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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.
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 14
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.
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 15
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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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
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.
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
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.
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
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.
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
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.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
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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.
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
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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.
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
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.
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
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.
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 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
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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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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.
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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.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
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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.
AL=Age Limit B/D=Medicare Part B vs.Part D GL=Gender Limit
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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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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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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.
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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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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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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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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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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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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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.
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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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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.
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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.
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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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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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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.
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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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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.
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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.
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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.
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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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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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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.
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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.
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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.
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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.
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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.
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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.
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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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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.
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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.
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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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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.
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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.
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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.
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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.
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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
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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
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
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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
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
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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
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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
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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
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
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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
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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
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
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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
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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
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
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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.
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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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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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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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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.
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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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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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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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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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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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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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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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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 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 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 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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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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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
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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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
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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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
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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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
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.
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
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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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
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.
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
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.
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
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.
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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
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
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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.
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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
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.
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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.
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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
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.
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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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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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
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.
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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.
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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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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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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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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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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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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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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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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.
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 195
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.
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
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
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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
www.healthnet.com 233
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
www.healthnet.com 237
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
www.healthnet.com 238
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
www.healthnet.com 239
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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