Your Federal Quarterly Tax Payments are due April 15th Get Help Now >>

Horizon Medicare Blue Rx Standard Comprehensive Formulary by suchenfz

VIEWS: 22 PAGES: 73

									           Horizon Blue Cross Blue Shield of New Jersey




                 Horizon Medicare Blue Rx Standard (PDP)

                                   2011 Formulary
                             (List of Covered Drugs)
   PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE
                   DRUGS WE COVER IN THIS PLAN

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.

 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, 2012.

All enclosed materials are available in other formats or languages. Please call 1-800-224-1234
(TTY/TDD users: 1-800-852-7899) Monday – Sunday, 8:00 a.m. to 8:00 p.m., ET.

Todos los materials incluidos están disponibles en Español. Para recibir copias en su idioma
favor de llamar a: 1-800-224-1234 (TTY/TDD 1-800-852-7899) Lunes a Viernes, 8:00 a.m. a
8:00 p.m.

Horizon Medicare Blue Rx Standard (PDP) is a Medicare prescription drug plan. It is issued by
Horizon Healthcare Services, Inc. d/b/a Horizon Blue Cross Blue Shield of New Jersey, which
is a Medicare approved Part D sponsor. Horizon Blue Cross Blue Shield of New Jersey is an
independent licensee of the Blue Cross and Blue Shield Association.

S5993_HORFORM11 File and Use 10012010                                Last Updated: 01/2011
Formulary ID: 00011041                                                           Version 11
What is the Horizon Medicare Blue Rx Standard Formulary?
A formulary is a list of covered drugs selected by Horizon Medicare Blue Rx Standard in
consultation with a team of health care providers, which represents the prescription therapies
believed to be a necessary part of a quality treatment program. Horizon Medicare Blue Rx
Standard will generally cover the drugs listed in our formulary as long as the drug is medically
necessary, the prescription is filled at a Horizon Medicare Blue Rx Standard network pharmacy,
and other plan rules are followed. For more information on how to fill your prescriptions,
please review your Evidence of Coverage.



Can the Formulary change?

Generally, if you are taking a drug on our 2011 formulary that was covered at the
beginning of the year, we will not discontinue or reduce coverage of the drug during the
2011 coverage year except when a new, less expensive generic drug becomes available or
when new adverse information about the safety or effectiveness of a drug is released.
Other types of formulary changes, such as removing a drug from our formulary, will not
affect members who are currently taking the drug. It will remain available at the same
cost-sharing for those members taking it for the remainder of the coverage year. We feel it
is important that you have continued access for the remainder of the coverage year to the
formulary drugs that were available when you chose our plan, except for cases in which
you can save additional money or we can ensure your safety.
If we remove drugs from our formulary, add prior authorization, quantity limits and/or step
therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify
affected members of the change at least 60 days before the change becomes effective, or at
the time the member requests a refill of the drug, at which time the member will receive a
60-day supply of the drug. If the Food and Drug Administration deems a drug on our
formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we
will immediately remove the drug from our formulary and provide notice to members who
take the drug. The enclosed formulary is current as of January 1, 2011. To get updated
information about the drugs covered by Horizon Medicare Blue Rx Standard, please visit
our Web site at www.HorizonBlue.com/Medicare or call Member Service at 1-866-236-
7376, 24 hours a day, 7 days a week. TTY/TDD users should call 1-866-236-1069. In the
event of mid-year non-maintenance formulary changes, Horizon Medicare Blue Rx Standard
will notify you of these changes.



How do I use the Formulary?

There are two ways to find your drug within the formulary:
Medical Condition
   The formulary begins on page 7. The drugs in this formulary are grouped into categories
   depending on the type of medical conditions that they are used to treat. For example, drugs
   used to treat a heart condition are listed under the category, “Direct Cardiac Inotropics”. If
   you know what your drug is used for, look for the category name in the list that begins on
   page 7. Then look under the category name for your drug.

Alphabetical Listing
   If you are not sure what category to look under, you should look for your drug in the Index
   that begins on page 64. The Index provides an alphabetical list of all of the drugs included
   in this document. Both brand name drugs and generic drugs are listed in the Index. Look in
   the Index and find your drug. Next to your drug, you will see the page number where you
   can find coverage information. Turn to the page listed in the Index and find the name of
   your drug in the first column of the list.

What are generic drugs?
   Horizon Medicare Blue Rx Standard 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.


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

      Prior Authorization: Horizon Medicare Blue Rx Standard requires you or your
       physician to get prior authorization for certain drugs. This means that you will need to
       get approval from Horizon Medicare Blue Rx Standard before you fill your
       prescriptions. If you don’t get approval, Horizon Medicare Blue Rx Standard may not
       cover the drug.

      Quantity Limits: For certain drugs, Horizon Medicare Blue Rx Standard limits the
       amount of the drug that Horizon Medicare Blue Rx Standard will cover. For example,
       Horizon Medicare Blue Rx Standard provides 20 units per prescription for Granisetron
       oral. This may be in addition to a standard one month or three month supply.

      Step Therapy: In some cases, Horizon Medicare Blue Rx Standard requires you to first
       try certain drugs to treat your medical condition before we will cover another drug for
       that condition. For example, if Drug A and Drug B both treat your medical condition,
       Horizon Medicare Blue Rx Standard may not cover Drug B unless you try Drug A first.
       If Drug A does not work for you, Horizon Medicare Blue Rx Standard will then cover
       Drug B.
You can find out if your drug has any additional requirements or limits by looking in the
formulary that begins on page 7. You can also get more information about the restrictions
applied to specific covered drugs by visiting our Web site at
www.HorizonBlue.com/Medicare.


You can ask Horizon Medicare Blue Rx Standard to make an exception to these restrictions or
limits. See the section, “How do I request an exception to the Horizon Medicare Blue Rx
Standard formulary?” below for information about how to request an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary, you should first contact Member Services and
confirm that your drug is not covered. If you learn that Horizon Medicare Blue Rx Standard
does not cover your drug, you have two options:

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

      You can ask Horizon Medicare Blue Rx Standard to make an exception and cover your
       drug. See below for information about how to request an exception.


How do I request an exception to the Horizon Medicare Blue Rx Standard
Formulary?


You can ask Horizon Medicare Blue Rx Standard to make an exception to our coverage rules.
There are several types of exceptions that you can ask us to make.


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

      You can ask us to waive coverage restrictions or limits on your drug. For example, for
       certain drugs, Horizon Medicare Blue Rx Standard limit the amount of the drug that we
       will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover
       more.

      You can ask us to provide a higher level of coverage for your drug. If your drug is
       contained in our non-preferred tier, you can ask us to cover it at the cost-sharing amount
       that applies to drugs in the preferred tier instead. This would lower the amount you must
       pay for your drug. Please note, if we grant your request to cover a drug that is not on our
       formulary, you may not ask us to provide a higher level of coverage for the drug. Also,
       you may not ask us to provide a higher level of coverage for drugs that are in the
       specialty/self-injectable tier.


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

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


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

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited,
we will cover a temporary 30 day supply (unless you have a prescription written for fewer days)
when you go to a network pharmacy. After your first 30-day supply, we will not pay for these
drugs, even if you have been a member of the plan less than 90 days.

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

A transition supply will also be available to you if you should have a change in your treatment
setting, such as going from a hospital to home care.
For more information

For more detailed information about your Horizon Medicare Blue Rx Standard prescription drug
coverage, please review your Evidence of Coverage and other plan materials.
 If you have questions about Horizon Medicare Blue Rx Standard, please call Member Services
at 1-866-236-7376, 24 hours a day, 7 days a week. TTY/TDD users should call 1-866-236-1069.
Or visit www.HorizonBlue.com/medicare .
If you have general questions about Medicare prescription drug coverage, please call Medicare
at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY/TDD users should
call 1-877-486-2048. Or, visit www.medicare.gov.


Horizon Medicare Blue Rx Standard’s Formulary

The formulary below provides coverage information about some of the drugs covered by
Horizon Medicare Blue Rx Standard. If you have trouble finding your drug in the list, turn to
the Index that begins on page 64.

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

The information in the Notes column tells you if Horizon Medicare Blue Rx Standard has any
special requirements for coverage of your drug.

Please note all of our drugs on this list can be obtained through our mail order service. If you
purchase a 90 day supply through this mail order service, the copay for generic drugs would be
$13.50. The same 90 day supply would cost $27 at your pharmacy. However, you cannot
purchase an extended day supply (more than 30 days) of specialty drugs regardless of where
they are filled. These drugs are indicated by coinsurance of 25% in the chart below.

      PA stands for Prior Authorization

      QL stands for Quantity Limits

      ST stands for Step Therapy
                                                        Requirements/ Limits
                                                        PA= Prior Authorization
                                                        B vs. D= “This drug may be covered
               Copayment                                under Medicare Part B or D depending
               $9= Generic* Your mail order copay       upon the circumstances. Information
               for a 90 day supply of this drug would   may need to be submitted describing
               be $13.50.                               the use and setting of the drug to make
               $38= Preferred Brand                     the determination.”
               $76= Non Preferred Brand                 ST= Step Therapy
               25%= Specialty                           QL= Quantity Limits



Drug Name                                               Copayment         Requirements/ Limits
Analgesics
OPIOID ANALGESICS
AVINZA                                                      $38           QL (120 EA per 30 day(s))
OXYCONTIN                                                   $38           QL (180 EA per 30 day(s))
tramadol tab                                                 $9           QL (720 EA per 90 day(s))
ANALGESICS
GOUT
allopurinol                                                  $9
allopurinol sodium                                           $9
colchicine-probenecid                                        $9
COLCRYS                                                     $38
probenecid                                                   $9
ULORIC                                                      $76           PA; ST
NON OPIOD ANALGESICS
CELEBREX                                                    $38           QL (180 EA per 90 day(s))
cod-butalbital-acetaminop-caf                                $9           QL (540 EA per 90 day(s))
diclofenac potassium                                         $9


      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
diclofenac sodium                                             $9
diflunisal                                                    $9
etodolac                                                      $9
fenoprofen                                                    $9
FLECTOR                                                      $76           QL (180 EA per 90 day(s))
flurbiprofen                                                  $9
ibuprofen                                                     $9
INDOCIN                                                      $76
indomethacin                                                  $9
ketoprofen                                                    $9
ketorolac                                                     $9           QL (20 EA per 30 day(s))
meclofenamate                                                 $9
meloxicam oral susp                                           $9           QL (900 ML per 90 day(s))
meloxicam tab                                                 $9           QL (90 EA per 90 day(s))
nabumetone                                                    $9
naproxen                                                      $9
naproxen sodium                                               $9
oxaprozin                                                     $9
piroxicam                                                     $9
sulindac                                                      $9
tolmetin                                                      $9
VOLTAREN                                                     $38
OPIOID ANALGESICS
acetaminophen-codeine elixir                                  $9           QL (2700 ML per 30 day(s))
acetaminophen-codeine tab ,                                   $9           QL (390 EA per 30 day(s))
ASCOMP W/CODEINE                                              $9           QL (540 EA per 90 day(s))
buprenorphine                                                 $9           PA; QL (360 EA per 90 day(s))
butorphanol tartrate inj                                      $9
butorphanol tartrate nasl                                     $9           QL (36 ML per 90 day(s))
CO-GESIC                                                      $9           QL (720 EA per 90 day(s))

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
DURAMORPH                                                     $9
ENDOCET                                                       $9           QL (240 EA per 30 day(s))
fentanyl                                                      $9           QL (15 EA per 30 day(s))
hydrocodone-acetaminophen oral soln                           $9           QL (900 ML per 10 day(s))
hydrocodone-acetaminophen tab 10-650 mg, 10-                  $9           QL (450 EA per 90 day(s))
660 mg, 10-750 mg, 5-325 mg, 5-500 mg, 7.5-325
mg, 7.5-500 mg, 7.5-650 mg, 7.5-750 mg
hydrocodone-acetaminophen tab 10-325 mg, 10-                  $9           QL (540 EA per 90 day(s))
500 mg
hydrocodone-acetaminophen tab 2.5-500 mg                      $9           QL (720 EA per 90 day(s))
hydrocodone-ibuprofen                                         $9           QL (180 EA per 30 day(s))
hydromorphone                                                 $9           QL (180 EA per 30 day(s))
hydromorphone (pf)                                            $9
ibuprofen-oxycodone                                           $9
levorphanol tartrate                                          $9
MARGESIC-H                                                    $9           QL (720 EA per 90 day(s))
methadone                                                     $9
METHADOSE                                                     $9           QL (240 EA per 30 day(s))
morphine inj                                                  $9
morphine oral soln 20 mg/5 mL                                 $9
morphine oral soln 10 mg/5 mL                                 $9           QL (1200 ML per 30 day(s))
morphine sr tab ,                                             $9           QL (120 EA per 30 day(s))
morphine tab                                                  $9           QL (180 EA per 30 day(s))
morphine (pf)                                                 $9
oxycodone                                                     $9           QL (180 EA per 30 day(s))
oxycodone hcl-oxycodone-asa                                   $9           QL (240 EA per 30 day(s))
oxycodone-acetaminophen                                       $9           QL (240 EA per 30 day(s))
ROXICET ORAL SOLN                                             $9           QL (1800 ML per 30 day(s))
ROXICET TAB                                                   $9           QL (240 EA per 30 day(s))
STAGESIC                                                      $9           QL (720 EA per 90 day(s))
SUBOXONE                                                     $38           PA; QL (360 EA per 90 day(s))

      * Your    mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                                Copayment          Requirements/ Limits
tramadol er 24 hr tab                                          $9           QL (90 EA per 90 day(s))
tramadol-acetaminophen                                         $9           QL (720 EA per 90 day(s))
ANESTHETICS
LOCAL ANESTHETICS
lidocaine (pf)                                                 $9
lidocaine hcl                                                  $9
ANTIDEPRESSANTS
ANTIDEPRESSANTS, OTHER
BUDEPRION SR                                                   $9
BUDEPRION XL                                                   $9
bupropion hcl                                                  $9
buspirone                                                      $9
maprotiline                                                    $9
mirtazapine                                                    $9
nefazodone                                                     $9
trazodone                                                      $9
MONOAMINE OXIDASE INHIBITORS (MAOIS)
EMSAM                                                         $76
MARPLAN                                                       $38
NARDIL                                                        $38
tranylcypromine                                                $9
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)
citalopram                                                     $9
fluoxetine                                                     $9
fluvoxamine                                                    $9
LEXAPRO                                                       $76
paroxetine hcl                                                 $9
sertraline                                                     $9
SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITORS (SNRIS)
CYMBALTA                                                      $76

       * Your    mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
EFFEXOR XR                                                   $76
PRISTIQ                                                      $76
venlafaxine er 24 hr tab                                     $38
venlafaxine tab                                               $9
TRICYCLIC AGENTS
amitriptyline                                                 $9
amitriptyline-chlordiazepoxide                                $9
amoxapine                                                     $9
clomipramine                                                  $9
desipramine                                                   $9
doxepin                                                       $9
imipramine hcl                                                $9
nortriptyline                                                 $9
perphenazine-amitriptyline                                    $9
protriptyline                                                 $9
SURMONTIL                                                    $76
ANTIDOTES
ALCOHOL DETERRENTS
ANTABUSE                                                      $9
CAMPRAL DOSE PAK                                             $38           PA
OPIOID ANTAGONISTS
DEPADE                                                        $9
naloxone                                                      $9
naltrexone                                                    $9
RELISTOR                                                     $38           PA
OTHER
amifostine crystalline                                        $9
fomepizole                                                    $9
SMOKING CESSATION AGENTS
CHANTIX TAB ,                                                $76           PA; QL (56 EA per 28 day(s))

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
CHANTIX TABS IN A DOSE PACK                                 $76           PA; QL (53 EA per 28 day(s))
NICOTROL                                                    $76
NICOTROL NS                                                 $76
ANTIFUNGALS
ANTIFUNGALS
ABELCET                                                     $38
AMBISOME                                                    $38
amphotericin b                                               $9
ANCOBON                                                     $76
CANCIDAS                                                    $38
clotrimazole                                                 $9
fluconazole oral susp                                        $9
fluconazole tab 100 mg, 200 mg, 50 mg                        $9
fluconazole tab 150 mg                                       $9           QL (6 EA per 90 day(s))
fluconazole in dextrose(iso-o)                               $9
griseofulvin microsize                                       $9
GRIS-PEG                                                    $76
itraconazole                                                 $9
ketoconazole                                                 $9
MYCAMINE                                                    $38
NOXAFIL                                                     $38           QL (1800 ML per 90 day(s))
nystatin                                                     $9
terbinafine                                                  $9           QL (84 EA per 365 day(s))
VFEND                                                       25%           PA
VFEND IV                                                    25%           PA
ANTI-INFECTIVES
AMINOGLYCOSIDES
amikacin                                                     $9
gentamicin                                                   $9
gentamicin in nacl (iso-osm)                                 $9

      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
gentamicin sulfate (pf)                                      $9
neomycin                                                     $9
paromomycin                                                  $9
AMINOPENICILLINS
amoxicillin                                                  $9
amoxicillin-pot clavulanate                                  $9
ampicillin                                                   $9
ampicillin sodium                                            $9
ampicillin-sulbactam                                         $9
ANTIMALARIALS
chloroquine phosphate                                        $9
COARTEM                                                     $38
DARAPRIM                                                    $76
hydroxychloroquine                                           $9
MALARONE                                                    $38
mefloquine                                                   $9
MEPRON                                                      $38           QL (900 ML per 90 day(s))
primaquine                                                   $9
ANTIPARASITICS
ALINIA                                                      $38           QL (180 ML per 30 day(s))
ANTIRETROVIRAL AGENTS
APTIVUS                                                     $38
ATRIPLA                                                     $38
COMBIVIR                                                    $38
CRIXIVAN                                                    $38
didanosine                                                   $9
EMTRIVA                                                     $38
EPIVIR                                                      $38
EPZICOM                                                     $38
FUZEON                                                      25%

      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
INTELENCE                                                   $38
INVIRASE                                                    $38
ISENTRESS                                                   $38
KALETRA                                                     $38
LEXIVA                                                      $38
NORVIR                                                      $38
PREZISTA                                                    $38
RESCRIPTOR                                                  $38
RETROVIR                                                    $38
REYATAZ                                                     $38
SELZENTRY                                                   $38
stavudine                                                    $9
SUSTIVA                                                     $38
TRIZIVIR                                                    $38
TRUVADA                                                     $38
VIDEX 2 GRAM PEDIATRIC                                      $38
VIDEX EC                                                    $38
VIRACEPT                                                    $38
VIRAMUNE                                                    $38
VIREAD                                                      $38
ZIAGEN                                                      $38
zidovudine                                                   $9
ANTITUBERCULAR AGENTS
CAPASTAT                                                     $9
ethambutol                                                   $9
ISONARIF                                                     $9
isoniazid                                                    $9
MYCOBUTIN                                                   $38
PASER                                                        $9
PRIFTIN                                                     $76

      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
pyrazinamide                                                  $9
rifampin                                                      $9
SEROMYCIN                                                     $9
TRECATOR                                                     $76
ANTIVIRALS
acyclovir                                                     $9
acyclovir sodium                                              $9
BARACLUDE                                                    $38
EPIVIR HBV                                                   $38
famciclovir                                                   $9
ganciclovir                                                   $9
HEPSERA                                                      $38
RIBAPAK DOSE PACK TABS 600-400 mg                            25%           PA; QL (168 EA per 84 day(s))
(28)-mg (28), 600-600 mg (28)-mg (28)
RIBAPAK DOSE PACK TABS 400-400 mg                            25%           PA; QL (252 EA per 84 day(s))
(28)-mg (28)
RIBASPHERE CAP                                               25%           PA; QL (588 EA per 84 day(s))
RIBASPHERE TAB 200 mg                                         $9           PA; QL (588 EA per 84 day(s))
RIBASPHERE TAB 600 mg                                        25%           PA; QL (168 EA per 84 day(s))
RIBASPHERE TAB 400 mg                                        25%           PA; QL (252 EA per 84 day(s))
ribavirin cap                                                25%           PA; QL (588 EA per 84 day(s))
ribavirin tab                                                 $9           PA; QL (588 EA per 84 day(s))
rimantadine                                                   $9
TAMIFLU CAP 30 mg                                            $38           QL (164 EA per 365 day(s))
TAMIFLU CAP 45 mg, 75 mg                                     $38           QL (84 EA per 365 day(s))
TAMIFLU ORAL SUSP                                            $38           QL (550 ML per 365 day(s))
TYZEKA                                                       $38           QL (90 EA per 90 day(s))
valacyclovir                                                  $9
VALCYTE                                                      $38
BETA-LACTAM, OTHER
AZACTAM                                                      $38

      * Your    mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
AZACTAM-ISO-OSMOTIC DEXTROSE                                 $38
MERREM                                                       $38
PRIMAXIN IM                                                  $38
PRIMAXIN IV                                                  $38
CEPHALOSPORINS - 1ST GENERATION
cefadroxil                                                    $9
cefazolin                                                     $9
cefazolin in dextrose (iso-os)                                $9
cephalexin                                                    $9
CEPHALOSPORINS - 2ND GENERATION
cefaclor                                                      $9
cefotetan                                                     $9
cefoxitin                                                     $9
cefprozil                                                     $9
cefuroxime axetil                                             $9
cefuroxime sodium                                             $9
CEPHALOSPORINS - 3RD GENERATION
cefdinir                                                      $9
cefotaxime                                                    $9
cefpodoxime                                                   $9
ceftriaxone                                                   $9
ceftriaxone in dextrose,iso-os                                $9
SUPRAX                                                        $9
CEPHALOSPORINS - 4TH GENERATION
cefepime                                                      $9
MAXIPIME                                                     $38
ERYTHROMYCINS
E.E.S. 400                                                    $9
ERYTHROCIN                                                    $9
ERYTHROCIN STEARATE                                           $9

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
erythromycin-sulfisoxazole                                    $9
FLUOROQUINOLONES
AVELOX                                                       $38           QL (21 EA per 30 day(s))
AVELOX ABC PACK                                              $38           QL (21 EA per 30 day(s))
AVELOX IN NACL (ISO-OSMOTIC)                                 $38
CIPRO                                                        $76
ciprofloxacin                                                 $9
CIPROFLOXACIN ER                                              $9           QL (15 EA per 30 day(s))
ofloxacin                                                     $9
MACROLIDES
azithromycin iv                                               $9
azithromycin oral susp 200 mg/5 mL                            $9
azithromycin oral susp 100 mg/5 mL                            $9           QL (2 ML per 30 day(s))
azithromycin tab 250 mg                                       $9           QL (12 EA per 30 day(s))
azithromycin tab 600 mg                                       $9           QL (24 EA per 84 day(s))
azithromycin tab 500 mg                                       $9           QL (6 EA per 30 day(s))
clarithromycin oral susp                                      $9
clarithromycin tab 250 mg                                     $9           QL (56 EA per 28 day(s))
clarithromycin tab 500 mg                                     $9           QL (60 EA per 30 day(s))
CLARITHROMYCIN ER                                             $9           QL (56 EA per 28 day(s))
MISCELLANEOUS
ALBENZA                                                      $38
BACI-IM                                                       $9
bacitracin                                                    $9
CLEOCIN CAP                                                  $38
CLEOCIN ORAL SOLUTION                                         $9
clindamycin hcl                                               $9
clindamycin phosphate                                         $9
colistimethate sodium                                         $9
CUBICIN                                                      $38

      * Your    mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
dapsone                                                       $9
INVANZ                                                       $38
LINCOCIN                                                     $38
mebendazole                                                   $9
methenamine hippurate                                         $9
metronidazole                                                 $9
metronidazole in nacl (iso-os)                                $9
polymyxin b sulfate                                           $9
sulfadiazine                                                  $9
sulfamethoxazole-trimethoprim                                 $9
SULFATRIM                                                     $9
trimethoprim                                                  $9
TYGACIL                                                      $38
VANCOCIN                                                     $38
vancomycin                                                    $9
XIFAXAN 550 mg                                               $38           QL (180 EA per 90 day(s))
ZYVOX IV                                                     25%
ZYVOX ORAL SUSP                                              25%           QL (1680 ML per 28 day(s))
ZYVOX TAB                                                    25%           QL (56 EA per 28 day(s))
NITROFURAN
FURADANTIN                                                   $76
MACRODANTIN                                                  $38
nitrofurantoin (macrocryst25%)                                $9
nitrofurantoin macrocrystal                                   $9
PENICILLINS
dicloxacillin                                                 $9
nafcillin                                                     $9
oxacillin                                                     $9
penicillin g potassium                                        $9
penicillin v potassium                                        $9

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
TIMENTIN                                                      $9
ZOSYN IN DEXTROSE (ISO-OSM)                                  $38
TETRACYCLINES
demeclocycline                                                $9
doxycycline hyclate                                           $9
doxycycline monohydrate                                       $9
minocycline                                                   $9
tetracycline                                                  $9
ANTIMYASTHENIC AGENTS
PARASYMPATHOMIMETICS
guanidine                                                    $38
MESTINON                                                     $38
MESTINON TIMESPAN                                            $38
MYTELASE                                                     $38
pyridostigmine bromide                                        $9
REGONOL                                                      $38
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
carboplatin                                                   $9           B vs. D
cisplatin                                                     $9           B vs. D
ELOXATIN                                                     $38           B vs. D
HORMONAL ANTINEOPLASTIC AGENTS
ARIMIDEX                                                     $76
AROMASIN                                                     $38
bicalutamide                                                  $9
FARESTON                                                     $38
FASLODEX                                                     $38
FEMARA                                                       $38
flutamide                                                     $9
leuprolide                                                    $9

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
LUPRON DEPOT IM KIT                                         $76
LUPRON DEPOT IM SYRINGE                                     25%
LUPRON DEPOT (3 MONTH) IM KIT                               $76
LUPRON DEPOT (3 MONTH) IM SYRINGE                           25%
LUPRON DEPOT (4 MONTH)                                      25%
LUPRON DEPOT-PED                                            25%
MEGACE ES                                                   $38
megestrol                                                    $9
NILANDRON                                                   $38
tamoxifen                                                    $9
TRELSTAR                                                    $76
INJECTABLE AGENTS
ALIMTA                                                      $38           B vs. D
BICNU                                                       $38           B vs. D
BUSULFEX                                                    $38           B vs. D
cladribine                                                   $9           B vs. D
COSMEGEN                                                    $38           B vs. D
cytarabine                                                   $9           B vs. D
cytarabine (pf)                                              $9           B vs. D
dacarbazine                                                  $9           B vs. D
daunorubicin                                                 $9           B vs. D
DOXIL                                                       $38           B vs. D
doxorubicin                                                  $9           B vs. D
epirubicin                                                   $9           B vs. D
etoposide                                                    $9           B vs. D
fludarabine                                                  $9           B vs. D
fluorouracil                                                 $9           B vs. D
GEMZAR                                                      $38           B vs. D
idarubicin                                                   $9           B vs. D
ifosfamide                                                   $9           B vs. D

      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
irinotecan                                                    $9           B vs. D
melphalan                                                     $9           B vs. D
methotrexate sodium                                           $9           B vs. D
methotrexate sodium (pf)                                      $9           B vs. D
mitomycin                                                     $9           B vs. D
mitoxantrone                                                  $9
MUSTARGEN                                                    $38           B vs. D
ONCASPAR                                                     25%           B vs. D
ONTAK                                                        $38           B vs. D
paclitaxel                                                    $9           B vs. D
pentostatin                                                   $9           B vs. D
PHOTOFRIN                                                    $38           B vs. D
PROLEUKIN                                                    $38           B vs. D
TAXOTERE                                                     $38           B vs. D
thiotepa                                                      $9           B vs. D
TOPOSAR                                                       $9           B vs. D
VIDAZA                                                       $76
vinblastine                                                   $9           B vs. D
vincristine                                                   $9           B vs. D
vinorelbine                                                   $9           B vs. D
MOLECULAR TARGET INHIBITORS
AFINITOR                                                     25%
GLEEVEC                                                      25%
IRESSA                                                       25%
NEXAVAR                                                      25%
SPRYCEL                                                      $38
SUTENT                                                       25%
TARCEVA                                                      25%
TASIGNA                                                      25%
TYKERB                                                       25%

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                                Copayment          Requirements/ Limits
VELCADE                                                       $76
VOTRIENT                                                      25%
MONOCLONAL ANTIBODIES
AVASTIN                                                       25%
CAMPATH                                                       $38           B vs. D
RITUXAN                                                       25%
ORAL AGENTS
CEENU                                                         $38
cyclophosphamide                                               $9           B vs. D
EMCYT                                                         $38
HEXALEN                                                       $38
hydroxyurea                                                    $9
LEUKERAN                                                      $38
LYSODREN                                                      $38
MATULANE                                                      $38
mercaptopurine                                                 $9
REVLIMID                                                      25%
thioguanine                                                   $38
ZOLINZA                                                       25%
PROTECTIVE AGENTS
dexrazoxane                                                    $9           B vs. D
ifosfamide-mesna                                               $9           B vs. D
leucovorin calcium inj                                         $9           B vs. D
leucovorin calcium oral                                        $9
mesna                                                          $9
MESNEX                                                        $38
RETINOIDS
PANRETIN                                                      $38
TARGRETIN                                                     $38
tretinoin (chemotherapy)                                       $9

        * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                                Copayment          Requirements/ Limits
ANTIPARKINSON AGENTS
ANTICHOLINERGICS
benztropine                                                    $9
bromocriptine                                                  $9
trihexyphenidyl                                                $9
ANTIPARKINSONIAN AGENTS, OTHER
amantadine                                                     $9
APOKYN                                                        25%           QL (180 ML per 90 day(s))
AZILECT                                                       $38           QL (90 EA per 90 day(s))
COMTAN                                                        $38
MIRAPEX                                                       $38
MIRAPEX ER                                                    $76
pramipexole                                                    $9
ropinirole                                                     $9
selegiline hcl                                                 $9
DOPAMINE PRECURSORS
ATAMET                                                         $9
carbidopa-levodopa                                             $9
LODOSYN                                                       $76
PARCOPA                                                        $9
STALEVO 100                                                   $38
STALEVO 125                                                   $38
STALEVO 150                                                   $38
STALEVO 200                                                   $38
STALEVO 50                                                    $38
STALEVO 75                                                    $38
ANTIPSYCHOTICS
ATYPICALS
ABILIFY IM                                                    $76
ABILIFY ORAL                                                  $38

       * Your    mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
ABILIFY DISCMELT                                             $76
clozapine                                                     $9
CLOZARIL                                                     $38
FANAPT                                                       $76
FAZACLO                                                      $76
GEODON                                                       $38
INVEGA                                                       $76
INVEGA SUSTENNA                                              $76
RISPERDAL CONSTA                                             $38
risperidone                                                   $9
SAPHRIS                                                      $76
SEROQUEL                                                     $38
SEROQUEL XR                                                  $38
ZYPREXA                                                      $38
ZYPREXA ZYDIS                                                $38
CONVENTIONAL
chlorpromazine                                                $9
fluphenazine decanoate                                        $9
fluphenazine hcl                                              $9
haloperidol                                                   $9
haloperidol decanoate                                         $9
haloperidol lactate                                           $9
loxapine succinate                                            $9
NAVANE                                                       $38
ORAP                                                         $38
perphenazine                                                  $9
thioridazine                                                  $9
thiothixene                                                   $9
trifluoperazine                                               $9
CARDIOVASCULAR

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
ACE INHIBITOR/ CALCIUM CHANNEL BLOCKER COMBINATIONS
amlodipine-benazepril                                         $9           QL (90 EA per 90 day(s))
TARKA                                                        $76           QL (90 EA per 90 day(s))
trandolapril-verapamil                                        $9           QL (90 EA per 90 day(s))
ACE INHIBITOR/ DIURETIC COMBINATIONS
benazepril-hydrochlorothiazide                                $9           QL (180 EA per 90 day(s))
captopril-hydrochlorothiazide tab 25-25 mg, 50-               $9           QL (180 EA per 90 day(s))
25 mg
captopril-hydrochlorothiazide tab 25-15 mg, 50-               $9           QL (270 EA per 90 day(s))
15 mg
enalapril-hydrochlorothiazide                                 $9           QL (180 EA per 90 day(s))
fosinopril-hydrochlorothiazide tab 10-12.5 mg                 $9           QL (180 EA per 90 day(s))
fosinopril-hydrochlorothiazide tab 20-12.5 mg                 $9           QL (360 EA per 90 day(s))
lisinopril-hydrochlorothiazide                                $9           QL (180 EA per 90 day(s))
moexipril-hydrochlorothiazide                                 $9           QL (180 EA per 90 day(s))
quinapril-hydrochlorothiazide                                 $9           QL (180 EA per 90 day(s))
ACE INHIBITORS
benazepril                                                    $9           QL (180 EA per 90 day(s))
captopril                                                     $9
enalapril maleate                                             $9           QL (180 EA per 90 day(s))
fosinopril                                                    $9           QL (180 EA per 90 day(s))
lisinopril tab 10 mg, 2.5 mg, 20 mg, 30 mg, 5 mg              $9           QL (180 EA per 90 day(s))
lisinopril tab 40 mg                                          $9           QL (90 EA per 90 day(s))
perindopril erbumine                                          $9           QL (180 EA per 90 day(s))
quinapril                                                     $9           QL (180 EA per 90 day(s))
ramipril                                                      $9           QL (180 EA per 90 day(s))
trandolapril                                                  $9           QL (180 EA per 90 day(s))
ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone                                                    $9           PA
spironolactone                                                $9
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
AVALIDE                                                     $38           QL (90 EA per 90 day(s))
DIOVAN HCT                                                  $38           QL (90 EA per 90 day(s))
losartan-hydrochlorothiazide                                 $9           QL (90 EA per 90 day(s))
VALTURNA                                                    $38           QL (90 EA per 90 day(s))
ANGIOTENSIN II RECEPTOR ANTAGONISTS
AVAPRO                                                      $38           QL (90 EA per 90 day(s))
DIOVAN                                                      $38           QL (90 EA per 90 day(s))
losartan tab 25 mg, 50 mg                                    $9           QL (180 EA per 90 day(s))
losartan tab 100 mg                                          $9           QL (90 EA per 90 day(s))
ANTIADRENERGICS - CENTRALLY ACTING
clonidine oral                                               $9
clonidine td                                                 $9           QL (13 EA per 90 day(s))
guanabenz                                                    $9
guanfacine                                                   $9
methyldopa                                                   $9
methyldopa-hydrochlorothiazide                               $9
reserpine                                                    $9
ANTIADRENERGICS - PERIPHERALLY ACTING
doxazosin                                                    $9
prazosin                                                     $9
terazosin                                                    $9
ANTIARRHYTHMICS
amiodarone                                                   $9
disopyramide                                                 $9
flecainide                                                   $9
mexiletine                                                   $9
MULTAQ                                                      $38
NORPACE CR                                                  $76
PACERONE TAB 400 mg                                         $38
PACERONE TAB 100 mg, 200 mg                                  $9

      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
procainamide                                                  $9
propafenone                                                   $9
quinidine gluconate                                           $9
quinidine sulfate                                             $9
SORINE                                                        $9
sotalol                                                       $9
TIKOSYN                                                      $38
BETA BLOCKERS NON-SELECTIVE
pindolol                                                      $9
timolol maleate                                               $9
BETA-BLOCKER/DIURETIC COMBINATIONS
atenolol-chlorthalidone                                       $9
bisoprolol-hydrochlorothiazide                                $9
metoprolol-hydrochlorothiazide                                $9
nadolol-bendroflumethiazide                                   $9
propranolol-hydrochlorothiazid                                $9
BETA-BLOCKERS
acebutolol                                                    $9
atenolol                                                      $9
betaxolol                                                     $9
bisoprolol fumarate                                           $9
carvedilol                                                    $9
labetalol                                                     $9
metoprolol succinate                                          $9
metoprolol tartrate                                           $9
nadolol                                                       $9
propranolol                                                   $9
CALCIUM CHANNEL BLOCKER/ ANGIOTENSIN II RECEPTOR ANTAGON COMB
AZOR                                                         $76           QL (90 EA per 90 day(s))
EXFORGE                                                      $38           QL (90 EA per 90 day(s))

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
EXFORGE HCT                                                  $38           QL (90 EA per 90 day(s))
CALCIUM CHANNEL BLOCKERS
AFEDITAB CR                                                   $9
amlodipine                                                    $9
CARTIA XT                                                     $9
diltiazem hcl                                                 $9
DILT-XR                                                       $9
felodipine                                                    $9
isradipine                                                    $9
nicardipine                                                   $9
NIFEDIAC CC                                                   $9
NIFEDICAL XL                                                  $9
nifedipine                                                    $9
nimodipine                                                    $9
nisoldipine                                                  $76
TAZTIA XT                                                     $9
verapamil                                                     $9
DIGITALIS GLYCOSIDES
digoxin                                                       $9
DIURETICS
acetazolamide                                                 $9
ALDACTAZIDE                                                  $38
amiloride                                                     $9
amiloride-hydrochlorothiazide                                 $9
bumetanide                                                    $9
chlorothiazide                                                $9
chlorthalidone                                                $9
furosemide                                                    $9
hydrochlorothiazide                                           $9
indapamide                                                    $9

      * Your    mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
methyclothiazide                                              $9
metolazone                                                    $9
spironolacton-hydrochlorothiaz                                $9
THALITONE                                                    $38
torsemide                                                     $9
triamterene-hydrochlorothiazid                                $9
DYSLIPIDEMICS
CHOLESTYRAMINE LIGHT                                          $9
colestipol                                                    $9
fenofibrate micronized                                        $9
gemfibrozil                                                   $9
LIPOFEN                                                      $38
LOVAZA                                                       $38           PA; QL (360 EA per 90 day(s))
NIASPAN EXTENDED-RELEASE                                     $38
PREVALITE                                                     $9
TRICOR                                                       $38
WELCHOL                                                      $38
ZETIA                                                        $76           PA; ST; QL (90 EA per 90 day(s))
ENDOTHELIN RECEPTOR ANTAGONISTS
LETAIRIS                                                     25%           PA; QL (90 EA per 90 day(s))
TRACLEER                                                     25%           PA; QL (180 EA per 90 day(s))
HMG COA REDUCTASE INHIBITOR COMB
ADVICOR                                                      $76           QL (90 EA per 90 day(s))
SIMCOR                                                       $38           QL (180 EA per 90 day(s))
HMG COA REDUCTASE INHIBITORS
LIPITOR                                                      $38           QL (90 EA per 90 day(s))
lovastatin tab 20 mg, 40 mg                                   $9           QL (180 EA per 90 day(s))
lovastatin tab 10 mg                                          $9           QL (90 EA per 90 day(s))
pravastatin                                                   $9           QL (90 EA per 90 day(s))
simvastatin                                                   $9           QL (90 EA per 90 day(s))

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                                Copayment          Requirements/ Limits
MISCELLANEOUS
RANEXA                                                        $38           PA; QL (180 EA per 90 day(s))
RENIN INHIBITOR
TEKTURNA                                                      $76           QL (90 EA per 90 day(s))
RENIN INHIBITOR COMBINATIONS
TEKTURNA HCT                                                  $76           QL (90 EA per 90 day(s))
VASODILATORS
ADCIRCA                                                       25%           PA; QL (180 EA per 90 day(s))
BIDIL                                                         $38
hydralazine                                                    $9
isosorbide dinitrate                                           $9
isosorbide mononitrate                                         $9
MINITRAN                                                       $9
minoxidil                                                      $9
NITRO-BID                                                     $76
NITRO-DUR                                                     $76
nitroglycerin                                                  $9
NITROLINGUAL                                                  $38
NITROSTAT                                                     $38
REVATIO                                                       25%           PA; QL (270 EA per 90 day(s))
VASOPRESSORS
midodrine                                                      $9
CENTRAL NERVOUS SYSTEM
AMPHETAMINES-ADHD
AMPHETAMINE SALT COMBO TAB 10 mg,                              $9           PA; QL (30 EA per 30 day(s))
15 mg, 5 mg, 7.5 mg
AMPHETAMINE SALT COMBO TAB 12.5 mg,                            $9           PA; QL (60 EA per 30 day(s))
20 mg, 30 mg
dexmethylphenidate                                             $9           PA
dextroamphetamine                                              $9           PA
methamphetamine                                                $9

        * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
VYVANSE                                                      $76           PA; QL (30 EA per 30 day(s))
ANTICONVULSANTS
BANZEL                                                       $38
carbamazepine                                                 $9
CARBATROL                                                    $38
CELONTIN                                                     $38
DILANTIN EXTENDED                                             $9
DILANTIN INFATABS                                             $9
DILANTIN-125                                                 $38
divalproex                                                    $9
EPITOL                                                        $9
ethosuximide                                                  $9
FELBATOL                                                     $38
gabapentin                                                    $9
GABITRIL                                                     $38
KEPPRA                                                       $38
KEPPRA XR                                                    $76
LAMICTAL ODT                                                 $76
LAMICTAL STARTER (BLUE) KIT                                  $76
LAMICTAL XR                                                  $76
LAMICTAL XR STARTER (BLUE)                                   $76
LAMICTAL XR STARTER (GREEN)                                  $76
LAMICTAL XR STARTER (ORANGE)                                 $76
lamotrigine                                                   $9
levetiracetam                                                 $9
LYRICA                                                       $76
NEURONTIN                                                    $38
oxcarbazepine                                                 $9
PEGANONE                                                     $38
phenytoin                                                     $9

      * Your    mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
phenytoin sodium                                              $9
phenytoin sodium extended                                     $9
primidone                                                     $9
SABRIL                                                       $38
TEGRETOL XR                                                  $76
topiramate                                                    $9
valproate sodium                                              $9
valproic acid                                                 $9
valproic acid (as sodium salt)                                $9
VIMPAT                                                       $38
zonisamide                                                    $9
ANTIDEMENTIA
ARICEPT                                                      $38           QL (90 EA per 90 day(s))
ARICEPT ODT                                                  $38           QL (90 EA per 90 day(s))
EXELON CAP                                                   $38           QL (180 EA per 90 day(s))
EXELON ORAL SOLN                                             $38           QL (540 ML per 90 day(s))
EXELON TD                                                    $38           QL (90 EA per 90 day(s))
galantamine sr 24 hr cap                                      $9           QL (90 EA per 90 day(s))
galantamine tab                                               $9           QL (180 EA per 90 day(s))
NAMENDA ORAL SOLN                                            $38           QL (900 ML per 90 day(s))
NAMENDA TAB                                                  $38           QL (180 EA per 90 day(s))
NAMENDA TITRATION PAK                                        $38           QL (1 EA per 365 day(s))
RAZADYNE                                                     $76           QL (540 ML per 90 day(s))
BIPOLAR AGENTS
lithium carbonate                                             $9
lithium citrate                                               $9
HYPNOTICS
zaleplon                                                      $9           QL (90 EA per 90 day(s))
zolpidem                                                      $9           QL (90 EA per 90 day(s))
MIGRAINE

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
dihydroergotamine                                            $9
ergoloid                                                     $9
ergotamine-caffeine                                          $9
MAXALT-MLT                                                  $38           ST; QL (54 EA per 90 day(s))
MIGERGOT                                                     $9
RELPAX                                                      $38           ST; QL (54 EA per 90 day(s))
sumatriptan succinate oral                                   $9           QL (54 EA per 90 day(s))
sumatriptan succinate subq                                   $9           QL (24 ML per 90 day(s))
MULTIPLE SCLEROSIS AGENTS
AVONEX                                                      25%           QL (12 EA per 84 day(s))
AVONEX ADMINISTRATION PACK                                  25%           QL (12 EA per 84 day(s))
BETASERON                                                   25%           QL (45 EA per 90 day(s))
COPAXONE                                                    25%           QL (90 EA per 90 day(s))
REBIF                                                       25%           QL (18 ML per 84 day(s))
REBIF TITRATION PACK                                        25%           QL (1 ML per 365 day(s))
MUSCULOSKELETAL THERAPY AGENTS
baclofen                                                     $9
dantrolene                                                   $9
metaxalone                                                   $9           QL (360 EA per 90 day(s))
NON-AMPHETAMINES, ADHD
METHYLIN ORAL SOLN                                          $76           PA
METHYLIN TAB                                                 $9
METHYLIN ER                                                  $9           QL (90 EA per 30 day(s))
methylphenidate sr tab                                       $9           QL (90 EA per 30 day(s))
methylphenidate tab                                          $9
STRATTERA CAP 10 mg, 18 mg, 25 mg                           $76           PA; QL (180 EA per 90 day(s))
STRATTERA CAP 100 mg, 40 mg, 60 mg, 80                      $76           PA; QL (90 EA per 90 day(s))
mg
NON-AMPHETAMINES, OTHER
NUVIGIL TAB 50 mg                                           $76           PA; QL (180 EA per 90 day(s))


      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
NUVIGIL TAB 150 mg, 250 mg                                   $76           PA; QL (90 EA per 90 day(s))
PROVIGIL                                                     $38           PA; QL (180 EA per 90 day(s))
RILUTEK                                                      25%
XYREM                                                        25%           PA; QL (1620 ML per 90 day(s))
OTHER
XENAZINE                                                     25%           PA; QL (360 EA per 90 day(s))
DENTAL AND ORAL AGENTS
MOUTH/THROAT/DENTAL AGENTS
chlorhexidine gluconate                                       $9
PERIOGARD                                                     $9
triamcinolone acetonide                                       $9
DERMATOLOGICAL AGENTS
DERMATOLOGY, ACNE
AMNESTEEM                                                     $9           PA
CLARAVIS                                                      $9           PA
clindamycin-benzoyl peroxide                                  $9
ERY PADS                                                      $9
erythromycin with ethanol                                     $9
erythromycin-benzoyl peroxide                                 $9
SOTRET                                                        $9           PA
tretinoin                                                     $9           PA
DERMATOLOGY, ACTINIC KERATOSIS
CARAC                                                         $9
SOLARAZE                                                     $38
DERMATOLOGY, ANTIBIOTICS
ALTABAX                                                      $76
BACTROBAN                                                    $38
mupirocin                                                     $9
silver sulfadiazine                                           $9
SSD                                                           $9

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
THERMAZENE                                                    $9
DERMATOLOGY, ANTIFUNGALS
ciclopirox                                                    $9
econazole                                                     $9
KURIC                                                         $9
MENTAX                                                       $76
nystatin-triamcinolone                                        $9
NYSTOP                                                        $9
OXISTAT                                                      $76
PEDI-DRI                                                      $9
DERMATOLOGY, ANTIPRURITIC
ZONALON                                                      $38
DERMATOLOGY, ANTIPSORIATICS
calcipotriene                                                 $9
DOVONEX                                                      $38
OXSORALEN ULTRA                                              $38
DERMATOLOGY, ANTIVIRALS
DENAVIR                                                      $38
ZOVIRAX                                                      $38
DERMATOLOGY, CORTICOSTEROIDS
ALA-CORT                                                      $9
alclometasone                                                 $9
amcinonide                                                    $9
betamethasone dipropionate                                    $9
betamethasone valerate                                        $9
betamethasone, augmented                                      $9
BETA-VAL                                                      $9
clobetasol                                                    $9
clobetasol-emollient                                          $9
clotrimazole-betamethasone                                    $9

      * Your    mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
desonide                                                     $9
desoximetasone                                               $9
diflorasone                                                  $9
fluocinolone                                                 $9
fluocinonide                                                 $9
fluocinonide-emollient                                       $9
fluticasone                                                  $9
halobetasol propionate                                       $9
hydrocortisone                                               $9
hydrocortisone butyrate                                      $9
hydrocortisone valerate                                      $9
LOKARA                                                       $9
mometasone                                                   $9
prednicarbate                                                $9
PROCTOCREAM-HC                                               $9
PROCTO-PAK                                                   $9
PROCTOSOL HC                                                 $9
PROCTOZONE-HC                                                $9
TRIDERM                                                      $9
DERMATOLOGY, IMMUNOMODULATORS
ELIDEL                                                      $38           PA
PROTOPIC                                                    $38           PA
DERMATOLOGY, LOCAL ANESTHETICS
lidocaine-prilocaine                                         $9
LIDODERM                                                    $38           PA
DERMATOLOGY, MISCELLANEOUS
8-MOP                                                       $76
ammonium lactate                                             $9
CONDYLOX                                                    $76
imiquimod                                                    $9

      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
OXSORALEN                                                   $76
podofilox                                                    $9
DERMATOLOGY, ROSACEA
FINACEA                                                     $76
DERMATOLOGY, SCABICIDES AND PEDICULIDES
ACTICIN                                                      $9
EURAX                                                       $38
lindane                                                      $9
malathion                                                    $9
permethrin                                                   $9
DERMATOLOGY, WOUND CARE AGENTS
REGRANEX                                                    $38           PA; QL (45 GM per 90 day(s))
SANTYL                                                      $38
DIABETIC THERAPY
ALPHA GLUCOSIDASE INHIBITORS
acarbose                                                     $9           QL (270 EA per 90 day(s))
GLYSET                                                      $76           QL (270 EA per 90 day(s))
AMYLIN ANALOGS
SYMLIN                                                      $38           PA; QL (60 ML per 90 day(s))
SYMLINPEN 60                                                $38           PA; QL (36 ML per 90 day(s))
BIGUANIDES
metformin er 24 hr tab 750 mg                                $9           QL (180 EA per 90 day(s))
metformin er 24 hr tab 500 mg                                $9           QL (360 EA per 90 day(s))
metformin tab 1,000 mg                                       $9           QL (225 EA per 90 day(s))
metformin tab 850 mg                                         $9           QL (270 EA per 90 day(s))
metformin tab 500 mg                                         $9           QL (450 EA per 90 day(s))
BIGUANIDES-THIAZOLIDINEDIONE COMBINATIONS
ACTOPLUS MET                                                $38           QL (270 EA per 90 day(s))
ACTOPLUS MET XR 24 HR TAB 15-1,000 mg                       $38           QL (180 EA per 90 day(s))
ACTOPLUS MET XR 24 HR TAB 30-1,000 mg                       $38           QL (90 EA per 90 day(s))

      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                             Copayment          Requirements/ Limits
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITOR/BIGUANIDE COMBINATIONS
JANUMET                                                    $38           QL (180 EA per 90 day(s))
DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS
JANUVIA                                                    $38           QL (90 EA per 90 day(s))
ONGLYZA                                                    $76           QL (90 EA per 90 day(s))
INCRETIN MIMETICS
BYETTA                                                     $38           PA; QL (9 ML per 90 day(s))
VICTOZA                                                    $76           PA; QL (27 ML per 90 day(s))
INSULIN
APIDRA                                                     $38
HUMALOG                                                    $76
HUMALOG MIX 50-50                                          $76
HUMALOG MIX 75-25                                          $76
HUMALOG PEN                                                $76
HUMULIN 70/30                                              $76
HUMULIN 70/30 PEN                                          $76
HUMULIN N                                                  $76
HUMULIN N PEN                                              $76
HUMULIN R                                                  $76
HUMULIN R U-500 "CONCENTRATED"                             $76
LANTUS                                                     $38
LANTUS SOLOSTAR                                            $38
LEVEMIR                                                    $38
LEVEMIR FLEXPEN                                            $38
NOVOLIN 70/30                                              $38
NOVOLIN 70/30 INNOLET                                      $38
NOVOLIN N                                                  $38
NOVOLIN N INNOLET                                          $38
NOVOLIN R                                                  $38
NOVOLOG                                                    $38

     * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
NOVOLOG FLEXPEN                                             $38
NOVOLOG MIX 70-30                                           $38
NOVOLOG MIX 70-30 FLEXPEN                                   $38
MEGLITINIDE ANALOGUES
nateglinide                                                  $9           QL (270 EA per 90 day(s))
PRANDIN                                                     $76           QL (720 EA per 90 day(s))
NEEDLES, SYRINGES AND SUPPLIES
alcohol swabs                                               $38
CURITY GAUZE                                                $38
INSULIN PEN NEEDLE                                          $38
insulin syringe-needle u-100                                $38
safety needles                                              $38
SULFONYLUREA-BIGUANIDE COMBINATIONS
glipizide-metformin tab 2.5-500 mg, 5-500 mg                 $9           QL (360 EA per 90 day(s))
glipizide-metformin tab 2.5-250 mg                           $9           QL (720 EA per 90 day(s))
glyburide-metformin tab 2.5-500 mg, 5-500 mg                 $9           QL (360 EA per 90 day(s))
glyburide-metformin tab 1.25-250 mg                          $9           QL (720 EA per 90 day(s))
SULFONYLUREAS
chlorpropamide tab 250 mg                                    $9           QL (270 EA per 90 day(s))
chlorpropamide tab 100 mg                                    $9           QL (720 EA per 90 day(s))
glimepiride tab 4 mg                                         $9           QL (180 EA per 90 day(s))
glimepiride tab 2 mg                                         $9           QL (360 EA per 90 day(s))
glimepiride tab 1 mg                                         $9           QL (720 EA per 90 day(s))
glipizide er 24 hr tab 10 mg                                 $9           QL (180 EA per 90 day(s))
glipizide er 24 hr tab 5 mg                                  $9           QL (360 EA per 90 day(s))
glipizide er 24 hr tab 2.5 mg                                $9           QL (720 EA per 90 day(s))
glipizide tab 10 mg                                          $9           QL (360 EA per 90 day(s))
glipizide tab 5 mg                                           $9           QL (720 EA per 90 day(s))
glyburide tab 5 mg                                           $9           QL (360 EA per 90 day(s))
glyburide tab 1.25 mg, 2.5 mg                                $9           QL (720 EA per 90 day(s))

      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
glyburide micronized tab 6 mg                                $9           QL (180 EA per 90 day(s))
glyburide micronized tab 1.5 mg, 3 mg                        $9           QL (360 EA per 90 day(s))
GLYCRON TAB 4.5 mg, 6 mg                                     $9           QL (180 EA per 90 day(s))
GLYCRON TAB 1.5 mg, 3 mg                                     $9           QL (360 EA per 90 day(s))
tolazamide                                                   $9           QL (360 EA per 90 day(s))
tolbutamide                                                  $9           QL (540 EA per 90 day(s))
SULFONYLUREA-THIAZOLIDINEDIONE COMBINATIONS
DUETACT                                                     $38           QL (90 EA per 90 day(s))
THIAZOLIDINEDIONES
ACTOS TAB 15 mg                                             $38           QL (270 EA per 90 day(s))
ACTOS TAB 30 mg, 45 mg                                      $38           QL (90 EA per 90 day(s))
DRUGS TO TREAT RARE DISEASES
ARSENIC TRIOXIDE
TRISENOX                                                    $38
BLEOMYCIN
bleomycin                                                    $9
ENDOCRINE AND METABOLIC
ANDROGENS
ANADROL-50                                                  $76
ANDRODERM                                                   $38           PA; QL (90 EA per 90 day(s))
ANDROID                                                      $9
oxandrolone                                                  $9           PA
TESTIM                                                      $38           PA; QL (900 GM per 90 day(s))
testosterone cypionate                                       $9           PA; QL (60 ML per 90 day(s))
testosterone enanthate                                       $9           PA; QL (30 ML per 90 day(s))
TESTRED                                                      $9
BISPHOSPHONATES
ACTONEL TAB 30 mg                                           $76           PA; ST; QL (60 EA per 365 day(s))
ACTONEL TAB 35 mg                                           $76           ST; QL (13 EA per 90 day(s))
ACTONEL TAB 150 mg                                          $76           ST; QL (3 EA per 84 day(s))

      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
ACTONEL TAB 5 mg                                             $76           ST; QL (90 EA per 90 day(s))
alendronate tab 35 mg, 70 mg                                  $9           QL (13 EA per 90 day(s))
alendronate tab 10 mg, 40 mg, 5 mg                            $9           QL (90 EA per 90 day(s))
BONIVA                                                       $38           QL (3 EA per 84 day(s))
etidronate disodium                                           $9
pamidronate                                                   $9           PA
ZOMETA                                                       $38           PA
CALCITONINS
calcitonin (salmon)                                           $9
FORTICAL                                                      $9
MIACALCIN                                                    $38
CALCIUM RECEPTOR ANTAGONISTS
SENSIPAR                                                     $38
CHELATING AGENTS
EXJADE                                                       25%           PA
SYPRINE                                                      $38
CONTRACEPTIVES
APRI                                                          $9
ARANELLE (28)                                                 $9
AVIANE                                                        $9
BALZIVA (28)                                                  $9
BREVICON (28)                                                 $9
CAMILA                                                        $9
CESIA                                                         $9
CRYSELLE (28)                                                 $9
ENPRESSE                                                      $9
ERRIN                                                         $9
FEMHRT 1/5                                                   $76
FEMHRT LOW DOSE                                              $76
JOLIVETTE                                                     $9

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                             Copayment          Requirements/ Limits
JUNEL 1.5/30 (21)                                           $9
JUNEL 1/20 (21)                                             $9
JUNEL FE 1.5/30 (28)                                        $9
JUNEL FE 1/20 (28)                                          $9
KARIVA                                                      $9
KELNOR 1/35 (28)                                            $9
LEENA 28                                                    $9
LESSINA                                                     $9
LEVORA-28                                                   $9
LOESTRIN 24 FE                                             $38
LOW-OGESTREL (28)                                           $9
LUTERA (28)                                                 $9
MICROGESTIN 1.5/30 (21)                                     $9
MICROGESTIN 1/20 (21)                                       $9
MICROGESTIN FE 1.5/30 (28)                                  $9
MICROGESTIN FE 1/20 (28)                                    $9
MONONESSA (28)                                              $9
NECON 0.5/35 (28)                                           $9
NECON 1/35 (28)                                             $9
NECON 10/11 (28)                                            $9
NECON 7/7/7 (28)                                            $9
NORA-BE                                                     $9
NORTREL 0.5/35 (28)                                         $9
NORTREL 1/35 (21)                                           $9
NORTREL 1/35 (28)                                           $9
NORTREL 7/7/7 (28)                                          $9
NUVARING                                                   $38           QL (3 EA per 84 day(s))
OCELLA                                                      $9
OGESTREL (28)                                               $9
ORTHO EVRA                                                 $38           QL (10 EA per 90 day(s))

     * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
ORTHO TRI-CYCLEN LO                                         $76
PORTIA                                                       $9
PREVIFEM                                                     $9
QUASENSE                                                     $9
RECLIPSEN (28)                                               $9
SOLIA                                                        $9
SPRINTEC (28)                                                $9
TRINESSA (28)                                                $9
TRI-PREVIFEM (28)                                            $9
TRI-SPRINTEC (28)                                            $9
TRIVORA (28)                                                 $9
VELIVET                                                      $9
YAZ 28                                                      $38
ZOVIA 1/35E (28)                                             $9
ZOVIA 1/50E (28)                                             $9
EMERGENCY CONTRACEPTIVES
NEXT CHOICE                                                  $9
ENDOMETRIOSIS
danazol                                                      $9
SYNAREL                                                     $38
ENZYME REPLACEMENTS
ADAGEN                                                      25%           PA
BUPHENYL                                                    25%
CEREZYME                                                    25%           PA
CREON                                                       $38
CYSTADANE                                                   $38
CYSTAGON                                                    $38
FABRAZYME                                                   25%           PA
NAGLAZYME                                                   25%           PA
ORFADIN                                                     25%           PA

      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                                Copayment          Requirements/ Limits
ZAVESCA                                                       25%           PA
ZENPEP                                                        $38
ESTROGEN/PROGESTINS
CLIMARA PRO                                                   $38           QL (13 EA per 90 day(s))
COMBIPATCH                                                    $38           QL (26 EA per 90 day(s))
estradiol-norethindrone acet                                   $9
PREFEST                                                       $76
PREMARIN                                                      $38
PREMPHASE                                                     $38
PREMPRO                                                       $38
ESTROGENS
ALORA                                                         $76           QL (26 EA per 90 day(s))
CENESTIN                                                      $38
ELESTRIN                                                      $76           QL (288 GM per 90 day(s))
ENJUVIA                                                       $38
ESTRACE                                                        $9
ESTRADERM                                                     $76           QL (26 EA per 90 day(s))
estradiol oral                                                 $9
estradiol td                                                   $9           QL (13 EA per 90 day(s))
estradiol valerate                                             $9
ESTRING                                                       $76           QL (1 EA per 90 day(s))
estropipate                                                    $9
FEMRING                                                       $38           QL (1 EA per 90 day(s))
ORTHO-EST 0.625                                                $9
ORTHO-EST 1.25                                                 $9
VAGIFEM                                                       $38
VIVELLE-DOT                                                   $76           QL (26 EA per 90 day(s))
GLUCOCORTICOIDS
A-METHAPRED                                                    $9
cortisone                                                      $9

       * Your    mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
dexamethasone                                                $9
DEXAMETHASONE INTENSOL                                       $9
methylprednisolone                                           $9
methylprednisolone acetate                                   $9
methylprednisolone sodium succ                               $9
prednisolone                                                 $9
prednisolone sodium phosphate                                $9
prednisone                                                   $9
PREDNISONE INTENSOL                                          $9
PRELONE                                                     $76
GLUCOSE ELEVATING AGENTS
GLUCAGON EMERGENCY                                          $38
PROGLYCEM                                                   $38
HUMAN GROWTH HORMONES
INCRELEX                                                    25%           PA
NORDITROPIN CARTRIDGE                                       25%           PA
NORDITROPIN NORDIFLEX                                       25%           PA
NUTROPIN                                                    25%           PA
NUTROPIN AQ                                                 25%           PA
MISCELLANEOUS
cabergoline                                                  $9           QL (52 EA per 90 day(s))
KUVAN                                                       25%           PA
octreotide acetate injection 50 mcg/mL                       $9           QL (2700 ML per 90 day(s))
octreotide acetate injection 1,000 mcg/mL                   25%
octreotide acetate injection 100 mcg/mL                     25%           QL (1350 ML per 90 day(s))
octreotide acetate injection 500 mcg/mL                     25%           QL (270 ML per 90 day(s))
octreotide acetate injection 200 mcg/mL                     25%           QL (720 ML per 90 day(s))
SANDOSTATIN LAR DEPOT                                       25%           PA; QL (3 EA per 84 day(s))
SOMATULINE DEPOT SUB-Q SYRINGE 60                           $38           PA; QL (3 ML per 84 day(s))
mg/0.2 mL


      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
SOMATULINE DEPOT SUB-Q SYRINGE 120                           25%           PA; QL (3 ML per 84 day(s))
mg/0.5 mL, 90 mg/0.3 mL
SOMAVERT                                                     25%           PA; QL (90 EA per 90 day(s))
PARATHYROID HORMONES
FORTEO                                                       $38           PA; QL (9 ML per 84 day(s))
PHOSPHATE BINDER AGENTS
FOSRENOL                                                     $38
RENAGEL                                                      $38
RENVELA                                                      $38
PROGESTINS
DEPO-SUBQ PROVERA 104                                        $38           QL (1 ML per 84 day(s))
medroxyprogesterone im                                        $9           QL (1 ML per 90 day(s))
medroxyprogesterone oral                                      $9
norethindrone acetate                                         $9
PROMETRIUM                                                   $76
SELECTIVE ESTROGEN RECEPTOR MODULATORS (SERMS)
EVISTA                                                       $38
THYROID AGENTS
LEVOTHROID                                                    $9
levothyroxine                                                 $9
LEVOXYL                                                       $9
liothyronine                                                  $9
methimazole                                                   $9
propylthiouracil                                              $9
SYNTHROID                                                    $38
UNITHROID                                                     $9
VASOPRESSIN RECEPTOR ANTAGONISTS
SAMSCA                                                       25%           PA; QL (120 EA per 365 day(s))
GASTROINTESTINAL
ANTIEMETICS


      * Your    mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
COMPRO                                                       $9
dronabinol                                                   $9           B vs. D; QL (180 EA per 90
                                                                          day(s))
EMEND CAP 125 mg                                            $38           B vs. D; QL (2 EA per 1 day(s))
EMEND CAP 40 mg, 80 mg                                      $38           B vs. D; QL (4 EA per 1 day(s))
EMEND CAPS IN DOSE PACK                                     $38           B vs. D; QL (6 EA per 1 day(s))
granisetron iv                                               $9           QL (3 ML per 1 day(s))
granisetron oral                                             $9           B vs. D; QL (20 EA per 1 day(s))
granisetron (pf)                                             $9           QL (3 ML per 1 day(s))
GRANISOL                                                     $9           B vs. D; QL (30 ML per 1 day(s))
meclizine                                                    $9
metoclopramide                                               $9
ondansetron tab, rapid dissolve 8 mg                         $9           B vs. D; QL (30 EA per 1 day(s))
ondansetron tab, rapid dissolve 4 mg                         $9           B vs. D; QL (42 EA per 1 day(s))
ondansetron hcl oral soln                                    $9           B vs. D; QL (210 ML per 1 day(s))
ondansetron hcl tab 24 mg                                    $9           B vs. D; QL (10 EA per 1 day(s))
ondansetron hcl tab 8 mg                                     $9           B vs. D; QL (30 EA per 1 day(s))
ondansetron hcl tab 4 mg                                     $9           B vs. D; QL (42 EA per 1 day(s))
ondansetron hcl (pf)                                         $9           QL (20 ML per 1 day(s))
prochlorperazine                                             $9
prochlorperazine edisylate                                   $9
prochlorperazine maleate                                     $9
SANCUSO                                                     $38           PA; QL (6 EA per 1 day(s))
ANTISPASMODICS
dicyclomine                                                  $9
glycopyrrolate                                               $9
methscopolamine                                              $9
H2-RECEPTOR ANTAGONISTS
famotidine                                                   $9
famotidine (pf)                                              $9


      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                                Copayment          Requirements/ Limits
nizatidine                                                     $9
ranitidine hcl                                                 $9
INFLAMMATORY BOWEL DISEASE
ASACOL                                                        $38
ASACOL HD                                                     $38
balsalazide                                                    $9
CANASA                                                        $38
COLOCORT                                                       $9
CORTENEMA                                                      $9
DIPENTUM                                                      $38
ENTOCORT EC                                                   $38
LIALDA                                                        $38
mesalamine                                                     $9
PENTASA                                                       $38
sulfasalazine                                                  $9
SULFAZINE EC                                                   $9
LAXATIVES
CONSTULOSE                                                     $9
ENULOSE                                                        $9
GENERLAC                                                       $9
HALFLYTELY-BISACODYL BOWEL KIT                                $38
lactulose                                                      $9
MOVIPREP                                                      $38
NULYTELY WITH FLAVOR PACKS                                    $76
TRILYTE WITH FLAVOR PACKETS                                    $9
MISCELLANEOUS
AMITIZA                                                       $76           PA; QL (180 EA per 90 day(s))
CARAFATE                                                      $38
loperamide                                                     $9
LOTRONEX                                                      $38           PA

       * Your    mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
misoprostol                                                   $9
pilocarpine hcl                                               $9
sucralfate                                                    $9
ursodiol                                                      $9
PROTON PUMP INHIBITOR/ANTI-INFECTIVE COMBINATIONS
PREVPAC                                                      $38           QL (14 EA per 30 day(s))
PYLERA                                                       $76           QL (120 EA per 30 day(s))
PROTON PUMP INHIBITORS
lansoprazole                                                  $9           QL (90 EA per 90 day(s))
NEXIUM                                                       $38           QL (90 EA per 90 day(s))
NEXIUM PACKET                                                $38           QL (90 EA per 90 day(s))
omeprazole                                                    $9           QL (90 EA per 90 day(s))
PREVACID SOLUTAB                                             $76           PA; ST; QL (90 EA per 90 day(s))
PROTONIX                                                     $38
Gastrointestinal Agents
ENZYME REPLACEMENTS
PANCREAZE                                                    $38
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
finasteride                                                   $9           QL (90 EA per 90 day(s))
RAPAFLO                                                      $76           QL (90 EA per 90 day(s))
tamsulosin                                                    $9
MISCELLANEOUS
ELMIRON                                                      $38
potassium citrate                                             $9
URINARY ANTISPASMODICS
bethanechol chloride                                          $9
DETROL                                                       $38           ST; QL (180 EA per 90 day(s))
DETROL LA                                                    $38           ST; QL (90 EA per 90 day(s))
ENABLEX                                                      $38           ST; QL (90 EA per 90 day(s))

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
oxybutynin chloride er 24 hr tab 10 mg, 15 mg                $9           QL (180 EA per 90 day(s))
oxybutynin chloride er 24 hr tab 5 mg                        $9           QL (90 EA per 90 day(s))
oxybutynin chloride syrup                                    $9           QL (2700 ML per 90 day(s))
oxybutynin chloride tab                                      $9           QL (540 EA per 90 day(s))
OXYTROL                                                     $76           ST; QL (26 EA per 90 day(s))
SANCTURA XR                                                 $76           ST; QL (90 EA per 90 day(s))
VESICARE                                                    $76           ST; QL (90 EA per 90 day(s))
VAGINAL ANTI-INFECTIVES
CLINDESSE                                                   $38
MICONAZOLE-3                                                 $9
terconazole                                                  $9
VANDAZOLE                                                    $9
ZAZOLE                                                       $9
Genitourinary Agents
BENIGN PROSTATIC HYPERPLASIA
AVODART                                                     $38           ST; QL (90 EA per 90 day(s))
HEMATOLOGIC
ANTICOAGULANTS
ARIXTRA SUB-Q SYRINGE 5 mg/0.4 mL                           $38           QL (36 ML per 90 day(s))
ARIXTRA SUB-Q SYRINGE 2.5 mg/0.5 mL                         $38           QL (45 ML per 90 day(s))
ARIXTRA SUB-Q SYRINGE 7.5 mg/0.6 mL                         $38           QL (54 ML per 90 day(s))
ARIXTRA SUB-Q SYRINGE 10 mg/0.8 mL                          $38           QL (72 ML per 90 day(s))
COUMADIN                                                    $38
heparin (porcine)                                            $9
heparin (porcine) in d5w                                     $9
heparin (porcine) in ns (pf)                                 $9
heparin (porcine)-0.45% nacl                                 $9
heparin, porcine (pf)                                        $9
JANTOVEN                                                     $9
LOVENOX SUB-Q                                               $38           QL (9 ML per 30 day(s))

      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                                Copayment          Requirements/ Limits
LOVENOX SUB-Q SYRINGE 30 mg/0.3 mL                            $38           QL (27 ML per 90 day(s))
LOVENOX SUB-Q SYRINGE 40 mg/0.4 mL                            $38           QL (36 ML per 90 day(s))
LOVENOX SUB-Q SYRINGE 60 mg/0.6 mL                            $38           QL (54 ML per 90 day(s))
LOVENOX SUB-Q SYRINGE 120 mg/0.8 mL,                          $38           QL (72 ML per 90 day(s))
80 mg/0.8 mL
LOVENOX SUB-Q SYRINGE 100 mg/mL, 150                          $38           QL (90 ML per 90 day(s))
mg/mL
PENTOPAK                                                       $9
pentoxifylline                                                 $9
warfarin                                                       $9
COAGULANTS
CYKLOKAPRON                                                   $38
HEMATOPOIETIC GROWTH FACTORS
ARANESP (POLYSORBATE) INJECTION 25                            $38           PA; QL (6 ML per 84 day(s))
mcg/mL, 40 mcg/mL
ARANESP (POLYSORBATE) INJECTION 100                           25%           PA; QL (6 ML per 84 day(s))
mcg/mL, 200 mcg/mL, 300 mcg/mL, 60 mcg/mL
ARANESP (POLYSORBATE) SYRINGE 25                              $38           PA; QL (6 ML per 84 day(s))
mcg/0.42 mL, 40 mcg/0.4 mL
ARANESP (POLYSORBATE) SYRINGE 500                             25%           PA; QL (4 ML per 84 day(s))
mcg/mL
ARANESP (POLYSORBATE) SYRINGE 100                             25%           PA; QL (6 ML per 84 day(s))
mcg/0.5 mL, 150 mcg/0.3 mL, 200 mcg/0.4 mL,
300 mcg/0.6 mL, 60 mcg/0.3 mL
EPOGEN INJECTION 2,000 unit/mL, 3,000                         $76           PA; QL (36 ML per 84 day(s))
unit/mL, 4,000 unit/mL
EPOGEN INJECTION 40,000 unit/mL                               25%           PA; QL (18 ML per 84 day(s))
EPOGEN INJECTION 20,000 unit/2 mL, 20,000                     25%           PA; QL (36 ML per 84 day(s))
unit/mL
LEUKINE                                                       25%           PA
NEULASTA                                                      25%           PA; QL (6 ML per 84 day(s))
NEUMEGA                                                       25%           PA; QL (62 EA per 90 day(s))
NEUPOGEN INJECTION                                            25%           PA; QL (84 ML per 90 day(s))


       * Your    mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
NEUPOGEN SYRINGE 300 mcg/0.5 mL                              25%           PA; QL (42 ML per 90 day(s))
NEUPOGEN SYRINGE 480 mcg/0.8 mL                              25%           PA; QL (84 ML per 90 day(s))
PROCRIT INJECTION 10,000 unit/mL, 2,000                      $38           PA; QL (36 ML per 84 day(s))
unit/mL, 3,000 unit/mL, 4,000 unit/mL
PROCRIT INJECTION 40,000 unit/mL                             25%           PA; QL (18 ML per 84 day(s))
PROCRIT INJECTION 20,000 unit/mL                             25%           PA; QL (36 ML per 84 day(s))
OTHER
PROMACTA                                                     25%           PA; QL (30 EA per 30 day(s))
PLATELET AGGREGATION INHIBITORS
AGGRENOX                                                     $38           QL (180 EA per 90 day(s))
anagrelide                                                    $9           PA
cilostazol                                                    $9
dipyridamole tab 25 mg                                        $9           QL (1440 EA per 90 day(s))
dipyridamole tab 75 mg                                        $9           QL (360 EA per 90 day(s))
dipyridamole tab 50 mg                                        $9           QL (720 EA per 90 day(s))
EFFIENT                                                      $76           PA; QL (90 EA per 90 day(s))
PLAVIX                                                       $38           QL (90 EA per 90 day(s))
ticlopidine                                                   $9           QL (180 EA per 90 day(s))
HORMONES
MINERALOCORTICOIDS
fludrocortisone                                               $9
VASOPRESSIN
desmopressin                                                  $9
IMMUNOLOGIC AGENTS
IMMUNE, GLOBULIN
CARIMUNE NF NANOFILTERED                                     25%           PA
GAMASTAN S/D                                                 $76           PA
GAMMAGARD LIQUID                                             25%           PA
GAMUNEX                                                      25%           PA
OCTAGAM                                                      25%           PA


       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
IMMUNOLOGIC AGENTS, PASSIVE
ATGAM                                                       $38           B vs. D
THYMOGLOBULIN                                               $38           B vs. D
IMMUNOMODULATORS
ACTIMMUNE                                                   25%           PA
ARCALYST                                                    25%
CUPRIMINE                                                   $38
ENBREL SUB-Q KIT                                            25%           PA; QL (48 EA per 84 day(s))
ENBREL SUB-Q SYRINGE 25 mg/0.5mL (0.51)                     $38           PA; QL (24 ML per 84 day(s))
ENBREL SUB-Q SYRINGE 50 mg/mL (0.98                         25%           PA; QL (24 ML per 84 day(s))
mL)
HUMIRA                                                      25%           PA; QL (12 EA per 84 day(s))
HUMIRA CROHN'S DIS START PCK                                25%           PA; QL (6 EA per 365 day(s))
INFERGEN                                                    25%           PA; QL (11 ML per 84 day(s))
INTRON A INJECTION                                          25%           PA
INTRON A SOLUTION FOR INJECTION                             $76           PA
INTRON A SUBQ PEN KIT 3,000,000 unit/0.2                    $76           PA
mL
INTRON A SUBQ PEN KIT 10,000,000 unit/0.2                   25%           PA
mL, 5,000,000 unit/0.2 mL
KINERET                                                     25%           QL (84 ML per 84 day(s))
leflunomide                                                  $9
ORENCIA                                                     25%
PEGASYS CONVENIENCE PACK                                    25%           PA; QL (12 EA per 84 day(s))
REMICADE                                                    25%           PA
RIDAURA                                                     $38
THALOMID CAP 150 mg                                         $38
THALOMID CAP 100 mg, 200 mg, 50 mg                          25%
IMMUNOSUPPRESSANTS
AZASAN                                                       $9           B vs. D
azathioprine                                                 $9           B vs. D

      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
azathioprine sodium                                           $9           B vs. D
CELLCEPT                                                     $76           B vs. D
cyclosporine                                                  $9           B vs. D
cyclosporine modified                                         $9           B vs. D
GENGRAF                                                       $9           B vs. D
mycophenolate mofetil                                         $9           B vs. D
NEORAL                                                       $38           B vs. D
PROGRAF                                                      $76           B vs. D
RAPAMUNE                                                     $38           B vs. D
SANDIMMUNE                                                   $38           B vs. D
tacrolimus                                                    $9           B vs. D
ZORTRESS 0.25 mg                                             $76           B vs. D
ZORTRESS 0.5 mg, 0.75 mg                                     25%           B vs. D
VACCINES
ACTHIB                                                       $38           B vs. D
ADACEL (ADOLESCENT & ADULT)                                  $38           B vs. D
ATTENUVAX (PF)                                               $38
BOOSTRIX                                                     $38           B vs. D
CERVARIX                                                     $76
COMVAX                                                       $38
DAPTACEL (PEDIATRIC) (PF)                                    $38           B vs. D
DECAVAC                                                      $38           B vs. D
ENGERIX-B (PF)                                               $38           B vs. D
GARDASIL                                                     $38
HAVRIX (PF)                                                  $38
IMOVAX RABIES VACCINE                                        $38
INFANRIX (PF)                                                $38           B vs. D
IPOL                                                         $38
JE-VAX                                                       $38
MENACTRA                                                     $38

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
MENOMUNE – A/C/Y/W-135 (PF)                                  $38
MERUVAX II (PF)                                              $38
M-M-R II (PF)                                                $38
PEDIARIX (PF)                                                $38           B vs. D
PEDVAX HIB                                                   $38
PROQUAD                                                      $38
RABAVERT (PF)                                                $38
RECOMBIVAX HB (PF)                                           $38           B vs. D
ROTATEQ VACCINE                                              $38
tetanus toxoid,adsorbed (pf)                                 $38           B vs. D
tetanus,diphtheria toxd ped-pf                                $9           B vs. D
tetanus-diphtheria toxoids-td                                 $9           B vs. D
TRIHIBIT PRESERVATIVE FREE                                   $38           B vs. D
TRIPEDIA (PF)                                                $38           B vs. D
TWINRIX (PF)                                                 $38
TYPHIM VI                                                    $38
VAQTA (PF)                                                   $38
VARIVAX (PF)                                                 $38
YF-VAX                                                       $38
ZOSTAVAX                                                     $38           QL (1 EA per 365 day(s))
METABOLIC BONE DISEASE AGENTS
HYPERPARATHYROID TREATMENT – VITAMIN D ANALOGS
HECTOROL                                                     $38
ZEMPLAR CAP 1 mcg, 2 mcg                                     $38           QL (180 EA per 90 day(s))
ZEMPLAR CAP 4 mcg                                            $38           QL (90 EA per 90 day(s))
METABOLIC DEFICIENCY AGENTS
CARNITINE REPLENISHER – AGENTS
levocarnitine                                                 $9
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES

      * Your    mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
ED K+10                                                      $9
KAON CL-10                                                   $9
KIONEX                                                       $9
KLOR-CON                                                     $9
KLOR-CON 10                                                  $9
KLOR-CON M20                                                 $9
OSMOPREP                                                    $38
PLASMA-LYTE 148                                             $38           B vs. D
PLASMA-LYTE 56                                              $38           B vs. D
PLASMA-LYTE A                                               $38           B vs. D
potassium chloride                                           $9
sodium polystyrene sulfonate                                 $9
VISICOL                                                     $76
IV NUTRITION
AMINOSYN 5 %                                                $38           B vs. D
AMINOSYN 7 % WITH ELECTROLYTES                              $38           B vs. D
AMINOSYN 8.5 %                                              $38           B vs. D
AMINOSYN II 15%                                             $38           B vs. D
AMINOSYN II 3.5 %-DEXTROSE 25%                              $38           B vs. D
AMINOSYN II 3.5% M/DEXTROSE 5%                              $38           B vs. D
AMINOSYN II 3.5%-LYTES-CA-D25W                              $38           B vs. D
AMINOSYN II 4.25%/DEXTROSE 20%                              $38           B vs. D
AMINOSYN II 4.25%-DEXTROSE 10%                              $38           B vs. D
AMINOSYN II 4.25%-DEXTROSE 25%                              $38           B vs. D
AMINOSYN II 4.25%-LYTES-CA-D25                              $38           B vs. D
AMINOSYN II 5%/DEXTROSE 25%                                 $38           B vs. D
AMINOSYN II 8.5 %-ELECTROLYTES                               $9           B vs. D
AMINOSYN-HBC 7%                                             $38           B vs. D
AMINOSYN-HF 8 %                                              $9           B vs. D
AMINOSYN-PF 10 %                                            $38           B vs. D

      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
CLINIMIX 2.75%/D5 SULFITE FREE                              $38           B vs. D
CLINIMIX 4.25%/D5 SULFITE FREE                              $38           B vs. D
CLINIMIX 5%/D15 SULFITE FREE                                $38           B vs. D
CLINIMIX 5%/D20 SULFITE FREE                                $38           B vs. D
CLINIMIX 5%/D25 SULFITE FREE                                $38           B vs. D
INTRALIPID                                                   $9           B vs. D
ISOLYTE-H IN D5W                                            $38           B vs. D
ISOLYTE-P IN D5W                                            $38           B vs. D
ISOLYTE-S                                                   $38           B vs. D
ISOLYTE-S IN D5W                                            $38           B vs. D
NEPHRAMINE 5.4 %                                            $38           B vs. D
NORMOSOL-M IN D5W                                            $9           B vs. D
NORMOSOL-R IN D5W                                            $9           B vs. D
NORMOSOL-R PH 7.4                                           $38           B vs. D
PLASMA-LYTE 148 IN D5W                                      $38           B vs. D
PLASMA-LYTE-56 IN D5W                                       $38           B vs. D
PREMASOL 6 %                                                 $9           B vs. D
PROCALAMINE 3%                                              $38           B vs. D
IV REPLACEMENT SOLUTIONS
½ ns with potassium chloride                                 $9
d10 %-0.45 % sodium chloride                                 $9
d10-1/4ns & potassium chloride                               $9
d2.5 %-0.45 % sodium chloride                                $9
d5 %-0.45 % sodium chloride                                  $9
d5 %-0.9 % sodium chloride                                   $9
d5-1/2 ns & potassium chloride                               $9
d5-1/3 ns & potassium chloride                               $9
d5-1/4 ns & potassium chloride                               $9
d5-lr with potassium chloride                                $9
d5-ns with potassium chloride                                $9

      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
d5w with potassium chloride                                   $9
dextrose 10% in water (d10w)                                  $9
dextrose 5% in water (d5w)                                    $9
dextrose 5%-0.3 % sod.chloride                                $9
dextrose 5%-1/4 normal saline                                 $9
lactated ringers                                              $9
ns with potassium chloride                                    $9
sodium chloride                                               $9
sodium chloride 0.45 %                                        $9
sodium chloride 0.9 %                                         $9
sodium chloride 3 %                                           $9
sodium chloride 5 %                                           $9
VITAMINS
calcitriol                                                    $9
calcium acetate                                               $9
PRENATABS OBN                                                 $9
OPHTHALMIC
ANTICHOLINERGICS
MYDRAL                                                        $9
tropicamide                                                   $9
BETA-BLOCKERS – OPHTHALMIC
BETOPTIC S                                                   $38
carteolol                                                     $9
levobunolol                                                   $9
metipranolol                                                  $9
BETA-BLOCKERS – OPHTHALMIC COMBINATIONS
COMBIGAN                                                     $38
dorzolamide-timolol                                           $9
OPHTHALMIC ADRENERGIC AGENTS
ALPHAGAN P                                                   $76

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
apraclonidine                                                 $9
brimonidine                                                   $9
OPHTHALMIC AGENTS, OTHERS
LACRISERT                                                    $38
NATACYN                                                      $38
PILOPINE HS                                                  $38
RESTASIS                                                     $38           PA
trifluridine                                                  $9
OPHTHALMIC ANTIALLERGIC
ALOCRIL                                                      $76
ALOMIDE                                                      $76
ALREX                                                        $38
azelastine                                                    $9           QL (18 ML per 90 day(s))
cromolyn                                                      $9
OPHTHALMIC ANTIBACTERIALS
AK-TOB                                                        $9
AZASITE                                                      $76
bacitracin-polymyxin b                                        $9
CILOXAN                                                      $38
dexamethasone sodium phosphate                                $9
DEXASPORIN                                                    $9
erythromycin                                                  $9
GENTAK                                                        $9
GENTASOL                                                      $9
neomycin-bacitracin-poly-hc                                   $9
neomycin-bacitracin-polymyxin                                 $9
neomycin-polymyxin-dexameth                                   $9
neomycin-polymyxin-gramicidin                                 $9
POLYCIN B                                                     $9
POLY-DEX                                                      $9

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                              Copayment          Requirements/ Limits
QUIXIN                                                      $76
ROMYCIN                                                      $9
sulfacetamide sodium                                         $9
tobramycin sulfate                                           $9
tobramycin-dexamethasone                                     $9
TOBRASOL                                                     $9
TOBREX                                                      $38
trimethoprim-polymyxin b                                     $9
VIGAMOX                                                     $38
ZYMAR                                                       $76
OPHTHALMIC ANTI-INFLAMMATORY AGENTS
BLEPHAMIDE S.O.P.                                            $9
fluorometholone                                              $9
flurbiprofen sodium                                          $9
FML FORTE                                                   $38
FML S.O.P.                                                  $38
LOTEMAX                                                     $76
NEVANAC                                                     $38
PRED MILD                                                   $76
prednisolone acetate                                         $9
sulfacetamide-prednisolone                                   $9
OPHTHALMIC CARBONIC ANHYDRASE INHIBITORS
AZOPT                                                       $38
dorzolamide                                                  $9
methazolamide                                                $9
OPHTHALMIC DECONGESTANTS
AK-CON                                                       $9
naphazoline                                                  $9
PROSTAGLANDINS – OPHTHALMIC
LUMIGAN                                                     $76           QL (15 ML per 90 day(s))

      * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
TRAVATAN Z                                                   $38           QL (15 ML per 90 day(s))
XALATAN                                                      $38           QL (15 ML per 90 day(s))
OTIC
OTIC ANTI-INFECTIVES
acetic acid                                                   $9
BOROFAIR                                                      $9
OTIC STEROID-ANTI-INFECTIVE COMBINATIONS
ACETASOL HC                                                   $9
CIPRO HC                                                     $38
CIPRODEX                                                     $38
CORTOMYCIN                                                    $9
hydrocortisone-acetic acid                                    $9
neomycin-polymyxin-hc                                         $9
RESPIRATORY
ALPHA 1 PROTEINASE INHIBITOR
PROLASTIN                                                    25%           PA
ZEMAIRA                                                      25%           PA
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
COMBIVENT                                                    $38           QL (90 GM per 90 day(s))
ipratropium-albuterol                                         $9           B vs. D; QL (1620 ML per 90
                                                                           day(s))
ANTICHOLINERGICS
ATROVENT HFA                                                 $38           QL (90 GM per 90 day(s))
ipratropium bromide inhl                                      $9           B vs. D; QL (900 ML per 90
                                                                           day(s))
ipratropium bromide nasl                                      $9
SPIRIVA WITH HANDIHALER                                      $38           QL (90 EA per 90 day(s))
ANTIHISTAMINES
carbinoxamine maleate                                         $9
cetirizine                                                    $9           QL (900 ML per 90 day(s))
clemastine                                                    $9

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
fexofenadine tab 30 mg, 60 mg                                $76           QL (180 EA per 90 day(s))
fexofenadine tab 180 mg                                      $76           QL (90 EA per 90 day(s))
BETA AGONISTS
albuterol sulfate inhl ,                                      $9           B vs. D
albuterol sulfate oral                                        $9
BROVANA                                                      $76           B vs. D; QL (360 ML per 90
                                                                           day(s))
FORADIL AEROLIZER                                            $38           QL (180 EA per 90 day(s))
levalbuterol hcl                                              $9           B vs. D
metaproterenol                                                $9
PROAIR HFA                                                   $38
SEREVENT DISKUS                                              $38           QL (180 EA per 90 day(s))
terbutaline                                                   $9
VENTOLIN HFA                                                 $38
XOPENEX                                                      $76           B vs. D
XOPENEX HFA                                                  $76
LEUKOTRIENE RECEPTOR ANTAGONISTS
ACCOLATE                                                     $76           QL (180 EA per 90 day(s))
SINGULAIR                                                    $38           QL (90 EA per 90 day(s))
LEUKOTRIENE SYNTHESIS INHIBITORS
ZYFLO CR                                                     $38           QL (360 EA per 90 day(s))
MAST CELL STABILIZERS
GASTROCROM                                                   $38
MISCELLANEOUS
acetylcysteine                                                $9           B vs. D
EPIPEN                                                       $38           QL (2 EA per 1 day(s))
EPIPEN JR                                                    $38           QL (2 EA per 1 day(s))
PULMOZYME                                                    25%           B vs. D; QL (450 ML per 90
                                                                           day(s))
TOBI                                                         25%           B vs. D; QL (280 ML per 50
                                                                           day(s))

       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Drug Name                                               Copayment          Requirements/ Limits
TYZINE                                                        $9
NASAL STEROIDS
flunisolide                                                   $9           QL (200 ML per 90 day(s))
NASONEX                                                      $38           ST; QL (102 GM per 90 day(s))
STEROID INHALANTS
ASMANEX TWISTHALER                                           $38           QL (3 GM per 90 day(s))
budesonide                                                    $9           B vs. D; QL (360 ML per 90
                                                                           day(s))
FLOVENT DISKUS                                               $38           QL (720 EA per 90 day(s))
FLOVENT HFA                                                  $38           QL (78 GM per 90 day(s))
PULMICORT FLEXHALER                                          $76           QL (6 EA per 90 day(s))
QVAR                                                         $76           QL (64 GM per 90 day(s))
VERAMYST                                                     $38           QL (30 GM per 90 day(s))
STEROID/BETA-AGONIST COMBINATIONS
ADVAIR DISKUS                                                $38           QL (180 EA per 90 day(s))
ADVAIR HFA                                                   $38           QL (36 GM per 90 day(s))
SYMBICORT                                                    $38           QL (33 GM per 90 day(s))
XANTHINES
aminophylline                                                 $9
ELIXOPHYLLIN                                                 $38
THEO-24                                                       $9
THEOCHRON                                                     $9
theophylline                                                  $9
TUMOR LYSIS SYNDROME
URATE OXIDASE ENZYME
ELITEK                                                       25%




       * Your   mail order copay for a 90 day supply of this drug would be $13.50
Index

1/2 NS with potassium chloride                     Alphagan P ........................... 58          amoxapine .............................11
   ...........................................57   Alrex ..................................... 59     amoxicillin ............................13
8-Mop....................................36        Altabax ................................. 34       amoxicillin-pot clavulanate...13
Abelcet ..................................12       amantadine............................ 23          Amphetamine Salt Combo....30
Abilify ...................................23      AmBisome............................ 12            amphotericin b ......................12
Abilify Discmelt....................24             amcinonide ........................... 35          ampicillin ..............................13
acarbose.................................37        A-Methapred......................... 44            ampicillin sodium..................13
Accolate ................................62        amifostine crystalline............ 11              ampicillin-sulbactam.............13
acebutolol ..............................27        amikacin ............................... 12        Anadrol-50 ............................40
acetaminophen-codeine...........8                  amiloride............................... 28        anagrelide..............................52
Acetasol HC ..........................61           amiloride-hydrochlorothiazide                      Ancobon................................12
acetazolamide........................28               .......................................... 28   Androderm ............................40
acetic acid..............................61        aminophylline ....................... 63           Android .................................40
acetylcysteine ........................62          Aminosyn 5 % ...................... 56             Antabuse ...............................11
ActHIB ..................................54        Aminosyn 7 % with                                  Apidra ...................................38
Acticin...................................37         Electrolytes ....................... 56          APOKYN ..............................23
Actimmune............................53            Aminosyn 8.5 % ................... 56              apraclonidine.........................59
Actonel ............................40, 41         Aminosyn II 15% ................. 56               Apri .......................................41
Actoplus MET.......................37              Aminosyn II 3.5 %-Dextrose                         Aptivus..................................13
Actoplus Met XR ..................37                 25%................................... 56        Aranelle (28) .........................41
Actos .....................................40      Aminosyn II 3.5% M/Dextrose                        Aranesp (polysorbate)...........51
acyclovir................................15          5%..................................... 56       Arcalyst .................................53
acyclovir sodium ...................15             Aminosyn II 3.5%-Lytes-Ca-                         Aricept...................................32
Adacel (Adolescent & Adult)54                        D25W ............................... 56          Aricept ODT .........................32
Adagen ..................................43        Aminosyn II 4.25%/Dextrose                         Arimidex ...............................19
Adcirca ..................................30         20%................................... 56        Arixtra ...................................50
Advair Diskus .......................63            Aminosyn II 4.25%-Dextrose                         Aromasin...............................19
Advair HFA...........................63              10%................................... 56        Asacol ...................................48
Advicor..................................29        Aminosyn II 4.25%-Dextrose                         Asacol HD.............................48
Afeditab CR ..........................28             25%................................... 56        Ascomp w/Codeine.................8
Afinitor..................................21       Aminosyn II 4.25%-Lytes-Ca-                        Asmanex Twisthaler .............63
Aggrenox...............................52            D25 ................................... 56       Atamet...................................23
AK-Con.................................60          Aminosyn II 5%/Dextrose 25%                        atenolol..................................27
AK-Tob .................................59            .......................................... 56   atenolol-chlorthalidone .........27
Ala-Cort ................................35        Aminosyn II 8.5 %-Electrolytes                     Atgam....................................53
Albenza .................................17           .......................................... 56   ATRIPLA..............................13
albuterol sulfate.....................62           Aminosyn-HBC 7%.............. 56                   Atrovent HFA .......................61
alclometasone........................35            Aminosyn-HF 8 %................ 56                 Attenuvax (PF)......................54
alcohol swabs ........................39           Aminosyn-PF 10 % .............. 56                 Avalide..................................26
Aldactazide............................28          amiodarone ........................... 26          Avapro...................................26
alendronate ............................41         Amitiza ................................. 48       AVASTIN .............................22
Alimta....................................20       amitriptyline ......................... 11         Avelox...................................17
Alinia.....................................13      amitriptyline-chlordiazepoxide                     Avelox ABC Pack.................17
allopurinol ...............................7          .......................................... 11   Avelox in NaCl (iso-osmotic)
allopurinol sodium ..................7             amlodipine ............................ 28            ...........................................17
Alocril ...................................59      amlodipine-benazepril .......... 25                Aviane ...................................41
Alomide.................................59         ammonium lactate ................ 36               Avinza .....................................7
Alora......................................44      Amnesteem ........................... 34           Avodart .................................50
Avonex ..................................33        Budeprion SR ....................... 10            cefuroxime axetil ..................16
Avonex Administration Pack 33                      Budeprion XL....................... 10             cefuroxime sodium................16
Azactam ................................15         budesonide............................ 63          Celebrex ..................................7
Azactam-iso-osmotic dextrose                       bumetanide ........................... 28          CellCept ................................54
   ...........................................16   Buphenyl............................... 43         Celontin.................................31
Azasan...................................53        buprenorphine......................... 8           Cenestin.................................44
Azasite...................................59       bupropion HCl ...................... 10            cephalexin .............................16
azathioprine...........................53          buspirone .............................. 10        Cerezyme ..............................43
azathioprine sodium ..............54               Busulfex................................ 20        Cervarix.................................54
azelastine...............................59        butorphanol tartrate ................ 8            Cesia......................................41
AZILECT ..............................23           Byetta.................................... 38      cetirizine................................61
azithromycin..........................17           cabergoline ........................... 45         Chantix............................11, 12
Azopt.....................................60       calcipotriene ......................... 35         chlorhexidine gluconate ........34
Azor.......................................27      calcitonin (salmon) ............... 41             chloroquine phosphate ..........13
Baci-IM .................................17        calcitriol................................ 58      chlorothiazide........................28
bacitracin...............................17        calcium acetate ..................... 58           chlorpromazine .....................24
bacitracin-polymyxin B.........59                  Camila................................... 41       chlorpropamide .....................39
baclofen.................................33        Campath................................ 22         chlorthalidone .......................28
Bactroban ..............................34         Campral Dose Pak ................ 11               Cholestyramine Light............29
balsalazide.............................48         Canasa................................... 48       ciclopirox ..............................35
Balziva (28)...........................41          Cancidas ............................... 12        cilostazol ...............................52
Banzel....................................31       Capastat ................................ 14       Ciloxan..................................59
Baraclude ..............................15         captopril................................ 25       Cipro .....................................17
benazepril ..............................25        captopril-hydrochlorothiazide                      Cipro HC...............................61
benazepril-hydrochlorothiazide                        .......................................... 25   CIPRODEX...........................61
   ...........................................25   Carac..................................... 34      ciprofloxacin .........................17
benztropine............................23          Carafate................................. 48       Ciprofloxacin ER ..................17
betamethasone dipropionate..35                     carbamazepine ...................... 31            cisplatin .................................19
betamethasone valerate .........35                 Carbatrol ............................... 31       citalopram .............................10
betamethasone, augmented ...35                     carbidopa-levodopa .............. 23               cladribine...............................20
Betaseron...............................33         carbinoxamine maleate......... 61                  Claravis .................................34
Beta-Val ................................35        carboplatin ............................ 19        clarithromycin .......................17
betaxolol................................27        Carimune NF Nanofiltered ... 52                    Clarithromycin ER ................17
bethanechol chloride .............49               carteolol ................................ 58      clemastine .............................61
Betoptic S..............................58         Cartia XT .............................. 28        Cleocin ..................................17
bicalutamide ..........................19          carvedilol .............................. 27       Climara Pro ...........................44
BiCNU ..................................20         CeeNU .................................. 22        clindamycin HCl ...................17
BiDil......................................30      cefaclor ................................. 16      clindamycin phosphate..........17
bisoprolol fumarate ...............27              cefadroxil.............................. 16        clindamycin-benzoyl peroxide
bisoprolol-hydrochlorothiazide                     cefazolin ............................... 16          ...........................................34
   ...........................................27   cefazolin in dextrose (iso-os) 16                  Clindesse ...............................50
bleomycin..............................40          cefdinir.................................. 16      Clinimix 2.75%/D5 Sulfite Free
Blephamide S.O.P. ................60               cefepime ............................... 16           ...........................................57
Boniva ...................................41       cefotaxime ............................ 16         Clinimix 4.25%/D5 Sulfite Free
BOOSTRIX...........................54              cefotetan ............................... 16          ...........................................57
Borofair .................................61       cefoxitin................................ 16       Clinimix 5%/D15 Sulfite Free
Brevicon (28) ........................41           cefpodoxime ......................... 16              ...........................................57
brimonidine ...........................59          cefprozil................................ 16       Clinimix 5%/D20 Sulfite Free
bromocriptine ........................23           ceftriaxone ............................ 16           ...........................................57
Brovana .................................62        ceftriaxone in dextrose,iso-os16
Clinimix 5%/D25 Sulfite Free                       D10 %-0.45 % sodium chloride                       dextrose 5%-0.3 % sod.chloride
   ...........................................57      .......................................... 57      ...........................................58
clobetasol ..............................35        D10-1/4NS & potassium                              dextrose 5%-1/4 normal saline
clobetasol-emollient ..............35                chloride ............................. 57           ...........................................58
clomipramine ........................11            D2.5 %-0.45 % sodium                               diclofenac potassium...............7
clonidine................................26          chloride ............................. 57        diclofenac sodium ...................8
clotrimazole...........................12          D5 %-0.45 % sodium chloride                        dicloxacillin...........................18
clotrimazole-betamethasone..35                        .......................................... 57   dicyclomine...........................47
clozapine ...............................24        D5 %-0.9 % sodium chloride 57                      didanosine .............................13
Clozaril..................................24       D5-1/2 NS & potassium                              diflorasone.............................36
Coartem.................................13           chloride ............................. 57        diflunisal .................................8
cod-butalbital-acetaminop-caf 7                    D5-1/3 NS & potassium                              digoxin ..................................28
Co-Gesic..................................8          chloride ............................. 57        dihydroergotamine ................33
colchicine-probenecid .............7               D5-1/4 NS & potassium                              Dilantin Extended .................31
Colcrys ....................................7        chloride ............................. 57        Dilantin Infatabs....................31
colestipol ...............................29       D5-LR with potassium chloride                      Dilantin-125 ..........................31
colistimethate sodium ...........17                   .......................................... 57   diltiazem HCl ........................28
Colocort.................................48        D5-NS with potassium chloride                      DILT-XR...............................28
Combigan ..............................58             .......................................... 57   Diovan...................................26
CombiPatch...........................44            D5W with potassium chloride                        Diovan HCT..........................26
Combivent.............................61              .......................................... 58   Dipentum...............................48
Combivir ...............................13         dacarbazine ........................... 20         dipyridamole .........................52
Compro .................................47         danazol.................................. 43       disopyramide.........................26
Comtan ..................................23        dantrolene ............................. 33        divalproex .............................31
Comvax .................................54         dapsone ................................. 18       dorzolamide...........................60
Condylox...............................36          Daptacel (Pediatric) (PF)...... 54                 dorzolamide-timolol..............58
Constulose.............................48          Daraprim............................... 13         Dovonex................................35
Copaxone ..............................33          daunorubicin ......................... 20          doxazosin ..............................26
Cortenema .............................48          DECAVAC........................... 54              doxepin..................................11
cortisone ................................44       demeclocycline ..................... 19            Doxil .....................................20
Cortomycin............................61           Denavir ................................. 35       doxorubicin ...........................20
Cosmegen..............................20           Depade.................................. 11        doxycycline hyclate ..............19
Coumadin ..............................50          Depo-SubQ provera 104....... 46                    doxycycline monohydrate .....19
Creon.....................................43       desipramine........................... 11          dronabinol .............................47
Crixivan.................................13        desmopressin ........................ 52           DUETACT ............................40
cromolyn ...............................59         desonide................................ 36        Duramorph ..............................9
Cryselle (28)..........................41          desoximetasone..................... 36             E.E.S. 400 .............................16
CUBICIN ..............................17           Detrol.................................... 49      econazole...............................35
Cuprimine..............................53          Detrol LA.............................. 49         ED K+10 ...............................56
Curity Gauze .........................39           dexamethasone ..................... 45             Effexor XR............................11
cyclophosphamide.................22                Dexamethasone Intensol....... 45                   Effient ...................................52
cyclosporine ..........................54          dexamethasone sodium                               Elestrin ..................................44
cyclosporine modified...........54                   phosphate.......................... 59           Elidel .....................................36
Cyklokapron..........................51            Dexasporin............................ 59          Elitek .....................................63
Cymbalta ...............................10         dexmethylphenidate.............. 30                Elixophyllin...........................63
Cystadane ..............................43         dexrazoxane.......................... 22           Elmiron .................................49
Cystagon ...............................43         dextroamphetamine .............. 30                Eloxatin .................................19
cytarabine ..............................20        dextrose 10% in water (D10W)                       Emcyt ....................................22
cytarabine (PF)......................20               .......................................... 58   Emend ...................................47
                                                   dextrose 5% in water (D5W) 58                      Emsam...................................10
Emtriva..................................13        Fabrazyme ............................ 43          fosinopril-hydrochlorothiazide
Enablex..................................49        famciclovir............................ 15            ...........................................25
enalapril maleate ...................25            famotidine............................. 47         FOSRENOL..........................46
enalapril-hydrochlorothiazide                      famotidine (PF)..................... 47            Furadantin .............................18
   ...........................................25   Fanapt ................................... 24      furosemide.............................28
Enbrel ....................................53      Fareston ................................ 19       Fuzeon...................................13
Endocet....................................9       Faslodex................................ 19        gabapentin .............................31
Engerix-B (PF)......................54             FazaClo................................. 24        Gabitril ..................................31
Enjuvia ..................................44       Felbatol ................................. 31      galantamine ...........................32
Enpresse ................................41        felodipine.............................. 28        GamaSTAN S/D ...................52
Entocort EC...........................48           Femara .................................. 19       Gammagard Liquid ...............52
Enulose..................................48        Femhrt 1/5 ............................ 41         Gamunex ...............................52
EpiPen ...................................62       Femhrt Low Dose ................. 41               ganciclovir.............................15
EpiPen Jr ...............................62        Femring................................. 44        GARDASIL ..........................54
epirubicin ..............................20        fenofibrate micronized.......... 29                Gastrocrom............................62
Epitol.....................................31      fenoprofen............................... 8        gemfibrozil............................29
Epivir.....................................13      fentanyl ................................... 9     Gemzar ..................................20
Epivir HBV ...........................15           fexofenadine ......................... 62          Generlac ................................48
eplerenone .............................25         Finacea.................................. 37       Gengraf .................................54
Epogen ..................................51        finasteride ............................. 49       Gentak ...................................59
Epzicom ................................13         flecainide .............................. 26       gentamicin.............................12
ergoloid .................................33       Flector..................................... 8     gentamicin in NaCl (iso-osm)
ergotamine-caffeine ..............33               Flovent Diskus...................... 63               ...........................................12
Errin ......................................41     Flovent HFA......................... 63            gentamicin sulfate (PF) .........13
Ery Pads ................................34        fluconazole ........................... 12         Gentasol ................................59
Erythrocin..............................16         fluconazole in dextrose(iso-o)                     Geodon..................................24
Erythrocin Stearate................16                 .......................................... 12   Gleevec .................................21
erythromycin .........................59           fludarabine............................ 20         glimepiride ............................39
erythromycin with ethanol ....34                   fludrocortisone...................... 52           glipizide.................................39
erythromycin-benzoyl peroxide                      flunisolide ............................. 63       glipizide-metformin ..............39
   ...........................................34   fluocinolone.......................... 36          Glucagon Emergency............45
erythromycin-sulfisoxazole...17                    fluocinonide.......................... 36          glyburide ...............................39
Estrace...................................44       fluocinonide-emollient ......... 36                glyburide micronized ............40
Estraderm ..............................44         fluorometholone ................... 60             glyburide-metformin .............39
estradiol.................................44       fluorouracil ........................... 20        glycopyrrolate .......................47
estradiol valerate ...................44           fluoxetine.............................. 10        Glycron .................................40
estradiol-norethindrone acet..44                   fluphenazine decanoate ........ 24                 Glyset ....................................37
Estring ...................................44      fluphenazine HCl.................. 24              granisetron.............................47
estropipate .............................44        flurbiprofen............................. 8        granisetron (PF) ....................47
ethambutol.............................14          flurbiprofen sodium .............. 60              Granisol.................................47
ethosuximide .........................31           flutamide............................... 19        griseofulvin microsize...........12
etidronate disodium...............41               fluticasone............................. 36        Gris-PEG...............................12
etodolac ...................................8      fluvoxamine.......................... 10           guanabenz .............................26
etoposide ...............................20        FML Forte ............................ 60          guanfacine .............................26
Eurax .....................................37      FML S.O.P............................ 60           guanidine...............................19
Evista.....................................46      fomepizole ............................ 11         HalfLytely-Bisacodyl Bowel
Exelon ...................................32       Foradil Aerolizer .................. 62               Kit .....................................48
Exforge..................................27        Forteo.................................... 46      halobetasol propionate ..........36
Exforge HCT.........................28             FORTICAL........................... 41             haloperidol ............................24
Exjade....................................41       fosinopril............................... 25       haloperidol decanoate ...........24
haloperidol lactate .................24            Insulin Pen Needle................ 39            labetalol.................................27
Havrix (PF) ...........................54          insulin syringe-needle U-100 39                  Lacrisert ................................59
Hectorol.................................55        Intelence ............................... 14     lactated ringers ......................58
heparin (porcine) ...................50            Intralipid ............................... 57    lactulose ................................48
heparin (porcine) in D5W .....50                   Intron A ................................ 53     Lamictal ODT .......................31
heparin (porcine) in NS (PF).50                    Invanz ................................... 18    Lamictal Starter (Blue) Kit ...31
heparin (porcine)-0.45% NaCl                       Invega ................................... 24    Lamictal XR..........................31
   ...........................................50   Invega Sustenna.................... 24           Lamictal XR Starter (Blue) ...31
heparin, porcine (PF).............50               Invirase ................................. 14    Lamictal XR Starter (Green).31
Hepsera..................................15        IPOL ..................................... 54    Lamictal XR Starter (Orange)
Hexalen .................................22        ipratropium bromide............. 61                 ...........................................31
Humalog................................38          ipratropium-albuterol............ 61             lamotrigine ............................31
Humalog Mix 50-50..............38                  IRESSA ................................ 21       lansoprazole ..........................49
Humalog Mix 75-25..............38                  irinotecan .............................. 21     Lantus....................................38
Humalog Pen.........................38             Isentress ................................ 14    Lantus Solostar......................38
Humira ..................................53        Isolyte-H in D5W ................. 57            Leena 28................................42
Humira Crohn's Dis Start Pck                       Isolyte-P in D5W.................. 57            leflunomide ...........................53
   ...........................................53   Isolyte-S................................ 57     Lessina ..................................42
Humulin 70/30 ......................38             Isolyte-S in D5W.................. 57            Letairis ..................................29
Humulin 70/30 Pen ...............38                IsonaRif ................................ 14     leucovorin calcium................22
Humulin N ............................38           isoniazid................................ 14     Leukeran ...............................22
Humulin N Pen .....................38              isosorbide dinitrate ............... 30          Leukine .................................51
Humulin R.............................38           isosorbide mononitrate ......... 30              leuprolide ..............................19
Humulin R U-500..................38                isradipine .............................. 28     levalbuterol HCl....................62
hydralazine ............................30         itraconazole........................... 12       Levemir .................................38
hydrochlorothiazide ..............28               Jantoven................................ 50      Levemir Flexpen ...................38
hydrocodone-acetaminophen ..9                      Janumet................................. 38      levetiracetam .........................31
hydrocodone-ibuprofen...........9                  Januvia.................................. 38     levobunolol ...........................58
hydrocortisone.......................36            Je-Vax................................... 54     levocarnitine..........................55
hydrocortisone butyrate.........36                 Jolivette................................. 41    Levora-28..............................42
hydrocortisone valerate .........36                Junel 1.5/30 (21)................... 42          levorphanol tartrate .................9
hydrocortisone-acetic acid ....61                  Junel 1/20 (21)...................... 42         Levothroid.............................46
hydromorphone .......................9             Junel FE 1.5/30 (28) ............. 42            levothyroxine ........................46
hydromorphone (PF) ...............9                Junel FE 1/20 (28) ................ 42           Levoxyl .................................46
hydroxychloroquine ..............13                Kaletra .................................. 14    Lexapro .................................10
hydroxyurea ..........................22           Kaon Cl-10 ........................... 56        Lexiva ...................................14
ibuprofen .................................8       Kariva ................................... 42    Lialda ....................................48
ibuprofen-oxycodone ..............9                Kelnor 1/35 (28) ................... 42          lidocaine (PF)........................10
idarubicin ..............................20        Keppra .................................. 31     lidocaine HCl ........................10
ifosfamide..............................20         Keppra XR............................ 31         lidocaine-prilocaine...............36
ifosfamide-mesna ..................22              ketoconazole ......................... 12        Lidoderm...............................36
imipramine HCl.....................11              ketoprofen............................... 8      Lincocin ................................18
imiquimod .............................36          ketorolac ................................. 8    lindane...................................37
Imovax Rabies Vaccine ........54                   Kineret .................................. 53    liothyronine ...........................46
Increlex..................................45       Kionex .................................. 56     Lipitor ...................................29
indapamide ............................28          Klor-Con............................... 56       Lipofen..................................29
Indocin ....................................8      Klor-Con 10.......................... 56         lisinopril ................................25
indomethacin...........................8           Klor-Con M20 ...................... 56           lisinopril-hydrochlorothiazide
Infanrix (PF)..........................54          Kuric ..................................... 35      ...........................................25
Infergen .................................53       Kuvan ................................... 45     lithium carbonate ..................32
lithium citrate ........................32      Mesnex ................................. 22       mirtazapine............................10
Lodosyn.................................23      Mestinon ............................... 19       misoprostol............................49
Loestrin 24 Fe .......................42        Mestinon Timespan .............. 19               mitomycin .............................21
LoKara ..................................36     metaproterenol...................... 62           mitoxantrone .........................21
loperamide.............................48       metaxalone............................ 33         M-M-R II (PF) ......................55
losartan ..................................26   metformin ............................. 37        moexipril-hydrochlorothiazide
losartan-hydrochlorothiazide 26                 methadone............................... 9          ...........................................25
Lotemax ................................60      Methadose............................... 9        mometasone ..........................36
Lotronex ................................48     methamphetamine................. 30               Mononessa (28).....................42
lovastatin ...............................29    methazolamide...................... 60            morphine .................................9
Lovaza...................................29     methenamine hippurate ........ 18                 morphine (PF) .........................9
Lovenox ..........................50, 51        methimazole ......................... 46          MoviPrep...............................48
Low-Ogestrel (28).................42            methotrexate sodium ............ 21               Multaq ...................................26
loxapine succinate .................24          methotrexate sodium (PF) .... 21                  mupirocin ..............................34
Lumigan ................................60      methscopolamine.................. 47              Mustargen .............................21
Lupron Depot ........................20         methyclothiazide................... 29            Mycamine .............................12
Lupron Depot (3 Month).......20                 methyldopa ........................... 26         Mycobutin .............................14
Lupron Depot (4 Month).......20                 methyldopa-                                       mycophenolate mofetil..........54
Lupron Depot-Ped.................20               hydrochlorothiazide.......... 26                Mydral...................................58
Lutera (28).............................42      Methylin ............................... 33       Mytelase................................19
Lyrica ....................................31   Methylin ER ......................... 33          nabumetone .............................8
Lysodren................................22      methylphenidate ................... 33            nadolol...................................27
Macrodantin ..........................18        methylprednisolone .............. 45              nadolol-bendroflumethiazide 27
Malarone ...............................13      methylprednisolone acetate .. 45                  nafcillin .................................18
malathion...............................37      methylprednisolone sodium                         Naglazyme ............................43
maprotiline ............................10        succ ................................... 45     naloxone................................11
Margesic-H..............................9       metipranolol.......................... 58         naltrexone..............................11
Marplan .................................10     metoclopramide .................... 47            Namenda ...............................32
Matulane................................22      metolazone............................ 29         Namenda Titration Pak .........32
Maxalt-MLT..........................33          metoprolol succinate............. 27              naphazoline ...........................60
Maxipime ..............................16       metoprolol tartrate ................ 27           naproxen..................................8
mebendazole..........................18         metoprolol-hydrochlorothiazide                    naproxen sodium.....................8
meclizine ...............................47       .......................................... 27   Nardil ....................................10
meclofenamate ........................8         metronidazole ....................... 18          Nasonex.................................63
medroxyprogesterone............46               metronidazole in NaCl (iso-os)                    Natacyn .................................59
mefloquine ............................13         .......................................... 18   nateglinide.............................39
Megace ES ............................20        mexiletine ............................. 26       Navane ..................................24
megestrol...............................20      Miacalcin .............................. 41       Necon 0.5/35 (28) .................42
meloxicam...............................8       Miconazole-3........................ 50           Necon 1/35 (28) ....................42
melphalan ..............................21      Microgestin 1.5/30 (21) ........ 42               Necon 10/11 (28) ..................42
Menactra................................54      Microgestin 1/20 (21) ........... 42              Necon 7/7/7 (28) ...................42
Menomune – A/C/Y/W-135                          Microgestin Fe 1.5/30 (28) ... 42                 nefazodone ............................10
   (PF) ...................................55   Microgestin FE 1/20 (28) ..... 42                 neomycin...............................13
Mentax ..................................35     midodrine.............................. 30        neomycin-bacitracin-poly-HC
Mepron ..................................13     Migergot ............................... 33         ...........................................59
mercaptopurine......................22          Minitran ................................ 30      neomycin-bacitracin-
Merrem..................................16      minocycline .......................... 19           polymyxin .........................59
Meruvax II (PF) ....................55          minoxidil............................... 30       neomycin-polymyxin-dexameth
mesalamine............................48        Mirapex................................. 23         ...........................................59
mesna ....................................22    Mirapex ER .......................... 23
neomycin-polymyxin-                                Novolin N InnoLet ............... 38               Oxytrol ..................................50
   gramicidin .........................59          Novolin R ............................. 38         Pacerone................................26
neomycin-polymyxin-HC .....61                      Novolog ................................ 38        paclitaxel ...............................21
Neoral....................................54       Novolog Flexpen .................. 39              pamidronate...........................41
Nephramine 5.4 %.................57                Novolog Mix 70-30 .............. 39                Pancreaze ..............................49
Neulasta.................................51        Novolog Mix 70-30 FlexPen 39                       Panretin .................................22
Neumega ...............................51          Noxafil.................................. 12       PARCOPA ............................23
Neupogen ........................51, 52            NS with potassium chloride.. 58                    paromomycin ........................13
Neurontin ..............................31         NuLYTELY with Flavor Packs                         paroxetine HCl ......................10
Nevanac.................................60            .......................................... 48   Paser......................................14
Nexavar .................................21        Nutropin................................ 45        Pediarix (PF) .........................55
Nexium..................................49         Nutropin AQ......................... 45            Pedi-Dri.................................35
Nexium Packet ......................49             NuvaRing.............................. 42          Pedvax HIB...........................55
Next Choice...........................43           Nuvigil............................ 33, 34         Peganone ...............................31
Niaspan Extended-Release....29                     nystatin ................................. 12      Pegasys Convenience Pack ...53
nicardipine.............................28         nystatin-triamcinolone.......... 35                penicillin G potassium ..........18
Nicotrol .................................12       Nystop................................... 35       penicillin V potassium ..........18
Nicotrol NS ...........................12          Ocella.................................... 42      Pentasa ..................................48
Nifediac CC...........................28           Octagam................................ 52         PentoPAK .............................51
Nifedical XL .........................28           octreotide acetate .................. 45           pentostatin .............................21
nifedipine ..............................28        ofloxacin ............................... 17       pentoxifylline ........................51
Nilandron ..............................20         Ogestrel (28)......................... 42          perindopril erbumine.............25
nimodipine ............................28          omeprazole ........................... 49          Periogard ...............................34
nisoldipine.............................28         Oncaspar ............................... 21        permethrin .............................37
Nitro-Bid ...............................30        ondansetron........................... 47          perphenazine .........................24
Nitro-Dur...............................30         ondansetron HCl................... 47              perphenazine-amitriptyline ...11
nitrofurantoin (macrocryst25%)                     ondansetron HCl (PF)........... 47                 phenytoin...............................31
   ...........................................18   Onglyza................................. 38        phenytoin sodium..................32
nitrofurantoin macrocrystal...18                   Ontak .................................... 21      phenytoin sodium extended ..32
nitroglycerin ..........................30         Orap ...................................... 24     Photofrin ...............................21
Nitrolingual ...........................30         ORENCIA ............................ 53            pilocarpine HCl .....................49
Nitrostat.................................30       Orfadin.................................. 43       Pilopine HS ...........................59
nizatidine...............................48        Ortho Evra ............................ 42         pindolol .................................27
Nora-BE ................................42         Ortho Tri-Cyclen Lo............. 43                piroxicam ................................8
Norditropin Cartridge............45                Ortho-Est 0.625 .................... 44            Plasma-Lyte 148 ...................56
Norditropin Nordiflex ...........45                Ortho-Est 1.25 ...................... 44           Plasma-Lyte 148 in D5W......57
norethindrone acetate ............46               OsmoPrep ............................. 56          Plasma-Lyte 56 .....................56
Normosol-M in D5W ............57                   oxacillin ................................ 18      Plasma-Lyte A ......................56
Normosol-R in D5W.............57                   oxandrolone .......................... 40          Plasma-Lyte-56 in D5W .......57
Normosol-R pH 7.4...............57                 oxaprozin ................................ 8       Plavix ....................................52
Norpace CR...........................26            oxcarbazepine ....................... 31           podofilox ...............................37
Nortrel 0.5/35 (28) ................42             Oxistat................................... 35      Polycin B...............................59
Nortrel 1/35 (21) ...................42            Oxsoralen.............................. 37         Poly-Dex ...............................59
Nortrel 1/35 (28) ...................42            Oxsoralen Ultra .................... 35            polymyxin B sulfate..............18
Nortrel 7/7/7 (28) ..................42            oxybutynin chloride.............. 50               Portia .....................................43
nortriptyline...........................11         oxycodone............................... 9         potassium chloride ................56
Norvir ....................................14      oxycodone HCl-oxycodone-                           potassium citrate ...................49
Novolin 70/30 .......................38               ASA .................................... 9      pramipexole...........................23
Novolin 70/30 InnoLet..........38                  oxycodone-acetaminophen ..... 9                    Prandin ..................................39
Novolin N..............................38          OxyContin .............................. 7         pravastatin .............................29
prazosin .................................26       ProQuad................................ 55         Risperdal Consta ...................24
Pred Mild ..............................60         Protonix ................................ 49       risperidone.............................24
prednicarbate.........................36           Protopic................................. 36       Rituxan..................................22
prednisolone ..........................45          protriptyline .......................... 11        Romycin ................................60
prednisolone acetate..............60               Provigil ................................. 34      ropinirole...............................23
prednisolone sodium phosphate                      Pulmicort Flexhaler .............. 63              RotaTeq Vaccine...................55
   ...........................................45   Pulmozyme ........................... 62           Roxicet ....................................9
prednisone .............................45         Pylera.................................... 49      Sabril .....................................32
Prednisone Intensol ...............45              pyrazinamide ........................ 15           safety needles ........................39
Prefest....................................44      pyridostigmine bromide........ 19                  Samsca ..................................46
Prelone ..................................45       Quasense............................... 43         Sanctura XR ..........................50
Premarin ................................44        quinapril................................ 25       Sancuso .................................47
Premasol 6 % ........................57            quinapril-hydrochlorothiazide                      Sandimmune .........................54
Premphase .............................44             .......................................... 25   Sandostatin LAR Depot ........45
Prempro.................................44         quinidine gluconate .............. 27              Santyl ....................................37
Prenatabs OBN......................58              quinidine sulfate ................... 27           Saphris...................................24
Prevacid SoluTab ..................49              Quixin ................................... 60      selegiline HCl........................23
Prevalite ................................29       Qvar ...................................... 63     Selzentry ...............................14
Previfem ................................43        RabAvert (PF) ...................... 55            Sensipar.................................41
Prevpac..................................49        ramipril ................................. 25      Serevent Diskus ....................62
Prezista ..................................14      Ranexa .................................. 30       Seromycin .............................15
Priftin ....................................14     ranitidine HCl ....................... 48          Seroquel ................................24
primaquine ............................13          Rapaflo ................................. 49       Seroquel XR..........................24
Primaxin IM ..........................16           Rapamune ............................. 54          sertraline................................10
Primaxin IV...........................16           Razadyne .............................. 32         silver sulfadiazine .................34
primidone ..............................32         Rebif ..................................... 33     Simcor ...................................29
Pristiq ....................................11     Rebif Titration Pack ............. 33              simvastatin ............................29
ProAir HFA...........................62            Reclipsen (28)....................... 43           Singulair................................62
probenecid...............................7         Recombivax HB (PF) ........... 55                  sodium chloride.....................58
procainamide.........................27            Regonol................................. 19        sodium chloride 0.45 % ........58
Procalamine 3% ....................57              Regranex............................... 37         sodium chloride 0.9 % ..........58
prochlorperazine....................47             Relistor ................................. 11      sodium chloride 3 % .............58
prochlorperazine Edisylate....47                   Relpax................................... 33       sodium chloride 5 % .............58
prochlorperazine maleate ......47                  Remicade .............................. 53         sodium polystyrene sulfonate56
Procrit....................................52      Renagel ................................. 46       Solaraze.................................34
ProctoCream-HC...................36                Renvela ................................. 46       Solia ......................................43
Procto-Pak.............................36          Rescriptor ............................. 14        Somatuline Depot............45, 46
Proctosol HC .........................36           reserpine ............................... 26       SOMAVERT.........................46
Proctozone-HC......................36              Restasis ................................. 59      Sorine ....................................27
Proglycem .............................45          Retrovir................................. 14       sotalol....................................27
Prograf...................................54       Revatio.................................. 30       Sotret .....................................34
Prolastin ................................61       REVLIMID........................... 22             Spiriva with HandiHaler .......61
Proleukin ...............................21        Reyataz ................................. 14       spironolactone .......................25
Promacta................................52         RibaPak Dose Pack............... 15                spironolacton-hydrochlorothiaz
Prometrium............................46           Ribasphere ............................ 15            ...........................................29
propafenone...........................27           ribavirin ................................ 15      Sprintec (28)..........................43
propranolol ............................27         Ridaura ................................. 53       Sprycel ..................................21
propranolol-hydrochlorothiazid                     rifampin ................................ 15       SSD .......................................34
   ...........................................27   Rilutek .................................. 34      Stagesic ...................................9
propylthiouracil.....................46            rimantadine ........................... 15         Stalevo 100............................23
Stalevo 125............................23          tetanus toxoid,adsorbed (PF) 55                     trihexyphenidyl .....................23
Stalevo 150............................23          tetanus,diphtheria toxd ped-PF                      TriHIBit Preservative Free....55
Stalevo 200............................23              .......................................... 55   TriLyte With Flavor Packets.48
Stalevo 50..............................23         tetanus-diphtheria toxoids-Td55                     trimethoprim .........................18
Stalevo 75..............................23         tetracycline ........................... 19         trimethoprim-polymyxin B ...60
stavudine ...............................14        Thalitone............................... 29         TriNessa (28) ........................43
Strattera .................................33      Thalomid............................... 53          Tripedia (PF) .........................55
Suboxone.................................9         Theo-24................................. 63         Tri-Previfem (28) ..................43
sucralfate ...............................49       Theochron............................. 63           Trisenox ................................40
sulfacetamide sodium............60                 theophylline .......................... 63          Tri-Sprintec (28) ...................43
sulfacetamide-prednisolone ..60                    Thermazene .......................... 35            Trivora (28)...........................43
sulfadiazine ...........................18         thioguanine ........................... 22          Trizivir ..................................14
sulfamethoxazole-trimethoprim                      thioridazine ........................... 24         tropicamide ...........................58
   ...........................................18   thiotepa ................................. 21       Truvada .................................14
sulfasalazine ..........................48         thiothixene ............................ 24         Twinrix (PF)..........................55
Sulfatrim................................18        Thymoglobulin ..................... 53              Tygacil ..................................18
Sulfazine EC .........................48           ticlopidine ............................. 52        Tykerb ...................................21
sulindac ...................................8      Tikosyn ................................. 27        Typhim VI.............................55
sumatriptan succinate............33                Timentin ............................... 19         Tyzeka...................................15
Suprax ...................................16       timolol maleate ..................... 27            Tyzine ...................................63
Surmontil...............................11         Tobi....................................... 62      Uloric ......................................7
Sustiva...................................14       tobramycin sulfate ................ 60              Unithroid ...............................46
Sutent ....................................21      tobramycin-dexamethasone.. 60                       ursodiol .................................49
Symbicort ..............................63         Tobrasol................................ 60         Vagifem.................................44
Symlin ...................................37       Tobrex................................... 60        valacyclovir...........................15
SymlinPen 60 ........................37            tolazamide............................. 40          Valcyte ..................................15
Synarel ..................................43       tolbutamide ........................... 40          valproate sodium...................32
Synthroid...............................46         tolmetin................................... 8       valproic acid..........................32
Syprine ..................................41       topiramate ............................. 32         valproic acid (as sodium salt)32
tacrolimus..............................54         Toposar ................................. 21        Valturna.................................26
Tamiflu..................................15        torsemide .............................. 29         Vancocin ...............................18
tamoxifen ..............................20         Tracleer................................. 29        vancomycin ...........................18
tamsulosin .............................49         tramadol............................ 7, 10          Vandazole .............................50
Tarceva..................................21        tramadol-acetaminophen ...... 10                    Vaqta (PF).............................55
Targretin................................22        trandolapril ........................... 25         Varivax (PF)..........................55
Tarka .....................................25      trandolapril-verapamil .......... 25                VELCADE ............................22
Tasigna ..................................21       tranylcypromine.................... 10              Velivet...................................43
Taxotere ................................21        Travatan Z ............................ 61          venlafaxine............................11
Taztia XT ..............................28         trazodone .............................. 10         Ventolin HFA........................62
Tegretol XR...........................32           Trecator................................. 15        Veramyst ...............................63
Tekturna ................................30        Trelstar.................................. 20       verapamil...............................28
Tekturna HCT .......................30             tretinoin................................. 34       Vesicare.................................50
terazosin ................................26       tretinoin (chemotherapy) ...... 22                  Vfend.....................................12
terbinafine .............................12        triamcinolone acetonide........ 34                  Vfend IV ...............................12
terbutaline..............................62        triamterene-hydrochlorothiazid                      Victoza ..................................38
terconazole ............................50             .......................................... 29   Vidaza ...................................21
Testim....................................40       Tricor .................................... 29      Videx 2 gram Pediatric .........14
testosterone cypionate ...........40               Triderm ................................. 36        Videx EC...............................14
testosterone enanthate ...........40               trifluoperazine....................... 24           Vigamox................................60
Testred...................................40       trifluridine............................. 59        Vimpat...................................32
vinblastine .............................21     Xopenex................................ 62       zolpidem................................32
vincristine..............................21     Xopenex HFA....................... 62            Zometa ..................................41
vinorelbine ............................21      Xyrem ................................... 34     Zonalon .................................35
Viracept.................................14     YAZ 28................................. 43       zonisamide ............................32
Viramune...............................14       YF-Vax ................................. 55      ZOSTAVAX .........................55
Viread....................................14    zaleplon................................. 32     Zosyn in dextrose (iso-osm)..19
Visicol ...................................56   ZAVESCA............................ 44           Zovia 1/35E (28) ...................43
Vivelle-Dot............................44       ZAZOLE............................... 50         Zovia 1/50E (28) ...................43
Voltaren...................................8    Zemaira................................. 61      Zovirax..................................35
Votrient .................................22    Zemplar................................. 55      Zyflo CR ...............................62
Vyvanse.................................31      Zenpep .................................. 44     Zymar ....................................60
warfarin .................................51    Zetia...................................... 29   Zyprexa .................................24
WelChol ................................29      Ziagen ................................... 14    Zyprexa Zydis .......................24
Xalatan ..................................61    zidovudine ............................ 14       Zyvox ....................................18
Xenazine................................34      Zolinza.................................. 22

								
To top