Documents
Resources
Learning Center
Upload
Plans & pricing Sign in
Sign Out
Get this document free

2008 provider formulary web

VIEWS: 12 PAGES: 140

									2008 Provider
 Formulary
100 North Academy Avenue
  Danville, PA 17822-3246
      (800) 988-4861

 www.thehealthplan.com
Section 1: Geisinger Health Plan Formularies




   Section 2: Geisinger Gold Formularies
           Information about this formulary
Purpose
The purpose of the Health Plan’s1 formulary is to optimize
member care through the rational selection and use of
medications, and to ensure quality, cost-effective prescribing.
The formulary is developed with the input of practicing
physicians and pharmacists. Medications in each therapeutic
class have been reviewed for efficacy, safety, and cost.
Maintenance of the formulary is a dynamic process; the
Pharmacy and Therapeutics Committee continually review
new medications as well as information related to medications
currently included in the formulary.

Comments and suggestions on the formulary are welcome and
should be directed to the Health Plan Pharmacy Department.
Participating physicians may also access the Health Plan’s Web
site www.thehealthplan.com, to verify formulary medication
status.
Mailing address:                                Telephone:
Geisinger Health Plan                           (570) 271-5673
Pharmacy Department                             (800) 988-4861
Internal Mail Code: 32-46
                                                Fax:
100 North Academy Avenue
                                                (570) 271-5610
Danville, PA 17822

Traditional and Triple Choice prescription benefits
The Health Plan offers two prescription drug plans: the
“traditional” benefit and the “Triple Choice” benefit. Exclusions
may differ based on the benefit chosen and are delineated in the
member’s prescription drug rider. The same quantity limits apply
to both benefits.



1
  Geisinger Health Plan, Geisinger Indemnity Insurance Company and
Geisinger Quality Options, Inc. shall be collectively referred to as “Health Plan”
in this Formulary booklet.
                                           1
Traditional benefit
The traditional benefit includes coverage only for the
prescription drugs listed in this formulary. Formulary exceptions
may be granted on a case by case basis. Members with this
benefit pay a set copayment or coinsurance for the approved
drugs.

Triple Choice benefit
The Triple Choice benefit assigns each prescription drug to one
of three different tiers, each representing a different copayment
amount. Drugs not approved by the Pharmacy and Therapeutics
Committee for inclusion in the formulary may be covered under
Tier 3 copayment/coinsurance. The copayment/coinsurance
amount will depend on the member’s prescription drug rider.
The tiers are defined below:
     • Tier 1–Includes most generic drugs and has the lowest
          copayment/coinsurance. Prior authorization is usually
          not necessary.
     • Tier 2–Includes certain formulary brand name drugs
          with no generic equivalent. Prior authorization may
          be necessary.
       • Tier 3–Includes certain formulary brand name drugs
            with a generic equivalent and non-formulary brand
            name drugs*. Prior authorization may be necessary.
The Health Plan maintains sole discretion of assigning drugs to
tiers and moving drugs from one tier to another. Several factors
are considered when assigning drugs to tiers. These factors
include, but are not limited to:
     • availability of a generic equivalent
     • absolute cost of a drug
     • cost of the drug relative to other drugs in the same
         therapeutic class
     • availability of over-the-counter alternatives
     • clinical and economic factors

                                  2
Please note: This formulary is accurate as of December 1, 2007
and is subject to change. A drug may change in tier status without
notice due to immediate generic availability.

*For Triple Choice benefit, see page 37 of this formulary for examples
of medications not included on the formulary that may still be covered
at the highest applicable copay level. These medications will not be
covered for members with the traditional prescription benefit.

Specialty Vendor Drug Program
Certain medications require the use of a contracted specialty
pharmacy vendor for purchase. Please contact the Pharmacy
Service Team at (800) 988-4861 or visit thehealthplan.com for
additional information on the program and a complete list of the
medications included.

Formulary Compliance
Non-formulary medications: The formulary is designed to meet
most therapeutic needs of the population served by the Health
Plan. Occasionally, because of allergy, therapeutic failure, or a
specific diagnostic-related need, formulary medications may not
meet the special needs of an individual member. In these special
instances, the prescribing physician may make requests to the
Health Plan Pharmacy Department for non-formulary or restricted
medications. The prescribing physician will receive written
documentation and/or a verbal response from the Health Plan
Pharmacy Department regarding the request. Under the Triple
Choice plan, most non-formulary medications, not specifically
excluded, do not require prior authorization and will be covered at
the highest copayment/coinsurance level.

Formulary addition requests: Requests for changes or additions
to the formulary can be made by written request to the Health Plan
Pharmacy Department. Any additions or deletions to the formulary
may be found in the publication “Briefly,” which is issued quarterly
to providers.



                                3
Formulary review process: Medications selected for inclusion in
the formulary are chosen in consideration of effectiveness, safety
and overall value. Evaluation for formulary inclusion is based
on formalized selection criteria to determine the most optimal
benefit to members. These criteria include but are not limited to:
     • medication name/dosage form
     • medication class/pharmacology
     • FDA-approved indications
     • adverse reactions
     • clinical evidence of safety and efficacy
     • recommendations of national agencies and rganizations
     • therapeutic equivalence
     • cost analysis

The criteria are reviewed by the Health Plan Pharmacy and
Therapeutics Committee, which is comprised of pharmacists and
participating physicians in active clinical practice from various
specialties. The medication is then reviewed and evaluated
by clinicians in particular specialties for additional feedback.
The feedback is discussed by the Pharmacy and Therapeutics
Committee prior to finalizing a decision on formulary status. To
be included, the medication must offer a distinct advantage over
existing formulary medications in the same therapeutic class.
Specifically, the medication must demonstrate such attributes as:
     • a distinct or unique therapeutic feature
     • greater efficacy, proven in clinical trials, over other
          medications in the same therapeutic category
     • an improved dosing schedule, safety profile or cost-
         effectiveness over existing formulary medications

If there are comparable therapeutic agents, additional analysis
may be considered. These factors include:
     • member satisfaction
     • cost analysis
                                   4
     • contract terms and conditions
     • market share analysis
     • patent life assessment
     • utilization management
     • consumer advertising
     • per member per month costs
     • impact on Health Plan population

Exclusions
Specific exclusions are noted below. Exclusions may vary
depending on the member’s prescription plan.
     • Over-the-counter (OTC) medications are not covered.
     • Oral contraceptives and infertility medications, unless
         indicated by the subscriber’s contract as an additional
         benefit.
     • Experimental, investigational, or unproven drug
         therapies.
     • Lifestyle medications or medications used for cosmetic
          purposes.
     • Medications for weight loss and weight management.
     • Medications for erectile dysfunction.

Prior authorization: To promote the most appropriate
utilization, select medications may require prior authorization by
the Health Plan to be eligible for coverage under the member’s
prescription benefit. Medications requiring prior authorization
under the traditional benefit are designated in the formulary
with an asterisk (*). Medications requiring prior authorization
under the Triple Choice benefit are designated in the formulary
with a (t) next to the medication name. The Pharmacy and
Therapeutics Committee determines prior authorization criteria.
In order for a member to receive coverage for a medication
requiring prior authorization, the prescribing physician must
obtain prior authorization by contacting the Health Plan
                                5
Pharmacy Department at the address, telephone or fax number
on page 1. Submission of medical documentation is required.
Quantity limits: There are quantity limits on some medications.
These medications are designated in the formulary with two
asterisks (**). Quantity limitations are the same for both the
traditional and Triple Choice benefits. The following table
lists medications with quantity limits currently in place. For
additional information, please contact the Health Plan Pharmacy
Department.

Drug name               Quantity limit
Ambien                    15 tablets per copay/coinsurance
Aranesp                   7-day limit per copay/coinsurance
Axert                     6 tablets per copay/coinsurance
Colestid                  Bulk packages only; unit dose packets
                          are not covered
EpiPen                    2 kits per copayment
Epogen                    7-day limit per copayment
Exjade                    15-day supply per copay/coinsurance
Fluoride supplements 60mL or 120 tablets per copay/coinsurance
Glucagon                  2 kits per copay/coinsurance
Humira                    1 copay/coinsurance per injection
Imitrex injection         2 kits (4 injections) per copay/coinsurance
Imitrex Nasal             4 per copay/coinsurance
Imitrex tablets           6 tablets per copay/coinsurance
Ketorolac                 5-day supply (20 tablets) per
                          copay/coinsurance
Kytril                    2 tablets per copay/coinsurance
Leukine                   7-day limit per copay/coinsurance
Maxalt                    6 tablets per copay/coinsurance
MVI w/fluoride            50mL or 100 tablets per copay/
                          coinsurance supplements
Neulasta                  7-day limit per copay/coinsurance
Neumega                   7-day limit per copay/coinsurance
Neupogen                  7-day limit per copay/coinsurance
Nexavar                   1 copay/coinsurance per 15 day supply
Prenatal vitamins         100 tablets per copay/coinsurance
Procrit                   7-day limit per copay/coinsurance
Questran                  Bulk packages only; unit dose packets
                          are not covered
Sutent                    1 copay/coinsurance per 15 day supply
Sprycel                   1 copay/coinsurance per 15 day supply
Sonata                    15 capsules per copay/coinsurance
(Please note: A percentage copay applies for human growth hormone and is
dependent upon the member’s prescription benefit.)
                                      6
Generic substitution policy: The Health Plan prescription
benefits are generically based. Generic substitution will occur for
those medications included in the “Approved Drug Products with
Therapeutic Equivalence Evaluations,” also known as “The Orange
Book,” published by the U.S. Department of Health and Human
Services. Generic medications, which have an equivalent rating
by these standards, are generally provided under the member’s
prescription drug benefit. The Health Plan may also elect to
include only one brand-name medication in the formulary even
if the medication is marketed by more than one company, or if
the brand name medication does not significantly differ from the
generic medication.

An index has been provided to assist in locating specific
medications quickly. Medications not listed are not included
on the formulary unless approved after the publication of this
booklet and communicated in Briefly or an Operations Bulletin.

Under the the traditional benefit:
When the generic equivalent appears in bold face type,
coverage is for the generic version. When this occurs,
medications in the “Brand Name” Column are not covered.

Under the Triple Choice benefit:
the bolded generic equivalent will be covered at the tier 1 copay
level and the corresponding brand name will be covered at the
tier 3 copay level.

KEY:
* Prior authorization required on traditional benefit.
   Call (800) 988-4861.
t
  Prior authorization required on Triple Choice benefit.
   Call (800) 988-4861.
** Quantity limit; please call (800) 988-4861 for details.
   Applies to both benefits.
c
  Controlled Substance



                                7
                       Table of Contents
Anti-infectives...................................................9
Antineoplastics .................................................12
Cardiovascular ..................................................13
Central Nervous System Drugs ........................16
Diabetic Agents ................................................21
Gastrointestinal ................................................22
Genito-Urinary ..................................................24
Hormonal ..........................................................25
Nutritional .........................................................28
Ophthalmics ......................................................29
Otics ...................................................................31
Respiratory........................................................32
Topicals ..............................................................33
Miscellaneous Medications .............................36
Nonformulary Medications..............................37
Alphabetical Index ...........................................39
  Abbreviations
  ASA - aspirin                            HC - hydrocortisone
  APAP - acetaminophen                     neo - neomycin
  but - butalbital                         sol - solution
  caff - caffeine                          susp - suspension
  Poly B - Polymyxin B                     oint - ointment
                                       8
Brand name         Tier           Generic name
Anti-infectives
Amebicides
Flagyl               1        Metronidazole
Aralen               1        Chloroquine phosphate
Yodoxin              2        Diiodohydroxyquin
Humatin              2        Paromomycin
Antihelmintics
Vermox               1        Mebendazole
Mintezol             2        Thiabendazole

Antifungals
Mycostatin           1        Nystatin
Nizoral              2        Ketoconazole
Grifulvin V          2        Griseofulvin microsize
Gris Peg             2        Griseofulvin ultra-microsize
Mycelex Troches      1        Clotrimazole
Diflucan             1        Fluconazole, oral
Sporanox*, t         1        Itraconazole*,t, oral
Sporanox*, t         3        Itraconazole, oral solution
Noxafil*,t           3        Posaconazole

Antimalarials
Vibramycin           1        Doxycycline
No brand name        1        Quinine sulfate
Plaquenil            1        Hydroxychloroquine
Daraprim             2        Pyrimethamine
Primaquine           2        Primaquine
Aralen               1        Chloroquine
Fansidar             2        Sulfadoxine+pyrimethamine
Lariam               2        Mefloquine

Anti-Tuberculars
Isoniazid            1        Isoniazid
Myambutol            2        Ethambutol
Pyrazinamide         1        Pyrazinamide
Mycobutin            2        Rifabutin
Rifadin              2        Rifampin
Rifater              2        Rifampin +pyrazinamide+INH

Antivirals
Symmetrel            1        Amantadine

                          9
Brand name           Tier        Generic name
Zovirax                1    Acyclovir (not topical)
Ziagen                 2    Abacavir
Epzicom                2    Abacavir, Lamivudine
Trizivir               2    Abacavir, Lamivudine, and Zidovudine
Agenerase              2    Amprenavir
Rescriptor             2    Delavirdine
Videx and Videx EC     1    Didanosine
Sustiva                2    Efavirenz
Truvada                2    Emtricitabine, tenovir disoproxil fumarate
Cytovene               1    Ganciclovir
Crixivan               2    Indinavir
Epivir                 2    Lamivudine (3TC)
Viracept               2    Nelfinavir
Viramune               2    Nevirapine
Rebetol                1    Ribavirin
Copegus                1    Ribavirin
Virazole               2    Ribavirin
Norvir                 2    Ritonavir
Kaletra                2    Lopinavir and Ritonavir
Invirase               2    Saquinavir Mesylate
Zerit                  2    Stavudine
Viread                 2    Tenofovir Disoproxil Fumarate
Valtrex                2    Valacyclovir
Valcyte                2    Valganciclovir
Hivid                  2    Zalcitabine
Retrovir               2    Zidovudine
Combivir               2    Zidovudine and Lamivudine
Fuzeon                 3    Enfuvirtide
Epivir HBV             2    Lamivudine
Hepsera                2    Adefovir dipivoxil
Reyataz                2    Atazanavir
Lexiva                 2    Fosamprenavir
Emtriva                2    Emtricitabine
Atripla                2    Efavirenz, Emtricitabine, tenofovir
                            disoproxil fumarate
Prezista               2    Darunavir

Cephalosporins
Keflex                 1    Cephalexin
Cefzil                 3    Cefprozil
Ceftin                 1    Cefuroxime Axetil
Omnicef                1    Cefdinir

Fluoroquinolones
Cipro                  1    Ciprofloxacin
                            10
Brand name              Tier              Generic name
Macrolides (Erythromycins)
Levaquin                     2        Levofloxacin
Avelox                       2        Moxifloxacin



Erytab                       1        Erythromycin Base
EES                          1        Erythromycin ethylsuccinate
Erythrocin                   1        Erythromycin stearate
Pediazole                    1        Erythromycin+sulfisoxazole
Zithromax                    1        Azithromycin
Biaxin                       1        Clarithromycin
Biaxin XL                    1        Clarithromycin ext. release

Miscellaneous Anti-Infectives
Bactrim/Bactrim DS           1        Trimethoprim+ sulfamethoxazole
                                      regular/DS
Furadantin                   1        Nitrofurantoin
Trimpex                      1        Trimethoprim
Macrodantin                  1        Nitrofurantoin Macrocrystals
Chloromycetin                1        Chloramphenicol
Macrobid                     1        Nitrofurantoin Macrocrystals
Mepron                       2        Atovaquone
Lamprene                     2        Clofazimine
Dapsone                      2        Dapsone
Nebupent                     2        Pentamidine

Miscellaneous Antibiotics
Flagyl                       1        Metronidazole
Mycifradin                   1        Neomycin
Cleocin                      1        Clindamycin
Cleocin Palmitate            2        Clindamycin palmitate oral soln
Vancocin                     2        Vancomycin
Tobi*, t                     3        Tobramycin, inhalation
Zyvox*, t                    3        Linezolid

Penicillins
Amoxil; Trimox               1        Amoxicillin
Pen VK; V-Cillin K           1        Penicillin VK
Dynapen                      1        Dicloxacillin
Augmentin                    1        Amoxicillin/clavulanate

Sulfonamides
Gantrisin                    1        Sulfisoxazole tablets
Azulfidine                   1        Sulfasalazine
                                 11
Brand name              Tier        Generic name
Azulfidine Entabs         2    Sulfasalazine, enteric coated
Gantrisin Suspension      2    Sulfisoxazole suspension

Tetracyclines
Sumycin; Achromycin-V     1    Tetracycline
Vibramycin                1    Doxycycline
Minocin                   1    Minocycline

Antineoplastics
Antineoplastics
Hexalen                   2    Altretamine
Cytadren                  2    Aminoglutethamide
Arimidex                  2    Anastrazole
Casodex                   2    Bicalutamide
Myleran                   2    Busulfan
Xeloda                    2    Capecitabine
Leukeran                  2    Chlorambucil
Cytoxan                   1    Cyclophosphamide
Emcyt                     2    Estramustine
Vepesid                   2    Etoposide
Eulexin                   2    Flutamide
Hydrea                    2    Hydroxyurea
Gleevec*                  3    Imatinib Mesylate
Intron-A                  2    Interferon-alfa-2b
Roferon-A                 2    Interferon-alfa-2a
Rebetron                  2    Interferon-alfa 2b injection+ribavirin oral
Actimmune*                3    Interferon gamma-1b*
Ceenu                     2    Lomustine
Megace                    1    Megestrol
Alkeran                   2    Melphalan
Purinethol                1    Mercaptopurine
Methotrexate              2    Methotrexate
Lysodren                  2    Mitotane
Nilandron                 2    Nilutamide
PEG-Intron                2    Peginterferon alfa-2B
Pegasys                   2    Peginterferon alfa-2a
Matulane                  2    Procarbazine
Nolvadex                  1    Tamoxifen
Thioguanine               2    Thioguanine
Femara                    2    Letrozole
Tarceva*,t                3    Erlotinib
Nexavar*,t,**             3    Sorafenib
Sutent*,t,**              3    Sunitinib
Sprycel*,t,**             3    Dasatinib
                               12
Brand name                    Tier            Generic name
Methotrexate Antagonist
Wellcovorin                     1         Leucovorin

Recombinant Blood Modifiers
Epogen**,*,t; Procrit**,*,t     2         Erythropoietin
Aranesp**,*,t                   2         Darbepoetin Alfa
Neulasta**                      2         Penfilgrastin
Neupogen**                      2         Filgrastim
Neumega**                       2         Oprelvekin
Leukine**                       2         Sargramostim

Cardiovascular
Ace Inhibitors
Capoten                         1         Captopril
Lotensin                        1         Benazepril
Prinivil                        1         Lisinopril
Vasotec                         1         Enalapril
Altace                          2         Ramipril
Accupril                        1         Quinapril

Ace Inhibitors/Diuretics
Lotensin HCT                    1         Benazepril+hctz
Capozide                        1         Captopril+hctz
Prinzide                        1         Lisinopril+hctz
Vaseretic                       1         Enalapril+hctz

Adrenergic Blocking Agents
Dibenzyline                     2         Phenoxybenzamine

Alpha-Beta Blocker
Trandate                        1         Labetalol
Coreg                           2         Carvedilol

Angiotensin II Blockers
Cozaar*, t                      2         Losartan
Diovan*, t                      2         Valsartan

Angiotensin II Blockers/Diuretics
Hyzaar*, t                      2         Losartan + hctz
Diovan HCT*, t                  2         Valsartan + hctz

Antiadrenergic (Peripheral Acting)
Minipress                       1         Prazosin
                                     13
Brand name              Tier           Generic name
Cardura                     1     Doxazosin
Hytrin                      1     Terazosin

Antiadrenergic (Central Acting)
Catapres                    1     Clonidine
Aldomet                     1     Methyldopa
Wytensin                    1     Guanabenz acetate
Tenex                       1     Guanfacine HCl
Catapres TTS                2     Clonidine

Antiarrhythmics
Lanoxin                     1     Digoxin
Norpace                     1     Disopyramide
Cordarone                   1     Amiodarone
Norpace-CR                  2     Disopyramide, sustained-release
Tikosyn                     2     Dofetilide
Tambocor                    1     Flecainide
Mexitil                     2     Mexiletine
Ethmozine                   2     Moricizine
Pronestyl                   1     Procainamide
Quinora                     1     Quinidine sulfate
Quinaglute Duratab          1     Quinidine gluconate
Quinidex                    2     Quinidine sulfate, extended-release
Procan SR                   1     Procainamide, sustained-release
Procanbid                   2     Procainamide, sustained-release
Rythmol                     1     Propafenone
Betapace                    1     Sotalol

Antihyperlipidemics
Questran**                  1     Cholestyramine Resin
Colestid**                  2     Colestipol
Lopid                       1     Gemfibrozil
Mevacor                     1     Lovastatin
Niaspan                     2     Niacin, sustained-release
Pravachol                   1     Pravastatin
Zocor                       1     Simvastatin
Crestor                     2     Rosuvastatin
Zetia                       2     Ezetimibe
Lofibra                     1     Fenofibrate

Beta Blockers
Sectral                     1     Acebutolol
Visken                      1     Pindolol
Corgard                     1     Nadolol
Tenormin                    1     Atenolol
                                  14
Brand name              Tier             Generic name
Inderal                     1        Propranolol
InnoPran XL                 2        Propanolol extended release
Lopressor                   1        Metoprolol
Toprol-XL                   1        Metoprolol extended-release

Beta Blocker/Diuretic
Ziac                        1        Bisoprolol+hctz

Calcium Channel Blockers
Calan; Isoptin              1        Verapamil
Adalat                      1        Nifedipine
Calan SR                    1        Verapamil SR
Cardizem                    1        Diltiazem
Cardizem-SR                 1        Diltiazem, long-acting
Plendil                     1        Felodipine
Dynacirc                    3        Isradipine
Adalat-CC                   1        Nifedipine, long-acting
Norvasc                     1        Amlodipine
Cardizem-CD                 1        Diltiazem, long-acting
Nimotop                     2        Nimodipine
Calcium Channel Blockers/
Ace Inhibitor Combination
Lotrel*                     3        Amlodipine + benazepril
Tarka*                      3        Verapamil+trandolapril

Diuretics
Lasix                       1        Furosemide
Hydrodiuril                 1        Hydrochlorothiazide
Aldactone                   1        Spironolactone
Hygroton                    1        Chlorthalidone
Aldactazide                 1        Spironolactone+hctz
Maxzide                     1        Triamterene+hctz
Dyazide                     1        Triamterene+hctz
Bumex                       1        Bumetanide
Diuril Suspension           2        Chlorothiazide suspension (pediatrics)
Zaroxolyn                   1        Metolazone
Demadex                     1        Torsemide

Miscellaneous Cardiac Agents
Ser-Ap-Es                   1        Reserpine+hydralazine+hctz
Proamatine                  1        Midodrine
Inspra*                     3        Eplerenone



                                15
Brand name              Tier        Generic name
Vasodilators
Persantine                1    Dipyridamole
Isordil                   1    Isosorbide dinitrate po, sl
Nitrostat                 1    Nitroglycerin
No brand name             1    Isosorbide mononitrate
Apresoline                1    Hydralazine
Nitrol                    1    Nitroglycerin, topical
Isordil Tembids           1    Isosorbide dinitrate sustanied release
No brand name             1    Nitroglycerin transdermal patch
Loniten                   1    Minoxidil (oral only)
Imdur                     1    Isosorbide mononitrate
                               extended release
Nitrodur                  2    Nitroglycerin transdermal patch
Tracleer                  3    Bosentan
Ventavis*, t              3    Iloprost inhalation solution
Remodulin                 3    Treprostinil Sodium

Blood Modifiers
Anti-coagulants
Coumadin                  1    Warfarin
Lovenox                   3    Enoxaparin
Anti-platelet Agents
Persantine                1    Dipyridamole
Agrylin                   1    Anagrelide
Plavix                    3    Clopidogrel
Ticlid                    1    Ticlopidine
Hemorrheologic Agents
Pletal                    1    Cilostazol
Trental                   1    Pentoxifylline
Hemostatics
Amicar                    2    Aminocaproic Acid

Central Nervous System Drugs
ALS Therapy
Rilutek*                  3    Riluzole

Analgesics
Avinza                    2    Morphine sulfate extended release
Fioricet                  1    But+APAP+Caff

                               16
Brand name                     Tier              Generic name
Fiorinalc                           1        But+ASA+Caff
Tylenol+Codeinec                    1        Codeine+APAP
Codeinec                            1        Codeine sulfate
Dolophinec                          1        Methadone
Darvocet-Nc                         1        Propoxyphene napsylate+APAP
Wygesicc                            1        Propoxyphene HCl +APAP
Phrenilinc                          2        APAP+But
Phrenilin Fortec                    2        APAP+But
Midrin                              2        APAP+dichloralphenazone
                                             +isometheptene
Vicodinc                            1        Hydrocodone+APAP
Morphine Sulfatec                   1        Morphine sulfate
Dilaudidc                           1        Hydromorphone
Levo-Dromoranc                      1        Levorphanol
Demerolc                            1        Meperidine
Percocetc                           1        Oxycodone + APAP
Roxicodonec                         2        Oxycodone
Fiorinal+Codeinec                   2        But.+ASA+Caff.+Codeine
Duragesicc                          1        Fentanyl transdermal
MS-Continc                          1        Morphine sulfate, extended-release
Oxycontinc                          1        Oxycodone, sustained-release
Ultramc                             1        Tramadol

Anticonvulsants
Valiumc                             1        Diazepam
Luminalc                            1        Phenobarbital
Tegretol                            1        Carbamazepine
Klonopinc                           1        Clonazepam
Tranxene (not sustained-release)c   1        Clorazepate
Mebaralc                            2        Mephobarbital
Dilantin                            1        Phenytoin sustained-release
Mysoline                            1        Primidone
Depakene                            1        Valproic Acid
Carbatrol                           2        Carbamazepine, sustained-release
                                             capsules
Tegretol-XR                         2        Carbamazepine, sustained-release
                                             tablets
Depakote                            2        Divalproex
Dilantin                            2        Phenytoin Suspension
Diastatc                            2        Diazepam rectal gel
Zarontin                            1        Ethosuximide
Felbatol                            2        Felbamate
Neurontin                           1        Gabapentin
Lamictal                            3        Lamotrigine
Gabitril                            2        Tiagabine
                                        17
Brand name              Tier         Generic name
Topamax                     3   Topiramate
Trileptal                   3   Oxcarbazepine
Keppra                      3   Levetiracetam
Phenytek                    2   Phenytoin, extended release
Lyrica*                     3   Pregabalin

Antidepressants
SSRIs
Celexa                      1   Citalopram
Paxil                       1   Paroxetine
Prozac                      1   Fluoxetine
Zoloft                      1   Sertraline
Luvox                       1   Fluvoxamine
Tricyclics
Elavil                     1    Amitriptyline
Tofranil                   1    Imipramine
Anafranil                  1    Clomipramine
Norpramin                  1    Desipramine
Sinequan                   1    Doxepin
Aventyl                    1    Nortriptyline
Miscellaneous Antidepressants
Desyrel                    1    Trazodone
Wellbutrin SR              1    Bupropion SR
Ludiomil                   1    Maprotiline
Effexor                    1    Venlafaxine
Effexor-XR                 2    Venlafaxine, sustained-release
Remeron                    1    Mirtazapine
Monoamine Oxidase Inhibitors
Nardil                      2   Phenelzine
Parnate                     2   Tranylcypromine

Antiparkinson Agents
Symmetrel                  1    Amantadine
Apokyn                     3    Apomorphine HCI
Cogentin                   1    Benztropine
Artane                     1    Trihexyphenidyl
Dopar                      1    Levodopa
Parlodel                   1    Bromocriptine
Sinemet                    1    Levodopa+carbidopa
Eldepryl                   1    Selegiline
Sinemet-CR                 1    Levodopa+carbidopa, sustained-release

                                18
Brand name                     Tier             Generic name
Azilect                             2        Rasagiline
Mirapex                             2        Pramipexole
Requip                              2        Ropinirole
Tasmar                              2        Tolcapone
Stalevo                             2        Carbidopa/Levodopa/Entacapone
Comtan                              2        Entacapone

Antipsychotics
Haldol                              1        Haloperidol
Thorazine                           1        Chlorpromazine
Eskalith                            1        Lithium carbonate
Compazine                           1        Prochlorperazine
Phenergan                           1        Promethazine
Mellaril                            1        Thioridazine
No brand name                       1        Lithium citrate syrup 300mg/5ml
Lithobid; Eskalith-CR               1        Lithium carbonate extended-release
Prolixin                            1        Fluphenazine
Serentil                            2        Mesoridazine
Trilafon                            1        Perphenazine
Orap                                2        Pimozide
Navane                              1        Thiothixene
Stelazine                           1        Trifluoperazine
Clozaril                            1        Clozapine
Zyprexa                             3        Olanzapine
Seroquel                            2        Quetiapine
Risperdal                           3        Risperidone
Geodon*, t                          3        Ziprasidone
Abilify                             2        Aripiprazole

Anxiolytics/Sedatives/Hypnotics
Noctecc                             1        Chloral Hydrate
Libriumc                            1        Chlordiazepoxide
Valiumc                             1        Diazepam
Restorilc                           1        Temazepam
Xanaxc                              1        Alprazolam
Klonopinc                           1        Clonazepam
Tranxenec (not sustained-release)   1        Clorazepate
Ativanc                             1        Lorazepam
Seraxc                              1        Oxazepam
Phenergan                           1        Promethazine
Buspar                              1        Buspirone
Ambien c,**                         1        Zolpidem
Sonata**                            2        Zaleplon



                                        19
Brand name              Tier            Generic name
Alzheimer’s Disease Therapies
Aricept                        3   Donepezil
Exelon                         2   Rivastigmine Tartrate
Razadyne                       3   Galantamine
Namenda                        2   Memantine
                                   Hydrochloride

CNS Stimulants
Dexedrinec                     1   Dextroamphetamine
Adderallc                      1   Dextroamphetamine/Amphetamine
Adderall XRc                   2   Dextroamphetamine/Amphetamine,
                                   extended-release
Ritalinc                       1   Methylphenidate
Ritalin-SRc                    1   Methylphenidate, sustained-release
Metadate CDc                   2   Methylphenidate, extended-release
Focalin                        1   Dexmethylphenidate

Migraine Medications
Midrin                         2   APAP+dichloralphenazone
                                   +isometheptene
Cafergot                       2   Ergotamine+caffeine
Imitrex**                      2   Sumatriptan (tablets)
Imitrex**                      2   Sumatriptan (nasal spray)
Imitrex**                      2   Sumatriptan (injection)
Maxalt**                       2   Rizatriptan
Maxalt MLT**                   2   Rizatriptan, oral disintegrating tablets
Axert**                        2   Almotriptan
Stadol NSc                     1   Butorphanol nasal spray
DHE-45                         3   Dihydroergotamine, injection
Migranal                       2   Dihydroergotamine nasal spray
Depakote ER                    2   Divalproex sodium tablets,
                                   extended release

Miscellaneous CNS Agents
Transderm-Scop                 2   Scopolamine, transdermal
Zyban                          1   Bupropion SR

Multiple Sclerosis Therapies
Copaxone                       2   Glatiramer
Betaseron                      2   Interferon-beta

NSAIDs
Motrin                         1   Ibuprofen
Indocin                        1   Indomethacin
                                   20
Brand name                      Tier             Generic name
Naprosyn                            1         Naproxen
Anaprox                             1         Naproxen Sodium
Nalfon                              1         Fenoprofen
Feldene                             1         Piroxicam
Disalcid                            1         Salsalate
Trilisate                           1         Choline magnesium salicylate
Ansaid                              1         Flurbiprofen
Dolobid                             1         Diflunisal
Meclomen                            1         Meclofenamate
Clinoril                            1         Sulindac
Tolectin                            1         Tolmetin
Indocin-SR                          1         Indomethacin sustained-release
Orudis                              1         Ketoprofen
EC-Naprosyn                         1         Naproxen, enteric coated
Voltaren                            1         Diclofenac
Lodine                              1         Etodolac
Toradol**                           1         Ketorolac
Lodine-XL                           1         Etodolac, extended release
Voltaren-XR                         1         Diclofenac, sustained-release
Relafen                             1         Nabumetone
Daypro                              1         Oxaprozin

Skeletal Muscle Relaxants
Valiumc                             1         Diazepam
Robaxin                             1         Methocarbamol
Paraflex                            1         Chlorzoxazone
Flexeril                            1         Cyclobenzaprine
Soma                                1         Carisoprodol
Lioresal                            1         Baclofen
Dantrium                            1         Dantrolene
Skelaxin                            2         Metaxalone
Parafon Forte DSC                   1         Chlorzoxazone 500mg
Zanaflex                            1         Tizanidine

Diabetic Agents
Supplies
These items are listed for plans that have specified coverage for the supplies.
Insulin pumps are covered as durable medical equipment and subject to DME
benefit limits. Insulin pens and refill cartridges are not covered.
Lancets                                 2       Lancets
Insulin Syringes                        2       Insulin Syringes
One Touch Profile and Basic;            2       Blood Glucose test strips



                                         21
Brand name                      Tier        Generic name
Surestep; Fast Take;
Ultra Test Strips

Biguanides
Glucophage                        1    Metformin
Glucophage XR                     1    Metformin extanded release

Insulins
Novolin vials, Novolog vials,     2    Insulin
Novolog mix vials
Lantus                            2    Insulin glargine

Miscellaneous Anti-Diabetics
Precose                           2    Acarbose
Glyset                            2    Miglitol
Prandin                           2    Repaglinide
Actos*, t                         2    Pioglitazone
Avandia*, t                       2    Rosiglitazone
Byetta*,t                         2    Exenatide
Januvia*,t                        2    Sitagliptin phosphate

Sulfonylureas
Diabinese                         1    Chlorpropamide
Micronase; Diabeta                1    Glyburide
Glucotrol                         1    Glipizide
Amaryl                            1    Glimepiride
Glucotrol-XL                      1    Glipizide, sustained-release
Glucovance                        1    Glyburide, metformin

Treatment of Hypoglycemia
Proglycem                         2    Diazoxide
Glucagon**, Glucagen**            2    Glucagon

Gastrointestinal
Antidiarrheals
Lomotilc                          1    Diphenoxylate+atropinec
Alinia                            2    Nitazoxanide

Antiemetics
Phenergan                         1    Promethazine
Compazine                         1    Prochlorperazine
Marinolc                          2    Dronabinol
Torecan                           2    Thiethylperazine
Kytril**                          3    Granisetron
                                       22
Brand name               Tier             Generic name
Zofran**                     1        Ondansetron
Antivert                     1        Meclizine

Antispasmodics
Donnatal                     1        Atropine+scopolamine +hyoscyamine
                                      +phenobarbital
No brand name               1         Belladonna+phenobarbital
Librax                      1         Chlordiazepoxide+clidinium
Levsin                      1         l-Hyoscyamine
Pro-Banthine                1         Propantheline
Bentyl                      1         Dicyclomine
Levsinex                    1         l-Hyoscyamine extended-release

Crohn’s/Ulcerative Colitis Agents
Azulfidine                   1        Sulfasalazine
Pentasa                      2        Mesalamine 250 controlled-release
                                      capsules
Asacol                       3        Mesalamine 400 delayed-release tablets
Azulfidine Entabs            1        Sulfasalazine, enteric coated
Rowasa                       2        Mesalamine enema
Dipentum                     2        Olsalazine
Colazal                      2        Balsalazide
Lialda                       2        Mesalamine
Entocort EC                  2        Budesonide

Cytoprotectives
Carafate                     1        Sucralfate tablets
Cytotec                      1        Misoprostol

Digestive Enzymes
Viokase                      2        Pancrelipase powder
Pancrease                    2        Pancrelipase
Pancrease MT                 2        Pancrelipase
Ultrase-MT                   2        Pancrelipase

Gall Bladder Agents
Actigall                     1        Ursodiol

GI Stimulants
Reglan                       1        Metoclopramide

H-2 Blockers
Tagamet                      1        Cimetidine
Zantac                       1        Ranitidine


                                 23
 Brand name                    Tier          Generic name
Pepcid                          1     Famotidine
Axid                            1     Nizatidine

Laxatives/Ammonia Detoxicants
Cephulac                        1     Lactulose
Kristalose                      2     Lactulose

Laxatives/Stool Softners
Visicol                         2     Sodium phosphate
Co-Lyte; Go-Lytely; Nulytely    1     Polyethylene glycol electrolyte solution
HalfLytely                      2     Polyethylene glycol electrolyte solution+
                                      bisacodyl tablets

Miscellaneous GI Agents
Sandostatin                     1     Octreotide
Amitiza*,t                      3     Lubiprostone

Proton Pump Inhibitor
Prevacid*                       2     Iansoprazole
Prilosec                        1     Omeprazole

Genito-Urinary
Urinary Incontinence
Ditropan                        1     Oxybutynin
Ditropan XL*                    1     Oxybutynin, sustained-release
Detrol*                         3     Tolterodine
Vesicare                        2     Solifenacin succinate

Urinary Retention
Urecholine                      2     Bethanechol

Urinary Tract Analgesics
Pyridium                        1     Phenazopyridine HCl

Miscellaneous Genito-Urinary Agents
Lithostat                       2     Acetohydroxamic acid
Calcibind                       2     Cellulose calcium phosphate
Cystagon                        2     Cysteamine bitartrate
B&O Supprettesc                 2     Opium/Belladonna suppository
Urocit-K                        2     Potassium citrate
Polycitra; Polycitra-K          1     Potassium citrate combinations
K-Phos                          2     Potassium acid phosphate
K-Phos Products                 2     Potassium acid phosphate+
                                      sodium acid phosphate
                                        24
Brand name                 Tier            Generic name
Bicitra; Oracit              1         Sodium citrate+citric acid solution
                                       (Shohl’s solution, modified)

Miscellaneous Renal
Fosrenol                     2         Lanthanum carbonate
PhosLo                       2         Calcium acetate
Renagel*                     3         Sevelamer

Hormonal
Adreno-Corticoids
Florinef                     1         Fludrocortisone

Androgens
Danocrine                    1         Danazol
Halotestinc                  1         Fluoxymesterone
Androdermc                   2         Testosterone, transdermal patch
Androgel*, c                 3         Testosterone gel

Benign Prostatic Hypertrophy
Proscar*, t                  1         Finasteride

Bisphosphonates
Actonel                      2         Risedronate
Actonel once weekly          2         Risedronate
Actonel with Calcium         2         Risedronate with Calcium
Fosamax                      2         Alendronate
Fosamax plus vitamin D       2         Alendronate plus Vitamin D
Fosamax once weekly          2         Alendronate
Didronel                     2         Etidronate
Boniva tablets**             2         Ibandronate

Corticosteroids
Deltasone                    1         Prednisone
Prednisolone tablet, 5mg     1         Prednisolone tablet, 5 mg
Medrol                       1         Methylprednisolone
Liquid Pred 5mg/5ml          2         Prednisone syrup 5mg/5ml
Prelone                      1         Prednisolone
Orapred                      2         Prednisolone syrup
Decadron                     1         Dexamethasone
Hydrocortone                 1         Hydrocortisone
Cortone                      1         Cortisone

Endometriosis Agents
Danocrine                    1         Danazol
                                  25
Brand name                Tier           Generic name
Synarel nasal spray           2     Nafarelin

Estrogens, Vaginal
Ortho-Dienestrol              2     Dienestrol vaginal cream
Premarin vaginal              2     Estrogens, conjugated
Estring                       2     Estradiol vaginal ring
Estrogen/Progestin Combinations
Prempro                       2     Estrogens, conjugated+
                                    medroxyprogesterone
Premphase                     2     Estrogens, conjugated and estrogens+
                                    medroxyprogesterone
Combipatch                    2     Estradiol+norethindrone
                                    transdermal patch
Prempro Low Dose              2     Estrogens, conjugated and
                                    medroxyprogesterone

Estrogens, Topical
Climara                       1     Estradiol transdermal
Estraderm                     1     Estradiol transdermal
Vivelle                       1     Estradiol transdermal

Estrogens, Oral
Premarin                      2     Estrogens, conjugated
Estrace                       1     Estradiol, micronized
Ortho-Est                     1     Estropipate tabs

Selective Estrogen Receptor Modifiers (SERMs)
Evista*                       3     Raloxifene

Estrogens/Androgens
Estratest-HS                  2     Estrogens, esterified+
                                    methyltestosterone

Human Growth Hormone
Human growth hormone*,t             20% Human growth hormone*, t

Hyperprolactinemia
Dostinex*                     3     Cabergoline

Infertility Agents (subject to benefit coverage)
Follistim AQ pen              3     Follitropin beta
Ganirelix                     3     Ganirelix acetate
Profasi                       1     Chorionic gonadotropins


                                    26
Brand name               Tier              Generic name
Clomid                      1          Clomiphene
Repronex                    3          Menotropins
Prochieve*                  3          Progesterone vaginal gel
Crinone*                    3          Progesterone vaginal gel

Oral Contraceptives (Biphasic)
Ortho-Novum 10/11           1          Norethindrone+ethinyl estradiol

Oral Contraceptives (Monophasic)
Ortho-Cept                  1          Desogestrel+ethinyl estradiol
Alesse                      1          Levonorgestrel+ethinyl estradiol
Ortho-Cyclen                1          Norethindrone+ethinyl estradiol
Ortho-Novum 1/35            1          Norethindrone+mestranol
Ortho-Novum 1/50            1          Norethindrone+mestranol
Lo/Ovral                    1          Norgestrel+ethinyl estradiol
Loestrin-FE                 1          Norethindrone acetate+ethinyl
                                       estradiol+Iron
Loestrin                    1          Norethindrone acetate+ethinyl estradiol
Nordette                    1          Levonorgestrel+ethinyl estradiol
Modicon                     1          Norethindrone+ethinyl estradiol

Oral Contraceptives (Triphasic)
Tri-Phasil                  1          Levonorgestrel+ethinyl estradiol
Ortho-Tricyclen             1          Norethindrone+ethinyl estradiol
Ortho-Novum 7/7/7           1          Norgestimate+ethinyl estradiol

Oral Contraceptives (Progestin)
Ovrette                     1          Norgestrel
Micronor                    1          Norethindrone 0.35 mg

Progestatinal Agents
Provera                     1          Medroxyprogesterone
Aygestin                    2          Norethindrone 5 mg
Prometrium*                 3          Progesterone, micronized, oral
No brand name               1          Progesterone, suppositories

Oxytocics
Methergine                  2          Methylergonovine maleate

Parathyroid (also see Vitamin D agents)
Calcimar*                   3          Calcitonin injection
Sensipar*                   3          Cinacalcet
Miacalcin                   2          Calcitonin nasal spray



                                  27
Brand name                  Tier            Generic name
Pituitary
DDAVP                           1     Desmopressin, 0.1 mg/mL, Rhinal tube
DDAVP                           2     Desmopressin tablets
Stimate                         2     Desmopressin acetate
                                      nasal spray, 1.5 mg/mL

Thyroid Blocking Medications
Tapazole                        1     Methimazole
PTU                             1     Propylthiouracil

Thyroid Replacement
Synthroid                       1     Levothyroxine
Levoxyl                         1     Levothyroxine

Nutritional
Note: GHP does not cover Multivitamins or Iron supplements as these products
are available over-the-counter. Folic Acid is available as a separate covered
prescription. Combination products with Folic Acid are not reimbursed.
Folic Acid Preparations
Folvite                         1     Folic acid, 1 mg

Fluoride Supplements**
Note: One copayment is applied to a full package size
[eg, 100 or 120 tablets or 50 ml liquid.
Karidium                        1     Sodium fluoride; chewable-dissolve
                                      tablet (0.25 mg, 0.5 mg, 1 mg/dose)
Luride                          1     Sodium fluoride; chewable- dissolve
                                      tablet (0.25 mg, 0.5 mg, 1 mg/dose)
Karidium                        1     Sodium fluoride; (0.125 mg, 0.25 mg,
                                      0.5 mg/dose) drops
Luride                          1     Sodium fluoride; (0.125 mg, 0.25 mg,
                                      0.5 mg/dose) drops
Tri-Vi-Flor                     1     Sodium fluoride with vitamins ADC
Poly-Vi-Flor with iron          1     Sodium fluoride with
                                      multi-vitamins and iron
Thera-Flur                      2     Sodium fluoride topical rinse 0.5%
Tri-Vi-Flor with iron           1     Sodium fluoride with vitamins A,D,C
                                      and iron
Poly-Vi-Flor                     1    Sodium fluoride with multi-vitamins
Prevident 5000 Plus Dental Cream 1    Sodium fluoride topical dental cream


                                       28
Brand name              Tier             Generic name
Potassium Removers
Kayexalate                  1        Sodium polystyrene sulfonate

Potasium Replacements
K-Dur                       1        Potassium chloride tabs
Kao-Chlor-SF                1        Potassium chloride liquid
K-Lyte                      1        Potassium bicarbonate
K-G Elixir                  1        Potassium gluconate liquid

Prenatal Vitamins
No brand name               1        Prenatal vitamins**

Vitamin A
Aquasol A                   1        Vitamin A, 50,000 units

Vitamin D and Derivatives
Calciferol                  1        Ergocalciferol 50,000 units
Rocaltrol capsules          1        Calcitriol
DHT; Hytakerol              2        Dihydrotachysterol
Hectorol                    2        Doxercalciferol
Zemplar                     2        Paricalcitol

Vitamin K
Mephyton                    2        Vitamin K (phytonadione) tablets

Ophthalmics
Anti-fungal
Natacyn                     2        Natamycin susp.

Anti-infectives
No brand name               1        Bacitracin oint
Ilotycin                    1        Erythromycin oint
Garamycin                   1        Gentamicin oint; sol
Bleph-10                    1        Sulfacetamide 10% oint; sol
Chloroptic                  1        Chloramphenicol oint; sol
Tobrex                      1        Tobramycin sol
Neosporin                   1        Neo+bacitracin+poly-b oint
Neosporin                   1        Neo+poly-b+gramicidin sol
Polysporin                  1        Poly-B+bacitracin oint
Polytrim                    1        Poly-B+trimethoprim sol
Tobrex                      2        Tobramycin oint
Ciloxan                     1        Ciprofloxacin sol
Ciloxan                     2        Ciprofloxacin oint
                                29
Brand name             Tier              Generic name
Ocuflox                    2     Ofloxacin sol

Anti-infectives/Anti-inflammatory
Cortisporin                1     Neo+poly-b+hc susp, oint
Pred-G                     2     Gentamicin+prednisolone
                                 acetate oint; susp
Maxitrol                   1     Poly-B+neo+dexamethasone oint; susp
Tobradex                   2     Tobramycin+ dexamethasone oint; susp
Blephamide                 2     Prednisolone+sodium sulfacetamide

Anti-viral
Viroptic                   1     Trifluridine solution

Beta-blockers (Glaucoma)
Timoptic                   1     Timolol sol
Timoptic-XE                1     Timolol gel, extended release
Betoptic S                 2     Betaxolol susp

Carbonic Anhydrase Inhibitors-oral
(Glaucoma)
Diamox                     1     Acetazolamide
Neptazane                  2     Methazolamide
Diamox Sequels             2     Acetazolamide, sustained-release

Carbonic Anhydrase Inhibitors-topical
(Glaucoma)
Azopt                      2     Brinzolamide susp
Trusopt                    2     Dorzolamide sol
Cosopt                     2     Dorzolamide +timolol sol

Miotics (Glaucoma)
Pilocar                    1     Pilocarpine HCl sol
Isopto-Carbachol           2     Carbachol sol
Phospholine Iodide         2     Echothiophate
Pilopine HS Gel            2     Pilocarpine gel

Sympathomimetic/Mydriatics (Glaucoma)
Propine                    2     Dipivefrin sol
Epifrin                    2     Epinephrine sol
Alphagan                   1     Brimonidine sol
Alphagan-P                 2     Brimonidine sol

Prostglandin Analog (Glaucoma)
Xalatan                    3     Latanoprost sol
Travatan                   2     Travoprost
                                    30
Brand name               Tier             Generic name
Mast Cell Stabilizer/Histamine-1
Antagonist Combo
Pataday                      2        Olopatadine

Cycloplegic Mydriatics
Isopto-Atropine              1        Atropine oint; sol
Isopto-Homatropine           1        Homatropine HBr
Isopto Hyoscine              2        Scopolamine sol

NSAIDs
Ocufen                       1        Flurbiprofen sol
Voltaren                     2        Diclofenac sol
Acular                       2        Ketorolac sol

Steroidal Anti-inflamatory
Decadron                     1        Dexamethasone sol 0.1%
Maxidex                      2        Dexamethasone susp 0.1%
Decadron                     1        Dexamethasone oint 0.05%
AK Pred                      1        Prednisolone sodium
                                      phosphate sol 0.125%
Fluor-Op; FML                1        Fluorometholone susp
AK Pred                      1        Prednisolone sodium phosphate sol 1%
FML                          2        Fluorometholone oint
Pred Forte                   1        Prednisolone acetate susp

Anti-inflamatory/Immunomodulator
Restasis*,t                  3        Cyclosporine Op. Emulsion*

Otics
Anti-infectives
Floxin Otic                  1        Ofloxacin sol

Anti-infectives/Anti-inflamatory
Cortisporin                  1        Neo+poly-b+HC sol; susp

Miscellaneous Otic
Vosol-HC                     1        Hydrocortisone+acetic acid sol
Dome Boro Otic               1        Acetic acid+aluminum acetate sol
Auralgan                     1        Benzocaine+antipyrine+glycerine sol
Cerumenex                    2        Triethanolamine+ chlorobutanol sol
Ciprodex                     2        Ciprofloxacin+dexamethasone



                                 31
Brand name               Tier            Generic name
Respiratory
Asthma/COPD
Anti-cholinergic
Atrovent                     2      Ipratropium inhaler
Atrovent                     1      Ipratropium sol
Spiriva                      2      Tiotropium
Anti-cholinergic/Beta Adrenergics
Combivent                    2      Ipratropium+albuterol, inhaler
Beta Adrenergics
Ventolin                     1      Albuterol, tablet, inhaler, sol, syrup
Vospire ER                   3      Albuterol, extended-release tablet
Maxair                       3      Pirbuterol, inhaler
Brethine                     2      Terbutaline, tablets
Epipen**                     2      Epinephrine
Serevent Diskus              2      Salmeterol Diskus
Foradil                      2      Formoterol
Inhaled Steroids
Azmacort                     3      Triamcinolone
Flovent                      2      Fluticasone
Pulmicort                    2      Budesonide
QVAR                         2      Beclomethasone
Inhaled Steroids/Beta Adrenergics
Advair                       2      Fluticasone+Salmeterol
Leukotriene Modifiers
Singulair                    2      Montelukast
Accolate                     2      Zafirlukast
Mast Cell Stabilizer
Intal                        1      Cromolyn sodium, nebulizer sol
Tilade                       2      Nedocromil, inhaler
Theophyllines
Uniphyl                      1      Theophylline, sustained-release
Theophylline liquid          2      Theophylline oral sol (80 mg/15 ml)

Antihistamines
Periactin                    1      Cyproheptadine
Atarax                       1      Hydroxyzine HCl, oral
                                    32
Brand name              Tier            Generic name
Vistaril                  1         Hydroxyzine pamoate
Phenergan                 1         Promethazine
Allegra                   1         Fexofenadine

Antihistamines/Decongestants
Allegra-D                 2         Fexofenadine+pseudo-ephedrine

Cough Medications
Hycodanc                  1         Hydrocodone+homatropine, syrupc
Phenergan w/ Codeinec     1         Promethazine+codeinec
Robitussin DACc           1         Guaifenesin+PSE+codeinec
Tussi-Organidin-NRc       1         Guaifenesin+codeine
Phenergan DM              1         Promethazine+DM
Tessalon                  1         Benzonatate

Mucolytic Agents
Mucomyst                  2         Acetylcysteine
Pulmozyme*,t              3         Dornase alfa

Nasal Steroids
Flonase                   1         Fluticasone
Nasonex                   2         Mometasone
Rhinocort AQ              2         Budesonide

Topicals
Acne Treatment
No brand name             1         Benzoyl peroxide
Cleocin-T                 1         Clindamycin
ATS                       1         Erythromycin solution
Eryderm                   1         Erythromycin solution
Sufacet-R                 1         Sulfacetamide+sulfur
Retin-A Cream*            1         Tretinoin cream*
Benzamycin                1         Erythromycin+benzoyl peroxide
Erygel                    1         Erythromycin gel
T-Stat                    1         Erythromycin swabs; solution
Retin-A gel*              1         Tretinoin gel*
Accutane                  1         Amnesteem
Differin*                 3         Adapalene*
Retin-A Microsphere*      3         Tretinoin microsphere*

Anti-Psoriatics
Dritho-scalp              1         Anthralin cream
Tazorac*                  3         Tazarotene
Dovonex                   2         Calcipotriene, 0.005% ointment
                               33
Brand name               Tier             Generic name
Antibiotic/Antibacterial (Topical)
Garamycin                    1       Gentamicin
Silvadene                    1       Silver sulfadiazine
Peridex Rinse                1       Chlorhexidene, oral
Sebizon                      2       Sulfacetamide
Metrogel                     2       Metronidazole
Bactroban                    2       Mupirocin ointment and cream

Antifungals (Topical)
Naftin                       2       Nafitine
Loprox                       2       Ciclopirox
Spectazole                   1       Econazole
Nizoral                      1       Ketoconazole cream; shampoo
Monistat-Derm                2       Miconazole topical

Antifungals/Steroid
Lotrisone                    1       Clotrimazole+betamethasone
Mycolog II                   1       Triamcinolone+nystatin

Anti-Inflammatory (Low Potency)
Synalar                      1       Fluocinolone acetonide 0.01% solution
Hytone                       1       Hydrocortisone 2.5% cream; oint; lotion
Aclovate                     1       Aclometasone diproprionate
                                     0.05% cream; oint

Anti-Inflammatory (Medium Potency)
Beta-Val                     1       Betamethasone valerate 0.1% cream
Kenalog                      1       Triamcinolone 0.1% cream; lotion
Kenalog                      1       Triamcinolone acetonide 0.025%
                                     cream; oint; lotion
Synalar                      1       Fluocinolone acetonide
                                     0.025% cream; oint
Cutivate                     2       Fluticasone propionate 0.005% cream; oint
Elocon                       1       Mometasone cream, oint
Kenalog                      1       Triamcinolone 0.5% cream
Kenalog                      2       Triamcinolone aerosol

Anti-Inflammatory (High Potency)
Beta-Val                     1       Betamethasone valerate 0.1% oint
Kenalog                      1       Triamcinolone acetonide 0.1% oint
Lidex                        1       Fluocinonide 0.05% cream; oint; gel
Diprolene AF                 2       Augmented betamethasone
                                     dipropironate 0.05% cream


                                     34
Brand name                 Tier            Generic name
Anti-Inflammatory (Very High Potency)
Diprolene                    1         Augmented betamethasone
                                       dipropironate 0.05% oint; gel; lotion
Temovate                     1         Clobetasol 0.05% cream; oint;
                                       scalp lotion
Psorcon                      1         Diflorasone diacetate oint

Antiviral/Immune Modifier
Aldara*                      3         Imiquimod*

Miscellaneous Topicals
Accuzyme                     2         Papain/urea
Santyl                       2         Collagenase
Efudex                       2         Fluorouracil
Elidel Cream*, t             2         Pimecrolimus Cream
Condylox                     2         Podophylox
Protopic*, t                 2         Tacrolimus ointment
Exsel                        1         Selenium Sulfide

Mouth and Throat
Xylocaine Viscous            1         Lidocaine, viscous

Rectal/Perineal Steroid
Proctofoam-HC                1         Hydrocortisone+pramoxine
Proctocort                   2         Hydrocortisone 1%
Anusol HC                    1         Hydrocortisone 2.5%
Cort-Dome                    1         Hydrocortisone, suppository
Cort-Enema                   1         Hydrocortisone

Scabicides/Pediculocides
Kwell                        1         Lindane shampoo; lotion
Elimite                      2         Permethrin

Vaginal Products
Vaginal Anti-fungal
Terazol                      1         Terconazole
Vaginal Anti-bacterial
Sultrin                      1         Triple sulfa vaginal cream
AVC                          2         Sulfanilamide
Metrogel-Vaginal             2         Metronidazole vaginal gel
Cleocin Vaginal Cream        2         Clindamycin vaginal cream
Clindesse                    2         Clindamycin phosphate
                                  35
Brand name               Tier        Generic name

Miscellaneous Medications
Anti-Alcoholic Drugs
Antabuse                   1    Disulfiram

Anti-Cholinergic Drugs
Robinul                    1    Glycopyrrolate

Anti-Rheumatoid Agents
Depen                      2    Penicillamine
Ridaura                    2    Auranofin
Solganal                   2    Aurothioglucose
Imuran                     1    Azathioprine
Aralen                     1    Chloroquine
Plaquenil                  1    Hydroxychloroquine
Rheumatrex                 1    Methotrexate
Neoral; Sandimmune         2    Cyclosporine
Arava                      3    Leflunomide
Enbrel*, t,**              3    Etanercept
Humira*,t,**               3    Adalimumab

Chelating Agents
Exjade**                   3    Deferasirox

Cholinergic Drugs
Salagen                    1    Pilocarpine, oral
Prostigmine                2    Neostigmine
Mestinon                   2    Pyridostigmine

Gaucher Disease Agents
Zavesca*,t                 3    Miglustat

Gout Medications
Zyloprim                   1    Allopurinol
Colchicine                 1    Colchicine
Benemid                    1    Probenecid
Anturane                   1    Sulfinpyrazone
Col-Benemid                1    Colchicine/Probenecid

Immunosuppressives
Neoral; Sandimmune         2    Cyclosporine
Cellcept                   2    Mycophenolate mofetil
Myfortic                   2    Mycophenolate sodium


                                36
Brand name                   Tier             Generic name
Rapamune*, t                     3        Sirolimus
Prograf                          2        Tacrolimus
Thalomid                         2        Thalidomide

Smoking Deterrents
Zyban                            1        Bupropion
Chantix*,t,**                    3        Varenicline tartrate
                          is available cessation is available which requires
Note: Chantix coverage for smokingvia prior authorizationvia prior authorization
participation in the Health Plan’s Tobacco Cessation Program. To begin the
which requires participation in the Health Plan’s Tobacco Cessation Program.
prior authorization process, please call (800) 883-6355. Chantix coverage
To begin the prior authorization process, please call (800) 883-6355. Chantix
is limited tolimited to perweeks per lifetime and copay/coinsurancesdefined
coverage is 24 weeks 24 lifetime and copay/coinsurances apply as apply
in the member’s pharmacy pharmacy benefit documents. If requirements
as defined in the member’s benefit documents. If requirements are met,
are met, will be at tier 3 at members who subscribe to the Triple Tier
coveragecoverage will befor tier 3 for members who subscribe to the Triple Tier
pharmacy benefit. For members who subscribe to the Traditional pharmacy
benefit, coverage will be in accordance with the cost sharing amount set
forth in their pharmacy benefit documents.
Examples of coverage status of nonformulary
medications under Triple Choice benefit
Note: The medications listed in this category are not covered under the
traditional prescription plan. For additional medications covered in this
category please call the Pharmacy Service Team at (800) 988-4861 or
(570) 271-5673 Monday through Friday, 8 a.m. to 5 p.m.
Aciphext                         3
Actoplus mett                    3
Amerge**                         3
Aromasin                         3
Arthrotec                        3
Asmanex                          3
Atacandt                         3
Atacand HCTt                     3
Avalidet                         3
Avandamett                       3
Avaprot                          3
Benicart                         3
Caduett                          3
Celebrex                         3
Clarinex                         3
Concerta                         3
Cymbalta                         3
Daytranat                        3
Detrol LAt                       3
Eli Lilly Insulinst              3
                                     37
Brand name                   Tier          Generic name
Emendt                            3
Enablext                          3
FemHRT                            3
Fentorat                          3
Flomax                            3
Focalin XRt                       3
Forteot                           3
Insulin pens and cartridgest      3
Invegat                           3
Ketekt                            3
Levemir                           3
Lexapro                           3
Lidodermt                         3
Lipitort                          3
Lotronext                         3
Micardist                         3
Micardis HCTt                     3
Nasacort AQt                      3
Nexiumt                           3
Nonformulary blood glucose test
strips and meterst                3
Nuvaring                          3
Omacor                            3
Ortho Evra                        3
Ortho Tricyclen Lot               3
Protonixt                         3
Raniclor                          3
Raptivat                          3
Rebift                            3
Relpax**                          3
Revlimidt                         3
Ritalin LAt                       3
Sancturat                         3
Seasonalet                        3
Strattera                         3
Symbyaxt                          3
Tevetent                          3
Tricor                            3
Verdesat                          3
Vytorin*,t                        3
Welchol                           3
Xopenext                          3
Yasmint                           3
Zolinza**,t                       3
Zomig**                           3
Zyrtect                           3   38
                          Index                                      Alesse .................................................. 27
                                                                     Alinia ................................................... 22
                                                                     Alkeran ............................................... 12
                               A                                     Allegra ................................................ 33
Abacavir ............................................. 10            Allegra-D............................................ 33
Abilify .................................................. 19        Allopurinol ........................................ 36
Acarbose ............................................ 22             Almotriptan ...................................... 20
Accolate ............................................. 32            Alphagan ........................................... 30
Accupril .............................................. 13           Alphagan-P ....................................... 30
Accutane............................................ 33              Alprazolam........................................ 19
Accuzyme .......................................... 35               Altace .................................................. 13
Acebutolol......................................... 14               Altretamine ....................................... 12
Acetazolamide ................................. 30                   Amantadine ...................................... 9, 18
Acetazolamide,                                                       Amaryl ................................................ 22
sustained-release............................ 30                     Ambien............................................... 19
Acetic acid+aluminum                                                 Amerge............................................... 37
acetate sol ......................................... 31             Amicar ................................................ 16
Acetohydroxamic acid .................. 24                           Aminocaproic Acid ........................ 16
Acetylcysteine ................................. 33                  Aminoglutethamide ...................... 12
Achromycin-V .................................. 12                   Amiodarone ..................................... 14
Aciphex .............................................. 37            Amitiza ............................................... 24
Aclometasone diproprionate                                           Amitriptyline .................................... 18
0.05% cream; oint ........................... 34                     Amlodipine ....................................... 15
Aclovate ............................................. 34            Amlodipine + benazepril ............. 15
Actigall ............................................... 23          Amnesteem ...................................... 33
Actimmune ....................................... 11, 12             Amoxicillin ........................................ 11
Actonel ............................................... 25           Amoxicillin/clavulanate................ 11
Actonel once weekly ..................... 25                         Amoxil................................................. 11
Actonel with Calcium .................... 25                         Amprenavir ....................................... 10
Actoplus met.................................... 37                  Anafranil ............................................ 18
Actos ................................................... 22         Anagrelide......................................... 16
Acular .................................................. 31         Anaprox.............................................. 21
Acyclovir (not topical) ................... 10                       Anastrazole ....................................... 12
Adalat.................................................. 15          Androdermc ..................................... 25
Adalat-CC........................................... 15              Androgel ............................................ 25
Adalimumab..................................... 36                   Ansaid ................................................. 21
Adapalene ......................................... 33               Antabuse ........................................... 36
Adderallc ........................................... 20             Anthralin cream .............................. 33
Adderall XR ....................................... 20               Antivert .............................................. 23
Adefovir dipivoxil ........................... 10                    Anturane ............................................ 36
Advair.................................................. 32          Anusol HC.......................................... 35
Agenerase ......................................... 10, 11           APAP+But .......................................... 17
Agrylin ................................................ 16          APAP+dichloralphenazone+
AK Pred ............................................... 31           isometheptene ................................ 17, 20
Albuterol, extended-release                                          Apokyn ............................................... 18
tablet ................................................... 32        Apomorphine HCI .......................... 18
Albuterol, tablet,                                                   Apresoline ......................................... 16
inhaler, sol, syrup ............................ 32                  Aquasol A .......................................... 29
Aldactazide ....................................... 15               Aralen.................................................. 9, 36
Aldactone .......................................... 15              Aranesp .............................................. 13
Aldara.................................................. 35          Arava ................................................... 36
Aldomet ............................................. 14             Aricept ................................................ 20
Alendronate...................................... 25                 Arimidex ............................................ 12
Alendronate plus Vitamin D ....... 25                                Aripiprazole ...................................... 19
                                                                39
Aromasin ........................................... 37           Bentyl .................................................. 23
Artane ................................................. 18       Benzamycin ...................................... 33
Arthrotec ........................................... 37          Benzocaine+antipyrine+
Asacol ................................................. 23       glycerine sol ..................................... 31
Asmanex ............................................ 37           Benzonatate ..................................... 33
Atacand HCT .................................... 37, 38, 38       Benzoyl peroxide ............................ 33
Atacandt ............................................ 37          Benztropine ...................................... 18
Atarax.................................................. 32       Beta-Val .............................................. 34
Atazanavir ......................................... 10           Betamethasone valerate
Atenolol ............................................. 14         0.1% cream ....................................... 34
Ativanc ............................................... 19        Betamethasone valerate
Atovaquone...................................... 11               0.1% oint ............................................ 34
Atropine+scopolamine+                                             Betapace ............................................ 14
hyoscyamine+phenobarbital .... 23                                 Betaseron .......................................... 20
Atropine oint; sol ............................ 31                Betaxolol susp.................................. 30
Atrovent ............................................. 32         Bethanechol ..................................... 24
ATS ....................................................... 33    Betoptic S .......................................... 30
Augmented betamethasone                                           Biaxin .................................................. 11
dipropironate 0.05% cream ........ 34, 35                         Biaxin XL ............................................ 11
Augmentin ........................................ 11             Bicalutamide .................................... 12
Auralgan ............................................ 31          Bicitra .................................................. 25
Auranofin........................................... 36           Bisoprolol+hctz ............................... 15
Aurothioglucose ............................. 36                  Bleph-10............................................. 29
Avandia .............................................. 22         Blephamide ...................................... 30
Avapro ................................................ 37        Blood Glucose test strips ............. 21
AVC ...................................................... 35     Boniva tablets .................................. 25
Avelox ................................................. 11       Bosentan............................................ 16
Aventyl ............................................... 18        Brethine ............................................. 32
Avinza ................................................. 16       Brimonidine sol ............................... 30
Avonex ............................................... 20         Brinzolamide susp .......................... 30
Axert .................................................... 20     Bromocriptine.................................. 18
Axid...................................................... 24     Budesonide....................................... 23, 32, 33
Aygestin ............................................. 27         Bumetanide ...................................... 15
Azathioprine..................................... 36              Bumex................................................. 15
Azilect ................................................. 19      Bupropion ......................................... 37
Azithromycin.................................... 11               Bupropion SR ................................... 18, 20
Azmacort ........................................... 32           Buspar ................................................. 19
Azopt................................................... 30       Buspirone .......................................... 19
Azulfidine .......................................... 11, 23      Busulfan ............................................. 12
Azulfidine Entabs............................ 12, 23              But+APAP+Caff ............................... 16
                                                                  But+ASA+Caff .................................. 17
                                 B                                But.+ASA+Caff. +Codeine ........... 17
B&O Supprettes............................... 24                  Butorphanol nasal spray .............. 20
Bacitracin oint .................................. 29             Byetta .................................................. 22
Baclofen ............................................. 21
Bactroban .......................................... 34
                                                                                                   C
Balsalazide ........................................ 23           Cabergoline ...................................... 26
Beclomethasone ............................. 32                   Cafergot ............................................. 20
Belladonna+phenobarbital ........ 23                              Calan; Isoptin ................................... 15
Benazepril ......................................... 13           Calan SR ............................................. 15
Benazepril+hctz .............................. 13                 Calcibind ............................................ 24
Benemid............................................. 36           Calciferol ............................................ 29
Benicar................................................ 37        Calcimar ............................................. 27

                                                                 40
Calcipotriene, 0.005% ointment 33                                    Chlorpromazine .............................. 19
Calcitonin injection........................ 27                      Chlorpropamide ............................. 22
Calcitonin nasal spray ................... 27                        Chlorthalidone ................................ 15
Calcitriol ............................................. 29          Chlorzoxazone................................. 21
Calcium acetate............................... 25                    Chlorzoxazone 500mg.................. 21
Capecitabine .................................... 12                 Cholestyramine Resin ................... 14
Capoten ............................................. 13             Choline magnesium salicylate... 21
Capozide ............................................ 13             Chorionic gonadotropins ............ 26
Captopril ............................................ 13            Ciclopirox .......................................... 34
Captopril+hctz ................................ 13                   Cilostazol ........................................... 16
Carafate .............................................. 23           Ciloxan................................................ 29
Carbachol sol ................................... 30                 Cimetidine......................................... 23
Carbamazepine ............................... 17                     Cinacalcet .......................................... 27
Carbamazepine,                                                       Cipro .................................................... 10
sustained-release capsules ......... 17                              Ciprodex ............................................ 31
Carbamazepine,                                                       Ciprofloxacin .................................... 10
sustained-release tablets ............. 17                           Ciprofloxacin+dexamethasone . 31
Carbatrol ............................................ 17            Ciprofloxacin oint ........................... 29
Carbidopa/Levodopa/                                                  Ciprofloxacin sol ............................. 29
Entacapone....................................... 19                 Citalopram ........................................ 18
Cardizem............................................ 15              Clarithromycin ................................. 11
Cardizem-CD .................................... 15                  Clarithromycin ext. release ......... 11
Cardizem-SR ..................................... 15                 Cleocin-T ............................................ 33
Cardura............................................... 14            Cleocin Vaginal Cream .................. 35
Carisoprodol ..................................... 21                Climara ............................................... 26
Carvedilol .......................................... 13             Clindamycin...................................... 11, 33
Casodex.............................................. 12             Clindamycin palmitate oral soln 11
Catapres ............................................. 14            Clindamycin phosphate ............... 35
Catapres TTS ..................................... 14                Clindamycin vaginal cream ........ 35
Ceenu.................................................. 12           Clindesse ........................................... 35
Cefdinir ............................................... 10          Clinoril ................................................ 21
Cefprozil ............................................. 10           Clobetasol 0.05%
Ceftin................................................... 10         cream; oint; scalp loti .................... 35
Cefuroxime Axetil ........................... 10                     Clofazimine ....................................... 11
Cefzil.................................................... 10        Clomid ................................................ 27
Celexa ................................................. 18          Clomiphene ...................................... 27
Cellcept .............................................. 36           Clomipramine .................................. 18
Cellulose calcium phosphate ..... 24                                 Clonazepam ..................................... 17, 19
Cephalexin ........................................ 10               Clonidine ........................................... 14
Cephulac............................................ 24              Clopidogrel ....................................... 16
Cerumenex ....................................... 31                 Clorazepate....................................... 17, 19
Chantix ............................................... 37           Clotrimazole ..................................... 9
Chloral Hydrate ............................... 19                   Clotrimazole+betamethasone .. 34
Chlorambucil.................................... 12                  Clozapine........................................... 19
Chloramphenicol ............................ 11                      Clozaril ................................................ 19
Chloramphenicol oint; sol ........... 29                             Co-Lyte ............................................... 24
Chlordiazepoxide ........................... 19                      Codeine+APAP ................................ 17
Chlordiazepoxide+clidinium...... 23                                  Codeinec............................................ 17
Chlorhexidene, oral ....................... 34                       Codeine sulfate ............................... 17
Chloromycetin ................................. 11                   Cogentin ............................................ 18
Chloroptic ......................................... 29              Col-Benemid..................................... 36
Chloroquine...................................... 9, 36              Colazal ................................................ 23
Chloroquine phosphate ............... 9                              Colchicine.......................................... 36
Chlorothiazide suspension ......... 15                               Colchicine/Probenecid ................. 36
                                                                41
Colestid .............................................. 14     DDAVP ................................................ 28
Colestipol .......................................... 14       Decadron ........................................... 25, 31
Collagenase ...................................... 35          Deferasirox ........................................ 36
Combipatch ...................................... 26           Delavirdine........................................ 10
Combivent ........................................ 32          Deltasone .......................................... 25
Combivir ............................................ 10       Demadex ........................................... 15
Compazine ........................................ 19, 22      Demerolc ........................................... 17
Comtan............................................... 19       Depakene .......................................... 17
Condylox............................................ 35        Depakote ........................................... 17
Copaxone .......................................... 20         Depakote ER ..................................... 20
Copegus ............................................. 10       Depen ................................................. 36
Cordarone ......................................... 14         Desipramine ..................................... 18
Coreg................................................... 13    Desmopressin, 0.1 mg/mL,
Corgard .............................................. 14      Rhinal tube........................................ 28
Cort-Dome ........................................ 35          Desmopressin acetate
Cort-Enema....................................... 35           nasal spray, 1.5 mg/mL ................. 28
Cortisone ........................................... 25       Desmopressin tablets ................... 28
Cortisporin ........................................ 30, 31    Desogestrel+ethinyl estradiol ... 27
Cortone .............................................. 25      Desyrel................................................ 18
Cosopt ................................................ 30     Detrol .................................................. 24
Coumadin.......................................... 16          Detrol LA ............................................ 37
Cozaar ................................................. 13    Dexamethasone.............................. 25
Crestor ................................................ 14    Dexamethasone oint 0.05% ....... 31
Crinone............................................... 27      Dexamethasone sol 0.1% ............ 31
Crixivan .............................................. 10     Dexamethasone susp 0.1%......... 31
Cromolyn sodium, nebulizer sol 32                              Dexedrinec........................................ 20
Cutivate .............................................. 34     Dexmethylphenidate .................... 20
Cyclobenzaprine ............................. 21               Dextroamphetamine .................... 20
Cyclophosphamide........................ 12                    Dextroamphetamine/
Cyclosporine..................................... 36           Amphetamine.................................. 20
Cyclosporine Op. Emulsion ......... 31                         DHE-45 ............................................... 20
Cymbalta ........................................... 37        DHT ...................................................... 29
Cyproheptadine .............................. 32               Diabinese........................................... 22
Cystagon ............................................ 24       Diamox ............................................... 30
Cysteamine bitartrate ................... 24                   Diamox Sequels .............................. 30
Cytadren ............................................ 12       Diastatc .............................................. 17
Cytotec ............................................... 23     Diazepam .......................................... 17, 19, 21
Cytovene............................................ 10        Diazepam rectal gel ....................... 17
Cytoxan .............................................. 12      Diazoxide ........................................... 22
                                                               Dibenzyline....................................... 13
                                 D                             Diclofenac ......................................... 21
Danazol .............................................. 25      Diclofenac, sustained-release .... 21
Danocrine.......................................... 25         Diclofenac sol................................... 31
Dantrium ........................................... 21        Dicloxacillin ...................................... 11
Dantrolene ........................................ 21         Dicyclomine...................................... 23
Dapsone............................................. 11        Didanosine........................................ 10
Daraprim............................................ 9         Didronel ............................................. 25
Darbepoetin Alfa ............................ 13               Dienestrol vaginal cream ............. 26
Darunavir ........................................... 10       Differin................................................ 33
Darvocet-N........................................ 17          Diflorasone diacetate oint ........... 35
Dasatinib............................................ 12       Diflucan .............................................. 9
Daypro ................................................ 21     Diflunisal ............................................ 21
Daytrana ............................................ 37       Digoxin ............................................... 14
                                                               Dihydroergotamine, injection ... 20
                                                              42
Dihydroergotamine nasal spray 20                                   EES ....................................................... 11
Dihydrotachysterol ........................ 29                     Efavirenz ............................................ 10
Diiodohydroxyquin........................ 9                        Effexor................................................. 18
Dilantin............................................... 17         Effexor-XR .......................................... 18
Dilaudidc ........................................... 17           Efudex ................................................. 35
Diltiazem............................................ 15           Elavil .................................................... 18
Diltiazem, long-acting .................. 15                       Eldepryl .............................................. 18
Diovan ................................................ 13         Elidel Cream...................................... 35
Diovan HCT ....................................... 13              Eli Lilly Insulins................................. 37
Dipentum .......................................... 23             Elimite ................................................. 35
Diphenoxylate+atropine ............. 22                            Elocon ................................................. 34
Dipivefrin sol .................................... 30             Emcyt .................................................. 12
Diprolene........................................... 35            Emend ................................................ 38
Diprolene AF .................................... 34               Emtricitabine.................................... 10
Dipyridamole ................................... 16                Emtriva ............................................... 10
Disalcid ............................................... 21        Enablex............................................... 38
Disopyramide .................................. 14                 Enalapril ............................................. 13
Disopyramide, sustained-release                                    Enalapril+hctz.................................. 13
14                                                                 Enbrel.................................................. 36
Disulfiram .......................................... 36           Enfuvirtide ........................................ 10
Ditropan............................................. 24           Enoxaparin ........................................ 16
Ditropan XL....................................... 24              Entacapone....................................... 19
Diuril Suspension ........................... 15                   Entocort EC ....................................... 23
Divalproex ......................................... 17            Epifrin.................................................. 30
Divalproex sodium tablets, extended                                Epinephrine ...................................... 32
release ................................................ 20        Epinephrine sol ............................... 30
Dofetilide ........................................... 14          Epipen ................................................ 32
Dolobid .............................................. 21          Epivir ................................................... 10
Dolophinec ....................................... 17              Epivir HBV .......................................... 10
Dome Boro Otic .............................. 31                   Eplerenone........................................ 15
Donepezil .......................................... 20            Epogen ............................................... 13
Donnatal ............................................ 23           Epzicom ............................................. 10
Dopar .................................................. 18        Ergocalciferol 50,000 units .......... 29
Dornase alfa...................................... 33              Ergotamine+caffeine .................... 20
Dorzolamide + timolol sol........... 30                            Erlotinib.............................................. 12
Dorzolamide sol .............................. 30                  Eryderm.............................................. 33
Dostinex............................................. 26           Erygel .................................................. 33
Dovonex ............................................ 33            Erytab.................................................. 11
Doxazosin .......................................... 14            Erythrocin .......................................... 11
Doxepin.............................................. 18           Erythromycin+benzoyl
Doxercalciferol................................. 29                peroxide ............................................. 33
Doxycycline ...................................... 9, 12           Erythromycin+sulfisoxazole ....... 11
Dritho-scalp ...................................... 33             Erythromycin Base ......................... 11
Dronabinol ........................................ 22             Erythromycin ethylsuccinate...... 11
Duragesicc ........................................ 17             Erythromycin gel ............................ 33
Dyazide .............................................. 15          Erythromycin oint........................... 29
Dynacirc ............................................. 15          Erythromycin solution .................. 33
Dynapen ............................................ 11            Erythromycin stearate .................. 11
                                                                   Erythromycin swabs; solution.... 33
                               E                                   Erythropoietin ................................. 13
EC-Naprosyn..................................... 21                Eskalith ............................................... 19
Echothiophate ................................. 30                 Estrace ................................................ 26
Econazole .......................................... 34            Estraderm .......................................... 26

                                                              43
Estradiol+norethindrone                                          Fiorinalc.............................................. 17
transdermal patch .......................... 26                  Flagyl................................................... 9
Estradiol, micronized..................... 26                    Flecainide .......................................... 14
Estradiol transdermal .................... 26                    Flexeril ................................................ 21
Estradiol vaginal ring .................... 26                   Flomax ................................................ 38
Estramustine .................................... 12             Flonase ............................................... 33
Estratest-HS ...................................... 26           Florinef ............................................... 25
Estring................................................. 26      Flovent................................................ 32
Estrogens, conjugated .................. 26                      Floxin Otic ......................................... 31
Estrogens, conjugated+                                           Fluconazole, oral ............................. 9
medroxyprogesterone ................. 26                         Fludrocortisone............................... 25
Estrogens, conjugated and                                        Fluocinolone acetonide
estrogens+                                                       0.01% solution ................................. 34
medroxprogesterone .................... 26                       Fluocinolone acetonide
Estrogens, esterified+                                           0.025% cream; oint ........................ 34
methyltestosterone ....................... 26                    Fluocinonide 0.05%
Estropipate tabs .............................. 26               cream; oint; gel ................................ 34
Etanercept ......................................... 36          Fluor-Op............................................. 31
Ethambutol ....................................... 9             Fluorometholone oint .................. 31
Ethmozine ......................................... 14           Fluorometholone susp ................. 31
Ethosuximide ................................... 17              Fluorouracil....................................... 35
Etidronate.......................................... 25          Fluoxetine.......................................... 18
Etodolac ............................................. 21        Fluoxymesterone............................ 25
Etodolac, extended release......... 21                           Fluphenazine ................................... 19
Etoposide .......................................... 12          Flurbiprofen...................................... 21
Eulexin ................................................ 12      Flurbiprofen sol ............................... 31
Evista ................................................... 26    Flutamide .......................................... 12
Exelon ................................................. 20      Fluticasone........................................ 32, 33
Exenatide ........................................... 22         Fluticasone+Salmeterol ............... 32
Exjade ................................................. 36      Fluticasone propionate
Exsel..................................................... 35    0.005% cream; oint ........................ 34
Ezetimibe........................................... 14          Fluvoxamine ..................................... 18
                                                                 FML ...................................................... 31
                                  F                              Folic acid, 1 mg................................ 28
Famotidine ........................................ 24           Follistim AQ pen.............................. 26
Fansidar .............................................. 9        Follitropin beta ................................ 26
Fast Take............................................. 22        Folvite ................................................. 28
Felbamate ......................................... 17           Foradil ................................................. 32
Felbatol .............................................. 17       Formoterol ........................................ 32
Feldene............................................... 21        Forteo ................................................. 38
Felodipine ......................................... 15          Fosamax ............................................. 25
Femara................................................ 12        Fosamax once weekly ................... 25
FemHRT .............................................. 38         Fosamax plus vitamin D ............... 25
Fenoprofen ....................................... 21            Fosamprenavir ................................. 10
Fentanyl transdermal .................... 17                     Fosrenol ............................................. 25
Fentora ............................................... 38       Furadantin......................................... 11
Fexofenadine ................................... 33              Furosemide ....................................... 15
Fexofenadine+                                                    Fuzeon ................................................ 10
pseudo-ephedrine ......................... 33
Filgrastim ........................................... 13
                                                                                                  G
Finasteride ........................................ 25          Gabapentin ....................................... 17
Fioricet................................................ 16      Gabitril ................................................ 17
Fiorinal+Codeinec .......................... 17                  Galantamine ..................................... 20

                                                                44
Ganciclovir ........................................ 10              Hydralazine ....................................... 16
Ganirelix ............................................. 26           Hydrea ................................................ 12
Ganirelix acetate ............................. 26                   Hydrochlorothiazide ..................... 15
Gantrisin ............................................ 11            Hydrocodone+APAP ..................... 17
Gantrisin Suspension .................... 12                         Hydrocodone+homatropine,
Garamycin ......................................... 29, 34           syrup ................................................... 33
Gemfibrozil ....................................... 14               Hydrocortisone ............................... 25, 35
Gentamicin ....................................... 34                Hydrocortisone+acetic acid sol. 31
Gentamicin+prednisolone                                              Hydrocortisone+pramoxine ....... 35
acetate oint; susp ........................... 30                    Hydrocortisone, suppository ..... 35
Gentamicin oint; sol ...................... 29                       Hydrocortisone 1% ........................ 35
Geodon .............................................. 19             Hydrocortisone 2.5%..................... 35
Glatiramer ......................................... 20              Hydrocortisone 2.5%
Gleevec............................................... 12            cream; oint; lotion .......................... 34
Glimepiride ....................................... 22               Hydrocortone .................................. 25
Glipizide ............................................. 22           Hydrodiuril ........................................ 15
Glipizide, sustained-release ........ 22                             Hydromorphone ............................. 17
Glucagen ........................................... 22              Hydroxychloroquine ..................... 9, 36
Glucagon ........................................... 22              Hydroxyurea ..................................... 12
Glucophage ...................................... 22                 Hydroxyzine HCl, oral.................... 32
Glucophage XR................................ 22                     Hydroxyzine pamoate .................. 33
Glucotrol ............................................ 22            Hygroton ........................................... 15
Glucotrol-XL...................................... 22                Hytakerol ........................................... 29
Glucovance ....................................... 22                Hytone ................................................ 34
Glyburide ........................................... 22             Hytrin .................................................. 14
Glyburide, metformin ................... 22                          Hyzaar ................................................. 13
Glycopyrrolate ................................. 36
Glyset .................................................. 22                                             I
Go-Lytely ........................................... 24             Iansoprazole ..................................... 24
Granisetron ....................................... 22               Ibandronate ...................................... 25
Grifulvin V .......................................... 9             Ibuprofen........................................... 20
Griseofulvin microsize .................. 9                          Iloprost inhalation solution ........ 16
Griseofulvin ultra-microsize........ 9                               Ilotycin ................................................ 29
Gris Peg .............................................. 9            Imatinib Mesylate ........................... 12
Guaifenesin+codeine.................... 33                           Imdur .................................................. 16
Guaifenesin+PSE+codeinec ....... 33                                  Imipramine ....................................... 18
Guanabenz acetate ........................ 14                        Imiquimod ........................................ 35
Guanfacine HCl................................ 14                    Imitrex ................................................ 20
                                                                     Imuran ................................................ 36
                                  H                                  Inderal................................................. 15
Haldol ................................................. 19          Indinavir ............................................. 10
HalfLytely........................................... 24             Indocin ............................................... 20
Haloperidol ....................................... 19               Indocin-SR ......................................... 21
Halotestinc ........................................ 25              Indomethacin .................................. 20
Hectorol ............................................. 29            Indomethacinsustained-release 21
Hepsera .............................................. 10            InnoPran XL ...................................... 15
Hexalen .............................................. 12            Inspra .................................................. 15
Hivid .................................................... 10        Insulin ................................................. 22
Homatropine HBr ........................... 31                       Insulin glargine................................ 22
Human growth hormone ............ 26                                 Insulin Syringes ............................... 21
Humatin ............................................. 9              Intal...................................................... 32
Humira................................................ 36            Interferon-alfa-2a ........................... 12
Hycodan............................................. 33              Interferon-alfa-2b ........................... 12

                                                                45
Interferon-alfa 2b                                                                                     L
injection +ribavirin oral................ 12
Interferon-beta ................................ 20                 l-Hyoscyamine ................................. 23
Interferon gamma-1b ................... 12                          l-Hyoscyamine
Intron-A .............................................. 12          extended-release............................ 23
Invega ................................................. 38         Labetalol ............................................ 13
Invirase ............................................... 10         Lactulose ........................................... 24
Ipratropium+albuterol, inhaler . 32                                 Lamictal.............................................. 17
Ipratropium inhaler ....................... 32                      Lamivudine ....................................... 10
Ipratropium sol................................ 32                  Lamivudine (3TC) ........................... 10
Isoniazid ............................................. 9           Lamotrigine ...................................... 17
Isopto-Atropine............................... 31                   Lamprene .......................................... 11
Isopto-Carbachol ............................ 30                    Lancets ............................................... 21
Isopto-Homatropine ..................... 31                         Lanoxin............................................... 14
Isopto Hyoscine .............................. 31                   Lanthanum carbonate .................. 25
Isordil .................................................. 16       Lantus ................................................. 22
Isordil Tembids ................................ 16                 Lariam ................................................. 9
Isosorbide dinitrate po, sl ............ 16                         Lasix..................................................... 15
Isosorbide dinitrate                                                Latanoprost sol................................ 30
sustanied release ............................ 16                   Leflunomide ..................................... 36
Isosorbide mononitrate ............... 16                           Letrozole ............................................ 12
Isosorbide mononitrate                                              Leucovorin ........................................ 13
extended release ............................ 16                    Leukeran ............................................ 12
Isradipine ........................................... 15           Leukine............................................... 13
Itraconazole, oral ............................ 9                   Levaquin ............................................ 11
Itraconazole, oral solution........... 9                            Levemir............................................... 38
                                                                    Levetiracetam .................................. 18
                                   J                                Levo-Dromoranc............................. 17
                                                                    Levodopa........................................... 18
Januvia ............................................... 22          Levodopa+carbidopa ................... 18
                                                                    Levodopa+carbidopa,
                                  K                                 sustained-release............................ 18
K-Dur ................................................... 29        Levofloxacin ..................................... 11
K-G Elixir ............................................. 29         Levonorgestrel+ethinyl
K-Lyte .................................................. 29        estradiol ............................................. 27
K-Phos ................................................. 24         Levorphanol ..................................... 17
K-Phos Products .............................. 24                   Levothyroxine .................................. 28
Kaletra................................................. 10         Levoxyl ............................................... 28
Kao-Chlor-SF .................................... 29                Levsin .................................................. 23
Karidium ............................................ 28            Levsinex ............................................. 23
Kayexalate ......................................... 29             Lexapro .............................................. 38
Keflex .................................................. 10        Lexiva .................................................. 10
Kenalog .............................................. 34           Lialda................................................... 23
Keppra ................................................ 18          Librax .................................................. 23
Ketek ................................................... 11, 38    Libriumc ............................................. 19
Ketoconazole ................................... 9                  Lidex .................................................... 34
Ketoconazole cream; shampoo . 34                                    Lidocaine, viscous .......................... 35
Ketoprofen ........................................ 21              Lidoderm ........................................... 38
Ketorolac............................................ 21            Lindane shampoo; lotion ............ 35
Ketorolac sol ..................................... 31              Linezolid ............................................ 11
Klonopinc .......................................... 17, 19         Lioresal ............................................... 21
Kristalose ........................................... 24           Liquid Pred 5mg/5ml .................... 25
Kwell .................................................... 35       Lisinopril ............................................ 13
Kytril .................................................... 22      Lisinopril+hctz................................. 13
                                                                   46
Lithium carbonate.......................... 19                       Medroxyprogesterone.................. 27
Lithium carbonate                                                    Mefloquine ....................................... 9
extended-release............................ 19                      Megace............................................... 12
Lithium citrate syrup                                                Megestrol .......................................... 12
300mg/5ml ....................................... 19                 Mellaril ................................................ 19
Lithobid; Eskalith-CR ..................... 19                       Melphalan ......................................... 12
Lithostat ............................................. 24           Memantine Hydrochloride.......... 20
Lo/Ovral ............................................. 27            Menotropins..................................... 27
Lodine ................................................. 21          Meperidine ....................................... 17
Lodine-XL .......................................... 21              Mephobarbital................................. 17
Loestrin .............................................. 27           Mephyton.......................................... 29
Loestrin-FE ........................................ 27              Mepron............................................... 11
Lomotil ............................................... 22           Mercaptopurine .............................. 12
Lomustine ......................................... 12               Mesalamine ...................................... 23
Loniten ............................................... 16           Mesalamine 250
Lopid ................................................... 14         controlled-release capsules ........ 23
Lopinavir and Ritonavir ................ 10                          Mesalamine 400
Lopressor ........................................... 15             delayed-release tablets ................ 23
Loprox................................................. 34           Mesalamine enema ....................... 23
Lorazepam ........................................ 19                Mesoridazine.................................... 19
Losartan ............................................. 13            Mestinon............................................ 36
Losartan + hctz................................ 13                   Metadate CD .................................... 20
Lotensin ............................................. 13            Metaxalone ....................................... 21
Lotensin HCT .................................... 13                 Metformin ......................................... 22
Lotrel ................................................... 15        Metformin extanded release ...... 22
Lotrisone............................................ 34             Methadone ....................................... 17
Lovastatin .......................................... 14             Methazolamide ............................... 30
Lovenox.............................................. 16             Methergine ....................................... 27
Lubiprostone.................................... 24                  Methimazole .................................... 28
Ludiomil ............................................. 18            Methocarbamol .............................. 21
Luminalc ............................................ 17             Methotrexate ................................... 12, 36
Luride .................................................. 28         Methyldopa ...................................... 14
Luvox................................................... 18          Methylergonovine maleate ........ 27
Lyrica ................................................... 18        Methylphenidate ............................ 20
Lysodren ............................................ 12             Methylprednisolone ...................... 25
                                                                     Metoclopramide ............................. 23
                                  M                                  Metolazone ....................................... 15
Macrobid ........................................... 11              Metoprolol ........................................ 15
Macrodantin ..................................... 11                 Metoprolol extended-release .... 15
Maprotiline ....................................... 18               Metrogel ............................................ 34
Marinolc ............................................. 22            Metrogel-Vaginal ............................ 35
Matulane............................................ 12              Metronidazole ................................. 9, 11, 34
Maxair ................................................. 32          Metronidazole vaginal gel .......... 35
Maxalt ................................................. 20          Mevacor ............................................. 14
Maxalt MLT ........................................ 20               Mexiletine.......................................... 14
Maxidex.............................................. 31             Mexitil ................................................. 14
Maxitrol .............................................. 30           Miacalcin............................................ 27
Maxzide .............................................. 15            Miconazole topical......................... 34
Mebaralc ............................................ 17             Micronase; Diabeta ........................ 22
Mebendazole ................................... 9                    Micronor ............................................ 27
Meclizine............................................ 23             Midodrine.......................................... 15
Meclofenamate ............................... 21                     Midrin ................................................. 17, 20
Meclomen ......................................... 21                Miglitol ............................................... 22
Medrol ................................................ 25           Miglustat............................................ 36
                                                                47
Migranal ............................................. 20       Natamycin susp. .............................. 29
Minipress ........................................... 13        Navane ............................................... 19
Minocin .............................................. 12       Nebupent .......................................... 11
Minocycline ...................................... 12           Nedocromil, inhaler ....................... 32
Minoxidil ............................................ 16       Nelfinavir ........................................... 10
Mintezol ............................................. 9        Neo+bacitracin+poly-b oint....... 29
Mirapex .............................................. 19       Neo+poly-b+gramicidin sol ....... 29
Mirtazapine....................................... 18           Neo+poly-b+HC sol; susp............ 31
Misoprostol ....................................... 23          Neo+poly-b+hc susp, oint .......... 30
Mitotane ............................................ 12        Neomycin .......................................... 11
Modicon............................................. 27         Neoral ................................................. 36
Mometasone .................................... 33              Neosporin.......................................... 29
Mometasone cream, oint ............ 34                          Neostigmine ..................................... 36
Monistat-Derm ................................ 34               Neptazane ......................................... 30
Montelukast ..................................... 32            Neulasta ............................................. 13
Moricizine.......................................... 14         Neumega ........................................... 13
Morphine Sulfate ............................ 17                Neupogen ......................................... 13
Morphine sulfate ............................ 17                Neurontin .......................................... 17
Morphine sulfate,                                               Nevirapine......................................... 10
extended-release............................ 17                 Nexavar .............................................. 12
Morphine sulfate                                                Niacin, sustained-release ............. 14
extended release ............................ 16                Niaspan .............................................. 14
Motrin ................................................. 20     Nifedipine.......................................... 15
Moxifloxacin ..................................... 11           Nifedipine, long-acting ................ 15
MS-Continc ....................................... 17           Nilandron .......................................... 12
Mucomyst.......................................... 33           Nilutamide ........................................ 12
Mupirocin ointment and cream 34                                 Nimodipine....................................... 15
Myambutol ....................................... 9             Nimotop............................................. 15
Mycelex Troches.............................. 9                 Nitazoxanide .................................... 22
Mycifradin ......................................... 11         Nitrodur ............................................. 16
Mycobutin ......................................... 9           Nitrofurantoin .................................. 11
Mycolog II .......................................... 34        Nitrofurantoin Macrocrystals ..... 11
Mycophenolate mofetil................ 36                        Nitroglycerin .................................... 16
Mycophenolate sodium ............... 36                         Nitroglycerin
Mycostatin ........................................ 9           transdermal patch .......................... 16
Myfortic .............................................. 36      Nitrol ................................................... 16
Myleran .............................................. 12       Nitrostat ............................................. 16
Mysoline ............................................ 17        Nizatidine .......................................... 24
                                                                Nizoral................................................. 9, 34
                                 N                              Noctecc .............................................. 19
Nabumetone .................................... 21              Nolvadex............................................ 12
Nadolol ............................................... 14      Nonformulary blood
Nafarelin ............................................ 26       glucose test strips and meters ... 38
Nafitine............................................... 34      Nordette ............................................ 27
Naftin .................................................. 34    Norethindrone+
Nalfon ................................................. 21     ethinyl estradiol .............................. 27
Namenda ........................................... 20          Norethindrone+mestranol ......... 27
Naprosyn ........................................... 21         Norethindrone 0.35 mg ............... 27
Naproxen ........................................... 21         Norethindrone 5 mg ..................... 27
Naproxen, enteric coated ............ 21                        Norethindrone acetate+
Naproxen Sodium .......................... 21                   ethinyl estradiol .............................. 27
Nardil................................................... 18    Norgestimate+ethinyl estradiol 27
Nasonex ............................................. 33        Norgestrel ......................................... 27
Natacyn .............................................. 29       Norgestrel+ethinyl estradiol ...... 27
                                                               48
Norpace.............................................. 14            Pancrease .......................................... 23
Norpace-CR ...................................... 14                Pancrease MT ................................... 23
Norpramin......................................... 18               Pancrelipase ..................................... 23
Nortriptyline..................................... 18               Pancrelipase powder..................... 23
Norvasc .............................................. 15           Papain/urea ...................................... 35
Norvir .................................................. 10        Paraflex ............................................... 21
Novolin vials ..................................... 22              Parafon Forte DSC .......................... 21
Novolog mix vials ........................... 22                    Paricalcitol ......................................... 29
Novolog vials.................................... 22                Parlodel .............................................. 18
Noxafil................................................. 9          Parnate ............................................... 18
Nulytely .............................................. 24          Paromomycin ................................... 9
Nystatin .............................................. 9           Paroxetine ......................................... 18
                                                                    Pataday............................................... 31
                                  O                                 Paxil ..................................................... 18
Octreotide ......................................... 24             Pediazole ........................................... 11
Ocufen ................................................ 31          PEG-Intron......................................... 12
Ocuflox ............................................... 30          Pegasys............................................... 12
Ofloxacin sol ..................................... 30, 31          Peginterferon alfa-2a .................... 12
Olanzapine........................................ 19               Peginterferon alfa-2B .................... 12
Olopatadine...................................... 31                Penfilgrastin ..................................... 13
Olsalazine .......................................... 23            Penicillamine .................................... 36
Omacor............................................... 38            Penicillin VK ...................................... 11
Omeprazole ...................................... 24                Pentamidine ..................................... 11
Omnicef ............................................. 10            Pentasa ............................................... 23
Ondansetron .................................... 23                 Pentoxifylline ................................... 16
One Touch Profile and Basic ....... 21                              Pen VK ................................................. 11
Opium/Belladonna suppository 24                                     Pepcid ................................................. 24
Oprelvekin......................................... 13              Percocetc ........................................... 17
Oracit .................................................. 25        Periactin ............................................. 32
Orap..................................................... 19        Peridex Rinse .................................... 34
Orapred .............................................. 25           Permax................................................ 19
Ortho-Cept ....................................... 27               Permethrin ........................................ 35
Ortho-Cyclen.................................... 27                 Perphenazine ................................... 19
Ortho-Dienestrol ............................ 26                    Persantine ......................................... 16
Ortho-Est ........................................... 26            Phenazopyridine HCl .................... 24
Ortho-Novum 1/35 ........................ 27                        Phenelzine ........................................ 18
Ortho-Novum 1/50 ........................ 27                        Phenergan......................................... 19, 22, 33
Ortho-Novum 10/11...................... 27                          Phenergan DM ................................ 33
Ortho-Novum 7/7/7 ...................... 27                         Phenergan w/ Codeinec .............. 33
Ortho-Tricyclen................................ 27                  Phenobarbital .................................. 17
Orudis ................................................. 21         Phenoxybenzamine....................... 13
Ovrette ............................................... 27          Phenytek ............................................ 18
Oxaprozin .......................................... 21             Phenytoin, extended release...... 18
Oxazepam ......................................... 19               Phenytoin Suspension .................. 17
Oxcarbazepine................................. 18                   Phenytoin sustained-release ...... 17
Oxybutynin ....................................... 24               PhosLo ................................................ 25
Oxybutynin, sustained-release .. 24                                 Phospholine Iodide........................ 30
Oxycodone ....................................... 17                Phrenilinc .......................................... 17
Oxycodone + APAP ........................ 17                        Phrenilin Fortec ............................... 17
Oxycodone, sustained-release .. 17                                  Pilocar ................................................. 30
Oxycontinc........................................ 17               Pilocarpine, oral .............................. 36
                                                                    Pilocarpine gel ................................. 30
                                  P                                 Pilocarpine HCl sol ......................... 30
                                                                    Pilopine HS Gel ................................ 30
                                                               49
Pimecrolimus Cream ..................... 35                      Pregabalin ......................................... 18
Pimozide ............................................ 19         Prelone ............................................... 25
Pindolol .............................................. 14       Premarin ............................................ 26
Pioglitazone...................................... 22            Premarin vaginal ............................. 26
Pirbuterol, inhaler........................... 32                Premphase ........................................ 26
Piroxicam ........................................... 21         Prempro ............................................. 26
Plaquenil ............................................ 9, 36     Prempro Low Dose......................... 26
Plavix ................................................... 16    Prenatal vitamins ............................ 29
Plendil ................................................. 15     Prevacid ............................................. 24
Pletal ................................................... 16    Prevident 5000 Plus ....................... 28
Podophylox ...................................... 35             Prezista ............................................... 10
Poly-B+bacitracin oint .................. 29                     Prilosec ............................................... 24
Poly-B+neo+dexamethasone                                         Primaquine ....................................... 9
oint; susp ........................................... 30        Primidone.......................................... 17
Poly-B+trimethoprim sol ............. 29                         Prinivil ................................................. 13
Poly-Vi-Flor ........................................ 28         Prinzide .............................................. 13
Poly-Vi-Flor with iron ..................... 28                  Pro-Banthine .................................... 23
Polycitra ............................................. 24       Proamatine ....................................... 15
Polycitra-K ......................................... 24         Probenecid........................................ 36
Polyethylene glycol........................ 24                   Procainamide ................................... 14
Polyethylene glycol electrolyte                                  Procainamide,
solution+bisacodyl tablets ......... 24                          sustained-release............................ 14
Polysporin ......................................... 29          Procanbid .......................................... 14
Polytrim.............................................. 29        Procan SR........................................... 14
Posaconazole ................................... 9               Procarbazine .................................... 12
Potassium acid phosphate .......... 24                           Prochieve ........................................... 27
Potassium acid phosphate+                                        Prochlorperazine ............................ 19, 22
sodium acid phosphate ............... 24                         Procrit ................................................. 13
Potassium bicarbonate................. 29                        Proctocort ......................................... 35
Potassium chloride liquid ............ 29                        Proctofoam-HC................................ 35
Potassium chloride tabs ............... 29                       Profasi ................................................. 26
Potassium citrate ............................ 24                Progesterone, micronized, oral . 27
Potassium citrate combinations 24                                Progesterone, suppositories....... 27
Potassium gluconate liquid ........ 29                           Progesterone vaginal gel............. 27
Pramipexole...................................... 19             Proglycem ......................................... 22
Prandin ............................................... 22       Prograf ................................................ 37
Pravachol ........................................... 14         Prolixin................................................ 19
Pravastatin ........................................ 14          Promethazine................................... 19, 22, 33
Prazosin .............................................. 13       Promethazine+codeine................ 33
Precose ............................................... 22       Promethazine+DM......................... 33
Pred-G ................................................. 30      Prometrium ...................................... 27
Pred Forte .......................................... 31         Pronestyl ............................................ 14
Prednisolone .................................... 25             Propafenone..................................... 14
Prednisolone+sodium                                              Propanolol extended release ..... 15
sulfacetamide .................................. 30              Propantheline .................................. 23
Prednisolone acetate susp .......... 31                          Propine ............................................... 30
Prednisolone sodium                                              Propoxyphene HCl +APAP .......... 17
phosphate sol 0.125% .................. 31                       Propoxyphene napsylate+APAP 17
Prednisolone sodium                                              Propranolol ....................................... 15
phosphate sol 1% ........................... 31                  Propylthiouracil ............................... 28
Prednisolone syrup ........................ 25                   Proscar ................................................ 25
Prednisolone tablet, 5 mg ........... 25                         Prostigmine ...................................... 36
Prednisone ........................................ 25           Protopic.............................................. 35
Prednisone syrup 5mg/5ml ........ 25                             Provera ............................................... 27
                                                                50
Prozac ................................................. 18          Reyataz ............................................... 10
Psorcon............................................... 35            Rheumatrex ...................................... 36
PTU ...................................................... 28        Rhinocort AQ ................................... 33
Pulmicort ........................................... 32             Ribavirin ............................................. 10
Pulmozyme....................................... 33                  Ridaura ............................................... 36
Purinethol.......................................... 12              Rifabutin ............................................ 9
Pyrazinamide ................................... 9                   Rifadin................................................. 9
Pyridium ............................................ 24             Rifampin ............................................ 9
Pyridostigmine ................................ 36                   Rifampin +pyrazinamide+INH ... 9
Pyrimethamine................................ 9                      Rifater.................................................. 9
                                                                     Rilutek ................................................. 16
                                  Q                                  Riluzole ............................................... 16
Questran ............................................ 14             Risedronate....................................... 25
Quetiapine ........................................ 19               Risedronate with Calcium ........... 25
Quinaglute Duratab ...................... 14                         Risperdal ............................................ 19
Quinapril ............................................ 13            Risperidone....................................... 19
Quinidex ............................................ 14             Ritalin-SRc ......................................... 20
Quinidine gluconate ..................... 14                         Ritalinc ................................................ 20
Quinidine sulfate ............................ 14                    Ritalin LA............................................ 38
Quinidine sulfate,                                                   Ritonavir............................................. 10
extended-release............................ 14                      Rivastigmine Tartrate .................... 20
Quinine sulfate ................................ 9                   Rizatriptan ......................................... 20
Quinora .............................................. 14            Rizatriptan, oral
QVAR ................................................... 32          disintegrating tablets.................... 20
                                                                     Robaxin .............................................. 21
                                  R                                  Robinul ............................................... 36
                                                                     Robitussin DAC................................ 33
Raloxifene.......................................... 26              Rocaltrol ............................................. 29
Ramipril .............................................. 13           Roferon-A .......................................... 12
Raniclor .............................................. 38           Ropinirole .......................................... 19
Ranitidine .......................................... 23             Rosiglitazone.................................... 22
Rapamune......................................... 37                 Rosuvastatin ..................................... 14
Rasagiline .......................................... 19             Rowasa ............................................... 23
Razadyne ........................................... 20              Roxicodonec..................................... 17
Rebetol ............................................... 10           Rythmol.............................................. 14
Rebetron ............................................ 12
Reglan................................................. 23                                             S
Relafen................................................ 21
Relpax ................................................. 38          Salagen............................................... 36
Remeron ............................................ 18              Salmeterol Diskus ........................... 32
Remodulin......................................... 16                Salsalate ............................................. 21
Renagel .............................................. 25            Sanctura ............................................. 38
Repaglinide....................................... 22                Sandimmune ................................... 36
Repronex ........................................... 27              Sandostatin....................................... 24
Requip ................................................ 19           Santyl .................................................. 35
Rescriptor .......................................... 10             Saquinavir Mesylate ...................... 10
Reserpine+hydralazine+hctz ..... 15                                  Sargramostim .................................. 13
Restasis ............................................... 31          Scopolamine, transdermal .......... 20
Restorilc ............................................. 19           Scopolamine sol.............................. 31
Retin-A Cream.................................. 33                   Sebizon............................................... 34
Retin-A gel ........................................ 33              Sectral ................................................. 14
Retin-A Microsphere...................... 33                         Selegiline ........................................... 18
Retrovir ............................................... 10          Selenium Sulfide ............................. 35
Revlimid ............................................. 38            Sensipar ............................................. 27
                                                                     Ser-Ap-Es ........................................... 15
                                                                51
Seraxc.................................................. 19      Sulfacetamide+sulfur.................... 33
Serentil ............................................... 19      Sulfacetamide 10% oint; sol ....... 29
Serevent Diskus............................... 32                Sulfadoxine+ pyrimethamine .... 9
Seroquel............................................. 19         Sulfanilamide ................................... 35
Sertraline ........................................... 18        Sulfasalazine..................................... 11, 23
Sevelamer.......................................... 25           Sulfasalazine, enteric coated ...... 12, 23
Silvadene ........................................... 34         Sulfinpyrazone................................. 36
Silver sulfadiazine........................... 34                Sulfisoxazole suspension ............. 12
Simvastatin ....................................... 14           Sulfisoxazole tablets ...................... 11
Sinemet .............................................. 18        Sulindac ............................................. 21
Sinemet-CR ....................................... 18            Sultrin ................................................. 35
Sinequan............................................ 18          Sumatriptan (injection) ................ 20
Singulair ............................................. 32       Sumatriptan (nasal spray)............ 20
Sirolimus ............................................ 37        Sumatriptan (tablets) .................... 20
Sitagliptin phosphate ................... 22                     Sumycin ............................................. 12
Skelaxin .............................................. 21       Sunitinib ............................................ 12
Sodium citrate+citric acid solution                              Surestep ............................................. 22
(Shohl’s solution, modified) ........ 25                         Sustiva ................................................ 10
Sodium fluoride; (0.125 mg,                                      Sutent ................................................. 12
0.25 mg, 0.5) drops......................... 28                  Symmetrel ......................................... 9, 18
Sodium fluoride;                                                 Synalar ................................................ 34
chewable-dissolve tablet ............ 28                         Synarel nasal spray......................... 26
Sodium fluoride                                                  Synthroid ........................................... 28
topical Dental Cream .................... 28
Sodium fluoride                                                                                    T
topical rinse 0.5% ........................... 28               T-Stat ................................................... 33
Sodium fluoride with                                            Tacrolimus ......................................... 37
multi-vitamins ................................. 28             Tacrolimus ointment ..................... 35
Sodium fluoride with                                            Tagamet ............................................. 23
vitamins A,D,C and iron ................ 28                     Tambocor .......................................... 14
Sodium fluoride with                                            Tamoxifen .......................................... 12
vitamins ADC ................................... 28             Tapazole ............................................. 28
Sodium phosphate ........................ 24                    Tarceva ............................................... 12
Sodium polystyrene sulfonate... 29                              Tarka .................................................... 15
Solganal ............................................. 36       Tasmar ................................................ 19
Solifenacin succinate .................... 24                   Tazarotene ........................................ 33
Soma ................................................... 21     Tazorac ............................................... 33
Sonata................................................. 19      Tegretol .............................................. 17
Sorafenib ........................................... 12        Tegretol-XR ....................................... 17
Sotalol................................................. 14     Temazepam ...................................... 19
Spectazole......................................... 34          Temovate ........................................... 35
Spiriva ................................................. 32    Tenex ................................................... 14
Spironolactone ................................ 15              tenofovir disoproxil fumarate .... 10
Spironolactone+hctz .................... 15                     Tenormin ........................................... 14
Sporanox ........................................... 9          tenovir disoproxil fumarate ........ 10
Sprycel ................................................ 12     Terazol ................................................ 35
Stadol NSc ......................................... 20         Terazosin ............................................ 14
Stalevo ................................................ 19     Terbutaline, tablets ........................ 32
Stavudine .......................................... 10         Terconazole....................................... 35
Stelazine ............................................ 19       Tessalon ............................................. 33
Stimate ............................................... 28      Testosterone,
Sucralfate tablets ............................ 23              transdermal patch .......................... 25
Sufacet-R............................................ 33        Testosterone gel ............................. 25
Sulfacetamide .................................. 34             Tetracycline....................................... 12
                                                               52
Thalidomide ..................................... 37                  Trental................................................. 16
Thalomid............................................ 37               Treprostinil Sodium ....................... 16
Theophylline, sustained-release 32                                    Tretinoin cream ............................... 33
Theophylline liquid ........................ 32                       Tretinoin gel ..................................... 33
Theophylline oral sol                                                 Tretinoin microsphere .................. 33
(80 mg/15 ml) .................................. 32                   Tri-Phasil ............................................ 27
Thera-Flur .......................................... 28              Tri-Vi-Flor ........................................... 28
Thiabendazole ................................. 9                     Tri-Vi-Flor with iron ........................ 28
Thiethylperazine ............................. 22                     Triamcinolone .................................. 32
Thioguanine ..................................... 12                  Triamcinolone+nystatin ............... 34
Thioridazine...................................... 19                 Triamcinolone 0.1%
Thiothixene....................................... 19                 cream; lotion .................................... 34
Thorazine........................................... 19               Triamcinolone 0.5% cream ......... 34
Tiagabine ........................................... 17              Triamcinolone acetonide
Ticlid .................................................... 16        0.025% cream; oint ........................ 34
Ticlopidine ........................................ 16               Triamcinolone acetonide
Tikosyn ............................................... 14            0.1% oint ............................................ 34
Tilade .................................................. 32          Triamcinolone aerosol .................. 34
Timolol gel, extended release .... 30                                 Triamterene+hctz ........................... 15
Timolol sol ......................................... 30              Triethanolamine+
Timoptic ............................................. 30             chlorobutanol sol ........................... 31
Timoptic-XE ...................................... 30                 Trifluoperazine ................................ 19
Tiotropium ........................................ 32                Trifluridine solution ....................... 30
Tizanidine .......................................... 21              Trihexyphenidyl .............................. 18
Tobi ...................................................... 11        Trilafon................................................ 19
Tobradex ............................................ 30              Trileptal .............................................. 18
Tobramycin+dexamethasone                                              Trilisate ............................................... 21
oint; susp ........................................... 30             Trimethoprim ................................... 11
Tobramycin, inhalation................. 11                            Trimethoprim+
Tobramycin oint .............................. 29                     sulfamethoxazole regular/DS .... 11
Tobramycin sol ................................ 29                    Trimox ................................................. 11
Tobrex ................................................. 29           Trimpex .............................................. 11
Tofranil................................................ 18           Triple sulfa vaginal cream ............ 35
Tolcapone .......................................... 19               Trizivir ................................................. 10
Tolectin............................................... 21            Trusopt ............................................... 30
Tolmetin ............................................. 21             Truvada .............................................. 10
Tolterodine........................................ 24                Tussi-Organidin-NRc...................... 33
Topamax ............................................ 18               Tylenol+Codeinec .......................... 17
Topiramate ........................................ 18
Toprol-XL ........................................... 15                                                U
Toradol ............................................... 21            Ultramc............................................... 17
Torecan ............................................... 22            Ultrase-MT......................................... 23
Torsemide.......................................... 15                Ultra Test Strips................................ 22
Tracleer ............................................... 16           Uniphyl ............................................... 32
Tramadol............................................ 17               Urecholine......................................... 24
Trandate ............................................. 13             Urocit-K .............................................. 24
Transderm-Scop.............................. 20                       Ursodiol.............................................. 23
Tranxene
(not sustained-release) ................. 17                                                            V
Tranxenec .......................................... 19
Tranylcypromine ............................. 18                      V-Cillin K ............................................. 11
Travatan ............................................. 30             Valacyclovir ....................................... 10
Travoprost ......................................... 30               Valcyte ................................................ 10
Trazodone ......................................... 18                Valganciclovir................................... 10
                                                                 53
Valiumc............................................... 17, 19, 21    Xylocaine Viscous ........................... 35
Valproic Acid .................................... 17
Valsartan ............................................ 13                                             Y
Valsartan + hctz............................... 13                   Yodoxin .............................................. 9
Valtrex ................................................. 10
Vancocin ............................................ 11                                              Z
Vancomycin ...................................... 11
Varenicline tartrate ........................ 37                     Zafirlukast ......................................... 32
Vaseretic............................................. 13            Zalcitabine ........................................ 10
Vasotec ............................................... 13           Zaleplon ............................................. 19
Venlafaxine ....................................... 18               Zanaflex ............................................. 21
Venlafaxine, sustained-release .. 18                                 Zantac ................................................. 23
Ventavis.............................................. 16            Zarontin ............................................. 17
Ventolin .............................................. 32           Zaroxolyn........................................... 15
Vepesid............................................... 12            Zavesca............................................... 36
Verapamil .......................................... 15              Zemplar.............................................. 29
Verapamil+trandolapril ................ 15                           Zerit ..................................................... 10
Verapamil SR .................................... 15                 Zetia .................................................... 14
Verdesa............................................... 38            Ziac ...................................................... 15
Vermox ............................................... 9             Ziagen................................................. 10
Vesicare .............................................. 24           Zidovudine ....................................... 10
Vibramycin ........................................ 9, 12            Zidovudine and Lamivudine ...... 10
Vicodinc ............................................. 17            Ziprasidone....................................... 19
Videx and Videx EC......................... 10                       Zithromax.......................................... 11
Viokase ............................................... 23           Zocor ................................................... 14
Viracept .............................................. 10           Zofran ................................................. 23
Viramune ........................................... 10              Zolinza ................................................ 38
Virazole............................................... 10           Zoloft .................................................. 18
Viread .................................................. 10         Zolpidem ........................................... 19
Viroptic ............................................... 30          Zomig .................................................
Visicol .................................................. 24        Zovirax ................................................ 10
Visken.................................................. 14          Zyban .................................................. 20, 37
Vistaril ................................................. 33        Zyloprim ............................................ 36
Vitamin A, 50,000 units................. 29                          Zyprexa .............................................. 19
Vitamin K (phytonadione)                                             Zyrtec ..................................................
tablets ................................................. 29         Zyvox................................................... 11
Vivelle ................................................. 26
Voltaren.............................................. 21, 31
Voltaren-XR ....................................... 21
Vosol-HC ............................................ 31
Vospire ER.......................................... 32

                                W
Warfarin ............................................. 16
Wellbutrin SR.................................... 18
Wellcovorin ....................................... 13
Wygesicc ............................................ 17
Wytensin ............................................ 14

                                 X
Xalatan ............................................... 30
Xanaxc ................................................ 19
Xeloda................................................. 12
                                                                    54
About this Formulary                                            we will not discontinue or reduce coverage of the drug
                                                                during the 2008 coverage year except when a new, less
This document includes partial formularies for
                                                                expensive generic drug becomes available or when new
• Geisinger Gold Standard Rx
                                                                adverse information about the safety or effectiveness
    and Gold Rx 1 Medicare Prescription Drug Plans
                                                                of a drug is released. Other types of formulary changes,
• Geisinger Gold $0 Deductible Rx
                                                                such as removing a drug from our formulary, will not
    Medicare Prescription Drug Plan
                                                                affect members who are currently taking the drug. It
• Geisinger Gold Rx 2 Medicare Prescription Drug Plan
                                                                will remain available at the same cost-sharing for those
This formulary is accurate as of December 1, 2007. For
                                                                members taking it for the remainder of the coverage
complete, updated formularies, please visit our Web site
                                                                year. We feel it is important that members have
at www.thehealthplan.com, or call (800) 498-9731, seven
                                                                continued access for the remainder of the coverage
days a week from 8 a.m. to 8 p.m.
                                                                year to the formulary drugs that were available when
                                                                a member chose our plan, except for cases in which
A formulary is a list of covered drugs selected by in
                                                                a member can save additional money or improve the
consultation with a team of health care providers, which
                                                                safety of drugs.
represents the prescription therapies believed to be
a necessary part of a quality treatment program. The
                                                                If we remove drugs from our formulary, add prior
Health Plan will generally cover the drugs listed in our
                                                                authorization, quantity limits, step therapy restrictions
formulary as long as the drug is medically necessary, the
                                                                on a drug and/or move a drug to a higher cost-sharing
prescription is filled at a participating pharmacy, and
                                                                tier, we must notify affected members of the change at
other plan rules are followed.
                                                                least 60 days before the change becomes effective, or
Can the formulary change?                                       at the time the member requests a refill of the drug, at
                                                                which time the member will receive a 60-day supply of
Generally, if a member is taking a drug on our 2008
                                                                the drug. If the Food and Drug Administration deems
formulary that was covered at the beginning of the year,
                                                            1
a drug on our formulary to be unsafe or the drug’s             What are generic drugs?
manufacturer removes the drug from the market, we
                                                               Geisinger Health Plan Gold or Gold Rx covers both
will immediately remove the drug from our formulary
                                                               brand-name drugs and generic drugs. A generic drug
and provide notice to members who take the drug.
                                                               has the same active-ingredient as the brand name drug.
This formulary is current as of December 1, 2007. To get
                                                               Generic drugs usually cost less than brand name drugs
updated information about covered drugs, please visit
                                                               and are approved by the Food and Drug Administration
our Web site at www.thehealthplan.com, or call (800)
                                                               (FDA).
498-9731, 7 days a week from 8 a.m. to 8 p.m. TTY/TDD
users should call (800) 447-2833, Monday through Friday        Restrictions on coverage?
from 8 a.m. to 8 p.m.                                          Some covered drugs may have additional requirements
                                                               or limits on coverage. These requirements and limits may
There are two ways to find                                     include:
a drug within the formulary:                                   Quantity Limits: There are quantity limits on some
                                                               medications. These medications are designated in
Medical Condition
                                                               the formulary with an asterisk (*) in the quantity limit
The drugs in this formulary are grouped into categories
                                                               column. Please see page 11 of this introduction for a list of
depending on the type of medical conditions that
                                                               medications with quantity limits.
they are used to treat. For example, drugs used to
                                                               Prior Authorization: Prior authorization by the Health Plan
treat a heart condition are listed under the category
                                                               may be required for certain drugs to be covered. Medications
“Cardiovascular Agents.”
                                                               requiring prior authorization have two asterisks (**) in the
Alphabetical Listing
                                                               prior authorization column.
Index that begins on page 65 provides an alphabetical
                                                               Specialty Vendor Program: Certain drugs must be
list of all of the drugs included in this document. Both
                                                               obtained through the Health Plan’s Specialty Vendor
brand-name drugs and generic drugs are listed in the
                                                               Program. These medications are designated in the formulary
Index.
                                                               with three asterisks (***) in the specialty vendor column.
                                                           2
Please contact the Pharmacy Service Team at (800)                 If you learn that a drug is not covered, a member has
988-4861 or visit thehealthplan.com for additional                two options:
information on the program.
Drug Tiers: Members can request non-preferred brand-              A member can ask the Customer Service Team for a list
name drugs on the 3rd tier to be covered at the 2nd tier          of similar drugs that are covered by the Health Plan,
copay. This will be approved if all formulary alternatives        show the list to his or her physician and ask him or her to
on the 2nd tier have been tried and failed.                       prescribe a similar drug that is covered.

You can find out if a drug has any additional                     A member can ask the Health Plan to make an exception
requirements or limits by looking in the formulary that           and cover the drug. See below for information about
begins on page 13.                                                how to request an exception.

Members can can ask for an exception to these                     NOTE: Due to a change in Medicare, most Medicare
restrictions or limits. See the section, “How to request an       Drug Plans will no longer cover erectile dysfunction (ED)
exception to the formulary?” on for information about             drugs like Viagra, Cialis, Levitra, and Caverject starting
how to request an exception.                                      January 1, 2007. Call your Medicare Drug Plan for more
                                                                  information.
What if a drug is not on the Formulary?
If a member’s drug is not included in this formulary, the         How to request an exception to the Formulary
member should first contact the Customer Service Team             A member can ask the Health Plan to make an exception
and ask if the drug is covered. This document includes            to our coverage rules. There are several types of
only a partial list of covered drugs, so the Health Plan          exceptions that a member can ask us to make.
may cover the drug.
                                                                  A member can ask us to cover a drug even if it is not on
                                                              3
our formulary.
                                                                 A member should contact us to ask us for an initial
A member can ask us to waive coverage restrictions               coverage decision for a formulary, tiering or utilization
or limits on a drug. For example, for certain drugs, the         restriction exception. When a member is requesting a
Health Plan limits the amount of the drug that we will           formulary, tiering or utilization restriction exception
cover. If a drug has a quantity limit, a member can ask us       that member should submit a statement from his or
to waive the limit and cover more.                               her physician supporting the request. Generally, we
                                                                 must make our decision within 72 hours of getting
                                                                 the prescribing physician’s supporting statement. The
A member can ask us to provide a higher level of
                                                                 member can request an expedited (fast) exception if the
coverage for a drug. If a drug is contained in our non-
                                                                 member or the doctor believe that the member’s health
preferred band name drug (3rd) tier, a member can ask
                                                                 could be seriously harmed by waiting up to 72 hours
us to cover it at the cost-sharing amount that applies
                                                                 for a decision. If the member’s request to expedite is
to drugs in the preferred brand-name drug (2nd) tier
                                                                 granted, we must make a decision no later than 24 hours
instead. This would lower the amount the member must
                                                                 after we get the prescribing physician’s supporting
pay for the drug. Please note, if we grant a request to
                                                                 statement.
cover a drug that is not on our formulary, the member
may not ask us to provide a higher level of coverage for         What a member should do before talking to a
the drug.                                                        doctor about changing drugs or requesting an
Generally, the Health Plan will only approve a request           exception
for an exception if the alternative drugs included on
the plan’s formulary, the lower-tiered drug or additional        A new or continuing member in our plan may be taking
utilization restrictions would not be as effective in            drugs that are not on our formulary. Or, the member
treating the condition and/or would cause adverse                may be taking a drug that is on our formulary but his or
medical effects.                                                 her ability to get it is limited. For example, the drug may
                                                             4
require prior authorization from us before the member              these drugs is limited, but the member is past the first 90
can fill the prescription. A member should discuss with            days of membership in our plan, we will cover a 34-day
his or her doctor switching to an appropriate drug that            emergency supply of that drug (unless a prescription
we cover or requesting a formulary exception so that               is written for fewer days) while the member pursues a
we will cover the drug the member takes. While the                 formulary exception.
member talks to his or her doctor to determine the right
course of action, we may cover your drug in certain                Transition Process for Medicare Part D
cases during the first 90 days he or she is a member of            Enrollees:
our plan.                                                          Upon written or verbal request for transition of current
                                                                   medication therapy from a member or member’s
For each of a member’s drugs that is not on our                    authorized representative, the member’s date of
formulary or if the member’s ability to get the drugs              enrollment, coverage status, and current medication
is limited, we will cover a temporary 60-day supply                therapy will be verified by a customer service
(unless a prescription is written for fewer days) when             representative. If the member is eligible for transition
the member goes to a network pharmacy. After the first             therapy, a prior authorization for the approved drug(s)
60-day supply, we will not pay for these drugs, even if he         will then be entered into the claims processing system
or she has been a member of the plan less than 90 days.            for a period of 90 days from the date of enrollment,
                                                                   allowing for a 60-day supply of medication. This
If a member is a resident of a long-term care facility, we         represents a temporary one-time transition supply. For
will cover a temporary 34-day transition supply (unless            continuation of therapy that extends beyond the initial
a prescription is written for fewer days). We will cover           90-day period, a formulary exception must be requested
more than one refill of these drugs for the first 90 days          and approved. The member or the member’s authorized
he or she is a member of our plan. If the member needs             representative will be notified of the determination of
a drug that is not on our formulary or if the ability to get       coverage verbally and in writing within 24 hours of the
                                                               5
receipt of the request. These notifications will include        representative will be notified of the determination of
the effective dates of coverage (the date the coverage          coverage verbally and in writing within 24 hours of the
begins and the date the coverage will terminate) as well        receipt of the request. These notifications will include
as the process to follow to request a formulary exception       the effective dates of coverage (the date the coverage
for continuation of coverage after the initial approval         begins and the date the coverage will terminate) as well
has expired.                                                    as the process to follow to request a formulary exception
                                                                for continuation of coverage after the initial approval
Emergency Medication Supply Process for                         has expired. For a long term care resident who transfers
Long Term Care Residents:                                       into the facility after the first 90-days of enrollment in
Upon written or verbal request for an emergency supply          the plan will be granted a 31-day emergency supply.
of current medication therapy for a member in a Long
Term Care facility, the member’s date of enrollment,            For more information
coverage status, and current medication therapy will            If you have questions, please call the Customer Service
be verified by a customer service representative. If            Team at (800) 498-9731, 7 days a week from 8 a.m. to 8
the member is eligible, a prior authorization for the           p.m. TTY/TDD users should call (800) 447-2833, Monday
approved drug(s) will then be entered into the claims           through Friday from 8 a.m. to 8 p.m. Or visit www.
processing system for a period of 90 days from the date         thehealthplan.com.
of enrollment. The pharmacist at the long term care
facility may then process the claim using the on-line           If you have general questions about Medicare
adjudication method. This represents an emergency               prescription drug coverage, please call Medicare at 1-
supply for the long term care member. For continuation          800-MEDICARE (1-800-633-4227) 24 hours a day/7 days
of therapy that extends beyond the initial 90-day               a week. TTY/TDD users should call 1-877-486-2048. Or,
period, a formulary exception must be requested and             visit www.medicare.gov.
approved. The member or the member’s authorized
                                                            6
Geisinger Gold Formulary
The formulary that begins on page 13 provides coverage
information about some of the drugs covered by
the Health Plan. Remember: this is only a partial list
of covered drugs. Please visit our Web site at www.
thehealthplan.com for a complete listing, or call the
Customer Service Team at (800) 498-9731, 7 days a week
from 8 a.m. to 8 p.m. TTY/TDD users should call (800)
447-2833, Monday through Friday from 8 a.m. to 8 p.m.
for additional help.




                                                         7
               Geisinger Gold Standard Rx and $0 Deductible Rx Cost-Sharing Summary
Coverage Level          Standard Rx                                            $0 Deductible Rx
                        $275 yearly deductible.                                $0 deductible.

Initial Coverage        After you pay your yearly deductible, you pay 25%      You pay the following until total yearly drug costs reach $2,510*:
                        until total yearly drug costs reach $2,510.            Tier 1
                                                                               $6 copay for a one-month (34-day) supply of drugs, $18 copay for a three-month
                                                                               (90-day) supply of drugs
                                                                               Tier 2
                                                                               $40 copay for a one-month (34-day) supply of drugs, $120 copay for a three-month
                                                                               (90-day) supply of drugs
                                                                               Tier 3
                                                                               $80 copay for a one-month (34-day) supply of drugs, $240 copay for a three-month
                                                                               (90-day) supply of drugs

Coverage Gap            After your total yearly drug costs reach $2,510, you   After your total yearly drug costs reach $2,510, you pay 100% until your yearly out-of-
                        pay 100% until your yearly out-of-pocket drug costs    pocket drug costs reach $4,050.
                        reach $4,050.

Catastrophic Coverage   After your yearly out-of-pocket drug costs reach       After your yearly out-of-pocket drug costs reach $4,050, you pay the greater of:
                        $4,050, you pay the greater of:                        $2.25 copay for generic (including brand drugs treated as generic) and $5.60 copay for
                        $2.25 copay for generic (including brand drugs         all other drugs, or 5% coinsurance.
                        treated as generic) and $5.60 copay for all other
                        drugs, or 5% coinsurance.                              *At an in-network retail pharmacy. Mail order and long term care pharmacy costs may
                                                                               be different. Please consult the Summary of benefits for details.

                                                                               Tier 1 = generic; Tier 2 = preferred brand;
                                                                               Tier 3 = non-preferred brand

                                                                                 8
                                Geisinger Gold Rx 1 and Rx 2 Cost-Sharing Summary
Coverage Level          Gold Rx 1                                     Gold Rx 2
                        $275 yearly deductible.                       $175 deductible on all drugs except generic drugs.
                                                                      You pay $3 copay for generic drugs until you reach the deductible.

Initial Coverage        After you pay your yearly deductible, you     After you pay your yearly deductible, you pay the following until total yearly drug costs reach
                        pay 25% until total yearly drug costs reach   $2,510*:
                        $2,510.                                       Tier 1
                                                                      $3 copay for a one-month (34-day) supply of drugs, $9 copay for a three-month (90-day)
                                                                      supply of drugs
                                                                      Tier 2
                                                                      $40 copay for a one-month (34-day) supply of drugs, $120 copay for a three-month (90-day)
                                                                      supply of drugs
                                                                      Tier 3
                                                                      $94 copay for a one-month (34-day) supply of drugs, $282 copay for a three-month (90-day)
                                                                      supply of drugs

Coverage Gap            After your total yearly drug costs reach      After your total yearly drug costs reach $2,510, you pay 100% until your yearly out-of-pocket
                        $2,510, you pay 100% until your yearly out-   drug costs reach $4,050.
                        of-pocket drug costs reach $4,050.

Catastrophic Coverage   After your yearly out-of-pocket drug costs    After your yearly out-of-pocket drug costs reach $4,050, you pay the greater of:
                        reach $4,050, you pay the greater of:         $2.25 copay for generic (including brand drugs treated as generic) and $ 5.60 copay for all
                        $ 2.25 copay for generic (including brand     other drugs, or 5% coinsurance.
                        drugs treated as generic) and $ 5.60 copay
                        for all other drugs, or 5% coinsurance.       *At an in-network retail pharmacy. Mail order and long term care pharmacy costs may be dif-
                                                                      ferent. Please consult the Summary of benefits for details.

                                                                      Tier 1 = generic; Tier 2 = preferred brand;
                                                                      Tier 3 = non-preferred brand
                                                                                 9
How to Identify Geisinger Gold and Gold Rx Members
All members are issued identification cards specific to their plan and benefits
with the name of the plan in the upper right-hand corner.
If members have prescription drug coverage, they will also receive a
prescription drug card similar to the one pictured here. For 2008, the pre-
scription drug card will include a letter in the lower right-hand corner which
identifies the formulary that is applicable for that member’s prescription
drug plan. You may see letters A through E:
Formulary A is for members with the Standard or Rx 1 drug coverage
options
Formulary B is for members with the $0 Deductible drug coverage
option
Formulary C is for members with the Gold Rx 2 stand-alone drug
coverage option
Formulary D is for employer group members with a flat copay drug
coverage plan
Formulary E is for employer group members with a triple tier drug
coverage plan

This formulary booklet includes information on Formularies A, B                  Sample ID cards subject to change pending
and C. If you see a member with a “D” or “E” on their ID card, please            CMS approval
consult our Web site at www.thehealthplan.com, or call the Health
Plan’s Pharmacy Department at (800) 988-4861 for information on
medications covered under these enhanced plans.
                                                              10
Standard Rx and Rx 1 Quantity Limits                                       $0 Deductible Rx and Rx 2 Quantity Limits
Brand        Generic                    Limit                              Brand        Generic                    Limit
Aranesp      darbepoetin alfa           1 copay per 14 day supply          Aranesp      darbepoetin alfa           1 copay per 14 day supply
Epogen       epoetin alfa               1 copay per 14 day supply          Epogen       epoetin alfa               1 copay per 14 day supply
Neulasta     pegfilgrastim              1 copay per 14 day supply          Lovenox      enoxaparin sodium          1 copay per 14 day supply
Neupogen     filgrastim                 1 copay per 14 day supply          Neulasta     pegfilgrastim              1 copay per 14 day supply
Procrit      epoetin alfa               1 copay per 14 day supply          Neupogen     filgrastim                 1 copay per 14 day supply
Enbrel       etanercept                 1 copay per 14 day supply          Procrit      epoetin alfa               1 copay per 14 day supply
Humira       adalimumab                 1 copay per injection              Enbrel       etanercept                 1 copay per 14-day supply
Lovenox      enoxaparin sodium          14 day supply                      Humira       adalimumab                 1 copay per injection
Ambien       zolpidem tartrate          15 tablets for 15 days             Lovenox      enoxaparin sodium          15 day supply
                                        per one copay                      Ambien       zolpidem tartrate          15 tablets per 15 days
Sonata       zaleplon                   15 capsules per 15 days                                                    for one copay
                                        per one copay                      Sonata       zaleplon                   15 tablets per 15 days
Axert        almotriptan malate         6 tablets per copay                                                        for one copay
Imitrex      sumatriptan succinate      6 tablets per copay                Axert        almotriptan malate         6 tablets per copay
Maxalt       rizatriptan                6 tablets per copay                Imitrex      sumatriptan succinate      6 tablets per copay
Maxalt-MLT   rizatriptan benzoate       6 tablets per copay                Maxalt-MLT rizatriptan benzoate         6 tablets per copay


Additional Rx 2 Covered Drugs (Drugs indicated as Formulary B are also covered by Gold Rx 2)
Brand            Generic                             Tier
Actonel          risedronate sodium                  3
Campral          acamprosate calcium                 3
Celebrex         celecoxib                           3 (Requires prior authorization)
Detrol la        tolterodine tartrate                3
Lescol xl        fluvastatin sodium                  3
Lipitor          atorvastatin calcium                3
Naltrexone hcl naltrexone hydrochloride              1
Nexium           esomeprazole magnesium              3
Protonix         pantoprazole sodium sesquihydrate   3
Wellbutrin       bupropion hcl                       1



                                                                      11
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                        Generic                                                Ti         Qu       Pr        Sp
          Analgesics
B         AVINZA                                           morphine sulfate                                         3
AB        CODEINE PHOSPHATE                                codeine phosphate                                        1
AB        DARVOCET                                         acetaminophen and propoxyphene
                                                           hydrochloride                                            1
AB        DEMEROL                                          meperidine hydrochloride                                 1
AB        DILAUDID                                         hydromorphone hydrochloride                              1
AB        DOLOPHINE                                        methadone hydrochloride                                  1
AB        DURAGESIC                                        fentanyl                                                 1
AB        FELDENE                                          piroxicam                                                1
AB        FENTANYL CITRATE ORAL TRA                        fentanyl citrate                                         1
AB        LEVO-DROMORAN                                    levorphanol tartrate                                     1
AB        MS CONTIN                                        morphine sulfate                                         1
AB        MSIR                                             morphine sulfate                                         1
AB        OXYCONTIN                                        oxycodone hydrochloride                                  1
AB        PERCOCET                                         acetaminophen and oxycodone
                                                           hydrochloride                                            1
AB        ROXICODONE                                       oxycodone hydrochloride                                  1
AB        TORADOL                                          ketorolac tromethamine                                   1
AB        TYLENOL #2                                       acetaminophen and codeine phosphate                      1
AB        TYLENOL #3                                       acetaminophen and codeine phosphate                      1
AB        TYLENOL #4                                       acetaminophen and codeine phosphate                      1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  12
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        TYLENOL WITH CODEINE                             acetaminophen and codeine phosphate                      1
AB        ULTRACET                                         acetaminophen and tramadol hcl                           1
AB        ULTRAM                                           tramadol hcl                                             1
AB        VICODIN                                          acetaminophen and hydrocodone bitartrate                 1
          Anesthetics
AB        LIDOCAINE/PRILOCAINE                             lidocaine and prilocaine                                 1
A         LIDODERM                                         lidocaine                                                2                    **
B         LIDODERM                                         lidocaine                                                3                    **
AB        XYLOCAINE                                        lidocaine hydrochloride                                  1
          Antibacterials
AB        AMOXIL                                           amoxicillin                                              1
AB        ANCEF                                            cefazolin sodium                                         1
AB        AUGMENTIN                                        amoxicillin and potassium clavulanate                    1
AB        AVELOX                                           moxifloxacin hydrochloride                               2
B         BACITRACIN                                       bacitracin                                               2
AB        BACTOCIL                                         oxacillin sodium                                         1
AB        BACTRIM                                          sulfamethoxazole and trimethoprim                        1
AB        BACTROBAN                                        bacitracin                                               1
AB        BIAXIN                                           clarithromycin                                           1
AB        CEFOXITIN                                        cefoxitin sodium                                         1
AB        CEFTIN                                           cefuroxime axetil                                        1
AB        CEFZIL                                           cefprozil                                                1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  13
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        CIPRO                                            ciprofloxacin                                            1
AB        CLAFORAN                                         cefotaxime sodium                                        1
AB        CLEOCIN                                          clindamycin hydrochloride                                1
B         CLINDESSE                                        clindamycin phosphate                                    2
AB        DOXYCYCLINE HYCLATE                              doxycycline hyclate                                      1
AB        DURICEF                                          cefadroxil monohydrate                                   1
AB        DYNAPEN                                          dicloxacillin sodium                                     1
AB        EES                                              erythromycin ethylsuccinate                              1
AB        ERYTAB                                           erythromycin                                             1
AB        ERYTHROCIN                                       erythromycin lactobionate                                1
AB        GARAMYCIN                                        gentamicin sulfate                                       1
AB        GEOCILLIN                                        carbenicillin indanyl sodium                             2
AB        KANTREX                                          kanamycin sulfate                                        1
AB        KEFLEX                                           cephalexin                                               1
A         KETEK                                            telithromycin                                            2                    **
B         KETEK                                            telithromycin                                            3                    **
AB        LEVAQUIN                                         levofloxacin hemihydrate                                 2
A         LINCOCIN                                         lincomycin hydrochloride                                 2
B         LINCOCIN                                         lincomycin hydrochloride                                 3
AB        MACROBID                                         nitrofurantoin macrocrystalline                          1
AB        MACRODANTIN                                      nitrofurantoin macrocrystalline                          1
AB        MAXIPIME                                         cefepime hydrochloride                                   2
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  14
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        MEFOXIN                                          ceftazidime                                              1
AB        MERREM                                           meropenem                                                2
AB        MINOCYCLINE HCL                                  minocycline hydrochloride                                1
AB        MUPIROCIN                                        mupirocin                                                1
AB        MYCIFRADIN                                       neomycin sulfate                                         1
AB        NAFCILLIN SODIUM                                 nafcillin sodium                                         1
AB        OXACILLIN SODIUM                                 oxacillin sodium                                         1
AB        PEN VK                                           penicillin v potassium                                   1
AB        PENICILLIN G POTASSIUM IN                        dextrose (anhydrous)
                                                           and penicillin g potassium                               1
AB        PENTIDS                                          dextrose (anhydrous)
                                                           and penicillin g potassium                               1
AB        PIPRACIL                                         piperacillin sodium                                      1
AB        PRIMAXIN I.M.                                    cilastatin sodium and imipenem                           2
AB        PRIMAXIN IV                                      cilastatin sodium and imipenem                           2
AB        PRINCIPEN                                        ampicillin                                               1
AB        ROCEPHIN                                         ceftriaxone sodium                                       1
AB        SSD                                              silver sulfadiazine                                      1
AB        STREPTOMYCIN SULFATE                             streptomycin sulfate                                     1
AB        SULFADIAZINE                                     sulfadiazine                                             1
AB        SUMYCIN                                          tetracycline hydrochloride                               1
AB        TIMENTIN                                         potassium clavulanate
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  15
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
                                                           and ticarcillin disodium                                 2
AB        TOBRAMYCIN SULFATE                               tobramycin sulfate                                       1
AB        TOBREX                                           tobramycin sulfate                                       1
AB        TRIMPEX                                          trimethoprim                                             1
A         TYGACIL                                          tigecycline                                              2
B         TYGACIL                                          tigecycline                                              3
AB        UNASYN                                           ampicillin sodium and sulbactam sodium                   1
B         UNIPEN                                           nafcillin sodium                                         1
B         VANCOCIN HCL (ORAL)                              vancomycin hydrochloride                                 2
AB        VANCOCIN IV                                      vancomycin hydrochloride                                 1
AB        ZITHROMAX                                        azithromycin                                             1
A         ZYVOX                                            linezolid                                                2                    **
B         ZYVOX                                            linezolid                                                3                    **
          Anticonvulsants
B         CARBATROL                                        carbamazepine                                            2
A         CELONTIN                                         methsuximide                                             2
B         CELONTIN                                         methsuximide                                             3
AB        DEPAKENE                                         valproate sodium                                         1
AB        DILANTIN                                         phenytoin sodium                                         1
AB        DILANTIN INFATABS                                phenytoin                                                2
AB        FELBATOL                                         felbamate                                                2
AB        GABITRIL                                         tiagabine hydrochloride                                  2
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  16
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        KEPPRA                                           levetiracetam                                            2
AB        LAMICTAL                                         lamotrigine                                              1
AB        LAMICTAL CHEWABLE                                lamotrigine                                              2
AB        LYRICA                                           pregabalin                                               2                    **
AB        MYSOLINE                                         primidone                                                1
AB        NEURONTIN                                        gabapentin                                               1
AB        PEGANONE                                         ethotoin                                                 2
B         PHENYTEK                                         phenytoin sodium                                         3
B         TEGRETOL-XR                                      carbamazepine                                            2
AB        TOPAMAX SPRINKLE                                 topiramate                                               2
AB        TRILEPTAL                                        oxcarbazepine                                            2
AB        ZARONTIN                                         ethosuximide                                             1
AB        ZONEGRAN                                         zonisamide                                               1
          Antidementia Agents
AB        ARICEPT                                          donepezil hydrochloride                                  2
AB        ERGOLOID MESYLATES                               ergot alkaloids, hydrogenated (mesylate)                 1
AB        EXELON                                           rivastigmine tartrate                                    2
AB        NAMENDA                                          memantine hydrochloride                                  2
A         RAZADYNE                                         galantamine hydrobromide                                 2
B         RAZADYNE                                         galantamine hydrobromide                                 3
A         RAZADYNE ER                                      galantamine hydrobromide                                 2
B         RAZADYNE ER                                      galantamine hydrobromide                                 3
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  17
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
          Antidepressants
AB        ANAFRANIL                                        clomipramine hcl                                         1
AB        ASENDIN                                          amoxapine                                                1
AB        CELEXA                                           citalopram hydrobromide                                  1
A         CYMBALTA                                         duloxetine hydrochloride                                 2                    **
B         CYMBALTA                                         duloxetine hydrochloride                                 3                    **
AB        DESYREL                                          trazodone hydrochloride                                  1
AB        EFFEXOR                                          venlafaxine hcl                                          1
AB        ELAVIL                                           amitriptyline hydrochloride                              1
A         EMSAM                                            selegiline                                               2                    **
B         EMSAM                                            selegiline                                               3
AB        IMIPRAMINE PAMOATE                               imipramine pamoate                                       1
B         LEXAPRO                                          escitalopram oxalate                                     3
AB        LUDIOMIL                                         maprotiline hydrochloride                                1
AB        LUVOX                                            fluvoxamine maleate                                      1
AB        NARDIL                                           phenelzine sulfate                                       2
AB        NEFAZODONE HCL                                   nefazodone hydrochloride                                 1
AB        NORPRAMIN                                        desipramine hydrochloride                                1
AB        PAMELOR                                          nortriptyline hydrochloride                              1
AB        PARNATE                                          tranylcypromine sulfate                                  1
AB        PAXIL                                            paroxetine hydrochloride                                 1
AB        PROZAC                                           fluoxetine hcl                                           1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  18
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        REMERON                                          mirtazapine                                              1
AB        SERZONE                                          nefazodone hydrochloride                                 1
AB        SURMONTIL                                        trimipramine maleate                                     1
AB        TOFRANIL                                         imipramine hydrochloride                                 1
AB        TRIMIPRAMINE MALEATE                             trimipramine maleate                                     1
AB        VIVACTIL                                         protriptyline hydrochloride                              2
AB        ZOLOFT                                           sertraline hydrochloride                                 1
          Antidotes, Deterrents,
          and Toxicologic Agents
AB        ANTABUSE                                         disulfiram                                               2
A         CAMPRAL                                          acamprosate calcium                                      2
A         CHANTIX                                          varenicline tartrate                                     2                    **
B         CHANTIX                                          varenicline tartrate                                     3                    **
B         EXJADE                                           deferasirox                                              3
AB        KAYEXALATE                                       sodium polystyrene sulfonate                             1
AB        NALTREXONE HCL                                   naltrexone hydrochloride                                 1
AB        NARCAN                                           naloxone hydrochloride                                   1
A         SUBOXONE                                         buprenorphine hydrochloride
                                                           and naloxone hydrochloride dihydrate                     2                    **
B         SUBOXONE                                         buprenorphine hydrochloride
                                                           and naloxone hydrochloride dihydrate                     3                    **
AB        WELLBUTRIN                                       bupropion hcl                                            1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  19
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
          Antiemetics
AB        ANTIVERT                                         meclizine hydrochloride                                  1
AB        ATARAX                                           hydroxyzine pamoate                                      1
AB        COMPAZINE                                        prochlorperazine                                         1
AB        EMEND                                            aprepitant                                               2                    **
B         KYTRIL                                           granisetron hcl                                          3
AB        PHENERGAN                                        promethazine hydrochloride                               1
AB        REGLAN                                           metoclopramide hydrochloride                             1
AB        TIGAN                                            trimethobenzamide hydrochloride                          1
AB        VISTARIL                                         hydroxyzine pamoate                                      1
AB        ZOFRAN                                           ondansetron hcl                                          1
AB        ZOFRAN ODT                                       ondansetron                                              1
          Antifungals
AB        DIFLUCAN                                         fluconazole                                              1
AB        DIFLUCAN IV                                      fluconazole and sodium chloride                          1
AB        ECONAZOLE NITRATE                                econazole nitrate                                        1
A         ERAXIS                                           anidulafungin                                            2
B         ERAXIS                                           anidulafungin                                            3
AB        GRIFULVIN V                                      griseofulvin                                             2
AB        GRIS-PEG                                         griseofulvin ultramicrosize                              2
A         LAMISIL                                          terbinafine hydrochloride                                2                    **
B         LAMISIL                                          terbinafine hydrochloride                                3                    **
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  20
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        MYCELEX                                          clotrimazole                                             1
AB        NAFTIN                                           naftifine hydrochloride                                  2
AB        NIZORAL                                          ketoconazole                                             1
AB        NYSTATIN                                         nystatin                                                 2
A         PENLAC NAIL LACQUER                              ciclopirox                                               2                    **
B         PENLAC NAIL LACQUER                              ciclopirox                                               3                    **
AB        SPECTAZOLE                                       econazole nitrate                                        1
AB        SPORANOX                                         itraconazole                                             1                    **
          Antigout Agents
AB        BENEMID                                          probenecid                                               1
AB        COLCHICINE                                       colchicine                                               1
AB        ZYLOPRIM                                         allopurinol                                              1
          Anti-inflammatory Agents
AB        ANAPROX                                          naproxen sodium                                          1
AB        ANSAID                                           flurbiprofen                                             1
AB        CATAFLAM                                         diclofenac potassium                                     1
AB        CLINORIL                                         sulindac                                                 1
AB        DAYPRO                                           oxaprozin                                                1
AB        DOLOBID                                          diflunisal                                               1
AB        INDOCIN                                          indomethacin                                             1
AB        LODINE                                           etodolac                                                 1
AB        LODINE XL                                        etodolac                                                 1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  21
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        MOBIC                                            meloxicam                                                1
AB        MOTRIN                                           ibuprofen                                                1
AB        NALFON                                           fenoprofen calcium                                       1
AB        NAPROXSYN                                        naproxen                                                 1
AB        ORUDIS                                           ketoprofen                                               1
AB        RELAFEN                                          nabumetone                                               1
AB        VOLTAREN                                         diclofenac potassium                                     1
          Antimigraine Agents
AB        AXERT                                            almotriptan malate                                       2         *
AB        CAFERGOT                                         caffeine and ergotamine tartrate                         1
AB        IMITREX                                          sumatriptan succinate                                    2         *
AB        INDERAL                                          propranolol hydrochloride                                1
AB        MAXALT                                           rizatriptan                                              2         *
B         MAXALT-MLT                                       rizatriptan benzoate                                     2         *
AB        TOPAMAX                                          topiramate                                               2

          Antimyasthenic Agents
AB        GUANIDINE HCL                                    guanidine hydrochloride                                  1
AB        MESTINON                                         pyridostigmine bromide                                   1
          Antimycobacterials
B         DAPSONE                                          dapsone                                                  2
AB        ISONIAZID                                        isoniazid                                                1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  22
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                        Generic                                                Ti         Qu       Pr        Sp
AB        MYAMBUTOL                                        ethambutol hydrochloride                                 1
B         MYCOBUTIN                                        rifabutin                                                2
AB        PYRAZINAMIDE                                     pyrazinamide                                             1
AB        RIFADIN                                          rifampin                                                 1
B         RIFAMPIN                                         rifampin                                                 2
          Antineoplastics
AB        ARIMIDEX                                         anastrozole                                              2
AB        AROMASIN                                         exemestane                                               2
AB        CEENU                                            lomustine                                                2
AB        EMCYT                                            estramustine phosphate sodium                            2
A         FARESTON                                         toremifene citrate                                       2
B         FARESTON                                         toremifene citrate                                       3
AB        FEMARA                                           letrozole                                                2
A         FLUTAMIDE                                        flutamide                                                2
B         FLUTAMIDE                                        flutamide                                                3
AB        GLEEVEC                                          imatinib mesylate                                        2
AB        HEXALEN                                          altretamine                                              2
AB        HYDREA                                           hydroxyurea                                              1
AB        LEUKERAN                                         chlorambucil                                             2
AB        MATULANE                                         procarbazine hydrochloride                               2
AB        MEGACE                                           megestrol acetate                                        1
AB        MESNEX                                           mesna                                                    2
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  23
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        MITOXANTRONE HCL                                 mitoxantrone hydrochloride                               1
A         NEXAVAR                                          sorafenib tosylate                                       2                    **            ***
B         NEXAVAR                                          sorafenib tosylate                                       3                    **            ***
AB        NILANDRON                                        nilutamide                                               2
AB        NOLVADEX                                         tamoxifen citrate                                        1
AB        NOVANTRONE                                       mitoxantrone hydrochloride                               1
AB        PANRETIN                                         alitretinoin                                             2
AB        PURINETHOL                                       mercaptopurine                                           1
A         REVLIMID                                         lenalidomide                                             2                    **            ***
B         REVLIMID                                         lenalidomide                                             3                    **            ***
AB        RITUXAN                                          rituximab                                                2
AB        SOLTAMOX                                         tamoxifen citrate                                        2
A         SPRYCEL                                          dasatinib                                                2                    **
B         SPRYCEL                                          dasatinib                                                3                    **
A         SUTENT                                           sunitinib malate                                         2                    **
B         SUTENT                                           sunitinib malate                                         3                    **
AB        TABLOID                                          thioguanine                                              2
A         TARCEVA                                          erlotinib                                                2                    **
B         TARCEVA                                          erlotinib                                                3                    **
A         TARGRETIN                                        bexarotene                                               2
B         TARGRETIN                                        bexarotene                                               3
AB        TESLAC                                           testolactone                                             2
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                    24
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        THALOMID                                         thalidomide                                              2
A         VESANOID                                         tretinoin                                                2
B         VESANOID                                         tretinoin                                                3
AB        ZOLINZA                                          vorinostat                                               2
          Antiparasitics
AB        ALBENZA                                          albendazole                                              2
AB        ARALEN                                           chloroquine phosphate                                    1
AB        DARAPRIM                                         pyrimethamine                                            2
AB        ELIMITE                                          permethrin                                               1
AB        LARIAM                                           mefloquine hcl                                           1
AB        LINDANE                                          lindane                                                  2
AB        MEPRON                                           atovaquone                                               2
AB        NEBUPENT                                         pentamidine isethionate                                  1
AB        PERMETHRIN                                       permethrin                                               1
AB        PLAQUENIL                                        hydroxychloroquine sulfate                               1
AB        PRIMAQUINE PHOSPHATE                             primaquine phosphate                                     1
AB        VERMOX                                           mebendazole                                              1
          Antiparkinson Agents
A         APOKYN                                           apomorphine hydrochloride                                2                                  ***
B         APOKYN                                           apomorphine hydrochloride                                3                                  ***
AB        ARTANE                                           trihexyphenidyl hydrochloride                            1
AB        AZILECT                                          rasagiline mesylate                                      2
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                    25
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        COGENTIN                                         benztropine mesylate                                     1
AB        COMTAN                                           entacapone                                               2
AB        DIPHENHYDRAMINE HCL                              diphenhydramine hydrochloride                            1
AB        ELDEPRYL                                         selegiline hcl                                           1
AB        REQUIP                                           ropinirole hydrochloride                                 2
AB        SINEMET                                          carbidopa anhydrous and levodopa                         1
AB        SINEMET SR                                       carbidopa anhydrous and levodopa                         1
AB        TRIHEXYPHENIDYL HCL                              trihexyphenidyl hydrochloride                            1
          Antipsychotics
AB        ABILIFY                                          aripiprazole                                             2
B         ABILIFY DISCMELT                                 aripiprazole                                             2
AB        CLOZARIL                                         clozapine                                                1
AB        COMPAZINE                                        prochlorperazine edisylate                               1
AB        FAZACLO                                          clozapine                                                2
A         GEODON                                           ziprasidone mesylate                                     2                    **
B         GEODON                                           ziprasidone mesylate                                     3                    **
AB        HALDOL                                           haloperidol                                              1
A         INVEGA                                           paliperidone                                             2                    **
B         INVEGA                                           paliperidone                                             3                    **
AB        LOXITANE                                         loxapine succinate                                       1
AB        MARPLAN                                          isocarboxazid                                            1
AB        MELLARIL                                         thioridazine hydrochloride                               1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  26
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        MOBAN                                            molindone hydrochloride                                  2
AB        NAVANE                                           thiothixene                                              1
AB        ORAP                                             pimozide                                                 2
AB        PERPHENAZINE                                     perphenazine                                             1
AB        PROLIXIN                                         fluphenazine decanoate                                   1
AB        PROLIXIN                                         fluphenazine hydrochloride                               1
AB        PROLIXIN IM                                      fluphenazine decanoate                                   1
AB        RISPERDAL                                        risperidone                                              2
AB        RISPERDAL CONSTA                                 risperidone                                              2
B         RISPERDAL M-TAB                                  risperidone                                              2
AB        SEROQUEL                                         quetiapine fumarate                                      2
AB        STELAZINE                                        trifluoperazine hydrochloride                            1
AB        THIORIDAZINE HCL                                 thioridazine hydrochloride                               1
AB        THIOTHIXENE                                      thiothixene                                              1
AB        THORAZINE                                        chlorpromazine hydrochloride                             1
AB        TRIFLUOPERAZINE HCL                              trifluoperazine hydrochloride                            1
AB        TRILAFON                                         perphenazine                                             1
AB        ZYPREXA                                          olanzapine                                               2
B         ZYPREXA ZYDIS                                    olanzapine                                               2
          Antispasticity Agents
AB        BACLOFEN                                         baclofen                                                 1

A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  27
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
          Antivirals
AB        AGENERASE                                        amprenavir                                               2
AB        APTIVUS                                          tipranavir                                               2
AB        ATRIPLA                                          efavirenz and emtricitabine
                                                           and tenofovir disoproxil fumarate                        2
AB        COMBIVIR                                         lamivudine and zidovudine                                2
AB        CRIXIVAN                                         indinavir sulfate                                        2
AB        CYTOVENE                                         ganciclovir                                              1
AB        EMTRIVA                                          emtricitabine                                            2
AB        EPIVIR                                           lamivudine                                               2
AB        EPZICOM                                          abacavir sulfate and lamivudine                          2
AB        FLUMADINE                                        rimantadine hydrochloride                                1
AB        FOSCARNET SODIUM                                 foscarnet sodium                                         1
AB        FUZEON                                           enfuvirtide                                              2                                  ***
AB        HEPSERA                                          adefovir dipivoxil                                       2
AB        INVIRASE                                         saquinavir mesylate                                      2
AB        KALETRA                                          lopinavir and ritonavir                                  2
AB        LEXIVA                                           fosamprenavir calcium                                    2
AB        NORVIR                                           ritonavir                                                2
AB        PREZISTA                                         darunavir                                                2
AB        REBETOL                                          ribavirin                                                1
AB        RELENZA DISKHALER                                zanamivir                                                2
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                    28
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        RESCRIPTOR                                       delavirdine mesylate                                     2
AB        RETROVIR                                         zidovudine                                               2
AB        RETROVIR IV INFUSION                             zidovudine                                               2
AB        REYATAZ                                          atazanavir sulfate                                       2
B         RIBAVIRIN                                        ribavirin                                                2
AB        RIMANTADINE HCL                                  rimantadine hydrochloride                                1
AB        SUSTIVA                                          efavirenz                                                2
AB        SYMMETREL                                        amantadine hydrochloride                                 1
AB        TRIZIVIR                                         abacavir sulfate and lamivudine
                                                           and zidovudine                                           2
AB        TRUVADA                                          emtricitabine and tenofovir
                                                           disoproxil fumarate                                      2
AB        VALCYTE                                          valganciclovir hydrochloride                             2
AB        VALTREX                                          valacyclovir hcl                                         2
AB        VIDEX                                            didanosine                                               1
AB        VIRACEPT                                         nelfinavir mesylate                                      2
AB        VIRAMUNE                                         nevirapine                                               2
AB        VIREAD                                           tenofovir disoproxil fumarate                            2
AB        VISTIDE                                          cidofovir dihydrate                                      2
AB        ZERIT                                            stavudine                                                2
AB        ZIAGEN                                           abacavir sulfate                                         2
AB        ZOVIRAX                                          acyclovir                                                1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  29
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
          Anxiolytics
AB        BUSPAR                                           buspirone hydrochloride                                  1
AB        EQUANIL                                          meprobamate                                              1
AB        PAXIL                                            paroxetine hydrochloride                                 1
AB        ZOLOFT                                           sertraline hydrochloride                                 1
          Bipolar Agents
AB        ABILIFY                                          aripiprazole                                             2
AB        ABILIFY DISCMELT                                 aripiprazole                                             2
AB        DEPAKENE                                         valproate sodium                                         1
AB        DEPAKOTE                                         divalproex sodium                                        2
AB        DEPAKOTE                                         valproate sodium                                         1
AB        DEPAKOTE ER                                      divalproex sodium                                        2
AB        DEPAKOTE SPRINKLES                               divalproex sodium                                        2
AB        ESKALITH                                         lithium carbonate                                        1
AB        ESKALITH                                         lithium citrate                                          1
AB        ESKALITH CR                                      lithium carbonate                                        1
AB        ESKALITH ER                                      lithium carbonate                                        1
AB        LITHIUM CITRATE                                  lithium citrate                                          1
AB        RISPERDAL                                        risperidone                                              2
AB        SEROQUEL                                         quetiapine fumarate                                      2
AB        TEGRETOL                                         carbamazepine                                            1
AB        ZYPREXA                                          olanzapine                                               2
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  30
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
          Blood Glucose Regulators
AB        ACTOS                                            pioglitazone hydrochloride                               2
AB        ALCOHOL SWABS                                    isopropyl alcohol                                        2
AB        AMARYL                                           glimepiride                                              1
AB        AVANDIA                                          rosiglitazone maleate                                    2
AB        BYETTA                                           exenatide                                                2                    **
AB        DIABETA                                          glyburide                                                1
AB        DIABETIC SUPPLIES, MISC                          needles, insulin disposable                              2
AB        DIABETIC SUPPLIES, MISC                          gauze pads & dressings - pads 2” x 2”                    2
AB        DIABINESE                                        chlorpropamide                                           1
AB        GLIPIZIDE XL                                     glipizide                                                1
AB        GLUCAGON EMERGENCY KIT                           glucagon rdna (human recombinant)                        2
AB        GLUCOPHAGE                                       metformin hydrochloride                                  1
AB        GLUCOTROL                                        glipizide                                                1
AB        GLUCOTROL XL                                     glipizide                                                1
B         GLYSET                                           miglitol                                                 3
AB        JANUVIA                                          sitagliptin phosphate                                    2                    **
AB        LANTUS                                           insulin glargine                                         2
AB        METAGLIP                                         glipizide and metformin hydrochloride                    1
AB        MICRONASE                                        glyburide                                                1
AB        NOVOLIN 70/30                                    insulin human (regular)
                                                           and insulin human, isophane (nph)                        2
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  31
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        NOVOLIN N                                        insulin human, isophane (nph)                            2
AB        NOVOLIN R                                        insulin human (regular)                                  2
AB        NOVOLIN R U-100                                  insulin human (regular)                                  2
AB        NOVOLOG                                          insulin aspart (human analog)                            2
AB        NOVOLOG MIX 70/30                                insulin aspart (human analog)
                                                           and insulin aspart protamine                             2
AB        ORINASE                                          tolbutamide                                              1
AB        PRANDIN                                          repaglinide                                              2
AB        PRECOSE                                          acarbose                                                 2
AB        PROGLYCEM                                        diazoxide                                                2
AB        SYMLIN                                           pramlintide acetate                                      2                    **
AB        TOLAZAMIDE                                       tolazamide                                               1
AB        TOLBUTAMIDE                                      tolbutamide                                              1
AB        TOLINASE                                         tolazamide                                               1
          Blood Products/ Modifiers/
          Volume Expanders
AB        AGGRENOX                                         aspirin and dipyridamole                                 2
A         ARANESP                                          darbepoetin alfa                                         2         *          **
B         ARANESP                                          darbepoetin alfa                                         3         *          **
A         ARIXTRA                                          fondaparinux sodium                                      2
B         ARIXTRA                                          fondaparinux sodium                                      3
AB        COUMADIN                                         warfarin sodium                                          1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  32
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        CYKLOKAPRON                                      tranexamic acid                                          2
AB        DIPYRIDAMOLE                                     dipyridamole                                             1
A         EPOGEN                                           epoetin alfa                                             2         *          **
B         EPOGEN                                           epoetin alfa                                             3         *          **
A         EXJADE                                           deferasirox                                              2
AB        LOVENOX                                          enoxaparin sodium                                        2         *
A         NEULASTA                                         pegfilgrastim                                            2         *
B         NEULASTA                                         pegfilgrastim                                            3         *
A         NEUPOGEN                                         filgrastim                                               2         *
B         NEUPOGEN                                         filgrastim                                               3         *
AB        PERSANTINE                                       dipyridamole                                             1
AB        PLAVIX                                           clopidogrel bisulfate                                    2
AB        PLETAL                                           cilostazol                                               1
AB        PROCRIT                                          epoetin alfa                                             2         *          **
AB        TICLID                                           ticlopidine hydrochloride                                1
          Cardiovascular Agents
AB        ACCUPRIL                                         quinapril hcl                                            1
AB        ACCURETIC                                        hydrochlorothiazide and quinapril hcl                    1
AB        ALDACTAZIDE                                      hydrochlorothiazide and spironolactone                   1
AB        ALDACTONE                                        spironolactone                                           1
AB        ALDOMET                                          methyldopa                                               1
AB        ALDOMET HCT                                      hydrochlorothiazide and methyldopa                       1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  33
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                        Generic                                                Ti         Qu       Pr        Sp
AB        ALDORIL                                          hydrochlorothiazide and methyldopa                       1
B         ALTACE                                           ramipril                                                 3
AB        APRESOLINE                                       hydralazine hydrochloride                                1
AB        BETAPACE                                         sotalol hydrochloride                                    1
AB        BETAPACE AF                                      sotalol hydrochloride                                    1
AB        BUMEX                                            bumetanide                                               1
AB        CALAN                                            verapamil hydrochloride                                  1
AB        CALAN SR                                         verapamil hydrochloride                                  1
AB        CAPOTEN                                          captopril                                                1
AB        CARDIZEM                                         diltiazem hydrochloride                                  1
AB        CARDIZEM LA                                      diltiazem hydrochloride                                  1
AB        CATAPRES                                         clonidine hydrochloride                                  1
AB        COLESTID                                         colestipol hydrochloride                                 1
AB        CORDARONE                                        amiodarone hcl                                           1
AB        COREG                                            carvedilol                                               1
AB        CORGARD                                          nadolol                                                  1
AB        COZAAR                                           losartan potassium                                       2                    **
AB        CRESTOR                                          rosuvastatin calcium                                     2
AB        DEMADEX                                          torsemide                                                1
AB        DIAMOX                                           acetazolamide                                            1
AB        DIGOXIN                                          digoxin                                                  1
AB        DISOPYRAMIDE PHOSPHATE                           disopyramide phosphate                                   1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  34
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        DIURIL                                           chlorothiazide                                           1
AB        DYAZIDE                                          hydrochlorothiazide and triamterene                      1
AB        DYNACIRC                                         isradipine                                               1
AB        FLECAINIDE ACETATE                               flecainide acetate                                       1
AB        HYDRODIURIL                                      hydrochlorothiazide                                      1
AB        HYGROTON                                         chlorthalidone                                           1
B         HYZAAR                                           hydrochlorothiazide and losartan potassium               3                    **
AB        IMDUR                                            isosorbide mononitrate                                   1
AB        INDAPAMIDE                                       indapamide                                               1
AB        INDERAL                                          propranolol hydrochloride                                1
AB        INDERIDE                                         hydrochlorothiazide
                                                           and propranolol hydrochloride                            1
A         INSPRA                                           eplerenone                                               2
B         INSPRA                                           eplerenone                                               3
AB        ISORDIL                                          isosorbide dinitrate                                     1
AB        LANOXIN                                          digoxin                                                  1
AB        LASIX                                            furosemide                                               1
AB        LOFIBRA                                          fenofibrate                                              1
AB        LONITEN                                          minoxidil                                                1
AB        LOPID                                            gemfibrozil                                              1
AB        LOPRESSOR                                        metoprolol tartrate                                      1
AB        LOPRESSOR HCT                                    hydrochlorothiazide and metoprolol tartrate              1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  35
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        LOTENSIN                                         benazepril hcl                                           1
AB        LOTENSIN HCT                                     benazepril hcl and hydrochlorothiazide                   1
AB        LOTREL                                           amlodipine besylate and benazepril hcl                   1
A         LOVAZA                                           dha ethyl ester and epa ethyl ester
                                                           and omega-3-acid ethyl esters                            2                    **
B         LOVAZA                                           dha ethyl ester and epa ethyl ester
                                                           and omega-3-acid ethyl esters                            3
AB        LOZOL                                            indapamide                                               1
AB        MAVIK                                            trandolapril                                             1
AB        METHAZOLAMIDE                                    methazolamide                                            1
AB        METOLAZONE                                       metolazone                                               1
AB        MEVACOR                                          lovastatin                                               1
AB        MEXILETINE HCL                                   mexiletine hydrochloride                                 1
AB        MEXITIL                                          mexiletine hydrochloride                                 1
AB        MIDAMOR                                          amiloride hydrochloride (anhydrous)                      1
AB        MINOXIDIL                                        minoxidil                                                1
AB        MOEXIPRIL HCL                                    moexipril hydrochloride                                  1
AB        MONOPRIL                                         fosinopril sodium                                        1
AB        MONOPRIL HCT                                     fosinopril sodium and hydrochlorothiazide                1
AB        NADOLOL                                          nadolol                                                  1
AB        NEPTAZANE                                        methazolamide                                            1
AB        NIASPAN                                          niacin                                                   2
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  36
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        NITRO-BID                                        nitroglycerin                                            1
AB        NITRODERM                                        nitroglycerin                                            1
AB        NITRO-DUR                                        nitroglycerin                                            1
AB        NITROGLYCERIN                                    nitroglycerin                                            1
AB        NITROSTAT                                        nitroglycerin                                            1
AB        NORPACE                                          disopyramide phosphate                                   1
AB        PAVABID                                          papaverine hydrochloride                                 1
AB        PLENDIL                                          felodipine                                               1
AB        PRAVACHOL                                        pravastatin sodium                                       1
AB        PRINIVIL                                         lisinopril                                               1
AB        PRINZIDE                                         hydrochlorothiazide and lisinopril                       1
AB        PROCAN                                           procainamide hydrochloride                               1
AB        PROCARDIA                                        nifedipine                                               1
AB        PROCARDIA XL                                     nifedipine                                               1
AB        QUESTRAN                                         cholestyramine                                           1
AB        QUINAGLUTE                                       quinidine gluconate                                      1
AB        QUINAGLUTE DURA-TABS                             quinidine gluconate                                      1
AB        QUINIDINE GLUCONATE                              quinidine gluconate                                      1
AB        QUINIDINE GLUCONATE CR                           quinidine gluconate                                      1
A         RANEXA                                           ranolazine                                               2                    **
B         RANEXA                                           ranolazine                                               3                    **
AB        SECTRAL                                          acebutolol hydrochloride                                 1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  37
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        TAMBOCOR                                         flecainide acetate                                       1
B         TARKA                                            trandolapril and verapamil hydrochloride                 3
A         TEKTURNA                                         aliskiren                                                2                    **
B         TEKTURNA                                         aliskiren                                                3                    **
AB        TENEX                                            guanfacine hcl                                           1
AB        TENORETIC                                        atenolol and chlorthalidone                              1
AB        TENORMIN                                         atenolol                                                 1
AB        TIKOSYN                                          dofetilide                                               2
AB        TOPROL XL                                        metoprolol succinate                                     1
AB        TRANDATE                                         labetalol hydrochloride                                  1
AB        VASERETIC                                        enalapril maleate and hydrochlorothiazide                1
AB        VASOTEC                                          enalapril maleate                                        1
AB        WYTENSIN                                         guanabenz acetate                                        1
AB        ZAROXOLYN                                        metolazone                                               1
AB        ZEBETA                                           bisoprolol fumarate                                      1
AB        ZEBETA HCTZ                                      bisoprolol fumarate and hydrochlorothiazide              1
AB        ZESTORETIC                                       hydrochlorothiazide and lisinopril                       1
AB        ZESTRIL                                          lisinopril                                               1
AB        ZETIA                                            ezetimibe                                                2
AB        ZIABETA                                          bisoprolol fumarate                                      1
AB        ZIABETA HCT                                      bisoprolol fumarate and hydrochlorothiazide              1
AB        ZOCOR                                            simvastatin                                              1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  38
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
          Central Nervous System Agents
AB        ADDERALL                                         amphetamine aspartate and amphetamine
                                                           sulfate and dextroamphetamine saccharate
                                                           and dextroamphetamine sulfate                            1
AB        DEXEDRINE                                        dextroamphetamine sulfate                                1
AB        METADATE CD                                      methylphenidate hydrochloride                            2
AB        METHYLIN                                         methylphenidate hydrochloride                            1
AB        METHYLIN ER                                      methylphenidate hydrochloride                            1
AB        METHYLPHENIDATE HCL                              methylphenidate hydrochloride                            1
B         PROVIGIL                                         modafinil                                                3                    **
AB        RITALIN                                          methylphenidate hydrochloride                            1
A         STRATTERA                                        atomoxetine hydrochloride                                2                    **
B         STRATTERA                                        atomoxetine hydrochloride                                3
B         XYREM                                            sodium oxybate                                           2
          Dental and Oral Agents
AB        CHLORHEXADINE GLUCONATE                          chlorhexidine gluconate                                  1
B         DENAVIR                                          penciclovir                                              3
AB        DOXYCYCLINE HYCLATE                              doxycycline hyclate                                      1
AB        MINOCIN                                          minocycline hydrochloride                                1
AB        TRIAMCINOLONE IN ORABASE                         triamcinolone acetonide                                  1
AB        VIBRAMYCIN                                       doxycycline hyclate                                      1

A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  39
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                        Generic                                                Ti         Qu       Pr        Sp
          Dermatological Agents
A         ALDARA                                           imiquimod                                                2
B         ALDARA                                           imiquimod                                                3
AB        AMNESTEEM                                        isotretinoin                                             1
AB        BACTROBAN                                        mupirocin                                                2
AB        CONDYLOX                                         podofilox                                                2
B         DIFFERIN                                         adapalene                                                3
A         DOVONEX                                          calcipotriene                                            2
B         DOVONEX                                          calcipotriene                                            3
AB        DOXEPIN HCL                                      doxepin hydrochloride                                    1
AB        DOXYCYCLINE MONOHYDRATE                          doxycycline monohydrate                                  1
AB        EFUDEX                                           fluorouracil                                             1
A         ELIDEL                                           pimecrolimus                                             2                    **
B         ELIDEL                                           pimecrolimus                                             3
AB        EXSEL                                            selenium sulfide                                         1
AB        FLAGYL                                           metronidazole                                            1
AB        LAC-HYDRIN                                       ammonium lactate                                         1
AB        METRONIDAZOLE                                    metronidazole                                            1
A         OXSORALEN                                        methoxsalen                                              2
B         OXSORALEN                                        methoxsalen                                              3
A         OXSORALEN ULTRA                                  methoxsalen                                              2
B         OXSORALEN ULTRA                                  methoxsalen                                              3
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  40
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
A         REGRANEX                                         becaplermin                                              2
B         REGRANEX                                         becaplermin                                              3
B         RENOVA                                           tretinoin                                                1
AB        RETIN A                                          tretinoin                                                1
B         RETIN-A MICRO                                    tretinoin                                                3
AB        SELSUN                                           selenium sulfide                                         1
AB        SINEQUAN                                         doxepin hydrochloride                                    1
A         SOLARAZE                                         diclofenac sodium                                        2
B         SOLARAZE                                         diclofenac sodium                                        3
B         TAZORAC                                          tazarotene                                               3
          Enzyme Replacements/ Modifiers
A         ADAGEN                                           pegademase bovine                                        2
B         ADAGEN                                           pegademase bovine                                        3
A         ALDURAZYME                                       laronidase                                               2                    **
B         ALDURAZYME                                       laronidase                                               3                    **
AB        BUPHENYL                                         sodium phenylbutyrate                                    2
A         CEREZYME                                         imiglucerase                                             2                    **
B         CEREZYME                                         imiglucerase                                             3                    **
AB        CYSTADANE                                        betaine (trimethylglycine)                               2
A         CYSTAGON                                         cysteamine bitartrate                                    2
B         CYSTAGON                                         cysteamine bitartrate                                    3
A         ELAPRASE                                         idursulfase                                              2                    **
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  41
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
B         ELAPRASE                                         idursulfase                                              3                    **
A         FABRAZYME                                        agalsidase beta                                          2                    **
B         FABRAZYME                                        agalsidase beta                                          3                    **
A         MYOZYME                                          alglucosidase alfa                                       2                    **
B         MYOZYME                                          alglucosidase alfa                                       3
A         NAGLAZYME                                        galsulfase                                               2                    **
B         NAGLAZYME                                        galsulfase                                               3                    **
AB        ORFADIN                                          nitisinone                                               2
AB        PANCREASE MT 10                                  amylase (diastase) and lipase
                                                           (as pancrelipase) and protease                           2
AB        PANCREASE MT 16                                  amylase (diastase) and lipase
                                                           (as pancrelipase) and protease                           2
AB        PANCREASE MT 20                                  amylase (diastase) and lipase
                                                           (as pancrelipase) and protease                           2
AB        PANCREASE MT 4                                   amylase (diastase) and lipase
                                                           (as pancrelipase) and protease                           2
AB        PANCRELIPASE                                     amylase (diastase) and lipase
                                                           (as pancrelipase) and protease                           1
AB        SUCRAID                                          sacrosidase                                              2
A         ZAVESCA                                          miglustat                                                2                    **
B         ZAVESCA                                          miglustat                                                3                    **

A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  42
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
          Gastrointestinal Agents
AB        ACTIGALL                                         ursodiol                                                 1
AB        AMITIZA                                          lubiprostone                                             2                    **
AB        ATROPINE SULFATE                                 atropine sulfate                                         1
AB        AXID                                             nizatidine                                               1
AB        BENTYL                                           dicyclomine hydrochloride                                1
AB        CARAFATE                                         sucralfate                                               1
AB        CEPHULAC                                         lactulose                                                1
AB        ENTOCORT EC                                      budesonide                                               2
AB        IMODIUM                                          loperamide hydrochloride                                 1
B         KRISTALOSE                                       lactulose                                                2
AB        LOMOTIL                                          atropine sulfate and diphenoxylate
                                                           hydrochloride                                            1
AB        LOPERAMIDE HCL                                   loperamide hydrochloride                                 1
AB        LOTRONEX                                         alosetron hydrochloride                                  2
AB        METHSCOPOLAMINE BROMIDE                          methscopolamine bromide                                  1
AB        MIRALAX                                          polyethylene glycol                                      1
AB        PAMINE                                           methscopolamine bromide                                  1
AB        PEPCID                                           famotidine                                               1
AB        POLYETHYLENE GLYCOL 3350                         polyethylene glycol                                      1
AB        PREVACID                                         lansoprazole                                             2                    **
AB        PREVACID I.V.                                    lansoprazole                                             2                    **
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  43
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        PREVACID SOLUTAB                                 lansoprazole                                             2                    **
AB        PRILOSEC                                         omeprazole                                               1
AB        PRO-BANTHINE                                     propantheline bromide                                    1
AB        ROBINUL                                          glycopyrrolate                                           1
AB        TAGAMENT                                         cimetidine                                               1
AB        URSODIOL                                         ursodiol                                                 1
AB        ZANTAC                                           ranitidine hydrochloride                                 1
          Genitourinary Agents
AB        CARDURA                                          doxazosin mesylate                                       1
AB        DITROPAN                                         oxybutynin chloride                                      1
AB        DITROPAN XL                                      oxybutynin XL                                            1
AB        ELMIRON                                          pentosan polysulfate sodium                              2
AB        FOSRENOL                                         lanthanum carbonate                                      2
AB        HYTRIN                                           terazosin hcl                                            1
AB        MINIPRESS                                        prazosin hydrochloride                                   1
AB        PROSCAR                                          finasteride                                              1
B         RENAGEL                                          sevelamer hydrochloride                                  3
AB        THIOLA                                           tiopronin                                                2
AB        VESICARE                                         solifenacin succinate                                    2
          Hormonal Agents, Stimulant/
          Replacement/ Modifying (Adrenal)
AB        ACLOVATE                                         alclometasone dipropionate                               1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  44
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                        Generic                                                Ti         Qu       Pr        Sp
B         ANDRODERM                                        testosterone                                             2
B         ANDROGEL                                         testosterone                                             3
AB        AVIANE                                           ethinyl estradiol and levonorgestrel                     1
AB        BETAMETHASONE DIPROPIONAT                        betamethasone dipropionate                               1
AB        BETA-VAL                                         betamethasone valerate                                   1
B         CENESTIN                                         estrogens, conjugated synthetic a                        2
AB        CLIMARA                                          estradiol                                                1
AB        CORTIFOAM                                        hydrocortisone acetate                                   2
B         CYTOMEL                                          liothyronine sodium                                      2
AB        CYTOTEC                                          misoprostol                                              1
B         DANAZOL                                          danazol                                                  2
AB        DDAVP                                            desmopressin acetate                                     1
AB        DECA- DURABOLIN                                  nandrolone decanoate                                     1
AB        DECADRON                                         dexamethasone                                            1
AB        DELATESTRYL                                      testosterone enanthate                                   1
AB        DEPO-TESTOSTERONE                                testosterone cypionate                                   1
AB        DERMATOP                                         prednicarbate                                            1
AB        DESOCORT                                         desonide                                                 1
AB        DIPROLENE AF                                     augmented betamethasone dipropionate                     1
B         EVISTA                                           raloxifene hydrochloride                                 2
AB        FLORINEF                                         fludrocortisone acetate                                  1
AB        HALOBETASOL PROPIONATE                           halobetasol propionate                                   1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  45
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        HCG                                              gonadotropin, chorionic                                  1
AB        HYDROCORDONE                                     hydrocortisone                                           1
AB        HYDROCORTISONE BUTYRATE                          hydrocortisone butyrate                                  1
AB        HYDROCORTISONE VALERATE                          hydrocortisone valerate                                  1
B         INCRELEX                                         mecasermin                                               3
AB        KENALOG                                          triamcinolone acetonide                                  1
AB        LESSINA-28                                       ethinyl estradiol and levonorgestrel                     1
B         LEVOXYL                                          levothyroxine sodium                                     3
AB        MEDROL                                           methylprednisolone acetate                               1
AB        METHYLPREDNISOLONE ACETAT                        methylprednisolone acetate                               1
AB        METHYLPREDNISOLONE SODIUM                        methylprednisolone sodium succinate                      1
AB        MICROGESTIN 1.5/30                               ethinyl estradiol and norethindrone acetate              1
AB        MICROGESTIN 1/20                                 ethinyl estradiol and norethindrone acetate              1
AB        MICROGESTIN FE                                   ethinyl estradiol and ferrous fumarate
                                                           and norethindrone acetate                                1
AB        MOMETASONE FUROATE                               mometasone furoate                                       1
B         NORDITROPIN CARTRIDGE                            somatropin                                               3                                  ***
AB        NORLUTIN                                         norethindrone acetate                                    1
AB        ORTHO-EST                                        estropipate                                              1
AB        OXANDROLONE                                      oxandrolone                                              1
AB        PITOCIN                                          oxytocin                                                 1
B         PLAN B                                           levonorgestrel                                           3
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                    46
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        PORTIA-28                                        ethinyl estradiol and levonorgestrel                     1
AB        PREDNICARBATE                                    prednicarbate                                            1
B         PREMARIN                                         estrogens, conjugated                                    2
B         PREMPHASE                                        estrogens, conjugated and
                                                           medroxyprogesterone acetate                              2
B         PREMPRO                                          estrogens, conjugated and
                                                           medroxyprogesterone acetate                              2
AB        PROVERA                                          medroxyprogesterone acetate                              1
AB        PSORCON                                          diflorasone diacetate                                    1
AB        SPRINTEC 28                                      ethinyl estradiol and norgestimate                       1
B         STRIANT                                          testosterone                                             3
AB        SYNALAR                                          fluocinolone acetonide                                   1
AB        SYNTHROID                                        levothyroxine sodium                                     1
AB        TEMOVATE                                         clobetasol propionate                                    1
AB        TOPICORT                                         desoximetasone                                           1
AB        TRIAMCINOLONE ACETONIDE                          triamcinolone acetonide                                  1
AB        TRI-NORINYL 28                                   ethinyl estradiol and norethindrone                      1
AB        TRI-SPRINTEC                                     ethinyl estradiol and norgestimate                       1
AB        ULTRAVATE                                        halobetasol propionate                                   1
          Hormonal Agents, Stimulant/
          Replacement/ Modifying (Pituitary)
AB        CHORIONIC GONADOTROPIN             gonadotropin, chorionic                                                1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  47
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        DDAVP                                            desmopressin acetate                                     1
A         INCRELEX                                         mecasermin                                               2
A         NORDITROPIN CARTRIDGE                            somatropin                                               2                                  ***
AB        OXYTOCIN                                         oxytocin                                                 1


          Hormonal Agents, Stimulant/
          Replacement/ Modifying
          (Prostaglandins)
AB        MISOPROSTOL                                      misoprostol                                              1
          Hormonal Agents, Stimulant/
          Replacement/ Modifying
          (Sex Hormones/ Modifiers)
AB        NANDROLONE DECANOATE                             nandrolone decanoate                                     1
AB        OXANDROLONE                                      oxandrolone                                              1
A         ANDRODERM                                        testosterone                                             2
A         DANAZOL                                          danazol                                                  2
AB        TESTOSTERONE CYPIONATE                           testosterone cypionate                                   1
AB        AVIANE                                           ethinyl estradiol and levonorgestrel                     1
A         CENESTIN                                         estrogens, conjugated synthetic a                        2
AB        CLIMARA                                          estradiol                                                1
AB        LESSINA-28                                       ethinyl estradiol and levonorgestrel                     1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                    48
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        MICROGESTIN 1.5/30                               ethinyl estradiol and norethindrone acetate              1
AB        MICROGESTIN 1/20                                 ethinyl estradiol and norethindrone acetate              1
AB        MICROGESTIN FE                                   ethinyl estradiol and ferrous fumarate
                                                           and norethindrone acetate                                1
AB        MICROGESTIN FE 1.5/30                            ethinyl estradiol and ferrous fumarate
                                                           and norethindrone acetate                                1
AB        ORTHO-EST                                        estropipate                                              1
AB        PORTIA-28                                        ethinyl estradiol and levonorgestrel                     1
A         PREMARIN                                         estrogens, conjugated                                    2
A         PREMPHASE                                        estrogens, conjugated
                                                           and medroxyprogesterone acetate                          2
A         PREMPRO                                          estrogens, conjugated
                                                           and medroxyprogesterone acetate                          2
AB        SPRINTEC 28                                      ethinyl estradiol and norgestimate                       1
AB        TRI-NORINYL 28                                   ethinyl estradiol and norethindrone                      1
AB        TRI-SPRINTEC                                     ethinyl estradiol and norgestimate                       1
AB        DEPO PROVERA                                     medroxyprogesterone acetate                              1
AB        NORETHINDRONE ACETATE                            norethindrone acetate                                    1
A         EVISTA                                           raloxifene hydrochloride                                 2
          Hormonal Agents, Stimulant/
          Replacement/ Modifying (Thyroid)
A         CYTOMEL                          liothyronine sodium                                                      2
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  49
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
A         LEVOXYL                                          levothyroxine sodium                                     2
AB        SYNTHROID                                        levothyroxine sodium                                     1
          Hormonal Agents,
          Suppressant (Adrenal)
AB        LYSODREN                                         mitotane                                                 2

          Hormonal Agents,
          Suppressant (Parathyroid)
AB        SENSIPAR                                         cinacalcet hydrochloride                                 2
          Hormonal Agents,
          Suppressant (Pituitary)
AB        DOSTINEX                                         cabergoline                                              1
AB        LUPRON                                           leuprolide acetate                                       1
AB        PARLODEL                                         bromocriptine mesylate                                   1
A         PLENAXIS                                         abarelix                                                 2
B         PLENAXIS                                         abarelix                                                 3
AB        SANDOSTATIN                                      octreotide acetate                                       1
A         SOMAVERT                                         pegvisomant                                              2
B         SOMAVERT                                         pegvisomant                                              3
A         ZOLADEX                                          goserelin acetate                                        2
B         ZOLADEX                                          goserelin acetate                                        3

A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  50
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
          Hormonal Agents, Suppressant
          (Sex Hormones/ Modifiers)
AB        CASODEX                                          bicalutamide                                             2
AB        FLOMAX                                           tamsulosin hydrochloride                                 2
          Hormonal Agents,
          Suppressant (Thyroid)
AB        PROPYLTHIOURACIL                                 propylthiouracil                                         1
AB        TAPAZOLE                                         methimazole                                              1
AB        METHIMAZOLE                                      methimazole                                              1
AB        PTU                                              propylthiouracil                                         1
          Immunological Agents
AB        ACTHIB                                           haemophilus b polysaccharide conj vacc                   2
A         ACTIMMUNE                                        interferon gamma-1b                                      2                                  ***
B         ACTIMMUNE                                        interferon gamma-1b                                      3                                  ***
AB        ADACEL                                           acellular pertussis and diphtheria
                                                           toxoid and tetanus toxoid                                2
AB        ARAVA                                            leflunomide                                              1
AB        ATGAM                                            anti-thymocyte globulin (equine)                         2
AB        ATTENUVAX                                        measles virus vaccine live                               2
A         AVONEX                                           interferon beta-1a                                       2                    **            ***
B         AVONEX                                           interferon beta-1a                                       3                    **            ***
AB        BETASERON                                        interferon beta-1b                                       2                                  ***
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                    51
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        BOOSTRIX                                         acellular pertussis and diphtheria toxoid
                                                           and tetanus toxoid                                       2
AB        CELLCEPT                                         mycophenolate mofetil                                    2
AB        COMVAX                                           haemophilus b polysaccharide conj vacc
                                                           and hepatitis b virus vaccine recombinant                2
AB        COPAXONE                                         glatiramer acetate                                       2                                  ***

AB        DAPTACEL                                         acellular pertussis and diphtheria toxoid
                                                           and tetanus toxoid                                       2
AB        DECAVAC                                          diphtheria toxoid and tetanus toxoid                     2
AB        DIPTHERIA/TETANUS TOXOID                         diphtheria toxoid and tetanus toxoid                     2
A         ENBREL                                           etanercept                                               2         *          **            ***
B         ENBREL                                           etanercept                                               3         *          **            ***
AB        ENGERIX-B                                        hepatitis b virus vaccine recombinant                    2
AB        FOLEX                                            methotrexate                                             1
AB        GARDASIL                                         quadrivalent hpv (6,11,16,18) recomb vac                 2
AB        HAVRIX                                           hepatitis a virus vaccine inactivated                    2
AB        HIBTITER                                         diphtheria toxoid crm-197 and
                                                           haemophilus b oligosaccharide conj vacc                  2
A         HUMIRA                                           adalimumab                                               2         *          **            ***
B         HUMIRA                                           adalimumab                                               3         *          **            ***
AB        IMOVAX RABIES (H.D.C.V.)                         rabies vaccine human diploid cell                        2
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                    52
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        IMURAN                                           azathioprine                                             1
AB        INTRON-A                                         interferon alfa-2b                                       2
AB        IPOL INACTIVATED IPV                             poliovirus vaccine inactivated                           2
AB        JE-VAX                                           japanese encephalitis virus vaccine                      2
AB        KINERET                                          anakinra                                                 2                    **            ***
AB        LEFLUNOMIDE                                      leflunomide                                              1
AB        MENACTRA                                         meningococcal polysaccharide vac a-c-y-w                 2
AB        MERUVAX II W/DILUENT 1 DO                        rubella virus vaccine live                               2
AB        METHOTREXATE                                     methotrexate                                             1
AB        M-M-R II W/DILUENT 1 DOSE                        measles virus vaccine live and mumps
                                                           virus vaccine live and rubella virus vaccine live        2
AB        M-M-R II W/DILUENT 10 DOS                        measles virus vaccine live and mumps
                                                           virus vaccine live and rubella virus vaccine live        2
AB        M-R-VAX II                                       measles virus vaccine live and rubella
                                                           virus vaccine live                                       2
AB        MUMPSVAX W/DILUENT 1 DOSE                        mumps virus vaccine live                                 2
AB        NEORAL                                           cyclosporine                                             1
AB        PANGLOBULIN                                      globulin, immune iv (baxter/am red cros)                 2
AB        PEDIARIX                                         acellular pertussis and diphtheria toxoid
                                                           and hepatitis b virus vaccine recombinant
                                                           and poliovirus vaccine inactivated
                                                           and tetanus toxoid                                       2
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                    53
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        PEGASYS                                          peginterferon alfa-2a                                    2
AB        PEG-INTRON                                       peginterferon alfa-2b                                    2
AB        PROGRAF                                          tacrolimus                                               2
AB        PROQUAD                                          measles virus vaccine live and mumps
                                                           virus vaccine live and rubella virus vaccine
                                                           live and varicella virus vaccine live                    2
AB        RABAVERT                                         rabies vaccine purified chick embryo cel                 2
AB        RAPAMUNE                                         sirolimus                                                2
AB        ROFERON-A                                        interferon alfa-2a                                       2
AB        ROTATEQ                                          rotavirus vaccine live pentavalent                       2
AB        TETANUS TOXOID                                   tetanus toxoid                                           2
AB        TETANUS TOXOID ADSORBED                          tetanus toxoid adsorbed                                  1
AB        TETANUS/DIPHTHERIA TOXOID                        diphtheria toxoid and tetanus toxoid                     2
AB        TWINRIX                                          hepatitis a virus vaccine inactivated
                                                           and hepatitis b virus vaccine recombinant                2
AB        TYPHIM VI                                        typhoid vi polysaccharide vaccine                        2
AB        VAQTA                                            hepatitis a virus vaccine inactivated                    2
AB        VARIVAX                                          varicella virus vaccine live                             2
AB        VIVOTIF BERNA                                    typhoid vaccine                                          2
A         XOLAIR                                           omalizumab                                               2                    **            ***
B         XOLAIR                                           omalizumab                                               3                    **            ***
AB        YF-VAX                                           yellow fever vaccine                                     2
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                    54
                                                                                                                                                            n
                                                                                                                                                       tio         or
                                                                                                                                               its iza          nd
                                                                                                                                       i   m    or            Ve
        a ry                                                                                                                        yL         h            y
     ul                                                                                                                          tit         ut         lit
                                                                                                                        r                  rA        ia
   rm                                                                                                               e          an       io        ec
 Fo            Brand                                       Generic                                               Ti         Qu       Pr        Sp
AB        ZOSTAVAX                        zoster vaccine live (oka/merck)                                         2
          Inflammatory Bowel Disease Agents
AB        ASACOL                          mesalamine (5-asa)                                                      2
AB        AZULFIDINE                      sulfasalazine                                                           1
A         CANASA                          mesalamine (5-asa)                                                      2
B         CANASA                          mesalamine (5-asa)                                                      3
A         COLAZAL                         balsalazide disodium                                                    2
B         COLAZAL                         balsalazide disodium                                                    3
AB        CORTISONE ACETATE               cortisone acetate                                                       1
AB        CORTONE                         cortisone acetate                                                       1
AB        DELTASONE                       prednisone                                                              1
A         ENTOCORT EC                     budesonide                                                              2                    **
B         ENTOCORT EC                     budesonide                                                              3
AB        ORAPRED                         prednisolone sodium phosphate                                           1
AB        PEDIAPRED                       prednisolone sodium phosphate                                           1
AB        PREDNISOLONE SODIUM PHOSP       prednisolone sodium phosphate                                           1
AB        PREDNISONE                      prednisone                                                              1
AB        SULFASALAZINE                   sulfasalazine                                                           1
          Metabolic Bone Disease Agents
AB        DIDRONEL                        etidronate disodium                                                     1
A         FORTEO                          teriparatide                                                            2                    **            ***
B         FORTEO                          teriparatide                                                            3                    **            ***
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2   Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                    55
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        FORTICAL                                         calcitonin, salmon (rdna)                                1
AB        FOSAMAX                                          alendronate sodium                                       2
AB        HECTOROL                                         doxercalciferol                                          2
AB        ZEMPLAR                                          paricalcitol                                             2
          Miscellaneous Therapeutic Agents
AB        AMINESS                                          amino acids                                              2

AB        AMINOSYN 7%/ELECTROLYTES                         acetate and alanine and arginine and
                                                           chloride ion and glycine                                 1
AB        ANTIZOL                                          fomepizole (4-methylpyrazole)                            2
A         BARACLUDE                                        entecavir monohydrate                                    2
B         BARACLUDE                                        entecavir monohydrate                                    3
AB        BLEOMYCIN SULFATE                                bleomycin sulfate                                        2
AB        CAMPATH                                          alemtuzumab                                              2
AB        CEREDASE                                         alglucerase                                              2
A         ELITEK                                           rasburicase                                              2
B         ELITEK                                           rasburicase                                              3
AB        HEPARIN SODIUM                                   heparin sodium (porcine)                                 1
AB        LACTATED RINGER’S DEXTROS                        calcium (+2) and chloride ion and
                                                           dextrose (anhydrous) and lactate
                                                           anion and potassium (+1)                                 1
AB        LIPOSYN II                                       glycerin and phospholipids and safflower
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  56
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
                                                           oil and soybean oil                                      2
AB        NEUTREXIN                                        trimetrexate glucuronate                                 2
A         ONTAK                                            denileukin diftitox                                      2                    **
B         ONTAK                                            denileukin diftitox                                      3
AB        PROLEUKIN                                        aldesleukin                                              2
AB        RENAMIN                                          amino acids                                              2

AB        RINGER’S INJECTION                               calcium (+2) and chloride ion and
                                                           potassium (+1) and sodium (+1)                           1
AB        STERILE WATER IRRIGATION                         water, sterile                                           1
B         TOBRADEX                                         dexamethasone and tobramycin sulfate                     2
AB        TRENTAL                                          pentoxifylline                                           1
AB        TRISENOX                                         arsenic trioxide                                         2
A         TYZEKA                                           telbivudine                                              2
B         TYZEKA                                           telbivudine                                              3
A         VELCADE                                          bortezomib                                               2
B         VELCADE                                          bortezomib                                               3
A         VIDAZA                                           azacitidine                                              2                    **
B         VIDAZA                                           azacitidine                                              3
          Ophthalmic Agents
AB        ACULAR                                           ketorolac tromethamine                                   2
AB        ALOMIDE                                          lodoxamide tromethamine (trometamol)                     2
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  57
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        ALPHAGAN                                         brimonidine tartrate                                     1
AB        ANSAID                                           flurbiprofen sodium                                      1
AB        AZOPT                                            brinzolamide                                             2
B         BETOPTIC-S                                       betaxolol hydrochloride                                  2
AB        BLEPH-10                                         sulfacetamide sodium                                     1
AB        CORTISPORIN                                      bacitracin zinc and neomycin sulfate
                                                           and polymyxin b sulfate                                  1
AB        COSOPT                                           dorzolamide hydrochloride
                                                           and timolol maleate                                      2
AB        DIAMOX                                           acetazolamide                                            2
AB        DIPIVEFRIN HCL                                   dipivefrin hydrochloride                                 1
AB        FLURBIPROFEN SODIUM                              flurbiprofen sodium                                      1
AB        FML                                              fluorometholone                                          1
AB        KERLONE                                          betaxolol hydrochloride                                  1
AB        LEVOBUNOLOL HCL                                  levobunolol hydrochloride                                1
AB        METIPRANOLOL                                     metipranolol                                             1
AB        MIOSTAT                                          carbachol                                                2
AB        NAPHAZOLINE HCL                                  naphazoline hydrochloride                                1
AB        NEO/POLY/BAC/HC                                  bacitracin zinc and hydrocortisone
                                                           acetate and neomycin sulfate
                                                           and polymyxin b sulfate                                  1
AB        NEOMYCIN/BACITRACIN/POLYM                        bacitracin zinc and neomycin sulfate
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  58
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
                                                           and polymyxin b sulfate                                  1
AB        NEOMYCIN/POLYMYXIN/DEXAME                        dexamethasone and neomycin sulfate
                                                           and polymyxin b sulfate                                  1
AB        NEOMYCIN/POLYMYXIN/GRAMIC                        gramicidin and neomycin sulfate
                                                           and polymyxin b sulfate                                  1
AB        OCUPRES                                          carteolol hcl                                            1
AB        OPTIVAR                                          azelastine hydrochloride                                 2
AB        PATADAY                                          olopatadine                                              2
AB        POLYMYXIN B                                      bacitracin zinc and hydrocortisone acetate
                                                           and neomycin sulfate and polymyxin b
                                                           sulfate                                                  1
AB        POLYSPORIN                                       bacitracin zinc and polymyxin b sulfate                  1
AB        PRED-FORTE                                       prednisolone acetate                                     1
AB        PRELONE                                          prednisolone acetate                                     1
AB        PROPINE                                          dipivefrin hydrochloride                                 1
A         RESTASIS                                         cyclosporine                                             2                    **
B         RESTASIS                                         cyclosporine                                             3
AB        SULFACETAMIDE SODIUM                             sulfacetamide sodium                                     1
AB        TIMOPTIC                                         timolol maleate                                          1
AB        TRAVATAN                                         travoprost                                               2
A         VIGAMOX                                          moxifloxacin hydrochloride                               2                    **
B         VIGAMOX                                          moxifloxacin hydrochloride                               3                    **
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  59
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
A    XALATAN                                               latanoprost                                              2                    **
B    XALATAN                                               latanoprost                                              3
A    ZYMAR                                                 gatifloxacin                                             2                    **
B    ZYMAR                                                 gatifloxacin                                             3                    **
Otic Agents
AB CIPRODEX                                                ciprofloxacin hcl and dexamethasone                      2
AB DERMOTIC                                                fluocinolone acetonide                                   2
AB DEXAMETHASONE SODIUM PHOS                               dexamethasone sodium phosphate                           1
AB FLOXIN OTIC                                             ofloxacin                                                2
AB NEOMYCIN/POLYMYXIN/HYDROC                               hydrocortisone and neomycin sulfate
                                                           and polymyxin b sulfate                                  1
AB        VOSOL                                            acetic acid and hydrocortisone                           1
          Respiratory Tract Agents
AB        ACCOLATE                                         zafirlukast                                              2
AB        ADVAIR DISKUS                                    fluticasone propionate
                                                           and salmeterol xinafoate                                 2
AB        ADVAIR HFA                                       fluticasone propionate
                                                           and salmeterol xinafoate                                 2
AB        ALLEGRA                                          fexofenadine hydrochloride                               1
AB        ALLEGRA-D                                        fexofenadine hydrochloride
                                                           and pseudoephedrine hydrochloride                        2
AB        AMINOPHYLLINE                                    aminophylline                                            1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  60
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        ATROVENT HFA                                     ipratropium bromide                                      2
AB        AZMACORT                                         triamcinolone acetonide                                  2
AB        CLEMASTINE FUMARATE                              clemastine fumarate                                      1
AB        COMBIVENT                                        albuterol sulfate and ipratropium bromide                2
AB        CYPROHEPTADINE HCL                               cyproheptadine hydrochloride                             1
AB        DEXCHLORPHENIRAMINE MALEA                        dexchlorpheniramine maleate                              1
AB        EPIPEN 2-PAK                                     epinephrine hydrochloride                                2
AB        FLONASE                                          fluticasone propionate                                   1
AB        FLOVENT HFA                                      fluticasone propionate                                   2
AB        FORADIL AEROLIZER                                formoterol fumarate                                      2
AB        INTAL INHALER                                    cromolyn sodium                                          2
B         MAXAIR AUTOHALER                                 pirbuterol acetate                                       2
AB        NASONEX                                          mometasone furoate monohydrate                           2
AB        PERIACTIN                                        cyproheptadine hydrochloride                             1
AB        POLARAMINE                                       dexchlorpheniramine maleate                              1
AB        PROAIR HFA                                       albuterol sulfate                                        1
A         PROLASTIN                                        proteinase inhibitor (human)                             2
B         PROLASTIN                                        proteinase inhibitor (human)                             3
AB        PROVENTIL                                        albuterol                                                1
AB        PULMICORT                                        budesonide                                               2
AB        QVAR                                             beclomethasone dipropionate                              2
A         REVATIO                                          sildenafil citrate                                       2                    **
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  61
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
B         REVATIO                                          sildenafil citrate                                       3                    **
A         RHINOCORT AQUA                                   budesonide                                               2
B         RHINOCORT AQUA                                   budesonide                                               3
AB        SEREVENT DISKUS                                  salmeterol xinafoate                                     2
AB        SINGULAIR                                        montelukast sodium                                       2
AB        SPIRIVA HANDIHALER                               tiotropium bromide monohydrate                           2
AB        TAVIST                                           clemastine fumarate                                      1
AB        THEO-DUR                                         theophylline                                             1
AB        THEOPHYLLINE CR                                  theophylline                                             1
AB        TILADE                                           nedocromil sodium                                        2
AB        TRACLEER                                         bosentan monohydrate                                     2                    **            ***
AB        TYZINE                                           tetrahydrozoline hydrochloride                           2
A         UNIPHYL                                          aminophylline                                            2
A         ZYFLO                                            zileuton                                                 2
B         ZYFLO                                            zileuton                                                 3
          Sedatives/ Hypnotics
AB        AMBIEN                                           zolpidem tartrate                                        1         *
AB        SONATA                                           zaleplon                                                 2         *
          Skeletal Muscle Relaxants
AB        FLEXERIL                                         cyclobenzaprine hydrochloride                            1
AB        NORFLEX                                          orphenadrine citrate                                     1
AB        ORPHENADRINE CITRATE ER                          orphenadrine citrate                                     1
A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                    62
                                                                                                                                                              n
                                                                                                                                                         tio         or
                                                                                                                                                 its iza          nd
                                                                                                                                         i   m    or            Ve
        a ry                                                                                                                          yL         h            y
     ul                                                                                                                            tit         ut         lit
                                                                                                                          r                  rA        ia
   rm                                                                                                                 e          an       io        ec
 Fo            Brand                                         Generic                                               Ti         Qu       Pr        Sp
AB        ROBAXIN                                          methocarbamol                                            1
AB        SKELAXIN                                         metaxalone                                               2
AB        SOMA                                             carisoprodol                                             1
AB        ZANAFLEX                                         tizanidine hydrochloride                                 1
          Therapeutic Nutrients/
          Minerals/ Electrolytes
AB        DEXTROSE 5%/LACTATED RING                        calcium (+2) and chloride ion
                                                           and dextrose (anhydrous) and lactate
                                                           anion and potassium (+1)                                 2
AB        FLUORIDE                                         fluoride prepartion                                      1

AB        KCL 0.3%/D5W/LR IV LAC RI                        calcium (+2) and chloride ion
                                                           and dextrose (anhydrous) and lactate
                                                           anion and potassium (+1)                                 2
AB        K-DUR                                            potassium chloride                                       1
AB        KLOR-CON                                         potassium citrate                                        1
AB        PHOSLO                                           calcium acetate                                          2
AB        PRENATAL VITAMINS                                prenatal with folic acid (>.8mg)                         1
AB        VITAMIN/MINERAL, MISC                            fluoride preparation                                     1



A = Standard Rx and Rx 1   B = $0 Deductible Rx and Rx 2     Additional Rx 2 covered drugs on Page 11   Quantity Limits listed on Page 11                  63
abacavir sulfate ..........................29            acetaminophen and codeine                                    ADVAIR HFA .................................60          almotriptan malate ...................22
abacavir sulfate and                                     phosphate ....................................13             agalsidase beta...........................42            ALOMIDE.......................................57
lamivudine ...................................28         acetaminophen and hydrocodone                                agalsidase beta...........................42            alosetron hydrochloride .........43
abacavir sulfate and lamivudine                          bitartrate.......................................13          AGENERASE .................................28           ALPHAGAN ..................................58
and zidovudine ..........................29              acetaminophen and oxycodone                                  AGGRENOX ..................................32           ALTACE...........................................34
abarelix..........................................50     hydrochloride .............................12                albendazole .................................25         altretamine ..................................23
abarelix..........................................50     acetaminophen and propoxy-                                   ALBENZA.......................................25        amantadine hydrochloride ....29
ABILIFY ..........................................26     phene hydrochloride ..............12                         albuterol .......................................61     AMARYL ........................................31
ABILIFY ..........................................30     acetaminophen and                                            albuterol sulfate .........................61           AMBIEN .........................................62
ABILIFY DISCMELT .....................26                 tramadol hcl ................................13              albuterol sulfate and                                   amiloride hydrochloride (anhy-
ABILIFY DISCMELT .....................30                 acetate and alanine and                                      ipratropium bromide ...............61                   drous).............................................36
acamprosate calcium ...............19                    arginine and chloride ion and                                alclometasone dipropionate .44                          AMINESS .......................................56
acarbose .......................................32       glycine ...........................................56        ALCOHOL SWABS.......................31                  amino acids .................................56
ACCOLATE ....................................60          acetazolamide ............................34                 ALDACTAZIDE .............................33             amino acids .................................57
ACCUPRIL .....................................33         acetazolamide ............................58                 ALDACTONE ................................33            AMINOPHYLLINE........................60
ACCURETIC...................................33           acetic acid and                                              ALDARA.........................................40       aminophylline.............................60
acebutolol hydrochloride .......37                       hydrocortisone ...........................60                 ALDARA.........................................40       aminophylline.............................62
acellular pertussis and diphtheria                       ACLOVATE.....................................44              aldesleukin...................................57        AMINOSYN
toxoid and tetanus toxoid ......51                       ACTHIB ..........................................51          ALDOMET .....................................33         7%/ELECTROLYTES ...................56
acellular pertussis and diphtheria                       ACTIGALL......................................43             ALDOMET HCT............................33               amiodarone hcl ..........................34
toxoid and hepatitis b virus vac-                        ACTIMMUNE ................................51                 ALDORIL ........................................34      AMITIZA ........................................43
cine recombinant and poliovirus                          ACTIMMUNE ................................51                 ALDURAZYME .............................41              amitriptyline hydrochloride ..18
vaccine inactivated and tetanus                          ACTOS ............................................31         ALDURAZYME .............................41              amlodipine besylate and benaz-
toxoid .............................................53   ACULAR .........................................57           alemtuzumab..............................56             epril hcl..........................................36
acellular pertussis and diphtheria                       acyclovir ........................................29         alendronate sodium .................56                  ammonium lactate ...................40
toxoid and tetanus toxoid .....52                        ADACEL .........................................51           alglucerase ...................................56       AMNESTEEM ................................40
acellular pertussis and diphtheria                       ADAGEN ........................................41            alglucosidase alfa ......................42             amoxapine ...................................18
toxoid and tetanus toxoid .....52                        ADAGEN ........................................41            alglucosidase alfa ......................42             amoxicillin ....................................13
acetaminophen and codeine                                adalimumab ................................52                aliskiren .........................................38   amoxicillin and potassium clavula-
phosphate ....................................12         adalimumab ................................52                aliskiren .........................................38   nate.................................................13
acetaminophen and codeine                                adapalene ....................................40             alitretinoin....................................24      AMOXIL .........................................13
phosphate ....................................12         ADDERALL....................................39               ALLEGRA .......................................60       amphetamine aspartate and
acetaminophen and codeine                                adefovir dipivoxil .......................28                 ALLEGRA-D ..................................60          amphetamine sulfate and dex-
phosphate ....................................12         ADVAIR DISKUS ..........................60                   allopurinol....................................21       troamphetamine saccharate and
                                                                                                                 64
dextroamphetamine sulfate..39                          apomorphine hydrochloride.25                                atropine sulfate and diphenoxylate                       bacitracin zinc and
ampicillin ......................................15    apomorphine hydrochloride.25                                hydrochloride .............................43            neomycin sulfate and polymyxin b
ampicillin sodium and sulbactam                        aprepitant ....................................20           ATROVENT HFA ...........................61               sulfate ............................................58
sodium ..........................................16    APRESOLINE ................................34               ATTENUVAX .................................51            bacitracin zinc and neomycin
amprenavir...................................28        APTIVUS ........................................28          augmented betamethasone dipro-                           sulfate and polymyxin b
amylase (diastase) and lipase (as                      ARALEN .........................................25          pionate ..........................................45     sulfate ............................................58
pancrelipase) and protease ...42                       ARANESP.......................................32            AUGMENTIN ................................13             bacitracin zinc and polymyxin b
amylase (diastase) and lipase (as                      ARANESP.......................................32            AVANDIA .......................................31        sulfate ............................................59
pancrelipase) and protease ...42                       ARAVA ............................................51        AVELOX ..........................................13      BACLOFEN ....................................27
amylase (diastase) and lipase (as                      ARICEPT.........................................17          AVIANE...........................................45      baclofen ........................................27
pancrelipase) and protease ...42                       ARIMIDEX .....................................23            AVIANE...........................................48      BACTOCIL .....................................13
amylase (diastase) and lipase (as                      aripiprazole ..................................26           AVINZA ..........................................12      BACTRIM .......................................13
pancrelipase) and protease ...42                       aripiprazole ..................................26           AVONEX.........................................51        BACTROBAN ................................13
amylase (diastase) and lipase (as                      aripiprazole ..................................30           AVONEX.........................................51        BACTROBAN ................................40
pancrelipase) and protease ...42                       aripiprazole ..................................30           AXERT.............................................22     balsalazide disodium ...............55
ANAFRANIL ..................................18         ARIXTRA ........................................32          AXID................................................43   balsalazide disodium ...............55
anakinra ........................................53    ARIXTRA ........................................32          azacitidine ....................................57       BARACLUDE .................................56
ANAPROX .....................................21        AROMASIN ...................................23              azacitidine ....................................57       BARACLUDE .................................56
anastrozole ..................................23       arsenic trioxide ...........................57              azathioprine ................................53          becaplermin ................................41
ANCEF ............................................13   ARTANE .........................................25          azelastine hydrochloride ........59                      becaplermin ................................41
ANDRODERM ..............................45             ASACOL .........................................55          AZILECT .........................................25      beclomethasone
ANDRODERM ..............................48             ASENDIN .......................................18           azithromycin ...............................16           dipropionate ...............................61
ANDROGEL...................................45          aspirin and dipyridamole .......32                          AZMACORT ..................................61            benazepril hcl .............................36
anidulafungin .............................20          ATARAX ..........................................20         AZOPT ............................................58     benazepril hcl and hydrochloro-
anidulafungin .............................20          atazanavir sulfate ......................29                 AZULFIDINE .................................55           thiazide .........................................36
ANSAID ..........................................21    atenolol .........................................38        BACITRACIN .................................13           BENEMID .......................................21
ANSAID ..........................................58    atenolol and chlorthalidone..38                             bacitracin ......................................13      BENTYL ..........................................43
ANTABUSE ....................................19        ATGAM ...........................................51         bacitracin ......................................13      benztropine mesylate ..............26
anti-thymocyte globulin                                atomoxetine hydrochloride ...39                             bacitracin zinc and hydrocortisone                       betaine (trimethylglycine).....41
(equine) .........................................51   atomoxetine hydrochloride ...39                             acetate and neomycin sulfate and                         BETAMETHASONE
ANTIVERT ......................................20      atovaquone .................................25              polymyxin b sulfate ..................58                 DIPROPIONAT .............................45
ANTIZOL........................................56      ATRIPLA .........................................28         bacitracin zinc and hydrocortisone                       betamethasone
APOKYN ........................................25      ATROPINE SULFATE ...................43                      acetate and neomycin sulfate and                         dipropionate ...............................45
APOKYN ........................................25      atropine sulfate ..........................43               polymyxin b sulfate .................59                  betamethasone valerate.........45
                                                                                                              65
BETAPACE .....................................34        BUMEX ...........................................34             CAMPATH......................................56        ceftazidime ..................................15
BETAPACE AF ...............................34           BUPHENYL ....................................41                 CAMPRAL......................................19        CEFTIN ...........................................13
BETASERON..................................51           buprenorphine hydrochloride                                     CANASA ........................................55      ceftriaxone sodium ...................15
BETA-VAL ......................................45       and naloxone hydrochloride                                      CANASA ........................................55      cefuroxime axetil .......................13
betaxolol hydrochloride .........58                     dihydrate ......................................19              CAPOTEN ......................................34       CEFZIL ............................................13
betaxolol hydrochloride .........58                     buprenorphine hydrochloride                                     captopril .......................................34    CELEXA ..........................................18
BETOPTIC-S ..................................58         and naloxone hydrochloride                                      CARAFATE .....................................43       CELLCEPT ......................................52
bexarotene...................................24         dihydrate ......................................19              carbachol ......................................58     CELONTIN .....................................16
bexarotene...................................24         bupropion hcl .............................19                   carbamazepine...........................16             CELONTIN .....................................16
BIAXIN ............................................13   BUSPAR ..........................................30             carbamazepine...........................17             CENESTIN ......................................45
bicalutamide ...............................51          buspirone hydrochloride ........30                              carbamazepine...........................30             CENESTIN ......................................48
bisoprolol fumarate ..................38                BYETTA ..........................................31             CARBATROL .................................16          cephalexin....................................14
bisoprolol fumarate ..................38                cabergoline..................................50                 carbenicillin indanyl sodium .14                       CEPHULAC....................................43
bisoprolol fumarate and hydro-                          CAFERGOT ....................................22                 carbidopa anhydrous and                                CEREDASE.....................................56
chlorothiazide.............................38           caffeine and ergotamine                                         levodopa.......................................26      CEREZYME ....................................41
bisoprolol fumarate and hydro-                          tartrate...........................................22           carbidopa anhydrous and                                CEREZYME ....................................41
chlorothiazide.............................38           CALAN ...........................................34             levodopa.......................................26      CHANTIX .......................................19
BLEOMYCIN SULFATE ...............56                     CALAN SR .....................................34                CARDIZEM ....................................34        CHANTIX .......................................19
bleomycin sulfate ......................56              calcipotriene ...............................40                 CARDIZEM LA..............................34            chlorambucil ...............................23
BLEPH-10 ......................................58       calcipotriene ...............................40                 CARDURA .....................................44        CHLORHEXADINE
BOOSTRIX .....................................52        calcitonin, salmon (rdna) ........56                            carisoprodol ................................63        GLUCONATE.................................39
bortezomib ..................................57         calcium (+2) and chloride ion and                               carteolol hcl .................................59      chlorhexidine gluconate.........39
bortezomib ..................................57         dextrose (anhydrous) and lactate                                carvedilol ......................................34    chloroquine phosphate ..........25
bosentan monohydrate ..........62                       anion and potassium (+1) ......63                               CASODEX ......................................51       chlorothiazide.............................35
brimonidine tartrate.................58                 calcium (+2) and chloride ion and                               CATAFLAM....................................21         chlorpromazine
brinzolamide ...............................58          dextrose (anhydrous) and lactate                                CATAPRES .....................................34       hydrochloride .............................27
bromocriptine mesylate .........50                      anion and potassium (+1) ......63                               CEENU............................................23    chlorpropamide .........................31
budesonide..................................43          calcium (+2) and chloride ion and                               cefadroxil monohydrate .........14                     chlorthalidone ............................35
budesonide..................................55          dextrose (anhydrous) and lactate                                cefazolin sodium........................13             cholestyramine...........................37
budesonide..................................55          anion and potassium (+1) ......56                               cefepime hydrochloride..........14                     CHORIONIC
budesonide..................................61          calcium (+2) and chloride ion                                   cefotaxime sodium ...................14                GONADOTROPIN .......................47
budesonide..................................62          and potassium (+1) and sodium                                   CEFOXITIN ....................................13       ciclopirox ......................................21
budesonide..................................62          (+1) .................................................57        cefoxitin sodium ........................13            ciclopirox ......................................21
bumetanide .................................34          calcium acetate ..........................63                    cefprozil ........................................13   cidofovir dihydrate....................29
                                                                                                                   66
cilastatin sodium and                                     codeine phosphate...................12                     cyclosporine ................................59       DDAVP ...........................................45
imipenem .....................................15          COGENTIN ....................................26            cyclosporine ................................59       DDAVP ...........................................48
cilastatin sodium and                                     COLAZAL ......................................55           CYKLOKAPRON ...........................33             DECA- DURABOLIN ...................45
imipenem .....................................15          COLAZAL ......................................55           CYMBALTA ....................................18       DECADRON ..................................45
cilostazol .......................................33      COLCHICINE .................................21             CYMBALTA ....................................18       DECAVAC ......................................52
cimetidine ....................................44         colchicine .....................................21         CYPROHEPTADINE HCL ...........61                      deferasirox ...................................19
cinacalcet hydrochloride ........50                       COLESTID ......................................34          cyproheptadine                                        deferasirox ...................................33
CIPRO .............................................14     colestipol hydrochloride .........34                       hydrochloride .............................61         DELATESTRYL ..............................45
CIPRODEX .....................................60          COMBIVENT .................................61              cyproheptadine                                        delavirdine mesylate ................29
ciprofloxacin................................14           COMBIVIR .....................................28           hydrochloride .............................61         DELTASONE ..................................55
ciprofloxacin hcl and dexametha-                          COMPAZINE .................................20              CYSTADANE .................................41         DEMADEX .....................................34
sone ................................................60   COMPAZINE .................................26              CYSTAGON ...................................41        DEMEROL......................................12
citalopram hydrobromide ......18                          COMTAN........................................26           CYSTAGON ...................................41        DENAVIR........................................39
CLAFORAN ...................................14            COMVAX........................................52           cysteamine bitartrate...............41                denileukin diftitox .....................57
clarithromycin.............................13             CONDYLOX...................................40              cysteamine bitartrate...............41                denileukin diftitox .....................57
CLEMASTINE FUMARATE.........61                            COPAXONE ...................................52             CYTOMEL ......................................45      DEPAKENE ....................................16
clemastine fumarate ................61                    CORDARONE ...............................34                CYTOMEL ......................................49      DEPAKENE ....................................30
clemastine fumarate ................62                    COREG ...........................................34        CYTOTEC .......................................45     DEPAKOTE ....................................30
CLEOCIN........................................14         CORGARD .....................................34            CYTOVENE ....................................28       DEPAKOTE ....................................30
CLIMARA .......................................45         CORTIFOAM .................................45              DANAZOL .....................................45       DEPAKOTE ER ..............................30
CLIMARA .......................................48         CORTISONE ACETATE................55                        DANAZOL .....................................48       DEPAKOTE SPRINKLES ..............30
clindamycin hydrochloride ....14                          cortisone acetate .......................55                danazol..........................................45   DEPO PROVERA ..........................49
clindamycin phosphate ..........14                        cortisone acetate .......................55                danazol..........................................48   DEPO-TESTOSTERONE .............45
CLINDESSE ...................................14           CORTISPORIN ..............................58               DAPSONE......................................22       DERMATOP ...................................45
CLINORIL .......................................21        CORTONE ......................................55           dapsone ........................................22    DERMOTIC ....................................60
clobetasol propionate .............47                     COSOPT .........................................58         DAPTACEL.....................................52       desipramine hydrochloride ...18
clomipramine hcl.......................18                 COUMADIN ..................................32              DARAPRIM....................................25        desmopressin acetate..............45
clonidine hydrochloride..........34                       COZAAR ........................................34          darbepoetin alfa ........................32           desmopressin acetate..............48
clopidogrel bisulfate ................33                  CRESTOR .......................................34          darbepoetin alfa ........................32           DESOCORT ...................................45
clotrimazole.................................21           CRIXIVAN.......................................28          darunavir ......................................28    desonide .......................................45
clozapine ......................................26        cromolyn sodium ......................61                   DARVOCET ...................................12        desoximetasone.........................47
clozapine ......................................26        cyclobenzaprine                                            dasatinib .......................................24   DESYREL ........................................18
CLOZARIL......................................26          hydrochloride .............................62              dasatinib .......................................24   dexamethasone .........................45
CODEINE PHOSPHATE..............12                         cyclosporine ................................53            DAYPRO .........................................21    dexamethasone and neomycin
                                                                                                                67
sulfate and polymyxin                                     diazoxide ......................................32            DIPIVEFRIN HCL ..........................58             DOXYCYCLINE HYCLATE ..........39
b sulfate ........................................59      diclofenac potassium ...............21                        dipivefrin hydrochloride .........58                    doxycycline hyclate ..................14
dexamethasone and tobramycin                              diclofenac potassium ...............22                        dipivefrin hydrochloride .........59                    doxycycline hyclate ..................39
sulfate ............................................57    diclofenac sodium.....................41                      DIPROLENE AF ............................45             doxycycline hyclate ..................39
DEXAMETHASONE SODIUM                                      diclofenac sodium.....................41                      DIPTHERIA/TETANUS                                       DOXYCYCLINE
PHOS ..............................................60     dicloxacillin sodium ..................14                     TOXOID ..........................................52     MONOHYDRATE .........................40
dexamethasone sodium phos-                                dicyclomine hydrochloride ....43                              DIPYRIDAMOLE ..........................33               doxycycline monohydrate .....40
phate ..............................................60    didanosine ...................................29              dipyridamole...............................33           duloxetine hydrochloride .......18
DEXCHLORPHENIRAMINE                                       DIDRONEL ....................................55               dipyridamole...............................33           duloxetine hydrochloride .......18
MALEA ...........................................61       DIFFERIN .......................................40            DISOPYRAMIDE PHOSPHATE.34                               DURAGESIC ..................................12
dexchlorpheniramine                                       diflorasone diacetate ...............47                       disopyramide phosphate .......34                        DURICEF ........................................14
maleate .........................................61       DIFLUCAN.....................................20               disopyramide phosphate .......37                        DYAZIDE ........................................35
dexchlorpheniramine                                       DIFLUCAN IV ................................20                disulfiram......................................19      DYNACIRC ....................................35
maleate .........................................61       diflunisal .......................................21          DITROPAN.....................................44         DYNAPEN......................................14
DEXEDRINE ..................................39            DIGOXIN ........................................34            DITROPAN XL...............................44            ECONAZOLE NITRATE ...............20
dextroamphetamine sulfate..39                             digoxin ..........................................34          DIURIL ............................................35   econazole nitrate .......................20
dextrose (anhydrous) and penicil-                         digoxin ..........................................35          divalproex sodium ....................30                econazole nitrate .......................21
lin g potassium ...........................15             DILANTIN ....................................16               divalproex sodium ....................30                EES ..................................................14
dextrose (anhydrous) and penicil-                         DILANTIN INFATABS ..................16                        divalproex sodium ....................30                efavirenz .......................................29
lin g potassium ...........................15             DILAUDID .....................................12              dofetilide ......................................38     efavirenz and emtricitabine
DEXTROSE 5%/LACTATED                                      diltiazem hydrochloride ..........34                          DOLOBID.......................................21        and tenofovir disoproxil
RING................................................63    diltiazem hydrochloride ..........34                          DOLOPHINE .................................12           fumarate .......................................28
dha ethyl ester and epa ethyl ester                       DIPHENHYDRAMINE HCL........26                                 donepezil hydrochloride ........17                      EFFEXOR........................................18
and omega-3-acid ethyl                                    diphenhydramine                                               dorzolamide hydrochloride and                           EFUDEX .........................................40
esters ..............................................36   hydrochloride .............................26                 timolol maleate ..........................58            ELAPRASE .....................................41
dha ethyl ester and epa ethyl ester                       diphtheria toxoid and tetanus                                 DOSTINEX .....................................50        ELAPRASE .....................................42
and omega-3-acid ethyl                                    toxoid .............................................52        DOVONEX.....................................40          ELAVIL ............................................18
esters ..............................................36   diphtheria toxoid and tetanus                                 DOVONEX.....................................40          ELDEPRYL .....................................26
DIABETA ........................................31        toxoid .............................................52        doxazosin mesylate ..................44                 ELIDEL ............................................40
DIABETIC SUPPLIES, MISC.......31                          diphtheria toxoid and tetanus                                 DOXEPIN HCL ..............................40            ELIDEL ............................................40
DIABETIC SUPPLIES, MISC.......31                          toxoid .............................................54        doxepin hydrochloride ............40                    ELIMITE ..........................................25
DIABINESE ....................................31          diphtheria toxoid crm-197 and                                 doxepin hydrochloride ............41                    ELITEK ............................................56
DIAMOX ........................................34         haemophilus b oligosaccharide                                 doxercalciferol ............................56          ELITEK ............................................56
DIAMOX ........................................58         conj vacc .......................................52           DOXYCYCLINE HYCLATE ..........14                        ELMIRON .......................................44
                                                                                                                   68
EMCYT ...........................................23      ERAXIS ...........................................20        synthetic a ....................................48        drone acetate ..............................46
EMEND...........................................20       ERAXIS ...........................................20        estropipate...................................46          ethinyl estradiol and norethin-
EMSAM ..........................................18       ERGOLOID MESYLATES ............17                           estropipate...................................49          drone acetate ..............................49
EMSAM ..........................................18       ergot alkaloids, hydrogenated                               etanercept....................................52          ethinyl estradiol and norethin-
emtricitabine...............................28           (mesylate) .....................................17          etanercept....................................52          drone acetate ..............................49
emtricitabine and tenofovir                              erlotinib ........................................24        ethambutol hydrochloride ....23                           ethinyl estradiol and
disoproxil fumarate ..................29                 erlotinib ........................................24        ethinyl estradiol and ferrous                             norgestimate...............................47
EMTRIVA ........................................28       ERYTAB ..........................................14         fumarate and norethindrone                                ethinyl estradiol and
enalapril maleate .......................38              ERYTHROCIN ...............................14                acetate ...........................................46     norgestimate...............................47
enalapril maleate and                                    erythromycin...............................14               ethinyl estradiol and ferrous                             ethinyl estradiol and
hydrochlorothiazide .................38                  erythromycin ethylsuccinate 14                              fumarate and norethindrone                                norgestimate...............................49
ENBREL ..........................................52      erythromycin lactobionate ....14                            acetate ...........................................49     ethinyl estradiol and
ENBREL ..........................................52      escitalopram oxalate ................18                     ethinyl estradiol and ferrous                             norgestimate...............................49
enfuvirtide ...................................28        ESKALITH ......................................30           fumarate and norethindrone                                ethosuximide ..............................17
ENGERIX-B ....................................52         ESKALITH ......................................30           acetate ...........................................49     ethotoin ........................................17
enoxaparin sodium...................33                   ESKALITH CR ................................30              ethinyl estradiol and levonorg-                           etidronate disodium.................55
entacapone..................................26           ESKALITH ER ................................30              estrel...............................................45   etodolac ........................................21
entecavir monohydrate...........56                       estradiol ........................................45        ethinyl estradiol and levonorg-                           etodolac ........................................21
entecavir monohydrate...........56                       estradiol ........................................48        estrel...............................................46   EVISTA ............................................45
ENTOCORT EC .............................43              estramustine phosphate                                      ethinyl estradiol and levonorg-                           EVISTA ............................................49
ENTOCORT EC .............................55              sodium ..........................................23         estrel...............................................47   EXELON .........................................17
ENTOCORT EC .............................55              estrogens, conjugated .............47                       ethinyl estradiol and levonorg-                           exemestane .................................23
epinephrine hydrochloride....61                          estrogens, conjugated .............49                       estrel...............................................48   exenatide......................................31
EPIPEN 2-PAK...............................61            estrogens, conjugated and me-                               ethinyl estradiol and levonorg-                           EXJADE ..........................................19
EPIVIR .............................................28   droxyprogesterone acetate ...49                             estrel...............................................48   EXJADE ..........................................33
eplerenone ..................................35          estrogens, conjugated and me-                               ethinyl estradiol and levonorg-                           EXSEL .............................................40
eplerenone ..................................35          droxyprogesterone acetate ...49                             estrel...............................................49   ezetimibe......................................38
epoetin alfa..................................33         estrogens, conjugated and me-                               ethinyl estradiol and norethin-                           FABRAZYME .................................42
epoetin alfa..................................33         droxyprogesterone acetate ...47                             drone..............................................47     FABRAZYME .................................42
epoetin alfa..................................33         estrogens, conjugated and me-                               ethinyl estradiol and norethin-                           famotidine ...................................43
EPOGEN.........................................33        droxyprogesterone acetate ...47                             drone..............................................49     FARESTON.....................................23
EPOGEN.........................................33        estrogens, conjugated                                       ethinyl estradiol and norethin-                           FARESTON.....................................23
EPZICOM .......................................28        synthetic a ....................................45          drone acetate ..............................46            FAZACLO .......................................26
EQUANIL .......................................30        estrogens, conjugated                                       ethinyl estradiol and norethin-                           felbamate .....................................16
                                                                                                                69
FELBATOL .....................................16           FLUORIDE .....................................63               FORTICAL......................................56             glipizide ........................................31
FELDENE .......................................12          fluoride preparation .................63                       FOSAMAX .....................................56              glipizide ........................................31
felodipine .....................................37         fluoride prepartion ...................63                      fosamprenavir calcium ............28                         glipizide ........................................31
FEMARA ........................................23          fluorometholone .......................58                      FOSCARNET SODIUM ...............28                           glipizide and metformin hydro-
fenofibrate ...................................35          fluorouracil...................................40              foscarnet sodium .......................28                   chloride .........................................31
fenoprofen calcium ..................22                    fluoxetine hcl ..............................18                fosinopril sodium ......................36                   GLIPIZIDE XL ................................31
fentanyl .........................................12       fluphenazine decanoate .........27                             fosinopril sodium and hydrochloro-                           globulin, immune iv (baxter/am
fentanyl citrate ...........................12             fluphenazine decanoate .........27                             thiazide .........................................36         red cros) ........................................53
FENTANYL CITRATE ORAL                                      fluphenazine hydrochloride ..27                                FOSRENOL ....................................44              GLUCAGON EMERGENCY KIT 31
TRA..................................................12    flurbiprofen..................................21               furosemide...................................35              glucagon rdna (human recombi-
fexofenadine hydrochloride ..60                            FLURBIPROFEN SODIUM .........58                                FUZEON.........................................28            nant) ...............................................31
fexofenadine hydrochloride                                 flurbiprofen sodium .................58                        gabapentin ..................................17              GLUCOPHAGE .............................31
and pseudoephedrine hydrochlo-                             flurbiprofen sodium .................58                        GABITRIL .......................................16           GLUCOTROL.................................31
ride..................................................60   FLUTAMIDE ..................................23                 galantamine hydrobromide ..17                                GLUCOTROL XL...........................31
filgrastim.......................................33        FLUTAMIDE ..................................23                 galantamine hydrobromide ..17                                glyburide ......................................31
filgrastim.......................................33        flutamide ......................................23             galantamine hydrobromide ..17                                glyburide ......................................31
finasteride ....................................44         flutamide ......................................23             galantamine hydrobromide ..17                                glycerin and phospholipids
FLAGYL ..........................................40        fluticasone propionate ............61                          galsulfase......................................42           and safflower oil and soybean
FLECAINIDE ACETATE ...............35                       fluticasone propionate ............61                          galsulfase......................................42           oil.....................................................56
flecainide acetate ......................35                fluticasone propionate and salme-                              ganciclovir....................................28            glycopyrrolate.............................44
flecainide acetate ......................38                terol xinafoate.............................60                 GARAMYCIN ................................14                 GLYSET ...........................................31
FLEXERIL .......................................62         fluticasone propionate and salme-                              GARDASIL .....................................52             gonadotropin, chorionic.........46
FLOMAX ........................................51          terol xinafoate.............................60                 gatifloxacin ..................................60            gonadotropin, chorionic.........47
FLONASE .......................................61          fluvoxamine maleate ...............18                          gatifloxacin ..................................60            goserelin acetate .......................50
FLORINEF ......................................45          FML .................................................58        gauze pads & dressings - pads 2” x                           goserelin acetate .......................50
FLOVENT HFA ..............................61               FOLEX ............................................52           2”......................................................31   gramicidin and neomycin sulfate
FLOXIN OTIC ................................60             fomepizole                                                     gemfibrozil...................................35             and polymyxin b sulfate .........59
fluconazole ..................................20           (4-methylpyrazole)....................56                       gentamicin sulfate ....................14                    granisetron hcl ...........................20
fluconazole and sodium                                     fondaparinux sodium ..............32                           GEOCILLIN ....................................14             GRIFULVIN V.................................20
chloride .........................................20       fondaparinux sodium ..............32                           GEODON .......................................26             griseofulvin ..................................20
fludrocortisone acetate ...........45                      FORADIL AEROLIZER ................61                           GEODON .......................................26             griseofulvin ultramicrosize.....20
FLUMADINE .................................28              formoterol fumarate.................61                         glatiramer acetate .....................52                   GRIS-PEG .......................................20
fluocinolone acetonide ...........47                       FORTEO .........................................55             GLEEVEC........................................23            guanabenz acetate ...................38
fluocinolone acetonide ...........60                       FORTEO .........................................55             glimepiride ..................................31             guanfacine hcl ............................38
                                                                                                                     70
GUANIDINE HCL .........................22                 hydrochlorothiazide and pro-                                     hydrochloride .............................12         indomethacin .............................21
guanidine hydrochloride ........22                        pranolol hydrochloride ...........35                             hydroxychloroquine sulfate ..25                       INSPRA...........................................35
haemophilus b polysaccharide conj                         hydrochlorothiazide and                                          hydroxyurea ................................23        INSPRA...........................................35
vacc.................................................51   lisinopril ........................................37            hydroxyzine pamoate ..............20                  insulin aspart
haemophilus b polysaccharide conj                         hydrochlorothiazide and                                          hydroxyzine pamoate ..............20                  (human analog)..........................32
vacc and hepatitis b virus vaccine                        lisinopril ........................................38            HYGROTON ..................................35         insulin aspart (human analog) and
recombinant................................52             hydrochlorothiazide and losartan                                 HYTRIN ..........................................44   insulin aspart protamine ........32
HALDOL ........................................26         potassium.....................................35                 HYZAAR.........................................35     insulin glargine...........................31
HALOBETASOL PROPIONATE .45                                hydrochlorothiazide and methyl-                                  ibuprofen......................................22     insulin human (regular)...........32
halobetasol propionate...........45                       dopa ...............................................33           idursulfase....................................41     insulin human (regular)...........32
halobetasol propionate...........47                       hydrochlorothiazide and methyl-                                  idursulfase....................................42     insulin human (regular) and insulin
haloperidol ..................................26          dopa ...............................................34           imatinib mesylate......................23             human, isophane (nph) ...........31
HAVRIX...........................................52       hydrochlorothiazide and metopro-                                 IMDUR............................................35   insulin human,
HCG.................................................46    lol tartrate.....................................35              imiglucerase ................................41       isophane (nph) ...........................32
HECTOROL ...................................56            hydrochlorothiazide and quinapril                                imiglucerase ................................41       INTAL INHALER ...........................61
HEPARIN SODIUM ......................56                   hcl....................................................33        imipramine hydrochloride .....19                      interferon alfa-2a .......................54
heparin sodium (porcine) .......56                        hydrochlorothiazide and spirono-                                 IMIPRAMINE PAMOATE ............18                     interferon alfa-2b ......................53
hepatitis a virus vaccine inacti-                         lactone...........................................33             imipramine pamoate ...............18                  interferon beta-1a .....................51
vated ..............................................52    hydrochlorothiazide and triam-                                   imiquimod ...................................40       interferon beta-1a .....................51
hepatitis a virus vaccine inacti-                         terene.............................................35            imiquimod ...................................40       interferon beta-1b.....................51
vated ..............................................54    HYDROCORDONE ......................46                            IMITREX .........................................22   interferon gamma-1b ..............51
hepatitis a virus vaccine inacti-                         hydrocortisone ...........................46                     IMODIUM ......................................43      interferon gamma-1b ..............51
vated and hepatitis b virus vaccine                       hydrocortisone acetate ...........45                             IMOVAX RABIES (H.D.C.V.) .......52                    INTRON-A .....................................53
recombinant................................54             hydrocortisone and neomycin                                      IMURAN.........................................53     INVEGA ..........................................26
hepatitis b virus vaccine recombi-                        sulfate and polymyxin b                                          INCRELEX ......................................46     INVEGA ..........................................26
nant ................................................52   sulfate ............................................60           INCRELEX ......................................48     INVIRASE .......................................28
HEPSERA .......................................28         HYDROCORTISONE                                                   INDAPAMIDE ...............................35          IPOL INACTIVATED IPV .............53
HEXALEN.......................................23          BUTYRATE .....................................46                 indapamide .................................35        ipratropium bromide ...............61
HIBTITER ........................................52       hydrocortisone butyrate .........46                              indapamide .................................36        isocarboxazid ..............................26
HUMIRA.........................................52         HYDROCORTISONE                                                   INDERAL ........................................22    ISONIAZID ....................................22
HUMIRA.........................................52         VALERATE......................................46                 INDERAL ........................................35    isoniazid ........................................22
hydralazine hydrochloride .....34                         hydrocortisone valerate ..........46                             INDERIDE ......................................35     isopropyl alcohol .......................31
HYDREA .........................................23        HYDRODIURIL .............................35                      indinavir sulfate .........................28         ISORDIL .........................................35
hydrochlorothiazide .................35                   hydromorphone                                                    INDOCIN........................................21     isosorbide dinitrate...................35
                                                                                                                      71
isosorbide mononitrate ..........35                     LAMICTAL .....................................17              LEVO-DROMORAN ....................12                    lithium carbonate......................30
isotretinoin ..................................40       LAMICTAL CHEWABLE..............17                             levofloxacin hemihydrate .......14                      LITHIUM CITRATE .......................30
isradipine ......................................35     LAMISIL..........................................20           levonorgestrel ............................46           lithium citrate .............................30
itraconazole .................................21        LAMISIL..........................................20           levorphanol tartrate .................12                lithium citrate .............................30
JANUVIA........................................31       lamivudine ...................................28              levothyroxine sodium ..............46                   LODINE ..........................................21
japanese encephalitis                                   lamivudine and zidovudine ...28                               levothyroxine sodium ..............47                   LODINE XL ....................................21
virus vaccine ................................53        lamotrigine ..................................17              levothyroxine sodium ..............50                   lodoxamide tromethamine (tro-
JE-VAX ............................................53   lamotrigine ..................................17              levothyroxine sodium ..............50                   metamol) ......................................57
KALETRA .......................................28       LANOXIN .......................................35             LEVOXYL .......................................46       LOFIBRA ........................................35
kanamycin sulfate .....................14               lansoprazole ................................43               LEVOXYL .......................................50       LOMOTIL .......................................43
KANTREX.......................................14        lansoprazole ................................43               LEXAPRO .......................................18       lomustine .....................................23
KAYEXALATE ................................19           lansoprazole ................................44               LEXIVA............................................28    LONITEN ........................................35
KCL 0.3%/D5W/LR IV LAC RI...63                          lanthanum carbonate ..............44                          lidocaine .......................................13     LOPERAMIDE HCL ......................43
K-DUR.............................................63    LANTUS .........................................31            lidocaine .......................................13     loperamide hydrochloride .....43
KEFLEX ...........................................14    LARIAM ..........................................25           lidocaine and prilocaine .........13                    loperamide hydrochloride .....43
KENALOG ......................................46        laronidase .....................................41            lidocaine hydrochloride ..........13                    LOPID .............................................35
KEPPRA ..........................................17     laronidase .....................................41            LIDOCAINE/PRILOCAINE .........13                        lopinavir and ritonavir .............28
KERLONE .......................................58       LASIX ..............................................35        LIDODERM....................................13          LOPRESSOR ..................................35
KETEK .............................................14   latanoprost ..................................60              LIDODERM....................................13          LOPRESSOR HCT ........................35
KETEK .............................................14   latanoprost ..................................60              LINCOCIN ......................................14       losartan potassium ...................34
ketoconazole...............................21           LEFLUNOMIDE ............................53                    LINCOCIN ......................................14       LOTENSIN......................................36
ketoprofen ...................................22        leflunomide .................................51               lincomycin hydrochloride ......14                       LOTENSIN HCT ............................36
ketorolac tromethamine .........12                      leflunomide .................................53               lincomycin hydrochloride ......14                       LOTREL...........................................36
ketorolac tromethamine .........57                      lenalidomide ...............................24                LINDANE .......................................25       LOTRONEX....................................43
KINERET .........................................53     lenalidomide ...............................24                lindane ..........................................25    lovastatin ......................................36
KLOR-CON ....................................63         LESSINA-28 ..................................46               linezolid.........................................16    LOVAZA .........................................36
KRISTALOSE..................................43          LESSINA-28 ..................................48               linezolid.........................................16    LOVAZA .........................................36
KYTRIL ............................................20   letrozole ........................................23          liothyronine sodium .................45                 LOVENOX ......................................33
labetalol hydrochloride ...........38                   LEUKERAN ....................................23               liothyronine sodium .................49                 loxapine succinate ....................26
LAC-HYDRIN ................................40           leuprolide acetate .....................50                    LIPOSYN II .....................................56      LOXITANE ......................................26
LACTATED RINGER’S                                       LEVAQUIN .....................................14              lisinopril ........................................37   LOZOL ............................................36
DEXTROS ......................................56        levetiracetam ..............................17                lisinopril ........................................38   lubiprostone ................................43
lactulose .......................................43     LEVOBUNOLOL HCL..................58                           lithium carbonate......................30               LUDIOMIL .....................................18
lactulose .......................................43     levobunolol hydrochloride ....58                              lithium carbonate......................30               LUPRON.........................................50
                                                                                                                 72
LUVOX............................................18     acetate ...........................................49         methimazole ...............................51         METHYLPREDNISOLONE
LYRICA............................................17    mefloquine hcl ...........................25                  methimazole ...............................51         SODIUM ........................................46
LYSODREN ....................................50         MEFOXIN.......................................15              methocarbamol .........................63             methylprednisolone sodium suc-
MACROBID ...................................14          MEGACE ........................................23             METHOTREXATE .........................53              cinate .............................................46
MACRODANTIN ..........................14                megestrol acetate .....................23                     methotrexate ..............................52         METIPRANOLOL .........................58
maprotiline hydrochloride .....18                       MELLARIL ......................................26             methotrexate ..............................53         metipranolol................................58
MARPLAN .....................................26         meloxicam....................................22               methoxsalen................................40         metoclopramide
MATULANE ...................................23          memantine hydrochloride .....17                               methoxsalen................................40         hydrochloride .............................20
MAVIK.............................................36    MENACTRA ..................................53                 methoxsalen................................40         METOLAZONE .............................36
MAXAIR AUTOHALER ...............61                      meningococcal polysaccharide vac                              methoxsalen................................40         metolazone..................................36
MAXALT ........................................22       a-c-y-w ...........................................53         METHSCOPOLAMINE                                       metolazone..................................38
MAXALT-MLT................................22            meperidine hydrochloride .....12                              BROMIDE ......................................43      metoprolol succinate ...............38
MAXIPIME .....................................14        meprobamate .............................30                   methscopolamine bromide ...43                         metoprolol tartrate ...................35
measles virus vaccine live.......51                     MEPRON........................................25              methscopolamine bromide ...43                         METRONIDAZOLE ......................40
measles virus vaccine live and                          mercaptopurine .........................24                    methsuximide.............................16           metronidazole ............................40
mumps virus vaccine live and                            meropenem.................................15                  methsuximide.............................16           metronidazole ............................40
rubella virus vaccine live and                          MERREM ........................................15             methyldopa .................................33        MEVACOR .....................................36
varicella virus vaccine live ......54                   MERUVAX II W/DILUENT                                          METHYLIN.....................................39       MEXILETINE HCL ........................36
measles virus vaccine live and                          1 DO................................................53        METHYLIN ER...............................39          mexiletine hydrochloride .......36
mumps virus vaccine live and                            mesalamine (5-asa) ...................55                      METHYLPHENIDATE HCL.........39                        mexiletine hydrochloride .......36
rubella virus vaccine live .........53                  mesalamine (5-asa) ...................55                      methylphenidate                                       MEXITIL..........................................36
measles virus vaccine live and                          mesalamine (5-asa) ...................55                      hydrochloride .............................39         MICROGESTIN 1.5/30................46
mumps virus vaccine live and                            mesna ............................................23          methylphenidate                                       MICROGESTIN 1.5/30................49
rubella virus vaccine live .........53                  MESNEX.........................................23             hydrochloride .............................39         MICROGESTIN 1/20 ...................46
measles virus vaccine live and                          MESTINON....................................22                methylphenidate                                       MICROGESTIN 1/20 ...................49
rubella virus vaccine live........53                    METADATE CD.............................39                    hydrochloride .............................39         MICROGESTIN FE .......................46
mebendazole ..............................25            METAGLIP .....................................31              methylphenidate                                       MICROGESTIN FE .......................49
mecasermin .................................46          metaxalone ..................................63               hydrochloride .............................39         MICROGESTIN FE 1.5/30 ..........49
mecasermin .................................48          metformin hydrochloride .......31                             methylphenidate                                       MICRONASE .................................31
meclizine hydrochloride .........20                     methadone hydrochloride .....12                               hydrochloride .............................39         MIDAMOR.....................................36
MEDROL ........................................46       METHAZOLAMIDE .....................36                         METHYLPREDNISOLONE                                    miglitol ..........................................31
medroxyprogesterone                                     methazolamide ..........................36                    ACETAT ..........................................46   miglustat ......................................42
acetate ...........................................47   methazolamide ..........................36                    methylprednisolone acetate .46                        miglustat ......................................42
medroxyprogesterone                                     METHIMAZOLE ...........................51                     methylprednisolone acetate .46                        MINIPRESS ....................................44
                                                                                                                 73
MINOCIN .......................................39      morphine sulfate .......................12                    naloxone hydrochloride..........19                    NEPTAZANE .................................36
MINOCYCLINE HCL ....................15                 MOTRIN .........................................22            NALTREXONE HCL .....................19                NEULASTA ....................................33
minocycline hydrochloride ....15                       moxifloxacin hydrochloride...13                               naltrexone hydrochloride.......19                     NEULASTA ....................................33
minocycline hydrochloride ....39                       moxifloxacin hydrochloride...59                               NAMENDA ....................................17        NEUPOGEN ..................................33
MINOXIDIL....................................36        moxifloxacin hydrochloride...59                               NANDROLONE DECANOATE ..48                             NEUPOGEN ..................................33
minoxidil .......................................35    M-R-VAX II .....................................53            nandrolone decanoate ............45                   NEURONTIN .................................17
minoxidil .......................................36    MS CONTIN ..................................12                nandrolone decanoate ............48                   NEUTREXIN ..................................57
MIOSTAT ........................................58     MSIR................................................12        NAPHAZOLINE HCL...................58                  nevirapine ....................................29
MIRALAX .......................................43      mumps virus vaccine live .......53                            naphazoline hydrochloride ...58                       NEXAVAR.......................................24
mirtazapine .................................19        MUMPSVAX W/DILUENT                                            naproxen ......................................22     NEXAVAR.......................................24
MISOPROSTOL ............................48             1 DOSE ...........................................53          naproxen sodium ......................21              niacin .............................................36
misoprostol..................................45        MUPIROCIN ..................................15                NAPROXSYN ................................22          NIASPAN........................................36
misoprostol..................................48        mupirocin .....................................15             NARCAN ........................................19     nifedipine .....................................37
mitotane .......................................50     mupirocin .....................................40             NARDIL ..........................................18   nifedipine .....................................37
MITOXANTRONE HCL ...............24                     MYAMBUTOL ...............................23                   NASONEX .....................................61       NILANDRON ................................24
mitoxantrone hydrochloride .24                         MYCELEX.......................................21              NAVANE .........................................27    nilutamide ....................................24
mitoxantrone hydrochloride .24                         MYCIFRADIN ................................15                 NEBUPENT ....................................25       nitisinone......................................42
M-M-R II W/DILUENT 1 DOSE .53                          MYCOBUTIN .................................23                 nedocromil sodium ..................62                NITRO-BID ....................................37
M-M-R II W/DILUENT 10 DOS .53                          mycophenolate mofetil...........52                            needles, insulin disposable ....31                    NITRODERM .................................37
MOBAN..........................................27      MYOZYME ....................................42                NEFAZODONE HCL ....................18                 NITRO-DUR ..................................37
MOBIC ............................................22   MYOZYME ....................................42                nefazodone hydrochloride ....18                       nitrofurantoin
modafinil ......................................39     MYSOLINE ....................................17               nefazodone hydrochloride ....19                       macrocrystalline ........................14
MOEXIPRIL HCL ..........................36             nabumetone ...............................22                  nelfinavir mesylate....................29             nitrofurantoin
moexipril hydrochloride .........36                    NADOLOL .....................................36               NEO/POLY/BAC/HC ...................58                 macrocrystalline ........................14
molindone hydrochloride ......27                       nadolol ..........................................34          neomycin sulfate .......................15            NITROGLYCERIN .........................37
MOMETASONE FUROATE ........46                          nadolol ..........................................36          NEOMYCIN/BACITRACIN/                                  nitroglycerin ................................37
mometasone furoate ...............46                   NAFCILLIN SODIUM ..................15                         POLYM ...........................................58   nitroglycerin ................................37
mometasone furoate                                     nafcillin sodium..........................15                  NEOMYCIN/POLYMYXIN/                                   nitroglycerin ................................37
monohydrate ..............................61           nafcillin sodium..........................16                  DEXAME ........................................59     nitroglycerin ................................37
MONOPRIL ...................................36         naftifine hydrochloride ...........21                         NEOMYCIN/POLYMYXIN/                                   nitroglycerin ................................37
MONOPRIL HCT ..........................36              NAFTIN ..........................................21           GRAMIC .........................................59    NITROSTAT ...................................37
montelukast sodium ................62                  NAGLAZYME................................42                   NEOMYCIN/POLYMYXIN/                                   nizatidine......................................43
morphine sulfate .......................12             NAGLAZYME................................42                   HYDROC ........................................60     NIZORAL .......................................21
morphine sulfate .......................12             NALFON ........................................22             NEORAL .........................................53    NOLVADEX ...................................24
                                                                                                                74
NORDITROPIN CARTRIDGE.....46                           OPTIVAR ........................................59           PAMELOR ......................................18         PENICILLIN G POTASSIUM IN .15
NORDITROPIN CARTRIDGE.....48                           ORAP ..............................................27        PAMINE ..........................................43      penicillin v potassium ..............15
NORETHINDRONE ACETATE ...49                            ORAPRED ......................................55             PANCREASE MT 10.....................42                   PENLAC NAIL LACQUER...........21
norethindrone acetate ............46                   ORFADIN .......................................42            PANCREASE MT 16.....................42                   PENLAC NAIL LACQUER...........21
norethindrone acetate ............49                   ORINASE........................................32            PANCREASE MT 20.....................42                   pentamidine isethionate ........25
NORFLEX.......................................62       orphenadrine citrate ................62                      PANCREASE MT 4 .......................42                 PENTIDS ........................................15
NORLUTIN.....................................46        orphenadrine citrate ................62                      PANCRELIPASE ............................42              pentosan polysulfate
NORPACE ......................................37       ORPHENADRINE CITRATE ER..62                                  PANGLOBULIN ............................53               sodium ..........................................44
NORPRAMIN ................................18           ORTHO-EST ..................................46               PANRETIN .....................................24         pentoxifylline ..............................57
nortriptyline hydrochloride ...18                      ORTHO-EST ..................................49               papaverine hydrochloride......37                         PEPCID ...........................................43
NORVIR ..........................................28    ORUDIS ..........................................22          paricalcitol ...................................56       PERCOCET ....................................12
NOVANTRONE.............................24              OXACILLIN SODIUM ..................15                        PARLODEL.....................................50          PERIACTIN ....................................61
NOVOLIN 70/30 ..........................31             oxacillin sodium .........................13                 PARNATE .......................................18        PERMETHRIN ...............................25
NOVOLIN N ..................................32         oxacillin sodium .........................15                 paroxetine hydrochloride.......18                        permethrin...................................25
NOVOLIN R ...................................32        OXANDROLONE .........................46                      paroxetine hydrochloride.......30                        permethrin...................................25
NOVOLIN R U-100 ......................32               OXANDROLONE .........................48                      PATADAY .......................................59        PERPHENAZINE ..........................27
NOVOLOG.....................................32         oxandrolone ................................46               PAVABID ........................................37       perphenazine..............................27
NOVOLOG MIX 70/30 ...............32                    oxandrolone ................................48               PAXIL ..............................................18   perphenazine..............................27
NYSTATIN ......................................21      oxaprozin......................................21            PAXIL ..............................................30   PERSANTINE ................................33
nystatin .........................................21   oxcarbazepine ............................17                 PEDIAPRED...................................55           phenelzine sulfate .....................18
octreotide acetate .....................50             OXSORALEN ................................40                 PEDIARIX .......................................53       PHENERGAN ................................20
OCUPRES ......................................59       OXSORALEN ................................40                 pegademase bovine.................41                     PHENYTEK ....................................17
ofloxacin .......................................60    OXSORALEN ULTRA...................40                         pegademase bovine.................41                     phenytoin .....................................16
olanzapine ...................................27       OXSORALEN ULTRA...................40                         PEGANONE ..................................17            phenytoin sodium.....................16
olanzapine ...................................27       oxybutynin chloride .................44                      PEGASYS .......................................54        phenytoin sodium.....................17
olanzapine ...................................30       oxybutynin XL.............................44                 pegfilgrastim ...............................33          PHOSLO .........................................63
olopatadine .................................59        oxycodone hydrochloride ......12                             pegfilgrastim ...............................33          pimecrolimus ..............................40
omalizumab ................................54          oxycodone hydrochloride ......12                             peginterferon alfa-2a ...............54                  pimecrolimus ..............................40
omalizumab ................................54          OXYCONTIN .................................12                peginterferon alfa-2b...............54                   pimozide.......................................27
omeprazole..................................44         OXYTOCIN ....................................48              PEG-INTRON ................................54            pioglitazone hydrochloride ...31
ondansetron................................20          oxytocin ........................................46          pegvisomant ...............................50            piperacillin sodium ...................15
ondansetron hcl.........................20             oxytocin ........................................48          pegvisomant ...............................50            PIPRACIL........................................15
ONTAK ...........................................57    paliperidone ................................26              PEN VK ...........................................15     pirbuterol acetate......................61
ONTAK ...........................................57    paliperidone ................................26              penciclovir ...................................39        piroxicam......................................12
                                                                                                               75
PITOCIN .........................................46      prednisolone acetate ...............59                      PRINCIPEN ....................................15       protriptyline hydrochloride ...19
PLAN B ...........................................46     prednisolone acetate ...............59                      PRINIVIL .........................................37   PROVENTIL ...................................61
PLAQUENIL ..................................25           PREDNISOLONE SODIUM                                         PRINZIDE.......................................37      PROVERA ......................................47
PLAVIX ...........................................33     PHOSP............................................55         PROAIR HFA .................................61         PROVIGIL.......................................39
PLENAXIS ......................................50        prednisolone sodium                                         PRO-BANTHINE...........................44              PROZAC.........................................18
PLENAXIS ......................................50        phosphate ....................................55            probenecid ..................................21        PSORCON .....................................47
PLENDIL.........................................37       prednisolone sodium                                         procainamide hydrochloride 37                          PTU .................................................51
PLETAL ...........................................33     phosphate ....................................55            PROCAN ........................................37      PULMICORT .................................61
podofilox ......................................40       prednisolone sodium                                         procarbazine hydrochloride ..23                        PURINETHOL ...............................24
POLARAMINE ..............................61              phosphate ....................................55            PROCARDIA .................................37          PYRAZINAMIDE ..........................23
poliovirus vaccine                                       PREDNISONE ...............................55                PROCARDIA XL ...........................37             pyrazinamide ..............................23
inactivated ...................................53        prednisone...................................55             prochlorperazine .......................20             pyridostigmine bromide.........22
polyethylene glycol ..................43                 prednisone...................................55             prochlorperazine edisylate ....26                      pyrimethamine...........................25
polyethylene glycol ..................43                 pregabalin ....................................17           PROCRIT ........................................33     quadrivalent hpv (6,11,16,18)
POLYETHYLENE GLYCOL                                      PRELONE .......................................59           PROGLYCEM.................................32           recomb vac ..................................52
3350................................................43   PREMARIN ....................................47             PROGRAF ......................................54       QUESTRAN ...................................37
POLYMYXIN B ..............................59             PREMARIN ....................................49             PROLASTIN...................................61         quetiapine fumarate ................27
POLYSPORIN ................................59            PREMPHASE.................................47                PROLASTIN...................................61         quetiapine fumarate ................30
PORTIA-28 ....................................47         PREMPHASE.................................49                PROLEUKIN ..................................57         QUINAGLUTE ...............................37
PORTIA-28 ....................................49         PREMPRO......................................47             PROLIXIN.......................................27      QUINAGLUTE DURA-TABS.......37
potassium chloride ...................63                 PREMPRO......................................49             PROLIXIN.......................................27      quinapril hcl ................................33
potassium citrate .......................63              PRENATAL VITAMINS.................63                        PROLIXIN IM ................................27         QUINIDINE GLUCONATE ..........37
potassium clavulanate and ticarcil-                      prenatal with folic acid                                    promethazine hydrochloride 20                          quinidine gluconate .................37
lin disodium.................................15          (>.8mg) ..........................................63        propantheline bromide...........44                     quinidine gluconate .................37
pramlintide acetate ..................32                 PREVACID......................................43            PROPINE ........................................59     quinidine gluconate .................37
PRANDIN.......................................32         PREVACID I.V. ...............................43             propranolol hydrochloride ....22                       quinidine gluconate .................37
PRAVACHOL .................................37            PREVACID SOLUTAB ..................44                       propranolol hydrochloride ....35                       QUINIDINE GLUCONATE CR ...37
pravastatin sodium ...................37                 PREZISTA .......................................28          PROPYLTHIOURACIL .................51                   QVAR ..............................................61
prazosin hydrochloride ...........44                     PRILOSEC ......................................44           propylthiouracil .........................51           RABAVERT.....................................54
PRECOSE .......................................32        PRIMAQUINE PHOSPHATE ......25                               propylthiouracil .........................51           rabies vaccine human
PRED-FORTE ................................59            primaquine phosphate ...........25                          PROQUAD.....................................54         diploid cell ...................................52
PREDNICARBATE ........................47                 PRIMAXIN I.M. .............................15               PROSCAR ......................................44       rabies vaccine purified chick
prednicarbate .............................45            PRIMAXIN IV.................................15              proteinase inhibitor (human)61                         embryo cel ...................................54
prednicarbate .............................47            primidone ....................................17            proteinase inhibitor (human)61                         raloxifene hydrochloride ........45
                                                                                                                76
raloxifene hydrochloride ........49                     REVATIO.........................................61           ROBAXIN .......................................63     simvastatin...................................38
ramipril ..........................................34   REVATIO.........................................62           ROBINUL .......................................44     SINEMET ........................................26
RANEXA .........................................37      REVLIMID ......................................24            ROCEPHIN ....................................15       SINEMET SR ..................................26
RANEXA .........................................37      REVLIMID ......................................24            ROFERON-A .................................54         SINEQUAN ....................................41
ranitidine hydrochloride .........44                    REYATAZ ........................................29           ropinirole hydrochloride.........26                   SINGULAIR....................................62
ranolazine.....................................37       RHINOCORT AQUA ....................62                        rosiglitazone maleate ..............31                sirolimus .......................................54
ranolazine.....................................37       RHINOCORT AQUA ....................62                        rosuvastatin calcium ................34               sitagliptin phosphate ...............31
RAPAMUNE ..................................54           RIBAVIRIN......................................29            ROTATEQ .......................................54     SKELAXIN ......................................63
rasagiline mesylate ...................25               ribavirin .........................................28        rotavirus vaccine live                                sodium oxybate .........................39
rasburicase ...................................56       ribavirin .........................................29        pentavalent .................................54       sodium phenylbutyrate ..........41
rasburicase ...................................56       rifabutin ........................................23         ROXICODONE..............................12            sodium polystyrene
RAZADYNE ...................................17          RIFADIN .........................................23          rubella virus vaccine live .........53                sulfonate .......................................19
RAZADYNE ...................................17          RIFAMPIN ......................................23            sacrosidase...................................42      SOLARAZE ....................................41
RAZADYNE ER .............................17             rifampin.........................................23          salmeterol xinafoate .................62              SOLARAZE ....................................41
RAZADYNE ER .............................17             rifampin.........................................23          SANDOSTATIN .............................50           solifenacin succinate ................44
REBETOL........................................28       RIMANTADINE HCL....................29                        saquinavir mesylate..................28               SOLTAMOX ...................................24
REGLAN .........................................20      rimantadine hydrochloride....28                              SECTRAL........................................37     SOMA .............................................63
REGRANEX....................................41          rimantadine hydrochloride....29                              selegiline.......................................18   somatropin ..................................46
REGRANEX....................................41          RINGER’S INJECTION.................57                        selegiline.......................................18   somatropin ..................................48
RELAFEN .......................................22       RISPERDAL....................................27              selegiline hcl................................26      SOMAVERT ...................................50
RELENZA DISKHALER ...............28                     RISPERDAL....................................30              selenium sulfide .........................40          SOMAVERT ...................................50
REMERON .....................................19         RISPERDAL CONSTA ..................27                        selenium sulfide .........................41          SONATA .........................................62
RENAGEL .......................................44       RISPERDAL M-TAB......................27                      SELSUN ..........................................41   sorafenib tosylate ......................24
RENAMIN ......................................57        risperidone...................................27             SENSIPAR ......................................50     sorafenib tosylate ......................24
RENOVA.........................................41       risperidone...................................27             SEREVENT DISKUS .....................62               sotalol hydrochloride ...............34
repaglinide...................................32        risperidone...................................27             SEROQUEL ....................................27       sotalol hydrochloride ...............34
REQUIP ..........................................26     risperidone...................................30             SEROQUEL ....................................30       SPECTAZOLE ................................21
RESCRIPTOR .................................29          RITALIN ..........................................39         sertraline hydrochloride .........19                  SPIRIVA HANDIHALER ..............62
RESTASIS .......................................59      ritonavir.........................................28         sertraline hydrochloride .........30                  spironolactone ...........................33
RESTASIS .......................................59      RITUXAN .......................................24            SERZONE .......................................19     SPORANOX...................................21
RETIN A ..........................................41    rituximab ......................................24           sevelamer hydrochloride ........44                    SPRINTEC 28 ................................47
RETIN-A MICRO...........................41              rivastigmine tartrate.................17                     sildenafil citrate ..........................61       SPRINTEC 28 ................................49
RETROVIR ......................................29       rizatriptan .....................................22          sildenafil citrate ..........................62       SPRYCEL ........................................24
RETROVIR IV INFUSION ............29                     rizatriptan benzoate .................22                     silver sulfadiazine ......................15          SPRYCEL ........................................24
                                                                                                                77
SSD..................................................15   SYNALAR.......................................47             terbinafine hydrochloride ......20                    thioridazine hydrochloride ....27
stavudine ......................................29        SYNTHROID..................................47                terbinafine hydrochloride ......20                    THIOTHIXENE ..............................27
STELAZINE ....................................27          SYNTHROID..................................50                teriparatide ..................................55     thiothixene ..................................27
STERILE WATER IRRIGATION ...57                            TABLOID ........................................24           teriparatide ..................................55     thiothixene ..................................27
STRATTERA...................................39            tacrolimus ....................................54            TESLAC ..........................................24   THORAZINE ..................................27
STRATTERA...................................39            TAGAMENT ...................................44               testolactone ................................24       tiagabine hydrochloride .........16
STREPTOMYCIN SULFATE ........15                           TAMBOCOR ..................................38                testosterone ................................45       TICLID.............................................33
streptomycin sulfate.................15                   tamoxifen citrate .......................24                  testosterone ................................45       ticlopidine hydrochloride .......33
STRIANT.........................................47        tamoxifen citrate .......................24                  testosterone ................................47       TIGAN .............................................20
SUBOXONE ...................................19            tamsulosin hydrochloride ......51                            testosterone ................................48       tigecycline....................................16
SUBOXONE ...................................19            TAPAZOLE .....................................51             TESTOSTERONE CYPIONATE ..48                           tigecycline....................................16
SUCRAID .......................................42         TARCEVA .......................................24            testosterone cypionate ...........45                  TIKOSYN ........................................38
sucralfate ......................................43       TARCEVA .......................................24            testosterone cypionate ...........48                  TILADE ...........................................62
SULFACETAMIDE SODIUM ......59                             TARGRETIN ...................................24              testosterone enanthate...........45                   TIMENTIN ......................................15
sulfacetamide sodium .............58                      TARGRETIN ...................................24              TETANUS TOXOID ......................54               timolol maleate ..........................59
sulfacetamide sodium .............59                      TARKA ............................................38         tetanus toxoid.............................54         TIMOPTIC ......................................59
SULFADIAZINE ............................15               TAVIST ............................................62        TETANUS TOXOID                                        tiopronin .......................................44
sulfadiazine..................................15          tazarotene ....................................41            ADSORBED ...................................54        tiotropium bromide
sulfamethoxazole and trim-                                TAZORAC ......................................41             tetanus toxoid adsorbed ........54                    monohydrate ..............................62
ethoprim.......................................13         TEGRETOL .....................................30             TETANUS/DIPHTHERIA                                    tipranavir ......................................28
SULFASALAZINE .........................55                 TEGRETOL-XR ..............................17                 TOXOID ..........................................54   tizanidine hydrochloride ........63
sulfasalazine ................................55          TEKTURNA ....................................38              tetracycline hydrochloride .....15                    TOBRADEX ...................................57
sulfasalazine ................................55          TEKTURNA ....................................38              tetrahydrozoline                                      TOBRAMYCIN SULFATE ............16
sulindac .........................................21      telbivudine...................................57             hydrochloride .............................62         tobramycin sulfate ....................16
sumatriptan succinate .............22                     telbivudine...................................57             thalidomide .................................25       tobramycin sulfate ....................16
SUMYCIN.......................................15          telithromycin...............................14               THALOMID ...................................25        TOBREX..........................................16
sunitinib malate .........................24              telithromycin...............................14               THEO-DUR ....................................62       TOFRANIL .....................................19
sunitinib malate .........................24              TEMOVATE ....................................47              theophylline ................................62       TOLAZAMIDE...............................32
SURMONTIL .................................19             TENEX ............................................38         theophylline ................................62       tolazamide ...................................32
SUSTIVA .........................................29       tenofovir disoproxil                                         THEOPHYLLINE CR ....................62                tolazamide ...................................32
SUTENT..........................................24        fumarate .......................................29           thioguanine .................................24       TOLBUTAMIDE ............................32
SUTENT..........................................24        TENORETIC ...................................38              THIOLA ..........................................44   tolbutamide.................................32
SYMLIN ..........................................32       TENORMIN ...................................38               THIORIDAZINE HCL ...................27                tolbutamide.................................32
SYMMETREL .................................29             terazosin hcl ................................44             thioridazine hydrochloride ....26                     TOLINASE......................................32
                                                                                                                  78
TOPAMAX .....................................22        IN ORABASE .................................39              TYLENOL WITH CODEINE ........13                        VASOTEC .......................................38
TOPAMAX SPRINKLE .................17                   TRIFLUOPERAZINE HCL ...........27                           TYPHIM VI .....................................54      VELCADE .......................................57
TOPICORT .....................................47       trifluoperazine                                             typhoid vaccine..........................54            VELCADE .......................................57
topiramate ...................................17       hydrochloride .............................27               typhoid vi polysaccharide                              venlafaxine hcl............................18
topiramate ...................................22       trifluoperazine                                             vaccine ..........................................54   verapamil hydrochloride ........34
TOPROL XL ...................................38        hydrochloride .............................27               TYZEKA ..........................................57    verapamil hydrochloride ........34
TORADOL......................................12        TRIHEXYPHENIDYL HCL ...........26                           TYZEKA ..........................................57    VERMOX ........................................25
toremifene citrate......................23             trihexyphenidyl                                             TYZINE ...........................................62   VESANOID ....................................25
toremifene citrate......................23             hydrochloride .............................25               ULTRACET .....................................13       VESANOID ....................................25
torsemide .....................................34      trihexyphenidyl                                             ULTRAM .........................................13     VESICARE ......................................44
TRACLEER .....................................62       hydrochloride .............................26               ULTRAVATE ...................................47        VIBRAMYCIN ................................39
tramadol hcl ................................13        TRILAFON .....................................27            UNASYN ........................................16      VICODIN ........................................13
TRANDATE ....................................38        TRILEPTAL .....................................17           UNIPEN ..........................................16    VIDAZA ..........................................57
trandolapril ..................................36      trimethobenzamide                                           UNIPHYL........................................62      VIDAZA ..........................................57
trandolapril and verapamil hydro-                      hydrochloride .............................20               URSODIOL ....................................44        VIDEX .............................................29
chloride .........................................38   trimethoprim ..............................16               ursodiol .........................................43   VIGAMOX ......................................59
tranexamic acid ..........................33           trimetrexate glucuronate .......57                          ursodiol .........................................44   VIGAMOX ......................................59
tranylcypromine sulfate ..........18                   TRIMIPRAMINE MALEATE ........19                             valacyclovir hcl ...........................29         VIRACEPT ......................................29
TRAVATAN.....................................59        trimipramine maleate ..............19                       VALCYTE ........................................29     VIRAMUNE....................................29
travoprost .....................................59     trimipramine maleate ..............19                       valganciclovir hydrochloride 29                        VIREAD...........................................29
trazodone hydrochloride........18                      TRIMPEX ........................................16          valproate sodium ......................16              VISTARIL ........................................20
TRENTAL ........................................57     TRI-NORINYL 28..........................47                  valproate sodium ......................30              VISTIDE ..........................................29
tretinoin ........................................25   TRI-NORINYL 28..........................49                  valproate sodium ......................30              VITAMIN/MINERAL, MISC ........63
tretinoin ........................................25   TRISENOX......................................57            VALTREX ........................................29     VIVACTIL........................................19
tretinoin ........................................41   TRI-SPRINTEC ..............................47               VANCOCIN HCL (ORAL)............16                      VIVOTIF BERNA ...........................54
tretinoin ........................................41   TRI-SPRINTEC ..............................49               VANCOCIN IV ...............................16          VOLTAREN.....................................22
tretinoin ........................................41   TRIZIVIR .........................................29        vancomycin hydrochloride ....16                        vorinostat .....................................25
TRIAMCINOLONE                                          TRUVADA ......................................29            vancomycin hydrochloride ....16                        VOSOL............................................60
ACETONIDE ..................................47         TWINRIX ........................................54          VAQTA ............................................54   warfarin sodium.........................32
triamcinolone acetonide ........39                     TYGACIL ........................................16          varenicline tartrate....................19             water, sterile ................................57
triamcinolone acetonide ........46                     TYGACIL ........................................16          varenicline tartrate....................19             WELLBUTRIN ...............................19
triamcinolone acetonide ........47                     TYLENOL #2 .................................12              varicella virus vaccine live ......54                  WYTENSIN ....................................38
triamcinolone acetonide ........61                     TYLENOL #3 .................................12              VARIVAX ........................................54     XALATAN .......................................60
TRIAMCINOLONE                                          TYLENOL #4 .................................12              VASERETIC ....................................38       XALATAN .......................................60
                                                                                                              79
XOLAIR...........................................54    ZEBETA ..........................................38           ziprasidone mesylate ...............26                zoster vaccine live
XOLAIR...........................................54    ZEBETA HCTZ ..............................38                  ZITHROMAX .................................16         (oka/merck) .................................55
XYLOCAINE ..................................13         ZEMPLAR ......................................56              ZOCOR ...........................................38   ZOVIRAX........................................29
XYREM ...........................................39    ZERIT ..............................................29        ZOFRAN.........................................20     ZYFLO.............................................62
yellow fever vaccine .................54               ZESTORETIC .................................38                ZOFRAN ODT...............................20           ZYFLO.............................................62
YF-VAX ...........................................54   ZESTRIL..........................................38           ZOLADEX ......................................50      ZYLOPRIM.....................................21
zafirlukast .....................................60    ZETIA ..............................................38        ZOLADEX ......................................50      ZYMAR ...........................................60
zaleplon ........................................62    ZIABETA .........................................38           ZOLINZA .......................................25     ZYMAR ...........................................60
ZANAFLEX ....................................63        ZIABETA HCT ...............................38                 ZOLOFT..........................................19    ZYPREXA .......................................27
zanamivir ......................................28     ZIAGEN ..........................................29           ZOLOFT..........................................30    ZYPREXA .......................................30
ZANTAC .........................................44     zidovudine ...................................29              zolpidem tartrate.......................62            ZYPREXA ZYDIS ..........................27
ZARONTIN ....................................17        zidovudine ...................................29              ZONEGRAN ..................................17         ZYVOX............................................16
ZAROXOLYN.................................38           zileuton .........................................62          zonisamide...................................17       ZYVOX............................................16
ZAVESCA .......................................42      zileuton .........................................62          ZOSTAVAX ....................................55
ZAVESCA .......................................42      ziprasidone mesylate ...............26




                                                                                                                80
HPM50 2008 Provider Formulary 12/07

								
To top