycin sulfate .............................................. 5paroxetine hcl ...................................................... 17paroxetine hcl er .................................................. 17PASER ................................................................... 5PATADAY .......................................................... 36PATANOL ........................................................... 36PAXIL .................................................................. 17pedi-dri ................................................................ 23PEDVAX HIB ..................................................... 33PEGANONE ........................................................ 10PEGASYS............................................................ 32PEGASYS PROCLICK ....................................... 3255

PEG-INTRON ..................................................... 32PEG-INTRON REDIPEN ................................... 32penicillin g potassium ............................................ 6PENICILLIN G POTASSIUM IN ISO-OSMOTICDEXTROSE .......................................................... 6penicillin g procaine .............................................. 6penicillin g sodium ................................................. 6penicillin v potassium ............................................ 6PENNSAID.......................................................... 14PENTASA ........................................................... 30pentostatin .............................................................. 9pentoxifylline er ................................................... 21PERFOROMIST .................................................. 38perindopril erbumine ........................................... 20periogard ............................................................. 25PERJETA ............................................................... 9permethrin ............................................................ 24perphenazine ........................................................ 17pfizerpen-g ............................................................. 6phenadoz .............................................................. 37phenelzine sulfate ................................................. 17phenobarbital ....................................................... 10phenytoin .............................................................. 10phenytoin sodium ................................................. 10phenytoin sodium extended .................................. 10PHISOHEX.......................................................... 23PHOSLYRA ........................................................ 40pilocarpine hcl ..................................................... 25pilocarpine hydrochloride ................................... 25PILOPINE HS ..................................................... 36pindolol ................................................................ 20pioglitazone hcl .................................................... 28pioglitazone hcl/metformin hcl ............................ 28pioglitazone hcl-glimepiride ................................ 28piperacillin sodium/tazobactam sodium ................ 6pirmella 1/35 ........................................................ 35piroxicam ............................................................. 14PLASMA-LYTE A .............................................. 41PLASMA-LYTE-148 .......................................... 41PLASMA-LYTE-56/D5W .................................. 41podofilox .............................................................. 23polyethylene glycol 3350 ..................................... 30POMALYST .......................................................... 9portia-28 .............................................................. 35potassium chloride ............................................... 40potassium chloride 0.15% /nacl 0.45% viaflex ... 40potassium chloride 0.15% d5w/nacl 0.33% ........ 40potassium chloride 0.15% d5w/nacl 0.45% viaflex............................................................................. 40potassium chloride 0.15% nacl 0.9% .................. 40potassium chloride 0.22% d5w/nacl 0.45% ........ 40potassium chloride 0.224%/dextrose 5% viaflex . 40potassium chloride 0.3%/ nacl 0.9% ................... 40potassium chloride 0.3%/d5w .............................. 40potassium chloride er .......................................... 40potassium citrate .................................................. 40POTIGA ............................................................... 10PRADAXA .......................................................... 21pramipexole dihydrochloride ............................... 11PRANDIN............................................................ 28pravastatin sodium............................................... 22prazosin hcl .......................................................... 20prednicarbate ....................................................... 24prednisolone acetate ............................................ 36prednisolone sodium phosphate .................... 26, 37prednisone ............................................................ 26prednisone intensol .............................................. 26PREFEST ............................................................. 34PREMARIN ......................................................... 34PREMASOL ........................................................ 41PREMPHASE ...................................................... 34PREMPRO ........................................................... 34prenatabs obn ...................................................... 41prevalite ............................................................... 22previfem ............................................................... 35PREVPAC ........................................................... 31PREZISTA ............................................................. 2PRIMAQUINE PHOSPHATE .............................. 5primidone ............................................................. 10PRIMSOL .............................................................. 6PRISTIQ .............................................................. 17PRIVIGEN ........................................................... 33PROAIR HFA ...................................................... 38probenecid ........................................................... 33probenecid/colchicine .......................................... 33procainamide hcl ................................................. 1856

procentra .............................................................. 17prochlorperazine .................................................. 30prochlorperazine edisylate .................................. 30prochlorperazine maleate .................................... 30PROCRIT ............................................................ 32procto-pak ............................................................ 30proctozone-hc ...................................................... 30progesterone ........................................................ 34PROGLYCEM ..................................................... 28PROGRAF ............................................................. 9PROLASTIN-C ................................................... 25PROLENSA ......................................................... 36PROLEUKIN ....................................................... 32PROLIA ............................................................... 33PROMACTA ....................................................... 21promethazine hcl .................................................. 37promethegan ........................................................ 37propafenone hcl ................................................... 18propafenone hcl er ............................................... 18propantheline bromide ......................................... 29propranolol hcl .................................................... 20propranolol hcl er ................................................ 20propranolol/hydrochlorothiazide ........................ 20propylthiouracil ................................................... 26PROQUAD .......................................................... 33PROTOPIC .......................................................... 23protriptyline hcl ................................................... 17PROVIGIL ........................................................... 17prudoxin ............................................................... 23PULMICORT ...................................................... 38PULMICORT FLEXHALER .............................. 38PULMOZYME .................................................... 38PYLERA .............................................................. 31pyrazinamide .......................................................... 5pyridostigmine bromide ....................................... 12QQUALAQUIN ....................................................... 5quasense ............................................................... 35quetiapine fumarate ............................................. 17quinapril hcl ......................................................... 20quinapril/hydrochlorothiazide ............................. 21quinidine gluconate cr ......................................... 18quinidine sulfate ................................................... 18quinidine sulfate er .............................................. 18quinine sulfate ........................................................ 5QVAR .................................................................. 38RRABAVERT ........................................................ 33ramipril ................................................................ 21RANEXA ............................................................. 22ranitidine hcl ........................................................ 31RAPAFLO ........................................................... 39RAPAMUNE ......................................................... 9RAVICTI ............................................................. 25REBETOL ............................................................. 2REBIF .................................................................. 32REBIF TITRATION PACK ................................ 32RECLAST............................................................ 25reclipsen ............................................................... 35RECOMBIVAX HB ............................................ 33RECTIV ............................................................... 30regonol ................................................................. 12REGRANEX ........................................................ 23RELENZA DISKHALER ..................................... 2RELISTOR .......................................................... 30RELPAX .............................................................. 11REMICADE ........................................................ 31REMODULIN ..................................................... 21RENVELA ........................................................... 25repaglinide ........................................................... 28reprexain .............................................................. 13RESCRIPTOR ....................................................... 2reserpine .............................................................. 21RESTASIS ........................................................... 36RETROVIR IV INFUSION .................................. 2REVATIO ............................................................ 38REVLIMID ............................................................ 9REYATAZ ............................................................. 2RHEUMATREX .................................................... 9RHINOCORT AQUA ......................................... 38ribapak ................................................................... 2ribasphere .............................................................. 2ribavirin ................................................................. 3RIDAURA ........................................................... 3457

ifampin.................................................................. 5RILUTEK ............................................................ 25riluzole ................................................................. 25rimantadine hcl ...................................................... 3ringers injection ................................................... 40RISPERDAL CONSTA....................................... 17risperidone ........................................................... 17risperidone odt ..................................................... 17RITALIN LA ....................................................... 17RITUXAN ............................................................. 9rivastigmine tartrate ............................................ 12rizatriptan benzoate ............................................. 11rizatriptan benzoate odt ....................................... 11ropinirole er ......................................................... 11ropinirole hcl ....................................................... 11ROTATEQ ........................................................... 33ROXICET ............................................................ 14SSABRIL ............................................................... 10SAMSCA ............................................................. 29SANCTURA XR ................................................. 39SANCUSO ........................................................... 31SANDIMMUNE .................................................... 9SANDOSTATIN LAR DEPOT ............................ 9SANTYL .............................................................. 24SAPHRIS ............................................................. 17SAVELLA ........................................................... 34SAVELLA TITRATION PACK ......................... 34selegiline hcl ........................................................ 11selenium sulfide ................................................... 22SELZENTRY ........................................................ 3SENSIPAR .......................................................... 29SEREVENT DISKUS ......................................... 38SEROMYCIN ........................................................ 5SEROQUEL XR .................................................. 17sertraline hcl ........................................................ 17SIGNIFOR ............................................................. 9sildenafil citrate ................................................... 38SILENOR ............................................................ 17silver sulfadiazine ................................................ 22SIMBRINZA ....................................................... 36SIMCOR .............................................................. 22SIMPONI ............................................................. 34SIMPONI ARIA .................................................. 34SIMULECT ........................................................... 9simvastatin ........................................................... 22SINGULAIR ........................................................ 38SIRTURO .............................................................. 5SKELID ............................................................... 25SKLICE ............................................................... 24sodium chloride ............................................. 25, 40sodium chloride 0.45% viaflex ............................ 40sodium chloride 0.9% .......................................... 25sodium fluoride .................................................... 41sodium phenylbutyrate ......................................... 25sodium polystyrene sulfonate ............................... 25sodium sulfacetamide ........................................... 37SOLARAZE ........................................................ 23SOLTAMOX ......................................................... 9SOLU-CORTEF .................................................. 26SOLU-MEDROL ................................................. 26SOMATULINE DEPOT ....................................... 9SOMAVERT ....................................................... 29SORIATANE ....................................................... 22sorine ................................................................... 18sotalol hcl ............................................................. 18sotalol hcl (af) ...................................................... 18spinosad ............................................................... 24SPIRIVA HANDIHALER................................... 38spironolactone ..................................................... 21spironolactone/hydrochlorothiazide .................... 21SPORANOX .......................................................... 1sprintec 28 ........................................................... 35SPRYCEL .............................................................. 9sronyx ................................................................... 35ssd ........................................................................ 22stagesic ................................................................ 14STALEVO 100 .................................................... 11STALEVO 125 .................................................... 11STALEVO 150 .................................................... 11STALEVO 200 .................................................... 11STALEVO 50 ...................................................... 11STALEVO 75 ...................................................... 11stavudine ................................................................ 3STIMATE ............................................................ 2958

STIVARGA ........................................................... 9STRATTERA ...................................................... 17STREPTOMYCIN SULFATE .............................. 5STRIBILD ............................................................. 3STROMECTOL ..................................................... 5SUBOXONE........................................................ 14SUCRAID ............................................................ 31sucralfate ............................................................. 31sulfacetamide sodium ..................................... 23, 37sulfacetamide sodium/prednisolone sodiumphosphate ............................................................. 36sulfadiazine ............................................................ 6sulfamethoxazole/trimethoprim ............................. 6sulfamethoxazole/trimethoprim ds ......................... 6SULFAMYLON .................................................. 23sulfasalazine ........................................................ 31sulfazine ec ........................................................... 31sulindac ................................................................ 14sumatriptan succinate .......................................... 11SUPRAX................................................................ 4SUPREP BOWEL PREP ..................................... 31SUSTIVA .............................................................. 3SUTENT ................................................................ 9SYLATRON ........................................................ 32SYMBICORT ...................................................... 38SYMBYAX ......................................................... 17SYMLINPEN 120 ............................................... 29SYMLINPEN 60 ................................................. 29SYNAREL ........................................................... 29SYNRIBO .............................................................. 9SYPRINE ............................................................. 25TTABLOID .............................................................. 9tacrolimus .............................................................. 9TAFINLAR ............................................................ 9TAMIFLU .............................................................. 3tamoxifen citrate .................................................... 9tamsulosin hcl ...................................................... 39TARCEVA ............................................................ 9TARGRETIN ......................................................... 9TASIGNA .............................................................. 9TAXOTERE .......................................................... 9TAZORAC .......................................................... 23taztia xt ................................................................. 21TECFIDERA ....................................................... 12TECFIDERA STARTER PACK ......................... 12TEFLARO ............................................................. 4TEGRETOL-XR .................................................. 10TEKAMLO .......................................................... 21TEKTURNA ........................................................ 21TEKTURNA HCT ............................................... 21temazepam ........................................................... 17terazosin hcl ......................................................... 21terbinafine hcl ........................................................ 1terbutaline sulfate ................................................ 38terconazole ........................................................... 34TESTIM ............................................................... 29testosterone cypionate ......................................... 29testosterone enanthate ......................................... 29tetanus toxoid adsorbed ....................................... 33TETANUS/DIPHTHERIA TOXOIDSADSORBEDADULT ................................................................ 33tetracycline hcl ....................................................... 6THALOMID .......................................................... 9theophylline cr ..................................................... 38theophylline er ..................................................... 38thioridazine hcl .................................................... 17thiotepa .................................................................. 9thiothixene ............................................................ 18THYMOGLOBULIN .......................................... 33tiagabine hydrochloride ....................................... 10ticlopidine hcl ...................................................... 21TIKOSYN ............................................................ 18timolol maleate .............................................. 21, 36timolol maleate ophthalmic gel forming .............. 36TIMOPTIC OCUDOSE....................................... 36tinidazole ................................................................ 5TIVICAY ............................................................... 3tizanidine hcl ........................................................ 12TOBI ...................................................................... 5TOBRADEX ........................................................ 36TOBRADEX ST .................................................. 36tobramycin sulfate ........................................... 5, 35tobramycin sulfate/sodium chloride ...................... 5tobramycin/dexamethasone ................................. 3659

TOBREX ............................................................. 35tolazamide ............................................................ 29tolbutamide .......................................................... 29tolmetin sodium .................................................... 14tolterodine tartrate ............................................... 39topiramate ............................................................ 11toposar ................................................................... 9topotecan hcl .......................................................... 9TORISEL ............................................................... 9torsemide .............................................................. 21TOVIAZ .............................................................. 39TRACLEER ......................................................... 38TRADJENTA ...................................................... 29tramadol hcl ......................................................... 14tramadol hcl er .................................................... 14trandolapril .......................................................... 21tranexamic acid ................................................... 34TRANSDERM-SCOP ......................................... 31tranylcypromine sulfate ....................................... 18travasol ................................................................ 41TRAVATAN Z .................................................... 36travoprost ............................................................. 36trazodone hcl ....................................................... 18TREANDA ............................................................ 9TRECATOR .......................................................... 5TRELSTAR DEPOT MIXJECT ........................... 9TRELSTAR LA MIXJECT ................................... 9TRELSTAR MIXJECT ......................................... 9tretinoin ............................................................ 9, 23triamcinolone acetonide ................................ 24, 38triamcinolone in orabase ..................................... 25triamterene/hydrochlorothiazide ......................... 21TRIBENZOR ....................................................... 21TRICOR ............................................................... 22triderm ................................................................. 24trifluoperazine hcl ................................................ 18trifluridine ............................................................ 36trihexyphenidyl hcl ............................................... 11tri-legest fe ........................................................... 35TRILEPTAL ........................................................ 11TRILIPIX ............................................................. 22trilyte .................................................................... 31trimethoprim .......................................................... 6trimethoprim sulfate/polymyxin b sulfate ............ 35trimipramine maleate ........................................... 18trinessa ................................................................. 35tri-previfem .......................................................... 35TRISENOX ............................................................ 9tri-sprintec ........................................................... 35trivora-28 ............................................................. 35TRIZIVIR .............................................................. 3TROPHAMINE ................................................... 41trospium chloride ................................................. 39trospium chloride er ............................................ 39TRUVADA ............................................................ 3TUDORZA PRESSAIR....................................... 38TWINJECT .......................................................... 37TWINRIX ............................................................ 33TWYNSTA .......................................................... 21TYGACIL .............................................................. 5TYKERB ............................................................... 9TYPHIM VI ......................................................... 33TYVASO ............................................................. 38TYZEKA ............................................................... 3TYZINE ............................................................... 25TYZINE PEDIATRIC NASAL DROPS ............. 25UUCERIS ............................................................... 31ULESFIA ............................................................. 24ULORIC .............................................................. 33unithroid .............................................................. 29UROXATRAL ..................................................... 39ursodiol ................................................................ 31UVADEX ............................................................ 23VVAGIFEM ........................................................... 34valacyclovir hcl ...................................................... 3VALCYTE ............................................................. 3valproate sodium ................................................. 11valproic acid ........................................................ 11valsartan/hydrochlorothiazide ............................. 21vancomycin hcl ...................................................... 6vandazole ............................................................. 34VAQTA ............................................................... 33VARIVAX ........................................................... 3360

VASCEPA ........................................................... 22VECTIBIX ............................................................. 9VELCADE ............................................................. 9velivet ................................................................... 35venlafaxine hcl ..................................................... 18venlafaxine hcl er ................................................. 18VERAMYST ....................................................... 38verapamil hcl ....................................................... 21verapamil hcl er ................................................... 21verapamil hcl sr ................................................... 21VEREGEN ........................................................... 23VESICARE .......................................................... 39vestura .................................................................. 35VFEND .................................................................. 1VFEND IV ............................................................. 1VIBATIV ............................................................... 6VIBRAMYCIN...................................................... 6vicodin .................................................................. 14vicodin es ............................................................. 14vicodin hp ............................................................. 14VICTOZA ............................................................ 29VICTRELIS ........................................................... 3VIDAZA ................................................................ 9VIDEX PEDIATRIC ............................................. 3VIGAMOX .......................................................... 35VIIBRYD ............................................................. 18VIMOVO ............................................................. 14VIMPAT .............................................................. 11vinblastine sulfate .................................................. 9vincasar pfs ............................................................ 9vincristine sulfate ................................................... 9vinorelbine tartrate ................................................ 9VIRACEPT ............................................................ 3VIRAMUNE .......................................................... 3VIRAMUNE XR ................................................... 3VIRAZOLE ........................................................... 3VIREAD ................................................................ 3VIVELLE-DOT ................................................... 34VOLTAREN GEL ............................................... 14voriconazole ........................................................... 1VOTRIENT ......................................................... 10VYTORIN ........................................................... 22Wwarfarin sodium ................................................... 21WELCHOL .......................................................... 22XXALKORI ........................................................... 10XARELTO ........................................................... 21XELJANZ ............................................................ 34XENAZINE ......................................................... 12XGEVA ................................................................. 7XIFAXAN ............................................................. 5XOLAIR .............................................................. 38XOPENEX HFA .................................................. 39XTANDI .............................................................. 10XYREM ............................................................... 18YYERVOY ............................................................. 10YF-VAX .............................................................. 33Zzafirlukast ............................................................ 39zaleplon ................................................................ 18ZALTRAP ........................................................... 10ZANOSAR .......................................................... 10ZANTAC ............................................................. 31ZAVESCA ........................................................... 29zazole ................................................................... 34ZELAPAR ........................................................... 11ZELBORAF ......................................................... 10ZEMPLAR ........................................................... 29zenchent fe ........................................................... 35ZENPEP ............................................................... 31zenzedi .................................................................. 18zeosa .................................................................... 35ZERIT .................................................................... 3ZETIA .................................................................. 22ZIAGEN ................................................................ 3zidovudine .......................................................... 3, 4ZINACEF IN ISO-OSMOTIC DEXTROSE......... 4ZINACEF IN ISO-OSMOTIC DILUENT ............ 4ZINECARD ........................................................... 7ziprasidone hcl ..................................................... 1861

ZIRGAN .............................................................. 36ZMAX .................................................................... 4zoledronic acid ............................................... 25, 29ZOLINZA ............................................................ 10zolpidem tartrate .................................................. 18zolpidem tartrate er ............................................. 18ZOMETA ............................................................. 29zonisamide ........................................................... 11ZORTRESS ......................................................... 10ZOSTAVAX ........................................................ 33ZOSYN .................................................................. 6zovia 1/35e ........................................................... 35zovia 1/50e ........................................................... 35ZOVIRAX ..................................................... 23, 24ZYFLO ................................................................ 39ZYFLO CR .......................................................... 39ZYLET ................................................................. 36ZYMAXID .......................................................... 35ZYTIGA .............................................................. 10ZYVOX ................................................................. 562

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