2009 Medicaid Preferred Drug List (List of Covered Drugs) by heapsofluvv

VIEWS: 1,198 PAGES: 18

									                                         Enema, Fleet® Phospho® Soda,           Carbinoxamine*                       Griseofulvin microsize*
     2009 Medicaid
                                         Fibercon®, Metamucil®                     PEDIATEX*                            GRIFULVIN V*,
  Preferred Drug List                                                           Chlorpheniramine* (OTC)              GRIS-PEG
(List of Covered Drugs)                  Mouth and Throat Products                 CHLOR-TRIMETON* (OTC)             Ketoconazole*
                                         Orabase®-B, Cepacol®, Cepastat®,       Clemastine* (OTC)                       NIZORAL*
  Vista Healthplan of                    Baby Orajel®                              TAVIST*                           Nystatin*
  South Florida, Inc                                                            Cyproheptadine*                         MYCOSTATIN*
                                         Pediculicide Products                     PERIACTIN*                        Fluconazole*
 Vista Healthplan, Inc                   Nix®, RID®, A-200® Lice Control,       Diphenhydramine* (OTC)                  DIFLUCAN*
                                         Pin-X®                                    BENADRYL* (OTC)                   Itraconazole*
COMMONLY COVERED OTCs                                                           Dexchlorpheniramine*                    SPORANOX* (PA)
                                         Topical Antifungal Products               POLARAMINE*                       Terbinafine* (QL)
Covered with a written prescription
                                         Lotrimin® AF, Micatin®, Tinactin®,     Hydroxyzine HCI*                        LAMISIL* (QL)
from the provider. Drugs are listed
                                         Lamisil® AT, Fungoid Tincture®,           ATARAX*                           (granules NF)
by brand name for reference only
                                         Nizoral® AD, Mycelex®                  Phenindramine Tartrate*
                                                                                   NOLAHIST*                         Cephalosporins and
This is not a complete list. Brand
                                         Topical Antimicrobial Products         Promethazine*                        Related Antibiotics
name OTCs will not be covered if a
                                         Bacitracin, Hydrogen Peroxide 3%,         PHENERGAN*                        1st Generation
generic is available.
                                         Neosporin®                             Pseudoephedrine* (OTC)               Cephalexin*
                                         Polysporin®                               SUDAFED*                            KEFLEX*
Analgesics
                                                                                Brompheniramine/Pseudoephedrine*     Cefadroxil*
Tylenol®, Bayer®, Ecotrin®, St.
                                         Topical Miscellaneous Products            BROMFED-PD*, BROMFED*               DURICEF*
Joseph’s Baby Aspirin®, Aleve®,
                                         Dr. Smith’s Ointment®, Calamine        Carbinoxamine/Pseudoephedrine*
Motrin® IB, Advil®, Advil Jr.®, Motrin
                                         Lotion USP®, Benadryl®, Moisturel®,       RONDEC*, ANDEHIST NR*             2nd Generation
Child®, Midol®, Tylenol Jr.®,
                                         Cortaid®, Eucerin®, Aquaphor®,         Chlorpheniramine/Pseudoephedrine*    Cefaclor*
Excedrin®, Exedrin Migraine®
                                         Duofilm®, A+D® Ointment, Cortaid,         DECONAMINE*, CHLOR-                 CECLOR*, CECLOR
                                         Abreva®, Benzoyl Peroxide®,            TRIMETON                             CD*
Antacids/Anti-gas Products
                                         AmLactin 12%®, Benzoyl Peroxide®,         DECONGESTANT*                     Cefuroxime Axetil*
Tums®, Maalox®, Mylicon®, Prilosec
                                         Caladryl®, Capsaicin®, Compound        Chlorpheniramine/Carbetapentane*       CEFTIN*
OTC®, Prilosec OTC® Oral
                                         W®, Cortizone-10®, Duofilm®,              TUSSI-12 S*                       Ceprozil*
Suspension, Gaviscon®, Mylanta®,
                                         Pedialyte®, Desitin®                   Chlorpheniramine/Phenylephrine/Me      CEFZIL*
Simethicone®, Zantac®, Pepcid®,
                                                                                thscopolamine*
Pepcid AC®, Pepcid Complete®,
                                         Vaginal Anti-Infectives                   EXTENDRYL*, DURADRYL*             3rd Generation
Tagamet®
                                         Femstat 3®, Gyne-Lotrimin®,            Chlorpheniramine/Phenylephrine/Pyr   Cefdinir*
                                         Monistat®,                             ilamine*                               OMNICEF*
Antidiarrheal Products
                                         Vagistat-1®, Mycelex-3®, Miconazole®      RYNATAN*                          Cefpodoxime*
Pepto-Bismol®, Pedialyte®, Imodium®
                                                                                Dexbrompheniramine/Pseudoephedr        VANTIN* (QL)
A-D, Kaopectate®
                                                                                ine* (OTC)
                                         Vitamin and Mineral Products              DRIXORAL COLD & ALLERGY*          Erythromycins/Macroli
Antihistamines
                                         Prenatal Vitamins, Caltrate 600+D®,    (OTC),                               des
Chlor-Trimeton®, Tavist®, Benadryl®,
                                         Fergon®, Feosol®, Fer-In-Sol®, Os-        Triprolidine/Pseudoephedrine*     Erythromycin Base 250,
Claritin®, Claritin-D®, Triaminic®,
                                         Cal®, Poly-Vi-Sol®,                    (OTC)                                333, and 500mg tabs*
Nolahist®, Dimetapp®, Zyrtec®,
                                         Poly-Vi-Sol® Iron, Citrocal®, ADEKS®      ACTIFED 12 HOUR* (OTC)              ERY-TAB*
Zyrtec-D®
                                                                                                                     Erythromycin Base
                                         Miscellaneous Products                 Second Generation                    Enteric Pellets*
Cough and Cold Products
                                         Condoms (QL 12), Plan B, Ipecac        Azelastine Nasal Spray                 ERYC*
Robitussin®, Robitussin® DM,
                                         Syrup®, Lactinex®, Lactaid®, Neutra-     ASTELIN                            Erythromycin Estolate*
Robitussin®-PE
                                         Phos®, Sodium Chloride®, Nicorette®,   Loratidine* (OTC)                      ILOSONE*
Sudafed®, Nasalcrom®, Drixoral®,
                                         Nicoderm®                                CLARITIN*, ALAVERT* (OTC)          (suspension only)
Coricidin®, Delsym®, Mucinex®
                                                                                Loratidine /Pseudoephedrine*         Erythromycin
                                         0400                                     CLARITIN-D* (OTC) (QL)             Ethylsuccinate*
Eye, Ear, and Nose Products
                                         ANTIHISTAMINES                         Fexofenadine*                          EES* 400 tab, EES*
Isopto® Tears, Tears Naturale®,
                                         &ANTIHISTAMINE/                          ALLEGRA* (QL) (ODT NF)             200, 400 suspension
Debrox®
                                         DECONGESTANT COMBINATIONS              Cetirizine*                          Erythromycin Stearate*
Vasocon®-A, Neo-Synephrine®,
                                         All generic combination cough            ZYRTEC* (OTC) (QL)                   ERYTHROCIN*
Ocean Mist®, Nasalcrom®, Afrin®,
                                         and cold products are on the           Cetirizine/Pseudoephedrine*          Erythromycin
Pediacare®, Saline Mist®, Visine®,
                                         formulary.                               ZYRTEC-D* (OTC) (QL)               w/Sulfisoxazole*
Swim Ear® , Zaditor OTC®
                                         Antihistamines                                                                PEDIAZOLE*
                                         First Generation                                                            Azithromycin*
Stool Softeners
                                         Most 1st generation antihistamines                                            ZITHROMAX* (QL)
Dulcolax®, Surfak®, Dialose®,                                                   0800
                                         (OTC & RX) are covered with written    ANTI-INFECTIVE AGENTS                Clarithromycin*
Colace®
                                         prescription.                                                                 BIAXIN*, BIAXIN XL*
Peri-Colace®, Citrate of Magnesia®,                                             Antifungals
                                         Brompheniramine*                                                            (QL)
Citrucel®, Milk of Magnesia®, Mineral                                           Clotrimazole*
Oil*, Senokot®, Senokot-S®, Fleet®         DIMETANE* (OTC)                        MYCELEX TROCHE*
                                                                                                                               Page 1 of 18
Penicillins                     APTIVUS                                PLAQUENIL*                           ANTINEOPLASTICS
Amoxicillin*                  Darunavir                              Chloroquine*                           COVERAGE OF
  AMOXIL*, TRIMOX*              PREZISTA                               ARALEN* (Not covered for travel      ONCOLOGY/
Ampicillin*                                                          prophylaxis) (PA)                               TRANSPLA
  PRINCIPEN*                  Nucleoside Reverse Transcriptase                                              NT DRUGS
Dicloxacillin*                Inhibitors                             Fluoroquinolones                       All oral antineoplastics
  DYNAPEN*                    Abacavir                               Ofloxacin*                             and
Penicillin VK*                  ZIAGEN                                 FLOXIN* (QL)                         immunosuppressants
  PEN VEE K*, BEEPEN-VK*,     Didanosine                                                                    are covered for FDA-
VEETIDS*                        VIDEX,VIDEX EC                       Quinolones                             approved indications.
Amoxicillin/Clavulanate*      Emtricitabine                          Ciprofloxacin
  AUGMENTIN*, AUGMENTIN ES*     EMTRIVA (QL)                           CIPRO, CIPRO XR (QL)
                              Emtricitabine/Tenofovir disoproxil     Levofloxacin                           Alkylating Agents
Tetracyclines                 fumarate                                 LEVAQUIN (QL)                        Altretamine
Doxycycline*                    TRUVADA                              Moxifloxacin                              HEXALEN
   VIBRAMYCIN*                                                         AVELOX (QL)                          Busulfan
Tetracycline*                 Lamivudine                                                                       MYLERAN
   ACHROMYCIN V* (tabs non-      EPIVIR,EPIVIR HBV                   Sulfonamides                           Chlorambucil
formulary)                    Stavudine                              Sulfisoxazole*                            LUEKERAN
                                 ZERIT, ZERIT XR                       GANTRISIN*                           Cyclophosphamide*
Antituberculosis              Zidovudine*                            Sulfamethoxazole/Trimethoprim*            CYTOXAN*
Ethambutol*                      RETROVIR*                             SEPTRA*, BACTRIM*, BACTRIM           Estramustine Phosphate
  MYAMBUTOL*                  Tenofovir disoproxil fumarate          DS*, SEPTRA DS*                        Sodium
Isoniazid*                       VIREAD                                                                        EMCYT
  ISONIAZID*                  Efavirenz/Emtricitabine/Tenofovir      Sulfones                               Lomustine
Pyrazinamide*                 disoproxil fumarate                    Dapsone*                                  CEENU
  PYRAZINAMIDE*                  ATRIPLA                               DAPSONE*                             Melphalan
Rifampin*                                                                                                      ALKERAN
  RIFADIN*                    Nucleoside Analog Reverse              Urinary Anti-Infectives/Analgesics
                              Transcriptase Inhibitor                Trimethoprim*                          Antimetabolites
Antivirals                    Combinations                             TRIMPEX*                             Capecitabine
Amantadine*                   Abacavir Sulfate / Lamivudine /        Phenazopyridine*                         XELODA (PA)
  SYMMETREL*                  Zidovudine                               PYRIDIUM*                            Mercaptopurine
Acyclovir*                      TRIZIVIR                                                                      PURINETHOL
  ZOVIRAX* (oral only)        Lamivudine / Zidovudine                Methylene Blue/ Benzoic Acid/          Thioguanine*
Ganciclovir*                    COMBIVIR                             Hyoscyamine/ Atropine/                   THIOGUANINE*
  CYTOVENE* (oral only)       Abacavir Sulfate / Lamivudine          Phenylsalicylate/ Methenamine
Famciclovir*                    EPZICOM                                URISED                               Hormones
  FAMVIR* (QL)                                                       Nitrofurantoin*                        Anastrozole
Entecavir                     Non-Nucleoside Reverse                   FURADANTIN*                            ARIMIDEX
  BARACLUDE (QL)              Transcriptase Inhibitors               Nitrofurantoin Macrocrystals*          Bicalutamide
Adefovir Dipivoxil            Delavirdine Mesylate                     MACROBID*, MACRODANTIN*                CASODEX (QL)
  HEPSERA (QL)                  RESCRIPTOR                                                                  Dietheylstilbestrol
Zanamir                       Efavirenz                              Miscellaneous                          Diphosphate*
  TAMIFLU (QL)                  SUSTIVA                              Neomycin*                                STILPHOSTROL*
                              Nevirapine                                NEOMYCIN*                           Exemestane
Antiretroviral Agents           VIRAMUNE                             Metronidazole*                           AROMASIN
Amprenavir                    Etravirine                                FLAGYL *(Flagyl ER non-             Flutamide*
  AGENERASE                     INTELENCE                            formulary)                               EULEXIN*
Fosamprenavir                                                        Acetic Acid                            Letrozole
  LEXIVA                      Fusion Inhibitors                         ACI-JEL Vaginal Gel                   FEMARA
Indinavir Sulfate             Enfuvirtide                            Sodium Borate, Boric Acid              Megestrol Acetate*
  CRIXIVAN                      FUZEON INJECTABLE (PA)                  TRIMO-SAN GEL (OTC)                   MEGACE*
Nelfinavir Mesylate                                                  Mebendazole*                           Nilutamide
  VIRACEPT                    Integrase Strand Transfer Inhibitors      VERMOX*                               NILANDRON
Ritonavir                     Raltegravir                            Clindamycin*                           Tamoxifen Citrate*
  NORVIR                         ISENTRESS (PA)                         CLEOCIN*                              TAMOXIFEN*,
Saquinavir                                                           Vancomycin                             NOLVADEX*,
  INVIRASE                    Antimalarials                             VANCOCIN                            SOLTAMOX
Atazanavir Sulfate            Primaquine*                            Tobramycin (solution for inhalation)   Testolactone
  REYATAZ                       PRIMAQUINE*                             TOBI                                  TESLAC
Lopinavir / Ritonavir         Quinine Sulfate*                       1000
  KALETRA                       QUININE SULFATE*                                                            Toremifene Citrate
Tipranavir                    Hydroxychloroquine*                                                             FARESTON

                                                                                                                      Page 2 of 18
                              SOMA*                                 BENTYL*
Miscellaneous               Carisoprodol/ASA*                     Ergotamine-PB-Belladona*                 Hemorrheologic
Bexarotene                    SOMA Compound*                        BELLERGAL-S*                           Agents
  TARGRETIN                 Methocarbamol*                        Trihexyphenidyl*                         Pentoxifylline*
Dasatinib                     ROBAXIN*                              ARTANE*                                  TRENTAL*
  SPRYCEL                   Baclofen*                             Hyoscyamine*
Erlotinib                     LIORESAL*                             LEVSIN*, LEVSINEX*,                    Iron Preparations
  TARCEVA                   Cyclobenzaprine*                      ANASPAZ*,                                Cyanocobalamin, Folic
Etoposide                     FLEXERIL* (10mg only)                 CYSTOSPAZ*                             Acid, Iron*
  VEPESID                   Chlorzoxazone*                        Propantheline*                              FERREX FORTE*
Hydroxyurea*                  PARAFON, PARAFON FORTE*               PROBANTHINE*
  HYDREA*, DROXIA           Dantrolene*
Imatinib Mesylate             DANTRIUM*                           Adrenergic Agents/Beta-Agonists,
                                                                                                           2400
  GLEEVEC                                                         Oral                                     CARDIOVASCULAR
Levamisole HCI              Smoking Deterrent                     Albuterol* (tablets, syrup)              DRUGS
  ERGAMISOL                 Nicotine gum/lozenge (PA)               PROVENTIL*, VENTOLIN*
                                                                                                           Antihypertensives
Mitotane                    Nicotine patch (PA)                   Metaproterenol* (10mg, 20mg
  LYSODREN                  Varenicline                           tablets)
                                                                                                           Calcium Channel
Nilotinib                    CHANTIX (PA)                           ALUPENT*, METAPREL*
                                                                                                           Blockers
  TASIGNA
                                                                                                           Diltiazem*
Procarbazine HCI                                                  Beta-Agonists/Bronchodilators,
                                                                                                              CARDIZEM*
  MATULANE                  Cholinergic Agents                    Inhaled
                                                                                                           Verapamil*
Sorafenib tosylate          Bethanechol*                          Albuterol* (inhaled, nebulizer soln)
                                                                                                              CALAN* (QL)
  NEXAVAR                     URECHOLINE*                            PROVENTIL*,
                                                                                                           Verapamil* (long-acting
Sunitinib malate            Pyridostigmine*                       ACCUNEB*,PROAIR HFA
                                                                                                           tablet)
  SUTENT                      MESTINON*                           Metaproterenol (inhaler, nebulized
                                                                                                              CALAN-SR,
Temozolomide                Donepezil                             soln)
                                                                                                           VERELAN SR* (QL)
  TEMODAR (PA)                ARICEPT, -ODT                          ALUPENT
                                                                                                           Nifedipine* (sustained-
Tretinoin                                                         Ipratropium* (inhaler, nebulized soln)
                                                                                                           release)
  VESANOID*                 NMDA Receptor Antagonist                 ATROVENT*, ATROVENT HFA
                                                                                                              ADALAT CC*,
Vorinostat                  Memantine                             Salmeterol
                                                                                                           PROCARDIA XL* (QL)
  ZOLINZA                    NAMENDA (QL)                            SEREVENT DISKUS
                                                                                                           Diltiazem* (long-acting
                                                                  Formoterol Fumarate
                                                                                                           capsule)
Immunosuppressives          Miscellaneous Autonomic Agents           FORADIL
                                                                                                              CARDIZEM SR*,
Azathioprine*               Disulfiram*
                                                                                                           CARDIZEM CD*,
  IMURAN*                     ANTABUSE*                           Vasoconstrictors
                                                                                                              CARTIA XT*,
Cyclosporine*                                                     Epinephrine
                                                                                                           DILACOR XR* (QL)
  SANDIMMUNE*, NEORAL       Antispasmodic, Urinary                  EPIPEN, EPIPEN JR,
                                                                                                           Felodipine*
Mycophenolate Mofetil       Oxybutynin*                           ADRENALIN, ANAKIT
                                                                                                              PLENDIL*
  CELLCEPT                    DITROPAN* (XL non-formulary)        Racemic Epinephrine (nebulizer)
                                                                                                           Amlodipine*
Sirolimus                   Flavoxate*                              S2 INH
                                                                                                              NORVASC* (QL)
  RAPAMUNE                    URISPAS*
                                                                                                           Nisoldipine
Tacrolimus
                                                                                                              SULAR (QL)
  PROGRAF                   Drugs for Migraine-Abortive
                                                                  2000                                     Nisoldipine
                            Acetaminophen/Dichloralphenazone/     BLOOD FORMATION &                           SULAR CR (QL)
Immunomodulators            Isometheptene*                        COAGULATION
Thalidomide                   MIDRIN*
                                                                  Coagulants, Anticoagulants, and
  THALOMID (PA)             Ergotamine/Caffeine*
                                                                  Antiplatelets                            Beta Blockers
                              CAFERGOT*,WIGRAINE*
                                                                  Aspirin*                                 Atenolol*
                            Sumatriptan
                                                                    ASPIRIN*                                 TENORMIN*
1200                          IMITREX (QL)
                                                                  Dipyridamole*                            Propranolol*
AUTONOMIC DRUGS             Rizatriptan
                                                                    PERSANTINE*                              INDERAL*, INDERAL
                              MAXALT, MLT (QL)
Antiparkinson Agents                                              Warfarin*                                LA* (QL)
Levodopa/Carbidopa*                                                 COUMADIN*                              Atenolol/Chlorthalidone*
                            Anticholinergics
  SINEMET*, SINEMET CR*                                           Ticlopidine*                               TENORETIC*
                            Atropine/Scopolamine/Hyoscyamine/Ph
Bromocriptine*                                                      TICLID*                                Metoprolol Tartrate*
                            enobarbital*
  PARLODEL*                                                       Aminocaproic Acid*                         LOPRESSOR* (QL,
                               DONNATAL* (capsules non-
Pergolide*                                                          AMICAR*                                except 25mg),
                            formulary)
  PERMAX*                                                         Cilostazol*                                TOPROL XL*
                            Benztropine*
Selegiline*                                                         PLETAL* (QL)                           Nadolol*
                               COGENTIN*
  ELDEPRYL*                                                       Clopidogrel                                CORGARD*
                            Chlordiazepoxide/Clidinium*
                                                                    PLAVIX (QL)                            Pindolol*
                               LIBRAX*
Skeletal Muscle Relaxants                                         Aspirin/Dipyridamole                       VISKEN*
                            Dicyclomine*
Carisoprodol*                                                       AGGRENOX                               Acebutolol*
                                                                                                                     Page 3 of 18
  SECTRAL*                      Olmesartan                          CORDARONE*
Bisoprolol fumarate*            medoximil/Hydrochlorothiazide
  ZEBETA*                         BENICAR-HCT (QL)                Antilipemic Agents
                                                                                                         2800
Carvedilol*                     Telmisartan/Hydrochlorothiazide   Niacin*                                CENTRAL NERVOUS
  COREG*                          MICARDIS-HCT (QL)                 NIASPAN*                             SYSTEM AGENTS
                                                                  Lovastatin/Niacin
                                                                                                         Nonsteroidal Anti-
Alpha and Beta Blockers         Endothelin Receptor Antagonists     ADVICOR
                                                                                                         Inflammatory Agents
Labetalol*                      Bosentan                          Simvastatin/Niacin
                                                                                                         Ibuprofen* (OTC) RX
  NORMODYNE*, TRANDATE*           TRACLEER                          SIMCOR (QL)
                                                                                                            MOTRIN*
                                                                                                         Acetaminophen* (OTC)
Alpha Adrenergic Blockers and   Vasodilators
                                                                                                            TYLENOL*
Centrally Acting Agents         Hydralazine*                      Bile Sequestrants
                                                                                                         Aspirin* (OTC)
Clonidine*                        APRESOLINE*                     Cholestyramine*
                                                                                                            ECOTRIN*, St.
  CATAPRES* (oral only)         Hydralazine/HCTZ*                   PREVALITE*, QUESTRAN*,
                                                                                                         JOSEPH* (OTC)
Methyldopa*                       APRESAZIDE*                     QUESTRAN
                                                                                                         Indomethacin*
  ALDOMET*                      Minoxidil*                          LIGHT*
                                                                                                         (suppository non-
Methyldopa/HCTZ*                  LONITEN*
                                                                                                         formulary)
  ALDORIL*                                                        Fibric Acid Derivatives
                                                                                                            INDOCIN*, INDOCIN
Prazosin*                       Diuretics                         Gemfibrozil*
                                                                                                         SR*
  MINIPRESS*                    Spironolactone/HCTZ*                LOPID*
                                                                                                         Piroxicam*
Guanfacine*                       ALDACTAZIDE*                    Fenofibrate*
                                                                                                            FELDENE*
  TENEX*                        Chlorothiazide*                     LOFIBRA*, TRIGLIDE* (QL),
                                                                                                         Salsalate*
Doxazosin*                        DIURIL*                         FENOGLIDE (QL)
                                                                                                            DISALCID*
  CARDURA* (XL NF) (QL)         Chlorthalidone*
                                                                                                         Choline Magnesium
Terazosin*                        HYGROTON*                       Statins
                                                                                                         Salicylate*
  HYTRIN*                       Amiloride*                        Lovastatin*
                                                                                                            TRILISATE*
                                  MIDAMOR*                          MEVACOR* (QL)
                                                                                                         Diflunisal*
Ace Inhibitors                  Amiloride/HCTZ*                   Lovastatin, extended release
                                                                                                            DOLOBID*
Captopril*                        MODURETIC*                        ALTOPREV
                                                                                                         Fenoprofen*
   CAPOTEN*                     Hydrochlorothiazide* (HCTZ)       Pravastatin*
                                                                                                            NALFON*
Quinapril*                        HYDRODIURIL*, MICROZIDE*          PRAVACHOL* (QL) (80mg NF)
                                                                                                         Meclofenamate*
   ACCUPRIL* (QL)               Furosemide*                       Simvastatin*
                                                                                                            MECLOMEN*
Quinapril/HCTZ                    LASIX*                            ZOCOR* (QL)
                                                                                                         Naproxen* (Naprelan
   ACCURETIC                    Spironolactone*                   Simvastatin/Niacin
                                                                                                         non-formulary)
Captopril/HCTZ*                   ALDACTONE*                        SIMCOR (QL)
                                                                                                            NAPROSYN*,
   CAPOZIDE*                    Triamterene/HCTZ*
                                                                                                         NAPROSYN EC*
Enalapril*                        MAXZIDE*,DYAZIDE*               Antihyperlipidemic Combination
                                                                                                         Naproxen Sodium*
   VASOTEC* (QL)                Bumetanide*                       Ezetimibe/Simvastatin
                                                                                                            ANAPROX*,
Lisinopril*                       BUMEX*                            VYTORIN(QL)
                                                                                                         ANAPROX DS*
   PRINIVIL*, ZESTRIL* (QL)     Indapamide*                         VYTORIN 10/10 (ST)
                                                                                                         Sulindac*
Lisinopril/HCTZ*                  LOZOL*
                                                                                                            CLINORIL*
   PRINZIDE*, ZESTERETIC*       Torsemide*                        Vasodilating Agents, Coronary
                                                                                                         Diclofenac Sodium*
Enalapril/HCTZ*                   DEMADEX*                        Dipyridamole*
                                                                                                            VOLTAREN*,
   VASERETIC*                                                        PERSANTINE*
                                                                                                         VOLTAREN XR*
Moexipril*                      Antiarrhythmics and Cardiac       Isosorbide Dinitrate* (chew tab non-
                                                                                                         Diclofenac Potassium*
   UNIVASC* (QL)                Glycosides                        formulary)
                                                                                                            CATAFLAM*
Moexipril/HCTZ* (QL)                                                 ISORDIL*
                                                                                                         Ketoprofen*
  UNIRETIC* (QL)                Antiarrhythmics                   Nitroglycerin Ointment*
                                                                                                            ORUDIS*, ORUVAIL*
Fosinopril*                     Digoxin*                             NITROL*, NITROBID*
                                                                                                         Flurbiprofen*
   MONOPRIL* (QL)                  LANOXIN*                       Nitrolglycerin Oral*
                                                                                                            ANSAID*
Fosinopril HCTZ*                Quinidine Sulfate*                   NITROBID*
                                                                                                         Etodolac*
   MONOPRIL HCTZ* (QL)             CIN-QUIN*, QUINORA*            Nitroglycerin Spray
                                                                                                            LODINE*, LODINE
Benazepril*                     Procainamide*                        NITROLINGUAL
                                                                                                         XL*
   LOTENSIN*                       PRONESTYL*                     Nitroglycerin Sublingual*
                                                                                                         Oxaprozin*
Benazepril/HCTZ*                Disopyramide*                        NITROSTAT SL*
                                                                                                            DAYPRO* (QL)
   LOTENSIN HCT*                   NORPACE*, NORPACE CR*          Isosorbide Dinitrate* (sustained-
                                                                                                         Ketorolac*
                                Quinidine Gluconate*              release)
                                                                                                            TORADOL* (QL)
Angiotension II Receptor           QUINAGLUTE*                       ISORDIL Titradose*
                                                                                                         Meloxicam*
Antagonists                     Quinidine Sulfate* (sustained-    Isosorbide Mononitrate*
                                                                                                            MOBIC* (QL) (tabs
Olmesartan Medoximil            release)                             IMDUR*, ISMO*, MONOKET*
                                                                                                         only)
  BENICAR (QL)                     QUINIDEX*                      Nitroglycerin Patches*
                                                                                                         Nabumetone*
Telmisartan                     Sotalol*                             NITRO-DUR*
                                                                                                            RELAFEN* (QL)
  MICARDIS (QL)                    BETAPACE*, BETAPACE AF*        Sildenafil Citrate
                                                                                                         Tolmetin Sodium*
                                Amiodarone*                          REVATIO (PA)
                                                                                                            TOLECTIN, DS (QL)
                                                                                                                  Page 4 of 18
                                        ZARONTIN* (QL)                                                     INVEGA (ST)
Narcotic Analgesics                   Primidone*                      Tricyclic                        Olanzapine
Codeine/Aspirin*                        MYSOLINE* (QL)                Antidepressants/Antipsychotics       ZYPREXA (ST)
   EMPIRIN #2,3,4*                    Clonazepam*                     Amitriptyline/Perphenazine*          ZYPREXA ZYDIS
Propoxyphene*                           KLONOPIN*                       TRIAVIL*, ETRAFON*             (ST)
   DARVON*, DARVON-N*                 Valproic Acid*
Codeine/Acetaminophen*                  DEPAKENE* (QL)                Miscellaneous Antidepressants
   TYLENOL #2, 3, 4* (capsules non-   Divalproex Sodium*              Trazodone*
                                                                                                       2820
formulary)                              DEPAKOTE*, DEPAKOTE ER          DESYREL*                       CEREBRAL
Hydrocodone                           (QL)                            Bupropion*                       STIMULANTS
Bitartrate/Acetaminophen*             Gapabentin*                       WELLBUTRIN*, WELLBUTRIN
                                                                                                       Respiratory and
   VICODIN*, VICODIN ES*                NEURONTIN* (QL)               SR*
                                                                                                       Cerebral Stimulants
Methadone*                            Zonisamide*                     Venlafaxine*
                                                                                                       Dextroamphetamine*
   DOLOPHINE*                           ZONEGRAN* (QL)                  EFFEXOR*, EFFEXOR XR (QL)
                                                                                                         DEXEDRINE*
Morphine Sulfate*                     Lamotrigine
                                                                                                       Methylphenidate*
   MSIR* (oral only)                    LAMICTAL (QL)                 MAO-I
                                                                                                         RITALIN*, RITALIN
Propoxyphene                          Topiramate                      Phenelzine
                                                                                                       SR*, METHYLIN ER*
Napsylate/Acetaminophen*                TOPAMAX (QL)                    NARDIL
                                                                                                       (QL)
   DARVOCET-N*                        Levetiracetam
                                                                                                       Dexmethylphenidate*
Codeine Sulfate*                        KEPPRA (QL)                   Antimanic Agents
                                                                                                         FOCALIN*
   CODEINE*                           Diazepam rectal gel             Lithium*
                                                                                                       Pemoline*
Oxycodone/Acetaminophen Tablet*         DIASTAT PED (QL), DIASTAT        LITHOBID*, ESKALITH*,
                                                                                                         CYLERT*
   PERCOCET*, TYLOX*                  ACUDIAL (QL)                    ESKALITH CR*
                                                                                                       Methylphenidate, long-
Oxycodone/Aspirin*                                                       (all forms) (QL)
                                                                                                       acting
   PERCODAN*
                                                                                                         CONCERTA (QL)
Oxycodone*                                                            Tetracyclic Antidepressants
                                      2816                                                             Amphetamine mixture*
   OXYIR*                             ANTIDEPRESSANT AGENTS           Maprotiline*
                                                                                                         ADDERALL*, (QL);
Meperidine*                                                             LUDIOMIL*
                                      Tricyclic Antidepressants                                        Caffeine, citrated*
   DEMEROL*
                                      Amitriptyline*                                                     CAFCIT* (oral only)
Morphine* (sustained-release)
                                        ELAVIL*
   MS CONTIN*
                                      Doxepin*                        281608                           Misc. Psychotherapy
Fentanyl Transdermal System*                                          ANTIPSYCHOTICS
                                        SINEQUAN*                                                      Agents
   DURAGESIC*(QL) (12.5mg NF)
                                      Imipramine* PM (NF)             Antipsychotics                   Atomoxetine
                                        TOFRANIL*                     Chlorpromazine* (spansule non-     STRATTERA (QL)
Non-Narcotic Analgesic
                                      Clomipramine*                   formulary)
Combinations
                                        ANAFRANIL*                       THORAZINE*
Acetaminophen/Dichloralphenazone/
                                                                      Haloperidol*
Isometheptine*
                                      Tetracyclic Antidepressants        HALDOL*                       2824
   MIDRIN*
                                      Mirtazapine*                    Thioridazine*                    ANXIOLYTICS,
Butalbital/Acetaminophen/Caffeine*
                                        REMERON* (SolTabs NF)            MELLARIL*                     SEDATIVES, &
   FIORICET*, ESGIC*
                                                                      Thiothixene*                     HYPNOTICS
Butalbital/Aspirin/Caffeine*
                                      Secondary Amines                   NAVANE* (oral only)           Anxiolytics, Sedatives
   FIORINAL* (capsules non-
                                      Desipramine*                    Perphenazine*                    and Hypnotics
formulary)
                                        NORPRAMIN*                       TRILAFON*                     Alprazolam*
Tramadol/acetaminophen* (QL)
                                      Nortriptyline*                  Loxapine*                          XANAX*
  ULTRACET* (QL)
                                        PAMELOR*,AVENTYL*                LOXITANE*                     Alprazolam er
Tramadol HCl*
                                      Amoxapine*                      Fluphenazine*                       XANAX XR*
   ULTRAM*
                                        ASENDIN*                         PROLIXIN*, PERMITIL*          Chloral Hydrate*
                                      Protriptyline*                  Trifluoperazine*                   NOCTEC*
Opiate Antagonist
                                        VIVACTIL*                        STELAZINE*                    Chlordiazepoxide* (XL &
Naltrexone*
                                                                      Clozapine*                       tablets non-formulary)
  REVIA*
                                      SSRIs                              CLOZARIL* (QL)                  LIBRIUM*
                                      Fluoxetine* - (capsules only)   Risperdone*                      Clorazepate* (long-
Anticonvulsants
                                        PROZAC* (40mg & weekly NF)       RISPERDAL* (oral only) (QL)   acting non-formulary)
Phenobarbital*
                                      Citalopram*                     Quetiapine fumurate                TRANXENE*
  PHENOBARBITAL*
                                        CELEXA* (QL)                     SEROQUEL (QL                  Diazepam*
Carbamazepine*
                                      Escitalopram                       SEROQUEL XR (QL)                VALIUM*
  TEGRETOL*, TEGRETOL XR*,
                                        LEXAPRO (QL)                  Aripiprazole                     Flurazepam*
CARBATROL (QL)
                                      Fluvoxamine*                        ABILIFY (ST)                   DALMANE*
Carbamazepine, extended-release
                                        LUVOX* (QL)                   Clozapine                        Hydroxyzine HCI*
  EQUETRO (QL)
                                      Paroxetine*                          FAZACLO (ST)                  ATARAX* (inj
Phenytoin*
                                        PAXIL* (QL)                   Ziprasidone                      available with QL)
  DILANTIN*, PHENYTEK (QL)
                                      Sertraline*                          GEODON (ST)
Ethosuximide*
                                        ZOLOFT* (QL)                  Paliperidone
                                                                                                                 Page 5 of 18
Hydroxyzine Pamoate capsule*       Packets* 20mEq, 25mEq, 50mEq,       Codeine/Triprolidine/Pseudoephedri   Hydrocortisone/Acetic
  VISTARIL*                        15mEq                               ne*                                  Acid*
Lorazepam*                           K-LOR*, K-LYTE*, KLORVESS*,         ACTIFED-C*                           VOSOL HC OTIC*
  ATIVAN* (QL)                     KLOR-CON*                           Dextromethorphan/Brompheniramine     Neomycin/Polymyxin B
Temazepam*                                                             /Pseudoephedrine*                    Sulfate/Hydrocortisone*
  RESTORIL* (7.5mg, 22.5mg NF)     Liquids                               BROMFED DM*                          CORTISPORIN
Oxazepam*                          Potassium Chloride*                 Dextromethorphan/Carbinoxamine/      OTIC*
  SERAX*                             KAOCHLOR*                         Pseudoephedrine*                     Pramoxine/Choroxylenol
Triazolam*                                                               CARBOFED*                          *
  HALCION*                         Hyperkalemic Agent                  Dextromethorphan/Guaifenesin*          PRAMOTIC DROPS
Promethazine*                      Sodium Polystyrene Sulfonate*       (OTC)                                Ofloxacin
  PHENERGAN*                         KAYEXALATE*                         ROBITUSSIN-DM* (OTC)                 FLOXIN OTIC
Buspirone*                                                             Dextromethorphan/Promethazine*       Ciprofloxacin/Dexameth
  BUSPAR*                          Alkalinizing Agent                    PHENERGAN DM*                      asone
Zaleplon* (QL)                     Potassium Citrate                   Dextromethorphan/Pseudoephedrine       CIPRODEX (QL)
   SONATA* (QL)                      UROCIT K                          /Guaifenesin* (OTC)
Zolpidem* (QL)                     Ammonia Detoxicants                   PEDIACARE* (OTC)                   Anti-Infectives
  AMBIEN* (QL)                     Lactulose*                          Guaifenesin* (OTC)                   (ophthalmic)
                                     CEPHULAC*                           ROBITUSSIN* (OTC)                  Bacitracin*
                                                                       Guaifenesin/Phenylephrine*              BACITRACIN*
4000
ELECTROLYTIC, CALORIC          &   Phosphate Binder                                CRANTEX*, Efasin*        Erythromycin*
WATER                              Calcium Acetate                     Guaifenesin/Hydrocodone/Pseudoep        ILOTYCIN*
                                     PHOSLO                            hedrine*                             Gentamicin*
Diuretics
                                   Sevelamer Carbonate                   C-COF XP*                             GENOPTIC*,
Spironolactone/HCTZ*                RENVELA                            Hydrocodone/Chlorpheniramine/Phe     GARAMYCIN*
  ALDACTAZIDE*                                                         nylephrine*                          Neomycin/Dexamethaso
Chlorothiazide*                    Urinary Acidifiers                    HISTUSSIN HC*                      ne*
  DIURIL*                          Phosphate Replacement               Hydrocodone/Guaifenesin*                NEO-DECADRON*
Chlorthalidone*                      K-PHOS NEUTRAL, K-PHOS              HYCOTUSS*                          Neomycin
  HYGROTON*                                                            Hydrocodone/Homatropine*             Sulfate/Gramicidin/Poly
Amiloride*                         Laxative                              HYCODAN*                           myxin B Sulfate*
  MIDAMOR*                         Peg 3350                            Hydrocodone/Pseudoephedrine*            NEOSPORIN
Amiloride/HCTZ*                      MIRALAX OTC                         HISTUSSIN D*                       solution*
  MODURETIC*                                                           Promethazine/Phenylephrine*          Polymyxin B
Hydrochlorothiazide* (HCTZ)                                              PHENERGAN VC*                      Sulfate/Neomycin
  HYDRODIURIL*, MICROZIDE*                                             Pseudoephedrine/Guaifenesin*         Sulfate/Dexamethasone
Furosemide*                        4800
                                   ANTITUSSIVE, EXPECTORANT &          (OTC)                                *
  LASIX*                                                                 ROBITUSSIN - PE* (OTC)                MAXITROL*
                                   MUCOLYTIC AGENTS
Spironolactone*                                                        Hydrocodonebitartrate*               Sulfacetamide/Phenylep
  ALDACTONE*                       Mucolytic Agents
                                                                         CODIMAL DH*                        hrine*
Triamterene/HCTZ*                  Acetylcysteine*                                                             VASOSULF*
  MAXZIDE*, DYAZIDE*                 MUCOMYST*                         Expectorant and Expectorant          Sulfacetamide 10%*
Bumetanide*                        Dornase Alfa                        Combinations                            BLEPH 10*,
  BUMEX*                             PULMOZYME                         Dextromethorphan/Carbinoxamine/      SULAMYD*,
Indapamide*                                                            Pseudoephedrine*                     CETAMIDE*,
  LOZOL*                           Antitussive/Decongestants             RONDEC DM*                            SULFACET R*
                                   Benzonatate*                        Guaifenesin/Pseudoephedrine*         Neomycin/Polymyxin B
Antidiuretic                          TESSALON PERLES* (100mg            MUCINEX D (OTC)                    Sulfate/Hydrocortisone/
Desmopressin*                      only) (QL)                          Guaifenesin*                         Bacitracin*
  DDAVP*                           Codeine/Guaifenesin*                  MUCINEX (OTC)                         CORTISPORIN*
                                      ROBITUSSIN AC*, GUIATUSS                                              Neomycin/Bacitracin/Pol
Uricosuric Agents                  AC*,                                                                     ymyxin B Sulfate*
Probenecid*                           CHERACOL*                                                                NEOSPORIN
                                                                       5200
  BENEMID*                         Codeine/Promethazine*                                                    ointment*
                                                                       EYE, EAR, NOSE & THROAT
                                      PHENERGAN W/CODEINE*                                                  Ofloxin
Potassium Supplements Tablets      Codeine/Promethazine/Phenylephrin   Topical Anti-Infectives/Anti-
                                                                                                               OCUFLOX
Potassium Chloride 8mEq*           e*                                  Inflammatory (otic)
                                                                                                            Tobramycin Sulfate*
  SLOW K*, KLOR-CON*                  PHENERGAN VC/CODEINE*            Carbamide Peroxide 6.5%* (OTC)
                                                                                                               TOBREX*
Potassium Chloride 10mEq, 20mEq*   Codeine/Pseudoephedrine/Chlorphe      DEBROX* (OTC)
  K-DUR*                           niramine*                           Acetic Acid*
                                                                                                            Antivirals (ophthalmic)
                                      NOVAHISTINE DH*                    VOSOL*
                                                                                                            Trifluridine*
                                   Codeine/Pseudoephedrine/Guaifene    Benzocaine/Acetic Acid*
                                                                                                              VIROPTIC*
Powders/Effervescent Tablets       sin*                                  AURALGAN*
                                      ROBITUSSIN DAC*                  Acetic Acid/ Aluminum Sol 2%*
                                                                         DOMEBORO OTIC SOLN* (OTC)
                                                                                                                      Page 6 of 18
Ophthalmic Anti-Inflammatories         Benzocaine/Pectin* (OTC)                 CREON                               Laxatives and Stool
Dexamethasone*                            ORABASE-B* (OTC)                    Pancrelipase*                         Softeners (OTC)
  DECADRON*                            Menthol/Cetylpyridium Lozenge*           PANCREASE* (all strengths),         Bisacodyl* (OTC)
Prednisolone Phosphate*                (OTC)                                  LIPRAM*                                 DULCOLAX* (OTC)
  INFLAMASE*, INFLAMASE                   CEPACOL* (OTC)                                                            Docusate Calcium*
FORTE*                                 Cromolyn*                              H2 Antagonists (OTC and RX)           (OTC)
Prednisolone Acetate*                     CROLOM*                             Cimetidine*                             SURFAK* (OTC)
  PRED MILD*, PRED FORTE*,             Travoprost                               TAGAMET*                            Docusate Potassium*
            ECONOPRED*,                   TRAVATAN (2.5ml only), Travatan Z   Ranitidine*                           (OTC)
ECONOPRED PLUS*                        (2.5ml only)                             ZANTAC* (efferdose non-formulary)     DIALOSE* (OTC)
Flurbiprofen*                          Bimatoprost                            Famotidine*                           Docusate Sodium*
  OCUFEN*                                 LUMIGAN (2.5ml only)                  PEPCID*                             (OTC)
Diclofenac Sodium                      Metipranolol                           Nizantadine*                            COLACE* (OTC)
  VOLTAREN                                OPTIPRANOLOL                          AXID*                               Docusate
                                       Brimonidine*                                                                 Sodium/Casanthrol*
Carbonic Anhydrase Inhibitors             ALPHAGAN* (P is non-formulary)      Proton Pump Inhibitors                (OTC)
Acetazolamide*                         Ketotifen*                             All non-formulary PPIs require PA.      PERI-COLACE*
  DIAMOX* (oral only)                     ZADITOR OTC*                        All formulary PPIs do NOT require     (OTC)
Methazolamide*                                                                PA.                                   Magnesium Citrate*
  NEPTAZANE*, GLAUCTABS*                                                      Omeprazole Magnesium                  (OTC)
Brinzolamide                           Nasal Steroids/Anti-Inflammatory          PRILOSEC OTC (QL)                    CITRATE OF
  AZOPT                                Cromolyn* (OTC)                        Omeprazole*                           MAGNESIA* (OTC)
                                         NASALCROM* (OTC)                        PRILOSEC* (40mg NF) (RX            Magnesium Hydroxide*
Miotics                                Flunisolide*                           strength) (QL)                        (OTC)
Pilocarpine* (Ocusert non-formulary)     NASALIDE*                            Pantoprazole*                           MILK OF
   ISOPTO CARPINE*                     Fluticasone*                              PROTONIX* (QL) (BRAND COVERED)     MAGNESIA* (OTC)
Cyclopentolate*                          FLONASE* (QL)                        Omeprazole/Sodium Bicarbonate         Methylcellulose* (OTC)
   CYCLOGYL*                           Mometasone Furoate                     (QL)                                    CITRUCEL* (OTC)
Dipivefrin HCl*                          NASONEX (QL)                            ZEGERID (QL)                       Mineral Oil* (OTC)
   PROPINE*                            PEAK FLOW METER (QL)                                                           MINERAL OIL*
                                       AEROCHAMBER (QL)                       GI Motility                           (OTC)
Mydriatics                                                                    Metoclopramide*                       Senna* (OTC)
Artificial Tears* (OTC)                                                         REGLAN*                               SENOKOT* (OTC)
  ISOPTO TEARS* (OTC)                                                                                               Senna/Docusate
                                       5600
Atropine*                              GASTROINTESTINAL DRUGS                 Cytoprotective Agents                 Sodium* (OTC)
  ISOPTO ATROPINE*                                                            Sucralfate*                             SENOKOT -S* (OTC)
                                       Miscellaneous
Homatropine*                                                                    CARAFATE*                           Sodium
  ISOPTO HOMATROPINE*                  Bismuth subsalicylate* (OTC)                                                 Phosphate/Sodium
                                         PEPTO-BISMOL* (OTC)                  Prostaglandins                        Biphosphate* (OTC)
Vasoconstrictors                       Calcium carbonate* (OTC)               Misoprostol*                            FLEET ENEMA*
Naphazoline*                             TUMS* (OTC)                            CYTOTEC*                            (OTC)
  PRIVINE*, ALBALON*                   Electrolyte Rehydrating (OTC)
Naphaxoline/Pheniramine* (OTC)           PEDIALYTE* (OTC)
  NAPHCON-A* (OTC)                     Loperamide* (OTC)                      Antiemetics
                                                                                                                    6000
                                         IMODIUM A-D* (OTC)                   Meclizine* (OTC)/RX                   ARTHRITIS/GOUT
Beta Blockers                          Ipecac syrup* (OTC)                      MECLIZINE* (OTC)/RX
                                         IPECAC* (OTC)                                                              Probenecid*
Levobunolol*                                                                  Trimethobenzamide*
                                       Magnesium Hydroxide/Aluminum                                                    BENEMID*
  BETAGAN*                                                                      TIGAN*
                                       Hydroxide* (OTC)                                                             Allopurinol*
Timolol*                                                                      Prochlorperazine*
                                         MAALOX* (OTC)                                                                 ZYLOPRIM*
  TIMOPTIC*, TIMOPTIC XE*                                                       COMPAZINE*
                                       Simethicone* (OTC)                                                           Colchicine*
Carteolol HCI*                                                                Ondansetron*
                                         MYLICON* (OTC)                                                                COLCHICINE*
  OCUPRESS*                                                                     ZOFRAN* (QL)
                                       Lactase* (OTC)                                                               Colchicine/Probenecid*
                                         LACTAID* (OTC)                                                                COLBENEMID*
Beta Blockers (Beta-1 Selective)                                              Miscellaneous GI Drugs
                                       Lactobacillus Acidophilus* (OTC)                                             Methotrexate*
Betaxolol*                                                                    Sulfasalazine*
                                         LACTINEX* (OTC)                                                               METHOTREXATE*,
  BETOPTIC* (Suspension NF)                                                     AZULFIDINE*, AZULFIDINE EN*
                                       Diphenoxylate/Atropine*                                                      RHEUMATREX*
                                                                              Mesalamine
                                         LOMOTIL*                                                                   Leflunomide*
Miscellaneous EENT                                                              ASACOL, CANASA
                                       Lactulose*                                                                      ARAVA* (QL)
Phenylephrine* (OTC)                                                          Ursodiol*
  NEO-SYNEPHRINE* (OTC)                  CEPHULAC*                              ACTIGALL*
Naphazoline/antazoline* (OTC)          Polyethylene glycol/electrolyte        Bismuth Subsalicylate,
  VASOCON-A* (OTC)                     solution*                              Metronidazole, Tetracycline HCl       6400
Sodium chloride spray* (OTC)             GOLYTELY, NULYTELY*                    PREVPAC                             RESPIRATORY
  OCEAN SPRAY* (OTC)                   Pancreatin                                                                   DRUGS

                                                                                                                              Page 7 of 18
Bronchodilators                        Liquids                             Levonorgestrel/Ethinyl Estradiol*      TRINESSA*, TRI-
Sodium Chloride* (OTC)                 Theophylline* (80mg/15cc)             NORDETTE*,LEVORA*,                 SPRINTEC*,
   BRONCHO SALINE* (OTC)                 THEOLAIR 80*,SLO-PHYLLIN*         LEVLEN*, PORTIA*                       ORTHO-TRI-CYCLEN
Sodium Chloride Soln for Inhalation*                                       Levonorgestrel/Ethinyl Estradiol*    LO
(OTC)                                  Beta-Agonists, Oral                   ALESSE*, AVIANE*, LESSINA*,
   SODIUM CHLORIDE * (OTC)             Albuterol (soln, syrup, tablets)*   LEVLITE*,                LUTERA*     Progestin-Only (oral
Albuterol*                               PROVENTIL*                        Norethindrone/Ethinyl Estradiol*     contraceptives)
   PROVENTIL* (nebulization) ,         Metaproterenol*                       ORTHO-NOVUM 1/35*, NECON           Medroxyprogesterone*
   PROAIR HFA                            METAPREL*, ALUPENT*               1/35*,                   NORTREL       CYCRIN*,
Ipratropium*                           Terbutaline*                        1/35*, NORINYL 1/35*,                PROVERA*
   ATROVENT*, ATROVENT HFA               BRETHINE*                           NORETHRIN 1/35*
Cromolyn                                                                   Norethindrone/Ethinyl Estradiol*     Norethindrone*
   INTAL INHALER                                                             MODICON*, NECON 0.5/35-21*,          ORTHO-MICRONOR*,
                                                                             NECON 0.5/35-28*, NORTREL          CAMILA*, ERRIN*,
                                       6800
Metaproterenol Sulfate                 HORMONES & SYNTHETIC                0.5/35*,                               JOLIVETTE*, NOR-BE*,
  ALUPENT                              SUBSTITUTES                           BREVICON*                          NOR-QD*, AYGESTIN*
Albuterol Tablets*                                                         Norgestrel/Ethinyl Estradiol*        Norgestrel
                                       Estrogens
  VOLMAX*, VOSPIRE ER*                                                       LO/OVRAL*, LOW-OGESTREL*,            OVRETTE
                                       Estrogens, Conjugated               CRYSELLE*                            Progesterone,
Terbutaline*
                                         PREMARIN (QL)                     Norethindrone/Ethinyl Estradiol*     micronized
  BRETHINE*
                                       Estrogens Estrogen                    LOESTRIN FE 1.5/20*,                 PROMETRIUM
Salmeterol
                                        MENEST                               MICROGESTIN FE
  SEREVENT DISKUS
                                       Estradiol*                            1.5/30*, JUNEL FE 1.5/20*          Anti-Androgens
Albuterol/Ipratropium
                                         ESTRACE*                          Norethindrone/Ethinyl Estradiol*     Dutasteride
  COMBIVENT
                                       Diethylstilbestrol*                   OVCON-50*, OVCON-35*,                AVODART
Formoterol
                                         DES*                              BALZIVA*                             Finasteride
  FORADIL
                                       Estropipate*                        Norethindrone/Ethinyl Estradiol*       PROSCAR (QL)
Tiotropium Bromide
                                         OGEN*                               LOESTRIN FE 1/20*,
  SPIRIVA
                                       Estradiol Transdermal System*       MICROGESTIN FE                       Androgens
                                         CLIMARA*                            1/20*, JUNEL FE 1/20*              Methyltestosterone
Inhaled Anti-Inflammatory Agents
Triamcinolone                                                              Norethindrone/Ethinyl Estradiol*       ANDROID
                                       Estrogens /Progestin                  ORTHO-NOVUM 10/11*, NECON          Testosterone Gel
  QVAR
                                       Estrogens,                          10/11*,                  GENCEPT       TESTIM (PA) (QL)
Fluticasone
                                       Conjugated/Medroxyprogesterone      10/11*
  FLOVENT, FLOVENT HFA
                                         PREMPRO, PREMPHASE (QL)           Norethindrone/Ethinyl Estradiol*     Drugs to Treat
Salmeterol/Fluticasone
  ADVAIR, ADVAIR HFA                                                         MIRCETTE*, KARIVA*                 Endometriosis
                                       Estrogens Agonist - Antagonist      Norethindrone/Mestranol*             Danazol*
Budesonide (Inhalation) (Turbohaler
                                       Raloxifene                            ORTHO-NOVUM 1/50*, NECON             DANOCRINE*
non-formulary)
                                         EVISTA                            1/50*,                   NORINYL
  PULMICORT RESPULES (only for
under 8yo)                                                                 1/50*                                Thyroid and
                                       Anti-Estrogen                       Norgestrel/Ethinyl Estradiol*        Antithyroid Agents
Mometasone
                                       Tamoxifen*                            OVRAL-28*, OGESTREL*               Levothyroxine* (use
  ASMANEX
                                         NOLVADEX*, TAMOXIFEN*             Norgestimate/Ethinyl Estradiol*      same brand
Budesonide/Formoterol
  SYMBICORT                                                                  ORTHO-CYCLEN*,                     consistently)
                                       Contraceptives                      MONONESSA*,                            LEVOXYL*,
                                       CONDOMS (QL)                          PREVIFEM*, SPRINTEC*               LEVOTHROID*,
Leukotriene Antagonist
                                       Etonogestrel-Ethinyl Estradiol                                           SYNTHROID*
Zafirlukast
                                       Vaginal Ring                        Multiphasics (oral contraceptives)   Methimazole*
  ACCOLATE
                                         NUVARING (QL)                     Desogestrel/Ethinyl Estradiol*         TAPAZOLE*
Montelukast
                                       Medroxyprogesterone Acetate           CYCLESSA*, CESIA*, VELIVET*        Propylthiouracil*
  SINGULAIR (PA)
                                       (Contraceptive)*                    Levonorgestrel/Ethinyl Estradiol*      PROPYLTHIOURACI
                                         DEPO-PROVERA INJ (QL)*              TRIPHASIL*, TRIVORA*               L* (PTU)
Theophylline and other Xanthines
                                       Levonorgestrel                      Norethindrone/Ethinyl Estradiol*     Thyroid*
Solids
                                         PLAN B                              ESTROSTEP FE*                        ARMOUR THYROID*
Theophylline*
  THEO-24*, THEO-DUR*, THEO-                                               Norethindrone/Ethinyl Estradiol*
                                       Oral Contraceptives                   ORTHO-NOVUM 7/7/7*, NECON          Antidiabetic Agents
VENT*,
                                       Desogestrel/Ethinyl Estradiol*      7/7/7*,                  NORTREL     Oral Agents
  THEOCHRON*, T-PHYL*, SLO-
                                         ORTHO-CEPT*, CYCLESSA*,           7/7/7*                               Acarbose*
BID*,                  RESPBID*,
                                       APRI*,                   SOLIA*,    Norethindrone/Ethinyl Estradiol*      PRECOSE*
QUIBRON-T*, UNI-DUR*,
                                       DESOGEN*, RECLIPSEN*                  TRI-NORINYL*, ARANELLE*,           Acetohexamide*
  UNIPHYL*
                                       Drospirenone/Ethinyl Estradiol      LEENA*                                 DYMELOR*
  (Combination products of
                                         YASMIN, YAZ                       Norgestimate/Ethinyl Estradiol*      Chlorpropamide*
Theophylline are
                                       Ethynodiol/Ethinyl Estradiol*         ORTHO-TRI-CYCLEN*,                   DIABINESE*
  non-formulary)
                                         DEMULEN*,ZOVIA*, KELNOR*          TRIPREVIFEM*,                        Tolbutamide*

                                                                                                                         Page 8 of 18
   ORINASE*                              EMLA* (cream only)                    GYNE-LOTRIMIN* (OTC),              SYNALAR*,
Tolazamide*                            Lidocaine                              MYCELEX-3 (OTC)                   FLUROSYN*
   TOLINASE*                             LIDODERM                                                               Triamcinolone
Glyburide*                                                                    Ticonazole* (OTC)                 Acetonide* Cream,
   MICRONASE*, DIABETA*,                                                        VAGISTAT-1* (OTC)               Oint.0.025%
GLYNASE*                                                                      Clindamycin*                        KENALOG*
                                       7600
Glipizide*                             OXYTOCICS                                CLEOCIN VAGINAL*                Betamethasone
   GLUCOTROL*, GLUCOTROL XL*                                                  Amino Acid, Urea                  Valerate Lotion 0.1%*
                                       Methylergonovine Maleate
(QL)                                                                            AMINO-CERV VAGINAL CREAM          VALISONE*
                                        METHERGINE
Glipizide/Metformin*                                                          Metronidazole*                    Desonide* Cream, Oint
   METAGLIP* (QL)                                                               METROGEL Vaginal*               0.05%
Glimepiride*                           8400                                   Terconazole*                        DESOWEN*
   AMARYL* (QL)                        SKIN & MUCOUS MEMBRANE                   TERAZOL*                        Amcinonide*
Metformin*                             Antibiotics-Topical                    Butoconazole Nitrate                CYCLOCORT*
   GLUCOPHAGE* (XR non-                Bacitracin* (OTC)                        GYNAZOLE-1
formulary)                                BACITRACIN * (OTC)                                                    Group V
Rosiglitazone/Metformin                Hydrogen Peroxide 3%* (OTC)            Antifungal-Topical                Triamcinolone
   AVANDAMET (QL)                         HYDROGEN PEROXIDE 3%*               Benzoyl Peroxide* (OTC)           Acetonide* Lot, Cream,
Sitagliptin/Metformin                  (OTC)                                    BENZOYL PEROXIDE* (OTC)         Oint 0.1%
   JANUMET (QL)                        Neomycin/Polymyxin B/Bacitracin*       Clotrimazole* (OTC)                 KENALOG*,
Glyburide/Metformin*                   (OTC)                                    MYCELEX*, NIS LOTRIMIN*,        ARTISTOCORT*
   GLUCOVANCE*                            NEOSPORIN* (OTC)                    LOTRIMIN*,                        Betamethasone
Pioglitazone                           Polymyxin B/Bacitracin* (OTC)            FUNGOID, LOTRIMIN AF (OTC)*     Valerate* Cream 0.1%
   ACTOS (QL)                             POLYSPORIN* (OTC)                   (1% Soln)                           VALISONE*
Rosiglitazone                          Bacitracin*                            Miconazole* (OTC)                 Fluocinolone Acetonide*
   AVANDIA (QL)                           BACIGUENT*                            MICATIN* (OTC)                  Cream 0.025%
Sitagliptin                            Polymyxin B/Bacitracin*                Tolnaftate* (OTC)                   SYNALAR*,
   JANUVIA (QL)                           POLYSPORIN*                           TINACTIN* (OTC)                 FLUROSYN*
                                       Gentamicin*                            Nystatin*
Insulin-Lilly Brands Only                 GARAMYCIN*                            MYCOSTATIN*,NILSTAT*            Group IV
Human Insulin, NPH, Regular,Mix        Silver Sulfadiazine*                   Nystatin/Triamcinolone*           Triamcinolone* Cream,
  HUMULIN, HUMALOG (pens NF)              SILVADENE*                            MYCOLOG II*                     Oint 0.5%
Insulin Human Glargine                 Mupirocin*                             Ketoconazole*                       KENALOG*,
  LANTUS (pen NF)                         BACTROBAN*, BACTROBAN                 NIZORAL*                        ARTISTOCORT*
Note: Insulin pens, cartridges,        NASAL                                  Ciclopirox*                       Fluocinolone Acetonide*
needles require prior authorization.                                            LOPROX* (cream and suspension   Oint 0.025%
                                       Antiacne                               only) (QL)                          SYNALAR*,
Lifescan glucometers/test strips are   Aluminum Cl Sol 20%*                   Ciclopirox*                       FLUROSYN*
covered on the formulary with a          DRYSOL SOL 20%*                        PENLAC* (QL)
written prescription (QL)              Erythromycin Solution*, Gel*, Pads*
                                         A/T/S*, ERY-DERM*, T-STAT*,          Scabicides and Pediculicides      Group III
Corticosteroids                        ERYMAX*,                               Permethrin 1%* (OTC)              Betamethasone
Prednisone*                              T-STAT*, EMGEL*                        NIX* (OTC)                      Valerate* Oint 0.1%
  ORASONE*                             Clindamycin*                           Pyrethrins Spray* (OTC)              VALISONE*
Hydrocortisone*                          CLEOCIN T* (lotion, gel, solution,     A-200 LICE CONTROL* (OTC)       Mometasone Furoate
  CORTEF*                              pads),                  CLINDETS*      Pyrethrins/Piperonyl Butoxide*    (cream, ointment, lotion)*
Dexamethasone*                         Erythromycin gel-benzoyl peroxide*     (OTC)                                ELOCON*
  DECADRON*                              BENZAMYCIN GEL*                        RID* (OTC)
Methylprednisolone*                    Tretinoin*                             Permethrin*                       Group II
  MEDROL*                                RETIN A* (micro non-formulary),        ELIMITE*                        Betamethasone
Prednisolone*                          AVITA*                                 Malathion                         Dipropionate* cream,
  PRELONE*, ORAPRED*,                  Azelaic Acid                             OVIDE (QL)                      Oint, Lot0.05%
PEDIAPRED*                               AZELEX, FINEVIN                                                          DIPROSONE*
                                       Tazarotene (PA)                        Anti-Inflammatory Agents          Fluocinonide* Cream,
Bone Metabolism                          TAZORAC                              (Topical)                         Oint, Gel, Soln 0.05%
Alendronate                            Isotretinoin*                          Group VII (Lowest Potency)          LIDEX*
  FOSAMAX                                ACCUTANE* (QL) (PA)                  Hydrocortisone 2.5%*              Desoximetasone*
Alendronate + Vit D                                                             HYTONE*                         Cream, Oint, Gel
  FOSAMAX+D (QL)                       Antibiotic-Vaginal                     Hydrocortisone 0.5,1%* (OTC)        TOPICORT*
                                       Butoconazole* (OTC)                      CORTAID* (OTC)                  Hydrocortisone Butyrate
                                         FEMSTAT-3* (OTC)                                                         LOCOID
                                       Miconazole* (OTC)                      Group VI                          LIPOCREAM*,
7200
LOCAL ANESTHETICS                        MONISTAT* (OTC)                      Fluocinolone Acetonide* Soln,       LOCOID CREAM*,
                                       Clotrimazole* (OTC)                    Cream 0.01%                         LOCOID OINTMENT*
Lidocaine/Prilocaine*
                                                                                                                           Page 9 of 18
                                        ALDARA                             PRENATAL M TAB*                        Rho (D) Immune
Group 1 (Highest Potency)             Enzyme combination, topical*         PRENATAL MR TAB 90 FE*                 Globulin Injectable
Diflorasone Diacetate*                  GRANULEX*, ACCUZYME*               PRENATAL MTR TAB SELENIUM*                RHOGAM, BAYRHO,
  PSORCON*, PSORCON E*                                                     PRENATAL NF TAB PLUS*                  WINRHO
Clobetasol* (Cream, Oint, Soln,                                            PRENATAL OPT TAB ADVANCE*              Epinephrine
Lotion) 0.05%                                                              PRENATAL PLS TAB*                         EPIPEN, EPIPEN JR,
  TEMOVATE*, CORMAX*,                                                      PRENATAL PLS TAB /IRON*                ADRENALIN, ANAKIT,
                                      8800
CLOBEX*                                                                    PRENATAL RX TAB*                          ANAGUARD KIT,
                                      VITAMINS
Halobetasol Propionate*                                                    PRENATAL RX TAB BETA-                  TWINJECT (QL)
                                      Folic Acid*                                                                 Enoxaparin Sodium
  ULTRAVATE*                                                               CAROTENE*
                                        FOLIC ACID*                                                                  LOVENOX (QL)
Augmented betamethasone*                                                   PRENATAL S TAB*
  DIPROLONE*, DIPROLONE AF*                                                PRENATAL Z TAB*                        Dalteparin Sodium
                                      Vitamin B-12                                                                   FRAGMIN (QL)
                                                                           PRENATAL Z TAB ADV FORM*
                                      Cyanocobalamin injection*                                                   Fondaparinux Sodium
Antipsoriatics and Antipruritics                                           PRENATAL-H CAP*
                                        VITAMIN B-12*                                                                ARIXTRA (QL)
Selenium Sulfide 2.5%*                                                     PRENATL CARE TAB*
  SELSUN*, EXSEL*                                                          PRETERNA TAB*                          Penicillin G
                                      Vitamin D                                                                      BICILLIN-LA (QL)
                                                                           TERNAMAR TAB*
                                      Ergocalciferol*                                                             Ceftriaxone Sodium
Rectal                                                                     ULT NATLCARE TAB*
                                        CALCIFEROL* (OTC)                                                            ROCEPHIN (QL)
Hydrocortisone*                                                            ULTRA NATAL TAB*
                                      Calcitriol*                                                                 Haloperidol
  ANUSOL-HC*                                                               ULTRA TABS*
                                        ROCALCTROL*                                                               Fluphenazine
Pramoxine                                                                  VINATE 90 TAB*
                                      Doxercalciferol*                                                            Dexamethasone
   PROCTOFOAM                                                              VINATE GT TAB*
                                        HECTOROL*                                                                 Hydroxyzine HCl
                                                                           VINATE M TAB*
                                      Paricalcitol*                                                               Injection* (single dose
Keratolytic Agent                                                          VINATE TAB ADVANCED*
                                        ZEMPLAR*                                                                  vial)
Ammonium Lactate* (OTC)                                                    VINATE ULTRA TAB*
  AMLACTIN 12% (OTC)*                                                      Pediatric/Fluoride                     Glucagon Injection
                                      Vitamin K                                                                      GLUCAGON (QL)
Podofilox*                                                                 Multivitamin* (OTC)
                                      Phytonadione                                                                Silver Nitrate*
  CONDYLOX*                                                                   POLY-VI-SOL* (OTC)
                                        MEPHYTON                                                                  Succimer
                                                                           Multivitamin + Iron (pediatric)*
Amino Acid Derivative                                                      (OTC)                                     CHEMET
                                      Prenatal
Levocarnitine*                                                                POLY-VI-SOL IRON* (OTC)
                                      All generic prenatal vitamins                                               Dental Products
  L-CARNITINE* (OTC)                                                       Fluoride/Polyvitamins* (drops and
                                      (OTC/Rx) are covered. This list is                                          Fluoride Rinse* (OTC)
                                                                           tablets)
                                      not all inclusive.                                                            ACT*, PERIOMED*,
Miscellaneous Skin & Mucous                                                   POLY-VI-FL OR*
Membrane Agent                                                             Vitamin, A, D, and C*                    PERIO-RINSE*
                                      ADVANCED TAB NATALCARE*                                                     (OTC)
Salicylic Acid 17%/Collodion* (OTC)                                           TRI-VI-SOL*
                                      ANEMAGEN OB CAP*                                                            Stannous Fluoride*
   DUOFILM* (OTC)                                                          Vitamin, A, D, and C with Iron*
                                      FERREX PC TAB FORTE*                                                        (OTC)/RX
Mineral Oil/Petrolatum Ointment*                                              TRI-VI-SOL with IRON*
                                      MATERNAL VIT TAB & MINERAL*                                                   PERIOMED*, GEL-
(OTC)                                                                      Sodium Fluoride* (drops and tablets)
                                      MATERNITY-90 TAB*                                                           KAM*, ETHEDENT*
   AQUAPHOR*, EUCERIN* (OTC)                                                  KARIDIUM*, LURIDE*
                                      NATAFOLIC-PN TAB*                                                           (OTC)
Benzocaine Aerosol* (OTC)
                                      NATALCARE 3 TAB*                                                            Doxycycline Hyclate*
   DERMACOAT*                                                              Minerals
                                      NATALCARE CPL*                                                                PERIOSTAT*
Zinc Oxide Oint* (OTC)                                                     Calcium Carbonate* (OTC)
                                      NATALCARE RX TAB*                                                           Chlorhexidine
   ZINC OXIDE* (OTC)                                                         TUMS* (OTC)
                                      NATALCARE TAB CFE 60*                                                       Gluconate*
Diphenhydramine Cream 2%*                                                  Calcium Carbonate w/Vitamin D*
                                      NATALCARE TAB PIC FORTE*                                                      PERIDEX*,
(OTC)                                                                      (OTC)
                                      NATALCARE TAB PLUS*                                                         PERIOGARD*
   BENADRYL* (OTC)                                                           CALTRATE 600+D* (OTC)
                                      NATALINS RX*
Vitamin A&D Ointment* (OTC)                                                Calcium Gluconate* (OTC)
                                      NATAREX TAB*
   A&D OINT* (OTC)                                                           CALCIUM GLUCONATE* (OTC)
                                      NATATAB CFE TAB*
Calamine Lotion* (OTC)                                                     Calcium Lactate* (OTC)
                                      NATATAB FA TAB*
   CALAMINE LOTION* (OTC)                                                    CALCIUM LACTATE* (OTC)
                                      NATATAB RX TAB*
Glycerin/Benzoylale/Petrolatum                                             Ferrous Fumarate* (OTC)
                                      PRENATAB CBF TAB*
Cream* (OTC)                                                                 FERROUS FUMARATE* (OTC)
                                      PRENA-TAB TAB*
   MOISTUREL* (OTC)                                                        Ferrous Gluconate* (OTC)
                                      PRENATABS FA TAB*
Urea                                                                         FERGON* (OTC)
                                      PRENATABS RX TAB*
   ZIOX                                                                    Ferrous Sulfate* (OTC)
                                      PRENATAL 1 TAB PLUS 1*
Triamcinolone 0.1%in Orabase*                                                FEOSOL* (OTC)
                                      PRENATAL 1/ TAB IRON*
   KENALOG IN ORABASE*                                                     Sodium Biphosate/Potassium
                                      PRENATAL 1+ TAB BETA
Fluorouracil*                                                              Phosphate* (OTC)
                                      CAROTENE*
   EFUDEX*                                                                   NEUTRA-PHOS POWDER*
                                      PRENATAL 1+1 TAB*
Pimecrolimus                                                               (OTC)
                                      PRENATAL 19 CHW TAB*
   ELIDEL (AR-for ages below 16yo
                                      PRENATAL 19 TAB*
only) (QL)
                                      PRENATAL AD TAB*
Imiquimod
                                      PRENATAL FOR TAB*                    MISCELLANEOUS DRUGS
                                                                                                                          Page 10 of 18
                                                      INDEX


                                       ALLEGRA* (QL) (ODT NF), 1        Antihypertensives, 3                AVELOX (QL), 2
                 A                     Allopurinol*, 7                  Anti-Infectives (ophthalmic), 6     AVIANE*, 8
                                       Alpha Adrenergic Blockers        Anti-Inflammatory Agents            AVITA*, 9
A&D OINT* (OTC), 10                         and, 4                           (Topical), 9                   AVODART, 8
A/T/S*, 9                              Alpha and Beta Blockers, 4       Antilipemic Agents, 4               AXID*, 7
A-200 LICE CONTROL* (OTC),             ALPHAGAN* (P is non-             Antimalarials, 2                    AYGESTIN*, 8
    9                                       formulary), 7               Antimanic Agents, 5                 Azathioprine*, 3
Abacavir, 2                            Alprazolam er, 5                 Antimetabolites, 2                  Azelaic Acid, 9
Abacavir Sulfate / Lamivudine, 2       Alprazolam*, 5                   Antiparkinson Agents, 3             Azelastine Nasal Spray, 1
Abacavir Sulfate / Lamivudine /        ALTOPREV, 4                      Antipsoriatics and                  AZELEX, 9
    Zidovudine, 2                      Altretamine, 2                        Antipruritics, 10              Azithromycin*, 1
ABILIFY (ST), 5                        Aluminum Cl Sol 20%*, 9          Antipsychotics, 5                   AZOPT, 7
Acarbose*, 8                           ALUPENT*, 3, 8                   Antiretroviral Agents, 2            AZULFIDINE*, AZULFIDINE EN*,
ACCOLATE, 8                            Amantadine*, 2                   Antispasmodic, Urinary, 3               7
ACCUNEB*, 3                            AMARYL* (QL), 9                  Antituberculosis, 2
ACCUPRIL* (QL), 4                      AMBIEN* (QL), 6                  ANTITUSSIVE, Expectorant &                        B
ACCURETIC, 4                           Amcinonide*, 9                        MUCOLYTIC AGENTS, 6
ACCUTANE* (QL) (PA), 9                 AMICAR*, 3                       Antitussive/Decongestants, 6        BACIGUENT*, 9
ACCUZYME*, 10                          Amiloride*, 4, 6                 Antivirals, 2, 6                    BACITRACIN * (OTC), 9
Ace Inhibitors, 4                      Amiloride/HCTZ*, 4, 6            Antivirals (ophthalmic), 6          Bacitracin*, 6, 9
Acebutolol*, 3                         Amino Acid Derivative, 10        ANUSOL-HC*, 10                      BACITRACIN*, 6
Acetaminophen* (OTC), 4                Amino Acid, Urea, 9              Anxiolytics, Sedatives and          Bacitracin* (OTC), 9
Acetaminophen/Dichloralphenazo         Aminocaproic Acid*, 3                 Hypnotics, 5                   Baclofen*, 3
    ne/Isometheptene*, 3               AMINO-CERV VAGINAL               APRESAZIDE*, 4                      BACTRIM DS*, 2
Acetazolamide*, 7                           CREAM, 9                    APRESOLINE*, 4                      BACTRIM*, 2
Acetic Acid*, 6                        Amiodarone*, 4                   APRI*, 8                            BACTROBAN NASAL, 9
Acetic Acid/ Aluminum Sol 2%*, 6       Amitriptyline*, 5                APTIVUS, 2                          BACTROBAN*, 9
Acetohexamide*, 8                      Amitriptyline/Perphenazine*, 5   AQUAPHOR*, EUCERIN*                 BALZIVA*, 8
Acetylcysteine*, 6                     AMLACTIN 12% (OTC)*, 10               (OTC), 10                      BARACLUDE (QL), 2
ACHROMYCIN V* (tabs non-               Amlodipine*, 3                   ARALEN* (Not covered for travel     BEEPEN-VK*, 2
    formulary), 2                      Ammonia Detoxicants, 6                prophylaxis) (PA), 2           BELLERGAL-S*, 3
ACI-JEL Vaginal Gel, 2                 Ammonium Lactate* (OTC), 10      ARANELLE*, 8                        BENADRYL* (OTC), 1, 10
ACT*, PERIOMED*,, 10                   Amoxapine*, 5                    ARAVA* (QL), 7                      Benazepril*, 4
ACTIFED 12 HOUR* (OTC), 1              Amoxicillin*, 2                  ARICEPT, -ODT, 3                    Benazepril/HCTZ*, 4
ACTIFED-C*, 6                          Amoxicillin/Clavulanate*, 2      ARIMIDEX, 2                         BENEMID*, 6, 7
ACTIGALL*, 7                           AMOXIL*, 2                       Aripiprazole, 5                     BENICAR (QL), 4
ACTOS (QL), 9                          Amphetamine mixture*, 5          ARIXTRA (QL), 10                    BENICAR-HCT (QL), 4
Acyclovir*, 2                          Ampicillin*, 2                   ARMOUR THYROID*, 8                  BENTYL*, 3
ADALAT CC*, PROCARDIA XL*              Amprenavir, 2                    AROMASIN, 2                         BENZAMYCIN GEL*, 9
    (QL), 3                            ANAFRANIL*, 5                    ARTANE*, 3                          Benzocaine Aerosol* (OTC), 10
ADDERALL*, (QL);, 5                    ANAGUARD KIT, 10                 ARTHRITIS/GOUT, 7                   Benzocaine/Acetic Acid*, 6
Adefovir Dipivoxil, 2                  ANAKIT, 3, 10                    Artificial Tears* (OTC), 7          Benzocaine/Pectin* (OTC), 7
ADRENALIN, 3, 10                       ANAPROX*, ANAPROX DS*, 4         ARTISTOCORT*, 9                     Benzonatate*, 6
Adrenergic Agents/Beta-                ANASPAZ*, 3                      ASACOL, 7                           BENZOYL PEROXIDE* (OTC), 9
    Agonists, Oral, 3                  Anastrozole, 2                   ASENDIN*, 5                         Benztropine*, 3
ADVAIR, ADVAIR HFA, 8                  Androgens, 8                     ASMANEX, 8                          Beta Blockers (Beta-1
ADVANCED TAB NATALCARE*,               ANDROID, 8                       Aspirin*, 3, 4                          Selective), 7
    10                                 ANEMAGEN OB CAP*, 10             Aspirin* (OTC), 4                   Beta-Agonists, Oral, 8
ADVICOR, 4                             Angiotension II Receptor         Aspirin/Dipyridamole, 3             Beta-Agonists/Bronchodilators,
AEROCHAMBER (QL), 7                         Antagonists, 4              ASTELIN, 1                              Inhaled, 3
AGENERASE, 2                           ANSAID*, 4                       ATARAX* (inj available with QL),    BETAGAN*, 7
AGGRENOX, 3                            ANTABUSE*, 3                          5                              Betamethasone Dipropionate*
ALBALON*, 7                            Antiacne, 9                      Atazanavir Sulfate, 2                   cream, Oint, Lot0.05%, 9
Albuterol (soln, syrup, tablets)*, 8   Anti-Androgens, 8                Atenolol*, 3                        Betamethasone Valerate Lotion
Albuterol*, 3, 8                       Antiarrhythmics, 4               Atenolol/Chlorthalidone*, 3             0.1%*, 9
Albuterol* (inhaled, nebulizer         Antiarrhythmics and Cardiac      ATIVAN* (QL), 6                     Betamethasone Valerate* Cream
    soln), 3                                Glycosides, 4               Atomoxetine, 5                          0.1%, 9
Albuterol/Ipratropium, 8               Antibiotics-Topical, 9           ATRIPLA, 2                          Betamethasone Valerate* Oint
ALDACTAZIDE*, 4, 6                     Antibiotic-Vaginal, 9            Atropine*, 7                            0.1%, 9
ALDACTONE*, 4, 6                       Anticholinergics, 3              Atropine/Scopolamine/Hyoscyamine/   BETAPACE*, BETAPACE AF*, 4
ALDARA, 10                             Anticonvulsants, 5                    Phenobarbital*, 3              Betaxolol*, 7
ALDOMET*, 4                            Antidiabetic Agents, 8           ATROVENT*, ATROVENT HFA,            Bethanechol*, 3
ALDORIL*, 4                            Antidiuretic, 6                       3, 8                           BETOPTIC* (Suspension NF), 7
Alendronate, 9                         Antiemetics, 7                   Augmented betamethasone*, 10        Bexarotene, 3
Alendronate + Vit D, 9                 Anti-Estrogen, 8                 AUGMENTIN*, AUGMENTIN               BIAXIN*, BIAXIN XL* (QL), 1
ALESSE*, 8                             Antifungals, 1                        ES*, 2                         Bicalutamide, 2
Alkalinizing Agent, 6                  Antifungal-Topical, 9            AURALGAN*, 6                        BICILLIN-LA (QL), 10
ALKERAN, 2                             Antihyperlipidemic               AVANDAMET (QL), 9                   Bile Sequestrants, 4
Alkylating Agents, 2                        Combination, 4              AVANDIA (QL), 9                     Bimatoprost, 7
                                                                                                                              Page 11 of 18
Bisacodyl* (OTC), 7                 Carisoprodol/ASA*, 3               CLARITIN*, ALAVERT* (OTC), 1      CYSTOSPAZ*, 3
Bismuth subsalicylate* (OTC), 7     Carteolol HCI*, 7                  CLARITIN-D* (OTC) (QL), 1         Cytoprotective Agents, 7
Bisoprolol fumarate*, 4             CARTIA XT*, DILACOR XR*            Clemastine* (OTC), 1              CYTOTEC*, 7
BLEPH 10*, 6                            (QL), 3                        CLEOCIN T* (lotion, gel,          CYTOVENE* (oral only), 2
Bone Metabolism, 9                  Carvedilol*, 4                         solution, pads),, 9           CYTOXAN*, 2
Bosentan, 4                         CASODEX (QL), 2                    CLEOCIN VAGINAL*, 9
BRETHINE*, 8                        CATAFLAM*, 4                       CLEOCIN*, 2                                      D
BREVICON*, 8                        CATAPRES* (oral only), 4           CLIMARA*, 8
Brimonidine*, 7                     C-COF XP*, 6                       Clindamycin*, 2, 9                DALMANE*, 5
Brinzolamide, 7                     CECLOR*, CECLOR CD*, 1             CLINDETS*, 9                      Dalteparin Sodium, 10
BROMFED DM*, 6                      CEENU, 2                           CLINORIL*, 4                      Danazol*, 8
BROMFED*, 1                         Cefaclor*, 1                       Clobetasol* (Cream, Oint, Soln,   DANOCRINE*, 8
BROMFED-PD*, 1                      Cefadroxil*, 1                         Lotion) 0.05%, 10             DANTRIUM*, 3
Bromocriptine*, 3                   Cefdinir*, 1                       Clomipramine*, 5                  Dantrolene*, 3
Brompheniramine*, 1                 Cefpodoxime*, 1                    Clonazepam*, 5                    DAPSONE*, 2
Brompheniramine/Pseudoephedri       CEFTIN*, 1                         Clonidine*, 4                     Darunavir, 2
    ne*, 1                          Ceftriaxone Sodium, 10             Clopidogrel, 3                    DARVOCET-N*, 5
BRONCHO SALINE* (OTC), 8            Cefuroxime Axetil*, 1              Clorazepate* (long-acting non-    DARVON*, DARVON-N*, 5
Bronchodilators, 8                  CEFZIL*, 1                             formulary), 5                 Dasatinib, 3
Budesonide (Inhalation)             CELEXA* (QL), 5                    Clotrimazole* (OTC), 9            DAYPRO* (QL), 4
    (Turbohaler non-formulary), 8   CELLCEPT, 3                        Clozapine*, 5                     DDAVP*, 6
Budesonide/Formoterol, 8            CENTRAL NERVOUS System             CLOZARIL* (QL), 5                 DEBROX* (OTC), 6
Bumetanide*, 4, 6                       AGENTS, 4                      Coagulants, Anticoagulants,       DECADRON*, 7, 9
BUMEX*, 4, 6                        Centrally Acting Agents, 4             and Antiplatelets, 3          DECONAMINE*, 1
Bupropion*, 5                       CEPACOL* (OTC), 7                  Codeine Sulfate*, 5               Delavirdine Mesylate, 2
BUSPAR*, 6                          Cephalexin*, 1                     CODEINE*, 5                       DEMADEX*, 4
Buspirone*, 6                       Cephalosporins and Related         Codeine/Acetaminophen*, 5         DEMEROL*, 5
Busulfan, 2                             Antibiotics, 1                 Codeine/Aspirin*, 5               DEMULEN*, 8
Butalbital/Acetaminophen/Caffein    CEPHULAC*, 6, 7                    Codeine/Guaifenesin*, 6           Dental Products, 10
    e*, 5                           Ceprozil*, 1                       Codeine/Promethazine*, 6          DEPAKENE* (QL), 5
Butalbital/Aspirin/Caffeine*, 5     CEREBRAL STIMULANTS, 5             Codeine/Promethazine/Phenylep     DEPAKOTE*, DEPAKOTE ER
Butoconazole Nitrate, 9             CESIA*, 8                              hrine*, 6                          (QL), 5
Butoconazole* (OTC), 9              CETAMIDE*, 6                       Codeine/Pseudoephedrine/Chlorp    DEPO-PROVERA INJ (QL)*, 8
                                    Cetirizine*, 1                         heniramine*, 6                DERMACOAT*, 10
               C                    Cetirizine/Pseudoephedrine*, 1     Codeine/Pseudoephedrine/Guaife    DES*, 8
                                    CHANTIX (PA), 3                        nesin*, 6                     Desipramine*, 5
CAFCIT* (oral only), 5              CHEMET, 10                         Codeine/Triprolidine/Pseudoephe   Desmopressin*, 6
CAFERGOT*, 3                        CHERACOL*, 6                           drine*, 6                     DESOGEN*, 8
Caffeine, citrated*, 5              Chloral Hydrate*, 5                CODIMAL DH*, 6                    Desogestrel/Ethinyl Estradiol*, 8
CALAMINE LOTION* (OTC), 10          Chlorambucil, 2                    COGENTIN*, 3                      Desonide* Cream, Oint 0.05%, 9
Calamine Lotion* (OTC), 10          Chlordiazepoxide* (XL & tablets    COLACE* (OTC), 7                  DESOWEN*, 9
CALAN* (QL), 3                          non-formulary), 5              COLBENEMID*, 7                    Desoximetasone* Cream, Oint,
CALAN-SR, 3                         Chlordiazepoxide/Clidinium*, 3     Colchicine*, 7                         Gel, 9
CALCIFEROL* (OTC), 10               Chlorhexidine Gluconate*, 10       Colchicine/Probenecid*, 7         DESYREL*, 5
Calcitriol*, 10                     Chloroquine*, 2                    COMBIVENT, 8                      Dexamethasone*, 7, 9
Calcium Acetate, 6                  Chlorothiazide*, 4, 6              COMBIVIR, 2                       Dexbrompheniramine/Pseudoeph
Calcium Carbonate w/Vitamin D*      Chlorpheniramine* (OTC), 1         COMPAZINE*, 7                          edrine* (OTC), 1
    (OTC), 10                       Chlorpheniramine/Carbetapentan     CONCERTA (QL), 5                  Dexchlorpheniramine*, 1
Calcium carbonate* (OTC), 7             e*, 1                          CONDOMS (QL), 8                   DEXEDRINE*, 5
Calcium Channel Blockers, 3         Chlorpheniramine/Phenylephrine/    CONDYLOX*, 10                     Dexmethylphenidate*, 5
Calcium Gluconate* (OTC), 10            Methscopolamine*, 1            Contraceptives, 8                 Dextroamphetamine*, 5
CALCIUM LACTATE* (OTC), 10          Chlorpheniramine/Phenylephrine/    CORDARONE*, 4                     Dextromethorphan/Bromphenira
Calcium Lactate* (OTC), 10              Pyrilamine*, 1                 COREG*, 4                              mine/Pseudoephedrine*, 6
CALTRATE 600+D* (OTC), 10           Chlorpheniramine/Pseudoephedri     CORGARD*, 3                       Dextromethorphan/Carbinoxamin
CANASA, 7                               ne*, 1                         CORTAID* (OTC), 9                      e/, 6
Capecitabine, 2                     Chlorpromazine* (spansule non-     CORTEF*, 9                        Dextromethorphan/Guaifenesin*
CAPOTEN*, 4                             formulary), 5                  Corticosteroids, 9                     (OTC), 6
CAPOZIDE*, 4                        Chlorpropamide*, 8                 CORTISPORIN OTIC*, 6              Dextromethorphan/Promethazine
Captopril*, 4                       Chlorthalidone*, 4, 6              CORTISPORIN*, 6                        *, 6
Captopril/HCTZ*, 4                  CHLOR-TRIMETON* (OTC), 1           COUMADIN*, 3                      Dextromethorphan/Pseudoephedr
CARAFATE*, 7                        Chlorzoxazone*, 3                  CRANTEX*, Efasin*, 6                   ine/Guaifenesin* (OTC), 6
Carbamazepine*, 5                   Cholestyramine*, 4                 CREON, 7                          DIABETA*, 9
Carbamazepine, extended-            Choline Magnesium Salicylate*, 4   CRIXIVAN, 2                       DIABINESE*, 8
    release, 5                      Cholinergic Agents, 3              CROLOM*, 7                        DIALOSE* (OTC), 7
Carbamide Peroxide 6.5%*            Ciclopirox*, 9                     Cromolyn* (OTC), 7                DIAMOX* (oral only), 7
    (OTC), 6                        Cilostazol*, 3                     CRYSELLE*, 8                      DIASTAT PED (QL), DIASTAT
Carbinoxamine*, 1                   Cimetidine*, 7                     Cyanocobalamin injection*, 10          ACUDIAL (QL), 5
Carbinoxamine/Pseudoephedrine       CIN-QUIN*, QUINORA*, 4             CYCLESSA*, 8                      Diazepam rectal gel, 5
    *, 1                            CIPRO, CIPRO XR (QL), 2            Cyclobenzaprine*, 3               Diazepam*, 5
CARBOFED*, 6                        CIPRODEX (QL), 6                   CYCLOCORT*, 9                     Diclofenac Potassium*, 4
Carbonic Anhydrase Inhibitors,      Ciprofloxacin, 2, 6                CYCLOGYL*, 7                      Diclofenac Sodium*, 4
    7                               Ciprofloxacin/Dexamethasone, 6     Cyclopentolate*, 7                Dicloxacillin*, 2
CARDIZEM SR*, CARDIZEM              Citalopram*, 5                     Cyclophosphamide*, 2              Dicyclomine*, 3
    CD*,, 3                         CITRATE OF MAGNESIA*               Cyclosporine*, 3                  Didanosine, 2
CARDIZEM*, 3                            (OTC), 7                       CYCRIN*, 8                        Dietheylstilbestrol Diphosphate*,
CARDURA* (XL NF) (QL), 4            CITRUCEL* (OTC), 7                 CYLERT*, 5                             2
Carisoprodol*, 3                    Clarithromycin*, 1                 Cyproheptadine*, 1                Diflorasone Diacetate*, 10
                                                                                                                            Page 12 of 18
DIFLUCAN*, 1                        ELDEPRYL*, 3                         Etonogestrel-Ethinyl Estradiol      Fondaparinux Sodium, 10
Diflunisal*, 4                      Electrolyte Rehydrating (OTC), 7         Vaginal Ring, 8                 FORADIL, 3, 8
Digoxin*, 4                         ELECTROLYTIC, Caloric            &   Etoposide, 3                        Formoterol, 3, 8
DILANTIN*, PHENYTEK (QL), 5             WATER, 6                         Etravirine, 2                       FOSAMAX, 9
Diltiazem*, 3                       ELIDEL (AR-for ages below 16yo       EULEXIN*, 2                         FOSAMAX+D (QL), 9
Diltiazem* (long-acting capsule),       only) (QL), 10                   EVISTA, 8                           Fosamprenavir, 2
     3                              ELIMITE*, 9                          Exemestane, 2                       Fosinopril HCTZ*, 4
DIMETANE* (OTC), 1                  ELOCON*, 9                           Expectorant and Expectorant         Fosinopril*, 4
Diphenhydramine Cream 2%*           EMCYT, 2                                 Combinations, 6                 FRAGMIN (QL), 10
     (OTC), 10                      EMLA* (cream only), 9                EXTENDRYL*, 1                       FUNGOID, 9
Diphenhydramine* (OTC), 1           EMPIRIN #2,3,4*, 5                   EYE, EAR, NOSE & THROAT, 6          FURADANTIN*, 2
Diphenoxylate/Atropine*, 7          Emtricitabine, 2                     Ezetimibe/Simvastatin, 4            Furosemide*, 4, 6
Dipivefrin HCl*, 7                  Emtricitabine/Tenofovir disoproxil                                       Fusion Inhibitors, 2
DIPROLONE*, DIPROLONE AF*,              fumarate, 2                                     F                    FUZEON INJECTABLE (PA), 2
     10                             EMTRIVA (QL), 2
DIPROSONE*, 9                       Enalapril*, 4                        Famciclovir*, 2                                   G
Dipyridamole*, 3, 4                 Enalapril/HCTZ*, 4                   Famotidine*, 7
DISALCID*, 4                        Endothelin Receptor                  FAMVIR* (QL), 2                     Ganciclovir*, 2
Disopyramide*, 4                        Antagonists, 4                   FARESTON, 2                         GANTRISIN*, 2
Disulfiram*, 3                      Enfuvirtide, 2                       FAZACLO (ST), 5                     Gapabentin*, 5
DITROPAN* (XL non-formulary),       Enoxaparin Sodium, 10                FELDENE*, 4                         GARAMYCIN*, 6, 9
     3                              Entecavir, 2                         Felodipine*, 3                      GASTROINTESTINAL DRUGS,
Diuretics, 4, 6                     Enzyme combination, topical*, 10     FEMARA, 2                               7
DIURIL*, 4, 6                       Epinephrine, 3, 10                   FEMSTAT-3* (OTC), 9                 GEL-KAM*, 10
Divalproex Sodium*, 5               EPIPEN, EPIPEN JR, 3, 10             Fenofibrate*, 4                     Gemfibrozil*, 4
Docusate Calcium* (OTC), 7          EPIVIR,EPIVIR HBV, 2                 FENOGLIDE (QL), 4                   GENCEPT 10/11*, 8
Docusate Potassium* (OTC), 7        EPZICOM, 2                           Fenoprofen*, 4                      GENOPTIC*, 6
Docusate Sodium* (OTC), 7           EQUETRO (QL), 5                      Fentanyl Transdermal System*, 5     Gentamicin*, 6, 9
Docusate Sodium/Casanthrol*         ERGAMISOL, 3                         FEOSOL* (OTC), 10                   GEODON (ST), 5
     (OTC), 7                       Ergocalciferol*, 10                  FERGON* (OTC), 10                   GI Motility, 7
DOLOBID*, 4                         Ergotamine/Caffeine*, 3              FERREX FORTE*, 3                    GLEEVEC, 3
DOLOPHINE*, 5                       Ergotamine-PB-Belladona*, 3          FERREX PC TAB FORTE*, 10            Glimepiride*, 9
DOMEBORO OTIC SOLN*                 Erlotinib, 3                         Ferrous Fumarate* (OTC), 10         Glipizide*, 9
     (OTC), 6                       ERRIN*, 8                            FERROUS FUMARATE* (OTC),            Glipizide/Metformin*, 9
Donepezil, 3                        ERYC*, 1                                  10                             GLUCAGON (QL), 10
DONNATAL* (capsules non-            ERY-DERM*, 9                         Ferrous Gluconate* (OTC), 10        Glucagon Injection, 10
     formulary), 3                  ERYMAX*, 9                           Ferrous Sulfate* (OTC), 10          GLUCOPHAGE* (XR non-
Dornase Alfa, 6                     ERY-TAB*, 1                          Fexofenadine*, 1                        formulary), 9
Doxazosin*, 4                       ERYTHROCIN*, 1                       Fibric Acid Derivatives, 4          GLUCOTROL XL* (QL), 9
Doxepin*, 5                         Erythromycin Base 250, 333, and      Finasteride, 8                      GLUCOTROL*, 9
Doxercalciferol*, 10                    500mg tabs*, 1                   FINEVIN, 9                          GLUCOVANCE*, 9
Doxycycline Hyclate*, 10            Erythromycin Base Enteric            FIORICET*, ESGIC*, 5                Glyburide*, 9
Doxycycline*, 2                         Pellets*, 1                      FIORINAL* (capsules non-            Glyburide/Metformin*, 9
DRIXORAL COLD & ALLERGY*            Erythromycin Estolate*, 1                 formulary), 5                  Glycerin/Benzoylale/Petrolatum
     (OTC),, 1                      Erythromycin Ethylsuccinate*, 1      FLAGYL *(Flagyl ER non-                 Cream* (OTC), 10
Drospirenone/Ethinyl Estradiol, 8   Erythromycin gel-benzoyl                  formulary), 2                  GLYNASE*, 9
DROXIA, 3                               peroxide*, 9                     Flavoxate*, 3                       GOLYTELY, 7
Drugs for Migraine-Abortive, 3      Erythromycin Solution*, Gel*,        FLEET ENEMA* (OTC), 7               GRANULEX*, 10
Drugs to Treat Endometriosis,           Pads*, 9                         FLEXERIL* (10mg only), 3            GRIFULVIN V*, 1
     8                              Erythromycin Stearate*, 1            FLONASE* (QL), 7                    Griseofulvin microsize*, 1
DRYSOL SOL 20%*, 9                  Erythromycin w/Sulfisoxazole*, 1     FLOVENT HFA, 8                      GRIS-PEG, 1
DULCOLAX* (OTC), 7                  Erythromycin*, 6                     FLOXIN OTIC, 6                      Guaifenesin*, 6
DUOFILM* (OTC), 10                  Erythromycins/Macrolides, 1          FLOXIN* (QL), 2                     Guaifenesin* (OTC), 6
DURADRYL*, 1                        Escitalopram, 5                      Fluconazole*, 1                     Guaifenesin/Hydrocodone/Pseud
DURAGESIC*(QL) (12.5mg NF),         ESKALITH*, ESKALITH CR*, 5           Flunisolide*, 7                         oephedrine*, 6
     5                              ESTRACE*, 8                          Fluocinolone Acetonide* Cream       Guaifenesin/Phenylephrine*, 6
DURICEF*, 1                         Estradiol Transdermal System*, 8          0.025%, 9                      Guaifenesin/Pseudoephedrine*, 6
Dutasteride, 8                      Estradiol*, 8                        Fluocinolone Acetonide* Oint        Guanfacine*, 4
DYAZIDE*, 4, 6                      Estramustine Phosphate Sodium,            0.025%, 9                      GYNAZOLE-1, 9
DYMELOR*, 8                             2                                Fluocinolone Acetonide* Soln,       GYNE-LOTRIMIN* (OTC), 9
DYNAPEN*, 2                         Estrogens, 8                              Cream 0.01%, 9
                                    Estrogens /Progestin, 8              Fluocinonide* Cream, Oint, Gel,                   H
                E                   Estrogens Agonist -                       Soln 0.05%, 9
                                        Antagonist, 8                    Fluoride Rinse* (OTC), 10           H2 Antagonists (OTC and RX),
ECONOPRED PLUS*, 7                  Estrogens Estrogen, 8                Fluoride/Polyvitamins* (drops and       7
ECONOPRED*, 7                       Estrogens, Conjugated, 8                  tablets), 10                   HALCION*, 6
ECOTRIN*, St. JOSEPH* (OTC),        Estrogens,                           Fluoroquinolones, 2                 HALDOL*, 5
    4                                   Conjugated/Medroxyprogeste       Fluorouracil*, 10                   Halobetasol Propionate*, 10
EES* 400 tab, EES* 200, 400             rone, 8                          Fluoxetine* - (capsules only), 5    Haloperidol*, 5
    suspension, 1                   Estropipate*, 8                      Fluphenazine*, 5                    HECTOROL*, 10
Efavirenz, 2                        ESTROSTEP FE*, 8                     Flurazepam*, 5                      Hemorrheologic Agents, 3
Efavirenz/Emtricitabine/Tenofovir   Ethambutol*, 2                       Flurbiprofen*, 4, 7                 HEPSERA (QL), 2
    disoproxil fumarate, 2          ETHEDENT* (OTC), 10                  Flutamide*, 2                       HEXALEN, 2
EFFEXOR*, EFFEXOR XR (QL),          Ethosuximide*, 5                     Fluticasone*, 7                     HISTUSSIN D*, 6
    5                               Ethynodiol/Ethinyl Estradiol*, 8     Fluvoxamine*, 5                     HISTUSSIN HC*, 6
EFUDEX*, 10                         Etodolac*, 4                         FOCALIN*, 5                         Homatropine*, 7
ELAVIL*, 5                                                               Folic Acid*, 10                     Hormones, 2
                                                                                                                               Page 13 of 18
HORMONES & SYNTHETIC                 IPECAC* (OTC), 7                    Leflunomide*, 7                      LURIDE*, 10
   SUBSTITUTES, 8                    Ipratropium*, 3, 8                  LESSINA*, 8                          LUTERA*, 8
Human Insulin, NPH,                  Ipratropium* (inhaler, nebulized    Letrozole, 2                         LUVOX* (QL), 5
   Regular,Mix, 9                         soln), 3                       Leukotriene Antagonist, 8            LYSODREN, 3
HUMULIN, HUMALOG (pens               Iron Preparations, 3                Levamisole HCI, 3
   NF), 9                            ISENTRESS (PA), 2                   LEVAQUIN (QL), 2                                   M
HYCODAN*, 6                          Isoniazid*, 2                       Levetiracetam, 5
HYCOTUSS*, 6                         ISONIAZID*, 2                       LEVLEN*, 8                           MAALOX* (OTC), 7
Hydralazine*, 4                      ISOPTO ATROPINE*, 7                 LEVLITE*, 8                          MACROBID*, 2
Hydralazine/HCTZ*, 4                 ISOPTO CARPINE*, 7                  Levobunolol*, 7                      MACRODANTIN*, 2
HYDREA*, 3                           ISOPTO HOMATROPINE*, 7              Levocarnitine*, 10                   Magnesium Citrate* (OTC), 7
Hydrochlorothiazide* (HCTZ), 4, 6    ISOPTO TEARS* (OTC), 7              Levodopa/Carbidopa*, 3               Magnesium Hydroxide* (OTC), 7
Hydrocodone                          ISORDIL Titradose*, 4               Levofloxacin, 2                      Magnesium Hydroxide/Aluminum
   Bitartrate/Acetaminophen*, 5      ISORDIL*, 4                         Levonorgestrel, 8                        Hydroxide* (OTC), 7
Hydrocodone/Chlorpheniramine/P       Isosorbide Dinitrate* (chew tab     Levonorgestrel/Ethinyl Estradiol*,   Malathion, 9
   henylephrine*, 6                       non-formulary), 4                   8                               MAO-I, 5
Hydrocodone/Guaifenesin*, 6          Isosorbide Dinitrate* (sustained-   LEVORA*, 8                           Maprotiline*, 5
Hydrocodone/Homatropine*, 6               release), 4                    LEVOTHROID*, 8                       MATERNAL VIT TAB &
Hydrocodone/Pseudoephedrine*,        Isosorbide Mononitrate*, 4          Levothyroxine* (use same brand           MINERAL*, 10
   6                                 Isotretinoin*, 9                         consistently), 8                MATERNITY-90 TAB*, 10
Hydrocodonebitartrate*, 6            Itraconazole*, 1                    LEVOXYL*, 8                          MATULANE, 3
Hydrocortisone 0.5,1%* (OTC), 9                                          LEVSIN*, 3                           MAXALT, MLT (QL), 3
Hydrocortisone 2.5%*, 9                              J                   LEVSINEX*, 3                         MAXITROL*, 6
Hydrocortisone Butyrate, 9                                               LEXAPRO (QL), 5                      MAXZIDE*, 4, 6
Hydrocortisone*, 9, 10               JANUMET (QL), 9                     LEXIVA, 2                            Mebendazole*, 2
Hydrocortisone/Acetic Acid*, 6       JANUVIA (QL), 9                     LIBRAX*, 3                           MECLIZINE* (OTC)/RX, 7
HYDRODIURIL*, 4, 6                   JOLIVETTE*, 8                       LIBRIUM*, 5                          Meclofenamate*, 4
HYDROGEN PEROXIDE 3%*                JUNEL FE 1.5/20*, 8                 LIDEX*, 9                            MECLOMEN*, 4
   (OTC), 9                          JUNEL FE 1/20*, 8                   Lidocaine, 9                         MEDROL*, 9
Hydrogen Peroxide 3%* (OTC),                                             Lidocaine/Prilocaine*, 9             Medroxyprogesterone Acetate
   9                                                 K                   LIDODERM, 9                              (Contraceptive)*, 8
Hydroxychloroquine*, 2                                                   Lifescan glucometers/test strips,    Medroxyprogesterone*, 8
Hydroxyurea*, 3                      KALETRA, 2                               9                               MEGACE*, 2
Hydroxyzine HCI*, 1, 5               KAOCHLOR*, 6                        LIORESAL*, 3                         Megestrol Acetate*, 2
Hydroxyzine HCl Injection* (single   KARIDIUM*, 10                       LIPRAM*, 7                           MELLARIL*, 5
   dose vial), 10                    KAYEXALATE*, 6                      Lisinopril*, 4                       Meloxicam*, 4
Hydroxyzine Pamoate capsule*, 6      K-DUR*, 6                           Lisinopril/HCTZ*, 4                  Melphalan, 2
HYGROTON*, 4, 6                      KEFLEX*, 1                          Lithium*, 5                          Memantine, 3
Hyoscyamine*, 3                      KELNOR*, 8                          LITHOBID*, 5                         MENEST, 8
Hyperkalemic Agent, 6                KENALOG IN ORABASE*, 10             LO/OVRAL*, 8                         Menthol/Cetylpyridium Lozenge*
HYTONE*, 9                           KENALOG*, 9                         LOCAL ANESTHETICS, 9                     (OTC), 7
HYTRIN*, 4                           KEPPRA (QL), 5                      LOCOID CREAM*,, 9                    Meperidine*, 5
                                     Keratolytic Agent, 10               LOCOID LIPOCREAM*,, 9                MEPHYTON, 10
                I                    Ketoconazole*, 1, 9                 LOCOID OINTMENT*, 9                  Mercaptopurine, 2
                                     Ketoprofen*, 4                      LODINE*, LODINE XL*, 4               Mesalamine, 7
Ibuprofen* (OTC) RX, 4               Ketorolac*, 4                       LOESTRIN FE 1.5/20*,, 8              MESTINON*, 3
ILOSONE* (suspension only), 1        Ketotifen*, 7                       LOESTRIN FE 1/20*, 8                 METAGLIP* (QL), 9
ILOTYCIN*, 6                         KLONOPIN*, 5                        LOFIBRA*, 4                          METAPREL*, 3, 8
Imatinib Mesylate, 3                 K-LOR*, 6                           LOMOTIL*, 7                          Metaproterenol (inhaler,
IMDUR*, ISMO*, MONOKET*, 4           KLOR-CON*, 6                        Lomustine, 2                             nebulized soln), 3
Imipramine* PM (NF), 5               KLORVESS*, 6                        LONITEN*, 4                          Metaproterenol Sulfate, 8
Imiquimod, 10                        K-LYTE*, 6                          Loperamide* (OTC), 7                 Metaproterenol*, 3, 8
IMITREX (QL), 3                      K-PHOS, 6                           LOPID*, 4                            Metaproterenol* (10mg, 20mg
Immunomodulators, 3                  K-PHOS NEUTRAL, 6                   Lopinavir / Ritonavir, 2                 tablets), 3
Immunosuppressives, 3                                                    LOPRESSOR* (QL, except               Metformin*, 9
IMODIUM A-D* (OTC), 7                                L                        25mg),, 3                       Methadone*, 5
IMURAN*, 3                                                               LOPROX* (cream and                   Methazolamide*, 7
Indapamide*, 4, 6                    Labetalol*, 4                            suspension only) (QL), 9        METHERGINE, 9
INDERAL*, INDERAL LA* (QL), 3        LACTAID* (OTC), 7                   Loratidine /Pseudoephedrine*, 1      Methimazole*, 8
Indinavir Sulfate, 2                 Lactase* (OTC), 7                   Loratidine* (OTC), 1                 Methocarbamol*, 3
INDOCIN SR*, 4                       LACTINEX* (OTC), 7                  Lorazepam*, 6                        Methotrexate*, 7
INDOCIN*, 4                          Lactobacillus Acidophilus* (OTC),   LOTENSIN HCT*, 4                     METHOTREXATE*,
Indomethacin* (suppository non-          7                               LOTENSIN*, 4                             RHEUMATREX*, 7
    formulary), 4                    Lactulose*, 6, 7                    LOTRIMIN AF (OTC)* (1% Soln),        Methylcellulose* (OTC), 7
INFLAMASE*, INFLAMASE                LAMICTAL (QL), 5                         9                               Methyldopa*, 4
    FORTE*, 7                        LAMISIL* (QL) (granules NF), 1      LOTRIMIN*, 9                         Methyldopa/HCTZ*, 4
Inhaled Anti-Inflammatory            Lamivudine, 2                       Lovastatin*, 4                       Methylene Blue/ Benzoic Acid/
    Agents, 8                        Lamivudine / Zidovudine, 2          Lovastatin, extended release, 4          Hyoscyamine/ Atropine/
Insulin Human Glargine, 9            Lamotrigine, 5                      Lovastatin/Niacin, 4                     Phenylsalicylate/
Insulin-Lilly Brands Only, 9         LANOXIN*, 4                         LOVENOX (QL), 10                         Methenamine, 2
INTAL INHALER, 8                     LANTUS (pen NF), 9                  LOW-OGESTREL*, 8                     Methylergonovine Maleate, 9
Integrase Strand Transfer            LASIX*, 4, 6                        Loxapine*, 5                         Methylphenidate*, 5
    Inhibitors, 2                    Laxative, 6                         LOXITANE*, 5                         Methylphenidate, long-acting, 5
INTELENCE, 2                         Laxatives and Stool Softeners       LOZOL*, 4, 6                         Methylprednisolone*, 9
INVEGA (ST), 5                           (OTC), 7                        LUDIOMIL*, 5                         Methyltestosterone, 8
INVIRASE, 2                          L-CARNITINE* (OTC), 10              LUEKERAN, 2                          Metipranolol, 7
Ipecac syrup* (OTC), 7               LEENA*, 8                           LUMIGAN (2.5ml only), 7              Metoclopramide*, 7
                                                                                                                                Page 14 of 18
Metoprolol Tartrate*, 3            MYLICON* (OTC), 7                   Nifedipine* (sustained-release), 3   Olmesartan
METROGEL Vaginal*, 9               MYSOLINE* (QL), 5                   NILANDRON, 2                            medoximil/Hydrochlorothiazid
Metronidazole, 2, 7, 9                                                 Nilotinib, 3                            e, 4
Metronidazole*, 2, 9                              N                    NILSTAT*, 9                          Omeprazole Magnesium, 7
MEVACOR* (QL), 4                                                       Nilutamide, 2                        Omeprazole*, 7
MICARDIS (QL), 4                   Nabumetone*, 4                      Nisoldipine, 3                       Omeprazole/Sodium Bicarbonate
MICARDIS-HCT (QL), 4               Nadolol*, 3                         NITROBID*, 4                            (QL), 7
MICATIN* (OTC), 9                  NALFON*, 4                          NITRO-DUR*, 4                        OMNICEF*, 1
Miconazole* (OTC), 9               Naltrexone*, 5                      Nitrofurantoin Macrocrystals*, 2     Ondansetron*, 7
MICROGESTIN FE, 8                  NAMENDA (QL), 3                     Nitrofurantoin*, 2                   Ophthalmic Anti-
MICRONASE*, 9                      Naphaxoline/Pheniramine*            Nitroglycerin Ointment*, 4              Inflammatories, 7
MICROZIDE*, 4, 6                       (OTC), 7                        Nitroglycerin Patches*, 4            Opiate Antagonist, 5
MIDAMOR*, 4, 6                     Naphazoline*, 7                     Nitroglycerin Spray, 4               OPTIPRANOLOL, 7
MIDRIN*, 3, 5                      Naphazoline/antazoline* (OTC), 7    Nitroglycerin Sublingual*, 4         ORABASE-B* (OTC), 7
MILK OF MAGNESIA* (OTC), 7         NAPHCON-A* (OTC), 7                 NITROL*, 4                           Oral Agents, 8
Mineral Oil* (OTC), 7              NAPROSYN*, NAPROSYN EC*,            Nitrolglycerin Oral*, 4              Oral Contraceptives, 8
MINERAL OIL* (OTC), 7                  4                               NITROLINGUAL, 4                      ORAPRED*, 9
Mineral Oil/Petrolatum Ointment*   Naproxen Sodium*, 4                 NITROSTAT SL*, 4                     ORASONE*, 9
    (OTC), 10                      Naproxen* (Naprelan non-            NIX* (OTC), 9                        ORINASE*, 9
Minerals, 10                           formulary), 4                   Nizantadine*, 7                      ORTHO-CEPT*, 8
MINIPRESS*, 4                      Narcotic Analgesics, 5              NIZORAL*, 1, 9                       ORTHO-CYCLEN*, 8
Minoxidil*, 4                      NARDIL, 5                           NMDA Receptor Antagonist, 3          ORTHO-MICRONOR*, 8
Miotics, 7                         Nasal Steroids/Anti-                NOCTEC*, 5                           ORTHO-NOVUM 1/35*, 8
MIRALAX OTC, 6                         Inflammatory, 7                 NOLAHIST*, 1                         ORTHO-NOVUM 1/50*, 8
MIRCETTE*, KARIVA*, 8              NASALCROM* (OTC), 7                 NOLVADEX*, 8                         ORTHO-NOVUM 10/11*, 8
Mirtazapine*, 5                    NASALIDE*, 7                        Non-Narcotic Analgesic               ORTHO-NOVUM 7/7/7*, 8
Misc. Psychotherapy Agents, 5      NASONEX (QL), 7                          Combinations, 5                 ORTHO-TRI-CYCLEN LO, 8
Miscellaneous                      NATAFOLIC-PN TAB*, 10               Non-Nucleoside Reverse               ORTHO-TRI-CYCLEN*, 8
    Antidepressants, 5             NATALCARE 3 TAB*, 10                     Transcriptase Inhibitors, 2     ORUDIS*, 4
Miscellaneous Autonomic            NATALCARE CPL*, 10                  Nonsteroidal Anti-Inflammatory       ORUVAIL*, 4
    Agents, 3                      NATALCARE RX TAB*, 10                    Agents, 4                       OVCON-35*, 8
Miscellaneous EENT, 7              NATALCARE TAB CFE 60*, 10           NOR-BE*, 8                           OVCON-50*, 8
Miscellaneous GI Drugs, 7          NATALCARE TAB PIC FORTE*,           NORDETTE*, 8                         OVIDE (QL), 9
Miscellaneous Skin & Mucous            10                              Norethindrone*, 8                    OVRAL-28*, 8
    Membrane Agent, 10             NATALCARE TAB PLUS*, 10             Norethindrone/Ethinyl Estradiol*,    OVRETTE, 8
Misoprostol*, 7                    NATALINS RX*, 10                         8                               Oxaprozin*, 4
Mitotane, 3                        NATAREX TAB*, 10                    Norethindrone/Mestranol*, 8          Oxazepam*, 6
MOBIC* (QL) (tabs only), 4         NATATAB CFE TAB*, 10                NORETHRIN 1/35*, 8                   Oxybutynin*, 3
MODICON*, NECON 0.5/35-21*,,       NATATAB FA TAB*, 10                 Norgestimate/Ethinyl Estradiol*, 8   Oxycodone*, 5
    8                              NATATAB RX TAB*, 10                 Norgestrel, 8                        Oxycodone/Acetaminophen
MODURETIC*, 4, 6                   NAVANE* (oral only), 5              Norgestrel/Ethinyl Estradiol*, 8        Tablet*, 5
Moexipril*, 4                      NECON 0.5/35-28*, NORTREL           NORINYL 1/35*, 8                     Oxycodone/Aspirin*, 5
Moexipril/HCTZ* (QL), 4                0.5/35*,, 8                     NORINYL 1/50*, 8                     OXYIR*, 5
MOISTUREL* (OTC), 10               NECON 1/35*, 8                      NORMODYNE*, 4                        OXYTOCICS, 9
Mometasone, 7, 8, 9                NECON 1/50*, 8                      NORPACE*, NORPACE CR*, 4
Mometasone Furoate (cream,         NECON 10/11*, 8                     NORPRAMIN*, 5                                       P
    ointment, lotion)*, 9          NECON 7/7/7*, 8                     NOR-QD*, 8
MONISTAT* (OTC), 9                 Nelfinavir Mesylate, 2              NORTREL 1/35*, 8                     Paliperidone, 5
MONONESSA*, 8                      NEO-DECADRON*, 6                    NORTREL 7/7/7*, 8                    PAMELOR*,AVENTYL*, 5
MONOPRIL HCTZ* (QL), 4             Neomycin                            Nortriptyline*, 5                    PANCREASE* (all strengths), 7
MONOPRIL* (QL), 4                      Sulfate/Gramicidin/Polymyxin    NORVASC* (QL), 3                     Pancreatin, 7
Montelukast, 8                         B Sulfate*, 6                   NORVIR, 2                            Pancrelipase*, 7
Morphine Sulfate*, 5               NEOMYCIN*, 2                        NOVAHISTINE DH*, 6                   Pantoprazole*, 7
Morphine* (sustained-release), 5   Neomycin/Bacitracin/Polymyxin B     Nucleoside Analog Reverse            PARAFON, PARAFON FORTE*,
MOTRIN*, 4                             Sulfate*, 6                          Transcriptase Inhibitor             3
Moxifloxacin, 2                    Neomycin/Dexamethasone*, 6               Combinations, 2                 Paricalcitol*, 10
MS CONTIN*, 5                      Neomycin/Polymyxin B                Nucleoside Reverse                   PARLODEL*, 3
MSIR* (oral only), 5                   Sulfate/Hydrocortisone*, 6           Transcriptase Inhibitors, 2     Paroxetine*, 5
MUCINEX (OTC), 6                   Neomycin/Polymyxin B                NULYTELY*, 7                         PAXIL* (QL), 5
MUCINEX D (OTC), 6                     Sulfate/Hydrocortisone/Bacitr   NUVARING (QL), 8                     PEAK FLOW METER (QL), 7
Mucolytic Agents, 6                    acin*, 6                        Nystatin*, 1, 9                      PEDIACARE* (OTC), 6
MUCOMYST*, 6                       Neomycin/Polymyxin                  Nystatin/Triamcinolone*, 9           PEDIALYTE* (OTC), 7
Multiphasics (oral                     B/Bacitracin* (OTC), 9                                               PEDIAPRED*, 9
    contraceptives), 8             NEOSPORIN ointment*, 6                              O                    PEDIATEX*, 1
Multivitamin + Iron (pediatric)*   NEOSPORIN solution*, 6                                                   Pediatric/Fluoride, 10
    (OTC), 10                      NEOSPORIN* (OTC), 9                 OCEAN SPRAY* (OTC), 7                PEDIAZOLE*, 1
Multivitamin* (OTC), 10            NEO-SYNEPHRINE* (OTC), 7            OCUFEN*, 7                           Peg 3350, 6
Mupirocin*, 9                      NEPTAZANE*, GLAUCTABS*, 7           OCUFLOX, 6                           Pemoline*, 5
MYAMBUTOL*, 2                      NEURONTIN* (QL), 5                  OCUPRESS*, 7                         PEN VEE K*, 2
MYCELEX TROCHE*, 1                 NEUTRA-PHOS POWDER*                 Ofloxacin, 2, 6                      Penicillin G, 10
MYCELEX*, 9                            (OTC), 10                       Ofloxacin*, 2                        Penicillin VK*, 2
MYCELEX-3 (OTC), 9                 Nevirapine, 2                       Ofloxin, 6                           Penicillins, 2
MYCOLOG II*, 9                     NEXAVAR, 3                          OGEN*, 8                             PENLAC* (QL), 9
Mycophenolate Mofetil, 3           Niacin*, 4                          OGESTREL*, 8                         Pentoxifylline*, 3
MYCOSTATIN*, 1, 9                  NIASPAN*, 4                         Olanzapine, 5                        PEPCID*, 7
Mydriatics, 7                      Nicotine gum/lozenge (PA), 3        Olmesartan Medoximil, 4              PEPTO-BISMOL* (OTC), 7
MYLERAN, 2                         Nicotine patch (PA), 3                                                   PERCOCET*, TYLOX*, 5
                                                                                                                               Page 15 of 18
PERCODAN*, 5                       PRELONE*, 9                       PROTONIX* (QL) (BRAND              RISPERDAL* (oral only) (QL), 5
Pergolide*, 3                      PREMARIN (QL), 8                      COVERED), 7                    Risperdone*, 5
PERIACTIN*, 1                      PREMPRO, PREMPHASE (QL),          Protriptyline*, 5                  RITALIN*, RITALIN SR*,
PERI-COLACE* (OTC), 7                  8                             PROVENTIL*, 3, 8                       METHYLIN ER* (QL), 5
PERIDEX*, PERIOGARD*, 10           PRENATAB CBF TAB*, 10             PROVENTIL* (nebulization), 8       Ritonavir, 2
PERIOMED*, 10                      PRENA-TAB TAB*, 10                PROVERA*, 8                        Rizatriptan, 3
PERIO-RINSE* (OTC), 10             PRENATABS FA TAB*, 10             PROZAC* (40mg & weekly NF), 5      ROBAXIN*, 3
PERIOSTAT*, 10                     PRENATABS RX TAB*, 10             Pseudoephedrine*, 1, 6             ROBITUSSIN - PE* (OTC), 6
PERMAX*, 3                         Prenatal, 1, 10                   Pseudoephedrine* (OTC), 1          ROBITUSSIN AC*, GUIATUSS
Permethrin 1%* (OTC), 9            PRENATAL 1 TAB PLUS 1*, 10        Pseudoephedrine/Guaifenesin*           AC*,, 6
Permethrin*, 9                     PRENATAL 1/ TAB IRON*, 10             (OTC), 6                       ROBITUSSIN DAC*, 6
PERMITIL*, 5                       PRENATAL 1+ TAB BETA              PSORCON*, PSORCON E*, 10           ROBITUSSIN* (OTC), 6
Perphenazine*, 5                       CAROTENE*, 10                 PULMICORT RESPULES (only           ROBITUSSIN-DM* (OTC), 6
PERSANTINE*, 3, 4                  PRENATAL 1+1 TAB*, 10                 for under 8yo), 8              ROCALCTROL*, 10
Phenazopyridine*, 2                PRENATAL 19 CHW TAB*, 10          PULMOZYME, 6                       ROCEPHIN (QL), 10
Phenelzine, 5                      PRENATAL 19 TAB*, 10              PURINETHOL, 2                      RONDEC DM*, 6
PHENERGAN DM*, 6                   PRENATAL AD TAB*, 10              Pyrazinamide*, 2                   RONDEC*, ANDEHIST NR*, 1
PHENERGAN VC*, 6                   PRENATAL FOR TAB*, 10             PYRAZINAMIDE*, 2                   Rosiglitazone, 9
PHENERGAN VC/CODEINE*, 6           PRENATAL M TAB*, 10               Pyrethrins Spray* (OTC), 9         Rosiglitazone/Metformin, 9
PHENERGAN W/CODEINE*, 6            PRENATAL MR TAB 90 FE*, 10        Pyrethrins/Piperonyl Butoxide*     RYNATAN*, 1
PHENERGAN*, 1, 6                   PRENATAL MTR TAB                      (OTC), 9
Phenindramine Tartrate*, 1             SELENIUM*, 10                 PYRIDIUM*, 2                                      S
Phenobarbital*, 5                  PRENATAL NF TAB PLUS*, 10         Pyridostigmine*, 3
PHENOBARBITAL*, 5                  PRENATAL OPT TAB                                                     Salicylic Acid 17%/Collodion*
Phenylephrine* (OTC), 7                ADVANCE*, 10                                  Q                      (OTC), 10
Phenytoin*, 5                      PRENATAL PLS TAB /IRON*, 10                                          Salmeterol, 3, 8
PHOSLO, 6                          PRENATAL PLS TAB*, 10             QUESTRAN, 4                        Salmeterol/Fluticasone, 8
Phosphate Binder, 6                PRENATAL RX TAB BETA-             QUESTRAN*, 4                       Salsalate*, 4
Phosphate Replacement, 6               CAROTENE*, 10                 Quetiapine fumurate, 5             SANDIMMUNE*, NEORAL, 3
Phytonadione, 10                   PRENATAL RX TAB*, 10              QUIBRON-T*, 8                      Saquinavir, 2
Pilocarpine* (Ocusert non-         PRENATAL S TAB*, 10               QUINAGLUTE*, 4                     Scabicides and Pediculicides, 9
    formulary), 7                  PRENATAL Z TAB ADV FORM*,         Quinapril*, 4                      Second Generation, 1
Pimecrolimus, 10                       10                            Quinapril/HCTZ, 4                  Secondary Amines, 5
Pindolol*, 3                       PRENATAL Z TAB*, 10               QUINIDEX*, 4                       SECTRAL*, 4
Pioglitazone, 9                    PRENATAL-H CAP*, 10               Quinidine Gluconate*, 4            Selegiline*, 3
Piroxicam*, 4                      PRENATL CARE TAB*, 10             Quinidine Sulfate*, 4              Selenium Sulfide 2.5%*, 10
PLAN B, 8                          PRETERNA TAB*, 10                 Quinidine Sulfate* (sustained-     SELSUN*, EXSEL*, 10
PLAQUENIL*, 2                      PREVALITE*, 4                        release), 4                     Senna* (OTC), 7
PLAVIX (QL), 3                     PREVIFEM*, 8                      Quinine Sulfate*, 2                Senna/Docusate Sodium* (OTC),
PLENDIL*, 3                        PREVPAC, 7                        QUININE SULFATE*, 2                    7
PLETAL* (QL), 3                    PREZISTA, 2                       Quinolones, 2                      SENOKOT -S* (OTC), 7
Podofilox*, 10                     PRILOSEC OTC (QL), 7              QVAR, 8                            SENOKOT* (OTC), 7
POLARAMINE*, 1                     PRILOSEC* (40mg NF) (RX                                              SEPTRA DS*, 2
Polyethylene glycol/electrolyte        strength) (QL), 7                             R                  SEPTRA*, 2
    solution*, 7                   Primaquine*, 2                                                       SERAX*, 6
Polymyxin B Sulfate/Neomycin       PRIMAQUINE*, 2                    Racemic Epinephrine (nebulizer),   SEREVENT DISKUS, 3, 8
    Sulfate/Dexamethasone*, 6      Primidone*, 5                         3                              SEROQUEL (QL, 5
Polymyxin B/Bacitracin*, 9         PRINCIPEN*, 2                     Raloxifene, 8                      SEROQUEL XR (QL), 5
Polymyxin B/Bacitracin* (OTC), 9   PRIVINE*, 7                       Raltegravir, 2                     Sertraline*, 5
POLYSPORIN*, 9                     PROAIR HFA, 3, 8                  Ranitidine*, 7                     Sevelamer Carbonate, 6
POLYSPORIN* (OTC), 9               PROBANTHINE*, 3                   RAPAMUNE, 3                        Sildenafil Citrate, 4
POLY-VI-FL OR*, 10                 Probenecid*, 6, 7                 RECLIPSEN*, 8                      SILVADENE*, 9
POLY-VI-SOL IRON* (OTC), 10        Procainamide*, 4                  Rectal, 10                         Silver Nitrate*, 10
POLY-VI-SOL* (OTC), 10             Procarbazine HCI, 3               REGLAN*, 7                         Silver Sulfadiazine*, 9
PORTIA*, 8                         Prochlorperazine*, 7              RELAFEN* (QL), 4                   SIMCOR (QL), 4
Potassium Chloride 10mEq,          PROCTOFOAM, 10                    REMERON* (SolTabs NF), 5           Simethicone* (OTC), 7
    20mEq*, 6                      Progesterone, micronized, 8       RENVELA, 6                         Simvastatin*, 4
Potassium Chloride 8mEq*, 6        Progestin-Only (oral              RESCRIPTOR, 2                      Simvastatin/Niacin, 4
Potassium Chloride*, 6                 contraceptives), 8            RESPBID*, 8                        SINEMET*, SINEMET CR*, 3
Potassium Citrate, 6               PROGRAF, 3                        Respiratory and Cerebral           SINEQUAN*, 5
Potassium Supplements              PROLIXIN*, 5                          Stimulants, 5                  SINGULAIR (PA), 8
    Tablets, 6                     Promethazine*, 1, 6               RESPIRATORY DRUGS, 7               Sirolimus, 3
Powders/Effervescent Tablets,      Promethazine/Phenylephrine*, 6    RESTORIL* (7.5mg, 22.5mg NF),      Sitagliptin, 9
    6                              PROMETRIUM, 8                         6                              Sitagliptin/Metformin, 9
PRAMOTIC DROPS, 6                  PRONESTYL*, 4                     RETIN A* (micro non-formulary),    Skeletal Muscle Relaxants, 3
Pramoxine, 6, 10                   Propantheline*, 3                     9                              SKIN & MUCOUS MEMBRANE,
Pramoxine/Choroxylenol*, 6         PROPINE*, 7                       RETROVIR*, 2                           9
PRAVACHOL* (QL) (80mg NF), 4       Propoxyphene                      REVATIO (PA), 4                    SLOW K*, KLOR-CON*, 6
Pravastatin*, 4                        Napsylate/Acetaminophen*, 5   REVIA*, 5                          Smoking Deterrent, 3
Prazosin*, 4                       Propoxyphene*, 5                  REYATAZ, 2                         Sodium Biphosate/Potassium
PRECOSE*, 8                        Propranolol*, 3                   Rho (D) Immune Globulin                Phosphate* (OTC), 10
PRED FORTE*, 7                     Propylthiouracil*, 8                  Injectable, 10                 Sodium Borate, Boric Acid, 2
PRED MILD*, 7                      PROPYLTHIOURACIL* (PTU), 8        RHOGAM, BAYRHO, WINRHO,            SODIUM CHLORIDE * (OTC), 8
Prednisolone Acetate*, 7           PROSCAR (QL), 8                       10                             Sodium Chloride Soln for
Prednisolone Phosphate*, 7         Prostaglandins, 7                 RID* (OTC), 9                          Inhalation* (OTC), 8
Prednisolone*, 9                   Proton Pump Inhibitors, 7         RIFADIN*, 2                        Sodium chloride spray* (OTC), 7
Prednisone*, 9                                                       Rifampin*, 2                       Sodium Chloride* (OTC), 8
                                                                                                                           Page 16 of 18
Sodium Fluoride* (drops and        TENEX*, 4                          Travatan Z (2.5ml only), 7                        V
    tablets), 10                   Tenofovir disoproxil fumarate, 2   Travoprost, 7
Sodium Phosphate/Sodium            TENORETIC*, 3                      Trazodone*, 5                     VAGISTAT-1* (OTC), 9
    Biphosphate* (OTC), 7          TENORMIN*, 3                       TRENTAL*, 3                       VALISONE*, 9
Sodium Polystyrene Sulfonate*, 6   TERAZOL*, 9                        Tretinoin, 3, 9                   VALIUM*, 5
SOLIA*, 8                          Terazosin*, 4                      Tretinoin*, 9                     Valproic Acid*, 5
SOMA Compound*, 3                  Terbinafine* (QL), 1               Triamcinolone, 8, 9, 10           VANCOCIN, 2
SOMA*, 3                           Terbutaline*, 8                    Triamcinolone 0.1%in Orabase*,    Vancomycin, 2
SONATA* (QL), 6                    Terconazole*, 9                         10                           VANTIN* (QL), 1
Sorafenib tosylate, 3              TERNAMAR TAB*, 10                  Triamcinolone Acetonide* Cream,   Varenicline, 3
Sotalol*, 4                        TESLAC, 2                               Oint.0.025%, 9               VASERETIC*, 4
SPIRIVA, 8                         TESSALON PERLES* (100mg            Triamcinolone Acetonide* Lot,     VASOCON-A* (OTC), 7
Spironolactone*, 4, 6                  only) (QL), 6                       Cream, Oint 0.1%, 9          Vasoconstrictors, 3, 7
Spironolactone/HCTZ*, 4, 6         TESTIM (PA) (QL), 8                Triamcinolone* Cream, Oint        Vasodilating Agents, Coronary,
SPORANOX* (PA), 1                  Testolactone, 2                         0.5%, 9                          4
SPRINTEC*, 8                       Testosterone Gel, 8                Triamterene/HCTZ*, 4, 6           Vasodilators, 4
SPRYCEL, 3                         Tetracyclic Antidepressants, 5     TRIAVIL*, ETRAFON*, 5             VASOSULF*, 6
SSRIs, 5                           Tetracycline HCl, 7                Triazolam*, 6                     VASOTEC* (QL), 4
Stannous Fluoride* (OTC)/RX,       Tetracycline*, 2                   Tricyclic Antidepressants, 5      VEETIDS*, 2
    10                             Tetracyclines, 2                   Tricyclic                         VELIVET*, 8
Statins, 4                         Thalidomide, 3                          Antidepressants/Antipsych    Venlafaxine*, 5
Stavudine, 2                       THALOMID (PA), 3                        otics, 5                     VENTOLIN*, 3
STELAZINE*, 5                      THEO-24*, THEO-DUR*, THEO-         Trifluoperazine*, 5               VEPESID, 3
STILPHOSTROL*, 2                       VENT*,, 8                      Trifluridine*, 6                  Verapamil*, 3
STRATTERA (QL), 5                  THEOCHRON*, T-PHYL*, SLO-          TRIGLIDE* (QL), 4                 Verapamil* (long-acting tablet), 3
Succimer, 10                           BID*,, 8                       Trihexyphenidyl*, 3               VERELAN SR* (QL), 3
Sucralfate*, 7                     THEOLAIR 80*,SLO-PHYLLIN*, 8       TRILAFON*, 5                      VERMOX*, 2
SUDAFED*, 1                        Theophylline and other             TRILISATE*, 4                     VESANOID*, 3
SULAMYD*, 6                            Xanthines Solids, 8            Trimethobenzamide*, 7             VIBRAMYCIN*, 2
SULAR CR (QL), 3                   Theophylline*, 8                   Trimethoprim*, 2                  VICODIN*, VICODIN ES*, 5
SULAR (QL), 3                      Theophylline* (80mg/15cc), 8       TRIMO-SAN GEL (OTC), 2            VIDEX,VIDEX EC, 2
SULFACET R*, 6                     Thioguanine*, 2                    TRIMOX*, 2                        VINATE 90 TAB*, 10
Sulfacetamide 10%*, 6              THIOGUANINE*, 2                    TRIMPEX*, 2                       VINATE GT TAB*, 10
Sulfacetamide/Phenylephrine*, 6    Thioridazine*, 5                   TRINESSA*, 8                      VINATE M TAB*, 10
Sulfamethoxazole/Trimethoprim*,    Thiothixene*, 5                    TRI-NORINYL*, 8                   VINATE TAB ADVANCED*, 10
    2                              THORAZINE*, 5                      TRIPHASIL*, 8                     VINATE ULTRA TAB*, 10
Sulfasalazine*, 7                  Thyroid and Antithyroid            TRIPREVIFEM*, 8                   VIRACEPT, 2
Sulfisoxazole*, 2                      Agents, 8                      Triprolidine/Pseudoephedrine*     VIRAMUNE, 2
Sulfonamides, 2                    Thyroid*, 8                             (OTC), 1                     VIREAD, 2
Sulfones, 2                        TICLID*, 3                         TRI-SPRINTEC*,, 8                 VIROPTIC*, 6
Sulindac*, 4                       Ticlopidine*, 3                    TRI-VI-SOL with IRON*, 10         VISKEN*, 3
Sumatriptan, 3                     Ticonazole* (OTC), 9               TRI-VI-SOL*, 10                   VISTARIL*, 6
Sunitinib malate, 3                TIGAN*, 7                          TRIVORA*, 8                       Vitamin A&D Ointment* (OTC),
SURFAK* (OTC), 7                   Timolol*, 7                        TRIZIVIR, 2                           10
SUSTIVA, 2                         TIMOPTIC*, TIMOPTIC XE*, 7         TRUVADA, 2                        Vitamin B-12, 10
SUTENT, 3                          TINACTIN* (OTC), 9                 T-STAT*, 9                        VITAMIN B-12*, 10
SYMBICORT, 8                       Tiotropium Bromide, 8              T-STAT*, EMGEL*, 9                Vitamin D, 10
SYMMETREL*, 2                      Tipranavir, 2                      TUMS* (OTC), 10                   Vitamin K, 10
SYNALAR*, FLUROSYN*, 9             TOBI, 2                            TUMS* (OTC), 7                    Vitamin, A, D, and C with Iron*,
                                   Tobramycin (solution for           TUSSI-12 S*, 1                        10
                                       inhalation), 2                 TWINJECT (QL), 10                 Vitamin, A, D, and C*, 10
               T                                                                                        VITAMINS, 10
                                   Tobramycin Sulfate*, 6             TYLENOL #2, 3, 4* (capsules
Tacrolimus, 3                      TOBREX*, 6                              non-formulary), 5            VIVACTIL*, 5
TAGAMET*, 7                        TOFRANIL*, 5                       TYLENOL*, 4                       VOLMAX*, VOSPIRE ER*, 8
TAMIFLU (QL), 2                    Tolazamide*, 9                                                       VOLTAREN, 4, 7
Tamoxifen Citrate*, 2              Tolbutamide*, 8                                                      VOLTAREN*, VOLTAREN XR*, 4
                                                                                     U                  Vorinostat, 3
Tamoxifen*, 8                      TOLECTIN, DS (QL), 4
TAMOXIFEN*, 2, 8                   TOLINASE*, 9                       ULT NATLCARE TAB*, 10             VOSOL HC OTIC*, 6
TAMOXIFEN*, NOLVADEX*,             Tolmetin Sodium*, 4                ULTRA NATAL TAB*, 10              VOSOL*, 6
    SOLTAMOX, 2                    Tolnaftate* (OTC), 9               ULTRA TABS*, 10                   VYTORIN, 4
TAPAZOLE*, 8                       TOPAMAX (QL), 5                    ULTRACET* (QL), 5                 VYTORIN 10/10 (ST), 4
TARCEVA, 3                         Topical Anti-Infectives/Anti-      ULTRAM*, 5
TARGRETIN, 3                           Inflammatory (otic), 6         ULTRAVATE*, 10                                    W
TASIGNA, 3                         TOPICORT*, 9                       UNI-DUR*,, 8
TAVIST*, 1                         Topiramate, 5                      UNIPHYL*, 8                       Warfarin*, 3
Tazarotene (PA), 9                 TOPROL XL*, 3                      UNIRETIC* (QL), 4                 WELLBUTRIN SR*, 5
TAZORAC, 9                         TORADOL* (QL), 4                   UNIVASC* (QL), 4                  WELLBUTRIN*, 5
TEGRETOL*, TEGRETOL XR*,           Toremifene Citrate, 2              Urea, 10                          WIGRAINE*, 3
    CARBATROL (QL), 5              Torsemide*, 4                      URECHOLINE*, 3
Telmisartan, 4                     TRACLEER, 4                        Uricosuric Agents, 6                              X
Telmisartan/Hydrochlorothiazide,   Tramadol HCl*, 5                   Urinary Acidifiers, 6
    4                              Tramadol/acetaminophen* (QL),      Urinary Anti-                     XANAX XR*, 5
Temazepam*, 6                          5                                  Infectives/Analgesics, 2      XANAX*, 5
TEMODAR (PA), 3                    TRANDATE*, 4                       URISED, 2                         XELODA (PA), 2
TEMOVATE*, CORMAX*,                TRANSPLANT DRUGS, 2                URISPAS*, 3
    CLOBEX*, 10                    TRANXENE*, 5                       UROCIT K, 6
Temozolomide, 3                    TRAVATAN (2.5ml only), 7           Ursodiol*, 7
                                                                                                                            Page 17 of 18
              Y     ZANTAC* (efferdose non-   Zidovudine*, 2               Zolpidem* (QL), 6
                       formulary), 7          Zinc Oxide Oint* (OTC), 10   ZONEGRAN* (QL), 5
YASMIN, YAZ, 8      ZARONTIN* (QL), 5         ZINC OXIDE* (OTC), 10        Zonisamide*, 5
                    ZEBETA*, 4                ZIOX, 10                     ZOVIA*, 8
              Z     ZEGERID (QL), 7           Ziprasidone, 5               ZOVIRAX* (oral only), 2
                    ZEMPLAR*, 10              ZITHROMAX* (QL), 1           ZYLOPRIM*, 7
ZADITOR OTC*, 7     ZERIT, ZERIT XR, 2        ZOCOR* (QL), 4               ZYPREXA (ST), 5
Zafirlukast, 8      ZESTERETIC*, 4            ZOFRAN* (QL), 7              ZYPREXA ZYDIS (ST), 5
Zaleplon* (QL), 6   ZESTRIL* (QL), 4          ZOLINZA, 3                   ZYRTEC* (OTC) (QL), 1
Zanamir, 2          ZIAGEN, 2                 ZOLOFT* (QL), 5              ZYRTEC-D* (OTC) (QL), 1




                                                                                           Page 18 of 18

								
To top