PRESCRIPTION DRUG PLAN 2011

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					                                                           PRESCRIPTION
                                                           DRUG PLAN
                                                           2011
                                                            Comprehensive Formulary
                                                            (List of covered drugs)

                                                            Current as of August 1, 2011



PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN




                        VA N TAG E MED I C A R E
                        V
                        A       D      V      A      N       T     A       G    E

                                                                                             VHP302 R100510
   Note to existing members: This formulary has changed since 

   last year. Please review this document to make sure that it still 

   contains the drugs you take. This document includes Vantage 

   Medicare Advantage’s complete formulary. Please visit our web 

   site at www.vhp-medicare.com to search for drugs. For additional 

   assistance, please call (888) 823-1910, 8am – 8pm, seven days 

   a week from November 15, 2010 through March 1, 2011. After 

   March 1, 2011, Member Services may be reached from 8am – 

   8pm, Monday – Friday. TTY users should call (866) 524-5144. 


   Beneficiaries must use network pharmacies to access their
   prescription drug benefit. Benefits, formulary, pharmacy network,     VANTAGE HEALTH PLAN, INC.
   premium and/or copayment/coinsurance may change on January
   1, 2012. Vantage Health Plan is a health plan with a Medicare 

                                                                         Making Healthcare Work!
   Advantage contract.


    H5576_5003_03_CY11 CMS File & Use 11/7/2010 Trad/SNP
                 Vantage Medicare Advantage Prescription Drug Plan 

                                2011 Comprehensive Formulary 



What is the Vantage Medicare Advantage Formulary?
A formulary is a list of covered drugs selected by Vantage Medicare Advantage in consultation with a team of
health care providers, which represents the prescription therapies believed to be a necessary part of a quality
treatment program. Vantage Medicare Advantage will generally cover the drugs listed in our formulary as
long as the drug is medically necessary, the prescription is filled at a Vantage Medicare Advantage network
pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please
review your Evidence of Coverage.


Can the Formulary change?
Generally, if you are taking a drug on our 2011 formulary that was covered at the beginning of the year, we
will not discontinue or reduce coverage of the drug during the 2011 coverage year, except when a new, less
expensive generic drug becomes available or when new adverse information about the safety or effectiveness
of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not
affect members who are currently taking the drug. It will remain available at the same cost-sharing for those
members taking it for the remainder of the coverage year. We feel it is important that you have continued
access for the remainder of the coverage year to the formulary drugs that were available when you chose our
plan, except for cases in which you can save additional money or improve the safety of your drugs.

If we remove drugs from our formulary, or add prior authorization, quantity limits, and/or step therapy
restrictions on a drug, we must notify affected members of the change at least 60 days before the change
becomes effective, or at the time the member requests a refill of the drug, at which time the member will
receive a 60-day supply of the drug. If the Food and Drug Administration (FDA) deems a drug on our
formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately
remove the drug from our formulary and provide notice to members who take the drug. The enclosed
formulary is current as of the date on the cover. To get updated information about the drugs covered by
Vantage Medicare Advantage, please visit our website at www.vhp-medicare.com or call Member Services at
(888) 823-1910, 8am – 8pm, and seven days a week from November 15, 2010, through March 1, 2011. After
March 1, 2011, Member Services may be reached from 8am – 8pm Monday – Friday. TTY users should call
(866) 524-5144.

In the event of mid-year non-maintenance formulary changes that are approved by CMS, Vantage Medicare
Advantage shall update the printed formulary. The updated version of the printed formulary will be available
upon request and the changes will be included in notices to members using the affected drug(s) no less than 60
days prior to the effective date of the change. The mid-year non-maintenance formulary changes will also be
made to the searchable online formulary as well.




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How do I use the Formulary?
There are two ways to find your drug within the formulary:

Medical Condition The formulary begins on page 6. The drugs in this formulary are grouped into categories
depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a
heart condition are listed under the category, “Cardiovascular Agents.” If you know what your drug is used
for, look for the category name in this formulary. Then look under the category name for your drug.

Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the
Index found at the back of this book. The Index provides an alphabetical list of all of the drugs included in this
document. Both brand-name drugs and generic drugs are listed in the Index. Look in the Index and find your
drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the
page listed in the Index and find the name of your drug in the first column of the list.


What are generic drugs?
Vantage Medicare Advantage covers both brand-name drugs and generic drugs. A generic drug is a
prescription drug that is approved by the FDA as having the same active ingredient as the brand-name
drug. Generally, generic drugs cost less than brand-name drugs.


Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits
may include:

   �   Prior Authorization: Vantage Medicare Advantage requires you or your physician to get prior
       authorization for certain drugs. This means that you will need to get approval from Vantage Medicare
       Advantage before you fill your prescriptions. If you do not get approval, Vantage Medicare Advantage
       may not cover the drug.

   �   Quantity Limits: For certain drugs, Vantage Medicare Advantage limits the amount of the drug that
       Vantage Medicare Advantage will cover. This may be in addition to a standard one month or three-
       month supply.

   �   Step Therapy: In some cases, Vantage Medicare Advantage requires you to first try certain drugs to
       treat your medical condition before we will cover another drug for that condition. For example, if Drug
       A and Drug B both treat your medical condition, Vantage Medicare Advantage may not cover drug B
       unless you try Drug A first. If Drug A does not work for you, Vantage Medicare Advantage will then
       cover Drug B.

   �   Generic Substitution: When there is a generic version of a brand-name drug available, the Vantage
       Medicare Advantage network pharmacies will automatically give you the generic version, unless your
       doctor has informed the plan that you must take the brand-name drug and the request has been
       approved.

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You can find out if your drug has any additional requirements or limits by looking in the formulary that begins
on page 6.

You can ask Vantage Medicare Advantage to make an exception to these restrictions or limits. See the section,
“How do I request an exception to the Vantage Medicare Advantage Formulary?” below for information about
how to request an exception.


What if my drug is not on the Formulary?
If your drug is not included in this formulary, you should first contact Member Services and confirm that your
drug is not covered. If you learn that Vantage Medicare Advantage does not cover your drug, you have two
options:

   �   You can ask Member Services for a list of similar drugs that are covered by Vantage Medicare
       Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar
       drug that is covered by Vantage Medicare Advantage.

   �   You can ask Vantage Medicare Advantage to make an exception and cover your drug. See below for
       information about how to request an exception.


How do I request an exception to the Vantage Medicare Advantage Formulary?
You can ask Vantage Medicare Advantage to make an exception to our coverage rules. There are several types
of exceptions that you can ask us to make.

   �   You can ask us to cover your drug even if it is not on our formulary.

   �   You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs,
       Vantage Medicare Advantage limits the amount of the drug that is covered. If your drug has a quantity
       limit, you can ask us to waive the limit and cover more.

Generally, Vantage Medicare Advantage will only approve your request for an exception if the alternative
drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in
treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction
exception. When you are requesting a formulary or utilization restriction exception, you should submit a
statement from your physician supporting your request. Generally, we must make our decision within 72 hours
of getting your prescribing physician’s supporting statement. You can request an expedited (fast) exception if
you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision.
If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your
prescribing physician’s supporting statement.




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What do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you
may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a
prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if
you should switch to an appropriate drug that we cover, or request a formulary exception so that we will cover
the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover
your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover
a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network
pharmacy. After your first 31-day supply, we will not pay for these drugs, even if you have been a member of
the plan less than 90 days.

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless
you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first
90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get
your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day
emergency supply of that drug (unless you have a prescription written for fewer days) while you pursue a
formulary exception.

Current enrollees with a level of care change (e.g., from a hospital to a long-term care facility) must follow
standard Prior Authorization procedures during the transition period. Vantage Medicare Advantage requires
you or your physician to get prior authorization for certain drugs. This means that you will need to get
approval from Vantage before you fill your prescriptions during the transition period.


For more information

For more detailed information about your Vantage Medicare Advantage prescription drug coverage, please
review your Evidence of Coverage and other plan materials.

If you have questions about Vantage Medicare Advantage, please call Member Services at (888) 823-1910,
8am – 8pm, and seven days a week November 15, 2010, through March 1, 2011. After March 1, 2011,
Member Services may be reached from 8am – 8pm Monday – Friday. TTY users should call (866) 524-5144.
Or visit www.vhp-medicare.com.

If you have general questions about Medicare prescription drug coverage, please call Medicare at
1-800-MEDICARE (1-800-633-4227) 24 hours a day/seven days a week. TTY users should call
1-877-486-2048. Or, visit www.medicare.gov.




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Vantage Medicare Advantage’s Formulary

The comprehensive formulary that begins on the next page provides coverage information about some of the
drugs covered by Vantage Medicare Advantage. If you have trouble finding your drug in the list, turn to the
Index at the back of the book.

The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g., LIPITOR) and
generic drugs are listed in lower-case italics (e.g., acetaminophen/codeine).

The information in the Notes column tells you if Vantage Medicare Advantage has any special requirements
for coverage of your drug. The formulary includes drugs which may have a Quantity Limit (QL) for that
particular drug, or which may require Prior Authorization (PA) from Vantage Medicare Advantage before
receiving them. B versus D determination drugs require the plan to make a determination as to whether a drug
is covered under the Medicare Part B or Part D benefits.




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                                              2011 Vantage Comprehensive Formulary


                                                                       Table of Contents

Analgesics .............................................................................................................................................................. 8


Anesthetics ........................................................................................................................................................... 12


Antibacterials ....................................................................................................................................................... 12


Anticonvulsants.................................................................................................................................................... 20


Antidementia Agents............................................................................................................................................ 23


Antidepressants .................................................................................................................................................... 24


Antidotes, Deterrents, and Toxicologic Agents ................................................................................................... 25


Antiemetics .......................................................................................................................................................... 26


Antifungals........................................................................................................................................................... 28


Antigout Agents ................................................................................................................................................... 30


Anti-inflammatory Agents ................................................................................................................................... 31


Antimigraine Agents ............................................................................................................................................ 32


Antimyasthenic Agents ........................................................................................................................................ 33


Antimycobacterials .............................................................................................................................................. 33


Antineoplastics..................................................................................................................................................... 34


Antiparasitics ....................................................................................................................................................... 39


Antiparkinson Agents .......................................................................................................................................... 40


Antipsychotics...................................................................................................................................................... 42


Antispasticity Agents ........................................................................................................................................... 43


Antivirals.............................................................................................................................................................. 44


Anxiolytics ........................................................................................................................................................... 46


Bipolar Agents ..................................................................................................................................................... 47


Blood Glucose Regulators ................................................................................................................................... 48


Blood Products/Modifiers/ Volume Expanders ................................................................................................... 51


Cardiovascular Agents ......................................................................................................................................... 53


Central Nervous System Agents .......................................................................................................................... 63


Dental and Oral Agents........................................................................................................................................ 64


Dermatological Agents ........................................................................................................................................ 64


Enzyme Replacements/ Modifiers ....................................................................................................................... 67


Gastrointestinal Agents ........................................................................................................................................ 68


Genitourinary Agents........................................................................................................................................... 71


Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal) ..................................................................... 72


Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary) .................................................................... 76


Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers) ........................................77


Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid) ..................................................................... 82


Hormonal Agents, Suppressant (Parathyroid) ..................................................................................................... 83


Hormonal Agents, Suppressant (Pituitary) .......................................................................................................... 83


Hormonal Agents, Suppressant (Sex Hormones/ Modifiers)............................................................................... 84


Hormonal Agents, Suppressant (Thyroid) ........................................................................................................... 84


Immunological Agents......................................................................................................................................... 84


Inflammatory Bowel Disease Agents .................................................................................................................. 89


Metabolic Bone Disease Agents .......................................................................................................................... 89


Ophthalmic Agents .............................................................................................................................................. 90


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Otic Agents .......................................................................................................................................................... 95
 

Respiratory Tract Agents ..................................................................................................................................... 95
 

Sedatives/Hypnotics ........................................................................................................................................... 100
 

Skeletal Muscle Relaxants ................................................................................................................................. 100
 

Therapeutic Nutrients/Minerals/ Electrolytes .................................................................................................... 101
 

Index................................................................................................................................................................... 106
 





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                             2011 Vantage Comprehensive Formulary



                                     CURRENT AS OF 8/1/2011 





                                                                Notes
                                                                PA= Prior Authorization
                                                                PA-NS= PA-New Starts Only
                                                                BvD= B vs D PA
                                   Tier                         ST= Step Therapy
                                   1= Tier 1                    ST-NS= ST-New Starts Only
UPPERCASE= Brand name              2= Tier 2                    MO= Mail Order
drugs                              3= Tier 3                    LA= Limited Access
 italics= Generic drugs            4= Tier 4                    QL= Quantity Limits



Drug                                                            Notes
Analgesics
Opioid Analgesics, Long-acting
AVINZA ORAL                                                     QL (60 EA per 25 day(s))
DURAGESIC TRANSDERM PATCH 12 mcg/hr,                            QL (10 EA per 25 day(s))
25 mcg/hr, 50 mcg/hr, 75 mcg/hr
DURAGESIC TRANSDERM PATCH 100                                   QL (10 EA per 25 day(s))
mcg/hr
EMBEDA ORAL                                                     QL (60 EA per 30 day(s))
fentanyl TD                                                     QL (10 EA per 25 day(s))
KADIAN ORAL                                                     QL (60 EA per 25 day(s))
morphine ER Tab 200 mg                                          QL (60 EA per 25 day(s))
morphine ER Tab 100 mg, 15 mg, 30 mg, 60 mg                     QL (90 EA per 25 day(s))
MS CONTIN TAB 200 mg                                            QL (60 EA per 25 day(s))
MS CONTIN TAB 100 mg, 15 mg, 30 mg, 60 mg                       QL (90 EA per 25 day(s))
OPANA ER ORAL                                                   QL (120 EA per 25 day(s))
ORAMORPH SR ORAL                                                QL (90 EA per 25 day(s))

       Page 8 of 122
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Drug                                  Notes
OXYCONTIN ORAL                        QL (120 EA per 25 day(s))
tramadol Oral
ULTRAM ER ORAL 

Opioid Analgesics, Short-acting
acetaminophen-codeine Oral
ACTIQ BUCL                            PA; QL (120 EA per 25 day(s))
ASCOMP W/CODEINE ORAL 

ASTRAMORPH-PF INJ 

buprenorphine SL
butorphanol tartrate Inj
butorphanol tartrate Nasl             QL (9 ML per 25 day(s))
CAPITAL WITH CODEINE ORAL 

cod-butalbital-acetaminop-caf Oral
codeine sulfate Oral
CO-GESIC ORAL 

COMBUNOX ORAL 

DEMEROL INJ 

DEMEROL ORAL 

DEMEROL (PF) INJ 

dihydrocode-acetaminophen-caff Oral
DILAUDID ORAL 

DILAUDID-5 ORAL 

DILAUDID-HP INJ 

DOLOPHINE TAB 5 mg                    QL (240 EA per 25 day(s))
DOLOPHINE TAB 10 mg                   QL (360 EA per 30 day(s))
DURAMORPH INJ 

ENDOCET ORAL 

fentanyl citrate Bucl                 PA; QL (120 EA per 25 day(s))
fentanyl citrate (PF) Inj
FENTORA BUCL                          PA; QL (120 EA per 25 day(s))
       Page 9 of 122 

       Effective: 08/01/11 

Drug                                          Notes
FIORICET-CODEINE ORAL 

FIORINAL-CODEINE #3 ORAL 

HYCET ORAL 

hydrocodone-acetaminophen Oral Soln 7.5-500
mg/15 mL
hydrocodone-acetaminophen Tab ,
hydrocodone-ibuprofen Oral
hydromorphone Oral
hydromorphone (PF) Inj
ibuprofen-oxycodone Oral
INFUMORPH P/F INJ 

levorphanol tartrate Oral
LORCET 10/650 ORAL 

LORCET PLUS ORAL 

LORTAB ORAL 

LORTAB ELIXIR ORAL 

MAGNACET ORAL 

MARGESIC-H ORAL 

MAXIDONE ORAL 

meperidine Oral
meperidine (PF) Inj
methadone Inj
methadone Oral Concentrate
methadone Oral Soln
methadone Tab                                 QL (240 EA per 25 day(s))
METHADOSE ORAL                                QL (240 EA per 25 day(s))
morphine Inj
morphine Tab
morphine (PF) Inj
morphine concentrate Oral

       Page 10 of 122 

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Drug                               Notes
nalbuphine Inj
NORCO ORAL 

NUCYNTA ORAL                       QL (180 EA per 30 day(s))
OPANA ORAL 

oxycodone Tab
oxycodone HCl-oxycodone-ASA Oral
oxycodone-acetaminophen Oral
oxycodone-aspirin Oral
oxymorphone Oral
PANLOR DC ORAL 

PANLOR SS ORAL 

pentazocine-acetaminophen Oral
pentazocine-naloxone Oral
PERCOCET ORAL 

PERCODAN ORAL 

REPREXAIN ORAL 

ROXICET ORAL SOLN 

ROXICET TAB 5-325 mg
ROXICET TAB 5-500 mg
ROXICODONE ORAL 

STADOL INJ 

STAGESIC ORAL 

SUBOXONE SL 

SUBUTEX SL 

SYNALGOS-DC ORAL 

TALACEN ORAL 

TALWIN INJ 

TALWIN NX ORAL 

tramadol Oral
tramadol-acetaminophen Oral
       Page 11 of 122 

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Drug                         Notes
TYLENOL-CODEINE #3 ORAL 

TYLENOL-CODEINE #4 ORAL 

TYLOX ORAL 

ULTRACET ORAL 

VICODIN ORAL 

VICODIN ES ORAL 

VICODIN HP ORAL 

VICOPROFEN ORAL 

XODOL 10/300 ORAL 

XODOL 5/300 ORAL 

XODOL 7.5/300 ORAL 

ZAMICET ORAL 

ZERLOR ORAL 

ZYDONE ORAL 

Anesthetics
Local Anesthetics
EMLA TOP                     BvD
lidocaine (PF) Inj
lidocaine HCl Inj
lidocaine HCl Top            BvD
lidocaine Mucosal Gel        BvD
lidocaine Mucosal Soln
lidocaine-prilocaine Top     BvD
LIDODERM TOP                 PA
PARCAINE OPHT 

SYNERA TOP                   BvD
XYLOCAINE INJ 

XYLOCAINE MM                 BvD
XYLOCAINE JELLY MM           BvD
Antibacterials
       Page 12 of 122
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Drug                                            Notes
Amino Derivative Penicillins
amoxicillin Oral
amoxicillin-pot clavulanate Oral
ampicillin Oral
ampicillin sodium Inj
ampicillin-sulbactam Inj
UNASYN INJ 

Aminoglycosides
amikacin Inj
gentamicin Inj
gentamicin Opht
gentamicin Top
gentamicin in sodium chloride(iso-osmotic) IV
Piggy Back 100 mg/100 mL, 60 mg/100 mL, 60
mg/50 mL, 80 mg/100 mL, 80 mg/50 mL
gentamicin in sodium chloride(iso-osmotic) IV
Piggy Back 70 mg/50 mL, 90 mg/100 mL
gentamicin sulfate (PF) IV
kanamycin Inj
neomycin Oral
paromomycin Oral
streptomycin IM
TOBI INHL 

tobramycin in NS IV
tobramycin sulfate Inj
tobramycin sulfate Opht
Antifolate Antibacterials
PRIMSOL ORAL 

trimethoprim Oral
Beta-lactam, Other
AZACTAM INJ 

       Page 13 of 122 

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Drug                                              Notes
AZACTAM-ISO-OSMOTIC DEXTROSE IV 

aztreonam Inj
CAYSTON INHL                                      PA; QL (84 ML per 28 day(s))
DORIBAX IV 

INVANZ INJ 

PRIMAXIN IM IM 

PRIMAXIN IV IV 

Cephalosporin Antibacterials, 1st Generation
cefadroxil Oral
cefazolin Inj
cefazolin in dextrose (iso-os) IV
cephalexin Oral
Cephalosporin Antibacterials, 2nd Generation
cefaclor Oral
cefotetan Inj
cefoxitin IV
cefprozil Oral
cefuroxime axetil Oral
cefuroxime sodium Inj
cefuroxime sodium IV
cefuroxime-dextrose (iso-osmotic) IV Piggy Back
750 mg/50 mL
cefuroxime-dextrose (iso-osmotic) IV Piggy Back
1.5 gram/50 mL
ZINACEF IV SOLUTION 7.5 gram
ZINACEF IV SOLUTION 1.5 gram, 750 mg
ZINACEF IN DEXTROSE (ISO-OSM) IV 

ZINACEF IN STERILE WATER IV 

Cephalosporin Antibacterials, 3rd Generation
cefdinir Oral

       Page 14 of 122 

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Drug                                           Notes
cefepime Inj
cefotaxime Inj
cefpodoxime Oral
ceftazidime Solution for Injection 2 gram
ceftriaxone Inj
ceftriaxone IV
FORTAZ INJ 

FORTAZ IV 

FORTAZ IN D5W IV 

SUPRAX ORAL SUSP 

TAZICEF INJ 

TAZICEF IV 

Cephalosporin Antibacterials, 4th Generation
MAXIPIME INJ 

MAXIPIME IV 

Extended Spectrum Penicillins
piperacillin-tazobactam IV
TIMENTIN IV 

ZOSYN IV 

ZOSYN IN DEXTROSE (ISO-OSM) IV 

Glycopeptide Antibacterials
VANCOCIN ORAL 

vancomycin IV Solution 1,000 mg, 10 gram       BvD
vancomycin IV Solution 500 mg                  BvD
VIBATIV IV                                     BvD
Lincomycin Antibacterials
CLEOCIN CAP 75 mg
CLEOCIN CAP 150 mg, 300 mg
CLEOCIN INJ 

CLEOCIN ORAL SOLUTION 

       Page 15 of 122 

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Drug                               Notes
CLEOCIN VAGINAL CREAM 

CLEOCIN VAGINAL SUPPOSITORY 

CLEOCIN IN D5W IV 

clindamycin HCl Oral
clindamycin phosphate IV
clindamycin phosphate Vagl
CLINDESSE VAGL 

LINCOCIN INJ 

Macrolides
azithromycin IV
azithromycin Oral
clarithromycin Oral
E.E.S. 400 ORAL 

E.E.S. GRANULES ORAL 

ERYPED 200 ORAL 

ERYPED 400 ORAL 

ERY-TAB ORAL 

ERYTHROCIN IV 

ERYTHROCIN STEARATE ORAL 

erythromycin Opht
erythromycin Oral
erythromycin ethylsuccinate Oral
erythromycin-sulfisoxazole Oral
KETEK ORAL 

ZMAX ADULT-PEDIATRIC ORAL 

Miscellaneous Antibacterials
alcohol swabs Top
ALTABAX TOP 

BACI-IM IM 

bacitracin IM
       Page 16 of 122 

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Drug                                Notes
BACTROBAN OINTMENT 

BACTROBAN TOPICAL CREAM 

BACTROBAN NASAL NASL 

chloramphenicol sod succinate IV
colistimethate sodium Inj           BvD
COLY-MYCIN M PARENTERAL INJ         BvD
CORTISPORIN TOP 

CUBICIN IV                          BvD
FLAGYL ORAL 

FLAGYL ER ORAL 

HIPREX ORAL 

meropenem IV
MERREM IV 

methenamine hippurate Oral
METROCREAM TOP 

METROGEL TOP 

METROGEL VAGINAL VAGL 

METROLOTION TOP 

metronidazole Oral
metronidazole Top
metronidazole Vagl
metronidazole in NaCl (iso-os) IV
MONUROL ORAL 

mupirocin Top
neomycin-polymyxin B GU IR
neomycin-polymyxin-HC Otic
NORITATE TOP 

PHISOHEX TOP 

polymyxin B sulfate Inj
PREVPAC ORAL 

       Page 17 of 122 

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Drug                                  Notes
SEPTRA ORAL 

SEPTRA DS ORAL 

SILVADENE TOP 

silver sulfadiazine Top
SSD TOP 

SULFAMYLON TOP 

SULFATRIM ORAL 

SYNERCID IV 

TEFLARO IV                            BvD
THERMAZENE TOP 

TYGACIL IV 

VANDAZOLE VAGL 

XIFAXAN ORAL 

Natural Penicillins
BICILLIN C-R IM 

BICILLIN L-A IM 

penicillin G pot in dextrose IV
penicillin G potassium Inj
penicillin G procaine IM
penicillin G sodium Inj
penicillin V potassium Oral
Nitrofuran Antibacterials
FURADANTIN ORAL 

MACROBID ORAL 

MACRODANTIN CAP 25 mg
MACRODANTIN CAP 100 mg, 50 mg
nitrofurantoin Oral
nitrofurantoin macrocrystal Oral
nitrofurantoin monohyd/m-cryst Oral
Oxazolidinone Antibacterials
       Page 18 of 122 

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Drug                                  Notes
ZYVOX IV 

ZYVOX ORAL 

Penicillinase-resistant Penicillins
dicloxacillin Oral
nafcillin Inj
nafcillin in D2.4W IV
NALLPEN IN D2.4W IV 

oxacillin Inj
oxacillin in dextrose, iso-osm IV
Quinolones
AVELOX ORAL 

AVELOX ABC PACK ORAL 

AVELOX IN NACL (ISO-OSMOTIC) IV 

CIPRO HC OTIC 

CIPRO IN D5W IV 

CIPRODEX OTIC 

ciprofloxacin IV
ciprofloxacin Opht
ciprofloxacin Oral
ciprofloxacin (mixture) Oral
LEVAQUIN IV 

LEVAQUIN ORAL 

LEVAQUIN IN D5W IV 

NOROXIN ORAL 

OCUFLOX OPHT 

ofloxacin Opht
ofloxacin Oral
ofloxacin Otic
Sulfonamides
BACTRIM ORAL 

       Page 19 of 122 

       Effective: 08/01/11 

Drug                                       Notes
BACTRIM DS ORAL 

sulfacetamide sodium (acne) Top
sulfacetamide-prednisolone Opht
sulfadiazine Oral
sulfamethoxazole-trimethoprim IV
sulfamethoxazole-trimethoprim Oral
Tetracyclines
demeclocycline Oral
doxycycline hyclate Cap
doxycycline hyclate Cap, Delayed Release
doxycycline hyclate IV Solution 100 mg
doxycycline hyclate Tab
doxycycline hyclate Tab, Delayed Release
doxycycline monohydrate Oral
minocycline Oral
ORACEA ORAL 

tetracycline Oral
Anticonvulsants
Anticonvulsants, Other
BANZEL ORAL                                MO
KEPPRA IV 

KEPPRA ORAL                                MO
KEPPRA XR 24 HR TAB 750 mg
KEPPRA XR 24 HR TAB 500 mg                 MO
levetiracetam IV
levetiracetam Oral                         MO
Calcium Channel Modifying Agents
CELONTIN ORAL                              MO
ethosuximide Oral                          MO


       Page 20 of 122 

       Effective: 08/01/11 

Drug                                               Notes
LYRICA CAP 100 mg, 150 mg, 200 mg, 225 mg,         MO; QL (120 EA per 25 day(s))
25 mg, 50 mg, 75 mg
LYRICA CAP 300 mg                                  MO; QL (60 EA per 25 day(s))
ZARONTIN ORAL                                      MO
ZONEGRAN ORAL                                      MO
zonisamide Oral                                    MO
Gamma-aminobutyric Acid (GABA) Augmenting Agents
DEPACON IV 

DEPAKENE ORAL                                      MO
DEPAKOTE ORAL                                      MO
DEPAKOTE ER ORAL                                   MO
DEPAKOTE SPRINKLES ORAL                            MO
divalproex Oral                                    MO
gabapentin Cap 100 mg                              MO; QL (1080 EA per 25 day(s))
gabapentin Cap 400 mg                              MO; QL (270 EA per 25 day(s))
gabapentin Cap 300 mg                              MO; QL (360 EA per 25 day(s))
gabapentin Oral Soln                               MO; QL (2350 ML per 25 day(s))
gabapentin Tab 800 mg                              MO; QL (120 EA per 25 day(s))
gabapentin Tab 600 mg                              MO; QL (180 EA per 25 day(s))
GABITRIL ORAL                                      MO
HORIZANT ORAL                                      QL (30 EA per 25 day(s))
MYSOLINE TAB 250 mg                                MO
NEURONTIN CAP 100 mg                               MO; QL (1080 EA per 25 day(s))
NEURONTIN CAP 400 mg                               MO; QL (270 EA per 25 day(s))
NEURONTIN CAP 300 mg                               MO; QL (360 EA per 25 day(s))
NEURONTIN ORAL SOLN                                MO; QL (2350 ML per 25 day(s))
NEURONTIN TAB 800 mg                               MO; QL (120 EA per 25 day(s))
NEURONTIN TAB 600 mg                               MO; QL (180 EA per 25 day(s))
primidone Oral                                     MO
SABRIL ORAL                                        MO

       Page 21 of 122 

       Effective: 08/01/11 

Drug                                  Notes
STAVZOR ORAL                          MO
valproate sodium IV
valproic acid Oral                    MO
valproic acid (as sodium salt) Oral   MO
Glutamate Reducing Agents
FELBATOL ORAL                         MO
LAMICTAL ORAL                         MO
LAMICTAL STARTER (BLUE) KIT ORAL      MO
LAMICTAL STARTER (GREEN) KIT ORAL     MO
LAMICTAL STARTER (ORANGE) KIT ORAL    MO
LAMICTAL XR ORAL                      MO
LAMICTAL XR STARTER (BLUE) ORAL       MO
LAMICTAL XR STARTER (GREEN) ORAL      MO
LAMICTAL XR STARTER (ORANGE) ORAL     MO
lamotrigine Oral                      MO
TOPAMAX ORAL                          MO
topiramate Oral
Sodium Channel Inhibitors
carbamazepine Chewable Tab            MO
carbamazepine ER 12 hr Tab
carbamazepine Oral Susp               MO
carbamazepine Tab                     MO
CARBATROL ORAL                        MO
CEREBYX INJ 

DILANTIN ORAL 

DILANTIN EXTENDED ORAL                MO
DILANTIN INFATABS ORAL                MO
DILANTIN-125 ORAL                     MO
EPITOL ORAL                           MO
fosphenytoin Inj
       Page 22 of 122 

       Effective: 08/01/11 

Drug                             Notes
oxcarbazepine Oral               MO
PEGANONE ORAL                    MO
PHENYTEK ORAL                    MO
phenytoin Oral                   MO
phenytoin sodium IV
phenytoin sodium extended Oral   MO
TEGRETOL ORAL                    MO
TEGRETOL XR ORAL                 MO
TRILEPTAL ORAL SUSP              MO
TRILEPTAL TAB                    MO
VIMPAT IV 

VIMPAT ORAL SOLN 

VIMPAT TAB                       MO
Antidementia Agents
Antidementia Agents, Other
ergoloid Oral                    MO
Cholinesterase Inhibitors
ARICEPT TAB 23 mg
ARICEPT TAB 10 mg, 5 mg          MO
ARICEPT ODT ORAL                 MO
COGNEX ORAL                      MO
donepezil Oral
EXELON ORAL                      MO
EXELON TD                        MO
galantamine Oral                 MO
RAZADYNE ORAL                    MO
RAZADYNE ER ORAL                 MO
rivastigmine Oral
Glutamate Pathway Modifiers
NAMENDA ORAL                     MO
       Page 23 of 122
       Effective: 08/01/11
Drug                                            Notes
NAMENDA TITRATION PAK ORAL                      MO
Antidepressants
Antidepressants, Other
BUDEPRION SR ORAL                               MO
BUDEPRION XL 24 HR TAB 150 mg
BUDEPRION XL 24 HR TAB 300 mg                   MO
BUPROBAN ORAL                                   PA-NS; MO; QL (62 EA per 31
                                                day(s))
bupropion HCl SR Tab 100 mg, 200 mg             MO
bupropion HCl SR Tab 150 mg                     PA-NS; MO; QL (62 EA per 31
                                                day(s))
bupropion HCl Tab                               MO
maprotiline Oral                                MO
mirtazapine Oral                                MO
nefazodone Oral                                 MO
REMERON ORAL                                    MO
REMERON SOLTAB ORAL                             MO
trazodone Oral                                  MO
VIIBRYD ORAL                                    QL (30 EA per 25 day(s))
WELLBUTRIN ORAL                                 MO
WELLBUTRIN SR ORAL                              MO
WELLBUTRIN XL ORAL                              MO
Monoamine Oxidase Inhibitors
EMSAM TD                                        MO
MARPLAN ORAL                                    MO
PARNATE ORAL                                    MO
tranylcypromine Oral                            MO
Serotonin/ Norepinephrine Reuptake Inhibitors
CYMBALTA ORAL                                   MO
EFFEXOR ORAL                                    MO

       Page 24 of 122
       Effective: 08/01/11
Drug                                             Notes
EFFEXOR XR ORAL                                  MO
PRISTIQ ORAL                                     MO
venlafaxine ER 24 hr Cap
venlafaxine ER 24 hr Tab                         MO
venlafaxine Tab                                  MO
Tricyclics
amitriptyline Oral                               MO
amoxapine Oral                                   MO
ANAFRANIL ORAL                                   MO
clomipramine Oral                                MO
desipramine Oral                                 MO
doxepin Cap 150 mg
doxepin Cap 10 mg, 100 mg, 25 mg, 50 mg, 75 mg   MO
doxepin Oral Concentrate                         MO
imipramine HCl Oral                              MO
imipramine pamoate Oral                          MO
NORPRAMIN ORAL                                   MO
nortriptyline Oral                               MO
PAMELOR ORAL                                     MO
perphenazine-amitriptyline Oral                  MO
protriptyline Oral                               MO
SILENOR ORAL                                     QL (31 EA per 31 day(s))
SURMONTIL CAP 100 mg                             MO
SURMONTIL CAP 25 mg, 50 mg                       MO
TOFRANIL ORAL                                    MO
TOFRANIL-PM ORAL                                 MO
VIVACTIL ORAL                                    MO
Antidotes, Deterrents, and Toxicologic Agents
Alcohol Deterrents
ANTABUSE TAB 250 mg
       Page 25 of 122 

       Effective: 08/01/11 

Drug                                Notes
ANTABUSE TAB 500 mg
CAMPRAL ORAL 

Antidotes
acetylcysteine Misc
amifostine crystalline IV
CHEMET ORAL 

ETHYOL IV 

EXJADE ORAL 

KIONEX ORAL 

leucovorin calcium Inj
leucovorin calcium Oral             MO
mesna IV
MESNEX IV 

MESNEX ORAL 

sodium polystyrene sulfonate Oral
SYPRINE ORAL 

Opioid Antagonists
BUPRENEX INJ 

buprenorphine Inj
DEPADE ORAL 

naloxone Inj
naltrexone Oral
REVIA ORAL 

VIVITROL IM 

Smoking Cessation Agents
CHANTIX ORAL                        PA
CHANTIX STARTING MONTH PAK ORAL     PA
NICOTROL INHL                       PA; QL (174 EA per 31 day(s))
NICOTROL NS NASL                    PA
Antiemetics
       Page 26 of 122 

       Effective: 08/01/11 

Drug                                        Notes
5-Hydroxytryptamine 3 (5-HT3) Antagonists
ALOXI IV 

ANZEMET IV 

ANZEMET ORAL                                BvD
granisetron IV
granisetron Oral                            BvD
granisetron (PF) IV
GRANISOL ORAL                               BvD
KYTRIL IV 

KYTRIL ORAL                                 BvD
ondansetron Oral                            BvD; QL (45 EA per 30 day(s))
ondansetron HCl Oral Soln                   BvD
ondansetron HCl Tab 4 mg, 8 mg              BvD; QL (45 EA per 30 day(s))
ondansetron HCl Tab 24 mg                   BvD; QL (7 EA per 30 day(s))
ondansetron HCl (PF) Inj
ZOFRAN IV 

ZOFRAN ORAL                                 BvD
ZOFRAN ODT ORAL                             BvD
Antiemetics, Other
ANTIVERT TAB 50 mg
ANTIVERT TAB 12.5 mg, 25 mg
CESAMET ORAL                                BvD; QL (60 EA per 25 day(s))
COMPRO RECT 

dronabinol Oral                             QL (60 EA per 25 day(s))
meclizine Oral
metoclopramide Inj
metoclopramide Oral
METOZOLV ODT ORAL 

PHENADOZ RECT 

PHENERGAN INJ 

       Page 27 of 122 

       Effective: 08/01/11 

Drug                                      Notes
prochlorperazine Rect
prochlorperazine Edisylate Inj
prochlorperazine maleate Oral
promethazine Inj
promethazine Oral
promethazine Rect
PROMETHAZINE VC ORAL 

PROMETHEGAN RECT 

REGLAN INJ 

REGLAN ORAL 

SANCUSO TD                                QL (2 EA per 15 day(s))
TIGAN IM 

TIGAN ORAL 

TRANSDERM-SCOP TD 

trimethobenzamide IM
trimethobenzamide Oral
Neurokinin 1 (NK1) Receptor Antagonists
EMEND CAP 40 mg                           BvD; QL (1 EA per 30 day(s))
EMEND CAP 125 mg                          BvD; QL (2 EA per 25 day(s))
EMEND CAP 80 mg                           BvD; QL (4 EA per 25 day(s))
EMEND CAPS IN DOSE PACK                   BvD; QL (12 EA per 30 day(s))
Antifungals
Allylamine Antifungals
LAMISIL ORAL                              PA
NAFTIN TOP 

terbinafine Oral                          PA
Antifungals (Other)
ANCOBON ORAL 

ciclopirox Top
GRIFULVIN V ORAL 

       Page 28 of 122
       Effective: 08/01/11
Drug                                Notes
griseofulvin microsize Oral
GRIS-PEG ORAL 

LOPROX SHAMPOO 

LOPROX TOPICAL GEL 

MENTAX TOP 

PENLAC TOP 

Azole Antifungals
clotrimazole MM
clotrimazole Top
clotrimazole-betamethasone Top
DIFLUCAN ORAL 

DIFLUCAN IN NACL (ISO-OSM) IV 

econazole Top
ERTACZO TOP 

EXELDERM TOP 

EXTINA TOP 

fluconazole Oral
fluconazole in dextrose(iso-o) IV
GYNAZOLE-1 VAGL 

itraconazole Oral                   PA
ketoconazole Oral
ketoconazole Top
KURIC TOP 

LAMISIL TOP 

LOTRISONE TOP 

MICONAZOLE-3 VAGL 

NIZORAL TOP 

NOXAFIL ORAL 

OXISTAT TOP 

SPORANOX CAP                        PA
       Page 29 of 122 

       Effective: 08/01/11 

Drug                                                             Notes
SPORANOX ORAL SOLN 

SPORANOX PULSEPAK ORAL                                           PA
TERAZOL 3 VAGL 

TERAZOL 7 VAGL 

terconazole Vagl
VFEND ORAL 

VFEND IV IV 

voriconazole Tab 50 mg
voriconazole Tab 200 mg
XOLEGEL TOP 

ZAZOLE VAGL 

Echinocandin Antifungals
ABELCET IV 

CANCIDAS IV 

ERAXIS(WATER DILUENT) IV 

MYCAMINE IV 

Polyene Antifungals
AMBISOME IV 

AMPHOTEC IV 

amphotericin b Inj
NATACYN OPHT 

nystatin Oral
nystatin Top
nystatin-triamcinolone Top
NYSTOP TOP 

PEDI-DRI TOP 

Antigout Agents
Antigout Agents (Non-renal Tubular Blocking Agents and Non-xanthine Inhibitors)
COLCRYS ORAL                                                     MO; QL (120 EA per 30 day(s))
Renal Tubular Blocking Agents
       Page 30 of 122 

       Effective: 08/01/11 

Drug                                   Notes
colchicine-probenecid Oral             MO
probenecid Oral                        MO
Xanthine Oxidase Inhibitors
allopurinol Oral                       MO
allopurinol sodium IV
ALOPRIM IV 

ZYLOPRIM ORAL                          MO
Anti-inflammatory Agents
Nonsteroidal Anti-inflammatory Drugs
ANAPROX ORAL
ANAPROX DS ORAL 

ARTHROTEC 50 ORAL 

ARTHROTEC 75 ORAL 

CATAFLAM ORAL 

CELEBREX ORAL 

CLINORIL ORAL 

DAYPRO ORAL 

diclofenac potassium Oral
diclofenac sodium Oral
diflunisal Oral
EC-NAPROSYN ORAL 

etodolac Oral
FELDENE ORAL 

fenoprofen Oral
flurbiprofen Oral
ibuprofen Oral
INDOCIN ORAL 

indomethacin Oral
ketoprofen Oral
ketorolac Inj
       Page 31 of 122
       Effective: 08/01/11
Drug                                   Notes
ketorolac Oral                         QL (20 EA per 25 day(s))
meclofenamate Oral
mefenamic acid Oral
meloxicam Oral
MOBIC ORAL 

nabumetone Oral
NALFON ORAL 

NAPRELAN CR 24 HR TAB 375 mg, 500 mg
NAPROSYN ORAL 

naproxen Oral
naproxen sodium Oral
oxaprozin Oral
piroxicam Oral
PONSTEL ORAL 

sulindac Oral
tolmetin Oral
VIMOVO ORAL                            ST; QL (60 EA per 30 day(s))
VOLTAREN ORAL 

VOLTAREN TOP 

VOLTAREN-XR ORAL 

Antimigraine Agents
Ergot Alkaloids
CAFERGOT ORAL
D.H.E.45 INJ 

dihydroergotamine Inj
ERGOMAR SL 

ergotamine-caffeine Oral
METHERGINE ORAL 

MIGERGOT RECT 

MIGRANAL NASL                          QL (8 ML per 25 day(s))
       Page 32 of 122
       Effective: 08/01/11
Drug                               Notes
Triptans
AMERGE ORAL                        QL (9 EA per 25 day(s))
AXERT ORAL                         QL (12 EA per 25 day(s))
FROVA ORAL                         QL (18 EA per 25 day(s))
IMITREX NASL                       QL (12 EA per 25 day(s))
IMITREX ORAL                       QL (9 EA per 25 day(s))
IMITREX SUBQ                       QL (10 ML per 25 day(s))
IMITREX STATDOSE KIT REFILL SUBQ   QL (4 EA per 25 day(s))
MAXALT ORAL                        QL (12 EA per 25 day(s))
MAXALT-MLT ORAL                    QL (12 EA per 25 day(s))
naratriptan Oral                   QL (9 EA per 25 day(s))
RELPAX ORAL                        QL (12 EA per 25 day(s))
sumatriptan Sub-Q 6 mg/0.5 mL      QL (10 ML per 25 day(s))
sumatriptan Sub-Q 4 mg/0.5 mL      QL (4 ML per 25 day(s))
sumatriptan succinate Oral         QL (9 EA per 25 day(s))
TREXIMET ORAL                      QL (9 EA per 25 day(s))
ZOMIG NASL                         QL (12 EA per 25 day(s))
ZOMIG ORAL                         QL (12 EA per 25 day(s))
ZOMIG ZMT ORAL                     QL (12 EA per 25 day(s))
Antimyasthenic Agents
Parasympathomimetics
guanidine Oral
MESTINON SYRUP
MESTINON TAB
MESTINON TIMESPAN ORAL
MYTELASE ORAL
pyridostigmine bromide Oral
REGONOL INJ
Antimycobacterials
Antimycobacterials, Other
       Page 33 of 122 

       Effective: 08/01/11 

Drug                         Notes
ACZONE TOP                   MO        

dapsone Oral
MYCOBUTIN ORAL 

Antituberculars
CAPASTAT INJ 

ethambutol Oral
ISONARIF ORAL 

isoniazid Inj
isoniazid Oral
MYAMBUTOL ORAL 

PASER ORAL 

PRIFTIN ORAL 

pyrazinamide Oral
RIFADIN IV 

RIFADIN ORAL 

RIFAMATE ORAL 

rifampin IV
rifampin Oral
RIFATER ORAL 

SEROMYCIN ORAL 

TRECATOR ORAL 

Antineoplastics
Alkylating Agents, Other
carboplatin IV
cisplatin IV
cyclophosphamide Oral        BvD; MO
dacarbazine IV
ELOXATIN IV 

IFEX IV 

ifosfamide IV
       Page 34 of 122
       Effective: 08/01/11
Drug                           Notes
ifosfamide-mesna IV 

MATULANE ORAL                  MO
oxaliplatin IV 

thiotepa Inj
vinblastine IV 

vincristine IV 

Antiangiogenic Agents
REVLIMID ORAL                  PA-NS; MO; LA
THALOMID ORAL                  PA-NS; MO
Anti-CD20 Antibodies
ARZERRA IV 

AVASTIN IV 

CAMPATH IV 

ERBITUX IV 

RITUXAN IV 
                   PA-NS
SIMULECT IV 

VECTIBIX IV 

Antimetabolites, Other
ALIMTA IV 

DROXIA ORAL                    MO
fluorouracil IV 

HYDREA ORAL                    MO
hydroxyurea Oral               MO
idarubicin IV 

Antineoplastics, Other
ABRAXANE IV 

ADRIAMYCIN PFS IV 

bleomycin Inj
CAMPTOSAR IV 

COSMEGEN IV 

       Page 35 of 122 

       Effective: 08/01/11 

Drug                           Notes
daunorubicin IV
DAUNOXOME IV 

docetaxel IV
doxorubicin IV
ELLENCE IV 

ELSPAR INJ 

epirubicin IV
ETOPOPHOS IV 

etoposide IV
HALAVEN IV                     PA-NS
HYCAMTIN IV 

irinotecan IV
ISTODAX IV                     PA-NS
JEVTANA IV                     PA-NS
LYSODREN ORAL                  MO
mitomycin IV
mitoxantrone IV
NOVANTRONE IV 

ONCASPAR INJ 

ONTAK IV 

paclitaxel IV
PANRETIN TOP                   MO
PHOTOFRIN IV 

TAXOTERE IV 

TOPOSAR IV 

topotecan IV
TORISEL IV 

TRISENOX IV 

VELCADE IV 

vinorelbine IV
       Page 36 of 122 

       Effective: 08/01/11 

Drug                                                                Notes
ZANOSAR IV 

ZOLINZA ORAL                                                        MO
ZYTIGA ORAL                                                         PA-NS
Aromatase Inhibitors, 3rd Generation
anastrozole Oral
ARIMIDEX ORAL                                                       MO
AROMASIN ORAL                                                       MO
exemestane Oral
FEMARA ORAL                                                         MO
letrozole Oral
Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors
IRESSA ORAL                                                         MO
TARCEVA TAB 100 mg, 150 mg                                          PA-NS; MO; QL (31 EA per 31
                                                                    day(s))
TARCEVA TAB 25 mg                                                   PA-NS; MO; QL (62 EA per 31
                                                                    day(s))
vandetanib Oral                                                     PA-NS; LA
Estrogen-nitrosoureas
EMCYT ORAL                                                          MO
FASLODEX IM 

Ethylenimines/ Methylmelamines
HEXALEN ORAL                                                        MO
Multitargeted Kinase Inhibitors, Bcr-Abl/c-kit Receptor Tyrosine Kinase Inhibitors
GLEEVEC ORAL                                                        MO
SPRYCEL ORAL                                                        MO
TASIGNA ORAL                                                        MO
Multitargeted Kinase Inhibitors, HER2 Receptor Tyrosine Kinase Inhibitors
HERCEPTIN IV 

TYKERB ORAL                                                         MO
Multitargeted Kinase Inhibitors, Vascular Endothelial Growth Factor Receptor Tyrosine Kinase Inhib.

       Page 37 of 122 

       Effective: 08/01/11 

Drug                                    Notes
AFINITOR TAB 5 mg                       PA-NS; MO; QL (31 EA per 31
                                        day(s))
AFINITOR TAB 10 mg                      PA-NS; MO; QL (62 EA per 31
                                        day(s))
AFINITOR TAB 2.5 mg                     PA-NS; QL (31 EA per 31 day(s))
NEXAVAR ORAL                            PA-NS; MO; QL (124 EA per 31
                                        day(s))
SUTENT CAP 12.5 mg                      PA-NS; MO; QL (124 EA per 31
                                        day(s))
SUTENT CAP 50 mg                        PA-NS; MO; QL (31 EA per 31
                                        day(s))
SUTENT CAP 25 mg                        PA-NS; MO; QL (62 EA per 31
                                        day(s))
VOTRIENT ORAL                           MO
ZORTRESS TAB 0.25 mg                    PA-NS
ZORTRESS TAB 0.5 mg, 0.75 mg            PA-NS
Nitrogen Mustards
ALKERAN IV 

LEUKERAN ORAL                           MO
melphalan IV
MUSTARGEN INJ 

Nitrosoureas
BICNU IV 

CEENU ORAL                              MO
Purine Analogs and Related Inhibitors
ARRANON IV 

cladribine IV
CLOLAR IV 

cytarabine Inj
cytarabine (PF) Inj
DACOGEN IV                              BvD
FLUDARA IV 

       Page 38 of 122 

       Effective: 08/01/11 

Drug                                                     Notes
fludarabine IV
gemcitabine IV                                           MO
GEMZAR IV 

LEUSTATIN IV 

mercaptopurine Oral                                      MO
NIPENT IV 

pentostatin IV
PURINETHOL ORAL                                          MO
TABLOID ORAL                                             MO
VIDAZA SUBQ 

Retinoids
TARGRETIN ORAL                                           MO
TARGRETIN TOP                                            MO
tretinoin (chemotherapy) Oral                            MO
Selective Estrogen Receptor Modulators, 1st Generation
FARESTON ORAL                                            MO
tamoxifen Oral                                           MO
Antiparasitics
Anthelmintics
ALBENZA ORAL 

BILTRICIDE ORAL 

mebendazole Oral
STROMECTOL ORAL 

Antimalarials
ARALEN ORAL 

chloroquine phosphate Oral
COARTEM ORAL                                             QL (24 EA per 31 day(s))
DARAPRIM ORAL 

hydroxychloroquine Oral
MALARONE ORAL 

       Page 39 of 122
       Effective: 08/01/11
Drug                                             Notes
mefloquine Oral
PLAQUENIL ORAL 

primaquine Oral
QUALAQUIN ORAL 

Antiprotozoals (Non-antimalarials)
ALINIA ORAL SUSP                                 QL (180 ML per 25 day(s)) 

ALINIA TAB                                       QL (12 EA per 25 day(s)) 

MEPRON ORAL 

NEBUPENT INHL                                    BvD
PENTAM INJ 

Pediculicides/ Scabicides
ACTICIN TOP 

EURAX TOP 

lindane Top
malathion Top
OVIDE TOP 

permethrin Top
Antiparkinson Agents
Anticholinergics
benztropine Inj
benztropine Oral                                 MO
COGENTIN INJ 

trihexyphenidyl Oral                             MO
Antiparkinson Agents, Other
amantadine Cap                                   MO
amantadine Syrup
amantadine Tab                                   MO
APOKYN SUBQ 

Catechol O-methyltransferase (COMT) Inhibitors
COMTAN ORAL                                      MO
       Page 40 of 122
       Effective: 08/01/11
Drug                                           Notes
TASMAR ORAL                                    MO
Dopamine Agonists, Ergot
bromocriptine Oral                             MO
cabergoline Oral                               MO
PARLODEL ORAL                                  MO
Dopamine Agonists, Nonergot
MIRAPEX ORAL                                   MO
MIRAPEX ER ORAL 

pramipexole Tab 0.75 mg
pramipexole Tab 0.125 mg, 0.25 mg, 0.5 mg, 1   MO
mg, 1.5 mg
REQUIP ORAL                                    MO
REQUIP XL 24 HR TAB 6 mg
REQUIP XL 24 HR TAB 12 mg, 2 mg, 4 mg, 8       MO
mg
ropinirole Oral                                MO
Dopamine Precursors
ATAMET ORAL                                    MO
carbidopa-levodopa Oral                        MO
LODOSYN ORAL                                   MO
PARCOPA ORAL                                   MO
SINEMET ORAL                                   MO
SINEMET 25-250 ORAL                            MO
SINEMET CR ORAL                                MO
STALEVO 100 ORAL                               MO
STALEVO 125 ORAL                               MO
STALEVO 150 ORAL                               MO
STALEVO 200 ORAL                               MO
STALEVO 50 ORAL                                MO
STALEVO 75 ORAL                                MO

       Page 41 of 122 

       Effective: 08/01/11 

Drug                                                 Notes
Monoamine Oxidase B (MAO-B) Inhibitors
AZILECT ORAL                                         MO
ELDEPRYL ORAL                                        MO
selegiline HCl Oral                                  MO
Antipsychotics
Atypicals
ABILIFY IM 

ABILIFY ORAL
                                        MO            

ABILIFY DISCMELT ORAL 
                              MO
clozapine Oral                                       MO            

CLOZARIL ORAL
                                       MO            

FANAPT ORAL 
                                        ST-NS; MO
FAZACLO TAB, RAPID DISSOLVE 150 mg, 

200 mg

FAZACLO TAB, RAPID DISSOLVE 100 mg, 
                MO
12.5 mg, 25 mg
GEODON IM 

GEODON ORAL                                          MO            

INVEGA ORAL
                                         MO
INVEGA SUSTENNA IM 

LATUDA TAB 80 mg                                     ST-NS; QL (30 EA per 30 day(s))
LATUDA TAB 40 mg                                     ST-NS; QL (90 EA per 30 day(s)) 

RISPERDAL ORAL 
                                     MO
RISPERDAL CONSTA IM 

RISPERDAL M-TAB ORAL                                 MO
risperidone Oral Soln                                MO
risperidone Tab                                      MO
risperidone Tab, Rapid Dissolve 0.25 mg, 0.5 mg, 

2 mg, 3 mg, 4 mg 

risperidone Tab, Rapid Dissolve 1 mg                 MO            

SAPHRIS SL 
                                         MO; QL (62 EA per 31 day(s))
       Page 42 of 122
       Effective: 08/01/11
Drug                                    Notes
SEROQUEL ORAL                           MO
SEROQUEL XR 24 HR TAB 150 mg, 50 mg
SEROQUEL XR 24 HR TAB 200 mg, 300 mg,   MO
400 mg
ZYPREXA IM 

ZYPREXA ORAL                            MO
ZYPREXA ZYDIS ORAL                      MO
Conventional
chlorpromazine Inj
chlorpromazine Oral                     MO
fluphenazine decanoate Inj
fluphenazine HCl Inj
fluphenazine HCl Oral                   MO
HALDOL INJ 

HALDOL DECANOATE IM 

haloperidol Oral                        MO
haloperidol decanoate IM
haloperidol lactate Inj
haloperidol lactate Oral                MO
loxapine succinate Oral                 MO
LOXITANE ORAL                           MO
NAVANE CAP 20 mg                        MO
NAVANE CAP 10 mg, 2 mg, 5 mg            MO
ORAP ORAL 

perphenazine Oral                       MO
thioridazine Oral                       MO
thiothixene Oral                        MO
trifluoperazine Oral                    MO
Antispasticity Agents
Antispasticity Agents

       Page 43 of 122 

       Effective: 08/01/11 

Drug                                Notes
baclofen Oral
DANTRIUM ORAL 

dantrolene Oral
tizanidine Oral
ZANAFLEX ORAL 

Antivirals
Anti-cytomegalovirus (CMV) Agents
foscarnet IV
ganciclovir Cap 250 mg
ganciclovir Cap 500 mg
VISTIDE IV 

Antihepatitis Agents
BARACLUDE ORAL 

COPEGUS ORAL                        PA
HEPSERA ORAL 

REBETOL ORAL                        PA
RIBAPAK DOSE PACK ORAL              PA
RIBASPHERE CAP                      PA
RIBASPHERE TAB 200 mg               PA
RIBASPHERE TAB 400 mg, 600 mg       PA
ribavirin Cap                       PA
ribavirin Tab 200 mg                PA
ribavirin Tab 400 mg, 600 mg        PA
TYZEKA ORAL 

VIRAZOLE INHL 

Antiherpetic Agents
acyclovir Oral
acyclovir sodium IV
DENAVIR TOP 

famciclovir Oral
       Page 44 of 122
       Effective: 08/01/11
Drug                                                               Notes
FAMVIR ORAL 

ganciclovir sodium IV
valacyclovir Oral
VALCYTE ORAL 

VALTREX ORAL 

ZOVIRAX ORAL 

ZOVIRAX TOP 

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors
ATRIPLA ORAL                                                       MO
EDURANT ORAL 

INTELENCE ORAL                                                     MO
RESCRIPTOR ORAL                                                    MO
SUSTIVA ORAL                                                       MO
VIRAMUNE ORAL                                                      MO
VIRAMUNE XR ORAL 

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors
COMBIVIR ORAL                                                      MO
didanosine Oral                                                    MO
EMTRIVA ORAL                                                       MO
EPIVIR ORAL                                                        MO
EPIVIR HBV ORAL                                                    MO
EPZICOM ORAL                                                       MO
RETROVIR IV 

RETROVIR ORAL                                                      MO
stavudine Cap                                                      MO
stavudine Oral Solution
TRIZIVIR ORAL                                                      MO
TRUVADA ORAL                                                       MO
VIDEX 2 GRAM PEDIATRIC ORAL                                        MO
VIDEX EC ORAL                                                      MO
       Page 45 of 122 

       Effective: 08/01/11 

Drug                                   Notes
VIREAD ORAL                            MO
ZERIT CAP                              MO
ZERIT ORAL SOLUTION                    MO
ZIAGEN ORAL                            MO
zidovudine Oral                        MO
Anti-HIV Agents, Other
FUZEON SUBQ 

ISENTRESS ORAL                         MO
SELZENTRY ORAL                         MO
Anti-HIV Agents, Protease Inhibitors
APTIVUS ORAL                           MO
CRIXIVAN ORAL                          MO
INVIRASE ORAL                          MO
KALETRA ORAL                           MO
LEXIVA ORAL                            MO
NORVIR CAP                             MO
NORVIR ORAL SOLN                       MO
NORVIR TAB 

PREZISTA TAB 150 mg
PREZISTA TAB 75 mg                     MO
PREZISTA TAB 400 mg, 600 mg            MO
REYATAZ ORAL                           MO
VIRACEPT ORAL                          MO
Anti-influenza Agents
FLUMADINE ORAL 

RELENZA DISKHALER INHL 

rimantadine Oral
TAMIFLU ORAL
Anxiolytics
Antidepressants
       Page 46 of 122 

       Effective: 08/01/11 

Drug                                     Notes
CELEXA ORAL                              MO
citalopram Oral                          MO
fluoxetine Cap                           MO
fluoxetine Cap, Delayed Release
fluoxetine Oral Soln                     MO
fluoxetine Tab                           MO
fluvoxamine Oral                         MO
LEXAPRO ORAL                             MO
NARDIL ORAL                              MO
paroxetine ER 24 hr Tab 37.5 mg
paroxetine ER 24 hr Tab 12.5 mg, 25 mg   MO
paroxetine Oral Susp                     MO
paroxetine Tab                           MO
PAXIL ORAL                               MO
PAXIL CR ORAL                            MO
PEXEVA ORAL                              MO
phenelzine Oral                          MO
PROZAC ORAL                              MO
PROZAC WEEKLY ORAL                       MO
RAPIFLUX ORAL 

SARAFEM ORAL                             MO
sertraline Oral                          MO
ZOLOFT ORAL                              MO
Anxiolytics, Other
amitriptyline-chlordiazepoxide Oral      MO
buspirone Oral                           MO
meprobamate Oral                         MO
Bipolar Agents
Bipolar Agents
EQUETRO ORAL 

       Page 47 of 122 

       Effective: 08/01/11 

Drug                                        Notes
lithium carbonate Oral
lithium citrate Oral
LITHOBID ORAL 

SYMBYAX ORAL                                MO
Blood Glucose Regulators
Alpha Glucosidase Inhibitors
acarbose Oral                               MO
GLYSET ORAL                                 MO
PRECOSE ORAL                                MO
Amylinomimetics
SYMLIN SUBQ 

SYMLINPEN 120 SUBQ 

SYMLINPEN 60 SUBQ 

Biguanides
FORTAMET ORAL                               MO
GLUCOPHAGE ORAL                             MO
GLUCOPHAGE XR ORAL                          MO
GLUMETZA ORAL                               MO
metformin Oral                              MO
RIOMET ORAL                                 MO
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
JANUMET ORAL                                MO
JANUVIA ORAL                                MO
ONGLYZA ORAL                                MO
Glycemic Agents
GLUCAGEN HYPOKIT INJ 

GLUCAGON EMERGENCY INJ 

Incretin Mimetics
BYETTA SUBQ 

VICTOZA SUBQ 

       Page 48 of 122
       Effective: 08/01/11
Drug                                                     Notes
Insulin Mixtures, Analogs
CURITY GAUZE TOP 

HUMALOG MIX 50-50 SUBQ 

HUMALOG MIX 50-50 KWIKPEN SUBQ 

HUMALOG MIX 75-25 SUBQ 

HUMALOG MIX 75-25 KWIKPEN SUBQ 

INSULIN PEN NEEDLE MISC 

insulin syringe-needle U-100 Misc
NOVOLOG MIX 70-30 SUBQ 

NOVOLOG MIX 70-30 FLEXPEN SUBQ 

safety needles Misc
Insulin Mixtures, Short-acting and Intermediate-acting
HUMULIN 70/30 SUBQ 

HUMULIN 70/30 PEN SUBQ 

NOVOLIN 70/30 SUBQ 

NOVOLIN 70/30 INNOLET SUBQ 

Insulin, Intermediate-acting
HUMULIN N SUBQ 

HUMULIN N PEN SUBQ 

NOVOLIN N SUBQ 

NOVOLIN N INNOLET SUBQ 

Insulin, Long-acting
LANTUS SUBQ 

LANTUS SOLOSTAR SUBQ 

LEVEMIR SUBQ 

LEVEMIR FLEXPEN SUBQ 

Insulin, Rapid-acting
APIDRA SUBQ 

APIDRA SOLOSTAR SUBQ 

HUMALOG SUBQ 

       Page 49 of 122 

       Effective: 08/01/11 

Drug                                   Notes
HUMALOG KWIKPEN SUBQ 

NOVOLOG SUBQ 

NOVOLOG FLEXPEN SUBQ 

Insulin, Short-acting
HUMULIN R INJ 

HUMULIN R U-500 "CONCENTRATED" INJ 

NOVOLIN R INJ 

Meglitinides
nateglinide Oral                       MO
PRANDIMET ORAL                         MO
PRANDIN ORAL                           MO
STARLIX ORAL                           MO
Sulfonylureas
AMARYL ORAL                            MO
chlorpropamide Oral                    MO
DIABETA ORAL                           MO
glimepiride Oral                       MO
glipizide Oral                         MO
glipizide-metformin Oral               MO
GLUCOTROL ORAL                         MO
GLUCOTROL XL ORAL                      MO
GLUCOVANCE ORAL                        MO
glyburide Oral                         MO
glyburide micronized Oral              MO
glyburide-metformin Oral               MO
GLYCRON TAB 1.5 mg, 3 mg, 6 mg         MO
GLYCRON TAB 4.5 mg                     MO
GLYNASE ORAL                           MO
METAGLIP ORAL                          MO
tolazamide Oral                        MO
       Page 50 of 122 

       Effective: 08/01/11 

Drug                                                 Notes
tolbutamide Oral                                     MO
Thiazolidinediones
ACTOPLUS MET ORAL                                    MO
ACTOPLUS MET XR ORAL 

ACTOS ORAL                                           MO
AVANDAMET ORAL                                       MO
AVANDARYL ORAL                                       MO
AVANDIA ORAL                                         MO
DUETACT ORAL                                         MO
Blood Products/Modifiers/ Volume Expanders
Adenosine Diphosphate P2Y12 Inhibitors
EFFIENT TAB 10 mg                                    MO; QL (36 EA per 31 day(s))
EFFIENT TAB 5 mg                                     MO; QL (43 EA per 31 day(s))
PLAVIX ORAL                                          MO
ticlopidine Oral                                     MO
Anticoagulants, Oral
COUMADIN IV 

COUMADIN ORAL                                        MO
JANTOVEN ORAL                                        MO
PRADAXA ORAL                                         PA; QL (60 EA per 30 day(s))
warfarin Oral                                        MO
Colony Stimulating Factors
LEUKINE INJ                                          PA
MOZOBIL SUBQ                                         PA
NEULASTA SUBQ                                        PA
NEUPOGEN INJ                                         PA
Cyclic Adenosine Monophosphate Reuptake Inhibitors
AGGRENOX ORAL                                        MO
AGRYLIN ORAL                                         MO
anagrelide Oral                                      MO
       Page 51 of 122
       Effective: 08/01/11
Drug                                              Notes
dipyridamole Oral                                 MO
PERSANTINE ORAL                                   MO
Erythropoietins
ARANESP (POLYSORBATE) INJ                         PA
EPOGEN INJECTION 2,000 unit/mL, 3,000             PA; QL (12 ML per 30 day(s))
unit/mL, 4,000 unit/mL
EPOGEN INJECTION 20,000 unit/2 mL, 20,000         PA; QL (12 ML per 30 day(s))
unit/mL, 40,000 unit/mL
NEUMEGA SUBQ                                      PA; QL (21 EA per 30 day(s))
PROCRIT INJECTION 10,000 unit/mL, 2,000           PA; QL (12 ML per 30 day(s))
unit/mL, 3,000 unit/mL, 4,000 unit/mL
PROCRIT INJECTION 20,000 unit/mL, 40,000          PA; QL (12 ML per 30 day(s))
unit/mL
PROMACTA TAB 75 mg                                PA-NS
PROMACTA TAB 25 mg, 50 mg                         PA-NS; MO
Factor Xa Inhibitors, Indirect
ARIXTRA SUBQ 

Low Molecular Weight Heparins
enoxaparin SubQ
FRAGMIN SUB-Q 

FRAGMIN SUB-Q SYRINGE 12,500 unit/0.5
mL, 15,000 unit/0.6 mL, 18,000 unit/0.72 mL,
2,500 unit/0.2 mL, 5,000 unit/0.2 mL, 7,500
unit/0.3 mL
FRAGMIN SUB-Q SYRINGE 10,000 unit/mL
heparin (porcine) Inj                             BvD
heparin (porcine) in D5W IV                       BvD
heparin (porcine) in NS (PF) IV                   BvD
heparin (porcine)-0.45% NaCl IV 25,000 unit/250   BvD
mL
heparin (porcine)-0.45% NaCl IV 25,000 unit/500   BvD
mL
heparin, porcine (PF) IV                          BvD
       Page 52 of 122
       Effective: 08/01/11
Drug                                                           Notes
INNOHEP SUBQ 

LOVENOX SUBQ 

Phosphodiesterase III/Adenosine Uptake Inhibitors
cilostazol Oral                                                MO
PLETAL ORAL                                                    MO
Protease Inhibitors
LYSTEDA ORAL 

Cardiovascular Agents
3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) Reductase Inhibitors
ADVICOR ORAL                                                   MO
ALTOPREV ORAL                                                  MO
CRESTOR ORAL                                                   MO
LESCOL ORAL                                                    MO
LESCOL XL ORAL                                                 MO
LIPITOR ORAL                                                   MO
LIVALO ORAL                                                    ST-NS; QL (30 EA per 30 day(s))
lovastatin Oral                                                MO
MEVACOR ORAL                                                   MO
PRAVACHOL ORAL                                                 MO
pravastatin Oral                                               MO
SIMCOR 24 HR TAB 1,000-40 mg, 500-40 mg
SIMCOR 24 HR TAB 1,000-20 mg, 500-20 mg,                       MO
750-20 mg
simvastatin Oral                                               MO
VYTORIN 10-10 ORAL                                             MO
VYTORIN 10-20 ORAL                                             MO
VYTORIN 10-40 ORAL                                             MO
VYTORIN 10-80 ORAL                                             MO
ZOCOR ORAL                                                     MO
Alpha-adrenergic Agonists

       Page 53 of 122
       Effective: 08/01/11
Drug                                             Notes
clonidine Oral                                   MO
clonidine TD                                     MO
CLORPRES ORAL                                    MO
guanabenz Oral                                   MO
guanfacine Oral                                  MO
methyldopa Oral                                  MO
methyldopa-hydrochlorothiazide Oral              MO
methyldopate IV
midodrine Oral                                   MO
PROAMATINE ORAL                                  MO
Alpha-adrenergic Blocking Agents
CARDURA XL ORAL                                  MO
DIBENZYLINE ORAL                                 MO
doxazosin Oral                                   MO
prazosin Oral                                    MO
terazosin Oral                                   MO
Angiotensin II Receptor Antagonists
BENICAR ORAL 

BENICAR HCT ORAL 

DIOVAN ORAL                                      MO
DIOVAN HCT ORAL                                  MO
EDARBI ORAL                                      ST; QL (30 EA per 30 day(s))
losartan Oral                                    QL (30 EA per 30 day(s))
losartan-hydrochlorothiazide Oral                QL (30 EA per 30 day(s))
MICARDIS TAB 80 mg
MICARDIS TAB 20 mg, 40 mg                        MO
MICARDIS HCT ORAL                                MO
Angiotensin-converting Enzyme (ACE) Inhibitors
AZOR ORAL                                        MO
benazepril Oral                                  MO
       Page 54 of 122 

       Effective: 08/01/11 

Drug                                   Notes
benazepril-hydrochlorothiazide Oral    MO
captopril Oral                         MO
captopril-hydrochlorothiazide Oral     MO
enalapril maleate Oral                 MO
enalapril-hydrochlorothiazide Oral     MO
EXFORGE ORAL                           MO
fosinopril Oral                        MO
fosinopril-hydrochlorothiazide Oral    MO
lisinopril Oral                        MO
lisinopril-hydrochlorothiazide Oral    MO
moexipril Oral                         MO
moexipril-hydrochlorothiazide Oral     MO
perindopril erbumine Oral              MO
quinapril Oral                         MO
quinapril-hydrochlorothiazide Oral     MO
ramipril Oral                          MO
trandolapril Oral                      MO
Antiarrhythmics - Class IA/II/III/IV
amiodarone IV
amiodarone Oral                        MO
PACERONE TAB 200 mg                    MO
PACERONE TAB 100 mg                    MO
PACERONE TAB 400 mg                    MO
Antiarrhythmics - Class II
LOPRESSOR IV 

metoprolol tartrate IV
propranolol IV
Antiarrhythmics - Class II/III
sotalol IV
sotalol Oral                           MO
       Page 55 of 122 

       Effective: 08/01/11 

Drug                                                           Notes
Antiarrhythmics - Class III 

TIKOSYN ORAL                                                   MO
Antiarrhythmics - Class IV
diltiazem IV
diltiazem IV powder for Solution
verapamil IV
Antiarrhythmics - Classes IA, B, and C
disopyramide Oral                                              MO
flecainide Oral                                                MO
mexiletine Oral                                                MO
MULTAQ ORAL                                                    MO
propafenone ER 12 hr Cap
propafenone Tab                                                MO
quinidine gluconate Inj
quinidine gluconate Oral                                       MO
quinidine sulfate Oral                                         MO
Beta-adrenergic Blocking Agents with Vasodilating Properties
BYSTOLIC TAB 20 mg
BYSTOLIC TAB 10 mg, 2.5 mg, 5 mg                               MO
carvedilol Oral                                                MO
COREG ORAL                                                     MO
COREG CR ORAL                                                  MO
labetalol IV
labetalol Oral                                                 MO
TRANDATE ORAL                                                  MO
Bile Acid Sequestrants
CHOLESTYRAMINE LIGHT ORAL                                      MO
COLESTID ORAL                                                  MO
colestipol Oral                                                MO
PREVALITE ORAL                                                 MO
       Page 56 of 122 

       Effective: 08/01/11 

Drug                                                     Notes
QUESTRAN ORAL                                            MO
WELCHOL ORAL                                             MO
Calcium Channel Blocking Agents (Non-dihydropyridines)
CALAN ORAL                                               MO
CALAN SR ORAL                                            MO
CARDIZEM ORAL                                            MO
CARDIZEM CD 24 HR CAP 360 mg                             MO
CARDIZEM CD 24 HR CAP 120 mg, 180 mg,                    MO
240 mg, 300 mg
CARDIZEM LA ORAL                                         MO
CARTIA XT ORAL                                           MO
COVERA-HS ORAL                                           MO
DILACOR XR ORAL                                          MO
diltiazem HCl Oral                                       MO
DILT-XR ORAL                                             MO
ISOPTIN SR ORAL                                          MO
MATZIM LA ORAL 

TAZTIA XT ORAL                                           MO
TIAZAC ORAL                                              MO
verapamil Oral                                           MO
VERELAN ORAL                                             MO
VERELAN PM ORAL                                          MO
Carbonic Anhydrase Inhibitors
acetazolamide Oral                                       MO
acetazolamide sodium Inj
DIAMOX SEQUELS ORAL                                      MO
methazolamide Oral                                       MO
Cardioselective Beta-adrenergic Blocking Agents
acebutolol Oral                                          MO
atenolol Oral                                            MO

       Page 57 of 122 

       Effective: 08/01/11 

Drug                                  Notes
atenolol-chlorthalidone Oral          MO
betaxolol Oral                        MO
bisoprolol fumarate Oral              MO
bisoprolol-hydrochlorothiazide Oral   MO
KERLONE ORAL                          MO
LOPRESSOR ORAL                        MO
LOPRESSOR HCT ORAL                    MO
metoprolol succinate Oral             MO
metoprolol tartrate Oral              MO
metoprolol-hydrochlorothiazide Oral   MO
SECTRAL ORAL                          MO
TENORETIC 100 ORAL                    MO
TENORETIC 50 ORAL                     MO
TENORMIN ORAL                         MO
TOPROL XL ORAL                        MO
ZEBETA ORAL                           MO
ZIAC ORAL                             MO
Cardiovascular Agents, Other
dexrazoxane IV
digoxin Inj
digoxin Oral                          MO
LANOXIN INJ 

LANOXIN ORAL                          MO
LANOXIN PEDIATRIC INJ 

RANEXA ORAL                           MO
reserpine Oral                        MO
SAMSCA ORAL                           MO
ZINECARD IV 

Cholesterol Absorption Inhibitors
ZETIA ORAL                            MO
       Page 58 of 122 

       Effective: 08/01/11 

Drug                                             Notes
Dihydropyridines
ADALAT CC ORAL                                   MO
AFEDITAB CR ORAL                                 MO
amlodipine Oral                                  MO
amlodipine-benazepril Cap 10-40 mg, 5-40 mg
amlodipine-benazepril Cap 10-20 mg, 2.5-10 mg,   MO
5-10 mg, 5-20 mg
CADUET ORAL                                      MO
DYNACIRC CR ORAL                                 MO
EXFORGE HCT TAB 10-160-12.5 mg                   MO; QL (90 EA per 90 day(s))
felodipine Oral                                  MO
isradipine Oral                                  MO
LOTREL CAP 10-40 mg, 5-40 mg                     MO; QL (31 EA per 31 day(s))
nicardipine IV
nicardipine Oral                                 MO
NIFEDIAC CC ORAL                                 MO
NIFEDICAL XL ORAL                                MO
nifedipine Cap 10 mg                             MO
nifedipine Cap 20 mg                             MO
nifedipine ER 24 hr Tab                          MO
nimodipine Oral                                  MO
nisoldipine Oral                                 MO
NORVASC ORAL                                     MO
PROCARDIA ORAL                                   MO
PROCARDIA XL ORAL                                MO
SULAR ORAL                                       MO
TRIBENZOR ORAL 

TWYNSTA ORAL                                     MO
Direct Renin Inhibitors
AMTURNIDE ORAL                                   QL (30 EA per 30 day(s))

       Page 59 of 122 

       Effective: 08/01/11 

Drug                            Notes
TEKAMLO ORAL 

TEKTURNA ORAL                   MO
TEKTURNA HCT ORAL               MO
VALTURNA ORAL                   MO
Fibrates
ANTARA ORAL                     MO
fenofibrate Oral                MO
fenofibrate micronized Oral     MO
FENOGLIDE ORAL                  MO
gemfibrozil Oral                MO
LIPOFEN CAP 150 mg
LIPOFEN CAP 50 mg               MO
LOFIBRA ORAL                    MO
LOPID ORAL                      MO
TRICOR ORAL                     MO
TRIGLIDE ORAL                   MO
Loop Diuretics
bumetanide Inj
bumetanide Oral                 MO
DEMADEX ORAL                    MO
EDECRIN ORAL                    MO
furosemide Inj
furosemide Oral                 MO
LASIX ORAL                      MO
SODIUM EDECRIN IV 

torsemide IV
torsemide Oral                  MO
Nicotinic Acid
NIACOR ORAL                     MO
NIASPAN EXTENDED-RELEASE ORAL   MO
       Page 60 of 122 

       Effective: 08/01/11 

Drug                                           Notes
Nonselective Beta-adrenergic Blocking Agents
CORGARD ORAL                                   MO
CORZIDE ORAL                                   MO
INDERAL LA ORAL                                MO
INNOPRAN XL ORAL                               MO
LEVATOL ORAL                                   MO
nadolol Oral                                   MO
nadolol-bendroflumethiazide Oral               MO
pindolol Oral                                  MO
propranolol Oral                               MO
propranolol-hydrochlorothiazid Oral            MO
SORINE ORAL                                    MO
timolol maleate Oral                           MO
Omega-3 Fatty Acids
LOVAZA ORAL                                    MO
Potassium-sparing Diuretics
ALDACTAZIDE TAB 50-50 mg                       MO
ALDACTAZIDE TAB 25-25 mg                       MO
amiloride Oral                                 MO
amiloride-hydrochlorothiazide Oral             MO
DYAZIDE ORAL                                   MO
DYRENIUM ORAL                                  MO
eplerenone Oral                                MO
MAXZIDE ORAL                                   MO
MAXZIDE-25MG ORAL                              MO
spironolactone Oral                            MO
spironolacton-hydrochlorothiaz Oral            MO
triamterene-hydrochlorothiazid Oral            MO
Thiazide Diuretics
chlorothiazide Oral                            MO
       Page 61 of 122 

       Effective: 08/01/11 

Drug                                          Notes
chlorothiazide sodium IV
chlorthalidone Oral                           MO
DIURIL ORAL                                   MO
DIURIL IV IV 

hydrochlorothiazide Oral                      MO
indapamide Oral                               MO
methyclothiazide Oral                         MO
metolazone Oral                               MO
MICROZIDE ORAL                                MO
THALITONE ORAL                                MO
ZAROXOLYN ORAL                                MO
Vasodilators, Direct-acting Arterial
hydralazine Inj
hydralazine Oral                              MO
minoxidil Oral                                MO
Vasodilators, Direct-acting Arterial/Venous
BIDIL ORAL                                    MO
DILATRATE-SR ORAL                             MO
IMDUR ORAL                                    MO
ISMO ORAL                                     MO
ISOCHRON ORAL                                 MO
ISORDIL ORAL                                  MO
ISORDIL TITRADOSE ORAL                        MO
isosorbide dinitrate Oral                     MO
isosorbide dinitrate SL                       MO
isosorbide mononitrate Oral                   MO
MINITRAN TD                                   MO
MONOKET ORAL                                  MO
NITRO-DUR TRANSDERM 24 HR PATCH 0.3           MO
mg/hr, 0.8 mg/hr

       Page 62 of 122 

       Effective: 08/01/11 

Drug                                     Notes
NITRO-DUR TRANSDERM 24 HR PATCH 0.1      MO
mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr
nitroglycerin IV
nitroglycerin TD                         MO
NITROLINGUAL TL                          MO
NITROMIST TL 

NITROSTAT SL                             MO
PENTOPAK ORAL                            MO
pentoxifylline Oral                      MO
PROGLYCEM ORAL                           MO
TRENTAL ORAL                             MO
Central Nervous System Agents
Amphetamines, ADHD
ADDERALL ORAL                            PA      

ADDERALL XR ORAL 
                       PA      

AMPHETAMINE SALT COMBO ORAL
             PA      

DEXEDRINE SPANSULE ORAL
                 PA
dextroamphetamine ER Cap
dextroamphetamine Tab                    PA
VYVANSE CAP 30 mg, 50 mg, 70 mg          PA
Non-amphetamines, ADHD
CONCERTA ORAL                            PA      

DAYTRANA TD 
                            PA      

DESOXYN ORAL
                            PA
dexmethylphenidate Oral                  PA      

FOCALIN ORAL
                            PA      

FOCALIN XR ORAL
                         PA      

METADATE CD ORAL 
                       PA      

METADATE ER ORAL 
                       PA
methamphetamine Oral                     PA

       Page 63 of 122
       Effective: 08/01/11
Drug                           Notes
METHYLIN CHEWABLE TAB          PA
METHYLIN ORAL SOLN             PA
METHYLIN TAB                   PA
METHYLIN ER ORAL 

methylphenidate Oral           PA
RITALIN ORAL                   PA
RITALIN LA ORAL                PA
RITALIN SR ORAL                PA
STRATTERA ORAL                 PA
Non-amphetamines, Other
AMPYRA ORAL                    PA; QL (60 EA per 30 day(s))
DEMSER ORAL 

GILENYA ORAL                   PA
NUEDEXTA ORAL                  PA; MO
NUVIGIL ORAL                   PA; QL (31 EA per 30 day(s))
PROVIGIL ORAL                  PA; QL (31 EA per 31 day(s))
RILUTEK ORAL                   MO
XENAZINE ORAL                  PA
XYREM ORAL                     LA
Dental and Oral Agents
Dental and Oral Agents
APHTHASOL MM
chlorhexidine gluconate MM
CYKLOKAPRON IV
EVOXAC ORAL
KEPIVANCE IV
PERIOGARD MM
pilocarpine HCl Oral
triamcinolone acetonide Dent
Dermatological Agents
       Page 64 of 122 

       Effective: 08/01/11 

Drug                                      Notes
Dermatological Acne Agents
adapalene Top                             PA
AKNE-MYCIN TOP 

AMNESTEEM ORAL 

ATRALIN TOP                               PA
AVITA TOP                                 PA
AZELEX TOP 

BENZACLIN CAREKIT TOP 

BENZAMYCIN TOP 

CLARAVIS ORAL 

CLEOCIN T TOP 

CLINDAGEL TOP 

clindamycin phosphate Top
clindamycin-benzoyl peroxide Top
DIFFERIN TOP                              PA
ERY PADS TOP 

erythromycin with ethanol Top
erythromycin-benzoyl peroxide Top
EVOCLIN TOP 

FINACEA TOP 

KLARON TOP 

RETIN-A TOP                               PA
RETIN-A MICRO TOP                         PA
SOTRET ORAL 

TAZORAC TOP 

tretinoin Top                             PA
ZIANA TOP 

Dermatological Anti-inflammatory Agents
SOLARAZE TOP 

Dermatological Antipruritic Agents
       Page 65 of 122 

       Effective: 08/01/11 

Drug                                             Notes
ZONALON TOP 

Dermatological Calcineurin Inhibitors
ELIDEL TOP                                       ST-NS
PROTOPIC TOP                                     ST-NS
Dermatological Caustic Agents
CONDYLOX TOP 

podofilox Top
Dermatological Emollients
ammonium lactate Top
LAC-HYDRIN TOP 

LACLOTION TOP 

Dermatological Genital Wart Agents
ALDARA TOP 

imiquimod Top
VEREGEN TOP 

Dermatological Mitotic Inhibitors
selenium sulfide Top
SELSUN TOP 

Dermatological Non-melanoma Skin Cancer Agents
CARAC TOP 

EFUDEX TOP 

FLUOROPLEX TOP 

fluorouracil Top
Dermatological Photochemotherapy Agents
8-MOP ORAL 

OXSORALEN TOP 

OXSORALEN ULTRA ORAL 

UVADEX INJ 

Dermatological Psoriasis Agents
AMEVIVE IM 

       Page 66 of 122 

       Effective: 08/01/11 

Drug                                             Notes
calcipotriene Top
DOVONEX TOPICAL CREAM 

DOVONEX TOPICAL SOLN 

SORIATANE ORAL 

TACLONEX TOP 

TACLONEX SCALP TOP 

Dermatological Wound Care Agents
REGRANEX TOP                                     PA
SANTYL TOP 

water for irrigation, sterile IR
Enzyme Replacements/ Modifiers
Anti-cystine Agents
CYSTAGON ORAL
Fabry Disease Treatment
FABRAZYME IV 

Gaucher's Disease Treatment
CEREDASE IV 

CEREZYME IV 

VPRIV IV                                         PA
Glucosylceramide Synthase Inhibitors
ZAVESCA ORAL                                     MO
Hereditary Tyrosinemia Type 1 (HT-1) Treatment
ORFADIN ORAL 

Hunter Syndrome Treatment
ELAPRASE IV 

Mucopolysaccharidosis Disease Treatment
ALDURAZYME IV 

NAGLAZYME IV 

Pancrelipase Replacement
CREON ORAL                                       MO
       Page 67 of 122
       Effective: 08/01/11
Drug                                                        Notes
PANCREAZE ORAL 

ZENPEP ORAL                                                 MO
Phenylketonuria Treatment
KUVAN ORAL 

Severe Combined Immunodeficiency Disease (SCID) Treatment
ADAGEN IM 

Urea Cycle Disorder Treatment
BUPHENYL ORAL POWDER 

BUPHENYL TAB 

ELITEK IV 

Gastrointestinal Agents
Antispasmodics, Gastrointestinal
atropine Inj
BENTYL IM 

BENTYL ORAL 

CANTIL ORAL 

dicyclomine IM
dicyclomine Oral
glycopyrrolate Inj
glycopyrrolate Oral
methscopolamine Oral
PAMINE ORAL 

PAMINE FORTE ORAL 

ROBINUL INJ 

ROBINUL ORAL 

ROBINUL FORTE ORAL 

Gastrointestinal Agents, Other
ACTIGALL ORAL                                               MO
AMITIZA ORAL 

COLYTE WITH FLAVOR PACKS ORAL 

       Page 68 of 122
       Effective: 08/01/11
Drug                                 Notes
CONSTULOSE ORAL 

DIPENTUM ORAL 

diphenoxylate-atropine Oral
ENULOSE ORAL 

GAVILYTE-C ORAL 

GAVILYTE-G ORAL 

GAVILYTE-N ORAL 

GOLYTELY ORAL 

HALFLYTELY-BISACODYL BOWEL KIT
ORAL
HELIDAC ORAL 

KAYEXALATE ORAL 

KRISTALOSE ORAL 

lactulose Oral
LOMOTIL ORAL 

loperamide Oral
MOTOFEN ORAL 

MOVIPREP ORAL 

NULYTELY WITH FLAVOR PACKS ORAL 

OSMOPREP ORAL 

polyethylene glycol 3350 Oral
PYLERA ORAL 

RELISTOR SUBQ 

TRILYTE WITH FLAVOR PACKETS ORAL 

URSO 250 ORAL                        MO
URSO FORTE ORAL                      MO
ursodiol Cap                         MO
ursodiol Tab
VISICOL ORAL 

Histamine2 (H2) Blocking Agents

       Page 69 of 122 

       Effective: 08/01/11 

Drug                                Notes
AXID ORAL 

cimetidine Inj
cimetidine Oral
famotidine Oral
famotidine (PF) IV
famotidine(PF) in sal (iso-os) IV
nizatidine Oral
PEPCID ORAL SUSP 

PEPCID TAB 

PEPCID IN NACL (ISO-OSMOTIC) IV 

ranitidine HCl Inj
ranitidine HCl Oral
ZANTAC INJ 

ZANTAC ORAL 

ZANTAC 25 EFFERDOSE ORAL 

ZANTAC IN 1/2 NS IV 

Irritable Bowel Syndrome Agents
CIMZIA SUBQ                         PA
CIMZIA POWDER FOR RECONST SUBQ      PA
LOTRONEX ORAL 

Protectants
CARAFATE ORAL SUSP 

CARAFATE TAB 

CYTOTEC ORAL 

misoprostol Oral
sucralfate Oral
Proton Pump Inhibitors
lansoprazole Oral
NEXIUM ORAL                         ST-NS; QL (31 EA per 31 day(s))
NEXIUM IV IV 

       Page 70 of 122 

       Effective: 08/01/11 

Drug                                 Notes
NEXIUM PACKET ORAL                   ST-NS; QL (31 EA per 31 day(s))
omeprazole Oral
omeprazole-sodium bicarbonate Oral
pantoprazole Oral
PRILOSEC ORAL 

PROTONIX IV 

PROTONIX ORAL 

ZEGERID ORAL 

Genitourinary Agents
5 Alpha-reductase Inhibitors
AVODART ORAL                         MO
finasteride Oral                     MO
JALYN ORAL                           QL (30 EA per 25 day(s))
PROSCAR ORAL                         MO
Alpha 1-adrenergic Blocking Agents
FLOMAX ORAL                          MO
tamsulosin Oral
UROXATRAL ORAL                       MO
Antispasmodics, Urinary
DETROL ORAL                          MO            

DETROL LA ORAL
                      MO            

DITROPAN XL ORAL
                    MO            

ENABLEX ORAL
                        MO
flavoxate Oral                       MO
oxybutynin chloride Oral             MO            

OXYTROL TD 
                         MO            

SANCTURA XR ORAL 
                   MO            

TOVIAZ ORAL
                         MO
trospium Oral
VESICARE ORAL                        MO
       Page 71 of 122
       Effective: 08/01/11
Drug                                                           Notes
Genitourinary Agents, Other
bethanechol chloride Oral                                      MO
ELMIRON ORAL                                                   MO
URECHOLINE ORAL                                                MO
Phosphate Binders
calcium acetate Oral
FOSRENOL ORAL                                                  MO
PHOSLO ORAL                                                    MO
RENAGEL ORAL                                                   MO
RENVELA ORAL                                                   MO
Hormonal Agents, Stimulant/ Replacement/ Modifying (Adrenal)
Glucocorticoids-Systemic
A-HYDROCORT INJ
A-METHAPRED INJ 

CELESTONE ORAL 

CORTEF ORAL 

cortisone Oral
DEPO-MEDROL INJ 

dexamethasone Oral
DEXAMETHASONE INTENSOL ORAL 

dexamethasone sodium phosphate Inj
DEXPAK ORAL 

hydrocortisone Oral
MEDROL ORAL 

MEDROL (PAK) ORAL 

methylprednisolone Oral
methylprednisolone acetate Inj
methylprednisolone sodium succ Inj
methylprednisolone sodium succ IV
MILLIPRED ORAL SOLN 

       Page 72 of 122
       Effective: 08/01/11
Drug                                   Notes
ORAPRED ORAL 

ORAPRED ODT ORAL 

PEDIAPRED ORAL 

prednisolone sodium phosphate Oral
prednisone Oral
PREDNISONE INTENSOL ORAL 

PRELONE ORAL 

SOLU-MEDROL IV 

SOLU-MEDROL (PF) INJ 

SOLU-MEDROL (PF) IV 

VERIPRED 20 ORAL 

Glucocorticoids-Topical-High Potency
amcinonide Top
betamethasone valerate Top
DESOWEN TOP 

DESOWEN OINTMENT & LOTION TOP 

desoximetasone Top
fluocinolone Top
fluocinonide Top
HALOG TOP 

KENALOG TOP 

LUXIQ TOP 

triamcinolone acetonide Top
TRIDERM TOP 

Glucocorticoids-Topical-Low Potency
ACLOVATE TOP 

ALA-CORT TOP 

ALA-SCALP TOP 

alclometasone Top
ANUSOL-HC RECT 

       Page 73 of 122 

       Effective: 08/01/11 

Drug                                     Notes
CARMOL HC TOP 

CLODERM TOP 

COLOCORT RECT 

CORTENEMA RECT 

CORTIFOAM RECT 

DESONATE TOP 

desonide Top
hydrocortisone Rect
hydrocortisone Top
LOKARA TOP 

PANDEL TOP 

PROCTOCORT RECT 

PROCTOCREAM-HC RECT 

PROCTO-PAK RECT 

PROCTOSOL HC RECT 

PROCTOZONE-HC RECT 

SOLU-CORTEF (PF) SOLUTION FOR
INJECTION 250 mg/2 mL
SOLU-CORTEF (PF) SOLUTION FOR
INJECTION 100 mg/2 mL
U-CORT TOP 

VERDESO TOP 

Glucocorticoids-Topical-Medium Potency
betamethasone dipropionate Top
betamethasone valerate Top
BETA-VAL TOP 

CAPEX TOP 

CORDRAN TOP 

CORDRAN SP TOP 

CUTIVATE TOP 


       Page 74 of 122 

       Effective: 08/01/11 

Drug                                              Notes
DERMA-SMOOTH/FS BODY OIL TOP 

DERMATOP TOP 

desoximetasone Top
ELOCON TOP 

fluocinolone Top
fluticasone Top
hydrocortisone butyrate Top
hydrocortisone valerate Top
LOCOID TOP 

LOCOID LIPOCREAM TOP 

mometasone Top
prednicarbate Top
TOPICORT TOP 

TOPICORT LP TOP 

triamcinolone acetonide Lotion
triamcinolone acetonide Ointment 0.025 %, 0.1 %
triamcinolone acetonide Ointment 0.05 %
triamcinolone acetonide Topical Cream
WESTCORT TOP 

Glucocorticoids-Topical-Very High Potency
betamethasone dipropionate Top
betamethasone, augmented Top
clobetasol Top
CLOBETASOL PROPIONATE 0.5 MG/ML
TOPICAL CREAM [ISOVATE]
clobetasol-emollient Top
CLOBEX TOP 

diflorasone Top
DIPROLENE TOP 

DIPROLENE AF TOP 


       Page 75 of 122 

       Effective: 08/01/11 

Drug                                                             Notes
fluocinonide-emollient Top
halobetasol propionate Top
OLUX-E TOP 

TEMOVATE TOP 

ULTRAVATE TOP 

VANOS TOP 

Mineralocorticoids
fludrocortisone Oral                                             MO
Hormonal Agents, Stimulant/ Replacement/ Modifying (Pituitary)
Gonadotropins
chorionic gonadotropin, human IM                                 BvD
NOVAREL IM                                                       BvD
PREGNYL IM                                                       BvD
Growth Hormone Analogs
GENOTROPIN SUBQ                                                  PA
GENOTROPIN MINIQUICK SUB-Q SYRINGE                               PA
0.2 mg/0.25 mL
GENOTROPIN MINIQUICK SUB-Q SYRINGE                               PA
0.4 mg/0.25 mL, 0.6 mg/0.25 mL, 0.8 mg/0.25
mL, 1 mg/0.25 mL, 1.2 mg/0.25 mL, 1.4 mg/0.25
mL, 1.6 mg/0.25 mL, 1.8 mg/0.25 mL, 2 mg/0.25
mL
HUMATROPE INJ                                                    PA
NORDITROPIN FLEXPRO SUBQ                                         PA
NORDITROPIN NORDIFLEX SUBQ                                       PA
NUTROPIN SUBQ                                                    PA
NUTROPIN AQ SUBQ                                                 PA
NUTROPIN AQ NUSPIN SUBQ                                          PA
SAIZEN SUBQ                                                      PA
SAIZEN CLICK.EASY SUBQ                                           PA
SEROSTIM SUBQ                                                    PA

       Page 76 of 122
       Effective: 08/01/11
Drug                                                            Notes
TEV-TROPIN SUBQ                                                 PA
ZORBTIVE SUBQ                                                   PA
Insulin-like Growth Factor Analogs
INCRELEX SUBQ                                                   PA
Vasopressin Analogs
DDAVP INJ 

DDAVP NASAL SPRAY AEROSOL                                       MO
DDAVP ORAL                                                      MO
desmopressin Inj
desmopressin Nasal Soln                                         MO
desmopressin Nasal Spray
desmopressin Oral                                               MO
STIMATE NASL                                                    MO
Hormonal Agents, Stimulant/ Replacement/ Modifying (Sex Hormones/ Modifiers)
Anabolic Steroids
ANADROL-50 ORAL 

oxandrolone Tab 2.5 mg                                          PA
oxandrolone Tab 10 mg                                           PA
Androgens
ANDROGEL TRANSDERMAL GEL PUMP                                   PA
ANDROGEL TRANSDERMAL PACKET                                     PA; MO
AXIRON TD                                                       PA
danazol Oral                                                    MO
TESTIM TD                                                       PA
testosterone cypionate IM                                       PA-NS
testosterone enanthate IM                                       PA-NS
Estrogens
ACTIVELLA ORAL                                                  MO
ALORA TD                                                        MO
ANGELIQ ORAL                                                    MO
       Page 77 of 122
       Effective: 08/01/11
Drug                                Notes
APRI ORAL                           MO
CENESTIN ORAL                       MO
CESIA ORAL                          MO
CLIMARA TD                          MO
COMBIPATCH TD                       MO
CRYSELLE (28) ORAL                  MO
CYCLESSA ORAL                       MO
DELESTROGEN IM 

DEPO-ESTRADIOL IM 

DESOGEN ORAL                        MO
DIVIGEL TD                          MO
ELESTRIN TD                         MO
ENJUVIA ORAL                        MO
ESTRACE ORAL                        MO
ESTRACE VAGL                        MO
ESTRADERM TD                        MO
estradiol Oral                      MO
estradiol TD                        MO
estradiol valerate IM
estradiol-norethindrone acet Oral   MO
ESTRING VAGL                        MO
estropipate Oral                    MO
ESTROSTEP FE-28 ORAL                MO
EVAMIST TD                          MO
FEMHRT 1/5 ORAL                     MO
FEMHRT LOW DOSE ORAL                MO
FEMRING VAGL                        MO
FEMTRACE ORAL                       MO
GIANVI ORAL 

GYNODIOL ORAL                       MO
       Page 78 of 122 

       Effective: 08/01/11 

Drug                           Notes
JINTELI ORAL                   MO
KARIVA ORAL                    MO
KELNOR 1/35 (28) ORAL          MO
MENEST ORAL                    MO
MENOSTAR TD                    MO
MONONESSA (28) ORAL            MO
NUVARING VAGL                  MO
OCELLA ORAL                    MO
OGEN 0.625 ORAL                MO
OGESTREL (28) ORAL             MO
ORTHO TRI-CYCLEN LO ORAL       MO
ORTHO-CEPT (28) ORAL           MO
ORTHO-EST 0.625 ORAL           MO
ORTHO-EST 1.25 ORAL            MO
PREFEST ORAL                   MO
PREMARIN INJ 

PREMARIN ORAL                  MO
PREMARIN VAGL                  MO
PREMPHASE ORAL                 MO
PREMPRO ORAL                   MO
PREVIFEM ORAL                  MO
RECLIPSEN (28) ORAL            MO
SOLIA ORAL                     MO
SPRINTEC (28) ORAL             MO
TRINESSA (28) ORAL             MO
TRI-PREVIFEM (28) ORAL         MO
TRI-SPRINTEC (28) ORAL         MO
VAGIFEM VAGL                   MO
VELIVET ORAL                   MO
VIVELLE-DOT TD                 MO
       Page 79 of 122 

       Effective: 08/01/11 

Drug                           Notes
YASMIN 28 ORAL                 MO
YAZ 28 ORAL                    MO
ZOVIA 1/35E (28) ORAL          MO
ZOVIA 1/50E (28) ORAL          MO
Progestins
ARANELLE (28) ORAL             MO
AVIANE ORAL                    MO
AYGESTIN ORAL                  MO
BALZIVA (28) ORAL              MO
BREVICON (28) ORAL             MO
CAMILA ORAL                    MO
CLIMARA PRO TD                 MO
CRINONE VAGL                   MO
CYCLAFEM 1/35 (28) ORAL 

CYCLAFEM 7/7/7 (28) ORAL 

DEPO-PROVERA IM 

DEPO-PROVERA IM SUSP 

DEPO-SUBQ PROVERA 104 SUBQ 

ENDOMETRIN VAGL                MO
ENPRESSE ORAL                  MO
ERRIN ORAL                     MO
JOLIVETTE ORAL                 MO
JUNEL 1.5/30 (21) ORAL         MO
JUNEL 1/20 (21) ORAL           MO
JUNEL FE 1.5/30 (28) ORAL      MO
JUNEL FE 1/20 (28) ORAL        MO
LEENA 28 ORAL                  MO
LESSINA ORAL                   MO
LEVORA-28 ORAL                 MO
LOESTRIN 1.5/30 (21) ORAL      MO
       Page 80 of 122 

       Effective: 08/01/11 

Drug                              Notes
LOESTRIN 1/20 (21) ORAL           MO
LOESTRIN 24 FE ORAL               MO
LOESTRIN FE 1.5/30 (28) ORAL      MO
LOESTRIN FE 1/20 (28) ORAL        MO
LO-OVRAL (28) ORAL                MO
LOSEASONIQUE ORAL 

LOW-OGESTREL (28) ORAL            MO
LUTERA (28) ORAL                  MO
LYBREL ORAL                       MO
medroxyprogesterone IM
medroxyprogesterone Oral          MO
MEGACE ES ORAL                    MO
MEGACE ORAL ORAL                  MO
megestrol Oral                    MO
MICROGESTIN 1.5/30 (21) ORAL      MO
MICROGESTIN 1/20 (21) ORAL        MO
MICROGESTIN FE 1.5/30 (28) ORAL   MO
MICROGESTIN FE 1/20 (28) ORAL     MO
MODICON (28) ORAL                 MO
NECON 0.5/35 (28) ORAL            MO
NECON 1/35 (28) ORAL              MO
NECON 10/11 (28) ORAL             MO
NECON 7/7/7 (28) ORAL             MO
NEXT CHOICE ORAL                  MO
NORA-BE ORAL                      MO
NORDETTE-28 ORAL                  MO
norethindrone acetate Oral        MO
NORINYL 1+35 (28) ORAL            MO
NOR-QD ORAL                       MO
NORTREL 0.5/35 (28) ORAL          MO
       Page 81 of 122 

       Effective: 08/01/11 

Drug                                                           Notes
NORTREL 1/35 (21) ORAL                                         MO
NORTREL 1/35 (28) ORAL                                         MO
NORTREL 7/7/7 (28) ORAL                                        MO
ORTHO EVRA TD                                                  MO
ORTHO MICRONOR ORAL                                            MO
ORTHO-CYCLEN (28) ORAL                                         MO
ORTHO-NOVUM 7/7/7 (28) ORAL                                    MO
OVCON-35 (28) ORAL                                             MO
OVCON-50 (28) ORAL                                             MO
PORTIA ORAL                                                    MO
PROCHIEVE VAGL                                                 MO
PROMETRIUM ORAL                                                MO
PROVERA ORAL                                                   MO
QUASENSE ORAL                                                  MO
SEASONALE ORAL                                                 MO
SEASONIQUE ORAL                                                MO
SRONYX ORAL                                                    MO
TRI-LEGEST FE ORAL                                             MO
TRI-NORINYL (28) ORAL                                          MO
TRIVORA (28) ORAL                                              MO
Selective Estrogen Receptor Modifying Agents
EVISTA ORAL                                                    MO
Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)
Hormonal Agents, Stimulant/ Replacement/ Modifying (Thyroid)
CYTOMEL ORAL                                                   MO
LEVOTHROID ORAL                                                MO
levothyroxine Oral                                             MO
LEVOXYL ORAL                                                   MO
liothyronine IV
liothyronine Oral
       Page 82 of 122
       Effective: 08/01/11
Drug                                         Notes
SYNTHROID ORAL                               MO
THYROLAR-1 ORAL                              MO
THYROLAR-1/4 ORAL                            MO
THYROLAR-2 ORAL                              MO
THYROLAR-3 ORAL                              MO
TIROSINT ORAL 

UNITHROID ORAL                               MO
ZEOSA ORAL 

Hormonal Agents, Suppressant (Parathyroid)
Calcimimetics
SENSIPAR TAB 30 mg                           MO
SENSIPAR TAB 60 mg, 90 mg                    MO
Hormonal Agents, Suppressant (Pituitary)
Gonadotropin-releasing Hormone Analogs
ELIGARD SUBQ
leuprolide SubQ
LUPRON DEPOT IM KIT 

LUPRON DEPOT IM SYRINGE 

LUPRON DEPOT (3 MONTH) IM KIT 

LUPRON DEPOT (3 MONTH) IM SYRINGE
KIT
LUPRON DEPOT (4 MONTH) IM 

LUPRON DEPOT-PED IM 

SYNAREL NASL 

TRELSTAR IM SUSP 

TRELSTAR IM SYRINGE 

Growth Hormone Antagonists
SOMAVERT SUBQ                                PA; QL (30 EA per 30 day(s))
Somatostatin Analogs
octreotide acetate Injection 50 mcg/mL       PA

       Page 83 of 122
       Effective: 08/01/11
Drug                                                     Notes
octreotide acetate Injection 1,000 mcg/mL, 100           PA
mcg/mL, 200 mcg/mL, 500 mcg/mL
SANDOSTATIN INJ                                          PA
SANDOSTATIN LAR DEPOT IM                                 PA
SOMATULINE DEPOT SUBQ                                    PA
Hormonal Agents, Suppressant (Sex Hormones/ Modifiers)
Antiandrogens
bicalutamide Oral
CASODEX ORAL                                             MO
flutamide Oral                                           MO
NILANDRON ORAL                                           MO
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole Oral
propylthiouracil Oral
TAPAZOLE ORAL 

Immunological Agents
Immune Suppressants (Non-TNF Inhibitors)
ARCALYST SUBQ                                            PA
AZASAN ORAL                                              BvD; MO
azathioprine Oral                                        BvD; MO
azathioprine sodium Inj
CELLCEPT ORAL                                            BvD; MO
CELLCEPT INTRAVENOUS IV 

CUPRIMINE ORAL                                           MO
cyclosporine IV
cyclosporine Oral                                        BvD; MO
cyclosporine modified Cap 100 mg
cyclosporine modified Cap 50 mg                          BvD; MO
cyclosporine modified Oral Soln                          BvD; MO

       Page 84 of 122
       Effective: 08/01/11
Drug                           Notes
DEPEN TITRATABS ORAL           MO
GENGRAF ORAL                   BvD; MO
IMURAN ORAL                    BvD; MO
methotrexate sodium Inj
methotrexate sodium Oral       MO
methotrexate sodium (PF) Inj
mycophenolate mofetil Oral     BvD
MYFORTIC ORAL                  BvD; MO
NEORAL ORAL                    BvD; MO
ORENCIA IV                     PA
ORTHOCLONE OKT3 IV 

PROGRAF IV 

PROGRAF ORAL                   BvD; MO
RAPAMUNE ORAL SOLN             BvD; MO
RAPAMUNE TAB 0.5 mg            BvD
RAPAMUNE TAB 1 mg, 2 mg        BvD; MO
RHEUMATREX ORAL                MO
SANDIMMUNE IV 

SANDIMMUNE ORAL                BvD; MO
tacrolimus Oral                BvD; MO
TREXALL ORAL                   BvD; MO
Immunoglobulins
ATGAM IV 

CARIMUNE NF NANOFILTERED IV    PA
GAMASTAN S/D IM 

GAMMAGARD LIQUID IV            PA
GAMMAPLEX IV                   PA
GAMUNEX IV                     PA
HIZENTRA SUBQ                  PA
PRIVIGEN IV                    PA
       Page 85 of 122 

       Effective: 08/01/11 

Drug                                     Notes
THYMOGLOBULIN IV 

VIVAGLOBIN SUBQ                          PA
Immunomodulators, Other
ACTEMRA IV                               PA
ARAVA ORAL                               MO
COPAXONE SUBQ                            PA-NS
KINERET SUBQ                             PA
leflunomide Oral                         MO
PROLEUKIN IV 

RIDAURA ORAL                             MO
STELARA SUBQ                             PA; QL (1 ML per 28 day(s))
SYNAGIS IM
Interferons, Alfa
INFERGEN SUBQ                            PA
INTRON A INJ                             PA-NS
INTRON A SUBQ                            PA-NS
PEGASYS SUBQ                             PA-NS; QL (4 ML per 30 day(s))
PEGASYS CONVENIENCE PACK SUBQ            PA-NS; QL (2 EA per 30 day(s))
PEGINTRON SUBQ                           PA-NS; QL (4 EA per 30 day(s))
PEGINTRON REDIPEN SUBQ                   PA-NS; QL (4 EA per 30 day(s))
Interferons, Beta
AVONEX IM                                PA-NS
AVONEX ADMINISTRATION PACK IM            PA-NS
BETASERON SUBQ                           PA-NS
REBIF SUBQ                               PA-NS
REBIF TITRATION PACK SUBQ                PA-NS
Interferons, Gamma
ACTIMMUNE SUBQ 

Tumor Necrosis Factor (TNF) Inhibitors
ENBREL SUBQ                              PA
       Page 86 of 122 

       Effective: 08/01/11 

Drug                                        Notes
HUMIRA SUBQ                                 PA
HUMIRA CROHN'S DIS START PCK SUBQ           PA
REMICADE IV                                 PA
Vaccines to Prevent Diphtheria
ADACEL (ADOLESCENT & ADULT) IM 

DECAVAC IM                                  BvD
tetanus,diphtheria toxd ped-PF IM           BvD
Vaccines to Prevent Haemophilus Type B
ACTHIB IM 

COMVAX IM 

PEDVAX HIB (PF) IM 

TRIHIBIT PRESERVATIVE FREE IM 

Vaccines to Prevent Hepatitis A
HAVRIX (PF) IM 

TWINRIX (PF) IM 

VAQTA (PF) IM 

Vaccines to Prevent Hepatitis B
ENGERIX-B (PF) IM                           BvD
PEDIARIX (PF) IM 

RECOMBIVAX HB (PF) IM                       BvD
Vaccines to Prevent Japanese Encephalitis
IXIARO (PF) IM 

JE-VAX SUBQ 

Vaccines to Prevent Measles
ATTENUVAX (PF) SUBQ 

M-M-R II (PF) SUBQ 

Vaccines to Prevent Meningococcal Disease
MENACTRA (PF) IM 

MENOMUNE - A/C/Y/W-135 (PF) SUBQ 

MENVEO A-C-Y-W-135-DIP (PF) IM 

       Page 87 of 122 

       Effective: 08/01/11 

Drug                                         Notes
Vaccines to Prevent Mumps
PROQUAD SUBQ 

Vaccines to Prevent Papillomavirus Disease
CERVARIX IM 

GARDASIL IM
Vaccines to Prevent Pertussis
TRIPEDIA (PF) IM
Vaccines to Prevent Poliovirus
IPOL INJ
Vaccines to Prevent Rabies
IMOVAX RABIES VACCINE IM
RABAVERT (PF) IM
Vaccines to Prevent Rotavirus Disease
ROTATEQ VACCINE ORAL
Vaccines to Prevent Rubella
MERUVAX II (PF) SUBQ
Vaccines to Prevent Tetanus
BOOSTRIX IM
DAPTACEL (PEDIATRIC) (PF) IM
INFANRIX (PF) IM
tetanus toxoid,adsorbed (PF) IM              BvD
tetanus-diphtheria toxoids-Td IM             BvD
Vaccines to Prevent Typhoid
TYPHIM VI IM 

Vaccines to Prevent Varicella
VARIVAX (PF) SUBQ 

Vaccines to Prevent Yellow Fever
YF-VAX SUBQ 

Vaccines to Prevent Zoster
ZOSTAVAX SUBQ 

       Page 88 of 122 

       Effective: 08/01/11 

Drug                                        Notes
Inflammatory Bowel Disease Agents
Glucocorticoids
ENTOCORT EC ORAL                            MO
Salicylates
APRISO ORAL                                 MO
ASACOL ORAL                                 MO
balsalazide Oral                            MO
CANASA RECT                                 MO
COLAZAL ORAL                                MO
LIALDA ORAL                                 MO
mesalamine Rect                             MO
PENTASA ORAL                                MO
ROWASA RECT                                 MO
Sulfonamides
AZULFIDINE ORAL                             MO
AZULFIDINE EN-TABS ORAL                     MO
sulfasalazine Oral                          MO
SULFAZINE EC ORAL                           MO
Metabolic Bone Disease Agents
Bisphosphonates, Oral
ACTONEL ORAL                                ST-NS; MO
alendronate Tab 10 mg, 35 mg, 5 mg, 70 mg   MO
alendronate Tab 40 mg                       ST-NS; MO
BONIVA ORAL                                 ST-NS; MO
DIDRONEL ORAL                               MO
etidronate disodium Oral                    MO
SKELID ORAL                                 PA-NS; MO; QL (62 EA per 31
                                            day(s))
Bisphosphonates, Parenteral
AREDIA IV SOLUTION 30 mg

       Page 89 of 122
       Effective: 08/01/11
Drug                                                     Notes
AREDIA IV SOLUTION 90 mg
BONIVA IV 

pamidronate IV 30 mg/10 mL (3 mg/mL), 90
mg/10 mL (9 mg/mL)
pamidronate IV 60 mg/10 mL (6 mg/mL)
RECLAST IV                                               BvD
ZOMETA IV 

Calcium Regulating Hormones
calcitonin (salmon) Nasl                                 BvD; MO
FORTICAL NASL                                            BvD; MO
MIACALCIN INJ                                            BvD
MIACALCIN NASL                                           BvD; MO
Parathyroid Hormone Analogs
FORTEO SUBQ                                              PA; QL (2.4 ML per 30 day(s))
Vitamin D–related Agents/Metabolic Bone Disease Agents
CALCIJEX IV                                              BvD
calcitriol IV 1 mcg/mL                                   BvD
calcitriol IV 2 mcg/mL                                   BvD
calcitriol Oral                                          BvD
CYSTADANE ORAL 

HECTOROL IV                                              BvD
HECTOROL ORAL                                            BvD
PROLIA SUBQ                                              PA
ROCALTROL ORAL                                           BvD
XGEVA SUBQ                                               PA
ZELAPAR ORAL 

ZEMPLAR IV                                               BvD
ZEMPLAR ORAL                                             BvD
Ophthalmic Agents
Alpha-adrenergic Agonists, Ophthalmic

       Page 90 of 122 

       Effective: 08/01/11 

Drug                                          Notes
ALPHAGAN P OPHT                               MO
apraclonidine Opht                            MO
brimonidine Opht                              MO
IOPIDINE OPHT                                 MO
PROPINE OPHT                                  MO
Beta-adrenergic Blocking Agents, Ophthalmic
BETAGAN OPHT                                  MO
betaxolol Opht                                MO
BETIMOL OPHT                                  MO
BETOPTIC S OPHT                               MO
carteolol Opht                                MO
COMBIGAN OPHT                                 MO
COSOPT OPHT                                   MO
dorzolamide-timolol Opht                      MO
ISTALOL OPHT                                  MO
levobunolol Opht                              MO
metipranolol Opht                             MO
OPTIPRANOLOL OPHT                             MO
timolol maleate Opht                          MO
TIMOPTIC OCUDOSE OPHT                         MO
TIMOPTIC-XE OPHT                              MO
Carbonic Anhydrase Inhibitors, Ophthalmic
AZOPT OPHT                                    MO
dorzolamide Opht                              MO
TRUSOPT OPHT                                  MO
Cholinergic Agonists, Ophthalmic
PHOSPHOLINE IODIDE OPHT                       MO
PILOPINE HS OPHT                              MO
Glucocorticoids, Ophthalmic
dexamethasone sodium phosphate Opht
       Page 91 of 122 

       Effective: 08/01/11 

Drug                                               Notes
FLAREX OPHT 

fluorometholone Opht
FML FORTE OPHT 

FML LIQUIFILM OPHT 

FML S.O.P. OPHT 

LOTEMAX OPHT 

MAXIDEX OPHT 

POLY-PRED OPHT 

PRED FORTE OPHT 

PRED MILD OPHT 

PRED-G OPHT 

PRED-G S.O.P. OPHT 

prednisolone acetate Opht
prednisolone sodium phosphate Opht
VEXOL OPHT 

Nonsteroidal Anti-inflammatory Drugs, Ophthalmic
ACULAR OPHT 

ACULAR LS OPHT 

ACUVAIL OPHT 

BROMDAY OPHT 

bromfenac Opht
diclofenac sodium Opht
flurbiprofen sodium Opht
ketorolac Opht
NEVANAC OPHT 

OCUFEN OPHT 

VOLTAREN OPHT 

Ophthalmic Agents, Other
AK-CON OPHT 

AK-TOB OPHT 

       Page 92 of 122 

       Effective: 08/01/11 

Drug                                 Notes
ALCAINE OPHT 

AZASITE OPHT 

bacitracin Opht
bacitracin-polymyxin B Opht
BLEPH-10 OPHT 

BLEPHAMIDE OPHT 

BLEPHAMIDE S.O.P. OPHT 

CILOXAN EYE DROPS 

CILOXAN EYE OINTMENT 

DEXASPORIN OPHT 

DUREZOL OPHT 

GENTAK OPHT 

GENTASOL OPHT 

IQUIX OPHT 

LACRISERT OPHT 

levofloxacin Opht
MAXITROL OPHT 

MOXEZA OPHT 

MYDRAL OPHT 

MYDRIACYL OPHT 

naphazoline Opht
neomycin-bacitracin-poly-HC Opht
neomycin-bacitracin-polymyxin Opht
neomycin-polymyxin-dexameth Opht
neomycin-polymyxin-gramicidin Opht
neomycin-polymyxin-HC Opht
NEOSPORIN OPHT 

POLYCIN B OPHT 

POLY-DEX OPHT 

POLYTRIM OPHT 

       Page 93 of 122 

       Effective: 08/01/11 

Drug                             Notes
proparacaine Opht
QUIXIN OPHT 

RESTASIS OPHT 

ROMYCIN OPHT 

sulfacetamide sodium Opht
TOBRADEX OPHT 

tobramycin-dexamethasone Opht
TOBRASOL OPHT 

TOBREX EYE DROPS 

TOBREX EYE OINTMENT 

trifluridine Opht
trimethoprim-polymyxin B Opht
tropicamide Opht
VIGAMOX OPHT 

VIROPTIC OPHT 

ZYLET OPHT 

ZYMAR OPHT 

ZYMAXID OPHT 

Ophthalmic Anti-allergy Agents
ALAMAST OPHT 

ALOCRIL OPHT 

ALOMIDE OPHT 

ALREX OPHT 

azelastine Opht
BEPREVE OPHT 

cromolyn Opht
ELESTAT OPHT 

EMADINE OPHT 

epinastine Opht
LASTACAFT OPHT 

       Page 94 of 122 

       Effective: 08/01/11 

Drug                                              Notes
OPTIVAR OPHT 

PATADAY OPHT 

PATANOL OPHT 

Ophthalmic Prostaglandin and Prostamide Analogs
latanoprost Opht                                  MO
LUMIGAN EYE DROPS 0.01 % 

LUMIGAN EYE DROPS 0.03 %                          MO
TRAVATAN Z OPHT                                   MO
XALATAN OPHT                                      MO
Otic Agents
Otic Anti-inflammatories
ACETASOL HC OTIC 

acetic acid Otic
BOROFAIR OTIC 

COLY-MYCIN S OTIC 

CORTISPORIN OTIC 

CORTISPORIN-TC OTIC 

CORTOMYCIN OTIC 

DERMOTIC OIL OTIC 

hydrocortisone-acetic acid Otic
Respiratory Tract Agents
Anti-inflammatories, Inhaled Corticosteroids
ADVAIR DISKUS INHL                                MO; QL (60 EA per 25 day(s))
ADVAIR HFA INHL                                   MO; QL (12 GM per 25 day(s))
ALVESCO INHL                                      MO; QL (13 GM per 25 day(s))
ASMANEX TWISTHALER BREATH                         MO; QL (15 GM per 25 day(s))
ACTIVATED 220 mcg (30 doses)
ASMANEX TWISTHALER BREATH                         MO; QL (29 GM per 25 day(s))
ACTIVATED 220 mcg (60 doses)
ASMANEX TWISTHALER BREATH                         MO; QL (58 GM per 25 day(s))
ACTIVATED 220 mcg (120 doses)
       Page 95 of 122
       Effective: 08/01/11
Drug                                 Notes
ASMANEX TWISTHALER BREATH            MO; QL (7 GM per 25 day(s))
ACTIVATED 220 mcg (14 doses)
ASMANEX TWISTHALER BREATH            QL (30 GM per 25 day(s))
ACTIVATED 110 mcg (30 doses)
BECONASE AQ NASL                     QL (50 GM per 25 day(s))
budesonide Inhl                      MO; QL (120 ML per 25 day(s))
DULERA INHL                          QL (13 GM per 30 day(s))
FLONASE NASL                         QL (16 GM per 25 day(s))
FLOVENT DISKUS INHL                  MO; QL (120 EA per 25 day(s))
FLOVENT HFA INHL                     MO; QL (24 GM per 25 day(s))
flunisolide Nasl                     QL (50 ML per 25 day(s))
fluticasone Nasl                     QL (16 GM per 25 day(s))
NASACORT AQ NASL                     QL (17 GM per 25 day(s))
NASONEX NASL                         QL (34 GM per 25 day(s))
OMNARIS NASL                         QL (13 GM per 25 day(s))
PULMICORT NEB SUSPENSION 0.25 mg/2   MO; QL (120 ML per 25 day(s))
mL, 0.5 mg/2 mL
PULMICORT NEB SUSPENSION 1 mg/2 mL   MO; QL (60 ML per 25 day(s))
PULMICORT FLEXHALER BREATH           MO; QL (2 EA per 25 day(s))
ACTIVATED 180 mcg/Inhalation
PULMICORT FLEXHALER BREATH           MO; QL (4 EA per 25 day(s))
ACTIVATED 90 mcg/Inhalation
QVAR INHL                            MO; QL (24 GM per 25 day(s))
RHINOCORT AQUA NASL                  QL (18 GM per 25 day(s))
SYMBICORT INHL                       MO; QL (11 GM per 25 day(s))
VERAMYST NASL                        QL (10 GM per 25 day(s))
Bronchodilators, Anticholinergic
ATROVENT NASL                        MO
ATROVENT HFA INHL                    MO; QL (26 GM per 25 day(s))
COMBIVENT INHL                       MO; QL (30 GM per 25 day(s))
DUONEB INHL                          MO; QL (540 ML per 25 day(s))

       Page 96 of 122 

       Effective: 08/01/11 

Drug                                                        Notes
ipratropium bromide Inhl                                    MO; QL (315 ML per 25 day(s))
ipratropium bromide Nasl                                    MO
ipratropium-albuterol Inhl                                  MO; QL (540 ML per 25 day(s))
SPIRIVA WITH HANDIHALER INHL                                MO; QL (30 EA per 25 day(s))
Bronchodilators, Phosphodiesterase Inhibitors (Xanthines)
aminophylline IV
aminophylline Oral                                          MO
ELIXOPHYLLIN ORAL                                           MO
LUFYLLIN ORAL                                               MO
THEO-24 ORAL                                                MO
THEOCHRON ORAL                                              MO
theophylline Oral                                           MO
UNIPHYL ORAL                                                MO
Bronchodilators, Sympathomimetic
ACCUNEB INHL                                                BvD; MO; QL (300 ML per 25
                                                            day(s))
albuterol sulfate Neb Solution 0.63 mg/3 mL, 1.25           MO; QL (300 ML per 25 day(s))
mg/3 mL, 2.5 mg /3 mL (0.083 %)
albuterol sulfate Neb Solution 5 mg/mL                      MO; QL (60 ML per 25 day(s))
albuterol sulfate Oral                                      MO
BROVANA INHL                                                MO; QL (120 ML per 25 day(s))
epinephrine HCl Inj
EPIPEN IM 

EPIPEN JR IM 

FORADIL AEROLIZER INHL                                      MO; QL (60 EA per 25 day(s))
levalbuterol HCl Inhl                                       MO; QL (180 EA per 25 day(s))
MAXAIR AUTOHALER INHL                                       MO; QL (14 GM per 25 day(s))
metaproterenol Oral                                         MO
PERFOROMIST INHL                                            BvD; MO; QL (120 ML per 25
                                                            day(s))
PROAIR HFA INHL                                             MO; QL (18 GM per 25 day(s))
       Page 97 of 122 

       Effective: 08/01/11 

Drug                                                   Notes
PROVENTIL HFA INHL                                     MO; QL (14 GM per 25 day(s))
SEREVENT DISKUS INHL                                   MO; QL (60 EA per 25 day(s))
terbutaline Oral                                       MO
terbutaline SubQ
TWINJECT AUTOINJECTOR IM 

VENTOLIN HFA INHL                                      MO; QL (36 GM per 25 day(s))
VOSPIRE ER ORAL                                        MO
XOPENEX INHL                                           MO; QL (288 ML per 25 day(s))
XOPENEX HFA INHL                                       MO; QL (30 GM per 25 day(s))
H1 Blocking Agents, Sedating
carbinoxamine maleate Oral
clemastine Oral
cyproheptadine Oral
dexchlorpheniramine maleate Oral
diphenhydramine HCl Inj
diphenhydramine HCl Oral
hydroxyzine HCl IM
hydroxyzine HCl Oral
hydroxyzine pamoate Oral
PALGIC ORAL 

VISTARIL ORAL 

Histamine1 (H1) Blocking Agents, Mildly/Non-sedating
ALLEGRA ORAL 

ASTELIN NASL                                           QL (60 ML per 25 day(s))
ASTEPRO NASL                                           QL (60 ML per 25 day(s))
azelastine Nasl                                        QL (60 ML per 25 day(s))
CLARINEX ORAL 

CLARINEX-D 12 HOUR ORAL 

CLARINEX-D 24 HOUR ORAL 

fexofenadine Oral
       Page 98 of 122 

       Effective: 08/01/11 

Drug                              Notes
levocetirizine Oral
PATANASE NASL 

SEMPREX-D ORAL 

XYZAL ORAL 

Mast Cell Stabilizers
cromolyn Inhl                     BvD; QL (240 ML per 25 day(s))
GASTROCROM ORAL 

Pulmonary Antihypertensives
LETAIRIS ORAL 

REMODULIN INJ 

REVATIO IV                        PA
REVATIO ORAL                      PA
TRACLEER ORAL                     LA
VENTAVIS INHL                     BvD
Receptor Antagonists
ACCOLATE ORAL                     MO
SINGULAIR ORAL                    MO
zafirlukast Oral
Respiratory Tract Agents, Other
ARALAST NP IV 

GLASSIA IV                        PA
MYOZYME IV 

PROLASTIN IV 

PROLASTIN C IV 

PULMOZYME INHL 

TYZINE NASL 

XOLAIR SUBQ                       PA
ZEMAIRA IV 

Synthesis Inhibitors
ZYFLO CR ORAL 

       Page 99 of 122 

       Effective: 08/01/11 

Drug                              Notes
Sedatives/Hypnotics
Sedatives/Hypnotics
AMBIEN ORAL
AMBIEN CR ORAL 

LUNESTA ORAL 

ROZEREM ORAL 

SONATA ORAL 

zaleplon Oral
zolpidem Oral
Skeletal Muscle Relaxants
Skeletal Muscle Relaxants
AMRIX ORAL 

BOTOX INJ 

carisoprodol Oral
carisoprodol-ASA-codeine Oral
carisoprodol-aspirin Oral
chlorzoxazone Oral
cyclobenzaprine Oral
FEXMID ORAL 

FLEXERIL ORAL 

metaxalone Oral
methocarbamol Oral
NORFLEX INJ 

orphenadrine citrate Inj
orphenadrine citrate Oral
ORPHENADRINE COMPOUND ORAL 

ORPHENADRINE COMPOUND-DS ORAL 

PARAFON FORTE DSC ORAL 

ROBAXIN INJ 

ROBAXIN ORAL 

       Page 100 of 122
       Effective: 08/01/11
Drug                                           Notes
SKELAXIN ORAL 

SOMA ORAL 

Therapeutic Nutrients/Minerals/ Electrolytes
Electrolytes/Minerals
1/2 NS with potassium chloride IV
alcohol in D5W IV
AMINOSYN 10 % IV                               BvD
AMINOSYN 3.5 % IV                              BvD
AMINOSYN 5 % IV                                BvD
AMINOSYN 7 % IV                                BvD
AMINOSYN 7 % WITH ELECTROLYTES IV              BvD
AMINOSYN 8.5 % IV                              BvD
AMINOSYN 8.5 %-ELECTROLYTES IV                 BvD
AMINOSYN II 10 % IV                            BvD
AMINOSYN II 15% IV                             BvD
AMINOSYN II 3.5 %/DEXTROSE 5 % IV              BvD
AMINOSYN II 3.5 %-DEXTROSE 25% IV              BvD
AMINOSYN II 3.5% M/DEXTROSE 5% IV              BvD
AMINOSYN II 3.5%-LYTES-CA-D25W IV              BvD
AMINOSYN II 4.25%/DEXTROSE 20% IV              BvD
AMINOSYN II 4.25%-DEXTROSE 10% IV              BvD
AMINOSYN II 4.25%-DEXTROSE 25% IV              BvD
AMINOSYN II 4.25%-LYTES-CA-D25 IV              BvD
AMINOSYN II 5%/DEXTROSE 25% IV                 BvD
AMINOSYN II 7 % IV                             BvD
AMINOSYN II 8.5 % IV                           BvD
AMINOSYN II 8.5 %-ELECTROLYTES IV              BvD
AMINOSYN M 3.5 % IV                            BvD
AMINOSYN-HBC 7% IV                             BvD
AMINOSYN-HF 8 % IV                             BvD
       Page 101 of 122
       Effective: 08/01/11
Drug                                Notes
AMINOSYN-PF 10 % IV                 BvD
AMINOSYN-PF 7 % (SULFITE-FREE) IV   BvD
ammonium chloride IV
CARNITOR IV                         BvD
CARNITOR ORAL                       BvD
CLINIMIX 2.75%/D5 SULFITE FREE IV   BvD
CLINIMIX 4.25%/D5 SULFITE FREE IV   BvD
CLINIMIX 4.25/D10 SULFITE FREE IV   BvD
CLINIMIX 4.25/D20 SULFITE FREE IV   BvD
CLINIMIX 4.25/D25 SULFITE FREE IV   BvD
CLINIMIX 5%/D15 SULFITE FREE IV     BvD
CLINIMIX 5%/D20 SULFITE FREE IV     BvD
CLINIMIX 5%/D25 SULFITE FREE IV     BvD
CLINIMIX E 2.75/D10 SULFITFREE IV   BvD
CLINIMIX E 2.75/D5 SULFITEFREE IV   BvD
CLINIMIX E 4.25/D25 SULFITFREE IV   BvD
CLINIMIX E 4.25/D5 SULFITEFREE IV   BvD
CLINIMIX E 5%/D15 SULFITE FREE IV   BvD
CLINIMIX E 5%/D20 SULFITE FREE IV   BvD
CLINIMIX E 5%/D25 SULFITE FREE IV   BvD
CLINISOL SF 15% IV                  BvD
D10 %-0.45 % sodium chloride IV
D10-0.2 % NaCl & Potassium Cl IV
D2.5 %-0.45 % sodium chloride IV
D5 %-0.45 % sodium chloride IV
D5 %-0.9 % sodium chloride IV
D5-1/2 NS & potassium chloride IV
D5-1/3 NS & potassium chloride IV
D5-1/4 NS & potassium chloride IV
D5-LR with potassium chloride IV
       Page 102 of 122 

       Effective: 08/01/11 

Drug                                          Notes
D5-NS with potassium chloride IV 20 mEq/L
D5-NS with potassium chloride IV 40 mEq/L
D5W with potassium chloride IV 20 mEq/L, 30
mEq/L, 40 mEq/L
D5W with potassium chloride IV 10 mEq/L
dextrose 10% in water (D10W) IV
dextrose 10%-1/4 normal saline IV
dextrose 5% in water (D5W) IV
dextrose 5%-0.3 % sod.chloride IV
dextrose 5%-1/4 normal saline IV
ED K+10 ORAL                                  MO
electrolyte-48 in D5W IV
FREAMINE HBC 6.9 % IV                         BvD
FREAMINE III 3 %-ELECTROLYTES IV              BvD
FREAMINE III 8.5 % IV                         BvD
HEPATAMINE 8% IV                              BvD
HEPATASOL 8 % IV                              BvD
INTRALIPID IV 20 %                            BvD
INTRALIPID IV 30 %                            BvD
IONOSOL-B IN D5W IV 

IONOSOL-MB IN D5W IV 

IONOSOL-T IN D5W IV 

ISOLYTE-H IN D5W IV 

ISOLYTE-M IN D5W IV 

ISOLYTE-P IN D5W IV 

ISOLYTE-S IV 

ISOLYTE-S IN D5W IV 

KAON CL-10 ORAL                               MO
KLOR-CON ORAL                                 MO
KLOR-CON 10 ORAL                              MO

       Page 103 of 122 

       Effective: 08/01/11 

Drug                                     Notes
KLOR-CON M15 ORAL                        MO
KLOR-CON M20 ORAL                        MO
K-TAB ORAL                               MO
lactated ringers IR
lactated ringers IV
levocarnitine IV                         BvD
levocarnitine Oral                       BvD
levocarnitine (with sucrose) Oral        BvD
LIPOSYN II IV                            BvD
LIPOSYN III IV 30 %                      BvD
LIPOSYN III IV 10 %, 20 %                BvD
magnesium sulfate Inj
magnesium sulfate IV
magnesium sulfate in D5W IV
NEPHRAMINE 5.4 % IV                      BvD
NORMOSOL-M IN D5W IV 

NORMOSOL-R IN D5W IV 

NORMOSOL-R PH 7.4 IV 

NOVAMINE 15 % IV                         BvD
NS with potassium chloride IV 20 mEq/L
NS with potassium chloride IV 40 mEq/L
PHYSIOLYTE IR 

PHYSIOSOL IRRIGATION IR 

PLASMA-LYTE 148 IV 

PLASMA-LYTE 148 IN D5W IV 

PLASMA-LYTE 56 IV 

PLASMA-LYTE A IV 

PLASMA-LYTE R IV 

PLASMA-LYTE-56 IN D5W IV 

potassium chloride IV
       Page 104 of 122 

       Effective: 08/01/11 

Drug                           Notes
potassium chloride Oral        MO
potassium citrate Oral
PREMASOL 10 % IV 
             BvD     

PREMASOL 6 % IV 
              BvD     

PRENATABS OBN ORAL


PROCALAMINE 3% IV 
            BvD     

PROSOL 20% IV 
                BvD     

RENAMIN 6.5 % IV 
             BvD
ringers IR 

ringers IV 

sodium bicarbonate IV

sodium chloride IR

sodium chloride IV

sodium chloride 0.45 % IV 

sodium chloride 0.9 % IV 

sodium chloride 3 % IV 

sodium chloride 5 % IV 

sodium fluoride Oral 

sodium lactate IV

TIS-U-SOL IR 

TPN ELECTROLYTES IV 

TRAVASOL 10 % IV 
             BvD     

TROPHAMINE 10 % IV 
           BvD     

TROPHAMINE 6% IV 
             BvD




       Page 105 of 122 

       Effective: 08/01/11 

Index

1/2 NS with potassium chloride                     Afinitor ................................. 38 
    amikacin ................................13 

  .........................................101
    Aggrenox .............................. 51 
       amiloride ...............................61 

8-Mop....................................66 
      Agrylin.................................. 51 
     amiloride-hydrochlorothiazide

Abelcet ..................................30 
     A-Hydrocort ......................... 72 
           ...........................................61

Abilify ...................................42 
    AK-Con ................................ 92 
       aminophylline .......................97 

Abilify Discmelt ....................42 
          Akne-Mycin.......................... 65 
          Aminosyn 10 %...................101 

Abraxane ...............................35 
       AK-Tob................................. 92
        Aminosyn 3.5 %..................101 

acarbose.................................48
       Ala-Cort................................ 73 
      Aminosyn 5 %.....................101 

Accolate ................................99 
      Alamast ................................. 94 
     Aminosyn 7 %.....................101 

AccuNeb................................97 
        Ala-Scalp .............................. 73 
      Aminosyn 7 % with 

acebutolol ..............................57 
      Albenza................................. 39 
        Electrolytes .....................101 

acetaminophen-codeine ...........9 
               albuterol sulfate .................... 97 
        Aminosyn 8.5 %..................101 

Acetasol HC ..........................95 
         Alcaine.................................. 93 
     Aminosyn 8.5 %-Electrolytes

acetazolamide ........................57 
         alclometasone ....................... 73 
           .........................................101

acetazolamide sodium ...........57 
               alcohol in D5W................... 101 
            Aminosyn II 10 % ...............101 

acetic acid..............................95 
      alcohol swabs........................ 16 
         Aminosyn II 15% ................101 

acetylcysteine ........................26 
        Aldactazide ........................... 61 
       Aminosyn II 3.5 %/Dextrose 5 

Aclovate ................................73 
      Aldara ................................... 66 
      % .....................................101 

Actemra .................................86 
      Aldurazyme .......................... 67 
         Aminosyn II 3.5 %-Dextrose 

ActHIB ..................................87 
      alendronate ........................... 89 
         25% .................................101 

Acticin...................................40 
     Alimta ................................... 35 
    Aminosyn II 3.5% M/Dextrose 

Actigall..................................68 
     Alinia .................................... 40 
     5% ...................................101 

Actimmune............................86 
          Alkeran ................................. 38 
     Aminosyn II 3.5%-Lytes-Ca­
Actiq........................................9 
   Allegra .................................. 98 
      D25W..............................101 

Activella ................................77 
     allopurinol............................. 31
       Aminosyn II 4.25%/Dextrose 

Actonel ..................................89 
     allopurinol sodium................ 31 
              20% .................................101 

Actoplus MET.......................51 
            Alocril................................... 94 
    Aminosyn II 4.25%-Dextrose 

Actoplus Met XR ..................51 
             Alomide ................................ 94 
        10% .................................101 

Actos .....................................51 
    Aloprim................................. 31
       Aminosyn II 4.25%-Dextrose 

Acular....................................92 
     Alora ..................................... 77 
     25% .................................101 

Acular LS ..............................92 
       Aloxi ..................................... 27 
   Aminosyn II 4.25%-Lytes-Ca­
Acuvail ..................................92 
     Alphagan P ........................... 91 
          D25..................................101 

acyclovir................................44 
      Alrex ..................................... 94 
   Aminosyn II 5%/Dextrose 25%

acyclovir sodium ...................44 
           Altabax ................................. 16 
       .........................................101

Aczone ..................................34 
      Altoprev................................ 53 
      Aminosyn II 7 % .................101 

Adacel (Adolescent & Adult) 87 
                   Alvesco ................................. 95 
     Aminosyn II 8.5 % ..............101 

Adagen ..................................68 
      amantadine ............................ 40 
       Aminosyn II 8.5 %-Electrolytes

Adalat CC..............................59 
        Amaryl .................................. 50 
       .........................................101

adapalene...............................65
        Ambien ............................... 100 
       Aminosyn M 3.5 % .............101 

Adderall.................................63
       Ambien CR ......................... 100 
          Aminosyn-HBC 7% ............101 

Adderall XR ..........................63 
         AmBisome............................ 30 
          Aminosyn-HF 8 % ..............101 

Adriamycin PFS ....................35 
            amcinonide ........................... 73 
        Aminosyn-PF 10 % .............102 

Advair Diskus .......................95 
          Amerge ................................. 33 
      Aminosyn-PF 7 % (Sulfite-

Advair HFA...........................95 
          A-Methapred......................... 72
             Free) ................................102 

Advicor..................................53 
      Amevive ............................... 66 
       amiodarone ............................55 

Afeditab CR ..........................59 
         amifostine crystalline............ 26 
            Amitiza ..................................68 


Page 106 of 122
Effective: 08/01/11
amitriptyline ..........................25 
       Aredia ............................. 89, 90
         Azasite...................................93

amitriptyline-chlordiazepoxide
                    Aricept .................................. 23 
      azathioprine ...........................84 

  ...........................................47
   Aricept ODT......................... 23 
            azathioprine sodium ..............84 

amlodipine.............................59
         Arimidex ............................... 37 
        azelastine......................... 94, 98

amlodipine-benazepril ...........59 
              Arixtra................................... 52
       Azelex ...................................65 

ammonium chloride ............102 
                Aromasin .............................. 37 
         AZILECT ..............................42 

ammonium lactate .................66 
             Arranon................................. 38 
        azithromycin .........................16 

Amnesteem............................65 
          Arthrotec 50.......................... 31 
          Azopt.....................................91 

amoxapine .............................25 
        Arthrotec 75.......................... 31 
          Azor.......................................54

amoxicillin ............................13 
       Arzerra.................................. 35 
       aztreonam..............................14 

amoxicillin-pot clavulanate ...13 
                Asacol ................................... 89 
      Azulfidine .............................89 

Amphetamine Salt Combo ....63 
                    Ascomp w/Codeine ................ 9 
                Azulfidine EN-tabs ...............89 

Amphotec ..............................30 
        Asmanex Twisthaler ....... 95, 96
                   Baci-IM .................................16 

amphotericin b.......................30 
          Astelin................................... 98
       bacitracin......................... 16, 93

ampicillin ..............................13 
      Astepro ................................. 98 
       bacitracin-polymyxin B ........93 

ampicillin sodium..................13 
            Astramorph-PF ....................... 9 
            baclofen.................................44 

ampicillin-sulbactam .............13 
             Atamet .................................. 41 
       Bactrim..................................19 

Ampyra..................................64 
       atenolol ................................. 57 
      Bactrim DS............................20 

Amrix ..................................100 
      atenolol-chlorthalidone......... 58 
                Bactroban ..............................17 

Amturnide .............................59 
        Atgam ................................... 85 
       Bactroban Nasal ....................17 

Anadrol-50 ............................77 
        Atralin................................... 65 
      balsalazide.............................89 

Anafranil ...............................25 
      ATRIPLA ............................. 45 
           Balziva (28)...........................80 

anagrelide ..............................51 
      atropine ................................. 68 
      Banzel ...................................20 

Anaprox.................................31
        Atrovent................................ 96 
        Baraclude ..............................44 

Anaprox DS...........................31 
          Atrovent HFA....................... 96 
             Beconase AQ ........................96 

anastrozole ............................37 
       Attenuvax (PF) ..................... 87 
            benazepril..............................54 

Ancobon ................................28 
       AVANDAMET .................... 51 
                  benazepril-hydrochlorothiazide

AndroGel...............................77
         Avandaryl ............................. 51 
            ...........................................55

ANGELIQ.............................77 
           Avandia................................. 51
         Benicar ..................................54 

Antabuse.......................... 25, 26
         AVASTIN............................. 35
             Benicar HCT .........................54 

Antara....................................60 
     Avelox .................................. 19 
       Bentyl....................................68 

Antivert .................................27 
     Avelox ABC Pack ................ 19 
                Benzaclin Carekit ..................65 

Anusol-HC ............................73 
         Avelox in NaCl (iso-osmotic)
                        Benzamycin...........................65

Anzemet ................................27 
          .......................................... 19 
   benztropine............................40 

Aphthasol ..............................64 
       Aviane................................... 80
        Bepreve .................................94 

Apidra....................................49 
     Avinza..................................... 8
       Betagan .................................91 

Apidra SoloStar.....................49 
           Avita ..................................... 65 
     betamethasone dipropionate. 74, 

APOKYN ..............................40 
          Avodart ................................. 71 
         75

apraclonidine.........................91 
         Avonex ................................. 86 
        betamethasone valerate ... 73, 74

Apri .......................................78 
   Avonex Administration Pack 86 
                      betamethasone, augmented ...75 

Apriso....................................89 
     Axert ..................................... 33 
     Betaseron...............................86

Aptivus ..................................46 
     Axid ...................................... 70 
     Beta-Val ................................74 

Aralast NP .............................99 
       Axiron................................... 77 
       betaxolol.......................... 58, 91

Aralen....................................39 
     Aygestin................................ 80 
        bethanechol chloride .............72 

Aranelle (28) .........................80 
        Azactam................................ 13 
         Betimol ..................................91 

Aranesp (polysorbate) ...........52 
              Azactam-iso-osmotic dextrose
                        Betoptic S..............................91 

Arava.....................................86 
        .......................................... 14 
   bicalutamide ..........................84 

Arcalyst .................................84 
     Azasan .................................. 84 
       Bicillin C-R...........................18 


Page 107 of 122
Effective: 08/01/11
Bicillin L-A ...........................18 
        Canasa................................... 89
        cefuroxime-dextrose (iso-osm)
BiCNU ..................................38 
        Cancidas ............................... 30 
           ...........................................14

BiDil......................................62 
     Cantil .................................... 68 
     Celebrex ................................31 

Biltricide................................39 
      Capastat ................................ 34 
       Celestone...............................72 

bisoprolol fumarate ...............58 
             Capex.................................... 74 
       Celexa ...................................47 

bisoprolol-hydrochlorothiazide
                     Capital with Codeine .............. 9 
              CellCept ................................84 

   ...........................................58
   captopril................................ 55 
       CellCept Intravenous ............84 

bleomycin ..............................35 
        captopril-hydrochlorothiazide
                       Celontin.................................20 

Bleph-10................................93 
           .......................................... 55 
   Cenestin.................................78

Blephamide ...........................93 
          Carac..................................... 66 
      cephalexin .............................14 

Blephamide S.O.P. ................93 
              Carafate................................. 70
        Cerebyx .................................22 

Boniva ............................. 89, 90
        carbamazepine ...................... 22 
            Ceredase................................67 

BOOSTRIX...........................88
              Carbatrol ............................... 22 
       Cerezyme ..............................67 

Borofair .................................95 
      carbidopa-levodopa .............. 41 
               Cervarix.................................88

Botox...................................100 
       carbinoxamine maleate ......... 98 
                 Cesamet.................................27 

Brevicon (28) ........................80 
          carboplatin ............................ 34 
        Cesia......................................78 

brimonidine ...........................91 
         Cardizem............................... 57
          Chantix..................................26 

Bromday ................................92 
        Cardizem CD ........................ 57 
            Chantix Starting Month Pak..26 

bromfenac..............................92 
         Cardizem LA ........................ 57 
            Chemet ..................................26 

bromocriptine ........................41 
          Cardura XL........................... 54 
           chloramphenicol sod succinate

Brovana .................................97 
       Carimune NF Nanofiltered ... 85 
                       ...........................................17

Budeprion SR........................24 
            carisoprodol ........................ 100 
          chlorhexidine gluconate ........64 

Budeprion XL .......................24 
            carisoprodol-ASA-codeine . 100 
                     chloroquine phosphate ..........39 

budesonide ............................96 
         carisoprodol-aspirin............ 100 
               chlorothiazide........................61 

bumetanide ............................60 
         CARMOL HC ...................... 74 
                chlorothiazide sodium ...........62 

Buphenyl ...............................68 
        Carnitor............................... 102 
        chlorpromazine .....................43 

Buprenex ...............................26 
        carteolol ................................ 91 
      chlorpropamide .....................50 

buprenorphine ................... 9, 26 
           Cartia XT .............................. 57 
        chlorthalidone .......................62 

Buproban...............................24 
         carvedilol .............................. 56 
       chlorzoxazone .....................100 

bupropion HCl ......................24 
            Casodex ................................ 84 
        Cholestyramine Light............56 

buspirone...............................47 
        Cataflam ............................... 31 
        chorionic gonadotropin, human

butorphanol tartrate .................9 
           Cayston ................................. 14 
          ...........................................76

Byetta ....................................48 
     CeeNU .................................. 38 
        ciclopirox ..............................28 

Bystolic .................................56 
      cefaclor ................................. 14 
      cilostazol ...............................53 

cabergoline ............................41 
        cefadroxil.............................. 14 
        Ciloxan..................................93 

Caduet ...................................59 
      cefazolin ............................... 14 
       cimetidine ..............................70 

Cafergot.................................32
        cefazolin in dextrose (iso-os) 14 
                  Cimzia ...................................70 

Calan .....................................57 
     cefdinir.................................. 14 
      Cimzia Powder for Reconst ..70 

Calan SR ...............................57 
        cefepime ............................... 15 
        Cipro HC...............................19 

Calcijex .................................90 
      cefotaxime ............................ 15 
         Cipro in D5W........................19 

calcipotriene ..........................67 
        cefotetan ............................... 14 
       CIPRODEX...........................19

calcitonin (salmon)................90 
             cefoxitin................................ 14 
       ciprofloxacin .........................19 

calcitriol ................................90 
     cefpodoxime ......................... 15 
           ciprofloxacin (mixture) .........19 

calcium acetate ......................72 
          cefprozil................................ 14 
       cisplatin .................................34 

Camila ...................................80 
      ceftazidime ........................... 15 
         citalopram .............................47 

Campath ................................35 
        ceftriaxone ............................ 15 
        cladribine...............................38

Campral .................................26 
       cefuroxime axetil .................. 14 
            Claravis .................................65 

Camptosar .............................35 
         cefuroxime sodium ............... 14 
               Clarinex.................................98 


Page 108 of 122
Effective: 08/01/11
Clarinex-D 12 HOUR ...........98 
                  CLOBETASOL                                        Corgard .................................61 

Clarinex-D 24 HOUR ...........98 
                     PROPIONATE 0.5 MG/ML                           Cortef ....................................72 

clarithromycin .......................16 
             TOPICAL CREAM                                  Cortenema .............................74 

clemastine..............................98 
           [ISOVATE] ...................... 75 
          Cortifoam ..............................74 

Cleocin ............................ 15, 16
        clobetasol-emollient ............. 75 
           cortisone................................72 

Cleocin in D5W ....................16 
             CLOBEX .............................. 75 
        Cortisporin ...................... 17, 95 

Cleocin T...............................65 
        Cloderm ................................ 74 
     Cortisporin-TC......................95 

Climara ..................................78 
      CLOLAR .............................. 38 
        Cortomycin ...........................95 

Climara Pro ...........................80 
         clomipramine ........................ 25 
        Corzide..................................61 

Clindagel ...............................65 
       clonidine ............................... 54 
    Cosmegen ..............................35 

clindamycin HCl ...................16 
             Clorpres ................................ 54 
    Cosopt ...................................91 

clindamycin phosphate.... 16, 65 
                  clotrimazole .......................... 29 
      Coumadin ..............................51 

clindamycin-benzoyl peroxide
                       clotrimazole-betamethasone . 29 
                 Covera-HS.............................57

   ...........................................65
   clozapine............................... 42 
     Creon.....................................67 

Clindesse ...............................16 
       Clozaril ................................. 42 
   Crestor...................................53 

Clinimix 2.75%/D5 Sulfite Free
                     Coartem ................................ 39 
     Crinone..................................80 

   .........................................102
    cod-butalbital-acetaminop-caf 9 
                 Crixivan.................................46

Clinimix 4.25%/D5 Sulfite Free
                     codeine sulfate ........................ 9 
      cromolyn ......................... 94, 99 

   .........................................102
    Cogentin ............................... 40 
     Cryselle (28)..........................78 

Clinimix 4.25/D10 Sulfite Free
                     Co-Gesic ................................. 9 
    CUBICIN ..............................17 

   .........................................102
    Cognex.................................. 23 
     Cuprimine .............................84 

Clinimix 4.25/D20 Sulfite Free
                     Colazal.................................. 89 
    Curity Gauze .........................49 

   .........................................102
    colchicine-probenecid........... 31
              Cutivate .................................74 

Clinimix 4.25/D25 Sulfite Free
                     Colcrys.................................. 30 
    Cyclafem 1/35 (28) ...............80 

   .........................................102
    Colestid................................. 56 
    Cyclafem 7/7/7 (28) ..............80 

Clinimix 5%/D15 Sulfite Free
                       colestipol............................... 56
     Cyclessa ................................78 

   .........................................102
    colistimethate sodium........... 17 
             cyclobenzaprine ..................100 

Clinimix 5%/D20 Sulfite Free
                       Colocort ................................ 74 
    cyclophosphamide.................34

   .........................................102
    Coly-Mycin M Parenteral..... 17 
                 cyclosporine ..........................84 

Clinimix 5%/D25 Sulfite Free
                       Coly-Mycin S ....................... 95 
         cyclosporine modified ...........84 

   .........................................102
    Colyte with Flavor Packs...... 68 
               Cyklokapron..........................64 

Clinimix E 2.75/D10 SulfitFree
                     Combigan ............................. 91 
       Cymbalta ...............................24 

   .........................................102
    CombiPatch .......................... 78 
        cyproheptadine ......................98 

Clinimix E 2.75/D5 SulfiteFree
                     Combivent ............................ 96 
       Cystadane..............................90 

   .........................................102
    Combivir ............................... 45 
     Cystagon ...............................67 

Clinimix E 4.25/D25 SulfitFree
                     Combunox .............................. 9 
       cytarabine..............................38 

   .........................................102
    Compro ................................. 27 
     cytarabine (PF) ......................38 

Clinimix E 4.25/D5 SulfiteFree
                     Comtan ................................. 40 
     Cytomel .................................82 

   .........................................102
    Comvax................................. 87
       Cytotec ..................................70 

Clinimix E 5%/D15 Sulfite 
                         Concerta................................ 63 
     D.H.E.45 ...............................32 

   Free..................................102 
      Condylox .............................. 66 
      D10 %-0.45 % sodium chloride

Clinimix E 5%/D20 Sulfite 
                         Constulose ............................ 69 
        .........................................102

   Free..................................102 
      Copaxone.............................. 86 
       D10-0.2 % NaCl & Potassium

Clinimix E 5%/D25 Sulfite 
                         Copegus ................................ 44 
       Cl.....................................102 

   Free..................................102 
      Cordran ................................. 74 
    D2.5 %-0.45 % sodium

Clinisol SF 15% ..................102 
             Cordran SP............................ 74 
         chloride ...........................102 

Clinoril ..................................31 
     Coreg .................................... 56 
   D5 %-0.45 % sodium chloride

clobetasol ..............................75 
       Coreg CR .............................. 56 
        .........................................102


Page 109 of 122
Effective: 08/01/11
D5 %-0.9 % sodium chloride                        DermOtic Oil ........................ 95 
           digoxin ..................................58 

  .........................................102
   desipramine........................... 25
           dihydrocode-acetaminophen­
D5-1/2 NS & potassium 
                           desmopressin ........................ 77 
              caff ......................................9 

  chloride............................102 
       Desogen ................................ 78 
        dihydroergotamine ................32 

D5-1/3 NS & potassium 
                           Desonate ............................... 74 
        Dilacor XR ............................57 

  chloride............................102 
       desonide................................ 74 
        Dilantin .................................22 

D5-1/4 NS & potassium 
                           DesOwen .............................. 73 
          Dilantin Extended .................22 

  chloride............................102 
       DesOwen Ointment & Lotion
                           Dilantin Infatabs....................22 

D5-LR with potassium chloride
                       .......................................... 73 
   Dilantin-125 ..........................22 

  .........................................102
   desoximetasone............... 73, 75
                Dilatrate-SR ..........................62 

D5-NS with potassium chloride
                    Desoxyn................................ 63 
         Dilaudid...................................9

  .........................................103
   Detrol.................................... 71 
      Dilaudid-5 ...............................9 

D5W with potassium chloride
                      Detrol LA.............................. 71 
         Dilaudid-HP ............................9 

  .........................................103
   dexamethasone ..................... 72 
             diltiazem HCl .................. 56, 57

dacarbazine............................34 
       Dexamethasone Intensol ....... 72 
                  DILT-XR...............................57

Dacogen ................................38 
      dexamethasone sodium
 
                              Diovan...................................54 

danazol ..................................77 
       phosphate.................... 72, 91 
            Diovan HCT..........................54 

Dantrium ...............................44 
      Dexasporin............................ 93 
          Dipentum...............................69

dantrolene..............................44 
      dexchlorpheniramine maleate98 
                      diphenhydramine HCl ...........98 

dapsone..................................34 
     Dexedrine Spansule .............. 63 
               diphenoxylate-atropine .........69 

Daptacel (Pediatric) (PF) ......88 
              dexmethylphenidate .............. 63 
               Diprolene...............................75

Daraprim ...............................39 
      DexPak ................................. 72 
        Diprolene AF ........................75 

daunorubicin..........................36 
        dexrazoxane.......................... 58 
           dipyridamole .........................52 

DaunoXome ..........................36 
          dextroamphetamine .............. 63 
                disopyramide .........................56 

Daypro...................................31
      dextrose 10% in water (D10W)
                        Ditropan XL ..........................71 

Daytrana ................................63 
        ........................................ 103 
    Diuril .....................................62 

DDAVP.................................77 
        dextrose 10%-1/4 normal saline
                      Diuril IV................................62 

DECAVAC ...........................87 
              ........................................ 103 
    divalproex .............................21 

Delestrogen ...........................78 
       dextrose 5% in water (D5W)
                          Divigel...................................78

Demadex ...............................60 
          ........................................ 103 
    docetaxel ...............................36 

demeclocycline......................20 
          dextrose 5%-0.3 % sod.chloride
                      Dolophine................................9 

Demerol...................................9
         ........................................ 103 
    donepezil ...............................23 

Demerol (PF) ..........................9 
        dextrose 5%-1/4 normal saline
                       Doribax .................................14 

Demser ..................................64 
        ........................................ 103 
    dorzolamide...........................91

Denavir..................................44 
     Diabeta.................................. 50 
       dorzolamide-timolol ..............91 

Depacon ................................21 
      Diamox Sequels .................... 57 
             Dovonex................................67 

Depade ..................................26 
     Dibenzyline........................... 54
           doxazosin ..............................54 

Depakene...............................21
        diclofenac potassium ............ 31 
               doxepin..................................25 

Depakote ...............................21 
      diclofenac sodium........... 31, 92
                 doxorubicin ...........................36 

Depakote ER .........................21 
         dicloxacillin .......................... 19 
        doxycycline hyclate ..............20 

Depakote Sprinkles ...............21 
            dicyclomine .......................... 68 
          doxycycline monohydrate .....20 

Depen Titratabs .....................85 
         didanosine............................. 45 
         dronabinol .............................27 

Depo-Estradiol ......................78 
         Didronel................................ 89 
        Droxia ...................................35 

Depo-Medrol.........................72 
          Differin ................................. 65 
      DUETACT............................51 

Depo-Provera ........................80 
         diflorasone ............................ 75 
        Dulera....................................96 

Depo-SubQ provera 104 .......80 
                 Diflucan ................................ 29 
       DuoNeb .................................96 

Derma-Smooth/FS Body Oil. 75 
                    Diflucan in NaCl (iso-osm) .. 29 
                   Duragesic ................................8 

DERMATOP.........................75
              diflunisal ............................... 31 
      Duramorph ..............................9 


Page 110 of 122
Effective: 08/01/11
Durezol..................................93 
       Entocort EC .......................... 89 
          Eurax .....................................40 

Dyazide .................................61 
       Enulose ................................. 69 
       Evamist .................................78 

DynaCirc CR.........................59 
            epinastine.............................. 94 
        Evista.....................................82

Dyrenium ..............................61 
         epinephrine HCl.................... 97 
             Evoclin ..................................65 

E.E.S. 400 .............................16 
        EpiPen................................... 97
        Evoxac...................................64

E.E.S. Granules .....................16 
           EpiPen Jr............................... 97 
        Exelderm ...............................29 

EC-Naprosyn.........................31
             epirubicin.............................. 36 
        Exelon ...................................23 

econazole...............................29 
        Epitol .................................... 22 
     exemestane ............................37 

ED K+10 .............................103 
          Epivir .................................... 45 
     Exforge..................................55 

Edarbi ....................................54 
     Epivir HBV........................... 45 
           Exforge HCT.........................59 

Edecrin ..................................60 
      eplerenone............................. 61
          Exjade ...................................26 

Edurant ..................................45 
      Epogen.................................. 52 
        Extina ....................................29 

Effexor ..................................24 
      Epzicom................................ 45 
         Fabrazyme .............................67 

Effexor XR............................25 
          Equetro ................................. 47 
       famciclovir ............................44 

Effient....................................51 
     Eraxis(Water Diluent) .......... 30 
                famotidine .............................70 

Efudex ...................................66 
      Erbitux .................................. 35 
      famotidine (PF) .....................70 

ELAPRASE ..........................67 
             ergoloid................................. 23 
       famotidine(PF) in sal (iso-os) 70 

Eldepryl.................................42 
       Ergomar ................................ 32 
        Famvir ...................................45 

electrolyte-48 in D5W.........103 
                 ergotamine-caffeine .............. 32 
              Fanapt....................................42 

ELESTAT .............................94 
           Errin...................................... 80 
     Fareston.................................39 

Elestrin ..................................78 
     Ertaczo.................................. 29 
       Faslodex ................................37 

Elidel .....................................66 
    Ery Pads................................ 65 
        FazaClo .................................42 

Eligard...................................83 
      EryPed 200 ........................... 16 
          Felbatol .................................22 

Elitek .....................................68 
    EryPed 400 ........................... 16 
          Feldene..................................31 

Elixophyllin...........................97
          Ery-Tab................................. 16 
        felodipine ..............................59 

Ellence...................................36
       Erythrocin ............................. 16 
        Femara...................................37

Elmiron..................................72 
       Erythrocin Stearate ............... 16 
             Femhrt 1/5 .............................78 

Elocon ...................................75 
      erythromycin......................... 16
            Femhrt Low Dose .................78 

Eloxatin .................................34 
      erythromycin ethylsuccinate . 16 
                   Femring .................................78 

Elspar ....................................36 
     erythromycin with ethanol .... 65 
                  Femtrace ................................78 

Emadine ................................94 
        erythromycin-benzoyl peroxide
                       fenofibrate .............................60 

Embeda....................................8 
          .......................................... 65 
   fenofibrate micronized ..........60 

Emcyt ....................................37 
      erythromycin-sulfisoxazole .. 16 
                   Fenoglide...............................60

Emend ...................................28 
       Estrace .................................. 78 
      fenoprofen .............................31 

EMLA ...................................12 
        Estraderm.............................. 78 
         fentanyl ...................................8 

Emsam...................................24
         estradiol ................................ 78 
      fentanyl citrate ........................9 

Emtriva ..................................45 
      estradiol valerate................... 78 
           fentanyl citrate (PF) ................9 

Enablex..................................71 
       estradiol-norethindrone acet . 78 
                  Fentora ....................................9 

enalapril maleate ...................55 
           Estring................................... 78
       Fexmid ................................100 

enalapril-hydrochlorothiazide
                      estropipate............................. 78
         fexofenadine..........................98 

   ...........................................55
   Estrostep Fe-28..................... 78 
            Finacea ..................................65 

Enbrel ....................................86 
     ethambutol ............................ 34 
         finasteride..............................71 

Endocet....................................9 
      ethosuximide......................... 20
            Fioricet-Codeine ...................10 

Endometrin ............................80 
         Ethyol ................................... 26 
      Fiorinal-Codeine #3 ..............10 

Engerix-B (PF)......................87 
            etidronate disodium .............. 89 
              Flagyl ....................................17 

Enjuvia ..................................78 
      etodolac................................. 31
        Flagyl ER ..............................17 

enoxaparin.............................52 
         Etopophos ............................. 36 
         Flarex ....................................92 

Enpresse ................................80 
       etoposide............................... 36 
        flavoxate................................71 


Page 111 of 122
Effective: 08/01/11
flecainide ...............................56 
      Freamine III 3 %-Electrolytes                        Glumetza ...............................48 

Flexeril ................................100 
         ........................................ 103 
    glyburide ...............................50 

Flomax ..................................71 
       Freamine III 8.5 % .............. 103 
              glyburide micronized ............50 

Flonase ..................................96 
      Frova..................................... 33 
      glyburide-metformin .............50 

Flovent Diskus ......................96 
           Furadantin............................. 18 
         glycopyrrolate .......................68 

Flovent HFA .........................96 
           furosemide ............................ 60 
         Glycron .................................50 

fluconazole ............................29 
        Fuzeon .................................. 46 
       Glynase .................................50 

fluconazole in dextrose(iso-o)
                     gabapentin............................. 21
          Glyset ....................................48 

   ...........................................29
   Gabitril.................................. 21 
      Golytely.................................69

Fludara ..................................38 
      galantamine........................... 23
           granisetron.............................27

fludarabine ............................39 
        GamaSTAN S/D ................... 85 
                granisetron (PF) ....................27 

fludrocortisone ......................76 
          Gammagard Liquid ............... 85 
                Granisol.................................27 

Flumadine..............................46 
         Gammaplex........................... 85
             Grifulvin V............................28 

flunisolide..............................96 
       Gamunex............................... 85
           griseofulvin microsize ...........29 

fluocinolone .................... 73, 75
           ganciclovir ............................ 44 
        Gris-PEG...............................29 

fluocinonide ..........................73 
         ganciclovir sodium ............... 45 
              guanabenz .............................54 

fluocinonide-emollient ..........76 
               Gardasil................................. 88
        guanfacine .............................54 

fluorometholone ....................92 
            Gastrocrom ........................... 99 
          guanidine...............................33 

Fluoroplex .............................66 
        Gavilyte-C ............................ 69 
         Gynazole-1............................29 

fluorouracil...................... 35, 66
          GaviLyte-G........................... 69 
           Gynodiol ...............................78 

fluoxetine ..............................47 
       GaviLyte-N........................... 69 
           Halaven .................................36 

fluphenazine decanoate .........43 
                gemcitabine........................... 39
           Haldol....................................43 

fluphenazine HCl ..................43 
             gemfibrozil ........................... 60 
         Haldol Decanoate ..................43 

flurbiprofen ...........................31 
        Gemzar ................................. 39 
        HalfLytely-Bisacodyl Bowel 

flurbiprofen sodium...............92 
              Gengraf ................................. 85 
          Kit .....................................69 

flutamide ...............................84 
       Genotropin............................ 76 
          halobetasol propionate ..........76 

fluticasone ....................... 75, 96
         Genotropin Miniquick .......... 76 
                 Halog.....................................73 

fluvoxamine ..........................47 
          Gentak................................... 93
        haloperidol ............................43 

FML Forte .............................92 
         gentamicin ............................ 13 
         haloperidol decanoate ...........43 

FML Liquifilm ......................92 
            gentamicin in NaCl (iso-osm)
                        haloperidol lactate .................43 

FML S.O.P. ...........................92 
             .......................................... 13 
   Havrix (PF) ...........................87 

Focalin...................................63
       gentamicin sulfate (PF)......... 13 
                Hectorol.................................90

Focalin XR ............................63 
         Gentasol................................ 93 
        Helidac ..................................69 

Foradil Aerolizer ...................97 
           Geodon ................................. 42 
        heparin (porcine) ...................52 

Fortamet ................................48 
       Gianvi ................................... 78 
      heparin (porcine) in D5W .....52 

Fortaz ....................................15 
     Gilenya ................................. 64 
       heparin (porcine) in NS (PF). 52 

Fortaz in D5W.......................15 
            Glassia .................................. 99 
      heparin (porcine)-0.45% NaCl

Forteo ....................................90 
     Gleevec ................................. 37 
          ...........................................52

FORTICAL ...........................90 
            glimepiride ............................ 50 
        heparin, porcine (PF) ............52 

foscarnet ................................44 
      glipizide ................................ 50 
      Hepatamine 8% ...................103 

fosinopril ...............................55 
      glipizide-metformin .............. 50 
              Hepatasol 8 % .....................103 

fosinopril-hydrochlorothiazide
                     GlucaGen HypoKit............... 48 
                 Hepsera .................................44 

   ...........................................55
   Glucagon Emergency ........... 48 
                  Herceptin...............................37 

fosphenytoin..........................22 
          Glucophage........................... 48 
           Hexalen .................................37 

FOSRENOL ..........................72 
             Glucophage XR .................... 48 
              Hiprex ...................................17 

Fragmin .................................52 
       Glucotrol............................... 50 
        Hizentra.................................85 

Freamine HBC 6.9 % ..........103 
                  Glucotrol XL ........................ 50 
           Horizant.................................21

                                                    Glucovance ........................... 50 
          Humalog ................................49 


Page 112 of 122
Effective: 08/01/11
Humalog KwikPen ................50 
                Increlex ................................. 77 
     Ixiaro (PF).............................87 

Humalog Mix 50-50 ..............49 
                indapamide ........................... 62 
         Jalyn ......................................71 

Humalog Mix 50-50 KwikPen
                          Inderal LA ............................ 61 
        Jantoven ................................51 

   ...........................................49
   Indocin.................................. 31 
      Janumet .................................48 

Humalog Mix 75-25 ..............49 
                indomethacin ........................ 31 
          Januvia ..................................48 

Humalog Mix 75-25 KwikPen
                          Infanrix (PF) ......................... 88 
        Je-Vax ...................................87 

   ...........................................49
   Infergen................................. 86
       Jevtana...................................36

Humatrope.............................76
           Infumorph P/F ...................... 10 
           Jinteli.....................................79 

Humira ..................................87 
       Innohep ................................. 53 
      Jolivette .................................80 

Humira Crohn's Dis Start Pck
                       InnoPran XL ......................... 61 
          Junel 1.5/30 (21) ...................80 

   ...........................................87
   Insulin Pen Needle................ 49 
             Junel 1/20 (21) ......................80 

Humulin 70/30 ......................49 
            insulin syringe-needle U-100 49 
                   Junel FE 1.5/30 (28)..............80 

Humulin 70/30 Pen ...............49 
               Intelence ............................... 45 
      Junel FE 1/20 (28).................80 

Humulin N ............................49 
          Intralipid ............................. 103 
      Kadian .....................................8 

Humulin N Pen .....................49 
             Intron A ................................ 86 
      Kaletra...................................46 

Humulin R .............................50 
         Invanz ................................... 14 
     kanamycin .............................13 

Humulin R U-500..................50 
               Invega ................................... 42 
     Kaon Cl-10..........................103 

Hycamtin ...............................36 
        Invega Sustenna.................... 42 
            Kariva....................................79 

Hycet .....................................10 
     Invirase ................................. 46 
     Kayexalate.............................69

hydralazine ............................62 
        Ionosol-B in D5W .............. 103 
               Kelnor 1/35 (28)....................79 

Hydrea...................................35 
       Ionosol-MB in D5W........... 103 
                  Kenalog .................................73 

hydrochlorothiazide ..............62 
              Ionosol-T in D5W............... 103 
               Kepivance .............................64 

hydrocodone-acetaminophen 10 
                      Iopidine................................. 91 
      Keppra...................................20 

hydrocodone-ibuprofen.........10 
                  IPOL ..................................... 88 
     Keppra XR ............................20 

hydrocortisone................. 72, 74
             ipratropium bromide ............. 97 
              Kerlone..................................58 

hydrocortisone butyrate.........75 
                ipratropium-albuterol ............ 97 
             KETEK .................................16 

hydrocortisone valerate .........75 
               Iquix...................................... 93 
    ketoconazole .........................29 

hydrocortisone-acetic acid ....95 
                 IRESSA ................................ 37 
        ketoprofen .............................31 

hydromorphone .....................10 
             irinotecan .............................. 36 
      ketorolac.................... 31, 32, 92

hydromorphone (PF) .............10 
                Isentress ................................ 46 
     Kineret...................................86

hydroxychloroquine ..............39 
               Ismo ...................................... 62 
    Kionex...................................26 

hydroxyurea ..........................35 
          ISOCHRON.......................... 62 
             Klaron ...................................65 

hydroxyzine HCl ...................98 
             Isolyte-H in D5W ............... 103 
              Klor-Con .............................103 

hydroxyzine pamoate ............98 
                Isolyte-M in D5W............... 103 
               Klor-Con 10 ........................103 

ibuprofen ...............................31 
       Isolyte-P in D5W................ 103 
              Klor-Con M15.....................104 

ibuprofen-oxycodone ............10 
                Isolyte-S.............................. 103 
       Klor-Con M20.....................104 

idarubicin ..............................35 
       Isolyte-S in D5W................ 103 
              Kristalose ..............................69 

Ifex ........................................34 
   IsonaRif ................................ 34 
      K-Tab ..................................104 

ifosfamide..............................34 
        isoniazid................................ 34 
      Kuric .....................................29 

ifosfamide-mesna ..................35 
             Isoptin SR ............................. 57 
       Kuvan....................................68 

Imdur.....................................62 
      Isordil.................................... 62 
    Kytril .....................................27 

imipramine HCl.....................25 
             Isordil Titradose.................... 62 
          labetalol.................................56 

imipramine pamoate..............25 
                isosorbide dinitrate ............... 62 
           Lac-Hydrin............................66 

imiquimod .............................66 
         isosorbide mononitrate ......... 62 
               LAClotion .............................66 

Imitrex ...................................33 
     isradipine .............................. 59 
      Lacrisert ................................93 

Imitrex STATdose Kit Refill 33 
                    Istalol .................................... 91 
   lactated ringers ....................104 

Imovax Rabies Vaccine ........88 
                  Istodax .................................. 36 
     lactulose ................................69 

Imuran ...................................85 
      itraconazole........................... 29
         Lamictal ................................22 


Page 113 of 122
Effective: 08/01/11
Lamictal Starter (Blue) Kit ...22 
                 Lexapro................................. 47 
         Lotronex................................70 

Lamictal Starter (Green) Kit . 22 
                 Lexiva ................................... 46 
       lovastatin ...............................53 

Lamictal Starter (Orange) Kit22 
                   Lialda.................................... 89 
       Lovaza...................................61 

Lamictal XR ..........................22 
          lidocaine (PF) ....................... 12 
           Lovenox ................................53 

Lamictal XR Starter (Blue) ...22 
                  lidocaine HCl ........................ 12 
           Low-Ogestrel (28).................81 

Lamictal XR Starter (Green) . 22 
                  lidocaine-prilocaine .............. 12 
              loxapine succinate .................43 

Lamictal XR Starter (Orange)
                       Lidoderm .............................. 12 
          Loxitane ................................43 

   ...........................................22
   Lincocin................................ 16 
         Lufyllin .................................97 

Lamisil ............................ 28, 29
        lindane .................................. 40 
       Lumigan ................................95 

lamotrigine ............................22 
        liothyronine........................... 82
           Lunesta................................100 

Lanoxin .................................58 
       Lipitor ................................... 53 
      Lupron Depot ........................83 

Lanoxin Pediatric ..................58 
            Lipofen ................................. 60 
        Lupron Depot (3 Month).......83 

lansoprazole ..........................70 
         Liposyn II ........................... 104 
          Lupron Depot (4 Month).......83 

Lantus....................................49 
      Liposyn III .......................... 104 
          Lupron Depot-Ped.................83 

Lantus Solostar......................49 
           lisinopril................................ 55 
       Lutera (28) ............................81 

Lasix......................................60 
     lisinopril-hydrochlorothiazide
                       Luxiq .....................................73 

Lastacaft ................................94 
          .......................................... 55 
   Lybrel....................................81 

latanoprost.............................95 
        lithium carbonate .................. 48 
             Lyrica ....................................21 

Latuda....................................42 
      lithium citrate........................ 48 
          Lysodren ...............................36 

Leena 28................................80 
        Lithobid ................................ 48 
        Lysteda..................................53 

leflunomide ...........................86 
         Livalo.................................... 53 
       Macrobid ...............................18 

Lescol ....................................53 
     Locoid................................... 75 
        Macrodantin ..........................18 

Lescol XL..............................53 
         Locoid Lipocream ................ 75 
                Magnacet...............................10 

Lessina ..................................80 
      Lodosyn ................................ 41 
         magnesium sulfate ..............104 

Letairis ..................................99 
     Loestrin 1.5/30 (21) .............. 80 
              magnesium sulfate in D5W . 104 

letrozole.................................37
       Loestrin 1/20 (21) ................. 81 
             Malarone ...............................39 

leucovorin calcium................26 
              Loestrin 24 Fe....................... 81 
            malathion...............................40

Leukeran................................38 
        Loestrin Fe 1.5/30 (28) ......... 81 
                maprotiline ............................24 

Leukine..................................51 
       Loestrin Fe 1/20 (28) ............ 81 
               Margesic-H ...........................10 

leuprolide ..............................83 
       Lofibra .................................. 60 
       Marplan .................................24 

Leustatin................................39 
       LoKara.................................. 74 
         Matulane ...............................35 

levalbuterol HCl....................97 
            Lomotil ................................. 69 
        Matzim LA ............................57 

Levaquin................................19 
        Lo-Ovral (28)........................ 81 
            Maxair Autohaler ..................97 

Levaquin in D5W..................19 
               loperamide ............................ 69 
          Maxalt ...................................33 

Levatol ..................................61 
      Lopid..................................... 60
        Maxalt-MLT .........................33 

Levemir .................................49 
       Lopressor ........................ 55, 58 
           Maxidex ................................92 

Levemir Flexpen ...................49 
             Lopressor HCT ..................... 58 
              Maxidone ..............................10 

levetiracetam .........................20 
         Loprox .................................. 29 
        Maxipime ..............................15 

levobunolol............................91 
         Lorcet 10/650........................ 10 
            Maxitrol.................................93

levocarnitine........................104 
          Lorcet Plus............................ 10 
          Maxzide.................................61

levocarnitine (with sucrose) 104 
                  Lortab ................................... 10 
       Maxzide-25mg ......................61 

levocetirizine.........................99 
         Lortab Elixir ......................... 10 
          mebendazole .........................39 

levofloxacin...........................93
          losartan ................................. 54 
       meclizine ...............................27 

Levora-28 ..............................80 
        losartan-hydrochlorothiazide 54 
                     meclofenamate ......................32 

levorphanol tartrate ...............10 
            LoSeasonique ....................... 81 
             Medrol...................................72 

Levothroid.............................82 
         Lotemax ................................ 92 
         Medrol (Pak) .........................72 

levothyroxine ........................82 
          Lotrel .................................... 59 
      medroxyprogesterone ............81 

Levoxyl .................................82 
       Lotrisone............................... 29 
         mefenamic acid .....................32 


Page 114 of 122
Effective: 08/01/11
mefloquine ............................40 
      methyldopate ........................ 54 
          Mobic ....................................32 

Megace ES ............................81 
       Methylin ............................... 64 
       Modicon (28) ........................81 

Megace Oral..........................81 
        Methylin ER ......................... 64 
          moexipril ...............................55 

megestrol ...............................81 
    methylphenidate ................... 64 
            moexipril-hydrochlorothiazide

meloxicam .............................32 
      methylprednisolone .............. 72 
                ...........................................55

melphalan ..............................38 
     methylprednisolone acetate .. 72 
                  mometasone ..........................75 

Menactra (PF) .......................87 
        methylprednisolone sodium
                          Monoket ................................62 

Menest...................................79 
      succ ................................... 72 
     Mononessa (28).....................79 

Menomune - A/C/Y/W-135 
                         metipranolol .......................... 91 
        Monurol.................................17

  (PF) ...................................87 
   metoclopramide .................... 27 
            morphine ........................... 8, 10 

Menostar................................79 
     metolazone ............................ 62 
        morphine (PF) .......................10 

Mentax ..................................29 
    metoprolol succinate ............. 58 
             morphine concentrate ............10 

Menveo A-C-Y-W-135-Dip 
                         metoprolol tartrate .......... 55, 58 
             Motofen.................................69 

  (PF) ...................................87 
   metoprolol-hydrochlorothiazide
                     MoviPrep...............................69

meperidine.............................10
         .......................................... 58 
   Moxeza..................................93 

meperidine (PF).....................10 
         Metozolv ODT...................... 27 
             Mozobil .................................51 

meprobamate.........................47 
         MetroCream.......................... 17 
           MS Contin...............................8 

Mepron ..................................40 
    Metrogel ............................... 17 
       Multaq ...................................56 

mercaptopurine......................39 
         Metrogel Vaginal.................. 17 
             mupirocin ..............................17 

meropenem ............................17 
       MetroLotion.......................... 17 
          Mustargen .............................38 

Merrem..................................17 
     metronidazole ....................... 17 
          Myambutol ............................34 

Meruvax II (PF) ....................88 
         metronidazole in NaCl (iso-os)
                     Mycamine .............................30 

mesalamine............................89 
         .......................................... 17 
   Mycobutin .............................34 

mesna ....................................26 
   Mevacor................................ 53 
        mycophenolate mofetil..........85 

Mesnex ..................................26 
    mexiletine ............................. 56 
       Mydral...................................93 

Mestinon ...............................33 
     Miacalcin .............................. 90 
       Mydriacyl..............................93 

Mestinon Timespan ...............33 
            Micardis................................ 54 
       Myfortic ................................85 

METADATE CD ..................63 
               Micardis HCT ....................... 54 
           Myozyme ..............................99 

METADATE ER ..................63 
               Miconazole-3........................ 29 
           Mysoline ...............................21 

Metaglip ................................50 
    Microgestin 1.5/30 (21) ........ 81 
               Mytelase................................33 

metaproterenol ......................97 
        Microgestin 1/20 (21) ........... 81 
              nabumetone ...........................32 

metaxalone ..........................100 
       Microgestin Fe 1.5/30 (28) ... 81 
                 nadolol...................................61

metformin ..............................48 
     Microgestin FE 1/20 (28) ..... 81 
                 nadolol-bendroflumethiazide 61 

methadone .............................10 
      Microzide.............................. 62 
        nafcillin .................................19 

Methadose .............................10 
      midodrine .............................. 54 
       nafcillin in D2.4W ................19 

methamphetamine .................63 
            Migergot ............................... 32 
       Naftin ....................................28 

methazolamide ......................57 
         Migranal ............................... 32 
       Naglazyme ............................67 

methenamine hippurate .........17 
              Millipred ............................... 72 
      nalbuphine.............................11 

Methergine ............................32 
      Minitran ................................ 62 
      Nalfon ...................................32 

methimazole ..........................84 
       minocycline .......................... 20 
         Nallpen in D2.4W .................19 

methocarbamol ....................100 
          minoxidil............................... 62
        naloxone................................26 

methotrexate sodium .............85 
            Mirapex................................. 41
        naltrexone..............................26 

methotrexate sodium (PF) .....85 
               Mirapex ER .......................... 41 
          Namenda ...............................23 

methscopolamine ..................68 
           mirtazapine ........................... 24 
        Namenda Titration Pak .........24 

methyclothiazide ...................62 
         misoprostol ........................... 70 
        naphazoline ...........................93 

methyldopa ............................54 
      mitomycin ............................. 36 
        Naprelan CR..........................32 

methyldopa­
                                     mitoxantrone ......................... 36 
         Naprosyn ...............................32 

  hydrochlorothiazide ..........54 
             M-M-R II (PF)...................... 87 
            naproxen................................32 


Page 115 of 122
Effective: 08/01/11
naproxen sodium ...................32 
             Nipent ................................... 39 
    NS with potassium chloride 104 

naratriptan .............................33 
       nisoldipine ............................ 59 
      Nucynta .................................11 

Nardil ....................................47 
     Nitro-Dur ........................ 62, 63
         Nuedexta ...............................64 

Nasacort AQ..........................96 
           nitrofurantoin........................ 18 
        NuLYTELY with Flavor Packs

Nasonex.................................96
         nitrofurantoin macrocrystal .. 18 
                   ...........................................69

Natacyn .................................30 
       nitrofurantoin monohyd/m­                          Nutropin ................................76 

nateglinide.............................50 
           cryst .................................. 18 
   Nutropin AQ .........................76 

Navane ..................................43 
       nitroglycerin ......................... 63 
       Nutropin AQ Nuspin.............76 

Nebupent ...............................40 
        Nitrolingual........................... 63
        NuvaRing ..............................79 

Necon 0.5/35 (28) .................81 
             Nitromist ............................... 63 
     Nuvigil ..................................64 

Necon 1/35 (28) ....................81 
            Nitrostat ................................ 63 
    nystatin..................................30 

Necon 10/11 (28) ..................81 
             nizatidine .............................. 70 
     nystatin-triamcinolone ..........30 

Necon 7/7/7 (28) ...................81 
            Nizoral .................................. 29 
    Nystop ...................................30 

nefazodone ............................24 
         Nora-BE................................ 81 
       Ocella ....................................79 

neomycin ...............................13 
        Norco .................................... 11 
    octreotide acetate ............ 83, 84

neomycin-bacitracin-poly-HC
                        Nordette-28........................... 81 
        Ocufen...................................92 

   ...........................................93
   Norditropin FlexPro.............. 76 
             Ocuflox .................................19 

neomycin-bacitracin­                                Norditropin Nordiflex........... 76 
              ofloxacin ...............................19 

   polymyxin .........................93 
          norethindrone acetate............ 81 
             Ogen 0.625............................79 

neomycin-polymyxin B GU ..17 
                      Norflex................................ 100 
      Ogestrel (28) .........................79 

neomycin-polymyxin-dexameth
                        Norinyl 1+35 (28)................. 81 
            Olux-E...................................76 

   ...........................................93
   Noritate ................................. 17 
    omeprazole ............................71 

neomycin-polymyxin­                                 Normosol-M in D5W ......... 104 
                  omeprazole-sodium bicarbonate

   gramicidin .........................93 
         Normosol-R in D5W .......... 104 
                    ...........................................71

neomycin-polymyxin-HC17, 93
                        Normosol-R pH 7.4 ............ 104 
               Omnaris .................................96 

Neoral....................................85 
      Noroxin................................. 19 
      Oncaspar ...............................36 

Neosporin ..............................93 
        Norpramin............................. 25
         ondansetron ...........................27 

Nephramine 5.4 %...............104 
                Nor-QD................................. 81 
       ondansetron HCl ...................27 

Neulasta.................................51
        Nortrel 0.5/35 (28)................ 81 
           ondansetron HCl (PF) ...........27 

Neumega ...............................52 
         Nortrel 1/35 (21)................... 82 
          Onglyza .................................48 

Neupogen ..............................51 
         Nortrel 1/35 (28)................... 82 
          Ontak.....................................36 

Neurontin ..............................21 
        Nortrel 7/7/7 (28).................. 82 
          Opana ....................................11 

Nevanac.................................92
         nortriptyline .......................... 25 
      Opana ER ................................8 

Nexavar .................................38 
       Norvasc................................. 59 
      Optipranolol ..........................91 

Nexium..................................70 
        Norvir ................................... 46 
    Optivar ..................................95 

Nexium IV.............................70 
          Novamine 15 % .................. 104 
             Oracea ...................................20 

Nexium Packet ......................71 
            Novantrone ........................... 36 
        Oramorph SR ..........................8 

Next Choice...........................81 
          Novarel ................................. 76 
     Orap.......................................43

Niacor....................................60 
      Novolin 70/30....................... 49 
          Orapred .................................73 

Niaspan Extended-Release....60 
                    Novolin 70/30 InnoLet ......... 49 
               Orapred ODT ........................73 

nicardipine.............................59
         Novolin N ............................. 49 
       ORENCIA.............................85 

Nicotrol .................................26 
      Novolin N InnoLet ............... 49 
             Orfadin ..................................67 

Nicotrol NS ...........................26 
         Novolin R ............................. 50 
       orphenadrine citrate ............100 

Nifediac CC...........................59 
          Novolog ................................ 50 
      Orphenadrine Compound ....100 

Nifedical XL .........................59 
          Novolog Flexpen .................. 50 
            Orphenadrine Compound-DS

nifedipine ..............................59 
       Novolog Mix 70-30 .............. 49 
                 .........................................100

Nilandron ..............................84 
        Novolog Mix 70-30 FlexPen 49 
                     Ortho Evra.............................82 

nimodipine ............................59 
         Noxafil.................................. 29 
     Ortho Micronor .....................82 


Page 116 of 122
Effective: 08/01/11
Ortho Tri-Cyclen Lo .............79 
             paroxetine HCl...................... 47 
          Phisohex................................17 

Ortho-Cept (28).....................79 
          Paser ..................................... 34 
   PhosLo ..................................72 

Orthoclone OKT3 .................85 
             Pataday ................................. 95 
     Phospholine Iodide................91 

Ortho-Cyclen (28) .................82 
           Patanase ................................ 99 
     Photofrin ...............................36 

Ortho-Est 0.625.....................79 
          Patanol .................................. 95 
    Physiolyte............................104 

Ortho-Est 1.25.......................79 
         Paxil...................................... 47 
   Physiosol Irrigation.............104 

Ortho-Novum 7/7/7 (28) .......82 
                Paxil CR................................ 47 
      pilocarpine HCl .....................64 

OsmoPrep ..............................69 
       Pediapred .............................. 73 
      Pilopine HS ...........................91 

Ovcon-35 (28) .......................82 
         Pediarix (PF)......................... 87 
        pindolol .................................61 

Ovcon-50 (28) .......................82 
         Pedi-Dri ................................ 30 
     piperacillin-tazobactam.........15 

Ovide.....................................40 
    Pedvax HIB (PF) .................. 87 
            piroxicam ..............................32 

oxacillin.................................19
     Peganone............................... 23
        Plaquenil ...............................40 

oxacillin in dextrose, iso-osm19 
                Pegasys ................................. 86 
     Plasma-Lyte 148 .................104 

oxaliplatin..............................35 
     Pegasys Convenience Pack... 86 
                   Plasma-Lyte 148 in D5W....104 

oxandrolone...........................77
         PegIntron .............................. 86 
      Plasma-Lyte 56 ...................104 

oxaprozin...............................32
       PegIntron Redipen ................ 86 
            Plasma-Lyte A ....................104 

oxcarbazepine........................23 
         penicillin G pot in dextrose .. 18 
               Plasma-Lyte R .....................104 

Oxistat ...................................29 
   penicillin G potassium.......... 18 
              Plasma-Lyte-56 in D5W .....104 

Oxsoralen ..............................66 
      penicillin G procaine ............ 18 
            Plavix ....................................51 

Oxsoralen Ultra .....................66 
         penicillin G sodium .............. 18 
            Pletal .....................................53 

oxybutynin chloride ..............71 
            penicillin V potassium.......... 18 
              podofilox ...............................66 

oxycodone .............................11 
       Penlac ................................... 29 
    Polycin B...............................93 

oxycodone HCl-oxycodone-
                         Pentam .................................. 40 
     Poly-Dex ...............................93 

  ASA...................................11
       Pentasa.................................. 89 
     polyethylene glycol 3350 ......69 

oxycodone-acetaminophen....11 
                   pentazocine-acetaminophen . 11 
                   polymyxin B sulfate ..............17 

oxycodone-aspirin.................11 
            pentazocine-naloxone ........... 11 
              Poly-Pred...............................92

OxyContin...............................9 
       PentoPAK ............................. 63 
        Polytrim.................................93

oxymorphone ........................11 
          pentostatin............................. 39
       Ponstel...................................32 

Oxytrol ..................................71 
    pentoxifylline........................ 63 
        Portia .....................................82 

Pacerone ................................55 
     Pepcid ................................... 70 
    potassium chloride ...... 104, 105 

paclitaxel ...............................36 
    Pepcid in NaCl (iso-osmotic) 70 
                  potassium citrate .................105 

PALGIC ................................98 
       Percocet ................................ 11 
     Pradaxa..................................51 

Pamelor .................................25 
     Percodan ............................... 11 
      pramipexole...........................41

pamidronate...........................90
         Perforomist ........................... 97 
       Prandimet ..............................50 

Pamine...................................68
      perindopril erbumine ............ 55 
             Prandin ..................................50 

Pamine Forte .........................68 
        Periogard............................... 64
       Pravachol...............................53

Pancreaze ..............................68 
      permethrin............................. 40
        pravastatin .............................53 

Pandel....................................74 
    perphenazine......................... 43 
         prazosin .................................54 

Panlor DC..............................11 
       perphenazine-amitriptyline ... 25 
                Precose ..................................48 

Panlor SS...............................11 
      Persantine ............................. 52 
      Pred Forte..............................92 

Panretin .................................36 
    PEXEVA .............................. 47 
         Pred Mild ..............................92 

pantoprazole ..........................71 
       Phenadoz............................... 27
        Pred-G ...................................92 

Parafon Forte DSC ..............100 
             phenelzine............................. 47 
       Pred-G S.O.P.........................92 

Parcaine.................................12 
     Phenergan ............................. 27 
       prednicarbate.........................75 

Parcopa..................................41 
     Phenytek ............................... 23 
      prednisolone acetate ..............92 

Parlodel .................................41 
    phenytoin .............................. 23 
      prednisolone sodium phosphate

Parnate...................................24
     phenytoin sodium ................. 23 
               ..................................... 73, 92

paromomycin ........................13 
          phenytoin sodium extended .. 23 
                  prednisone .............................73 


Page 117 of 122
Effective: 08/01/11
Prednisone Intensol ...............73 
            Promethegan ......................... 28 
           Reclast...................................90 

Prefest....................................79 
    Prometrium ........................... 82 
          Reclipsen (28) .......................79 

Pregnyl ..................................76 
     propafenone .......................... 56 
          Recombivax HB (PF) ............87 

Prelone ..................................73 
     proparacaine ......................... 94 
          Reglan ...................................28 

Premarin ................................79 
      Propine.................................. 91 
       Regonol .................................33 

Premasol 10 % ....................105 
            propranolol ..................... 55, 61 
           Regranex ...............................67 

Premasol 6 % ......................105 
           propranolol-hydrochlorothiazid
                      Relenza Diskhaler .................46 

Premphase .............................79 
           .......................................... 61 
   Relistor..................................69 

Prempro .................................79 
      propylthiouracil .................... 84 
           Relpax ...................................33 

Prenatabs OBN....................105 
             ProQuad................................ 88 
         Remeron ................................24 

Prevalite ................................56 
     Proscar .................................. 71 
      Remeron SolTab ...................24 

Previfem ................................79 
      Prosol 20%.......................... 105 
           Remicade...............................87

Prevpac..................................17 
      Protonix ................................ 71 
       Remodulin .............................99 

Prezista ..................................46 
    Protopic................................. 66
        Renagel .................................72 

Priftin ....................................34 
   protriptyline .......................... 25 
        Renamin 6.5 % ....................105 

Prilosec..................................71 
     Proventil HFA ...................... 98 
            Renvela .................................72 

primaquine ............................40 
        Provera.................................. 82 
       Reprexain ..............................11 

Primaxin IM ..........................14 
         Provigil ................................. 64 
      Requip ...................................41 

Primaxin IV ...........................14 
        Prozac ................................... 47 
      Requip XL.............................41 

primidone ..............................21 
       Prozac Weekly ...................... 47 
            Rescriptor..............................45 

Primsol ..................................13 
     Pulmicort .............................. 96 
        reserpine................................58 

Pristiq ....................................25 
   Pulmicort Flexhaler .............. 96 
              Restasis .................................94 

Privigen .................................85 
     Pulmozyme ........................... 99 
           Retin-A..................................65 

ProAir HFA...........................97 
          Purinethol ............................. 39 
        Retin-A Micro.......................65 

ProAmatine ...........................54 
         Pylera.................................... 69 
      Retrovir .................................45 

probenecid.............................31 
        pyrazinamide ........................ 34 
           Revatio ..................................99 

Procalamine 3% ..................105 
             pyridostigmine bromide........ 33 
                  Revia .....................................26 

Procardia ...............................59 
      Qualaquin ............................. 40 
         REVLIMID ...........................35 

Procardia XL .........................59 
         Quasense............................... 82 
         Reyataz..................................46 

Prochieve...............................82
        Questran................................ 57 
        Rheumatrex ...........................85 

prochlorperazine....................28 
           quinapril................................ 55 
       Rhinocort Aqua .....................96 

prochlorperazine Edisylate....28 
                 quinapril-hydrochlorothiazide
                       RibaPak Dose Pack ...............44 

prochlorperazine maleate ......28 
                   .......................................... 55 
   Ribasphere.............................44

Procrit....................................52 
    quinidine gluconate .............. 56 
              ribavirin.................................44 

Proctocort ..............................74 
      quinidine sulfate ................... 56 
           Ridaura..................................86 

ProctoCream-HC...................74
               Quixin ................................... 94 
      Rifadin...................................34

Procto-Pak.............................74 
        Qvar ...................................... 96 
     Rifamate ................................34 

Proctosol HC .........................74 
         RabAvert (PF) ...................... 88 
            rifampin .................................34 

Proctozone-HC......................74 
            ramipril ................................. 55 
      Rifater ...................................34 

Proglycem .............................63 
        Ranexa .................................. 58 
       Rilutek...................................64 

Prograf...................................85
      ranitidine HCl ....................... 70 
          rimantadine ...........................46 

Prolastin ................................99 
     Rapamune ............................. 85 
          ringers .................................105 

Prolastin C.............................99 
       Rapiflux ................................ 47 
       RIOMET ...............................48 

Proleukin ...............................86 
      Razadyne .............................. 23 
         Risperdal ...............................42 

Prolia .....................................90 
   Razadyne ER ........................ 23 
            Risperdal Consta ...................42 

Promacta................................52 
       REBETOL ............................ 44 
            Risperdal M-TAB .................42 

promethazine .........................28 
         Rebif ..................................... 86 
     risperidone.............................42

Promethazine VC ..................28 
             Rebif Titration Pack ............. 86 
              Ritalin....................................64 


Page 118 of 122
Effective: 08/01/11
Ritalin LA .............................64 
       Simcor................................... 53
        Stalevo 50..............................41 

Ritalin SR..............................64 
       Simulect ................................ 35 
       Stalevo 75..............................41 

Rituxan ..................................35 
     simvastatin ............................ 53 
        Starlix....................................50 

rivastigmine...........................23
         Sinemet ................................. 41 
       stavudine ...............................45 

Robaxin ...............................100 
       Sinemet 25-250 ..................... 41 
            Stavzor ..................................22 

Robinul..................................68 
      Sinemet CR ........................... 41 
          Stelara ...................................86 

Robinul Forte ........................68 
         Singulair ............................... 99 
       Stimate ..................................77 

Rocaltrol................................90 
      Skelaxin .............................. 101 
        Strattera .................................64 

Romycin ................................94 
       Skelid.................................... 89 
      streptomycin ..........................13 

ropinirole...............................41 
      sodium bicarbonate ............. 105 
               Stromectol .............................39 

RotaTeq Vaccine...................88 
             sodium chloride .................. 105 
             Suboxone...............................11

Rowasa ..................................89 
      sodium chloride 0.45 % ...... 105 
                  Subutex .................................11 

Roxicet ..................................11 
     sodium chloride 0.9 % ........ 105 
                 sucralfate ...............................70 

Roxicodone ...........................11 
         sodium chloride 3 % ........... 105 
                Sular ......................................59 

Rozerem ..............................100 
        sodium chloride 5 % ........... 105 
                sulfacetamide sodium............94 

Sabril .....................................21 
   Sodium Edecrin .................... 60 
             sulfacetamide sodium (acne). 20 

safety needles ........................49 
        sodium fluoride ................... 105 
            sulfacetamide-prednisolone ..20 

Saizen ....................................76 
    sodium lactate ..................... 105 
           sulfadiazine ...........................20 

Saizen click.easy ...................76 
          sodium polystyrene sulfonate 26 
                    sulfamethoxazole-trimethoprim

Samsca ..................................58 
      Solaraze ................................ 65 
          ...........................................20

Sanctura XR ..........................71 
         Solia...................................... 79 
     Sulfamylon ............................18 

Sancuso .................................28 
      Solu-Cortef (PF) ................... 74 
            sulfasalazine ..........................89 

Sandimmune .........................85 
           Solu-Medrol.......................... 73 
           Sulfatrim ...............................18 

Sandostatin ............................84 
       Solu-Medrol (PF).................. 73 
              Sulfazine EC .........................89 

Sandostatin LAR Depot ........84 
                 Soma ................................... 101 
       sulindac .................................32 

Santyl ....................................67 
    Somatuline Depot ................. 84 
              sumatriptan succinate ............33 

Saphris...................................42
      SOMAVERT ........................ 83 
               Suprax ...................................15 

Sarafem .................................47 
      Sonata ................................. 100 
       Surmontil...............................25

Seasonale...............................82
        Soriatane ............................... 67 
       Sustiva...................................45 

Seasonique ............................82 
        Sorine.................................... 61 
      Sutent ....................................38 

Sectral....................................58 
    sotalol ................................... 55 
     Symbicort ..............................96 

selegiline HCl........................42 
         Sotret..................................... 65
      Symbyax ...............................48 

selenium sulfide ....................66 
          Spiriva with HandiHaler....... 97 
                  Symlin ...................................48 

Selsun ....................................66 
    spironolactone....................... 61
            SymlinPen 120 ......................48 

Selzentry................................46 
      spironolacton-hydrochlorothiaz
                      SymlinPen 60 ........................48 

Semprex-D ............................99 
            .......................................... 61 
   Synagis..................................86 

Sensipar.................................83 
      Sporanox......................... 29, 30 
           Synalgos-DC .........................11 

Septra ....................................18 
    Sporanox Pulsepak ............... 30 
               Synarel ..................................83 

Septra DS ..............................18 
       Sprintec (28) ......................... 79 
         Synera ...................................12 

Serevent Diskus ....................98 
           Sprycel.................................. 37 
       Synercid ................................18 

Seromycin .............................34 
        Sronyx................................... 82
        Synthroid...............................83 

Seroquel ................................43 
      SSD....................................... 18 
      Syprine ..................................26 

Seroquel XR..........................43 
          Stadol.................................... 11 
      Tabloid ..................................39 

Serostim ................................76 
      Stagesic................................. 11 
       Taclonex................................67 

sertraline................................47 
     Stalevo 100 ........................... 41 
         Taclonex Scalp ......................67 

Silenor ...................................25 
    Stalevo 125 ........................... 41 
         tacrolimus ..............................85 

Silvadene...............................18 
       Stalevo 150 ........................... 41 
         Talacen..................................11 

silver sulfadiazine .................18 
          Stalevo 200 ........................... 41 
         Talwin ...................................11 


Page 119 of 122
Effective: 08/01/11
Talwin NX.............................11 
          Thyrolar-1............................. 83 
      Trecator .................................34 

Tamiflu ..................................46 
      Thyrolar-1/4.......................... 83 
       Trelstar ..................................83 

tamoxifen ..............................39 
        Thyrolar-2............................. 83 
      Trental ...................................63 

tamsulosin .............................71 
        Thyrolar-3............................. 83 
      tretinoin .................................65 

Tapazole ................................84 
       Tiazac ................................... 57 
   tretinoin (chemotherapy) .......39 

Tarceva..................................37 
       ticlopidine ............................. 51 
    Trexall ...................................85 

Targretin................................39 
       Tigan..................................... 28 
   Treximet ................................33 

Tasigna ..................................37 
      Tikosyn ................................. 56 
    triamcinolone acetonide . 64, 73, 

Tasmar...................................41
        Timentin ............................... 15 
        75

Taxotere ................................36 
       timolol maleate ............... 61, 91
           triamterene-hydrochlorothiazid

TAZICEF ..............................15 
          Timoptic Ocudose ................ 91 
               ...........................................61

Tazorac..................................65 
       Timoptic-XE ......................... 91 
        Tribenzor...............................59 

Taztia XT ..............................57 
        Tirosint ................................. 83 
   Tricor.....................................60

Teflaro...................................18 
      Tis-U-Sol ............................ 105 
      Triderm .................................73 

Tegretol .................................23 
      tizanidine .............................. 44 
    trifluoperazine .......................43 

Tegretol XR...........................23 
          Tobi....................................... 13
   trifluridine .............................94 

Tekamlo ................................60 
        TobraDex.............................. 94 
       Triglide..................................60 

Tekturna ................................60 
       tobramycin in NS .................. 13 
          trihexyphenidyl .....................40 

Tekturna HCT .......................60 
            tobramycin sulfate ................ 13 
          TriHIBit Preservative Free....87 

Temovate...............................76
          tobramycin-dexamethasone .. 94 
                  Tri-Legest Fe.........................82 

Tenoretic 100 ........................58 
          Tobrasol................................ 94 
     Trileptal.................................23 

Tenoretic 50 ..........................58 
         Tobrex................................... 94
     TriLyte With Flavor Packets . 69 

Tenormin ...............................58 
        Tofranil ................................. 25 
   trimethobenzamide ................28 

Terazol 3 ...............................30 
       Tofranil-PM.......................... 25 
        trimethoprim .........................13 

Terazol 7 ...............................30 
       tolazamide............................. 50
       trimethoprim-polymyxin B ...94 

terazosin ................................54 
      tolbutamide ........................... 51 
      TriNessa (28) ........................79 

terbinafine .............................28 
       tolmetin ................................. 32 
   Tri-Norinyl (28) ....................82 

terbutaline..............................98 
       Topamax ............................... 22 
      Tripedia (PF) .........................88 

terconazole ............................30 
        Topicort ................................ 75 
    Tri-Previfem (28) ..................79 

Testim....................................77 
      Topicort LP........................... 75 
       Trisenox ................................36 

testosterone cypionate ...........77 
              topiramate ............................. 22 
     Tri-Sprintec (28) ...................79 

testosterone enanthate ...........77 
              Toposar ................................. 36 
    Trivora (28) ...........................82 

tetanus toxoid,adsorbed (PF) 88 
                   topotecan............................... 36
      Trizivir ..................................45 

tetanus,diphtheria toxd ped-PF
                     Toprol XL............................. 58 
       TrophAmine 10 %...............105 

   ...........................................87
   Torisel................................... 36 
   Trophamine 6% ...................105 

tetanus-diphtheria toxoids-Td88 
                   torsemide .............................. 60 
     tropicamide ...........................94 

tetracycline ............................20 
       Toviaz ................................... 71 
   trospium ................................71 

Tev-Tropin ............................77 
         TPN Electrolytes ................ 105 
           Trusopt ..................................91 

Thalitone ...............................62 
       Tracleer................................. 99 
    Truvada .................................45 

Thalomid ...............................35 
        tramadol ............................ 9, 11
      Twinject Autoinjector ...........98 

Theo-24 .................................97 
       tramadol-acetaminophen ...... 11 
                Twinrix (PF)..........................87 

Theochron .............................97 
         Trandate................................ 56 
     Twynsta.................................59 

theophylline...........................97
          trandolapril ........................... 55 
     Tygacil ..................................18 

Thermazene ...........................18 
          Transderm-Scop ................... 28 
           Tykerb ...................................37 

thioridazine............................43 
        tranylcypromine.................... 24 
          Tylenol-Codeine #3 ..............12 

thiotepa..................................35 
      Travasol 10 %..................... 105 
          Tylenol-Codeine #4 ..............12 

thiothixene.............................43
         Travatan Z ............................ 95 
      Tylox .....................................12 

Thymoglobulin ......................86 
            trazodone .............................. 24 
     Typhim VI .............................88 


Page 120 of 122
Effective: 08/01/11
Tyzeka...................................44 
    Vicodin ................................. 12 
     Xgeva ....................................90 

Tyzine....................................99 
   Vicodin ES............................ 12 
        Xifaxan..................................18 

U-Cort ...................................74 
   Vicodin HP ........................... 12 
        Xodol 10/300 ........................12 

Ultracet..................................12 
   Vicoprofen............................ 12 
        Xodol 5/300 ..........................12 

Ultram ER ...............................9 
     Victoza.................................. 48 
     Xodol 7.5/300 .......................12 

Ultravate................................76 
    Vidaza................................... 39 
     Xolair ....................................99 

Unasyn ..................................13 
    Videx 2 gram Pediatric......... 45 
               Xolegel..................................30 

Uniphyl .................................97 
    Videx EC .............................. 45 
       Xopenex ................................98 

Unithroid ...............................83 
    Vigamox ............................... 94 
       Xopenex HFA .......................98 

Urecholine.............................72 
      Viibryd.................................. 24 
     Xylocaine ..............................12 

Uroxatral ...............................71 
    Vimovo ................................. 32 
      Xylocaine Jelly......................12 

URSO 250 .............................69 
       Vimpat .................................. 23 
     Xyrem ...................................64 

URSO Forte ..........................69 
        vinblastine............................. 35
       Xyzal .....................................99 

ursodiol .................................69 
   vincristine ............................. 35 
     Yasmin 28 .............................80 

Uvadex ..................................66 
    vinorelbine............................ 36 
       YAZ 28 .................................80 

Vagifem.................................79
      Viracept ................................ 46 
     YF-Vax .................................88 

valacyclovir...........................45 
      Viramune .............................. 45 
       zafirlukast..............................99 

Valcyte ..................................45 
   Viramune XR........................ 45 
           zaleplon ...............................100 

valproate sodium ...................22 
         Virazole ................................ 44 
     Zamicet .................................12 

valproic acid..........................22 
      Viread ................................... 46 
    Zanaflex ................................44 

valproic acid (as sodium salt) 22 
              Viroptic................................. 94 
     Zanosar..................................37 

Valtrex...................................45
    Visicol................................... 69
     Zantac....................................70 

Valturna.................................60
     Vistaril .................................. 98 
   Zantac 25 EFFERdose ..........70 

Vancocin ...............................15 
     Vistide................................... 44
     Zantac in 1/2 NS ...................70 

vancomycin ...........................15 
       Vivactil ................................. 25 
    Zarontin.................................21 

Vandazole..............................18 
      Vivaglobin ............................ 86 
       Zaroxolyn..............................62 

vandetanib .............................37 
     Vivelle-Dot ........................... 79 
       ZAVESCA ............................67 

Vanos ....................................76 
   Vivitrol ................................. 26 
    ZAZOLE ...............................30 

Vaqta (PF) .............................87 
     Voltaren .......................... 32, 92
        Zebeta....................................58 

Varivax (PF)..........................88 
       Voltaren-XR ......................... 32 
         Zegerid ..................................71 

Vectibix.................................35 
    voriconazole ......................... 30 
        Zelapar ..................................90 

VELCADE ............................36 
         Vospire ER ........................... 98 
        Zemaira .................................99 

Velivet...................................79 
   Votrient................................. 38 
     Zemplar .................................90 

venlafaxine ............................25 
     VPRIV .................................. 67 
      Zenpep...................................68

Ventavis ................................99 
    Vytorin 10-10 ....................... 53 
         Zeosa .....................................83 

Ventolin HFA........................98 
         Vytorin 10-20 ....................... 53 
         Zerit.......................................46 

Veramyst ...............................96 
     Vytorin 10-40 ....................... 53 
         Zerlor.....................................12

verapamil......................... 56, 57
       Vytorin 10-80 ....................... 53 
         Zetia ......................................58 

Verdeso .................................74 
    Vyvanse ................................ 63 
      Ziac .......................................58 

Veregen .................................66 
    warfarin................................. 51
      Ziagen ...................................46 

Verelan ..................................57 
   water for irrigation, sterile.... 67 
             Ziana .....................................65 

Verelan PM ...........................57 
       WelChol................................ 57 
       zidovudine.............................46 

Veripred 20 ...........................73 
      Wellbutrin............................. 24 
       Zinacef ..................................14 

Vesicare.................................71
     Wellbutrin SR....................... 24 
          Zinacef in dextrose (iso-osm)14 

Vexol.....................................92 
   Wellbutrin XL ...................... 24 
          Zinacef in Sterile Water ........14 

Vfend.....................................30
    Westcort................................ 75 
      Zinecard ................................58 

Vfend IV ...............................30 
     Xalatan.................................. 95 
     Zmax Adult-Pediatric............16 

Vibativ...................................15
    Xenazine ............................... 64 
      Zocor .....................................53 


Page 121 of 122
Effective: 08/01/11
Zofran....................................27 
   zonisamide ............................ 21 
      Zyflo CR ...............................99 

ZOFRAN ODT .....................27 
             Zorbtive ................................ 77 
    Zylet ......................................94 

Zolinza ..................................37 
   Zortress ................................. 38 
   Zyloprim ...............................31 

Zoloft.....................................47
   ZOSTAVAX......................... 88
             Zymar ....................................94 

zolpidem..............................100 
      Zosyn .................................... 15 
   Zymaxid ................................94 

Zometa ..................................90 
    Zosyn in dextrose (iso-osm) . 15 
                Zyprexa .................................43 

Zomig ....................................33 
   Zovia 1/35E (28)................... 80 
          Zyprexa Zydis .......................43 

Zomig ZMT...........................33 
         Zovia 1/50E (28)................... 80 
          Zytiga ....................................37 

Zonalon .................................66 
    Zovirax ................................. 45 
    Zyvox ....................................19 

Zonegran ...............................21 
     Zydone.................................. 12 





Page 122 of 122
Effective: 08/01/11
          CONTACT INFORMATION
Monroe Location                 Shreveport Location
130 DeSiard Street, Suite 300   855 Pierremont Rd., Suite 109 

Monroe, LA 71201                Shreveport, LA 71106

LOCAL: (318) 361-0900           TOLL-FREE: (888) 823-1910

TOLL-FREE: (888) 823-1910       TTY (866) 524-5144

TTY (866) 524-5144
             (for the hearing impaired)
(for the hearing impaired)




            www.vhp-medicare.com
 


				
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