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					Health Net Medicare Part D
2012 Classic Formulary
                             (List of Covered Drugs)

Please read: This documenT conTains informaTion abouT The drugs we cover in
THIS PLAN AS OF JULY 1, 2012.

note to existing members: This formulary has changed since last year. Please review this document to
make sure that it still contains the drugs you take. To get updated information about the drugs covered by
Health Net, please visit our website at www.healthnet.com.

Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary,
pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2013.

This information is available for free in other languages. Please contact our Customer Service department
at the toll-free number listed at the beginning of this booklet.

Esta información está disponible en forma gratuita en otros idiomas. Comuníquese con nuestro departamento
de Servicio al Cliente al número de teléfono gratuito que aparece al comienzo de este folleto.




A Medicare Advantage organization with a Medicare contract. A stand-alone prescription drug plan with a
Medicare contract.




6025491
Material ID# Y0035_2012_0021_A (H0351, H0562, H5439, H5520, H6815, S5678)
CMS Approved 09152011
HPMS Approved Formulary File Submission ID 12051, Version 12
    If you would like to contact Health Net     CAliforniA
    Customer Service, please find the contact
    information for your state below:           For medICal plaNS:
                                                Health Net
                                                p.o. Box 10198
    ArizonA                                     Van Nuys, Ca 91410-0198
                                                Fax- 1-818-676-8100
    For medICal plaNS:
    Health Net                                  For HealtH Net oraNge,
    attn: arizona medicare program              part d preSCrIptIoN drug
    p.o. Box 10420                              plaNS:
    Van Nuys, Ca 91410-0420                     Health Net
    Fax- 1-866-375-3790                         p.o. Box 6501
                                                rensselaer, NY 12144-6501
    For HealtH Net oraNge,                      Fax- 1-888-268-2393
    part d preSCrIptIoN drug                    Hours are: 8:00 a.m. – 8:00 p.m.,
    plaNS:                                      seven days a week.
    Health Net
    p.o. Box 6501
                                                Current members:
    rensselaer, NY 12144-6501                   Health Net Seniority Plus Ruby
    Fax- 1-888-268-2393                         (HMO), Health Net Green (HMO),
    Hours are: 8:00 a.m. – 8:00 p.m.,           Salud con Health Net (HMO),
    seven days a week.                          Health Net Healthy Heart (HMO)
                                                1-800-275-4737, ttY 1-800-929-9955
    Current members:
                                                Health Net Amber (HMO SNP)
    All medical plans                           1-800-431-9007, ttY 1-800-929-9955
    1-800-977-7522, ttY 1-800-977-6757
                                                Health Net Violet (PPO)
    Health Net Orange (PDP)                     1-800-960-4638, ttY 1-800-929-9955
    prescription drug plans
    1-800-806-8811, ttY 1-800-929-9955          Health Net Orange (PDP)
                                                prescription drug plans
                                                1-800-806-8811, ttY 1-800-929-9955
    Prospective members:
    All medical plans                           Prospective members:
    1-800-333-3930, ttY 1-800-977-6757          All medical plans
                                                1-800-977-6738, ttY 1-800-929-9955
    Health Net Orange
    prescription drug plans                     Health Net Orange
    1-800-865-9431, ttY 1-800-929-9955          prescription drug plans
i                                               1-800-865-9431, ttY 1-800-929-9955
     oregon/WAshington–                   All other stAtes –
     ClArk County only                    For HealtH Net oraNge,
                                          part d preSCrIptIoN drug
     For medICal plaNS:
                                          plaNS:
     Health Net medicare advantage
                                          Health Net
     13221 SW 68th parkway, Ste. 200
                                          p.o. Box 6501
     tigard, or 97223
                                          rensselaer, NY 12144-6501
     Fax- 1-818-337-7241
                                          Fax- 1-888-268-2393
                                          Hours are: 8:00 a.m. – 8:00 p.m.,
     For HealtH Net oraNge,
                                          seven days a week.
     part d preSCrIptIoN drug
     plaNS:
                                          Current members:
     Health Net
     p.o. Box 6501                        Health Net Orange (PDP)
     rensselaer, NY 12144-6501            prescription drug plans
     Fax- 1-888-268-2393                  1-800-806-8811, ttY 1-800-929-9955
     Hours are: 8:00 a.m. – 8:00 p.m.,
     seven days a week.
                                          Prospective members:
     Current members:                     Health Net Orange
                                          prescription drug plans
     All medical plans                    1-800-865-9431, ttY 1-800-929-9955
     1-888-445-8913, ttY 1-800-929-9955

     Health Net Orange (PDP)
     prescription drug plans
     1-800-806-8811, ttY 1-800-929-9955

     Prospective members:
     All medical plans
     1-800-949-6192, ttY 1-800-929-9955

     Health Net Orange
     prescription drug plans
     1-800-865-9431, ttY 1-800-929-9955




ii
Welcome to Health Net. We                       Which Health Net Medicare Part D
are glad you have chosen us to                  formulary applies to you?
be your plan of choice for your                 this document contains detailed
                                                information for one of Health Net’s
prescription needs. This easy-to-
                                                formularies. the name of the formulary
read formulary provides you with                appears on the front cover of this
valuable information about the                  document. to confirm you are viewing
                                                the formulary that applies to your benefit,
formulary (also known as a “drug
                                                locate your plan name or type in the table
list”) that applies to your benefit,            below. If you are not sure of your plan
the prescription drugs we cover,                name, you can find it on your eoC.
copayment or coinsurance levels                 Plan                         Formulary
and details on how to use your                  Health Net orange
benefit. To quickly find your                   option 1 (pdp)          Value
                                                Health Net Value orange Formulary
drug, turn to the index at the
                                                option 2 (pdp)
end of this booklet. For detailed
                                                Health Net orange
information on how to read the                  option 2 (pdp)               Classic
formulary, turn to page ix.                     all mapd medical plans       Formulary
                                                (Hmo, ppo, and poS)
What is the Health Net Medicare
Part D formulary?                               Can the formulary change?
this formulary represents the entire list       generally, if you are taking a drug on
of part d drugs covered by Health Net. a        the 2012 formulary that was covered at
formulary is a list of covered drugs selected   the beginning of the year, we will not
by Health Net in consultation with a team       discontinue or reduce coverage of the
of health care providers, which represents      drug during the 2012 coverage year except
the prescription therapies believed to be       when a new, less expensive generic drug
a necessary part of a quality treatment         becomes available and is offered at a
program. Health Net will generally cover        lower tier or lower cost to you, or when
the drugs listed on the formulary as            new information about the safety or
long as the drug is medically necessary,        effectiveness of a drug is released.
the prescription is filled at a Health Net
network pharmacy, and other plan rules
are followed. For more information on
how to fill your prescriptions, please
review your evidence of Coverage (eoC).

                                                                                              iii
     In most cases, formulary changes such         What if my drug is not on the
     as applying a new or revised restriction      formulary?
     to a drug, moving a drug to a more
                                                   If your drug is not included on the
     expensive tier or removing a drug from
                                                   formulary, you should first contact
     the formulary, will not affect you if you
                                                   Customer Service and ask if your drug is
     are currently taking the drug. the drug
                                                   covered. If you learn that Health Net does
     will remain available at the same cost
                                                   not cover your drug, you have two options:
     for the remainder of the year. We feel it
     is important that you have continued          •	 You	can	ask	Customer	Service	for	a	list	
     access for the remainder of the year to the      of similar drugs that are covered by
     formulary drugs that were available when         Health Net. When you receive the list,
     you chose our plan.                              show it to your prescriber and ask him
                                                      or her to prescribe a similar drug that is
     However, in some cases, these types of
                                                      covered by Health Net.
     formulary changes may affect you. If a
     formulary change will affect you, we will     •	 You	can	ask	Health	Net	to	make	an	
     notify you in advance of the change. You         exception and cover your drug. See
     will receive notification at least 60 days       “How do I request an exception to the
     before the change becomes effective, or          Health Net medicare part d formulary?”
     you may receive a 60-day supply when you         for information about how to request an
     request a refill of the drug which will act      exception.
     as your notification. If we make any non-
     maintenance formulary changes during the      Are there any restrictions on
     year, you will be notified via mail and the   my coverage?
     changes will be posted on our website.        Some drugs may have additional
                                                   restrictions or limits on coverage. You can
     If the united States Food and drug
                                                   find out if your drug has any restrictions
     administration (Fda) deems a drug
                                                   or limits by looking in the limits column
     on the formulary to be unsafe or if the
                                                   on the formulary.
     manufacturer of the drug removes the
     drug from the market, we will immediately
     remove the drug from the formulary and
     provide notice to you if you are currently
     receiving the drug.

     to get the most up-to-date information
     about the drugs covered by
     Health Net, please visit our website at
     www.healthnet.com where you may view
     and print a formulary. You may also call
     our Customer Service department at the
     toll-free number listed at the beginning of
iv   this booklet.
the table below provides a description of abbreviations that may appear in the limits
column on the formulary:

Abbreviation                  Definition                    Description
AL                            Age Limit                     Some drugs may require
                                                            prior authorization if
                                                            your age does not meet
                                                            manufacturer, FDA, or
                                                            clinical recommendations.
B/D                           Medicare Part B vs. Part D    Some drugs require
                                                            prior authorization to
                                                            determine coverage under
                                                            the Medicare Part B or
                                                            Part D benefit, according
                                                            to Medicare guidelines.
                                                            Your prescriber may need
                                                            to supply additional
                                                            information, which will allow
                                                            Health Net to make the
                                                            determination. If the drug
                                                            qualifies for coverage under
                                                            Medicare Part B and you do
                                                            not have Medicare
                                                            Part B coverage through
                                                            Health Net, the drug will not
                                                            be covered by Health Net.
GL                            Gender Limit                  Some drugs are only
                                                            covered for males
                                                            or females based on
                                                            manufacturer, FDA, or
                                                            clinical recommendations.




                                                                                            v
     LA   Limited Access        Some drugs may be
                                subject to limited access
                                or restricted access. This
                                means that a drug may
                                only be available at one
                                or a limited number of
                                pharmacies. Limited access
                                may be due to the following
                                reasons:
                                • The FDA has restricted
                                  distribution of a drug
                                  to certain facilities,
                                  pharmacies or prescribers,
                                  or
                                • Certain drugs require
                                  special handling,
                                  coordination of care, or
                                  patient education that
                                  cannot be provided at a
                                  retail pharmacy.
                                You should talk to your
                                prescriber or pharmacist
                                for details about acquiring
                                limited access drugs.
     MO   Mail Order            These drugs are available
                                at Health Net’s network
                                mail order pharmacy in
                                addition to other network
                                pharmacies.
     PA   Prior Authorization   Some drugs require prior
                                authorization for coverage,
                                clinical effectiveness, or
                                safety reasons. This means
                                that you or your prescriber
                                must request approval from
                                Health Net before the drug
                                will be covered.
     QL   Quantity Limit        For some drugs, Health Net
                                limits the amount of the
                                drug covered based on
                                manufacturer, FDA, clinical
                                dosing or treatment
                                recommendations.
                                This may replace your
                                standard days supply limit.



vi
ST                              Step Therapy                  In some cases, Health Net
                                                              requires you to first try
                                                              certain drugs to treat your
                                                              medical condition before
                                                              covering another drug for
                                                              that condition.
                                                              For example, if Drug A
                                                              and Drug B both treat your
                                                              medical condition, Health
                                                              Net may not cover Drug
                                                              B unless you try Drug A
                                                              first. If Drug A is found
                                                              in your recent Health Net
                                                              prescription claims history,
                                                              Drug B will be automatically
                                                              approved.

You can ask Health Net to make an exception to these restrictions or limits.
See the next section.

How do I request an exception to                 for the tier 2 (preferred Brand tier)
                                                 copayment. please note, if we grant your
the Health Net Medicare Part D
                                                 request to cover a drug that is not on the
formulary?                                       formulary, the drug will be available for
You can ask Health Net to make an                the tier 3 (Non-preferred Brand tier)
exception to our coverage rules. there are       copayment. the drug is not eligible for
several types of exceptions that you can ask     an exception for payment at a lower tier.
us to make.                                      also, drugs on tier 2 (preferred Brand
•	 You	can	ask	us	to	cover	your	drug	even	if	    tier) and tier 5 (Specialty tier) are not
   it is not on the formulary.                   eligible for an exception for payment at a
                                                 lower tier.
•	 You	can	ask	us	to	waive	coverage	
   restrictions or limits on your drug.         generally, Health Net will only approve
   For example, for certain drugs,              your request for an exception if preferred
   Health Net may limit the amount of the       alternative drugs or utilization restrictions
   drug that will be covered. If your drug      would not be as effective in treating your
   has a quantity limit, you can ask us to      condition and/or would cause you to have
   waive the limit and cover more.              adverse medical effects.
•	 You	can	ask	us	to	make	an	exception	and	     You may contact us to request an
   cover your drug at a lower tier. If your     exception. When requesting an exception,
   drug is on tier 3 (Non-preferred Brand       we require a statement from your
   tier) or on tier 4 (Injectable tier), you    prescriber supporting your request.
   can ask us for an exception to cover it      generally, we must make our decision
                                                                                                vii
       within 72 hours of receiving your              harmed by waiting up to 72 hours for a
       prescriber’s supporting statement. You or      decision. If your request to expedite is
       your prescriber may request an expedited       granted, we must give you a decision no
       (fast) exception if you or your prescriber     later than 24 hours after we receive your
       believe that your health could be seriously    prescriber’s supporting statement.

       Formulary tier descriptions
       to determine how much you will be required to pay for a drug, the abbreviations in
       the table below appear in the Brand tier and generic tier columns on the formulary.
       the copayment or coinsurance level you will be required to pay is displayed in the
       Copayment/Coinsurance column. If you do not know your copayment or coinsurance for
       each tier, please refer to your Summary of Benefits or eoC.

       Abbreviation                   Copayment/ Coinsurance          Description
       1                              Tier 1 copayment                Preferred generic drugs.
       2                              Tier 2 copayment                Preferred brand drugs.
       3                              Tier 3 copayment                Non-preferred brand drugs.
       4 (Injectable Tier)            Tier 4 copayment or             Includes injectable drugs
                                      coinsurance                     that do not meet the
                                                                      Centers for Medicare and
                                                                      Medicaid Services (CMS)
                                                                      minimum cost threshold
                                                                      required to be placed on
                                                                      the Specialty Tier (Tier 5).
                                                                      These drugs may be limited
                                                                      to a maximum 30-day
                                                                      supply per fill.
       5 (Specialty Tier)             Tier 5 copayment or             High cost drugs. Some of
                                      coinsurance                     these drugs may be limited
                                                                      to a maximum 30-day
                                                                      supply per fill. Specialty
                                                                      Tier (Tier 5) drugs are not
                                                                      eligible for exceptions for
                                                                      payment at a lower tier.
       NF                             Non-formulary –                 Drugs not covered on
                                      If Health Net approves an       Health Net’s Medicare
                                      exception request for a non-    Part D formulary. You may
                                      formulary drug, the Non-        request an exception from
                                      preferred Brand Tier (Tier 3)   Health Net to cover these
                                      copayment will apply.           drugs. See the section,
                                                                      “How do I request an
                                                                      exception to the Health Net
                                                                      Medicare Part D formulary?”
                                                                      for information about how
viii                                                                  to request an exception.
How do I use the formulary?                   the name of each drug can be found in
the drugs in this formulary are               the first column. Brand name drugs are
grouped into therapeutic Category and         in uppercase (example: ZoCor) and
therapeutic Class Name. If you know           generic drugs are in lowercase (example:
what your drug is used for, look for the      simvastatin). When there is a brand name
category or class name which is listed        drug with a generic equivalent available,
alphabetically. For example, drugs used       the drugs will be listed on the same line
to treat depression are listed under the      with the generic drug in parentheses, for
category, aNtIdepreSSaNtS.                    example: ZoCor (simvastatin).

the index at the end of this booklet          Tier status
provides an alphabetical list of all of the
                                              the tier status is shown to the right of
drugs included in the formulary. Both
                                              the drug name. generally, when there is a
brand name drugs and generic drugs are
                                              brand name drug with a generic equivalent
listed in the index. Next to the drug, you
                                              available, the brand name drug will be
will see the page number where you can
                                              non-preferred or non-formulary.
find coverage information.

How do I read the formulary?
If you have trouble finding a drug, turn to
the index at the end of this booklet.

Brand and generic drugs
Health Net covers both brand name drugs
and generic drugs. a generic drug is
approved by the Fda as having the same
active ingredient as the brand name drug.
generally, generic drugs cost less than
brand name drugs.




                                                                                          ix
                Limits
                the information in the limits column tells you if there are any limits or restrictions on
                a drug. For a complete description of abbreviations found in the limits column, please
                refer to the abbreviations table beginning on page v.

                                                                                             Sample of
                Note: Example only                                                           abbreviations;
                BrAND Drug (generic drug) Brand Tier generic Tier Limits                     Turn to pages
                                                                                             v – vii for a
                therapeutic Category Name                                                    complete
Brand drug      therapeutic Class Name -                                                     description of
only; generic   BraNd Name (generic name) 3                      1              B/D, MO,     abbreviations
not available                                                                   PA, QL
                BraNd Name                         2                            LA, ST


                Health Net’s transition program                your drug in certain cases during the first
                                                               90 days you are a member of our plan.
                the transition program is designed
                                                               this may also apply if you are a renewing
                to ensure continuity of care for new
                                                               member and experience a change in the
                members, existing members who may
                                                               formulary at the beginning of the contract
                be subject to formulary changes, and
                                                               year. during this time, if your drug is not
                members who experience a level of care
                                                               on the formulary or if your ability to get
                change. the program also allows members
                                                               your drug is limited, we will cover a one-
                in long term Care (ltC) facilities access
                                                               time temporary 30-day transition supply
                to a temporary transition supply of drugs.
                                                               (unless you have a prescription written
                                                               for fewer days) when you go to a network
                Initial eligibility                            pharmacy. If your prescription is written
                If you are a new member in our plan, you       for less than a 30-day transition supply,
                may be taking drugs that are not on the        refills for up to a cumulative 30-day supply
                formulary, or you may be taking a drug         will be covered.
                that is on the formulary with restrictions
                or limits. For example, you may need a         If you are a resident of a ltC facility, we
                prior authorization from us before your        will cover a temporary 34-day transition
                prescription can be filled. You should         supply (unless you have a prescription
                talk to your prescriber to decide if you       written for fewer days). We will allow you
                should change to a drug that we cover          to refill your prescription until we have
                or request an exception so that we will        provided you with a 102-day transition
                cover the drug you take. While you talk        supply, consistent with the dispensing
                to your prescriber to determine the right      increment, (unless you have a prescription
                course of action for you, we may cover         written for fewer days).


x
Emergency supply                                 For more information
If you are a resident of an ltC facility and     For more detailed information about your
need a drug that is not on the formulary         Health Net prescription drug coverage,
or your ability to get your drug is limited,     please review your eoC and other plan
but you are past the first 90 days of            materials.
membership in our plan, we will cover
                                                 If you have questions about Health Net,
a 34-day emergency supply of that drug
                                                 please call our Customer Service
(unless you have a prescription written for
                                                 department at the toll-free number listed
fewer days) while you pursue an exception.
                                                 at the beginning of this booklet, or visit
                                                 www.healthnet.com.
Level of care changes
                                                 If you have general questions about
If you experience a level of care change,
                                                 medicare prescription drug coverage,
we will cover a transition supply of your
                                                 please call medicare at 1-800-medICare
drugs. a level of care change occurs when
                                                 (1-800-633-4227) 24 hours a day/
you are discharged from a hospital or
                                                 7 days a week. ttY/tdd users should
moved to or from a long-term care facility.
                                                 call 1-877-486-2048. or, visit
•	 If	you	move	from	a	LTC	facility	or	a	         www.medicare.gov.
   hospital to home and need a transition
   supply right away, we will cover one
   30-day supply, or less if your prescription
   is written for fewer days (in which case
   we will allow multiple fills to provide
   up to a total of a 30-day supply of
   medication).
•	 If	you	move	from	home	or	a	hospital	
   to a long-term care facility and need
   a transition supply right away, we will
   cover one 34-day supply, or less if your
   prescription is written for fewer days (in
   which case we will allow multiple fills to
   provide up to a total of a 34-day supply
   of medication).




                                                                                              xi
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS
Amphetamines
ADDERALL (amphetamine-                                                      MO
dextroamphetamine) TABS OR 1.25 MG,     3                         1
1.875 MG, 2.5 MG, 3.125 MG, 3.75 MG, 5
MG, 7.5 MG
ADDERALL XR (amphetamine-                                                   MO
dextroamphetamine) CP24 OR 1.25 MG, 2.5 3                         1
MG, 3.75 MG, 5 MG, 6.25 MG, 7.5 MG
DESOXYN (methamphetamine hcl) TABS                                          MO
                                        3                         1
OR 5 MG
DEXEDRINE (dextroamphetamine sulfate)                                       MO
                                        3                         1
CP24 OR 10 MG, 15 MG, 5 MG
DEXEDRINE (dextroamphetamine sulfate)                                       MO
                                        3                         1
TABS OR 5 MG
DEXTROSTAT (dextroamphetamine sulfate)                                      MO
                                        3                         1
TABS OR 10 MG
PROCENTRA (dextroamphetamine sulfate)                                       MO
                                        3                         1
SOLN OR 5 MG/5ML
VYVANSE CAPS OR 20 MG, 30 MG, 40 MG,                                        MO
                                        3
50 MG, 60 MG, 70 MG
Anti-Obesity Agents
XENICAL CAPS OR 120 MG                               3                      PA; ; MO

Attention-Deficit/Hyperactivity Disorder (ADHD) Agents
INTUNIV TB24 OR 1 MG, 2 MG, 3 MG, 4 MG               3                      MO

KAPVAY TB12 OR 0.1 MG                                3                      MO

STRATTERA CAPS OR 10 MG, 100 MG, 18                                         MO
                                                     2
MG, 25 MG, 40 MG, 60 MG, 80 MG
Stimulants - Misc.
CONCERTA (methylphenidate hcl) TBCR OR                                      MO
                                                      2           1
18 MG, 27 MG, 36 MG, 54 MG
DAYTRANA PTCH TD 10 MG/9HR, 15                                              MO
                                                      3
MG/9HR, 20 MG/9HR, 30 MG/9HR
FOCALIN (dexmethylphenidate hcl) TABS                                       MO
                                                      3           1
OR 10 MG, 2.5 MG, 5 MG
FOCALIN XR CP24 OR 10 MG, 15 MG, 20                                         MO
                                                      3
MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG
METADATE CD CPCR OR 10 MG, 20 MG,                                           MO
                                                      3
30 MG, 40 MG, 50 MG, 60 MG
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy

 www.healthnet.com                                                                     13
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
METHYLIN CHEW OR 10 MG, 2.5 MG, 5 MG                 2                      MO

METHYLIN (methylphenidate hcl) SOLN OR                                      MO
                                                     3            1
10 MG/5ML, 5 MG/5ML
methylin er tbcr or 10 mg                                         1

methylphenidate hcl er tbcr or 10 mg                              1         MO

MODAFINIL TABS OR 100 MG, 200 MG                     3                      PA; ; MO

NUVIGIL TABS OR 150 MG, 250 MG, 50 MG                2                      PA; ; MO

PROVIGIL TABS OR 100 MG, 200 MG                      3                      PA; ; MO

RITALIN (methylphenidate hcl) TABS OR 10                                    MO
                                                     3            1
MG, 20 MG, 5 MG
RITALIN LA (methylphenidate hcl) CP24 OR                                    MO
                                                     3            1
20 MG, 30 MG, 40 MG
RITALIN LA CP24 OR 10 MG                             3                      MO

RITALIN SR (methylphenidate hcl) TBCR OR                                    MO
                                                     3            1
20 MG
AMINOGLYCOSIDES
Aminoglycosides
AMIKACIN SULFATE (amikacin sulfate)                  4            4
SOLN IJ 50 MG/ML
amikacin sulfate soln ij 250 mg/ml                                4

amikacin sulfate soln ij 500 mg/2ml                               4         MO

AMIKIN (amikacin sulfate) SOLN IJ 50                 4            4
MG/ML
AMIKIN (amikacin sulfate) SOLN IJ 1                                         MO
                                                     4            4
GM/4ML
GARAMYCIN (gentamicin sulfate) SOLN IJ                                      MO
                                                     4            4
40 MG/ML
gentamicin sulfate soln ij 10 mg/ml                               4         MO

gentamicin sulfate soln iv 10 mg/ml                               4
GENTAMICIN SULFATE/0.9% SODIUM
CHLORIDE (gentamicin in saline) SOLN IV               4           4
0.9 %, MG/ML, 0.9-1.4 %, MG/ML
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
gentamicin sulfate/0.9% sodium chloride soln
iv 0.9-1 %, mg/ml, 0.9-1.2 %, mg/ml, 0.9-1.6                      4
%, mg/ml
gentamicin sulfate/0.9% sodium chloride soln                                MO
                                                                  4
iv 0.8-0.9 %, mg/ml
gentamicin sulfate/sodium chloride soln iv
0.6-0.9 %, mg/ml, 0.9-1 %, mg/ml, 0.9-1.2 %,                      4
mg/ml, 0.9-1.6 %, mg/ml
gentamicin sulfate/sodium chloride soln iv                                  MO
                                                                  4
0.8-0.9 %, mg/ml
HUMATIN (paromomycin sulfate) CAPS OR                                       MO
                                                     3            1
250 MG
ISOTONIC GENTAMICIN SOLN IV 0.9-2 %,                 4
MG/ML
isotonic gentamicin soln iv 0.6-0.9 %, mg/ml,
0.9-1 %, mg/ml, 0.9-1.2 %, mg/ml, 0.9-1.6 %,                      4
mg/ml
isotonic gentamicin soln iv 0.8-0.9 %, mg/ml                      4         MO

KANAMYCIN SULFATE SOLN IJ 333 MG/ML                  4                      MO

NEO-FRADIN SOLN OR 25 MG/ML                          2                      MO

neomycin sulfate tabs or 500 mg                                   1         MO

STREPTOMYCIN SULFATE SOLR IM 1 GM                    4                      MO

TOBI NEBU IN 300 MG/5ML                              5                      B/D

tobramycin sulfate soln ij 10 mg/ml, 40 mg/ml                     4
tobramycin sulfate soln ij 1.2 gm/30ml, 40                        4         MO
mg/ml, 80 mg/2ml
tobramycin sulfate solr ij 1.2 gm                                 4
TOBRAMYCIN SULFATE ADD-VANTAGE                       4
SOLN IV 10 MG/ML
TOBRAMYCIN SULFATE/SODIUM
CHLORIDE (tobramycin sulfate in saline)              4            4
SOLN IV 0.8-0.9 %, MG/ML
tobramycin sulfate/sodium chloride soln iv                        4
0.9-1.2 %, mg/ml
ANALGESICS - ANTI-INFLAMMATORY
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
Anti-TNF-alpha - Monoclonoal Antibodies
HUMIRA KIT SC 20 MG/0.4ML, 40                                               PA
                                                     5
MG/0.8ML
HUMIRA PEN KIT SC 40 MG/0.8ML                        5                      PA

HUMIRA PEN-CROHNS DISEASESTARTER                                            PA
                                                     5
KIT SC 40 MG/0.8ML
HUMIRA PEN-PSORIASIS STARTER KIT                                            PA
                                                     5
SC 40 MG/0.8ML
SIMPONI SOLN SC 50 MG/0.5ML                          5                      PA

Antirheumatic Antimetabolites
RHEUMATREX TABS OR 2.5 MG                            2                      MO

Gold Compounds
RIDAURA CAPS OR 3 MG                                 2                      MO

Interleukin-1 Blockers
ARCALYST SOLR SC 220 MG                              5                      LA

Interleukin-1 Receptor Antagonist (IL-1Ra)
KINERET SOLN SC 100 MG/0.67ML                        5                      PA

Interleukin-1beta Blockers
ILARIS SOLR SC 180 MG                                5                      LA

Interleukin-6 Receptor Inhibitors
ACTEMRA SOLN IV 200 MG/10ML, 400                                            PA
                                                     5
MG/20ML, 80 MG/4ML
Nonsteroidal Anti-inflammatory Agents (NSAIDs)
ANAPROX (naproxen sodium) TABS OR 275                                       MO
                                                      3           1
MG
ANAPROX DS (naproxen sodium) TABS OR                                        MO
                                                      3           1
550 MG
ARTHROTEC 50 TABS OR 200-50 MCG,                                            MO
                                                      3
MG
ARTHROTEC 75 TABS OR 200-75 MCG,                                            MO
                                                      3
MG
CATAFLAM (diclofenac potassium) TABS OR                                     MO
                                                      3           1
50 MG
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
CELEBREX CAPS OR 100 MG, 200 MG, 400                                        MO
                                                     2
MG, 50 MG
CLINORIL (sulindac) TABS OR 200 MG                   3            1         MO

DAYPRO (oxaprozin) TABS OR 600 MG                    3            1         MO

DUEXIS TABS OR 26.6-800 MG                           3                      MO

EC-NAPROSYN (naproxen) TBEC OR 375                                          MO
                                                     3            1
MG, 500 MG
etodolac caps or 200 mg                                           1         MO

etodolac tabs or 400 mg, 500 mg                                   1         MO

etodolac cr tb24 or 400 mg                                        1         MO

etodolac er tb24 or 400 mg, 500 mg, 600 mg                        1         MO

FELDENE (piroxicam) CAPS OR 10 MG, 20                                       MO
                                                     3            1
MG
fenoprofen calcium tabs or 600 mg                                 1         MO

flurbiprofen tabs or 100 mg, 50 mg                                1         MO

ibuprofen susp or 100 mg/5ml                                      1         MO

INDOCIN SUSP OR 25 MG/5ML                            2                      MO

indomethacin caps or 25 mg, 50 mg                                 1         MO

indomethacin cr cpcr or 75 mg                                     1         MO

indomethacin er cpcr or 75 mg                                     1         MO

ketoprofen caps or 50 mg, 75 mg                                   1         MO

ketoprofen er cp24 or 200 mg                                      1         MO

ketorolac tromethamine soln ij 15 mg/ml, 30                                 MO
                                                                  4
mg/ml, 300 mg/10ml, 60 mg/2ml
ketorolac tromethamine soln im 30 mg/ml, 60                                 MO
                                                                  4
mg/2ml
LODINE (etodolac) CAPS OR 300 MG                     3            1         MO

Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
meclofenamate sodium caps or 100 mg, 50                                 MO
                                                                 1
mg
MEFENAMIC ACID (mefenamic acid) CAPS                                    MO
                                                    3            1
OR 250 MG
MOBIC (meloxicam) SUSP OR 7.5 MG/5ML                3            1      MO

MOBIC (meloxicam) TABS OR 15 MG, 7.5                                    MO
                                                    3            1
MG
MOTRIN (ibuprofen) TABS OR 400 MG, 600                                  MO
                                                    3            1
MG, 800 MG
NALFON CAPS OR 200 MG                               3                   MO

NAPRELAN (naproxen sodium) TB24 OR                                      MO
                                                    2            1
500 MG
NAPRELAN TB24 OR 375 MG                             2                   MO

NAPRELAN TB24 OR                                    3                   500 MG & 750 MG Pack

NAPRELAN TB24 OR 750 MG                             3                   MO

NAPROSYN (naproxen) SUSP OR 125                                         MO
                                                    3            1
MG/5ML
NAPROSYN (naproxen) TABS OR 250 MG,                                     MO
                                                    3            1
375 MG, 500 MG
PONSTEL (mefenamic acid) CAPS OR 250                                    MO
                                                    3            1
MG
RELAFEN (nabumetone) TABS OR 500 MG,                                    MO
                                                    3            1
750 MG
SPRIX SOLN NA 15.75 MG/SPRAY                        3                   MO

sulindac tabs or 150 mg                                          1      MO

tolmetin sodium caps or 400 mg                                   1      MO

tolmetin sodium tabs or 200 mg, 600 mg                           1      MO

TORADOL ORAL (ketorolac tromethamine)                                   MO
                                                    3            1
TABS OR 10 MG
VIMOVO TBEC OR 20-375 MG, 20-500 MG                 2                   MO

VOLTAREN (diclofenac sodium) TBEC OR                                      MO
                                                      3           1
25 MG, 50 MG, 75 MG
VOLTAREN-XR (diclofenac sodium) TB24                                      MO
                                                      3           1
OR 100 MG
Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
ZIPSOR CAPS OR 25 MG                                3                   MO

Pyrimidine Synthesis Inhibitors
ARAVA (leflunomide) TABS OR 10 MG, 20                                   MO
                                                    3            1
MG
Selective Costimulation Modulators
ORENCIA SOLN SC 125 MG/1ML                          5                   PA

ORENCIA SOLR IV 250 MG                              5                   PA

Soluble Tumor Necrosis Factor Receptor Agents
ENBREL KIT SC 25 MG                                 5                   PA

ENBREL SOLN SC 25 MG/0.5ML, 50 MG/ML                5                   PA

ENBREL SURECLICK SOLN SC 50 MG/ML                   5                   PA

ANALGESICS - NonNarcotic
Analgesics Other
DURACLON (clonidine hcl (analgesia)) SOLN           4            4
EP 100 MCG/ML, 500 MCG/ML
Analgesics-Peptide Channel Blockers
PRIALT SOLN IT 100 MCG/ML, 500                      5
MCG/20ML, 500 MCG/5ML
Salicylates
diflunisal tabs or 500 mg                                        1      MO

ANALGESICS - OPIOID
Opioid Agonists
ABSTRAL SUBL SL 100 MCG, 200 MCG,
300 MCG, 400 MCG, 600 MCG, 800 MCG                  5

ACTIQ (fentanyl citrate) LPOP BU 200 MCG            5            1      PA; ; MO

ACTIQ (fentanyl citrate) LPOP BU 1200                                   PA; ; MO
MCG, 1600 MCG, 400 MCG, 600 MCG, 800                5            5
MCG
astramorph soln ij 0.5 mg/ml, 1 mg/ml                            4
AVINZA CP24 OR 120 MG, 30 MG, 45 MG,                                      MO
                                                      2
60 MG, 75 MG, 90 MG
Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
codeine sulfate tabs or 60 mg                                    1

codeine sulfate tabs or 15 mg, 30 mg, 60 mg                      1      MO

DAZIDOX TABS OR 20 MG                               2
DEMEROL (meperidine hcl) SOLN IJ 25                 4            4
MG/ML, 75 MG/ML
DEMEROL (meperidine hcl) SOLN IJ 100                                    MO
                                                    4            4
MG/ML, 50 MG/ML
DEMEROL SOLN IJ 100 MG/2ML, 25                      4
MG/0.5ML, 75 MG/1.5ML
DEMEROL SOLN IJ 75 MG/1.5ML                         4                   MO

DEMEROL SYRP OR 50 MG/5ML                           3                   MO

DEMEROL (meperidine hcl) TABS OR 100                                    MO
                                                    3            1
MG, 50 MG
DILAUDID (hydromorphone hcl) SOLN IJ 4              4            4
MG/ML
DILAUDID (hydromorphone hcl) SOLN IJ 1                                  MO
                                                    4            4
MG/ML, 2 MG/ML
DILAUDID (hydromorphone hcl) TABS OR 2                                  MO
                                                    3            1
MG, 4 MG, 8 MG
DILAUDID-5 (hydromorphone hcl) LIQD OR 1                                MO
                                                    2            1
MG/ML
DILAUDID-HP (hydromorphone hcl) SOLN IJ                                 MO
                                                    4            4
10 MG/ML
DILAUDID-HP SOLR IJ 250 MG                          4
DOLOPHINE (methadone hcl) TABS OR 10                                    MO
MG                                                  3            1
DOLOPHINE HCL (methadone hcl) TABS                                      MO
                                                    3            1
OR 5 MG
DURAGESIC (fentanyl) PT72 TD 100                                        MO
MCG/HR, 12 MCG/HR, 25 MCG/HR, 50                    3            1
MCG/HR, 75 MCG/HR
duramorph soln ij 0.5 mg/ml, 1 mg/ml                             4
EMBEDA CPCR OR 1.2-30 MG, 100-4 MG,                   2
2-50 MG
EMBEDA CPCR OR 0.8-20 MG, 2.4-60 MG,                                      MO
                                                      2
3.2-80 MG
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
EXALGO TB24 OR 12 MG, 16 MG, 8 MG                    3                      MO

fentanyl citrate soln ij 0.5 mg/ml                                4         MO

FENTORA TABS BU 300 MCG                              5                      PA

FENTORA TABS BU 100 MCG, 200 MCG,                                           PA; ; MO
                                                     5
400 MCG, 600 MCG, 800 MCG
hydromorphone hcl soln ij 50 mg/5ml, 500                                    MO
                                                                  4
mg/50ml
INFUMORPH 200 SOLN IJ 10 MG/ML                       4                      MO

INFUMORPH 500 SOLN IJ 25 MG/ML                       4                      MO

KADIAN (morphine sulfate) CP24 OR 100                                       MO
                                                     2            1
MG, 20 MG, 30 MG, 50 MG, 60 MG, 80 MG
KADIAN CP24 OR 10 MG, 200 MG                         2                      MO

LAZANDA SOLN NA 100 MCG/ACT, 400                                            PA
                                                     5
MCG/ACT
LEVO DROMORAN SOLN IJ 2 MG/ML                        4
LEVO-DROMORAN (levorphanol tartrate)                                        MO
                                                     3            1
TABS OR 2 MG
meperidine hcl soln ij 10 mg/ml                                   4

meperidine hcl soln or 50 mg/5ml                                  1         MO

meperidine hcl tabs or 50 mg                                      1

methadone hcl conc or 10 mg/ml                                    1

methadone hcl conc or 10 mg/ml                                    1         MO

METHADONE HCL SOLN IJ 10 MG/ML                       4

methadone hcl soln or 10 mg/5ml, 5 mg/5ml                         1         MO

methadone hcl tbso or 40 mg                                       1

methadone hcl intensol conc or 10 mg/ml                           1         MO

methadose conc or 10 mg/ml                                        1         MO

Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                                     21
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
methadose tbso or 40 mg                                          1

methadose sugar-free conc or 10 mg/ml                            1      MO

morphine sulfate soln ij 0.5 mg/ml, 1 mg/ml                      4

morphine sulfate soln iv 1 mg/ml                                 4
MORPHINE SULFATE (morphine sulfate)                                     MO
                                                    2            1
SOLN OR 10 MG/5ML
MORPHINE SULFATE SOLN OR 20                                             MO
                                                    2
MG/10ML
morphine sulfate soln or 20 mg/5ml, 20 mg/ml                     1      MO

morphine sulfate tabs or 15 mg, 30 mg                            1

morphine sulfate tabs or 15 mg, 30 mg                            1      MO

morphine sulfate stick-gard soln iv 1 mg/ml                      4
MS CONTIN (morphine sulfate) TB12 OR                                    MO
                                                    3            1
100 MG, 15 MG, 200 MG, 30 MG, 60 MG
NUCYNTA TABS OR 100 MG, 50 MG, 75                                       MO
                                                    2
MG
NUCYNTA ER TB12 OR 100 MG, 150 MG,                                      MO
                                                    2
200 MG, 250 MG, 50 MG
NUMORPHAN SOLN IJ 1 MG/ML                           4
ONSOLIS FILM BU 1200 MCG, 200 MCG,                                      PA; LA
                                                    5
400 MCG, 600 MCG, 800 MCG
OPANA SOLN IJ 1 MG/ML                               4
OPANA (oxymorphone hcl) TABS OR 10 MG,                                  MO
                                                    3            1
5 MG
OPANA ER TB12 OR 10 MG, 15 MG, 20 MG,               2
30 MG, 40 MG, 7.5 MG
OPANA ER TB12 OR 5 MG                               2                   MO

OPANA ER (CRUSH RESISTANT) TB12 OR                    2
5 MG
OPANA ER (CRUSH RESISTANT) TB12 OR                                        MO
                                                      2
10 MG, 20 MG, 30 MG, 40 MG
ORAMORPH SR (morphine sulfate) TB12                                       MO
                                                      3           1
OR 100 MG, 15 MG, 30 MG, 60 MG
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                               22
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
OXECTA TABS OR 5 MG                                 3

OXECTA TABS OR 7.5 MG                               3                   MO

oxycodone hcl caps or 5 mg                                       1      MO

oxycodone hcl conc or 20 mg/ml                                   1      MO

oxycodone hcl tabs or 10 mg, 20 mg                               1      MO

OXYCODONE HCL CR (oxycodone hcl)                                        MO
                                                    2            1
TB12 OR 10 MG, 20 MG, 40 MG, 80 MG
OXYCONTIN (oxycodone hcl) TB12 OR 10                                    MO
                                                    2            1
MG, 20 MG, 40 MG, 80 MG
OXYCONTIN TB12 OR 15 MG, 30 MG, 60                                      MO
                                                    2
MG
oxymorphone hydrochloride er tb12 or 15 mg,                             MO
                                                                 1
7.5 mg
ROXICODONE (oxycodone hcl) TABS OR 15                                   MO
                                                    3            1
MG, 30 MG, 5 MG
RYBIX ODT TBDP OR 50 MG                             3                   MO

RYZOLT (tramadol hcl) TB24 OR 100 MG,                                   MO
                                                    3            1
300 MG
RYZOLT TB24 OR 200 MG                               3                   MO

SUBLIMAZE (fentanyl citrate) SOLN IJ 0.05                               MO
                                                    4            4
MG/ML
tramadol hcl er tb24 or 200 mg                                   1

ULTRAM (tramadol hcl) TABS OR 50 MG                 3            1      MO

ULTRAM ER (tramadol hcl) TB24 OR 100                                    MO
                                                    3            1
MG, 200 MG, 300 MG
Opioid Combinations
acetaminophen/codeine soln or 12-120-7 %,                               MO
                                                                 1
mg/5ml, 12-120-7.4 %, mg/5ml
acetaminophen/codeine tabs or 15-300 mg                          1      MO

acetaminophen/codeine #2 tabs or 15-300                                   MO
                                                                  1
mg
acetaminophen/codeine #3 tabs or 30-300                                   MO
                                                                  1
mg
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                             23
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
acetaminophen/codeine phosphate tabs or                                 MO
                                                                 1
30-300 mg
ANEXSIA (hydrocodone-acetaminophen)                                     MO
                                                    3            1
TABS OR 650-7.5 MG
anexsia tabs or 325-5 mg, 325-7.5 mg, 5-500                             MO
                                                                 1
mg
BANCAP-HC (hydrocodone-acetaminophen)                                   MO
                                                    3            1
CAPS OR 5-500 MG
capital/codeine susp or 12-120 mg/5ml                            1      MO

co-gesic tabs or 5-500 mg                                        1      MO

cocet plus tabs or 60-650 mg                                     1
COMBUNOX (oxycodone-ibuprofen) TABS                                     MO
                                                    3            1
OR 400-5 MG
endocet tabs or 10-325 mg, 10-650 mg, 325-                              MO
                                                                 1
5 mg, 325-7.5 mg, 500-7.5 mg
FIORICET/CODEINE (butalbital-                                           MO
acetaminophen-caffeine w/ codeine) CAPS             3            1
OR 30-325-40-50 MG
FIORINAL/CODEINE #3 (butalbital-aspirin-                                MO
                                                    3            1
caffeine w/cod) CAPS OR 30-325-40-50 MG
hycet soln or 325-7-7.5 %, mg/15ml                               1      MO

hydrocodone bitartrate/acetaminophen soln                               MO
                                                                 1
or , 325-7-7.5 %, mg/15ml
hydrocodone bitartrate/acetaminophen tabs                               MO
or , 10-300 mg, 10-750 mg, 300-5 mg, 300-                        1
7.5 mg
hydrocodone/acetaminophen soln or 500-7-                                MO
                                                                 1
7.5 %, mg/15ml, 500-7.5 mg/15ml
hydrocodone/acetaminophen tabs or 10-325                         1
mg, 325-5 mg, 325-7.5 mg
hydrocodone/acetaminophen tabs or 10-325                                MO
mg, 10-500 mg, 10-660 mg, 325-5 mg, 325-                         1
7.5 mg, 5-500 mg, 500-7.5 mg, 7.5-750 mg
hydrocodone/ibuprofen tabs or                                    1      MO

ibudone tabs or 10-200 mg                                        1      MO

LORCET 10/650 (hydrocodone-                                               MO
                                                      3           1
acetaminophen) TABS OR 10-650 MG
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
lortab elix or 500-7-7.5 %, mg/15ml                               1         MO

LORTAB (hydrocodone-acetaminophen)                                          MO
                                                     3            1
TABS OR 2.5-500 MG
lortab tabs or 10-500 mg, 5-500 mg, 500-7.5                                 MO
                                                                  1
mg
MAGNACET (oxycodone w/ acetaminophen)                                       MO
                                                     3            1
TABS OR 400-5 MG, 400-7.5 MG
MAGNACET TABS OR 2.5-400 MG                          3                      MO

magnacet tabs or , 10-400 mg                                      1         MO

maxidone tabs or 10-750 mg                                        1         MO

norco tabs or 10-325 mg, 325-5 mg, 325-7.5                                  MO
                                                                  1
mg
oxycodone/acetaminophen caps or 5-500 mg                          1         MO

oxycodone/acetaminophen tabs or 10-325                                      MO
mg, 10-650 mg, 2.5-325 mg, 325-5 mg, 325-                         1
7.5 mg, 500-7.5 mg
oxycodone/aspirin tabs or 325-4.835 mg                            1         MO

panlor dc caps or 16-30-356.4 mg                                  1         MO

PANLOR SS (acetaminophen-caff-                                              MO
                                                     3            1
dihydrocod) TABS OR 32-60-712.8 MG
pentazocine/acetaminophen tabs or 25-650                          1
mg
pentazocine/acetaminophen tabs or 25-650                                    MO
                                                                  1
mg
percocet tabs or 10-325 mg, 10-650 mg, 2.5-                                 MO
                                                                  1
325 mg, 325-5 mg, 325-7.5 mg, 500-7.5 mg
PERCODAN (oxycodone-aspirin) TABS OR                 3            1
0.38-325-4.5 MG
PERCODAN (oxycodone-aspirin) TABS OR                                        MO
                                                     3            1
0.38-325-4.835 MG
PERLOXX (oxycodone w/ acetaminophen)                NF            1
TABS OR 300-7.5 MG
PERLOXX (oxycodone w/ acetaminophen)                                        MO
                                                    NF            1
TABS OR 10-300 MG, 300-5 MG
primalev tabs or 2.5-300 mg                                       1
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                               25
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
primlev tabs or                                                   1

primlev tabs or                                                   1         MO

REPREXAIN (hydrocodone-ibuprofen) TABS                                      MO
                                                     3            1
OR 200-5 MG
reprexain tabs or 10-200 mg, 2.5-200 mg                           1         MO

roxicet soln or 325-5 mg/5ml                                      1         MO

ROXICET (oxycodone w/ acetaminophen)                                        MO
                                                     2            1
TABS OR 5-500 MG
roxicet tabs or 325-5 mg                                          1         MO

SYNALGOS-DC CAPS OR 16-30-356.4 MG                   3                      MO

tramadol hydrochloride/acetaminophen tabs                                   MO
                                                                  1
or
trezix caps or 16-30-356.4 mg                                     1         MO

tylenol/codeine #3 tabs or 30-300 mg                              1         MO

TYLENOL/CODEINE #4 (acetaminophen w/                                        MO
                                                     3            1
codeine) TABS OR 300-60 MG
tylox caps or 5-500 mg                                            1         MO

ULTRACET (tramadol-acetaminophen) TABS                                      MO
                                                     3            1
OR 325-37.5 MG
vanacet tabs or 5-500 mg                                          1         MO

vicodin tabs or 5-500 mg                                          1         MO

vicodin es tabs or 7.5-750 mg                                     1         MO

vicodin hp tabs or 10-660 mg                                      1         MO

VICOPROFEN (hydrocodone-ibuprofen)                                          MO
                                                     3            1
TABS OR 200-7.5 MG
xodol tabs or , 10-300 mg, 300-5 mg, 300-                                   MO
                                                                  1
7.5 mg
ZAMICET (hydrocodone-acetaminophen)                                         MO
                                                     3            1
SOLN OR 10-325-6.7 %, MG/15ML
zolvit soln or , 10-300 mg/15ml                                   1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                               26
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
zydone tabs or 10-400 mg, 400-5 mg, 400-                                    MO
                                                                  1
7.5 mg
Opioid Partial Agonists
BUPRENEX (buprenorphine hcl) SOLN IJ 0.3                                    MO
                                                     4            4
MG/ML
butorphanol tartrate soln ij 1 mg/ml                              4         MO

butorphanol tartrate soln na 10 mg/ml                             1         MO

BUTRANS PTWK TD 10 MCG/HR, 20                                               MO
                                                     3
MCG/HR, 5 MCG/HR
nalbuphine hcl soln ij 20 mg/ml                                   4
NUBAIN (nalbuphine hcl) SOLN IJ 10                                          MO
                                                     4            4
MG/ML, 20 MG/ML
pentazocine/naloxone hcl tabs or 0.5-50 mg                        1

pentazocine/naloxone hcl tabs or 0.5-50 mg                        1         MO

STADOL (butorphanol tartrate) SOLN IJ 2                                     MO
                                                     4            4
MG/ML
SUBOXONE SUBL SL 0.5-2 MG, 2-8 MG                    3                      PA; ; MO

SUBUTEX (buprenorphine hcl) SUBL SL 2                                       PA; ; MO
                                                     3            1
MG, 8 MG
TALWIN SOLN IJ 30 MG/ML                              4                      MO

ANDROGENS-ANABOLIC
Anabolic Steroids
ANADROL-50 TABS OR 50 MG                             5                      MO

OXANDRIN (oxandrolone) TABS OR 10 MG,                                       MO
                                                     3            1
2.5 MG
Androgens
ANDRODERM PT24 TD 2 MG/24HR, 2.5                                            GL; MO
                                                     2
MG/24HR, 4 MG/24HR, 5 MG/24HR
ANDROGEL GEL TD 25 MG/2.5GM, 50                                             GL; MO
                                                     2
MG/5GM
ANDROGEL PUMP GEL TD 1.25 GM/ACT,                                           GL; MO
                                                     2
1.62 %
android caps or 10 mg                                             1         MO

Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                                     27
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
ANDROXY TABS OR 10 MG                               2                   MO

AXIRON SOLN TD 30 MG/ACT                            3                   GL; MO

danazol caps or 100 mg, 200 mg, 50 mg                            1      MO

DELATESTRYL (testosterone enanthate) OIL                                MO
                                                    4            4
IM 200 MG/ML
depo-testosterone oil im 100 mg/ml, 200                                 MO
                                                                 4
mg/ml
FORTESTA GEL TD 10 MG/ACT                           3                   GL; MO

methitest tabs or 10 mg                                          1      MO

STRIANT MISC BU 30 MG                               3                   GL; MO

TESTIM GEL TD 1 %                                   2                   GL; MO

testosterone cypionate oil im 100 mg/ml, 200                            MO
                                                                 4
mg/ml
testred caps or 10 mg                                            1      MO

ANORECTAL AGENTS
Intrarectal Steroids
CORTENEMA (hydrocortisone (intrarectal))                                MO
                                                    3            1
ENEM RE 100 MG/60ML
CORTIFOAM FOAM RE 90 MG                             3                   MO

Rectal Combinations
ANALPRAM-HC CREA RE 1 %                             3                   MO

ANALPRAM-HC SINGLES CREA RE 1 %                     3                   MO

PROCTOFOAM HC (hydrocortisone acetate                                   MO
                                                   NF            1
w/ pramoxine) FOAM RE 1 %
Rectal Steroids
anusol-hc crea re 2.5 %                                          1      MO

procto-kit crea re 2.5 %                                         1      MO

PROCTOCORT (hydrocortisone (rectal))                                      MO
                                                      3           1
CREA RE 1 %
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
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 www.healthnet.com                                                               28
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
proctocream hc crea re 2.5 %                                      1         MO

proctocream-hc crea re 2.5 %                                      1         MO

proctosol hc crea re 2.5 %                                        1         MO

proctozone-hc crea re 2.5 %                                       1         MO

Vasodilating Agents
RECTIV OINT RE 0.4 %                                 2                      MO

ANTHELMINTICS
Anthelmintics
ALBENZA TABS OR 200 MG                               3                      MO

BILTRICIDE TABS OR 600 MG                            2                      MO

mebendazole chew or 100 mg                                        1

STROMECTOL TABS OR 3 MG                              3                      MO

ANTI-INFECTIVE AGENTS - MISC.
Anti-infective Agents - Misc.
AZACTAM (aztreonam) SOLR IJ 2 GM                     4            4

AZACTAM (aztreonam) SOLR IJ 1 GM                     4            4         MO

AZACTAM IN DEXTROSE SOLN IV 1 GM, 2                  4
GM
AZACTAMIN ISO-OSMOTIC DEXTROSE                       4
SOLN IV 1 GM, 2 GM
baciim solr im 50000 unit                                         4         MO

bacitracin solr im 50000 unit                                     4         MO

CAYSTON SOLR IN 75 MG                                5                      LA

COLY-MYCIN M (colistimethate sodium)                                        MO
                                                     4            4
SOLR IJ 150 MG
COLY-MYCIN-M (colistimethate sodium)                                        MO
                                                     4            4
SOLR IJ 150 MG
FLAGYL (metronidazole) CAPS OR 375 MG                3            1         MO

Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                               29
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
FLAGYL (metronidazole) TABS OR 250 MG,                                      MO
                                                     3            1
500 MG
FLAGYL ER TB24 OR 750 MG                             3                      MO

METRO IV SOLN IV 0.74-500 %, MG/100ML                4
metronidazole in nacl 0.79% soln iv 0.79-5 %,                               MO
                                                                  4
mg/ml, 0.79-500 %, mg/100ml
NEBUPENT SOLR IN 300 MG                              2                      MO; B/D

PENTAM 300 (pentamidine isethionate)                                        MO
                                                     4            4
SOLR IJ 300 MG
PRIMSOL SOLN OR 50 MG/5ML                            2                      MO

PROLOPRIM (trimethoprim) TABS OR 100                                        MO
                                                     3            1
MG
VANCOCIN HCL (vancomycin hcl) CAPS OR                                       PA; ; MO
                                                     5            5
125 MG, 250 MG
vancomycin hcl solr iv 10 gm, 5000 mg, 750                                  B/D
                                                                  4
mg
vancomycin hcl solr iv 1000 mg, 500 mg                            4         MO; B/D

VANCOMYCIN HCL IN DEXTROSE SOLN                                             B/D
IV 1 GM/200ML, 500 MG/100ML, 750                     4
MG/150ML
XIFAXAN TABS OR 200 MG                               3                      MO

XIFAXAN TABS OR 550 MG                               5                      MO

 Anti-infective Misc. - Combinations
BACTRIM (sulfamethoxazole-trimethoprim)                                     MO
TABS OR 400-80 MG                                     3           1
BACTRIM DS (sulfamethoxazole-                         3           1         MO
trimethoprim) TABS OR 160-800 MG
PEDIAZOLE (erythromycin-sulfisoxazole)                                      MO
                                                      3           1
SUSR OR 200-600 MG/5ML
SEPTRA (sulfamethoxazole-trimethoprim)                                      MO
                                                      3           1
SUSP OR 200-40 MG/5ML
SEPTRA (sulfamethoxazole-trimethoprim)                                      MO
                                                      3           1
TABS OR 400-80 MG
SEPTRA DS (sulfamethoxazole-trimethoprim)                                   MO
                                                      3           1
TABS OR 160-800 MG
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                                     30
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
SULFAMETHOXAZOLE/TRIMETHOPRIM                                               MO
(sulfamethoxazole-trimethoprim) SOLN IV              4            4
400-50-500-80 MG/5ML
sulfamethoxazole/trimethoprim soln iv 400-80                                MO
                                                                  4
mg/5ml
sulfamethoxazole/trimethoprim susp or 0.04-                                 MO
160-800 %, mg/20ml, 0.04-200-40 %,                                1
mg/5ml, 0.1-0.26-200-40 %, mg/5ml, 0.1-0.5-
200-40 %, mg/5ml, 0.5-200-40 %, mg/5ml
Antiprotozoal Agents
ALINIA SUSR OR 100 MG/5ML                            3                      MO

ALINIA TABS OR 500 MG                                3                      MO

MEPRON SUSP OR 750 MG/5ML                            5                      MO

NEUTREXIN SOLR IV 25 MG                              4
Carbapenems
DORIBAX SOLR IV 500 MG                               4

DORIBAX SOLR IV 250 MG                               5

imipenem/cilastatin solr iv , 250 mg, 500 mg                      1

INVANZ SOLR IJ 1 GM                                  4                      MO

INVANZ SOLR IV 1 GM                                  4
MERREM (meropenem) SOLR IV 1 GM, 500                                        MO
                                                     4            4
MG
PRIMAXIN I.M. SOLR IM 500 MG                         2
PRIMAXIN IV (imipenem-cilastatin) SOLR IV                                   MO
                                                     2            1
250 MG, 500 MG
Chloramphenicols
CHLORAMPHENICOL SODIUM                               4
SUCCINATE SOLR IV 1 GM
CHLOROMYCETIN SOLR IV 1 GM                           4
Cyclic Lipopeptides
CUBICIN SOLR IV 500 MG                               5                      MO; B/D

Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                                    31
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
Glycylcyclines
TYGACIL SOLR IV 50 MG                                4
Ketolides
KETEK TABS OR 300 MG                                 3

KETEK TABS OR 400 MG                                 3                      MO

KETEK PAK TABS OR 400 MG                             3                      MO

Leprostatics
dapsone tabs or 100 mg, 25 mg                                     1         MO

Lincosamides
CLEOCIN (clindamycin hcl) CAPS OR 75 MG              2            1         MO

CLEOCIN (clindamycin hcl) CAPS OR 150                                       MO
                                                     3            1
MG, 300 MG
CLEOCIN IN D5W SOLN IV , 300-5 %,                    4
MG/50ML
cleocin pediatric granules solr or 75 mg/5ml                      1         MO

CLEOCIN PHOSPHATE (clindamycin
phosphate) SOLN IJ 150 MG/ML, 300                    4            4
MG/2ML
CLEOCIN PHOSPHATE (clindamycin                                              MO
phosphate) SOLN IJ 600 MG/4ML, 900                   4            4
MG/6ML
CLEOCIN PHOSPHATE (clindamycin                       4            4
phosphate) SOLN IV 150 MG/ML
CLEOCIN PHOSPHATE SOLN IV 600                        4
MG/4ML
CLEOCINGALAXY SOLN IV 5-600 %,                       4
MG/50ML, 5-900 %, MG/50ML
clindamycin palmitate hcl solr or 75 mg/5ml                       1         MO

clindamycin phosphate soln ij 9000 mg/60ml                        4
CLINDAMYCIN PHOSPHATE SOLN IV 150                     4
MG/ML
clindamycin phosphateadd-vantage soln iv                          4
150 mg/ml
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                               32
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
LINCOCIN SOLN IJ 300 MG/ML                           4                      MO

Oxazolidinones
ZYVOX SOLN IV 2 MG/ML                                5                      PA

ZYVOX SUSR OR 100 MG/5ML                             5                      PA; ; MO

ZYVOX TABS OR 600 MG                                 5                      PA; ; MO

Polymyxins
polymyxin b sulfate solr ij 500000 unit                           4
Streptogramins
SYNERCID SOLR IV 150-350 MG                          4
ANTIANGINAL AGENTS
Antianginals-Other
RANEXA TB12 OR 1000 MG, 500 MG                       3                      PA; ; MO

Nitrates
DILATRATE SR CPCR OR 40 MG                           2                      MO

IMDUR (isosorbide mononitrate) TB24 OR                                      MO
                                                     3            1
120 MG, 30 MG, 60 MG
ISMO (isosorbide mononitrate) TABS OR 20                                    MO
                                                     3            1
MG
isochron tbcr or 40 mg                                            1         MO

isoditrate er tbcr or 40 mg                                       1         MO

ISORDIL TITRADOSE TABS OR 40 MG                      2                      MO

ISORDIL TITRADOSE (isosorbide dinitrate)                                    MO
                                                     3            1
TABS OR 5 MG
isosorbide dinitrate subl sl 5 mg                                 1

isosorbide dinitrate subl sl 2.5 mg, 5 mg                         1         MO

isosorbide dinitrate tabs or 10 mg, 20 mg                         1

isosorbide dinitrate tabs or 30 mg                                1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                                     33
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
isosorbide dinitrate er tbcr or 40 mg                             1         MO

isosorbide mononitrate er tb24 or 120 mg, 30                      1
mg, 60 mg
MONOKET (isosorbide mononitrate) TABS                                       MO
                                                     3            1
OR 10 MG, 20 MG
nitro-bid oint td 2 %                                             1         MO

NITRO-DUR PT24 TD 0.3 MG/HR, 0.8                                            MO
                                                     2
MG/HR
NITRO-DUR (nitroglycerin) PT24 TD 0.1                                       MO
                                                     3            1
MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR
NITROGLYCERIN (nitroglycerin) SOLN IV 5              4            4
MG/ML
NITROGLYCERIN IN DEXTROSE 5%
(nitroglycerin in d5w) SOLN IV 100-5 %,              4            4
MCG/ML, 200-5 %, MCG/ML, 400-5 %,
MCG/ML
NITROLINGUAL PUMPSPRAY (nitroglycerin)                                      MO
                                                     3            1
SOLN TL 0.4 MG/SPRAY
NITROLINGUAL PUMPSPRAY DUO PACK                                             MO
                                                     3            1
(nitroglycerin) SOLN TL 0.4 MG/SPRAY
NITROMIST AERS TL 400 MCG/SPRAY                      2                      MO

NITROSTAT (nitroglycerin) SUBL SL 0.3 MG,                                   MO
                                                     2            1
0.4 MG, 0.6 MG
ANTIANXIETY AGENTS
Antianxiety Agents - Misc.
ATARAX (hydroxyzine hcl) SYRP OR 10                                         MO
                                                     3            1
MG/5ML
BUSPAR (buspirone hcl) TABS OR 10 MG,                                       MO
                                                     3            1
15 MG, 30 MG, 5 MG
droperidol soln ij 2 mg/ml                                        4         MO

hydroxyzine hcl soln im 25 mg/ml                                  4

hydroxyzine hcl soln im 50 mg/ml                                  4         MO

hydroxyzine hcl soln or 10 mg/5ml                                 1         MO

hydroxyzine hcl tabs or 10 mg, 25 mg, 50 mg                       1         MO

Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                               34
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
hydroxyzine pamoate caps or 100 mg                                1         MO

hyzine soln im 50 mg/ml                                           4         MO

INAPSINE (droperidol) SOLN IJ 2.5 MG/ML              4            4         MO

meprobamate tabs or 200 mg, 400 mg                                1         MO

VANSPAR (buspirone hcl) TABS OR 7.5 MG               3            1         MO

VISTARIL (hydroxyzine pamoate) CAPS OR                                      MO
                                                     3            1
25 MG, 50 MG
ANTIARRHYTHMICS
Antiarrhythmics - Misc.
ADENOCARD (adenosine) SOLN IV 6                                             MO
                                                     4            4
MG/2ML
Antiarrhythmics Type I-A
NORPACE (disopyramide phosphate) CAPS                                       MO
                                                     3            1
OR 100 MG, 150 MG
NORPACE CR CP12 OR 100 MG                            2                      MO

NORPACE CR (disopyramide phosphate)                                         MO
                                                     3            1
CP12 OR 150 MG
PROCAINAMIDE HCL (procainamide hcl)                  4            4
SOLN IJ 100 MG/ML, 500 MG/ML
QUINIDINE GLUCONATE SOLN IJ 80                       4
MG/ML
quinidine gluconate cr tbcr or 324 mg                             1         MO

quinidine gluconate er tbcr or 324 mg                             1         MO

quinidine gluconate sa tbcr or 324 mg                             1         MO

quinidine sulfate tabs or 200 mg, 300 mg                          1         MO

quinidine sulfate er tbcr or 300 mg                               1         MO

Antiarrhythmics Type I-B
LIDOCAINE HCL (lidocaine hcl (cardiac))                                     MO
                                                     4            4
SOLN IV 10 MG/ML
lidocaine hcl in d5w soln iv 4-5 %, mg/ml                         4
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                               35
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
lidocaine hcl/dextrose soln iv 4-5 %, mg/ml                       4
mexiletine hcl caps or 150 mg, 200 mg, 250                                  MO
                                                                  1
mg
XYLOCAINE (lidocaine hcl (cardiac)) SOLN                                    MO
                                                     4            4
IV 20 MG/ML
Antiarrhythmics Type I-C
propafenone hcl tabs or 300 mg                                    1         MO

RYTHMOL (propafenone hcl) TABS OR 150                                       MO
                                                     3            1
MG, 225 MG
RYTHMOL SR (propafenone hcl) CP12 OR                                        MO
                                                     2            1
225 MG, 325 MG, 425 MG
TAMBOCOR (flecainide acetate) TABS OR                                       MO
                                                     3            1
100 MG, 150 MG, 50 MG
 Antiarrhythmics Type III
AMIODARONE HCL (amiodarone hcl) SOLN                 4            4
IV 900 MG/18ML
amiodarone hcl soln iv 150 mg/3ml, 450                            4
mg/9ml, 50 mg/ml
amiodarone hcl tabs or 400 mg                                     1         MO

CORDARONE (amiodarone hcl) TABS OR                                          MO
                                                     3            1
200 MG
CORDARONE I.V. (amiodarone hcl) SOLN IV              4            4
50 MG/ML
MULTAQ TABS OR 400 MG                                2                      MO

PACERONE TABS OR 300 MG                              2

pacerone tabs or 100 mg, 400 mg                                   1         MO

TIKOSYN CAPS OR 125 MCG, 250 MCG,                    2
500 MCG
 ANTIASTHMATIC AND BRONCHODILATOR AGENTS
 Anti-Inflammatory Agents
INTAL (cromolyn sodium) NEBU IN 20                                          MO; B/D
                                     3                            1
MG/2ML
Antiasthmatic - Monoclonal Antibodies
XOLAIR SOLR SC 150 MG                                5                      LA

Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                                    36
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
Bronchodilators - Anticholinergics
ATROVENT HFA AERS IN 17 MCG/ACT                      2                      MO

ipratropium bromide soln in 0.02 %, 0.2 %                         1         MO; B/D

SPIRIVA HANDIHALER CAPS IN 18 MCG                    2                      MO

Leukotriene Modulators
ACCOLATE (zafirlukast) TABS OR 10 MG,                                       MO
                                                     2            1
20 MG
SINGULAIR CHEW OR 4 MG, 5 MG                         2                      MO

SINGULAIR PACK OR 4 MG                               2                      MO

SINGULAIR TABS OR 10 MG                              2                      MO

ZYFLO CR TB12 OR 600 MG                              3                      MO

Selective Phosphodiesterase 4 (PDE4) Inhibitors
DALIRESP TABS OR 500 MCG                             3                      PA; ; MO

Steroid Inhalants
ALVESCO AERS IN 160 MCG/ACT, 80                                             MO
                                                     3
MCG/ACT
ASMANEX 120 METERED DOSES AEPB IN                                           MO
                                                     2
220 MCG/INH
ASMANEX 14 METERED DOSES AEPB IN                                            MO
                                                     2
220 MCG/INH
ASMANEX 30 METERED DOSES AEPB IN                                            MO
                                                     2
110 MCG/INH, 220 MCG/INH
ASMANEX 60 METERED DOSES AEPB IN                                            MO
                                                     2
220 MCG/INH
ASMANEX 7 METERED DOSES AEPB IN                                             MO
                                                     2
110 MCG/INH
AZMACORT AERS IN 75 MCG/ACT                          3
FLOVENT DISKUS AEPB IN 100                                                  MO
MCG/BLIST, 250 MCG/BLIST, 50                         2
MCG/BLIST
FLOVENT HFA AERO IN 110 MCG/ACT,                                            MO
                                                     2
220 MCG/ACT, 44 MCG/ACT
PULMICORT SUSP IN 1 MG/2ML                           2                      MO; B/D

Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                                     37
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
PULMICORT (budesonide (inhalation)) SUSP                                    MO; B/D
                                                     3            1
IN 0.25 MG/2ML, 0.5 MG/2ML
PULMICORT FLEXHALER AEPB IN 180                                             MO
                                                     3
MCG/ACT, 90 MCG/ACT
QVAR AERS IN 40 MCG/ACT, 80 MCG/ACT                  2                      MO

Sympathomimetics
ACCUNEB (albuterol sulfate) NEBU IN 0.63                                    MO; B/D
                                                     3            1
MG/3ML, 1.25 MG/3ML
ADVAIR DISKUS AEPB IN 100-50                                                MO
MCG/DOSE, 250-50 MCG/DOSE, 50-500                    2
MCG/DOSE
ADVAIR HFA AERO IN 115-21 MCG/ACT,                                          MO
                                                     2
21-230 MCG/ACT, 21-45 MCG/ACT
airet nebu in 0.83 %                                              1         MO; B/D

albuterol sulfate nebu in 0.5 %, 0.83 %                           1         MO; B/D

albuterol sulfate syrp or 2 mg/5ml                                1         MO

albuterol sulfate tabs or 2 mg, 4 mg                              1         MO

ARCAPTA NEOHALER CAPS IN 75 MCG                      3                      MO

BRETHINE (terbutaline sulfate) TABS OR 2.5                                  MO
                                                     3            1
MG, 5 MG
BROVANA NEBU IN 15 MCG/2ML                           3                      MO; B/D

COMBIVENT AERO IN 103-18 MCG/ACT                     2                      MO

DULERA AERO IN , 100-5 MCG/ACT, 200-5                                       MO
                                                     2
MCG/ACT
DUONEB (ipratropium-albuterol) SOLN IN                                      MO; B/D
                                                     3            1
0.5-2.5 MG/3ML
epinephrine hcl soln ij 0.1 mg/ml                                 4         MO

FORADIL AEROLIZER CAPS IN 12 MCG                     2                      MO

ISUPREL SOLN IJ 0.2 MG/ML                            4                      MO

metaproterenol sulfate nebu in 0.4 %, 0.6 %                       1         B/D

metaproterenol sulfate syrp or 10 mg/5ml                          1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                                    38
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
metaproterenol sulfate tabs or 10 mg, 20 mg                       1         MO

PERFOROMIST NEBU IN 20 MCG/2ML                       3                      MO; B/D

PROAIR HFA AERS IN 108 MCG/ACT                       2                      MO

PROVENTIL (albuterol sulfate) NEBU IN                                       MO; B/D
                                                     3            1
0.083 %
PROVENTIL HFA AERS IN 108 MCG/ACT                    2                      MO

SEREVENT DISKUS AEPB IN 50                                                  MO
                                                     2
MCG/DOSE
SYMBICORT AERO IN 160-4.5 MCG/ACT,                                          MO
                                                     2
4.5-80 MCG/ACT
terbutaline sulfate soln ij 1 mg/ml                               4         MO

VENTOLIN HFA AERS IN 108 MCG/ACT                     3                      MO

VOSPIRE ER (albuterol sulfate) TB12 OR 4                                    MO
                                                     3            1
MG, 8 MG
XOPENEX NEBU IN 0.31 MG/3ML, 0.63                                           MO; B/D
                                                     3
MG/3ML, 1.25 MG/3ML
XOPENEX CONCENTRATE (levalbuterol                                           MO; B/D
                                                     3            1
hcl) NEBU IN 1.25 MG/0.5ML
XOPENEX HFA AERO IN 45 MCG/ACT                       3                      MO

Xanthines
aminophylline soln iv 25 mg/ml                                    4         MO

aminophylline tabs or 100 mg, 200 mg                              1         MO

elixophyllin elix or 80 mg/15ml                                   1         MO

LUFYLLIN TABS OR 200 MG, 400 MG                      3                      MO

QUIBRON-T/SR (theophylline) TB12 OR 300                                     MO
                                                     3            1
MG
THEO-24 CP24 OR 100 MG, 200 MG, 300                                         MO
                                                     2
MG, 400 MG
theochron tb12 or 450 mg                                          1

theochron tb12 or 100 mg, 200 mg                                  1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                                    39
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
theophylline cr tb12 or 100 mg, 200 mg                            1         MO

theophylline er tb12 or 450 mg                                    1
theophylline er tb12 or 100 mg, 200 mg, 450                                 MO
                                                                  1
mg
theophylline er tb24 or 400 mg, 600 mg                            1         MO

theophylline td tb12 or 100 mg, 200 mg                            1         MO

THEOPHYLLINE/D5W (theophylline in
dextrose) SOLN IV 0.8-5 %, MG/ML, 1.6-5 %,           4            4
MG/ML, 2-5 %, MG/ML, 3.2-5 %, MG/ML, 4-5
%, MG/ML
uniphyl tb24 or 400 mg, 600 mg                                    1         MO

ANTICOAGULANTS
Coumarin Anticoagulants
COUMADIN SOLR IV 5 MG                                4                      MO

COUMADIN (warfarin sodium) TABS OR 1                                        MO
MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5               3            1
MG, 6 MG, 7.5 MG
Direct Factor Xa Inhibitors
XARELTO TABS OR 10 MG, 15 MG, 20 MG                  2                      MO

Heparins And Heparinoid-Like Agents
ARIXTRA (fondaparinux sodium) SOLN SC                                       MO
10 MG/0.8ML, 2.5 MG/0.5ML, 5 MG/0.4ML,               4            4
7.5 MG/0.6ML
FRAGMIN INJ SC 10000 UNIT/ML, 2500
UNIT/0.2ML, 25000 UNIT/ML, 5000                      4
UNIT/0.2ML, 7500 UNIT/0.3ML
FRAGMIN SOLN SC 95000 UNIT/9.5ML                     4
FRAGMIN SOLN SC 10000 UNIT/ML, 12500                                        MO
UNIT/0.5ML, 15000 UNIT/0.6ML, 18000
UNT/0.72ML, 2500 UNIT/0.2ML, 25000                   4
UNIT/ML, 5000 UNIT/0.2ML, 7500
UNIT/0.3ML
HEPARIN SODIUM SOLN IJ 2500 UNIT/ML                  4                      B/D

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                                40
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
heparin sodium soln ij 1000 unit/ml, 10000                              MO; B/D
                                                                 4
unit/ml, 20000 unit/ml, 5000 unit/ml
HEPARIN SODIUM SOLN IV 2000 UNIT/ML                 4                   B/D

heparin sodium dcu soln ij 20000 unit/ml                         4      MO; B/D

HEPARIN SODIUM/D5W (heparin sod                                         B/D
(porcine) in d5w) SOLN IV 100-5 %,                  4            4
UNIT/ML, 5-50 %, UNIT/ML
HEPARIN SODIUM/D5W SOLN IV 0.2-100-5                                    B/D
                                                    4
%, MG/ML, UNIT/ML
heparin sodium/d5w soln iv 0.2-40-5 %,                                  B/D
                                                                 4
mg/ml, unit/ml, 40-5 %, unit/ml
HEPARIN SODIUM/NACL 0.45% SOLN IJ                                       B/D
                                                    4
0.45-100 %, UNIT/ML, 0.45-50 %, UNIT/ML
HEPARIN SODIUM/SODIUM CHLORIDE                                          B/D
0.9% (heparin (porcine) in sodium chloride)         4            4
SOLN IJ 0.9-2 %, UNIT/ML
INNOHEP SOLN SC 20000 UNIT/ML                       4                   MO

LOVENOX (enoxaparin sodium) SOLN IJ 300                                 MO
                                                    4            4
MG/3ML
LOVENOX (enoxaparin sodium) SOLN SC                                     MO
100 MG/ML, 120 MG/0.8ML, 150 MG/ML, 30              4            4
MG/0.3ML, 40 MG/0.4ML, 60 MG/0.6ML, 80
MG/0.8ML
Thrombin Inhibitors
ARGATROBAN SOLN IV 100 MG/ML                        4                   MO

IPRIVASK SOLR SC 15 MG                              5

PRADAXA CAPS OR 150 MG, 75 MG                       2                   MO

REFLUDAN SOLR IV 50 MG                              5                   MO

ANTICONVULSANTS
Anticonvulsants - Misc.
BANZEL SUSP OR 40 MG/ML                             2                   MO

BANZEL TABS OR 200 MG, 400 MG                       2                   MO

CARBATROL (carbamazepine) CP12 OR                                         MO
                                                      3           1
100 MG, 200 MG, 300 MG
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                                41
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
GABARONE (gabapentin) TABS OR 100                   3            1
MG, 300 MG, 400 MG
KEPPRA (levetiracetam) SOLN IV 500                                      MO
                                                    4            4
MG/5ML
KEPPRA (levetiracetam) SOLN OR 100                                      MO
                                                    3            1
MG/ML
KEPPRA (levetiracetam) TABS OR 1000 MG,                                 MO
                                                    3            1
250 MG, 500 MG, 750 MG
KEPPRA XR (levetiracetam) TB24 OR 500                                   MO
                                                    2            1
MG, 750 MG
LAMICTAL CHEW OR 2 MG                               3
LAMICTAL (lamotrigine) TABS OR 100 MG,                                  MO
                                                    3            1
150 MG, 200 MG, 25 MG
LAMICTAL CHEWABLE DISPERSIBLE                                           MO
                                                    3            1
(lamotrigine) CHEW OR 25 MG, 5 MG
LAMICTAL ODT KIT OR                                 3                   MO

LAMICTAL ODT TBDP OR 100 MG, 200 MG,                                    MO
                                                    3
25 MG, 50 MG
LAMICTAL STARTER/NOT TAKING                                             MO
                                                    3            1
CARBAMAZEPINE (lamotrigine) KIT OR
LAMICTAL STARTER/TAKING                                                 MO
CARBAMAZEPINE/NOT TAKING                            3            1
VALPROATE (lamotrigine) KIT OR
LAMICTAL STARTER/TAKING VALPROATE                                       MO
                                                    3            1
(lamotrigine) KIT OR 25 MG
LAMICTAL XR KIT OR                                  3

LAMICTAL XR KIT OR                                  3                   MO

LAMICTAL XR TB24 OR 100 MG, 200 MG,                                     MO
                                                    3
25 MG, 250 MG, 300 MG, 50 MG
levetiracetam soln or 500 mg/5ml                                 1      MO

LEVETIRACETAM SOLN IV                               4
LYRICA CAPS OR 100 MG, 150 MG, 200                                        MO
MG, 225 MG, 25 MG, 300 MG, 50 MG, 75                  2
MG
MYSOLINE (primidone) TABS OR 250 MG,                                      MO
                                                      3           1
50 MG
NEURONTIN (gabapentin) CAPS OR 100                                        MO
                                                      3           1
MG, 300 MG, 400 MG
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy

 www.healthnet.com                                                             42
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
NEURONTIN (gabapentin) SOLN OR 250                                          MO
                                                     2            1
MG/5ML
NEURONTIN (gabapentin) TABS OR 600                                          MO
                                                     3            1
MG, 800 MG
POTIGA TABS OR 50 MG                                 3                      MO

POTIGA TABS OR 400 MG                                5

POTIGA TABS OR 200 MG, 300 MG                        5                      MO

TEGRETOL (carbamazepine) CHEW OR 100                                        MO
                                                     3            1
MG
TEGRETOL (carbamazepine) SUSP OR 100                                        MO
                                                     3            1
MG/5ML
TEGRETOL (carbamazepine) TABS OR 200                                        MO
                                                     3            1
MG
TEGRETOL-XR TB12 OR 100 MG                           2                      MO

TEGRETOL-XR (carbamazepine) TB12 OR                                         MO
                                                     3            1
200 MG, 400 MG
TOPAMAX (topiramate) TABS OR 100 MG,                                        MO
                                                     3            1
200 MG, 25 MG, 50 MG
TOPAMAX SPRINKLE (topiramate) CPSP                                          MO
                                                     3            1
OR 15 MG, 25 MG
TRILEPTAL (oxcarbazepine) SUSP OR 300                                       MO
                                                     3            1
MG/5ML
TRILEPTAL (oxcarbazepine) TABS OR 150                                       MO
                                                     3            1
MG, 300 MG, 600 MG
VIMPAT SOLN IV 200 MG/20ML                           4

VIMPAT SOLN OR 10 MG/ML                              2                      MO

VIMPAT TABS OR 100 MG, 150 MG, 200                                          MO
                                                     2
MG, 50 MG
ZONEGRAN (zonisamide) CAPS OR 100                                           MO
                                                     3            1
MG, 25 MG, 50 MG
Carbamates
FELBATOL (felbamate) SUSP OR 600                                            MO
                                                     3            1
MG/5ML
FELBATOL (felbamate) TABS OR 400 MG,                                        MO
                                                     2            1
600 MG
GABA Modulators
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                               43
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
GABITRIL TABS OR 12 MG, 16 MG, 2 MG, 4                                  MO
                                                    2
MG
SABRIL PACK OR 500 MG                               5                   LA

SABRIL TABS OR 500 MG                               5                   LA

Hydantoins
CEREBYX (fosphenytoin sodium) SOLN IJ               4            4
100 MG PE/2ML
CEREBYX (fosphenytoin sodium) SOLN IJ                                   MO
                                                    4            4
500 MG PE/10ML
DILANTIN (phenytoin) SUSP OR 125                                        MO
                                                    3            1
MG/5ML
dilantin caps or 100 mg, 30 mg                                   1      MO

dilantin infatabs chew or 50 mg                                  1      MO

PEGANONE TABS OR 250 MG                             3                   MO

PHENYTEK (phenytoin sodium extended)                                    MO
                                                    3            1
CAPS OR 300 MG
phenytek caps or 200 mg                                          1      MO

phenytoin sodium soln ij 50 mg/ml                                4
phenytoin sodium extended caps or 100 mg,                               MO
                                                                 1
200 mg
Succinimides
CELONTIN CAPS OR 300 MG                             2                   MO

ethosuximide soln or 250 mg/5ml                                  1      MO

ZARONTIN (ethosuximide) CAPS OR 250                                     MO
                                                    3            1
MG
zarontin soln or 250 mg/5ml                                      1      MO

Valproic Acid
DEPACON (valproate sodium) SOLN IV 100                                    MO
                                                      4           4
MG/ML
DEPAKENE (valproate sodium) SYRP OR                                       MO
                                                      3           1
250 MG/5ML
DEPAKENE (valproic acid) CAPS OR 250                                      MO
                                                      3           1
MG
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                             44
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
DEPAKOTE (divalproex sodium) TBEC OR                                        MO
                                                     3            1
125 MG, 250 MG, 500 MG
DEPAKOTE ER (divalproex sodium) TB24                                        MO
                                                     3            1
OR 250 MG, 500 MG
DEPAKOTE SPRINKLES (divalproex                                              MO
                                                     3            1
sodium) CPSP OR 125 MG
STAVZOR CPDR OR 125 MG, 250 MG, 500                                         MO
                                                     3
MG
valproate sodium soln iv 500 mg/5ml                               4         MO

valproic acid soln or 250 mg/5ml                                  1         MO

ANTIDEPRESSANTS
Alpha-2 Receptor Antagonists (Tetracyclics)
mirtazapine tabs or 7.5 mg                                        1         MO

REMERON (mirtazapine) TABS OR 15 MG,                                        MO
                                                     3            1
30 MG, 45 MG
REMERON SOLTAB (mirtazapine) TBDP OR                                        MO
                                                     3            1
15 MG, 30 MG, 45 MG
Antidepressants - Misc.
APLENZIN TB24 OR 174 MG, 348 MG, 522                                        MO
                                                     3
MG
maprotiline hcl tabs or 25 mg, 50 mg, 75 mg                       1         MO

WELLBUTRIN (bupropion hcl) TABS OR 100                                      MO
                                                     3            1
MG, 75 MG
WELLBUTRIN SR (bupropion hcl) TB12 OR                                       MO
                                                     3            1
100 MG, 150 MG, 200 MG
WELLBUTRIN XL (bupropion hcl) TB24 OR                3            1         MO
150 MG, 300 MG
Modified Cyclics
DESYREL (trazodone hcl) TABS OR 100                                         MO
                                                     3            1
MG, 150 MG, 300 MG, 50 MG
nefazodone hcl tabs or 100 mg, 150 mg, 200                                  MO
                                                                  1
mg, 250 mg, 50 mg
OLEPTRO TB24 OR 150 MG, 300 MG                       3                      MO

VIIBRYD KIT OR                                       3

VIIBRYD TABS OR 10 MG, 20 MG, 40 MG                  3                      MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               45
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
Monoamine Oxidase Inhibitors (MAOIs)
EMSAM PT24 TD 12 MG/24HR, 6 MG/24HR,                                        MO
                                                     3
9 MG/24HR
MARPLAN TABS OR 10 MG                                2                      MO

NARDIL (phenelzine sulfate) TABS OR 15                                      MO
                                                     2            1
MG
PARNATE (tranylcypromine sulfate) TABS                                      MO
                                                     3            1
OR 10 MG
Selective Serotonin Reuptake Inhibitors (SSRIs)
CELEXA (citalopram hydrobromide) SOLN                                       QL; MO
                                               3                  1
OR 10 MG/5ML
CELEXA (citalopram hydrobromide) TABS                                       QL; MO
                                               3                  1
OR 10 MG, 20 MG, 40 MG
FLUOXETINE HCL TABS OR 60 MG                         3                      MO

fluvoxamine maleate tabs or 100 mg, 25 mg,                                  MO
                                                                  1
50 mg
LEXAPRO (escitalopram oxalate) SOLN OR                                      MO
                                                     2            1
5 MG/5ML
LEXAPRO (escitalopram oxalate) TABS OR                                      MO
                                                     2            1
10 MG, 20 MG, 5 MG
LUVOX CR CP24 OR 100 MG, 150 MG                      3                      MO

PAXIL (paroxetine hcl) SUSP OR 10 MG/5ML             3            1         MO

PAXIL (paroxetine hcl) TABS OR 10 MG, 20                                    MO
                                                     3            1
MG, 30 MG, 40 MG
PAXIL CR (paroxetine hcl) TB24 OR 12.5                                      MO
                                                     3            1
MG, 25 MG, 37.5 MG
PEXEVA TABS OR 10 MG, 20 MG, 30 MG,                                         MO
                                                     3
40 MG
PROZAC (fluoxetine hcl) CAPS OR 10 MG,                                      MO
                                                     3            1
20 MG, 40 MG
PROZAC (fluoxetine hcl) SOLN OR 20                                          MO
                                                     3            1
MG/5ML
PROZAC (fluoxetine hcl) TABS OR 10 MG                3            1         MO

PROZAC WEEKLY (fluoxetine hcl) CPDR OR                                      MO
                                                     3            1
90 MG
RAPIFLUX (fluoxetine hcl) TABS OR 20 MG              3            1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                                   46
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
ZOLOFT (sertraline hcl) CONC OR 20                                          MO
                                                     3            1
MG/ML
ZOLOFT (sertraline hcl) TABS OR 100 MG,                                     MO
                                                     3            1
25 MG, 50 MG
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
CYMBALTA CPEP OR 20 MG, 30 MG, 60                                           MO
                                              2
MG
EFFEXOR (venlafaxine hcl) TABS OR 100                                       MO
                                              3                   1
MG, 25 MG, 37.5 MG, 50 MG, 75 MG
EFFEXOR TABS OR 37 MG                                3                      MO

EFFEXOR XR (venlafaxine hcl) CP24 OR                                        MO
                                                     2            1
150 MG, 37.5 MG, 75 MG
EFFEXOR XR CP24 OR 37 MG                             2                      MO

PRISTIQ TB24 OR 100 MG, 50 MG                        3                      MO

venlafaxine hcl er tb24 or 150 mg, 225 mg,                                  MO
                                                                  1
37.5 mg, 75 mg
Tricyclic Agents
amitriptyline hcl tabs or 10 mg, 100 mg, 150                                MO
                                                                  1
mg, 25 mg, 50 mg, 75 mg
amoxapine tabs or 100 mg, 150 mg, 25 mg,                                    MO
                                                                  1
50 mg
ANAFRANIL (clomipramine hcl) CAPS OR 25                                     MO
                                                     3            1
MG, 50 MG, 75 MG
doxepin hcl caps or 100 mg, 150 mg                                1         MO

doxepin hcl conc or 10 mg/ml                                      1         MO

imipramine hcl tabs or 10 mg, 25 mg, 50 mg                        1         MO

NORPRAMIN (desipramine hcl) TABS OR 10                                      MO
MG, 100 MG, 150 MG, 25 MG, 50 MG, 75                  3           1
MG
PAMELOR (nortriptyline hcl) CAPS OR 10                                      MO
                                                      3           1
MG, 25 MG, 50 MG, 75 MG
PAMELOR (nortriptyline hcl) SOLN OR 10                                      MO
                                                      3           1
MG/5ML
SINEQUAN (doxepin hcl) CAPS OR 10 MG,                                       MO
                                                      3           1
25 MG, 50 MG, 75 MG
SURMONTIL (trimipramine maleate) CAPS                                       MO
                                                      3           1
OR 100 MG, 25 MG, 50 MG
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               47
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
tofranil tabs or 10 mg, 25 mg, 50 mg                             1      MO

TOFRANIL-PM (imipramine pamoate) CAPS                                   MO
                                                    3            1
OR 100 MG, 125 MG, 150 MG, 75 MG
VIVACTIL (protriptyline hcl) TABS OR 10                                 MO
                                                    3            1
MG, 5 MG
ANTIDIABETICS
Alpha-Glucosidase Inhibitors
GLYSET TABS OR 100 MG, 25 MG, 50 MG                 3                   MO

PRECOSE (acarbose) TABS OR 100 MG, 25                                   MO
                                                    3            1
MG, 50 MG
Antidiabetic - Amylin Analogs
SYMLIN SOLN SC 600 MCG/ML                           4

SYMLINPEN 120 SOLN SC 1000 MCG/ML                   4                   MO

SYMLINPEN 60 SOLN SC 1000 MCG/ML                    4                   MO

Antidiabetic Combinations
ACTOPLUS MET TABS OR 15-500 MG, 15-                                     MO
                                                    2
850 MG
ACTOPLUS MET XR TB24 OR 1000-15 MG,                                     MO
                                                    2
1000-30 MG
AVANDAMET TABS OR 1000-2 MG, 1000-4                 2
MG, 2-500 MG, 4-500 MG
AVANDARYL TABS OR 1-4 MG, 2-4 MG, 2-8               2
MG, 4 MG, 4-8 MG
DUETACT TABS OR 2-30 MG, 30-4 MG                    2                   MO

GLUCOVANCE (glyburide-metformin) TABS                                   MO
                                                    3            1
OR 1.25-250 MG, 2.5-500 MG, 5-500 MG
JANUMET TABS OR 1000-50 MG, 50-500                                      MO
                                                    2
MG
JANUMET XR TB24 OR                                  2                   MO

JENTADUETO TABS OR                                  2                   MO

JUVISYNC TABS OR 10-100 MG, 100-20                                        MO
                                                      2
MG, 100-40 MG
KOMBIGLYZE XR TB24 OR 1000-2.5 MG,                                        MO
                                                      2
1000-5 MG, 5-500 MG
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                             48
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
METAGLIP (glipizide-metformin hcl) TABS                                     MO
                                                     3            1
OR 2.5-250 MG, 2.5-500 MG, 5-500 MG
PRANDIMET TABS OR 1-500 MG, 2-500 MG                 3                      MO

Biguanides
FORTAMET (metformin hcl) TB24 OR 1000                                       MO
                                                     3            1
MG, 500 MG
GLUCOPHAGE (metformin hcl) TABS OR                                          MO
                                                     3            1
1000 MG, 500 MG, 850 MG
GLUCOPHAGE XR (metformin hcl) TB24 OR                                       MO
                                                     3            1
500 MG, 750 MG
GLUMETZA TB24 OR 1000 MG, 500 MG                     3                      MO

RIOMET SOLN OR 500 MG/5ML                            2                      MO

Diabetic Other
GLUCAGEN SOLR IJ 1 MG                                2                      MO

GLUCAGEN HYPOKIT SOLR IJ 1 MG                        2                      MO

glucagon emergency kit kit ij 1 mg                                1         MO

PROGLYCEM SUSP OR 50 MG/ML                           3                      MO

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
JANUVIA TABS OR 100 MG, 25 MG, 50 MG                 2                      MO

ONGLYZA TABS OR 2.5 MG, 5 MG                         2                      MO

TRADJENTA TABS OR 5 MG                               2                      MO

Dopamine Receptor Agonists - Antidiabetic
CYCLOSET TABS OR 0.8 MG                              3                      MO

Incretin Mimetic Agents (GLP-1 Receptor Agonists)
BYDUREON SUSR SC 2 MG                                4                      PA; ; MO

BYETTA SOLN SC 10 MCG/0.04ML, 5                                             PA; ; MO
                                                     4
MCG/0.02ML
VICTOZA SOLN SC 18 MG/3ML                            4                      PA; ; MO

Insulin Sensitizing Agents
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                                     49
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
ACTOS TABS OR 15 MG, 30 MG, 45 MG                   2                   MO

AVANDIA TABS OR 2 MG, 4 MG, 8 MG                    2
Insulin
APIDRA SOLN IJ 100 UNIT/ML                          3                   MO

APIDRA SOLN SC 100 UNIT/ML                          3                   MO

APIDRA SOLOSTAR SOLN SC 100                                             MO
                                                    3
UNIT/ML
HUMALOG SOLN SC 100 UNIT/ML                         2                   MO

HUMALOG KWIKPEN SOLN SC 100                                             MO
                                                    2
UNIT/ML
HUMALOG MIX 50/50 SUSP SC 0.89-2.2-50                                   MO
                                                    2
%, MG/ML
HUMALOG MIX 50/50 KWIKPEN SUSP SC                                       MO
                                                    2
0.89-2.2-50 %, MG/ML
HUMALOG MIX 50/50 PEN SUSP SC 0.89-                                     MO
                                                    2
2.2-50 %, MG/ML
HUMALOG MIX 75/25 SUSP SC 0.715-1.76-                                   MO
                                                    2
25-75 %, MG/ML
HUMALOG MIX 75/25 KWIKPEN SUSP SC                                       MO
                                                    2
0.715-1.76-25-75 %, MG/ML
HUMALOG MIX 75/25 PEN SUSP SC 0.715-                                    MO
                                                    2
1.76-25-75 %, MG/ML
HUMALOG PEN SOLN SC 100 UNIT/ML                     2                   MO

HUMULIN 50/50 SUSP SC 50 %                          2

HUMULIN 70/30 SUSP SC 30-70 %                       2                   MO

HUMULIN 70/30 PEN SUSP SC 30-70 %                   2                   MO

HUMULIN N SUSP SC 100 UNIT/ML                       2                   MO

HUMULIN N U-100 PEN SUSP SC 100                                         MO
                                                    2
UNIT/ML
HUMULIN R SOLN IJ 100 UNIT/ML                       2                   MO

HUMULIN R U-500 (CONCENTRATED)                                            MO
                                                      2
SOLN SC 500 UNIT/ML
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                             50
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
LANTUS SOLN SC 100 UNIT/ML                           2                      MO

LANTUS FOR OPTICLIK SOLN SC 100                                             MO
                                                     2
UNIT/ML
LANTUS SOLOSTAR SOLN SC 100                                                 MO
                                                     2
UNIT/ML
LEVEMIR SOLN SC 100 UNIT/ML                          2                      MO

LEVEMIR FLEXPEN SOLN SC 100 UNIT/ML                  2                      MO

NOVOLIN 70/30 SUSP SC 30-70 %                        3                      MO

NOVOLIN 70/30 INNOLET SUSP SC 30-70                                         MO
                                                     3
%
NOVOLIN 70/30 PENFILL SUSP SC 30-70 %                3                      MO

NOVOLIN N SUSP SC 100 UNIT/ML                        3                      MO

NOVOLIN N INNOLET SUSP SC 100                                               MO
                                                     3
UNIT/ML
NOVOLIN N U-100 PENFILL SUSP SC 100                                         MO
                                                     3
UNIT/ML
NOVOLIN R SOLN IJ 100 UNIT/ML                        3                      MO

NOVOLIN R INNOLET SOLN IJ 100                                               MO
                                                     3
UNIT/ML
NOVOLIN R U-100 PENFILL SOLN IJ 100                                         MO
                                                     3
UNIT/ML
NOVOLOG SOLN SC 100 UNIT/ML                          3                      MO

NOVOLOG FLEXPEN SOLN SC 100                                                 MO
                                                     3
UNIT/ML
NOVOLOG MIX 70/30 SUSP SC 1.5-1.72-30-                                      MO
70 %, MG/ML                                          3
NOVOLOG MIX 70/30 PENFILL SUSP SC                                           MO
                                                     3
1.5-1.72-30-70 %, MG/ML
NOVOLOG MIX 70/30 PREFILLED                                                 MO
FLEXPEN SUSP SC 1.5-1.72-30-70 %,                    3
MG/ML
NOVOLOG PENFILL SOLN SC 100 UNIT/ML                  3                      MO

RELION 70/30 SUSP SC 30-70 %                         3                      MO

Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                               51
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
RELION N SUSP SC 100 UNIT/ML                         3                      MO

RELION R SOLN IJ 100 UNIT/ML                         3                      MO

Meglitinide Analogues
PRANDIN TABS OR 0.5 MG, 1 MG, 2 MG                   2                      MO

STARLIX (nateglinide) TABS OR 120 MG, 60                                    MO
                                                     3            1
MG
Sulfonylureas
AMARYL (glimepiride) TABS OR 1 MG, 2                                        MO
                                                     3            1
MG, 4 MG
chlorpropamide tabs or 100 mg, 250 mg                             1         MO

DIABETA (glyburide) TABS OR 1.25 MG, 2.5                                    MO
                                                     3            1
MG, 5 MG
GLUCOTROL (glipizide) TABS OR 10 MG, 5                                      MO
                                                     3            1
MG
GLUCOTROL XL (glipizide) TB24 OR 10 MG,                                     MO
                                                     3            1
2.5 MG, 5 MG
GLYCRON TABS OR 4.5 MG                               2
GLYNASE (glyburide micronized) TABS OR                                      MO
                                                     3            1
1.5 MG, 3 MG, 6 MG
MICRONASE (glyburide) TABS OR 1.25 MG,                                      MO
                                                     3            1
2.5 MG, 5 MG
tolazamide tabs or 250 mg, 500 mg                                 1         MO

tolbutamide tabs or 500 mg                                        1         MO

ANTIDIARRHEALS
Antiperistaltic Agents
diphenoxylate/atropine liqd or 0.025-2.5                                    MO
                                                                  1
mg/5ml
LOMOTIL LIQD OR 0.025-15-2.5 %, MG/5ML               3                      MO

LOMOTIL (diphenoxylate w/ atropine) TABS                                    MO
                                                     3            1
OR 0.025-2.5 MG
loperamide hcl caps or 2 mg                                       1         MO

MOTOFEN TABS OR 0.025-1 MG                           3                      MO

Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                               52
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
ANTIDOTES
Antidotes - Chelating Agents
CHEMET CAPS OR 100 MG                                3                      MO

EXJADE TBSO OR 125 MG                                3                      LA

EXJADE TBSO OR 250 MG, 500 MG                        5                      LA

FERRIPROX TABS OR 500 MG                             5                      PA; LA

Antidotes
ANTIZOL (fomepizole) SOLN IV 1 GM/ML                 4            4
DESFERAL (deferoxamine mesylate) SOLR                                       B/D
                                                     5            5
IJ 2 GM, 500 MG
fomepizole soln iv 1.5 gm/1.5ml                                   4
Benzodiazepine Antagonists
flumazenil soln iv 0.5 mg/5ml, 1 mg/10ml                          4
ROMAZICON (flumazenil) SOLN IV 0.1                   4            4
MG/ML
Opioid Antagonists
NALOXONE HCL (naloxone hcl) SOLN IJ 0.4                                     MO
                                                     4            4
MG/ML
naloxone hcl soln ij 1 mg/ml                                      4

REVIA (naltrexone hcl) TABS OR 50 MG                 3            1         MO

VIVITROL SUSR IM 380 MG                              5
ANTIEMETICS
5-HT3 Receptor Antagonists
ALOXI SOLN IV 0.25 MG/5ML                            4                      MO

ALOXI SOLN IV 0.075 MG/1.5ML                         5

ANZEMET SOLN IV 20 MG/ML                             4                      MO

ANZEMET TABS OR 100 MG, 50 MG                        3                      MO; B/D

Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                                    53
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
granisetron hcl soln iv 4 mg/4ml                                  4         MO

KYTRIL (granisetron hcl) SOLN IV 0.1                                        MO
                                                     4            4
MG/ML, 1 MG/ML
KYTRIL (granisetron hcl) SOLN OR 2                                          MO; B/D
                                                     3            1
MG/10ML
KYTRIL (granisetron hcl) TABS OR 1 MG                3            1         MO; B/D

ONDANSETRON HCL SOLN IV 32-450                       4
MG/50ML
SANCUSO PTCH TD 3.1 MG/24HR                          3                      MO

ZOFRAN (ondansetron hcl) SOLN IJ 4                                          MO
                                                     4            4
MG/2ML, 40 MG/20ML
ZOFRAN (ondansetron hcl) SOLN OR 4                                          MO; B/D
                                                     3            1
MG/5ML
ZOFRAN (ondansetron hcl) TABS OR 24                                         MO; B/D
                                                     3            1
MG, 4 MG, 8 MG
ZOFRAN (ondansetron hcl and dextrose)                4            4
SOLN IV 32-5 %, MG/50ML
ZOFRAN ODT (ondansetron) TBDP OR 4                                          MO; B/D
                                                     3            1
MG, 8 MG
ZUPLENZ FILM OR 4 MG, 8 MG                           3                      MO; B/D

Antiemetics - Anticholinergic
ANTIVERT (meclizine hcl) TABS OR 12.5                                       MO
                                                     3            1
MG, 25 MG
ANTIVERT TABS OR 50 MG                               3                      MO

DIMENHYDRINATE SOLN IJ 50 MG/ML                      4
TIGAN (trimethobenzamide hcl) CAPS OR                                       MO
                                                     3            1
300 MG
TIGAN (trimethobenzamide hcl) SOLN IM                                       MO
                                                     4            4
100 MG/ML
TRANSDERM-SCOP PT72 TD 1.5 MG                        3                      MO

Antiemetics - Miscellaneous
CESAMET CAPS OR 1 MG                                 3                      MO; B/D

MARINOL (dronabinol) CAPS OR 10 MG, 2.5                                     MO; B/D
                                                     3            1
MG, 5 MG
Substance P/Neurokinin 1 (NK1) Receptor Antagonists
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                                    54
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
EMEND CAPS OR 40 MG                                 3                   MO

EMEND CAPS OR , 125 MG, 80 MG                       3                   MO; B/D

EMEND SOLR IV 115 MG, 150 MG                        4                   MO

ANTIFUNGALS
Antifungal - Glucan Synthesis Inhibitors (Echinocandins)
CANCIDAS SOLR IV 50 MG, 70 MG                       5

ERAXIS SOLR IV 100 MG, 50 MG                        4

MYCAMINE SOLR IV 100 MG, 50 MG                      5                   MO

Antifungals
ABELCET SUSP IV 5 MG/ML                             5                   MO

AMBISOME SUSR IV 50 MG                              5                   MO

amphocin solr ij 50 mg                                           4      MO

AMPHOTEC SUSR IV 100 MG, 50 MG                      4

amphotericin b solr ij 50 mg                                     4      MO

ANCOBON (flucytosine) CAPS OR 250 MG,               3            1
500 MG
grifulvin v tabs or 500 mg                                       1      MO

GRIS-PEG TABS OR 125 MG, 250 MG                     2                   MO

griseofulvin microsize susp or 125 mg/5ml                        1      MO

LAMISIL PACK OR 125 MG, 187.5 MG                    2                   PA; ; MO

LAMISIL (terbinafine hcl) TABS OR 250 MG            3            1      PA; ; MO

nystatin tabs or 500000 unit                                     1      MO

Imidazole-Related Antifungals
DIFLUCAN (fluconazole) SUSR OR 10                                         MO
                                                      3           1
MG/ML, 40 MG/ML
DIFLUCAN (fluconazole) TABS OR 100 MG,                                    MO
                                                      3           1
150 MG, 200 MG, 50 MG
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                                 55
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
DIFLUCAN IN ISO-OSMOTIC DEXTROSE
(fluconazole in dextrose) SOLN IV 400                4            4
MG/200ML
DIFLUCAN IN NACL (fluconazole in nacl)               4            4
SOLN IV 0.9-200 %, MG/100ML
DIFLUCAN IN NACL (fluconazole in nacl)                                      MO
                                                     4            4
SOLN IV 0.9-400 %, MG/200ML
fluconazole in nacl soln iv , 0.9-100 %,                          4
mg/50ml, 0.9-400 %, mg/200ml
fluconazole in nacl soln iv                                       4         MO

ketoconazole tabs or 200 mg                                       1         MO

NOXAFIL SUSP OR 40 MG/ML                             5                      MO

SPORANOX (itraconazole) CAPS OR 100                                         MO
                                                     3            1
MG
SPORANOX SOLN OR 10 MG/ML                            3                      MO

SPORANOX PULSEPAK (itraconazole)                                            MO
                                                     3            1
CAPS OR 100 MG
VFEND SUSR OR 40 MG/ML                               5                      PA; ; MO

VFEND (voriconazole) TABS OR 200 MG, 50                                     PA; ; MO
                                                     5            5
MG
VFEND IV (voriconazole) SOLR IV 200 MG               4            4         PA

ANTIHISTAMINES
Antihistamines - Alkylamines
dexchlorpheniramine maleate syrp or 2                                       MO
                                                                  1
mg/5ml
Antihistamines - Ethanolamines
BENADRYL (diphenhydramine hcl) SOLN IJ                                      MO
                                                     4            4
50 MG/ML
clemastine fumarate syrp or 0.67 mg/5ml                           1         MO

clemastine fumarate tabs or 2.68 mg                               1         MO

diphenhydramine hcl caps or 50 mg                                 1         MO

diphenhydramine hcl elix or 12.5 mg/5ml                           1
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                                     56
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
HISTEX PD (carbinoxamine maleate) LIQD                                      MO
                                                     3            1
OR 4 MG/5ML
PALGIC (carbinoxamine maleate) LIQD OR 4                                    MO
                                                     3            1
MG/5ML
PALGIC (carbinoxamine maleate) TABS OR                                      MO
                                                     3            1
4 MG
Antihistamines - Non-Sedating
ALLEGRA SUSP OR 30 MG/5ML                            3

cetirizine hcl syrp or 5 mg/5ml                                   1         MO

CLARINEX SYRP OR 0.5 MG/ML                           3                      MO

CLARINEX TABS OR 5 MG                                3                      MO

CLARINEX REDITABS TBDP OR 2.5 MG, 5                                         MO
                                                     3
MG
XYZAL (levocetirizine dihydrochloride) SOLN                                 MO
                                                     2            1
OR 2.5 MG/5ML
XYZAL (levocetirizine dihydrochloride) TABS                                 MO
                                                     2            1
OR 5 MG
ZYRTEC (cetirizine hcl) SYRP OR 1 MG/ML              3            1         MO

Antihistamines - Phenothiazines
phenadoz supp re 12.5 mg                                          1         MO

PHENERGAN (promethazine hcl) SOLN IJ                 4            4
25 MG/ML
PHENERGAN SOLN IJ 50 MG/ML                           4

phenergan soln ij 25 mg/ml, 50 mg/ml                              4         MO

PHENERGAN (promethazine hcl) SUPP RE                                        MO
                                                     3            1
25 MG
PHENERGAN SUPP RE 12 MG                              3                      MO

prometh-50 soln ij 50 mg/ml                                       4         MO

promethazine hcl soln ij 25 mg/ml, 50 mg/ml                       4         MO

promethazine hcl soln or 6.25 mg/5ml                              1         MO

promethazine hcl supp re 12.5 mg, 50 mg                           1         MO

Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                               57
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
promethazine hcl syrp or 6.25 mg/5ml                             1      MO

promethazine hcl tabs or 12.5 mg, 25 mg, 50                             MO
                                                                 1
mg
promethazine hcl plain syrp or 6.25 mg/5ml                       1      MO

promethegan supp re 12.5 mg, 50 mg                               1      MO

Antihistamines - Piperidines
cyproheptadine hcl syrp or 2 mg/5ml                              1      MO

cyproheptadine hcl tabs or 4 mg                                  1      MO

ANTIHYPERLIPIDEMICS
Antihyperlipidemics - Combinations
VYTORIN TABS OR 10 MG, 10-20 MG, 10-                                    MO
                                                    2
40 MG
VYTORIN TABS OR 10-80 MG                            2                   PA; ; MO

Antihyperlipidemics - Misc.
LOVAZA CAPS OR 1-375-4-465 GM, MG                   2                   MO

Bile Acid Sequestrants
cholestyramine pack or 4 gm                                      1      MO

COLESTID (colestipol hcl) GRAN OR 5 GM              3            1      MO

COLESTID (colestipol hcl) PACK OR 5 GM              3            1      MO

COLESTID (colestipol hcl) TABS OR 1 GM              3            1      MO

COLESTID FLAVORED (colestipol hcl)                                      MO
                                                    3            1
GRAN OR 5 GM
COLESTID FLAVORED PACK OR 5                                             MO
                                                    3
GM/7.5GM
questran pack or 4 gm                                            1      MO

QUESTRAN (cholestyramine) POWD OR 4                                       MO
                                                      3           1
GM/DOSE
QUESTRAN LIGHT (cholestyramine light)                                     MO
                                                      3           1
PACK OR 4 GM
QUESTRAN LIGHT (cholestyramine light)                                     MO
                                                      3           1
POWD OR 4 GM/DOSE
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                                 58
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
WELCHOL PACK OR 3.75 GM                             3                   MO

WELCHOL TABS OR 625 MG                              3                   MO

Fibric Acid Derivatives
ANTARA CAPS OR 130 MG, 43 MG                        2                   MO

fenofibrate tabs or 54 mg                                        1      MO

fenofibrate micronized caps or 134 mg, 200                              MO
                                                                 1
mg, 67 mg
FENOGLIDE TABS OR 120 MG, 40 MG                     3                   MO

FIBRICOR (fenofibric acid) TABS OR 105                                  MO
                                                    3            1
MG, 35 MG
LIPOFEN CAPS OR 150 MG, 50 MG                       3                   MO

lofibra tabs or 54 mg                                            1      MO

lofibra caps or 134 mg, 200 mg, 67 mg                            1      MO

LOPID (gemfibrozil) TABS OR 600 MG                  3            1      MO

TRICOR TABS OR 145 MG, 48 MG                        2                   MO

TRIGLIDE (fenofibrate) TABS OR 160 MG               3            1      MO

TRIGLIDE TABS OR 50 MG                              3                   MO

TRILIPIX CPDR OR 135 MG, 45 MG                      2                   MO

HMG CoA Reductase Inhibitors
ADVICOR TB24 OR 1000-20 MG, 1000-40                                     MO
                                                    3
MG, 20-500 MG, 20-750 MG
ALTOPREV TB24 OR 20 MG, 40 MG, 60 MG                3                   MO

CRESTOR TABS OR 10 MG, 20 MG, 40 MG,                                    MO
                                                    2
5 MG
LESCOL (fluvastatin sodium) CAPS OR 20                                  MO
                                                    3            1
MG, 40 MG
LESCOL XL TB24 OR 80 MG                             3                   MO

LIPITOR (atorvastatin calcium) TABS OR 10                                 MO
                                                      3           1
MG, 20 MG, 40 MG, 80 MG
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                             59
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
LIVALO TABS OR 1 MG, 2 MG, 4 MG                     3                   MO

MEVACOR (lovastatin) TABS OR 10 MG, 20                                  MO
                                                    3            1
MG, 40 MG
PRAVACHOL (pravastatin sodium) TABS OR                                  MO
                                                    3            1
10 MG, 20 MG, 40 MG, 80 MG
SIMCOR TB24 OR 1000-20 MG, 1000-40                                      MO
                                                    2
MG, 20-500 MG, 20-750 MG, 40-500 MG
ZOCOR (simvastatin) TABS OR 10 MG, 20                                   MO
                                                    3            1
MG, 40 MG, 5 MG
ZOCOR (simvastatin) TABS OR 80 MG                   3            1      PA; ; MO

Intestinal Cholesterol Absorption Inhibitors
ZETIA TABS OR 10 MG                                 2                   MO

Nicotinic Acid Derivatives
NIASPAN TBCR OR 1000 MG, 500 MG, 750                                    MO
                                                    2
MG
ANTIHYPERTENSIVES
ACE Inhibitors
ACCUPRIL (quinapril hcl) TABS OR 10 MG,                                 MO
                                                    3            1
20 MG, 40 MG, 5 MG
ACEON (perindopril erbumine) TABS OR 2                                  MO
                                                    3            1
MG, 4 MG, 8 MG
ALTACE (ramipril) CAPS OR 1.25 MG, 10                                   MO
                                                    3            1
MG, 2.5 MG, 5 MG
ALTACE CAPS OR 1.5 MG                               3                   MO

CAPOTEN (captopril) TABS OR 100 MG,                                     MO
                                                    3            1
12.5 MG, 25 MG, 50 MG
CAPOTEN TABS OR 12 MG                               3                   MO

enalaprilat inj iv 1.25 mg/ml                                    4

lisinopril tabs or 2 mg                                          1      MO

LOTENSIN (benazepril hcl) TABS OR 10                                      MO
                                                      3           1
MG, 20 MG, 40 MG, 5 MG
MAVIK (trandolapril) TABS OR 1 MG, 2 MG,                                  MO
                                                      3           1
4 MG
MONOPRIL (fosinopril sodium) TABS OR 10                                   MO
                                                      3           1
MG, 20 MG, 40 MG
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                                 60
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
PRINIVIL (lisinopril) TABS OR 10 MG, 20                                 MO
                                                    3            1
MG, 5 MG
UNIVASC (moexipril hcl) TABS OR 15 MG,                                  MO
                                                    3            1
7.5 MG
VASOTEC (enalapril maleate) TABS OR 10                                  MO
                                                    3            1
MG, 2.5 MG, 20 MG, 5 MG
ZESTRIL (lisinopril) TABS OR 10 MG, 2.5                                 MO
                                                    3            1
MG, 20 MG, 30 MG, 40 MG, 5 MG
Agents for Pheochromocytoma
DEMSER CAPS OR 250 MG                               5                   MO

DIBENZYLINE CAPS OR 10 MG                           3                   MO

phentolamine mesylate solr ij 5 mg                               4      MO

Angiotensin II Receptor Antagonists
ATACAND TABS OR 16 MG, 32 MG, 4 MG,                                     MO
                                                    3
8 MG
AVAPRO (irbesartan) TABS OR 150 MG, 300                                 MO
                                                    3            1
MG, 75 MG
BENICAR TABS OR 20 MG, 40 MG, 5 MG                  2                   MO

COZAAR (losartan potassium) TABS OR 100                                 MO
                                                    3            1
MG, 25 MG, 50 MG
DIOVAN TABS OR 160 MG, 320 MG, 40 MG,                                   MO
                                                    2
80 MG
EDARBI TABS OR 40 MG, 80 MG                         3                   MO

MICARDIS TABS OR 20 MG, 40 MG, 80 MG                3                   MO

TEVETEN (eprosartan mesylate) TABS OR                                   MO
                                                    3            1
600 MG
TEVETEN TABS OR 400 MG                              3                   MO

Antiadrenergic Antihypertensives
CARDURA (doxazosin mesylate) TABS OR 1                                    MO
                                                      3           1
MG, 2 MG, 4 MG, 8 MG
CATAPRES (clonidine hcl) TABS OR 0.1                                      MO
                                                      3           1
MG, 0.2 MG, 0.3 MG
CATAPRES-TTS-1 (clonidine hcl) PTWK TD                                    MO
                                                      3           1
0.1 MG/24HR
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                             61
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
CATAPRES-TTS-2 (clonidine hcl) PTWK TD                                      MO
                                                     3            1
0.2 MG/24HR
CATAPRES-TTS-3 (clonidine hcl) PTWK TD                                      MO
                                                     3            1
0.3 MG/24HR
guanabenz acetate tabs or 4 mg, 8 mg                              1
HYTRIN (terazosin hcl) CAPS OR 1 MG, 10                                     MO
                                                     3            1
MG, 2 MG, 5 MG
methyldopa tabs or 250 mg, 500 mg                                 1         MO

METHYLDOPATE HCL SOLN IV 250                         4
MG/5ML
MINIPRESS (prazosin hcl) CAPS OR 1 MG,                                      MO
                                                     3            1
2 MG, 5 MG
reserpine tabs or 0.1 mg, 0.25 mg                                 1         MO

TENEX (guanfacine hcl) TABS OR 1 MG, 2                                      MO
                                                     3            1
MG
Antihypertensive Combinations
ACCURETIC (quinapril-hydrochlorothiazide)                                   MO
TABS OR 10-12.5 MG, 12.5-20 MG, 20-25                3            1
MG
amlodipine besylate/benazepril hcl caps or                        1         MO

amlodipine besylate/benazepril hydrochloride                                MO
                                                                  1
caps or
AMTURNIDE TABS OR 10-12.5-300 MG, 10-                                       MO
25-300 MG, 12.5-150-5 MG, 12.5-300-5 MG,             2
25-300-5 MG
ATACAND HCT TABS OR 12.5-16 MG, 12.5-                                       MO
                                                     3
32 MG, 25-32 MG
AVALIDE TABS OR 25-300 MG                            3
AVALIDE TABS OR 12.5-150 MG, 12.5-300                                       MO
                                                      3
MG
AZOR TABS OR 10-20 MG, 10-40 MG, 20-5                                       MO
                                                      2
MG, 40-5 MG
BENICAR HCT TABS OR 12.5-20 MG, 12.5-                                       MO
                                                      2
40 MG, 25-40 MG
captopril/hydrochlorothiazide tabs or 15-25                       1
mg, 15-50 mg
captopril/hydrochlorothiazide tabs or 15-25                                 MO
                                                                  1
mg, 15-50 mg, 25 mg, 25-50 mg
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                               62
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
clorpres tabs or 0.1-15 mg, 0.2-15 mg, 0.3-15                           MO
                                                                 1
mg
CORZIDE (nadolol & bendroflumethiazide)                                 MO
                                                    3            1
TABS OR 40-5 MG, 5-80 MG
DIOVAN HCT TABS OR 12.5-160 MG, 12.5-                                   MO
320 MG, 12.5-80 MG, 160-25 MG, 25-320               2
MG
DUTOPROL TB24 OR                                    3                   MO

EDARBYCLOR TABS OR                                  3                   MO

EXFORGE TABS OR 10-160 MG, 10-320                                       MO
                                                    2
MG, 160-5 MG, 320-5 MG
EXFORGE HCT TABS OR 10-12.5-160 MG,                                     MO
10-160-25 MG, 10-25-320 MG, 12.5-160-5              2
MG, 160-25-5 MG
HYDRALAZINE/HYDROCHLOROTHIAZIDE                     3
CAPS OR 25 MG
HYZAAR (losartan potassium &                                            MO
hydrochlorothiazide) TABS OR 100-12.5 MG,           3            1
100-25 MG, 12.5-50 MG
irbesartan/hydrochlorothiazide tabs or                           1      MO

lisinopril/hydrochlorothiazide tabs or                           1      MO

LOPRESSOR HCT (metoprolol &                                             MO
hydrochlorothiazide) TABS OR 100-25 MG,             3            1
100-50 MG, 25-50 MG
LOTENSIN HCT (benazepril &                                              MO
hydrochlorothiazide) TABS OR 10-12.5 MG,            3            1
12.5-20 MG, 20-25 MG, 5-6.25 MG
LOTREL (amlodipine besylate-benazepril hcl)                             MO
CAPS OR 10-2.5 MG, 10-20 MG, 10-40 MG,              3            1
10-5 MG, 20-5 MG, 40-5 MG
methyldopa/hydrochlorothiazide tabs or 15-                              MO
                                                                 1
250 mg, 25-250 mg
metoprolol/hydrochlorothiazide tabs or                           1      MO

MICARDIS HCT TABS OR 12.5-40 MG, 12.5-                                    MO
                                                      3
80 MG, 25-80 MG
MONOPRIL HCT (fosinopril sodium &                                         MO
hydrochlorothiazide) TABS OR 10-12.5 MG,              3           1
12.5-20 MG
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                             63
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
PRINZIDE (lisinopril & hydrochlorothiazide)                             MO
TABS OR 10-12.5 MG, 12.5-20 MG, 20-25               3            1
MG
propranolol/hydrochlorothiazide tabs or 25-40                    1
mg
propranolol/hydrochlorothiazide tabs or 25-40                           MO
                                                                 1
mg, 25-80 mg
quinapril/hydrochlorothiazide tabs or                            1      MO

TARKA (trandolapril-verapamil hcl) TBCR OR                              MO
                                                    3            1
1-240 MG, 180-2 MG, 2-240 MG, 240-4 MG
TEKAMLO TABS OR 10-150 MG, 10-300                                       MO
                                                    2
MG, 150-5 MG, 300-5 MG
TEKTURNA HCT TABS OR 12.5-150 MG,                                       MO
                                                    2
12.5-300 MG, 150-25 MG, 25-300 MG
TENORETIC 100 (atenolol & chlorthalidone)                               MO
                                                    3            1
TABS OR 100-25 MG
TENORETIC 50 (atenolol & chlorthalidone)                                MO
                                                    3            1
TABS OR 25-50 MG
TEVETEN HCT TABS OR 12.5-600 MG, 25-                                    MO
                                                    3
600 MG
TIMOLIDE 10/25 TABS OR 10-25 MG                     2
TRIBENZOR TABS OR 10-12.5-40 MG, 10-                                    MO
25-40 MG, 12.5-20-5 MG, 12.5-40-5 MG, 25-           2
40-5 MG
TWYNSTA TABS OR 10-40 MG, 10-80 MG,                                     MO
                                                    3
40-5 MG, 5-80 MG
UNIRETIC (moexipril-hydrochlorothiazide)                                MO
TABS OR 12.5-15 MG, 12.5-7.5 MG, 15-25              3            1
MG
VALTURNA TABS OR 150-160 MG, 300-320                                    MO
                                                    2
MG
VASERETIC (enalapril maleate &                                          MO
hydrochlorothiazide) TABS OR 10-25 MG,              3            1
12.5-5 MG
VASERETIC TABS OR                                   3                   MO

ZESTORETIC (lisinopril &                                                  MO
hydrochlorothiazide) TABS OR 10-12.5 MG,              3           1
12.5-20 MG, 20-25 MG
ZIAC (bisoprolol & hydrochlorothiazide) TABS                              MO
                                                      3           1
OR 10-6.25 MG, 2.5-6.25 MG, 5-6.25 MG
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                             64
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
Direct Renin Inhibitors
TEKTURNA TABS OR 150 MG, 300 MG                      2                      MO

 Selective Aldosterone Receptor Antagonists (SARAs)
INSPRA (eplerenone) TABS OR 25 MG, 50                                       MO
                                              3                   1
MG
Vasodilators
hydralazine hcl soln ij 20 mg/ml                                  4
hydralazine hcl tabs or 10 mg, 100 mg, 25                                   MO
                                                                  1
mg, 50 mg
minoxidil tabs or 10 mg, 2 mg, 2.5 mg                             1         MO

ANTIMALARIALS
Antimalarial Combinations
ATOVAQUONE/PROGUANIL HCL TABS OR                                            MO
                                                     3
25-62.5 MG
COARTEM TABS OR 120-20 MG                            2                      MO

FANSIDAR TABS OR 25-500 MG                           2                      MO

MALARONE (atovaquone-proguanil hcl)                                         MO
                                                     3            1
TABS OR 100-250 MG
MALARONE TABS OR 25-62.5 MG                          3                      MO

Antimalarials
ARALEN (chloroquine phosphate) TABS OR                                      MO
                                                     3            1
500 MG
chloroquine phosphate tabs or 250 mg                              1         MO

DARAPRIM TABS OR 25 MG                               2                      MO

LARIAM (mefloquine hcl) TABS OR 250 MG               3            1         MO

PLAQUENIL (hydroxychloroquine sulfate)                                      MO
                                                     3            1
TABS OR 200 MG
primaquine phosphate tabs or 26.3 mg                              1         MO

QUALAQUIN CAPS OR 324 MG                             2                      PA; ; MO

ANTIMYASTHENIC AGENTS
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                                     65
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
Antimyasthenic Agents
guanidine hcl tabs or 125 mg                                      1

MESTINON SYRP OR 60 MG/5ML                           2                      MO

MESTINON (pyridostigmine bromide) TABS                                      MO
                                                     3            1
OR 60 MG
MESTINON TIMESPAN TBCR OR 180 MG                     2                      MO

MYTELASE TABS OR 10 MG                               2                      MO

REGONOL SOLN IJ 5 MG/ML                              4
ANTIMYCOBACTERIAL AGENTS
Anti TB Combinations
RIFAMATE (isoniazid & rifampin) CAPS OR                                     MO
                                                     3            1
150-300 MG
RIFATER TABS OR 120-300-50 MG                        3                      MO

Antimycobacterial Agents
CAPASTAT SULFATE SOLR IJ 1 GM                        4

cycloserine caps or 250 mg                                        1         MO

ISONIAZID SOLN IJ 100 MG/ML                          4

isoniazid syrp or 50 mg/5ml                                       1         MO

isoniazid tabs or 100 mg, 300 mg                                  1         MO

MYAMBUTOL (ethambutol hcl) TABS OR                   3            1         MO
100 MG, 400 MG
MYCOBUTIN CAPS OR 150 MG                             2                      MO

NYDRAZID SOLN IJ 100 MG/ML                           4

paser pack or 4 gm                                                1         MO

PRIFTIN TABS OR 150 MG                               3                      MO

pyrazinamide tabs or 500 mg                                       1         MO

RIFADIN (rifampin) CAPS OR 300 MG                    3            1         MO

Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               66
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
rifadin caps or 150 mg                                            1         MO

RIFADIN (rifampin) SOLR IV 600 MG                    4            4         MO

rifampin caps or 150 mg                                           1         MO

seromycin caps or 250 mg                                          1         MO

TRECATOR TABS OR 250 MG                              3                      MO

TRECATOR-SC TABS OR 250 MG                           3                      MO

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES
Alkylating Agents
ALKERAN (melphalan hcl) SOLR IV 50 MG                4            4

BICNU SOLR IV 100 MG                                 4

BUSULFEX SOLN IV 6 MG/ML                             4
carboplatin soln iv 10 mg/ml, 150 mg/15ml,                        1
450 mg/45ml, 50 mg/5ml, 600 mg/60ml
carboplatin soln iv 50 mg/5ml                                     1         MO

CARBOPLATIN (carboplatin) SOLR IV 150                4            4
MG
CEENU CAPS OR 300 MG                                 2

CEENU CAPS OR 10 MG, 100 MG, 40 MG                   2                      MO

CISPLATIN (cisplatin) SOLN IV 200                    4            4
MG/200ML
cisplatin soln iv 1 mg/ml                                         4
CYTOXAN (cyclophosphamide) SOLR IJ 1                 4            4
GM, 2 GM, 500 MG
CYTOXAN (cyclophosphamide) TABS OR 25                                       MO; B/D
                                                     3            1
MG, 50 MG
ELOXATIN (oxaliplatin) SOLN IV 100                                          MO
                                                     5            5
MG/20ML, 50 MG/10ML
ELOXATIN SOLN IV 200 MG/40ML                         5

ELOXATIN (oxaliplatin) SOLR IV 50 MG                 4            4
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                                    67
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
HEXALEN CAPS OR 50 MG                                5                      MO

IFEX (ifosfamide) SOLR IV 1 GM                       4            4

IFEX SOLR IV 3 GM                                    4

ifosfamide soln iv 1 gm/20ml, 3 gm/60ml                           4

IFOSFAMIDE SOLR IV 3 GM                              4

LEUKERAN TABS OR 2 MG                                2                      MO

MUSTARGEN SOLR IJ 10 MG                              4

oxaliplatin solr iv 100 mg                                        4
PARAPLATIN (carboplatin) SOLN IV 150                 2            1
MG/15ML, 600 MG/60ML
PARAPLATIN (carboplatin) SOLN IV 450                                        MO
                                                     2            1
MG/45ML
PARAPLATIN SOLN IV 50 MG/5ML                         4

PARAPLATIN (carboplatin) SOLR IV 150 MG              4            4
PLATINOL AQ (cisplatin) SOLN IV 100                  4            4
MG/100ML, 50 MG/50ML
TEMODAR SOLR IV 100 MG                               5

thiotepa solr ij 15 mg                                            4         MO

TREANDA SOLR IV 100 MG, 25 MG                        5

ZANOSAR SOLR IV 1 GM                                 4                      MO

Antimetabolites
adrucil soln iv 2.5 gm/50ml, 5 gm/100ml                           4         MO

ALIMTA SOLR IV 100 MG                                5

ALIMTA SOLR IV 500 MG                                5                      MO

ARRANON SOLN IV 5 MG/ML                              5

CLOLAR SOLN IV 1 MG/ML                               4
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               68
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
cytarabine soln ij 100 mg/ml                                     4

CYTARABINE SOLR IJ 100 MG                           4                   MO

cytarabine solr ij 1 gm, 2 gm, 500 mg                            4
CYTARABINEAQUEOUS (cytarabine) SOLN                                     MO
                                                    4            4
IJ 20 MG/ML
cytarabineaqueous soln ij 100 mg/ml                              4

DACOGEN SOLR IV 50 MG                               5

FLUDARA SOLR IV 50 MG                               4

fludarabine phosphate soln iv 50 mg/2ml                          4

fludarabine phosphate solr iv 50 mg                              1      MO

FLUOROURACIL (fluorouracil) SOLN IV 500                                 MO
                                                    4            4
MG/10ML
fluorouracil soln iv 1 gm/20ml                                   4

fluorouracil soln iv 2.5 gm/50ml, 5 gm/100ml                     4      MO

FOLOTYN SOLN IV 20 MG/ML, 40 MG/2ML                 5
GEMCITABINE SOLN IV 1 GM/26.3ML, 2                  5
GM/52.6ML, 200 MG/5.26ML
gemcitabine hcl solr iv 2 gm                                     5
GEMZAR (gemcitabine hcl) SOLR IV 1 GM,                                  MO
                                                    5            5
200 MG
LEUSTATIN (cladribine) SOLN IV 1 MG/ML              4            4      MO

methotrexate tabs or 2.5 mg                                      1      MO

methotrexate sodium soln ij 1 gm/40ml, 25                               MO
                                                                 4
mg/ml, 250 mg/10ml, 50 mg/2ml
methotrexate sodium solr ij 1 gm                                 4      MO

methotrexate sodium lpf soln ij 25 mg/ml                         4      MO

PURINETHOL (mercaptopurine) TABS OR                                       MO
                                                      3           1
50 MG
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                             69
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
TABLOID TABS OR 40 MG                                2                      MO

TREXALL (methotrexate sodium) TABS OR                                       MO
                                                     3            1
10 MG, 15 MG, 5 MG
TREXALL TABS OR 7 MG                                 3                      MO

trexall tabs or 7.5 mg                                            1         MO

VIDAZA SUSR IJ 100 MG                                5
Antineoplastic - Angiogenesis Inhibitors
AVASTIN SOLN IV 100 MG/4ML, 400                      5
MG/16ML
Antineoplastic - Antibodies
ARZERRA CONC IV 100 MG/5ML                           5

CAMPATH SOLN IV 30 MG/ML                             5
ERBITUX SOLN IV 100 MG/50ML, 200                     5
MG/100ML
HERCEPTIN SOLR IV 440 MG                             5

MYLOTARG SOLR IV 5 MG                                5

RITUXAN CONC IV 10 MG/ML                             5
VECTIBIX SOLN IV 100 MG/5ML, 200                     5
MG/10ML, 400 MG/20ML
YERVOY SOLN IV 200 MG/40ML, 50                       5
MG/10ML
Antineoplastic - Hedgehog Pathway Inhibitors
ERIVEDGE CAPS OR 150 MG                              5                      LA

Antineoplastic - Hormonal and Related Agents
ARIMIDEX (anastrozole) TABS OR 1 MG                  2            1         MO

AROMASIN (exemestane) TABS OR 25 MG                  3            1         MO

CASODEX (bicalutamide) TABS OR 50 MG                 3            1         MO

DEPO-PROVERA SUSP IM 400 MG/ML                       4                      MO

Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                               70
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
ELIGARD KIT SC 7.5 MG                                4

ELIGARD KIT SC 22.5 MG                               4                      QL

ELIGARD KIT SC 30 MG                                 4                      QL

ELIGARD KIT SC 45 MG                                 4                      QL

EMCYT CAPS OR 140 MG                                 3                      MO

FARESTON TABS OR 60 MG                               2                      MO

FASLODEX SOLN IM 125 MG/2.5ML, 250                   5
MG/5ML
FEMARA (letrozole) TABS OR 2.5 MG                    3            1         MO

FIRMAGON SOLR SC 80 MG                               4

FIRMAGON SOLR SC 120 MG                              5

flutamide caps or 125 mg                                          1         MO

leuprolide acetate kit ij 1 mg/0.2ml, 5 mg/ml                     4         QL

LEUPROLIDE ACETATE SOLN SC 1                                                QL
                                                     4
MG/0.2ML
LUPRON DEPOT KIT IM 3.75 MG                          4

LUPRON DEPOT KIT IM 7.5 MG                           5

LUPRON DEPOT KIT IM 11.25 MG                         4                      QL

LUPRON DEPOT KIT IM 22.5 MG                          5                      QL

LUPRON DEPOT KIT IM 30 MG                            5                      QL

LUPRON DEPOT KIT IM 45 MG                            5                      QL

LYSODREN TABS OR 500 MG                              2                      MO

MEGACE ORAL (megestrol acetate) SUSP                                        MO
                                                     3            1
OR 40 MG/ML
megestrol acetate susp or 400 mg/10ml                             1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                               71
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
megestrol acetate tabs or 20 mg, 40 mg                            1         MO

NILANDRON TABS OR 150 MG                             3                      MO

NOLVADEX (tamoxifen citrate) TABS OR 10                                     MO
                                                     3            1
MG, 20 MG
SOLTAMOX SOLN OR 10 MG/5ML                           3

TRELSTAR DEPOT SUSR IM 3.75 MG                       4
TRELSTAR DEPOT MIXJECT SUSR IM 3.75                  4
MG
TRELSTAR LA SUSR IM 11.25 MG                         4
TRELSTAR LA MIXJECT SUSR IM 11.25                    4
MG
TRELSTAR MIXJECT SUSR IM 22.5 MG                     5

VANTAS KIT SC 50 MG                                  5

ZOLADEX IMPL SC 3.6 MG                               4

ZOLADEX IMPL SC 10.8 MG                              5                      QL

ZYTIGA TABS OR 250 MG                                5
Antineoplastic Antibiotics
adriamycin soln iv 2 mg/ml                                        4         MO

adriamycin solr iv 10 mg, 20 mg                                   4

adriamycin solr iv 50 mg                                          4         MO

BLENOXANE (bleomycin sulfate) SOLR IJ 30             4            4
UNIT
BLENOXANE (bleomycin sulfate) SOLR IJ 15                                    MO
                                                     4            4
UNIT
CERUBIDINE (daunorubicin hcl) SOLR IV 20             4            4
MG
COSMEGEN (dactinomycin) SOLR IV 0.5                                         MO
                                                     4            4
MG
daunorubicin hcl inj iv 5 mg/ml                                   4
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                               72
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
DAUNOXOME INJ IV 2 MG/ML                             4
DOXIL (doxorubicin hcl liposomal) INJ IV 2           5            5
MG/ML
doxorubicin hcl soln iv 2 mg/ml                                   4         MO

doxorubicin hcl solr iv 10 mg                                     4

doxorubicin hcl solr iv 50 mg                                     4         MO

ELLENCE (epirubicin hcl) SOLN IV 200                                        MO
                                                     4            4
MG/100ML, 50 MG/25ML
EPIRUBICIN HCL (epirubicin hcl) SOLN IV              4            4
10 MG/5ML, 150 MG/75ML
EPIRUBICIN HCL SOLR IV 50 MG                         4
IDAMYCIN PFS (idarubicin hcl) SOLN IV 10             4            4
MG/10ML, 20 MG/20ML, 5 MG/5ML
mitomycin solr iv 20 mg, 40 mg, 5 mg                              4
mitoxantrone hcl conc iv 20 mg/10ml, 25                           4
mg/12.5ml, 30 mg/15ml
NOVANTRONE (mitoxantrone hcl) CONC IV                4            4
2 MG/ML
 Antineoplastic Combinations
IFEX/MESNEX COMBO PACK (ifosfamide &                 4            4
mesna) KIT IV 1 GM, 1000-3000 MG
IFOSFAMIDE/MESNA (ifosfamide & mesna)                4            4
KIT IV 1 GM, 1000-3000 MG
Antineoplastic Enzyme Inhibitors
AFINITOR TABS OR 10 MG, 2.5 MG, 5 MG,
                                                     5
7.5 MG
CAPRELSA TABS OR 100 MG, 300 MG                      5

GLEEVEC TABS OR 100 MG, 400 MG                       5

INLYTA TABS OR 1 MG, 5 MG                            5                      LA

IRESSA TABS OR 250 MG                                5                      LA; MO

ISTODAX SOLR IV 10 MG                                5
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy




 www.healthnet.com                                                                   73
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
JAKAFI TABS OR 10 MG, 15 MG, 20 MG, 25                                      LA
                                                     5
MG, 5 MG
NEXAVAR TABS OR 200 MG                               5                      LA

SPRYCEL TABS OR 100 MG, 140 MG, 20                   5
MG, 50 MG, 70 MG, 80 MG
SUTENT CAPS OR 12.5 MG, 25 MG, 50 MG                 5
TARCEVA TABS OR 100 MG, 150 MG, 25                   5
MG
TASIGNA CAPS OR 150 MG, 200 MG                       5

TORISEL SOLN IV 25 MG/ML                             5

TYKERB TABS OR 250 MG                                5

VANDETANIB TABS OR 100 MG, 300 MG                    5

VELCADE SOLR IV 3.5 MG                               5

VOTRIENT TABS OR 200 MG                              5

XALKORI CAPS OR 200 MG, 250 MG                       5

ZELBORAF TABS OR 240 MG                              5                      LA

ZOLINZA CAPS OR 100 MG                               5
Antineoplastic Enzymes
ELSPAR SOLR IJ 10000 UNIT                            4

ONCASPAR SOLN IM 750 UNIT/ML                         4
Antineoplastics Misc.
ACTIMMUNE SOLN SC 2000000                                                   LA
                                                     5
UNIT/0.5ML
DACARBAZINE SOLR IV 100 MG                           4

DTIC-DOME (dacarbazine) SOLR IV 200 MG               4            4         MO

HYDREA (hydroxyurea) CAPS OR 500 MG                  3            1         MO

INTRON-A KIT SC 3 MU/0.2ML                           4
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               74
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
INTRON-A KIT SC 10 MU/0.2ML, 5                       5
MU/0.2ML
INTRON-A SOLN IJ 3000000 UNIT/0.5ML,                 4
6000000 UNIT/ML
INTRON-A SOLN IJ 10 MU/ML                            5

INTRON-A W/DILUENT SOLR IJ 10 MU                     4
INTRON-A W/DILUENT SOLR IJ 18 MU, 50                 5
MU
MATULANE CAPS OR 50 MG                               5

NIPENT (pentostatin) SOLR IV 10 MG                   4            4

ONTAK SOLN IV 150 MCG/ML                             4

PHOTOFRIN SOLR IV 75 MG                              4

PROLEUKIN SOLR IV 22000000 UNIT                      5
SYLATRON KIT SC 296 MCG, 444 MCG,                    5
888 MCG
TARGRETIN CAPS OR 75 MG                              5

THERACYS SUSR IS 81 MG/VIAL                          4                      MO

TICE BCG SUSR IS 50 MG                               4                      MO

TRISENOX SOLN IV 10 MG/10ML                          4                      MO

UVADEX SOLN IJ 20 MCG/ML                             4
VESANOID (tretinoin (chemotherapy)) CAPS                                    MO
                                                     5            5
OR 10 MG
Chemotherapy Adjuncts
ELITEK SOLR IV 1.5 MG, 7.5 MG                        5

KEPIVANCE SOLR IV 6.25 MG                            5                      MO

Chemotherapy Rescue/Antidote Agents
amifostine solr iv 500 mg                                         1         MO

CALCIUM FOLINATE SOLN IJ 100                          4
MG/10ML, 300 MG/30ML
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               75
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
ETHYOL SOLR IV 500 MG                                4

FUSILEV SOLR IV 50 MG                                4
LEUCOVORIN CALCIUM (leucovorin                                              MO
                                                     4            4
calcium) SOLN IV 10 MG/ML
LEUCOVORIN CALCIUM (leucovorin                                              MO
                                                     4            4
calcium) SOLR IJ 350 MG
LEUCOVORIN CALCIUM SOLR IJ 50 MG                     4

leucovorin calcium solr ij 500 mg                                 4

leucovorin calcium solr ij 100 mg, 200 mg                         4         MO

leucovorin calcium tabs or 10 mg, 15 mg, 25                                 MO
                                                                  1
mg, 5 mg
MESNEX (mesna) SOLN IV 100 MG/ML                     4            4         MO

MESNEX TABS OR 400 MG                                2                      MO

TOTECT (dexrazoxane) SOLR IV 500 MG                  4            4
ZINECARD (dexrazoxane) SOLR IV 250 MG,               4            4
500 MG
Mitotic Inhibitors
ABRAXANE SUSR IV 100 MG                              5                      MO

DOCEFREZ SOLR IV 20 MG, 80 MG                        5
DOCETAXEL CONC IV 20 MG/0.5ML, 80                                           MO
                                                     4
MG/2ML
DOCETAXEL CONC IV 20 MG/ML, 80                       5
MG/4ML
DOCETAXEL SOLN IV 160 MG/16ML, 20                    5
MG/2ML, 80 MG/8ML
ETOPOPHOS SOLR IV 100 MG                             4                      MO

etoposide soln iv 20 mg/ml                                        4         MO

HALAVEN SOLN IV 1 MG/2ML                             5

IXEMPRA KIT SOLR IV 15 MG, 45 MG                     5
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                               76
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
JEVTANA SOLN IV 60 MG/1.5ML                          5
PACLITAXEL (paclitaxel) CONC IV 150                  4            4
MG/25ML
paclitaxel conc iv 100 mg/16.7ml, 300                             4
mg/50ml
paclitaxel conc iv 30 mg/5ml, 6 mg/ml                             4         MO

TAXOL (paclitaxel) CONC IV 100                                              MO
                                                     4            4
MG/16.7ML, 30 MG/5ML, 300 MG/50ML
TAXOTERE CONC IV 20 MG/0.5ML, 80                                            MO
                                                     4
MG/2ML
TAXOTERE CONC IV 20 MG/ML, 80                        5
MG/4ML
toposar soln iv 20 mg/ml                                          4         MO

VINBLASTINE SULFATE SOLN IV 1 MG/ML                  4                      MO

vinblastine sulfate solr iv 10 mg                                 4

vincasar pfs soln iv 1 mg/ml                                      4         MO

vincristine sulfate soln iv 1 mg/ml                               4         MO

vinorelbine tartrate soln iv 10 mg/ml, 50                         4
mg/5ml
Topoisomerase I Inhibitors
CAMPTOSAR (irinotecan hcl) SOLN IV 100                                      MO
                                                     4            4
MG/5ML, 40 MG/2ML
CAMPTOSAR SOLN IV 300 MG/15ML                        4

HYCAMTIN (topotecan hcl) SOLR IV 4 MG                5            5         MO

irinotecan soln iv 500 mg/25ml                                    4

TOPOTECAN HCL SOLN IV 4 MG/4ML                       5
ANTIPARKINSON AGENTS
Antiparkinson Adjuvants
LODOSYN TABS OR 25 MG                                3                      MO

Antiparkinson Anticholinergics
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
benztropine mesylate tabs or 0.5 mg, 1 mg, 2                                MO
                                                                  1
mg
COGENTIN (benztropine mesylate) SOLN IJ                                     MO
                                                     4            4
1 MG/ML
trihexyphenidyl hcl elix or 0.4 mg/ml                             1         MO

trihexyphenidyl hcl tabs or 2 mg, 5 mg                            1         MO

Antiparkinson COMT Inhibitors
COMTAN TABS OR 200 MG                                2                      MO

TASMAR TABS OR 200 MG                                3

TASMAR TABS OR 100 MG                                3                      MO

Antiparkinson Dopaminergics
amantadine hcl caps or 100 mg                                     1         MO

amantadine hcl syrp or 50 mg/5ml                                  1         MO

APOKYN SOLN SC 10 MG/ML                              5

APOKYN SOLN SC 10 MG/ML                              5                      LA

bromocriptine mesylate tabs or 2 mg                               1         MO

CARBIDOPA/LEVODOPA/ENTACAPONE                                               MO
                                                     2
TABS OR
MIRAPEX (pramipexole dihydrochloride)                                       MO
TABS OR 0.125 MG, 0.25 MG, 0.5 MG, 0.75              3            1
MG, 1 MG, 1.5 MG
MIRAPEX TABS OR 0.25 MG, 0.5 MG, 1 MG                3                      MO

MIRAPEX ER TB24 OR 0.375 MG, 0.75 MG,                                       MO
                                                      3
1.5 MG, 2.25 MG, 3 MG, 3.75 MG, 4.5 MG
PARCOPA (carbidopa-levodopa) TBDP OR                                        MO
                                                      3           1
10-100 MG, 100-25 MG, 25-250 MG
PARLODEL (bromocriptine mesylate) CAPS                                      MO
                                                      3           1
OR 5 MG
PARLODEL (bromocriptine mesylate) TABS                                      MO
                                                      3           1
OR 2.5 MG
REQUIP (ropinirole hydrochloride) TABS OR                                   MO
0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG,              3           1
5 MG
Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
REQUIP XL (ropinirole hydrochloride) TB24                               MO
                                                    3            1
OR 12 MG, 2 MG, 4 MG, 6 MG, 8 MG
SINEMET (carbidopa-levodopa) TABS OR                                    MO
                                                    3            1
10-100 MG, 100-25 MG, 25-250 MG
SINEMET CR (carbidopa-levodopa) TBCR                                    MO
                                                    3            1
OR 100-25 MG, 200-50 MG
STALEVO 100 TABS OR 100-200-25 MG                   2                   MO

STALEVO 125 TABS OR 125-200-31.25 MG                2                   MO

STALEVO 150 TABS OR 150-200-37.5 MG                 2                   MO

STALEVO 200 TABS OR 200-50 MG                       2                   MO

STALEVO 50 TABS OR 12.5-200-50 MG                   2                   MO

STALEVO 75 TABS OR 18.75-200-75 MG                  2                   MO

SYMMETREL (amantadine hcl) TABS OR                                      MO
                                                    3            1
100 MG
Antiparkinson Monoamine Oxidase Inhibitors
AZILECT TABS OR 0.5 MG, 1 MG                        2                   MO

ELDEPRYL (selegiline hcl) CAPS OR 5 MG              3            1      MO

selegiline hcl tabs or 5 mg                                      1      MO

ZELAPAR TBDP OR 1.25 MG                             3                   MO

ANTIPSYCHOTICS/ANTIMANIC AGENTS
Antimanic Agents
ESKALITH (lithium carbonate) CAPS OR 300                                MO
                                                    3            1
MG
ESKALITH CR (lithium carbonate) TBCR OR                                 MO
                                                    3            1
450 MG
LITHIUM CARBONATE (lithium carbonate)                                   MO
                                                    3            1
CAPS OR 150 MG
lithium carbonate caps or 600 mg                                 1      MO

lithium carbonate tabs or 300 mg                                 1      MO

LITHIUM CITRATE (lithium citrate) SOLN OR                                 MO
                                                      3           1
8 MEQ/5ML
Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
lithium citrate syrp or 8 meq/5ml                                1      MO

LITHOBID (lithium carbonate) TBCR OR 300                                MO
                                                    3            1
MG
Antipsychotics - Misc.
EQUETRO CP12 OR 100 MG, 200 MG, 300                                     MO
                                                    3
MG
GEODON (ziprasidone hcl) CAPS OR 20                                     MO
                                                    2            1
MG, 40 MG, 60 MG, 80 MG
GEODON SOLR IM 20 MG                                4                   MO

LATUDA TABS OR 20 MG, 40 MG, 80 MG                  3                   MO

Benzisoxazoles
FANAPT TABS OR 1 MG, 10 MG, 12 MG, 2                                    MO
                                                    3
MG, 4 MG, 6 MG, 8 MG
FANAPT TITRATION PACK TABS OR                       3
INVEGA TB24 OR 1.5 MG, 3 MG, 6 MG, 9                                    MO
                                                    2
MG
INVEGA SUSTENNA SUSP IM 117                                             MO
MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39              4
MG/0.25ML, 78 MG/0.5ML
RISPERDAL (risperidone) SOLN OR 1                                       MO
                                                    3            1
MG/ML
RISPERDAL (risperidone) TABS OR 0.25                                    MO
                                                    3            1
MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG
RISPERDAL CONSTA SUSR IM 12.5 MG,                                       MO
                                                    4
25 MG
RISPERDAL CONSTA SUSR IM 37.5 MG,                                       MO
50 MG                                               5
RISPERDAL M-TAB (risperidone) TBDP OR                                   MO
                                                    3            1
0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG
risperidone odt tbdp or 0.25 mg                                  1      MO

Butyrophenones
HALDOL (haloperidol lactate) SOLN IJ 5                                    MO
                                                      4           4
MG/ML
HALDOL DECANOATE 100 (haloperidol                                         MO
                                                      4           4
decanoate) SOLN IM 100 MG/ML
HALDOL DECANOATE 50 (haloperidol                                          MO
                                                      4           4
decanoate) SOLN IM 50 MG/ML
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
HALDOL DECANOATE-100 (haloperidol                                           MO
                                                     4            4
decanoate) SOLN IM 100 MG/ML
HALDOL DECANOATE-50 (haloperidol                                            MO
                                                     4            4
decanoate) SOLN IM 50 MG/ML
haloperidol tabs or 0.5 mg, 1 mg, 10 mg, 2                                  MO
                                                                  1
mg, 20 mg, 5 mg
haloperidol conc or 2 mg/ml                                       1         MO

haloperidol lactate soln ij 5 mg/ml                               4
Dibenzapines
CLOZAPINE (clozapine) TABS OR 200 MG                 2            1

clozapine tabs or 50 mg                                           1
CLOZARIL (clozapine) TABS OR 100 MG, 25              3            1
MG
FAZACLO TBDP OR 100 MG, 12.5 MG, 150                 3
MG, 200 MG, 25 MG
loxapine caps or 10 mg, 25 mg, 5 mg, 50 mg                        1
loxapine succinate caps or 10 mg, 25 mg, 5                                  MO
                                                                  1
mg, 50 mg
loxitane caps or 10 mg, 25 mg, 5 mg, 50 mg                        1         MO

SAPHRIS SUBL SL 10 MG, 5 MG                          2                      MO

SEROQUEL (quetiapine fumarate) TABS OR                                      MO
100 MG, 200 MG, 25 MG, 300 MG, 400 MG,               2            1
50 MG
SEROQUEL XR TB24 OR 150 MG, 200 MG,                                         MO
300 MG, 400 MG, 50 MG                                2

ZYPREXA (olanzapine) SOLR IM 10 MG                   4            4         MO

ZYPREXA (olanzapine) TABS OR 10 MG, 15                                      MO
                                                     2            1
MG, 2.5 MG, 20 MG, 5 MG, 7.5 MG
ZYPREXA TABS OR 2 MG, 7 MG                           2                      MO

ZYPREXA RELPREVV SUSR IM 210 MG,                     5
300 MG, 405 MG
ZYPREXA ZYDIS (olanzapine) TBDP OR 10                                       MO
                                                     2            1
MG, 15 MG, 20 MG, 5 MG
Dihydroindolones
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
MOBAN TABS OR 10 MG, 25 MG, 5 MG, 50                 3
MG
Phenothiazines
chlorpromazine hcl soln ij 25 mg/ml                               4         MO

chlorpromazine hcl tabs or 10 mg, 100 mg,                                   MO
                                                                  1
25 mg, 50 mg
compro supp re 25 mg                                              1         MO

FLUPHENAZINE DECANOATE                                                      MO
                                                     4            4
(fluphenazine decanoate) SOLN IJ 25 MG/ML
fluphenazine hcl conc or 5 mg/ml                                  1         MO

fluphenazine hcl elix or 2.5 mg/5ml                               1         MO

fluphenazine hcl soln ij 2.5 mg/ml                                4         MO

fluphenazine hcl tabs or 1 mg, 10 mg, 2.5 mg,                               MO
                                                                  1
5 mg
perphenazine tabs or 16 mg, 2 mg, 4 mg, 8                                   MO
                                                                  1
mg
prochlorperazine supp re 25 mg                                    1         MO

prochlorperazine edisylate soln ij 5 mg/ml                        4         MO

prochlorperazine maleate tabs or 10 mg, 5                                   MO
                                                                  1
mg
thioridazine hcl tabs or 10 mg, 100 mg, 25                                  MO
                                                                  1
mg, 50 mg
THORAZINE (chlorpromazine hcl) TABS OR                                      MO
                                                     3            1
200 MG
trifluoperazine hcl tabs or 1 mg, 10 mg, 2 mg,                              MO
                                                                  1
5 mg
Quinolinone Derivatives
ABILIFY SOLN IM 9.75 MG/1.3ML                        4                      MO

ABILIFY SOLN OR 1 MG/ML                              2                      MO

ABILIFY TABS OR 10 MG, 15 MG, 2 MG, 20                                      MO
                                                     2
MG, 30 MG, 5 MG
ABILIFY DISCMELT TBDP OR 10 MG, 15                                          MO
                                                     2
MG
Thioxanthenes
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
NAVANE CAPS OR 20 MG                                 2
NAVANE (thiothixene) CAPS OR 10 MG, 2                                       MO
                                                     3            1
MG, 5 MG
thiothixene caps or 1 mg                                          1         MO

ANTISEPTICS & DISINFECTANTS
Chlorine Antiseptics
PHISOHEX LIQD EX 3 %                                 2                      MO

ANTIVIRALS
Antiretrovirals
APTIVUS CAPS OR 250 MG                               5                      MO

APTIVUS SOLN OR 100 MG/ML                            2

ATRIPLA TABS OR 200-300-600 MG                       5                      MO

COMBIVIR (lamivudine-zidovudine) TABS                                       MO
                                                     2            1
OR 150-300 MG
COMPLERA TABS OR 200-25-300 MG                       5                      MO

CRIXIVAN CAPS OR 100 MG, 333 MG                      2

CRIXIVAN CAPS OR 200 MG, 400 MG                      2                      MO

EDURANT TABS OR 25 MG                                5                      MO

EMTRIVA CAPS OR 200 MG                               2                      MO

EMTRIVA SOLN OR 10 MG/ML                             2                      MO

EPIVIR SOLN OR 10 MG/ML                              2                      MO

EPIVIR (lamivudine) TABS OR 150 MG, 300                                     MO
                                                     2            1
MG
EPIVIR HBV SOLN OR 5 MG/ML                           2                      MO

EPIVIR HBV TABS OR 100 MG                            2                      MO

EPZICOM TABS OR 300-600 MG                           2                      MO

FUZEON KIT SC 90 MG                                  5
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
FUZEON SOLR SC 90 MG                                 5

INTELENCE TABS OR 25 MG                              3

INTELENCE TABS OR 100 MG, 200 MG                     5                      MO

INVIRASE CAPS OR 200 MG                              3                      MO

INVIRASE TABS OR 500 MG                              5                      MO

ISENTRESS TABS OR 400 MG                             5                      MO

KALETRA SOLN OR 100-400-42.4 %,                                             MO
                                                     5
MG/5ML
KALETRA TABS OR 100-25 MG                            3                      MO

KALETRA TABS OR 200-50 MG                            5                      MO

lamivudine/zidovudine tabs or                                     1         MO

LEXIVA SUSP OR 50 MG/ML                              2                      MO

LEXIVA TABS OR 700 MG                                2                      MO

NEVIRAPINE SUSP OR 50 MG/5ML                         2                      MO

NORVIR CAPS OR 100 MG                                3                      MO

NORVIR SOLN OR 80 MG/ML                              3                      MO

NORVIR TABS OR 100 MG                                3                      MO

PREZISTA TABS OR 75 MG                               2
PREZISTA TABS OR 150 MG, 400 MG, 600                                        MO
                                                     2
MG
RESCRIPTOR TABS OR 100 MG, 200 MG                    2                      MO

RETROVIR (zidovudine) CAPS OR 100 MG                 3            1         MO

RETROVIR (zidovudine) SYRP OR 50                                            MO
                                                     3            1
MG/5ML
RETROVIR (zidovudine) TABS OR 300 MG                 3            1         MO

Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
RETROVIR IV INFUSION SOLN IV 10                      4
MG/ML
REYATAZ CAPS OR 100 MG, 150 MG, 200                                         MO
                                                     2
MG, 300 MG
SELZENTRY TABS OR 150 MG, 300 MG                     5                      MO

SUSTIVA CAPS OR 100 MG                               2

SUSTIVA CAPS OR 200 MG, 50 MG                        2                      MO

SUSTIVA TABS OR 600 MG                               2                      MO

TRIZIVIR TABS OR 150-300 MG                          2                      MO

TRUVADA TABS OR 200-300 MG                           5                      MO

VIDEX EC (didanosine) CPDR OR 125 MG,                                       MO
                                                     3            1
200 MG, 250 MG, 400 MG
VIDEXPEDIATRIC SOLR OR 2 GM, 4 GM                    2                      MO

VIRACEPT POWD OR 50 MG/GM                            2                      MO

VIRACEPT TABS OR 250 MG, 625 MG                      2                      MO

VIRAMUNE SUSP OR 50 MG/5ML                           2                      MO

VIRAMUNE (nevirapine) TABS OR 200 MG                 2            1         MO

VIRAMUNE XR TB24 OR 400 MG                           3                      MO

VIREAD POWD OR 40 MG/GM                              5
VIREAD TABS OR 150 MG, 200 MG, 250                   2
MG
VIREAD TABS OR 300 MG                                2                      MO

ZERIT (stavudine) CAPS OR 15 MG, 20 MG,                                     MO
                                                     3            1
30 MG, 40 MG
ZERIT (stavudine) SOLR OR 1 MG/ML                    3            1         MO

ZIAGEN SOLN OR 20 MG/ML                              2                      MO

ZIAGEN (abacavir sulfate) TABS OR 300 MG             2            1         MO

CMV Agents
Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand       Generic Limits
BRAND DRUG (generic drug)                         Tier        Tier
CYTOVENE (ganciclovir) CAPS OR 250 MG               3            1

CYTOVENE CAPS OR 500 MG                             5
CYTOVENE (ganciclovir sodium) SOLR IV                                   MO
                                                    4            4
500 MG
FOSCARNET SODIUM SOLN IV 24 MG/ML                   4

FOSCAVIR SOLN IV 24 MG/ML                           4

GANCICLOVIR CAPS OR 500 MG                          5

VALCYTE SOLR OR 50 MG/ML                            5                   MO

VALCYTE TABS OR 450 MG                              5                   MO

VISTIDE SOLN IV 75 MG/ML                            5                   MO

Hepatitis Agents
BARACLUDE SOLN OR 0.05 MG/ML                        2                   MO

BARACLUDE TABS OR 0.5 MG, 1 MG                      5                   MO

COPEGUS (ribavirin (hepatitis c)) TABS OR           3            1
200 MG
HEPSERA TABS OR 10 MG                               3                   MO

INCIVEK TABS OR 375 MG                              5                   PA

INFERGEN INJ SC 15 MCG/0.5ML, 9                                         PA
                                                    5
MCG/0.3ML
PEG-INTRON KIT SC 120 MCG/0.5ML, 150                                    PA
                                                    5
MCG/0.5ML, 50 MCG/0.5ML, 80 MCG/0.5ML
PEG-INTRON REDIPEN KIT SC 120                                           PA
MCG/0.5ML, 150 MCG/0.5ML, 50                        5
MCG/0.5ML, 80 MCG/0.5ML
PEG-INTRON REDIPEN PAK 4 KIT SC 120                                     PA
MCG/0.5ML, 150 MCG/0.5ML, 50                        5
MCG/0.5ML, 80 MCG/0.5ML
PEGASYS KIT SC 180 MCG/0.5ML                        5                   PA

PEGASYS SOLN SC 180 MCG/0.5ML, 180                                        PA
                                                      5
MCG/ML
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
PEGASYS PROCLICK SOLN SC 135                                                PA
                                                     5
MCG/0.5ML, 180 MCG/0.5ML
REBETOL (ribavirin (hepatitis c)) CAPS OR            5            1
200 MG
REBETOL SOLN OR 40 MG/ML                             2

TYZEKA TABS OR 600 MG                                5                      MO

VICTRELIS CAPS OR 200 MG                             5                      PA

Herpes Agents
ACYCLOVIR SODIUM SOLN IV 50 MG/ML                    4

ACYCLOVIR SODIUM SOLR IV 1000 MG                     4
FAMVIR (famciclovir) TABS OR 125 MG, 250                                    MO
                                                     3            1
MG, 500 MG
valacyclovir hcl tabs or 1000 mg                                  1         MO

VALTREX (valacyclovir hcl) TABS OR 1 GM,                                    MO
                                                     3            1
500 MG
ZOVIRAX (acyclovir) CAPS OR 200 MG                   3            1         MO

ZOVIRAX (acyclovir) SUSP OR 200 MG/5ML               3            1         MO

ZOVIRAX (acyclovir) TABS OR 400 MG, 800                                     MO
                                                     3            1
MG
ZOVIRAX (acyclovir sodium) SOLR IV 500                                      MO
                                                     4            4
MG
Influenza Agents
FLUMADINE (rimantadine hydrochloride)                                       MO
                                                     3            1
TABS OR 100 MG
RELENZA DISKHALER AEPB IN 5                                                 MO
                                                     3
MG/BLISTER
TAMIFLU CAPS OR 30 MG, 45 MG, 75 MG                  3                      MO

TAMIFLU SUSR OR 12 MG/ML, 6 MG/ML                    3                      MO

Respiratory Syncytial Virus (RSV) Agents
VIRAZOLE SOLR IN 6 GM                                3
ASSORTED CLASSES
Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
Chelating Agents
CUPRIMINE CAPS OR 125 MG                            2

CUPRIMINE CAPS OR 250 MG                            2                   MO

DEPEN TITRATABS TABS OR 250 MG                      2                   MO

SYPRINE CAPS OR 250 MG                              3                   MO

Enzymes
XIAFLEX SOLR IJ 0.9 MG                              5
Immunomodulators
REVLIMID CAPS OR 2.5 MG                             5
REVLIMID CAPS OR 10 MG, 15 MG, 25 MG,                                   LA
                                                    5
5 MG
THALOMID CAPS OR 100 MG, 150 MG, 200                5
MG, 50 MG
Immunosuppressive Agents
ATGAM INJ IV 50 MG/ML                               4                   B/D

azasan tabs or 100 mg, 75 mg                                    1       MO; B/D

AZATHIOPRINE SODIUM SOLR IJ 100 MG                  4                   MO; B/D

CELLCEPT (mycophenolate mofetil) CAPS                                   MO; B/D
                                                    3           1
OR 250 MG
CELLCEPT SUSR OR 200 MG/ML                          2                   MO; B/D

CELLCEPT (mycophenolate mofetil) TABS                                   MO; B/D
                                                    3           1
OR 500 MG
CELLCEPT INTRAVENOUS SOLR IV 500                                        B/D
                                                    4
MG
cyclosporine modified caps or 50 mg                             1       MO; B/D

IMURAN (azathioprine) TABS OR 50 MG                 3           1       MO; B/D

MYFORTIC TBEC OR 180 MG, 360 MG                     3                   MO; B/D

NEORAL (cyclosporine modified (for                                        MO; B/D
                                                      3           1
microemulsion)) CAPS OR 100 MG, 25 MG
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
NEORAL (cyclosporine modified (for                                          MO; B/D
                                                     3            1
microemulsion)) SOLN OR 100 MG/ML
NULOJIX SOLR IV 250 MG                               5                      MO; B/D

ORTHOCLONE OKT3 INJ IV 1 MG/ML                       5                      B/D

PROGRAF (tacrolimus) CAPS OR 0.5 MG, 1                                      MO; B/D
                                                     3            1
MG
PROGRAF (tacrolimus) CAPS OR 5 MG                    5            5         MO; B/D

PROGRAF SOLN IV 5 MG/ML                              4                      B/D

RAPAMUNE SOLN OR 1 MG/ML                             2                      MO; B/D

RAPAMUNE TABS OR 0.5 MG, 1 MG, 2 MG                  2                      MO; B/D

SANDIMMUNE (cyclosporine) CAPS OR 100                                       MO; B/D
                                                     3            1
MG, 25 MG
SANDIMMUNE (cyclosporine) SOLN IV 50                                        B/D
                                                     4            4
MG/ML
SANDIMMUNE (cyclosporine) SOLN OR 100                                       MO; B/D
                                                     3            1
MG/ML
SIMULECT SOLR IV 10 MG, 20 MG                        5                      B/D

THYMOGLOBULIN SOLR IV 25 MG                          2                      B/D

ZENAPAX CONC IV 25 MG/5ML                            5                      B/D

ZORTRESS TABS OR 0.25 MG                             2                      MO; B/D

ZORTRESS TABS OR 0.5 MG, 0.75 MG                     5                      MO; B/D

 Irrigation Solutions
lactated ringers irrigation soln ir 109-130-28-                   1
3-4 meq/l
physiolyte soln ir 140-23-27-3-5-98                               1
meq/1000ml
PHYSIOSOL IRRIGATION PH 7.4 (irrigation
solutions, physiological) SOLN IR 222-30-37-         3            1
502-526 MG/100ML
ringers irrigation soln ir 147-156-4-4.5 meq/l                    1

sterile water for irrigation soln ir                              1         MO

Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
sterile water irrigation soln ir                                 1      MO

sterile water irrigationplastic bottle soln ir                   1      MO

sterile water irrigationw/hanger soln ir                         1      MO

tis-u-sol soln ir 147-156-4-4.5 meq/l                            1

tis-u-sol viaflex soln ir 147-156-4-4.5 meq/l                    1
 Potassium Removing Resins
KAYEXALATE (sodium polystyrene                                          MO
                                                    3            1
sulfonate) POWD OR
kionex susp or 15 gm/60ml                                        1
sodium polystyrene sulfonate susp or 15                          1
gm/60ml
sodium polystyrene sulfonate susp re 30                          1
gm/120ml, 50 gm/200ml
sps susp or 15 gm/60ml                                           1      MO

sps 30gm/120ml enema susp re 30 gm/120ml                         1

sps 50gm/200ml enema susp re 50 gm/200ml                         1
Systemic Lupus Erythematosus Agents
BENLYSTA SOLR IV 120 MG, 400 MG                     5
BETA BLOCKERS
Alpha-Beta Blockers
COREG (carvedilol) TABS OR 12.5 MG, 25                                  MO
                                                    3            1
MG, 3.125 MG, 6.25 MG
COREG CR CP24 OR 10 MG, 20 MG, 40                                       MO
                                                    3
MG, 80 MG
TRANDATE (labetalol hcl) TABS OR 100                                    MO
                                                    3            1
MG, 200 MG, 300 MG
TRANDATE IV (labetalol hcl) SOLN IV 5               4            4
MG/ML
Beta Blockers Cardio-Selective
BYSTOLIC TABS OR 10 MG, 2.5 MG, 20                                        MO
                                                      2
MG, 5 MG
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                             90
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
KERLONE (betaxolol hcl) TABS OR 10 MG,                                      MO
                                                     3            1
20 MG
LOPRESSOR (metoprolol tartrate) SOLN IV                                     MO
                                                     4            4
1 MG/ML
LOPRESSOR (metoprolol tartrate) TABS OR                                     MO
                                                     3            1
100 MG, 50 MG
metoprolol tartrate soln iv 5 mg/5ml                              4         MO

metoprolol tartrate tabs or 25 mg                                 1         MO

SECTRAL (acebutolol hcl) CAPS OR 200                                        MO
                                                     3            1
MG, 400 MG
TENORMIN (atenolol) TABS OR 100 MG, 25                                      MO
                                                     3            1
MG, 50 MG
TOPROL XL (metoprolol succinate) TB24 OR                                    MO
                                                     3            1
100 MG, 200 MG, 25 MG, 50 MG
ZEBETA (bisoprolol fumarate) TABS OR 10                                     MO
                                                     3            1
MG, 5 MG
Beta Blockers Non-Selective
BETAPACE (sotalol hcl) TABS OR 120 MG,                                      MO
                                                     3            1
160 MG, 240 MG, 80 MG
BETAPACE AF (sotalol hcl (afib/afl)) TABS                                   MO
                                                     3            1
OR 120 MG, 160 MG, 80 MG
CARTROL TABS OR 2.5 MG, 5 MG                         3

CORGARD (nadolol) TABS OR 160 MG                     3            1
CORGARD (nadolol) TABS OR 20 MG, 40                                         MO
                                                     3            1
MG, 80 MG
INDERAL (propranolol hcl) TABS OR 10 MG,                                    MO
                                                     3            1
20 MG, 40 MG, 60 MG, 80 MG
INDERAL LA (propranolol hcl) CP24 OR 120                                    MO
                                                     3            1
MG, 160 MG, 60 MG, 80 MG
INNOPRAN XL CP24 OR 120 MG, 80 MG                    3                      MO

LEVATOL TABS OR 20 MG                                3                      MO

NADOLOL (nadolol) TABS OR 160 MG                     3            1

pindolol tabs or 10 mg, 5 mg                                      1         MO

PROPRANOLOL HCL (propranolol hcl)                     4           4
SOLN IV 1 MG/ML
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
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PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               91
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
propranolol hcl soln or 20 mg/5ml, 40 mg/5ml                     1      MO

timolol maleate tabs or 10 mg, 20 mg, 5 mg                       1      MO

BIOLOGICALS MISC
Biologicals Misc
ADAGEN SOLN IM 250 UNIT/ML                          5
CALCIUM CHANNEL BLOCKERS
Calcium Channel Blockers
ADALAT CC (nifedipine) TB24 OR 30 MG, 60                                MO
                                                    3            1
MG, 90 MG
CALAN (verapamil hcl) TABS OR 120 MG,                                   MO
                                                    3            1
40 MG, 80 MG
CALAN SR (verapamil hcl) TBCR OR 120                                    MO
                                                    3            1
MG, 180 MG, 240 MG
CARDENE (nicardipine hcl) CAPS OR 20                                    MO
                                                    3            1
MG, 30 MG
CARDENE I.V. (nicardipine hcl) SOLN IV 2.5          4            4
MG/ML
CARDENE SR CP12 OR 30 MG                            3                   MO

CARDIZEM SOLN IV 5 MG/ML                            4
CARDIZEM (diltiazem hcl) TABS OR 120                                    MO
                                                    3            1
MG, 30 MG, 60 MG, 90 MG
CARDIZEM CD (diltiazem hcl coated beads)                                MO
                                                    2            1
CP24 OR 360 MG
CARDIZEM CD (diltiazem hcl coated beads)                                MO
CP24 OR 120 MG, 180 MG, 240 MG, 300                 3            1
MG
CARDIZEM LA (diltiazem hcl coated beads)                                MO
TB24 OR 180 MG, 240 MG, 300 MG, 360                 3            1
MG, 420 MG
CARDIZEM LA TB24 OR 120 MG                          3                   MO

COVERA-HS TB24 OR 180 MG, 240 MG                    3                   MO

DILACOR XR (diltiazem hcl) CP24 OR 120                                    MO
                                                      3           1
MG, 180 MG, 240 MG
diltiazem hcl soln iv 125 mg/25ml, 25 mg/5ml,                     4
50 mg/10ml
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                             92
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
DILTIAZEM HCL SOLR IV 100 MG                         4
diltiazem hcl er cp12 or 120 mg, 60 mg, 90                                  MO
                                                                  1
mg
DYNACIRC CR TB24 OR 10 MG, 5 MG                      3                      MO

DYNACIRC-CR TB24 OR 5 MG                             3                      MO

ISOPTIN SR (verapamil hcl) TBCR OR 120                                      MO
                                                     3            1
MG, 180 MG, 240 MG
isradipine caps or 5 mg                                           1

isradipine caps or 2.5 mg, 5 mg                                   1         MO

nifedipine caps or 20 mg                                          1         MO

nimodipine caps or 30 mg                                          1         MO

NORVASC (amlodipine besylate) TABS OR                                       MO
                                                     3            1
10 MG, 2.5 MG, 5 MG
PLENDIL (felodipine) TB24 OR 10 MG, 2.5                                     MO
                                                     3            1
MG, 5 MG
PROCARDIA (nifedipine) CAPS OR 10 MG                 3            1         MO

PROCARDIA XL (nifedipine) TB24 OR 30                                        MO
                                                     3            1
MG, 60 MG, 90 MG
SULAR (nisoldipine) TB24 OR 17 MG, 25.5                                     MO
                                                     2            1
MG, 34 MG, 8.5 MG
TIAZAC (diltiazem hcl extended release                                      MO
beads) CP24 OR 120 MG, 180 MG, 240 MG,               3            1
300 MG, 360 MG, 420 MG
verapamil hcl soln iv 2 mg/ml, 2.5 mg/ml                          4         MO

VERELAN (verapamil hcl) CP24 OR 120 MG,                                     MO
                                                     3            1
180 MG, 240 MG, 360 MG
VERELAN PM (verapamil hcl) CP24 OR 100                                      MO
                                                     3            1
MG, 200 MG, 300 MG
CARDIOTONICS
Cardiac Glycosides
digoxin soln or 0.05 mg/ml                                        1         MO

digoxin tabs or 0.25 mg, 0.5 mg                                   1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                               93
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
LANOXIN ELIX OR 0.5 MG/ML                            3                      MO

LANOXIN (digoxin) SOLN IJ 0.25 MG/ML                 4            4         MO

LANOXIN SOLN IJ 0.1 MG/ML                            4
LANOXIN (digoxin) TABS OR 0.125 MG,                                         MO
                                                     3            1
0.25 MG
Phosphodiesterase Inhibitors
milrinone lactate soln iv 1 mg/ml                                 4
CARDIOVASCULAR AGENTS - MISC.
Cardiovascular Agents Misc. - Combinations
AMLODIPINE BESYLATE/ATORVASTATIN                                            MO
CALCIUM TABS OR 10 MG, 10-2.5 MG, 10-
20 MG, 10-40 MG, 10-5 MG, 10-80 MG, 2.5-             3
20 MG, 2.5-40 MG, 20-5 MG, 40-5 MG, 5-80
MG
BIDIL TABS OR 20-37.5 MG                             3                      MO

CADUET TABS OR 10 MG, 10-2.5 MG, 10-                                        MO
20 MG, 10-40 MG, 10-5 MG, 10-80 MG, 2.5-             3
20 MG, 2.5-40 MG, 20-5 MG, 40-5 MG, 5-80
MG
Prostaglandin Vasodilators
FLOLAN (epoprostenol sodium) SOLR IV 0.5                                    B/D
                                                     5            5
MG, 1.5 MG
REMODULIN SOLN IJ 1 MG/ML, 10 MG/ML,                                        LA
                                                     5
2.5 MG/ML, 5 MG/ML
TYVASO SOLN IN 0.6 MG/ML                             5                      B/D

TYVASO REFILL SOLN IN 0.6 MG/ML                      5                      B/D

TYVASO STARTER SOLN IN 0.6 MG/ML                     5                      B/D

VELETRI (epoprostenol sodium) SOLR IV 1.5                                   B/D
                                                     5            5
MG
VENTAVIS SOLN IN 20 MCG/ML                           2                      B/D

VENTAVIS SOLN IN 10 MCG/ML                           2                      LA; B/D

Pulmonary Hypertension - Endothelin Receptor Antagonists
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                                    94
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
LETAIRIS TABS OR 10 MG, 5 MG                         5                      LA

TRACLEER TABS OR 125 MG, 62.5 MG                     5                      LA

Pulmonary Hypertension - Phosphodiesterase Inhibitors
ADCIRCA TABS OR 20 MG                                5

REVATIO SOLN IV 10 MG/12.5ML                         5                      PA

REVATIO TABS OR 20 MG                                5                      PA

CEPHALOSPORINS
Cephalosporins - 1st Generation
cefazolin sodium solr ij 20 gm                                    4

cefazolin sodium solr ij 1 gm, 10 gm, 500 mg                      4         MO

cefazolin sodium solr iv 1 gm                                     4

CEFAZOLIN SODIUM SOLN IV 5-500 %, MG                 4

cefazolin sodium soln iv 1-5 %, gm                                4
CEFAZOLIN SODIUM/DEXTROSE SOLR IV                    4
, 1-4 %, GM
cephalexin susr or 125 mg/5ml, 250 mg/5ml                         1         MO

cephalexin tabs or 250 mg, 500 mg                                 1         MO

DURICEF (cefadroxil) CAPS OR 500 MG                  3            1         MO

DURICEF (cefadroxil) SUSR OR 250                                            MO
                                                     3            1
MG/5ML, 500 MG/5ML
DURICEF (cefadroxil) TABS OR 1 GM                    3            1         MO

KEFLEX (cephalexin) CAPS OR 250 MG,                                         MO
                                                     3            1
500 MG
KEFLEX CAPS OR 750 MG                                3                      MO

keflex susr or 125 mg/5ml, 250 mg/5ml                             1         MO

Cephalosporins - 2nd Generation
cefaclor caps or 250 mg, 500 mg                                   1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               95
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
cefaclor susr or 125 mg/5ml, 187 mg/5ml,                          1
250 mg/5ml, 375 mg/5ml
cefaclor er tb12 or 500 mg                                        1         MO

cefotetan solr ij 1 gm, 10 gm, 2 gm                               4
CEFOTETAN/DEXTROSE SOLR IV 1-3.58                    4
%, GM, 2-2.08 %, GM
cefoxitin sodium solr iv 1-4 %, gm, 2-2.2 %,                      4
gm
CEFTIN (cefuroxime axetil) SUSR OR 125                                      MO
                                                     3            1
MG/5ML, 250 MG/5ML
CEFTIN (cefuroxime axetil) TABS OR 250                                      MO
                                                     3            1
MG, 500 MG
cefuroxime sodium solr iv 7.5 gm                                  4
CEFUROXIME/DEXTROSE SOLR IV 1.5-2.9                  4
%, GM, 4.1-750 %, MG
CEFZIL (cefprozil) SUSR OR 125 MG/5ML,                                      MO
                                                     3            1
250 MG/5ML
CEFZIL (cefprozil) TABS OR 250 MG, 500                                      MO
                                                     3            1
MG
MEFOXIN (cefoxitin sodium) SOLR IJ 10 GM             4            4

MEFOXIN (cefoxitin sodium) SOLR IV 1 GM              4            4

MEFOXIN (cefoxitin sodium) SOLR IV 2 GM              4            4         MO

mefoxin soln iv 1-2 gm/50ml, 1.1-2 gm/50ml                        5
MEFOXIN ADD-VANTAGE (cefoxitin sodium)               4            4
SOLR IV 1 GM
MEFOXIN ADD-VANTAGE (cefoxitin sodium)                                      MO
                                                     4            4
SOLR IV 2 GM
MEFOXIN IN DEXTROSE 3.9% SOLN IV 1-                  4
3.9 %, GM/50ML
RANICLOR CHEW OR 250 MG, 375 MG                      3
ZINACEF (cefuroxime sodium) SOLR IJ 1.5              4            4
GM, 7.5 GM, 750 MG
ZINACEF (cefuroxime sodium) SOLR IV 1.5              4            4
GM
ZINACEF SOLR IV 750 MG                               4
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               96
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
ZINACEFIN ISO-OSMOTIC DEXTROSE                       4
SOLN IV 750 MG
ZINACEFIN ISO-OSMOTIC DILUENT SOLN                   4
IV 1.5 GM
Cephalosporins - 3rd Generation
CEDAX CAPS OR 400 MG                                 3                      MO

CEDAX SUSR OR 180 MG/5ML, 90 MG/5ML                  3                      MO

CEFIZOX IN DEXTROSE 5% SOLN IV 1-5                   4
%, GM/50ML, 2-5 %, GM/50ML
CEFOTAXIME SODIUM SOLR IJ 20 GM                      4
CEFTAZIDIME/DEXTROSE SOLR IV 1-5 %,                  4
GM/50ML, 2-5 %, GM/50ML
CEFTRIAXONE IN ISO-OSMOTIC                           4
DEXTROSE SOLN IV 20 MG/ML
CEFTRIAXONE IN ISO-OSMOTIC                           5
DEXTROSE SOLN IV 40 MG/ML
ceftriaxone sodium solr ij 1 gm, 500 mg                           4         MO

ceftriaxone sodium solr iv 1 gm                                   4
CEFTRIAXONE/DEXTROSE SOLR IV 1-3.74                  4
%, GM, 2-2.22 %, GM
CLAFORAN (cefotaxime sodium) SOLR IJ                 4            4
500 MG
CLAFORAN (cefotaxime sodium) SOLR IJ 1                                      MO
                                                     4            4
GM, 10 GM, 2 GM
CLAFORAN SOLR IV 1 GM, 2 GM                          4
CLAFORAN/D5W SOLN IV 1-5 %, GM/50ML,                 4
2-5 %, GM/50ML
FORTAZ (ceftazidime) SOLR IJ 6 GM                    4            4
FORTAZ (ceftazidime) SOLR IJ 1 GM, 2 GM,                                    MO
                                                     4            4
500 MG
FORTAZ (ceftazidime) SOLR IV 1 GM, 2 GM              4            4
FORTAZ SOLN IV 1-5 %, GM/50ML, 2-5 %,                4
GM/50ML
OMNI-PAC (cefdinir) CAPS OR 300 MG                   3            1         MO

Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               97
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
OMNICEF (cefdinir) CAPS OR 300 MG                    3            1         MO

OMNICEF (cefdinir) SUSR OR 125 MG/5ML,                                      MO
                                                     3            1
250 MG/5ML
ROCEPHIN (ceftriaxone sodium) SOLR IJ 2                                     MO
                                                     4            4
GM, 250 MG
rocephin solr ij 1 gm, 500 mg                                     4         MO

ROCEPHIN (ceftriaxone sodium) SOLR IV 10                                    MO
                                                     4            4
GM, 2 GM
ROCEPHIN IN ISO-OSMOTIC DEXTROSE                     4
SOLN IV 20 MG/ML
ROCEPHIN IN ISO-OSMOTIC DEXTROSE                     5
SOLN IV 40 MG/ML
SPECTRACEF (cefditoren pivoxil) TABS OR                                     MO
                                                     3            1
200 MG, 400 MG
SUPRAX SUSR OR 200 MG/5ML                            3                      MO

suprax susr or 100 mg/5ml                                         1         MO

SUPRAX TABS OR 400 MG                                3                      MO

VANTIN (cefpodoxime proxetil) SUSR OR                                       MO
                                                     3            1
100 MG/5ML, 50 MG/5ML
VANTIN (cefpodoxime proxetil) TABS OR                                       MO
                                                     3            1
100 MG, 200 MG
Cephalosporins - 4th Generation
CEFEPIME SOLN IV 1 GM/50ML, 2                        4
GM/100ML
MAXIPIME (cefepime hcl) SOLR IJ 1 GM, 2                                     MO
                                                     4            4
GM
MAXIPIME SOLR IV 1 GM, 2 GM                          4
Cephalosporins - 5th Generation
TEFLARO SOLR IV 400 MG, 600 MG                       4
CONTRACEPTIVES
Combination Contraceptives - Oral
ALESSE-28 (levonorgestrel & eth estradiol)                                  MO
                                                     3            1
TABS OR 0.1-20 MCG, MG
altavera tabs or 0.03-0.15 mg                                     1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               98
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
alyacen 1/35 tabs or                                              1         MO

azurette tabs or                                                  1         MO

BEYAZ TABS OR 0.02-0.451-3 MG                        3                      MO

BREVICON-28 (norethindrone & eth                                            MO
                                                     3            1
estradiol) TABS OR 0.5-35 MCG, MG
CYCLESSA (desogestrel-ethinyl estradiol                                     MO
                                                     3            1
(triphasic)) TABS OR
DEMULEN 1/35-28 (ethynodiol diacet & eth                                    MO
                                                     3            1
estrad) TABS OR 1-35 MCG, MG
DEMULEN 1/50-28 (ethynodiol diacet & eth                                    MO
                                                     3            1
estrad) TABS OR 1-50 MCG, MG
DESOGEN (desogestrel & ethinyl estradiol)                                   MO
                                                     3            1
TABS OR 0.15-30 MCG, MG
enpresse-28 tabs or                                               1         MO

ESTROSTEP FE (norethindrone acetate-                                        MO
                                                     3            1
ethinyl estradiol-fe) TABS OR 1-75 MG
FEMCON FE (norethindrone & ethinyl                                          MO
                                                     3            1
estradiol-fe) CHEW OR 0.4-35 MCG, MG
GENERESS FE CHEW OR 0.8-25-75 MCG,                                          MO
                                                     3
MG
gildess fe 1/20 tabs or 1-20-75 mcg, mg                           1         MO

junel fe 1/20 tabs or 1-20-75 mcg, mg                             1         MO

kariva tabs or                                                    1         MO

LEVLEN CONTRACT PACK (levonorgestrel                                        MO
                                                      3           1
& eth estradiol) TABS OR 0.15-30 MCG, MG
LEVLEN-28 (levonorgestrel & eth estradiol)                                  MO
                                                      3           1
TABS OR 0.15-30 MCG, MG
LEVLITE-28 (levonorgestrel & eth estradiol)                                 MO
                                                      3           1
TABS OR 0.1-20 MCG, MG
LO LOESTRIN FE TABS OR 1-10-75 MCG,                                         MO
                                                      3
MG
LO/OVRAL-28 (norgestrel & ethinyl estradiol)                                MO
                                                      3           1
TABS OR 0.3-30 MCG, MG
LOESTRIN 1.5/30-21 (norethindrone acet &                                    MO
                                                      3           1
eth estra) TABS OR 1.5-30 MCG, MG
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy




 www.healthnet.com                                                               99
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
LOESTRIN 1/20-21 (norethindrone acet & eth                              MO
                                                    3            1
estra) TABS OR 1-20 MCG, MG
LOESTRIN 24 FE TABS OR 1-20-75 MCG,                                     MO
                                                    3
MG
LOESTRIN FE 1.5/30 (norethin acet &                                     MO
                                                    3            1
estrad-fe) TABS OR 1.5-30-75 MCG, MG
loestrin fe 1/20 tabs or 1-20-75 mcg, mg                         1      MO

LOSEASONIQUE (levonorgestrel-ethinyl                                    QL; MO
                                                    3            1
estradiol (91-day)) TABS OR
LYBREL (levonorgestrel-ethinyl estradiol                                MO
                                                    3            1
(continuous)) TABS OR 20-90 MCG
marlissa tabs or                                                 1      MO

microgestin fe tabs or 1-20-75 mcg, mg                           1      MO

MIRCETTE TABS OR                                    3

mircette tabs or                                                 1      MO

MODICON (norethindrone & eth estradiol)                                 MO
                                                    3            1
TABS OR 0.5-35 MCG, MG
MODICON-28 (norethindrone & eth estradiol)                              MO
                                                    3            1
TABS OR 0.5-35 MCG, MG
myzilra tabs or                                                  1      MO

NATAZIA TABS OR                                     3                   MO

NECON 10/11-28 TABS OR 35 MCG                       2                   MO

NORDETTE-28 (levonorgestrel & eth                                       MO
                                                    3            1
estradiol) TABS OR 0.15-30 MCG, MG
norgestimate/ethinyl estradiol tabs or                           1      MO

NORINYL 1+35 (norethindrone & eth                                       MO
                                                    3            1
estradiol) TABS OR 1-35 MCG, MG
NORINYL 1+50 (norethindrone & mestranol)                                MO
                                                    3            1
TABS OR 1-50 MCG, MG
ogestrel tabs or 0.5-50 mcg, mg                                  1      MO

ORTHO TRI-CYCLEN (norgestimate-ethinyl                                    MO
                                                      3           1
estradiol (triphasic)) TABS OR
ORTHO TRI-CYCLEN LO (norgestimate-                                        MO
                                                      2           1
ethinyl estradiol (triphasic)) TABS OR
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               100
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
ORTHO-CEPT (desogestrel & ethinyl                                           MO
                                                     3            1
estradiol) TABS OR 0.15-30 MCG, MG
ORTHO-CEPT-28 (desogestrel & ethinyl                                        MO
                                                     3            1
estradiol) TABS OR 0.15-30 MCG, MG
ORTHO-CYCLEN (norgestimate-ethinyl                                          MO
                                                     3            1
estradiol) TABS OR 0.25-35 MCG, MG
ORTHO-CYCLEN-28 (norgestimate-ethinyl                                       MO
                                                     3            1
estradiol) TABS OR 0.25-35 MCG, MG
ORTHO-NOVUM 1/35-28 (norethindrone &                                        MO
                                                     3            1
eth estradiol) TABS OR 1-35 MCG, MG
ORTHO-NOVUM 1/50-28 (norethindrone &                                        MO
                                                     3            1
mestranol) TABS OR 1-50 MCG, MG
ORTHO-NOVUM 10/11-28 TABS OR 35                                             MO
                                                     2
MCG
ORTHO-NOVUM 7/7/7 (norethindrone-eth                                        MO
                                                     3            1
estradiol (triphasic)) TABS OR
ORTHO-NOVUM 7/7/7-28 (norethindrone-eth                                     MO
                                                     3            1
estradiol (triphasic)) TABS OR
OVCON FE (norethindrone & ethinyl                                           MO
                                                     3            1
estradiol-fe) CHEW OR 0.4-35 MCG, MG
OVCON-35 (norethindrone & eth estradiol)                                    MO
                                                     3            1
TABS OR 0.4-35 MCG, MG
OVCON-50 28 TABS OR 1-50 MCG, MG                     2                      MO

philith tabs or                                                   1         MO

portia-28 tabs or 0.03-0.15 mg                                    1         MO

SAFYRAL TABS OR 0.03-0.451-3 MG                      3                      MO

SEASONALE (levonorgestrel-ethinyl estradiol                                 QL; MO
                                                     3            1
(91-day)) TABS OR 0.03-0.15 MG
SEASONIQUE (levonorgestrel-ethinyl                                          QL; MO
                                                     3            1
estradiol (91-day)) TABS OR
TRI-NORINYL 28 (norethindrone-eth                                           MO
                                                     3            1
estradiol (triphasic)) TABS OR
trivora-28 tabs or                                                1         MO

vestura tabs or                                                   1         MO

viorele tabs or                                                   1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy




 www.healthnet.com                                                                   101
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
YASMIN 28 (drospirenone-ethinyl estradiol)                                  MO
                                                     3            1
TABS OR 0.03-3 MG
YAZ (drospirenone-ethinyl estradiol) TABS                                   MO
                                                     2            1
OR 0.02-3 MG
Combination Contraceptives - Transdermal
ORTHO EVRA PTWK TD 150-20 MCG/24HR                   2                      MO

Combination Contraceptives - Vaginal
NUVARING RING VA 0.015-0.12 MG/24HR                  2                      MO

Emergency Contraceptives
ELLA TABS OR 30 MG                                   3
PLAN B (levonorgestrel (emergency oc))               3            1
TABS OR 0.75 MG
PLAN B ONE-STEP TABS OR 1.5 MG                       3
Progestin Contraceptives - Implants
IMPLANON IMPL SC 68 MG                               4

NEXPLANON IMPL SC 68 MG                              4
 Progestin Contraceptives - Injectable
DEPO-PROVERA CONTRACEPTIVE                                                  QL; MO
(medroxyprogesterone acetate                         4            4
(contraceptive)) SUSP IM 150 MG/ML
DEPO-SUBQ PROVERA 104 SUSP SC 104                                           QL; MO
                                                     4
MG/0.65ML
 Progestin Contraceptives - Oral
NOR-QD (norethindrone (contraceptive))                                      MO
                                                     3            1
TABS OR 0.35 MG
ORTHO MICRONOR (norethindrone                                               MO
                                                     3            1
(contraceptive)) TABS OR 0.35 MG
CORTICOSTEROIDS
Glucocorticosteroids
ARISTOSPAN INTRA-ARTICULAR SUSP IJ                                          MO
                                                     3
20 MG/ML
baycadron elix or 0.5 mg/5ml                                      1         MO

CELESTONE SOLN OR 0.6 MG/5ML                         3                      MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                                   102
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
CELESTONE-SOLUSPAN (betamethasone                                           MO
sod phosphate & acetate) SUSP IJ 0.1-0.2-3           4            4
MG/ML
CORTEF (hydrocortisone) TABS OR 10 MG,                                      MO
                                                     3            1
20 MG, 5 MG
cortisone acetate tabs or 25 mg                                   1         MO

DEPO-MEDROL (methylprednisolone                                             MO
                                                     4            4
acetate) SUSP IJ 40 MG/ML, 80 MG/ML
DEPO-MEDROL SUSP IJ 20 MG/ML                         4                      MO

dexamethasone elix or 0.5 mg/5ml                                  1         MO

dexamethasone soln or 0.5 mg/5ml                                  1         MO

dexamethasone tabs or 0.5 mg, 0.75 mg, 1                                    MO
                                                                  1
mg, 1.5 mg, 2 mg, 4 mg, 6 mg
dexamethasone intensol conc or 1 mg/ml                            1         MO

dexamethasone sodium phosphate soln ij 10                                   MO
                                                                  4
mg/ml, 4 mg/ml
dexpak 10 day tabs or 1.5 mg                                      1         MO

dexpak 13 day tabs or 1.5 mg                                      1         MO

dexpak 6 day tabs or 1.5 mg                                       1         MO

ENTOCORT EC (budesonide) CP24 OR 3                                          MO
                                                     3            1
MG
FLO-PRED SUSP OR 15 MG/5ML                           3                      MO

KENALOG-10 (triamcinolone acetonide)                                        MO
                                                     4            4
SUSP IJ 10 MG/ML
KENALOG-40 (triamcinolone acetonide)                                        MO
                                                     4            4
SUSP IJ 40 MG/ML
MEDROL TABS OR 2 MG                                  2                      MO

MEDROL (methylprednisolone) TABS OR 16                                      MO
                                                     3            1
MG, 32 MG, 4 MG, 8 MG
MEDROL DOSEPAK (methylprednisolone)                                         MO
                                                     3            1
TABS OR 4 MG
millipred tabs or 5 mg                                            1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                               103
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
millipred soln or 10 mg/5ml                                      1

millipred dp tabs or 5 mg                                        1      MO

ORAPRED (prednisolone sodium phosphate)                                 MO
                                                    3            1
SOLN OR 15 MG/5ML
ORAPRED ODT TBDP OR 10 MG, 15 MG,                                       MO
                                                    3
30 MG
PEDIAPRED (prednisolone sodium                                          MO
                                                    3            1
phosphate) SOLN OR 6.7 MG/5ML
prednisolone soln or 15 mg/5ml                                   1      MO

prednisolone syrp or 5 mg/5ml                                    1

prednisolone syrp or 15 mg/5ml                                   1      MO

prednisolone tabs or 5 mg                                        1      MO

prednisolone sodium phosphate soln or 5                                 MO
                                                                 1
mg/5ml
prednisone soln or 5 mg/5ml                                      1      MO

prednisone tabs or 1 mg, 10 mg, 2.5 mg, 20                              MO
                                                                 1
mg, 5 mg, 50 mg
prednisone intensol conc or 5 mg/ml                              1      MO

SOLU-CORTEF (hydrocortisone sod                     4            4
succinate) SOLR IJ 500 MG
SOLU-CORTEF (hydrocortisone sod                                         MO
                                                    4            4
succinate) SOLR IJ 100 MG
SOLU-CORTEF SOLR IJ 1000 MG                         4

SOLU-CORTEF SOLR IJ 250 MG                          4                   MO

SOLU-MEDROL (methylprednisolone sod                                     MO
succ) SOLR IJ 1 GM, 1000 MG, 125 MG, 40             4            4
MG, 500 MG
SOLU-MEDROL SOLR IJ 2 GM                            4

STERAPRED (prednisone) TABS OR 5 MG                 3            1      MO

STERAPRED 12 DAY (prednisone) TABS                                        MO
                                                      3           1
OR 5 MG
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                             104
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
STERAPRED DS (prednisone) TABS OR 10                                        MO
                                                     3            1
MG
STERAPRED DS 12 DAY (prednisone) TABS                                       MO
                                                     3            1
OR 10 MG
veripred 20 soln or 20 mg/5ml                                     1         MO

zema-pak 10 day tabs or 1.5 mg                                    1         MO

zema-pak 13 day tabs or 1.5 mg                                    1         MO

zema-pak 6 day tabs or 1.5 mg                                     1         MO

Mineralocorticoids
fludrocortisone acetate tabs or 0.1 mg                            1         MO

COUGH/COLD/ALLERGY
Cough/Cold/Allergy Combinations
CLARINEX-D 12 HOUR TB12 OR 120-2.5                                          MO
                                                     3
MG
CLARINEX-D 24 HOUR TB24 OR 240-5 MG                  3                      MO

promethazine vc syrp or 5-6.25 mg/5ml                             1         MO

promethazine vc plain syrp or 5-6.25 mg/5ml                       1         MO

SEMPREX-D CAPS OR , 60-8 MG                          3                      MO

Mucolytics
acetylcysteine soln in 20 %                                       1         MO; B/D

MUCOMYST-10 (acetylcysteine) SOLN IN 10                                     MO; B/D
                                                     3            1
%
DERMATOLOGICALS
Acne Products
ACANYA GEL EX 1.2-2.5 %                              3                      MO

ACCUTANE (isotretinoin) CAPS OR 10 MG,               3            1
20 MG, 40 MG
AKNE-MYCIN OINT EX 2 %                               3                      MO

ATRALIN GEL EX 0.05 %                                3                      MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                                    105
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
AZELEX CREA EX 20 %                                  3                      MO

BENZACLIN (clindamycin phosphate-benzoyl                                    MO
                                                     3            1
peroxide) GEL EX 1-5 %
BENZACLIN CARE KIT KIT EX 1-5 %                      3
BENZACLIN WITH PUMP (clindamycin                                            MO
                                                     3            1
phosphate-benzoyl peroxide) GEL EX 1-5 %
BENZAMYCIN GEL EX 16-3-5 %                           3                      MO

claravis caps or 30 mg                                            1
CLEOCIN-T (clindamycin phosphate                                            MO
                                                     3            1
(topical)) GEL EX 1 %
CLEOCIN-T (clindamycin phosphate                                            MO
                                                     3            1
(topical)) LOTN EX 1 %
CLEOCIN-T (clindamycin phosphate                                            MO
                                                     3            1
(topical)) SOLN EX 1 %
CLEOCIN-T (clindamycin phosphate                                            MO
                                                     3            1
(topical)) SWAB EX 1 %
CLINDAGEL (clindamycin phosphate                                            MO
                                                     3            1
(topical)) GEL EX 1 %
DIFFERIN (adapalene) CREA EX 0.1 %                   3            1         MO

DIFFERIN (adapalene) GEL EX 0.1 %                    3            1         MO

DIFFERIN GEL EX 0.3 %                                3                      MO

DIFFERIN LOTN EX 0.1 %                               3                      MO

DUAC GEL EX 1-5 %                                    3                      MO

emcin clear pads ex 2 %                                           1         MO

EPIDUO GEL EX 0.1-2.5 %                              3                      MO

ery pads ex 2 %                                                   1         MO

eryderm soln ex 2 %                                               1         MO

ERYGEL (erythromycin (acne aid)) GEL EX 2                                   MO
                                                     3            1
%
erythromycin pads ex 2 %                                          1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                               106
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
erythromycin soln ex 2 %                                          1         MO

erythromycin/benzoyl peroxide gel ex , 3-5 %                      1         MO

EVOCLIN (clindamycin phosphate (topical))                                   MO
                                                     3            1
FOAM EX 1 %
KLARON (sulfacetamide sodium (acne))                                        MO
                                                     3            1
LOTN EX 10 %
RETIN-A (tretinoin) CREA EX 0.025 %, 0.05                                   MO
                                                     3            1
%, 0.1 %
RETIN-A (tretinoin) GEL EX 0.01 %, 0.025 %           3            1         MO

RETIN-A MICRO GEL EX 0.04 %, 0.1 %                   3                      MO

RETIN-A MICRO PUMP GEL EX 0.04 %, 0.1                                       MO
                                                     3
%
sotret caps or 30 mg                                              1

sulfacetamide sodium susp ex 10 %                                 1         MO

tretinoin crea ex 0.25 %, 0.5 %                                   1         MO

tretinoin gel ex 0.1 %, 0.25 %                                    1         MO

VELTIN GEL EX 0.025-1.2 %                            3                      MO

ZIANA GEL EX 0.025-1.2 %                             3                      MO

Agents for External Genital and Perianal Warts
VEREGEN OINT EX 15 %                                 3                      MO

Anti-inflammatory Agents - Topical
FLECTOR PTCH TD 1.3 %                                3                      MO

PENNSAID SOLN TD 1.5 %                               3                      MO

VOLTAREN GEL TD 1 %                                  3                      MO

Antibiotics - Topical
ALTABAX OINT EX 1 %                                  3                      MO

BACTROBAN (mupirocin) OINT EX 2 %                    3            1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                               107
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
BACTROBAN CREA EX 2 %                                3                      MO

CORTISPORIN OINT EX 0.5-1-400-5000 %,                                       MO
                                                     2
UNIT/GM
CORTISPORIN CREA EX 0.5-10000 %,                                            MO
                                                     2
UNIT/GM
gentamicin sulfate crea ex 0.1 %                                  1         MO

gentamicin sulfate oint ex 0.1 %                                  1         MO

Antifungals - Topical
ciclopirox olamine crea ex 0.77 %                                 1         MO

clotrimazole crea ex 1 %                                          1         MO

clotrimazole soln ex 1 %                                          1         MO

ERTACZO CREA EX 2 %                                  3                      MO

EXELDERM CREA EX 1 %                                 3                      MO

EXELDERM SOLN EX 1 %                                 3                      MO

EXTINA (ketoconazole (topical)) FOAM EX 2                                   MO
                                                     3            1
%
ketoconazole crea ex 2 %                                          1         MO

kuric crea ex 2 %                                                 1         MO

LAMISIL SOLN EX 1 %                                  2                      MO

LOPROX (ciclopirox) GEL EX 0.77 %                    3            1         MO

LOPROX (ciclopirox olamine) SUSP EX 0.77             3            1         MO
%
LOPROX SHAMPOO (ciclopirox) SHAM EX 1                                       MO
                                                     3            1
%
LOTRISONE (clotrimazole w/                                                  MO
                                                     3            1
betamethasone) CREA EX 0.05-1 %
LOTRISONE (clotrimazole w/                                                  MO
                                                     3            1
betamethasone) LOTN EX 0.05-1 %
MENTAX CREA EX 1 %                                   2                      MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                               108
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
MYCOSTATIN (nystatin (topical)) CREA EX                                     MO
                                                     3            1
100000 UNIT/GM
NAFTIN CREA EX 1 %, 2 %                              3                      MO

NAFTIN GEL EX 1 %                                    3                      MO

NAFTIN-MP CREA EX 1 %                                3                      MO

NIZORAL (ketoconazole (topical)) SHAM EX                                    MO
                                                     3            1
2%
nyamyc powd ex 100000 unit/gm                                     1         MO

nystatin oint ex 100000 unit/gm                                   1         MO

nystatin powd ex 100000 unit/gm                                   1         MO

nystatin/triamcinolone crea ex 0.1-100000 %,                      1
unit/gm
nystatin/triamcinolone crea ex 0.1-100000 %,                                MO
                                                                  1
unit/gm
nystatin/triamcinolone oint ex 0.1-100000 %,                      1
unit/gm
nystatin/triamcinolone oint ex 0.1-100000 %,                                MO
                                                                  1
unit/gm
nystop powd ex 100000 unit/gm                                     1         MO

OXISTAT CREA EX 1 %                                  3                      MO

OXISTAT LOTN EX 1 %                                  3                      MO

pedi-dri powd ex 100000 unit/gm                                   1         MO

PENLAC NAIL LACQUER (ciclopirox) SOLN                                       MO
                                                     3            1
EX 8 %
SPECTAZOLE (econazole nitrate) CREA EX                                      MO
                                                     3            1
1%
VUSION OINT EX 0.25-15-81.35 %                       3                      MO

XOLEGEL GEL EX 2 %                                   3                      MO

Antineoplastic or Premalignant Lesion Agents - Topical
CARAC CREA EX 0.5 %                                  2                      MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                               109
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
EFUDEX (fluorouracil (topical)) CREA EX 5                                   MO
                                                     3            1
%
EFUDEX (fluorouracil (topical)) SOLN EX 2                                   MO
                                                     3            1
%, 5 %
FLUOROPLEX CREA EX 1 %                               2                      MO

PANRETIN GEL EX 0.1 %                                5                      MO

PICATO GEL EX 0.015 %, 0.05 %                        3                      MO

SOLARAZE GEL EX 3 %                                  2                      MO

SOLARAZE GEL TD 3 %                                  2                      MO

TARGRETIN GEL EX 1 %                                 5
Antipruritics - Topical
PRUDOXIN CREA EX 5 %                                 3                      MO

ZONALON CREA EX 5 %                                  3                      MO

Antipsoriatics
8-MOP CAPS OR 10 MG                                  2                      MO

AMEVIVE SOLR IM 15 MG                                5                      PA; LA

CALCITRIOL OINT EX 3 MCG/GM                          2                      MO

DOVONEX CREA EX 0.005 %                              2                      MO

DOVONEX (calcipotriene) OINT EX 0.005 %              2            1         MO

DOVONEX (calcipotriene) SOLN EX 0.005 %              3            1         MO

DOVONEX SCALP (calcipotriene) SOLN EX                                       MO
                                                     3            1
0.005 %
OXSORALEN ULTRA CAPS OR 10 MG                        2                      MO

SORIATANE CAPS OR 10 MG, 17.5 MG,                                           MO
                                                     5
22.5 MG, 25 MG
SORIATANE CK KIT CO 10 MG                            3

SORIATANE CK KIT CO 25 MG                            5
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                                   110
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
STELARA SOLN SC 45 MG/0.5ML, 90                                             PA; QL
                                                     5
MG/ML
TAZORAC CREA EX 0.05 %, 0.1 %                        2                      MO

TAZORAC GEL EX 0.05 %, 0.1 %                         2                      MO

VECTICAL OINT EX 3 MCG/GM                            2                      MO

Antiseborrheic Products
SELSUN SHAMPOO (selenium sulfide)                                           MO
                                                     3            1
LOTN EX 2.5 %
Antivirals - Topical
DENAVIR CREA EX 1 %                                  2                      MO

XERESE CREA EX 1-5 %                                 3                      MO

ZOVIRAX CREA EX 5 %                                  2                      MO

ZOVIRAX OINT EX 5 %                                  2                      MO

Burn Products
SILVADENE (silver sulfadiazine) CREA EX 1                                   MO
                                                     3            1
%
SULFAMYLON CREA EX 85 MG/GM                          3                      MO

SULFAMYLON PACK EX 50 GM                             3                      MO

Corticosteroids - Topical
ACLOVATE (alclometasone dipropionate)                                       MO
                                                     3            1
CREA EX 0.05 %
ACLOVATE (alclometasone dipropionate)                                       MO
                                                     3            1
OINT EX 0.05 %
ala cort crea ex 1 %                                              1         MO

ALA SCALP (hydrocortisone (topical)) LOTN                                   MO
                                                     3            1
EX 2 %
ala-cort lotn ex 1 %                                              1         MO

alphatrex gel ex 0.05 %                                           1         MO

amcinonide lotn ex 0.1 %                                          1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                                   111
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
amcinonide oint ex 0.1 %                                          1         MO

apexicon oint ex 0.05 %                                           1         MO

ARISTOCORT A (triamcinolone acetonide                                       MO
                                                     3            1
(topical)) CREA EX 0.1 %
ARISTOCORT A (triamcinolone acetonide                                       MO
                                                     3            1
(topical)) OINT EX 0.1 %
augmented betamethasone dipropionate gel                                    MO
                                                                  1
ex 0.05 %
beta-val crea ex 0.1 %                                            1         MO

beta-val lotn ex 0.1 %                                            1         MO

betamethasone dipropionate crea ex 0.05 %                         1         MO

betamethasone dipropionate lotn ex 0.05 %                         1         MO

betamethasone dipropionate oint ex 0.05 %                         1         MO

betamethasone dipropionate gel ex 0.05 %                          1         MO

betamethasone valerate crea ex 0.1 %                              1         MO

betamethasone valerate lotn ex 0.1 %                              1         MO

betamethasone valerate oint ex 0.1 %                              1         MO

CAPEX SHAM EX 0.01 %                                 3                      MO

CARMOL-HC (urea-hc acetate) CREA EX 1-                                      MO
                                                     3            1
10 %
cetacort lotn ex 1 %                                              1         MO

CLOBEX LIQD EX 0.05 %                                3                      MO

CLOBEX (clobetasol propionate) LOTN EX                                      MO
                                                     3            1
0.05 %
CLOBEX LOTN EX 0.5 %                                 3                      MO

CLOBEX (clobetasol propionate) SHAM EX                                      MO
                                                     3            1
0.05 %
CLODERM CREA EX 0.1 %                                3                      MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                               112
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
CLODERM PUMP CREA EX 0.1 %                           3                      MO

CORDRAN LOTN EX 0.05 %, 0.5 %                        3                      MO

CORDRAN SP CREA EX 0.05 %                            3                      MO

CORDRAN TAPE TAPE EX 4 MCG/SQCM                      3                      MO

CUTIVATE (fluticasone propionate) CREA                                      MO
                                                     3            1
EX 0.05 %
CUTIVATE (fluticasone propionate) LOTN EX                                   MO
                                                     3            1
0.05 %
CUTIVATE (fluticasone propionate) OINT EX                                   MO
                                                     3            1
0.005 %
CYCLOCORT (amcinonide) CREA EX 0.1 %                 3            1         MO

del-beta lotn ex 0.05 %                                           1         MO

DERMA-SMOOTHE/FS BODY OIL                                                   MO
                                                     3            1
(fluocinolone acetonide) OIL EX 0.01 %
DERMA-SMOOTHE/FS SCALP OIL                                                  MO
                                                     3            1
(fluocinolone acetonide) OIL EX 0.01 %
DERMATOP (prednicarbate) CREA EX 0.1 %               3            1         MO

DERMATOP (prednicarbate) OINT EX 0.1 %               3            1         MO

DESONATE GEL EX 0.05 %                               3                      MO

desonide lotn ex 0.05 %                                           1         MO

DESOWEN (desonide) CREA EX 0.05 %                    3            1         MO

desowen lotn ex 0.05 %                                            1         MO

DESOWEN (desonide) OINT EX 0.05 %                    3            1         MO

DESOWEN CREAM/CETAPHIL LOTION KIT                                           MO
                                                     3
EX 0.05 %
DESOWEN LOTION/CETAPHIL CREAM KIT                    3
EX 0.05 %
DESOWEN OINTMENT/CETAPHIL LOTION                     3
KIT EX 0.05 %
desoximetasone crea ex 0.05 %                                     1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                               113
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
DESOXIMETASONE OINT EX 0.05 %                        3                      MO

diflorasone diacetate crea ex 0.05 %                              1

diflorasone diacetate crea ex 0.05 %                              1         MO

diflorasone diacetate oint ex 0.05 %                              1         MO

DIPROLENE GEL EX 0.5 %                               3                      MO

DIPROLENE (betamethasone dipropionate                                       MO
                                                     3            1
augmented) LOTN EX 0.05 %
DIPROLENE (betamethasone dipropionate                                       MO
                                                     3            1
augmented) OINT EX 0.05 %
DIPROLENE AF (betamethasone                                                 MO
                                                     3            1
dipropionate augmented) CREA EX 0.05 %
ELOCON (mometasone furoate) CREA EX                                         MO
                                                     3            1
0.1 %
ELOCON LOTN EX 0.1 %                                 3                      MO

ELOCON (mometasone furoate) OINT EX 0.1                                     MO
                                                     3            1
%
embeline crea ex 0.5 %                                            1         MO

embeline gel ex 0.5 %                                             1         MO

embeline oint ex 0.5 %                                            1         MO

embeline soln ex 0.5 %                                            1         MO

embeline e crea ex 0.5 %                                          1         MO

EPIFOAM FOAM EX 1 %                                  3                      MO

fluocinolone acetonide crea ex 0.01 %                             1         MO

fluticasone propionate crea ex 0.5 %                              1         MO

HALOG CREA EX 0.1 %                                  3                      MO

HALOG OINT EX 0.1 %                                  3                      MO

hydrocortisone crea ex 1 %                                        1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                               114
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
hydrocortisone lotn ex 1 %                                        1         MO

hydrocortisone oint ex 1 %, 2.5 %                                 1         MO

hydrocortisone in absorbase oint ex 1 %                           1         MO

HYTONE (hydrocortisone (topical)) CREA EX                                   MO
                                                     3            1
2.5 %
HYTONE (hydrocortisone (topical)) LOTN EX                                   MO
                                                     3            1
2.5 %
HYTONE OINT EX 2 %                                   3                      MO

KENALOG AERS EX                                      2                      MO

KENALOG (triamcinolone acetonide (topical))                                 MO
                                                     3            1
CREA EX 0.1 %
KENALOG (triamcinolone acetonide (topical))                                 MO
                                                     3            1
LOTN EX 0.1 %
KENALOG (triamcinolone acetonide (topical))                                 MO
                                                     3            1
OINT EX 0.1 %
lacticare-hc lotn ex 1 %, 2 %                                     1         MO

LIDEX (fluocinonide) CREA EX 0.05 %                  3            1         MO

LIDEX (fluocinonide) GEL EX 0.05 %                   3            1         MO

LIDEX (fluocinonide) OINT EX 0.05 %                  3            1         MO

LIDEX (fluocinonide) SOLN EX 0.05 %                  3            1         MO

LIDEX-E (fluocinonide emulsified base)                                      MO
                                                     3            1
CREA EX 0.05 %
LOCOID (hydrocortisone butyrate) CREA EX                                    MO
                                                     3            1
0.1 %
LOCOID LOTN EX 0.1 %                                 3                      MO

LOCOID (hydrocortisone butyrate) OINT EX                                    MO
                                                     3            1
0.1 %
LOCOID (hydrocortisone butyrate) SOLN EX                                    MO
                                                     3            1
0.1 %
LOCOID LIPOCREAM CREA EX 0.1 %                       2                      MO

lokara lotn ex 0.05 %                                             1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               115
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
LUXIQ FOAM EX 0.12 %                                 3                      MO

MAXIFLOR CREA EX 0.5 %                               3                      MO

MAXIFLOR OINT EX 0.5 %                               3                      MO

mometasone furoate soln ex 0.1 %                                  1         MO

nutracort lotn ex 1 %, 2 %                                        1         MO

OLUX (clobetasol propionate) FOAM EX 0.05                                   MO
                                                     3            1
%
OLUX-E FOAM EX 0.05 %                                3                      MO

PANDEL CREA EX 0.1 %                                 3                      MO

pramosone crea ex 1 %                                             1         MO

pramosone lotn ex 1 %, 1-2.5 %                                    1         MO

procto-kit crea ex 1 %                                            1         MO

PSORCON E (diflorasone diacetate emollient                                  MO
                                                    NF            1
base) CREA EX 0.05 %
SYNALAR (fluocinolone acetonide) CREA EX                                    MO
                                                     3            1
0.025 %
SYNALAR (fluocinolone acetonide) OINT EX                                    MO
                                                     3            1
0.025 %
SYNALAR (fluocinolone acetonide) SOLN EX                                    MO
                                                     3            1
0.01 %
TACLONEX OINT EX 0.005-0.064 %                       3                      MO

TACLONEX SCALP SUSP EX 0.005-0.064                                          MO
                                                      3
%
TEMOVATE (clobetasol propionate) CREA                                       MO
                                                      3           1
EX 0.05 %
TEMOVATE (clobetasol propionate) GEL EX                                     MO
                                                      3           1
0.05 %
TEMOVATE (clobetasol propionate) OINT EX                                    MO
                                                      3           1
0.05 %
TEMOVATE (clobetasol propionate) SOLN                                       MO
                                                      3           1
EX 0.05 %
TEMOVATE E (clobetasol propionate                                           MO
                                                      3           1
emollient base) CREA EX 0.05 %
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                               116
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
TEXACORT SOLN EX 2.5 %                              3

TEXACORT SOLN EX 2 %                                3                   MO

texacort soln ex 1 %                                             1

texacort soln ex 2.5 %                                           1      MO

TOPICORT (desoximetasone) CREA EX 0.25                                  MO
                                                    3            1
%
topicort crea ex 0.05 %                                          1      MO

TOPICORT (desoximetasone) GEL EX 0.05                                   MO
                                                    3            1
%
TOPICORT (desoximetasone) OINT EX 0.25                                  MO
                                                    3            1
%
TOPICORT OINT EX 0.05 %                             3                   MO

triamcinolone acetonide crea ex 0.025 %, 0.5                            MO
                                                                 1
%
triamcinolone acetonide lotn ex 0.025 %                          1      MO

triamcinolone acetonide oint ex 0.025 %, 0.5                            MO
                                                                 1
%
triamcinolone acetonide in absorbase oint ex                            MO
                                                                 1
0.05 %
trianex oint ex 0.05 %                                           1      MO

TRIDESILON CREA EX 0.5 %                            3                   MO

TRIDESILON OINT EX 0.5 %                            3                   MO

ULTRAVATE (halobetasol propionate) CREA                                 MO
                                                    3            1
EX 0.05 %
ULTRAVATE (halobetasol propionate) OINT                                 MO
                                                    3            1
EX 0.05 %
ULTRAVATE PAC (halobetasol propionate &                                 MO
                                                    3            1
ammonium lactate) KIT EX 0.05-12 %
VANOS CREA EX 0.1 %                                 3                   MO

VERDESO FOAM EX 0.05 %                              3                   MO

WESTCORT (hydrocortisone valerate) CREA                                   MO
                                                      3           1
EX 0.2 %
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                             117
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
WESTCORT (hydrocortisone valerate) OINT                                 MO
                                                    3            1
EX 0.2 %
 Emollients
LAC-HYDRIN (lactic acid (ammonium                                       MO
                                                    3            1
lactate)) CREA EX 12 %
LAC-HYDRIN (lactic acid (ammonium                                       MO
                                                    3            1
lactate)) LOTN EX 12 %
Enzymes - Topical
SANTYL OINT EX 250 UNIT/GM                          2                   MO

Immunomodulating Agents - Topical
ALDARA (imiquimod) CREA EX 5 %                      3            1      MO

ZYCLARA CREA EX 3.75 %                              3                   MO

ZYCLARA PUMP CREA EX 3.75 %                         3                   MO

Immunosuppressive Agents - Topical
ELIDEL CREA EX 1 %                                  3                   MO

PROTOPIC OINT EX 0.03 %, 0.1 %                      2                   MO

Keratolytic/Antimitotic Agents
CONDYLOX GEL EX 0.5 %                               2                   MO

CONDYLOX (podofilox) SOLN EX 0.5 %                  3            1      MO

CONDYLOXW/APPLICATORS (podofilox)                                       MO
                                                    3            1
SOLN EX 0.5 %
Local Anesthetics - Topical
EMLA (lidocaine-prilocaine) CREA EX 2.5 %           3            1      MO; B/D

lidocaine oint ex 5 %                                            1      MO

LIDODERM PTCH EX 5 %                                2                   MO

SYNERA PTCH EX 70 MG                                3                   MO

XYLOCAINE (lidocaine hcl) SOLN EX 4 %               3            1      MO

XYLOCAINE JELLY (lidocaine hcl) GEL EX 2                                  MO
                                                      3           1
%
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                                118
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
Pigmenting-Depigmenting Agents
OXSORALEN LOTN EX 1 %                                3                      MO

Rosacea Agents
FINACEA GEL EX 15 %                                  3                      MO

METROCREAM (metronidazole (topical))                                        MO
                                                     3            1
CREA EX 0.75 %
METROGEL GEL EX 1 %                                  2                      MO

METROGEL GEL EX 0.5 %                                3                      MO

METROLOTION (metronidazole (topical))                                       MO
                                                     3            1
LOTN EX 0.75 %
metronidazole gel ex 0.75 %                                       1         MO

NORITATE CREA EX 1 %                                 3                      MO

ORACEA CPDR OR 40 MG                                 3                      MO

rosadan gel ex 0.75 %                                             1         MO

Scabicides & Pediculicides
ELIMITE (permethrin) CREA EX 5 %                     3            1         MO

EURAX CREA EX 10 %                                   2                      MO

EURAX LOTN EX 10 %                                   2                      MO

lindane lotn ex 1 %                                               1         MO

lindane sham ex 1 %                                               1         MO

OVIDE (malathion) LOTN EX 0.5 %                      3            1         MO

OVIDE LOTN EX 0.5-78 %                               3                      MO

ULESFIA LOTN EX 5 %                                  3                      MO

Wound Care Products
REGRANEX GEL EX 0.01 %                               5                      MO

DIGESTIVE AIDS
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               119
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
Digestive Enzymes
CREON CPEP OR 12000-38000-60000                                         MO
UNIT, 120000-24000-76000 UNIT, 15000-               2
3000-9500 UNIT, 19000-30000-6000 UNIT
PANCREAZE CPEP OR 10000-17500-4200                                      MO
UNIT, 10500-25000-43750 UNIT, 16800-                2
40000-70000 UNIT, 21000-37000-61000
UNIT
PANCRELIPASE CPEP OR 17000-27000-                                       MO
                                                    2
5000 UNIT
SUCRAID SOLN OR 8500 UNIT/ML                        2                   LA

ZENPEP CPEP OR 10000-16000-3000                                         MO
UNIT, 10000-34000-55000 UNIT, 109000-
20000-68000 UNIT, 136000-25000-85000                2
UNIT, 15000-51000-82000 UNIT, 17000-
27000-5000 UNIT
DIURETICS
Carbonic Anhydrase Inhibitors
acetazolamide tabs or 125 mg, 250 mg                             1      MO

acetazolamide sodium solr ij 500 mg                              4

DIAMOX (acetazolamide) CP12 OR 500 MG               3            1      MO

methazolamide tabs or 25 mg, 50 mg                               1      MO

neptazane tabs or 25 mg, 50 mg                                   1      MO

Diuretic Combinations
ALDACTAZIDE TABS OR 50 MG                           2                   MO

ALDACTAZIDE (spironolactone &                                           MO
                                                    3            1
hydrochlorothiazide) TABS OR 25 MG
amiloride/hydrochlorothiazide tabs or 5-50 mg                    1      MO

DYAZIDE (triamterene & hydrochlorothiazide)                               MO
                                                      3           1
CAPS OR 25-37.5 MG
MAXZIDE (triamterene &                                                    MO
                                                      3           1
hydrochlorothiazide) TABS OR 50-75 MG
MAXZIDE-25 (triamterene &                                                 MO
                                                      3           1
hydrochlorothiazide) TABS OR 25-37.5 MG
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                             120
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
triamterene/hydrochlorothiazide caps or 25-                             MO
                                                                 1
50 mg
Loop Diuretics
bumetanide soln ij 0.25 mg/ml, 0.5 mg/ml                         4
DEMADEX (torsemide) TABS OR 10 MG,                                      MO
                                                    3            1
100 MG, 20 MG, 5 MG
EDECRIN TABS OR 25 MG                               3                   MO

furosemide soln ij 10 mg/ml                                      4      MO

furosemide soln or 10 mg/ml, 8 mg/ml                             1      MO

LASIX (furosemide) TABS OR 20 MG, 40                                    MO
                                                    3            1
MG, 80 MG
SODIUM EDECRIN SOLR IV 50 MG                        4

torsemide soln iv 20 mg/2ml                                      4

torsemide soln iv 50 mg/5ml                                      4      MO

Osmotic Diuretics
mannitol soln iv 25 %                                            4      MO

Potassium Sparing Diuretics
ALDACTONE (spironolactone) TABS OR 100                                  MO
                                                    3            1
MG, 25 MG, 50 MG
DYRENIUM CAPS OR 100 MG, 50 MG                      3                   MO

MIDAMOR (amiloride hcl) TABS OR 5 MG                3            1      MO

Thiazides and Thiazide-Like Diuretics
chlorothiazide tabs or 250 mg, 500 mg                            1      MO

chlorthalidone tabs or 25 mg, 50 mg                              1      MO

DIURIL SUSP OR 250 MG/5ML                           2                   MO

DIURIL IV (chlorothiazide sodium) SOLR IV             4           4
500 MG
hydrochlorothiazide tabs or 12.5 mg, 25 mg,                               MO
                                                                  1
50 mg
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                             121
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
indapamide tabs or 1.25 mg, 1.5 mg, 2 mg,                               MO
                                                                 1
2.5 mg
methyclothiazide tabs or 5 mg                                    1      MO

MICROZIDE (hydrochlorothiazide) CAPS OR                                 MO
                                                    3            1
12.5 MG
THALITONE TABS OR 15 MG                             2                   MO

ZAROXOLYN (metolazone) TABS OR 10                                       MO
                                                    3            1
MG, 2.5 MG, 5 MG
ZAROXOLYN TABS OR 2 MG                              3                   MO

ENDOCRINE AND METABOLIC AGENTS - MISC.
Bone Density Regulators
ACTONEL TABS OR 75 MG                               2
ACTONEL TABS OR 150 MG, 30 MG, 35                                       MO
                                                    2
MG, 5 MG
ACTONEL WITH CALCIUM TABS OR 1250-                  2
35 MG
AREDIA (pamidronate disodium) SOLR IV 30                                MO; B/D
                                                    4            4
MG, 90 MG
ATELVIA TBEC OR 35 MG                               2                   MO

BONIVA SOLN IV 3 MG/3ML                             4                   QL; MO; B/D

BONIVA (ibandronate sodium) TABS OR 150                                 MO; B/D
                                                    2            1
MG
DIDRONEL (etidronate disodium) TABS OR                                  MO
                                                    3            1
400 MG
etidronate disodium tabs or 200 mg                               1

etidronate disodium tabs or 200 mg                               1      MO

FORTEO SOLN SC 600 MCG/2.4ML, 750                   2
MCG/3ML
fortical soln na 200 unit/act                                    1      MO

FOSAMAX SOLN OR 70 MG/75ML                          2
FOSAMAX (alendronate sodium) TABS OR                                      MO
                                                      3           1
10 MG, 35 MG, 40 MG, 5 MG, 70 MG
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                                    122
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
FOSAMAX PLUS D TABS OR 2800-70 MG,                                          MO
                                                     3
UNIT, 5600-70 MG, UNIT
MIACALCIN SOLN IJ 200 UNIT/ML                        4                      MO; B/D

MIACALCIN (calcitonin (salmon)) SOLN NA              3            1
200 UNIT/ACT
PAMIDRONATE DISODIUM (pamidronate                                           B/D
                                                     4            4
disodium) SOLN IV 90 MG/10ML
PAMIDRONATE DISODIUM (pamidronate                                           MO; B/D
                                                     4            4
disodium) SOLN IV 30 MG/10ML
pamidronate disodium soln iv 6 mg/ml                              4         MO; B/D

PROLIA SOLN SC 60 MG/ML                              4                      QL

RECLAST SOLN IV 5 MG/100ML                           4                      QL

SKELID TABS OR 200 MG                                2

XGEVA SOLN SC 120 MG/1.7ML                           5

ZOMETA CONC IV 4 MG/5ML                              5

ZOMETA SOLN IV 4 MG/100ML                            5
Corticotropin
ACTHAR HP GEL IJ 80 UNIT/ML                          5
Fertility Regulators
chorex-10 solr im 10000 unit                                      4

chorionic gonadotropin solr im 10000 unit                         4

novarel solr im 10000 unit                                        4
pregnyl w/diluent benzylalcohol/nacl solr im                      4
10000 unit
Growth Hormone Receptor Antagonists
SOMAVERT SOLR SC 10 MG, 15 MG, 20                                           LA
                                                     5
MG
Growth Hormone Releasing Hormones (GHRH)
EGRIFTA SOLR SC 1 MG                                 5
Growth Hormones
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                                    123
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
GENOTROPIN SOLR SC 5 MG                              4

GENOTROPIN SOLR SC 12 MG                             5
GENOTROPIN MINIQUICK SOLR SC 0.2                     4
MG, 0.4 MG, 0.6 MG
GENOTROPIN MINIQUICK SOLR SC 0.8
MG, 1 MG, 1.2 MG, 1.4 MG, 1.6 MG, 1.8 MG,            5
2 MG
HUMATROPE SOLR IJ 6 MG                               4

HUMATROPE SOLR IJ 12 MG, 24 MG, 5 MG                 5

HUMATROPE COMBO PACK SOLR IJ 5 MG                    5
NORDITROPIN CARTRIDGE SOLN SC 5                      4
MG/1.5ML
NORDITROPIN CARTRIDGE SOLN SC 15                     5
MG/1.5ML
NORDITROPIN FLEXPRO SOLN SC 10                       4
MG/1.5ML, 5 MG/1.5ML
NORDITROPIN FLEXPRO SOLN SC 15                       5
MG/1.5ML
NORDITROPIN NORDIFLEX PEN SOLN SC                    4
10 MG/1.5ML, 5 MG/1.5ML
NORDITROPIN NORDIFLEX PEN SOLN SC                    5
15 MG/1.5ML, 30 MG/3ML
NUTROPIN SOLR SC 5 MG                                4

NUTROPIN SOLR SC 10 MG                               5

NUTROPIN AQ SOLN SC 10 MG/2ML                        5
NUTROPIN AQ NUSPIN 10 SOLN SC 10                     5
MG/2ML
NUTROPIN AQ NUSPIN 20 SOLN SC 20                     5
MG/2ML
NUTROPIN AQ PEN SOLN SC 10 MG/2ML,                   5
20 MG/2ML
OMNITROPE SOLN SC 10 MG/1.5ML, 5                     4
MG/1.5ML
OMNITROPE SOLR SC 5.8 MG                             5
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                            124
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
SAIZEN SOLR IJ 5 MG, 8.8 MG                         5

SAIZEN CLICK.EASY SOLR IJ 8.8 MG                    5

SEROSTIM SOLR SC 4 MG, 5 MG, 6 MG                   5

SEROSTIM SOLR SC 8.8 MG                             5                   LA

TEV-TROPIN SOLR SC 5 MG                             4

ZORBTIVE SOLR SC 8.8 MG                             5                   LA

Hormone Receptor Modulators
EVISTA TABS OR 60 MG                                2                   MO

Insulin-Like Growth Factors (Somatomedins)
INCRELEX SOLN SC 40 MG/4ML                          4                   LA

LHRH/GnRH Agonist Analog Pituitary Suppressants
LUPRON DEPOT-PED KIT IM 11.25 MG, 15       4
MG, 7.5 MG
LUPRON DEPOT-PED KIT IM 11.25 MG, 30                                    QL; ; 3 Month Kit
                                           5
MG
SYNAREL SOLN NA 2 MG/ML                             5                   MO

Metabolic Modifiers
ALDURAZYME SOLN IV 2.9 MG/5ML                       5                   LA

BUPHENYL POWD OR                                    5                   MO

BUPHENYL TABS OR 500 MG                             5                   MO

CALCIJEX (calcitriol) SOLN IV 1 MCG/ML              4           4       B/D

CALCITRIOL SOLN IV 2 MCG/ML                         4                   B/D

CARNITOR (levocarnitine (metabolic                                        MO; B/D
                                                      4           4
modifiers)) SOLN IV 200 MG/ML
CARNITOR (levocarnitine (metabolic                                        MO; B/D
                                                      3           1
modifiers)) SOLN OR 1 GM/10ML
CARNITOR (levocarnitine (metabolic                                        MO; B/D
                                                      3           1
modifiers)) TABS OR 330 MG
Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
CARNITOR SF (levocarnitine (metabolic                                   MO; B/D
                                                    3            1
modifiers)) SOLN OR 1 GM/10ML
CYSTADANE POWD OR                                   3

ELAPRASE SOLN IV 6 MG/3ML                           5                   LA

FABRAZYME SOLR IV 5 MG                              5

FABRAZYME SOLR IV 35 MG                             5                   LA

HECTOROL CAPS OR 0.5 MCG, 1 MCG, 2.5                                    MO; B/D
                                                    3
MCG
HECTOROL SOLN IV 2 MCG/ML, 4                                            MO; B/D
                                                    4
MCG/2ML
KUVAN TBSO OR 100 MG                                5                   LA

LUMIZYME SOLR IV 50 MG                              5                   LA

MYOZYME SOLR IV 50 MG                               5                   LA

NAGLAZYME SOLN IV 1 MG/ML                           5                   LA

ORFADIN CAPS OR 10 MG, 2 MG, 5 MG                   2                   LA

ROCALTROL (calcitriol) CAPS OR 0.25                                     MO; B/D
                                                    3            1
MCG, 0.5 MCG
ROCALTROL (calcitriol) SOLN OR 1                                        MO; B/D
                                                    3            1
MCG/ML
SENSIPAR TABS OR 30 MG                              2

SENSIPAR TABS OR 60 MG, 90 MG                       5
ZEMPLAR CAPS OR 1 MCG, 2 MCG, 4                                         MO; B/D
                                                    2
MCG
ZEMPLAR SOLN IV 2 MCG/ML, 5 MCG/ML                  4                   MO; B/D

Posterior Pituitary Hormones
DDAVP (desmopressin acetate) SOLN IJ 4                                    MO
                                                      4           4
MCG/ML
DDAVP (desmopressin acetate) TABS OR                                      MO
                                                      3           1
0.1 MG, 0.2 MG
DDAVP (desmopressin acetate refrigerated)                                 MO
                                                      3           1
SOLN NA 0.01 %
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                                126
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
DDAVP (desmopressin acetate spray) SOLN                                     MO
                                                     3            1
NA 0.01 %
desmopressin acetate soln na 0.01 %, 0.1                                    MO
                                                                  1
mg/ml
minirin soln na 0.1 mg/ml                                         1         MO

STIMATE SOLN NA 1.5 MG/ML                            3
Prolactin Inhibitors
DOSTINEX (cabergoline) TABS OR 0.5 MG                3            1         MO

Somatostatic Agents
octreotide acetate soln ij 1000 mcg/5ml                           4
SANDOSTATIN (octreotide acetate) SOLN IJ             4            4
100 MCG/ML, 200 MCG/ML, 50 MCG/ML
SANDOSTATIN (octreotide acetate) SOLN IJ             5            5
1000 MCG/ML, 500 MCG/ML
SANDOSTATIN LAR DEPOT KIT IM 10 MG,                  5
20 MG, 30 MG
SOMATULINE DEPOT SOLN SC 120                         5
MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML
Vasopressin Receptor Antagonists
SAMSCA TABS OR 15 MG, 30 MG                          5

VAPRISOL SOLN IV 20-5 %, MG/100ML                    4
ESTROGENS
Estrogen Combinations
ACTIVELLA (estradiol & norethindrone                                        MO
                                                     3            1
acetate) TABS OR 0.1-0.5 MG, 0.5-1 MG
ANGELIQ TABS OR 0.5-1 MG                             3                      MO

CLIMARA PRO PTWK TD 0.015-0.045                                             MO
                                                      2
MG/DAY
COMBIPATCH PTTW TD 0.05-0.14                                                MO
                                                      3
MG/DAY, 0.05-0.25 MG/DAY
FEMHRT 1/5 (norethindrone acetate-ethinyl                                   MO
                                                      3           1
estradiol) TABS OR 1-5 MCG, MG
FEMHRT LOW DOSE TABS OR 0.5-2.5                                             MO
                                                      3
MCG, MG
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                               127
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
PREFEST TABS OR                                      3                      MO

PREMPHASE TABS OR 0.625-5 MG                         2                      MO

PREMPRO TABS OR 0.3-1.5 MG, 0.45-1.5                                        MO
                                                     2
MG, 0.625-2.5 MG, 0.625-5 MG
Estrogens
ALORA PTTW TD 0.025 MG/24HR, 0.05                                           MO
                                                     3
MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR
CENESTIN TABS OR 0.3 MG, 0.45 MG,                                           MO
                                                     3
0.625 MG, 0.9 MG, 1.25 MG
CLIMARA (estradiol) PTWK TD 0.025                                           MO
MG/24HR, 0.05 MG/24HR, 0.06 MG/24HR,                 3            1
0.075 MG/24HR, 0.1 MG/24HR, 37.5
MCG/24HR
DELESTROGEN (estradiol valerate) OIL IM                                     MO
                                                     4            4
10 MG/ML, 20 MG/ML, 40 MG/ML
depo-estradiol oil im 5 mg/ml                                     4         MO

DIVIGEL GEL TD 0.25 MG/0.25GM, 0.5                                          MO
                                                     3
MG/0.5GM, 1 MG/GM
ELESTRIN GEL TD 0.06 %                               3                      MO

ENJUVIA TABS OR 0.3 MG, 0.45 MG, 0.625                                      MO
                                                     3
MG, 0.9 MG, 1.25 MG
ESTRACE (estradiol) TABS OR 0.5 MG, 1                                       MO
                                                     3            1
MG, 2 MG
ESTRADERM PTTW TD 0.05 MG/24HR, 0.1                                         MO
                                                     3
MG/24HR
ESTRASORB EMUL TD 4.35 MG/1.74GM                     3                      MO

EVAMIST SOLN TD 1.53 MG/SPRAY                        3                      MO

FEMTRACE TABS OR 1.8 MG                              3

FEMTRACE TABS OR 0.45 MG, 0.9 MG                     3                      MO

GYNODIOL TABS OR 1.5 MG                              3
menest tabs or 0.3 mg, 0.625 mg, 1.25 mg,                                   MO
                                                                  1
2.5 mg
MENOSTAR PTWK TD 14 MCG/24HR                         3                      MO

Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
OGEN (estropipate) TABS OR 0.75 MG, 1.5                                 MO
                                                    3            1
MG, 3 MG
PREMARIN SOLR IJ 25 MG                              4                   MO

PREMARIN TABS OR 0.3 MG, 0.45 MG,                                       MO
                                                    2
0.625 MG, 0.9 MG, 1.25 MG
VIVELLE PTTW TD 0.05 MG/24HR, 0.1                                       MO
                                                    3
MG/24HR
VIVELLE-DOT PTTW TD 0.025 MG/24HR,                                      MO
0.0375 MG/24HR, 0.05 MG/24HR, 0.075                 3
MG/24HR, 0.1 MG/24HR
FLUOROQUINOLONES
Fluoroquinolones
AVELOX TABS OR 400 MG                               2                   MO

AVELOX SOLN IV 0.8-400 %, MG/250ML                  4

AVELOX ABC PACK TABS OR 400 MG                      2                   MO

CIPRO SUSR OR 5 GM/100ML, 500                                           MO
                                                    2
MG/5ML
CIPRO (ciprofloxacin hcl) TABS OR 250 MG,                               MO
                                                    3            1
500 MG, 750 MG
CIPRO I.V. (ciprofloxacin) SOLN IV 200                                  MO
                                                    4            4
MG/20ML, 400 MG/40ML
CIPRO I.V. SOLN IV 10 MG/ML, 400 MG                 4
CIPRO I.V.-IN D5W (ciprofloxacin in d5w)
SOLN IV 200-5 %, MG/100ML, 400-5 %,                 4            4
MG/200ML
CIPRO I.V.-IN D5W SOLN IV 200 MG/20ML,
                                                    4
200-5 %, MG, 400 MG/40ML, 400-5 %, MG
CIPRO XR (ciprofloxacin-ciprofloxacin hcl)                              MO
                                                    3            1
TB24 OR 1000 MG, 500 MG
CIPROFLOXACIN SOLN IV 1200 MG/120ML                 4

ciprofloxacin hcl tabs or 100 mg                                 1      MO

FACTIVE TABS OR 320 MG                              3                   MO

FLOXIN (ofloxacin) TABS OR 200 MG, 300                                    MO
                                                      3           1
MG, 400 MG
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
LEVAQUIN (levofloxacin) SOLN IV 25                   4            4
MG/ML
LEVAQUIN (levofloxacin) SOLN OR 25                                          MO
                                                     2            1
MG/ML
LEVAQUIN (levofloxacin) TABS OR 250 MG,                                     MO
                                                     2            1
500 MG, 750 MG
LEVAQUIN (levofloxacin in d5w) SOLN IV               4            4
250-5 %, MG/50ML, 5-500 %, MG/100ML
LEVAQUIN (levofloxacin in d5w) SOLN IV 5-                                   MO
                                                     4            4
750 %, MG/150ML
LEVAQUIN LEVA-PAK (levofloxacin) TABS                                       MO
                                                     2            1
OR 750 MG
LEVAQUIN PREMIX (levofloxacin in d5w)
SOLN IV 250-5 %, MG/50ML, 5-500 %,                   4            4
MG/100ML
NOROXIN TABS OR 400 MG                               3                      MO

PROQUIN XR TB24 OR 500 MG                            3
GASTROINTESTINAL AGENTS - MISC.
Gallstone Solubilizing Agents
ACTIGALL (ursodiol) CAPS OR 300 MG                   3            1         MO

chenodal tabs or 250 mg                                           5

URSO 250 (ursodiol) TABS OR 250 MG                   3            1         MO

URSO FORTE (ursodiol) TABS OR 500 MG                 3            1         MO

 Gastrointestinal Antiallergy Agents
GASTROCROM (cromolyn sodium                                                 MO
                                                     3            1
(mastocytosis)) CONC OR 100 MG/5ML
Gastrointestinal Chloride Channel Activators
AMITIZA CAPS OR 24 MCG, 8 MCG                        2                      MO

Gastrointestinal Stimulants
METOCLOPRAMIDE HCL (metoclopramide                                          MO
                                                     4            4
hcl) SOLN IJ 5 MG/ML
metoclopramide hcl soln or 10 mg/10ml, 5                                    MO
                                                                  1
mg/5ml
METOZOLV ODT TBDP OR 10 MG, 5 MG                     3                      MO

Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
REGLAN (metoclopramide hcl) SOLN IJ 5                                       MO
                                                     4            4
MG/ML
REGLAN (metoclopramide hcl) TABS OR 10                                      MO
                                                     3            1
MG, 5 MG
Inflammatory Bowel Agents
APRISO CP24 OR 0.375 GM                              2                      MO

ASACOL TBEC OR 400 MG                                2                      MO

ASACOL HD TBEC OR 800 MG                             2                      MO

AZULFIDINE (sulfasalazine) TABS OR 500                                      MO
                                                     3            1
MG
AZULFIDINE EN-TABS (sulfasalazine) TBEC                                     MO
                                                     3            1
OR 500 MG
CANASA SUPP RE 1000 MG                               2                      MO

CIMZIA KIT SC 200 MG, 200 MG/ML                      5                      PA

CIMZIA STARTER KIT KIT SC 200 MG/ML                  5                      PA

COLAZAL (balsalazide disodium) CAPS OR                                      MO
                                                     3            1
750 MG
DIPENTUM CAPS OR 250 MG                              3                      MO

LIALDA TBEC OR 1.2 GM                                2                      MO

PENTASA CPCR OR 250 MG, 500 MG                       3                      MO

REMICADE SOLR IV 100 MG                              5                      PA

ROWASA (mesalamine) ENEM RE 4 GM                     3            1         MO

ROWASA (mesalamine w/ cleanser) KIT RE                                      MO
                                                     3            1
4 GM
Intestinal Acidifiers
enulose soln or 10 gm/15ml                                        1         MO

generlac soln or 10 gm/15ml                                       1         MO

lactulose soln or 10 gm/15ml                                      1         MO

Irritable Bowel Syndrome (IBS) Agents
Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
LOTRONEX TABS OR 0.5 MG, 1 MG                       2                   MO

Peripheral Opioid Receptor Antagonists
RELISTOR KIT SC 12 MG/0.6ML                         4                   MO

RELISTOR SOLN SC 12 MG/0.6ML, 8                                         MO
                                                    4
MG/0.4ML
Phosphate Binder Agents
ELIPHOS (calcium acetate (phosphate                                     MO
                                                    2            1
binder)) TABS OR 667 MG
FOSRENOL CHEW OR 1000 MG, 250 MG,                                       MO
                                                    2
500 MG, 750 MG
PHOSLO (calcium acetate (phosphate                                      MO
                                                    3            1
binder)) CAPS OR 667 MG
PHOSLYRA SOLN OR 667 MG/5ML                         2                   MO

RENVELA PACK OR 0.8 GM, 2.4 GM                      2                   MO

RENVELA TABS OR 800 MG                              2                   MO

GENITOURINARY AGENTS - MISCELLANEOUS
Alkalinizers
potassium citrate tbcr or 1080 mg, 540 mg                        1      MO

potassium citrate er tbcr or 1080 mg, 540 mg                     1      MO

Cystinosis Agents
CYSTAGON CAPS OR 150 MG, 50 MG                      3
Genitourinary Irrigants
acetic acid 0.25% soln ir 0.25 %, 0.5 %                          1      MO

curity sterile saline soln ir 0.9 %                              1      MO

neomycin/polymyxin b sulfates soln ir 0.1-                                MO
                                                                  1
200000-40 %, mg/ml, unit/ml
NEOSPORIN GU IRRIGANT                                                     MO
(neomycin/polymyxin b gu) SOLN IR 200000-             3           1
40 MG/ML, UNIT/ML
RENACIDIN SOLN IR 0.023-0.198-3.177-                                      MO
                                                      3
6.602 GM/100ML
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
sodium chloride soln ir 0.9 %                                     1         MO

sodium chloride 0.9% soln ir 0.9 %                                1         MO

sodium chloride 0.9% soln ir 0.9 %                                1         MO

SORBITOL SOLN IR 3 %, 3.3 %                          3

sorbitol-mannitol soln ir 0.54-2.7 gm/100ml                       1
Interstitial Cystitis Agents
ELMIRON CAPS OR 100 MG                               3                      MO

RIMSO-50 (dimethyl sulfoxide) SOLN IS 50                                    MO
                                                     3            1
%
Prostatic Hypertrophy Agents
AVODART CAPS OR 0.5 MG                               2                      GL; MO

CARDURA XL TB24 OR 4 MG, 8 MG                        3                      MO

FLOMAX (tamsulosin hcl) CAPS OR 0.4 MG               3            1         MO

JALYN CAPS OR 0.4-0.5 MG                             2                      GL; MO

PROSCAR (finasteride) TABS OR 5 MG                   3            1         GL; MO

RAPAFLO CAPS OR 4 MG, 8 MG                           2                      MO

UROXATRAL (alfuzosin hcl) TB24 OR 10 MG              3            1         MO

GOUT AGENTS
Gout Agent Combinations
probenecid/colchicine tabs or , 0.5-500 mg                        1         MO

Gout Agents
ALOPRIM (allopurinol sodium) SOLR IV 500             4            4
MG
COLCRYS TABS OR 0.6 MG                               2                      MO

KRYSTEXXA SOLN IV 8 MG/ML                            5

ULORIC TABS OR 40 MG, 80 MG                          2                      MO

Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
ZYLOPRIM (allopurinol) TABS OR 100 MG,                                      MO
                                                     3            1
300 MG
Uricosurics
probenecid tabs or 500 mg                                         1         MO

HEMATOLOGICAL AGENTS - MISC.
Bradykinin B2 Receptor Antagonists
FIRAZYR SOLN SC 30 MG/3ML                            5
Complement Inhibitors
BERINERT KIT IV 500 UNIT                             5

CINRYZE SOLR IV 500 UNIT                             5                      LA

Hematorheologic Agents
TRENTAL (pentoxifylline) TBCR OR 400 MG              3            1         MO

Plasma Kallikrein Inhibitors
KALBITOR SOLN SC 10 MG/ML                            5
Platelet Aggregation Inhibitors
AGGRENOX CP12 OR 200-25 MG                           2                      MO

AGRYLIN (anagrelide hcl) CAPS OR 0.5 MG,                                    MO
                                                     3            1
1 MG
BRILINTA TABS OR 90 MG                               3                      MO

EFFIENT TABS OR 10 MG, 5 MG                          2                      MO

PERSANTINE (dipyridamole) TABS OR 25                                        MO
                                                     3            1
MG, 50 MG, 75 MG
PLAVIX (clopidogrel bisulfate) TABS OR 300           2            1
MG
PLAVIX (clopidogrel bisulfate) TABS OR 75                                   MO
                                                     2            1
MG
PLETAL (cilostazol) TABS OR 100 MG, 50                                      MO
                                                     3            1
MG
TICLID (ticlopidine hcl) TABS OR 250 MG              3            1         MO

Protamine
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
PROTAMINE SULFATE SOLN IV 10 MG/ML                   4                      MO

HEMATOPOIETIC AGENTS
Agents for Gaucher Disease
CEREDASE SOLN IV 80 UNIT/ML                          5                      LA

CEREZYME SOLR IV 400 UNIT                            5

CEREZYME SOLR IV 200 UNIT                            5                      LA

VPRIV SOLR IV 400 UNIT                               5

ZAVESCA CAPS OR 100 MG                               5                      LA

Agents for Sickle Cell Anemia
DROXIA CAPS OR 200 MG, 300 MG, 400                                          MO
                                                     3
MG
Hematopoietic Growth Factors
ARANESP ALBUMIN FREE SOLN IJ 100                                            PA; ; B/D
MCG/0.5ML, 100 MCG/ML, 25 MCG/0.42ML,                4
25 MCG/ML, 40 MCG/0.4ML, 40 MCG/ML,
60 MCG/0.3ML, 60 MCG/ML
ARANESP ALBUMIN FREE SOLN IJ 150                                            PA; ; B/D
MCG/0.3ML, 150 MCG/0.75ML, 200                       5
MCG/0.4ML, 200 MCG/ML, 300 MCG/0.6ML,
300 MCG/ML, 500 MCG/ML
ARANESP ALBUMIN FREE SURECLICK                                              PA; ; B/D
SOLN IJ 100 MCG/0.5ML, 25 MCG/0.42ML,                4
40 MCG/0.4ML, 60 MCG/0.3ML
ARANESP ALBUMIN FREE SURECLICK                                              PA; ; B/D
SOLN IJ 150 MCG/0.3ML, 200 MCG/0.4ML,                5
300 MCG/0.6ML, 500 MCG/ML
EPOGEN SOLN IJ 10000 UNIT/ML, 2000                                          PA; ; B/D
UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML,                4
4000 UNIT/ML
EPOGEN SOLN IJ 40000 UNIT/ML                         5                      PA; ; B/D

LEUKINE SOLN IJ 500 MCG/ML                           5                      PA

LEUKINE SOLR IV 250 MCG                              5                      PA

NEULASTA SOLN SC 6 MG/0.6ML                          5                      PA

Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
NEUMEGA SOLR SC 5 MG                                 2                      PA

NEUPOGEN SOLN IJ 300 MCG/0.5ML, 300                                         PA
                                                     5
MCG/ML, 480 MCG/0.8ML, 480 MCG/1.6ML
NPLATE SOLR SC 250 MCG, 500 MCG                      5
PROCRIT SOLN IJ 10000 UNIT/ML, 2000                                         PA; ; B/D
UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML,                2
4000 UNIT/ML, 40000 UNIT/ML
PROMACTA TABS OR 12.5 MG, 25 MG, 50                  5
MG, 75 MG
Stem Cell Mobilizers
MOZOBIL SOLN SC 24 MG/1.2ML                          5
HEMOSTATICS
Hemostatics - Systemic
amicar syrp or 25 %                                               1         MO

aminocaproic acid syrp or 25 %                                    1         MO

CYKLOKAPRON (tranexamic acid) SOLN IV                                       MO
                                                     2            1
100 MG/ML
LYSTEDA TABS OR 650 MG                               3                      MO

HYPNOTICS
Hypnotics - Tricyclic Agents
SILENOR TABS OR 3 MG, 6 MG                           2                      MO

Non-Barbiturate Hypnotics
AMBIEN (zolpidem tartrate) TABS OR 10                                       MO
                                                     3            1
MG, 5 MG
AMBIEN CR (zolpidem tartrate) TBCR OR                                       MO
                                                     2            1
12.5 MG, 6.25 MG
EDLUAR SUBL SL 10 MG, 5 MG                           3                      MO

LUNESTA TABS OR 1 MG, 2 MG, 3 MG                     3                      ST; MO

SONATA (zaleplon) CAPS OR 10 MG, 5 MG                3            1         MO

ZOLPIMIST SOLN OR 5 MG/ACT                           3                      MO

Selective Melatonin Receptor Agonists
Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
ROZEREM TABS OR 8 MG                                3                   MO

 LAXATIVES
 Laxative Combinations
COLYTE (peg 3350-kcl-sod bicarb-sod                                     MO
chloride-sod sulfate) SOLR OR 2.98-22.72-           3            1
240-5.84-6.72 GM
COLYTE-FLAVOR PACKS (peg 3350-kcl-sod                                   MO
bicarb-sod chloride-sod sulfate) SOLR OR            3            1
2.98-22.72-240-5.84-6.72 GM
COLYTE-FLAVOR PACKS SOLR OR 2.82-                   3
21.5-227.1-5.53-6.36 GM
GOLYTELY (peg 3350-kcl-sod bicarb-sod                                   MO
chloride-sod sulfate) SOLR OR 2.97-22.74-           3            1
236-5.86-6.74 GM
GOLYTELY SOLR OR 2.82-21.5-227.1-5.53-                                  MO
                                                    3
6.36 GM
HALFLYTELY BOWEL PREP KIT OR 0.74-                                      MO
                                                    2
2.86-210-5-5.6 GM, MG
HALFLYTELY BOWEL PREP/FLAVOR                                            MO
                                                    2
PACKS KIT OR 0.74-2.86-210-5-5.6 GM, MG
MOVIPREP SOLR OR 1.015-100-2.691-4.7-                                   MO
                                                    3
5.9-7.5 GM
NULYTELY (peg 3350-potassium chloride-                                  MO
sod bicarbonate-sod chloride) SOLR OR               3            1
1.48-11.2-420-5.72 GM
NULYTELY/FLAVOR PACKS (peg 3350-                                        MO
potassium chloride-sod bicarbonate-sod              3            1
chloride) SOLR OR 1.48-11.2-420-5.72 GM
SUPREP BOWEL PREP SOLN OR 1.6-17.5-                                     MO
                                                    3
3.13 GM/180ML
Laxatives - Miscellaneous
constulose soln or 10 gm/15ml                                    1      MO

KRISTALOSE PACK OR 20 GM                            3                   MO

kristalose pack or 10 gm                                         1      MO

lactulose soln or 10 gm/15ml, 20 gm/30ml                         1      MO

MIRALAX (polyethylene glycol 3350) PACK                                   MO
                                                      3           1
OR
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
MIRALAX (polyethylene glycol 3350) POWD                                     MO
                                                     3            1
OR
Saline Laxatives
OSMOPREP TABS OR 0.398-1.102 GM                      3                      MO

VISICOL TABS OR 0.398-1.102 GM                       3                      MO

 LOCAL ANESTHETICS-Parenteral
 Local Anesthetic Combinations
bupivacaine/epinephrine soln ij 0.1-0.25-1 %,                     4
:200000, mg/ml
bupivacaine/epinephrine soln ij 0.1-0.5-1 %,                                MO
                                                                  4
:200000, mg/ml
lidocaine/epinephrine soln ij 1-1.5 %,                            4
:200000, 1-2 %, :50000
lidocaine/epinephrine soln ij 1-2 %, :100000                      4         MO

MARCAINE/EPINEPHRINE (bupivacaine w/                                        MO
epinephrine) SOLN IJ 0.5-1 %, :200000,                4           4
MG/ML
MARCAINE/EPINEPHRINE SOLN IJ 0.25-                    4
0.5-1 %, :200000, MG/ML
MARCAINE/EPINEPHRINE SOLN IJ 0.5-1                                          MO
                                                      4
%, :200000, MG/ML
SENSORCAINE-MPF/EPINEPHRINE SOLN                      4
IJ 0.75-1 %, :200000
sensorcaine-mpf/epinephrine soln ij 0.25-1 %,                     4
:200000
sensorcaine-mpf/epinephrine soln ij 0.5-1 %,                                MO
                                                                  4
:200000
sensorcaine/epinephrine soln ij 0.25-1 %,                         4
:200000, mg/ml
sensorcaine/epinephrine soln ij 0.5-1 %,                                    MO
                                                                  4
:200000, mg
XYLOCAINE-MPF/EPINEPHRINE (lidocaine
w/ epinephrine) SOLN IJ 0.5-1-1.5 %,                  4           4
:200000, MG/ML, 0.5-1-2 %, :200000,
MG/ML
XYLOCAINE-MPF/EPINEPHRINE SOLN IJ                     4
0.5-1 %, :200000, MG
XYLOCAINE/EPINEPHRINE (lidocaine w/                   4           4
epinephrine) SOLN IJ 0.5-1 %, :200000
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
XYLOCAINE/EPINEPHRINE (lidocaine w/                                         MO
epinephrine) SOLN IJ 0.5-1 %, :100000,               4            4
MG/ML, 0.5-1-2 %, :100000, MG/ML, 1 %,
:100000
Local Anesthetics - Amides
bupivacaine hcl soln ij 0.5 %                                     4         MO

CARBOCAINE (mepivacaine hcl) SOLN IJ                 4            4
1.5 %, 2 %
CARBOCAINE (mepivacaine hcl) SOLN IJ 1                                      MO
                                                     4            4
%
lidocaine hcl/dextrose soln iv 5-7.5 %                            4
MARCAINE (bupivacaine hcl) SOLN IJ 0.25              4            4
%, 0.5 %
MARCAINE (bupivacaine hcl) SOLN IJ 0.25                                     MO
                                                     4            4
%, 0.5 %
MARCAINE SOLN IJ 0.5-1 %, MG/ML                      4                      MO

MARCAINE SPINAL (bupivacaine in                      4            4
dextrose) SOLN IT 0.75-8.25 %
MARCAINE W/O EPI (bupivacaine hcl) SOLN                                     MO
                                                     4            4
IJ 0.75 %
mepivacaine hcl soln ij 3 %                                       4
NAROPIN SOLN IJ 2 MG/ML, 5 MG/ML, 7.5                4
MG/ML
sensorcaine-mpf soln ij 0.25 %                                    4
XYLOCAINE (lidocaine hcl (local anesth.))            4            4
SOLN IJ 0.5 %
XYLOCAINE (lidocaine hcl (local anesth.))                                   MO
                                                     4            4
SOLN IJ 1 %, 2 %
XYLOCAINE-MPF (lidocaine hcl (local                  4            4
anesth.)) SOLN IJ 0.5 %, 1.5 %
XYLOCAINE-MPF (lidocaine hcl (local                                         MO
                                                     4            4
anesth.)) SOLN IJ 1 %, 2 %, 4 %
Local Anesthetics - Esters
NESACAINE (chloroprocaine hcl) SOLN IJ 2             4            4
%
NESACAINE SOLN IJ 10 MG/ML                           4
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
NESACAINE-MPF (chloroprocaine hcl) SOLN              4            4
IJ 2 %, 3 %
MACROLIDES
Azithromycin
azithromycin pack or 1 gm                                         1         MO

AZITHROMYCIN SOLR IV 500 MG                          4

ZITHROMAX PACK OR 1 GM                               2
ZITHROMAX (azithromycin) SOLR IV 500                                        MO
                                                     4            4
MG
ZITHROMAX (azithromycin) SUSR OR 100                                        MO
                                                     3            1
MG/5ML, 200 MG/5ML
ZITHROMAX (azithromycin) TABS OR 250                                        MO
                                                     3            1
MG, 500 MG, 600 MG
ZITHROMAX TRI-PAK (azithromycin) TABS                                       MO
                                                     3            1
OR 500 MG
ZITHROMAX Z-PAK (azithromycin) TABS                                         MO
                                                     3            1
OR 250 MG
ZMAX SUSR OR 2 GM                                    3                      MO

ZMAX PEDIATRIC SUSR OR 2 GM                          3                      MO

Clarithromycin
BIAXIN (clarithromycin) SUSR OR 125                                         MO
                                                     3            1
MG/5ML, 250 MG/5ML
BIAXIN (clarithromycin) TABS OR 250 MG,                                     MO
                                                     3            1
500 MG
BIAXIN XL (clarithromycin) TB24 OR 500 MG            3            1         MO

BIAXIN XL PAC (clarithromycin) TB24 OR                                      MO
500 MG                                               3            1

Erythromycins
e.e.s. 200 susp or 200 mg/5ml                                     1

e.e.s. 400 tabs or 400 mg                                         1         MO

E.E.S. GRANULES SUSR OR 200 MG/5ML                   2                      MO

ery-tab tbec or 250 mg, 333 mg, 500 mg                            1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                               140
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
ERYPED 200 SUSR OR 200 MG/5ML                        2                      MO

ERYPED 400 SUSR OR 400 MG/5ML                        2                      MO

ERYTHROCIN SOLR IV 1000 MG                           4
ERYTHROCIN LACTOBIONATE SOLR IV                      4
1000 MG, 500 MG
erythrocin stearate tabs or 500 mg                                1

erythrocin stearate tabs or 250 mg                                1         MO

erythromycin cpep or 250 mg                                       1         MO

erythromycin base tabs or 250 mg, 500 mg                          1         MO

erythromycin ethylsuccinate susp or 200                           1
mg/5ml
erythromycin ethylsuccinate tabs or 400 mg                        1         MO

PCE TBEC OR 333 MG, 500 MG                           3                      MO

Fidaxomicin
DIFICID TABS OR 200 MG                               5                      PA; ; MO

MEDICAL DEVICES
Bandages-Dressings-Tape
amd foam dressing 2"x2" pads xx                                   1         MO

curity amd gauze sponge 2"x2" 8 ply pads xx                       1         MO

gauze pads 2"x2" pads xx                                          1         MO

Parenteral Therapy Supplies
1ST CHOICE PEN NEEDLES 31GX6MM                                              MO
                                                      2
MISC XX
1ST TIER UNIFINE PENTIPS29GX12MM                                            MO
                                                      2
MISC XX
1ST TIER UNIFINE PENTIPS31GX6MM                                             MO
                                                      2
MISC XX
ACCUSURE INSULIN SYRINGE/1ML/31G X                                          MO
                                                      2
5/16" MISC XX
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                                     141
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
ADVOCATE INSULIN SYRINGE/U-                                                 MO
                                                     2
100/0.3ML/29GX1/2" MISC XX
ADVOCATE INSULIN SYRINGE/U-                                                 MO
                                                     2
100/1ML/31GX5/16" MISC XX
AIMSCO INSULIN SYRINGE ULTRA-THIN                                           MO
                                                     2
II/U-100/0.3ML/29G X 1/2" MISC XX
AURORA PEN NEEDLES 29GX12MM MISC                                            MO
                                                     2
XX
AURORA PEN NEEDLES 31G X6MM MISC                                            MO
                                                     2
XX
AUTOPEN DEVI XX                                      3                      MO

B-D INSULIN SYRINGE ULTRAFINE                                               MO
                                                     2
II/1ML/31G X 5/16" MISC XX
BD AUTOSHIELD 29G X 1/2" MISC XX                     2                      MO

BD AUTOSHIELD 29G X 3/16" MISC XX                    2

BD AUTOSHIELD 29G X 5/16" MISC XX                    2                      MO

BD AUTOSHIELD DUO 30G X 3/16" MISC                                          MO
                                                     2
XX
BD INSULIN SYRINGE ULTRAFINE                                                MO
                                                     2
II/SHORT/1ML/31G X 5/16" MISC XX
BD INSULIN SYRINGE                                                          MO
                                                     2
ULTRAFINE/1ML/31G X 5/16" MISC XX
BD INSULIN SYRINGE ULTRAFINE/U-                                             MO
                                                     2
100/0.3ML/29G X 1/2" MISC XX
BD PEN MISC XX                                       3                      MO

BD PEN MINI MISC XX                                  3                      MO

BD PEN NEEDLE/NANO/ULTRAFINE/32G X                                          MO
                                                      2
4MM MISC XX
BD PEN NEEDLE/ULTRAFINE/29G X                                               MO
                                                      2
12.7MM MISC XX
BD PEN NEEDLE/ULTRAFINE/29GX1/2"                                            MO
                                                      2
12.7MM MISC XX
BL INSULIN SYRINGE/1ML/31G X 5/16"                                          MO
                                                      2
MISC XX
BRITE LIFE ULTRA COMFORTINSULIN                                             MO
                                                      2
SYRINGE/0.3ML/29G X 1/2" MISC XX
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                               142
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
BROOKS INSULIN SYRINGE/0.3ML/29G X                                      MO
                                                    2
1/2" MISC XX
CAREONE ULTIGUARD INSULIN                                               MO
                                                    2
SYRINGE/0.3ML/29G X 1/2" MISC XX
CAREONE UNIFINE PENTIPS 29GX12MM                                        MO
                                                    2
MISC XX
CAREONE UNIFINE PENTIPS 31GX6MM                                         MO
                                                    2
MISC XX
CLEVER CHOICE COMFORT EZINSULIN                                         MO
                                                    2
SYRINGE/0.3ML/29G X 1/2" MISC XX
CLEVER CHOICE COMFORT EZINSULIN                                         MO
                                                    2
SYRINGE/U-100/1ML/31GX5/16" MISC XX
CLEVER CHOICE COMFORT EZPEN                                             MO
                                                    2
NEEDLES 31GX6MM MISC XX
CLICKFINE PEN NEEDLE                                                    MO
                                                    2
UNIVERSAL/31GX1/4" MISC XX
CLICKFINE PEN NEEDLES/31GX1/4" MISC                                     MO
                                                    2
XX
CLICKFINE UNIVERSAL PEN NEEDLES                                         MO
                                                    2
31GX1/4" MISC XX
CVS INSULIN SYRINGE/0.3ML/29G X 1/2"                                    MO
                                                    2
MISC XX
D&K INSULIN SYRINGE/U-100/0.3ML/29G X                                   MO
                                                    2
1/2" MISC XX
DRUG EMPORIUM INSULIN SYRINGE/U-                                        MO
                                                    2
100/0.3ML/29G X 1/2" MISC XX
DRUG MART ULTRA COMFORT INSULIN                                         MO
                                                    2
SYRINGE/0.3ML/29G X 1/2" MISC XX
DRUG MART UNIFINE PENTIPS29G X                                          MO
                                                    2
12MM MISC XX
DRUG MART UNIFINE PENTIPS31GX6MM                                        MO
                                                    2
MISC XX
DUANE READE UNIFINE PENTIPS 29G X                                       MO
                                                    2
12MM MISC XX
DUANE READE UNIFINE PENTIPS 31G X                                       MO
                                                    2
6MM ULTRA SHORT MISC XX
EASY TOUCH 32GX5MM MISC XX                          2                   MO

EASY TOUCH 32GX6MM MISC XX                          2                   MO

EASY TOUCH INSULIN SYRINGE/U-                                             MO
                                                      2
100/1ML/31G X 5/16" MISC XX
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                             143
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
EASY TOUCH PEN NEEDLES 29GX1/2"                                             MO
                                                      2
MISC XX
EASY TOUCH PEN NEEDLES 31GX1/4"                                             MO
                                                      2
MISC XX
ECK INSULIN SYRINGE/0.3ML/29G X 1/2"                                        MO
                                                      2
MISC XX
ELITE-THIN INSULIN SYRINGE/U-                                               MO
                                                      2
100/1ML/31G X 5/16" MISC XX
EQL INSULIN SYRINGE/0.3ML/29G X 1/2"                                        MO
                                                      2
MISC XX
EQL INSULIN SYRINGE/1ML/31G X 5/16"                                         MO
                                                      2
MISC XX
EQL INSULIN SYRINGE/U-100/0.3ML/29G X                                       MO
                                                      2
1/2" MISC XX
EQL ULTRA SHORT PEN NEEDLES 31G X                                           MO
                                                      2
6MM MISC XX
EXEL INSULIN PEN NEEDLES29GX1/2"                                            MO
                                                      2
12MM MISC XX
EXEL INSULIN PEN NEEDLES31GX1/4"                                            MO
                                                      2
6MM MISC XX
EXEL INSULIN SYRINGE/0.3ML/29G X 1/2"                                       MO
                                                      2
MISC XX
FIFTY50 SUPERIOR COMFORTINSULIN                                             MO
                                                      2
SYRINGE/1ML/31G X 5/16" MISC XX
FIRST CHOICE INSULIN SYRINGE/U-                                             MO
                                                      2
100/0.3ML/29G X 1/2" MISC XX
FP INSULIN SYRINGE/0.3ML/29G X 1/2"                                         MO
                                                      2
MISC XX
FP INSULIN SYRINGE/1ML/31G X 5/16"                                          MO
                                                      2
MISC XX
FP INSULIN SYRINGE/U-100/0.3ML/29G X                                        MO
                                                      2
1/2" MISC XX
FREESTYLE PRECISION INSULIN                                                 MO
                                                      2
SYRINGE/U-100/1ML/31G X 5/16" MISC XX
GLOBAL EASE INJECT PEN NEEDLES                                              MO
                                                      2
29GX12MM MISC XX
GLOBAL INJECT EASE INSULIN                                                  MO
                                                      2
SYRINGE/U-100/0.3ML/29G X 1/2" MISC XX
GLOBAL INJECT EASE INSULIN                                                  MO
                                                      2
SYRINGE/U-100/1ML/31G X 5/16" MISC XX
GLUCOPRO INSULIN SYRINGE/U-                                                 MO
                                                      2
100/1ML/31G X 5/16" MISC XX
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               144
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
GNP CLICKFINE UNIVERSAL PEN                                             MO
                                                    2
NEEDLES 31GX1/4" MISC XX
GNP INSULIN SYRINGE/0.3ML/29G X 1/2"                                    MO
                                                    2
MISC XX
GNP INSULIN SYRINGE/1ML/31G X 5/16"                                     MO
                                                    2
MISC XX
GNP ULTRA COMFORT INSULIN                                               MO
                                                    2
SYRINGE/0.3ML/29G X 1/2" MISC XX
GNP ULTRA COMFORT INSULIN                                               MO
SYRINGE/1ML/31G X 5/16" SHORT MISC                  2
XX
GNP ULTRA COMFORT INSULIN                                               MO
                                                    2
SYRINGE/U-100/0.3ML/29G X 1/2" MISC XX
H-E-B IN CONTROL PEN NEEDLES                                            MO
                                                    2
31GX6MM MISC XX
H-E-B INCONTROL PEN NEEDLES                                             MO
                                                    2
29GX12MM MISC XX
HCA INSULIN SYRINGE/U-100/0.3ML/29G X                                   MO
                                                    2
1/2" MISC XX
HCA ULTRA COMFORT                                                       MO
INSULINSYRINGE/1ML/31G X 5/16" MISC                 2
XX
HEALTHWISE MINI PEN NEEDLES                                             MO
                                                    2
31GX6MM MISC XX
HEALTHWISE PEN NEEDLES 29GX12MM                                         MO
                                                    2
MISC XX
HEALTHY ACCENTS UNIFINE PENTIPS                                         MO
                                                    2
PEN NEEDLES 29GX12MM MISC XX
HEALTHY ACCENTS UNIFINE PENTIPS                                         MO
                                                    2
PEN NEEDLES 31GX6MM MISC XX
HM MONOJECT INSULIN SYRINGE/U-                                          MO
                                                    2
100/0.3ML/29G X 1/2" MISC XX
HUMAPEN LUXURA HD DEVI XX                           3                   MO

HUMAPEN MEMOIR DEVI XX                              3                   MO

HY-VEE INSULIN SYRINGE/U-                                                 MO
                                                      2
100/0.3ML/29G X 1/2" MISC XX
INSULIN SYRINGE/0.3ML/28G X 1" MISC                   2
XX
INSULIN SYRINGE/0.3ML/29G X 1" MISC                   2
XX
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                             145
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
INSULIN SYRINGE/0.3ML/29G X 1/2" MISC                                       MO
                                                     2
XX
INSULIN SYRINGE/0.3ML/29G X 5/16" MISC               2
XX
INSULIN SYRINGE/0.3ML/30G X 1" MISC                  2
XX
INSULIN SYRINGE/0.5ML/28G X 1" MISC                  2
XX
INSULIN SYRINGE/0.5ML/30G X 1" MISC                  2
XX
INSULIN SYRINGE/1ML/31G X 5/16" MISC                                        MO
                                                     2
XX
INSULIN SYRINGE/U-100/0.3ML/29G X 1/2"                                      MO
                                                     2
MISC XX
INSULIN SYRINGE/U-100/1ML/29G X 1"                   2
MISC XX
INSULIN SYRINGE/U-100/1ML/30G X 1"                   2
MISC XX
INSULIN SYRINGE/U-100/1ML/31G X 5/16"                                       MO
                                                     2
MISC XX
INSUPEN PEN NEEDLES 32G X4MM MISC                                           MO
                                                     2
XX
INSUPEN SENSITIVE 32GX6MM MISC XX                    2                      MO

INSUPEN SENSITIVE 32GX8MM MISC XX                    2                      MO

INSUPEN ULTRAFIN 29GX12MM MISC XX                    2                      MO

INSUPEN ULTRAFIN 30GX8MM MISC XX                     2                      MO

INSUPEN ULTRAFIN 31GX6MM MISC XX                     2                      MO

KINRAY INSULIN SYRINGE PREFERRED                                            MO
                                                      2
PLUS/1ML/31G X 5/16" MISC XX
KROGER INSULIN SYRINGE/0.3ML/29G X                                          MO
                                                      2
1/2" MISC XX
KROGER INSULIN SYRINGE/1ML/31G X                                            MO
                                                      2
5/16" MISC XX
KROGER INSULIN SYRINGE/U-                                                   MO
                                                      2
100/0.3ML/29G X 1/2" MISC XX
KROGER PEN NEEDLES 29G X12MM MISC                                           MO
                                                      2
XX
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                               146
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
KROGER PEN NEEDLES 31GX1/4" MISC                                            MO
                                                      2
XX
LEADER INSULIN SYRINGE/0.3ML/29G X                                          MO
                                                      2
1/2" MISC XX
LEADER INSULIN SYRINGE/1ML/31G X                                            MO
                                                      2
5/16" MISC XX
LEADER INSULIN SYRINGE/U-                                                   MO
                                                      2
100/0.3ML/29G X 1/2" MISC XX
LITE TOUCH INSULIN SYRINGE/0.3ML/29G                                        MO
                                                      2
X 1/2" MISC XX
LITE TOUCH INSULIN SYRINGE/1ML/31G X                                        MO
                                                      2
5/16" MISC XX
LITETOUCH PEN NEEDLES 29GX12.7MM                                            MO
                                                      2
MISC XX
LIVE BETTER PEN NEEDLES 29G X 12MM                                          MO
                                                      2
MISC XX
LIVE BETTER PEN NEEDLES 31G X 6MM                                           MO
                                                      2
MISC XX
LONGS INSULIN SYRINGE/U-                                                    MO
                                                      2
100/0.3ML/29G X 1/2" MISC XX
MAGELLAN INSULIN SAFETY SYRINGE/U-                                          MO
                                                      2
100/0.3ML/29G X 1/2" MISC XX
MAJOR INSULIN SYRINGE/U-                                                    MO
                                                      2
100/0.3ML/29G X 1/2" MISC XX
MEDICINE SHOPPE PEN NEEDLES 29G X                                           MO
                                                      2
12MM MISC XX
MEDICINE SHOPPE PEN NEEDLES 31G X                                           MO
                                                      2
6MM MISC XX
MEIJER PEN NEEDLES 29G X12MM MISC                                           MO
                                                      2
XX
MEIJER PEN NEEDLES 31G X6MM MISC                                            MO
                                                      2
XX
MONOJECT INSULIN SYRINGE/0.3ML/29G                                          MO
                                                      2
X 1/2" MISC XX
MONOJECT INSULIN SYRINGE/1ML/31G X                                          MO
                                                      2
5/16" MISC XX
MONOJECT INSULIN                                                            MO
SYRINGE/SAFETY/PERM                                   2
NEEDLE/0.3ML/29G X 1/2" MISC XX
MONOJECT ULTRA COMFORT INSULIN                                              MO
                                                      2
SYRINGE/0.3ML/29G X 1/2" MISC XX
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy




 www.healthnet.com                                                               147
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
MS INSULIN SYRINGE/0.3ML/29G X 1/2"                                     MO
                                                    2
MISC XX
MS INSULIN SYRINGE/1ML/31G X 5/16"                                      MO
                                                    2
MISC XX
MS INSULIN SYRINGE/U-100/0.3ML/29G X                                    MO
                                                    2
1/2" MISC XX
NOVOFINE 30GX8MM MISC XX                            2                   MO

NOVOFINE 31 MISC XX                                 2                   MO

NOVOFINE 32GX6MM MISC XX                            2                   MO

NOVOFINE AUTOCOVER 30GX8MM MISC                                         MO
                                                    2
XX
NOVOPEN 3 INSULIN DELIVERY SYSTEM                                       MO
                                                    3
MISC XX
NOVOPEN 3 PENMATE MISC XX                           3                   MO

NOVOPEN JR (GREEN) MISC XX                          3                   MO

NOVOPEN JR (YELLOW) MISC XX                         3                   MO

NOVOTWIST 30GX8MM MISC XX                           2                   MO

NOVOTWIST 32GX5MM MISC XX                           2                   MO

PC UNIFINE PENTIPS 29G X1/2" MISC XX                2                   MO

PC UNIFINE PENTIPS 31G X6MM ULTRA                                       MO
                                                    2
SHORT MISC XX
PEN NEEDLES 29G X 12MM MISC XX                      2                   MO

PEN NEEDLES 29GX1/2" MISC XX                        2                   MO

PEN NEEDLES 30GX5/16" MISC XX                       2                   MO

PEN NEEDLES 31G X 1/4" SHORT MISC XX                2                   MO

PEN NEEDLES 31G X 6MM MISC XX                       2                   MO

PRECISION SURE-DOSE PLUSINSULIN                                           MO
                                                      2
SYRINGE/0.3ML/29G X 1/2" MISC XX
PREFERRED PLUS INSULIN SYRINGE/U-                                         MO
                                                      2
100/0.3ML/29G X 1/2" MISC XX
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                             148
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
PREFERRED PLUS ULTRA COMFORT                                                MO
INSULIN SYRINGE/0.3ML/29G X 1/2 MISC                 2
XX
PREFERRED PLUS UNIFINE PENTIPS 29G                                          MO
                                                     2
X 12MM MISC XX
PREFERRED PLUS UNIFINE PENTIPS 31G                                          MO
                                                     2
X 6MM ULTRA SHORT MISC XX
PRODIGY INSULIN PEN NEEDLES/29G X                                           MO
                                                     2
1/2" MISC XX
PX EXTRA SHORT PEN NEEDLES                                                  MO
                                                     2
31GX6MM MISC XX
PX INSULIN SYRINGE/U-100/1ML/31G X                                          MO
                                                     2
5/16" MISC XX
PX PEN NEEDLE 29GX12MM MISC XX                       2                      MO

QC INSULIN SYRINGE/0.3ML/29G X 1/2"                                         MO
                                                     2
MISC XX
QC INSULIN SYRINGE/1ML/31G X 5/16"                                          MO
                                                     2
MISC XX
QC PEN NEEDLES 29G X 12MM MISC XX                    2                      MO

QC PEN NEEDLES 31G X 6MM MISC XX                     2                      MO

RELION INSULIN SYRINGE/U-                                                   MO
                                                      2
100/0.3ML/29G X 1/2" MISC XX
RELION INSULIN SYRINGE/U-100/1ML/31G                                        MO
                                                      2
X 5/16" MISC XX
RELION MINI PEN NEEDLES 31GX6MM                                             MO
                                                      2
MISC XX
RELION PEN NEEDLES 29GX12MM MISC                                            MO
                                                      2
XX
RELION ULTRA COMFORT INSULIN                                                MO
                                                      2
SYRINGE/0.3ML/29G X 1/2" MISC XX
SAFETY-GLIDE INSULIN                                                        MO
                                                      2
SYRINGE/0.3ML/29G X 1/2" MISC XX
SB INSULIN SYRINGE/U-100/1ML/31G X                                          MO
                                                      2
5/16" MISC XX
SELECT BRAND INSULIN SYRINGE/U-                                             MO
                                                      2
100/0.3ML/29G X 1/2" MISC XX
SM INSULIN SYRINGE/1ML/31G X 5/16"                                          MO
                                                      2
MISC XX
SM INSULIN SYRINGE/U-100/0.3ML/29G X                                        MO
                                                      2
1/2" MISC XX
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               149
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
SURE COMFORT INSULIN SYRINGE/U-                                             MO
                                                      2
100/0.3ML/29G X 1/2" MISC XX
SURE COMFORT INSULIN SYRINGE/U-                                             MO
                                                      2
100/1ML/31G X 5/16" MISC XX
SURE COMFORT PEN NEEDLES29GX1/2"                                            MO
                                                      2
(12MM) MISC XX
SURE ONE INSULIN SYRINGE/U-                                                 MO
                                                      2
100/1ML/31G X 5/16" MISC XX
SURE-FINE PEN NEEDLES 29GX 1/2"                                             MO
                                                      2
12.7MM MISC XX
SURE-FINE PEN NEEDLES 29GX1/2"                                              MO
                                                      2
12.7MM MISC XX
SURE-JECT INSULIN SYRINGE/U-                                                MO
                                                      2
100/0.3ML/29G X 1/2" MISC XX
SURE-JECT INSULIN SYRINGE/U-                                                MO
                                                      2
100/1ML/31G X 5/16" MISC XX
TERUMO INSULIN SYRINGE/U-                                                   MO
                                                      2
100/0.3ML/29G X 1/2" MISC XX
TERUMO SURGUARD INSULIN                                                     MO
                                                      2
SYRINGE/0.3ML/29G X 1/2" MISC XX
THINPRO INSULIN SYRINGE/0.3ML/29G X                                         MO
                                                      2
1/2" MISC XX
TODAYS HEALTH MINI PEN NEEDLES 31G                                          MO
                                                      2
X 1/4" MISC XX
TODAYS HEALTH ORIGINAL PEN                                                  MO
                                                      2
NEEDLES 29G X 1/2" MISC XX
TOPCARE CLICKFINE UNIVERSAL PEN                                             MO
                                                      2
EEDLES 31GX1/4" MISC XX
TOPCARE ULTRA COMFORT INSULIN                                               MO
                                                      2
SYRINGE/1ML/31G X 5/16" MISC XX
TOPCARE ULTRA COMFORT INSULIN                                               MO
                                                      2
SYRINGE/U-100/0.3ML/29G X 1/2" MISC XX
TOPCO INSULIN SYRINGE/U-                                                    MO
                                                      2
100/0.3ML/29G X 1/2" MISC XX
ULTICARE INSULIN SYRINGE/0.3ML/29G X                                        MO
                                                      2
1/2" MISC XX
ULTICARE INSULIN SYRINGEULTRAFINE                                           MO
                                                      2
U-100/1ML/31G X 5/16" MISC XX
ULTICARE MICRO PEN NEEDLES/32G X                                            MO
                                                      2
4MM MISC XX
ULTICARE MINI PEN NEEDLES ULTI-FINE                                         MO
                                                      2
IV MISC XX
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               150
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
ULTICARE MINI PEN NEEDLES31GX6MM                                            MO
                                                     2
MISC XX
ULTICARE ORIGINAL PEN NEEDLES ULTI-                                         MO
                                                     2
FINE MISC XX
ULTIGUARD INSULIN SYRINGE/U-                                                MO
                                                     2
100/0.3ML/29G X 1/2" MISC XX
ULTIGUARD INSULIN SYRINGEULTI-FINE                                          MO
                                                     2
U-100/1ML/31G X 5/16" MISC XX
ULTILET PEN NEEDLE MISC XX                           2
ULTRA COMFORT INSULIN                                                       MO
                                                     2
SYRINGE/1ML/31G X 5/16" MISC XX
ULTRA COMFORT INSULIN SYRINGE/U-                                            MO
                                                     2
100/0.3ML/29G X 1/2" MISC XX
ULTRA-COMFORT INSULIN SYRINGE/U-                                            MO
                                                     2
100/0.3ML/29G X 1/2" MISC XX
ULTRA-COMFORT INSULIN SYRINGE/U-                                            MO
                                                     2
100/1ML/31G X 5/16" MISC XX
ULTRA-THIN II INSULIN                                                       MO
                                                     2
SYRINGE/0.3ML/29G X 1/2" MISC XX
ULTRA-THIN II INSULIN SYRINGE/U-                                            MO
                                                     2
100/0.3ML/29G X 1/2" MISC XX
ULTRA-THIN II PEN NEEDLE/29G X 1/2"                                         MO
                                                     2
MISC XX
UNIFINE PENTIPS MISC XX                              2                      MO

UNIFINE PENTIPS 29GX12MM MISC XX                     2                      MO

UNIFINE PENTIPS 31GX6MM MISC XX                      2                      MO

V-R MONOJECT INSULIN SYRINGE/U-                                             MO
                                                      2
100/0.3ML/29G X 1/2" MISC XX
VALUMARK PEN NEEDLES 29GX12MM                                               MO
                                                      2
MISC XX
VALUMARK PEN NEEDLES 31GX 6MM                                               MO
                                                      2
MISC XX
VIDA MIA UNIFINE PENTIPSMINI                                                MO
                                                      2
31GX6MM MISC XX
VIDA MIA UNIFINE PENTIPSORIGINAL                                            MO
                                                      2
29GX12MM MISC XX
VP INSULIN SYRINGE/U-100/0.3ML/29G X                                        MO
                                                      2
1/2" MISC XX
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                               151
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
WD MEDIC INSULIN SYRINGE/0.3ML/29G                                          MO
                                                     2
X 1/2" MISC XX
MIGRAINE PRODUCTS
Migraine Combinations
CAFERGOT SUPP RE 100-2 MG                            2                      MO

CAFERGOT (ergotamine w/ caffeine) TABS                                      MO
                                                     3            1
OR 1-100 MG
MIGERGOT SUPP RE 100-2 MG                            2                      MO

TREXIMET TABS OR 500-85 MG                           3                      MO

Migraine Products - NSAIDs
CAMBIA PACK OR 50 MG                                 3                      MO

Migraine Products
D.H.E. 45 (dihydroergotamine mesylate)                                      MO
                                                     4            4
SOLN IJ 1 MG/ML
ERGOMAR SUBL SL 2 MG                                 2                      MO

MIGRANAL SOLN NA 4 MG/ML                             3                      MO

Serotonin Agonists
AMERGE (naratriptan hcl) TABS OR 1 MG,                                      MO
                                                     2            1
2.5 MG
AXERT TABS OR 12 MG, 12.5 MG, 6.25 MG                3                      MO

FROVA TABS OR 2.5 MG                                 3                      MO

IMITREX (sumatriptan) SOLN NA 20                      3           1         MO
MG/ACT, 5 MG/ACT
IMITREX (sumatriptan succinate) SOLN SC 6                                   MO
                                                      4           4
MG/0.5ML
IMITREX (sumatriptan succinate) TABS OR                                     MO
                                                      3           1
100 MG, 25 MG, 50 MG
IMITREX STATDOSE REFILL (sumatriptan                                        MO
succinate) SOLN SC 4 MG/0.5ML, 6                      4           4
MG/0.5ML
IMITREX STATDOSE SYSTEM (sumatriptan                                        MO
succinate) SOLN SC 4 MG/0.5ML, 6                      4           4
MG/0.5ML
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                               152
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
MAXALT TABS OR 10 MG, 5 MG                           3                      MO

MAXALT-MLT TBDP OR 10 MG, 5 MG                       3                      MO

RELPAX TABS OR 20 MG, 40 MG                          3                      MO

sumatriptan succinate tabs or 100 mg                              1

SUMAVEL DOSEPRO DEVI SC 6 MG/0.5ML                   4                      MO

ZOMIG SOLN NA 5 MG                                   3                      MO

ZOMIG TABS OR 2 MG, 2.5 MG, 5 MG                     3                      MO

ZOMIG ZMT TBDP OR 2 MG, 2.5 MG, 5 MG                 3                      MO

MINERALS & ELECTROLYTES
Bicarbonates
sodium acetate soln iv 2 meq/ml                                   4

sodium bicarbonate soln iv 7 %, 7.5 %                             4

sodium bicarbonate soln iv 8 %, 8.4 %                             4         MO

sodium bicarbonate stick-gard soln iv 8.4 %                       4         MO

SODIUM LACTATE (sodium lactate) SOLN                 4            4
IV 167 MEQ/L, 5 MEQ/ML
Calcium
calcium chloride soln iv 10 %                                     4
Chloride
ammonium chloride soln iv 5 meq/ml                                4         MO

 Electrolyte Mixtures
DEXTROSE 10%/NACL 0.45% SOLN IV                       4
0.45-10 %
DEXTROSE 5%/ELECTROLYTE #48
VIAFLEX (electrolyte-48 in dextrose) SOLN             4           4
IV 20-23-24-25-3-5 %, MEQ/L
DEXTROSE 10%/NACL 0.2% (dextrose w/                   4           4
sodium chloride) SOLN IV 0.2-10 %
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                               153
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
dextrose 2.5%/nacl 0.45% soln iv 0.45-2.5 %                       4
dextrose 2.5%/sodium chloride 0.45% soln iv                       4
0.45-2.5 %
dextrose 5%/lactated ringers soln iv 109-130-                     4
2.7-28-4-5 %, meq/l
dextrose 5%/nacl 0.2% soln iv 0.2-5 %                             4
DEXTROSE 5%/NACL 0.225% (dextrose w/                 4            4
sodium chloride) SOLN IV 0.225-5 %
DEXTROSE 5%/NACL 0.3% SOLN IV 0.3-5                  4
%
dextrose 5%/nacl 0.33% soln iv 0.33-5 %                           4

dextrose 5%/nacl 0.45% soln iv 0.45-5 %                           4

dextrose 5%/nacl 0.9% soln iv 0.9-5 %                             4         MO

DEXTROSE 5%/POTASSIUM CHLORIDE                       4
0.075% SOLN IV 0.075-5 %, 10-5 %, MEQ/L
dextrose 5%/potassium chloride 0.15% soln                         4
iv 0.15-5 %, 20-5 %, meq/l
dextrose 5%/sodium chloride 0.2% soln iv                          4
0.2-5 %
dextrose 5%/sodium chloride 0.33% soln iv                         4
0.33-5 %
dextrose 5%/sodium chloride 0.45% soln iv                         4
0.45-5 %
dextrose 5%/sodium chloride 0.9% soln iv                                    MO
                                                                  4
0.9-5 %
hyperlyte r conc iv 20-25-30-5 meq/25ml                           4         B/D

IONOSOL-B/DEXTROSE 5% SOLN IV 13-                     4
25-49-5-57 %, MEQ/L
IONOSOL-MB/DEXTROSE 5% SOLN IV 20-                    4
22-23-25-3-5 %, MEQ/L
IONOSOL-T/DEXTROSE 5% SOLN IV 15-                     4
20-35-40-5 %, MEQ/L
ISOLYTE-H/DEXTROSE 5% SOLN IV 13-17-                  4
3-39-42-5 %, MEQ/L
isolyte-m/dextrose 5% soln iv 15-20-35-38-                        4
44-5 %, meq/l
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                                154
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
ISOLYTE-P/DEXTROSE 5% (electrolyte-p in              4            4
dextrose) SOLN IV 20-23-25-3-5 %, MEQ/L
isolyte-s soln iv 140-23-27-3-5-98 meq/l                          4
isolyte-s ph 7.4 soln iv 1-141-23-27-3-5-98                       4
meq/1000ml
isolyte-s/dextrose 5% soln iv 142-23-3-30-5-                      4
98 %, meq/l
kcl 0.075%/d5w/nacl 0.2% soln iv 0.2-10-5 %,                      4
meq/l
kcl 0.075%/d5w/nacl 0.45% soln iv 0.075-                          4
0.45-5 %, 0.45-10-5 %, meq/l
KCL 0.15%/D10W/NACL 0.2% SOLN IV 0.2-                 4
10-20 %, MEQ/L
kcl 0.15%/d5w/ nacl 0.3% soln iv 0.15-0.33-5                      4
%, 0.33-20-5 %, meq/l
KCL 0.15%/D5W/LR SOLN IV 130-149-24-                  4
28-3-5 %, MEQ/L
kcl 0.15%/d5w/nacl 0.2% soln iv 0.2-20-5 %,                       4
meq/l
KCL 0.15%/D5W/NACL 0.225% SOLN IV                     4
0.225-20-5 %, MEQ/L
kcl 0.15%/d5w/nacl 0.225% soln iv 0.15-                           4
0.225-5 %
kcl 0.15%/d5w/nacl 0.45% soln iv 0.45-20-5                        4
%, meq/l
KCL 0.15%/D5W/NACL 0.9% (potassium
chloride in dextrose & sodium chloride) SOLN          4           4
IV 0.9-20-5 %, MEQ/L
kcl 0.224%/d5w/nacl 0.2% soln iv 0.2-0.224-5                      4
%, 0.2-30-5 %, meq/l
kcl 0.224%/d5w/nacl 0.45% soln iv 0.224-                          4
0.45-5 %
KCL 0.3%/D5W/LR SOLN IV 130-149-28-3-                 4
44-5 %, MEQ/L
KCL 0.3%/D5W/LR IV LAC RING SOLN IV                   4
130-149-28-3-44-5 %, MEQ/L
kcl 0.3%/d5w/nacl 0.2% soln iv 0.2-0.3-5 %,                       4
0.2-40-5 %, meq/l
kcl 0.3%/d5w/nacl 0.45% soln iv 0.3-0.45-5                        4
%, 0.45-40-5 %, meq/l
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy




 www.healthnet.com                                                            155
                                                 Brand       Generic Limits
BRAND DRUG (generic drug)                         Tier        Tier
KCL 0.3%/D5W/NACL 0.9% (potassium
chloride in dextrose & sodium chloride) SOLN          4           4
IV 0.9-40-5 %, MEQ/L
lactated ringers soln iv 109-130-2.7-28-4                         4
meq/l, 109-130-28-3-4 meq/l
lactated ringers dextrose 5% soln iv 109-130-                     4
2.7-28-4-5 %, meq/l
lactated ringers dextrose 5% viaflex soln iv                      4
109-130-2.7-28-4-5 %, meq/l
lactated ringers viaflex soln iv 109-130-28-3-4                   4
meq/l
NORMOSOL -R (electrolyte-r) SOLN IV 140-              4           4
23-27-3-5-98 MEQ/L
normosol-m in d5w soln iv 13-16-3-40-5 %,                         4
meq/l
NORMOSOL-R SOLN IV 140-23-27-3-5-98                   4
MEQ/L
NORMOSOL-R IN D5W SOLN IV 140-23-27-                  4
3-5-98 %, MEQ/L
nutrilyte conc iv 0.25-0.4-1.25-1.68-2.03 meq,                            B/D
                                                                  4
meq/ml, 0.25-0.4-1.25-1.68-2.03 meq/ml
nutrilyte ii conc iv 0.225-0.25-1-1.475-1.75                              B/D
                                                                  4
meq/ml
PLASMA-LYTE 56 SOLN IV 13-16-3-40                     4
MEQ/L
PLASMA-LYTE A SOLN IV 140-23-27-3-5-98                4
MEQ/L
PLASMA-LYTE-148 SOLN IV 140-23-27-3-5-                4
98 MEQ/L
PLASMA-LYTE-148/D5W SOLN IV 140-23-
27-3-5-98 %, MEQ/L                                    4
PLASMA-LYTE-56/D5W SOLN IV 13-16-3-                   4
40-5 %, MEQ/L
plasma-lyte-m/d5w soln iv 12-16-3-40-5 %,                         4
meq/l
plasma-lyte-r soln iv 10-103-140-3-47-5-8                         4
meq/l
potassium chloride 0.075%/d5w/nacl 0.225%                         4
soln iv 0.2-10-5 %, meq/l
potassium chloride 0.15%/d5w soln iv 0.15-5                       4
%, 20-5 %, meq/l
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy




 www.healthnet.com                                                              156
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
POTASSIUM CHLORIDE 0.15%/NACL
0.45% VIAFLEX (potassium chloride in nacl)           4            4
SOLN IV 0.45-20 %, MEQ/L
POTASSIUM CHLORIDE 0.15%/NACL 0.9%                                          MO
(potassium chloride in nacl) SOLN IV 0.9-20          4            4
%, MEQ/L
potassium chloride 0.15%d5w/nacl 0.33%                            4
soln iv 0.33-20-5 %, meq/l
potassium chloride 0.15%d5w/nacl 0.45%                            4
soln iv 0.15-0.45-5 %, 0.45-20-5 %, meq/l
potassium chloride 0.15%d5w/nacl 0.45%                            4
viaflex soln iv 0.45-20-5 %, meq/l
potassium chloride 0.15%w/nacl 0.9% viaflex                                 MO
                                                                  4
soln iv 0.15-0.9 %
potassium chloride 0.22%d5w/nacl 0.45%                            4
soln iv 0.45-30-5 %, meq/l
potassium chloride 0.224%/d5w soln iv                             4
0.224-5 %, 30-5 %, meq/l
potassium chloride 0.224%/d5w/nacl 0.45%                          4
soln iv 0.224-0.45-5 %, 0.45-30-5 %, meq/l
potassium chloride 0.224%/dextrose 5%                             4
viaflex soln iv 30-5 %, meq/l
POTASSIUM CHLORIDE 0.224%D5W/NACL                    4
0.33% SOLN IV 0.33-30-5 %, MEQ/L
potassium chloride 0.224%d5w/nacl 0.45%                           4
viaflex soln iv 0.45-30-5 %, meq/l
potassium chloride 0.3%/d5w soln iv 0.3-5 %,                      4
40-5 %, meq/l
potassium chloride 0.3%/d5w/viaflex soln iv                       4
40-5 %, meq/l
POTASSIUM CHLORIDE 0.3%/NACL 0.9%
(potassium chloride in nacl) SOLN IV 0.9-40          4            4
%, MEQ/L
ringers injection soln iv 0.03-0.033-0.86 %,                      4
147-156-4-4.5 meq/l
tpn electrolytes conc iv 20-29.5-35-4.5-5                                   B/D
                                                                  4
meq/20ml
tpn electrolytes soln iv 20-29.5-35-4.5-5                                   B/D
                                                                  4
meq/20ml
Fluoride
sodium fluoride tabs or 1 mg                                      1
Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
Magnesium
MAGNESIUM SULFATE SOLN IJ 40 MG/ML,                  4
80 MG/ML
magnesium sulfate soln ij 50 %                                    4         MO

MAGNESIUM SULFATE IN D5W SOLN IV                     4
10-5 %, MG/ML, 20-5 %, MG/ML
Phosphate
sodium phosphate soln iv 3 mmole/ml                               4         MO

Potassium
K-DUR (potassium chloride                                                   MO
microencapsulated crystals cr) TBCR OR 10            3            1
MEQ, 20 MEQ
K-TABS (potassium chloride) TBCR OR 10                                      MO
                                                     3            1
MEQ
klor-con 8 tbcr or 8 meq                                          1         MO

klor-con m15 tbcr or 15 meq                                       1         MO

MICRO-K (potassium chloride) CPCR OR 10                                     MO
                                                     3            1
MEQ, 8 MEQ
potassium acetate soln iv 2 meq/ml                                4
POTASSIUM CHLORIDE (potassium
chloride) SOLN IV 20 MEQ/100ML, 30                   4            4
MEQ/100ML, 40 MEQ/100ML
POTASSIUM CHLORIDE (potassium                                               MO
                                                     4            4
chloride) SOLN IV 10 MEQ/100ML
POTASSIUM CHLORIDE SOLN IV 10
MEQ/50ML                                             4
POTASSIUM CHLORIDE SOLN IV 20                                               MO
MEQ/50ML                                             4
potassium chloride soln iv 0.4 meq/ml, 2                                    MO
                                                                  4
meq/ml
potassium chloride er tbcr or 8 meq                               1         MO

potassium chloride er tbcr or 15 meq                              1         MO

potassium chloride mini-vial soln iv 2 meq/ml                     4         MO

potassium chloride sa tbcr or 8 meq                               1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               158
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
potassium chloride sr tbcr or 8 meq                               1         MO

Sodium
sodium chloride soln ij 2 meq/ml, 2.5 meq/ml                      4         MO

sodium chloride soln iv 0.9 %, 3 %, 5 %                           4         MO

sodium chloride 0.45% soln iv 0.45 %, 0.5 %                       4

sodium chloride 0.45% quad pk soln iv 0.5 %                       4

sodium chloride 0.45% viaflex soln iv 0.45 %                      4

sodium chloride pab soln iv 0.9 %                                 4         MO

MOUTH/THROAT/DENTAL AGENTS
Anesthetics Topical Oral
LTA 360 KIT SOLN MT 4 %                              3
XYLOCAINE VISCOUS (lidocaine hcl                                            MO
                                                     3            1
(mouth-throat)) SOLN MT 2 %
Anti-infectives - Throat
clotrimazole lozg mt 10 mg                                        1         MO

MYCELEX (clotrimazole) TROC MT 10 MG                 3            1         MO

nystatin susp mt 100000 unit/ml                                   1         MO

ORAVIG TABS BU 50 MG                                 3
Antiallergy Agents - Mouth/Throat
APHTHASOL PSTE MT 5 %                                3                      MO

 Antiseptics - Mouth/Throat
PERIDEX (chlorhexidine gluconate (mouth-                                    MO
                                                     3            1
throat)) SOLN MT 0.12 %
Steroids - Mouth/Throat
oralone pste mt 0.1 %                                             1         MO

triamcinolone acetonide pste mt 0.1 %                             1         MO

triamcinolone in orabase pste mt 0.1 %                            1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
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 www.healthnet.com                                                               159
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
Throat Products - Misc.
EVOXAC CAPS OR 30 MG                                3                   MO

SALAGEN (pilocarpine hcl (oral)) TABS OR 5                              MO
                                                    3            1
MG, 7.5 MG
 MULTIVITAMINS
 Prenatal Vitamins
NOVANATAL (prenatal without a vit w/ iron                               MO
carbonyl-folic acid) TABS OR 1-120-15-150-          3            1
20-200-29-3-30-400-8 MCG, MG, UNIT
MUSCULOSKELETAL THERAPY AGENTS
Central Muscle Relaxants
AMRIX (cyclobenzaprine hcl) CP24 OR 15                                  MO
                                                    3            1
MG, 30 MG
baclofen tabs or 10 mg, 20 mg                                    1      MO

chlorzoxazone tabs or 250 mg                                     1

cyclobenzaprine hcl tabs or 7.5 mg                               1      MO

ed baclofen tabs or 10 mg                                        1      MO

fexmid tabs or 7.5 mg                                            1      MO

FLEXERIL (cyclobenzaprine hcl) TABS OR                                  MO
                                                    3            1
10 MG, 5 MG
LIORESAL INTRATHECAL SOLN IT 0.05                   4
MG/ML
LIORESAL INTRATHECAL SOLN IT 10                                         MO; B/D
                                                    4
MG/20ML, 10 MG/5ML, 40 MG/20ML
orphenadrine citrate soln ij 30 mg/ml                            4      MO

orphenadrine citrate er tb12 or 100 mg                           1      MO

PARAFON FORTE DSC (chlorzoxazone)                                       MO
                                                    3            1
TABS OR 500 MG
ROBAXIN SOLN IJ 100 MG/ML                           4
ROBAXIN (methocarbamol) TABS OR 500                                       MO
                                                      3           1
MG
ROBAXIN-750 (methocarbamol) TABS OR                                       MO
                                                      3           1
750 MG
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                                160
                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
SKELAXIN (metaxalone) TABS OR 800 MG                3            1      MO

SOMA (carisoprodol) TABS OR 250 MG, 350                                 MO
                                                    3            1
MG
ZANAFLEX (tizanidine hcl) CAPS OR 2 MG,                                 MO
                                                    3            1
4 MG, 6 MG
ZANAFLEX (tizanidine hcl) TABS OR 2 MG,                                 MO
                                                    3            1
4 MG
Direct Muscle Relaxants
DANTRIUM (dantrolene sodium) CAPS OR                                    MO
                                                    3            1
100 MG, 25 MG, 50 MG
DANTRIUM IV SOLR IV 20 MG                           4
Muscle Relaxant Combinations
carisoprodol/aspirin/codeine tabs or                             1      MO

NORGESIC (orphenadrine w/ aspirin & caff)                               MO
                                                    3            1
TABS OR 25-30-385 MG
orphenadrine compound ds tabs or 50-60-                                 MO
                                                                 1
770 mg
SOMA COMPOUND (carisoprodol w/ aspirin)                                 MO
                                                    3            1
TABS OR 200-325 MG
SOMA COMPOUND/CODEINE (carisoprodol                                     MO
w/ aspirin & codeine) TABS OR 16-200-325            3            1
MG
NASAL AGENTS - SYSTEMIC AND TOPICAL
Nasal Anti-infectives
BACTROBAN NASAL OINT NA 2 %                         3                   MO

Nasal Antiallergy
ASTELIN (azelastine hcl) SOLN NA 137                                    MO
MCG/SPRAY                                           3            1

ASTEPRO SOLN NA 0.15 %                              2                   MO

ASTEPRO (azelastine hcl) SOLN NA 137                                    MO
                                                    3            1
MCG/SPRAY
PATANASE SOLN NA 0.6 %                              3                   MO

Nasal Anticholinergics
ATROVENT (ipratropium bromide (nasal))                                    MO
                                                      3           1
SOLN NA 0.03 %, 0.06 %
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
Nasal Steroids
BECONASE AQ SUSP NA 42 MCG/SPRAY                     3                      MO

FLONASE (fluticasone propionate (nasal))                                    MO
                                                     3            1
SUSP NA 50 MCG/ACT
flunisolide soln na 0.025 %, 29 mcg/act                           1

flunisolide soln na 0.025 %                                       1         MO

NASACORT AQ AERS NA 55 MCG/ACT                       3                      MO

NASONEX SUSP NA 50 MCG/ACT                           2                      MO

OMNARIS SUSP NA 50 MCG/ACT                           3                      MO

RHINOCORT AQUA SUSP NA 32 MCG/ACT                    3                      MO

triamcinolone acetonide inha na 55 mcg/act                        1         MO

VERAMYST SUSP NA 27.5 MCG/SPRAY                      2                      MO

Sympathomimetic Decongestants
TYZINE SOLN NA 0.1 %                                 3                      MO

tyzine pediatric nasal drops soln na 0.05 %                       1         MO

NEUROMUSCULAR AGENTS
ALS Agents
RILUTEK TABS OR 50 MG                                5                      MO

Neuromuscular Blocking Agent - Neurotoxins
BOTOX SOLR IJ 100 UNIT, 200 UNIT                     4                      PA

XEOMIN SOLR IM 100 UNIT, 50 UNIT                     4
Nondepolarizing Muscle Relaxants
vecuronium bromide solr iv 10 mg                                  4
NUTRIENTS
Carbohydrates
ALCOHOL 5%/DEXTROSE 5% (alcohol in                    4           4
d5w) SOLN IV 5 %
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                               162
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
dextrose 10% soln iv 10 %                                         4         B/D

dextrose 10%flex container soln iv 10 %                           4         B/D

dextrose 10%partial fill soln iv 10 %                             4         B/D

dextrose 10%viaflex soln iv 10 %                                  4         B/D

dextrose 5% soln iv 5 %                                           4         MO; B/D

dextrose 5%           flex container soln iv 5                              MO; B/D
                                                                  4
%
dextrose 5%flex container soln iv 5 %                             4         MO; B/D

dextrose 5%viaflex soln iv 5 %                                    4         MO; B/D

dextrose 50% soln iv 50 %                                         4         B/D

dextrose 50% partial fill soln iv 50 %                            4         B/D

dextrose 50% viaflex partial fill soln iv 50 %                    4         B/D

dextrose 70% soln iv 70 %                                         4         B/D

Lipids
INTRALIPID EMUL IV 1.2-1.7-30 %                      4                      B/D

intralipid emul iv 1.2-10-2.25 %, 1.2-2.25-20                               B/D
                                                                  4
%
intralipid 20% emul iv 1.2-2.25-20 %                              4         B/D

LIPOSYN II EMUL IV 1.2-10-2.5 %, 1.2-2.5-5                                  B/D
%, 10-2.5 %, 2.5-5 %                                 4
LIPOSYN III EMUL IV 1.2-10-2.5 %, 1.2-2.5-           4                      B/D
20 %
liposyn iii emul iv 1.8-2.5-30 %                                  4         B/D

Proteins
AMINESS SOLN IV 5.2 %                                4                      B/D

amino acids soln iv                                               4         B/D

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy




 www.healthnet.com                                                                    163
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
AMINOSYN SOLN IV 105-140-147-154-182-                                       B/D
252-280-300-31-329-343-448-46-56-7
MEQ/L, MG/100ML, 105-140-147-154-182-
252-280-300-31-329-343-448-51-56 MEQ/L,
MG/100ML, 1100-150-260-340-35-370-380-
44-460-5.4-620-624-680-750-810-850-90
MEQ/L, MG/100ML, 120-140-189-209-210-                 4
280-31.3-350-371-462-490-50.3-505-517-
695-700-713-735 MEQ/L, MG/100ML, 1280-
148-160-300-400-420-44-440-5.4-520-720-
800-860-940-980 MEQ/L, MG/100ML, 150-
200-210-220-260-360-400-430-44-470-490-
5.4-640-80-86 MEQ/L, MG/100ML
AMINOSYN 7%/ELECTROLYTES SOLN IV                                            B/D
10-120-124-210-280-30-300-310-370-44-
510-560-610-65-660-690-900-96 MEQ/L,
MG/100ML, MMOLE/L, 10-120-124-210-280-                4
30-300-310-370-44-510-560-610-66-660-
690-70-900-96 MEQ/L, MG/100ML,
MMOLE/L
aminosyn 8.5%/electrolytes soln iv 10-1100-                                 B/D
142-150-260-30-340-370-380-44-460-620-                            4
624-65-680-750-810-850-98 meq/l, mg/100ml
AMINOSYN II (amino acid infusion) SOLN IV                                   B/D
1000-1018-1050-172-200-270-298-300-400-               4           4
44.4-500-530-660-700-71.8-722-738-993
MEQ/L, MG/100ML
AMINOSYN II SOLN IV 0.02-1050-107.6-                                        B/D
1083-1107-1490-1500-1527-1575-258-300-
405-447-450-600-62.7-750-795-990 %,
MEQ/L, MG/100ML, 1000-1018-1050-172-
200-270-298-300-400-45.3-500-530-660-700-
71.8-722-738-993 MEQ/L, MG/100ML, 1050-
107.6-1083-1107-1490-1500-1527-1575-258-
300-405-447-450-50-600-750-795-990                    4
MEQ/L, MG/100ML, 1050-107.6-1083-1107-
1490-1500-1527-1575-258-300-405-447-450-
600-62.7-750-795-990 MEQ/L, MG/100ML,
120-140-189-209-210-280-31.3-350-371-462-
490-50.3-505-517-695-700-713-735 MEQ/L,
MG/100ML, 146-170-230-253-255-33.3-340-
425-450-561-595-61.1-614-627-844-850-865-
893 MEQ/L, MG/100ML
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy




 www.healthnet.com                                                                164
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
AMINOSYN II 3.5%/DEXTROSE25% SOLN                                           B/D
IV 104-105-140-175-18-186-231-245-25-                 4
25.2-252-258-348-350-356-368-60-70-94 %,
MEQ/L, MG/100ML
AMINOSYN II 3.5%/DEXTROSE5% SOLN IV                                         B/D
104-105-140-175-18-186-231-245-25.2-252-              4
258-348-350-356-368-5-60-70-94 %, MEQ/L,
MG/100ML
AMINOSYN II 3.5/DEXTROSE25% SOLN IV                                         B/D
104-105-140-15-175-186-231-245-25-25.2-               4
252-258-33-348-350-356-368-40-48-5-60-70-
94 %, MEQ/L, MG/100ML, MMOLE/L
AMINOSYN II 4.25/DEXTROSE10% SOLN                                           B/D
IV 10-115-126-128-170-19-212-225-280-298-             4
30.6-307-314-422-425-432-446-73-85 %,
MEQ/L, MG/100ML
AMINOSYN II 4.25/DEXTROSE20% SOLN                                           B/D
IV 115-126-128-170-19-20-212-225-258-280-             4
298-30.6-307-422-425-432-446-73-85 %,
MEQ/L, MG/100ML
AMINOSYN II 4.25/DEXTROSE25% SOLN                                           B/D
IV 115-126-128-15-170-212-225-25-280-298-             4
30.6-307-314-33-42-422-425-432-446-48-5-
73-85 %, MEQ/L, MG/100ML, MMOLE/L
AMINOSYN II 4.25/DEXTROSE25% SOLN                                           B/D
IV 115-126-128-170-19-212-225-25-280-298-             4
30.6-307-314-422-425-432-446-73-85 %,
MEQ/L, MG/100ML
AMINOSYN II 5/DEXTROSE 25 SOLN IV                                           B/D
100-135-149-150-200-22.2-25-250-265-330-              4
35.9-350-361-369-496-500-509-525-86 %,
MEQ/L, MG/100ML
aminosyn ii 8.5%/electrolytes soln iv 10-146-                               B/D
170-230-253-255-30-340-425-450-561-595-
61-614-627-66-80-844-850-86-865-893                               4
meq/l, mg/100ml, mmole/l
AMINOSYN II M 3.5%/DEXTROSE 5%                                              B/D
SOLN IV 104-105-13-140-175-186-231-245-
25.1-252-258-3-3.5-348-350-356-36.5-368-              4
41-5-60-70-94 %, MEQ/L, MG/100ML,
MMOLE/L
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy




 www.healthnet.com                                                                165
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
AMINOSYN II M 4.25/DEXTROSE 10%                                             B/D
SOLN IV 10-115-126-128-13-170-212-225-
280-298-3-3.5-30.5-307-314-36.5-422-425-              4
43.7-432-446-73-85 %, MEQ/L, MG/100ML,
MMOLE/L
AMINOSYN M SOLN IV 105-13-140-147-                                          B/D
154-182-252-280-3-3.5-300-31-329-343-40-
448-47-56-58 MEQ/L, MG/100ML, MMOLE/L,                4
105-13-140-147-154-182-252-280-3-3.5-300-
31-329-343-40-448-56-65 MEQ/L,
MG/100ML, MMOLE/L
AMINOSYN-HBC SOLN IV 1.12-154-1576-                                         B/D
206-221-228-265-272-33-4-448-507-660-7.1-             4
789-88 GM/100ML, MEQ/100ML, MG/100ML
aminosyn-hf soln iv 100-1100-115-20-240-3-                                  B/D
450-500-600-610-62-66-770-800-840-900                             4
meq/l, mg/100ml
AMINOSYN-PF SOLN IV 1200-1227-180-3.4-                                      B/D
312-385-427-44-46-495-512-527-673-677-                4
698-70-760-812-820 MEQ/L, MG/100ML
AMINOSYN-PF 7% SOLN IV 10.69-125-220-                                       B/D
270-300-32.5-347-360-370-44-452-475-490-              4
50-534-570-576-70-831-861 GM/L, MEQ/L,
MG/100ML
AMINOSYN-RF SOLN IV 105-165-330-429-                                        B/D
462-5.4-528-535-600-726 MEQ/L,                        4
MG/100ML, 113-165-330-429-462-528-535-
600-726 MEQ/L, MG/100ML
CLINIMIX 2.75%/DEXTROSE 5% SOLN IV                                          B/D
11-110-116-132-138-154-159-160-165-187-               4
201-24-283-316-5-50-570 GM/100ML,
MEQ/1000ML, MG/100ML
CLINIMIX 4.25%/DEXTROSE 10% SOLN IV                                         B/D
10-17-170-179-204-213-238-247-255-289-
311-37-438-489-77-880 GM/100ML, MEQ/L,                4
MG/100ML
CLINIMIX 4.25%/DEXTROSE 20% SOLN IV                                         B/D
17-170-179-20-204-213-238-247-255-289-                4
311-37-438-489-77-880 GM/100ML, MEQ/L,
MG/100ML
CLINIMIX 4.25%/DEXTROSE 25% SOLN IV                                         B/D
17-170-179-204-213-238-247-25-255-289-                4
311-37-438-489-77-880 GM/100ML, MEQ/L,
MG/100ML
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                                166
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
CLINIMIX 4.25%/DEXTROSE 5% SOLN IV                                          B/D
17-170-179-204-213-238-247-255-289-311-               4
37-438-489-5-77-880 GM/100ML, MEQ/L,
MG/100ML
CLINIMIX 5%/DEXTROSE 15% SOLN IV                                            B/D
1035-15-20-200-210-240-250-280-290-300-               4
340-365-42-515-575-90 GM/100ML,
MEQ/1000ML, MG/100ML
CLINIMIX 5%/DEXTROSE 20% SOLN IV                                            B/D
1035-20-200-210-240-250-280-290-300-340-              4
365-42-515-575-90 GM/100ML, MEQ/L,
MG/100ML
CLINIMIX 5%/DEXTROSE 25% SOLN IV                                            B/D
1035-20-200-210-240-25-250-280-290-300-               4
340-365-42-515-575-90 GM/100ML, MEQ/L,
MG/100ML
CLINIMIX E 2.75%/DEXTROSE 10% SOLN                                          B/D
IV 10-11-110-112-116-132-138-154-159-160-             4
165-187-201-217-261-316-33-454-50-51-570
GM/100ML, MG/100ML
CLINIMIX E 2.75%/DEXTROSE 5% SOLN IV                                        B/D
11-110-112-116-132-138-154-159-160-165-               4
187-201-217-261-316-33-454-5-50-51-570
GM/100ML, MG/100ML
CLINIMIX E 4.25%/DEXTROSE 25% SOLN                                          B/D
IV 17-170-179-204-213-238-247-25-255-261-             4
289-297-311-33-489-51-702-77-880
GM/100ML, MG/100ML
CLINIMIX E 4.25%/DEXTROSE 5% SOLN IV                                        B/D
17-170-179-204-213-238-247-255-261-289-               4
297-311-33-489-5-51-702-77-880
GM/100ML, MG/100ML
CLINIMIX E 5%/DEXTROSE 15% SOLN IV                                          B/D
1035-15-20-200-210-240-250-261-280-290-
300-33-340-365-51-575-59-826-90                       4
GM/100ML, MG/100ML
CLINIMIX E 5%/DEXTROSE 20% SOLN IV                                          B/D
1035-20-200-210-240-250-261-280-290-300-              4
33-340-365-51-575-59-826-90 GM/100ML,
MG/100ML
CLINIMIX E 5%/DEXTROSE 25% SOLN IV                                          B/D
1035-20-200-210-240-25-250-261-280-290-               4
300-33-340-365-51-575-59-826-90
GM/100ML, MG/100ML
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy



 www.healthnet.com                                                                167
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
CLINIMIX E 5%/DEXTROSE 35% SOLN IV                                          B/D
1035-20-200-210-240-250-261-280-290-300-              4
33-340-35-365-51-575-59-826-90
GM/100ML, MG/100ML
clinisol sf 15% soln iv 1040-1180-1470-151-                                 B/D
2170-250-39-434-592-749-894-960 meq/l,                            4
mg/100ml
FREAMINE HBC 6.9% SOLN IV 10-1370-14-                                       B/D
160-200-250-3-320-330-400-410-580-59.3-               4
630-760-880-90 MEQ/L, MG/100ML
FREAMINE III SOLN IV 10-1120-120-1400-                                      B/D
150-24-280-3-400-530-560-590-660-690-                 4
710-730-89-910-950 MEQ/L, MG/100ML,
MMOLE/L
freamine iii soln iv 10-100-115-1190-130-14-                                B/D
240-3-340-450-480-500-560-590-600-620-                            4
72-770-810-950 meq/l, mg/100ml, mmole/l
FREAMINE III 3% SOLN IV 120-160-170-                                        B/D
180-20-200-210-220-24.5-270-290-340-35-               4
41-420-44-46-5-7-85 MEQ/L, MG/100ML,
MMOLE/L
freamine iii 8.5%/electrolytes soln iv 10-1190-                             B/D
125-130-20-240-340-40-450-480-500-560-                            4
590-60-600-620-770-810-950 meq/l,
mg/100ml, mmole/l
hepatamine soln iv 100-1100-115-20-240-3-                                   B/D
450-500-600-610-62-66-770-800-840-900                             4
meq/l, mg/100ml
HEPATASOL SOLN IV 0.02-0.065-0.1-0.115-                                     B/D
0.24-0.45-0.5-0.6-0.77-0.8-0.81-0.84-0.9-1.1          4
GM/100ML
hepatasol soln iv 0.02-0.065-0.1-0.115-0.24-                                B/D
0.45-0.5-0.6-0.61-0.77-0.8-0.84-0.9-1.1                           4
gm/100ml
NEPHRAMINE SOLN IV 20-200-250-400-44-                                       B/D
                                                      4
560-6-640-880 MEQ/L, MG/100ML
novamine soln iv 1040-1180-1470-151-2170-                                   B/D
250-39-434-592-749-894-960 meq/l,                                 4
mg/100ml
premasol soln iv 120-140-15-190-20-200-                                     B/D
220-230-250-290-3-300-320-410-470-490-5-                          4
56-730-840 meq/l, mg/100ml
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy




 www.healthnet.com                                                                168
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
PROCALAMINE SOLN IV 120-160-170-180-                                        B/D
20-200-210-220-24-270-290-3-340-35-41-               4
420-46-47-5-7-85 MEQ/L, MG/100ML,
MMOLE/L
PROSOL SOLN IV 1-1.02-1.08-1.18-1.34-                                       B/D
1.35-1.44-1.96-2.06-2.76-320-50-600-760-             4
980 GM/100ML, MG/100ML
RENAMIN SOLN IV 6.5 %                                4                      B/D

TRAVASOL (amino acid infusion) SOLN IV                                      B/D
152-1760-34-356-372-390-406-492-52-526-               4           4
880 MEQ/L, MG/100ML
TRAVASOL SOLN IV 1140-22-230-241-252-                                       B/D
263-318-340-43-570-99 MEQ/L, MG/100ML,
                                                      4
152-1760-34-356-372-390-406-492-526-67-
880 MEQ/L, MG/100ML
TRAVASOL 2.75%/DEXTROSE 10% SOLN                                            B/D
IV 10-11-112-115-120-126-132-159-170-216-             4
261-285-50-51-570 %, MG/100ML
TRAVASOL 2.75%/DEXTROSE 5% SOLN IV                                          B/D
11-112-115-120-126-132-159-170-216-261-               4
285-5-50-51-570 %, MG/100ML
TRAVASOL 3.5%/ELECTROLYTES SOLN IV                                          B/D
131-14-147-154-161-168-203-217-218-35-                4
364-51-63-728 MG/100ML
TRAVASOL 4.25%/DEXTROSE 10% SOLN                                            B/D
IV 10-17-178-186-195-203-246-261-263-297-             4
440-51-76-77-880 %, MG/100ML
TRAVASOL 4.25%/DEXTROSE 25% SOLN                                            B/D
IV 17-178-186-195-203-246-25-261-263-297-             4
440-51-76-77-880 %, MG/100ML
TRAVASOL 5.5%/DEXTROSE 10% SOLN IV                                          B/D
10-200-250-400-44-560-6-640-880-900 %,                4
MEQ/L, MG/100ML
TRAVASOL 5.5%/DEXTROSE 20% SOLN IV                                          B/D
20-200-250-400-44-560-6-640-880-900 %,                4
MEQ/L, MG/100ML
TRAVASOL 5.5%/ELECTROLYTES SOLN IV                                          B/D
10-101-102-1140-22-224-230-241-252-263-               4
318-340-431-522-570-60-70-99 MEQ/L,
MG/100ML
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy




 www.healthnet.com                                                                169
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
TRAVASOL 8.5%/DEXTROSE 10% SOLN IV                                          B/D
10-1100-150-260-340-35-370-380-44-460-               4
5.4-620-624-680-750-810-850-90 %, MEQ/L,
MG/100ML
TRAVASOL 8.5%/DEXTROSE 20% SOLN IV                                          B/D
1100-150-20-260-340-35-370-380-44-460-               4
5.4-620-624-680-750-810-850-90 %, MEQ/L,
MG/100ML
TRAVASOL 8.5%/DEXTROSE 50% SOLN IV                                          B/D
1100-150-260-340-35-370-380-44-460-5.4-              4
50-620-624-680-750-810-850-90 %, MEQ/L,
MG/100ML
travasol 8.5%/electrolytes soln iv 10-102-130-                              B/D
152-154-1760-34-356-372-390-406-492-522-                          4
526-594-60-70-880 meq/l, mg/100ml
TROPHAMINE SOLN IV 0.014-0.015-0.05-                                        B/D
0.12-0.14-0.19-0.2-0.22-0.23-0.25-0.29-0.3-
0.32-0.41-0.47-0.49-0.73-0.84 GM/100ML,              4
0.025-0.2-0.24-0.32-0.34-0.36-0.38-0.42-
0.48-0.5-0.54-0.68-0.78-0.82-1.2-1.4-5-97
GM/100ML, MEQ/L
OPHTHALMIC AGENTS
Artificial Tears and Lubricants
LACRISERT INST OP 5 MG                               3                      MO

Beta-blockers - Ophthalmic
BETAGAN (levobunolol hcl) SOLN OP 0.5 %              3            1         MO

betaxolol hcl soln op 0.5 %                                       1         MO

BETIMOL SOLN OP 0.25 %, 0.5 %                        2                      MO

BETOPTIC-S SUSP OP 0.25 %                            2                      MO

carteolol hcl soln op 1 %                                         1         MO

COMBIGAN SOLN OP 0.005-0.2-0.5 %                     3                      MO

COSOPT (dorzolamide hcl-timolol maleate)                                    MO
                                                     3            1
SOLN OP 22.3-6.8 MG/ML
COSOPT SOLN OP 0.5-2 %                               3                      MO

ISTALOL SOLN OP 0.5 %                                2                      MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


 www.healthnet.com                                                                170
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
levobunolol hcl soln op 0.25 %                                    1         MO

OPTIPRANOLOL (metipranolol) SOLN OP                                         MO
                                                     3            1
0.3 %
TIMOPTIC (timolol maleate (ophth)) SOLN                                     MO
                                                     3            1
OP 0.25 %, 0.5 %
TIMOPTIC OCUDOSE (timolol maleate                                           MO
                                                     3            1
(ophth)) SOLN OP 0.25 %, 0.5 %
TIMOPTIC-XE (timolol maleate (ophth))                                       MO
                                                     3            1
SOLG OP 0.25 %, 0.5 %
Cycloplegic Mydriatics
ak-pentolate soln op 1 %                                          1         MO

cyclogyl soln op 0.5 %, 1 %, 2 %                                  1         MO

cyclopentolate hcl soln op 1 %                                    1

cyclopentolate hcl soln op 1 %, 2 %                               1         MO

cylate soln op 1 %                                                1         MO

mydral soln op 0.5 %, 1 %                                         1         MO

mydriacyl soln op 1 %                                             1         MO

tropicamide soln op 0.5 %, 1 %                                    1         MO

 Miotics
ISOPTO CARPINE (pilocarpine hcl) SOLN                                       MO
                                                     2            1
OP 1 %, 2 %, 4 %
PHOSPHOLINE IODIDE SOLR OP 0.125 %                   3

PILOPINE HS GEL OP 4 %                               2                      MO

Ophthalmic - Angiogenesis Inhibitors
EYLEA SOLN IO 2 MG/0.05ML                            5

LUCENTIS SOLN IO 0.5 MG/0.05ML                       5
Ophthalmic Adrenergic Agents
ALPHAGAN P SOLN OP 0.1 %                             2                      MO

Please refer to pages v - vi for a complete description of abbreviations.
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LA=Limited Access MO=Available at Mail Order
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
ALPHAGAN P (brimonidine tartrate) SOLN                                      MO
                                                     3            1
OP 0.15 %
brimonidine tartrate soln op 0.2 %                                1         MO

IOPIDINE (apraclonidine hcl) SOLN OP 0.5                                    MO
                                                     3            1
%
IOPIDINE SOLN OP 1 %                                 3                      MO

PROPINE (dipivefrin hcl) SOLN OP 0.1 %               3            1
Ophthalmic Anti-infectives
ak-poly-bac oint op 10000-500 unit/gm                             1         MO

AZASITE SOLN OP 1 %                                  3                      MO

bacitracin oint op 500 unit/gm                                    1         MO

bacitracin/neomycin/polymyxin oint op 10000-                                MO
                                                                  1
400-5 mg/gm, unit/gm
bacitracin/polymyxin b oint op 10000-500                                    MO
                                                                  1
unit/gm
BESIVANCE SUSP OP 0.6 %                              3                      MO

BETADINE OPHTHALMIC PREP SOLN OP                     3
5%
BLEPH-10 (sulfacetamide sodium (ophth))                                     MO
                                                     3            1
SOLN OP 10 %
CILOXAN OINT OP 0.3 %                                2                      MO

CILOXAN (ciprofloxacin hcl (ophth)) SOLN                                    MO
                                                     3            1
OP 0.3 %
erythromycin oint op 5 mg/gm                                      1         MO

garamycin oint op 0.3 %                                           1         MO

garamycin soln op 0.3 %                                           1         MO

genoptic soln op 0.3 %                                            1         MO

gentacidin soln op 0.3 %                                          1         MO

gentak oint op 0.3 %                                              1         MO

Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                               172
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
gentak soln op 0.3 %                                              1         MO

gentamicin sulfate oint op 0.3 %                                  1         MO

gentamicin sulfate soln op 0.3 %                                  1         MO

gentasol soln op 0.3 %                                            1         MO

ilotycin oint op 5 mg/gm                                          1         MO

IQUIX SOLN OP 1.5 %                                  3

MOXEZA SOLN OP 0.5 %                                 2                      MO

NATACYN SUSP OP 5 %                                  2                      MO

neo-polycin oint op 10000-3.5-400 mg/gm,                                    MO
                                                                  1
unit/gm
neocin oint op 10000-400-5 mg/gm, unit/gm                         1         MO

neocin-pg soln op 0.025-10000-2.5 mg/ml,                                    MO
                                                                  1
unit/ml
neomycin/bacitracin/polymyxin oint op 10000-                                MO
                                                                  1
400-5 mg/gm, unit/gm
neomycin/polymyxin/bacitracin zinc oint op                                  MO
                                                                  1
10000-400-5 mg/gm, unit/gm
neomycin/polymyxin/gramicidin soln op                                       MO
                                                                  1
0.001-0.025-1.75-10000 %, mg/ml, unit/ml
neosporin soln op 0.001-0.025-1.75-10000                                    MO
                                                                  1
%, mg/ml, unit/ml
OCUFLOX (ofloxacin (ophth)) SOLN OP 0.3                                     MO
                                                     3            1
%
ocutricin soln op 0.025-10000-2.5 mg/ml,                                    MO
                                                                  1
unit/ml
polycin b oint op 10000-500 unit/gm                               1         MO

POLYTRIM (polymyxin b-trimethoprim) SOLN                                    MO
                                                     3            1
OP 0.1-10000 %, UNIT/ML
QUIXIN (levofloxacin (ophth)) SOLN OP 0.5                                   MO
                                                     3            1
%
romycin oint op 5 mg/gm                                           1         MO

SULFACETAMIDE SODIUM OINT OP 10 %                    2
Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
TOBREX OINT OP 0.3 %                                2                   MO

TOBREX (tobramycin sulfate (ophth)) SOLN                                MO
                                                    3            1
OP 0.3 %
trimethoprim sulfate/polymyxin b sulfate soln                           MO
                                                                 1
op 0.004-0.1-10000 %, unit/ml
triple antibiotic oint op 10000-400-5 mg/gm,                            MO
                                                                 1
unit/gm
VIGAMOX SOLN OP 0.5 %                               2                   MO

VIROPTIC (trifluridine) SOLN OP 1 %                 3            1      MO

ZIRGAN GEL OP 0.15 %                                3                   MO

ZYMAR SOLN OP 0.3 %                                 3

ZYMAXID SOLN OP 0.5 %                               3                   MO

Ophthalmic Decongestants
ak-con soln op 0.1 %                                             1      MO

allersol soln op 0.1 %                                           1

naphazoline hcl soln op 0.1 %                                    1
Ophthalmic Immunomodulators
RESTASIS EMUL OP 0.05 %                             2                   MO

Ophthalmic Local Anesthetics
OPHTHETIC (proparacaine hcl) SOLN OP                                    MO
                                                    3            1
0.5 %
Ophthalmic Steroids
ALREX SUSP OP 0.2 %                                 3                   MO

BLEPHAMIDE SUSP OP 0.2-10 %                         2                   MO

BLEPHAMIDE S.O.P. OINT OP 0.2-10 %                  2                   MO

CORTISPORIN SUSP OP 1-10000-5 %,                                          MO
                                                      3
MG/ML, UNIT/ML
dexamethasone sodium phosphate soln op                                    MO
                                                                  1
0.1 %
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
dexasol soln op 0.1 %                                             1         MO

dexasporin susp op 0.1-0.5-10000 %, unit/ml                       1         MO

DUREZOL EMUL OP 0.05 %                               2                      MO

ECONOPRED PLUS (prednisolone acetate                                        MO
                                                     3            1
(ophth)) SUSP OP 1 %
FLAREX SUSP OP 0.1 %                                 2                      MO

FML OINT OP 0.1 %                                    2                      MO

FML FORTE SUSP OP 0.25 %                             2                      MO

FML LIQUIFILM (fluorometholone (ophth))                                     MO
                                                     3            1
SUSP OP 0.1 %
LOTEMAX OINT OP 0.5 %                                3                      MO

LOTEMAX SUSP OP 0.5 %                                2                      MO

MAXIDEX SUSP OP 0.1 %                                3                      MO

MAXITROL (neomycin-polymy-dexameth)                                         MO
OINT OP 0.01-0.05-0.1-10000-3.5 %,                    3           1
MG/GM, UNIT/GM
MAXITROL (neomycin-polymy-dexameth)                                         MO
SUSP OP 0.004-0.1-10000-3.5 %, MG/ML,                 3           1
UNIT/ML
methadex susp op 0.004-1-10000-3.5 %,                                       MO
                                                                  1
mg/ml, unit/ml
neomycin/polymyxin/bacitracin/hydrocortison                                 MO
e oint op 0.5-1-10000-400 %, unit/gm, 1-                          1
10000-3.5-400 %, mg/gm, unit/gm
neomycin/polymyxin/dexamethasone oint op                                    MO
                                                                  1
0.1-10000-3.5 %, mg/gm, unit/gm
neomycin/polymyxin/hydrocortisone susp op                                   MO
                                                                  1
1-10000-3.5 %, mg/ml, unit/ml
OMNIPRED (prednisolone acetate (ophth))                                     MO
                                                      3           1
SUSP OP 1 %
POLY-PRED SUSP OP 0.001-0.35-0.5-                     3
10000 %, UNIT/ML
PRED FORTE (prednisolone acetate (ophth))                                   MO
                                                      3           1
SUSP OP 1 %
Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                               175
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
PRED MILD SUSP OP 0.12 %                             2                      MO

PRED-G SUSP OP 0.3-1 %                               3                      MO

PRED-G S.O.P. OINT OP 0.3-0.6 %                      3                      MO

prednisol soln op 1 %                                             1         MO

prednisolone sodium phosphate soln op 1 %                         1         MO

sulfacetamide sodium/prednisolone sodium                                    MO
                                                                  1
phosphate soln op 0.01-0.23-10 %
TOBRADEX OINT OP 0.1-0.3 %                           3                      MO

TOBRADEX (tobramycin-dexamethasone)                                         MO
                                                     3            1
SUSP OP 0.01-0.1-0.3 %
TOBRADEX ST SUSP OP 0.05-0.1-0.3 %                   3                      MO

TRIESENCE SUSP IO 40 MG/ML                           4                      MO

VEXOL SUSP OP 1 %                                    3                      MO

ZYLET SUSP OP 0.01-0.3-0.5 %                         2                      MO

 Ophthalmics - Misc.
ACULAR (ketorolac tromethamine (ophth))                                     MO
                                                     3            1
SOLN OP 0.5 %
ACULAR LS (ketorolac tromethamine                                           MO
                                                     3            1
(ophth)) SOLN OP 0.4 %
ACULAR PF (ketorolac tromethamine                                           MO
                                                     3            1
(ophth)) SOLN OP 0.5 %
ACUVAIL SOLN OP 0.45 %                               3                      MO

ALAMAST SOLN OP 0.1 %                                3

ALOCRIL SOLN OP 2 %                                  3                      MO

ALOMIDE SOLN OP 0.1 %                                3                      MO

AZOPT SUSP OP 1 %                                    2                      MO

BEPREVE SOLN OP 1.5 %                                3                      MO

BROMDAY SOLN OP 0.09 %                               3                      MO

Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                               176
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
crolom soln op 4 %                                                1         MO

cromolyn sodium soln op 4 %                                       1         MO

ELESTAT (epinastine hcl (ophth)) SOLN OP                                    MO
                                                     3            1
0.05 %
EMADINE SOLN OP 0.05 %                               3                      MO

LASTACAFT SOLN OP 0.25 %                             3                      MO

NEVANAC SUSP OP 0.1 %                                2                      MO

OCUFEN (flurbiprofen sodium) SOLN OP                                        MO
                                                     3            1
0.03 %
OPTIVAR (azelastine hcl (ophth)) SOLN OP                                    MO
                                                     3            1
0.05 %
PATADAY SOLN OP 0.2 %                                2                      MO

PATANOL SOLN OP 0.1 %                                3                      MO

TRUSOPT (dorzolamide hcl) SOLN OP 2 %                3            1         MO

VOLTAREN (diclofenac sodium (ophth))                                        MO
                                                     3            1
SOLN OP 0.1 %
XIBROM (bromfenac sodium (ophth)) SOLN                                      MO
                                                     3            1
OP 0.09 %
Prostaglandins - Ophthalmic
LUMIGAN SOLN OP 0.01 %, 0.03 %                       2                      MO

TRAVATAN SOLN OP 0.004 %                             2

TRAVATAN Z SOLN OP 0.004 %                           2                      MO

XALATAN (latanoprost) SOLN OP 0.005 %                3            1         MO

OTIC AGENTS
Otic Agents - Miscellaneous
acetic acid/aluminum acetate soln ot 2 %                          1         MO

borofair soln ot 2 %                                              1         MO

VOSOL (acetic acid (otic)) SOLN OT 2 %               3            1         MO

Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                               177
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
Otic Anti-infectives
FLOXIN OTIC (ofloxacin (otic)) SOLN OT 0.3                                  MO
                                                     3            1
%
FLOXIN OTIC SINGLES (ofloxacin (otic))                                      MO
                                                     3            1
SOLN OT 0.3 %
Otic Combinations
antibiotic ear soln ot 1-10000-3.5 %, mg/ml,                                MO
                                                                  1
unit/ml
antibiotic ear susp ot 1-10000-3.5 %, mg/ml,                                MO
                                                                  1
unit/ml
aurobiotic-hc soln ot 1-10000-3.5 %, mg/ml,                                 MO
                                                                  1
unit/ml
CIPRO HC SUSP OT 0.2-1-9 %, MG/ML                    3                      MO

CIPRODEX SUSP OT 0.1-0.3 %                           2                      MO

COLY-MYCIN S SUSP OT 0.002-0.5-10-3-                                        MO
                                                     3
3.3 %, MG/ML
CORTISPORIN (neomycin-polymyxin-hc                                          MO
(otic)) SOLN OT 0.1-1-10000-3.5 %, MG/ML,            3            1
UNIT/ML
CORTISPORIN (neomycin-polymyxin-hc                                          MO
(otic)) SUSP OT 0.01-1-10000-3.5 %,                  3            1
MG/ML, UNIT/ML
CORTISPORIN-TC SUSP OT 0.002-0.5-10-                                        MO
                                                     3
3-3.3 %, MG/ML
cortomycin soln ot 1-10000-3.5 %, mg/ml,                                    MO
                                                                  1
unit/ml
cortomycin susp ot 1-10000-3.5 %, mg/ml,                                    MO
                                                                  1
unit/ml
neomycin/polymyxin/hc soln ot 1-10000-3.5                                   MO
                                                                  1
%, mg/ml, unit/ml
neomycin/polymyxin/hydrocortisone susp ot                                   MO
0.01-0.9-1-10000-3.5 %, mg/ml, unit/ml, 1-                        1
10000-3.5 %, mg/ml, unit/ml
oticin hc soln ot 0.1-1-10000-5 %, mg/ml,                                   MO
                                                                  1
unit/ml
PEDIOTIC SUSP OT 0.001-1-10000-3.5 %,                                       MO
                                                     3
MG/ML, UNIT/ML
Otic Steroids
acetasol hc soln ot 0.02-1-2-3 %                                  1         MO

Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
DERMOTIC (fluocinolone acetonide (otic))                                    MO
                                                     3            1
OIL OT 0.01 %
hydrocortisone/acetic acid soln ot 0.02-1-2-3                               MO
                                                                  1
%, 1-2 %
VOSOL HC (hydrocortisone w/acetic acid)                                     MO
                                                     3            1
SOLN OT 1-2-3 %
OXYTOCICS
Oxytocics
METHERGINE (methylergonovine maleate)                                       MO
                                                     2            1
TABS OR 0.2 MG
PASSIVE IMMUNIZING AGENTS
Immune Serums
CARIMUNE NANOFILTERED SOLR IV 1                                             B/D
                                                     5
GM, 12 GM, 3 GM, 6 GM
FLEBOGAMMA SOLN IV 5 %                               5                      B/D

FLEBOGAMMA DIF SOLN IV 10 %, 5 %                     5                      B/D

GAMASTAN S/D INJ IM                                  4                      B/D

GAMMAGARD LIQUID SOLN IJ                             5                      B/D

GAMMAGARD S/D SOLR IV 2.5 GM                         2                      B/D

GAMMAGARD S/D (immune globulin                                              B/D
                                                     5            5
(human) iv) SOLR IV 10 GM
GAMMAGARD S/D SOLR IV 5 GM                           5                      B/D

GAMMAGARD S/D IGA LESS THAN                                                 B/D
1MCG/ML (immune globulin (human) iv)                 5            5
SOLR IV 10 GM
GAMMAGARD S/D IGA LESS THAN                                                 B/D
                                                     5
1MCG/ML SOLR IV 5 GM
GAMMAKED SOLN IJ 1 GM/10ML, 10                                              B/D
GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5                5
GM/50ML
GAMMAPLEX SOLN IV 10 GM/200ML, 2.5                                          B/D
                                                     5
GM/50ML, 5 GM/100ML
GAMUNEX SOLN IV 10 %                                 5                      B/D

Please refer to pages v - vi for a complete description of abbreviations.
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 www.healthnet.com                                                                179
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
GAMUNEX-C SOLN IJ 1 GM/10ML, 10                                             B/D
GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 5                5
GM/50ML
HEPAGAM B SOLN IJ 0.03 %                             4
HIZENTRA SOLN SC 1 GM/5ML, 2                                                B/D
                                                     4
GM/10ML, 4 GM/20ML
HYPERHEP B S/D SOLN IM                               4

IMMUNE GLOBULIN INJ IM                               4                      B/D

NABI-HB SOLN IM                                      4
OCTAGAM SOLN IV 1 GM/20ML, 10                                               B/D
GM/200ML, 2.5 GM/50ML, 25 GM/500ML, 5                5
GM/100ML
PANGLOBULIN SOLR IV 1 GM, 3 GM, 6 GM                 5                      B/D

PANGLOBULIN NF SOLR IV 6 GM                          5                      B/D

POLYGAM S/D SOLR IV 2.5 GM                           2                      B/D

POLYGAM S/D (immune globulin (human) iv)                                    B/D
                                                     5            5
SOLR IV 10 GM
PRIVIGEN SOLN IV 10 GM/100ML, 20                                            B/D
                                                     5
GM/200ML, 5 GM/50ML
VIVAGLOBIN SOLN SC 160 MG/ML                         5                      B/D

Monoclonal Antibodies
SYNAGIS SOLN IM 100 MG/ML, 50                        5
MG/0.5ML
PENICILLINS
Aminopenicillins
amoxicillin caps or 250 mg, 500 mg                                1         MO

amoxicillin chew or 125 mg                                        1

amoxicillin chew or 125 mg, 250 mg                                1         MO

amoxicillin susr or 125 mg/5ml, 250 mg/5ml                        1         MO

AMOXIL (amoxicillin) CHEW OR 200 MG,                  3           1
400 MG
Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
AMOXIL SUSR OR 50 MG/ML                             2
AMOXIL (amoxicillin) SUSR OR 200                                        MO
                                                    3            1
MG/5ML, 400 MG/5ML
amoxil susr or 250 mg/5ml                                        1      MO

AMOXIL (amoxicillin) TABS OR 500 MG, 875                                MO
                                                    3            1
MG
ampicillin caps or 250 mg, 500 mg                                1      MO

ampicillin susr or 125 mg/5ml                                    1

ampicillin susr or 250 mg/5ml                                    1      MO

ampicillin sodium solr ij 10 gm, 125 mg, 250                     4
mg, 500 mg
ampicillin sodium solr ij 1 gm, 2 gm                             4      MO

AMPICILLIN SODIUM (ampicillin sodium)               4            4
SOLR IV 1 GM, 2 GM
ampicillin sodium solr iv 10 gm                                  4

MOXATAG TB24 OR 775 MG                              3                   MO

trimox susr or 125 mg/5ml, 250 mg/5ml                            1      MO

Extended-Spectrum Penicillins
PIPERACILLIN SODIUM SOLR IJ 2 GM, 3                 4
GM, 4 GM
PIPERACILLIN SODIUM SOLR IV 40 GM                   4
Natural Penicillins
BICILLIN L-A SUSP IM 1200000 UNIT/2ML,                                  MO
                                                    4
2400000 UNIT/4ML, 600000 UNIT/ML
penicillin g potassium solr ij 5 mu                              4

penicillin g potassium solr ij 20 mu                             4      MO

PENICILLIN G POTASSIUM IN ISO-
OSMOTIC DEXTROSE SOLN IV 20000                        4
UNIT/ML, 40000 UNIT/ML, 60000 UNIT/ML
PENICILLIN G PROCAINE (penicillin g                                       MO
                                                      4           4
procaine) SUSP IM 600000 UNIT/ML
Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
PENICILLIN G SODIUM (penicillin g sodium)           4            4
SOLR IJ 5000000 UNIT
penicillin v potassium solr or 125 mg/5ml, 250                          MO
                                                                 1
mg/5ml
penicillin v potassium tabs or 250 mg, 500 mg                    1      MO

pfizerpen-g solr ij 5 mu                                         4

pfizerpen-g solr ij 20 mu                                        4      MO

veetids solr or 125 mg/5ml, 250 mg/5ml                           1      MO

veetids tabs or 250 mg, 500 mg                                   1      MO

Penicillin Combinations
amoxicillin/clavulanate potassium chew or                               MO
                                                                 1
200-28.5 mg, 400-57 mg
amoxicillin/clavulanate potassium susr or                        1      MO

amoxicillin/clavulanate potassium tabs or                        1      MO

amoxicillin/potassium clavulanate chew or                               MO
                                                                 1
200-28.5 mg, 400-57 mg
ampicillin-sulbactam solr ij                                     4

ampicillin-sulbactam solr ij                                     4      MO

AMPICILLIN-SULBACTAM SOLR IV 1-2 GM                 4

ampicillin-sulbactam solr iv , 10-5 gm                           4

AUGMENTIN CHEW OR 250-62.5 MG                       2

AUGMENTIN SUSR OR 125-31.25 MG/5ML                  2                   MO

AUGMENTIN (amoxicillin & pot clavulanate)                                 MO
SUSR OR 200-28.5 MG/5ML, 250-62.5                     3           1
MG/5ML, 400-57 MG/5ML
AUGMENTIN (amoxicillin & pot clavulanate)                                 MO
TABS OR 125-250 MG, 125-500 MG, 125-                  3           1
875 MG
AUGMENTIN ES-600 (amoxicillin & pot                                       MO
                                                      3           1
clavulanate) SUSR OR 42.9-600 MG/5ML
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
AUGMENTIN XR (amoxicillin & pot                                             MO
                                                     3            1
clavulanate) TB12 OR 1000-62.5 MG
BICILLIN C-R SUSP IM 0.01-0.1-300000-                4
900000 %, UNIT/2ML, 300000 UNIT/ML
BICILLIN C-R SUSP IM 0.01-0.1-300000 %,                                     MO
                                                     4
UNIT/ML, 300000 UNIT/ML
piperacillin/tazobactam solr iv                                   4

piperacillin/tazobactam solr iv                                   4         MO

TIMENTIN SOLN IV 0.1-3 GM/100ML                      4

TIMENTIN SOLR IV 0.1-3 GM, 1-30 GM                   4
UNASYN (ampicillin & sulbactam sodium)               4            4
SOLR IJ 0.5-1 GM
UNASYN (ampicillin & sulbactam sodium)                                      MO
                                                     4            4
SOLR IJ 1-2 GM
UNASYN (ampicillin & sulbactam sodium)               4            4
SOLR IV 0.5-1 GM
UNASYN SOLR IV 1-2 GM                                4
UNASYN ADD-VANTAGE (ampicillin &                     4            4
sulbactam sodium) SOLR IV 0.5-1 GM
UNASYN ADD-VANTAGE SOLR IV 1-2 GM                    4
UNASYN BULK PACK (ampicillin &                       4            4
sulbactam sodium) SOLR IJ 10-5 GM
ZOSYN (piperacillin sodium-tazobactam                4            4
sodium) SOLR IV 0.25-2 GM, 36-4.5 GM
ZOSYN (piperacillin sodium-tazobactam                                       MO
sodium) SOLR IV , 0.375-3 GM, 0.5-4 GM               4            4

ZOSYN SOLR IV 0.25-0.5-2 GM, MG                      4
ZOSYN SOLR IV 0.375-0.75-3 GM, MG, 0.5-                                     MO
                                                     4
1-4 GM, MG
ZOSYN SOLN IV 0.25-0.5-2-5 %, GM/50ML,
MG/50ML, 0.375-0.75-3-5 %, GM/50ML,                  4
MG/50ML, 0.5-1-4-5 %, GM/100ML,
MG/100ML
Penicillinase-Resistant Penicillins
BACTOCILL IN DEXTROSE SOLN IV 1                       4
GM/50ML
Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
BACTOCILL IN DEXTROSE SOLN IV 2                     5
GM/50ML
dicloxacillin sodium caps or 250 mg, 500 mg                      1      MO

nafcillin sodium solr ij 1 gm, 10 gm, 2 gm                       4
NAFCILLIN SODIUM (nafcillin sodium) SOLR            4            4
IV 1 GM
NAFCILLIN SODIUM SOLR IV 2 GM                       4
NALLPEN ISO-OSMOTIC IN DEXTROSE                     4
SOLN IV 2 GM/100ML
NALLPEN/DEXTROSE SOLN IV 1                          4
GM/50ML, 2 GM/50ML
OXACILLIN SODIUM (oxacillin sodium)                                     MO
                                                    4            4
SOLR IJ 2 GM
OXACILLIN SODIUM SOLR IJ 1 GM                       4
OXACILLIN SODIUM (oxacillin sodium)                 5            5
SOLR IJ 10 GM
OXACILLIN SODIUM SOLR IV 1 GM, 2 GM                 4
PROGESTINS
Progestins
aygestin tabs or 5 mg                                            1      MO

MAKENA OIL IM 2-250-46 %, MG/ML                     5

medroxyprogesterone acetate tabs or 2 mg                         1      MO

MEGACE ES SUSP OR 625 MG/5ML                        3                   MO

norethindrone acetate tabs or 5 mg                               1      MO

PROMETRIUM (progesterone micronized)                                    MO
                                                    3            1
CAPS OR 100 MG, 200 MG
PROVERA (medroxyprogesterone acetate)                                   MO
                                                    3            1
TABS OR 10 MG, 2.5 MG, 5 MG
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC.
Agents for Chemical Dependency
ANTABUSE (disulfiram) TABS OR 250 MG,                                     MO
                                                      2           1
500 MG
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
CAMPRAL TBEC OR 333 MG                               2                      MO

Anti-Cataplectic Agents
XYREM SOLN OR 500 MG/ML                              5                      LA

Antidementia Agents
ARICEPT (donepezil hydrochloride) TABS                                      MO
                                                     2            1
OR 10 MG, 5 MG
ARICEPT TABS OR 23 MG                                2                      MO

ARICEPT ODT (donepezil hydrochloride)                                       MO
                                                     2            1
TBDP OR 10 MG, 5 MG
COGNEX CAPS OR 10 MG, 20 MG                          3

COGNEX CAPS OR 30 MG, 40 MG                          3                      MO

EXELON PT24 TD 4.6 MG/24HR, 9.5                                             MO
                                                     2
MG/24HR
EXELON (rivastigmine tartrate) CAPS OR 1.5                                  MO
                                                     2            1
MG, 3 MG, 4.5 MG, 6 MG
EXELON SOLN OR 2 MG/ML                               2                      MO

NAMENDA SOLN OR 10 MG/5ML                            2                      MO

NAMENDA TABS OR 10 MG, 5 MG                          2                      MO

NAMENDA TITRATION PAK TABS OR                        2                      MO

RAZADYNE (galantamine hydrobromide)                                         MO
                                                     3            1
SOLN OR 4 MG/ML
RAZADYNE (galantamine hydrobromide)                                         MO
                                                     3            1
TABS OR 12 MG, 4 MG, 8 MG
RAZADYNE ER (galantamine hydrobromide)                                      MO
                                                     3            1
CP24 OR 16 MG, 24 MG, 8 MG
REMINYL (galantamine hydrobromide) SOLN                                     MO
                                                     3            1
OR 4 MG/ML
Combination Psychotherapeutics
LIMBITROL (chlordiazepoxide-amitriptyline)                                  MO
                                                     3            1
TABS OR 12.5-5 MG
LIMBITROL DS (chlordiazepoxide-                                             MO
                                                     3            1
amitriptyline) TABS OR 10-25 MG
olanzapine/fluoxetine caps or                                     1         MO

Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
perphenazine/amitriptyline tabs or 10-2 mg,                                 MO
                                                                  1
10-4 mg, 2-25 mg, 25-4 mg, 4-50 mg
SYMBYAX CAPS OR 12-25 MG, 12-50 MG,                                         MO
                                                     2
25-3 MG, 25-6 MG, 50-6 MG
Fibromyalgia Agents
SAVELLA TABS OR 100 MG, 12.5 MG, 25                                         PA; ; MO
                                                     3
MG, 50 MG
SAVELLA TITRATION PACK MISC OR                       3                      PA; ; MO

Movement Disorder Drug Therapy
XENAZINE TABS OR 12.5 MG, 25 MG                      5                      LA

Multiple Sclerosis Agents
AMPYRA TB12 OR 10 MG                                 5
AVONEX KIT IM 30 MCG/0.5ML, 30                       5
MCG/VIAL
AVONEX PEN KIT IM 30 MCG/0.5ML                       5

BETASERON SOLR SC 0.3 MG                             5

COPAXONE KIT SC 20 MG/ML                             5

EXTAVIA SOLR SC 0.3 MG                               5                      PA

GILENYA CAPS OR 0.5 MG                               5                      PA

REBIF SOLN SC 22 MCG/0.5ML, 44                                              PA
                                                     5
MCG/0.5ML
REBIF TITRATION PACK SOLN SC                         5                      PA

TYSABRI CONC IV 300 MG/15ML                          5                      PA

Postherpetic Neuralgia (PHN) Agents
GRALISE TABS OR 300 MG, 600 MG                       3                      MO

GRALISE STARTER MISC OR                              3                      MO

Premenstrual Dysphoric Disorder (PMDD) Agents
SARAFEM TABS OR 15 MG                                3
Pseudobulbar Affect (PBA) Agents
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
NUEDEXTA CAPS OR 10-20 MG                            2                      MO

Psychotherapeutic and Neurological Agents - Misc.
ergoloid mesylates tabs or 1 mg                                   1         MO

ORAP TABS OR 1 MG, 2 MG                              3                      MO

Restless Leg Syndrome (RLS) Agents
HORIZANT TB24 OR 600 MG                              3                      MO

Smoking Deterrents
CHANTIX TABS OR 0.5 MG, 1 MG                         3                      PA; ; MO

CHANTIX CONTINUING MONTHPAK TABS                                            PA; ; MO
                                                     3
OR 1 MG
CHANTIX STARTING MONTH PAK TABS                                             PA; ; MO
                                                     3
OR
NICOTROL INHALER INHA IN 10 MG                       3                      MO

NICOTROL NS SOLN NA 10 MG/ML                         3                      MO

ZYBAN (bupropion hcl (smoking deterrent))                                   MO
                                                     3            1
TB12 OR 150 MG
RESPIRATORY AGENTS - MISC.
Alpha-Proteinase Inhibitor (Human)
ARALAST SOLR IV 800 MG                               5

ARALAST SOLR IV 400 MG                               5                      LA

ARALAST NP SOLR IV 500 MG                            2                      LA

ARALAST NP SOLR IV 800 MG                            5

ARALAST NP SOLR IV 1000 MG, 400 MG                   5                      LA

GLASSIA SOLN IV 1000 MG/50ML                         4

PROLASTIN SOLR IV 500 MG                             2                      LA

PROLASTIN SUSR IV 1000 MG                            5                      LA

PROLASTIN-C SOLR IV 1000 MG                          5                      LA

Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
ZEMAIRA SOLR IV 1000 MG                             5                   LA

Cystic Fibrosis Agents
PULMOZYME SOLN IN 1 MG/ML                           5                   B/D

SULFONAMIDES
Sulfonamides
sulfadiazine tabs or 500 mg                                      1      MO

TETRACYCLINES
Tetracyclines
ADOXA (doxycycline (monohydrate)) TABS                                  MO
                                                    3            1
OR 50 MG
adoxa tabs or 100 mg, 75 mg                                      1      MO

adoxa pak 1/100 tabs or 100 mg                                   1      MO

ADOXA PAK 1/150 (doxycycline                                            MO
                                                    3            1
(monohydrate)) TABS OR 150 MG
adoxa pak 1/75 tabs or 75 mg                                     1      MO

adoxa pak 2/100 tabs or 100 mg                                   1      MO

avidoxy tabs or 100 mg                                           1      MO

demeclocycline hcl tabs or 150 mg, 300 mg                        1      MO

DORYX (doxycycline hyclate) TBEC OR 100                                 MO
                                                    3            1
MG, 150 MG, 75 MG
doxycycline hyclate caps or 50 mg                                1      MO

doxycycline hyclate cpep or 100 mg, 75 mg                        1

doxycycline hyclate solr iv 100 mg                               4      MO

doxycycline monohydrate tabs or 100 mg, 75                              MO
                                                                 1
mg
DYNACIN (minocycline hcl) CAPS OR 75 MG             3            1      MO

dynacin tabs or 100 mg, 50 mg, 75 mg                             1      MO

MINOCIN (minocycline hcl) CAPS OR 100                                     MO
                                                      3           1
MG, 50 MG
Please refer to pages v - vi for a complete description of abbreviations.
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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
MINOCIN SOLR IV 100 MG                              4
minocycline hcl tabs or 100 mg, 50 mg, 75                               MO
                                                                 1
mg
MONODOX (doxycycline (monohydrate))                                     MO
                                                    3            1
CAPS OR 100 MG, 50 MG, 75 MG
PERIOSTAT (doxycycline hyclate) TABS OR                                 MO
                                                    3            1
20 MG
SOLODYN (minocycline hcl) TB24 OR 135                                   MO
                                                    3            1
MG, 45 MG, 90 MG
SOLODYN TB24 OR 105 MG, 115 MG, 55                                      MO
                                                    3
MG, 65 MG, 80 MG
tetracycline hcl caps or 250 mg                                  1

tetracycline hcl caps or 250 mg, 500 mg                          1      MO

VIBRAMYCIN (doxycycline (monohydrate))                                  MO
                                                    3            1
SUSR OR 25 MG/5ML
VIBRAMYCIN SYRP OR 50 MG/5ML                        2                   MO

VIBRAMYCIN (doxycycline hyclate) CAPS                                   MO
                                                    3            1
OR 100 MG
VIBRATAB (doxycycline hyclate) TABS OR                                  MO
                                                    3            1
100 MG
THYROID AGENTS
Antithyroid Agents
methimazole tabs or 10 mg, 5 mg                                  1

methimazole tabs or 10 mg, 5 mg                                  1      MO

northyx tabs or 10 mg, 5 mg                                      1      MO

propylthiouracil tabs or 50 mg                                   1      MO

tapazole tabs or 10 mg, 5 mg                                     1      MO

Thyroid Hormones
ARMOUR THYROID (thyroid) TABS OR 180                  3           1
MG
ARMOUR THYROID (thyroid) TABS OR 120                                      MO
MG, 15 MG, 240 MG, 30 MG, 300 MG, 60                  3           1
MG, 90 MG
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
CYTOMEL (liothyronine sodium) TABS OR                                       MO
                                                     3            1
25 MCG, 5 MCG, 50 MCG
levothroid tabs or 112 mcg                                        1

levothyroxine sodium tabs or 112 mcg                              1

levoxyl tabs or 112 mcg                                           1
NATURE-THROID TABS OR 260 MG, 325                    3
MG
NATURE-THROID TABS OR 97.5 MG                        3                      MO

SYNTHROID (levothyroxine sodium) TABS                                       MO
OR 100 MCG, 112 MCG, 125 MCG, 137
                                                     3            1
MCG, 150 MCG, 175 MCG, 200 MCG, 25
MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG
thyroid tabs or 130 mg, 32.5 mg, 65 mg                            1

THYROLAR-1 TABS OR 60 MG                             2                      MO

THYROLAR-1/2 TABS OR 30 MG                           2                      MO

THYROLAR-1/4 TABS OR 15 MG                           2                      MO

THYROLAR-2 TABS OR 120 MG                            2                      MO

THYROLAR-3 TABS OR 180 MG                            2                      MO

TRIOSTAT (liothyronine sodium) SOLN IV 10            4            4
MCG/ML
unithroid tabs or 112 mcg                                         1

unithroid direct tabs or 112 mcg                                  1

WESTHROID (thyroid) TABS OR 195 MG                   3            1
WESTHROID TABS OR 16.25 MG, 162.5                    3
MG, 260 MG, 325 MG
WESTHROID TABS OR 97.5 MG                            3                      MO

TOXOIDS
Toxoid Combinations
ADACEL SUSP IM 15.5-2-5 LF/0.5ML,                     4
MCG/0.5ML
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
BOOSTRIX SUSP IM 18.5-2.5-5 LF/0.5ML,                4
MCG/0.5ML
DAPTACEL SUSP IM 10-15-5 LF/0.5ML,                   4
MCG/0.5ML
DECAVAC INJ IM 2-5 LFU                               4
DIPHTHERIA/TETANUS TOXOID                            4
PEDIATRIC INJ IM 5-6.7 LFU/0.5ML
INFANRIX SUSP IM 10-25-58 LFU/0.5ML,                 4
MCG/0.5ML
KINRIX SUSP IM 10-25-58 LFU/0.5ML,                   4
MCG/0.5ML
PEDIARIX SUSP IM 10-2.5-25-58                        4
LFU/0.5ML, MCG/0.5ML, MG/0.5ML
PENTACEL SUSR IM 15-48-5 LFU/0.5ML,                  4
MCG/0.5ML
TENIVAC INJ IM 2-5 LFU                               4
TETANUS/DIPHTHERIA TOXOIDS-                          4
ADSORBED ADULT SUSP IM 2 LF/0.5ML
TRIHIBIT KIT IM 46.8-5-6.7 LFU, MCG                  4
TRIPEDIA SUSP IM 46.8-5-6.7 LFU/0.5ML,               4
MCG/0.5ML
Toxoids
TETANUS TOXOID ADSORBED SOLN IM 5                                           B/D
                                                     4
LFU
ULCER DRUGS
Antispasmodics
ATROPINE SULFATE SOLN IJ 0.05 MG/ML                  4

atropine sulfate soln ij 0.1 mg/ml                                4

BENTYL (dicyclomine hcl) CAPS OR 10 MG               3            1         MO

BENTYL (dicyclomine hcl) SOLN IM 10                  4            4
MG/ML
BENTYL SYRP OR 10 MG/5ML                             3                      MO

BENTYL (dicyclomine hcl) TABS OR 20 MG               3            1         MO

CANTIL TABS OR 25 MG                                 3                      MO

Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
CUVPOSA SOLN OR 1 MG/5ML                             2

dicyclomine hcl soln or 10 mg/5ml                                 1         MO

PAMINE (methscopolamine bromide) TABS                                       MO
                                                     3            1
OR 2.5 MG
PAMINE FORTE (methscopolamine bromide)                                      MO
                                                     3            1
TABS OR 5 MG
propantheline bromide tabs or 15 mg                               1         MO

ROBINUL (glycopyrrolate) SOLN IJ 0.2                                        MO
                                                     4            4
MG/ML
ROBINUL SOLN IJ 0.2-0.9 %, MG/ML                     4                      MO

ROBINUL (glycopyrrolate) TABS OR 1 MG                3            1         MO

ROBINUL FORTE (glycopyrrolate) TABS OR                                      MO
                                                     3            1
2 MG
H-2 Antagonists
AXID (nizatidine) SOLN OR 15 MG/ML                   3            1         MO

cimetidine tabs or 200 mg                                         1         MO

cimetidine hcl soln ij 150 mg/ml                                  4

cimetidine hcl soln or 300 mg/5ml                                 1         MO

FAMOTIDINE PREMIXED SOLN IV 0.4-0.9                  4
%, MG/ML
nizatidine caps or 150 mg, 300 mg                                 1         MO

PEPCID (famotidine) SUSR OR 40 MG/5ML                2            1         MO

PEPCID (famotidine) TABS OR 20 MG, 40                                       MO
                                                     3            1
MG
PEPCID I.V. (famotidine) SOLN IV 10 MG/ML            4            4         MO

PEPCID PREMIXED SOLN IV 0.4-0.9 %,                   4
MG/ML
ranitidine hcl caps or 300 mg                                     1         MO

ranitidine hcl soln ij 150 mg/6ml, 50 mg/2ml                      4         MO

Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
ranitidine hcl syrp or 150 mg/10ml, 75 mg/5ml                     1         MO

TAGAMET (cimetidine) TABS OR 300 MG,                                        MO
                                                     3            1
400 MG, 800 MG
TALADINE (ranitidine hcl) CAPS OR 150 MG             3            1         MO

ZANTAC PACK OR 150 MG                                2

ZANTAC (ranitidine hcl) SOLN IJ 25 MG/ML             4            4

ZANTAC SOLN IJ 25 MG/ML                              4                      MO

ZANTAC (ranitidine hcl) SYRP OR 15 MG/ML             3            1         MO

ZANTAC (ranitidine hcl) TABS OR 150 MG,                                     MO
                                                     3            1
300 MG
ZANTAC TBEF OR 25 MG                                 2                      MO

ZANTAC SOLN IV 0.45-50 %, MG/50ML                    4
Misc. Anti-Ulcer
CARAFATE SUSP OR 1 GM/10ML                           2                      MO

CARAFATE (sucralfate) TABS OR 1 GM                   3            1         MO

Proton Pump Inhibitors
ACIPHEX TBEC OR 20 MG                                2                      MO

DEXILANT CPDR OR 30 MG, 60 MG                        3                      ST; MO

lansoprazole cpdr or 30 mg                                        1         MO

NEXIUM CPDR OR 20 MG, 40 MG                          3                      ST; MO

NEXIUM PACK OR 10 MG, 20 MG, 40 MG                   3                      ST; MO;

NEXIUM I.V. SOLR IV 20 MG                            4

NEXIUM I.V. SOLR IV 40 MG                            4                      MO

PREVACID (lansoprazole) CPDR OR 30 MG                3            1

PREVACID (lansoprazole) CPDR OR 15 MG                3            1         MO

Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
PREVACID SOLUTAB (lansoprazole) TBDP                 3            1
OR 30 MG
PREVACID SOLUTAB (lansoprazole) TBDP                                        MO
                                                     3            1
OR 15 MG
PRILOSEC (omeprazole) CPDR OR 10 MG,                                        MO
                                                     3            1
20 MG, 40 MG
PRILOSEC PACK OR 10 MG, 2.5 MG                       3                      ST; MO

PROTONIX PACK OR 40 MG                               3                      MO

PROTONIX SOLR IV 40 MG                               4
PROTONIX (pantoprazole sodium) TBEC OR                                      MO
                                                     3            1
20 MG, 40 MG
Ulcer Drugs - Prostaglandins
CYTOTEC (misoprostol) TABS OR 100                                           MO
                                                     3            1
MCG, 200 MCG
Ulcer Therapy Combinations
HELIDAC MISC OR                                      3                      MO

PREVPAC MISC OR                                      3

PYLERA CAPS OR 125-140 MG                            3                      MO

ZEGERID (omeprazole-sodium bicarbonate)                                     ST; MO
                                                     3            1
CAPS OR 1100-20 MG, 1100-40 MG
ZEGERID PACK OR 1680-20 MG, 1680-40                                         ST; MO
                                                     3
MG
URINARY ANTI-INFECTIVES
Urinary Anti-infectives
FURADANTIN (nitrofurantoin) SUSP OR 25                                      MO
                                                     3            1
MG/5ML
HIPREX (methenamine hippurate) TABS OR                                      MO
                                                     3            1
1 GM
MACROBID (nitrofurantoin monohyd macro)                                     MO
                                                     3            1
CAPS OR 100 MG
MACRODANTIN CAPS OR 25 MG                            2                      MO

MACRODANTIN (nitrofurantoin macrocrystal)                                   MO
                                                     3            1
CAPS OR 100 MG, 50 MG
MONUROL PACK OR 5.631 GM                             3                      MO

Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
nitrofurantoin monohydrate caps or 100 mg                         1
URINARY ANTISPASMODICS
Urinary Antispasmodics
DETROL TABS OR 1 MG, 2 MG                            2                      MO

DETROL LA CP24 OR 2 MG, 4 MG                         2                      MO

DITROPAN (oxybutynin chloride) SYRP OR 5                                    MO
                                                     3            1
MG/5ML
DITROPAN (oxybutynin chloride) TABS OR 5                                    MO
                                                     3            1
MG
DITROPAN XL (oxybutynin chloride) TB24                                      MO
                                                     3            1
OR 10 MG, 15 MG, 5 MG
ENABLEX TB24 OR 15 MG, 7.5 MG                        2                      MO

GELNIQUE GEL TD 3 %                                  3                      MO

GELNIQUE GEL TD 10 %                                 3                      MO

OXYTROL PTTW TD 3.9 MG/24HR                          3                      MO

SANCTURA (trospium chloride) TABS OR 20                                     MO
                                                     3            1
MG
SANCTURA XR CP24 OR 60 MG                            3                      MO

TOVIAZ TB24 OR 4 MG, 8 MG                            2                      MO

URECHOLINE (bethanechol chloride) TABS                                      MO
                                                     3            1
OR 10 MG, 25 MG, 5 MG, 50 MG
URISPAS (flavoxate hcl) TABS OR 100 MG               3            1         MO

VESICARE TABS OR 10 MG, 5 MG                         2                      MO

VACCINES
Bacterial Vaccines
ACTHIB SOLR IM                                       4

BIOTHRAX SUSP IM                                     4

HIBERIX SOLR IM                                      4
Please refer to pages v - vi for a complete description of abbreviations.
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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
HIBTITER SOLN IM 10-25 MCG                           4

MENACTRA INJ IM 48 MCG/0.5ML                         4

MENOMUNE-A/C/Y/W-135 INJ SC                          4

MENVEO SOLR IM                                       4

PEDVAX HIB SOLN IM                                   4

TYPHIM VI SOLN IM 25 MCG/0.5ML                       4
Mixed Vaccine Combinations
COMVAX SUSP IM 5-7.5 MCG/0.5ML                       4
Viral Vaccines
ATTENUVAX INJ SC                                     4

CERVARIX SUSP IM                                     4
ENGERIX-B INJ IM 10 MCG/0.5ML, 20                                           B/D
                                                     4
MCG/ML
ENGERIX-B SUSP IJ 10 MCG/0.5ML, 20                                          B/D
                                                     4
MCG/ML
GARDASIL SUSP IM                                     4                      MO

HAVRIX SUSP IM 1440 ELU/ML, 720                      4
ELU/0.5ML
IMOVAX RABIES (H.D.C.V.) INJ IM 2.5                                         B/D
                                                     4
UNIT/ML
IPOL INACTIVATED IPV INJ IJ                          4

IXIARO SUSP IM                                       4

JE-VAX SOLR SC                                       4

M-M-R II W/DILUENT 1 DOSE INJ SC                     4

M-M-R II W/DILUENT 10 DOSE INJ SC                    4

MERUVAX II W/DILUENT 1 DOSE INJ SC                   4

MERUVAX II W/DILUENT 10 DOSE INJ SC                  4
Please refer to pages v - vi for a complete description of abbreviations.
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PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


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                                                 Brand      Generic Limits
BRAND DRUG (generic drug)                         Tier       Tier
MUMPSVAX W/DILUENT 1 DOSE INJ SC                    4

MUMPSVAX W/DILUENT 10 DOSE INJ SC                   4

PROQUAD INJ SC                                      4

RABAVERT SUSR IM 0.3 MG                             4                   B/D

RECOMBIVAX HB SUSP IJ 10 MCG/ML, 40                                     B/D
                                                    4
MCG/ML, 5 MCG/0.5ML
ROTARIX SUSR OR                                     3

ROTATEQ SUSP OR                                     2
TWINRIX SUSP IM 20-720 ELU/ML,                      4
MCG/ML
VAQTA SUSP IM 25 UNIT/0.5ML, 50                     4
UNIT/ML
VARIVAX INJ SC 1350 PFU/0.5ML                       4

YF-VAX INJ SC                                       4

ZOSTAVAX SOLR SC 19400 UNT/0.65ML                   4
VAGINAL PRODUCTS
Vaginal Anti-infectives
CLEOCIN (clindamycin phosphate vaginal)                                 MO
                                                    3            1
CREA VA 2 %
CLEOCIN SUPP VA 100 MG                              3                   MO

CLINDESSE CREA VA 2 %                               3

GYNAZOLE-1 CREA VA 2 %                              3
METROGEL-VAGINAL (metronidazole                                         MO
                                                    3            1
vaginal) GEL VA 0.75 %
MONISTAT 3 (miconazole nitrate vaginal)                                 MO
                                                    3            1
SUPP VA 200 MG
nystatin tabs va 100000 unit                                     1      MO

nystatin vaginal tabs va 100000 unit                             1      MO

TERAZOL 3 (terconazole vaginal) CREA VA                                   MO
                                                      3           1
0.8 %
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy


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                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
TERAZOL 3 (terconazole vaginal) SUPP VA                                     MO
                                                     3            1
80 MG
TERAZOL 7 (terconazole vaginal) CREA VA                                     MO
                                                     3            1
0.4 %
Vaginal Estrogens
estrace crea va 0.1 mg/gm                                         1         MO

ESTRING RING VA 2 MG                                 3                      QL; MO

FEMRING RING VA 0.05 MG/24HR, 0.1                                           QL; MO
                                                     3
MG/24HR
PREMARIN CREA VA 0.625 MG/GM                         2                      MO

VAGIFEM TABS VA 25 MCG                               3

VAGIFEM TABS VA 10 MCG                               3                      MO

Vaginal Progestins
CRINONE GEL VA 4 %, 8 %                              3                      MO

ENDOMETRIN INST VA 100 MG                            3                      MO

PROCHIEVE GEL VA 4 %, 8 %                            3                      MO

VASOPRESSORS
Anaphylaxis Therapy Agents
ADRENACLICK DEVI IJ 0.15 MG/0.15ML,                                         MO
                                                     2
0.3 MG/0.3ML
EPINEPHRINE DEVI IJ 0.15 MG/0.15ML, 0.3                                     MO
                                                     2
MG/0.3ML
EPIPEN DEVI IJ 0.3 MG/0.3ML                          2                      MO

EPIPEN 2-PAK DEVI IJ 0.3 MG/0.3ML                    2                      MO

EPIPEN-JR DEVI IJ 0.15 MG/0.3ML                      2                      MO

EPIPEN-JR 2-PAK DEVI IJ 0.15 MG/0.3ML                2                      MO

TWINJECT DEVI IJ 0.15 MG/0.15ML, 0.3                                        MO
                                                     2
MG/0.3ML
Vasopressors
dobutamine hcl soln iv 12 mg/ml, 250                              4
mg/20ml, 500 mg/40ml
Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy

 www.healthnet.com                                                                   198
                                                  Brand      Generic Limits
BRAND DRUG (generic drug)                          Tier       Tier
dobutamine hcl/d5w soln iv 1-5 %, mg/ml, 2-5                      4
%, mg/ml, 4-5 %, mg/ml
DOBUTAMINE/DEXTROSE 5% SOLN IV                       4
0.25-4-5 %, MG/ML
dobutamine/dextrose 5% soln iv 2-25-5 %,                          4
mg/100ml, mg/ml, 2-5 %, mg/ml
dopamine hcl soln iv 40 mg/ml                                     4
dopamine hcl-dextrose 5% soln iv 0.5-0.8-5                        4
%, mg/ml, 0.8-5 %, mg/ml, 1.6-5 %, mg/ml
dopamine hcl/dextrose 5% soln iv 1.6-5 %,                         4
mg/ml
dopamine/d5w soln iv 0.8-5 %, mg/ml, 1.6-5                        4
%, mg/ml
PROAMATINE (midodrine hcl) TABS OR 10                                       MO
                                                     3            1
MG, 2.5 MG, 5 MG
VITAMINS
Water Soluble Vitamins
niacor tabs or 500 mg                                             1         MO

Please refer to pages v - vi for a complete description of abbreviations.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
LA=Limited Access MO=Available at Mail Order
PA=Prior Authorization QL=Quantity Limit ST=Step Therapy




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Index
1ST CHOICE PEN NEEDLES         ACTIMMUNE 2000000           ADOXA PAK 1/150 150 MG 188
31GX6MM                141     UNIT/0.5ML             74
1ST TIER UNIFINE               ACTIQ 1200 MCG, 1600 MCG,   ADRENACLICK 0.15
PENTIPS29GX12MM        141     400 MCG, 600 MCG, 800       MG/0.15ML, 0.3 MG/0.3ML 198
1ST TIER UNIFINE               MCG                    19   ADVAIR DISKUS 100-50
PENTIPS31GX6MM         141     ACTIQ 200 MCG            19 MCG/DOSE, 250-50
                                                           MCG/DOSE, 50-500
8-MOP 10 MG               110 ACTIVELLA 0.1-0.5 MG, 0.5-1  MCG/DOSE                   38
                               MG                      127 ADVAIR HFA 115-21 MCG/ACT,
ABELCET 5 MG/ML             55 ACTONEL 150 MG, 30 MG, 35   21-230 MCG/ACT, 21-45
                               MG, 5 MG                122 MCG/ACT                    38
ABILIFY 1 MG/ML             82                             ADVICOR 1000-20 MG, 1000-40
                               ACTONEL 75 MG           122 MG, 20-500 MG, 20-750 MG 59
ABILIFY 10 MG, 15 MG, 2 MG,
20 MG, 30 MG, 5 MG          82 ACTONEL WITH CALCIUM        ADVOCATE INSULIN
                               1250-35 MG              122 SYRINGE/U-
ABILIFY 9.75 MG/1.3ML       82 ACTOPLUS MET 15-500 MG,     100/0.3ML/29GX1/2"        142
                               15-850 MG                48 ADVOCATE INSULIN
ABILIFY DISCMELT 10 MG, 15                                 SYRINGE/U-
MG                          82 ACTOPLUS MET XR 1000-15     100/1ML/31GX5/16"         142
                               MG, 1000-30 MG           48 AFINITOR 10 MG, 2.5 MG, 5
ABRAXANE 100 MG             76 ACTOS 15 MG, 30 MG, 45
                                                           MG, 7.5 MG                 73
ABSTRAL 100 MCG, 200 MCG,      MG                       50
300 MCG, 400 MCG, 600 MCG,                                 AGGRENOX 200-25 MG       134
                               ACULAR 0.5 %            176
800 MCG                     19
                                                           AGRYLIN 0.5 MG, 1 MG     134
ACANYA 1.2-2.5 %          105 ACULAR LS 0.4 %          176
                                                           AIMSCO INSULIN SYRINGE
ACCOLATE 10 MG, 20 MG       37 ACULAR PF 0.5 %         176 ULTRA-THIN II/U-
                                                           100/0.3ML/29G X 1/2"     142
ACCUNEB 0.63 MG/3ML, 1.25      ACUVAIL 0.45 %          176 AKNE-MYCIN 2 %           105
MG/3ML                      38
ACCUPRIL 10 MG, 20 MG, 40   ACYCLOVIR SODIUM 1000
MG, 5 MG                  60MG                        87 ALA SCALP 2 %        111
ACCURETIC 10-12.5 MG, 12.5- ACYCLOVIR SODIUM 50
20 MG, 20-25 MG           62MG/ML                     87 ALAMAST 0.1 %        176
ACCUSURE INSULIN            ADACEL 15.5-2-5 LF/0.5ML,
SYRINGE/1ML/31G X 5/16" 141 MCG/0.5ML               190 ALBENZA 200 MG         29
ACCUTANE 10 MG, 20 MG, 40
MG                       105ADAGEN 250 UNIT/ML        92 ALCOHOL 5%/DEXTROSE 5% 5
                                                         %                    162
                            ADALAT CC 30 MG, 60 MG, 90
ACEON 2 MG, 4 MG, 8 MG   60 MG                        92 ALDACTAZIDE 25 MG    120
ACIPHEX 20 MG            193 ADCIRCA 20 MG            95 ALDACTAZIDE 50 MG          120
                            ADDERALL 1.25 MG, 1.875        ALDACTONE 100 MG, 25 MG,
ACLOVATE 0.05 %        111 MG, 2.5 MG, 3.125 MG, 3.75
                                                           50 MG                  121
ACTEMRA 200 MG/10ML, 400    MG, 5 MG, 7.5 MG          13
MG/20ML, 80 MG/4ML       16 ADDERALL XR 1.25 MG, 2.5       ALDARA 5 %               118
                            MG, 3.75 MG, 5 MG, 6.25 MG,
ACTHAR HP 80 UNIT/ML   123 7.5 MG                     13   ALDURAZYME 2.9 MG/5ML 125
ACTHIB                   195 ADENOCARD 6 MG/2ML       35
                                                           ALESSE-28 0.1-20 MCG, MG 98
ACTIGALL 300 MG          130 ADOXA 50 MG             188
                                                           ALIMTA 100 MG             68



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                                                              AMINOSYN II 0.02-1050-107.6-
ALIMTA 500 MG              68 AMIKACIN SULFATE 50
                              MG/ML                        14 1083-1107-1490-1500-1527-
                                                              1575-258-300-405-447-450-600-
ALINIA 100 MG/5ML          31   AMIKIN 1 GM/4ML            14 62.7-750-795-990 %, MEQ/L,
                                                              MG/100ML, 1000-1018-1050-
ALINIA 500 MG              31   AMIKIN 50 MG/ML            14 172-200-270-298-300-400-45.3-
                                                              500-530-660-700-71.8-722-738-
ALKERAN 50 MG              67   AMINESS 5.2 %             163 993 MEQ/L, MG/100ML, 1050-
                                AMINOSYN 105-140-147-154- 107.6-1083-1107-1490-1500-
ALLEGRA 30 MG/5ML          57   182-252-280-300-31-329-343-   1527-1575-258-300-405-447-
                                448-46-56-7 MEQ/L,            450-50-600-750-795-990 MEQ/L,
ALOCRIL 2 %               176   MG/100ML, 105-140-147-154-    MG/100ML, 1050-107.6-1083-
                                182-252-280-300-31-329-343-   1107-1490-1500-1527-1575-258-
ALOMIDE 0.1 %             176   448-51-56 MEQ/L, MG/100ML, 300-405-447-450-600-62.7-750-
                                1100-150-260-340-35-370-380- 795-990 MEQ/L, MG/100ML,
ALOPRIM 500 MG            133   44-460-5.4-620-624-680-750-   120-140-189-209-210-280-31.3-
                                810-850-90 MEQ/L,             350-371-462-490-50.3-505-517-
ALORA 0.025 MG/24HR, 0.05                                     695-700-713-735 MEQ/L,
MG/24HR, 0.075 MG/24HR, 0.1     MG/100ML, 120-140-189-209-
                                210-280-31.3-350-371-462-     MG/100ML, 146-170-230-253-
MG/24HR                  128                                  255-33.3-340-425-450-561-595-
                                490-50.3-505-517-695-700-
ALOXI 0.075 MG/1.5ML       53   713-735 MEQ/L, MG/100ML,      61.1-614-627-844-850-865-893
                                1280-148-160-300-400-420-44- MEQ/L, MG/100ML             164
ALOXI 0.25 MG/5ML          53   440-5.4-520-720-800-860-940-  AMINOSYN II 1000-1018-1050-
                                980 MEQ/L, MG/100ML, 150-     172-200-270-298-300-400-44.4-
ALPHAGAN P 0.1 %          171   200-210-220-260-360-400-430- 500-530-660-700-71.8-722-738-
                                44-470-490-5.4-640-80-86      993 MEQ/L, MG/100ML        164
                                MEQ/L, MG/100ML           164 AMINOSYN II
ALPHAGAN P 0.15 %         172                                 3.5%/DEXTROSE25% 104-105-
                                AMINOSYN
                                7%/ELECTROLYTES 10-120-       140-175-18-186-231-245-25-
ALREX 0.2 %               174                                 25.2-252-258-348-350-356-368-
                                124-210-280-30-300-310-370-
                                44-510-560-610-65-660-690-    60-70-94 %, MEQ/L,
ALTABAX 1 %               107                                 MG/100ML                   165
                                900-96 MEQ/L, MG/100ML,
ALTACE 1.25 MG, 10 MG, 2.5      MMOLE/L, 10-120-124-210-      AMINOSYN II
MG, 5 MG                   60   280-30-300-310-370-44-510-    3.5%/DEXTROSE5% 104-105-
ALTACE 1.5 MG              60   560-610-66-660-690-70-900-96 140-175-18-186-231-245-25.2-
                                MEQ/L, MG/100ML,              252-258-348-350-356-368-5-60-
ALTOPREV 20 MG, 40 MG, 60       MMOLE/L                   164 70-94 %, MEQ/L, MG/100ML 165
                                                              AMINOSYN II
MG                        59                                  3.5/DEXTROSE25% 104-105-
ALVESCO 160 MCG/ACT, 80                                       140-15-175-186-231-245-25-
MCG/ACT                   37                                  25.2-252-258-33-348-350-356-
AMARYL 1 MG, 2 MG, 4 MG    52                                 368-40-48-5-60-70-94 %, MEQ/L,
                                                              MG/100ML, MMOLE/L          165
AMBIEN 10 MG, 5 MG        136                                 AMINOSYN II
                                                              4.25/DEXTROSE10% 10-115-
AMBIEN CR 12.5 MG, 6.25                                       126-128-170-19-212-225-280-
MG                        136                                 298-30.6-307-314-422-425-432-
                                                              446-73-85 %, MEQ/L,
AMBISOME 50 MG             55                                 MG/100ML                   165
                                                              AMINOSYN II
AMERGE 1 MG, 2.5 MG       152                                 4.25/DEXTROSE20% 115-126-
                                                              128-170-19-20-212-225-258-280-
AMEVIVE 15 MG             110                                 298-30.6-307-422-425-432-446-
                                                              73-85 %, MEQ/L, MG/100ML 165


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AMINOSYN II                        AMINOSYN-RF 105-165-330-       ANDRODERM 2 MG/24HR, 2.5
4.25/DEXTROSE25% 115-126-          429-462-5.4-528-535-600-726    MG/24HR, 4 MG/24HR, 5
128-15-170-212-225-25-280-298-     MEQ/L, MG/100ML, 113-165-      MG/24HR                  27
30.6-307-314-33-42-422-425-        330-429-462-528-535-600-726    ANDROGEL 25 MG/2.5GM, 50
432-446-48-5-73-85 %, MEQ/L,       MEQ/L, MG/100ML          166   MG/5GM                   27
MG/100ML, MMOLE/L            165   AMIODARONE HCL 900             ANDROGEL PUMP 1.25
AMINOSYN II                        MG/18ML                   36   GM/ACT, 1.62 %           27
4.25/DEXTROSE25% 115-126-
128-170-19-212-225-25-280-298-     AMITIZA 24 MCG, 8 MCG 130 ANDROXY 10 MG                 28
30.6-307-314-422-425-432-446-      AMLODIPINE
73-85 %, MEQ/L, MG/100ML 165       BESYLATE/ATORVASTATIN         ANEXSIA 650-7.5 MG        24
AMINOSYN II 5/DEXTROSE 25          CALCIUM 10 MG, 10-2.5 MG,
100-135-149-150-200-22.2-25-       10-20 MG, 10-40 MG, 10-5      ANGELIQ 0.5-1 MG         127
250-265-330-35.9-350-361-369-      MG, 10-80 MG, 2.5-20 MG,
496-500-509-525-86 %, MEQ/L,                                     ANTABUSE 250 MG, 500
                                   2.5-40 MG, 20-5 MG, 40-5 MG, MG                        184
MG/100ML                     165   5-80 MG                    94
AMINOSYN II M                                                    ANTARA 130 MG, 43 MG      59
3.5%/DEXTROSE 5% 104-105-          AMOXIL 200 MG, 400 MG 180
13-140-175-186-231-245-25.1-       AMOXIL 200 MG/5ML, 400        ANTIVERT 12.5 MG, 25 MG 54
252-258-3-3.5-348-350-356-36.5-    MG/5ML                    181
368-41-5-60-70-94 %, MEQ/L,                                      ANTIVERT 50 MG            54
MG/100ML, MMOLE/L            165   AMOXIL 50 MG/ML           181
AMINOSYN II M
4.25/DEXTROSE 10% 10-115-                                        ANTIZOL 1 GM/ML           53
                                   AMOXIL 500 MG, 875 MG 181
126-128-13-170-212-225-280-
298-3-3.5-30.5-307-314-36.5-       AMPHOTEC 100 MG, 50           ANZEMET 100 MG, 50 MG     53
422-425-43.7-432-446-73-85 %,      MG                         55
MEQ/L, MG/100ML,                   AMPICILLIN SODIUM 1 GM, 2 ANZEMET 20 MG/ML              53
MMOLE/L                      166   GM                        181
AMINOSYN M 105-13-140-147-         AMPICILLIN-SULBACTAM 1-2 APHTHASOL 5 %                 159
154-182-252-280-3-3.5-300-31-      GM                        182
329-343-40-448-47-56-58                                          APIDRA 100 UNIT/ML        50
MEQ/L, MG/100ML, MMOLE/L,          AMPYRA 10 MG              186
105-13-140-147-154-182-252-                                      APIDRA SOLOSTAR 100
280-3-3.5-300-31-329-343-40-       AMRIX 15 MG, 30 MG        160 UNIT/ML                   50
448-56-65 MEQ/L, MG/100ML,                                       APLENZIN 174 MG, 348 MG,
                                   AMTURNIDE 10-12.5-300 MG, 522 MG                        45
MMOLE/L                      166   10-25-300 MG, 12.5-150-5 MG,
AMINOSYN-HBC 1.12-154-1576-        12.5-300-5 MG, 25-300-5       APOKYN 10 MG/ML           78
206-221-228-265-272-33-4-448-      MG                         62
507-660-7.1-789-88 GM/100ML,
MEQ/100ML, MG/100ML          166   ANADROL-50 50 MG           27 APRISO 0.375 GM          131
AMINOSYN-PF 1200-1227-180-         ANAFRANIL 25 MG, 50 MG, 75 APTIVUS 100 MG/ML
3.4-312-385-427-44-46-495-512-                                                            83
                                   MG                      47
527-673-677-698-70-760-812-
820 MEQ/L, MG/100ML          166   ANALPRAM-HC 1 %         28 APTIVUS 250 MG              83
AMINOSYN-PF 7% 10.69-125-
220-270-300-32.5-347-360-370-      ANALPRAM-HC SINGLES 1    ARALAST 400 MG               187
44-452-475-490-50-534-570-576-     %                     28
70-831-861 GM/L, MEQ/L,            ANAPROX 275 MG        16 ARALAST 800 MG               187
MG/100ML                     166                               ARALAST NP 1000 MG, 400
                                   ANAPROX DS 550 MG        16 MG                      187
                                   ANCOBON 250 MG, 500 MG55 ARALAST NP 500 MG            187



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ARALAST NP 800 MG       187 AROMASIN 25 MG           70 ATROVENT HFA 17
                                                        MCG/ACT                    37
ARALEN 500 MG            65 ARRANON 5 MG/ML          68 ATTENUVAX                 196
ARANESP ALBUMIN FREE 100       ARTHROTEC 50 200-50 MCG,AUGMENTIN 125-250 MG, 125-
MCG/0.5ML, 100 MCG/ML, 25      MG                    16500 MG, 125-875 MG        182
MCG/0.42ML, 25 MCG/ML, 40      ARTHROTEC 75 200-75 MCG,AUGMENTIN 125-31.25
MCG/0.4ML, 40 MCG/ML, 60       MG                    16MG/5ML                    182
MCG/0.3ML, 60 MCG/ML     135                           AUGMENTIN 200-28.5 MG/5ML,
ARANESP ALBUMIN FREE 150    ARZERRA 100 MG/5ML      70 250-62.5 MG/5ML, 400-57
MCG/0.3ML, 150 MCG/0.75ML,                             MG/5ML                    182
200 MCG/0.4ML, 200 MCG/ML,  ASACOL 400 MG          131
300 MCG/0.6ML, 300 MCG/ML,                             AUGMENTIN 250-62.5 MG 182
500 MCG/ML               135ASACOL HD 800 MG       131 AUGMENTIN ES-600 42.9-600
ARANESP ALBUMIN FREE                                   MG/5ML                    182
SURECLICK 100 MCG/0.5ML,    ASMANEX 120 METERED
                            DOSES 220 MCG/INH       37 AUGMENTIN XR 1000-62.5
25 MCG/0.42ML, 40 MCG/0.4ML,                           MG                        183
60 MCG/0.3ML             135ASMANEX 14 METERED
ARANESP ALBUMIN FREE        DOSES 220 MCG/INH       37 AURORA PEN NEEDLES
SURECLICK 150 MCG/0.3ML,    ASMANEX 30 METERED         29GX12MM                  142
200 MCG/0.4ML, 300          DOSES 110 MCG/INH, 220     AURORA PEN NEEDLES 31G
MCG/0.6ML, 500 MCG/ML 135   MCG/INH                 37 X6MM                      142
                            ASMANEX 60 METERED
                                                    37 AUTOPEN
ARAVA 10 MG, 20 MG       19 DOSES 220 MCG/INH                                    142
                            ASMANEX 7 METERED          AVALIDE 12.5-150 MG, 12.5-300
ARCALYST 220 MG          16 DOSES 110 MCG/INH       37 MG                         62
ARCAPTA NEOHALER 75            ASTELIN 137 MCG/SPRAY 161 AVALIDE 25-300 MG         62
MCG                      38
                                                          AVANDAMET 1000-2 MG, 1000-
AREDIA 30 MG, 90 MG  122 ASTEPRO 0.15 %         161       4 MG, 2-500 MG, 4-500 MG 48
                         ASTEPRO 137                      AVANDARYL 1-4 MG, 2-4 MG,
ARGATROBAN 100 MG/ML 41 MCG/SPRAY               161       2-8 MG, 4 MG, 4-8 MG      48
                         ATACAND 16 MG, 32 MG, 4
ARICEPT 10 MG, 5 MG  185 MG, 8 MG                         AVANDIA 2 MG, 4 MG, 8 MG 50
                                                 61
                         ATACAND HCT 12.5-16 MG,        AVAPRO 150 MG, 300 MG, 75
ARICEPT 23 MG        185 12.5-32 MG, 25-32 MG    62     MG                        61
                                                        AVASTIN 100 MG/4ML, 400
ARICEPT ODT 10 MG, 5 MG 185 ATARAX 10 MG/5ML         34 MG/16ML                   70
                                                        AVELOX 0.8-400 %,
ARIMIDEX 1 MG            70 ATELVIA 35 MG           122 MG/250ML                129
ARISTOCORT A 0.1 %        112 ATGAM 50 MG/ML         88 AVELOX 400 MG           129
ARISTOSPAN INTRA-             ATOVAQUONE/PROGUANIL
ARTICULAR 20 MG/ML        102 HCL 25-62.5 MG         65 AVELOX ABC PACK 400 MG 129
                                                    105 AVINZA75 MG, 90 MG 45 MG,
ARIXTRA 10 MG/0.8ML, 2.5                                       120 MG, 30 MG,
                              ATRALIN 0.05 %
MG/0.5ML, 5 MG/0.4ML, 7.5                               60 MG,                   19
MG/0.6ML                   40 ATRIPLA 200-300-600 MG 83 AVODART 0.5 MG          133
ARMOUR THYROID 120 MG, 15
MG, 240 MG, 30 MG, 300 MG,    ATROPINE SULFATE 0.05     AVONEX 30 MCG/0.5ML, 30
60 MG, 90 MG              189 MG/ML                 191 MCG/VIAL                186
ARMOUR THYROID 180 MG 189 ATROVENT 0.03 %, 0.06         AVONEX PEN 30
                              %                     161 MCG/0.5ML               186


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AXERT 12 MG, 12.5 MG, 6.25
                          152 BANZEL 200 MG, 400 MG    41 BENTYL 10 MG/ML           191
MG
AXID 15 MG/ML           192 BANZEL 40 MG/ML            41 BENTYL 20 MG              191

AXIRON 30 MG/ACT         28 BARACLUDE 0.05 MG/ML       86 BENZACLIN 1-5 %           106

AZACTAM 1 GM            29 BARACLUDE 0.5 MG, 1 MG 86 BENZACLIN CARE KIT 1-5 106
                                                        %
                           BD AUTOSHIELD 29G X          BENZACLIN WITH PUMP 1-5
AZACTAM 2 GM            29 1/2"                     142 %                       106
AZACTAM IN DEXTROSE 1 GM, BD AUTOSHIELD 29G X
                                                    142 BENZAMYCIN 16-3-5 %     106
2 GM                    29 3/16"
AZACTAMIN ISO-OSMOTIC      BD AUTOSHIELD 29G X
                                                    142 BEPREVE 1.5 %           176
DEXTROSE 1 GM, 2 GM     29 5/16"
AZASITE 1 %           172 BD AUTOSHIELD DUO 30G X BERINERT 500 UNIT             134
                           3/16"                    142
AZATHIOPRINE SODIUM 100    BD INSULIN SYRINGE
                                                        BESIVANCE 0.6 %         172
MG                      88 ULTRAFINE
                           II/SHORT/1ML/31G X 5/16" 142 BETADINE OPHTHALMIC PREP
AZELEX 20 %           106 BD INSULIN SYRINGE            5%                      172
                           ULTRAFINE/1ML/31G X
AZILECT 0.5 MG, 1 MG    79 5/16"                    142 BETAGAN 0.5 %           170
                           BD INSULIN SYRINGE
                      140 ULTRAFINE/U-100/0.3ML/29G BETAPACE MG MG, 160 MG, 91
                                                                   120
AZITHROMYCIN 500 MG                                     240 MG, 80
                           X 1/2"                   142
                                                        BETAPACE AF 120 MG, 160
AZMACORT 75 MCG/ACT     37 BD PEN                   142 MG, 80 MG                91
AZOPT 1 %                176 BD PEN MINI             142   BETASERON 0.3 MG         186
AZOR 10-20 MG, 10-40 MG, 20- BD PEN                        BETIMOL 0.25 %, 0.5 %    170
5 MG, 40-5 MG             62 NEEDLE/NANO/ULTRAFINE/3
AZULFIDINE 500 MG        131 2G X 4MM                142   BETOPTIC-S 0.25 %        170
                             BD PEN
AZULFIDINE EN-TABS 500       NEEDLE/ULTRAFINE/29G X        BEYAZ 0.02-0.451-3 MG     99
MG                       131 12.7MM                  142
B-D INSULIN SYRINGE          BD PEN                        BIAXIN 125 MG/5ML, 250
ULTRAFINE II/1ML/31G X       NEEDLE/ULTRAFINE/29GX1/2      MG/5ML                   140
5/16"                    142 " 12.7MM                142
BACTOCILL IN DEXTROSE 1      BECONASE AQ 42                BIAXIN 250 MG, 500 MG    140
GM/50ML                  183 MCG/SPRAY               162
BACTOCILL IN DEXTROSE 2                                    BIAXIN XL 500 MG         140
GM/50ML                  184 BENADRYL 50 MG/ML        56
                                                           BIAXIN XL PAC 500 MG     140
BACTRIM 400-80 MG         30 BENICAR 20 MG, 40 MG, 5
                             MG                       61  BICILLIN C-R 0.01-0.1-300000
BACTRIM DS 160-800 MG     30 BENICAR HCT 12.5-20 MG,      %, UNIT/ML, 300000
                             12.5-40 MG, 25-40 MG     62  UNIT/ML                    183
                             BENLYSTA 120 MG, 400         BICILLIN C-R 0.01-0.1-300000-
BACTROBAN 2 %            107                              900000 %, UNIT/2ML, 300000
                             MG                       90
                                                          UNIT/ML                    183
BACTROBAN NASAL 2 %     161 BENTYL 10 MG              191 BICILLIN L-A 1200000
                                                          UNIT/2ML, 2400000 UNIT/4ML,
BANCAP-HC 5-500 MG       24 BENTYL 10 MG/5ML          191 600000 UNIT/ML             181



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BICNU 100 MG               67 BUSULFEX 6 MG/ML          67 CAPOTEN 100 MG, 12.5 MG, 25
                                                           MG, 50 MG                60
BIDIL 20-37.5 MG           94 BUTRANS510 MCG/HR, 20 27 CAPOTEN 12 MG                    60
                              MCG/HR, MCG/HR
BILTRICIDE 600 MG          29 BYDUREON 2 MG             49 CAPRELSA 100 MG, 300 MG 73

BIOTHRAX                  195 BYETTA 10 MCG/0.04ML, 5 49      CARAC 0.5 %              109
                              MCG/0.02ML
BL INSULIN SYRINGE/1ML/31G BYSTOLIC 10 MG, 2.5 MG, 20         CARAFATE 1 GM            193
X 5/16"                   142 MG, 5 MG                   90
                              CADUET 10 MG, 10-2.5 MG,
BLENOXANE 15 UNIT          72 10-20 MG, 10-40 MG, 10-5        CARAFATE 1 GM/10ML       193
                              MG, 10-80 MG, 2.5-20 MG,        CARBATROL 100 MG, 200 MG,
BLENOXANE 30 UNIT          72 2.5-40 MG, 20-5 MG, 40-5 MG,    300 MG                  41
                              5-80 MG                    94   CARBIDOPA/LEVODOPA/ENTA
BLEPH-10 10 %             172
                              CAFERGOT 1-100 MG         152   CAPONE                  78
BLEPHAMIDE 0.2-10 %       174                                 CARBOCAINE 1 %           139
                              CAFERGOT 100-2 MG         152
BLEPHAMIDE S.O.P. 0.2-10                                      CARBOCAINE 1.5 %, 2 %    139
%                         174 CALAN 120 MG, 40 MG, 80
                              MG                         92
BONIVA 150 MG             122 CALAN SR 120 MG, 180 MG,        CARBOPLATIN 150 MG        67
                              240 MG                     92
BONIVA 3 MG/3ML           122                                 CARDENE 20 MG, 30 MG      92
                              CALCIJEX 1 MCG/ML         125
BOOSTRIX 18.5-2.5-5 LF/0.5ML,                                 CARDENE I.V. 2.5 MG/ML    92
MCG/0.5ML                 191 CALCITRIOL 2 MCG/ML 125
BOTOX 100 UNIT, 200 UNIT 162                                  CARDENE SR 30 MG          92
                              CALCITRIOL 3 MCG/GM 110
                                                              CARDIZEM 120 MG, 30 MG, 60
BRETHINE 2.5 MG, 5 MG      38 CALCIUM FOLINATE 100            MG, 90 MG                92
BREVICON-28 0.5-35 MCG,       MG/10ML, 300 MG/30ML       75
                                                              CARDIZEM 5 MG/ML          92
MG                         99 CAMBIA 50 MG              152
                                                         CARDIZEM CD 120 MG, 180
BRILINTA 90 MG            134
                                CAMPATH 30 MG/ML      70 MG, 240 MG, 300 MG       92
BRITE LIFE ULTRA
COMFORTINSULIN                                           CARDIZEM CD 360 MG       92
                                CAMPRAL 333 MG       185
SYRINGE/0.3ML/29G X 1/2" 142
                                CAMPTOSAR 100 MG/5ML, 40 CARDIZEM LA 120 MG       92
BROMDAY 0.09 %            176   MG/2ML                77 CARDIZEM LA 180 MG, 240 MG,
BROOKS INSULIN                  CAMPTOSAR 300 MG/15ML 77 300 MG, 360 MG, 420 MG   92
SYRINGE/0.3ML/29G X 1/2" 143                             CARDURA 1 MG, 2 MG, 4 MG, 8
BROVANA 15 MCG/2ML         38   CANASA 1000 MG       131 MG                       61
                                                         CARDURA XL 4 MG, 8 MG 133
BUPHENYL                  125   CANCIDAS 50 MG, 70 MG 55
                                                         CAREONE ULTIGUARD
BUPHENYL 500 MG           125   CANTIL 25 MG         191 INSULIN SYRINGE/0.3ML/29G X
                                                         1/2"                    143
                                CAPASTAT SULFATE 1 GM 66 CAREONE UNIFINE PENTIPS
BUPRENEX 0.3 MG/ML         27                            29GX12MM                143
BUSPAR 10 MG, 15 MG, 30 MG,     CAPEX 0.01 %         112 CAREONE UNIFINE PENTIPS
5 MG                     34                              31GX6MM                 143


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CARIMUNE NANOFILTERED 1      CEFTAZIDIME/DEXTROSE 1-
                                                             CEREZYME 200 UNIT         135
GM, 12 GM, 3 GM, 6 GM    179 5 %, GM/50ML, 2-5 %,
                             GM/50ML                    97
CARMOL-HC 1-10 %         112 CEFTIN 125 MG/5ML, 250          CEREZYME 400 UNIT         135
                             MG/5ML                     96
CARNITOR 1 GM/10ML       125                                 CERUBIDINE 20 MG           72
                             CEFTIN 250 MG, 500 MG 96
CARNITOR 200 MG/ML       125 CEFTRIAXONE IN ISO-             CERVARIX                  196
                             OSMOTIC DEXTROSE 20
CARNITOR 330 MG          125 MG/ML                      97   CESAMET 1 MG               54
                             CEFTRIAXONE IN ISO-
CARNITOR SF 1 GM/10ML 126 OSMOTIC DEXTROSE 40                CHANTIX 0.5 MG, 1 MG      187
                             MG/ML                      97
                                                             CHANTIX CONTINUING
CARTROL 2.5 MG, 5 MG      91 CEFTRIAXONE/DEXTROSE 1-
                             3.74 %, GM, 2-2.22 %, GM 97     MONTHPAK 1 MG         187
                                                             CHANTIX STARTING MONTH
CASODEX 50 MG             70 CEFUROXIME/DEXTROSE
                             1.5-2.9 %, GM, 4.1-750 %,       PAK                   187
CATAFLAM 50 MG            16 MG                         96   CHEMET 100 MG              53
                             CEFZIL 125 MG/5ML, 250
CATAPRES 0.1 MG, 0.2 MG, 0.3 MG/5ML                     96   CHLORAMPHENICOL SODIUM
MG                        61                                 SUCCINATE 1 GM       31
CATAPRES-TTS-1 0.1           CEFZIL 250 MG, 500 MG      96
                                                             CHLOROMYCETIN 1 GM         31
MG/24HR                   61 CELEBREX 100 MG, 200 MG,
CATAPRES-TTS-2 0.2           400 MG, 50 MG              17   CILOXAN 0.3 %             172
MG/24HR                   62
CATAPRES-TTS-3 0.3           CELESTONE 0.6 MG/5ML 102
                                                             CIMZIA 200 MG, 200 MG/ML 131
MG/24HR                   62 CELESTONE-SOLUSPAN 0.1-
                                                             CIMZIA STARTER KIT 200
CAYSTON 75 MG             29 0.2-3 MG/ML               103
                             CELEXA 10 MG, 20 MG, 40         MG/ML                     131
CEDAX 180 MG/5ML, 90         MG                         46   CINRYZE 500 UNIT          134
MG/5ML                    97
                             CELEXA 10 MG/5ML           46   CIPRO 250 MG, 500 MG, 750
CEDAX 400 MG              97                                 MG                         129
CEENU 10 MG, 100 MG, 40      CELLCEPT 200 MG/ML         88   CIPRO 5 GM/100ML, 500
MG                        67                                 MG/5ML                     129
                             CELLCEPT 250 MG            88   CIPRO HC 0.2-1-9 %,
CEENU 300 MG              67                                 MG/ML                      178
CEFAZOLIN SODIUM 5-500 %,    CELLCEPT 500 MG            88   CIPRO I.V. 10 MG/ML, 400
MG                        95 CELLCEPT INTRAVENOUS            MG                         129
CEFAZOLIN                    500 MG                     88   CIPRO I.V. 200 MG/20ML, 400
SODIUM/DEXTROSE , 1-4 %,                                     MG/40ML                    129
GM                        95 CELONTIN 300 MG            44   CIPRO I.V.-IN D5W 200
CEFEPIME 1 GM/50ML, 2        CENESTIN 0.3 MG, 0.45 MG,       MG/20ML, 200-5 %, MG, 400
GM/100ML                  98 0.625 MG, 0.9 MG, 1.25          MG/40ML, 400-5 %, MG       129
CEFIZOX IN DEXTROSE 5% 1-5 MG                          128   CIPRO I.V.-IN D5W 200-5 %,
%, GM/50ML, 2-5 %,                                           MG/100ML, 400-5 %,
GM/50ML                   97 CEREBYX 100 MG PE/2ML 44        MG/200ML                   129
CEFOTAXIME SODIUM 20                                         CIPRO XR 1000 MG, 500
GM                        97 CEREBYX 500 MG PE/10ML44        MG                         129
CEFOTETAN/DEXTROSE 1-3.58                                    CIPRODEX 0.1-0.3 %        178
%, GM, 2-2.08 %, GM       96 CEREDASE 80 UNIT/ML 135
                                                             CIPROFLOXACIN 1200
                                                             MG/120ML                  129

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                                                             CLINIMIX 5%/DEXTROSE 20%
CISPLATIN 200 MG/200ML    67 CLICKFINE PEN NEEDLE 143        1035-20-200-210-240-250-280-
                             UNIVERSAL/31GX1/4"
CLAFORAN 1 GM, 10 GM, 2      CLICKFINE PEN                   290-300-340-365-42-515-575-90
GM                        97 NEEDLES/31GX1/4"         143    GM/100ML, MEQ/L,
                                                             MG/100ML                   167
CLAFORAN 1 GM, 2 GM       97 CLICKFINE UNIVERSAL PEN         CLINIMIX 5%/DEXTROSE 25%
                             NEEDLES 31GX1/4"         143
                             CLIMARA 0.025 MG/24HR,          1035-20-200-210-240-25-250-
CLAFORAN 500 MG           97 0.05 MG/24HR, 0.06              280-290-300-340-365-42-515-
CLAFORAN/D5W 1-5 %,          MG/24HR, 0.075 MG/24HR,         575-90 GM/100ML, MEQ/L,
GM/50ML, 2-5 %, GM/50ML 97 0.1 MG/24HR, 37.5                 MG/100ML                   167
                             MCG/24HR                 128    CLINIMIX E 2.75%/DEXTROSE
CLARINEX 0.5 MG/ML        57 CLIMARA PRO 0.015-0.045         10% 10-11-110-112-116-132-
                             MG/DAY                   127    138-154-159-160-165-187-201-
CLARINEX 5 MG             57                                 217-261-316-33-454-50-51-570
                             CLINDAGEL 1 %            106    GM/100ML, MG/100ML         167
CLARINEX REDITABS 2.5 MG, 5                                  CLINIMIX E 2.75%/DEXTROSE
MG                        57 CLINDAMYCIN PHOSPHATE           5% 11-110-112-116-132-138-
CLARINEX-D 12 HOUR 120-2.5 150 MG/ML                    32   154-159-160-165-187-201-217-
MG                       105 CLINDESSE 2 %            197    261-316-33-454-5-50-51-570
CLARINEX-D 24 HOUR 240-5                                     GM/100ML, MG/100ML         167
MG                       105 CLINIMIX 2.75%/DEXTROSE         CLINIMIX E 4.25%/DEXTROSE
                             5% 11-110-116-132-138-154-      25% 17-170-179-204-213-238-
CLEOCIN 100 MG           197 159-160-165-187-201-24-283-     247-25-255-261-289-297-311-33-
                             316-5-50-570 GM/100ML,          489-51-702-77-880 GM/100ML,
CLEOCIN 150 MG, 300 MG 32 MEQ/1000ML, MG/100ML 166           MG/100ML                   167
                             CLINIMIX 4.25%/DEXTROSE         CLINIMIX E 4.25%/DEXTROSE
CLEOCIN 2 %              197 10% 10-17-170-179-204-213-      5% 17-170-179-204-213-238-
                             238-247-255-289-311-37-438-     247-255-261-289-297-311-33-
CLEOCIN 75 MG             32 489-77-880 GM/100ML,            489-5-51-702-77-880 GM/100ML,
                             MEQ/L, MG/100ML          166    MG/100ML                   167
CLEOCIN IN D5W , 300-5 %,    CLINIMIX 4.25%/DEXTROSE         CLINIMIX E 5%/DEXTROSE
MG/50ML                   32 20% 17-170-179-20-204-213-      15% 1035-15-20-200-210-240-
CLEOCIN PHOSPHATE 150        238-247-255-289-311-37-438-     250-261-280-290-300-33-340-
MG/ML                     32 489-77-880 GM/100ML,            365-51-575-59-826-90
CLEOCIN PHOSPHATE 150        MEQ/L, MG/100ML          166    GM/100ML, MG/100ML         167
MG/ML, 300 MG/2ML         32 CLINIMIX 4.25%/DEXTROSE         CLINIMIX E 5%/DEXTROSE
CLEOCIN PHOSPHATE 600        25% 17-170-179-204-213-238-     20% 1035-20-200-210-240-250-
MG/4ML                    32 247-25-255-289-311-37-438-      261-280-290-300-33-340-365-51-
CLEOCIN PHOSPHATE 600        489-77-880 GM/100ML,            575-59-826-90 GM/100ML,
MG/4ML, 900 MG/6ML        32 MEQ/L, MG/100ML          166    MG/100ML                   167
                             CLINIMIX 4.25%/DEXTROSE         CLINIMIX E 5%/DEXTROSE
CLEOCIN-T 1 %            106 5% 17-170-179-204-213-238-      25% 1035-20-200-210-240-25-
                             247-255-289-311-37-438-489-     250-261-280-290-300-33-340-
CLEOCINGALAXY 5-600 %,       5-77-880 GM/100ML, MEQ/L,
MG/50ML, 5-900 %, MG/50ML 32 MG/100ML                        365-51-575-59-826-90
                                                      167    GM/100ML, MG/100ML         167
CLEVER CHOICE COMFORT        CLINIMIX 5%/DEXTROSE 15%
EZINSULIN                                                    CLINIMIX E 5%/DEXTROSE
                             1035-15-20-200-210-240-250-     35% 1035-20-200-210-240-250-
SYRINGE/0.3ML/29G X 1/2" 143 280-290-300-340-365-42-515-
CLEVER CHOICE COMFORT                                        261-280-290-300-33-340-35-365-
                             575-90 GM/100ML,                51-575-59-826-90 GM/100ML,
EZINSULIN SYRINGE/U-         MEQ/1000ML, MG/100ML 167
100/1ML/31GX5/16"        143                                 MG/100ML                   168
CLEVER CHOICE COMFORT                                        CLINORIL 200 MG            17
EZPEN NEEDLES
31GX6MM                  143                                 CLOBEX 0.05 %             112


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CLOBEX 0.5 %             112 COMBIVIR 150-300 MG    83 CORTISPORIN 0.5-10000 %, 108
                                                       UNIT/GM
CLODERM 0.1 %            112 COMBUNOX 400-5 MG      24 CORTISPORIN 1-10000-5 %, 174
                                                       MG/ML, UNIT/ML
CLODERM PUMP 0.1 %       113 COMPLERA 200-25-300 MG 83 CORTISPORIN-TC 0.002-0.5-10-
                                                       3-3.3 %, MG/ML           178
CLOLAR 1 MG/ML            68 COMTAN 200 MG            78 CORZIDE 40-5 MG, 5-80 MG 63

CLOZAPINE 200 MG          81 COMVAX 5-7.5         196 COSMEGEN 0.5 MG               72
                             MCG/0.5ML
CLOZARIL 100 MG, 25 MG    81 CONCERTA 18 MG, 27 MG, 36 COSOPT 0.5-2 %              170
                             MG, 54 MG              13
COARTEM 120-20 MG         65 CONDYLOX 0.5 %          118 COSOPT 22.3-6.8 MG/ML     170
                                                           COUMADIN 1 MG, 10 MG, 2
COGENTIN 1 MG/ML            78 CONDYLOXW/APPLICATORS MG, 2.5 MG, 3 MG, 4 MG, 5 MG,
                               0.5 %                  118
                                                           6 MG, 7.5 MG              40
COGNEX 10 MG, 20 MG       185 COPAXONE 20 MG/ML       186
                                                           COUMADIN 5 MG             40
COGNEX 30 MG, 40 MG       185 COPEGUS 200 MG            86 COVERA-HS 180 MG, 240
                                                           MG                        92
COLAZAL 750 MG            131 CORDARONE 200 MG          36 COZAAR 100 MG, 25 MG, 50
                                                           MG                        61
COLCRYS 0.6 MG            133 CORDARONE I.V. 50            CREON 12000-38000-60000
                               MG/ML                    36
                                                           UNIT, 120000-24000-76000
COLESTID 1 GM               58 CORDRAN 0.05 %, 0.5 % 113 UNIT, 15000-3000-9500 UNIT,
                                                           19000-30000-6000 UNIT    120
COLESTID 5 GM               58 CORDRAN SP 0.05 %      113 CRESTOR 10 MG, 20 MG, 40
                                                           MG, 5 MG                  59
COLESTID FLAVORED 5 GM 58 CORDRAN TAPE 4
                               MCG/SQCM               113 CRINONE 4 %, 8 %          198
COLESTID FLAVORED 5            COREG 12.5 MG, 25 MG,
GM/7.5GM                    58 3.125 MG, 6.25 MG        90 CRIXIVAN 100 MG, 333 MG 83
                               COREG CR 10 MG, 20 MG, 40
COLY-MYCIN M 150 MG         29 MG, 80 MG                90 CRIXIVAN 200 MG, 400 MG 83
COLY-MYCIN S 0.002-0.5-10-3- CORGARD 160 MG             91
3.3 %, MG/ML              178                              CUBICIN 500 MG            31
                               CORGARD 20 MG, 40 MG, 80
COLY-MYCIN-M 150 MG         29 MG                       91 CUPRIMINE 125 MG          88
COLYTE 2.98-22.72-240-5.84-    CORTEF 10 MG, 20 MG, 5
6.72 GM                   137 MG                      103 CUPRIMINE 250 MG           88
COLYTE-FLAVOR PACKS 2.82- CORTENEMA 100 MG/60ML28
21.5-227.1-5.53-6.36 GM   137                              CUTIVATE 0.005 %         113
COLYTE-FLAVOR PACKS 2.98- CORTIFOAM 90 MG               28
22.72-240-5.84-6.72 GM    137                              CUTIVATE 0.05 %          113
                               CORTISPORIN 0.01-1-10000-
COMBIGAN 0.005-0.2-0.5 % 170 3.5 %, MG/ML, UNIT/ML    178 CUVPOSA 1 MG/5ML          192
COMBIPATCH 0.05-0.14           CORTISPORIN 0.1-1-10000-
MG/DAY, 0.05-0.25 MG/DAY 127 3.5 %, MG/ML, UNIT/ML    178 CVS INSULIN
COMBIVENT 103-18               CORTISPORIN 0.5-1-400-5000 SYRINGE/0.3ML/29G X 1/2" 143
MCG/ACT                     38 %, UNIT/GM             108 CYCLESSA                   99



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                            DAYTRANA 10 MG/9HR, 15
CYCLOCORT 0.1 %         113 MG/9HR, 20 MG/9HR, 30          DEPEN TITRATABS 250 MG 88
                            MG/9HR                 13
CYCLOSET 0.8 MG          49                                DEPO-MEDROL 20 MG/ML 103
                            DAZIDOX 20 MG          20
                                                           DEPO-MEDROL 40 MG/ML, 80
CYKLOKAPRON 100 MG/ML 136
                            DDAVP 0.01 %          126      MG/ML                  103
CYMBALTA 20 MG, 30 MG, 60                                  DEPO-PROVERA 400 MG/ML 70
MG                       47 DDAVP 0.1 MG, 0.2 MG  126
                                                           DEPO-PROVERA
CYSTADANE               126                                CONTRACEPTIVE 150
                            DDAVP 4 MCG/ML        126
                                                           MG/ML                 102
CYSTAGON 150 MG, 50 MG 132                                 DEPO-SUBQ PROVERA 104
                            DECAVAC 2-5 LFU       191      104 MG/0.65ML         102
CYTARABINE 100 MG        69                                DERMA-SMOOTHE/FS BODY
                            DELATESTRYL 200 MG/ML 28
CYTARABINEAQUEOUS 20                                       OIL 0.01 %            113
MG/ML                    69 DELESTROGEN 10 MG/ML,          DERMA-SMOOTHE/FS SCALP
CYTOMEL 25 MCG, 5 MCG, 50   20 MG/ML, 40 MG/ML    128      OIL 0.01 %            113
MCG                     190 DEMADEX 10 MG, 100 MG, 20      DERMATOP 0.1 %          113
CYTOTEC 100 MCG, 200        MG, 5 MG              121
MCG                     194 DEMEROL 100 MG, 50 MG 20       DERMOTIC 0.01 %         179
CYTOVENE 250 MG           86 DEMEROL 100 MG/2ML, 25
                                                      20 DESFERAL 2 GM, 500 MG      53
                             MG/0.5ML, 75 MG/1.5ML
CYTOVENE 500 MG           86 DEMEROL 100 MG/ML, 50
CYTOXAN 1 GM, 2 GM, 500      MG/ML                    20 DESOGEN 0.15-30 MCG, MG 99
MG                        67 DEMEROL 25 MG/ML, 75
                                                      20 DESONATE 0.05 %           113
                             MG/ML
CYTOXAN 25 MG, 50 MG      67
                             DEMEROL 50 MG/5ML        20   DESOWEN 0.05 %          113
D&K INSULIN SYRINGE/U-
100/0.3ML/29G X 1/2"     143 DEMEROL 75 MG/1.5ML           DESOWEN CREAM/CETAPHIL
                                                      20   LOTION 0.05 %          113
D.H.E. 45 1 MG/ML        152                               DESOWEN LOTION/CETAPHIL
                              DEMSER 250 MG           61   CREAM 0.05 %           113
DACARBAZINE 100 MG         74 DEMULEN 1/35-28 1-35 MCG,    DESOWEN
                              MG                      99   OINTMENT/CETAPHIL LOTION
DACOGEN 50 MG              69 DEMULEN 1/50-28 1-50 MCG,    0.05 %                 113
                              MG                      99   DESOXIMETASONE 0.05 % 114
DALIRESP 500 MCG           37
                              DENAVIR 1 %            111
DANTRIUM 100 MG, 25 MG, 50                                 DESOXYN 5 MG             13
MG                       161 DEPACON 100 MG/ML        44   DESYREL 100 MG, 150 MG, 300
DANTRIUM IV 20 MG        161                               MG, 50 MG                45
                              DEPAKENE 250 MG         44
DAPTACEL 10-15-5 LF/0.5ML,                                 DETROL 1 MG, 2 MG       195
MCG/0.5ML                191 DEPAKENE 250 MG/5ML      44
DARAPRIM 25 MG             65 DEPAKOTE 125 MG, 250 MG,     DETROL LA 2 MG, 4 MG    195
                              500 MG                  45   DEXEDRINE 10 MG, 15 MG, 5
DAUNOXOME 2 MG/ML          73 DEPAKOTE ER 250 MG, 500      MG                        13
                              MG                      45   DEXEDRINE 5 MG           13
DAYPRO 600 MG              17 DEPAKOTE SPRINKLES 125
                              MG                      45   DEXILANT 30 MG, 60 MG   193


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DEXTROSE 10%/NACL 0.45%          DILAUDID 4 MG/ML       20 DOLOPHINE HCL 5 MG        20
0.45-10 %                  153
DEXTROSE
5%/ELECTROLYTE #48               DILAUDID-5 1 MG/ML     20 DORIBAX 250 MG            31
VIAFLEX 20-23-24-25-3-5 %,
MEQ/L                      153   DILAUDID-HP 10 MG/ML   20 DORIBAX 500 MG            31
DEXTROSE 10%/NACL 0.2%
0.2-10 %                   153   DILAUDID-HP 250 MG     20 DORYX 100 MG, 150 MG, 75 188
                                                           MG
DEXTROSE 5%/NACL 0.225%
0.225-5 %                  154   DILTIAZEM HCL 100 MG   93 DOSTINEX 0.5 MG          127
DEXTROSE 5%/NACL 0.3% 0.3-    DIMENHYDRINATE 50
5%                         154                              DOVONEX 0.005 %         110
                              MG/ML                    54
DEXTROSE 5%/POTASSIUM         DIOVAN 160 MG, 320 MG, 40
CHLORIDE 0.075% 0.075-5 %,                                  DOVONEX SCALP 0.005 % 110
                              MG, 80 MG                61
10-5 %, MEQ/L              154DIOVAN HCT 12.5-160 MG,
                                                            DOXIL 2 MG/ML            73
DEXTROSTAT 10 MG           13 12.5-320 MG, 12.5-80 MG,
                              160-25 MG, 25-320 MG     63   DROXIA 200 MG, 300 MG, 400
DIABETA 1.25 MG, 2.5 MG, 5                                  MG                       135
MG                         52 DIPENTUM 250 MG         131
                                                            DRUG EMPORIUM INSULIN
DIAMOX 500 MG             120 DIPHTHERIA/TETANUS            SYRINGE/U-100/0.3ML/29G X
                              TOXOID PEDIATRIC 5-6.7        1/2"                     143
DIBENZYLINE 10 MG          61 LFU/0.5ML               191   DRUG MART ULTRA COMFORT
                              DIPROLENE 0.05 %        114   INSULIN SYRINGE/0.3ML/29G X
DIDRONEL 400 MG           122                               1/2"                     143
                                                            DRUG MART UNIFINE
                              DIPROLENE 0.5 %         114   PENTIPS29G X 12MM        143
DIFFERIN 0.1 %            106
                                                            DRUG MART UNIFINE
                              DIPROLENE AF 0.05 %     114   PENTIPS31GX6MM           143
DIFFERIN 0.3 %            106
                              DITROPAN 5 MG           195   DTIC-DOME 200 MG         74
DIFICID 200 MG            141
                              DITROPAN 5 MG/5ML       195   DUAC 1-5 %              106
DIFLUCAN 10 MG/ML, 40
MG/ML                      55 DITROPAN XL 10 MG, 15 MG,     DUANE READE UNIFINE
DIFLUCAN 100 MG, 150 MG,      5 MG                    195   PENTIPS 29G X 12MM     143
200 MG, 50 MG              55                               DUANE READE UNIFINE
                              DIURIL 250 MG/5ML       121   PENTIPS 31G X 6MM ULTRA
DIFLUCAN IN ISO-OSMOTIC
DEXTROSE 400 MG/200ML 56                                    SHORT                  143
DIFLUCAN IN NACL 0.9-200 %, DIURIL IV 500 MG          121
                                                            DUETACT 2-30 MG, 30-4 MG 48
MG/100ML                   56 DIVIGEL 0.25 MG/0.25GM, 0.5
DIFLUCAN IN NACL 0.9-400 %, MG/0.5GM, 1 MG/GM         128   DUEXIS 26.6-800 MG       17
MG/200ML                   56 DOBUTAMINE/DEXTROSE
DILACOR XR 120 MG, 180 MG, 5% 0.25-4-5 %, MG/ML       199   DULERA , 100-5 MCG/ACT,
240 MG                     92                               200-5 MCG/ACT           38
                              DOCEFREZ 20 MG, 80 MG 76
DILANTIN 125 MG/5ML        44                               DUONEB 0.5-2.5 MG/3ML    38
                              DOCETAXEL 160 MG/16ML,
                                                            DURACLON 100 MCG/ML, 500
                           33 20 MG/2ML, 80 MG/8ML     76
DILATRATE SR 40 MG                                          MCG/ML                  19
                              DOCETAXEL 20 MG/0.5ML, 80
                                                            DURAGESIC 100 MCG/HR, 12
DILAUDID 1 MG/ML, 2 MG/ML 20 MG/2ML                    76
                              DOCETAXEL 20 MG/ML, 80        MCG/HR, 25 MCG/HR, 50
                                                            MCG/HR, 75 MCG/HR       20
DILAUDID 2 MG, 4 MG, 8 MG 20 MG/4ML                    76
                              DOLOPHINE 10 MG          20   DUREZOL 0.05 %          175


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DURICEF 1 GM              95 EFFEXOR XR 150 MG, 37.5 47 ELOXATIN 50 MG           67
                             MG, 75 MG
DURICEF 250 MG/5ML, 500
                          95 EFFEXOR XR 37 MG       47 ELSPAR 10000 UNIT         74
MG/5ML
DURICEF 500 MG            95 EFFIENT 10 MG, 5 MG   134 EMADINE 0.05 %           177

DUTOPROL                  63 EFUDEX 2 %, 5 %       110 EMBEDA 0.8-20 MG, 2.4-60 MG,
                                                       3.2-80 MG                 20
                                                       EMBEDA 1.2-30 MG, 100-4 MG,
DYAZIDE 25-37.5 MG        120 EFUDEX 5 %           110 2-50 MG                   20
DYNACIN 75 MG             188 EGRIFTA 1 MG         123 EMCYT 140 MG              71

DYNACIRC CR 10 MG, 5 MG 93 ELAPRASE 6 MG/3ML       126 EMEND , 125 MG, 80 MG     55

DYNACIRC-CR 5 MG          93 ELDEPRYL 5 MG          79 EMEND 115 MG, 150 MG      55

DYRENIUM 100 MG, 50 MG 121 ELESTAT 0.05 %          177 EMEND 40 MG               55
E.E.S. GRANULES 200
                          140 ELESTRIN 0.06 %      128 EMLA 2.5 %               118
MG/5ML
                                                   118 EMSAM 129 MG/24HR 6
                                                                MG/24HR,
EASY TOUCH 32GX5MM        143 ELIDEL 1 %               MG/24HR,                  46
EASY TOUCH 32GX6MM        143 ELIGARD 22.5 MG       71 EMTRIVA 10 MG/ML          83
EASY TOUCH INSULIN
SYRINGE/U-100/1ML/31G X        ELIGARD 30 MG        71 EMTRIVA 200 MG            83
5/16"                    143
EASY TOUCH PEN NEEDLES         ELIGARD 45 MG        71 ENABLEX 15 MG, 7.5 MG    195
29GX1/2"                 144
EASY TOUCH PEN NEEDLES         ELIGARD 7.5 MG       71 ENBREL 25 MG              19
31GX1/4"                 144
EC-NAPROSYN 375 MG, 500        ELIMITE 5 %         119 ENBREL 25 MG/0.5ML, 50
                                                       MG/ML                     19
MG                        17
ECK INSULIN                    ELIPHOS 667 MG      132 ENBREL SURECLICK 50
                                                       MG/ML                      19
SYRINGE/0.3ML/29G X 1/2" 144ELITE-THIN INSULIN
                                                       ENDOMETRIN 100 MG         198
ECONOPRED PLUS 1 %      175 SYRINGE/U-100/1ML/31G X
                            5/16"                  144 ENGERIX-B 10 MCG/0.5ML, 20
EDARBI 40 MG, 80 MG      61 ELITEK 1.5 MG, 7.5 MG   75 MCG/ML                    196
                                                       ENJUVIA 0.3 MG, 0.45 MG,
EDARBYCLOR               63 ELLA 30 MG             102 0.625 MG, 0.9 MG, 1.25 MG 128
                                                       ENTOCORT EC 3 MG          103
EDECRIN 25 MG           121 ELLENCE 200 MG/100ML, 50
                            MG/25ML                 73
                                                       EPIDUO 0.1-2.5 %          106
EDLUAR 10 MG, 5 MG      136 ELMIRON 100 MG         133
                                                       EPIFOAM 1 %               114
EDURANT 25 MG            83 ELOCON 0.1 %           114
                                                       EPINEPHRINE 0.15 MG/0.15ML,
EFFEXOR 100 MG, 25 MG, 37.5 ELOXATIN 100 MG/20ML, 50   0.3 MG/0.3ML              198
MG, 50 MG, 75 MG         47 MG/10ML                 67
                                                       EPIPEN 0.3 MG/0.3ML       198
EFFEXOR 37 MG            47 ELOXATIN 200 MG/40ML 67



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EPIPEN 2-PAK 0.3                                            EXFORGE HCT 10-12.5-160
MG/0.3ML                  198 ERYTHROCIN 1000 MG 141        MG, 10-160-25 MG, 10-25-320
                              ERYTHROCIN                    MG, 12.5-160-5 MG, 160-25-5
EPIPEN-JR 0.15 MG/0.3ML 198 LACTOBIONATE 1000 MG,           MG                          63
EPIPEN-JR 2-PAK 0.15          500 MG                  141   EXJADE 125 MG              53
MG/0.3ML                  198 ESKALITH 300 MG          79
EPIRUBICIN HCL 10 MG/5ML,                                   EXJADE 250 MG, 500 MG      53
150 MG/75ML                73 ESKALITH CR 450 MG       79
EPIRUBICIN HCL 50 MG       73 ESTRACE 0.5 MG, 1 MG, 2       EXTAVIA 0.3 MG            186
                              MG                      128
EPIVIR 10 MG/ML            83 ESTRADERM 0.05 MG/24HR,       EXTINA 2 %                108
                              0.1 MG/24HR             128
EPIVIR 150 MG, 300 MG      83 ESTRASORB 4.35                EYLEA 2 MG/0.05ML         171
                              MG/1.74GM               128
EPIVIR HBV 100 MG          83                               FABRAZYME 35 MG           126
                              ESTRING 2 MG            198
EPIVIR HBV 5 MG/ML         83                               FABRAZYME 5 MG            126
                              ESTROSTEP FE 1-75 MG 99
EPOGEN 10000 UNIT/ML, 2000                                  FACTIVE 320 MG            129
UNIT/ML, 20000 UNIT/ML, 3000 ETHYOL 500 MG             76
UNIT/ML, 4000 UNIT/ML     135                            FAMOTIDINE PREMIXED 0.4-
                                                         0.9 %, MG/ML             192
EPOGEN 40000 UNIT/ML     135 ETOPOPHOS 100 MG         76 FAMVIR 125 MG, 250 MG, 500
                                                         MG                        87
EPZICOM 300-600 MG        83 EURAX 10 %              119 FANAPT 1 MG, 10 MG, 12 MG, 2
EQL INSULIN                                              MG, 4 MG, 6 MG, 8 MG      80
                             EVAMIST 1.53 MG/SPRAY 128
SYRINGE/0.3ML/29G X 1/2" 144                             FANAPT TITRATION PACK 80
EQL INSULIN                  EVISTA 60 MG            125
SYRINGE/1ML/31G X 5/16" 144                              FANSIDAR 25-500 MG        65
EQL INSULIN SYRINGE/U-
                         144 EVOCLIN 1 %             107
100/0.3ML/29G X 1/2"                                     FARESTON 60 MG            71
EQL ULTRA SHORT PEN          EVOXAC 30 MG            160 FASLODEX 125 MG/2.5ML, 250
NEEDLES 31G X 6MM        144
EQUETRO 100 MG, 200 MG,      EXALGO 12 MG, 16 MG, 8      MG/5ML                    71
300 MG                    80 MG                       21 FAZACLO 100 MG, 12.5 MG,
                             EXEL INSULIN PEN            150 MG, 200 MG, 25 MG     81
ERAXIS 100 MG, 50 MG      55 NEEDLES29GX1/2" 12MM 144
                                                         FELBATOL 400 MG, 600 MG 43
ERBITUX 100 MG/50ML, 200     EXEL INSULIN PEN
MG/100ML                  70 NEEDLES31GX1/4" 6MM 144 FELBATOL 600 MG/5ML           43
                             EXEL INSULIN
ERGOMAR 2 MG             152 SYRINGE/0.3ML/29G X
                             1/2"                    144 FELDENE 10 MG, 20 MG      17
ERIVEDGE 150 MG           70
                             EXELDERM 1 %            108 FEMARA 2.5 MG             71
ERTACZO 2 %              108 EXELON 1.5 MG, 3 MG, 4.5
                             MG, 6 MG                185 FEMCON FE 0.4-35 MCG, MG 99
ERYGEL 2 %               106
                             EXELON 2 MG/ML          185 FEMHRT 1/5 1-5 MCG, MG 127
ERYPED 200 200 MG/5ML 141 EXELON 4.6 MG/24HR, 9.5        FEMHRT LOW DOSE 0.5-2.5
                             MG/24HR                 185 MCG, MG                  127
ERYPED 400 400 MG/5ML 141 EXFORGE 10-160 MG, 10-320
                             MG, 160-5 MG, 320-5 MG 63

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FEMRING 0.05 MG/24HR, 0.1
                         198 FLO-PRED 15 MG/5ML       103 FORTAZ 1 GM, 2 GM, 500 MG97
MG/24HR
FEMTRACE 0.45 MG, 0.9                                  94 FORTAZ 1-5 %, GM/50ML, 2-5 97
MG                       128 FLOLAN 0.5 MG, 1.5 MG        %, GM/50ML
FEMTRACE 1.8 MG         128 FLOMAX 0.4 MG             133 FORTAZ 6 GM                 97

FENOGLIDE 120 MG, 40 MG 59 FLONASE 50 MCG/ACT         162 FORTEO 600 MCG/2.4ML, 750
                                                          MCG/3ML                 122
FENTORA 100 MCG, 200 MCG, FLOVENT DISKUS 100
400 MCG, 600 MCG, 800       MCG/BLIST, 250 MCG/BLIST,       FORTESTA 10 MG/ACT        28
MCG                      21 50 MCG/BLIST             37     FOSAMAX 10 MG, 35 MG, 40
                            FLOVENT HFA 110 MCG/ACT,        MG, 5 MG, 70 MG         122
FENTORA 300 MCG          21 220 MCG/ACT, 44
                            MCG/ACT                  37     FOSAMAX 70 MG/75ML       122
FERRIPROX 500 MG         53 FLOXIN 200 MG, 300 MG, 400
                                                            FOSAMAX PLUS D 2800-70 MG,
                            MG                      129     UNIT, 5600-70 MG, UNIT 123
FIBRICOR 105 MG, 35 MG   59
                            FLOXIN OTIC 0.3 %       178     FOSCARNET SODIUM 24
FIFTY50 SUPERIOR                                            MG/ML                   86
COMFORTINSULIN              FLOXIN OTIC SINGLES 0.3
SYRINGE/1ML/31G X 5/16" 144 %                       178     FOSCAVIR 24 MG/ML         86
FINACEA 15 %            119 FLUDARA 50 MG               69 FOSRENOL 1000 MG, 250 MG,
                                                           500 MG, 750 MG             132
FIORICET/CODEINE 30-325-40-   FLUMADINE 100 MG          87 FP INSULIN
50 MG                    24                                SYRINGE/0.3ML/29G X 1/2" 144
FIORINAL/CODEINE #3 30-325-   FLUOROPLEX 1 %           110 FP INSULIN SYRINGE/1ML/31G
40-50 MG                 24                                X 5/16"                    144
                              FLUOROURACIL 500             FP INSULIN SYRINGE/U-
FIRAZYR 30 MG/3ML       134   MG/10ML                   69 100/0.3ML/29G X 1/2"       144
FIRMAGON 120 MG          71   FLUOXETINE HCL 60 MG 46      FRAGMIN 10000 UNIT/ML,
                                                           12500 UNIT/0.5ML, 15000
                              FLUPHENAZINE DECANOATE UNIT/0.6ML, 18000 UNT/0.72ML,
FIRMAGON 80 MG           71   25 MG/ML                  82 2500 UNIT/0.2ML, 25000
FIRST CHOICE INSULIN
SYRINGE/U-100/0.3ML/29G X     FML 0.1 %                175 UNIT/ML, 5000 UNIT/0.2ML,
                                                           7500 UNIT/0.3ML             40
1/2"                    144                                FRAGMIN 10000 UNIT/ML, 2500
                              FML FORTE 0.25 %         175 UNIT/0.2ML, 25000 UNIT/ML,
FLAGYL 250 MG, 500 MG    30
                                                           5000 UNIT/0.2ML, 7500
                              FML LIQUIFILM 0.1 %      175 UNIT/0.3ML                  40
FLAGYL 375 MG            29
                              FOCALIN 10 MG, 2.5 MG, 5     FRAGMIN 95000 UNIT/9.5ML 40
FLAGYL ER 750 MG         30   MG                        13
                              FOCALIN XR 10 MG, 15 MG,     FREAMINE HBC 6.9% 10-1370-
FLAREX 0.1 %            175   20 MG, 25 MG, 30 MG, 35 MG, 14-160-200-250-3-320-330-400-
                              40 MG, 5 MG               13 410-580-59.3-630-760-880-90
                              FOLOTYN 20 MG/ML, 40         MEQ/L, MG/100ML            168
FLEBOGAMMA 5 %          179                                FREAMINE III 10-1120-120-
                              MG/2ML                    69
FLEBOGAMMA DIF 10 %, 5        FORADIL AEROLIZER 12         1400-150-24-280-3-400-530-560-
%                      179    MCG                       38 590-660-690-710-730-89-910-
                              FORTAMET 1000 MG, 500        950 MEQ/L, MG/100ML,
FLECTOR 1.3 %           107   MG                        49 MMOLE/L                    168
FLEXERIL 10 MG, 5 MG    160 FORTAZ 1 GM, 2 GM          97



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FREAMINE III 3% 120-160-170-
180-20-200-210-220-24.5-270-     GELNIQUE 10 %           195 GLUCOTROL 10 MG, 5 MG      52
290-340-35-41-420-44-46-5-7-85
MEQ/L, MG/100ML,                 GELNIQUE 3 %             195 GLUCOTROL XL 10 MG, 2.5 52
                                                              MG, 5 MG
MMOLE/L                    168   GEMCITABINE 1 GM/26.3ML,     GLUCOVANCE 1.25-250 MG,
FREESTYLE PRECISION              2 GM/52.6ML, 200             2.5-500 MG, 5-500 MG       48
INSULIN SYRINGE/U-               MG/5.26ML                 69 GLUMETZA 1000 MG, 500
100/1ML/31G X 5/16"        144
                                 GEMZAR 1 GM, 200 MG       69 MG                         49
FROVA 2.5 MG              152                                 GLYCRON 4.5 MG             52
                                 GENERESS FE 0.8-25-75
FURADANTIN 25 MG/5ML      194    MCG, MG                   99 GLYNASE 1.5 MG, 3 MG, 6
                                 GENOTROPIN 12 MG         124 MG                         52
FUSILEV 50 MG              76                                 GLYSET 100 MG, 25 MG, 50
                                 GENOTROPIN 5 MG          124 MG                         48
FUZEON 90 MG               83                                 GNP CLICKFINE UNIVERSAL
                                 GENOTROPIN MINIQUICK 0.2 PEN NEEDLES 31GX1/4"          145
GABARONE 100 MG, 300 MG,         MG, 0.4 MG, 0.6 MG       124 GNP INSULIN
400 MG                    42     GENOTROPIN MINIQUICK 0.8 SYRINGE/0.3ML/29G X 1/2" 145
GABITRIL 12 MG, 16 MG, 2 MG,     MG, 1 MG, 1.2 MG, 1.4 MG,    GNP INSULIN
4 MG                      44     1.6 MG, 1.8 MG, 2 MG     124 SYRINGE/1ML/31G X 5/16" 145
GAMASTAN S/D              179    GENTAMICIN SULFATE/0.9% GNP ULTRA COMFORT
                                 SODIUM CHLORIDE 0.9 %,       INSULIN SYRINGE/0.3ML/29G X
                                 MG/ML, 0.9-1.4 %, MG/ML 14 1/2"                        145
GAMMAGARD LIQUID          179
                                 GEODON 20 MG              80 GNP ULTRA COMFORT
GAMMAGARD S/D 10 GM       179                                 INSULIN SYRINGE/1ML/31G X
                                 GEODON 20 MG, 40 MG, 60      5/16" SHORT               145
                                 MG, 80 MG                 80 GNP ULTRA COMFORT
GAMMAGARD S/D 2.5 GM      179
                                 GILENYA 0.5 MG           186 INSULIN SYRINGE/U-
                                                              100/0.3ML/29G X 1/2"      145
GAMMAGARD S/D 5 GM        179                                 GOLYTELY 2.82-21.5-227.1-
                                 GLASSIA 1000 MG/50ML 187 5.53-6.36 GM
GAMMAGARD S/D IGA LESS                                                                  137
THAN 1MCG/ML 10 GM        179                                 GOLYTELY 2.97-22.74-236-5.86-
                                 GLEEVEC 100 MG, 400 MG 73 6.74 GM
GAMMAGARD S/D IGA LESS                                                                  137
THAN 1MCG/ML 5 GM         179    GLOBAL EASE INJECT PEN
GAMMAKED 1 GM/10ML, 10           NEEDLES 29GX12MM         144 GRALISE 300 MG, 600 MG 186
GM/100ML, 2.5 GM/25ML, 20        GLOBAL INJECT EASE
GM/200ML, 5 GM/50ML       179    INSULIN SYRINGE/U-           GRALISE STARTER           186
GAMMAPLEX 10 GM/200ML, 2.5       100/0.3ML/29G X 1/2"     144
GM/50ML, 5 GM/100ML       179    GLOBAL INJECT EASE           GRIS-PEG 125 MG, 250 MG 55
                                 INSULIN SYRINGE/U-
GAMUNEX 10 %              179    100/1ML/31G X 5/16"      144 GYNAZOLE-1 2 %            197
GAMUNEX-C 1 GM/10ML, 10       GLUCAGEN 1 MG           49
GM/100ML, 2.5 GM/25ML, 20                                     GYNODIOL 1.5 MG          128
GM/200ML, 5 GM/50ML       180 GLUCAGEN HYPOKIT 1 MG49         H-E-B IN CONTROL PEN
GANCICLOVIR 500 MG         86 GLUCOPHAGE 1000 MG, 500         NEEDLES 31GX6MM          145
                                                              H-E-B INCONTROL PEN
                              MG, 850 MG              49      NEEDLES 29GX12MM         145
GARAMYCIN 40 MG/ML         14 GLUCOPHAGE XR 500 MG,
                              750 MG                  49      HALAVEN 1 MG/2ML          76
GARDASIL                  196 GLUCOPRO INSULIN
GASTROCROM 100                SYRINGE/U-100/1ML/31G X         HALDOL 5 MG/ML            80
MG/5ML                    130 5/16"                 144


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HALDOL DECANOATE 100 100         HEPARIN SODIUM/SODIUM
                                 CHLORIDE 0.9% 0.9-2 %,            HUMATIN 250 MG            15
MG/ML                       80
HALDOL DECANOATE 50 50           UNIT/ML                      41   HUMATROPE 12 MG, 24 MG, 5
MG/ML                       80   HEPATASOL 0.02-0.065-0.1-         MG                    124
HALDOL DECANOATE-100 100         0.115-0.24-0.45-0.5-0.6-0.77-
                                 0.8-0.81-0.84-0.9-1.1             HUMATROPE 6 MG           124
MG/ML                       81
HALDOL DECANOATE-50 50           GM/100ML                   168 HUMATROPE COMBO PACK 5
MG/ML                       81   HEPSERA 10 MG               86 MG                     124
HALFLYTELY BOWEL PREP                                           HUMIRA 20 MG/0.4ML, 40
0.74-2.86-210-5-5.6 GM, MG 137   HERCEPTIN 440 MG            70 MG/0.8ML                16
HALFLYTELY BOWEL
PREP/FLAVOR PACKS 0.74-                                            HUMIRA PEN 40 MG/0.8ML    16
                                 HEXALEN 50 MG               68
2.86-210-5-5.6 GM, MG      137                                  HUMIRA PEN-CROHNS
HALOG 0.1 %               114 HIBERIX                       195 DISEASESTARTER 40
                                                                MG/0.8ML                     16
HAVRIX 1440 ELU/ML, 720          HIBTITER 10-25 MCG         196 HUMIRA PEN-PSORIASIS
ELU/0.5ML               196                                     STARTER 40 MG/0.8ML          16
HCA INSULIN SYRINGE/U-           HIPREX 1 GM                194 HUMULIN 50/50 50 %           50
100/0.3ML/29G X 1/2"    145
HCA ULTRA COMFORT                HISTEX PD 4 MG/5ML          57 HUMULIN 70/30 30-70 %
INSULINSYRINGE/1ML/31G X                                                                     50
5/16"                   145      HIZENTRA 1 GM/5ML, 2
HEALTHWISE MINI PEN              GM/10ML, 4 GM/20ML     180 HUMULIN 70/30 PEN 30-70 % 50
NEEDLES 31GX6MM         145      HM MONOJECT INSULIN
HEALTHWISE PEN NEEDLES           SYRINGE/U-100/0.3ML/29G X HUMULIN N 100 UNIT/ML      50
29GX12MM                145      1/2"                   145 HUMULIN N U-100 PEN 100
HEALTHY ACCENTS UNIFINE          HORIZANT 600 MG        187 UNIT/ML                   50
PENTIPS PEN NEEDLES
29GX12MM                145                                        HUMULIN R 100 UNIT/ML     50
                                 HUMALOG 100 UNIT/ML         50
HEALTHY ACCENTS UNIFINE                                            HUMULIN R U-500
PENTIPS PEN NEEDLES              HUMALOG KWIKPEN 100               (CONCENTRATED) 500
31GX6MM                 145      UNIT/ML                   50      UNIT/ML                 50
HECTOROL 0.5 MCG, 1 MCG,         HUMALOG MIX 50/50 0.89-           HY-VEE INSULIN SYRINGE/U-
2.5 MCG                 126      2.2-50 %, MG/ML           50      100/0.3ML/29G X 1/2"   145
HECTOROL 2 MCG/ML, 4             HUMALOG MIX 50/50
MCG/2ML                 126      KWIKPEN 0.89-2.2-50 %,            HYCAMTIN 4 MG             77
                                 MG/ML                     50      HYDRALAZINE/HYDROCHLOR
HELIDAC                   194    HUMALOG MIX 50/50 PEN             OTHIAZIDE 25 MG      63
                                 0.89-2.2-50 %, MG/ML      50
HEPAGAM B 0.03 %          180                                      HYDREA 500 MG             74
                                 HUMALOG MIX 75/25 0.715-
HEPARIN SODIUM 2000              1.76-25-75 %, MG/ML       50
UNIT/ML                      41  HUMALOG MIX 75/25                 HYPERHEP B S/D           180
HEPARIN SODIUM 2500              KWIKPEN 0.715-1.76-25-75 %,
UNIT/ML                      40  MG/ML                     50      HYTONE 2 %               115
HEPARIN SODIUM/D5W 0.2-          HUMALOG MIX 75/25 PEN
100-5 %, MG/ML, UNIT/ML      41  0.715-1.76-25-75 %, MG/ML 50      HYTONE 2.5 %             115
HEPARIN SODIUM/D5W 100-5         HUMALOG PEN 100
                                 UNIT/ML                   50   HYTRIN 1 MG, 10 MG, 2 MG, 5
%, UNIT/ML, 5-50 %, UNIT/ML 41                                  MG                         62
HEPARIN SODIUM/NACL 0.45% HUMAPEN LUXURA HD                 145 HYZAAR 100-12.5 MG, 100-25
0.45-100 %, UNIT/ML, 0.45-50                                    MG, 12.5-50 MG             63
%, UNIT/ML                   41 HUMAPEN MEMOIR              145 IDAMYCIN PFS 10 MG/10ML, 20
                                                                MG/20ML, 5 MG/5ML          73

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IFEX 1 GM                68 INFUMORPH 500 25 MG/ML 21 INTELENCE 25 MG                 84

IFEX 3 GM                68 INLYTA 1 MG, 5 MG        73 INTRALIPID 1.2-1.7-30 %      163
IFEX/MESNEX COMBO PACK 1 INNOHEP 20000 UNIT/ML 41          INTRON-A 10 MU/0.2ML, 5
GM, 1000-3000 MG           73                              MU/0.2ML                   75
IFOSFAMIDE 3 GM            68 INNOPRAN XL 120 MG, 80 91    INTRON-A 10 MU/ML          75
                              MG
IFOSFAMIDE/MESNA 1 GM,
                           73 INSPRA 25 MG, 50 MG     65   INTRON-A 3 MU/0.2ML        74
1000-3000 MG
                           16 INSULIN SYRINGE/0.3ML/28G    INTRON-A 3000000 UNIT/0.5ML,
ILARIS 180 MG                 X 1"                   145   6000000 UNIT/ML           75
IMDUR 120 MG, 30 MG, 60       INSULIN SYRINGE/0.3ML/29G    INTRON-A W/DILUENT 10 MU75
MG                         33 X 1"                   145
IMITREX 100 MG, 25 MG, 50     INSULIN SYRINGE/0.3ML/29G    INTRON-A W/DILUENT 18 MU,
MG                        152 X 1/2"                 146   50 MU                       75
IMITREX 20 MG/ACT, 5          INSULIN SYRINGE/0.3ML/29G    INTUNIV 1 MG, 2 MG, 3 MG, 4
MG/ACT                    152 X 5/16"                146   MG                          13
                              INSULIN SYRINGE/0.3ML/30G
IMITREX 6 MG/0.5ML        152 X 1"                         INVANZ 1 GM                31
                                                     146
IMITREX STATDOSE REFILL 4     INSULIN SYRINGE/0.5ML/28G    INVEGA 1.5 MG, 3 MG, 6 MG, 9
MG/0.5ML, 6 MG/0.5ML      152 X 1"                   146   MG                         80
IMITREX STATDOSE SYSTEM 4 INSULIN SYRINGE/0.5ML/30G        INVEGA SUSTENNA 117
MG/0.5ML, 6 MG/0.5ML      152 X 1"                   146   MG/0.75ML, 156 MG/ML, 234
                              INSULIN SYRINGE/1ML/31G X    MG/1.5ML, 39 MG/0.25ML, 78
IMMUNE GLOBULIN           180 5/16"                        MG/0.5ML                   80
                                                     146
IMOVAX RABIES (H.D.C.V.) 2.5 INSULIN SYRINGE/U-            INVIRASE 200 MG            84
UNIT/ML                   196 100/0.3ML/29G X 1/2"   146
IMPLANON 68 MG            102 INSULIN SYRINGE/U-           INVIRASE 500 MG            84
                              100/1ML/29G X 1"       146
                              INSULIN SYRINGE/U-           IONOSOL-B/DEXTROSE 5% 13-
IMURAN 50 MG               88 100/1ML/30G X 1"             25-49-5-57 %, MEQ/L      154
                                                     146
                              INSULIN SYRINGE/U-           IONOSOL-MB/DEXTROSE 5%
INAPSINE 2.5 MG/ML         35 100/1ML/31G X 5/16"          20-22-23-25-3-5 %, MEQ/L 154
                                                     146
                              INSUPEN PEN NEEDLES 32G      IONOSOL-T/DEXTROSE 5% 15-
INCIVEK 375 MG             86 X4MM                         20-35-40-5 %, MEQ/L      154
                                                     146
INCRELEX 40 MG/4ML        125 INSUPEN SENSITIVE            IOPIDINE 0.5 %            172
                              32GX6MM                146
INDERAL 10 MG, 20 MG, 40      INSUPEN SENSITIVE            IOPIDINE 1 %              172
MG, 60 MG, 80 MG           91 32GX8MM                146
INDERAL LA 120 MG, 160 MG,    INSUPEN ULTRAFIN             IPOL INACTIVATED IPV      196
60 MG, 80 MG               91 29GX12MM               146
                              INSUPEN ULTRAFIN             IPRIVASK 15 MG             41
INDOCIN 25 MG/5ML          17 30GX8MM                146
INFANRIX 10-25-58 LFU/0.5ML, INSUPEN ULTRAFIN              IQUIX 1.5 %               173
MCG/0.5ML                 191 31GX6MM                146
INFERGEN 15 MCG/0.5ML, 9                                   IRESSA 250 MG              73
                           86 INTAL 20 MG/2ML         36
MCG/0.3ML
INFUMORPH 200 10 MG/ML 21 INTELENCE 100 MG, 200 84         ISENTRESS 400 MG           84
                              MG



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ISMO 20 MG                33 KADIAN 10 MG, 200 MG      21 KEPPRA 500 MG/5ML           42
ISOLYTE-H/DEXTROSE 5% 13- KADIAN 100 MG, 20 MG, 30
17-3-39-42-5 %, MEQ/L  154 MG, 50 MG, 60 MG, 80 MG 21 KEPPRA XR 500 MG, 750 MG 42
ISOLYTE-P/DEXTROSE 5% 20- KALBITOR 10 MG/ML       134 KERLONE 10 MG, 20 MG     91
23-25-3-5 %, MEQ/L     155
ISONIAZID 100 MG/ML       66 KALETRA 100-25 MG         84 KETEK 300 MG                32
ISOPTIN SR 120 MG, 180 MG,    KALETRA 100-400-42.4 %,
                                                        84 KETEK 400 MG                32
240 MG                     93 MG/5ML
ISOPTO CARPINE 1 %, 2 %, 4
                          171 KALETRA 200-50 MG         84 KETEK PAK 400 MG            32
%
ISORDIL TITRADOSE 40 MG 33 KANAMYCIN SULFATE 333 15 KINERET 100 MG/0.67ML              16
                              MG/ML
                                                           KINRAY INSULIN SYRINGE
ISORDIL TITRADOSE 5 MG 33 KAPVAY 0.1 MG                 13 PREFERRED PLUS/1ML/31G X
ISOTONIC GENTAMICIN 0.9-2                                  5/16"                      146
                           15 KAYEXALATE                90 KINRIX 10-25-58 LFU/0.5ML,
%, MG/ML
                                                           MCG/0.5ML                  191
ISTALOL 0.5 %             170 KCL 0.15%/D10W/NACL 0.2%
                              0.2-10-20 %, MEQ/L       155 KLARON 10 %                107
                              KCL 0.15%/D5W/LR 130-149-
ISTODAX 10 MG              73 24-28-3-5 %, MEQ/L       155 KOMBIGLYZE XR 1000-2.5 MG,
                              KCL 0.15%/D5W/NACL           1000-5 MG, 5-500 MG         48
ISUPREL 0.2 MG/ML          38 0.225% 0.225-20-5 %,
                                                           KRISTALOSE 20 GM           137
                              MEQ/L                    155
IXEMPRA KIT 15 MG, 45 MG 76 KCL 0.15%/D5W/NACL 0.9%        KROGER INSULIN
                              0.9-20-5 %, MEQ/L        155 SYRINGE/0.3ML/29G X 1/2" 146
IXIARO                    196 KCL 0.3%/D5W/LR 130-149-     KROGER INSULIN
JAKAFI 10 MG, 15 MG, 20 MG,   28-3-44-5 %, MEQ/L       155 SYRINGE/1ML/31G X 5/16" 146
25 MG, 5 MG                74 KCL 0.3%/D5W/LR IV LAC       KROGER INSULIN SYRINGE/U-
                              RING 130-149-28-3-44-5 %,    100/0.3ML/29G X 1/2"       146
JALYN 0.4-0.5 MG          133 MEQ/L                    155 KROGER PEN NEEDLES 29G
JANUMET 1000-50 MG, 50-500    KCL 0.3%/D5W/NACL 0.9%       X12MM                      146
MG                         48 0.9-40-5 %, MEQ/L        156 KROGER PEN NEEDLES
                                                           31GX1/4"                   147
JANUMET XR                 48 KEFLEX 250 MG, 500 MG 95
                                                           KRYSTEXXA 8 MG/ML          133
JANUVIA 100 MG, 25 MG, 50     KEFLEX 750 MG             95
MG                         49                              KUVAN 100 MG               126
JE-VAX                    196 KENALOG                  115
                                                           KYTRIL 0.1 MG/ML, 1 MG/ML 54
JENTADUETO                 48 KENALOG 0.1 %            115
                                                           KYTRIL 1 MG                 54
JEVTANA 60 MG/1.5ML        77 KENALOG-10 10 MG/ML 103
                                                           KYTRIL 2 MG/10ML            54
JUVISYNC 10-100 MG, 100-20    KENALOG-40 40 MG/ML 103
MG, 100-40 MG              48                              LAC-HYDRIN 12 %            118
K-DUR 10 MEQ, 20 MEQ      158 KEPIVANCE 6.25 MG         75
                                                           LACRISERT 5 MG             170
K-TABS 10 MEQ             158 KEPPRA 100 MG/ML          42
                                                           LAMICTAL 100 MG, 150 MG,
                              KEPPRA 1000 MG, 250 MG,      200 MG, 25 MG               42
                              500 MG, 750 MG            42

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LAMICTAL 2 MG              42 LEADER INSULIN X 5/16"147 LEVLEN-28 0.15-30 MCG, MG 99
                              SYRINGE/1ML/31G
LAMICTAL CHEWABLE             LEADER INSULIN
DISPERSIBLE 25 MG, 5 MG 42 SYRINGE/U-100/0.3ML/29G X LEVLITE-28 0.1-20 MCG, MG 99
                              1/2"                  147
LAMICTAL ODT               42                           LEVO DROMORAN 2 MG/ML 21
                              LESCOL 20 MG, 40 MG    59
LAMICTAL ODT 100 MG, 200                                LEVO-DROMORAN 2 MG             21
MG, 25 MG, 50 MG           42 LESCOL XL 80 MG        59
LAMICTAL STARTER/NOT                                    LEXAPRO 10 MG, 20 MG, 5
TAKING CARBAMAZEPINE 42 LETAIRIS 10 MG, 5 MG         95 MG                             46
LAMICTAL STARTER/TAKING
CARBAMAZEPINE/NOT TAKING LEUCOVORIN CALCIUM 10          LEXAPRO 5 MG/5ML               46
VALPROATE                  42 MG/ML                  76
LAMICTAL STARTER/TAKING       LEUCOVORIN CALCIUM 350    LEXIVA 50 MG/ML                84
VALPROATE 25 MG            42 MG                     76
                              LEUCOVORIN CALCIUM 50     LEXIVA 700 MG                  84
LAMICTAL XR                42 MG                     76
LAMICTAL XR 100 MG, 200 MG,                             LIALDA 1.2 GM                131
25 MG, 250 MG, 300 MG, 50     LEUKERAN 2 MG          68
MG                         42                           LIDEX 0.05 %                 115
                              LEUKINE 250 MCG       135
LAMISIL 1 %               108                           LIDEX-E 0.05 %               115
                              LEUKINE 500 MCG/ML    135
LAMISIL 125 MG, 187.5 MG 55                             LIDOCAINE HCL 10 MG/ML 35
                              LEUPROLIDE ACETATE 1
LAMISIL 250 MG             55 MG/0.2ML               71
                                                        LIDODERM 5 %                 118
                              LEUSTATIN 1 MG/ML      69
LANOXIN 0.1 MG/ML          94                           LIMBITROL 12.5-5 MG          185
                              LEVAQUIN 25 MG/ML     130
LANOXIN 0.125 MG, 0.25 MG 94                            LIMBITROL DS 10-25 MG        185
                              LEVAQUIN 250 MG, 500 MG,
LANOXIN 0.25 MG/ML         94 750 MG                130
                                                        LINCOCIN 300 MG/ML             33
                              LEVAQUIN 250-5 %,
LANOXIN 0.5 MG/ML          94 MG/50ML, 5-500 %,         LIORESAL INTRATHECAL 0.05
                              MG/100ML              130 MG/ML                        160
                              LEVAQUIN 5-750 %,         LIORESAL INTRATHECAL 10
LANTUS 100 UNIT/ML         51 MG/150ML              130 MG/20ML, 10 MG/5ML, 40
LANTUS FOR OPTICLIK 100       LEVAQUIN LEVA-PAK 750     MG/20ML                      160
UNIT/ML                    51 MG                    130 LIPITOR 10 MG, 20 MG, 40 MG,
LANTUS SOLOSTAR 100           LEVAQUIN PREMIX 250-5 %,  80 MG                          59
UNIT/ML                    51 MG/50ML, 5-500 %,
                              MG/100ML              130 LIPOFEN 150 MG, 50 MG          59
LARIAM 250 MG              65
                              LEVATOL 20 MG          91 LIPOSYN II 1.2-10-2.5 %, 1.2-
LASIX 20 MG, 40 MG, 80 MG 121                           2.5-5 %, 10-2.5 %, 2.5-5 % 163
                              LEVEMIR 100 UNIT/ML    51 LIPOSYN III 1.2-10-2.5 %, 1.2-
LASTACAFT 0.25 %          177 LEVEMIR FLEXPEN 100       2.5-20 %                     163
                                                        LITE TOUCH INSULIN
LATUDA 20 MG, 40 MG, 80       UNIT/ML                51 SYRINGE/0.3ML/29G X 1/2" 147
MG                         80 LEVETIRACETAM          42 LITE TOUCH INSULIN
LAZANDA 100 MCG/ACT, 400                                SYRINGE/1ML/31G X 5/16" 147
MCG/ACT                    21 LEVLEN CONTRACT PACK      LITETOUCH PEN NEEDLES
LEADER INSULIN                0.15-30 MCG, MG        99 29GX12.7MM                   147
SYRINGE/0.3ML/29G X 1/2" 147

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LITHIUM CARBONATE 150                                   LUPRON DEPOT-PED 11.25
MG                        79 LORCET 10/650 10-650 MG 24 MG, 15 MG, 7.5 MG      125
LITHIUM CITRATE 8                                       LUPRON DEPOT-PED 11.25
                          79 LORTAB 2.5-500 MG       25 MG, 30 MG
MEQ/5ML                                                                        125
LITHOBID 300 MG           80 LOSEASONIQUE               100 LUVOX CR 100 MG, 150 MG 46

LIVALO 1 MG, 2 MG, 4 MG   60 LOTEMAX 0.5 %              175 LUXIQ 0.12 %                116
LIVE BETTER PEN NEEDLES        LOTENSIN 10 MG, 20 MG, 40       LYBREL 20-90 MCG         100
29G X 12MM              147    MG, 5 MG                   60
LIVE BETTER PEN NEEDLES        LOTENSIN HCT 10-12.5 MG,        LYRICA 100 MG, 150 MG, 200
31G X 6MM               147    12.5-20 MG, 20-25 MG, 5-6.25    MG, 225 MG, 25 MG, 300 MG,
LO LOESTRIN FE 1-10-75 MCG,    MG                         63   50 MG, 75 MG               42
MG                       99    LOTREL 10-2.5 MG, 10-20
                               MG, 10-40 MG, 10-5 MG, 20-5     LYSODREN 500 MG           71
LO/OVRAL-28 0.3-30 MCG,
MG                       99    MG, 40-5 MG                63
                                                               LYSTEDA 650 MG           136
LOCOID 0.1 %              115 LOTRISONE 0.05-1 %        108
                                                            M-M-R II W/DILUENT 1
LOCOID LIPOCREAM 0.1 % 115     LOTRONEX 0.5 MG, 1 MG 132 DOSE                      196
                                                            M-M-R II W/DILUENT 10
                               LOVAZA 1-375-4-465 GM,       DOSE                   196
LODINE 300 MG             17   MG                        58
                               LOVENOX 100 MG/ML, 120       MACROBID 100 MG        194
LODOSYN 25 MG             77   MG/0.8ML, 150 MG/ML, 30      MACRODANTIN 100 MG, 50
                               MG/0.3ML, 40 MG/0.4ML, 60    MG                     194
LOESTRIN 1.5/30-21 1.5-30      MG/0.6ML, 80 MG/0.8ML     41
MCG, MG                    99                               MACRODANTIN 25 MG      194
LOESTRIN 1/20-21 1-20 MCG,     LOVENOX 300 MG/3ML        41
MG                        100                               MAGELLAN INSULIN SAFETY
LOESTRIN 24 FE 1-20-75 MCG,    LTA 360 KIT 4 %         159 SYRINGE/U-100/0.3ML/29G X
MG                        100                               1/2"                   147
LOESTRIN FE 1.5/30 1.5-30-75   LUCENTIS 0.5 MG/0.05ML 171 MAGNACET 2.5-400 MG        25
MCG, MG                   100
LOMOTIL 0.025-15-2.5 %,                             MAGNACET 400-5 MG, 400-7.5
                              LUFYLLIN 200 MG, 400 MG 39
MG/5ML                     52                       MG                       25
                                                    MAGNESIUM SULFATE 40
                              LUMIGAN 0.01 %, 0.03 % 177
LOMOTIL 0.025-2.5 MG       52                       MG/ML, 80 MG/ML         158
LONGS INSULIN SYRINGE/U-      LUMIZYME 50 MG        MAGNESIUM SULFATE IN D5W
                                                     126
100/0.3ML/29G X 1/2"      147 LUNESTA 1 MG, 2 MG, 3 10-5 %, MG/ML, 20-5 %,
                                                    MG/ML                   158
LOPID 600 MG               59 MG                     136
                                                    MAJOR INSULIN SYRINGE/U-
                           LUPRON DEPOT 11.25 MG 71 100/0.3ML/29G X 1/2"    147
LOPRESSOR 1 MG/ML       91                          MAKENA 2-250-46 %,
                           LUPRON DEPOT 22.5 MG 71 MG/ML                    184
LOPRESSOR 100 MG, 50 MG 91                          MALARONE 100-250 MG      65
LOPRESSOR HCT 100-25 MG,   LUPRON DEPOT 3.75 MG 71
100-50 MG, 25-50 MG     63                          MALARONE 25-62.5 MG      65
                           LUPRON DEPOT 30 MG    71
LOPROX 0.77 %          108                          MARCAINE 0.25 %, 0.5 %  139
                           LUPRON DEPOT 45 MG    71
LOPROX SHAMPOO 1 %     108                          MARCAINE 0.5-1 %, MG/ML 139
                           LUPRON DEPOT 7.5 MG   71


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MARCAINE SPINAL 0.75-8.25
                         139 MEFOXIN 2 GM          96      METHERGINE 0.2 MG         179
%
MARCAINE W/O EPI 0.75 % 139 MEFOXIN ADD-VANTAGE 1 96    METHYLDOPATE HCL 250
                             GM                         MG/5ML                     62
MARCAINE/EPINEPHRINE 0.25- MEFOXIN ADD-VANTAGE 2        METHYLIN 10 MG, 2.5 MG, 5
0.5-1 %, :200000, MG/ML  138 GM                    96   MG                         14
MARCAINE/EPINEPHRINE 0.5-1 MEFOXIN IN DEXTROSE          METHYLIN 10 MG/5ML, 5
%, :200000, MG/ML        138 3.9% 1-3.9 %, GM/50ML 96   MG/5ML                     14
MARINOL 10 MG, 2.5 MG, 5                                METOCLOPRAMIDE HCL 5
MG                        54 MEGACE ES 625 MG/5ML 184   MG/ML                     130
                                                        METOZOLV ODT 10 MG, 5
MARPLAN 10 MG             46   MEGACE ORAL 40 MG/ML 71 MG                         130
                               MEIJER PEN NEEDLES 29G   METRO IV 0.74-500 %,
MATULANE 50 MG           75    X12MM                147 MG/100ML                   30
                               MEIJER PEN NEEDLES 31G
MAVIK 1 MG, 2 MG, 4 MG    60                        147 METROCREAM 0.75 %         119
                               X6MM
                               MENACTRA 48
MAXALT 10 MG, 5 MG       153                        196 METROGEL 0.5 %            119
                               MCG/0.5ML
MAXALT-MLT 10 MG, 5 MG 153 MENOMUNE-A/C/Y/W-135 196 METROGEL 1 %                     119

                         175 MENOSTAR 14                 METROGEL-VAGINAL 0.75
MAXIDEX 0.1 %                MCG/24HR                128 %                     197
MAXIFLOR 0.5 %           116 MENTAX 1 %              108 METROLOTION 0.75 %          119

MAXIPIME 1 GM, 2 GM       98 MENVEO                  196 MEVACOR 10 MG, 20 MG, 40 60
                                                         MG
MAXITROL 0.004-0.1-10000-3.5 MEPRON 750 MG/5ML        31   MIACALCIN 200 UNIT/ACT    123
%, MG/ML, UNIT/ML         175
MAXITROL 0.01-0.05-0.1-10000- MERREM 1 GM, 500 MG     31   MIACALCIN 200 UNIT/ML     123
3.5 %, MG/GM, UNIT/GM     175
                          120 MERUVAX II W/DILUENT 1 196   MICARDIS 20 MG, 40 MG, 80
MAXZIDE 50-75 MG              DOSE                         MG                        61
                          120 MERUVAX II W/DILUENT 10      MICARDIS HCT 12.5-40 MG,
MAXZIDE-25 25-37.5 MG         DOSE                   196   12.5-80 MG, 25-80 MG      63
MEDICINE SHOPPE PEN
                          147 MESNEX 100 MG/ML        76   MICRO-K 10 MEQ, 8 MEQ     158
NEEDLES 29G X 12MM
MEDICINE SHOPPE PEN                                        MICRONASE 1.25 MG, 2.5 MG,
                          147 MESNEX 400 MG           76
NEEDLES 31G X 6MM                                          5 MG                     52
MEDROL 16 MG, 32 MG, 4 MG, MESTINON 60 MG             66   MICROZIDE 12.5 MG         122
8 MG                      103
MEDROL 2 MG              103 MESTINON 60 MG/5ML       66 MIDAMOR 5 MG                121

MEDROL DOSEPAK 4 MG   103 MESTINON TIMESPAN 180 66         MIGERGOT 100-2 MG         152
                          MG
                          METADATE CD 10 MG, 20
MEFENAMIC ACID 250 MG 18 MG, 30 MG, 40 MG, 50 MG, 60       MIGRANAL 4 MG/ML          152
                          MG                        13     MINIPRESS 1 MG, 2 MG, 5
MEFOXIN 1 GM           96 METAGLIP 2.5-250 MG, 2.5-        MG                        62
                          500 MG, 5-500 MG          49
MEFOXIN 10 GM          96 METHADONE HCL 10                 MINOCIN 100 MG            189
                          MG/ML                     21


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MINOCIN 100 MG, 50 MG    188 MOTOFEN 0.025-1 MG       52 NABI-HB                    180

MIRALAX                    137 MOTRIN 400 MG, 600 MG, 800   NADOLOL 160 MG           91
                               MG                      18
MIRAPEX 0.125 MG, 0.25 MG,     MOVIPREP 1.015-100-2.691-
0.5 MG, 0.75 MG, 1 MG, 1.5                                  NAFCILLIN SODIUM 1 GM   184
                               4.7-5.9-7.5 GM         137
MG                          78
MIRAPEX 0.25 MG, 0.5 MG, 1     MOXATAG 775 MG         181   NAFCILLIN SODIUM 2 GM   184
MG                          78
MIRAPEX ER 0.375 MG, 0.75      MOXEZA 0.5 %           173   NAFTIN 1 %              109
MG, 1.5 MG, 2.25 MG, 3 MG,
3.75 MG, 4.5 MG             78 MOZOBIL 24 MG/1.2ML    136   NAFTIN 1 %, 2 %         109
MIRCETTE                 100 MS CONTIN 100 MG, 15 MG,       NAFTIN-MP 1 %           109
                             200 MG, 30 MG, 60 MG    22
MOBAN 10 MG, 25 MG, 5 MG,    MS INSULIN
50 MG                     82 SYRINGE/0.3ML/29G X            NAGLAZYME 1 MG/ML       126
MOBIC 15 MG, 7.5 MG       18 1/2"                   148
                                                            NALFON 200 MG            18
                             MS INSULIN
MOBIC 7.5 MG/5ML          18 SYRINGE/1ML/31G X 5/16"148     NALLPEN ISO-OSMOTIC IN
                             MS INSULIN SYRINGE/U-          DEXTROSE 2 GM/100ML    184
MODAFINIL 100 MG, 200 MG 14 100/0.3ML/29G X 1/2"    148     NALLPEN/DEXTROSE 1
                             MUCOMYST-10 10 %       105     GM/50ML, 2 GM/50ML     184
MODICON 0.5-35 MCG, MG 100                                  NALOXONE HCL 0.4 MG/ML 53
MODICON-28 0.5-35 MCG,       MULTAQ 400 MG           36
MG                       100 MUMPSVAX W/DILUENT 1           NAMENDA 10 MG, 5 MG     185
MONISTAT 3 200 MG        197 DOSE                   197
                                                            NAMENDA 10 MG/5ML       185
                             MUMPSVAX W/DILUENT 10
MONODOX 100 MG, 50 MG, 75 DOSE                      197
MG                       189                                NAMENDA TITRATION PAK 185
MONOJECT INSULIN             MUSTARGEN 10 MG         68
SYRINGE/0.3ML/29G X 1/2" 147 MYAMBUTOL 100 MG, 400          NAPRELAN                 18
MONOJECT INSULIN             MG                      66
SYRINGE/1ML/31G X 5/16" 147                                 NAPRELAN 375 MG          18
MONOJECT INSULIN             MYCAMINE 100 MG, 50 MG 55
SYRINGE/SAFETY/PERM                                         NAPRELAN 500 MG          18
NEEDLE/0.3ML/29G X 1/2" 147 MYCELEX 10 MG           159
MONOJECT ULTRA COMFORT                                      NAPRELAN 750 MG          18
INSULIN SYRINGE/0.3ML/29G X MYCOBUTIN 150 MG         66
1/2"                     147                                NAPROSYN 125 MG/5ML      18
                             MYCOSTATIN 100000
MONOKET 10 MG, 20 MG      34 UNIT/GM                109     NAPROSYN 250 MG, 375 MG,
MONOPRIL 10 MG, 20 MG, 40    MYFORTIC 180 MG, 360           500 MG                   18
MG                        60 MG                      88
                                                            NARDIL 15 MG             46
MONOPRIL HCT 10-12.5 MG,     MYLOTARG 5 MG           70
12.5-20 MG                63                           NAROPIN 2 MG/ML, 5 MG/ML,
                                                       7.5 MG/ML              139
MONUROL 5.631 GM         194 MYOZYME 50 MG          126
                                                       NASACORT AQ 55
MORPHINE SULFATE 10          MYSOLINE 250 MG, 50 MG 42 MCG/ACT                162
MG/5ML                    22                           NASONEX 50 MCG/ACT     162
MORPHINE SULFATE 20          MYTELASE 10 MG         66
MG/10ML                   22


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                                                        74 NORDITROPIN CARTRIDGE 124
                                                                                  5
NATACYN 5 %             173 NEXAVAR 200 MG                 MG/1.5ML
                               NEXIUM 10 MG, 20 MG, 40     NORDITROPIN FLEXPRO 10
NATAZIA                 100    MG                      193 MG/1.5ML, 5 MG/1.5ML   124
NATURE-THROID 260 MG, 325      NEXIUM 20 MG, 40 MG     193 NORDITROPIN FLEXPRO 15124
MG                     190                                 MG/1.5ML
                                                           NORDITROPIN NORDIFLEX
NATURE-THROID 97.5 MG 190      NEXIUM I.V. 20 MG       193 PEN 10 MG/1.5ML, 5
                                                           MG/1.5ML               124
NAVANE 10 MG, 2 MG, 5 MG 83    NEXIUM I.V. 40 MG       193 NORDITROPIN NORDIFLEX
                                                           PEN 15 MG/1.5ML, 30
NAVANE 20 MG             83    NEXPLANON 68 MG         102 MG/3ML                 124
                               NIASPAN 1000 MG, 500 MG,    NORGESIC 25-30-385 MG 161
NEBUPENT 300 MG          30    750 MG                   60
                               NICOTROL INHALER 10         NORINYL 1+35 1-35 MCG,
NECON 10/11-28 35 MCG   100    MG                      187 MG                     100
                                                           NORINYL 1+50 1-50 MCG,
NEO-FRADIN 25 MG/ML      15    NICOTROL NS 10 MG/ML 187 MG                        100
NEORAL 100 MG, 25 MG     88 NILANDRON 150 MG            72 NORITATE 1 %             119
                                                           NORMOSOL -R 140-23-27-3-5-
NEORAL 100 MG/ML         89    NIPENT 10 MG             75 98 MEQ/L                 156
NEOSPORIN GU IRRIGANT          NITRO-DUR 0.1 MG/HR, 0.2    NORMOSOL-R 140-23-27-3-5-98
200000-40 MG/ML, UNIT/ML 132   MG/HR, 0.4 MG/HR, 0.6       MEQ/L                    156
NEPHRAMINE 20-200-250-400-     MG/HR                    34 NORMOSOL-R IN D5W 140-23-
44-560-6-640-880 MEQ/L,        NITRO-DUR 0.3 MG/HR, 0.8    27-3-5-98 %, MEQ/L       156
MG/100ML                 168   MG/HR                    34 NOROXIN 400 MG           130
NESACAINE 10 MG/ML      139    NITROGLYCERIN 5 MG/ML 34
                                                           NORPACE 100 MG, 150 MG 35
                               NITROGLYCERIN IN
NESACAINE 2 %           139    DEXTROSE 5% 100-5 %,        NORPACE CR 100 MG         35
                               MCG/ML, 200-5 %, MCG/ML,
NESACAINE-MPF 2 %, 3 % 140     400-5 %, MCG/ML          34
                               NITROLINGUAL PUMPSPRAY NORPACE CR 150 MG              35
NEULASTA 6 MG/0.6ML     135    0.4 MG/SPRAY             34 NORPRAMIN 10 MG, 100 MG,
                               NITROLINGUAL PUMPSPRAY 150 MG, 25 MG, 50 MG, 75
NEUMEGA 5 MG            136    DUO PACK 0.4 MG/SPRAY 34 MG                           47
NEUPOGEN 300 MCG/0.5ML,        NITROMIST 400               NORVASC 10 MG, 2.5 MG, 5
300 MCG/ML, 480 MCG/0.8ML,     MCG/SPRAY                34 MG                        93
480 MCG/1.6ML           136    NITROSTAT 0.3 MG, 0.4 MG,   NORVIR 100 MG             84
NEURONTIN 100 MG, 300 MG,      0.6 MG                   34
400 MG                   42    NIZORAL 2 %            109 NORVIR 80 MG/ML            84
NEURONTIN 250 MG/5ML     43                              NOVANATAL 1-120-15-150-20-
                               NOLVADEX 10 MG, 20 MG 72 200-29-3-30-400-8 MCG, MG,
NEURONTIN 600 MG, 800
MG                       43                              UNIT                     160
                               NOR-QD 0.35 MG        102
NEUTREXIN 25 MG          31                              NOVANTRONE 2 MG/ML        73
                               NORDETTE-28 0.15-30 MCG,
                               MG                    100 NOVOFINE 30GX8MM         148
NEVANAC 0.1 %           177    NORDITROPIN CARTRIDGE
                               15 MG/1.5ML           124 NOVOFINE 31              148
NEVIRAPINE 50 MG/5ML     84


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NOVOFINE 32GX6MM         148 NUBAIN 10 MG/ML, 20           OMNI-PAC 300 MG          97
                             MG/ML                    27
NOVOFINE AUTOCOVER           NUCYNTA 100 MG, 50 MG, 75     OMNICEF 125 MG/5ML, 250
30GX8MM                  148 MG                       22   MG/5ML                  98
                             NUCYNTA ER 100 MG, 150
NOVOLIN 70/30 30-70 %     51 MG, 200 MG, 250 MG, 50        OMNICEF 300 MG           98
NOVOLIN 70/30 INNOLET 30-70 MG                        22
                                                           OMNIPRED 1 %            175
%                         51 NUEDEXTA 10-20 MG       187
NOVOLIN 70/30 PENFILL 30-70                                OMNITROPE 10 MG/1.5ML, 5
%                         51 NULOJIX 250 MG           89   MG/1.5ML                124
NOVOLIN N 100 UNIT/ML     51 NULYTELY 1.48-11.2-420-5.72   OMNITROPE 5.8 MG        124
NOVOLIN N INNOLET 100        GM                      137
                             NULYTELY/FLAVOR PACKS         ONCASPAR 750 UNIT/ML     74
UNIT/ML                   51
NOVOLIN N U-100 PENFILL 100 1.48-11.2-420-5.72 GM    137   ONDANSETRON HCL 32-450
UNIT/ML                   51 NUMORPHAN 1 MG/ML        22   MG/50ML                54
NOVOLIN R 100 UNIT/ML     51                               ONGLYZA 2.5 MG, 5 MG     49
                             NUTROPIN 10 MG          124
NOVOLIN R INNOLET 100                                      ONSOLIS 1200 MCG, 200 MCG,
UNIT/ML                   51 NUTROPIN 5 MG           124   400 MCG, 600 MCG, 800
NOVOLIN R U-100 PENFILL 100                                MCG                     22
UNIT/ML                   51 NUTROPIN AQ 10 MG/2ML124      ONTAK 150 MCG/ML         75
NOVOLOG 100 UNIT/ML       51 NUTROPIN AQ NUSPIN 10 10
                                                           OPANA 1 MG/ML            22
NOVOLOG FLEXPEN 100          MG/2ML                  124
UNIT/ML                   51 NUTROPIN AQ NUSPIN 20 20      OPANA 10 MG, 5 MG        22
NOVOLOG MIX 70/30 1.5-1.72-  MG/2ML                  124
30-70 %, MG/ML            51 NUTROPIN AQ PEN 10            OPANA ER (CRUSH
NOVOLOG MIX 70/30 PENFILL    MG/2ML, 20 MG/2ML       124   RESISTANT) 10 MG, 20 MG, 30
1.5-1.72-30-70 %, MG/ML   51 NUVARING 0.015-0.12           MG, 40 MG                 22
NOVOLOG MIX 70/30            MG/24HR                 102   OPANA ER (CRUSH
PREFILLED FLEXPEN 1.5-1.72-  NUVIGIL 150 MG, 250 MG, 50    RESISTANT) 5 MG           22
30-70 %, MG/ML            51 MG                       14   OPANA ER 10 MG, 15 MG, 20
NOVOLOG PENFILL 100                                        MG, 30 MG, 40 MG, 7.5 MG 22
                             NYDRAZID 100 MG/ML       66
UNIT/ML                   51                               OPANA ER 5 MG            22
NOVOPEN 3 INSULIN            OCTAGAM 1 GM/20ML, 10
DELIVERY SYSTEM          148 GM/200ML, 2.5 GM/50ML, 25     OPHTHETIC 0.5 %         174
                             GM/500ML, 5 GM/100ML 180
NOVOPEN 3 PENMATE        148
                             OCUFEN 0.03 %           177   OPTIPRANOLOL 0.3 %      171
NOVOPEN JR (GREEN)       148
                             OCUFLOX 0.3 %           173   OPTIVAR 0.05 %          177
NOVOPEN JR (YELLOW)      148 OGEN 0.75 MG, 1.5 MG, 3
                                                           ORACEA 40 MG            119
                             MG                      129
NOVOTWIST 30GX8MM        148                               ORAMORPH SR 100 MG, 15
                             OLEPTRO 150 MG, 300 MG 45     MG, 30 MG, 60 MG       22
NOVOTWIST 32GX5MM        148
                             OLUX 0.05 %             116   ORAP 1 MG, 2 MG         187
NOXAFIL 40 MG/ML          56
                             OLUX-E 0.05 %           116   ORAPRED 15 MG/5ML       104
NPLATE 250 MCG, 500 MCG136                                 ORAPRED ODT 10 MG, 15 MG,
                             OMNARIS 50 MCG/ACT      162   30 MG                  104

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                         159 OXACILLIN SODIUM 1 GM,184 PANCRELIPASE 17000-27000-
                                                    2
ORAVIG 50 MG                 GM                        5000 UNIT               120
                             OXACILLIN SODIUM 10
ORENCIA 125 MG/1ML        19 GM                    184 PANDEL 0.1 %            116

                          19 OXACILLIN SODIUM 2 GM 184 PANGLOBULIN 1 GM, 3 GM, 180
                                                                               6
ORENCIA 250 MG                                         GM
ORFADIN 10 MG, 2 MG, 5
                         126 OXANDRIN 10 MG, 2.5 MG 27 PANGLOBULIN NF 6 GM         180
MG
ORTHO EVRA 150-20
                         102 OXECTA 5 MG              23 PANLOR SS 32-60-712.8 MG 25
MCG/24HR
ORTHO MICRONOR 0.35
                         102 OXECTA 7.5 MG            23 PANRETIN 0.1 %            110
MG
ORTHO TRI-CYCLEN         100 OXISTAT 1 %             109 PARAFON FORTE DSC 500 160
                                                         MG
ORTHO TRI-CYCLEN LO      100 OXSORALEN 1 %           119 PARAPLATIN 150 MG          68
ORTHO-CEPT 0.15-30 MCG,       OXSORALEN ULTRA 10          PARAPLATIN 150 MG/15ML,
MG                      101   MG                    110   600 MG/60ML             68
ORTHO-CEPT-28 0.15-30 MCG,    OXYCODONE HCL CR 10 MG,     PARAPLATIN 450 MG/45ML    68
MG                      101   20 MG, 40 MG, 80 MG    23
ORTHO-CYCLEN 0.25-35 MCG,     OXYCONTIN 10 MG, 20 MG,     PARAPLATIN 50 MG/5ML      68
MG                      101   40 MG, 80 MG           23
ORTHO-CYCLEN-28 0.25-35       OXYCONTIN 15 MG, 30 MG,     PARCOPA 10-100 MG, 100-25
MCG, MG                 101   60 MG                  23   MG, 25-250 MG             78
ORTHO-NOVUM 1/35-28 1-35      OXYTROL 3.9 MG/24HR    195 PARLODEL 2.5 MG            78
MCG, MG                 101
ORTHO-NOVUM 1/50-28 1-50      PACERONE 300 MG         36 PARLODEL 5 MG              78
MCG, MG                 101
ORTHO-NOVUM 10/11-28 35       PACLITAXEL 150 MG/25ML 77 PARNATE 10 MG               46
MCG                     101
ORTHO-NOVUM 7/7/7        101 PALGIC 4 MG              57 PATADAY 0.2 %             177

ORTHO-NOVUM 7/7/7-28     101 PALGIC 4 MG/5ML          57 PATANASE 0.6 %            161
ORTHOCLONE OKT3 1           PAMELOR 10 MG, 25 MG, 50
                                                      47 PATANOL 0.1 %            177
MG/ML                    89 MG, 75 MG
OSMOPREP 0.398-1.102 GM138 PAMELOR 10 MG/5ML          47 PAXIL 10 MG, 20 MG, 30 MG, 40
                                                         MG                         46
                            PAMIDRONATE DISODIUM 30 PAXIL 10 MG/5ML
OVCON FE 0.4-35 MCG, MG 101 MG/10ML                                                 46
                                                     123
OVCON-35 0.4-35 MCG, MG 101 PAMIDRONATE DISODIUM123 PAXIL CR 12.5 MG, 25 MG, 37.5
                                                      90
                            MG/10ML                      MG                         46
OVCON-50 28 1-50 MCG,                                    PC UNIFINE PENTIPS 29G
                        101 PAMINE 2.5 MG            192 X1/2"
MG                                                                                148
OVIDE 0.5 %             119 PAMINE FORTE 5 MG        192 PC UNIFINE PENTIPS 31G 148
                                                         X6MM ULTRA SHORT
                            PANCREAZE 10000-17500-
OVIDE 0.5-78 %          119 4200 UNIT, 10500-25000-      PCE 333 MG, 500 MG       141
                            43750 UNIT, 16800-40000-
OXACILLIN SODIUM 1 GM 184 70000 UNIT, 21000-37000-       PEDIAPRED 6.7 MG/5ML     104
                            61000 UNIT               120


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PEDIARIX 10-2.5-25-58                                    PHYSIOSOL IRRIGATION PH
LFU/0.5ML, MCG/0.5ML,        PENTAM 300 300 MG        30 7.4 222-30-37-502-526
MG/0.5ML                  191 PENTASA 250 MG, 500        MG/100ML                89
PEDIAZOLE 200-600 MG/5ML 30 MG                       131 PICATO 0.015 %, 0.05 % 110
PEDIOTIC 0.001-1-10000-3.5 %, PEPCID 20 MG, 40 MG    192
                                                           PILOPINE HS 4 %         171
MG/ML, UNIT/ML            178
                              PEPCID 40 MG/5ML       192   PIPERACILLIN SODIUM 2 GM, 3
PEDVAX HIB                196                              GM, 4 GM               181
PEG-INTRON 120 MCG/0.5ML,     PEPCID I.V. 10 MG/ML   192   PIPERACILLIN SODIUM 40
150 MCG/0.5ML, 50 MCG/0.5ML, PEPCID PREMIXED 0.4-0.9 %,    GM                     181
80 MCG/0.5ML               86 MG/ML                  192
PEG-INTRON REDIPEN 120                                     PLAN B 0.75 MG          102
                              PERCODAN 0.38-325-4.5
MCG/0.5ML, 150 MCG/0.5ML, 50 MG                       25
MCG/0.5ML, 80 MCG/0.5ML 86                                 PLAN B ONE-STEP 1.5 MG 102
PEG-INTRON REDIPEN PAK 4      PERCODAN 0.38-325-4.835
120 MCG/0.5ML, 150            MG                      25   PLAQUENIL 200 MG         65
MCG/0.5ML, 50 MCG/0.5ML, 80   PERFOROMIST 20
MCG/0.5ML                  86 MCG/2ML                 39   PLASMA-LYTE 56 13-16-3-40
                                                           MEQ/L                    156
PEGANONE 250 MG            44 PERIDEX 0.12 %         159   PLASMA-LYTE A 140-23-27-3-5-
                                                           98 MEQ/L                 156
PEGASYS 180 MCG/0.5ML      86 PERIOSTAT 20 MG        189   PLASMA-LYTE-148 140-23-27-3-
PEGASYS 180 MCG/0.5ML, 180 PERLOXX 10-300 MG, 300-5        5-98 MEQ/L               156
MCG/ML                     86 MG                      25   PLASMA-LYTE-148/D5W 140-
PEGASYS PROCLICK 135                                       23-27-3-5-98 %, MEQ/L    156
                              PERLOXX 300-7.5 MG      25   PLASMA-LYTE-56/D5W 13-16-3-
MCG/0.5ML, 180 MCG/0.5ML 87
                              PERSANTINE 25 MG, 50 MG,     40-5 %, MEQ/L            156
PEN NEEDLES 29G X 12MM 148 75 MG                     134   PLATINOL AQ 100 MG/100ML,
                              PEXEVA 10 MG, 20 MG, 30      50 MG/50ML                68
PEN NEEDLES 29GX1/2"      148 MG, 40 MG               46 PLAVIX 300 MG             134
PEN NEEDLES 30GX5/16" 148     PHENERGAN 12 MG         57
                                                         PLAVIX 75 MG              134
PEN NEEDLES 31G X 1/4"        PHENERGAN 25 MG         57 PLENDIL 10 MG, 2.5 MG, 5
SHORT                     148
                                                         MG                         93
PEN NEEDLES 31G X 6MM 148 PHENERGAN 25 MG/ML          57
                                                         PLETAL 100 MG, 50 MG      134
PENICILLIN G POTASSIUM IN     PHENERGAN 50 MG/ML      57 POLY-PRED 0.001-0.35-0.5-
ISO-OSMOTIC DEXTROSE
20000 UNIT/ML, 40000 UNIT/ML, PHENYTEK 300 MG            10000 %, UNIT/ML          175
                                                      44
60000 UNIT/ML             181                            POLYGAM S/D 10 GM         180
PENICILLIN G PROCAINE
600000 UNIT/ML            181 PHISOHEX 3 %            83
                                                         POLYGAM S/D 2.5 GM        180
PENICILLIN G SODIUM 5000000
UNIT                      182 PHOSLO 667 MG          132 POLYTRIM 0.1-10000 %,
PENLAC NAIL LACQUER 8                                    UNIT/ML                   173
%                         109 PHOSLYRA 667 MG/5ML 132
                                                         PONSTEL 250 MG             18
PENNSAID 1.5 %            107 PHOSPHOLINE IODIDE 0.125 POTASSIUM CHLORIDE
                              %                      171
PENTACEL 15-48-5 LFU/0.5ML,                              0.15%/NACL 0.45% VIAFLEX
MCG/0.5ML                 191 PHOTOFRIN 75 MG         75 0.45-20 %, MEQ/L          157



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POTASSIUM CHLORIDE              PREFERRED PLUS UNIFINE        PRIVIGEN 10 GM/100ML, 20
0.15%/NACL 0.9% 0.9-20 %,       PENTIPS 31G X 6MM ULTRA       GM/200ML, 5 GM/50ML         180
MEQ/L                     157   SHORT                     149
POTASSIUM CHLORIDE                                            PROAIR HFA 108 MCG/ACT 39
0.224%D5W/NACL 0.33% 0.33-      PREFEST                   128
                                                              PROAMATINE 10 MG, 2.5 MG, 5
30-5 %, MEQ/L             157   PREMARIN 0.3 MG, 0.45 MG,     MG                          199
POTASSIUM CHLORIDE              0.625 MG, 0.9 MG, 1.25        PROCAINAMIDE HCL 100
0.3%/NACL 0.9% 0.9-40 %,        MG                        129 MG/ML, 500 MG/ML             35
MEQ/L                     157
POTASSIUM CHLORIDE 10           PREMARIN 0.625 MG/GM 198 PROCALAMINE 120-160-170-
                                                              180-20-200-210-220-24-270-290-
MEQ/100ML                 158
POTASSIUM CHLORIDE 10           PREMARIN 25 MG            129 3-340-35-41-420-46-47-5-7-85
                                                              MEQ/L, MG/100ML,
MEQ/50ML                  158
POTASSIUM CHLORIDE 20           PREMPHASE 0.625-5 MG 128 MMOLE/L                          169
MEQ/100ML, 30 MEQ/100ML, 40     PREMPRO 0.3-1.5 MG, 0.45-     PROCARDIA 10 MG              93
MEQ/100ML                 158   1.5 MG, 0.625-2.5 MG, 0.625-5 PROCARDIA XL 30 MG, 60 MG,
POTASSIUM CHLORIDE 20           MG                        128 90 MG                        93
MEQ/50ML                  158
                                PREVACID 15 MG            193 PROCENTRA 5 MG/5ML           13
POTIGA 200 MG, 300 MG     43
                                PREVACID 30 MG           193 PROCHIEVE 4 %, 8 %          198
POTIGA 400 MG             43
                             PREVACID SOLUTAB 15              PROCRIT 10000 UNIT/ML, 2000
POTIGA 50 MG              43 MG                     194       UNIT/ML, 20000 UNIT/ML, 3000
                             PREVACID SOLUTAB 30              UNIT/ML, 4000 UNIT/ML, 40000
PRADAXA 150 MG, 75 MG     41 MG                     194       UNIT/ML                   136
PRANDIMET 1-500 MG, 2-500    PREVPAC                194       PROCTOCORT 1 %              28
MG                        49 PREZISTA 150 MG, 400 MG,
PRANDIN 0.5 MG, 1 MG, 2      600 MG                  84       PROCTOFOAM HC 1 %           28
MG                        52                                  PRODIGY INSULIN PEN
PRAVACHOL 10 MG, 20 MG, 40 PREZISTA 75 MG            84
                                                              NEEDLES/29G X 1/2"         149
MG, 80 MG                 60 PRIALT 100 MCG/ML, 500
PRECISION SURE-DOSE          MCG/20ML, 500 MCG/5ML 19         PROGLYCEM 50 MG/ML          49
PLUSINSULIN
SYRINGE/0.3ML/29G X 1/2" 148 PRIFTIN 150 MG          66       PROGRAF 0.5 MG, 1 MG        89
PRECOSE 100 MG, 25 MG, 50
MG                        48 PRILOSEC 10 MG, 2.5 MG 194       PROGRAF 5 MG                89
PRED FORTE 1 %           175 PRILOSEC 10 MG, 20 MG, 40        PROGRAF 5 MG/ML             89
                             MG                     194
PRED MILD 0.12 %         176 PRIMAXIN I.M. 500 MG    31       PROLASTIN 1000 MG          187
PRED-G 0.3-1 %            176 PRIMAXIN IV 250 MG, 500
                              MG                      31 PROLASTIN 500 MG                187
PRED-G S.O.P. 0.3-0.6 %   176 PRIMSOL 50 MG/5ML       30 PROLASTIN-C 1000 MG             187
PREFERRED PLUS INSULIN          PRINIVIL 10 MG, 20 MG, 5
SYRINGE/U-100/0.3ML/29G X       MG                        61 PROLEUKIN 22000000 UNIT 75
1/2"                    148
PREFERRED PLUS ULTRA            PRINZIDE 10-12.5 MG, 12.5-
COMFORT INSULIN                 20 MG, 20-25 MG           64 PROLIA 60 MG/ML        123
SYRINGE/0.3ML/29G X 1/2 149     PRISTIQ 100 MG, 50 MG     47 PROLOPRIM 100 MG             30
PREFERRED PLUS UNIFINE
PENTIPS 29G X 12MM      149

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PROMACTA 12.5 MG, 25 MG,   PULMICORT FLEXHALER 180 RAPIFLUX 20 MG           46
50 MG, 75 MG           136 MCG/ACT, 90 MCG/ACT  38
PROMETRIUM 100 MG, 200                         188 RAZADYNE 12 MG, 4 MG, 8 185
MG                     184 PULMOZYME 1 MG/ML       MG
PROPINE 0.1 %           172 PURINETHOL 50 MG          69 RAZADYNE 4 MG/ML         185
PROPRANOLOL HCL 1                PX EXTRA SHORT PEN         RAZADYNE ER 16 MG, 24 MG,
MG/ML                         91 NEEDLES 31GX6MM        149 8 MG                   185
                                 PX INSULIN SYRINGE/U-
PROQUAD                      197 100/1ML/31G X 5/16"    149 REBETOL 200 MG          87

PROQUIN XR 500 MG            130 PX PEN NEEDLE          149 REBETOL 40 MG/ML        87
                                 29GX12MM
PROSCAR 5 MG                 133 PYLERA 125-140 MG      194 REBIF 22 MCG/0.5ML, 44
                                                            MCG/0.5ML              186
PROSOL 1-1.02-1.08-1.18-1.34- QC INSULIN
1.35-1.44-1.96-2.06-2.76-320-50- SYRINGE/0.3ML/29G X        REBIF TITRATION PACK   186
600-760-980 GM/100ML,            1/2"                   149
MG/100ML                     169 QC INSULIN                 RECLAST 5 MG/100ML     123
PROTAMINE SULFATE 10             SYRINGE/1ML/31G X 5/16"149 RECOMBIVAX HB 10 MCG/ML,
MG/ML                        135 QC PEN NEEDLES 29G X       40 MCG/ML, 5 MCG/0.5ML 197
                                 12MM                   149
PROTONIX 20 MG, 40 MG 194                                   RECTIV 0.4 %            29
                                 QC PEN NEEDLES 31G X
                             194 6MM                    149
PROTONIX 40 MG                                              REFLUDAN 50 MG          41
                                 QUALAQUIN 324 MG        65
PROTOPIC 0.03 %, 0.1 %       118                            REGLAN 10 MG, 5 MG     131
                                 QUESTRAN 4 GM/DOSE      58
PROVENTIL 0.083 %             39                            REGLAN 5 MG/ML         131
                                 QUESTRAN LIGHT 4 GM     58
PROVENTIL HFA 108
MCG/ACT                       39 QUESTRAN LIGHT 4           REGONOL 5 MG/ML         66
PROVERA 10 MG, 2.5 MG, 5         GM/DOSE                 58
MG                           184                            REGRANEX 0.01 %        119
                                 QUIBRON-T/SR 300 MG     39
PROVIGIL 100 MG, 200 MG 14                                  RELAFEN 500 MG, 750 MG 18
                                 QUINIDINE GLUCONATE 80
                              46 MG/ML                   35 RELENZA DISKHALER 5
PROZAC 10 MG
PROZAC 10 MG, 20 MG, 40          QUIXIN 0.5 %           173 MG/BLISTER              87
MG                            46 QVAR 40 MCG/ACT, 80        RELION 70/30 30-70 %    51
                              46 MCG/ACT                 38 RELION INSULIN SYRINGE/U-
PROZAC 20 MG/5ML
                                 RABAVERT 0.3 MG        197 100/0.3ML/29G X 1/2"   149
PROZAC WEEKLY 90 MG           46                            RELION INSULIN SYRINGE/U-
                                 RANEXA 1000 MG, 500 MG 33 100/1ML/31G X 5/16"     149
PRUDOXIN 5 %                 110                            RELION MINI PEN NEEDLES
                                 RANICLOR 250 MG, 375       31GX6MM                149
                                 MG                      96
PSORCON E 0.05 %             116                            RELION N 100 UNIT/ML    52
                                 RAPAFLO 4 MG, 8 MG     133
PULMICORT 0.25 MG/2ML, 0.5                                  RELION PEN NEEDLES
MG/2ML                        38 RAPAMUNE 0.5 MG, 1 MG, 2   29GX12MM               149
                                 MG                      89
PULMICORT 1 MG/2ML            37                            RELION R 100 UNIT/ML    52
                                 RAPAMUNE 1 MG/ML        89



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RELION ULTRA COMFORT            RETROVIR IV INFUSION 10
INSULIN SYRINGE/0.3ML/29G X MG/ML                              RITALIN SR 20 MG          14
                                                          85
1/2"                        149
                                REVATIO 10 MG/12.5ML      95   RITUXAN 10 MG/ML          70
RELISTOR 12 MG/0.6ML        132
RELISTOR 12 MG/0.6ML, 8         REVATIO 20 MG             95   ROBAXIN 100 MG/ML        160
MG/0.4ML                    132
                                REVIA 50 MG               53   ROBAXIN 500 MG           160
RELPAX 20 MG, 40 MG         153
                                REVLIMID 10 MG, 15 MG, 25
REMERON 15 MG, 30 MG, 45                                       ROBAXIN-750 750 MG       160
                                MG, 5 MG                  88
MG                           45
REMERON SOLTAB 15 MG, 30        REVLIMID 2.5 MG           88   ROBINUL 0.2 MG/ML        192
MG, 45 MG                    45 REYATAZ 100 MG, 150 MG,
                                                               ROBINUL 0.2-0.9 %, MG/ML 192
REMICADE 100 MG             131 200 MG, 300 MG            85
                                RHEUMATREX 2.5 MG         16   ROBINUL 1 MG             192
REMINYL 4 MG/ML             185
                                RHINOCORT AQUA 32
REMODULIN 1 MG/ML, 10                                          ROBINUL FORTE 2 MG       192
                                MCG/ACT                 162
MG/ML, 2.5 MG/ML, 5 MG/ML 94                                   ROCALTROL 0.25 MCG, 0.5
RENACIDIN 0.023-0.198-3.177-    RIDAURA 3 MG              16   MCG                     126
6.602 GM/100ML              132
                                RIFADIN 300 MG            66   ROCALTROL 1 MCG/ML       126
RENAMIN 6.5 %               169
                                RIFADIN 600 MG            67   ROCEPHIN 10 GM, 2 GM      98
RENVELA 0.8 GM, 2.4 GM 132
                                RIFAMATE 150-300 MG       66   ROCEPHIN 2 GM, 250 MG     98
RENVELA 800 MG              132
                                                               ROCEPHIN IN ISO-OSMOTIC
                                RIFATER 120-300-50 MG 66
REPREXAIN 200-5 MG           26                                DEXTROSE 20 MG/ML       98
                                                               ROCEPHIN IN ISO-OSMOTIC
REQUIP 0.25 MG, 0.5 MG, 1       RILUTEK 50 MG           162    DEXTROSE 40 MG/ML       98
MG, 2 MG, 3 MG, 4 MG, 5 MG 78
REQUIP XL 12 MG, 2 MG, 4 MG, RIMSO-50 50 %              133    ROMAZICON 0.1 MG/ML       53
6 MG, 8 MG                   79
RESCRIPTOR 100 MG, 200          RIOMET 500 MG/5ML         49   ROTARIX                  197
MG                           84 RISPERDAL 0.25 MG, 0.5 MG,
                                                               ROTATEQ                  197
RESTASIS 0.05 %             174 1 MG, 2 MG, 3 MG, 4 MG    80
                                RISPERDAL 1 MG/ML         80   ROWASA 4 GM              131
RETIN-A 0.01 %, 0.025 %     107
                                RISPERDAL CONSTA 12.5
RETIN-A 0.025 %, 0.05 %, 0.1                                   ROXICET 5-500 MG          26
                                MG, 25 MG                 80
%                           107 RISPERDAL CONSTA 37.5          ROXICODONE 15 MG, 30 MG, 5
RETIN-A MICRO 0.04 %, 0.1       MG, 50 MG                 80   MG                      23
%                           107 RISPERDAL M-TAB 0.5 MG, 1
RETIN-A MICRO PUMP 0.04 %, MG, 2 MG, 3 MG, 4 MG                ROZEREM 8 MG             137
                                                          80
0.1 %                       107 RITALIN 10 MG, 20 MG, 5
                                                               RYBIX ODT 50 MG           23
RETROVIR 100 MG              84 MG                        14
                                RITALIN LA 10 MG          14   RYTHMOL 150 MG, 225 MG    36
RETROVIR 300 MG              84
                                RITALIN LA 20 MG, 30 MG, 40    RYTHMOL SR 225 MG, 325 MG,
RETROVIR 50 MG/5ML           84 MG                        14   425 MG                  36



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RYZOLT 100 MG, 300 MG    23 SEASONIQUE                101 SINEMET CR 100-25 MG, 200-79
                                                          50 MG
RYZOLT 200 MG            23    SECTRAL 200 MG, 400 MG 91 SINEQUAN 10 MG, 25 MG, 50 47
                                                          MG, 75 MG
                               SELECT BRAND INSULIN
SABRIL 500 MG            44    SYRINGE/U-100/0.3ML/29G X SINGULAIR 10 MG            37
SAFETY-GLIDE INSULIN           1/2"                   149
                                                          SINGULAIR 4 MG            37
SYRINGE/0.3ML/29G X 1/2" 149   SELSUN SHAMPOO 2.5 % 111
SAFYRAL 0.03-0.451-3 MG 101    SELZENTRY 150 MG, 300      SINGULAIR 4 MG, 5 MG      37
                               MG                      85
SAIZEN 5 MG, 8.8 MG     125                               SKELAXIN 800 MG         161
                               SEMPREX-D , 60-8 MG    105
SAIZEN CLICK.EASY 8.8                                     SKELID 200 MG           123
MG                      125    SENSIPAR 30 MG         126
                                                          SM INSULIN SYRINGE/1ML/31G
SALAGEN 5 MG, 7.5 MG    160
                               SENSIPAR 60 MG, 90 MG 126 X 5/16"                  149
                                                          SM INSULIN SYRINGE/U-
SAMSCA 15 MG, 30 MG     127    SENSORCAINE-               100/0.3ML/29G X 1/2"    149
                               MPF/EPINEPHRINE 0.75-1 %,
SANCTURA 20 MG          195    :200000                138 SODIUM EDECRIN 50 MG 121
SANCTURA XR 60 MG       195 SEPTRA 200-40 MG/5ML        30 SODIUM LACTATE 167 MEQ/L,
                                                           5 MEQ/ML              153
SANCUSO 3.1 MG/24HR      54 SEPTRA 400-80 MG            30 SOLARAZE 3 %          110
SANDIMMUNE 100 MG, 25          SEPTRA DS 160-800 MG      30 SOLODYN 105 MG, 115 MG, 55
MG                       89                                 MG, 65 MG, 80 MG          189
                               SEREVENT DISKUS 50           SOLODYN 135 MG, 45 MG, 90
SANDIMMUNE 100 MG/ML     89    MCG/DOSE                  39 MG                        189
                               SEROQUEL 100 MG, 200 MG,
SANDIMMUNE 50 MG/ML      89    25 MG, 300 MG, 400 MG, 50    SOLTAMOX 10 MG/5ML         72
                               MG                        81
SANDOSTATIN 100 MCG/ML,        SEROQUEL XR 150 MG, 200      SOLU-CORTEF 100 MG        104
200 MCG/ML, 50 MCG/ML 127      MG, 300 MG, 400 MG, 50
SANDOSTATIN 1000 MCG/ML,       MG                        81 SOLU-CORTEF 1000 MG       104
500 MCG/ML            127      SEROSTIM 4 MG, 5 MG, 6
SANDOSTATIN LAR DEPOT 10       MG                      125 SOLU-CORTEF 250 MG         104
MG, 20 MG, 30 MG      127
                               SEROSTIM 8.8 MG         125
SANTYL 250 UNIT/GM      118                                 SOLU-CORTEF 500 MG        104
                               SILENOR 3 MG, 6 MG      136 SOLU-MEDROL 1 GM, 1000
SAPHRIS 10 MG, 5 MG      81                                 MG, 125 MG, 40 MG, 500
                               SILVADENE 1 %           111 MG                         104
SARAFEM 15 MG           186
                               SIMCOR 1000-20 MG, 1000-40 SOLU-MEDROL 2 GM            104
SAVELLA 100 MG, 12.5 MG, 25    MG, 20-500 MG, 20-750 MG,
MG, 50 MG                186   40-500 MG                 60 SOMA 250 MG, 350 MG       161
SAVELLA TITRATION PACK 186     SIMPONI 50 MG/0.5ML       16 SOMA COMPOUND 200-325
SB INSULIN SYRINGE/U-                                       MG                        161
100/1ML/31G X 5/16"     149    SIMULECT 10 MG, 20 MG 89 SOMA COMPOUND/CODEINE
                               SINEMET 10-100 MG, 100-25    16-200-325 MG             161
SEASONALE 0.03-0.15 MG 101                                  SOMATULINE DEPOT 120
                               MG, 25-250 MG             79
                                                            MG/0.5ML, 60 MG/0.2ML, 90
                                                            MG/0.3ML                  127

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SOMAVERT 10 MG, 15 MG, 20                                104 SURE COMFORT PEN
MG                      123 STERAPRED 5 MG                   NEEDLES29GX1/2" (12MM) 150
                                                             SURE ONE INSULIN
SONATA 10 MG, 5 MG        136   STERAPRED DS 10 MG 105 SYRINGE/U-100/1ML/31G X
                                STERAPRED DS 12 DAY 10       5/16"                   150
SORBITOL 3 %, 3.3 %       133                                SURE-FINE PEN NEEDLES
                                MG                       105
SORIATANE 10 MG, 17.5 MG,                                    29GX 1/2" 12.7MM        150
                                STIMATE 1.5 MG/ML        127 SURE-FINE PEN NEEDLES
22.5 MG, 25 MG          110
                                STRATTERA 10 MG, 100 MG, 29GX1/2" 12.7MM             150
SORIATANE CK 10 MG        110   18 MG, 25 MG, 40 MG, 60 MG,  SURE-JECT INSULIN
                                80 MG                     13 SYRINGE/U-100/0.3ML/29G X
SORIATANE CK 25 MG        110   STREPTOMYCIN SULFATE 1       1/2"                    150
                                GM                        15 SURE-JECT INSULIN
SPECTAZOLE 1 %            109                                SYRINGE/U-100/1ML/31G X
                                STRIANT 30 MG             28 5/16"                   150
SPECTRACEF 200 MG, 400                                       SURMONTIL 100 MG, 25 MG, 50
MG                         98   STROMECTOL 3 MG           29 MG                        47
SPIRIVA HANDIHALER 18
MCG                       37 SUBLIMAZE 0.05 MG/ML     23 SUSTIVA 100 MG             85
SPORANOX 10 MG/ML         56 SUBOXONE 0.5-2 MG, 2-8      SUSTIVA 200 MG, 50 MG      85
                             MG                       27
SPORANOX 100 MG           56
                             SUBUTEX 2 MG, 8 MG       27 SUSTIVA 600 MG             85
SPORANOX PULSEPAK 100                                    SUTENT 12.5 MG, 25 MG, 50
MG                        56 SUCRAID 8500 UNIT/ML 120 MG                            74
SPRIX 15.75 MG/SPRAY      18 SULAR 17 MG, 25.5 MG, 34    SYLATRON 296 MCG, 444
SPRYCEL 100 MG, 140 MG, 20   MG, 8.5 MG               93 MCG, 888 MCG               75
                                                         SYMBICORT 160-4.5 MCG/ACT,
MG, 50 MG, 70 MG, 80 MG   74 SULFACETAMIDE SODIUM 10 4.5-80 MCG/ACT                 39
                             %                       173
STADOL 2 MG/ML            27 SULFAMETHOXAZOLE/TRIM       SYMBYAX 12-25 MG, 12-50 MG,
                             ETHOPRIM 400-50-500-80      25-3 MG, 25-6 MG, 50-6 MG 186
STALEVO 100 100-200-25 MG79 MG/5ML                    31 SYMLIN 600 MCG/ML          48
STALEVO 125 125-200-31.25    SULFAMYLON 50 GM        111 SYMLINPEN 120 1000
MG                        79                             MCG/ML                     48
STALEVO 150 150-200-37.5     SULFAMYLON 85 MG/GM 111 SYMLINPEN 60 1000
MG                        79                             MCG/ML                     48
                             SUMAVEL DOSEPRO 6
STALEVO 200 200-50 MG     79 MG/0.5ML                153 SYMMETREL 100 MG           79
STALEVO 50 12.5-200-50 MG 79 SUPRAX 200 MG/5ML          98 SYNAGIS 100 MG/ML, 50
                                                           MG/0.5ML                  180
STALEVO 75 18.75-200-75         SUPRAX 400 MG           98
MG                         79                              SYNALAR 0.01 %            116
                                SUPREP BOWEL PREP 1.6-
STARLIX 120 MG, 60 MG      52   17.5-3.13 GM/180ML     137   SYNALAR 0.025 %         116
STAVZOR 125 MG, 250 MG, 500     SURE COMFORT INSULIN
                                SYRINGE/U-100/0.3ML/29G X    SYNALGOS-DC 16-30-356.4
MG                       45                                  MG                      26
                                1/2"                   150
STELARA 45 MG/0.5ML, 90         SURE COMFORT INSULIN
MG/ML                   111     SYRINGE/U-100/1ML/31G X      SYNAREL 2 MG/ML         125
STERAPRED 12 DAY 5 MG 104       5/16"                  150
                                                             SYNERA 70 MG            118



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SYNERCID 150-350 MG       33 TEGRETOL 100 MG           43 TEV-TROPIN 5 MG           125
SYNTHROID 100 MCG, 112
MCG, 125 MCG, 137 MCG, 150   TEGRETOL 100 MG/5ML       43   TEVETEN 400 MG           61
MCG, 175 MCG, 200 MCG, 25
MCG, 300 MCG, 50 MCG, 75     TEGRETOL 200 MG           43   TEVETEN 600 MG           61
MCG, 88 MCG              190                                TEVETEN HCT 12.5-600 MG,
                             TEGRETOL-XR 100 MG        43
SYPRINE 250 MG            88                                25-600 MG                64
                             TEGRETOL-XR 200 MG, 400        TEXACORT 2 %            117
TABLOID 40 MG             70 MG                        43
                             TEKAMLO 10-150 MG, 10-300      TEXACORT 2.5 %          117
TACLONEX 0.005-0.064 % 116 MG, 150-5 MG, 300-5 MG 64
                             TEKTURNA 150 MG, 300
TACLONEX SCALP 0.005-0.064 MG                               THALITONE 15 MG         122
                                                       65
%                        116 TEKTURNA HCT 12.5-150 MG,    THALOMID 100 MG, 150 MG,
TAGAMET 300 MG, 400 MG,      12.5-300 MG, 150-25 MG, 25-  200 MG, 50 MG               88
800 MG                   193 300 MG                    64 THEO-24 100 MG, 200 MG, 300
TALADINE 150 MG          193 TEMODAR 100 MG            68 MG, 400 MG                  39
                                                          THEOPHYLLINE/D5W 0.8-5 %,
TALWIN 30 MG/ML           27   TEMOVATE 0.05 %        116 MG/ML, 1.6-5 %, MG/ML, 2-5 %,
                                                          MG/ML, 3.2-5 %, MG/ML, 4-5 %,
TAMBOCOR 100 MG, 150 MG,                                  MG/ML                       40
50 MG                    36    TEMOVATE E 0.05 %      116
                                                          THERACYS 81 MG/VIAL         75
TAMIFLU 12 MG/ML, 6
MG/ML                    87    TENEX 1 MG, 2 MG        62 THINPRO INSULIN
TAMIFLU 30 MG, 45 MG, 75                                  SYRINGE/0.3ML/29G X 1/2" 150
MG                       87    TENIVAC 2-5 LFU        191
                                                          THORAZINE 200 MG            82
TARCEVA 100 MG, 150 MG, 25
MG                       74    TENORETIC 100 100-25 MG64
                                                          THYMOGLOBULIN 25 MG         89
TARGRETIN 1 %            110   TENORETIC 50 25-50 MG 64
                                                          THYROLAR-1 60 MG           190
TARGRETIN 75 MG           75   TENORMIN 100 MG, 25 MG,
                               50 MG                   91 THYROLAR-1/2 30 MG         190
TARKA 1-240 MG, 180-2 MG, 2-
240 MG, 240-4 MG          64   TERAZOL 3 0.8 %        197
                                                          THYROLAR-1/4 15 MG         190
TASIGNA 150 MG, 200 MG    74   TERAZOL 3 80 MG        198
                                                          THYROLAR-2 120 MG          190
TASMAR 100 MG             78   TERAZOL 7 0.4 %        198
                                                          THYROLAR-3 180 MG          190
TASMAR 200 MG             78   TERUMO INSULIN
                               SYRINGE/U-100/0.3ML/29G X TIAZAC 120 MG, 180 MG, 240
TAXOL 100 MG/16.7ML, 30        1/2"                   150 MG, 300 MG, 360 MG, 420
MG/5ML, 300 MG/50ML      77    TERUMO SURGUARD            MG                          93
TAXOTERE 20 MG/0.5ML, 80       INSULIN SYRINGE/0.3ML/29G
MG/2ML                   77    X 1/2"                 150 TICE BCG 50 MG              75
TAXOTERE 20 MG/ML, 80       TESTIM 1 %          28 TICLID 250 MG                    134
MG/4ML                   77
                            TETANUS TOXOID
TAZORAC 0.05 %, 0.1 %   111 ADSORBED 5 LFU     191 TIGAN 100 MG/ML                   54
                            TETANUS/DIPHTHERIA
TEFLARO 400 MG, 600 MG 98 TOXOIDS-ADSORBED ADULT TIGAN 300 MG                        54
                            2 LF/0.5ML         191


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TIKOSYN 125 MCG, 250 MCG,                                      TRAVASOL 4.25%/DEXTROSE
                         36 TOPICORT 0.25 %        117         25% 17-178-186-195-203-246-
500 MCG
TIMENTIN 0.1-3 GM, 1-30     TOPOTECAN HCL 4                    25-261-263-297-440-51-76-77-
GM                      183 MG/4ML                  77         880 %, MG/100ML             169
                                                               TRAVASOL 5.5%/DEXTROSE
TIMENTIN 0.1-3 GM/100ML 183 TOPROL XL 100 MG, 200 MG,          10% 10-200-250-400-44-560-6-
                            25 MG, 50 MG            91
                                                               640-880-900 %, MEQ/L,
TIMOLIDE 10/25 10-25 MG    64 TORADOL ORAL 10 MG         18    MG/100ML                    169
                                                               TRAVASOL 5.5%/DEXTROSE
TIMOPTIC 0.25 %, 0.5 %    171 TORISEL 25 MG/ML           74    20% 20-200-250-400-44-560-6-
                                                               640-880-900 %, MEQ/L,
TIMOPTIC OCUDOSE 0.25 %,                                       MG/100ML                    169
                       171 TOTECT 500 MG                 76
0.5 %                                                          TRAVASOL
TIMOPTIC-XE 0.25 %, 0.5 % 171 TOVIAZ 4 MG, 8 MG         195    5.5%/ELECTROLYTES 10-101-
                                                               102-1140-22-224-230-241-252-
TOBI 300 MG/5ML            15 TRACLEER 125 MG, 62.5            263-318-340-431-522-570-60-70-
                              MG                         95    99 MEQ/L, MG/100ML          169
                                                               TRAVASOL 8.5%/DEXTROSE
TOBRADEX 0.01-0.1-0.3 % 176 TRADJENTA 5 MG               49    10% 10-1100-150-260-340-35-
                                                               370-380-44-460-5.4-620-624-
TOBRADEX 0.1-0.3 %        176 TRANDATE 100 MG, 200 MG,         680-750-810-850-90 %, MEQ/L,
                              300 MG                 90
TOBRADEX ST 0.05-0.1-0.3                                       MG/100ML                    170
                                TRANDATE IV 5 MG/ML      90    TRAVASOL 8.5%/DEXTROSE
%                        176
TOBRAMYCIN SULFATE ADD-         TRANSDERM-SCOP 1.5             20% 1100-150-20-260-340-35-
VANTAGE 10 MG/ML          15    MG                        54   370-380-44-460-5.4-620-624-
TOBRAMYCIN                      TRAVASOL 1140-22-230-241-      680-750-810-850-90 %, MEQ/L,
SULFATE/SODIUM CHLORIDE         252-263-318-340-43-570-99      MG/100ML                    170
0.8-0.9 %, MG/ML          15    MEQ/L, MG/100ML, 152-1760-     TRAVASOL 8.5%/DEXTROSE
                                34-356-372-390-406-492-526-    50% 1100-150-260-340-35-370-
TOBREX 0.3 %              174   67-880 MEQ/L, MG/100ML 169     380-44-460-5.4-50-620-624-680-
                                TRAVASOL 152-1760-34-356-      750-810-850-90 %, MEQ/L,
TODAYS HEALTH MINI PEN                                         MG/100ML                    170
NEEDLES 31G X 1/4"      150     372-390-406-492-52-526-880
TODAYS HEALTH ORIGINAL          MEQ/L, MG/100ML          169   TRAVATAN 0.004 %           177
PEN NEEDLES 29G X 1/2" 150      TRAVASOL
TOFRANIL-PM 100 MG, 125         2.75%/DEXTROSE 10% 10-11-      TRAVATAN Z 0.004 %         177
MG, 150 MG, 75 MG        48     112-115-120-126-132-159-170-
TOPAMAX 100 MG, 200 MG, 25      216-261-285-50-51-570 %,       TREANDA 100 MG, 25 MG       68
MG, 50 MG                43     MG/100ML                 169
                                TRAVASOL
TOPAMAX SPRINKLE 15 MG,         2.75%/DEXTROSE 5% 11-112-      TRECATOR 250 MG             67
25 MG                    43     115-120-126-132-159-170-216-
TOPCARE CLICKFINE               261-285-5-50-51-570 %,         TRECATOR-SC 250 MG          67
UNIVERSAL PEN EEDLES            MG/100ML                 169
31GX1/4"                150     TRAVASOL                       TRELSTAR DEPOT 3.75 MG 72
TOPCARE ULTRA COMFORT           3.5%/ELECTROLYTES 131-
INSULIN SYRINGE/1ML/31G X                                      TRELSTAR DEPOT MIXJECT
                                14-147-154-161-168-203-217-    3.75 MG                72
5/16"                   150     218-35-364-51-63-728
TOPCARE ULTRA COMFORT           MG/100ML                 169   TRELSTAR LA 11.25 MG        72
INSULIN SYRINGE/U-              TRAVASOL
100/0.3ML/29G X 1/2"    150     4.25%/DEXTROSE 10% 10-17-      TRELSTAR LA MIXJECT 11.25
TOPCO INSULIN SYRINGE/U-        178-186-195-203-246-261-263-   MG                       72
100/0.3ML/29G X 1/2"    150     297-440-51-76-77-880 %,        TRELSTAR MIXJECT 22.5
                                MG/100ML                 169   MG                       72
TOPICORT 0.05 %           117


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                        134 TWINJECT 0.15 MG/0.15ML,           ULTRA COMFORT INSULIN
TRENTAL 400 MG              0.3 MG/0.3ML           198         SYRINGE/1ML/31G X 5/16" 151
TREXALL 10 MG, 15 MG, 5     TWINRIX 20-720 ELU/ML,             ULTRA COMFORT INSULIN
MG                       70 MCG/ML                 197         SYRINGE/U-100/0.3ML/29G X
                                                               1/2"                     151
TREXALL 7 MG             70 TWYNSTA 10-40 MG, 10-80 64         ULTRA-COMFORT INSULIN
                            MG, 40-5 MG, 5-80 MG
                                                               SYRINGE/U-100/0.3ML/29G X
TREXIMET 500-85 MG        152 TYGACIL 50 MG              32    1/2"                     151
                                                               ULTRA-COMFORT INSULIN
TRI-NORINYL 28            101 TYKERB 250 MG              74    SYRINGE/U-100/1ML/31G X
TRIBENZOR 10-12.5-40 MG, 10- TYLENOL/CODEINE #4 300-           5/16"                    151
25-40 MG, 12.5-20-5 MG, 12.5-                                  ULTRA-THIN II INSULIN
                                  60 MG                   26   SYRINGE/0.3ML/29G X 1/2" 151
40-5 MG, 25-40-5 MG            64
                                  TYPHIM VI 25 MCG/0.5ML 196   ULTRA-THIN II INSULIN
TRICOR 145 MG, 48 MG           59                              SYRINGE/U-100/0.3ML/29G X
                                  TYSABRI 300 MG/15ML    186   1/2"                     151
TRIDESILON 0.5 %              117                              ULTRA-THIN II PEN
                                  TYVASO 0.6 MG/ML        94   NEEDLE/29G X 1/2"        151
TRIESENCE 40 MG/ML            176                              ULTRACET 325-37.5 MG       26
                                  TYVASO REFILL 0.6 MG/ML 94
TRIGLIDE 160 MG                59                              ULTRAM 50 MG               23
                                  TYVASO STARTER 0.6
TRIGLIDE 50 MG                 59 MG/ML                   94   ULTRAM ER 100 MG, 200 MG,
                                  TYZEKA 600 MG           87   300 MG                   23
TRIHIBIT 46.8-5-6.7 LFU,
MCG                           191                              ULTRAVATE 0.05 %          117
TRILEPTAL 150 MG, 300 MG,         TYZINE 0.1 %           162
600 MG                         43                              ULTRAVATE PAC 0.05-12 % 117
                                  ULESFIA 5 %            119
TRILEPTAL 300 MG/5ML           43                              UNASYN 0.5-1 GM           183
                                  ULORIC 40 MG, 80 MG    133
TRILIPIX 135 MG, 45 MG         59                              UNASYN 1-2 GM             183
                                  ULTICARE INSULIN
TRIOSTAT 10 MCG/ML            190 SYRINGE/0.3ML/29G X          UNASYN ADD-VANTAGE 0.5-1
                                  1/2"                   150   GM                    183
TRIPEDIA 46.8-5-6.7 LFU/0.5ML, ULTICARE INSULIN                UNASYN ADD-VANTAGE 1-2
MCG/0.5ML                     191 SYRINGEULTRAFINE U-          GM                    183
                                  100/1ML/31G X 5/16"    150
TRISENOX 10 MG/10ML            75 ULTICARE MICRO PEN           UNASYN BULK PACK 10-5
                                  NEEDLES/32G X 4MM      150   GM                    183
TRIZIVIR 150-300 MG            85 ULTICARE MINI PEN            UNIFINE PENTIPS           151
TROPHAMINE 0.014-0.015-0.05- NEEDLES ULTI-FINE IV        150
0.12-0.14-0.19-0.2-0.22-0.23-     ULTICARE MINI PEN            UNIFINE PENTIPS
0.25-0.29-0.3-0.32-0.41-0.47-     NEEDLES31GX6MM         151   29GX12MM                  151
0.49-0.73-0.84 GM/100ML,          ULTICARE ORIGINAL PEN        UNIFINE PENTIPS
0.025-0.2-0.24-0.32-0.34-0.36-    NEEDLES ULTI-FINE      151   31GX6MM                   151
0.38-0.42-0.48-0.5-0.54-0.68-     ULTIGUARD INSULIN            UNIRETIC 12.5-15 MG, 12.5-7.5
0.78-0.82-1.2-1.4-5-97            SYRINGE/U-100/0.3ML/29G X    MG, 15-25 MG                64
GM/100ML, MEQ/L               170 1/2"                   151   UNIVASC 15 MG, 7.5 MG      61
                                  ULTIGUARD INSULIN
TRUSOPT 2 %                   177 SYRINGEULTI-FINE U-          URECHOLINE 10 MG, 25 MG, 5
                                  100/1ML/31G X 5/16"    151   MG, 50 MG              195
TRUVADA 200-300 MG             85
                                  ULTILET PEN NEEDLE     151   URISPAS 100 MG            195


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UROXATRAL 10 MG         133 VASERETIC 10-25 MG, 12.5-5 VICOPROFEN 200-7.5 MG      26
                             MG                      64
URSO 250 250 MG         130 VASOTEC 10 MG, 2.5 MG, 2061 VICTOZA 18 MG/3ML         49
                             MG, 5 MG
URSO FORTE 500 MG       130 VECTIBIX 100 MG/5ML, 200 70 VICTRELIS 200 MG          87
                             MG/10ML, 400 MG/20ML
UVADEX 20 MCG/ML          75 VECTICAL 3 MCG/GM     111 VIDA MIA UNIFINE
                                                        PENTIPSMINI 31GX6MM      151
V-R MONOJECT INSULIN                                    VIDA MIA UNIFINE
SYRINGE/U-100/0.3ML/29G X    VELCADE 3.5 MG          74 PENTIPSORIGINAL
1/2"                    151                             29GX12MM                 151
                             VELETRI 1.5 MG          94
VAGIFEM 10 MCG          198                             VIDAZA 100 MG             70
                             VELTIN 0.025-1.2 %    107 VIDEX EC 125 MG, 200 MG, 250
VAGIFEM 25 MCG          198                             MG, 400 MG                85
                             VENTAVIS 10 MCG/ML      94 VIDEXPEDIATRIC 2 GM, 4
VALCYTE 450 MG            86                            GM                        85
                             VENTAVIS 20 MCG/ML      94
VALCYTE 50 MG/ML          86                            VIGAMOX 0.5 %            174
                             VENTOLIN HFA 108
VALTREX 1 GM, 500 MG      87 MCG/ACT                 39 VIIBRYD                   45
                             VERAMYST 27.5
VALTURNA 150-160 MG, 300-    MCG/SPRAY             162 VIIBRYD 10 MG, 20 MG, 40
320 MG                    64                            MG                        45
VALUMARK PEN NEEDLES         VERDESO 0.05 %        117 VIMOVO 20-375 MG, 20-500
29GX12MM                151                             MG                        18
VALUMARK PEN NEEDLES         VEREGEN 15 %          107
                                                        VIMPAT 10 MG/ML           43
31GX 6MM                151 VERELAN 120 MG, 180 MG,
VANCOCIN HCL 125 MG, 250     240 MG, 360 MG          93 VIMPAT 100 MG, 150 MG, 200
MG                        30 VERELAN PM 100 MG, 200     MG, 50 MG                 43
VANCOMYCIN HCL IN            MG, 300 MG              93 VIMPAT 200 MG/20ML
DEXTROSE 1 GM/200ML, 500                                                          43
MG/100ML, 750 MG/150ML 30    VESANOID 10 MG          75 VINBLASTINE SULFATE 1
VANDETANIB 100 MG, 300                                  MG/ML                     77
MG                        74 VESICARE 10 MG, 5 MG 195
                                                        VIRACEPT 250 MG, 625 MG 85
VANOS 0.1 %             117 VEXOL 1 %              176
                                                        VIRACEPT 50 MG/GM         85
VANSPAR 7.5 MG            35 VFEND 200 MG, 50 MG     56
                                                        VIRAMUNE 200 MG           85
VANTAS 50 MG              72 VFEND 40 MG/ML          56
                                                        VIRAMUNE 50 MG/5ML        85
VANTIN 100 MG, 200 MG     98 VFEND IV 200 MG         56
VANTIN 100 MG/5ML, 50                                   VIRAMUNE XR 400 MG        85
MG/5ML                    98 VIBRAMYCIN 100 MG     189
VAPRISOL 20-5 %,                                        VIRAZOLE 6 GM             87
MG/100ML                127 VIBRAMYCIN 25 MG/5ML 189 VIREAD 150 MG, 200 MG, 250
VAQTA 25 UNIT/0.5ML, 50                                 MG                        85
UNIT/ML                 197 VIBRAMYCIN 50 MG/5ML 189
                                                        VIREAD 300 MG             85
VARIVAX 1350 PFU/0.5ML 197 VIBRATAB 100 MG         189
                                                        VIREAD 40 MG/GM           85
VASERETIC                 64


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VIROPTIC 1 %             174 WELCHOL 3.75 GM             59 XOPENEX HFA 45 MCG/ACT 39

VISICOL 0.398-1.102 GM   138 WELCHOL 625 MG              59 XYLOCAINE 0.5 %           139

VISTARIL 25 MG, 50 MG     35 WELLBUTRIN 100 MG, 75 45 XYLOCAINE 1 %, 2 %              139
                             MG
VISTIDE 75 MG/ML          86 WELLBUTRIN SR 100 MG, 45 XYLOCAINE 20 MG/ML               36
                             150 MG, 200 MG
VIVACTIL 10 MG, 5 MG      48 WELLBUTRIN XL 150 MG, 300 XYLOCAINE 4 %                  118
                             MG                     45
VIVAGLOBIN 160 MG/ML     180 WESTCORT 0.2 %             117 XYLOCAINE JELLY 2 %       118
VIVELLE 0.05 MG/24HR, 0.1       WESTHROID 16.25 MG, 162.5 XYLOCAINE VISCOUS 2 % 159
MG/24HR                   129   MG, 260 MG, 325 MG     190
VIVELLE-DOT 0.025 MG/24HR,
0.0375 MG/24HR, 0.05            WESTHROID 195 MG       190 XYLOCAINE-MPF 0.5 %, 1.5 139
                                                           %
MG/24HR, 0.075 MG/24HR, 0.1
MG/24HR                   129   WESTHROID 97.5 MG      190 XYLOCAINE-MPF 1 %, 2 %, 4
                                                           %                           139
VIVITROL 380 MG           53                               XYLOCAINE-
                                XALATAN 0.005 %        177 MPF/EPINEPHRINE 0.5-1 %,
VOLTAREN 0.1 %           177                               :200000, MG                 138
                                XALKORI 200 MG, 250 MG 74 XYLOCAINE-
                                XARELTO 10 MG, 15 MG, 20   MPF/EPINEPHRINE 0.5-1-1.5 %,
VOLTAREN 1 %             107
                                MG                      40 :200000, MG/ML, 0.5-1-2 %,
VOLTAREN 25 MG, 50 MG, 75       XENAZINE 12.5 MG, 25       :200000, MG/ML              138
MG                       18     MG                     186 XYLOCAINE/EPINEPHRINE 0.5-
                                                           1 %, :100000, MG/ML, 0.5-1-2 %,
VOLTAREN-XR 100 MG        18    XENICAL 120 MG          13 :100000, MG/ML, 1 %,
                                                           :100000                     139
VOSOL 2 %                177    XEOMIN 100 UNIT, 50        XYLOCAINE/EPINEPHRINE 0.5-
                                UNIT                   162 1 %, :200000                138
VOSOL HC 1-2-3 %         179    XERESE 1-5 %           111 XYREM 500 MG/ML             185
VOSPIRE ER 4 MG, 8 MG     39 XGEVA 120 MG/1.7ML         123 XYZAL 2.5 MG/5ML           57
VOTRIENT 200 MG           74 XIAFLEX 0.9 MG              88 XYZAL 5 MG                 57
VP INSULIN SYRINGE/U-
100/0.3ML/29G X 1/2"     151 XIBROM 0.09 %              177 YASMIN 28 0.03-3 MG       102
VPRIV 400 UNIT           135 XIFAXAN 200 MG              30 YAZ 0.02-3 MG             102
VUSION 0.25-15-81.35 %   109 XIFAXAN 550 MG              30 YERVOY 200 MG/40ML, 50
VYTORIN 10 MG, 10-20 MG, 10-                                MG/10ML                 70
40 MG                     58 XOLAIR 150 MG               36 YF-VAX                 197
VYTORIN 10-80 MG          58 XOLEGEL 2 %            109 ZAMICET 10-325-6.7 %,
VYVANSE 20 MG, 30 MG, 40                                MG/15ML                        26
                             XOPENEX 0.31 MG/3ML, 0.63
MG, 50 MG, 60 MG, 70 MG   13 MG/3ML, 1.25 MG/3ML     39 ZANAFLEX 2 MG, 4 MG           161
WD MEDIC INSULIN             XOPENEX CONCENTRATE
SYRINGE/0.3ML/29G X 1/2" 152 1.25 MG/0.5ML              ZANAFLEX 2 MG, 4 MG, 6
                                                     39 MG                            161



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                         68 ZESTRIL 10 40 MG, 5 MG 20 61 ZOFRAN 32-5 %, MG/50ML
                                        MG, 2.5 MG,
ZANOSAR 1 GM                                                                         54
                            MG, 30 MG,
ZANTAC 0.45-50 %,                                     60 ZOFRAN 4 MG/2ML, 40
MG/50ML                 193 ZETIA 10 MG                  MG/20ML                     54
                        193 ZIAC5-6.25 MG
                                 10-6.25 MG, 2.5-6.25
ZANTAC 15 MG/ML                                       64 ZOFRAN 4 MG/5ML             54
                            MG,
ZANTAC 150 MG           193 ZIAGEN 20 MG/ML             85 ZOFRAN ODT 4 MG, 8 MG     54

ZANTAC 150 MG, 300 MG   193 ZIAGEN 300 MG               85 ZOLADEX 10.8 MG           72

ZANTAC 25 MG            193 ZIANA 0.025-1.2 %          107 ZOLADEX 3.6 MG            72

ZANTAC 25 MG/ML         193 ZINACEF 1.5 GM              96 ZOLINZA 100 MG            74

                          44 ZINACEF 1.5 GM, 7.5 GM, 750   ZOLOFT 100 MG, 25 MG, 50
ZARONTIN 250 MG              MG                       96   MG                       47
ZAROXOLYN 10 MG, 2.5 MG, 5 ZINACEF 750 MG             96   ZOLOFT 20 MG/ML           47
MG                       122
ZAROXOLYN 2 MG           122 ZINACEFIN ISO-OSMOTIC 97      ZOLPIMIST 5 MG/ACT       136
                             DEXTROSE 750 MG
ZAVESCA 100 MG           135 ZINACEFIN ISO-OSMOTIC 97      ZOMETA 4 MG/100ML        123
                             DILUENT 1.5 GM
ZEBETA 10 MG, 5 MG        91 ZINECARD 250 MG, 500          ZOMETA 4 MG/5ML          123
                             MG                       76
ZEGERID 1100-20 MG, 1100-40 ZIPSOR 25 MG              19   ZOMIG 2 MG, 2.5 MG, 5 MG 153
MG                       194
ZEGERID 1680-20 MG, 1680-40 ZIRGAN 0.15 %            174   ZOMIG 5 MG               153
MG                       194
ZELAPAR 1.25 MG          79 ZITHROMAX 1 GM             140 ZOMIG ZMT 2 MG, 2.5 MG, 5 153
                                                           MG
ZELBORAF 240 MG          74 ZITHROMAX 100 MG/5ML, 140 ZONALON 5 %            110
                            200 MG/5ML
ZEMAIRA 1000 MG         188 ZITHROMAX 250 MG, 500 MG, ZONEGRAN 100 MG, 25 MG, 50
                            600 MG                140 MG                      43
ZEMPLAR 1 MCG, 2 MCG, 4
                          126 ZITHROMAX 500 MG         140 ZORBTIVE 8.8 MG          125
MCG
ZEMPLAR 2 MCG/ML, 5           ZITHROMAX TRI-PAK 500
                                                       140 ZORTRESS 0.25 MG          89
MCG/ML                    126 MG
ZENAPAX 25 MG/5ML          89 ZITHROMAX Z-PAK 250
                              MG                       140 ZORTRESS 0.5 MG, 0.75 MG 89
ZENPEP 10000-16000-3000
UNIT, 10000-34000-55000 UNIT, ZMAX 2 GM                140 ZOSTAVAX 19400
                                                           UNT/0.65ML                197
109000-20000-68000 UNIT,                                   ZOSYN , 0.375-3 GM, 0.5-4
136000-25000-85000 UNIT,      ZMAX PEDIATRIC 2 GM      140 GM                        183
15000-51000-82000 UNIT,       ZOCOR 10 MG, 20 MG, 40
17000-27000-5000 UNIT     120 MG, 5 MG                  60 ZOSYN 0.25-0.5-2 GM, MG 183
ZERIT 1 MG/ML              85 ZOCOR 80 MG                  ZOSYN 0.25-0.5-2-5 %,
                                                        60 GM/50ML, MG/50ML, 0.375-
ZERIT 15 MG, 20 MG, 30 MG, 40 ZOFRAN 24 MG, 4 MG, 8        0.75-3-5 %, GM/50ML,
MG                         85 MG                        54 MG/50ML, 0.5-1-4-5 %,
ZESTORETIC 10-12.5 MG, 12.5-                               GM/100ML, MG/100ML       183
20 MG, 20-25 MG            64

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ZOSYN 0.25-2 GM, 36-4.5
                         183 ZYVOX 600 MG                 33   ala-cort 1 %                   111
GM
ZOSYN 0.375-0.75-3 GM, MG,    acetaminophen/codeine #2 15-     albuterol sulfate 0.5 %, 0.83 % 38
0.5-1-4 GM, MG           183 300 mg                       23
ZOVIRAX 200 MG             87 acetaminophen/codeine #3 30-     albuterol sulfate 2 mg, 4 mg    38
                              300 mg                      23
                              acetaminophen/codeine 12-
ZOVIRAX 200 MG/5ML         87 120-7 %, mg/5ml, 12-120-7.4      albuterol sulfate 2 mg/5ml      38
                              %, mg/5ml                   23
ZOVIRAX 400 MG, 800 MG     87 acetaminophen/codeine 15-300     allersol 0.1 %                 174
                              mg                          23
ZOVIRAX 5 %              111 acetaminophen/codeine             alphatrex 0.05 %               111
                              phosphate 30-300 mg         24
ZOVIRAX 500 MG             87                                  altavera 0.03-0.15 mg           98
                              acetasol hc 0.02-1-2-3 % 178
ZUPLENZ 4 MG, 8 MG         54 acetazolamide 125 mg, 250        alyacen 1/35                    99
                              mg                         120
ZYBAN 150 MG             187 acetazolamide sodium 500          amantadine hcl 100 mg           78
                              mg                         120
ZYCLARA 3.75 %           118 acetic acid 0.25% 0.25 %, 0.5     amantadine hcl 50 mg/5ml        78
                              %                          132
ZYCLARA PUMP 3.75 %      118 acetic acid/aluminum acetate 2    amcinonide 0.1 %               111
                              %                          177
ZYFLO CR 600 MG            37                                  amd foam dressing 2"x2"        141
                              acetylcysteine 20 %        105
ZYLET 0.01-0.3-0.5 %     176                                   amicar 25 %                    136
                              adoxa 100 mg, 75 mg        188
ZYLOPRIM 100 MG, 300 MG 134                                    amifostine 500 mg               75
                              adoxa pak 1/100 100 mg 188
ZYMAR 0.3 %              174                                   amikacin sulfate 250 mg/ml      14
                              adoxa pak 1/75 75 mg       188
ZYMAXID 0.5 %            174                                   amikacin sulfate 500 mg/2ml     14
                              adoxa pak 2/100 100 mg 188
                                                               amiloride/hydrochlorothiazide 5-
ZYPREXA 10 MG              81
                              adriamycin 10 mg, 20 mg     72   50 mg                         120
ZYPREXA 10 MG, 15 MG, 2.5                                      amino acids                    163
MG, 20 MG, 5 MG, 7.5 MG    81 adriamycin 2 mg/ml          72
ZYPREXA 2 MG, 7 MG         81                                  aminocaproic acid 25 %         136
                              adriamycin 50 mg            72
ZYPREXA RELPREVV 210 MG,                                       aminophylline 100 mg, 200 mg 39
300 MG, 405 MG             81 adrucil 2.5 gm/50ml, 5
ZYPREXA ZYDIS 10 MG, 15       gm/100ml                    68
                                                               aminophylline 25 mg/ml          39
MG, 20 MG, 5 MG            81 airet 0.83 %                38
                                                               aminosyn 8.5%/electrolytes 10-
ZYRTEC 1 MG/ML             57                                  1100-142-150-260-30-340-370-
                              ak-con 0.1 %               174
                                                               380-44-460-620-624-65-680-750-
ZYTIGA 250 MG              72                                  810-850-98 meq/l, mg/100ml 164
                              ak-pentolate 1 %           171   aminosyn ii 8.5%/electrolytes 10-
ZYVOX 100 MG/5ML           33 ak-poly-bac 10000-500            146-170-230-253-255-30-340-
                              unit/gm                    172   425-450-561-595-61-614-627-66-
ZYVOX 2 MG/ML              33                                  80-844-850-86-865-893 meq/l,
                              ala cort 1 %               111   mg/100ml, mmole/l             165



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aminosyn-hf 100-1100-115-20-
240-3-450-500-600-610-62-66-      ampicillin-sulbactam        182 betamethasone dipropionate 0.05
                                                                  %                           112
770-800-840-900 meq/l,            ampicillin-sulbactam , 10-5     betamethasone valerate 0.1
mg/100ml                    166   gm                          182 %                           112
amiodarone hcl 150 mg/3ml, 450
mg/9ml, 50 mg/ml             36   android 10 mg                27 betaxolol hcl 0.5 %              170
amiodarone hcl 400 mg          36 anexsia 325-5 mg, 325-7.5 mg,      borofair 2 %                  177
                                  5-500 mg                      24
amitriptyline hcl 10 mg, 100 mg,  antibiotic ear 1-10000-3.5 %,
150 mg, 25 mg, 50 mg, 75 mg 47 mg/ml, unit/ml                        brimonidine tartrate 0.2 %    172
                                                              178
amlodipine besylate/benazepril
hcl                            62 anusol-hc 2.5 %               28   bromocriptine mesylate 2 mg    78
amlodipine besylate/benazepril                                       bumetanide 0.25 mg/ml, 0.5
hydrochloride                  62 apexicon 0.05 %             112    mg/ml                      121
ammonium chloride 5 meq/ml 153 astramorph 0.5 mg/ml, 1               bupivacaine hcl 0.5 %         139
                                  mg/ml                         19
amoxapine 100 mg, 150 mg, 25                                    bupivacaine/epinephrine 0.1-
mg, 50 mg                      47 atropine sulfate 0.1 mg/ml 1910.25-1 %, :200000, mg/ml     138
amoxicillin 125 mg           180 augmented betamethasone        bupivacaine/epinephrine 0.1-0.5-
                                 dipropionate 0.05 %        112 1 %, :200000, mg/ml          138
amoxicillin 125 mg, 250 mg   180 aurobiotic-hc 1-10000-3.5 %,
                                 mg/ml, unit/ml             178 butorphanol tartrate 1 mg/ml 27
amoxicillin 125 mg/5ml, 250
mg/5ml                      180 avidoxy 100 mg                188 butorphanol tartrate 10 mg/ml 27
amoxicillin 250 mg, 500 mg   180 aygestin 5 mg                184 calcium chloride 10 %            153
amoxicillin/clavulanate
potassium                      182 azasan 100 mg, 75 mg        88 capital/codeine 12-120 mg/5ml 24
amoxicillin/clavulanate potassium
200-28.5 mg, 400-57 mg         182 azithromycin 1 gm          140 captopril/hydrochlorothiazide 15-
                                                                  25 mg, 15-50 mg                 62
amoxicillin/potassium clavulanate                                 captopril/hydrochlorothiazide 15-
200-28.5 mg, 400-57 mg         182 azurette                    99 25 mg, 15-50 mg, 25 mg, 25-50
amoxil 250 mg/5ml            181 baciim 50000 unit                mg                              62
                                                               29 carboplatin 10 mg/ml, 150
                                                                  mg/15ml, 450 mg/45ml, 50
amphocin 50 mg                55 bacitracin 500 unit/gm       172 mg/5ml, 600 mg/60ml             67
amphotericin b 50 mg          55 bacitracin 50000 unit         29 carboplatin 50 mg/5ml             67

ampicillin 125 mg/5ml        181 bacitracin/neomycin/polymyxin       carisoprodol/aspirin/codeine 161
                                 10000-400-5 mg/gm,
ampicillin 250 mg, 500 mg    181 unit/gm                    172      carteolol hcl 1 %             170
                                 bacitracin/polymyxin b 10000-
                                                                     cefaclor 125 mg/5ml, 187
                             181 500 unit/gm                172
ampicillin 250 mg/5ml                                                mg/5ml, 250 mg/5ml, 375
                                 baclofen 10 mg, 20 mg      160      mg/5ml                        96
ampicillin sodium 1 gm, 2 gm 181
                                 baycadron 0.5 mg/5ml       102      cefaclor 250 mg, 500 mg        95
ampicillin sodium 10 gm      181
                                 benztropine mesylate 0.5 mg, 1      cefaclor er 500 mg             96
ampicillin sodium 10 gm, 125 mg, mg, 2 mg                    78
250 mg, 500 mg               181                                     cefazolin sodium 1 gm          95
                                 beta-val 0.1 %             112



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cefazolin sodium 1 gm, 10 gm,
                              95 cimetidine hcl 150 mg/ml     192 crolom 4 %                       177
500 mg
cefazolin sodium 1-5 %, gm     95 cimetidine hcl 300 mg/5ml 192 cromolyn sodium 4 %                177

cefazolin sodium 20 gm         95 ciprofloxacin hcl 100 mg    129 curity amd gauze sponge 2"x2" 8
                                                                  ply                         141
cefotetan 1 gm, 10 gm, 2 gm    96 cisplatin 1 mg/ml            67 curity sterile saline 0.9 %      132
cefoxitin sodium 1-4 %, gm, 2-2.2 claravis 30 mg               106   cyclobenzaprine hcl 7.5 mg    160
%, gm                          96
ceftriaxone sodium 1 gm        97 clemastine fumarate 0.67           cyclogyl 0.5 %, 1 %, 2 %      171
                                  mg/5ml                        56
ceftriaxone sodium 1 gm, 500
                               97 clemastine fumarate 2.68 mg 56     cyclopentolate hcl 1 %        171
mg
cefuroxime sodium 7.5 gm       96 cleocin pediatric granules 75 32   cyclopentolate hcl 1 %, 2 %   171
                                  mg/5ml
cephalexin 125 mg/5ml, 250        clindamycin palmitate hcl 75       cycloserine 250 mg             66
mg/5ml                         95 mg/5ml                        32
                                  clindamycin phosphate 9000
cephalexin 250 mg, 500 mg      95 mg/60ml                            cyclosporine modified 50 mg    88
                                                                32
cetacort 1 %                  112 clindamycin phosphateadd- 32       cylate 1 %                    171
                                  vantage 150 mg/ml
                                  clinisol sf 15% 1040-1180-
cetirizine hcl 5 mg/5ml        57 1470-151-2170-250-39-434-          cyproheptadine hcl 2 mg/5ml    58
                                  592-749-894-960 meq/l,
chenodal 250 mg               130 mg/100ml                     168   cyproheptadine hcl 4 mg        58
                                  clorpres 0.1-15 mg, 0.2-15 mg,
chloroquine phosphate 250 mg 65 0.3-15 mg                       63   cytarabine 1 gm, 2 gm, 500 mg 69
chlorothiazide 250 mg, 500        clotrimazole 1 %             108   cytarabine 100 mg/ml           69
mg                            121
chlorpromazine hcl 10 mg, 100     clotrimazole 10 mg           159   cytarabineaqueous 100 mg/ml 69
mg, 25 mg, 50 mg               82
                                                                     danazol 100 mg, 200 mg, 50
chlorpromazine hcl 25 mg/ml 82 clozapine 50 mg                  81
                                                                     mg                            28
chlorpropamide 100 mg, 250          co-gesic 5-500 mg          24 dapsone 100 mg, 25 mg             32
mg                             52
chlorthalidone 25 mg, 50 mg 121 cocet plus 60-650 mg        24 daunorubicin hcl 5 mg/ml     72
                                codeine sulfate 15 mg, 30 mg,
chlorzoxazone 250 mg        160 60 mg                       20 del-beta 0.05 %             113

cholestyramine 4 gm          58 codeine sulfate 60 mg       20 demeclocycline hcl 150 mg, 300
                                                               mg                          188
chorex-10 10000 unit        123 compro 25 mg                82 depo-estradiol 5 mg/ml      128
chorionic gonadotropin 10000     constulose 10 gm/15ml        137 depo-testosterone 100 mg/ml,
unit                         123                                  200 mg/ml                     28
                                                                  desmopressin acetate 0.01 %,
ciclopirox olamine 0.77 %    108 cortisone acetate 25 mg      103
                                                                  0.1 mg/ml                    127
                                  cortomycin 1-10000-3.5 %,
cimetidine 200 mg             192 mg/ml, unit/ml            178 desonide 0.05 %                    113




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                            113 dextrose 5%/nacl 0.9% 0.9-5          dobutamine hcl 12 mg/ml, 250
desowen 0.05 %                  %                           154      mg/20ml, 500 mg/40ml        198
                                dextrose 5%/potassium                dobutamine hcl/d5w 1-5 %,
desoximetasone 0.05 %       113 chloride 0.15% 0.15-5 %, 20-5        mg/ml, 2-5 %, mg/ml, 4-5 %,
dexamethasone 0.5 mg, 0.75 mg, %, meq/l                     154      mg/ml                       199
1 mg, 1.5 mg, 2 mg, 4 mg, 6     dextrose 5%/sodium chloride          dobutamine/dextrose 5% 2-25-5
mg                          103 0.2% 0.2-5 %                154      %, mg/100ml, mg/ml, 2-5 %,
                                dextrose 5%/sodium chloride          mg/ml                       199
dexamethasone 0.5 mg/5ml 103 0.33% 0.33-5 %                 154      dopamine hcl 40 mg/ml       199
dexamethasone intensol 1        dextrose 5%/sodium chloride
mg/ml                       103 0.45% 0.45-5 %              154   dopamine hcl-dextrose 5% 0.5-
dexamethasone sodium            dextrose 5%/sodium chloride       0.8-5 %, mg/ml, 0.8-5 %, mg/ml,
phosphate 0.1 %             174 0.9% 0.9-5 %                154   1.6-5 %, mg/ml              199
dexamethasone sodium            dextrose 5%flex container 5       dopamine hcl/dextrose 5% 1.6-5
phosphate 10 mg/ml, 4 mg/ml 103 %                           163   %, mg/ml                    199
                                                                  dopamine/d5w 0.8-5 %, mg/ml,
dexasol 0.1 %                175 dextrose 5%viaflex 5 %       163 1.6-5 %, mg/ml              199
dexasporin 0.1-0.5-10000 %,                                  163 doxepin hcl 10 mg/ml             47
unit/ml                     175 dextrose 50% 50 %
dexchlorpheniramine maleate 2   dextrose 50% partial fill 50      doxepin hcl 100 mg, 150 mg      47
mg/5ml                       56 %                            163
                            103 dextrose 50% viaflex partial 163 doxorubicin hcl 10 mg
                                                             fill                                 73
dexpak 10 day 1.5 mg            50 %
dexpak 13 day 1.5 mg        103 dextrose 70% 70 %            163 doxorubicin hcl 2 mg/ml          73

dexpak 6 day 1.5 mg          103 dicloxacillin sodium 250 mg, 184 doxorubicin hcl 50 mg           73
                                 500 mg
dextrose 10% 10 %            163 dicyclomine hcl 10 mg/5ml 192 doxycycline hyclate 100 mg        188
dextrose 10%flex container 10    diflorasone diacetate 0.05       doxycycline hyclate 100 mg, 75
%                            163 %                            114 mg                           188
dextrose 10%partial fill 10 % 163 diflunisal 500 mg            19 doxycycline hyclate 50 mg    188
                                                                  doxycycline monohydrate 100
dextrose 10%viaflex 10 %     163 digoxin 0.05 mg/ml            93 mg, 75 mg                   188
dextrose 2.5%/nacl 0.45% 0.45-                                       droperidol 2 mg/ml           34
2.5 %                         154 digoxin 0.25 mg, 0.5 mg       93
dextrose 2.5%/sodium chloride                                        duramorph 0.5 mg/ml, 1 mg/ml 20
                              154 dilantin 100 mg, 30 mg        44
0.45% 0.45-2.5 %
dextrose 5%         flex                                             dynacin 100 mg, 50 mg, 75
                              163 dilantin infatabs 50 mg       44   mg                          188
container 5 %
                              163 diltiazem50 mg/10ml
                                             hcl 125 mg/25ml, 25     e.e.s. 200 200 mg/5ml       140
dextrose 5% 5 %                   mg/5ml,                       92
dextrose 5%/lactated ringers 109- diltiazem hcl er 120 mg, 60 mg,    e.e.s. 400 400 mg           140
130-2.7-28-4-5 %, meq/l       154 90 mg                         93
dextrose 5%/nacl 0.2% 0.2-5       diphenhydramine hcl 12.5           ed baclofen 10 mg           160
%                             154 mg/5ml                        56
dextrose 5%/nacl 0.33% 0.33-5                                        elixophyllin 80 mg/15ml      39
%                             154 diphenhydramine hcl 50 mg 56
dextrose 5%/nacl 0.45% 0.45-5     diphenoxylate/atropine 0.025-      embeline 0.5 %              114
%                             154 2.5 mg/5ml                    52


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embeline e 0.5 %            114 etodolac cr 400 mg            17 fluticasone propionate 0.5 % 114

emcin clear 2 %             106 etodolac er 400 mg, 500 mg, 17 fluvoxamine maleate 100 mg, 25
                                600 mg                         mg, 50 mg                    46
enalaprilat 1.25 mg/ml        60 etoposide 20 mg/ml           76 fomepizole 1.5 gm/1.5ml            53
endocet 10-325 mg, 10-650 mg,
325-5 mg, 325-7.5 mg, 500-7.5    fenofibrate 54 mg             59   fortical 200 unit/act          122
mg                            24 fenofibrate micronized 134 mg,     freamine iii 10-100-115-1190-
enpresse-28                   99 200 mg, 67 mg                 59   130-14-240-3-340-450-480-500-
                                                                    560-590-600-620-72-770-810-
                                 fenoprofen calcium 600 mg 17       950 meq/l, mg/100ml,
enulose 10 gm/15ml          131                                     mmole/l                         168
                                 fentanyl citrate 0.5 mg/ml    21   freamine iii 8.5%/electrolytes 10-
epinephrine hcl 0.1 mg/ml     38                                    1190-125-130-20-240-340-40-
                                 fexmid 7.5 mg                160   450-480-500-560-590-60-600-
ergoloid mesylates 1 mg     187                                     620-770-810-950 meq/l,
                                 fluconazole in nacl           56   mg/100ml, mmole/l               168
ery 2 %                     106
                                 fluconazole in nacl , 0.9-100      furosemide 10 mg/ml            121
ery-tab 250 mg, 333 mg, 500      %, mg/50ml, 0.9-400 %,
mg                          140 mg/200ml                       56   furosemide 10 mg/ml, 8
                                                                    mg/ml                          121
eryderm 2 %                 106 fludarabine phosphate 50 mg 69
                                                                 garamycin 0.3 %               172
                                 fludarabine phosphate 50
erythrocin stearate 250 mg 141 mg/2ml                         69 gauze pads 2"x2"              141
                                 fludrocortisone acetate 0.1
erythrocin stearate 500 mg 141 mg                            105 gemcitabine hcl 2 gm           69
                                 flumazenil 0.5 mg/5ml, 1
erythromycin 2 %             106 mg/10ml                      53 generlac 10 gm/15ml           131
erythromycin 250 mg          141 flunisolide 0.025 %         162
                                                                 genoptic 0.3 %                172
                                 flunisolide 0.025 %, 29
erythromycin 5 mg/gm         172 mcg/act                     162 gentacidin 0.3 %              172
erythromycin base 250 mg, 500    fluocinolone acetonide 0.01
mg                           141 %                           114 gentak 0.3 %                  172
erythromycin ethylsuccinate 200
mg/5ml                       141 fluorouracil 1 gm/20ml       69
                                                                 gentamicin sulfate 0.1 %      108
erythromycin ethylsuccinate 400  fluorouracil 2.5 gm/50ml, 5
mg                           141 gm/100ml                     69 gentamicin sulfate 0.3 %      173
erythromycin/benzoyl peroxide , fluphenazine hcl 1 mg, 10 mg,
3-5 %                        107 2.5 mg, 5 mg                 82 gentamicin sulfate 10 mg/ml 14
estrace 0.1 mg/gm            198 fluphenazine hcl 2.5 mg/5ml 82 gentamicin sulfate/0.9% sodium
                                                                 chloride 0.8-0.9 %, mg/ml      15
ethosuximide 250 mg/5ml       44 fluphenazine hcl 2.5 mg/ml 82 gentamicin sulfate/0.9% sodium
                                                                 chloride 0.9-1 %, mg/ml, 0.9-1.2
etidronate disodium 200 mg 122 fluphenazine hcl 5 mg/ml       82 %, mg/ml, 0.9-1.6 %, mg/ml     15
                                                                 gentamicin sulfate/sodium
etodolac 200 mg               17 flurbiprofen 100 mg, 50 mg 17 chloride 0.6-0.9 %, mg/ml, 0.9-1
                                                                 %, mg/ml, 0.9-1.2 %, mg/ml, 0.9-
etodolac 400 mg, 500 mg       17 flutamide 125 mg             71 1.6 %, mg/ml                   15



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gentamicin sulfate/sodium          hydrocodone                        indapamide 1.25 mg, 1.5 mg, 2
chloride 0.8-0.9 %, mg/ml       15 bitartrate/acetaminophen ,         mg, 2.5 mg                  122
                                   325-7-7.5 %, mg/15ml          24
gentasol 0.3 %                173 hydrocodone/acetaminophen           indomethacin 25 mg, 50 mg       17
gildess fe 1/20 1-20-75 mcg,       10-325 mg, 10-500 mg, 10-660
                                                                      indomethacin cr 75 mg           17
mg                              99 mg, 325-5 mg, 325-7.5 mg, 5-
                                   500 mg, 500-7.5 mg, 7.5-750
glucagon emergency kit 1 mg 49 mg                                24   indomethacin er 75 mg           17
                                   hydrocodone/acetaminophen
                                                                      intralipid 1.2-10-2.25 %, 1.2-2.25-
granisetron hcl 4 mg/4ml        54 10-325 mg, 325-5 mg, 325-7.5
                                   mg                            24   20 %                            163
grifulvin v 500 mg              55 hydrocodone/acetaminophen          intralipid 20% 1.2-2.25-20 % 163
                                   500-7-7.5 %, mg/15ml, 500-7.5
griseofulvin microsize 125         mg/15ml                       24   ipratropium bromide 0.02 %, 0.2
mg/5ml                          55                                    %                             37
                                   hydrocodone/ibuprofen         24
guanabenz acetate 4 mg, 8 mg 62                                       irbesartan/hydrochlorothiazide 63
                                   hydrocortisone 1 %          114
guanidine hcl 125 mg            66                                    irinotecan 500 mg/25ml          77
haloperidol 0.5 mg, 1 mg, 10 mg, hydrocortisone 1 %, 2.5 % 115        isochron 40 mg                  33
2 mg, 20 mg, 5 mg               81 hydrocortisone in absorbase 1
haloperidol 2 mg/ml             81 %                           115    isoditrate er 40 mg             33
                                   hydrocortisone/acetic acid 0.02-
                                                                      isolyte-m/dextrose 5% 15-20-35-
haloperidol lactate 5 mg/ml     81 1-2-3 %, 1-2 %              179
                                   hydromorphone hcl 50 mg/5ml,       38-44-5 %, meq/l              154
heparin sodium 1000 unit/ml,       500 mg/50ml                   21   isolyte-s 140-23-27-3-5-98
10000 unit/ml, 20000 unit/ml,      hydroxyzine hcl 10 mg, 25 mg,      meq/l                         155
5000 unit/ml                    41 50 mg                         34   isolyte-s ph 7.4 1-141-23-27-3-5-
heparin sodium dcu 20000                                              98 meq/1000ml                 155
unit/ml                         41 hydroxyzine hcl 10 mg/5ml 34       isolyte-s/dextrose 5% 142-23-3-
heparin sodium/d5w 0.2-40-5 %,                                        30-5-98 %, meq/l              155
mg/ml, unit/ml, 40-5 %, unit/ml 41 hydroxyzine hcl 25 mg/ml      34
hepatamine 100-1100-115-20-                                           isoniazid 100 mg, 300 mg        66
240-3-450-500-600-610-62-66-       hydroxyzine hcl 50 mg/ml      34
770-800-840-900 meq/l,                                                isoniazid 50 mg/5ml             66
mg/100ml                      168 hydroxyzine pamoate 100             isosorbide dinitrate 10 mg, 20
hepatasol 0.02-0.065-0.1-0.115-    mg                            35
                                   hyperlyte r 20-25-30-5             mg                             33
0.24-0.45-0.5-0.6-0.61-0.77-0.8-
0.84-0.9-1.1 gm/100ml         168 meq/25ml                     154    isosorbide dinitrate 2.5 mg, 5
                                                                      mg                             33
hycet 325-7-7.5 %, mg/15ml 24 hyzine 50 mg/ml                    35
                                                                      isosorbide dinitrate 30 mg      33
hydralazine hcl 10 mg, 100 mg,   ibudone 10-200 mg              24
25 mg, 50 mg                  65                                      isosorbide dinitrate 5 mg       33
hydralazine hcl 20 mg/ml      65 ibuprofen 100 mg/5ml           17
                                                                      isosorbide dinitrate er 40 mg   34
hydrochlorothiazide 12.5 mg, 25     ifosfamide 1 gm/20ml, 3
mg, 50 mg                    121    gm/60ml                     68 isosorbide mononitrate er 120
hydrocodone                                                        mg, 30 mg, 60 mg               34
                                    ilotycin 5 mg/gm           173 isotonic gentamicin 0.6-0.9 %,
bitartrate/acetaminophen , 10-
300 mg, 10-750 mg, 300-5 mg,        imipenem/cilastatin , 250 mg,  mg/ml, 0.9-1 %, mg/ml, 0.9-1.2
300-7.5 mg                     24   500 mg                      31 %, mg/ml, 0.9-1.6 %, mg/ml     15
                                    imipramine hcl 10 mg, 25 mg,   isotonic gentamicin 0.8-0.9 %,
                                    50 mg                       47 mg/ml                          15


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isradipine 2.5 mg, 5 mg      93 kuric 2 %                        108 lidocaine/epinephrine 1-1.5 %,138
                                                                     :200000, 1-2 %, :50000
                                   lactated ringers 109-130-2.7-     lidocaine/epinephrine 1-2 %,
isradipine 5 mg              93    28-4 meq/l, 109-130-28-3-4        :100000                        138
                                   meq/l                         156
junel fe 1/20 1-20-75 mcg, mg 99   lactated ringers dextrose 5%      lindane 1 %                    119
                                   109-130-2.7-28-4-5 %,
kariva                       99    meq/l                         156 liposyn iii 1.8-2.5-30 %       163
kcl 0.075%/d5w/nacl 0.2% 0.2-      lactated ringers dextrose 5%
                                   viaflex 109-130-2.7-28-4-5 %,     lisinopril 2 mg                 60
10-5 %, meq/l                155
kcl 0.075%/d5w/nacl 0.45%          meq/l                         156
0.075-0.45-5 %, 0.45-10-5 %,       lactated ringers irrigation 109-  lisinopril/hydrochlorothiazide 63
meq/l                        155   130-28-3-4 meq/l               89
kcl 0.15%/d5w/ nacl 0.3% 0.15-     lactated ringers viaflex 109-     lithium carbonate 300 mg        79
0.33-5 %, 0.33-20-5 %, meq/l 155   130-28-3-4 meq/l              156
kcl 0.15%/d5w/nacl 0.2% 0.2-20-    lacticare-hc 1 %, 2 %         115 lithium carbonate 600 mg        79
5 %, meq/l                   155
kcl 0.15%/d5w/nacl 0.225% 0.15-    lactulose 10 gm/15ml        131 lithium citrate 8 meq/5ml      80
0.225-5 %                    155                                   loestrin fe 1/20 1-20-75 mcg,
kcl 0.15%/d5w/nacl 0.45% 0.45-     lactulose 10 gm/15ml, 20
20-5 %, meq/l                155   gm/30ml                     137 mg                            100
kcl 0.224%/d5w/nacl 0.2% 0.2-      lamivudine/zidovudine        84 lofibra 134 mg, 200 mg, 67 mg 59
0.224-5 %, 0.2-30-5 %, meq/l 155
kcl 0.224%/d5w/nacl 0.45%          lansoprazole 30 mg          193 lofibra 54 mg                    59
0.224-0.45-5 %               155
kcl 0.3%/d5w/nacl 0.2% 0.2-0.3-5   leucovorin calcium 10 mg, 15    lokara 0.05 %                115
%, 0.2-40-5 %, meq/l         155   mg, 25 mg, 5 mg              76
kcl 0.3%/d5w/nacl 0.45% 0.3-       leucovorin calcium 100 mg, 200 loperamide hcl 2 mg            52
0.45-5 %, 0.45-40-5 %, meq/l 155   mg                           76
                                                                   lortab 10-500 mg, 5-500 mg, 500-
keflex 125 mg/5ml, 250             leucovorin calcium 500 mg 76 7.5 mg                           25
mg/5ml                        95
                                leuprolide acetate 1 mg/0.2ml,  lortab 500-7-7.5 %, mg/15ml 25
ketoconazole 2 %           108 5 mg/ml                       71
                                                                loxapine 10 mg, 25 mg, 5 mg, 50
ketoconazole 200 mg          56 levetiracetam 500 mg/5ml     42 mg                             81
                                                                loxapine succinate 10 mg, 25 mg,
ketoprofen 50 mg, 75 mg      17 levobunolol hcl 0.25 %      171 5 mg, 50 mg                    81
                                                                loxitane 10 mg, 25 mg, 5 mg, 50
ketoprofen er 200 mg         17 levothroid 112 mcg          190 mg                             81
ketorolac tromethamine 15       levothyroxine sodium 112        magnacet , 10-400 mg           25
mg/ml, 30 mg/ml, 300 mg/10ml,   mcg                         190
60 mg/2ml                    17 levoxyl 112 mcg             190 magnesium sulfate 50 %        158
ketorolac tromethamine 30
mg/ml, 60 mg/2ml             17 lidocaine 5 %               118 mannitol 25 %                 121
kionex 15 gm/60ml            90 lidocaine hcl in d5w 4-5 %,     maprotiline hcl 25 mg, 50 mg, 75
                                mg/ml                        35 mg                             45
klor-con 8 8 meq           158 lidocaine hcl/dextrose 4-5 %,    marlissa                      100
                                mg/ml                        36
klor-con m15 15 meq        158 lidocaine hcl/dextrose 5-7.5     maxidone 10-750 mg             25
                                %                           139
kristalose 10 gm           137


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mebendazole 100 mg            29 methitest 10 mg                28 mircette                      100
meclofenamate sodium 100 mg,       methotrexate 2.5 mg          69 mirtazapine 7.5 mg             45
50 mg                         18
medroxyprogesterone acetate 2      methotrexate sodium 1 gm     69 mitomycin 20 mg, 40 mg, 5 mg 73
mg                          184
mefoxin 1-2 gm/50ml, 1.1-2         methotrexate sodium 1          mitoxantrone hcl 20 mg/10ml, 25
gm/50ml                       96   gm/40ml, 25 mg/ml, 250         mg/12.5ml, 30 mg/15ml         73
megestrol acetate 20 mg, 40        mg/10ml, 50 mg/2ml          69
                                   methotrexate sodium lpf 25     mometasone furoate 0.1 % 116
mg                            72
megestrol acetate 400              mg/ml                       69 morphine sulfate 0.5 mg/ml, 1
mg/10ml                       71   methyclothiazide 5 mg      122 mg/ml                         22
menest 0.3 mg, 0.625 mg, 1.25                                       morphine sulfate 1 mg/ml      22
mg, 2.5 mg                  128    methyldopa 250 mg, 500 mg 62
meperidine hcl 10 mg/ml        21 methyldopa/hydrochlorothiazide    morphine sulfate 15 mg, 30 mg 22
                                  15-250 mg, 25-250 mg         63   morphine sulfate 20 mg/5ml, 20
meperidine hcl 50 mg           21
                                  methylin er 10 mg            14   mg/ml                         22
                                                                    morphine sulfate stick-gard 1
meperidine hcl 50 mg/5ml       21 methylphenidate hcl er 10         mg/ml                         22
                                  mg                           14
mepivacaine hcl 3 %           139 metoclopramide hcl 10             mydral 0.5 %, 1 %            171
                                  mg/10ml, 5 mg/5ml           130
meprobamate 200 mg, 400 mg 35                                       mydriacyl 1 %                171
                                  metoprolol tartrate 25 mg    91
metaproterenol sulfate 0.4 %, 0.6                                   myzilra                      100
%                              38 metoprolol tartrate 5 mg/5ml 91
metaproterenol sulfate 10 mg, 20                                    nafcillin sodium 1 gm, 10 gm, 2
mg                             39 metoprolol/hydrochlorothiazide    gm                            184
metaproterenol sulfate 10         63
                                                                    nalbuphine hcl 20 mg/ml       27
mg/5ml                         38 metronidazole 0.75 %        119
methadex 0.004-1-10000-3.5 %,                                       naloxone hcl 1 mg/ml          53
mg/ml, unit/ml                175 metronidazole in nacl 0.79%
methadone hcl 10 mg/5ml, 5        0.79-5 %, mg/ml, 0.79-500 %,
                                                                    naphazoline hcl 0.1 %        174
mg/5ml                         21 mg/100ml                     30
                                  mexiletine hcl 150 mg, 200 mg,    nefazodone hcl 100 mg, 150 mg,
methadone hcl 10 mg/ml         21 250 mg                       36   200 mg, 250 mg, 50 mg        45
                                  microgestin fe 1-20-75 mcg,       neo-polycin 10000-3.5-400
methadone hcl 40 mg            21 mg                          100   mg/gm, unit/gm              173
methadone hcl intensol 10         millipred 10 mg/5ml         104   neocin 10000-400-5 mg/gm,
mg/ml                          21                                   unit/gm                     173
                                                                    neocin-pg 0.025-10000-2.5
methadose 10 mg/ml             21 millipred 5 mg              103
                                                                    mg/ml, unit/ml              173
methadose 40 mg               22 millipred dp 5 mg             104 neomycin sulfate 500 mg        15
methadose sugar-free 10                                    94 neomycin/bacitracin/polymyxin
                                   milrinone lactate 1 mg/ml
mg/ml                         22                              10000-400-5 mg/gm, unit/gm 173
methazolamide 25 mg, 50 mg 120 minirin 0.1 mg/ml          127 neomycin/polymyxin b sulfates
                                                              0.1-200000-40 %, mg/ml,
                               minocycline hcl 100 mg, 50 mg, unit/ml                      132
methimazole 10 mg, 5 mg    189 75 mg                      189 neomycin/polymyxin/bacitracin
                               minoxidil 10 mg, 2 mg, 2.5     zinc 10000-400-5 mg/gm,
                               mg                          65 unit/gm                      173

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neomycin/polymyxin/bacitracin/hy     nutrilyte 0.25-0.4-1.25-1.68-    oxycodone/acetaminophen 5-500
drocortisone 0.5-1-10000-400 %,      2.03 meq, meq/ml, 0.25-0.4-      mg                             25
unit/gm, 1-10000-3.5-400 %,          1.25-1.68-2.03 meq/ml         156oxycodone/aspirin 325-4.835
mg/gm, unit/gm               175     nutrilyte ii 0.225-0.25-1-1.475- mg                             25
neomycin/polymyxin/dexamethas        1.75 meq/ml                   156oxymorphone hydrochloride er 15
one 0.1-10000-3.5 %, mg/gm,
unit/gm                      175     nyamyc 100000 unit/gm        109 mg, 7.5 mg                     23
neomycin/polymyxin/gramicidin                                         pacerone 100 mg, 400 mg        36
0.001-0.025-1.75-10000 %,            nystatin 100000 unit         197
mg/ml, unit/ml               173                                      paclitaxel 100 mg/16.7ml, 300
neomycin/polymyxin/hc 1-10000-       nystatin 100000 unit/gm      109 mg/50ml                        77
3.5 %, mg/ml, unit/ml        178                                      paclitaxel 30 mg/5ml, 6 mg/ml 77
neomycin/polymyxin/hydrocortiso      nystatin 100000 unit/ml      159
ne 0.01-0.9-1-10000-3.5 %,                                            pamidronate disodium 6
mg/ml, unit/ml, 1-10000-3.5 %,       nystatin 500000 unit          55 mg/ml                         123
mg/ml, unit/ml               178                                      panlor dc 16-30-356.4 mg       25
neomycin/polymyxin/hydrocortiso      nystatin vaginal 100000 unit 197
ne 1-10000-3.5 %, mg/ml,                                              paser 4 gm                     66
unit/ml                      175     nystatin/triamcinolone 0.1-
neosporin 0.001-0.025-1.75-          100000 %, unit/gm            109
10000 %, mg/ml, unit/ml      173                                      pedi-dri 100000 unit/gm       109
                                     nystop 100000 unit/gm        109
neptazane 25 mg, 50 mg        120    octreotide acetate 1000          penicillin g potassium 20 mu 181
                                     mcg/5ml                      127
niacor 500 mg                 199    ocutricin 0.025-10000-2.5        penicillin g potassium 5 mu 181
                                     mg/ml, unit/ml               173 penicillin v potassium 125
nifedipine 20 mg               93
                                     ogestrel 0.5-50 mcg, mg      100 mg/5ml, 250 mg/5ml            182
nimodipine 30 mg               93                                     penicillin v potassium 250 mg,
                                     olanzapine/fluoxetine        185 500 mg                        182
nitro-bid 2 %                  34                                     pentazocine/acetaminophen 25-
                                     oralone 0.1 %                159 650 mg                         25
nitrofurantoin monohydrate 100                                        pentazocine/naloxone hcl 0.5-50
mg                           195     orphenadrine citrate 30          mg                             27
                                     mg/ml                        160 percocet 10-325 mg, 10-650 mg,
nizatidine 150 mg, 300 mg     192    orphenadrine citrate er 100      2.5-325 mg, 325-5 mg, 325-7.5
norco 10-325 mg, 325-5 mg, 325-      mg                           160 mg, 500-7.5 mg                 25
7.5 mg                       25      orphenadrine compound ds 50- perphenazine 16 mg, 2 mg, 4 mg,
                                     60-770 mg                    161 8 mg                           82
norethindrone acetate 5 mg    184    oticin hc 0.1-1-10000-5 %,       perphenazine/amitriptyline 10-2
                                     mg/ml, unit/ml               178 mg, 10-4 mg, 2-25 mg, 25-4 mg,
norgestimate/ethinyl estradiol 100                                    4-50 mg                       186
                                     oxaliplatin 100 mg            68
normosol-m in d5w 13-16-3-40-5                                        pfizerpen-g 20 mu             182
%, meq/l                   156       oxycodone hcl 10 mg, 20 mg 23
northyx 10 mg, 5 mg           189                                     pfizerpen-g 5 mu              182
                                     oxycodone hcl 20 mg/ml        23
novamine 1040-1180-1470-151-                                          phenadoz 12.5 mg               57
2170-250-39-434-592-749-894-         oxycodone hcl 5 mg            23
960 meq/l, mg/100ml       168                                         phenergan 25 mg/ml, 50 mg/ml57
                                     oxycodone/acetaminophen 10-
novarel 10000 unit            123    325 mg, 10-650 mg, 2.5-325       phentolamine mesylate 5 mg 61
                                     mg, 325-5 mg, 325-7.5 mg,
nutracort 1 %, 2 %            116    500-7.5 mg                    25
                                                                      phenytek 200 mg                44


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                                 potassium chloride                 premasol 120-140-15-190-20-
phenytoin sodium 50 mg/ml     44 0.224%d5w/nacl 0.45% viaflex       200-220-230-250-290-3-300-320-
phenytoin sodium extended 100    0.45-30-5 %, meq/l           157   410-470-490-5-56-730-840
mg, 200 mg                    44 potassium chloride 0.3%/d5w        meq/l, mg/100ml             168
                                 0.3-5 %, 40-5 %, meq/l       157
philith                      101 potassium chloride                 primalev 2.5-300 mg           25
physiolyte 140-23-27-3-5-98      0.3%/d5w/viaflex 40-5 %,
                                                                    primaquine phosphate 26.3 mg 65
meq/1000ml                    89 meq/l                        157
                                 potassium chloride 0.4 meq/ml,
pindolol 10 mg, 5 mg          91 2 meq/ml                     158   primlev                       26
                                 potassium chloride er 15
piperacillin/tazobactam      183 meq                          158   probenecid 500 mg            134
plasma-lyte-m/d5w 12-16-3-40-5   potassium chloride er 8            probenecid/colchicine , 0.5-500
%, meq/l                     156 meq                          158   mg                            133
plasma-lyte-r 10-103-140-3-47-5- potassium chloride mini-vial 2     prochlorperazine 25 mg        82
8 meq/l                      156 meq/ml                       158
                                 potassium chloride sa 8            prochlorperazine edisylate 5
polycin b 10000-500 unit/gm 173 meq                           158   mg/ml                        82
polymyxin b sulfate 500000       potassium chloride sr 8            prochlorperazine maleate 10 mg,
unit                          33 meq                          159   5 mg                         82
                                 potassium citrate 1080 mg, 540
portia-28 0.03-0.15 mg       101 mg                           132   procto-kit 1 %               116
                                 potassium citrate er 1080 mg,
potassium acetate 2 meq/ml 158 540 mg                         132   procto-kit 2.5 %              28
potassium chloride               pramosone 1 %                116   proctocream hc 2.5 %          29
0.075%/d5w/nacl 0.225% 0.2-10-
5 %, meq/l                   156 pramosone 1 %, 1-2.5 % 116         proctocream-hc 2.5 %          29
potassium chloride 0.15%/d5w
0.15-5 %, 20-5 %, meq/l      156 prednisol 1 %                176   proctosol hc 2.5 %            29
potassium chloride
0.15%d5w/nacl 0.33% 0.33-20-5 prednisolone 15 mg/5ml          104
%, meq/l                     157                                    proctozone-hc 2.5 %           29
potassium chloride
0.15%d5w/nacl 0.45% viaflex      prednisolone 5 mg            104   prometh-50 50 mg/ml           57
0.45-20-5 %, meq/l           157                                    promethazine hcl 12.5 mg, 25
potassium chloride               prednisolone 5 mg/5ml        104
                                                                    mg, 50 mg                     58
0.15%d5w/nacl 0.45% 0.15-0.45- prednisolone sodium                  promethazine hcl 12.5 mg, 50
5 %, 0.45-20-5 %, meq/l      157 phosphate 1 %                176   mg                            57
potassium chloride 0.15%w/nacl   prednisolone sodium
0.9% viaflex 0.15-0.9 %      157 phosphate 5 mg/5ml                 promethazine hcl 25 mg/ml, 50
                                                              104   mg/ml                         57
potassium chloride               prednisone 1 mg, 10 mg, 2.5
0.22%d5w/nacl 0.45% 0.45-30-5 mg, 20 mg, 5 mg, 50 mg          104   promethazine hcl 6.25 mg/5ml 57
%, meq/l                     157
potassium chloride 0.224%/d5w    prednisone 5 mg/5ml          104   promethazine hcl plain 6.25
0.224-5 %, 30-5 %, meq/l     157                                    mg/5ml                        58
potassium chloride               prednisone intensol 5              promethazine vc 5-6.25
0.224%/d5w/nacl 0.45% 0.224-     mg/ml                        104   mg/5ml                       105
0.45-5 %, 0.45-30-5 %, meq/l 157 pregnyl w/diluent                  promethazine vc plain 5-6.25
potassium chloride               benzylalcohol/nacl 10000           mg/5ml                       105
0.224%/dextrose 5% viaflex 30-5 unit                          123
%, meq/l                     157                                    promethegan 12.5 mg, 50 mg 58




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propafenone hcl 300 mg        36 romycin 5 mg/gm             173 sodium phosphate 3
                                                                 mmole/ml                     158
                                                                 sodium polystyrene sulfonate 15
propantheline bromide 15 mg 192 rosadan 0.75 %               119 gm/60ml                       90
propranolol hcl 20 mg/5ml, 40                                 26 sodium polystyrene sulfonate 30
mg/5ml                         92 roxicet 325-5 mg               gm/120ml, 50 gm/200ml         90
propranolol/hydrochlorothiazide                                  sorbitol-mannitol 0.54-2.7
                               64 roxicet 325-5 mg/5ml        26 gm/100ml
25-40 mg                                                                                      133
propranolol/hydrochlorothiazide
                               64 selegiline hcl 5 mg          79 sotret 30 mg                      107
25-40 mg, 25-80 mg
propylthiouracil 50 mg       189 sensorcaine-mpf 0.25 %      139 sps 15 gm/60ml                      90

                              66 sensorcaine-mpf/epinephrine        sps 30gm/120ml enema 30
pyrazinamide 500 mg              0.25-1 %, :200000          138     gm/120ml                         90
                                 sensorcaine-mpf/epinephrine        sps 50gm/200ml enema 50
questran 4 gm                 58 0.5-1 %, :200000           138     gm/200ml                         90
                                 sensorcaine/epinephrine 0.25-1
quinapril/hydrochlorothiazide 64 %, :200000, mg/ml                  sterile water for irrigation     89
                                                            138
                                 sensorcaine/epinephrine 0.5-1
quinidine gluconate cr 324 mg 35 %, :200000, mg                     sterile water irrigation         90
                                                            138
quinidine gluconate er 324 mg 35 seromycin 250 mg              67 sterile water irrigationplastic
                                                                  bottle                             90
quinidine gluconate sa 324 mg 35 sodium acetate 2 meq/ml     153 sterile water irrigationw/hanger 90
quinidine sulfate 200 mg, 300     sodium bicarbonate 7 %, 7.5       sulfacetamide sodium 10 %       107
mg                             35 %                           153
                                  sodium bicarbonate 8 %, 8.4       sulfacetamide
quinidine sulfate er 300 mg    35 %                                 sodium/prednisolone sodium
                                                              153
ranitidine hcl 150 mg/10ml, 75    sodium bicarbonate stick-gard     phosphate 0.01-0.23-10 %   176
mg/5ml                        193 8.4 %                       153   sulfadiazine 500 mg             188
ranitidine hcl 150 mg/6ml, 50     sodium chloride 0.9% 0.9
mg/2ml                        192 %                           133   sulfamethoxazole/trimethoprim
                                  sodium chloride 0.45% 0.45 %,     0.04-160-800 %, mg/20ml, 0.04-
ranitidine hcl 300 mg         192 0.5 %                             200-40 %, mg/5ml, 0.1-0.26-200-
                                                              159
reprexain 10-200 mg, 2.5-200      sodium chloride 0.45% quad pk     40 %, mg/5ml, 0.1-0.5-200-40 %,
mg                             26 0.5 %                       159   mg/5ml, 0.5-200-40 %, mg/5ml 31
                                                                    sulfamethoxazole/trimethoprim
reserpine 0.1 mg, 0.25 mg      62 sodium chloride 0.45% viaflex     400-80 mg/5ml                 31
                                  0.45 %                      159
rifadin 150 mg                67 sodium chloride 0.9 %          133 sulindac 150 mg                  18
                                                                    sumatriptan succinate 100
                                 67 sodium chloride 0.9 %, 3 %, 159 mg
                                                                5
rifampin 150 mg                                                                                     153
                                    %
ringers injection 0.03-0.033-0.86 sodium chloride 0.9% 0.9 % 133 suprax 100 mg/5ml                   98
%, 147-156-4-4.5 meq/l         157
ringers irrigation 147-156-4-4.5    sodium chloride 2 meq/ml, 2.5   tapazole 10 mg, 5 mg            189
meq/l                            89 meq/ml                      159
risperidone odt 0.25 mg          80 sodium chloride pab 0.9 % 159 terbutaline sulfate 1 mg/ml        39
                                                                 testosterone cypionate 100
rocephin 1 gm, 500 mg         98 sodium fluoride 1 mg        157 mg/ml, 200 mg/ml                    28
                                                                    testred 10 mg                    28


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tetracycline hcl 250 mg         189 tolmetin sodium 200 mg, 600 18 trihexyphenidyl hcl 2 mg, 5 mg 78
                                    mg
tetracycline hcl 250 mg, 500                                         trimethoprim sulfate/polymyxin b
                                189 tolmetin sodium 400 mg        18 sulfate 0.004-0.1-10000 %,
mg
                                                                     unit/ml                       174
texacort 1 %                    117 topicort 0.05 %              117 trimox 125 mg/5ml, 250
                                                                     mg/5ml                        181
texacort 2.5 %                  117 toposar 20 mg/ml              77 triple antibiotic 10000-400-5
                                                                     mg/gm, unit/gm                174
theochron 100 mg, 200 mg         39 torsemide 20 mg/2ml          121
                                                                     trivora-28                    101
theochron 450 mg                 39 torsemide 50 mg/5ml          121
                                                                     tropicamide 0.5 %, 1 %        171
theophylline cr 100 mg, 200         tpn electrolytes 20-29.5-35-4.5-
mg                               40 5 meq/20ml                   157 tylenol/codeine #3 30-300 mg 26
theophylline er 100 mg, 200 mg,
                                 40 tramadol hcl er 200 mg        23
450 mg                                                               tylox 5-500 mg                 26
theophylline er 400 mg, 600         tramadol
mg                               40 hydrochloride/acetaminophen 2 tyzine pediatric nasal drops 0.05
                                    6                                %                             162
theophylline er 450 mg           40 travasol 8.5%/electrolytes 10-
theophylline td 100 mg, 200         102-130-152-154-1760-34-356- uniphyl 400 mg, 600 mg             40
mg                               40 372-390-406-492-522-526-594- unithroid 112 mcg                 190
thioridazine hcl 10 mg, 100 mg,     60-70-880 meq/l, mg/100ml 170
25 mg, 50 mg                     82 tretinoin 0.1 %, 0.25 %      107 unithroid direct 112 mcg      190
thiotepa 15 mg                   68
                                    tretinoin 0.25 %, 0.5 %      107 valacyclovir hcl 1000 mg       87
thiothixene 1 mg                 83
                                    trexall 7.5 mg                70 valproate sodium 500 mg/5ml 45
thyroid 130 mg, 32.5 mg, 65
mg                              190 trezix 16-30-356.4 mg         26 valproic acid 250 mg/5ml       45
timolol maleate 10 mg, 20 mg, 5
mg                               92 triamcinolone acetonide 0.025
                                    %                            117 vanacet 5-500 mg               26
tis-u-sol 147-156-4-4.5 meq/l 90 triamcinolone acetonide 0.025       vancomycin hcl 10 gm, 5000 mg,
tis-u-sol viaflex 147-156-4-4.5     %, 0.5 %                     117 750 mg                         30
meq/l                            90 triamcinolone acetonide 0.1      vancomycin hcl 1000 mg, 500
                                    %                            159 mg                             30
tobramycin sulfate 1.2 gm        15 triamcinolone acetonide 55
tobramycin sulfate 1.2 gm/30ml,     mcg/act                      162 vecuronium bromide 10 mg 162
40 mg/ml, 80 mg/2ml              15 triamcinolone acetonide in       veetids 125 mg/5ml, 250
tobramycin sulfate 10 mg/ml, 40     absorbase 0.05 %             117 mg/5ml                        182
mg/ml                            15 triamcinolone in orabase 0.1
tobramycin sulfate/sodium           %                            159 veetids 250 mg, 500 mg        182
chloride 0.9-1.2 %, mg/ml        15 triamterene/hydrochlorothiazide venlafaxine hcl er 150 mg, 225
                                    25-50 mg                     121 mg, 37.5 mg, 75 mg             47
tofranil 10 mg, 25 mg, 50 mg 48                                      verapamil hcl 2 mg/ml, 2.5
                                    trianex 0.05 %               117
                                                                     mg/ml                          93
tolazamide 250 mg, 500 mg        52 trifluoperazine hcl 1 mg, 10 mg,
                                    2 mg, 5 mg                    82 veripred 20 20 mg/5ml         105
tolbutamide 500 mg               52
                                    trihexyphenidyl hcl 0.4 mg/ml 78 vestura                       101



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vicodin 5-500 mg               26

vicodin es 7.5-750 mg          26

vicodin hp 10-660 mg           26

vinblastine sulfate 10 mg      77

vincasar pfs 1 mg/ml           77

vincristine sulfate 1 mg/ml    77
vinorelbine tartrate 10 mg/ml, 50
mg/5ml                          77
viorele                       101
xodol , 10-300 mg, 300-5 mg,
300-7.5 mg                   26
zarontin 250 mg/5ml            44

zema-pak 10 day 1.5 mg        105

zema-pak 13 day 1.5 mg        105

zema-pak 6 day 1.5 mg         105

zolvit , 10-300 mg/15ml        26
zydone 10-400 mg, 400-5 mg,
400-7.5 mg                  27




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